UWOLRD NCLEX RN

COMPREHENSIVE STUDY
GUIDE
2020
 FUNDAMENTALS OF NURSING
BASIC CARE AND COMFORT
DYSPHAGIA DIET

Clients with dysphagia are at risk for aspiration and aspiration pneumonia. Dietary modifications and swallowing
rehabilitation measures can reduce the risk of aspiration in clients who can tolerate oral feedings. Specific techniques
include the following:

o Modification of food consistency (pureed, mechanically altered, soft)

o Thickened liquids
o Having the client sit upright at a 90-degree angle
o Placing food on the stronger side of the mouth to aid in bolus formation
o Tilting the neck slightly to assist with laryngeal elevation and closure of the epiglottis

Some clients who have suffered a cerebrovascular accident (CVA) are also left with visual impairment such
as hemianopsia; in this condition, a person sees only a portion of the visual field from each eye. A client with a right-
sided CVA may have left-sided hemianopsia. Having the client turn the head during a meal will help the client see
everything on the plate
Adding milk to mashed potatoes will alter the consistency; if the consistency is too thin, the client will be at increased
risk of aspiration.
Using a straw for drinking liquids might cause increased swallowing difficulty and choking. Controlling liquid intake
through a straw is more difficult than drinking straight from a cup or glass.

BREAST PROSTHESIS

A breast prosthesis is an artificial appliance that is fitted to the external chest wall or inserted into a female client's
undergarments to simulate previous symmetry after a mastectomy or breast trauma.
 This is an option for clients who are not interested in, or are not candidates for, breast reconstruction surgery. This
appliance assists in the promotion of well-being, body image, and sexuality.
When evaluating the use of a breast prosthesis, nurses should assess the client for body image disturbance using
open-ended questions and therapeutic communication
NON-THERAPEUTIC COMMUNICATION TECHNIQUES
THERAPEUTIC COMMUNICATION

INTERPRETER

Clients from many cultures will be more responsive if the interpreter is the same gender, especially when the condition
is highly personal or sensitive
The nurse should maintain good eye contact when communicating with the client. The interpreter should translate the
client's words literally.
Communication is with the client, not the interpreter. The nurse should use basic English rather than medical terms,
speak slowly, and pause after 1-2 sentences to allow for translation
Providing simple instructions about upcoming actions in the order they will occur will be easier for the client to
understand. For example, the nurse can indicate that there will be surgery and then a follow-up visit as opposed to,
"You'll follow up with the health care provider after your procedure"
 The nurse should obtain feedback to be certain that the client understands. This feedback should extend beyond
nodding as some people nod to indicate that they are listening or nod in agreement to "save face" even though they do
not understand. It is better to use a tactic such as having the client repeat back information (which is then translated
into English).
Using a fee-based agency or language line is preferred if an appropriate bilingual employee is not available. The client
may not want the friend/relative to know about this personal situation, or the person may not be able to adequately
translate medical concepts and/or understand client rights.

BENEFICENCE

Beneficence is the ethical principle of doing good. It involves helping to meet the client's (including the family)
emotional needs through understanding. This can involve withholding information at times.
Stating that the client is critically ill and is being cared for meets the ethical principle of veracity (telling the truth) but
also avoids overwhelming the family before they travel to the hospital. The nurse does not want the family to be too
distressed to process the situation and arrive safely.

PRINCIPLES OF CULTURALLY COMPETENT CARE

All clients have cultural influences that can affect their beliefs and concerns about causes of medical conditions and
expectations for treatment.
The nurse should have clients express what caused their medical illnesses or problems to gain knowledge of
their beliefs and understandings about the conditions; this is fundamental to developing a culturally sensitive and
appropriate teaching and care plan.
Culturally competent care requires the nurse to recognize that the client's interpretation of an illness is more
significant than the nurse's knowledge of the illness.
Clients' beliefs about health and disease may be complex and tightly rooted in centuries-old traditions.
Some clients welcome scientific explanations about their conditions, whereas others ignore a nurse's teaching that
does not align with their personal perspectives.
The nurse must never assume that a client knows (or does not know) about a subject; accurate assessment about
knowledge and beliefs is necessary.
Culturally competent nursing care involves recognizing certain cultural and religious beliefs.
A health-related belief of Jehovah's Witnesses is that transfusions containing blood in any form are not acceptable.
Witnesses do not accept transfusions of whole blood or any of its 4 major components (ie, red cells, white cells,
platelets, and plasma
Shock prevention is a major concern in the setting of blood loss and can be accomplished with the use of non-blood
volume expanders such as saline, lactated Ringer's, dextran, and hetastarch. These can be administered safely to
clients who refuse blood products
Recombinant human erythropoietin (eg, epoetin alfa) and IV iron are accepted by most Jehovah's Witnesses. These
medications stimulate the bone marrow to produce more red blood cells, resulting in increased hematocrit and
hemoglobin levels
To provide culturally competent care, it is important for the nurse to realize that in many Arab cultures, a man is not
allowed to be alone with a woman other than his wife. It may also be inappropriate for a female health care worker
to physically care for him; however, in some instances, direct physical care from the opposite sex is allowed if a third
party is present.
Eye contact varies greatly among cultural groups. Some cultures (eg, Arab, Asian, Native American) view eye contact
as a sign of disrespect or aggressiveness. This could be a concern with this client, but it is not as high a priority as
respecting the client's cultural beliefs of not being alone in the same room with a member of the opposite sex.
Some cultures (eg, Native American, Asian) are comfortable with silence and see it as a sign of respect, privacy, or
respect for elders.
In some Asian and Hispanic cultures, the head is thought to be the basis of one's strength or soul, and touching a
person's head is considered disrespectful.

The culturally competent nurse is aware that some alternative medicine practices of nondominant cultures in North
America can present with dermatologic findings.
Markings that appear to be human bites would require further follow-up as these are not common in alternative
medicine.
Although nurses should be aware of various cultural practices, any marks consistent with child abuse (eg, bite marks,
cigarette burns, bruises in various stages of healing) should be reported to the appropriate authorities.
Garlic application involves placing crushed garlic directly on the skin. It is thought to heal infections but can cause
contact dermatitis and burns on the wrists. This is appropriate to include in a culturally competent care in-service.
Cupping is used by many cultures to remove illness from the body. The mouth of a steam-filled cup is placed on the
skin, causing circular, bruised blemishes. This is appropriate to include in a culturally competent care in-service.
 Coining is believed by some cultures (eg, Chinese, Vietnamese) to remove illness from the body. A rounded surface
(eg, coin, spoon) is firmly stroked on the lubricated skin of the back and can produce weltlike linear lesions. This is
appropriate to include in a culturally competent care in-service.

S/P MASTECTOMY

Immediately after mastectomy surgery, the client is placed in a semi-Fowler's position with the affected side's arm and
hand elevated on several pillows to promote drainage and prevent venous and lymphatic pooling.
Flexing and bending of the affected side's fingers is begun immediately with gradual increase in arm movement over
the next few postoperative days.
Postoperative arm and shoulder exercises are initiated slowly with the goal of full range of motion of the affected side
within 4-6 weeks of the mastectomy.

QUALITY IMPROVEMENT PROGRAM

Measurements should be objective, rather than subjective. Evidence-based criteria should be used, if applicable.
These survey results are objective, retrospective measurements of a positive change.

HOSPICE CARE

The goal of end-of-life care is comfort and quality of life. In many cases, clients may be more comfortable when they
do not eat or drink.
Anorexia is a common complication in clients who are dying and may be exacerbated by many factors (eg,
medication, anxiety, underlying disease).
The client should be allowed to refuse food and drink.
However, the nurse can implement strategies to stimulate appetite or alleviate symptoms associated with anorexia,
including:
o Assessing the need for analgesia, antiemetic medications (eg, ondansetron), and appetite stimulants (eg, dexamethasone,
megestrol acetate, dronabinol) to enhance client comfort and increase intake
o Involving the client in meal planning to encourage autonomy and helping the client select foods that are preferred and well
tolerated, regardless of nutritional value, to increase appetite and oral intake
 o Providing opportunities for meals with friends/family outside of the client's room, if possible, to promote stimulation and
enjoyment
o Providing oral care frequently, especially after eating, and using topical treatments to minimize oral discomfort and dry mouth

DEHISCENCE

Dehiscence is a complication of poor wound healing that occurs when the edges of a surgical wound fail to
approximate and separate (ie, partial or total separation of the skin and/or tissue layers).
Dehiscence is associated with factors that impair circulation, tissue oxygenation, and wound healing (eg, diabetes,
smoking, obesity, advanced age, malnutrition, infection, steroid use) and with mechanical stress on the wound (eg,
straining to cough, vomit, or defecate).
Interventions to prevent abdominal wound dehiscence include:

o Administering stool softeners (eg, docusate) to prevent straining and constipation from postoperative immobility and opioid
pain medications
o Administering antiemetics (eg, ondansetron) as needed for nausea to prevent straining that can occur with vomiting
o Applying an abdominal binder to provide hemostasis, support the incision, and reduce mechanical stress on the wound when
coughing and moving
o Monitoring blood sugar to maintain tight glycemic control (<140 mg/dL [7.8 mmol/L] fasting glucose; <180 mg/dL [10
mmol/L] random glucose) to decrease infection risk and promote wound healing
o Splinting the abdomen by holding a pillow or folded blanket against the wound for support when coughing and moving

(Wound healing requires adequate caloric and protein intake. Although this client is obese and needs education to
promote weight loss, caloric restriction could delay wound healing.
PRESSURE INJURIES
Pressure injuries develop from external pressure compressing capillaries and underlying soft tissue, or from friction
and shearing forces.
The nurse should assess every client's risk for pressure injuries (using the Braden scale) upon admission and at least
once daily during hospitalization. To prevent pressure injuries:

o Use emollients and barrier creams to hydrate, protect, and strengthen the skin
o Use foam padding on chairs, commode seats, and other surfaces to help reduce pressure on bony prominences
o Provide prompt incontinence care and use additional barrier cream to keep skin clean and dry; this will further help reduce
irritation and associated breakdown of the skin
o Reposition clients with a turn sheet every 2 hours using devices (eg, pillows, foam wedges) to maintain position; avoid
pulling/dragging the client up in bed, as shearing can occur.

Massage is not an acceptable intervention for pressure injury prevention as it can lead to deep tissue damage. It is
contraindicated in the presence of inflammation, damaged blood vessels, or fragile skin.
POST-OPERATIVE COGNITIVE DYSFUNCTION

Clients who have undergone surgery (eg, coronary artery bypass graft) may experience some postoperative
cognitive dysfunction (POCD).
This may include memory impairment and problems with concentration, language comprehension, and social
integration.
Some clients may cry easily or become teary. The risk for POCD increases with advanced age and in clients with
preexisting cognitive deficits, longer operative times, intraoperative complications, and postsurgical infections. POCD
can occur days to weeks following surgery.
Most symptoms typically resolve after complete healing has occurred. In some cases, this condition can become a
permanent disorder

POST-MORTEM CARE

Postmortem care is conducted with respect and dignity. The nurse should provide opportunities for family
participation and accommodate religious and cultural rituals when possible
 To perform postmortem care:

o Maintain standard or isolation precautions in place at the time of death.

o Gently close the client's eyes
o Remove tubes and dressings per policy, unless an autopsy or organ harvest is pending.
o Straighten and wash the body and change the linens. Handle the body carefully, as tissue damage and bruising occur easily
after circulation has ceased.
o Leave dentures in place, or replace if removed, to maintain the shape of the face; it is difficult to place dentures once rigor
mortis sets in. A towel folded under the chin may be needed to keep the jaw closed.
o Place a pad under the perineum to absorb any stool or urine leaking from relaxed sphincters
o Place a pillow under the head to prevent blood from pooling and discoloring the face.
o Remove equipment and soiled linens from the room.
o Give client's belongings to a family member or send with the body.

ORTHODOX JEWISH FAITH

Members of the Orthodox Jewish faith observe strict dietary laws that dictate whether certain foods and
medications are considered kosher (fit to be consumed).
Most capsules are coated in gelatin, a substance made from the collagen of animals, which is generally
considered nonkosher.
The nurse should first ask the pharmacist if an equivalent, gelatin-free form of the medication (eg, tablets) is available.
If no alternate form is available, the client may want to consult with a rabbi as laws may be relaxed for those who are
ill.
Individuals who practice Orthodox Judaism follow Kosher dietary laws. These regulations are strict regarding the
consumption of certain animal products (eg, no pork, shellfish, fish without scales) and the separation of
meat/poultry from dairy.
When meat or poultry is consumed, at least 3-6 hours must pass before a dairy product is consumed.
Certain foods, including fresh fruits and vegetables, grains, tea, and coffee, are considered neutral and can be
consumed at any time.
Hard-boiled eggs and blueberries are nondairy foods and would be an appropriate snack. This choice also provides a
combination of carbohydrates and protein, which would help in regulating blood glucose.
HEAT EXHAUSTION

Heat exhaustion is the result of prolonged exposure to excessive heat. Heat exhaustion manifests with elevated
body temperature (hyperthermia), intravascular volume depletion, and electrolyte imbalance.
Manifestations include dizziness, weakness, fatigue, sweating, flushing, nausea, tachycardia, and muscle
cramping.
If heat exhaustion is suspected, the client should be moved to cooler temperatures and provided a cool sports
drink, another electrolyte-containing beverage (eg, Gatorade), or water
The priority is to lower the body temperature to prevent heat stroke, a potentially fatal condition associated with
mental status changes (ie, indicating brain damage) and additional organ damage (eg, kidney injury, rhabdomyolysis).
If the client's temperature continues to rise after moving to cooler temperatures, ice packs placed on the axilla and
groin may help to dissipate heat; further medical help may be necessary.
The client should not leave until the symptoms subside, especially if driving. It is not necessary to have the client visit
a health care provider if symptoms resolve.
Assessment can be continued once the client has been moved to a cooler environment and provided with hydration.
Alcohol consumption may compound heat exhaustion but does not change initial management of the client.

TEACHING STRATEGIES

The nurse needs to consider several factors when selecting teaching strategies; these include client characteristics
(eg, age, educational background, language skills, culture), subject matter, and available resources. Learning can be
improved as follows:

o Using pictures and simplified text is beneficial to the older adult with low literacy.
o Including a family member in the teaching process will assist the client in reinforcement of the material at a later date.
o Professionally produced programs are beneficial as they contain high quality visual content as well a delivery of auditory
content in lay person's language.

Older adults are using the internet in increasing numbers as are clients with low literacy. Several organizations are
developing and promoting user-friendly websites. Society in general relies heavily on web-based health information. It
is important for the nurse to teach the client and possibly supply a list of reputable sites for the client to view.
Unless the client is hard of hearing, speaking slowly and loudly is unnecessary and demeaning.
SLEEP HYGIENE

Sleep hygiene refers to a group of practices that promote regular, restful sleep. The nurse should encourage clients
who have trouble sleeping (insomnia) to maintain good sleep habits. A primary objective is reducing stimuli in the
bedroom. Clients should be taught to avoid non sleep-related activities (eg, reading, television, working) other
than sex in bed. Relaxed reading before bed is helpful for stimulating sleep but should occur in a different setting,
not in bed
The nurse should encourage the following healthy sleep habits:

o Avoid caffeine, nicotine, and alcohol within 4-6 hours of sleep

o Exercise daily but avoid exercise or strenuous activity within 4-6 hours of sleep
o Avoid going to bed hungry or eating a heavy meal just before bed
o Practice relaxation techniques (eg, deep breathing) if stress is causing insomnia

It is best to avoid naps during the day, especially later in the day. Any naps taken should be short (20-30 min).
The client should keep the bedroom slightly cool, quiet, and dark for comfort.
As much as possible, the client should develop a consistent sleep-wake pattern (ie, same bedtime and wake time each
day) to obtain 7-8 hours of sleep nightly.

FECAL INCONTINENCE

Disruptions of motor function (anal sphincter and rectal floor muscle dysfunction) and/or sensory function (lack of urge
to defecate or inability to sense stool) can result in fecal incontinence.
The presence of stool can lead to skin breakdown, urinary tract infections, spread of infection (eg, Clostridium difficile),
and contamination of wounds. Therefore, maintenance of perineal and perianal skin integrity is the highest priority.
Stool should be removed promptly from the skin by gently cleansing the perineum and perianal area with mild soap.
Dry the soiled area and apply a thick moisture barrier product to the skin. Clean, dry linens and clothing should be
provided.
Wound care and incontinence specialists are useful resources in developing a bowel and/or incontinence management
plan; however, the highest priority is promotion of skin integrity.
 Rectal tubes and other indwelling containment devices can cause skin/mucosal breakdown, decreased response of
the anal sphincter, and infection. Skin integrity may be maintained without the risks associated with these devices;
however, if other measures fail, these devices may be used.
Absorptive incontinence products (eg, pads, undergarments) can be used after interventions to prevent incontinence
and maintain perineal hygiene have failed.
Incontinence products such as adult briefs may cause chemical irritation of the skin, further exacerbating skin
breakdown. These products should wick moisture away from the client's skin.
INFILTRATION

During IV therapy, the nurse should monitor the site to assess for patency and signs of infection (eg, redness,
drainage, edema, discomfort, warmth, coolness, hardness).
Infiltration is a complication that occurs when solution infuses into the surrounding tissues of the infusion site.
Interventions include:

o Discontinuing the IV line immediately and starting a new IV, preferably on the opposite extremity
o Continuing to monitor the infiltration site for swelling or other abnormalities (eg, redness, warmth, coolness)
o Elevating the affected extremity to decrease swelling
o Notifying the health care provider if severe complications (eg, cellulitis, tissue necrosis, nerve damage) develop
o Applying a cold or warm, moist compress based on the solution infiltrated. Heat is avoided when extravasation of a
vesicant (ie, drug capable of causing tissue necrosis) occurs.

Peripheral IV sites should be changed no more frequently than every 72-96 hours unless complications develop. This
client's IV line will likely be discontinued at discharge and is not the highest priority.
It is important to flush saline locks every 8-12 hours as prescribed. However, this client is not the highest priority.
An IV infusing at 20 mL/hr will take 5 hours to complete when 100 mL remain in the bag.

PSYCHOSOCIAL CARE

Family member presence at bedside during invasive procedures or resuscitation efforts is an important component
of psychosocial care for the client and family.
When a client's support person is allowed to be present at bedside to witness care during acute events, the support
person is often able to better understand the client's condition and may have decreased anxiety and better
 coping with unexpected or poor outcomes (eg, cardiac arrest, death). Therefore, the nurse should, when possible,
support and facilitate family presence in the room and provide information about the events that are occurring
Requiring family members to watch through the window, rather than at the bedside, may increase their stress and
impair coping. Although chaplains may assist with an individual's emotional or spiritual needs, chaplains are not
trained to provide information related to medical or surgical interventions.
Denying the support person's presence in the room may be appropriate in certain situations (eg, uncontrollable
emotional outbursts, interference with care, risks to support person health/safety). However, the nurse should provide
the option of being present in the room when possible.
Although some health care professionals express concern that support person presence may negatively impact client
outcomes, there is no evidence for this claim.

Alzheimer disease (AD) is a progressive neurodegenerative disease that causes reduced cognitive function
(dementia) in older individuals (most commonly age >60).
Conversation becomes progressively more difficult, and the client experiences word-finding difficulty. The best way for
the nurse to obtain information and communicate is to use simple statements and questions
Facing the client allows the client to visualize the speaker's face and helps reduce distraction
Providing a quiet environment (eg, turning off the television, closing the door) removes competing or distracting
stimuli
Asking open-ended questions is a valuable communication technique for collecting information from most clients, but it
may confuse the client with AD. The nurse should instead ask simple, direct questions.
AD results in a reduction in cognitive function. Speaking loudly does not improve comprehension and may increase
anxiety and confusion.

INCISIONS

Incisions may take 4-6 weeks to heal. The nurse should instruct clients on how to care for their incisions; these
instructions are as follows:

o Wash incisions daily with soap and water in the shower. Gently pat dry
o Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves
 o Tub baths should be avoided due to risk of introducing infection
o Do not apply powders or lotions on incisions as these trap the bacteria at the incision
o Report any redness, swelling, and increase in drainage or if the incision has opened
o Wear a supportive elastic hose on the legs. Elevate legs when sitting to decrease swelling

NEGATIVE PRESSURE WOUND THERAPY

Negative-pressure wound therapy is the application of negative pressure to a wound to enhance bacteria and
exudate removal.
Negative pressure promotes healing by stimulating cell growth and vessel perfusion in the wound bed.
Medications are administered preprocedure to prevent discomfort
After wound cleansing, a skin protectant is applied around the wound to prevent breakdown and promote an air-tight
seal
A sterile foam dressing is cut to fit the wound shape and size and is placed in the wound bed. An occlusive dressing
large enough to extend 1.2-2 inches (3-5 cm) beyond the wound edges is applied to create a seal. Then a vacuum-
assisted closure unit is connected to create negative pressure. The foam dressing should compress when the device
is turned on, indicating a proper seal and functioning equipment
The foam dressing is placed using sterile, not clean, technique to prevent wound contamination.
The foam dressing is cut to the size of the wound bed but is never cut directly over it because material can fall into the
wound or injure the client.

EAR IRRIGATION

Ear irrigation may be prescribed to remove impacted or excess cerumen; the following steps describe this procedure:
1. Assess client for contraindications (eg, fever, ear infection). Use an otoscope to inspect the external ear canal. Verify that
the tympanic membrane is intact and ensure there are no foreign bodies
2. Explain the procedure to the client, including possible sensations (eg, vertigo, fullness, warmth).
3. Place the client in a side-lying or sitting position with the head tilted toward the affected ear . Place a towel and an emesis
basin under the ear
4. Verify that the irrigation solution is at body temperature (98.6 F [37 C]) to minimize discomfort.
5. Straighten the ear canal, pulling the pinna up and back for
 6. Irrigate gently with a slow, steady flow of solution, directing the syringe tip toward the top of the ear canal. Avoid occluding
the canal to prevent increased pressure and rupture of the tympanic membrane. Stop immediately if the client experiences
severe pain, nausea, or dizziness.
7. Repeat as tolerated until the ear canal is clear or the prescribed amount is instilled.
8. Document the type, temperature, and volume of solution; exudate characteristics; response to the irrigation; and client
teaching.

BLIND PATIENT

The nurse should create a therapeutic and safe environment for the client who is blind while fostering as
much independence as possible. Nursing interventions include the following:

o Offer the client an elbow for guidance while walking slightly ahead and describing the environment
o Announce room entry and exit to orient and avoid startling the client
o Describe the location of items (eg, food, hygiene supplies) using a clock-face orientation so the client can find them easily
o Instruct the client to use a cane with the dominant hand and to sweep areas in front from side to side for orientation.

Orient the client to the room and maintain this orientation for safety.
Asking the caregiver or family member about the client's personal preferences does not promote independence or self-
advocacy. The nurse should ask the client directly about the desired room arrangement.
The nurse should speak to the client in a normal tone of voice to facilitate communication. Speaking slowly and
slightly louder would be useful for a client with a hearing deficit.

OXYGEN MASK

The Venturi mask is a high-flow device that delivers a guaranteed oxygen concentration regardless of the client's
respiratory rate, depth, or tidal volume (TV). The adaptor or barrel can be set to deliver 24% 50% (varies with
manufacturer) oxygen concentration. In the presence of tachypnea, shallow breathing with decreased TV,
hypercarbia, and hypoxemia, it is the most appropriate oxygen delivery device for this client as rapid changes in
inspired oxygen concentration can blunt the hypoxemic drive to breathe in clients with COPD.
 The nasal cannula can deliver adequate oxygen concentrations and is best for clients with adequate TV and normal
vital signs. It is not the best choice in an unstable COPD client with varying TVs because the inspired oxygen
concentration is not guaranteed.
The non-rebreathing reservoir mask can deliver 60% 95% oxygen concentrations and is usually used short term. It is
often used for clients with low saturations resulting from asthma, pneumonia, trauma, and severe sepsis; it is not the
most appropriate device for a COPD client in this situation.
An oxymizer is a nasal reservoir cannula-type device that conserves on oxygen use. Clients can be sustained on a
prescribed oxygen level using much less oxygen (eg, 3 L/min nasal cannula is equivalent to 1 L/min oxymizer device)
to reach the same saturation. It is not the best choice in an unstable COPD client with varying TVs as the inspired
oxygen concentration is not guaranteed.
OXYGEN
Oxygen is a colorless, odorless gas that supports combustion and makes up about 21% of the atmosphere. Oxygen
is not combustible itself, but it can feed a fire if one occurs. When using home oxygen, safety precautions are
imperative.
1. Vaseline is an oil-based, flammable product and should be avoided. A water-soluble lubricant may be used instead.
2. Oxygen canisters should be kept at least 5-10 feet away from gas stoves, lighted fireplaces, wood stoves, candles, or other
sources of open flames. Clients should use precautions as cooking oils and grease are highly flammable.
3. The prescribed concentration of oxygen, usually 24%-28% for clients with COPD, should be maintained. Oxygen is
prescribed to raise the PaO2 to 60-70 mm Hg and the saturations from 90%-93%. A flow rate of 2 L/min provides
approximately 28% oxygen concentration, and 6 L/min provides approximately 44%. Higher rates usually do not help and
can even be dangerous in clients with COPD as they can decrease the drive to breathe. The client should notify the care
provider about excessive shortness of breath as additional treatment may be indicated.
The client understands that nail polish remover and nail polish contain acetone, which is highly combustible.
Clients should avoid synthetic and wool fabrics because they can cause static electricity, which may ignite a fire in
the presence of oxygen. Clients should use cotton blankets and wear cotton fabrics.
 FUNDAMENTALS
MEDICATION ADMINISTRATION
EARDROPS

When administering an otic medication to an adult or child age 3 and older, the pinna is pulled upward and back to
straighten the external ear canal.
For an infant, the pinna is pulled downward and straight back.
The child should be placed in the prone or supine position with the head turned to the appropriate side.
Otic medication should be warmed to room temperature if removed from a refrigerator prior to administration. Holding
the bottle in the palm of the hand is an effective method of warming. Instilling cold drops into the ear can cause a
vestibular reaction, resulting in dizziness and vomiting.
The medication dropper should be held near the entrance to the ear canal without touching it. This technique allows
the drops to fall against the wall of the canal, reducing discomfort while avoiding contamination of the dropper.
After instilling the drops, the child should remain with the affected ear up for several minutes to allow full coverage of
the medication.
Otic medications are used to treat infection, soften cerumen for later removal, and facilitate removal of an insect
trapped in the ear canal. They are contraindicated in a client with a perforated eardrum.
The general procedure for instilling ear drops includes the following steps:
1. Perform hand hygiene and don clean gloves. The ear canal is not sterile, but aseptic technique is used
2. Position the client side-lying with the affected ear up (if not contraindicated). This facilitates administration and prevents
drops from leaking out of the ear
3. Warm ear drops to room temperature (ie, use hand or warm water) to help avoid vertigo, dizziness, or nausea as the internal
ear is sensitive to temperature extremes
4. Pull the pinna up and back to straighten the ear canal in clients >4 years old and adults. Pull the pinna down and back in
clients <3 years old
 5. Support hand on the client's head and instill the prescribed number of drops by holding the dropper 1 cm (1/2 in) above the
ear canal. This avoids damaging the ear canal with the dropper
6. Apply gentle pressure to the tragus (fleshy part of external ear canal) if it does not cause pain, which facilitates the flow of
medication into the ear canal
7. Instruct the client to remain side-lying for at least 2-3 minutes to facilitate medication distribution and prevent leakage
8. Place a cotton ball loosely in the client's outermost ear canal for 15 minutes, only if needed, to absorb excess medication.
Perform this with caution and avoid in infants or very young clients as it is a choking hazard
PARENTERAL ADMINISTRATION
When reconstituting a powdered medication for parenteral administration, the nurse should:
1. Perform hand hygiene and don clean gloves prior to handling medication. This is a universal practice for aseptic handling of
any medication. Cleanse the vial top with alcohol and let it dry to prevent possible microbial contamination.
2. Withdraw an amount of air from the vial equal to the prescribed amount of diluent to create negative pressure that will be
equalized when the diluent is injected into the vial. The medication manufacturer will specify the needed amount and type of
diluent
3. Inject the appropriate diluent (eg, sterile saline, sterile water) into the vial. The diluent reconstitutes the medication by
dissolving the powder Roll the vial
4. between the palms of the hands to gently mix the solution. Avoid shaking the vial as bubbles may develop, making
withdrawal of the reconstituted medication difficult
5. Withdraw the reconstituted medication from the vial into a sterile syringe for administration. Verify the dosage by checking
the prepared medication against the medication administration record and medication label.
6. Label the syringe with the medication name and dosage to prevent medication errors at the bedside
Parenteral medications are administered via injection into body tissues using aseptic technique (eg, intradermal,
intramuscular, subcutaneous, IV).
Intradermal
Administer injections at a 5- to 15-degree angle to reduce risk of injection into subcutaneous tissue
Apply firm pressure to the injection site to reduce bleeding. Massaging the site introduces medication into deeper tissues
and should be avoided
Subcutaneous

Administer injections at 90 degrees if 2 in (5 cm) of subcutaneous tissue can be grasped or at 45 degrees if only 1 in (2.5
cm) can be grasped

Intramuscular

Acceptable sites include the deltoid, vastus lateralis, and ventrogluteal. The ventrogluteal is preferred as fewer large blood
vessels and nerves are present.
Position the client supine, prone, or side-lying with the knee and hip flexed when administering ventrogluteal injections.
Flexing the knee and hip reduces muscle tension, improves access, and promotes client comfort
A filter needle must be used when withdrawing medication from a glass ampule to prevent aspiration and injection of glass
shards. After the medication is withdrawn, the filter needle is discarded and an injection needle (eg, 20-gauge, 1-in [2.5-cm]
needle) is attached to the syringe.

SUBCUTANEOUS INJECTION

The injection should be made on the right or left side of the abdomen, at least 2 in from the umbilicus. An inch of
skin should be pinched up and the injection made into the fold of skin with the needle inserted at a 90-degree angle.
 When administering subcutaneous anticoagulant injections (eg, heparin, enoxaparin), the nurse must select the
appropriate needle length and angle to avoid accidental intramuscular injection, especially in clients
with insufficient adipose tissue (eg, cachexia).
Intramuscular injection of heparin would cause rapid absorption, resulting in a hematoma and painful muscle irritation.
The nurse should administer subcutaneous injections at 90 degrees if 2 in (5 cm) of subcutaneous tissue can be
grasped, or at 45 degrees if only 1 in (2.5 cm) can be grasped.
Anticoagulants are best absorbed if administered in the abdomen at least 2 in (5 cm) away from the umbilicus.
INJECTION
NG TUBE MEDICATION ADMINISTRATION

CASE: The nurse plans to administer 9:00

AM medications via the nasogastric (NG)
route to a client with an NG tube. The nurse
contacts the primary health care provider
(PHCP) to clarify which prescriptions that are
contraindicated using this route?

ANS:
ENTERIC COATED IBUPROFEN 200MG
TABLET
METOPROLOL EXTENDED RELEASE
50MG TABLET
TAMSULOSIN 0.4MG SLOW RELEASE
CAPSULE
Enteric-coated drugs have a barrier coating that dissolves at a slower rate (usually in the small intestine) to protect
the stomach from irritant effects. Crushing enteric-coated medications (eg, ibuprofen) disrupts the barrier coating and
may cause stomach irritation. In addition, the particles from the coating may clog the NG tube, particularly small-
bore NG tubes.
Slow-, extended-, or sustained-release drug formulations are designed to dissolve very slowly within a specific time
frame. Crushing these medications alters this property and introduces the risk of adverse effects from toxic blood
levels due to more rapid drug absorption. Therefore, the nurse should first contact the PHCP for clarification.
Double- and extra-strength drugs such as sulfamethoxazole and acetaminophen may be crushed and administered
separately through an NG tube as long as they are not enteric-coated. The nurse should flush the tube with water
before and after each drug administration.
PATIENT CONTROLLED ANALGESIA
Patient-controlled analgesia (PCA) delivers a set amount of IV analgesic each time the client presses the
administration button. With many PCA pumps, a continuous IV solution (eg, normal saline) is required to keep the
vein open and flush the PCA medication through the line so that the boluses reach the client.
Many facilities have a policy regarding IV fluid for use with PCA; however, a prescription may be required.
To ensure uninterrupted delivery of this client's PCA, the nurse should contact the health care provider to clarify the
prescription to discontinue the normal saline.
A "keep-vein-open" rate (eg, 5-20 mL/hr) may be appropriate; however, a prescription is necessary before the nurse
can implement this.
This client is still receiving PCA, so it is inappropriate to convert the IV to a saline lock. In addition, this does not
address the need to flush the PCA medication through the line.
Continuous IV fluids may be required to deliver the PCA boluses; before discontinuing the normal saline, the nurse
should receive clarification from the health care provider.

RECTAL SUPPOSITORY
 Pediatric administration of rectal suppositories is similar to the adult technique, with a few key modifications due to
the small size of a child's colon and varying developmental needs.
Age-appropriate explanations and/or distractions should be implemented to reduce distress.
Toddlers and infants may benefit from distraction with a toy; preschoolers and older children can be instructed to take
deep breaths or count during the procedure.
Basic steps for suppository administration include the following:

1. Apply clean gloves and position the client appropriately based on age and size (eg, infant supine with knees and feet
raised, older child side-lying with knees bent)
2. Lubricate the tip of the suppository with water-soluble jelly. Petroleum-based products can reduce absorption.
3. Insert the suppository past the internal sphincter using the fifth finger if the child is under 3 years. Use of the index finger
may cause injury to the colon or sphincters in children younger than age 3 years.
4. Angle suppository and guide it along the rectal wall. The suppository should remain in contact with the rectal mucosa (and not
be buried inside stool) to ensure systemic absorption
5. Hold the buttocks together for several minutes, or until the urge to defecate has passed, to prevent immediate expulsion
6. If a bowel movement occurs within 10-30 minutes, observe for the presence of the suppository.

The suppository must be inserted past both the external and internal sphincters for proper placement. If not inserted
far enough, it may be expelled before achieving a therapeutic effect.
TIOTROPIUM MEDICATION

Tiotropium (Spiriva) is a long-acting, 24-hour, anticholinergic, inhaled medication used to control chronic
obstructive pulmonary disease (COPD).
It is administered most commonly using a capsule-inhaler system called the HandiHaler. The powdered medication
dose is contained in a capsule. The client places the capsule in the inhaler device and pushes a button on the side of
the device, which pokes a hole in the capsule. As the client inhales, the powder is dispersed through the hole.
Unlike most inhaled medications, tiotropium looks like an oral medication because it comes in a capsule. Therefore, it
is important to teach the client proper administration prior to the first dose, emphasizing that the capsule should not
be swallowed and that the button on the inhaler must be pushed to allow for medication dispersion. During future
appointments, the nurse should assess/reassess the client's ability to use this medication correctly.
Clients should rinse the mouth after using tiotropium and inhaled steroids (eg, beclomethasone, budesonide,
fluticasone) to remove any medication remaining in the mouth, which decreases the risk of developing thrush.
 Tiotropium is a controller medication for COPD with a peak effect of approximately 1 week; therefore, it should not be
used as a rescue medication. Instead, short-acting bronchodilators (eg, albuterol and/or ipratropium) should be used
for symptom rescue. Clients must discontinue ipratropium before taking tiotropium as both are anticholinergic.
Anticholinergic inhaled medications (eg, ipratropium, tiotropium, umeclidinium) do not reduce inflammation in the
airway. Instead, they relax the airway by blocking parasympathetic bronchoconstriction. They also help dry up airway
secretions.
CLONIDINE PATCH PLACEMENT
Clonidine is a potent antihypertensive agent and is available as a transdermal patch. The patches should be replaced
every 7 days and can be left in place during bathing.
Instructions for using the clonidine (transdermal) patch:

o Apply the patch to a dry hairless area on the upper outer arm or chest once every 7 days
o Do not shave the area before applying the patch. The skin should be free from cuts, scrapes, calluses, or scars
o Wash hands with soap and water before and after applying the patch as some medication may remain on the hands after
application.
o Wash the area with soap and water, then rinse and wipe with a clean, dry tissue.
o Remove the patch from the package. Do not touch the sticky side.
o Rotate sites of patch application with each new patch. Remove the old patch only when applying a new one. Do not wear
more than 1 patch at a time unless directed by your health care provider (HCP).
o When removing the patch, fold it in half with the sticky sides together. Discard the patch out of the reach of children and
pets. Even after it has been used, the patch contains active medicine that may be harmful if accidentally applied or ingested
o Notify the HCP if you are experiencing side effects such as dizziness or slow pulse rate. Do not remove the patch without
discussing this with the HCP as rebound hypertension can occur
IV SOLUTIONS

FENTANYL PATCHES
Fentanyl, a potent opioid analgesic, is administered IV to treat acute pain and as a transdermal patch (Duragesic)
dosed in mcg/hr to treat chronic pain.
When given via transdermal patch, fentanyl is absorbed systemically through the skin to provide continuous
analgesia.
Patches are replaced every 72 hours, and the used patch must be removed before applying a new one
Used patches must be folded and discarded immediately, as some medication remains in a used patch.
Opioid medications must be stored and disposed of securely (eg, flushed down the toilet, discarded in a sharps
container) as accidental exposure is potentially fatal for children, pets, and caregivers
Heat (eg, heating pad) should not be placed over a patch as this accelerates absorption.
 Cutting a transdermal patch damages the drug-delivery system, results in administration of an imprecise dose, and
risks exposure to the person cutting the patch.
Transdermal patches should be applied to an area of flat, intact skin (eg, upper back, chest) to prevent accidental
removal. The site should be clean, with little hair. Unlike transdermal patches, topical analgesic patches (eg,
lidocaine, capsicum) deliver drug locally and are placed near the site of pain.
OPHTHALMIC OINTMENT
Ophthalmic lubricants (drops, ointment, gel) replace tears and add moisture to the eyes. They are prescribed to treat
dry eyes, a common symptom in clients with Sjögren's syndrome, an autoimmune disorder.
Administering an ophthalmic ointment by tightly closing the eyes and rubbing the lid for 2-3 minutes can squeeze the
ointment out of the eye and cause injury. The client is taught to gently close the eyes for 2-3 minutes to distribute the
medication after applying the ointment.
This statement indicates the client's understanding that when self-administering the medication, the client should
squeeze a thin strip of ointment onto the lower eyelid, from the inner to the outer edge, and without letting the tube
touch the eye to prevent contamination.
This statement indicates the client's understanding that when self-administering the medication, the client tilts the head
back, pulls the lower lid down, and looks toward the ceiling to help decrease blink reflex.
Some clients use the ophthalmic ointment at bedtime and the eye drops during the day due to blurred vision that
ointments and gels can cause.
If applicable, the nurse requests that the client remove contact lenses. The nurse then dons clean gloves and uses
aseptic technique to administer ophthalmic medications (eg, eye drops, lubricant) that lubricate the eye and treat eye
conditions (eg, glaucoma, infection). The Joint Commission disallows the use of abbreviations for right eye (OD), left
eye (OS), and both eyes (OU). The nurse must verify the prescription if the health care provider (HCP) uses these
abbreviations.
The general procedure for the administration of ophthalmic medications includes the following steps in sequence:
1. Remove dried secretions with moistened (warm water or normal saline) sterile gauze pads by wiping from the inner to
outer canthus to keep eyelid and eyelash debris from entering the eye and to prevent transfer of debris into the lacrimal
(tear) duct
 2. Place client in the supine or sitting position with head tilted back toward side of the affected eye to prevent excess
medication from flowing into the lacrimal duct and minimize systemic absorption through the nasal mucosa
3. Rest hand on client's forehead and hold dropper 1-2 cm (1/2-3/4 in) above the conjunctival sac, which keeps the dropper
away from the eye globe and avoids contamination
4. Pull lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac
5. Instruct client to look upward and then instill drops of medication into the conjunctival sac. This minimizes the blink reflex
and retracts the cornea up and away from the conjunctival sac to avoid instillation onto the cornea
6. Instruct client to close the eyelid and move the eye around (if able). Then apply pressure to the lacrimal duct for 30-60
seconds if medication has systemic effects (eg, beta blocker, timolol maleate [Timoptic]). This will distribute the medication,
prevent overflow into the lacrimal duct, and reduce possible systemic absorption
7. Remove excess medication from each eye with a new tissue or gauze pad to prevent cross-contamination
8. Wait 5 minutes before instilling a different medication into the same eye

IV ADMINISTRATION
The priority when administering 2 IV medications concurrently is to determine drug compatibility. Incompatible drugs
given through the same IV line will deteriorate or form a precipitate. This change is visualized through either a color
change, a clouding of the solution, or the presence of particles.
If 2 or more drugs are not compatible, the nurse may consider inserting a second IV or consulting the pharmacist and
the health care provider to determine the safest and most beneficial plan for the client.
Assessing the IV site for complications (eg, infiltration, phlebitis) should always be performed before giving any IV
medication. This will be completed after determining drug compatibility.
Verification using 2 client identifiers pertains to the "right client" in the "6 rights" of medication administration. Drug
compatibility should be determined prior to entering the client's room and verifying identity.
Hand hygiene is a standard precaution taken before any type of client interaction to prevent contamination and
infection; hand washing will be completed after checking for drug compatibility.
NASAL SPRAY ADMINISTRATION
The proper positioning and administration of nasal sprays allow the medication to reach the nasal passages. When
educating a client on how to self-administer nasal sprays, the nurse teaches the client to:
o Assume a high Fowler's position with head slightly tilted forward
o Insert the nasal spray nozzle into an open nostril, occluding the other nostril with a finger
o Point the nasal spray tip toward the side and away from the center of the nose
o Spray the medication into the nose while inhaling deeply
o Remove the nozzle from the nose and breathe through the mouth
o Repeat the above steps for the other nostril
o Blot a runny nose with a facial tissue, but avoid blowing the nose for several minutes after instillation
 FUNDAMENTALS
SAFETY & INFECTION CONTROL

PPE DONNING
PPE REMOVAL

LATEX ALLERGY

People with latex allergy usually have a cross-allergy to foods such as bananas, kiwis, avocados, tomatoes,
peaches, and grapes because some proteins in rubber are similar to food proteins. Latex sensitivity increases with
exposure and should be suspected in the following situations:
 Allergic contact dermatitis (rash, itching, vesicles) developing 3 4 days after exposure to a rubber latex product. This is a type
IV hypersensitivity reaction (delayed onset).
Anaphylaxis - many cases of anaphylaxis have been reported in both medical and non-medical settings. These represent a type
I hypersensitivity reaction and should be treated with intramuscular epinephrine injections. Some common settings include:
o Glove use
o Procedures involving balloon-tipped catheters (eg, arterial catheterization)
o Blowing up toy balloons
o Use of bottle nipples, pacifiers
o Use of condoms or diaphragms during sex
Clients with severe allergies should wear a Medic Alert bracelet and carry an injectable epinephrine pen due to cross-
sensitivity with many food and industrial products that can be impossible to avoid.

CELLULITIS

Cellulitis is inflammation of the subcutaneous tissues that is typically caused by bacterial infection
(eg, Staphylococcus aureus, group A Streptococcus) resulting from an insect bite, cut, abrasion, or open wound.
Cellulitis is characterized by redness, edema, pain, and fever.
Nurses caring for clients with cellulitis should ensure that the affected extremity is elevated when the client is sitting
or lying down to promote lymphatic drainage. Flat or dependent positioning may worsen edema, which delays
recovery and contributes to pain
In addition, clients with weeping or draining wounds must be protected from prolonged exposure to moist or soiled
linens as this exposure promotes tissue injury and infection.
Applying warm compresses promotes circulation to the area of infection, alleviates discomfort, and helps reduce
edema.
Daily marking and dating of reddened areas assist with monitoring improvement or worsening of the infection.
Redness that progresses past the marked areas indicates ineffective antibiotic therapy and should be reported to the
health care provider.
Although standard precautions are typically sufficient for cellulitis, a gown and gloves are worn when contact with body
fluids (eg, urine, stool) or potentially infectious drainage is expected, such as during bathing.

PRE-OP NURSING RESPONSIBILITIES

 Nursing responsibilities prior to surgery include assessment, client teaching, and communication with the health
care provider. Client allergies and history are confirmed while baseline vital signs are collected. Other nursing
preoperative responsibilities include:

o Confirming that informed consent has taken place and signed documents are placed in the client's chart
o Encouraging the client to void to reduce the risk of retention in the immediate recovery period
o Ensuring that the client has been on NPO status to avoid aspiration during surgery and documenting when it started
o Witnessing and documenting preoperatively that the correct surgical site is marked by the surgeon with a permanent
marker. Verify this with the client, ensuring that surgery will take place on the correct side/site

If an IV line has not been started, an 18-gauge catheter is preferred. However, if a functioning IV line is already
present, a 20-gauge is acceptable. Blood products, if needed during surgery, can be transfused through a 20-gauge
catheter if necessary.

Clopidogrel (Plavix) is an antiplatelet medication that should be discontinued 5-7 days before surgery to decrease
the risk for excessive bleeding. The client took this drug 48 hours ago. Therefore, the nurse must notify the HCP.
The surgery may be postponed due to the increased risk for intra- and post-operative bleeding
All clients should try not to smoke for at least 24 hours before surgery to help prevent oxygenation problems.
The client takes gingko biloba to relieve symptoms of intermittent claudication; it was discontinued 2 weeks ago
because it can increase the risk for excessive bleeding.
Nonsteroidal anti-inflammatory drugs (NSAIDS) such as naproxen (Naprosyn) should be discontinued 7 days before
scheduled surgery as they can increase the risk for excessive bleeding. Acetaminophen can be taken to control pain
up until surgery.

NEUTROPENIC PRECAUTIONS
The following neutropenic precautions are indicated:

o A private room
o Strict handwashing
o Avoiding exposure to people who are sick
o Avoiding all fresh fruits, vegetables, and flowers
o Ensuring that all equipment used with the client has been disinfected
AIRBORNE PRECAUTIONS

Varicella (chickenpox) is a highly contagious infection characterized by a generalized rash of itchy, vesicular lesions.
Both chickenpox and shingles are caused by the varicella-zoster virus (VZV), which is transmitted through airborne
particles or contact with open vesicles.
For chickenpox and disseminated (widespread) shingles, the nurse should use precautions for both airborne
isolation (ie, N95 respirator mask), negative air pressure room) and contact isolation (eg, gown, gloves, disposable
equipment)
Once the vesicles have crusted, the client is no longer contagious, and isolation precautions may be discontinued
Rooms with negative air pressure are equipped with specialized air equipment that continuously filters air out of the
room and creates a negative pressure gradient that prevents infectious airborne particles from escaping through the
doorway
Pregnant health care workers should not be exposed to clients with TORCH infections (Toxoplasmosis, Other
[VZV/parvovirus B19], Rubella, Cytomegalovirus, Herpes simplex virus), as these infections can cause fetal
abnormalities
 Infectious agents that are spread by air currents are among the most contagious of pathogens. Therefore, clients
with airborne infections (measles, tuberculosis, varicella, severe acute respiratory syndrome) should be isolated
first using airborne precautions.
These infections are spread via very small particles that circulate in the air.
Clients with airborne infections are placed in an isolation room with negative pressure that provides air exchange or
with a high-efficiency particulate air filtration system.

CONTACT PRECAUTIONS

Clients with a health care-associated infection, such as methicillin-resistant Staphylococcus aureus, are placed
on contact precautions to prevent transmission of microorganisms.
Contact precautions include standard precaution measures in addition to use of a gown and gloves and single-client-
use equipment (eg, stethoscopes, blood pressure cuffs, thermometers).
Disposable or single-client-use equipment must not be shared between clients or transferred to other care areas.
Dedicated equipment should be kept in the room for client care, and then disinfected or discarded when no longer
needed
The urine specimen should be placed in a leak-proof specimen cup and then sealed in a biohazard bag before
transport to the laboratory.
To prevent specimen contamination and the introduction of bacteria into the client's urinary tract, the nurse should
scrub the Foley collection port with alcohol or chlorhexidine for 15 seconds before withdrawing a specimen.
Hand hygiene with an alcohol-based hand rub is recommended, unless there is visible soiling of the hands with body
fluids, or after contact with Clostridium difficile. In both situations, hand hygiene must be performed with soap and
water to thoroughly remove contaminants left behind by alcohol-based rubs.

Clostridium difficile is a highly infectious bacteria causing severe colitis in infected clients. When caring for a client
with C difficile, it is critical that the nurse implement contact isolation precautions to prevent transmission of
microorganisms between clients, including:

o Placing the client in a single-client room, if possible, or in a cohort with other clients infected with C difficile
o Wearing a single-use, disposable gown and clean gloves during all client care and discarding the equipment before leaving
the room
o Performing hand hygiene before and immediately after client care with soap and water
o Using dedicated medical equipment (eg, stethoscope, blood pressure cuff) that is not shared between clients and always
remains in the client's room

Clean, rather than sterile, gloves are required during care of a client with C difficile to prevent transmission of infection
to other individuals.
Surgical masks are required when caring for a client prescribed droplet isolation precautions but are needed only in
clients with contact isolation precautions if performing activities with the possibility of body fluid splashing (eg,
suctioning, wound care).
When caring for clients with C difficile, it is critical to perform hand hygiene with soap and water, rather than alcohol-
based sanitizers. Alcohol-based sanitizers are unable to effectively kill spore-forming bacteria (eg, C difficile, anthrax).

Infections caused by methicillin-resistant Staphylococcus aureus(MRSA), C difficile, vancomycin-

resistant Enterococcus (VRE), and scabies require contact precautions to be used.
Contact precautions include:

o Placing client in private room (preferred) or cohorting clients with the same infection
o Using dedicated equipment (must be disinfected when removing from room)
o Wearing gloves when entering room
o Perform proper hand hygiene before exiting room (use soap and water or alcohol-based hand rubs for MRSA and VRE, but
only soap and water for C difficile and scabies)
o Wearing gown with client contact and removing before leaving room
o Place door notice for visitors
o Having client leave room only for essential clinical reasons (ie, tests, procedures). If an x-ray is needed, try to arrange for a
portable one.

C difficile poses a unique hazard in health care settings. This infection of the colon may develop/spread through
contact with the organism or after prolonged antibiotic therapy alters normal bowel flora, allowing for C
difficile overgrowth.
Clients with C difficile infection should be placed on strict contact precautions in private rooms. These precautions
require staff to wear protective gowns and gloves when entering the client's room
Hand hygiene using soap and water is the only effective method for removing C difficile spores
In addition, alcohol is not an effective agent for killing C difficile spores; therefore, a diluted bleach solution must be
used to disinfect contaminated equipment and surfaces
Contact precautions require the caregiver to wear a gown and gloves. A face mask must be worn as personal
protective equipment if an organism is spread via droplets. However, it is not required to prevent the spread of a
contact-transmissible infection.
The nurse should not wear a mask solely to avoid the unpleasant odor associated with C difficile diarrhea as this may
be offensive and embarrassing to the client.
CONTACT AND AIRBORNE PRECAUTION

The order of removal for personal protective equipment (PPE) should be from most to least contaminated,
because this reduces the risk of contaminating the nurse's skin and clothes.
When exiting the room of a client on both contact and airborne precautions, the nurse should perform the following
actions in order:
1. Place the call light within the client's reach and ensure that the client's bed is locked and in the lowest position.
 2. Remove the gown and gloves (ie, contact isolation PPE) in order of most to least contaminated. The nurse can
remove gloves and then gown, or alternately, can remove gown and gloves together.
3. Discard the gown and gloves and then perform hand hygiene.
4. Exit the negative pressure room and immediately close the door to prevent infectious airborne microorganisms
from escaping into the hallway or isolation anteroom.
5. Remove and discard the N95 respirator mask and then perform final hand hygiene.
Negative pressure rooms continuously filter air out of the room, creating a lower pressure gradient that prevents
airborne microorganisms from escaping through the doorway.
To prevent exposure to infectious airborne microorganisms, nurses should remove N95 respirator masks only after
exiting the room.

DROPLET PRECAUTION

Bacterial meningitis (eg, Neisseria meningitidis) and many respiratory illnesses (eg, influenza) are transmitted
through large droplets of secretions spread into the air by coughing, sneezing, or talking.
These droplets can land on surfaces up to 6 feet (1.8 meters) away from the client.
Droplet precautions for routine care (eg, medication administration) require the use of a surgical mask, as the highest
risk of transmission is through inhalation of droplets
 Wearing a face shield, gown, and gloves is required if there is a risk of splash or contact with body fluids from
procedural client care (eg, suctioning, wound care).
Dedicated medical equipment (eg, stethoscope, blood pressure cuff) should remain in the room to limit spread of
infection.

PERTUSSIS

Paroxysms of rapid coughing that lead to vomiting are a key feature of pertussis infection.
Pertussis is a highly contagious disease and requires droplet precautions.
It can be deadly if contracted in infancy before vaccination is started. This client should be placed in isolation
immediately to prevent the spread of disease.

PHYSICAL RESTRAINT

A physical restraint that restricts body movement should be the last resort to keep a client from interfering with
medical treatment.
Restraints can cause bodily injury such as pressure ulcers, neurovascular and peripheral circulatory deficits, and
psychological trauma. Therefore, less restrictive methods should always be tried first.
Concealing the IV site and tubing by wrapping the forearm in gauze and an elastic stockinette can be effective in
keeping a confused client from pulling at the IV line.

BED BUG

Although full-blown bed bug infestations are uncommon in a school setting, a bed bug brought in on the clothing or
possessions of one student could easily "hitch" a ride to another student's home and cause an outbreak there.
The most important measure to prevent bed bugs from infesting other students' homes is to prevent the bugs from
entering the school in the first place.
Laundering clothing in hot water and using the highest temperature setting on a dryer will kill any bed bugs attached to
clothes. The clothing should then be stored in tightly sealed plastic bags to prevent additional infestation
 A professional pest control company should be brought in to evaluate the classroom/school for bed bugs; treatment
with an insecticide may or may not be necessary.
Sending letters home to parents is premature at this point. After professional pest control personnel evaluate the
classroom/school, letters can be sent to inform parents of the findings and any precautions that should be taken.
Sending the child home is unnecessary and may be perceived as punitive and stigmatizing. Bed bugs do not inhabit
humans; this child is not "infested" (seen in children with head lice).
It is a common misconception that bed bugs are drawn only to dirty environments. They can inhabit any environment
and can travel and spread easily in clothing, bags, furniture, and bedding. Although they do not pose significant harm,
bed bugs can cause an itchy red rash that can be uncomfortable and affect sleep. Bed bugs should be exterminated,
especially in a home with children.
It is important to treat the entire house for bed bugs. Washing a single pillowcase or blanket will not stop the
infestation. Bed bugs multiply quickly and can hide in any crevice.
Once pest control is complete, the home will need to be monitored for signs of lingering bugs.
Bed bug bites can cause a rash that clients, especially children, will be inclined to scratch. Precautions should be
taken to help alleviate the rash as itching can cause complications such as secondary skin infections.
Once a home is infested, the bugs can travel quickly and occupy spaces and crevices. All household members and
pets will be afflicted.

LEAVE AGAINST MEDICAL ADVICE (AMA)

A competent client can refuse medical treatment and leave against medical advice (AMA). The nurse should inform
the health care provider (HCP) immediately.
If the client decides to leave the facility, even after the HCP and nurse explain the consequences (including death), or
cannot wait until the HCP speaks with the client, the client should be allowed to do so.
It is most important that the client's IV catheter be removed to prevent complications (eg, infections) and misuse (eg,
access for illicit drug injections). The nurse should document the fluid infused, the site's appearance, and the integrity
of the IV catheter.
The goal is for the client to always have an informed refusal and to sign the legal form to indicate understanding of
that information. However, if the client refuses to sign, the client is still allowed to leave (failure to do so constitutes
false imprisonment).
The nurse should have witnesses to the events and clearly document in the chart what happened and that the client
refused to sign.
 Discharge instructions, results, and prescriptions can be given despite the client leaving AMA. However, it is not
essential to provide the clients with results. Removing the catheter is the priority.
Reassuring that a client can return is ethical as the desire is for the client to receive needed care. However, it is not a
priority over removal of the catheter.

NOSOCOMIAL INFECTION

A nosocomial infection occurs in a hospital (hospital-acquired) or other health care setting and is not the reason for
the client's admission.
Many nosocomial infections are caused by multidrug resistant organisms. These infections occur 48 hours or more
after admission or up to 90 days after discharge.
Clients at greater risk include young children, the elderly, and those with compromised immune systems.
Other risk factors include long hospital stays, being in the intensive care unit, the use of indwelling catheters, failure of
health care workers to wash their hands, and the overuse of antibiotics.
The most common nosocomial infection is urinary tract infection, followed by surgical site infections, pneumonia,
and bloodstream infections.

CHEMICAL RESTRAINTS

Chemical restraints are medications (eg, benzodiazepines, psychotropics) used to restrict freedom of movement or
to control socially disruptive behavior in clients who have no medical indications for them.
Although this client is at risk of injury from falling, the use of a psychotropic drug is not considered the standard
treatment for a client with a history of falls who keeps getting out of bed without assistance.
The least restrictive method to ensure client safety (eg, bed alarm, sitter, assistive devices) should be tried first
before administering a chemical restraint. Therefore, the nurse should question the prescription for haloperidol
(Haldol) in this client
Benzodiazepines (eg, lorazepam [Ativan], diazepam, chlordiazepoxide) are considered standard treatment to control
agitation in the client in alcohol withdrawal.
Antipsychotics (eg, olanzapine [Zyprexa], ziprasidone [Geodon], haloperidol) are considered standard treatment to
control violent behavior in the client with schizophrenia.
Propofol (Diprivan) is considered standard treatment to sedate the client receiving mechanical ventilation to provide
ventilator control, prevent accidental extubation, and promote comfort.
CENTRAL VENOUS ACCESS

In adult clients, central venous access sites in the upper body (internal jugular or subclavian) are preferred to minimize
the risk of infection.
Access sites in the inguinal area (femoral) are easily contaminated by urine or feces, and it is difficult to place an
occlusive dressing over these sites.
A central venous catheter (CVC) should be placed where aseptic technique can be applied. The site should be
assessed daily for signs/symptoms of infection (eg, redness, swelling, drainage).
The duration of CVC placement should be based on clinical need and judgment that there is no evidence of infection.
Internal Jugular Line Although this site has been in use for 6 days, it is a preferred site; the CVC was inserted in the
operating room, where surgical asepsis was easily accomplished. The site can be used as long as there is a clinical
need and no evidence of infection.
Peripherally inserted central catheter (PICC) lines can be left in for weeks or months. The occlusion of one lumen
does not necessitate removal of the catheter.
The subclavian vein is a preferred site for a CVC. Although slight redness is present at the suture sites, it is not
located at the insertion site. The femoral line is still at higher risk for infection.

Most CVC lumens require anticoagulation in the form of a heparin flush to maintain patency and prevent clotting
when not in use. The nurse should check the institution's protocol and the HCP prescription to determine the correct
dose.
Doses of 2 3 mL containing 10 units/mL 100 units/mL are the standard of care for flushing a CVC.
Doses of 1000 10,000 units are given for cases of venous thromboembolism; therefore, this prescription is an error
and should be clarified by the nurse.
The Centers for Disease Control and Prevention (CDC) recommend that a single-dose vial or prefilled syringe be used
to reduce infection risk.
Heparin is a high-alert medication (at high risk for causing significant harm to the client if given in error).
TPN should be administered through a CVC. Because of its viscosity and high glucose, lipids, electrolytes, vitamins
and minerals, it is safest when administered through a CVC or peripherally inserted central catheter.
According to the CDC, an occlusive dressing should be changed every 7 days. The nurse should check the
institution's protocol for frequency of dressing changes.
The distal port of a triple lumen CVC is the largest lumen (tube) and should be used for CVP (right atrium pressure)
monitoring. The distal end of the CVC is in reverse as regards the client; therefore, the distal end is at the tip of the
catheter in the superior vena cava vein, closest to the right atrium of the heart.
MOUTHWASH INGESTION

Many mouthwashes have an ethanol (alcohol) content ranging from the equivalent of wine to half the strength of hard
liquor. Because children's bodies absorb alcohol quickly, the symptoms of alcohol poisoning can occur within 30
minutes or less after consumption.
Clinical indications include confusion, vomiting and seizures, difficulty breathing, flushed or pale skin, and coma
secondary to low blood sugar.
The exact amount of alcohol that this child presumably ingested is unknown. It is most important to assess the
child's condition (eg, behavior, mental status, physical signs and symptoms) to determine if immediate emergency
measures (eg, calling 911, cardiorespiratory support) are necessary or if the parent should be instructed to contact the
poison control center
It is the nurse's professional responsibility to provide instruction and guidance to the parent. Although caregivers
should have the number of the poison control center readily available, referral might delay care and place the child at
further risk of a negative outcome if the child is already deteriorating.
If the child's condition is stable, the nurse should instruct the parents to contact the center for further evaluation and
instructions.
Giving the child water or any other liquid will not change the amount of alcohol ingested. In addition, alcohol can
impair swallowing, placing the child at risk for choking and aspiration.
Parents should be advised not to perform any interventions before contacting the poison control center.

INTERNAL RADIATION IMPLANT

An internal radiation implant (ie, brachytherapy) emits radiation in or near a tumor to treat certain malignancies.
When caring for clients undergoing brachytherapy, the nurse should monitor closely for evidence of implant
dislodgment. The dislodged implant emits radiation that can be dangerous to health care workers at the bedside.
Long-handled forceps and a lead-lined container should be kept in the room of the client who has a radioactive implant
in case of dislodgment.
If dislodgment occurs, the nurse should first use long-handled forceps to place the implant in a lead-
lined container to contain radiation exposure. The nurse should also notify the health care provider (radiation
oncologist).
(Containing the source quickly is a priority as the implant continues to emit radiation that could be dangerous to the
staff coming to evaluate the client and clean the room.
 The nurse should not handle dislodged radiation implants without the use of forceps. Furthermore, device reinsertion
should be performed only by the health care provider.
Wrapping the implant in linens and placing it within a biohazard bag does not reduce radiation exposure.

FALLS

Falls can occur with any client; however, advanced age, incontinence, confusion, and presence of lines, tubes, and
drains increase the risk for falls and injury. Interventions to reduce falls in high-risk clients include:

o Hourly rounding (eg, assessing pain, offering toileting and nutrition)

o Moving the client to a room close to the nurses' station
o Activating bed alarms to alert staff if the client gets out of bed unassisted
o Asking family members or visitors to stay at the bedside with the client

Falls are a leading predictor of mortality and morbidity in older adults.

General exercise programs, especially those including gait, balance, and strength training, not only reduce the risk
of falls but also prevent injuries from falls
 Vision impairment can contribute to fall risks; most adults need additional light by age 50. The nurse should ensure
that clients are wearing needed prescription glasses
Handrails, particularly in stairwells, hallways, and bathrooms, have been shown to reduce falls
Studies show that staff rounds at regular intervals (hourly or every other hour) decrease falls and call light use. The
practice allows staff to intervene early in needs.
Typically staff checks on the "Ps": potty, position, pain, and placement/proximity of personal items (eg, bed height, call
light, water, tissues, urinal). A common reason clients get out of bed unassisted is to use the bathroom
Non-slip rubber-soled shoes are recommended to prevent falls.

The client with right-brain damage following a stroke often experiences left-sided weakness, spatial-perceptual
deficits, and impulsiveness, making this client at high risk for falls.
Other factors that increase fall risk for older adults include:

o Unfamiliar surroundings
o Unsteady gait, decreased strength and coordination
o Altered mental status
o Orthostatic hypotension (related to dehydration)
o Bowel/bladder urgency and/or frequency

Application of color-coded, nonslip socks helps prevent a client from slipping and alerts staff to a client's increased risk
for falls. Placing a commode by the right (stronger) side of the bed decreases the number of steps and time needed
to get to a toilet . It also decreases the chance of tripping on equipment (eg, IV pump, tubing).
Moving the client to a room close to the nurses' station allows frequent observation and a faster response time to calls
for assistance. A bed alarm alerts staff when the client attempts to get out of bed, which allows for prompt response
CASE: A client on fall precautions is found
on the floor by the bed when the unlicensed
assistive personnel make hourly rounds.
Place the actions the registered nurse should
take in the appropriate order.
When determining which nursing diagnosis to address first, the nurse should consider factors that affect
client safety. Risk for falls is an immediate safety concern
Nursing diagnoses that relate to chronic conditions (eg, anxiety, chronic pain) are addressed after risk for falls. The
nurse should immediately implement fall risk precautions by placing the bed in the lowest position, ensuring that the
call light is within reach, and turning on the bed alarm.
Interventions for addressing other client needs may be carried out after measures to ensure client safety.
Advanced age is associated with decreased visual acuity, muscle mass, strength, and reaction time.
Medications that cause dizziness or drowsiness increase the risk for falls. Diuretics (eg, furosemide) increase urinary
frequency and may cause hypotension. Antihypertensive medications (eg, lisinopril, metoprolol) may cause
bradycardia and dizziness.
Safety needs are addressed before love and belonging needs (eg, anxiety). Anxiety interventions (eg, therapeutic
touch, medication) may be implemented after safety interventions.
Safety is the immediate concern for a client with a high fall risk. Arthritic joint changes are a source of chronic pain.
Pain interventions (eg, medication, repositioning) may be implemented after safety interventions.
A client with advanced age in an unfamiliar environment may develop acute confusion during the hospital course, but a
high fall risk is a more immediate concern on admission.
 To prevent injury to the nurse and the client if the client is falling, the nurse uses good body mechanics to try to break
the fall and guide the client to the floor if necessary. These actions include:

o Step slightly behind the client and place the arms under the axillae or around the client's waist
o Place feet wide apart with knees bent - creates a broad base of support, provides stability, and reduces the risk for back
injury to the nurse
o Place one foot behind the other and extend the front leg - allows the nurse to bring the client backward by using the leg
muscles to rock backward while supporting the client's weight
o Let the client slide down the extended leg to the floor - lowers the client gently to the floor while keeping the client's head
protected from injury

ROMBERG SIGN

The Romberg test, part of a focused neurologic examination, assesses clients' perceptions of their head in space
(vestibular function) and body in space (proprioception).
It is used to determine the reason for loss of coordination (ataxia).
Clients are asked to stand with the feet together and hands at the sides of the body. They are then asked to close
their eyes while ability to maintain balance is assessed.
A loss of balance is considered to be a positive Romberg sign and indicates that ataxia is sensory in nature rather
than cerebellar.
Clients demonstrating a positive Romberg test are likely to have ataxia, or be prone to lose balance, and would
require assistance with ambulation.
CRUTCHES

Interventions to promote safety when using crutches in the home include the following:

o Keep the environment free of clutter and remove scatter rugs to reduce fall risk
o Look forward, not down at the feet, when walking to maintain an upright position, which will help prevent muscle and joint
strain, maintain balance, and reduce fall risk
o Use a small backpack, fanny pack, or shoulder bag to hold small personal items (eg, eyeglasses, cell phone), which will
keep hands free when walking
o Wear rubber- or non-skid-soled slippers or shoes without laces to reduce fall risk
o Rest crutches upside down on the axilla crutch pads when not in use to prevent them from falling and becoming a trip
hazard
o Keep crutch rubber tips dry. Replace them if worn to prevent slipping.

IMPLIED CONSENT

Implied consent in emergency situations includes the following criteria:

o There is an emergency
o Treatment is required to protect the client's health
o It is impractical to obtain consent
o It is believed that the client would want treatment if able to consent

EBOLA (VIRAL HEMORRHAGIC FEVER)

Ebola (viral hemorrhagic fever) is an extremely contagious disease with a high mortality rate.
Clients require standard, contact, droplet, and airborne precautions (eg, impermeable gown/coveralls, N95
respirator, full face shield, doubled gloves with extended cuffs, single-use boot covers, single-use apron).
The client is placed in a single-client airborne isolation room with the door closed
Visitors are prohibited unless absolutely necessary for the client's well-being (eg, parent visiting an infected child).
For disease surveillance, a log is maintained of everyone entering or exiting the room, and all logged individuals are
monitored for symptoms
Procedures and use of sharps/needles are limited whenever possible.
 There are currently no medications or vaccines approved by the Food and Drug Administration to treat Ebola.
Prevention is crucial.
In a private airborne isolation room, the client does not require a respirator mask. However, all other individuals
entering the room must don appropriate personal protective equipment (PPE).
The PPE removal process after caring for a client with Ebola requires strict monitoring by a trained observer. The
outer gloves are first cleaned with disinfectant and removed. The inner gloves are wiped between removal of every
subsequent piece of PPE (eg, respirator, gown) and removed last.
VIOLENCE

Violence (eg, offensive language, physical aggression) may be precipitated by substance abuse, emotional stress,
mental instability, or altered mentation from medical conditions.
To de-escalate a violent situation and ensure the safety of the client and others, the nurse should:

o Remove other clients from the area.

o Keep a safe distance from the client with a clear path to safety.
o Maintain a calm demeanor, keeping the hands visible.
o Use clear, nonthreatening communication focusing on mutual goals

During periods of extreme anxiety and stress, clients are prone to irrational thinking. The nurse should avoid
reasoning (eg, explaining the dangers of refusing treatment) until the situation has been de-escalated and the client is
no longer in crisis.
Bargaining with the client by providing false reassurance (eg, promising not to involve authorities) is nontherapeutic
and may cause the client to lose trust in the nurse.
The client with impaired thinking from substance abuse is legally incompetent to leave the hospital against medical
advice.

MRSA

Clients at highest risk for hospital-acquired MRSA are older adults and those with suppressed immunity, long
history of antibiotic use, or invasive tubes or lines (hemodialysis clients).
Clients in the intensive care unit (ICU) are especially at risk for MRSA. The 80-year-old client with COPD in the ICU
on the ventilator has several of these risk factors. COPD is a chronic illness that can affect the immune system, and
 clients experience exacerbations that may require frequent antibiotic and corticosteroid use. This client is elderly and
also has an invasive tube from the ventilator.
A student athlete could be colonized with MRSA from time spent in locker rooms and around athletic equipment.
MRSA more often appears as skin infections in this age group. Unless this client has an open fracture, there is no
break in skin integrity.
This client does have an incision (portal of entry) and invasive lines but is younger and has no evidence of suppressed
immunity.
This client is older and does have a small surgical incision but is not as high risk as the client with COPD. All clients
undergoing pacemaker placement will receive a prophylactic antibiotic to prevent surgical site infection just before
surgery.

FIRE EXTINGUISHER

A small fire can quickly become very dangerous. During an emergency situation, such as a fire, anxiety can narrow a
person's focus, causing hesitation or difficulty in responding to the situation, especially when operation of unfamiliar
equipment (eg, fire extinguisher) is involved.
The mnemonic PASS is often used to help people remember the steps used in operating a fire extinguisher:
P Pull the pin on the handle to release the extinguisher's locking mechanism
A Aim the spray at the base of the fire
S Squeeze the handle to release the contents/extinguishing agent
S Sweep the spray from side to side until the fire is extinguished

MENIERE DISEASE

Meniere disease (endolymphatic hydrops) results from excess fluid accumulation in the inner ear.
Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness.
The vertigo can be severe and is associated with nausea and vomiting.
Clients report feeling being pulled to the ground (drop attacks).
 Fall precautions that should be instituted include assisting the client when arising and ambulating, placing the bed in
low position, and raising side rails.
However, raising all side rails is considered a restraint and would be inappropriate. The nurse would need to
intervene and instruct the UAP that 2 or 3 side rails lifted up would be sufficient
Vertigo may be minimized by staying in a quiet, dark room and avoiding sudden head movements.
The client should reduce stimulation by not watching television and not looking at flickering lights.

LATEX ALLERGY

Latex allergy is an exaggerated immune-mediated reaction when one is exposed to products or dusts containing
latex, a natural rubber used in many medical devices (eg, gloves, catheters, tape).
Many people, particularly health care workers and individuals requiring chronic invasive procedures (eg, self-
catheterization), develop latex allergy from repeated exposures.
When assessing for potential latex allergies, the nurse should inquire about the client's reactions to common latex-
containing objects and potentially cross-allergenic products.
Balloons commonly contain latex, and reports of lip swelling, itching, or hives after contact indicate a high risk for
anaphylactic reactions with continued exposure
Many food allergies (eg, avocado, banana, tomato) also increase the risk for latex allergy because the food proteins
are similar to those found in latex

PSEUDOHYPERKALEMIA

With the exception of clients in end-stage renal disease, a serum potassium value >6.5 mEq/L (6.5 mmol/L) in any
client who is walking and talking should raise the suspicion of an erroneously elevated serum potassium
(pseudohyperkalemia) from poor hematology technique, hemolysis, or clotting.
A serum potassium level of 7.0 mEq/L (7.0 mmol/L) would normally constitute a life-threatening electrolyte imbalance
that would cause severe weakness or paralysis, unstable arrhythmias, and eventual cardiac arrest.
An assessment would focus on evaluating cardiac symptoms and muscle strength and be reported to the health care
provider (HCP). In this case, it is likely that a repeat blood draw would be prescribed.
Pseudohyperkalemia can be avoided on the repeat blood draw by using heparin-impregnated hematology vials to
prevent clotting, minimal use of a tourniquet and fist clenching, and use of a larger gauge needle for the sample.
CLIENT TRANSFER

CASE: The nurse is preparing to transfer a

client from the bed to the chair for the first
time. The client has generalized weakness
and is unable to follow instructions. Which
would be the most appropriate method for the
nurse to use to transfer this client safely?
To determine the most appropriate method to transfer a client safely for the first time, the nurse should assess 2
factors:

Whether the client can bear weight:

o Neurological deficits (eg, paralysis, paresis [weakness])

o Decreased muscle strength (eg, prolonged immobility, multiple sclerosis, muscular dystrophy)
o Trauma (eg, amputee, hip fracture)

Whether the client is cooperative and able to follow instructions:

o Altered mental status (eg, delirium, drug intoxication)

o Decreased cognitive ability (eg, dementia, head injury)

A 1-person standby assistance is appropriate for a client with full weight-bearing ability who is either uncooperative or
at high risk for falls.
 A pivot transfer or standing-assist lift transfer requires client cooperation with instructions to promote safety during the
transfer.
ADVERSE EVENT

An adverse event is an injury to a client caused by medical management rather than a client's underlying condition. It
may or may not be preventable. The Institute of Medicine (2000) recognizes 4 types of errors. They are:

o Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring)
o Treatment (error in performance of procedure, treatment, dose; avoidable delay)
o Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment)
o Other (failure of communication, equipment failure, system failure)

PHYSICAL RESTRAINT

A physical restraint is a device or method used to immobilize or limit physical mobility or body movement to prevent
falls, injury to self or others, or removal of medical devices.
The client situation, rather than the device, determines whether it is classified as a restraint.
Prescribed orthopedic immobilizers and protective devices used temporarily during routine procedures or
examinations are not considered physical restraints and do not require authorization for use from a health care
provider.
Restraints should be used only after less invasive methods have failed and must be discontinued at the earliest
time possible once it is safe to do so.
The belt restraint is applied at the waist and tied to the bed frame under the mattress with straps using a quick-
release knot. It is used to protect a confused or disoriented client who is on bed rest. Although the client can turn, it is
considered a restraint because it restricts physical mobility and confines the client to the bed involuntarily
Soft limb restraints (eg, wrist, ankle) immobilize one or more extremities and are used for the prevention of falls or
attempted removal of devices. Following a procedure requiring sedation, clients may require restraints to protect them
from disrupting a surgical site or medical device until they are alert enough to follow instructions independently
Limb restraints should be applied loosely enough that 2 fingers can be inserted underneath the secured restraint.
The nurse should closely monitor the peripheral neurovascular status and skin integrity of a client's restrained
extremity.
 Elbow restraints used as a protective device to temporarily immobilize a child (<30 minutes) to perform a medical,
diagnostic (eg, drawing blood), or surgical procedure are not considered a physical restraint.
The use of full padded side rails in the raised position for clients during a seizure protects them from immediate injury;
these are not considered a restraint.
PREPARING STERILE FIELD
The general steps for preparing the sterile field for a wet-to-damp dressing change include:

1. Perform hand hygiene.

2. Open a sterile gauze package with ungloved hands.
3. Hold the inverted opened gauze package 6" (15 cm) above the sterile field.
4. Place the sterile gauze dressing more than 1" (2.5 cm) from the edge of the sterile field.
5. Use sterile NSS from a recapped bottle that was opened <24 hours ago (if policy permits).

CHEMICAL CONTAMINATION EMERGENCY

Nursing priorities when implementing a chemical contamination emergency response plan include the following:

1. Restricting other clients, staff, and bystanders from the victims' vicinity to protect non-affected individuals and the health
care facility from the contaminant
2. Donning personal protective equipment to protect the nurse when providing care
3. Decontaminating the clients outside the facility before initiating treatment. If the chemical is not removed, it will continue
to cause respiratory distress; contaminated clothing is left outside the facility to reduce the risk of contaminating staff and
other clients
4. Assessing and providing treatment of symptoms. Initial treatment is for the symptoms (eg, wheezing), regardless of the
specific cause

SEIZURE PRECAUTIONS

Clients with seizures are at increased risk for injury during seizure activity. Seizure precautions are nursing
interventions that can help protect a client during a seizure. These precautions typically include:

1. Raising the upper side rails on the bed to prevent the client from falling to the floor during a seizure. The side rails are
also padded to prevent client injury due to hitting the hard plastic rails during a seizure
 2. During a seizure, a client may be unable to control secretions, increasing the risk for an impaired airway. Suction equipment
and oxygen equipment are set up at the bedside. Some facilities also encourage the use of a continuous pulse oximeter.

Clients may experience urinary incontinence during a seizure, but unless the health care provider prescribes a urinary
catheter, it is not typically used as part of seizure precautions. Inserting a urinary catheter puts the client at risk for a
urinary tract infection.
It is not necessary to remove all linen from the client's bed. If a client has a seizure, any blankets or pillows that are in
the way or pose a threat can be removed, but the client may have linen on the bed while on seizure precautions.

HEALTH CARE CATHETER ASSOCIATED UTI

Health care catheter-associated UTIs are prevalent among hospitalized clients with indwelling urinary catheters. Steps
to prevent infections in clients with urinary catheters include the following:

o Wash hands thoroughly and regularly

o Perform routine perineal hygiene with soap and water each shift and after bowel movements
o Keep drainage system off the floor or contaminated surfaces
o Keep the catheter bag below the level of the bladder
o Ensure each client has a separate, clean container to empty collection bag and measure urine
o Use sterile technique when collecting a urine specimen
o Facilitate drainage of urine from tube to bag to prevent pooling of urine in the tube or backflow into the bladder
o Avoid prolonged kinking, clamping, or obstruction of the catheter tubing
o Encourage oral fluid intake in clients who are awake and if not contraindicated
o Secure the catheter in accordance with hospital policy (tape or Velcro device)
o Inspect the catheter and tubing for integrity, secure connections, and possible kinks

Catheter-associated urinary tract infections are prevalent in hospital settings. Only indwelling urinary
catheters should be used when appropriate.
Appropriate uses include the following:

o Clients with urinary obstruction or retention, or a need for strict intake and output in critically ill clients
o Perioperative use for surgical procedures such as urologic surgery or prolonged surgeries, or when large doses of fluid or
diuretics are given during surgery
o During prolonged immobilization when bedrest is essential
 o To improve end-of-life comfort
o To facilitate healing of an open perineal or sacral wound in incontinent clients

Inappropriate uses include the following:

o Convenience or replacement for nursing care when the client is elderly, confused, incontinent, or voids frequently
o For obtaining a urine culture when the client can follow instructions and void voluntarily
o Postoperatively for prolonged periods when other appropriate indications are not present

MIDDLE EAST RESPIRATORY SYNDROME

Middle East respiratory syndrome (MERS) is a viral respiratory illness caused by the coronavirus (MERS-CoV).
Symptoms include fever, cough, and shortness of breath that often worsen and cause death in many of those
afflicted.
The incubation period is 5-6 days but can range from 2-14 days.
How the virus spreads is not fully understood, but it is thought to spread via respiratory secretions.
Because it has easily spread to those who care for infected persons, the Centers for Disease Control and Prevention
recommends the use of standard, contact, and airborne precautions with eye protection when caring for clients
with MERS.

SHINGLES (HERPES ZOSTER)

Shingles (herpes zoster) is a reactivation of the varicella-zoster (chicken pox) virus. It is more likely to occur when a
client's immune system is compromised by disease (eg, HIV infection) or treatments (eg, chemotherapy).
Shingles lesions that are open may transmit the infection by both air and contact.
The client with disseminated shingles that are not crusted over will require contact precautions, airborne
precautions, and a negative airflow room to prevent transmission of the infection to others in the hospital.
Negative airflow pulls air from the hospital environment into the room, and the air from the hospital room then goes
directly to the outside rather recirculating to the rest of the hospital.
Localized shingles require only standard precautions for clients with intact immune systems and contained/covered
lesions.
 Negative airflow and airborne precautions are also required in addition to contact precautions. Droplet precautions are
not necessary.
Positive airflow would pull fresh air from outside into the hospital room, and then the air from the room would circulate
throughout the rest of the hospital. It is not appropriate for this type of infection. Instead, positive airflow would be
used for protective isolation in a client who is immunocompromised.
A semi-private room is not appropriate for this client with a communicable illness. Standard precautions are used for
localized shingles in clients with intact immune systems and contained/covered lesions.

MRI
Clients must be screened for contraindications before exposure to a magnetic field (MRI) as it can damage implanted
devices or metallic implants.
Absolute contraindications can preclude testing, and relative contraindications can pose a hazard to the client's
devices or implants, affect the quality of the images, or cause discomfort.
Absolute contraindications:

o Cardiac pacemaker
o Implantable cardioverter defibrillator
o Cochlear implant
o Retained metallic foreign body, especially in organs such as the eye

Relative contraindications:
o Prosthetic heart valve
o Metal plate, pin, brain aneurysm clip, or joint prosthesis Some of these devices have nonferrous MRI-safe
materials and should be verified.
o Implanted device (eg, insulin pump, medication port)

Other factors that can affect the client's eligibility include inability to remain supine for 30-60 minutes and
claustrophobia; however, these concerns are often controllable (eg, sedation can be prescribed, open MRI machine
can be used).
A colostomy is not a contraindication for MRI.
 Transdermal metal-containing medication patches (clonidine, nicotine, scopolamine, testosterone, or fentanyl) are not
a contraindication for MRI. However, the nurse should remove the patch beforehand due to the risk of burns and
replace after testing.

PERIPHERALLY INSERTED CENTRAL CATHETER (PICC)

A peripherally inserted central catheter (PICC) is a venous access device that is inserted via the cephalic or basilic
vein and terminates in the superior vena cava. It is indicated for administration of noxious medications (eg, parenteral
nutrition, chemotherapy), for long-term IV therapy, or in clients with poor venous access.
Proper care and aseptic technique are important to maintain lumen patency and eliminate the risk of life-threatening
central line-associated bloodstream infection (CLABSI).
The nurse should inspect the insertion site for signs of infection (redness, drainage) and dressing integrity.
Routine care includes sterile dressing changes every 48 hours with a gauze dressing or 7 days with a
transparent semipermeable dressing (biopatch) as well as immediately if dressing is loose/torn, soiled, or damp.
The line should be flushed before and after medication administration and per facility protocol
Blood pressure and venipuncture should not be performed on the affected arm as compression of the vein can alter its
integrity
All infusing medications (except vasopressors) must be paused before drawing blood from the PICC to prevent
false interpretation of the client's serum levels
Dressings that no longer occlude the insertion site must be changed immediately. Loose corners may be temporarily
reinforced with tape.
The nurse should "scrub the hub" with alcohol or chlorhexidine/alcohol for 10-15 seconds. This should be done
before flushing, drawing blood, or administering medication.
TRICYCLIC ANTIDEPRESSANT OVERDOSE

Amitriptyline is a tricyclic antidepressant (TCA) that can produce cardiac toxicity and neurological
disturbances by altering cholinergic pathways, sodium channels, and calcium channels, causing symptoms such as
atrioventricular block, hypotension, cardiac arrest, and seizure.
TCAs have a narrow therapeutic index and rapid onset of action, so ingestion of even a small amount may be life-
threatening for a toddler. Symptoms of toxicity are usually evident within hours of ingestion, but cardiac failure can
develop days after. Neurological and hemodynamic assessments, as well as ECG monitoring in an emergency
department setting, are recommended
Syrup of ipecac is no longer routinely recommended for oral poisonings. The uncontrolled vomiting and vagal
response induced can be harmful after ingestion of toxic substances. Treatments such as oral activated charcoal may
be used in the inpatient setting to remove the ingested toxin if the client presents immediately after the ingestion.
The caregiver should not be instructed to stay home to monitor for symptoms due to the rapid onset of toxicity.
An outpatient clinic is not sufficiently staffed or equipped for acute management of amitriptyline toxicity. The nurse
should refer the client to the nearest emergency department, which is the safest environment for monitoring and
treatment.

IDENTIFIERS
"The right client" is one of the "6 rights" of medication administration.
Two identifiers are used to compare client statements and information on the identification band with the client's
medication administration record.
An identifier should be permanent and unique to the client.
 Acceptable identifiers include first and last name and date of birth. These two identifiers are commonly used
together because there is a chance that more than one client may share a similar surname or date of birth, which
increases the risk of administering a medication to the wrong client.
Medical record numbers are also an acceptable form of identification and may help further differentiate clients

UNCONSCIOUS CLIENT

The unconscious client requires a thorough head-to-toe assessment on admission to assess for foreign objects,
devices, or belongings that have potential for harm. This includes checking for:

o Medical alert bracelets/necklaces: Indicating allergy status, emergency contact, or code status
o Contact lenses: Remove to prevent corneal injury
o Medication patches: To prevent drug interactions and determine conditions currently being treated
o Tampons (in female clients): Remove to prevent toxic shock syndrome or infection
o Rings and jewelry: Remove to prevent constrictive injury or vascular damage if edema develops

Medication patches should not be removed without first consulting the health care provider. Clients are often
prescribed transdermal patches for chronic conditions (eg, clonidine for hypertension, nitroglycerin for angina).
Removing and discarding a medication patch without additional information may harm the client.

ENTERAL FEEDINGS

Clients who are critically ill are at increased risk for aspiration of oropharyngeal secretions and gastric contents,
particularly when they are receiving enteral feedings.
Nursing interventions to reduce aspiration risk for clients receiving enteral tube feedings include:

o Assess client for gastrointestinal intolerance to feedings every 4 hours by monitoring gastric residual and assessing for
abdominal distension, abdominal pain, bowel movements, and flatus
o Assess feeding tube placement at regular intervals
o Keep head 30 degrees, with 30-45 degrees being optimal to reduce gastroesophageal reflux and aspiration
risk unless otherwise indicated
o Keep endotracheal cuff inflated at appropriate pressure (about 25 cm H20) for intubated clients, as low cuff pressure
increases the risk for aspirating oropharyngeal secretions and/or gastric contents
 o Suction any secretions that may have collected above the endotracheal tube before deflating the cuff if deflation is
necessary
o Use caution when giving sedatives and frequently monitor for over-sedation, which can slow gastric emptying and reduce
gag reflex
o Avoid bolus tube feedings for clients at high risk for aspiration

OVER THE COUNTER MEDICATIONS

Over-the-counter (OTC) medications are available without a prescription and are used to treat common illnesses. It
is estimated that nearly four times as many health conditions are independently managed with OTC medications as
are managed under the supervision of a health care provider (HCP).
Prior to taking OTC medications, the client should talk with an HCP or pharmacist, particularly if already taking
prescribed medications
Even when taken as directed by the OTC medication label, interactions and adverse effects may occur when used
in combination with prescription medications
All medications, herbal products, and supplements must be discussed with HCPs so that they can
be reconciled and considered before changing or adding new treatments
When OTC medications are used to manage symptoms (eg, ibuprofen for back pain), the diagnosis and treatment of
serious underlying medical conditions (eg, malignancy) may be delayed
Herbal products and supplements, although they are prepared from plants or "all-natural" substances, may contain
compounds that interact with prescription medications. These interactions may cause increased or decreased
prescription medication effect, serious adverse effects, and medication toxicities.
SEIZURE

Protecting the ambulating client from injury is the immediate priority. The nurse assists the client to the floor, cradles
the head, and places the client in the left lateral position.
 Left lateral position is preferred to avoid the risk of aspiration. Hard or sharp objects should be removed from the
client's environment to prevent injury.
The nurse remains with the client until the seizure is over to assess seizure activity and postictal symptoms and to
minimize injury.
No objects should be placed in a client's mouth during a seizure. Following the seizure, the client may require
assessment and maintenance of the airway, suctioning, and oxygen administration.
Attempting to restrain a client during a seizure may cause injury to the client.
NEEDLESTICK INJURY
SITTING DOWN WITH CRUTCH

Clients prescribed crutches after a musculoskeletal injury must understand appropriate device use to facilitate
independent ambulation, promote wound healing, and prevent reinjury.
When educating a client to rise from sitting, the nurse instructs the client to hold the hand grips of both crutches in
the hand on the affected side, move to the chair's edge, and hold the armrest with the hand on the unaffected side.
The client then uses the crutches, armrest, and unaffected leg for support when rising.
To sit, the client backs up to the chair and moves both crutches into the hand on the affected side. The client holds
the armrest with the other hand and lowers the body.
To rise from a chair, the client should move to the edge of the chair and flex the unaffected leg for support.
Before sitting, the client should back up to the chair until the unaffected leg touches the chair seat.
When standing or sitting, clients should place the hand opposite the injury on the armrest or chair seat for support.
 FUNDAMENTALS
SKILLLS AND PROCEDURES
CALCULATIONS

CASE: The nurse is caring for a client with

gastroenteritis and dehydration who is
prescribed strict intake and output monitoring
with calculation of net fluid balance each shift.
Calculate the client's net fluid balance for the
shift.

ANS: 655
Net fluid balance is calculated by subtracting total output from total intake. The nurse should record all
occurrences of intake and output.
Daily weights are always the best indicator of fluid balance; however, calculating net fluid balance from intake and
output helps to identify clients at risk for a fluid volume imbalance. The following steps are used to calculate the net
fluid balance:
 1. Convert all volumes to milliliters

(1 L )(1000 mLL )=1000 mL normal saline1 L 1000 mLL =1000 mL normal saline
(5 tbsp )(15 mLtbsp)=75 mL vancomycin5 tbsp 15 mLtbsp=75 mL vancomycin
2. Calculate intake and output totals

Intake: 180 mL+75 mL+240 mL+360 mL+1000 mL+250 mL=2105 mL total

intakeIntake: 180 mL+75 mL+240 mL+360 mL+1000 mL+250 mL=2105 mL total intake
Output: 150 mL+1300 mL=1450 mL total outputOutput: 150 mL+1300 mL=1450 mL total output
3. Calculate the net fluid balance

Total intake-total output=net fluid balance

2105 mL=655 mL2105 mL-1450 mL=655 mL

CASE: The health care provider prescribes a

continuous IV infusion of regular insulin at 5
units/hr. The infusion bag contains 50 units
of regular insulin in 100 mL of normal saline
solution. At what rate in milliliters per hour
(mL/hr) does the nurse set the IV pump?

ANS: 10
CASE: The nurse has received a prescription
from the health care provider to administer
80 mg of methylprednisolone IV piggyback.
The available vial contains 125 mg in 2 mL.
Select the syringe containing the appropriate
amount of medication to be administered.
CASE: A client with hypokalemia is
prescribed IV potassium chloride (KCl) to
infuse at 10 mEq/hr. The pharmacy sends
20 mEq of KCl in 250 mL of D5W. To deliver
the prescribed dose, the nurse sets the
infusion pump at how many milliliters per
hour (mL/hr)?

ANS: 125ML/HR

CASE: The nurse cares for an 11-lb (5-kg)

infant admitted with dehydration and
prepares to calculate intake and output over
an 8-hour shift. Using the data in the exhibit,
calculate the total output in milliliters for the
8-hour shift.

ANS: 178ML
CASE: A client with heart failure is
prescribed a continuous IV infusion of
dobutamine at 10 mcg/kg/min. He weighs 70
kg. The concentration of dobutamine is 250
mg in 500 mL D5W. For how many milliliters
per hour should the nurse program the IV
pump?

ANS: 84

Dobutamine hydrochloride (Dobutrex) is a positive inotropic drug that increases cardiac muscle contractility. The
dosage is weight-based and is prescribed in micrograms per kilogram per minute (mcg/kg/min) and administered with
an IV pump. Because IV pumps are set by milliliters per hour (mL/hr), the nurse must be able to calculate the drug
dose and the infusion rate in mL/hr.
Dobutrex can be diluted in dextrose or normal saline, and concentrations usually range from 500-2,000 micrograms
per milliliter (mcg/mL) depending on client status. This medication may be administered in acute or long-term facilities
or in the home. It is most often administered in the emergency department, intensive care unit, and step-down units.
The nurse must always follow institution policy and procedure in relation to its dilution, dosage, administration, and
titration.
CASE: The nurse is to administer an
albuterol nebulizer treatment to a client with
acute bronchospasm. The prescribed
dosage is 5 mg every 4 hours. The available
solution is albuterol (0.083%) inhaled, 2.5
mg/3 mL. How many milliliters (mL) should
the nurse administer with each dose?

ANS: 6
CASE: The health care provider prescribes a
continuous heparin infusion at 18 units/kg/hr
for a client who has a pulmonary embolus
and weighs 198 lb. The infusion bag
contains 25,000 units of heparin in 500 mL of
D5W. At what rate in milliliters per hour
(mL/hr) does the nurse set the IV infusion
pump?

ANS: 32
CASE: The nurse is caring for a client who is
prescribed ampicillin 1.5 g in 100 mL of
normal saline IV to be administered over 30
minutes every 6 hours. The nurse has IV
tubing with a drip factor of 15 gtt/mL. At
what rate in drips per minute (gtt/min) should
the nurse administer the IV ampicillin?

ANS: 50

CASE: The nurse is to administer prescribed

heparin 70 units/kg IV bolus before initiating
the continuous infusion as prescribed.
Heparin 1,000 units/mL is available. The
client weighs 108 lb. How many milliliters of
heparin bolus should the nurse administer?

ANS: 3.4
CASE: A continuous regular insulin IV
infusion of 0.2 units/kg/hr is prescribed for a
10-year-old client who weighs 51 lb and has
diabetes mellitus. How many units per hour
(units/hr) would the nurse administer to this
client?

ANS: 4.6
CASE: A health care provider prescribes
cefuroxime 30 mg/kg/day PO divided in
equal doses every 12 hours for a child with a
urinary tract infection. The child weighs 34
lb. Based on the available concentration of
cefuroxime, how many mL would the nurse
administer per dose?

ANS: 4.6
CASE: A client postoperative from a
transurethral prostatectomy has a triple-
lumen, indwelling urinary catheter and is
receiving continuous bladder irrigation of
sterile normal saline solution at 175 mL/hr.
The nurse empties the urine drainage bag for
a total of 2300 mL at the end of the 8-hour
shift. How many milliliters (mL) should the
nurse document as the net urine output for
the shift?

ANS: 900
CASE: The health care provider prescribes 2
mEq (2 mmol)/kg of 8.4% sodium
bicarbonate IV to be administered over the
next 4 hours. The client weighs 150 lb, and
the pharmacy supplies the following IV
solution: 8.4% sodium bicarbonate in 1000
mL of D5W with 150 mEq (150 mmol) of
sodium bicarbonate. At what rate in
milliliters per hour (mL/hr) should the nurse
set the infusion pump?

ANS: 227
CASE: An infant is experiencing respiratory
depression immediately after a vaginal
delivery using epidural analgesia with
morphine. The health care provider
prescribes 0.1 mg/kg naloxone IM to be
given STAT once. The client weighs 3600
grams and naloxone 0.4 mg/mL is available.
How many milliliters will the nurse
administer?

ANS: 0.9
CASE: The nurse cares for a client receiving
intermittent peritoneal dialysis who is
prescribed strict intake and output monitoring
with calculation of net fluid balance each
shift. Calculate the total net fluid balance for
the shift.

ANS: 890

Peritoneal dialysis allows waste products to be removed from the bloodstream through the semipermeable membrane
of the peritoneum.
Dialysate (ie, dialysis fluid) is infused into the peritoneal cavity, retained for a prescribed dwell time (eg, 20 minutes),
and then drained as dialysate outflow.
For clients on peritoneal dialysis, fluid balance should be tracked closely with daily weights and strict intake and output
monitoring.
Net fluid balance is calculated by subtracting total output from total intake.
CASE: A client with ascites had 5400 mL of
fluid removed during paracentesis. The
health care provider prescribes 8 g of
albumin IV per 1000 mL of fluid removed. If
the albumin is supplied as 25 g in 100-mL
bottles, how many mL will the nurse
administer?

ANS: 172.8
CASE: A nurse is instructing the caregiver of
an 8-month-old client regarding
administration of oral amoxicillin. The client
is prescribed 25 mg/kg/day of amoxicillin in 2
divided doses for 5 days. The client weighs
16.5 lb and the amoxicillin solution is
prepared as 125 mg/5 mL. How many mL of
amoxicillin should the nurse instruct the
caregiver to administer for each dose?

ANS: 3.75
CASE: A pediatric client weighing 66 lb is
prescribed ibuprofen 5 mg/kg by mouth
every 6 hr PRN for fever. It is available as
an oral solution of 20 mg/mL. How many
milliliters (mL) of ibuprofen should be given
to the client per dose?

ANS: 7.5
CASE: The nurse is preparing to administer
an antibiotic to a child with pneumonia. The
prescription reads: 7.5 mg/kg every 24 hours
divided into 2 doses, PO in liquid form. The
client weighs 78 lb. The pharmacy has
supplied the drug in 125 mg/5 mL. How
many milliliters (mL) should the client receive
for each dose?

ANS: 5.3
CASE: An IV infusion of norepinephrine at 8
mcg/min is prescribed for a client in shock.
The concentration of norepinephrine is 4 mg
in 250 mL of D5W. For how many milliliters
per hour (mL/hr) should the nurse program
the IV pump?

ANS: 30
CASE: A child with congenital heart disease
weighing 44 lb is prescribed furosemide 1
mg/kg PO every 8 hours. It is available as
an oral solution of 10 mg/mL. How many
milliliters (mL) of furosemide should the
nurse administer to the client each dose?

ANS: 2
CASE: The nurse is caring for a client who
has deep venous thrombosis and is
prescribed a continuous IV infusion of
heparin 25,000 units in 500 mL of D5W at
1300 units/hr. After 6 hours of the heparin
infusion, the client's PTT is 44 seconds. The
nurse must adjust the infusion rate according
to the heparin drip protocol (shown in the
exhibit). According to the protocol, at what
rate in milliliters per hour (mL/hr) should the
nurse set the IV infusion pump?
ANS: 28

MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY

Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive diagnostic test used to visualize the
biliary, hepatic, and pancreatic ducts via MRI.
MRCP uses oral or IV gadolinium (noniodine contrast material) and is a safer, less-invasive alternative to endoscopic
retrograde cholangiopancreatography to determine the cause of cholecystitis, cholelithiasis, or biliary obstruction.
The nurse must assess for contraindications before the procedure, including the presence of certain metal and/or
electrical implants (eg, aneurysm clip, pacemaker, cochlear implant) or any previous allergy or reaction to
gadolinium .
A client with a history of rash following prior IV contrast administration should be assessed to determine the type of
contrast that caused the reaction. Although allergies to iodine-based contrast material are more common, the nurse
must rule out a gadolinium allergy
Pregnancy also is a contraindication for MRCP as gadolinium crosses the placenta and may adversely affect the
fetus. Delayed/irregular menses may be a normal variation in some clients; however, delayed menses may indicate
pregnancy and should be reported for further investigation prior to MRCP
Many clients should be NPO for 4 hours prior to the procedure to allow better visualization of the anatomical features.
Smoking does not affect MRI visualization and is not a contraindication.
SLING

A sling is used to support the shoulder after a fracture, dislocation, injury, or surgery. Commercially made slings are
used almost exclusively. They have a sleeve that fits around the injured extremity and extends above the elbow and
adjustable straps to provide a snug and comfortable fit around the waist and neck.
To prevent injury and provide proper support of the affected extremity, the nurse should evaluate the proper fit of the
sling by assessing for the following factors:

o Elbow is flexed at 90 degrees to support the forearm, prevent swelling, and relieve shoulder pressure
o Hand is held slightly above the level of the elbow, through adjustment of the neck strap, to prevent venous pooling and
edema
o Bottom of the sling ends in the middle of the palm with the fingers visible, to be able to assess circulation, sensation,
and movement
o Sling supports the wrist joint with the thumb facing upward or inward toward the body, to maintain proper alignment
o Skin irritation, which can occur under the sling and around the neck if the strap is too tight

DRY DRESSING CHANGE

Prior to discharge, the nurse must evaluate the client's ability to perform home wound care. When performing a
simple dry dressing change, the client should:

o Don clean gloves and perform hand hygiene before and after removing the old dressing
o Cleanse the wound bed using sterile saline (or a prescribed cleanser) by moving from "clean" to "dirty," or from the center of
the wound outward
o Thoroughly dry the wound and surrounding skin using sterile gauze to prevent maceration (breakdown) of underlying tissues
o Monitor the site for signs of infection (eg, redness, warmth, purulent drainage)
o Apply dry, sterile gauze over the wound bed
o Cover the gauze with an occlusive sterile dressing to keep gauze in place and maintain asepsis. The covering should be
applied without touching the wound bed

When performing a dry dressing change, the client must make sure that the bandaging materials applied (ie, gauze)
are dry. Sterile gauze moistened with sterile saline is used for wet-to-dry dressing changes and is not appropriate for
a dry dressing change.
CLEAN CATCH URIN SPECIMEN

A clean catch urine specimen is commonly performed in clients requiring urinalysis. The correct collection method
for a female client is as follows:

1. Perform hand hygiene and open the specimen container, leaving the sterile side of the collection lid positioned upward to
prevent contamination.
2. Spread the labia using the index finger and the thumb of the nondominant hand so that the specimen cup can be held with
the dominant hand.
3. Cleanse the vulva in a front-to-back motion with provided antiseptic wipes, using a new towelette with each wipe to prevent
contamination.
4. Initiate the urinary stream to flush any remaining microorganisms from the urethral meatus before passing the container into
the stream for the collection of 30-60 mL of urine.
5. Remove the specimen container from the stream before the urinary flow ends and the labia are released to prevent
contamination.
6. Replace the sterile cap without contaminating it and repeat hand hygiene.

BLOOD TRANSFUSION

The procedure for safe blood administration includes the following:

1. Obtain a unit of blood from the blood bank and verify the blood product with type and crossmatch results and at least 2 client
identifiers with another nurse at the client's bedside. The blood is obtained and infused one unit at a time
2. Assess the client, obtain vital signs for baseline, and teach signs of a transfusion reaction and how to call for help.
3. Use a Y tubing, prime with NS, and then clamp the NS side
4. Spike the blood product, leaving the blood side of the Y tube open while keeping the saline side clamped for infusion. The
saline is only used to prime the tubing and flush after the infusion. It does not infuse simultaneously.
5. Set the infusion pump to deliver blood over 2 4 hours as prescribed. Rapid infusion of the blood puts the client at greater
risk for transfusion reaction and fluid volume overload.
6. Remain with the client for at least the 1st 15 minutes and watch for signs of blood transfusion reaction, including fever, chills,
nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea. Stop the transfusion immediately if
a reaction occurs. The first 15 minutes of infusion should be slow to watch for these reactions.
7. Take another set of vital signs 15 minutes after infusion starts and continue in accordance with facility policy. Always take a
final set of vital signs after the infusion is complete.
8. On completion of the blood transfusion, open the saline side clamp of the Y tubing to flush all blood in the tubing through with
NS.
 9. Return the blood bag with the attached set-up to the laboratory after completion or dispose of in accordance with hospital
policy. Use new IV Y tubing set-up for the second unit of blood.

Blood transfusions are commonly administered to clients experiencing anemia or acute blood loss. To ensure client
safety during blood administration, the nurse should:

o Verify two client identifiers (eg, name, medical record number, date of birth), the prescription, and the blood products with
another licensed health care provider
o Ensure that blood type and Rh type are compatible. An Rh-positive client can safely receive Rh-positive or Rh-negative
blood.
o Administer the blood via filtered tubing with normal saline to prevent clumping in the tube and hemolysis of red blood
cells
o Monitor vital signs during transfusion per facility-specific protocol (eg, before transfusion, 15 minutes after transfusion
begins, periodically).
o Transfuse blood products within 4 hours due to the risk for bacterial growth.

NG TUBE INSERTION

Steps for inserting a nasogastric tube for gastric decompression include the following:

1. Perform hand hygiene and apply clean gloves (no need for sterile gloves)
2. Place client in high Fowler's position
3. Assess nares and oral cavity and select naris
4. Measure and mark the tube
5. Curve 4-6" tube around index finger and release
6. Lubricate end of tube with water-soluble jelly
7. Instruct client to extend neck back slightly
8. Gently insert tube just past nasopharynx, aiming tip downward
9. Rotate tube slightly if resistance is met, allowing rest periods for client
10. Continue insertion until just above oropharynx
11. Ask client to flex head forward and swallow small sips of water (or dry if NPO)
12. Advance tube to marked point
13. Verify tube placement and anchor - use agency policy and procedure to verify placement by anchoring tube in place
and obtaining an abdominal x-ray. Aspirating gastric contents and testing the pH may also give an indication of placement
(pH should be 5.5 or below). Auscultation of inserted air is acceptable for confirming tube placement initially, but
 is not definitive as it is not an evidence-based method. Nothing may be administered through the tube until x-ray
confirmation is obtained, or this may cause aspiration.

During NG tube insertion, the tube sometimes slips into the larynx or coils in the throat, which can result in coughing
and gagging.
The nurse should withdraw the tube slightly and then stop or pause while the client takes a few breaths.
After the client stops coughing, the nurse can proceed with advancement, asking the client to take small sips of water
to facilitate advancement to the stomach.
The client should not be asked to swallow during coughing or aspiration may occur. If resistance or obstruction occurs
during tube advancement, the nurse should rotate the tube while trying to advance it.
If resistance continues, the tube should be withdrawn and inserted into the other naris if possible

FOREIGN BODY ASPIRATION

Foreign body aspiration is an emergency that requires immediate intervention when witnessed or highly suspected.
The primary rescue intervention for adults and children over age 1 is abdominal thrusts, known as the Heimlich
maneuver. This maneuver entails applying upward thrusts with a fist to the upper abdomen just beneath the rib
cage. The upward action causes the diaphragm to forcefully expel air out of the airway, carrying the foreign body out
with it.
If the child is conscious and able to cough or make sounds, the nurse should ask the child to forcefully cough before
intervening. These signs indicate a partial obstruction still allowing airflow, which may be cleared with strong
coughing. However, any signs of respiratory distress (eg, stridor, inability to speak, weak cough, and cyanosis) require
immediate intervention.
Back blows and chest thrusts are appropriate interventions for a choking infant under age 1. Older children require
abdominal thrusts to clear an obstructed airway.
Blind sweeping a child's mouth can force a loosely obstructing object to fully block the airway or cause the object to fall
farther into the airway, requiring surgical removal.
This child is experiencing a blocked airway, which is a medical emergency that requires intervention at the skill level of
a nurse. The nurse can ask a bystander to contact 911 while attempting to clear the airway. This differs from a
situation such as anaphylaxis, in which the nurse would require epinephrine and would call 911 for immediate
assistance.
IFC

Obstruction (eg, clots, sediment), kinking/compression of catheter tubing, bladder spasms, and improper catheter size
can cause leakage of urine from the insertion site of an indwelling urinary catheter.
The nurse's first action should be to assess for a mechanical obstruction by inspecting the catheter tubing
These interventions may alleviate obstruction:

o Remove kinking or compression of the catheter or tubing.

o Attempt to dislodge a visible obstruction by milking the tubing. This involves squeezing and releasing the full length of
the tubing, starting from a point close to the client and ending at the drainage bag.

If these interventions fail, the nurse should then notify the health care provider (HCP)
Irrigation is usually avoided as pus or sediment can be washed back into the bladder; however, it is sometimes
prescribed to relieve an obstruction to urine flow. If there is a discrepancy in expected urine output compared with fluid
intake, a blockage is suspected and a bladder scan is then performed to confirm the presence of urine in the bladder.
The client has the recommended size of catheter and balloon for an adult male. The HCP may prescribe removal and
reinsertion of a different-size catheter if other measures fail to relieve obstruction.
URINE SPECIMEN COLLECTION FROM IFC

CASE: The charge nurse observes a new

staff nurse collecting a urine sample for
urinalysis and culture as pictured. What is
the charge nurse's best action?

ANS: ADVISE THE STAFF NURSE TO

DISCARD THE COLLECTED URINE
SPECIMEN AND RECORD THE OUTPUT
Urine specimens must be collected aseptically from the port located on the catheter tubing of an indwelling urinary
catheter. Obtaining urine from a collection bag is improper technique, and it would not be considered a viable
specimen. In this case, the collected urine should be measured and discarded. Colonization and multiplication of
bacteria within the stagnant urine in the collection bag may occur and cause incorrect results. In addition, some
urinary drainage bags are impregnated with an antimicrobial agent to help prevent catheter-associated urinary tract
infections; these agents can also negatively affect the results of a urinalysis or culture.
To collect a urine specimen:

1. Clean the collection port with an alcohol swab

2. Aspirate urine with a sterile syringe
3. Use aseptic technique to transfer the specimen to a sterile specimen cup
MIXING REGULAR AND NPH INSULINS

CASE: A client with type 1 diabetes has a

prescription for 20 units of NPH insulin
daily at 7:30 AM and regular insulin
before meals, based on a sliding scale.
At 7:00 AM, the client's blood glucose
level is 220 mg/dL (12.2 mmol/L), and the
client's breakfast tray has arrived. What
action should the nurse take?
ANS: ADMINISTER 26 U OF NPH
MIXED WITH 6 U OF REGULAR
INSULIN IN THE SAME SYRINGE,
DRAWING UP THE REGULAR INSULIN
FIRST

Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular) and rapid-acting (lispro, aspart)
insulins in one syringe (Option 4). Six units of regular insulin are needed to address the client's blood glucose reading
(220 mg/dL [12.21 mmol/L]) along with the scheduled 20 units of NPH insulin.
Prepare the mixed dose:

1. Inject the NPH insulin vial with 20 units of air without inverting the vial or passing the needle into the solution.
2. Inject 6 units of air into the regular insulin vial and withdraw the dose, leaving no air bubble.
3. Draw NPH, totaling 26 units in one syringe. Any overdraw of NPH into the syringe will necessitate wasting the total
quantity.

Most long-acting insulins (eg, glargine, detemir) are not suitable for mixing and typically are packaged in prefilled
injection pens.
The 2 insulins may be safely given together before the meal because regular insulin has a rapid onset of action,
whereas NPH has a slower onset but longer duration.
The insulins can be given as 2 separate injections; however, this increases client discomfort and infection risk.
Regular insulin should be drawn first to avoid contaminating the regular insulin vial with NPH insulin (mnemonic
RN: Regular comes before NPH).
 When drawing up multiple insulins, there is a risk for contaminating the shorter-acting vials with the longer-acting
insulin, which would slow the action of later doses withdrawn from the shorter-acting insulin vial. Multidose vials of
regular insulin that have been contaminated with other insulins are unsafe for IV administration. When drawing up
multiple insulins, the nurse should:

1. Clean both vial tops with alcohol swabs (Option 1).

2. Inject air into the NPH insulin vial without touching the needle to the solution (Option 4).
3. Withdraw the needle from the NPH insulin vial and inject air into the regular insulin vial (Option 5).
4. Invert the regular vial and withdraw the regular solution into the syringe (Option 3).
5. Insert the needle into the NPH insulin vial and withdraw the solution

INTRADERMAL INJECTIONS

Intradermal dermal injections deliver a small amount of medication (0.1 mL) into the dermal layer of the skin, just under
the epidermis. This parenteral route is used to perform allergy testing and tuberculosis (TB) screening.
The correct procedure for administering a TB intradermal injection is as follows:
1. Choose a 1 mL tuberculin syringe with a 27-gauge 1/4 inch needle then don clean gloves the syringe is
calibrated in hundredths of a millimeter and the intradermal needle is short enough to remain in the dermis with
length range of 1/4-5/8 inch
2. Position the left forearm to face upward, and cleanse site that is a hands width above the wrist the left arm is
commonly used for TB testing; the forearm has little hair and subcutaneous tissue and is readily accessible to
observe a skin reaction.
3. Place non-dominant hand 1 inch below the insertion site and pull skin downward so that it is taut taut skin
makes it easier to insert the needle and promotes comfort.
4. Insert the needle almost parallel to skin at a 10-degree angle with bevel up this is important as the medication
can enter the subcutaneous tissue if the angle is >15 degrees
5. Advance the tip of the needle through epidermis into dermis; outline of bevel should be visible under the skin
verify that the medication will be injected into dermis
 6. Inject medication slowly while raising a small wheal (bleb) on the skin verify that the medication is being
deposited into the dermis
7. Remove needle and do not rub the area rubbing promotes leakage through the insertion site and medication
deposition into the tissue.
8. Circle the area with a pen to assess for redness and induration (according to institution policy) this delineates
the border for measurement of reaction.
CENTRAL VENOUS CATHETER
Leakage of more than 500 mL of air into a central venous catheter is potentially fatal. An air embolism in the small
pulmonary capillaries obstructs blood circulation. A central venous catheter leaks air rapidly at 100 mL/sec. This
client requires immediate intervention to prevent further complications (eg, cardiac arrest, death). The nurse should
not delay emergency treatment, not even to stop and contact the HCP or the rapid response team (RRT).
Priority interventions for active or suspected air embolism are as follows:

1. Clamp the catheter to prevent more air from embolizing into the venous circulation.
2. Place the client in Trendelenburg position on the left side, causing any existing air to rise and become trapped in the right
atrium.
3. Administer oxygen if necessary to relieve dyspnea.
4. Notify the HCP or call an RRT to provide further resuscitation measures.
5. Stay with the client to provide reassurance and monitoring as the air trapped in the right atrium is slowly absorbed into the
bloodstream over the course of a few hours.

Flushing the lumen of a central venous access device (central venous catheter [CVC]) with normal saline is
recommended to assess patency before medication infusion, prevent medication incompatibilities after infusion, and
prevent occlusion after blood sampling.
A 10-mL syringe is generally preferred for flushing the lumen of a CVC
The smaller the syringe, the greater the amount of pressure per square inch exerted during injection, increasing the
risk for damage to the CVC.
The "push-pause" method involves slowly injecting normal saline into the CVC catheter and stopping for any
resistance. Injecting against resistance can damage the CVC, which may result in complications,
 including embolism and malfunction. The nurse should always consult the specific manufacturer guidelines and
facility policy when caring for a CVC.
A smaller syringe (eg, 1 mL, 3 mL) creates more pressure, which increases the risk for damage to the CVC.
A 30-mL syringe is unnecessarily large to flush a CVC.

CONDOM CATHETER

Paraphimosis occurs when the uncircumcised male foreskin cannot be returned (reduced) to its original position, after
being pulled back (retracted) behind the glans penis, resulting in pain, progressive swelling of the foreskin, and
impaired lymph and blood flow.
Paraphimosis can occur when a health care worker accidentally leaves the foreskin in the retracted position for an
extended period of time (eg, under a condom catheter sheath). It is critical for the precepting nurse to intervene when
the student nurse retracts the foreskin before applying the condom catheter to avoid permanent damage to the glans
resulting from impaired circulation
The drainage tubing is attached to a leg collection bag in a mobile client to enable ambulation, prevent tube kinking,
and facilitate gravity drainage.
A 1-2 in (2.5-5 cm) space should be left between the tip of the penis and the end of the condom to prevent penile
irritation and pooling of urine in the condom.
If the condom catheter is not self-adhesive, elastic adhesive is used in a spiral fashion to secure the device to the
penis. Adhesive tape may cause irritation and/or injury, and should not be used.

ABDOMINAL ASSESSMENT

Nursing assessments are generally performed in order of least to most invasive.

To perform an abdominal assessment, the nurse places the client in the supine position to promote relaxation of the
abdominal muscles. Standing on the right side of the client, the nurse makes a visual inspection of the abdomen
before touching the client.
After inspection, the nurse auscultates the abdomen. Auscultation is performed next because percussion and
palpation may increase peristalsis, potentially leading the nurse to make an erroneous interpretation of bowel sounds.
The nurse should lightly place the diaphragm of the stethoscope in the right lower quadrant because high-pitched
bowel sounds are normally present in this region.
 After auscultation, the nurse proceeds to percussion.
Palpation is performed last because it may induce pain, resulting in abdominal rigidity, guarding, and a change in
respirations. This rigidity may affect the tone heard on percussion. Percussion is also intended to identify borders of
organs that move with respiration (eg, liver, spleen).
A client in pain from abdominal tenderness will likely take quick, shallow breaths, which will change how far organs are
displaced and make it more difficult for the examiner to identify true borders of organs.
ENTERAL FEEDING
Enteral feedings are given to provide nutrition to clients who are unable to take in nutrients by mouth. Placement verification is
imperative prior to initiating enteral feedings to prevent complications such as aspiration. Lung aspiration can lead to pneumonia,
acute respiratory distress syndrome, and abscess formation. Methods to verify the tube placement include the following:

1. Imaging - visualization of tube placement by x-ray is the standard protocol to ensure proper placement prior to initiating
enteral tube feedings
2. Gastric content pH testing - although testing the pH of aspirated contents is an evidence-based method, it is typically used
to assess for displacement after initial x-ray verification. It can also be used to test the position of the tube prior to each feed
as the frequent x-rays expose the client to radiation. Gastric pH is usually acidic (<5) because of acid secretion.
indicates bronchial secretions and incorrect placement.
3. Air auscultation - verification by auscultating air is not an evidence-based method for placement verification

After placement is verified, the nurse may flush the tube with water, administer prescribed medications, flush the tube
again, and then prepare and deliver the enteral feeding
A nasoenteric feeding tube is used for administration of continual or intermittent enteral feedings and medications.
The tube is marked at the exit site (nare) with indelible ink during the initial placement x-ray. The tube may have
moved out of the correct position if its external length changes. If this occurs, the nurse should contact the health care
provider (HCP) and request a prescription for a repeat x-ray to determine tube location. Based on the x-ray results,
enteral feeding may be resumed or the HCP may prescribe insertion of a new tube according to institution policy
Even if bedside methods to determine placement are used (eg, gastric aspirate pH and appearance), advancing the
tube to the original marking does not guarantee correct placement; these methods are not accurate indicators. Tube
feedings should not be resumed after tube dislodgment without x-ray verification of correct placement.
A prescription for hand mitts to keep a confused client from disrupting enteral nutrition may be appropriate if other less
restrictive interventions (eg, keeping tubing out of client's sight, one-on-one sitter) are ineffective or unavailable.
However, this should not be the nurse's next action.
The guide wire (stylet) is secured before tube insertion and remains in place until placement is verified by x-ray. Once
removed, the guide wire should never be reinserted while the tube is in place as it can protrude and damage both the
tube and the client's mucosa.
When administering bolus enteral feedings, the nurse should elevate the head of the bed to 30-45 degrees (semi-
Fowler position) and keep it elevated for 30-60 minutes afterwards to decrease aspiration risk.
Many institutions require the nurse to hold feeding if the client must remain supine (eg, diagnostic tests).
Feeding tubes should be flushed before and after feedings to keep the tube patent
Gastric residual volumes (GRVs) are traditionally checked every 4 hours with continuous feeding or before each bolus
feeding. Per facility policy, enteral feedings may be held for high GRV (eg, >500 mL) to reduce aspiration risk. Low
GRV indicates that the client is tolerating feedings well
Some facilities no longer routinely check GRVs because recent evidence shows that the procedure may not truly
indicate aspiration risk and actually impairs calorie delivery.
Regardless of GRV checks, the nurse should closely monitor clients for symptoms of intolerance (eg, abdominal
distension, nausea/vomiting), which may indicate that feedings should be held or reduced in volume.
Aspirated GRV should be returned to the stomach. If acidic gastric juices are repeatedly discarded, there is risk for
hypokalemia and metabolic alkalosis.
( -ray confirmation of tube placement. Newly inserted
nasogastric tubes also require x-ray confirmation before feedings are initiated.

Failure to correctly administer medications through feeding tubes (eg, nasogastric, gastrostomy) can result in
obstruction of the tube, reduced medication absorption or efficacy, and medication toxicity. Before administering
medications through a feeding tube, the nurse should determine if any of the medications are available in a liquid
form because liquid medications are less likely to clog the tube
Medications should be crushed, dissolved, and administered separately to prevent interactions (eg, chemical
reactions) between medications or interference with absorption.
In addition, a feeding tube should be flushed before and after each medication is given to avoid potential drug
interactions and ensure tube patency
When using a feeding tube, each medication should be administered individually to prevent interactions between
medications.
 Medications mixed with enteral feedings may form a thick consistency and clog the tube.
HEART AUSCULTATION

Aortic stenosis (AS) is a type of valvular heart disease characterized by narrowing of the aortic valve opening, which
limits the left ventricle's ability to eject blood into the aorta.
AS may occur from hardening (ie, calcification) of the valves, congenital heart disorders, or inflammation. If left
untreated, AS may result in heart failure and pulmonary hypertension as compensatory mechanisms fail.
When assessing a client with AS, the nurse should auscultate in the aortic area (ie, second intercostal space at the
right sternal border) for a loud, systolic ejection murmur heard following the first heart sound.
The aortic area, rather than directly over the heart valve, is the preferred location for auscultation as the heart sounds
travel in the direction the blood flows. Additional clinical manifestations of aortic stenosis include chest pain, shortness
of breath, and/or syncope that are worsened by exertion.

NEONATAL HEEL STICK

 The neonatal heel stick (heel lancing) is used to collect a blood sample to assess capillary glucose and perform
newborn screening for inherited disorders (eg, congenital hypothyroidism, phenylketonuria).
Proper technique is essential for minimizing discomfort and preventing complications and includes:

o Select a location on the medial or lateral side of the outer aspect of the heel. Avoid the center of the heel to prevent
accidental insult to the calcaneus. Puncture should not occur over edematous or infected skin.
o Warm the heel for several minutes with a warm towel compress or approved single-use instant heat pack to promote
vasodilation. Cleanse the intended puncture site with alcohol. Sucrose and nonnutritive sucking on a pacifier may reduce
procedural pain.
o Use an automatic lancet, which controls the depth of puncture. Lancing the heel too deeply can result in penetration of the
calcaneus bone, leading to osteochondritis or osteomyelitis.

An acceptable alternate method of blood collection in the neonate is venipuncture (ie, drawing blood from a vein).
Venipuncture is considered less painful and often requires fewer punctures to obtain a sample, especially if a larger
volume is needed

TRACHEOSTOMY CARE

When performing tracheostomy care, the nurse follows institution policy and observes principles of infection control
and client safety. Sterile technique is used to prevent infection of the lower airway. The steps for performing the
procedure for a client with a disposable inner cannula include the following:

1. Gather supplies to the bedside, then place client in semi-Fowler's position, if not contraindicated, to promote lung
expansion and oxygenation and prevent aspiration of secretions.
2. Don personal protective equipment (mask, goggles, and clean gloves) to maintain universal precautions. Auscultate lungs
and suction secretions if necessary.
3. Remove soiled dressing and also remove clean gloves.
4. Don sterile gloves; remove old disposable cannula and replace with a new one. While stabilizing the back plate with the
nondominant hand, unlock (unclip) the old cannula with the dominant hand; remove gently by pulling it out in line with its
curvature; pick up the new cannula, touching only the outer locking portion (to prevent contamination and maintain asepsis);
insert; and lock (clip) into place.
5. Clean around stoma with sterile water or saline, dry and replace sterile gauze pad to remove dried secretions, and dry
around stoma well to limit the growth of microorganisms. Some tracheostomy tubes are sutured in place and do not require a
dressing. If secretions are copious, apply a dressing.
 The process of suctioning a client's airway removes oxygen in addition to the secretions; therefore, the client should
be preoxygenated with 100% O2, and suction should be applied for no more than 10 seconds during each pass to
prevent hypoxia
The nurse must wait 1-2 minutes between passes for the client to ventilate to prevent hypoxia
In addition, deep rebreathing should be encouraged.
The suction catheter should be no more than half the width of the artificial airway and inserted without suction.
The nurse should don sterile gloves if the client does not have a closed suction system in place. Suction should be set
at medium pressure (100-120 mm Hg for adults, 50-75 mm Hg for children) as excess pressure will traumatize the
mucosa and can cause hypoxia.
Clients usually cough as the catheter enters the trachea, and this helps loosen secretions. The catheter should be
advanced until resistance is felt and then, to prevent mucosal damage, retracted 1 cm before applying suction.

PULSUS PARADOXOSUS

Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade. This
results in the build-up of fluid in the pericardial sac, which leads to compression of the heart.
Cardiac output begins to fall as cardiac compression increases, resulting in hypotension.
Additional signs and symptoms of tamponade include tachypnea, tachycardia, jugular venous distension, narrowed
pulse pressure, and the presence of a pulsus paradoxus.
Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration.
The procedure for measurement of pulsus paradoxus is as follows:

1. Place client in semirecumbent position

2. Have client breathe normally
3. Determine the SBP using a manual BP cuff
4. Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP
5. Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure
6. Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure
7. Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox
8. The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade.
VENIPUNCTURE

A tourniquet is applied 3-5 inches above the desired puncture site for no longer than 1 minute when looking for a vein.
If longer time is needed, release the tourniquet for at least 3 minutes before reapplying.
Prolonged obstruction of blood flow by the tourniquet can change some test results.
Pulsating bright red blood indicates that an artery was accessed. If this happens, the needle should be removed
immediately and pressure should be applied for at least 5 minutes, followed by a pressure dressing to prevent a
hematoma.
Skin preparation involves cleaning using an antiseptic solution and friction and allowing the skin to air dry. Remaining
solution may hemolyze and/or dilute the blood sample.
Traditionally, alcohol (alone or with povidone iodine) is applied in a circular motion, from insertion site outward (clean
to dirty).
Current research suggests that the most effective method is applying chlorhexidine (2%) in a back and forth motion,
followed by adequate drying time.
The veins on the ventral aspect of the wrist are located near nerves, resulting in painful venipuncture and a higher risk
of nerve injury. There is also an increased risk of arterial access on the ventral aspect of the wrist, and so this site
should be avoided.
The filled tube should be gently inverted 5-10 times to mix anticoagulant solution with the blood. Vigorously shaking
the tube can cause hemolysis and false results.
The preferred site for venipuncture when collecting blood specimens is the antecubital fossa's median cubital vein.
The basilic vein lies close to the brachial nerve and artery. When severe, shooting pain radiates down a client's arm
during venipuncture, nerve injury may be occurring. The client may also report feelings of "pins and needles" or
numbness at and/or near the venipuncture site. If this occurs, the nurse should promptly withdraw the needle, obtain
new equipment, and choose a different site for specimen collection
(Because the pain and numbness during venipuncture indicate a nerve injury, the nurse should reattempt the
specimen collection using a different site. Reattempting at the same site with a smaller-gauge needle or from a
different angle could cause nerve damage.
Reassurance may help calm an anxious client, and stabilization may help prevent injury if a client attempts to withdraw
the arm during routine venipuncture. However, this client has nerve pain, which indicates that the attempt should be
stopped immediately to prevent nerve damage.
THORACENTESIS

Thoracentesis is commonly used to treat pleural effusion. The health care provider (HCP) will prepare the skin, inject
a local anesthetic, and then insert a needle between the ribs into the pleural space where the fluid is located.
A complication of thoracentesis is pneumothorax, which occurs when the needle goes into the lung and causes the
lung to slowly deflate, like a balloon with a small hole in it. Bleeding is another, yet less common, complication of the
procedure.
Signs of pneumothorax include increased respiratory rate, increased respiratory effort, respiratory distress, low oxygen
saturation, and absent breath sounds on the side where the procedure was done (where the lung is collapsed).
Tension pneumothorax may also develop, with tracheal shift to the unaffected side, severe respiratory distress, and
cardiovascular compromise. Altered level of consciousness may occur due to decreased oxygenation and blood flow
to the brain.
A tension pneumothorax may be prevented by early detection of pneumothorax through appropriate monitoring.
Infection would be a later complication (occurring a few days after the procedure), so monitoring temperature is not
required during the initial postprocedure period.
Urine output should not be affected by thoracentesis or the drugs administered for this procedure.

ORTHOSTATIC VITAL SIGNS

Orthostatic vital signs help assess the body's ability to compensate hemodynamically during postural changes.
Changing position normally triggers vasoconstriction in the extremities to promote venous return. Without this
response, hypotension and subsequent hypoperfusion of internal organs and the brain occur.
Clients with impaired compensatory mechanisms (eg, hypovolemia, sepsis) may exhibit orthostatic hypotension, in
which hypotension and/or neurologic impairment (eg, syncope) occur with position change. This increases the
client's risk for falls.
Orthostatic vital signs involve measuring the client's blood pressure (BP) and heart rate in the supine, sitting, and
standing positions. Each measurement should be obtained after maintaining each position for 2 minutes.
If any position change produces decreased systolic BP , decreased diastolic BP m Hg, and/or

recumbent position, and notify the health care provider

 It is unsafe to assist the client to a standing position after identifying orthostatic hypotension, as a syncopal event may
occur and the client may fall.
Positioning the client in reverse Trendelenburg position and reassessing BP at a different site in the supine position
are unnecessary and delay treatment of orthostatic hypotension.

CLEANSING ENEMA

Cleansing enemas (eg, normal saline, soapsuds, tap water) relieve constipation by stimulating intestinal peristalsis.
When administering an enema, appropriate interventions include:

o Place the client in a left lateral position with the right knee flexed (ie, Sims position) to promote flow of the enema into the
colon
o Hang the enema bag no more than 12 in (30 cm) above the rectum to avoid overly rapid administration.
o Lubricate the enema tubing tip and gently insert 3-4 in (7.6-10 cm) into the rectum.
o Direct the tubing tip toward the umbilicus (ie, anteriorly) during insertion to prevent intestinal perforation
o Encourage the client to retain the enema for as long as possible (eg, 5-10 minutes)
o Open the roller clamp on the tubing to allow the solution to flow in by gravity. If the client reports abdominal cramping, use
the roller clamp to slow the rate of administration

Enemas are administered at room temperature or warmed, as cold enema solutions cause intestinal spasms and
painful cramping. Enemas may be warmed by placing the container of solution in a basin of hot water.
TRIPLE LUMEN CATHETER

Catheter occlusion is the most common complication of central venous access devices. Kinked tubing, catheter
malposition, medication precipitate, or thrombus can occlude the lumen, preventing the ability to flush or aspirate
blood.
The nurse should first assess for mechanical, nonthrombotic problems by:

1. Repositioning the client (eg, head, arm) as the catheter tip may be resting against a vessel wall (
2. Assessing IV tubing for clamps, kinks, and precipitate
 The nurse should then attempt to flush the device again. If the occlusion remains, the nurse should not flush against
resistance as applying force may damage the catheter or dislodge a thrombus. Instead, the nurse should contact the
health care provider (HCP), who may prescribe medication (ie, alteplase) to dissolve a thrombus or fibrin sheath.
Most needleless connector manufacturers recommend flushing with normal saline. Some facilities may use
heparinized saline flushes; the nurse should follow HCP prescriptions and institution guidelines. Heparin flushes
should be at the lowest acceptable dose (eg, 10 units/mL) to prevent heparin-induced thrombocytopenia.
Flushing with a syringe smaller than 10 mL causes increased intraluminal pressure and may damage the catheter.
The nurse should rule out a mechanical problem before notifying the HCP.
A central line or central venous catheter (CVC) is inserted by the health care provider in a "central" vein (eg,
subclavian, internal jugular, femoral) and is used to administer fluids, medications, and parenteral nutrition and for
hemodynamic monitoring.
Proper hand hygiene should be performed when caring for a CVC to prevent infection, and nonsterile gloves should
be worn to protect the nurse from blood or body fluids at the port site as one or more lumens are often used to draw
blood
The Centers for Disease Control and Prevention recommend that catheter hubs always be handled aseptically to
prevent catheter-associated infections. The hubs should be disinfected with a hospital-approved antiseptic (eg, 70%
alcohol sterile pads; > 0.5% chlorhexidine with alcohol; 10% povidone-iodine). Always allow the antiseptic to
dry before using the hub/port
CVCs may have multiple lumens. These are used to administer incompatible drugs simultaneously, for blood draws,
and for hemodynamic monitoring

PHLEBOTOMY

When performing phlebotomy, clean the site, "fix" or hold the vein taut, and then insert the needle bevel up at a 15-
degree angle (no steeper than 30 degree). Some recommend bevel down for children. This will help prevent going
through the vein completely.
The Infusion Nurses Society (INS) identifies the standard of care as no more than 2 attempts by any 1 individual. If
the nurse is unable to successfully draw blood after 2 attempts, a phlebotomist or a different nurse should be asked to
complete the blood draw.
The affected side of a client who has had a mastectomy (especially with lymph node removal) should not be used. It
places the client at risk for infection and lymphedema.
 An arm without IV infusion is preferred. If it is necessary to use the arm with the IV infusion, the specimen should be
collected from a vein several centimeters below (distal to) the point of IV infusion, with the tourniquet placed in
between.
The finger specimen should be obtained from the third or fourth finger on the side of the fingertip, midway between the
edge and midpoint. The puncture should be made perpendicular to the fingerprint ridges. Puncture parallel to the
ridges tends to make the blood run down the ridges and will hamper collection.
A heel stick collection on an infant should be done on the plantar surface.

INCENTIVE SPIROMETRY

Incentive spirometry is recommended in postoperative clients to prevent atelectasis associated with incisional pain,
especially in upper abdominal incisions (close to the diaphragm).
Adequate pain medication should be administered before using the incentive spirometry.
Guidelines recommend 5-10 breaths per session every hour while awake. Volume-oriented or flow-oriented
sustained maximal inspiration (SMI) devices can be used.
The client instructions for using a volume-oriented SMI device include:

1. Assume a sitting or high Fowler position, which optimizes lung expansion, and exhale normally
2. While holding the device at an even level, seal the lips tightly on the mouthpiece to prevent leakage of air around it
3. Inhale deeply through the mouth until the piston is elevated to the predetermined level of tidal volume. The piston is visible
on the device and helps provide motivation.
4. Hold the breath for at least 2-3 seconds (up to 6 seconds) as this maintains maximal inhalation
5. Exhale slowly to prevent hyperventilation
6. Breathe normally for several breaths before repeating the process
7. Cough at the end of the session to help with secretion expectoration

VENIPUNCTURE

A modified radical mastectomy includes removal of axillary lymph nodes that are involved in lymphatic drainage of the
arm. Any trauma (eg, IV extravasation) to the arm on the operative side can result in lymphedema, characterized by
painful and lengthy swelling, as normal lymphatic circulation is impaired by scarring. Therefore, starting an IV line in
this arm is contraindicated.
The nurse should insert the IV line into the most distal site of the unaffected side.
 For client safety, it is also important to ensure documentation of the mastectomy history, place a restricted
extremity armband on the affected arm, and place a sign above the client's bed notifying hospital staff of
necessary mastectomy precautions (eg, no blood pressure measurements, venipuncture, or IV lines)
In general, venipuncture is contraindicated in upper extremities affected by:

o Weakness
o Paralysis
o Infection
o Arteriovenous fistula or graft (used for hemodialysis)
o Impaired lymphatic drainage (prior mastectomy)

The stylet should be advanced until blood return is seen (approximately ¼ inch). If advanced fully, the stylet may
penetrate the posterior wall of the vein and cause a hematoma.
Keeping the affected arm in a dependent position for a long time can increase lymphedema. The client should be
reminded that raising the limb helps drainage.
The client's medical history should be reviewed prior to starting an IV line so that the nurse can identify any
contraindications to specific anatomical sites.
Lymph node removal during a mastectomy may affect lymphatic fluid drainage on the affected side and
cause lymphedema or other complications such as infection, venous thromboembolism, or trauma to the affected
arm.
The nurse must avoid any needlesticks, IV insertions, or blood pressure measurements in the affected arm
The nondominant side is preferred when no medical contraindications exist. However, in this case, the right forearm is
best because the client had a left-sided mastectomy
Other considerations when selecting IV sites include avoidance of areas that have obstructed blood flow, dialysis sites,
areas distal to old puncture sites, bruised areas, painful areas, or areas with skin conditions or signs of infection.
The antecubital space should be avoided when possible (except for emergency insertion) as it inhibits mobility and
may be positional.

URINE DIPSTICK

The protein test pad measures the amount of albumin in the urine. Normally, there will not be detectable quantities.
 Albumin is smaller than most other proteins and is typically the first protein that is seen in the urine when kidney
dysfunction begins to develop.
Proteinuria is characterized by elevated urine protein and can be an early sign of kidney disease. Occasional loss of
up to 150 mg/day of protein in the urine, which may reflect as negative or trace protein on a dipstick, is typically
considered normal and usually does not require further evaluation.
Common benign causes of transient proteinuria include fever, strenuous exercise, and prolonged standing.

TIMED URINE COLLECTION TESTS

Timed urine collection tests are usually done to assess kidney function and measure substances excreted in the
urine (eg, creatinine, protein, uric acid, hormones). These tests require the collection of all urine produced in
a specified time period (a crucial step) to ensure accurate test results. The proper container (with or without
preservative) for any specific test is obtained from the laboratory. The collection container must be kept cool (eg, on
ice, refrigerated) to prevent bacterial decomposition of the urine.
Not all of the client's urine was saved during the collection period. Therefore, the nurse or UAP must discard the urine
and container and restart the specimen collection procedure.
Although a 24-hour urine collection can begin at any time of the day after the client empties the bladder, it is common
practice to start the collection in the morning after the client's first morning voiding and to end it at the same
hour the next morning after the morning voiding
To start the collection period, the nurse asks the client to void and discards this specimen (it is not added to the
collection container). The 24-hour period starts at the time of the client's first voiding.

MODIFIED THREE-POINT GAIT

Clients prescribed crutches after a musculoskeletal injury must be educated on appropriate device use to facilitate
independent ambulation, promote wound healing, and prevent reinjury.
A common method used to climb stairs is the modified three-point gait ("leading with the good leg"), which is used to
prevent weight-bearing on the injured leg.
Nurses should instruct clients with crutches to use the following steps to ascend the stairs with the modified three-
point gait:
 1. Assume the tripod position (ie, crutch stance) and place body weight on the crutches while preparing to move
the unaffected leg.
2. Place the unaffected leg (ie, good leg) onto the step.
3. Transfer body weight from the crutches to the unaffected leg and then use the unaffected leg (ie, good leg) to
raise the body up onto the step.
4. Advance the affected leg and the crutches together up the step.
5. Realign the crutches with the unaffected leg on the step before repeating the process.

PULSE OXIMETER READING

A pulse oximeter is a noninvasive device that estimates arterial blood oxygen saturation by using a sensor attached
to the client's finger, toe, earlobe, nose, or forehead.
The sensor (reusable clip or disposable adhesive) contains light-emitting and light-sensing components that measure
the amount of light absorbed by oxygenated hemoglobin. Because the sensor estimates the value at
a peripheral site, the pulse oximeter measurement is reported as blood oxygen saturation (SpO2).
Normal SpO2 for a healthy client is 95%-100%. Any factor that affects light transmission or peripheral blood
flow can result in a false reading. Common causative factors of falsely low SpO2 include:

Dark fingernail polish or artificial acrylic nails

Hypotension and low cardiac output (eg, heart failure)
Vasoconstriction (eg, hypothermia, vasopressor medications)
Peripheral arterial disease

EPIPEN

The EpiPen is designed to be administered through clothing with a swing and firm push against the mid-outer
thigh until the injector clicks.
The position should be held for 10 seconds to allow the entire contents to be injected
 The site should be massaged for an additional 10 seconds. Timing is essential in the delivery of epinephrine during
an anaphylactic reaction.
The nurse should administer the medication immediately on the playground without removing the child's clothing. Any
delays can cause client deterioration and make maintenance of a patent airway difficult
The EpiPen should be injected into the mid-outer thigh, not the upper arm.
A critical part of self-care for a person with a history of anaphylactic reaction is the use of emergency epinephrine
injection (EpiPen or EpiPen Jr). The client and/or caregiver should be taught the following principles:

o The EpiPen should always be available for emergency use and so should be taken along (in purse, pocket, backpack) when
the client leaves home
o The EpiPen should be given when the client first notices any anaphylactic symptoms, such as tightening or swelling of the
airway, difficulty breathing, wheezing, stridor, or shock
o The injection should be given in the mid-outer thigh and can be given through clothing
o The client should receive emergency care as soon as possible by calling 911 or going to the emergency department to
monitor for further problems

INTRAMUSCULAR INJECTIONS

Intramuscular (IM) injections (eg, hepatitis B vaccine, vitamin K) are commonly administered to newborns shortly
after birth or before discharge.
The vastus lateralis muscle in the anterolateral middle portion of the thigh is the preferred site for IM injections in
newborns (age <1 month) and infants (age 1-12 months).
The deltoid muscle is an inappropriate injection site for newborns due to inadequate muscle mass

adequate for reaching the muscle mass while avoiding underlying tissues (eg, nerves, bone). A 22- to 25-gauge
needle is appropriate for clients age <12 months.

FEMALE IFC INSERTION

Steps for indwelling urinary catheter insertion for the female client include:

o Position the client supine with knees flexed and hips slightly externally rotated.
o Perform hand hygiene and open a sterile catheterization kit
o Apply sterile gloves and place a sterile drape underneath the client's buttocks
 o Remove the protective covering from the catheter, lubricate the catheter tip, and pour antiseptic solution over cotton balls or
swab sticks while maintaining sterility of gloves and sterile field.
o Use the nondominant hand to gently spread the labia. The nondominant hand is now contaminated
o Use the dominant (sterile) hand to cleanse the labia and urinary meatus with antiseptic-soaked cotton balls or swab
sticks. Cleanse in an anteroposterior direction (from the clitoris toward the anus). Use a new swab for each swipe to
avoid transferring bacteria between areas. Cleanse the labia majora first, then the labia minora, and lastly the urinary
meatus
o Use the dominant hand to insert the catheter until urine return is visualized in the tubing (usually 2-3 inch [5-7.6 cm]), and
then advance it an additional 1-2 inch (2.5-5 cm)
o Hold the catheter in place with the nondominant hand, and then use the dominant hand to inflate the balloon.

CANE

To prevent falls after a total knee replacement, clients should use a cane to provide maximum support when climbing
up and down any stairs. Clients should hold the cane on the stronger side and move the cane before moving the
weaker leg, regardless of the direction. Clients must also keep 2 points of support on the floor at all times (ie, both
feet, foot and cane).
When descending stairs, the client should:

1. Lead with the cane

2. Bring the weaker leg down next (in this client, it is the left leg)
3. Finally, step down with the stronger leg

When ascending stairs, the client should:

1. Step up with the stronger leg first

2. Move the cane next, while bearing weight on the stronger leg
3. Finally, move the weaker leg

To remember the order, use the mnemonic "up with the good and down with the bad." The cane always moves
before the weaker leg.
PERIPHERAL ARTERIAL PULSES

The DP pulse is located on the top or dorsal part of the foot.

The nurse should compare the characteristics of the arteries on the right and left extremities simultaneously to
determine symmetry.
The force of the pulse should be rated on the following scale.

0 Absent

1+ Weak

2+ Normal

3+ Increased, full, bounding

OROPHARYNGEAL AIRWAY

An oropharyngeal airway (OPA) is a temporary, artificial airway device used to prevent tongue displacement and
tracheal obstruction in clients who are sedated or unconscious.
As consciousness and the ability to protect the airway return, the client will often cough or gag, indicating a need to
remove the OPA; clients may also independently remove or expel the OPA.
Nurses caring for a client with an OPA must ensure that the device is easily removable from the client's mouth, as an
obstructed (eg, taped) OPA may cause choking and aspiration
The OPA should be inserted with the distal end pointing upward toward the roof of the mouth to prevent displacement
of the tongue and obstruction of the trachea.
Once the OPA reaches the soft palate (eg, back of the mouth), the nurse rotates the OPA tip downward toward the
esophagus, which pushes the tongue forward and maintains airway patency.
Appropriate OPA size should be measured prior to insertion, as inappropriate size could push the tongue back and
cause airway obstruction.
 The OPA should be measured with the flange next to the client's cheek. With correct sizing, the OPA curve will reach
the jaw angle.

WOUND IRRIGATION

Before an open wound is closed, irrigation is performed to wash out debris and bacteria to ensure appropriate wound
healing. This is important for wounds obtained in an outdoor environment (eg, playground) as contamination with soil
or dirt greatly increases the risk of infection.
To perform wound irrigation:

o Administer the analgesic 30-60 minutes before the procedure to allow medication to reach therapeutic effect
o Don a gown and mask with face shield to protect from splashing fluid and sterile gloves to maintain surgical asepsis and
prevent infection.
o Fill a 30- to 60-mL sterile irrigation syringe with the prescribed irrigation solution.
o Attach an 18- or 19-gauge needle or angiocatheter to the syringe and hold 1 in (2.5 cm) above the area.
o Use continuous pressure to flush the wound, repeating until drainage is clear
o Dry the surrounding wound area to prevent skin breakdown and irritation.

Immunization history is reviewed to determine tetanus vaccination status

Typically, a tetanus vaccination is administered if the client has not had one within the last 5-10 years, depending on
the contamination level of the wound.
Wounds should be cleaned from the least to the most contaminated area to prevent recontamination.
A 10-mL syringe would require frequent refilling; a larger syringe is more appropriate. The narrow lumen of a 27-
gauge needle would provide excessive irrigation pressure.

HEARING AID

Proper use and care of hearing aids is essential to the success of hearing aid therapy and is associated with
improved outcomes. Proper hearing aid use and care include:
o Minimize distracting sounds (eg, television, radio) during conversation to enhance effectiveness
o Turn the volume off prior to insertion, then gradually turn up the volume to a comfortable level
 o To adjust to the new hearing aids, initially wear them for a short time (eg, 20 minutes) and gradually increase length of
wear time.
o Do not wear the hearing aids when using hair dryers or heat lamps.
o Regularly check that the battery compartment is clean, the batteries are inserted correctly, and the compartment is shut
before insertion
o Remove the battery (if possible) at night and when the aid is not in use to extend battery life.

Each aid must be cleaned with a soft cloth. Hearing aids should not be immersed in water, as this can damage the
electrical components.
Store hearing aids in a safe, dry place when not in use. This will help prevent the hearing aids from becoming lost or
damaged.

EXTRAVASATION

Extravasation is the infiltration of a drug into the tissue surrounding the vein.
Norepinephrine (Levophed) is a vasoconstrictor and vesicant that can cause skin breakdown and/or necrosis if
absorbed into the tissue.
Pain, blanching, swelling, and redness are signs of extravasation. Norepinephrine should be infused through a central
line when possible. However, it may be infused at lower concentrations via a large peripheral vein for up to 12 hours
until central venous access is established.
The nurse should implement the following interventions to manage norepinephrine extravasation:

o Stop the infusion immediately and disconnect the IV tubing

o Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while aspirating.
o Elevate the extremity above the heart to reduce edema
o Notify the health care provider and obtain a prescription for the antidote phentolamine (Regitine), a vasodilator that is
injected subcutaneously to counteract the effects of some adrenergic agonists (eg, norepinephrine, dopamine)

The nurse should not flush the infiltrated IV site or use it for further drug administration. Although new IV access must
be obtained, access should be established ideally through a central line or on an unaffected extremity.
LUMBAR PUNCTURE

A lumbar puncture (spinal tap) is a sterile procedure used to gather a specimen of cerebrospinal fluid (CSF) for
diagnostic purposes (eg, meningitis). A needle is inserted into the vertebral spaces between L3 and L4 or L4 and L5,
and a sample of CSF is drawn. The nurse's role when assisting with a lumbar puncture includes the following:

1. Verify informed consent

2. Gather the lumbar puncture tray and needed supplies
3. Explain the procedure to older child and adult
4. Have client empty the bladder
5. Place client in the appropriate position (eg, side-lying with knees drawn up and head flexed or sitting up and bent forward
over a bedside table)
6. Assist the client in maintaining the proper position (hold the client if necessary)
7. Provide a distraction and reassure the client throughout the procedure
8. Label specimen containers as they are collected
9. Apply a bandage to the insertion site
10. Deliver specimens to the laboratory

CHEST TUBE REMOVAL

A chest tube is removed when drainage is minimal (<200 mL/24 hr) or absent, an air leak (if present) is resolved, and
the lung has reexpanded. The general steps for chest tube removal include:

1. Premedicate the client with analgesic (eg, IV opioid, nonsteroidal anti-inflammatory drug [ketorolac]) 30-60 minutes before
the procedure to promote comfort as evidence indicates that most clients report significant pain during removal
2. Provide the health care provider (HCP) with sterile suture removal equipment
3. Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the tube is removed to decrease the risk
for a pneumothorax. Most HCPs use this technique to increase intrathoracic pressure and prevent air from entering the
pleural space
4. Apply a sterile airtight occlusive dressing to the chest tube site immediately; this will prevent air from entering the pleural
space
5. Perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure pneumothorax or fluid accumulation
usually develops within this time frame.
 The client should be placed in semi-Fowler's position or on the unaffected side to promote comfort and facilitate
access for tube removal.

SMALL BORE NASOENTERIC

Small-bore nasoenteric (eg, nasoduodenal, nasojejunal) tubes are often placed using a stylet (guide wire), a metal
wire running through the tube that facilitates advancement through the gastrointestinal tract.
Once the tube is inserted, the nurse should obtain an x-ray to verify that the tube terminates in the intestine as
prescribed, not in the airway or stomach.
After placement verification, the nurse should remove the stylet to allow tube feeding
To avoid perforating the gut, the nurse should never reinsert the stylet when a feeding tube is in place. If the tube is
not properly positioned and the stylet has been removed, the nurse must remove the tube and start over.
The client should sip water during insertion to close the airway and open the esophagus. With each swallow the nurse
should advance the tube a little. The nurse should stop advancing when the client is inhaling or coughing to avoid
inserting the tube into the airway and then continue advancing when the client is able to swallow again.
Marking the exit point from the naris on the tube allows visualization of changes in external tube length that may
indicate tube dislodgement.

24 HOUR URINE COLLECTION

A 24-hour urine is collected to evaluate Cushing syndrome (a condition that results from chronic increased
corticosteroids). The urine is tested for free cortisol, and results >80-120 mcg/24 hr (220-330 nmol/day) indicate that
Cushing syndrome is present. Instructions for collecting a 24-hour urine are as follows:

o Use a dark jug containing a special powder (obtained from the lab) to protect the urine from light during collection. The
powder helps preserve the urine and adjusts its acidity
o Collection of the 24-hour urine should span over exactly 24 hours. It is important to first record the time and empty the
bladder into the toilet so that the start time coincides with an empty bladder. At that exact time the next day, the bladder
 should be emptied for a final time and collected into the jug. All urine between the start time and end time should be
collected into the container. The time for each urination between start and end does not need to be recorded
o Keep the urine in a refrigerator or a cooled ice chest with the lid tightly screwed on for preservation

CLIENT POSITIONING

For medical procedures, the nurse should ensure that the client:

o Has an empty bladder and is in high Fowler's or a sitting position for paracentesis
o Is Trendelenburg on the left side for suspected air embolism
o Has the arm raised above the head on the affected side for chest tube insertion
o Lies on the right side (for 2 hours) and then supine (12-14 hours) after liver biopsy
o Is side-lying with the head, back, and knees flexed for lumbar puncture

ETT SUCTIONING

Clients with endotracheal tubes (ETTs) have impaired cough and gag reflexes and require suction to clear
retained bronchial secretions and promote ventilatory efficacy. Ventilator circuits for ETTs typically have a reusable
in-line endotracheal suction device, which remains sterile, in a flexible plastic sleeve. Oral secretions may pool near
the base of the ETT and drip into the trachea; therefore, oropharyngeal suctioning and oral care are performed before
ETT suctioning to prevent introduction of oral bacteria into the lungs.
The steps for suctioning an ETT include:

1. Perform hand hygiene and don clean gloves

2. Suction the oropharynx and perform oral care
3. Ensure that the system is connected to appropriate wall suction (<120 mm Hg).
4. Hyperoxygenate the lungs (100% FiO2)
5. Advance the catheter into the trachea just until resistance is met (level of the carina). Do not suction while advancing the
catheter.
6. Gently remove the catheter while suctioning and rotating it. Do not suction for more than 10 seconds
7. Evaluate client tolerance; if further secretions remain, suctioning can be repeated 1 or 2 times. Document the procedure
when complete
8. Resume oxygenation and ventilation settings as prescribed.

CONTINUOUS ENTERAL FEEDING

 The steps for administering a continuous enteral feeding include:

o Identify the client using 2 identifiers (eg, first and last name, medical record number, date of birth) and explain the
procedure to the client. Perform hand hygiene and apply clean gloves.
o and keep it elevated for at least 30 minutes after feeding to minimize the risk of
aspiration
o Validate tube placement by checking the gastric pH as well as assessing the external tube length and comparing it with the
measurement at the time of insertion. The tube should be marked at the nostril with a permanent marker during the initial x-
ray validation
o Check gastric residual volume.
o Flush the tube with 30 mL of water after checking residual volume, every 4-6 hours during feeding, and before and after
medication administration
o Administer the prescribed enteral feeding solution by connecting the tubing and setting the rate on the infusion pump

SPUTUM C/S TESTING

Sputum culture and sensitivity testing is used to identify infectious organisms in the respiratory tract and determine
which antimicrobials are most effective at treating the identified organism. Nurses assisting a client to collect
sputum should instruct the client to:
o Rinse the mouth with water before collecting the sputum sample to reduce bacteria in the mouth and prevent specimen
contamination by oral flora
o Avoid touching the inside of the sterile container or lid to avoid accidental specimen contamination by normal flora of the
skin
o Inhale deeply several times and then cough forcefully, which promotes expectoration of lower lung secretions and
increases sample volume
o Assume a sitting or upright position before specimen collection, if possible, to promote cough strength during collection
Sputum specimens should be collected early in the morning after awakening, which improves the quality of the sample
because secretions accumulate overnight due to cough inhibition. A nebulizer treatment may be prescribed to help
mobilize thick secretions.
PERIPHERALLY INSERTED CENTRAL VENOUS CATHETERS (PICC)
 Peripherally inserted central venous catheters (PICC) are commonly used for long-term antibiotic administration,
chemotherapy treatments, and nutritional support with total parenteral nutrition (TPN).
Complications related to the PICC are occlusion of the catheter, phlebitis, air embolism, and infection due to bacterial
contamination.
Prior to a central line dressing change, the nurse performs hand hygiene. The central line dressing change is
performed using sterile technique with the nurse wearing a mask to prevent contamination of the site with
microorganisms or respiratory secretions
During injection cap and tubing changes, the client is instructed to hold the breath (or perform the Valsalva
maneuver) to prevent air from entering the line, traveling to the heart, and forming an air embolism
When performing the dressing change, the client should be instructed to turn the head away from the PICC site to
prevent potential contamination of the insertion site by microorganisms from the client's respiratory tract.
During dressing, injection caps, and tubing changes, the client is placed in the supine position. If an air embolism is
suspected, the client should be placed in the Trendelenburg position (head down) on the left side, causing any existing
air to rise and become trapped in the right atrium.

WOUND CULTURE

Wound cultures identify microorganisms to aid in prescribing appropriate antibiotics and are obtained as follows:

1. Perform hand hygiene, and apply clean gloves. Remove the old dressing. Remove and discard gloves.
2. Perform hand hygiene, and apply sterile gloves. Assess the wound bed. Cleanse the wound bed and surrounding skin
with normal saline (eg, flushing, swabbing with gauze) to remove drainage and debris. Remove and discard gloves.
3. Perform hand hygiene, and apply clean gloves. Gently swab the wound bed with a sterile swab, from the wound
center toward the outer margin. Avoid contact with skin at the wound edge as it can contaminate the specimen with
skin flora.
4. Place the swab in a sterile specimen container; avoid touching the swab to the outside of the container.
5. Apply prescribed topical medication (eg, bacitracin) after obtaining cultures to prevent interference with microorganism
identification. Apply new dressing.
6. Remove and discard gloves, and perform hand hygiene. Label the specimen, and document the procedure.
BLOOD ADMINISTRATION TUBING

Normal saline (NS) is the only fluid that can be given with a blood transfusion.
Dextrose solutions may lyse the red blood cells. All other IV solutions and medications may cause precipitation and
are incompatible with blood.
Blood transfusions should be infused through a dedicated IV line. If a transfusion must be started in an IV catheter
currently in use, the nurse should discontinue the infusion(s) and tubing, and then flush the catheter with NS prior to
connecting the blood administration tubing.
After transfusion, the catheter should be cleared with NS before any other IV fluids are administered.
Packed red blood cells are not compatible with D5W. The nurse must discontinue the D5W and flush the catheter with
NS before administering blood.
Although an 18-gauge IV catheter is preferred for blood administration, a 20-gauge catheter is acceptable. The nurse
can start a second IV catheter if required, but there is no need to discontinue the original one.
Blood should not be run with any other fluid except NS. Blood can be infused with an IV pump if the fluid in the tubing
is compatible.

TRACHEOSTOMY TUBE SUCTIONING

When performing the suctioning procedure, the nurse follows institution policy and observes principles of infection
control and client safety. Strict aseptic technique is maintained because suctioning can introduce bacteria into the
lower airway and lungs.

1. Place the client in semi-Fowler's position, if not contraindicated, to promote lung expansion and oxygenation.
2. Preoxygenate with 100% oxygen (hyper-oxygenate) to prevent hypoxemia and microatelectasis. Alternately, if the client is
breathing room air independently, ask the client to take 3-4 deep breaths.
3. Insert the catheter gently the length of the airway without applying suction to prevent mucosal tissue damage. The distance
can be premeasured (0.4-0.8 in [1-2 cm] past the distal end of the tube).
 4. Withdraw the catheter slightly (0.4-0.8 in [1-2 cm]) if resistance is felt at the carina (bifurcation of the left and right
mainstem) to prevent mucosal tissue damage.
5. Apply intermittent suction while rotating the suction catheter during withdrawal to prevent mucosal tissue damage. Limit
suction time to 5-10 seconds with each suction pass to prevent mucosal tissue damage and limit hypoxia.

OPEN ENDOTRACHEAL SUCTIONING

Open endotracheal (ET) suctioning is a skill performed to remove pulmonary secretions and maintain airway
patency in clients who are unable to clear secretions independently. ET suctioning is important to promote gas
exchange and prevent alveolar collapse, but inappropriate technique increases the client's risk for complications (eg,
pneumonia, hypoxemia) or tracheal injury (eg, trauma, bleeding). To reduce the risk of complications and injury during
ET suctioning, the nurse should:
o Preoxygenate with 100% oxygen and allow for reoxygenation periods between suction passes

o Suction only while withdrawing the catheter from the airway

o Use strict sterile technique throughout suctioning

o Limit suctioning to on each suction pass

IFC REMOVAL

Because signs of traumatic injury are present, the nurse should follow steps to remove the catheter before further
complications such as obstruction occur.
Steps for removing an indwelling catheter include the following:

o Perform hand hygiene

o Ensure privacy and explain the procedure to the client
o Apply clean gloves
o Place a waterproof pad underneath the client
o Remove any adhesive tape or device anchoring the catheter
o Follow specific manufacturer instructions for balloon deflation
o Loosen the syringe plunger and connect the empty syringe hub into the inflation port
o Deflate the balloon by allowing water to flow back into the syringe naturally, removing all 10 mL, or applicable amount (note
the size of the balloon labeled on the balloon port). If water does not flow back naturally, use only gentle aspiration.
o Remove the catheter gently and slowly; inspect to make sure it is intact and fragments were not left in the client.
o If any resistance is met, stop the removal procedure and consult with the urologist for removal
 o Empty and measure urine before discarding the catheter and drainage bag in the biohazard bin or according to hospital policy
o Remove gloves and perform hand hygiene

LIVER BIOPSY

The client's coagulation status is checked before the liver biopsy using PT/INR and PTT.
The liver ordinarily produces many coagulation factors and is a highly vascular organ. Therefore, bleeding
risk should be assessed and corrected prior to the biopsy
Blood should be typed and crossmatched in case hemorrhage occurs
After the procedure, frequent vital sign monitoring is indicated as the early signs of hemorrhage are rising pulse and
respirations, with hypotension occurring later
The needle is inserted between ribs 6 and 7 or 8 and 9 while the client lies supine with the right arm over the head
and holding the breath.
A full bladder is a concern with paracentesis when a trocar needle is inserted into the abdomen to drain ascites. An
empty bladder may aid comfort, but it is not essential for safety.
The client must lie on the right side for a minimum of 2-4 hours to splint the incision site. The liver is a "heavy" organ
and can "fall on itself" to tamponade any bleeding. The client stays on bed rest for 12-14 hours.

KCL IV INFUSION
The recommended rates for an intermittent IV infusion of potassium chloride (KCl) are no greater than 10 mEq (10
mmol) over 1 hour when infused through a peripheral line and no greater than 40 mEq/hr (40 mmol/hr) when
infused through a central line (follow facility guidelines and policy).
If the nurse were to administer the medication as prescribed, the rate would exceed the recommended rate of 10
mEq/hr (10 mmol/hr) (ie, 10 mEq [10 mmol] over 30 minutes = 20 mEq/hr [20 mmol/hr]).
A too rapid infusion can lead to pain and irritation of the vein and postinfusion phlebitis.
Contacting the health care provider to verify this prescription is the priority action.
IV INSERTION

Steps to promote safety and reduce infection risk when initiating IV therapy include the following:

1. Perform hand hygiene using Centers for Disease Control and Prevention guidelines
2. Prepare equipment: Open IV tray, prime tubing with prescribed IV solution for infusion, set IV pump if indicated, prepare
tape, and open the over-the-needle catheter (ONC) with safety device
3. Don clean (non-sterile) gloves
4. Identify a possible venipuncture site
5. Apply a tourniquet, ensuring it is tight enough to impede venous return but not tight enough to occlude the artery
6. Select a venipuncture site after palpating the vein. Ask the client to open and close the hand several times to promote vein
distension. The tourniquet may need to be released temporarily to restore blood flow and prevent trauma from extended
application.
7. Clean the site with chlorhexidine, alcohol, or povidone iodine. Use friction and clean per facility protocol, either back and
forth or in a circular motion from insertion site to outward area (clean to dirty direction).
8. Stretch the skin taut using the nondominant hand to stabilize the vein
9. Insert the IV ONC bevel up at a 10- to 30-degree angle and watch for blood backflow as the catheter enters the vein lumen,
advancing ¼ inch into the vein to release the stylet. On visualization of blood return, lower the ONC almost parallel with the
skin and thread the plastic cannula completely into the vein to the insertion site. Never reinsert the stylet after it is loosened.
Use the push-tab safety device to advance the catheter.
10. Apply firm but gentle pressure about 1¼ inch above the catheter tip, release the tourniquet, and retract the stylet from the
ONC
11. On removal, guide the protective guard over the stylet for safety and feel for a click as the device is locked. Never try to
recap a stylet.
12. Attach a sterile connection of primed IV tubing to the hub of the catheter and stabilize the catheter with tape and dressing
using sterile technique. Dispose of the stylet in the sharps container.

SUCTIONING

Artificial airways (eg, tracheostomies, endotracheal tubes) impair the cough mechanism and ciliary function,
causing an increase in thick secretions that may occlude the airway. Focused respiratory assessments are critical to
determine the need for suctioning and to maintain a patent airway. To decrease the risks associated with the
procedure (eg, atelectasis, hypoxemia, trauma, infection), suctioning should be performed only when necessary.
Assessment findings that indicate a need for suctioning include:
 o Decreased oxygen saturation
o Altered mental status (eg, irritability, lethargy)
o Increased heart rate (normal infant range: 90-160)
o Increased respiratory rate (normal infant range: 30-60)
o Increased work of breathing (eg, flared nostrils, use of accessory muscles)
o Adventitious breath sounds (eg, crackles, wheezes, rhonchi)
o Pallor, mottled, or cyanotic skin coloring

PERCUTANEOUS KIDNEY BIOPSY

Percutaneous kidney biopsy is an invasive diagnostic procedure. It involves inserting a needle through the skin to
obtain a tissue sample that is then used to determine the cause of certain kidney diseases.
The kidney is a highly vascular organ; therefore, uncontrolled hypertension is a contraindication for kidney biopsy
as increased renal arterial pressure places the client at risk for post-procedure bleeding.
Blood pressure must be lowered and well-controlled (goal <140/90 mm Hg) using antihypertensive medications before
performing a kidney biopsy
An elevated serum creatinine level (normal: 0.6-1.3 mg/dL [53-115 µmol/L) can be expected in a client with probable
renal disease. This is not the most important finding to report to the HCP.
A decreased hemoglobin level (normal adult male: 13.2-17.3 g/dL [132-173 g/L]; normal adult female: 11.7-15.5 g/dL
[117-155 g/L]) can be expected in a client with probable renal disease due to decreased erythropoietin production.
The nurse should continue to monitor the client's hemoglobin post-procedure as it can decrease further (within 6
hours) if bleeding occurs.
Only neurosurgery and ocular surgery require a platelet count >100,000/mm3 (100 x 109/L). Most other surgeries can
be performed when the platelet count is >50,000/mm3 (50 x 109/L). Although the platelet count is low (normal 150,000-
400,000/mm3 [150-400 x109/L]), it is not the most important finding to report to the HCP.

IV CATHETER SIZE
When selecting catheter size, the need for rapid fluid administration and the type of fluid administered versus client
discomfort should be assessed. A lower IV catheter gauge number corresponds to a larger bore IV catheter.
 1. A 14-gauge (large-bore) catheter may be used for administering fluids and drugs in an emergency or prehospital setting, or
for hypovolemic shock
2. In somewhat stable adult clients who require large amounts of fluids or blood, an 18-gauge catheter is preferred.

A 20-22-gauge catheter is sufficient for administering general IV fluids and medications to adult clients; a 20-gauge is
acceptable for blood transfusion. However, 20-22-gauge is not preferred for blood administration.
A 24-gauge catheter is recommended for children and some older adults with small, fragile veins.

4-POINT CRUTCH GAIT

The client who is rehabilitating from an injury of the lower extremity usually progresses from no touch down, non-
weight bearing status, using the 3-point gait to touch down with partial weight bearing status, using the 2 point-gait, to
full weight bearing status, using the 4-point gait.
The nurse teaches the client how to use the most advanced gait, the 4-point crutch gait. It requires weight bearing
on both legs and is the most stable as there are 3 points of support on the ground at all times (eg, 2 crutches and 1
foot; 2 feet and 1 crutch). It is the easiest to use as it resembles normal walking: advance right crutch, then left
foot, and advance left crutch, then right foot.
There are 5 crutch gaits: 2-point, 3-point, 4-point, swing-to, and swing-through. There is no 5-point crutch gait.
TST (MANTOUX TEST)

TST (Mantoux) is the standard method for conducting tuberculosis (TB) surveillance of HCWs and involves 2 steps:

1. Injection of purified protein derivative solution under the first layer of skin of the forearm
2. Evaluation of the injection site 48-72 hours later

The health care practitioner inspects and palpates the site to determine if a local skin reaction has occurred.
 Induration (not redness) indicates a positive test, which means that the individual has been exposed to TB, has
developed antibodies, and is infected with TB bacteria.
Further testing is needed to determine the presence of latent TB infection or active TB disease.
Presence of symptoms, positive sputum culture, and chest x-ray abnormalities confirm active TB.
The QuantiFERON-TB (QFT) blood test is an alternative to TST that measures how the immune system reacts to TB
bacteria.
Like TST, a positive QFT test only indicates that the individual has been infected with TB bacteria. Although the test is
more expensive, it requires only a single visit to the health care provider and results are available in 24 hours.

TRANSFUSION REACTION

It is important for the nurse to remain with the client for 15 minutes after starting a blood transfusion to monitor for
signs of a reaction. These signs include fever, chills, nausea, vomiting, pruritus, hypotension, decreased urine output,
back pain, and dyspnea. The client may report a variety of symptoms ranging from none to a feeling of impending
doom. If signs of a transfusion reaction occur, the nurse should:

o Stop the transfusion immediately

o Using new tubing, infuse normal saline to keep the vein open
o Continue to monitor hemodynamic status and notify the health care provider and blood bank.
o Administer any emergency or prescribed medications to treat the reaction; these may include vasopressors, antihistamines,
steroids, or IV fluids
o Collect a urine specimen to be assessed for a hemolytic reaction
o Document the occurrence and send the remaining blood and tubing set back to the blood bank for analysis
 Oxygen delivery systems & devices
Inspired
Oxygen delivery system oxygen
Device Advantages Indications & key points
characteristics concentration
& flow

Stable client
Low cost
Low, nonfixed
Comfort
24%-44% concentration of O2
Low flow Nasal cannula Long-term use
1-6 L/min Concentration of
Can eat & drink
O2varies
Flow rate does not
meet inspiratory
demand Stable client
Room air is entrained Low, nonfixed
(pulled in) Reservoir Low cost concentration of O2
Concentration of Comfort Concentration of
nasal cannula 30%-50%
O2 varies with changes Long-term use O2varies
1-6 L/min
in respiratory rate, Can eat & drink Uses 50% less
depth & TV (Oxymizer) oxygen than simple
Deep breathing cannula
entrains more room
air & decreases
(dilutes) concentration Mouth breather
of O2 Less drying to
Simple 35%-50%
Shallow breathing mucosa Low, nonfixed
facemask 6-8 L/min
entrains less air & concentration of O2
increases
concentration of O2
Use small-bore tubing Can deliver higher Emergency situation
Nonrebreather (hypoxemia)
60%-95% concentration of
(reservoir) Short-term use
8-15 L/min O2 without intubation
mask Requires tight seal
One-way valve on
 mask prevents
entrainment of room
air & exhaled CO2 into
reservoir
Bag must not deflate

Chronic hypercarbia,
Consistent
hypoxemia (eg,
concentration of
High flow 24%-50% COPD)
Venturi mask O2regardless of
4-8 L/min Fixed concentration
ventilatory pattern
Flow rate meets of O2
inspiratory demand
Humidification
Controls mixture of provides moisture; Chronic hypercarbia,
room air so that less drying to hypoxemia
inspired concentration Aerosol mask 21%-100%
mucosa Artificial airway (eg,
of O2 is constant (nebulizer) 12-15 L/min
Consistent tracheostomy)
concentration of O2
Concentration of O2 is
"guaranteed" & does
not vary with changes Consistent
in respiratory rate, Respiratory failure
concentration of
depth & TV Ventilatory muscle
O2regardless of
Use large-bore tubing Mechanical rest
Up to 100% ventilatory pattern
ventilator Cardiac arrest
Controlled
Requires intubation
ventilation
 ADULT HEALTH
CARDIOLOGY

Cardiac catheterization involves injection of iodine contrast using a catheter to examine for obstructed coronary
arteries.
Complications include:
Allergic reaction: Clients with a previous allergic reaction to IV contrast may require premedication (eg,
corticosteroids, antihistamines) or another contrast medium. Clients with shellfish allergies were once believed to
be at higher risk, but this has been disproved.
Contrast nephropathy: Iodine-containing contrast can cause kidney injury, although this risk can be reduced with
adequate hydration. However, clients with renal impairment (eg, serum creatinine >1.3 mg/dL [115 µmol/L]) should
not receive IV contrast unless absolutely necessary.
Lactic acidosis: Metformin (Glucophage) with IV iodine contrast increases the risk for lactic acidosis. Metformin
is usually discontinued 24-48 hours before exposure and restarted after 48 hours, when stable renal function is
confirmed
Bleeding at the puncture site indicates that a clot has not formed at the insertion site. This is an arterial bleed as
catheterization was done via the femoral artery. Arterial bleeds can lead to hypovolemic shock and death if not
treated immediately.
Reduced warmth in the lower extremity of the insertion site is a sign of decreased perfusion (lack of oxygenated
blood flow) to the extremity and can result in tissue necrosis of the affected area.
The client may lie flat for several hours and is encouraged to engage in quiet activities for 24 hours after the
procedure to prevent dislodging the clot at the insertion site.
BNP
- is a peptide that causes natriuresis. B-type natriuretic peptides are made, stored, and released primarily by the ventricles. They
are produced in response to stretching of the ventricles due to the increased blood volume and higher levels of extracellular fluid
(fluid overload) that accompany heart failure.
- Elevation of BNP >100 pg/mL helps to distinguish cardiac from respiratory causes of dyspnea.

Clients with an implanted permanent pacemaker

should be assessed for both electrical capture of heart rhythm and mechanical capture of heart rate. In atrial
pacing, pacer spikes precede P waves, whereas in ventricular pacing, pacer spikes precede QRS
complexes. Pacing spikes should be immediately followed by their appropriate electrical waveform, indicating
electrical capture.
Checking for mechanical capture is essential to ensure that the electrical activity of the heart corresponds to a
pulsatile rhythm. The best method for checking for a pulsatile rhythm is to assess a central pulse (eg, auscultation
of apical, palpation of femoral). This rate should be compared to the electrical rate displayed on the cardiac monitor
to assess for pulse deficit.
 Discharge teaching for the client with a permanent pacemaker should include the following:

o Report fever or any signs of redness, swelling, or drainage at the incision site.
o Carry a pacemaker identification card and wear a medical alert bracelet.
o Take the pulse daily and report it to the health care provider (HCP) if below the predetermined rate.
o Avoid MRI scans, which can affect or damage a pacemaker
o Avoid carrying a cell phone in a pocket directly over the pacemaker and, when talking on a cell phone, hold it to the ear on the
opposite side of the pacemaker
o Notify airport security of a pacemaker; a handheld screening wand should not be held directly over the device
o Avoid standing near antitheft detectors in store entryways; walk through at a normal pace and do not linger near the device.
o Avoid lifting the arm above the shoulder on the side of the pacemaker until approved by the HCP as this can cause
dislodgement of the pacemaker lead wires.

In heart failure
cardiac output is reduced because the heart is unable to pump blood adequately. This reduction in cardiac output
reduces perfusion to the vital organs, including the kidneys.
Decreased renal blood flow triggers the kidneys to activate the renin-angiotensin system as a compensatory
mechanism, which increases blood volume by increasing water resorption in the kidneys.
This compensatory mechanism results in fluid volume excess and dilutional hyponatremia (more free water than
sodium).
Dilutional hyponatremia can be treated with fluid restriction, loop diuretics, and ACE inhibitors (eg, lisinopril,
captopril). Furosemide works to resolve hyponatremia by promoting free water excretion, allowing for
hemoconcentration and increased sodium levels
The basic life support sequence

compressions, airway, and breathing (mnemonic - CAB). High-quality CPR is associated with improved client
outcomes and begins with high-quality chest compressions (ie, 100-120/min, 2-2.4 in [5-6 cm] deep). Any
unwitnessed collapse should be treated with 2 minutes of CPR, followed by activating the emergency response system
and obtaining an automated external defibrillator. If no shock is advised, the nurse should resume high-quality chest
compressions immediately
Rescue breaths every 5-6 seconds (10-12 breaths/min) are given to clients who have a pulse but are not breathing
normally. For clients with no pulse, the nurse should deliver cycles of 30 compressions followed by 2 rescue breaths.
The jaw-thrust maneuver is used instead of the head-tilt/chin-lift method in clients who may have a head/spinal injury.
Repositioning the jaw forward opens the airway to allow for assessment and delivery of rescue breathing. Assessing
the airway is not indicated at this time.

The rhythm strip of a client with a single-chamber atrial pacemaker displays a pacer spike before the P wave,
followed by a QRS complex, on an electrocardiogram (ECG). The P wave may appear normal or somewhat distorted
following the spike. Atrial pacemakers are often placed for clients experiencing sinoatrial node dysfunction (eg,
atrial fibrillation, bradycardia, heart blocks).
In first-degree atrioventricular block, every impulse is conducted to the ventricles, but the time of atrioventricular
conduction is prolonged. This is evidenced by a prolonged PR interval of >0.20 second.

The rhythm shows that the client is experiencing a second-degree atrioventricular (AV) block, type 1. This is an
intermittent block usually occurring at the level of the AV node characterized by a progressively lengthening PR
interval until a QRS complex is dropped.
AV block can be associated with myocardial ischemia (eg, coronary artery disease) or certain medications (eg, beta
blockers, digoxin). Assess the client first for any evidence of symptoms associated with the rhythm (eg, hypotensive,
dizzy, shortness of breath).
Treatment is only indicated if the client is symptomatic. If the client is experiencing symptoms, atropine and
temporary pacing may be indicated. If there are no associated symptoms, the nurse should continue to closely
monitor the client and be ready to intervene if symptoms arise.
Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). Unlike
the QRS complexes in this client's ECG, PVCs are not associated with P waves, and the QRS complexes are wide
and distorted.

Failure to sense appears on an ECG as asynchronous pacer spikes in inappropriate or random locations (eg, pacer
spike on the T wave).

It should not be confused with failure to capture, in which pacer spikes are located appropriately but there is no
electrical response elicited from the heart (eg, no QRS complex after a pacer spike).
An atrioventricular pacemaker (also known as a sequential or dual chamber pacemaker) paces the right atrium and
right ventricle in sequence.
The ECG will have 2 pacer spikes, one before the P wave and one before the QRS complex.
The P wave following the atrial pacer spike may be normal or abnormal appearing. The QRS complex following the
ventricular pacer spike is typically wide and distorted. An atrioventricular pacemaker can improve synchrony between
the atria and ventricles. It may be implanted in the client with bradycardia, heart block, or cardiomyopathy.

Sinus tachycardia
Atrial fibrillation (AF) is a common dysrhythmia after cardiac surgery. It is characterized by a
total disorganization of atrial electrical activity that results in the loss of effective atrial contraction. P
waves are not visible; they are replaced by fibrillatory waves. The ventricular rate varies, but the rhythm is
typically irregular. AF results in decreased cardiac output due to a loss of atrial kick and/or a rapid ventricular
response. Clots may form in the atria, putting the client at increased risk for stroke.
Treatment goals include a decrease in ventricular rate to <100/min and adequate anticoagulation to prevent
thromboembolic complications. Medications used for rate control include calcium channel blockers (eg, diltiazem,
verapamil), beta blockers (eg, metoprolol), and digoxin. Medications that convert to and maintain sinus rhythm
include amiodarone, flecainide, and sotalol. Electrical cardioversion may also be considered in hemodynamically
unstable clients.

Complete Heart Block

Ventricular Fibrillation

VF is characterized on the ECG by irregular waveforms of varying shapes and amplitudes. This represents the
firing of multiple ectopic foci originating in the ventricle. Mechanically, the ventricle is quivering with no effective
contraction or cardiac output. VF is considered a lethal dysrhythmia. It results in
an unresponsive, pulseless, apneic state.If not treated rapidly, the client will not recover.
VF commonly occurs in acute myocardial infarction and myocardial ischemia and in chronic heart diseases such as
heart failure and cardiac myopathy. It may occur in cardiac pacing or catheterization procedures due to catheter
stimulation of the ventricle.
Treatment consists of rapid initiation of CPR, defibrillation, and the use of drug therapy (eg, epinephrine,
vasopressin, amiodarone).

Ventricular tachycardia (VT) is a potentially life-threatening dysrhythmia characterized by a ventricular rate of 100-
250/min. The rhythm is often regular, but it can be irregular. QRS complexes are wider than 0.12 seconds and the
P wave is usually buried in the QRS complex, making a PR interval unmeasurable. Pulseless VT is treated with
cardiopulmonary resuscitation (CPR) and defibrillation.
A premature ventricular contraction (PVC) is a contraction originating from an ectopic foci in the ventricle. It appears early in the
rhythm and has a wide and distorted shape as compared to the underlying rhythm.

In PSVT, the heart rate can be 150-220/min. With prolonged episodes, the client may experience evidence of reduced
cardiac output such as hypotension, palpitations, dyspnea, and angina.
Treatment includes vagal maneuvers such as Valsalva, coughing, and carotid massage. Adenosine is the drug of
choice for PSVT treatment. Due to its very short half-life, adenosine is administered rapidly via IVP over 1-2 seconds
and followed by a 20-mL saline bolus. An increased dose may be given twice if previous administration is ineffective.
Beta blockers, calcium channel blockers, and amiodarone can also be considered as alternatives. If vagal maneuvers
and drug therapy are unsuccessful, synchronized cardioversion may be used.
 Atrial Flutter

Supraventricular tachycardia (SVT) is a dysrhythmia that originates from an ectopic focus above the bifurcation of
the bundle of His. The heart rate can be 150-220/min. The rhythm is usually regular. P waves are often hidden. If
visible, they may have an abnormal shape and the PR interval may be shortened. The QRS complex is usually narrow
(<0.12 second).
Stimulants (eg, nicotine, caffeine, cocaine) and organic heart disease can cause SVT. Clinical significance depends
on the client's symptoms. A prolonged episode of SVT with a heart rate >180/min will cause decreased cardiac
output and hypotension. The client may also experience palpitations, dyspnea, and angina.
Treatment includes vagal stimulation and drug therapy. Common vagal maneuvers include Valsalva, coughing, and
carotid massage. IV adenosine is the drug of choice to convert SVT to a sinus rhythm. If vagal stimulation and drug
therapy are ineffective and the client becomes hemodynamically unstable, synchronized cardioversion is used.
Recurrent SVT may require radiofrequency catheter ablation.
Mechanical prosthetic valves
are more durable than biological valves but require long-term anticoagulation therapy due to the increased risk of
thromboembolism. The client should be taught ways to reduce the risk of bleeding.
Teaching topics for clients on anticoagulants:

o Take medication at the same time daily

o Depending on medication, report for periodic blood tests to assess therapeutic effect
o Avoid any action that may cause trauma/injury and lead to bleeding (eg, contact sports, vigorous teeth brushing, use of a
razor blade)
 o Avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs)
o Limit alcohol consumption
o Avoid changing eating habits frequently (eg, dramatically increasing intake of foods high in vitamin K such as kale, spinach,
broccoli, greens) and do not take vitamin K supplements
o Consult with health care provider before beginning or discontinuing any medication or dietary/herbal supplement (eg, Ginkgo
biloba and ginseng affect blood clotting and may increase bleeding risk)
o Wear a medical alert bracelet indicating what anticoagulant is being taken

Early in the recovery period, care of the incision site typically includes washing with soap and water and patting it dry.
Ointments (eg, vitamin E) may be applied after the incision has healed.
CVP
is a measurement of right ventricular preload (volume within the ventricle at the end of diastole) and reflects fluid
volume problems.
the normal CVP is 2-8 mm Hg. An elevated CVP can indicate right ventricular failure or fluid volume overload.
Clinical signs of fluid volume overload include the following:

o Peripheral edema
o Increased urine output that is dilute
o Acute, rapid weight gain
o Jugular venous distension
o S3 heart sound in adults
o Tachypnea, dyspnea, crackles in lungs
o Bounding peripheral pulses
Open aneurysm repair
involves a large abdominal incision and requires cross-clamping the aorta proximally and distally to the aneurysm.
Establishing baseline data is essential for comparison with postoperative assessments. The nurse should pay special
attention to the character and quality of peripheral pulses and renal and neurologic status.
Dorsalis pedis and posterior tibial pulse sites should be marked for easy location postoperatively. A decreased or
absent pulse with cool, pale, mottled, or painful extremity postoperatively can indicate embolization or graft occlusion.
Graft occlusion may require reoperation.
Chest pain
It is very important to rapidly diagnose and treat the client with chest pain and potential myocardial infarction to
preserve cardiac muscle.
Initial interventions in emergency management of chest pain are as follows:

o Assess airway, breathing, and circulation (ABCs)

o Position client upright unless contraindicated
o Apply oxygen, if the client is hypoxic
 o Obtain baseline vital signs, including oxygen saturation
o Auscultate heart and lung sounds
o Obtain a 12-lead electrocardiogram (ECG)
o Insert 2-3 large-bore intravenous catheters
o Assess pain using the PQRST method
o Medicate for pain as prescribed (eg, nitroglycerin)
o Initiate continuous electrocardiogram (ECG) monitoring (cardiac monitor)
o Obtain baseline blood work (eg, cardiac markers, serum electrolytes)
o Obtain portable chest x-ray
o Assess for contraindications to antiplatelet and anticoagulant therapy
o Administer aspirin unless contraindicated

Myocardial Infarction

Clients with myocardial infarction (MI) are at risk for life-threatening dysrhythmias (eg, heart block, ventricular
tachycardia, ventricular fibrillation) both during the MI and following reperfusion therapy (eg, coronary artery stenting).
Female, elderly, and diabetic clients tend to present with atypical symptoms of myocardial infarction (MI), such as
diaphoresis, nausea, fatigue, or dyspnea, but may not always experience chest discomfort.
Pain may be absent or atypical or may radiate to unusual locations (eg, jaw, back).
Some clients may report pain as "indigestion" (epigastric burning or gas). The nurse should obtain a 12-lead
electrocardiogram (ECG) on any client with atypical MI symptoms to assess for evidence of ischemia, injury, or
infarction.
 ST-segment elevation MI is life-threatening and requires rapid coronary intervention.
Myocardial ischemia damages cardiac muscle cells, causing electrical irritability (eg, premature ventricular
contractions) that can be exacerbated by electrolyte imbalances (eg, hypokalemia).
Hypokalemia hyperpolarizes cardiac electrical conduction pathways, increasing the risk for dysrhythmias. Therefore,
prompt potassium replacement is the priority in these clients
ACE inhibitors (eg, captopril, enalapril, lisinopril) help reduce the risk of future MIs by reducing blood pressure and
cardiac workload and inhibiting ventricular remodeling. ACE inhibitors should be administered after MI; however, life-
threatening dysrhythmias pose a higher risk to the client
A large anterior wall MI can affect the pumping ability of the left ventricle, putting the client at risk for developing heart
failure and cardiogenic shock. The new development of pulmonary congestion on x-ray, auscultation of a new
S3 heart sound, crackles on auscultation of breath sounds, or jugular venous distension can signal heart failure and
should be reported immediately to the HCP.
Clients may experience nausea and vomiting during an MI resulting from stimulation of the vomiting center by severe
pain or from vasovagal reflexes initiated from the area of the infarction. This finding is not as high a priority as the
S3heart sound.
Dysrhythmias are a common complication after an MI. Occasional PVCs are not significant, but the nurse should
further assess the client's potassium level and assess the apical-radial pulse for the presence of a pulse deficit.
An increase in temperature following a MI is usually due to a systemic inflammatory process caused by myocardial cell
death. The elevation may last as long as a week. This finding is not as significant as the S3 heart sound.

Chronic venous insufficiency (CVI)

 occurs when the valves in the veins of the lower extremities consistently fail to keep venous blood moving forward,
which causes chronic increased venous pressure. The increased pressure pushes fluid out of the vascular space and
into the surrounding tissues, where tissue enzymes break down red blood cells.
The destruction of red blood cells releases hemosiderin (a reddish-brown protein that stores iron), which causes a
brownish skin discoloration; chronic edema and inflammation cause the tissue to harden and appear leathery.
Affected skin is highly prone to breakdown and ulcerations (eg, venous leg ulcers), commonly on the inside of the
ankle.

Peripheral artery disease (PAD [previously called peripheral vascular disease]) refers to arteries that have thickened,
have lost elasticity due to calcification of the artery walls, and are narrowed by atherosclerotic plaques (made up of fat and
fibrin).
Pain due to decreased blood flow is the most common symptom of PAD.
Cramping pain in the muscles of the legs during exercise, known as intermittent claudication, is usually relieved with
rest.
 However, with critical arterial narrowing, pain can be present at rest and is typically described as "burning pain" that
is worsened by elevating the legs and improved when the legs are dependent.
Skin becomes cool, dry, shiny, and hairless (due to lack of oxygen).
Ulcers and gangrene occur usually at the most distal part of the body, where circulation is poorest. Clients should
be advised that a progressive walking program will aid the development of collateral circulation.
Chronic venous insufficiency refers to inadequate venous blood return to the heart.
Too much venous blood remains in the lower legs, and venous pressure increases. This increased venous pressure
inhibits arterial blood flow to the area, resulting in inadequate supply of oxygen and nutrients to area cells and the
development of stasis ulcers, which are typically found around the medial side of the ankle.
By the end of the day or after prolonged standing, the legs become edematous with dull pain due to venous
engorgement. The skin of the lower leg becomes thick with a brown pigmentation.
Home management instructions for PAD include:

o Lower the extremities below the heart when sitting and lying down - improves arterial blood flow
o Engage in moderate exercise (eg, 30- to 45-minute walk, twice daily) - promotes collateral circulation and distal tissue
perfusion
o Perform daily skin care, including application of lotion - prevents skin breakdown from dry skin
o Maintain mild warmth (eg, lightweight blankets, socks) - improves blood flow and circulation
o Stop smoking - prevents vessel spasm and constriction
o Avoid tight clothing and stress - prevents vasoconstriction
o Take prescribed medications (eg, vasodilators, antiplatelets) - increases blood flow and prevents blood clot development

An implantable cardioverter defibrillator (ICD)

can sense and defibrillate life-threatening dysrhythmias.

It also includes pacemaker capabilities such as overdrive pacing for rapid heart rhythms or back-up pacing for
bradycardias that may occur after defibrillation.
The ICD consists of a lead system placed into the endocardium via the subclavian vein.
The pulse generator is implanted subcutaneously over the pectoral muscle.
Postoperative care and teaching are similar to those for pacemaker implantation.
Clients are instructed to refrain from lifting the affected arm above the shoulder (until approved by the health care
provider) to prevent dislodgement of the lead wire on the endocardium
Firing of the ICD may be painful. Clients have described the feeling as a blow to the chest.
Driving may be approved by the health care provider after healing has occurred. Long-term decisions are based on
the ongoing presence of dysrhythmias, frequency of ICD firings, and state laws regarding drivers with ICDs.
Travel is not restricted. The ICD may set off the metal detector in security areas. A hand-held wand may be used but
should not be held directly over the ICD. The client should carry the ICD identification card and a list of medications
while traveling.
Clients with a diagnosis of chronic congestive heart failure
experience clinical manifestations of both right-sided (systemic venous congestion) and left-sided (pulmonary
congestion) failure.
Crackles are discontinuous, adventitious lung sounds usually heard on inspiration and indicate the presence of
pulmonary congestion (left-sided failure) in this client. Increased jugular venous distention reflects an increase in
pressure and volume in the systemic circulation, resulting in elevated central venous pressure (CVP) (right-sided
failure) in this client. Although dependent pitting edema of the extremities can be associated with other conditions (eg,
hypoproteinemia, venous insufficiency), it is related to sodium and fluid retention (right-sided failure) in this client.
Client and family education is important for those with heart failure to prevent/minimize exacerbations, decrease
symptoms, prevent target organ damage, and improve quality of life. The use of any nonsteroidal anti-inflammatory
drugs (NSAIDS) is contraindicated as they contribute to sodium retention, and therefore fluid retention
To monitor fluid status, clients are instructed to weigh themselves daily, at the same time, with the same amount of
clothing, and on the same scale. Weights should be recorded to allow for day-to-day comparisons to help identify
early signs of fluid retention.
Frozen meals are often high in sodium. Most heart failure clients are instructed to limit sodium intake. All foods high
in sodium (>400 mg/serving) should be avoided.
Diuretic medications cause clients to urinate more. Morning is the appropriate time to take this type of medication.
Evening administration would cause nocturia and interrupted sleep.
Exercise training, such as cardiac rehabilitation, improves symptoms of chronic heart failure. It has been found to be
safe and improves the client's overall sense of well-being. It has also been correlated with reduction in mortality.

Chest drainage
>100 mL/hr should be reported to the HCP. Large losses of blood may indicate a compromise of the surgical suture
site and may require repair. The client can quickly become hemodynamically unstable and may require a return to
surgery or transfusion of blood products.
Infective Endocarditis
o Stroke
o Right and left Valve and endocardial vegetations
 o Septic pulmonary emboli
o Kidney Infarction and hematuria
o Splenic infarction can occur with infection of the heart valves (endocarditis). They may be caused by vessel
damage from swelling of the blood vessels (vasculitis) or tiny clots that damage the small capillaries
(microemboli).
o Osler nodes
o Petechiae
Ischemia/gangrene and painful cold limbIn IE, the vegetations over the valves can break off and embolize to various
organs, resulting in life-threatening complications. These include the following:

1. Stroke - paralysis on one side

2. Spinal cord ischemia - paralysis of both legs
3. Ischemia to the extremities - pain, pallor, and cold foot or arm
4. Intestinal infarction - abdominal pain
5. Splenic infarction - left upper-quadrant pain

The nurse or the client (if at home) should report these manifestations immediately to the HCP.
IE commonly presents with fever, arthralgias (multiple joints pains), weakness, and fatigue. These are expected and
do not need to be reported during the initial stages of treatment.
IE clients typically require intravenous antibiotics for 4-6 weeks. Fever may persist for several days after treatment is
started. If the client is persistently febrile after 1-2 weeks of antibiotics, this must be reported as it may indicate
ineffective antibiotic therapy.

A coronary arteriogram (angiogram)

is an invasive diagnostic study of the coronary arteries, heart chambers, and function of the heart. It requires that the
client have an intravenous (IV) line started for sedating medications; the femoral or radial artery will be accessed
during the procedure. The client should be instructed:
 1. Not to eat or drink anything for 6-12 hours prior to the procedure (depending on the particular health care provider
performing the procedure)
2. The client may feel warm or flushed while the contrast dye is being injected
3. Hemostasis must be obtained in the artery that was cannulated for the procedure. Most commonly, this is the femoral artery.
Compression is applied to the puncture site and the client may have to lie flat for several hours to ensure hemostasis

Repair of abdominal aortic aneurysms can be done via femoral percutaneous placement of a stent graft (endovascular aneurysm
repair) or via an open surgical incision of the aneurysm and placement of a synthetic graft.

With either procedure, postoperative monitoring for graft leakage or separation is a priority.
Manifestations of graft leakage include
o ecchymosis of the groin, penis, scrotum, or perineum;
o increased abdominal girth;
o tachycardia;
o weak or absent peripheral pulses;
o decreasing hematocrit and hemoglobin;
o increased pain in the pelvis, back, or groin;
o decreased urinary output

Renal perfusion status is monitored closely in a client who has had abdominal aneurysm repair.
Hypotension, dehydration, prolonged aortic clamping during surgery, blood loss, or embolization can lead to
decreased renal perfusion and potential kidney injury.
The nurse should routinely monitor the client's blood urea nitrogen (BUN) and creatinine levels as well as urine
output.
Urine output should be at least 30 mL/hr.

An inferior vena cava filter is a device that is inserted percutaneously, usually via the femoral vein.
The filter traps blood clots from lower extremity vessels (eg, embolus from deep venous thrombosis) and prevents
them from migrating to the lungs and causing a pulmonary embolism (PE).
It is prescribed when clients have recurrent emboli or anticoagulation is contraindicated.
 Clients should be questioned about and report any metallic implants (eg, vascular filters/coils) to the health care team
prior to radiologic imaging, specifically MRI.
Physical activity should be promoted, and clients should avoid crossing their legs to promote venous return from the
legs
Leg pain, numbness, or swelling may indicate impaired neurovascular status distal to the insertion site and should be
reported immediately
The Dietary Approaches to Stop Hypertension (DASH) diet
is often suggested to clients with hypertension due to its ability to reduce blood pressure. The diet focuses
on elimination or reduction of foods and beverages high in sodium, sugar, cholesterol, and trans or saturated
fats, which all contribute to increased blood pressure. The DASH diet focuses on:
o Including fresh fruits and vegetables, and whole grains in the daily diet
o Choosing fat-free or low-fat dairy products
o Choosing meats lower in cholesterol (eg, fish, poultry) and alternate protein sources (eg, legumes) instead of red
meats (Option 1)
o Limiting intake of sweets, foods high in sodium (eg, potato chips, frozen meals, canned foods), and sugary
beverages to the occasional treat

Venous thromboembolism
includes both DVT and pulmonary embolism (PE). DVT is the most common form and occurs most often (80%) in
the proximal deep veins (iliac, femoral) of the lower extremities. Virchow's triad describes the 3 most common
theories behind the pathophysiology of the venous thrombosis: venous stasis, endothelial damage, and
hypercoagulability of blood.
Risk factors associated with DVT formation include the following:

1. Trauma (endothelial injury and venous stasis from immobility)

2. Major surgery (endothelial injury and venous stasis from immobility)
3. Prolonged immobilization (eg, stroke, long travel) causing venous stasis
 4. Pregnancy (induced hypercoagulable state and some venous stasis by the pressure on inferior vena cava)
5. Oral contraceptives (estrogen is thrombotic)
6. Underlying malignancy (cancer cells release procoagulants)
7. Smoking (produces endothelial damage by inflammation)
8. Old age
9. Obesity and varicose veins (venous stasis)
10. Myeloproliferative disorders (increase blood viscosity)

Interventions to prevent DVT reoccurrence include:

o Obtain adequate fluid intake and limit caffeine and alcohol intake to avoid dehydration because dehydration increases the
risk for blood hypercoagulability
o Elevate the legs when sitting and dorsiflex the feet often to reduce edema and promote venous return
o Resume an exercise program (eg, walking, swimming) and change positions frequently to promote venous return
o Stop smoking to prevent endothelial damage and vasoconstriction.
o Avoid restrictive clothing (eg, tight jeans), which interferes with circulation and promotes clotting.
o Consult with a dietitian if overweight; excess weight increases venous insufficiency by compressing large pelvic vessels.

Mitral valve regurgitation

is the result of a disrupted papillary muscle(s) or ruptured chordae tendineae, allowing a backflow of blood from the
left ventricle through the mitral valve into the left atrium.
This backflow can lead to dilation of the left atrium, reduced cardiac output, and pulmonary edema. Clients are often
asymptomatic but are instructed to report any new symptoms indicative of heart failure (eg, dyspnea,
orthopnea, weight gain, cough, fatigue).
Approach to Sinus Bradycardia

Sodium nitroprusside
is a highly potent vasodilator (both venous and arteriolar). Venous dilation reduces preload (volume of blood in
ventricles at the end of diastole), and arterial dilation reduces afterload (resistance ventricle must overcome to eject
blood during systole). Sodium nitroprusside is commonly used in hypertensive emergencies and for conditions in
which blood pressure control is of utmost importance (eg, aortic dissection, acute hypertensive heart failure).
Nitroprusside begins to act within 1 minute and can produce a sudden and drastic drop in blood pressure
(symptomatic hypotension) if not monitored properly. Therefore, the client's blood pressure should be monitored
closely (every 5 10 minutes). Nitroprusside metabolizes to cyanide, and clients with renal disease can occasionally
develop fatal cyanide toxicity.
A Holter monitor
continuously records a client's electrocardiogram rhythm for 24-48 hours. Electrodes are placed on the client's
chest and a portable recording unit is kept with the client. At the end of the prescribed period, the client returns the
unit to the health care provider's (HCP) office. The data can then be recalled, printed, and analyzed for any
abnormalities.
Client instructions include the following:

1. Keep a diary of activities and any symptoms experienced while wearing the monitor so that these may later be correlated
with any recorded rhythm disturbances
2. Do not bathe or shower during the test period
3. Engage in normal activities to simulate conditions that may produce symptoms that the monitor can record

Orthostatic BP measurement
may be done to detect volume depletion or postural hypotension caused by medications or autonomic dysfunction.
Procedure for measurement of orthostatic BP

1. Have the client lie down for at least 5 minutes

2. Measure BP and HR
3. Have the client stand
4. Repeat BP and HR measurements after standing at 1- and 3-minute intervals

A drop in systolic BP of or in diastolic BP of , or experiencing lightheadedness or dizziness

is considered abnormal

Hypertensive crisis
is a life-threatening medical emergency characterized by severely elevated blood pressure
Hg and/or diastolic .
 The client may have symptoms of hypertensive encephalopathy, including severe headache, confusion,
nausea/vomiting, and seizure.
Hypertensive crisis poses a high risk for end-organ damage (eg, hemorrhagic stroke, kidney injury, heart failure,
papilledema).
The nurse should prioritize neurological assessment (eg, level of consciousness [LOC], cranial nerves) as
decreased LOC may indicate onset of hemorrhagic stroke, which requires immediate surgical intervention.
Treatment for hypertensive crisis typically includes IV nitrates or antihypertensives (eg, nitroprusside, labetalol,
nicardipine) and continuous monitoring (eg, blood pressure, telemetry, urine output) in a critical care setting.
Emergency treatment includes IV vasodilators such as nitroprusside sodium. It is important to lower the blood
pressure slowly, as too rapid a drop may cause decreased perfusion to the brain, heart, and kidneys. This may
result in stroke, renal failure, or MI. The initial goal is usually to decrease the MAP by no more than 25% or to
maintain MAP at 110-115 mm Hg. The pressure can then be lowered further over a period of 24 hours. MAP is
calculated by adding the systolic blood pressure (SBP) and double the diastolic blood pressure (DBP), and then
dividing the resulting value by 3.
MAP = (2 x DBP + SBP) / 3

Atropine

is given to the client experiencing symptomatic bradycardia.

In symptomatic bradycardia, the heart rate is <60/min and is inadequate for the client's condition, causing symptoms
such as hypotension, chest pain, or syncope.
Atropine acts to increase the heart rate by inhibiting the action of the vagus nerve (parasympatholytic effect). A normal
sinus rhythm and reversal of clinical symptoms indicate that the medication has had the desired effect.

Dysrhythmias

are the most frequent complication following myocardial infarction (MI).

Ventricular fibrillation is the most common of these dysrhythmias and is regularly the cause of sudden cardiac death in
clients with MI.
The nurse should attach the cardiac monitor to the client before performing any other interventions.
 If ventricular tachycardia or premature ventricular contractions (PVCs) are observed, the client should be treated
quickly (with antidysrhythmic drugs) as these rhythms usually precede ventricular fibrillation; early identification and
treatment are imperative to improve outcomes.

Raynaud phenomenon

is a vasospastic disorder resulting in an episodic vascular response related to cold temperatures or emotional stress.
It most commonly affects women age 15-40. Vasospasms induce a characteristic color change in the appendages
(eg, fingers, toes, ears, nose). When vasoconstriction occurs, the affected appendage initially turns white from
decreased perfusion, followed by a bluish-purple appearance due to cyanosis. Clients usually report numbness and
coldness during this stage. When blood flow is subsequently restored, the affected area becomes reddened and
clients experience throbbing or aching pain, swelling, and tingling. Acute vasospasms are treated by immersing the
hands in warm water.
Client teaching regarding prevention of vasospasms includes:

o Wear gloves when handling cold objects

o Dress in warm layers, particularly in cold weather.
o Avoid extremes and abrupt changes in temperature.
o Avoid vasoconstricting drugs (eg, cocaine, amphetamines, ergotamine, pseudoephedrine).
o Avoid excessive caffeine intake
o Refrain from use of tobacco products
o Implement stress management strategies (eg, yoga, tai chi)

If conservative management is unsuccessful, clients may be prescribed calcium channel blockers to relax arteriole
smooth muscle and prevent recurrent episodes.
ST segment should also be monitored as reinfarction may occur; the client may or may not have the usual MI-related
symptoms (eg, chest pain, shortness of breath, vomiting).

Performing Cardioversion
The synchronizer switch must be turned on when cardioversion is planned. The synchronize circuit in the
defibrillator is programmed to deliver a shock on the R wave of the QRS complex on the electrocardiogram (ECG).
 This allows the unit to sense this client's rhythm and time the shock to avoid having it occur during the T wave. A
shock delivered during the T wave could cause this client to go into a more lethal rhythm (eg, ventricular tachycardia,
ventricular fibrillation).
If this client becomes pulseless, the synchronize function should be turned off and the nurse should proceed with
defibrillation.
Synchronized cardioversion is indicated for ventricular tachycardia with a pulse, supraventricular tachycardia, and
atrial fibrillation with a rapid ventricular response
If client is awake and hemodynamically stable, sedation is indicated.

Angina Pectoris

Angina pectoris is defined as chest pain brought on by myocardial ischemia (decreased blood flow to the heart
muscle). Any factor that increases oxygen demand or decreases oxygen supply to cardiac muscle may cause angina,
including the following:

o Physical exertion (eg, exercise, sexual activity): Increases heart rate and reduces diastole (time of maximum blood flow to the
myocardium)
o Intense emotion (eg, anxiety, fear): Initiates the sympathetic nervous system and increases cardiac workload
o Temperature extremes: Usually cold exposure and hypothermia (vasoconstriction); occasionally hyperthermia (vasodilation
and blood pooling)
o Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon monoxide; nicotine causes vasoconstriction
and catecholamine release
o Stimulants (eg, cocaine, amphetamines): Increase heart rate and cause vasoconstriction
o Coronary artery narrowing (eg, atherosclerosis, coronary artery spasm): Decreases blood flow to myocardium
Post-op CABG

The RN providing discharge instructions for a client recovering from a CABG should include the following guidelines:

1. Explain the need for modification of cardiac risk factors, including smoking cessation, weight reduction, maintaining a healthy
diet, and increasing activity levels through exercise.
2. Encourage a daily shower as a bath could introduce microorganisms into the surgical incision sites. Surgical incisions are
washed gently with mild soap and water and patted dry. The incisions should not be soaked or have lotions or creams
applied as this could introduce pathogens.
3. Explain that light house work may begin in 2 weeks, but there is to be no lifting of any object weighing >5 lb (2.26 kg) without
approval of the HCP. Lifting, carrying, and pushing heavy objects are isometric activities. Heart rate and blood pressure
increase rapidly during isometric activities, which should be limited until approved by the HCP, generally about 6 weeks after
discharge. Guide the client to gradually resume activity and possibly participate in a cardiac rehabilitation program.
4. Clarify no driving for 4-6 weeks or until the HCP approves.
5. If the client is able to walk 1 block or climb 2 flights of stairs without symptoms (eg, chest pain, shortness of breath, fatigue), it
is usually safe to resume sexual activity
6. Notify the HCP if the following symptoms occur:
o Chest pain or shortness of breath that does not subside with rest
o Fever >101 F (38.3 C)
o Redness, drainage, or swelling at the incision sites.
Heparin

Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on a partial thromboplastin
time (PTT).
The therapeutic PTT target is 1.5-2.0 times the normal reference range of 25-35 seconds.
A PTT value >100 seconds would be considered critical and could result in life-threatening side effects.
Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestinal bleeds.

Hypovolemic Shock

Hypovolemic shock most commonly occurs from blood loss but can occur in any condition that reduces
intravascular volume. Hypovolemia is classified as either an absolute (eg, hemorrhage, surgery, gastrointestinal
bleeding, vomiting, diarrhea) or a relative (eg, pancreatitis, sepsis) fluid loss. Reduced intravascular volume results in
decreased venous return, decreased stroke volume and cardiac output, inadequate tissue perfusion, and impaired
cellular metabolism.
Clinical manifestations of hypovolemic shock are associated with inadequate tissue perfusion and include:

o Change in mental status

o Tachycardia with thready pulse
o Cool, clammy skin
o Oliguria
o Tachypnea

Decreased urine output (<0.5 mL/kg/hr) despite fluid replacement indicates inadequate tissue perfusion to the kidneys
and is a manifestation of hypovolemic shock in a client with normal renal function

Acute Pericarditis

Acute pericarditis is inflammation of the membranous sac (pericardium) surrounding the exterior of the heart, which
can cause an increase in the amount of fluid in the pericardium (ie, pericardial effusion). If pericardial effusions
accumulate rapidly or are very large, they may compress the heart, altering the mechanics of the cardiac cycle
(ie, cardiac tamponade).
 Cardiac tamponade decreases atrioventricular filling and impairs the heart's ability to contract and eject blood; it is life-
threatening without prompt recognition and treatment
Clinical features of cardiac tamponade include hypotension or narrow pulse pressure, muffled heart sounds,
and neck vein distension (Beck triad).
In addition, pulsus paradoxus (ie, systolic blood pressure decrease >10 mm Hg during inhalation), chest pain,
tachypnea, and tachycardia may be present.
Development of cardiac tamponade requires emergency pericardiocentesis (ie, needle insertion into the pericardium
to remove fluid) to prevent cardiac arrest.
In acute pericarditis, the inflamed pericardium rubs against the heart, causing pain that often worsens with deep
breathing or when positioned supine. The client should be placed in the Fowler position with a support (eg, bedside
table) to lean on for comfort.
ST-segment elevation in almost all ECG leads is a characteristic of acute pericarditis that typically resolves as
pericardial inflammation decreases. This is in contrast to acute myocardial infarction, in which ST-segment elevation is
seen in only localized leads (depending on which vessel is occluded).
Pericardial friction rub is an expected finding with acute pericarditis that occurs from the layers of the pericardium
rubbing together to create a characteristic high-pitched, leathery, and grating sound.

Mediastinal Chest Tube

Mediastinal chest tubes are used to drain air or fluid from the mediastinal space and/or pericardial cavity (ie, after
cardiac surgery).
Obstruction (eg, clot) of the chest tube will result in excess fluid buildup in the pericardium, leading to inhibited
cardiac contractility and eventual diagnosis of cardiac tamponade.
Cardiac tamponade is a life-threatening form of obstructive shock marked by decreased cardiac output and eventually
obstructive cardiac arrest if untreated.
If chest tube drainage is markedly decreased, the nurse should quickly assess for signs of cardiac tamponade and if
no such signs are present should troubleshoot other possible causes of chest tube occlusion.
Stripping (or milking) a chest tube should not be performed, unless specifically prescribed, as it can exert excessively
high negative pressure and traumatize tissues within the mediastinum.
Cardiac Tamponade

Pericardial effusion is a buildup of fluid in the pericardium.

Tamponade, a serious complication of pericardial effusion, develops as the effusion increases in volume and results
in compression of the heart. The heart struggles to contract effectively against the fluid, and cardiac output can
decrease drastically.
This life-threatening complication requires an emergency pericardiocentesis (a needle inserted into the pericardial
sac to remove fluid).
Signs and symptoms of cardiac tamponade include:

o Hypotension with narrowed pulse pressure

o Muffled or distant heart tones
 o Jugular venous distension
o Pulsus paradoxus
o Dyspnea, tachypnea
o Tachycardia

Femoral Popliteal bypass Surgery

Femoral-popliteal bypass surgery involves circumventing a blockage in the femoral artery with a synthetic or
autogenous (artery or vein) graft to restore blood flow.
The nurse performs neurovascular assessments on the affected extremity (ie, pulses, color and skin temperature,
capillary refill, pain, movement) and compares the findings with the preoperative baselines.
The client's nonpalpable pedal pulse that is present only with Doppler distal to the graft (ie, post-tibial, pedal) can
indicate compromised blood flow or graft occlusion and should be reported to the health care provider immediately.

Right Sided Heart Failure

Right-sided heart failure results from pulmonary hypertension, right ventricular myocardial infarction, or left-sided
heart failure.
The right ventricle cannot effectively pump blood to the lungs, which results in incomplete emptying of the right
ventricle.
The resulting decrease in forward blood flow causes blood to back up into the right atrium and then into venous
circulation, resulting in venous congestion and increased venous pressure throughout the systemic circulation.
Clinical manifestations of right-sided heart failure include:

o Peripheral and dependent edema (eg, sacrum, legs, hands), especially in the lower extremities
o Jugular venous distension
o Increased abdominal girth due to venous congestion of the gastrointestinal tract (eg, hepatomegaly, splenomegaly) and
ascites. Nausea and anorexia may also occur as a result of increased abdominal pressure and decreased gastrointestinal
circulation
o Hepatomegaly due to hepatic venous congestion.
Pulmonary Edema

In the presence of acute left ventricular failure, pulmonary vasculature overload causes increased pulmonary venous
pressure that forces fluid out of the vascular space into the pulmonary interstitium and, if untreated, into the alveoli.
Clinical manifestations of pulmonary edema include:

o A history of orthopnea and/or paroxysmal nocturnal dyspnea

o Anxiety and restlessness
o Tachypnea (often >30/min), dyspnea, and use of accessory muscles
o Frothy, blood-tinged sputum
o Crackles on auscultation

The priority of care is to improve oxygenation by reducing pulmonary pressure and congestion.
Diuretics (eg, furosemide) are prescribed to remove excess fluid in pulmonary edema
Management of acute decompensated heart failure (ADHF) may also include oxygen therapy, vasodilators (eg,
nitroglycerin, nesiritide), and positive inotropes (eg, dopamine, dobutamine).
Vasodilators decrease preload thus improving cardiac output and decreasing pulmonary congestion.
Positive inotropes improve contractility but are only recommended if other medications have failed or in the presence
of hypotension.
Coronary Artery Disease

Sexual Counseling for Cardiac Clients

Sexual counseling is important for cardiac clients, yet can be difficult for clients and HCPs to discuss and is often
neglected. Clients' concern about resumption of sexual activity can prove to be more stressful than would be the
activity itself. The nurse should encourage clients to discuss concerns with the HCP; in general, if a client can walk 1
block or climb 2 flights of stairswithout symptoms, the client can resume sexual activity safely.
The use of erectile agents is contraindicated if the client is consuming any form of nitrates.
Resumption of sexual activity depends on the emotional readiness of the client and the client's partner and on the
HCP's assessment of recovery. In general, it is safe to resume sexual activity 7-10 days after an uncomplicated MI.

Prophylactic antibiotics prior to Dental Procedures

Certain individuals should receive prophylactic antibiotics prior to dental procedures to prevent infective endocarditis
(IE). These include the following:

o Prosthetic heart valve or prosthetic material used to repair heart valve

o Previous history of IE
 o Some forms of congenital heart disease

Unrepaired cyanotic congenital defect

Repaired congenital defect with prosthetic material or device for 6 months after procedure
Repaired congenital defect with residual defects at the site or adjacent to the site of a prosthetic patch or device

o Cardiac transplantation recipients who develop heart valve disease

Pharmacologic Nuclear Stress Test

A pharmacologic nuclear stress test utilizes vasodilators (eg, adenosine, dipyridamole) to simulate exercise when
clients are unable to tolerate continuous physical activity or when their target heart rate is not achieved through
exercise alone.
These drugs produce vasodilation of the coronary arteries in clients with suspected coronary heart disease.
A radioactive dye is injected so that a special camera can produce images of the heart.
Based on these images, the health care provider (HCP) can visualize if there is adequate coronary perfusion.
Pre-procedure client instructions include the following:

o Do not eat, drink, or smoke on the day of the test (NPO for at least 4 hours). Small sips of water may be taken with
medications
o Avoid caffeine products 24 hours before the test
o Avoid decaffeinated products 24 hours before the test as these contain trace amounts of caffeine
o Do not take theophylline 24-48 hours prior to the test (if tolerated).
o If insulin/pills are prescribed for diabetes, consult the HCP about appropriate dosage on the day of the test. Hypoglycemia can
result if the medicine is taken without food
o Some medications can interfere with the test results by masking angina. Do not take the following cardiac medications unless
the HCP directs otherwise, or unless needed to treat chest discomfort on the day of the test:

Nitrates (nitroglycerine or isosorbide)

Dipyridamole
Beta blockers
 Buerger's disease (thromboangiitis obliterans) is a nonatherosclerotic vasculitis involving the arteries and veins of
the lower and upper extremities.
It occurs most often in young men (age <45) with a long history of tobacco or marijuana use and chronic periodontal
infection, but no other cardiovascular risk factors.
Clients experience thrombus formation, resulting in distal extremity ischemia, ischemic digit ulcers, or digit
gangrene.
They often have intermittent claudication of the feet and hands. Over time, rest pain and ischemic ulcerations may
occur. Many clients also develop secondary Raynaud phenomenon (cold sensitivity).
The mainstay treatment of Buerger's disease is the cessation of all tobacco and marijuana use in any form.
Nicotine replacement products (eg, nicotine patch) are contraindicated.
However, bupropion and varenicline can be used for smoking cessation.
Clients may have to choose between continued use of tobacco and marijuana and their affected limbs.
Conservative management includes avoidance of cold exposure to affected limbs, a walking program, antibiotics for
any infected ulcers, analgesics for ischemic pain, and avoidance of trauma to the extremities.

Central Venous Catheter

Air embolism is a rare but life-threatening complication of central venous catheter (CVC) placement in which air
enters the bloodstream.
This air displaces blood in the pulmonary vessels, which prevents oxygenation of blood by the lungs.
Air embolism may occur after CVC removal, as air can enter the bloodstream via the open, large-bore insertion site.
Clients with air embolism can rapidly develop respiratory distress leading to cardiopulmonary collapse.
Nurses caring for clients with symptoms of air embolism (eg, hypoxemia, dyspnea, sense of impending doom) after
CVC removal or dislodgement should perform these actions:
o Apply an occlusive dressing to the insertion site to prevent entry of additional air into the bloodstream
o Administer 100% oxygen via non-rebreather mask to improve oxygenation
 o Position the client in left lateral Trendelenburg position to promote venous air pooling in the heart apex rather than
the lung capillary beds
o Continuously monitor vital signs and client respiratory effort to identify changes in client status
o Notify the health care provider immediately

Aortic Stenosis
Aortic stenosis is a narrowing of the aortic valve, which obstructs blood flow from the left ventricle to the aorta.
As stenosis progresses, the heart cannot overcome the worsening obstruction, and ejects a smaller fraction of blood
volume from the left ventricle during systole.
This decreased ejection fraction results in a narrowed pulse pressure (ie, the difference between systolic and
diastolic blood pressures) and weak, thready peripheral pulses.
With exertion, the volume of blood that is pumped to the brain and other parts of the body is insufficient to meet
metabolic demands, resulting in exertional dyspnea, anginal chest pain, and syncope.
On auscultation, aortic stenosis produces a loud, ejection systolic murmur over the aortic area as blood is ejected
from the left ventricle through the stenosed aortic valve during systole.

Organ Transplantation

Immunosuppressive therapy (eg, mycophenolate, tacrolimus, corticosteroids) is required after organ transplantation
to prevent acute and chronic rejection of the organ.
This is a lifelong drug regimen for the transplant client, and it has adverse side effects (eg, nephrotoxicity,
hepatotoxicity, infection susceptibility).
Prior to surgery, the client needs to fully understand the physical, psychological, and financial commitment required.
It is important for the nurse at every opportunity to emphasize strict immunosuppressive therapy compliance to prevent
acute transplanted organ rejection.
Loop Diuretics

Loop diuretics (furosemide, torsemide, bumetanide) are used to treat fluid retention, such as that found in clients with
heart failure or cirrhosis.
When administering loop diuretics, the nurse can expect the client's kidneys to excrete a significant amount of water
and potassium.
When potassium is excreted at a fast rate, the client could develop hypokalemia, a medical emergency that can result
in other life-threatening complications such as heart arrythmias, as well as muscle cramps and weakness
Blood pressure should also be assessed prior to administration of loop diuretics as excess diuresis may cause
intravascular volume depletion that results in low blood pressure.
A client with baseline hypotension may develop a critically low blood pressure.
Excess diuresis can also affect kidneys, and the blood urea nitrogen and creatinine levels can become elevated as
well. Therefore, these levels should be assessed
Heparin Therapy

A significant reduction in platelets after initiation of heparin therapy can indicate heparin-induced
thrombocytopenia (HIT), a severe, potentially lethal complication.
HIT is an immune reaction to heparin that causes a drastic and a paradoxical increase
in arterial and venous thrombosis.
The nurse should notify the health care provider immediately and anticipate stopping heparin therapy and initiating
a non-heparin anticoagulant (eg, warfarin, rivaroxaban, argatroban)
Clients with HIT have increased risk for deep venous thrombosis (DVT) and pulmonary embolism.
The nurse should perform a neurovascular assessment and report evidence of vascular clots (eg, DVT) to the health
care provider.
The nurse should also measure a full set of vital signs to assess for pulmonary embolism (eg, tachycardia, tachypnea,
decreased oxygen saturation)
When large changes are noted in laboratory values, it is important to draw repeat samples to confirm those values,
as errors in sampling or specimen handling could result in inappropriate intervention
Clients who are suspected of having HIT or who have a history of HIT should never receive heparin or low-molecular-
weight heparin (eg, enoxaparin). Only non-heparin anticoagulants may be given.
Client teaching for Heart Failure

Synchronized Cardioversion

Synchronized cardioversion is a procedure used to convert tachyarrhythmias (eg, supraventricular tachycardia,

ventricular tachycardia) with a pulse to stable cardiac rhythms via transcutaneous electrical shock.
The shock in cardioversion is timed by the defibrillator ("sync" feature enabled) to be delivered only during the R
wave of the QRS complex, when the ventricles depolarize.
 Accidentally delivering shocks during the T wave, when heart ventricles are repolarizing, causes R-on-T
phenomenon, which frequently results in lethal arrhythmias (eg, ventricular fibrillation).
The nurse must ensure that the defibrillator's "sync" feature is enabled when preparing to perform synchronized
cardioversion.
Disabling or failing to enable the "sync" feature may result in a potentially lethal, asynchronous shock being delivered
to the client

Endovascular abdominal aortic aneurysm repair

Endovascular abdominal aortic aneurysm repair is a minimally invasive procedure that involves the placement of a
sutureless aortic graft inside the aortic aneurysm via the femoral artery.
It does not require an abdominal incision.
The nurse will need to monitor the puncture sites in the groin area for bleeding or hematoma formation
Peripheral pulses should be palpated and monitored frequently in the early post-op period and routinely afterward
Renal artery occlusion can occur due to graft migration or thrombosis so careful monitoring of urine output and kidney
function should be part of nursing care

Minimally invasive direct coronary artery bypass (MIDCAB)

MIDCAB does not involve a sternotomy incision or placement on cardiopulmonary bypass.

Several small incisions are made between the ribs.
A thoracotomy scope or robot is used to dissect the internal mammary artery (IMA) that is used as a bypass graft.
Radial artery or saphenous veins may be used if the IMA is not available.
Recovery time is typically shorter with these procedures and clients are able to resume activities sooner than with
traditional open chest coronary artery bypass graft surgery.
However, clients may report higher levels of pain with MIDCAB due to the thoracotomy incisions made between the
ribs.
Cardiomyopathy

Cardiomyopathy is a group of diseases in which the heart muscle (ie, myocardium) has a reduced ability to pump
blood effectively, placing clients at risk for cardiogenic shock.
Cardiogenic shock is manifested by reduced cardiac output (eg, hypotension, narrow pulse pressure), which can
lead to pulmonary edema (eg, tachypnea, bibasilar crackles, decreased oxygen saturation) caused by blood "backing
up" into the pulmonary capillaries.
To compensate, catecholamines (eg, epinephrine) and vasopressin are released by the adrenal glands to increase
cardiac output.
However, this compensatory mechanism eventually fails, causing decreased perfusion and oxygenation of tissues
as well as death.
The client may need additional support with ionotropic agents (eg, norepinephrine) in these situations.
Supplemental oxygen is appropriate for treatment given low oxygen saturation, chest pain, and tachypnea.
If chest pain is present, obtaining an ECG and testing cardiac enzymes (eg, creatine kinase-MB, troponin I) are
appropriate
IV fluids should not be given rapidly (ie, bolused) in cardiogenic shock as this will suddenly increase circulating volume
and cardiac workload, which may precipitate pulmonary edema.
Nitroglycerin can worsen hypotension and should be held. Other pain medications (eg, morphine) may be given for
chest pain if blood pressure is low.
Aortic Dissection

Aortic dissection is a tear in the inner lining of the aorta that allows blood to surge between the layers of the arterial
wall, separating and weakening the aortic wall.
Perfusion to vital organs may become impaired, and the dissection can rapidly progress to life-threatening cardiac
tamponade or aortic rupture.
Aortic dissection is characterized by acute onset of excruciating, sharp or "ripping" chest pain that radiates to the
back. Emergency surgical repair is usually required.
Before surgical repair, the priority is decreasing the risk of aortic rupture by maintaining normal pressure in the
aorta.
Administering IV beta blocker medication (eg, labetalol, metoprolol, propranolol) helps achieve this by lowering
the heart rate and blood pressure, which are often elevated with aortic dissection.
 ENDOCRINOLOGY
DM DIET

Black bean chili with brown rice is a low-fat, low glycemic index, high-fiber meal. The other meals do contain some
acceptable items but none are the best option due to low-fiber content and high glycemic index.
The American Diabetic Association recommends a simple "Create My Plate" method for meal planning. Specific
dietary recommendations include:

1. Monitor carbohydrate intake

2. Manage caloric intake if weight loss is desired
3. High-fiber foods (30-35 g of fiber per day), including whole grains, legumes, fruits, vegetables, and low-fat dairy products
 4. Use monounsaturated fats, limit use of saturated fat, and eliminate trans fatty acids
5. Choose foods with a low glycemic index
6. Consume total cholesterol of <300 mg per day
7. Reduce sodium intake
8. Limit intake of foods containing sucrose
9. Limit intake of alcoholic beverages

IV FLUIDS

Isotonic fluids (eg, normal saline) are appropriate for clients with volume deficit such as those with gastrointestinal
bleeding.
Septic shock involves an inflammatory response to pathogens that leads to massive vasodilation and increased
capillary permeability, resulting in intravascular hypovolemia and severe hypotension. An isotonic solution (eg, 0.9%
NaCl) bolus is prescribed to expand intravascular volume and increase blood pressure.
 A burn injury causes tissue damage and increased capillary permeability; this leads to fluid and electrolyte losses
related to evaporation and intravascular fluid shifts into the interstitial tissue, which result in hypovolemia,
hemoconcentration (eg, hematocrit >53% [0.53]), and hypotension. An isotonic solution (eg, lactated Ringer's) is
prescribed to replace fluid and electrolyte losses.

SYNDROME OF INAPPROPRIATE ANTI-DIURETIC HORMOME (SIADH)

SIADH is an endocrine condition in which too much ADH is produced, causing water retention, increased total body
water, and dilutional hyponatremia (low serum sodium).
Some cancer cells, particularly those of small cell lung cancer, have the ability to produce and secrete ADH, leading to
SIADH.
Other causes include central nervous system disorders (eg, stroke, trauma, neurosurgery) and some commonly used
medications (eg, desmopressin, carbamazepine).
Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is associated with increased water reabsorption
and excessive intra- and extracellular fluid, which result in hypervolemia from fluid retention and dilutional
hyponatremia. In the setting of SIADH, the nurse should question a prescription for a hypotonic solution (eg, 0.45%
NaCl; or dextrose water) as it would worsen the fluid and electrolyte imbalance.
A prescription for fluid restriction and a hypertonic IV solution (eg, 3% NaCl) administered in small quantities would
be appropriate to shift fluid back into the vascular compartment and correct hyponatremia.
Syndrome of inappropriate antidiuretic hormone (SIADH) is potential complication of head injury. In SIADH, the
extra ADH leads to excessive water absorption by the kidneys. Low serum osmolality and low serum sodium are
the result of increased total body water (dilution). As ADH is secreted and water is retained, urine output is
decreased and concentrated, resulting in a high specific gravity.

Hyperthyroidism refers to a sustained hyperfunctioning of the thyroid gland due to an increase in thyroid
hormones (T3 and T4). Elevated thyroid hormones suppress serum TSH levels.
The symptoms are a result of the hypermetabolic rate caused by the increase in thyroid hormones.
These include weight loss, heart palpitations, heat intolerance, excessive sweating, anxiety, hand tremors,
diarrhea, and insomnia.
Hyperthyroidism can also cause retro-orbital tissue expansion and weakness of the muscle fibers in the
eye. Exophthalmos is an irreversible protrusion of the eyeballs. Eyelid lag (ie, Graefe's sign) is a delayed
movement in the eyelid when the eye looks downward.
Thyroid storm is a life-threatening condition that can occur in uncontrolled hyperthyroidism or Graves' disease when
a stressful incident, such as this client's motor vehicle accident, triggers a sudden surge of thyroid hormone.
Manifestations of thyroid storm include a rapid onset of fever, tachycardia, and elevated blood pressure.
The client often feels anxious, tremulous, or restless.
Confusion and psychosis can occur, as can seizures and coma. Rapid treatment is necessary.
Thyroid storm is a serious and potentially life-threatening emergency for clients with Graves disease.
This condition occurs when the thyroid gland releases large amounts of thyroid hormone in response to stress (eg,
trauma, surgery, infection).
Characteristic features include tachycardia, hypertension, cardiac arrhythmias (eg, atrial fibrillation), and fever up to
104-106 F (40-41 C).
Other findings include severe nausea, vomiting, anxiety, altered mentation, and seizures.
Hyperthyroidism refers to sustained hyperfunctioning of the thyroid gland due to excessive secretion thyroid
hormones (T3, T4); this leads to an increased metabolic rate.
In clients with hyperthyroidism, teaching and learning objectives to satisfy hunger and prevent weight loss and tissue
wasting include:

o Adherence to a high calorie diet (4000-5000 calories per day).

o Consumption of approximately 6 full meals and snacks per day. These should be packed with protein (1-2 g/kg of ideal body
weight), carbohydrates, and be full of vitamins and minerals (Option 1).
o Avoidance of high-fiber foods due to the constant hyperstimulation of the gastrointestinal (GI) tract. High-fiber foods may
increase GI symptoms (eg, diarrhea). However, high-fiber diets are recommended if the client with hyperthyroidism has
constipation.
o Avoidance of stimulating substances (eg, caffeinated drinks: coffee, tea, soft drinks).
o Avoidance of spicy foods as these can also increase GI stimulation.
HYPOTHYROIDISM

Primary hypothyroidism is an endocrine disorder identified by low circulating thyroid hormone (ie, triiodothyronine
[T3], thyroxine [T4]) and high thyroid-stimulating hormone (TSH) levels. Primary hypothyroidism occurs when TSH
is unable to stimulate the thyroid to produce thyroid hormones, often after trauma or autoimmune-related tissue
damage (eg, Hashimoto thyroiditis). Therefore, TSH levels remain elevated as primary counterregulatory hormone (ie,
T3, T4) levels remain low.
Thyroid hormones act in multiple body sites to stimulate and increase metabolic functions (eg, body temperature,
cellular energy, oxygen consumption, neuron conduction). Therefore, clients with hypothyroidism exhibit clinical
manifestations of low metabolic state, including:

o Bradycardia and hypotension

o Hypothermia and cold intolerance
o Constipation
 o Fragile, dry skin and hair loss
o Forgetfulness, slurred speech, and confusion

Clients with hypothyroidism often gain weight and develop dry, fragile skin because of decreased metabolic activity.
Weight loss and warm, moist skin are characteristic of an increased metabolic rate, as found in clients with
hyperthyroidism.

DIABETES INSIPIDUS

Diabetes insipidus (DI) is a condition that occurs due to insufficient production/suppression of antidiuretic hormone
(ADH).
Increased urine output is associated with diabetes insipidus (DI). In DI, ADH is suppressed, causing polyuria, severe
dehydration, and high serum osmolality if the client is unable to drink enough to maintain a fluid balance.
Neurogenic DI is a type of DI that results from impaired ADH secretion, transport, or synthesis. It sometimes occurs
after manipulation of the pituitary or other parts of the brain during surgery, brain tumors, head injury, or central
nervous system infections.
DI is characterized by polydipsia (increased thirst) and polyuria (increased urine output) with low urine specific
gravity (dilute urine). As a result, fluids should be replaced orally/intravenously to prevent dehydration
ADH release is impaired in neurogenic DI. As a result, ADH replacement with vasopressin (Pitressin) can be used to
treat DI. However, it also has vasoconstrictive properties. Therefore, desmopressin (DDAVP), an analog without
vasopressor activity, is the preferred therapy. Clients on this treatment should be monitored for urine output, urine
specific gravity, and serum sodium (to avoid hyponatremia due to excess DDAVP).
DI is not associated with low/high blood glucose and should not be confused with diabetes mellitus (DM) as both DI
and DM involve symptoms of excessive urination (polyuria).
INSULIN

NPH insulin is intermediate-acting with an onset of 1-2 hours, peak of 4-12 hours, and duration of 12-18 hours.
Due to its long peak, hypoglycemia (blood glucose <70 mg/dL [<3.9 mmol/L]) can result from use of NPH, especially
because the overnight hours (during sleep) typically represent the longest interval between meals.
To prevent hypoglycemia related to an evening dose of NPH, the client should eat a bedtime snack consisting
of protein and complex carbohydrates (eg, cereal with milk, crackers with peanut butter) (Option 2). Complex
carbohydrates paired with protein provide sustained, slow release of glucose, thereby preventing hypoglycemia.
Glargine (Lantus) is a long-acting (basal) insulin given to prevent hyperglycemia for 24 hours. The drug has no
peak, and so timing of administration is not dependent on food intake. However, if the client is NPO for more than 12
hours, the provider may hold it.
Lispro (Humalog) is a rapid-acting insulin with a peak of 30 minutes to 3 hours and should be given only if it is
certain the client will eat within 15 minutes. Lispro is prescribed in two ways:
o Scheduled prandial (ie, fixed dosage) given to prevent hyperglycemia with consumption of food. Typically, this would not
be held unless the blood sugar is below normal (70 mg/dL [3.9 mmol/L]) or according to facility guidelines.
o Correctional (ie, sliding-scale dosage) given to correct hyperglycemia. Typically, this would be held when blood glucose is
below 150 mg/dL (8.3 mmol/L).
Both glargine and lispro would be given according to schedule, as the client is not NPO and plans to eat immediately,
and glucose is above 70 mg/dL [3.9 mmol/L]
Holding glargine will increase the blood sugar level over 24 hours. Holding lispro will cause blood glucose to rise
uncontrollably due to the consumption of food.

THYROID SURGERY
Respiratory distress is a life-threatening complication of thyroid surgery that occurs when swelling in the surgical
area at the base of the neck compresses the airway.
 Stridor and/or difficulty breathing in the client who has had thyroid surgery should be reported immediately to the
registered nurse, and a rapid response should be activated.
Although elevated blood pressure is important to monitor, it is a less serious symptom than stridor.
An irregular heart rate is a less serious symptom than stridor, and it may be a baseline finding in the client with
hyperthyroidism.
Although low oxygen saturation is a sign of impending airway compromise, it is also commonly seen in all types of
postoperative clients, making it a less specific sign of airway obstruction than noisy breathing in the thyroidectomy
client.

MYXEDEMA COMA

Myxedema coma refers to a state of severe hypothyroidism causing decreased level of consciousness (eg, lethargy,
stupor) that may progress to a comatose state.
Myxedema coma is characterized by hypothermia, bradycardia, hypotension, and hypoventilation. Hypoventilation
may occur as a result of respiratory muscle fatigue and mechanical obstruction by an edematous tongue.
Clients with signs of respiratory failure (eg, slow or shallow breathing, low oxygen saturation) require emergency
endotracheal intubation and mechanical ventilation. The nurse should provide respiratory support (eg, ventilation
with a bag-valve-mask) and prepare to assist with intubation
Clients with myxedema coma require thyroid hormone replacement with IV levothyroxine to correct the hypothyroid
state but only after respiratory status is secured. Improvement in clinical status may not occur for up to a week after
initiation of hormone replacement.
A serum thyroid panel (eg, TSH, triiodothyronine, thyroxine) is required to confirm hypothyroidism, and these
measurements should be monitored during treatment; however, the nurse should ensure that the client is stable before
reviewing laboratory values.
A warming blanket should be placed on the client to treat hypothermia; however, respiratory support is the priority.

Addison disease, or primary adrenocortical insufficiency, is also described as hypofunction of the adrenal cortex.
The adrenal gland is responsible for secretion of glucocorticoids, androgens, and mineralocorticoids.
Bronze hyperpigmentation of the skin in sun-exposed areas is caused by an increase in adrenocorticotropic
hormone (ACTH) by the pituitary in response to low cortisol (ie, glucocorticoid) levels
Clients with Addison disease may also have vitiligo, or patchy/blotchy skin, which is usually present when the
etiology of the disease is an autoimmune problem. The immune cells are thought to destroy melanocytes which
produce melanin (or brown pigment), resulting in a patchy appearance.
Other common manifestations of Addison disease include the following:

o Slow, progressive onset of weakness and fatigue

o Anorexia and weight loss
o Orthostatic hypotension
o Hyponatremia and hyperkalemia
o Salt cravings
o Nausea and vomiting
o Depression and irritability

Addison's disease is adrenocortical insufficiency or hypofunction of the adrenal cortex.

 A deficiency in all 3 classes of adrenal corticosteroids, including glucocorticoids, mineralocorticoids, and androgens, is
present in Addison's disease.
Addisonian crisis, or acute adrenocortical insufficiency, is a potentially life-threatening complication of Addison's
disease.
It can lead to shock and should be reported immediately to the PHCP. Addisonian crisis is triggered by stress, and its
manifestations include the following:

o Hypotension and tachycardia

o Dehydration
o Hyperkalemia and hyponatremia
o Hypoglycemia
o Fever
o Weakness and confusion

RAIU

RAIU measures the metabolic activity in the thyroid gland in order to differentiate between the many types of thyroid
disorders.
A RAIU test involves administering a low dose of radioactive iodine, in contrast to radioactive iodine treatment for
some types of thyroid cancer, which uses a high dose to destroy all thyroid tissue. The thyroid gland is the only tissue
that uses iodine, which is a key component of thyroid hormones.
A scan is performed at 2, 6, and 24 hours to assess the areas actively absorbing iodine, which can narrow the
diagnosis to hyperfunctioning thyroid disorders (eg, Graves' disease).
Important nursing considerations:

o Notify the primary health care provider (PHCP) if computerized tomography scan or other recent x-ray using iodine contrast
has been performed; the iodine may alter the test results.
o Antithyroid or thyroid hormone medication should be held for 5-7 days before undergoing a RAIU test as these can also
alter results.
o All premenopausal women must take a pregnancy test before the procedure, as radioactive iodine could adversely affect the
development of the fetal thyroid gland.
 Important aspects of client education:

o Maintain nothing by mouth (NPO) status for 2-4 hours prior to the procedure. Eating may resume 1-2 hours after
swallowing the iodine; a normal diet can be restarted when the test ends. Remove dentures and jewelry/metal around the
neck to allow clear visualization during the scan.
o Drink plenty of fluids after the procedure to clear RAI from the system. Notify the PHCP if you are allergic to any medications
(eg, iodine). However, a RAIU test is generally safe (even in the presence of an iodine allergy) due to the diminutive amount
of iodine used.
o You will be awake during the procedure but there should be no discomfort
o Do not breastfeed immediately after this procedure, and ask your PHCP when breastfeeding may resume.

METABOLIC SYNDROME

Metabolic syndrome s that increase a client's risk for stroke, diabetes

mellitus, and cardiovascular disease. Criteria include:

1. Abdominal obesity: nches [89 cm] in women)

2. High serum triglycerides >150 mg/dL (1.7 mmol/L) or hypertriglyceridemia drug treatment
3. Low levels of high-density lipoprotein (HDL) cholesterol (<40 mg/dL [1.0 mmol/L] in men, <50 mg/dL [1.3 mmol] in women)
4. Hypertension Hg or hypertension drug treatment
5. (5.6 mmol/L) or hyperglycemia drug treatment

HYPOCALCEMIA

Normal serum calcium is 8.6-10.2 mg /dL (2.15-2.55 mmol/L).

Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of parathyroidectomy because
the parathyroids regulate calcium levels in the blood.
When one or more parathyroids are removed, it may take some time for others that have been dormant during
hyperparathyroidism (which causes an increase in serum calcium) to begin regulating serum calcium.
 Trousseau's sign may indicate hypocalcemia before other signs and symptoms of hypocalcemia, such as tetany,
occur. Trousseau's sign can be elicited by placing the BP cuff on the arm, inflating to a pressure > than systolic BP,
and holding in place for 3 minutes. This will occlude the brachial artery and induce a spasm of the muscles of
the hand and forearm when hypocalcemia is present.
Chevostek's sign another early indicator of hypocalcemia, should also be assessed. It may be elicited by tapping
the face at the angle of the jaw and observing for contraction on the same side of the face.

DIABETIC NEPHROPATHY
The normal serum creatinine for an adult is 0.6-1.3 mg/dL (53-115 µmol/L). It provides an estimation of the glomerular
filtration rate and is an indicator of kidney function. A level of 2 mg/dL (177 µmol/L) is clearly abnormal.
The client with diabetes mellitus is at risk for diabetic nephropathy, a complication associated with microvascular
blood vessel damage in the kidney.
Early treatment and tight control of blood glucose levels are indicated to prevent progressive renal injury in a client
with diabetic nephropathy.

THYROIDECTOMY

Thyroidectomy is a surgery involving partial or complete removal of the thyroid, often to treat hyperthyroidism or
thyroid cancer.
Clients undergoing a thyroidectomy require close monitoring as they are at increased risk for airway
compromise due to potential neck swelling, hypocalcemia, and nerve damage.
Nurses planning care following a thyroidectomy promote client recovery and monitor for and prevent complications by:
o Assessing for and immediately reporting signs of hypocalcemia (eg, facial or extremity numbness or tingling,
stridor, Trousseau and Chvostek signs), which may occur from parathyroid gland trauma during surgery
o Assessing for stridor and new or worsening changes in voice strength and quality (eg, hoarseness, whispering), which
may indicate laryngeal nerve damage that can result in respiratory arrest
o Keeping emergency airway equipment (eg, tracheostomy kit, suction, oxygen) at the bedside in case respiratory distress
develops
 o Maintaining the client in semi-Fowler position, which promotes drainage of surgical site edema around the neck and reduces
the risk of respiratory distress
Postoperatively, the client should avoid excessive neck flexion and extension, which may strain and cause disruption
of the incision site, leading to hemorrhage. Encourage the client to maintain neutral head and neck alignment.

DIABETES MELLITUS

Type 1 diabetes mellitus is an endocrine disorder characterized by the absence of insulin production in the
pancreas, causing hyperglycemia and intracellular energy deficits.
Clients with type 1 diabetes mellitus require consistent insulin administration, typically of both short- or rapid-acting
and intermediate- or long-acting insulins, to prevent hyperglycemia and provide energy to the cells.
The nurse should contact the health care provider (HCP) to report the serum glucose (270 mg/dL [14.9 mmol/L]) and
request an additional insulin prescription.
The client requires rapid-acting insulin (eg, lispro, aspart) before eating to correct the hyperglycemia; long-acting
insulins are not effective for immediate correction.
Detemir is a long-acting (basal) insulin, prescribed once or twice daily. Long-acting insulins are given to prevent, not
correct, hyperglycemia. However, if the blood glucose remains elevated, the detemir dose may need to be increased.

Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet due
to the chronic complication of peripheral neuropathy.

Peripheral neuropathy results from damage to the nerves in the extremities. Clients may be unable to feel injuries if
they occur and must take extra measures in caring for their feet. Clients should be taught to wear closed-toed,
leather-based shoes to prevent injury.

Careful, daily attention to foot care can prevent long-term complications. The following instructions can be used in
teaching diabetic foot care:

o Proper footwear Wear shoes that are comfortable, supportive, and well-fitting (preferably leather). Avoid high-heeled,
open-heeled, and open-toed shoes. Wear clean, absorbent (eg, cotton) socks.
 o Daily hygiene and inspection Use a mild soap and warm water; dry feet thoroughly, especially between toes. Apply
lanolin lotion to prevent drying (but not between toes). Inspect for any break in skin integrity using a mirror or a second
person to visualize the bottom of the feet. Trim toenails straight across; file edges along contour of the toes.
o Injury avoidance Do not walk barefoot, use hot water or heating pads, wear restrictive shoes or clothing, or cross the legs
for extended periods
o Report problems Do not self-treat corns, calluses, or ingrown toenails. Cleanse cuts or abrasions with mild soap and
water; report non-healing or infected injuries to the health care provider immediately.

HYPERGLYCEMIA

Stress-induced hyperglycemia (gluconeogenesis) can occur in hospitalized clients in relation to surgery, trauma,
acute illness, and infection.
Hyperglycemia (glucose level >140 mg/dL [7.8 mmol/L]) affects both diabetic and non-diabetic hospitalized clients,
especially those who are critically ill.
Approximately 80% of clients in the intensive care unit who develop hyperglycemia have no history of diabetes before
admission.
Hyperglycemia is associated with increased risk of complications (eg, health care-associated infection, increased
length of stay, acute kidney injury).
To minimize complications and avoid hypoglycemia, the recommended glucose target range for critically ill clients
is 140-180 mg/dL [7.8-10.0 mmol/L].
For non-critically ill clients, <140 mg/dL [7.8 mmol/L] fasting and <180 mg/dL [10.0 mmol/L] random blood glucose are
recommended.
Hospital hyperglycemia is not a direct cause of type II diabetes mellitus. In the non-diabetic client, the glucose level
usually returns to normal after resolution of the disease process and/or discontinuation of steroid medications. A
target glucose range of <140 mg/dL [7.8 mmol/L) is not recommended for this client.
The prevalence of diabetes in hospitalized clients is high (about 1 in 4) and may be an undiagnosed pre-existing
condition. A normal-range glucose level (70-110 mg/dL [3.9-6.1 mmol/L]) is not the recommended target range in this
client due to the risk of hypoglycemia (with aggressive control) and worse outcomes.
 Although hyperglycemia does affect the ability to fight infection, 70-110 mg/dL [3.9-6.1 mmol/L] is not the
recommended target range for this client.

HYPOGYLCEMIA
Hypoglycemia, a potentially life-threatening complication of diabetes mellitus, is identified by blood glucose <70
mg/dL (<3.9 mmol/L) and often occurs as a result of illness or inappropriate use of antidiabetic medications. When
blood glucose levels (BGLs) are low, the body activates the autonomic nervous system, causing shakiness,
palpitations, and sweating. Without intervention, hypoglycemia may cause altered mental status (eg, difficulty
speaking, confusion), which may progress to seizures, coma, and death.
Nurses caring for clients with hypoglycemia and altered mental status or dysphagia should immediately administer IV
glucose replacement (eg, 50% dextrose in water) to quickly restore BGLs and prevent potentially lethal neurological
changes. Afterward, the nurse should retest the BGL every 15 minutes, repeating treatment if it remains low.
Clients with altered mental status (eg, obtunded, responsive only to painful stimuli) are at high risk for aspiration and
are not appropriate candidates for oral glucose replacement.
Obtundation, a sign of severe hypoglycemia, and a confirmed BGL of 38 mg/dL (2.11 mmol/L) are sufficient indicators
for implementing emergency intervention. Assessment of additional signs of hypoglycemia, heart rate, and blood
pressure should not delay implementation of lifesaving treatment.

HBA1C

Hemoglobin A1C is a diagnostic test used to measure the percentage of glycosylated hemoglobin in the blood.
A normal hemoglobin A1C is 4%-6% in clients without diabetes; the goal is to keep the level <7% in clients with
diabetes.
The A1C test measures blood glucose control over a period of 2-3 months; higher measurements indicate higher
glycemic levels.
High levels may indicate poor adherence to the recommended diet and exercise plan or ineffective antihyperglycemic
medication regimen.
It is important for the nurse to review the diet, exercise, and medication plan with the client who has a high hemoglobin
A1C.
PHEOCHROMOCYTOMA

Pheochromocytoma is a condition caused by a tumor in the adrenal medulla. This results in excess release
of catecholamines such as epinephrine and norepinephrine, leading to paroxysmal hypertensive crisis.
Important points to note when caring for these clients include the following:

1. Hypertension is difficult to treat and is often resistant to multiple drugs.

2. The client should avoid activities that can precipitate a hypertensive crisis (eg, bending, lifting, Valsalva maneuver).
3. Abdominal palpation should be avoided as manipulation of the adrenal gland and release of catecholamines can precipitate
a hypertensive crisis.

Hypertensive crisis puts the client at risk for stroke and so has the highest priority for
treatment. Nitroprusside (Nitropress, Nipride) is a vasodilator given via infusion and can be titrated to keep the BP
within a desired parameter.
Administration of acetaminophen and use of a fan may help relieve symptoms. Drawing an electrolyte panel is
appropriate. However, these are not life-saving interventions and so are not the highest priority.

DIABETIC KETOACIDOSIS (DKA)

DKA is a life-threatening emergency caused by a relative or absolute insulin deficiency. The condition is characterized
by hyperglycemia, ketosis, metabolic acidosis, and dehydration.
The most likely contributing factors in this client include stress associated with illness and infection (elevated
temperature) and inadequate insulin dosage and self-management.
Deficient fluid volume related to osmotic diuresis secondary to hyperglycemia as evidenced by dry mucous
membranes and client report of frequent urination, thirst, and weakness is the priority ND.
Hyperglycemia leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and
renal failure. Therefore, this condition requires rapid correction through the infusion of isotonic intravenous fluids and
poses the greatest risk to the client's survival.
All clients with DKA experience dehydration due to osmotic diuresis. Prompt and adequate fluid therapy restores
tissue perfusion and suppresses the elevated levels of stress hormones. The initial hydrating solution is 0.9%
saline infusion.
Insulin therapy should be started after the initial rehydration bolus as serum glucose levels fall rapidly after volume
expansion.
Cushing syndrome is the result of prolonged exposure to excess corticosteroids, especially glucocorticoid steroids.
The most common cause is the administration of corticosteroids, such as prednisone or hydrocortisone, for other
conditions. However, pituitary adenomas can secrete adrenocorticotropic hormone (ACTH), which in turn causes the
adrenal glands to produce too much cortisol.
Clinical manifestations include:

o Androgen excess from adrenal gland stimulation can result in acne, hirsutism, and menstrual irregularities (eg,
oligomenorrhea).
o Metabolic complications include truncal obesity (subsequently causing peripheral insulin resistance), hypertension,
and hyperglycemia (ie, excess cortisol stimulating gluconeogenesis). Fat accumulation in the face (ie, moon face) and the
back of neck (ie, buffalo hump) is common
o Dermatological changes are possible and include easy bruising, purple striae, and skin atrophy; these result from loss of
collagen.
o Proximal muscle weakness and bone loss (ie, osteoporosis) due to steroid catabolism on muscles and bone can develop in
untreated clients.
 GASTROENTEROLOGY
LAPAROSCOPIC CHOLECYSTECTOMY

A laparoscopic cholecystectomy is the safest and most commonly used procedure for gallbladder removal.
A laparoscope and grasping forceps are inserted through small punctures made in the abdomen.
The procedure is associated with decreased postoperative pain, better cosmetic results, shorter hospital stays, and
fewer days for recovery versus the open technique.
Postoperative teaching includes:

o Diet a low-fat diet is recommended postoperatively as it is well tolerated. A regular diet can be resumed after a few weeks
although weight loss may be recommended
o Activity and work resume normal activity slowly, as tolerated. Most individuals can return to work within a week
o Incision care and hygiene - dressings can be removed the day after surgery, and showering is permitted at this time. Signs
and symptoms of infection (redness, edema, pus, severe pain, nausea, fever, chills) should be reported immediately

AREAS OF REFERRED PAIN IN THE ABDOMEN

ACUTE CHOLECYSTITIS

Cardinal symptoms of acute cholecystitis from cholelithiasis include pain in the RUQ with referred pain to the
right shoulder and scapula
Clients often report fatty food ingestion 1 3 hours before the initial onset of pain.
Associated symptoms include low-grade fever, chills, nausea, vomiting, and anorexia
During an acute attack, inflammation of the mucous lining and wall of the gallbladder occurs as a result of gallstone(s)
obstruction of the cystic bile duct.
The inflammation and increased pressure in the gallbladder from the blocked bile duct results in Murphy's sign;
palpation over the RUQ causes pain and inability to take a deep breath.
Laboratory results show leukocytosis.

ACUTE PANCREATITIS
Pancreatitis is an acute inflammation of the pancreas that results in autodigestion.
The most common causes are cholelithiasis and alcoholism.
Classic presentation includes severe epigastric pain radiating to the back due to the retroperitoneal location of the
pancreas.
The pancreatic enzymes (amylase and lipase) are elevated. Serious complications to monitor for include
hypergly
(ARDS), peritonitis, and hypocalcemia.
Pancreatitis can cause hypocalcemia, but the etiology is unclear. Chvostek's (facial twitching) and Trousseau's (carpal
spasm) signs are an indication of hypocalcemia from the decrease in threshold for contraction.
Sustained muscle contraction (tetany) and decreased cardiac contractility (cardiac arrhythmia) are concerns related to
hypocalcemia.
The client with acute pancreatitis will report a sudden onset of unrelenting, severe pain in the left upper
quadrant or midepigastric area of the abdomen that often radiates to the back.
The pain is referred to the back as the pancreas is a retroperitoneal organ.
Pain improves with leaning forward and worsens with lying flat.
The pain is often preceded or made worse by a high-fat meal.
Nausea and vomiting are common due to severe pain.
Clients are at risk of developing hypovolemia (third spacing of fluids), acute respiratory distress syndrome (due to
intense systemic inflammatory response), and hypocalcemia (necrosed fat binding calcium).
Clients with acute pancreatitis are at risk for pancreatic abscess development. This mainly results from secondary
infection of pancreatic pseudocysts or pancreatic necrosis. High fever, leukocytosis, and increasing abdominal pain
may indicate abscess formation. The abscess must be treated promptly to prevent sepsis. The health care provider
should be notified immediately as antibiotic therapy and immediate surgical management may be required.
Supportive care for symptom relief and prevention of complications are the major goals in clients with acute
pancreatitis. These strategies include:

o NPO status - The client is maintained on NPO status as any ingestion of food will stimulate the excretion of pancreatic
enzymes. A nasogastric tube is used to suction out gastric secretions; this will reduce nausea and lessen stimulation of the
pancreas as these juices will move to the duodenum.
o Pain management - Intravenous opioids (eg, hydromorphone, fentanyl) are frequently utilized for pain management.
Morphine can also be used; worsening pancreatitis due to increase in sphincter of Oddi pressure has not been proven in
studies.
 o IV fluids - Aggressive fluid replacement to prevent hypovolemic shock is critical. Inflammation of the pancreas releases
chemical mediators that increase capillary permeability and cause third spacing (fluid going into empty spaces).
o The client should maintain positions that flex the trunk and draw the knees up to the abdomen (semi-Fowler's) to
decrease tension on the abdomen. A side-lying position with the head elevated to 45 degrees will help relieve the
pain even better.

PERITONITIS
Peritonitis is a common but serious complication of peritoneal dialysis that typically occurs as a result of
contamination during infusion connections or disconnections.
Typically, the earliest indication of peritonitis is the presence of cloudy peritoneal effluent.
Later manifestations include low-grade fever, chills, generalized abdominal pain, and rebound tenderness.
To detect rebound tenderness, one hand is pressed firmly into the abdominal wall and quickly withdrawn.
Rebound tenderness is present when there is pain on removal, indicating inflammation of the peritoneal cavity.
The nurse should collect peritoneal effluent from the drainage bag for culture and sensitivity.
Treatment of peritonitis is antibiotic therapy based on the culture results.
Antibiotics may be added to dialysate, given orally, or administered intravenously.

VEGAN DIET
Clients who follow a vegan diet eat only plant-based foods, omitting animal proteins (eg, meat, poultry, fish) and
products (eg, dairy, eggs).
Clients who are vegan are at risk for deficiency of vitamin B12 (cobalamin), which is primarily supplied by animal
products.
Chronic vitamin B12 deficiency may precipitate megaloblastic anemia and neurological symptoms across the entire
nervous system, from peripheral nerves to the spinal cord and brain.
Manifestations of chronic deficiency include:
 o Peripheral neuropathy (eg, tingling, numbness)
o Neuromuscular impairment (eg, gait problems, poor balance)
o Memory loss/dementia (in cases of severe/prolonged deficiencies)

Clients who follow a vegan diet are encouraged to take supplemental vitamin B12 to prevent severe neurological
complications.
In addition, clients are taught to incorporate vitamin B12-fortified foods (eg, cereals, grain products, soy and nut milks,
meat substitutes).
GASTROESOPHAGEAL REFLUX DISEASE

Gastroesophageal reflux disease (GERD) occurs when chronic reflux of stomach contents causes inflammation of
the esophageal mucosa.
The lower esophageal sphincter (LES) normally prevents stomach contents from entering the esophagus.
Any factor that decreases the tone of the LES (eg, caffeine, alcohol), delays gastric emptying (eg, fatty foods),
or increases gastric pressure (eg, large meals) can precipitate GERD.
Lifestyle and dietary measures that may prevent GERD and associated symptoms include:

o Weight loss, as excessive abdominal fat may increase gastric pressure

o Small, frequent meals with sips of water or fluids to help facilitate the passage of stomach contents into the small intestine
and prevent reflux from becoming overly full during meals
o Avoiding GERD triggers such as caffeine, alcohol, nicotine, high-fat foods, chocolate, spicy foods, peppermint, and
carbonated beverages
o Chewing gum to promote salivation, which may help neutralize and clear acid from the esophagus
o Sleeping with the head of the bed elevated
o Refraining from eating at bedtime and/or lying down immediately after eating

MALNUTRITION

Malnutrition occurs when there is insufficient nutrient intake to meet body needs and relates to multiple factors (eg,
poor diet, chronic illness, physical or cognitive impairments).
Malnutrition may impair critical physiologic processes (eg, organ and immune system function, wound healing) and
can have rapid and potentially lethal implications.
 Therefore, nurses should frequently assess clients for malnutrition, particularly those at increased risk (eg, advanced
age, altered functional status).
Assessing for malnutrition involves collecting dietary data (eg, 24-hour diet recall), laboratory values (eg, albumin or
prealbumin), physical measurements (eg, BMI), and history of recent weight loss.
Reports of weight loss, especially unintentional, are critical findings often indicative of malnutrition.
In serious conditions (eg, cancer,
tuberculosis, failure to thrive).
Malnutrition occurs due to inadequate intake of major nutrients (eg, calories, carbohydrates, fat, protein) or
micronutrients (eg, minerals, vitamins).
As malnutrition worsens and protein intake is reduced, muscles become fatigued and weak.
Clinical manifestations depend on the severity of the malnutrition, ranging from mild to extreme (eg, emaciation).
Weight gain is the best indicator that the client is responding to medical nutritional therapy.

GUIAC FECAL OCCULT BLOOD TEST

The guaiac fecal occult blood test is used to assess for microscopic blood in the stool as a screening tool
for colorectal cancer. The steps for collecting a sample include:

1. Assess for recent ingestion (within last 3 days) of red meat or medications (eg, vitamin C, aspirin, anticoagulants, iron,
ibuprofen, corticosteroids) that may interfere and produce false test results.
2. Obtain supplies (Hemoccult test paper, wooden applicator, Hemoccult developer), wash hands, and apply nonsterile gloves
3. Open the slide's flap and use the wooden applicator to apply 2 separate stool samples to the boxes on the slide. Collect from
2 different areas of the specimen as some portions of the stool may not contain microscopic blood
4. Close the slide cover and allow the stool specimen to dry for 3-5 minutes.
5. Open the back of the slide and apply 2 drops of developing solution to the boxes on the slide
6. Assess the color of the Hemoccult slide paper within 30-60 seconds. A positive guaiac result will turn the test paper blue,
indicating presence of microscopic blood in the stool
7. Dispose of used gloves and the wooden applicator and perform hand hygiene.
8. Document the results
HEMORRHOIDS

Hemorrhoids (distended, inflamed veins located in the anus or lower rectum) are caused by increased anorectal
pressure (straining to defecate, constipation).
Clients may experience symptoms such as rectal bleeding, pain, pruritus, and prolapse.
Although removal of hemorrhoids (hemorrhoidectomy) is a minor procedure, the pain associated with it is due
to spasms of the anal sphincter and is severe.
Nursing management for the post-hemorrhoidectomy client includes the following:

o Pain relief: Initially, pain is managed with pain medications, including nonsteroidal anti-inflammatory drugs (eg, ibuprofen)
and/or acetaminophen; opioids can be prescribed initially but may worsen constipation. Beginning 1-2 days postoperatively,
warm sitz baths are used as a means to relieve pain. Clients often dread their first bowel movement due to severe pain with
defecation. Therefore, pain must be appropriately controlled to prevent further constipation
o Preventing constipation: Encourage a high-fiber diet and adequate fluid intake (at least 1500 mL/day). Administer a stool
softener such as docusate (Colace) as prescribed. An oil-retention enema may be used if constipation persists for 2-3 days

LABORATORY RESULTS SEEN IN LIVER DYSFUNCTION

IRRITABLE BOWEL SYNDROME

Irritable bowel syndrome (IBS) is a common, chronic bowel condition caused by altered intestinal motility.
Peristaltic action is affected, causing diarrhea, constipation, or a combination of both.
Management focuses on reducing diarrhea or constipation, abdominal pain, and stress.
Clients can manage symptoms with diet, medications, exercise, and stress management.
To manage IBS, clients should restrict gas-producing foods (eg, bananas, cabbage, onions); caffeine; alcohol;
fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) (eg, honey, high-fructose corn syrup, wheat);
and other gastrointestinal (GI) irritants (eg, spices, hot/cold food or drink, dairy products, fatty foods).
Clients should gradually increase fiber intake (eg, whole grains, legumes, nuts, fruits, vegetables) as tolerated.
Foods that are generally well tolerated include proteins, breads, and bland foods
PEPTIC ULCER DISEASE

Peptic ulcer disease (PUD) is characterized by ulceration of the protective layers (ie, mucosa) of the esophagus,
stomach, and/or duodenum.
Mucosal "breaks" allow digestive enzymes and stomach acid to digest underlying tissues, leading to
potential gastrointestinal bleeding and perforation.
Risk factors for PUD include gastrointestinal Helicobacter pylori infections, genetic predisposition, chronic NSAID (eg,
aspirin, ibuprofen, naproxen) use, stress, and diet and lifestyle choices.
Nurses educating clients with PUD about ulcer prevention should focus on modifiable risk factors:
o NSAIDs: Chronic use of NSAIDs can damage the gastric mucosa and delay ulcer healing
o Caffeine: Cola, tea, and coffee should be avoided as they stimulate stomach acid secretion
o Smoking: Tobacco increases secretion of stomach acid and delays ulcer healing
o Alcohol: Alcohol should be avoided as it stimulates stomach acid secretion and impairs ulcer healing
o Meal timing: Eating multiple small meals throughout the day or eating shortly before sleeping may actually worsen PUD by
increasing stomach acid secretion.
Client teaching related to peptic ulcer disease (PUD) includes lifestyle changes (eg, dietary modifications, stress
reduction), PUD complications, and medication administration.
Helicobacter pylori infection and treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) are risk factors
for complicated PUD.
 H pylori treatment includes antibiotics and proton-pump inhibitors for acid suppression. The recommended initial
treatment is 7-14 days of triple-drug therapy with omeprazole (Prilosec), amoxicillin, and clarithromycin (Biaxin).
Clients with PUD should avoid NSAIDs [eg, aspirin, ibuprofen (Motrin)] as they inhibit prostaglandin synthesis,
increase gastric secretion, and reduce the integrity of the mucosal barrier.

DIVERTICULAR DISEASE

Diverticular disease of the colon occurs when saclike protrusions form in the large intestine.
When diverticula become infected and inflamed, the client has diverticulitis.
Complications that can occur in some clients are abscess formation (continuous fever despite antibiotics and
palpable mass) and intestinal perforation resulting in diffuse peritonitis (progressive pain in other quadrants of the
abdomen, rigidity, guarding, rebound tenderness).
The client with peritonitis prefers to lie still and take shallow breaths to avoid stretching the inflamed peritoneum.
Peritonitis is a potentially lethal complication and should be reported immediately.
Acute care for diverticulitis focuses on allowing the colon to rest and the inflammation to resolve. This includes
the following:

o IV antibiotic therapy to cover the gram-negative and anaerobic organisms that reside in the colon and contribute to
diverticulitis; these commonly include metronidazole (Flagyl) plus trimethoprim/sulfamethoxazole (TMZ) (Bactrim or Bactrim
DS; Septra) or ciprofloxacin (Cipro)
o NPO status more acute cases require complete rest of the bowel (NPO status); less severe cases may be handled at
home, and clients may tolerate a low-fiber or clear liquid diet
o NG suction in severe cases of abdominal distention, nausea, or vomiting
o IV fluids prevent dehydration
o Bed rest

Any procedure or treatment that increases intraabdominal pressure (lifting, straining, coughing, bending), increases
peristalsis (laxative, enema), or could lead to perforation or rupture of the inflamed diverticula should be avoided
during the acute disease process.
 The most common area for diverticula to form is the sigmoid colon. Inserting a rectal
tube/colonoscope/sigmoidoscope may cause further damage or perforation of the inflamed diverticula by increasing
pressure and stimulating the rectum.
A barium enema may be used after treatment with antibiotics and the inflammation is resolved.
Diagnostic examinations, such as abdominal x-rays or CT scans, may be used without risking rupture.

ULCERATIVE COLITIS

Ulcerative colitis (UC) is a chronic inflammatory bowel disease characterized by inflammation and ulceration of the
large intestine (colon) that results in abdominal pain, frequent bouts of bloody diarrhea, anorexia, and anemia.
Ulcerative colitis (UC) is a form of inflammatory bowel disease characterized by remitting periods of mucosal irritation
in the large intestine, resulting in profuse, bloody diarrhea. Management of clients with UC often includes dietary
interventions to reduce symptoms and prevent reoccurrence, malnutrition, and dehydration.
Nutrition and hydration management:
o Diets consisting of high-calorie, high-protein foods are recommended to prevent weight loss and muscle wasting
o Multivitamins containing calcium are often prescribed to supplement nutrition and should be taken regardless of symptoms
o Oral hydration is critical in UC as >10 liquid stools may occur daily during flares, placing clients at risk for dehydration.
Instruct clients to drink at least 2 liters of water daily
o Dietary triggers for UC vary greatly between individuals and may include dairy, nuts/legumes, cereal, alcohol, caffeine, and
fatty and processed foods. Diet journaling is recommended to assist with identifying triggers
o Caffeine, alcohol, and tobacco are gastric irritants that stimulate the intestine and should be avoided
The nurse planning care for a client with UC should:
o Manage pain: Intestinal inflammation often produces severe abdominal pain that limits treatment compliance. Provide
prescribed analgesics to promote comfort and treatment adherence
o Address psychosocial needs: Chronic illness may increase the risk of hopelessness and/or depression due to prolonged
treatment and frustration over lack of improvement or symptom control. Encourage clients to discuss emotions and feelings
o Assess fluid balance: Diarrhea, blood loss, and poor oral intake contribute to dehydration. Strict intake and output
monitoring helps ensure adequate fluid intake and prevent dehydration
o Evaluate treatment adherence: UC exacerbations may be spontaneous or may be precipitated by certain foods or lack of
adherence to prescribed treatments (eg, medications). Assess compliance with prescribed treatments and provide education
as needed to promote adherence
o Promote nutrition: Pain after eating may lead to anorexia, and intestinal inflammation decreases nutrient absorption; both
result in nutritional deficiency. Help clients select nutrient-dense, high-protein foods to promote recovery and meet
nutritional needs

A low-residue, high-protein, high-calorie diet, along with daily vitamin and mineral supplements, is encouraged to
meet the nutritional and metabolic needs of the client with ulcerative colitis.
The low-residue diet limits trauma to the inflamed colon and may lessen symptoms.
Easily digested foods such as enriched breads, rice, pastas, cooked vegetables, canned fruits, and tender meats are
included in the diet.
Raw fruits and vegetables, whole grains, highly seasoned foods, fried foods, and alcohol are avoided.
The well-balanced diet includes at least 2000-3000 mL/day of fluid to maintain fluid and electrolyte balance and
hydration.
Small, frequent meals are encouraged to lessen the amount of fecal material present in the gastrointestinal tract and to
decrease stimulation.
Caffeine, alcohol, and tobacco are gastric irritants that stimulate the intestine and should be avoided.
The prescribed sulfasalazine should be continued even when symptoms subside to prevent relapse. Because
sulfasalazine hinders the absorption of folate, folic acid supplements are encouraged.
The client with ulcerative colitis who has abdominal distension, bloody diarrhea, and fever likely has toxic megacolon.
This is a common, life-threatening complication of inflammatory bowel disease and is seen more frequently
in ulcerative colitis than in Crohn disease. Toxic megacolon can also be associated with Clostridium difficile infection
and other forms of infectious colitis.
Severe colonic inflammation causes release of inflammatory mediators and bacterial products which contribute to
colonic smooth muscle paralysis. Rapid colonic distension ensues, thinning the intestinal wall and making it prone to
perforation. Imaging confirms the diagnosis.
ABDOMINAL SURGERY

Wound evisceration is the protrusion of internal organs through the wall of an incision.
It typically occurs 6-8 days after surgery and is more common in clients who have had abdominal surgery, those with
poor wound healing, and those who are obese.
It is considered a medical emergency.
The nurse should remain with the client while calling for help.
The health care provider should be notified immediately and supplies brought to the room by another staff member.
The wound should be covered with sterile normal saline dressings.
While the nurse remains in the room, the client should be positioned in low Fowler's position with the knees bent.
This position lessens abdominal tension on the suture line and can prevent further evisceration.
The client should be prepared for immediate return to surgery.
BALLOON TAMPONADE TUBE

A balloon tamponade tube (eg, Sengstaken-Blakemore, Minnesota) is used to temporarily control bleeding
from esophageal varices.
It contains 2 balloons and 3 lumens.
The gastric lumen drains stomach contents, the esophageal balloon compresses bleeding varices above the
esophageal sphincter, and the gastric balloon compresses from below.
A weight is attached to the external end of the tube to provide tension and hold the gastric balloon securely in place
below the esophageal sphincter.
Airway obstruction can occur if the balloon tamponade tube becomes displaced and a balloon migrates into the
oropharynx.
 Scissors are kept at the bedside as a precaution; in the event of airway obstruction, the nurse can emergently cut
the tube for rapid balloon deflation and tube removal

COLONOSCOPY
A risk of a colonoscopy (or any procedure in which a firm scope is inserted into a "hollow tube" organ)
is perforation.
Signs of perforation include abdominal pain (with shoulder tip pain), positive rebound tenderness, guarding,
abdominal distension, tenesmus, and/or boardlike (rigid) abdomen.
Another potential complication is rectal bleeding.
Abdominal cramping post procedure is an expected finding. It is caused by the stimulation of peristalsis as the bowel
is constantly inflated with air during the procedure.
The preparation for the procedure, emptying the colon of stool, includes clear liquids, cathartics, and/or enemas. The
stool is watery and copious and may continue for a short time after the procedure. It is not a concerning finding.
During the procedure, air is inflated into the colon. The client needs to expel this "gas" afterward. It is an expected
finding.
Colonoscopy evaluates colonic mucosa. Therefore, clients should follow instructions to keep the colon clean with no
stool left for better visualization during the procedure. These instructions include:

1. Clear liquid diet the day before

2. Nothing by mouth 8 12 hours prior to the examination
3. The health care provider prescribes a bowel-cleansing agent such as a cathartic, enema, or polyethylene
glycol(GoLYTELY) the day before the test. The type of prep depends on the health care provider's preference and client
health status.

WEIGHT REDUCTION DIET

Sugary beverages, such as regular soft drinks, are key contributors to the excess consumption of calories and
the obesity epidemic.
Individuals who are attempting to lose weight should consume beverages with nutritional value and little-to-no caloric
value, including:
 o Water
o Club soda (flavored or unflavored)
o Unsweetened tea and/or coffee
o Fresh vegetable juice
o Nonfat or low-fat milk (in limited amounts)

A 12-oz (355-mL) serving in a typical can of regular cola-type beverage contains around 140 calories (kcal).

Behavioral management includes:

o Creating a reward system with many small, attainable goals to incentivize positive health behaviors
o Developing health goals unrelated to weight (eg, climbing stairs without shortness of breath) to measure progress regardless
of current weight
o Adopting anxiety-reducing diversional activities (eg, reading, meditating, listening to music) as coping mechanisms to reduce
stress eating
o Placing visual cues (eg, motivational quotes) throughout the environment as positive reinforcement

APPENDICITIS
The appendix is a blind pouch located at the junction of the ileum of the small intestine and the beginning of the large
intestine (cecum).
When infected or obstructed (foreign body, fecal material, tumor, lymph tissue), the appendix becomes inflamed,
causing acute appendicitis.
Signs and symptoms of acute appendicitis include the following:

o Pain: Continuous; begins in the periumbilical region and then moves to the right lower quadrant centering at McBurney's point
(one-third of the distance from the right anterior superior iliac spine to the umbilicus) (Option 3)
o Gastrointestinal symptoms: Anorexia, nausea, and vomiting
o Rebound tenderness and guarding
Clients with acute appendicitis attempt to decrease pain by preventing increased intraabdominal pressure (eg,
avoiding coughing, sneezing, deep inhalation) and lying still with the right leg flexed.
Appendicitis is inflammation of the appendix often resulting from obstruction by fecal matter.
Appendiceal obstruction traps fluid and mucus typically secreted into the colon, causing increased intraluminal
pressure and inflammation.
As appendiceal intraluminal pressure and inflammation increase, blood circulation to the appendix is impaired,
resulting in swelling and ischemia.
These factors increase the risk for appendiceal perforation, a medical emergency, which may lead
to peritonitis and sepsis.
Appendicitis is often treated surgically via removal of the appendix (ie, appendectomy).
Nurses caring for clients with appendicitis should avoid interventions that increase intestinal blood circulation, gut
motility, or appendiceal intraluminal pressure.
The application of heat to the abdomen (eg, heating pad, warm blanket) increases intestinal circulation and the risk
for appendiceal perforation
When prioritizing care of the client with appendicitis, the nurse should utilize the ABCs
(ie, airway, breathing, circulation).
Fluid resuscitation with IV crystalloids (eg, normal saline, lactated Ringer solution) is an important intervention aimed
at preventing circulatory collapse resulting from fluid losses (eg, vomiting, diarrhea) and NPO status
COLERECTAL CANCER

Colorectal cancer occurs most often in adults over age 50.

Risk factors include history of colon polyps; family history of colorectal cancer; inflammatory bowel disease (eg, Crohn
disease, ulcerative colitis); and history of other cancers (eg, gastric, ovarian).
Symptoms of colorectal cancer may include:

o Blood in the stool (eg, positive occult blood, melena) from fragile, bleeding polyps or tumors
o Abdominal discomfort and/or mass (not common)
o Anemia due to intestinal bleeding, which may result in fatigue and dyspnea with exertion
o Change in bowel habits (eg, diarrhea, constipation) due to obstruction by polyps or tumors
o Unexplained weight loss due to impaired nutrition from altered intestinal absorption

Colorectal cancer often goes unnoticed, as many of the symptoms are painless and nonspecific.
Clients should be assessed for these symptoms and receive regular routine colorectal cancer screening tests (eg,
occult blood test every year, colonoscopy every 10 years).
POST-OPERATIVE DIET PROGRESSION

DIARRHEA

Most bouts of diarrhea are self-

Clients experiencing diarrhea that lasts >48 hours or accompanied by fever or bloody stools should be evaluated by
a health care provider (HCP).
Causes may include infectious agents, dietary intolerances, malabsorption syndromes, medication side effects, or
laxative overuse.
The HCP will need to assess for dehydration and electrolyte imbalances and identify underlying causes of the diarrhea
that may require further treatment (eg, Clostridium difficile).
CIRRHOSIS
Cirrhosis, the end stage of many chronic liver diseases, is characterized by diffuse hepatic fibrosis with replacement
of the normal architecture by regenerative nodules.
The resulting structural changes alter blood flow through the liver and decrease the liver's functionality.
Elevated bilirubin (jaundice) results from functional derangement of liver cells and compression of bile ducts by
nodules. The liver has a decreased ability to conjugate and excrete bilirubin
Most coagulation factors are produced in the liver. A cirrhotic liver cannot produce the factors essential for blood
clotting. As a result, coagulation studies (prothrombin time [PT]/International Normalized Ratio [INR] and activated
partial thromboplastin time [aPTT]) are usually elevated
Ammonia from intestinal deamination of amino acids normally goes to the liver and is converted to urea and excreted
by the kidney. This does not happen in cirrhosis. Instead, the ammonia level rises as the cirrhosis progresses;
ammonia crosses the blood-brain barrier and results in hepatic encephalopathy
Albumin holds water inside the blood vessels. In cirrhosis, the liver is unable to synthesize albumin (protein), so
hypoalbuminemia would be expected. This is the primary reason that fluid leaks out of vascular spaces into interstitial
spaces (eg, edema, ascites). The kidneys perceive this as low perfusion and try to reabsorb (conserve) both sodium
and water. The large amount of water in the body results in a dilutional effect (low sodium).
A client with cirrhosis may experience pruritus (itching) due to buildup of bile salts beneath the skin. Clients with
cirrhosis are also at an increased risk for skin breakdown due to the development of edema, which increases skin
fragility and impedes wound healing, and the loss of muscle and fat tissue from pressure points (eg, heels, sacrum).
The nurse encourages the client to cut the nails short, wear cotton gloves, and wear long-sleeved shirts to avoid
injury to the skin from scratching.
Other comfort measures include baking soda baths; calamine lotion; and cool, wet cloths, which cool and soothe
irritated skin
Cholestyramine (Questran) may be prescribed to increase the excretion of bile salts in feces, thereby decreasing
pruritus. It is packaged in powdered form, must be mixed with food (applesauce) or juice (apple juice), and should be
given 1 hour after all other medications.
Temperature extremes (eg, hot baths/showers) may intensify pruritus. The nurse should instruct the client to bathe
with tepid water until the pruritus has subsided.
In a client with cirrhosis and ascites, discomfort is often due to pressure of the fluid on the surrounding organs.
Shortness of breath occurs due to the upward pressure exerted by the abdominal ascites on the diaphragm, which
restricts lung expansion.
Positioning the client in semi-Fowler or Fowler position can promote comfort, as this position can reduce the
pressure on the diaphragm. In semi-Fowler position, the head of the bed is elevated 30-45 degrees; in Fowler
position, elevation is 45-60 degrees. Side-lying with the head elevated can also be a position of comfort for the
client with ascites as it allows the heavy, enlarged abdomen to rest on the bed, reducing pressure on internal organs
and allowing for relaxation.
Meticulous skin care is a priority due to the increased susceptibility of skin breakdown from edema, ascites, and
pruritus. It is important to use a specialty mattress and implement a turning schedule of every 2 hours
A distraction can take the client's mind off the current symptoms and may also help promote comfort in many different
situations. Some of these distractions include listening to music, watching television, playing video games, or taking
part in hobbies
Higher levels of fluid or sodium intake can worsen these conditions.
In Trendelenburg position, the bed is tilted with the head lower than the legs. This position is contraindicated in the
client with ascites, as it may exacerbate shortness of breath by causing the abdominal ascites to push upward on the
diaphragm, restricting lung expansion.
PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)

A PEG is a minimally invasive procedure performed under conscious sedation.

Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through an
incision made in the abdominal wall. To keep it secured, the PEG tube has an outer bumper and an inner balloon or
bumper.
The tube's tract begins to mature in 1-2 weeks and is not fully established until 4-6 weeks.
It begins to close within hours of tube dislodgement.
The nurse should notify the health care provider who placed the PEG tube as early dislodgement (ie, <7 days from
placement) requires either surgical or endoscopic replacement
HYPOMAGNESEMIA
Hypomagnesemia, a low blood magnesium level (normal 1.5-2.5 mEq/L [0.75-1.25 mmol/L]), is associated with
alcohol abuse due to poor absorption, inadequate nutritional intake, and increased losses via the gastrointestinal and
renal systems.
It is associated with 2 major issues:

1. Ventricular arrhythmias (torsades de pointes): This is the most serious concern (priority).
2. Neuromuscular excitability: Manifestations of low magnesium, similar to those found in hypocalcemia and demonstrated by
neuromuscular excitability, include tremors, hyperactive reflexes, positive Trousseau and Chvostek signs, and seizures.

FIBER-RICH DIET

Dietary fiber is composed of indigestible complex carbohydrates that absorb and retain water, which increases stool
bulk and makes stool softer and easier to pass.
Consuming a diet high in fiber-rich foods (eg, fruits, vegetables, legumes, whole grains) improves stool elimination,
which helps prevent constipation and decreases the risk of colorectal cancer
Fiber-rich foods tend to have a low glycemic load (less sugar per serving) and are nutrient dense, yet they have
lower caloric density.
Clients may also experience increased satiety as fiber absorbs water and produces fullness. This may help reduce
caloric intake, improve blood glucose control, and promote weight loss
Fiber binds to cholesterol in the intestines, which reduces serum cholesterol levels by decreasing the amount of
dietary cholesterol that enters the bloodstream.
Decreasing serum cholesterol levels helps reduce vascular plaque buildup and atherosclerosis.
A high intake of fiber-rich foods directly correlates with a reduced risk of vascular diseases, including coronary artery
disease and stroke
DUMPING SYNDROME

Following a partial gastrectomy, many clients experience dumping syndrome, which occurs when gastric contents
empty too rapidly into the duodenum, causing a fluid shift into the small intestine.
This results in hypotension, abdominal pain, nausea/vomiting, dizziness, generalized sweating, and tachycardia.
The symptoms usually diminish over time.
Recommendations to delay gastric emptying include:

o Consume meals high in fat, protein, and fiber, which take more time to digest and remain in the stomach longer than
carbohydrates. These foods also help meet the body's energy needs.
o Avoid consuming fluids with meals because this causes stomach contents to pass faster into the jejunum, which worsens
symptoms. Fluid intake should occur up to 30 minutes before or after meals.
o Slowly consume small, frequent meals to reduce the amount of food in the stomach
o Avoid meals high in simple carbohydrates (eg, sugar, syrup) because these may trigger symptoms when the
carbohydrates break down into simple sugars.
o Avoid sitting up after a meal because gravity increases gastric emptying. Instead, lying down after meals is encouraged

HIGH CALORIE AND PROTEIN DIET

Reduced appetite and significant, unintentional weight loss are included in the diagnostic criteria for unipolar major
depression (major depressive disorder). A 35-lb (15.9-kg) weight loss within 3 months is a 23% change in this client's
usual body weight and is considered severe weight loss.
The client needs a diet high in calories and protein to promote adequate nutrition and weight gain.
In addition, the client has a diagnosis of depression and may have a low energy level; providing foods that are easier
to chew and swallow may be better choices for promoting intake.
 Foods that are protein and/or calorie dense include:

o Whole milk and dairy products (eg, milkshakes), fruit smoothies

o Granola, muffins, biscuits
o Potatoes with sour cream and butter
o Meat, fish, eggs, dried beans, almond butter
o Pasta/rice dishes with cream sauce

COLOSTOMY

A colostomy is a surgical procedure that creates an opening (stoma) in the abdominal wall for the passage of stool to
bypass an obstructed or diseased portion of the colon.
The stoma should be pink to brick red, indicating vascularity and viability.
Minor bleeding and oozing may occur, and mild to moderate swelling is normal for 2-3 weeks after surgery.
In the immediate postoperative period, stool will be absent.
If the bowel is cleansed prior to surgery, the draining of stool will be delayed by several days. Otherwise, stool
appears when peristalsis resumes
Inadequate blood supply can cause a change in the stoma color.
Indications of poor vascularity include pale, dusky, or cyanotic color changes, any of which requires immediate
notification of the HCP and surgical intervention to prevent ischemia and necrosis.
Clients with a descending or sigmoid colostomy drain stool that is more formed and similar to a normal bowel
movement.
Although less common, some clients choose to irrigate their colostomy in order to create a bowel regimen that allows
them to wear a smaller pouch or a dressing over the stoma.
When irrigated daily, the client gains increased control over the passage of stool.
Proper care of the stoma and pouch appliance that should be taught to the client or caregiver includes the following:

o Ensure sufficient fluid intake (at least 3,000 mL/day unless contraindicated) to prevent dehydration; identify times to increase
fluid requirements (hot weather, increased perspiration, diarrhea)
o Identify and eliminate foods that cause gas and odor (broccoli, cauliflower, dried beans, brussels sprouts)
o Empty the pouch when it becomes one-third full to prevent leaks due to increasing pouch weight

The procedure for bowel irrigation is as follows:

 o Fill the irrigation container with 500-1000 mL of lukewarm water, flush irrigation tubing, and reclamp; hang the container on
a hook or intravenous pole
o Instruct the client to sit on the toilet, place the irrigation sleeve over the stoma, extend the sleeve into the toilet, and place the
irrigation container approximately 18-24 inches above the stoma
o Lubricate cone-tipped irrigator, insert cone and attached catheter gently into the stoma, and hold in place
o Slowly open the roller clamp, allowing irrigation solution to flow for 5-10 minutes
o Clamp the tubing if cramping occurs, until it subsides
o Once the desired amount of solution is instilled, the cone is removed and feces is allowed to drain through the sleeve into the
toilet

SMALL BOWEL OBSTRUCTION

Small-bowel obstruction can have mechanical or non-mechanical causes.

Mechanical obstruction is commonly caused by obstruction of the bowel resulting from surgical adhesions, hernias,
intussusception, or tumors.
Paralytic ileus, a non-mechanical obstruction, may occur after abdominal surgery or narcotic use.
When a small-bowel obstruction develops, fluid and gas collect proximal to the obstruction, producing rapid
onset of nausea and vomiting, colicky intermittent abdominal pain, and abdominal distension.
The nurse should recognize symptoms of bowel obstruction quickly as delay could lead to vascular compromise,
bowel ischemia, or perforation.
Nursing management of an obstruction includes placing the client on NPO status, inserting a nasogastric tube,
administering prescribed IV fluids, and instituting pain control measures.

PARACENTESIS
Paracentesis is a procedure that involves removal of excess fluid from the peritoneal cavity (ascites) or to collect a
specimen of ascitic fluid for diagnostic testing and is performed to relieve dyspnea and discomfort related to increased
intra-abdominal pressure and fluid volume.
Hypovolemia is an associated complication related to intravascular fluid shifts that occur during and post-procedure
and also to high volume peritoneal fluid removal (>5 L).
 The nurse should first validate the presence of light-headedness and unsteady gait, monitor vital signs, and assess for
manifestations of hypovolemia (eg, orthostatic hypotension, tachycardia, reduced pulse volume, decreased urine
output), as decreased circulating volume can lead to hemodynamic instability.
Clients may receive IV albumin (a colloid) after paracentesis, which increases intravascular oncotic pressure resulting
in increased intravascular fluid volume.
Albumin administration prevents hypotension and tachycardia by mitigating hemodynamic changes associated with
paracentesis
Paracentesis is not a permanent solution for treating ascites and is performed only if the client is experiencing
impaired breathing or pain due to ascites.
Prior to a paracentesis, nursing actions include:

o Verify that the client received necessary information to give consent and witness informed consent
o Instruct the client to void to prevent puncturing the bladder
o Assess the client's abdominal girth, weight, and vital signs
o Place the client in the high Fowler position or as upright as possible

LACTASE DEFICIENCY

Clients with lactase deficiency (lactose intolerance) experience varying degrees of gastrointestinal symptoms after
ingesting milk products, including flatulence, diarrhea, bloating, and cramping.
This is due to a deficiency of the enzyme lactase, which is required for digestion of lactose.
Treatment includes restricting lactose-containing foods in the diet.
These clients may also take lactase enzyme replacements (eg, Lactaid) to decrease symptoms.
Supplementation of calcium and vitamin D is recommended due to insufficient intake of fortified milk
Milk and ice cream contain the highest amounts of lactose and should be restricted depending on the client's individual
tolerance.
Some dairy products, including aged cheeses and live-culture yogurts, contain little to no lactose and can be
tolerated by most clients with lactase deficiency
 Lactase deficiency is not an immune reaction (allergy) to milk products. Rather, the gastrointestinal symptoms are due
to a deficiency of the enzyme lactase and the resultant inability to digest lactose.

LAPAROSCOPIC CHOLECYSTECTOMY
Postoperative nursing care after a laparoscopic cholecystectomy focuses on prevention of complications.
Carbon dioxide (CO2) is used to inflate and expand the abdominal cavity during laparoscopic procedures to allow
insertion of surgical instruments and better visualization of the abdominal organs.
CO2 can irritate the phrenic nerve and diaphragm, causing shallow breathing and referred pain to the right shoulder.
The nurse should assist the client with early ambulation and deep breathing to facilitate dissipation of the CO2 used
during surgery.
Early ambulation not only improves breathing but also decreases the risk of thromboembolism and stimulates
peristalsis.

HIATAL HERNIA
Hiatal hernia is a group of medical conditions characterized by abnormal movement of the stomach and/or
esophagogastric junction into the chest due to a weakness in the diaphragm. Although hiatal hernias may be
asymptomatic, many people experience heartburn, chest pain, dysphagia, and shortness of breath when the
abdominal organs move into the chest.
Symptoms of hiatal hernias are often exacerbated by increased abdominal pressure, which promotes upward
movement of abdominal organs. Clients with hiatal hernias who are obese are often encouraged to lose excess
weight by performing light activities (eg, short walks) because obesity increases abdominal pressure. However,
nurses should teach clients to avoid activities that promote straining (eg, weight lifting), which increases abdominal
pressure
Sitting up for several hours after meals and sleeping with the head of the bed elevated at least 6 inches (15 cm)
reduces upward movement of the hernia and decreases the risk of gastric reflux.
If symptoms of hiatal hernias are uncontrolled with home management (eg, weight loss, diet modification, positioning
after meals), surgical revision of the diaphragm may be required to prevent organ movement.
Conditions that increase intraabdominal pressure (eg, pregnancy, obesity, ascites, tumors, heavy lifting)
and weaken the muscles of the diaphragm may allow a portion of the stomach to herniate through an opening in the
diaphragm, causing a hiatal hernia.
A sliding hernia occurs when a portion of the upper stomach squeezes through the hiatal opening in the diaphragm.
A paraesophageal hernia (rolling hernia) occurs when the gastroesophageal junction remains in place but a portion
of upper stomach folds up along the esophagus and forms a pocket. Paraesophageal hernias are a medical
emergency.
Although hiatal hernias may be asymptomatic, many clients experience signs and symptoms commonly associated
with gastroesophageal reflux disease (GERD), including heartburn, dysphagia, and pain caused by increased
intraabdominal pressure or supine positioning. Interventions to reduce herniation include the following:
 o Diet modification avoid high-fat foods and those that decrease lower esophageal sphincter pressure (eg, chocolate,
peppermint, tomatoes, caffeine). Eat small, frequent meals, and decrease fluid intake during meals to prevent gastric
distension. Avoid consumption of meals close to bedtime and nocturnal eating
o Lifestyle changes smoking cessation, weight loss
o Avoid lifting or straining
o Elevate the head of the bed to approximately 30 degrees this can be done at home using pillows or 4 - 6 inch blocks under
the bed

UPPER GASTROINTESTINAL BLEEDING (UGIB)

Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening condition commonly caused by

bleeding gastroesophageal varices or peptic ulcers.
Gastroesophageal varices are distended, fragile blood vessels within the stomach and/or esophagus that frequently
occur secondary to cirrhosis.
Due to the fragility of these veins, clients are closely monitored for variceal rupture.
Rupture of gastroesophageal varices is an emergency complication that rapidly results in massive gastrointestinal
bleeding, hypovolemic shock, and death.
Variceal rupture commonly occurs due to a sudden increase in portal venous pressure (eg, coughing, straining,
vomiting) and from mechanical injury (eg, chest trauma, consuming sharp/hard foods).
In UGIB, nasogastric tube insertion may be prescribed for gastric decompression or evacuation.
However, nasogastric tube insertion without visualization of the esophagus may traumatize and rupture varices,
causing hemorrhage
Pantoprazole is prescribed for clients with UGIB to reduce gastric acid secretion and help prevent ulceration of the
gastric mucosa.
Octreotide may be used to help control UGIB related to bleeding gastroesophageal varices, as it reduces portal
venous pressure, which reduces bleeding.
NPO status may be prescribed in cases of UGIB to prepare the client for invasive diagnostic or therapeutic procedures
(eg, esophagogastroduodenoscopy, variceal ligation).
IRON DEFICIENCY ANEMIA

Iron-deficiency anemia occurs when the body lacks sufficient iron to form red blood cells and synthesize hemoglobin.
Iron-deficiency anemia can result from:

1. Diets low in iron (eg, vegetarian and low-protein diets)

2. Iron not being absorbed (eg, following many gastrointestinal [GI] surgeries, malabsorption syndrome)
3. Increased iron requirement (eg, children's growth spurts, pregnancy, breastfeeding)
4. Blood loss (eg, menstruation, bleeding in the GI tract [eg, ulcers, hemorrhoids])

Foods rich in iron include:

o Meats (eg, beef, lamb, liver, chicken, pork)

o Shellfish (eg, oysters, clams, shrimp)
o Eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal

Eating foods rich in vitamin C (eg, citrus fruits, potatoes, tomatoes, green vegetables) with iron-rich foods will
enhance iron absorption but coffee and tea consumption interferes with this process.

BARIATRIC SURGERY
 Bariatric surgery for weight loss involves a surgical modification of the client's stomach and/or small intestine to restrict
the client's intake.
Postoperative nursing care focuses on managing pain and nausea and monitoring for complications (eg, infection, fluid
and electrolyte imbalance, dumping syndrome, anastomotic leak).
Nasogastric tubes are contraindicated after gastric surgery due to potential disruption of the surgical site, which can
cause hemorrhage and anastomotic leak.
Postoperative nausea would be controlled using IV antiemetics.
Clients are placed on a clear liquid diet for the first 48-72 hours after bariatric surgery to promote healing.
The diet is restricted to low-carbohydrate (eg, sugar-free) liquids to decrease the risk of dumping syndrome, rapid
emptying into the small intestines that causes unpleasant vasomotor symptoms (eg, sweating, dizziness, cramping,
diarrhea).
After bariatric surgery, low Fowler position is preferred during mealtimes as it slows gastric emptying, reducing the risk
of dumping syndrome.
Morphine and patient-controlled analgesia pumps are commonly used to manage pain after bariatric surgery.

TOTAL PARENTERAL NUTRITION

Total parenteral nutrition (TPN) is administered via a central venous catheter to meet the nutritional needs (eg,
glucose, amino acids, vitamins, minerals) of clients who cannot digest nutrients via the gastrointestinal tract.
The nurse should hang 10% dextrose in water at the same infusion rate of 75 mL/hr until the new bag arrives.
If the 20% dextrose solution is temporarily replaced with an infusion lacking dextrose (eg, normal saline, lactated
Ringer's [LR]), the pancreas will continue to produce insulin in response to the residual glucose, which may cause
hypoglycemia
A complication of total parenteral nutrition (TPN) is hyperglycemia, as evidenced by excessive thirst, increased
urination, abdominal pain, headache, fatigue, and blurred vision.
The development of hyperglycemia is related to the following:

o Excessive dextrose infusion

o A low tolerance for dextrose in critically ill clients due to the inflammatory response and the resulting production of
counterregulatory hormones
o High infusion rate
o Administration of medications such as steroids
o Infection
 Interventions to resolve TPN-associated hyperglycemia include reducing the amount of carbohydrate in the TPN
solution, slowing down the infusion rate, and administering subcutaneous insulin.

SALEM SUMP TUBE

Continuous suction can be applied to decompress the stomach if a double lumen Salem sump tube is in place.
The larger lumen is attached to suction and the smaller lumen (within the larger one) is open to the atmosphere.
Checking for residual volume is not an appropriate intervention because the Salem sump is attached to continuous
suction for decompression and is not being used to administer enteral feeding
The air vent (blue pigtail) must remain open as it provides a continuous flow of atmospheric air through the
drainage tube at its distal end (to prevent excessive suction force). This prevents damage to the gastric mucosa. If
gastric content refluxes, 10-20 mL of air can be injected into the air vent. However, the air vent is kept above the level
of the client's stomach to prevent reflux
General interventions to maintain gastric suction using a Salem sump tube include:

o Place the client in semi-Fowler's position to help keep the tube from lying against the stomach wall; this is done to help
prevent gastric reflux
o Provide mouth care every 4 hours as this helps to maintain moisture of oral mucosa and promote client comfort
o Turn off suction briefly during auscultation as the suction sound can be mistaken for bowel sounds
o Inspect the drainage system for patency (eg, tubing kink or blockage).

INGUINAL HERNIA
An inguinal hernia is the protrusion of abdominal contents through the inguinal canal, which appears as a bulge in the
lateral groin.
Herniation occurs spontaneously or results from increased intraabdominal pressure (eg, heavy lifting).
Inguinal hernias occur most commonly in male clients and are usually repaired with minimally invasive surgery.
If intestinal strangulation develops, the client requires emergency treatment to prevent bowel ischemia or perforation.
Strangulation symptoms include abdominal distension, severe pain, nausea, and vomiting.
To prevent hernia reoccurrence after surgical repair, the client is taught to avoid activities that increase
intraabdominal pressure (eg, coughing, heavy lifting) for 6-8 weeks.
If sneezing or coughing are unavoidable, the client should splint incisions and keep the mouth open while sneezing.
Scrotal support garments and ice packs help decrease postoperative pain and scrotal swelling. The scrotum should
be elevated with a pillow while the client is in bed.
The nurse monitors urine output to assess for difficulty voiding after inguinal hernia repair. Male clients are
encouraged to stand when voiding to improve bladder emptying
 To prevent postoperative complications (eg, pneumonia, constipation) following inguinal hernia repair, the client should
reposition frequently, ambulate as soon as possible, and practice deep breathing every 2 hours.

PARALYTIC ILEUS
Paralytic ileus is characterized by temporary paralysis of a portion of the bowel, which affects peristalsis and bowel
motility.
Signs and symptoms include abdominal discomfort, distension, and nausea/vomiting. Risk factors for paralytic
ileus include:

o Abdominal surgery
o Perioperative medications (eg, anesthesia, analgesics)
o Immobility (eg, stroke)

To prevent further abdominal distension and resulting nausea, the client should remain NPO.
Nasogastric tube to wall suction may be necessary to decompress the stomach.
IV fluid and electrolyte replacement (eg, normal saline) may be necessary to correct losses that occur from nasogastric
suction.
Nausea can be treated with prescribed antiemetics (eg, ondansetron, promethazine)
The client should not take medications by mouth (due to NPO status), and opioid medications should be avoided as
they prolong paralytic ileus. Instead, non-opioid IV analgesics (eg, ketorolac, ibuprofen, acetaminophen) should be
administered as prescribed if the client is in pain

CELIAC DISEASE

Celiac disease is an autoimmune disorder in which chronic inflammation caused by gluten damages the small
intestine.
The following are important dietary principles to teach clients with celiac disease:
1. All gluten-containing products should be eliminated from the diet. These include wheat, barley, rye, and oats.
2. Rice, corn, and potatoes are gluten free and are allowed on the diet
 3. Processed foods (eg, chocolate candy, hot dogs) may contain "hidden" sources of gluten, such as modified food starch, malt,
and soy sauce. Food labels should indicate that the product is gluten free.
4. Clients will need to be on a gluten-free diet for the rest of their lives. Eliminating gluten from their diet reduces the risk for
nutritional deficiencies and intestinal cancer (lymphoma).
5. Eating even small amounts of gluten will damage the intestinal villi, although the client may have no clinical symptoms. All
sources of gluten must be eliminated from the diet.
An assessment of the client's food intake must be obtained to determine if it includes foods that contain gluten, a
protein in barley, rye, oats, and wheat (mnemonic: BROW).
The most common reason for non-responsiveness to a gluten-free diet in clients with celiac disease is that gluten has
not been entirely eliminated from their food intake.

HEPATITIS

Viral hepatitis is a disease of the liver characterized by inflammation, necrosis, and cirrhosis.
One of the most common viral strains that causes hepatitis is hepatitis B. The transmission of hepatitis B is primarily
through contact with blood, semen, and vaginal secretions (mnemonic: B for body fluids), commonly through
unprotected sexual intercourse and intravenous illicit drug use.
Infants born to infected mothers are also at risk for vertical transmission of hepatitis B.
Although kissing, sneezing, sharing drinks/utensils, and breastfeeding are not known routes of transmission, hepatitis
B could possibly be transmitted through saliva entering the bloodstream via sharing a toothbrush or receiving a bite.
Hepatitis B has an insidious onset of illness, and clients may be asymptomatic carriers.
Early symptoms are often nonspecific (eg, malaise, nausea, vomiting, abdominal pain).
Hepatitis B may produce jaundice, weight loss, clay-colored stools, and thrombocytopenia in late stages of illness. An
effective vaccine is widely available for hepatitis B.
The transmission of hepatitis A occurs through the fecal-oral route via poor hand hygiene and improper food handling.
Therefore, this infection is seen primarily in developing countries. Hepatitis B is not transmitted through feces.
Urine is not known to be a mode of transmission for any form of hepatitis.

Hepatitis (inflammation of the liver) is often caused by infection, toxins, or trauma (eg, drug use, viral hepatitis, acute
poisoning), resulting in impairment of liver function (eg, bile production, detoxification of blood, metabolism). Nursing
interventions for clients with acute viral hepatitis include:

o Rest

Alternate periods of rest and activity to reduce metabolic demands and avoid fatigue
Avoid hepatotoxins (eg, alcohol, acetaminophen) as they worsen injury to liver cells
Medications (eg, appetite stimulants, antipruritics, analgesics, sedatives) metabolized in the liver should be used
cautiously to allow hepatocytes to heal.

o Nutrition

Encourage low fat, small, frequent meals to decrease nausea and promote intake in clients with anorexia. Anorexia is
lowest in the morning; promote eating a larger breakfast
Provide oral care and avoid extremes in food temperature to increase appetite.
Promote water consumption (2500-3000 mL/day) and diets adequate in carbohydrates and calories.

o Infection control

Hepatitis B is transmitted through sexual contact and infected blood (eg, drug use, accidental needle stick, perinatal
mother-to-child infection).
A condom should be used during sexual intercourse. Clients should not share razors or toothbrushes

o Diets high in fat should be avoided as liver bile production, which is needed for fat digestion, may be impaired.
Encourage protein and carbohydrate intake to assist with liver healing.
STOOL CHARACTERISTICS

FASTING

Fasting for more than 1 or 2 days can cause a number of health problems:

o Increased stress when fasting, the body goes into "starvation mode;" metabolism slows down and cortisol production
increases
 o Muscle damage in starvation mode, the body breaks down muscle and converts amino acids to glucose
o Fluid loss glycogen stores in the liver are also broken down as an energy source; this metabolic process releases water,
resulting in fluid loss
o Increased hunger appetite hormones are suppressed during a fast; however, when regular eating habits are resumed,
appetite will be increased
o Depletion of essential nutrients
o Fatigue, headache, dehydration, dizziness, and muscle weakness

GASTRODUODENOSTOMY (BILROTH I)

A gastroduodenostomy (Billroth I) involves removing the distal two-thirds of the stomach with anastomosis of the
remaining stomach to the duodenum.
Following partial gastrectomy, clients should remain NPO until bowel sounds return.
Once tolerated, consumption of small, frequent meals will help prevent the occurrence of dumping syndrome (ie, rapid
emptying of stomach contents into the small intestine).
Postoperative clients are at risk for developing venous thromboembolism (VTE) due to reduced mobility levels and
require VTE prophylaxis (eg, sequential compression devices, compression hose).
Clients are also at risk for hypoventilation and respiratory compromise due to sedation, pain, and immobility.
Encourage clients to turn, cough, and deep breathe while splinting the surgical site to prevent development of
atelectasis
In the postoperative period, the nurse should elevate the head of the bed to improve ventilation and reduce the risk of
aspiration. Only clients who experience dumping syndrome should lay supine for a short period after eating.
Clients may have a nasogastric tube postoperatively for gastric decompression. Clogged nasogastric tubesshould
be reported to the surgeon. Attempting to manipulate or flush the device may disrupt the surgical site,
causing hemorrhage or gastric perforation.

AUSCULTATION OF BOWEL SOUNDS

Auscultation of abdominal sounds during physical assessment includes bowel and cardiovascular components.
 Bowel sounds are normally intermittent (every 5-15 seconds), high-pitched, gurgling sounds that can be auscultated
with the diaphragm of the stethoscope in all 4 quadrants.
Cardiovascular bruits (swishing, humming, buzzing) are rarely benign and usually indicate arterial narrowing or
dilation.
Procedures that require bowel manipulation cause a temporary halting of peristalsis (paralytic ileus) for the first 24-
48 hours,resulting in absent bowel sounds.
For bowel sounds to be considered absent, the nurse must auscultate for 2-5 minutes in each quadrant.
Peristalsis will usually return in the small intestine in 24 hours, but the large intestine may be delayed 3-5 days.
Other procedures requiring general anesthesia, late stages of mechanical obstruction, and peritonitis may cause
absent bowel sounds.
Borborygmi sounds are loud, gurgling sounds suggesting increased peristalsis. Potential disease processes resulting
in borborygmi include gastroenteritis, diarrhea, and the early phases of mechanical obstruction.

HEPATIC ENCEPHALOPATHY

Hepatic encephalopathy is a reversible neurological complication of cirrhosis caused primarily by increased

ammonia levels in the blood.
Normally, ammonia created in the intestines is converted to urea in the liver and excreted in the kidneys.
However, in the presence of liver damage, blood is shunted around the liver portal system and ammonia is able to
cross the blood-brain barrier, leading to neurological dysfunction
Hepatic encephalopathy is a serious complication of end-stage liver disease (ESLD) that results from inadequate
detoxification of ammonia from the blood.
Symptoms include lethargy, confusion, and slurred speech; coma can occur if this condition remains untreated.
Asterixis, or a flapping tremor of the hands when the arms are extended with the hands facing forward, may also be
noted in the client with encephalopathy.
The client with ESLD exhibiting confusion and lethargy should be evaluated for worsening encephalopathy by
assessing for asterixis and comparing current mental status and ammonia level to previous findings.
If encephalopathy continues to worsen, medical treatment should include higher doses of lactulose and rifaximin,
and discharge should be delayed until the client is stable.
Lactulose is the most common treatment for hepatic encephalopathy.
 Lactulose is not digested or absorbed until it reaches the large intestines where it is metabolized, producing
an acidic environment and a hyperosmotic effect (laxative).
In this acidic environment, ammonia (NH3) is converted to ammonium (NH4+) and excreted rapidly. Lactulose can be
given orally with water, juice, or milk (to improve flavor) or it can be administered via enema. For faster results, it can
be administered on an empty stomac
The desired therapeutic effect of lactulose is the production of 2-3 soft bowel movements each day; therefore, the
dose is titrated until the therapeutic effect is achieved.
This therapeutic dose should not be held but instead should be maintained until the desired outcomes are reached
(improved mental status, decreased ammonia levels).
The client's electrolyte levels should be closely monitored during therapy as lactulose is a laxative that can cause
dehydration, hypernatremia, and hypokalemia.

SMALL BOWEL FOLLOW THOUGH TEST (SBFT)

An SBFT examines the anatomy and function of the small intestine using x-ray images taken in succession.
Barium is ingested, and x-ray images are taken every 15-60 minutes to visualize the barium as it passes through the
small intestine.
Using this technique, decreased motility (eg, ileus), increased motility (eg, malabsorption syndromes), fistulas, or
obstructions are identified.
Clients should be instructed as follows:

o Fast 8 hours prior to the examination.

o The test usually takes 60-120 minutes, but if obstruction or decreased motility is present, it can take longer.
o Drink plenty of fluids after the examination to facilitate barium removal. Chalky stools may be present 24-72 hours after the
examination. If brown stools do not return after 72 hours or abdominal pain or fullness is present, contact the HCP.

Black, tarry stools (melena) are not an expected symptom of an SBFT; melena is indicative of gastrointestinal bleeding
and should be reported immediately to an HCP.

ILEOSTOMY
 An ileostomy is a surgically created opening (stoma) in the abdominal wall that connects the small intestine to the
external abdomen.
Stool from the small intestine bypasses the colon and exits through the ileostomy.
Functions of the colon (eg, fluid and electrolyte absorption, vitamin K production) do not occur, resulting in liquid
stool that drains into an external ostomy appliance attached to the skin.
In the immediate postoperative period of an ileostomy, a low-residue diet (low-fiber) is prescribed to prevent
obstruction of the narrow lumen of the small intestine and stoma (1-in [2.54-cm] diameter or less).
After the ileostomy heals, the client reintroduces fibrous foods one at a time. The client is instructed to thoroughly
chew food and monitor for changes in stool output.
Foods to be avoided include:

o High fiber: popcorn, coconut, brown rice, multigrain bread

o Stringy vegetables: celery, broccoli, asparagus
o Seeds or pits: strawberries, raspberries, olives
o Edible peels: apple slices, cucumber, dried fruit

After an ileostomy, a client may consume fruits and vegetables that are pitted, peeled, and/or cooked (eg, peaches,
bananas, potatoes).
Low-fiber carbohydrate options include white rice, refined grains, and pasta.

BARIUM ENEMA

A barium enema, or lower gastrointestinal series, uses fluoroscopy to visualize the colon outlined by contrast to
detect polyps, ulcers, tumors, and diverticula.
This procedure is contraindicated for clients with acute diverticulitis as it may rupture inflamed diverticula and cause
subsequent peritonitis.
Preprocedure instructions include:

o Take a cathartic (eg, magnesium citrate, polyethylene glycol) to empty stool from the colon.
o Follow a clear liquid diet the day before the procedure to aid in bowel preparation and to prevent dehydration; avoid red and
purple liquids.
o Do not eat or drink anything 8 hours before the test
o Expect to be placed in various positions during the procedure. You may experience abdominal cramping and an urge to
defecate
 Postprocedure instructions include:

o Expect the passage of chalky, white stool until all barium contrast has been expelled
o Take a laxative (eg, magnesium hydroxide [Milk of Magnesia]) to assist in expelling the barium. Retained barium can lead to
fecal impaction
o Drink plenty of fluids to promote hydration and eat a high-fiber diet to prevent constipation.

REFEEDING SYNDROME

Refeeding syndrome is a potentially lethal complication of nutritional replenishment in significantly malnourished

clients and can occur with oral, enteral, or parenteral feedings.
After a period of starvation, carbohydrate-rich nutrition (glucose) stimulates insulin production along with a shift of
electrolytes from the blood into tissue cells for anabolism.
The client's lack of oral intake results in the pancreas making less insulin. After the client receives food or IV fluids
with glucose, insulin secretion is increased, leading to phosphorous, potassium, and magnesium shifting
intracellularly.
Phosphorus is the primary deficient electrolyte as it is required for energy (adenosine triphosphate).
Hypophosphatemia causes muscle weakness and respiratory failure.
Deficiencies in potassium and magnesium potentiate cardiac arrhythmias. Therefore, aggressive initiation of nutrition
without adequate electrolyte repletion can quickly precipitate cardiopulmonary failure.
The key signs of refeeding syndrome are rapid declines in phosphorous, potassium, and/or magnesium
(mnemonic PPM).
Other findings may include fluid overload, sodium retention, hyperglycemia, and thiamine deficiency.
Actions to prevent refeeding syndrome include the following:

o Obtaining baseline electrolytes

o Initiating nutrition support cautiously with hypocaloric feedings
o Closely monitoring electrolytes
o Increasing caloric intake gradually

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

 Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure in which an endoscope is passed
through the mouth into the duodenum to assess the pancreatic and biliary ducts.
Using fluoroscopy with contrast media, the ducts can be visualized and treatments including removal of obstructions,
dilation of strictures, and biopsies can be performed.
Perforation or irritation of these areas during the procedure can cause acute pancreatitis, a potentially life-
threatening complication after an ERCP.
Signs and symptoms include acute epigastric or left upper quadrant pain, often radiating to the back, and a rapid
rise in pancreatic enzymes (eg, amylase, lipase)

JACKSONN-PRATT RESERVOIR

It is common for clients to be discharged with a JP closed-wound surgical drain in place after abdominal and breast
reconstruction surgery.
The purpose of the drain is to prevent fluid buildup in a closed space, which can put tension on the suture line and
compromise the integrity of the incision, increase the risk for infection, and decrease wound healing.
The general procedure for emptying the drainage device includes the following steps in order:
 o Perform hand hygiene as asepsis must be maintained to prevent the transmission of microorganisms even though there is
less chance of bacteria entering the wound using a closed-wound drainage device (eg, JP, Hemovac) than an open-drain
device (eg, Penrose)
o Pull the plug on the bulb to open the device and pour the drainage into a small, calibrated container (eg, plastic water
cup, urine specimen container) as this facilitates recording accurate drainage output
o Empty the device every 4-12 hours unless it is 1/2 to 2/3 full before then because as the small capacity bulb (100 mL)
fills, the amount of negative pressure in the bulb decreases
o Compress the empty bulb by squeezing it from side-to-side with 1 or 2 hands until it is totally collapsed. Although the
reservoir can be collapsed by pressing the bottom towards the top, compressing the sides of the reservoir (bulb) is
recommended as it is more effective in establishing negative pressure
o Clean the spout on the bulb with alcohol and replace the plug when it is totally collapsed to restore negative pressure

ESOPHAGEAL CANCER

Esophageal cancer is a rare, rapidly growing malignancy of the esophageal lining with a low 5-year survival rate.
Squamous cell carcinoma usually develops in the upper part of the esophagus, whereas adenocarcinoma usually
develops in the lower part.
Major risk factors include smoking (eg, cigarettes, pipe, cigars) and excessive alcohol consumption (ie,
approximately >15 drinks/week for men, >8 drinks/week for women)
Barrett esophagus is also a significant risk factor for esophageal cancer; this condition occurs when the distal portion
of the esophagus develops precancerous changes. Obesity (which allows stomach acid to flow upward into the
esophagus due to increased abdominal pressure) and uncontrolled gastroesophageal reflux disease contribute to
the development of Barrett esophagus; they are both closely linked with esophageal cancer
Consumption of salty foods is not associated with an increased risk of esophageal cancer but increases the risk of
gastric cancer. Dietary factors that may increase a client's risk of esophageal cancer include high intake of
nitrosamine-containing foods (eg, pickled foods, beer), frequent ingestion of extremely hot beverages (thermal injury),
and deficient intake of fruits and vegetables.

HEMATOLOGY/ONCOLOGY
TUMOR LYSIS SYNDROME
 Tumor lysis syndrome (TLS), an oncologic emergency, occurs when cancer treatment successfully kills cancer
cells, resulting in the release of intracellular components (eg, potassium, phosphate, nucleic acids). Clients with TLS
develop significant imbalances of serum electrolytes and metabolites.
TLS may result in the following life-threatening conditions:

o Hyperkalemia (>5.0 mEq/L [5.0 mmol/L]) that can cause lethal dysrhythmias
o Large amounts of nucleic acids (normally converted to uric acid and excreted by the kidneys) that can overwhelm the kidneys
and cause hyperuricemia and acute kidney injury (AKI) from uric acid crystal formation
o Hyperphosphatemia (>4.4 mg/dL [1.42 mmol/L]) that can cause AKI and dysrhythmias
o Hypocalcemia (<8.6 mg/dL [2.15 mmol/L]) that can cause tetany and cardiac dysrhythmias

Potassium-sparing medications (eg, spironolactone) can worsen hyperkalemia. Loop or osmotic diuretics may be
prescribed to increase urine output and lower serum potassium. Sodium polystyrene sulfonate (Kayexalate) also
helps to reduce potassium.
Hypouricemic agents (eg, allopurinol) prevent the formation of uric acid, and aggressive fluid hydration (eg, IV normal
saline) flushes out the kidneys to avoid the accumulation of toxins. Hydration therapy also dilutes serum potassium,
lowering the risk for lethal dysrhythmias.
Health care providers often prescribe mealtime phosphate binders (eg, sevelamer, lanthanum carbonate, calcium
acetate) to prevent absorption of additional nutritional phosphorus.

POLYCYTHEMIA VERA

Polycythemia vera (PV) is a chronic myeloproliferative disorder in which the bone marrow produces an abnormally
high number of red blood cells (RBCs).
Although PV is an abnormality of the bone marrow, secondary polycythemia can occur in an individual with chronic
hypoxemia, such as chronic obstructive pulmonary disease or chronic lung disease.
The danger of PV is seen when the client develops blood clots due to the increased viscosity of the blood, which
makes the circulation sluggish and decreasing tissue perfusion.
Treatment of PV usually includes periodic phlebotomy, the removal of 300 to 500 milliliters of blood through
venipuncture, to reduce the RBC count and achieve a hematocrit of less than 45%. Initially, clients may require
phlebotomy every other day until the goal hematocrit is reached. Hematocrit is then monitored monthly, and additional
blood draws performed as necessary.
Transfusion is contraindicated in a client with PV as this would have the opposite effect of what would be desired,
further increasing the RBC count and clotting.
Although an IV fluid bolus may be helpful in the short-term to reduce blood viscosity, it would not be a maintenance
treatment for PV. Instead, the client should be encouraged to drink 3 or more liters of fluid daily and avoid
dehydration.
Steroid injections are not typically used to treat PV.
Polycythemia vera (PV) is a hematological disorder in which too many RBCs (and often WBCs and platelets) are
produced, causing increased blood viscosity, venous stasis, and increased risk for thrombus formation.
The nurse should teach clients with PV measures to prevent thrombus (eg, wearing graduated compression stockings,
elevating legs when sitting, maintaining adequate hydration).
Clients should also learn to monitor for and report signs and symptoms of thrombus (eg, redness, tenderness, or
swelling in one leg). Reports of possible thrombus require immediate intervention to avoid serious injury (eg, stroke,
pulmonary embolism)
Venous stasis causes the skin on the face, hands, and feet to become ruddy (red). This is an expected finding.
Occasional headaches or blurred vision can result from sluggish, viscous blood flow in the brain. Aspirin therapy is
used for its antiplatelet and analgesic action. The nurse should assess the client's headaches; however, they are not
the priority.
Pruritis is a common occurrence in clients with PV, often after bathing. Clients should bathe with cool water and pat
(not rub) themselves dry with a towel to avoid histamine release and use antihistamine creams for relief. Venous
stasis can also cause itching, and aspirin can help.
Polycythemia vera (PV) is a chronic disorder of the bone marrow in which too many red blood cells, white cells,
and platelets are produced.
 Clients with PV are at risk of developing blood clots due to increased blood volume and viscosity. Clients are
instructed to elevate the legs and feet when sitting, wear support stockings, and report signs of thrombosis (eg,
swelling and tenderness in the legs). Adequate fluid intake during exercise and hot weather is important to reduce
fluid loss and decrease viscosity
Increasing intake of iron-containing foods and supplements can further increase hemoglobin production and is not
recommended. Clients with PV need periodic phlebotomy to remove excess blood.
Itching is a common and frustrating symptom of PV. Reducing water temperature, using starch baths, and patting the
skin dry rather than rubbing vigorously are beneficial.

MACROCYTIC ANEMIA
Megaloblastic anemia is caused by vitamin B12 or folic acid deficiency.
Vitamin B12 deficiency can also result in peripheral neuropathy and cognitive impairment.
Vitamin B12 is formed by microorganisms and found only in animal foods; some plant foods may contain minimal
amounts of vitamin B12 only if they accidentally contain animal particles.
Natural sources of vitamin B12include meat, fish, poultry, eggs, and milk; some breads and cereals may be fortified with
vitamin B12 as well as some nutritional yeasts.
Vegans are strict vegetarians; they exclude all animal products, including eggs, milk, and milk products, from the diet.
They also may avoid foods that are processed or not organically grown, thereby eliminating potentially fortified food
sources of vitamin B12.
Individuals who practice any form of vegetarianism are at risk for vitamin B12 deficiency. A vegan diet, with its
elimination of all animal products, poses the highest risk. A vitamin B12 supplement is recommended when dietary
intake is inadequate.
Lacto-ovo-vegetarian eggs, milk, and milk products are included, but no meat is consumed.
Lacto-vegetarian milk and milk products are included in the diet; eggs and meats are excluded.
Macrobiotic whole grains, vegetables, fruits, and seaweeds are emphasized; fish and seafood may be included in
the diet up to several times a week.
HEMOPHILIA
Hemophilia is a group of disorders characterized by deficiencies in production or use of coagulation proteins (eg,
factor VIII, factor IX), resulting in impaired clot formation and increased risk for uncontrolled bleeding.
Hemophilia is typically identified by prolonged or excessive bleeding, severe bruising, or joint bleeding (ie,
hemarthrosis) after injuries or procedures.
Administration of supplemental IV clotting factors (eg, factor VIII, factor IX) is the primary treatment for acute
bleeding in clients with hemophilia
Clients with hemophilia have increased risk of hemarthrosis (ie, bleeding in joint). In addition to administration of IV
clotting factors, hemarthrosis is managed with rest, ice, compression, and elevation (RICE). Application of ice or cold
packs promotes local vasoconstriction and clot formation. The affected joint should be maintained in the extended
position to prevent flexion contracture
Frequent neurologic assessments are required for clients with hemophilia who have suspected (facial laceration in
this client) or confirmed head trauma, as neurologic alteration may indicate intracranial bleeding
When caring for clients with hemophilia, the nurse should eliminate factors that increase bleeding risk or promote
complications from bleeding. NSAIDs (eg, aspirin, ibuprofen) are avoided as they inhibit platelet aggregation, which
increases bleeding risk

THROMBOTIC THROMBOCYTOPENIC PURPURA (TTP)

Thrombotic thrombocytopenic purpura (TTP) consists of hemolytic anemia with fragmentation of erythrocytes, signs of
intravascular hemolysis, thrombocytopenia, decreased renal function, and fever.
Regardless of the cause of the low platelets, the concern in this case is the critically low (below 10,000/mm3 (10 x
109/L) platelet count, which puts this client at risk for internal bleeding, especially within the brain.
Change in level of consciousness is the most clinically significant finding requiring an emergency response.

PURPURA
 Purpura refers to reddish-purple blotches on the skin that do not blanch with pressure due to bleeding underneath the
skin. Further assessment must be done to evaluate for a potentially serious etiology, such as blood dyscrasia.

RADIATION

Radiation damages the DNA, which causes cell destruction.

Radiation (and chemotherapy) usually affects tissues with rapidly proliferating cells (eg, oral mucosa,
gastrointestinal tract, bone marrow) first, followed by tissues with slowly proliferating cells (eg, cartilage, bone,
kidney).
As a result, early manifestations of radiation damage include oral mucosal ulcerations, vomiting/diarrhea, and low
blood cell counts.
The extent of radiation exposure can be monitored indirectly by measuring blood cell counts.

LYMPH NODES

CASE: The nurse is admitting a client who

had mastectomy 6 months ago and is
scheduled for elective surgery. During the
physical assessment, the nurse notices a 0.5
cm mobile, firm, nontender lymph node in the
upper arm. What action should the nurse
take?

REASSURE THE CLIENT THAT IT IS AN

EXPECTED FINDING
 Ordinarily, lymph nodes are not palpable in adults. However, a lymph node that is palpable, superficial, small (0.5-1
cm), mobile, firm, and nontender is considered a normal finding. It could easily be explained by the relatively recent
mastectomy (trauma) with resulting inflammation and lymph flow interference.
A tender, hard, fixed, or enlarged node is an abnormal finding. Tender nodes are usually due to inflammation but hard
or fixed nodes could indicate malignancy.
A biopsy is performed for an abnormal lymph node finding that could suggest malignancy.
The swelling is caused by inadequate lymph drainage or inflammation, not localized edema. Ice is not recommended
for this normal finding.
There is no indication of lymphangiitis requiring antibiotics. This may produce a red streak with induration following the
course of the lymphatic collecting duct. Infected skin lesions may also be present.

HEPARIN INDUCED THROMBOCYTOPENIA

A significant reduction in platelets after initiation of heparin therapy can indicate heparin-induced
thrombocytopenia (HIT), a severe, potentially lethal complication.
HIT is an immune reaction to heparin that causes a drastic and a paradoxical increase
in arterial and venous thrombosis. The nurse should notify the health care provider immediately and
anticipate stopping heparin therapy and initiating a non-heparin anticoagulant (eg, warfarin, rivaroxaban,
argatroban)
Clients with HIT have increased risk for deep venous thrombosis (DVT) and pulmonary embolism. The nurse
should perform a neurovascular assessment and report evidence of vascular clots (eg, DVT) to the health care
provider. The nurse should also measure a full set of vital signs to assess for pulmonary embolism (eg, tachycardia,
tachypnea, decreased oxygen saturation)
When large changes are noted in laboratory values, it is important to draw repeat samples to confirm those values,
as errors in sampling or specimen handling could result in inappropriate intervention
Clients who are suspected of having HIT or who have a history of HIT should never receive heparin or low-molecular-
weight heparin (eg, enoxaparin). Only non-heparin anticoagulants may be given.
 A significant reduction in platelets after initiation of heparin or low-molecular-weight heparin
(eg, enoxaparin [Lovenox]) therapy can indicate heparin-induced thrombocytopenia (HIT), a severe, potentially
lethal complication.
HIT is an immune reaction to heparin-based anticoagulants that causes a drastic decrease in platelet count (ie,
of pretreatment levels and/or platelet count <150,000/mm3 [150 × 109/L]) and a paradoxical increase in risk for arterial
and venous thrombosis (eg, deep venous thrombosis, pulmonary embolism).
The nurse should notify the health care provider immediately of decreased platelet levels and anticipate stopping
enoxaparin therapy and initiating a nonheparin anticoagulant (eg, rivaroxaban, argatroban)

PULMONARY EMBOLISM
Death from pulmonary embolism is often attributed to a missed diagnosis. Early identification of risk factors
(eg, venous stasis, hypercoagulability of blood, endothelial damage) can have a positive effect on client outcome.
This postoperative client is at greatest risk due to the presence of the following 4 risk factors:

o Abdominal cesarean section surgery (endothelial damage)

o Engorged pelvic vessels from pregnancy (venous stasis, hypercoagulability of blood)
o I ours related to positioning during surgery and the immediate postoperative period and epidural
anesthesia (venous stasis)
o Postpartum state (hypercoagulability of blood)

S/P MASTECTOMY

After a mastectomy, an important goal is restoring function in the client's affected arm. Measures to promote
function are initiated immediately after surgery.
Elevating the affected arm to heart level (eg, on a pillow) is crucial to reduce fluid retention and prevent
lymphedema in the affected arm.
 Hand and arm exercises are implemented gradually, beginning with finger flexion and extension. These activities
maintain muscle tone, prevent contractures, and improve lymph and blood circulation, which promote function and also
prevent lymphedema.
The return of full range of motion in the affected arm is desired within 4-6 weeks.
Additional nursing care for clients after a mastectomy includes keeping the client in semi-Fowler position and placing
a sign over the bed that specifies, "No blood pressure, venipuncture, or injections on left arm," as these actions could
cause lymphedema.
Ice reduces inflammation, swelling, and pain. Although this reduces discomfort, it does not directly contribute to
restoring arm function and is not the priority.
Frequent ambulation is not the priority in the initial postoperative period as it does not facilitate lymph drainage or help
restore arm function.
Pneumatic compression devices may be used to facilitate lymph drainage when lymphedema is present. Elevating
and exercising the arm help prevent lymphedema from developing and are priority in this client.

LYMPHEDEMA
Lymphedema is the accumulation of lymph fluid in the soft tissue. It can occur as a result of lymph node removal or
radiation treatment. When the axillary nodes cannot return lymph fluid to central circulation, the fluid can accumulate
in the arm, hand, or breast. The client's arm may feel heavy or painful, and motor function may be impaired. The
presence of lymphedema increases the client's risk for infection or injury of the affected limb.
Interventions to manage lymphedema include:

o Decongestive therapy (massage technique to mobilize fluid)

o Compression sleeves or intermittent pneumatic compression sleeve

Compression sleeves are graduated with increased distal pressure and less proximal pressure.
Clothing should also be less constrictive at the proximal arm and over the chest.
 o Elevation of arm above the heart
o Isometric exercises
o Avoidance of venipunctures (eg, IV catheter insertion, blood draw), blood pressure measurements, and injections (eg,
vaccinations) on the affected limb
o Injury prevention (limb less sensitive to temperature changes)
Infection prevention (limb more prone to infection through skin breaks)

ORAL CANCER
Oral cancer refers to cancers of the lips, tongue, mouth, pharynx (ie, throat), and larynx (ie, vocal cords). The most
common type of oral cancer is squamous cell carcinoma, which initially presents as a nonhealing lesion or ulcer.
Other symptoms of oral cancer include mucosal thickening, difficulty swallowing, mouth bleeding, sore
spots, leukoplakia (ie, white patch), and changes in salivation.
Modifiable risk factors include:

o Chronic alcohol and/or tobacco use

o Poor oral hygiene habits
o Chronic irritation to the mucosa (eg, chipped teeth, improperly fitted dental appliances)
o Excessive exposure to ultraviolet light

In addition, unprotected sexual activity (eg, oral sex, multiple partners) increases the risk for sexually transmitted
infections in the oral cavity (eg, human papillomavirus virus), which can cause oral cancer.

SPINAL CORD COMPRESSION

CASE: The nurse receives report on the

assigned team of clients on the oncology
unit. All are receiving chemotherapy. Which
client should the nurse check on first?

NEW ONSET BACK PAIN AND WEAKNESS

IN LEGS

A new-onset finding is more concerning than chronic or expected findings. There is a risk of spinal cord
compression from a metastatic tumor in the epidural space. The classic symptoms are localized, persistent back
pain; motor weakness; and sensory changes (eg, numbness, paresthesia). There can also be autonomic
dysfunction, reflected by bowel or bladder dysfunction.
Neurologic changes are a priority because the symptoms are subtle and time sensitive for permanent negative
outcomes. Bone is a common site for metastasis due to its vascularity.

RADIATION THERAPY TO HEAD AND NECK

Radiation therapy to the head and neck can decrease a client's oral intake due to the development of mucositis (ie,
inflammation of the mouth, esophagus, and oropharynx) and xerostomia (ie, dry mouth). These adverse side effects
affect speech, taste, and ability to swallow and can have a significant impact on the client's nutritional status.
The nurse teaches the client to:

o Avoid irritants such as spicy, acidic, dry, or crumbly foods; coffee; and alcohol
o Consume supplemental nutritional drinks (eg, Ensure), which are often easier to swallow
o Use artificial saliva to manage xerostomia and the production of thick saliva due to altered salivary gland function . Sipping
water throughout the day is equally effective and less expensive.

Topical anesthetics (eg, lidocaine) have been found to increase comfort and improve oral intake in clients with
mucositis due to radiation therapy.
Clients on radiation therapy need to maintain more frequent (eg, before and after meals, at bedtime) oral hygiene (eg,
using soft toothbrush, rinsing with baking soda solution) due to the drying effects of mucositis.

BLOOD TRANSFUSION
 The nurse should ask the client to void or empty the urinary catheter and discard urine prior to starting a blood
transfusion.
In the event of an acute hemolytic transfusion reaction, a fresh urine specimen should be collected and sent to the
laboratory to analyze for hemolyzed RBCs.
An acute hemolytic transfusion reaction is a life-threatening reaction in which the host's antibodies rapidly destroy the
transfused RBCs and is generally related to incompatibility.
Early signs of a hemolytic reaction include red urine, fever, and hypotension; late signs include disseminated
intravascular coagulation and hypovolemic shock. The transfusion should be stopped immediately if any sign of
transfusion reaction occurs.
Starting the transfusion with an empty bladder will help ensure that any urine specimen collected after a reaction is
reflective of the body's physiological processes after the blood transfusion has started
Hypotension is a sign of a transfusion reaction and is not expected. Bedrest is not required, but the client should
be assisted if out of bed during a transfusion to prevent falls.

CERVICAL CANCER
 Almost all cases of cervical cancer result from persistent infection due to human papillomavirus (HPV), a primary
risk factor (Option 2).
HPV is the most common sexually transmitted infection but is usually transient and resolves spontaneously. However,
persistent HPV infection can cause abnormal changes in cervical epithelial tissue that slowly progress to invasive
cancer if not treated.
Most other risk factors for cervical cancer are related to behaviors that increase the client's risk of contracting HPV or
an inability to clear the infection.
Clients who have multiple sexual partners or initiate sexual activity at an early age (<18) increase their risk for
exposure to HPV.
Clients with weakened immunity (eg, HIV, immunosuppressive therapy) may have an impaired ability to clear HPV,
which increases the risk for cervical cancer due to persistent infection
Nulliparity (ie, no previous pregnancies) is not a risk factor for cervical cancer; however, it is a risk factor for breast
cancer.

IRON DEFICIENCY ANEMIA

Iron-deficiency anemia occurs when the body lacks sufficient iron to form red blood cells and synthesize hemoglobin.
Iron-deficiency anemia can result from:

1. Diets low in iron (eg, vegetarian and low-protein diets)

2. Iron not being absorbed (eg, following many gastrointestinal [GI] surgeries, malabsorption syndrome)
3. Increased iron requirement (eg, children's growth spurts, pregnancy, breastfeeding)
4. Blood loss (eg, menstruation, bleeding in the GI tract [eg, ulcers, hemorrhoids])

Foods rich in iron include:

o Meats (eg, beef, lamb, liver, chicken, pork)

o Shellfish (eg, oysters, clams, shrimp)
o Eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal
 Eating foods rich in vitamin C (eg, citrus fruits, potatoes, tomatoes, green vegetables) with iron-rich foods will
enhance iron absorption but coffee and tea consumption interferes with this process.
Chicken in a salad is a good source of iron. However, bread, pudding, and milk do not contain significant amounts of
iron.
Fat-free yogurt, carrot sticks, apple slices, and diet soda do not offer a significant source of iron.
Ham is a good source of iron. However, carrots, green beans, and gelatin desserts are not significant sources.
Furthermore, the tea will inhibit iron absorption.

CANCER

Cancer is a growth of abnormal cells in an organ system that may impair the organ's function and spread throughout
the body. Many cancers are invasive and life threatening if allowed to reach late stages of development. However,
cancer is often difficult to identify early as the client may be asymptomatic or have only vague symptoms.
Nurses should screen clients for and immediately report warning signs of cancer, which can be remembered with the
mnemonic CAUTION:

o Change in bowel or bladder habits

o A sore that does not heal
o Unusual bleeding or discharge from a body orifice
o Thickening or a lump in the breast or elsewhere
o Indigestion or difficulty in swallowing that does not go away
o Obvious change in a wart or mole
o Nagging cough or hoarseness

COLORECTAL CANCER

Early signs of colorectal cancer are usually nonspecific and include fatigue, weight loss, anemia, and occult
gastrointestinal bleeding.
 Clients should have regular screening colonoscopy for colon cancer starting at age 50 if their risk is average or
earlier if their risk is high.
Colorectal screening can also include fecal occult blood test or fecal immunochemical test annually.
New-onset anemia should be taken seriously at this client's age, and colon cancer must be ruled out.
The etiology of anemia must be determined prior to recommending treatment.
The cause of anemia must be determined before recommendations can be provided for iron deficiency. There are
many causes of anemia (including pernicious anemia) in older adults that involve deficiencies in vitamin B12, not iron.
Colorectal cancer is the third most common cancer and the second leading cause of cancer deaths affecting both
genders equally. Various risk factors for colorectal cancer include:

o Personal or family (first-degree relative) history of colorectal cancer/polyps

o Personal history of inflammatory bowel disease, Crohn's disease, or ulcerative colitis
o History of hereditary non-polyposis colorectal cancer (Lynch syndrome)
o Lifestyle factors such as obesity, a diet high in red meat, cigarette smoking, and alcohol consumption

HEMA IN COPD

CASE: The nurse is caring for a client with

severe chronic obstructive pulmonary
disease (COPD). The nurse anticipates
which laboratory results for this client?

POLYCYTHEMIA
The client with severe COPD will have a chronically low oxygen level, hypoxemia. To compensate, the body produces
more red blood cells (RBCs) to carry needed oxygen to the cells. A high RBC count is called polycythemia.
Anemia is not expected and will worsen symptoms of COPD.
Neutropenia (low white blood cell count) is not expected in COPD. Chemotherapy and many medications (clozapine
[antipsychotic], methimazole [antithyroid]) can cause neutropenia which increases the risk of infection.
 Thrombocytopenia (low platelet count) is not anticipated in COPD. Alcohol use, HIV infection, and many medications
(heparin) can cause thrombocytopenia.

NEUTROPENIA
CASE: A hospitalized client is receiving
chemotherapy. Based on today's blood
laboratory results, what action should the nurse
take?

PLACE A MASK ON THE CLIENT

The normal range for a WBC count is 4,000-11,000/mm3 (4.0-11.0×109/L). Clients with neutropenia (a reduction in
WBCs) are predisposed to infection. The absolute neutrophil count (ANC) is determined by multiplying the total WBC
count by the percentage of neutrophils.
Neutropenia is an ANC below 1,000/mm3 (1.0×109/L). An ANC below 500/mm3 (0.5×109/L) is defined as severe
neutropenia and is a critical emergency. This client's neutropenia is probably a result of bone marrow suppression
from the chemotherapy.
 The client needs reverse or protective isolation from organisms that people or objects may have that the client lacks
resistance to. A hospitalized client needs to be in a private room, and the room may need to be equipped with HEPA
(high-efficiency particulate air) filtration (or positive pressure air flow).
Until the room can be readied, the client should be protected with a mask and separated from infectious clients.
Additional neutropenic precautions include avoiding raw fruits/vegetables, standing water, and undercooked
meat. In addition, no infectious health care providers (eg, with colds) should care for the client.
Thrombocytopenia (low platelets) can result from bone marrow suppression caused by chemotherapy. This client's
platelets are at the low end of the normal range (150,000-400,000/mm3 [150-400× 109/L]). Spontaneous or surgical
bleeding from thrombocytopenia rarely occurs with a platelet count of >50,000/mm3 (50 × 109/L).
This client's potassium level is slightly low (normal 3.5-5.0 mEq/L [3.5-5.0 mmol/L]). Low potassium, if it affects the
cardiac tracing, causes flattened T waves. Peaked or tented T waves on a cardiac tracing are related to hyperkalemia.
Epoetin alfa (human recombinant erythropoietin) is a hematopoietic growth factor. The erythropoietin is produced in
the kidney and stimulates bone marrow production of red blood cells (RBCs), a process called erythropoiesis. Epoetin
alfa is used to stimulate RBC production but is not typically prescribed unless the client has symptomatic anemia with
hemoglobin of <10 g/dL (100 g/L).

ORAL MUCOSITIS
Oral mucositis, inflammation or ulceration of the oral mucosa, results from chemotherapy or radiation therapy.
Oral hygiene practices that minimize oral mucositis and promote comfort include the following:

o Cleansing the mouth with normal saline after meals and at bedtime to promote oral health
o Use of a soft-bristle toothbrush to decrease gum irritation
o Application of prescribed viscous lidocaine HCl (Xylocaine) to alleviate oral pain
o Use of water-soluble lubricating agents to moisten mouth tissues that may become dry due to therapy
o Avoidance of hot liquids and spicy/acidic foods, which can cause oral discomfort

Clients with mucositis should avoid antiseptic mouthwashes with alcohol as they are irritating to mucous membranes.
 Administration of palifermin (Kepivance), a recombinant human keratinocyte growth factor, prevents oral mucositis in
clients diagnosed with hematologic malignancies. However, it does not help with pain. Viscous lidocaine HCl
(Xylocaine) alleviates the oral pain caused by mucositis.

PROSTATE CANCER

Prostate cancer is a slow-growing and predictable malignancy. If not treated, it can metastasize to nearby lymph
nodes, liver, lungs, and bone.
Clients should discuss the risks and benefits of screening for prostate cancer (eg, checking serum prostate-specific
antigen) with their health care provider.
Certain factors place clients at greater risk, and early screening can detect prostate cancer before it becomes invasive
(metastasizes).
The nurse should educate clients about risk factors.
Nonmodifiable risk factors (eg, those the client cannot control) include African American ethnicity, having a first-
degree relative with prostate cancer, and increasing age (>50)
Clients can lower the risk for prostate cancer by avoiding modifiable (ie, those the client can control) risk factors, which
include:

o Diet high in red meat, animal fat, high-fat dairy products, and refined carbohydrates (Option 2)
o Low fiber intake
o Obesity

Long-term use of NSAIDs (eg, aspirin, ibuprofen) can be a protective factor against certain types of cancer (eg,
colorectal, prostate). However, before regularly taking NSAIDs, clients should speak with their health care provider
because NSAIDs can increase the risk for adverse effects (eg, cardiovascular disease, bleeding).

THROMBOCYTOPENIA

CASE: After receiving report, which client

should the nurse assess first?
Client on a heparin infusion with platelet count
of 86,000/mm3 (86 x 109/L)

Thrombocytopenia is a serious complication of heparin products (eg, unfractionated heparin and low-molecular-weight
heparin [eg, enoxaparin]).
Regardless of its cause, thrombocytopenia usually results in bleeding complications. However, in heparin-induced
thrombocytopenia (HIT) this usually leads to paradoxical venous and/or arterial thrombosis and less commonly to
bleeding.
The mechanism for thrombosis is unclear. The danger of HIT is risk of organ damage from local thrombi and/or
embolization, leading to stroke and/or pulmonary embolism.
HIT occurs over several days. The nurse should monitor platelet levels of clients on heparin and report a decrease of
aseline or a drop below 150,000/mm3 (150 x 109/L) to the health care provider.
If the client has HIT, all heparin products must be stopped immediately, and a different anticoagulant (eg, argatroban)
should be started to prevent thrombosis risk.
Client with dehydration with BUN of 24mg/dL
This client with mildly elevated blood urea nitrogen (normal 6-20 mg/dL [2.1-7.1 mmol/L]) needs IV fluids. This is not
the priority.

Client with myelodysplastic syndrome with WBC of 2,000

The client with myelodysplastic syndrome does not produce adequate blood cells. Low white blood cell count, platelets,
and hemoglobin are expected. Although this client is at risk for infection, HIT has a higher priority.

Client with sickle cell disease with hgb of 7.9

 Decreased hemoglobin and hematocrit are
expected in sickle cell disease due to
chronic/acute hemolysis. A packed red
blood cell transfusion may be needed, but
this is not the priority.

TRANSFUSION REACTION

Signs of a transfusion reaction include chills, fever, low back pain, flushing, and itching. Nursing interventions
include:

1. Stop transfusion immediately and disconnect tubing at the catheter hub.

2. Maintain IV access with normal saline, using new tubing to prevent hypotension and vascular collapse
3. Notify health care provider (HCP) and blood bank.
4. Monitor vital signs.
5. Recheck labels, numbers, and the client's blood type.
6. Treat client's symptoms according to the HCP's prescription.
7. Collect blood and urine specimens to evaluate for hemolysis.
8. Return blood and tubing set to the blood bank for additional testing.
9. Complete necessary facility paperwork to document the reaction.

VON WILLEBRAND DISEASE

Von Willebrand disease is a genetic bleeding disorder caused by a deficiency of von Willebrand factor (vWF),
which plays an important role in coagulation. Intranasal desmopressin or topical therapies (eg, thrombin) may be
 prescribed to stop minor bleeding, whereas major bleeding may require replacement of vWF. Clients should wear
medical identification bracelets in case of emergency.
Client teaching includes:

o Notify the health care provider of signs of bleeding (eg, severe joint pain or swelling, headache [especially after injury],
blood in urine/stool, uncontrollable nosebleed).
o Use a humidifier or nasal spray to keep the mucosa moist, reducing the risk of nosebleeds
o Avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).
o Avoid activities with a higher risk for injury (eg, contact sports)
o Maintain gum integrity (eg, soft-bristled toothbrush, gentle flossing) to minimize bleeding potential
o Report heavy menstrual bleeding (eg, soaking a pad in <3 hours), which can be managed with hormonal therapies and
intranasal desmopressin

Clients should avoid medications that can exacerbate bleeding, including aspirin and NSAIDs (eg, ibuprofen,
naproxen, ketorolac). Clients should instead use the mnemonic RICE (rest, ice, compression, elevation) to help with
pain and inflammation.

HEMATOCRIT

Hematocrit (Hct) is the percentage of red blood cells (RBCs) in a volume of whole blood. Hct and hemoglobin (Hgb)
values are related (approximately 3 x Hgb = Hct); when one value is decreased, the other is also.
This client likely has hemoglobin of 7 g/dL (70 g/L) (normal, 13.2-17.3 g/dL [132-173 g/L] for males and 11.7-15.5 g/dL
[117-155 g/L] for females).
Hgb is a component of the RBC that carries oxygen to the body's tissues.
A decrease in Hgb decreases oxygen-carrying capacity and transport to tissues.
RBCs may be 100% saturated with oxygen at rest, but desaturation may occur with increased activity and oxygen
demand in the presence of decreased Hct and Hgb.
Manifestations associated with decreased oxygen transport include shortness of breath with activity, tachypnea, and
tachycardia.
SICKLE CELL CRISIS
Clients with sickle cell crisis often have excruciating pain related to the occlusion from the sickling and resulting
ischemia. These individuals usually need large doses of narcotics as prior treatment has led to drug tolerance; they
may also metabolize the drugs differently. Using only external cues to judge a client's pain is invalid as these clients
have often learned how to distract themselves from focusing on the pain. Use of continuous PCA is recommended for
relief rather than prn administration.
Nonsteroidal anti-inflammatory drugs (eg, ibuprofen) are not very effective in treating the pain of sickle cell crisis.
Meperidine (Demerol) is contraindicated for a sickle cell crisis as large frequent doses can result in normeperidine
(toxic metabolite) accumulation. Symptoms start with tremors and can result in a seizure.
Clients with sickle cell crisis are often undertreated due to the suspicion of drug abuse. However, studies have shown
that the risk of abuse is small (0%-9%) and this range is similar to substance abuse risk in the general population.
Therefore, the client's self-report is valid and appropriate treatment in the acute setting is warranted.

SEVERE ANEMIA
A normal hemoglobin level for an adult male is 13.2-17.3 g/dL (132-173 g/L) and female is 11.7-15.5 g/dL (117-155
g/L).
A client with severe anemia will have tachycardia, which will maintain cardiac output. The cardiovascular system
must increase the heart rate and stroke volume to achieve adequate perfusion.
Shortness of breath (dyspnea) may occur due to an insufficient number of red blood cells. The respiratory system
must increase the respiratory rate to maintain adequate levels of oxygen and carbon dioxide.
Pallor (pale complexion) occurs from reduced blood flow to the skin.
Coarse crackles occur with fluid overload but not with anemia.
Respiratory depression does not occur with anemia. Respiratory depression may occur post-administration of a
narcotic or during oversedation.

TELETHERAPY
Clients receiving teletherapy (external beam radiation therapy) often experience significant effects to the skin of the
treatment area. Teaching essential skin care standards to these clients is focused on preventing
infection and promoting healing of the affected skin.
Key measures of skin care that clients receiving teletherapy should take include:

o Protect the skin from infection by not rubbing, scratching, or scrubbing

Wear soft, loose-fitting clothing

Use soft, cotton bed sheets and towels
Pat skin dry after bathing
Avoid applying bandages or tape to the treatment area

o Cleanse the skin daily by taking a lukewarm shower

Use mild soap without fragrance or deodorant

Do not wash off any radiation ink markings

o Use only creams or lotions approved by the health care provider (HCP)

Avoid over-the-counter creams, oils, ointments, or powders unless specifically recommended by the HCP as
they can worsen any irritation

o Shield the skin from the effects of the sun during and after treatment

Avoid tanning beds and sunbathing

Wear a broad-brimmed hat, long sleeves, and long pants when outside
Use a sunscreen that is SPF 30 or higher

o Avoid extremes in skin temperature

Avoid heating pads and ice packs / Maintain a cool, humid environment for comfort
 INFECTIOUS DISEAS
SEPSIS

Sepsis is an overwhelming response to infection that causes impaired organ function. Septic shock occurs when
sepsis causes cardiovascular collapse and/or impairs the body's ability to maintain normal metabolic and cellular
processes.
Manifestations of septic shock include:
o Fever or hypothermia (>100.4 F [38 C]; <96.8 F [36 C]) Either fever or low body temperature is found in sepsis and septic
shock. Fever occurs in response to infection, whereas low body temperature can occur as shock worsens due to metabolic
alterations and inadequate tissue perfusion (Option 3).
o Hypotension Systolic blood pressure <90 mm Hg or mean arterial pressure <65 mm Hg in a client with infection may
indicate septic shock. Altered perfusion from hypotension may cause lactic acid accumulation and metabolic acidosis (Option
1).
o Prolonged capillary refill A refill time >3-4 seconds in adults indicates inadequate tissue perfusion as a result of altered
peripheral circulation and hypotension (Option 2).
o Tachycardia A resting heart rate >90/min is common in septic shock to compensate for decreased systemic vascular tone
and hypotension.
o WBC count >12,000/mm3 (12 x 109/L) or immature neutrophils (bands) of >10% An increased WBC count, especially with
bands, indicates severe infection (Option 5).

Clients with septic shock typically develop decreased urine output (ie, <0.5 mL/kg/hr) due to inadequate organ
perfusion.

TUBERCULOSIS
Mycobacterium tuberculosis is a gram-positive, acid-fast bacillus that is transmitted through the airborne route.
TB is usually (85%) pulmonary but can also be extrapulmonary (eg, meninges, genitourinary, bone and joints,
gastrointestinal).
TB, regardless of location, commonly presents with constitutional symptoms, including:

o Low-grade fever
o Night sweats
o Anorexia and weight loss
o Fatigue

Additional symptoms depend on the location of the infection. Pulmonary tuberculosis typically includes:

o Cough
o Purulent or blood-tinged sputum
o Shortness of breath

Dyspnea and hemoptysis are typically seen in the late stages. The classic manifestations of TB can be absent in
immunocompromised clients and the elderly.
TB is curable if the client completes the prescribed medication regimen.
Noncompliance with the treatment plan is a major problem in treating TB due to the length of time drug therapy is
required (usually about 6 months) and the associated unpleasant side effects.
DOT is an effective patient-centered treatment strategy developed by the World Health Organization that increases
compliance with drug therapy, prevents reinfection and the development of multi-drug resistant TB strains, and
controls the spread of TB disease worldwide.
The public health nurse provides and watches the client swallow every prescribed medication for at least the
first 2 months of antitubercular medication therapy, preferably longer. Any designated person (ie, caregiver) can
provide the medications and observe the client swallow them. This can take place in any designated area (eg, clinic,
home, school, workplace).
TB disease is spread from person to person via inhalation of airborne droplets containing tubercle bacilli bacteria.
These droplets are coughed, sneezed, or exhaled (eg, breathing, singing, talking, laughing) into the air by an individual
with active TB disease.
 The probability of becoming infected is related to sharing airspace and the amount of time spent with the client.
All health care workers caring for clients with TB disease must follow standard and airborne transmission
precautions and wear high-efficiency particulate or N95 respirator masks.
Bacteriologic testing is performed in clients with suspected TB disease to confirm the diagnosis. A stained sputum
smear is examined microscopically for the presence of Mycobacterium tuberculosis (tubercle bacillus), and a culture
identifies the growth of the microorganisms.
Collect an early morning sputum sterile specimen on 3 consecutive days for an acid-fast bacilli (AFB) smear and
culture. Fluids and/or expectorants can be given at bedtime to help liquefy secretions. It is usually easier for clients to
produce a specimen upon awakening as secretions collect in the airways during the night.

WEST NILE VIRUS

West Nile virus is a mosquito-borne disease (encephalitis) that occurs mainly during the summer months,
especially during humid weather.
Prevention focuses on avoiding mosquitoes and using an insect repellent.
Prevention also includes wearing long sleeves, long pants, and light colors and avoiding outdoor activities at dawn and
dusk when mosquitoes are most active

RHEUMATIC FEVER
 RF is an acute inflammatory disease of the heart. It is a complication that occurs 2-3 weeks after a streptococcal
pharyngitis. RF is caused by a delayed-onset autoimmune reaction involving anti-streptococcal antibodies that
cross-react with the antigens in the heart and other organs. Recurrent, untreated streptococcal pharyngitis will lead to
faster onset and increased severity of rheumatic heart disease due to increased autoimmune activity.
RF affects the heart, skin, joints, and central nervous system. The presence of 2 major criteria or 1 major and 2
minor criteria and evidence of a preceding streptococcal infection indicate a high probability of RF.
Family history is not a risk factor for RF

ANTI-RETROVIRAL THERAPY
 Antiretroviral therapy (ART) is a medication regimen consisting of multiple drugs for managing and preventing
progression of HIV infections. ART impairs viral replication at multiple points, which leads to decreased viral
loads and increased CD4+ (ie, helper T) cell counts.
When educating clients about ART, it is critical to explain that treatment is lifelong and requires strict adherence
(Option 1). Even clients with undetectable viral loads remain infected with HIV. The discontinuation of, or poor
adherence to, ART results in the progression of HIV (which may lead to AIDS) and promotes viral drug resistance.
Clients with HIV who are sexually active are at increased risk for sexually transmitted infections (STIs). Regular
Is are recommended.
Latex or polyurethane barriers should be used during sex to prevent STI transmission, as nonbarrier contraception and
natural skin condoms (eg, lambskin) offer poor protection against HIV and STI transmission.
IV drug use is a common source of HIV infection. Although abstinence from IV drugs is preferred, clients who continue
to use them should be instructed to avoid sharing needles and receive information about needle and syringe exchange
programs.

PPD TEST (MANTOUX TEST)

The intradermal purified protein derivative (PPD) test, or Mantoux test, is administered to screen
for tuberculosis (TB).
The forearm is injected with 0.1 mL of the PPD, and the client returns in 48-72 hours to have the site assessed for
induration (a raised area).
Redness alone is not read as a positive response. An area of induration >15 mm is considered a positive response in
any client (Option 1). However, a positive PPD test does not mean that the client has active TB infection but rather
that the client has been exposed to TB and has developed an immune response.
Positive sputum cultures, chest x-rays, and the presence of symptoms confirm that the client has active disease
A second injection is not needed when the client has a positive PPD.
Placing the client in airborne precautions before confirming the presence of active TB is premature. Only clients with
active TB (eg, symptoms, positive chest x-ray or sputum stain/culture) require isolation.
In a heathy client, an induration >15 mm indicates a positive TST; this means that the client was exposed to TB,
developed antibodies to the disease, and has a TB infection.
Additional tests are needed to determine if the client has latent TB infection (LTBI) or active TB disease.
 Clients with LTBI are asymptomatic and cannot transmit the microorganism to others.
Clients with active TB disease usually are symptomatic and can transmit the microorganisms through the air.
The elderly have decreased immunity and may be unable to develop antibodies to react to the tuberculin; this can
result in a false-negative TST reaction.
A positive reaction to TST means that the client is infected with TB bacteria. The infectious bacteria are concealed by
the body's defense and do not lead to active TB disease in most individuals. When the client has a decreased
immunity (eg, immunosuppression), bacteria cause an active TB disease. Additional diagnostic tests (eg, chest x-
rays, bacteriologic sputum smear for acid-fast bacilli and culture) are needed to determine if this client has active TB
disease.
A positive reaction indicates a TB infection only. Further evaluation and bacteriologic testing is necessary. If active
TB is suspected before testing is completed, airborne transmission precautions will then be initiated.

INFLUENZA
Influenza (flu) is a contagious viral infection that affects the respiratory tract.
Symptoms include fever, chills, severe muscle aches, headache, cough, sore throat, nasal congestion, and malaise.
Influenza treatment includes rest, hydration, humidified air, and antipyretics/analgesics.
Antiviral medications (eg, zanamivir [Relenza], oseltamivir [Tamiflu]) are given to clients with symptom
onset within the last 48-72 hours. These medications inhibit viral reproduction and can shorten the duration of the
illness.
Annual vaccination is recommended to prevent influenza.
To prevent spreading influenza, infected clients should be on droplet precautions (eg, surgical mask, private
room), wear a mask when being transported out of the room, and be taught to cover the mouth and nose while
coughing or sneezing.
Hand hygiene should also be emphasized as the influenza virus can persist on unwashed hands and surfaces.
(Oseltamivir is an appropriate antiviral medication for this client who reports onset of influenza symptoms 36 hours
ago.
The influenza virus is spread via droplet transmission when infected persons cough or sneeze. Hospital personnel
caring for clients with influenza should adhere to droplet precautions in addition to standard (universal) precautions.
 The influenza virus has an incubation period of 1-4 days, with peak transmission starting at about 1 day before
symptoms appear and lasting up to 5-7 days after the illness stage begins
Influenza is transmitted by inhaling droplets that an infected individual exhales into the air when sneezing, coughing, or
speaking. If contact with others is unavoidable, wearing a mask can offer some protection against virus transmission.
Individuals with the influenza virus can transmit the virus during the incubation period and illness stage of the
infection. It is not appropriate to assume that the spouse can no longer transmit the infection.
Although vaccination provides immunity against influenza in about 2 weeks after inoculation, it does not offer complete
protection against all virus strains. Therefore, close contact with others should be avoided during the illness stage,
especially those with an impaired immune system.

MENINGOCOCCAL MENINGITIS

Bacterial meningitis is an inflammation of the membranes that cover the brain and spinal cord and is caused by
bacterial infection. Symptoms include headache, neck stiffness, nausea, vomiting, photophobia, fever, and altered
mental status. The client with meningitis is at risk for seizure due to increased neuroirritability from fever and
alterations in intracranial pressure.
Bacterial meningitis is frequently caused by Neisseria meningitidis (meningococcus) in adults. Meningococcal
meningitis is highly infectious and requires strict droplet isolation precautions (eg, surgical mask, private room, client
masked during transport)
For clients with meningitis, a restful, reduced stimulus environment (eg, quiet, dimly lighted, cool temperature)
promotes healing and reduces neuroirritability and seizure risk. The client should be on bed rest with the head of the
bed elevated 10-30 degrees to promote venous return from the brain and reduce sudden changes in intracranial
pressure
Seizure precautions (eg, padded bed rails, oxygen and suction equipment at bedside) should be maintained for a
client with meningitis. The client may require suction after a seizure has occurred, but nothing should be inserted into
the client's mouth during a seizure, including a padded tongue blade, due to the risk of damaging the teeth or oral
mucosa.
URINARY TRACT INFECTIONS

Urinary tract infections (UTIs) are usually bacterial in origin and are most often caused by Escherichia coli. The
microorganisms from the perineal area enter the urethra, causing inflammation and infection (urethritis). They ascend
to the bladder, where they multiply, causing inflammation and infection (cystitis). The bacteria may continue to ascend
the urinary tract to the ureters and kidneys, causing inflammation and infection in the kidneys (pyelonephritis).
A UTI is classified as upper or lower according to its location within the urinary tract.
Cystitis is the most common community-acquired UTI. It is an infection of the lower urinary tract and involves
inflammation of the bladder mucosa, leading to hyperemia, tissue hemorrhage, and pus formation. This inflammatory
process leads to burning with urination (dysuria), urinary frequency and urgency, hematuria, and suprapubic
discomfort
 When the infection ascends to the kidneys (pyelonephritis), clients become very ill. They develop nausea, vomiting,
fever with chills, and flank pain. Assessment shows costovertebral angle tenderness. If the infection is not recognized
and treated, clients can become septic.

HIV
Human immunodeficiency virus (HIV) is a viral infection of the CD4+ (helper T) cells, resulting in progressive
immune system impairment. Clients with HIV are susceptible to opportunistic infections that typically occur during
periods of low CD4+ counts.
To reduce the risk of infection, nurses should educate clients with HIV to:
o Obtain and remain up to date on vaccinations, including the annual influenza vaccination
o Avoid eating undercooked meats (eg, steak that is pink) and having contact with cat feces (eg, cat litter box) because both
are sources of Toxoplasma gondii, an opportunistic parasite that causes encephalitis
o Avoid drinking water from poorly sanitized (eg, developing countries) or potentially contaminated (eg, rivers, wells) sources
because it may contain infectious pathogens (eg, Cryptosporidium, Isospora, Giardia). Instead, use bottled or purified
water when drinking and brushing teeth
Educate clients with HIV to always use synthetic barriers (eg, condoms) during sex to reduce the risk of transmitting
HIV and being infected with additional HIV strains or other sexually transmitted infections. Clients with an
undetectable viral load have a lower risk of transmitting HIV to a sexual partner but should still use barrier
contraception.
Human immunodeficiency virus (HIV) is a viral infection of the CD4+ (helper T) cells, resulting in progressive
immune system impairment. When educating clients with HIV, the nurse should discuss health promotion and
infection transmission prevention strategies, particularly safe sex practices.
Unprotected sex increases the risk of transmitting HIV and other sexually transmitted infections (STIs). Protected
sex is important even with HIV-positive partners as HIV has multiple strains and coinfection results in HIV
superinfection, which may hasten progression to AIDS (Option 1).
Clients with HIV should use latex or synthetic condoms and/or dental dams during sexual activity involving mucous
membrane exposure (ie, oral, vaginal, anal) to semen or vaginal secretions. Natural barriers (eg, lambskin) do not
prevent transmission of STIs due to the presence of small pores
 Sharing personal hygiene devices that may have been exposed to blood (eg, toothbrushes, razors) increases HIV
transmission risk and should be avoided.
Immunosuppressed clients should be educated to avoid raw or undercooked foods (eg, eggs, meats, seafood) to avoid
foodborne illnesses.
To prevent transmission of HIV, hepatitis B virus, and other bloodborne diseases, IV drug users should be taught to
avoid reusing or sharing needles or syringes.

GENITAL HERPES
Acyclovir (Zovirax), famciclovir, and valacyclovir are commonly used to treat herpes infection as they shorten the
duration and severity of active lesions.
Genital herpes is a sexually transmitted infection caused by a herpes simplex virus and is highly contagious,
especially when lesions are active. It remains dormant in the body even when active lesions are healed. There is no
cure for genital herpes; treatment is aimed at relieving symptoms and preventing the spread of infection. Touching the
lesions and then rubbing or scratching another part of the body can spread the infection. Therefore, gloves should be
used when applying topical antiviral or analgesic (eg, lidocaine) medications.
Herpetic lesions should be kept clean and dry. They can be cleansed with warm water and soap or other solutions.
Bandages are not applied to the lesions.
There is no cure for herpes infection. Genital herpes often leads to local recurrence. Some clients may need long-
term suppressive therapy.
During periods of active lesions, abstinence from sexual intercourse is indicated. Condoms should be used during
periods of dormancy due to viral shedding.

POST-OPERATIVE INFECTIONS
Some potential postoperative infections include:
 o Pneumonia can occur when atelectasis (alveolar collapse) prevents clearing of secretions, promoting bacterial growth.
Symptoms include cough with or without sputum, tachypnea, and shortness of breath. Postoperative incentive spirometry,
ambulation, and cough/deep breathing exercises help keep alveoli open and prevent pneumonia
o Surgical site infections present with localized redness, warmth, swelling, and purulent drainage. Proper wound care and
sterile dressing changes help prevent infection
o Urinary tract infections (UTIs), caused by the use of indwelling urinary catheters during surgery, can present with frequency,
urgency, and dysuria. Prompt removal of catheters after surgery helps prevent UTIs.
o Peritonitis (peritoneal infection) presents with rebound tenderness, boardlike abdominal rigidity, and shallow breathing
related to abdominal distension. Peritonitis may lead to sepsis and death if untreated
Clients recovering from laparoscopic surgery may experience referred left shoulder pain during the first few
postoperative days. This is due to diaphragmatic nerve irritation caused by the carbon dioxide used to inflate the
abdomen during laparoscopic surgery.

CLOSTRIDIUM DIFFICILE

Clostridium difficile overgrowth in the intestine often occurs when normal gastrointestinal (GI) flora is destroyed (eg,
antibiotic use).
Clients with C difficile often have watery diarrhea, nausea, fever, and abdominal pain. Hypovolemia can easily
develop through the loss of fluids and electrolytes in the stool, especially in infants and the elderly.
Clients with hypovolemia from GI losses will often have hyponatremia, hypokalemia, and elevated blood urea
nitrogen (BUN) (poor renal perfusion). This client has hyponatremia (normal, 135-145 mEq/L [135-145 mmol/L]),
hypokalemia (normal, 3.5-5.0 mEq/L [3.5-5.0 mmol/L]), and an elevated BUN (normal, 6-20 mg/dL [2.1-7.1 mmol/L]).
Hypovolemia can cause hypotension and renal failure, and electrolyte abnormalities can cause cardiac arrhythmias;
therefore, these are priority to report. Fluid resuscitation and electrolyte replacement should be initiated promptly to
prevent complications.

OROPHARYNGEAL CANDIDIASIS
 Oropharyngeal candidiasis, or thrush (moniliasis), is an infection of the mucous membranes generally caused by the
yeastlike fungus Candida albicans. The fungus causes pearly, "milk-curd" lesions on the oral or laryngeal mucosa that
may bleed when removed.
Immunosuppressed individuals such as those taking corticosteroid medications, clients undergoing chemotherapy
or radiation, or clients with immune deficiency states (eg, AIDS) have an increased incidence. Clients receiving
prolonged or high-dose antibiotic treatment are at increased risk as the normal microbial flora of the mouth is
reduced, allowing other opportunistic infections to arise. Individuals with dentures and infants also commonly
experience monilial infections. Treatment is antifungal medications (eg, nystatin) and proper oral hygiene.
Inhaled beta-2 agonists (eg, albuterol) do not increase the risk for fungal infections. However, individuals taking an
inhaled corticosteroid (eg, budesonide, fluticasone) are at increased risk for oral candidiasis. To reduce this risk, the
client should rinse the mouth after each inhaled dose and maintain good oral hygiene.
Proper oral hygiene and nutrition are important in prevention of oral candidiasis. However, the client with braces or
poor hygiene and inadequate nutrition is at lower risk than one who is immunosuppressed or taking antibiotics.

NURSING DIAGNOSIS FOR TB

Knowledge deficit is the lack of adequate information required for health recovery, maintenance, and promotion. The
priority ND is knowledge deficit of the prescribed therapeutic regimen manifested by the client's verbalization
of nonadherence to the prescribed MDR-TB therapy.
Medication to treat MDR-TB usually must be taken for 6 to 9 months. The length of the treatment regiment, the cost
and amount of medications that must be taken, and the unpleasant side effects all contribute to clients
becoming nonadherent with treatment. If clients do not properly complete the entire medication regimen, they
risk reactivating the MDR-TB disease, increasing the bacteria's drug-resistance, and spreading the disease to
others. The medications cannot be discontinued until therapy is complete.
Activity intolerance is an insufficient physiological or psychological energy to complete daily activities. In this client, it
is related to side effects of the medications and a deconditioned state and is manifested as fatigue or weakness. This
is appropriate to include in the care plan but is not the priority ND.
Imbalanced nutrition, less than body requirements, is an insufficient intake of nutrients to meet metabolic needs. In
this client, it is related to inability to ingest foods secondary to nausea, fatigue, and anorexia and is manifested by
 inadequate caloric intake and a loss of appetite. This is appropriate to include in the care plan but is not the priority
ND.
In this client, nausea is related to medication side effects and is suggested by a verbal report of nausea and loss of
appetite. It is appropriate to include this in the care plan but is not the priority ND.

INFECTIVE ENDOCARDITIS
Clients with IE usually have fever for several days during the initial stages of antibiotic therapy. By the time they are
discharged, fever subsides or becomes occasional and low-grade. The nurse should teach the client to
monitor temperature regularly at home. Persistent temperature elevations may mean that the antibiotic therapy
is ineffective or complications have developed. The client should notify the HCP if a fever persists at home.
A client who has had IE is at risk for reoccurrence. This client should receive prophylactic antibiotics for certain high-
risk procedures (eg, manipulation of gingival tissue).
IE causes the formation of vegetations on valve and endocardial surfaces. Embolization to various organ sites can
occur. Slurred speech could indicate that embolization has caused a possible stroke.
IE can require IV antibiotics for up to 4-6 weeks. The client may be discharged home once hemodynamically stable,
and a home health nurse will come to administer the antibiotics through the client's PICC line.

LYME DISEASE

Lyme disease develops after a bite from a deer tick infected with Borrelia burgdorferi.
Clients initially develop flulike symptoms (eg, headache, fever, myalgia, fatigue).
Many clients develop erythema migrans, a bull's-eye rash; however, it is not always present. Any of these symptoms
should be reported immediately to a health care provider.
The client will likely be prescribed antibiotics (eg, doxycycline, amoxicillin) to treat Lyme disease and prevent it from
causing complications (eg, carditis, chronic arthritis, meningitis, facial paralysis).
To prevent tick bites during outdoor activities, clients should:
o Apply an insect repellent spray that contains tick-repelling ingredients (eg, DEET, picaridin)
o Avoid tall grass and thick underbrush, and hike only in the center of the trails
o Wear long-sleeved shirts tucked into pants, long pants tucked into socks or boots, and closed-toed shoes
 Covering attached ticks with petroleum jelly or nail polish is a folk remedy that actually increases the chance of
infection by keeping the tick on the skin. Ticks should be promptly removed using tweezers, being careful to grasp the
tick close to the attachment site and not crush it during removal.
VANCOMYCIN TREATMENT FOR MRSA

CASE: The nurse prepares to administer IV

vancomycin to an 80-year-old client with a
methicillin-resistant Staphylococcus
aureus infection. The nurse should notify the
health care provider about which serum
laboratory results before administering the
drug?

BUN 60MG/DL
CREA 2.1

Vancomycin is a glycopeptide antibiotic that is excreted by the kidneys. It is used to treat serious infections with
gram-positive microorganisms (Staphylococcus aureus [methicillin-resistant Staphylococcus aureus]) and diarrhea
associated with Clostridium difficile.
Serum vancomycin trough level is monitored before the 4th dose (15-20 mg/L [10.4-13.8 µmol/L] is optimal).
Blood urea nitrogen (BUN) and creatinine levels are monitored regularly (usually 2-3 times/week) in clients
receiving the drug due to increased risk of nephrotoxicity, especially in those with impaired renal function, receiving
aminoglycosides, and who are >60 years old. The health care provider (HCP) can lower the dose, decrease the drug
administration frequency, or discontinue vancomycin. It is important to know the baseline values of BUN and
creatinine to monitor trending and identify if there is an increase.
Before administering this drug, the nurse should notify the HCP that the client's BUN (60 mg/dL [21.4 mmol/L]) and
creatinine (2.1 mg/dL [185.6 µmol/L]) are both increased. The normal range for BUN is 6-20 mg/dL (2.1-7.1 mmol/L)
and creatinine is 0.6-1.3 mg/dL (53-115 µmol/L).

HERPES ZOSTER
 Herpes zoster, or shingles, has a characteristic unilateral, linear pattern of fluid-filled blisters.
Affected clients commonly report pain and itching. Herpes zoster infection is due to the varicella-zoster virus (VZV),
which also causes chickenpox. After initial VZV infection (chickenpox) in early childhood, the virus remains dormant
in the sensory nerves. Reactivation of VZV when the immune system is compromised (eg, aging,
immunosuppression) results in the formation of lesions along the distribution of one or more such nerves (dermatomal
distribution). Vaccination can prevent shingles.
If this rash is determined to be due to shingles, the affected area should be covered to prevent the spread of infection.
Therefore, it is a priority to ask if this client has had chickenpox.
This client's linear rash has a dermatomal distribution that is characteristic of herpes zoster. These questions should
be addressed, but assessing a history of chickenpox is the priority.
HEPATITIS A
The transmission of hepatitis A occurs most commonly through the fecal-oral route through poor hand hygiene and
improper food handling by infected persons. It is seen primarily in developing countries. After infection, the hepatitis A
virus reproduces in the liver and is secreted in bile. Therefore, hand hygiene (especially after toileting and before
meals) is the most important intervention to reduce the occurrence of hepatitis A infection
Vaccination against hepatitis A is recommended for all children at age 1 and for adults at risk of contracting the virus
(health care workers, men who have sex with men, drug users, those who travel to areas with a high prevalence, those
with clotting disorders, and those with liver disease).
Hepatitis A is secreted in bile and is more often transmitted via the fecal-oral route. However, the virus can also be
spread through needle sharing between intravenous drug users and unsafe sexual practices. These practices should
be discouraged and hand hygiene encouraged as the most important intervention for prevention.
Vaccination is an important means of preventing infection. However, hygienic measures (eg, hand washing,
sanitation, cleanliness, avoiding sharing personal items) are readily implemented by all clients regardless of means.

INTEGUMENTARY
SKIN CANCER
Skin cancers are most often caused by damage to the skin's DNA. This damage is typically due to exposure
to ultraviolet (UV) radiation, primarily from the sun but also from other sources (eg, tanning beds, sunlamps).
The instructions to prevent sunburn and other sun-related damage include:

o Avoid the sun, if possible, especially between 10 AM and 4 PM. UV rays are not blocked by cloud coverage and can be
reflected off water, sand, snow, and concrete. As a result, clients can burn in the shade or even during outdoor winter
activities (eg, skiing)
o Wear protective clothing (eg, long sleeves, wide-brimmed hats, umbrellas) when possible.
o Apply sunscreen:

Use a broad-spectrum sunscreen to block both UVA and UVB rays.

SPF 30 for outdoor activities and sun-sensitive individuals.
Sunscreen should be applied 15-30 minutes prior to sun exposure to allow the formation of a protective film on the
skin. Regardless of the type of sunscreen used, it should be reapplied at least every 2 hours, or more often if
possible
Because sunscreen is washed off with swimming and sweating, it should be reapplied, even for products labeled
"water-resistant" or "very water-resistant"

o Avoid the use of tanning beds as they emit UV radiation

Skin cancers are most often linked to damage of skin cells' DNA by overexposure to ultraviolet radiation (eg,
sunlight, tanning beds). The three most common types of skin cancer are squamous cell carcinoma, basal cell
carcinoma, and melanoma. Melanomas grow rapidly and are highly metastatic, making them the deadliest form of
skin cancer. Basal cell and squamous cell carcinomas generally have a much lower risk of metastasis.
Risk factors for skin cancer include:
o Family or personal history of skin cancer
o Celtic ancestry traits (eg, light skin, red or blond hair, blue or green eyes, many freckles)
o Aging
o Atypical or high number of moles because some skin cancers develop from pre-existing moles
o Immunosuppression (eg, immunosuppressant medications, HIV), which lowers the body's ability to defend against
cancerous mutations
o Ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation, tanning bed use, history of severe sunburns)
 Clients should be taught to avoid overexposure to sunlight, perform monthly skin checks with the ABCDE assessment,
and immediately report any abnormal findings to their health care provider. Early detection and treatment significantly
improve outcomes.

PARKLAND FORMULA

CASE: The nurse admits an adult client with

partial-thickness burns to the anterior surface
of the right leg and the anterior and posterior
torso. The client weighs 198 lb. The total
body surface area burned is calculated using
the rule of nines. How many mL of IV fluid
will the client require in the first 24 hours?
 The Parkland formula is an IV fluid resuscitation protocol used to calculate the fluid replacement needed in the first
24 hours after a burn injury. Half of the calculated fluid volume is administered during the first 8 hours after the injury,
when many clients have the greatest amount of intravascular volume loss. Use the following steps to calculate the
volume needed for infusion:

1. Calculate the total body surface area (TBSA) burned using the rule of nines

(anterior torso)+(posterior torso)+(anterior leg)=TBSA burnedanterior torso+posterior torso+anterior leg=TBSA burned

OR

18%+18%+9%=45% TBSA burned18%+18%+9%=45% TBSA burned

 2. Convert pounds to kilograms to determine body weight

(1 kg2.2 lb)(198 lb )=90 kg1 kg2.2 lb198 lb =90 kg

3. Calculate the volume needed for infusion

4 mL × body weight (kg)×TBSA burned (%)=infusion volume (mL)4 mL × body weight kg×TBSA burned %=infusion
volume mL
OR

4 mL × 90 kg × 45% TBSA = 16200 mL

CASE: The nurse is calculating IV fluid

resuscitation for a client weighing 85 kg with
visible partial-thickness burns covering 40%
of the body. Using the Parkland formula,
how many liters of IV fluid resuscitation are
needed during the first 8 hours?

1. Calculate the total volume needed for infusion for 24 hours

4 mL×weight (kg)×TBSA burned=total infusion volume4 mL×weight kg×TBSA burned=total infusion volume
OR

4 mL×85 kg×40% TBSA=13,600 mL4 mL×85 kg×40% TBSA=13,600 mL

2. Calculate the volume needed for infusion during the first 8 hours

24-hr infusion volume2 =8 hour infusion volume24-hr infusion volume2 =8 hour infusion volume
OR

13,600 mL2=6800 mL13,600 mL2=6800 mL

3. Convert milliliters to liters

(6800 mL1)(L1000 mL)=6.8 L

POISON IVY

Poison ivy can cause a contact dermatitis rash in those who are sensitive to the oily resin found on the leaves,
stems, and roots of the plant.
About 50% of people who come in contact with the plant develop a rash.
It is often linear in appearance where the plant brushed against the skin.
The rash develops 12-48 hours after exposure and can last for several weeks.
The severity of the rash depends on the amount of resin on the skin.
It is most important to first thoroughly wash the area to remove the resin and prevent its spread to other areas of
the body.
Applying cool, wet compresses; applying topical cortisone; and discouraging the child from scratching the area are all
appropriate after the rash has developed.
Washing the area has the highest priority and is most important immediately after exposure.

PSORIASIS

Psoriasis is a chronic autoimmune disease that causes a rapid turnover of epidermal cells.
Characteristic silver plaques on reddened skin may be found bilaterally on the elbows, knees, scalp, lower back,
and/or buttocks.
The goal of therapy is to slow epidermal turnover, heal lesions, and control exacerbations.
There is no cure for psoriasis; disease management includes avoidance of triggers (eg, stress, trauma,
infection), topical therapy (eg, corticosteroids, moisturizers), phototherapy (eg, ultraviolet light), and systemic
medications, including cytotoxic (eg, methotrexate) and biologic (eg, infliximab) agents
 The client should avoid alcohol as it can worsen psoriasis.
In addition, the liver, kidneys, and bone marrow are specifically affected by the systemic medications commonly used
to control psoriasis.
Exposure to ultraviolet light (eg, phototherapy, sunlight) can help slow epidermal turnover and decrease
exacerbations; however, there is a greater long-term risk of skin cancer. Therefore, frequent skin examinations by a
health care provider are important.

BURN INJURY

Immediate care of minor burn injuries involves removal of clothing and debris from the affected area, cooling and
cleansing of the wound, and pain management. Minor burn injuries can be treated on an outpatient basis with wound
care and dressing changes. Major burn injuries require hospitalization and emergency interventions (eg, airway
management, fluid resuscitation).
First-degree (superficial) burns are dry with blanchable redness. They usually damage the epidermis only.
Second-degree (partial-thickness) burns appear as moist or weeping wounds with blisters and shiny, fluid-filled
vesicles, and clients have moderate to severe pain. Both the epidermis and dermis are damaged.
Third-degree (full-thickness) burns are dry and inelastic with waxy white, leathery, or charred black color. They
destroy the dermis and may involve subcutaneous tissue.
Fourth-degree (full-thickness) burns have the same appearance as third-degree burns, with additional involvement of
fascia, muscle, and/or bone tissue. Due to nerve damage, pain is not the major feature, unlike with second-degree
burns.
After a burn injury, increased capillary permeability leads to third spacing (fluid shifts to areas where normally
minimal or absent), allowing proteins, plasma, and electrolytes to leave the vascular space and occupy other spaces
and tissues.
This creates a state of hypovolemic shock, which poses the highest risk of mortality in the initial phase of the burn
process.
Therefore, aggressive fluid resuscitation to correct hypovolemia is a priority. Adequate urine output (at least 30
mL/hr, or 0.5 mL/kg/hr) depends on adequate renal perfusion and is the greatest indicator that fluid resuscitation
therapy has effectively restored tissue perfusion.

<120/min) indicate client improvement, urine output is the greatest indicator of adequate fluid resuscitation.
A decrease in serum potassium from 5.7 mEq/L to 5.0 mEq/L (5.7 mmol/L to 5.0 mmol/L) indicates that hyperkalemia
is resolving but is not an indicator of tissue perfusion.
Rapid increase in weight indicates that fluid shifts continue to occur and the kidneys are not eliminating properly. This
could be a sign of fluid overload.
The rehabilitation phase begins after the client's wounds have fully healed and lasts about 12 months. The
initiation of this phase depends on the extent of the burns and the client's ability to care for themselves.
Interventions in the rehabilitation phase are aimed at improving mobility and independence and minimizing the
potential for long-term complications. These interventions include:

o Counseling or other psychosocial support

o Gentle massage with water-based lotion to alleviate itching and minimize scarring
o Planning for reconstructive surgery
o Pressure garments to prevent hypertrophic scars and promote circulation
o Range-of-motion exercises to prevent contractures
o Sunscreen and protective clothing to prevent sunburns and hyperpigmentation

Daily application of water-based lotion is necessary to minimize scar formation and alleviate itching. Infection is not
likely as the rehabilitation phase begins after the wounds are fully healed.

The greatest immediate threat to a client with severe and extensive burn injuries is hypovolemic shock and
electrolyte imbalance. This is due to cellular damage and increased capillary permeability caused by direct thermal
trauma, which result in fluid loss. In the emergent phase of burn management, it is critical to establish an airway and
replenish lost intravascular fluid, proteins, and electrolytes.
Lactated Ringer's (LR), also known as Ringer's lactate, is the solution of choice for fluid resuscitation of a burned
client due to its similarity in chemical composition to human plasma. LR remains in the intravascular space longer
than other solutions, which helps to stabilize blood pressure and avert shock.
Hypotonic solutions (eg, 0.45% normal saline) quickly leave the intravascular space and are not useful in replacing
intravascular volume. They may also contribute to peripheral and interstitial edema, which can lead to pulmonary
complications.
Hypertonic solutions (eg, 5% dextrose in 0.9% normal saline [D5NS], 3% saline) can cause further electrolyte
imbalances in a client with severe burns, resulting in hypernatremia, hyperchloremia, and arrhythmias.
Although technically an isotonic solution, 5% dextrose in water (D5W) behaves as a hypotonic solution when
dextrose is metabolized by the body and free water is released to the tissues rather than remaining in the intravascular
space.
Burn injuries cause tissue damage that leads to increased vascular permeability and fluid shifts (eg, second and third
spacing). In the emergent phase after a burn (first 24-72 hours), fluid, proteins, and intravascular components leak
into the surrounding interstitium, causing decreased intravascular oncotic pressure and decreased intravascular
volume, and resulting in fluid shifts and hypovolemia.
Potassium, the predominant intracellular cation, is released when cellular damage occurs, resulting
in hyperkalemia (potassium >5.0 mEq [5.0 mmol/L]). Clients with hyperkalemia experience muscle weakness, ECG
changes (tall, peaked T waves, shortened QT interval), and cardiac arrhythmias
Hematocrit and hemoglobin values will be elevated due to hypovolemia (hemoconcentration).
The sympathetic nervous system is activated in response to a burn, causing decreased peristalsis. Nausea, vomiting,
gastric distension, and paralytic ileus may occur.
Sodium is the most abundant extracellular cation. Hyponatremia (sodium <135 mEq/L [135 mmol/L]) occurs as
sodium is lost via fluid shifts and insensible losses.

The nurse should consider Maslow's Hierarchy of Needs to determine the importance of various interventions. This
client in the acute phase of burn management continues to have increased physiological needs. Clients with burns
have increased metabolism and calorie requirements that must be met for healing to occur.
The nutrition needed for healing increases proportionally with the percentage of burned tissue. Therefore, providing
proper nutrition as soon as possible is the highest priority
Although it is important to promote activities of daily living, physiological needs such as nutrition are priorities.
Psychological and spiritual needs are important but do not take precedence over the client's physiological needs.
Physiological needs include direct care for the burned area, infection prevention, and giving the client prescribed
medications for healing. Education of the family comes after meeting any type of physiological need.

Circulatory compromise is common after sustaining a burn, as extensive tissue injury combined with the systemic
inflammatory response causes increased capillary permeability, fluid and electrolyte shifts, and decreased
 intravascular volume. These intravascular losses begin rapidly after a burn and may lead to hypovolemic shock and
death. Therefore, the nurse should prioritize initiation of fluid resuscitation
Although full-thickness burns destroy nerves and may be painless, clients with burns often have severe pain.
However, pain is not life-threatening and may be treated after restoration of ABCs.
Burn injuries impair immune system function and skin integrity, increasing the risk for infection. Prevention of infection
with topical antimicrobials (eg, bacitracin, silver sulfadiazine) is important. However, restoration of ABCs is the priority.
An escharotomy is a surgery involving incisions made through eschar (burned tissue) and is performed to prevent
tissue ischemia and necrosis from impaired circulation. However, stabilizing circulatory status is the priority.
In clients with severe burns, medications are best administered through the intravenous route given the possibility of
reduced absorption from other routes (subcutaneous, intramuscular, oral).

WOUND DEHISCENCE AND EVISCERATION

Total separation of wound layers with protrusion of the internal viscera through the incision is known as evisceration.
Evisceration is a medical emergency that can lead to localized ischemia, peritonitis, and shock.
Emergency surgical repair is necessary.
Clients at risk for poor wound healing (eg, obesity, diabetes mellitus) are at increased risk for evisceration.
When an abdominal wound evisceration occurs, the nurse should take the following actions:

o Remain calm and stay with the client. Have someone notify the HCP immediately and bring sterile supplies. Instruct the
client not to cough or strain.
o Place the client in low Fowler's position (no more than 20 degrees) with knees slightly flexed to relieve pressure on the
abdominal incision and have the client maintain absolute bed rest to prevent tissue injury.
o Assess vital signs (and repeat every 15 minutes) to detect possible signs and symptoms of shock (eg, hypotension,
tachycardia, tachypnea).
o Cover the viscera with sterile dressings saturated in NS solution to prevent bacterial invasion and keep the exposed
viscera from drying out.
o Document interventions taken and the appearance of the wound and eviscerated organ (eg, color, drainage). If the blood
supply is interrupted, the protruding organs can become ischemic (dusky) and necrotic (black).
 This client should immediately be made NPO in preparation for possible emergency surgery. Only IV analgesics
should be administered if the client is in pain.

TOXIC EPIDERMAL NECROLYSIS

Toxic epidermal necrolysis is an acute skin disorder, most commonly associated with a medication reaction that results
in widespread erythema, blistering, epidermal shedding, keratoconjunctivitis, and skin erosion (ie, denuded skin). It
is a severe form of Stevens-Johnson syndrome. The major cause of death related to toxic epidermal necrolysis
is sepsis; therefore, infection prevention is critical.
Basic supportive care includes:

o Wound care: Sterile, moist dressings are applied to open areas of skin
o Infection prevention: Strict sterile technique and reverse isolation decrease infection risk. The nurse should also monitor for
any signs of infection (eg, fever)
o Fluids and nutrition: Vital signs and urine output are monitored for signs of hypovolemia. Oral feeding should be initiated
early to promote wound healing; a nasogastric tube may be necessary.
o Hypothermia prevention: Maintain a room temperature of 85 F (29.4 C) or more, and use passive rewarming methods such
as sterile, single-use warming blankets or digitally regulated warming pads
o Pain management: Analgesics are administered around the clock and before painful procedures.
o Eye care: Sterile, cool compresses are applied to relieve discomfort. Lubricants may relieve dryness and prevent corneal
abrasion

Massage is inappropriate due to cutaneous tenderness and epidermal shedding.

SUNBURN

Sunburn is a painful inflammatory skin reaction resulting from overexposure to ultraviolet radiation (eg,
natural sunlight, tanning beds). Sunburns may be classified as superficial (ie, red, painful) or partial-thickness (ie,
blistering, weeping) burns.
Severe sunburns may cause systemic symptoms such as fever, chills, nausea, and headache.
Sunburns increase insensible fluid loss and place the client at an increased risk for dehydration.
Sunburn prevention is important because sunburn may cause permanent skin damage and increases the risk of skin
cancers. However, when minor sunburns occur, symptom management includes:
 o Protecting the burned area from further sun exposure (eg, avoid going outside during midday when the sun's rays are
hottest)
o Promoting increased fluid intake to avoid dehydration
o Providing pain relief with over-the-counter analgesics such as ibuprofen or acetaminophen
o Reducing inflammation and pain by taking tepid baths; using cool compresses; and applying soothing, protective
lotions or gels (eg, aloe vera, calamine) to the sunburned area

Corticosteroid creams (eg, hydrocortisone) have not been shown to reduce symptom severity or healing times. Some
preparations can be drying to the skin, which may exacerbate symptoms of sunburn.

PRESSURE INJURY
 Pressure injuries are staged from 1 to 4 to classify the degree of tissue damage and determine the most effective
wound treatment.
Unstageable pressure injuries have full-thickness skin loss with slough and/or eschar, which prevents visualization
of the wound base.
Slough in a wound base appears as yellow or tan stringy tissue; eschar is dried, black or brown necrotic tissue. The
wound cannot be staged until slough and eschar are debrided by a wound care nurse or health care provider and the
base can be visualized
Stage 2 pressure injuries present as shallow, open wounds with partial-thickness skin loss of the dermis. The wound
bed is red or pink, and may be shiny or dry.
Stage 3 pressure injuries have full-thickness skin loss. Subcutaneous fat may be observed; however, underlying
tendon, muscle, or bone is not visible. The wound bed may tunnel or extend under the edge of surrounding skin, as a
lip or pocket (undermining).
A deep-tissue injury presents as an area of dark purple or maroon discolored, intact skin, which is caused by a
pressure or shearing injury to underlying tissue.

TINEA CORPORIS
Tinea corporis (ringworm) is a fungal infection of the skin often transmitted from one person to another or from an
infected animal to a human.
It appears as a scaly, pruritic patch that is often circular or oval in shape.
It is highly contagious and can be spread via items such as grooming tools, hats, towels, and bedding.
Tinea corporis often spreads via shared athletic equipment or in athletic locker rooms due to the proximity of infected
gear.
This condition is treated with topical antifungals (eg, tolnaftate, haloprogin, miconazole, clotrimazole).

MALIGNANT SKIN NEOPLASM

The examination for skin cancer follows the ABCDE rule:

1. Asymmetry (eg, one half unlike the other)

2. Border irregularity (eg, edges are notched or irregular)
3. Color changes and variation (eg, different brown or black pigmentation)
4. Diameter of 6 mm or larger (about the size of a pencil eraser)
5. Evolving (eg, appearance is changing in shape, size, color)

Normal variations in skin will blanch with manual pressure. Failure to blanch is typically an indication that there is
blood beneath the skin, as in petechiae and/or purpura.
Pus or purulent drainage is usually indicative of an infectious process, not cancer.
Client education on early detection of skin cancer is important as most cases of malignant melanoma are discovered
by the client. A full medical workup of every mole is unnecessary. Routine self-evaluation followed by medical
assessment of questionable growths is sufficient. Clients with advanced age or reduced mobility may need to see a
dermatologist for a full-body skin survey.
Rapid changes in a mole should be evaluated immediately.
Amelanotic melanomas are pink growths similar to basal cell carcinomas of the skin. Blue, white, and red colorations
can occur in melanoma.
Malignant expansions of previous growths (moles, nevi) are common.
 MUSCULOSKELETAL
BUCK TRACTION

Buck traction is a type of skin traction used to immobilize hip fractures and reduce pain and spasm until the client
can undergo surgical repair of the fracture. A traction boot is applied to the leg, below the fracture site.
A weight gently and continuously pulls on the leg and hip, helping maintain alignment of the limb. The nurse should
ensure that the traction boot is fitted properly and that the limb remains straight in a neutral position
Skin traction exerts pressure on nerves, blood vessels, and soft tissue. The nurse should frequently assess
neurovascular status (eg, pulse, capillary refill, color, temperature, sensation, movement) and skin integrity in the
limb to which the boot is applied. Overall pain level and efficacy of administered pain medications should be
monitored closely, as increasing pain in the limb in traction may indicate neurovascular compromise
Side-to-side repositioning of the client in Buck traction can cause injury. Side-to-side position changes cause the
affected leg to be adducted or abducted, which, when paired with the force of traction, can increase spasm and pain
and contribute to neurovascular and orthopedic compromise.
Buck's skin traction maintains proper alignment of an injured body part by using weights to apply a continuous pulling
force.
Appropriate actions for a client in Buck's skin traction include:
 o The client should be supine or in semi-Fowler's position (maximum of 20-30 degrees). Elevating the head of the bed more
than 30 degrees would promote sliding
o Regularly assess the neurovascular status and skin integrity of the limb in traction. Loosen Velcro straps if the boot is too
tight as they can impair neurovascular status and skin integrity; tighten the straps if the boot is too loose as this can decrease
effectiveness of the traction. When a change is made in the application of the boot or traction pulley system, the nurse
should reassess neurovascular status in 30 minutes
o Provide a fracture pan, which is smaller than a bedpan, for elimination needs to minimize client movement and provide
comfort
o Weights should be free-hanging at all times and should never be placed onto the bed or touch the floor. A staff member
should support the weight while the client is repositioned up in bed to prevent excessive pull on the extremity

Skeletal traction is applied directly to the bone with a metal wire or pin and is used to immobilize, position, or align a fracture
when continuous traction is needed and skin traction is not possible. Removing the weights can cause injury to the client and
should never be removed unless there is a life-threatening situation.

SCOLIOSIS

The Boston brace, Wilmington brace, thoracolumbosacral orthosis (TLSO) brace, and Milwaukee brace are used
to diminish the progression of deformed spinal curves in scoliosis.
Braces do not cure the existing spinal deformities but do prevent further worsening. These braces are also
sometimes used for clients who undergo spinal fusion.
The braces are molded plastic shells worn around the trunk of the body under the client's outer clothing. Due to the
risk for skin breakdown, clients should wear a cotton t-shirt under the brace to decrease skin irritation and absorb
sweat.
Compliance is a major problem in most adolescents as they are preoccupied with body image and appearance.
Psychosocial issues (eg, body image, sense of control, socialization) are very important to discuss. Many clients may
find it helpful to meet other individuals their age who also wear the braces.
The use of lotion or powder can cause skin irritation due to heat buildup beneath the brace.
It is important to build and maintain strength in the spinal muscles to promote stabilization throughout treatment. Most
prescribed bracing courses allow brace removal for such exercises.
The exact course of bracing treatment varies based on the type of brace and severity of spinal curvature. Most braces
are worn for 18-23 hours per day and removed for bathing and exercise.
 Clients should never shower while wearing a hard brace as padding will absorb moisture and promote skin breakdown.

OSTEOPOROSIS

The primary treatment goal for elderly clients with osteoporosis is to prevent bone fracture, especially hip fracture.
Teaching to increase bone mineral density and prevent bone loss (resorption) includes:

o Bisphosphonate medication (eg, alendronate [Fosamax], risedronate [Actonel], zoledronic [Reclast])

o Calcium and Vitamin D supplementation
o Smoking cessation and alcohol avoidance, as these increase bone resorption and contribute to falls
o Weight-bearing exercise
increasing mechanical stress on bone increases bone density

Interventions to prevent falls and resulting hip fracture include:

o Maintain bed in low and locked position

o Ensure that call light and personal belongings are within reach
o Orient client and ensure use of non-skid footwear, eyeglasses and hearing aids, and assist devices if needed
o Keep environment well-lit and free of clutter

A client should not be placed on bed rest solely for the prevention of falls. Immobilization actually increases fracture
risk due to bone resorption, a condition called disuse osteoporosis. The nurse should encourage and assist with
mobility and weight-bearing exercises to prevent muscle atrophy and bone resorption.
The client may actually incur more injury from a fall if trying to climb over side rails to get out of bed. The nurse should
utilize bed alarms if the client is prone to getting out of bed without assistance.
TOTAL JOINT REPLACEMENT SURGERY

A recent/current infection is a contraindication to total joint replacement surgery as a wound infection is more
likely to occur in a client with a preexisting infection. The nurse should report the new onset of burning on urination to
the HCP. Burning could indicate the presence of a urinary tract infection.
Allergy to strawberries is not a contraindication to the scheduled surgery. However, a latex allergy should be
documented.
Severe knee pain is expected in a client undergoing a total knee replacement.
Clients are directed to stop taking nonsteroidal anti-inflammatory drugs, including selective COX-2 inhibitors (eg,
celecoxib [Celebrex]), 7 days before surgery to decrease the risk of intra- and postoperative bleeding.

A Colles' fracture is a type of wrist fracture (distal radius fracture) that causes a characteristic dinner fork deformity of
the wrist. It usually occurs when the client tries to break a fall with an outstretched arm or hand, and lands on the
heel of the hand. It is one of the most common fractures in women age >50 and is related to osteopenia or
osteoporosis.
While the client is undergoing evaluation by the health care provider (HCP) in the emergency department (ED),
nursing interventions should include:

o Performing a neurovascular assessment (eg, pulse, temperature, color, capillary refill, sensation, movement). This is
the priority nursing action as neurovascular insufficiency related to swelling (eg, compartment syndrome) or arterial/nerve
damage by the bone fragments is associated with a Colles' fracture. If neurovascular status is compromised, urgent
reduction of the fracture is indicated.
o Administering analgesia to promote comfort
o Applying an ice pack to the wrist to help reduce edema and inflammation
o Elevating the extremity on a pillow above heart level to reduce edema
o Instructing the client to move the fingers to reduce edema, increase venous return, and help improve range of motion.
CRUTCHES

Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axilla.
This leads to a reversible condition known as crutch paralysis, or palsy, which manifests as muscle weakness and/or
sensory symptoms (tingling, numbness) of the arm, wrist, and hand. It is caused by crutches that are too long or by
leaning on the top of the crutches when ambulating. Therefore, clients are taught to support body weight on the
hands and arms, not the axillae, when ambulating to ensure that there is a 1-2 in (2.5-5 cm) space between the axilla
and the axilla crutch pad. Crutches should be checked for proper length.
Triceps muscle spasm can occur due to increased muscle use, especially in clients with decreased upper body
strength. Triceps and biceps muscle spasms are not complications associated with crutch walking.
Forearm swelling is not a common complication associated with crutch walking. In rare cases, arterial obstruction can
cause ischemic symptoms.
Restricted shoulder range of motion is not a major complication of crutch use.

NEUROPATHY

Numbness and tingling in both lower extremities are classic examples of neuropathic pain. The common causes of
bilateral peripheral neuropathy include the following:

o Diabetic neuropathy most common; distribution is usually sock-and-glove pattern

o Autoimmune neuropathy Guillain-Barré syndrome
o Toxic neuropathy alcohol use

Establishing that the sensations the client is experiencing were present before surgery indicates whether this is a
complication of surgery. Because the sensation is bilateral and the surgery was on the right knee, the "numbness and
tingling" are probably baseline diabetic neuropathy. This should be confirmed by gathering more information from the
client
Diabetic neuropathy is not usually treated with traditional post-surgical medications such as opioids. Medications for
diabetic neuropathy are usually given on a fixed, timed schedule and include duloxetine, pregabalin, amitriptyline, and
gabapentin. If the client uses an as-needed medication, it is important to ask for more information before
administering it. The client should be asked whether the pain is baseline and what medication is taken.
 The nurse should question any abnormal finding, whether expected or unexpected. Questioning the client further
would allow the nurse to gather more information and confirm that the client's "numbness and tingling" do not indicate
a more serious situation.
It is not necessary to notify the HCP immediately. Bilateral pedal pulses and normal capillary refill indicate sufficient
blood flow to the extremities.

FAT EMBOLISM SYNDROME

FES is a rare, but life-threatening complication that occurs in clients with long bone and pelvis fractures. It can also
occur in nontrauma related conditions, such as pancreatitis and liposuction. It usually develops 24-72 hours following
the injury or surgical repair.
There are no specific diagnostic tests to identify FES. However, the initial characteristic signs and symptoms include:

o Respiratory problems (eg, dyspnea, tachypnea, hypoxemia) after a fat embolus travels through the pulmonary circulation
and lodges in a pulmonary capillary, leading to impaired gas exchange and acute respiratory failure. This pathophysiology is
similar to that of a pulmonary embolus
o Neurologic changes (eg, altered mental status, confusion, restlessness), which occur due to cerebral embolism and hypoxia
o Petechial rash (eg, pin-sized purplish spots that do not blanch with pressure), which appears on the neck, chest, and axilla due
to microvascular occlusion. This defining characteristic differentiates a fat embolus from a PE
o Fever (>101.4 F [38.6 C]), which is due to a cerebral embolism leading to hypothalamus dysfunction.

Increasing, severe pain unrelieved by opioid analgesia or pain that is disproportionate to the injury and paresthesia
(eg, numbness, tingling, burning) of the affected extremity are assessment findings indicative of compartment
syndrome.

Fat embolism syndrome (FES) is a life-threatening condition that has no specific treatment. Therefore, prevention,
early diagnosis, and immediate management of symptoms are critical.
When a long bone is fractured, pressure within the bone marrow leads to release of fat globules into the bloodstream.
These combine with platelets (fat embolus) and can travel to the brain, lungs, and kidneys, leading to small-vessel
occlusion and tissue ischemia.
Therefore, early stabilization of the injury and surgery as soon as possible to repair long bone (eg, humerus, radius,
ulna, femur, tibia, fibula) fractures is recommended to reduce further injury to soft tissue.
 The nurse should minimize movement of the injured extremity to reduce the risk for fat emboli.

TOTAL KNEE REPLACEMENT (KNEE ARTHOPLASTY)

Total knee replacement (knee arthroplasty) is a surgery that replaces the knee joint with an artificial implant. Knee
arthroplasties are primarily performed for clients with severe pain or mobility impairment from arthritis. Following a
knee arthroplasty, the nurse must plan care to reduce the client's risk of complications while promoting comfort and
recovery.
Contracture of the operative joint is a serious complication of knee arthroplasty that impairs the client's mobility. To
prevent contracture formation, the nurse should maintain the operative knee in an extended position with a knee
immobilizer or pillow placed under the lower leg or heel. Placing a pillow behind the knee causes joint flexion,
which increases the risk of contracture
Cold packs may be applied intermittently over the operative joint to reduce postoperative swelling and pain.
Using a continual passive motion device, if prescribed, may improve range of motion through knee flexion and
extension and prevent contractures.
Applying a leg immobilizer during ambulation provides support, maintains alignment, and prevents dislocation of
unstable operative joints.
Blood loss is a common complication of a total knee replacement, and a hemoglobin level of 7 g/dL (70 g/L) is very low
(normal adult male: 13.2-17.3 g/dL [132-173 g/L]; normal adult female: 11.7-15.5 g/dL [117-155 g/L]). This client
needs to be assessed for any active bleeding as well as for respiratory and cardiac complications (eg, rapid pulse,
shortness of breath) resulting from the low hemoglobin level. The health care provider must be notified.

The average hospital length of stay following total knee arthroplasty is 3-5 days.
After the surgery, immediate initiation of physical therapy is a priority. An isometric quadriceps setting is initiated on
the 1st postoperative day.
The client should be fully weight bearing by discharge.
Clients use an assistive device (eg, walker, crutches, cane, grab bar, hand rails) to help them sit, rise safely from a
sitting to a standing position, and to negotiate steps.
A knee immobilizer is used to maintain extension during ambulation and at rest for about 4 weeks.
 Venous thromboembolism (eg, deep vein thrombosis [DVT], pulmonary embolism [PE]) following knee arthroplasty is a
major preventable complication. Anticoagulation with oral anticoagulants (rivaroxaban) or enoxaparin (Lovenox)
injections is therefore prescribed for at least 2 weeks after surgery.
Ankle exercises, anti-embolic stockings, and frequent mobilization are prescribed as well.
Clients are taught to recognize the warning signs and symptoms of DVT (eg, new swelling, tenderness, pain below the
knee) or PE (eg, shortness of breath, pleuritic chest pain).
A raised toilet seat facilitates sitting on and rising from the toilet without over-bending the knee. Assistive devices,
such as a long-handled shoehorn, shower chair, or grab bar, are also helpful for client safety at home.

RESIDUAL LIMB CARE

Residual limb care following an above-knee amputation (AKA) or a below-knee amputation (BKA) is an important
component of rehabilitation and focuses on maintaining skin integrity, controlling pain, preventing infection,
and restoring mobility. It is also important for the nurse to consider that the client may experience grief due to
disturbed body image.
The nurse should include the following residual limb care instructions when discharging a client after an AKA or BKA:
o Clean the limb by washing it daily with soap and warm water. Thoroughly dry after washing to prevent skin maceration
o Thoroughly inspect the limb for signs of infection (eg, redness) and areas that may be at risk for infection (eg, irritation, skin
breakdown)
o Keep limb socks, wraps, and appliances/prostheses clean and dry
o Perform daily range-of-motion exercises to improve muscle strength and mobility.
Hip flexion contractures are a common complication during the recovery process. Nurses should teach clients to lie
prone several times each day and to avoid sitting in a chair for .
Clients should be taught to avoid applying potential irritants (eg, alcohol, lotion, powder) to the residual limb, unless
prescribed by the health care provider. This reduces the risk of skin breakdown and infection.
OSTEOMALACIA

Osteomalacia is a reversible bone disorder caused by vitamin D deficiency and is characterized by weak, soft,
and painful bones that can easily fracture or become deformed. In vitamin D deficiency, calcium and phosphorus
cannot be absorbed from the gastrointestinal tract and are unavailable for calcification of bone tissue. Vitamin D
deficiency is also associated with increased risk of falls, especially in elderly clients, due to muscle weakness.
Nursing management focuses on:

o Implementing safety measures such as canes or walkers to prevent falls and injury
o Encouraging light to moderate activity, which can help promote bone strength and health
o Increasing dietary intake of:

Calcium (eg, leafy green vegetables, dairy)

Phosphorus (eg, milk, organ meats, nuts, fish, poultry, whole grains)
Vitamin D (eg, vitamin D-fortified milk and cereal, egg yolks, saltwater fish, liver); exposure to sunlight is also
recommended as it synthesizes vitamin D

o Taking over-the-counter or prescription supplemental vitamin D

HALO EXTERNAL FIXATION DEVICE

A halo external fixation device stabilizes a cervical or high thoracic fracture when there is insignificant damage to the
ligaments or spinal cord. Sensory and muscle function should be monitored to determine any new deficits, and pin
sites should be regularly assessed for loose pins or infection.
Care for the client with a halo device includes:

o Cleaning pin sites with sterile solution (eg, chlorhexidine, water) to prevent infection
o Keeping the vest liner clean and dry (eg, changing weekly or when soiled, using a cool blow-dryer to dry) to protect the skin
o Placing foam inserts under pressure points to prevent pressure injury
o Placing a small pillow under the client's head when supine to reduce pressure on the device
o Keeping the correct-sized wrench available at all times in case of emergency

Only the health care provider can adjust the pins.

 The nurse should avoid grabbing the device frame when moving or positioning the client, as this may cause the
screws to loosen or alter device alignment.

RHEUMATOID ARTHRITIS

Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory, autoimmune condition of unknown origin that has
periods of exacerbation and remission. The body's immune system attacks the lining of the joints, leading to bone
erosion and joint deformity. Although there is no cure for the disease, early diagnosis and appropriate treatment can
help limit localized joint destruction and systemic organ damage.
Characteristic features of RA include the following:

o Symmetrical pain and swelling that initially affects the small joints of the hands and feet
o Morning joint stiffness that lasts from 60 minutes to several hours
o Elevated ESR and rheumatoid factor levels

Asymmetrical pain in the weight bearing joints is characteristic of osteoarthritis. Crepitus, especially over the knee
joints, is also present in osteoarthritis.
Low back pain and stiffness, worse in the morning and improving as the day progresses, is characteristic of ankylosing
spondylitis. RA typically does not involve the spine, except the cervical spine.
Pain, swelling, and redness of one or more extremity joints (typically the great toe) are characteristic of
acute gout attack.
Rheumatoid arthritis is an autoimmune disorder that affects joints and other body systems. Chronic inflammation of
the synovial joints causes increasing pain and swelling in the joints and eventual joint deformities with decreased or
absent range of motion and loss of function.
Clients become easily fatigued and must learn to pace themselves and use assistive devices to accomplish activities
of daily living. Goals of treatment are to manage pain, minimize loss of joint mobility, maximize self-care, and
maintain self-esteem and a positive body image. Assessing for adequate pain control is the priority, as inadequate
pain control will cause disuse of joints, leading to stiffness and decreased joint mobility
If pain is not adequately controlled, the client will be unlikely to use assistive devices and be too fatigued to perform
activities of daily living. This can lead to being dependent on others, causing frustration and poor self-esteem and
body image.
Rheumatoid arthritis (RA) is a chronic, relapsing autoimmune disorder causing painful inflammation of synovial
joints and fibrosis and stiffening of synovial membranes.
Contracture of ligaments and joint remodeling may occur, resulting in weakness and deformity. Clients with RA
require education on prevention of disease progression, including:
o Joint protection Fibrosis from RA can shorten tendons and ligaments when joints are flexed for prolonged
periods. Body aligners or immobilizers should be used when resting to keep extremities straight (especially with
advanced disease).
o Medications RA is often treated using a regimen of disease-modifying antirheumatic drugs (eg, methotrexate),
and clients should take their medication as prescribed regardless of symptoms
Joint deformity can be prevented with appropriate treatment, including use of disease-modifying antirheumatic drugs
and joint protection.
Obesity is a risk factor for osteoarthritis, in which mechanical erosion of joint cartilage occurs. However, obesity is
unrelated to RA, and clients with RA experience chronic fatigue and pain that may limit oral intake and cause weight
loss. The nurse should ensure that clients with RA have access to adequate nutrition.
During painful episodes, periods of rest are encouraged; however, clients should frequently perform range of motion
exercises to prevent loss of function.

Prolonged morning stiffness of the affected joints is a major complication of rheumatoid arthritis (RA).
Taking a warm shower or bath first on awakening would be the best intervention as heat decreases stiffness and
promotes muscle relaxation and mobility.
With increased flexibility and decreased stiffness, the client's usual morning activities (eg, dressing, making breakfast)
would be easier and less painful and tiring to perform.
A balanced diet and weight control are important. Diet and exercise should be proportional, especially during periods
of disease exacerbation and decreased physical activity as excess weight exerts additional stress on weight-bearing
joints.
Range of motion exercises are more effective after a warm bath or shower as stiffness is decreased, thereby
improving flexibility.
 Nonsteroidal anti-inflammatory drugs (NSAIDS) (eg, naproxen [Naprosyn], ibuprofen [Motrin]) should not be taken on
an empty stomach as these can cause gastrointestinal upset. If prescribed once daily, these are probably best taken
in the evening after dinner as RA symptoms slowly increase during the night and worsen in the morning.
A higher serum drug level in the morning can help to reduce inflammation and stiffness. Therefore, if NSAIDS are
prescribed twice daily, taking them in the morning with breakfast and in the evening with dinner is recommended.

To maximize functional ability and quality of life, the nurse should educate clients with RA about home-care and
symptom-management strategies:
o Perform gentle range-of-motion exercises daily to maintain joint flexibility
o Apply moist heat packs to stiff joints and ice packs to painful joints
o Plan frequent rest periods to reduce fatigue and inflammation of affected joints during activities
Clients with RA should be instructed to sleep and rest in a flat, neutral position. Body aligners or immobilizers may be
used to keep joints straight, but prolonged flexion of joints (eg, elevating knees on pillows) increases the risk of
contracture and may hasten decline of joint function.

TOTAL HIP REPLACEMENT (HIP ARTHROPLASTY)

To prevent hip prosthesis dislocation following hip arthroplasty, a client must not force the hip into >90 degrees of
flexion. Clients should use a chair with armrests and a high firm seat and proceed to place the hands on the armrests
for support while lowering themselves onto the seat and when rising from it. Bending forward when getting into a chair
creates excessive hip flexion (>90 degrees) and must be avoided.
The client performs leg exercises 2-3 times a day to help strengthen the muscles surrounding the hip and continues
them for several months after discharge. These include isometric quadriceps and gluteal setting, leg raises,
and abduction exercises from the supine and standing positions.
The client must not twist from the waist, reach across the affected extremity, or bend forward >90 degrees when
dressing or putting on slippers, shoes, and socks. The client is instructed to use assistive equipment when getting
dressed, such as a reacher/grabber, sock puller, or a long-handled shoehorn.
The client should use a toilet riser or a bedside commode chair with arms to prevent excessive hip flexion when getting
on and off the toilet seat.
Common complications following total hip replacement are bleeding, prosthesis dislocation, deep vein thrombosis,
and infection.
Total joint replacements carry a risk of serious blood loss; therefore, the nurse should check the drainage device and
dressing frequently to monitor blood loss, especially during the first several postoperative hours.
Pain is typically controlled via a patient-controlled analgesia device with a programmed dosage and lockout. The
client's level of pain should be assessed, but assessing for hemorrhage is the priority.
Following total hip replacement, the client will have an abduction pillow between the legs to prevent adduction of the
affected leg.
Adduction of the leg could potentiate dislocation of the prosthesis. It is important that the client not flex the affected hip
more than 90 degrees, as this could dislocate the prosthesis. Therefore, the client should be provided elevated toilet
seats and chairs that do not recline.
The nurse should assess for signs of hip dislocation, including shortening and internal rotation of the leg. Although
providing an abduction pillow is important, assessing for hemorrhage is the priority.
Assessment of the urine in a postoperative client's catheter bag is important but is not priority in this situation.
Interventions to help prevent dislocation of a hip prosthesis following total hip replacement surgery include positioning

placing an abductor pillow wedge between the legs when turning the client to the unaffected side; and instructing the
client to avoid crossing the legs.
COMPARTMENT SYNDROME

Compartment syndrome, a serious postoperative complication, is caused by decreased blood flow to the tissue distal
to the injury. It results from either decreased compartment size (restrictive dressings, splints, or casts) or increased
pressure within the compartment (bleeding, inflammation, and edema).
Earliest symptoms may include pain or numbness that is unrelieved by medication. Subsequent findings include
diminished/absent pulses, pallor, coolness, swelling, decreased movement, and cyanosis.
Failure to treat this condition can lead to loss of limb function, paralysis, and tissue necrosis. The nurse should assess
neurovascular status and report to the health care provider immediately
Removal of tight bandages/casts and fasciotomy (surgery) are required to relieve the pressure.
Heat should not be applied to a client experiencing altered sensation, as it may burn the client. Active range of motion
will not resolve compartment syndrome and delays needed care.
Elevating the arm on pillows and providing additional analgesia may help reduce symptoms but may also reduce
perfusion of the extremity. Instead, the extremity should be positioned at the level of the heart.
Documenting findings is important. However, reassurance and reassessment 1 hour later without immediate
intervention delays needed care.

Compartment syndrome (CS) results from compression of vascular structures by either external compression
(restrictive dressings/casts) or increased pressure within a compartment (bleeding, inflammation, and edema).
 After an injury or trauma (eg, surgery), the vessels surrounding the injury site are compressed by swelling muscle and
connective tissues.
Muscle is encapsulated by a fibrous layer of fascia (ie, a compartment), which does not yield to swelling. Eventually,
compression of tissues within the compartment restricts blood flow to the extremity.
Signs of CS include the 6 Ps pain (unrelieved by repositioning or analgesics), pallor, pulselessness, paresthesias,
poikilothermia (coolness), and paralysis.
The nurse should notify the health care provider immediately as CS is a limb-threatening emergency and requires
immediate surgery (fasciotomy)
If the client is in pain, blood pressure and pulse may increase. However, assessing the client's vital signs and giving
the client more analgesic medication do not address the signs of CS. These actions delay emergency intervention.
This client has enough evidence for suspicion of CS.
If CS is suspected, the nurse should place the extremity at heart level to promote venous return and limit swelling
and loosen tight bandaging/casting material.
If conservative measures fail, a fasciotomy (incision to open the fascia of the affected muscle compartment) may be
required to relieve the compression.

PELVIC FRACTURE

Motor vehicle collisions and motorcycle crashes, followed by falls, are the most common mechanisms for pelvic
fractures.
The pelvis contains several large vascular structures (eg, internal and external iliac veins and arteries) and abdominal
and pelvic organs (eg, small bowel, sigmoid colon, bladder, urethra, uterus, prostate).
Therefore, when caring for a client with a fractured pelvis, in addition to pain, the nurse should assess for internal
hemorrhage (eg, abdominal distension, vital signs, hematocrit, hemoglobin), paralytic ileus (eg, bowel sounds),
neurovascular deficits (eg, extremity circulation, sensation, movement), and abdominal and genitourinary organ
injuries (eg, hematuria, urine output <0.5 mL/kg/hr).
Abdominal distension could be due to serious intra-abdominal bleeding or injury to the bowel or urinary structures.
Absent bowel sounds can indicate the presence of a paralytic ileus related to the trauma and/or a retroperitoneal
hematoma; these should be reported to the health care provider (HCP)
Tenderness, bruising, and ecchymosis over the injured bones are expected and do not need to be reported to the
HCP. However, it would be important to communicate ecchymosis over the suprapubic area to the HCP as this could
indicate organ damage and internal hemorrhage.
 Hemoglobin of 11.5 g/dL (115 g/L) and hematocrit of 34% (0.34) are slightly lower than normal and may be from the
bleeding. During the acute hemorrhage, hemoglobin and hematocrit can be normal and will take some time to reduce
to significant levels. This is a second priority over actual bleeding findings.

ACUTE COMPARTMENT SYNDROME

Clients with casted extremities after an acute injury are at risk for decreased peripheral perfusion due to increased
edema and a cast that restricts the skin's ability to expand. Together, these create an impingement of the circulation,
or acute compartment syndrome (ACS), which is a medical emergency.
Nurses must prioritize clients demonstrating symptoms of ACS versus normal symptoms of a casted extremity.
Expected responses include mild to moderate edema, warmth or throbbing secondary to edema, pain on movement or
pain that improves with analgesics, itching (pruritus), and dry skin under the cast
High-priority symptoms that may indicate ACS include:

o Severe pain unresponsive to analgesics

o Immobility of digits
o Changes in sensation tingling or numbness (indicating early nerve ischemia)
o Lack of pulses in distal extremity (not reliable for early ACS; absence of pulses indicates advanced/severe ACS)
o Cool and pale distal extremity

JOINT DISLOCATIONS

Joint dislocations may become orthopedic emergencies because articular bone may compress surrounding
vasculature, causing limb-threatening distal ischemia.
When a joint is dislocated, the articular tissues, blood vessels, and nerves are often traumatized by stretching.
Signs of joint dislocation include pain, deformity, decreased range of motion, and extremity paresthesia. The nurse
should frequently assess neurovascular status and provide analgesics until the dislocation can be reduced and
immobilized.
 In incomplete greenstick fractures, the bone bends and cracks but remains in one piece. These fractures are most
common in children, as their bones are soft and flexible. The nurse should provide analgesics and offer reassurance;
however, the client with neurovascular impairment should be assessed first.
Fractures of the bones of the hand (ie, metacarpals) are common in fall injuries, when the brunt of the fall is borne
against the hands and fingers, resulting in hyperflexion or hyperextension. The nurse should provide analgesics;
however, the client with neurovascular impairment should be assessed first.
Pathologic vertebral compression fractures and pain are expected in clients with multiple myeloma. These clients
commonly experience fractures of the vertebral column and spinal processes as the cancer weakens and decalcifies
the vertebrae. This client should be evaluated next to rule out spinal cord involvement.

JOINT REPLACEMENT SURGERY

Infection is a major complication associated with joint replacement surgery.

A 2) is at even greater risk for infection due to inadequate tissue

oxygenation as the vascularity of adipose tissue is decreased. This client is also at increased risk for postoperative
pneumonia because obesity can lead to impaired pulmonary function, sleep apnea, and obesity hypoventilation
syndrome.
Leukocytosis can indicate a wound infection or postoperative pneumonia. Therefore, the increased WBC count
(>11,000 mm3 [11.0 ×109/L]) is of greatest concern and should be reported to the HCP immediately
The BUN is slightly above the normal limits (6-20 mg/dL [2.1-7.1 mmol/L]) and is not the greatest concern.
The glucose is elevated (normal, 70-110 mg/dL [3.9-6.1 mmol/L]). However, the recommended random glucose level
for hospitalized clients is <180 mg/dL (10 mmol/L); the recommended level before meals is <140 mg/dL (7.8 mmol/L).
Obesity is often associated with metabolic syndrome and insulin resistance, and the physiologic stress of surgery can
contribute to hyperglycemia as well. Although the nurse will report the glucose level and continue to monitor it, the
level is not the greatest concern.
Decreased hematocrit (normal adult female 35%-47% [0.35-0.47]), and hemoglobin levels (normal 11.7-15.5 g/dL
[117-155 g/L]) are to be expected in a client who has undergone joint replacement due to blood loss during the
surgery. The nurse will continue to monitor these, but the current levels are not the greatest concern.

CAST CARE

Casts (eg, fiberglass, plaster) are applied to immobilize fractured extremities during healing.
 Instructions for cast care include:

o Report foul odors or hot areas (hot spots) in the cast, which may indicate infection
o Avoid getting the cast wet, which may damage the cast and cause skin irritation/infection
o Elevate the affected extremity above heart level for the first 48 hours to reduce edema
o Regularly perform isometric and range of motion exercises to prevent muscle atrophy.

The client should also be instructed to contact the health care provider about symptoms of impaired circulation in the
affected extremity, including numbness or tingling, pallor, coolness, loss of pulse distal to the cast, or pain that is
unrelieved by ice, elevation, and pain medication.
Swelling within the cast may result in compartment syndrome, a condition that involves limb-threatening tissue
ischemia due to compression of blood vessels and nerves within the extremity's internal compartments.
The client should never insert objects inside the cast due to the risk of tissue injury and infection. Directing air inside
the cast with a hair dryer on the cool setting may help relieve itching.

To relieve itching underneath a casted area, clients should use the cool setting of a hair dryer to direct air under the
cast. Clients should never place any object, lotions, or powders in or around the casted area as skin irritation, injury,
or infection may occur. Signs and symptoms of infection (eg, sores, purulent drainage, foul odors) and persistent
itching should be reported to the health care provider.
Nothing should be placed inside a cast due to the risk for injury and infection.
The skin of the casted extremity should be assessed as the client could have damaged it by inserting a pointed object.
Regular neurovascular checks should be performed on a client with a new cast as the client is at risk for compartment
syndrome. However, there is no indication of peripheral vascular impairment (eg, changes in extremity color,
temperature, or pulse) or peripheral neurologic impairment (eg, loss of sensory or motor function) of the casted
extremity; therefore, this is not the priority at this time.

MANDIBULAR FRACTURE

The priority for a client with a mandibular fracture whose teeth have been wired together is maintaining a patent
airway.
 If the client begins to choke on oral secretions, the nurse should immediately attempt to clear the airway
by suctioning via the oral or nasopharyngeal route. If this intervention is ineffective, cutting the wires may be
necessary.
Cutting the wires can cause collapse of the fractured jaw and exacerbate the airway problem. This action is not the
first priority unless the situation is an emergency (eg, acute respiratory distress, cardiopulmonary arrest requiring
intubation). A wire cutter must be taped to the head of the client's bed at all times, including during travel.
Elevating the head of the bed is a preventive measure. Because the client is choking, the priority is suctioning
secretions to clear the airway. The nurse should also turn the client to the side if the client has excessive oral
secretions or begins to vomit to decrease the risk of aspiration.
The nurse should intervene to maintain the airway before calling the health care provider. A prescription for
nasogastric suction to decompress the stomach may be indicated to reduce the risk of vomiting.

Common clinical manifestations in a client with a fractured mandible are pain, edema of the face and jaw, difficulty
speaking, drooling, and bleeding. Appropriate nursing interventions include oral suction to maintain airway patency,
administration of oxygen and analgesia, and application of ice to the face.

MUSCLE SPASM

CASE: The nurse is reviewing new

prescriptions from the health care provider.
Which prescription would require further
clarification?

CYCLOBENZAPRINE FOR MUSCLE

SPASMS IN A CLIENT WITH HEPATITIS

Cyclobenzaprine (Flexeril) is a common, centrally acting skeletal muscle relaxant prescribed for muscle spasticity,
muscle rigidity, and acute or chronic muscle pain/injury.
 Centrally acting muscle relaxants interfere with reflexes within the central nervous system (CNS) to decrease muscle
spasm and rigidity. Like many medications, muscle relaxants are metabolized by the liver. The presence of liver
disease (eg, hepatitis) decreases hepatic metabolism and can cause a buildup of medication, leading to medication
toxicity and increased CNS depression (eg, weakness, confusion, drowsiness, lethargy). The prescription for a
muscle relaxant would need to be clarified in a client with liver disease

ANKYLOSING SPONDYLITIS

Ankylosing spondylitis (AS), an inflammatory disease affecting the spine, has no known cause or cure.
AS is characterized by stiffness and fusion of the axial joints (eg, spine, sacroiliac), leading to restricted spinal
mobility.
Low back pain and morning stiffness that improve with activity are the classic findings. Involvement of the thoracic
spine (costovertebral) and costosternal junctions can limit chest wall expansion, leading to hypoventilation.
The client with AS should:

o Promote extension of the spine with proper posture, daily stretching, and spine-stretching exercises (eg, swimming,
racquet sports)
o Stop smoking and practice breathing exercises to increase chest expansion and reduce lung complications
o Manage pain with moist heat and NSAIDs.
o Take immunosuppressant and anti-inflammatory medications as prescribed to reduce inflammation and increase mobility.

It is best to rest during flare-ups. The client should delay exercise until the pain and inflammation are under control.
Clients with AS are encouraged to sleep on their backs on a firm mattress to prevent spinal flexion and the resulting
deformity.
Ibuprofen and other NSAIDs should be taken with a meal or snack to avoid gastric upset.
EXTERNAL FIXATOR OF FEMUR FRACTURE

An external fixator is a device used to stabilize broken bones; metal pins are placed through the tissue into the bone
and connect to a frame outside the skin.
The nurse should monitor clients with external fixation closely for signs of neurovascular compromise and pin site
infection, which can lead to osteomyelitis.
When caring for clients with external fixation, the nurse can help prevent infection and maintain extremity and device
integrity by:

o Assessing the pin sites regularly for new, increased, and/or purulent drainage and checking the skin surrounding the pins for
erythema, warmth, pain, or breakdown
o Assessing for signs of compartment syndrome (eg, decreased pulses, coolness, pain, numbness)
o Performing pin site care with a sterile cleaning solution (eg, chlorhexidine, sterile normal saline) and gauze
o Monitoring pins and device for loosening and reporting to the health care provider (HCP) if they are loose

The nurse should never manipulate loose pins but should instead notify the HCP immediately if loose pins are noted
on assessment.
The nurse should promote early mobilization for clients with external fixation devices. Some clients may begin walking
with physical therapy the day after surgery.

HIP FRACTURE

The most common clinical manifestations of hip fractures include:

o Ecchymosis and tenderness over the thigh and hip occur from bleeding into the surrounding tissue as the femur is very
vascular and a fracture can result in significant blood loss (>1000 mL)
o Groin and hip pain with weight bearing
o Muscle spasm in the injured area occurs as the muscles surrounding the fracture contract to try to protect and stabilize the
injured area
o Shortening of the affected extremity occurs because the fracture can reduce the length of the bone and the muscles above
the fracture line pull the extremity upward
o Abduction or adduction of the affected extremity depending on location and mechanism of injury.

The affected extremity is usually externally rotated.

SPRAIN

A sprain is a stretch and/or tear of a ligament. Treatment for a sprained ankle includes:

o Rest Activity should be stopped and movement limited for 24-48 hours to promote healing. The health care provider may
prescribe no weight-bearing on the joint for 48 hours, and crutches may be required.
o Ice (cold, cryotherapy) Cold therapy or an ice pack should be applied for 10-15 minutes every hour for the first 24-48 hours.
Vasoconstriction helps to reduce pain, inflammation, and swelling. Ice should not be applied directly to the skin.
o Compression (eg, ACE wrap, splint) Pressure/compression can help prevent edema and promote fluid return
o Elevation The extremity should be kept elevated above the heart on pillows for 24-48 hours to help reduce swelling by
promoting fluid return
o Analgesia Mild analgesia with a nonsteroidal anti-inflammatory drug (eg, ibuprofen) can be taken every 6 hours as needed
to relieve pain and reduce swelling
o Exercise rehabilitation program This should be initiated as soon as possible after the injury (ie, when pain subsides) to
restore range of motion, flexibility, and strength and prevent reinjury

Cold therapy or ice should be used initially; after the first 24-48 hours, moist heat can be applied for 20-30 minutes at a
time to reduce swelling, with a cooldown between applications.
Rest is indicated during the acute injury phase (24-48 hours). After this acute phase, the client is encouraged to use
the extremity and move the joint to improve circulation and reduce swelling as long as the joint is protected with some
type of immobilizer (eg, brace, tape, splint).

RHABDOMYOLYSIS

Rhabdomyolysis occurs when muscle fibers are released into the blood, usually after an intense muscle injury from
exercise, heat stroke, or physical trauma.
Acute renal failure can occur when elevated myoglobin (protein found in muscle tissue) levels overwhelm the kidneys'
filtration ability.
The nurse's priority is to prevent kidney damage using rapid IV fluid resuscitation to flush the damaging myoglobin
pigment from the body.
Common signs of rhabdomyolysis are dark, oftentimes bloody urine, oliguria, and fatigue.
 With muscle injury, intracellular potassium is released into the circulation, potentially causing dangerous arrythmias.
Therefore, ECG and cardiac monitoring are needed. However, with IV fluid administration, potassium levels decrease
rapidly.
In addition, clients with rhabdomyolysis have extensive third spacing of the fluids into the injured muscles. Therefore,
aggressive fluid resucitation is a high priority.
The general rule is that treatment/prevention of an underlying expected problem is a priority over testing to
identify the problem.
Pain and symptom management should be a high priority but should not take precedence over preserving the client's
kidney function.
Although obtaining a urine specimen to assess the characteristics is important, laboratory testing would not take
priority over treatment to preserve kidney function.

CANE USE

Clients with one-sided weakness or injury, increased joint pressure, or poor balance can use a cane to provide support
and stability when walking. Cane length should equal the distance from the client's greater trochanter to the floor as
incorrect cane length can cause back injury. A cane measured from the waist would be too long to provide optimal
support
Teaching points to assist a client in appropriate use of a cane include:

1. Hold the cane on the stronger side to provide maximum support and body alignment, keeping the elbow slightly flexed (20-30
degrees)
2. Place the cane 6"-10" (15-25 cm) in front of and to the side of the foot to keep the body weight on both legs to provide balance
3. For maximum stability, move the weaker leg forward to the level of the cane, so that body weight is divided between the cane
and the stronger leg. If minimal support is needed, the cane and weaker leg are advanced forward at the same time.
4. Move the stronger leg forward past the cane and the weaker leg, so the weight is divided between the cane and the weaker
leg.
5. Always keep at least 2 points of support on the floor at all times.
ACUTE GOUT

Gout is an inflammatory condition caused by ineffective metabolism of purines, which causes uric acid accumulation
in the blood. Uric acid crystals typically form in the joints. Kidney stones can also develop, increasing the risk of
kidney damage.
Clients with medical risk factors (eg, obesity, hypertension, dyslipidemia, insulin resistance) and other lifestyle factors
(eg, poor diet, alcohol consumption, sedentary lifestyle) have increased risk for future gout attacks. Improvements in
uric acid control are often seen when weight loss is accompanied by dietary modificationS.
Suggested modifications include:

o Increasing fluid intake (2 L/day) to help eliminate excess uric acid

o Implementing a low-purine diet, particularly avoiding organ meats (eg, liver, kidney, brain) and certain seafood (eg, sardines,
shellfish)
o Limiting alcohol intake, especially beer
o Following a healthy, low-fat diet, as excess dietary fats impair urinary excretion of urates

It is unpalatable and impractical to avoid all foods containing protein. The risk of developing gout increases with high
dietary purine intake but not necessarily with protein intake. Low-fat dairy products are good sources of protein that
are associated with a reduced risk of gout.
Increasing intake of meat, especially organ meats, will not prevent future gout attacks but may precipitate them.

VOLKMANN CONTRACTURE

Volkmann contracture occurs as a result of compartment syndrome associated with distal humerus fractures.
Swelling of antecubital tissue causes pressure within the muscle compartment, restricting arterial blood
flow (brachial artery).
The resulting ischemia leads to tissue damage, wrist contractures, and an inability to extend the fingers.
A Volkmann contracture is a medical emergency that can cause permanent damage to the extremity if left untreated.
Any restrictive dressing should be removed immediately, and the health care provider (HCP) must be notified for
possible surgical intervention (eg, fasciotomy).

POST-CARE PROCEDURES
 To prevent hip flexion contractures in clients with above-the-knee amputation, the residual limb should not be
elevated, especially after 24 hours. Instead, edema should be managed using a figure eight compression bandage.
The bandage should be worn at all times until the residual limb is healed, and care should be taken not to wrap it too
tightly. Hip flexion contractures can also be avoided by placing the client in prone position with hip in extension
for 30 minutes 3 or 4 times a day.
Following total hip replacement, hip dislocation is prevented by using an abductor pillow to maintain the hip in a
straight and neutral position. The nurse should also teach the client not to bend at the hip more than 90 degrees or
cross the legs or ankles.
Buck traction immobilizes hip and femur fractures. A boot or traction tape is applied to the affected extremity and a
prescribed weight pulls the limb into traction. The client is typically placed in supine position with the foot of the bed
raised to maintain countertraction.
After a new cast is placed, the nurse should elevate the client's limb above the heart for the first 48 hours to increase
venous return and decrease edema in the affected extremity. However, the extremity should not be elevated
if compartment syndrome develops.

ROTATOR CUFF INJURY

The rotator cuff is a group of 4 shoulder muscles and tendons that attach to the humeral head. It allows for rotation
of the arm.
A partial or full thickness rotator cuff tear can occur gradually over time as a result of aging, repetitive use, or an injury
to the shoulder.
It can also occur as a result of a sports injury involving repetitive overhead arm motion (eg, swimming, tennis,
baseball, weight lifting).
Characteristic symptoms of rotator cuff injury usually include shoulder pain and weakness. Severe pain when the
arm is abducted between 60 and 120 degrees (painful arc) is characteristic
Restriction of active and passive ranges of motion of the shoulder (complete stiffness) is seen with frozen shoulder.
Pain and paresthesia over the first 3½ fingers suggest carpal tunnel syndrome.
Tenderness over the lateral epicondyle is seen with tennis elbow.
OSTEOARTHRITIS

Osteoarthritis (OA) is a degenerative disorder of the synovial joints (eg, knee, hip, fingers) that causes progressive
erosion of the articular (joint) cartilage and bone beneath the cartilage. As the degenerative process continues, bone
spurs (osteophytes), calcifications, and ulcerations develop within the joint space, and the "cushion" between the ends
of the bones breaks down.
Clinical manifestations of OA of the knee include:

o Pain exacerbated by weight-bearing activities: Results from synovial inflammation, muscle spasm, and nerve irritation
o Crepitus, a grating noise or sensation with movement that can be heard or palpated: Results from the presence of bone and
cartilage fragments that float in the joint space
o Morning stiffness that subsides within 30 minutes of arising
o Decreased joint mobility and range of motion
o Atrophy of the muscles that support the joint (eg, quadriceps, hamstring) due to disuse

Low-grade fever develops as part of systemic inflammation. OA is typically a noninflammatory, nonsystemic disorder.
Occasional OA inflammation is limited to affected joints.
Serum rheumatoid factor is positive in clients with systemic rheumatoid arthritis. No diagnostic laboratory tests or
biomarkers exist for OA.

CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome (CTS) is pain and paresthesia of the hand caused by median nerve compression within
the carpal tunnel at the wrist. Nerve compression can occur due to inflammation of the tendons; narrowing or
compression of the carpal tunnel; or wrist flexion or extension.
Symptoms of CTS are often exacerbated during sleep due to prolonged and unintentional wrist flexion.
Most clients with CTS can conservatively manage symptoms with wrist immobilization splints
Splinting and immobilization of the wrist (particularly during sleep) reduces pain by preventing flexion or extension and
subsequent nerve compression.
Clients with CTS may require surgery to permanently relieve symptoms.
Instructing clients to perform repetitive hand exercises or wear elastic compression hose could worsen symptoms of
CTS by increasing median nerve compression.
 Although educating clients to avoid tobacco and caffeinated products is appropriate to improve general health,
avoidance of such substances does not impact symptoms of CTS.

KNEE REPLACEMENT

CASE: The office nurse for an orthopedic

health care provider receives 4 telephone
messages. Which client does the nurse call
back first?
Client who had a left total knee replacement 7
days ago and report cramping pain in the left
calf

The nurse should call the client with the knee replacement first. Cramping calf pain can indicate the presence of a
deep vein thrombosis (DVT), which can occur following joint replacement surgery despite prophylactic
anticoagulation. This symptom needs immediate intervention with diagnostic testing (eg, venous Doppler study) as a
venous embolus can lead to a pulmonary embolus, which is potentially life-threatening.

Client with a fractured wrist who reports severe itching under a cast that was applied 3 days ago
Itching is to be expected due to drying of the skin under the cast. The nurse can suggest directing the air from a hair
dryer on a cool setting under the cast to help relieve itching. This is not a potentially life-threatening event.

Client with an ankle sprain who is using crutches and reports tingling in the forearm and fingers
This client is most likely using the crutches incorrectly or they are not fitted correctly. Pressure on the ulna or radial
nerves can lead to numbness and tingling of the fingers and hand weakness. This symptom needs intervention, but it
is not potentially life-threatening.
 Client with an intact anterior cruciate ligament injury who reports tightness in the knee unrelieved with ice
Pain and swelling are to be expected with an anterior cruciate ligament injury and are treated with RICE (rest, ice,
compression, elevation) for 24-48 hours. Pain and a feeling of tightness can indicate an effusion that may require
aspiration, but the condition is not potentially life-threatening.

POST-CAST APPLICATION

Neurovascular integrity should always be tested first after cast application by performing circulation, motor, and
sensory checks.
The client should have no numbness or tingling.
If pain is not relieved (especially with passive range of motion) by prescribed pain medication or is out of proportion
to the injury, the nurse should notify the health care provider (HCP).
Permanent damage to the circulatory and nervous systems (compartment syndrome) can occur if this is not addressed
immediately.
Pallor, pulselessness, and paralysis are late signs of compartment syndrome.
Blood stains on a cast after an open orthopedic surgical procedure are not unusual. The nurse should circle the stains
and mark the date and time on the cast so further bleeding can be easily visualized. However, rapid enlargement of a
stain needs to be reported to the HCP.
The skin on the affected extremity should be pink and warm. When blanched, it should return to normal color in <3
seconds.
Mild swelling/edema of the toes can occur from cast pressure and can be reduced with leg elevation using pillows.
Increasing swelling should be reported to the HCP. Most clients report severe pain when the cause is compartment
syndrome, which is a priority.
OSTEOPENIA

Osteopenia is more than normal bone loss for the client's age and sex. Adequate dietary intake of calcium and
vitamin D is necessary to promote bone growth, prevent resorption (bone loss), and prevent progression to
osteoporosis.
Milk and milk products are the best sources of calcium.
However, other food sources are available for individuals who are lactose intolerant. They include some fish (eg,
sardines, salmon, trout), tofu, some green vegetables (eg, spinach, kale, broccoli), and almonds.
Good food sources of vitamin D include egg yolks and oily fish (eg, salmon, sardines, tuna).
Canned sardines are the best choice as sardines are an excellent source of calcium and vitamin D
 NEUROLOGY
STROKE

Strokes may be either ischemic or hemorrhagic.

Ischemic stroke occurs when circulation to parts of the brain is interrupted by occlusion of cerebral blood vessels by a
thrombosis or embolus.
Hemorrhagic stroke occurs when a cerebral blood vessel ruptures and bleeds into the cranial vault.
Both types of stroke result in brain tissue death without prompt treatment.
A client with stroke symptoms must have an immediate CT scan or MRI of the head to determine the type and
location of the stroke.
Determining exactly when symptoms began is essential for diagnosis and planning treatment.
Thrombolytic therapy (eg, alteplase, tissue plasminogen activator [tPA]) is used to dissolve blood clots and restore
perfusion to brain tissue in clients with an ischemic stroke unless contraindicated (eg, active bleeding, uncontrolled
hypertension, aneurysm).
It must be administered within 4.5 hours from onset of symptoms.
A baseline neurologic assessment is essential for tracking ongoing neurologic symptoms that indicate improvement
or complications which guide later treatments
Consultation with a speech pathologist and providing the family with information about community resources are
important later but not during the initial (acute) phase of stroke management.
Strokes cause different neurological deficits depending on the location of the affected area within the brain and the
extent of injury.
Cerebellar deficits affect balance and equilibrium; fall precautions are appropriate
Cranial nerves IX (glossopharyngeal) and X (vagus) control the gag and swallowing mechanisms, making swallow
precautions necessary
Blindness in the same half of each visual field, homonymous hemianopsia, is suspected when clients ignore objects on
one side. Initially, the nurse assists (eg, places utensil in unaffected visual field), but the client must learn to turn the
head to scan the environment
A stroke affecting cranial nerve VII, the facial nerve, can cause an asymmetrical smile or inability to raise one
eyebrow.

Clients experiencing receptive aphasia, impaired comprehension of speech and writing, typically have injury to
the Wernicke area of the brain, located in the left temporal lobe. The nurse would not speak louder as this does not
aid comprehension. The nurse should speak clearly, ask "yes" or "no" questions, and use gestures and pictures to
increase understanding.
A flaccid extremity and change in verbal ability are symptoms of a stroke, which is considered an emergency.
Clients with stroke symptoms are immediately triaged using a special team and set of tools to determine the correct
course of action with the goal of preventing further brain damage.
In any emergency, the first priority nursing action is to maintain a patent airway.
Depending on the mechanism of injury, the symptoms may include changes in airway clearance, which is a priority.
The nurse, or another member of the emergency department or stroke alert team, will prepare the client for an
immediate head CT scan to rule out a hemorrhagic stroke and determine the location and extent of the injury. This
person will also ensure that the client has 2 large-bore IV lines for rapid infusion of fluids or medications as needed
It is vital to determine the onset of symptoms as thrombolytic medications are used in a short time frame (typically
within 4.5 hours of onset).
Thrombolytic medications are used only in ischemic strokes, so the head CT must be completed to confirm the type of
stroke (ischemic versus hemorrhagic).
With all of these interventions, the priority nursing actions remain the same: ABC - airway, breathing, and circulation.
The parietal lobe of the brain integrates somatic and sensory input. Injury to the parietal lobe could result in a deficit
with sensation. The nurse would verify the client's injuries and documented imaging studies to confirm that this was an
expected deficit and document it accordingly. If it is a new or unexpected deficit, the nurse should inform the health
care provider immediately.
The frontal lobe controls higher-order processing, such as executive function and personality. Injury to the frontal
lobe often results in behavioral changes.
The temporal lobe integrates visual and auditory input and past experiences. Temporal lobe injury clients cannot
understand verbal or written language.
The occipital lobe of the brain registers visual images. Injury to the occipital lobe could result in a deficit with vision.
The development of Alzheimer disease (AD) is related to a combination of genetic, lifestyle, and environmental
factors.
Clients with AD are usu Early-onset AD is a rare form of the disease that develops before
age 60 and is strongly related to genetics. Children of clients with early-onset AD have a 50% chance of developing
the disease.
For late-onset AD, the strongest known risk factor is advancing age.
Having a first-degree relative (eg, parent, sibling) with late-onset AD also increases the risk of developing AD.
Trauma to the brain has been associated with the development of AD in the future.
Brain trauma may be prevented by wearing seat belts and sports helmets and taking measures to prevent falls.
Research suggests that healthy lifestyle choices (eg, smoking cessation, avoiding excessive alcohol intake,
exercising regularly, participating in mentally challenging activities) reduce the risk for developing AD
When a client with Alzheimer disease is being cared for in the home, the caregiver should be instructed
regarding safety modifications to ease the burden of caregiving and promote the client's independence and dignity.
Injury-prevention modifications include:
o Arrange furniture to allow for free movement to prevent falls
 o Place frequently used items within easy, visible reach of the client
o Place locks on stairwells and outside doors to decrease the client's risk of falls and becoming lost during periods of
wandering
o Label the doors to the bathroom and other commonly used rooms to assist with environment interpretation and
promote independent functioning
o Providing a night light in the sleeping area can prevent falls, aid in orientation, and decrease illusions.
Strategies for caring for clients with Alzheimer disease address progressive memory loss and declining ability to
communicate, think clearly, and perform activities of daily living.
Caregivers should also learn to manage clients' problematic behavior and mood swings.
Therapeutic guidelines include:

o Use distraction and redirection (eg, going for a walk) to manage agitation
o Speak slowly and use simple words and yes-or-no questions. Ask questions that can be answered with yes, no, or very
few words. Do not ask open-ended questions, which can overwhelm the client and cause increased stress and frustration.
o Do not try to rationalize with the client.
o Use visual cues when giving directions.
o Interact with the client as an adult, even as the client regresses to childlike affect and behavior; respect client dignity by
avoiding use of pet names (eg, "honey," "sweetie," "darling")
o Break down complex activities into steps with simple instructions.
o Decrease the client's anxiety by limiting the number of choices
o Allow plenty of time for task completion. The client cannot process information rapidly, and hurrying or rushing can
cause agitation or anxiety.
HEAD INJURY

An essential aspect of discharging a client with a head injury is ensuring that a responsible adult will check on the
client as the level of consciousness can change
Brain edema or increased intracranial pressure (IICP) may not be evident immediately.
The client should return to the emergency department or notify the primary care provider if any of the following
signs/symptoms are present in the next 2-3 days:

o Change in level of consciousness (eg, increased drowsiness, difficulty arousing, confusion)

o Worsening headache or stiff neck, especially if unrelieved by over-the-counter analgesics
 o Visual changes (eg, blurring)
o Motor problems (eg, difficulty walking, slurred speech)
o Sensory disturbances
o Seizures
o Nausea/vomiting or bradycardia (indicates IICP)

The client is also to abstain from alcohol, check before taking medications that can affect level of consciousness (eg,
muscle relaxants, opioids), and avoid driving or operating heavy machinery

TRANSSPHENOIDAL HYPOPHYSECTOMY

Transsphenoidal hypophysectomy is the surgical removal of the pituitary gland, an endocrine gland that produces,
stores, and excretes hormones (eg, antidiuretic hormone [ADH], growth hormone, adrenocorticotropic hormone)
Clients undergoing hypophysectomies are at risk for developing neurogenic diabetes insipidus (DI), a metabolic
disorder of low ADH levels.
ADH promotes water reabsorption in the kidneys. Therefore, loss of circulating ADH results in massive
diuresis of dilute urine.
Clinical manifestations associated with DI include:

o Decreased urine specific gravity (<1.003)

o Elevated serum osmolality (>295 mOsm/kg [295 mmol/kg])
o Hypernatremia (>145 mEq/L [145 mmol/L])
o Hypovolemia and potential hypotension
o Polydipsia
o Polyuria (2-20 L/day)

LUMBAR PUNCTURE

A lumbar puncture involves removing a sample of cerebrospinal fluid through a needle inserted between vertebrae.
Elevated intracranial pressure is a contraindication to performing a lumbar puncture.
The client is placed in the fetal position or sitting and leaning over a table.
 Continued leaking fluid indicates that the site did not seal off and a blood patch (autologous blood into the epidural
space) is required.
Fluids are encouraged to help replace the cerebrospinal fluid.
The client should lie flat for at least 4 hours.
The prone or supine position is recommended to help prevent a headache.
Up to 5%-30% of clients have the common complication of headache.
It is thought to be a result of leakage of fluid through the dural puncture site. The symptom is treated and is
normally self-limiting.
Cerebrospinal fluid (CSF) is assessed for color, contents, and pressure. Normal CSF is clear and colorless, and
contains a little protein, a little glucose, minimal white blood cells, no red blood cells, and no microorganisms. Normal
CSF pressure is 60 150 mm H2O. Abnormal CSF pressure or contents can help diagnose the cause of headaches in
complicated cases. CSF is collected via lumbar puncture or ventriculostomy.
Prior to a lumbar puncture, clients are instructed as follows:

1. Empty the bladder before the procedure

2. The procedure can be performed in the lateral recumbent position or sitting upright. These positions help widen the space
between the vertebrae and allow easier insertion of the needle
3. A sterile needle will be inserted between the L3/4 or L4/5 interspace
4. Pain may be felt radiating down the leg, but it should be temporary

After the procedure, instruct the client as follows:

1. Lie flat with no pillow for at least 4 hours to reduce the chance of spinal fluid leak and resultant headache
2. Increase fluid intake for at least 24 hours to prevent dehydration

EPIDURAL HEMATOMA

Epidural hematoma is an accumulation of blood between the skull bone and dura mater. The majority of epidural
hematomas are associated with fracture of the temporal bone and subsequent rupture or tear of the middle
meningeal artery. The bleed is arterial in origin, and so hematoma develops quickly.
The clinical presentation of epidural hematoma is characteristic.
The client may lose consciousness at the time of impact.
 The client then regains consciousness quickly and feels well for some time after the injury.
This transient period of well-being is called a lucid interval. It is followed by a quick decline in mental function that
can progress into coma and death.

AMYOTROPHIC LATERAL SCLEROSIS

Amyotrophic lateral sclerosis (ALS, Lou Gehrig disease) is a debilitating neurodegenerative disease with no cure.
ALS causes progressive degeneration of motor neurons in the brain and spinal cord.
Physical symptoms include fatigue, progressive muscle weakness, twitching and muscle spasms, difficulty
swallowing, difficulty speaking, and respiratory failure.
Most clients survive only 3-5 years after the diagnosis as there is no cure.
Treatment focuses on symptom management. Interventions include:

o Respiratory support with noninvasive positive pressure (eg, bilevel positive airway pressure [BiPAP]) or invasive mechanical
ventilation (eg, via tracheostomy)
o Feeding tube for enteral nutrition
o Medications to decrease symptoms (eg, spasms, uncontrolled secretions, dyspnea)
o Mobility assistive devices (eg, walker, wheelchair)
o Communication assistive devices (eg, alphabet boards, specialized computers)

Constipation due to decreased mobility is more common in ALS.

APHASIA

Broca (expressive) aphasia is a nonfluent aphasia resulting from damage to the frontal lobe. Clients with Broca
aphasia can comprehend speech but demonstrate speech difficulties. The speech pattern often consists of short,
limited phrases that make sense but display great effort and frequent omission of smaller words (eg, "and," "is," "the").
Clients with Broca aphasia are aware of their deficits and can become frustrated easily.
In comparison, clients with Wernicke (receptive) aphasia are unaware of their speech impairment.
COUP CONTRECOUP INJURY

Coup-contrecoup injury occurs when a body in motion stops suddenly (eg, head hits car windshield), causing
contusions (bruising) of brain tissue as the brain moves back and forth within the skull.
First, the soft tissue strikes the hard skull in the same direction as the momentum (coup).
As the body bounces back, the brain strikes the opposing side of the skull (contrecoup).
When the forward collision occurred, the frontal lobe most likely suffered the primary impact (coup).
Executive function, memory, speech (Broca area), and voluntary movement are controlled by the frontal lobe.
The contrecoup most likely injured the occipital lobe, where vision is processed.
Bell's palsy (peripheral facial paralysis) is an inflammation of the facial nerve (CN VII) in the absence of other disease
etiologies, such as stroke.
There is flaccidity of the affected side with drooling.
This differs from the concerning drooling with epiglottis in which the client's throat is too sore and/or swollen to swallow
saliva.
Treatment includes steroids, measures to relieve symptoms, and protection of the eye (which may not close tightly),
but the condition is not emergent.
TRIGEMINAL NEURALGIA (TIC DUOLOUREUX)

Trigeminal neuralgia (tic douloureux) presents with paroxysms of unilateral excruciating facial pain along the
distribution of the trigeminal nerve (CN V) that are often triggered by touch, talking, or hot/cold air or intake.
Carbamazepine (Tegretol) is the drug of choice; the condition is not life-threatening.

MULTIPLE SCLEROSIS

Multiple sclerosis (MS) is a progressive, demyelinating disease of the central nervous system that interrupts nerve
impulses, causing a variety of symptoms.
Symptoms may vary, but muscle weakness, spasticity, incoordination, loss of balance, and fatigue are usually
present, causing impaired mobility and risk for fall and injury.
Walking with the feet apart increases the support base, improving steadiness and gait.
Assistive devices, such as a cane or walker, are usually required as demyelination of the nerve fibers progresses.
Range-of-motion, strengthening, and stretching exercises help limit spasticity and contractures in clients with MS.
Fatigue is a common symptom with MS. Rather than increasing the duration, clients should balance exercise with
rest. Clients should also exercise when the weather is cool and stay hydrated; dehydration and extremes in
temperature cause symptom exacerbation.
Wheelchairs are advised only if exercise and gait training are not successful as clients should maintain mobility and
independence as long as possible.

GUILLAIN-BARRE SYNDROME

GBS is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle
weakness and absent deep-tendon reflexes.
Many clients have a history of antecedent respiratory tract or GI infection.
Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves.
However, neuromuscular respiratory failure is the most life-threatening complication.
Early signs indicating impending respiratory failure include:
 o Inability to cough
o Shallow respirations
o Dyspnea and hypoxia
o Inability to lift the head or eye brows

Assessing the client's pulmonary function by serial spirometry is also recommended. Measurement of forced vital
capacity (FVC) is the gold standard for assessing ventilation; a decline in FVC indicates impending respiratory arrest
requiring endotracheal intubation.
Severe autonomic dysfunction can present as diaphoresis and facial flushing.
The client with GBS is also at risk for paralytic ileus, which is related to either immobility or nerve damage. As a result,
the nurse should monitor for the presence hypoactive/absent bowel sounds.
Clients with GBS are at risk of developing deep venous thrombosis due to lack of ambulation and should receive
pharmacologic prophylaxis (heparin) and support stockings.

HUNTINGTON DISEASE

Huntington disease (HD) is an incurable autosomal dominant hereditary disease that causes progressive nerve
degeneration, which results in impaired movement, swallowing, speech, and cognitive abilities.
Chorea (involuntary, tic-like movement) is a hallmark sign.
The onset of active disease is usually at age 30-50, and death from neuromuscular and respiratory
complications typically occurs within 20 years of diagnosis.
HD is confirmed by genetic testing. Clients who have a parent with HD and are considering having biological children
should receive genetic counseling

SPINAL IMMOBILIZATION
Spinal immobilization is not a benign procedure. An acronym to help determine the need for spinal immobilization is
NSAIDs:
o N - Neurological examination. Focal deficits include numbness and decreased strength.
o S - Significant traumatic mechanism of injury
o A - Alertness. The client may be disoriented or have an altered level of consciousness
o I - Intoxication. The client could have impaired decision-making ability or lack awareness of pain
o D - Distracting injury. Another significant injury could distract the client from spinal pain.
 o S - Spinal examination. Point tenderness over the spine or neck pain on movement (if there is no midline
tenderness) may be present

AUTONOMIC DYSREFLEXIA

Autonomic dysreflexia is an acute, life-threatening response to noxious stimuli, which clients with spinal
cord injuries above T6 are unable to feel. Signs and symptoms include hypertension, bradycardia, a
pounding headache, diaphoresis, and nausea.
It is essential that the nurse assess for and remove noxious stimuli to prevent a stroke
Clients with a high (T6 or above) spinal cord injury are at risk for autonomic dysreflexia (autonomic hyperreflexia).
It is an uncompensated sympathetic nervous system stimulation.
Classic signs include hypertension (up to 300 mm Hg systolic), throbbing headache, diaphoresis above the level of
injury, bradycardia (30-40/min), piloerection ("goose bumps"), flushing, and nausea.
This is a life-threatening condition that requires immediate intervention to prevent complications (eg, hypertensive
stroke, seizures).
Clients with a spinal cord injury should have their blood pressure checked when they report a headache
The most common cause of autonomic dysreflexia is bladder irritation due to distention.
The client needs to be catheterized or the possibility of a kink in the existing catheter must be assessed.
Bowel impaction can also be a cause; a digital rectal examination should be performed.
Constrictive clothing should be removed to decrease skin stimulation
The primary health care provider should be notified. An alpha-adrenergic blocker or an arteriolar vasodilator (eg,
nifedipine) may be prescribed.
Headaches associated with autonomic dysreflexia are typically due to severe hypertension and often resolve after
blood pressure has been treated.
The client should have the head of the bed elevated 45 degrees or high Fowler's to lower blood pressure.

SUBSTANCE ABUSE

The goals of emergency care for the client with suspected substance abuse who exhibits signs of central nervous
system depression (eg, altered level of consciousness, bradypnea, hypotension, bradycardia) are to promote
adequate ventilation and oxygenation and preserve hemodynamic stability.
 Interventions are prioritized according to the ABCs (ie, airway, breathing, circulation).
Initial actions involve maintaining patency of the client's airway, including appropriate positioning, oropharyngeal
suctioning, and artificial airway placement (if needed).
Respiratory depression occurring after the ingestion of an unknown substance (eg, depressants [opioids,
benzodiazepines, barbiturates]) should initially be treated with administration of reversal agents (eg, naloxone,
flumazenil).
Naloxone rapidly reverses the effects of opioids and may restore spontaneous respiration and normal ventilatory
pattern, averting initiation of mechanical ventilation, the possibility of respiratory arrest, and death

DYSPHAGIA

Dysphagia increases the risk for aspiration of oropharyngeal secretions, gastric content, food, and/or fluid into the
lungs. Aspiration of foreign material into the lungs increases the risk for developing aspiration pneumonia.
Interventions to help decrease aspiration and resulting aspiration pneumonia in susceptible clients (eg, elderly,
neurologic dysfunction, decreased cough or gag reflexes, decreased immunity, chronic disease), include the following:

o Swallowing 2 times before taking another bite of food. This clears food from the pharynx.
o Thickening liquids to assist swallowing
o Avoiding over-the-counter cold medications. Antihistamine cold preparation medications also have some anticholinergic
properties, such as causing drowsiness, decreasing saliva (xerostomia) production, and making the mouth dry. Saliva is a
lubricant, and it helps bind food together to facilitate swallowing.
o Sitting upright for at least 30-40 minutes after meals. This uses gravity to move food or fluid through the alimentary tract,
decreases gastroesophageal reflux, and helps decrease risk for aspiration.
o Brushing teeth and using antiseptic mouthwash before and after meals. This reduces the bacterial count before eating
because bacteria as well as food can be aspirated. After-meal use removes particles of food that can be aspirated later.
o Smoking cessation. Smoking decreases mucociliary clearance and increases bacterial count in the mouth.
o Positioning the chin slightly downward toward the neck (chin-tuck) when swallowing can be effective in some clients
with dysphagia due to its facilitating closure of the epiglottis to help prevent tracheal aspiration.

DELIRIUM

Delirium is characterized by behavior changes and confusion that have an acute onset, and it is usually reversible.
 Common causes in older adults include infection, medications, and hypoxia.
Nursing priority is to perform a targeted assessment to determine whether the client has delirium and its cause.

MENINGITIS

The client with suspected bacterial meningitis should be placed on droplet precaution isolation until the causative
agent has been identified and appropriate treatment is initiated.
Meningococcal meningitis and Haemophilus influenzae type B meningitis are highly transmissible to others, and the
client must remain on droplet isolation until these can be ruled out.
Precautions can usually be discontinued 24 hours after beginning antibiotic therapy.
Viral meningitis and other types of bacterial meningitis (ie, other than meningococcal meningitis) usually do not require
droplet precautions.

Parkinson's disease (PD) is a chronic, progressive neurodegenerative disorder that involves degeneration of the
dopamine-producing neurons.
Damage to dopamine neurons makes it difficult to control muscles through smooth movement.
PD is characterized by a delay in initiation of movement (bradykinesia), increased muscle tone (rigidity), resting
tremor, and shuffling gait.
SEIZURE

Safety is the immediate priority in a client experiencing a seizure. Nursing interventions include:

o Remain at the client's bedside while noting duration and symptoms of the seizure
o Call for help so that other team members can assist with care of the client
o Protect client from hitting hard surfaces by padding the side rails
o Turn client on the side if possible to allow for drainage of secretions and prevent the tongue from occluding the airway
o Loosen clothing around the neck and chest to promote ventilation
o Use suction equipment after the seizure subsides as needed to maintain a patent airway

The client should not be restrained as this could cause an injury. Oral airways should be kept at the bedside for
postictal airway management and recovery, but during an active seizure it is dangerous to attempt to insert anything in
the client's mouth, especially if the teeth are clenched

Seizure manifestations generally are classified into 4 phases:

1. The prodromal phase is the period with warning signs that precede the seizure (before the aural phase).
2. The aural phase is the period before the seizure when the client may experience visual or other sensory changes. Not all clients
experience or can recognize a prodromal or aural phase before the seizure.
3. The ictal phase is the period of active seizure activity.
4. During the postictal phase, the client may experience confusion while recovering from the seizure. The client may also
experience a headache. Postictal confusion can help identify clients by differentiating seizures from syncope. In syncope, there
will be only a brief loss of consciousness without prolonged post-event confusion.

CRANIAL NERVE
NEUROLOGIC ASSESSMENT
Serial neurologic assessments are important as neurologic abnormalities are often initially subtle, making it
important to note the trend. Interventions for neurologic issues are most effective when made early.
The level of consciousness is the most important, sensitive, and reliable indicator of the client's neurological status.
Changes in the level of consciousness can represent increased intracranial pressure and reduced cerebral blood flow.
Changes in vital signs usually do not appear until intracranial pressure has been elevated for some time, or they may
be sudden in cases of head trauma.
Clients must be awakened for a prescribed, necessary neurologic assessment.
A neurologic assessment includes:

1. Glasgow Coma Scale (GCS) best eye, verbal, and motor responses. Best verbal response assesses orientation to person,
place, and time (time is the most sensitive).
2. Pupils equal, round, response to light, and accommodate (PERRLA)
3. Motor strength and movement in all four extremities
4. Vital signs especially any signs of Cushing's triad of bradycardia, bradypnea/abnormal breathing pattern and widening
pulse pressure (the difference between systolic and diastolic blood pressure readings). The nurse is assessing for signs of
increased intracranial pressure (ICP).

BOTULISM

Botulism is caused by the gastrointestinal absorption of the neurotoxin produced by Clostridium botulinum.
The neurotoxin blocks acetylcholine at the neuromuscular junction, resulting in muscle paralysis.
The organism is found in the soil and can grow in any food contaminated with the spores.
Manifestations include descending flaccid paralysis (starting from the face), dysphagia, and constipation (smooth
muscle paralysis).
The main source is improperly canned or stored food.
A metal can's swollen/bulging end can be caused by the gases from C botulinum and should be discarded.
The infant form of botulism can occur in children under age 1 year if they eat honey, particularly raw (wild) honey.
The immature gut system in these children makes them more susceptible.
CEREBELLAR

The cerebellum is involved in 2 major functions: coordination of voluntary movements and maintenance of balance
and posture.
Maintenance of balance is assessed with gait testing and includes watching the client's normal gait first and then the
gait on heel-to-toe (tandem), on toes, and on heels
Coordination testing involves the following:

1. Finger tapping ability to touch each finger of one hand to the hand's thumb
2. Rapid alternating movements rapid supination and pronation
3. Finger-to-nose testing clients touch the clinician's finger and then their own nose as the clinician's finger varies in location
4. Heel-to-shin testing client runs each heel down each shin while in a supine position

CONCUSSION

A concussion is considered a minor traumatic brain injury and results from blunt force or an acceleration/deceleration
head injury.
Typical signs of concussion include:

1. A brief disruption in level of consciousness

2. Amnesia regarding the event (retrograde amnesia)
3. Headache

These clients should be observed closely by family members and not participate in strenuous or athletic activities for
1 2 days. Rest and a light diet are encouraged during this time.
The following manifestations indicate more serious brain injury and are not expected with simple concussion:

o Worsening headaches and vomiting (indicate high intracranial pressure)

o Sleepiness and/or confusion (indicate high intracranial pressure)
o Visual changes
o Weakness or numbness of part of the body
EPILEPSY

Epilepsy is characterized by chronic seizure activity. Clients typically require lifelong anticonvulsant medication.
The nurse should provide education about identifying and avoiding seizure triggers, such as excessive alcohol intake,
sleep deprivation, and stress.
Practicing relaxation techniques (eg, biofeedback) may help reduce the number of episodes.
The client should also be encouraged to wear an epilepsy medical identification bracelet in case of emergency
Phenytoin (Dilantin), a hydantoin anticonvulsant, may decrease the effectiveness of some medications (eg, oral
contraceptives, warfarin) due to stimulation of hepatic metabolism. An alternate, nonhormonal birth
control method (eg, condoms, copper intrauterine device) should be used in addition to or instead of oral
contraceptives . Clients should discuss pregnancy plans with their health care provider, as phenytoin can cause fetal
abnormalities (eg, cleft palate, heart malformations, bleeding disorders).
Clients taking phenytoin should also receive education about practicing good oral hygiene as gingival hyperplasia is a
potential complication.
Anticonvulsants should not be stopped abruptly, as this increases the risk of seizure
For a client with epilepsy, it is not necessary to go to an emergency department after a seizure, unless status
epilepticus (ie, prolonged, repeated seizures) occurs or the client is injured.

STATUS EPILEPTICUS

This client is in status epilepticus, a serious and life-threatening emergency in which a client has been seizing for 5
minutes or longer.
Grunting and a dazed appearance are 2 common signs.
A client with hydrocephalus (abnormal collection of cerebrospinal fluid in the head) and a ventriculoperitoneal (VP)
shunt is at a higher risk for seizures.
Stopping seizure activity is the first nursing priority.
IV benzodiazepines (diazepam or lorazepam) are used acutely to control seizures. However, rectal diazepam is
often prescribed when the IV form is unavailable or problematic. Parents often get prescriptions for rectal diazepam
and are advised to administer a dose before bringing a child to the emergency department.
CEREBRAL EDEMA

Mannitol (Osmitrol) is an osmotic diuretic used to treat cerebral edema (increased intracranial pressure) and acute
glaucoma.
When administered, mannitol causes an increase in plasma oncotic pressure (similar to excess glucose) that draws
free water from the extravascular space into the intravascular space, creating a volume expansion.
This fluid, along with the drug, is excreted through the kidneys, thereby reducing cerebral edema and intracranial
pressure.
However, if a higher dose of mannitol is given or it accumulates (as in kidney disease), fluid overload that may cause
life-threatening pulmonary edema results.
An early sensitive indicator of fluid overload is new onset of crackles auscultated in the lungs.
To prevent these complications, clients require frequent monitoring of serum osmolarity, input and output, serum
electrolytes, and kidney function.
Urine output would be expected to increase from the diuretic effect of mannitol. This is not a complication.
Glasgow Coma Scale scores range from 3-15. Improved mental status (orientation, alertness) is a desired effect of
treatment.
The presence of crackles is a more sensitive sign of fluid overload than pedal edema. Furthermore, in a bedridden
client, the assessment should take place at a dependent part of the body, usually the sacral area.
EMERGENCY TRAUMA ASSESSMENT

Cushing's triad is related to increased intracranial pressure (ICP).

Early signs include change in level of consciousness.
Later signs include bradycardia, increased systolic blood pressure with a widening pulse pressure (difference
between systolic and diastolic), and slowed irregular (Cheyne-Stokes) respirations.
Cushing's triad is a later sign that does not appear until the ICP is increased for some time. It indicates brain stem
compression.
 The skull cannot expand after the fontanels close at age 18 months, so anything taking up more space inside the skull
(eg, hematoma, tumor, swelling, etc.) is a concern for causing pressure on the brain tissue/brain stem and potential
herniation.
In this scenario, hidden head trauma causing an intracranial bleed must be ruled out with diagnostic testing.

CEREBRAL ANUERYSM

A ruptured cerebral aneurysm is a surgical emergency with a high mortality rate.

Cerebral aneurysms are usually asymptomatic unless they rupture; they are often called "silent killers" as they may go
undetected for many years before rupturing without warning signs.
The distinctive description of a cerebral aneurysm rupture is the abrupt onset of "the worst headache of my life" that
is different from previous headaches (including migraines).
Immediate evaluation for a possible ruptured aneurysm is critical for any client experiencing a severe headache with
changes in or loss of consciousness, neurologic deficits, diplopia, seizures, vomiting, or a stiff neck.
Early identification and prompt surgical intervention help increase the chance for survival.

MYASTHENIA GRAVIS

Myasthenia gravis is an autoimmune disease involving a decreased number of acetylcholine receptors at the
neuromuscular junction.
As a result, there is fluctuating weakness of skeletal muscles, most often presented as ptosis/diplopia, bulbar
signs (difficulty speaking or swallowing), and difficulty breathing.
Muscles are stronger in the morning and become weaker with the day's activity as the supply of available
acetylcholine is depleted.
Treatment includes anticholinesterase drugs (pyridostigmine [Mestinon]) that are administered before meals so that
the client's ability to swallow is strongest during the meal
Semi-solid foods (easily-chewed foods) are preferred over solid foods (to avoid stressing muscles involved in
chewing and swallowing) or liquids (aspiration risk)
 All clients with a serious chronic co-morbidity should receive the annual flu vaccine (also the pneumonia vaccine if
appropriate) as they are more likely to have a negative outcome if the illness is contracted. It is especially important in
clients with myasthenia gravis as the flu (or pneumonia) would tax the already compromised respiratory muscles
An anticholinergic drug, such as atropine, is used for treatment in a cholinergic crisis (eg, the medication is too high or
there is excess acetylcholine). The need would not be anticipated during a myasthenic crisis (eg, exacerbation of
myasthenia gravis), which is usually a result of too little medication related to noncompliance, illness, or surgery.
The skeletal muscles are involved in myasthenia gravis; dysfunction of the reflexes or central nervous system affects
bowel and bladder control. This issue is classic with multiple sclerosis.

DELIRIUM

Delirium is characterized by an acute or fluctuating change in mental status that is often reversible and related to
an underlying medical condition. Evidence-based assessment tools, such as the Confusion Assessment Method
(CAM), help clinicians quickly recognize delirium.
Criteria of the CAM tool include an acute or fluctuating change in mentation, inattention, disorganized thinking, and
altered level of consciousness.
Precipitating factors of delirium are numerous and include:

o Medications (eg, opioids, anticholinergics)

o Electrolyte imbalances (eg, hyponatremia)
o Hypoxia
o Acute infection (eg, fever, positive culture)
o Sleep deprivation
o Dehydration or malnutrition
o Metabolic disorders (eg, hypoglycemia)

Nursing interventions include treating the underlying cause as prescribed to resolve delirium (eg, antibiotics,
supplemental oxygen), maintaining a safe environment (eg, continuous monitoring, room near the nurses' station, bed
alarm), reorienting the client frequently, promoting a regular sleep cycle, providing familiar items from home, and
encouraging family and friends to stay with the client.
CAROTID ENDARTERECTOMY

A carotid endarterectomy is a surgical procedure performed to remove plaque from the carotid artery to improve
cerebral perfusion. The nurse must closely assess for signs of new or worsening alterations in neurologic status,
as surgical manipulation of arteries and blood flow increases the risk of stroke.
Monitoring the client's neurologic status postoperatively can be challenging, as the effects of anesthesia degrade the
neurologic examination.
Nurses should use the FAST acronym to assess for stroke:

o Facial drooping: Numbness or droopiness on one side of the face

o Arm weakness: Weakness or drifting of one arm when raised to shoulder level
o Speech difficulties: Slurring of words, incomprehensible speech, inability to understand others
o Time: Notation of the time of symptom onset, which is critical for guiding treatment
 REPRODUCTIVE HEALTH
BREAST CANCER

Breast cancer is the unregulated growth of abnormal breast tissue cells and the second most common cause of
cancer deaths among women. When palpated, the breast lump is usually described as hard, irregularly shaped, non-
mobile, and nontender. Mammography usually detects breast cancer.
Non-modifiable breast cancer risk factors include:

o
o First-degree relative (mother or sister) with history of breast cancer
o BRCA1 and BRCA2 genetic mutations
o Personal history of endometrial or ovarian cancer
o Menarche before age 12 or menopause after age 55

Modifiable breast cancer risk factors include:

o Hormone therapy with estrogen and/or progesterone (increased risk if taken after menopause)
o Postmenopausal weight gain and obesity as fat cells store estrogen
o History of smoking and alcohol consumption
o Dietary fat intake
o Sedentary lifestyle

A client whose menstrual period began at age 17 would not be at increased risk for breast cancer. Clients who began
menarche early (before age 12) or had late menopause (after age 55) are at increased risk for breast cancer.

PROGESTIN ONLY PILLS (POP)

Progestin-only pills (POPs), a form of oral contraception, work by thickening cervical mucus (ie, hinders sperm
motility), thinning the endometrium (ie, hinders implantation), and preventing ovulation.
Cervical mucus changes last only approximately 24 hours, so the client must take the pill at the same time every
day for it to be effective. If the pill is taken , a barrier method (eg, condom) is advised until the pill is
taken correctly for 2 days
 An additional POP should be taken if diarrhea or vomiting occurs within 3 hours of the last dose.
In a POP pack, there are no inactive pills. The client does not take a break from the hormone to menstruate;
subsequently, breakthrough bleeding is commonly reported.
Signs of deep venous thrombosis (eg, calf pain, warmth, swelling) are especially concerning for clients taking
estrogen-containing contraceptives, as estrogen increases the risk for blood clots. In contrast, POPs have a low
cardiovascular risk profile (eg, hypertension, venous thromboembolism).

MARFAN SYNDROME

Marfan syndrome is a connective tissue disorder that causes visual and cardiac defects and a distinct long, slender
body type. In Marfan syndrome with aortic vessel involvement, the root of the aorta is dilated or weakened,
increasing the risk of aortic dissection and aortic rupture. Increases in blood volume and cardiac workload that
occur during pregnancy may worsen aortic root dilation and further increase the risk of aortic dissection/rupture.
Pregnancy in clients with Marfan syndrome, especially those with aortic root dilation, poses a high risk of maternal
mortality. Clients should be instructed about the importance of consistently using reliable birth control methods
to prevent pregnancy.
 Beta blockers are commonly used to treat clients with Marfan syndrome to limit aortic root dilation. Such medications
are generally safe to use during pregnancy, so the client should not discontinue therapy unless directed to do so by
the health care provider.
Clients with Marfan syndrome considering pregnancy should be counseled to complete childbearing in early adulthood
because aortic root dilation and the risk of aortic dissection/rupture increase with time.
Marfan syndrome is an autosomal dominant condition with a 50% chance of inheritance in offspring.

FIBROCYSTIC BREAST CHANGES

One of the most common benign breast disorders is fibrocystic breast changes. Fibrocystic changes correlate to
estrogen/progesterone hormone fluctuations during the menstrual cycle.
Clients may report cysts, nodules, or lumps that are more tender, swollen, and/or noticeable prior to menses. The
condition typically resolves after menopause.
The nurse instructs the client on breast self-awareness and emphasizes that any noncyclic breast changes (ie, not
related to the menstrual cycle) may indicate malignancy (ie, cancer) and should be immediately reported to the
health care provider (HCP)
Clients should be instructed that cyclic pain and swelling may be reduced by decreasing caffeine and sodium intake;
taking vitamins E, A, and B complex; wearing a support bra; utilizing cold compresses; and taking nonsteroidal anti-
inflammatory drugs (eg, ibuprofen).
Clients age >40 should receive yearly clinical breast examinations by an HCP and practice breast self-awareness.
Emphasis is placed on the importance of reporting any suspicious breast changes.
The client should be taught that fibrocystic breast changes are benign and do not increase the risk of breast cancer;
however, reporting noncyclic changes is a higher priority.

CLOMIPHENE

Clomiphene (Clomid, Serophene) is a selective estrogen receptor modulator that is used as a first-line treatment for
infertility for women and works by stimulating ovulation. This medication blocks estrogen receptors in the
hypothalamus and pituitary, which causes the release of hormones (ie, gonadotropin-releasing hormone, follicle-
stimulating hormone, luteinizing hormone) that stimulate the ovaries to release an egg.
The medication is taken orally for 5 days early in the menstrual cycle (eg, beginning on days 3-5 of menses).
Ovulation typically occurs 5-9 days after completing the medication. Therefore, it is necessary for the client to
 understand the importance of engaging in frequent sexual intercourse (eg, every other day for 1 week) 5 days
after completing the medication for the best chance of successful conception
One of the risks of taking clomiphene is that more than one ovarian follicle sometimes develops, causing 2 or more
eggs to be released, which may result in multiple gestation.
Mood swings, nausea, hot flashes, and headaches are common side effects associated with clomiphene.
Clomiphene helps body release eggs and increase chance of becoming pregnant.

INFERTILITY

Teaching about menstrual cycle physiology increases fertility awareness and helps couples optimize their chances
of becoming pregnant sooner. Timing of sexual intercourse near ovulation (ie, "fertile window") is essential to
conception because the ovum and sperm have limited viability in the reproductive tract.
Instructing the client about how to track menstrual cycles (eg, length and regularity of menses) and recognize signs of
ovulation (eg, cyclic changes in cervical mucus) may improve fertility awareness.
Urine ovulation predictor kits may also be used to detect the surge of luteinizing hormone (LH) that precedes
ovulation by 12-24 hours. These predictor kits are easily accessed, over-the-counter tests that can help the client time
intercourse during the "fertile window" to improve chances of conceiving
It is best to provide teaching and encouragement rather than alternatives to pregnancy (eg, adoption, surrogacy).
Teaching about fertility-enhancing medications (eg, clomiphene) may be indicated for clients unable to conceive
naturally but is not the best reply to this client at this time.
Infertility is the inability to conceive after 12 months of frequent, unprotected intercourse for clients without medical
complications (eg, advanced maternal age). However, this is not the best response because this teaching does not
assist the client.
Difficulty achieving pregnancy may affect a couple's social, financial, and intimate relationships. Therefore, clients
may benefit from a holistic approach to care.
The nurse should be alert for signs of psychosocial distress such as expressions of guilt, denial, anger,
or isolation.
Anxiety and depression are common among couples with infertility concerns and require further evaluation of the
client's emotions.
Active listening and open-ended questions may help clients speak more openly and honestly about their feelings
ns (eg, endometriosis, history of male subfertility) should
generally seek fertility evaluation after 6 months of regular, unprotected intercourse.
 Assessing intercourse timing helps the nurse discuss awareness of fertility and natural conception methods. However,
the nurse should prioritize the client's psychosocial needs before providing this type of education.
Encouraging the client to focus on the positive aspects of life does not address the client's emotional concerns, places
the client's feelings on hold, and invalidates the client's feelings.
Female fertility declines as women age, with the first significant decrease seen after age 35.
Hormonal dysfunction (eg, polycystic ovarian syndrome) can cause ovarian cysts and anovulatory cycles (ie, lack of
ovulation during a menstrual cycle), which impair fertility
Some sexually transmitted infections (eg, chlamydia) may be asymptomatic in females, which can delay treatment
(eg, antibiotics). Untreated or recurrent infections cause inflammation (eg, pelvic inflammatory disease), scarring, and
damage to the reproductive tract, leading to infertility
Endometriosis is characterized by endometrial tissue (ie, inner lining of the uterus) depositing outside the uterus.
These endometrial lesions can result in chronic inflammation, pelvic pain, menstrual cycle abnormalities, and infertility
Optimal female fertility is achieved at a BMI of 18.5-24.9 kg/m2; a BMI of 22 kg/m2 is within this normal range. Very
low or very high BMI is associated with hormonal dysfunction and impaired fertility.
PRIAPISM

Priapism is a sustained, painful erection often associated with sickle cell anemia, as the sickling (crescent shaping) of
red blood cells can lead to penile vascular occlusion, erectile tissue hypoxia, and tissue necrosis. Bluish
discoloration is of most concern as it can be a sign of ischemia to the penis.
Some factors, such as alcohol intake; spinal cord injury; and phosphodiesterase-5 enzyme inhibitor (ie, sildenafil),
psychotropic (ie, trazodone), and illegal (ie, cocaine) drugs can contribute to the development of priapism. Possible
penile ischemia is a more urgent concern than alcohol intake.
Extreme pain related to tissue hypoxia is an expected, characteristic manifestation of priapism and requires analgesia,
but it is not as urgent a concern as possible penile ischemia.
Difficulty voiding and urinary retention are complications associated with priapism. It is important to monitor urine
output as catheterization may be necessary, but this is not as urgent a concern as possible penile ischemia.

S/P BREAST RECONSTRUCTION SURGERY

A closed-wound drainage system device (eg, Jackson-Pratt, Hemovac) consists of fenestrated drainage tubing
connected to a flexible, vacuum (self-suction) reservoir unit. The distal end lies within the wound and can be sutured
 to the skin. It is usually inserted near the surgical site through a small puncture wound rather than in the surgical
incision. The purpose of the drain is to prevent fluid buildup (eg, blood, serous fluid) in a closed space.
Although it depends on the client and type of surgical procedure, about 80-120 mL of serosanguineous or sanguineous
drainage per hour during the first 24 hours after surgery can be expected. The priority action is to notify the HCP due
to the change in type and amount of drainage after the first 24 hours following surgery.
Excessive bleeding and fluid collection into the closed space following breast reconstruction can greatly affect the
integrity of the surgical incision, the tissue reconstruction, and wound healing
Opening the bulb does not release excessive negative pressure. It would release all negative pressure, drainage
would cease, and even more fluid would collect in the closed space, compromising the integrity of the incision even
further.
Recording the amount of wound drainage on the output record is an appropriate intervention. However, it is not the
priority action.
Although repositioning the client could affect the amount of drainage, it is not likely as drainage is maintained by
negative pressure, not gravity.

CHLAMYDIA

Chlamydia is the most common sexually transmitted infection and is diagnosed frequently among women,
adolescents, and those with multiple sexual partners.
Many clients are asymptomatic or have minor symptoms (eg, spotting after sex, dysuria, abnormal vaginal discharge)
but can still transmit the infection. Therefore, all sexually active women age <25 and
(eg, new or several sexual partners) are screened annually for chlamydia and gonorrhea.
The client's sexual partners should also receive treatment to prevent transmission and reinfection
If not treated appropriately, chlamydia can ascend the female genital tract, producing serious complications such
as pelvic inflammatory disease and infertility.
Clients should also be instructed in general safe sex practices (eg, using condoms, avoiding multiple partners) to help
prevent transmission of sexually transmitted infections.
Clients should be taught to abstain from sexual intercourse for 7 days after initiation of drug therapy (eg, single
dose of azithromycin, 7 days of doxycycline). This client received treatment today and therefore must wait 7 days
before resuming intercourse
PELVIC INFLAMMATORY DISEASE (PID)

Pelvic inflammatory disease (PID), a leading cause of ectopic pregnancy and infertility, occurs when bacteria from
the genital tract spread upward through the cervix and cause infection of the female reproductive organs (eg,
uterus, fallopian tubes, ovaries) and pelvic cavity.
Symptoms may include pelvic or lower abdominal pain, menstrual irregularities or increased menstrual cramps, painful
intercourse, fever, and abnormal vaginal discharge.
Untreated sexually transmitted infections (STIs) (eg, gonorrhea, chlamydia) are the most common cause of PID.
The nurse should assess for other risk factors, including:
o History of PID
o Multiple sexual partners
o Previous STI
o Unprotected sexual intercourse (ie, without condom use)
o Placement of an intrauterine device within the past 3 weeks
o Recent abortion or pelvic surgery

Oral contraceptive use and age at menarche are not associated with an increased risk of PID.
Gonorrhea and chlamydia can lead to pelvic inflammatory disease (PID) and infertility. They are referred to as
"silent infections" because many affected women show no symptoms.
Infections of the fallopian tubes and uterus can lead to permanent damage and infertility.
 The Centers for Disease Control and Prevention recommend annual chlamydia and gonorrhea screening for all
sexually active females age <25 and older females with risk factors. Both chlamydia and gonorrhea are treatable.
The use of latex condoms is recommended to reduce the risk of contracting chlamydia and gonorrhea.

SEXUAL ASSAULT

Sexual assault, or the coercing or forcing of sexual encounters (eg, groping, rape, incest, human trafficking), may
happen to any individual regardless of age, gender, ethnicity, or relationship to the perpetrator.
Nurses providing emergency care should support victims' complex physical and psychosocial needs, initiate
preventive and therapeutic treatments, and collect and preserve forensic evidence.
Priority nursing actions include:

o Determining whether the client has bathed, showered, or douched, as these actions may compromise evidence
o Educating the victim that a pelvic examination is recommended to identify injuries and collect evidence
o Obtaining the date of the client's last menstrual period and current method of birth control to identify risk for pregnancy
o Performing a head-to-toe assessment to identify physical injuries requiring treatment and thoroughly documenting all
injuries on a body map
o Providing prophylactic therapies for sexually transmitted infections and pregnancy

POST-MENOPAUSAL

Loss of ovarian function during menopause causes a decrease in estrogen production, leading to reduced
osteoblast activity and cardioprotective effect. Therefore, postmenopausal clients are at increased
risk for osteoporosis and coronary artery disease (CAD).
Other physiological changes after menopause may include weight gain, sleep disturbances, fat redistribution, and
vaginal atrophy.
Clients should utilize health promotion strategies to reduce the effects of decreased estrogen levels, including:
o Consuming optimal amounts of dietary calcium (green, leafy vegetables; dairy products) and engaging in weight-
bearing exercise to promote bone health
 o Closely monitoring cholesterol levels (eg, HDL, LDL, triglycerides), as increased LDL cholesterol increases risk
for CAD
o Considering seeking the assistance of a dietitian, and maintaining a low-calorie diet rich in fruits and vegetables,
as hormone changes may cause a predisposition to weight gain
o Seeking support to cope with any emotional symptoms (eg, depression, mood swings, sadness, difficulty
concentrating) caused by changing hormone levels
The average age of menopause in the United States is 50-52. Major health risks of menopause include osteoporosis
and heart disease.
Bisphosphonates, such as alendronate (Fosamax), risedronate (Actonel), or ibandronate (Boniva), decrease bone
resorption so that loss of bone density is minimized. They must be consumed in the morning, on an empty stomach,
with at least 30 minutes before other drugs. The medication is taken with a full glass of water and the client must
remain upright for at least 30 minutes to aid absorption and prevent esophageal irritation
Adequate sources (both food and supplements) of calcium and vitamin D are required to build bone mass
HRT can improve bone mass and prevent osteoporosis but is associated with increased risk of thrombotic
complications (deep vein thrombosis, stroke, myocardial infarction) and some cancers (breast, uterine). Therefore, it
is used only in clients who have disabling hot flashes. Unilateral leg swelling is a classic symptom of venous
thromboembolism (
Anemia in older adults is usually not related to lack of iron intake, especially once menstruation has stopped.
Excessive iron intake can lead to iron overload, and the risk of excess iron tends to be higher with aging.
Postmenopausal bleeding or abnormal premenopausal bleeding is the most common symptom of endometrial cancer
and requires follow-up.

GONORRHEA
To avoid re-infection with gonorrhea, it is essential that the client's partner be tested and treated.
During the visit, the nurse should counsel the client about the importance of partner evaluation and treatment and the
likely recurrence of the infection if the partner refuses to be treated.
The client should avoid sexual relations until treatment is completed and the client and partner no longer have
symptoms.
SYPHILIS IN PREGNANT WOMEN

Nurses have an ethical responsibility to respect the pregnant client's authority to make decisions for herself and on
behalf of her fetus, authority known as the principle of autonomy.
A woman's autonomy and right to make decisions regarding her body do not change during pregnancy.
The nurse assists the client by educating about the need for treatment and the consequences of refusing treatment for
herself and her fetus, thereby ensuring that the client's refusal of treatment is an informed decision
Syphilis is a sexually transmitted infection that crosses the placenta.
Refusing treatment for syphilis in pregnancy may result in fetal harm or death.
The only treatment available in pregnancy is IM penicillin injection.
The expected outcome of treatment is resolution of maternal infection and prevention or successful treatment of fetal
infection.
Rather than elevating the rights of the fetus or using coercion or legal channels, the nurse should respect the client's
decision and counsel the client on the need for treatment.
The nurse respects a client's right to refuse treatment, but this does not mean that discussion of the diagnosis and
treatment is avoided. The nurse maintains responsibility to educate and advocate for the health of the client and fetus.

EMERGENCY CONTRACEPTION

Emergency contraception (EC) prevents pregnancy after unprotected intercourse.

EC pills (eg, levonorgestrel [Plan B]) should be taken within 5 days of intercourse; however, efficacy is reduced after 3
days (72 hours).
The copper intrauterine device (IUD) may be inserted for up to 5 days after intercourse as another form of EC.
Women in stable, monogamous relationships are good candidates for IUD placement. IUDs provide no protection
against sexually transmitted infections (STIs) and increase the risk of pelvic inflammatory disease.
Backup contraception is required for 7 days after starting oral contraceptives unless the pill pack is started on the first
day of menses. In this case, backup barrier contraception may be used to prevent STIs but is not required to prevent
pregnancy.
Diaphragms are flexible latex/silicone devices inserted before intercourse to cover the cervix and prevent pregnancy.
They do not provide protection against STIs such as HIV.
TESTICULAR SELF-EXAMINATION

Testicular cancer is the most common form of cancer in men age 15-35. When diagnosed early, it is highly curable.
Clients at high risk for developing a tumor (eg, history of undescended testis) are encouraged to perform a monthly
TSE.
Client instructions for a TSE include:

o Perform TSE monthly on the same day (easy to remember)

o Perform TSE while taking a warm shower or bath as warm temperatures will relax the scrotal tissue and make the testis
hang lower in the scrotum
o Use both hands to feel each testis separately
o Palpate each testicle gently, using the thumb and first 2 fingers
o Check that the testicle is normally egg-shaped and movable with a smooth surface

The clinical findings that should be reported to the health care provider include:

o Painless, hardened lump on testes

o Scrotal swelling or heaviness
o Dull ache in pelvis or scrotum

It is normal for one testicle to be slightly larger or hang lower than the other. Some people may also confuse
epididymis (small coiled tube) as a small lump at the beginning. These do not need to be reported.
GENITAL HERPES

Herpes simplex virus type 2 (HSV-2) is usually associated with genital herpes. Lesions are painful and appear as
multiple small, vesicular lesions.
Management strategies focus on disease spread, including autoinoculation (eg, fingers) and pain relief, and include:

o Avoid sexual activity when lesions are present as the virus spreads through contact with the lesion; barrier contraception
is not sufficient during an outbreak. After the outbreak has resolved, condoms should be used in future sexual encounters as
transmission is possible even in the absence of active lesions.
o Keep the area with lesions clean and dry.
o Avoid use of perfumed soaps and bubble baths.
o Maintain proper hand hygiene and avoid touching the lesions to prevent spreading.
o Use sitz baths and oatmeal baths to provide comfort and relief of itching and burning.
 Vesicles contain numerous virus particles, leading to the possibility of self-inoculation. This can be prevented by
avoidance of hand contact with lesions during an outbreak.
Use of a hair dryer on a cool setting is an effective means of drying the lesions and promoting client comfort.
Warm water provides symptomatic relief. Mild soap containing no perfumes reduces the risk of irritation to the area.

RADICAL PROSTATECTOMY

Following open radical prostatectomy, any rectal interventions such as suppositories or enemas must
be avoided to prevent stress on the suture lines and problems with healing in the surgical area.
The client should not strain when having a bowel movement for these reasons. Therefore, interventions to prevent
constipation are an important part of postoperative care and discharge teaching. Prevention of constipation is
particularly important while the client remains on opioid analgesics, which can cause constipation
Fluid intake should be encouraged in this client.
The client is at risk for postoperative deep vein thrombosis and pulmonary embolism. Ambulation is an important part
of preventing these serious surgical complications. Ambulation will also help reduce constipation.
The client who goes home with an indwelling catheter should learn how to clean around the catheter at the urinary
meatus with warm water and soap to prevent infection.

PRENATAL CARRIER SCREENING

Carrier screening offers clients who are unaffected by a genetic disorder the option to discover whether they possess
an abnormal gene (ie, are carriers) that may affect health outcomes of future offspring. This type of genetic testing is
frequently offered preconceptionally/prenatally to guide pregnancy decision-making.
Cystic fibrosis follows an autosomal recessive inheritance pattern, meaning that offspring must receive
two abnormal genes (one from each parent) to be affected with the disorder.Other disorders following this
inheritance pattern include phenylketonuria, Tay-Sachs disease, and sickle cell disease.
Male and female offspring have the same likelihood of inheriting autosomal recessive disorders because the abnormal
gene is not linked to a sex chromosome.
X-linked recessive disorders (eg, hemophilia, Duchenne muscular dystrophy) most often affect male offspring. This
inheritance pattern occurs because male offspring who receive an abnormal sex chromosome from a female carrier
(ie, X chromosome) will have the disorder because, unlike female offspring, they only have one X chromosome.
 Because carriers with no evidence of the disorder can pass an abnormal gene to offspring, autosomal recessive
conditions may not present in every generation. However, autosomal dominant inheritance patterns (eg, Huntington
disease, achondroplasia) are noted in each previous generation because affected offspring must have an affected
parent.

CERVICAL CAP

The cervical cap is a barrier method of contraception used with spermicide (eg, nonoxynol-9). The reusable, cup-
shaped cap is placed over the cervix before intercourse to block sperm from the uterus. To allow time for sperm to
die, the cap should remain in place for but should not remain for more than 48 hours.
The cap may remain in place for multiple acts of intercourse, but clients should confirm correct placement and insert
additional spermicide into the vagina each time.
Prior to insertion, spermicide is applied to the cervical cap to maximize contraceptive effectiveness. Spermicide
should be applied inside the cap, along the rim of the cap, and in the groove on the underside of the cap.
Use of cervical caps during menses (or during the postpartum period in clients with lochia discharge) increases the
risk of toxic shock syndrome; an alternate contraceptive method should be used during this time.
Inserting the cervical cap several hours before intercourse is acceptable and may improve correct use. Before each
use, the client should inspect the cap for holes, cracks, or tears to ensure its effectiveness for blocking sperm.

HUMAN PAPILLOMA VIRUS (HPV)

Human papillomavirus (HPV), one of the most common sexually transmitted infections, is associated with genital
warts and cervical cancer. There are many different strains of HPV, with types 16 and 18 causing nearly all cases of
cervical cancer.
HPV infection is often asymptomatic, and genital warts due to HPV are typically painless. Prevention
includes vaccination against HPV before sexual activity begins and safe sex practices/abstinence. The
recommended age for vaccination in both boys and girls is age 11-12, but the vaccine can be given as early as age 9
and up to age 26.
Clients with HPV and their partners should be educated that the virus can still be spread through skin-to-skin contact,
even with the use of condoms .
Safe sex practices decrease the risk of disease transmission but do not prevent it entirely.
HPV can be spread through sexual contact, even if symptoms are not present.
 HPV may be transmitted through vaginal, anal, or oral sex.
Clients with HPV need to have annual Papanicolaou tests as the virus increases the risk of cervical cell changes (ie,
dysplasia) and subsequent risk of cervical cancer.
INFLAMMATORY BREAST CANCER

The nurse would be most concerned about the client who describes symptoms of inflammatory breast cancer.
In this aggressive form of cancer, breast lymph channels are blocked by cancer cells, creating breast tissue that
becomes red, warm, and has an orange peel (peau d'orange), pitting appearance on the skin surface.
The nurse would be most concerned about this client and make an immediate referral to the health care provider for
examination and evaluation.

VASECTOMY

A vasectomy is a surgical procedure performed for permanent male sterilization. During the procedure, the vasa
deferentia (ie, ducts that carry sperm from the testicles to the urethra) are cut and sealed, preventing sperm from
entering the ejaculate. The vasa deferentia are severed in the scrotum at the site before the seminal vesicles and
prostate. As a result, the procedure should not affect the ability to ejaculate, amount and consistency of ejaculatory
fluid, or other physiological mechanisms (eg, hormone production, erection, orgasm). Following a vasectomy, sperm
continue to be produced but are absorbed by the body.
Following the procedure, it can take several months for the remaining sperm to be ejaculated or
absorbed. Alternative birth control should be used until the health care provider confirms that semen samples
taken at a follow-up appointment are free of sperm; otherwise, pregnancy can occur
The length of time and number of ejaculations necessary to evacuate remaining sperm will vary. The only way to
ascertain that the ejaculate no longer contains sperm is to test a client's semen samples.

PAP TESTING

Pap testing allows early detection of cervical dysplasia (ie, abnormal cell growth) that may indicate cervical cancer.
Human papillomavirus (HPV), an extremely common sexually transmitted infection (STI), causes almost all cases of
cervical cancer. However, most women have transient infections that resolve spontaneously. Therefore, cervical
cancer screening guidelines balance the need to screen for persistent (cancer-causing) infection with the knowledge
that overtreating (eg, cold knife cone) may cause more harm than good.
 Cervical cancer screening is typically initiated at , regardless of age at onset of sexual activity. Women
age 21-29 should be screened with Pap testing every 3 years in the United States or every 1-3 years in Canada
Regardless of sexual activity history, adolescents do not need Pap testing because HPV infection very rarely
progresses to cancer in women age <21. However, testing for other STIs (eg, gonorrhea, chlamydia, HIV) is
appropriate.
A client whose uterus and cervix were removed for reasons unrelated to cervical cancer does not need Pap testing if
prior Pap tests were normal.
For clients who have a history of regular Pap testing with normal results, practice guidelines recommend discontinuing
nited S

OVARIAN CANCER

Ovarian cancer results in more deaths than any other gynecologic cancer.
Symptoms are often subtle and may include abdominal bloating; pelvic pain or pressure; abdominal girth increase;
early satiety; abdominal, back, or leg pain; urinary urgency/frequency; and gastrointestinal disturbances.
Due to the lack of routine screening and reports of vague symptoms, ovarian cancer may not be diagnosed until an
advanced stage.

VAGINAL HYSTERECTOMY

The nurse should take immediate action when a client recovering from a vaginal hysterectomy saturates more than
one perineal pad in an hour. The nurse should further assess the client and report these findings and excessive
vaginal bleeding to the health care provider (HCP).
The client should be encouraged to perform leg exercises while in bed to promote circulation and prevent deep vein
thrombosis (DVT).
The client's voiding of 500 mL of straw-colored urine is a normal finding.

ACUTE PROSTATITIS

Prostatitis is inflammation of the prostate gland, usually caused by a bacterial infection. Symptoms include
rectogenital pain, burning, urinary hesitancy, and/or urinary urgency.
Management of prostatitis includes antimicrobial and anti-inflammatory medications (eg, ibuprofen). Alpha-
adrenergic blockers (eg, tamsulosin, alfuzosin) help relax the bladder and prostate.
Suprapubic catheterization may be necessary for urinary retention in severe cases of acute prostatitis.
Urethral catheterization is contraindicated due to the risk of exacerbating pain and urethral inflammation.

Clients should be instructed to:

o Hydrate with clear liquids (eg, water, fruit juices). Avoid coffee, tea, and other caffeinated beverages due to diuretic and
stimulant properties, which may worsen symptoms
o Complete the full course of antibiotics regardless of symptom improvement to ensure infection resolution
o Engage in sexual intercourse or masturbation to reduce discomfort related to retained prostatic fluid. Clients should use
a barrier prophylactic method (eg, condoms) when engaging in sexual activity with a partner to prevent transmission of the
causative organism
o Take stool softeners as prescribed to reduce straining during defecation; tension of the pubic muscles presses against the
prostate, causing pain
o Take sitz baths, in which the hips and buttocks are immersed in warm water, to help relieve symptoms.
 RESPIROLOGY
PLEURAL FRICTION

Pleurisy is characterized by stabbing chest pain that usually increases on inspiration or with cough.
It is caused by inflammation of the visceral pleura (over the lung) and the parietal pleura (over the chest cavity).
The pleural space (between the 2 layers) normally contains about 10 mL of fluid to help the layers glide easily with
respiration.
When inflamed, they rub together, causing pleuritic pain.
A pleural friction rub is auscultated in the lateral lung fields over the area of inflammation.
The sound is produced by the 2 layers rubbing together and can indicate pleurisy, a complication of pneumonia.
It is characterized by squeaking, crackling, or the sound heard when the palm is placed over the ear and the back of
the hand is rubbed with the fingers.
Complications of pneumonia are more prevalent in elderly clients with underlying chronic disease.
RESPIRATORY FAILURE

Acute severe asthma exacerbations (status asthmaticus) occur when severe airway obstruction and lung hyperinflation
(air trapping) persist despite aggressive treatment with bronchodilators and corticosteroid therapy.
Clinical manifestations indicating impending respiratory failure include:

o PaCO2 Indicates hypercapnia and hypoventilation resulting from fatigue and labored breathing. As
initial tachypnea subsides and respiratory rate returns to normal, PaCO 2 rises and respiratory acidosis develops
o PaO2 Indicates hypoxemia resulting from increased work of breathing, decreased gas exchange
(hyperinflation and air trapping), and inability of the lungs to meet the body's oxygen demand
o Paradoxical breathing (ie, abnormal inward movement of the chest on inspiration and outward movement on expiration):
Indicates diaphragm muscle fatigue and use of respiratory accessory muscles
o Mental status changes (eg, restlessness, confusion, lethargy, drowsiness): Sensitive indicators of hypoxemia and hypoxia
 o Absence of wheezing and silent chest (ie, no sound of air movement on auscultation): Ominous signs indicating severe
hyperinflation and air trapping in the lungs
o Single-word dyspnea: Inability to speak >1 word before pausing to breathe due to shortness of breath

ACUTE RESPIRATORY FAILURE

ARF is defined as inadequate gas exchange that is intrapulmonary (pneumonia, pulmonary embolism) or
extrapulmonary (head injury, opioid overdose) in origin.
Respiratory failure associated with an alteration in O 2 transfer or absorption is type I hypoxemic failure (eg, acute
respiratory distress syndrome, pulmonary edema, shock).
Respiratory failure associated with carbon dioxide (CO 2) retention is type II hypercapnic, or ventilatory failure (eg,
chronic obstructive pulmonary disease, myasthenia gravis, flail chest).
ARF is a potential complication of major surgical procedures, especially those involving the thorax and abdomen, as in
this client.
ABG values that indicate the presence of ARF are PaO2 60 mm Hg (8.0 kPa) or PaCO2 50 mm Hg (6.67 kPa).

Immediate intervention with high O2 concentrations is indicated, and noninvasive or invasive, positive-pressure
mechanical ventilation may be necessary.

PULMONARY EMBOLISM

Pulmonary embolism (PE) is a potentially life-threatening medical emergency occurring when a blood clot, fat or air
embolus, or tissue (eg, tumor) travels via the venous system into the pulmonary circulation and obstructs blood flow
into the lung.
This prevents deoxygenated blood from reaching the alveoli, which leads to hypoxemia due to impaired gas exchange
and cardiac strain due to congested blood flow in the pulmonary arteries.
Clinical manifestations of PE range from mild (eg, anxiety, cough) to severe (eg, heart failure, sudden death).
However, many clients initially have mild, nonspecific symptoms that are often misdiagnosed and inadequately
managed, greatly increasing the likelihood of progression to shock and/or cardiac arrest.
Clinical manifestations of PE include:

o Pleuritic chest pain (ie, sharp lung pain while inhaling)

o Dyspnea and hypoxemia
o Tachypnea and cough (eg, dry or productive cough with bloody sputum)
o Tachycardia - the heart attempts to compensate for hypoxemia, right ventricular overfilling, and decreased left ventricular
cardiac output.
o Unilateral leg swelling, erythema, or tenderness related to deep vein thrombosis

Pulmonary embolism (PE) is usually caused by a dislodged thrombus that travels through the pulmonary circulation,
becomes lodged in a pulmonary vessel, and causes an obstruction to blood flow in the lung.
The nursing diagnosis of impaired gas exchange involves an alteration in the normal exchange of oxygen and carbon
dioxide at the alveolar-capillary membrane, resulting in inadequate oxygenation and hypoxemia (respiratory alkalosis,
pO2 <80 mm Hg, restlessness, dyspnea, and tachycardia).
Impaired gas exchange related to a ventilation-perfusion (V/Q) imbalance is the highest priority nursing diagnosis.
It addresses the most basic physiologic need oxygen. Clients will not survive without adequate oxygenation.
PNEUMONIA

Pneumonia is an acute infection of the lungs. Findings in a client with pneumonia include:

o Crackles - Fine or coarse crackling sounds caused by air passing through alveoli and small airways obstructed with mucus
o Fever, chills, productive cough, dyspnea, and pleuritic chest paiN
o Increased vocal/tactile fremitus - Transmission of palpable vibrations (fremitus) is increased when transmitted through
consolidated versus normal lung tissue.
o Bronchial breath sounds in peripheral lung fields - High-pitched, harsh sounds conducted through consolidated lung
tissue, which are abnormal when heard in an area distant from where normally heard (ie, trachea); this finding can be
an early sign of pneumonia.
o Unequal chest expansion - Decreased expansion of affected lung on palpation
o Dullness - Percussion of medium-pitched sounds over consolidated lung tissue (pneumonia) or fluid-filled space (eg, pleural
effusion, a complication of pneumonia)
In pneumonia, the lung is filled with infectious debris and exudate. This increase in secretions and a simultaneous
decrease in mucociliary clearance result in possible airway obstruction.
Interventions to facilitate airway clearance include the following:

o Hydration - IV fluids, oral intake (2-3 L/day), and respiratory humidification help thin secretions, maintain moisture of mucous
membranes, and promote mucociliary clearance.
o Huff coughing technique - the most effective way to raise secretions from the lower to the upper airway for expectoration. If
pain limits deep breathing and coughing, anaLgesia can be prescribed
o Chest physiotherapy (percussion, vibration, and postural drainage) to open airways and break up thickened secretions
o Fowler's position - Sitting upright with the head of the bed at 45-60 degrees promotes lung expansion and facilitates
coughing and secretion removal.

Clients should be taught to understand that symptoms of pneumonia (eg, cough, sputum production, shortness of
breath, fatigue, and activity intolerance) remain after discharge even though the bacteria are no longer present and will
dissipate over a 2-4 week period, depending on current health status and preexisting conditions. Discharge teaching
includes the following instructions:

o Avoid the use of over-the-counter cough suppressant medicines. Unless prescribed by the HCP, cough suppressants
are avoided as they impair secretion clearance, especially in clients with chronic bronchitis.
o Schedule a follow-up with the HCP and chest x-ray. Follow-up is needed at about 2 weeks after completion of antibiotic
therapy. X-ray may be needed at a later time in certain high-risk clients to make sure the pneumonia is resolved with no
underlying cancer.
o Use a cool mist humidifier in your bedroom at night. Humidifiers keep mucus membranes moist, maintain effectiveness
of the mucociliary escalator, and facilitate expectoration of mucus. A warm bath also loosens the secretions.
o Continue using the incentive spirometer at home. Deep breathing and coughing promote lung expansion, ventilation,
oxygenation, and airway clearance.
o Drink 1-2 liters of water a day, if not contraindicated, to help thin secretions and facilitate mobilization. Limit caffeine and
alcohol as they can dry mucus membranes due to diuretic effects.
o Notify the HCP of any increase in symptoms (eg, shortness of breath, cough, sputum production, chest pain, fever,
confusion).
o Avoid all tobacco products and second-hand smoke as these irritate the airways and impair mucociliary clearance and
oxygenation.
o Eat a balanced diet, increase activity slowly over about 2 weeks, and take rest periods when needed to help maintain
resistance to infection.
CHEST TUBE

Clamping the chest tube during transport is contraindicated. Doing so can cause air to accumulate in the pleural
cavity as it has no means of escape. This can lead to the development of a tension pneumothorax, a potentially life-
threatening condition. A tension pneumothorax results in compression of the unaffected lung and pressure on the
heart and great vessels. As the pressure increases, venous return is decreased and cardiac output falls.
The wall suction needs to be temporarily disconnected during transport. It should be reconnected promptly at the
destination.
The chest tube collection unit should be hung below the level of the chest to promote drainage and keep fluids from re-
entering the chest cavity.
All connections should be secured with tape to prevent accidental disconnection or air to enter the system.

CHEST DRAINAGE SYSTEM

The suction control chamber (Section A) maintains and controls suction to the chest drainage system; continuous,
gentle bubbling indicates that the suction level is appropriate.
The amount of suction is controlled by the amount of water in the chamber and not by wall suction. Increasing the
amount of wall suction would cause vigorous bubbling but does not increase suction to the client as excess suction is
drawn out through the vent of the suction control chamber.
Vigorous bubbling would increase water evaporation and therefore decrease the negative pressure applied to the
system.
The nurse should check the water level and add sterile water, if necessary, to maintain the prescribed level.
The water seal chamber contains water, which prevents air from flowing into the client. Up and down movement of
fluid (tidaling) in Section B would be seen with inspiration and expiration and indicates normal functioning of the
system. This will gradually reduce in intensity as the lung reexpands.
 The air leak monitor (Section C) is part of the water seal chamber. Continuous or intermittent bubbling seen here
indicates the presence of an air leak.
The collection chamber (Section D) is where drainage from the client will accumulate. The nurse will assess amount
and color of the fluid and record as output.

ALLERGY SKIN TESTING

Allergy skin testing involves introducing common environmental and food allergens (ie, antigens) into the skin
surface and then observing the site for an allergic reaction (eg, formation of a wheal, erythema).
Several different antigens, as well as positive and negative controls, are usually tested at the same time for accuracy.
To ensure an accurate result, the client should avoid antihistamines (eg, diphenhydramine [Benadryl], loratadine
[Claritin], promethazine [Phenergan]) for up to 2 weeks prior to the test
Antihistamines block mast cell release of histamines that are responsible for allergic symptoms.
Systemic corticosteroids, used to treat the inflammatory component of asthma, may also affect the accuracy of
allergy skin testing; therefore, the use of these medications is assessed by the health care provider.

BRONCHITIS

Bronchitis is inflammation of the upper airways (bronchi) often precipitated by a viral infection.
Rhonchi (ie, sonorous wheeze) are continuous, low-pitched adventitious breath sounds that occur when thick
secretions or foreign bodies (eg, tumors) obstruct airflow in the upper airways.
The resulting sound resembles moaning or snoring and is heard primarily during expiration but may also be present
during inspiration.
Rhonchi are commonly heard in bronchitis, cystic fibrosis, or some types of pneumonia, and may clear with coughing
or suctioning

Chronic bronchitis is characterized by excessive mucus production, chronic cough, and recurrent respiratory tract
infections. Interventions to help reduce viscosity of mucus, facilitate secretion removal, and promote comfort include
the following:
 o Increasing oral fluids to 2-3 L/day if not contraindicated prevents dehydration and keeps secretions thin
o Cool mist humidifier increases room humidity of inspired air
o Guaifenesin (Robitussin) is an expectorant that reduces the viscosity of thick secretions by increasing respiratory tract fluid;
drinking a full glass of water after taking the medication is recommended.
o Abdominal breathing with the huff, a forced expiratory cough technique, is effective in mobilizing secretions into the large
airways so that they can be expectorated
o Chest physiotherapy (postural drainage, percussion, vibration)
o Airway clearance handheld devices, which use the principle of positive expiratory pressure to help loosen secretions when
the client exhales through the mouthpiece

LUNG SOUNDS

Asthma typically manifests with high-pitched, musical wheezes caused by airway narrowing. These wheezes are
typically heard during expiration but may also occur on inspiration during acute asthma exacerbations.
Croup often manifests with stridor, a high-pitched inspiratory breath sound that can often be heard without using a
stethoscope. Stridor is caused by partial obstruction of the upper airway and is often louder over the throat.
Pleurisy manifests with pleural friction rub, a loud, rough rubbing or grating sound heard throughout inspiration and
expiration that is caused by the pleural surfaces rubbing together. Pleural friction rub sounds similar to crackles, but
crackles are typically heard only during inspiration.
Coarse crackles (loud, low-pitched bubbling) are heard primarily during inspiration and are not cleared by
coughing. The sound is similar to that of Velcro being pulled apart. Coarse crackles may be confused with fine
crackles (eg, atelectasis), which have a high-pitched popping sound.
Coarse crackles are present when fluid or mucus collects in the lower respiratory tract (eg, pulmonary edema,
pulmonary fibrosis). In heart failure, the left ventricle fails to eject enough blood, causing increased pressure in the
pulmonary vasculature. As a result, fluid leaks into the alveoli (pulmonary edema).
Diuretics (eg, furosemide) treat pulmonary edema by increasing fluid excretion by the kidneys
Clients with asthma or chronic obstructive pulmonary disease (eg, emphysema) develop wheezing due to
bronchospasm. Bronchodilators (eg, albuterol, ipratropium) are indicated for these clients.
Emphysema is a chronic hyperinflation of the alveoli. Clients with emphysema are taught the pursed-lip
breathing technique to prevent alveolar collapse during exhalation. Emphysema causes diminished lung sounds,
prolonged expiration, and wheezing.
Chest tubes are inserted into the pleural space to remove trapped air (eg, pneumothorax) or fluids (eg, hemothorax,
pleural effusion). Lung sounds are diminished or absent when lung tissue is compressed by air or fluids in the
pleural space.
RAPID RESPONSE TEAM (RRT)

The rapid response team (RRT) consists of a group of health care providers who bring critical care expertise to the bedside of
clients demonstrating early signs of deterioration such as dyspnea, confusion, and restlessness. This team differs from the
"Code" team that is called when a client stops breathing or goes into cardiac arrest. Any health care worker can call the RRT.
COPD

Chronic obstructive pulmonary disease (COPD) generally refers to 2 conditions, emphysema and chronic bronchitis. A
combination of the 2 is common.
It affects about 12 million people and is the 3rd leading cause of death in the United States.
It occurs most commonly in the seventh decade of life. COPD is categorized by slowly progressive, persistent
airflow obstruction that is closely associated with chronic airway inflammation.
The major risk factor is tobacco smoke (eg, cigarette, pipe, cigar).
Although the client quit smoking cigarettes last year, he smoked a pack a day for 53 years.
Working as a car mechanic for 40 years is a major risk factor because of prolonged exposure to carbon monoxide
fumes.
Exposure to irritating chemicals, fumes, or vapors in the presence of cigarette smoking increases the risk of
developing COPD.
Clients with chronic obstructive pulmonary disease (COPD) suffer from progressive inflammatory tissue damage,
which eventually leads to lung scarring and airway remodeling. Through these mechanisms, COPD leads to chronic
air trapping and reduced gas exchange by decreasing ventilation.
Clients with COPD are at increased risk for respiratory infections, which can trigger an acute exacerbation of
COPD. Therefore, it is vital that clients receive both routine flu and pneumococcal vaccinations.
It is also important that clients seek medical help for increased sputum, worsening shortness of breath, or lack of
relief from prescribed emergency medications (eg, albuterol, ipratropium)
COPD may lead to polycythemia (increased red blood cells), in which the body attempts to compensate for chronic
hypoxia by increased proliferation of erythrocytes. This occurs when erythropoietin is released from the kidneys in
response to hypoxemia and leads to erythropoiesis. This ultimately has the opposite effect of anemia, making
supplementation with iron not necessary and possibly even harmful.
Clients with COPD have increased work of breathing and are often winded by simple activities (eg, eating). Clients
should eat frequent, small, high-calorie meals to conserve energy and meet nutritional requirements.
Consuming adequate nutrition is difficult for clients with advanced chronic obstructive pulmonary disease (COPD),
as chewing and swallowing increase work of breathing and a full stomach increases pressure on the diaphragm. As a
result, clients often lose weight because their energy expenditure is greater than their nutritional intake.
To optimize nutritional intake, clients should:

o Drink fluids between meals, rather than before or during, to prevent stomach distension and decrease pressure on the
diaphragm while eating
o Eat small, frequent meals, snacks, and supplements that are high in calories and protein. Smaller meals require less
energy to chew and swallow, resulting in less fatigue and dyspnea
o Perform oral hygiene before meals. Chronic mouth breathing leads to dry mouth; excessive sputum and medication side
effects can alter the taste of food, decreasing the appetite

For clients with advanced COPD, exercise is discouraged for 1 hour before and 1 hour after eating as it increases
oxygen demand and fatigue.
Gas-forming foods (eg, broccoli, beans, cabbage) and carbonated beverages should be avoided as they cause
intestinal bloating and increased pressure on the diaphragm.
Clients with chronic obstructive pulmonary disease (COPD) often develop ineffective coughing patterns due to
weakened muscles and narrowed airways prone to collapse under increased pressure. Therefore, clients with COPD
are unable to cough effectively and require additional teaching to effectively expectorate secretions and prevent
overexertion.
Huff coughing is a series of low-pressure coughs using the following steps:

o Sit upright in a chair with feet spread shoulder-width apart and lean forward with shoulders relaxed; forearms supported on
thighs or pillows; head and knees slightly flexed; and feet touching the floor
o Perform a slow, deep inhalation through the mouth or nose using the diaphragmatic muscle
o Hold breath for 2 3 seconds, keeping the throat open, and then perform a quick, forceful exhalation, creating an audible
"huff" sound
o Repeat the "huff" once or twice more to expectorate any mucus
o Rest for 5-10 regular breaths and repeat as necessary until all mucus is cleared

The pursed-lip breathing technique helps to decrease shortness of breath by preventing airway
collapse, promoting carbon dioxide elimination, and reducing air trapping in clients with chronic obstructive
pulmonary disease (COPD).
Clients with COPD are taught to use this technique when experiencing dyspnea as it increases ventilation and
decreases work of breathing. Regular practice (eg, 5 10 minutes 4 times daily) enables the client to do pursed lip
breathing when short of breath, without conscious effect.
Clients are taught the following steps:

1. Relax the neck and shoulders

2. Inhale for 2 seconds through the nose with the mouth closed
3. Exhale for 4 seconds through pursed lips. If unable to exhale for this long, exhale twice as long as inhaling
PERITONSILLAR ABSCESS

Peritonsillar, or retropharyngeal, abscess is a serious complication that can result from tonsillitis or pharyngitis.
The presenting features of peritonsillar abscess, in addition to fever, include a "hot potato" (muffled)
voice, trismus (inability to open the mouth), pooling of saliva (drooling), and deviation of the uvula to one side.
The abscess can progress to life-threatening airway obstruction (eg, dysphagia, stridor, restlessness).
The nurse should immediately assess the client with symptoms of peritonsillar abscess and monitor for signs of airway
obstruction

NASOPHARYNGEAL AIRWAY

A nasopharyngeal airway (NPA) is a tube-like device used to maintain upper airway patency.
NPAs are frequently used in alert or semiconscious clients, as they are less likely to cause gagging, and in clients with
oral trauma or maxillofacial surgery.
NPAs should never be inserted in clients who may have head trauma (eg, facial or basilar skull fractures), such as
might occur during an unwitnessed seizure.
 NPAs inserted in clients with skull fractures may be malpositioned into underlying tissues/structures (eg, brain).
Therefore, the nurse should immediately clarify prescriptions for NPAs in clients with head trauma.
An NPA may be inserted after imaging (eg, CT scan) rules out fracture.
Once skull fracture is ruled out and an NPA is inserted, the nurse verifies appropriate airway placement by
auscultating the lungs.
Inappropriate NPA size increases the risk for airway obstruction, sinus blockage, and infection.
To select an appropriate size, the nurse measures from the tip of the client's nose to the earlobe and selects a
diameter smaller than the naris.
Bleeding disorders and use of anticoagulant or antiplatelet medication (eg, aspirin) are relative contraindications to
NPA insertion, as these increase the risk of bleeding.
However, skull fracture must be excluded prior to placement.

PEAK EXPIRATORY FLOW

An asthma action plan is an individualized management plan developed collaboratively between the client and the
HCP to facilitate self-management of asthma.
It includes information on daily and long-term treatment, prescribed medicines and when to take them according to a
zone system, how to manage worsening symptoms or attacks, and when to call the HCP or go to the emergency
department.
The action plan uses traffic signal colors to categorize into zones degrees of asthma symptom severity and airway
obstruction (peak flow meter readings):

o Green zone indicates asthma is under control and PEF is 80%-100% of personal best. When in this zone, there is no
worsening of cough, wheezing, or trouble breathing
o Yellow zone means caution; even on a return to the green zone after use of rescue medication, further medication or a
change in treatment is needed
o Red zone indicates a medical alert and signals the need for immediate medical treatment if the level does not return to
yellow immediately after taking rescue medications
CYSTIC FIBROSIS

In cystic fibrosis (CF), a defective protein responsible for transporting sodium and chloride causes the secretions
from the exocrine glands to be thicker and stickier than normal.
These abnormal secretions plug smaller airway passages and ducts in the GI tract, which can impair digestive
enzymes and result in ineffective absorption of essential nutrients.
These sticky respiratory secretions lead to a chronic cough and inability to clear the airway, eventually
causing chronic lung disease (bronchiectasis).
As a result of these changes, the client's life span is shortened; most affected individuals live only into their 30s.
The sticky respiratory secretions lead to the inability to clear the airway and a chronic cough.
The client eventually develops chronic lung disease (bronchiectasis) and is at risk for recurrent lung infections.
These clients are also at risk for rupture of the damaged alveoli, which results in sudden-onset pneumothorax.
Findings of pneumothorax include sudden worsening of dyspnea, tachypnea, tachycardia, and a drop in oxygen
saturation.
Because many of these findings can be seen with lung infection, a sudden drop in oxygen saturation could be the only
early clue.
The client with CF will often have a decreased pulse oximetry (reflects oxygen saturation in the blood) reading due to
the chronicity of the disease process and damage to the lungs; however, a reading of 90% requires urgent
intervention.
Clients with CF often cough up blood-streaked sputum (hemoptysis) as a result of damage to blood vessels in the
airway walls secondary to infections.
However, this usually resolves with treatment of the infection.
Frank hemoptysis needs urgent assessment.
Maintaining weight is a challenge in those with CF due to the malabsorption of carbohydrates, fats, and proteins
caused by the impaired enzyme secretions in the gastrointestinal tract.
In addition, weight and appetite loss may indicate an undiagnosed underlying lung infection. This will need to be
addressed, but oxygenation is the priority.
Fecal retention and impaction are common in CF due to decreased water and salt secretion into the intestines. This
will need to be addressed, but oxygenation is the priority.
Chest physiotherapy helps remove sticky secretions that cause ineffective airway clearance
Aerobic exercise is beneficial to promote removal of airway secretions, improve muscle strength, and increase lung
capacity
Financial needs must be discussed, as clients with CF have a large financial burden due to health care costs,
medications, and special equipment
A diet high in fat and calories is recommended due to defective digestive enzymes and impaired nutrient absorption.
Fluids are not restricted; liberal intake is recommended to assist in thinning respiratory secretions.
ARTERIAL BLOOD GAS

Arterial blood gas (ABG) assessment parameters provide objective data about the efficiency of gas exchange in the
lungs and effectively evaluate the following:

o Acid-base balance (pH, HCO3)

o Oxygenation status (PaO2, partial pressure of oxygen in the arterial blood)
o Tissue oxygenation (SaO2, percentage of available hemoglobin saturated with oxygen)
o Ventilation (PaCO2, partial pressure of carbon dioxide in the arterial blood)

Respiratory failure can occur when oxygenation is inadequate (hypoxemic failure) and/or when ventilation is
inadequate (hypercapnic failure). The adequacy of oxygenation and ventilation in a client with respiratory failure is
best evaluated through ABG analysis.

THORACOTOMY
 Immediately following a thoracotomy, chest tube drainage (50-500 mL for the first 24 hours) is expected to be
sanguineous (bright red) for several hours and then change to serosanguineous (pink) followed by serous (yellow)
over a period of a few days.
A rush of dark bloody drainage from the chest tube when the client was turned following a period of minimal drainage
is most likely related to retained blood due to a partial blockage in the tube.
Bright red drainage indicates active bleeding and would be of immediate concern.
The nurse would notify the health care provider immediately of bright red drainage or continued increased drainage
(>100 mL/hr) and of changes in the client's vital signs and cardiovascular status that could indicate bleeding (eg,
hypotension, tachycardia, tachypnea, decreased capillary refill, cool and pale skin).

PNEUMOTHORAX

In a traumatic, or "open," pneumothorax, air rushes in through the wound with each inspiration, creating a sucking
sound, and fills the pleural space. The lungs cannot expand, so the client develops respiratory distress and air
hunger.
Tachycardia and hypotension result from impaired venous return, as the heart and great vessels shift with each
breath.
A tension pneumothorax may also develop if air cannot escape the pleural space.
The priority action in this medical emergency is to apply a sterile occlusive dressing (eg, petroleum gauze) taped
on three sides, preventing inward air flow while allowing air to escape the pleural space.

THORACENTESIS

A thoracentesis involves the insertion of a large-bore needle through an intercostal space to remove excess fluid.
The procedure has the following advantages:

1. Diagnostic - analysis of fluid to diagnose the underlying cause of the pleural effusion (eg, infection, malignancy, heart
failure), including cytology, bacterial culture, and related testing
2. Therapeutic - removal of excess fluid (>1 L) improves dyspnea and client comfort
 Complications from insertion of the needle and removal of large amounts of fluid include iatrogenic pneumothorax,
hemothorax, pulmonary edema, and infection.
After the procedure, the nurse assesses for pain and difficulty breathing; monitors vital signs and oxygen saturation;
and observes for changes in respiratory rate and depth, symmetry of chest expansion, and breath sounds. If any
abnormalities are noted, a post-procedure chest x-ray is obtained.
Decreased chest expansion with inspiration and breath sounds on the affected side, tachypnea, tracheal deviation to
the opposite side, and hyperresonance (air) on the affected side are manifestations of a pneumothorax. These should
be reported immediately.

POST-OPERATIVE RESPIRATORY COMPLICATIONS

Ineffective airway clearance, which is the inability to clear secretions or obstructions from the respiratory tract to
maintain a clear airway, is the priority ND as it poses the greatest threat to survival.
The most common causes of respiratory complications in the immediate postoperative period include the following:

o Airway obstruction, which can be due to retained secretions or the tongue falling backward against the soft palate in
sedated clients. Suctioning and an artificial oral airway can be used to prevent obstruction until the client becomes more
responsive.
o Hypoxemia, which can be due to atelectasis from increased retained secretions or hypoventilation, aspiration, or
bronchospasm. Pulse oximetry and supplemental oxygen are used to maintain pulse oximeter readings >92%; placing the
client in side-lying position and administrating antiemetic medications help to decrease aspiration.
o Hypoventilation, which can be due to depression of the respiratory drive as a result of anesthesia, pain, and opioid
analgesia.

During the initial postoperative period, a client needs respiratory interventions to keep the lungs expanded and prevent
atelectasis and postoperative pneumonia.
Atelectasis is maximal during the second postoperative night. Clients can be asymptomatic or have increased work
of breathing, hypoxia, and basal crackles.
Postoperative pain, opioid respiratory depression, limited mobility, and reluctance to take a deep breath due to
anticipated pain contribute to postoperative atelectasis.
The elderly and postoperative abdominal and thoracic surgery clients are at increased risk for atelectasis.
The incentive spirometer encourages the client to breathe deeply with maximum inspiration. This action improves
ventilation and oxygenation by expanding the lungs, encourages coughing, and prevents or improves atelectasis.
 In a client whose pain is regulated with client-controlled analgesia (eg, morphine), administration of a bolus dose is not
indicated and may increase the risk for respiratory depression.
Fine crackles in the lungs usually indicate atelectasis. The presence of coarse crackles, elevated jugular venous
distension, and peripheral edema usually indicates volume overload (fluid in the alveoli). In addition, clients with fluid
overload breathe at a rapid rate (tachypnea) rather than take slow, shallow breaths. IV furosemide (Lasix) is an
appropriate intervention for volume overload but not for atelectasis.
As-needed oxygen may be prescribed postoperatively, especially with blood loss. A non-rebreather mask, which has
100% oxygen, is not indicated in this client as the pulse oximeter shows 96% saturation, indicating adequate
oxygenation.

Strategies to prevent postoperative pneumonia include the following:

o Adequate pain control is a priority so that the client can move, deep breathe, and cough more effectively and comfortably.
Opioids are effective for relieving postoperative pain, but because they depress respirations and the cough reflex, assessing
the client's response to the medication and level of sedation is important.
o Ambulate within 8 hours after surgery, if possible. Mobilization/early ambulation decreases atelectasis and
hypoventilation, and promotes coughing, deep breathing, and lung expansion. Usually, it can be initiated within 4-8 hours
after surgery.
o Coughing with splinting every hour. Splinting of the incision and adequate pain management are useful for promoting an
effective cough (huff, cascade) that clears the airway of secretions.
o Deep breathing and use of the incentive spirometer every hour. Deep breathing in conjunction with the use of the
incentive spirometer promotes ventilation and oxygenation. It opens the pores of Kohn that permit air from well-ventilated
alveoli to move into collapsed alveoli, and it helps to prevent/decrease atelectasis and hypoventilation caused by the effects
of anesthesia, analgesia, and pain.
o Place in Fowler's position. Elevating the head of the bed 45-60 degrees helps to promote oxygenation and prevent
aspiration. Turn and reposition the client at least every 2 hours.
o Swab mouth with chlorhexidine swabs every 12 hours. Mouth care prevents ventilator-associated and postoperative
pneumonia.
o Use hand hygiene (all personnel) to decrease transmission of microorganisms.

CHEST DRAINAGE

When chest drainage stops abruptly, the nurse must perform assessments and interventions to ascertain if this is an
expected finding.
 Auscultating breath sounds helps the nurse detect whether breath sounds are audible in all lung fields, potentially
indicating that the lung has re-expanded and there is no more drainage.
Other interventions to facilitate drainage include having the client cough and deep breathe and repositioning the
client
If a client has been in one position for a prolonged period, drainage may accumulate and a position change may
facilitate improved drainage.
A change in suction level should be performed only after obtaining a health care provider (HCP) prescription.
The nurse should perform the assessment of breath sounds, coughing and deep breathing, and client repositioning
before notifying the HCP about a change in suction level.
In general, suction above 20 cm H2O is not indicated.
Milking chest tubes to maintain patency is performed only if prescribed. It is generally contraindicated due to potential
tissue damage from highly increased pressure changes in the pleural space.

BILEVEL POSITIVE AIRWAY PRESSURE (BIPAP) FOR PATIENTS WITH COPD

An elevated carbon dioxide (CO2) level (normal: 35-45 mm Hg [4.7-6.0 kPa]) is usually an indicator of hypercapneic
respiratory failure.
The bilevel positive airway pressure (BIPAP) machine will provide positive pressure oxygen and expel CO2 from the
lungs.
This client is already showing signs of lethargy and confusion, which is usually a late indicator of respiratory decline.
Therefore, the nurse's priority should be to get the client on the BIPAP machine as soon as possible.
Nebulizer treatments are commonly part of the treatment plan for a client with chronic obstructive pulmonary disease
(COPD).
However, these do not take priority when the client has CO 2 retention and is deteriorating.
If mental status worsens further (due to continued CO2 retention), the client will need intubation.
Many BIPAP machines are able to deliver nebulizer treatment while providing positive pressurized oxygen.
Steroid therapy is a common pharmaceutical intervention for COPD exacerbation, but it does not take priority over
BIPAP in this deteriorating client. In addition, steroids take hours to days to have an effect.
In a client with an elevated CO2 level and a history of COPD, the nurse should not increase the oxygen level as this
could cause an increase in CO2 retention, resulting in further respiratory failure.
CHEST TUBE

If the chest tube disconnects from the drainage tubing without contamination, wipe the end of the chest tube with an
antiseptic and immediately reconnect it.
To prevent accidental disconnection of the chest tube from the tubing, secure all connections with tape or bands,
according to hospital policy and procedure.
If the chest tube is disconnected with contamination and cannot be immediately reattached, or if the chest drainage
unit breaks, cracks, or malfunctions, submerge the distal end of the chest tube 1-2 in (2-4 cm) below the surface
of a 250 mL bottle of sterile water or saline.
This creates an immediate water seal and prevents air from entering into the pleural space as the new chest drainage
system is established.
To be prepared for this contingency, emergency equipment should be kept at the bedside, which includes 2 chest tube
clamps, a 250 mL bottle of sterile water or saline solution, and antiseptic wipes.
Unless prescribed by the HCP, chest tube clamping time should not exceed 1 minute as it raises intrapleural pressure
and can lead to a tension pneumothorax.
Clamping briefly is acceptable when checking for an air leak in the system or when changing the disposable collection
unit.
It is not necessary to notify the HCP when replacing a chest drainage system unless the client develops respiratory
distress.
Positioning the client on the left side is appropriate if a central line is inadvertently pulled out so that any air that may
have been sucked in will rise to the right atrium.
It is not an appropriate intervention for a chest tube disconnection or crack or malfunction in a chest drainage unit.
Chest tubes are indicated to drain air or fluid from the pleural space and reestablish negative pressure, which allows
for proper lung expansion. When the lung has reexpanded or fluid drainage is no longer needed, the chest tube can
be discontinued. The client should be given an analgesic 30-60 minutes prior to the procedure. A suture removal kit,
petroleum gauze, and occlusive dressing supplies will be needed.
The client should be instructed to take a deep breath, hold it, and bear down (Valsalva maneuver) while the tube is
being removed. This will prevent air from being pulled back into the pleural space and possibly causing a
pneumothorax.
A post-procedure chest x-ray must be performed to ensure there is no reaccumulation of air or fluid in the pleural
space.
Breathing slowly or normally during the procedure may cause the client to inhale during the removal, pulling air back
into the pleural space.
 Rapid shallow breaths increase the chance of inhaling during removal and pulling air into the pleural space, causing
recollapse of the lung.
If the chest tube is dislodged from the client and the nurse hears air leaking from the site, the nurse's immediate action
should be to apply a sterile occlusive dressing (eg, petroleum jelly dressing) taped on 3 sides. This action permits
air to escape on exhalation and inhibits air intake on inspiration. The nurse would then notify the HCP and arrange for
the reinsertion of another chest tube

NURSING DIAGNOSIS

Impaired gas exchange is a deficit in oxygenation and/or elimination of carbon dioxide at the alveolar-capillary
membrane. Impaired gas exchange related to a bacterial infectious process as evidenced by shortness of
breath and tachypnea is an appropriate ND for a client with pneumococcal pneumonia.
Impaired spontaneous ventilation is the inability to maintain independent ventilation to support life and requires
mechanical ventilation.
Ineffective breathing pattern, this problem is secondary to impaired gas exchange. An increased respiratory rate is the
body's attempt to compensate for hypoxia caused by consolidations and secretions preventing adequate gas
exchange in the lungs.
Risk for infection is the increased risk for invasion of microorganisms.

ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)

ARDS involves damage to the alveolar-capillary membrane, the blood-gas barrier across which oxygen diffuses into
the alveoli. When the membrane is damaged, the alveoli collapse and fluid leaks into the alveolar space and impairs
gas exchange. Impaired gas exchange related to alveolar-capillary changes and ventilation-perfusion imbalance is
the priority ND for a client with ARDS.
Imbalanced nutrition (less than body requirements) related to increased metabolic needs and inability to ingest foods
due to endotracheal intubation, is an appropriate ND for the client with ARDS. However, it does not pose the greatest
threat to survival and is not the priority ND.
Impaired tissue (integumentary) related to altered circulation, immobility, and nutritional deficits is an appropriate ND
for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND.
Risk for infection related to the presence of an endotracheal tube, frequent suctioning, intravenous devices, and
indwelling catheters is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to
survival and is not the priority ND.

The nurse activates a rapid response because the client is in acute respiratory distress. While waiting for the team,
the nurse should implement the following actions in order:

o Place in high Fowler's position quickly maximizes ability to expand lungs, promotes oxygenation, and helps to decrease
risk of further aspiration
o Perform oropharyngeal suctioning the priority is clearing the airway after the client has been placed in a position that
prevents further aspiration
o Administer 100% oxygen by nonrebreather mask corrects hypoxemia/hypoxia once the airway has been cleared to allow
passage of oxygen. The nurse has already gathered focused assessment data and determined the need for emergent oxygen
delivery (eg, tachycardia, tachypnea, hypoxia, cyanosis, decreased level of consciousness).
o Assess lung sounds determines air movement and presence of adventitious sounds (eg, crackles, wheezing, stridor) that
can indicate obstruction, secretions, atelectasis, or fluid. This assessment is performed once emergency measures are in
place (eg, oxygen) and the client has been stabilized.
o Notify the primary HCP to report the situation and assessment data

Refractory hypoxemia is the hallmark of acute respiratory distress syndrome (ARDS), a progressive form of acute
respiratory failure that has a high mortality rate.
It can develop following a pulmonary insult (eg, aspiration, pneumonia, toxic inhalation) or nonpulmonary insult (eg,
sepsis, multiple blood transfusions, trauma) to the lung.
The insult triggers a massive inflammatory response that causes the lung tissue to release inflammatory mediators
(leukotrienes, proteases) that cause damage to the alveolar-capillary (A-C) membrane.
As a result of the damage, the A-C membrane becomes more permeable, and intravascular fluid then leaks into the
alveolar space, resulting in a noncardiogenic pulmonary edema.
The lungs become stiff and noncompliant, which makes ventilation and oxygenation less than optimal and results in
increased work of breathing, tachypnea and alkalosis, atelectasis, and refractory hypoxemia.
Profound hypoxemia despite high concentrations of oxygen is a key sign of ARDS and is the most important
assessment finding to report to the HCP.
ENDOSCOPIC BRONCHOSCOPY

An endoscopic bronchoscopy is a procedure in which the bronchi are visualized with a flexible fiberoptic
bronchoscope that is passed down through the nose (or through the mouth, or endotracheal or tracheostomy tube).
The client receives mild sedation (eg, midazolam) to provide relaxation and promote comfort.
A topical anesthetic (eg, lidocaine, benzocaine) is applied to the nares and throat to suppress the gag and cough
reflexes, prevent laryngospasm, and facilitate passage of the scope.
The procedure is done to diagnose, obtain tissue samples for biopsy, lavage, and to remove secretions (mucus plugs),
foreign objects, or abnormal tissue with a laser. Blood-tinged sputum is common and can occur from inflammation
of the airway, but hemoptysis of bright red blood can indicate hemorrhage, especially if a biopsy was performed.
Absence of the gag reflex for about 2 hours following the procedure is expected from the topical anesthetic.
Headache is not a complication of bronchoscopy.
Respirations of 10/min and saturation of 92% are expected after mild sedation before and/or or during the procedure.

TRACHEOSTOMY

The immediate postoperative priority goal for a client with a new tracheostomy is to prevent accidental dislodgement of
the tube and loss of the airway. If dislodgement occurs during the first postoperative week, reinsertion of the tube is
difficult as it takes the tract about 1 week to heal. For this reason, dislodgement is a medical emergency. The priority
nursing action is to ensure the tube is placed securely by checking the tightness of ties and allowing for 1 finger
to fit under these ties.
Changing of the inner cannula and tracheostomy ties is not usually performed until 24 hours after insertion; this is due
to the risk of dislodgement with an immature tract. However, the dressing can be changed if it becomes wet or soiled.
Suctioning can be performed to remove mucus and maintain the airway.
The cuff is kept inflated to prevent aspiration from secretions and postoperative bleeding. Cuffs are not regularly
deflated and re-inflated. The respiratory therapist should monitor the amount of air in the cuff several times a day to
prevent excessive pressure and mucosal tissue damage.
Frequent mouth care to help prevent stomal and pulmonary infection is important in a client with an artificial airway,
but it is not the priority action immediately following tracheostomy.
A tracheostomy tube, an artificial airway inserted into the trachea through the neck, may be secured with sutures or
tracheostomy ties.
 Accidental dislodgment of a tracheostomy tube is a medical emergency often resulting in respiratory distress from
closure of the stoma and airway loss.
If accidental dislodgment of mature tracheostomies (ie, >7 days after insertion) occurs where the tract is well formed,
the nurse should attempt to open the airway by inserting a curved hemostat to maintain stoma patency and insert
a new tracheostomy tube with an obturator
Application of supplemental oxygen via nonrebreather face mask may not resolve respiratory distress because air can
escape from the stoma.
Covering the stoma with a sterile, occlusive dressing (eg, petroleum gauze, foam tape) and ventilating the lungs with a
bag-valve mask over the nose/mouth may be necessary if the tube cannot be reinserted or the stoma is immature.
Dry gauze is porous and does not adequately seal the stoma for ventilation.
Tracheal suctioning may be necessary once the airway is re-secured. However, suctioning prior to establishing an
airway does not improve ventilation and may further reduce the oxygen supply.

HOSPITAL ACQUIRED PNEUMONIA (HAP)

HAP is a bacterial infection acquired in a health care facility that was not present on admission.
Almost all clients with bacterial pneumonia develop leukocytosis (WBC >11,000/mm3).
Antibiotic therapy is the first-line treatment, but antibiotic resistance frequently occurs in HAP.
If antibiotic therapy is effective, clinical improvement usually occurs within 3-4 days of initiation of IV antibiotics.
The nurse monitors WBC as the best indicator of treatment effectiveness as antibiotics cause bacterial lysis or
hinder bacterial DNA reproduction.
The reduced number of bacteria and the resulting decrease in inflammation cause a decrease in the number of white
blood cells needed to fight the infection.
Other indicators of treatment effectiveness include improvement of infiltrates on chest x-ray, oxygenation, and signs
and symptoms (cough, fever, sputum production).
The color of sputum (eg, clear, yellow, green, grey, rusty, blood-tinged) can vary with different types of pneumonia; it is
not the best indicator of treatment effectiveness.
Adventitious/abnormal lung sounds (crackles, low-pitched wheeze, bronchial breath sounds) can be present as the
pneumonia resolves or can be a sign of further complication (pleural effusion). However, these are not the best
indicators of treatment effectiveness.
 Saturation is an indicator of oxygenation but can be affected by many other factors, such as coexisting disease,
peripheral circulation, and drugs. It is not the best indicator of treatment effectiveness.

NON-REBREATHER MASK

A nonrebreather mask is an oxygen delivery device used in a medical emergency.

It consists of a face mask with an attached reservoir bag and a one-way valve between the bag and mask that
prevents exhaled air from entering the bag and diluting the oxygen concentration.
The liter flow must be high enough (up to 15 L/min) to keep the reservoir bag at least 2/3 inflated during inhalation and
to prevent the buildup of carbon dioxide in the bag.

RESPIRATORY DEPRESSION

The combination of excessive alcohol ingestion and the benzodiazepine alprazolam (Xanax) causes respiratory
depression, which leads to alveolar hypoventilation secondary to carbon dioxide retention, and respiratory
acidosis.
Therefore, clients should be advised not to take multiple substances that increase the risk of respiratory depression
(eg, opioids, benzodiazepines, alcohol, sedating antihistamines).

PEAK FLOW METER

The peak flow meter is a hand-held device used to measure peak expiratory flow rate (PEFR) and is most helpful for
clients with moderate to severe asthma. Exhaling as quickly and forcibly as possible through the mouthpiece of the
device evaluates the degree of airway narrowing by measuring the volume of air that can be exhaled in one breath.
Use of the device permits self-management and provides information to guide and evaluate treatment.
The client moves the indicator on the numbered scale to 0 or to the lowest number on the scale before using the
device.
The personal best reading is the highest peak flow reading the client can attain, usually over a 2-week period, when
asthma is in good control.
The peak flow meter is used after a short-acting bronchodilator rescue MDI to evaluate response, not after a
corticosteroid MDI
 A peak flow meter is a handheld device that measures the client's ability to push air out of the lungs. Measurements
from a peak flow meter often guide the client's use of respiratory medications and the need to schedule an
appointment with a health care provider.
To obtain the most accurate readings to help guide, maintain, and evaluate treatment in clients with asthma, the
procedure is performed in the following order:

o Before each use, slide the indicator on the numbered scale on the flow meter to 0 (or the lowest value), and stand or sit as
upright as possible
o Inhale deeply, place the mouthpiece in the mouth, and close the lips tightly around the mouthpiece to form a seal
o Exhale as quickly and completely as possible and note the reading on the numbered scale
o Repeat the procedure 2 more times, with a 5- to 10-second rest period between exhalations
o Record the highest reading (ie, personal best) in the peak flow log

OBSTRUCTIVE SLEEP APNEA (OSA)

Obstructive sleep apnea (OSA) is characterized by partial or complete airway obstruction during sleep that occurs
from relaxation of the pharyngeal muscles. and hypopnea

Common symptoms include frequent periods of sleep disturbance, snoring, morning headache, daytime sleepiness,
difficulty concentrating, forgetfulness, mood changes, and depression.
Interventions include:

o Continuous positive airway pressure device at night to keep the structures of the pharynx and tongue from collapsing
backward
o Limiting alcohol intake at bedtime as it can cause muscles of the oral airway to relax and lead to airway obstruction
o Weight loss and exercise can reduce snoring and sleep apnea-associated airway obstruction. Obesity contributes to the
development of OSA
o Avoiding sedating medications (eg, benzodiazepines, sedating antidepressants, antihistamines, opiates) as they may
exacerbate OSA and worsen daytime sleepiness

Obstructive sleep apnea (OSA) is the most common type of breathing disorder during sleep and is characterized by
repeated periods of apnea (>10 seconds) and diminished airflow (hypopnea).
 A partial or complete obstruction occurs due to upper airway narrowing that results from relaxation of the pharyngeal
muscles or from the tongue falling back on the posterior pharynx due to gravity.
During periods of apnea, desaturation (hypoxemia) and hypercapnia occur; these stimulate the client to arouse and
breathe momentarily to restore airflow. These cycles of apnea and restored airflow can occur several hundred times
per night, resulting in restless and fragmented sleep.
Partners of clients with OSA witness loud snoring, apnea episodes, and waking with gasping or a choking sensation
During the day, clients experience morning headaches, irritability, and excessive sleepiness.
Excessive daytime sleepiness can lead to poor work performance, motor vehicle crashes, and increased mortality
Frequent (not difficult) arousal from sleep is associated with OSA.

CONTINOUS POSITIVE AIRWAY PRESSURE (CPAP)

CPAP is an effective treatment for OSA; it involves using a nasal or full face mask that delivers positive pressure to the
upper airway to keep it open during sleep.
In this case, the nurse's first action should be to check the tightness of the straps that hold the mask in place. The
full face mask must fit snugly over the client's nose and mouth without air leakage to maintain the positive airway
pressure and prevent obstruction of upper airway airflow. Readjustment of the head straps may be necessary
Underlying OSA is the most likely reason for this client's drop in oxygen saturation during sleep. If CPAP is not
effective, then the characteristic OSA signs (eg, hypoxia, hypercapnia) will occur. In addition, decreased level of
consciousness and lung sounds are expected when there is no airflow to the lungs.
If the attempt to readjust the straps and mask seal does not reverse the client's hypoxemia quickly, the nurse should
notify the health care provider and respiratory therapist (per institution policy).
Supplemental oxygen may be indicated if readjustment of the straps and mask seal does not reverse the client's
hypoxemia quickly. SUCTIONING
Risks associated with suctioning include hypoxemia, microatelectasis, and cardiac dysrhythmias.
Suctioning removes secretions and oxygen.
To minimize both the amount of oxygen removed and mucosal trauma, suction is applied when removing, not
inserting, the catheter into the artificial airway. If secretions are thick and difficult to remove, increasing hydration, not
suctioning time, is indicated.
 Aerosols of sterile normal saline or mucolytics such as acetylcysteine (Mucomyst) administered by nebulizer can
also be used to thin the thick secretions, but water should not be used. Aerosol therapy may induce bronchospasm in
certain individuals and can be relieved by use of a bronchodilator (albuterol).
Morphine is administered to promote breathing synchrony with the mechanical ventilator, reduce anxiety, and promote
comfort in clients receiving MV.
Preoxygenation with 100% oxygen for 30 seconds before suctioning, unless otherwise specified, is the
recommended practice to reduce suctioning-associated risks for hypoxemia, microatelectasis, and cardiac
dysrhythmias.
It is appropriate to suction the client when the high-pressure alarm on the MV sounds, saturations drop, rhonchi are
auscultated, and secretions are audible or visible. These manifestations can indicate excessive secretions impairing
airway patency.

CARBON MONOXIDE POISONING

Carbon monoxide (CO) is a colorless, odorless gas produced by burning fuel (eg, oil, kerosene, coal, wood) in
a poorly ventilated setting.
CO toxicity (poisoning) is most often associated with smoke inhalation from structure fires, but is also generated by
furnaces/hot water heaters fueled by natural gas or oil, coal or wood stoves, fireplaces, and engine exhaust.
 Clients with CO toxicity often have nonspecific symptoms, and the diagnosis can be missed. It is important to assess
for possible CO exposure to initiate appropriate emergency care and prevent hypoxic neurologic impairment.
To help identify elevated CO levels in the home, the nurse can ask about the following:

o Similar symptoms in other family members, or an illness in an indoor pet that developed at the same time
o Fuel-burning heating/cooking appliances; risk of CO toxicity increases in the fall and winter due to increased used of heat
sources in an enclosed space

VENTILATOR ACQUIRED PNEUMONIA (VAP)

VAP is the second most common health care-associated infection (HAI) in the United States and is associated with
increased mortality, hospital cost, and length of stay.
-3 days after
initiation of mechanical ventilation (MV).
Characteristic clinical manifestations of VAP include purulent sputum, positive sputum culture, leukocytosis
(12,000 mm3), elevated temperature (>100.4 F [38 C]), and new or progressive pulmonary infiltrates suggestive of
pneumonia on chest x-ray.

PLEURAL EFFUSION

A pleural effusion is an abnormal collection of fluid (>15 mL) in the pleural space that prevents the lung from
expanding fully, resulting in decreased lung volume, atelectasis, and ineffective gas exchange.
It is usually secondary to another disease (eg, heart failure, pneumonia, nephrotic syndrome). Pleural effusions are
diagnosed by chest x-ray or CT scan. Thoracentesis can be performed to remove fluid from the pleural space and
resolve symptoms.
Clients commonly report dyspnea with a nonproductive cough, as well as pleural chest pain with respirations.
On assessment, clients have diminished breath sounds, dullness to percussion, decreased tactile fremitus, and
decreased movement over the affected lung
BRONCHIAL ASTHMA
Asthma is an obstructive lung disease characterized by hyperreactive airways and chronic inflammation. Asthma
exacerbations occur due to various triggers (eg, allergens, respiratory infection, exercise, cold air), resulting in edema,
hypersecretion of mucus, and bronchospasm.
Narrowing of the airways culminates in increased airway resistance, air trapping, and lung hyperinflation. In severe
asthma, breath sounds may be diminished due to closure of bronchioles.
Absent breath sounds in a client with asthma are a medical emergency.
Clinical manifestations of an asthma exacerbation include:
o Accessory respiratory muscle use related to increased work of breathing and diaphragm fatigue
o Chest tightness related to air trapping
o Cough from airway inflammation and increased mucus production
o Diminished breath sounds related to hyperinflation
o High-pitched expiratory wheezing caused by narrowing airways; wheezing may be heard on both inspiration and expiration
as asthma worsens
o Tachypnea related to inability to take a full, deep breath

Clients with obstructive lung disease (eg, asthma, chronic obstructive pulmonary disease) develop prolonged
expiratory phase as a physiologic response to hyperinflation and trapped air.
In clients with asthma, the airways are chronically inflamed with varying degrees of airway obstruction that can be
exacerbated by exposure to triggering agents. Common asthma triggers include:

o Allergens: Dander (eg, cat, dog), dust mites, pollen

o Drugs: Beta blockers; nonsteroidal anti-inflammatory agents, including aspirin
o Environmental: Chemicals, sawdust, soaps/detergents
o Infectious: Upper respiratory infections
o Intrinsic: Emotional stress, gastrointestinal reflux disease
o Irritants: Aerosols/perfumes, cigarette smoke (including secondhand smoke), dry/polluted air

Clients must be able to identify their individual triggers and avoid or learn to manage them.
TONSILLECTOMY

Tonsillectomy is usually performed as an outpatient procedure.

Postoperative bleeding is an uncommon but important complication and it can last up to 2 weeks.
It manifests with frequent or continuous swallowing and/or cough from the trickling blood; some clients may also
develop restlessness.
Discharge teaching includes:

o Avoid coughing, clearing the throat, or blowing of the nose

o Limit physical activity
o Milk products are discouraged due to their coating effect, which can prompt clearing of the throat
o Oral mouth rinses, gargling, and vigorous tooth brushing should be avoided to prevent irritation

The presence of slight ear pain, a low-grade fever, and objectionable mouth odor are common findings during the first
5-10 days after the procedure. Persistent moderate-to-severe earache, fever, or cough requires further evaluation.
 NEPHROLOGY
BLADDER CANCER

The tell-tale symptom of bladder cancer, seen in >75% of cases, is painless hematuria; the client will report seeing
blood in the urine with no associated pain.
As with many other types of cancer, the primary cause of bladder cancer is cigarette smoking or other tobacco use
Poorer outcomes are seen with increased length of time as a smoker and higher number of packs per day.
Clients who have family members with bladder cancer have an increased risk of developing bladder cancer
themselves; however, the primary risk factor is tobacco use.
Occupational carcinogen exposure is the second most common risk factor. Occupational exposures include
printing, iron and aluminum processing, industrial painting, metal work, machining, and mining. Clients are exposed to
carcinogens through direct skin contact and inhalation (aerosols and vapors).
Consuming a high-fat diet and using artificial sweeteners are risk factors for developing bladder cancer, but they are
not the primary cause.

STRESS INCONTINENCE

The nursing care plan for a client experiencing stress incontinence includes pelvic floor exercises, bladder training,
incontinence products, and lifestyle modifications.

o The highest priority for a client newly diagnosed with stress incontinence is preventing skin breakdown and urinary tract
infections through bladder training. Teaching the client to empty the bladder every 2 hours when awake and every 4 hours
at night reduces these risks
o Pelvic floor exercises (eg, Kegel exercises), which strengthen the sphincter and structural supports of the bladder, are an
essential part of the teaching plan but are not the priority for this client. It will take approximately 6 weeks for pelvic floor
muscle strength to improve.
o Natural bladder irritants (eg, smoking, caffeine, alcohol) increase incontinence and should be eliminated but are not the
priority in this client
o Pessaries relieve minor pelvic organ prolapse and may be used in some clients when initial conservative measures fail. This
client should receive initial instruction on the importance of emptying the bladder often
URINALYSIS

This client's urinalysis reveals that the client is most likely dehydrated. Amber color indicates concentrated urine. The
specific gravity evaluates the ability of the kidneys to concentrate solutes in the urine. The normal urine specific
gravity value ranges from 1.003 to 1.030. Causes of increased specific gravity include fluid deficit.
Glucose should be absent in the urine. Its presence is suspicious for diabetes mellitus.
Dysuria (burning or difficulty urinating) may be indicative of infection or inflammation. The number of white blood cells
(WBCs) should be very few (0-5 per high power field), as seen in this client. Increased numbers indicate infection or
inflammation.
Hematuria is indicative of possible renal trauma. The normal range for red blood cells is 0-4 per high power field.
None are present on this client's urinalysis results.
URGE INCONTINENCE

Urge incontinence (UI), also known as overactive bladder, occurs when the bladder contracts randomly, causing a
strong, sudden urge to urinate that is followed by urine leakage.
UI may occur without cause or may result from spinal cord injury and impairment of the bladder (eg, interstitial cystitis)
or neurological system (eg, Parkinson disease, stroke).
Interventions for clients with UI include:
o Loss of excess weight to reduce pressure on the pelvic floor

o Anticholinergic medications (eg, oxybutynin, tolterodine) to decrease bladder spasms. Dry mouth (xerostomia) is
a frequent adverse effect
o Avoidance of bladder irritants (eg, artificial sweeteners, caffeine, citrus juices, alcohol, carbonated drinks,
nicotine)
o Pelvic floor exercises (eg, Kegel) to strengthen the muscles and help prevent urinary leakage

o Bladder training (eg, voiding every 2 hours while awake) and gradually lengthening intervals between voiding

ARTERIOVENOUS GRAFT FISTULA

The creation of an AVF for hemodialysis access involves an anastomosis between an artery and a vein (usually the
cephalic or basilic vein). The fistula permits the arterial blood to flow through the vein, causing the vein to become
larger in diameter and the walls to thicken, enabling blood to flow at high pressures. After the AVF is placed, it
takes 2-4 months for it to mature to accommodate the repeated venipunctures necessary for hemodialysis access.
The major complications of an AVF are infection (especially in end-stage kidney disease and diabetes), stenosis,
thrombosis, and hemorrhage.
Clients are taught the following preventive interventions:

o Report numbness or tingling of the extremity to the HCP to prevent neuromuscular damage
o Do not allow anyone (other than dialysis personnel) to draw blood or take blood pressure measurements on the
extremity to prevent thrombosis
o Avoid wearing restrictive clothing or jewelry to prevent thrombosis
o Do not use the arm with vascular access to carry heavy objects (more than 5 lb [2.26 kg]); however, exercises to increase
strength could include squeezing a soft ball or sponge several times a day
o Check the function of the vascular access several times a day by feeling for vibration to assess for patency, stenosis, and
clotting
o Do not sleep on the arm with vascular access or use creams or lotions on the site
o Monitor for signs of infection and bleeding after dialysis and report immediately
o Keep the site clean to help prevent infection

An arteriovenous fistula is a surgical connection of an artery to a vein created to provide vascular access for
hemodialysis therapy in clients with kidney disease. Arterial blood flowing through this vein causes it to engorge and
thicken (mature) over a period of several weeks, after which it can sustain frequent access by 2 large-bore needles
required for dialysis. Maturing of the fistula is aided by having the client perform hand exercises, such as squeezing a
rubber ball, that increase blood flow through the vein.
Following fistula placement, it is important to monitor for patency. A palpable thrill (vibration) over the fistula or an
auscultated bruit (blowing or swooshing sound caused by turbulent blood flow) indicates a patent fistula. Absence of
the thrill or bruit can indicate potential clot formation in the fistula. Client reports of numbness or tingling as well as
decreased capillary refill can also signal potential clotting.
Capillary refill of <3 seconds is considered normal and indicates acceptable blood flow to the area.
Daily hand exercises such as squeezing handgrips or a rubber ball are performed to help properly mature the fistula.
A dry surgical incision without redness, warmth, and induration is an optimal finding. Sterile skin closures (eg, Steri-
Strips) are used to help hold the incision together as it heals.
Arteriovenous fistula (AVF) is a permanent hemodialysis access surgically created by connecting an artery to a vein,
typically in the forearm or upper arm. This anastomosis diverts arterial blood into the vein, which increases
intravenous blood flow and causes the vein to thicken and expand (ie, "mature"). The matured AVF can then sustain
frequent access by large-bore needles during hemodialysis.
Arterial steal syndrome is an AVF complication that occurs when the anastomosed vein "steals" too much arterial
blood, causing distal extremity ischemia. Symptoms occur distal to the AVF, including skin pallor, pain, numbness,
tingling, diminished pulses, and poor capillary refill. Without prompt intervention, ischemia may lead to limb
necrosis
After AVF creation, edema may occur due to venous congestion but typically improves spontaneously. Extremity
elevation helps reduce edema. Severe or prolonged edema (eg, >2 weeks) could indicate venous hypertension that
may require surgery to prevent AVF failure.
A loud swooshing sound (ie, bruit) auscultated over the AVF is expected due to turbulent blood flow at the
arteriovenous anastomosis.
Hand-grip exercises (eg, ball squeezing, hand flexing) are encouraged after AVF creation to promote fistula
maturation. Postoperative surgical site pain is expected; however, pain distal to the AVF may indicate tissue ischemia.
CONTINUOUS BLADDER IRRIGATION

Case: A client underwent a transurethral

resection of the prostate (TURP) today and
has a 3-way Foley urinary catheter with
continuous bladder irrigation (CBI). The
client reports lower abdominal pain rated as
an 8 on a scale of 0-10. What action should
the nurse carry out first?

Blood and mucus can obstruct the Foley catheter if the CBI is not infused at a sufficient rate. Bladder pain will result
from distention if the flow is obstructed.
The nurse should ensure that there is adequate urinary drainage and no blockage from blood clots before treating the
pain. If the urinary flow is obstructed, manual irrigation with sterile normal saline should be performed until there are
no clots or the urine is clear/pink.
Belladonna-opium suppositories or antispasmodics (eg, oxybutynin) are used for bladder spasms, an expected
complication of the TURP procedure.
Clients should be instructed not to urinate around the catheter as this would increase bladder pressure and
spasms. Narcotics can be used for postoperative pain. If the urinary flow is adequate, a description of the pain would
help to determine whether to give the client a narcotic or an antispasmodic.
Before treating the resulting pain, the possibility of a physiological etiology for procedure-related pain (eg, blockage of
urinary flow from blood clots) should be ruled out first.
Large intestine peristalsis does not usually return for at least 24 hours. Intestinal pain is usually related to the
presence of flatus. It is too soon for this to be the primary cause. An etiology related to the procedure should be ruled
out first.

ACUTE URINARY RETENTION

Acute urinary retention is best treated with rapid, complete bladder decompression rather than the intermittent
urine drainage that is limited to 500 to 1000 mL at a time.
 Rapid decompression can be associated with hematuria, hypotension, and postobstructive diuresis. However, these
are rarely clinically significant if appropriate supportive care is administered, whereas inability to relieve the obstruction
can be associated with infection and kidney injury
Dysuria from catheterization can be treated with analgesics or antispasmodic medications. Maintaining perfusion and
adequate blood pressure is the priority concern.
With sudden release of bladder obstruction, cardiovascular autonomic activity occurs and the blood pressure and heart
rate are reduced due to the excitation of the parasympathetic system.
Opioids (eg, morphine sulfate), anticholinergic medications, and tricyclic antidepressants can cause urinary
retention; they increase bladder sphincter tone and/or relax bladder muscle. The nurse should assess the client's
suprapubic area to determine if the client has urinary retention. If the area is distended and dull to percussion, the
nurse should proceed with interventions.
While asking if a bedpan is needed is an important nursing intervention, it does not aid in the assessment of urinary
retention.
Gathering assessment data indicating the presence of urinary retention is necessary prior to other interventions. The
nurse should assess for fluid intake after assessing bladder distension.
The client's skin turgor is assessed after the nurse checks for urinary retention and fluid intake. There is no need to
assess skin turgor until other indicators of adequate fluid intake are reviewed.

PERITONEAL DIALYSIS
In peritoneal dialysis (PD), the abdominal lining (peritoneum) is used as a semipermeable membrane to dialyze
clients with decreased kidney function.
A catheter is placed in the peritoneal cavity for infusing and draining dialysate (dialysis fluid). Dialysate is infused
and dwells in the abdomen, which allows waste products and electrolytes to cross the peritoneum into the dialysate for
removal.
After the prescribed dwell time, the dialysate, electrolytes, and wastes are drained via gravity.
When administering PD, it is essential to use sterile technique when spiking and attaching bags of dialysate to the
client's PD catheter to prevent contamination and infection
Bacterial peritonitis, an infection of the peritoneum, is a potential complication of PD that may lead to sepsis. Signs
of peritonitis should be reported to the health care provider.
(Proper positioning of the catheter drainage bag (ie, below the abdomen) and the client (eg, Fowler or semi-Fowler
position) promotes effluent outflow but is not a priority over infection prevention.
Cloudy effluent may indicate infection, whereas bloody or brown effluent may indicate bowel perforation. Documenting
effluent characteristics is important but not a priority over maintaining asepsis.
During peritoneal dialysis (PD), a catheter is placed into the peritoneal cavity to infuse dialysate (dialysis fluid); the
tubing is then clamped to allow the fluid to dwell for a specified period. After the dwell time, the catheter is unclamped
and the fluid (effluent) drains out via gravity.
Cloudy outflow (effluent), tachycardia, and low-grade fever are signs of peritonitis, an infection of the peritoneal
cavity and a major concern with PD. Bloody fluid can indicate intestinal perforation or that the client may be
menstruating. Brown effluent can indicate fecal contamination from perforation. All these findings need to be reported
to the health care provider.
Oliguria (very low urine output) is associated with acute or chronic kidney failure and is the reason the client is
receiving peritoneal dialysis. It does not indicate a complication of PD.
Pruritus (itching) is a common finding in clients with kidney failure, and may occur due to dry skin, neuropathy, or skin
deposits of waste products (eg, urea, calcium-phosphate) that are normally removed via the kidney. PD can help
relieve this symptom of kidney failure by filtering waste products.
Peritoneal dialysis uses the abdominal lining (ie, peritoneum) as a semipermeable membrane to dialyze a client with
insufficient renal function. A catheter is placed into the peritoneal cavity, and dialysate (ie, dialysis fluid) is infused.
The tubing is clamped to allow the fluid to remain in the cavity, usually for 20-30 minutes (dwell phase). The catheter
is then unclamped to allow dialysate to drain via gravity.
Insufficient outflow results most often from constipation when distended intestines block the catheter's holes. If
outflow becomes sluggish, the nurse should assess the client's bowel patterns and administer appropriate prescribed
medications (eg, stool softeners). The nurse should also check the tubing for kinks and reposition the client to
 a side-lying position or assist with ambulation. The drainage bag should be maintained below the abdomen to
promote gravity flow. The nurse should assess for fibrin clots and milk the tubing to dislodge or administer fibrinolytics
(eg, alteplase) as prescribed. If these measures are ineffective, an x-ray may be needed to check the catheter
location.
The nurse should identify the problem before instilling additional fluids and perform routine assistive measures before
contacting the health care provider.

HEMODIALYSIS

Dialysis disequilibrium syndrome (DDS) is a rare but potentially life-threatening complication that can occur in
clients during the initial stages of hemodialysis (HD); it can be prevented by slowing the rate of dialysis.
During HD, solutes (ie, urea) are removed more quickly from the blood than from the brain cells and cerebrospinal
fluid, creating a concentration gradient that can lead to excess fluid in the brain cells and increased intracranial
pressure.
Characteristic neurologic manifestations include nausea and vomiting, headache, restlessness, change in mentation,
and seizure activity.
If DDS is suspected, the health care provider should be contacted immediately
If severe, DDS can progress to coma and death. If DDS is identified during treatment, the rate of dialysis should
be slowed or stopped. Treatment focuses on interventions to decrease cerebral edema and manage symptoms.
Antihypertensives are withheld prior to HD to minimize the risk for hypotension. If the client is not hypotensive after
HD, prescribed antihypertensives should be administered but are not the priority intervention for a client with DDS.
Antiemetics should be administered to treat nausea associated with DDS, but they are not the priority intervention.
Trendelenburg position may increase cerebral edema and would be inappropriate for a client with DDS.
Prior to dialysis treatment, the nurse should assess the client's fluid status (weight, blood pressure, peripheral edema,
lung and heart sounds), vascular access (arteriovenous fistula, arteriovenous grafts), and vital signs.
The amount of fluid removed (ultrafiltration) is determined by calculating the difference between the last post-dialysis
weight and the client's current pre-dialysis weight
After the client is connected to the dialysis machine, IV heparin is added to the blood from the client to prevent
clotting that can occur when blood contacts a foreign substance. Giving subcutaneous heparin prior to initiation is not
necessary
 During dialysis, excess fluid is removed, making the client prone to hypotension. In addition, medications are removed
from the blood during hemodialysis, making them ineffective. Many medications that are taken once daily can be held
until after the dialysis treatment to prevent their removal. If blood pressure medications are given prior to dialysis, the
client can develop hypotension during the dialysis and then uncontrolled hypertension (decreased drug
concentrations).
Arteriovenous fistulas are created by anastomosing an artery to a vein; a thrill can be felt when palpating the fistula,
and a bruit can be heard during auscultation when the fistula is functioning properly.
Medication administration may require modification on days that clients are scheduled to receive dialysis. The nurse
should consider whether the medication will be dialyzed out of the client's system or may create adverse effects during
dialysis. Fluid is removed during dialysis, which may cause hypotension.
Typically, antihypertensives are held before dialysis to prevent hypotension. In addition, some medications
are dialyzed out of the client's system and should therefore be held until after dialysis. Commonly held medications
are water-soluble vitamins (eg, vitamins B and C), antibiotics, and digoxin.
Clients with chronic kidney disease have high phosphorus levels as the kidney is unable to filter the phosphate from
the body; dialysis also does not filter it. Therefore, the client should still take phosphate binders prior to dialysis.
Phosphate binders (eg, calcium containing [calcium carbonate and calcium acetate]) and non-calcium containing
[sevelamer and lanthanum]) block absorption of ingested phosphate from the intestine and excrete it through feces.
Lispro is a fast-acting insulin that should be given 15-30 minutes before meals. It is appropriate to give scheduled
lispro with breakfast prior to dialysis.
Vitamin E is a fat-soluble vitamin that is not affected by dialysis. It is given to some clients to prevent leg cramps that
can be experienced by dialysis clients.

CYSTOSCOPY

A cystoscopy is a procedure that uses a flexible fiber-optic scope inserted through the urethra into the urinary bladder
with the client in the lithotomy position.
Complications associated with cystoscopy include urinary retention, hemorrhage, and infection. Therefore, clients
are instructed to notify the health care provider (HCP) immediately if they have bright red blood when urinating, blood
clots, inability to urinate, fever >100.4 F (38 C) and chills, or abdominal pain unrelieved by analgesia. These
conditions necessitate evaluation by the HCP and may require antibiotic therapy or the insertion of a urinary catheter
to irrigate the bladder, remove clots, or drain the bladder
 Pink-tinged urine, frequency, and dysuria are expected for up to 48 hours following a cystoscopy. Clients are
instructed to increase fluids, drink 4-6 glasses of water daily to help dilute the urine, and avoid alcohol and caffeine for
24-48 hours as these can irritate the bladder.
Abdominal discomfort and bladder spasms may occur for up to 48 hours following the procedure. Clients are taught to
take a mild analgesic (eg, acetaminophen, ibuprofen) and a warm tub/sitz bath (except with recurrent urinary tract
infections) for pain relief.

NEPHROSTOMY

Percutaneous nephrolithotripsy involves the insertion of a needle and sheath through the skin into the pelvis of the
kidney. A nephroscope is inserted through the sheath to break and remove kidney stones too large to remove with
other methods. Post procedure, a temporary percutaneous nephrostomy tube may be placed to prevent obstruction
by stone fragments and to promote healing of injured tissue; maintaining tube patency is critical.
This client is experiencing left flank pain and has no drainage from the nephrostomy tube, which may indicate
obstruction to urine flow in the left kidney that can lead to kidney injury (pressure atrophy). Gentle irrigation of
the nephrostomy tube with a small volume of sterile normal saline (as prescribed or per protocol) using aseptic
technique is the appropriate intervention. If tube patency cannot be established after irrigation, the health care
provider is notified
The indwelling urethral catheter is appropriately draining 42 mL/hr, so it is not likely kinked or obstructed. The urine
flow is likely coming from a normal-functioning right kidney.
The client is placed in the prone position for the procedure, but this does not facilitate drainage.

CREATININE CLEARANCE

Creatinine clearance is a measure of glomerular function and is a sensitive indicator of renal disease progression.
A 24-hour urine collection is needed for the test. When the test begins, the first urine specimen is discarded and the
time is noted. All other voided urine for the next 24 hours is collected in a container and kept cool. At the end of the
24 hours, the client should void one last time and add the specimen to the container. Blood is drawn to measure
serum creatinine level in addition to urine creatinine.
An in-and-out catheter (straight catheter) is used for any test requiring a urine specimen when the client is unable to
urinate or unable to follow the specimen collection procedure. A catheter is also used for a cystourethrogram or a
residual urine test.
 Clean catch or midstream urine samples are collected for urinalysis or urine culture and sensitivity testing. For a
creatinine clearance test, all urine for the 24-hour period must be collected or the test must be started again.
The first AM void is preferable for a urinalysis or urine culture and sensitivity as an overnight specimen is more
concentrated.

URINARY TRACT INFECTION

Acute pyelonephritis is an infection of the kidney usually caused by an extension of infection from the lower urinary
tract (bladder). Chills and fever, vomiting, flank pain, and costovertebral tenderness are characteristic.
Blood and urine cultures should be obtained prior to initiation of antibiotic therapy whenever possible to identify the
causative microorganisms and determine the most effective antibiotics. Given this client's age and underlying
diabetes, sepsis can occur quickly. Therefore, antibiotics should be given immediately after cultures are obtained
The nurse should check the client's baseline renal function and complete blood count tests to compare subsequent
findings. This is not the priority nursing intervention.
The client has a history of renal calculi. Straining all urine is not the priority nursing intervention.
Case: The nurse is caring for a 78-year-old
client with a urinary tract infection (UTI).
Which assessment finding would
be most concerning and require immediate
follow-up by the nurse?

Confusion is a common clinical manifestation of urinary tract infections in the elderly but still should be cause for
concern and requires follow-up to rule out other possible causes.
Confusion is not a normal finding in the elderly adult client. Some causes of confusion in the elderly include
dehydration, lack of blood flow to the brain (stroke), decreased ability to metabolize medications, and concurrent
infections.

Urinary tract infections (UTIs) can occur in the kidneys (pyelonephritis), bladder (cystitis), and/or urethra
(urethritis). Pyelonephritis (inflammation of the kidney parenchyma) causes flank pain that is experienced in the
back at the costovertebral angle (the angle between the lower ribs and adjacent vertebrae) and may spread toward the
umbilicus. Cystitis alone does not cause nausea/vomiting or chills. Presence of these, fever, and signs and
symptoms of a lower UTI (dysuria, urgency, and frequency) indicate pyelonephritis.
The client with a distended bladder experiences constant pain increased by any pressure over the bladder. Bladder
distension is found through palpation (firmness, pain, urgency) and percussion (dullness) over the suprapubic area.
Bladder and urethral pain is usually dull and continuous and may be experienced as spasms. The detrusor muscle of
the bladder may spasm if cystitis is present.
Renal colic pain (in response to renal calculi) is excruciating, sharp, and stabbing; the client would be tossing in the
bed unable to find a comfortable position. Pain radiates down to the groin area as the stone travels down the ureter.

WOUND HEALING

Case: The nurse evaluates the results of

laboratory tests completed on a client
admitted for a non-healing wound. Which of
the following values would be a priority for
the nurse?
Nutritional deficiencies (eg, zinc, protein, vitamin C) and dehydration can impair wound healing. Dehydration (loss of
free water) can increase serum sodium levels. The normal value for serum sodium is 135-145 mEq/L (135-145
mmol/L). The value listed, 153 mEq/L (153 mmol/L), is high. Increased serum sodium level (hypernatremia) has an
osmotic action that causes water to be pulled from the interstitial spaces into the vascular system. Remember that
"water goes where salt is." This action decreases wound healing at a cellular level, reducing the nutrients cells need
for repair.
Normal blood urea nitrogen (BUN) values are 6-20 mg/dL (2.1-7.1 mmol/L). Elevated BUN may indicate dehydration
and could impair wound healing.
Malnutrition can impair wound healing. Serum albumin and prealbumin levels are obtained to assess nutritional
status. The normal value for albumin is 3.5-5.0 g/dL (35-50 g/L).
The normal value for serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L).

CHRONIC KIDNEY DISEASE

Clients with chronic kidney disease (CKD) have decreased glomerular filtration, resulting in retention of fluid,
potassium, and phosphorus. Fluid retention is initially treated with sodium restriction and diuretic therapy. Dietary
adjustments should also be made to reduce serum potassium and phosphorus.
Laboratory values are key to determining allowable foods. Dairy products (eg, milk, yogurt) and certain fruits (eg,
bananas, oranges, coconuts, watermelons, and avocados) contain high potassium levels. Dairy products also contain
high phosphorus levels.
Examples of allowable foods for CKD clients include apples, pears, grapes, pineapple, blackberries, blueberries, and
plums.
Avocados are high in potassium; the chips may be high in sodium.
Pudding and yogurt contain dairy products and are high in phosphorous and potassium. Oranges are high in
potassium.

Case: A clinic nurse receives messages on 4

clients. Which client should the nurse call
back first?
Client with CKD reporting n/v & HA

The kidneys regulate fluid volume and blood pressure. Because renal damage often results in elevated blood
pressure, clients with chronic kidney disease are at risk for uncontrolled hypertension and hypertensive
emergencies.
Hypertensive encephalopathy is a type of hypertensive crisis characterized by nausea, vomiting, and headache.
Treatment is urgent (ie, within 1 hour) to prevent damage to the heart, kidney, and brain. The client should check
blood pressure at home, if possible, and then proceed to the emergency department for further assessment and
treatment (eg, titration of antihypertensive medication).

Clients with chronic kidney disease (CKD) are at risk for fluid overload and hyperkalemia. Clients should avoid
salt substitutes, which typically contain potassium chloride and may contribute to hyperkalemia
To avoid further complications and prevent progressive kidney damage, clients with CKD are advised to follow certain
dietary restrictions, including:

o Sodium restriction Avoid high-sodium foods such as cured meats, pickled foods, canned soups, frankfurters, cold cuts, soy
sauce, and salad dressings
o Potassium restriction Avoid high-potassium foods such as raw carrots, tomatoes, and orange juice
o Fluid intake monitoring Monitor fluid intake closely and accurately, being careful to include foods that are liquid-based (eg,
popsicles, gelatin), because fluid is often restricted
o Low-protein diet Eat 0.6-0.8 g/kg/day of protein to help prevent progression of kidney disease. If the client is already on
hemodialysis, increased protein intake is recommended to prevent malnutrition.
o Low-phosphorus diet Avoid foods high in phosphorus (eg, chicken, turkey, dairy).

ILEAL CONDUIT

An ileal conduit is a surgical technique that uses an excised piece of the client's ileum to create an incontinent urinary
diversion. The client's ureters are connected to the ileal conduit, which is used to create an abdominal stoma that
allows the passage of urine.
 A healthy stoma should be pink to brick-red and moist, indicating vascularity and viability. If the stoma is dusky or
any shade of blue, the nurse should suspect impaired perfusion and contact the HCP immediately. This finding is
considered a medical emergency
Infection is a potential complication; signs and symptoms of infection may include fever, elevated white blood cell
count, odor, and delayed healing. A bluish grey color indicates impaired perfusion, not infection.
Although the nurse will document the findings and monitor for changes, lack of perfusion to the stoma is an emergency
that must be reported immediately.
Applying an appropriate-size pouching system (approximately 0.1 in [0.25 cm] larger than the stoma) prevents
decreased perfusion and skin irritation. Using a larger drainage bag, especially at night, prevents urine backflow
through the stoma and reduces the risk for infection. These are important concepts of stoma care but are not the
priority at this time.

RADICAL PROSTATECTOMY

A prostatectomy uses either minimally invasive or open surgical techniques to remove all or part of the prostate gland
for clients with related disorders (eg, cancer, benign prostatic hyperplasia). For up to 36 hours after surgery, small
blood clots may occur, although they should not impair the urine stream. Consistent passage of clots after this time
could indicate a postoperative complication. Signs of such complications (eg, reduced urine stream,
persistent bleeding/blood clots, urinary retention, fever, dysuria) after discharge should be evaluated by the health
care provider for further treatment (Option 1).
The presence of blood clots 6 days after surgery is not normal and may indicate bleeding from the prostatic fossa.
This client requires further evaluation.
Clients should avoid the Valsalva maneuver for up to 8 weeks after prostatectomy because the exerted pressure may
injure the healing tissue, causing hematuria.
Maintaining adequate fluid intake helps prevent blood clot formation. However, this client is reporting blood clots with
a decreased urinary stream and needs further evaluation.
METABOLIC ACIDOSIS

Metabolic acidosis is due to an increase in the production or retention of acid or the depletion of bicarbonate via the
kidneys or gastrointestinal (GI) tract. In metabolic acidosis there is a decrease in pH (<7.35) and HCO3- (<22 mEq [22
mmol/L]).
Common causes of metabolic acidosis include:

o GI bicarbonate losses (eg, diarrhea)

o Ketoacidosis (eg, diabetes, alcoholism, starvation)
o Lactic acidosis (eg, sepsis, hypoperfusion)
o Renal failure (eg, hemodialysis with inaccessible arteriovenous shunt)
o Salicylate toxicity

A client with claustrophobia who was stuck in an elevator is at risk for an anxiety attack, which leads to
hyperventilation and respiratory alkalosis (pH >7.45, PaCO2 <35 mm Hg [4.66 kPa]).
 A client with excessive vomiting is at risk for metabolic alkalosis due to loss of stomach acid.
DIAGNOSTIC SCANS

Various diagnostic tests, including bladder scans, urine cultures, cystoscopy, renal arteriograms, and renal scans,
assess the renal system. It is necessary to understand the purpose and procedures for each examination when
evaluating complications arising from these assessments.
Portable ultrasonic bladder scanners are used at the bedside to determine the amount of residual urine in the bladder.
Amounts >100 mL should be reported as the client may be experiencing urinary retention
A cystoscope is inserted through the urethra to directly visualize the bladder wall and urethra. Irritation of the
urethral and bladder lining from the insertion and manipulation of the cystoscope may cause a slight burning sensation
with voiding for a day or two.
Renal arteriogram is a radiologic test performed to visualize renal blood vessels to detect abnormalities (renal artery
stenosis or aneurysm). A contrast medium is injected into the femoral artery; therefore, the client should be taught to
increase fluid intake after the procedure to flush the dye from the body. Increased output is an expected finding.
Urine is sterile, but the urethra contains bacteria and a few white blood cells. Less than 10,000 organisms/mL is a
normal value for urine culture. Values >10,000 organisms/mL indicate urinary tract infection (UTI).

RENAL CALCULI

The formation of renal calculi (ie, kidney stones) can be due to various factors (eg, family history, dietary imbalances,
immobilization, dehydration). Manifestations include sudden, severe abdominal or flank pain and nausea/vomiting.
Client management focuses on analgesics administered at regularly scheduled intervals, rehydration of up to 3 L/day
unless contraindicated by other comorbidities, and ambulation to facilitate the passage of calculi
To retrieve stones that the client may pass, the nurse should strain all urine obtained. The collected stones are
analyzed to determine their composition (eg, calcium oxalate, calcium phosphate, struvite, uric acid, cystine), which
can then direct preventive measures, such as dietary and lifestyle changes, after discharge.
Immobilization is a contributing cause of renal calculi formation and should be avoided. Ambulation and frequent
mobilization are encouraged as tolerated to help facilitate the passage of calculi.
Massage therapy to the flank should not be performed to prevent further instigation of renal colic. Other interventions,
such as monitored heat therapy, would be acceptable.
BENIGN PROSTATIC HYPERPLASIA

Benign prostatic hyperplasia (BPH) is an abnormal prostate enlargement that most commonly affects male clients
age >50. The prostate gradually enlarges and compresses the urethra, causing voiding problems.
Symptoms include urinary urgency, frequency, and hesitancy, dribbling urine after voiding, nighttime frequency
(nocturia), and urinary retention.
Treatment includes lifestyle changes and medications that shrink or slow growth of the prostate, and symptom
management interventions (eg, voiding schedule, avoidance of caffeine and antihistamines). Surgical prostate
resection may be required.
Clients with BPH have increased risk for urinary tract infection (UTI) because of incomplete bladder
emptying and urine retention. Symptoms of UTI are often similar to those of BPH; however, burning
sensation with urination and cloudy/foul-smelling urine are specific UTI symptoms that require further assessment and
treatment
Dribbling after urination and nocturia are expected findings with BPH.
Finasteride (Proscar) is a medication that inhibits further growth of the prostate. Appreciable differences in prostate
size are noticed only after several months of therapy. Missing three doses would not cause immediate or long-term
adverse effects.
With increasing age (typically age >50), male clients experience hormone changes that can lead to prostate
enlargement, known as benign prostatic hyperplasia (BPH). BPH is often not diagnosed until it begins to compress
the surrounding bladder and urethra, causing voiding difficulties and abnormalities.
Clients with BPH exhibit the following signs and symptoms:

o Urinary retention
o Sensation of incomplete emptying and/or increased urgency to void
o Straining or difficulty initiating voiding (hesitancy)
o Weak and/or intermittent stream of urine during voiding
o Frequent voiding patterns throughout the day (eg, urinating more than once in 2 hours) and night (nocturia)

Frequency of sexual intercourse is unrelated to urinary retention and BPH in the male client.
PESSARY

A pessary is a vaginal device that provides support for the bladder. Clients can remain sexually active while
wearing a pessary. They are fitted for the proper type and size by an HCP in the office. Surgery is not required for
pessary placement; clients who are able can insert and remove the pessary themselves. If a pessary or other
treatment (eg, pelvic muscle exercises, estrogen replacement therapy) is ineffective, reconstructive surgery may be
indicated.
Clients who are able to remove and reinsert the pessary on their own will have the choice to remove it weekly, possibly
even nightly, for cleaning. Clients who are sexually active may prefer to remove the pessary prior to intercourse,
although this is not necessary. When the client cannot remove the pessary regularly, removal by an HCP at 2- to 3-
month intervals is recommended.
Increased vaginal discharge is a common side effect. However, if an odor is present, the client should be instructed to
notify the HCP to be treated for a possible infection.

CREATININE

Case: The evening shift nurse reviews the

preoperative checklist and latest serum
laboratory values for an elderly client with a
ruptured diverticulum who is scheduled for
surgery in the early morning. Which
laboratory value is most important for the
nurse to report to the health care provider?

Creatinine level 2.5mg/dl (221 umol)

Creatinine level of 2.5 mg/dL (221 µmol/L) is the most important abnormal value (normal 0.6-1.3 mg/dL [53-115
µmol/L]) for the nurse to report to the health care provider.
 An elevated creatinine level increases the risk for intra- and postoperative complications. Nothing-by-mouth (NPO)
status preoperatively, dehydration (ie, fluid shift from peritonitis), intraoperative fluid losses, antibiotic therapy, and
advanced age affect renal function and increase the risk for postoperative exacerbation of kidney injury in this client.

SEVERE HYPERKALEMIA

CASE: A client with advanced kidney

disease has serum potassium of 7.1 mEq/L
(7.1 mmol/L) and creatinine of 4.5 mg/dL
(398 µmol/L). What is
the priority prescribed intervention?

ADMINISTER IV 50% DEXTROSE AND

REGULAR INSULIN

Severe hyperkalemia (potassium >7.0 mEq/L [7.0 mmol/L]) requires urgent treatment because cardiac muscle
cannot tolerate very high potassium levels. Severe hyperkalemia increases the risk for life-threatening ventricular
dysrhythmias (eg, ventricular tachycardia and fibrillation, asystole).
IV administration of 50 mL 50% dextrose with 10 units of regular insulin is the priority intervention as it is most
effective in reducing the potassium level quickly. The insulin temporarily shifts the potassium from the extracellular
fluid back into the intracellular fluid. The dextrose prevents hypoglycemia associated with the increase of insulin in
the body and can be eliminated if the client has hyperglycemia.
If the client has ECG changes (eg, tall peaked T waves), calcium gluconate should be given before insulin/dextrose.
This will stabilize the cardiac muscle until the potassium level can be reduced with insulin/dextrose.
Furosemide (Lasix) increases the renal excretion of potassium and is usually prescribed for clients with fluid overload.
However, administration of furosemide would take time to be effective and is not the priority.
Sodium polystyrene sulfonate (Kayexalate) is administered by mouth or enema to remove potassium from the body by
exchanging sodium for potassium ions in the intestines; these are then excreted in feces. This is not the priority due to
the delayed onset of potassium removal.
Hemodialysis is an invasive procedure that can be initiated if more conservative, noninvasive therapies are ineffective
in reducing the potassium level. Placement of the catheter will delay treatment.
TRANSURETHRAL RESECTION OF THE PROSTATE (TURP)

Transurethral resection of the prostate (TURP) involves the insertion of a scope to remove obstructing prostate
tissue. Continuous bladder irrigation (CBI) with a 3-way Foley catheter is initiated after the procedure. The
catheter balloon applies direct pressure to the bleeding tissue while the tubing allows the urine to drain. During the
first 24 hours, the urine color changes from reddish-pink to pink. Small clots are also expected for up to 36 hours after
surgery. However, the nurse should adjust the irrigation rate with these normal findings so that the urine remains light
pink without clots
Vital signs within normal limits indicate hemodynamic stability but will not reflect the patency of the draining catheter.
Painful bladder spasms are expected after TURP and catheter placement. Spasms are typically treated with
antispasmodics (eg, belladonna-opium suppositories, oxybutynin [Ditropan]).
The total Foley output should be more than the CBI input, as the Foley output includes CBI fluid (not processed
through the kidneys) plus the normal renal output of urine. An obstruction is indicated if the CBI input is equal to or
greater than the Foley output.

RENAL PHYSICAL EXAMINATION

Examination of the urinary system requires an abdominal assessment. Therefore, assessment techniques must be
reordered to optimize the examination. The steps for a renal system assessment are:
1. Empty the bladder to avoid discomfort during percussion and palpation and to provide a clean-catch sample (if
prescribed)
2. Inspect the abdomen and lower back for color, contour, symmetry, distension, and movements (eg, visible
peristalsis). Inspection is always done first during physical examination
3. The nurse should auscultate immediately after inspection as percussion or palpation may increase bowel motility
and interfere with sound transmission during auscultation. Listen for renal artery bruits in the right and left upper
abdominal quadrants
4. Percuss for kidney borders, costovertebral angle tenderness, and bladder distension. A dull percussion sound
indicates solid structures or fluid-filled cavities (eg, distended bladder). Palpate for bladder distension, masses,
and tenderness. A distended bladder may be palpated at any point from the symphysis pubis to the umbilicus and
is felt as a firm, rounded organ. A normal kidney is not usually palpable; a palpable kidney may indicate
hydronephrosis or polycystic kidney disease
 5. Document all renal assessment findings immediately after the examination

HYPERKALEMIA

Hyperkalemia can be asymptomatic but may cause fatigue, generalized weakness, or in severe cases muscle
paralysis and/or dysrhythmias. Management includes preventing life-threatening dysrhythmias and correcting
serum potassium levels.
Intravenous calcium gluconate is administered to hyperkalemic clients with ECG changes (eg, peaked T waves).
Calcium gluconate itself does not decrease the serum potassium level but temporarily stabilizes the myocardium by
raising the threshold for dysrhythmia occurrence. Once the nurse stabilizes the client by administering calcium
gluconate, other prescriptions may then be implemented to decrease serum potassium level (eg, intravenous regular
insulin with dextrose, sodium polystyrene sulfonate, hemodialysis)
Intravenous regular insulin temporarily corrects hyperkalemia by shifting potassium into the cells. Dextrose is
administered concurrently to prevent hypoglycemia. Although intravenous regular insulin will effectively decrease
serum potassium levels, calcium gluconate will provide immediate protection from dysrhythmias.
 Sodium polystyrene sulfonate causes excretion of potassium from the body via the gastrointestinal tract. Although this
will effectively decrease serum potassium levels, calcium gluconate will provide immediate protection from
dysrhythmias.
Although hemodialysis will effectively decrease serum potassium levels, calcium gluconate will provide immediate
protection from dysrhythmias.

OVERFLOW URINARY INCONTINENCE

Overflow urinary incontinence occurs due to compression of the urethra (eg, uterine prolapse, prostate
enlargement) or impairment of the bladder muscle (eg, spinal cord injury, diabetic neuropathy, anticholinergic
medications). Both types involve incomplete bladder emptying and urinary retention, which lead to overdistension and
overfilling of the bladder and frequent involuntary dribbling of urine.
When caring for clients with overflow incontinence, the nurse should:
o Implement a fixed voiding schedule (eg, every 2 hours) to prevent bladder overfilling.
o Instruct the client to use the Valsalva maneuver (ie, "bearing down") and Credé maneuver (ie, gently applying
pressure to the lower abdomen) to help facilitate bladder emptying
o Assess the perineal area for skin breakdown related to incontinence
o Measure postvoid residual volumes as prescribed to ensure that the client is not retaining large amounts of
urine
o Instruct the client to wait 20-30 seconds after voiding and then attempt to void a second time (ie, double
voiding) to help empty residual urine
Fluid restriction can lead to dehydration with concentrated urine, which irritates the bladder and increases the risk for
urinary tract infection. Dehydration also contributes to constipation, which worsens incontinence by compressing the
bladder.

EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL)

 Extracorporeal shock wave lithotripsy (ESWL) is a noninvasive procedure that uses high-energy acoustic shock
waves to break up kidney stones into small fragments that can be excreted in the urine. The procedure is typically
performed in an outpatient setting under general anesthesia. Temporary ureteral stents are often placed during the
procedure to facilitate the passage of the stone fragments and prevent occlusion of the ureter. Stents are typically
removed in 1-2 weeks.
After an ESWL procedure, the client should be instructed to:

o Increase fluid intake to help flush out the kidney stone fragments
o Expect some bruising and pain of the back and/or flank of the affected side. Analgesics may be required
o Expect to see blood in the urine (hematuria). Urine color should progress from bright red to pink-tinged during the first
several hours. Hematuria is concerning if the urine remains bright red for a prolonged period (eg, >24 hours)
o Report any symptoms of infection (eg, fever, chills) to the health care provider

Ambulation is encouraged after ESWL to facilitate passage of the stone fragments.

BLADDER CATHETERIZATION

The flow of urine is dependent on gravity. In order to maintain gravity flow, the drainage bag should be hung below the
level of the bladder. Impaired urine flow can lead to urinary retention and distension of the bladder.
Catheters placed in the kidney pelvis are irrigated using gentle pressure and small amounts of sterile saline solution
me) to avoid damaging renal tissues.
Securing an indwelling urinary catheter by taping it to a client's leg is acceptable to maintain gravity flow and prevent
kinks and occlusions. Also, Velcro securement devices may be available at certain facilities.
Fluid intake of 3,000 mL per day should be encouraged in clients after surgery involving the urinary system. Increased
fluid intake ensures the maintenance of a high urinary output, reducing the risk for infection. Dilute urine is less
irritating to the skin surrounding the stoma site. Electrolyte reabsorption from reservoirs may increase risk for calculi.
However, high fluid intake and urine output reduce this risk.

URINARY RETENTION

CASE: The nurse is caring for a 68-year-old

male client following a laparoscopic
cholecystectomy 8 hours ago. The client has
not urinated since surgery. Which would be
the most appropriate initial intervention?

HELP THE CLIENT OUT OF BED

Urinary retention occurs frequently after surgery due to administration of opioids (eg, morphine) and anesthesia, and
in older men, who often have an enlarged prostate gland or benign prostatic hyperplasia (BPH). Up to 50% of men
over age 60 have an enlarged prostate.
Body position can also contribute to urinary retention. Most men are used to urinating when standing up; therefore,
the nurse or assistive personnel should help the client out of bed rather than offer a urinal for use in bed
Providing privacy may also aid in relaxation and urination.
The second intervention should be a bladder scan. If the client is unable to urinate, an ultrasound scan can be used to
noninvasively assess the volume of urine in the bladder. It can also be used to determine the residual bladder volume
after the client has urinated to assess the amount of retention.
An indwelling catheter is not currently indicated for this client. Catheter-associated urinary tract infection (CAUTI) is a
significant hospital-acquired infection. The risk of CAUTI can be reduced by using an indwelling catheter only when
other interventions have failed to produce desired outcomes.
Intermittent catheterization would be the third intervention if the client has been unable to urinate or has significant
urinary retention (>300-400 mL).

UTI IN SEXUALLY ACTIVE WOMEN

The nurse should encourage a sexually active female client to implement the following interventions to help prevent
recurrent UTIs:

o Take all antibiotics as prescribed even if symptoms have improved as bacteria may still be present
o Increase fluid intake; this dilutes the urine (minimizing bladder irritation), promotes frequent urination, and prevents urinary
stasis. The client should void at least every 2-4 hours. Some health care providers recommend drinking cranberry juice as it
inhibits bacterial attachment to the bladder wall, but there is no clinical evidence to support its effectiveness in preventing
UTIs
 o Wipe from front to back to prevent introducing bacteria from the vagina and anus into the urethra
o Avoid synthetic fabrics as these materials (eg, nylon, spandex) seal in moisture and create an environment conducive to
bacterial proliferation; cotton underwear is recommended instead
o Void after sexual intercourse to flush out bacteria that may have entered the urethra

Avoid douching and using feminine perineal products (eg, deodorants, powders, sprays), as they can alter the
vaginal pH and normal flora, increasing the risk for infection. Take showers instead of baths as bath products (eg,
bubble bath, oils) and bacteria in bath water can irritate the urethra and increase the risk of infection.
Avoid spermicidal contraceptive jelly as it can suppress the production of protective vaginal flora. Discontinue
diaphragm use temporarily (until symptoms subside and antibiotic course is completed); a diaphragm increases
pressure on the urethra and bladder neck, which may inhibit complete bladder emptying.

KIDNEY BIOPSY

A kidney biopsy involves obtaining a tissue sample for pathological evaluation to determine the cause of certain kidney
diseases (eg, nephritis, transplant rejection). The kidney has extensive vasculature (similar to the liver);
therefore, bleeding from the biopsy site is the major complication following a percutaneous kidney biopsy.
Before the procedure, the client must give informed consent and discontinue all anticoagulants (eg, heparin,
warfarin, rivaroxaban) and antiplatelet agents (eg, aspirin, clopidogrel, nonsteroidal anti-inflammatory drugs) for at
least one week. The client should be typed and crossmatched for blood (although the need for a transfusion is
rare). Blood pressure should be well-controlled.
After the procedure, the nurse should monitor vital signs at least every 15 minutes for the first hour as tachycardia,
tachypnea, and hypotension can indicate blood loss. The nurse should also assess the puncture site dressing for
bleeding
Blood urea nitrogen (BUN) and creatinine levels would not change significantly within 30-60 minutes. These are
usually measured once every 24 hours and rarely every 12 hours.
Insertion of an indwelling urinary catheter is not necessary to perform a kidney biopsy and is not part of the usual
protocol.
Post-procedure, the client should be positioned on the affected (left) side for 30-60 minutes to provide pressure and
help prevent bleeding. The client is usually placed in the prone position during the procedure to facilitate access to the
kidney.
PERITONEAL DIALYSIS

During peritoneal dialysis, dialysate is infused into the abdominal cavity and the tubing is then clamped to allow the
fluid to dwell for a specified period. After the dwell time, the catheter is unclamped and the fluid drains out via gravity.
During the instillation and dwell portions of the cycle, clients are monitored closely for indications of respiratory
distress (eg, difficulty breathing, rapid respirations, crackles) that can result from instilling the dialysate too rapidly,
overfilling of the abdomen, or fluid entering the thoracic cavity. Crackles can also occur if over time there is more
dialysate infused than is removed (fluid gain).
Clients receive peritoneal dialysis due to chronic kidney failure. The client's blood pressure is likely elevated
secondary to the renal failure. This assessment is important to monitor, but crackles in the lungs are the priority.
Clients with renal failure typically have electrolyte abnormalities (eg, acidosis) that lead to nausea. This is not a
priority.
Edema in the extremities can also indicate volume overload. However, this could be due to many other factors (eg,
blood pressure medications such as amlodipine) or fluid overload from kidney disease. It is not a priority over
crackles, which indicate direct seeping of excess peritoneal cavity fluid into the thorax through diaphragmatic
channels.

OPTHAMOLOGY /AUDIOLOGY
RETINAL DETACHMENT

Retinal detachment is separation of the sensory retina from the underlying pigment epithelium. Clients experiencing
retinal detachment may report a gradual, curtain-like loss of the visual field. Traumatic retinal detachment may also
result in abrupt vision loss. Retinal detachment requires emergency surgery to attempt to restore vision. Surgical
repair involves rebinding the choroid and retina. After repair, interventions focus on promoting retinal
reattachment. Postoperative teaching should include:

o Avoiding activities that increase intraocular pressure (eg, rubbing the eye, straining)
o Reporting sudden pain, flashes of light, vision loss, or bleeding, which may indicate detachment or infection, to the health
care provider
o Avoiding focused activities (eg, reading, writing, sewing), which can cause rapid eye movements and increase the risk for
detachment
o Wearing an eye patch or shield as directed to prevent rubbing/scratching of the eye and minimize eye movement
o Ensuring appropriate positioning as instructed by the surgeon because clients may receive intravitreal oil or gas, which holds
the retina in a specific position to allow healing

Signs of retinal detachment include floaters, sudden flashes of light, and loss of vision. If signs of detachment occur,
the surgeon should be notified immediately.
 Chronic hyperglycemia can cause microvascular damage in the retina, leading to diabetic retinopathy, the most
common cause of new blindness in adults.
A retinal detachment requiring emergency management. A partial retinal detachment may be painless and cause
symptoms such as a curtain blocking part of the visual field, floaters or lines, and sudden flashes of light. An
unrepaired complete retinal detachment can cause blindness.
Retinal detachment is separation of the sensory retina from the underlying pigment epithelium with fluid
accumulation. It can be a result of spontaneous atrophic retinal breaks or acute trauma. Common symptoms include
a painless loss of vision "like a curtain" coming across the field of vision, light flashes, or a gnat/hairnet appearance
in the vision field.
This report needs emergent evaluation. Untreated symptomatic retinal detachment usually leads to blindness in that
eye. In addition, this is the only presentation that is acute: the rule for prioritization is acute before chronic.
Blunt-force trauma to the head is associated with potentially severe complications (eg, brain damage and
herniation, retinal detachment, seizures). Prompt recognition of potential complications is essential to prevent
irreversible changes to the client's neurological status and level of function.
Retinal detachment is a separation of the retina from the posterior wall of the eye that may occur following head
trauma. This is an ocular emergency as permanent blindness may result without intervention. Signs of retinal
detachment include perception of lightning flashes or floaters and a curtain-like or gnats/hairnet/cobweb effect
throughout the visual field

MACULAR DEGENERATION
Age-related macular degeneration is a degenerative eye disease that brings about the gradual loss of central
vision, leaving peripheral vision intact.
Macular degeneration is a progressive, incurable disease of the eye in which the central portion of the retina, the
macula, begins to deteriorate. This deterioration causes distortion (blurred or wavy visual disturbances) or loss of
the central field of vision, whereas the peripheral vision remains intact
Macular degeneration has two different etiologies. "Dry" macular degeneration involves ischemia and atrophy of the
macula that results from blockage of the retinal microvasculature. "Wet" macular degeneration involves the abnormal
growth of new blood vessels in the macula that bleed and leak fluid, eventually destroying the macula. Progression of
macular degeneration may be slowed with smoking cessation, intake of specific supplements (eg, carotenoids,
vitamins C and E), laser therapy, and injection of antineoplastic medications.
Risk factors for macular degeneration include advanced age, family history, hypertension, smoking, and long-term
poor intake of carotenoid-containing fruits and vegetables.

Meniere disease (endolymphatic hydrops) results from excess fluid accumulation in the inner ear.
Clients have episodic attacks of vertigo, tinnitus, hearing loss, and feelings of fullness or pressure in the ear. The
disorder typically affects only one ear and can lead to permanent hearing loss.
Attacks of Meniere disease can result in a total loss of proprioception, and clients often report feeling "pulled to the
ground" (drop attacks), making client safety a priority.
Vertigo can be severe and is associated with nausea, vomiting, and feelings of anxiety.
Self-care for Meniere disease may include:
o Consuming a low-sodium diet to decrease the potential for fluid excess within the inner ear. Intake of potassium
and other electrolytes does not need to be restricted
o Limiting or avoiding aggravating substances (eg, nicotine, caffeine, alcohol) and stimuli (eg, flickering lights,
watching television)
o Adhering to prescribed therapies for relief of symptoms (eg, antiemetics, antihistamines, sedatives, and mild
diuretics)
o Avoiding sudden changes in the position of the head (eg, bending over) during vertigo spells
o Participating in vestibular rehabilitation therapy
o Implementing safety measures during attacks (eg, assistance with walking, bed rest)

During an attack, the client is treated with vestibular suppressants, including sedatives (eg, benzodiazepines such as
diazepam), antihistamines (eg, diphenhydramine, meclizine), anticholinergics (eg, scopolamine), and antiemetics.
The nurse's priority is to plan for client safety with fall precautions given the severe vertigo and use of sedating
medications.
Fall precautions include adjusting the bed to a low position with side rails up and instructing the client to call for help
before getting up.
Vertigo may be minimized by staying in a quiet, dark room and avoiding sudden head movements.
The client should reduce stimulation by not watching television or looking at flickering lights.
The client's diet should be salt restricted to prevent fluid buildup in the ear.
An emesis basin should be provided at the bedside, but fall precautions are the priority.
A quiet environment can help minimize vertigo. However, it is a lower priority than the fall precautions.
Most clients with Meniere disease require parenteral fluids given the nausea and vomiting. However, these are not the
highest priority.
CATARACT SURGERY

A cataract is cloudiness (ie, opacity) of the lens that may occur at birth or more commonly in older adults. The
signs/symptoms of a cataract include painless, gradual loss of visual acuity with blurry vision; scattered light on the
lens producing glare and halos, which are worse at night; and decreased color perception.
Following cataract surgery, the client will be instructed that for several days (or until approved by the
surgeon), activities that may increase intraocular pressure should be avoided to decrease the risk of damage to
sutures or surgical site. These include bending (eg, vacuuming floors, playing golf), lifting more than 5 lb,
sneezing, coughing, rubbing or placing pressure on the eye, or straining during a bowel movement.
The nurse should encourage this client to increase fluids and fiber in the diet as well as consider an over-the-counter
stool softener or laxative.
It may take 1-2 weeks before visual acuity is improved.
It is common for the client to experience itching ("sand" in the eye), photophobia, and mild pain for several days
following surgery. Purulent drainage, increased redness, and severe pain should be reported.
Sleeping on 2 pillows will elevate the head of the bed and decrease intraocular pressure.
ACUTE ANGLE CLOSURE GLAUCOMA

Primary open-angle glaucoma (POAG) is an eye condition characterized by an increase in intraocular pressure and
gradual loss of peripheral vision (ie, tunnel vision). The signs/symptoms of POAG develop slowly and include
painless impairment of peripheral vision with normal central vision, difficulty with vision in dim lighting, increased
sensitivity to glare, and halos observed around bright lights. POAG can lead to blindness if left untreated.
Acute angle-closure glaucoma is a form of glaucoma that requires immediate medical intervention. Glaucoma
disorders are characterized by increased intraocular pressure (IOP) due to decreased outflow of the aqueous
humor, resulting in compression of the optic nerve that can lead to permanent blindness.
In acute angle-closure glaucoma, IOP increases rapidly and drastically, which can lead to the following manifestations:

o Sudden onset of severe eye pain

o Reduced central vision
o Blurred vision
o Ocular redness
o Report of seeing halos around lights

Gradual loss of peripheral vision and difficulty adjusting to different lighting are manifestations of chronic open-angle
glaucoma. Although further evaluation and treatment are necessary, this condition develops slowly and is not
considered an emergency situation.
 Opaque lenses are characteristic of cataracts, which are not a medical emergency.

OCULAR CHEMICAL BURNS

Ocular chemical burns require emergency care to prevent permanent vision loss. Alkali burns (eg, ammonia,
cement, lye-containing drain cleanser) are particularly dangerous as they will quickly penetrate deep into the eye,
causing severe, irreversible damage. For all types of ocular chemical burns, copious eye irrigation with sterile saline
or water should begin immediately to flush the chemical irritant out of the eye
Before transport to an emergency care facility, tap water can be used for eye irrigation. If transported by ambulance,
emergency care personnel continue irrigation during transport with IV tubing or a Morgan lens. Irrigation is continued
until the pH of the eye returns to normal (pH 6.5-7.5), which typically requires 30-60 minutes depending on the type of
chemical.
Depending on the severity of the burn, anesthetic eye drops may be instilled prior to irrigation because ocular burns
are very painful, but systemic analgesia is not a priority.
Care of ocular burns may include covering the eye with an eye patch and use of eye drops to prevent eye muscle
spasms; however, eye irrigation should be performed first.
The Snellen eye chart is commonly used to assess visual acuity. However, eye irrigation is essential and should not
be delayed.

EYE INJURY

CASE: During a camping trip, a camp

counselor falls and gets a small splinter of
wood embedded in the right eye. What
action should the volunteer camp nurse
take first?

PATCH BOTH EYES WITH EYE SHIELDS

The camp nurse protects the injured eye using an eye shield (eg, small Styrofoam or paper cup), ensuring the shield
does not touch the foreign body. The eyes work in synchrony with each other; therefore, the non-injured eye is
patched to prevent further eye movement. The nurse also facilitates transport to the nearest emergency care center
for assessment and treatment by an ophthalmologist.
Flushing the eye with cool water is contraindicated as it may cause further damage by moving the splinter and/or
introducing potential wound pathogens.
Instilling optic antibiotic ointment would interfere with ophthalmologic medical examination. Optic antibiotic ointment
may be prescribed by the health care provider to reduce the risk of infection once the object is removed from the eye.
The nurse should not attempt to remove a foreign body embedded in the eye. An ophthalmologist, a health care
provider who specializes in the surgical and nonsurgical evaluation and treatment of eye conditions, should remove
the embedded object as soon as possible
 CRITICAL CARE CONCEPTS IN NURSING
JAW THRUST MANEUVER
Clinical situations involving trauma should follow ABC: Airway, Breathing, and Circulation.
Airway assessment is particularly critical in clients with injuries to the head, neck, and upper back.
Injury to the upper back should be treated as spinal trauma until the client has been cleared by an Advanced Trauma
Life Support-qualified health care provider.
Until the spine is appropriately assessed, the client should be placed on a backboard and stabilized.
The nurse should use the jaw-thrust maneuver to avoid movement of an unstable spine. One provider should
stabilize the cervical vertebra allowing the second provider to articulate the jaw independently of the spinal column.

The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface,
is easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery
can be confirmed with a positive modified Allen's test.
 The modified Allen's test includes the following steps:

o Instruct the client to make a tight fist (if possible)

o Occlude the radial and ulnar arteries using firm pressure
o Instruct the client to open the fist; the palm will be white if both arteries are sufficiently occluded
o Release the pressure on the ulnar artery; the palm should turn pink within 15 seconds as circulation is restored to the hand,
indicating patency of the ulnar artery (positive Allen's test)

If the Allen's test is positive, the arterial blood gas can be drawn; if negative and the palm does not return to a pink
color, an alternate site (eg, brachial artery, femoral artery) must be used.

DIABETIC KETOACIDOSIS

DKA is a life-threatening complication of type 1 diabetes characterized by hyperglycemia (>250 mg/dL [13.9 mmol/L])
resulting in ketosis, a metabolic acidosis.
Glucose cannot be taken out of the bloodstream and used for energy without insulin, which individuals with type 1
diabetes cannot produce.
Similar to a state of starvation, the body begins to break down fat stores into ketones, causing a metabolic acidosis
(low pH and low HCO3).
 As a compensatory mechanism, this client has deep and rapid respirations with fruity/acetone smell (Kussmaul
respirations) in an attempt to reduce carbon dioxide levels by inducing a respiratory alkalosis to partially compensate
for the ketoacidosis, which has nearly normalized the pH.

EXTUBATION
Recently extubated clients are at high risk for aspiration, airway obstruction (laryngeal edema and/or spasm), and
respiratory distress.
To prevent complications, clients are placed in high Fowler position to maximize lung expansion and prevent
aspiration of secretions.
Warmed, humidified oxygen is administered immediately after extubation to provide high concentrations of
supplemental oxygen without drying out the mucosa
Oral care is provided to decrease bacteria and contaminants as well as promote comfort
Clients are instructed to frequently cough, deep breathe, and use an incentive spirometer to expand alveoli and
prevent atelectasis
Clients are kept NPO after extubation to prevent aspiration. They may have either a bedside swallow screen or a
more formal swallow evaluation by a speech therapist prior to swallowing any food, drink, or medication.
PHLEBOSTATIC AXIS ARTERIAL LINE

The phlebostatic axis is an external anatomical point on the chest at the level of the atria of the heart (fourth
intercostal space at the midaxillary line or midway point of the anterior posterior diameter of the chest).
It is used as a reference point for correct placement of the zeroing point of the transducer when measuring continual
arterial blood pressure (BP), central venous pressure (CVP) using a central line, and/or cardiopulmonary pressures via
a pulmonary artery (Swan-Ganz) catheter.
The nurse places the transducer and marks the chest at the phlebostatic axis, which helps to assure accuracy of
measurement.
After it is placed, the zero reference stopcock of the transducer is "leveled," or aligned with the level of the atrium,
using a ruler or carpenter's level. If the zeroing stopcock is placed below this level, falsely high readings occur; if it is
too high, falsely low readings are obtained.
The phlebostatic axis is also used as a reference point for the upper arm when measuring BP indirectly using a
noninvasive BP device or the auscultatory method with sphygmomanometer and stethoscope. If the upper arm is
above or below this level, the BP reading will be inaccurate.
INCREASE ICP
Metabolic demands (eg, pain, straining, agitation, shivering, fever, hypoxia) increase brain blood supply and raise
ICP. Nursing interventions to control ICP include:

o Elevating the head of the bed to 30 degrees with the head/neck in a neutral position to reduce venous congestion
o Administering stool softeners to reduce the risk of straining (eg, Valsalva maneuver)
o Managing pain well while monitoring sedation
o Managing fever (eg, cool sponges, ice, antipyretics) while preventing shivering
o Maintaining a calm environment with minimal noise (eg, alarms, television, hall noise)
o Ensuring adequate oxygenation
o Hyperventilating and preoxygenating the client before suctioning; reducing CO2 (a potent cerebral vasodilator) by
hyperventilation induces vasoconstriction and reduces ICP

Stimulation increases oxygen metabolism within the brain, increasing the risk for irreversible brain damage in
increased ICP. Limit performing interventions unless absolutely necessary and avoid performing interventions in
clusters.
The nurse should suction a maximum of 10 seconds and only as necessary to remove secretions. Prolonged
suctioning increases ICP.

DOPAMINE

Dopamine (Intropin) is a sympathomimetic inotropic medication used therapeutically to improve hemodynamic status
in clients with shock and heart failure. It enhances cardiac output by increasing myocardial contractility, increasing
heart rate, and elevating blood pressure through vasoconstriction. Renal perfusion is also improved, resulting in
increased urine output.
The lowest effective dose of dopamine should be used as dopamine administration leads to an increased cardiac
workload. Significant adverse effects include tachycardia, dysrhythmias, and myocardial ischemia. A heart rate
of 120/min may indicate that the dopamine infusion needs to be reduced
NEAR DROWNING
The initial management of a near-drowning victim focuses on airway management due to potential aspiration (leading
to acute respiratory distress syndrome), pulmonary edema, or bronchospasm (leading to airway obstruction). Hypoxia
is managed and prevented by ensuring a patent airway via intubation and mechanical ventilation as necessary
Careful handling of the hypothermic client is important because as the core temperature decreases, the cold
myocardium becomes extremely irritable.
Frequent turning could cause spontaneous ventricular fibrillation and should not be performed during the acute
stage of hypothermia. Continuous cardiac monitoring should be initiated
There are passive, active external, and active internal rewarming methods. Passive rewarming methods include
removing the client's wet clothing, providing dry clothing, and applying warm blankets. Active external rewarming
involves using heating devices or a warm water immersion. Active internal rewarming is used for moderate to severe
hypothermia and involves administering warmed IV fluids and warm humidified oxygen
Near-drowning occurs when a client is under water and unable to breathe for an extended period. In a matter of
seconds, major body organs begin to shut down from lack of oxygen and permanent damage results. Decerebrate
posturing is a sign of severe brain damage. During assessment, the nurse would observe arms and legs straight
out, toes pointed down, and the head/neck arched back. These assessment findings indicate that severe injury has
occurred.
Hypothermia occurs when the core temperature is below 95 F (35 C) and the body is unable to compensate for heat
loss. As the core temperature decreases, the cold myocardium becomes extremely irritable and prone
to dysrhythmias. The client should be handled gently as spontaneous ventricular fibrillation could develop when
moved or touched. Therefore, placing the client on a cardiac monitor is a high priority; the nurse should anticipate
defibrillation in these clients.
ARTERIAL BLOOD GAS
NEUROGENIC SHOCK

Neurogenic shock belongs to the group of distributive (vasodilatory) shock. It affects the vasomotor center in the
medulla and causes a disruption in the sympathetic nervous system (SNS); the parasympathetic nervous system
(PNS) remains intact.
The imbalance of activity between the SNS and PNS results in massive vasodilation and pooling of blood in the
venous circulation, causing hypotension and bradycardia, the characteristic manifestations of neurogenic shock.
Warm, dry skin is more likely to be present in neurogenic shock; cool, clammy skin is not a characteristic manifestation
BASIC LIFE SUPPORT

All members of the health care team must follow basic life support guidelines to perform cardiopulmonary
resuscitation (CPR) for clients experiencing cardiac arrest. Essential components of adult CPR include:
o Chest compressions are performed at a rate of 100-120/min and a depth of 2.0-2.4 inches (5-6 cm), allowing complete chest
recoil between compressions
o Defibrillator pads are placed on the right upper chest, just below the clavicle, and on the left lateral chest, near the anterior
axillary line below the nipple line
RAPID RESPONSE TEAM

The rapid response team is activated to marshal additional experienced and specialized resources for an acute need
to try to prevent a client from deterioration into a code/arrest situation. The team has critical care expertise to provide
immediate attention to unstable clients in noncritical care units and usually consists of a respiratory therapist, a critical
care nurse, and a physician or advanced practice registered nurse.
Recommended criteria to consider according to the Institute for Healthcare Improvement include the following:

o Any provider worried about the client's condition OR

o An acute change in any of the following:

Heart rate <40 or >130/min

Systolic blood pressure <90 mm Hg
Respiratory rate <8 or >28/min
Oxygen saturation <90 despite oxygen
Urine output <50 mL/4 hr
Level of consciousness

TORSADES DE POINTES

Torsades de pointes (ie, "twisting of the points") is a polymorphic ventricular tachycardia characterized by QRS
complexes that change size and shape in a characteristic twisting pattern.
Torsades de pointes is usually due to a prolonged QT interval (more than half the RR interval), which is the result of
electrolyte imbalances, especially hypomagnesemia, or some medications. The first-line treatment is IV
magnesium. Treatment may also include defibrillation and discontinuation of any QT-prolonging medications.
POSITIVE PRESSURE VENTILATION
Positive pressure ventilation (PPV) delivers positive pressure to the lungs using a mechanical ventilator (MV), either
invasively through a tracheostomy or endotracheal tube or noninvasively through a nasal mask/facemask, nasal
prongs, or a mouthpiece. The most common type used in the acute care setting for clients with acute respiratory
failure is the volume cycled positive pressure MV, which delivers a preset volume and concentration of oxygen (eg,
21%-100%) with varying pressure.
Positive pressure applied to the lungs compresses the thoracic vessels and increases intrathoracic pressure during
inspiration. This leads to reduced venous return, ventricular preload, and cardiac output, which results
in hypotension. The hypotensive effect of PPV is even greater in the presence of hypovolemia (eg, hemorrhage,
hypovolemic shock) and decreased venous tone (eg, septic shock, neurogenic shock).

MALIGNANT HYPERTHERMIA
Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs
used to induce general anesthesia in susceptible clients.
The triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction
and rigidity. It can occur in the operating room or in the post-anesthesia care unit (PACU).
The most specific characteristic signs and symptoms of MH include hypercapnia (earliest sign), generalized muscle
rigidity (eg, jaw, trunk, extremities), and hyperthermia.
Hyperthermia is a later sign and can confirm a suspicion of MH. The nurse monitors the temperature as it can rise 1
degree Celsius every 5 minutes and can exceed 105 F (40.6 C).
The nurse would notify the health care provider, indicating the need for immediate treatment (eg, dantrolene,
cooling blanket, fluid resuscitation)
COPD
An exacerbation of COPD is characterized by the acute worsening of a client's baseline symptoms (eg, dyspnea,
cough, sputum color and production).
NIPPV is often prescribed short-term to support gas exchange in clients who have moderate to severe COPD
exacerbations and acidosis (pH <7.3) or hypercapnia (PaCO2 >45 mm Hg). NIPPV can prevent the need for tracheal
intubation and is administered until the underlying cause of the ventilatory failure is reversed with pharmacologic
therapy (eg, corticosteroids, bronchodilators, antibiotics).
BIPAP involves the use of a mechanical device and facemask in a conscious client who is breathing spontaneously.
BIPAP delivers oxygen to the lungs and then removes carbon dioxide (CO2).
CO2 retention causes mental status changes. If the client becomes drowsy or confused, it is likely that more CO2 is
being retained than what BIPAP can remove; this should be reported to the HCP. Arterial blood gas evaluation should
be obtained to determine CO2 level and BIPAP effectiveness.
Altered mental status poses the greatest threat to a client's survival as it can lead to decreased protective reflexes (eg,
gag, swallow, cough), periods of apnea, and airway compromise

HYPOVOLEMIC SHOCK

Hypovolemic (hemorrhagic) shock may occur after abdominal trauma or surgery as mesenteric edema resolves and
previously compressed sites of bleeding reopen.
The shock continuum is staged in severity from initial (I) to irreversible (IV). During the initial stage, there is
inadequate oxygen to supply the demand at the cellular level and anaerobic metabolism develops. At this point, there
may be no recognizable signs or symptoms.
As shock progresses to the compensatory stage, sympathetic compensatory mechanisms are activated to maintain
homeostasis (eg, oxygenation, cardiac output).
 THIRD SPACING
Third-spacing of fluids can occur 24-72 hours after extensive abdominal surgery as a result of increased capillary
permeability due to tissue trauma. It occurs when too much fluid moves from the intravascular into the interstitial or
third space, a place between cells where fluid does not normally collect (ie, injured site, peritoneal cavity). This fluid
serves no physiologic purpose, cannot be measured, and leads to decreased circulating volume (hypovolemia) and
cardiac output.
The priority intervention is to assess vital signs as the manifestations associated with third-spacing include weight
gain, decreased urinary output, and signs of hypovolemia, such as tachycardia and hypotension. If third-spacing
is not recognized and corrected early on, postoperative hypotension can lead to decreased renal perfusion, prerenal
failure, and hypovolemic shock

CERVICAL SPINE INJURY

The initial priorities for a client with a suspected cervical spine injury are to ensure a patent airway and immobilize
the spine to prevent further injury. This includes applying a rigid hard collar, placing the client on a firm surface (eg,
a backboard), and moving the client as a unit (logrolling) if required
A soft foam cervical collar does not provide immobilization. Further stabilization is achieved by taping down the client's
head and using straps to immobilize the arms, especially if the client is not cooperating.
After immobilizing the client, the nurse should obtain a baseline set of vital signs to monitor for neurogenic shock (eg,
hypotension, bradycardia, poikilothermia [ie, inability to regulate body temperature]), a potential complication of spinal
cord injury.
The nurse should also assess the client's respiratory rate, pattern, and effort. Presence of abdominal breathing or
increased work of breathing may indicate impending loss of airway and require prompt rapid-sequence intubation
CPR IN PREGNANT WOMEN
Common causes of sudden cardiac arrest in pregnant clients include embolism, eclampsia, magnesium overdoses,
and uterine rupture. If cardiopulmonary resuscitation (CPR) is required, several modifications must be made to ensure
efficacy of the rescue efforts.
During pregnancy, the heart is displaced toward the left because the growing uterus pushes upward on the diaphragm,
particularly in the third trimester. To accommodate this displacement, the hands should be placed on the sternum
slightly higher than usual for chest compressions during CPR
In addition, a gravid uterus can significantly compress the client's vena cava and aorta, thereby hindering effective
blood flow during CPR. The uterus should be manually displaced to the client's left to reduce this pressure. The
nurse can also place a rolled blanket or wedge under the right hip to displace the uterus.
If return of spontaneous circulation (ROSC) does not occur after 4 minutes of CPR, emergency cesarean section is
usually initiated. Delivery should occur within 5 minutes of initiating CPR.

SUPRAVENTRICULAR TACHYCARDIA

Clients with paroxysmal supraventricular tachycardia (SVT) (regular, narrow QRS complex tachycardia) are initially
treated with vagal maneuvers. The act of "bearing down" as if having a bowel movement (Valsalva) is an example of
these maneuvers and may need to be attempted more than once. Vagal maneuvers work by increasing intra-thoracic
pressure and stimulating the vagus nerve, which supplies parasympathetic nerve fibers to the heart, resulting in
slowed electrical conduction through the atrioventricular node.
 Cardioversion (not defibrillation) is used with this type of arrhythmia when it is refractory to medication. Cardioversion
delivers a synchronized electrical current to the heart. This works by stopping the electrical activity to the heart and
briefly allowing a normal heartbeat to return.
Adenosine is the drug of choice to treat SVT and has a 5- to 6-second half-life (the time it takes for the drug to be
reduced to half of its original concentration). Placing the IV line as close as possible, not distal, to the heart is
essential for the drug to have full effect. Adenosine is given rapidly over 1-2 seconds and then followed by a rapid 20-
mL normal saline flush. Transient asystole is common, and clients often experience flushing and dizziness.

MECHANICAL VENTILATOR

Clients requiring mechanical ventilation are at risk for a variety of ventilator-associated complications (eg,
aspiration, pneumonia). When caring for a client receiving mechanical ventilation, the nurse should:

o Monitor respiratory status (eg, lung sounds, breathing pattern), airway patency, and ventilator functionality (eg, settings,
alarm parameters).
o Maintain the head of the bed at 30-45 degrees to reduce aspiration risk
o Use the minimum amount of sedation necessary for client comfort (eg, compliant with ventilator, opens eyes to voice).
Continuous IV sedation should be paused daily for evaluation of spontaneous respiratory effort and appropriateness for
weaning off the ventilator
o Perform oral care with chlorhexidine oral solution every 2 hours, or per facility policy. Perform tracheal suctioning as needed.
o Monitor correct endotracheal tube placement by noting insertion depth.
o Place emergency equipment at bedside (eg, manual resuscitation bag)
Mechanical ventilator alarms (eg, high- or low-pressure limit) alert the nurse to potential problems caused by a
change in the client's condition, a problem with the artificial airway (eg, endotracheal or tracheostomy tube), and/or a
problem with the ventilator.
Peak airway pressure is the amount of pressure required to deliver a tidal volume.
Any condition that increases the peak airway pressure can trigger the ventilator high-pressure limit alarm. When this
alarm sounds, the nurse should assess for conditions that increase airway resistance and/or decrease lung
compliance, such as:

o Excessive secretions: Obstruct the airway, increasing resistance

o Biting the endotracheal tube and kinked ventilator tubing: Air flow is obstructed, increasing resistance

Any condition that decreases airway resistance (eg, tubing disconnect, extubation, endotracheal or tracheostomy tube
cuff leak) can trigger the low-pressure limit alarm.
GUILLAN-BARRE SYNDROME

Guillain-Barré syndrome (GBS) is an acute, immune-mediated polyneuropathy that is most often accompanied
by ascending muscle paralysis and absence of reflexes.
Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves (CNs).
Neuromuscular respiratory failure is the most life-threatening complication. The rate and depth of the respirations
should be monitored
Measurement of serial bedside forced vital capacity (spirometry) is the gold standard for assessing early ventilation
failure.

NEUROLOGIC INJURY

Neurologic injury is the most common cause of mortality in clients who have had cardiac arrest, particularly
ventricular fibrillation or pulseless ventricular tachycardia.
Inducing therapeutic hypothermia in these clients within 6 hours of arrest and maintaining it for 24 hours has been
shown to decrease mortality rates and improve neurologic outcomes.
It is indicated in all clients who are comatose or do not follow commands after resuscitation.
The client is cooled to 89.6-93.2 F (32-34 C) for 24 hours before rewarming. Cooling is accomplished by cooling
blankets; ice placed in the groin, axillae, and sides of the neck; and cold IV fluids.
The nurse must closely assess the cardiac monitor (bradycardia is common), core body temperature, blood pressure
(mean arterial pressure to be kept >80 mm Hg), and skin for thermal injury. The nurse must also apply
neuroprotective strategies such as keeping the head of the bed elevated to 30 degrees. After 24 hours, the client is
slowly rewarmed.

DEFIBRILLATION
Defibrillation is indicated in clients with ventricular fibrillation (Vfib) and pulseless ventricular tachycardia.
Cardiopulmonary resuscitation (CPR) should be initiated and compressions continued until the shock is ready to be
delivered
 Certain pulseless rhythms (asystole and pulseless electrical activity) do not need defibrillation.
Steps to perform defibrillation are as follows:

1. Turn on the defibrillator

2. Place defibrillator pads on the client's chest (
3. Charge defibrillator. Chest compressions should continue until defibrillator has charged and is ready to deliver the shock.
4. Before delivering the shock, ensure that the area is "all clear." Confirm that no personnel are touching the client, bed, or any
equipment attached to the client
5. Deliver the shock
6. Immediately resume chest compressions

FROSTBITE

Frostbite involves tissue freezing, resulting in ice crystal formation in intracellular spaces that causes peripheral
vasoconstriction, reduced blood flow, vascular stasis, and cell damage.
Superficial frostbite can manifest as mottled, blue, or waxy yellow skin. Deeper frostbite may cause skin to appear
white and hard and unable to sense touch. This can eventually progress to gangrene.
Treatment of frostbite should include the following:

o Remove clothing and jewelry to prevent constriction.

o Do not massage, rub, or squeeze the area involved. Injured tissue is easily damaged
o Immerse the affected area in water heated to 98.6-102.2 F (37-39 C), preferably in a whirlpool. Higher temperatures do not
significantly decrease rewarming time but can intensify pain
o Avoid heavy blankets or clothing to prevent tissue sloughing.
o Provide analgesia as the rewarming procedure is extremely painful
o As thawing occurs, the injured area will become edematous and may blister. Elevate the injured area after rewarming to
reduce edema
o Keep wounds open immediately after a water bath or whirlpool treatment and allow them to dry before applying loose,
nonadherent, sterile dressings
o Monitor for signs of compartment syndrome.
BASILAR SKULL FRACTURE

Cerebrospinal fluid (CSF) rhinorrhea (or CSF otorrhea) can confirm that a skull fracture has occurred and
transversed the dura.
If the drainage is clear, dextrose testing can determine if it is CSF. However, the presence of blood would make this
test unreliable as blood also contains glucose. In this case, the halo/ring test should be performed by adding a few
drops of the blood-tinged fluid to gauze and assessing for the characteristic pattern of coagulated blood surrounded by
CSF.
Identification of this pattern is very important as CSF leakage places the client at risk for infection. The client's nose
should not be packed.
No nasogastric or oral gastric tube should be inserted blindly when a basilar skull fracture is suspected as there is a
risk of penetrating the skull through the fracture site and having the tube ascend into the brain. These tubes are
placed under fluoroscopic guidance in clients with such fractures.

PEDIATRIC AED

An automated external defibrillator (AED) should be used as soon as it is available.

Pediatric AED pads or a pediatric dose attenuator should be used for children age birth to 8 years if available.
Standard adult pads can be used as long as they do not overlap or touch.
 If adult AED pads are used, one should be placed on the chest and the other on the back ("sandwiching the heart").

POSITIVE END EXPIRATORY PRESSURE

Positive end-expiratory pressure (PEEP) applies a given pressure at the end of expiration during mechanical
ventilation. It counteracts small airway collapse and keeps alveoli open so that they can participate in gas exchange.
PEEP is usually kept at 5 cm H2O (3.7 mm Hg). However, a higher level of PEEP is an effective treatment strategy for
acute respiratory distress syndrome (ARDS), a type of progressive respiratory failure that causes damage to the type
II surfactant-producing pneumocytes that then leads to atelectasis, noncompliant lungs, poor gas exchange, and
refractory hypoxemia.
High levels of PEEP (10-20 cm H2O [7.4-14.8 mm Hg]) can cause overdistension and rupture of the alveoli, resulting
in barotrauma to the lung.
Air from ruptured alveoli can escape into the pulmonary interstitial space or pleural space, resulting in
a pneumothorax and/or subcutaneous emphysema.

VENTRICULAR TACHYCARDIA

Clients in ventricular tachycardia (VT) can be pulseless or have a pulse. Treatment is based on this important initial
assessment.
VT with a pulse should be further assessed for clinical stability or instability. Signs of instability include hypotension,
altered mental status, signs of shock, chest pain, and acute heart failure.
 The unstable client in VT with a pulse is treated with synchronized cardioversion. The stable client in VT with a
pulse is treated with antiarrhythmic medications (eg, amiodarone, procainamide, sotalol).
Oxygen saturation should be assessed after the presence of a pulse has been established.
CPR and defibrillation should be initiated only in a client who is pulseless.

GASTRIC LAVAGE
Gastric lavage (GL) is performed through an orogastric tube to remove ingested toxins and irrigate the stomach. GL
is rarely performed as it is associated with a high risk of complications (eg, aspiration, esophageal or gastric
perforation, dysrhythmias). GL is only indicated if the overdose is potentially lethal and if GL can be initiated within
one hour of the overdose. Activated charcoal administration is the standard treatment for overdose, but it is ineffective
for some drugs (eg, lithium, iron, alcohol).
Intubation and suction supplies should always be available at the bedside during GL in case the client develops
aspiration or respiratory distress
GL is usually performed through a large-bore (36 to 42 French) orogastric tube so that a large volume of water or
saline can be instilled in and out of the tube.
During GL, clients should be placed on their side or with the head of bed elevated to minimize aspiration risk.
GL should be initiated within one hour of overdose ingestion to be effective. The client's stomach should be
decompressed first, but lavage should be initiated as soon as possible afterwards.
PULSE OXIMETER

The erratic pulse oximeter tracing is representative of an artifact plethysmograph waveform caused by motion.
When an electronic assessment reading is questionable, the nurse should always assess the client first for possible
etiology.
The assessment includes the client's oxygenation and perfusion status (skin temperature, color), the level of
consciousness (in sedated clients), and restlessness or agitation. This assessment data guides the nurse in the
correct analysis of the tracing.
 PEDIATRICS
CARDIOLOGY /ENDOCRINOLOGY

TYPE I DM

Management of type 1 diabetes mellitus requires understanding of blood sugar regulation.

If the child becomes hypoglycemic or hyperglycemic, complications could develop.
The priority for caregivers should be to focus on the child's safety. Managing the child's blood sugars should be the
initial goal.
An acute illness (eg, scarlet fever) in clients with type 1 diabetes may trigger the release of stress hormones, which
leads to higher blood glucose and ketone levels (sometimes leading to ketoacidosis).
Clients with type 1 diabetes do not produce any insulin (unlike those with type 2 diabetes), so clients should not skip
administration of external insulin even if not eating. Insulin therapy should be continued as prescribed during an
acute illness
Additional sick-day management includes:
o Increasing frequency of blood glucose level checks (every 1-4 hours)
o Increasing or decreasing the dose of insulin as needed based on blood glucose levels
o Maintaining adequate hydration
o Testing for urinary ketones frequently

Stress hormones released during illness cause increased insulin resistance and lead the body to break down fat for
energy.
Ketones are produced when fat is broken down, which can lead to diabetic ketoacidosis (DKA).
The client's urine should be monitored frequently for ketones while the client is sick. Fluids are encouraged to clear
ketones from the system and prevent dehydration.
Blood glucose should be assessed frequently while the client is ill due to the potentially unpredictable and rapidly
changing levels caused by illness and/or fasting.
Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) presents an immediate danger to the client as life-
threatening neurologic impairment (eg, lethargy, seizures, coma) can occur when the brain becomes glucose
depleted.
If a client with diabetes has symptoms of hypoglycemia (eg, sweating, irritability, tremor, tachycardia, hunger), the
nurse should immediately assess the client, check capillary blood glucose, and provide a simple carbohydrate snack
that can be digested rapidly (eg, juice, soft drink, candy)
Hypoglycemia treatment in a conscious client is administration of 15 g of a quick-acting carbohydrate
After treatment, the nurse should recheck BG every 15 minutes, repeating treatment if it remains low. Quick-acting
carbohydrate options include:

o 4 oz (120 mL) of a regular soft drink or fruit juice

o 8 oz (240 mL) of low-fat milk
o 1 tablespoon (15 mL) of honey or syrup
o 6 hard candies
o Commercial dextrose products

The nurse should hold the client's scheduled insulin until the client's BG is normal and symptoms resolve.
An emergency glucagon IM injection is indicated if the client is somnolent, unconscious, seizing, or unable to swallow.
After the client's BG improves, the client should eat a meal. However, if the next meal is more than an hour away, the
nurse should give the client a serving of carbohydrate plus protein or fat (eg, peanut butter, cheese) to maintain
glucose levels.
 Appropriate diabetes management tasks for school-aged children include:

o Choosing and cleaning a finger for blood glucose testing before a parent or caregiver performs the puncture
o Selecting the site for insulin injection, with a parent or caregiver verifying appropriate site rotation
o Pushing the syringe plunger to administer insulin after a parent or caregiver inserts the needle
o Identifying signs and symptoms of hypoglycemia and hyperglycemia

TETRALOGY OF FALLOT

Tetralogy of Fallot is a congenital cardiac defect that typically has 4 characteristics: pulmonary stenosis, right
ventricular hypertrophy, overriding aorta, and ventricular septal defect.
This infant is experiencing a hypercyanotic episode, or "tet spell," which is an exacerbation of tetralogy of Fallot
that can happen when a child cries, becomes upset, or is feeding.
 Hypercyanotic episodes (ie, "tet" spell) occur when unoxygenated blood enters the systemic circulation, resulting in
cyanosis and hypoxemia. Tet spells usually occur during stressful or painful procedures; on waking; and with hunger,
crying, and feeding.
Home interventions to reduce the incidence of tet spells include:

o Providing a calm environment, particularly on waking

o Soothing and quieting the infant when crying or distressed
o Offering a pacifier
o Swaddling or holding the infant during procedures or times of stress
o Providing frequent smaller feedings to reduce frustration due to hunger and limit sucking fatigue

During an acute tet spell, the infant may be placed in the knee-chest position to improve pulmonary blood flow by
increasing systemic vascular resistance; older children may assume a squatting position. Intermittent oxygen can also
be used to treat the spell, if necessary.
Tet spells occur more often during stressful situations or on waking, so sleep should not be interrupted whenever
possible.
The child should first be placed in a knee-to-chest position. Flexion of the legs provides relief of dyspnea as this
angle improves oxygenation by reducing the volume of blood that is shunted through the overriding aorta and the
ventricular septal defect.
Morphine may be considered if the dyspnea is not relieved by the knee-to-chest position.
If oxygen saturation remains low, oxygen may need to be administered.
Vital signs and pulse oximetry may be checked after the infant has been placed in the knee-chest position.

ATRIAL SEPTAL DEFECT

 The nurse would expect to hear a murmur with an atrial septal defect. This defect is an abnormal opening between
the right and left atria, allowing blood from the higher pressure left atrium to flow into the lower pressure right atrium.
The back-and-forth flow of blood between the 2 chambers causes a vibration that is heard as a murmur on
auscultation.
ASD has a characteristic systolic murmur with a fixed split second heart sound. Some clients may also have a
diastolic murmur.
COARCTATION OF AORTA
CHEST COMPRESSIONS FOR INFANTS

Two techniques are acceptable for performing chest compressions on a newborn or infant. In the first, two thumbs are
placed on the middle third of the sternum, with the fingers encircling the chest and supporting the back.
The thumbs should be positioned side by side, just below the nipple line. This technique is preferred because it may
result in improved cardiac perfusion. If the newborn or infant is extremely small or the rescuer's thumbs are extremely
large, the thumbs may be superimposed (one on top of the other). The xiphoid portion of the sternum should not be
compressed because this may damage the liver.
The alternate method, especially if the resuscitator's hands are too small to encircle the chest, is to place only the
index and middle fingers of one hand on the sternum just below the nipple line. The other hand should support the
back. This technique is preferred if umbilical cord access is needed or in single rescuer situations.
During compressions, the sternum is compressed approximately one-third of the anteroposterior chest diameter at
a rate of 100-120/min (compression-ventilation ratio: 30:2 for 1 rescuer and 15:2 for 2 rescuers). The thumbs or
fingers should not be lifted from the sternum during the relaxation phase.
Although rare, cardiac arrest in infants can occur and usually stems from a respiratory etiology. The American Heart
Association provides guidelines for basic life support of infants (<12 months), including information about initial client
evaluation, emergency services notification, defibrillation, and performance of high-quality CPR.
Certain CPR modifications for infants include the location of pulse check and the timing of emergency services
notification. The rescuer should check the infant's brachial pulse for no longer than 10 seconds
During an unwitnessed collapse, a single rescuer should provide approximately two minutes of CPR at a rate of at
least 100 compressions per minute before notifying emergency services
The rescuer should deliver chest compressions at a depth equal to one-third of the chest's anterior-posterior diameter
(~1.5 in [4 cm]) and allow for recoil between compressions.
The rescuer should perform infant chest compressions using either two fingers or two thumbs on the sternum just
below the nipple line.
When a single rescuer is performing infant CPR, 30 chest compressions should be delivered and then two breaths (ie,
30:2). A chest compression-to-breath ratio of 15:2 is used when two rescuers are involved.
To check a pulse on an infant, the nurse should palpate the brachial artery by placing 2 or 3 fingers halfway between
the shoulder and elbow on the medial aspect of the arm.
The pulse should be assessed for 5-10 seconds to determine its presence and quality before CPR is initiated.
The brachial pulse is preferred in infants as the brachial artery is close to the surface and is easily palpable.
The carotid pulse can be difficult to assess due to a child's shorter neck. Extending an infant's neck to attempt to
palpate the carotid pulse can cause injury. This pulse is recommended for clients age >1 year.
The femoral pulse may be used for all clients; however, it is often not easily accessible for palpation due to diapers
and clothing.
The radial pulse is used in responsive clients age >1 year. It is not a recommended method of pulse detection in an
unresponsive client as a weak or thready pulse is difficult to palpate at this location.
HEART FAILURE

Following repair of tetralogy of Fallot, clients often develop chronic pulmonary regurgitation.
Insufficient flow into the pulmonary vasculature causes the right ventricle to work harder, leading to right ventricular
hypertrophy and a subsequent reduction in right ventricular function and cardiac output.
The decrease in forward blood flow causes blood to back up into venous circulation, resulting in heart failure.
Clinical manifestations of heart failure include:

o Pale, cool extremities due to reduced perfusion to the systemic circulation

o Periorbital edema (puffiness around the eyes) and rapid weight gain due to systemic venous congestion and fluid retention
o Reduction in the number of wet diapers due to reduced perfusion to the kidneys

Infants with heart failure generally have decreased appetite and feeding due to dyspnea and fatigue.
KAWASAKI DISEASE
Kawasaki disease (KD) is a childhood condition that causes inflammation of arterial walls (vasculitis).
The coronary arteries are affected in KD, and some children develop coronary aneurysms.
The etiology of KD is unknown; there are no diagnostic tests to confirm the disease, and it is not contagious. KD has
3 phases:

1. Acute - sudden onset of high fever that does not respond to antibiotics or antipyretics. The child becomes very irritable and
develops swollen red feet and hands. The lips become swollen and cracked, and the tongue can also become red
(strawberry tongue).
2. Subacute - skin begins to peel from the hands and feet. The child remains very irritable.
3. Convalescent - symptoms disappear slowly. The child's temperament returns to normal.

Initial treatment consists of IV gamma globulin (IVIG) and aspirin. IVIG creates high plasma oncotic pressure, and
signs of fluid overload and pulmonary edema develop if it is given in large quantities. Therefore, the child should be
 monitored for symptoms of heart failure (eg, decreased urinary output, additional heart sounds, tachycardia, difficulty
breathing).

During the acute phase (swollen hands and feet), skin discomfort can be eased with cool compresses and lotions. No
treatment is needed in the subacute phase (skin peeling), but the new skin might be very tender.
The child will be very irritable during the acute phase of KD. A non-stimulating, quiet environment will help to promote
rest. After a KD episode, it is important for parents to understand that their child's irritability may last for up to 2
months and that follow-up appointments for cardiac evaluation are important.
During the acute phase (painful swollen lips and tongue), the child should be given soft foods and clear liquids as
these are tolerated best.
When children with KD are discharged home, parents are instructed to monitor them for fever by checking the
temperature (orally or rectally) every 6 hours for the first 48 hours following the last fever.
Temperature should also be checked daily until the follow-up appointment. If the child develops a fever, the health
care provider should be notified as this may indicate the acute phase of KD recurrence.
The child may require additional treatment with IV immunoglobulin to prevent development of coronary artery
aneurysms and occlusions.

SUPRAVENTRICULAR TACHYCARDIA

Supraventricular tachycardia (SVT) is the most common tachyarrhythmia of childhood and refers to a rapid heart
rate of 200-300/min with no variation in rate during activity. It can lead to life-threatening congestive heart failure if left
untreated. Symptoms in children may include palpitations, dizziness, or chest pain.
Once an ECG confirms SVT, the nurse should anticipate nonpharmacological interventions (ie, vagal maneuvers) to
convert SVT to sinus rhythm if the client is stable. Placing an ice bag to the client's face and instructing the client
to hold their breath while bearing down (Valsalva) are vagal maneuvers that can slow electrical conduction through
the heart's atrioventricular node
If these maneuvers are ineffective, or if the client becomes unstable, administration of adenosine or synchronized
cardioversion is indicated.
VENTRICULAR SEPTAL DEFECT
Ventricular septal defect (VSD) is a congenital abnormality in which a septal opening between ventricles
causes left-to-right shunting, leading to excess blood flow to the lungs. This places the client at risk for congestive
heart failure (CHF) and pulmonary hypertension.
Clinical manifestations of VSD include a systolic murmur auscultated near the sternal border at the third or fourth
intercostal spaces, and hallmark CHF signs (eg, diaphoresis, tachypnea, dyspnea).
The client is currently showing signs of increased respiratory exertion (eg, grunting) and requires further
assessment for CHF

CONGENITAL HYPOTHYROIDISM

Congenital hypothyroidism occurs when abnormal development of the thyroid gland causes complete
or decreased secretion of thyroid hormone (TH).
Untreated hypothyroidism can cause severe intellectual disability in infants if undetected.
 Screening occurs after birth for all infants in the United States and Canada to prevent disability and encourage
early treatment (ie, levothyroxine).
TH plays an important role in growth, development, and regulation of many bodily functions (eg, heat production,
muscle tone, skin function, cardiac function, metabolism).
Clinical manifestations in affected infants reflect the pathophysiology of decreased TH and may include:

o Difficulty awakening, lethargy, or hyporeflexia due to alterations in central nervous system function
o Dry skin due to alterations in skin function
o Hoarse cry caused by swelling of the vocal cords due to fluid retention
o Constipation due to slowed metabolism
o Bradycardia due to the effect of TH on cardiac function

LEFT TO RIGHT SHUNTING

Congenital heart defects that cause blood to shunt from the higher pressure left side of the heart to the lower
pressure right side (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) increase pulmonary
blood flow.
Left-to-right shunting results in pulmonary congestion, causing increased work of breathing and decreased lung
compliance. Compensatory mechanisms (eg, tachycardia, diaphoresis) result from sympathetic stimulation. Clinical
manifestations of acyanotic defects may include:

o Tachypnea
o Tachycardia, even at rest
o Diaphoresis during feeding or exertion
o Heart murmur or extra heart sounds
o Signs of congestive heart failure
o Increased metabolic rate with poor weight gain

CHEST TUBE
 Chest tubes may be placed during cardiac surgery to help drain fluid and air and to ensure room for lung expansion.
The chest tube and chamber should be assessed every hour for color and quantity of drainage.
Drainage >3 mL/kg/hr for 3 consecutive hours or >5-10 mL/kg in 1 hour should be reported immediately to the
health care provider
This could indicate postoperative hemorrhage and requires immediate intervention.
Cardiac tamponade can develop rapidly in children and can be life-threatening. This child weighs 4 kg and an output
of 50 mL in 1 hour is excessive.

PATENT DUCTUS ARTERIOSUS

Patent ductus arteriosus (PDA) is an acyanotic congenital defect more common in premature infants. When fetal
circulation changes to pulmonary circulation outside the womb, the ductus arteriosus should close spontaneously.
This closure is caused by increased oxygenation after birth.
If a PDA is present, blood will shunt from the aorta back to the pulmonary arteries via the opened ductus arteriosus.
Many newborns are asymptomatic except for a loud, machine-like systolic and diastolic murmur.
The PDA will be treated with surgical ligation or IV indomethacin to stimulate duct closure.

PULMONIC STENOSIS

Pulmonic stenosis causes increased pressure in the right side of the heart as the ventricle tries to push blood
through the narrowed pulmonary area to the lungs.
In severe pulmonic stenosis, higher pressure in the right side of the heart causes unoxygenated blood to travel to the
left side through the foramen ovale (or other congenital defect) and into the systemic circulation, leading to chronic
hypoxia and cyanosis and requiring repair (interventional catheterization or surgery).
The presence of severe diaper rash should be reported to the health care provider (HCP). This could delay the
procedure if the rash is in the groin area where access is planned for a femorally inserted arterial cannula. Yeast or
bacteria may be present on the rash and could be introduced into the bloodstream with the arterial stick
Children are NPO for 4-6 hours or longer before the procedure. Younger children and infants may have a shorter
period of NPO status and should be fed right up to the time recommended by the HCP.
 Cyanosis indicates severe pulmonic stenosis with right-to-left shunt and the need for interventional catheterization or
surgery without delay.

ATRIOVENTRICULAT (AV) CANAL DEFECT

Atrioventricular (AV) canal defect is a cardiac anomaly often associated with trisomy 21 (Down syndrome).
As an echocardiogram is already scheduled for that day, documenting the assessment finding would be the
appropriate action for the nurse to complete at this time.

GROWTH & DEVELOPMENT

PLAY

Play is an important developmental task of childhood and reflects the child's physical, social, and emotional health.
Parallel play is independent play near other children with minimal group interaction and is typical of toddlers (age
12-36 months. Toddlers engaging in parallel play may share toys and verbalize thoughts, but they primarily focus
on doing their own activities rather than directly interacting with others in organized play. Toddlers engaging in
parallel play may play with similar toys but are not directly influenced by the choices of other children.
Preschoolers (age 3-5 years) are more likely to interact with each other and borrow each other's toys in associative
play. Preschoolers (age 3-6) enjoy associative play, in which they engage in similar activities or play with the
same or similar items, but the play is unorganized without specific goals or rules. They often borrow items from
each other without directing each other's play. Preschoolers also enjoy play involving motor activities and imaginative,
pretend play.

During solitary play, children play alone while focusing on their own activities but also enjoy interactions with familiar
people (eg, parents) or objects (eg, favorite toy). This type of play is typical of infants (age <12 months).
During cooperative play, one or two children direct the activity and assign roles while others follow. This type of play
is typical of school-age children (age 6-12 years) and may involve a formal game or task (eg, building a castle from
blocks).
NON-PHARMACOLOGIC PAIN MANAGEMENT
Painful procedures (eg, capillary heel sticks, immunizations) are frequently required to provide optimal care but may
cause considerable stress or alterations in a client's status (eg, vital sign changes, instability) without proper
management.
Nonpharmacological pain management is a method for stopping or reducing the sensation of pain and may
eliminate or decrease the need for pharmacological intervention.
Appropriate nonpharmacological pain-management interventions for infants and newborns include:

o Offering concentrated sucrose, if prescribed, which is associated with reduced indicators of pain (eg, presence and duration
of crying, grimacing)
o Assisting the parent to hold the infant skin-to-skin (kangaroo care), which provides sensory stimulation that is calming and
reduces indicators of pain
o Offering nonnutritive sucking interventions (eg, pacifiers), which help calm the infant during painful procedures
o Swaddling the infant, which provides a sense of comfort and security and reduces the heart rate and incidences of crying

Before a heel stick is performed, a warm (not cold) pack should be applied to help facilitate blood flow to the area.
Although a cold pack is a nonpharmacological pain-management technique, it causes vasoconstriction and impedes
blood flow, which may result in a need to apply pressure to obtain blood or to perform multiple heel sticks.

MEDICAL PLAY

Clients with influenza are maintained on droplet precautions, and anyone entering the room must wear a facemask.
Medical play during the preschool period (age 3-6 years) facilitates psychosocial integrity. Crayons are age-
appropriate toys. Drawing noses on facemasks will help the child feel more comfortable with procedures and provides
a developmentally appropriate diversion.
Puzzles would be more appropriate for the school-age child (6-12 years).
Stacking blocks would be more appropriate for the toddler (age 1-3 years).
Maintaining contact with peers would be more appropriate for the adolescent (age 12-19 years).
BEDTIME SLEEP
During the school-age years (6-12), sleep needs of a child depend on health status, activity level, and age. Children
in this age group need approximately 11 hours of sleep daily at age 5 and 9 hours at age 12
Children are often unaware of their level of fatigue. Bedtimes should be established to prevent fatigue the next day.
Bedtime issues are usually not a concern, although many children retain bedtime rituals such as reading or listening to
music.
Quiet activity (eg, coloring, reading) prior to bedtime should be planned to promote restful sleep.
Growth rate is slowed during the school-age years, which accounts for variations in sleep needs.

NOCTURNAL ENURESIS
Involuntary bedwetting at night in a child beyond the age of expected bladder continence is known as nocturnal
enuresis. Certain medications (eg, oral desmopressin) may be useful in treating nocturnal enuresis;
however, nonpharmacologic techniques should be attempted first. The nurse should educate the child's parents
about the following strategies:

o Limit the child's intake of caffeine and sugar

o Instruct the child to void before going to bed
o Avoid punishing, scolding, or ridiculing the child
o Encourage the child to assist with changing soiled pajamas and linens, which helps them feel more control over the
situation, but provide reassurance that it is not punishment
o Use positive reinforcement to motivate the child (eg, calendar showing wet and dry nights, rewards)
o Awaken the child nightly at a specified time to void
o Use an enuresis alarm (ie, a moisture-sensitive alarm worn on sleep clothes that awakens the child when voiding occurs)

The nurse should remind parents to avoid disposable training pants or diapers at bedtime because these discourage
motivation to get up and void during the night.
Rather than restrict fluids throughout the day, parents should restrict fluids only after the evening meal (ie, take small
sips).
 Pharmacological interventions are often used as second-line treatment for nocturnal enuresis in children age >5
years; this is done when there has been little or no response to behavioral approaches and/or when short-term
improvement of enuresis is desired for attending sleepovers or overnight camp.
A trial run is usually done at least 6 weeks before camp to determine the appropriate drug dose and effectiveness.
However, there is a high risk of relapse once the drug is discontinued.
Medications used to treat nocturnal enuresis include the following:
1. Desmopressin reduces urine production during sleep.
2. Tricyclic antidepressants such as imipramine, amitriptyline, and desipramine improve functional bladder capacity.

ASSESSMENT

Always complete the assessment by performing the least invasive parts first and then progressing to the most
invasive.
By first establishing a rapport with the parent, the nurse will elicit the child's trust and cooperation.
Playing with the child will help the child relax and perceive the nurse as less of a threat
Measuring the child's height and weight should be performed next
Auscultation of the heart and lungs should then be performed.
 Allowing the child to play with the equipment first will make this part of the assessment easier
Taking vital signs can be difficult as a blood pressure cuff can be perceived as painful; once the child is upset, it
becomes difficult to continue with the assessment.
The sequence of examination steps for infants requires a different approach than the typical head-to-toe order used for
older clients. The steps are altered to accommodate the developmental needs of the infant, minimize the infant's
stress, and increase assessment accuracy.
The correct order of assessment in infants is:

o Before handling the infant, the nurse first observes the infant for activity level, skin color, and respiratory rate and pattern to
obtain findings during a calm state
o Auscultation is performed next while the infant is still quiet, allowing the nurse to hear sounds clearly
o Palpation and percussion are then performed while the infant remains relatively still. This allows the nurse to accurately
assess the abdomen while the abdominal muscles are relaxed. The fontanelles are also palpated while the infant is calm, as
crying can cause temporary bulging
o Traumatic procedures (eg, examine eyes, ears, mouth) are performed near the end of the assessment after completing any
procedures that require accurate observation or counting
o Elicitation of the Moro reflex (ie, reflexive startle and cry to a sudden dropping or jarring motion) is performed last because the
infant is usually awake and moving around by this point

NIGHT FEARS
Preschool children (age 3-6) are magical thinkers. Night fears are common during this period, and distinguishing
between reality and fantasy is difficult. It is appropriate for parents to acknowledge their child's fears.
A preschooler would be comforted and fears would be allayed if the parents looked under the bed and reassured the
child that no tigers were there

COMMUNICATION

The first step in effective communication is to establish trust between the nurse, the child, and the parent.
 By actively including a school-age child in the health history interview, the nurse shows respect to that child and
obtains valuable insight into their health status.
Allowing the child to describe how they feel or where they hurt gives the nurse a better understanding of the issue.
Using clear, age-appropriate explanations will enhance communication with the child while maintaining the
participation of the caregiver.
Open-ended questions allow the child or caregiver to elaborate on the question, giving the nurse detailed information
to guide further assessment. Non-verbal cues also play an important role in communication (eg, staying at eye
level with the child to ease any potential nervousness).
Closed-ended questions usually result in a "yes" or "no" answer. There are times in an interview that closed-ended
questions are appropriate to gather specific information, but broader, more descriptive answers are generally desired
when conducting a health history interview.
The nurse should interview a school-age child together with their caregiver unless there is an indication of child
abuse. The child may feel more at ease, and a more complete assessment may be obtained through answers from
both the child and caregiver.

DENTAL VISIT
The recommendation from pediatric professional organizations, including the American Dental Association, American
Academy of Pediatrics, and Canadian Dental Association, is that children have their first dental visit within 6 months
of first tooth eruption or by their first birthday
A child's first tooth usually erupts around age 6 months, and the child should be seen by a dentist soon after. The
purposes of the first visit include:

o Assessing risk for dental disease

o Providing dental care and treatment of dental caries
o Providing anticipatory guidance about dental hygiene, fluoride, diet and dietary habits, and non-nutritive sucking
o Establishing care with a licensed dentist and scheduling future visits
 Taking a child to the dentist at an early age also helps the child become accustomed to the dentist's office, oral
examinations, and dental care.

SCHOOL-AGED CHILDREN

According to Erikson's stages of psychosocial development, school-age children deal with the conflict of industry
versus inferiority.
Attaining a sense of industry (competence) is the most significant developmental goal for children age 6-12.
Parents should therefore be encouraged to provide a hospitalized child with missed school work on a regular basis.
This will help the child keep up with school demands, learn new skills, cope with the stressors of hospitalization, and
avoid a sense of inferiority.

DEVELOPMENTAL MILESTONES OF INFANTS

DEVELOPMENTAL MILESTONES OF TODDLERS
DEVELOPMENTAL MILESTONES OF PRE-SCHOOLERS

SEPARATION ANXIETY

Some of the first stressors faced by children from infancy through the preschool years are related to illness and
hospitalization.
Separation anxiety, also known as anaclitic depression, particularly affects children age 6-30 months.
Separation or stranger anxiety occurs when the primary caregivers leave the child in the care of others who are not
familiar to the child. This behavior starts around age 6 months, peaks at age 10-18 months, and can last until age
3 years. Separation anxiety produces more stress than any other factor (eg, pain, injury, change in surroundings) for
children in this age range. However, this reaction is normal and resolves as the child approaches age 3 years.
There are 3 stages of separation anxiety: protest, when the child refuses attention from others, screams for the
parent to return, and cries inconsolably; despair, when the child is withdrawn, quiet, uninterested in activities or meals,
and displays younger behavior (eg, use of pacifier, wetting the bed); and detachment, when the child suddenly
appears happy and interested in building relationships.
 Nursing care of hospitalized clients experiencing separation anxiety focuses on maintaining a calm environment and a
supportive demeanor to build trust between the nurse and the child, and encouraging connection with family and
familiar environments, even when they are absent. Key interventions include:

o Encouraging the parents to leave favorite toys, books, and pictures from home
o Establishing a daily schedule that is similar to the child's home routine
o Maintaining a close, calming presence when the child is visibly upset
o Facilitating phone or video calls when parents are available
o Providing opportunities for the child to play and participate in activities

When the child is visibly upset, it is important to provide a calming presence and implement strategies to reduce the
child's anxiety. Leaving the child alone at such times can further increase stress.
Providing pictures of the child's family is actually beneficial, as it reminds the child of something familiar and safe.

S THEORY OF COGNITIVE DEVELOPMENT

SHAKEN BABY SYNDROME

 Shaken baby syndrome (SBS) is a type of abusive head injury and is defined by the Centers for Disease Control and
Prevention (CDC) as severe physical child abuse resulting from violent shaking of an infant by the arms, legs, or
shoulders. The impact of the shaking causes bleeding within the brain or the eyes.
It is not uncommon for the diagnosis of SBS to be missed as the clinical findings are often vague and nonspecific
vomiting, irritability, lethargy, inability to suck or eat, seizures, and inconsolable crying. Usually, there are no
external signs of trauma except for occasional small bruises on the chest or upper arms where the child was held
during the shaking episode.
The most common reasons that caregivers seek medical attention for children with SBS are breathing difficulty, apnea,
seizures, and lifelessness.
Caregivers typically do not offer a history of trauma nor do they report the episodes of shaking. By contrast, children
who have sustained unintentional head injury are typically brought for treatment out of concern by their caregivers
even when the children are asymptomatic.
Abdominal bruising is not an expected clinical finding of SBS.
External signs of trauma are usually absent on physical examination of an infant with SBS. Minimal bruising on the
extremities or chest may be present.

HOSPITALIZATION
Pediatric clients are at increased risk for impaired psychosocial integrity during stressful experiences (eg,
hospitalization, surgical procedures, medical treatment) and require developmentally appropriate care based on
their age to assist with managing stress. Unaddressed or ineffectively managed developmental needs may lead to or
worsen the client's anxiety, disobedient behavior, and/or social withdrawal.
Developmentally appropriate nursing care for an adolescent client includes:
o Encouraging interaction with peers (eg, hospital visits, internet communication), which supports the developmental need for
social connection and support and reduces stress and anxiety (Option 2)
o Involving the client in care planning to address the developmental needs for control and independence (Option 4)
o Assisting the client to discuss emotions or fears related to treatment (eg, changes in body image, disability, possibility of
death) to improve coping, support the developmental need for understanding, and decrease anxiety
Strict scheduling by the nurse reduces the adolescent's perception of control and independence, which may increase
stress. Adolescents should be allowed to determine their daily schedule when possible.
Loss of privacy (eg, forced parental presence) can increase anxiety in the adolescent client. Adolescents should be
asked if they want parents present for procedures and what level of parental involvement they prefer.
Toddlers (age 1-3) display an egocentric approach as they strive for autonomy. They attempt to control their
experiences through intense emotional displays, such as temper tantrums or forceful negative responses (eg, "no!").
Hospitalization results in loss of a toddler's usual routines and rituals, often resulting in regressive behavior. The
toddler may also be frequently separated from the parents, leading to separation anxiety.
Nursing care activities should be similar to home routines, such as providing preferred snacks and anticipating nap
time. The toddler should be given options rather than asked yes/no questions to limit the potential negative
responses. It is also important to encourage participation and presence of the parents whenever possible.
Hospitalization for toddlers (ie, 12-36 months) is particularly difficult due to separation anxiety and a limited ability to
cope with stress.
Toddlers thrive on home rituals and routines, which bring stability and reassurance. Hospitalization can severely
disrupt these routines, triggering frustration and temper tantrums.
Caregivers should maintain as many home routines as possible (eg, sleeping, eating) to help the child cope with
unfamiliar hospital surroundings and procedures
Parents should also stay with the child as much as possible, including overnight (ie, rooming-in), to provide
consistency and alleviate separation anxiety
Play, an important part of a child's emotional and social well-being, is an effective coping mechanism for children of all
ages to deal with the stress of being away from home.
The playroom is a safe place for children to act out their fears and anxieties related to illness and hospitalization
Around 6 months of age, infants begin to experience separation anxiety. This anxiety may be heightened during
hospitalization because of exposure to many unfamiliar stressors. Appropriate nursing care can play a significant role
in reducing the infant's physiologic and psychologic stress. Key interventions include:
o Adhering to the infant's home routine (eg, meal and sleep times) as closely as possible
o Providing a favorite toy or pacifier
 o Encouraging caregivers to remain whenever possible during hospitalization
o Providing a quiet sleep environment with reduced stimulation to promote restful sleep
o Offering a familiar object (eg, caregiver's shirt, blanket, voice recording) during stressful situations

FAILURE TO THRIVE

FTT, or growth failure, is a state of undernutrition and inadequate growth in infants and young children. Most cases of
FTT are related to an inadequate intake of calories, which can be tied to many different etiologies.
Physiologic risk factors for FTT include preterm birth, breastfeeding difficulties, gastroesophageal reflux, and cleft
palate. Socioeconomic risk factors include:

o Poverty most common

o Social or emotional isolation parents may lack the support system needed to assist them with the problems of child rearing
o Cognitive disability or mental health disorder
o Lack of nutritional education parents may not have knowledge of proper feeding techniques or appropriate calorie intake
based on age and size of the child

FTT is generally defined as weight less than 80% of ideal for age and/or depressed weight for length, correcting for
gestational age, sex, and special medical conditions.
The underlying cause of FTT is inadequate dietary intake; contributing factors include a disturbance in feeding
behavior and psychosocial factors.
Observing the child feeding or when hungry will provide the nurse the opportunity to identify potential factors
contributing to insufficient intake.
The nurse can observe the type of food being offered, the quantity of food consumed, how the child is held or
positioned while being fed, the amount of time for feeding, the parent's response to the child's cues, the tone of the
feeding, and the interaction between the child and the parent.
FTT in a child is characterized by a low weight/height ratio and/or falling below the 5th percentile on the growth curve
due to inadequate caloric intake, inadequate absorption of calories, or excess caloric expenditure. Most children with
 a diagnosis of FTT have inadequate caloric intake caused by multiple behavioral or psychosocial factors, including
disturbances in child-parent interaction. Risk factors for FTT include:

o Young parent age

o Unplanned or unwanted pregnancy
o Lower levels of parental education
o Single-parent home
o Social isolation
o Chronic life stresses/anxiety in the home
o Disordered feeding techniques

Prolonged breast or bottle feeding

Unstructured meal times
Negative or difficult interactions at meal time
Poor parental feeding skills
Negative attitudes toward food fear of obesity or an overweight child

o Substance abuse
o Domestic violence and/or parental history of child abuse
o Poverty, food insecurity
o Parents who have a negative perception of the child

GROWTH HORMONE REPLACEMENT THERAPY

A child who demonstrates a slow growth pattern will undergo diagnostic evaluation to determine the cause. If the
cause is found to be growth hormone deficiency, the child may undergo growth hormone replacement therapy.
The biosynthetic hormone is administered via subcutaneous injection on a daily basis. Despite replacement therapy,
the child may still have a final height less than "normal."
Treatment is most successful when diagnosis and replacement therapy begin early in the child's life. When to stop
therapy is decided by the client, family, and provider. However, growth less than 1 inch (2.5 cm) per year and bone
age of 14 years in girls and 16 years in boys are the criteria often used to stop therapy.
 Growth hormone replacement does not guarantee that a child will grow at a rate equal to peers. Treated children often
remain shorter than their peers.
Replacement therapy is not continued throughout a child's life. It is stopped when bone growth begins to cease or
when the child, parents, and provider make the decision.
Replacement therapy is most successful when treatment begins early, as soon as growth delays are noted.

PUBERTY
Testicular enlargement, including scrotal changes, is the first manifestation of puberty and sexual maturation.
This typically occurs at age 9½-14. It is followed by the appearance of pubic, axillary, facial, and body hair.
The penis increases in size and the voice changes.
Some boys also experience an increase in breast size.
Growth spurt changes of increased height and weight may not be apparent until mid-puberty.

LEAD POISONING

Lead poisoning still occurs in the United States, although not as often as in previous decades.
A common source of exposure is lead-based paints found in houses built before 1978, when such paint was banned.
Blood lead level (BLL) screenings are recommended at ages 1 and 2, and up to age 6 if not previously tested.
Because lead poisoning particularly affects the neurological system
dangerous in young children due to immature development of the brain and nervous system.
A mild to moderate increase in BLL can manifest with hyperactivity and impulsiveness; prolonged low-level exposure
can cause developmental delays, reading difficulties, and visual-motor issues.
Extremely elevated BLLs can lead to permanent cognitive impairment, seizures, blindness, or even death.

INFANT GROWTH
 Infant growth is fast paced during the first year of life, with birth weight doubling by age 6 months and tripling by
age 12 months. During the first year, birth length increases by approximately 50%. At birth, head circumference is
slightly more than chest circumference, but these equalize by age 12 months.
At birth, the infant has non-ossified membranes called fontanelles; these "soft spots" lie between the bones of the
cranium.
The 2 most noticeable are the anterior and posterior fontanelles, which are soft and non-fused.
Fontanelles should be flat, but slight pulsations noted in the anterior fontanelle are normal as is temporary bulging
when the infant cries, coughs, or is lying down.
The posterior fontanelle fuses by age 2 months, and the anterior fontanelle fuses by age 18 months.

AUTISM
The concerns presented by this child's parent are suggestive of a developmental delay and very possibly autism
spectrum disorder (ASD).
ASD is a complex neurodevelopmental disorder characterized by the onset of abnormal functioning before age 3. The
2 core symptoms of ASD are abnormalities in social interactions and communication (verbal and nonverbal),
and patterns of behavior, interests, or activities that can be restricted and repetitive.
Social skills, especially communication, are delayed more significantly than other developmental functioning and are
the focus during client assessment.
The vast majority of children diagnosed with ASD lack the acquisition of communication skills during the first 2 years of
life. A healthy 2-year-old should have a vocabulary of about 300 words and should be able to string 2 or more words
together in a meaningful phrase. Assessing this child's language abilities would be the priority.
Although not the priority assessment, it would be important to ask the parent about the child's play activities. Children
with ASD often have a restricted interest in and preoccupation with a single toy, exhibit repetitive behaviors when
playing with the toy, and insist on the same play routine.
HEARING IMPAIRMENT

Hearing impairment in children may be related to family history, an infection, use of certain medications, or a
congenital disorder.
Toddlers with hearing deficits may appear shy, timid, or withdrawn, often avoiding social interaction. They may seem
extremely inattentive when given directions and appear "dreamy."
Speech is usually monotone, difficult to understand, and loud. Increased use of gestures and facial expressions is
also common.
Children typically begin to use well-formed syllables such as "mama" and "dada" by approximately age 7 months.
A referral for a hearing test should be made if there is an absence of well-formed syllables by age 11 months or
intelligible speech is not present by 24 months.
Lack of attentiveness and appropriate response when given a direction is characteristic of a toddler who has a hearing
impairment.

BELIEFS ABOUT DEATH

 Understanding a child's perception of illness and death can empower caregivers (eg, parents) to support the child
during the loss of a loved one.
A child's developmental stage as well as the caregiver's view of death and relationship with the child will influence
coping during bereavement.
The nurse should educate the parent of an 8-year-old client about how to assist with coping based on the knowledge
that school-aged children (age 6-12 years) most likely have both a curiosity and fear about the implications of
death (eg, process of dying, funeral services) and understand that death is permanent. Therefore, it is important for
the parents to be honest during discussions about death, talk about the lost loved one, and provide anticipatory
guidance to reduce fears.
Infants (age 1-12 months) and toddlers (age 12-36 months) mostly react to separation from caregivers, both temporary
and permanent, because it affects daily routines.
A child will most likely be aware that death affects everyone and also perceive it as evil by age 10-12 years.
Adolescents are most likely to think about the religious and spiritual aspects of death, although this may occur earlier
for some children.

WEIGHT LOSS

Before initiating a treatment plan for weight loss, it is most important to make certain that the child and family are ready
for change. Attempting to engage the family and child in weight loss strategies and dietary changes before they are
ready could easily result in frustration, treatment failure, and reluctance to try new approaches in the future. The nurse
needs to explore the reasons and desire for weight loss by assessing:

o Motivation and confidence

o Willingness to change behaviors and food choices
o Perceived importance of a weight loss treatment plan
o Confidence in ability to take on healthier eating habits

PSEUDOMENSTRUATION

Mammary gland enlargement, non-purulent vaginal discharge (leukorrhea), and mild uterine withdrawal bleeding
(pseudomenstruation) are benign transient findings commonly seen in newborns; these are physiologic responses to
 transplacental maternal estrogen exposure. Reassurance should be provided. Monitoring the amount, color, and
consistency is the appropriate action
The blood-tinged mucus will cease within a few days after birth when hormone levels return to normal. No additional
workup or medications are indicated.
Pseudomenstruation is a physiological process and is not caused by trauma or abuse.

FETAL ALCOHOL SYNDROME

 Fetal alcohol syndrome (FAS) is a leading cause of intellectual disability and developmental delay in the United
States.
Diagnosis includes history of prenatal exposure to any amount of alcohol, growth deficiency, neurological symptoms
(eg, microcephaly), or specific facial characteristics (indistinct philtrum, thin upper lip, epicanthal folds, flat
midface, and short palpebral fissures).
Asking about alcohol use during pregnancy can identify newborns and infants who are at risk for FAS.
Family support, early intervention, and prevention for subsequent pregnancies are important for families with an infant
with this diagnosis.

TRISOMY 21 (DOWN SYNDROME)

HEAD LAG

Head and neck strength is a critical assessment in infants. Typically, infants display head lag (ie, head falling behind
the shoulders when raised from a supine to a sitting position) from birth through age 4-6 months.
Head lag remaining after age 6 months is an abnormal finding often associated with cerebral palsy or autism
POSITIONAL PLAGIOCEPHALY

Positional plagiocephaly (flat head syndrome) occurs when an infant's soft, pliable skull is placed in the same
position for an extended time.
Positional plagiocephaly has become common due to the Safe to Sleep (formerly Back to Sleep) campaign, which
advocates for infants to sleep in the supine position to prevent sudden infant death syndrome (SIDS).
The risk of SIDS outweighs the benefit of a shapely head; the infant should not be placed in the prone position to
sleep, even for a daytime nap
Plagiocephaly can usually be prevented or corrected by:
o Frequently alternating the supine infant's head position from side to side
o Minimizing the amount of time an infant's head rests against a firm surface (eg, car seat)
o Placing pictures and toys opposite the favored (affected) side to encourage turning the head
o Placing the infant in the prone position for 30-60 min/day ("tummy time")
 THEORY

THUMBSUCKING

Rooting and sucking are a part of an infant's natural reflexes. Nonnutritive sucking assists in helping the infant
to feel secure.
Some parents become very concerned about their infants sucking fingers, thumbs, or a pacifier and try to stop the
behavior.
As a rule, if thumb sucking stops before the permanent teeth begin to erupt, misalignment of the teeth and
malocclusion can be avoided.
 Parents should be taught that teasing and punishing a child for using a pacifier or sucking the thumb is not an effective
method for getting the child to stop. This can increase the child's anxiety and cause the child to increase the behavior.

PLAY

Play is an integral part of a child's mastery of emotional, social, and physical development. When a child is
hospitalized, play can also serve as a diversion and a way to express stress and anxiety.
Preschoolers enjoy play that enables them to imitate others and be dramatic. They have rich imaginations and
enjoy make-believe. Their play often centers on imitating adult behaviors by playing dress up and using
housekeeping toys, telephones, medical kits, dolls, and puppets.
Quiet play appropriate for the preschooler includes finger paints, crayons, illustrated books, puzzles with large pieces,
and clay. Through playing with objects such as dolls or puppets, preschoolers can often process fears and anxieties
that are difficult for them to express.
Board games are appropriate for children of school age, when play becomes more complex and competitive.
Soap bubbles are appropriate for toddlers, who learn from tactile play and environmental exploration.
Stacking and nesting toys are appropriate for toddlers who are developing fine motor skills.

WEIGHT GAIN
Weight gain slows during the toddler years with an average yearly weight gain of 4-6 lb (1.8-2.7 kg). By age 30
months, current weight should be approximately 4 times greater than birth weight. A toddler weighing 6 times the
initial birth weight requires further evaluation. Family nutrition and meal habits should be discussed.
A toddler achieves bowel and bladder sphincter control by age 24 months as bladder capacity increases.
Chest circumference exceeds abdominal circumference after age 2, resulting in a taller and more slender appearance.
Head circumference increases by 1 in (2.5 cm) during the second year and then slows to a growth rate of 0.5 in (1.25
cm) per year until age 5.
TOILET TRAINING
Toilet training is a major developmental achievement for the toddler. The degree of readiness progresses relative to
development of neuromuscular maturity with voluntary control of the anal and urethral sphincters occurring at age 18-
24 months.
Bowel training is less complex than bladder training; bladder training requires more self-awareness and self-discipline
from the child and is usually achieved at age 2½-3½ years.
In addition to physiological factors, developmental milestones rather than the child's chronological age signal a child's
readiness for toilet training. These include the ability to:

o Ambulate to and sit on the toilet

o Remain dry for several hours or through a nap
o Pull clothes up and down
o Understand a two-step command
o Express the need to use the toilet (urge to defecate or urinate)
o Imitate the toilet habits of adults or older siblings
o Express an interest in toilet training

In order to achieve toilet training, the child will need to be able to pull clothing up and down but not necessarily dress
and undress autonomously.
Having the child sit on the toilet until urination occurs is not appropriate and will not facilitate bladder control; any
urination that occurs is accidental and not due to sphincter control. However, the child should have the ability to
remain on the toilet for about 5 8 minutes without getting off or crying.
Age 15 months is too early to begin toilet training; voluntary control of the anal and urethral sphincters does not occur
until age 18-24 months.
MARFAN SYNDROME

Marfan syndrome is an autosomal dominant disorder affecting the connective tissues of the body. Abnormalities are
mainly seen in the cardiovascular, musculoskeletal, and ocular systems. Clients with Marfan syndrome are very tall
and thin, with disproportionately long arms, legs, and fingers.
Cardiovascular manifestations of Marfan syndrome include abnormalities of the aorta and cardiac valves, including
aneurysms, tears (dissection), and leaky heart valves that may require replacement or repair. Therefore, competitive
or contact sports are discouraged due to the risk of cardiac injury and sudden death
 The client may also experience crowding of the teeth from a very high-arched palate. Preventive antibiotics prior to
dental work may be needed to provide prophylaxis against infective endocarditis, especially in clients with an artificial
valve replacement. However, this is not a priority.
These clients have an increased risk for scoliosis, especially during the adolescent years of increased growth;
therefore, the child should be monitored regularly for curvature of the spine. This is not a priority.
Ocular problems (eg, lens dislocation [ectopia lentis], retinal detachment, cataracts, glaucoma) can be common for
the child with Marfan syndrome. Annual eye examinations with an ophthalmologist are important to monitor for
developing issues.

REGRESSION
Regression during hospitalization is a normal response to the stress of an unfamiliar environment, the fear and pain
of invasive procedures, and the change in a child's normal routine.
Toilet-trained children may start bed-wetting, and children who gave up the bottle or pacifier may ask for it.
It is important for the nurse to explain that this behavior is completely normal and that the child will gain back previous
milestones after discharge

GASTROINTESTINAL AND NUTRITION

HYPERTROPHIC PYLORIC STENOSIS

In pyloric stenosis, there is gradual hypertrophy of the pylorus until symptom onset at age 3-5 weeks. It is common
in first-born boys and the etiology is unclear. Pyloric stenosis presents with postprandial projectile vomiting (ejected
up to 3 feet) followed by hunger (eg, "hungry vomiter"). This is clearly distinguished from the "wet burps" infants
have due to a weak lower esophageal sphincter.
The emesis is nonbilious as the obstruction is proximal to the bile duct. Infants have poor weight gain and are often
dehydrated (eg, sunken fontanelle, decreased skin turgor, delayed capillary refill).
 The amount of milk consumed (particularly with bottle feedings) along with the mother's technique (mainly adequate
burping) should be assessed to ensure there is no excessive air swallowing or overfeeding as an etiology.
In pyloric stenosis, a hypertrophied pyloric muscle causes postprandial projectile vomiting secondary to an
obstruction at the gastric outlet.
An olive-shaped mass may be palpated in the epigastric area just to the right of the umbilicus.
Emesis is nonbilious (formula in/formula out) and leads to progressive dehydration.
Infants will be hungry constantly despite regular feedings.
A hematocrit of 57% (0.57) is elevated and indicative of hemoconcentration caused by dehydration. Elevated blood
urea nitrogen is also a sign of dehydration.
The stomach contains acid, which becomes depleted with excess vomiting (or during nasogastric [NG] suctioning),
leading to metabolic alkalosis (increased bicarbonate and pH of >7.45).
PHYSIOLOGIC ANOREXIA
Physiologic anorexia occurs when the very high metabolic demands of infancy slow down to keep pace with the
moderate growth of toddlerhood. During this phase, toddlers are increasingly picky about their food choices and
schedules. Although to the parents it may appear that the child is not consuming enough calories, intake over several
days actually meets nutritional and energy needs. Parents should be educated concerning what constitutes a healthy
diet for toddlers and which foods they are more likely to consume.
Some strategies for dealing with a toddler during a stage of physiologic anorexia and pickiness include:

o Set and enforce a schedule for all meals and snacks

o Offer the child 2 or 3 choices of food items
o Do not force the child to eat
o Keep food portions small
o Expose the child repeatedly to new foods on several separate occasions
o Avoid TV and games during meals or snacks

HIRSCHSPRUNG DISEASE
Hirschsprung disease (HD) occurs when a child is born with some sections of the distal large intestine missing
nerve cells, rendering the internal anal sphincter unable to relax.
As a result, there is no peristalsis and stool is not passed. These newborns exhibit symptoms of distal intestinal
obstruction.
They have a distended abdomen and will not pass meconium within the expected 24-48 hours. They also have
difficulty feeding and often vomit green bile.
Surgical removal of the defective section of bowel is necessary and colostomy may be required.
A potentially fatal complication is Hirschsprung enterocolitis, an inflammation of the colon, which can lead to sepsis
and death.
Enterocolitis will present with fever; lethargy; explosive, foul-smelling diarrhea; and rapidly worsening abdominal
distension.
 In Hirschsprung's disease, a portion of the colon has no innervation and must be removed. Some children require
a temporary colostomy. The stoma created from the surgery should remain beefy red in the immediate
postoperative period. Any paleness or graying of the stoma indicates decreased blood supply to that area.
Due to irritation of the intestinal mucosa during surgery, blood-tinged mucus would be expected the first few days after
surgery.
By postoperative day 6, stool would be expected from the colostomy as part of the fluid-absorbing portion of the large
intestine has been removed.
It is not uncommon for a stoma to bleed a small amount with manipulation in the postoperative period.

CYSTIC FIBROSIS

In CF, unusually thick mucus obstructs the pancreatic ducts, preventing pancreatic enzymes (amylase, trypsin, and
lipase) from reaching the small intestine.
The result is malabsorption of carbohydrates, fats, and proteins; the inability to absorb fat-soluble vitamins (A, D, E,
and K) is of particular concern.
Gastrointestinal signs and symptoms of CF include flatulence, abdominal cramping, ongoing diarrhea, and/or
steatorrhea.
Nutritional therapy includes the administration pancreatic enzyme supplements with or just before every meal or
snack
These enzymes are enteric-coated beads designed to dissolve only in an alkaline environment similar to that of the
small intestine. They must not be mixed with a substance that would cause them to dissolve prior to reaching the
jejunum.
Capsule contents may be sprinkled on applesauce, yogurt, or acidic, soft, room-temperature foods with pH <4.5.
Capsules should be swallowed whole and not crushed or chewed; chewing the capsules could cause irritation of the
oral mucosa.
Excessive intake of pancreatic enzymes can result in fibrosing colonopathy
In cystic fibrosis (CF), a protein responsible for transporting sodium and chloride is defective and causes the
secretions from the exocrine glands to be thicker and stickier than normal.
 These abnormal secretions plug smaller airway passages and ducts in the gastrointestinal (GI) tract.
The thick secretions block pancreatic ducts, resulting in a deficient amount of pancreatic enzymes entering the bowel
to aid in digestion and nutrient absorption.
Clients require multiple vitamin supplements and supplemental pancreatic enzymes that are administered with meals.
To meet the growth needs of clients with CF, a diet high in calories, fat, and protein is required.

IRON DEFICIENCY ANEMIA

Iron deficiency during infancy causes reduced hemoglobin production, resulting in anemia, decreased immune
function, and delayed growth and development.
During gestation, the fetus stores iron received from the mother; the amount of iron stored is dependent on the length
of gestation.
After birth, iron stores are progressively depleted and nutritional sources of iron are eventually required.
Infants born at preterm gestation have less time in utero to accumulate iron. Preterm infants typically deplete iron
stores by age 2-3 months and require additional iron supplementation (eg, oral iron drops, iron-fortified formula).
Therefore, a 3-month-old infant born at preterm gestation who is exclusively receiving breastmilk is most at risk for
anemia
Infants born at term gestation have sufficient iron stores for the first 4-6 months of life. However, infants receiving
exclusively breastmilk require iron supplementation (eg, oral iron drops) around age 4 months until food sources of
iron (eg, iron-fortified infant cereal) are adequate around age 6 months.
Iron deficiency anemia is the most common chronic nutritional disorder in children. There are many risk factors for
iron deficiency, including insufficient dietary intake, premature birth, delayed introduction of solid food, and
consumption of cow's milk before age 1 year.
One common cause in toddlers is excessive milk intake, over 24 oz/day. In addition to becoming overweight,
toddlers who consume too much milk develop iron deficiency due to the likely exclusion of iron-rich foods in favor of
milk, a poor source of available iron.
 Treatment of iron deficiency anemia includes oral iron supplementation and increased consumption of iron-rich
foods (eg, leafy green vegetables, red meats, poultry, dried fruit, fortified cereal). It is also important to limit milk intake
(16-24 oz/day) in toddlers to ensure a balanced diet.

VEGAN DIET
With careful monitoring of nutritional intake, a vegan diet (ie, excluding all animal-derived products [eg, meat, dairy,
eggs]) can be appropriate for clients in all age groups.
Pediatric clients consuming a vegan diet are at increased risk for nutritional deficiencies (eg, protein, calories,
calcium, vitamin D, iron, vitamin B12) due to rapid growth and development. Nurses educating clients about preventing
nutritional deficiencies in vegan diets should include information about:

o Iron: Plant sources of iron, which are in smaller quantities and difficult to absorb, should be supplemented with fortified
cereals and breads to decrease risk of iron-deficient anemia
o Vitamin C: Iron absorption is improved when dietary sources of iron and vitamin C are taken together
o Calcium: Without animal sources of calcium (eg, dairy, eggs, fish), vegan diets require supplementation of calcium and
vitamin D for bone health

Many plant-based proteins (eg, legumes, grains) do not individually contain all the essential amino acids to support
growth and tissue repair; therefore, vegan clients will require further teaching on combinations of protein sources.
Fruits and vegetables do not provide vitamin B12. The nurse should educate the parents on the need for multivitamins
or fortified grains as quality vitamin B12 sources.

INTUSSUSCEPTION
Intussusception is an intestinal obstruction that occurs when a segment of the bowel folds (ie, telescopes) into
another segment.
Pressure gradually increases within the bowel, causing ischemia and leakage of blood and mucus into the lumen,
which produces the characteristic stool mixed with blood and mucus (ie, red, "currant jelly").
Initially, some infants may have only general symptoms (eg, irritability, diarrhea, lethargy). Subsequently, episodes
of sudden abdominal pain (cramping), drawing the knees up to the chest, and inconsolable crying are seen.
After an episode, the infant may vomit and then appear otherwise normal. Assessment may show a sausage-
shaped abdominal mass.
Most cases of intussusception are successfully treated without surgery using hydrostatic (saline) or pneumatic (air)
enema.
The nurse will monitor for passage of normal brown stool, indicating reduction of intussusception. If this occurs,
the HCP should be notified immediately to modify the plan of care and stop all plans for surgery.
In intussusception, the stools are mixed with blood and mucus, giving a characteristic "currant jelly" appearance. This
is an expected finding.
 Pain in intussusception is typically intermittent. It occurs every 15-20 minutes, along with screaming and drawing up
of the knees. Therefore, if a child stops crying, it may not be due to reduction of intussusception.
Intense pain causes spasms of the pyloric muscle that lead to vomiting after each episode. Vomiting tends to resolve
once the intussusception is reduced.
Intussusception occurs when part of the intestine telescopes into another adjacent part and causes a blockage. This
leads to swelling and decreased blood supply to the intestine. Tissue death as well as perforation to the bowel may
result.
If perforation occurs, the client could develop peritonitis in which the peritoneum in the abdomen becomes inflamed
due to infection. This can quickly lead to sepsis and multiple organ failure.
Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness. This condition can
be fatal if it is not treated quickly.
A contrast enema is used for diagnostic purposes and often reduces the intussusceptions.
An air enema is considered safer than a barium enema.

ASSESSMENT
Assessment based on the client's developmental age includes the following:

o Clients as young as 3 can tell and/or show the examiner where they hurt or how they feel in their own terms
o 10-year-olds are capable of understanding and assisting in their physical examination. In fact, school-age clients are usually
quite interested in equipment and how it works.
o 10-year-olds are becoming modest and do not want a parent, especially of the opposite sex, in the room with them during a
physical examination

Pain is the fifth vital sign and is subjective data. A 10-year-old can describe and rate pain accurately.
10-year-olds will think there is something seriously wrong with them if the nurse and parent will not explain the results
of the examination to them.
 Calcium and vitamin D are nutrients in cow's milk that are essential for proper bone development in children and
adolescents
To obtain the recommended 500 mg of daily calcium (for ages 1-3 years), the parents should serve foods such as
beans, dark green vegetables, and calcium-fortified cereals and juices.
Vitamin D, which enhances the absorption of calcium, is synthesized in the skin by exposure to direct sunlight.
Alternate dietary sources include fish oils, egg yolks, and vitamin D-fortified foods (eg, orange juice).

ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL FISTULA

The initial nursing action for a client experiencing cyanosis and excess oral secretions is suctioning the mouth (ie,
oropharynx) to clear the airway
Excessive frothy mucus and cyanosis in a newborn could be due to esophageal atresia
(EA) and tracheoesophageal fistula (TEF).
If EA/TEF is suspected, the infant should be kept supine with the head elevated at least 30 degrees to prevent
aspiration.
A nasogastric tube should be inserted and connected to continuous or intermittent suction until surgical repair.
Esophageal atresia (EA) and tracheoesophageal fistula (TEF) consist of a variety of congenital malformations that
occur when the esophagus and trachea do not properly separate or develop.
In the most common form of EA/TEF, the upper esophagus ends in a blind pouch and the lower esophagus
connects to the primary bronchus or the trachea through a small fistula. EA/TEF can usually be corrected with
surgery.
Clinical manifestations of EA/TEF include frothy saliva, coughing, choking, and drooling. Clients may also
develop apnea and cyanosis during feeding
Aspiration is the greatest risk for clients with EA/TEF, and newborns who demonstrate signs of the condition are
immediately placed on nothing by mouth (NPO) status.
A newborn with EA/TEF may have a distended abdomen due to the buildup of air in the stomach via the fistula from
the trachea to the lower esophagus. A concave (ie, scaphoid) abdomen is associated with a congenital diaphragmatic
hernia due to the migration of abdominal organs to the thoracic space.
LEAD POISONING

Lead poisoning occurs from repeated lead exposure, either via ingestion of lead-based paints (eg, walls, toys),
glazes (eg, pottery) or water from lead pipes, or by inhalation of contaminated dust or soil found around older homes.
Elevated blood lead levels (BLLs) impair neural, blood, and renal development. A BLL screening is recommended
between ages 1 and 2, or up to age 6 if the child was not previously screened.
[0.24 µmol/L]) require follow-up blood work to ensure that levels decrease
Chelation therapy may be required if levels remain elevated.
The priority intervention for clients with elevated BLLs is preventing continued exposure.
The home environment should be assessed for lead sources
Pediatric and pregnant clients should not live in homes being renovated until the work is complete.
Handwashing, especially before eating, is important to remove lead residue
Vacuuming spreads lead dust in the air, which increases inhalation exposure. Hard surfaces should be wet-dusted or
mopped at least weekly.
Hot tap water dissolves lead from older pipes; therefore, cold water should be used for consumption if lead plumbing
is present. Taps should be flushed for several minutes to clear out contaminated water before use.

CELIAC DISEASE

The following are important principles to teach clients with celiac disease:
All gluten-containing products should be eliminated from the diet. These include wheat, barley, rye, and oats.
Rice, corn, and potatoes are gluten free and are allowed on the diet.
Deficient vitamins (mainly fat-soluble vitamins), iron, and folic acid should be replaced.
Processed foods (eg, chocolate candy, hot dogs) may contain "hidden" sources of gluten such as modified food starch, malt, and
soy sauce. Food labels should indicate that the product is gluten free.
Clients will need to be on a gluten-free diet for the rest of their lives. Eliminating gluten from the diet reduces the risk of
nutritional deficiencies and intestinal cancer (lymphoma).
Eating even small amounts of gluten will damage the intestinal villi although the client may have no clinical symptoms. All
sources of gluten must be eliminated from the diet
DENTAL CARIES
 Dental caries (ie, cavities) form when bacteria (eg, Streptococcus mutans) digest carbohydrates in the mouth,
producing acids that break down tooth enamel and cause mineral loss.
Oral hygiene and dietary intake are significant factors contributing to the development of caries.
Clients should increase intake of cariostatic foods, which have an inhibitory effect on the progression of dental
caries (eg, dairy products, whole grains, fruits and vegetables, sugar-free gum containing xylitol)
Cariogenic foods increase the risk for cavities and should be avoided. These include refined, simple sugars; sweet,
sticky foods such as dried fruit (eg, raisins) and candy; and sugary beverages (eg, colas and other carbonated
beverages, fruit drinks/juices)
Additional practices to prevent dental caries include:

o Brushing after meals

o Flossing at least twice a day
o Rinsing the mouth with water after meals or snacks
o Drinking tap water rather than bottled water (most tap water sources add fluoride to promote dental health, whereas most
bottled water does not contain fluoride)
o Finishing meals with a high-protein food

Fruit drinks/juices contain high amounts of simple sugars; substituting these for other sugary beverages does not
prevent dental caries. Whole fruits are better choices.

PHENYLKETONURIA

Phenylketonuria (PKU) is one of a few genetic inborn errors of metabolism. Individuals with PKU lack the enzyme
(phenylalanine hydroxylase) required for converting the amino acid phenylalanine into the amino acid tyrosine.
As unconverted phenylalanine accumulates, irreversible neurologic damage can occur.
A low-phenylalanine diet is essential in the treatment of PKU
Phenylalanine cannot be entirely eliminated from the diet as it is an essential amino acid and necessary for normal
development.
The diet must meet nutritional needs while maintaining phenylalanine levels within a safe range (2-6 mg/dL [120-360
µmol/L] for clients age <12). There is no known age at which the diet can be discontinued safely, and lifetime dietary
restrictions are recommended for optimal health
Management of the client with PKU includes:
 o Monitoring serum levels of phenylalanine
o Including synthetic proteins and special formulas (eg, Lofenalac, Phenyl-Free) in the diet
o Eliminating high-phenylalanine foods (eg, meats, eggs, milk) from the diet
o Encouraging the consumption of natural foods low in phenylalanine (most fruits and vegetables)

Restriction of dietary tyrosine is not necessary. Tyrosine levels in clients with PKU may be normal or slightly
decreased.

WATER INTOXICATION

Water intoxication (water overload) resulting in hyponatremia may occur in infants when formula is diluted to
"stretch" the feeding to save money.
Hyponatremia may also result from ingestion of plain water (eg, caregiver attempting to rehydrate an infant who has
been ill).
Infants have immature renal systems with a low glomerular filtration rate, which decreases their ability to excrete
excess water and makes them susceptible to water intoxication.
Symptoms of hyponatremia include irritability, lethargy, and, in severe cases, hypothermia and seizure activity.
Breast milk and/or formula are the only sources of hydration an infant needs for the first 6 months of life. Formula
should be prepared per the manufacturer's instructions.

CLEFT PALATE

A cleft palate is a malformation of the roof (palate) of the mouth occurring from incomplete fusion of the palatine bones
and maxilla during fetal development. Cleft palate causes an opening (cleft) in the mouth into the nasal cavity, which
leads to difficulty in sucking and feeding.
Clients with cleft palate typically undergo surgical repair between age 6-24 months.
Postoperative nursing interventions for clients with a cleft palate repair include:
 o Implementing pharmacological and nonpharmacological pain management (eg, encouraging caregiver soothing), as
uncontrolled pain leads to crying, which stresses the surgical site and promotes hemorrhage
o Positioning the child in an upright, supine position, particularly after feedings, to prevent airway compromise
and obstruction from secretions and/or feedings
o Utilizing elbow restraints to prevent the child from disrupting the surgical site by placing hands or objects into the mouth,
and monitoring skin and neurovascular status by removing elbow restraints per agency policy

Hard objects (eg, utensils, tongue depressors, pacifiers, straws) should not be placed into the mouth as they may
damage the surgical site, which can lead to hemorrhage.

SNACKS

When choosing snacks and meals for toddlers (age 1 3), 3 factors must be considered:

o Safety small, hard, sticky and/or slippery foods pose a choking risk and should not be offered to children under age 3.
Examples include hot dogs, grapes, nuts, raw carrot sticks, popcorn, peanut butter, hard candy, and raisins.
o Nutrient density (the nutrients a food provides relative to the number of calories it contains). The snack should be of high
nutritional value rather than "empty calories."
o Potential for food-borne illness children are at higher risk for developing a food-related infection if given raw,
unpasteurized foods such as juice, partially cooked eggs, raw fish, or raw bean sprouts.

Examples of healthy snacks for children under age 3 include pieces of cheese, whole-wheat crackers, banana slices,
yogurt, cooked vegetables, mini pizzas, and cottage cheese with cut-up fruit.
Although orange juice is a source of vitamin C, it is considered a "sugary" beverage and lacks the fiber of whole fruit.
It is recommended that young children have no more than 4 6 ounces of fruit juice per day. It is best to serve juice
with a meal so the child does not become accustomed to snacking on sugary foods.
Cookies do not have high nutritional value. Graham crackers or whole-wheat crackers with cream cheese would be
better snack choices.
Raw carrot sticks pose a choking risk. Carrots and other hard vegetable should be served grated or cooked.

FECAL INCONTINENCE
 Fecal incontinence (ie, encopresis, soiling) refers to the repeated passage of stool in inappropriate places by children
In more than 80% of cases, it is due to functional constipation (retentive type); in about 20% of cases,
it may be caused by psychosocial triggers (nonretentive type).
Management of fecal incontinence/constipation primarily includes 3 components: Disimpaction followed by prolonged
laxative therapy, dietary changes (increased fiber and fluid intake), and behavior modification. Behavioral strategies
are used to promote and restore regular toileting habits and to gain the child's cooperation and participation in the
treatment program.
Behavioral interventions include the following:

o Regularly schedule toilet sitting times 5-10 minutes after meals for 10-15 minutes
o Provide a quiet activity for the child during toilet sitting, which will help pass the time and make the experience more
"enjoyable"
o Initiate a reward system to boost the child's participation in the treatment program; the reward would be given for effort, not
for success of evacuation in the toilet (children with retentive encopresis have dysfunctional anal sphincters and little control
over bowel movements; giving a reward for something the child has no control over would not be effective)
o Keep a diary or log of toilet sitting times, stooling, medications, and episodes of soiling to evaluate the success of the
treatment

BABY BOTTLE TOOTH DECAY

Putting a child to bed with a bottle of milk or other beverage containing sugar leads to extensive and rapid dental
caries in the developing teeth, a condition known as baby bottle tooth decay.
The carbohydrate-rich fluid pools around the teeth and nourishes decay, producing bacteria (Streptococcus mutans).
Sucking on a bottle for extended periods can also push the jawline out of shape. Bottles containing milk or sugary
beverages should not be used as bedtime pacifiers.
Whole fruit chopped in small pieces is a better choice than juice. Fruit juice is higher in sugar, has no fiber, promotes
tooth decay, and can affect the child's appetite for other non-sugary foods.
Providing water to a child between meals has several benefits:
 o It accustoms the child to the taste of water, and the child will be more likely drink water than a sugary beverage when thirsty
o It helps reduce the risk of constipation and urinary tract infections
o It helps the child maintain a healthy weight

Spacing the introduction of new foods by several days to a week allows for detection of a food intolerance or allergic
reaction.

ACUTE DIARRHEA

During bouts of acute diarrhea and dehydration, treatment focuses on maintaining adequate fluid and electrolyte
balance.
The first-line treatment is oral rehydration therapy, using oral rehydration solutions (ORSs) to increase reabsorption
of water and sodium. Even if the diarrhea is accompanied by vomiting, ORS should still be offered in small amounts at
frequent intervals.
Continuing the child's normal diet (solid foods) is encouraged as it shortens the duration and severity of the diarrhea.
The BRAT (bananas, rice, applesauce, and toast) diet is not recommended as it does not provide sufficient protein or
energy.
Use of antidiarrheal medications is discouraged as these have little effect in controlling diarrhea and may actually be
harmful by prolonging some bacterial infections and causing fatal paralytic ileus in children.
Parents should be taught to monitor their child for signs of dehydration by checking the amount of fluid intake, number
of wet diapers, presence of sunken eyes, and the condition of the mucous membranes.
Protecting the perineal skin from breakdown during bouts of diarrhea can be accomplished by using skin barrier
creams (eg, petrolatum or zinc oxide).

INFANT BOTULISM
 Clostridium botulinum spores in honey or soil can colonize an infant's immature gastrointestinal system and
release a toxin that causes botulism, a rare but serious illness.
The toxin attacks the neuromuscular system, causing progressive muscle paralysis that can potentially lead to
respiratory failure and death.
Initial manifestations may include constipation, generalized weakness, difficulty feeding, and decreased gag reflex.
Iron-fortified infant cereals (eg, oatmeal) mixed with formula or breastmilk are appropriate for infants >6 months;
however, honey (especially raw or wild) is not recommended for infants age <12 months due to the risk of botulism

INFANT FORMULA
Infant formula is readily available as ready-to-feed, concentrate, or powder. Parents should exactly follow the
manufacturer's recommendations for preparation. Basic guidelines for preparation, safe storage, and handling of
formula include:

o Keep bottles, nipples, caps, and other parts as clean as possible (ie, boil or wash in dishwasher).
o Wash the tops of formula cans (eg, concentrated formula) with hot water and soap prior to opening to prevent contamination
 o Refrigerate any unused, prepared formula or unused, opened formula (eg, ready-to-feed, concentrated), but use within 48
hours or discard to reduce the risk of bacterial growth
o Warm bottles in a pan of hot water or under warm tap water for several minutes.
o Test formula temperature on the inner wrist before serving to the infant (should feel lukewarm, not hot).

Never overdilute or overconcentrate formula. Dilution reduces necessary calories, vitamins, and minerals, which
hinders growth and development. Overconcentration results in intake of excessive proteins and minerals beyond the
excretory ability of the infant's immature kidneys.
Never microwave formula as it causes "hot spots" in the milk that can burn the infant's mouth.

HEMATOLOGY / ONCOLOGY /IMMUNILOGY &

INFECTIONS

APPENDICITIS
A child with acute-onset right lower quadrant abdominal pain, nausea, and vomiting and a high white blood cell count
likely has acute appendicitis.
Appendicitis is a serious condition that usually requires emergency surgery due to the risk of appendix rupture.
The pain results from swelling and inflammation of the appendix. However, once the appendix ruptures, pain is relieved
only temporarily and will return with full-blown peritonitis and sepsis.

COMPASSION FATIGUE

Nurses who care for dying children experience many of the same feelings that the child's family does, resulting in
stress that may lead to compassion fatigue.
 To remain positive in the caring role, nurses must implement appropriate coping strategies to enhance self-care and
grief resolution.
Attending a memorial service can demonstrate care for the grieving family while also providing closure for the
nurse.
Other helpful strategies for coping include: taking time off from work if distancing is needed, utilizing personal and
professional support systems (eg, spouse, employee assistance programs, experienced mentors), and maintaining
good health through adequate rest, regular exercise, and proper nutrition.

STANDARD VACCINE
 Routine immunization is particularly beneficial to children who are HIV-positive as they are more susceptible to
preventable diseases due to a compromised immune system.
The standard vaccine schedule for a 12-month-old includes Hib, PCV (PVC13), MMR, varicella, and Hep A.
HIV-positive children who are asymptomatic and not extremely immunocompromised can receive the appropriate age-
specific immunizations as recommended.
However, live vaccine preparations (eg, MMR, varicella) are contraindicated in the presence of marked
immunosuppression, as determined by CD4 lymphocyte percentages and/or counts
An individual with a CD4 lymphocyte percentage <15% is considered to be severely immunocompromised.
Low CD4 lymphocyte counts vary slightly by age due to the normal occurrence of elevated CD4 counts during infancy
and early childhood.
Low CD4 counts are defined as <750/mm3 for infants 12 months or younger, <500/mm3 for children between age 1-
5 years, and <200/mm3 for children age >5 years and adults.

EPISTAXIS
Epistaxis (nosebleed) is a common and rarely serious nasal condition that can be caused by dry mucous membranes,
local injury (eg, nose-picking), insertion of a foreign body, or rhinitis.
Epistaxis usually involves the anterior nasal septum and often resolves spontaneously or with simple home
management.
Home management of epistaxis includes:
o Prioritizing application of direct, continuous pressure to the soft, compressible area below the nasal bone for 5-15
minutes to promote clot formation
o Holding a cold cloth or ice pack to the bridge of the nose to induce vasoconstriction and slow bleeding
o Attempting to keep the client with epistaxis quiet and calm as emotional outbursts and noncooperation create a challenge to
implementing interventions and stopping bleeding
 Positioning a child with epistaxis in a horizontal position or with the head tilted backward promotes drainage of blood
into the throat, which increases the risk of swallowing or aspirating blood.
Clients with epistaxis should sit upright and tilt the head forward.

DEHYDATION

Infants and young children have a higher percentage of body water than older children and adults. As a result, they
become dehydrated quickly due to fluid losses caused by vomiting and diarrhea.
Signs of severe dehydration include lethargy, sunken fontanel, increased capillary refill time, increased heart rate, and
increased respiratory rate.
When dehydration is severe enough to affect the client's hemodynamic status or to potentiate shock,
the priority is intravenous rehydration
ROTAVIRUS

Rotavirus is a contagious virus and the leading cause of diarrhea in children less than 5 years old; it is also the cause
of many nosocomial infections each year.
Rotavirus is spread via the fecal-oral route. Because the virus lives easily outside a human host, transmission can
occur through contact with food, toys, diapers, and hands. Meticulous handwashing and proper diaper disposal
prevent the spread of the virus
Symptoms include foul-smelling, watery diarrhea that lasts 5-7 days and is often accompanied by fever and
vomiting.
Vaccination is available and must be given before the child is 8 months old. However, vaccinated children can still
acquire Rotavirus as many strains are not covered by the vaccine. Antibiotics are not effective against this viral agent.
Because the virus can easily lead to dehydration, parents should be taught the symptoms (eg, lack of tears when
crying, extremely fussy or sleepy, decreased urination, dry mucous membranes). Oral rehydration solutions should be
used to combat dehydration
Breastfeeding and normal diet should be maintained. There is no evidence that these are harmful.
Parents should change the child's diapers more frequently and wash the perianal area with mild soap and water.
Commercial baby wipes containing alcohol should not be used as they are irritating. Protective zinc oxide can be
applied instead.

VARICELLA (CHICKENPOX)
Varicella-zoster virus (VZV) infection (chickenpox) is characterized by lesions that begin as a maculopapular rash,
progress to weeping vesicular lesions, and typically crust over within approximately 1 week. The lesions are often
pruritic and/or painful, and clients frequently have an accompanying fever.
In most cases, treatment is supportive in nature and includes:
o Cool oatmeal baths and topical antihistamines (eg, diphenhydramine) applied to lesions for itching

o Acetaminophen as needed for fever or pain

 Immunocompromised clients (eg, clients with acute myelogenous leukemia [AML]) are at risk for severe
varicella (eg, disseminated, pneumonia) and require aggressive therapy, including an antiviral agent (eg, acyclovir).
Antiviral therapy should be continued until all the lesions have crusted over
VZV is spread via airborne and contact transmission. Clients are most infectious in the days leading up to the rash
and continue to be infectious until the entire rash reaches the crusting stage
Immunocompromised clients should not receive live attenuated vaccines (eg, varicella virus vaccine). In addition, the
vaccine is not indicated for a client who has already developed immunity after recovering from VZV infection.
This child has chicken pox (varicella), given the vesicular lesions. Chicken pox is transmitted primarily by airborne
spread of secretions from the nasopharyngeal secretions of an infected individual and through direct contact of open
lesions.
It is most contagious 1 2 days before the rash until shortly after onset of rash (until all lesions are crusted over).
Supportive care is usually adequate, and most children recover fully.
Children who are immunocompromised are at risk for complications. Contact and airborne precautions are used. A
mask will help prevent the spread of infection until the child is placed in an isolation negative airflow room.
Antihistamines help relieve itching and acetaminophen helps reduce fever. Fingernails should be cut short to prevent
excoriation and secondary bacterial infection. However, these are not the first priority actions.
A negative air pressure room is a ventilation system that removes more exhaust air from the room than air allowed into
the room. It prevents the infection from spreading out into the environment. A negative air pressure flow room would
be required to prevent the airborne spread of the disease.

PERTUSSIS

Pertussis (whooping cough) is a very contagious communicable disease caused by the Bordetella
pertussis bacteria. These organisms attach to the small hairs in the airway and release a toxin that causes swelling
and irritation.
Pertussis is spread from person to person by coughing, sneezing, and close contact. As a result, an affected client
should be placed in standard (universal) and droplet isolation precautions when hospitalized.
 At first, symptoms similar to the common cold and a mild fever occur, but eventually these clients develop a
characteristic violent, spasmodic cough.
Coughing is so severe that the person is forced to inhale afterward, resulting in a distinctive, high-pitched "whooping"
sound.
Coughing episodes may continue until a thick mucus plug is expectorated and are sometimes followed by vomiting
(posttussive emesis).
Treatment consists of antibiotics and supportive measures. Humidified oxygen and adequate fluids will help loosen
the thick mucus. Suction as needed is important in infants.
Respiratory status should be monitored for obstruction. The client should be positioned on the left side to prevent
aspiration if vomiting occurs.
Vaccination against whooping cough is available, but some individuals will still develop the disease, although in a
milder form.

BOTULISM
Infant botulism is food poisoning that occurs after consuming Clostridium botulinum, a bacteria found in soil and
animal products (eg, raw honey, milk). In infants, the bacteria often colonize the gastrointestinal tract and release an
exotoxin that causes rapid, life-threatening paralysis.
In addition to young age, absence of competitive bowel flora predisposes infants (age <1 year) to this infection.
Therefore, infants should not be fed honey.
Early clinical manifestations of infant botulism often include constipation, difficulty feeding, decreased head control,
and diminished deep-tendon reflexes
It is essential to recognize symptoms early, because botulism progresses rapidly to respiratory failure and arrest.
Management of infant botulism often includes administering intravenous botulism immune globulin (BIG-IV), which
reduces severity and duration of symptoms by improving immune response. In addition, close monitoring and
supportive care (eg, mechanical ventilation, enteral tube feedings) are provided.
PINWORM INFECTION
The most common worm infection in the United States is pinworm, which is easily spread by inhaling or swallowing
microscopic pinworm eggs, which can be found on contaminated food, drink, toys, and linens.
Once eggs are ingested, they hatch in the intestines. During the night, the female pinworm lays thousands of
microscopic eggs in the skinfolds around the anus, resulting in anal itching and troubled sleep.
When the infected person scratches, eggs are transferred from the fingers and fingernails to other surfaces. Pinworm
infection is treated with anti-parasitic medications.

IRON DEFICIENCY
Iron deficiency is the leading cause of anemia worldwide. Most cases of iron deficiency anemia (IDA) result from
inadequate intake of foods high in iron.
In IDA, red blood cells are small (microcytic) with reduced hemoglobin content, appearing paler (hypochromic)
under a microscope.
The richest dietary sources of iron include meat, fish, and poultry, which provide a form of iron that is easily
absorbed by the body
Plant-based foods (eg, dried fruits, nuts, legumes, green leafy vegetables, whole grains) are not as iron rich and
contain a less bioavailable form of iron than animal-based foods. However, foods high in vitamin C (eg, tomatoes,
potatoes, strawberries) may boost iron absorption when consumed with iron-rich foods.
Fruits and vegetables are not the best sources of dietary iron.
Milk and milk products are poor sources of dietary iron, and excessive calcium intake interferes with iron absorption.
Overconsumption of milk, along with little or no consumption of other foods, is a leading cause of iron deficiency in
young children.

RINGWORM
 Ringworm, or tinea corporis, is a fungal infection on the superficial keratin layers of the skin, hair, and/or nails.
Ringworm is a misleading name as the condition is not caused by a worm infestation. However, it is
highly contagious and spreads via contact.
Management includes teaching appropriate hygiene (eg, washing hands after touching infected areas), limited contact
with personal items (eg, hair brush), and treatment with the prescribed shampoos as well as topical and/or oral
medications (eg, terbinafine [Lamisil], miconazole).
Antifungal cream (terbinafine [Lamisil]) is the preferred treatment and is applied to infected areas twice a day. It may
take 1-4 weeks to complete treatment depending on infection severity.
Ringworm is spread via contact with shared surfaces (eg, bathroom floors, gymnasium mats, car seats), personal
items, or pets. Important preventive measures include cleaning surfaces frequently, not sharing personal items, and
practicing hand hygiene.
MEASLES
Measles (ie, rubeola) is a highly contagious viral illness that affects people of all ages.
Measles spreads when infected individuals cough or sneeze, sending the virus through the air, where it remains
suspended for up to 2 hours.
Widespread vaccination with the measles, mumps, and rubella (MMR) vaccine, such as in the United States, has
reduced measles incidence by 99%. However, an increase in international travel and unvaccinated children have
caused a resurgence of the disease.
For hospitalized clients with measles, the plan of care should include the following:

o Recommendation of postexposure prophylaxis (ie, MMR vaccine) for eligible, susceptible (eg, unvaccinated) family
members within 72 hours of exposure to decrease the severity and duration of symptoms in case they contract the disease
 o Implementation of airborne precautions, including a negative-pressure isolation room and use of an N95 respirator mask,
during contact with the client by health care staff
o Administration of vitamin A supplements to prevent severe, measles-induced vitamin A deficiency, which can cause
blindness, particularly in clients in low-resource areas

An erythematous, maculopapular, morbilliform rash is characteristic of measles, but it is not typically pruritic. Calamine
lotion is effective for soothing pruritic rashes (eg, varicella [chickenpox]).
A tracheostomy tray is not required for this client with measles because respiratory paralysis or emergency intubation
is not expected.

CHRONIC ALLERGIC RHINITIS

Chronic allergic rhinitis is a hypersensitivity response to specific allergen triggers (eg, dust, mold, pollen, animal
dander). Symptoms include sneezing, nasal drainage and congestion, throat soreness, and itching of the eyes and/or
nose. Clients and their families can minimize symptoms by identifying the client's individualized allergen triggers and
implementing strategies to reduce or avoid exposure to them.
Interventions to reduce exposure to household and environmental allergens include:

o Installing high-efficiency particulate air (HEPA) air-conditioner filters

o Keeping windows closed and staying indoors, particularly during times of heavy pollen
o Applying hypoallergenic pillow and mattress covers to prevent exposure to dust mites
o Reducing or removing carpet and area rugs
o Vacuuming carpet at least once a week with a HEPA filter vacuum
o Mopping hard floors and damp-dusting furniture at least once a week

GROUP A B-HEMOLYTIC STREPTOCCOCUS

Pharyngitis caused by -hemolytic Streptococcus is a contagious bacterial throat infection that can lead to
renal (glomerulonephritis) or cardiac complications (rheumatic fever) if not treated.
Children may refuse to eat due to pain. A soft diet and cool liquids (ice chips) should be offered rather than solid
foods
 It is important to complete the full course of antibiotics to prevent reinfection and complications
Toothbrushes should be replaced 24 hours after starting antibiotics; the bristles can harbor the bacteria and
reinfection may occur
Young children may have minor cold symptoms and still be infected. The health care provider should test siblings age
<3.
Children with streptococcal pharyngitis may return to school or daycare after they have completed 24 hours of
antibiotics and are afebrile.
Throat lozenges can be given to older children but are a choking hazard in younger children.
Acetaminophen or ibuprofen (liquid preparations) should be given for pain.

SCARLET FEVER

Scarlet fever (ie, scarlatina), a complication of group A streptococcal infection (eg, streptococcal pharyngitis), is
common in early childhood and is characterized by a distinctive red rash.
 The rash begins on the neck and chest and spreads to the extremities, resembles a bad sunburn, blanches with
pressure, and has fine bumps like sandpaper.
Additional manifestations of streptococcal pharyngitis (eg, exudative pharyngitis, fever, swollen anterior cervical lymph
nodes) are typically present.
Because the clinical presentation (ie, rash plus sore throat) is characteristic, but not diagnostic, of scarlet fever, the
health care provider will prescribe a rapid streptococcal antigen test to confirm symptom etiology
Swabbing the posterior pharynx and tonsils provides test results within minutes. Throat culture may be necessary to
verify results.

PEDICULOSIS CAPITIS
Preventing the spread of pediculosis capitis (head lice) may be accomplished by using hot water to launder clothing,
sheets, and towels in the washing machine; these items should then be placed in a hot dryer for 20 minutes.
Treatment of head lice consists of the use of pediculicides and the removal of nits (eggs).
Items that cannot be washed or dry cleaned may be placed in sealed plastic bags for 14 days to kill active lice or lice
that hatch from the nits in 7-10 days.
Vacuuming of furniture, carpets, stuffed toys, rugs, and mattresses is also recommended to prevent the spread of lice
and nits.

VARICELLA IMMUNIZATION

The varicella immunization is administered to prevent infection of varicella zoster, commonly known as chickenpox.
Side effects of the immunization include discomfort, redness, and a few vesicles at the injection site.
 Covering the vesicles with clothing or a small bandage will reduce the risk of transmission from any exudate. Once the
vesicles have dried, or crusted, a dressing is no longer necessary.
Discomfort, redness, and a few vesicles at the injection site are common side effects of the varicella immunization and
do not require the attention of an HCP.

SICKLE CELL CRISIS

This client is exhibiting signs and symptoms of sickle cell crisis, which occurs when the client's sickle-shaped
cells block blood flow through the vessels.
These clients tend to have a small spleen due to repeated small splenic infarctions (autosplenectomy). Splenic
sequestration crisis occurs when a large number of "sickled" cells get trapped in the spleen,
causing splenomegaly. This is a life-threatening emergency as it can lead to severe hypovolemic (hypotensive)
shock. The classic assessment finding is a rapidly enlarging spleen.
Normal red blood cells live about 120 days. Sickle cells break apart and die within less than 20 days; therefore, the
client always has a shortage of red blood cells (anemia). Due to anemia, clients often report feeling fatigued.
Right arm weakness could indicate new-onset stroke, a common complication of sickle cell disease that needs to be
assessed. However, splenic sequestration is immediately life-threatening and a priority.
Swelling of hands and feet (dactylitis) is another symptom of this disease due to the sickled red blood cells blocking
blood flow to the hands and feet. This is often detected in babies as the first sign of the disease.
A child in vaso-occlusive sickle cell crisis will be experiencing a high level of pain due to the occlusion of small blood
vessels from increased red blood cell sickling. Supportive and symptomatic treatment includes round-the-clock pain
management with opioids, intravenous fluids for hydration, and bed rest to decrease energy expenditure and oxygen
demand.
Age-specific nonpharmacologic strategies should also be implemented to manage pain and help limit the amount of
needed narcotic analgesia. For a school-aged child, such activities include distraction (watching TV, listening to
music, reading), relaxation, guided imagery, warm soaks, positioning, and gentle massage.
Finger painting is messy and best done in the activity room; it is not appropriate for a child confined to bed.
 A child must be on bed rest when in vaso-occlusive sickle cell crisis. Playing a game in the activity room does not
maintain bed rest and would be too stimulating for the child.
Playing video games may be too exciting and stimulating for the child; an environment low in stimuli will promote rest.
BACTERIAL CONJUNCTIVITIS
Bacterial conjunctivitis (pink eye) is highly contagious. The hands must be washed properly before and after
instilling eye drops and after cleaning away eye drainage or crusting; this is the single best method to prevent the
spread of infection to the other eye, the parents, other family members, or anyone else.
Therefore, parents should ensure that affected children wash their hands frequently and discourage them from
rubbing their eyes.
Tissues used to clean the eye should be discarded.
The child's washcloths and towels should be kept separate. Many schools and day care centers require that children
be kept at home during the time when they are most contagious.

FLACC SCALE
 The FLACC scale (face, legs, activity, cry, and consolability) can be used to assess pain in the child who is
nonverbal. This includes assessment for:

o Facial grimacing
o Leg movement, tension, or bending up toward the chest
o Activity, including squirming, arching, jerking
o Crying or moaning
o Difficulty consoling or comforting the child

The nurse will provide teaching on signs that should prompt the parent to administer as-needed pain medication to the
child.

HEMOPHILIA

Hemophilia is a bleeding disorder caused by a deficiency in coagulation proteins, increasing the risk for bleeding.
The nurse should avoid procedures that can cause bleeding (eg, intramuscular injections, rectal temperature
measurement).
 Vaccinations are administered subcutaneously whenever possible to prevent intramuscular hematoma. The smallest
gauge needle is used, and firm, continuous pressure is applied at the site for 5 minutes
Children with hemophilia should avoid aspirin and nonsteroidal anti-inflammatory drugs due to the risk of bleeding.
Acetaminophen is recommended for pain relief.
Firm pressure should be held on the site without rubbing or massaging due to the risk of bleeding and hematoma
formation. Superficial bleeding can be controlled using ice packs, which promote vasoconstriction. Applying a warm
compress would cause vasodilation and prolong bleeding.
Hemophilia is a bleeding disorder caused by a deficiency in coagulation proteins.
Clients with classic hemophilia, or hemophilia A, lack factor VIII. Clients with hemophilia B (Christmas disease) lack
factor IX.
When injured, clients with hemophilia should be monitored closely for external as well as internal bleeding.
The most frequent sites of bleeding are the joints (80%), especially the knee.
Hemarthrosis can occur with minimal or no trauma, with episodes beginning during toddlerhood when the child is
active and ambulatory. Over time, chronic swelling and deformity can occur.

Hemophilia is a hereditary bleeding disorder caused by a deficiency in coagulation proteins.

Treatment consists of replacing the missing clotting factor and teaching the client about injury prevention, including:

o Avoid medications such as ibuprofen and aspirin that have platelet inhibition properties
o Avoid intramuscular injections; subcutaneous injections are preferred.
o Avoid contact sports and safety hazards; noncontact activities (eg, swimming, jogging, tennis) and use of protective
equipment (eg, helmets, padding) are encouraged
o Dental hygiene is necessary to prevent gum bleeding, and soft toothbrushes should be used.
o MedicAlert bracelets should be worn at all times

KAWASAKI DISEASE
 Kawasaki disease is treated with aspirin and IVIG to prevent coronary artery aneurysms. Antibodies acquired from
the IVIG therapy will remain in the body for up to 11 months and may interfere with the desired immune response to
live vaccines.
Therefore, live vaccines (eg, varicella, MMR) should be delayed for 11 months after IVIG administration as this therapy
may decrease the child's ability to produce the appropriate amount of antibodies to provide lifelong immunity

URINARY TRACT INFECTION

UTIs are one of the most common conditions in children, with a higher occurrence in girls (due to the short urethra and
its close proximity to the vagina and anus). Girls should be taught to wipe from front to back; this will help minimize
the chances of bacteria entering the urethra from the perianal area
Urinary stasis (incomplete emptying of the bladder) is the most common contributing factor to UTIs; sedentary urine
provides an ideal environment for bacterial growth.
Constipation and straining increase the pressure on the bladder neck and may prevent the bladder from emptying
completely. The child should be encouraged to drink plenty of fluids and use the restroom as soon as the urge to go is
felt, which will decrease the risk of constipation and promote frequent urination. Avoiding "holding in" urine and
voiding regularly help to prevent urinary retention and flush bacteria out of the urinary tract
Scented soaps or commercially prepared bubble bath products should be avoided as they cause irritation to the
urethra. Antibacterial soap should not be used for bathing a child as it may reduce the presence of normal flora. The
bathtub should be filled with water only, and the hair should be washed last
Tight clothing and synthetic fabrics (eg, nylon, spandex, Lycra) should be avoided as they seal in moisture and
promote bacterial growth. Cotton underwear is recommended as it absorbs moisture.

MENINGOCOCCAL MENINGITIS
Nursing care for a child with known or suspected meningococcal meningitis includes key safety and comfort
measures.
Droplet precautions are initiated because this form of meningitis is easily transferred through secretions.
 Precautions should be continued for 24 hours after initiation of antibiotic therapy.
Clients with somnolence or other altered level of consciousness should be kept on NPO status to prevent aspiration
Comfort measures include promoting a quiet environment, minimizing stimuli in the room, and allowing the client
to self-position
Due to nuchal rigidity, most clients prefer to lie with the head of the bed slightly raised and without a pillow, or in
a side-lying position.
Under droplet precautions, the nurse should wear a mask when caring for the client. However, the client does not
need to wear a mask unless transportation outside the room (eg, to perform an imaging study) is necessary.

REYE SNDROME
Children who develop Reye syndrome often have had a recent viral infection, especially varicella (chicken pox)
or influenza.
Clinical manifestations include fever, lethargy, acute encephalopathy, and altered hepatic function.
Elevated serum ammonia levels are an expected laboratory finding. Acute encephalopathy manifests with vomiting
and a severely altered level of consciousness; it can rapidly progress to seizures and/or coma.
The risk of developing Reye syndrome increases if aspirin therapy is used to treat the fever associated with varicella
or influenza.
As a result of this awareness, there has been a significant increase in the use of acetaminophen or ibuprofen for fever
management in children.

FIFTH DISEASE

Fifth disease ("slapped face," or erythema infectiosum) is a viral illness caused by the human parvovirus and affects
mainly school-age children.
The virus spreads via respiratory secretions, and the period of communicability occurs before onset of symptoms.
 The child will have a distinctive red rash on the cheeks that gives the appearance of having been slapped. The rash
spreads to the extremities and a maculopapular rash develops, which then progresses from the proximal to distal
surfaces.
The child may have general malaise and joint pain that are typically well controlled with nonsteroidal anti-inflammatory
drugs such as ibuprofen. Affected children typically recover quickly, within 7-10 days.
Once these children develop symptoms (eg, rash, joint pains), they are no longer
infectious. Isolation is not usually required unless the child is hospitalized with aplastic crisis or
immunocompromising condition.

FEBRILE SEIZURE
This client likely has febrile seizures. It is important to never leave seizing clients alone as the goal is to prevent
them from causing self-injury. The nurse should call out for help if needed.
The main objective is to ensure that seizing clients maintain their airway; therefore, it is important to monitor their
oxygen saturation levels. If these levels begin to drop or cyanosis occurs, prompt intervention is needed, which may
be as simple as a head tilt or jaw thrust.
Aspirin should not be used in children to treat fever, except in a setting such as Kawasaki disease; this is because
aspirin use is associated with Reye syndrome (swelling of the liver and brain). Fever in children is treated with
ibuprofen or acetaminophen.
Most clients experiencing a febrile seizure do not require anti-seizure medications to stop convulsions. Once
seizing has stopped, the fever needs to be treated. If seizing is continuous, medication administration may be
necessary.

INFECTIOUS MONONUCLEOSIS
 Mononucleosis is caused by the Epstein-Barr virus. It is typically seen in adolescence from the sharing of
drinks, kissing, or other direct exposure to saliva. Symptoms may include fatigue, fever, sore throat,
splenomegaly, hepatomegaly, and swollen lymph nodes.
Antibiotic treatment is inappropriate for a viral infection. Inadvertent intake of antibiotics (amoxicillin) can cause a
rash.
Treatment for mononucleosis is management of symptoms and includes hydration, rest, control of pain, and reducing
fever as necessary. Sore throat is treated with saline gargles or anesthetic troches.
Complications include airway obstruction (eg, stridor, difficult breathing) from swollen lymph nodes around the neck
and severe abdominal pain (splenic rupture). These should be reported to the health care provider (HCP)
immediately.
Ibuprofen or acetaminophen is appropriate treatment to control pain and manage fever in the child with
mononucleosis. Aspirin should be avoided in children due to the risk of Reye syndrome.
Fatigue is a symptom of mononucleosis. Rest is very important in the care of a client with mononucleosis.
Mononucleosis may cause splenomegaly or hepatomegaly. Contact sports such as soccer should be avoided to
prevent injury to the spleen or liver.

MMR VACCINE
The Centers for Disease Control and Prevention (CDC) recommends that the first dose of MMR vaccine be given to
children between age 12-15 months to ensure optimal vaccine response.
However, the vaccine is safe for children age <12 months; it could provide some protection or modify the clinical
course of the disease if administered within 72 hours of the child's initial measles exposure.
Immunoglobulin, if administered within 6 days of exposure, is also utilized as post-exposure prophylaxis.
A child who receives the MMR vaccine prior to the first birthday will need to be revaccinated at age 12-15 months and
again between age 4-6 years.
TONSILLECTOMY
A tonsillectomy may be indicated in some cases of chronic tonsillitis, peritonsillar abscess, or obstructive sleep
apnea.
Postoperative bleeding is a primary concern after a tonsillectomy because the surgical site is not easily visualized
and is vulnerable to irritation and trauma from swallowing and coughing. The nurse should observe for signs of
postoperative bleeding (eg, frequent, increased swallowing or clearing of the throat; vomiting bright red blood) and
notify the health care provider
Expected postoperative findings include ear pain when swallowing (ie, referred pain from the throat) and low-grade
fever (<101 F [38.3 C]); analgesics (eg, acetaminophen) may be administered as needed
Superficial infection at the surgical site is common and causes white, fluid-filled exudate in the throat with halitosis (ie,
bad breath); this is not concerning because it usually resolves spontaneously after 5-10 days
Drinking through a straw creates suction that causes localized pressure at the back of the throat and may contribute to
bleeding. The client should avoid use of straws or other pointed objects in the mouth.
Routine suctioning can cause trauma to the surgical site and induce bleeding. Suction equipment should be available
but used only for emergency airway obstruction.

SCABIES
Scabies is a highly contagious skin infestation of the Sarcoptes scabiei mite. Scabies spreads easily via
direct person-to-person contact (eg, skilled nursing facility, day care, prison).
The pregnant female mite burrows into the outer skin layer to lay eggs and feces, leaving a superficial burrow track.
Intense itching, especially at night, occurs due to the body's inflammatory response to the mite's eggs and feces.
Treatment for scabies typically involves 1 or 2 applications of a scabicide cream (eg, 5% permethrin).
For infants and children, permethrin should be massaged into all skin surfaces from the head to the feet, avoiding
contact with the eyes (
 Even after effective treatment, itching often continues for several weeks. All persons in close contact with the client
during the lengthy 30- to 60-day incubation period (time from infestation to symptom onset) should also seek
treatment
To prevent reinfection, clothing and linens should be washed and dried on the hottest settings
Discarding stuffed animals is not required. Nonwashable belonging
because scabies mites can survive away from skin for only 2-3 days.
Fumigation of living areas is not necessary.

PERITONSILLAR ABSCESS

Trismus (inability to open the mouth due to a tonic contraction of the muscles used for chewing) may indicate a more
serious complication of tonsillitis, a peritonsillar or retropharyngeal abscess (collection of pus).
Other features include a "hot potato" or muffled voice, pooling of saliva, and deviation of the uvula to one side. This
abscess can occlude the airway, making it a medical emergency.
 Surgical intervention (tonsillectomy or incision and drainage) is often required. In the meantime, maintaining an
adequate airway is essential

MUSCULOSKELETAL AND INTEGUMENTARY

DEVELOPMENTAL DYSPLASIA OF THE HIP

Developmental dysplasia of the hip (DDH) is a range of various hip abnormalities that may be present at birth or
develop during the first few years of life.
There are many risk factors, including breech birth, large infant size, and family history. Although all cases cannot be
prevented, several interventions have been shown to help reduce the risk of DDH development.
Key measures include:
o Proper swaddling technique - infants should be swaddled with their hips bent up (flexion) and out (abduction), allowing room
for hip movement
o Choosing infant carriers or car seats with wide bases - infant seats should allow for proper hip positioning in an abducted
manner
o Avoiding any positioning device, seat, or carrier that causes hip extension with the knees straight and together
Narrow infant carriers prevent proper hip abduction, putting a strain on the hip ligaments and possibly leading to DDH.
Double/triple diapering is no longer recommended as a preventive measure for DDH. This practice can cause
extension of the hip, leading to abnormal development.
Infant swings, bouncers, wraps, and other similar items can cause the legs to be positioned straight and together,
which can increase the risk for DDH.
Because it is much easier to treat during infancy, DDH screening is a standard assessment for newborns and
infants. Manifestations in infants age <2-3 months include:

1. The presence of extra inguinal or thigh folds

2. Laxity of the hip joint on the affected side. Hip laxity/instability is tested through the Barlow and Ortolani maneuvers.
However, these tests must only be performed by an experienced health care provider to avoid further hip injury. If DDH is not
treated, these signs disappear after age 2-3 months due to the development of muscle contractures.

Limited hip abduction occurs as contractures develop, particularly once the infant is age >3 months.
In children with one-sided DDH, the affected leg may be shorter than the opposite leg. However, this is also
apparent after age 3 months.
If DDH is not corrected in infancy, additional manifestations develop when the child learns to walk. These signs
include a notable limp, walking on the toes, and a positive Trendelenburg sign (pelvis tilts down on unaffected side
when standing on the affected leg). In the case of bilateral DDH, the child may also develop a waddling gait and
severe lordosis.

Developmental dysplasia of the hip (DDH) is instability or dislocation of the hip joint that may be present at birth or
develop during the first few years of life. Nonsurgical treatment methods, such as a harness or cast, are most
successful when initiated during the first 6 months of life. After this time, surgery is frequently required.
A Pavlik harness, the most common tool used in treating early DDH, maintains the infant's hips in a slightly flexed
and abducted position, allowing for proper hip development.
Pavlik harnesses are typically worn for about 3-5 months or until the hip joint is stable. The straps are adjusted
periodically by the health care provider to account for infant growth.
Instructions on care for the infant wearing a Pavlik harness are as follows:

o Regularly assess skin for redness or breakdown under the straps

o Dress the child in a shirt and knee socks under the harness to protect the skin
o Avoid lotions and powders to prevent irritation and excess moisture
 o Lightly massage the skin under the straps every day to promote circulation
o Only apply 1 diaper at a time reases risk of incorrect hip placement
o Apply diapers underneath the straps to keep harness clean and dry

The Pavlik harness is usually worn all the time, particularly during the first few weeks of treatment. Some providers
may allow the harness to be removed for a short bath once a day, but it should be left in place for all other care
activities, including diaper changes.
The Pavlik harness is the most common tool used to treat early DDH. It maintains the infant's hips in a slightly
flexed and abducted position (ie, legs bent and spread apart), allowing for proper hip development
Pavlik harnesses are typically worn for 3-5 months or until the hip joint is stable.
The straps are assessed every 1-2 weeks by the health care provider (HCP) and adjusted as necessary to account for
infant growth. However, parents should not alter the strap placements at home as incorrect positioning can lead to
damage to the nerves or vascular supply of the hip
Care of the infant wearing a Pavlik harness includes the following:
Assess skin 2-3 times daily for redness or breakdown under the straps

o Dress the child in a shirt and knee socks under the harness to protect the skin
o Apply diapers underneath the straps to keep the harness clean and dry
o Leave the harness on at all times, unless otherwise indicated by the HCP

ATOPIC DERMATITIS

Atopic dermatitis, also known as eczema, is a chronic skin disorder characterized by pruritus, erythema, and dry
skin. In infants, red, crusted, scaly lesions may also be present. It is commonly first diagnosed before age 1 year.
The exact cause is unknown, although it is associated with an impaired skin barrier that allows penetration of
allergens, leading to an immune response.
The primary goals of management are to alleviate pruritus and keep the skin hydrated to prevent scratching.
Scratching leads to the formation of new lesions and predisposes to secondary infections.
Important measures to prevent scratching include cutting and filing nails short, placing gloves or cotton stockings over
the hands, not wearing rough fabrics or woolen clothing, and applying moisturizer. These measures would have an
immediate effect in preventing scratching.
Atopic dermatitis (AD), also known as eczema, is a chronic skin disorder characterized by pruritus, erythema, and
dry skin. The exact cause of AD is unknown, although it may be associated with an impaired skin barrier and
resulting immune response to invading allergens.
The primary goals of management are to alleviate pruritus and keep skin hydrated to reduce scratching. Scratching
leads to formation of new lesions and potential secondary infections.

o Parents should be instructed to give tepid baths using gentle soap; hot water and long bubble baths dry skin and should be
avoided
o Skin should be gently patted dry after bathing, followed by immediate application of an emollient (eg, Eucerin, Cetaphil) to
seal in moisture
o Nails should be trimmed short and kept filed to reduce scratches
o Clothing should be soft (eg, cotton) and climate-appropriate to reduce perspiration, which can intensify pruritus. Long
sleeves should be worn at night.
o Avoid trigger factors such as heat and low humidity
 OSTEOGENESIS IMPERFECTA

Osteogenesis imperfecta (OI) (brittle bone disease) is a rare genetic condition resulting in impaired synthesis
of collagen by osteoblasts.
Collagen allows bone to be somewhat flexible while still maintaining strength. Impaired collagen causes bones to be
frail and easily fractured.
Clinical manifestations can range from mild defects to lethal disease in utero. OI is usually transmitted by autosomal
dominant inheritance.
The nurse's priority for a client with OI is careful handling to minimize additional fractures. Care of the infant with OI
includes:

o Checking blood pressure manually to avoid cuff over-tightening, which may occur with automatic blood pressure cuffs
o Lifting the infant by slipping a hand under the broadest areas of the body (eg, back, buttocks) so the pressure is distributed
 o Repositioning the infant frequently using supportive devices and gel padding to avoid molding of the soft bones of the skull

Lifting by the ankles or under the arms puts too much pressure on the delicate bones (eg, legs, ribcage).

COLD INJURY

The clinical indications of a cold injury include redness and swelling of the skin (chilblains or pernio) and blanched
skin with hardness of the affected area (frostbite).
For any cold injury, it is important to re-warm the area as soon as possible to restore blood flow and reduce the risk of
permanent tissue damage.
The recommendation for re-warming is immersion of the affected area in warm water (104 F [40 C]) for about 30
minutes or until the area turns pink in cases of frostbite. The face and ears can be re-warmed with the application of
warm facecloths
Once re-warming has been effective, the child should be seen by an HCP as soon as possible
Massaging a body part that has sustained a cold injury is contraindicated due to the risk of tissue injury.

COMPARTMENT SYNDROME

Parents of children with casts are taught to check for emergency signs of circulatory impairment, including changes in
sensation and motor function, which could indicate early signs of compartment syndrome due to swelling within the
confined space of the cast. However, some swelling is expected, so this symptom alone is not indicative of
compartment syndrome.
The 6 Ps of compartment syndrome include:

1. Pain: Increasing despite elevation, analgesics, and ice. Pain will also increase with passive stretching/movement.
Increasing pain is an early sign and indicates muscle ischemia
2. Pressure: Affected extremity or digits are firm and tense; skin is tight and appears shiny.
3. Paresthesia: Tingling, numbness, or burning sensation, which is also an early sign and indicates nerve ischemia
 4. Pallor: Skin appears pale; capillary refill is >3 seconds. These indicate poor perfusion.
5. Pulselessness: Pulse distal to injury or compartment is impalpable. Absent pulses are a late sign.
6. Paralysis: Loss of function or inability to move extremity or digits. Muscle weakness occurs before paralysis which is also a
late sign and indicates dead muscle tissue.

An itching sensation under the cast is expected, clients and parents are taught to avoid inserting anything into the cast
to scratch the skin. Instead, they should use a hair dryer on the cold setting.
Arm elevation is indicated for the first 48 hours after cast placement to reduce edema. However, if compartment
syndrome develops, the arm should be kept at torso level (not high or low).
BURN

Proper emergency care immediately following a burn can prevent infection, hypothermia, and further tissue damage.
Once the source of the burn is contained, the nurse teaches the client home care that can be given prior to arrival to
the emergency department.
Client teaching includes:

o Soak area briefly in cool water to stop the burning process

o Remove any clothing or jewelry around the burn to avoid constriction as edema develops. This also allows for quick
assessment of the burn by clinicians. Only a health care provider may remove clothing that is stuck to the burned area
o Cover with a clean, dry cloth to prevent contamination, further trauma, and hypothermia

Medications should not be applied to a burn until prescribed by a health care provider as they may interfere with
assessment of the burned area.
Placing ice on a burn or wrapping the area in ice can increase tissue damage and may cause hypothermia with large
burns. No ice, ointments, creams, or butter should be placed on the open skin.

JUVENILE IDIOPATHIC ARTHRITIS

Children with JIA are at high risk for becoming deconditioned due to decreased muscle strength and endurance and
overall capacity for exercise. They tend to tire quickly even when the disease is in remission.
 Both aerobic and anaerobic exercise can help minimize this risk, and resistance training can increase muscle strength
and endurance. Exercise may also have a positive effect on low bone density, a secondary condition often associated
with JIA.
In general, low-impact, weight-bearing, and non-weight-bearing exercises that involve range of motion and
stretching to preserve joint mobility and strengthen muscles are best. High-impact activities and those that cause
overtiring and joint pain should be avoided.
Swimming is often considered the ideal activity for children with JIA as it allows for exercising a large number of joints
with minimal gravitational pull. Other recommended activities include riding a stationary bike, throwing or kicking a
ball, low-impact aerobic dancing, walking, and yoga.
TINEA CAPITIS
Tinea capitis (ringworm of the scalp) is a contagious fungal infection that lives on the surface of the scalp, resulting in
scaly, pruritic, erythematous, circular patches with hair loss. The infection is transmitted via direct contact with
infected persons, pets, or objects (eg, hairbrushes, bedding, towels, hats).
Treatment may include 1% selenium sulfide shampoo applied several times each week in combination with
an antifungal medication (eg, griseofulvin oral suspension) that the client must take for several weeks to months.
Keratin-producing cells absorb griseofulvin, causing resistance to the fungus; because the fungus requires keratin
(protein in hair and skin cells) to live and grow, it is not able to reproduce.
To ensure that infected keratin is shed completely, treatment with griseofulvin should not be discontinued early,
even if symptoms (eg, itching, scaling) decrease
The client will best absorb griseofulvin (ie, suspension, microsized tablets) when taken after/with high-fat foods (eg, ice
cream).
(Photosensitivity is a common side effect of griseofulvin treatment, and the client should avoid prolonged exposure to
the sun and use sunscreen.
The client should apply medicated shampoo (eg, 1% selenium sulfide) to the scalp a few times each week.
DENTAL AVULSION
Dental avulsion (ie, tooth separated from the mouth) of a permanent tooth is a dental emergency.
The priority nursing action is to rinse and reinsert the tooth into the gingival socket and hold it in place (eg, with a
finger) until stabilized by a dentist. Reimplantation within 15 minutes of injury re-establishes blood supply, increasing
the probability of tooth survival.
If the tooth cannot be reinserted it should be kept moist by submerging it in commercially prepared solution (eg, Hanks
Balanced Salt Solution), cold milk, sterile saline, or as a last resort due to bacteria saliva (eg, holding it under the
tongue).
Scrubbing the root would damage it. The tooth should be gently rinsed with sterile saline or clean, running water.
Placing the tooth in water (a hypotonic solution) would lyse the cells, killing the tooth.
Wrapping the tooth in sterile gauze would dry it out. In addition, the nurse should arrange for immediate transfer to a
dentist rather than advise the parent to schedule an appointment that might not be available for days.

ACNE VULGARIS
Acne vulgaris is a skin disorder characterized by obstructed sebaceous glands, which form comedones (ie,
blackheads, whiteheads).
Bacteria consume and metabolize the obstructed sebum, and the metabolic products cause inflammation, pustules,
papules, and nodules.
Acne usually develops during puberty, and multiple factors influence its development (eg, overgrowth of normal
bacteria, heredity, stress, hormones).
Treatment includes topical and oral medications such as tretinoin (Retin-A), benzoyl peroxide, isotretinoin (Accutane),
and oral contraceptives.
Antibacterial soaps are harsh and ineffective, increase the pH of the skin, and can dry the skin. The client should
instead gently wash the face with a mild facial cleanser.
Additional self-care measures include:

o Using noncomedogenic skin care products (ie, products that do not clog pores) to avoid creating new lesions Maintaining
a healthy lifestyle (eg, moderate exercise, balanced diet, adequate sleep) to reduce stress and promote healing
 o Refraining from squeezing, picking, and vigorously scrubbing lesions to prevent additional inflammation and worsening
the acneIMPETIGO

Impetigo is a highly contagious bacterial skin infection, most commonly occurring in children during hot, humid
weather. Impetigo is characterized by itchy, burning, red pustules that rupture to form honey-colored crusts. When
treated with antibiotic ointment and/or oral antibiotics, lesions are no longer contagious after 24-48 hours and
typically heal within a week. Without antibiotics, impetigo typically resolves within 2-3 weeks but remains highly
contagious until lesions heal.
To care for and decrease transmission of impetigo, interventions include:

o Performing handwashing before and after touching the infected area

o Isolating the infected person's clothing and linens and washing them in hot water
o Keeping the infected person's fingernails short and clean to prevent bacteria from collecting under them and to deter
scratching
o Avoiding close contact with others for 24-48 hours after initiation of antibiotic therapy
o Keeping the infected area covered with gauze when in contact with others (eg, while at school)

Impetigo lesions should be soaked with warm water, saline, or Burow's solution (a skin-soothing astringent) and gently
cleansed with mild antibacterial soap before applying antibiotic ointment. This helps remove infected crusts and
reduce irritation. Alcohol is irritative and should be avoided.
DUCHENNE MUSCULAR DYSTROPHY
Duchenne muscular dystrophy is an X-linked recessive (carried by females and affecting males) disorder that
causes the progressive replacement of dystrophin, a protein needed for muscle stabilization, with connective
tissue.
The proximal lower extremities and pelvis are affected first. In response to proximal muscle weakness, the calf
muscles hypertrophy (pseudohypertrophy) initially and are later replaced by fat and connective tissue.
Children with Duchenne muscular dystrophy raise themselves to a standing position using the classic Gower
sign/maneuver (placing hands on the thighs to push up to stand) and walk on tiptoes. Parents may also
report frequent tripping and falling
There is no effective cure. Most children are wheelchair bound by adolescence and die by age 20 30 from
respiratory failure. It is important to avoid floor clutter (eg, throw rugs) and prevent falls/injury
SCOLIOSIS

Lateral curvature to the spine of this 10-year-old girl may indicate scoliosis, which is one of the most commonly
diagnosed spinal deformities and is characterized by lateral curvature of the spine and spinal rotation.
Although scoliosis may result from congenital or pathologic conditions, it is most often determined to be idiopathic (of
unknown cause). It is commonly first noticed during periods of rapid growth, particularly during early adolescence in
girls.
Screenings may occur in schools or at well-child office visits for girls age 10-12 and for boys age 13-14. Early
detection and prompt treatment may reduce the need for surgical intervention.

OPTHAMOLOGY /NEUROLOGY / AUDIOLOGY

VENTRICULOPERITONEAL SHUNT

A ventriculoperitoneal shunt is used to treat hydrocephalus and is usually placed at age 3-4 months.
Blockage and infection are complications of shunt placement. Blockage results in signs of increased intracranial
pressure (ICP). The normal pulse range for a 1-year-old is 100-160/min.
A pulse of 78/min is considered bradycardia, a part of Cushing's triad (bradycardia, slowed respiration, widened pulse
pressure).
The caregiver of a child with a VP shunt must understand symptoms of increased intracranial pressure (ICP), which
indicate shunt malfunction.
Vomiting may be a sign of increased ICP and would require that the HCP be contacted.

BACTERIAL MENINGITIS

Bacterial meningitis is an inflammation of the membranes covering the brain and spinal cord (ie, meninges) caused
by a bacterial infection.
The inflammatory process and bacterial growth within the meninges lead to increased volumes of cerebrospinal fluid
and, subsequently, increased intracranial pressure (ICP).
 Without intervention, increased ICP may lead to nerve ischemia, permanent functional impairment (eg, hearing loss,
visual impairment, paralysis), brain damage, herniation, and death.
The initial priority of nursing care is protecting other clients and staff from exposure, as bacterial meningitis is highly
contagious and transmitted by droplets.
After isolating the client, the nurse should initiate prescribed antibiotics as quickly as possible, as bacterial
meningitis can progress rapidly and lead to death without treatment
Bacterial meningitis is inflammation of the meninges of the brain and spinal cord caused by infection.
General manifestations in infants and children age <2 include fever, restlessness, and a high-pitched cry.
One common acute complication of bacterial meningitis is hydrocephalus, an increase in intracranial pressure (ICP)
resulting from obstruction of cerebrospinal fluid flow.
Increased ICP can progress to permanent hearing loss, learning disabilities, and brain damage.
Bulging/tense fontanels and increasing head circumference are important early indicators of increased ICP in
children.
Frequent assessment for developing complications is vital for any client with suspected bacterial meningitis.

Clinical manifestations of bacterial meningitis in infants age <2 include:

o Fever or possible hypothermia

o Irritability, frequent seizures
o High-pitched cry
o Poor feeding and vomiting
o Nuchal rigidity
o Bulging fontanelle possible but not always present

FEBRILE SEIZURES
Febrile seizures are an alarming experience for parents. They most commonly occur in children between ages 6
months to 6 years, with the peak of incidence occurring at age 18 months.
The etiology is unknown.
 Simple febrile seizure management typically involves reassurance regarding the benign nature of most febrile
seizures, and education about the risk of recurrence and seizure safety precautions (eg, side-lying positioning,
removal from harmful environments).
Parents should use antipyretics such as acetaminophen or ibuprofen (in children age >6 months) to control fever and
make the child more comfortable. However, there is no evidence that antipyretics reduce the risk of future febrile
seizures.
After the administration of antipyretics, additional cooling methods that may be beneficial for reducing fever include
applying cool, damp compresses to the forehead; increasing air circulation in the room; and wearing loose or
minimal clothing.
Bathing an infant in tepid water and placing ice bags under the arms and around the neck are not recommended
techniques as these induce shivering, increase metabolic activity, have no antiseizure effects, and cause discomfort
for the child.
Parents should be instructed to call 911 and seek medical assistance for a seizure lasting more than 5 minutes.
Neurologic damage can occur with frequent and prolonged seizures.

MENINGOCELE

Meningocele is a saclike protrusion through a bony defect that contains meninges and cerebrospinal fluid; it is corrected
with surgery.
In some children, residual bowel and bladder incontinence can result despite surgery.
 If bowel and bladder control is obtained but incontinence reoccurs, the child should be evaluated for infection (a
common complication).
Myelomeningocele occurs when the neural tube fails to fuse properly during fetal development.
An outpouching of spinal fluid, spinal cord, and nerves covered by only a thin membrane occurs, typically in the lumbar
area. The newborn is at high risk for infection at this area.
A priority nursing intervention is to cover the area with a sterile, moist dressing to decrease the risk of infection until
surgical repair can occur.

MYOPIA

Myopia, or nearsightedness, is reduced visual acuity when viewing objects at a distance.

Myopia occurs when the eye structure causes images to focus before they arrive at the retina. Near vision is usually
intact, and many clients with myopia report needing to hold objects near their face or sit near objects to see clearly
Myopia in pediatric clients may first be discovered by the school nurse during routine visual acuity testing. Children
often report headaches, dizziness, and the need to squint the eyes to see clearly
School performance may be affected because of impaired ability to see class presentations.
 INCREASED ICP

Hydrocephalus is an increase in intracranial pressure (ICP) that results from obstruction of cerebrospinal fluid
flow.
Increased ICP can progress to brain damage and death. Signs of increased ICP in children include bulging
fontanelles, increasing head circumference, and sunset eyes (or setting-sun sign) (sclera visible above the iris).
Sunset eyes occur when periaqueductal structures are compressed from increased ICP, paralyzing the upward gaze.
This is a late sign of increased ICP that requires timely treatment (eg, shunt placement) and is the priority

LUMBAR PUNCTURE
The optimal position for access during a lumbar puncture is to have the client's head and knees tucked in and the back
rounded out. This provides the most room for the health care provider (HCP) to perform the procedure and allows for
a good hold to keep the client still.
 A lumbar puncture is a sensitive procedure, and it is important to keep the child from moving during needle insertion.
Unless the client has improper air exchange, oxygen administration is not needed. The nasal cannula will most likely
bother the child and lead to unnecessary movement during needle placement.
The HCP performing the lumbar puncture will feel the spine for correct needle placement and then sterilize and
prepare the chosen area for needle insertion.

ACUTE OTITIS MEDIA

AOM is an infection of the middle ear resulting from dysfunction of the Eustachian tube. OM typically occurs in infants
and children age <2, often following a respiratory tract infection.
Clinical manifestations of AOM include high fever (up to 104 F [40 C]), ear pain, irritability/restlessness, loss of
appetite, and pulling on the affected ear.
In AOM, the tympanic membrane will typically be bulging and very red. If the tympanic membrane ruptures from the
buildup of fluid, the client will experience immediate pain relief and a gradually decreasing fever; purulent drainage
may be observed in the external ear canal.
AOM is an infection of the middle ear. Potential complications of AOM include hearing loss and spread of the
infection.
To prevent permanent damage, severe cases of AOM are treated with antibiotics.
 Amoxicillin is the standard treatment in most cases. However, if AOM symptoms do not improve within 48-72
hours of initiating antibiotic therapy, the client should return for further assessment.
The HCP will then assess for other causes of persistent symptoms and determine if a different antibiotic is required to
treat drug-resistant organisms.
Following treatment with antibiotics, clients with AOM should be evaluated for complete infection resolution
and screened for hearing impairment.
The eustachian tubes in infants and young children are short, straight, and fairly horizontal, which results in ineffective
drainage and protection from respiratory secretions.
Infants with exposure to tobacco smoke are at risk for OM due to the resulting respiratory inflammation. OM risk is
also higher with activities such as using a pacifier or drinking from a bottle when lying down as these allow fluid to
pool in the mouth and then reach the eustachian tubes.
Key preventive measures include eliminating exposure to smoke, obtaining routine immunizations to prevent
infection, and reducing or eliminating use of a pacifier after age 6 months.

OTITIS EXTERNA
 Severe pain experienced with direct pressure on the tragus or with pulling on the pinna is a manifestation of otitis
externa, an infection of the outer ear.

STRABISMUS

Strabismus (crossed eyes) is a disorder involving misalignment of the eyes caused by a congenital defect or acquired
weakness of an eye muscle. One eye may appear deviated inward (esotropia) or outward (exotropia).
When the visual axes are not in alignment, the brain perceives 2 images (diplopia) and suppresses the weaker image
to compensate.
If left untreated by age 4-6, permanent reduction or loss of visual acuity in the affected eye (amblyopia) can occur.
Initial treatments vary depending on the underlying cause.
One common treatment is to strengthen the muscles of the weaker eye by wearing a patch over the stronger eye or
using special corrective lenses.
If nonsurgical methods are unsuccessful, surgical intervention to shorten or reposition an eye muscle for more
effective movement may be required.

VISUAL ACUITY

Visual acuity testing in children ages 6 and older is generally assessed by use of the Snellen letter chart. The child
is positioned 10 ft (3 m) from the chart and asked to read the letters, beginning with the lines of large text to small text.
Standard testing for visual acuity is at 20 ft (6 m); however, the American Academy of Pediatrics recommends testing
at 10 ft as it is easier to maintain the child's attention and provides a more accurate result.
If the child wears glasses, they remain in place. Both eyes should remain open while one eye at a time is covered to
read the chart.
The child must identify 4 of 6 letters in each line before moving to the next. A referral to an ophthalmologist is made if
a child is unable to identify 4 correct letters on the 10/15 line (equivalent to 20/30 vision) with either eye.
RETINOBLASTOMA

Retinoblastoma, a unilateral or bilateral retinal tumor, is the most common childhood intraocular malignancy. It is
typically diagnosed in children under age 2 and is usually first recognized when parents report a white "glow" of the
pupil (leukocoria).
Light reflecting off the tumor will cause the pupil to appear white instead of displaying the usual red reflex
Parents may even accidentally visualize leukocoria when taking a photograph of the child using a flash.
Strabismus (misalignment of the eyes) is the second most common sign; visual impairment is a late sign indicative of
advanced disease.
Treatment depends on severity and may include radiation therapy or enucleation (removal of the eye) and fitting for
prosthesis.
Siblings should undergo regular ocular screening, as some forms of retinoblastoma are hereditary.

ABSENCE SEIZURE
Absence seizures occur in children age 4-12 and usually disappear at puberty.
Clinical manifestations include a brief loss of consciousness and an appearance
of inattention or daydreaming (the absence attack) without loss of postural body tone. However, slight loss of tone
may lead to dropping objects held in hands.
Most absence seizures last less than 10 seconds and often go unrecognized. Following an attack, behavior and
awareness return immediately to normal.
The child does not experience a postictal period but usually has no recollection that a seizure has occurred.
A child may have multiple absence seizures each day.
Treatment includes the use of anticonvulsant medication(s).
AUTISM SPECTRUM DISORDER

Children with autism spectrum disorder (ASD) often exhibit sensory processing problems; they may be hyper- or
hypo-sensitive to sounds, lights, movement, touch, taste, and smells. A calming environment with minimal
stimulation should be provided; a private room away from the nurses' station is the best location.
The nurse can also facilitate a calming environment by:

o Using a quiet or monotone voice when speaking to the child

o Using eye contact and gestures carefully
o Moving slowly
o Limiting visual clutter
o Maintaining minimal lighting
o Providing the child with a single object to focus on

Although the cause of autism spectrum disorder (ASD) is unknown, numerous studies indicate that it has a strong
genetic component.
The underlying genetic source is unknown in the majority of cases; however, researchers hypothesize that genetic
factors predispose to an autism phenotype and that genetic expression is influenced by environmental factors.

ELECTROENCEPHALOGRAM

An electroencephalogram (EEG) is a diagnostic procedure used to evaluate the presence of abnormal electrical
discharges in the brain, which may result in a seizure disorder.
The EEG can be done in a variety of ways, such as with the child asleep or awake with or without stimulation.
Teaching for the parent includes the following:

1. Hair should be washed to remove oils and hair care products, and accessories such as ribbons or barrettes should be
removed. Hair may need to be washed after the procedure to remove electrode gel.
2. Avoid caffeine, stimulants, and central nervous system depressants prior to the test.
3. The test is not painful, and no analgesia is required.

Food and liquids are not restricted prior to an EEG except for caffeinated beverages. Cocoa contains caffeine.
 RESPIROLOGY / UROLOGY
ASTHMA

Symptoms of an asthma exacerbation include wheezing, chest tightness, dyspnea, cough (may be nocturnal, dry, or
productive), and retractions.
A cough is often the earliest sign of an asthma exacerbation in children. Bronchospasm leads to CO2 trapping and
retention. The bronchospasm forces the client to work harder to exhale and the expiratory phase becomes prolonged.
The nurse needs to further assess this client to validate the severity of the exacerbation before implementing an
intervention.
By assessing the client's peak expiratory flow, the nurse can determine the severity of the symptoms. The nurse will
also need to assess the client's respiratory rate and lung sounds.
When an acute asthma exacerbation occurs, the child has rapid, labored respirations using accessory muscles. The
child often appears tired due to the ongoing effort. In the case of severe obstruction (from airway narrowing as a result
of bronchial constriction, airway swelling, and copious mucus), wheezing/breath sounds are not heard due to lack of
airflow. This "silent chest" is an ominous sign and an emergency priority. In this situation, the onset of wheezing will
be an improvement as it shows that air is now moving in the lungs.
Asthma is a chronic inflammatory disease of the lungs in genetically susceptible children. Frequent cough, especially
at night, is the warning signal that the child's airway is very sensitive to stimuli; it may be the only sign in "silent"
asthma. Common triggers include indoor contaminants (eg, tobacco smoke, pet dander, cockroach feces), outdoor
contaminants (eg, air pollution), and allergic disease (eg, hay fever, food allergies).
Treatment of an acute attack can include nebulized breathing treatment with a short-acting beta-agonist medication
such as albuterol, and oral or IV corticosteroids. Oxygen saturation is the best indicator of treatment effectiveness
as it reflects gas exchange.
SUBMERSION INJURY

Clients with morbidity related to immersion in water are described as having submersion injury. Even if an individual
was submerged for a very brief time, it is possible that water may have been aspirated, which can lead to respiratory
compromise.
Observation for at least 6 hours is recommended as the majority of significant respiratory problems will manifest in
this time period.
A marked decrease in respiratory rate or increased work of breathing may indicate respiratory fatigue, and
immediate intervention is needed. Impending respiratory failure is the immediate priority.

RESPIRATORY TRACT INFECTIONS

EPIGLOTTITIS

Epiglottitis should be considered first in a 3-7-year-old child with acute respiratory distress, toxic appearance (eg,
sitting up, leaning forward, drooling), stridor, and high-grade fever.
Tachycardia and tachypnea are also present. This is a pediatric emergency and should be managed with
endotracheal intubation; however, intubation of such clients is difficult, and preparation for possible tracheostomy is
also standard.
The complications of epiglottitis are serious and include sudden airway obstruction.

This is a classic description of epiglottitis (supraglottitis). It is an inflammation by bacteria of the tissues surrounding
the epiglottis, a long, narrow structure that closes off the glottis during swallowing.
Edema can develop rapidly (as quickly as a few minutes) and obstruct the airway by occluding the trachea. There has
been a 10-fold decrease in its incidence due to the widespread use of the Hib (Haemophilus influenzae type B)
vaccine.
The classic symptoms include a high-grade fever with toxic appearance, severe sore throat, and the 4 Ds dysphonia
(muffled voice), dysphagia (difficulty swallowing), drooling, and distressed respiratory effort.
 The tripod position opens the airway and helps air flow. The child should be allowed to assume a position of comfort
(usually sitting rather than lying down). The priority nursing response is to protect the airway.

ASPIRATION OF FOREIGN BODY

Aspiration of a foreign body occurs most often in the toddler age group. Swallowing of objects such as buttons,
small parts of toys, or food particles can be life-threatening and result in airway obstruction due to the small diameter
of the airway.
Manifestations include choking, gagging, cyanosis, and inability to speak when the object is lodged in the larynx.

HEMOLYTIC UREMIC SYNDROME

Hemolytic uremic syndrome (HUS) is a life-threatening complication of Escherichia coli diarrhea and results in red
cell hemolysis, low platelets, and acute kidney injury.
Hemolysis results in anemia, and low platelets manifest as petechiae or purpura. Therefore, the presence of
petechiae in this client could indicate underlying HUS and needs further assessment.

BRONCHIOLITIS

Bronchiolitis is a common viral illness of childhood that is usually caused by RSV. It typically begins with viral upper
respiratory symptoms (eg, rhinorrhea, congestion) that progress to lower respiratory tract symptoms such as
tachypnea, cough, and wheezing.
Bronchiolitis is a self-limited illness and supportive care is the mainstay of treatment. Most children can be managed
in the home environment.
Breastfeeding should be continued and additional fluids offered if there is a risk of dehydration due to frequent
coughing and vomiting
 Parents should be instructed to use saline nose drops and then suction the nares with a bulb syringe to remove
secretions prior to feedings and at bedtime

Wilms tumor (nephroblastoma) is a kidney tumor that usually occurs in children age <5.
Most often it involves only one kidney, and the prognosis is good if the tumor has not metastasized. Wilms tumor is
usually diagnosed after caregivers observe an unusual contour in the child's abdomen.
Once the diagnosis is suspected or confirmed, the abdomen should not be palpated, as this can disrupt the
encapsulated tumor. It is important to post the sign "DO NOT PALPATE ABDOMEN" at the bedside. It is also
essential that the child be handled carefully during bathing.

INHALER SPACER

The proper method of delivering a dose via MDI includes the following steps:

1. First shake MDI and attach it to the spacer.

2. Exhale completely to optimize inhalation of the medication.
3. Place lips tightly around the mouth piece.
4. Deliver a single puff of medication into spacer.
5. Take a slow, deep breath and hold it for 10 seconds to allow for effective medication distribution.
6. After the dose, rinse mouth with water to remove any left-over medication from oral mucous membranes. Spit out the water
to ensure no medication is swallowed.

NEPHROTIC SYNDROME

Nephrotic syndrome, an autoimmune disease, affects children age 2-7 and is characterized by increased
permeability of the glomerulus to proteins (eg, albumin, immunoglobulins, natural anticoagulants).
Loss of albumin in urine leads to hypoalbuminemia; this causes decreased plasma oncotic pressure, which allows
fluid to leak out of the vascular spaces.
Reduced plasma volume (hypovolemia) activates kidneys to retain salt and water (via the renin-angiotensin-
aldosterone system).
Clients experience generalized edema, weight gain, loss of appetite (from ascites), and decreased urine output.
The loss of immunoglobulins causes increased susceptibility to infection.
Caregivers should minimize the risk of infection during relapses (eg, limiting visitors)
Treatment typically includes:

o Corticosteroids and other immunosuppressants (eg, cyclosporine)

o Loss of appetite management (eg, making foods fun and attractive)
o Infection prevention (eg, limiting social interaction until the child is in remission)

A regular diet without added salt is prescribed to prevent edema while in remission. More stringent sodium restrictions
are necessary when symptoms are present.
Fluid restriction is needed in cases of edema or rapid weight gain.
There is a high risk for recurrence after recovery, and relapses may occur several times per year. The
parent/caregiver should test daily for proteinuria, weigh the child weekly, and keep a diary of results.
The most accurate indicator of fluid loss or gain in an acutely ill client is weight, as accurate intake and output and
assessment of insensible losses may be difficult
Nephrotic syndrome is a collection of symptoms resulting from various causes of glomerular injury. Below are the 4
classic manifestations of nephrotic syndrome:

o Massive proteinuria caused by increased glomerular permeability

o Hypoalbuminemia resulting from excess protein loss in the urine
o Edema specifically periorbital and peripheral edema and ascites; caused by low serum protein and albumin as fluid is pulled
into interstitial spaces and body cavities
o Hyperlipidemia related to increased compensatory protein and lipid production by the liver

Additional symptoms include decreased urine output, fatigue, pallor, and weight gain.
The most common cause of nephrotic syndrome in children is minimal change nephrotic syndrome, which is
generally considered idiopathic.
 Less common secondary causes may be related to systemic disease or infection, such as glomerulonephritis, drug
toxicity, or acquired immunodeficiency syndrome.

TRACHEOSTOMY

In the event of an accidental decannulation or another urgent need to change a tracheostomy tube, the most
important action is to quickly replace the tube as it is the client's only means to ventilate. Clients should always carry
two spare tracheostomy tubes, one the same size and one a size smaller. If the tube is not easily replaced or is
meeting resistance, the smaller tube should be used.
Changing a tracheostomy tube is a high-risk procedure that should be done only if respiratory distress is noted and
other interventions (eg, suctioning) have failed. Mucus plugs (ie, thickening and buildup of mucus due to dehydration)
are one of the most common causes of respiratory distress.
Humidification is crucial for clients with a tracheostomy as the upper airway, which provides natural humidity for
inhaled air, is bypassed. Humidification helps keep secretions thin and reduces formation of mucus plugs. The
humidifier should not be removed if the child develops more secretions as this is the intended effect.

ACUTE GLUMERULONEPHRITIS

Acute glomerulonephritis (AGN) in children is an immune complex disease most commonly induced by prior group A
beta-hemolytic streptococcal infection of the skin or throat.
A latent period of 2-3 weeks occurs between the streptococcal infection (eg, pharyngitis) and the symptoms of AGN.
Clinical manifestations include periorbital and facial/generalized edema, hypertension, and oliguria, which are
primarily due to fluid retention (decreased kidney filtration). The urine is tea-colored and cloudy due to the presence
of protein and blood.
Although most clients recover spontaneously within days, severe hypertension is an anticipated complication that
must be identified early. Monitoring and control of blood pressure are most important as they prevent further
progression of kidney injury and development of hypertensive encephalopathy or pulmonary edema.
 Hematuria is common with AGN. It is usually minimal and resolves spontaneously. Monitoring is important but not a
priority.
The most important measure of fluid status is a daily weight as it identifies fluid retention and response to treatment.
Monitoring intake and output is important but is not the priority action over hypertension monitoring and control.
Monitoring for edema is important but not the priority. Moderate sodium restriction is needed, especially if
hypertension and edema are present. Otherwise, avoiding high-sodium foods and having no added salt in the diet
may be adequate measures.

CYSTIC FIBROSIS
Cystic fibrosis (CF) is an inherited disorder (autosomal recessive) characterized by thickened secretions due to
impaired chloride and sodium channel regulation that causes exocrine gland dysfunction. Management of a client with
CF should primarily address potential complications related to the following body systems:
o Pulmonary: Alterations in respiratory secretions (ie, thick sputum) make it difficult to clear the airway and can result in
frequent respiratory infections and sinusitis. Frequent infections and inflammation damage lung tissue and may lead
to chronic hypoxemia.
o Gastrointestinal: Thickened secretions obstruct the release of pancreatic enzymes, causing malabsorption of fat-
soluble vitamins (eg, A, E, D, K) and other nutritional deficiencies. High-protein, high-calorie foods and supplemental
enzymes with meals are necessary.
o Reproductive: Thickened reproductive secretions (eg, seminal fluid, cervical mucus) or the absence of the vas deferens in
men contributes to CF-related infertility.
 Diabetes mellitus, not diabetes insipidus, is a potential complication for clients with CF due to pathologic pancreatic
changes (eg, fibrosis).
Due to impaired gastrointestinal absorption, weight loss and failure to thrive are more common and a greater concern
than obesity.

CHEST PHYSIOTHERAPY

Chest physiotherapy (CPT) describes techniques of airway clearance, which is an important component of
treatment for clients with cystic fibrosis that loosens and drains thick respiratory secretions. CPT can be performed
by percussing (ie, clapping) the chest with a cupped hand or by wearing an inflatable high-frequency chest wall
oscillation (HFCWO) vest. The HFCWO vest inflates and deflates rapidly, causing vibration over the chest wall and
mobilizing secretions into the large airways that the child can expectorate.
The HFCWO vest's rapid vibrations may induce nausea and vomiting in some clients. Therefore, the client
should avoid meals and snacks 1 hour before, during, or 2 hours following CPT to prevent gastrointestinal upset .
The nurse may suggest other more appropriate ways to ensure compliance with CPT, such as allowing the child to
watch a favorite television show or reading the child a story while wearing the HFCWO vest.
Nebulized bronchodilators are often given before or during CPT treatments to open the airways and mobilize
secretions.
CPT can be administered using various methods, including percussion (ie, clapping) of the chest wall with cupped
hands.
CPT should be performed at least twice a day, and more often if needed.HYPOSPADIAS
Hypospadias is a congenital defect in which the urethral opening is on the underside of the penis. Except in very
mild cases, the condition is typically corrected around age 6-12 months by surgically redirecting the urethra to the
penis tip.
Circumcision is delayed so the foreskin can be used to reconstruct the urethra. If not corrected, clients may have
toilet-training difficulties, more frequent urinary tract infections, and inability to achieve erections later in life.
Postoperatively, the client will have a catheter or stent to maintain patency while the new meatus heals.
Urinary output is an important indication of urethral patency. Fluids are encouraged, and the hourly output is
documented. Absence of urinary output for over an hour indicates that a kink or obstruction may have occurred and
requires immediate follow-up
 MATERNAL NEW BORN _ANTEPARTUM
2ND TRIMESTER

The second trimester (14 wk 0 d to 27 wk 6 d) is a time of positive changes for many pregnant clients (eg, improved
nausea) and when physical evidence of the pregnancy is noted (eg, increased fundal height).
The nurse should prepare clients for expected physical changes and discuss prevention of potential complications.

o Quickening, or a client's first perception of light fetal movement, is expected around 16-20 weeks gestation, depending on
parity
o Weight gain increases by approximately 1 lb (0.5 kg) per week if pre-pregnancy BMI has been normal
o Increasing intake of iron-rich foods (eg, meat, dried fruit) and continuing prenatal vitamins both help to
prevent anemia caused by increased fetal iron requirements after 20 weeks gestation
o Preterm labor warnings and signs of preeclampsia should be reviewed beginning at 20 weeks gestation.

The nurse should also discuss routine screening/diagnostic tests performed during the second trimester.
An ultrasound is performed around 18-20 weeks gestation to evaluate fetal anatomy and the placenta
Screening for gestational diabetes mellitus (GDM) occurs between 24-28 weeks gestation (ie, 1-hour glucose challenge test).
GDM is a complication of pregnancy caused by hormonally related maternal insulin resistance.
 ZIKA VIRUS

Zika virus is transmitted via mosquitoes, sexual contact, and infected bodily fluids.
Zika causes viral symptoms (eg, low-grade fever, arthralgias) and has been shown to
cause microcephaly, developmental dysfunction, and encephalitis in babies born to Zika-infected women.
Women who are attempting to conceive and those who are pregnant are encouraged to avoid travel to areas affected
by Zika until after birth
For clients currently living in a Zika-affected area, proper mosquito precautions (eg, insect repellant containing DEET)
and safe sex practices (eg, barrier methods) should be utilized, and routine Zika testing may be provided.
Zika virus can affect women in all stages of pregnancy.

SIGNS OF PREGNANCY
MAGNESIUM TOXICITY

IV magnesium sulfate is administered for seizure (eclampsia) prophylaxis in pregnant clients with pre-eclampsia.
A loading dose of 4-6 g of magnesium sulfate, followed by a maintenance dose of 1-2 g/hr, helps
achieve therapeutic magnesium levels of 4-7 mEq/L (2.0-3.5 mmol/L).
Magnesium toxicity may occur when magnesium levels are >7 mEq/L (3.5 mmol/L), which causes central nervous
system depression and blocks neuromuscular transmission
Absent or decreased deep tendon reflexes (DTRs) are the earliest sign of magnesium toxicity. DTRs, scored on a
scale of 0 to 4+, should be frequently assessed during magnesium sulfate infusion; normal findings are 2+
If toxicity is not recognized early (eg, decreasing DTRs), clients can progress to respiratory depression (<12
breaths/min), followed by cardiac arrest
Administration of calcium gluconate (antidote) is recommended in the event of cardiorespiratory compromise.
FUNDAL HEIGHT

The enlarging pregnant uterus should be just above the symphysis pubis at approximately 12 weeks gestation
At 16 weeks gestation, the fundus is roughly halfway between the symphysis pubis and the umbilicus.
It reaches the umbilicus at 20-22 weeks gestation and approaches the xiphoid process around 36
weeks gestation.
At 38-40 weeks, the fetus engages into the maternal pelvis and the fundal height drops.
After 20 weeks gestation, the fundal height, measured in centimeters from the symphysis pubis to the top of the fundus,
correlates closely to the weeks of gestation.
PREECLAMPSIA

Preeclampsia is a systemic disease characterized by hypertension and proteinuria after the 20th gestational week
with unknown etiology.
Eclampsia is the onset of convulsions or seizures that cannot be attributed to other causes in a woman with
preeclampsia.
Delivery is the only cure for preeclampsia-eclampsia syndrome.
Magnesium sulfate is a central nervous system depressant used to prevent/control seizure activity in
preeclampsia/eclampsia clients. During administration, the nurse should assess vital signs, intake and output, and
monitor for signs of magnesium toxicity (eg, decreased deep-tendon reflexes, respiratory depression, decreased urine
output).
A therapeutic magnesium level of 4-7 mEq/L (2.0-3.5 mmol/L) is necessary to prevent seizures in a preeclamptic
client.
Hypertension is a sign of preeclampsia. Hydralazine (Apresoline), methyldopa (Aldomet), or labetalol (Trandate) is
used to lower blood pressure (BP) if needed (usually considered when BP is >160/110 mm Hg).
Proteinuria is a symptom of preeclampsia. Control of hypertension and delivery will reduce the protein level.
Magnesium sulfate is not prescribed to decrease proteinuria.
Tocolytic drugs (eg, terbutaline, magnesium sulfate, indomethacin, nifedipine) are used to suppress uterine
contractions in preterm labor, allowing pregnancy to be prolonged for 2-7 days so that corticosteroid administration can
improve fetal lung maturity.

PRETERM BIRTH
Preterm birth is defined as birth before 37 weeks and 0 days gestation.
Infection (eg, periodontal disease, urinary tract infection) is strongly associated with preterm labor, particularly when
untreated
Infection causes release of inflammatory mediators such as prostaglandins, which are uterotonic (ie, promote
contractions) and contribute to cervical softening.
 Some risk factors for preterm birth may be modifiable with lifestyle changes and early treatment. Risk factors should
be addressed at the initial and each subsequent prenatal visit to allow for early identification and management.
Some risk factors for preterm birth include:

o History of spontaneous preterm birth in a previous pregnancy (single largest independent risk factor)
o Previous cervical surgery, such as a cone biopsy (weakens cervical support)
o Tobacco and/or illicit drug use
o Maternal ages <17 and >35 are associated with increased risk for preterm birth.
Maternal undernutrition can increase the risk for preterm birth and low infant birth weight. However, a balanced
vegetarian diet with adequate pregnancy weight gain does not increase preterm birth risk.
Non-Hispanic black women have the highest rates of preterm labor and birth.

DIETARY SOURCES OF FOLIC ACID

Folic acid, or folate, is a water-soluble, B-complex vitamin necessary for red blood cell production. Pregnant women
and those attempting pregnancy need a minimum of 400 mcg of folic acid per day to decrease the chance of
fetal neural tube defects (eg, spina bifida, anencephaly).
Most prenatal vitamins contain 400-800 mcg of folic acid; additional folic acid can come from the diet. Leafy green
vegetables are the best dietary sources of folic acid. However, other appropriate food choices include cooked beans,
rice, fortified cereals, and peanut butter, which provide at least 40 mcg folic acid per serving
RUBELLA TITER

In a pregnant client, a serum sample is collected at the first prenatal visit to determine immunity to the rubella virus.
A positive immune response indicates immunity to the rubella virus, attributed to either past infection or vaccination. A
negative, or nonimmune, response indicates that the client is susceptible to rubella disease and requires
vaccination.
An equivocal response indicates partial immunity to rubella and is treated clinically the same as nonimmune status.
Measles-mumps-rubella (MMR) is a live attenuated vaccine.
Live vaccines are contraindicated in pregnancy due to the theoretical risk of contracting the disease from the
vaccine. Maternal rubella infection can be teratogenic for the fetus.
The fetal effects of congenital rubella syndrome include congenital cataracts, deafness, heart defects (patent ductus
arteriosus), and cerebral palsy. The best time to administer an MMR vaccine to a nonimmune client is in the
postpartum period just prior to discharge. The MMR vaccine can safely be administered to breastfeeding clients.
MMR vaccine is contraindicated in pregnancy. Also, pregnancy should be avoided for at least 1 3 months after the
immunization is given.
This client is rubella nonimmune and is susceptible to rubella if exposed. The vaccine should be offered in the
postpartum period.

FETAL MOVEMENTS
Fetal movement is a sign of fetal health and indicates an intact fetal central nervous system. Fetal movement may
occur numerous times per hour during the last trimester of pregnancy, although the client may not perceive every
movement.
Multiple factors (eg, maternal substance abuse, medications, fasting, fetal sleep) can affect fetal movement. However,
fetal movements should not decrease as the fetus increases in size.
Decreased fetal movement is a potential warning sign of fetal compromise (ie, impaired oxygenation), which may
precede fetal death. The nurse prioritizes assessment of client reports of decreased fetal movement to evaluate fetal
well-being (eg, nonstress test).
 Leg cramps commonly occur in the third trimester, especially at night, due to the weight of the gravid uterus applying
pressure to nerves affecting calf muscles. Home interventions include stretching legs, massaging calves, and
increasing fluid intake.
Dependent edema in the lower extremities is common in the third trimester due to decreased venous return (gravid
uterus pressure on vena cava), especially with prolonged sitting/standing. This is not a priority over decreased fetal
movement.
As the uterus rises in the third trimester, the diaphragm is prevented from allowing full lung expansion, causing
dyspnea, especially with exertion.

OLIGOHYDRAMNIOS

Amniotic fluid is produced by the fetal kidney and serves 2 major purposes - to prevent cord compression and promote
lung development.
Oligohydramnios is a condition characterized by low amniotic fluid volume. This can occur due to fetal kidney
anomalies (eg, renal agenesis or urine flow obstruction) or fluid leaking through the vagina (eg, undiagnosed ruptured
membranes). Fluid volume also declines gradually after 41 weeks. Small uterine size for gestational age or a fetal
outline that is easily palpated through the maternal abdomen should raise suspicion for oligohydramnios. Ultrasound
confirms the diagnosis.
Major complications of oligohydramnios are:
 1. Pulmonary hypoplasia - due to the lack of normal alveolar distension by aspirated amniotic fluid. Therefore, additional
neonatal personnel should attend the birth in anticipation of possible resuscitation
2. Umbilical cord compression - continuous (not intermittent) fetal monitoring should be applied to monitor for variable
decelerations

Operative vaginal birth (ie, use of forceps or vacuum) may be indicated due to prolonged second-stage labor or fetal
distress. Oligohydramnios does not increase the likelihood of operative vaginal birth.
HELLP SYNDROME

Right upper quadrant (RUQ) or epigastric pain can be an indicator of HELLP syndrome, a severe form of
preeclampsia.
HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is often mistaken for viral
gastroenteritis due to its variable and nonspecific presentation.
Misdiagnosis may lead to severe complications (eg, placental abruption, liver failure, stroke) and/or maternal/fetal
death.
Clients may have RUQ pain, nausea, vomiting, and malaise. Headache, visual changes, proteinuria, and
hypertension may or may not be present.

AORTOCAVAL COMPRESSION SYNDROME

During stabilization of a pregnant client after trauma (eg, motor vehicle collision, fall), uterine displacement is the first
step to address supine hypotension (due to aortocaval compression and decreased venous return to the heart) and
promote blood circulation to the fetus.
The client should be tilted laterally while strapped on the backboard to promote venous return and protect the client
from further potential spinal injury
Manifestations of aortocaval compression (eg, hypotension, pallor, dizziness) may mimic those of other complications
of trauma. It is therefore critical to reassess blood pressure after uterine displacement to identify persistent
hypotension, which may indicate hemorrhage caused by trauma (eg, placental abruption).
An IV fluid bolus of isotonic fluids (eg, lactated Ringer solution) to correct hypotension is appropriate if position
changes do not relieve symptoms or hemorrhage is suspected. Client positioning should be considered first.
 Naegele's rule, which is the last menstrual period minus 3 months plus 7 days, can be used to calculate a client's
expected date of delivery. The accuracy of this method may be influenced by the regularity and length of the client's
menstrual cycle. September 7 minus 3 months is June 7, plus 7 days is June 14
Detection of a fetal heart rate is possible using a Doppler by 10-12 weeks gestation
Urinary frequency, a presumptive sign of pregnancy common in the first trimester, occurs primarily due to hormonal
changes and anatomical changes in the renal system
Quickening, the awareness of fetal movements, occurs around 18-20 weeks gestation in primigravidas and at 14-16
weeks in multigravidas.

NITRAZINE PH TEST

Testing vaginal secretions with a nitrazine pH test strip can help differentiate between amniotic fluid, which
is alkaline, and normal vaginal fluids or urine, which are acidic.
A yellow, olive, or green color suggests that amniotic membranes are intact.
A bluish color suggests probable rupture of membranes (ROM). However, the presence of blood or semen may
result in a false positive, as serum and prostatic fluid are alkaline.
A client history of recent sexual intercourse should alert the nurse to notify the health care provider that nitrazine
results may be falsely positive due to the presence of semen in the vagina
GTPAL SYSTEM

The GTPAL system is a shorthand system of documenting a client's obstetric history. Under this system, twins,
triplets, or other multiple births count as one in the term (T) or preterm (P) category but are counted separately (as 2,
3, or more) in the living child (L) category.
A current pregnancy (not yet delivered), as in this client, counts in the gravida (G) category as this category
includes all pregnancies, past and present.
ECTOPIC PREGNANCY

Ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity. The majority of ectopic
pregnancies occur in the fallopian tubes.
Risk factors include recurrent sexually transmitted infections, tubal damage or scarring, intrauterine devices, and
previous tubal surgeries (eg, tubal ligation for sterilization).
Clinical manifestations are lower-quadrant abdominal pain on one side, mild to moderate vaginal bleeding, and missed
or delayed menses.
Signs of subsequent hypovolemic (hemorrhagic) shock from ruptured ectopic pregnancy include dizziness,
hypotension, and tachycardia.
Free intraperitoneal blood pooling under the diaphragm can cause referred shoulder pain.
Peritoneal signs (eg, tenderness, rigidity, low-grade fever) may develop subsequently.
PLACENTA PREVIA

Placenta previa is an abnormal implantation of the placenta resulting in partial or complete covering of the cervical os
(opening). The condition is diagnosed by ultrasound.
In clients reporting painless vaginal bleeding after 20 weeks gestation, placenta previa should be suspected.
Placenta previa found early in pregnancy may resolve by the third trimester, but women with persistent placenta previa
or hemorrhage require cesarean birth.
A type and screen to determine blood type and Rh status is appropriate due to the potential for excessive blood loss
and need for blood transfusion
Fetal well-being is assessed via continuous electronic fetal monitoring to help determine appropriate timing for
birth
Large-bore IV access is established in anticipation of fluid resuscitation and administration of blood products
The client should also be monitored frequently for any changes in bleeding via pad counts
 Digital vaginal examinations are contraindicated in the presence of vaginal bleeding of unknown origin. When
placenta previa is present, manual manipulation of the cervix can damage placental blood vessels, causing
subsequent bleeding that can progress to hemorrhage. Clients with placenta previa are on pelvic rest (ie, no
intercourse, nothing per vagina).
Because of the increased risk of hemorrhage if contractions result in cervical change, a cesarean birth is planned for
after 36 weeks gestation and prior to the onset of labor.
A stable client with no active bleeding and reassuring fetal status may be discharged home and managed in an
outpatient setting. However, the client must be closely monitored and instructed to return to the hospital immediately if
bleeding recurs.
As pregnancy progresses, the placenta grows in size and can potentially migrate away from the cervical opening,
resulting in complete resolution of the previa. Therefore, an additional ultrasound is usually performed around 36
weeks gestation to assess placental location

ABRUPTIO PLACENTA

Placental abruption is a possible complication of preeclampsia that can be life-threatening to mother and baby.
It occurs when the placenta tears away from the wall of the uterus due to stress, causing significant bleeding to the
mother and depriving the baby of oxygen.
Bleeding can be concealed inside the uterus. This may require immediate delivery of the baby.

INTRAHEPATIC CHOLESTASIS

Intrahepatic cholestasis of pregnancy is a liver disorder exclusive to pregnancy that manifests with intense,
generalized itching but no rash. Itching often involves the hands and feet and worsens at night. This
condition increases the risk of intrauterine fetal demise and requires priority assessment by the health care
provider
Management includes laboratory testing (eg, elevated bile acids), fetal surveillance (eg, biophysical profile, nonstress
test), medication (ie, ursodeoxycholic acid), and labor induction around 37 weeks gestation.
Intrahepatic cholestasis of pregnancy begins to resolve after birth.
ANTEPARTUM BLEEDING

Placental abruption occurs when the placenta separates prematurely from the uterine wall,
causing hemorrhage beneath the placenta.
Abruptions are classified as partial, complete, or marginal and may be overt (visible vaginal bleeding) or concealed
(bleeding behind placenta). Risk factors include abdominal trauma, hypertension, cocaine use, history of previous
abruption, and preterm premature rupture of membranes.
Symptoms and their severity depend on extent of abruption and include abdominal and/or back pain, uterine
contractions, uterine rigidity, and dark red vaginal bleeding. Tachysystole (ie, excessive uterine contractions),
with or without fetal distress, is often present, and continuous fetal monitoring is necessary
A type and crossmatch should be drawn as treatment may include blood transfusion
In severe cases, emergent cesarean birth is indicated. Although blood loss is maternal, the loss of functional placental
surface area can result in decreased placental perfusion, impaired fetal oxygenation, and fetal death.
Maternal vital signs should be assessed frequently for signs of shock (eg, tachycardia, hypotension) as client
condition can decline rapidly.
 Abruption may require rapid volume replacement with IV fluid and blood products, requiring large-bore IV access.
Peripheral IV access with a 16- or 18-gauge catheter should be initiated.

TOXOPLASMOSIS

Toxoplasmosis is a parasitic infection caused by Toxoplasma gondii, which may be acquired from exposure to
infected cat feces or ingestion of undercooked meat or soil-contaminated fruits/vegetables.
Pregnant clients who contract toxoplasmosis can transfer the infection to the fetus and potentially cause serious fetal
harm (eg, stillbirth, malformations, blindness, mental disability).
Pregnant clients should be advised to take precautions when gardening and thoroughly wash all produce to decrease
exposure risk.

HEARTBURN

Pyrosis, or heartburn, is common during pregnancy due to an increase in the hormone progesterone and uterine
enlargement that displaces the stomach.
Progesterone relaxes smooth muscles and causes esophageal sphincter relaxation.
Gastric contents are then regurgitated, usually causing a burning sensation behind the sternum.
The nurse should educate the client about lifestyle changes to reduce heartburn such as:

o Keeping the head of the bed elevated using pillows

o Sitting upright after meals
o Eating small, frequent meals
o Avoiding tight-fitting clothing
o Eliminating common dietary triggers (eg, fried/fatty foods, caffeine, citrus, chocolate, spicy foods, tomatoes, carbonated
drinks, peppermint)

Minimizing gastric distension by drinking minimal amounts of fluid while eating and by not overeating helps to reduce
gastric acid production and subsequent reflux. The client should be instructed to cluster fluid intake between meals
instead.

CERVICAL CERCLAGE
 A cervical cerclage is placed to prevent preterm delivery, usually in clients with histories of second trimester loss or
premature birth.
A heavy suture is placed transvaginally or transabdominally to keep the internal cervical os closed.
Placement occurs at 12 14 weeks gestation for clients with a history of cervical insufficiency (ie, painless, premature
cervical dilation and miscarriage or preterm delivery) or up to 23 weeks gestation if signs of cervical insufficiency (eg,
short cervix) are noted.
Discharge instructions include activity restriction and recognition of signs of preterm labor (eg, low back aches,
contractions, pelvic pressure) and rupture of membranes
Bed rest is usually recommended for a few days after the procedure. Long-term bed rest is individualized but
uncommon and increases the risk for complications (eg, deep vein thrombosis). Pelvic rest (eg, avoiding sexual
intercourse) is determined by the health care provider.
Mild abdominal cramping following cerclage placement is common; however, regular contractions, pelvic pressure,
and low back aches may indicate preterm labor.
The cerclage remains in place until 36 37 weeks gestation. Early removal is indicated by rupture of membranes (to
prevent infection) or preterm labor (to prevent damage to the cervix as it dilates).

GESTATIONAL DIABETES MELLITUS

Gestational diabetes mellitus (GDM) is diagnosed in clients who have impaired blood glucose (BG) regulation due to
physiologic pregnancy changes (eg, rising BG levels, insulin resistance).
GDM screening occurs at 24-28 weeks gestation. If GDM is diagnosed, management includes nutritional counseling
and, if needed, pharmacologic therapy.
Two-step GDM testing begins with a screening test: the 1-hour glucose challenge test (GCT). The 1-hour GCT can
be performed any time of day and does not require fasting
If the client's serum BG is <140 mg/dL (7.8 mmol/L), GDM is unlikely, and the client requires no further testing.
equires a 2- or 3-hour glucose tolerance test (GTT) to diagnose
GDM.
HYPEREMESIS GRAVIDARUM

Hyperemesis gravidarum (HG) is characterized by severe, persistent nausea and vomiting during pregnancy that
usually leads to considerable weight loss (i mbalances (eg,
hypokalemia), and nutritional deficiencies.
Clients with HG may require hospitalization for IV fluid replacement and antiemetic therapy.
 Routine laboratory assessment for HG includes urinalysis dipstick testing to monitor the client's health status.
Expected findings include an elevated urine specific gravity and ketonuria
Urine specific gravity increases when urine is concentrated due to dehydration, and ketones are a by-product of
the fat breakdown that occurs in starvation states.

DIET
During pregnancy, it is important for the client to consume a balanced diet with appropriate nutrients, vitamins, and
minerals.
Foods containing folic acid, protein, whole grains, iron, and omega-3 fatty acids are especially important.
Due to the risk for bacterial contamination (eg, Listeria, toxoplasmosis), pregnant clients should avoid consuming
unpasteurized milk products, unwashed fruits and vegetables, deli meat and hot dogs (unless heated until steaming
hot), and raw fish/meat.
They should also avoid intake of fish high in mercury (eg, shark, swordfish, king mackerel, tilefish).

HIV IN PREGNANCY

Perinatal transmission of HIV infection can occur from mother to baby anytime during the antepartum, intrapartum,
or postpartum periods.
Maternal antiretroviral therapy (ART) during pregnancy is imperative for decreasing viral load (amount of virus
detectable in maternal serum) and decreasing risk of transmission to the fetus.
HIV can be transmitted to the newborn via breast milk. Breastfeeding is contraindicated for HIV-positive mothers in
developed countries, where safe alternatives (eg, commercial formula) are available.
In addition to routine newborn care, infants born to HIV-positive clients should receive ART at birth and for at least 4-6
weeks after birth to reduce the chance of developing HIV infection. Infants are tested for HIV infection at birth and
again at age 1 and 4 months. Identification of HIV-negative status requires 2 consec
 Pregnant clients who are HIV positive are immunocompromised and at increased risk for other infections. They should
receive all inactivated vaccines that are recommended for the general pregnant population, such as tetanus-
diphtheria-pertussis and intramuscular influenza. Live vaccines (eg, measles-mumps-rubella) are not given during
pregnancy.

GENITAL HERPES SIMPLEX VIRUS

Painful genital lesions can be indicative of an outbreak of genital herpes simplex virus (HSV) and are a priority
assessment finding to report to the health care provider.
Herpes in pregnant women can be transmitted to the infant in utero (congenital HSV), perinatally, or postnatally as a
result of direct contact with virus particles shed from the infected vulva, vagina, cervix, or perineum.
Neonatal HSV infection has serious morbidity (eg, permanent neurologic sequelae) and mortality.
Immediate antiviral therapy (eg, acyclovir) should be initiated to treat the active infection.
Vaginal birth is not recommended in the presence of active lesions; cesarean birth helps reduce the risk of
transmission to the newborn

PRECONCEPTION COUNSELING

Preconception counseling assesses for pregnancy risk factors and implements appropriate interventions to promote
a healthy pregnancy. Some behaviors the client may begin independently include eating a nutritious diet; exercising;
abstaining from alcohol, tobacco, and illicit drugs; and taking folic acid supplements.
Obesity (BMI >30 kg/m2) during pregnancy is associated with an increased risk for fetal/maternal complications (eg,
gestational diabetes, hypertension, cesarean birth). Achieving a normal BMI (18.5-24.9 kg/m2) is optimal
No amount of alcohol is considered safe in pregnancy; complete abstinence from alcohol is recommended to
avoid fetal alcohol syndrome. Smoking cessation is encouraged due to its association with fetal growth restriction;
illicit drugs may also cause fetal harm
Folic acid supplementation of at least 400 mcg per day for 3 months before pregnancy is recommended to reduce
the incidence of neural tube defects. Neural tube development begins around the third week following conception,
before a woman may realize that she is pregnant.
 Finally, clients should visit their health care provider to discuss pregnancy's effect on certain health conditions (eg,
asthma, diabetes) and check rubella immunity. Rubella vaccination should be given if the client is nonimmune, and
pregnancy should be avoided for at least 4 weeks after vaccination. Regular visits with a dentist can help prevent
periodontal disease, which is associated with poor pregnancy outcomes (eg, preterm birth, low birth weight)
SYPHILLIS IN PREGNANCY
Sexually transmitted infection, teratogenic & readily crosses the placenta. It effects fetal development, causing fetal
death/hemolytic anemia/ preterm labor/birth, fetal hepatomegaly/jaundice/ low platelets/ long bone abnormalities & failure
to thrive. The only tx is regardless of phase, whether its primary, secondary or
penicillin desensitization ine is an
alternative tx for non-pregnant women with syphilis and is contraindicated in pregnancy bc impairs bone mineralization
permanent teeth discoloration.

INDIRECT COOMBS TEST

During pregnancy, the mother and fetus have separate blood supply mechanisms. However, disruption of this
separation can occur at delivery or when trauma results in fetomaternal hemorrhage (eg, placental abruption after a
motor vehicle collision).
If an Rh-negative mother (eg, O negative blood type) is exposed to Rh-positive fetal blood (if the father is Rh positive),
the pregnant client develops antibodies to the Rh antigen (ie, Rh sensitization), placing the current fetus and all
future pregnancies at risk for serious complications (eg, hemolytic anemia).
An indirect Coombs test is performed to screen for Rh sensitization any time hemorrhage secondary to placental
abruption is suspected (eg, maternal trauma)
Rh immune globulin (eg, RhoGAM) is administered to all Rh-negative pregnant clients at 28 weeks gestation and
within 72 hours postpartum, as well as after any maternal trauma, to prevent the development of permanent Rh
antibodies. RhoGAM is not effective once sensitization has occurred.

CONSTIPATION
Constipation is a common discomfort of pregnancy and is due to an increase in the hormone progesterone, which
causes decreased gastric motility. Ferrous sulfate (iron) supplementation may also cause constipation.
Interventions to prevent or treat constipation include:

1. High-fiber diet: High amounts of fruits, vegetables, breakfast cereals, whole-grain bread, prunes
2. High fluid intake: 10-12 cups of fluid daily
3. Regular exercise: Moderate-intensity exercise (eg, walking, swimming, aerobics)
4. Bulk-forming fiber supplements: Psyllium, methylcellulose, wheat dextrin

HYPERTENSIVE DISORDERS OF PREGNANCY

 Gestational hypertension is new-onset high blood pressure ( ) that occurs after 20 weeks
gestation without proteinuria.
The development of proteinuria with hypertension indicates preeclampsia, which may manifest with symptoms such
as headache, visual disturbances, and facial swelling.
This client is exhibiting symptoms of preeclampsia and should be assessed first
Complications of preeclampsia may include thrombocytopenia, liver dysfunction, and renal insufficiency.
Clients with preeclampsia must be monitored closely for sudden worsening, which can lead to serious complications,
including eclampsia and/or HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets).

PICA

Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally
valuable or edible.
Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to
pregnancy, many women only have pica when they are pregnant.
Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption.
However, the exact relationship between pica and anemia is not fully understood.
The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia.

URINARY TRACT INFECTION

Urinary tract infections (UTIs) are common during pregnancy due to physiologic renal system changes (eg, ureter
dilation, urine stasis). Most UTIs are confined to the lower urinary tract (ie, cystitis, or bladder infection).
Symptoms include urinary frequency, dysuria, urgency, foul-smelling urine, and a sensation of bladder fullness.
Diagnostic testing includes urinalysis and urine culture.
Oral antibiotics are required to appropriately treat cystitis.
If cystitis goes unreported or untreated, the infection may ascend to the kidneys and cause pyelonephritis.
 During pregnancy, pyelonephritis requires IV antibiotics and hospitalization because of the increased risk of preterm
labor. Therefore, priority assessment is to rule out indicators of pyelonephritis (eg, flank pain, fever) in clients who
report UTI symptoms to ensure appropriate diagnosis and treatment
LABORATORY VALUES

Pregnant women experience a 40%-45% increase in total blood volume during pregnancy to meet the increased
oxygen demand and nutritional needs of the growing fetus and maternal tissues.
Because the increase in plasma volume is greater than the increase in red blood cells, a hemodiluted state
called physiologic anemia of pregnancy occurs, and is reflected in lower hemoglobin and hematocrit values.
It is also normal for the white blood cell count to increase during pregnancy; counts can be as high as
15,000/mm3 (15.0 x 109/L).

MORNING SICKNESS

Morning sickness, characterized by nausea with or without vomiting, is a common problem during the first
trimester of pregnancy. Although it is referred to as "morning" sickness, it can happen anytime throughout the day. It
is thought to be due to rising hormone levels (ie, estrogen, progesterone, human chorionic gonadotropin).
Initial interventions, focusing on diet management and triggering avoidance, include:
 o Eating several small meals during the day (ie, high in protein or carbohydrates and low in fat)
o Drinking fluids (preferably clear, cold, carbonated beverages) between, rather than with, meals
o Having a high-protein snack before bedtime and on awakening (Option 3)
o Consuming foods/drinks with ginger (eg, ginger tea, ginger lollipops, ginger chews)
o Consuming foods high in vitamin B6 (eg, nuts, seeds, legumes.

DRUG RISK CATEGORY

Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen, indomethacin, naproxen) inhibit prostaglandin
synthesis and can be taken to decrease pain and inflammation or to reduce fever.
NSAIDs are pregnancy category C in the first and second trimesters and pregnancy category D in the third
trimester.
NSAIDs must be avoided during the third trimester due to the risk of causing premature closure of the ductus
arteriosus in the fetus
During the first and second trimesters, NSAIDs should be taken only if benefits outweigh risks and under the
supervision of a health care provider (HCP).

SUPINE HYPOTENSIVE SYNDROME

Supine hypotensive syndrome occurs when the weight of the abdominal contents compresses the vena
cava causing decreased venous return to the heart. This results in low cardiac output (maternal hypotension)
and reflex tachycardia.
Manifestations include dizziness, pallor, and cold and clammy skin. The client should be immediately repositioned
onto the right or left side until the symptoms subside.
Prevention of this condition includes using a wedge under the client's hip while in a supine position.

FETAL SEX

By the end of 12 weeks gestation, fetal sex can often be determined by the appearance of the external genitalia on
ultrasound, depending on the quality of the image.
By the end of 8 weeks gestation, all major organ systems are in place, and many are functioning in a simple way. By 7
weeks gestation, fetal heart tones can be detected.
 Clients typically begin feeling fetal movements in the second trimester at around 16-20 weeks gestation. Parous (have
been pregnant before) clients can notice this earlier than the nulliparous (first pregnancy).

TRAVEL DURING PREGNANCY

Travel during pregnancy requires special modifications and precautions to ensure client safety and reduce the
potential for injury and pregnancy complications.
Clients should get their health care provider's approval prior to traveling long distances.
Domestic air travel is usually allowed for healthy clients at <36 weeks gestation. When reinforcing education about
travel safety, the nurse should instruct the client to:

o carry an updated copy of the prenatal record in case emergency medical care is necessary during travel
o increase fluid intake to prevent dehydration and reduce the risk of thrombus formation or preterm contractions
o secure the lap belt under the gravid abdomen and across the hips and, if available, place shoulder belts lateral to the
uterus and between the breasts to prevent complications from abdominal trauma (eg, placental abruption)
o wear compression stockings and unrestrictive clothing to improve venous return and decrease the risk of thrombus
formation
o avoid traveling to Zika- or malaria-prevalent areas and remote areas with poor medical care or lack of sanitation.

Pregnancy is a hypercoagulable state that augments the risk of thrombus formation. The nurse should encourage
pregnant clients who embark on long travel to walk every 1-2 hours to decrease the risk of thrombus formation.
 MATERNAL NEW BORN > LABOR AND DELIVERY
LABOR

True labor is defined as contractions that cause progressive cervical change over time.
Probable signs of labor are identified by assessing the timing and intensity of contractions, the success of comfort
measures in relieving the pain, and the location of the pain
Consistent, intense contractions that get stronger and closer together (more frequent over time) and are associated
with lower back discomfort that radiates to the abdomen are indicative of true labor
If a woman is experiencing Braxton Hicks contractions (ie, "false labor"), the nurse should provide encouragement and
education about signs of labor and suggest comfort measures.
Comfort measures relieve maternal anxiety, increase coping, and encourage normal progression of labor. The
nurse may suggest walking, taking a warm bath, resting in a lateral position, having a snack, staying hydrated, and
voiding often.

FETAL POSITION
Fetal occiput posterior (OP) position is a common fetal malposition that occurs when the fetal occiput rotates and
faces the mother's posterior or sacrum.
OP fetal position can cause increased back pain or "back labor." Many fetuses in OP position during early labor
spontaneously rotate to occiput anterior position (occiput facing the mother's anterior or pubis).
The nurse or labor support person can apply counterpressure to the client's sacrum during contractions to help
alleviate back pain associated with OP fetal positioning. Firm, continuous pressure is applied with a closed fist, heel of
the hand, or other firm object (eg, tennis ball, back massager)
Clients should be encouraged to change positions frequently (every 30-60 minutes) during labor to promote fetal
rotation/descent and increase maternal comfort. Remaining in bed during early labor increases the risk for persistent
fetal malposition and slows labor progression.
Left lateral positioning is better for uteroplacental blood flow and fetal oxygenation than supine positioning when the
client is resting in bed. However, it may not alleviate the client's back pain.

A laboring client may experience lower back pain with contractions, or "back labor," when the fetus is in the
right occiput posterior (ROP) position. This variation of vertex presentation causes the fetal occiput to exert added
pressure on the woman's sacrum during contractions. Positioning the woman on her hands and knees often helps
decrease back pain and facilitates fetal rotation into an anterior position.
This fetus is in the right occiput anterior (ROA) position, which is optimal for birth as it allows for rotation of the fetal
head through the birth canal.

This fetus is in the right occiput transverse (ROT) position. When the fetus remains in the OP or OT position, labor is
often prolonged. Most fetuses in these positions will rotate spontaneously to the OA position during labor. Manual
rotation may be attempted with persistent OP or OT position.
Breech presentation, with the fetal feet or buttocks presenting first in the maternal pelvis, does not cause back labor.
Potential complications from breech presentation include ineffective dilation of the cervix and increased risk of
umbilical cord prolapse.
FETAL HEART RATE TRACING
A sinusoidal fetal heart rate (FHR) pattern is characterized by repetitive, wave-like fluctuations with absent variability
and no response to contractions; it is usually an ominous finding requiring immediate intervention
A sinusoidal pattern (ie, a Category III FHR tracing) is suggestive of severe fetal anemia potentially due to
fetomaternal hemorrhage (eg, abdominal trauma) or some fetal infections (eg, parvovirus B19).
If a sinusoidal pattern is noted, especially after abdominal trauma (eg, fall, motor vehicle collision, injury), the nurse
should notify the health care provider immediately, initiate intrauterine resuscitation (eg, positioning, IV fluids, oxygen),
and anticipate an expedited birth.

Fetal tachycardia (ie, FHR baseline >160 beats/min) may be caused by fetal anemia, maternal fever, or infection but is
not more concerning than a sinusoidal pattern, particularly in this case because FHR accelerations and moderate
variability are present.
Early decelerations seconds from onset to
nadir). Early decelerations indicate fetal head compression and are a normal finding.

Variable decelerations are abrupt decreases in the FHR (ie, <30 seconds from onset to nadir) and at least 15 beats/min
econds to <2 minutes.
Variables are usually correctable with maternal position change to relieve umbilical cord compression. If
recurrent/prolonged, variable decelerations can impair fetal oxygenation over time.
Amnioinfusion is administered through an intrauterine pressure catheter to relieve variable decelerations

Late decelerations occur after the onset of a uterine contraction and continue beyond its end. The lowest point
(nadir) occurs near the end of the contraction before the fetal heart rate gradually returns to baseline.
Late decelerations occur when fetal oxygenation is compromised (eg, uteroplacental insufficiency, uterine
tachysystole, hypotension). Immediate steps to correct late decelerations include:

o Stopping oxytocin if it is being administered

o Repositioning the client to the left/right side
o Administering oxygen by face mask
o Administering an IV bolus of isotonic fluid (eg, lactated Ringer solution, 0.9% saline) as needed

If late decelerations persist or variability is absent or minimal, the nurse should prepare for emergency delivery.
This fetal heart rate strip shows 2 accelerations and moderate variability.
An acceleration of the fetal heart rate of at least 15/min above the baseline lasting for at least 15 seconds is a
reassuring finding most often indicating fetal movement.
Moderate variability refers to fluctuations in the baseline heart rate between 6-25/min.
It is considered normal and indicates that the fetus is healthy and has adequate oxygenation and normal function of
the autonomic nervous system. No immediate intervention is needed.

Umbilical cord prolapse may occur after rupture of membranes if the presenting fetal part is not firmly applied to the
cervix.
Cord compression caused by a prolapsed cord will produce abrupt fetal heart rate deceleration, fetal bradycardia, and
disruption of fetal oxygen supply. The priority action is to inspect the vaginal area and perform a sterile vaginal
examination to assess for a prolapsed cord
 If a prolapsed cord is visualized or palpated, the nurse should then manually elevate the presenting fetal part off the
umbilical cord, leave the hand in place, and call for help.

UTERINE ATONY

After delivery of the placenta, the uterus begins the process of involution. The uterus should be firmly contracted,
midline, and at or slightly below the umbilicus.
A boggy uterus indicates uterine atony, a state in which the uterus fails to contract adequately and compress vessels
at the placental detachment site. This may lead to excessive blood loss and clots.
 The initial nursing action for uterine atony with a midline fundus is fundal massage, which stimulates contraction of
the uterine smooth muscle
If the uterus becomes firm with massage, the nurse should continue to monitor uterine tone, position, and lochia at
least every 15 minutes in the initial hour after birth.
The nurse should monitor lochia frequently in the immediate postpartum period, especially underneath the client where
blood can pool and go undetected. However, fundal massage is most important because uncorrected uterine atony
will eventually result in excessive blood loss.
Uterotonics (eg, oxytocin, methylergonovine) stimulate the uterus to contract. If the uterus fails to contract despite
massage, further administration of uterotonics is indicated.
Monitoring blood pressure and pulse are important interventions for postpartum clients, especially those at risk for
excessive blood loss. This intervention may be delayed until after fundal massage to reduce further blood loss.

OXYTOCIN
Oxytocin (Pitocin) is a uterotonic (uterine stimulant) medication used for labor induction/augmentation.
A common adverse effect of oxytocin is uterine tachysystole (ie, >5 contractions in 10 minutes averaged over 30
minutes).
If not corrected, uterine tachysystole can lead to reduced placental blood flow, impaired fetal oxygenation, and
abnormal fetal heart rate (FHR) patterns.
If nonreassuring FHR patterns (eg, late decelerations, fetal tachycardia, bradycardia) occur, the nurse should stop
oxytocin immediately to decrease uterine stimulation and increase blood flow to the fetus. Simply decreasing the
dose is inappropriate
Other appropriate actions include:

o Repositioning client to a side-lying position, which increases placental blood flow

o Administering oxygen via face mask at 8-10 L/min and an IV fluid bolus to improve oxygen availability and blood volume to
the fetus. These interventions are most effective after repositioning to maximize blood and oxygen delivery.
o Preparing to administer a subcutaneous injection of terbutaline (Brethine) to relax the uterus if other interventions are
unsuccessful
o Notifying the health care provider (HCP) after implementing initial interventions (eg, positioning, oxygen, fluids). Another
nurse can also notify the HCP while the primary nurse is implementing resuscitative measures.
o Documenting findings, actions, and HCP notification as soon as possible

Oxytocin (Pitocin) stimulates contraction of the uterine smooth muscle. It is commonly administered to induce or
augment labor and to prevent postpartum hemorrhage. Oxytocin, a high-alert medication, is administered cautiously
to avoid potential adverse effects, including:

o Category II or III fetal heart rate (FHR) patterns (eg, late decelerations, bradycardia). Abnormal or indeterminate FHR
patterns are very common when using oxytocin and may occur because of reduced blood flow to the fetus during
contractions
o Emergency cesarean birth, which may be required due to persistent abnormal FHR pattern
o Postpartum hemorrhage - Uterine atony and uterine fatigue may occur if the client experiences prolonged exposure to
exogenous oxytocin
o Water intoxication - Oxytocin has an antidiuretic effect when administered at high doses over prolonged periods.
o Uterine tachysystole (ie, >5 contractions in 10 minutes)

Endogenous oxytocin is excreted by the pituitary gland and triggers the milk ejection/let-down reflex. Administration of
exogenous oxytocin (ie, synthetic oxytocin) has no known effect on milk production.
Uterine stimulation from oxytocin increases the risk of placental abruption and uterine rupture.
Oxytocin is a high-alert medication commonly used for labor induction or augmentation. It should be administered
via an electronic infusion pump, which decreases medication errors, provides for accurate dosing, and prevents
maternal hypotension associated with rapid oxytocin bolus.
The nurse should evaluate and document the fetal heart rate and uterine contraction pattern every 15 minutes
during the first stage of labor and every 5 minutes during the second stage. Continuous electronic fetal heart rate
monitoring, not intermittent auscultation, is necessary
The nurse should also monitor maternal intake and output to identify fluid retention, which precedes water
intoxication, a potential adverse reaction of oxytocin administration causing dilutional hyponatremia, convulsions, and
death.
Oxytocin is administered through a secondary IV line connected to a main IV line (ie, isotonic fluid) via the port
closest to the client (ie, proximal port). This helps prevent an inadvertent oxytocin bolus and allows for rapid
discontinuation of infusion.
 Oxytocin is not titrated according to cervical diation, which cannot be assessed continuously and varies among
clients. Instead, oxytocin is initiated at the lowest possible dose and titrated until contractions are 2-3 minutes apart
and last for 80-90 seconds. The infusion is decreased/discontinued if uterine tachysystole (ie, >5 contractions in 10
minutes) or fetal distress occurs.

POSTPARTUM COMPLICATIONS

A vaginal hematoma is formed when trauma to the tissues of the perineum occurs during delivery. Vaginal
hematomas are more likely to occur following a forceps- or vacuum-assisted birth or an episiotomy.
The client reports persistent, severe vaginal pain or a feeling of fullness. If the client had epidural anesthesia, pain
may not be felt until the effects have worn off.
Vaginal bleeding is unchanged. The uterus is firm and at the midline on palpation. If the hematoma is large, the
hemoglobin level and vital signs can change significantly.
In a client with epidural analgesia, a change in vital signs may be an important indicator of hematoma.
UTERINE INVERSION

Uterine inversion is a rare, obstetrical emergency that occurs after birth when the uterine fundus collapses (partially
or completely) into the uterine cavity, causing sudden hemorrhage, severe pelvic pain, and hypovolemic shock.
Successful manual replacement of the inverted uterus through the vaginal canal by the health care provider (HCP) is
the first step in resolving the inversion and requires a soft, uncontracted uterus. Tocolytics (eg, terbutaline) or
inhaled anesthetics may be needed to assist with uterine relaxation.
Uterotonic medications (eg, oxytocin, carboprost) must be delayed or discontinued until after the HCP has
corrected the inversion (ie, manual uterine replacement). After uterine replacement, uterotonics are administered to
reinforce its location in the pelvis and control further bleeding.
Initiating a second, large-bore (eg, 18-gauge) IV line is an important intervention that allows for adequate volume
resuscitation (eg, fluids, blood products) as needed for hemorrhage.
Serial blood pressure monitoring (eg, every 3-5 min) helps the nurse assess for worsening hypovolemic shock.
If manual uterine replacement through the vagina is unsuccessful, emergency laparotomy (ie, replacement via
abdominal incision) may be necessary; it is appropriate to notify surgical staff members who will be involved.

UTERINE RUPTURE
Clients attempting vaginal birth after cesarean (VBAC) have a slightly increased risk for uterine rupture due to
previous surgical scarring of the uterus.
Clients desiring VBAC are usually encouraged to wait for spontaneous onset of labor rather than undergo induction
and are monitored closely throughout labor and delivery.
The first sign of uterine rupture is usually abnormal fetal heart rate (FHR) patterns.
Other manifestations include constant abdominal pain, loss of fetal station, and sudden cessation of uterine
contractions
Hemorrhage, hypovolemic shock, and maternal tachycardia may occur if severe rupture occurs unrecognized.
Most commonly, FHR decelerations followed by fetal bradycardia are indicative of uterine rupture.

PRETERM LABOR
 Preterm labor (PTL) is defined as progressive cervical dilation and/or effacement resulting from uterine contractions
before term gestation.
The nurse should anticipate the following interventions for clients in PTL before 34 weeks gestation:

o Administering IM antenatal glucocorticoids (eg, betamethasone, dexamethasone) to stimulate fetal lung maturation and
promote surfactant development
o Administering antibiotics (eg, penicillin) to prevent group B Streptococcus infection in the newborn if preterm birth occurs
o Initiating an IV magnesium sulfate infusion for fetal neuroprotection if at <32 weeks gestation
o Giving tocolytic medications (eg, nifedipine, indomethacin) to suppress uterine activity, which allows antenatal
glucocorticoids time to have a therapeutic effect
o Monitoring pertinent laboratory results, including cultures for vaginal or urinary tract infection and group B Streptococcus, if
obtained

Clients with suspected PTL should be placed on continuous fetal monitoring to assess for increasing frequency and
duration of contractions and to evaluate fetal tolerance of labor.
Continuous fetal monitoring is also required if the client is receiving a magnesium sulfate infusion

STAGES OF LABOR
 The end of the first stage of labor (8-10 cm dilation) is commonly referred to as the "transition phase" of labor.
This period is often characterized by perineal/rectal pressure due to fetal descent, which the client may perceive as
an urge to have a bowel movement. The maternal ischial spines are designated as the "0 station" landmark. During
this period, descent of fetal station below the maternal ischial spines (ie, +1 station or greater) often results
in nausea and vomiting and trembling or shivering
Other maternal signs of the end of the first stage include increased pain, fear, irritability, anxiety, and self-doubt in
the ability to birth. The client may require more assertive direction and emotional support during this period.
Cervical dilation of 0-5 cm denotes the early/latent phase of labor. During this phase, pain is usually well managed.
Although possibly apprehensive, the client is usually able to maintain focus and follow directions. For these reasons,
the latent phase is the best time to provide client education.
Cervical dilation of 6-7 cm denotes the start of the active phase of labor. During this period, apprehension and pain
increase, and the ability to follow instruction decreases. The client's demeanor is more serious. Pain management,
reassurance, and encouragement are priorities.
The period of active labor from 8-10 cm dilation (ie, "transition") is often the most emotionally challenging phase of
labor, marked by increased maternal anxiety.
A mixture of mucus and pink/dark brown blood ("bloody show") is commonly observed during transition. Nursing
priorities include providing emotional support and encouragement, and coaching the client in breathing techniques
Meperidine (Demerol) is an opioid occasionally prescribed for analgesia during early labor. It has a rapid onset (5
minutes) when given IV, and a duration of 2-3 hours. However, it should be avoided within 1-4 hours of birth due to
the potential for neonatal respiratory depression.
The second stage of labor begins once complete dilation (10 cm) is achieved. Clients may feel the urge to push
(Ferguson reflex) prior to complete dilation if the fetal head is low in the pelvis. However, pushing should be delayed
until complete dilation is achieved to avoid cervical swelling and/or cervical lacerations.
Although lithotomy positioning may be more convenient for the birth attendant, upright or lateral positions encourage
fetal rotation and descent, increase client comfort, and decrease the risk of perineal trauma. This client has not yet
reached complete dilation and should be allowed to move freely.
PUDENDAL NERVE BLOCK
A pudendal nerve block infiltrates local anesthesia (ie, lidocaine) into the areas surrounding the pudendal nerves
that innervate the lower vagina, perineum, and vulva.
 When birth is imminent, a pudendal block provides the best pain relief with the least maternal/newborn side
effects and could be administered quickly by the health care provider.
It does not relieve contraction pain but does relieve perineal pressure when administered in the late second stage of
labor
In clients without an epidural, pudendal blocks may be used in preparation for forceps-assisted birth or laceration
repair.
UTERINE CONTRACTIONS

Uterine contractions decrease circulation through the spiral arterioles and the intervillous space, which can stress the
fetus. Uterine contraction duration should not exceed 90 seconds.
During the first stage of labor, duration should be 45-80 seconds. A duration exceeding 90 seconds can result in
reduction of blood flow to the placenta due to uterine hypertonicity.
SHOULDER DYSTOCIA

Shoulder dystocia is an obstetrical emergency in which the fetal head emerges but the anterior shoulder remains
wedged behind the maternal symphysis pubis.
The nurse may initially observe the fetal head retracting back toward the maternal perineum after birth of the head
(ie, turtle sign).
The condition is frequently associated with macrosomia (fetal weight >8 lb 13 oz [4000 g]) secondary to gestational
diabetes mellitus. However, the occurrence of shoulder dystocia is unpredictable and may be related to maternal
factors, such as suboptimal pelvic shape, obesity, or short stature, rather than fetal size.
 The nurse's primary responsibilities during shoulder dystocia include performing the McRoberts maneuver (ie, sharp
flexion of maternal thighs toward abdomen to widen space between pubic bone and sacrum) and applying suprapubic
pressure (ie, downward pressure applied to maternal pubic bone to dislodge fetal shoulder)
nutes is correlated with almost certain fetal asphyxia resulting from prolonged
compression of the umbilical cord. Minimizing the time it takes to deliver the fetal body is essential for reducing
adverse outcomes (eg, hypoxia, nerve injury, death).
When shoulder dystocia occurs, the primary nursing interventions include:

o Documenting the exact time of events (eg, birth of fetal head, shoulder dystocia maneuvers)
o Verbalizing passing time to guide decision-making by the health care provider (eg, "two minutes have passed")
o Performing maneuvers to relieve shoulder impaction (eg, McRoberts maneuver, suprapubic pressure)
o Requesting additional help from staff (eg, nurses, neonatologist) immediately

Administering a tocolytic agent to stop contractions or relax the uterus is not recommended and does not resolve
shoulder dystocia.
Fundal pressure is contraindicated, as it may wedge the fetal shoulder further into the symphysis pubis or cause
uterine rupture.
Application of a vacuum extractor is contraindicated because it may further wedge the fetal shoulder into the
symphysis pubis, increasing the risk for brachial plexus injury.

ANENCEPHALY
Anencephaly is a severe neural tube defect (NTD) resulting in little to no brain tissue or skull formation in utero.
Many newborns with anencephaly are stillborn, and those born alive are not compatible with life.
Comfort care for the newborn and emotional support for the family is priority at the time of birth. Drying, bundling, and
placing the newborn skin-to-skin provides warmth, and administering oxygen may decrease discomfort to the
newborn. Allowing the family to hold the newborn will assist with the grieving process.
ADOPTION

Adoption, the decision to relinquish care of a child to another, is complex and involves a variety of emotional and
psychosocial responses from clients.
The nurse should encourage the birth mother to create memories with her newborn to facilitate the grieving
process.
This may include holding the newborn, taking pictures, and naming the newborn
When the time comes, offering the client a chance to say goodbye to the newborn supports the birth mother in her
emotional transition and acknowledges the importance of her relationship with the newborn
The nurse protects the client by notifying relevant staff of the decision, which prevents unintended, potentially hurtful
remarks
Substituting phrases like "giving up" and "giving away" with "choosing adoption" reinforce adoption as a loving decision
and not neglect or abandonment
Avoiding discussion of adoption details until after the birth inhibits the nurse's ability to plan care that respects the birth
mother's wishes for interaction with the newborn and/or involvement of the adoptive parents in the birth process.
Acknowledging the adoption plan early in the plan of care encourages the client to express emotions and be involved
in decision-making.

AMNIOTOMY
Amniotomy refers to the artificial rupture of membranes (AROM) and may be performed by the health care
provider to augment or induce labor. After AROM, there is a risk of umbilical cord prolapse if the fetal head is not
applied firmly to the cervix.
A prolapsed cord can cause fetal bradycardia due to cord compression. The nurse should assess the fetal heart rate
before and after the procedure
The nurse should note the amniotic fluid color, amount, and odor. Amniotic fluid should be clear/colorless and without
a foul odor. Yellowish-green fluid can indicate the fetal passage of meconium in utero, and a strong, foul odor may
 indicate infection. Once the membranes are ruptured, there is an increased risk for infection. The nurse should
monitor the client's temperature at least every 2 hours after AROM
Supine positioning decreases uteroplacental blood flow and fetal oxygenation. The client should be assisted to upright
positions after AROM to allow for drainage of amniotic fluid and to encourage the fetal head to remain firmly applied to
the cervix.

AMNIOINFUSION

An amnioinfusion is a transvaginal infusion of isotonic fluids through an intrauterine pressure catheter to compensate
for low amniotic fluid (eg, oligohydramnios, ruptured membranes) in the uterus. During labor, an amnioinfusion is
indicated to relieve persistent, recurrent variable decelerations caused by umbilical cord compression.
Uterine overdistension is a potential complication due to infusion of too much fluid. Therefore, the nurse should
use an infusion pump to control the rate and amount of fluid, evaluate for fluid return frequently, and monitor uterine
resting tone closely.
If baseline uterine resting tone is elevated minimal to absent fluid return is noted, the
nurse should pause the infusion and notify the health care provider immediately
PLACENTA ACCRETA
Placenta accreta is a condition of abnormal placental adherence in which the placenta implants directly in the
myometrium rather than the endometrium.
Prenatal ultrasound usually detects placenta accreta, although detection can rarely occur after birth when the placenta
is adherent (ie, retained placenta). A cesarean birth before term gestation at a facility with adequate resources (eg,
blood products, intensive care unit) is recommended for clients with placenta accreta.
The major complication of placenta accreta is life-threatening hemorrhage, which occurs during attempted placental
separation. At least two large-bore IVs (eg, 18-gauge) and a blood type and crossmatch are priority concerns in
case blood transfusions are necessary
 Previous cesarean birth is a risk factor for placenta accreta. Knowing the client's medical/surgical history is important
but is not prioritized over the client's readiness for a blood transfusion.
A hysterectomy during cesarean birth with the placenta left in place may be required to reduce blood loss. The client
should understand the implications of the procedure (ie, no future childbearing), but this is not a priority over ensuring
readiness for a potential blood transfusion.

BISHOP SCORE

The Bishop score is a system for the assessment and rating of cervical favorability and readiness for induction of
labor.
The cervix is scored (0-3) on consistency, position, dilation, effacement, and station of the fetal presenting part.
A higher Bishop score indicates an increased likelihood of successful induction that results in vaginal birth.
For nulliparous women, a score usually indicates that induction will be successful
NON-STRESS TEST

A reactive nonstress test indicates that the fetus is well oxygenated and establishes fetal well-being. It does not provide
information about the likely success or failure of labor induction.

OPIOIDS

Opioid agonist-antagonist medications used in labor include butorphanol tartrate (Stadol) and nalbuphine
hydrochloride (Nubain).
Maternal adverse effects include sedation, dizziness, and nausea. Butorphanol tartrate crosses the placental
barrier, peaking in 30-60 minutes; its duration of action is approximately 2-4 hours. If given near the time of birth,
there is a risk for newborn respiratory depression, which may require naloxone (Narcan) to reverse the effects.
IV opioids are safest for clients who will give birth 2-4 hours after administration so that the opioid effect has time to
wear off before the birth. IV opioids are also best for clients in active labor or those with a well-established
contraction pattern because opioid administration may slow labor progression in the latent phase
Although this client is in active labor, recent heroin use is a contraindication to opioid agonist-antagonists because
of the risk for maternal and/or fetal withdrawal symptoms.
An urge to push may indicate imminent birth, especially in a multiparous client. To ensure newborn safety, imminent
birth is a relative contraindication for the administration of narcotics.
UMBILICAL CORD PROLAPSE
Umbilical cord prolapse occurs when the umbilical cord slips below the presenting fetal part and causes cord
compression and impaired fetal oxygenation. A loop of cord may be palpated during vaginal examination or visualized
protruding from the vagina.
An emergency cesarean birth is usually required unless vaginal birth is imminent and considered safe by the health
care provider (HCP).
Positioning the client on the hands and knees with the buttocks elevated above the head (knee-chest position) or in
the Trendelenburg position relieves pressure on the compressed cord.
The nurse may also use a sterile, gloved hand to lift the presenting part off the cord. Other actions include
administration of oxygen and IV fluids.

COPING IN LABOR

Developing cultural competence (ie, understanding, attitudes, and abilities acquired to meet the needs of culturally
diverse clients) helps the nurse provide culturally sensitive labor support and pain management.
Clients from Japanese culture may value silence and nonverbal communication over overt forms of communication.
It may be considered culturally appropriate to be stoic (ie, showing admirable patience) during labor, and pain may be
accepted as a part of the process. Therefore, the client may not desire pharmacologic pain management.
 In addition to performing frequent pain assessments, the nurse should assess the client's ability to cope with labor by
asking about the client's comfort and perceptions of labor, as well as monitoring for nonverbal cues of ineffective
coping. Clients may report a high pain score, yet be coping effectively and not desire pharmacologic pain relief.

EPIDURAL BLOCK
An epidural block (a form of regional anesthesia) can provide effective pain relief during labor; however, it also
inhibits the sympathetic nervous system (SNS).
SNS inhibition causes peripheral vasodilation, which may produce significant hypotension (ie, systolic blood

If a client exhibits hypotensive symptoms (eg, lightheadedness, nausea) while receiving epidural anesthesia, the nurse
should first assess blood pressure to confirm the presence of hypotension before intervening
If hypotension is present, initial nursing interventions include administering an IV fluid bolus to increase blood volume
and positioning the client in the left lateral position to alleviate pressure on the vena cava.
Epidural anesthesia, an elective procedure for pain relief in labor, may be contraindicated in clients with
uncorrected hypotension, coagulopathies (eg, extremely low platelets, clotting disorders), or infection at the
epidural site.
Low platelets in pregnancy may occur as part of HELLP syndrome (hemolysis, elevated liver enzymes, low platelets)
or for idiopathic reasons (eg, gestational thrombocytopenia).
Clients with low platelets (especially <100,000/mm3 [100 × 109/L]) are at risk for bleeding at the epidural puncture
site, which may lead to hematoma formation, spinal cord compression, and subsequent neurologic dysfunction

PRECIPITOUS LABOR

Precipitous birth occurs when labor lasts <3 hours from contraction onset until birth.
Signs of imminent birth include involuntary pushing/bearing down with contractions, grunting, or report of
sensations of having a bowel movement.
If a client arrives at the hospital in second-stage labor (ie, pushing), the nurse rapidly assesses whether birth is
imminent by applying gloves and observing the perineum for bulging or crowning of the presenting fetal part
 If the health care provider is not present, the nurse stays with the client, ensures safe client positioning (eg, not
standing or on the toilet), and is prepared to act as a birth attendant. The nurse may direct others to perform needed
actions (eg, contact provider, assess fetal heart tones, initiate IV access).

IV NARCOTICS

Administration of IV narcotics (eg, nalbuphine, butorphanol, meperidine) during the peak of contractions can
help decrease sedation of the fetus and subsequent newborn respiratory depression at birth
Uteroplacental blood flow is significantly reduced during contraction peaks, and administration of IV medication at this
time results in less medication crossing the placental barrier. In addition, a higher concentration of medication remains
in the maternal vasculature, which increases the effectiveness of pain relief.

GROUP B STREPTOCCOCUS

Group B Streptococcus (GBS) may be present as part of normal vaginal flora in up to 30% of pregnant clients.
Although colonization with GBS rarely poses harm to the client, it can be transmitted to the newborn during labor and
birth, resulting in serious complications (eg, neonatal GBS sepsis, pneumonia).
Pregnant clients are tested for GBS colonization at 35-37 weeks gestation and receive prophylactic antibiotics during
labor if results are positive.
If GBS status is unknown, antibiotics are typically indicated when membra

SEIZURES
Seizures are a potential complication of worsening preeclampsia, also known as eclampsia.
Seizure precautions should be in place for all clients with preeclampsia. Side rails should be padded and the bed kept
in the lowest position to prevent trauma during a seizure. Functioning suction equipment and supplemental oxygen
should be available at the bedside
During a seizure, the nurse should turn the client to the left side to prevent aspiration and promote uteroplacental
blood flow. After the seizure subsides, the nurse should suction any oral secretions and apply oxygen 8-10 L/min by
facemask.
Magnesium sulfate is a central nervous system (CNS) depressant commonly prescribed to prevent seizures in clients
with preeclampsia. Deep tendon reflexes should be assessed hourly during administration. Hyperreflexia or clonus
may indicate impending seizure activity, whereas hyporeflexia may indicate magnesium toxicity.
Calcium gluconate is the reversal agent administered in the event of magnesium toxicity and should be immediately
available
Environmental stimuli should be minimized to decrease risk for seizures. This may include limiting visitors and the
number of caregivers entering/exiting the client's room
 NEW BORN HEALTH

ABNORMAL FINDINGS
When caring for newborns, the nurse should recognize abnormal findings and report them to the health care
provider. Some abnormal newborn findings include:

o Abnormal respiratory effort (eg, nasal flaring, chest wall retractions, grunting, tachypnea [>60/min]): Signs of respiratory
distress should be evaluated promptly to determine necessary treatment
o Jaundice, especially in the first 24 hours of life (pathologic): Yellowish hues may be initially noted on the face or eyes and
progress to the trunk and extremities. Although newborn jaundice after 24 hours of life is usually physiologic and resolves
spontaneously, it should still be reported and monitored closely to ensure resolution.
o No voiding in 24 hours: A newborn should void and pass meconium within 24 hours after birth. Not voiding on the first day
of life or in the past 24 hours is concerning for a structural anomaly or dehydration

Desquamation (peeling skin) is a normal finding in some newborns, especially those born at late- or post-term
gestation. Moisturizers can be applied if desired, but desquamation resolves on its own over several days.
Average newborn head circumference is approximately 13-14 in (33-35 cm). A smaller or larger head circumference
may indicate an abnormal condition (eg, microcephaly, hydrocephalus).

RESPIRATORY DISTRESS

Newborns normally have respirations of 30-60/min, with periodic pauses lasting <20 seconds.
Sustained tachypnea, nasal flaring, retractions, and grunting are signs of newborn respiratory distress. Respiratory
distress may be related to retained amniotic fluid in the lungs (more common following cesarean birth), meconium
aspiration, or infection
The newborn should be placed on continuous monitoring and may require respiratory support (eg, oxygen, continuous
positive airway pressure) until the underlying cause is corrected and respiratory status stabilizes.
HEPATITIS B VIRUS

Hepatitis B virus infection is a bloodborne disease that poses a significant infection risk to the newborn because
of exposure to maternal blood and bodily fluids during birth. The most important interventions to prevent maternal-to-
newborn transmission after birth include initiation of the hepatitis B vaccine series and administration of hepatitis B
immune globulin (HBIG) within 12 hours of birth.
Clients who desire to breastfeed should be encouraged to do so if possible because very few absolute
contraindications to breastfeeding exist.
Breastfeeding has not been shown to affect newborn infection rates and is not contraindicated as long as the client's
nipples are intact (eg, not bleeding) and immunoprophylaxis (ie, HBIG, hepatitis B vaccine) is appropriately
administered
APGAR SCORE
WEIGHT LOSS

During the first 3-4 days of life, a weight loss of approximately 5%-6% of birth weight is expected due to fluid
excretion (eg, urine, stool, respirations). Weight loss usually ceases around 5 days of life in healthy newborns, who
return to their birth weight by 7-14 days of life. A weight loss of >7% of birth weight warrants further evaluation.
The nurse should assess the newborn, review intake and output, observe breastfeeding technique (eg, positioning,
effective latching), and notify the health care provider. To prevent further weight loss, breastfeeding
support and formula supplementation (eg, via spoon or syringe) may be indicated until exclusive breastfeeding is
adequate

SPINA BIFIDA

Spina bifida, a neural tube defect occurring when spinal vertebrae do not close during fetal development, potentially
allows spinal cord contents to protrude through the opening.
The mildest form is spina bifida occulta, usually located at the fifth lumbar or first sacral vertebra. The newborn
may have no impairments or may experience neurologic disturbances (eg, bowel/bladder incontinence, sensory loss)
of varying severity.
Manifestations of spina bifida occulta may include a tuft of hair, hemangioma, nevus, or dimple along the base of
the spine.
The nurse should notify the health care provider because further assessment and surgical repair may be required

CAPUT SUCCEDANEUM
 Caput succedaneum (mnemonic - caput succedaneum = crosses suture), edema of the soft tissue of the scalp due to
prolonged pressure of the presenting part against the cervix during labor, resolves in a few days.

CONGENITAL DERMAL MELANOCYTOSIS

Flat, bluish, discolored areas on the lower back and/or buttocks indicate the benign finding, congenital dermal
melanocytosis (ie, Mongolian spots).
 Congenital dermal melanocytosis (mongolian spots) is a benign discoloration of the skin most often seen in
newborns of ethnicities with darker skin tones (eg, African American, Native American, Hispanic, Asian).
Mongolian spots are usually bluish gray and fade over the first 1-2 years of life. Because they are easily
misidentified as bruises, it is important for the nurse to measure and document the area for reference during future
health care assessments.

HYPOGLYCEMIA

Poorly controlled diabetes mellitus during pregnancy exposes the fetus to high blood glucose (BG) levels. This
results in fetal hyperglycemia, which causes insulin hypersecretion by the fetus and promotes abnormal growth and
storage of fat (macrosomia).
Immediately after birth, transient hyperinsulinemia and sudden cessation of the maternal glucose supply put
the newborn at risk for hypoglycemia.
Although there is no standard definition for newborn hypoglycemia, a normal range for serum BG in a newborn age
<24 hours is 40-60 mg/dL (2.2-3.3 mmol/L), and a low BG is <40-45 mg/dL (<2.2-2.5 mmol/L).
If a newborn has a low BG and is asymptomatic, immediate feeding with formula or breast milk should begin to
increase BG and prevent further hypoglycemia
If the newborn is symptomatic or BG levels remain <40-45 mg/dL (2.2-2.5 mmol/L) after feeding, the nurse should
notify the health care provider and prepare to administer IV glucose.
Asymptomatic hypoglycemia in newborns with blood glucose (BG) <35 mg/dL (<1.94 mmol/L) if age 4-24 hours or
<25 mg/dL (<1.39 mmol/L) if age <4 hours should be initially treated with feeding; an exclusively breastfed newborn
should receive breast milk when possible
Feeding the newborn is a simple, noninvasive method of increasing and stabilizing BG.

CERVICAL SPINE POSITION IN NEONATAL RESUSCITATION

The neonate should be placed on the back with the neck slightly extended. This is a neutral or "sniffing" position.
A blanket or towel roll can be placed under the shoulders, elevating them 0.75-1.0 in (19-25.4 mm) off the
mattress. This is particularly useful if the infant has a large occiput from molding or edema.
 The nurse must watch that the infant's head does not shift to an improper position during caregiving activities.

ACROCYANOSIS

Acrocyanosis or peripheral cyanosis of the hands and feet is a benign finding during a newborn's transition to
extrauterine life. It is especially common during the first 24 hours of life or in the first week if the newborn is cold.
Manifestations include a bluish discoloration of the hands and feet and sometimes the skin around the mouth.
Acrocyanosis results from poor perfusion to the periphery of the body, an initial mechanism to reduce heat loss and
stabilize temperature. Initial nursing management includes promoting thermoregulation by placing the newborn skin-
to-skin with the mother or under a radiant warmer and assessing axillary temperature

INEFFECTIVE BREASTFEEDING

Ineffective breastfeeding can be attributed to many factors, including prematurity; breast anomaly or previous breast
surgery; poor infant latch or sucking reflex; or the use of formula feeding.
The use of supplemental formula feedings and artificial nipples should be avoided, as research demonstrates
it interferes with the mother's ability to exclusively breastfeed
Supplemental formula feeds are only provided for medical indications (eg, newborn hypoglycemia, dehydration,
excessive weight loss) and if alternate breastfeeding techniques are unsuccessful.
A mother having difficulty with breastfeeding may be able to pump or hand express small amounts of colostrum that
can be fed to the newborn by syringe, cup, or spoon. Hand expression may be preferable before the mature milk
supply is established and is also useful when a breast pump is not available.
If ineffective breastfeeding occurs, the nurse should:

o Assess the baby's sucking reflex and physical condition

o Assess the mother's breastfeeding technique (positioning, behavior/anxiety during breastfeeding)
o Teach how to express milk by hand and use an electric pump to enhance milk production
o Refer to a lactation consultant for a thorough assessment and breastfeeding plan if ineffective breastfeeding occurs longer
than 24 hours
ILLICIT DRUGS

A pregnant client's repeated use of illicit drugs will cause dependence in the neonate.
The abrupt withdrawal from the drug due to delivery can cause abstinence syndrome in the neonate.
This is most commonly seen with opioid use, although other central nervous system depressant drug use (eg,
benzodiazepines) can contribute.
Manifestations include:
o Autonomic nervous system symptoms stuffy nose, sweating, frequent yawning and sneezing, tachycardia, and
tachypnea. Treatment includes swaddling and keeping nasal passages clear
o Central nervous system symptoms irritability, restlessness, high-pitched crying, abnormal sleep pattern, and
hypertonicity/hyperactive primitive reflexes. Treatment includes medication and protecting the skin
o Gastrointestinal symptoms poor feeding, vomiting, and diarrhea. These are treated with small, frequent feedings

RUBIN THEORY

According to the Rubin theory, there are 3 phases of postpartum adaptation to motherhood.

o Taking-in: In the first 24 48 hours postpartum, the mother is physically recovering from childbirth. During this time, she is
more dependent on the health care team to help with care of the baby.
o Taking-hold: During 2 10 days postpartum, the mother still is learning the technical skills of mothering but may feel
inadequate.
o Letting-go: After 10 days postpartum, the mother becomes comfortable with the new role.

CIRCUMCISION

Common complications of circumcision include hemorrhage, infection, and voiding difficulty. Parents
should clean the area with warm water (without soap) to remove urine and feces and prevent infection. Prepackaged
alcohol-based wipes delay healing and cause discomfort; they should be avoided until the circumcision site has healed
(usually takes 5-6 days).
 Immediately after the procedure, the glans penis should appear dark red and, after 24 hours, will be covered with
a yellow exudate. Parents should not try to wipe or forcefully remove the exudate that will persist for 2-3 days; this is a
normal healing process. Redness, swelling, odor, and discharge indicate infection.
Infant crying is expected during diaper and petroleum (Vaseline) gauze changes. Parents are often anxious and
concerned about inflicting pain on their newborn. They should be informed that the discomfort is only brief and be
encouraged to provide extra comfort measures (holding, feeding, nonnutritive suckling) after diaper changes.
Diapers should be changed when soiled or at least every 4 hours to keep the area clean and assess for evidence of
infection or bleeding. Petroleum gauze or ointment should be applied at every diaper change (unless Plastibell used)
to prevent sticking. The diaper should be secured loosely to minimize pressure against the healing circumcision site.

SUDDEN DEATH INFANT SYNDROME

 SIDS is the sudden unexplained death of an infant age <1 year. It is the leading cause of death among infants, with
the highest occurrence at 2-4 months.
Smoking cessation, breastfeeding, up-to-date vaccinations, and pacifier use are protective factors against SIDS.
Pacifier use has been associated with an increased risk of otitis media and early cessation of breastfeeding; however,
its use is also associated with a dramatic reduction in SIDS. Because the data is more beneficial for SIDS reduction,
pacifiers can be used at naptime and bedtime for newborns once the breastfeeding technique has been well
established (age 1 month).
CANDIDA ALBICANS

Manifestations of oral candidiasis (thrush) include white patches on the oral mucosa, palate, and tongue. The patches
are nonremovable and tend to bleed when touched.
The affected infant may have difficulty sucking or feeding due to the associated pain. Thrush is generally linked to
antibiotic therapy or poor caregiver hand hygiene. The infection is usually self-limiting, but treatment with a fungicide
(eg, nystatin) may hasten recovery.

ERYTHEMA TOXICUM NEONATARUM

 Erythema toxicum neonatarum is characterized by firm, white or yellow papules or pustules surrounded by erythema.
This idiopathic rash, which closely resembles flea bites, appears in the first few days after birth and resolves within 5-7
days. There are no additional systemic effects, and the rash requires no treatment.

EPSTEIN PEARLS

Epstein pearls are small, white cysts found on the hard palate of newborns. These cysts are considered common
findings, and they disappear a few weeks after birth.

NEONATAL RESUSCITATION
CLEFT PALATE

A child with a cleft palate (CP) is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties.
This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be
repaired, the following feeding strategies increase oral intake and decrease aspiration risk:

o Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of
aspiration
o Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft.
 o Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices allow
formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the
caregiver to apply pressure in rhythm with the infant's own sucking and swallowing
o These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension
and regurgitation
o Feeding slowly over 20 30 minutes reduces the risk of aspiration and promotes adequate intake of formula.
o Feeding every 3 4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be
fed more frequently if they are not consuming adequate amounts of formula.

PHOTOTHERAPY

Phototherapy is the use of fluorescent lights to treat hyperbilirubinemia or jaundice in newborns. The light is
absorbed by the newborn's skin and converts bilirubin into a water-soluble form, allowing it to be excreted in the stool
and urine.
The newborn should be fully exposed, except for a diaper, when placed under the phototherapy lights. Lotions and
ointments should not be applied as they can absorb the heat and cause burns. Maintaining skin integrity is
important as bilirubin products in the stool can cause loose stool with frequency and produce skin excoriation and
breakdown.
Allowing parents to feed the newborn promotes bonding. The newborn should not be removed from the lights except
during feedings for optimal effect of the phototherapy.
Adequate hydration with human milk or infant formula (not water) is important as infants are prone to dehydration
from phototherapy.
Temperature should be monitored closely, with the incubator placed on a low-heat setting.
The newborn's eyes should be covered with patches or guards to prevent retinal damage or cataracts when under
the phototherapy lights.

GASTROESOPHAGEAL REFLUX

Gastroesophageal reflux (GER) is attributed to an immature lower esophageal sphincter. It is common in infants
spitting up after feeds. If an infant is gaining weight and meeting developmental
 milestones, treatment is aimed at controlling the symptoms. Because infants with GER are at risk for aspiration and
apnea, caregivers should be instructed in cardiopulmonary resuscitation.
Burping the baby frequently helps expel trapped air before milk builds up over it. If there is milk over an air pocket,
the milk will come up with the burp
Holding the baby upright for 20-30 minutes after feedings allows gravity to assist in keeping the food in the stomach
while the stomach settles
Feeding the baby smaller but more frequent feeds prevents the stomach from becoming too full and expelling extra
milk and allows for more complete emptying before the next feed. It also ensures that the child is getting the required
ounces daily
These infants should not be rocked or agitated by active play for at least 30 minutes after feeding and should
be kept calm and upright. Placing them on the stomach creates abdominal pressure, which can aggravate the
reflux. Infants should not be placed in a car seat after feedings as this can increase intra-abdominal pressure and
cause reflux.

NECROTIZING ENTEROCOLITIS

Necrotizing enterocolitis occurs predominantly in preterm infants secondary to gastrointestinal and immunologic
immaturity.
On initiation of enteral feeding, bacteria can be introduced into the bowel, where they can proliferate excessively due
to compromised immune clearance. This results in inflammation and ischemic necrosis of the intestine.
As the disease progresses, the bowel becomes congested and gangrenous with gas collections forming inside the
bowel wall.
Measuring the client's abdominal girth daily is an important nursing intervention to note any worsening intestinal gas-
associated swelling.
Clients are made NPO and receive nasogastric suction to decompress the stomach and intestines. Parenteral
hydration and nutrition and IV antibiotics are given.

TETRALOGY OF FALLOT

Infants with tetralogy of Fallot (TOF), a cyanotic cardiac defect, experience chronic hypoxemia due to decreased
pulmonary blood flow and circulation of poorly oxygenated blood.
 To compensate for prolonged tissue hypoxia, erythropoietin production increases to produce additional oxygen-
carrying RBCs.
Increased RBCs result in increased circulatory viscosity or polycythemia (ie, hemoglobin >22 g/dL [220 g/L] or
hematocrit >65%).
Polycythemia increases the risk for blood clotting (ie, thrombus formation), which can cause stroke. Therefore, a
hemoglobin level of 24.9 g/dL (249 g/L) is a priority to report to the health care provider because close observation and
additional interventions such as IV hydration and (possibly) partial exchange transfusion are required

POST-DELIVERY

Nursing interventions for a newborn immediately after delivery include:

o Standard precautions - The unbathed newborn is covered in maternal blood and bodily fluid. Standard precautions (eg,
gloves) are implemented when contact with blood or bodily fluid is anticipated.
o Maintain a clear airway - Suction the pharynx first followed by the nasal passages to prevent aspiration if the newborn gasps
with nasal suctioning.
o Thermoregulation (97.5-99 F [36.4-37.2 C]) reduces oxygen and stored calorie consumption. Hypothermia predisposes the
newborn to metabolic acidosis, hypoxia, and shock. A radiant warmer is used while performing assessments and
interventions. Use pre-warmed linens, an infant stocking cap, and a thermal skin sensor for monitoring. Skin-to-skin contact
aids in thermoregulation.
o Vitamin K is administered intramuscularly in the vastus lateralis (midanterior lateral thigh) within 6 hours of birth to prevent
bleeding due to absence of vitamin K-producing intestinal bacteria.
o Ophthalmic ointment - Prophylactic antibiotic eye ointment for Neisseria gonorrhoeae is legally required; application may be
delayed up to 1 hour after delivery.
o Initial bathing of the newborn is limited to removing blood, bodily fluids, or meconium. Vernix caseosa, a waxy, white
coating, protects the skin and should not be vigorously removed

GESTATIONAL AGE ASSESSMENT

 A gestational age assessment assists the nurse in providing developmentally appropriate care to preterm newborns.
This assessment uses indicators of neuromuscular and physical maturity that are assessed, scored, and added, which
correlates to an estimation of gestational age.
Lanugo, a fine, downy hair found mostly on the backs and shoulders of preterm newborns, begins disappearing
around 36 weeks gestation. At 28 weeks, the newborn has abundant lanugo over most of the body. The 28-week
newborn also has smooth, pink skin with visible veins as skin is thin and transparent with lack of subcutaneous fat.
The areolae of extremely premature infants may be barely visible, with no raised breast buds. Palpable, raised breast
buds measuring 5-10 mm would be expected in newborns closer to term gestation.
At 28 weeks gestation, a newborn's feet have very smooth soles with only faint red marks or possibly a single anterior
transverse crease. Creases over the entire sole and/or peeling skin would be expected in a full- or post-term (ie, 40+
weeks) newborn.
The testes of a male infant born at 28 weeks gestation would not yet have descended into the scrotal sac and may be
palpable in the upper inguinal canal.

COLD STRESS
Neonates are unable to generate heat by shivering due to their lack of muscle tissue and immature nervous systems;
they therefore produce heat by increasing their metabolic rates through nonshivering thermogenesis.
Brown adipose tissue (BAT), developed during the third trimester, is metabolized for thermogenesis when available.
Once BAT is depleted, nonshivering thermogenesis is less effective and the neonate may experience cold stress,
possibly leading to death.
Preterm neonates have fewer stores of BAT and are at higher risk for cold stress. Frequent temperature monitoring is
the best method to assess if an infant is cold.
In cold stress, metabolism increases to generate heat, causing a greater demand for oxygen and glucose and the
release of norepinephrine. If adequate oxygenation is not
maintained, hypoxia and acidemia occur. Hypoglycemia develops when available glucose is depleted, and repletion
of glucose is impaired by gastrointestinal immotility and poor oral intake.
Clinical manifestations of cold stress include:

o Neurological - altered mental status (irritability or lethargy)

o Cardiovascular - bradycardia
o Respiratory - tachypnea early, followed by apnea and hypoxia
 o Gastrointestinal - high gastric residuals, emesis, hypoglycemia
o Musculoskeletal - hypotonia, weak suck and cry

MORO REFLEX

Primitive newborn reflexes help determine the client's neurological status and development.
The Moro reflex (ie, startle reflex), present until age 3-6 months, is elicited by quickly lowering the infant's head
relative to the body, simulating a falling sensation. It is also a response to sudden loud noises and jarring of the crib.
Initially, the newborn extends and raises the arms with fingers fanned out and then curls into the fetal position.
Absence of the Moro reflex may indicate an underdeveloped or damaged brain or spinal cord and should be
reported to the health care provider

TRISOMY 18 (EDWARDS SYNDROME)

 Trisomy 18 (Edwards syndrome) is a life-threatening chromosomal abnormality that affects multiple organ
systems. Many fetuses affected by this condition die in utero. Of the newborns that survive birth, half will die in the
first week of life and most do not make it to the first birthday.
Before withdrawal of ventilator support, it is appropriate for the nurse to request a collaborative meeting between the
health care providers (HCPs) and the palliative care team to help the parents understand their child's condition as
well as make decisions about interventions and the potential need for end-of-life care
The nurse should not notify parents of genetic test results; this is the responsibility of the HCP. Information regarding
the newborn's condition may be provided after the HCP notifies the parents of test results.
There is no cure for a newborn with trisomy 18 because it is a chromosomal abnormality.
The nurse should be sensitive toward the parents and provide accurate information. Telling the parents that their
newborn might live long enough to go home is inappropriate because it gives them false hope, as this possibility
occurs in only a small number of newborns with trisomy 18.

NEWBORN SAFETY

Principles of newborn safety should be reinforced during postpartum discharge teaching. The following safe sleep
practices help prevent sudden infant death syndrome:
o Dress newborns in no more than one more layer of clothing than an adult requires. A wearable blanket (ie, sleep sack)
can keep the newborn warm and prevents the head from being covered
o Always place the newborn in the supine position during sleep
o Ensure no loose bedding or other objects are in the crib (eg, blankets, stuffed toys, pillows).
 o Prevent newborn head entrapment by ensuring crib slats are no more than 2¼ inches (5.72 cm) apart.

Essential teaching for proper car safety seat use includes:

o Secure the safety seat harness to fit snuggly against the newborn's body, with the retaining clip secured near the level of the
armpits. No bulky jackets or blankets should be between the newborn and the harness because this would reduce its
effectiveness during a crash
o Place the newborn in a federally approved, rear-facing car seat secured in the back seat
o Position the newborn at a 45-degree angle to prevent airway obstruction. Rolled blankets/car seat inserts on both
sides/under the crotch strap may be used to prevent slouching.

NEONATAL ABSTINENCE SYNDROME

A neonate born to an opioid-dependent mother (eg, heroin, methadone, hydrocodone) is at high risk for neonatal
abstinence syndrome, in which the newborn experiences opioid withdrawal typically within 24-48 hours after birth.
Clinical manifestations of withdrawal in infants include irritability, jitteriness, high-pitched cry, sneezing, diarrhea,
vomiting, and poor feeding.
Hypersensitivity can make feeding difficult; the newborn should be placed in a side-lying position while swaddled to
minimize stimulation and promote nutritive sucking
Between feedings, a pacifier may be used to soothe the infant and help establish an organized sucking pattern.
Excessive movement places the newborn at high risk for skin excoriation; the infant should be tightly swaddled with
arms flexed to minimize irritation and prevent damage to the skin.
Hand mittens and barrier skin protection to the knees, elbows, and heels may also be used.
 Stimulation should be avoided due to the newborn's hypersensitive state; the newborn should be placed in a quiet,
dim-lit section of the nursery. The nurse should also organize tasks ("cluster care") to minimize stimulation.
The newborn should be placed on the right side after feeding to promote gastric emptying and reduce the risk of
vomiting.

INFANT OF DIABETIC MOTHER

Poorly controlled maternal diabetes negatively affects fetal growth and oxygenation throughout pregnancy. As a
result, infants of diabetic mothers are at an increased risk for postnatal complications.
In clients with poorly controlled diabetes, the fetus experiences hyperglycemia and produces excess insulin. To
compensate, the fetus increases metabolic activity and oxygen consumption.
 Fetal erythropoietin production subsequently increases to produce additional red blood cells (erythropoiesis), which
are needed to transport oxygen to tissues. This increased production of red blood cells leads to polycythemia
(ie, hematocrit >65%) and increased circulatory viscosity
When caring for newborns, the nurse should recognize abnormal findings and report them to the health care
provider. Some abnormal newborn findings include:

o Abnormal respiratory effort (eg, nasal flaring, chest wall retractions, grunting, tachypnea [>60/min]): Signs of respiratory
distress should be evaluated promptly to determine necessary treatment
o Jaundice, especially in the first 24 hours of life (pathologic): Yellowish hues may be initially noted on the face or eyes and
progress to the trunk and extremities. Although newborn jaundice after 24 hours of life is usually physiologic and resolves
spontaneously, it should still be reported and monitored closely to ensure resolution.
o No voiding in 24 hours: A newborn should void and pass meconium within 24 hours after birth. Not voiding on the first day
of life or in the past 24 hours is concerning for a structural anomaly or dehydration

Desquamation (peeling skin) is a normal finding in some newborns, especially those born at late- or post-term
gestation. Moisturizers can be applied if desired, but desquamation resolves on its own over several days.
Average newborn head circumference is approximately 13-14 in (33-35 cm). A smaller or larger head circumference
may indicate an abnormal condition (eg, microcephaly, hydrocephalus).

RESPIRATORY DISTRESS

Newborns normally have respirations of 30-60/min, with periodic pauses lasting <20 seconds.
Sustained tachypnea, nasal flaring, retractions, and grunting are signs of newborn respiratory distress. Respiratory
distress may be related to retained amniotic fluid in the lungs (more common following cesarean birth), meconium
aspiration, or infection
The newborn should be placed on continuous monitoring and may require respiratory support (eg, oxygen, continuous
positive airway pressure) until the underlying cause is corrected and respiratory status stabilizes.
HEPATITIS B VIRUS
 Hepatitis B virus infection is a bloodborne disease that poses a significant infection risk to the newborn because
of exposure to maternal blood and bodily fluids during birth. The most important interventions to prevent maternal-to-
newborn transmission after birth include initiation of the hepatitis B vaccine series and administration of hepatitis B
immune globulin (HBIG) within 12 hours of birth.
Clients who desire to breastfeed should be encouraged to do so if possible because very few absolute
contraindications to breastfeeding exist.
Breastfeeding has not been shown to affect newborn infection rates and is not contraindicated as long as the client's
nipples are intact (eg, not bleeding) and immunoprophylaxis (ie, HBIG, hepatitis B vaccine) is appropriately
administered

APGAR SCORE
WEIGHT LOSS

During the first 3-4 days of life, a weight loss of approximately 5%-6% of birth weight is expected due to fluid
excretion (eg, urine, stool, respirations). Weight loss usually ceases around 5 days of life in healthy newborns, who
return to their birth weight by 7-14 days of life. A weight loss of >7% of birth weight warrants further evaluation.
 The nurse should assess the newborn, review intake and output, observe breastfeeding technique (eg, positioning,
effective latching), and notify the health care provider. To prevent further weight loss, breastfeeding
support and formula supplementation (eg, via spoon or syringe) may be indicated until exclusive breastfeeding is
adequate

SPINA BIFIDA

Spina bifida, a neural tube defect occurring when spinal vertebrae do not close during fetal development, potentially
allows spinal cord contents to protrude through the opening.
The mildest form is spina bifida occulta, usually located at the fifth lumbar or first sacral vertebra. The newborn
may have no impairments or may experience neurologic disturbances (eg, bowel/bladder incontinence, sensory loss)
of varying severity.
Manifestations of spina bifida occulta may include a tuft of hair, hemangioma, nevus, or dimple along the base of
the spine.
The nurse should notify the health care provider because further assessment and surgical repair may be required

CAPUT SUCCEDANEUM
 Caput succedaneum (mnemonic - caput succedaneum = crosses suture), edema of the soft tissue of the scalp due to
prolonged pressure of the presenting part against the cervix during labor, resolves in a few days.

CONGENITAL DERMAL MELANOCYTOSIS

Flat, bluish, discolored areas on the lower back and/or buttocks indicate the benign finding, congenital dermal
melanocytosis (ie, Mongolian spots).
 Congenital dermal melanocytosis (mongolian spots) is a benign discoloration of the skin most often seen in
newborns of ethnicities with darker skin tones (eg, African American, Native American, Hispanic, Asian).
Mongolian spots are usually bluish gray and fade over the first 1-2 years of life. Because they are easily
misidentified as bruises, it is important for the nurse to measure and document the area for reference during future
health care assessments.

HYPOGLYCEMIA

Poorly controlled diabetes mellitus during pregnancy exposes the fetus to high blood glucose (BG) levels. This
results in fetal hyperglycemia, which causes insulin hypersecretion by the fetus and promotes abnormal growth and
storage of fat (macrosomia).
Immediately after birth, transient hyperinsulinemia and sudden cessation of the maternal glucose supply put
the newborn at risk for hypoglycemia.
Although there is no standard definition for newborn hypoglycemia, a normal range for serum BG in a newborn age
<24 hours is 40-60 mg/dL (2.2-3.3 mmol/L), and a low BG is <40-45 mg/dL (<2.2-2.5 mmol/L).
If a newborn has a low BG and is asymptomatic, immediate feeding with formula or breast milk should begin to
increase BG and prevent further hypoglycemia
If the newborn is symptomatic or BG levels remain <40-45 mg/dL (2.2-2.5 mmol/L) after feeding, the nurse should
notify the health care provider and prepare to administer IV glucose.
Asymptomatic hypoglycemia in newborns with blood glucose (BG) <35 mg/dL (<1.94 mmol/L) if age 4-24 hours or
<25 mg/dL (<1.39 mmol/L) if age <4 hours should be initially treated with feeding; an exclusively breastfed newborn
should receive breast milk when possible
Feeding the newborn is a simple, noninvasive method of increasing and stabilizing BG.

CERVICAL SPINE POSITION IN NEONATAL RESUSCITATION

The neonate should be placed on the back with the neck slightly extended. This is a neutral or "sniffing" position.
A blanket or towel roll can be placed under the shoulders, elevating them 0.75-1.0 in (19-25.4 mm) off the
mattress. This is particularly useful if the infant has a large occiput from molding or edema.
 The nurse must watch that the infant's head does not shift to an improper position during caregiving activities.

ACROCYANOSIS

Acrocyanosis or peripheral cyanosis of the hands and feet is a benign finding during a newborn's transition to
extrauterine life. It is especially common during the first 24 hours of life or in the first week if the newborn is cold.
Manifestations include a bluish discoloration of the hands and feet and sometimes the skin around the mouth.
Acrocyanosis results from poor perfusion to the periphery of the body, an initial mechanism to reduce heat loss and
stabilize temperature. Initial nursing management includes promoting thermoregulation by placing the newborn skin-
to-skin with the mother or under a radiant warmer and assessing axillary temperature

INEFFECTIVE BREASTFEEDING

Ineffective breastfeeding can be attributed to many factors, including prematurity; breast anomaly or previous breast
surgery; poor infant latch or sucking reflex; or the use of formula feeding.
The use of supplemental formula feedings and artificial nipples should be avoided, as research demonstrates
it interferes with the mother's ability to exclusively breastfeed
Supplemental formula feeds are only provided for medical indications (eg, newborn hypoglycemia, dehydration,
excessive weight loss) and if alternate breastfeeding techniques are unsuccessful.
A mother having difficulty with breastfeeding may be able to pump or hand express small amounts of colostrum that
can be fed to the newborn by syringe, cup, or spoon. Hand expression may be preferable before the mature milk
supply is established and is also useful when a breast pump is not available.
If ineffective breastfeeding occurs, the nurse should:

o Assess the baby's sucking reflex and physical condition

o Assess the mother's breastfeeding technique (positioning, behavior/anxiety during breastfeeding)
o Teach how to express milk by hand and use an electric pump to enhance milk production
o Refer to a lactation consultant for a thorough assessment and breastfeeding plan if ineffective breastfeeding occurs longer
than 24 hours
ILLICIT DRUGS

A pregnant client's repeated use of illicit drugs will cause dependence in the neonate.
The abrupt withdrawal from the drug due to delivery can cause abstinence syndrome in the neonate.
This is most commonly seen with opioid use, although other central nervous system depressant drug use (eg,
benzodiazepines) can contribute.
Manifestations include:
o Autonomic nervous system symptoms stuffy nose, sweating, frequent yawning and sneezing, tachycardia, and
tachypnea. Treatment includes swaddling and keeping nasal passages clear
o Central nervous system symptoms irritability, restlessness, high-pitched crying, abnormal sleep pattern, and
hypertonicity/hyperactive primitive reflexes. Treatment includes medication and protecting the skin
o Gastrointestinal symptoms poor feeding, vomiting, and diarrhea. These are treated with small, frequent feedings

RUBIN THEORY

According to the Rubin theory, there are 3 phases of postpartum adaptation to motherhood.

o Taking-in: In the first 24 48 hours postpartum, the mother is physically recovering from childbirth. During this time, she is
more dependent on the health care team to help with care of the baby.
o Taking-hold: During 2 10 days postpartum, the mother still is learning the technical skills of mothering but may feel
inadequate.
o Letting-go: After 10 days postpartum, the mother becomes comfortable with the new role.

CIRCUMCISION

Common complications of circumcision include hemorrhage, infection, and voiding difficulty. Parents
should clean the area with warm water (without soap) to remove urine and feces and prevent infection. Prepackaged
alcohol-based wipes delay healing and cause discomfort; they should be avoided until the circumcision site has healed
(usually takes 5-6 days).
 Immediately after the procedure, the glans penis should appear dark red and, after 24 hours, will be covered with
a yellow exudate. Parents should not try to wipe or forcefully remove the exudate that will persist for 2-3 days; this is a
normal healing process. Redness, swelling, odor, and discharge indicate infection.
Infant crying is expected during diaper and petroleum (Vaseline) gauze changes. Parents are often anxious and
concerned about inflicting pain on their newborn. They should be informed that the discomfort is only brief and be
encouraged to provide extra comfort measures (holding, feeding, nonnutritive suckling) after diaper changes.
Diapers should be changed when soiled or at least every 4 hours to keep the area clean and assess for evidence of
infection or bleeding. Petroleum gauze or ointment should be applied at every diaper change (unless Plastibell used)
to prevent sticking. The diaper should be secured loosely to minimize pressure against the healing circumcision site.

SUDDEN DEATH INFANT SYNDROME

SIDS is the sudden unexplained death of an infant age <1 year. It is the leading cause of death among infants, with
the highest occurrence at 2-4 months.
Smoking cessation, breastfeeding, up-to-date vaccinations, and pacifier use are protective factors against SIDS.
Pacifier use has been associated with an increased risk of otitis media and early cessation of breastfeeding; however,
its use is also associated with a dramatic reduction in SIDS. Because the data is more beneficial for SIDS reduction,
pacifiers can be used at naptime and bedtime for newborns once the breastfeeding technique has been well
established (age 1 month).
CANDIDA ALBICANS

Manifestations of oral candidiasis (thrush) include white patches on the oral mucosa, palate, and tongue. The patches
are nonremovable and tend to bleed when touched.
The affected infant may have difficulty sucking or feeding due to the associated pain. Thrush is generally linked to
antibiotic therapy or poor caregiver hand hygiene. The infection is usually self-limiting, but treatment with a fungicide
(eg, nystatin) may hasten recovery.

ERYTHEMA TOXICUM NEONATARUM

Erythema toxicum neonatarum is characterized by firm, white or yellow papules or pustules surrounded by erythema.
This idiopathic rash, which closely resembles flea bites, appears in the first few days after birth and resolves within 5-7
days. There are no additional systemic effects, and the rash requires no treatment.
EPSTEIN PEARLS
 Epstein pearls are small, white cysts found on the hard palate of newborns. These cysts are considered common
findings, and they disappear a few weeks after birth.

NEONATAL RESUSCITATION
CLEFT PALATE

A child with a cleft palate (CP) is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties.
This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be
repaired, the following feeding strategies increase oral intake and decrease aspiration risk:

o Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of
aspiration
o Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft.
 o Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices allow
formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the
caregiver to apply pressure in rhythm with the infant's own sucking and swallowing
o These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension
and regurgitation
o Feeding slowly over 20 30 minutes reduces the risk of aspiration and promotes adequate intake of formula.
o Feeding every 3 4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be
fed more frequently if they are not consuming adequate amounts of formula.

PHOTOTHERAPY

Phototherapy is the use of fluorescent lights to treat hyperbilirubinemia or jaundice in newborns. The light is
absorbed by the newborn's skin and converts bilirubin into a water-soluble form, allowing it to be excreted in the stool
and urine.
The newborn should be fully exposed, except for a diaper, when placed under the phototherapy lights. Lotions and
ointments should not be applied as they can absorb the heat and cause burns. Maintaining skin integrity is
important as bilirubin products in the stool can cause loose stool with frequency and produce skin excoriation and
breakdown.
Allowing parents to feed the newborn promotes bonding. The newborn should not be removed from the lights except
during feedings for optimal effect of the phototherapy.
Adequate hydration with human milk or infant formula (not water) is important as infants are prone to dehydration
from phototherapy.
Temperature should be monitored closely, with the incubator placed on a low-heat setting.
The newborn's eyes should be covered with patches or guards to prevent retinal damage or cataracts when under
the phototherapy lights.

GASTROESOPHAGEAL REFLUX

Gastroesophageal reflux (GER) is attributed to an immature lower esophageal sphincter. It is common in infants
spitting up after feeds. If an infant is gaining weight and meeting developmental
 milestones, treatment is aimed at controlling the symptoms. Because infants with GER are at risk for aspiration and
apnea, caregivers should be instructed in cardiopulmonary resuscitation.
Burping the baby frequently helps expel trapped air before milk builds up over it. If there is milk over an air pocket,
the milk will come up with the burp
Holding the baby upright for 20-30 minutes after feedings allows gravity to assist in keeping the food in the stomach
while the stomach settles
Feeding the baby smaller but more frequent feeds prevents the stomach from becoming too full and expelling extra
milk and allows for more complete emptying before the next feed. It also ensures that the child is getting the required
ounces daily
These infants should not be rocked or agitated by active play for at least 30 minutes after feeding and should
be kept calm and upright. Placing them on the stomach creates abdominal pressure, which can aggravate the
reflux. Infants should not be placed in a car seat after feedings as this can increase intra-abdominal pressure and
cause reflux.

NECROTIZING ENTEROCOLITIS

Necrotizing enterocolitis occurs predominantly in preterm infants secondary to gastrointestinal and immunologic
immaturity.
On initiation of enteral feeding, bacteria can be introduced into the bowel, where they can proliferate excessively due
to compromised immune clearance. This results in inflammation and ischemic necrosis of the intestine.
As the disease progresses, the bowel becomes congested and gangrenous with gas collections forming inside the
bowel wall.
Measuring the client's abdominal girth daily is an important nursing intervention to note any worsening intestinal gas-
associated swelling.
Clients are made NPO and receive nasogastric suction to decompress the stomach and intestines. Parenteral
hydration and nutrition and IV antibiotics are given.

TETRALOGY OF FALLOT

Infants with tetralogy of Fallot (TOF), a cyanotic cardiac defect, experience chronic hypoxemia due to decreased
pulmonary blood flow and circulation of poorly oxygenated blood.
 To compensate for prolonged tissue hypoxia, erythropoietin production increases to produce additional oxygen-
carrying RBCs.
Increased RBCs result in increased circulatory viscosity or polycythemia (ie, hemoglobin >22 g/dL [220 g/L] or
hematocrit >65%).
Polycythemia increases the risk for blood clotting (ie, thrombus formation), which can cause stroke. Therefore, a
hemoglobin level of 24.9 g/dL (249 g/L) is a priority to report to the health care provider because close observation and
additional interventions such as IV hydration and (possibly) partial exchange transfusion are required

POST-DELIVERY

Nursing interventions for a newborn immediately after delivery include:

o Standard precautions - The unbathed newborn is covered in maternal blood and bodily fluid. Standard precautions (eg,
gloves) are implemented when contact with blood or bodily fluid is anticipated.
o Maintain a clear airway - Suction the pharynx first followed by the nasal passages to prevent aspiration if the newborn gasps
with nasal suctioning.
o Thermoregulation (97.5-99 F [36.4-37.2 C]) reduces oxygen and stored calorie consumption. Hypothermia predisposes the
newborn to metabolic acidosis, hypoxia, and shock. A radiant warmer is used while performing assessments and
interventions. Use pre-warmed linens, an infant stocking cap, and a thermal skin sensor for monitoring. Skin-to-skin contact
aids in thermoregulation.
o Vitamin K is administered intramuscularly in the vastus lateralis (midanterior lateral thigh) within 6 hours of birth to prevent
bleeding due to absence of vitamin K-producing intestinal bacteria.
o Ophthalmic ointment - Prophylactic antibiotic eye ointment for Neisseria gonorrhoeae is legally required; application may be
delayed up to 1 hour after delivery.
o Initial bathing of the newborn is limited to removing blood, bodily fluids, or meconium. Vernix caseosa, a waxy, white
coating, protects the skin and should not be vigorously removed
GESTATIONAL AGE ASSESSMENT

A gestational age assessment assists the nurse in providing developmentally appropriate care to preterm newborns.
This assessment uses indicators of neuromuscular and physical maturity that are assessed, scored, and added, which
correlates to an estimation of gestational age.
Lanugo, a fine, downy hair found mostly on the backs and shoulders of preterm newborns, begins disappearing
around 36 weeks gestation. At 28 weeks, the newborn has abundant lanugo over most of the body. The 28-week
newborn also has smooth, pink skin with visible veins as skin is thin and transparent with lack of subcutaneous fat.
The areolae of extremely premature infants may be barely visible, with no raised breast buds. Palpable, raised breast
buds measuring 5-10 mm would be expected in newborns closer to term gestation.
At 28 weeks gestation, a newborn's feet have very smooth soles with only faint red marks or possibly a single anterior
transverse crease. Creases over the entire sole and/or peeling skin would be expected in a full- or post-term (ie, 40+
weeks) newborn.
The testes of a male infant born at 28 weeks gestation would not yet have descended into the scrotal sac and may be
palpable in the upper inguinal canal.
COLD STRESS

Neonates are unable to generate heat by shivering due to their lack of muscle tissue and immature nervous systems;
they therefore produce heat by increasing their metabolic rates through nonshivering thermogenesis.
Brown adipose tissue (BAT), developed during the third trimester, is metabolized for thermogenesis when available.
Once BAT is depleted, nonshivering thermogenesis is less effective and the neonate may experience cold stress,
possibly leading to death.
Preterm neonates have fewer stores of BAT and are at higher risk for cold stress. Frequent temperature monitoring is
the best method to assess if an infant is cold.
In cold stress, metabolism increases to generate heat, causing a greater demand for oxygen and glucose and the
release of norepinephrine. If adequate oxygenation is not
maintained, hypoxia and acidemia occur. Hypoglycemia develops when available glucose is depleted, and repletion
of glucose is impaired by gastrointestinal immotility and poor oral intake.
Clinical manifestations of cold stress include:

o Neurological - altered mental status (irritability or lethargy)

 o Cardiovascular - bradycardia
o Respiratory - tachypnea early, followed by apnea and hypoxia
o Gastrointestinal - high gastric residuals, emesis, hypoglycemia
o Musculoskeletal - hypotonia, weak suck and cry

MORO REFLEX

Primitive newborn reflexes help determine the client's neurological status and development.
The Moro reflex (ie, startle reflex), present until age 3-6 months, is elicited by quickly lowering the infant's head
relative to the body, simulating a falling sensation. It is also a response to sudden loud noises and jarring of the crib.
Initially, the newborn extends and raises the arms with fingers fanned out and then curls into the fetal position.
Absence of the Moro reflex may indicate an underdeveloped or damaged brain or spinal cord and should be
reported to the health care provider
TRISOMY 18 (EDWARDS SYNDROME)
 Trisomy 18 (Edwards syndrome) is a life-threatening chromosomal abnormality that affects multiple organ
systems. Many fetuses affected by this condition die in utero. Of the newborns that survive birth, half will die in the
first week of life and most do not make it to the first birthday.
Before withdrawal of ventilator support, it is appropriate for the nurse to request a collaborative meeting between the
health care providers (HCPs) and the palliative care team to help the parents understand their child's condition as
well as make decisions about interventions and the potential need for end-of-life care
The nurse should not notify parents of genetic test results; this is the responsibility of the HCP. Information regarding
the newborn's condition may be provided after the HCP notifies the parents of test results.
There is no cure for a newborn with trisomy 18 because it is a chromosomal abnormality.
The nurse should be sensitive toward the parents and provide accurate information. Telling the parents that their
newborn might live long enough to go home is inappropriate because it gives them false hope, as this possibility
occurs in only a small number of newborns with trisomy 18.

NEWBORN SAFETY

Principles of newborn safety should be reinforced during postpartum discharge teaching. The following safe sleep
practices help prevent sudden infant death syndrome:
o Dress newborns in no more than one more layer of clothing than an adult requires. A wearable blanket (ie, sleep sack)
can keep the newborn warm and prevents the head from being covered
o Always place the newborn in the supine position during sleep
o Ensure no loose bedding or other objects are in the crib (eg, blankets, stuffed toys, pillows).
o Prevent newborn head entrapment by ensuring crib slats are no more than 2¼ inches (5.72 cm) apart.

Essential teaching for proper car safety seat use includes:

o Secure the safety seat harness to fit snuggly against the newborn's body, with the retaining clip secured near the level of the
armpits. No bulky jackets or blankets should be between the newborn and the harness because this would reduce its
effectiveness during a crash
o Place the newborn in a federally approved, rear-facing car seat secured in the back seat
o Position the newborn at a 45-degree angle to prevent airway obstruction. Rolled blankets/car seat inserts on both
sides/under the crotch strap may be used to prevent slouching.

NEONATAL ABSTINENCE SYNDROME

A neonate born to an opioid-dependent mother (eg, heroin, methadone, hydrocodone) is at high risk for neonatal
abstinence syndrome, in which the newborn experiences opioid withdrawal typically within 24-48 hours after birth.
Clinical manifestations of withdrawal in infants include irritability, jitteriness, high-pitched cry, sneezing, diarrhea,
vomiting, and poor feeding.
Hypersensitivity can make feeding difficult; the newborn should be placed in a side-lying position while swaddled to
minimize stimulation and promote nutritive sucking
Between feedings, a pacifier may be used to soothe the infant and help establish an organized sucking pattern.
 Excessive movement places the newborn at high risk for skin excoriation; the infant should be tightly swaddled with
arms flexed to minimize irritation and prevent damage to the skin.
Hand mittens and barrier skin protection to the knees, elbows, and heels may also be used.
Stimulation should be avoided due to the newborn's hypersensitive state; the newborn should be placed in a quiet,
dim-lit section of the nursery. The nurse should also organize tasks ("cluster care") to minimize stimulation.
The newborn should be placed on the right side after feeding to promote gastric emptying and reduce the risk of
vomiting.
INFANT OF DIABETIC MOTHER

Poorly controlled maternal diabetes negatively affects fetal growth and oxygenation throughout pregnancy. As a
result, infants of diabetic mothers are at an increased risk for postnatal complications.
In clients with poorly controlled diabetes, the fetus experiences hyperglycemia and produces excess insulin. To
compensate, the fetus increases metabolic activity and oxygen consumption.
 Fetal erythropoietin production subsequently increases to produce additional red blood cells (erythropoiesis), which
are needed to transport oxygen to tissues. This increased production of red blood cells leads to polycythemia
(ie, hematocrit >65%) and increased circulatory viscosity

ABNORMAL FINDINGS
When caring for newborns, the nurse should recognize abnormal findings and report them to the health care
provider. Some abnormal newborn findings include:

o Abnormal respiratory effort (eg, nasal flaring, chest wall retractions, grunting, tachypnea [>60/min]): Signs of respiratory
distress should be evaluated promptly to determine necessary treatment
o Jaundice, especially in the first 24 hours of life (pathologic): Yellowish hues may be initially noted on the face or eyes and
progress to the trunk and extremities. Although newborn jaundice after 24 hours of life is usually physiologic and resolves
spontaneously, it should still be reported and monitored closely to ensure resolution.
o No voiding in 24 hours: A newborn should void and pass meconium within 24 hours after birth. Not voiding on the first day
of life or in the past 24 hours is concerning for a structural anomaly or dehydration

Desquamation (peeling skin) is a normal finding in some newborns, especially those born at late- or post-term
gestation. Moisturizers can be applied if desired, but desquamation resolves on its own over several days.
Average newborn head circumference is approximately 13-14 in (33-35 cm). A smaller or larger head circumference
may indicate an abnormal condition (eg, microcephaly, hydrocephalus).

RESPIRATORY DISTRESS

Newborns normally have respirations of 30-60/min, with periodic pauses lasting <20 seconds.
Sustained tachypnea, nasal flaring, retractions, and grunting are signs of newborn respiratory distress. Respiratory
distress may be related to retained amniotic fluid in the lungs (more common following cesarean birth), meconium
aspiration, or infection
The newborn should be placed on continuous monitoring and may require respiratory support (eg, oxygen, continuous
positive airway pressure) until the underlying cause is corrected and respiratory status stabilizes.

HEPATITIS B VIRUS
 Hepatitis B virus infection is a bloodborne disease that poses a significant infection risk to the newborn because
of exposure to maternal blood and bodily fluids during birth. The most important interventions to prevent maternal-to-
newborn transmission after birth include initiation of the hepatitis B vaccine series and administration of hepatitis B
immune globulin (HBIG) within 12 hours of birth.
Clients who desire to breastfeed should be encouraged to do so if possible because very few absolute
contraindications to breastfeeding exist.
Breastfeeding has not been shown to affect newborn infection rates and is not contraindicated as long as the client's
nipples are intact (eg, not bleeding) and immunoprophylaxis (ie, HBIG, hepatitis B vaccine) is appropriately
administered

APGAR SCORE
WEIGHT LOSS

During the first 3-4 days of life, a weight loss of approximately 5%-6% of birth weight is expected due to fluid
excretion (eg, urine, stool, respirations). Weight loss usually ceases around 5 days of life in healthy newborns, who
return to their birth weight by 7-14 days of life. A weight loss of >7% of birth weight warrants further evaluation.
The nurse should assess the newborn, review intake and output, observe breastfeeding technique (eg, positioning,
effective latching), and notify the health care provider. To prevent further weight loss, breastfeeding
support and formula supplementation (eg, via spoon or syringe) may be indicated until exclusive breastfeeding is
adequate
SPINA BIFIDA

Spina bifida, a neural tube defect occ

urring when spinal vertebrae do not close during fetal development, potentially allows spinal cord contents to protrude
through the opening.
The mildest form is spina bifida occulta, usually located at the fifth lumbar or first sacral vertebra. The newborn
may have no impairments or may experience neurologic disturbances (eg, bowel/bladder incontinence, sensory loss)
of varying severity.
Manifestations of spina bifida occulta may include a tuft of hair, hemangioma, nevus, or dimple along the base of
the spine.
The nurse should notify the health care provider because further assessment and surgical repair may be required

CAPUT SUCCEDANEUM

Caput succedaneum (mnemonic - caput succedaneum = crosses suture), edema of the soft tissue of the scalp due to
prolonged pressure of the presenting part against the cervix during labor, resolves in a few days.
CONGENITAL DERMAL MELANOCYTOSIS

Flat, bluish, discolored areas on the lower back and/or buttocks indicate the benign finding, congenital dermal
melanocytosis (ie, Mongolian spots).
Congenital dermal melanocytosis (mongolian spots) is a benign discoloration of the skin most often seen in
newborns of ethnicities with darker skin tones (eg, African American, Native American, Hispanic, Asian).
Mongolian spots are usually bluish gray and fade over the first 1-2 years of life. Because they are easily
misidentified as bruises, it is important for the nurse to measure and document the area for reference during future
health care assessments.

HYPOGLYCEMIA

Poorly controlled diabetes mellitus during pregnancy exposes the fetus to high blood glucose (BG) levels. This
results in fetal hyperglycemia, which causes insulin hypersecretion by the fetus and promotes abnormal growth and
storage of fat (macrosomia).
Immediately after birth, transient hyperinsulinemia and sudden cessation of the maternal glucose supply put
the newborn at risk for hypoglycemia.
Although there is no standard definition for newborn hypoglycemia, a normal range for serum BG in a newborn age
<24 hours is 40-60 mg/dL (2.2-3.3 mmol/L), and a low BG is <40-45 mg/dL (<2.2-2.5 mmol/L).
If a newborn has a low BG and is asymptomatic, immediate feeding with formula or breast milk should begin to
increase BG and prevent further hypoglycemia
If the newborn is symptomatic or BG levels remain <40-45 mg/dL (2.2-2.5 mmol/L) after feeding, the nurse should
notify the health care provider and prepare to administer IV glucose.
 Asymptomatic hypoglycemia in newborns with blood glucose (BG) <35 mg/dL (<1.94 mmol/L) if age 4-24 hours or
<25 mg/dL (<1.39 mmol/L) if age <4 hours should be initially treated with feeding; an exclusively breastfed newborn
should receive breast milk when possible
Feeding the newborn is a simple, noninvasive method of increasing and stabilizing BG.

CERVICAL SPINE POSITION IN NEONATAL RESUSCITATION

The neonate should be placed on the back with the neck slightly extended. This is a neutral or "sniffing" position.
A blanket or towel roll can be placed under the shoulders, elevating them 0.75-1.0 in (19-25.4 mm) off the
mattress. This is particularly useful if the infant has a large occiput from molding or edema.
The nurse must watch that the infant's head does not shift to an improper position during caregiving activities.

ACROCYANOSIS

Acrocyanosis or peripheral cyanosis of the hands and feet is a benign finding during a newborn's transition to
extrauterine life. It is especially common during the first 24 hours of life or in the first week if the newborn is cold.
Manifestations include a bluish discoloration of the hands and feet and sometimes the skin around the mouth.
Acrocyanosis results from poor perfusion to the periphery of the body, an initial mechanism to reduce heat loss and
stabilize temperature. Initial nursing management includes promoting thermoregulation by placing the newborn skin-
to-skin with the mother or under a radiant warmer and assessing axillary temperature

INEFFECTIVE BREASTFEEDING

Ineffective breastfeeding can be attributed to many factors, including prematurity; breast anomaly or previous breast
surgery; poor infant latch or sucking reflex; or the use of formula feeding.
The use of supplemental formula feedings and artificial nipples should be avoided, as research demonstrates
it interferes with the mother's ability to exclusively breastfeed
Supplemental formula feeds are only provided for medical indications (eg, newborn hypoglycemia, dehydration,
excessive weight loss) and if alternate breastfeeding techniques are unsuccessful.
 A mother having difficulty with breastfeeding may be able to pump or hand express small amounts of colostrum that
can be fed to the newborn by syringe, cup, or spoon. Hand expression may be preferable before the mature milk
supply is established and is also useful when a breast pump is not available.
If ineffective breastfeeding occurs, the nurse should:

o Assess the baby's sucking reflex and physical condition

o Assess the mother's breastfeeding technique (positioning, behavior/anxiety during breastfeeding)
o Teach how to express milk by hand and use an electric pump to enhance milk production
o Refer to a lactation consultant for a thorough assessment and breastfeeding plan if ineffective breastfeeding occurs longer
than 24 hours

ILLICIT DRUGS

A pregnant client's repeated use of illicit drugs will cause dependence in the neonate.
The abrupt withdrawal from the drug due to delivery can cause abstinence syndrome in the neonate.
This is most commonly seen with opioid use, although other central nervous system depressant drug use (eg,
benzodiazepines) can contribute.
Manifestations include:
o Autonomic nervous system symptoms stuffy nose, sweating, frequent yawning and sneezing, tachycardia, and
tachypnea. Treatment includes swaddling and keeping nasal passages clear
o Central nervous system symptoms irritability, restlessness, high-pitched crying, abnormal sleep pattern, and
hypertonicity/hyperactive primitive reflexes. Treatment includes medication and protecting the skin
o Gastrointestinal symptoms poor feeding, vomiting, and diarrhea. These are treated with small, frequent feedings

RUBIN THEORY

According to the Rubin theory, there are 3 phases of postpartum adaptation to motherhood.

o Taking-in: In the first 24 48 hours postpartum, the mother is physically recovering from childbirth. During this time, she is
more dependent on the health care team to help with care of the baby.
 o Taking-hold: During 2 10 days postpartum, the mother still is learning the technical skills of mothering but may feel
inadequate.
o Letting-go: After 10 days postpartum, the mother becomes comfortable with the new role.

CIRCUMCISION

Common complications of circumcision include hemorrhage, infection, and voiding difficulty. Parents
should clean the area with warm water (without soap) to remove urine and feces and prevent infection. Prepackaged
alcohol-based wipes delay healing and cause discomfort; they should be avoided until the circumcision site has healed
(usually takes 5-6 days).
Immediately after the procedure, the glans penis should appear dark red and, after 24 hours, will be covered with
a yellow exudate. Parents should not try to wipe or forcefully remove the exudate that will persist for 2-3 days; this is a
normal healing process. Redness, swelling, odor, and discharge indicate infection.
Infant crying is expected during diaper and petroleum (Vaseline) gauze changes. Parents are often anxious and
concerned about inflicting pain on their newborn. They should be informed that the discomfort is only brief and be
encouraged to provide extra comfort measures (holding, feeding, nonnutritive suckling) after diaper changes.
Diapers should be changed when soiled or at least every 4 hours to keep the area clean and assess for evidence of
infection or bleeding. Petroleum gauze or ointment should be applied at every diaper change (unless Plastibell used)
to prevent sticking. The diaper should be secured loosely to minimize pressure against the healing circumcision site.

SUDDEN DEATH INFANT SYNDROME

 SIDS is the sudden unexplained death of an infant age <1 year. It is the leading cause of death among infants, with
the highest occurrence at 2-4 months.
Smoking cessation, breastfeeding, up-to-date vaccinations, and pacifier use are protective factors against SIDS.
Pacifier use has been associated with an increased risk of otitis media and early cessation of breastfeeding; however,
its use is also associated with a dramatic reduction in SIDS. Because the data is more beneficial for SIDS reduction,
pacifiers can be used at naptime and bedtime for newborns once the breastfeeding technique has been well
established (age 1 month).

CANDIDA ALBICANS

Manifestations of oral candidiasis (thrush) include white patches on the oral mucosa, palate, and tongue. The patches
are nonremovable and tend to bleed when touched.
The affected infant may have difficulty sucking or feeding due to the associated pain. Thrush is generally linked to
antibiotic therapy or poor caregiver hand hygiene. The infection is usually self-limiting, but treatment with a fungicide
(eg, nystatin) may hasten recovery.
ERYTHEMA TOXICUM NEONATARUM

Erythema toxicum neonatarum is characterized by firm, white or yellow papules or pustules surrounded by erythema.
This idiopathic rash, which closely resembles flea bites, appears in the first few days after birth and resolves within 5-7
days. There are no additional systemic effects, and the rash requires no treatment.
EPSTEIN PEARLS
 Epstein pearls are small, white cysts found on the hard palate of newborns. These cysts are considered common
findings, and they disappear a few weeks after birth.

NEONATAL RESUSCITATION
CLEFT PALATE

A child with a cleft palate (CP) is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties.
This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be
repaired, the following feeding strategies increase oral intake and decrease aspiration risk:

o Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of
aspiration
o Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft.
o Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices allow
formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the
caregiver to apply pressure in rhythm with the infant's own sucking and swallowing
o These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension
and regurgitation
o Feeding slowly over 20 30 minutes reduces the risk of aspiration and promotes adequate intake of formula.
o Feeding every 3 4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be
fed more frequently if they are not consuming adequate amounts of formula.

PHOTOTHERAPY

Phototherapy is the use of fluorescent lights to treat hyperbilirubinemia or jaundice in newborns. The light is
absorbed by the newborn's skin and converts bilirubin into a water-soluble form, allowing it to be excreted in the stool
and urine.
The newborn should be fully exposed, except for a diaper, when placed under the phototherapy lights. Lotions and
ointments should not be applied as they can absorb the heat and cause burns. Maintaining skin integrity is
important as bilirubin products in the stool can cause loose stool with frequency and produce skin excoriation and
breakdown.
 Allowing parents to feed the newborn promotes bonding. The newborn should not be removed from the lights except
during feedings for optimal effect of the phototherapy.
Adequate hydration with human milk or infant formula (not water) is important as infants are prone to dehydration
from phototherapy.
Temperature should be monitored closely, with the incubator placed on a low-heat setting.
The newborn's eyes should be covered with patches or guards to prevent retinal damage or cataracts when under
the phototherapy lights.

GASTROESOPHAGEAL REFLUX

Gastroesophageal reflux (GER) is attributed to an immature lower esophageal sphincter. It is common in infants
spitting up after feeds. If an infant is gaining weight and meeting developmental
milestones, treatment is aimed at controlling the symptoms. Because infants with GER are at risk for aspiration and
apnea, caregivers should be instructed in cardiopulmonary resuscitation.
Burping the baby frequently helps expel trapped air before milk builds up over it. If there is milk over an air pocket,
the milk will come up with the burp
Holding the baby upright for 20-30 minutes after feedings allows gravity to assist in keeping the food in the stomach
while the stomach settles
Feeding the baby smaller but more frequent feeds prevents the stomach from becoming too full and expelling extra
milk and allows for more complete emptying before the next feed. It also ensures that the child is getting the required
ounces daily
These infants should not be rocked or agitated by active play for at least 30 minutes after feeding and should
be kept calm and upright. Placing them on the stomach creates abdominal pressure, which can aggravate the
reflux. Infants should not be placed in a car seat after feedings as this can increase intra-abdominal pressure and
cause reflux.

NECROTIZING ENTEROCOLITIS

Necrotizing enterocolitis occurs predominantly in preterm infants secondary to gastrointestinal and immunologic
immaturity.
On initiation of enteral feeding, bacteria can be introduced into the bowel, where they can proliferate excessively due
to compromised immune clearance. This results in inflammation and ischemic necrosis of the intestine.
 As the disease progresses, the bowel becomes congested and gangrenous with gas collections forming inside the
bowel wall.
Measuring the client's abdominal girth daily is an important nursing intervention to note any worsening intestinal gas-
associated swelling.
Clients are made NPO and receive nasogastric suction to decompress the stomach and intestines. Parenteral
hydration and nutrition and IV antibiotics are given.

TETRALOGY OF FALLOT

Infants with tetralogy of Fallot (TOF), a cyanotic cardiac defect, experience chronic hypoxemia due to decreased
pulmonary blood flow and circulation of poorly oxygenated blood.
To compensate for prolonged tissue hypoxia, erythropoietin production increases to produce additional oxygen-
carrying RBCs.
Increased RBCs result in increased circulatory viscosity or polycythemia (ie, hemoglobin >22 g/dL [220 g/L] or
hematocrit >65%).
Polycythemia increases the risk for blood clotting (ie, thrombus formation), which can cause stroke. Therefore, a
hemoglobin level of 24.9 g/dL (249 g/L) is a priority to report to the health care provider because close observation and
additional interventions such as IV hydration and (possibly) partial exchange transfusion are required

POST-DELIVERY

Nursing interventions for a newborn immediately after delivery include:

o Standard precautions - The unbathed newborn is covered in maternal blood and bodily fluid. Standard precautions (eg,
gloves) are implemented when contact with blood or bodily fluid is anticipated.
o Maintain a clear airway - Suction the pharynx first followed by the nasal passages to prevent aspiration if the newborn gasps
with nasal suctioning.
o Thermoregulation (97.5-99 F [36.4-37.2 C]) reduces oxygen and stored calorie consumption. Hypothermia predisposes the
newborn to metabolic acidosis, hypoxia, and shock. A radiant warmer is used while performing assessments and
interventions. Use pre-warmed linens, an infant stocking cap, and a thermal skin sensor for monitoring. Skin-to-skin contact
aids in thermoregulation.
o Vitamin K is administered intramuscularly in the vastus lateralis (midanterior lateral thigh) within 6 hours of birth to prevent
bleeding due to absence of vitamin K-producing intestinal bacteria.
 o Ophthalmic ointment - Prophylactic antibiotic eye ointment for Neisseria gonorrhoeae is legally required; application may be
delayed up to 1 hour after delivery.
o Initial bathing of the newborn is limited to removing blood, bodily fluids, or meconium. Vernix caseosa, a waxy, white
coating, protects the skin and should not be vigorously removed

GESTATIONAL AGE ASSESSMENT

A gestational age assessment assists the nurse in providing developmentally appropriate care to preterm newborns.
This assessment uses indicators of neuromuscular and physical maturity that are assessed, scored, and added, which
correlates to an estimation of gestational age.
Lanugo, a fine, downy hair found mostly on the backs and shoulders of preterm newborns, begins disappearing
around 36 weeks gestation. At 28 weeks, the newborn has abundant lanugo over most of the body. The 28-week
newborn also has smooth, pink skin with visible veins as skin is thin and transparent with lack of subcutaneous fat.
The areolae of extremely premature infants may be barely visible, with no raised breast buds. Palpable, raised breast
buds measuring 5-10 mm would be expected in newborns closer to term gestation.
At 28 weeks gestation, a newborn's feet have very smooth soles with only faint red marks or possibly a single anterior
transverse crease. Creases over the entire sole and/or peeling skin would be expected in a full- or post-term (ie, 40+
weeks) newborn.
The testes of a male infant born at 28 weeks gestation would not yet have descended into the scrotal sac and may be
palpable in the upper inguinal canal.
COLD STRESS
Neonates are unable to generate heat by shivering due to their lack of muscle tissue and immature nervous systems;
they therefore produce heat by increasing their metabolic rates through nonshivering thermogenesis.
Brown adipose tissue (BAT), developed during the third trimester, is metabolized for thermogenesis when available.
Once BAT is depleted, nonshivering thermogenesis is less effective and the neonate may experience cold stress,
possibly leading to death.
Preterm neonates have fewer stores of BAT and are at higher risk for cold stress. Frequent temperature monitoring is
the best method to assess if an infant is cold.
In cold stress, metabolism increases to generate heat, causing a greater demand for oxygen and glucose and the
release of norepinephrine. If adequate oxygenation is not
maintained, hypoxia and acidemia occur. Hypoglycemia develops when available glucose is depleted, and repletion
of glucose is impaired by gastrointestinal immotility and poor oral intake.
Clinical manifestations of cold stress include:

o Neurological - altered mental status (irritability or lethargy)

o Cardiovascular - bradycardia
o Respiratory - tachypnea early, followed by apnea and hypoxia
 o Gastrointestinal - high gastric residuals, emesis, hypoglycemia
o Musculoskeletal - hypotonia, weak suck and cry
o

MORO REFLEX

Primitive newborn reflexes help determine the client's neurological status and development.
The Moro reflex (ie, startle reflex), present until age 3-6 months, is elicited by quickly lowering the infant's head
relative to the body, simulating a falling sensation. It is also a response to sudden loud noises and jarring of the crib.
Initially, the newborn extends and raises the arms with fingers fanned out and then curls into the fetal position.
Absence of the Moro reflex may indicate an underdeveloped or damaged brain or spinal cord and should be
reported to the health care provider

TRISOMY 18 (EDWARDS SYNDROME)

Trisomy 18 (Edwards syndrome) is a life-threatening chromosomal abnormality that affects multiple organ
systems. Many fetuses affected by this condition die in utero. Of the newborns that survive birth, half will die in the
first week of life and most do not make it to the first birthday.
Before withdrawal of ventilator support, it is appropriate for the nurse to request a collaborative meeting between the
health care providers (HCPs) and the palliative care team to help the parents understand their child's condition as
well as make decisions about interventions and the potential need for end-of-life care
The nurse should not notify parents of genetic test results; this is the responsibility of the HCP. Information regarding
the newborn's condition may be provided after the HCP notifies the parents of test results.
There is no cure for a newborn with trisomy 18 because it is a chromosomal abnormality.
The nurse should be sensitive toward the parents and provide accurate information. Telling the parents that their
newborn might live long enough to go home is inappropriate because it gives them false hope, as this possibility
occurs in only a small number of newborns with trisomy 18.
NEWBORN SAFETY

Principles of newborn safety should be reinforced during postpartum discharge teaching. The following safe sleep
practices help prevent sudden infant death syndrome:
o Dress newborns in no more than one more layer of clothing than an adult requires. A wearable blanket (ie, sleep sack)
can keep the newborn warm and prevents the head from being covered
o Always place the newborn in the supine position during sleep
o Ensure no loose bedding or other objects are in the crib (eg, blankets, stuffed toys, pillows).
o Prevent newborn head entrapment by ensuring crib slats are no more than 2¼ inches (5.72 cm) apart.

Essential teaching for proper car safety seat use includes:

o Secure the safety seat harness to fit snuggly against the newborn's body, with the retaining clip secured near the level of the
armpits. No bulky jackets or blankets should be between the newborn and the harness because this would reduce its
effectiveness during a crash
o Place the newborn in a federally approved, rear-facing car seat secured in the back seat
o Position the newborn at a 45-degree angle to prevent airway obstruction. Rolled blankets/car seat inserts on both
sides/under the crotch strap may be used to prevent slouching.
NEONATAL ABSTINENCE SYNDROME

A neonate born to an opioid-dependent mother (eg, heroin, methadone, hydrocodone) is at high risk for neonatal
abstinence syndrome, in which the newborn experiences opioid withdrawal typically within 24-48 hours after birth.
Clinical manifestations of withdrawal in infants include irritability, jitteriness, high-pitched cry, sneezing, diarrhea,
vomiting, and poor feeding.
Hypersensitivity can make feeding difficult; the newborn should be placed in a side-lying position while swaddled to
minimize stimulation and promote nutritive sucking
Between feedings, a pacifier may be used to soothe the infant and help establish an organized sucking pattern.
Excessive movement places the newborn at high risk for skin excoriation; the infant should be tightly swaddled with
arms flexed to minimize irritation and prevent damage to the skin.
Hand mittens and barrier skin protection to the knees, elbows, and heels may also be used.
Stimulation should be avoided due to the newborn's hypersensitive state; the newborn should be placed in a quiet,
dim-lit section of the nursery. The nurse should also organize tasks ("cluster care") to minimize stimulation.
The newborn should be placed on the right side after feeding to promote gastric emptying and reduce the risk of
vomiting.
INFANT OF DIABETIC MOTHER

Poorly controlled maternal diabetes negatively affects fetal growth and oxygenation throughout pregnancy. As a
result, infants of diabetic mothers are at an increased risk for postnatal complications.
In clients with poorly controlled diabetes, the fetus experiences hyperglycemia and produces excess insulin. To
compensate, the fetus increases metabolic activity and oxygen consumption.
 Fetal erythropoietin production subsequently increases to produce additional red blood cells (erythropoiesis), which
are needed to transport oxygen to tissues. This increased production of red blood cells leads to polycythemia
(ie, hematocrit >65%) and increased circulatory viscos

MATERNAL NEW BORN > POST PARTUM

STILLBIRTH
Intrauterine fetal demise, or stillbirth, is the birth of an infant who is not alive. The nurse can assist with the perinatal
bereavement process by using therapeutic communication, encouraging the parents and family to hold the infant,
and providing privacy.
Parents and family members may wish to help bathe and dress the infant, and should be encouraged to view and hold
the body before discharge to the funeral home
The nurse should offer to obtain handprints and footprints, cut a lock of the infant's hair, and photograph the infant.
These keepsakes are often precious mementos for grieving families who must leave the hospital without a child.
However, none of these actions should be forced if the parents decline.

PULMONARY EMBOLISM
Pregnancy is a hypercoagulable state that provides protection from hemorrhage after birth, but also greatly
augments risk of thrombus formation.
Women who give birth by cesarean section are at particularly increased risk for deep venous thrombosis (DVT).
Additional risk factors for DVT include obesity, smoking, and genetic predisposition.
If unrecognized, DVT may progress to pulmonary embolism (PE), often characterized
by anxiety/restlessness, pleuritic chest pain/tightness, shortness of breath, tachycardia, hypoxemia, and
hemoptysis.
 The nurse's priority is rapidly identifying symptoms, assessing respiratory status, administering supplemental oxygen,
and notifying the health care provider (HCP)

POSTPARTUM DEPRESSION

Postpartum depression (PPD) is a perinatal mood disorder that affects women following childbirth.
Symptoms may include crying, irritability, difficulty sleeping (or sleeping more than usual), anxiety, and feelings
of guilt.
Symptoms typically arise within 4 weeks of delivery and can affect the mother's ability to care for herself and the
newborn.
The nurse should ask specific questions about depression or hopelessness to assess for PPD. It is also important
to ask about thoughts of self-harm or harm to the newborn.
POSTPARTUM ENDOMETRITIS

Postpartum endometritis occurs when the endometrium (uterine lining) becomes infected after birth, often beginning
at the placental site. Endometritis is characterized by uterine tenderness and subinvolution, foul-smelling or purulent
lochia, fever, tachycardia, and chills. Cesarean birth is a primary risk factor, particularly if performed emergently or
after prolonged labor.
The infection is usually polymicrobial and requires treatment with broad-spectrum antibiotics (eg, IV clindamycin
plus IV gentamicin).
Antibiotic administration is a priority because it treats the primary cause of endometritis and prevents complications
related to the spread of infection (eg, abscess, peritonitis).
Antibiotics are required until approximately 24 hours after symptoms resolve.
BREAST ENGORGEMENT
Breast engorgement is often painful. The management of engorgement varies based on the client's breastfeeding
status; for clients who choose not to breastfeed, treatment focuses on managing symptoms while promoting reduced
milk production.
Comfort measures include:

o Applying ice packs to both breasts for 15-20 minutes every 3-4 hours to reduce blood flow and swelling
o Applying chilled, fresh cabbage leaves to both breasts, replacing with fresh leaves after they wilt. The mechanism of action
is unclear but may be related to the cool temperature or to phytoestrogens from the leaves
o Taking an anti-inflammatory analgesic (eg, ibuprofen) as directed to reduce pain
o Maintaining firm breast support (eg, supportive bra, breast binder) until milk flow is diminished

Heat application increases blood flow and worsens engorgement. Although running warm water over the breasts may
make milk leak and temporarily relieve pressure, more milk is produced later, which is counterproductive in a client
who has chosen not to breastfeed.
Breastfeeding is a supply-and-demand process. Massaging the breasts or manually expressing milk stimulates milk
production, which exacerbates engorgement if the client is not breastfeeding.

LOCHIA

A foul odor of lochia suggests endometrial infection.

 This client has an increased risk of infection due to her prolonged labor, which involved multiple cervical
examinations.
The odor of lochia is usually described as "fleshy" or "musty."
A foul smell warrants further evaluation. Other signs of endometrial infection are maternal fever, tachycardia, and
uterine pain/tenderness.

POSTPARTUM HEMORRHAGE

Postpartum hemorrhage (PPH) is usually defined as maternal blood loss of >500 mL after a vaginal birth or >1000
mL after a cesarean birth.
Uterine atony, characterized by a soft, "boggy," and poorly contracted uterus, is the most common cause of early
PPH (occurring after birth).
Delayed PPH (>24 hours after birth) usually results from retained placental fragments associated with a long third
stage of labor (ie, time from birth of baby to expulsion of placenta, lasting >30 minutes).
Risk factors for PPH include:

o History of PPH in prior pregnancy

o Uterine distension due to:

Multiple gestation
Polyhydramnios (ie, excessive amniotic fluid)
Macrosomic infant

o Uterine fatigue (labor lasting >24 hours)

o High parity
o Use of certain medications:

Magnesium sulfate
Prolonged use of oxytocin during labor
Inhaled anesthesia (ie, general anesthesia
 Postpartum hemorrhage (PPH) may be primary (ie, <24 hours since birth) or secondary/delayed (ie, >24 hours but
<6 weeks postpartum).
Secondary PPH usually results from uterine subinvolution, retained placental fragments/membranes, or uterine
infection.
The nurse should expect a client >3-4 days postpartum to report a progressive change in lochia from lochia rubra
(dark-red vaginal bleeding) to lochia serosa (pink or brown discharge).
A gradual decrease in the amount of lochia is reassuring and expected. However, reports of increased vaginal
bleeding, soaking a pad in <1-2 hours, reverting from lochia serosa back to lochia rubra, or passing several/large
clots (ie, larger than a nickel) are concerning findings that require the nurse's immediate follow-up
If excessive bleeding persists after initial interventions (eg, firm fundal massage, oxytocin bolus), second-line
uterotonic drugs (eg, carboprost, methylergonovine, misoprostol) may be given.
Methylergonovine [Methergine] is contraindicated for clients with high blood pressure (eg, preeclampsia,
preexisting hypertension) because the primary mechanism of action is vasoconstriction. If administered to a
hypertensive client, it can lead to further blood pressure elevation, seizure, or stroke
Misoprostol combats uterine atony by contracting the uterine muscle, rather than through vasoconstriction, making it a
safe option for clients with hypertension. The drug is often given per rectum for PPH to increase absorption.
Obtaining a hemoglobin and hematocrit is appropriate to further evaluate how the client is handling the blood loss and
helps determine the need for a transfusion.
Because blood products cannot be given in the same IV line as other medications, starting a second IV line is
appropriate for clients who may require a transfusion to allow for adequate fluid resuscitation and rapid blood product
administration. Blood products are given through an 18-gauge, or larger, catheter.

LACTATIONAL MASTITIS
Lactational mastitis (infection and inflammation of breast tissue) may result from inadequate milk duct drainage or
poor breastfeeding technique. Bacteria from the infant's nasopharynx or mother's skin can enter the nipple, especially
 if it is damaged, and multiply in stagnant milk. Manifestations include fever, muscle aches, and breast pain and
inflammation (eg, warmth, redness, edema).
Staphylococcus aureus is the most common causative organism and requires antibiotic treatment (eg, dicloxacillin,
cephalexin). In addition, the nurse should encourage the client to:

o Continue breastfeeding frequently (ie, every 2-3 hr) to ensure adequate milk drainage.
o Ensure proper breastfeeding technique (eg, alternate newborn feeding positions, proper latch).
o Apply warm compresses and massage the breast to facilitate complete emptying. Cool compresses can also be used
between breastfeeding as needed for comfort.
o Ensure adequate rest, nutrition, and hydration
o Relieve pain and inflammation with analgesics compatible with breastfeeding (eg, acetaminophen, ibuprofen)
o Wash hands before and after feeding.

POSTPARTUM URINARY RETENTION

 Postpartum urinary retention is commonly related to decreased bladder sensation (eg, due to regional anesthesia,
prolonged labor, or perineal trauma) and postpartum diuresis. Urinary retention can cause bladder distension, which
may be noted by a displaced and/or boggy uterus, or by a palpable bladder.
If bladder distension cannot be resolved with spontaneous voiding, in-and-out (I&O) catheterization may be
indicated, especially if the client:

o Is unable to ambulate to the restroom or void into a bedpan (Option 3)

o Has not voided within 6-8 hours after delivery or removal of the indwelling urinary catheter after cesarean delivery
o Has difficulty emptying bladder completely (ie, voiding <100 mL frequently)

A displaced fundus (ie, elevated above the umbilicus and/or to one side) is evidence of bladder distension.
Reassessing in an hour may increase the risk of postpartum hemorrhage, as a full bladder can cause uterine atony.

ECLAMPSIA

Persistent headache and blurred vision could indicate postpartum preeclampsia.

The majority of clients with preeclampsia develop symptoms before birth; however, a small percentage do not develop
the complication until several days after birth.
This potentially serious condition can rapidly worsen, leading to seizures and death if left untreated.
Additional signs and symptoms may include high blood pressure, proteinuria, and edema

UTERINE ATONY
 Postpartum vaginal bleeding that saturates a perineal pad in <1 hour is considered excessive. This client saturated
a perineal pad in 20 minutes.
Based on the nurse's assessment, the boggy fundus indicates uterine atony. The fundus is also elevated above the
umbilicus and deviated to the right, indicating a distended bladder. Bladder distension prevents the uterus from
contracting sufficiently to control bleeding at the previous placental site. The client should be assisted to void to
correct the bladder distension. The nurse should then perform fundal massage.
Oxytocin is a uterotonic that increases contraction of the myometrium, constricting vessels at the previous placental
implantation site. An oxytocin infusion should be initiated if initial attempts to control postpartum bleeding (relief of
bladder distention and fundal massage) have failed. The usual postpartum oxytocin IV dosage is 125-200
milliunits/min.
A complete blood count is needed to determine hematocrit and hemoglobin levels following excessive postpartum
bleeding. However, this is not the immediate priority.
Oxygen delivery at 10 L/min via a nonrebreather facemask may be initiated if the client becomes symptomatic
following excessive blood loss. However, the first priority is to control the bleeding.

BREASTFEEDING
Sore nipples and painful breastfeeding are common reasons clients discontinue breastfeeding.
Teaching proper technique helps clients continue breastfeeding, promotes comfort for the mother, and ensures
adequate newborn nutrition.
Key principles of proper breastfeeding and latch technique include:

o Breastfeed every 2-3 hours on average (8-12 times/day)

o Breastfeed "on demand" whenever the newborn exhibits hunger cues (eg, sucking, rooting reflex)
o Position the newborn "tummy to tummy" with mouth in front of nipple and head in alignment with body
o Ensure a proper latch (ie, grasps both nipple and part of areola)
o Feed for at least 15-20 minutes per breast or until the newborn appears satisfied
o Insert a clean finger beside the newborn's gums to break suction before unlatching (Option 3)
o Alternate which breast is offered first at each feeding

POSTPARTUM SEXUAL ACTIVITY

Most client resume sexual activity before first postpartum (4-6 wks) visit. Encourage barrier protection to prevent pregnancy
as ovulation (especially clients feeding formula) can occur even before resumption of menses as early as 4 weeks after birth.
Sexual Activity can resume once laceration/ episiotomy is healed, while the risk of infection or bleeding is low (at 2 weeks)
with a normal vaginal delivery. Sexual arousal takes more time for postpartum clients d/t hormonal changes. Lactating clients
experience a dec in estrogen (vaginal drying) in which case lubrication is recommended for comfort. Sexual arousal may
stimulate breast leaking of breast milk and therefore feeding the infant before alleviates these concerns

PSYCHIATRIC/MENTAL HEALTH NURSING

SOMATIC SYMPTOM DISORDER
Somatic symptom disorder (SSD) is a psychological disorder that develops from stress, resulting in
medically unexplainable physical symptoms (eg, abdominal pain) that disrupt daily life.
Clients with SSD focus an excessive amount of time, thought, and energy on the symptoms, often seeking medical
care from multiple health care providers.
Nursing interventions focus on minimizing indirect benefits and developing client insight.
To minimize the indirect benefits from being "sick" (secondary gains), the nurse should:

o Redirect somatic complaints to unrelated, neutral topics

o Limit time spent discussing physical symptoms

To promote insight and healthy coping mechanisms, the nurse should assist the client to:
o Identify secondary gains (eg, increased attention, freedom from responsibilities)
o Recognize factors that intensify symptoms (eg, increased stress, reminders of a deceased family member)
o Incorporate appropriate coping strategies (eg, relaxation training, physical activity)
An elimination diet would increase the client's focus on the symptoms and is inappropriate, as physiological causes
have already been ruled out.
The client's symptoms are real despite the lack of diagnostic findings. The nurse should administer analgesics as
prescribed.
Disputing the validity of the client's symptoms may increase the client's stress level and exacerbate symptoms.

ANOREXIA NERVOSA
Anorexia nervosa is a psychogenic eating disorder with potentially fatal physiological implications. Clients commonly
become extremely underweight and protein-energy malnourished. Clients admitted for anorexia nervosa are typically
in a crisis state, and the priority is restoring physiological integrity through appropriate weight gain and nutritional
intake.
Nursing care includes:

o Assisting the client in reflecting on triggers for dysfunctional eating and fears and feelings related to gaining weight
o Maintaining strict documentation of dietary protein and calorie intake to ensure healthy weight gain
o Remaining with the client during and 1 hour following meals to ensure intake and prevent purging behaviors
o Establishing a weekly weight-gain goal (typically 2-3 lb/wk [0.91-1.36 kg/wk])
o Weighing the client at the same time each morning (after voiding and before any oral intake) and wearing the same clothing
to assess efficacy of nutritional support
o Limiting physical activity initially and gradually increasing as oral intake improves
o Not focusing on food initially, but encouraging participation in meal planning as the client nears target weight

Clinical manifestations of anorexia nervosa include:

1. Fear of weight gain clients resort to self-induced vomiting, extensive dieting, and intense exercise resulting in excessive
weight loss (<85% expected weight). Clients who self-induce vomiting may experience enlargement of the salivary glands
and erosion of tooth enamel.
2. Fluid and electrolyte imbalance excessive vomiting can cause hypokalemia and metabolic alkalosis
3. Amenorrhea clients are often amenorrheic due to decreased body fat (low estrogen)
4. Decreased metabolic rate severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold
intolerance
5. Lanugo (fine terminal hair) can be seen in extreme case
 Nutrition support (enteral tube feedings and total parenteral nutrition) is usually reserved for clients with anorexia
nervosa who are severely ill and/or have not responded to oral nutritional therapy. Such clients are at high risk for
medical complications from anorexia nervosa, including death. Criteria for nutrition support include:

o Severe weight loss that is life threatening

o Client's unwillingness to adhere to a treatment plan of oral feedings

The priority nursing actions for this high-risk client include interventions to meet physiological and safety needs.
Providing one-on-one supervision during the tube feeding will ensure that the client is actually receiving the feeding
and prevent the client from stopping the feeding and/or pulling out the nasogastric tube.
During the one-on-one contact with the client, the nurse can promote a therapeutic and trusting relationship with the
client by:

o Being honest and accepting of the client

o Presenting the reality of the condition
o Acknowledging the client's feelings of loss of control and anger
o Encouraging the client to express feelings and fears

This is an appropriate intervention for a client with anorexia nervosa. Feelings related to lack of control are an
underlying problem for these clients, who use food as a way to deal with them. Keeping a diary or journal of feelings
will help the client recognize and express them more clearly. However, this is not the priority nursing action.
This may be a true statement; clients with anorexia nervosa are usually discharged to out-patient follow-up and
treatment or to a residential treatment facility once an acceptable weight gain has been achieved and maintained.
However, this is not the priority nursing action.

INVOLUNTARY ADMISSION
 Clients have the right to refuse hospital admission and treatment. However, all states and provinces have laws and
procedures for involuntary admission that require clients to receive inpatient treatment for a psychiatric disorder
against their will. The legal criteria for involuntary admission include:

o The individual appears to be an imminent danger to self or others

o The individual has a grave disability (ie, is unable to adequately care for basic needs [food, clothing, shelter, medical care,
personal safety]) as a result of a mental illness

Clients also have the right to the least restrictive environment in which treatment can be provided in a safe manner.
Involuntary commitment is generally used as a last resort in dealing with a client whose illness is so severe that
judgment and insight in deciding to refuse treatment are markedly impaired.
TERMINAL ILLNESS

ANTI-SOCIAL PERSONALITY DISORDER

Clients with antisocial personality disorder often disregard the rules, have a history of irresponsible behavior,
and blame others for their behavior.
 They avoid responsibility for their own behavior and the consequences of their actions using numerous excuses and
justifications.
Nursing interventions include setting firm limits and making clients with antisocial personality disorder aware of the
rules and acceptable behaviors. The nurse should require the client to take responsibility for his/her own behavior and
the consequences of not following the rules and regulations of the unit.

PSYCHOMOTOR RETARDATION
Psychomotor retardation is a clinical symptom of major depressive disorder. Manifestations of psychomotor
retardation include slowed speech, decreased movement, and impaired cognitive function. The individual may not
have the energy or ability to perform activities of daily living or to interact with others. Psychomotor retardation may
range from severe (total immobility and speechlessness -catatonia) or mild (slowing of speech and behavior).
Specific clinical findings of psychomotor retardation include the following:

o Movement impairment - body immobility, slumping posture, slowed movement, delay in motor activity, slow gait
o Lack of facial expression
o Downcast gaze
o Speech impairment reduced voice volume, slurring of speech, delayed verbal responses, short responses
o Social interaction reduced or non-interaction

DOMESTIC ABUSE

The priority for possible domestic abuse victims is to remove them from any sources of immediate danger, including
suspected abusers.
Such clients should be questioned and assessed alone so that the suspected abusers do not guide their answers or
intimidate them from providing truthful responses.
In this case, the spouse appears angry and should, as a priority, be removed from the room to prevent further potential
harm to the client or staff
HALLUCINATIONS

An important step toward self-management of hallucinations is for the client to recognize that the hallucinations are
not real.
When a client is experiencing hallucinations, the nurse needs to reinforce reality and acknowledge how the client
may be feeling.
The nurse can point out his/her own perceptions without denying the client's experience.
It is nontherapeutic to argue with or challenge the client about the hallucination, saying, for example, "How could a
man get into your room? This is a locked hospital unit."
Examples of additional therapeutic responses to a client who is experiencing hallucinations include the following:

o "I don't see anything, but I understand that what you are seeing may be very upsetting to you."
o "I understand that you are worried about the voices you are hearing. They are a part of your disease and not real."
o "I know the voices seem real to you and may be scary. I do not hear the voices."

The priority nursing action is to explore the content of the hallucinations. This client may be experiencing command
auditory hallucinations that could lead to self-directed or other-directed injury and harm. After the content of the
hallucinations has been explored, implementing an intervention may be necessary to reduce the potential for violence.
Hallucinations are false sensory perceptions that have no external stimuli. They can occur in any of the 5 senses.
Auditory hallucinations are the most common, followed by visual, tactile (touch), olfactory (smell), and gustatory
(taste).
Additional ways to deal with hallucinations include the following:

o Telling the client that you know they are real to the client but that you do not hear the voices (or see the vision, feel the
sensation)
o Not arguing with or challenging the client about the hallucinations
o Directing the client to a reality-oriented topic of conversation or activity
PARANOID PERSONALITY

Individuals with paranoid personality disorder have a pervasive distrust and suspicion of others; they believe that
people's motives are malicious and assume that others are out to exploit, harm, or deceive them.
These thoughts permeate every aspect of their lives and interfere with their relationships.
Individuals with paranoid personality disorder are usually difficult to get along with as they may express their suspicion
and hostility by arguing, complaining, making sarcastic comments, or being stubborn.
Because these clients do not trust others, they have a strong need to be self-sufficient and maintain a high degree of
control over their environment.

CAREGIVER ROLE STRAIN

Caregiver role strain (CRS) is a caregiver's perception of the multifactorial difficulties associated with providing care
to another person (usually a family member). The nurse should assess caregivers for signs of physical (eg, fatigue,
insomnia, weight loss/gain), emotional (eg, depression, anxiety, anger), and social (eg, isolation, loss of support
systems) problems.
Monitoring caregivers for CRS is important, as it can have a significant negative impact on their health and well-being.
Asking about the nature and requirements of providing daily care allows the caregiver to discuss the demands of
providing care and helps the nurse understand stressors and unmet needs
This type of inquiry is a therapeutic response that encourages verbalization of thoughts, feelings, and concerns.
Assessment of caregiving challenges also helps to identify opportunities for assistance (eg, skills training, support
groups) and community resources (eg, home health care, food/nutrition services).

CRITICAL INCIDENT
This client's spouse has experienced a traumatic or crisis event (also referred to as "a critical incident").
 When faced with a traumatic situation, clients are often overwhelmed and respond with a wide range of emotions and
thoughts, including shock, denial, anger, helplessness, numbness, disbelief, and confusion.
Clients may also experience physical symptoms, such as hyperventilation, abdominal pain, and dizziness.
Priority nursing actions need to be directed at the here and now, providing therapeutic interventions aimed at
alleviating the immediate emotional impact of this disruptive crisis event.
Acknowledging the severity of the event validates and normalizes the spouse's reaction. Assisting the spouse in
identifying feelings and giving the spouse opportunity to ventilate will help reduce immediate emotional stress.

ADHD
The core symptoms of ADHD include hyperactivity, impulsiveness, and inattention.
Hyperactive children are restless; have difficulty remaining seated when required; and exhibit excessive talking,
blurting out answers prematurely, and interrupting others.
Inattention is characterized by reduced ability to focus and attention to detail, easy distractibility, and failure to follow
through (eg, homework, chores).
The primary symptoms of ADHD have a negative impact and can make life difficult for children in school, at work, and
in social situations.
Symptoms interfere with opportunities to acquire social skills and may also result in rejection and critical judgment
by peers.
The negative consequences of ADHD include:

o Poor self-esteem
o Increased risk for depression and anxiety
o Increased risk for substance abuse
o Academic or work failure
o Trouble interacting with peers and adults

A key feature of attention-deficit hyperactivity disorder (ADHD) is hyperactivity; however, some children with ADHD
behave aggressively and have difficulty controlling anger, especially when frustrated or if unable to meet demands
and challenges.
 An immediate intervention to help settle an out-of-control child is deep breathing. Taking slow, deep breaths relaxes
the body, slows the heart rate, and distracts the child from inappropriate behaviors. Asking the child to blow up a
balloon provides an easy mode of distraction and engages the child in a deep breathing exercise. After the child is
calm, the nurse and the child can further discuss the disruptive behavior.
Nursing interventions include the following:

o Stay calm and remove the child from the source of frustration/anger
o Assist the child in calming down with deep breathing exercises
o Discuss what precipitated the behavior and why the behavior is wrong
o Discuss acceptable ways of expressing anger and frustration
o Acknowledge that controlling anger is difficult
o Provide rewards for appropriate behavior
o Discuss the consequences of inappropriate behavior

PERSECUTORY DELUSIONS

Clients with persecutory delusions (paranoid delusions) believe that they are being persecuted or harmed (eg, spied
on, cheated, followed, poisoned).
Focusing on the client's feelings secondary to the delusion is an example of empathy, one of the most important parts
of the therapeutic nurse-client relationship.
When nurses attempt to understand clients' feelings and their meaning, clients realize that someone is trying to
understand them and the nurse-client relationship grows
Focusing on reality and verbally reinforcing it will decrease the time that the client spends thinking about the
delusions
For example, the nurse may focus on the client's feelings by stating, "I understand that it is frightening to know that
someone is trying to poison you." Reality orientation may also be helpful by telling the client, "What you are thinking is
part of your disease and not real."
Attempting to explore the meaning behind a delusion will encourage the client to focus/think more on this delusion.
Confronting the client about the delusion is not therapeutic because arguing will not eradicate the delusion. It also
hinders the development of a trusting nurse-client relationship.
 Clients believe that their delusions are real despite proof otherwise. Presenting logical explanations to discredit the
delusions will not help.

POSTTRAUMATIC STRESS DISORDER

Posttraumatic stress disorder (PTSD) is a reaction to a traumatic or catastrophic event that is typically life-
threatening to oneself or others.
There are 3 categories of PTSD symptoms:
1. Reexperiencing the traumatic event
Examples include intrusive memories, flashbacks, recurring nightmares, and feelings of intense distress/loss of control or
strong physical reactions to event reminders (rapid, pounding heart; gastrointestinal distress; diaphoresis)
2. Avoiding reminders of the trauma
Examples include avoidance of activities, places, thoughts, or other triggers that could be trauma reminders, feeling detached
and emotionally numb, loss of interest in life, lack of future goals, and amnesia related to important details of the event
3. Increased anxiety and emotional arousal
Examples include insomnia, irritability, outbursts of anger and/or rage, difficulty concentrating, hypervigilance, and feeling
jumpy
The first step toward resolution of posttraumatic stress disorder (PTSD) is the client's readiness (ability and
willingness) to discuss the details of the traumatic event without experiencing high levels of anxiety.
The nurse must assess clients with PTSD for their readiness to talk about the experience and encourage them to
discuss the trauma at their own pace. The nurse should also use active listening as a therapeutic approach to build
trust and allow clients to vent. This will assist in decreasing their feelings of isolation.
The nurse can also guide the client in identifying event details that are most troubling and trigger a sense of loss of
control. The effectiveness of the client's coping mechanisms can be identified, and alternate strategies to replace
maladaptive ones can be explored.

OCD
 Clients with OCD engage in rituals and behaviors that help reduce the anxiety or stress rooted in their obsessions
(recurrent thoughts, impulses, or images that cause notable distress). If the ritual is interrupted, the client will
experience increased anxiety.
A client with compulsive behavior often does not realize the amount of time or how many times the same activity has
been performed. By providing reflective feedback about the client's behavior, the nurse is acknowledging the behavior
in a nonjudgmental manner. The nurse should also help the client become involved in other activities and problem-
solving skills.
Individuals with obsessive-compulsive personality disorder are typically self-willed and obstinate, punctual, pay
attention to rules and regulations, and need to control both internal and external experiences. These traits are very
extreme and result in rigidity and inflexibility. In this scenario, a change has been made in the client's schedule for
the day and is outside of the client's control. This could cause significant distress and impaired functioning so that the
client feels emotionally paralyzed.

DEFENSE MECHANISMS
BULIMIA NERVOSA

Bulimia nervosa (BN) is an eating disorder characterized by episodes of uncontrollable binge-eating (consuming
very large amounts of food, often in secret) followed by inappropriate compensatory behaviors to prevent weight gain.
Compensatory behaviors may include laxative or diuretic use, self-induced vomiting, or excessive exercise 1-2 hours
after binging .Other signs of BN may include:

o Physical changes related to self-induced vomiting (eg, scars or calluses on the hand, enlarged parotid glands, erosion of
tooth enamel, dental caries)
o Preoccupation with body image, weight, food, and dieting

TRANSGENDER

Transgender clients may fear judgment or embarrassment and withhold information, avoid seeking treatment, or
refuse care as a result. This is often related to past experiences of discrimination or stigma when receiving health
care. Therefore, it is important to use therapeutic communication and avoid stereotypes to establish trust.
Transgender clients may identify as male or female or as neither or both genders. It is important for the nurse to
determine clients' gender identity by asking open-ended questions that allow clients to explain their identities in their
own words
DELIRIUM
Major predisposing factors for the development of delirium in hospitalized clients include:

1. Advanced age
2. Underlying neurodegenerative disease (stroke, dementia)
3. Polypharmacy
4. Coexisting medical conditions (eg, infection)
5. Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia)
6. Metabolic and electrolyte disturbances
7. Impaired mobility - early ambulation prevents delirium
8. Surgery (postoperative setting)
9. Untreated pain and inadequate analgesia

The Confusion Assessment Method (CAM) is used to determine delirium. The signs are acute mental status
changes that fluctuate and inattention with disorganized thinking and/or altered level of consciousness. The
disorganized thinking includes hallucinations. Risk factors for delirium include older age, prior cognitive impairment,
presence of infection, severe illness or multiple comorbidities, dehydration, psychotropic medication use, alcoholism,
vision impairment, and pain.
Delirium has an abrupt onset and is a symptom of other problems. Up to 60% of hospitalized elderly clients have
delirium prior to or during hospitalization, but it is often missed by nursing.
DELUSIONS

Delusions are one of the positive symptoms of schizophrenia. Delusions are false beliefs that have no basis in
reality and are unrelated to a client's culture or intelligence. When presented with proof that the delusion is irrational
or untrue, the client continues to believe it is real. Clients experiencing delusions of reference will believe that songs,
newspaper articles, and other events are personal and significant to them.
Other examples of delusions are below:

o Grandeur "I need to get to Washington for my meeting with the president."
o Control "Don't drink the tap water. That's how the government controls us."
o Nihilistic "It doesn't matter if I take my medicine. I'm already dead."
o Somatic "The doctor said I'm fine, but I really have lung cancer."

Delusions are fixed, false beliefs that are accepted by the client as real and cannot be changed by logic, reason, or
persuasion. Categories of delusions include the following:

o Persecutory client thinks others are "out to get me"

o Ideas of reference common events refer specifically to the client
o Grandiose client has the perception of special importance or powers that are not realistic
o Somatic false ideas about bodily functioning
 Nursing interventions include the following:

o Not arguing or challenging the belief

o Reinforcing reality by talking about and encouraging the client to participate in real events. The nurse should not delve into or
have long conversations about the delusional belief system.

CHILD ABUSE

Typical characteristics of child abuse perpetrators include:

o Unrealistic expectations of the child's performance, behavior, and/or accomplishments; overly critical of the child
o Confusion between punishment and discipline; having a stern, authoritative approach to discipline
o Having to cope with ongoing stress and crises such as poverty, violence, illness, lack of social support, and isolation
o Low self-esteem a sense of incompetence or unworthiness as a parent
o A history of substance abuse; use of alcohol or drugs at the time the abuse occurs
o Punitive treatment and/or abuse as a child
o Lack of parenting skills, inexperience, minimal knowledge about child care and child development, and young parental age
o Resentment or rejection of the child
o Low tolerance for frustration and poor impulse control
o Attempts to conceal the child's injury or being evasive about an injury; shows little concern about the child's injury

Child abusers are not easily identified by appearance; they often appear calm and well in control but may have violent
outbursts, typically in private.
When speaking with a child about abuse, the nurse should be direct and honest. The nurse should allow the child to
disclose the abuse at a comfortable pace, rather than probe for additional information. The nurse should use open-
ended questions and avoid leading questions and statements.
Guidelines for the interview:

o Speak with the child in private

o Be honest about reporting requirements
o Use language appropriate to the child's age
o Avoid making assumptions or communicating anger, shock, or disapproval
o Reassure the child about not being at fault or in trouble
 When the nurse suspects that a child may be the victim of child abuse, the parent or caregiver should be questioned,
and all possibilities (eg, alternate caregivers) should be explored to find the source of the abuse.
If possible, the interview should be done without the child present. The nurse should remain supportive and
empathetic and convey a nonjudgmental, nonthreatening attitude, avoiding words such as "abuse" and "violence."
Open-ended questions are less threatening and provide more detailed responses. Information to gather includes:

o Caregiver's perspective on the child's behavior

o Methods of discipline used with the child
o Routine caregivers for the child
o Caregiver stress, coping, and support systems
o Person or persons who care for the child when regular caregivers are away

BORDERLINE PERSONALITY DISORDER

Individuals with borderline personality disorder (BPD) live in fear of rejection and abandonment. To avoid
abandonment, they use manipulation and control, often unconsciously, to prevent a person from leaving.
The manipulative behavior may be of a positive nature, such as the use of flattery, or a negative nature, such as
distancing from the other person.
An individual with BPD may also engage in self harm or suicidal behaviors in an attempt to gain attention from the
other person and keep that person from leaving.
For this client, the nursing care plan must include the assignment of different staff members. This will help diminish
the client's dependence on a particular individual and help the client learn to relate to more than one person.

AUTISM SPECTRUM DISORDER

A structured routine and consistency during hospitalization are critical in the care of clients with autism spectrum
disorder (ASD).
 The nurse should talk with the parent and/or caregiver to determine the client's usual patterns and habits for a typical
day at home, including meal times, bath time, and play time.
In the unfamiliar and often unpredictable environment of the acute care setting, a schedule of activities can decrease
anxiety and help the client with ASD anticipate what will happen next.

ELECTROCONVULSIVE THERAPY
Electroconvulsive therapy (ECT) induces a generalized seizure by passing an electrical current through electrodes
applied to the scalp.
Although the exact mechanism is unknown, 15-20 second seizures are proven effective in treating mood disorders
(eg, major depression, bipolar disorder) and schizophrenia. Client teaching includes:

o NPO status is required for 6-8 hours prior to treatment except for sips of water with medications
o Anesthesia (eg, methohexital, propofol) and a muscle relaxant (eg, succinylcholine) will be administered; clients
are unconscious and feel no pain during the procedure.
o Driving is not permitted during the course of ECT treatment
o Temporary memory loss and confusion in the immediate recovery period are common side effects of ECT

Post-treatment nursing care includes monitoring vital signs, ensuring a patent airway, assessing mental status, and providing
frequent reorientation during periods of postictal confusion.
Due to the severity of this client's clinical presentation, ECT would be the appropriate initial treatment.
The client's depression has psychotic features and the suicide attempt used a highly lethal method. The client
continues to be highly suicidal as evidenced by behavior and thought content.
ECT can be highly effective in helping severe depression, when clients pose a severe threat to themselves and it is not
safe to wait until medications take effect.
ECT is also used in clients who have not responded to medication or cannot tolerate side effects.
During ECT, the client is treated with pulses of electrical energy through electrodes applied to the scalp; the electrical
stimulus is sufficient to cause a brief convulsion.
General anesthesia and a skeletal muscle relaxant are administered to minimize the motor seizure and prevent
musculoskeletal injury. The client feels nothing from the procedure, but confusion and memory loss are common
side effects.
 The usual course of acute therapy is 6-12 ECT treatments performed 2-3 times a week. Response to ECT can be
dramatic and life-saving. Maintenance therapy (treatment at 1- to 8-week intervals) can continue on a long-term basis
to help prevent relapses. Medication therapy is often given in combination with ECT and is associated with improved
outcomes.
The best response to a client or family member who expresses doubts about ECT is to ask about their concerns.
Responses such as, "Tell me about your concerns," or "What do you understand about ECT?" allow the nurse to
assess their knowledge and implement educational interventions to address any misinformation or knowledge gaps.

CODEPENDENT BEHAVIOR

Codependent behaviors are those that allow the codependent person to maintain control by fulfilling the needs of the
addict first.
Behaviors such as keeping the addiction secret, suffering physical or psychological abuse from the addict, not allowing
the addict to suffer the consequences of actions, and making excuses for the addict's habit are hallmarks of
codependency.
If the addict isn't happy, the codependent person will try to make the addict happy.
Codependent persons will focus all their attention on others at the expense of their own sense of self.
Codependent spouses, friends, and family members keep the client from focusing on treatment; this behavior
is counterproductive to both themselves and the client.

Memantine is used to ease the symptoms of moderate to severe Alzheimer disease (AD), thereby improving the
quality of life for clients and caregivers. Memantine is an N-methyl-D-aspartate (NMDA) antagonist that works by
binding to NMDA receptors, blocking the brain's NMDA glutamate pathways, and protecting brain cells from
overexposure to glutamate (excess levels of glutamate contribute to brain cell death).
Clients with moderate to severe AD may experience improvement in:

o Cognition memory, thinking, language

o Daily functioning dressing, bathing, grooming, eating
o Behavioral problems agitation, depression, hallucinations
 Clients with Alzheimer disease (AD) often exhibit behavioral problems (eg, agitation, resisting care) due to cognitive
decline. Behavioral management techniques include:

o Acknowledgement of the client's emotions, which reduces feelings of being isolated and misunderstood
o Reassurance that the client will be kept safe from harm
o Distraction (eg, photographs, music, television) to divert the client's attention
o Redirection to simple tasks (eg, folding towels/napkins, stacking plates)

INTIMATE PARTNER VIOLENCE

Intimate partner violence (IPV) is physically, emotionally, verbally, sexually, or economically abusive behavior
inflicted by one partner against another in an intimate relationship, to maintain power and control. Nurses must be
aware of the risk factors and signs of IPV to recognize victims of abuse and to intervene (eg, separating the victim
from the abuser during the health history interview, providing information about community resources). Features of
IPV include:
o The abusive partner exhibits intense jealousy and possessiveness
o The victim of IPV chooses to stay in the relationship for a variety of reasons (eg, fear for life, financial or child custody
concerns, religious beliefs)
o The abuse begins or intensifies during pregnancy

SCHIZOPHRENIA
Clients with schizophrenia have difficulty initiating and maintaining social interactions with other people.
The nurse can facilitate interpersonal functioning by providing one-on-one interaction in which the client can practice
basic social skills in a non-threatening way. Once the client feels more comfortable, the nurse can encourage
participation in activities that require some interaction with others.
Impaired social interaction is one of the negative symptoms of schizophrenia; others include the following:

o Inappropriate, flat, or bland affect, and apathy

o Emotional ambivalence, disheveled appearance
o Inability to establish and move toward goal accomplishment
o Lack of energy, pacing and rocking, odd posturing
o Regressive behavior, inability to experience pleasure
o Seeming lack of interest in the world and people

Clients with schizophrenia often become anxious when around other individuals and will seek to be alone to relieve
anxiety. Impaired social and interpersonal functioning (eg, social withdrawal, poor social interaction skills) are
common negative symptoms of schizophrenia. These are more difficult to treat than the positive symptoms (eg,
hallucinations, delusions) and contribute to a poor quality of life.
Nursing interventions directed at improving the social interaction skills of a client with schizophrenia include the
following:

o Making brief, frequent contacts

o Accepting the client unconditionally by minimizing expectations and demands
o Assessing the client's readiness for longer contacts with the nurse and/or other staff and clients
o Being with or close by the client during group activities
o Offering positive reinforcement when the client interacts with others

It is the negative symptoms of schizophrenia that affect a client's ability to establish personal relationships and manage
day-to-day social interactions.
The positive symptoms of schizophrenia (hallucinations, delusions, thought impairment) often improve with
psychotropic medications; negative symptoms tend to persist even with medication.
Psychosocial and supportive treatment, including psychotherapy, education, behavioral training, cognitive therapy, and
social skills therapy, may be beneficial in improving the quality of life for clients with schizophrenia.
A diagnosis of schizophrenia with catatonia can be made if the clinical features meet the criteria for a diagnosis of
schizophrenia and include at least 2 of the following additional features:
o Immobility the client remains in a fixed stupor or position for long periods

Refuses to move about or engage in activities of daily living

May have brief spurts of excitement or hyperactivity

o Remaining mute
o Bizarre postures the client holds the body rigidly in one position
o Extreme negativism the client resists instructions or attempts to be moved
o Waxy flexibility the client's limbs stay in the same position in which they are placed by another person
o Staring
o Stereotyped movements, prominent mannerisms, or grimacing

Clients with catatonic schizophrenia are unable to meet their basic needs for adequate fluid and food intake and are at
high risk for dehydration and malnutrition. The priority nursing action is to anticipate the client's needs, and to
ensure that the client is well hydrated and has adequate nourishment. Some clients will need total care.
SUICIDE
DEPENDENT PERSONALITY DISORDER

Individuals with dependent personality disorder have a persistent and extreme need to be taken care of that
manifests as submissive and clinging behaviors and fear of separation.
Additional characteristics of dependent personality disorder may include:

o Difficulty in making day-to-day decisions

o An excessive need for advice, reassurance, and nurturance from others
o Lack of self-confidence - afraid to do things on one's own
o Afraid of confrontation or expressing disagreement with others
o Feelings of helplessness and anxiety when alone; fear of being unable to take care of oneself

A client making a decision about and carrying out a daily activity on his/her own would be indicative of progress toward
a therapeutic outcome.
DEMENTIA

Individuals with dementia may wander and become lost during any stage of the disease. The most effective strategy
to prevent wandering is to make modifications to secure the environment. These include:

o Placing locks above or below eye level on doors that lead to the outside. Clients with Alzheimer disease (AD) lose their
peripheral vision; they cannot see objects unless they are directly in front of them or they purposely move their heads
o Adding a motion sensor or alarm that goes off when someone tries to exit
o Placing a large stop sign on door exits
o Disguising a door with a curtain or wall hanging
o Using childproof doorknob covers
o Placing a black mat or black strip by an exit. The client may perceive this as an impassable black hole due to changes in
depth perception.

DISULFIRAM

Disulfiram (Antabuse) is a form of aversion therapy that promotes abstinence from alcohol. If the client consumes
alcohol while taking disulfiram, unpleasant side effects (eg, headache, intense nausea/vomiting, flushed skin,
sweating, dyspnea, confusion, tachycardia, hypotension) can occur. If large amounts are consumed, the reaction can
be fatal.
Disulfiram therapy does not cure alcoholism; the client should continue seeing a therapist
Due to the hazards of treatment, clients are carefully selected for disulfiram therapy, and informed consent is often
required. It is a priority for the nurse to educate the client about the hazards of drinking alcohol and about sources of
hidden alcohol. Teaching includes:

o Avoid hidden alcohol in:

liquid cold and cough medications

aftershave lotions, colognes, and mouthwashes
foods such as sauces, vinegars, and flavor extracts

o Abstain from alcohol for 2 weeks after the last dose as the disulfiram reaction could still occur
o Wear a bracelet alerting others of being on disulfiram therapy
BEHAVIOR MODIFICATION

Successful behavior modification (eg, diet and exercise for effective weight loss) requires client readiness and
motivation to change, which can be assessed using the Stages of Change Model.
With the appropriate support (eg, listening, not pressuring the client), clients can move from one stage to the next:
o Precontemplation: The client does not believe a problem exists, although others may point it out (eg, encouraging healthy
eating)
o Contemplation: The client recognizes a change is needed but is undecided whether it would be possible or worthwhile
o Preparation: The client has decided to change, explores emotions related to the decision, and begins establishing goals (eg,
fitting into a dress)
o Action: The client has firmly committed to changing, has developed a plan (eg, dietary modifications, exercise plans),
and actively takes steps toward new behavior (eg, choosing activity over television)
o Maintenance: The client continues to uphold the new behavior and focuses on preventing relapse.
o Termination: The client has achieved the desired change. This stage may be theoretical, as relapse to former behaviors is
always possible.

DISSOCIATIVE IDENTITY DISORDER

Dissociative identity disorder is a condition in which 2 or more identities alternately control the client's behavior.
The alternate identities likely develop as a response to abuse or traumatic events and serve to protect the client
from stressful memories.
The client may not be aware of the alternate identities and may be confused by "lost time" and gaps in memory.
Switching between identities occurs as a reaction to stress and individual triggers. The goal of treatment is
to integrate the identities into one personality while maintaining safety.
The client should journal about feelings and dissociation triggers and use a grounding technique (eg, deep breathing,
rubbing a stone, counting coins) to counter dissociative episodes
Identities may be volatile and should be monitored for indications of harm to self or others
 The nurse should attempt to form trusting, therapeutic relationships with each identity to explore feelings and facilitate
identity integration
Dissociation and memory gaps are protective mechanisms. Forcing the client to hear or attempt to recall memories
may result in distress and regression. Allow clients to recall memories at their own pace.
ELDER ABUSE

Elder abuse or neglect occurs when caregivers intentionally or unintentionally fail to meet the older adult
client's physical, emotional, or social needs. Approximately 1 in 10 older adult clients are victims of physical,
psychological, or sexual abuse by a caregiver.
Commonly neglected necessities include water, food, medication, hygiene, and clothing. The client's living
conditions may be unsafe or have inadequate access to public utilities. Objective findings consistent with abuse or
neglect include:
 o Dehydration, malnutrition, and weight loss
o Poor hygiene, soiled bedding or clothing, and pressure ulcers
Missing/broken assistive devices (eg, eyeglasses); medications withheld or expired
Clients who have experienced abuse or neglect may find the situation difficult to discuss and display apprehension, restlessness,
withdrawal, poor eye contact, shame, and despair . The client may also deny or minimize the extent of the abuse out of fear or
embarrassment.

SCHOOL PHOBIA

School phobia (also known as school refusal or school avoidance) is a childhood anxiety disorder in which the child
experiences an irrational and persistent fear of going to school.
Having the child return to school immediately is the best approach for resolving school phobia and is associated
with a faster recovery.
If necessary, gradual exposure to the school environment can be implemented; the child can attend school for a few
hours and then gradually increase the time to a full day.
A gradual approach may decrease the child's sensitization to the classroom. If the child is allowed to remain out of
school, the problem will only worsen, with potential deterioration of academic performance and social relationships.

MANIA
In developing a care plan for a client experiencing acute mania, the nurse is aware that an acute manic episode is
characterized by the following:

o Excessive psychomotor activity

o Euphoric mood
o Poor impulse control
o Flight of ideas, non-stop talking
o Poor attention span, distractibility
o Hallucinations and delusions
o Insomnia
 o Wearing bizarre or inappropriate clothing, jewelry, and makeup
o Neglected hygiene and inadequate nutritional intake

The care plan for a client experiencing an acute manic episode includes the following:
o Reduction of environmental stimuli

Providing a quiet, calm environment

Limiting the number of people who come in contact with the client
One-on-one interactions rather than group activities
Low lighting

o A structured schedule of activities to help the client stay focused

o Physical activities to help relieve excess energy
o Providing high-protein, high-calorie meals and snacks that are easy to eat
o Setting limits on behavior

ACUTE STRESS DISORDER

Acute stress disorder (ASD) occurs following a traumatic or extremely stressful event. ASD is characterized
by intrusive memories of the event, negative mood, dissociative symptoms (eg, altered sense of reality), and
arousal and reactivity symptoms (eg, hyperactive sensory state, sleep disturbances, difficulty concentrating, easily
startled). If these symptoms continue beyond a month after the event, the diagnosis becomes post-traumatic stress
disorder. Nursing interventions for a client with ASD include:
o Assessing for ideas and plans to commit self-harm
o Assessing for ineffective coping (eg, use of drugs and alcohol)
o Assessing impact of ASD on the client's job performance, relationships, sleep pattern, and ability to perform activities of daily
living
o Explaining that feelings and/or symptoms occurring after traumatic events are normal, as this can help alleviate the client's
anxiety
o Exploring coping strategies used in previous stressful situations
 The client should be encouraged to discuss the traumatic event. As part of the debriefing process, the nurse should
acknowledge and validate the associated feelings and behaviors.

OPIOID WITHDRAWAL

Clients with opioid dependence (eg, oxycodone, hydrocodone, heroin) may develop acute withdrawal if opioids
are abruptly stopped, dosage is reduced, or a reversal agent (ie, naloxone [Narcan]) is administered.
Withdrawal symptoms (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to
increased sympathetic nervous system activity as the depressant effect of the opioid wanes
Although opioid withdrawal is seldom life-threatening, clients who demonstrate signs of acute withdrawal may be given
medications, such as methadone, to alleviate discomfort.
The nurse should alert the health care provider of suspected withdrawal to facilitate appropriate opioid weaning or
maintenance interventions.
BORDERLINE PERSONALITY DISORDER
Clients diagnosed with borderline personality disorder (BPD) often make suicidal threats, gestures, and attempts.
They may use these behaviors to bring about a response when there is a real or perceived risk of abandonment from a
significant other.
All suicidal behavior should be taken seriously; the client's current self-injurious action needs to be evaluated to
assess whether it involved suicidal intent.
 Clients with BPD have been known to demonstrate years of benign suicide threats and gestures before completing a
suicide.
Predicting a client's risk for completing a suicide is difficult due to the impulsive nature of the behavior.

SOCIAL ANXIETY DISORDER

Social anxiety disorder (SAD) is characterized by an excessive and persistent fear of social or performance
situations in which the client is exposed to strangers and the possibility of scrutiny by others.
Examples of such social interactions include meeting unfamiliar people, being observed eating or drinking in public,
and giving a speech.
The client may fear criticism, embarrassment, humiliation, and rejection from unfamiliar people in unfamiliar social
situations and will exhibit physical symptoms of anxiety such as sweating, trembling, palpitations, diarrhea, and
blushing.
Clients with SAD often have anticipatory anxiety and worry for days or weeks before a feared event. They may
recognize that their fear is exaggerated and will seek assistance and counseling.

MAJOR DEPRESSIVE DISORDER

 Major depressive disorder (also known as unipolar depression) is a subtype of depressive disorder, classified by
specific symptoms that interfere with the ability to perform activities of daily living, work, sleep, and enjoy activities that
are usually pleasurable to the client.
For the diagnosis to be made, 5 or more of the following symptoms must be present almost every day for at least 2
weeks, and 1 of the symptoms must be depressed mood or loss of interest or pleasure.

NARCISSISTIC PERSONALITY DISORDER

A client with narcissistic personality disorder (NPD) exhibits a recurrent pattern of grandiosity, need for admiration,
and lack of empathy. Clients with NPD may project a picture of superiority, uniqueness, and independence that hides
their true sense of emptiness.
From a psychodynamic perspective, individuals with NPD have a fragile and damaged ego resulting from a childhood
environment that fostered a sense of inferiority, poor self-esteem, and severe self-criticism. Narcissistic characteristics
develop as a way to regulate self-esteem and protect the ego from further psychic injury.
HISTRIONIC PERSONALITY DISORDER
The nurse should recognize the following characteristics associated with histrionic personality disorder:

o Self-dramatizing, exaggerated or shallow emotional expression

o Attention-seeking, needs to be the center of attention
o Overly friendly and seductive, attempts to keep others engaged
o Demands immediate gratification and has little tolerance for frustration

An individual with histrionic personality disorder displays these behaviors and characteristics persistently. The signs
and symptoms are maladaptive and have a negative impact on the client's social, interpersonal, and occupational life.

THOUGHT PROCESSES

Disturbance in logical form of thought is characteristic and one of the positive symptoms of schizophrenia. The client
will often have trouble concentrating and maintaining a train of thought. Thought disturbances are often accompanied
by a high level of functional impairment, and the client may also be agitated and behave aggressively.
 Types of impaired thought processes seen in individuals with schizophrenia include the following:

o Neologisms made-up words or phrases usually of a bizarre nature; the words have meaning to the client only. Example: "I
would like to have a phjinox."
o Concrete thinking literal interpretation of an idea; the client has difficulty with abstract thinking. Example: The phrase,
"The grass is always greener on the other side," would be interpreted to mean that the grass somewhere else is literally
greener
o Loose associations rapid shifting from one idea to another, with little or no connection to logic or rationality
o Echolalia repetition of words, usually uttered by someone else
o Tangentiality going from one topic to the next without getting to the point of the original idea or topic
o Word salad a mix of words and/or phrases having no meaning except to the client. Example: "Here what comes table,
sky, apple."
o Clang associations rhyming words in a meaningless, illogical manner. Example: "The pike likes to hike and Mike fed the
bike near the tyke."
o Perseveration repeating the same words or phrases in response to different questions

BIPOLAR DISORDER

Bipolar disorder is a psychiatric condition characterized by cycling periods of depression and mania.
Clients with acute mania often display elevated mood, increased and excessive activity levels, and altered decision-
making that can result in high-risk behavior (eg, hypersexuality, excessive spending).
Clients with mania are also easily distractible, leading to neglect of personal needs (eg, hydration, nutrition, sleep,
hygiene) and the need for medical intervention.
When managing the nutritional needs of clients with mania, the nurse should frequently offer energy- and protein-
dense foods that are easily carried and consumed (eg, sandwiches, shakes, hamburgers, pizza slices, burritos, fruit
juices, granola bars).
These "on-the-go" foods promote nutritional intake in clients who are unable to sit down and complete a traditional
meal
ELDERLY

ALCOHOL WITHDRAWAL SYNDROME

VIOLENCE
Violence in the health care setting poses a safety risk to clients, staff, and visitors. It also decreases the quality of
care that a violent client receives due to avoidant and fearful behaviors by staff.
 Risk factors for violence include altered level of consciousness, substance abuse, emotional stress, and
behavioral/psychiatric disorders.
Nursing interventions that help prevent violence include using clear, thorough communication; encouraging
active participation in care; promoting a low-stimulation environment; and providing comfort through
pharmacological and nonpharmacological methods.
The nurse should demonstrate undivided attention to the client (eg, facing the client, unhurried body language, calm
tone).

PANIC ATTACK
This client is experiencing the symptoms of a panic attack and should not be left alone. The priority nursing action is
to stay with the client to ensure the client's safety and offer support.
Additional nursing actions while the client is experiencing panic symptoms include:

o Maintaining a calm, matter-of-fact approach

o Speaking calmly and using simple, clear words and phrases when providing information on emergency department
procedures
o Placing the client in a room with as few stimuli as possible
o Administering an anti-anxiety medication such as a benzodiazepine (per health care provider prescription)
o Having the client take slow, deep breaths if hyperventilation is a problem
 PHARAMACOLOGY
ANALGESICS / MUSCULOSKELETAL / INTEGUMENTART
/OPTHAMOLOGY /AUDIOLOGY

OXYCODONE

Extended-release oxycodone (Oxycontin) is a long-acting opioid agonist prescribed to manage severe chronic
pain when nonopioids and immediate-release opioids (eg, immediate-release oxycodone, hydrocodone) are
inadequate.
The nurse should teach the client's caregiver to administer extended-release oxycodone as scheduled, even if the
client does not report pain.
Administration twice daily is necessary to maintain a therapeutic level and provide continuous relief as the duration of
the analgesic effect is 12 hours.
Immediate-release opioids and nonopioids are coadministered with long-acting opioids for relief of breakthrough pain.
Respiratory status should be monitored; however, clients who receive long-term therapy become opioid tolerant and
are less likely to experience adverse effects.
Because the goal of hospice care is comfort, this client should be relieved of breakthrough pain regardless of
respiratory status.
The dose and frequency cannot be changed without a prescription. Also, breakthrough pain is best treated with short-
acting opioids.
Long-term opioid therapy leads to drug tolerance and physical dependence; higher doses are eventually required for
therapeutic effect.
In the dying client, it is not appropriate to taper the dose. Rather, it should be titrated upward for effective pain relief.
Oxycodone is a morphine-like opioid medication. Opioid medications bind to opioid receptors in the intestine, which
slows peristalsis and increases water absorption, leading to constipation.
 Constipation is an almost universally expected side effect from opioid medications. Clients will not develop tolerance
to this side effect. Although clients with idiopathic chronic constipation are not commonly advised to take laxatives,
opioid-induced constipation is treated with simultaneous use of senna (stimulant) and docusate (stool softener).
Opioids cause the release of histamine, a vasodilator, which is responsible for pruritus and flushing. Opioids can also
cause peripheral vasodilation and nervous system depression; both can lead to hypotension. These develop in some
clients when the treatment is initiated but usually resolve over time. Antihistamines (eg, diphenhydramine) can prevent
the pruritus. Lifestyle changes (eg, rising slowly from a seated position) and adequate hydration can prevent
hypotension.
Opioids stimulate the opioid receptors in the gastrointestinal tract and the chemoreceptor trigger zone in the brain,
producing nausea. This is also not seen with long-term use. Antiemetics (eg, ondansetron) can be helpful.

PHENYTOIN

Phenytoin is an anticonvulsant prescribed for the treatment of seizures. Clients should never abruptly stop taking the
medication due to the possibility of seizure reoccurrence and status epilepticus.
An exception is the development of a rash, which may indicate Stevens-Johnson syndrome (SJS).
SJS is a rare but potentially life-threatening hypersensitivity reaction. SJS often starts with flu-like symptoms and a
painful, purple or red rash to the skin or mucous membranes that may resemble a third-degree burn
Immediate discontinuation of the triggering agent and notification of the health care provider is necessary to prevent
rapid progression and multiple organ failure.
Gingival hyperplasia (ie, swollen, bleeding gums) is common with cyclosporine and phenytoin. Clients should be
instructed on proper dental hygiene.

BOTULINUM TOXIN TYPE A (BOTOX)

Botulinum toxin type A (Botox) blocks neuromuscular transmission by inhibiting acetylcholine release from nerve
endings.
The drug is used for treating wrinkles, blepharospasm, and cervical dystonia.
Complications are uncommon when Botox is used for cosmetic purposes but can be life-threatening if they occur.
 The toxin can also relax the muscles used for swallowing and breathing, resulting in dysphagia (aspiration risk) and
respiratory paralysis.
Botulism can be associated with constipation and urinary retention due to relaxation of smooth muscle.

NALOXONE
A client in the post-operative period that is unresponsive to painful stimuli is likely still under the effects of medications
used during anesthesia.
Using the opioid antagonist naloxone (Narcan) will temporarily reverse the effects of any opioid medications.
Unfortunately, the half-life of naloxone is much shorter than most opioid medications, wearing off in 1 2 hours.
The nurse should make repeat assessments of the post-surgical client's respiratory rate and administer prescribed
oxygen for respiratory support. The health care provider should be notified and a second dose of naloxone should be
prepared and administered as prescribed (either as a one-time dose or a continuous drip, depending on the
prescription).
An overly sedated client is not an indication for a rapid response team. Although this intervention is unlikely to cause
harm to the client, it is not necessary and may result in overuse of personnel resources.
If additional information indicates a more serious situation (eg, respiratory rate <8 breaths/min, oxygen saturation
<90%), it may be appropriate to initiate the emergency response system.

DRUG INTERACTIONS
Iron is absorbed better on an empty stomach; ascorbic acid (vitamin C), such as found in citrus fruits and juices,
increases the absorption of iron. However, milk products decrease iron absorption and should be avoided
Metronidazole (Flagyl) is used to treat trichomoniasis and amebiasis. Consuming alcohol while taking the
medication may elicit a disulfiram (Antabuse)-like reaction. Alcohol should be avoided for at least 48 hours after
treatment is completed
 Many antihistamines also have anticholinergic effects. Anticholinergics have an antimuscarinic effect that can
increase intraocular pressure and are therefore contraindicated in closed-angle glaucoma. Other contraindications
include urinary retention (benign prostatic hyperplasia) and bowel obstruction related to the anticholinergic drug's
effect on the smooth muscle in the urinary and gastrointestinal tract
Enteral nutrition decreases levothyroxine absorption; as a result, it should be taken early in the morning on an empty
stomach (at least 30 minutes before food intake).
Phenazopyridine (Pyridium) is used as a local anesthetic in the treatment of urinary tract infection. The azo dye turns
the urine an orange-red color. The client needs to be reassured that this is an expected result and could stain
clothing.

KETOROLAC
This client has chronic kidney disease with an elevated serum creatinine level. Ketorolac (Toradol) is a highly potent
nonsteroidal anti-inflammatory drug (NSAID) often used for pain and available in intravenous form.
However, NSAIDs (eg, indomethacin, ibuprofen, naproxen, ketorolac) are nephrotoxic and should be avoided in
clients with kidney disease.
Also, the client should not be given 2 types of NSAIDs simultaneously (eg, naproxen plus ibuprofen) as they can be
toxic to the stomach and kidneys.

CALCIUM CARBONATE

Calcium and vitamin D are essential for bone strength. Calcium carbonate (Caltrate) has the most available
elemental calcium of OTC products and is inexpensive; it is therefore the preferred calcium supplement for most
clients with osteoporosis.
Calcium absorption is impaired when taken in excess of 500 mg per dose. Therefore, most clients should take
supplements in divided doses (<500 mg per dose). These should be taken within an hour of meals as food
increases calcium absorption.
 Constipation is a frequent side effect of calcium supplements, so clients should be advised to take appropriate
precautions.
Calcium carbonate and calcium acetate (PhosLo) are used to reduce serum phosphorous levels in clients with chronic
kidney disease. In such cases, calcium should remain in the intestine and bind the phosphorous present in food; the
calcium phosphorus product would then be excreted in stool. Therefore, these clients should take calcium
supplements before meals.

ISOTRETINOIN
Isotretinoin is an oral acne medication derived from vitamin A. Due to teratogenic risk and severity of side effects
(eg, Stevens-Johnson syndrome, suicide risk), isotretinoin is used to treat only severe and/or cystic acne not
responding to other treatments.
Exposure to any amount of this medication during pregnancy can cause birth defects. Clients are required to enter a
Web-based risk management plan (iPLEDGE) and use 2 forms of contraception
Taking vitamin A supplements along with isotretinoin can cause vitamin A toxicity, which can cause increased
intracranial pressure, gastrointestinal upset, liver damage, and changes in skin and nails. Therefore, clients should be
instructed to avoid vitamin A supplements while taking this medication
Blood donation is also prohibited during the duration of treatment and up to a month after treatment ends due to the
possibility of inadvertent transfusion to a pregnant woman.
Isotretinoin should not be taken with tetracycline because the latter also increases the risk for intracranial
hypertension.
Isotretinoin (Accutane, Amnesteem) is prescribed for severe, disfiguring nodular acne that has been unresponsive to
other therapies (eg, antibiotics). It works by decreasing sebum secretion and shrinking sebaceous glands (often
permanently); one course of isotretinoin is typically very effective. However, isotretinoin is a teratogenic medication
known to cause serious harm to a fetus if taken during pregnancy.
Females prescribed isotretinoin must participate in a risk management program. Requirements generally include
two negative pregnancy tests before initiating isotretinoin and two forms of contraception (ie, use 1 month prior to
starting isotretinoin, during treatment, and for 1 month after discontinuing isotretinoin). Refills can be only obtained
 after a negative pregnancy test (performed monthly during therapy). Blood donation is also discouraged for both
males and females during therapy.
Dryness of the eyes, mouth, and skin are common side effects. Lubricating eye drops may be needed to wear
contacts. Some clients are unable to wear contacts while taking isotretinoin.
Capsules should not be broken, crushed, or
chewed as the contents could irritate the esophagus.
Isotretinoin sometimes causes photosensitivity. The nurse should teach the client to use sunscreen routinely.

NSAIDS
Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can cause cardiovascular side
effects, including heart attack, stroke, high blood pressure, and heart failure from fluid retention.
These drugs also decrease the effectiveness of diuretics and other blood pressure medications.
The risks can be even higher in the client who already has cardiovascular disease or takes NSAIDs routinely or for a
long time.
In addition, long-term use of NSAIDs is associated with peptic ulcers and chronic kidney disease.
These clients should use NSAIDs cautiously, at the lowest dose necessary and for a short time.
The nurse should notify the health care provider that this client is routinely taking ibuprofen.

METHOTREXATE

Methotrexate is an antirheumatic drug prescribed to treat rheumatoid arthritis. It acts by interfering with folic acid
metabolism, which inhibits DNA synthesis and cell reproduction.
Adverse effects associated with methotrexate include bone marrow suppression, hepatotoxicity (ie, drug-induced
liver injury), and gastrointestinal irritation (eg, nausea, vomiting, diarrhea).
Bone marrow suppression is a serious adverse effect that leads to anemia, leukopenia, and thrombocytopenia.
Thrombocytopenia (especially platelet count <100,000/mm3 [100 × 109/L]) is characterized by petechiae (ie, small,
 purple hemorrhagic spots), purpura, and/or other signs of bleeding (eg, melena, hematemesis, bleeding
gums) (Option 3). Bone marrow suppression is managed by dose reduction or discontinuation of the medication.
Nausea and vomiting are the most common side effects associated with methotrexate. The nurse should notify the
health care provider and request a prescription for an antiemetic; however, vomiting is not the priority concern.
Some substances decrease the effectiveness of methotrexate (eg, caffeine, folic acid) and should be avoided.
Methotrexate is teratogenic, so pregnancy must be prevented. Effective contraceptives must be used throughout
treatment and for one ovulatory cycle after completing treatment for women (three months after completion for men).

OPIOIDS

Respiratory depression is the most serious side effect of narcotic medication. Sedation precedes respiratory
depression. Falling asleep during a conversation scores "3" on the Pasero Opioid-Induced Sedation Scale (POSS); no
additional narcotics should be given to the client. Other classes of drugs (eg, non-steroidal anti-inflammatory
medications) can be given if the client is still in pain.
 The client will also be at increased risk for respiratory depression if the pain is completely relieved and/or it is night
time. No additional narcotics should be given until the client is at level 2 sedation on POSS (eg, slightly drowsy, easily
aroused).
Opioid analgesics (eg, hydromorphone, morphine) are effective for controlling moderate to severe pain. Major side
effects include sedation, respiratory depression, hypotension, and constipation. The client is at risk for
falls from sedation or hypotension and should not get out of bed unassisted
Slowed bowel motility persists throughout opioid use, and measures to prevent constipation (eg, administration of
daily stool softeners) should be implemented
IV hydromorphone should be administered slowly over 2-3 minutes. Rapid IV administration of opioid analgesics can
cause severe hypotension and respiratory or cardiac arrest.
Postoperative clients may experience pain with breathing exercises (eg, turning, coughing, deep breathing,
incentive spirometry). Uncontrolled postoperative pain may cause clients to avoid deep breathing and lead to
atelectasis and pneumonia. The nurse should administer opioids to achieve adequate pain control as needed to
encourage participation in postoperative exercises and prevent complications.
The nurse should reassess pain and sedation level during the opioid's peak effect, which is 15-30 minutes after
administration of IV hydromorphone.
The following are at greatest risk for respiratory depression related to opioid use for analgesia: the elderly; those with
underlying pulmonary disease, history of snoring (with or without apnea), obesity, or smoking (more than 20-pack-year
history); the opiate naïve, especially if treated for acute pain; and post surgery (first 24 hours).

ALLOPURINOL

Allopurinol is a medication frequently used in the prevention of gout. Gout is a buildup of uric acid deposited in the
joints that causes pain and inflammation. The medication helps to prevent uric acid deposits in the joints and the
formation of uric acid kidney stones.
Any rash in a client taking allopurinol, even if mild, should be reported immediately to the HCP. The nurse should
direct the client to stop taking the medication immediately, schedule an appointment, and notify the HCP. A
 rash caused by allopurinol may be followed by more severe hypersensitivity reactions that can be fatal, including
Stevens-Johnson syndrome and toxic epidermal necrolysis.
Allopurinol can take several months to become effective. Its primary use is to prevent gout attacks; it is not effective
in treating acute attacks. The client will need to continue to take anti-inflammatory drugs (eg, nonsteroidal anti-
inflammatory drugs or colchicine) for acute attacks.
Clients are directed to take allopurinol with a full glass of water and to increase daily fluid intake to prevent kidney
stones. This will cause an increase in urination and is an expected outcome.
Nausea can be prevented by instructing the client to take the medication with food or following a meal.
Allopurinol is prescribed to prevent gout attacks (pain and inflammation in joints caused by uric acid deposits). It
inhibits uric acid production and improves solubility.
Allopurinol should be taken with a full glass of water, and it is very important for the nurse to educate the client
about fluid intake with this medication.
The client should also increase daily fluid intake as this will help prevent the formation of renal stones and promote
diuresis (increase drug and uric acid excretion).

IV PCA
When providing care for a client prescribed IV PCA, the nurse assesses pain on a regular and as-needed basis.
The client's self-report is considered to be the most reliable indicator of pain, so the priority nursing action is to perform
a thorough pain assessment to determine the cause of worsening/continuous pain despite the medication. This
includes location, quality, radiation, severity, and associated factors (eg, nausea, diaphoresis) for the severe pain. The
assessment data will guide the nurse's subsequent interventions
An IV PCA bolus is an extra, as-needed dose of analgesia (eg, 1-2 mg) for increased pain (eg, before a painful
procedure) that is prescribed by the HCP when the PCA is initiated. If needed, the nurse programs the pump to
deliver the bolus dose because no one but the client is permitted to push the button. However, this is not the priority
action.
 If the client's attempts are twice the number of doses actually delivered and adequate pain relief is not achieved, the
nurse would notify the HCP to request a dose increase or shorter dose interval. However, this is done after the pain
assessment.

NAPROXEN
Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) commonly prescribed to decrease joint pain and
inflammation.
All NSAIDs (eg, indomethacin, ibuprofen) are associated with the following:

1. Gastrointestinal (GI) toxicity - symptoms of GI bleeding such as black tarry stools should be reported. Gastrointestinal
upset (eg, dyspepsia, pain) can be reduced if the medicine is taken with food.
2. Kidney injury - long-term use is associated with kidney injury
3. Hypertension and heart failure - NSAIDs can cause fluid retention, which can exacerbate conditions such as heart failure,
cirrhosis/ascites, and hypertension
4. Bleeding risk - clients should notify the HCP if taking concurrently with aspirin, other NSAIDs, or anticoagulant or antiplatelet
drugs as they can increase the risk of GI bleeding.

TETRACYCLINES

The following should be taught to clients taking tetracyclines (eg, tetracycline, doxycycline, minocycline):

1. Take on an empty stomach for optimum absorption, tetracyclines should be taken 1 hour before or 2 hours after meals
2. Avoid antacids or dairy products tetracyclines should not be taken with iron supplements, antacids, or dairy products as
they bind with the drug and decrease its absorption
3. Take with a full glass of water tetracyclines can cause pill-induced esophagitis and gastritis; the risk can be reduced by
taking with a full glass of water and remaining upright after pill ingestion
4. Photosensitivity severe sunburn can occur with tetracycline. The client should use sunblock

Medications such as tetracycline and rifampin can decrease the effectiveness of oral contraceptives; additional
contraceptive techniques will be needed
 Tetracycline taken at bedtime has been associated with esophageal irritation and stricture development as it increases
reflux of the gastric contents into the esophagus. This can be prevented by taking the medicine with plenty of water
and during the day when upright.

METHADONE

Methadone is a potent narcotic with a longer half-life than its duration of action due to its lipophilic properties. The risk
for overdose exists as clients can inadvertently take too many tablets for additional pain relief even though fat cells will
continue to release high amounts of the drug into circulation.
Early signs of toxicity include nausea/vomiting and lethargy. A client who falls asleep with stimulation (ie, is
obtunded) requires additional observation/monitoring. Sedation precedes respiratory depression, a life-threatening
complication of severe toxicity
An acceptable pulse oximetry reading for a normal, healthy nonsmoking adult is considered 95%-100%. A reading of
90% is low and indicates inadequate depth or rate of respiration with possible respiratory depression
Itching sensation (pruritus) is an expected finding with narcotic use, especially in opioid-naïve clients. It can be
managed with an antihistamine.
Occasional premature ventricular contractions are a common, insignificant finding in most adults. The client should
have cardiac monitoring in the setting of methadone use/overdose as there is a risk of QT interval
prolongation (normal 0.34-0.43 sec, or less than half the RR interval), which can lead to cardiac arrhythmias (eg,
torsades de pointes).

TOPICAL CAPSAICIN

Topical capsaicin cream (Zostrix) is an over-the-counter analgesic that effectively relieves minor pain (eg,
osteoarthritis, neuralgia). The nurse should instruct the client to wait at least 30 minutes after massaging the cream
into the hands before washing to ensure adequate absorption
 The client should avoid contact with mucous membranes (eg, nose, mouth, eyes) or skin that is not intact, as
capsaicin is a component of hot peppers and can cause burning. When applying cream to other areas of the body
(eg, knee), the client should wear gloves or wash hands immediately after application.
The application of heat with capsaicin is contraindicated as heat causes vasodilation, which increases medication
absorption and can possibly lead to a chemical burn.
Local irritation (burning, stinging, erythema) is quite common and usually subsides within the first week of regular use.
If the client experiences persistent pain, redness, or blistering, the cream should be discontinued and the health care
provider notified.
Topical capsaicin is often used concurrently with acetaminophen or nonsteroidal anti-inflammatory drugs (eg,
naproxen, celecoxib) to effectively treat osteoarthritis pain. Capsaicin should be used regularly (3-4 times daily) for
long periods (eg, weeks to months) to achieve the desired effect.

ASPIRIN
Aspirin is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs can cause gastrointestinal (GI) bleeding by
decreasing the production of prostaglandins, which protect the lining of the stomach and intestines from digestive
acids.
NSAIDs (especially aspirin) also decrease platelet aggregation and thereby inhibit blood clotting.
Coffee-ground emesis and black tarry stools (melena) are signs of GI bleeding.
Bruising can occur due to the decreased platelet aggregation.
Tinnitus (ringing in the ears) is the earliest sign of aspirin toxicity.
An NSAID overdose will cause tachycardia (not bradycardia) and hypotension (not hypertension). However,
tachycardia and hypotension occur later, secondary to blood loss and dehydration due to nausea and vomiting
(common side effects).
 CARDIOVASCULAR PHARMACOLOGY

STATINS

Statins (rosuvastatin, atorvastatin, simvastatin) are the most preferred agents to reduce low-density lipoprotein
(LDL) cholesterol, total cholesterol, and triglyceride levels.
This client's LDL level has decreased to a target range (diabetic client <100 mg/dL [2.6 mmol/L]), total cholesterol has
decreased to a normal range (adult <200 mg/dL [5.2 mmol/L]), and triglyceride level has decreased to a normal range
(adult <150 mg/dL [1.7 mmol/L)); all these changes indicate a therapeutic response
The adult therapeutic range of alanine aminotransferase (ALT) is 10-40 U/L (0.17-0.68 µkat/L). Increased aspartate
aminotransferase (AST) and ALT may indicate hepatic dysfunction, a potential adverse effect of statin medication.
The therapeutic range of high-density lipoprotein (HDL) cholesterol for adult men is >40 mg/dL (1.04 mmol/L). HDL is
good cholesterol.
 Rosuvastatin (Crestor) is a strong statin drug that can cut LDL drastically and reduce total cholesterol and
triglycerides. It also increases HDL.

A serious complication associated with statin medication is rhabdomyolysis.

Rhabdomyolysis is the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood.
These substances can be harmful to the kidney and often cause kidney damage. The client should immediately
report any signs of muscle aches or weakness to the HCP. These could be early signs of rhabdomyolysis, which
can be fatal.

Atorvastatin (Lipitor) is a statin drug, or HMG-CoA reductase inhibitor, prescribed to lower cholesterol and reduce the
risk of atherosclerosis and coronary artery disease. A serious adverse effect of statins, including atorvastatin and
rosuvastatin (Crestor), is myopathy with ongoing generalized muscle aches and weakness.
A client who develops muscle aches while on a statin drug should call the HCP who will then obtain a blood sample to
assess the creatine kinase (CK) level.
drug will then be discontinued.

Prior to starting therapy with statin medications (eg, rosuvastatin, simvastatin, pravastatin, atorvastatin), the
client's liver function tests should be assessed. The drug is metabolized by the hepatic enzyme system and could
cause drug-induced hepatitis and increased liver enzymes. Liver function tests should be assessed prior to the start of
therapy.

LOOP DIURETIC

Most clients with heart failure are prescribed a loop diuretic (eg, furosemide, torsemide, bumetanide) to reduce
fluid retention.
If the client has signs and symptoms of excessive fluid accumulation, the nurse will need to assess the situation by
asking the client about dietary and fluid intake, adherence to prescribed medications, and the presence of any other
associated symptoms (eg, shortness of breath).
 If the client is stable, the nurse may anticipate the need to increase the dosage of the prescribed loop diuretic (eg,
bumetanide).

IV furosemide may cause ototoxicity, particularly when high doses are administered in clients with compromised
renal function. The rate of administration should not exceed 4 mg/min in doses >120 mg. To determine the correct
rate of administration for the dose above, use the following formula:
(160 mg) / (4 mg/min) = 40 min

THIAZIDE DIURETICS

Thiazide diuretics (eg, hydrochlorothiazide, chlorthalidone) are prescribed to treat hypertension and edema. The
major side effects of thiazide diuretics include:
o Hypokalemia - manifests as muscle cramps. Hypokalemia is the most serious side effect of thiazide diuretics as it
can lead to life-threatening cardiac dysrhythmias
o Hyponatremia - manifests as altered mental status and seizure
o Hyperuricemia - may precipitate or worsen gout attacks
o Hyperglycemia - may require adjustment of diabetic medications
Most thiazide diuretics are sulfa derivatives and can therefore cause photosensitivity. The nurse should encourage the
client to use sunscreen and wear protective clothing.

POTASSIUM-SPARING DIURETICS

Potassium-sparing diuretics (eg, spironolactone, amiloride, triamterene eplerenone) are generally very weak
diuretics and antihypertensives. However, they are useful when combined with thiazide diuretics to reduce
potassium (K+) loss.
Thiazide diuretics can cause hypokalemia when used as monotherapy.
 A potassium level of 4.2 mEq/L (4.2 mmol/L) falls in the normal range (3.5-5.0 mEq/L [3.5-5.0 mmol/L]), which
indicates that spironolactone has been effective in preventing hypokalemia in this client receiving a thiazide diuretic
(eg, hydrochlorothiazide, chlorthalidone)

ANGIOTENSIN II RECEPTOR BLOCKERS (ARB)

Losartan, valsartan, and candesartan (sartans) are the commonly used angiotensin II receptor blockers.
They are used in clients who cannot take ACE inhibitors (eg, lisinopril, ramipril). They block the renin-angiotensin-
aldosterone system but will not affect the fluid status of the client with acute heart failure.
Losartan is an angiotensin II receptor blocker (ARB) prescribed to treat hypertension. ACE inhibitors (eg, lisinopril,
enalapril) and ARBs are teratogenic, causing renal and cardiac defects or death of the fetus. ARBs and ACE
inhibitors have black box warnings that indicate contraindication in pregnancy.
The nurse should not give an ARB to a pregnant client
The health care provider should be notified so that an alternate antihypertensive may be prescribed that is safe to take
during pregnancy (eg, labetalol, methyldopa).

ACE INHIBITORS

ACE inhibitors ("-prils") and angiotensin II receptor blockers (ARBs) ("-sartans") may potentiate hyperkalemia.
ACE inhibitors decrease the excretion of aldosterone.
Aldosterone promotes sodium retention and causes potassium excretion. However, when the ACE inhibitor
suppresses aldosterone, potassium rises, placing clients at risk for hyperkalemia, especially in the presence of
impaired renal function.
The nurse should question the administration of an ACE inhibitor in a client with hyperkalemia
Lisinopril (Prinivil, Zestril) is an angiotensin-converting enzyme (ACE) inhibitor prescribed to treat hypertension and
slow the progression of heart failure. Lisinopril has a low incidence of serious adverse effects except angioedema
(rapid swelling of lips, tongue, throat, face, and larynx). Angioedema can lead to airway obstruction and possible
death. ACE inhibitors are the most frequent medications causing drug-induced angioedema. The risk is 5 times
greater for African Americans than for Caucasians.
If clients experience symptoms of angioedema, they are instructed to discontinue the drug and notify the HCP
immediately.
(Options 1 and 2) Persistent, dry cough is a common (5%-20%), annoying adverse effect of ACE inhibitors that is
caused by a buildup of bradykinin in the lung. If the client cannot tolerate this side effect, the HCP can prescribe an
angiotensin-receptor blocker instead, which has a similar action. Other common adverse effects of ACE inhibitors
include orthostatic hypotension (dizziness) and hyperkalemia.
Major side effects of angiotensin-converting enzyme (ACE) inhibitors include:

o Symptomatic hypotension
o Intractable cough
o Hyperkalemia
o Angioedema (allergic reaction involving edema of the face and airways)
o Temporary increase in serum creatinine

For clients unable to tolerate ACE inhibitors, angiotensin II receptor blockers (ARBs) such
as valsartan or losartan are recommended. ARBs prevent the vasoconstrictor and aldosterone-secreting effects of
angiotensin II by binding to the angiotensin II receptor sites.
Angiotensin converting enzyme (ACE) inhibitors (eg, captopril, enalapril, lisinopril, ramipril) prevent the
pathological enlargement of the left ventricle of the heart. They work by blocking a crucial step in the renin-
angiotensin-aldosterone system, the main hormonal mechanism involved in blood pressure regulation.
Interrupting this step of the renin-angiotensin-aldosterone system has following effects:

1. A shortage of angiotensin II results in an absence of the vasoconstrictive responses (orthostatic reflex, renal blood flow
regulation) causing orthostatic hypotension. Clients may be more prone to experiencing orthostatic hypotension early in
treatment with ACE inhibitors and should be taught ways to prevent it.
2. A shortage of aldosterone causes hyperkalemia. Aldosterone Saves Sodium and Pushes Potassium out of the body.
3. ACE inhibitors are contraindicated in pregnancy due to teratogenic effects on the fetus (eg, oligohydramnios, fetal kidney
injury).

The other important side effects of ACE inhibitors, cough and angioedema, are thought to be due to the accumulation
of bradykinin.
(Renal function (blood urea nitrogen, creatinine) is commonly checked during the first week of treatment. Regular
measurements to ensure therapeutic drug levels are required for lithium, phenytoin, and digoxin.
 A common side effect of ACE inhibitor is mild hyperkalemia, which may require a lower intake of foods high in
potassium. Clients taking loop diuretics (eg, furosemide) will need to increase their intake of foods high in potassium.
ACE inhibitors do not directly affect the heart rate. Clients prescribed digoxin are taught to take their pulse and hold
their medication if the heart rate is <60/min.
ADENOSINE

Adenosine is the first-line drug of choice for the treatment of paroxysmal supraventricular tachycardia (SVT; a rapid
rhythm exceeding 150/min).
The half-life is <5 seconds, so adenosine should be administered rapidly as a 6-mg bolus IV over 1-2 seconds
followed by a 20-mL saline flush. Repeat boluses of 12 mg may be given twice if the rapid rhythm persists.
The injection site should be as close to the heart as possible (eg, antecubital area). The client's ECG should be
monitored continuously. A brief period of asystole is due to adenosine slowing impulse conduction through the
atrioventricular node.
The client should be monitored for flushing, dizziness, chest pain, or palpitations during and after administration.
Although the drug should be administered as close to the heart as possible, central venous access is not required.
Because of the drug's short half-life (5-10 seconds), it should be administered rapidly, not slowly, and should not be
diluted.

BETA-BLOCKERS

Beta blockers, or "lols" (metoprolol, carvedilol, bisoprolol, atenolol), are the mainstay of therapy for clients
with chronic heart failure as these improve survival rates for both systolic and diastolic heart failure. However, in
certain situations beta blockers can worsen heart failure symptoms by decreasing normal compensatory sympathetic
nervous system responses and myocardial contractility.
In this client with acute decompensated heart failure (ADHF), marginally low blood pressure (BP), crackles in the
lungs, low oxygen saturation, jugular venous distension (JVD), and peripheral edema, the administration of beta
blockers can cause the client to further deteriorate. Beta blockers at low doses may be able to be restarted after this
client has stabilized and exacerbation of ADHF has resolved with diuresis.

Propranolol is a nonselective beta-blocker that inhibits beta1 (heart) and beta2 (bronchial) receptors. It is used for
many indications (eg, essential tremor) in addition to blood pressure control. Blood pressure decreases secondary to
a decrease in heart rate.
 Bronchoconstriction may occur due to the effect on the beta2 receptors. The presence of wheezing in a client
taking propranolol may indicate that bronchoconstriction or bronchospasm is occurring. The nurse should assess
for any history of asthma or respiratory problems with this client and notify the health care provider (HCP).

CALCIUM CHANNEL BLOCKERS

Calcium channel blockers (nifedipine, amlodipine, felodipine, nicardipine) are vasodilators used to treat
hypertension and chronic stable angina. They promote relaxation of vascular smooth muscles leading to
decreased systemic vascular resistance and arterial blood pressure.
The most important adverse effects of calcium channel blockers include dizziness, flushing, headache, peripheral
edema, and constipation.
The reduced blood pressure may initially cause orthostatic hypotension.
The client should be taught to change positions slowly to prevent falls. Leg elevation and compression can help to
reduce the edema. Constipation should be prevented with daily exercise and increased intake of fluids,
fruits/vegetables, and high-fiber foods.

VANCOMYCIN

When the infusion is given

too fast, the client may develop red man syndrome, which is characterized by facial and upper body flushing.
If this occurs, the infusion should be slowed or stopped and restarted at a slower rate after 30 minutes.
Facial flushing in isolation is not indicative of an allergic or anaphylactic reaction, and the nurse can independently
manage this side effect.
NITROGYCERIN

Nitroglycerin is a nitrate that causes vasodilation and relaxation of vascular smooth muscle. In clients with acute
coronary syndrome, it is administered by IV infusion to decrease preload and prevent spasm of the coronary
arteries, thereby increasing perfusion and oxygen supply to the cardiac muscle. Due to systemic vasodilation, this
client is at risk for significant hypotension.
The nurse should follow up immediately if the client reports dizziness or lightheadedness, which may indicate
profound hypotension. If the client is found to be hypotensive, the nurse may need to decrease or discontinue the
infusion.
Headache is a common side effect of nitroglycerin therapy and is often a sign that the medication is working properly.
It is not a priority, although acetaminophen may be given for pain relief.
Systemic vasodilation and decreased cardiac preload may cause the client to feel flushed and nervous during
infusion. However, reports of dizziness and lightheadedness should take priority.

Current evidence shows that up to 50% of clients lack knowledge about NTG administration procedures, storage, and
side effects. Proper teaching can prevent many hospital visits for chest pain due to stable angina.
Instructions for proper NTG administration include:

o Tablets are heat and light sensitive: They should be kept in a dark bottle and capped tightly. An opened bottle should be
discarded after 6 months
o Take up to 3 pills in a 15-minute period: Take 1 pill every 5 minutes (up to 3 doses). Emergency medical services (EMS)
should be called if pain does not improve or worsens 5 minutes after the first tablet has been taken. Previously, clients were
taught to call after the third dose was taken, but newer studies suggest this causes a significant delay in treatment
o Avoid fatal drug interactions: Concurrent use of erectile dysfunction drugs (sildenafil, tadalafil, vardenafil) or alpha blockers
(terazosin, tamsulosin) is contraindicated due to potentially fatal hypotension
o Headache may occur: Headache and flushing are common side effects of NTG due to systemic vasodilation and do not
warrant medication discontinuation

Acute coronary syndrome (ACS) is a broad term that encompasses a range of cardiac events, including unstable
angina and myocardial infarction (with or without ST-segment elevation). Clients with ACS require immediate
treatment to prevent continued ischemia of cardiac muscle.
Intravenous nitroglycerin (glyceryl trinitrate) is used to increase cardiac blood flow and provide pain relief for
clients with ACS until a definitive treatment plan (eg, percutaneous coronary intervention, thrombolytic therapy,
bypass surgery) is determined.
Because nitroglycerin is a vasodilator, continuous hemodynamic monitoring is required to prevent severe
hypotension. T
he infusion rate is titrated by the nurse based on pain level and blood pressure (BP), usually every 3-5 minutes until
pain is relieved and BP is stable.
If systolic BP drops to <90 mm Hg or falls >30 mm Hg below client baseline, the infusion rate should be decreased or
stopped

Angina is chest pain due to myocardial ischemia. A client with chronic stable angina experiences intermittent chest
pain relieved with rest or administration of nitroglycerin.

The priority action for acute angina is administration of rapid-acting (1-3 minutes) sublingual nitroglycerin to
restore cardiac perfusion.

Nitroglycerin is a vasodilator that decreases cardiac workload (decreasing oxygen consumption), reduces preload,
and increases myocardial perfusion. Onset and duration of action of nitroglycerin varies with route of administration.
 Transdermal nitroglycerin patches have a delayed onset of action (40-60 minutes) and are not effective in the
treatment of acute anginal pain. If a patch is accidentally removed, a new one may be applied after the nurse first
administers sublingual nitroglycerin.

Nitroglycerin patches are transdermal patches used to prevent angina in clients with coronary artery disease.
They are usually applied once a day (not as needed) and worn for 12 14 hours and then removed. Continuous
use of patches without removal can result in tolerance.

No more than one patch at a time should be worn. The patch should be applied to the upper body or upper arms.
Clean, dry, hairless skin that is not irritated, scarred, burned, broken, or calloused should be used. A different
location should be chosen each day to prevent skin irritation.
Phosphodiesterase inhibitors used in erectile dysfunction (eg, tadalafil, sildenafil, vardenafil)
are contraindicated with the use of nitrates. Both have similar mechanisms and cause vascular smooth muscle
dilation. Combined use can result in severe hypotension.
Patches may be worn in the shower.

UNFRACTIONATED HEPARIN

Unfractionated heparin is used as an anticoagulant in unstable angina. It prevents the conversion of fibrinogen to
fibrin and prothrombin to thrombin, both components of clot formation.
The aPTT is a laboratory test that characterizes blood coagulation. It is used to monitor treatment effects of clients
receiving heparin. The normal aPTT is 25 35 seconds.
Heparin infusions are titrated to obtain a therapeutic value of aPTT, typically 1.5 2 times the normal value.
Therapeutic value for aPTT is 46 70 seconds.
The nurse would evaluate the aPTT for a therapeutic value and make adjustments in the rate of infusion of the heparin
as needed.

With a heparin drip infusion, the goal is to reach the therapeutic range of the drug's effect and not the "normal" or
"control value." Once the therapeutic effect range has been reached (usually 1.5-2.0 times the control value), it
usually remains within this range without titrating the heparin infusion rate.
Heparin has a short duration (approximately 2-6 hours IV). Therefore, if it is not being infused, the aPTT level will go
back to the control value (aPTT level without administration of anticoagulants). In addition, the volume of heparin
being infused is small (because the standard concentration is 100 units/mL) so it is possible to miss an infiltration.
 Fondaparinux (Arixtra), unfractionated heparin, and low molecular weight heparin (eg, enoxaparin, dalteparin)
are anticoagulants commonly used for deep vein thrombosis and pulmonary embolism prophylaxis after hip/knee
replacement or abdominal surgery. However, fondaparinux is not administered until more than 6 hours after any
surgery, and anticoagulants are not given while an epidural catheter is in place
Fondaparinux is associated with epidural hematoma. Any bleeding in the tight epidural space, which does not expand,
could result in spinal cord compression. Signs of epidural spinal hematoma can include severe back pain and
paralysis.

The heparin slows the time it takes blood to clot, thereby keeping the current clot from growing bigger and preventing
new clots from forming.

WARFARIN
Warfarin (Coumadin) is a vitamin K antagonist used to prevent blood clots in clients with atrial fibrillation, artificial
heart valves, or a history of thrombosis.
Excessive intake of vitamin K rich foods (eg, broccoli, spinach, liver) can decrease the anticoagulant effects of
warfarin therapy
Clients should be consistent with intake of foods high in vitamin K after initiation of warfarin because dosing is
individualized to the client and dietary changes may require dose adjustment.
A therapeutic INR for most conditions is 2-3 but can be up to 3.5 for heart valve disease. However, it is never
between 4 and 5
Intestinal bacteria produce vitamin K; most antibiotics kill these bacteria, leading to vitamin K deficiency. Warfarin is a
vitamin K antagonist; therefore, INR would overshoot in the setting of vitamin K deficiency, placing the client at risk for
bleeding
Leafy-green vegetables contain a high amount of vitamin K, which may lower a client's INR and make it difficult to
maintain a therapeutic INR. Clients do not have to avoid consumption of leafy-green vegetables, but they should eat a
consistent quantity and have their INR checked periodically
It is important to take warfarin at the same time daily to maintain a consistent therapeutic drug level.
Clients should call their health care provider if they miss or forget to take a warfarin dose. Double dosing is
contraindicated.
Clients discharged on warfarin (Coumadin) are taught interventions to prevent injury, such as removing scatter
rugs in the home to reduce the risk of tripping and falling (especially in elderly)
Clients are educated to avoid aspirin, drugs containing aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs),
and alcohol when taking warfarin due to an increased risk for bleeding
Warfarin is usually administered for 3-6 months following PE to prevent further thrombus formation. A longer duration
(lifelong) of anticoagulation is recommended in clients with recurrent PE. Prothrombin time and INR must be
monitored regularly to adjust the dose and maintain a therapeutic anticoagulant level.
Clients should be taught to avoid trauma or injury to decrease the risk for bleeding. Preventive measures include
gently brushing teeth with a soft-bristled toothbrush, avoiding use of alcohol-based mouthwash, avoiding contact
sports or rollerblading, and using a straight razor. Flossing should also be avoided in general, but waxed dental floss
may be used with care in some clients.
Clients are instructed to wear a MedicAlert tag (eg, necklace, bracelet) when taking anticoagulants (eg, warfarin,
heparin).
ANTI-PLATELET AGENTS

Antiplatelet agents (eg, clopidogrel, ticagrelor, prasugrel, aspirin) prevent platelet aggregation and are given to
clients to prevent stent re-occlusion.
They prolong bleeding time and should not be taken by clients with a bleeding peptic ulcer, active bleeding, or
intracranial hemorrhage.
Ginkgo biloba also interferes with platelet aggregation and can cause increased bleeding time.
Antiplatelet agents and Ginkgo biloba should not be taken together. If this were to occur, this client would be at
an increased risk for bleeding. This information should be reported to the prescribing health care provider before the
client is discharged.

THROMBIN INHIBITORS

Thrombin inhibitors such as dabigatran (Pradaxa) reduce the risk of clot formation and stroke in clients with chronic
atrial fibrillation.
The nurse should educate the client about implementing bleeding precautions (eg, using a soft-bristle toothbrush,
shaving with an electric razor).
Dabigatran capsules should be kept in their original container or blister pack until time of use to prevent moisture
contamination
Red urine or blood in the stool may indicate internal bleeding caused by thrombin inhibitors. The client should report
these symptoms to the health care provider.
(Thrombin inhibitors should only be stopped under the direction of the health care provider. The nurse should educate
the client that stopping dabigatran will increase the risk for stroke. Taking the medication with food will not affect how
much is absorbed, and food or a full glass of water may prevent gastrointestinal side effects (eg, nausea, indigestion).
Thrombin inhibitor capsules should not be crushed or opened as crushing pills increases absorption and risk of
bleeding.

ANTI-COAGULANTS

A pulmonary embolism (PE) occurs when the pulmonary arteries are blocked by a thrombus. Initial management of
PE includes low-molecular-weight heparin (eg, enoxaparin, dalteparin) or unfractionated IV heparin.
 Once the PE is resolved, maintenance drug therapy often includes oral anticoagulants such as factor Xa
inhibitors (eg, apixaban, rivaroxaban, dabigatran).
Anticoagulants place the client at increased risk of bleeding, and the nurse should provide education regarding signs
and symptoms of bleeding (eg, bruising; blood in the urine; black, tarry stools) and bleeding precautions (eg, use of an
electric razor and soft-bristled toothbrush).
Concurrent NSAID use (eg, indomethacin, ibuprofen, meloxicam) significantly increases the risk of bleeding.

THROMBOLYTICS

Thrombolytic therapy aims to stop the infarction process, dissolve the thrombus in the coronary artery, and reperfuse
the myocardium.
This treatment is used when facilities do not have an interventional cardiac catheterization laboratory or when such a
facility is too far away to transfer the client safely.
Client selection is important because all thrombolytics lyse the pathologic clot but may also lyse other clots (eg, at a
postoperative site).
Minor or major bleeding can be a complication.
Inclusion criteria for thrombolytic therapy in clients with acute myocardial infarction include ch
hours, 12-lead ECG findings indicating acute ST-elevation myocardial infarction, and no absolute
contraindications (eg, history of cerebral arteriovenous malformation)
 Active menstruation is not a contraindication for thrombolytic therapy. Research shows that the risk of increased
menstrual bleeding due to thrombolytic administration is low and not life-threatening. Physiologic menstrual bleeding
is also not a contraindication for anticoagulation therapy.
Chest pain is one of the inclusion criteria for thrombolytic therapy.
Uncontrolled blood pressure of >180 mm Hg systolic or >110 mm Hg diastolic is a relative contraindication for
thrombolytic therapy. This client's blood pressure (170/92 mm Hg) is elevated but not uncontrolled, which does not
rule out this therapy.
KAWASAKI DISEASE

Kawasaki disease (
bilateral nonexudative conjunctivitis, mucositis, cervical lymphadenopathy, rash, and extremity swelling.
 Coronary artery aneurysms are the most serious potential sequelae in untreated clients, leading to complications
such as myocardial infarction and death. Echocardiography is used to monitor these cardiovascular complications.
Intravenous immunoglobulin (IVIG) along with aspirin is used to prevent coronary aneurysms and subsequent
occlusion. KD is one of the few pediatric illnesses in which aspirin therapy is warranted due to its antiplatelet and anti-
inflammatory properties. However, parents should be cautioned about the risk of Reye syndrome. Cardiopulmonary
resuscitation should also be taught to parents of children with coronary artery aneurysms.
KD is a vasculitis of unknown etiology, but it is not an infectious process. Because the child will often have a similar
clinical presentation to that of an infection (eg, persistent fever, inflammatory immune response), KD may be mistaken
for a bacterial or viral illness.
Polymorphous rash of the trunk and extremities is an expected finding in a child with KD. Cool compresses,
unscented lotions, and loose-fitting clothing can minimize discomfort. IVIG is not given to control rash.
Lymphadenopathy (usually a single palpable anterior cervical node >1.5 cm) and splenomegaly are included in the
clinical presentation of KD. IVIG therapy is not indicated to reduce incidence of these findings.

ORTHOSTATIC HYPOTENSION

Drugs commonly associated with orthostatic hypotension include:

1. Most antihypertensive medications, particularly sympathetic blockers such as beta blockers (eg, metoprolol) and alpha
blockers (eg, terazosin)
2. Antipsychotic medications (eg, olanzapine, risperidone) and antidepressants (eg, selective serotonin reuptake inhibitors)
3. Volume-depleting medications such as diuretics (eg, furosemide, hydrochlorothiazide)
4. Vasodilator medications (eg, nitroglycerine, hydralazine)
5. Narcotics (eg, morphine)

Clients at risk for developing orthostatic hypotension should be instructed to:

1. Take medications at bedtime, if approved by the health care provider

2. Rise slowly from a supine to standing position, in stages (especially in the morning)
3. Avoid activities that reduce venous return and worsen orthostatic hypotension (eg, straining, coughing, walking in hot
weather)
4. Maintain adequate hydration
ETHAMBUTOL

Ethambutol (Myambutol) is used to treat tuberculosis but can cause ocular toxicity, resulting in vision loss and loss
of red-green color discrimination. Vision acuity and color discrimination must be monitored regularly

RIFAMPICIN

Rifampin (Rifadin), used to treat tuberculosis, normally causes red-orange discoloration of all body fluids. The client
should be alerted to expect this change but does not need to notify the HCP.

LEVOFLOXACIN

Levofloxacin (Levaquin) is a quinolone antibiotic. For this class of antibiotics, 2 hours should pass between drug
ingestion and consumption of aluminum/magnesium antacids, iron supplements, multivitamins with zinc, or sucralfate.
These substances can bind up to 98% of the drug and make it ineffective.

SUCRALFATE

Sucralfate (Carafate, Sulcrate), prescribed to treat gastric ulcers, should be administered before meals to coat the
mucosa and prevent irritation of the ulcer during meals. It should also be given at least 2 hours before or after other
medications to prevent interactions that reduce drug efficacy.

DIGOXIN

Digoxin (Lanoxin) is a cardiac glycoside that increases cardiac contractility but slows the heart rate and conduction. It
is used in heart failure (to increase cardiac output) and atrial fibrillation (to reduce the heart rate).
The drug is excreted almost exclusively by the kidney. BUN and creatinine levels are measurements of kidney
function. The normal range for creatinine is 0.6-1.3 mg/dL (53-115 µmol/L).
Elderly clients tend to develop age-related decrease in glomerular filtration rate (GFR). These clients and those with
obvious kidney injury (possibly due to diabetes in this client) can accumulate digoxin.
The early symptoms of toxicity are nausea and vomiting. Later signs of toxicity are arrhythmias, including heart
blocks. Therefore, clients at risk for digoxin toxicity require frequent drug level monitoring and dose adjustment.
Digoxin levels are monitored for suspicion of digoxin toxicity (ie, serum levels >2 ng/mL). Potassium levels should
also be monitored in clients receiving digoxin, as hypokalemia can potentiate digoxin toxicity
Drug toxicity is common with digoxin due to its narrow therapeutic range.
Many contributing factors (eg, hypokalemia) can cause toxicity. However, in the absence of other factors, potassium
does not need to be increased just because a client is on digoxin. If the client also takes some other potassium-
depleting medications, such as diuretics, potassium supplements may be needed.
Signs and symptoms of digoxin toxicity include the following:

1. Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) are frequently the earliest symptoms
2. Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion)
3. Visual symptoms are characteristic and include alterations in color vision, scotomas, or blindness
4. Cardiac arrhythmias most dangerous

Drug levels are frequently monitored until a steady state is achieved and when changes are expected, such as in
clients with chronic kidney disease and electrolyte disturbances (eg, hypokalemia, hypomagnesemia).
Digoxin toxicity can result in bradycardia and heart block. Clients are instructed to check their pulse and report to the
HCP if it is low or has skipped beats.

Digoxin is a cardiac glycoside given to infants and children in heart failure. It is given to increase myocardial
contraction, which increases cardiac output and improves circulation and tissue perfusion. Digoxin is a potentially
dangerous drug due to its narrow margin of safety in dosage. Parents should receive thorough education and in
return demonstrate appropriate administration procedures for this medication.
Parent teaching for administration of digoxin includes the following:

o Inform parents of the pulse rate at which to hold the medication based on HCP prescription. In general, digoxin is held if
pulse <90-110/min for infants and young children or <70/min for an older child.
o Administer oral liquid in the side and back of the mouth
o Do not mix the drug with food or liquids as the refusal to take these would result in inaccurate intake of medication
o If a dose is missed, do not give an extra dose or increase the dose. Stay on the same schedule.
o If more than 2 doses are missed, notify the HCP
o If the child vomits, do not give a second dose. Nausea, vomiting, or slow pulse rate could indicate toxicity. Notify the HCP
o Give water or brush the client's teeth after administration to remove the sweetened liquid
AMIODARONE

Amiodarone is an antiarrhythmic medication used to treat life-threatening arrhythmias that cannot be controlled
with other medications. Amiodarone therapy is used only if other treatments have failed, as it has many toxic, adverse
effects that may be severe.
Pulmonary toxicity is a life-threatening adverse effect of amiodarone, which is believed to cause direct cellular
damage and activation of an immune response in the lungs. Clients who develop pulmonary toxicity may report
respiratory symptoms such as dry cough, pleuritic chest pain, and dyspnea.
Clients with clinical manifestations of pulmonary toxicity require immediate intervention to prevent fatal, irreversible
lung damage
CLONIDINE

Central-acting alpha2 agonists (eg, clonidine, methyldopa) decrease the sympathetic response from the brainstem to
the peripheral vessels, resulting in decreased peripheral vascular resistance and vasodilation.
Clonidine is a highly potent antihypertensive. Abrupt discontinuation (including the patch) can result in
serious rebound hypertension due to the rapid surge of catecholamine secretion that was suppressed during
therapy. Clonidine should be tapered over 2-4 days. Abrupt withdrawal of beta blockers can also result in rebound
hypertension and in precipitation of angina, myocardial infarction, or sudden death.
Dizziness is a side effect of clonidine. The nurse should teach the client to change positions slowly and sit for a few
minutes before rising to prevent falls.
Drowsiness is also quite common with clonidine. Clients should not use it with alcohol or central nervous system
depressants. However, dizziness and drowsiness should diminish with continued use of the medication.
Dry mouth is a side effect of clonidine. Use of over-the-counter mouth moisturizers, chewing gum, or hard candy may
be helpful for clients with dry mouth.

LICORICE ROOT

Licorice root is an herbal remedy sometimes used for gastrointestinal disorders such as stomach ulcers, heartburn,
colitis, and chronic gastritis.
Clients with heart disease or hypertension should be cautious about using licorice root. When used in combination
with a diuretic such as hydrochlorothiazide, it can increase potassium loss, leading to hypokalemia.
Hypokalemia can cause dangerous cardiac dysrhythmias. Thiazide diuretics are considered "potassium-wasting"
diuretics, so this client is already at risk for hypokalemia.
The addition of licorice root could potentiate the potassium loss. The nurse should discourage the client from using
this herbal remedy and report the client's use to the PHCP.

SILDENAFIL

Sildenafil (Viagra) is a phosphodiesterase inhibitor used to treat erectile dysfunction.

The use of sildenafil is most important for the nurse to report to the HCP. This must be communicated immediately as
concurrent use of nitrate drugs (commonly prescribed to treat unstable angina) is contraindicated as it can cause life-
threatening hypotension.
 Before any nitrate drugs can be administered, further action is necessary to determine when sildenafil was taken last
(ie, half-life is about 4 hours).

MILRINONE

Milrinone (Primacor) is a phosphodiesterase-3 inhibitor given via IV infusion to increase contractility and promote
vasodilation.
Milrinone, an inotropic agent, is often prescribed to clients with heart failure unresponsive to other pharmacologic
therapies.
The medication is usually infused over 48-72 hours in a hospital setting; however, home infusion through a central line
is becoming more common as a palliative measure for end-stage heart failure.
Milrinone infusion requires central venous access (eg, peripherally inserted central catheter) as the medication is a
vesicant and can cause extravasation if infused through a peripheral IV line.
The home health nurse should perform the following:

o Ensure that an infusion pump is used to control the rate, and instruct the family on basic troubleshooting (
o Evaluate medication effectiveness and possible side effects.
o Monitor the central line insertion site for infection.
o Change the central line dressing as prescribed
o Monitor daily weight
o Monitor blood pressure for possible hypotension
o Implement safety precautions as hypotension increases the client's risk of falling.
 ENDOCRININE PHARMACOLOGY

HYPOTHYROIDISM

Thyroid-stimulating hormone (TSH) is released from the pituitary gland to stimulate the thyroid to secrete hormones
(T3, T4). When sufficient thyroid hormone is circulating, negative feedback causes a normally functioning pituitary to
slow or stop the release of TSH.
In primary hypothyroidism, the thyroid is unable to synthesize enough T3 or T4, slowing the metabolic rate. In
response to low circulating thyroid hormones, the pituitary continues to release TSH, resulting in high
TSH levels. Levothyroxine (Synthroid), a thyroid hormone replacement drug, is commonly used to treat
hypothyroidism. Levothyroxine dosing is adjusted to regulate circulating thyroid hormone levels; this creates a
euthyroid (normal) state and TSH levels are decreased
Decreasing the dose or discontinuing levothyroxine would lead to increased TSH and worsening hypothyroidism as the
amount of circulating thyroid hormone decreases.
 Levothyroxine should be taken on a consistent morning schedule, at least 30 minutes before a meal. Foods
containing certain ingredients (eg, walnuts, soy products, dietary fiber, calcium) can decrease drug absorption.

LEVOTHYROXINE

Hypothyroidism during pregnancy places clients at increased risk for other complications of pregnancy (eg,
preeclampsia, placental abruption, preterm labor).
Symptoms of hypothyroidism may include fatigue, cold intolerance, constipation, dry skin, and brittle hair/nails.
Levothyroxine (Synthroid) is the first-line medication for treatment of hypothyroidism during pregnancy. The client
may experience some relief of symptoms beginning approximately 3-4 weeks after initiating levothyroxine therapy
Hormone levels are usually rechecked every 4-6 weeks until normal thyroid hormone levels are achieved. It may
take up to 8 weeks after initiation to see the full therapeutic effect.
Adequate levels of maternal thyroid hormones are important for fetal brain development, particularly during the first
trimester. Levothyroxine should not be stopped during pregnancy, even if symptoms resolve.
Prenatal vitamins containing iron can affect the absorption of levothyroxine and decrease its effectiveness. The nurse
should instruct the client to take levothyroxine in the morning on an empty stomach, at least 4 hours before or after
taking a prenatal vitamin.
As the pregnancy advances, the client's dose of levothyroxine may need to be increased. Thyroid stimulating
hormone (TSH) levels are closely monitored during pregnancy, and the client's dose is modified as needed to maintain
normal levels.
Several medications impair the absorption of levothyroxine (Synthroid). Common offenders are antacids, calcium,
and iron preparations. Some of these could be present in several over-the-counter multivitamin and mineral tablets.
Therefore, clients with hypothyroidism should be instructed to take levothyroxine on an empty stomach, preferably in
the morning, separately from other medications.
The most common reason for inadequately treated hypothyroidism is deficient knowledge related to the medication
regimen (eg, not taking daily, taking with other medications).
Levothyroxine dosing is adjusted based on blood tests for thyroid-stimulating hormone or other thyroid hormone
levels. The dose is not the same for each client.
Thyroid supplementation with levothyroxine usually requires lifelong therapy.
Levothyroxine has a long half-life, so dosing is once daily.
 Levothyroxine sodium (eg, Levoxyl, Levothroid, Synthroid) is used to replace thyroid hormone in clients with
hypothyroidism (inadequate thyroid hormone) and for those who have had their thyroid removed. These clients must
understand that this medication must be taken for the rest of their lives
A client's dose is adjusted based on serum TSH levels to prevent too much or too little hormone. Clients must be
taught to report signs of excess thyroid hormone such as heart palpitations/tachycardia, weight loss, and insomnia
Clients with hypothyroidism experience lethargy and somnolence. Hormone replacement therapy will increase
metabolic activity and alertness.
This medication is a hormone that is normally present in the body, so it is safe to take during pregnancy. The dose
may need to be altered due to the metabolic demands of pregnancy, but the drug will not harm the fetus.
It is best to take this medication first thing in the morning as it is best absorbed on an empty stomach (1 hour before or
2 hours after a meal).

The client's therapeutic response to levothyroxine (Synthroid) is evaluated by resolution of hypothyroidism symptoms.

The expected response includes improved well-being with elevated mood, higher energy levels, and a heart rate that
is within normal limits

The nurse should consult the health care provider if the heart rate is >100/min, or if the client reports chest pain,
nervousness, or tremors; this may indicate that the dose is higher than necessary. Pharmacological therapy manages
the symptoms of hypothyroidism, but it takes up to 8 weeks after initiation to see the full therapeutic effect.

TYPE I DIABETES MELLITUS

Type 1 diabetes mellitus is an endocrine disorder characterized by the absence of insulin production in the
pancreas, causing hyperglycemia and intracellular energy deficits.
 Clients with type 1 diabetes mellitus require regular administration of insulin to prevent hyperglycemia and provide
energy to the cells.
Insulin shifts glucose and potassium from the intravascular to the intracellular space. This shift of potassium into
cells may cause or worsen hypokalemia (<3.5 mEq/L [3.5 mmol/L]) and place the client at risk for life-threatening
dysrhythmias (eg, ventricular tachycardia, ventricular fibrillation).
The nurse should notify the health care provider (HCP) before administering insulin to clients with hypokalemia,
as supplemental potassium may be required to prevent cardiac dysrhythmias
The nurse should notify the HCP of the client's hypokalemia before administering insulin, as such administration may
worsen the hypokalemia and result in potentially fatal cardiac dysrhythmias. Once supplemental potassium is
administered, insulin should be administered to address the client's hyperglycemia and prevent diabetic ketoacidosis.
Assessing for ketonuria and rechecking the client's blood glucose are appropriate but do not address the potentially
life-threatening hypokalemia caused by insulin administration. These checks can occur after potassium has been
replaced.
INSULIN

Insulin is a medication commonly used to control and lower blood glucose levels in clients with diabetes mellitus.
 Clients may require a combination of long-acting insulin (eg, glargine) with rapid- (eg, lispro) or short-acting (eg,
regular) insulin to manage glucose levels.
The different onsets, peaks, and durations mimic the body's natural insulin levels and enhance glycemic control.
Insulin glargine, a long-acting (basal) insulin, has no peak and may last 24 hours or longer.
Short-acting insulins peak 2-5 hours after administration and last approximately 5-8 hours.
Regular or rapid-acting insulins may be given on a sliding scale at prescribed intervals (eg, before meals and at
bedtime) and are dosed based on the client's blood glucose measurement.
Insulin glargine and regular insulin may be safely given concurrently due to the differences in onset, peak, and
duration
Insulin glargine has no peak effect and should not potentiate hypoglycemia, whereas regular insulin may cause
hypoglycemia. Concurrent administration of regular insulin with insulin glargine will not increase the risk of
hypoglycemia as each medication has a different onset, peak, and duration; therefore, a snack is not required.
Insulin glargine should not be mixed in a single syringe with any other insulin as the mixture may alter the
pharmacodynamics of the drug.
Subcutaneous injection is the indicated route for NPH insulin administration; it should never be administered via IV
push. Regular insulin is the only insulin that can be administered via IV push; this is typically performed only in an
acute care facility under close observation by the nurse.

SULFONYLUREA

The major adverse effects of sulfonylurea medications (eg, glyburide, glipizide, glimepiride)
are hypoglycemia and weight gain.
Weight gain should be addressed. Clients taking glyburide should be taught to use sunscreen and protective clothing
as serious sunburns can occur.
Clients taking sulfonylureas should avoid alcohol as it lowers blood glucose and can lead to severe hypoglycemia.
Hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]) is a major side effect of sulfonylurea medications. A fasting
blood glucose <60 mg/dL (3.3 mmol/L) indicates moderate to severe hypoglycemia and the medication needs to be
reassessed.
Even foods labeled "diabetic", "sugar free," or "sugarless" may contain carbohydrates such as honey, brown sugar,
and corn syrup, all of which can elevate blood sugar.
 Regular insulin is a short-acting insulin that reaches the peak effect within 2-5 hours after subcutaneous
administration. Therefore, clients who receive regular insulin subcutaneously at 11:30 AM are at highest risk for
hypoglycemia between 1:30 PM and 4:30 PM
Rapid-acting insulins (eg, lispro, aspart) take peak effect in 30 minutes to 3 hours. Clients who receive rapid-acting
insulin at 11:30 AM would be most at risk for hypoglycemia from 12:00-2:30 PM.
Both insulin NPH, an intermediate-acting insulin, and insulin detemir, a long-acting insulin, have peak effect times that
may cause hypoglycemia at 5-6 PM in clients who receive the medication at 11:30 AM.
METFORMIN

Metformin is an oral antidiabetic medication used to manage hyperglycemia in clients with type 2 diabetes.
Metformin increases the sensitivity of insulin receptors in cells and reduces glucose production by the liver.
These actions increase the efficacy of insulin present in the body and prevent large rises in blood glucose after
meals.
Because metformin does not stimulate insulin secretion by the pancreas, the risk of hypoglycemia is minimal
Although skipping meals would cause a drop in blood glucose, metformin would not cause further hypoglycemia.

INSULIN SENSITIZERS

Thiazolidinediones (rosiglitazone [Avandia] and pioglitazone [Actos]) are used to treat type 2 diabetes mellitus.
These agents improve insulin sensitivity but do not release excess insulin, leading to a low risk for hypoglycemia
 (similar to metformin). These drugs can worsen heart failure by causing fluid retention and increase the risk
of bladder cancer. Heart failure or volume overload is a contraindication to thiazolidinedione use. These medications
also increase the risk of cardiovascular events such as myocardial infarction.
The target blood pressure for a client with diabetes is <140/90 mm Hg.
The goal HbA1c for diabetic clients is <7%.

DESMOPRESSIN

Desmopressin is a medication often used to treat central diabetes insipidus, a disease characterized by reduced
antidiuretic hormone (ADH) levels that may result in dehydration and hypernatremia.
Desmopressin mimics the effects of naturally occurring ADH, which increases renal water resorption and
concentrates urine. However, this effect also increases the risk for water intoxication from decreased urine output.
Clients receiving desmopressin must have their fluid and electrolyte status closely monitored for symptoms of water
intoxication/hyponatremia (eg, headache, mental status changes, weakness).
The nurse should immediately notify the health care provider (HCP) of client reports of water intoxication symptoms,
as severe hyponatremia may progress to seizure, neurologic damage, or death
Clients on desmopressin are often on fluid restriction as part of therapy. Frequent reinforcement may be necessary.
Rhinitis and upper respiratory infection (eg, a cold) can decrease the effectiveness of desmopressin nasal spray
therapy and may require dosage adjustments by the HCP. However, dosage adjustments can be addressed after
symptoms of water intoxication.
Side effects of desmopressin nasal spray include nasal irritation, congestion, and pain. If the client cannot tolerate
side effects of nasal spray, oral dosing may be prescribed by the HCP.
RAI

RAI is the primary treatment for nonpregnant adults with hyperthyroid disorders such as Graves' disease (a type of
autoimmune hyperthyroid disease).
The use of RAI is contraindicated in pregnancy and could cause harm to a fetus.
Pregnancy results should therefore be confirmed using a valid pregnancy test in all clients who still have menstrual
cycles rather than using a subjective form of assessment such as asking when the last menstrual period occurred
Radiation thyroiditis and parotitis, which cause dryness and irritation to the mouth, may occur after RAI treatment. A
baseline assessment is helpful but is not the most important action listed. The nurse can teach the client to take sips
of water frequently or to use a salt and soda gargle solution 3-4 times daily to relieve these symptoms.
 RAI damages or destroys the thyroid tissue, thereby limiting thyroid secretion, and can result in hypothyroidism.
Clients need to take thyroid supplementation (levothyroxine) for life. Because these symptoms are delayed, this
teaching can occur before or after the procedure. It is not as important as assessing pregnancy status.

RAI has a delayed response, requiring up to 3 months for maximal effect. After treatment, the client emits radiation,
and excreted bodily fluids are radioactive.
The nurse teaches home precautions to protect those who come in contact with the client. Depending on the
dosage, clients should use the following precautions for up to 1 week:

o Limit close contact and time spent with pregnant women and children
o Use a separate toilet, and flush 2 or 3 times after each use to remove urine residue
o Use disposable cups, plates, and utensils, and do not share foods that could transfer saliva
o Isolate personal laundry (eg, clothing, linens) and wash it separately
o Sleep in a separate bed from others.
o Do not sit near others for a prolonged time (eg, train or flight travel).

After RAI therapy, breast milk excreted by the client is radioactive and can permanently damage an infant's thyroid.
Breastfeeding should be stopped 6 weeks before treatment to prevent RAI from accumulating in the breasts after
treatment. Breastfeeding is not resumed with the current child but can be resumed with future pregnancies.

ADDISON DISEASE

Addison disease (primary adrenocortical insufficiency) is characterized by a deficiency in all three types of adrenal
steroids (ie, glucocorticoids, androgens, mineralocorticoids), most commonly caused by an autoimmune response.
Corticosteroid therapy (eg, hydrocortisone, dexamethasone, prednisone) is the primary treatment for Addison
disease.
Long-term use of corticosteroids can cause immunosuppression, and the anti-inflammatory effects may also mask
signs of infection (eg, inflammation, redness, tenderness, heat, fever, edema).
Signs and symptoms of infection (eg, low-grade fever) should be reported to the health care provider immediately as
infection can develop quickly and spread rapidly
In addition, physiological stress such as infection can trigger Addisonian crisis, a life-threatening complication of
Addison disease that would require an increase in the corticosteroid dose.
 Side effects of long-term corticosteroid therapy mimic the signs and symptoms of Cushing syndrome, including buffalo
hump, moon-shaped face, and hypokalemia. Increased weight, blood pressure, and blood glucose levels can also
occur; however, these effects are not as life-threatening as infection.

DIABETES INSIPIDUS

Diabetes insipidus (DI) results in low levels of antidiuretic hormone (ADH), which is produced by the hypothalamus
and stored in the pituitary gland.
The function of ADH is to concentrate urine by signaling the kidneys to retain water in the setting of thirst.
When ADH levels are insufficient, the kidneys excrete large quantities of very dilute urine (polyuria). This causes
hypernatremia (elevated serum sodium due to deficit of free water) and increased serum osmolality, which lead to
excessive thirst (polydipsia).
Desmopressin acetate (DDAVP) is a synthetic form of ADH, which can be administered intravenously, orally, or via
nasal spray.
Effectiveness of therapy with desmopressin would be manifested by decreased urinary output and increased urine
specific gravity as the urine becomes less dilute

CORTICOSTEROID

Clients taking long-term corticosteroid replacement should be taught the following:

1. Do not discontinue glucocorticoid therapy abruptly. Abrupt discontinuation could lead to addisonian crisis, a life-threatening
complication
2. Report any signs and symptoms of infection to the HCP immediately. Corticosteroid use can cause immunosuppression, and
infection can develop quickly and spread rapidly. Corticosteroids' anti-inflammatory effects may also mask signs of
infection such as inflammation, redness, tenderness, heat, fever, and edema (Option 3).
3. Stay attuned to signs and symptoms of stress and increase dose of corticosteroid during times of stress. A stress
response (surgery, trauma) can cause a sudden decrease in cortisol levels, triggering addisonian crisis (Option 6).
4. A side effect of corticosteroid therapy is hyperglycemia. Report signs of hyperglycemia, including increased urine, hunger,
and thirst. Clients with diabetes mellitus must be vigilant in checking blood glucose levels
5. Corticosteroids are catabolic to bone (osteoporosis) and muscle (muscle weakness). A diet high in calcium (at least 1500
mg/day) and protein (1.5 g/kg/day) but low in fat and simple carbohydrates is recommended.
 6. Cataracts are a side effect of corticosteroids, particularly glucocorticoid therapy. Make an appointment with an optometrist
yearly to assess for cataracts
7. Corticosteroid medications can cause gastric irritation and should not be taken on an empty stomach
8. Recognize signs and symptoms of Cushing syndrome and report to the PHCP.
9. Develop a regular HCP-approved exercise program.

INSULIN PUMP

An insulin pump is a small, battery-operated device about the size of a pager. The infusion set holds a syringe
(reservoir) filled with rapid-acting insulin (175-315 units) and delivers the drug from the pump to the client through a
needle or catheter that is usually secured to the abdomen with an adhesive patch. The pump delivers insulin in 2
ways:

o As a steady, measured, and continuous dose (basal rate) 24 hours a day

o As an intermittent dose (bolus) administered manually at mealtime to cover carbohydrate intake and as a supplemental dose
to orrect pre- or postprandial hyperglycemia.

CSII therapy delivers the insulin more accurately than injections, so the client experiences fewer swings in blood
glucose levels and hypoglycemic episodes, as compared with the administration of insulin using a needle and
syringe, or pen.
Although the pump can calculate and deliver a more precise dose to regulate blood glucose levels more effectively, a
bolus dose must be administered manually at mealtime to cover carbohydrate intake.
Pumps used most commonly (open-loop) cannot respond to changes in the client's glucose levels. The American
Diabetes Association recommends that clients using CSII check their blood glucose levels 4-8 times a day: fasting,
pre-meal, 2-hours postprandial, bedtime, at 3:00 AM weekly, when experiencing symptoms of hypoglycemia, after
treating low blood sugar, and before exercise.
Some insulin pumps (closed-loop system) are equipped with continuous blood glucose monitoring (CBGM) systems,
which can detect blood glucose levels without a fingerstick. However, CBGM does not completely eliminate the need
to test blood sugar because some machines must be calibrated every day to validate accuracy.
Use of the insulin pump facilitates tighter glucose control, leading to more normal metabolism. However, if the client
continues to take in more calories than needed for a given amount of activity or exercise, glucose that is not used by
the cells accumulates as fat and results in weight gain.
GASTROENTEROLOGY PHARMACOLOGY / NUTRITIONAL
METOCLOPRAMIDE

Metoclopramide is a commonly used antiemetic medication that treats nausea, vomiting, and gastroparesis by
increasing gastrointestinal motility and promoting stomach emptying. With extended use and/or high doses,
metoclopramide may lead to the development of tardive dyskinesia (TD), a movement disorder that is characterized
by uncontrollable motions (eg, sucking/smacking lip motions) and is often irreversible
The movement alterations of TD may impact a client's essential activities of daily living (eg, eating, dressing) and
overall quality of life. The nurse should question the administration of a medication associated with TD in clients
experiencing movement alterations.
Metoclopramide increases gastrointestinal motility, which may result in diarrhea in some clients. This symptom is
reversible and usually easily managed.
Headache is a common adverse effect of metoclopramide that typically improves spontaneously.
DICYCLOMINE HYDROCHLORIDE

Dicyclomine hydrochloride (Bentyl) is an anticholinergic medication. Anticholinergics are used to relax smooth muscle
and dry secretions. Anticholinergic side effects include pupillary dilation, dry mouth, urinary retention,
and constipation. Therefore, the classic contraindications are closed-angle glaucoma, bowel ileus, and urinary
retention.
The common eye contraindication is narrow-angle glaucoma as it could worsen the condition.
Diarrhea is an expected finding with irritable bowel syndrome or other increased peristalsis and is a common reason
for the drug to be prescribed.
Anticholinergic drugs are contraindicated in the presence of a bowel ileus or atony as constipation is a side effect and
further relaxation of the intestines could worsen these conditions.
MISOPROSTOL

Misoprostol (Cytotec) is a synthetic prostaglandin that protects against gastric ulcers by reducing stomach acid and
promoting mucus production and cell regeneration. It is often prescribed to prevent gastric ulcers in clients
receiving long-term nonsteroidal anti-inflammatory drug (NSAID) therapy.
Antacids, especially those that contain magnesium (eg, Gaviscon), can increase the adverse effects of misoprostol
(eg, diarrhea, dehydration). If clients require therapy with antacids, they should choose one that does not contain
magnesium (eg, calcium carbonate [Tums]) and contact the health care provider if adverse effects occur
Taking misoprostol with food can help decrease gastrointestinal side effects (eg, abdominal pain, cramping, diarrhea).
Misoprostol is also used for labor induction and is classified as a pregnancy category X drug. Women of childbearing
age must be educated on using reliable birth control and the possible sensation of uterine cramping while taking
misoprostol. Clients who suspect they are pregnant must stop taking the medication and contact their health care
provider immediately.
The client can continue taking ibuprofen (an NSAID) with misoprostol because misoprostol is designed to reduce side
effects of ibuprofen.

OMEPRAZOLE
Omeprazole is a proton pump inhibitor (PPI) that suppresses the production of gastric acid by inhibiting the proton
pump in the parietal cells of the stomach.
In most hospitalized clients without a history of GERD or ulcers, PPIs are prescribed to prevent stress ulcers from
developing during surgery or a major illness.
Although evidence has shown that two-thirds of clients who receive PPIs do not need them, these medications are still
widely prescribed in hospitalized clients. PPIs can be identified by their "-prazole" ending (eg, pantoprazole,
lansoprazole, esomeprazole).
PPIs may be associated with an increased risk of Clostridium difficile infection with antibiotic use.
Long-term use of proton pump inhibitors (PPIs) is common as these medications are available over the counter.
 PPIs impair intestinal calcium absorption and therefore are associated with decreased bone density, which increases
the possibility of fractures of the spine, hip, and wrist.
PPIs cause acid suppression that otherwise would have prevented pathogens from more easily colonizing the upper
gastrointestinal tract. This leads to increased risk of pneumonias.
PPI use may also increase the risk for clostridium difficile-associated diarrhea (CDAD); currently the cause is
unclear.
A safety alert has been issued by the US Food and Drug Administration (FDA) advising health care providers to
consider CDAD for unresolved diarrhea in PPI users. This client would be receiving antibiotics for a urinary tract
infection, further increasing the risk for C difficile infection

LACTULOSE
Hepatic encephalopathy in cirrhosis results from higher serum ammonia levels that cause neurotoxic effects,
including mental confusion.
Oral lactulose is given to reduce the ammonia by trapping it in the gut and then expelling it with a laxative effect.
Improved mental status implies reduction of ammonia levels.

SUCRALFATE
Sucralfate is an oral medication that forms a protective layer in the gastrointestinal mucosa, which provides
a physical barrier against stomach acids and enzymes. It does not neutralize or reduce acid production but is
prescribed to treat and prevent both stomach and duodenal ulcers.
Sucralfate is generally prescribed 1 hour before meals and at bedtime and, for effective results, is taken on an empty
stomach with a glass of water.
Sucralfate forms a better protective layer at a low pH level. Therefore, antacids or other acid-reducing
medications (eg, proton pump inhibitors, H2 blockers) should be avoided within 30 minutes of taking sucralfate to
prevent altered absorption
Sucralfate binds with many medications (eg, digoxin, warfarin, phenytoin), reducing their bioavailability and
effectiveness. -2 hours before or after taking sucralfate.
 Constipation is a common side effect of sucralfate.

PANCRELIPASE
Cystic fibrosis affects the pancreatic excretion of digestive enzymes. Without these enzymes, the client is unable to
absorb fats, starches, and some proteins from the diet. Pancrelipase provides these enzymes to the client and must
be given with every snack and meal so that the client can digest and absorb the nutrients eaten.
If the client is not eating when the medication is scheduled, there are no nutrients to digest. Therefore, the dose
should be held until the client eats.

ACTIVATED CHARCOAL

Activated charcoal is an important treatment in early acetylsalicylic acid (ASA) toxicity; it is recommended for
gastrointestinal decontamination in clients with clinical signs of ASA poisoning (disorientation, vomiting, hyperpnea,
diaphoresis, restlessness) as well as in those who are asymptomatic.
Activated charcoal binds to available salicylates, thus limiting further absorption in the small intestine and enhancing
elimination.
IV sodium bicarbonate is an appropriate treatment for aspirin toxicity after the administration of activated charcoal.
It is given to make the blood and urine more alkaline, therefore promoting urinary excretion of salicylate.

ORLISTAT

Orlistat is a lipase inhibitor that prevents the breakdown and absorption of fats from the intestine. This medication
is prescribed to clients with obesity who have difficulty losing weight or a comorbidity that makes weight loss
therapeutically essential (eg, diabetes, heart disease). Orlistat should always be used with diet modification and an
exercise regimen.
Because orlistat blocks the absorption of fats, it also interferes with fat-soluble vitamin uptake. Clients should offset
this effect by taking a multivitamin that contains vitamins A, D, E, and K. To be most effective, multivitamins should be
taken >2 hours after taking orlistat
 Clients may experience fecal incontinence, flatulence, oily stools, and oily spotting because unabsorbed fat is
eliminated through defecation.
A low-fat diet is an essential component of weight loss when a lipase inhibitor has been prescribed.
The nurse should teach the client to take orlistat with, or within 1 hour of, meals that contain fat. If the client selects
foods that do not contain fat, the dose may be skipped.

SULFASALAZINE

Sulfasalazine (Azulfidine) contains sulfapyridine and aspirin (5-ASA) and is used as a topical gastrointestinal anti-
inflammatory and immunomodulatory agent in inflammatory bowel disease (IBD).
When the 5-ASA is combined with the sulfa preparation, the drug does not become absorbed until it reaches the
colon.
Dehydration is a risk with IBD as the client can have up to 20 diarrheal stools a day.
The client usually does not feel thirsty until after there is a fluid volume deficit. Sulfa can crystallize in the kidney if
the client is dehydrated.
Normal urine specific gravity is 1.003-1.030. Elevated specific gravity can indicate concentrated urine and be a sign of
dehydration.

ONCOLOGICAL/HEMATOLIGICAL PHARMACOLOGY
TAMOXIFEN

Tamoxifen is a selective estrogen receptor modulator that is prescribed to treat certain types of breast cancer and
to prevent breast cancer recurrence.
Tamoxifen works by blocking estrogen receptors in certain estrogen-sensitive tissues (eg, breast, vagina), but it also
increases affinity for estrogen in some tissues, such as the uterus.
In the treatment of breast cancer, tamoxifen inhibits growth of estrogen receptor positive tumors.
 Clients typically take tamoxifen for several (eg, 5-10) years after treatment to prevent breast cancer recurrence.
Common side effects of tamoxifen therapy, like the effects typically seen in menopause (eg, hot flashes, vaginal
dryness, menstrual irregularities), are related to decreased estrogen.
Follow-up would be required for clients with symptoms or a history of tamoxifen's most serious side effects, including:

o Thromboembolic events (eg, deep venous thrombosis, pulmonary embolism, stroke)

o Endometrial cancer (eg, abnormal vaginal bleeding)

Selective estrogen receptor modulators (eg, tamoxifen) have differential action in different tissues (mixed
agonist/antagonist). In the breast, they block estrogen (antagonist) and are therefore helpful in inhibiting the growth of
estrogen-receptive breast cancer cells.
However, tamoxifen has estrogen-stimulating (agonist) activity in the uterus, resulting in excessive endometrial
proliferation (endometrial hyperplasia). This hyperplasia can eventually lead to cancer. Irregular or excessive
menstrual bleeding in premenopausal woman or any bleeding in postmenopausal women can be a sign
of endometrial cancer.
Due to its estrogen-agonist actions, tamoxifen also poses a risk for thromboembolic events (eg, stroke, pulmonary
embolism, deep vein thrombosis).
Clients with breast cancer take tamoxifen for several (5-10) years to prevent recurrence. Therefore, monitoring for life-
threatening side effects is very important.
Because tamoxifen blocks estrogen receptors, it can cause symptoms of menopause. Vaginal dryness, hot flashes,
and decreased libido (sexual dysfunction) are common and would be discussed after addressing more concerning
symptoms.

TUMOR LYSIS SYNDROME

A potential complication of chemotherapy is acute tumor lysis syndrome (TLS), a rapid release of intracellular
components into the bloodstream. Massive cell lysis releases intracellular ions (potassium and phosphorus) and
nucleic acids into the bloodstream.
 Catabolism of the nucleic acids produces uric acid, resulting in severe hyperuricemia. Released phosphorus binds
calcium, producing calcium phosphate mixture but lowering serum calcium levels.
Both calcium phosphate and uric acid are deposited into the kidneys, causing renal injury.
Allopurinol (Zyloprim) blocks the nucleic acid catabolism and prevents hyperuricemia but would not affect potassium,
phosphate, and calcium levels. Chronic gout and uric acid calculi also require the administration of allopurinol to
decrease uric acid accumulation. A normal blood uric acid level for an adult male is 4.4 7.6 mg/dL (262 452 µmol/L)
and female is 2.3-6.6 mg/dL (137-393 µmol/L).
The normal calcium level for adults is 8.6 10.2 mg/dL (2.15 2.55 mmol/L). The client with this complication would
experience hypocalcemia.
The normal phosphate level for adults is 2.4 4.4 mg/dL (0.78 1.42 mmol/L). In this condition, the phosphate level
would show hyperphosphatemia.
The normal potassium level for adults is 3.5 5.0 mEq/L (3.5 5.0 mmol/L). Hyperkalemia is usually present in a client
with this chemotherapy-induced complication.

CISPLATIN

Urine output is a good indicator of renal function. Cisplatin is an antineoplastic medication that can cause renal
toxicity.
The client's elevated BUN (normal 6-20 mg/dL [2.1-7.1 mmol/L]) may be due to dehydration (prerenal disease) or
decreased kidney function.
The creatinine is also elevated (normal 0.6-1.3 mg/dL [53-115 µmol/L]), an indication of kidney injury. In addition to
laboratory results, the health care provider will also need to know urine output. The medication dosage may then be
adjusted or discontinued.

HERBAL SUPPLEMENTS

Clients are often aware of the need to discontinue prescription medications such as aspirin and anticoagulants prior to
elective surgery, but they may not know that some herbal supplements can increase bleeding risk.
The nurse should question the client specifically about the use of herbal supplements.
Herbal supplements that can increase risk for bleeding include:
 o Gingko biloba
o Garlic
o Ginseng
o Ginger
o Feverfew

GLYCOPROTEIN (GP) IIb/IIIa RECEPTOR INHIBITORS

Glycoprotein (GP) IIb/IIIa receptor inhibitors (eg, abciximab, eptifibatide, tirofiban) are used as platelet inhibitors to
prevent the occlusion of treated coronary arteries during percutaneous coronary intervention procedures and prevent
acute ischemic complications.
GP IIb/IIIa receptor inhibitors can cause serious bleeding. The nurse should closely monitor the client for any
bleeding at the groin puncture site after the percutaneous coronary intervention
The nurse should check the client's baseline complete blood count (eg, hemoglobin, platelet count). Some clients may
develop serious thrombocytopenia within a few hours, further increasing the bleeding risk.
Hypotension, tachycardia, changes in heart rhythm, blood in the urine, abdominal/back pain, mental status changes,
and black tarry stools may also indicate internal bleeding and should be monitored carefully when GP IIb/IIIa receptor
inhibitors are administered
During and after the infusion of GP IIb/IIIa receptor inhibitors, no traumatic procedures (initiation of IV sites,
intramuscular injections) should be performed unless absolutely necessary due to the risk of bleeding.

ENOXAPARIN
Enoxaparin (Lovenox) is a low molecular weight heparin (LMWH) that may be prescribed for up to 10-14 days
following hip and knee surgery to prevent deep venous thrombosis.
Discharge teaching for the client on enoxaparin therapy includes:

1. Pinch an inch of skin upwards and insert the needle at a 90-degree angle into the fold of skin.
2. Continue to hold the skin fold throughout the injection and then remove the needle at a 90-degree angle.
 3. Mild pain, bruising, irritation, or redness of the skin at the injection site is common. Do NOT rub the site with the hand. Using
an ice cube on the injection site can provide relief
4. Avoid taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements (Ginkgo biloba, vitamin E)
without health care provider approval as these can increase the risk of bleeding
5. Monitor complete blood count to assess for thrombocytopenia.

Vitamin K-rich foods do not need to be eliminated from the diet during enoxaparin therapy; prothrombin time (PT) and
international normalized ratio (INR) are not affected. However, PT and INR are decreased when a vitamin K
antagonist (eg, warfarin [Coumadin]) is taken with vitamin K-rich foods.
Routine coagulation studies (eg, PT, INR, partial thromboplastin time [PTT]) do not need to be monitored in a client
who is taking enoxaparin. However, periodic assessment of complete blood count (CBC) is usually required to monitor
for hidden bleeding and thrombocytopenia (especially in older clients with renal insufficiency).
HEPARIN

Heparin is a natural anticoagulant. Its risk is heparin-induced thrombocytopenia (HIT), also known as heparin-
associated thrombocytopenia.
Normal platelet range is 150,000-400,000/mm3 (150-400 x 109/L). A mild lowering of platelets may occur and resolve
spontaneously around the 4th day of administration.
The danger is type II HIT, a more severe form in which there is an acute drop in the number of platelets (more than
50% from baseline), which requires discontinuing heparin

WARFARIN

Warfarin (Coumadin) is an anticoagulant given to clients with a mechanical valve replacement. To determine if the
client is receiving an appropriate dose, the INR needs to be checked regularly.
A therapeutic INR for a client with a mechanical heart valve is 2.5-3.5. The nurse should not administer warfarin
without checking the INR first. If the INR is >3.5, the nurse should hold the dose and contact the health care
provider for further direction.
ANTI-COAGULANTS

Factor Xa inhibitors (eg, rivaroxaban [Xarelto], edoxaban, apixaban) are anticoagulants used to prevent and treat
venous thromboembolism.
Factor Xa inhibitors are being prescribed more frequently than other oral anticoagulants (eg, warfarin), as they have a
lower risk of bleeding and require less ongoing monitoring (eg, PT/INR).
Clients prescribed rivaroxaban should be educated to avoid taking over-the-counter medications or supplements
that increase bleeding risk, such as NSAIDs (eg, aspirin), garlic, and ginger.
The combined effects of rivaroxaban and other anticoagulants may greatly increase the risk of uncontrolled bleeding
(eg, epidural, intracranial, gastrointestinal) and hemorrhage
Unlike warfarin, factor Xa inhibitors are not affected by vitamin K, which is found in many green, leafy vegetables (eg,
spinach, kale).
Anticoagulants, particularly factor Xa inhibitors, increase the risk for spontaneous intracranial bleeding or formation of
epidural hematomas. Clients taking factor Xa inhibitors should be instructed to immediately contact their health care
provider for symptoms of neurological impairment (eg, extremity weakness, altered sensation, numbness).
Routine monitoring of clotting times (eg, PT/INR, PTT) is unnecessary for clients prescribed factor Xa inhibitors.

ANTI-PLATELET
Clopidogrel (Plavix) is a platelet aggregation inhibitor used to prevent blood clot formation in clients with recent
myocardial infarction, acute coronary syndrome, cardiac stents, stroke, or peripheral vascular disease. Because it can
cause thrombocytopenia and increase the risk for bleeding, the nurse should notify the health care provider (HCP)
of the low platelet count (normal: 150,000-400,000/mm3 [150-400 × 109/L]) before administering clopidogrel.

BRACHYTHERAPY

Internal radiation (brachytherapy) involves direct application of a radioactive implant to the cancerous site or tumor for
a short time, usually 24 72 hours. This technique is used to treat cervical and endometrial cancer and delivers a high
 dose of radiation to the cancerous tissues with a limited dose to adjacent normal tissues. Implementation of the
following nursing measures is vital as the client receiving brachytherapy emits radiation.
Following the principles of time, distance, and shielding provides staff and visitors protection from exposure to
radiation.

1. Time spent near the radiation source is restricted. The guideline is to limit staff time spent in the room to 30 minutes per
shift.
o Cluster nursing care to minimize exposure to the radiation source
o Rotate daily staff responsibilities to limit time spent in the client room
o All staff must wear a dosimeter film badge when assigned to care for a client receiving internal radiation
o No individuals who are pregnant or under age 18 may be in the room
2. All staff and visitors must keep the maximum distance possible from the radiation source. Maintaining a distance of at
least 6 feet is an established standard.
o Assign the client to a private room with a private bath
o Keep the door to the room closed
o Ensure that a sign stating, "Caution, Radioactive Material" is affixed to the door
o Instruct the client to remain on bedrest to prevent dislodgement of the implant
3. Shielding with lead diminishes exposure to radiation. All staff providing nursing care that requires physical contact must
wear a lead apron.

The client receiving brachytherapy for endometrial cancer is instructed to remain on bedrest while the radiation implant
is in place. If the implant dislodges from the vaginal cavity, the implant is never touched with the hands; instead, long-
handled forceps are used to pick it up for placement in a lead container.

OPEN FRACTURE

The Joint Commission Surgical Improvement Project CORE measure set has shown that preventives (eg, heparin,
enoxaparin, aspirin) in select surgical procedures, given 24 hours before and after surgery, reduce the risk of venous
thromboembolism.
However, the estimated blood loss in a client with a fracture can be significant depending on the site (eg, 250-1200
mL).
Although this client's admission hematocrit (36% [0.36]) and hemoglobin (12 g/dL [120 g/L]) are only slightly low for an
adult male (normal: 39%-50% [0.39-0.50], 13.2-17.3 g/dL [132-173 g/L]), the blood loss may not yet be evident.
 Therefore, the nurse would validate the prescription for enoxaparin (Lovenox) with the health care provider before
administration.
Medications commonly prescribed for a client with an open fracture include:
o Cefazolin (Ancef), a bone-penetrating cephalosporin antibiotic that is active against skin flora (Staphylococcus aureus); it is
given prophylactically before and after surgery to prevent infection
o Cyclobenzaprine (Flexeril), a central and peripheral muscle relaxant given to treat pain associated with muscle spasm;
carisoprodol (Soma) or methocarbamol (Robaxin) can also be prescribed
o Tetanus and diphtheria toxoid, an immunization given prophylactically to prevent infection (Clostridium tetani) if
immunizations are not up to date (>10 years), unavailable, or unknown
o Ketorolac (Toradol), a nonsteroidal anti-inflammatory drug given to decrease inflammation and pain
o Opioids (eg, morphine, hydrocodone [Vicodin]), given for analgesia

TUMOR NECROSIS INHIBITOR DRUGS

TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade], adalimumab [Humira]) block the action of TNF, a
mediator that triggers a cell-mediated inflammatory response in the body.
These drugs reduce the manifestations of rheumatoid arthritis (RA) and slow the progression of joint damage
by inhibiting the inflammatory response. The medication causes immunosuppression and increased
susceptibility for infection and malignancies.
Clients should have a baseline TST before initiating therapy and yearly skin tests thereafter.
Those with latent tuberculosis (TB) must be treated with antitubercular agents before initiating treatment with these
drugs. Otherwise, TB reactivation would occur

FILGRASTIM
Chemotherapy can cause suppression of rapidly reproducing cells, including bone marrow suppression. This can
result in decreased red blood cells, white blood cells, and platelets, all manufactured in the bone marrow.
 It is most likely to be seen with chemotherapy (versus radiation), with the lowest counts (the nadir) usually at 7-10 days
after therapy initiation.
Leukopenia is a decrease in total circulating white blood cell count (<4,000/mm3) and neutropenia is a decrease in
circulating neutrophils (usually <1500/mm3).
Filgrastim (Neupogen) and pegfilgrastim (Neulasta) stimulate neutrophil production and are given prophylactically
or if the client has an infection and more neutrophils are needed to fight it.

IMMUNOLOGICAL/INFECTIOUS PHARMACOLOGY
ANAPHYLACTIC SHOCK

Anaphylactic shock has an acute onset, and manifestations usually develop quickly (20-30 minutes). Circulatory
failure and respiratory manifestations, including laryngeal edema (from inflammation) and bronchoconstriction
(primarily from release of histamine), can lead to cardiac/respiratory arrest.
The management of anaphylactic shock includes:

1. Ensure patent airway, administer oxygen

2. Remove insect stinger if present
3. IM epinephrine is the drug of choice and should be given to this client. Epinephrine stimulates both alpha- and beta-
adrenergic receptors and dilates bronchial smooth muscle (beta 2) and provides vasoconstriction (alpha 1). The IM route
(mid anterior lateral thigh) is better than the subcutaneous route. Repeat dose every 5-15 minutes.
4. Place in recumbent position and elevate legs
5. Maintain blood pressure with IV fluids, volume expanders or vasopressors
6. Bronchodilator (inhaled beta agonist) such as albuterol is administered to dilate the small airways and reverse
bronchoconstriction
7. Antihistamine (diphenhydramine) is administered to modify the hypersensitivity reaction and relieve pruritus
8. Corticosteroids (methylprednisolone [Solu-Medrol]) are administered to decrease airway inflammation and swelling
associated with the allergic reaction
9. Anticipate cricothyrotomy or tracheostomy with severe laryngeal edema
ISONIAZID

INH interferes with the action of vitamin B6 (pyridoxine), resulting in peripheral neuropathy; it manifests as ataxia
and paresthesia.
Individuals who are most predisposed to becoming neurotoxic from taking INH include older adults, those who are
malnourished, diabetic clients, pregnant or breastfeeding clients, alcoholics, children, those with liver or renal disease,
and HIV-positive individuals.
To prevent these complications, a vitamin B6 supplement at a dose of 25 50 mg/day is recommended for those at high
risk.

ETHAMBUTOL
Ethambutol (Myambutol) is used in combination with other antitubercular drugs (eg, isoniazid, rifampin, pyrazinamide)
to treat active tuberculosis.
The client must have baseline and periodic eye examinations during therapy as optic neuritis is a potentially
reversible adverse effect. The client is instructed to report signs of decreased visual acuity and loss of color (red-
green) discrimination.

VANCOMYCIN

Vancomycin (Vancocin) is a potent antibiotic used to treat gram-positive bacterial infections (eg, Staphylococcus
aureus, Clostridium difficile).
To lower the risk of dose-related nephrotoxicity, especially in clients with renal impairment and those who are >60
years of age, serum vancomycin trough levels should be monitored to assess for therapeutic range (10-20 mg/L [6.9-
13.8 µmol/L]).
A vancomycin trough level above the normal range and/or elevated creatinine and blood urea nitrogen (BUN) values
should be reported to the health care provider (HCP) as this may indicate nephrotoxicity.
When administering IV vancomycin, the nurse should assess for and work to prevent possible complications by
performing the following:
 o Draw the prescribed trough level prior to administration. Therapeutic vancomycin levels range from 10-20 mg/L (6.9-13.8
µmol/L) for hemodynamically stable clients. Adverse effects of vancomycin toxicity include nephrotoxicity (eg, elevated
creatinine levels) and ototoxicity (eg, hearing loss, vertigo, tinnitus).
o Infuse medication over at least 60 minutes Faster rates increase the likelihood of complications
o Monitor blood pressure during the infusion. Hypotension is a possible adverse effect
o Assess for hypersensitivity. Red man syndrome is a nonallergic histamine reaction characterized by sudden onset of
severe hypotension, flushing, and/or maculopapular rash of the face, neck, chest, and upper extremities
o Monitor for anaphylaxis (eg, rash, pruritus, laryngeal edema, wheezing).
o Observe IV site every 30 minutes for pain, redness, or swelling. Vancomycin is a vesicant and may cause thrombophlebitis
or, if extravasation occurs, tissue necrosis. Administration using a central venous catheter is preferred; however, a
peripheral IV may be used for short-term therapy

REDMAN SYNDROME

Red man syndrome (RMS) is a condition that can occur with rapid IV vancomycin administration. It is characterized
by flushing, erythema, and pruritus, typically on the face, neck, and chest. Muscle pain, spasms, dyspnea, and
hypotension may also occur.
RMS is usually a rate-related infusion reaction and not an allergic reaction. It can be reduced by infusing vancomycin
over a minimum of 60 minutes. It can be difficult to differentiate severe RMS from anaphylaxis as flushing and
hypotension can occur in both conditions. However, hives, angioedema (lip swelling), wheezing, and respiratory
distress are more suggestive of anaphylaxis.
The client exhibiting signs and symptoms suggestive of anaphylaxis should have the vancomycin infusion stopped
immediately and be treated with intramuscular (IM) epinephrine. The infusion must not be restarted if anaphylaxis is
suspected. A slowed infusion rate or pre-medications will not prevent a future anaphylactic response.
Muscle pain and spasms may be symptoms of RMS. The nurse should also assess for other medications the client
may be taking that could cause these symptoms (ie, statins).
Flushing and pruritus may also be symptoms of RMS. The nurse should further assess the client's airway for possible
anaphylaxis.
 Low blood pressure (BP) can have many causes, RMS being one of them. If low BP is due to RMS, stopping or
reducing the rate of vancomycin (depending on severity) would solve this. If low BP is due to anaphylaxis, IM
epinephrine must be given in addition to stopping the vancomycin infusion.

FIBROMYALGIA

Fibromyalgia is a chronic, nonspecific pain disorder. Common sequelae include fatigue, sleep disturbances, emotional
distress (eg, anxiety, depression), and even mild cognitive impairments (eg, forgetfulness, difficulty concentrating).
Treatment is focused on symptom management and often includes:
o Muscle relaxers (eg, cyclobenzaprine)
o Narcotic analgesics (eg, tramadol, hydrocodone)
o Nonsteroidal anti-inflammatory drugs (eg, ibuprofen, naproxen, celecoxib)
o Neuropathic pain relievers (eg, pregabalin, gabapentin)
o Antidepressants such as selective serotonin reuptake inhibitors (eg, fluoxetine, duloxetine) and tricyclic antidepressants (eg,
amitriptyline).
Antidepressants can cause suicidal ideation and behaviors, especially during the initial few weeks of therapy.
This risk is even higher for young adults (age 18-24). The nurse must assess for this adverse effect and alert the
provider
Fibromyalgia (FM) results from abnormal central nervous system pain transmission and processing. It is
characterized by chronic, bilateral musculoskeletal axial pain (above and below the waist), multiple tender points,
fatigue, and sleep/cognitive disturbances.
Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor that has both antidepressant and pain-
relieving effects. It is used to relieve chronic pain that interferes with normal sleep patterns in clients with FM. With
the restoration of normal sleep patterns, fatigue often improves as well
 Other effective drugs to treat the chronic pain associated with FM include pregabalin and amitriptyline (Elavil), an older
tricyclic antidepressant drug.
Although depression often accompanies chronic pain, duloxetine can be prescribed specifically to treat the chronic
pain associated with FM.
(Option 3) Duloxetine is prescribed for major depressive disorder and to relieve pain associated with diabetic
neuropathy and FM. It is not given to relieve the adverse effects of other drugs.

INFLUENZA VACCINE
 Influenza is a respiratory illness common during the cooler months of the year. Each year, a new influenza vaccine is
created to help protect against specific viral strains.
The Centers for Disease Control and Prevention and Public Health Agency of Canada recommend that all clients age
receive the influenza vaccine annually unless the client has a life-threatening allergy to the vaccine or
one of its ingredients.
Special emphasis should be placed on vaccinating the following high-risk individuals:

o Clients with chronic conditions (eg, asthma, heart failure, cancer) may experience exacerbation of symptoms if infected
o Immunocompromised clients (eg, HIV) have decreased ability to fight infection
o Health care workers and caretakers are at greater risk for acquiring and transmitting infection to other clients
o Healthy children age 6-23 months and clients age are at greatest risk for serious, flu-related complications (eg,
pneumonia, dehydration)
o Pregnant clients are at increased risk for premature labor/delivery or influenza complications due to pregnancy-related
physiologic changes.

MACROLIDE ANTIBIOTICS

All macrolide antibiotics (eg, azithromycin, erythromycin, clarithromycin) can cause a prolonged QT interval, which
may lead to sudden cardiac death due to torsades de pointes. Therefore, an electrocardiogram (ECG) should be
monitored. Concurrent use of macrolide antibiotics with other drugs that prolong QT interval (eg, amiodarone, sotalol,
haloperidol, ziprasidone, azole antifungals) will further increase this risk.
Macrolides can also cause hepatotoxicity when taken in high doses or in combination with other hepatotoxic
medications such as acetaminophen, phenothiazines, and sulfonamides.
Elevation of aspartate transaminase and alanine transaminase levels (liver enzymes) may indicate that hepatotoxicity
is occurring, and the nurse should report these results to the HCP.

AMOXICILLIN-CLAVULANATE
Amoxicillin/clavulanate belongs to aminopenicillin group and is often used to treat respiratory infections. Instructions
for parents about amoxicillin include:
 o The medication may be taken with or without food as food does not affect absorption
o The most common side effects of this medication are nausea, vomiting, and diarrhea. If nausea or diarrhea develops, the
medicine may be administered with food to decrease the gastrointestinal side effects
o Shake the liquid well prior to administration. Administer at evenly spaced intervals throughout the day to maintain
therapeutic blood levels
o Ensure that the child receives the full course of therapy; do not discontinue the medication if the child is feeling better or
symptoms have resolved

Rash, itching, dyspnea, or facial/laryngeal edema may indicate an allergic reaction, and the medication should be
discontinued.

ALLERGY IMMUNOTHERAPY INJECTIONS

Allergy immunotherapy injections (allergy shots) trigger an increase in the body's production of specific
immunoglobulins to reduce the client's allergy symptoms when exposed to specific allergens (eg, pollen, cat dander,
dust mite). Small doses of the allergen(s) are injected subcutaneously on a client-specific schedule.
Rarely, allergy shots may induce an immediate and potentially fatal anaphylactic reaction. The client must remain at
the facility for 30 minutes after an injection so the nurse can monitor for severe systemic reactions (eg, respiratory
failure, tongue and throat swelling)
For the first few months, allergy shots are typically given every week, with a dose increase at every injection until the
target maintenance dose is reached. The maintenance dose is then given every few weeks for 3-5 years.
Although rare, the client may have a mild, systemic allergic reaction (eg, hives, itching, facial swelling, mild
asthma) up to 24 hours after an allergy shot. The occurrence of any systemic reaction should be reported to the
health care provider as the next dose increase may need to be delayed.
It is common to have a localized reaction to an allergy shot. The nurse should reinforce teaching that some redness
and swelling at the injection site is expected and not life-threatening.
NYSTATIN
Nystatin is an antifungal medication commonly used to treat mucocutaneous candidal infections (ie, oral, intestinal,
vaginal, skin). When caring for a client prescribed nystatin, the nurse should:
 o Assist clients with oral candida who wear dentures in removing them and soaking them in nystatin suspension because
dentures often become a reservoir for reinfection
o Assess the appearance of the affected area (eg, oral cavity, skin lesions) frequently throughout nystatin therapy (eg, before
administration, during routine assessments) to monitor treatment efficacy and identify potential side effects (eg, mucous
membrane irritation)
o Instruct clients prescribed nystatin liquid suspension for oral thrush to swish the suspension in the mouth for several minutes
and then swallow the medication to allow treatment of any esophageal candida
o Ensure that liquid suspension forms of nystatin are shaken well before being measured for dosing because medication
precipitates and causes unequal concentrations within the liquid

Clients receiving nystatin should be educated to take the medication as prescribed each day and avoid missing doses;
nystatin therapy is continued for at least 48 hours after symptoms subside to prevent recurrence of the infection.

RIFAMPIN

Active TB is treated with combination drug therapy. Isoniazid causes hepatotoxicity and peripheral neuropathy.
Rifampin (Rifadin) also causes hepatotoxicity. Therefore, baseline liver function tests should be obtained. Clients
should be advised to watch for signs and symptoms of hepatotoxicity (eg, jaundice, anorexia). Ethambutol causes
ocular toxicity, and clients will need frequent eye examinations.
A teaching plan for a client prescribed rifampin includes these additional instructions:

o Rifampin changes the color of body fluids (eg, urine, sweat) due to its body-wide distribution. Tears can turn red, making
contact lenses appear discolored. Client should wear eyeglasses instead of soft contact lenses while taking this
medication.
o Women should use nonhormonal birth control methods while taking this drug as it can decrease the effectiveness of oral
contraceptives.

Red urine is an expected finding with rifampin use; clients should not be concerned.
Clients should be advised to not consume alcohol and drugs that can increase the risk for hepatotoxicity (eg,
acetaminophen) during long-term use of this drug.
The effectiveness of treatment for active TB is determined by 3 negative sputum cultures and chest x-ray. If the entire
course of therapy (6-9 months) is not completed, reinfection, spread to others, and development of resistant strains of
TB bacteria can result.
HYDROXYCHLOROQUINE

Hydroxychloroquine (Plaquenil) is an antimalarial drug, but it is more commonly prescribed to reduce fatigue and
treat the skin and arthritic (eg, joint inflammation, pain) manifestations of systemic lupus erythematosus (SLE).
Hydroxychloroquine can also help to reduce lupus exacerbations in clients with inactive to mild disease, but several
months can pass before its therapeutic effects become apparent.
Although rare, serious adverse drug reactions such as retinal toxicity and visual disturbances can occur with
hydroxychloroquine. Therefore, clients are instructed to undergo regular ophthalmologic examination every 6-12
months
Hydroxychloroquine should be taken with food to decrease gastrointestinal upset (common side effect).
Some clients with severe SLE are prescribed long-term corticosteroid (prednisone) therapy to prevent organ damage
and are at risk for adverse reactions, such as accelerated osteoporosis. Osteoporosis is not an adverse reaction of
hydroxychloroquine, and vitamin D and calcium supplementation is not required.

ADALIMUMAB
Adalimumab (Humira) is a tumor necrosis factor (TNF) inhibitor, a biologic disease-modifying antirheumatic drug
(DMARD) classified as a monoclonal antibody.
Its major adverse effects are similar to those of other TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab
[Remicade]) and include immunosuppression and infection (eg, current, reactivated).
An elevated white blood cell count in this client can indicate underlying infection and should be reported immediately.

EPI PEN

Epinephrine auto-injectors (EAIs) are devices used as an emergency treatment for anaphylactic reactions to
allergens (eg, insect bites, foods, chemicals). Clients with a history of anaphylaxis must be properly educated on EAI
 use because delaying or failing to administer epinephrine is a frequent cause of death. Nurses educating clients on
EAI use should include the following information:
o Administer injection at a 90-degree angle into the outer thigh at the first sign of an allergic reaction
o Hold the auto-injector in place for 10 seconds to ensure delivery of the entire dose
o Seek immediate medical care after an injection because anaphylactic reactions may resume when the effects of the
epinephrine subside (ie, 10-20 minutes)
o Expect to experience tachycardia, palpitations, and/or dizziness after administration
o Store EAIs at room temperature in a dark place to prevent inactivation by heat or light, or device failure from cold

Clients should be instructed to administer EAIs as quickly as possible if symptoms of anaphylaxis develop. Skin
preparation is not necessary, and delaying administration to cleanse the injection site increases the risk of death from
anaphylactic shock.

AZATHIOPRINE

Azathioprine is an immunosuppressant drug that can cause bone marrow depression and increase the risk for
infection. It is prescribed to treat autoimmune conditions such as inflammatory bowel diseases (eg, Crohn disease)
and to prevent organ transplant rejection.
Fatigue and nausea can be expected as minor adverse effects or may be associated with the disease.
However, leukopenia (white blood cell count <4,000/mm3 [4 × 109/L]) can be a severe adverse effect of the drug and
should be reported to the health care provider before administering the medication due to high risk for infection

METRONIDAZOLE

Metronidazole is an antibiotic medication used to treat bacterial, parasitic, and protozoal infections.
Nurses educating clients about metronidazole should ensure that the client is aware of drug interactions and side
effects to watch for and report.
The client should be instructed to abstain completely from consuming food, drinks, or products
containing alcohol during, and for 3 days after, therapy.
 The combination of alcohol and metronidazole may cause clients to experience facial flushing, headaches, nausea,
vomiting, and abdominal cramping
Metronidazole commonly causes a harmless but unpleasant metallic taste in the mouth and darkening of urine (eg,
brown, rust-colored).
Although it is rare, metronidazole may cause Stevens-Johnson syndrome (SJS), a life-threatening complication
characterized by necrosis and sloughing of the skin and mucous membranes. Clients should be educated
to immediately
report signs of SJS (eg, rash, skin peeling).

BISMUTH SALICYLATE
The nurse should tell the parent to discontinue the use of bismuth subsalicylate (Pepto-Bismol) as it contains
a salicylate (same class as aspirin) and could possibly cause Reye syndrome.
Reye syndrome can develop in children with a recent viral illness such as varicella or influenza.
It can cause acute encephalopathy and hepatic dysfunction. Children with viral infections should not be given aspirin
or products containing salicylates.

LINEZOLID

Linezolid (Zyvox) is an oxazolidinone antibiotic prescribed for vancomycin- and methicillin-resistant bacteria,
pneumonia, and skin infections.
Linezolid has monoamine oxidase inhibitor (MAOI)-type properties; concurrent use with selective serotonin
reuptake inhibitors (SSRIs) (eg, paroxetine, fluoxetine, sertraline) increases the risk of serotonin syndrome, a
potentially fatal accumulation of serotonin
Due to this risk, SSRIs are contraindicated while on linezolid therapy. SSRIs can be resumed 24 hours after linezolid
therapy has been discontinued.
Headaches may be a side effect of linezolid therapy. Acetaminophen is not contraindicated.
 Due to the MAOI-like properties of linezolid, clients should not consume foods or beverages containing tyramine during
therapy to avoid adverse effects (eg, severe hypertension).
Diarrhea is a common adverse effect of linezolid therapy. However, increased diarrhea or fever may indicate a
complication from the regimen (eg, serotonin syndrome, Clostridium difficile infection) and should be reported
promptly.

TRIMETHOPRIM-SULFAMETHOXAZOLE
Trimethoprim-sulfamethoxazole (Bactrim) is a sulfonamide antibiotic, commonly referred to as a sulfa drug. These
antibiotics are prescribed to treat bacterial infections (eg, urinary tract infections).
Contraindications include hypersensitivity to sulfa drugs, and pregnancy or breastfeeding.
Glyburide is a sulfonylurea and has the potential to cause a sulfa cross-sensitivity reaction.
Commonly used diuretics (eg, thiazides, furosemide) are also sulfa derivatives and can cause cross-sensitivity
reaction. Although this reaction is uncommon, an alternate antibiotic, if possible, can be prescribed by the health care
provider.
Crystalluria is a potential adverse effect of sulfa medications. Clients should drink at least 2-3 L of water daily to
prevent crystalluria.
Angiotensin-converting enzyme inhibitors (eg, lisinopril) can produce an intractable cough. The only way to relieve this
adverse effect is to discontinue the medication. There is no cross-reactivity with sulfa medications.
Birth control implants (eg, IMPLANON, NEXPLANON) are progestin rods placed subdermally in the upper arm that
provide contraception for up to 3 years. They are not contraindicated with concurrent trimethoprim-sulfamethoxazole
use.

SULFASALAZINE

Sulfasalazine (Azulfidine) is a sulfonamide (salicylate and sulfa antibiotic) and nonbiologic disease-modifying
antirheumatic drug (DMARD) used for mild to moderate chronic inflammatory rheumatoid arthritis (RA) and
inflammatory bowel disease (eg, ulcerative colitis). It inhibits the production of prostaglandin, a mediator in the body's
inflammatory response.
Most "sulfa" medications (eg, trimethoprim, sulfamethoxazole) share common side effects, including:
 1. Crystalluria causing kidney injury client should drink 8 glasses of water daily to maintain adequate urine output (eg, 1200-
1500 mL/day)
2. Photosensitivity and risk for sunburn client should avoid sun exposure and apply sunscreen
3. Folic acid deficiency (megaloblastic anemia and stomatitis) client should eat folate-rich foods and take 1 mg/day folic acid
supplement
4. Rarely life-threatening agranulocytosis (leukopenia) client should be monitored for complete blood count at the start of
therapy and report fever or sore throat immediately
5. Stevens-Johnson syndrome client should stop the medicine if rash develops

Urine and skin can turn an orange-yellow color but will return to normal when the drug is discontinued. This is an
expected finding.

METHOTREXATE

Methotrexate (Rheumatrex) is classified as a folate antimetabolite, antineoplastic, immunosuppressant drug to

treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) to treat rheumatoid
arthritis and psoriasis.
The client's statement about getting an eye examination every 6 months indicates that further teaching is necessary as
these examinations are not indicated for clients prescribed methotrexate
However, frequent eye examinations are required for clients prescribed the nonbiologic antimalarial DMARD
hydroxychloroquine (Plaquenil) as it can cause retinal damage.
Methotrexate is an immunosuppressant and can cause bone marrow suppression. Clients are at risk for infection.
They should avoid crowded places and individuals with known infection and should receive appropriate killed
(inactivated) vaccines (eg, influenza, pneumococcal). Live vaccines (eg, herpes zoster) are contraindicated.
Clients should not become pregnant while taking methotrexate or for at least 3 months after it is discontinued as the
drug is teratogenic and can cause congenital abnormalities and fetal death.
Clients taking methotrexate should avoid alcohol as the prescription drug is hepatotoxic and drinking alcohol
increases the risk for hepatotoxicity.
CEPHALOSPORINS
Clients with an allergy to penicillin antibiotics (eg, amoxicillin, ampicillin) can possibly experience a cross-sensitivity
reaction to cephalosporin antibiotics (eg, cefazolin, cephalexin, ceftriaxone), because the drug molecules are
structurally similar.
The nurse should obtain more information about this client's reported allergies, as reactions range from mild to
severe. In particular, the nurse must first assess the type of reaction the client had to amoxicillin
The nurse should then clarify the prescription with the health care provider (HCP) prior to administration.
If this client's reaction to amoxicillin was a rash or other mild reaction that was not life-threatening, the HCP may
decide that cephalosporin can be safely administered. However, cephalosporins are contraindicated for a client with
a history of anaphylactic reactions to penicillin, and a different antibiotic should be prescribed.

AMINOGLYCOSIDES
Serious adverse reactions to aminoglycosides (eg, gentamicin, tobramycin, amikacin)
include ototoxicity and nephrotoxicity.
Age, renal function, and drug dose affect the occurrence of these adverse reactions.
Careful dosing is especially important for older clients. Tinnitus and vertigo are early signs of ototoxicity.
The nurse should carefully assess for changes in the client's hearing, balance, and urinary output.

TUMOR NECROSIS FACTOR INHIBITOR

Infliximab, adalimumab, and etanercept are tumor necrosis factor (TNF) inhibitors that suppress the inflammatory
response in autoimmune diseases such as rheumatoid arthritis, Crohn disease, and psoriasis.
Due to the immunosuppressive action of TNF inhibitors, clients taking these drugs are at increased risk for
infection. A client with current, recent, or chronic infection should not take a TNF inhibitor
 The immunosuppressive action of TNF inhibitors can activate latent tuberculosis (TB). Therefore, a tuberculin skin
test (TST) should be administered prior to beginning TNF inhibitor therapy, and clients who test positively for latent TB
must also undergo treatment for TB before starting therapy. Clients should have a TST every year while receiving the
drug.
Clients taking immunosuppressive TNF inhibitors (eg, adalimumab) should receive an annual inactivated (injectable)
influenza vaccine to reduce the risk of contracting the flu virus.
Clients taking TNF inhibitors or other immunosuppressants are at risk for infection and therefore should not receive
live attenuated vaccines.
Many clients with rheumatoid arthritis use nonsteroidal anti-inflammatory medications (eg, celecoxib, naproxen) in
conjunction with antirheumatic and/or targeted therapies (eg, methotrexate, adalimumab, etanercept) to effectively
treat pain and minimize inflammation.

NEUROLOGICAL PHARMACOLOGY
TISSUE PLASMINOGEN ACTIVATOR

Tissue plasminogen activator (tPA) dissolves clots and restores perfusion in clients with ischemic stroke. It must
be administered within a 3- to 4½-hour window from onset of symptoms for full effectiveness. The nurse assesses
for contraindications to tPA due to the risk of hemorrhage.
The client should not have a history of intracranial hemorrhage or be actively bleeding. Surgery within the last 2
weeks is a contraindication as tPA dissolves all clots in the body and may disrupt the surgical site. This client
indicates a recent stomach surgery, which would need further clarification to determine eligibility to receive tPA
A client's history of stroke or head trauma in the last 3 months could exclude tPA use.
The nurse should determine when the client first developed stroke symptoms. tPA can be administered if symptoms
started within the last 3 to 4½ hours or based on facility guidelines.
 Current anticoagulant use may exclude a client from receiving tPA. The duration of action for warfarin is 2-5 days;
this client can safely receive tPA as warfarin was discontinued 4 weeks ago. However, if pending coagulation studies
drawn prior to tPA administration are elevated, the infusion may be discontinued.

CARBIDOPA-LEVODOPA
Parkinson disease is caused by low levels of dopamine in the brain.
Levodopa is converted to dopamine in the brain, but much of this drug is metabolized before reaching the brain.
Carbidopa helps prevent the breakdown of levodopa before it can reach the brain and take effect.
This combination medication is particularly effective in treating bradykinesia (generalized slowing of movement).
Tremor and rigidity may also improve to some extent. Carbidopa-levodopa (Sinemet) once started should never be
stopped suddenly as this can lead to akinetic crisis (complete loss of movement). However, prolonged use can also
result in dyskinesias (spontaneous involuntary movements) and on/off periods when the medication will start or stop
working unpredictably.
Carbidopa-levodopa is a combination antiparkinsonian medication used to reduce physical symptoms of PD
by increasing dopamine levels in the brain.
Levodopa is converted to dopamine in the brain but is largely metabolized before reaching the brain.
Carbidopa does not have a therapeutic effect on PD but prevents breakdown of levodopa before reaching the brain,
which makes levodopa more effective.
Client teaching for carbidopa-levodopa includes:

o Implementing fall precautions (eg, changing positions slowly, removing rugs), as orthostatic hypotension is a common side
effect
o Knowing that carbidopa-levodopa takes several weeks to reach its maximum effectiveness
o Understanding that harmless discoloration (eg, red, brown, black) of secretions (eg, urine, perspiration, saliva) may occur
while taking carbidopa-levodopa
o Avoiding high-protein meals, which interfere with the absorption of carbidopa-levodopa

Dyskinesia (eg, facial or eyelid twitching, tongue protrusion, facial grimacing) may indicate overdose or toxicity of
carbidopa-levodopa and should be reported immediately to the health care provider.
Carbidopa-levodopa often decreases, but does not eliminate, tremor and rigidity.
LEVETIRACETAM

Levetiracetam (Keppra) is an anticonvulsant prescribed for seizure disorders. As with other antiseizure
medications, levetiracetam has a depressing effect on the central nervous system (CNS), which may
cause drowsiness, somnolence, and fatigue as clients adjust to the medication. Clients should be assured that this is
common and typically improves within 4-6 weeks. However, the CNS-depressing effects of levetiracetam may be
enhanced if taken with other CNS-depressing substances (eg, alcohol) or medications.
New or increased agitation, anxiety, and/or depression or mood changes should be reported immediately as
levetiracetam is associated with suicidal ideation
Like other anticonvulsants, levetiracetam can trigger Stevens-Johnson syndrome, a rare but life-threatening
blistering reaction of the skin. Rash, blistering, muscle/joint pain, or conjunctivitis should be reported and assessed
immediately
Clients with seizure disorders should avoid driving or operating heavy machinery until they have permission from their
health care provider and have met the requirements of their department of transportation. Typically, the client must be
free from seizures for an allotted time period.

TRIGEMINAL NEURALGIA
Trigeminal neuralgia is sudden, sharp pain along the distribution of the trigeminal nerve. The symptoms are usually
unilateral and primarily in the maxillary and mandibular branches.
Clients may experience chronic pain with periods of less severe pain, or "cluster attacks" of pain between long
periods without pain.
Triggers can include washing the face, chewing food, brushing teeth, yawning, or talking. Pain is severe, intense,
burning, or electric shock-like.
The primary intervention for trigeminal neuralgia is consistent pain control with medications and lifestyle changes.
The drug of choice is carbamazepine. It is a seizure medication but is highly effective for neuropathic pain.
Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk. Clients should be advised to
report any fever or sore throat.
Behavioral interventions include the following:

1. Oral care use a small, soft-bristled toothbrush or a warm mouth wash

 2. Use lukewarm water; avoid beverages or food that are too hot or cold
3. Room should be kept at an even and moderate temperature
4. Avoid rubbing or facial massage. Use cotton pads to wash the face if necessary.
5. Have a soft diet with high calorie content; avoid foods that are difficult to chew. Chew on the unaffected side of the mouth.

A high-fiber diet is not required for a client with trigeminal neuralgia, and the additional chewing with higher-fiber foods
may serve as a pain trigger.
Clients with trigeminal neuralgia are encouraged not to massage the face as this can trigger pain.

MALIGNANT HYPERTHERMIA

Malignant hyperthermia (MH) is a rare but life-threatening inherited muscle abnormality that is triggered by
specific, inhaled anesthetic agents and the depolarizing muscle relaxant succinylcholine (Anectine) used to induce
general anesthesia.
In MH-susceptible clients, the triggering agent leads to excessive release of calcium from the muscles, leading to
sustained muscle contraction and rigidity (usually of the jaw and upper body [early sign]), increased oxygen demand
and metabolism, and dangerously high temperature (later sign).
As MH is an inherited condition, proper screening and a thorough preoperative nursing assessment and health history
can help minimize the client's risk

PHENYTOIN
Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures. The therapeutic serum
phenytoin range is 10-20 mcg/mL (40-79 mcmol/L).
In the presence of an elevated phenytoin level (32 mcg/mL [127 mcmol/L]), the nurse anticipates that the health care
provider will prescribe a decreased daily dose
The nurse should continue to monitor for signs of toxicity, typically presenting as neurological manifestations (eg,
ataxia, nystagmus, slurred speech, decreased mentation).
Phenytoin (Dilantin) is an anticonvulsant drug commonly used to treat seizure disorders. Steady absorption is
necessary to maintain a therapeutic dosage range and drug level to control seizure activity.
 The nurse's priority action is to stop the feeding for 1 to 2 hours before and after administering phenytoin as products
containing calcium (eg, antacids, calcium supplements) and/or nutritional enteral tube feedings can decrease the
absorption and the serum level of this drug.
Unless clients have renal insufficiency, renal function tests are not routinely monitored during prescribed phenytoin
therapy. Phenytoin is metabolized in the liver and can cause liver damage. Monitoring of liver function test during
therapy is recommended.
Flushing the tube with 30-50 mL of water before and after administering phenytoin is recommended to minimize drug
loss and drug-drug incompatibility. Flushing with normal saline before and after drug administration is recommended
in clients receiving intravenous (IV) phenytoin.
BP is not usually affected in clients prescribed oral phenytoin therapy for seizure disorders. However, IV phenytoin
can cause hypotension and arrhythmias.

Early signs of toxicity include horizontal nystagmus and gait unsteadiness. These may be followed by slurred
speech, lethargy, confusion, and even coma.

Bradyarrhythmias and hypotension are usually seen with intravenous phenytoin.

Gingival hyperplasia is a common expected side effect of phenytoin and does not indicate drug toxicity. It occurs more
often in clients <23 years of age who are prescribed >500 mg/day. Good oral hygiene can limit symptoms.

SUMATRIPTAN

Sumatriptan is a selective serotonin agonist prescribed to treat migraine headaches, which are thought to be caused
by dilated cranial blood vessels. Triptan drugs, like sumatriptan, work by constricting cranial blood vessels, and
clients should be instructed to take a dose at the first sign of a migraine to help prevent and relieve symptoms.
Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because its
vasoconstrictive properties increase the risk of angina, hypertensive urgency, decreased cardiac perfusion, and acute
 myocardial infarction. The nurse should question the client about a past medical history of uncontrolled hypertension
and report this to the health care provider

TRICYCLIC ANTI-DEPRESSANTS (TCA)

MELATONIN

Melatonin supplements are thought to help the body adjust quickly to new surroundings and time zones (jet lag).
Most practitioners agree that the lowest possible dose should be used and should be taken only for a short time.
There are no long-term studies on the safety of melatonin. Higher doses may cause side effects such as vivid dreams
and nightmares.
Research suggests that taking melatonin once a person has reached the travel destination is sufficient and that
starting it prior to or during air travel may actually slow the recovery of jet lag, energy, and alertness.

MIDAZOLAM
Midazolam (Versed) is a benzodiazepine commonly used to induce conscious sedation in clients undergoing
endoscopic procedures.
The initial dose is 1 mg and is titrated up slowly (eg, 2 minutes before each 1-mg increment) until speech becomes
slurred.
Usually no more than 3.5 mg is necessary to induce conscious sedation. It is commonly administered with an opioid
analgesic (eg, morphine, Fentanyl) because of their synergistic effects.
Side effects can include airway occlusion, apnea, hypotension (especially in the presence of an opioid), and oxygen
desaturation with resultant respiratory arrest.
Flumazenil (Romazicon) is the antidote drug used to reverse the sedative effects of benzodiazepines.

FENTANYL

A transdermal fentanyl patch is prescribed for clients suffering from moderate to severe chronic pain. The patch
provides continuous analgesia for up to 72 hours. However, the drug is absorbed slowly through the skin into the
systemic circulation and can take up to 17 hours to reach its full analgesic effect. Therefore, it is not recommended for
treating acute postoperative, temporary, or intermittent pain as it does not provide immediate analgesia when applied.
A lidocaine 5% transdermal patch provides a localized, topical anesthetic to intact skin. It is commonly prescribed for
clients with chronic postherpetic neuralgia, a painful, debilitating condition that can develop following a herpes zoster
(shingles) infection.
 The client with opioid abuse history would be experiencing the same type and degree of pain as other clients with a
fractured femur. However, a higher dose or a stronger opioid analgesic (eg, hydromorphone) is needed for pain relief
due to the client's increased opioid tolerance.
Tramadol is a synthetic opioid analgesic prescribed to treat moderate to severe postoperative pain. It is appropriate to
prescribe at discharge as it has fewer complications related to respiratory depression compared with other opioids.

BENZTROPINE
Parkinson disease (PD) is a progressive neurological disorder characterized by bradykinesia (loss of autonomic
movements), rigidity, and tremors. Clients with PD have an imbalance between dopamine and acetylcholine in which
dopamine is not produced in high enough quantities to inhibit acetylcholine.
Anticholinergic medications (eg, benztropine, trihexyphenidyl) are commonly used to treat tremor in these clients.
However, in clients with benign prostatic hyperplasia or glaucoma, caution must be taken as anticholinergic drugs can
precipitate urinary retention and an acute glaucoma episode. As a result, such medications are contraindicated in
these clients.
Decreased ability to exercise is common in clients with PD due to tremors and bradykinesia, and they require physical
and occupational therapy consultations. However, acute glaucoma can be sight threatening and is the priority.
Esomeprazole is safe to take with benztropine and will not cause an adverse reaction.
Constipation is a common side effect of benztropine. Due to the characteristic decreased mobility, PD can also cause
constipation. The client should be instructed to increase dietary fiber intake and drink plenty of water. However, this is
not the most concerning issue.

AMYOTROPHIC LATERAL SCLEROSIS (ALS)

Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig disease, is a debilitating, progressive
neurodegenerative disease with no cure.
Clients develop fatigue and muscle weakness that progresses to paralysis, dysphagia, difficulty speaking,
and respiratory failure. Most clients diagnosed with ALS survive only 3-5 years.
 Riluzole (Rilutek) is the only medication approved for ALS treatment. Riluzole, a glutamate antagonist, is thought to
slow neuron degeneration by decreasing the production and activity of the neurotransmitter glutamate in the brain and
spinal cord.
In some clients, riluzole may slow disease progression and prolong survival by 3-6 months. The nurse should
provide teaching about the purpose of the medication so that the client can make an informed decision about taking it

SCOPOLAMINE
Scopolamine is an anticholinergic medication used to prevent nausea and vomiting from motion sickness and as
an adjunct to anesthesia to control secretions.
Transdermal scopolamine is placed on a hairless, clean, dry area behind the ear for proper absorption.
Clients should be instructed to:
o Apply the patch to allow for absorption and medication onset. Transdermal patches have a
slower onset but a longer duration of action.
o Replace the patch every 72 hours as prescribed to ensure continuous medication delivery.
o Remove and discard the old patch before placing a new one to prevent accidental overdose
o Dispose of the old patch out of reach of children and pets to avoid accidental ingestion
o Wash hands with soap and water after handling the patch to avoid inadvertent drug absorption or contact with the eyes

MORPHINE

Morphine is an opioid analgesic that can be given intravenously for moderate to severe pain. An adverse reaction to
morphine administration is respiratory depression.
A respiratory rate <12/min would be a reason to hold morphine administration. The nurse should perform a more
in-depth assessment of the client's pain and causes. The morphine dose may need to be decreased or the time
between administrations may need to be increased. The nurse should not administer additional doses until the
respiratory rate increases.
 Morphine can cause burning during IV administration. This can be reduced by diluting the morphine with normal saline and
administering it slowly over 4-5 minutes.
The nurse should instruct the client to call for help before getting up to go to use the bathroom to avoid falls caused by
dizziness from the morphine.
Morphine can lower blood pressure, and clients receiving it should have blood pressure monitored.

PSYCHIATRIC PHARMACOLOGY
BUPROPION

Bupropion hydrochloride (Wellbutrin) is an atypical antidepressant used to treat depressive disorders, including major
depressive disorder, seasonal affective disorder, and persistent depressive disorder (dysthymia). Preparations of
bupropion hydrochloride include immediate-release, sustained release (SR), and extended-release (XL) tablets.
Any medication marked SR or XL should not be chewed, cut, or crushed due to the risk of adverse effects from too
rapid absorption of the drug. No form of bupropion hydrochloride should be altered; tablets should be swallowed
whole, with or without food. Seizures are of particular concern if a client takes a high or toxic dose of bupropion
hydrochloride.
Clients on any kind of antidepressant need to be monitored closely for worsening depression, sudden or unusual
behavior or mood changes, and the emergence of suicidal thoughts and behaviors. Clients with a diagnosis of
depression and/or their family members need education and information on the increased risk of suicide
Additional instructions to a client about the use of bupropion hydrochloride include the following:

o Limit alcohol; inform the health care provider if you are used to consuming large amounts of alcohol
o Do not double up on the medication if a scheduled dose is missed
o Take the medication at the same time each day
o It may take several weeks to feel the effects of bupropion hydrochloride
o Weight loss may occur when taking this medication
LITHIUM

Lithium is a mood stabilizer commonly prescribed for mania (eg, bipolar disorder) as long-term maintenance therapy.
Because lithium has a narrow therapeutic range (eg, 0.6-1.2 mEq/L [0.6-1.2 mmol/L]), serum levels should be
monitored regularly (eg, following dose changes) to prevent toxicity (>1.5 mEq/L [1.5 mmol/L]).
Lithium is excreted through the kidneys. To prevent toxicity the nurse should hold doses and clarify prescriptions for
clients who have:

o Conditions/illnesses in which the kidneys try to conserve sodium (eg, hyponatremia, dehydration) as sodium and lithium are
absorbed in proximal tubules simultaneously
o Decreased glomerular filtration rate (eg, severe renal dysfunction) as less of the drug is filtered into the urine

Lithium is often used in the treatment of bipolar disorder. It has expected, mild side effects as well as potentially
serious ones related to drug toxicity. Drowsiness, weight gain, dry mouth, and gastrointestinal upset are expected,
mild side effects.
Lithium toxicity usually occurs with the following:

o Dehydration
o Decreased renal function (eg, elderly clients)
o Diet low in sodium
o Drug-drug interactions (nonsteroidal anti-inflammatory drugs [NSAIDs] and thiazide diuretics)
 Lithium and sodium are closely related in the body.
Acute viral gastroenteritis (stomach flu) presents with abrupt onset of diarrhea, nausea, vomiting, and abdominal
pain. Clients with vomiting and diarrhea are at risk of developing dehydration and/or low serum sodium, increasing the
risk for lithium toxicity
Drowsiness is an expected side effect. The nurse should advise the client to avoid hazardous activities and driving
until the effects of lithium are known or this side effect subsides.
Weight gain is an expected side effect. The nurse should provide client education about healthy food choices and
proper exercise and/or provide for a dietary consult.
Dry mouth is an expected side effect. The nurse should provide client teaching about measures to counteract this
side effect (eg, ice chips, sugarless gum or candy, drinking plenty of water). However, excessive urination and
polydipsia indicate nephrogenic diabetes insipidus from lithium toxicity.
Lithium has a very narrow range of therapeutic serum levels; the usual ranges are 1.0-1.5 mEq/L (1.0-1.5 mmol/L) for
treatment of acute mania and 0.6-1.2 mEq/L (0.6-1.2 mmol/L) for maintenance therapy.

POLYPHARMACY

Polypharmacy and physiologic changes associated with aging (eg, decreased renal and hepatic function, orthostatic
hypotension, decreased visual acuity, balance and gait problems) place the elderly at increased risk of adverse drug
effects.
The Beers criteria provide a list that classifies potentially harmful drugs to avoid or administer with caution in the
elderly due to the high incidence of drug-induced toxicity, cognitive dysfunction, and falls. Some commonly used
medications in this list include antipsychotics, anticholinergics, antihistamines, antihypertensives,
benzodiazepines, diuretics, opioids, and sliding insulin scales.
Amitriptyline (Elavil) is a tricyclic antidepressant used to treat depression and neuropathic pain; its anticholinergic
properties may cause dry mouth, constipation, blurred vision, and dysrhythmias
Chlorpheniramine (ChlorTrimeton) is a sedating histamine H 1 antagonist used to treat allergy symptoms. Increased
central nervous system effects (eg, drowsiness, dizziness) may occur due to its reduced clearance in the elderly
Lorazepam (Ativan) is a benzodiazepine with a long half-life (10-17 hours). Side effects include drowsiness, dizziness,
ataxia, and confusion
 Docusate is a stool softener and does not increase risk of injury in the elderly.
Donepezil (Aricept) is an acetylcholinesterase inhibitor used to treat Alzheimer dementia. It does not place the elderly
at increased risk of adverse effects.

ADHD
Stimulant medications (eg, methylphenidate, dextroamphetamine, lisdexamfetamine) are first-line agents in the
treatment of attention-deficit hyperactivity disorder (ADHD).
Methylphenidate (Ritalin) is administered in divided doses 2 or 3 times daily, usually 30-45 minutes before meals. As
a stimulant, methylphenidate may interfere with sleep and should be given no later than around 6 PM (Option 3).
The sustained-release preparation should be given in the morning. The dosage in children is usually started low and
titrated to the desired response.
Contrary to popular myth, sugar does not increase hyperactivity; although an additive-free diet may be a healthy
approach for children, eliminating additives or food colorings does not decrease the symptoms of ADHD.
A team approach (parents, teachers, health care providers) is the most effective way to help a child with ADHD.
School-based interventions may include specific classroom modifications or accommodations to be incorporated into
the treatment plan.
Children should be monitored closely during initial treatment for development of tics and continuously for adherence
and response to therapy.
Stimulant medications are commonly used to treat ADHD in children and adults. Methylphenidate (Ritalin)
and amphetamines (eg, dextroamphetamine, lisdexamfetamine) are the most commonly used stimulants.
The major problems with stimulant medications include:
o Decreased appetite and weight loss can lead to growth delays. Parents and caregivers should be instructed to
weigh the child with ADHD at least weekly due to the risk of temporary interruption of growth and development. It is
very important to compare weight/height measures from one well-child checkup to the next. If weight loss
becomes a serious problem, methylphenidate can be given after meals; however, before meals is preferable.
o Cardiovascular effects hypertension and tachycardia (particularly in adults)
o Appearance of new or exacerbation of vocal/motor tics
o Excess brain stimulation restlessness, insomnia
o Abuse potential misuse, diversion, addiction
 Although methylphenidate (eg, Ritalin, Concerta) is classified as a stimulant, in children with ADHD it improves
attention, decreases distractibility, helps maintain focus on an activity, and improves listening skills.
For many years, the effects of methylphenidate in children were labeled as paradoxical. Now, research has shown
that methylphenidate significantly increases levels of dopamine in the central nervous system (CNS) that lead to
stimulation of the inhibitory system of the CNS. Methylphenidate works quickly; symptom relief is often seen after the
first dose.
This is a true statement; methylphenidate is generally safe for most children, adolescents, and adults.
Methylphenidate can cause adverse reactions, but these affect a very small percentage of users.
A child's school grades may improve due to the benefits of methylphenidate. This would be seen over time as a
secondary benefit; the immediate therapeutic effects are often observed with the first dose.

CLOZAPINE
The client taking clozapine is exhibiting classic signs of neuroleptic malignant syndrome (NMS), an uncommon but life-
threatening adverse reaction to anti-psychotic medications.
NMS is characterized by high fever, muscular rigidity, altered mental status, and autonomic dysfunction.
Treatment includes supportive care (eg, rehydration, cooling body temperature) and immediate discontinuation of the
medication.
Due to the life-threatening nature of NMS, this client needs to be seen first to assess for generalized muscle
rigidity.
Clozapine (Clozaril) is an atypical antipsychotic medication used to manage schizophrenia in clients who have not
improved with other antipsychotic medications. Clozapine is highly effective at controlling schizophrenia; however, it
has many severe, life-threatening adverse effects, including agranulocytosis, cardiac disease (myocarditis), and
seizures.
Agranulocytosis (decreased neutrophils) increases the risk for infection. Clients require serial monitoring of white
blood cell counts and frequent assessment for signs of infection (eg, sore throat, fever, flulike symptoms), which
should be reported immediately to the health care provider
 Weight gain is a common side effect. Clients should be educated about weight management.
Hypersalivation and drooling are common side effects. When excessive, they can occasionally pose risk for
aspiration, especially while the client is sleeping. This is important but not an immediate priority. The side effect can
be reduced by lowering the dose. The client should chew sugarless gum to promote swallowing and reduce drooling.
Many clients experience significant sedation when the medication is started. Most will develop tolerance to this and
eventually improve.
ZIPRASIDONE
Ziprasidone hydrochloride (Geodon) is an atypical antipsychotic drug that is used for acute bipolar mania, acute
psychosis, and agitation. Its use carries a risk for QT prolongation leading to torsade de pointes. A baseline
electrocardiogram and potassium are usually checked. At a minimum, the client should be placed on a cardiac
monitor. The client should also be monitored for hypotension and seizures, especially if the previous medical history
is not known or obtainable. The risk for adverse effects is increased with the interaction of alcohol.
Although knowing past psychiatric history will assist in determining the cause of this episode, this knowledge is not
essential when caring for this client's current needs. Any physical reasons for the behavior should be ruled out before
focusing on psychiatric history. Risk for suicide also needs to be assessed after the client is alert and sober.
This should be reassessed after the drug is wearing off, not before the medication is peaking. The client could
suddenly wake up and become violent again. Also, it is a priority to perform restraint monitoring per protocol, including
checks on circulation and hydration/elimination needs. The client's physiological response is priority.
It would be beneficial to know the current alcohol (ethanol) level in order to estimate the client's level of intoxication
and when the client will be sober. The body normally clears alcohol at a rate of 25-50 mg/dL per hour. However, there
is a reliable history that the client had been drinking, and the presence of alcohol in the blood carries a risk for drug
interaction. Therefore, it is more important to monitor the client for any negative effects (adverse physiological
responses) from the drug than to quantify the current alcohol level.

Commonly used monoamine oxidase inhibitors (MAOIs) include isocarboxazid, phenelzine, and tranylcypromine.
These first-generation antidepressants are used only for resistant depression due to serious adverse affects. These
medications inhibit the enzyme that breaks up norepinephrine, serotonin, and dopamine, thereby increasing their
availability in the body.
Clients taking MAOIs or other antidepressants are at increased risk for suicidal ideation, particularly children,
adolescents, and young adults. The risk of suicidal thoughts can be more prevalent when starting the medication or
with dose increases. Feelings of hopelessness or despair must be evaluated to assess if suicidal ideation or thoughts
of self-harm are present
MAOIs should be administered in the morning, as sleep dysfunction is common. This client statement should prompt a
discussion of current medication habits, but is not the priority.
Clients taking MAOIs need to avoid tyramine-containing foods (eg, cheese, overripe fruit, liquor, beef/chicken liver,
fermented products) due to risk of hypertensive crisis. A medication change might be considered if a client is unable
to adhere to the restrictions, but would not be priority.
Nausea and constipation are adverse effects of MAOIs. Although strategies for management of adverse effects
should be discussed, this is not priority.
HERBAL SUPPLEMENT
St John's wort is an herbal supplement commonly used to treat depression and anxiety. Some clients with mild or
moderate depression claim that its antidepressant effect is comparable to that of prescription medications. The herbal
supplement mimics the action of selective serotonin reuptake inhibitors (SSRIs) by increasing available serotonin in
the brain.
Taken in combination with an SSRI (eg, sertraline, fluoxetine, citalopram, paroxetine), St John's wort may cause an
excess of serotonin, resulting in serotonin syndrome, which is characterized by mental status changes, autonomic
dysregulation, and neuromuscular hyperactivity.
Drugs, which may trigger this reaction, include selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase
inhibitors (MAOIs), dextromethorphan, ondansetron, St. John's wort, and tramadol.

The client with a newly diagnosed depressive disorder will likely be prescribed an antidepressant. The nurse should
teach the client not to take St John's wort concurrently with SSRIs to prevent serotonin syndrome
TRICYCLIC ANTI-DEPRESSANT (TCA)
When a client switches from a tricyclic antidepressant (TCA) (eg, imipramine, amitriptyline, nortriptyline) to
a monoamine oxidase inhibitor (MAOI) (eg, phenelzine, isocarboxazid, tranylcypromine), a drug-free period of at
least 2 weeks should elapse between the tapered discontinuation of the TCA and the initiation of the MAOI. This
timing is based on the half-life value and allows for the first medication to leave the system.
Without a washout period, the client could experience hypertensive crisis (eg, blurred vision, dizziness, severe
headache, shortness of breath). If the TCA is withdrawn abruptly, the client may experience a discontinuation
syndrome.
A tyramine-restricted diet is indicated for clients on an antidepressant regimen containing an MAOI to decrease the
risk of hypertensive crisis. Because this client is starting an MAOI, the diet should be initiated 2 weeks prior to starting
the medication. If the switch was from an MAOI inhibitor to another antidepressant, the client would need to continue
to follow the dietary restrictions for 2 weeks after discontinuing the MAOI.
An overnight washout period is inadequate to clear the imipramine from the client's system before starting the
phenelzine.
TCAs and MAOIs cannot be taken at the same time due to the risk of a hypertensive crisis.

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI)

Selective serotonin reuptake inhibitors (SSRIs) (eg, escitalopram) cannot be combined with monoamine oxidase
inhibitors (MAOIs) (eg, phenelzine) as there is a risk of serotonin syndrome.
MAOI effects persist long after dosing stops. An MAOI should be withdrawn at least 14 days before starting an SSRI.
Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat major depression and anxiety disorders.
SSRIs (eg, fluoxetine, paroxetine, citalopram, escitalopram, sertraline) are generally well tolerated except for sexual
dysfunction.
Clients often underreport this side effect. However, when asked specifically, over 50% of clients taking SSRIs may be
experiencing some type of sexual dysfunction.
This can be a decrease in sexual desire, arousal, or orgasm and may vary by gender. The nurse should discuss this
with the client.
 The side effect may decrease or cease after a 2- to 4-week waiting period for the therapeutic effect, or the client
may be able to switch to a different antidepressant medication (eg, bupropion).

PAROXETINE

Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) often prescribed for major depression and anxiety
disorders.
Other SSRIs include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), and sertraline (Zoloft). Weight
gain is a common side effect of long-term SSRI use.
The nurse should teach the client to eat a healthy diet and engage in regular exercise to combat the weight gain.
Other major side effects of SSRIs include increased suicide risk (at the beginning of therapy), sexual dysfunction,
and serotonin syndrome when taken in excess doses.
SSRIs should not be stopped abruptly without discussion with the HCP. Dosages should be gradually tapered before
discontinuation to avoid withdrawal symptoms.
Most clients will start to see symptom improvement in 1-2 weeks. However, some may take several weeks and
require dose adjustments. Clients should continue to take the medication and discuss it with the HCP.
SSRIs can cause sexual dysfunction. Clients should notify the HCP for a change of medication or to add medications
to increase sexual performance.

BENZTROPINE
Benztropine (Cogentin) is an anticholinergic medication used to treat some extrapyramidal symptoms, which are
side effects of some antipsychotic medications. These side effects include:

o Pseudoparkinsonism: Symptoms that resemble parkinsonism (eg, masklike face, shuffling gait, rigidity, resting tremor,
psychomotor retardation [bradykinesia])
o Dystonia: Abnormal muscle movements of the face, neck, and trunk caused by sustained muscular contractions (eg,
torticollis, oculogyric crisis, opisthotonos)
TRAZODONE

Trazodone (Oleptro), a serotonin modulator, is used to treat major depressive disorders. In addition to affecting
serotonin levels, the drug blocks alpha and histamine (H1) receptors.
Blockade of alpha receptors can cause orthostatic hypotension similar to that from other alpha blockers (eg,
terazosin, tamsulosin) used to treat benign prostatic hyperplasia.
Blockade of H1 receptors leads to sedation. Therefore, this drug is particularly effective in treating insomnia
associated with depression. However, concurrent intake of other medications or substances that cause sedation can
be detrimental; these include benzodiazepines (eg, alprazolam, lorazepam, diazepam), sedating antihistamines (eg,
chlorpheniramine, hydroxyzine), and alcohol
Priapism is a known serious side effect of trazodone. A client with an erection lasting several hours should go to the
hospital.
Clients should be advised to rise from supine to standing slowly, in stages, due to the risk of orthostatic hypotension.
The drug should be taken at bedtime to avoid daytime sedation.

BUSPIRONE
Buspirone (Buspar) is an anxiolytic medication that differs from other medications used to manage anxiety disorders
(eg, benzodiazepines) because it typically lacks central nervous system depressant effects and has a low abuse
potential. Therefore, buspirone has a favorable side-effect profile because it usually does not produce withdrawal
symptoms, dependence, or psychomotor slowing (eg, slowing of thought, impaired movement).
However, unlike other anxiolytic medications, buspirone does not work immediately. Onset of symptom relief
occurs after 1 week of therapy, with full effects occurring between 2 and 4 weeks
As with any medication, the nurse should advise clients to avoid driving until individual effects are known. However, it
is unlikely that buspirone will cause psychomotor impairment and require cessation of driving or operating machinery
for the duration of treatment.
 Buspirone should be taken as prescribed and is not indicated for relief of acute anxiety or panic attacks. The health
care provider may prescribe an additional medication with a fast-acting effect for panic attacks.
Buspirone does not cause physical dependence or tolerance, and withdrawal symptoms do not occur with
discontinuation of use.

PHENYTOIN

The nurse should discuss the need to perform good oral hygiene with a soft-bristle toothbrush and to visit the dentist
regularly as phenytoin can cause gingival hyperplasia (overgrowth of the gum tissues or reddened gums that bleed
easily), especially in high doses. Folic acid supplementation can also reduce this side effect.
The other major side effects of phenytoin use are an increase in body hair, rash, folic acid depletion, and decreased
bone density (osteoporosis).
Long-term use of phenytoin can cause folic acid deficiency and decreased bone density. Therefore, a diet high in folic
acid and calcium should be recommended.
TERATOGENIC MEDICATIONS
 Clients with preexisting conditions (eg, asthma, hypertension, diabetes) may require changes to medication therapy if
they become pregnant. In particular, teratogenic or unnecessary medications should be discontinued (before
conception, when possible).
The nurse should refer a client taking contraindicated medications to a health care provider immediately. For
example:

o Doxycycline, a tetracycline antibiotic, is avoided in pregnancy because it can impair bone mineralization and discolor
permanent teeth in the fetus
o Isotretinoin (Accutane) has a black box warning for severe birth defects. Retinoids may not be prescribed to women of
childbearing age without a formal agreement to participate in iPLEDGE (a prescription tracking program) and a commitment
to use two forms of contraception
o ACE inhibitors such as lisinopril (Prinivil) have a black box warning for use in pregnancy because they can affect fetal
renal function and lung development or cause fetal death

BENZODIAZEPINES

Benzodiazepines (eg, alprazolam [Xanax], lorazepam [Ativan], clonazepam, diazepam) are commonly used
antianxiety drugs.
They work by potentiating endogenous GABA, a neurotransmitter that decreases excitability of nerve cells, particularly
in the limbic system of the brain, which controls emotions.
 Benzodiazepines may cause sedation, which can interfere with daytime activities. Giving the dose at bedtime will
help the client sleep.
A benzodiazepine should never be stopped abruptly. Instead, it should be tapered gradually to prevent rebound
anxiety and a withdrawal reaction characterized by increased anxiety, confusion, and more.

COMBINATION DRUGS

Clients are often prescribed medications from more than one class to effectively treat anxiety and depression;
however, monoamine oxidase inhibitors (MAOIs) (eg, selegiline [Emsam]) interact with many medications,
including many antidepressants. Concurrent use of MAOIs with selective serotonin reuptake inhibitors (SSRIs)
(eg, escitalopram [Lexapro]) may precipitate life-threatening adverse reactions (eg, serotonin syndrome, neuroleptic
malignant syndrome, hypertensive crisis).
If a client's prescribed medication regimen will change to or from an MAOI, the existing medication should be tapered
and discontinued, followed by a 2-week "washout" period without either medication. The client can then begin taking
the new medication.
SSRIs (eg, citalopram [Celexa], escitalopram, sertraline [Zoloft]) can be given safely with benzodiazepines (eg,
alprazolam [Xanax], lorazepam [Ativan]) or hypnotics (eg, zolpidem [Ambien]). Benzodiazepines control acute anxiety
and SSRIs help treat long-term anxiety without abuse potential.
Clients with bipolar disorder often need antipsychotic medication (eg, risperidone [Risperdal], haloperidol [Haldol]) to
control acute psychosis and lithium for long-term maintenance therapy.

REPRODUCTIVE /MATERNITY & NEW BORN &

NEHROLOGICAL PHARMACOLOGY

BLACK COHOSH

The nurse should follow up regarding the quantity of the herb and how it is used. Black cohosh is used by some
clients for menopausal hot flashes. The main side effects are thickening of the uterine lining and potential liver toxicity.
 Herbs can cause harmful reactions when taken in combination with other drugs. It is most important to determine that
an herb does not interfere with other medications. Herbal therapy is usually stopped 2-3 weeks before any surgery.

METFORMIN
IV iodinated contrast used for CT scan or cardiac catheterization can cause kidney injury (contrast-induced
nephropathy). The side effect of metformin (Glucophage) is lactic acidosis.
If the client takes metformin and develops kidney injury from contrast, then the lactic acidosis will worsen.
As a result, most HCPs discontinue metformin on the day of IV iodine contrast exposure (regardless of baseline
creatinine) and restart the drug at least 48 hours later, after stable renal function has been documented.

IV SODIUM BICARBONATE

Metabolic acidosis is due to an increase in the production or retention of acid (eg, lactic acidosis, ketoacidosis, renal
failure) or the depletion of bicarbonate (HCO3-) via the kidneys or gastrointestinal tract.
In metabolic acidosis, there is a decrease in pH (<7.35) and HCO3- (<22 mEq [22 mmol/L]). Acidosis damages cells,
causing them to release intracellular contents (eg, potassium).
Hyperkalemia (potassium >5.0 mEq/L [5 mmol/L]) frequently occurs with acidosis, putting the client at risk for cardiac
arrhythmias.
Depending on the cause and severity of acidosis, the client can exhibit altered mental status and tachypnea.
Management focuses on treating the underlying cause and administering IV sodium bicarbonate to correct the
imbalance. Arterial blood gas pH 7.39, HCO3- 24 mEq/L (24 mmol/L), and serum potassium 3.8 mEq/L (3.8 mmol/L)
are within normal limits, indicating the sodium bicarbonate has effectively corrected acidosis.

VAGINAL CANDIDIASIS
Candida albicans (yeast) can colonize and cause infections of the vulvovaginal region. Vaginal candidiasis often
causes itching and painful urination due to urine stinging the inflamed areas of the vulva. Assessment shows a thick,
white, curd-like vaginal discharge and reddened vulvar lesions.
 Miconazole (Monistat), an antifungal cream commonly prescribed to treat vaginal candidiasis, is inserted high into
the vagina using an applicator. It is best applied at bedtime so that it will remain in the vagina for an extended period
Sexual intercourse is avoided until the inflammation is resolved, typically for the duration of treatment, approximately
3-7 days. However, sexual activity is not a significant cause of infection or reinfection of candida, and partner
evaluation is not needed.
Trichomoniasis, syphilis, gonorrhea, and HIV are mainly sexually transmitted; therefore, partners should be evaluated
and treated.
Other teaching points for this client should include:

o Ensuring proper hygiene of the perineum - cleansing from anterior to posterior (front to back) to prevent accidental
introduction of fecal organisms
o Wearing loosely fitted cotton underwear and avoiding synthetic undergarments to promote ventilation, decrease friction, and
reduce moisture
o Refraining from douching, which can introduce organisms higher up into the vaginal canal and cervix

SAW PALMETTO

Herbal preparations are not regulated by governmental agencies and are generally classified as food or dietary
supplements.
Manufacturers are therefore able to avoid the scientific scrutiny exercised when prescription drugs are readied for the
market.
Saw palmetto is one such herbal preparation, and clients most often use it to treat benign prostatic hyperplasia.

SODIUM POLYSTYRENE SULFONATE (KAYEXALATE)

Sodium polystyrene sulfonate (Kayexalate) is used to treat mild to moderate hyperkalemia.

Potassium is exchanged for sodium in the intestines and excreted in the stool, thereby lowering the serum potassium.
In clients without normal bowel function (eg, post surgery, constipation, fecal impaction), there is a risk for intestinal
necrosis.
 During sodium polystyrene sulfonate therapy, severe hypokalemia (palpitations, lethargy, cramping) can develop.
Frequent monitoring of electrolyte status is required. Because potassium exchanges with sodium content of the resin,
excess sodium absorption could put clients at risk of developing volume overload (water follows sodium).
The client should be monitored for signs of fluid overload (eg, crackles, jugular venous distension, edema) and have
daily weights and intake and output assessment.

SODIUM POLYSTYRENE SULFONATE (KAYEXELATE) RETENTION ENEMA

Sodium polystyrene sulfonate (Kayexalate) retention enema is a medicated enema administered to clients with high
serum potassium levels.
The resin in Kayexalate replaces sodium ions for potassium ions in the large intestine and promotes evacuation of
potassium-rich waste from the body, thereby lowering the serum potassium level.
Kayexalate can also be given orally and is much more effective. Kayexalate can rarely be associated with intestinal
necrosis.
CHRONIC KIDNEY DISEASE

The client with kidney disease is at risk for both hyperkalemia (normal potassium 3.5-5.0 mEq/L [3.5-5.0 mmol/L])
and hyperphosphatemia due to reduced glomerular filtration rate. Untreated hyperkalemia may cause life-
threatening cardiac arrhythmias. Sodium polystyrene sulfonate (Kayexalate) can be used to treat hyperkalemia. It
works in the gastrointestinal tract to trade sodium for potassium, thereby eliminating excess potassium through the
stool and reducing the serum potassium level.
Serum calcium levels (normal 8.6-10.2 mg/dL [2.15-2.55 mmol/L]) may decrease with diminished renal function due to
lower activation of vitamin D and subsequent impaired gut absorption of calcium. Calcium supplements are used to
increase the serum calcium level. Sodium polystyrene sulfonate does not affect the serum calcium level.
Sodium polystyrene sulfonate does not affect serum creatinine levels. Creatinine levels may decrease after dialysis.
 Phosphorus is also not filtered with kidney injury and the levels increase in serum (normal 2.4-4.4 mg/dL [0.78-1.42
mmol/L]). Phosphate binders (calcium acetate/carbonate) administered orally eliminate phosphorus through stool.
Sodium polystyrene sulfonate does not bind phosphorus.

COPPER IUD

A copper intrauterine device (IUD) is a form of long-acting, reversible contraception that causes an intrauterine
inflammatory effect that impairs sperm mobility and prevents implantation of a fertilized egg. It is a highly
effective contraceptive and is also used for emergency contraception.
IUD insertion commonly causes mild discomfort, cramping, and/or light vaginal bleeding
Ibuprofen is recommended before and after insertion for relief of cramping/pain.
Menstrual changes are also common among IUD users. For clients with copper IUDs, heavier
bleeding and increased cramping during menses are the most common and expected side effects
The client should check for the strings at least monthly to ensure that the IUD has not been expelled
Unlike levonorgestrel IUDs, copper IUDs have an immediate contraceptive effect; backup contraception is not
required. Condoms are recommended for clients who are at risk for sexually transmitted infections.
 Although pregnancy risk is low (<1%) when using the copper IUD, pregnancy is possible (eg, device expelled).
Ovulation and menses still occur when using the copper IUD because the device does not contain hormones. A
pregnancy test is necessary if a period is missed.

TRICHOMONIASIS
Trichomoniasis is a sexually transmitted infection caused by Trichomonas vaginalis.
Infected clients may be asymptomatic but usually seek care when a profuse, frothy, yellow-green, malodorous vaginal
discharge is noted.
Pruritus, dysuria, and dyspareunia (ie, pain during sex) may also occur.
Oral metronidazole (Flagyl) is the most common drug used to treat trichomoniasis. Client education includes:
o Abstain from sexual intercourse until the infection is cleared (ie, about 1 week after treatment)
o Avoid drinking alcohol while taking metronidazole and for 3 days after completion of therapy because the combination can
cause flushing, nausea/vomiting, and severe abdominal pain
o Have partner(s) treated simultaneously to avoid reinfection. Use condoms to prevent the infection in the future
o Know that potential side effects of metronidazole may include a metallic taste, gastrointestinal upset, or dark-colored urine
Vaginal douching is not recommended as it gets rid of good bacteria and alters the pH of the vagina, increasing the
risk for infection (eg, bacterial vaginosis). Teach the client to cleanse the exterior vulva using only unscented
products, wear breathable undergarments, and report persisting odors/discharge to the health care provider.

KCL TABLETS

Loop diuretics (eg, furosemide [Lasix], bumetanide [Bumex]) are "potassium-wasting" diuretics, meaning that
clients may experience potassium loss and hypokalemia. Hypokalemia in a client with heart failure creates a risk for
life-threatening cardiac dysrhythmias. Therefore, clients taking loop diuretics usually require potassium
supplementation.
Potassium is an erosive substance that can cause pill-induced esophagitis. To prevent esophageal erosion, the
client should take potassium tablets with plenty of water (at least 4 oz [120 mL]) and remain sitting upright
 minutes after ingestion. This prevents the tablet from becoming lodged in the esophagus or refluxing from the
stomach
Pill-induced esophagitis is also common with tetracyclines (eg, doxycycline) and bisphosphonates ("dronates":
alendronate, ibandronate, pamidronate, risedronate), so clients taking these medications should be given similar
instructions.
A diet rich in protein and vitamin D helps with calcium-supplement, not potassium, absorption.
Sustained-release medications should never be crushed as this would cause the client to absorb the medication too
rapidly.
Potassium should be taken during or immediately following meals to prevent gastric upset.

PHENAZOPYRIDINE HYDROCHLORIDE (PYRIDIUM)

Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic prescribed to relieve the pain and burning
associated with a urinary tract infection.
The urine will turn bright red-orange while on this medication; other body fluids can be discolored as well.
Because staining of underwear, clothing, bedding, and contact lenses can occur, the nurse should suggest that the
client use sanitary napkins and wear eyeglasses while taking the medication.
Phenazopyridine hydrochloride provides symptomatic relief but no antibiotic action, and so it is important that the client
take a full course of antibiotics.

ERYTHROPOEITIN

Anemia associated with chronic kidney disease is treated with recombinant human erythropoietin (Epogen/Procrit,
epoetin).
Therapy is initiated when hemoglobin is <10 g/dL (100 g/L) to alleviate the symptoms of anemia (eg, fatigue) and the
need for blood transfusions.
 Therapy should be discontinued or the dose reduced for hemoglobin >11 g/dL (110 g/L) to prevent venous
thromboembolism and adverse cardiovascular outcomes from blood thickened by high concentrations of RBCs.
Hypertension is a major adverse effect of erythropoietin administration. Therefore, uncontrolled hypertension is
a contraindication to recombinant erythropoietin therapy. Blood pressure should be well controlled prior to
administering erythropoietin
Erythropoietin is administered intravenously or in any subcutaneous area (not intramuscularly).
Iron in the form of iron sucrose (Venofer) or ferric gluconate (Ferrlecit) may be prescribed to promote an adequate
response to erythropoietin. Adequate stores of iron, vitamin B12, and folic acid are required for the erythropoietin to
work.
The dose should be held if the client has a hemoglobin level >11 g/dL (110 g/L) or uncontrolled hypertension.

OXYBUTYNIN
Oxybutynin (Ditropan) is an anticholinergic medication that is frequently used to treat overactive bladder. Common
side effects include:

o New-onset constipation
o Dry mouth
o Flushing
o Heat intolerance
o Blurred vision
o Drowsiness

Decreased sweat production may lead to hyperthermia. The nurse should instruct the client to be cautious in hot
weather and during physical activity
Increasing dietary intake of fluids and bulk-forming foods (eg, fruits, vegetables) promotes normal bowel function and
prevents constipation.
Sedation is a common side effect of anticholinergic drugs. Clients should be taught not to drive or operate heavy
machinery until they know how the drug affects them.
KCL

KCL, an electrolyte replacement to correct hypokalemia, is a high-alert drug that is never administered by the IV push,
intramuscular, or subcutaneous routes. The recommended peripheral infusion rate is 5-10 mEq/hr. However, the
nurse should always follow institution IV guidelines and policy and procedure for administering KCL.
The nurse's priority action is to slow the infusion rate if the client feels a burning discomfort at the IV site shortly after
initiation of the infusion. KCL irritates the vein, and irritation and discomfort at the site is expected. Slowing the
infusion rate is effective in alleviating discomfort.
KCL in concentrations 20-40 mEq/100 mL at a maximum rate of 40 mEq/hr should be administered through a central
venous access device (CVAD) (eg, PICC, centrally inserted catheter) to prevent postinfusion phlebitis. A
concentration of 10 mEq KCL/100 mL can be administered through a peripheral vein at the recommended infusion
rate.
The IV infusion is preferred over the oral preparation to decrease the risk for dysrhythmias when hypokalemia must be
corrected quickly. Some clients may need both oral and IV forms if the serum potassium levels are markedly low.
However, this action is not a priority.
Rapid correction of this client's hypokalemia (2.8 mEq/L) is necessary due to risk for hypokalemia-associated
dysrhythmias. Stopping the infusion when not necessary further increases risk. The nurse assesses the site at least
every hour for adverse reactions (eg, redness, pain, swelling, phlebitis, thrombosis, extravasation or infiltration), and
stops the infusion if any occur.

FETAL HEART RATE VARIABILITY

Opioid medications administered during pregnancy (eg, meperidine hydrochloride [Demerol]) cross the placenta,
resulting in minimal variability or pseudosinusoidal fetal heart rate (FHR) patterns and neonatal respiratory
depression after birth.
This FHR strip shows a baseline of 140/min, minimal variability, periodic early decelerations, positive accelerations,
and 60-second contractions every 4 minutes. It is a category II FHR tracing due to minimal variability.
The most appropriate nursing action is to continue monitoring the FHR as long as nonreassuring signs are absent
(eg, late decelerations, persistent minimal variability, bradycardia), making sure to document recent opioid
administration
 Invasive assessments (eg, sterile vaginal examinations) are unnecessary unless signs of imminent birth (eg, urge to
push, bearing down, nonreassuring FHR patterns) are present.
A more accurate tracing of minimal variability can be obtained with a fetal scalp electrode instead of external
monitoring. However, invasive internal monitors are unnecessary because minimal variability will likely resolve after
the narcotic wears off. (The duration of action for IV meperidine hydrochloride is 2-4 hours.)
Discontinuation of oxytocin is not generally indicated for minimal variability associated with opioid administration. If
further nonreassuring signs (eg, persistent minimal variability, late decelerations, tachysystole) occur, oxytocin should
be discontinued.

LEVONORGESTREL RELEASING IUD

Priority teaching related to intrauterine devices (IUDs) for long-term contraception focuses on prevention of sexually
transmitted infections, which increase the risk for pelvic inflammatory disease, and early recognition of a dislodged
device, which places the client at risk for pregnancy. The nurse may use the acronym PAINS to discuss potential
complications of IUDs.
The client should assess the string position weekly for the first 4 weeks and then after each menses to ensure that
the device remains in place. A longer, shorter, or missing string may indicate that the IUD is no longer in the uterus;
the client should notify the health care provider and abstain from intercourse or use a barrier method (eg, condom)
until placement is verified
 Copper IUDs (eg, ParaGard) provide 10 years of contraception. Levonorgestrel-releasing IUDs provide 3 years (eg,
Skyla) or 5 years (eg, Mirena) of contraception.

TOLRETODINE

Tolterodine (Detrol LA), oxybutynin (Ditropan), and solifenacin (Vesicare) are

antimuscarinic/anticholinergic medications used for overactive bladder and urge urinary incontinence.
They decrease urinary urgency and frequency. The most common side effects are anticholinergic (eg, dry mouth,
constipation, cognitive dysfunction). The client's report of not urinating the entire day while at work may indicate that
the dosage is too high and is causing urinary retention.
Urinary retention can lead to bladder infections and distension. This information should be reported to the health care
provider (HCP).
Artificial saliva products and sugar-free hard candy and gum are acceptable ways to manage dry mouth caused by
anticholinergic medications.
Occasional dizziness is a side effect of tolterodine. The client should rise and change positions slowly. However, if
this client is receiving too high a dose, reduction of the dose may alleviate the dizziness. Severe dizziness should be
reported to the HCP.
Constipation can be managed with increased fiber in the diet, fluids, stool softeners, or laxatives.
ESTROGEN-PROGESTIN ORAL CONTRACEPTIVE PILLS

The use of hormonal contraception (ie, estrogen with or without progestin) places women at a 2- to 4-fold increased
risk for developing blood clots due to resulting hypercoagulability.
Hormone levels vary among contraceptives, and higher levels of hormone content correlate to an increased risk of
adverse thrombotic events (eg, stroke, myocardial infarction). Clients who are prescribed oral contraceptive pills
(OCPs) containing estrogen should be educated on potential warning signs (eg, chest pain, vision loss, severe leg
pain)
In addition, clients should be instructed not to smoke while taking combined OCPs due to an increased risk of blood
clots
 Irregular bleeding and spotting between menses are common side effects of combined OCPs. These side effects may
be bothersome but are not serious and may improve within 3 months of initiation. If the client cannot tolerate side
effects, a different OCP may be considered.
Clients should be counseled that breast tenderness is a common side effect of combined OCPs and does not warrant
emergent reporting to the health care provider.
TERAZOSIN
Terazosin is an alpha-adrenergic blocker that can relieve urinary retention in clients with BPH.
It relaxes the smooth muscle in the bladder neck and prostate gland; however, it also relaxes smooth muscle in the
peripheral vasculature, which can cause orthostatic hypotension, syncope (blacking out), and falls.
This is particularly common when the drug is started (first-dose hypotension) or when the dosage is increased.
The serious effects can be avoided by instructing the client to take the medication at bedtime, change positions
slowly when going from lying to standing, and avoid any medications that also increase smooth muscle relaxation
(eg, phosphodiesterase-5 inhibitors [sildenafil or vardenafil] used to treat erectile dysfunction).
Some clients may also experience ejaculatory dysfunction (decreased or absent ejaculation).
Alpha-1-adrenergic antagonists (eg, terazosin, doxazosin, tamsulosin, alfuzosin) should be taken at bedtime, not in the
morning, to avoid orthostatic hypotension.

RESPIRATORY PHARMACOLOGY
CODEINE

Codeine is a narcotic analgesic used for acute pain or as a cough suppressant.

Depressing the cough reflex can cause an accumulation of secretions in the presence of chronic obstructive
pulmonary disease (COPD), leading to respiratory difficulty.
In general, sedatives (eg, narcotics, benzodiazepines) can also depress the respiratory center and effort; therefore,
they should not be given to clients with respiratory diseases (eg, asthma, COPD).
 Codeine is an opioid drug prescribed as an analgesic to treat mild to moderate pain and as an antitussive to suppress
the cough reflex. Although the antitussive dose (10-20 mg orally every 4-6 hours) is lower than the analgesic dose,
clients can still experience the common adverse effects (eg, constipation, nausea, vomiting, orthostatic hypotension,
dizziness) associated with the drug.
Codeine decreases gastric motility, resulting in constipation. Increasing fluid intake and fiber in the diet and taking
laxatives are effective measures to prevent constipation
Changing position slowly is effective in preventing the orthostatic hypotension associated with codeine, especially in
the elderly
Taking the medication with food is effective in preventing the gastrointestinal irritation (eg, nausea, vomiting)
associated with codeine

FLUTICASONE/SALMETEROL

Fluticasone/salmeterol (Advair) is a combination drug containing a corticosteroid (fluticasone) and a bronchodilator

(salmeterol).
Salmeterol is a long- -adrenergic agonist that promotes relaxation of the bronchial smooth muscles
over 12 hours.
Fluticasone decreases inflammation. This medication is used as part of the treatment plan for prevention and long-
term control of asthma.
Client instructions include:

o After inhalation, rinse the mouth with water without swallowing to reduce the risk of oral/esophageal candidiasis
o Avoid smoking and using tobacco products
o Receive the pneumococcal and influenza vaccines if there is a risk for infection

Fluticasone/salmeterol is not a rescue inhaler and does not treat acute exacerbations of asthma. The client should
always have a rescue inhaler (eg, albuterol [short- -adrenergic agonist] or ipratropium [Atrovent]) for sudden
changes in breathing and call 911 if the rescue inhaler does not relieve the breathing problem.
ACETYLCYSTEINE (MUCOMYST)

Acetylcysteine (Mucomyst) may be given via nebulizer to help loosen and liquefy respiratory secretions to more
easily clear them from the airway.
Inhaled acetylcysteine may be used for clients with cystic fibrosis or other respiratory conditions with thick bronchial
mucus.
Acetylcysteine has no therapeutic effect on airway smooth muscle as it works primarily on secretions and has been
shown to cause and/or worsen bronchospasm.
Nurses caring for clients with reactive airway diseases (eg, asthma) prescribed acetylcysteine should clarify the
prescription with the health care provider

ISONIAZID

Isoniazid (INH) is a first-line antitubercular drug prescribed as monotherapy to treat latent tuberculosis infection.
Combined with other drugs, INH is also used for active tuberculosis treatment. Two serious adverse effects of INH
use are hepatotoxicity and peripheral neuropathy.
A teaching plan for a client prescribed INH includes the following:

o Avoid intake of alcohol and limit use of other hepatotoxic agents (eg, acetaminophen) to reduce risk of hepatotoxicity
o Take pyridoxine (vitamin B6) if prescribed to prevent neuropathy
o Avoid aluminum-containing antacids (eg, aluminum hydroxide (Maalox)) within 1 hour of taking INH. Concurrent use of
antacids containing aluminum decreases INH absorption. The medication may be taken with food if gastric irritation is a
concern.
o Report changes in vision (eg, blurred vision, vision loss)
o Report signs/symptoms of severe adverse effects such as:

Hepatoxicity (eg, scleral and skin jaundice, vomiting, dark urine, fatigue)
Peripheral neuropathy (eg, numbness, tingling of extremities)

ASTHMA

Asthma is an inflammatory condition in which the smaller airways constrict and become filled with mucus. Breathing,
especially on expiration, becomes more difficult.
Pharmacologic treatment for acute asthma includes the following:
 1. Oxygen to maintain saturation >90%
2. High-dose inhaled short-acting beta agonist (albuterol or levalbuterol) and anticholinergic agent (ipratropium) nebulizer
treatments every 20 minutes
3. Systemic corticosteroids (Solu-Medrol) to control the underlying inflammation. These will take some time to show an effect.

Nonsteroidal anti-inflammatory agents (eg, ibuprofen, naproxen, indomethacin) and aspirin can worsen asthma
symptoms in some clients and are not indicated unless necessary.
Montelukast (Singulair) is a leukotriene (chemical mediator of inflammation) inhibitor and is not used to treat acute
episodes. It is given orally in combination with beta agonists and corticosteroid inhalers (eg, fluticasone, budesonide)
to provide long-term asthma control.
Two groups of commonly used drugs, nonsteroidal anti-inflammatory drugs and beta-adrenergic antagonists (beta
blockers), have the potential to cause problems for clients with asthma.
Ibuprofen (Motrin) and aspirin are common over-the-counter anti-inflammatory drugs that are effective in relieving pain,
discomfort, and fever. About 10%-20% of asthmatics are sensitive to these medications and can experience severe
bronchospasm after ingestion. This is prevalent in clients with nasal polyposis.
Clinical manifestations characteristic of moderate to severe asthma exacerbations include tachycardia (>120/min),
tachypnea (>30/min), saturation <90% on room air, use of accessory muscles to breathe, and peak expiratory flow
(PEF) <40% of predicted or best (<150 L/min).
Pharmacologic treatment modalities recommended by the Global initiative for Asthma (2014) to correct hypoxemia,
improve ventilation, and promote bronchodilation include the following:

o Oxygen to maintain saturation >90%

o High-dose inhaled short-acting beta agonist (SABA) (albuterol) and anticholinergic agent (ipratropium) nebulizer treatments
every 20 minutes
o Systemic corticosteroids (Solu-Medrol)

Montelukast (Singulair) is a leukotriene receptor blocker with both bronchodilator and anti-inflammatory effects; it is
used to prevent asthma attacks but is not recommended as an emergency rescue drug in asthma.
A long-acting beta agonist (Salmeterol) is administered with an inhaled corticosteroid for long-term control of moderate
to severe asthma; it is not used as an emergency rescue drug in asthma.
 Albuterol (Proventil) is a short-acting beta agonist (SABA) administered as a quick-relief, rescue drug to relieve
symptoms (eg, wheezing, breathlessness, chest tightness) associated with intermittent or persistent asthma.
Beclomethasone (Beconase) is an inhaled corticosteroid (ICS) normally used as a long-term, first-line drug to
control chronic airway inflammation.
When using an ICS metered-dose inhaler (MDI), small particles of the medication are deposited and can impact the
tongue and mouth.
Rinsing the mouth and throat well after using the MDI and not swallowing the water are recommended to help
prevent a Candida infection (thrush) (white spots on tongue, buccal mucosa, and throat), a common side effect of
ICSs.
The use of a spacer with the inhaler can also decrease the risk of developing thrush (
When both MDIs are to be taken at the same time, clients are instructed to take the SABA first to open the airways and
then the ICS to provide better delivery of the medication. It is important for the nurse to clarify indications and
sequencing as the SABA is a rescue drug taken on an as-needed basis and is not always taken with the ICS
Inhaled corticosteroids (eg, fluticasone, beclomethasone) are not rescue drugs. They are prescribed to be taken on a
regular schedule (eg, morning, bedtime) on a long-term basis to prevent exacerbations and should not be omitted
even if the SABA is effective.
Taking the albuterol (Proventil) inhaler apart, washing the mouthpiece (not canister) under warm running water, and
letting it air dry at least 1 2 times a week is recommended. Medication particles can deposit in the mouthpiece and
prevent a full dose of medication from being dispensed.
Taking the ICS inhaler apart and cleaning it every day is recommended.

ALBUTEROL

Albuterol (Proventil) is a short-acting inhaled beta-2 agonist used to control airway obstruction caused by chronic
obstructive pulmonary disease, asthma, or bronchitis. It also is used to prevent exercise-induced asthma.
The therapeutic effect is relaxation of the smooth muscles of the airways, which results in immediate
bronchodilation.
Bronchodilation decreases airway resistance, facilitates mucus drainage (expectorates mucus plugs), decreases the
work of breathing, and increases oxygenation.
As a result of these actions, the respiratory rate will decrease and peak flow will be increased (if tested).
 However, short-acting beta-2 agonists are associated with the following side effects (not therapeutic effects): tremor
(most frequent), tachycardia and palpitations, restlessness, and hypokalemia.
These side effects are due to the oral deposition of medication (subsequent systemic absorption) and can be reduced
with the use of a spacer or chamber device.
Dosing in an acute asthma exacerbation should not exceed 2-4 puffs every 20 minutes x 3. If albuterol is not effective,
an inhaled corticosteroid is indicated to treat the inflammatory component of the disease. Albuterol is
a sympathomimetic drug. Expected side effects mimic manifestations related to stimulation of the sympathetic
nervous system, and commonly include insomnia, nausea and vomiting, palpitations (from tachycardia), and mild
tremor.

TIOTROPIUM

A common side effect of tiotropium (Spiriva) and other anticholinergics (eg, ipratropium, benztropine)
is xerostomia (dry mouth) due to the blockade of muscarinic receptors of the salivary glands, which inhibits
salivation. Sugar-free candies or gum may be used to alleviate dry mouth and throat
Tiotropium capsules should not be swallowed. These capsules are placed inside the inhaler device, and the capsule is
pierced, allowing the client to inhale its contents

GLUCOCORTICOIDS

Glucocorticoids (eg, prednisone), when taken in combination with aspirin or nonsteroidal anti-inflammatory drugs
(NSAIDs) such as naproxen, can increase the risk of gastrointestinal ulceration and bleeding. The client should
report black, tarry stools (ie, melena) to the health care provider as they could indicate gastrointestinal bleeding

NSAID

Tinnitus (ie, ringing in the ears) is an uncommon side effect of NSAID (eg, naproxen) use. Tinnitus is commonly
associated with toxicity related to salicylate-containing NSAIDs (eg, aspirin) or aminoglycosides (eg, gentamicin,
neomycin, tobramycin); its onset should be reported by a client taking these medications. The medication may need to
be discontinued to prevent permanent hearing loss.
RIFAPENTINE

Rifapentine (Priftin), a derivative of rifampin, is an antitubercular agent used with other drugs (eg, isoniazid) as a
combination therapy in active and latent tuberculosis infections. Both rifampin and rifapentine reduce the efficacy
of oral contraceptives by increasing their metabolism; therefore, this client will need an alternate birth control plan
(non-hormonal) to prevent pregnancy during treatment
Rifapentine should be taken with meals for best absorption and to prevent stomach upset.
Hepatotoxicity may occur; therefore, liver function tests are required at least every month. Signs and symptoms of
hepatitis include jaundice of the eyes and skin, fatigue, weakness, nausea, and anorexia.
Rifapentine may cause red-orange-colored body secretions, which is an expected finding. Dentures and contact
lenses may be permanently stained.

THEOPHYLLINE
Theophylline is a bronchodilator with a low therapeutic index and a narrow therapeutic range (10-20 mcg/mL).
The serum level should be monitored frequently to avoid severe adverse effects.
Toxicity is likely to occur at levels >20 mcg/mL. Individual titration is based on peak serum theophylline levels, so it
is necessary to draw a blood level 30 minutes after dosing.
Theophylline can cause seizures and life-threatening arrhythmias. Toxicity is usually due to intentional overdose or
concurrent intake of medications that increase serum theophylline levels.
Cimetidine and ciprofloxacin can dramatically increase serum theophylline levels (>80%). Therefore, they should
not be used in these clients.
Caffeinated products (eg, coffee, cola, chocolate) should be avoided as they would intensify the adverse effects (eg,
tachycardia, insomnia, restlessness) of theophylline.
The best way to prevent toxicity is to monitor drug levels periodically and adjust the dose.
The signs of toxicity that should be reported are anorexia, nausea, vomiting, restlessness, and insomnia.
 Toxicity can be acute or chronic. Conditions associated with chronic toxicity include advanced age (>60), drug
interactions (eg, alcohol, macrolide and quinolone antibiotics), and liver disease. Acute toxicity is associated with
intentional or accidental overdose.
Symptoms of toxicity usually manifest as central nervous system stimulation (eg, headache, insomnia, seizures),
gastrointestinal disturbances (eg, nausea, vomiting), and cardiac toxicity (eg, arrhythmia).

DEATH RATTLE
The "death rattle" is a loud rattling sound with breathing that occurs in a client who is actively dying.
When the client cannot manage airway secretions, the movement of these secretions during breathing causes a
noisy rattling sound. This can distress family and friends at the bedside of the dying client.
The "death rattle" can be treated using anticholinergic medications to dry the client's secretions. Medications
include atropine drops administered sublingually or a transdermal scopolamine patch.

PSYCHIATRIC NURSING
SOMATIC SYMPTOM DISORDER
Somatic symptom disorder (SSD) is a psychological disorder that develops from stress, resulting in
medically unexplainable physical symptoms (eg, abdominal pain) that disrupt daily life.
Clients with SSD focus an excessive amount of time, thought, and energy on the symptoms, often seeking medical
care from multiple health care providers.
Nursing interventions focus on minimizing indirect benefits and developing client insight.
To minimize the indirect benefits from being "sick" (secondary gains), the nurse should:

o Redirect somatic complaints to unrelated, neutral topics

o Limit time spent discussing physical symptoms

To promote insight and healthy coping mechanisms, the nurse should assist the client to:
o Identify secondary gains (eg, increased attention, freedom from responsibilities)
o Recognize factors that intensify symptoms (eg, increased stress, reminders of a deceased family member)
o Incorporate appropriate coping strategies (eg, relaxation training, physical activity)
An elimination diet would increase the client's focus on the symptoms and is inappropriate, as physiological causes
have already been ruled out.
The client's symptoms are real despite the lack of diagnostic findings. The nurse should administer analgesics as
prescribed.
Disputing the validity of the client's symptoms may increase the client's stress level and exacerbate symptoms.

ANOREXIA NERVOSA
Anorexia nervosa is a psychogenic eating disorder with potentially fatal physiological implications. Clients commonly
become extremely underweight and protein-energy malnourished. Clients admitted for anorexia nervosa are typically
in a crisis state, and the priority is restoring physiological integrity through appropriate weight gain and nutritional
intake.
Nursing care includes:

o Assisting the client in reflecting on triggers for dysfunctional eating and fears and feelings related to gaining weight
o Maintaining strict documentation of dietary protein and calorie intake to ensure healthy weight gain
o Remaining with the client during and 1 hour following meals to ensure intake and prevent purging behaviors
o Establishing a weekly weight-gain goal (typically 2-3 lb/wk [0.91-1.36 kg/wk])
o Weighing the client at the same time each morning (after voiding and before any oral intake) and wearing the same clothing
to assess efficacy of nutritional support
o Limiting physical activity initially and gradually increasing as oral intake improves
o Not focusing on food initially, but encouraging participation in meal planning as the client nears target weight

Clinical manifestations of anorexia nervosa include:

6. Fear of weight gain clients resort to self-induced vomiting, extensive dieting, and intense exercise resulting in excessive
weight loss (<85% expected weight). Clients who self-induce vomiting may experience enlargement of the salivary glands
and erosion of tooth enamel.
7. Fluid and electrolyte imbalance excessive vomiting can cause hypokalemia and metabolic alkalosis
8. Amenorrhea clients are often amenorrheic due to decreased body fat (low estrogen)
9. Decreased metabolic rate severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold
intolerance
10. Lanugo (fine terminal hair) can be seen in extreme case
 Nutrition support (enteral tube feedings and total parenteral nutrition) is usually reserved for clients with anorexia
nervosa who are severely ill and/or have not responded to oral nutritional therapy. Such clients are at high risk for
medical complications from anorexia nervosa, including death. Criteria for nutrition support include:

o Severe weight loss that is life threatening

o Client's unwillingness to adhere to a treatment plan of oral feedings

The priority nursing actions for this high-risk client include interventions to meet physiological and safety needs.
Providing one-on-one supervision during the tube feeding will ensure that the client is actually receiving the feeding
and prevent the client from stopping the feeding and/or pulling out the nasogastric tube.
During the one-on-one contact with the client, the nurse can promote a therapeutic and trusting relationship with the
client by:

o Being honest and accepting of the client

o Presenting the reality of the condition
o Acknowledging the client's feelings of loss of control and anger
o Encouraging the client to express feelings and fears

This is an appropriate intervention for a client with anorexia nervosa. Feelings related to lack of control are an
underlying problem for these clients, who use food as a way to deal with them. Keeping a diary or journal of feelings
will help the client recognize and express them more clearly. However, this is not the priority nursing action.
This may be a true statement; clients with anorexia nervosa are usually discharged to out-patient follow-up and
treatment or to a residential treatment facility once an acceptable weight gain has been achieved and maintained.
However, this is not the priority nursing action.
INVOLUNTARY ADMISSION

Clients have the right to refuse hospital admission and treatment. However, all states and provinces have laws and
procedures for involuntary admission that require clients to receive inpatient treatment for a psychiatric disorder
against their will. The legal criteria for involuntary admission include:

o The individual appears to be an imminent danger to self or others

o The individual has a grave disability (ie, is unable to adequately care for basic needs [food, clothing, shelter, medical care,
personal safety]) as a result of a mental illness
 Clients also have the right to the least restrictive environment in which treatment can be provided in a safe manner.
Involuntary commitment is generally used as a last resort in dealing with a client whose illness is so severe that
judgment and insight in deciding to refuse treatment are markedly impaired.
TERMINAL ILLNESS

ANTI-SOCIAL PERSONALITY DISORDER

Clients with antisocial personality disorder often disregard the rules, have a history of irresponsible behavior,
and blame others for their behavior.
They avoid responsibility for their own behavior and the consequences of their actions using numerous excuses and
justifications.
Nursing interventions include setting firm limits and making clients with antisocial personality disorder aware of the
rules and acceptable behaviors. The nurse should require the client to take responsibility for his/her own behavior and
the consequences of not following the rules and regulations of the unit.
PSYCHOMOTOR RETARDATION
 Psychomotor retardation is a clinical symptom of major depressive disorder. Manifestations of psychomotor
retardation include slowed speech, decreased movement, and impaired cognitive function. The individual may not
have the energy or ability to perform activities of daily living or to interact with others. Psychomotor retardation may
range from severe (total immobility and speechlessness -catatonia) or mild (slowing of speech and behavior).
Specific clinical findings of psychomotor retardation include the following:

o Movement impairment - body immobility, slumping posture, slowed movement, delay in motor activity, slow gait
o Lack of facial expression
o Downcast gaze
o Speech impairment reduced voice volume, slurring of speech, delayed verbal responses, short responses
o Social interaction reduced or non-interaction

DOMESTIC ABUSE

The priority for possible domestic abuse victims is to remove them from any sources of immediate danger, including
suspected abusers.
Such clients should be questioned and assessed alone so that the suspected abusers do not guide their answers or
intimidate them from providing truthful responses.
In this case, the spouse appears angry and should, as a priority, be removed from the room to prevent further potential
harm to the client or staff

HALLUCINATIONS

An important step toward self-management of hallucinations is for the client to recognize that the hallucinations are
not real.
When a client is experiencing hallucinations, the nurse needs to reinforce reality and acknowledge how the client
may be feeling.
The nurse can point out his/her own perceptions without denying the client's experience.
It is nontherapeutic to argue with or challenge the client about the hallucination, saying, for example, "How could a
man get into your room? This is a locked hospital unit."
Examples of additional therapeutic responses to a client who is experiencing hallucinations include the following:

o "I don't see anything, but I understand that what you are seeing may be very upsetting to you."
o "I understand that you are worried about the voices you are hearing. They are a part of your disease and not real."
 o "I know the voices seem real to you and may be scary. I do not hear the voices."

The priority nursing action is to explore the content of the hallucinations. This client may be experiencing command
auditory hallucinations that could lead to self-directed or other-directed injury and harm. After the content of the
hallucinations has been explored, implementing an intervention may be necessary to reduce the potential for violence.
Hallucinations are false sensory perceptions that have no external stimuli. They can occur in any of the 5 senses.
Auditory hallucinations are the most common, followed by visual, tactile (touch), olfactory (smell), and gustatory
(taste).
Additional ways to deal with hallucinations include the following:

o Telling the client that you know they are real to the client but that you do not hear the voices (or see the vision, feel the
sensation)
o Not arguing with or challenging the client about the hallucinations
o Directing the client to a reality-oriented topic of conversation or activity

PARANOID PERSONALITY

Individuals with paranoid personality disorder have a pervasive distrust and suspicion of others; they believe that
people's motives are malicious and assume that others are out to exploit, harm, or deceive them.
These thoughts permeate every aspect of their lives and interfere with their relationships.
Individuals with paranoid personality disorder are usually difficult to get along with as they may express their suspicion
and hostility by arguing, complaining, making sarcastic comments, or being stubborn.
Because these clients do not trust others, they have a strong need to be self-sufficient and maintain a high degree of
control over their environment.
CAREGIVER ROLE STRAIN
Caregiver role strain (CRS) is a caregiver's perception of the multifactorial difficulties associated with providing care
to another person (usually a family member). The nurse should assess caregivers for signs of physical (eg, fatigue,
insomnia, weight loss/gain), emotional (eg, depression, anxiety, anger), and social (eg, isolation, loss of support
systems) problems.
Monitoring caregivers for CRS is important, as it can have a significant negative impact on their health and well-being.
 Asking about the nature and requirements of providing daily care allows the caregiver to discuss the demands of
providing care and helps the nurse understand stressors and unmet needs
This type of inquiry is a therapeutic response that encourages verbalization of thoughts, feelings, and concerns.
Assessment of caregiving challenges also helps to identify opportunities for assistance (eg, skills training, support
groups) and community resources (eg, home health care, food/nutrition services).

CRITICAL INCIDENT
This client's spouse has experienced a traumatic or crisis event (also referred to as "a critical incident").
When faced with a traumatic situation, clients are often overwhelmed and respond with a wide range of emotions and
thoughts, including shock, denial, anger, helplessness, numbness, disbelief, and confusion.
Clients may also experience physical symptoms, such as hyperventilation, abdominal pain, and dizziness.
Priority nursing actions need to be directed at the here and now, providing therapeutic interventions aimed at
alleviating the immediate emotional impact of this disruptive crisis event.
Acknowledging the severity of the event validates and normalizes the spouse's reaction. Assisting the spouse in
identifying feelings and giving the spouse opportunity to ventilate will help reduce immediate emotional stress.
ADHD
The core symptoms of ADHD include hyperactivity, impulsiveness, and inattention.
Hyperactive children are restless; have difficulty remaining seated when required; and exhibit excessive talking,
blurting out answers prematurely, and interrupting others.
Inattention is characterized by reduced ability to focus and attention to detail, easy distractibility, and failure to follow
through (eg, homework, chores).
The primary symptoms of ADHD have a negative impact and can make life difficult for children in school, at work, and
in social situations.
Symptoms interfere with opportunities to acquire social skills and may also result in rejection and critical judgment
by peers.
The negative consequences of ADHD include:
 o Poor self-esteem
o Increased risk for depression and anxiety
o Increased risk for substance abuse
o Academic or work failure
o Trouble interacting with peers and adults

A key feature of attention-deficit hyperactivity disorder (ADHD) is hyperactivity; however, some children with ADHD
behave aggressively and have difficulty controlling anger, especially when frustrated or if unable to meet demands
and challenges.
An immediate intervention to help settle an out-of-control child is deep breathing. Taking slow, deep breaths relaxes
the body, slows the heart rate, and distracts the child from inappropriate behaviors. Asking the child to blow up a
balloon provides an easy mode of distraction and engages the child in a deep breathing exercise. After the child is
calm, the nurse and the child can further discuss the disruptive behavior.
Nursing interventions include the following:

o Stay calm and remove the child from the source of frustration/anger
o Assist the child in calming down with deep breathing exercises
o Discuss what precipitated the behavior and why the behavior is wrong
o Discuss acceptable ways of expressing anger and frustration
o Acknowledge that controlling anger is difficult
o Provide rewards for appropriate behavior
o Discuss the consequences of inappropriate behavior

PERSECUTORY DELUSIONS

Clients with persecutory delusions (paranoid delusions) believe that they are being persecuted or harmed (eg, spied
on, cheated, followed, poisoned).
Focusing on the client's feelings secondary to the delusion is an example of empathy, one of the most important parts
of the therapeutic nurse-client relationship.
When nurses attempt to understand clients' feelings and their meaning, clients realize that someone is trying to
understand them and the nurse-client relationship grows
 Focusing on reality and verbally reinforcing it will decrease the time that the client spends thinking about the
delusions
For example, the nurse may focus on the client's feelings by stating, "I understand that it is frightening to know that
someone is trying to poison you." Reality orientation may also be helpful by telling the client, "What you are thinking is
part of your disease and not real."
Attempting to explore the meaning behind a delusion will encourage the client to focus/think more on this delusion.
Confronting the client about the delusion is not therapeutic because arguing will not eradicate the delusion. It also
hinders the development of a trusting nurse-client relationship.
Clients believe that their delusions are real despite proof otherwise. Presenting logical explanations to discredit the
delusions will not help.

POSTTRAUMATIC STRESS DISORDER

Posttraumatic stress disorder (PTSD) is a reaction to a traumatic or catastrophic event that is typically life-
threatening to oneself or others.
There are 3 categories of PTSD symptoms:
4. Reexperiencing the traumatic event
Examples include intrusive memories, flashbacks, recurring nightmares, and feelings of intense distress/loss of control or
strong physical reactions to event reminders (rapid, pounding heart; gastrointestinal distress; diaphoresis)
5. Avoiding reminders of the trauma
Examples include avoidance of activities, places, thoughts, or other triggers that could be trauma reminders, feeling detached
and emotionally numb, loss of interest in life, lack of future goals, and amnesia related to important details of the event
6. Increased anxiety and emotional arousal
Examples include insomnia, irritability, outbursts of anger and/or rage, difficulty concentrating, hypervigilance, and feeling
jumpy
The first step toward resolution of posttraumatic stress disorder (PTSD) is the client's readiness (ability and
willingness) to discuss the details of the traumatic event without experiencing high levels of anxiety.
 The nurse must assess clients with PTSD for their readiness to talk about the experience and encourage them to
discuss the trauma at their own pace. The nurse should also use active listening as a therapeutic approach to build
trust and allow clients to vent. This will assist in decreasing their feelings of isolation.
The nurse can also guide the client in identifying event details that are most troubling and trigger a sense of loss of
control. The effectiveness of the client's coping mechanisms can be identified, and alternate strategies to replace
maladaptive ones can be explored.

OCD

Clients with OCD engage in rituals and behaviors that help reduce the anxiety or stress rooted in their obsessions
(recurrent thoughts, impulses, or images that cause notable distress). If the ritual is interrupted, the client will
experience increased anxiety.
A client with compulsive behavior often does not realize the amount of time or how many times the same activity has
been performed. By providing reflective feedback about the client's behavior, the nurse is acknowledging the behavior
in a nonjudgmental manner. The nurse should also help the client become involved in other activities and problem-
solving skills.
Individuals with obsessive-compulsive personality disorder are typically self-willed and obstinate, punctual, pay
attention to rules and regulations, and need to control both internal and external experiences. These traits are very
extreme and result in rigidity and inflexibility. In this scenario, a change has been made in the client's schedule for
the day and is outside of the client's control. This could cause significant distress and impaired functioning so that the
client feels emotionally paralyzed.
DEFENSE MECHANISMS

BULIMIA NERVOSA
 Bulimia nervosa (BN) is an eating disorder characterized by episodes of uncontrollable binge-eating (consuming
very large amounts of food, often in secret) followed by inappropriate compensatory behaviors to prevent weight gain.
Compensatory behaviors may include laxative or diuretic use, self-induced vomiting, or excessive exercise 1-2 hours
after binging .Other signs of BN may include:

o Physical changes related to self-induced vomiting (eg, scars or calluses on the hand, enlarged parotid glands, erosion of
tooth enamel, dental caries)
o Preoccupation with body image, weight, food, and dieting

TRANSGENDER

Transgender clients may fear judgment or embarrassment and withhold information, avoid seeking treatment, or
refuse care as a result. This is often related to past experiences of discrimination or stigma when receiving health
care. Therefore, it is important to use therapeutic communication and avoid stereotypes to establish trust.
Transgender clients may identify as male or female or as neither or both genders. It is important for the nurse to
determine clients' gender identity by asking open-ended questions that allow clients to explain their identities in their
own words
DELIRIUM
Major predisposing factors for the development of delirium in hospitalized clients include:

10. Advanced age

11. Underlying neurodegenerative disease (stroke, dementia)
12. Polypharmacy
13. Coexisting medical conditions (eg, infection)
14. Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia)
15. Metabolic and electrolyte disturbances
16. Impaired mobility - early ambulation prevents delirium
17. Surgery (postoperative setting)
18. Untreated pain and inadequate analgesia

The Confusion Assessment Method (CAM) is used to determine delirium. The signs are acute mental status
changes that fluctuate and inattention with disorganized thinking and/or altered level of consciousness. The
 disorganized thinking includes hallucinations. Risk factors for delirium include older age, prior cognitive impairment,
presence of infection, severe illness or multiple comorbidities, dehydration, psychotropic medication use, alcoholism,
vision impairment, and pain.
Delirium has an abrupt onset and is a symptom of other problems. Up to 60% of hospitalized elderly clients have
delirium prior to or during hospitalization, but it is often missed by nursing.

DELUSIONS

Delusions are one of the positive symptoms of schizophrenia. Delusions are false beliefs that have no basis in
reality and are unrelated to a client's culture or intelligence. When presented with proof that the delusion is irrational
or untrue, the client continues to believe it is real. Clients experiencing delusions of reference will believe that songs,
newspaper articles, and other events are personal and significant to them.
Other examples of delusions are below:

o Grandeur "I need to get to Washington for my meeting with the president."
o Control "Don't drink the tap water. That's how the government controls us."
o Nihilistic "It doesn't matter if I take my medicine. I'm already dead."
o Somatic "The doctor said I'm fine, but I really have lung cancer."

Delusions are fixed, false beliefs that are accepted by the client as real and cannot be changed by logic, reason, or
persuasion. Categories of delusions include the following:
 o Persecutory client thinks others are "out to get me"
o Ideas of reference common events refer specifically to the client
o Grandiose client has the perception of special importance or powers that are not realistic
o Somatic false ideas about bodily functioning

Nursing interventions include the following:

o Not arguing or challenging the belief

o Reinforcing reality by talking about and encouraging the client to participate in real events. The nurse should not delve into or
have long conversations about the delusional belief system.

CHILD ABUSE

Typical characteristics of child abuse perpetrators include:

o Unrealistic expectations of the child's performance, behavior, and/or accomplishments; overly critical of the child
o Confusion between punishment and discipline; having a stern, authoritative approach to discipline
o Having to cope with ongoing stress and crises such as poverty, violence, illness, lack of social support, and isolation
o Low self-esteem a sense of incompetence or unworthiness as a parent
o A history of substance abuse; use of alcohol or drugs at the time the abuse occurs
o Punitive treatment and/or abuse as a child
o Lack of parenting skills, inexperience, minimal knowledge about child care and child development, and young parental age
o Resentment or rejection of the child
o Low tolerance for frustration and poor impulse control
o Attempts to conceal the child's injury or being evasive about an injury; shows little concern about the child's injury

Child abusers are not easily identified by appearance; they often appear calm and well in control but may have violent
outbursts, typically in private.
When speaking with a child about abuse, the nurse should be direct and honest. The nurse should allow the child to
disclose the abuse at a comfortable pace, rather than probe for additional information. The nurse should use open-
ended questions and avoid leading questions and statements.
Guidelines for the interview:

o Speak with the child in private

o Be honest about reporting requirements
 o Use language appropriate to the child's age
o Avoid making assumptions or communicating anger, shock, or disapproval
o Reassure the child about not being at fault or in trouble

When the nurse suspects that a child may be the victim of child abuse, the parent or caregiver should be questioned,
and all possibilities (eg, alternate caregivers) should be explored to find the source of the abuse.
If possible, the interview should be done without the child present. The nurse should remain supportive and
empathetic and convey a nonjudgmental, nonthreatening attitude, avoiding words such as "abuse" and "violence."
Open-ended questions are less threatening and provide more detailed responses. Information to gather includes:

o Caregiver's perspective on the child's behavior

o Methods of discipline used with the child
o Routine caregivers for the child
o Caregiver stress, coping, and support systems
o Person or persons who care for the child when regular caregivers are away

BORDERLINE PERSONALITY DISORDER

Individuals with borderline personality disorder (BPD) live in fear of rejection and abandonment. To avoid
abandonment, they use manipulation and control, often unconsciously, to prevent a person from leaving.
The manipulative behavior may be of a positive nature, such as the use of flattery, or a negative nature, such as
distancing from the other person.
An individual with BPD may also engage in self harm or suicidal behaviors in an attempt to gain attention from the
other person and keep that person from leaving.
For this client, the nursing care plan must include the assignment of different staff members. This will help diminish
the client's dependence on a particular individual and help the client learn to relate to more than one person.
AUTISM SPECTRUM DISORDER
A structured routine and consistency during hospitalization are critical in the care of clients with autism spectrum
disorder (ASD).
 The nurse should talk with the parent and/or caregiver to determine the client's usual patterns and habits for a typical
day at home, including meal times, bath time, and play time.
In the unfamiliar and often unpredictable environment of the acute care setting, a schedule of activities can decrease
anxiety and help the client with ASD anticipate what will happen next.

ELECTROCONVULSIVE THERAPY
Electroconvulsive therapy (ECT) induces a generalized seizure by passing an electrical current through electrodes
applied to the scalp.
Although the exact mechanism is unknown, 15-20 second seizures are proven effective in treating mood disorders
(eg, major depression, bipolar disorder) and schizophrenia. Client teaching includes:

o NPO status is required for 6-8 hours prior to treatment except for sips of water with medications
o Anesthesia (eg, methohexital, propofol) and a muscle relaxant (eg, succinylcholine) will be administered; clients
are unconscious and feel no pain during the procedure.
o Driving is not permitted during the course of ECT treatment
o Temporary memory loss and confusion in the immediate recovery period are common side effects of ECT

Post-treatment nursing care includes monitoring vital signs, ensuring a patent airway, assessing mental status, and providing
frequent reorientation during periods of postictal confusion.
Due to the severity of this client's clinical presentation, ECT would be the appropriate initial treatment.
The client's depression has psychotic features and the suicide attempt used a highly lethal method. The client
continues to be highly suicidal as evidenced by behavior and thought content.
ECT can be highly effective in helping severe depression, when clients pose a severe threat to themselves and it is not
safe to wait until medications take effect.
ECT is also used in clients who have not responded to medication or cannot tolerate side effects.
During ECT, the client is treated with pulses of electrical energy through electrodes applied to the scalp; the electrical
stimulus is sufficient to cause a brief convulsion.
General anesthesia and a skeletal muscle relaxant are administered to minimize the motor seizure and prevent
musculoskeletal injury. The client feels nothing from the procedure, but confusion and memory loss are common
side effects.
 The usual course of acute therapy is 6-12 ECT treatments performed 2-3 times a week. Response to ECT can be
dramatic and life-saving. Maintenance therapy (treatment at 1- to 8-week intervals) can continue on a long-term basis
to help prevent relapses. Medication therapy is often given in combination with ECT and is associated with improved
outcomes.
The best response to a client or family member who expresses doubts about ECT is to ask about their concerns.
Responses such as, "Tell me about your concerns," or "What do you understand about ECT?" allow the nurse to
assess their knowledge and implement educational interventions to address any misinformation or knowledge gaps.

CODEPENDENT BEHAVIOR

Codependent behaviors are those that allow the codependent person to maintain control by fulfilling the needs of the
addict first.
Behaviors such as keeping the addiction secret, suffering physical or psychological abuse from the addict, not allowing
the addict to suffer the consequences of actions, and making excuses for the addict's habit are hallmarks of
codependency.
If the addict isn't happy, the codependent person will try to make the addict happy.
Codependent persons will focus all their attention on others at the expense of their own sense of self.
Codependent spouses, friends, and family members keep the client from focusing on treatment; this behavior
is counterproductive to both themselves and the client.
ALZHEI

Memantine is used to ease the symptoms of moderate to severe Alzheimer disease (AD), thereby improving the
quality of life for clients and caregivers. Memantine is an N-methyl-D-aspartate (NMDA) antagonist that works by
binding to NMDA receptors, blocking the brain's NMDA glutamate pathways, and protecting brain cells from
overexposure to glutamate (excess levels of glutamate contribute to brain cell death).
Clients with moderate to severe AD may experience improvement in:

o Cognition memory, thinking, language

o Daily functioning dressing, bathing, grooming, eating
o Behavioral problems agitation, depression, hallucinations
 Clients with Alzheimer disease (AD) often exhibit behavioral problems (eg, agitation, resisting care) due to cognitive
decline. Behavioral management techniques include:

o Acknowledgement of the client's emotions, which reduces feelings of being isolated and misunderstood
o Reassurance that the client will be kept safe from harm
o Distraction (eg, photographs, music, television) to divert the client's attention
o Redirection to simple tasks (eg, folding towels/napkins, stacking plates)

INTIMATE PARTNER VIOLENCE

Intimate partner violence (IPV) is physically, emotionally, verbally, sexually, or economically abusive behavior
inflicted by one partner against another in an intimate relationship, to maintain power and control. Nurses must be
aware of the risk factors and signs of IPV to recognize victims of abuse and to intervene (eg, separating the victim
from the abuser during the health history interview, providing information about community resources). Features of
IPV include:
o The abusive partner exhibits intense jealousy and possessiveness
o The victim of IPV chooses to stay in the relationship for a variety of reasons (eg, fear for life, financial or child custody
concerns, religious beliefs)
o The abuse begins or intensifies during pregnancy
SCHIZOPHRENIA
Clients with schizophrenia have difficulty initiating and maintaining social interactions with other people.
The nurse can facilitate interpersonal functioning by providing one-on-one interaction in which the client can practice
basic social skills in a non-threatening way. Once the client feels more comfortable, the nurse can encourage
participation in activities that require some interaction with others.
Impaired social interaction is one of the negative symptoms of schizophrenia; others include the following:

o Inappropriate, flat, or bland affect, and apathy

o Emotional ambivalence, disheveled appearance
o Inability to establish and move toward goal accomplishment
o Lack of energy, pacing and rocking, odd posturing
o Regressive behavior, inability to experience pleasure
o Seeming lack of interest in the world and people

Clients with schizophrenia often become anxious when around other individuals and will seek to be alone to relieve
anxiety. Impaired social and interpersonal functioning (eg, social withdrawal, poor social interaction skills) are
common negative symptoms of schizophrenia. These are more difficult to treat than the positive symptoms (eg,
hallucinations, delusions) and contribute to a poor quality of life.
Nursing interventions directed at improving the social interaction skills of a client with schizophrenia include the
following:

o Making brief, frequent contacts

o Accepting the client unconditionally by minimizing expectations and demands
o Assessing the client's readiness for longer contacts with the nurse and/or other staff and clients
o Being with or close by the client during group activities
o Offering positive reinforcement when the client interacts with others

It is the negative symptoms of schizophrenia that affect a client's ability to establish personal relationships and manage
day-to-day social interactions.
The positive symptoms of schizophrenia (hallucinations, delusions, thought impairment) often improve with
psychotropic medications; negative symptoms tend to persist even with medication.
Psychosocial and supportive treatment, including psychotherapy, education, behavioral training, cognitive therapy, and
social skills therapy, may be beneficial in improving the quality of life for clients with schizophrenia.
A diagnosis of schizophrenia with catatonia can be made if the clinical features meet the criteria for a diagnosis of
schizophrenia and include at least 2 of the following additional features:
o Immobility the client remains in a fixed stupor or position for long periods

Refuses to move about or engage in activities of daily living

May have brief spurts of excitement or hyperactivity

o Remaining mute
o Bizarre postures the client holds the body rigidly in one position
o Extreme negativism the client resists instructions or attempts to be moved
o Waxy flexibility the client's limbs stay in the same position in which they are placed by another person
o Staring
o Stereotyped movements, prominent mannerisms, or grimacing

Clients with catatonic schizophrenia are unable to meet their basic needs for adequate fluid and food intake and are at
high risk for dehydration and malnutrition. The priority nursing action is to anticipate the client's needs, and to
ensure that the client is well hydrated and has adequate nourishment. Some clients will need total care.
SUICIDE
DEPENDENT PERSONALITY DISORDER

Individuals with dependent personality disorder have a persistent and extreme need to be taken care of that
manifests as submissive and clinging behaviors and fear of separation.
Additional characteristics of dependent personality disorder may include:

o Difficulty in making day-to-day decisions

o An excessive need for advice, reassurance, and nurturance from others
o Lack of self-confidence - afraid to do things on one's own
o Afraid of confrontation or expressing disagreement with others
o Feelings of helplessness and anxiety when alone; fear of being unable to take care of oneself

A client making a decision about and carrying out a daily activity on his/her own would be indicative of progress toward
a therapeutic outcome.
DEMENTIA

Individuals with dementia may wander and become lost during any stage of the disease. The most effective strategy
to prevent wandering is to make modifications to secure the environment. These include:

o Placing locks above or below eye level on doors that lead to the outside. Clients with Alzheimer disease (AD) lose their
peripheral vision; they cannot see objects unless they are directly in front of them or they purposely move their heads
o Adding a motion sensor or alarm that goes off when someone tries to exit
o Placing a large stop sign on door exits
o Disguising a door with a curtain or wall hanging
o Using childproof doorknob covers
o Placing a black mat or black strip by an exit. The client may perceive this as an impassable black hole due to changes in
depth perception.

DISULFIRAM

Disulfiram (Antabuse) is a form of aversion therapy that promotes abstinence from alcohol. If the client consumes
alcohol while taking disulfiram, unpleasant side effects (eg, headache, intense nausea/vomiting, flushed skin,
sweating, dyspnea, confusion, tachycardia, hypotension) can occur. If large amounts are consumed, the reaction can
be fatal.
Disulfiram therapy does not cure alcoholism; the client should continue seeing a therapist
Due to the hazards of treatment, clients are carefully selected for disulfiram therapy, and informed consent is often
required. It is a priority for the nurse to educate the client about the hazards of drinking alcohol and about sources of
hidden alcohol. Teaching includes:

o Avoid hidden alcohol in:

liquid cold and cough medications

aftershave lotions, colognes, and mouthwashes
foods such as sauces, vinegars, and flavor extracts

o Abstain from alcohol for 2 weeks after the last dose as the disulfiram reaction could still occur
o Wear a bracelet alerting others of being on disulfiram therapy
BEHAVIOR MODIFICATION

Successful behavior modification (eg, diet and exercise for effective weight loss) requires client readiness and
motivation to change, which can be assessed using the Stages of Change Model.
With the appropriate support (eg, listening, not pressuring the client), clients can move from one stage to the next:
o Precontemplation: The client does not believe a problem exists, although others may point it out (eg, encouraging healthy
eating)
o Contemplation: The client recognizes a change is needed but is undecided whether it would be possible or worthwhile
o Preparation: The client has decided to change, explores emotions related to the decision, and begins establishing goals (eg,
fitting into a dress)
o Action: The client has firmly committed to changing, has developed a plan (eg, dietary modifications, exercise plans),
and actively takes steps toward new behavior (eg, choosing activity over television)
o Maintenance: The client continues to uphold the new behavior and focuses on preventing relapse.
o Termination: The client has achieved the desired change. This stage may be theoretical, as relapse to former behaviors is
always possible.
DISSOCIATIVE IDENTITY DISORDER

Dissociative identity disorder is a condition in which 2 or more identities alternately control the client's behavior.
The alternate identities likely develop as a response to abuse or traumatic events and serve to protect the client
from stressful memories.
The client may not be aware of the alternate identities and may be confused by "lost time" and gaps in memory.
Switching between identities occurs as a reaction to stress and individual triggers. The goal of treatment is
to integrate the identities into one personality while maintaining safety.
The client should journal about feelings and dissociation triggers and use a grounding technique (eg, deep breathing,
rubbing a stone, counting coins) to counter dissociative episodes
Identities may be volatile and should be monitored for indications of harm to self or others
The nurse should attempt to form trusting, therapeutic relationships with each identity to explore feelings and facilitate
identity integration
 Dissociation and memory gaps are protective mechanisms. Forcing the client to hear or attempt to recall memories
may result in distress and regression. Allow clients to recall memories at their own pace.

ELDER ABUSE

Elder abuse or neglect occurs when caregivers intentionally or unintentionally fail to meet the older adult
client's physical, emotional, or social needs. Approximately 1 in 10 older adult clients are victims of physical,
psychological, or sexual abuse by a caregiver.
Commonly neglected necessities include water, food, medication, hygiene, and clothing. The client's living
conditions may be unsafe or have inadequate access to public utilities. Objective findings consistent with abuse or
neglect include:
o Dehydration, malnutrition, and weight loss
 o Poor hygiene, soiled bedding or clothing, and pressure ulcers
Missing/broken assistive devices (eg, eyeglasses); medications withheld or expired
Clients who have experienced abuse or neglect may find the situation difficult to discuss and display apprehension, restlessness,
withdrawal, poor eye contact, shame, and despair . The client may also deny or minimize the extent of the abuse out of fear or
embarrassment.

SCHOOL PHOBIA

School phobia (also known as school refusal or school avoidance) is a childhood anxiety disorder in which the child
experiences an irrational and persistent fear of going to school.
Having the child return to school immediately is the best approach for resolving school phobia and is associated
with a faster recovery.
If necessary, gradual exposure to the school environment can be implemented; the child can attend school for a few
hours and then gradually increase the time to a full day.
A gradual approach may decrease the child's sensitization to the classroom. If the child is allowed to remain out of
school, the problem will only worsen, with potential deterioration of academic performance and social relationships.

MANIA
In developing a care plan for a client experiencing acute mania, the nurse is aware that an acute manic episode is
characterized by the following:

o Excessive psychomotor activity

o Euphoric mood
o Poor impulse control
o Flight of ideas, non-stop talking
o Poor attention span, distractibility
o Hallucinations and delusions
o Insomnia
o Wearing bizarre or inappropriate clothing, jewelry, and makeup
 o Neglected hygiene and inadequate nutritional intake

The care plan for a client experiencing an acute manic episode includes the following:
o Reduction of environmental stimuli

Providing a quiet, calm environment

Limiting the number of people who come in contact with the client
One-on-one interactions rather than group activities
Low lighting

o A structured schedule of activities to help the client stay focused

o Physical activities to help relieve excess energy
o Providing high-protein, high-calorie meals and snacks that are easy to eat
o Setting limits on behavior

ACUTE STRESS DISORDER

Acute stress disorder (ASD) occurs following a traumatic or extremely stressful event. ASD is characterized
by intrusive memories of the event, negative mood, dissociative symptoms (eg, altered sense of reality), and
arousal and reactivity symptoms (eg, hyperactive sensory state, sleep disturbances, difficulty concentrating, easily
startled). If these symptoms continue beyond a month after the event, the diagnosis becomes post-traumatic stress
disorder. Nursing interventions for a client with ASD include:
o Assessing for ideas and plans to commit self-harm
o Assessing for ineffective coping (eg, use of drugs and alcohol)
o Assessing impact of ASD on the client's job performance, relationships, sleep pattern, and ability to perform activities of daily
living
o Explaining that feelings and/or symptoms occurring after traumatic events are normal, as this can help alleviate the client's
anxiety
o Exploring coping strategies used in previous stressful situations
 The client should be encouraged to discuss the traumatic event. As part of the debriefing process, the nurse should
acknowledge and validate the associated feelings and behaviors.

OPIOID WITHDRAWAL

Clients with opioid dependence (eg, oxycodone, hydrocodone, heroin) may develop acute withdrawal if opioids
are abruptly stopped, dosage is reduced, or a reversal agent (ie, naloxone [Narcan]) is administered.
Withdrawal symptoms (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to
increased sympathetic nervous system activity as the depressant effect of the opioid wanes
Although opioid withdrawal is seldom life-threatening, clients who demonstrate signs of acute withdrawal may be given
medications, such as methadone, to alleviate discomfort.
The nurse should alert the health care provider of suspected withdrawal to facilitate appropriate opioid weaning or
maintenance interventions.

BORDERLINE PERSONALITY DISORDER

Clients diagnosed with borderline personality disorder (BPD) often make suicidal threats, gestures, and attempts.
They may use these behaviors to bring about a response when there is a real or perceived risk of abandonment from a
significant other.
 All suicidal behavior should be taken seriously; the client's current self-injurious action needs to be evaluated to
assess whether it involved suicidal intent.
Clients with BPD have been known to demonstrate years of benign suicide threats and gestures before completing a
suicide.
Predicting a client's risk for completing a suicide is difficult due to the impulsive nature of the behavior.

SOCIAL ANXIETY DISORDER

Social anxiety disorder (SAD) is characterized by an excessive and persistent fear of social or performance
situations in which the client is exposed to strangers and the possibility of scrutiny by others.
Examples of such social interactions include meeting unfamiliar people, being observed eating or drinking in public,
and giving a speech.
The client may fear criticism, embarrassment, humiliation, and rejection from unfamiliar people in unfamiliar social
situations and will exhibit physical symptoms of anxiety such as sweating, trembling, palpitations, diarrhea, and
blushing.
Clients with SAD often have anticipatory anxiety and worry for days or weeks before a feared event. They may
recognize that their fear is exaggerated and will seek assistance and counseling.
MAJOR DEPRESSIVE DISORDER

Major depressive disorder (also known as unipolar depression) is a subtype of depressive disorder, classified by
specific symptoms that interfere with the ability to perform activities of daily living, work, sleep, and enjoy activities that
are usually pleasurable to the client.
For the diagnosis to be made, 5 or more of the following symptoms must be present almost every day for at least 2
weeks, and 1 of the symptoms must be depressed mood or loss of interest or pleasure.

NARCISSISTIC PERSONALITY DISORDER

A client with narcissistic personality disorder (NPD) exhibits a recurrent pattern of grandiosity, need for admiration,
and lack of empathy. Clients with NPD may project a picture of superiority, uniqueness, and independence that hides
their true sense of emptiness.
From a psychodynamic perspective, individuals with NPD have a fragile and damaged ego resulting from a childhood
environment that fostered a sense of inferiority, poor self-esteem, and severe self-criticism. Narcissistic characteristics
develop as a way to regulate self-esteem and protect the ego from further psychic injury.
HISTRIONIC PERSONALITY DISORDER
The nurse should recognize the following characteristics associated with histrionic personality disorder:

o Self-dramatizing, exaggerated or shallow emotional expression

o Attention-seeking, needs to be the center of attention
o Overly friendly and seductive, attempts to keep others engaged
o Demands immediate gratification and has little tolerance for frustration

An individual with histrionic personality disorder displays these behaviors and characteristics persistently. The signs
and symptoms are maladaptive and have a negative impact on the client's social, interpersonal, and occupational life.

THOUGHT PROCESSES

Disturbance in logical form of thought is characteristic and one of the positive symptoms of schizophrenia. The client
will often have trouble concentrating and maintaining a train of thought. Thought disturbances are often accompanied
by a high level of functional impairment, and the client may also be agitated and behave aggressively.
Types of impaired thought processes seen in individuals with schizophrenia include the following:

o Neologisms made-up words or phrases usually of a bizarre nature; the words have meaning to the client only. Example: "I
would like to have a phjinox."
o Concrete thinking literal interpretation of an idea; the client has difficulty with abstract thinking. Example: The phrase,
"The grass is always greener on the other side," would be interpreted to mean that the grass somewhere else is literally
greener
o Loose associations rapid shifting from one idea to another, with little or no connection to logic or rationality
o Echolalia repetition of words, usually uttered by someone else
o Tangentiality going from one topic to the next without getting to the point of the original idea or topic
o Word salad a mix of words and/or phrases having no meaning except to the client. Example: "Here what comes table,
sky, apple."
o Clang associations rhyming words in a meaningless, illogical manner. Example: "The pike likes to hike and Mike fed the
bike near the tyke."
o Perseveration repeating the same words or phrases in response to different questions
BIPOLAR DISORDER

Bipolar disorder is a psychiatric condition characterized by cycling periods of depression and mania.
Clients with acute mania often display elevated mood, increased and excessive activity levels, and altered decision-
making that can result in high-risk behavior (eg, hypersexuality, excessive spending).
Clients with mania are also easily distractible, leading to neglect of personal needs (eg, hydration, nutrition, sleep,
hygiene) and the need for medical intervention.
When managing the nutritional needs of clients with mania, the nurse should frequently offer energy- and protein-
dense foods that are easily carried and consumed (eg, sandwiches, shakes, hamburgers, pizza slices, burritos, fruit
juices, granola bars).
These "on-the-go" foods promote nutritional intake in clients who are unable to sit down and complete a traditional
meal
ELDERLY
ALCOHOL WITHDRAWAL SYNDROME

VIOLENCE
Violence in the health care setting poses a safety risk to clients, staff, and visitors. It also decreases the quality of
care that a violent client receives due to avoidant and fearful behaviors by staff.
Risk factors for violence include altered level of consciousness, substance abuse, emotional stress, and
behavioral/psychiatric disorders.
Nursing interventions that help prevent violence include using clear, thorough communication; encouraging
active participation in care; promoting a low-stimulation environment; and providing comfort through
pharmacological and nonpharmacological methods.
The nurse should demonstrate undivided attention to the client (eg, facing the client, unhurried body language, calm
tone).

PANIC ATTACK
This client is experiencing the symptoms of a panic attack and should not be left alone. The priority nursing action is
to stay with the client to ensure the client's safety and offer support.
Additional nursing actions while the client is experiencing panic symptoms include:
o Maintaining a calm, matter-of-fact approach
o Speaking calmly and using simple, clear words and phrases when providing information on emergency department
procedures
o Placing the client in a room with as few stimuli as possible
o Administering an anti-anxiety medication such as a benzodiazepine (per health care provider prescription)
o Having the client take slow, deep breaths if hyperventilation is a problem.
 LEADERSHIP AND MANAGEMENT IN NURSING

CHILD NEGLECT

Child neglect occurs when a caregiver purposely withholds or does not adequately provide necessary resources to
fulfill the basic needs of a child (eg, adequate nutrition, security, hygiene). Supervisory neglect, leaving
children without adequate guardianship to ensure safety, is one form of child
Children age <12 lack formal operational reasoning and cannot anticipate safety risks or respond appropriately to
emergencies, and should therefore not be left to supervise other children.
It is a priority for the nurse to intervene, as this is an unsafe situation for the young children. The nurse, or social
services, should report the situation to an appropriate government child protective service and/or law enforcement.
Potential job loss indicates that the parent may be overwhelmed. The nurse should alert a social worker about the
situation at a later time to discuss potential assistance.
Transitioning to the role of a single parent can present mental and financial stressors, possibly requiring assistance
from a social worker. However, this does not require immediate intervention.
A parent stealing food may warrant calling the police or security, but the children's safety is a priority requiring
immediate action.
REPOSITIONING AND TRANSFERRING

Repositioning and transferring clients can be delegated to unlicensed assistive personnel (UAP) when it is
deemed safe and appropriate.
The nurse must provide UAPs with detailed instructions, including when to move the client, which techniques to
use, and when to use assistive persons or devices.
The nurse must also notify UAPs of any client mobility restrictions. Unstable clients and spinal cord
stabilization require the presence of a nurse for repositioning or moving
The client who is 8 hours postoperative total hip replacement requires assessment prior to repositioning as the client is
at risk for hip dislocation. A wedge may be needed to maintain abduction; nursing judgment is required
To reduce the risk of client and staff injury, safe transfers and repositioning are achieved using the following
guidelines:

o Use a gait/transfer belt to transfer a partially weight-bearing client to a chair

 o Use 2 or more caregivers to reposition clients who are uncooperative or unable to assist (eg, comatose, medicated)
o Use a full-body sling lift to move/transfer nonparticipating clients.
o Use 2-3 caregivers to move cooperative clients weighing less than 200 lb (91 kg).
o Use 3 or more caregivers to move cooperative clients weighing more than 200 lb (91 kg)

INTERDISCIPLINARY TEAM

Several adjunctive professional services assist clients in the post-acute phase of their illness as part of an
overall interdisciplinary team.
Speech therapy focuses on speech and communication but also on swallowing/eating issues
A client with a stroke will need to be evaluated for any aspiration risks and taught how to minimize those risks (eg,
chin-down positioning, chewing on the non-affected side of the mouth).
Social workers assist with developing coping skills, securing adequate financial resources or housing, and making
referrals to volunteer organizations
Wound care is a resource for assessing and planning the optimal care of any wound
Occupational therapy emphasizes the skills necessary for activities of daily living (eg, dressing, bathing, cognitive or
perception issues); however, walker training is performed by a physical therapist. An overly broad generalization is
that occupational therapy is for "above the waist."
Physical therapy focuses on mobility, ambulation, ability to transfer, and use of related equipment. An overly broad
generalization is that physical therapy is for "below the waist." Dressing skills would be taught via occupational
therapy.
The case manager and social worker on the interdisciplinary team have expertise in discharge planning and health
care finance. They can assess the adequacy of the discharge setting and support systems, arrange for resources at
home, or discharge to an alternate setting, such as a rehabilitation facility. They can also help advocate for safe,
effective discharge planning.
The clinical psychologist's role is to assess the client's psychological issues and assist with counseling and coping
strategies.

CASE MANAGER

Case management involves assessing, planning, facilitating, and advocating for client health services to accomplish
cost-effective quality client outcomes. This is done through communication and use of available resources.
 A professional nurse often serves in the case manager role. The case manager in the hospital setting assesses client
needs, decreases fragmentation of care, helps to coordinate care and communication between HCPs, makes referrals,
ensures quality standards are being met, and arranges for home health or placement after discharge
Case managers typically do not provide direct client care. Medication reconciliation should be done between the
primary nurse directly caring for the client and the HCP.
Case managers often make daily rounds to the nursing department to review documentation in the client's chart but do
not necessarily visit the client personally.

LATERAL VIOLENCE (HORIZONTAL VIOLENCE)

Lateral violence (also known as horizontal violence) can be defined as acts of aggression carried out by a co-worker
against another co-worker and designed to control, diminish, or devalue a colleague.
These behaviors usually take the form of verbal abuse such as name-calling, unwarranted criticism, intimidation, and
blaming. However, other acts, such as refusing to help someone, sabotage, exclusion, and unfair assignments, also
fall under the category of lateral violence.
Violence in the workplace should not be tolerated or ignored by either staff or management. Actions that staff
members can take if they become victims of lateral violence include:

o Documenting and keeping a file of all incidents

o Reporting the incidents to the immediate supervisor
o Letting the bully know that the behavior will not be tolerated
o Observing interactions between the bully and other colleagues (may validate the victim's experiences and serve as a source
of support)
o Seek support from within the facility or from an external source

UNPROFESSIONAL CONDUCT

The stress of bullying and workplace violence impairs clinical judgment and creates an unsafe environment for
clients.
In response to unprofessional conduct, the nurse should shift the focus of the conversation back to the client's
needs, especially in situations that may result in client injury
 Discussing facility policies does not direct the conversation to the client's needs and fails to address the urgency of the
situation. The priority is for the nurse to advocate for the client's needs because the client is experiencing a serious,
limb-threatening, postsurgical complication.
Confrontational statements are more likely to provoke a fight than result in appropriate intervention for the client.
Incidents of bullying and workplace violence should be reported to a nursing supervisor, but the priority is to ensure
that the client's needs are addressed.
SBAR (SITUATION-BACKGROUND-ASSESSMENT-RECOMMENDATION/REQUEST)
The SBAR (Situation-Background-Assessment-Recommendation) provides a framework for communicating
information about a change in client status to the health care provider (HCP). It includes the following information:

1. S = Situation what prompted the communication

2. B = Background pertinent information, relevant history, vital signs
3. A = Assessment the nurse's assessment of the situation
4. R = Recommendation request for prescription or action from the HCP

The report given by the nurse contains the most appropriate and complete information. The nurse includes pertinent
data related to history, admission, and present treatment (background); indicates when and what changes occurred
(situation, assessment); and requests a prescription from the HCP (recommendation).
SUBDURAL HEMATOMA

A subdural hematoma is caused by bleeding into the subdural space and is the result of blunt force head trauma. It is
life-threatening, as increased pressure from the hematoma on the brain can lead to decreased cerebral perfusion
and herniation (mid-line shift).
Assessing for signs of increased intracranial pressure, including change in level of consciousness, Cushing triad
(hypertension, bradycardia, and irregular respirations), ipsilateral pupil dilation, headache, and vomiting, is critical as
surgery to evacuate the hematoma and relieve the pressure may be necessary.

MEDICAL INTERPRETER

The nursing role in advocating for the client includes ensuring the use of interpreters for clients who speak a different
language, particularly during the informed consent process. The person interpreting for the client should ideally
possess the following:

o Training in medical terminology and procedures

o Ability to protect the client's rights in a medical setting
o Fluency in the language
o Understanding of cultural beliefs and nuances

For these reasons, and to protect client confidentiality, family members should not be used as medical interpreters
unless the situation is urgent and a family member is the only one available to fill this role.
An interpreter's job is to literally translate the words/concepts spoken (as much as possible).
The role does not include personally editorializing or embellishing with advice beyond what the health care provider
(HCP) said.
It is important to find out if there was any discussion related to the procedure or if the follow-up conversation was about
other topics (eg, social).
The nurse needs to obtain feedback to be certain that the client understands about the procedure and had no
additional questions that the interpreter personally answered.
The nurse can ask the client additional questions using this interpreter or use a different interpreter/a language line.
After the nurse is satisfied that no additional information was provided and the client understands what the client is
signing, the nurse (as the hospital employee) should then witness the signature. The nurse should indicate that an
interpreter was used in the process.
 Gestures/pantomime may be adequate for basic actions, such as obtaining a blood pressure. In this case, there is
specific information that must be clear and should be communicated with interpretation.
Federal law requires accommodations for people with limited English proficiency. The Joint Commission indicates that
clients' rights include translation.
Clarifying the content of the conversation is the priority. The nurse (as an employee of the hospital) should be the
witness whenever the signature is obtained. However, the name and the contact information of the interpreter should
be documented.
The consent should not be signed until it is clearly established that no additional information/advice was given by or
asked of the interpreter after the HCP left.

TRANSFORMATIONAL NURSE MANAGER

The transformational nurse manager provides a supportive culture in which learning is valued and best practices are
implemented to ensure the appropriate skill level and experience of each staff member.
A workshop would provide the graduate nurses with an opportunity to learn and ask questions about the cultures
represented on their unit. It would also help develop cultural awareness and sensitivity, leading to respect for the
diverse cultures represented on the unit.
Cultural diversity is present in every clinical unit; therefore, it is not feasible to assign the graduate nurses to a unit
without cultural diversity.
To provide culturally competent care, the graduate nurses must know about the various cultures represented on their
unit.
Culturally competent care is first attained through education. Afterward, the graduate nurses are ready to implement
best practices in the care of clients from diverse cultures.
Although researching various cultures would assist the graduate nurses in learning, the new graduates are novices
and have not fully developed cultural competency; therefore, they are not the best individuals to provide an in-service
on this topic.
STANDARDS OF NURSING PRACTICE AND CARE

Standards of nursing practice and care are universal criteria that are used when determining if appropriate,
professional care has been delivered. The definition of this minimum acceptable level of care reflects
what reasonable, prudent, and careful nurses would do in specific circumstances. The state or province/territory
boards of nursing help to regulate these standards.
 Sources used to define standard of care include statements from professional organizations, agency policies and
procedures, textbooks, current literature, expert consensus, the Nurse Practice Act, and statutes from regulatory
organizations
The standard of care includes objective criteria and does not consider intention. Guidelines are used in determining if
duties were performed in an appropriate manner. A nurse can have good intentions but still fail to meet the standards
of professional nursing practice.
Standard of care is determined by objective, third-party authoritative/reasonably reliable sources.
Nurses who are suspected of negligence, yet cannot provide documentation of the event in question, can testify about
their interpretation of usual custom and practice as it relates to the incident. However, an individual's typical actions
are not authoritative in determining the universal standard of nursing care and cannot replace the use of objective,
authoritative, and predetermined standards of care.

UNIT QUALITY IMPROVEMENT COMMITTEE

A unit quality improvement committee assesses process standards (guidelines, systems, and operations)
and clinical issues on a specific unit that affect delivery of client care and client outcomes.
The committee implements a process to improve performance if the standards are not being met.
Examples requiring unit quality improvement include the following:

1. Medications prescribed STAT are not available in a timely manner

2. Catheter-associated bacterial infections are increasing within the unit

SEXUAL HARASSMENT

Sexual harassment, including soliciting sexual favors in exchange for favorable job benefits, is prohibited. Other
behaviors that could be defined as sexual harassment include asking someone for a date after the other person
expressed disinterest or making remarks about a person's gender or body.
The receiving nurse should first immediately and clearly indicate that the attention is unwanted and the offending HCP
should stop. The offending HCP may have erroneously perceived a mutual attraction. If that is not effective,
additional action should be taken. The American Nurses Association cites 4 tactics to fight workplace sexual
harassment: confront, report, document, and support.
 The incident should be reported, especially if the offending HCP does not stop. If the harasser is the immediate
supervisor, the receiving nurse should go up the chain of command. However, the nurse should first simply tell the
offending HCP to stop and see if that resolves the issue.
The nurse should respond with assertiveness, not avoidance. Ignoring the situation may imply that the nurse does not
mind the HCP's attention.
The receiving nurse should document what occurred and how the nurse responded. The presence of witnesses
should be documented. Documentation should be stored somewhere other than the workplace. However, the nurse
should initially communicate assertively that the actions are to stop before documenting them.
HANDOFF REPORT

Current respiratory status is essential to include in handoff report, as it is objective information related to the client's
current condition.
Information communicated during report should allow the oncoming nurse to prioritize care and obtain baseline
measurements of the client's current status and response to treatment. It is especially important to include
information that may not be documented in the medical record.
Respiratory status can change rapidly, and the most current measurements may not be documented, as vital signs are
often documented every 4, 8, or 12 hours
Handoff report typically includes:

o Client's name, location, age, gender, health care provider, and diagnoses
o Client's current baseline measurements, treatment plan, goals, and response to treatment
o Priority and outstanding tasks and changes from previous days

A handoff of care report is the critical communication that occurs when transferring client care to another nurse (eg,
shift change, department transfer). Transitions of care require thorough, precise communication to ensure client
wellness and safety. Appropriate handoff communication allows for continuity of care and provides a synopsis of
client needs and details of the client's care.
To ensure appropriate and effective handoff communication, the nurse should:

o Provide identifying information (eg, client's name and room number).

o Note care priorities and upcoming or outstanding tasks (eg, time to replace a medication infusion bag, need to perform
delayed wound care and cause of delay)
o Provide exact, pertinent information (eg, medication dose, time, measurable outcomes) (Option 3).
 o Include multidisciplinary plans (eg, radiology examinations, family meetings, physical therapy)
o Relay significant client changes in a clear manner (ie, assessment, interventions, outcomes, evaluation).

Report statements should include exact information (ie, time medication is administered, measurable outcome using a
pain scale). "Good relief" is a vague term.
Handoff should not include biased information or personal opinions (eg, "rude") and should include visitor information
only if the visitor is involved in client care and/or teaching. It is appropriate to include information about a client's
medication list.

ROOM ASSIGNMENT

When clients must be housed together in less than ideal circumstances, those infected with the same causative
pathogens can be placed together. However, a client who is infectious should not be placed with an
immunosuppressed client (eg, on steroids/chemotherapy, HIV positive, new post-operative, multiple chronic co-
morbidities, splenectomy, diabetes, very young/elderly).
 Every client in the hospital is on universal precautions; therefore, there should be no concern about placing a
vulnerable post-operative client in the same room where standard precautions are being taken for another client. In a
disaster setting, clients of different age groups can be placed in the same room together so long as both are stable
and noninfectious (even if this is not socially acceptable).
(Option 1) Though both clients are on contact isolation, they are infected with different organisms and this places
them at risk for cross-infection.
(Option 3) By around age 4, clients with sickle cell disease have some level of immunosuppression as their spleens
are dysfunctional due to infarctions from the sickling episodes. The spleen then fails to carry out protective
phagocytosis, especially to encapsulated bacteria (eg, streptococcus pneumoniae).

TRIAGE
WRITTEN CONSENT

Written consent is required for invasive procedures and surgery. Clients must be informed of and competent to
understand information about the procedure, alternate treatments, and risks. They must also be informed that they
have the right to refuse the procedure or surgery.
The nurse's role in informed consent is to witness that the client signed the consent voluntarily and
was competent at the time of signing
The nurse should ensure that the client received necessary information and has no remaining questions about the
procedure. After obtaining the signature, the nurse should document in the client's medical record that the
informed consent was given and the date/time of the signature
The health care provider is responsible for explaining all aspects of the procedure, ensuring that the client has a
correct understanding of the procedure and its potential risks, providing the names/qualifications of those who will be
involved, describing available alternate treatments, and reinforcing that the client has the right to refuse the
procedure.
The health care provider should be contacted if the client does not have a correct understanding of the procedure.
The nurse should not try to explain procedures as he/she could be held liable for giving incorrect/incomplete
information.
RADIATON EXPOSURE

The key aspects related to radiation exposure are time and distance. The greater the distance, the less dosage
received.
Acute radiation syndrome has the following phases: prodromal, latent, manifest, and recovery or death. Initially, all
victims will appear well; however, the damage is mainly internal, leads to cell destruction, and manifests later on.
Victims farthest away from the radiation source are the most salvageable. In this scenario, the principle of disaster
nursing is to do the most good for the most people with the available resources.
Nerve agents used as biological weapons (eg, sarin) inhibit acetyl-cholinesterase, and their effects are caused by the
resulting excess acetylcholine. Common symptoms are miosis, rhinorrhea, copious secretions, shortness of breath,
and flaccid paralysis. Treatment is with suction and support ventilation and circulation. However, these symptoms are
not related to radiation contamination.
Damage from radiation affects the most radiosensitive cells first; these are the hematopoietic, digestive, central
nervous system, and cutaneous cells. The presence of severe symptoms indicates extensive internal damage and
that the victims are less salvageable in the long term.
 Neurologic symptoms such as symmetrical descending flaccid paralysis with cranial nerve palsies (ptosis, diplopia,
dysphagia, dysphonia) are classic of botulism, which is caused by toxins from the spore-forming anaerobic
bacillus Clostridium botulinum. Treatment includes ventilator assistance and the heptavalent botulism antitoxin.
ADVERSE EVENT

Adverse event is an injury to a client caused by medical management rather than a client's underlying condition. It
may or may not be preventable. The Institute of Medicine (2000) recognizes 4 types of errors. They are:

o Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring)
o Treatment (error in performance of procedure, treatment, dose; avoidable delay)
o Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment)
o Other (failure of communication, equipment failure, system failure)

SENTINEL EVENT

A sentinel event is any unanticipated event in a health care setting that results in death or serious physical or
psychological injury.
Warfarin is an anticoagulant often used in clients with the following:

o Atrial fibrillation (to prevent clot formation and reduce the risk for stroke)
o Deep venous thrombosis and pulmonary embolism (to prevent additional clots)
o Mechanical heart valves (to prevent clot formation on valves)
 The International Normalized Ratio (INR) is a blood test used to monitor the effectiveness of warfarin therapy. The
typical target INR is 2-3. In some instances (eg, mechanical heart valves), the therapeutic INR target is as high as
3.5. The higher the INR, the higher the bleeding risk. The nurse should not administer warfarin if the INR is over 4.
(Option 1) Flumazenil is the appropriate antidote for a benzodiazepine overdose.
(Option 2) Insulin quickly lowers serum potassium by pushing it intracellularly. Dextrose is given to prevent
hypoglycemia. This is an appropriate action.
(Option 4) Nitroprusside is a potent vasodilator often used for hypertensive urgencies.

The role of the nurse as advocate is to protect the rights of the client, including the right to adequate pain control. The
nurse acting as advocate speaks up for clients when they cannot easily speak for themselves.
In the role of caregiver, the nurse promotes healing and well-being by helping the client and family set and achieve
goals through the nursing process.
In the role of educator, the nurse helps the client and family learn about topics relevant to their health.
In the role of manager, the nurse coordinates the care of the client among different members of the interdisciplinary
team and across care settings.
ANTI-EMBOLISM STOCKINGS
Anti-embolism stockings are part of venous thromboembolism (VTE) prophylaxis in hospitalized clients. Anti-
embolism stockings improve blood circulation in the leg veins by applying graduated compression. When fitted
properly and worn consistently, the stockings decrease VTE risk.
The stockings should not be rolled down, folded down, cut, or altered in any way. If stockings are not fitted and
worn correctly, venous return can actually be impeded.
Anti-embolism stockings should be applied before ambulating while the client is in bed; this maximizes the
compression effects of the stockings and promotes venous return.
Wrinkles should be smoothed out to avoid impeding venous return.
The toe opening should be located on the plantar side of the foot/under the toes.
MEDICAL ABBREVIATIONS

The Joint Commission (2004) and Institute for Safe Medication Practices prohibit error-prone or "dangerous"
abbreviations, descriptions of symptoms, and dose designations in medical documentation.
"Cm" (centimeters) and "II" (2) (eg, decubitus staging) are acceptable abbreviations/notations (Option 1).
The abbreviations "ac" (before meals), "pc" (after meals), and "c/o" (complains of) are acceptable (Option 4).
"QID" (4 times a day) is acceptable. Abbreviations that are not acceptable include "qd" (daily) and "q1d" (daily), which
can be mistaken for "qid" (4 times a day), and "qod" (every other day), which can be mistaken for "qd" (daily) (Option
5).
(Option 2) A trailing zero after the decimal point is not acceptable as it could be interpreted as 40 instead of 4 if the
decimal point is not noted. The use of "u" for unit is not acceptable as it can be mistaken for the number 0 or 4 (eg, 4u
seen as 40). "SSRI" (sliding-scale regular insulin) is not acceptable to indicate insulin as it can be mistaken for
selective serotonin reuptake inhibitor. "Mg" for milligrams is acceptable.
(Option 3) A zero must precede the decimal dose. If the decimal point is missed, ".5" could be mistaken for 5 mg.

ANTICIPATORY GUIDANCE

Anticipatory guidance prepares clients and caregivers for future health needs and is useful throughout life, from
pediatric growth and development to anticipated changes related to disease processes.
 This type of education promotes health and helps to reduce client/caregiver stress and anxiety, which heighten with
unexpected cognitive, physical, and emotional changes.
Anticipatory guidance educational goals should be client-oriented, realistic, objective, measurable, and focused
on preparing for future needs specific to the clien

DELEGATION
SCOPE OF PRACTICE

UNLICENSED ASSISTIVE PERSONNEL (UAP)

The RN can safely delegate the following tasks to the UAP to promote client safety during toileting and ambulating:

o Place the bedside commode, assistive devices (eg, canes, walkers), and personal belongings (eg, eyeglasses, hearing aids,
cell phones) as close to the client as possible
o Remind the client of the importance of changing position slowly to minimize orthostatic hypotension
o Report observations of changes in the client's condition (eg, level of consciousness, vital signs, pain level) immediately
o Keep the bed in the lowest position (locked) as it reduces the distance to the floor in the event of a fall
o Provide nonskid footwear for the client before ambulating
o Keep the environment dry and free of clutter and obstacles (eg, intravenous infusion device tubing and poles, electronic
device wires and cords)

The risk of falling is highest on the night of admission. Clients wake in the middle of the night, attempt to get up
unassisted in unfamiliar surroundings, and fall. Client orientation and teaching are the responsibilities of the RN and
are not appropriate to delegate to the UAP.
Alterations in gait, balance, and range of motion places the client at a higher risk for falling. Evaluating the client for
gait and balance deficits requires assessment and is a function of the registered nurse. The UAP may assist the client
in ambulating with assistive devices, but evaluating and educating are not delegated.
Unlicensed assistive personnel (UAP) may assist stable clients with activities of daily living, hygiene needs,
ambulation, and turning and repositioning. UAP may also collect and record vital signs (eg, pulse oximetry);
obtain and set up equipment; and take precautions to prevent aspiration (eg, oral care and suctioning).
When delegating to UAP, the registered nurse (RN) clearly defines the task, time frame for completion, and expected
outcomes (eg, report client's difficulty breathing, tolerance of procedures, results of vital sign measurements).
Furthermore, the RN should be certain that all UAP demonstrate competency and have been validated in all delegated
tasks.
The RN can safely delegate these tasks to UAP:

o Ambulate and promote mobility of stable clients

o Assist with activities of daily living (eg, feeding, bathing, dressing, hygiene)
o Perform oral (nonsterile) suctioning for clients during oral care
o Collect and document vital signs
o Turn and reposition stable clients

Delegating care to unlicensed assistive personnel (UAP) requires understanding of both body policies and staff
member training.
UAP may assist with care of stable clients related to tasks of basic hygiene (eg, bathing, toileting) and daily living
(eg, feeding, positioning, range-of-motion exercises); measurement and documentation of vital signs and intake
and output; and technical skills (eg, capillary blood glucose monitoring, IV catheter removal) with appropriate training
Assurance of appropriateness and completion of delegated tasks remain the duty of the nurse.
Many clients with advanced Alzheimer disease reside in long-term care centers; therefore, most routine care activities
can be delegated to the licensed practical nurse (LPN) and unlicensed assistive personnel (UAP).
The role of UAP includes:

o Assisting with activities of daily living (eg, toileting, bathing, skin care, oral care, personal hygiene)
o Assisting with feeding
o Reporting changes in ability to eat or difficulty swallowing
o Reporting changes in behavior
o Placing bed alarms to reduce risk of falls

The UAP has the skills and knowledge to perform standard procedures to prevent immobility hazards for a client in
traction (eg, pneumonia, pressure ulcers, foot drop, thromboembolism). When providing care for a stable client, the
RN can safely delegate these tasks to the UAP:

o Assist with active and passive ROM exercises after the client has been taught how to perform them by the RN or physical
therapist
o Notify the RN of client reports of pain, tingling, or decreased sensation in the affected extremity
o Remind the client to use the incentive spirometer after the client has been taught proper use by the RN or respiratory
therapist
o Maintain proper use of pneumatic compression devices
o Remind the client to move frequently using the overhead trapeze

Clients requiring mechanical ventilation receive care from many members of the health care team. Nurses must
often delegate tasks to ensure that care is provided in a timely manner. When delegating, nurses must consider
the stability of the client and the experience level of unlicensed assistive personnel (UAP). In accordance with
the five rights of delegation, nurses may delegate the following client care tasks to the UAP:

o Performing routine oral care, which will not affect medical stability in a client with a tracheostomy tube
o Measuring and obtaining vital signs
o Testing blood glucose (per hospital policy)
o Performing personal hygiene and skin care (eg, bathing)
o Performing passive and/or active range-of-motion exercises
o Measuring output (eg, urinary, drainage)
LICENSED PRACTICAL NURSE (LPN)

Nurses preparing to delegate client care to a licensed practical nurse (LPN) and/or unlicensed assistive personnel
(UAP) should consider the 5 rights of delegation. The LPN can monitor and care for stable clients who have been
initially evaluated by a registered nurse (RN). Interventions LPNs may perform include:

o Administering oral and parenteral medications, but excluding administering IV medications, which vary by state legislation
o Reinforcing teaching and skills that have been initially taught by the RN
o Focused assessments (eg, bowel sounds) after the RN's initial assessment

The following actions related to ostomy care are generally within the LPN scope of practice:

o Provide ostomy care and observe for skin breakdown

o Perform specific assessments (eg, bowel sounds, stoma color)
o Monitor drainage characteristics (eg, color, amount)
o Reinforce education
o Irrigate an established ostomy
o Document observations and interventions

The charge nurse should assign the most stable and predictable client to the LPN.
LPNs should not be assigned to clients who require complex care and clinical judgment and have potential negative
outcomes.
Licensed practical nurses (LPNs) can execute higher-level skills under the direction of a registered nurse (RN).
These include administering routine medications for expected needs and performing focused assessments such as
breath sounds, bowel sounds, and neurovascular checks (eg, pulse, capillary refill, numbness).
LPNs can also monitor findings such as flow rate and drainage in a client receiving continuous bladder irrigation
Wound care and routine medication administration are the most appropriate tasks to assign to the LPN. The LPN
can perform sterile procedures and cleanse and dress wounds for which there is an established prescription plan

After performing the initial assessment of the client post-procedure and comparing it to the pre-procedure baseline, the
registered nurse (RN) may assign the following tasks to the licensed practical nurse (LPN):

o Administer medications
o Monitor neurovascular status of involved extremity
 o Monitor for bleeding at catheter site every 15 minutes for the first hour, then according to facility policy
o Report any changes in neurovascular status or bleeding to the RN

Many clients with advanced Alzheimer disease reside in long-term care centers; therefore, most routine care activities
can be delegated to the licensed practical nurse (LPN) and unlicensed assistive personnel (UAP).
The role of the LPN includes:

o Administration of enteral feedings (if prescribed)

o Administration of medications
o Monitoring for safety hazards
o Monitoring for behavioral changes

DELEGATION
Delegation is the process of transferring responsibility of performing a task while maintaining the ultimate
responsibility for the action and its outcome.
The registered nurse (RN) should take into account the five rights of delegation (right task, right person, right
circumstances, right communication/direction, and right supervision/evaluation) and the scope of practice when
deciding which tasks to delegate.
The RN needs to direct the UAP's actions and communicate clearly about the assigned tasks including any specific
information necessary for completion (eg, methods for collection, time frame, when to report back to the RN). Option
2 gives the UAP directions with prioritization and specific instructions for reporting back findings.
(Option 1) The time frame in this option should be more specific. In addition, there is no communication about what
the RN expects as follow-up.
(Option 3) The instruction to "keep a close eye" on the client leaves the UAP too much room for interpretation. The
expectation from the RN is not clear and the UAP needs more direction.
(Option 4) The instructions are too broad and don't give a specific time frame. This delegation also needs to
communicate the method needed to accomplish the task.
BLOOD TRANSFUSION

The registered nurse (RN) is responsible for most of the care rendered to a client during a blood transfusion as this is
considered a high-acuity procedure requiring a high level of nursing assessment and judgment.
Based on the individual state or provincial practice act and institutional policy, the RN may have assistance from a
licensed practical nurse with checking blood products, verifying client identification, and monitoring the blood
transfusion rate.
Unlicensed assistive personnel (UAP) can obtain the blood product from the blood bank and courier it to the floor
where the RN will verify the blood product with another nurse
UAP can also take vital signs before the transfusion begins and any time after the first 15 minutes of infusion
Only nurses are able to verify blood product and client identification for blood transfusion procedures.
It is the responsibility of the RN to stay with the client during the first 15 minutes of the transfusion, monitor client
response, and measure vital signs. A transfusion reaction is most likely to occur during this time. However, the RN
may delegate measurement of vital signs after the first 15 minutes.
FLOATING NURSES

When asked to "float" to help out in another unit, the nurse should clarify the duties to be performed.
Many skills/knowledge, such as vital signs and routine medication administration, are the same in all units.
The nurse should be given a unit orientation. The nurse should then clarify applicable skills.
For instance, the nurse could perform basic care but not feel comfortable watching the telemetry cardiac monitors or
assisting with insertion of a pacemaker. These limitations are usually understood and respected.
The qualified and experienced registered nurses on the unit perform specialized client needs, and the "float" nurse
performs basic client needs.
The nurse is liable to provide safe care for the assigned duties and perform them in a competent manner.
The nurse should personally document any concerns raised with the supervisor and avoid discussing personal feelings
about the "float" with clients or other staff.
There is legal precedence that refusal to go when asked to "float" can result in disciplinary action.
Options in which the nurse can provide safe care rather make an across-the-board refusal should be explored.
The hospital is required to provide safe care and is liable if a unit is insufficiently staffed.
 ETHICAL / LEGAL
ADVANCE DIRECTIVE

Advance directives are prepared by a client prior to the need to indicate the client's wishes.
A living will gives instructions about future medical care and treatment if the client is unable to communicate.
A medical power of attorney is the individual designated to make health care decisions should a client become unable
to make an informed decision. It allows more flexibility to deal with unique situations.
Advance directives are determined ahead of time to guide decision making at the time of the event. The client can
indicate a desire to make a change, and the original decision should be honored.
The client's advance directives take legal precedence over the spouse's wishes. The spouse is consulted when there
are no advance directives or durable power of attorney for health care.
Advance directives include living wills with written directives on how to handle situations.
A medical power of attorney is used in situations not covered by the written directives.
A durable power of attorney for health care is used only when clients have not expressed wishes or cannot speak for
themselves.
When the advance directive is completed, a copy should be placed in the client's medical record and copies should be
given to everyone listed as health care proxies. The client should also keep a copy in a safe place.
The advance directive form does not need to be notarized, and so it can be completed in the health care setting if
there are 2 witnesses.
The advance directive is used to document a client's wishes, but it is not a medical order. It will not prevent from
performing CPR on a client when necessary. If this client does not want CPR, a portable "do not resuscitate" (DNR)
order should be used to ensure that the DNR order is followed outside the hospital setting. Types of portable orders
include a POLST (Portable Orders for Life Sustaining Treatment) form, an out-of-hospital DNR, and a DNR bracelet.
Two witnesses are required for completion of the advance directive form. The witnesses cannot be health care
providers involved in the care of the client or individuals named as health care proxies in the document.
The 2 most common forms of advance directives are living wills and durable power of attorney for health care
(health care surrogate/proxy). These take effect when the client cannot self-advocate. A living will represents the
client's wishes regarding actions to be taken in specific situations. A durable power of attorney is an individual who
decides actions to fluid situations according to an understanding of the client's wishes.
 A durable power of attorney takes effect when there is no living will indicating what actions to take on the client's
behalf.

A power of attorney (POA) designates a representative to act on a person's behalf in the event that the individual
becomes incapacitated. There are different types of POAs, including medical and financial.
An advance directive or living will describes the client's health care decisions (eg, do not resuscitate). As part of an
advance directive, the client may designate a representative to make health care decisions for the client - a durable
POA for health care or POA for health care (Canada). This client's statement requires further clarification regarding
what type of POA is in place

MATURE MINORS

"Mature minors" are adolescents who are age 14-18 and are deemed able to understand treatment risks. They are
legally allowed to give independent consent to receive/refuse treatment for some limited conditions.
Classically, these conditions include testing and treatment for STIs, family planning, drug and alcohol abuse, blood
donation, and mental health care.
A minor who is a parent, pregnant, or an emancipated minor can also give consent. An emancipated minor is a self-
supporting adolescent under age 18 who is married, on active duty in the military, granted emancipation by the court,
or not living at home.

INCIDENT REPORT
All incidents, accidents, or occurrences that cause actual or potential harm to a client, employee, or visitor must be
reported. The person who witnesses an unusual occurrence or event must file an incident report in the institution's
computer documentation system using an electronic form.
Alternately, a paper form may be completed and filed. The purposes of the report are to inform risk management of
the occurrence, allowing them to consider changes that might prevent similar incidents, and to notify administration of
a potential litigation claim.
 The nurse should not document that an incident report was filed, or refer to the incident report in the medical
record.
Because the incident report is not a part of the medical record, an objective note should be placed in the client's
medical record documenting the facts and events of the incident, HCP notification and findings, prescriptions,
treatment, follow-up care, and monitoring.
Incident/occurrence reports are used in a health facility to document events that pose unanticipated actual or
potential risk to the health or safety of a client, visitor, or employee. Incident/occurrence reporting is a method
of quality improvement and should not be considered punitive in nature or be documented in the health record.
Examples of events requiring reporting include:

Assault and injury

o Physical, verbal, or sexual assault occurring in a health facility (

o Client falls, with or without injury
o Staff and visitor falls, regardless of acceptance or refusal of treatment

Treatment and intervention

o Failure to obtain or intervene upon the results of diagnostic procedures

o Inadequate or delayed diagnosis and monitoring
o Delay, omission, or incorrect performance or administration of prescribed therapies and medications
o Hospital equipment failure

LEGAL REPORT

There are several circumstances in which the nurse is legally required to report to appropriate civil authorities:

o Suspected elder abuse must be reported to the appropriate authorities for investigation. The nurse has a legal obligation to
report signs of abuse regardless of clients' ability or willingness to advocate for themselves
 o The nurse should report deaths that meet medical examiner reporting guidelines (eg, suspected to be the result of a crime,
trauma, or suicide) to the authorities for investigation. The local medical examiner has the legal authority and obligation to
perform an autopsy independent of the family's wishes
o For the sake of client safety, nurses should immediately report impaired or intoxicated health care workers, regardless of their
position
o Under the Health Insurance Portability and Accountability Act, a client's reason for an emergency department visit cannot be
communicated to employers without the client's permission
o Health authorities must be notified of a reportable sexually transmitted disease regardless of client wishes. Depending on the
condition, authorities may report findings to sexual contacts, but it is a violation of client privacy for the nurse to share this
information with the client's family or spouse

HEALTHCARE PROXY

When a client is unable to make decisions, the health care proxy is legally able to make decisions for the client.
In the event that the health care proxy is unable to fulfill this role, the responsibility goes to the alternate proxies
identified on the advance directive.
If the client does not have a health care proxy, the family members would make decisions for the client.
Occasionally, there is no family and no proxy. If this happens, a proxy may be appointed, an ethics board may make
the decision, or the HCP may be responsible for making the decision.
The health care proxy would be the legally appointed primary decision maker.

LEAVE AGAINST MEDICAL ADVICE (AMA)

To leave against medical advice (AMA), the client must be legally competent to make an educated decision to stop
treatment.
Disqualifications for legal competency include altered consciousness, mental illness (ie, a danger to self or
others), and being under chemical influence (eg, drugs or alcohol).
 For a competent client to leave AMA, the health care provider must explain the risks of discontinuing treatment. The
nurse must witness and document the discussion on risks of leaving AMA and the client's understanding of these risks
("informed refusal").
A client leaving AMA can, and should, receive discharge instructions and the option to return at any time.
Clients have the right to leave AMA, even if it is not in their best interests to leave (eg, even if potentially life-
threatening). Not allowing a competent client to leave AMA is a form of false imprisonment, a legally liable action by
the nurse.

VISITOR EMERGENCY
Providing care establishes a legal caregiver obligation/relationship between the nurse and the visitor.
If a relationship is started, the nurse has a duty to continue care until the visitor is stable or other health care
personnel can take over.
If proper care is not continued, the nurse could be accused of negligence (ie, failure to act in a prudent manner as
would a nurse with similar education/experience).
This visitor's symptoms are potentially serious as sudden onset of headache and numbness in half of the body may
indicate stroke. In the event of a visitor emergency, the nurse should not establish a caregiver relationship but
rather implement facility protocol to help the visitor get to the emergency department promptly to receive immediate
assessment and further evaluation
Asking the visitor to call the health care provider (HCP) or giving advice to lie down delays the essential assessment
and treatment that this visitor with potentially serious symptoms requires.
When a nurse provides care (eg, takes blood pressure), a client-caregiver relationship is established. The nurse
caring for a visitor is ill-equipped to provide care without any HCP prescriptions in place and risks being negligent.
ELECTRONIC RECORD

The electronic record is a legal document and should contain factual, descriptive, objective information that the
nurse sees, feels, hears, and smells. It should be the result of direct observation and measurement. "Inspiratory
wheezes heard in bilateral lung fields" best fits these criteria. The nurse should avoid vague terms such as "appears,"
"seems," and "normal." These words suggest that the nurse is stating an opinion and do not accurately communicate
facts or provide information on behaviors exhibited by the client. The nurse should provide exact measurements,
establish accuracy, and not provide opinions or assumptions.
(Option 1) The nurse should not use the word "appears" as it is too vague. "Eyes closed" is a factual observation. A
more accurate entry would be, "Client lying in bed with eyes closed. Respirations even and unlabored."
(Option 2) It is a good practice to document client quotes. However, in this case, the nurse should have elicited more
information from the client, such as a pain scale, and then documented the analgesic the client was given.
(Option 4) This documentation would be more descriptive if it listed how much urine, its color and clarity, and if an
odor was present.

INFORMED CONSENT
Informed consent is required before any nonemergency procedure. The 3 principles of informed consent include:

o The surgeon explains the diagnosis, planned procedure with risks and benefits, expected outcome, alternate treatments, and
prognosis without surgery.
o The client indicates understanding of the information.
 o The client is competent and gives voluntary consent.

The nurse is responsible for witnessing the client's signature and ensuring that the client is competent and
understands information provided by the surgeon.
Clients unconscious or under the influence of mind-altering drugs (eg, opioids) cannot provide consent.
If the sedated client requires procedures not listed on the consent form, the client's medical power of attorney, legal
guardian, or next of kin should be contacted so that the surgeon can explain the situation and obtain consent
Modifying a consent form after it has been signed is an illegal falsification of documentation.

ADVANCE CARE PLANNING

Advance care planning is a process that includes:

o Considering treatments that may be needed in the future

o Making decisions to guide future treatments, particularly if the client is no longer able to make own decisions
o Ensuring that treatment decisions are legally documented on the appropriate forms, such as the advance directive, and in the
medical record
o Ensuring that advance directive documents are in the medical record so that they are available to HCPs who care for the
client in the future

o Ensuring that the health care proxy (or durable power of attorney for health care) has information and documentation to
support that role if this person needs to make decisions for the client

The nurse's role as advocate includes discussing options with the client and ensuring that the client's wishes are
communicated and documented appropriately so that the health care proxy and health care team will have the
necessary information.

Advance care planning is an ongoing process that should be revisited yearly and after changes in condition. Legal
documentation is needed to ensure that the client's advance care plan is carried out correctly.

Advance care planning documents may include the following:

o A health care proxy (durable power of attorney for health care or medical power of attorney) is a person appointed by the
client to make decisions on behalf of the client. The proxy document only goes into effect when the health care team
 determines that the client lacks the capacity to make decisions. This should be deactivated if the client regains decision-
making capacity.
o A living will is an advanced directive describing the type of life-sustaining treatments (eg, cardiopulmonary resuscitation,
intubation, mechanical ventilation, feeding tube) that the client wants initiated if unable to make decisions.

ETHICAL NURSING PRACTICES

Ethical principles guide decision making and appropriate behavior.

Justice is treating every client equally regardless of gender, sexual orientation, religion, ethnicity, disease, or social
standing
Accountability refers to accepting responsibility for one's actions and admitting errors
Nonmaleficence means doing no harm. It also relates to protecting clients who are unable to protect themselves due
to their physical or mental condition. Examples include infants/children, clients under the effects of anesthesia, and
clients with dementia
Beneficence is a nurse's duty to promote good and do what is best for the client.

Paternalism is a type of beneficence whereby clients are treated as children. The nurse claims to know what is best
for the client and coerces the client to act as the nurse wishes without considering the client's autonomy.
Veracity refers to the duty to tell the truth. This principle should always be applied to client care and documentation.

Autonomy is freedom for a competent client to make decisions for oneself, even if the nurse or family does not agree
(eg, informed consent, advanced directive). The nurse can provide information and should respect the client's
decisions.
Confidentiality means that information shared with the nurse is kept in confidence unless permission is given to share
or it is required by law to be shared to protect the client and/or community (eg, reportable infectious diseases). If a
client discusses suicidal ideation with the nurse, it must be appropriately reported to protect the client from self-harm.
 Fidelity is exhibiting loyalty and fulfilling commitments made to oneself and others. It includes meeting the expected
responsibilities of professional nursing practice and provides the basis of accountability (taking responsibility for one's
actions)

STATE BOARD OF NURSING

The National Council of State Boards of Nursing advises any individual who has knowledge of a potential violation of a
nursing law or rule to file a complaint with the appropriate state board of nursing. A nurse should be knowledgeable
concerning the presiding board's stance on mandatory reporting and which actions are considered reportable. In
general, reportable actions may include any behavior by a licensed nurse that
is unsafe, unethical, incompetent, impaired (eg, by substances or a mental or physical condition), or in violation of
nursing law.

o Practicing outside of the scope of the license is reportable even if the practice meets quality standards
o Documenting an intervention that was not performed is considered falsification of records regarding client care and is a
reportable action
o Stealing narcotics is a criminal offense (a violation punishable by the state that can result in prison or a fine) and is
reportable in all states. Many states offer an alternate rehabilitation program to nurses who diverted or abused drugs
o Abandonment (eg, leaving without proper replacement of personnel and transfer of responsibility for client care) is reportable
in all states

EMERGENT CALL

The nurse contacts the health care provider (HCP) for certain circumstances, regardless of the time of day. An
emergent call is warranted if a client:

o Falls
o Deteriorates significantly or dies
o Has critical laboratory results
o Needs a prescription that requires clarification
o Leaves against medical advice or runs away
o Refuses key treatments in a relevant period
 The HCP should be called after the initiation of hospital protocols (eg, stroke, code blue) and after a concerning
assessment finding (eg, significant change in vital signs, unilateral drift, change in level of consciousness, signs of
trauma after a fall )

CONFIDENTIALITY

Nurses need to maintain privacy and confidentiality when caring for clients. Health care workers (HCWs) need to use
the minimum necessary standard (reasonable precautions) to protect a client's health information.
Confidentiality is violated when information about a client's personal health (eg, diagnosis, test results) is accessed
by or given to those without permission or without a "need to know."
For example, a transport technician may require pertinent client information (eg, fragility) to transport a client safely
but never needs to know the client's exact diagnosis
Other violations include when HCWs access medical records of clients not currently assigned or discuss client
diagnoses with nonessential personnel
Certain incidental disclosures are allowed if reasonable precautions are taken. Common precautions include:

o Allowing medical record access to a HCW only when necessary to perform job duties
o Employing room dividers/curtains in semiprivate spaces
o Avoiding discussions about clients and their conditions in public areas
o Listing only last names on whiteboards at nurses' stations
o Placing communication whiteboards where they are least visible to the public
o Communicating with lowered voices in semiprivate spaces (eg, nurses' stations, client rooms)

The nurse is ethically and legally obligated to protect clients' privacy and maintain confidentiality of their medical
information.
Clients' health information should be shared only with other health care team members directly involved in those
clients' care.
Report sheets used by nursing staff often include clients' private health information and must be shredded at the end
of the shift
Without the client's permission, information about the diagnosis or diagnostic tests cannot be shared with a hospital
roommate
 The nurse is ethically and legally obligated to protect clients' privacy and maintain confidentiality of their medical
information.

If another staff member asks a question about a client's medical information in an open area with visitors, the nurse
should first move the conversation to a secure area. Answering the question will promote further conversation,
making it likely that the client's privileged health care information will be discussed and overheard by others. The best
response is to suggest changing the location of the conversation so that the information can be discussed privately

LOCAL ORGAN PROCUREMENT SERVICE

Local organ procurement services (OPS) are notified for every client death, per hospital protocol. If the client is
deemed appropriate as a donor, then OPS collaborate with hospital staff in approaching the client's family about organ
donation.
Cardiac support (eg, dopamine, epinephrine) and respiratory support (eg, ventilator) continue as organ donation is
discussed and/or performed. Life support is withdrawn only if the client is not a candidate for donation due to
physiological reasons or the client/family does not consent.
Organ donation is discussed before final arrangements and funeral plans are made. In most cases, the family is
referred to the hospital chaplain or someone outside the hospital for assistance with final arrangements.
Medical and nursing care would continue as organ donation is discussed due to organ and tissue perfusion being
necessary for viable donation.
Local OPS are contacted before life support is removed so that physiological support is continued in the event that the
client is a viable donor.

IMPAIRED NURSE
An impaired nurse cannot safely give care regardless of the reason for impairment. If impairment is suspected, the
nurse has a duty to take action that will both protect the client and ensure that the impaired individual receives
assistance.
 The charge nurse/nurse supervisor should be notified (so the nurse can be replaced and sent home safely),
the incident documented, and the nurse not allowed to give care while impaired

GOOD SAMARITAN LAW

Good Samaritan laws prevent civil action against nurses who stop of their own accord (eg, not part of their job duties)
to help injured individuals after an accident. The nurse cannot receive payment for any care given
It is essential for the nurse to perform in the same manner as any reasonable and prudent medical professional
would in the same or similar circumstances. A reasonable, prudent nurse would apply pressure to help control an
arterial bleed
Although this nurse is not legally obligated to offer assistance, it can be argued that there is an ethical responsibility.
Once the nurse starts to render care, the nurse is responsible to continue until the care can be handed off to an
appropriate caregiver, such as a paramedic. The nurse is not obligated to accompany the client to the hospital.
Knowing the client does not affect the application of Good Samaritan laws.
This nurse is not liable for the victim's outcome as long as the nurse performs in a competent manner.

LEGAL ISSUES
Assault is an act that threatens the client and causes the client to fear harm, but without the client being touched (
False imprisonment is the confinement of a client against the client's will or without legal justification (eg, client is
not a threat to self or others)
Invasion of privacy includes disclosing medical information to others without client consent. Under the Health
Insurance Portability and Accountability Act (HIPAA), a client's information regarding medical treatment is private and
cannot be released without the client's permission
Battery involves making physical contact with the client without permission. This includes harmful acts or acts that
the client refuses (eg, performing a procedure).
When interacting with the client, it is important to practice veracity, the ethical principle of being truthful.
 Battery is the intentional touching of a person that is legally defined as unacceptable or occurs without the
person's consent.
Many routine actions that are permissible when proper consent is obtained would otherwise be considered medical
battery. Furthermore, actions can be considered battery even if no physical injury results.
Any health care provider (HCP) who performs a medical or surgical procedure without receiving the required informed
consent from a competent client (or parent/legal guardian in the case of a child) is committing battery and could be
legally charged
A competent client has the right to refuse any treatment, even if it is for the client's benefit. The nurse should help the
client understand the need (eg, informed refusal), but the client's decision should be upheld. Proceeding to administer
treatment to a competent client who has refused that treatment is medical battery

PROFESSIONAL BOUNDARIES
Professional boundaries set limits to maintain a therapeutic professional relationship between the nurse and client.
However, the line between professional and personal interactions is sometimes blurred in extended relationships or
when care is given in the client's home. The nurse should always put the client's needs first and never seek
personal gain (eg, accepting gift worth >$20, asking for financial investment/loan)
The nurse should follow a facility's policy on professional standards of behavior. In the absence of a formal policy, the
nurse should consider if the action would be appropriate to include in the medical record. If the nurse is unsure, it may
be indicative of a violation of professional boundaries (eg, flirting with client, consuming alcoholic beverages with
client)
An occasional visit to a previous client in a different circumstance (hospital, nursing home) is considered appropriate
and caring.
It is appropriate for the nurse to offer assistance in meeting a client's spiritual needs if the client desires it. The nurse
should not force their own beliefs, religion, or practices on the client.
Sending a sympathy card to acknowledge a family's loss is a holistic and therapeutic measure.
PATIENT CARE PARTNERSHIP (PATIENT BILL OF RIGHT)
The Patient Care Partnership (formerly known as the Patient's Bill of Rights) is a set of standards developed by the
American Hospital Association. It informs patients/clients about what they should expect during their hospital stay with
regard to their rights and responsibilities. Client rights originate in laws or desirable ethical principles but have
limitations.
Clients have the right to know the names and positions of their health care providers (HCPs). These individuals
should introduce themselves by name and discipline
Clients have the right to access information within their own medical record. A release form may need to be signed, or
the HCP can review information (eg, biopsy results) with the client. In 2014, the Department of Health and Human
Services further strengthened the rights of clients to access their test results
Pain management is also addressed by the Joint Commission and is considered a basic client right. Although
success in pain relief is not guaranteed, the issue is to at least be addressed with the goal of successful management
Clients do not have an open-ended right to choose their nurse for every shift. If the client has a special request (eg,
does not want a male nurse based on religious beliefs), the facility will usually try to accommodate these wishes.
There is no basic right for clients to have whatever procedures they want. Clients sometimes want things that are not
essential to their health or that they do not need (eg, those with body dysmorphic syndrome who desire plastic
surgery, those with Munchausen syndrome who act ill and request unnecessary treatment). A client is offered
treatment that the HCP feels is needed and has the right to choose or refuse the treatment.

EMANCIPATION
 An unaccompanied minor should be treated if the medical condition is an emergency and should be assessed and
stabilized. This client clearly has a medical need and could suffer consequences if not treated. In this scenario, care
should be rendered and then explained later to the parent or guardian. This approach is supported by the ethical
principles of beneficence and nonmaleficence.
In addition, underage clients may consent in certain circumstances without parental consent. These circumstances
usually include treatment for substance abuse problems, psychiatric disorders, or sexual transmitted diseases.

PRIORITIZATION

CASE: The office nurse receives 4 telephone

messages. Which client should the nurse call
back first?
 An abdominal aortic aneurysm (AAA) is a blood-filled bulge in the abdominal aorta caused by weakening in the vessel wall due to
increased pressure. Risk factors include male sex, age >65, coronary artery and peripheral vascular diseases, hypertension, and
family and smoking history. AAA dissection (blood leakage into a vessel tear) or rupture may manifest as acute-onset abdominal
pain radiating to the back and is typically associated with symptoms of hemorrhagic shock (eg, decreased systolic pressure;
increased, weak pulses; pallor). h can lead to life-threatening
vascular hemorrhage.
(Option 1) This client's pain is most likely musculoskeletal in origin and due to a lumbosacral strain. Although assessment and
treatment (eg, nonsteroidal anti-inflammatory drugs, muscle relaxants) are necessary, this is not a life-threatening condition.
(Option 2) This client's pain is most likely radicular (irritation of the sciatic nerve) in origin. Although neurovascular evaluation for
a herniated disk (L5-S1) is necessary, this is not a life-threatening condition.
(Option 3) This client's pain and fever can be associated with a postoperative infection in the bone and surrounding tissue
(osteomyelitis). Although diagnosis and treatment with prescribed antibiotics are crucial to prevent sepsis, a potential massive
hemorrhage is a higher priority.
CASE: The nurse receives handoff report on 4
clients. Which client should the nurse assess first?
 Monoamine oxidase inhibitors (MAOIs) (eg, isocarboxazid [Marplan], phenelzine [Nardil], tranylcypromine [Parnate]) are often
prescribed for depression. MAOIs deactivate an enzyme that breaks down norepinephrine, dopamine, and serotonin. Increased
levels of norepinephrine can increase blood pressure. This increased norepinephrine level combined with certain
medications that also increase blood pressure (eg, nasal decongestants [eg, pseudoephedrine, oxymetazoline]) may lead
to hypertensive crisis, a complication that can result in hemorrhagic stroke and death. Headache is a common, early symptom
of hypertensive crisis that should be evaluated immediately in clients taking MAOIs (Option 3).
(Option 1) Buspirone, an anxiolytic medication, and diphenhydramine, an antihistamine and anticholinergic, commonly cause
dry mouth. This adverse effect is inconvenient but does not pose a risk to the client.
(Option 2) Beta blockers, such as metoprolol, and ACE inhibitors, such as lisinopril, are used to treat hypertension. These
medications commonly cause orthostatic hypotension characterized by dizziness when rising to stand. The nurse should follow
up, but this is not the priority.
(Option 4) Metformin is a biguanide oral antidiabetic medication used to treat type 2 diabetes mellitus. Lovastatin is a statin
medication used to treat hyperlipidemia. A common side effect of metformin is stomach upset. The nurse should assess the
client's symptoms, but this is not the priority.
CASE: A nurse in the emergency department
assesses 4 clients. Based on the laboratory
results, which client is the highest priority for
treatment?

Carbon monoxide (CO) is a toxic inhalant that enters the blood and binds more readily to hemoglobin than oxygen does. When
hemoglobin is saturated with CO, the pulse oximeter reading is falsely normal as conventional devices detect saturated
hemoglobin only and cannot differentiate between CO and oxygen.
The diagnosis of CO poisoning is often missed in the emergency department because symptoms are nonspecific (eg, headache,
dizziness, fatigue, nausea, dyspnea) and the pulse oximeter reading often appears within normal limits. A serum
carboxyhemoglobin test is needed to confirm the diagnosis. Normal values are <5% in nonsmokers and slightly higher (<10%)
in smokers. This client with CO poisoning is the highest priority for treatment and requires immediate administration of 100%
oxygen to increase the rate at which CO dissipates from the blood to prevent tissue hypoxia and severe hypoxemia (Option 3).
 (Option 1) Normal blood alcohol content is 0 mg/dL (0 mmol/L), and the legal level for driving under the influence is 80 mg/dL
(0.08 mg% [17.4 mmol/L]). The client's abdominal pain and increased respiratory rate require adequate assessment but are not
the highest priority.
(Option 2) The arterial blood gases indicate compensated respiratory acidosis, which is characteristic for a client with chronic
obstructive pulmonary disease; this is not the highest priority.
(Option 4) Emesis of 100 mL coffee-ground gastric contents would indicate an older, not fresh, gastrointestinal bleed; the
hemoglobin level is normal (13.2-17.3 g/dL [132-173 g/L] for males, 11.7-15.5 g/dL [117-155 g/L] for females). The cause of the
gastrointestinal bleed must be determined, but this is not the highest priority.
CASE: Which client should the nurse assess first?

Third-degree atrioventricular (AV) block, or complete heart block, occurs when electrical conduction from the atria to the
ventricles is blocked, causing decreased cardiac output (eg, dizziness, syncope, mental status changes, heart failure,
hypotension, bradycardia). The client with third-degree AV block is a high priority, as the client may decompensate to
cardiogenic shock and even periods of asystole (Option 4). Treatment includes administration of atropine and temporary pacing
(eg, transcutaneous) until a permanent pacemaker can be placed.
(Option 1) Atrial fibrillation puts clients at risk for development of atrial thrombi, which can embolize and cause a stroke.
Administration of warfarin (a long-term anticoagulant) is important to prevent thrombus formation; however, symptomatic third-
degree AV block is a higher priority.
(Option 2) Clients with chronic obstructive pulmonary disease often have pulse oximetry readings that are lower than normal
(eg, 91%). The goal in this client population is to keep the oxygen saturation 88-92%.
(Option 3) The client experiencing severe postoperative pain should be assessed for surgical complications (eg, infection), and
the pain should be treated (eg, with hydrocodone). However, severe pain does not take priority over third-degree AV block. The
nurse can see the client as soon as possible or ask another nurse for help.
CASE: The nurse receives the following information
in the hand-off report. Which client should the
nurse assess first?
 The nurse should first assess the client with alcoholic cirrhosis, as this condition is associated with gastritis, clotting
abnormalities (eg, thrombocytopenia, coagulation disorders), and esophageal varices that increase the risk
for hemorrhage (coffee ground emesis from oxidized blood). Hypotension and tachycardia in the presence of blood loss can
indicate hypovolemia. The nurse should monitor for signs of hemodynamic instability (eg, hypotension, decreased urine output,
peripheral vasoconstriction, pallor) and notify the health care provider of any significant changes from baseline as
immediate esophagogastroduodenoscopy is necessary to determine the bleeding site. Treatment to stop the bleeding (eg,
heat probe, sclerotherapy) may be indicated.
(Option 1) A paralytic ileus is a non-mechanical intestinal obstruction that can occur following abdominal surgery. Expected
manifestations include absent or hypoactive bowel sounds due to the lack of bowel motility and peristalsis, and abdominal
distension and nausea due to the accumulation of gas and fluids in the bowel.
(Option 3) Bacterial peritonitis (peritoneal inflammation) involves the entry of bacteria into the peritoneal cavity and is associated
with a ruptured appendix. Elevated temperature would be an expected finding.
(Option 4) Sore throat discomfort from irritation of the oropharynx is expected in a client with a nasogastric tube.
CASE: The nurse is performing beginning of shift
assessments on 4 clients. Which client's
assessment findings should the
nurse immediately report to the health care
provider?
 Sepsis is an exaggerated response to an infection in the bloodstream, often originating from a local infection (eg, pressure injury),
that results in potentially life-threatening organ impairment. Older adults are at increased risk for sepsis due to normal, age-
related decreases in the immune and inflammatory response (ie, immunosenescence).
Because of altered immune function, older adults often do not develop typical signs of infection (eg, fever, leukocytosis). Instead,
nurses must observe for and immediately report atypical indicators of infection (eg, altered mental status, hypothermia,
leukopenia) because early identification and intervention reduce mortality (Option 4).
(Option 1) Chronic use of central nervous system depressants (eg, alcohol) causes a reflexive increase in catecholamine
production (eg, epinephrine). During alcohol withdrawal, hypertension, agitation, and anxiety occur because catecholamine
production is no longer inhibited.
(Option 2) Clients with stable angina (ie, chest and jaw pain relieved with sublingual nitroglycerin) often experience orthostatic
hypotension, an adverse effect of nitrate drugs.
(Option 3) Clients with chronic kidney disease (CKD) commonly experience nausea and pruritus due to buildup of nitrogenous
wastes in the blood (ie, azotemia). Elevated creatinine is an expected finding in CKD. Hypertension does require intervention by
the nurse after management of infection and sepsis.
CASE: The nurse receives handoff of care report
on four clients. Which client should the nurse
assess first?

The nurse should first assess the client with asthma who reports shortness of breath 15 minutes after receiving a nebulizer
treatment with albuterol. Asthma exacerbations may require repeat nebulization every 20 minutes, or continuous nebulization
for 1 hour, to relieve severe bronchoconstriction until the administered corticosteroids take effect and start to reduce the
inflammation (Option 2). The nurse should assess the client for wheezing, decreased breath sounds, use of accessory muscles
to breathe, capillary refill, respiratory rate, and pulse oximeter reading and pulse.
(Option 1) Subcutaneous emphysema is air that leaks into the tissue surrounding the chest tube insertion site. The amount is
usually small and reabsorbs spontaneously. The nurse should auscultate for lung sounds, assess for a popping sound, and
palpate the site for a crackling sensation. However, this client does not have the most urgent need.
 (Option 3) Clients with an exacerbation of COPD are prescribed noninvasive positive pressure ventilation with a BIPAP device
to treat hypercapnia and hypoxemia and improve gas exchange. An oxygen saturation of 88-92% is adequate in clients with
COPD. The nurse should perform a thorough pulmonary assessment, but this client does not have the most urgent need.
(Option 4) The nurse should follow institution policy and either start the IV or notify the IV team to restart the infusion. Although
it is important to initiate antibiotic therapy as soon as possible to treat an existing infection, this client does not have the most
urgent need.
CASE: The clinic nurse receives phone calls
about the following 4 clients. Which call should
the nurse return first?

Inconsolable crying and drawing up of the legs toward the abdomen in a child age 6-36 months could
indicate intussusception or some other abdominal pathology (eg, appendicitis). Additional findings in intussusception include
stools that have mucus and blood, often called "currant jelly" stools, and vomiting. Intussusception occurs when one section
of bowel telescopes over another, which can block the passage of intestinal contents, interrupt blood supply, and cause intestinal
tears (perforation). It is an emergency, and the client should be brought to the emergency department for further evaluation.
(Option 1) Mild to moderate fever and local reactions are common after diphtheria, tetanus, acellular pertussis (DTaP)
injections. Severe allergic reaction (eg, anaphylaxis) and encephalopathy (eg, decreased level of consciousness, prolonged
seizures) are the most serious reactions that require priority attention.
(Option 3) Pneumonia is often accompanied by chest and side pain that worsens with deep breathing due to rubbing of the
nearby inflamed pleura (pleuritis). This would not be the priority phone call.
(Option 4) These symptoms are consistent with bacterial conjunctivitis, or inflammation of the clear membrane (conjunctiva) that
covers the eye. This client is second in priority.
CASE: The nurse receives the change of shift
report for assigned clients at 7 AM. Which
client should the nurse assess first?
 Change in level of consciousness is a high priority problem as it can indicate a neurologic deficit that can be associated with a
closed head injury. At the beginning of the shift, the nurse must perform a basic neurologic assessment (eg, pupil size and
response, level of consciousness (LOC), mentation, speech, hand grasps). This is done to obtain the baseline data against
which subsequent assessments can be compared and to assess for indicators of increased intracranial pressure (eg, change in
LOC, Cushing's triad, pupillary changes).
(Option 2) The client with chronic headaches is scheduled for an MRI in 2 hours. Preparation for the test is not urgent at this
time; this client's assessment does not take priority.
(Option 3) A pulse oximeter reading of 89%-92% is adequate and is an expected finding in a client with COPD who often relies
on the hypoxemic drive to breathe. This finding is nonurgent and this client's assessment does not take priority.
(Option 4) When the heart does not pump effectively, excess fluid in the body develops, blood accumulates in the veins of the
legs, and fluid from the capillaries leaks into the interstitial spaces, causing pitting edema. Pitting edema in the lower extremities
is an expected finding in a client with heart failure. This is a nonurgent finding and this client's assessment does not take priority.
CASE: Four clients with different skin alterations
come to the emergency department. Which client
should the nurse advise that the health care
provider (HCP) see first?

Petechiae (small pinpoint red/purple spots on mucus membrane or skin) and purpura (irregular purplish blotches) can be a sign of
blood dyscrasia, including thrombocytopenia due to a severe drug response. This systemic symptom takes priority over a more
localized dermatological presentation.
(Option 1) Oropharyngeal candidiasis/thrush (moniliasis) is a fungal infection of skin or mucous membranes. It resembles
curdled milk and can bleed when removed. The etiology may be due to not rinsing the mouth after steroid inhaler use. It is
treated with antifungal suspensions (nystatin) and is nonurgent.
 (Option 3) Shingles (herpes zoster) is reactivation of dormant varicella virus. The lesions follow the nerve dermatome and can
be quite painful. Incidence increases after age 50. Active chickenpox requires airborne and contact precautions, but not the
shingles with crusted lesions, especially if the lesions are covered with clothes. It can be contagious to individuals who have not
had varicella or who are immunocompromised. However, this is the second priority as this is a localized issue; the nurse can
place this client in a private area.
(Option 4) Folliculitis is usually due to the presence of staphylococci in moist areas where there is friction. It is most common in
the scalp, beard, and extremities in men. It can be treated with medicated soap, topical antibiotics, and warm compresses.
CASE: Which client in the emergency department
should the nurse see first?

Acute epiglottitis is a supraglottic inflammatory process that occurs most commonly in children with Haemophilus
influenzae type b (Hib) infection. Inflammation of the epiglottis can cause airway obstruction and is a medical emergency.
Common signs of impending airway obstruction include restlessness, stridor, and drooling due to dysphagia. The nurse
should prepare to assist with emergent endotracheal intubation.
(Option 2) If left untreated, the inflamed appendix may rupture, causing peritonitis, major abscess, or partial bowel obstruction.
The client with acute appendicitis may require antibiotic administration and emergent surgical appendectomy. Although
appendicitis is an emergent condition, a client with impending airway obstruction from epiglottitis must be seen immediately.
(Option 3) Immune thrombocytopenia (ITP) is an acquired disorder in which antibodies cause decreased platelet survival and
production. Petechiae, pinpoint lesions on the skin from capillary hemorrhages, are a common sign of ITP. Acute ITP usually
resolves spontaneously without complications, and management is primarily supportive (eg, platelet monitoring, corticosteroids,
IV immunoglobulin).
(Option 4) Cystic fibrosis affects the secretory glands, resulting in thick sputum that may become blood-tinged from frequent
coughing. A client with cystic fibrosis who has blood-tinged sputum should be evaluated but is not a priority.
CASE: The registered nurse is performing triage at
a pediatric emergency department. Which client
should be seen first?
The client with abdominal pain has abnormal vital signs, which is a sign of a systemic condition. Adult criteria apply to adolescent
clients in terms of physiological signs/symptoms. A pulse of 120/min signals dehydration and this client's respirations are above
normal. This is the most serious acuity.
(Option 1) The client with a history of CF would be treated second as clients with CF have chronic respiratory issues related to
the thick mucus plugging the airways. This client will probably need antibiotics but is stable and can wait. The severity of the
situation is considered when prioritizing client care based on airway, breathing, and circulation (ABC). The seriousness of the
adolescent client's condition related to "C" (dehydration) is a priority over a relatively stable "B." There is nothing indicating that
this client is in respiratory distress.
(Option 2) The infant has diaper dermatitis from irritation of urine and stool on the skin. A secondary infection with Candida
albicans can occur. Diaper dermatitis is most common in infants age 9-12 months. Ointment will be provided. Mild diaper
dermatitis is treated with a topical water-impermeable barrier (eg, zinc oxide). If the infant has an infection with Candida albicans,
an antifungal topical medication is also used. When care must be prioritized, young children do not automatically go first.
Prioritization is decided by the client's acuity.
(Option 3) The grade-school client has a limited extremity injury and the priority principle is always "life before limb." Therefore,
the client with abdominal pain is more important.

Clients with dementia are expected to be alert, with a gradual development of symptoms showing cognitive decline (eg,
disorientation, forgetfulness). The sudden onset of a new behavior (eg, restlessness, confusion) may indicate delirium caused
by an infection (eg, pneumonia, urinary tract infection) or another serious etiology (eg, hypoglycemia, stroke, hypoxemia) and is
considered a priority (Option 2).
(Option 1) The client at 24 weeks gestation with a productive cough and no signs of labor may have an upper respiratory
infection but is currently stable and not the priority. Pregnant clients and children are not automatic priorities.
(Option 3) The client who had a seizure earlier is now stable. The nurse can maintain a safe environment (ie, in the event of
another seizure) until the client is seen, but the client with dementia and behavior changes is the priority.
(Option 4) The client with a potential fracture and pain has normal circulation and sensation. Although further evaluation and
treatment (eg, x-rays, analgesics, ice, elevation) are needed, this client is not the priority.

A subarachnoid intercerebral bleed is an emergent, serious presentation often described as the "worst headache of my
life." The onset is usually abrupt due to rupture of the vessel. Subarachnoid hemorrhage has a high mortality from recurrent
bleeding and is the highest priority presentation.
(Option 1) Gout is hyperuricemia. If not properly treated, urate crystal deposits (tophi) develop on the joints. Although gout can
cause severe pain, it is not the highest priority.
(Option 2) A headache in a client with a known history of migraines is not an urgent concern if it is the same as or similar to
previous headaches. These clients usually have accompanying neurologic dysfunction such as nausea/vomiting or sensitivity to
light or sound.
(Option 3) Severe epigastric pain radiating to the back after an alcohol binge is most likely due to acute pancreatitis. It is a
serious condition but usually not immediately life-threatening.
The nurse should assess the postoperative client first by monitoring vital signs, examining the dressing and amount and
appearance of the drainage, and performing a neurovascular assessment (eg, pulses, skin color and temperature, sensation,
movement). Serosanguineous (pink) drainage would be expected 2 hours after surgery, but a dressing saturated with
sanguineous (bright red) drainage indicates excessive blood loss with possible hemorrhage; it should be reported immediately to
the health care provider for evaluation. A pressure dressing may be required to provide wound hemostasis, or the client may
need to return to the operating room for cauterization of a bleeding vessel. This client is at highest risk for morbidity and
mortality (Option 1).
(Option 2) The dressing on an infected foot ulcer is usually removed before the foot is placed in a whirlpool bath (hydrotherapy).
The nurse can apply a new dressing or cover and wrap the foot using a sterile towel or gauze bandage to protect it from
microorganisms. This client is not the priority.
(Option 3) Dialysis grafts are prone to infection. This client needs to be assessed for erythema, graft tenderness, fever, and
tachycardia. These are not immediately life-threatening conditions.
(Option 4) Infection can cause delirium (altered mental status). This client needs one-to-one observation and repeated
reorientation while antibiotics take effect. However, this client is not a priority over a client who is actively bleeding.

Myasthenia gravis (MG) is a chronic, neurologic autoimmune disorder that involves damage to acetylcholine receptors at the
neuromuscular junctions, which results in skeletal muscle weakness. The ocular (ptosis) and facial muscles, along with those
responsible for chewing and swallowing, are affected initially; however, weakness can progress to the respiratory muscles (eg,
intercostal, diaphragm).
Pyridostigmine (Mestinon) is a first-line drug that inhibits acetylcholine breakdown and is prescribed to temporarily increase
muscle strength in clients with MG. It is the priority medication as difficulty swallowing indicates weakness of the muscles
involved in swallowing and increases aspiration risk.
(Option 1) Acetylsalicylic acid (Aspirin) is prescribed daily to prevent ischemic attacks and myocardial infarction in clients with
coronary artery disease and ischemic stroke; it is not the priority medication.
(Option 2) Metformin (Glucophage) is an anti-hyperglycemic drug that can cause lactic acidosis in clients with kidney disease.
Contrast used for CT scan can cause kidney injury. It is recommended that the drug be held before and resumed 48 hours after
the CT scan (if renal function [creatinine] is normal).
(Option 3) Analgesia with opioids is appropriate to treat chronic pain associated with terminal cancer. However, decreasing the
aspiration risk is more urgent than providing pain relief.

Tension pneumothorax causes marked compression and shifting of mediastinal structures (tracheal deviation), including the
heart and great vessels, resulting in reduced cardiac output and hypotension. This is a life-threatening emergency. The client
should have emergency large-bore needle decompression, followed by chest tube placement, to relieve the compression on
the mediastinal structures.
(Option 2) Clients who have a head injury and lose consciousness are at high risk of intracranial injury (bleed). This client would
likely need a head CT scan to assess for further damage, but the client with pneumothorax is the priority.
(Option 3) A grossly swollen upper thigh likely represents a femur fracture with extensive bleeding. It requires intervention,
especially IV fluids and surgical correction. However, this is a second priority after the client with pneumothorax.
(Option 4) Thoracic spine pain and leg paralysis likely represent injury to the spinal cord. Precautions such as a hard cervical
collar and backboard should be used to prevent further injury. This client requires further testing and treatment but is not a
priority over the client with pneumothorax.

The ABC priority framework stands for airway, breathing, and circulation. This is the order in which clients should be assessed
and treated.
Smoke inhalation is the leading cause of death in burn clients as it causes thermal injury to the upper airways, chemical injury to
the tracheobronchial tree, and carbon monoxide and/or cyanide poisoning. Clients should receive 100% oxygen to displace
carbon monoxide and cyanide from hemoglobin. Intubation is indicated if there is evidence of upper airway edema with
respiratory distress. An obstructed airway can lead to cardiac arrest if not treated immediately.
(Option 1) According to the ABC priority framework, this client who is bleeding after a recent colon resection should be seen
after the burn client has been treated.
(Option 3) The client with gastroenteritis who is vomiting profusely should be assessed and given antiemetics and fluid
resuscitation as ordered. However, this is not the priority in this situation.
(Option 4) The client experiencing severe pain from peritonitis should certainly be assessed as soon as possible, but this is not
the priority according to the ABC priority framework.

Foreign body aspiration can be life-threatening depending on the object's location, type, and size. Up to 50% of children with
foreign body ingestion are asymptomatic at the beginning. Alkaline batteries can be corrosive to the esophageal and intestinal
mucosa; if ingested, they must be removed emergently by endoscopy as perforation can occur.
(Option 2) This client likely has nursemaid's elbow due to the mechanism (swinging by the arms) by which the injury occurred.
This condition is common in children and characterized by a subluxation of the radial head. It can seem like an urgent condition
due to the suddenness of the child's inability to use the arm. A simple reduction of the arm by a health care provider should
reposition the radial head.
(Option 3) Clients with cerebral palsy commonly have an implanted baclofen pump to help control muscle spasms. Increased
spasms indicate a possible problem with the pump, such as infection or displacement. Baclofen should not be stopped abruptly.
This client needs prompt evaluation, but the condition is not immediately life-threatening.
(Option 4) Osteogenesis imperfecta (imperfect bones) is a condition in which bones are brittle and fracture easily. Head trauma
indicates a possible skull fracture and alerts the need to assess for intracranial hemorrhage. This child is walking, and so
bleeding is unlikely. However, the child should be examined for fracture.
Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). PVCs in the
presence of a myocardial infarction (MI) indicate ventricular irritability and increase the risk for a more serious dysrhythmia (eg,
ventricular tachycardia, ventricular fibrillation). Possible causes of ventricular bigeminy include electrolyte imbalances and
ischemia. After assessing the client's vital signs, the nurse should assess potassium and magnesium levels and apical-radial
pulse, administer the scheduled amiodarone, and notify the health care provider (HCP).
(Option 1) The client with atrial fibrillation (AF) should be seen after the MI client. Vital signs are stable, but the International
Normalized Ratio (INR) should be lower (therapeutic range of 2.0-3.0 for AF). The nurse should assess for signs of bleeding and
notify the HCP; the scheduled dose of warfarin should likely be held.
(Option 2) A temperature of 99 F (37.2 C) is not uncommon in the days immediately following surgery. The nurse should assess
surgical incisions and respiratory status and give the scheduled antibiotic.
(Option 4) After NPO status is discontinued, the client should be offered fluids. This task can be delegated to unlicensed
assistive personnel and is not the priority.

Testicular torsion is an emergency condition in which blood flow to the testis (scrotum) has stopped. The testicle rotates and
twists the spermatic cord, initially causing venous drainage obstruction that leads to swelling and severe pain. Arterial blood
supply is subsequently interrupted, resulting in testicular ischemia and necrosis, which require surgical removal of the testis.
The condition can be diagnosed with ultrasound. There is a short time frame in which testicular torsion can be treated (to
untwist the rotation), generally 4-6 hours, making this condition a priority.
(Option 1) Right lower quadrant pain referred from the periumbilical area is a classic sign of appendicitis. If left untreated, the
appendix could perforate and release bacteria into the abdomen, causing peritonitis, a more serious condition. Surgery is usually
required within 24 hours. This client should receive prompt attention but is not a priority over the client with testicular torsion.
(Option 3) Clients with sickle cell disease have episodes of sickle cell crisis, in which the sickle-shaped cells occlude the blood
vessels. This decreased blood flow is responsible for the generalized body pain. This client should be treated emergently with
pain medications and IV fluids but is not a priority over the client with testicular torsion.
(Option 4) Sudden-onset, right-sided flank pain radiating to the groin is classic for renal stones. Kidney stones are very painful
but in most cases cause no permanent damage unless a stone completely blocks kidney flow. This client is not a priority over the
client with testicular torsion.

Obstructive sleep apnea (OSA) is characterized by partial or complete airway obstruction that occurs from relaxation of the
pharyngeal muscles, airway closure, and lack of airflow.

Administration of general anesthesia or sedating medications (eg, opioids and benzodiazepines) can exacerbate OSA by
decreasing pharyngeal muscle tone and increasing airway closure even further. Therefore, being on continuous positive airway
pressure (CPAP) is very important in these clients, especially during sleep.
The nurse should assess level of consciousness, lung sounds, vital signs, and pulse oximeter readings, and then compare these
with the client's baseline measurements. The nurse should also continue to monitor respiratory status as IV morphine peaks in
20 minutes and has a duration of 3-4 hours.
(Option 1) This 22-year-old with sickle cell crisis will likely need large doses of narcotics due to increased tolerance from prior
use. The nurse needs to assess the pain and any complications from narcotic use. However, this is not the first priority.
(Option 2) This 26-year-old has pneumonia and right side pain on deep inspiration, which indicate pleuritic pain (inflammation of
the 2 layers of pleura). Pleuritic pain is an expected finding associated with pneumonia and is not the priority assessment.
(Option 3) Moderate to severe postoperative pain and lack of audible bowel sounds (due to general anesthesia, bowel
manipulation, and opioid drugs) are expected findings 1 day after major abdominal surgery. This client is not the priority.
The prioritization principle is that systemic symptoms are more important than local symptoms. Trousseau's sign (carpal spasm
with blood pressure cuff inflation) indicates hypocalcemia. This is a known risk after a thyroidectomy as the parathyroid gland
can be inadvertently removed during the surgery due to its very small size. Acute hypocalcemia can cause tetany, laryngeal
stridor, seizures, and cardiac dysrhythmias. Assessing this client is a priority over pain or expected findings.
(Option 1) This client likely has postoperative urinary retention and needs to be evaluated as soon as possible (second in
priority). Although, this condition is painful and could result in kidney injury, it is not immediately life-threatening.
(Option 2) This client has isolated systolic hypertension, which is common in elderly clients and they are often asymptomatic.
Systolic blood pressure is usually >160 mm Hg but diastolic blood pressure is <90 mm Hg. Treatment might benefit these clients,
but this is not a priority.
(Option 3) ALT and AST are enzymes released when hepatocytes are destroyed as part of the hepatitis pathology. Hepatitis is
-3 times the normal value. The hepatitis C virus usually causes chronic infection. The
client's acuity is not directly related to the level of enzymes; this client is not more seriously ill because the enzymes are higher
than a client whose labs results are twice the normal value. This is an expected finding and is not a priority.

External fixation stabilizes bone by inserting metal pins through skin into the bone and attaching them to a metal rod outside the
skin. The nurse should assess this client first as any signs and symptoms of an infection (eg, low-grade fever, drainage, pain,
redness, swelling) warrant immediate evaluation and treatment. Localized pin tract infection can progress to osteomyelitis, a
serious bone infection that requires long-term treatment with antibiotics.
(Option 1) The dose of levothyroxine, a thyroid replacement drug that raises the metabolic rate, may need to be adjusted as the
client is now exhibiting manifestations of hyperthyroidism (eg, nervousness, sweating, insomnia).
(Option 2) Hemoptysis can sometimes be seen with pneumonia, lung abscess, tuberculosis, and lung cancer, as well as in
bronchiectasis. Unless there is a significant amount of blood, this is not a concerning finding.
(Option 4) Epigastric abdominal pain and steatorrhea (voluminous, foul-smelling, fatty stools) due to fat malabsorption are
expected findings in chronic pancreatitis. Appropriate pain medication and pancreatic enzyme supplements (prior to each meal)
are administered for prevention.

The client with atrial fibrillation is at increased risk for the development of atrial thrombi due to blood stasis, which can embolize
and lead to an ischemic brain attack. The INR (normal 0.75-1.25) is a measurement used to assess and monitor coagulation
status in clients receiving anticoagulation therapy. The therapeutic INR level for a client receiving warfarin (Coumadin) to treat
atrial fibrillation is 2-3. The subtherapeutic INR of 1.3 is the most important result to report to the health care provider (HCP) as
the client is at increased risk for a stroke and dose adjustment is needed.
(Option 2) A client with chronic obstructive pulmonary disease and chronic bronchitis has chronic alveolar hypoxia, which
stimulates erythropoiesis (red blood cell production) and leads to polycythemia (hematocrit >53% [0.53] in males, >46% [0.46] in
females; hemoglobin >17.5 g/dL [175 g/L] in males, >16 g/dL [160 g/L] in females). Increased hematocrit and hemoglobin are
expected in this client and are not the most important results to report to the HCP.
(Option 3) Leukocytosis (white blood cells >11,000/mm3 [11 × 109/L]) is expected in a client with C difficile infection and is not
the most important result to report to the HCP.
(Option 4) A client receiving gentamycin, a nephrotoxic drug, has a normal creatinine level (0.6-1.3 mg/dL [53-115 µmol/L),
which is not the most important result to report to the HCP.
Abdominal aneurysms may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. A bruit may
be auscultated over the site. Back/abdominal pain can be present due to compression of nearby anatomical sites or nerve
compression from an expanding/rupturing abdominal aortic aneurysm (AAA). Rupture of an abdominal aneurysm can quickly
cause exsanguination and death. This client may need emergency surgery to repair the aneurysm.
(Option 1) Fever, suprapubic pain, and dysuria in a young female client indicate urinary tract infection, a much lower priority than
AAA.
(Option 2) Diffuse pain and a rigid abdomen indicate peritonitis (eg, from ruptured appendicitis or perforated bowel). Peritonitis
is also an emergency but not immediately life-threatening like AAA rupture. This client should be seen next after the client with
AAA.
(Option 4) Fever and left lower quadrant pain in an elderly client are usually due to acute diverticulitis. The client needs bowel
rest, antibiotics, and IV fluids. This is a lower priority than AAA and peritonitis.

Sepsis is a condition associated with a serious infection in the bloodstream. Evidence-based guidelines recommend the early
administration of antibiotic therapy to reduce mortality. Cultures should be obtained quickly and antibiotics administered as soon
as possible. Failure to treat early sepsis can lead to septic shock (persistent hypotension) and multiorgan dysfunction syndrome.
(Option 1) Subcutaneous venous thromboembolism prophylaxis with enoxaparin following abdominal surgery is usually
prescribed once every 24 hours, so administration is not urgent.
(Option 2) This client has high blood pressure and needs treatment. However, this is not immediately life-threatening. If
nausea, vomiting, and headache were also present, then the client would likely have hypertensive urgency or encephalopathy
and need to be treated emergently.
(Option 4) This client has high blood glucose and needs to be treated. However, it is not immediately life-threatening unless the
client has hyperosmolar hyperglycemic syndrome or diabetic ketoacidosis.
A client who is status post tonsillectomy and adenoidectomy is at risk for hemorrhage up to 14 days after surgery. Because
of the location of the surgery, hemorrhage can lead to life-threatening airway compromise. The client who had a tonsillectomy 3
days ago and has signs of hemorrhage (eg, restlessness, frequent swallowing or clearing of the throat, vomiting of blood, pallor)
should be seen first. The client may require surgery to cauterize the bleeding vessel(s). To decrease the risk of hemorrhage, the
nurse should educate the client to limit coughing, gargling, and clearing of the throat.
(Option 1) Persistent vomiting and diarrhea in an 8-month-old would warrant concern for dehydration. IV fluid resuscitation may
be required. This client, with potential circulatory compromise, should be seen second.
(Option 2) A foreign body lodged in the nose does not compromise the airway and therefore is not life threatening. This client
should be seen last.
(Option 4) A second-degree burn is not full thickness and is not considered life threatening. This client needs treatment for pain
and infection prevention and should be seen third.

This client with altered mental status and not following commands is at risk for aspiration and airway compromise from vomiting.
This client should be assessed first; the client needs to be placed in the lateral position with head elevated and may need
emergent intubation if airway cannot be protected.
(Option 1) Clients receiving hemodialysis are at risk for bloodstream infections. Blood cultures need to be obtained from a client
with a bloodstream infection, and antibiotics would then be administered. This is not a priority over airway compromise.
(Option 2) Clients with ankylosing spondylitis often take nonsteroidal anti-inflammatory drugs to control back pain and are at risk
of developing gastric ulcers. They can cause melena (black stools). The client needs further assessment of orthostatic vital
signs and hemoglobin level. This is not a priority over airway compromise.
(Option 4) Clients with acute diverticulitis (inflammation of the diverticula) are at risk for perforation, which can be manifested by
increasing abdominal pain, rigidity, guarding, and rebound tenderness (peritoneal signs). This client needs further assessment,
but this is not a priority over airway compromise.

The nurse must deal with the visitor on the floor first, either by approaching/assessing the visitor or asking another nurse/charge
nurse to deal with it urgently. The visitor could have fallen and hit the head. Responsiveness must be established and the need
for any life-saving measures (eg, providing respirations or compression) must be ruled out. Visitor status does not matter, this
individual is on hospital property and the nurse is obligated to respond.
(Option 1) The nurse can speak to the HCP after dealing with this emergency.
(Option 3) An analgesic can be administered after assessing the client and confirming that a medication has been ordered;
however, a person needing potential life-saving measures is a priority.
(Option 4) Although this is an urgent need and the nurse should assess the site/pump (not delegate for someone else to just
push the button to silence the alarm), potential life-saving measures take priority. The IV line will not occlude waiting a few
minutes to be dealt with.

In this scenario, a client with a drug overdose (OD) is the highest priority as the actual amount taken and its effects are
unknown. In addition, clients who deliberately OD often consume other substances (eg, alcohol) that can potentiate the effect of
the drug. OD is especially concerning for a tricyclic antidepressant (TCA) due to the effect this can have on the cardiovascular
and central nervous systems (eg, dysrhythmias, seizures). TCA use for depression is an uncommon second-line treatment, but
the drug class is used for neuropathic pain and sometimes bed-wetting (enuresis).
A client with head trauma (a vascular area of the body) who is currently on an anticoagulant could have potential intracranial
bleeding and should be treated next.
The 6-month-old client is exhibiting classic signs of otitis media (eg, fever, ear pulling/rubbing). This infection of the middle ear
is a common childhood illness, often in conjunction with an upper respiratory infection. The child should be treated third and will
need antibiotics, but this is nonurgent. Antipyretics can be given for comfort by protocol or direct order from the health care
provider while the child is still in the triage/waiting area.
The 10-day old client's mark is a salmon-colored patch (nevus simplex or angel kiss); this is a developmental vascular
abnormality that will disappear within 1 year. It is at the nape of the neck but can also be seen on the eyelid, upper lip, or
between the eyes. The mother needs reassurance and teaching.

The child with status asthmaticus is at risk for rapid deterioration of respiratory status and respiratory failure. The clinical finding
of -to-moderate status asthmaticus. This client needs to
be treated immediately.
(Option 1) This client needs assessment and monitoring of neurological functioning following head trauma. The client is
currently stable and has the least priority at this time. Development of altered mental status, spinal pain, nausea, vomiting, or
loss of consciousness would shift the status to a higher priority.
(Option 2) The clinical findings of fatigue, abdominal pain, and blood glucose level of 690 mg/dL (38.3 mmol/L) indicate
developing diabetic ketoacidosis. This client is at risk of life-threatening hemodynamic instability and needs immediate
treatment. However, the client can be seen after the child with status asthmaticus and impending respiratory deterioration.
(Severe respiratory instability takes precedence over hemodynamic instability.)
(Option 4) This client's history is indicative of dehydration. She needs restoration of normal fluid balance, but she is not at risk of
impending severe respiratory or hemodynamic instability
Health care workers are required to abide by Occupational Safety and Health Administration standards and regulations to reduce
work-related injuries (eg, sharps) and exposure to bloodborne pathogens (eg, HIV, hepatitis B and C). A sharps disposal
container should not be overfilled and should be replaced on a regular basis to reduce the risk for a needle stick during disposal.
(Option 1) If any urine is discarded by accident during a 24-hour collection test, the procedure must be restarted. A new
container will need to be labeled with the appropriate times and date, but immediate intervention is not required.
(Option 2) The nurse will arrange for a visit from clergy to administer the last rites (Sacrament of the Sick), a religious ceremony
for Roman Catholic clients who are extremely or terminally ill. Although the situation requires prompt intervention, it does not
involve a safety hazard.
(Option 4) A fingerstick glucose of 80 mg/dL (4.4 mmol/L) is normal (70-110 mg/dL [3.9-6.1 mmol/L]) and requires no
intervention unless the client received insulin and refuses or is unable to eat.

Compartment syndrome results from swelling and increased pressure within a confined space (a compartment). It is most
common with lower extremity injuries but can also occur in the arm. Pressure from bleeding/edema can exceed capillary
perfusion pressure and lead to decreased perfusion and tissue ischemia below the site of increased pressure. Early
manifestations include increasing pain unrelieved by opioids or elevation, pain with passive motion, pallor, and paresthesia
due to nerve compression and ischemia. If the pressure is not relieved within 4-6 hours of onset (eg, surgical fasciotomy, cast
removal), irreversible nerve and muscle injury can occur.
(Option 2) Immobilization of the extremity in a sling can lead to venous pooling and edema of the hands and fingers if the sling is
not applied properly. The nurse should evaluate the elbow and hand positions and perform a neurovascular assessment, but this
is not the priority.
(Option 3) Sanguineous (red) wound drainage at 25 mL/hr is expected 1 day postoperative knee replacement. Drains are
usually removed in 24 hours unless drainage is excessive (eg, >1500 mL/24 hr).
(Option 4) Anticoagulant therapy (eg, unfractionated heparin, enoxaparin, fondaparinux) is standard following total hip
replacement. Slightly decreased hematocrit and hemoglobin levels (normal male: 39%-50% [0.39-.50], 13.2-17.3 g/dL [132-173
g/L], respectively) are expected due to intra- and postoperative blood loss.

The client with pneumonia and asthma is at risk for problems related to airway management and should be assessed first.
Clients with symptomatic asthma will receive inhaled beta agonists (eg, albuterol); however, even after medication, it is a priority
to assess this client's lung sounds, work of breathing, and level of consciousness to determine respiratory status. A sudden
decrease in wheezing may signal the development of silent chest, where airflow is rapidly reduced due to increased bronchial
constriction. This scenario can quickly progress to status asthmaticus, respiratory failure, unconsciousness, and death.
(Option 1) Unresolved pain should be reassessed by the nurse, but a client with a possible respiratory emergency takes priority.
(Option 2) Shortness of breath with activity is expected in a client with chronic kidney disease and anemia. This is most likely
due to lack of erythropoiesis (red blood cell production) related to decreased erythropoietin production in the kidney and does not
require immediate attention.
(Option 3) Dilutional hyponatremia (<135 mEq/L (135 mmol/L) is expected in a client with heart failure due to excess fluid and
can cause fatigue and headache. Change in level of consciousness and seizures can occur with sodium <120 mEq/L (120
mmol/L), but a borderline low level does not require immediate attention.

The first phone call the nurse should return is to the client with acute sinusitis prescribed azithromycin 3 days ago and now
reporting hives. Hives can be a manifestation of hypersensitivity to the macrolide antibiotic azithromycin. Anaphylaxis is a
potential complication, and the drug should be discontinued immediately. Anaphylaxis poses the greatest threat to survival, so
this is the priority call.
(Option 2) Narcotic refills cannot be prescribed on the telephone and a new prescription is necessary; this is not the priority call.
(Option 3) A low-grade temperature, myalgia, headache, congestion, pain, redness, and itching at the injection site are common
side effects within 24 hours after receiving the influenza vaccine. Clients often believe they have the flu because the
manifestations are similar; this is not the priority call.
(Option 4) Palpitations are a common, expected side effect after use of a short-acting beta-agonist metered-dose inhaler. The
nurse will assess the client's respiratory status and ask how often the client uses the rescue inhaler; this is not the priority call.

Infants with underlying infection and increased intracranial pressure (ICP) will be very irritable and have fever and a high-
pitched cry. Other signs of increased ICP include changes in pupillary reaction, sunset eyes, dilated scalp veins, poor
feeding, vomiting, and bulging fontanelles. The 3-month-old needs to be seen first due to the potential for bacterial
meningitis. If bacterial meningitis is suspected, droplet precautions should be initiated and the infant should be treated with
antibiotics immediately.
(Option 2) The absence of tears when crying indicates moderate dehydration. This infant needs evaluation but is not the
priority.
(Option 3) In children under age 6 years, the diaphragm is the major respiratory muscle. This infant is displaying normal
respiratory effort. Furthermore, cold symptoms are common in children.
(Option 4) Separation anxiety (distress when the primary caregiver is absent) is common in this age group (age 8 months to 2
years).

Nausea, vomiting, abdominal distension, and decreased stool production may signal a bowel obstruction or obstructed
ileostomy. Bowel obstruction can lead to electrolyte disturbances, dehydration, bowel perforation and infection (eg, peritonitis),
and/or tissue necrosis. It is urgent and potentially life-threatening. The client must be evaluated by the health care provider in a
timely manner.
(Option 1) Constipation is common after abdominal surgery due to opioid usage and decreased peristalsis from bowel
manipulation. Increasing food or fluids might help the client have a bowel movement.
(Option 3) Phantom limb pain is a sensation of pain or tingling in the amputated body part. Wrapping the extremity or applying
ice or heat might help until the client can be evaluated by the health care provider.
(Option 4) Active infection is a relative contraindication for elective surgical procedures. The client should be called back for
assessment and likely rescheduling of surgery but would not take priority over a client with bowel obstruction.
Clients with large body casts are at risk for bowel obstruction, which can be caused by decreased peristalsis or by cast
syndrome (ie, superior mesenteric artery [SMA] syndrome). Cast syndrome is a rare complication of an overly tight cast that
involves compression of the duodenum by the SMA. Immobilization of clients in body casts decreases peristalsis and may
cause a paralytic ileus (ie, bowel obstruction).
If severe, bowel obstruction can result in bowel ischemia. The nurse should immediately report symptoms of a bowel
obstruction (eg, abdominal pain, distension, nausea, vomiting) (Option 1). If cast syndrome is suspected, the cast may have a
window cut out over the abdomen to relieve pressure.
(Option 2) After a mastectomy, tingling, numbness, and itching are common at the incision site. A client experiencing this likely
requires reassurance, but this is a lower priority.
(Option 3) Chewing may be difficult after a neck dissection due to tissue trauma. A client experiencing this may require a diet
change, but this is a lower priority.
(Option 4) Antibiotics disrupt normal vaginal flora and may precipitate the development of a yeast infection, which presents with
vaginal discharge and itching. A client reporting this needs to be assessed, but this is a lower priority.

Cauda equina syndrome is a disorder that results from injury to the lumbosacral nerve roots (L4-L5) causing motor and sensory
deficits. The main symptoms are severe lower back pain, inability to walk, saddle anesthesia (ie, motor weakness/loss of
sensation to inner thighs and buttocks), and bowel and bladder incontinence (late sign). Cauda equina syndrome is a medical
emergency. Treatment requires urgent reduction of pressure on the spinal nerves to prevent permanent damage. This client
displays characteristic late signs of cauda equine syndrome (ie, incontinence); therefore, the nurse should assess this client first.
(Option 1) Clients with acute cholecystitis may experience referred pain to the right shoulder due to irritation of the diaphragm
from the inflamed gallbladder. Although the client's pain should be addressed, this client is not the priority.
(Option 2) Clients with gastroparesis have delayed gastric emptying and often report persistent nausea and vomiting.
Treatment includes antiemetics, but this client is not the priority.
(Option 4) Ménière disease is an inner ear disorder. Expected symptoms include episodic vertigo, tinnitus, and muffled
hearing. Treatment during an acute attack includes antihistamines, anticholinergics, and benzodiazepines. As long as the client
is safe from falling, treatment is not emergent.
Hypertensive encephalopathy (HE) is a medical emergency caused by a sudden elevation in blood pressure (eg, hypertensive
crisis) creating cerebral edema and increased intracranial pressure (ICP). Triggers of HE include an acute exacerbation of
pre-existing hypertension, drug use, MAOI-tyramine interaction, head injury, and pheochromocytoma. The client may report
severe headache, visual impairment, anxiety, confusion, and observed epistaxis, seizures, or coma.
HE may precipitate life-threatening complications such as myocardial infarction, hemorrhagic stroke, and acute kidney injury.
The client with a history of chronic hypertension and active signs of increased ICP (eg, anxiety, epistaxis) requires immediate
assessment and treatment (Option 1).
(Option 2) The client with a unilateral, pulsating headache has symptoms consistent with migraine. Supportive care for this
client includes pain and environmental management but is not a priority over a client with HE.
(Option 3) The client with abdominal cramping and vomiting may likely have food poisoning and require nonemergency
supportive care, along with additional assessment.
(Option 4) The client with multiple sclerosis (MS) may have recurrent exacerbations, including symptoms of blurred vision (due
to optic neuritis), focal weakness, and/or sensory abnormalities (eg, numbness, tingling). MS exacerbations are treated with
corticosteroids but are not immediately life-threatening.

This client who was prescribed spironolactone (Aldactone), a potassium-sparing diuretic that counteracts the potassium loss
caused by other diuretics, has high serum potassium (normal 3.5-5.0 mEq/L [3.5-5.0 mmol/L]). The continuation of this
medication puts this client at risk for life-threatening hyperkalemia-induced cardiac dysrhythmias. This finding is of highest
priority for the nurse to follow-up with the health care provider (HCP).
(Option 1) This client has positive gram-negative blood cultures. Tobramycin, an aminoglycoside antibiotic drug, is used to treat
serious gram-negative bacterial infections. There is no indication to follow-up with the HCP.
(Option 2) BNP is a hormone released by heart muscle in response to mechanical stress (stretching). BNP levels are usually
elevated (normal <100 pg/mL [100 ng/L]) in clients with heart failure, and the prescription for furosemide (Lasix), a loop diuretic, is
expected.
(Option 4) This client has hyponatremia (normal 135-145 mEq/L [135-145 mmol/L]) and is receiving isotonic normal saline
solution; there is no indication to follow-up with the HCP.

The spleen is part of the immune system and functions as a filter to purify the blood and remove specific microorganisms that
cause infections (eg, pneumococcal pneumonia, meningococcal meningitis). Overwhelming postsplenectomy bacterial
infection or rapid-onset sepsis are major lifelong complications in a client without a functioning spleen. A minor infection can
quickly become life-threatening, and so any indicator of infection such as a low-grade fever, chills, or headache needs immediate
intervention (eg, cultures, imaging, antibiotic therapy). Therefore, the client with the splenectomy who is reporting headache and
chills requires immediate action.
(Option 2) Immune thrombocytopenic purpura (ITP) is an autoimmune condition in which clients have abnormal platelet
destruction with a count <150,000/mm3 (150 x 109/L). ITP is associated with an increased risk of bleeding. A common
manifestation of ITP includes petechiae, which are pinpoint flat, red or brown microhemorrhages under the skin caused by
leakage of red blood cells. Petechiae are an expected finding.
(Option 3) A client with marked anemia can develop exertional dyspnea due to the body's inability to meet the metabolic
demands (oxygen supply) associated with activity. This is an expected finding.
(Option 4) Polycythemia vera (true primary polycythemia) is a chronic myeloproliferative disease characterized by bone marrow
overproduction of red blood cells, white blood cells, and platelets. This leads to increased hematocrit (>53% [0.53]) and blood
volume, enhanced blood viscosity, and abnormal clotting. A hematocrit of 66% (0.66) is an expected finding.
A fat embolism is life-threatening; therefore, the client with the femur fracture is the priority. There is a risk for the formation of fat
emboli following certain fractures, typically those of the long bones and pelvis. Globules of fat leave the bone and travel through
the bloodstream to the lungs, skin, and brain where they cause damage by occluding small vessels. Altered mental status will
result from blocked blood vessels in the brain. An embolism to the lung would result in respiratory distress. A hallmark sign of
fat emboli is the presence of petechiae (pin-sized red/purple spots) that result from small-vessel clotting and appear across the
chest, in the axillae, and in the soft palate.
(Option 1) This hospitalized heroin user is likely experiencing heroin withdrawal, which manifests with vomiting, abdominal
cramping, and diarrhea; restlessness and diaphoresis; frequent yawning; rhinorrhea and lacrimation; and myalgias and
arthralgias. This client needs treatment, but this condition is not life-threatening.
(Option 3) Moderate hyponatremia (normal sodium 135-145 mEq/L [135-145 mmol/L]) can cause altered mental status and can
lead to seizures if it becomes severe. This client needs treatment and should be the second priority after the client with fat
embolism.
(Option 4) Infections can cause altered mental status, especially in elderly clients. As the infection resolves, mental status
improves.

An inguinal hernia is a protrusion of intraperitoneal contents (eg, bowel, tissue) through a weakened area in the abdominal wall
(eg, groin, scrotum). Clients may experience dull pain exacerbated by exercise or straining and a palpable bulge on
assessment. A hernia is reducible if the organs can be returned to the peritoneal cavity by applying pressure to the bulge; and
incarcerated, if they cannot.
Manifestations of a mechanical bowel obstruction (eg, pain, distension, nausea, vomiting) are caused by compressed loops of
bowel incarcerated by the hernia. Subsequent bowel ischemia and strangulation can lead to infection and death. Immediate
evaluation and urgent surgical intervention are critical.
(Option 1) Elevated creatinine is expected in a client scheduled for hemodialysis. The nurse should review the prescribed
medications as many are removed by dialysis. The nurse should follow institution guidelines on holding medications before and
after dialysis and seek direction from the health care provider if necessary.
(Option 2) Medications with anticholinergic properties (eg, antihistamines [diphenhydramine]; tricyclic antidepressants
[amitriptyline]) can precipitate urinary retention, especially in susceptible clients (eg, those with benign prostatic hyperplasia).
Urinary catheterization is needed as soon as possible but is not a priority over strangulated bowel.
(Option 3) The client with excessive yellow, foul-smelling drainage will need a dressing change; however, these findings are
expected in a client with an infected venous leg ulcer.

Sexual assault is a medical emergency requiring a thorough head-to-toe physical examination by a specially trained health care
provider (eg, sexual assault nurse examiner) to identify and treat injuries. A student reporting potential sexual assault (eg,
waking in a strange room, signs of physical assault) should be instructed to seek immediate medical attention and not to bathe,
brush teeth, urinate, douche, or change clothes. These activities can delay a medical-forensic examination and interfere with
evidence retrieval and preservation. Many college and university health centers have providers for this specialized physical and
emotional care, but if they do not, the student should be referred to a local hospital emergency department.
(Option 1) The student should be reassured that although contracting viral meningitis is possible, it is unlikely as the incubation
period is 1 week and typical symptoms include headache, fever, photophobia, and stiff neck.
(Option 2) The student most likely has a rotator cuff injury and should be instructed to rest, apply ice and heat, take a
nonsteroidal anti-inflammatory drug, and seek medical evaluation.
(Option 4) The student's vaginal discharge is most likely related to a candidiasis (ie, yeast) fungal infection. The student should
be instructed to seek medical attention and refrain from sexual activity until testing for sexually transmitted diseases is completed.
Amyotrophic lateral sclerosis (ALS) is characterized by the progressive loss of motor neurons in the brainstem and spinal
cord. Clients have spasticity, muscle weakness, and atrophy. Neurons involved in swallowing and respiratory function are
eventually impaired, leading to aspiration, respiratory failure, and death. Care of clients with ALS focuses on maintaining
respiratory function, adequate nutrition, and quality of life. There is no cure, and death usually occurs within 5 years of diagnosis.
The client with ALS and worsening ability to speak (dysarthria) may also have dysphagia and respiratory distress; this client
should be seen first (Option 1).
(Option 2) The client with chronic obstructive pulmonary disease and peripheral edema may have cor pulmonale, or right-sided
heart failure, from vasoconstriction of the pulmonary vessels. Cor pulmonale is treated with long-term, low-flow oxygen;
bronchodilators; and diuretics. This client should be seen second. Right-sided heart failure (peripheral edema) is not as
dangerous as left-sided heart failure (pulmonary edema).
(Option 3) Fever often occurs with strep throat This client should be
seen last and should receive an antipyretic.
(Option 4) Wavelike flank pain is characteristic of urolithiasis (urinary stones). This client needs pain medication and, possibly,
further treatment (eg, lithotripsy) and should be seen third.

The nurse should first call the client with tingling in the right foot. Musculoskeletal injuries and immobilization devices (cast) can
cause neurologic or vascular damage to the extremity distal to the injury. Paresthesia (eg, numbness, tingling) is an early sign of
neurovascular impairment (nerve ischemia). It would be important for the client to report to the HCP for immediate evaluation.
This is the most urgent call to return.
(Option 1) Nausea is an expected side effect of the synthetic opioid pain reliever, oxycodone. The nurse can instruct this client
to take this medication with food, which may help alleviate the nausea. This is not the most urgent call.
(Option 3) Clients with diabetes are usually able to take the prescribed insulin dose when ill, and some clients may need a
higher dose. Illness is a physiologic stressor and can increase blood glucose level. On the other hand, if the oral intake is low,
blood sugars can be low and insulin may need to be reduced. The best step is to instruct this client to check glucose level and
repeat every 4 hours and to report glucose levels above or below the target range to the HCP for specific orders. This is not the
most urgent call.
(Option 4) Amitriptyline (Elavil), a tricyclic antidepressant drug, can be prescribed for difficulty sleeping due to chronic pain of
fibromyalgia, but it may not be effective in all clients. This is not the most urgent call.

The nurse should first assess the client showing symptoms of a deep venous thrombosis (DVT) (eg, unilateral edema,
warmth, redness, tenderness on palpation). DVT is a postoperative complication related to venous stasis and subsequent
thrombosis. If a DVT is suspected, early diagnostic testing (eg, venous ultrasound) and treatment with anticoagulant therapy (eg,
heparin, enoxaparin) are critical to prevent clots from traveling to the pulmonary circulation and causing pulmonary embolism.
(Option 1) The client is experiencing a common post laparoscopic cholecystectomy problem of referred pain to the right
shoulder. Carbon dioxide, used to inflate the abdominal cavity during surgery, causes irritation to the phrenic nerve and
diaphragm, which may cause difficulty breathing. Interventions for alleviation include the Sims position, deep breathing,
ambulation, and analgesics.
(Option 2) A small amount of pink serosanguineous drainage at the new tracheostomy site is expected postoperatively. The
nurse should notify the health care provider if bleeding becomes excessive.
(Option 4) Conditions that increase the likelihood of surgical site infection include obesity, immunosuppression, malnutrition,
diabetes, and advanced age. The nurse should notify the health care provider of signs and symptoms of infection (eg, fever,
purulent drainage), but the client with a DVT is priority due to the risk of pulmonary embolism.
Clients with sepsis are at risk for developing disseminated intravascular coagulation (DIC), a condition that initially causes
clotting within the microvessels. Platelets and clotting factors are consumed in clotting and become unavailable for body use,
leading to bleeding complications. The initial clotting also disrupts blood flow to extremities and organs.
Signs of DIC include frank external bleeding (eg, venipuncture site bleeding), signs of internal bleeding (petechiae,
ecchymosis, hematuria, hematemesis, and bloody stools), and respiratory distress (eg, bleeding/clotting into lungs). Signs of DIC
need immediate assessment and emergency intervention. Rapid replacement of clotting factors (fresh frozen plasma), platelets,
and blood is needed to save the client from death.
(Option 1) Stool leaking from an ileostomy bag is not a priority.
(Option 2) It is common for clients with chronic obstructive pulmonary disease to have diminished breath sounds; the goal
SpO2level in this
(Option 3) Although missing warfarin can increase the risk of clotting, most clients will usually have a therapeutic INR for 1-2
days. This is not a priority over the DIC client.
Epiglottitis refers to inflammation of the epiglottis that may result in life-threatening airway obstruction. Haemophilus
influenzae type b (Hib) was the most common cause, but the incidence has decreased dramatically with widespread Hib
vaccination.
Symptoms begin with abrupt onset of high-grade fever and a severe sore throat, followed by the 4 Ds: drooling, dysphonia,
dysphagia, and distressed airway (inspiratory stridor). Children are typically toxic-appearing and may be "tripoding" (sitting
up and leaning forward) with inspiratory stridor.
This client should be assessed first due to being unstable from an airway disorder. The client has a respiratory illness and is
drooling, which indicates respiratory distress (Option 4).
(Option 1) Purulent drainage is expected in a 1-day post tubal myringotomy client. The drainage shows the procedure was
successful.
(Option 2) A fever of 102 F (38.8 C) and petechiae in a post valve replacement client could indicate endocarditis. This client
would need to be seen second, as this is a circulation disorder.
(Option 3) A murmur is expected in a client with a patent ductus arteriosus. It is best heard at the left infraclavicular area and
has a continuous "machinery" quality.

Autonomic dysreflexia (hyperreflexia) can occur in any individual with a spinal cord injury at or above T6. The condition causes
an exaggerated sympathetic nervous system response resulting in uncontrolled hypertension.
Common triggers include bladder or rectum distention and pressure ulcers. Characteristic manifestations include acute onset
of throbbing headache, nausea, and blurred vision; hypertension and bradycardia; and diaphoresis and skin flushing above the
level of the injury. It is a medical emergency that requires immediate intervention (eg, bladder catheterization) to remove the
precipitating trigger.
(Option 1) Oliguria (<0.5 mL/kg/hr or <280 mL in 8 hours for an adult of average weight [154 lb or 70 kg]) is an expected finding
in a client with kidney injury scheduled for hemodialysis; this client assessment is not the priority.
(Option 2) Bladder spasms are an expected finding in a client with an indwelling urinary catheter following a prostatectomy. The
nurse can administer prescribed analgesic and antispasmodic drugs (eg, Belladonna-opium suppositories, oxybutynin) to
alleviate discomfort. However, this client assessment is not the priority.
(Option 3) Laser lithotripsy breaks down a large stone into small fragments to ease stone elimination. The ureteral stent
maintains ureter patency by preventing obstruction caused by edema or stone fragments. Burning on urination and hematuria
are common expected side effects associated with this procedure. This client assessment is not the priority.

The nurse should care for the client with adenocarcinoma scheduled for a lobectomy at 9:00 AM first. Not being able to sleep the
night before surgery is a common manifestation of anxiety and fear; these emotions can negatively affect recovery. For this
reason, it is important to identify and listen to the client's concerns (eg, diagnosis of cancer, fear of death, pain, anesthesia),
teach the client about what to expect following surgery (eg, pain control, tubes, intensive care environment), and provide
emotional support to help alleviate the fear and anxiety. The nurse can provide for the physical preparation of the client and
complete the preoperative checklist as well.
(Option 1) Tramadol (Ultram) 50-100 mg orally every 4-6 hours is prescribed for moderate-to-severe postoperative pain. The
client was medicated 1.5 hours ago. The drug onset is 1 hour, the peak is 2-3 hours, and the duration is 4-6 hours. Therefore,
this client is most likely stable at this time. The nurse does not need to care for this client first.
(Option 2) Moderate-to-mild bleeding 1-2 days after undergoing TURP is expected. Pink urine is a normal assessment finding.
The nurse does not need to care for this client first.
(Option 3) The client who is scheduled for discharge is stable and needs teaching about how to change the surgical dressing.
The nurse does not need to care for this client first.
Glyburide is used to treat diabetes mellitus, and it can cause significantly low blood sugar if ingested by a client who does not
have diabetes, especially a child. Based on the symptoms the child is exhibiting (irritability, confusion), hypoglycemia is likely.
This client requires immediate intervention as severe hypoglycemia can result in coma and/or death.
(Option 2) Buttock abscess, although painful, is not an emergency. Incision and drainage are needed.
(Option 3) Immune thrombocytopenia can be a serious condition due to the risk for bleeding. A client with this condition should
be assessed for internal bleeding following an injury, especially to the head. Shoulder pain is not a symptom associated with life-
threatening bleeding; therefore, this client is not the top priority.
(Option 4) This child with brassy (barking) cough most likely has croup, which can be life-threatening and needs urgent
assessment. However, because this client seems to be stable, the child with possible glyburide ingestion should be seen first.
This child has mild retractions, a sign that the child is still moving air but work of breathing has increased. The presence of stridor
or severe suprasternal, subcostal, and intercostal retractions would make this client a higher priority.

Sickle cell disease (SCD) is a group of hereditary blood disorders characterized by RBCs that become sickle-shaped, rather
than oval, when deoxygenated. Sickled RBCs are prone to clump together and obstruct blood vessels, particularly during
periods of dehydration or stress (eg, infection), which causes a sickle cell crisis (SCC).
When caring for clients with SCD, it is critical to observe for indicators of SCC. Severe, acute pain is a common symptom of
SCC due to impaired capillary blood flow (ie, vasoocclusion) and tissue ischemia. Without prompt recognition and intervention,
vasoocclusion may lead to irreversible tissue damage (eg, myocardial infarction, limb necrosis, stroke) and death (Option 3).
(Option 1) New or worsening tachycardia in clients with Graves disease, a common cause of hyperthyroidism, may be an
indicator of acute thyrotoxicosis (thyroid storm). However, tachycardia can also occur normally in clients with hyperthyroidism
and is less concerning in the presence of other normal vital signs. This client requires further assessment but is not the priority.
(Options 2 and 4) Administration of antibiotics (after changing the occluded catheter) and correction of hyperglycemia can be
safely addressed after resolving potentially life-threatening complications.

Acute pyelonephritis is a severe bacterial infection of the kidney that causes it to swell. It can lead to permanent scarring of the
kidney and can be life-threatening. Initial treatment includes vigorous parenteral IV fluids and IV antibiotics. This client's needs
are the priority as treatment is dependent on patent IV access.
(Option 2) A client scheduled for surgery who has questions about the procedure will need to speak to the health care provider
(HCP). The nurse should arrange this as soon as possible as the surgery is scheduled in 2 hours. This client is the second
priority.
(Option 3) A colostomy is a surgical opening (stoma) in the abdominal wall through which a section of large intestine is brought
outside the body, either temporarily or permanently. A colostomy bag is placed over the stoma to collect stool. It is very
important that the bag have a good fit and seal around the stoma to prevent skin breakdown due to leaking stool. The colostomy
bag can leak if not emptied or cared for properly. This client needs assessment but is not a priority over the client with acute
pyelonephritis.
(Option 4) The client who had a total hip replacement and reports no bowel movement for 2 days requires assessment.
Postoperative pain medications often cause constipation, and client teaching about the importance of adequate fluid and fiber
intake needs to be reinforced. The nurse should check the medical record for a prescription for a PRN stool softener, laxative, or
enema; if it is not included, the nurse should contact the HCP for further instructions.
First-level priorities include issues of airway, breathing, cardiac and circulation, and vital signs, respectively. A client receiving the
first dose of an antibiotic is at risk for allergic reactions, including anaphylaxis. Signs and symptoms of anaphylaxis include
itching, flushing, hives, wheezing, bronchospasm, swelling of the oral mucosa, and hypotension. This is a potentially fatal
complication that requires immediate intervention (Option 3).
(Option 1) This client with a moderate pleural effusion awaiting the corrective procedure would be the last client to be assessed
by the nurse. Shortness of breath is an expected symptom of pleural effusion. If signs or symptoms of respiratory distress or
hypoxemia occur, this client will increase in priority.
(Option 2) This client with a new cast experiencing severe pain would be the second client to be assessed. This client is at risk
for compartment syndrome and limb loss. Increasing fluid (eg, bleeding) in a confined space or decreasing compartmental
capacity (eg, casting) causes neurovascular compromise as the vessels are compressed and unable to deliver oxygen to the
tissues. Long bone fractures account for most cases of acute compartment syndrome.
(Option 4) This client with sickle cell pain would be evaluated third. Although in crisis, the client is not at risk for loss of life or
limb.

Swelling of the neck and increased pain after a thyroidectomy may indicate hematoma formation or increased tissue inflammation.
These complications have a high priority due to potential interference with airway patency.
The nurse should assess for signs and symptoms of airway compromise (eg, stridor, use of accessory muscles, restlessness). Suction
equipment should be available to clear the airway of secretions, and a tracheostomy tray should be at the bedside in case an
emergency tracheotomy is required.
(Option 1) Bruising, edema, and pain in the ankle following a popping sound indicate a possible sprain. The client should have an x-
ray, receive pain medication (eg, nonsteroidal anti-inflammatory drugs), and have the ankle iced and immobilized; however, this client is
the lowest priority.
(Option 3) Blood glucose of 423 mg/dL (23.5 mmol/L), dehydration, and ketonuria indicate possible diabetic ketoacidosis. This client
needs an IV fluid bolus, insulin, and likely electrolyte replacement following additional diagnostic testing. This client has potentially
compromised circulation and should be seen second.
(Option 4) Acute altered mental status in an elderly client may indicate infection (eg, urinary tract). Diagnostic testing is needed to
identify the source of the altered mental status; however, airway complications and circulatory compromise have a higher priority. This
client should be seen third.

Heart failure involves the inability of the heart to pump blood effectively to meet the body's oxygen needs. The nurse should first
administer the IV bumetanide (Bumex) or furosemide (Lasix) to promote diuresis and mobilize excess fluid in the systemic
circulation and lungs. This is the priority action as it improves oxygenation and gas exchange in the lungs and helps relieve
dyspnea.
(Option 2) The second unit of packed red blood cells is required to raise the hemoglobin to increase the blood's oxygen-carrying
capacity, but this is not as urgent as improving gas exchange in the lungs.
(Option 3) The patient-controlled analgesia tubing is connected to a running IV that is attached to an IV pump, so the IV line
should remain patent even if the opioid syringe is empty. A short delay in receiving analgesia does not pose a threat to the
client's survival, so this is not the priority action.
(Option 4) An electronic IV pump is used to administer a heparin infusion. A new IV container is replaced when 50 mL is
remaining to ensure the bag does not run dry. At the current rate of 50 mL/hr with 100 mL remaining, the new bag should be
hung in about 1 hour, so this is not the priority action.
A client with a traumatic head injury from blunt force can have delayed symptoms if there is bruising in the brain and subdural
hematoma/cerebral edema develops. A subdural hematoma is typically a slower venous bleed, and symptoms appear 24-48
hours later. Signs and symptoms are similar to those of increased intracranial pressure and include change in level of
consciousness, projectile vomiting, ataxia, ipsilateral (unilateral) pupil dilation, and seizures. Brain herniation can occur if the
condition is not recognized and treated.
(Option 2) Neuropsychiatric symptoms such as agitation, aggression, delusions, hallucinations, wandering, and depression are
very common in clients with dementia. Some may have an underlying etiology (eg, pain, infection) that requires identification and
treatment. This client is the second priority as the condition is not immediately life-threatening.
(Option 3) Carpal tunnel syndrome is a compression of the median nerve within the carpal tunnel at the wrist. Clinical
manifestations are weakness, pain, numbness, and impaired sensation in the median nerve distribution. Numbness is an
expected symptom; a splint is worn to relieve the pressure.
(Option 4) The third cranial nerve controls the majority (4/6) of the extraocular muscles. As a result, the lesion can cause
weakness in eye movements with resultant diplopia, which is an expected finding.

Postpartum psychosis is a rare but serious perinatal mood disorder. Research suggests a multifactorial etiology, including
genetic predisposition and hormone fluctuation after birth. Risk factors include history of bipolar disorder and previous
discontinuation of mood-stabilizing medications (eg, lithium).
Signs appear within 2 weeks after birth and include hallucinations, delusions, paranoia, severe mood changes, delirium, and
feelings that someone will harm the baby (Option 2). Postpartum psychosis is a psychiatric emergency requiring
hospitalization, pharmacologic intervention, and long-term supportive care. Women exhibiting signs of postpartum psychosis are
at increased risk of suicide and infanticide, and their assessment should take priority to ensure the safety of mother and baby.
(Option 1) Post-surgical constipation is caused by narcotic and anesthetic administration, decreased ambulation, and
manipulation of the bowels during surgery. Fluids, fiber, ambulation, and stool softeners should be encouraged. Absence of
flatus or associated nausea/vomiting would be more concerning. This is not an emergent issue; this client would be called third.
(Option 3) Urinary incontinence can occur after vaginal birth due to neuromuscular trauma and can improve with pelvic floor
exercises. This client would be called last.
(Option 4) Fatigue is common with a new baby. However, sleeping too much might indicate postpartum depression. The nurse
should call this client second for further assessment.

Clear, colorless fluid draining from the nose or ears after head trauma is suspicious for cerebrospinal fluid (CSF)
leakage (Option 3). When the drainage is clear, dextrose testing can be used to determine if the drainage is CSF. However, the
presence of blood would make this test unreliable as blood also contains glucose.
This child is at risk for intracerebral bleeding and meningitis. Vascular compromise may occur with even minimal head trauma;
therefore, the nurse should evaluate any changes in level of consciousness and temperature as well as assess the head and
neck for subcutaneous bleeding. The nurse should anticipate a CT scan of the head and neck and prophylactic antibiotics.
(Option 1) Iron ingestion is the major concern with vitamin toxicity in children. However, children's formulations contain minimal
or no iron. As a result, ingestion of an unknown quantity is unlikely to cause serious toxicity. This child should be seen second.
(Option 2) A low-grade fever is common after immunizations; this child can be seen last.
(Option 4) Although infection and pain are important, this child can be seen third.
Although this elderly client may be unconscious due to intoxication, vomit and decreased level of consciousness place this client
at risk for airway obstruction. Treatment of this client is a priority, and measures must be taken to protect the airway (eg, rescue
position, head of bed elevation, intubation).
(Option 1) Bacterial infection is the most common cause of COPD exacerbation. Although clients with COPD usually have
cough and sputum, it becomes a concern when the sputum changes in color, consistency, or volume. This client needs
antibiotics. The goal pulse oximetry reading for COPD is typically 90%-93% as many clients with COPD rely on their hypoxemic
drive to breathe. Therefore, this client is stable and can wait until the unconscious elderly client is treated.
(Option 2) This child has fifth disease ("slapped-cheek," erythema infectiosum), which is caused by parvovirus B19. Symptoms,
in addition to a bright-red facial rash, include fever and general flulike symptoms. It is harmless unless the client has a
hemolytic/immunodeficient condition. Pregnant women should avoid contact with infected individuals as the virus can be
transmitted to the fetus and cause anemia. Prioritization is determined by acuity, and therefore children do not automatically
receive higher priority. However, due to the potential exposure of this child to a pregnant client in the ED, the triage RN should
prioritize this client ahead of the one with vaginal infection.
(Option 3) This client is exhibiting a classic sign of the common Candida vaginitis (yeast) infection. Classic signs and symptoms
include itching and irritation in the vulva or vagina, white cheesy vaginal discharge, and low vaginal pH. Although uncomfortable,
this client is stable and can safely wait up to 2 hours for treatment.
This client is exhibiting localized (eg, pain, limited range of motion) and systemic infection symptoms (eg, fever), which may
indicate septic arthritis. Possible causes include recent surgery, injections, trauma, or spread from adjacent infection (eg,
cellulitis).
A septic hip is considered a surgical emergency. The hip joint is prone to develop avascular necrosis (eg, damage to the
femoral head) from compromised blood supply due to infection or injury (eg, fracture). This can result in sequelae that are
significant in both the short term (eg, sepsis, death) and long term (eg, joint destruction). Management includes culturing synovial
fluid and blood, giving antibiotics, and debriding the infected joint.
(Option 1) Bronchitis is linked to viral upper respiratory infections and is common during childhood. Congestion and a
productive cough are anticipated. This client is currently able to maintain an airway and manage secretions and therefore is not
the priority.
(Option 2) This client with epistaxis should be instructed to sit slightly forward while pinching the nose. The client should be
reevaluated in 10-20 minutes for resolution of bleeding.
(Option 3) Urinary tract infections may present with urinary frequency, burning with urination, and fever. This is not a priority
over potential septic arthritis.

Meningococcal meningitis is a highly contagious condition that involves inflammation and bacterial infection in the tissues
covering the brain and spinal cord (meninges). It is transmitted through direct contact or by inhaling droplets from infected
individuals (ie, upper respiratory tract infections) and is prevalent among those living in close proximity (eg, prisons, dormitories).
Characteristic signs include fever, headache, nuchal rigidity (stiff neck), photophobia, nausea, vomiting, and changes in mental
status. If any of these are present, prompt testing (eg, lumbar puncture [LP], cultures) and initiation of antibiotic therapy
immediately following the LP are critical as this is a life-threatening medical emergency.
(Option 2) Although this client has an infection, is at increased risk for septicemia, and needs to be treated with antibiotics and
antipyretics, this situation is not immediately life-threatening.
(Option 3) Fever and hyperglycemia are expected responses to infection, and this client needs to be treated with antibiotics and
insulin. However, this situation is not immediately life-threatening.
(Option 4) This client is at increased risk for pneumonia and needs to be treated with antibiotics, antipyretics, bronchodilators,
and expectorants. This situation is not immediately life-threatening.

An ECG should be performed immediately on all adult clients with chest pain; all chest pain should be considered cardiac until
proven otherwise. After the initial ECG, the client with chest pain will need to be placed on a cardiac monitor and assessed by
the health care provider before the other 3 clients.
(Option 2) This client will need a prescription renewal. Glargine (Lantus) is given once a day, typically in the evening, as basal
insulin. The consequence of late administration is hyperglycemia. A single temporary rise in glucose will not have a significant
negative impact. The damage to vessels in a diabetic client comes from long-term uncontrolled diabetes. The other clients are a
higher priority.
(Option 3) This client may have a deep vein thrombosis and will probably require anticoagulant therapy. However, this client is
hemodynamically stable without evidence of active pulmonary embolism and can safely wait to be seen after the higher-risk client
with chest pain.
(Option 4) This client may have acute diverticulitis and should be seen urgently, but after the client with chest pain. Prioritization
should be based on which client is most ill and not on advanced age.
The ABC (airway, breathing, circulation) and Maslow's hierarchy of needs frameworks are commonly used to prioritize client
needs.
This client with heart failure who is short of breath and coughing up pink frothy sputum has developed acute pulmonary edema
(fluid filling the alveoli), a potentially life-threatening condition. This client's status has deteriorated from baseline, is potentially
the most hemodynamically unstable, and should be assessed first.
(Option 1) This client with shortness of breath and high-pitched expiratory wheezing is experiencing expected clinical
manifestations of asthma and is the second most unstable client at this time.
(Option 2) Diabetic stasis leg ulcers can be associated with large amounts of serous or serosanguineous drainage and is an
expected manifestation. This client is not the most unstable at this time.
(Option 4) Absent breath sounds in the lung base in this client with pleural effusion is an expected finding as the collection of
fluid in the pleural space prevents the lung from expanding. This client is not the most unstable at this time.

Acute transfusion reaction is a priority as it can be life-threatening if not immediately stopped and supportive care initiated. If
untreated, hypotension, vascular collapse, respiratory distress, and disseminated intravascular coagulation ensue quickly.
(Option 1) Opioid withdrawal can be quite painful but usually is not life-threatening.
(Option 3) Pyelonephritis (kidney infection) is also serious and requires an IV antibiotic as soon as possible. However, it is not
immediately life-threatening as complications do not usually occur within minutes to hours.
(Option 4) Clients with hepatic encephalopathy need lactulose (takes hours to days to take effect). However, this condition is
not immediately life-threatening.

During a weather-related emergency, home care visits are classified as:

o High priority unstable clients who need care and are at risk for hospitalization if not seen.
o Moderate priority clients who are moderately stable and will suffer no harm if a visit is postponed; telephonic care
management can be provided to these clients.
o Low priority clients who are stable and can engage in self-care and/or have a caregiver who can provide or assist with care.

The client with a DVT should be seen first. This client has a current clot and is at risk for development of a pulmonary
embolism (PE) if the clot mobilizes. Enoxaparin is a low-molecular-weight heparin given as an anticoagulant and should not be
delayed. The nurse should monitor the client for signs and symptoms of bleeding and clinical manifestations of a PE such as
dyspnea, chest pain, or hypoxemia.
(Option 1) Atelectasis is a common complication after heart surgery. The nurse needs to assess the client and encourage
coughing, deep breathing, and use of the incentive spirometer. These interventions are important but should be done after the
other client has received enoxaparin.
(Option 2) At 4 hours post permanent pacemaker insertion, the client will need vital signs measured less frequently. The pacer
is 100% paced, indicating that it is working appropriately. This client needs assessment by the nurse but is a lower priority than
the client with DVT.
(Option 4) The client with atrial fibrillation is at risk of forming left atrial clots, which can embolize and cause stroke. Warfarin
and other anticoagulants (eg, dabigatran, rivaroxaban, apixaban) are given for prevention of clot formation. It is important that
this client receive anticoagulants, but the client with the DVT is a higher priority due to the current clot that could mobilize and
cause a PE.

A carotid endarterectomy is a surgical procedure that removes atherosclerotic plaque from the carotid artery. Clients with
carotid artery disease are at increased risk for transient ischemic attack and stroke. Post-surgical risks include cerebral ischemia
and infarction as well as bleeding.
Blood pressure is closely monitored during the first 24 hours post surgery. Hypertension may strain the surgical site and
trigger hematoma formation, which can cause hemorrhage or airway obstruction. Systolic blood pressure is maintained
at 100-150 mm Hg to ensure adequate cerebral perfusion and avoidance of hemorrhage or strain.
(Option 2) It can take 24-48 hours for peristalsis to return after bowel surgery due to manipulation of the bowels and anesthesia.
This client should be monitored for return of bowel function and should be assessed last.
(Option 3) Clients with atrial fibrillation may experience tachycardia and irregular heart rhythm even with treatment. This client
should be assessed after the client with an endarterectomy.
(Option 4) Total parenteral nutrition (TPN) should never be discontinued abruptly (due to the risk for hypoglycemia). This client
should be seen third so that TPN is not interrupted.
Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) is the most life-threatening condition listed. It occurs when the
proportion of insulin exceeds the glucose in the blood. Counterregulatory hormones (eg, epinephrine) are then released and
the autonomic nervous system is activated, causing multiple hypoglycemia-associated symptoms, including increased heart rate,
shakiness, sweating, hunger, anxiety, and pallor. The lack of glucose in the brain is also responsible for other symptoms,
including disorientation, impaired vision and speech, seizures, and coma. However, most clients respond rapidly to the
correction of hypoglycemia.
(Options 1 and 2) The client post cholecystectomy with incisional pain and the client reporting nausea after open reduction of
the right femur are in need of nursing attention. However, these are not life-threatening problems.
(Option 4) The client with type 2 diabetes mellitus has a blood glucose level of 250 mg/dL (13.9 mmol/L), but this is not
immediately life-threatening compared to the client with hypoglycemia.

Bronchiolitis is a lower respiratory tract infection most commonly caused by respiratory syncytial virus. It causes
inflammation and obstruction of the lower respiratory tract. Depending on the severity of the infection, infants with bronchiolitis
can experience mild cold symptoms or respiratory distress. The infant will have difficulty feeding and can become dehydrated.
Medical care is supportive and includes suctioning, oxygen, and hydration. The infant with irritability may be exhibiting signs
of hypoxia. The nurse should see this client first.
(Option 1) Intussusception can be reduced with hydrostatic enema (nonoperative approach). This is important but is not a
priority over a child with bronchiolitis and respiratory distress.
(Option 2) Chemotherapy can result in neutropenia and immunosuppression. Even a low-grade fever should be taken seriously
as it can result in lethal sepsis. The client needs cultures and empiric antibiotics. However, the client with bronchiolitis is the
priority.
(Option 3) Increased intracranial pressure will occur with shunt malfunction. The nurse should routinely measure the head
circumference, but it is not a priority over a client with respiratory distress.

New-onset agitation is a change in mental status for someone with dementia and requires assessment. It is possible for a client
to develop delirium in addition to dementia. Delirium is a sign of a different issue, such as worsening infection/condition, fluid and
electrolyte imbalance, or drug-drug interaction.
(Option 1) Bowel and/or bladder incontinence or retention is an expected sign/symptom in clients with multiple sclerosis.
(Option 2) Guillain-Barré syndrome is ascending bilateral paralysis from segmental demyelination (remyelination eventually
occurs). Normal deep tendon reflexes are 2+. Hypotonia (muscle weakness) and areflexia (loss of reflexes) are common
manifestations. The current level of paralysis is at the knees and is therefore not the priority as it has not yet reached the
diaphragm.
(Option 3) Drooling, lack of blinking, mask-like facial expressions, and lack of swinging arms with walking are expected findings
of Parkinson disease. This loss of autonomic movements results from alterations of the basal ganglia and extrapyramidal portion
of the central nervous system.

Infectious mononucleosis is caused by the Epstein-Barr virus. Spleen rupture is a serious complication of infectious
mononucleosis that can occur spontaneously and present with sudden onset of left upper quadrant abdominal pain. The 16-year-
old client should be taken to the emergency department for close monitoring of hemoglobin levels, supportive care to prevent
hemorrhagic shock, and possible surgery.
(Option 1) Skin peeling is expected in the subacute stage of Kawasaki disease; the new skin might be tender. This client is not
the priority.
(Option 2) Fever, cough, and a sore throat in a 7-year-old must be evaluated. However, the client's condition is not immediately
life-threatening; this client should be treated after the client with infectious mononucleosis.
(Option 3) Corticosteroid inhalers can cause oral thrush. Clients must perform proper oral care (rinsing after use) and may use
a nystatin oral suspension (swish throughout the mouth as long as possible before swallowing). This client is not the priority.

An aortic dissection occurs when the arterial wall intimal layer tears and allows blood between the inner (intima) and middle
(media) layers. Clients with ascending aortic dissections typically have chest pain, which can radiate to the back. Descending
aortic dissection is more likely associated with back pain and abdominal pain. It is frequently abrupt in onset and described as
"worst ever," "tearing," or "ripping" pain. Hypertension is a contributing factor. Extending dissection from uncontrolled
hypertension can cause cardiac tamponade or arterial rupture, which is rapidly fatal. Emergency treatment includes surgery
and/or lowering the blood pressure.
(Option 2) Severe lower back pain after lifting heavy boxes is likely due to disc herniation. Some clients may report
radiculopathy pain radiating down the leg below the knee. While uncomfortable, this is not life-threatening.
(Option 3) This is a description of intermittent claudication in the lower extremity due to peripheral artery disease. It is an
ischemic muscle pain (due to the buildup of lactic acid from anaerobic metabolism) related to exercise that resolves with rest.
(Option 4) This is a description of a deep venous thrombosis (DVT) resulting from immobility during a flight. The embolization of
DVT can cause life-threatening pulmonary embolism; the client with aortic dissection already has a life-threatening condition.
Celecoxib (Celebrex), a COX-2 inhibitor, has a black box warning for increased risk of cardiovascular complications.
Myocardial infarction symptoms, which can be vague in female clients, include nausea and upper back and shoulder pain. These
symptoms would be the priority to assess first, and immediate testing (ie, ECG, cardiac enzymes) would be warranted.
(Option 2) This client's nutritional status is concerning and needs to be addressed but would not be a priority over a client
experiencing a possible acute myocardial infarction.
(Option 3) This client needs cleaning as soon as possible to prevent fecal matter from entering into wounds. Cleaning the client
can be delegated to a licensed practical nurse or unlicensed assistive personnel and would not be a priority over a client
experiencing a possible acute myocardial infarction. The registered nurse can assess the wounds and dressings later.
(Option 4) This client's nausea and pain medication need to be addressed; they would not be a priority over a client
experiencing a possible acute myocardial infarction.

Peak expiratory flow rate (PEFR) is the peak velocity of exhaled air during forced exhalation. Clients with asthma use a peak
flow meter to monitor their PEFR and determine their level of asthma control.
An optimal PEFR is determined by recording the client's personal best peak flow number during 2 weeks of well-controlled
asthma symptoms. Guided by their personal best, clients are taught asthma self-care using peak flow "zones":
no intervention needed
Yellow zone (50%-79% of personal best): intervention needed (eg, short-acting bronchodilator [eg, albuterol]) and/or treatment
plan modification by the health care provider)
Red zone (<50% of personal best): emergency medical care and short-acting bronchodilators required and hospital admission
possible (Option 1)
(Option 2) Clients with small, uncomplicated pneumothoraxes may have a flutter (Heimlich) valve placed but can be safely
discharged home. Scant, clear pleural drainage is expected.
(Option 3) Rifampin, an antibiotic used to treat tuberculosis, may cause reddish-orange body fluids (eg, urine, sweat, tears).
This discoloration may stain contact lenses but is harmless.
(Option 4) Clients with chronic obstructive pulmonary disease (COPD) may be chronically hypoxic and hypercapnic. An
88% is generally acceptable in an asymptomatic client with COPD.

Children can have strokes. Ischemic strokes are more common in children with sickle cell disease. Other causes can include
carotid abnormalities/dissection. The most common presentation of an ischemic stroke is the sudden onset of numbness or
weakness of an arm and/or leg. These are handled with a similar emergent approach as for stroke in an adult. Children may
require exchange blood transfusion to prevent the stroke from worsening.
(Option 2) Viral meningitis can cause fever, headache, and meningeal signs (neck stiffness). Headache is expected and not a
priority over a client with stroke.
(Option 3) Intussusception occurs when one portion of the intestine prolapses and then telescopes into another. It is a frequent
cause of intestinal obstruction during infancy. Onset is abrupt, initially with pain and brown stool. The condition then progresses
to bilious emesis, palpable abdominal mass, and stools with a red, "currant jelly" appearance due to blood and mucus. This is an
expected finding for this condition, and surgery is already scheduled to address it.
(Option 4) Hemophilia is seen primarily in males and is due to a lack of clotting factors. Symptoms include spontaneous
bleeding (hemarthrosis) into the joints, especially the knee, ankle, or elbow. Treatment includes replacing the missing clotting
factor. Desmopressin (DDAVP) stimulates the release of factor VIII. The child is receiving treatment already and joint rest has
been prescribed. The sudden neurological change in the child with sickle cell crisis is a priority.
Clients who are bedridden, have undergone major surgery (eg, hip or knee replacement), or are taking estrogen-containing
contraceptive pills are at high risk of developing deep venous thrombosis. This condition can result in subsequent embolus and
life-threatening pulmonary embolism. When blood flow is blocked to certain parts of the lung, the area can become infarcted,
resulting in chest pain, shortness of breath, and cough. These clients require immediate anticoagulation to prevent extension of
the blood clot.
(Option 1) Clients with acute pericarditis have chest pain that is worse with inspiration/coughing and improves with leaning
forward. This is an expected finding. Large pericardial effusion with resultant cardiac tamponade is more serious and is
evidenced by jugular venous distension, hypotension, and muffled heart sounds.
(Option 2) This client who underwent femoropopliteal surgery likely has acute occlusion of the graft and is at risk of limb loss if
flow is not restored. However, loss of life is a priority over loss of limb.
(Option 4) Atrial fibrillation requires assessment but is not immediately life-threatening in most situations. This client has stable
blood pressure and is not the priority.

A chronic subdural hematoma involves bleeding into the subdural space that can occur several weeks to months following a
mild head trauma. Elderly clients and those taking anticoagulants are at high risk. Older individuals are vulnerable due to
age-related changes in the brain and increased risks for falls. Manifestations indicating a chronic subdural hematoma (eg,
headache, gait disturbance, memory loss, decreased level of consciousness) should be investigated immediately as the condition
can lead to increased intracranial pressure and death.
(Option 1) This client describes a bull's eye rash that can occur typically in the area of a tick bite. Evaluation is necessary, and
prophylactic antibiotics (eg, doxycycline) may be prescribed as disseminated Lyme disease can develop if left untreated;
however, this is not as urgent as a possible neurosurgical emergency.
(Option 2) Antibiotics can cause Candida infection (eg, thrush, vaginitis). Candida vaginitis can cause white, curd- or cheeselike
discharge. This client needs antifungal treatment such as fluconazole, but this condition is not immediately life-threatening.
(Option 4) Gastrointestinal side effects (diarrhea, abdominal pain, nausea and vomiting) are extremely common, reversible
adverse effects of colchicine therapy. This is not life-threatening.

The client with a BKA is experiencing phantom limb pain, pain/tingling felt in a missing portion of a limb. It is real pain that
many amputees experience immediately following surgery and that sometimes becomes chronic. This client is rating the pain at
a high level on the scale (7 of 10). The nurse should prioritize this client and administer prescribed opiates or other analgesics.
(Option 1) Because the bowels have been manipulated in AAA surgery, hypoactive sounds are common for several days
afterward.
(Option 3) Bed rest is no longer required for a client with DVT unless the client is having severe edema or leg pain. Early
ambulation does not increase the short-term risk of pulmonary embolism, and it can reduce edema and leg pain. The nurse
should see this client second to assess the affected limb.
(Option 4) Raynaud's phenomenon is usually triggered by cold exposure. During a typical episode, digital arteries (most often in
the fingers) constrict and blood flow is impaired, causing the skin to turn pale and then blue and to feel numb and cold. As blood
flow returns to the affected digits, the skin turns red and a throbbing or tingling sensation is often felt. This is an expected finding;
episodes usually resolve in 15-20 minutes once the trigger has been removed (eg, rewarming of the fingers).
The client with DVT who is experiencing chest discomfort and cough should be seen first. This client is exhibiting possible signs
of pulmonary embolism (PE), which can be a life-threatening complication. Signs and symptoms of PE include dyspnea,
hypoxemia, tachypnea, cough, chest pain, hemoptysis, tachycardia, syncope, and hemodynamic instability. The nurse should
elevate the head of the bed, administer oxygen, and assess the client. The health care provider should be notified of these
findings.
(Option 1) The administration of an IV antibiotic is important but should be done after the nurse has assessed the client with
DVT.
(Option 3) This client is hypertensive and most likely has a headache due to the high blood pressure. The nurse should assess
this client after the client with DVT and administer any antihypertensives needed.
(Option 4) This client can be delegated to unlicensed assistive personnel who can go to the room immediately.

Although it is not a STAT order, an extra dose of furosemide was prescribed for the client with congestive heart failure. The
shortness of breath is most likely due to a change in fluid status, and this client is the priority. Furosemide works immediately and
should be given urgently.
(Option 1) Even though this client has asthma exacerbation, steroids (methylprednisolone [Solu-Medrol]) do not show their
effect immediately. These drugs control underlying inflammation but take several hours/days to take effect. Bronchodilators such
as albuterol or ipratropium work immediately.
(Option 3) This client has intestinal obstruction and needs nasogastric tube placement. However, this is not a priority over a
client with heart failure.
(Option 4) This client with a sternal wound infection needs a dressing change and an antibiotic. Although this localized infection
is important, it is not the priority.
Mean arterial pressure (MAP) is the average pressure within the arteries. Compared to blood pressure alone, MAP is a more
precise measurement of the body's ability to perfuse organs and tissues. MAP of at least 60 mm Hg is required to
adequately perfuse vital organs Without intervention, MAP <60 mm Hg may progress to
ischemia, organ damage, and death (Option 3).
Common causes of low MAP include hypovolemia (eg, hemorrhage, severe dehydration), sepsis, and heart failure. Typical
interventions include replacing intravascular volume (eg, IV fluids, albumin, blood products) and administering IV medications
such as vasopressors (eg, norepinephrine, vasopressin) to induce peripheral vasoconstriction and inotropes (eg, dobutamine)
to increase cardiac contractility.
MAP is calculated automatically by intra-arterial blood pressure monitors and some noninvasive blood pressure machines. MAP
can also be calculated manually using the systolic blood pressure (SBP) and diastolic blood pressure (DBP) readings and the
following formula: MAP = (SBP + [2 × DBP])/3.
(Options 1 and 2) Central venous pressure of 6 mm Hg and cardiac output of 5 L/min are within normal limits.
(Option 4) Blood pressure of 168/95 mm Hg is an elevated reading requiring further assessment. However, low MAP is the
highest priority due to risk for tissue ischemia.

The nurse should assess the postoperative client who had the bowel resection and is currently reporting shortness of breath and
chest pain first. Abdominal surgery can cause engorgement of the large vessels in the pelvis leading to venous stasis and
increased risk for a pulmonary embolism (PE). Therefore, this client's problem poses the greatest threat to survival and requires
immediate attention.
(Option 2) This client likely developed postoperative pneumonia. Though pneumonia needs to be assessed and treated as soon
possible, it is not as life-threatening as acute PE. Pneumonia is fatal to clients within a period of days (rarely hours), but PE can
lead to death in minutes to hours, depending on its severity.
(Option 3) This client requires a thorough respiratory assessment. However, this client arrived 15 minutes ago, vital signs,
including pulse oximetry, were already measured; and the day shift nurse who received the report from the PACU nurse
assessed the client.
(Option 4) Flank pain is expected in a client who is hospitalized for a kidney stone. Providing pain relief and comfort are
priorities, but this client does not have the most urgent problem.

Post-procedure care of a client who has undergone heart catheterization should focus on evaluating hemodynamics - blood
pressure, heart rate, strength of the distal pulses, color, and temperature of extremities. The client should be also assessed
several times per hour for active bleeding, hematoma, or pseudoaneurysm formation at the incision.
The first hour after cardiac catheterization requires assessment every 15 minutes. Any report of back or flank pain should be
assessed for possible retroperitoneal bleeding as back pain, tachycardia, and hypotension may be the only indication of internal
bleeding. More than a liter of blood can pool behind the peritoneum in the pelvis undetected, and it may take up to 12 hours
before a significant drop in hematocrit can be measured. Internal bleeding after cardiac catheterization is particularly dangerous
due to frequent use of anticoagulant prescriptions in these clients.
(Option 2) A heparin infusion is used for a client with DVT. An aPTT of 60 indicates a therapeutic value. The therapeutic range
for a client on anticoagulation is usually 46-70 seconds (1½ -2 times the normal value).
(Option 3) This client should be evaluated hourly for any change in neurological status. However, because the highest possible
score on the Glasgow Coma Scale is 15 for a fully alert person, a client with a score of 14 is not in need of urgent reassessment.
(Option 4) The report of incisional pain on postoperative day 2 would take second priority for further assessment, but evaluating
a client with possible internal bleeding takes priority.
Vomiting and dry heaving place increased mechanical stress on surgical wound edges and increase the risk for wound
dehiscence and evisceration. Obese clients who have undergone extensive abdominal surgery are especially vulnerable.
Therefore, the nurse should first assess the client who is nauseated and dry heaving and administer an antiemetic
medication (Option 3).
(Option 1) This client trying to leave against medical advice is the second priority. The nurse needs to assess this client for pain
and determine when pain medication was administered last. If this situation cannot be resolved quickly, the nurse should notify
the client's health care provider immediately to determine level of competency and inform the client of the risks of refusing
treatment.
(Option 2) The nurse must follow-up 30 minutes after the morphine is administered, not immediately, to assess the effectiveness
of the pain medication.
(Option 4) Providing discharge instructions to this client can wait without consequence.

A lung contusion (bruised lung) caused by blunt force can occur when an individual's chest hits a car steering wheel. This
injury is potentially life-threatening because bleeding into the lung and alveolar collapse can lead to acute respiratory distress
syndrome. Clients should be monitored for 24-48 hours as symptoms (eg, dyspnea, tachypnea, tachycardia) are usually absent
initially but develop as the bruise worsens. Inspiratory chest pain can lead to hypoventilation, and an oxygen saturation of 90%
(normal: 95%-100%) indicates hypoxemia. Therefore, the nurse should assess this client with lung contusion first and then
notify the health care provider as immediate interventions to decrease the work of breathing and improve gas exchange (eg,
supplemental oxygen, medications, ventilatory support) may be necessary.
(Option 1) Ecchymosis and bruising due to trauma would be expected.
(Option 2) Skin irritation under rough cast edges is common; oval strips of adhesive or moleskin tape applied to the cast edge
(petals) can provide padding. Neurovascular assessment and elevation are necessary as swelling can indicate venous
compression. This is not a life-threatening priority.
(Option 4) In a client with a pneumothorax, intermittent bubbling in the water-seal chamber consistent with respirations (due to
air escaping from the pleural space) is expected until the lung has fully expanded.

Immediate postoperative nursing care focuses on management of the airway, breathing, circulation, bleeding, and pain.
Although antiemetic medications are typically administered immediately after surgery to control nausea and vomiting, nausea is
still a common complication caused by anesthetic side effects and decreased gastrointestinal motility. Clients are at high risk
for aspiration (and possible asphyxiation) due to their altered level of consciousness, which is caused by anesthesia. Clients
reporting nausea should be placed immediately on their side to prevent aspiration of vomit.
(Option 2) Mild oozing of blood from the surgical site is normal during the postoperative period. The nurse will note the amount
and appearance of the drainage, reinforce the dressings, and continue to monitor the client. This client would be seen third.
(Option 3) Pain control after surgery is important for client recovery. Because short-acting pain medications are given to
minimize respiratory depression, a client's pain can increase quickly. This client would be seen second.
(Option 4) After transurethral resection of the prostate, continuous bladder irrigation for 24-36 hours flushes out small clots and
prevents obstruction. Reddish-pink drainage is expected in the immediate postoperative period. This client would be seen last.
Infants <30 days old have immature immune systems and a blunted response to infection. The 7-day-old infant is at high risk for
bacteremia. Infectious manifestations are often subtle at this age (eg, fever can be the only symptom), although some infants
may have hypothermia, lethargy, poor feeding, or decreased urine output. Rectal temperature >100.4 F (38.0 C) or <96.8 F (36.0
C) is a "red flag" in a neonate.
(Option 2) The client receiving radiation therapy is stable, and there is 6- to 8-hour window in which to safely close the wound.
This is not a high-risk client.
(Option 3) Bacterial conjunctivitis (pink eye) presents with conjunctival erythema; thick, purulent drainage; and "crusted"
eyelids. The client will receive antibiotic drops or ointment, warm soaks/cool compresses, and infection control. Pink eye is
highly contagious but not emergent.
(Option 4) The parent has postpartum blues/depression and is not emergent. This client can be counseled or provided
resources later after the infant with fever is seen.

The nurse should check on the assigned clients in the following order:
1. Client with the gastrointestinal bleed receiving packed red blood cells (PRBCs) the nurse should:
o Check the infusion device; flow rate; and IV site, tubing, and filter
o Collect baseline physical assessment data against which to compare subsequent assessments
 o Assess for complications associated with the administration of PRBCs, which include fluid overload and an acute
transfusion reaction; these can occur at any time during the transfusion (Option 1)
2. Client with chronic kidney disease scheduled for dialysis in 30 minutes - the nurse should perform a baseline assessment
before dialysis is initiated. The nurse should then prepare the client by making sure the client eats breakfast, administering
prescribed morning medications that are not dialyzed out, and holding those that are dialyzed out. Elevated creatinine level
(eg, normal 0.6-1.3 mg/dL [53-115 µmol/L]) is an expected finding. (Option 4)
3. Client with ulcerative colitis (UC) with elevated temperature and abdominal pain UC is an inflammatory bowel disease; fever
and lower-quadrant abdominal cramping are expected findings. After assessing the client, the nurse will administer an
analgesic and an antipyretic as prescribed. (Option 2)
4. Client with history of atrial fibrillation, prescribed warfarin (Coumadin) the client is on telemetry; in most facilities, if
dysrhythmias occur, the monitor technician/nurse will notify the primary care nurse immediately. The goal INR is 2.0 to 3.0 for
atrial fibrillation. An INR of 3.2 is expected when adjusting the warfarin dose. (Option 3)

Clients undergoing lower-extremity amputation may experience surgical site pain or phantom limb pain. However, shoulder pain
radiating down the arm is an unexpected finding following an extremity amputation and may indicate myocardial ischemia.
Women, older adults, or clients with diabetes may have atypical presentations (eg, indigestion, jaw/shoulder pain, dyspnea,
diaphoresis, nausea/vomiting) other than chest pain during a myocardial infarction (Option 1).
(Option 2) In clients with pancreatitis, autodigestion of the pancreas by pancreatic enzymes causes severe, continuous,
piercing, or penetrating abdominal pain.
(Option 3) Multiple myeloma is a cancer of the bone marrow that causes bone degeneration and skeletal pain. Clients
commonly report spinal, pelvic, and rib pain with physical activity.
(Option 4) Clients with sickle cell disease experience acute painful episodes (sickle cell crisis) from exacerbation of red blood
cell sickling and vasoocclusion. Vasoocclusion can cause severe pain, most often in the upper back, arms, or legs.
Triaging clients involves decision-making about whose needs/problems are most urgent and create the greatest risk to survival.
Two popular frameworks can assist the nurse in making these decisions and setting priorities. In the "First, Second, and Third"
priority level framework, the priority needs progress from the first (most immediate) to the third (least) level of risk. They include:

1. ABCs plus V airway, breathing, circulation, and vital signs

2. Mental status changes, acute pain, unresolved medical issues, acute elimination problems, abnormal laboratory values, and
risk
3. Longer-term issues such as health education, rest, and coping
Maslow's Hierarchy of Needs is a 5-level framework in which the priority needs progress from the bottom to the top level of the
pyramid.
Infants have a high percentage of body water (70%-80% of body weight) and become dehydrated rapidly. This client is at
increased risk for fluid and electrolyte disturbances. In addition, the infant is lethargic (listless), indicating a change in level of
consciousness. This client would be assessed first (Option 2).
(Option 1) Because this client's laceration is superficial, excessive bleeding is an unlikely risk and is a relatively minor problem.
(Option 3) The hematuria and elevated temperature may be associated with a urinary tract infection or glomerulonephritis in this
client and do not present an immediate threat to survival.
(Option 4) Acute abdominal pain can be a medical emergency that could indicate appendicitis, ovarian cyst, ectopic pregnancy,
ureteral colic, or bowel obstruction. This client would be seen second.

Heatstroke occurs when excessive environmental heat exposure and/or overexertion (eg, athletics) cause hyperthermia and
depletion of fluid and electrolytes (sweating, increased respirations), specifically sodium. Eventually, hypothalamic
thermoregulation fails and sweat production stops, causing a rapid elevation of core temperature. Symptoms include:

o Temperature 104 F (40 C)

o Hot, dry skin
o Hemodynamic instability (tachycardia, hypotension)
o Altered mental status/neurological symptoms (confusion, lethargy, coma)

Risk for permanent neurological injury or death from heatstroke is related directly to the degree and duration of hyperthermia.
Treatment involves stabilization of ABCs and rapid cooling interventions (eg, cool water immersion, cool IV fluid infusion).
Antipyretics are ineffective as hyperthermia is unrelated to the inflammatory process (infection).
(Option 1) Epinephrine auto-injectors (eg, EpiPen) for emergency treatment of allergic reactions can be accidentally injected,
potentially causing adverse effects related to adrenergic activation (eg, tachycardia and hypertension). This client requires
monitoring and supportive care (eg, antihypertensive medications).
(Option 2) A child with vaginal lacerations requires evaluation for possible sexual abuse (ie, physical examination, evidence
collection, mandatory reporting). This client needs treatment but is not the priority.
(Option 3) An abscess requires treatment with antibiotics and, possibly, surgical intervention. However, this client is presently
stable and not the priority.

Phlebitis is an inflammation of a vein. Common manifestations include pain, swelling, warmth at the site, and redness extending
along the vein. Causes include irritating drugs (eg, vancomycin), catheter movement within the vein (eg, inadequate
stabilization), or bacteria (eg, poor aseptic technique). If signs of phlebitis are present, immediate removal of the catheter is
necessary as phlebitis can lead to thrombophlebitis and emboli or a bloodstream infection.
(Option 1) Itching (pruritus) and nausea are common and expected adverse effects associated with the administration of
opioids. Histamine blockers, such as diphenhydramine (Benadryl) or hydroxyzine (Atarax), and an antiemetic, such as
ondansetron (Zofran), can provide relief.
(Option 2) Evidence-based practice guidelines recommend changing a continuous IV peripheral tubing administration set no
earlier than every 72 hours unless it becomes contaminated (institutional policies and procedures vary). Intermittent infusions
and hypertonic solutions (eg, total parenteral nutrition, propofol, blood) require more frequent changes (eg, 4-24 hours) due to
increased risk for infection.
(Option 3) Parenteral and oral anticoagulant medications are administered concurrently until the International Normalized Ratio
reaches a therapeutic range of 2-3, at which time the heparin infusion can be discontinued and the warfarin continued. This
therapy is expected.
Priapism is a prolonged, painful erection (>2 hours) caused by trapping of blood in the penile vasculature that can lead to erectile
tissue hypoxia and necrosis. The condition is usually idiopathic, secondary to prescription medications (eg, sildenafil, trazodone)
or a preexisting medical condition (eg, sickle cell disease, cocaine use). The nurse should return this call first as the condition is
a medical emergency that can result in permanent erectile dysfunction; it requires urgent treatment in the emergency
department.
(Option 1) Urinary tract infections can recur in sexually active women. This client needs antibiotics but is not a priority.
(Option 3) This client may have some degree of prostatic hyperplasia given his age. Decongestants (eg, pseudoephedrine) or
antihistamines (eg, diphenhydramine) should be used with caution as they can lead to difficulty voiding and acute urinary
retention. The client needs to be assessed, but this is not the most emergent call.
(Option 4) The client with prostate cancer may need increasing pain medication as clients develop tolerance to opioids.
However, this is not a priority.

A peripherally inserted central catheter (PICC) is inserted via the basilic or cephalic veins into the superior vena cava. The nurse
should measure and document the external length of the PICC during dressing changes. A change in the length of the external
portion of the catheter can indicate migration of the tip of the catheter from its original position. The nurse should hold IV fluids
and medications, secure the PICC to prevent further movement, and notify the health care provider for x-ray evaluation of
catheter tip placement.
(Option 1) After abdominal surgery, placement of a nasogastric tube to decompress the stomach and the absence of bowel
sounds for 24-72 hours due to postoperative paralytic ileus would be expected.
(Option 3) The client with malabsorption syndrome is unable to digest and absorb nutrients by the gastrointestinal tract.
Peripheral parenteral nutrition with 10% dextrose is an expected treatment.
(Option 4) The hemoglobin A1C level of 9% is above the recommended level (ie, <7%) and reflects inadequate glycemic control,
which can be expected in a client with diabetes mellitus.

The American Society for Parenteral and Enteral Support (ASPEN) recommends 140-180 mg/dL (7.8-10.0 mmol/L) as the target
range for glucose control in clients receiving nutritional support. Hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]) can be
due to slowing the rate of the infusion. Although it occurs less frequently in clients receiving total parenteral nutrition (TPN) than
hyperglycemia (serum glucose >180 mg/dL [10.0 mmol/L]) does, hypoglycemia can lead to life-threatening complications (eg,
seizures, nervous system dysfunction). Therefore, the serum glucose of 68 mg/dL (3.8 mmol/L) is the laboratory finding of
highest priority for the nurse to report to the health care provider (HCP).
(Option 1) A CD4+ cell count of 500/mm3 (0.5 × 109/L) in a client with HIV who is receiving oral fluconazole (Diflucan) to treat
oral candidiasis is within normal limits (500-1,200/mm3 [0.5-1.2 × 109/L]) and does not need to be reported to the HCP.
(Option 2) A hemoglobin A1C (HbA1c) of 7.3% in a client with type 2 diabetes who is receiving IV levofloxacin to treat pneumonia
is not exceptionally high; the recommended goal is <7%. A bacterial infection causes physiologic stress and increased serum
glucose. This increases insulin requirements but would not affect the current HbA 1c level, as it reflects glucose control over a 2-3
month period. Therefore, this finding is not the highest priority for the nurse to report to the HCP.
(Option 3) Heparin can lead to thrombocytopenia. However, a platelet count of 148,000/mm3 (148 × 109/L) is just below normal
limits (150,000-400,000/mm3 [150-400 × 109/L]). Therefore, this finding does not need to be reported to the HCP.
Rhabdomyolysis occurs when muscle tissue is damaged and myoglobin (protein found in muscle tissue) is released into the
blood, usually after an injury from overexertion, dehydration, severe vasoconstriction (eg, cocaine use), heat stroke, or
trauma. Acute kidney injury can occur when myoglobin overwhelms the kidneys' filtration ability. As myoglobin is excreted,
the urine becomes very dark and is described as being a cola-brown color.
Severely elevated creatine kinase levels, typically >15,000 U/L (>250 µkat/L), are observed with severe muscle damage and
can be a precursor to kidney injury (Option 2). Forced saline diuresis with intravenous fluids (to prevent blockage of the renal
tubules with myoglobin) is necessary to prevent permanent kidney damage.
(Option 1) Postoperative leukocytosis (leukocytes >11,000 mm3 [>11X109/L]) is common in the first 48 hours after orthopedic
surgery from normal inflammatory immune responses.
(Option 3) Clients with end-stage renal disease commonly have elevated creatinine and blood urea nitrogen levels. These are
expected findings.
(Option 4) Increased brain natriuretic peptide levels can indicate stretching of the chambers of the heart in heart failure. Levels
>100 pg/mL (>100 pmol/L) can indicate heart failure and would be expected in this client.
Sepsis neonatorum is a medical emergency. Newborns may not exhibit obvious signs of infection but instead may have
elevated temperature or be hypothermic. Subtle changes such as irritability, increased sleepiness, and poor feeding should
be considered red flags. Blood, urine, and cerebrospinal fluid cultures should be obtained immediately and broad-spectrum
antibiotics started.
(Option 2) This infant has signs of a hydrocele, a fluid-filled testicular mass. Most hydroceles resolve before the first birthday
and are not a medical emergency.
(Option 3) Children's bubble soap is non-toxic. As a precaution, the poison control center should be contacted, but this is not a
priority over a newborn with fever.
(Option 4) This child likely has an upper respiratory viral or bacterial (streptococcal) infection. This localized infection is not a
priority over generalized/bloodstream infection (neonatal sepsis).

The nurse should assess first the newly admitted client with gastroenteritis as prolonged vomiting increases the risk
for dehydration, acid-base and electrolyte disturbances (eg, orthostatic hypotension, acid loss, hypokalemia, hyponatremia),
and potential cardiac dysrthythmias. The client is exhibiting manifestations of hypokalemia, including muscle cramps and
muscle weakness. Hypokalemia can lead to dangerous cardiac arrhythmias (Option 2).
(Option 1) A histamine-related reaction (eg, pruritus) is an expected adverse effect associated with the administration of epidural
morphine (Astramorph), so this client does not need to be assessed first. An antihistamine such as IV diphenhydramine
(Benadryl) may be prescribed to help alleviate itching.
(Option 3) This client may have been excessively diuresed (eg, with bumetanide [Bumex]) and could have orthostatic
hypotension. This client is the second priority. Because the client is in the hospital, the risk of severe hypokalemia is low (as
most clients receive potassium supplements), and the client is not exhibiting symptoms of hypokalemia.
(Option 4) Gross hematuria is an expected manifestation of poststreptococcal glomerulonephritis. It is usually mild and does not
require urgent attention.

The nurse should assess the client with seizure activity first. This client is at increased risk for injury, aspiration, and airway
obstruction. The nurse should obtain baseline neurological vital signs (eg, level of consciousness, pupillary reaction, speech,
hand grasps) against which to compare subsequent findings and to evaluate the client's response to lorazepam. The client
requires a safe environment, so the nurse should also ensure that fall and seizure precautions (eg, full side rail pads, low bed,
floor mats, suction equipment, oxygen at bedside) have been initiated.
(Option 1) A serious ABO incompatibility/transfusion reaction typically occurs within the first 15 minutes or 50 mL of transfusion.
The unit of packed red blood cells was hung 1 hour ago; therefore the baseline 15- and 30-minute vital signs have already been
recorded. The nurse will assess the client and infusion rate and site but does not need to check on this client first.
(Option 2) Hemoglobin of 7 g/dL (70 g/L) is not life-threatening and many clients can tolerate this level. IV iron administration is
not a priority.
(Option 4) The nurse should ensure that the consent form is signed and the client understands the bone marrow biopsy (BMB)
procedure, but this client should not be assessed first. BMB is done at the bedside and usually does not have major
complications.
The liver is a highly vascular organ and bleeding is a major complication. Tachycardia is an early sign of internal hemorrhage.
The 65-year-old client should be assessed first.
(Option 1) Tachycardia can be caused by underlying infection and can resolve with treatment of the infection. Valve infections
can require several weeks of antibiotics. This client is not the priority.
(Option 2) Pancreatitis is a very painful condition and sinus tachycardia is expected. These clients are also at risk of developing
complications such as third spacing of volume and require large quantities of IV fluids. This client is the second priority.
(Option 4) Atrial fibrillation is commonly treated with calcium channel blockers such as diltiazem. The dosage needs to be
adjusted to achieve a goal heart rate of <100/min. Atrial fibrillation is usually not immediately life-threatening.
Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is often caused by the ectopic production of ADH by a
malignant lung tumor (eg, lung cancer). Increased ADH leads to increased water reabsorption and intravascular volume, which
results in dilutional hyponatremia. Severe neurologic dysfunction (eg, confusion, seizures) can occur when serum sodium
drops below 120 mEq/L (120 mmol/L) (normal: 135-145 mEq/L [135-145 mmol/L]). Therefore, hyponatremia is the highest
priority to report as it poses the greatest threat to survival. Hyponatremia requires immediate evaluation and treatment (eg,
seizure precautions, fluid restriction, intravenous hypertonic saline) by the health care provider.
(Option 1) Albumin (normal: 3.5-5.0 g/dL [35-50 g/L]) is a protein formed in the liver. Hepatocytes lose the ability to synthesize
albumin when the cells are diseased. Hypoalbuminemia (<3.5 g/dL [<35 g/L]) should be expected in this client.
(Option 2) B-type natriuretic peptide (BNP) (normal: <100 pg/mL [100 pmol/L]) is a substance secreted from the cardiac
ventricles in response to increases in ventricular pressures and volume. Therefore, BNP is a marker for heart failure and is
elevated in clients with both stable and decompensated heart failure. BNP is an expected finding in this client.
(Option 3) Clients in alcohol withdrawal usually require magnesium supplements. Hypomagnesemia (<1.5 mEq/L [<0.75
mmol/L]) results from poor dietary intake, malnutrition, and increased renal excretion, and is common in clients with chronic
alcoholism. This finding is within normal limits (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]).
Sepsis is an exaggerated response to an infection in the bloodstream, often originating from a local infection (eg, pressure injury),
that results in potentially life-threatening organ impairment. Older adults are at increased risk for sepsis due to normal, age-
related decreases in the immune and inflammatory response (ie, immunosenescence).
Because of altered immune function, older adults often do not develop typical signs of infection (eg, fever, leukocytosis). Instead,
nurses must observe for and immediately report atypical indicators of infection (eg, altered mental status, hypothermia,
leukopenia) because early identification and intervention reduce mortality (Option 4).
(Option 1) Chronic use of central nervous system depressants (eg, alcohol) causes a reflexive increase in catecholamine
production (eg, epinephrine). During alcohol withdrawal, hypertension, agitation, and anxiety occur because catecholamine
production is no longer inhibited.
(Option 2) Clients with stable angina (ie, chest and jaw pain relieved with sublingual nitroglycerin) often experience orthostatic
hypotension, an adverse effect of nitrate drugs.
(Option 3) Clients with chronic kidney disease (CKD) commonly experience nausea and pruritus due to buildup of nitrogenous
wastes in the blood (ie, azotemia). Elevated creatinine is an expected finding in CKD. Hypertension does require intervention by
the nurse after management of infection and sepsis.

The kidney transplant client is likely immunosuppressed by steroids and anti-rejection drugs (eg, cyclosporine, tacrolimus). In
general, organ transplant clients will have a blunted response to infection, such as a low-grade fever. This client has systemic
symptoms, which may indicate a serious underlying infection. Some of these clients develop fulminant sepsis within a few hours
if the antibiotics are delayed. As a whole, management of systemic signs/symptoms takes priority over that of localized
signs/symptoms.
(Option 1) This client likely has cellulitis from IV drug use and will need cultures and antibiotics. However, this should not be
prioritized over an immunosuppressed client.
(Option 3) This elderly client with diverticulosis likely has diverticulitis (infection of the existing diverticula) and will need bowel
rest and antibiotics. However, this is not the priority.
(Option 4) This client with fever and right knee swelling after knee replacement likely has prosthetic joint infection. The joint
needs to be tapped, and the client will need antibiotics and potential prosthesis removal. However, this is not immediately life-
threatening. It is important to know that such clients (with knee or hip joint replacement) do not take immunosuppressants.

Systemic inflammatory response syndrome (SIRS) is a pathophysiologic response mediated by the release of large quantities
of inflammatory cytokines from the inflammatory cascade. Overwhelming release of inflammatory cytokines triggers vasodilation
and capillary leakage, leading to hypotension and impaired end-organ perfusion. SIRS may occur in response to trauma, tissue
ischemia, infection (ie, sepsis), and shock and can rapidly progress to hemodynamic instability, respiratory failure,
and multiorgan dysfunction.
Clinical manifestations of SIRS include fever or hypothermia, tachycardia, leukocytosis or leukopenia, and tachypnea (often
associated with a low PaCO2 value). Clients who develop multiple symptoms of SIRS require aggressive fluid
resuscitation and treatment to address possible causes (eg, antibiotics for infection) as SIRS may be life-threatening (Option 3).
(Options 1 and 2) Addressing a client's postoperative pain and nausea and further assessing a client with hyperglycemia and
diabetes are important but are lower priorities than initiating care for SIRS.
(Option 4) A client with persistent diarrhea should have both total intake and output and recent electrolyte levels assessed, but
signs of SIRS should be addressed first.
Older individuals, diabetic clients, and women may have atypical angina symptoms rather than the characteristic crushing,
substernal type of chest pain. These symptoms include atypical pain (jaw or arm), shortness of breath, indigestion, nausea,
dizziness, and cold sweats. This client reports symptoms thought to be related to a dental problem, but the nurse needs to
gather more information. The symptoms can indicate a cardiac medical emergency (myocardial ischemia or acute myocardial
infarction) that requires immediate evaluation and intervention.
(Option 1) Minor expected adverse effects can occur 1-2 days after influenza vaccination. Symptoms include flulike symptoms
(eg, fever, aching, itching at the injection site); analgesia with ibuprofen or acetaminophen can help provide relief.
(Option 2) The client's symptoms began following a specific event and can indicate a rotator cuff injury. Imaging, treatment with
nonsteroidal anti-inflammatory drugs, and physical therapy may be indicated. Although further evaluation is necessary, this is not
a medical emergency.
(Option 4) Solifenacin (VESicare) is a cholinergic antagonist prescribed to treat symptoms associated with an overactive bladder
(eg, urge incontinence, frequency). Common expected adverse effects include dry mouth and constipation. The nurse should
caution the client about safety when performing activities until the response to the medication is determined, as it can also cause
dizziness and blurred vision. This is not a medical emergency.
Overdoses are generally a priority due to the unpredictability of dosing and client response. Specifically, the tricyclic
antidepressant amitriptyline (Elavil) is lethal if taken in overdose, especially if consumed with alcohol. It is estimated that 70%-
80% of clients with tricyclic antidepressant overdose die before reaching the hospital.
Amitriptyline was historically used for depression; it is now used for insomnia and neuropathic pain. Death results from serious
cardiac arrhythmias.
(Option 1) An anterior cruciate ligament injury is common in athletes and results from sudden twisting of the knee. Rapid
effusion, pain, and an audible "pop" are classic signs. A pop can also be heard in fractures. Regardless of the specific
diagnosis, this is an isolated orthopedic injury. As a rule, a systemic problem (eg, overdose) takes priority over a localized one.
(Option 2) Glomerulonephritis is inflammation (acute or chronic) of the kidney; manifestations include hematuria that results in
urine with a rusty, smoky, or "iced tea" color due to the presence of blood. Because most acute episodes resolve spontaneously,
this is not the priority.
(Option 3) This client has a reasonable potential explanation (scratched cornea) and no history of foreign substance requiring
emergent irrigation. Although the client is uncomfortable, the overdose is the priority.
The nurse should first assess the client who had bowel surgery as hypotension can be a manifestation of bleeding, hypovolemia,
and early septic shock. The nurse should check vital signs and perform a cardiovascular assessment.
(Option 2) Cheyne-Stokes respiration is a repetitive, abnormal, irregular breathing pattern characterized by alternating deep and
shallow respirations followed by periods of apnea (10-20 seconds). The pattern is usually associated with certain neurologic
conditions (eg, stroke, increased intracranial pressure) and with end of life; it would be expected in this client.
(Option 3) Shortness of breath and tachycardia with activity related to decreased hemoglobin level, red cells, and oxygen-
carrying capacity would be expected in a client with moderate to severe anemia.
(Option 4) Kussmaul breathing is characterized by regular but rapid, deep respirations and is associated with conditions that
cause metabolic acidosis (eg, renal failure, diabetic ketoacidosis, shock). Kussmaul breathing would be expected in this client as
it is a compensatory action by the lungs to excrete excess acid from the body by hyperventilating, thereby blowing off carbon
dioxide (acid gas).
Declining neurological status threatens the airway and breathing; therefore, the client with the Glasgow Coma Scale (GCS) score
of 9 is the highest priority according to the ABCDs and Maslow's Hierarchy of Needs. A GCS score of 8 or lower is classified as a
coma. Comatose clients are usually intubated to protect the airway ("when you are 8, intubate").
(Option 1) Clients with migraine headaches have episodes of severe pain (migraine attacks). Development of new-onset
headache without a known etiology would be concerning. The client with declining neurological status and a GCS score of 9 is
the highest priority.
(Option 2) After a tonic-clonic seizure, the client wakes up gradually. It is not unusual for the client to be confused and
disoriented on awakening and then to sleep for a few hours. The key concern is safety (eg, use of padded side rails, raised side
rails, suction equipment in room). The nurse can teach family members the disease process and emergency care of seizures
later. For now, they should encourage the client to remain in the bed with the side rails up.
(Option 3) Amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease) involves a progressive neurological loss of motor
neurons. Typical expected symptoms are limb weakness, dysarthria (difficulty speaking), and dysphagia.

A bronchoscopy is an invasive procedure that allows visualization of the internal air passages via a flexible tube (bronchoscope)
passed through either the nose or mouth to the internal airways. Following the procedure, the client will need to be monitored for
complications such as bleeding, bronchial perforation, pneumothorax, and bronchial spasm. Potential for airway compromise
requires that this client be seen first.
(Option 1) A child with a potential hip dislocation will need to be evaluated, but this is not a priority.
(Option 3) A CT scan can be done with or without the use of contrast (dye). Use of contrast would require monitoring for an
allergic reaction to the dye. This client is young and has no parents present; the nurse will need to ascertain that basic needs are
being met.
(Option 4) This client is awaiting surgery. The nurse will need to assess that consent is signed and check for preoperative
prescriptions. Although important, it is not a priority over the 6-year-old client's airway.

The client with a low body temperature and drowsiness needs immediate intervention to prevent and/or reverse physiologic
compromise. Signs of hypothermia include a core temperature (eg, rectal) less than 95 F (35 C), mental status changes,
shivering, and impaired coordination. Alterations in acid-base balance, coagulation values, and cardiac function may also occur.
Hypothermia can lead to cardiac and respiratory failure and coma (Option 4).
Homeless clients are at higher risk for hypothermia from exposure to the elements, infections, and poorly managed chronic
health conditions. The nurse should anticipate a workup for sepsis and various types of shock, in addition to environmental
factors, while addressing this client's hypothermia.
(Option 1) Hemorrhagic cystitis (eg, bladder inflammation) is a well-known complication
of cyclophosphamide (immunosuppressant and chemotherapy agent). The client is instructed to drink plenty of fluids. This
client may need IV hydration and other preventive measures (eg, mesna therapy). Bleeding is usually minimal and occasionally
requires a blood transfusion, but is rarely life threatening.
(Option 2) Nausea and vomiting are expected side effects after chemotherapy. This client needs IV access established (if the
chemotherapy port cannot be accessed) to address the nausea and prevent dehydration. However, this client would not take
priority.
(Option 3) This client needs to have all wounds cleaned and irrigated prior to suturing, but would not take priority.
Life-threatening physiological problems (eg, airway, breathing, circulation) are the highest priority followed by less threatening
problems (eg, pain, potential for infection). Unilateral edema and calf pain could be signs of a deep venous thrombosis
(DVT), a high-priority circulation problem in which a lower-extremity clot may dislodge, travel, and cause life-threatening
complications (eg, pulmonary embolism). Prolonged immobilization (eg, airplane travel, bed rest) increases the risk for DVT.
(Option 1) A client with leg pain during activity that is relieved by rest may have intermittent claudication, a classic sign of
peripheral artery disease. This condition is not an immediate threat to survival.
(Option 2) The client with diabetes has a preexisting medical condition. Physiologic stress related to elevated temperature and
possible infection would most likely increase serum glucose level. Although infection in a client with diabetes can present a risk
to survival, it is not immediate at this time.
(Option 4) The client with a dog bite will need antibiotics and possibly a rabies vaccination, but there is no immediate threat to
survival.

A common adverse effect of chemotherapy is bone marrow suppression (eg, anemia, leukopenia, thrombocytopenia) and
immunosuppression. A decreased neutrophil (type of white blood cell) count, termed neutropenia, increases the client's
susceptibility to infection. A fever can signal an infection and, in the presence of neutropenia (ie, neutropenic fever), can rapidly
develop into life-threatening sepsis. Even a low-grade fever should be taken seriously in these clients.
(Option 1) Hodgkin lymphoma is a malignant cancer of the lymphatic system. Expected early manifestations include painless
enlarged lymph nodes, fatigue, fever, weight loss, and drenching night sweats. The client's white blood cell count is within
normal limits (4,000-11,000 mm3 [4.0-11.0 × 109/L]).
(Option 2) Acute cholecystitis involves inflammation of the gallbladder. Expected manifestations include right upper quadrant
pain that can radiate to the right shoulder, nausea, vomiting, fever, and leukocytosis (white blood cells count >11,000/mm 3 [11.0
× 109/L]). The client is scheduled for surgery and is likely on antibiotics. Even if the client is not on antibiotics, neutropenia is a
priority over acute cholecystitis.
(Option 3) Clostridium difficile is a toxin-producing bacterium that proliferates in the lower gastrointestinal tract. Expected
manifestations include diarrhea, fever, and leukocytosis. First-line pharmacologic treatment includes metronidazole (Flagyl) and
oral vancomycin.

The child with a recent tonsillectomy is at highest safety risk. Postoperative hemorrhage from tonsillectomy is uncommon but
may occur up to 14 days after surgery. During the healing process, white scabs will form at the surgical sites. Sloughing then
occurs approximately 7 days after the procedure, increasing the risk for bleeding. Caregivers should be taught to observe for
signs of bleeding (eg, frequent swallowing or throat clearing). The child may also experience increased pain. The nurse should
instruct this parent that the child should not resume strenuous activity or contact sports for at least 7-14 days post surgery.
(Option 1) Tympanostomy tubes or grommets are pressure-equalizing tubes placed in the tympanic membrane to facilitate
drainage of middle ear fluid (eg, for eustachian tube dysfunction or recurrent otitis media with effusion). One of this child's tubes
has most likely fallen out of the eardrum. No immediate intervention is required; however, the health care provider should be
notified.
(Option 2) Clients often report ear pain (otalgia) following adenotonsillectomy due to irritation of the 9th cranial nerve
(glossopharyngeal) in the throat, causing referred pain to the ears. This is a normal, expected finding.
(Option 3) The contagious period for strep throat starts at the onset of symptoms and lasts through the first 24 hours of
beginning antibiotic treatment. This client is able to return to activities and does not require an immediate call back.