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ATI PN Comprehensive Predictor Review (complete A+ study guide)

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ATI PN Comprehensive Predictor Review Do not delegate - What you can *EAT* *E*-evaluate *A*-assess * T-*teach Addison's & Cushings - Addison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia Better peripheral perfusion? - Elevate veins, D-Angle Arteries APGAR - Appearance (all pink, pink and blue, blue (pale) Pulse (100, 100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent) Airborne precautions - MTV or My chicken hez tb measles, chickenpox (varicella) Herpes zoster/shingles TB Airborne precautions protective equip - private room, neg pressure with 6-12 air exchanges/hr mask & respirator N95 for TB Droplet precautions - spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room and mask) Contact precaution - MRS WHISE protect visitors & caregivers when 3 ft of the pt. Multidrug-resistant organisms RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by micro-organisms (C diff), Gloves and gowns worn by the caregivers and visitors Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag PMGG= Private room/ share same illness, mask, gown and gloves Skin infection- *VCHIPS* - Varicella zoster Cutaneous diptheria Herpes simplez Impetigo Peduculosis Scabies Air or Pulmonary Embolism - S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.) Woman in labor (un-reassuring FHR) - (late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids! Tube feeding with decreased LOC - Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration) LOC - Level of Consciousness After lumbar puncture and oil based myelogram - pt is flat SUPINE (prevent headache and leaking of CSF) Pt with heat stroke - flat with legs elevated during Continuous Bladder Irrigation (CBI) - catheter is taped to the thigh. leg must be kept straight. After Myringotomy - position on the side of AFFECTED ear, allows drainage. Myringotomy - surgical incision into the eardrum, to relieve pressure or drain fluid. After Cateract surgery - pt sleep on UNAFFECTED side with a night shield for *1-4 weeks* after Thyroidectomy - low or semi-fowler's position, support head, neck and shoulders. Infant with Spina Bifida - Prone so that sac does not rupture Buck's Traction (skin) - elevate foot of bed for counter traction After total hip replacement - don't sleep on side of surgery, don't flex hip more than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows. Prolapsed cord - Knee to chest or Trendelenburg oxygen 8 to 10 L Cleft Lip - position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position. To prevent dumping syndrome - (post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent meals. AKA (above knee amputation) - elevate for first 24 hours on pillow. position prone daily to maintain hip extension. BKA (below knee amputation) - foot of bed elevated for first 24 hours. position prone to provide hip extension. detached retina - area of detachment should be in the dependent position dependent position - supported administration of enema - pt should be left side lying (Sim's) with knee flexed. supratentorial - (incision behind hairline on forhead) e After supratentorial surgery - elevate HOB 30-40 degrees HOB - head of bed infratentorial - (incision at the nape of neck) After infratentorial surgery - position pt flat and lateral on either side. During internal radiation - on bed rest while implant in place Autonomic Dysreflexia/Hyperreflexia - S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST! Shock - bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg) Head Injury - elevate HOB 30 degrees to decrease ICP Peritoneal Dialysis (when outflow is inadequate) - turn pt from side to side BEFORE checking for kinks in tubing Lumbar Puncture - After the procedure, the pt should be supine for 4-12 hours as prescribed. Myesthenia Gravis - worsens with exercise and improves with rest Myesthenia Gravis - a positive reaction to Tensilon---will improve symptoms Cholinergic Crisis - Caused by excessive medication ---stop giving Tensilon...will make it worse. Liver biopsy (prior) - must have lab results for prothrombin time Myxedema/ hypothyroidism - slowed physical and mental function, sensitivity to cold, dry skin and hair. Grave's Disease/ hyperthyroidism - accelerated physical and mental function. Sensitivity to heat. Fine/soft hair. Thyroid storm - increased temp, pulse and HTN Post-Thyroidectomy - semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside Hypo-parathyroid - CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet Hyper-parathyroid - fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet Hypovolemia - increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity 1.030 Hypervolemia - bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity 1.010. semi fowler's Diabetes insipidus (decreased ADH) - excessive urine output and thirst, dehydration, weakness, administer Pitressin SIADH (increased ADH) - change in LOC, decreased deep tendon reflexes, tachycardia. N/V HA administer Declomycin, diuretics hypokalemia - muscle weakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges, beans, potatoes, carrots, celery) Hyperkalemia - MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes Hyponatremia - nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids Hypernatremia - increased temp, weakness, disorientation, dilusions, hypotension, tachycardia. give hypotonic solution. Hypocalcemia - CATS Convulsions, Arrythmias, Tetany, spasms and stridor Hypercalcemia - muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, shallow respirations, emergency! Hypo Mg - Tremors, tetany, seizures, dysthythmias, depression, confusion, dysphagia, (dig toxicity) Hyper Mg - depresses the CNS. Hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations. EMERGENCY Addison's - Hypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. GI stress. Cushings - Hyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump Addesonian crisis - N/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP Pheochromocytoma - hypersecretion of epi/norepi. persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods (surgery to remove tumor) Tetrology of Fallot - DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis) Autonomic Dysreflexia - (potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) FHR patterns for OB - Think VEAL CHOP! V-variable decels; C- cord compression caused E-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill what to check with pregnancy - Never check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope. Position of the baby by fetal heart sounds - Posterior --heard at sides Anterior---midline by unbilicus and side Breech- high up in the fundus near umbilicus Vertex- by the symphysis pubis. Ventilatory alarms - HOLD High alarm--Obstruction due to secretions, kink, pt cough etc Low alarm--Disconnection, leak, etc ICP and Shock - ICP- Increased BP, decreased pulse, decreased resp Shock--Decreased BP, increased pulse, increased resp Cor pumonae - Right sided heart failure caused by left ventricular failure (edema, jugular vein distention) Heroin withdrawal neonate - irritable, poor sucking brachial pulse - pulse area on an infant lead poisoning - test at 12 months of age Before starting IV antibiotics - obtain cultures! pt with leukemia may have - epistaxis due to low platelets when a pt comes in and is in active labor - first action of nurse is to listen to fetal heart tones/rate for phobias - use systematic desensitization NCLEX answer tips - choose assessment first! (assess, collect, auscultate, monitor, palpate) only choose intervention in an emergency or stress situation. If the answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment. ARDS and DIC - are always secondary to another disease or trauma In an emergency - patients with a greater chance to live are treated first Cardinal sign of ARDS - hypoxemia Edema is located - in the interstitial space, not the cardiovascular space (outside of the circulatory system) the best indicator of dehydration? - weight---and skin turgor heat/cold - hot for chronic pain; cold for accute pain (sprain etc) When pt is in distress....medication administration - is rarely a good choice pneumonia - fever and chills are usually present. For the elderly confusion is often present. before IV antibiotics? - check allergies (esp. penicillin) make sure cultures and sensitivity has been done before first dose. COPD and O2 - with COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be low because high O2 concentration takes away the pt's stimulation to breathe. Prednisone toxicity - Cushings (buffalo hump, moon face, high blood sugar, HTN) Neutropenic pts - no fresh fruits or flowers Chest tubes are placed - in the pleural space Preload/Afterload - Preload affects the amount of blood going into Right ventricle. Afterload is the systemic resistance after leaving the heart. CABG - Great Saphenous vein in leg is taken and turned inside out (because of valves inside) . Used for bypass surgery of the heart. Unstable Angina - not relieved by nitro PVC's - can turn into V fib. 1 tsp - 5 mL 1 oz - 30 mL 1 cup - 8 oz 1 quart - 2 pints 1 pint - 2 cups 1 g (gram) - 1000 mg 1 kg - 2.2 lbs I lb - 16 oz centigrade to Fahrenheit conversion - F= C+40 multiply 5/9 and subtract 40 C=F+40 multiply 9/5 and subtract 40 Angiotenson II - In the lungs...potent vasodialator, aldosterone attracts sodium. Iron toxicity reversal - deferoxamine S3 sound - normal in CHF. Not normal in MI After endoscopy - check gag reflex TPN given in - subclavian line pain with diverticulitis - located in LLQ appendicitis pain - located in RLQ Trousseau and Chvostek's signs observed in - Hypocalcemia never give K+ in - IV push DKA is rare - in DM II (there is enough insulin to prevent fat breakdown) Glaucoma patients lose - peripheral vision. Autonomic dysreflexia - patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above) Spinal shock occurs - immediately after injury multiple sclerosis - myelin sheath destruction. disruptions in nerve impulse conduction Myasthenia gravis - decrease in receptor sites for acetylcholine. weakness observed in muscles, eyes mastication and pharyngeal musles. watch for aspiration. Gullian -Barre syndrome - ascending paralysis. watch for respiratory problems. TIA - transient ischemic attack....mini stroke, no dead tissue. CVA - cerebriovascular accident. brain tissue dies. Hodgkin's disease - cancer of the lymph. very curable in early stages burns rule of Nines - head and neck 9% each upper ext 9% each lower ext 9% front trunk 18% back trunk 18% genitalia 1% birth weight - doubles by 6 months triples by 1 year if HR is 100 (children) - Hold Dig early sign of cystic fibrosis - meconium in ileus at birth Meningitis--check for - Kernig's/ brudinski's signs wilm's tumor - encapsulated above kidneys...causes flank pain hemophilia is x linked - passed from mother to son when phenylaline increases - brain problems occur buck's traction - knee immobility russell traction - femur or lower leg dunlap traction - skeletal or skin bryant's traction - children 3 y 35 lbs with femur fx eclampsia is - a seizure perform amniocentesis - before 20 weeks to check for cardiac and pulmonary abnormalities Rh mothers receive Rhogam - to protect next baby anterior fontanelle closes by...posterior by.. - 18 months, 6-8 weeks caput succedaneum - diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days pathological jaundice occurs: physiological jaundice occurs: - before 24 hours (lasts 7 days) after 24 hours placenta previa s/s placental abrution s/s - there is no pain, but there is bleeding there is pain, but no bleeding (board like abd) bethamethasone (celestone) - surfactant. premature babies milieu therapy - taking care of pt and environmental therapy cognitive therapy - counseling five interventions for psych patients - safety setting limits establish trusting relationship meds least restrictive methods/environment SSRI's - take about 3 weeks to work patients with hallucinations patients with delusions - redirect them distract them Thorazine and Haldol - can cause EPS Alzheimer's - 60% of all dementias, chronic, progressive degenerative cognitive disorder. draw up regular and NHP? - Air into NHP, air into Regular. Draw regular, then NHP Cranial nerves - S=sensory M=motor B=both Oh (Olfactory I) Some Oh (Optic II ) Say Oh (Oculomotor III) Marry To (trochlear IV) Money Touch (trigeminal V) But And (Abducens VI ) My Feel (facial VII) Brother A (auditory VIII) Says Girl's (glossopharyngeal IX) Big Vagina (vagus X) Bras And (accessory XI) Matter Hymen (Hypoglossal XII) More Hypernatremia - S (Skin flushed) A (agitation) L (low grade fever ) T (thirst) Developmental - 2-3 months: turns head side to side 4-5 months: grasps, switch and roll 6-7 months: sit at 6 and waves bye bye 8-9 months: stands straight at 8 10-11 months: belly to butt 12-13 months: 12 and up, drink from a cup Hepatitis A - Ends in a vowel, comes from the bowel Hepatitis b - B= blood and body fluids (hep c is the same) Apgar measures - HR RR Muscle tone, reflexes, skin color. Each 0-2 points. 8-10 ok, 0-3 resuscitate Glasgow coma scale - eyes, verbal, motor Max- 15 pts, below 8= coma Addison's disease: Cushing's syndrome: - "add" hormone have extra "cushion" of hormone Dumping syndrome - increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis. Wait 1 hr after meals to drink Disseminated herpes zoster localized herpes zoster - Disseminated herpes=airborne precautions Localized herpes= contact precautions. A nurse with localized may take care of patients as long as pts are not immunosuppressed and the lesions must be covered! Isoniazid - causes peripheral neuritis Weighted NI (naso intestinal tubes) - Must float from stomach to intestine. Don't tape right away after placement. May leave coiled next to pt on HOB. Position pt on RIGHT to facilitate movement through pyloris Cushings ulcers - r/t brain injury Cushing's triad - r/t ICP (HTN, bradycardia, irritability, sleep, widening pulse pressure) Thyroid storm - HOT (hyperthermia) Myxedema coma - COLD (hypothermia) Glaucoma - No atropine Non Dairy calcium - Rhubarb sardines collard greens Koplick's spots - prodomal stage of measles. Red spots with blue center, in the mouth--think kopLICK in the mouth INH can cause peripheral neuritis - Take vitamin B6 to prevent. Hepatotoxic pancreatitis pts - put them in fetal position, NPO, gut rest, Prepare anticubital site for PICC, they are probably going to get TPN/Lipids Murphy's sign - Pain with palplation of gall bladder (seen with cholecystitis) Cullen's sign - ecchymosis in umbilical area, seen with pancreatitis Turner's sign - Flank--greyish blue. (turn around to see your flanks) Seen with pancreatitis McBurney's point - Pain in RLQ with appendicitis LLQ - Diverticulitis RLQ - appendicitis watch for peritonitis Guthrie test - Tests for PKU. Baby should have eaten protein first shilling test - Test for pernicious anemia Peritoneal dialysis - Its ok to have abd cramps, blood tinged outflow and leaking around site if the cath (tenkoff) was placed in the last 1-2 weeks. Cloudy outflow is never ok Hyper reflexes absent reflexes - upper motor neuron issue (your reflexes are over the top) Lower motor neuron issue Latex allergies - assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes and peaches Tensilon - used in myesthenia gravis to confirm diagnosis ALS - (amyotrophic lateral sclerosis) degeneration of motor neurons in both upper and lower motor neuron systems Transesophageal fistula - esophagus doesn't fully develop. This is a surgical emergency (3 signs in newborn: choking, coughing, cyanosis) MMR - is given SQ not IM codes for pt care - Red- unstable, ie.. occluded airway, actively bleeding...see first Yellow--stable, can wait up to an hour for treatment Green--stable can wait even longer to be seen---walking wounded Black--unstable, probably will not make it, need comfort care DOA--dead on arrival Contraindication for Hep B vaccine - anaphylactic reaction to baker's yeast what to ask before flu shot - allergy to eggs what to ask before MMR - allergy to eggs or neomycin when on nitroprusside monitor: - cyanide. normal value should be 1. William's position - semi Fowler's with knees flexed to reduce low back pain S/S of hip fx - External rotation, shortening adduction Fat embolism - blood tinged sputum r/t inflammations. Increase ESR, respiratory alkalosis. Hypocalcemia, increased serum lipids. complications of mechanical ventilation - pneumothorax, ulcers Paget's disease - tinnitus, bone pain, elnargement of bone, thick bones with allopurinol - no vitamin C or warfarin! IVP requires - bowel prep so bladder can be visualized acid ash diet - cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread alk ash diet - milk, veggies, rhubarb, salmon orange tag in psych - is emergent psych thyroid med side effects - insomnia. body metabolism increases Tidal volume is - 7-10 ml/kg COPD patients and O2 - 2LNC or less. They are chronic CO2 retainers expect sats to be 90% or less Kidney glucose threshold - 180 Stranger anxiety is greatest at what age? - 7-9 months..separation anxiety peaks in toddlerhood when drawing an ABG - put in heparinized tube. Ice immediately, be sure there are no bubbles and label if pt was on O2 Munchausen syndrome vs munchausen by proxy - Munchausen will self inflict injury or illness to fabricate symptoms of physical or mental illness to receive medical care or hospitalization. by proxy mother or other care taker fabricates illness in child multiple sclerosis - motor s/s limb weakness, paralysis, slow speech. sensory s/s numbness, tingling, tinnitis cerebral s/s nystagmus, atazia, dysphagia, dysarthia hungtington's - 50% genetic autosomal dominanat disorder.. s/s uncontrolled muscle movements of face, limbs and body. no cure WBC left shift - pt with pyelo. neutrophils kick in to fight infections pancreatic enzymes are taken - with each meal! infants IM site - Vastus lateralis Toddler 18 months+ IM site - Ventrogluteal IM site for children - deltoid and gluteus maximus Thoracentesis: - position pt on side or over bed table. no more than 1000 cc removed at a time. Listen for bilateral breath sounds, V.S, check leakage, sterile dressing Cardiac cath - NPO 8-12 hours. empty bladder, pulses, tell pt may feel heat, palpitations or desire to cough with injection of dye. Post: V.S.--keep leg straight. bedrest for 6-8 hr Cerebral angio prep - well hydrated, lie flat, site shaved, pulses marked. Post--keep flat for 12-14 hr. check site, pulses, force fluids. lumbar puncture - fetal position. post-neuro assess q15-30 until stable. flat 2-3 hour. encourage fluids, oral analgesics for headache. ECG - no sleep the night before, meals allowed, no stimulants/tranquilizers for 24-48 hours before. may be asked to hyperventilate 3-4 min and watch a bright flashing light. watch for seizures after the procedure. Myelogram - NPO for 4-6 hours. allergy hx phenothiazines, cns depressants and stimulants withheld 48 hours prior. Table moved to various positions during test. Post--neuro assessment q2-4 hours, water soluble HOB UP. oil soluble HOB down. oralanalgesics for HA. No po fluids. assess for distended bladder. Inspect site Liver biopsy - administer Vitamin K, NPO morning of exam 6 hrs. Give sedative. Teach pt to expect to be asked to hold breath for 5-10 sec. supide position, lateral with upper arms elevated. Post--position on RIGHT side. frequent VS. report severe ab pain STAT. no heavy lifting 1 wk Paracentesis - semi fowler's or upright on edge of bed. Empty bladder. post VS--report elevated temp. watch for hypovolemia laparoscopy - CO2 used to enhance visual. general anesthesia. foley. post--ambulate to decrease CO2 buildup PTB - low grade afternoon fever pneumonia - rusty sputum asthma - wheezing on expiration emphysema - barrel chest kawasaki syndrome - strawberry tongue pernicious anemia - red beefy tongue downs syndrome - protruding tongue cholera - rice watery stool malaria - stepladder like fever--with chills typhoid - rose spots on the abdomen diptheria - pseudo membrane formation measles - koplick's spots sle (systemic lupus) - butterfly rash pyloric stenosis - olive like mass Addison's - bronze like skin pigmentation Cushing's - moon face, buffalo hump hyperthyroidism/ grave's disease - exophthalmos myasthenia gravis - descending musle weakness gullian-barre syndrome - ascending muscle weakness angina - crushing, stabbing chest pain relieved by nitro MI - crushing stabbing chest pain unrelieved by nitro cystic fibrosis - salty skin DM - polyuria, polydipsia,polyphagia DKA - kussmal's breathing (deep rapid) Bladder CA - painless hematuria BPH - reduced size and force of urine retinal detachment - floaters and flashes of light. curtain vision glaucoma - painful vision loss. tunnel vision. halo retino blastoma - cat's eye reflex increased ICP - hypertension, bradypnea,, bradycarday (cushing's triad) shock - Hypotension, tachypnea, tachycardia Lymes disease - bullseye rash intraosseous infusion - often used in peds when venous access can't be obtained. hand drilled through tibia where cryatalloids, colloids, blood products and meds are administered into the marrow. one med that CANNOT be administered IO is isoproterenol, a beta agonist. sickle cell crisis - two interventions to prioritize: fluids and pain relief. glomuloneprhitis - the most important assessment is blood pressure children 5 and up - should have an explanation of what will happen a week before surgery Kawasaki disease - (inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms. ventriculoperitoneal shunt - watch for abdominal distention. watch for s/s of ICP such as high pitch cry, irritability and bulging fontanels. In a toddler watch for loss of appetite and headache. After shunt is placed bed position is FLAT so fluid doesn't reduce too rapidly. If presenting s/s of ICP then raise the HOB 15-30 degrees 3-4 cups of milk a day for a child? - NO too much milk can reduce the intake of other nutrients especially iron. Watch for ANEMIA MMR and varicella immunizaions - after 15 months! cryptorchidism - undescended testicles! risk factor for testicular cancer later in life. Teach self exam for boys around age 12--most cases occur in adolescence CSF meningitis - HIGH protein LOW glucose Head injury or skull fx - no nasotracheal suctioning otitis media - feed upright to avoid otitis media! positioning for pneumonia - lay on affected side, this will splint and reduce pain. However, if you are trying to reduce congestion, the sick lung goes up! (like when you have a stuffy nose and you lay with that side up, it clears!) for neutropenic pts - no fresh flowers, fresh fruits or veggies and no milk antiplatelet drug hypersensitivity - bronchospasm bowel obstruction - more important to maintain fluid balance than to establish a normal bowel pattern (they cant take in oral fluids) Basophils reliease histamine - during an allergic response Iatragenic - means it was caused by treatment, procedure or medication Tamoxifen - watch for visual changes--indicates toxicity post spelectomy - pneumovax 23 is administered to prevent pneumococcal sepsis Alkalosis/ Acidosis and K+ - ALKalosis=al K= low sis. Acidosis (K+ high) No phenylalanine - to a kid with PKU. No meat, dairy or aspartame never give potassium - to a pt who has low urine output! nephrotic syndrome - characterized by massive proteinuria caused by glomerular damage. corticosteroids are the mainstay the first sign of ARDS - increased respirations! followed by dyspnea and tachypnea normal PCWC (pulmonary capillary wedge pressure) - is 8-13 readings 18-20 are considered high first sign of PE - sudden chest pain followed by dyspnea and tachypnea Digitalis - increases ventricular irritability ----could convert a rhythm to v-fib following cardioversion Cold stress and the newborn - biggest concern resp. distress Parathyroid relies on - vitamin D to work Glucagon increases the effects of? - anticoagulants Sucking stab wound - cover wound and tape on 3 sides to allow air to escape. If you cover and occlude it--it could turn into a closed pneumo or tension pneumo! chest tube pulled out? - occlusive dressing PE - Needs O2! DKA - acetone and keytones increase! once treated expect postassium to drop! have K+ ready Hirschprung's - diagnosed with rectal biopsy. S/S infant-failure to pass meconium and later the classic ribbon-like/foul smelling stools Intussusception - Common in kids with CF. Obstruction may cause fecal emesis, current jelly stools. enema---resolution=bowel movements laboring mom's water breaks? - first thing--worry about prolapsed cord! Toddlers need to express - independence! Addison's - causes sever hypotension! pancreatitis - first pain relief, second cough and deep breathe CF chief concern? - Respiratory problems a nurse makes a mistake? - take it to him/her first then take up the chain nitrazine paper - turns blue with alkaline amniotic fluid. turns pink with other fluids up stairs with crutches? down stairs with crutches? - good leg first followed by crutches(good girls go to heaven) crutches with the injured leg followed by the good leg. dumping syndrome? - use low fowler's to avoid. limit fluids TB drugs are - hepatotoxic! clozapine, Clozaril - antipsychotic anticholinergic clozapine s/e - weight gain, hypotension, hyperglycemia, agranulocytosis dehydration - -hypovolemia - elevated urine specific gravity flumazenil, Romazicon - benzo overdose umbilical cord compression - reposition side to side or knee-chest short cord - discontinue pictocin TB - A positive Mantoux test indicates pt developed an immune response to TB. Acid-fast bacilli smear and culture:(+suggests an active infection) the diagnosis is CONFIRM by a positive culture for M TB A chest x-ray may be ordered to detect active lesions in the lungs QuantiFERON-TB Gold: DIAGNOSTIC for infection, whether it is active or latent Battery - performing procedure without consent Assault - Threatening to give pt. medication putting another person in fear of a harmful or an offensive contact. Imprisonment - Telling the client you cannot leave the hospital Defamation - is a false communication or careless disregard for the truth that causes damage to someone's reputation. in writing(Libel) or Verbally(Slander) Sprain or Strain - RICE Rest Ice Compress Elevate

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Instelling
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Voorbeeld van de inhoud

ATI PN Comprehensive Predictor Review
Do not delegate - What you can *EAT*
*E*-evaluate
*A*-assess
* T-*teach

Addison's & Cushings - Addison's = down down down up down
Cushings= up up up down up
hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia,
hypo/hyperglycemia

Better peripheral perfusion? - Elevate veins, D-Angle Arteries

APGAR - Appearance (all pink, pink and blue, blue (pale)
Pulse (>100, <100, absent)
Grimace (cough, grimace, no response)
Activity (flexed, flaccid, limp)
Respirations (strong cry, weak cry, absent)

Airborne precautions - MTV or My chicken hez tb measles, chickenpox (varicella)
Herpes zoster/shingles TB

Airborne precautions protective equip - private room, neg pressure with 6-12 air
exchanges/hr mask & respirator N95 for TB

Droplet precautions - spiderman! sepsis, scarlet fever, streptococcal pharyngitis,
parvovirus, pneumonia, pertussis,
influenza,
diptheria,
epiglottitis,
rubella,
mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus
(Private room and mask)

Contact precaution - MRS WHISE
protect visitors & caregivers when 3 ft of the pt.
Multidrug-resistant organisms
RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases
caused by micro-organisms (C diff),

Gloves and gowns worn by the caregivers and visitors
Disposal of infectious dressing material into a single, nonporous bag without touching
the outside of the bag

,PMGG= Private room/ share same illness, mask, gown and gloves

Skin infection- *VCHIPS* - Varicella zoster
Cutaneous diptheria
Herpes simplez
Impetigo
Peduculosis
Scabies

Air or Pulmonary Embolism - S/S chest pain, dyspnea, tachycardia, pale/cyanotic,
sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.)

Woman in labor (un-reassuring FHR) - (late decels, decreased variability, fetal
bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids!

Tube feeding with decreased LOC - Pt on Right side (promotes emptying of the
stomach) Head of bed elevated (prevent aspiration)

LOC - Level of Consciousness

After lumbar puncture and oil based myelogram - pt is flat SUPINE (prevent headache
and leaking of CSF)

Pt with heat stroke - flat with legs elevated

during Continuous Bladder Irrigation (CBI) - catheter is taped to the thigh. leg must be
kept straight.

After Myringotomy - position on the side of AFFECTED ear, allows drainage.

Myringotomy - surgical incision into the eardrum, to relieve pressure or drain fluid.

After Cateract surgery - pt sleep on UNAFFECTED side with a night shield for *1-4
weeks*

after Thyroidectomy - low or semi-fowler's position, support head, neck and shoulders.

Infant with Spina Bifida - Prone so that sac does not rupture

Buck's Traction (skin) - elevate foot of bed for counter traction

After total hip replacement - don't sleep on side of surgery, don't flex hip more than 45-
60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction
by separating thighs with pillows.

Prolapsed cord - Knee to chest or Trendelenburg

, oxygen 8 to 10 L

Cleft Lip - position on back or in infant seat to prevent trauma to the suture line. while
feeding hold in upright position.

To prevent dumping syndrome - (post operative ulcer/stomach surgeries) eat in
reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals,
low CHO and fiber diet. small, frequent meals.

AKA (above knee amputation) - elevate for first 24 hours on pillow. position prone daily
to maintain hip extension.

BKA (below knee amputation) - foot of bed elevated for first 24 hours. position prone to
provide hip extension.

detached retina - area of detachment should be in the dependent position

dependent position - supported

administration of enema - pt should be left side lying (Sim's) with knee flexed.

supratentorial - (incision behind hairline on forhead) e

After supratentorial surgery - elevate HOB 30-40 degrees

HOB - head of bed

infratentorial - (incision at the nape of neck)

After infratentorial surgery - position pt flat and lateral on either side.

During internal radiation - on bed rest while implant in place

Autonomic Dysreflexia/Hyperreflexia - S/S pounding headache, profuse sweating, nasal
congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate
HOB) FIRST!

Shock - bedrest with extremities elevated 20 degrees. knees straight, head slightly
elevated (modified Trendelenberg)

Head Injury - elevate HOB 30 degrees to decrease ICP

Peritoneal Dialysis (when outflow is inadequate) - turn pt from side to side BEFORE
checking for kinks in tubing

Geschreven voor

Instelling
Vak

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Recent door jou bekeken

Waarom studenten kiezen voor Stuvia

Gemaakt door medestudenten, geverifieerd door reviews

Kwaliteit die je kunt vertrouwen: geschreven door studenten die slaagden en beoordeeld door anderen die dit document gebruikten.

Niet tevreden? Kies een ander document

Geen zorgen! Je kunt voor hetzelfde geld direct een ander document kiezen dat beter past bij wat je zoekt.

Betaal zoals je wilt, start meteen met leren

Geen abonnement, geen verplichtingen. Betaal zoals je gewend bent via iDeal of creditcard en download je PDF-document meteen.

Student with book image

“Gekocht, gedownload en geslaagd. Zo makkelijk kan het dus zijn.”

Alisha Student

Bezig met je bronvermelding?

Maak nauwkeurige citaten in APA, MLA en Harvard met onze gratis bronnengenerator.

Bezig met je bronvermelding?

Veelgestelde vragen