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UWORLD REVIEW
TB and all airborne transmission based precautions (chickenpox, measles) Use a surgical mask not an N 95 for clients. This helps protect Health care workers and other clients from respiratory secretions, and contain respiratory secretions The HCWs who transport the clients from a negative pressure room to another location need to wear an N 95 mask to protect themselves from infection. Cirrhosis of the liver. These blood tests would be elevated in the lab results: Ammonia, bilirubin, prothrombin time Elevated bilirubin (jaundice) exists due to the decreased inability of the liver 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, the PT, aPTT, and INR levels are elevated. Total knee replacement A recent/current infection is a contraindication to total replacement surgery as a wound infection is more likely to occur in a client with a pre existing infection. Burning on urination should be investigated as it could indicate a UTI Severe knee pain is expected. Stop taking NSAIDS including selective COX 2 inhibitors (celecoxib) 7 days prior to surgery to decrease the risk of intra and post op bleeding. Transfusion reaction Chills, fever, low back pain, flushing, itching) Stop transfusion immediately, maintain IV line with NS, monitor VS, notify HCP and blood bank, recheck tags numbers and client’s blood type, and return bag to blood bank for further testing. Collect blood and urine sample to evaluate hemolysis, and complete necessary facility paperwork to document the reaction. Chronic kidney disease with a large plural effusion. Findings : Decreased fremitus Diminished lung sounds A pleural effusion is an abnormal collection of fluid (> 15 20 ml) in the pleural space between the parietal and visceral pleurae that prevents the lung from expanding fully. This results in decreased lung volume, Atelectasis, and ineffective gas exchange. Other s/s: dyspnea on exertion, non productive cough, diminished breath sounds, dullness to percussion, and decreased tactile fremitus. If the effusion is large, the trachea is deviated to the opposite side. Sounds travel faster in solids (consolidation) than in an aerated lung, resulting in increased fremitus in pneumonia. fluid or air outside the lung interrupts the transmission of sound, resulting in decreased fremitus in pleural effusion and Pneumothorax.
Cancer Unintentional weight loss of greater than 10 percent of usual weight (in nonobese) clients require evaluation and could indicate underlying cancer. N, anorexia, and dysgeusia (altered taste sensation) are also clinical features of cancer and contribute to weight loss. CAUTION acronym of cancer Change in bowel or bladder habits A sore throat that does not heal Unusual bleeding or discharge from body orifice Thickening or lump in the breast or elsewhere Indigestion or difficulty in swallowing Obvious change in wart or mole Nagging cough or hoarseness Orange peel appearance of breast tissue, or retracted nipple Restrained client Position sideways or semi fowlers, because supine position can cause risk of aspiration Don’t tie the knot a square knot. Do a quick release knot. Tie to bed frame not bed rail Provide care to meet basic needs every 2 hours Gout To prevent future exacerbations 1 ) Achieve and maintain a healthy weight 2 ) Drink plenty of fluids 3 ) Limit alcohol consumption and carbonated beverages containing high fructose corn syrup. You don’t need to eliminate all foods with protein. Just red meats and seafood intake Hip fractures external rotation, abduction, muscle spasm, and shortening of the affected extremity. Raynaud’s phenomenon An episodic vasospastic disorder of the small cutaneous arteries, mainly of the fingers and toes. Occurs most often in young women age 15 40. Vasospasm induced color changes of the fingers, toes, ears, and nose. Decreased perfusion initially causes pallor (white) followed by cyanotic (blue purple) and last color change is red. Coldness numbness, followed by throbbing, aching, tingling, swelling (hyperemic phase). Exposure to cold, emotional stress, and caffeine, and tobacco use may bring on symptoms. Don’t use substances with vasoconstrictive properties
It’s an antibiotic Trisomy 18 A genetic disorder with a short life expectancy (a few weeks after birth). It’s a chromosome anomaly characterized by severe cardiac defects and multiple musculoskeletal deformities. End of life issues should be discussed early after the diagnosis is confirmed. Trisomy 13 (patau syndrome) also results in death No treatment at this time available Warfarin Anticoagulant. Range: 2. 3 3. 5. Warfarin should only be administered after INR has been checked. Can be given if it is less than 3. 5 and should be held and HCP contacted if greater than 3. 5. Antidote: Vitamin K Neutrophils Normal: > 1500 /mm 3 Neutropenic precautions: private room, strict Handwashing, avoid exposure to people who are sick, avoid ALL fresh fruits, veggies, and flowers; ensure all equipment used with the client has been disinfected. Infections in immunosuppressed clients are life threatening Avoid IM injections and minimize venipunctures when platelet count is below 50 , 000 as these can cause prolonged bleeding Blood lead levels Common source is lead based paint found in houses built before 1978. Screenings are recommended at ages 1 , 2 , and up to 6 , if not previously tested. Lead poisoning particularly affects the neurological system, due to immature development of the brain and nervous system. This is more concerning than the other effects. Can cause neuro impairment, developmental delays, reading difficulties, visual motor issues; can lead to permanent cognitive impairment, seizures, blindness, or even death. GI bleeding is for iron toxicity not lead poisoning. Lead poisoning is the most threatening to the kidneys and neuro system (developmental delays, cognitive impairment, seizures). Liver injury typically does not occur. Severe liver damage is closely associated with acetaminophen overdose or Reye syndrome. Asystole Total absence of ventricular electrical activity (pulseless, apneic, unresponsive) Treatment: CPR, ACLS, epinephrine and/or vasopressin, advanced airway use, and any reversible treatment. Vasopressin is a vasopressor, that increases vasoconstriction and MAP
SIDS
Sudden unexplained death of an infant age < 1 year. Highest occurrence at 2 4 months. Protective factors: Supine sleeping position Breast feeding Pacifier use during sleep Up to date vaccinations Appropriate clothing (sleep sack) Firm sleep surface Removal of loose items from bed Risk factors: Prone/side sleeping position Tobacco smoke exposure before/after birth or any drugs Premature birth/low birth weight Overheating during sleep Soft sleep surface Bumper pads, toys and loose pillows/blankets Adalimumab (tumor necrosis factor) inhibitor Reduces inflammatory response for rheumatoid arthritis. TNF is a factor in the immune system response that increases inflammation. Cause immunosuppression, and increases risk of new infections or reactivation of previous infections (latent TB, hepatitis B virus) Other TNF inhibitors: etanercept, infliximab Opioid intoxication clinical features: Depressed mental status Decreased resp rate (< 12 /min) most notable Constricted (miotic) pupils not present in every client Decreased/absent bowel sounds Mild hypotension from histamine release and Bradycardia from CNS depression Taking other CNS depressants like alcohol and benzo can worsen resp depression Flumazenil is a benzo antagonist that can be administered if there is no response to the naloxone (Opioid antagonist) and ingestion of benzo is suspected. Administer naloxone (Narcan) a potent narcotic antagonist to reverse CNS and resp depression Burn patients Initial management is ABCs Should be treated with high flow O 2 via a non rebreather mask initially. Requires significant volume replacement to compensate for fluids lost through wounds in more than 15 % total body surface area (TBSA) involved. Lactated ringers usually used. Follow the Parkland formula ( 4 mg/kg of body weight
TB drugs Isoniazid, rifampin, ethambutol, pyrazinamide Isoniazid causes hepatotoxicity and peripheral neuropathy. Rifampin causes hepatotoxicity. Baseline liver function tests should be obtained. Watch for s/s of hepatotoxicity (jaundice, anorexia). Ethambutol causes ocular toxicity, and clients will need frequent eye examination. Rifampin: Changes color of body fluids (urine, sweat) due to its body wide distribution (red orange colors). Tears can turn red, making contact lenses appear discolored. Client should wear sunglasses instead of soft contact lenses while taking this medication. Women should use non hormonal birth control methods while taking this drug as it can decrease the effectiveness of oral contraceptives. Don’t consume alcohol and drugs that can increase the risk for hepatotoxicity (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, re infection, spread to others, and development of resistant strains of TB bacteria can result). Increased metabolism of some drugs (oral contraceptives, hypoglycemic, and warfarin) can occur as s/e/ Vitamin K is the antidote for warfarin related bleeding. aPTT 46 70 , INR 2 3 Sodium polystyrene sulfonate (kayexalate) is a sodium exchange resin administered to reduce elevated serum K levels in clients with chronic kidney disease and hyperkalemia. Warfarin is started about 5 days before a continuous heparin infusion is d/c as it takes this long for warfarin to reach therapeutic levels Propranolol Beta blocker that inhibits beta 1 (heart) and beta 2 (bronchial) receptors. It is used for many indications (essential tremor) in addition to BP control. BP decreases secondary to a decrease in HR. Bronchoconstriction may occur due to the effect on the B 2 receptors. Wheezing in a client taking this drug may indicate bronchoconstriction or bronchospasm. Nurse should assess for any history of asthma or resp problems with this client and notify the HCP. Headache is common occurrence with HTN. Analgesic can be given as needed. It may take several days of treatment for the BP to reduce to a more normal finding. Reduction in HR is expected with beta blockers. Nurse should monitor it for further reduction. Pancreatitis
Pancreatic enzymes help with digestion and are inactive when they are inside the pancreas. They activate in the small intestine. If you are an alcoholic scar tissue occurs in pancreas. It creates an occlusion in pancreas and prevents enzymes coming out Gallstones can occlude the enzymes from coming out too The enzymes then activate inside the pancreas as it gets tired to wait to activate. This causes pancreatitis (pancreas eats itself) Hepatic encephalopathy Serious complication of end stage liver disease resulting from inadequate detoxification of ammonia from the blood. (lethargy, confusion, slurred speech) Increased ammonia levels and asterxis are characteristic of HE. Asterxis (flapping tremors of the hands). It is assessed by having the client extent the arms and Dorsiflex the wrists. Fetor hepaticus (musty, sweet odor of breath) from accumulated digestive by products. Other s/s: sleep disturbances, lethargy, and altered mental status, coma (decreased LOC) Spider angiomas, gynecomastia, testicular atrophy, and palmar erythema are expected findings in cirrhosis d/t altered metabolism of hormones in liver. Precipitating factors: hypokalemia, constipation, GI hemorrhage, infection It’s the frequent complication of liver cirrhosis. It results from accumulation of ammonia and other toxic substances in the blood. Lactulose is the DOC which helps excrete ammonia through the bowels as soft or loose stools. Rifaximin (antibiotic ) can also be given Clients with cirrhosis typically have hypokalemia due to hyperaldosteronism (as it is not metabolized by the damaged liver). It can also occur d/t diuretics used to treat fluid retention and ascites. Ileostomy Surgical procedure that creates an opening (stoma) in the abdominal wall that originated from the intestinal mucosa of the ileum. In the beginning: LOW FIBER DIET. To prevent obstruction of the narrow lumen of the small intestine. Foods to be avoided include: Stringy texture: celery, broccoli, asparagus stalks High fiber: bread, brown rice, oatmeal Seeds or pits: strawberries, raspberries, olives Edible peels: apple slices, raw cucumber, dried fruits Nuts: peanuts, almonds, cashews Foods to eat: Fruits and veggies that are pitted, peeled cooked Low fiber carbs (white rice, refined grains/pastas, cooked cereals) Dumping syndrome Rapid emptying of hypertonic gastric contents into duodenum and small intestine
LAB VALUES
WBC count: 4 , 000 11 , 000 /mm 3 BUN levels: 7 18 mg/dL Creatinine level: 0. 6 1. 2 md/dL Hemoglobin levels: 13. 5 17 g/dL in men; 12 16 in women). Magnesium levels: 1. 5 2. 5 mEq/L Salicylate acid (aspirin) Toxicity: tinnitus, dizziness, N, V, hypotension, tachycardia, tachypnea, hyperventilation, and decreased LOC. Accumulation of acids results in metabolic acidosis. Respiratory system compensates for increased metabolic acidity by hyperventilating. This is the body’s attempt to restore acid base balance by blowing off carbon dioxide (acid gas) to normalize the pH. Pyelonephritis UTIs that occur in the kidneys (inflammation of the kidney parenchyma) (in the bladder cystitis) and or urethra (urethritis). It causes flank pain that is experienced in the back at the costovertebral angle and may spread to toward the umbilicus. Cystitis alone does not cause N, V, or chills. Presence of these, fever, and signs and symptoms of a lower UTI (Dysuria, urgency, and frequency) indicate pyelo... Pain in pyelo is dull, constant, and maximal at the costovertebral angle area. Cystitis UTI in bladder Suprapubic pain, and spasms, dull and continuous Distended bladder Constant pain increased by pressure over the bladder. Distention is found through palpation (firmness, pain, urgency) and percussion (dullness) over suprapubic area. Renal Colic pain Excruciating, sharp, stabbing Unable to find a comfortable position; tossing in bed Pain radiates down to the groin area from flank, as stone travels down the ureter.
Acute Rheumatic Fever An acute inflammatory disease of the heart. It occurs about 2 3 weeks after a streptococcal pharyngitis RF affects the heart, skin, joints, and CNS. The presence of 2 major or 1 major and 2 minor criteria and evidence of a preceding streptococcal infection indicates a high probability of RF. Family history, and failing to complete a course of Abs is not a direct cause or risk of RF. Fever is a symptom of many illnesses, not just RF. The nurse should ask about a streptococcal throat infection when collecting health history info in a client suspected of having RF. Infection Tr ansmission: Airborn: TB, influenza (airborne droplets) Pneumonia: respiratory disease Sepsis SIRS (systemic inflammatory response syndrome) with an infection (suspected or proven). (complication of pneumonia) Can be diagnosed with 2 of these 4 criteria: Temp: > 28 C or < 36 C HR: > 90 bpm R: > 20 /min WBC > 12 , 000 /mm 3 ; < 4 , 000 mm 3 or > 10 % immature (band) forms Additional s/s: SBP: < 90 mm Hg Altered mental status Hyperglycemia (> 140 mg/dL) Early therapy: aggressive fluid resuscitation and early administration of antibiotics. Can occur as a complication of pneumonia who don’t respond to a/b care. It is caused by the entry of bacteria from the alveoli into the bloodstream. It can progress to septic shock and/or multisystem organ dysfunction syndrome. To limit progression assess oxygenation (pulse oximeter, ABGs); airway (patency); breathing (resp pattern and rate); circulation (vital signs); tissue perfusion (LOC, cap refill, skin temp and color, bowel sounds) and urine output. Paralytic ileus occurs in the presence of sepsis and hypoxia as blood is shunted away from the GI to the vital organs. Prolonged cap refill (> 3 4 seconds in an adult) indicates inadequate blood flow to peripheral tissues. Serum glucose > 140 : gluconeogenesis occurs in response to the physiologic stress of infection. insulin resistance is associated with anaerobic metabolism
Allowable foods: apples, pears, grapes, pineapple, blackberries, blueberries, plum Lasix(furosemide) Potassium depleting loop diuretic. Hypokalemia can lead to heart palpitations and/or dysrhythmias. Bladder cancer: Tell tale symptom: painless Hematuria. Primary cause is cigarette SMOKING or other tobacco use Occupation cal carcinogen exposure is the second most common factor (printing, ironing, and most aluminum processing, industrial painting, metal work, machining, and mining). Clients are exposed to carcinogens through direct skin contact and inhalation (aerosols and vapors) Other risk factors: high fat diet and artificial sweeteners Influenza 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 illness stage begins. Transferred through inhaling airborne droplets (sneezing, coughing, speaking) and DIRECT CONTACT Wear a mask if contact with infected person is unavoidable. Those with influenza cannot transmit the virus during the incubation period and illness stage of the infection. Avoid close contact with others during illness stage, esp those with impaired immune system TB Gram positive acid fast bacillus (mycobacterium tb) Transmitted airborne droplets (cough or sneeze in the air, or exhaling breathing, singling talking, laughing) Need standard and airborne transmission precautions and wear a high efficacy particulate or N 95 resp. Mask. PTB Not spread with contact of clients blood, urine or soiled clothing, bed linens, or eating utensils 85 % pulmonary, but can also be extra pulmonary (meninges, genitourinary, bone and joints, GI) Symptoms: Low grade fever
Night sweats Anorexia and weight loss Fatigue Pulmonary TB: cough, purulent or blood tinged sputum, SOB Genitourinary TB: Dysuria Liver involvement jaundice, but also as a side effect to TB drugs (Isoniazid) Spinal tb: back pain Cardinal (major) constitutional (minor) s/s/ Dyspnea and hemoptysis seen in later stages Classic signs of TB can be absent in immunocompromised clients and the elderly. Vancomycin to an MRSA infected client Check the Bun and creatinine before administering the drug ( 2 3 times a week) d/t increased risk of nephrotoxicity especially in those that are > 60 y/o and have an impaired renal function. Vancomycin is excreted by the kidneys. It is used to treat gram positive (MRS and diarrhea associated with C.Diff). Normal BUN levels: 7 18 mg/dL Normal creatinine level: 0. 6 1. 2 md/dL An increased glucose level is expected in clients with an infection due to physiological stress and gluconeogenesis. Does not need to be reported to the HCP. An elevated WBC count is expected and not needed to be reported. Hemoglobin levels: 13. 5 17 g/dL in men; 12 16 in women). Magnesium levels: 1. 5 2. 5 mEq/L Antiplatelet therapy (aspirin, clopidogrel, prasugrel, ticagrelor) Initiated to prevent platelet aggregation in those at risk for MI, stroke, or other thrombolytic events. This therapy increases the risk of bleeding. Assess for bruising, tarry stools, and other signs of bleeding. It can cause thrombotic thrombocytopenia purpurea. Baseline liver enzymes assessment is not needed
Hep A and typhoid Transmitted fecal, oral and through contaminated food, water Ringworm Superficial fungal(tinea) skin infection that mostly affects scalp or feet (athlete’s foot) Limit contact with infected pets Spread through contact and indirect contact Fungus thrives in warm, moist areas. s/s: itchy, red, raised, scaly patches that may blister or ooze. Sharply defined edges. Red on the outside normal skin on the inside, looking like a ring. Tests: KOH exam, skin biopsy, skin culture, skin observation Keep skin clean, dry. Apply antifungals (miconazole, ketoconazoletc); shampoo regularly, especially after haircuts, do not share personal items, wear sandals and shoes at gyms, lockers, pools, avoid touching pets with bald spots. Allergies/asthma (from mites) or scabies (contagious skin infection by mites) Wash bedding in hot water Ur ine testing Clear catch or midstream urine samples are collected for urinalysis or urine culture and sensitivity testing. Creatinine clearance test: all urine for 24 hours must be collected. The first urine specimen is discarded in a container and kept cool and the time is noted. After 24 hours, the client should void one last time and add the specimen to the container. Blood is also drain to measure the creatinine level. Creatinine clearance is the measure of the glomerular function and is a sensitive indicator of renal disease progression. An in an out catheter (straight catheter) is used for any rest 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. The first AM void is preferable for a urinalysis or urine culture and sensitivity as an overnight specimen is more concentrated. Infected endocarditis: Check temperature regularly as persistent elevations could mean the a/b therapy is
ineffective or complications have developed. Client should notify HCP if fever persists at home. Client has risk of reoccurrence. They should receive prophylactic a/b before high risk procedures. Vegetations on valves and surfaces can form, and embolization to various organ sites can occur. Slurred speech could indicate that this has occurred, and could lead to a possible stroke. s/s: one sided weakness, slurred speech, paralysis, painful, cold extremities. a/bs for up to 4 6 weeks. Morphine sulfate N, V are expected s/e of opioid meds when treatment is initiated. But, tolerance develops quickly and persistent Take an anti emetic with the pain med. N, V less likely to occur in a recumbent position, and risk increases by 40 % in clients who are up and walking. Taking meds on empty stomach may increase risk of N N, V decreases when the pt lies in a flat position Pain In the right lower quadrant: appendicitis. Pain starts in periumblical region and migrates to the McBurney’s point. Client will attempt to decrease pain by lying still, with right leg flexed and preventing intra abdominal pressure (avoid coughing, sneezing, deep inhalation) In the left lower quadrant: diverticulitis (often in the sigmoid colon). Other s/s include palpable tender abdominal mass, and systemic symptoms of infection (fever, increased C reactive protein, and Leukocytosis with a left shift) C reactive protein: a by product of inflammation; a globulin that is found in the blood in some cases of acute inflammation. It’s a protein made by the liver and released within a few hours of tissue injury, start of infection/cause of inflammation. Pain in the right upper quadrant referred to the right scapula: acute cholecystitis. Also experience indigestion, N, V, restlessness, and diaphoresis Small Bowel Follow Through (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. This can help identify decreased motility, increased motility, fistulas, and obstructions. Clients should follow these instructions: fast 8 hours prior to the exam. Polyethylene glycol is prescribed as bowel prep for a colonoscopy NOT an SBFT.
pressure. Diet mod: avoid high fat foods, and those that decrease lower esophageal sphincter pressure (chocolate, peppermint, tomatoes, caffeine). Eat small, frequent meals; decrease fluid intake during meals to prevent distention. Avoid meals close to bedtime and nocturnal eating. Lifestyle changes: smoking cessation, weight loss Avoid lighting/straining Elevate the HOB to 30 degrees: this can be done at home using pillows or 4 6 in blocks under the bed. Wearing a girdle or tight clothes increases pressure and should be avoided. Colostomy care: 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) Identify and eliminate foods that cause gas and odor (broccoli, cauliflower, dried beans, Brussels sprouts) Empty pouch when it becomes 1 / 3 full to prevent leaks due to increasing pouch weight PPIs (pr oton...) Are associated with decreased bone density (calcium malabsorption) which increases the possibility of fractures of the spine, hip and wrist. It causes acid suppression that otherwise would have prevented pathogens from more easily colonizing the upper GI tract. This leads to increased risk of pneumonias. It can also increase the risk of C diff associated diarrhea. Unclear cause. Receiving a/bs for a UTI will further increase risk of C diff infection. Take medication prior to meals. PPIs don’t affect BP Increase calcium and vitamin D intake to prevent osteoporosis. Phenytoin Anticonvulsant Toxicity: gait disturbances (ataxia) Bisphosphonate (Alendronate, risedronate) Bisphosphonates are a class of drugs that prevent the loss of bone mass, used to treat osteoporosis and similar diseases Drink extra water and stay upright for 30 mins after taking the drug to prevent
esophagitis. Jaw necrosis is a toxicity s/s Lithium (mood stabilizing drug) and Albuterol (bronchodilator, short acting beta agonist) Toxicity: tremors Dialysis Peritonitis is the most common complication of dialysis. Chills may indicate elevated temp (sign of infection) and rebound tenderness a sign of peritonitis (inflammation of the peritoneal cavity, with cloudy effluent). Abdo pain also present. Assess peritoneal fluid for C&S. Clients receiving peritoneal dialysis often have diabetes, and glucose (dextrose) is the osmotic agent in dialysate. Monitor glucose levels closely. Regular insulin can be added to the dialysate before the solution is instilled or it can be administered subQ to control glucose levels. Ulcerative colitis Chronic disease , inflammation of the large intestine Results in urgent, frequent bloody diarrhea; abdo pain, anorexia; and anemia. The gFOBT (guaiac fecal occult blood test) Correct sequence of test: Obtain supplies, wash hands, don non sterile gloves Open the slide’s flap and use the wooden applicator to apply 2 separate stool samples to the boxes on the side Wait 3 5 mins Open the back of the slide and apply 2 drops of developing solution to the boxes on the side Wait 30 60 seconds Document the results in the EMR This test is used to assess the microscopic blood in the stool and as a screening tool for colorectal cancer. Assess recent consumption of red meat or Vit C in the last 3 days, or using certain meds (aspirin, anticoagulants, iron, ibuprofen, and corticosteroids) as they can interfere with the results. If the test paper turns blue, the test is positive and the stool contains blood.
