Escolar Documentos
Profissional Documentos
Cultura Documentos
REGISTERED NURSE
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Addison’s disease or Chronic Adrenal Insufficient occurs when the adrenal gland
does not produce enough steroid hormones (mineralocorticoids, glucocorticoids,
androgens).
Symptoms: 1. Weight loss 2. Muscle weakness. 3. Hypoglycemia. 4. Low BP.
5. Hyperpigmentation
Cushing’s disease
Clogged Tube when a feeding tube is clogged, the nurse should first attempt to unclog
the tube with a large-barrel syringe to flush and aspirate with warm water in a back and
forth motion. If that does not work, a digestive enzyme solution should be used.
Instilling a carbonated beverage is not appropriate.
The Brain
1. Hypothalamus exerts control over the actions of the autonomic nervous system
and regulates appetite and temperature.
2. Thalamus integrates all sensory input (except smell) on its way to the cortex and is
involved with emotions and mood.
3. Amygdala is in the temporal lobe of the brain and may play a major role in
memory processing and “learned fear.”
4. Medulla of the brain contains vital centers that regulate heart rate; blood pressure;
respiration; and reflex centers for swallowing, sneezing, coughing, and vomiting.
Allen Test- Tests the patency of the ulna artery.
If the Allen test is positive (when blood returns to palm, ABG can be drawn.
If the test is negative, move on to another site…brachial, femoral.
The Radial ARTERY is the preferred site for collecting arterial blood gas because
it’s on the surface, easy to palpate and stabilize and has good collateral supply
from the ulnar artery.
The patency of the ulnar artery can be verified by the positive Allen test
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Acanthosis Nigricans a skin condition that occurs with obesity or diabetes that appear
like dark lines or grooves on the neck or underarms.
Diabetes-
Emancipated Minor: Someone under 18 who has been legally freed from parental control
through a court order due to military enlistment, marriage, pregnancy
Air Embolism, the client should be placed in Trendelenburg (head down, feet up), and
positioned on LEFT SIDE, this would allow the air to rise to the right atrium and the
physician should be notified immediately and nurse stays with the patient.
Tube Insertion – arm should be raised above the head of the affected side and client
placed 30-60 degrees to reduce risk of injuring the diaphragm.
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After Liver Biopsy- client should be placed on the affected side (right side) for a
minimum of 2 hours to apply pressure and splint the puncture site. Then 12-14 hours on
the back side (supine).
After Lumber Puncture – client should be place supine (on back) at 30 degrees.
Ankylosing Spondylitis An inflammatory arthritis affecting the spine and large joints.
Client takes NSAID to control back pain and are at risk of gastric ulcer
The meds can cause melena (black stool)
Heimlich Maneuver (abdominal thrust) is the primary rescue intervention for chokings
on adults and children over 1 year of age.
Back Blows and Chest Thrust are used for infants and children under the age of 1
Pulsus Paradoxus is defined as a fall of systolic blood pressure of >10 mmHg during the
inspiratory phase.
Pulsus paradoxus can be observed in cardiac tamponade and in conditions where
intrathoracic pressure swings are exaggerated or the right ventricle is distended,
such as severe acute asthma or exacerbations of chronic obstructive pulmonary
disease.
Aphasia involves the inability to express feelings and thoughts due to a brain dysfunction
and includes both verbal and writing skills.
A Sentinel Event is an unanticipated event in a healthcare setting resulting in death or
serious physical or psychological injury to a patient or patients, not related to the
natural course of the patient's illness
Abdominal Aneurysm is a life threatening abdominal problem which can present back
pain, pulsating mass around the periumbilical area, left to the midline.
Rigid abdomen and diffuse pain indicates peritonitis.
UTI- Fever, suprapubic pain & dysuria.
Patient’s Rights-
Right to adequate evaluation and treatment of pain
Right to know the identity/names of care provider and position
Right to personal information and how to share it
Ethical Nursing Practice:
Autonomy: Is freedom for a competent person to make medical decision by
himself even if the nurse or family does not agree (e.g informed consent, A.D)
Accountability: accepting responsibility for one’s actions and admitting error.
Confidentiality: means that information shared with the nurse is kept secret
unless permission is given to share it or it’s required by law to share it such as STD
suicidal ideation to help protect the client.
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Justice: is treating everyone equally regardless of gender, sexual orientation,
race/ethnicity, religion or social standing.
Nonmaleficence: means doing no harm and protecting others
Beneficence: To do good- to implement intervention to promote health.
Veracity means to tell the truth to build a trusting relationship
Acute Pyelonephritis is a severe, life-threatening bacterial infection of the kidney that
causes it to swell. It can lead to a permanent scaring of the kidney and can be.
Treatments: IV parenteral fluid and IV antibiotics.
Extravasation is the infiltration of a drug into the tissue surrounding the vein.
Ground Coffee emesis indicates upper gastrointestinal bleeding.
Ear drop
Kids 3 and adults – UP and back
Kids 3 and down – Down and back
Enema-
During instillation, client complains of pain and cramp, stop, wait 30 secs and
continue slowly
Nurse as a client ADVOCATE #S
In the role of client advocate, the nurse protects the client's human and legal rights and
provides assistance in asserting those rights if the need arises:
The nurse advocates for the client by providing information needed so that the
client can make an informed decision.
The nurse also defends clients' rights in a general way by speaking out against
policies or actions that might endanger the client's well-being or conflict with his
or her rights. Informed consent is part of the health care provider–client
relationship; in most situations, obtaining the client's informed consent does not
fall within the nursing duty. Even though the nurse assumes the responsibility for
witnessing the client's signature on the consent form, the nurse does not legally
assume the duty of obtaining informed consent.
The nurse needs to consider the client's religion and culture when functioning as
an advocate and when providing care. The nurse would not ignore the client's
religious or cultural beliefs in discussions about treatment plans, so that an
informed decision can be made.
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basilic veins into the superior vena cava.
The nurse should measure and document the length of the external PICC during
dressing changes. A change in the length of the external PICC indicates migration
of the tip of the catheter from the original position.
The nurse should hold IV fluids, medications and secure the tube to avoid further
shifting & notify DR to obtain x-ray to verify placement of the tip.
A client with MALABSORPTION syndrome should not be able to digest nor absorb
nutrients from the gastrointestinal tract. Peripheral parenteral nutrition of 10% dextrose is
the proper treatment.
PCA- Patient-Controlled Analgesia- delivers a set of IV analgesia each time the pt.
presses a button
Needs normal saline to keep the veins open
If HCP stops the order, call to clarify
BLOOD TRANSFUSION-
Verify 2 identifiers with another RN
Prime with normal saline
Transfuse btw 2-4hrs (not over 4hrs)
RN stays in room for first 15 minutes/50 ml
Check vital signs
Fourth vital sign can be delegated to CN 1hrs after infusion
Phlebotomy-Procedure
Clean the site with alcohol
Insert needle bevel at 15 degrees’ angle, not more than 30 degrees
If pulsating red blood is noticed, pull out and press the site for at least 5 minutes
Pulsating red blood indicates artery was assessed.
After 2 unsuccessful attempts to withdraw blood, another nurse or phlebotomist
should try.
Avoid hands with mastectomy
Never draw blood above an IV infusion
Tube should be inverted 5-10 times to mix with anticoagulant.
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Juglar Vein Distention (JVD):
Position client on 30-45 degree to reveal prominent neck vein or pulsation
If fluid overload is observed, reposition patient to 60-90 degree.
Placenta Previa is the low implantation of the placenta. The types of placenta
previa are the following:
1. Low-lying placenta previa – the implantation took place in the lower
portion rather than the upper portion of the uterus.
2. Marginal placenta previa – the placental edges are approaching the cervical
3. Partial placenta previa – a portion of carvel os is occluded by the placental
portion.
4. Total placenta previa – implantation that totally obstructs the cervical os.
that cause PP:>> Increased parity. Advanced maternal age. Past
cesarean births. Past uterine curettage. Multiple gestation
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Bleeding – bright red blood. The lower uterine segment begins to
differentiate with the upper segment later in pregnancy. Placenta has the
inability to stretch to accommodate the differing shape of the lower uterine
segment or the cervix, thus, abrupt and bright red bleeding occurs.
Therapeutic Management
1. Place the woman immediately on bed rest in a side-lying position.
2. Weigh perineal pads.
3. NEVER attempt a pelvic or rectal examination because it may initiate
massive blood loss.
4. Blood typing
5. Initiate 2 large IV catheter for Fluid restoration and blood transfusion
Abruptio Placenta this is when correctly implanted placenta separates
prematurely.
Risk factors >>High parity. Advanced maternal age. A short umbilical cord.
Chronic hypertensive disease. Pregnancy-induced hypertension. Direct trauma
Vasoconstriction from cigarette use.
Signs and symptoms
Sharp, stabbing pain high in the uterine fundus (during initial separation)
Tenderness felt on uterine palpation
Heavy bleeding (not clear). Blood can either pool under the placenta and be
hidden from view. External bleeding is only present if the placenta separates
first at the edges and blood escapes freely from the cervix.
Hard, boardlike uterus with no apparent or minimally apparent bleeding
Dark red blood (in bleeding episodes)
Management
Fluid replacement. Oxygen by mask. Monitor FHR. Keep the woman in a
lateral position. DO NOT perform any vaginal or pelvic examinations or
give enema
Pregnancy must be terminated because the fetus cannot obtain adequate
oxygen and nutrients. If birth does not seem imminent, cesarean birth is
method of choice for delivery.
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&
Prioritization can be achieved with two frameworks:
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Constipation is normal after abdominal surgery due to opioid usage and
peristalsis manipulation during surgery.
Mature Minor are adolescents who are ages 14-18 and are deemed able to
understand treatable risks. They are legally allowed to give consent or refuse
treatment to limited conditions such as testing for STI, family planning, blood
donation, alcohol/drug abuse and mental health issue.
When you see a question, check for ABSOLUTE WORDS like: only, every, all
& get rid of them before going back to crosscheck your elimination. EXCEPT in a
SAFETY ISSUE question.
SBAR
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Using the NURSING PROCESS
hift in thinking…
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But in a disaster situation, there is a shift from doing what is best for the individual
to doing the greatest good for the largest number of people. The key is to
maximize patient survival with an efficient use of available resources.
To help determine how to “sort” victims, a widely accepted and systematic color-
coding system has been developed:
RED = “immediate” – people whose lives are in immediate danger and require
immediate treatment.
YELLOW = “delayed” – these people’s lives are not in immediate danger; they will
require urgent, not immediate, medical care (usually most victims).
BLACK = “expectant” (or no priority) – people who are dead when initially assessed
or those with such extensive injuries that they cannot be saved with the limited
available resources.
When checking victims and determining which group they should be assigned to,
the primary assessments to use can be remembered using the acronym: R-P-M
R = respiration
M = mental status
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Children under 10 should automatically be UPGRADED to 1 level higher than the
triaged urgency of their medical issues.
UAP/CNA- Unlicensed Assistive Personnel
Can empty, measure and record output from a surgical drainage BUT only the RN
can assess the drainage i.e. determine the type. Amount, odor and color.
Can courier blood products to and from the lab.
Can carry put comfort measures such as escorting family members to waiting
room.
Can perform ROM range of motion exercises
Reapply restraints after exercise
Report changes in skin integrity
Turn and reposition client in bed
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RNs are required by law to report suspected abuse to vulnerable clients: minors,
elderlies, demented even IF other practitioners don’t agree or the client denies it.
Client diagnosed of gonorrhea: partners need to know and get treated & PH
Child with STI - sexual abuse must be reported
Adult with injuries
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Manifestations of a mechanical bowel obstruction (pain, distension, nausea, vomiting) are
caused by compressed loops of bowel incarcerated by the hernia.
Intestinal obstruction and strangulated bowel are life threatening complications
associated with incarcerated hernia and require immediate evaluation and urgent surgical
intervention.
Bronchiolitis is a lower respiratory tract infection that is mostly caused by respiratory
syncytial virus. It causes inflammation and obstruction of the lower respiratory tract.
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S3 SOUND is made when blood from atrium is pumped into noncompliant ventricle.
It can be a normal finding in young people BUT in OLDER ALDUTS it’s significant
as it shows heart failure or fluid overload.
Post procedure for client who have undergone heart catheterization should focus on
hemodynamics: BP, HR, distal pulse strength, color and temperature of extremities.
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NORMAL LAB VALUES
Albumin = 3.5 – 5.0 g/dL
Made by the liver
Maintains intravascular pressure and prevent fluids from leaking out of the vessels.
Hypoalbuminemia causes pitting edema, periorbital edema, and ascites.
Calcium = 8.5 – 11
Hypocalcemia = causes muscle reflexes, spasm, tingling, confusion, petechiae.
Hypercalcemia = causes constipation and polyuria
Hemoglobin level- Male 13.2 – 17.3 Female 11.7 – 15.5 Low level may cause blood loss
(during or due to surgery), cardiac and respiratory complications during surgery.
Partial thromboplastin time (PTT) -30-40 seconds-is a blood test that measures the
time it takes your blood to clot.
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aPTT- (activated Partial Thromboplastic Time) Therapeutic range for clients on
anticoagulant = 40- 70 seconds (times 1.5-2 of normal range of 30- 40 seconds)
BUN = 10 – 30 mg/dL
Hypernatremia =
ALT & AST are enzymes released when hepatocytes are destroyed as part of the hepatitis
pathology. Hepatitis is diagnosed when these enzymes are 2-3 times higher than normal
values
RESPIRATION
COPD- Chronic Obstructive Pulmonary Disease –Permanent airflow limitation
causes trapped air
Client is very susceptible to pulmonary infections
Client with COPD has cough and mucus production at baseline
Report increased sputum and purulence – indicates infection/bacterial
Advice client to get pneumococcal vaccine & influenza vaccine
Anxiety is common for clients with COPD teach them breathing exercises &
relaxation.
Steroid Therapy & nebulizer treatment are common pharmaceutical
intervention of COPD exacerbation.
BIPAP Therapy (bilevel positive airway pressure) is an effective way treatment of
decrease CO2 in client with hypercapnic respiratory failure. BIPAP machine
provides positive pressure oxygen and expels CO2 from the lungs.
Asthma – is a disease characterized by airway hyper activities, use of accessory
muscles, high-pitched sibilant wheezing on expiration, chest tightness, diminished
breath sounds, tachypnea, cough and chronic inflammation resulting in
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Acute Pancreatitis can cause respiratory complications including pleural
effusion, atelectasis (1 or more lung collapse), & ARDS (acute respiratory distress
syndrome). These complications are due to activated enzymes released into the
circulation and they cause systemic inflammation. ARDS can cause respiratory
failure in minutes. Refractory Hypoxemia is life threatening & the inability to
improve oxygenation hallmark of ARDS.
Pleural Effusion - Is the accumulation of fluid into the pleural space that prevents
the LUNGS from expanding, decreases lung volume, atelectasis, and ineffective gas
exchange.
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Signs & Symptoms: Dyspnea on exertion, nonproductive cough, diminished
breath sounds, dullness to percussion, decreased tactile fremitus.
Integumentary
1st degree burn or superficial =
2nd degree burn or partial thickness =
3rd degree burn or full thickness= Brown, white, charred leathery. No pain because
nerves are damaged.
Burn injuries cause increased vascular permeability and fluid shift (2nd and 3rd spacing).
24 – 72 hours after a burn, fluids leak out of the vascular tissue causing hypovolemia.
Potassium, the predominant cellular cation gets released whenever there is a cellular
damage causing hyperkalemia which causes tall, peaked T waves.
Burn clients are mostly given their medications via intravascular (IV)
Urine output of 30ml/hr. is a good indication fluid resuscitation has taken place in
someone with a burnt injury.
First fluid given to a severe burnt client is lactated Ringer’s solution made of Na, Ca,
Cl, K and H2O.
PARKLAND FORMULA
The amount of fluid required for the first 24 hours is calculated using Parkland
formula: 4ml X kg (of BODY WEIGHT) X % of TBSA burned.
1/2 is infused in the first 8 hrs. 1/4 of 2nd ½ is infused in the 2nd 8hrs and the 2nd 1/4 of 2nd
½ is infused in the last 8hrs = 24hrs.
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BLEEDING
Cardiac
Ventricular arrhythmia (torsades de pointes)
Hypocal
Pharmacology
Sulfasalazine (Azulfidine) = Treats ulcerative colitis & rheumatoid arthritis
Side Effects: Turn eyes, skin/eyes, urine into permanent yellow.
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S/E= Tremor, tacchy, palpitations
Glyburide is used to treat diabetes mellitus
It causes low blood sugar if ingested by a client who does NOT have a DIABETES
Enoxaparin (Lovenox) – Treat DVT
Is given subcutaneous 2 inches from left of right side of the navel/umbilicus
Injects at 90 degrees angle
Discourage the client from rubbing on the injection site to prevent excessive
bruising
Roflumilast is a phosphodiestrace-4 inhibitor that is used in the treatment of patients
with severe COPD due to chronic bronchitis. This medication can cause increased
suicidal thoughts, and the patient should be monitored for this while taking Roflumilast.
Prednisone is a corticosteroid and can cause hyperglycemia and bruising.
Heparin
Insulin
Venlaphazine = antidepressant
Dobutamine – Treats heart failure/ helps the heart pump blood
ACE Inhibitors: (-prils-cause hyperkalemia): captopril, enalapril, Lisinopril, Ramipril =
treat high blood pressure.
Angiotensin Receptor Blockers: (-sartans): valsartan, losartan, telmisartan (cause
hyperkalemia)
Ethambutol (Myambutol)– Treats tuberculosis but can cause vision loss. Monitor vision.
Levofloxacin (Levaquin)- quinolone antibiotic.
Wait 2hrs before giving any other drugs
Sucralfate (Carafate, Sulcrate)- Treats gastric ulcer.
Give 2hrs before meals and 2hrs after other medications
Rifampin (Rifadin)- Treats TB.
Causes red-orange discoloration of body fluids.
Leflunomide (Arava)- Treats rheumatoid arthritis
Assess for ROM, check for onset of rash or cough
Lamivudine (Epivir)-
Lorazepam (Ativan) – Prescribes for epilepsy, sedative and also given to cocaine addicts
every 15 minutes to reduce withdrawal symptoms.
Lansoprazole (Prevacid)-
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Norepinephrine (Levophed) is vasoconstrictor and a vesicant than can cause tissue
necrosis IF absorbed into the tissue.
If extravasation of norepinephrine occurs
o Stop the infusion right away and disconnect the tubing
o Use syringe to aspirate the drug from IV catheter and remove catheter
o Elevate the affected side above the heart to reduce edema
o Notify the health care provide and prepare
o Prepare phentolamine (Regitine/antidote) a vasodilator that is used to
counter the effects of adrenergic drugs like epi, dopamine.
o Flush the site and reuse again
Platelet- Normal count- 150,000 – 400,000 (Thrombocytopenia- a complication of
heparin therapy- is low level of platelet)
Nifedipine (Procardia) – is a potent calcium channel blocker antihypertensive. Should
not be given when client’s BP is low.
PEDIATRICS REVIEW
Normal Infant respiration= 30- 60
Glucose= 40 - 60
Sepsis in Neonates may NOT show visible symptoms but rectal temperature greater than
100.4 F (38.0 C) or less than 96.8 F, FEVER, INSCREASED SLEEPING, POOR FEEDING is
RED FLAG.
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SAUDERS REVIEW
The situational leadership style uses a style depending on the situation and events.
This type of leadership style is used in emergency situations when the nurse manager
needs to quickly delegate activities to achieve a successful outcome for the situation.
The autocratic style of leadership is task oriented and directive. The leader uses his or
her power and position in an authoritarian manner to set and implement organizational
goals or solutions.
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activity levels. The diet is high in calories but low in protein. It is unnecessary to monitor
the temperature as frequently as every 2 hours.
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