Final Kaplan Fundamental A and B PDF

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This is a review for a final a kaplan exam,...

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Kaplan Fundamental A and B 

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Chronic pain o episode of pain that lasts for 3 months or more o Serves no useful function o characterized by weight loss or gain, fatigue tetanus o fatal disease caused by bacterium that can live for a long time in soil and dirt o can enter blood via wounds o after a dirty wound, the tetanus toxoid booster is given to ensure protection against tetanus If client received at least 3 doses of Td o administer tetanus toxoid booster If client received less than 3 doses of Td o Administer both Td and tetanus immune globulin (TIG) Lockjaw o 1st sign of generalized tetanus Wound diet o high in vitamin C o high in protein (tissue growth) o high in carbohydrates (used for energy so the protein is properly utilized for repair of tissue to have a bowel elimination, the patient should? o increase dietary bulk contact precautions o appropriate for:  wound infections  C. Dif  Multi resistant strains  respiratory syncytial virus airborne precautions o Appropriate for:  Measles  Tuberculosis  Varicella  Disseminated zoster droplet precautions o Appropriate for  Diphtheria  Strep  Pneumonia  Influenza 1

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Neutropenic precautions o Used for clients at increased risk for infection i.e. immunosuppressed o Absolute neutrophil count < 1000 mm3 o No fresh fruit or flowers o meticulous body hygiene o no staf or visitors with cold or sore throat 5th vital sign o Pain Normal range of wbc o 5,000 - 10, 000/ mm3 o if elevated = infection Serum creatinine level o Normal = 0.5 0 1.5 mg/ dL o measures renal function o elevated in acute kidney injury and chronic kidney disease ADT o measures damage to liver and heart o normal is 10- 40 u/L Efects of morphine o Depresses CNS, especially respiratory center o would cause decreasing or fluctuating of consciousness vitamin C o necessary for formation of cartilage in CT o maintain integrity of intracellular cement (i.e. capillary walls) High fowlers o Best position to deep breath and cough Purpose of a drain o keep the tissues close together so healing can occur o provide exit route (gravity or vacuum) for air, blood, and other material following surgery To make sure NG tube is reliably in correct position? o aspirate for gastric contents and check pH o pH of gastric aspirate is 4 or less Warfarin o Anticoagulant o interferes with synthesis of vitamin K dependent clotting factors o has prolonged action; duration is 2-5 days aspirin/ salicylates prolonged usage o GI bleeding, blood dyscrasia, and acid- base disturbances underweight BMI o < 18.5 normal BMI 2

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o 18.5-24.9 Overweight BMI o 25- 29.9 Obese BMI o 30 - 39.9 morbid obese BMI o > 40 Atelectasis o probable cause for crackles o secretions block the bronchioles and the alveoli collapse --> hypoventilation Heart failure o failure of the cardiac muscle to pump sufficient blood to meet the body's metabolic needs o manifestations  dyspnea  orthopnea  pleural efusion  dependent edema  bounding pulses Thrombophlebitis o unilateral edema o warmth o tenderness o firmness of muscle of Lower extremity o swelling o localized redness over a vein with IV catheter pulmonary embolism o dyspnea o tachypnea o pleuritic chest pain ideal rate of weight loss o losing 1-2 lbs. per week eczema o itchy red skin rash o may ooze serum and form a crust o often associated with allergic reaction o onset usually in infancy around 2-3 months; outgrown by 2-3 y o administer topical steroids and antihistamines Change in pattern of urine elimination as usually associated with aging d/t o decreased sphincter reflexes primary reason that elderly adults have constipation o less peristalsis 3

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o decreased muscle tone in GI tract reduced activity serum albumin o indicator for malnutrition important part of nutritional assessment albumin o protein formed in liver o contributes to osmotic pressure o transports enzymes, drugs, hormones o indicates liver and nutritional status o will be increased if dehydrated Partial thromboplastin time o lab test used to monitor the efectiveness of heparin o must be measured at least once a week prothrombin time o used to measure therapeutic level of warfarin bleeding time o measures the duration of bleeding after standardized skin incising protein electrophoresis o diferentiates between protein fractions heparin o anticoagulant o used for short term therapy o given IV or subQ o inactivates thrombin o dosage is adjusted according to PTT most important when caring for a client in pain o establish a trusting relationship with the client separation o largest fear for toddler age presurgery mutilation o largest fear for preschool age presurgery loss of control o largest fear for school age presurgery Loss of independence; being diferent from peers o largest fear for teenagers presurgery Physical decline decreased independence fear of death fear of nursing home placement o largest fear for elderly presurgery midazolam 4

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o provides anxiety reduction, sedation preop medicine given risk factors for pressure ulcer o impaired sensory perception (diabetic, paraplegic) o impaired mobility o altered LOC o Shear o Friction o Moisture o Anemia ASSESS BEFORE IMPLEMENTING o ASSESS BEFORE IMPLEMENTING spinal anesthesia o injected into lumbar intervertebral space beyond dura mater into subarachnoid space o blocks pain sensation and movements o causes anesthesia of lower extremities, lower abdomen o hypotensive possible psoriasis o lifelong scaling skin disorder o inflammation o recurrent itchy, erythematous papules/ plaques covered with silvery white scales o chronic autoimmune reaction o noninfectious o elevated sedimentation rate with negative rheumatoid factor vital signs for patient in pain o Increase BP o increase HR o Rapid, irregular respirations o Decreased skin temperature lumbar lordosis o exaggerated concavity in the lumbar region kyphosis o exaggerated convexity in thoracic region scoliosis o lateral curvature in a portion of the vertebral column flexion o decrease angle of joint o Ex: bending elbow Extension o increase angle of joint o Ex: straightening elbow 5

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Hyperextension o excessively increase angle of joint o Ex: bending head backwards Abduction o move body part away from midline of body adduction o move body part toward the midline of the body rotation o move joint around central access pronation o turn wrist so palm is down supination o turn wrist so palm is up dorsiflexion o point the toes toward the head plantar flexion o point the toes away from the head inversion o rotate ankle and sole of foot inward eversion o rotate ankle and sole of foot outward radial flexion o rotate the hand inward at the wrist ulnar flexion o rotate the hand outward at the wrist rest o basic physiologic need o allows body to repair its own damaged cells o enhances removal of waste products from the body o restores tissue to maximum functional ability before another activity is begun activity o maintains muscle tone and posture o serves as outlet for tension and anxiety exercise o maintain joint mobility and function o promotes muscle strength o stimulates circulation o promotes optimum ventilation o stimulates appetite o promotes elimination o enhances metabolic rate flat/ supine 6

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o minimizes hip flexion side o allows drainage of oral secretions Sims o side with legs bent o allows drainage of oral secretions (ab. tension) Fowlers o head elevated o Increased venous return = maximal lung expansion Modified Trendelenburg o feet elevated 20 degrees o head slightly elevated o Increased venous return o increased blood supply to brain prone o promotes extension of hip joint passive ROM o performed by nurse without assistance from client Isometric exercise o performed by client o alternate contraction and relaxation of muscle without moving joint o maintains muscle strength when joint is immobilized Prevent negative nitrogen balance o give high protein and easily digestible diet in small, frequent feedings prevent constipation o ambulate as appropriate o increase fluid intake o administer stool softeners i.e. Colace Prevent pressure ulcers o frequent turning o skin care; keep skin dry esp. incontinent pt. o Ambulate as feasible o Use draw sheet o Balanced diet with adequate protein o Use air mattress, flotation pads, elbow and heel pads, sheepskin Prevent thrombus formation o leg exercises- flexion and extension of toes and feet for 5 min q hr. o Ambulate as appropriate o Frequent change of position o Use TEDs Prevent stasis of respiratory secretions o Turning 7

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o Coughing o deep breathing o High fowler position o Administer postural drainage as appropriate o Use incentive spirometer how often should restraints should be checked o every 1-2 hours Pain definition o "whatever the person says it is, and it exists whenever the person says it does" acute pain o episode that lasts from a split second - 6 months o may cause decreased healing, vital sign changes, diaphoresis chronic pain o episode that lasts 6 months or longer o may cause depression, weight gain, fatigue, immobility Phases of Pain experience o Anticipatory (fear, anxiety about impending pain) o Sensation of pain (mild, moderate, severe) o Pain aftermath (weakness, nausea, sweating) responses to pain stimuli o Increased BP and HR (allow increased blood flow to brain and muscles) o Rapid, irregular RR (increased O2 to brain and muscles) o Increased papillary diameter = increased eye accommodation to light o Increased perspiration = decreased temperature o Increased muscle tension, leads to neuromuscular responsiveness o Aroused apprehension, anxiety, irritability o Verbalized pain Preventive approach to pain o If pain is expected to occur throughout most of a 24-hour period, a regular schedule is better than prn 24 Pain Profile = COLDERR o C- Character and intensity- acute/ chronic; mild vs. severe o O- onset- sudden or insidious o L- Location o D- Duration o E- Exacerbation o R- Radiation o R- Relief PCA/ Patient controlled analgesia pump o portable device that delivers predetermined dosage of IV pain med aspirin/ salicylates side efects o Short term 8

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 GI bleeding  Heartburn  Nausea o Long term  Salicylism  Metabolic acidosis  Respiratory alkalosis  Dehydration  Tinnitus Acetaminophen/ Tylenol side efects o Over dosage may be fatal o Liver toxicity o Rare GI side efects Morphine sulfate side efects o Liver damage o Dizziness and weakness o Sedation or paradoxid excitement o Nausea o Sweating o Respiratory depression o Decreased cough reflex o Constipation o Hypotension Codeine side efects o Same as morphine o Constipation o High dosage = restlessness and excitement o less potent than morphine Methadone/ dolophine side efects o same as morphine Propoxyphene/ Darvon side efects o Restlessness o Tremors o Mild euphoria Meperidine HCl/ Demerol side efects o Frequent dizziness o Tremors o Uncoordinated muscle movements o Constipation o Urinary retention o Bradycardia o Confusion in older adults 9

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Hydromorphone/ Dilaudid o Sedation o Hypotension o Urine retention Oxycodone and acetaminophen o Percocet oxycodone and aspirin o Percodan Percocet* and Percodan side efects o Light headedness o Dizziness o Sedation o Nausea o Constipation o Pruritus o Administer with milk after meals Nonsteroidal anti-inflammatory drugs (NSAIDs) o Ibuprofen = Motrin o Naproxen = Anaprox and Naprosyn o Ketoorolac = Toradol Nonsteroidal anti-inflammatory drugs (NSAIDs) side efects o Headache o Dizziness o epigastric distress o peptic ulcer disease o prolonged bleeding o renal impairment o Administer with food Cellulitis o bacterial skin infection with involvement of CT Localized infection o Inflammation o Redness o Warmth o Swelling o Pain o loss of function o Drainage- serous, bloody cloudy, or purulent o Cellulitis Generalized infection o Weakness o Headache 10

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o Malaise o Fever o increased P and change in BP Neutrophils o increased most in bacterial infections o phagocytosis during acute infection Eosinophils o increased in allergic reactions Lymphocytes o Increased in chickenpox, mumps, measles, infectious mononucleosis, viral hepatitis o important in immune response Monocytes o increased in TB, rickettsia disease, and in convalescent phase of acute infections o immature macrophages "Shift to left" o increased # of immature neutrophils Highly sensitive C- Reactive protein (hsCRP) o marker of inflammation Tuberculosis o Airborne precautions o Wear fit-test respirator mask Epidermis o outer layer o dead squamous cells o no blood supplies Dermis o collagen fibers, blood vessels, nerves function of skin o protection against injury o temperature, water, and electrolyte regulation impetigo o Reddish macule becomes honey-colored crusted vesicle o caused by Staph, strep o Administer antibiotics Herpes Simplex type 1 o pruritic vesicular groupings on nose, lips, and oral mucous membranes o chronically recurrent o Spread by direct contact o Administer antivirals herpes zoster/ shingles o Vesicular eruption along nerve distribution 11

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o Pain, tenderness, and pruritus over afected region o Primarily seen on face, thorax, trunk o caused by reactivation of chickenpox virus/ varicella or decreased immunity o Analgesics o Compress o Oatmeal bath o Systemic corticosteroids to diminish severity Scabies o minute, reddened, itchy lesions o linear burrowing of a mite at finger webs, wrists, elbows, ankles, penis o Rash and itching may last for 2-3 weeks even though mite has been destroyed; treat with antipruritic pediculosis/ lice o Scalp: white eggs (nits) on hair shaft with itchy scalp o Body: macules and papules o Pubis: red macules Tinea o Pedis = athlete foot- vesicular eruptions in interdigital webs o Capitis = ringworm- breakage and loss of hair; scaly and circumscribed red patches on scalp that spread in circular pattern o Corporis- ringworm of body- rings of red scaly areas that spread with central cleaning o Administer antifungal acne vulgaris o comedones (blackheads and whiteheads) o Papules o Pustules o Cysts occurring often on face, shoulders, neck, and back REVIEW SKIN LESIONS KAPLAN P. 53-54 seborrheic dermatitis = cradle cap o Crusting of infant's scalp due to hyperactive sebaceous glands caused by maternal hormones Pre-Op Check list o informed consent o Lab tests, chest X ray, EKG o Skin prep o Bowel prep o IVs o NPO o Preop meds, sedation, antibiotics o Removal of dentures, jewelry, nail polish Neuropsychological post op care 12

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o stimulate client post anesthesia o measure LOC Cardiovascular post op care o Vital signs Q 15 min times 4; q 30 min times 2; q 1 h times 2; then as needed o Monitor I and O o Check K level o Monitor CVP Respiratory post op care o Check breath sounds o Turn, cough, and deep breathe (NOT if post brain, spinal, or eye surgery) o Splint wounds o Ofer pain med o Teach incentive spirometer o Get out of bed as soon as possible GI post op care o Check bowel sounds in 4 quadrants 5 min each o Keep NPO until bowel sounds present o Provide good mouth care while NPO o Provide antiemetics for nausea and vomiting o Check for distended ab o Check for passage of flatus and stool Genitourinary post op care o Monitor I and O o Encourage to void o Notify provider if unable to void within 8 hours o Catheterize if necessary Extremities post op care o Check pulses o Assess for color, edema, temperature o Do not cross legs o Keep knee gatch flat o Prohibit pillows behind knee o Apply TEDs o Monitor for Calf pain and swelling o Pneumatic compression device Penrose drains o simple latex drain T- Tube drain o used after gallbladder surgery o Placed in common bile duct to allow passage of bile Jackson- Pratt (JP) drain o Portable wound self-suction device with reservoir 13

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HemoVac Drain o Large portable would self-suction device with reservoir o common after mastectomy

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