***electrolyte imbalances: findings associated with hypocalcemia chapter 44
-Tetany most common.
-parasthesia of the fingers and lips (early manifestations)
-muscle twitch
-seizure due to the irritability of the CNS
-frequent, painful muscle spasms at the rest in the foot and calf
-hyperactive DTRs
-positive chvostek's sign
-poss
***head injury: making room assignments for a group of clients chapter 14
A. Close monitoring of the client's vital signs and neurological status will allow early reporting of changes in the GCS score, an increase in the blood pressure, and an alteration in respiratory pattern and effort.
B. Care should include professionals fr
infection control: admitting a client who has pertussis chapter 11 FUND
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tuberculosis: client interventions to mange infections chapter 23
exposed family should be tested for TB. Educate on following the full medication regimen of 6-12 months, even up to 2 years for multi-drug resistant TB. Instruct follow up care for 1 full year. Sputum samples are needed q2-4 weeks. Clients are no longer i
cardiovascular and hematologic disorders: dietary teaching with a client with heart failure chapter 12 NUTRITION
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***pituitary disorders: interventions for a client who has diabetes insipidus chapter 77
obtain baseline weight, vitals, serum electrolytes and osmolarity, and urine specific gravity. monitor hourly vital signs, urine specific gravity and weight. Discontinue the test and re hydrate the client for loss of more than 2 kg in body weight. Monitor
***emergency nursing principles and management: adverse effects following epinephrine administration chapter 2
can lead to hypertensive crisis. May lead to angina. Monitor for Dysrhythmias, change in heart rate, and chest pain. Monitor for hyperglycemia in clients with diabetes mellitus.
pulmonary embolism: planning care for a client who is receiving enoxaparin chatper 24
A. Assess for contraindications (active bleeding, peptic ulcer disease, history of stroke, recent trauma).
B. Monitor bleeding times. Prothrombin time (PT) & international normalized ration (INR), partial thromboplastin time, & complete blood count.
C. Mo
***rheumatoid arthritis: reviewing lab values chapter 88
A. Erythrocyte sedimentation rate (ESR) and high-sensitivity
B. C-reactive protein may be increased slightly related to secondary synovitis.
C. Osteoarthritis without synovitis is not an inflammatory disorder.
***cardiovascular diagnostic and therapeutic procedures: teaching about a peripherally inserted central catheter chapter 27
can last up to 12 months. used for the administration of blood, long term chemo agents, antibiotics, and TPN. During the insertion, the procedure is sterile. Should be confirmed placement with an X-ray. clean with alcohol for 15 seconds and left dry fully
medications affecting blood pressure: administering valsartan for heart failure chapter 20 PHARM
A. Do not take this medicine in larger or smaller amounts or for longer than recommended.
B. You may take valsartan with or without food.
C. Take the medicine at the same time each day
***pharmacokinetics and routes of administration: discharge teaching about a metered-dose inhaler chapter 46 FUND
A. Remove the cap from the inhaler mouthpiece.
B. Shake the inhaler five or six times.
C. Hold the inhaler with the mouthpiece at the bottom.
***stroke: administration of tissue plasminogen activator chapter 15
A. dissolving a clot or preventing new clots during the first 24 hr.
B. Administering the medication in a manner that provides direct contact with the thrombus can be more effective and lessen the chance of bleeding.
C. Monitor the client for bleeding (in
***intravenous therapy: priority response to infusion pump alarms chapter 4 PHARM
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***acid-base imbalances: interpreting postoperative arterial blood gas values chapter 45
pH 7.35-7.45 acidic or alkalotic
PACO2 35-45 respiratory
HCO3 22-26. metabolic
pacreatitis: expected laboratory findings chapter 54
increased serum amylase, serum lipase, WBC, liver enzymes, bilirubin, glucose, erythrocyte sedimentation rate.
Decreased: platelets, serum calcium and magnesium.
***polycystic kidney disease: acute kidney injury and chronic kidney disease: alteration of laboratory values chapter 59
increased: serum creatinine, BUN, potassium, phosphorus, magnesium.
decreased: sodium can be decreased, hypocalcemia, hematocrit decreased. Decreased Hgb and Hct.
presence of sediment in urinalysis.
polycystic kidney disease, acute kidney injury, and chronic kidney disease: findings to report chapter 59
Assess for edema and findings of heart failure and pulmonary edema. Assess for flank pain, nausea, and vomiting (nephrolithiasis). Monitor for ECG dysrhythmias. Assess for changes of urination pattern/stream. Assess for weight changes, BP changes.
hemodialysis and peritoneal dialysis: manifestation of peritonitis chapter 57
A. sharp, constant abdominal pain, fever, nausea, vomiting
B. diminished
C. absent bowel sounds.
***gastrointestinal therapeutic procedures: identifying placement of transverse colostomy chapter 47
http://www.shieldhealthcare.com/community/wp-content/uploads/2016/08/different-stomas.jpg
ingestion, digestion, absorption, and metabolism: findings of malnutrition chapter 2 NUTRITION
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***neurologic diagnostic procedures: determining a glasgow coma scale score chapter 3
Best possible score is 15. Score less than 8 is associated with a severe head injury or coma. score of 9-12 indicates moderate head injury. Score greater than 13 is associated with minor head injury.
Eye opening: 4 (spontaneously), 3 (sound), 2 (pain), 1
cancer disorders: client teaching following a partial glossectomy chapter 92
A. Diet: Advance diet from clear liquids (water, popsicles, Jell-O, sherbet, apple and grape juice, Kool-aid, etc.) to full liquids then soft foods then full diet as tolerated. Avoid hot or cold liquids.
B. Activity: No work, strenuous activity or swimmin
invasive cardiovascular procedures: teaching about left sided cardiac catheterization chapter 30
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***cancer treatment options: expected response to radiation therapy chapter 92
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hyperthyroidism: priority finding following complete thyroidectomy chapter 78
Will need thyroid hormone replacement therapy. Will receive propylthiouracil or methimazole 4-6weeks before surgery. should receive iodine for 10-14 days before surgery so it reduces the size of the gland' and prevents excess bleeding. Need to follow a hi
respiratory managemnt and mechanical ventilation: meeting psychological neds of the client chapter 19
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electrocardiography and dysrhythmia monitoring: meidcaitons used to treat atrial fibrillation chapter 28
pg. 171 for picture
- tx w/ amiodarone, adenosine, and verapamil
***heart failure and pulmonary edema: teaching a client who has heart failure chapter 32
left-sided:
- dyspnea
- displaced apical pulse
- gallop
- pulmonary congeston
- frothy sputum
- altered mental status
- manifestations of organ failure
right sided:
- JVD
- ascending dependent edema
- abd. distention
- fatigue/weakness
- nausea and anorex
***pacemakers: monitoring client's permanent pacemaker rhythm chapter 29
A. Monitor ECG to ensure heart rate is within programmed parameters. Pacer spikes should be
B. adequate in number and occur directly before P or QRS complexes.
C. Pacer spikes that occur on the T wave can cause life-threatening arrhythmias.
***acid-base imbalances: evaluating arterial blood gas results chapter 45
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***complications of diabetes mellitus: planning care for a client who has diabetic ketoacidosis chapter 83
A. Encourage all clients to wear a medical alert bracelet.
B. Take measures to decrease the risk of dehydration. Drink at least 3 L of water/day unless contraindicated by other health problems.
C. Monitor glucose every 4 hr when ill and continue to take i
***diabetes mellitus management: teaching about foot care chapter 82
inspect feet daily. wash with mild soap and warm water. check water temperature with hands before washing feet. Pat dry. Avoid lotion/moisture between the toes. Use mild foot powder on sweaty feet. Do not use commercial remedies for calluses or corns. Con
head injury: identification of altered respiratory patterns chapter 14
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heart failure and pulmonary edema: teaching about left-sided heart failure chapter 32
dyspnea, orthopnea, nocturnal dyspnea, fatigue, displaced apical pulse, S1 heart sound (gallop), pulmonary congestion (cough, bibasilar crackles), frothy sputum, altered mental status, manifestation of organ failure such as oliguria
***HIV/AIDS: immunization recommendations chapter 86
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***angina and myocardial infarction: priority finding for a client who has chest pain chapter 31
A. Angina pectoris is a warning sign of an impending acute MI
B. Pain unrelieved by rest or nitroglycerin and lasting for more than 15 min differentiates an MI from angina
C. When the cardiac muscle suffers ischemic injury, cardiac enzymes are released in
***peptic ulcer disease: emergency care for upper gastrointestinal bleeding chapter 49
Can cause manifestations of shock such as hypotension, tachycardia, dizziness, confusion and decreased hemoglobin. Will perform frequent assessments of pain and vitals. Provide oxygen and ventilator support. Start two large bore IV lines for blood and IV
***peripheral vascular diseases: expeced findings for raynaud's disease chapter 35
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postoperative nursing care: interventions for wound disruption chapter 96
A. Call for help, stay with the client, cover the wound with a sterile towel or dressing that is moistened with sterile saline
B. do not attempt to reinsert organs
C. Place in supine position with hips and knees bent, monitor for shock, and notify the pro
spinal cord injury: care of a client who has a halo device chapter 16
DO not use the halo device to turn or move the client. maintain body alignment and ensure cervical tong weights hang freely. monitor skin integrity by providing pin care and assessing the skin under the halo fixation vest as appropriate. Teach client sign
immunizations: recommended vaccinations for older adult clients chapter 85
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pulmonary embolism: risk factors for deep-vein thrombosis chapter 24
long term immobility, oral contraceptives and estrogen, pregnancy, tobacco use, hypercoagulability (^ platelet count), obesity, surgery, central venous catheters, heart failure or chronic atrial fibriliation, autimmune hemolytic anemia (sickle), long bone
musculoskeletal trauma : maintaining proper traction chapter 71
assess neurovascular every hour for 24hs then q4hrs. Avoid lifting or removing weights. Ensure weights hang freely and are not resting on floor. Ensure ropes are free of knots, fraying, loosening, and improper positioning atleast every 8-12hrs. Notify pro
electrolyte imbalances: priority assessment for hypokalemia chapter 44
Dysrhythmias. Assess for phlebitis, maintain and monitor urine output. Observe for ineffective respirations and diminished breath sounds. Monitor cardiac rhythm. Monitor clients receiving digoxin. Monitor level of consciousness, monitor bowel sounds and a
pain management: monitoring effects of long-term NSAID use chapter 4
monitor for bleeding. Can increase the effects of warfarin.
blood and blood product transfusions: indications of a transfusion reaction chapter 40
chills, fever, low back pain, tachycardia, flushing, hypotension, chest tightening, tachypnea, nausea, anxiety, hemoglobinuria, sense of impending doom.
blood and blood product transfusions: steps to administer a blood transfusion chp 40
1. explain procedure.
2. vital prior to transfusion.
3. verify the prescription.
4. Initiate large bore IV.
5. Obtain blood from blood bang.
6. 2 RNs veriy.
7. Prime line and begin transfusion
blood and blood product transfusions: treatment for circulatory overload chapter 40
Slow or stop the transfusion depending on the severity of the manifestations. Position the client upright with feet lower than the level of the heart. Administer oxygen, diuretics, and morphine as prescribed.
cardiovascular diagnostic and therapeutic procedures: administering medication through a nontunneled percutaneous central catheter chapter 27
short term use only. location I the subclavian vein, jugular vein, tip in the distal third of the superior vena cava. Used for the administration of blood, long term administration of chemo drugs, antibiotics and total parenteral nutrition.
cardiovascular diagnostic and therapeutic procedures: removing a peripherally inserted central catheter chapter 27
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gastrointestinal therapeutic procedures: central venous assess device care chapter 47
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electrolyte imblanaces: effective action of magnesium sulfate chapter 44
hypomagnesium and used to prevent and treat seizures in pregnancy.
heart failure and pulmonary edema: client teaching for furosemide chapter 32
rapid acting/loop diuretic. Administer no faster than 20 mg/min with IV. It can cause hypokalemia and so potassium supplements may be required. Teasch clients to ingest foods and drinks that are high in potassium to counter the effects of hypokalemia.
electrolyte imbalances: adequate nutritional status with total parenteral nutrition chapter 44
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electrocardiography and dysrhythmia monitoring: analyzing ECG chapter 28
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hyperthyroidism: assessing a client for chvostek's sign following a thyroidectomy chapter 78
May indicate hypocalcemia and tetany that may occur if parathyroid glands are damaged or removes. Ensure that IV calcium gluconate and calcium chloride are immediately available.
acid-base imbalances: interpreting ABG results chapter 45
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postoperative nursing care: findings to report following a colon resection chapter 96
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head injury: monitoring neurological status chapter 14
Glasgow coma scale is the earliest sign or neurological deterioration.
noninflammatory bowel disorders: findings to report chapter 51
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burns: priority action in the resuscitation phase chapter 75
begins with the injury and continues for 24-48hrs. Priorities is to secure the airway, supporting circulation and organ perfusion by fluid replacement, managing pain, preventing infection through wound care, maintaining body temperature, and providing emo
gastrointestinal therapeutic procedures: appropriate actions for an abdominal paracentesis chapter 47
vitals, weight, measuring abdominal girth. Temperature q4hrs for 48hrs. Fever can indicate a bowel perforation. I&Os q4hrs. diuretic to control fluid volum. Head of bed elevated to promote lung expansion. Document odor, description of fluid removed, locat
sensory perception: performing ear irrigation chapter 45 FUND
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chest tube insertion and monitoring: clarifying provider prescription chapter 18
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hemodialysis and peritoneal dialysis: proper administration of peritoneal dialysis chapter 57
Continuous cycle peritoneal dialysis (CCPD), occurs during then ight and then left in to dwell during the day. Automated peritoneal dialysis occurs 30 min exchange over 8-10hr while the patient is sleeping. Monitor vitals frequently during initial dialysi
infections of the renal and urinary system: assessment of flank pain chapter 60
pyelonephritis. which is the infection/inflammation of the kidney pelvis, calyces, and medulla. usually begins int he lower urinary tract with organisms ascending into the kidney pelvis.
meningitis: planning interventions for care chapter 5
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burns: assessment findings of early phase of injuery chapter 75
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electrolyte imbalances: sodium imbalances chapter 44
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hyperthyroidism: caring for a client following a thyroidectomy chapter 78
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electrocardiography and dyshythmia monitoring: identifyng first-degree heart block chapter 28
...
brain tumors: pharmacological treatment of diabetes insipidus chapter 9
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emergency nursing principles and management: emergency illness management chapter 2
...
intravenous therapy: priority action for central venous access device complications chapter 49 FUND
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respiratory failure manifestations of acute respiratory failure chapter 26
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gastrointestingal diagnostic procedures: plan of care for a client who has gastroenteritis chapter 46
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hypertension: teaching preventive measures chapter 36
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diagnostic and therapeutic procedures for female reproductive disorders: client teaching about genital herpes chapter 62
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stroke: caring for a client who has left-sided hemiplegia chapter 15
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polycystic kidney disease, acute kidney injury, and chronic kidney disease: dietary recommendations for a client who has nephrotic syndrome chapter 59
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antibiotics affecting the bacterial cell wall: manifestations to report to the provider chapter 44 PHARM
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medications affecting blood pressure: monitoring for medication interactions chapter 20 PHARM
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nonopioid analgesics: medication interactions chapter 35
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cardiovascular diagnostic and therapeutic procedures: accessing implanted port chapter 27
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cardiovascular diagnostic and therapeutic procedures: peripherally inserted central catheter care chapter 27
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***angina and myocardial infarction: client teaching about nitroglycerin chapter 31
Stop activity and rest. Place tablet under tongue to dissolve for quick absorption. If pain unrelieved in 5 minutes, call 911. Can take up to 2 more doses in 5 minute intervals. Remind that a headache is a common side effect. sit and lie down slowly.
cardiovascular and hematologic disorders: teaching about food interactions with warfarin chapter 12 NUTRITION
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hematologic diagnostic procedures: evaluating client understanding of anticoagulant therapy chapter 39
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pituitary disorders: treatment for diabetes insipidus chapter 77
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tuberculosis: teaching about medication therapy chapter 23
A. Monitor liver enzymes and hemoglobin and hematocrit.
B. Teach clients to avoid crowds and other chances of exposures to infectious diseases, and to report indications of infection. The client is at risk for development or reactivation of tuberculosis.
principles of antimicrobial therapy: appropriate intervention for suspected septicemia chapter 43 PHARM
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acid-base imbalances: interpreting ABG values chapter 45
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electrolyte imbalances: increasing the risk for digoxin toxicity chapter 44
...
peptic ulcer disease: monitoring nasogastric output chapter 49
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hepatitis and cirrhosis: client positioning following a biopsy chapter 55
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cushing's disease/syndrome: ongoing assessment to detect abnormal findings chapter 80
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gastrointestinal therapeutic procedures: ostomy complications chapter 47
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hemodynamic shock: multiple organ dysfunction syndrome chapter 37
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hemodialysis and peritoneal diaylsis: monitoring patency of an arteriovenous graft chapter 57
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meningitis: assessing for client findings chapter 5
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renal calculi: assessing client pain chapter 61
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acid-base imbalances: identifying client at risk for metabolic alkalosis chapter 45
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asthma: using a peak flow meter chapter 18 NCC
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cardiovascular diagnostic and therapeutic procedures: assessing with placement of a central venous catheter chapter 27
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hemodialysis and peritoneal diaylsis: intervening for decreased dialysate flow rate chaper 57
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pancreatitis: planning care for acute pancreatitis chapter 54
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postoperative nursing care: monitoring for wound complications chapter 96
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postopertaive nursing care: priority findings following general anesthesia chapter 96
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fluid imbalances: clinical manifestation of hypervolemia chapter 43
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complications of diabetes mellitus: priority interventions for diabetic ketoacidosis chapter 83
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disorders of the eye: indications of glaucoma chapter 12
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hemodialysis and peritoneal dialysis: manifestations of peritonitis chapter 57
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hepatitis and cirrhosis: priority finding to report chapter 55
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preoperative nursing care: recognizing deviations of laboratory values chapter 95
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respiratory management and mechanical ventilation: interventions for mechanical ventilation chapter 19
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polycystic kidney disease: acute kidney injury and chronic kidney disease: nursing interventions to prevent acute kidney failure chapter 59
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heart failure and pulmonary edema: recognizing manifestations of left-sided heart failure chapter 32
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tuberculosis: client interventions to manage infection chapter 23
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infection control: client control about wound care FUND chapter 11
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diabetes mellitus management: teaching about self-administration of insulin chapter 82
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electrocardiography and dysrhythmia monitoring: analyzing a cardiac rhythm strip chapter 28
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acid-base imbalances: interpreting laboratory values for a client who is vomiting chapter 45
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respiratory diagnostic procedures: client positioning for thoracentesis chapter 17
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meningitis: assessing for client findings chapter 5
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stroke: client assessment during a transient ischemic attack chapter 15
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invasive cardiovascular procedures: teaching about left-sided cardiac catheterization chapter 30
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electrolyte imbalances: clinical manifestations of hypokalemia chapter 44
1. risk factors: decreased total body potassium from GI loss, kidney loss or skin loss, insufficient potassium or intracellular shift.
2. weak, irregular pulse, hypotension, respiratory distress.
3. may see PVCs, bradycardia, heart blocks, ventricular tac
electrolyte imbalances: findings associated with hypocalcemia chapter 44
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burns: prioritizing the care of a client following an electric shock injury chapter 75
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seizures and epilepsy: implementing precautions for a client who has a seizure disorder chapter 6
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burns: evaluating fluid resuscitation in a client who has a burn injury chapter 75
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hemodynamic shock: manifestations of systemic inflammatory response syndrome chapter 37
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pituitary disorders: manifestations of syndrome of inappropriate antidiuretic hormone chapter 77
A. urine becomes concentrated
B. urinary output decreases
C. extracellular fluid volume is increased
hemodialysis and peritoneal dialysis: assessment of an arteriovenous fistula chapter 57
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