Comprehensive Guide to Kidney Disease and Burn Injury Management, Exams of Nursing

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Final Exam Study Guide Assessment Questions with Complete Solutions Know chronic kidney disease s/s - Correct Answer § fluid overload, weight, electrolyte imbalances, excretion of waste products § In early stages of CKD the patient will be asymptomatic § ↑ urea (BUN) and creatinine (Azotemia) (↑ nitrogen) § Uremia (↑ urea only)= N/V, itching (pruritus), decreased attention span § These increases will lead to neurological changes and itching - related to the accumulation of urea under the skin § ↑ fluids in the body → hypervolemia → HTN → increased pressure on the heart → weakness of the heart to pump, allowing fluids backing up into the lung → pulmonary edema and cardiac issues Know chronic kidney disease s/s (continued) - Correct Answer ....§ ↓ UOP § UOP < less than 400 mL/day = oliguria § UOP < less than 100 mL/day = anuria § ↑ potassium § ↑ PO₄ § ↓ Ca: increased level of PO₄ decreases the level of Ca because PO₄ binds to Ca removing it from the blood § Parathyroid gland will sense a decrease level of Ca causing the gland to release PTH softening the bones to release Ca to the blood. Bones will be weak and brittle as a result of loosing Ca § ↑ Mg § + proteinuria → ↓ of oncotic pressure facilitating water to scape to the interstitial space and ↑ edema and swelling § + hematuria → ↓ on RBCs → anemia § Metabolic acidosis (Kussmaul resp), confusion, anemia Know signs and symptoms of hypocalcemia - Correct Answer o Trousseau sign= The hand adopts a characteristic posture when the sphygmomanometer cuff is inflated above the systolic blood pressure within 3 minutes o Chvostek's sign= a contraction of ipsilateral facial muscles subsequent to percussion over the facial nerve o circumoral and finger paresthesia o muscle cramps/spasms/weakness (neuromuscular irritability) o seizures o Prolonged QT and ST, Vtach, laryngospasm, diarrhea/cramps fractures, risk for bleeding, dysrhythmias · Know signs and symptoms of hyperkalemia - Correct Answer o Irregular heartbeat, hypotension, bradycardia, ST elevation, Peaked T wave (v fib and cardiac standstill in severe cases) o Respiratory failure o Increased motility, hyperactive bowel sounds, diarrhea o Confusion, profound muscle weakness, cramps, increased DTR, paralysis, tingling, burning numbness Potassium normal level & reasons for high and low - Correct Answer 3.5-5 § Hyperkalemia · Spironolactone (K sparing), ACE inhibitors, NSAIDs (ibuprofen) · Acidosis, cellular destruction (burns, trauma), hypoaldosteronism (Addison's) · Renal failure, AKI, CKD, dialysis patient- decreased K excretion Salt substitute § Hypokalemia · Furosemide aka Lasix (K wasting), Hydrochlorothiazide (thiazide diuretic) Vomiting, gastric suction Sodium normal level & reasons for high and low - Correct Answer o Sodium 135-145 mEq/L § Hypernatremia · Loss of fluid (infection, diarrhea, diaphoresis), DI (hemoconcentration- low ADH), renal problems, processed foods, IV hypertonic solution, aldosterone excess (cushing's) § Hyponatremia · NG tube, vomiting, peeing, diarrhea, diaphoresis, SIADH (diluted), Adrenal insufficiency (Addison's), hydrochlorothiazide, furosemide Calcium normal level & reasons for high and low - Correct Answer 8.6-10.3 § Hypercalcemia · Hyperparathyroidism, Antacid, malignant cancer cells, low phosphate § Hypocalcemia · CKD, AKI (increased PO4 binding to Ca), hypoparathyroidism (decreased PTH, thyroidectomy), pancreatitis, laxative, furosemide, corticosteroids, phenytoin, phosphate enemas, Celiac and crohn's, low vitamin D, low Mg, increased phosphate levels, hyperthyroid? · Know S/S of hyponatremia - Correct Answer o Fatigue, nausea, vomiting, headache, malaise, altered LOC, lethargy, seizures, brain stem herniation, coma, respiratory arrest o Hypovolemic - increased HR, decreased BP, increased RR o Hypervolemic- increased HR, increased BP, decreased RR o ST elevation o SOB, dyspnea o N/V, abdominal cramp § Last part of coagulation cascade is PTT- so PTT will be prolonged in case of hemophilia (because you are unable to make the fibrin) ** exam Q § aPTT is increased · Know nursing education for patients with hemophilia - Correct Answer o No aspirin/anticoagulants o Control of topical bleeding with hemostatic agents, pressure, and application of ice. o Management of complications associated with hemorrhage. o Monitor S/S of complications; hemarthrosis, intracranial bleeding o Assist in management of pain; measures include joint immobilization, application of ice, and administration of analgesics; aspirin and drugs affecting coagulation are avoided. o Control bleeding and maintain hemostasis through direct pressure, and application of ice or topical hemostatic agents (absorbable gelatin sponge, microfibrillar collagen hemostat, or topical thrombin) · Know nursing education for patients with hemophilia (continued) - Correct Answer ....o Administer medications as prescribed o S/S that require immediate medical attention; severe joint pain, trauma or injury, and S/S of uncontrolled internal bleeding o Bleeding precautions o Medic alert bracelet alerting of hemophilia o Good dental hygiene to decrease need for invasive dental procedures o Adhere to scheduled visits and follow-up with provider · Know types of hemophilia and its corresponding coagulation factor deficiency - Correct Answer § Factor VIII deficiency= Hemophilia A § Factor IX deficiency= Hemophilia B § Factor XI deficiency= Hemophilia C Von Willebrand's disease is a related disorder caused by deficiency of von Willebrand factor (vWF), which is necessary for factor VIII activity and platelet adhesion · Know nursing education about iron therapy - Correct Answer o Iron supplement o Be very careful because if you have sickle cell anemia= hemolytic anemia in sickle cell anemia- a lot of circulating iron can become toxic for patient o If iron losses are mild, oral iron supplements, such as ferrous sulfate (FeSO4) for 6 months one hour before meals, are started until the hemoglobin level returns to normal. Other forms of oral iron include ferrous gluconate (Fergon®) and ferrous fumarate (Ircon®, Femiron®) o Instruct patients to take the iron supplement between meals to reduce GI distress, and with orange juice for better absorption, but avoid grapefruit juice. o Oral liquid form can stain teeth; patients should use a straw or place spoon at back of mouth to take supplement and rinse mouth thoroughly afterward. o When iron deficiency anemia is severe, iron solutions (iron dextran [Dexferrum®, INFeD®, Pri-Dextra®]; ferumoxytol [Feraheme®]) can be given parenterally. o Administer parenteral iron deep intramuscularly (IM) via Z track method; use separate needles for withdrawing and injecting dose. o Monitor stool consistency, color (normally black with the use of iron supplements), frequency and amount. · Know S/S of Iron deficiency anemia - Correct Answer o With chronic iron deficiency, RBCs are small (microcytic) and pale (hypochromic) and the patient has mild symptoms of anemia, including weakness and pallor. - Other mani: fatigue, reduced exercise tolerance, - fissures at corners of mouth (cheilosis)** need to remember specific for iron anemia -Koilonychia (spooning of nails) - Smooth sore tongue and pica (craving unusual things like ice, clay, and most likely for iron deficiency- dirt) · Know nursing care/monitorization of patients post transsphenoidal hypophysectomy (TWO QUESTIONS) - Correct Answer - Monitor blood glucose before/during/after surgery - (Text book pg.925) Use a soft toothbrush (decreases potential damage to incision line), avoid activities (cough, sneeze, bending at waist) that strain surgical site, report increase of drainage of clear fluid from nose (may indicate CSF leak, which increases risk of meningitis). HOB 45-60 degrees, nasal drainage pad under nose (frequently monitored for drainage) ■ Nurse needs to monitor for s/s of meningitis (elevated temperature, nuchal rigidity (stiff neck), and photophobia). ■ Frequent vital signs: At risk for post-operative DI- tachycardia and hypotension. ■ Monitor neurologic status: Possible increased ICP- changes in LOC and visual field changes r/t post-op cerebral edema. ■ Monitor I&O and urine specific gravity- lack of ADH= increased excretion of large amounts of dilute urine. ■ Monitor/frequent care of mucous membranes and mouth: Due to nasal packing, PT breathes primarily through mouth= increased dryness. Humidified oxygen facilitates maintenance of moist mucous membranes. Provide frequent oral care and adequate oral fluids. ■ Monitor serum sodium and osmolality- increase r/t increased excretion of water secondary to lack of ADH. · Know nursing care for patients with leukemia receiving chemotherapy (THREE QUESTIONS) - Correct Answer - Assist in bone marrow biopsy; apply pressure to site for 5-10 minutes or until bleeding stops; frequently assess site for signs of bleeding up to 4 hours after procedure. -neutropenic and bleeding precautions. - Prevent fatigue, uninterrupted rest, diversionary activities. - Nutrition= dietician - Assist in maintaining good personal hygiene; institute measures to promote oral hygiene. - Refer to "Meals on Wheels", American Cancer Society, Leukemia Society, etc. - Referral for counseling and support group to patient and family. Emotional support - Administer drugs that are Rx and monitor for s/e. - Monitor labs to evaluate effectiveness of interventions and therapy. - keep oral cavity moist; rinse mouth with saline; lubricate lips and oral mucosa with water-soluble lubricants every 2 hours; avoid alcohol-based mouthwash solutions; use sponge-tipped applicators for oral hygiene if neutrophil and platelet counts are low. - Prevent peri-rectal complications; wash and clean peri area thoroughly after BM -Avoid sick people - Avoid live flower in room - Don't eat raw food -no contact sports Nephritic syndrome/ glomerulonephritis - Correct Answer hematuria and mild proteinuria - Tea or cola-colored urine Periorbital edema Fluid overload •→ Heart failure, hypertension (HTN), renal issues (renal failure), respiratory distress (pulmonary edema)Decreased glomerular filtration rate (GFR) • ↑ BUN + creatinine •↓ UOP: oliguria - < 400 mL/day •↑ K⁺ levels - because less blood is being filtered Hypertension •↓ GFR → fluid and Na⁺ retention → HTN •If HTN remains untreated and for a longer period of time it can lead to hypertensive encephalopathy - which can cause alteration of mental status and seizures HAD STREP (nephritic/APSGN) - Correct Answer •Hypertension •ASO (antistreptolysin O) titers + : group A β-hemolytic streptococci produce streptolysin O enzyme •Decreased GFR (↓ UOP) •Swelling in face/eyes...mild •Tea, cola-colored urine •Recent strep infection •Elevated BUN/creatinine •Proteinuria (mild) · Know S/S of nephrotic syndrome - Correct Answer - Massive proteinuria >3g/day - Anasarca (generalized edema) - HLD (liver tries to produce more albumin but also produces cholesterol and triglyceride) - Loss of immunoglobulin- infection risk - Loss of proteins to prevent clot- increased clot risk •Dark foamy or frothy looking urine •Hypoalbuminemia -Generalized edema: extremities, abdomen, face/eyes (anasarca) · Know nursing care for patients following an autograft and grafting to a burn wound (continued) - Correct Answer ......- Burn wound infection - Prevent/detect infection, safe environment - Drug therapy, isolation therapy, and environmental management are strategies for preventing and managing infection - Tetanus toxoid, 0.5 mL given IM, enhances immunity to C. tetani and is routinely given on admission - Topical antimicrobial drugs are used for infection prevention in burn wounds - ointments and creams (e.g., silver sulfadiazine [Silvadene®, Thermazene®], Sulfamylon®, Bacitracin®) Acticoat®, Mepilex Ag®, and Aquacel Ag®. Systemic ABX for s/s infection/septicemia (BSAbx) - Handwashing - Assign any equipment used in daily routine care (e.g., blood pressure cuffs, stethoscopes) to each patient for the duration of his or her stay - No raw foods, plants/flowers, visitors restricted, avoid sick people -Severe infection= surgical excision of wound · Know S/S of Carbon Monoxide toxicity (at different levels) in inhalation injury - Correct Answer - Bright cherry color to the skin and to their lips - Levels 10 to 20% - Headache and nausea - Levels > 20% - Dizziness, generalized weakness, difficulty concentrating, and impaired judgment - Levels > 30% - Dyspnea during exertion, chest pain (in patients with coronary artery disease), and confusion - Higher levels can cause syncope, seizures, and obtundation - Hypotension, coma, respiratory failure, and death may occur, usually when levels are > 60% - Treatment: 100% oxygen on a non-rebreather mask to help replenish that oxygen that body needs · Know Eschar debridement medication: Mafenide Acetate (Sulfamylon®) - Correct Answer - Ucentral: An antibacterial of the sulfonamide class, used topically in cream for treating burns - electrical burn and has thick eschar over the burn site= Use topical antibacterial Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream - Mafenide acetate 10% hydrophilic-based cream is the agent of choice when there is a need to penetrate thick eschar. -notes: ***Sulfamylon—is not only antibiotic but also has an enzymatic action to remove the eschar, if you apply and cover with dressing it will be painful because the eschar is being digested. If patient is complaining of pain, explain that is something that could happen with sulfamylon- the medication goes thru eschar. · Know S/S of Diabetes Insipidus - Correct Answer -Greatly increased urine output (polyuria) - 4 to 30 L/day -Low urine specific gravity (<1.005) -Hypotension -Dehydration -Increased plasma osmolarity (50 to 200 mOsm/kg) -Hypernatremia -Increased thirst -Output does not decrease when fluid intake decreases Cardiovascular, urinary, skin and neuro manifestation of diabetes insipidus (DI) - Correct Answer Cardio -Hypotension -Tachycardia -Weak peripheral pulses -Hemoconcentration Kidney/Urinary manifestation of diabetes insipidus (DI) -Increased urine output -Dilute, low specific gravity Skin manifestations of diabetes insipidus (DI) -Poor turgor -Dry mucous membranes Neurologic manifestations of diabetes insipidus (DI) -Decreased cognition* -Ataxia* -Increased thirst -Irritability* -*Occurs when access to water is limited and rapid dehydration results · Know S/S of hyperparathyroidism - Correct Answer -May be asymptomatic -Apathy, fatigue, muscle weakness, nausea, vomiting, constipation, hypertension and cardiac dysrhythmias -Excess calcium in the brain can lead to psychoses -Renal lithiasis can lead to renal damage and even failure -Demineralization of bones with back and joint pain, pain on weight bearing, pathologic fractures -Peptic ulcers and pancreatitis can also occur · Know S/S of complications after parathyroidectomy - Correct Answer -Risk of ineffective breathing, Tracheal obstruction, Swelling, Bleeding, Laryngeal spasm. - Hypocalcemia= give IV calcium gluconate - Be watchful for signs of tetany, seizures, and respiratory difficulties, elevated temperature, tachycardia, dysrhythmias, respiratory distress and cyanosis. - Observe for neuromuscular irritability (twitching, numbness, paranesthesia, positive Chvostek's and Trousseau's signs, seizure activity). - Thyroid storm? · Know assessment of patients with pheochromocytoma - Correct Answer -Usually benign tumor- chromaffin cell of adrenal medulla -May be associated with thyroid carcinoma or parathyroid hyperplasia or tumor - S/S: -Headache, diaphoresis, palpitations, hypertension -May have hyperglycemia related to excess epinephrine secretion -Tremors, flushing and anxiety as well -Blurring of vision -Feeling of impending doom -Associated with the 5 H's—hypertension, headache, hyperhidrosis, hypermetabolism and hyperglycemia -Urinary catecholamines and metanephrine are direct and conclusive tests -Serum epinephrine and norepinephrine levels will be elevated -Urinary vanillymandelic acid also diagnostic-- Must avoid coffee, tea, bananas, chocolate, vanilla and ASA, nicotine, amphetamines, decongestants before 24h urine testing -Clonidine suppression test—in normal individual, would block catecholamine release -Imaging studies · Know assessment for complications after thyroidectomy - Correct Answer -Impaired verbal communication -Vocal cord injury, Laryngeal nerve damage, Tissue edema, Pain, Discomfort - Thyroid storm -Chest pain and shortness of breath. -Tachycardia. -Atrial fibrillation and high pulse pressure. -Congestive heart failure. -Agitation, restlessness and delirium. -Psychosis. -Coma. -Tremor, nervousness and disorientation. -Hyperpyrexia with flushing and sweating. Hypocalcemia risk -Monitor RR/depth/work of breathing. -Auscultation of breath sounds, noting presence of rhonchi. -Assess for SOB/stridor/cyanosis. -Note quality of voice. -Regularly check dressing conditions and the area under the patient's neck and shoulders for drainage. -Assess neck dressing for signs of tightness. -Assess neck for signs of swelling, which is frequently related to hematoma formation · Know levothyroxine (Synthroid®) therapy - patient education (TWO QUESTIONS) - Correct Answer - Avoid hyponotic/sedatives/benzodiazepine -Never D/C abruptly because the pt may develop myxedema coma. -Teach pts s/s of myxedema coma: Swelling on the face, tongue, puffy face, waxy face, orange peel, dry skin, Hypothermia, extreme drowsiness, bradycardia, resp failure, hypoglycemia (progresses to coma), hyponatremia - Pleural pain - Asymmetrical chest wall expansion - Decreased breath sounds - OPEN PNEUMOTHORAX: Sucking sound with inspiration & Tracheal deviation - TENSION PNEUMOTHORAX: Air enters pleural cavity Ø escape, Respiratory Distress, Hypotension, Paradoxical chest movement, Tracheal deviation, Hyperresonance*, Mediastinal deviation*, Decrease in breath sounds · Know S/s of rib fracture (PPT) - Correct Answer Pain on inspiration and local tenderness. PT may have flail chest if &gt;1 rib broken. Chest wall will be unstable, PT may have paradoxical respiration, respiratory distress, chest pain. · Know S/S of flail chest - Correct Answer - Unstable chest wall - Paradoxical respiration - Respiratory distress - Chest pain - Need to Suction patient · Know early S/S of ARDS - Correct Answer - Resp alkalosis (pH >7.45, CO2 <35, Bicarb normal?) - Labored respirations (early ARDS) - Restlessness (early ARDS) - Dry non-productive cough (early ARDS) · Know S/S of Pulmonary Embolism - Correct Answer - Google: Shortness of breath. - Chest pain that may become worse when breathing in. - Cough, which may contain blood. - Leg pain or swelling. - Pain in your back. - Excessive sweating. - Lightheadedness, dizziness or passing out. - Blueish lips or nails. - petechiae on chest, feeling of impending doom, anxiety · Know nursing intervention when the nurse is unable to troubleshoot a low-pressure alarm on the ventilator - Correct Answer - If troubleshooting is not available manually bag the patient · Know S/S of pulmonary edema - Correct Answer - Frothy pink sputum - Crackles - Hypoxia - Anxiety - Confusion - SOB - Cold moist hands - Cyanosis - JVD -Persistent cough First degree heart block - Correct Answer § The electrical impulse at the PR interval is moving slowly through the AN node without missing a beat § PR interval are going to be abnormally long - greater than 0.20 seconds § This condition could happens in well condition athletes and the young Atrial fibrillation - Correct Answer § In atrial fibrillation when we are looking at the strip all we can see is the QRSs and the T-wave § In between that we see this little squiggly lines § Some people may interpret them as P-waves - those are not P-waves; they are called fibrillatory waves - which are called F-waves Ventricular fibrillation - Correct Answer § V-Fib the most deadly rhythm of all time § V-Fib is one of the only two rhythm that you defibrillate - the other one is pulseless V- Tach § V-Fib is a chaotic pattern of electrical activity in the ventricles in which electrical impulses arise from many multiple foci § There is no real ventricular contraction which leads to no cardiac output - basically meaning no oxygen to the body Ventricular tachycardia - Correct Answer -A lot of tachycardias except for ventricular tachycardia (V-TACH), you will find a narrow QRS complex, but in V-TACH if you look at the QRS complex is really wide o Normal sinus rhythm (NSR) - Correct Answer o Sinus bradycardia - Correct Answer · Know first nursing action when troubleshooting alarms from any patient monitoring device - Correct Answer Assess patient first, then check machine · Know assessment and care of the AV fistula for hemodialysis - Correct Answer AV fistulas are formed by surgically connecting an artery to a vein - Do not take blood pressure reading using the extremity where vascular access is placed -Do not perform venipunctures or start an IV in that extremity -Palpate for thrills and auscultate for bruits over the vascular access every 4 hrs -Assess the patients distal pulses and circulation in the arm with access -Elevate affected arm postoperatively -Encourage ROM exercises -Check for bleeding at needle insertion sites, assess for infection -Teaching: do not carry heavy objects or compress extremity, do not sleep with body weight on arm · Know S/S of BPH - Correct Answer - DRE enlarged prostate - May have s.s of cystitis - Dysuria - Pyuria- pus in the urine - Fever - Classic symptoms - Frequency, urgency - Nocturia - Difficulty starting stream and stopping stream- hesitance - Weak stream - Overflow dribbling - Feeling of being unable to completely empty the bladder - Hematuria ** - Hydronephrosis · Know S/S of Disequilibrium Syndrome post Hemodialysis - Correct Answer - May develop during HD or after HD has been completed. - It is characterized by mental status changes and can include seizures or coma; it is uncommon to observe this severity of disequilibrium syndrome with today's HD practice. - A mild form of disequilibrium syndrome includes manifestations of nausea, vomiting, headaches, fatigue, and restlessness. - It is thought to be the result of a rapid reduction in electrolytes and other particles (solutes) in a short time frame · Peritoneal dialysis complications: Know importance of maintain dwelling time as prescribed in diabetic patients receiving peritoneal dialysis - Correct Answer -In patients with DM, it is important to maintain Rx dwell time because an extended dwell time increases the risk of hyperglycemia Hyperacute kidney transplant rejection - Correct Answer • Occurs within 48 hours after surgery • Results from antibody-mediated reaction to donor antigens (must be ABO compatible &amp; Human Leukocyte Antigen); it causes the formation of small blood clots occluding vessels, and resulting in massive cellular destruction • Occurs rarely now due to better histocompatibility assessments • UOP stops; fever; HTN, pain at the transplanted site • Examination of kidney shows a blue, flaccid appearance • Management include immediate removal of transplanted kidney • Patient must resume hemodialysis until (possibly) another kidney is available Acute kidney transplant rejection - Correct Answer • Occurs 1 week to 2 years after surgery • An antibody-mediated response causing vasculitis (inflammation of the blood vessels) in the donor kidney, and cellular destruction starts with inflammation that causes lysis of the donor kidney - No cure - Google: About 50% of patients survive for less than 3 years after diagnosis, and about 20% survive for 5-10 years. Patients with ALS invariably develop respiratory weakness, and most die of pulmonary complications. · Know Tensilon test: Medication to anticipate complications - Correct Answer - Atropine should be available to control the side effects of edrophonium, which include bradycardia, sweating, and cramping · Know medications for Myasthenia Gravis (MG): Patient teaching - Correct Answer - Cholinergic medications "rest and digest" - Pyridostigmine bromide (Mestinon)- an anticholinesterase medication is the first line of therapy. -The dosage is gradually increased to a daily maximum and is administered in divided doses (usually four times/day) -Fewer side effects than other anticholinesterase medications. Patient Teaching: -Take with small amounts of food to minimize GI side effects, meals 45 min-1 hr after taking medication. ➢ If pyridostigmine bromide does not improve muscle strength & control fatigue, the next agents used are the immunomodulating drugs. · Know medications for Myasthenia Gravis (MG): Patient teaching (CONTINUED...) - Correct Answer .....■ The goal of immunosuppressive therapy is to reduce production of the antibody. ■ An initial dose of prednisone is given daily and maintained for 1-2 mo; as symptoms improve, the medication is tapered off. ➢ Cytotoxic medications are used to treat myasthenia gravis if there is inadequate response to steroids. ■ Azathioprine (imuran) inhibits T lymphocytes and B cell proliferation and reduces acetylcholine receptor antibody levels. ◆ Therapeutic effects may not be evident for 3-12 mo. ◆ Leukopenia and hepatotoxicity are serious adverse effects, so monthly evaluation of liver enzymes and white blood cell count is necessary. ➢ Intravenous immune globulin (IVIG) is also used to treat exacerbations; in selected patients, it is used on long-term adjective basis. ■ IVIG treatment is easy to administer and involves the administration of pooled human gamma-globulin; improvement occurs in a few days. · Know assessment for complications of Guillain-Barre syndrome - Correct Answer Assessment findings ● Paresthesia (numbness or tingling) and pain ● Cranial nerve dysfunction resulting in facial weakness, dysphagia, and/or diplopia ● Muscle weakness or flaccid paralysis without muscle wasting in an ascending, distal- to-proximal progression (symmetrical) hyporeflexia ● Respiratory compromise or failure: -Decrease peripheral oxygenation(Spo2) -Dyspnea , tachypnea , or paradoxical breathing -Decreased breath sounds from reduced tidal volume or vital capacity -Increase oral secretions, inability to swallow , or compromised airway patency ● Bowel and bladder incontinence ● Autonomic dysfunction evidenced by: - Labile blood pressure -Cardiac dysrhythmias, including tachycardia ■ Complications Respiratory Failure , Autonomic Dysfunction - Lumbar puncture- increased protein (same as MS) BUT WITHOUT increase in WBC ** -cognition/loc NOT affected · Know burns treatment: S/S of systemic effects of Sulfamylon - Correct Answer (notes)- metabolic acidosis- watch for s/s compensation= hyperventilation · Know MG: patient teaching - Correct Answer -if they choke on fluid try to thicken a little bit more ** eat or drink fluid in SITTING position not laying down -Meals given 45min-1hr after drug (need effect to kick in so they have swallowing function) -Drooping of eye- may not be able to close eye properly- maintain eye lubrication and also application of alternate patch 2-3 hrs a day to relieve diplopia - Drugs containing magnesium, morphine, curare, quinine, quinidine, procainamide, hypnotics, neomycin, kanamycin, streptomycin, polymyxin B, tetracyclines= avoid - Emphasize specific points concerning the disease process: 1. MG is characterized by episodic exacerbations (worsening of symptoms). If rest does not relieve symptoms or respiratory distress occurs, contacting your health care provider is indicated. 2. Avoid factors that predispose the patient to exacerbation, such as infection, stress, surgery, and hard physical exercise. · Know MG: patient teaching (continued...) - Correct Answer .....3. Teach the patient and family to monitor for these two types of crises: · a. Myasthenic crisis: an exacerbation (flare-up or worsening) of the myasthenic symptoms caused by not enough anticholinesterase drugs · b. Cholinergic crisis: an acute exacerbation of muscle weakness caused by too many anticholinesterase drugs - Promote lifestyle adaptations, such as avoiding heat (sauna, sunbathing), crowds, overeating, and erratic changes in sleep habits. - Provide information concerning the drug regimen, and include the name, effects, side effects, and the importance of taking drugs on time and not missing doses - Refer the patient to community agencies and support groups such as the Myasthenia Gravis Foundation. · A delegation question - unlicensed assistive personal (UAP) (what UAP CAN do) - Correct Answer class notes: Acute phase burn- ROM exercise 3x/day- can delegate to the UAP*** Google: It is within a UAP's scope of practice to: § Assist patients with activities of daily living (ADL's), including: § Eating § Bathing § Toileting § Ambulating § Perform routine procedures that do not require clinical assessment or critical thinking, such as: · Phlebotomy (except for arterial punctures) · Take vital signs · Monitor intake and output (of food and drink, urine, etc.) · A delegation question - unlicensed assistive personal (UAP) what UAP can NOT do - Correct Answer It is not within a UAP's scope of practice to: § Perform assessments § Delegate tasks § Perform patient education § Perform tasks that require clinical expertise, including 'routine' tasks such as: · Administering medications · Administering tube feedings · Performing wound care or dressing changes · Know assessment and intervention for inhalation injury - Correct Answer ** how to confirm inhalation injury? Through bronchoscopy - Levels of CO in blood can be detected by carboxyhemoglobin levels - Carbon Monoxide (CO) Poisoning - Bright cherry color to the skin and to their lips - Levels 10 to 20% - Headache and nausea - Levels > 20% - Dizziness, generalized weakness, difficulty concentrating, and impaired judgment - Levels > 30% - Dyspnea during exertion, chest pain (in patients with coronary artery disease), and confusion - Higher levels can cause syncope, seizures, and obtundation - Hypotension, coma, respiratory failure, and death may occur, usually when levels are > 60% - 100% oxygen on a non-rebreather mask to help replenish that oxygen that body needs · Know Parkland Formula calculation for fluid resuscitation - Correct Answer 4ml RL x patients weight in Kg x % BSA (body surface area) = the total volume in the first 24 hours. This is administered by infusing : 1/2 volume in the first 8 hours. 1/4 volume in the second 8 hours. 1/4 in the third 8 hours. During the 2nd 24 hours 1/2 to2/3 of initial daily volume will be given. o Decreased immunoglobulins · Know nursing intervention to prevent bacterial translocation from the gut in patients sustaining severe burn - Correct Answer Beginning enteral feedings early · Know assessment of effectiveness in mechanical debridement - Correct Answer o removal of necrotic/infected tissue o -allows ulcer examination o -decreases bacterial concentration in wounds, improves healing o -decreases infection (cellulitis, sepsis) -class notes= surgeon excises the wound until bleeding is encountered (so you know you the necrotic tissue has been removed) · Know the use elastic pressure garment in burn patients: patient education - Correct Answer - Elastic pressure garments are worn continuously (i.e., 23 hours a day) - notes- Pressure garment- 1-2 years for 23 yrs/day · ALL THAT APPLY: Know care of sickle cell patient in vaso-occlusive crisis - Correct Answer - Fluid replacement (NS or 5% dextrose in saline) - Pain management- opioids (morphine sulfate ATC/PCA pump) - Administer oxygen. - Administer prescribed pain medication. - Hydrate the patient with normal saline IV and with beverages of choice (without caffeine) orally. - Remove any constrictive clothing. - Encourage the patient to keep extremities extended to promote venous return. - Do not raise the knee position of the bed. - Elevate the head of the bed no more than 30 degrees. - Keep room temperature at or above 72° F (22.2° C). - Avoid taking blood pressure with external cuff. - Check circulation q hr · ALL THAT APPLY: Know nursing interventions for patient sustaining a burn in face, neck, chest, and extremities - Correct Answer - continued assessment and maintenance of the cardiovascular and respiratory systems, as well as toward GI and nutrition status, burn wound care, pain control, and psychosocial interventions · ALL THAT APPLY: Know S/S of thyroid storm - Correct Answer Thyroid storm § -Chest pain and shortness of breath. § -Tachycardia. § -Atrial fibrillation and high pulse pressure. § -Congestive heart failure. § -Agitation, restlessness and delirium. § -Psychosis. § -Coma. § -Tremor, nervousness and disorientation. -Hyperpyrexia with flushing and sweating · ALL THAT APPLY: SIADH as a result of lung cancer - assessment and treatment - Correct Answer - (PPT) Early manifestations: Water retention (hypervolemia, edema, weight gain), GI disturbances, - (PPT) Interventions for SIADH should focus on restricting fluid intake, promoting the excretion of water, replacing lost sodium, and interfering with the action of ADH. - Give diuretics (Lasix), fluid restriction (500-1,000 mL/24 hr), I&O, daily weight, lab chemistries. May use 3% NaCl in conjunction with Lasix (watch for O2 sat, low potassium, crackles). Drug of choice= declomycin, can also use tolvaptan or conivaptant (vasopressin antagonists) that promote water excretion without causing sodium loss (in hospital only- need to monitor for hypernatremia). - Crackles in the lung field Behavioral changes headache nausea · ALL THAT APPLY: Nursing interventions for Acute Pancreatitis - Correct Answer - Insert NG tube to avoid stimulation of pancreas - Morphine iv - Combined with antispasmodic agent and Histamine blocker - Monitor vital signs, administer IV fluids, observe for S/E of meds, assess respiratory function, assess/manage pain and nausea, FREQUENT POSITION CHANGES: comfort= side-lying with HOB elevated 45 degrees; knees up to abdomen. Monitor F&E- hypocalcemia, hypomagnesemia. NG tube care- frequent oral/nasal care, observe for s/s of infection. · ALL THAT APPLY: Nursing interventions when outflow is less than inflow in peritoneal dialysis - Correct Answer -Place the client in good body alignment - Check the level of the drainage bag - Check the peritoneal dialysis system for kinks - Reposition the client to his or her side - Move patient from side to side emergent phase change physiological (maybe SATA) (class notes) - Correct Answer - Plasma leaves to insterstitial space leading to edema (due to increased capillary permeability) - Sodium will leave too - Hyponatremia *** - Hypoalbuminemia- r/t disruption of intravascular oncotic pressure - Increased hematocrit- when fluid are given will see decreased H& H - Sickle cell disease- microcirculation is going to be affected due to thickness of blood - vaso occlusive crisis - Hyperkalemia - Leukopenia - Shift to the left- neutrophil Way of monitoring for effectiveness of escharotomy and fasciotomy (class notes- burn) - Correct Answer - Pressure from compartment syndrome- fasciotomy- need monitor pulses, respiration (for example escharotomy on chest to allow patient to breathe) and skin color to evaluate effectiveness of procedure Parenteral feeding plus stress leads to - Correct Answer ** study guide- parenteral feeding has a lot of glucose, patient with burn is stressed and fight or flight—going to have hyperglycemia/high level of glucose- monitor glucose level High cal high protein high carb diet for healing (class notes) ** SATA protective isolation emergent burn - Correct Answer - Hair covering - Gloves - Gown - Mask - Shoe covering - Any linen, covers, gloves for wound care need to be STERILE - Take care of one wound, change the gloves for a sterile glove and take care of other wound so you don't cross contaminate** Multiple sclerosis meds (notes) - Correct Answer urine incontinence **= anticholinergic -OXYBUTININ For urine retention- cholinergic medication= bethanechol **** Fatigue medication- modafinil and amantadine Tremor- propranolol (beta blocker), isoniazid (anti TB med but also helps with tremor) Spasticity- baclofen, benzos, dantrolene ataxia- propanolol, gabapentin, clonazepam Consitpation- Increase fiber Metamucil, stool softener