NURS 4626 Final Exam Blueprint Comprehensive Exam Preparations review Guide, Study notes of Nursing

Download NURS 4626 Final Exam Blueprint Comprehensive Exam Preparations review Guide and more Study notes Nursing in PDF only on Docsity! NURS 4626 Final Exam Blueprint Comprehensive Exam Preparations review Guide Alternate question types-22; Dosage Calculations-2 When studying content, focus on clinical manifestations, diagnostics, interprofessional care, and nursing interventions. Be thinking about what are the most life-threatening complications, ABCs of priority care. COMPREHENSIVE REVIEW OF PREVIOUS EXAM CONTENT – 61 Week 1. Fluid, Electrolytes, and Acid/Base Imbalances and perioperative – 6 Pre and post op nursing interventions – 3 ● Pre-op goal is to identify risk factors and plan care to ensure safety ○ Allergies ○ Medications ○ Health history ○ Education- what to expect, remove nail polish ○ Informed consent-witness, make sure site is marked ○ Labs-make sure available, pregnancy test ○ Meds- antibiotic (one hour cut time), atropine (secretions), morphine (pain management), benzos (anxiety), PPI/H2 blockers ○ Give valuable to family, document ● Post-op ○ Monitor VS and make sure patient does not have adverse effects following surgery (baseline) very interested in respirations, any change oxygen first ○ ABCs, LOC ○ Due to void, asses bladder, palpate, bladder scan ○ Urinary output should be at least 0.5ml/kg/hr following surgery ○ coughing , deep breathing ○ Ambulation ○ Acid/Base Imbalances – 2 * Decreased BP © Hyperkalemia ¢ Muscle Twitching ° Warm, Flushed Skin (Vasodilation) ° Nausea, Vomiting Diarrhea METABOLIC ACIDOSIS * Headache © Changes in LOC (Confusion, tdrowsiness) Kussmaul Respirations Compensatory Hyperventilation ° Causes: DKA Severe Diarrhea Renal Failure Shock RESPIRATORY ACIDOSIS * Hypoventilation 4 Hypoxia * Razid, Shallow * Drowsiness, Dizziness, Respiratione Disorientation «Lo * Muscle Weakness, Hygerrefiexia * Skin/Mucosa Pale to Cyanotic * Causes: ¥ ¢ Respiratory Depression NN (Anesthesia, Overdose, tiCP) Airway Opgtrustion f ¢ Headache * Hyperkalemia * Dyorhythmias (Te) ○ Associated with Mi, ischemia, disease States, procedures ○ Unresponsive, pulseless and apnic ○ If not treated properly, Jessica result ○ Treat with immediate CPR and ACLs ○ defibrillation and drug therapy such as epinephrine and vasopressin Cardioversion - 1 ● Check that the synchronizer switches off for Defibrillation ● Turn the synchronizer switch on for cardioversion ● never apply defibrillator pads over a pacemaker or implantable cardioverter defibrillator ● be careful that personnel are all clear before discharging the device ● Before placing the ECG leads on the patient, prepare the skin. Artifact is a district portion of the baseline and waveform seen on the ECG. It is hard to interpret the rhythm when the artifact is present; you will see artifacts when its leads are not secure, the gel is becoming dry, or there is muscle activity. You want to clip the chest hair. ● ·Be sure to tell the patient that pacing can be uncomfortable (transcutaneous Pacemaker) ● Radiofrequency catheter ablation therapy uses electrical therapy to burn or bleed areas of the conduction system Pacemakers - 1 ● Blocks ● Afib ● Cardiomyopathy ● Heart failure ● Tachy dysrhythmias ● Nursing management includes monitor with ECG, monitor Rhythm, IV antibiotics are given prophylactically prevent infection, have patient limit arm and shoulder movement on the operative side to prevent dislodging, no heavy lifting, report palpitations, microwaves are fine ● Patient education includes no MRIS, avoid direct blows to the Pacemaker site, where a Medic Alert bracelet, importance of follow-up care, monitor self for infection, teach to take own pulse, travel is not restricted, but make sure to tell security because it can set off metal detector Week 3. Cardiac – 6 Acute coronary syndrome – 3 ● Unstable angina- leads to MI ● STEMI- MONA, get to cath lab within 90 minutes, can give thrombolytics ● NSTEMI-PCI can wait 12-72 hours, no thrombolytics ● Myoglobin first, CKMB (3 days, definite diagnosis), Troponin I (7 days) ● Position upright, oxygen therapy, vital signs, auscultate heart and lungs, 12 lead ecg, insert 2 IVs, pain, meds (nitro), ECG monitoring Pericarditis – 2 ● Friction rub , tripod position helps relieve pain, have pt hold breath on inspiration, lower left sternal border lean forward ● Tamponade- drop in SBP greater than 10 on inspiration (pulsus paradoxus) ● Pleural effusion- hiccups and hoarseness ● Pericardiocentesis- monitor for arrhythmias and tamponade (stop anticoags, expanders, and positive inotropes) ● Txt with coroticos, antibiods, NSAID, cholcezine ● Pain relief is priority (NSAID, positioning, tripod), can radiate, dyspnea, Valvular heart disease – 1 ● Biologic(tissue, remove all the cells off for transplants not rejected, no anticoag, more natural pattern of blood flow) vs mechanical (lifelong anticoag therapy, more durable, longer lasting) ● TRAVR, closed percutaneously, femoral artery ● Open-full sternotomy ● Minimally invasive Week 4. Specific Lower Respiratory Problems – 6 Tracheostomy – 1 ● Pre oxygenate for 30 seconds before suctioning (125 mmHg) ● Cough is when you stop 10-15 second passes no more than 3 passes ● 2 person tapes one side at a time ● If comes out call for help try to reinsert w/ hemostats then obturator if no worky in the hole and bag them ● Insertion- make sure cuff inflated first, inflate lungs, end tidal co2, suction, no change tape for 24 hours, provider first time ● No cut gauze, aspiration (culture and antibiotics), bleeding notify HCP, Chest Tubes – 2 ● Bubbles in water seal chamber (b and c) bad- air leak ● Bubbles in suction good (a) ● Tidaling w/ suction off (b and c) in water seal fine ● Put in sterile water if comes out , chest comes out put in petroleum gauze dressing replace water if below 20mL ● 100 mL/hour 200 mL (d)in first hour, subq emphy, report to HCP ● Infection-fever, increased WBC, redness, drainage or swelling at site ● Pulmonary embolism – 1 ● Dyspnea most common symptom, tachy shit, anxiety, hypotension ● Helical CT, d-dimer, V/Q for no contrast hoes give fibrinolytics and then anticoags, fall precautions, bed rest, DVT prophy, IVC filter for no anticoag hoes, embolectomy no anticoag hoes (massive) ● Oxygen, anticoags, thrombolytics, IVC filter (no anticoag) Pneumothorax - 2 ● Mild tachycardia and dyspnea w/ air hunger, ● Tent dressing (3 sided occlusive), sucking (open), stabilize object with bulky dressing ● Tension-Mediastinal shift (tracheal deviation ), urgent needle decompression ● Unaffected side (good lung down) ● O2 <90, pain meds PRN ● Chylothorax- octopussy drug ● Hemothorax- chest tube, thoracentesis Week 5. Respiratory Failure and Acute Respiratory Distress Syndrome – 6 ● X ray, ABG, pulse ox, lowest Fio2 possible, 30 degree HOB, good lung down, augmented coughing, staged coughing, positioning, suctioning (humidification, hydration), PPV, Respiratory failure (hypoxemia and hypercapnia) - 2 ● Hypoxemic- change in mental, cyanosis late sign, intercostal muscle retraction ● ,60 on Fio2 >60, V/Q mismatch, shunt, hypovent, ARDS, most often multifactorial, lactic acid buildup ● Hypercapnia- morning headache, pursed lip breathing, tripod position, hypertension, necrosis, decreased DTRs, tremors, tachypnea (hyperventilation), increase in paCO2 >50 pH<7.35, pump failure ARDS – 2 ● X-ray show whiteou t Refractory hypoxemia, oxygen, PEEP (high), PaCo2 up to 60, low Vt Prone, ECMO, PaO2/ FiO2 greater than 400 is normal, less than 100 terrible ● White out x-ray, permissive hypercapnia, prone 16 hours/day, inotropes, IV fluids, opioids, benzos, propofol, neuromuscular blockade (iums) ● Comps-barotrauma, decreased venous return (decreased BP) Mechanical ventilation - 2 ● Hypo- increase dark green veggies, soybeans, tofu, avoid spinach and rhubarb ● Hyper-bisphosphonates (dronates) Week 9. Intracranial Problems, Stroke and Delirium – 6 ICP Monitoring – 1 ● 5-15, 20 bad, ventriculostomy (strict aseptic technique) ● Factors influence ○ Arterial/venous pressure, intraabdominal, posture, intrathoracic, temp, ABGs (particularly Co2) ● Monroe Kelly - one increases other two will compensate (blood, CSF, tissue) ● Cushing’s triad- Brady, increased SBP w/ widening pulse/ bounding pulse, decreased resp ● CPP- 60-100, MAP-ICP (less than 50 ischemia, less than 30 death) ● Headaches, vomiting ● Unilateral Dilated pupil- herniation (blown) Increased ICP management – 2 ● Mannitol and hypertonic solutions- dry out brain, Corticos(decrease inflam) and Barbs (decrease cerebral metab, used later when other shit no work) ● Glascow Coma Scale- high number good 15, lowest 3 under 8 bad ● Avoid neck or hips flexion, decorticate vs deceberate Stroke – 2 ● TPA (vitals stop if BP gets too high and call HCP and neuro status) for ischemic within 3-4.5 hours, aspirin for 24-78 hours after ● Ischemic - less than 185, ● CT to rule out hemorrhagic ● Hemorrhagic - SBP less than 160 ○ SAH: hyrdochelaplus (ventriculostomy), ○ hyperdynamic therapy- hypertension to increase MAP ○ Volume expansion- crystalloids or colloids ○ CCBs for vasospasm ● Right sided- left side paralysis, no recog, minimize, crack ● Left sided- right side paralysis, speech, slow, cautious, aware, depressy ● Non mod vs modifiable ● Tx- fibrinolytics SBP<185, not candidate SBP <220, Hemorrhagic <160 Delirium – 1 ● Minimize stimulus , reorient, treat the cause ● Dementia, dehydration, electrolyte imbalance, emotional stress, lung, liver kidney brain, infection/icu, rx, injury/immobility, untreated pain, unfam environment. Metabolic disorders ● Priority is safety, consistent staff, ativan for severe agitation Week 10. Chronic Neurologic Problems, Peripheral Nerve and Spinal Cord Problems – 6 Myasthenic Crisis – 1 ● Muscle weakness, difficulty in swallowing and breathing, antichol, corticos, immunosuppressants ADLs in AM, plasmapheresis(remove antibodies), IV IG and intubation Trigeminal Neuralgia – 1 ● Advise against stimuli like cold/stress, soft bristle toothbrush, soft vegan chew on unaffected side, electric razor, unilateral pain ● Take meds at bedtime, phenytoin, TCA Parkinson’s Disease - 1 ● Levodopa-carbidopa, lots of appetizing food ● TRAP (tremor, rigidity, akinesia, postural instability) ● No ondansetron (extrapyramidal syndrome) ● Antichols and diphenhydramine for tremors ● Fiber and frequent small meals and fruit increase, protein/B6 in evening meal ● Exercise, prevent falls, step over imaginary line, rock side to side after standing, walking to a beat, swinging arms Spinal Cord Injury management – 2 ● Stabilize c-spine , above C4 ventilation, T2 and below paraplegia ● Autonomic dysreflexia- hypertensive and bradycardic, immediate cath (general too), stool impaction (stimulation of anus), remove clothes ● Move with log roll, SP02 >92, MAP 85-90, SBP >90, keep ABGs WNL ● NSAIDs best, bowel retraining, skin care (wound care counsults) Neurogenic shock – 1 ● Hypotension, bradycardia, loss of SNS, temp dysregulation ● Atropine and vasopressors, temp support NEW CONTENT: 39 Week 11: 8 · Describe the clinical manifestations, complications, diagnostic studies, interprofessional care including drug therapy, and nursing management of: · Fractures - 2 ● Immediate localized pain, decreased function, and inability to bear weight or use affected part. Patient guards and protects extremity from movement. ● Diagnostics: CT/MRI, X-ray is diagnostic ● Keep extremity aligned, immobilization is key in non surgical ● Muscles relaxants ( Carisoprodel, cyclobenzaprine, methocarbamol) ○ Watch for decreased BP, increased HR, and in severe cases respiratory depression ● Sedatives (Opioids, NSAIDS) ● Vaccines- tetanus, and diphtheria for open (DTAP) ● Prevent constipation ○ Increasing activity, diet high in fiber and fruits, normal bowel elimination schedule, give stool softeners, fluid intake of 2500 mL/day ● Renal Stones ○ Maintain fluid intake 2500 mL/day ● Asses site of injury, maintain strict aseptic technique for post-op if applicable ● Infection ○ Debridement, IV antibiotics for three days. Cephalos bc they penetrate the bone ● Compartment Syndrome ○ Edema constricts blood flow ○ 6 P’s: pain out of proportion for injury or unrelieved with meds (1st sign), increasing pressure, paresthesia,pallor, coolness and loss of normal color in the extremity, paralysis or loss of function, and pulselessness ○ Notify HCP ○ Do not elevate the extremity above the heart, do not apply cold compresses ○ Fasciotomy may be needed (watch for infection), Amputation in severe cases. ● VTE ○ Common anticoags (LMWH, Warfarin, aspirin or facer Xa inhibitors) ○ Compression devices/stockings ● Fat Embolism Syndrome (FES) ○ Early recognition is crucial (happens 24 to 48 hours after surgery) ○ Chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, and hypoxemia ○ Changes in mental status, trunk petechiae (diagnostic of this) ○ Supportive Therapy: O2, blood, fluids ○ Prevention is the tea with immobilization (happens in long bones) ● Work with PT to maximize activity levels · Amputation - 1 ● Health Promotion: Control of illness (underlying causes like DM, PVD) ○ Examine lower extremities carefully, help from family members ● Proper bandaging with compression bandages-promotes shrinkage ● Don’t use lotions, creams etc. unless ordered ● Perform ROM daily ● Post-Op care: ○ Assess for hemorrhage ○ Flexion contractures (Most debilitating complication) Dx: Int Care: Drugs: ● Perforation and peritonitis ● Endoscopy- primary tool, do lavage 1st ● Angiography- when endoscopy can’t be done, ● CBC, BUN (this will be increased ), ABGs, type and crossmatch, stools tested for gross and occult blood ● Emergency Management ○ Asses for symptoms of shock (tachy, weak pulse, hypotension, cool extremities, prolonged cap refill, apprehension) ○ Urine output- cath hourly output recorded ○ Central line, O2 sat, isotonic crystalloid solution ● Endoscopic Shit ○ First 24 hours, goal is hemostasis, heat ablation, ligation ● Surgical therapy- for non fixing bleeding, dangerous for old people ● PPI to decrease HCL secretion, started before endoscopy ● Long term PPI, H2 Blockers, Misoprostol- take with meals or snacks Nursing Management: ● Stop smoking, don't take any OTC w/o provider order ● Educate on how to monitor stools for occult blood ● Acute care: ○ 2 Large Bore IVs ○ Monitor Urine output- at least 5mL/kg/hr ○ Watch for fluid overload (asses the lungs and shit) ○ Gradually increase food and fluids b/c of GI upset · Appendicitis - 2 Clinical Manifestations: ● Begins with dull periumbilical pain, followed by anorexia, nausea, vomiting ● McBurney’s point ● Low-grade fever, localized tenderness, rigidity, rebound tenderness, muscle guarding ● Right-leg flexed Dx: ● Differential WBC (will be high) ● UA- rule out other shit that mimics ● CT- preferred, Ultrasound and MRI Nursing Management: ● Relieving pain and preventing comps ● Keep patient NPO ● Ambulation-few hours after surgery, can resume normal activities 2-3 weeks · Peritonitis - 2 Clinical Manifestations: ● Abdominal pain-most common symptom ● Universal sign- tenderness over involved area ● Rebound tenderness, muscular rigidity, and spasm, abdominal distention, fever, tachycardia, tachypnea, nausea, vomiting Comps: ● Hypovolemic shock, sepsis, intraabdominal abscess formation, paralytic ileus, and ARDS Dx: ● CBC (elevations in the WBC), Peritoneal aspiration, abdominal x-ray, Ultrasound and CT scans ● Peritoneoscopy- helpful in pt’s without ascites Nursing Management: ● NPO, NG tube, low-flow oxygen PRN, isotonic fluids, antibiodics · Intestinal obstruction - 2 Clinical Manifestations: ● 4 Hallmark: Abdominal pain, nausea, vomiting, distention, constipation Dx: ● Abdominal x-ray, CT scan. Sigmoidoscopy, colonoscopy ● CBC (high WBC may mean strangulation or perforation), Serum electrolytes (dehydration) Int Care: ● Depends on cause, strangulation/perforation needs emergency surgery ● NPO, IV fluid therapy, NG tube for decompression, some patients need PN Nursing Management: ● Monitor for signs of dehydration and electrolyte imbalances ● Give IV fluids as ordered, Provide comfort measures, frequent oral care and water soluble lubricant for lips, Clean and dry skin area daily, check NG tube for patency. · Acute hepatitis - 2 Clinical Manifestations: ● Many have none, int or ongoing anorexia, lethargy, nausea, vomiting, skin rashes, diarrhea, constipation, malaise, fatigue, myalgias, arthralgias, right upper quadrant tenderness, jaundice, urine dark, clay colored stools, smokers may have distaste for cigs Complications: ● Acute liver failure: (DIC, leukocytosis, ascites, edema, hypotension, resp failure) ○ liver transplants Diagnostics: ● Only definitive dx for differentiating: blood test ● Viral genotype testing for drug therapy, Liver diagnostics ● Liver biopsy: if diagnosis in doubt ● Non invasive assessment of liver fibrosis- FibroScan ● Degree of liver fibrosis- FibroTest Int Care: ● No specific treatment, most managed at home ● Adequate nutrition, avoiding alch,avoiding acetaminophen notifying contacts for testing and prophy Nursing Management: ● All children at 1 year of age should receive vaccine ● Asses jaundice presence/degree, Urine dark brown or brownish red ● Comfort measures to relieve itching, headache, arthralgias ● Nutrition- frequent meals, measures to stimulate appetite, mouth care, antimetics, attractively served meals, drinking carbonated beverages, avoiding very hot or cold items ● Adequate fluid intake (2500-3000 mL/day) ● Rest, diversion activities, activities after periods of rest, regular follow-ups, should avoid alcohol · Acute pancreatitis - 2 Clinical Manifestations: ● Abdominal pain (left upper quadrant may be midepigastric), radiates to back, sudden onset, severe, deep, piercing, continuous/steady, eating worsens pain ● Pain starts when patient is in recumbent position, pain is not relieved, may move a lot ● Nausea, vomiting, w/ flushing, cyanosis, and dyspnea ● Low grade fever, leukocytosis, hypotension, tachycardia, jaundice ● Abdominal tenderness with guarding, bowel sounds decreased or absent, paralytic ileus ● Crackles, cyanosis or greenish abdominal wall ● Ecchymosis (blue color) of the flanks (Grey Turner’s), periumbilical (Cullen’s) Complications: Week 13: 12 · Differentiate among effects, toxicity, withdrawal, overdose, screening tools, and nursing management of: · Stimulants 1 ● CNS exciter, feelings of euphoria, increased alertness, boost of energy ● Toxicity: ○ Palpitations, tachycardia, hypertension, dysrhythmias, myocardial ischemia, angina, agitation, euphoria, insomnia, combativeness, seizures, hallucinations, confusion, paranoia, fever ○ ABCs, no specific antidote, supportive therapy ● Withdrawal not an emergency ● Safe, quiet environment, allow patient to sleep and eat as desired · Depressants 1 ● Sedative hypnotics(barbs and benzos) and opioids ● Toxicity: ○ Aggression, stupor, hallucinations, slurred speech, cold clammy skin, weak pulses, seizures, decreased o2 sat, hypo, dysrhythmias, cardiac or respiratory arrest ○ ABCs and naloxone (opioids) flumazenil (benzos) ● Withdrawal: ○ Benzos- IV diazepam, ○ Opioids-long acting opioids (methadone, buprenorphine), Alpha agonists (clonidine), ondansetron, NSAIDs, acetaminophen, antihistamines · Cannabis 1 ● Chemo (GI, pain,appetite), AIDS (appetite increase and pain management) ● Acute toxicity: ABCs and supportive therapy ● Adequate hydration, analgesics, benzos for withdrawal symptoms · Tobacco 2 ● CNS stimulant, get “high” or “buzzed” for 1-2 hours ● 5As to quit: Ask, Advise, Assess, Assist, Arrange ● 5Rs unwilling to quit: Relevance, Risks, Rewards, Roadblocks, Repetition ● Varenicline and Bupropion · Alcohol 2 ● CNS depressant, change in impulse, mood,behavior, coordination ● Toxicity: ○ Respiratory and circulatory failure, unconsciousness, coma, death, hypokalemia, hypomag, hypoglycemia ● Withdrawal: ○ Peaks after 24-48hr hours ○ Delirium- 2-3 days after last drink, deadly (disorientation, hallucinations, seizures) ○ Agitation, anxiety, tachycardia, hypertension, diaphoresis, GI upset, tremors, insomnia, hyperactivity ● CIWA-Ar scale to determine treatment(0-7) high score bad, AUDIT (risk)- 9 or more is bad ● Naltrexone: withdrawal and relapse prevention ● Disulfiram: maintenance, relapse prevention, aversion therapy ● Benzos: for symptomatic relief · Describe the risk factors, protective factors, and nursing management of a patient with suicidal ideation. 3 ● Hard methods (high risk): ○ gun, jumping off a high place, hanging, poisoning with carbon monoxide, staging a car crash ● Soft methods (lower-risk): ○ cutting one’s wrist, inhaling natural gas, ingesting pills ● Biological factors, psychological factors, environmental (copycat suicide), cultural (highest among whites), Societal factors ● Religiosity, marriage- decreased rates of Suicide ● Professionals and people with chronic illnesses have increased risk ● Protective factors: ○ Effective mental healthcare ○ Strong connections to individuals, family, community and social institutions ○ Problem-solving and conflict resolution skills ○ Contact with providers ● Interventions are common sense · Identify six aspects of crisis that have relevance for nurses involved in crisis intervention. 1 494 box 26.1 (mh) 479-lethality ● Self limiting (resolved in 4-6 weeks) ● At resolution patient will emerge at one of three diff levels ○ Higher, same, lower ● Goal: return them to the pre-crisis level of functioning ● People are often more receptive to outside interventions and with this can learn different problem solving skills to correct the negative solutions ● Patient in crisis is assumed to be mentally healthy, to have functioned well in the past, and is just in a present state of disequilibrium ● Resolution of the here and now ● Nurse must take active even directive role intervention ● Early intervention is best ● Have patient set realistic goals and plan together with nurse · Compare and contrast the differences among primary, secondary, and tertiary intervention including appropriate intervention strategies. 1 ● Primary: ○ Health promotion, prophylactic interventions ● Secondary: ○ Intervention during acute crisis ● Tertiary: ○ Care for people who have already experienced a crisis Total = 100