NCSBN All System Points to Remember
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NCSBN All System Points to Remember/Quiz NCSBN Cardiovascular
Points to Remember
Cardiovascular disease is the leading cause of death among Americans.
Measure blood pressure correctly o give client 5 minutes rest, with 2 to 3 minutes between checks o take blood pressure while client is lying, sitting, and standing o ask client if s/he has recently smoked, drank a beverage containing caffeine or was emotionally upset; if s/he answers yes to any of the questions, repeat blood pressure in 30 minutes o use the correct size BP cuff o ensure the client's arm is supported and does not have legs crossed Rarely, the heart may lie on the right side instead of the left (this is called dextrocardia ). Valves control the direction of the blood flow through the heart; flow is unidirectional. When the atria contract, the atrioventricular valves swing open, allowing the blood to flow down into the ventricles. When the ventricles contract the valves snap shut preventing blood from flowing back up into the atria; semilunar valves open allowing blood to eject during ventricular contraction. If the SA node fails to generate an impulse, the AV node takes over, generating a slower rate. If the AV node fails to generate an impulse, the Bundle of His takes over, generating an even slower rate. If the Bundle of His fails to generate an impulse, the Purkinje fibers take over and generate an even slower rate.
More Points to Remember
Damaged areas of the heart may also stimulate contractions and produce arrhythmias. Rapid, short-term control of blood pressure is achieved by cardiac and vascular reflexes that are initiated by stretch receptors (baroreceptors) in the walls of the carotid sinus and the aortic arch. Many clients with angina or who have experienced a heart attack benefit from involvement in a structured cardiac rehabilitation program to assist clients to increase their activity level in a monitored environment. Current research suggests that cardiovascular changes once related aging can now be attributed to lifestyle and personal habits. The elderly are less able to physically adapt to stressful physical and emotional conditions, because their hearts do three things less quickly: o the myocardium contracts less easily o the left ventricle ejects blood less quickly o the heart is slower to conduct the impulse for a heartbeat Because different enzymes are released into the blood at varying periods after a myocardial infarction, it is important to evaluate enzyme levels in relation to the onset of the physical symptoms, e.g., chest pain.
Clients who are in postoperative recovery, on bed rest, obese, taking hormonal contraceptives or had knee or hip surgery should be monitored closely for the development of thrombophlebitis.
Points to Remember
Oxygen is essential for life; therefore a priority nursing action is to keep the airways open and ease breathing effort. COPD causes poor gas exchange in the lungs, leading to decreased oxygen levels and increased carbon dioxide levels in the blood and shortness of breath. Nursing interventions for clients with chronic lung disease should include pacing of activities, because these clients have little reserve for exertion. Treatment of COPD consists of cessation of smoking, medications to open the airways and decrease inflammation, prevention of lung infections, oxygen supplementation, and pulmonary rehabilitation, i.e., using diaphragmatic breathing and pursed-lip breathing, proper use of respiratory equipment, and occupational or physical therapy. Clients with asthma must understand the different types of inhalers and when to use each type: some rescue inhalers are for acute dyspnea while other inhalers are for maintenance or prevention. To maximize therapeutic effect of inhalers, the key is technique; teach clients the right technique and observe how well they use the inhaler.
Points to Remember 2
A pulse oximeter reading is simply one element of an assessment; it is not the whole picture. Arterial blood gases will give a more complete picture of oxygenation. Cyanosis, a late finding, is determined by oxygenation and hemoglobin content. Clients with anemia may be severely hypoxemic and never turn blue; they may appear ashen. Remember to check nail beds and mucous membrane for changes; don't forget different skin coloring affects the appearance of anemia. Clients with polycythemia may be cyanotic with adequate tissue oxygenation. The serious public health issue of pulmonary tuberculosis requires control and reporting of any incidence and recent contacts that the client had so prophylactic therapy for two to three months can be initiated. Clients with pulmonary tuberculosis (TB) need intensive community follow up to ensure that they continue with long term pharmacological treatment. Clients who stop therapy too soon are a source for more deadly multi-drug resistant forms of pulmonary TB.
Points to Remember 3
If an alarm sounds on a ventilator, first assess the client. If the alarm continues to sound and the client develops distress, disconnect the client from the ventilator, use a manual resuscitation bag to ventilate with 100% oxygen, and page or call the respiratory therapist or the rapid response team immediately.
If the high pressure alarm sounds on the ventilator, the nurse should check for some type of obstruction or occlusion of the airway: mucous plugs, biting of the tube by the client, the tube has slipped into right main stem bronchus, or increased secretions. Smoking cessation is critical to reduce the risk and severity of lung disease. Second-hand smoke enhances the risk of children to develop asthma or other chronic lung diseases. The best approach to pulmonary embolus is prevention; use compression stockings (TEDS), along with sequential compression devices (SCDs), range of motion exercises (passive or active), and repositioning, to help prevent clots in the deep veins. When caring for a client who just had a chest tube inserted, validate that there's no leak from the lung. Only when there is no leak should an occlusive dressing be applied. Gentle tidaling is expected in the water seal chamber of a chest tube; continuous bubbling indicates an air leak and requires immediate intervention.
Points to Remember
Peripheral nerves can regenerate whereas nerves in the spinal cord do not regenerate. Cranial nerves can have either motor or sensory functions or both motor and sensory functions. In multiple sclerosis, early changes tend to be in vision and motor sensation; late changes tend to be in cognition and bowel control. During a seizure, do not force anything into the client's mouth or attempt to suction the mouth. Tremors associated with Parkinson's disease occur at rest; they disappear when the client reaches for something. Alzheimer's victims should not be concurrently treated with donepezil (Aricept) and the antidepressant paroxetine (Paxil). Donepezil increases acetylcholine in the brain and paroxetine works by decreasing acetylcholine levels in the brain. The client with myasthenia gravis will have more severe muscle weakness in the evening due to the fact that muscles weaken with activity - described as progressive muscle weakness - and clients usually regain strength with rest. When caring for a comatose client, remember that the hearing is the last sense to be lost. A major problem often associated with a left-sided brain infarction (CVA) is an alteration in communication. Clients with CVAs are at a greater risk for aspiration; evaluate to determine if dysphagia is present. Changes in a client's respirations (rate, rhythm and depth) are more sensitive indicators of increases in intracranial pressure than blood pressure and pulse. After a CVA, clients often have a loss of memory, emotional lability and a decreased attention span. Communication difficulties of a client with a CVA usually indicate involvement of the dominant hemisphere (usually the left brain) and is associated with right sided hemiplegia or hemiparesis.
Points to Remember
Anything that dilates the pupil obstructs the canal of Schlemm and increases intraocular pressure. Color blindness is caused by a deficiency in one or more types of cones and is caused by a sex-linked recessive gene. Destruction of either the right or left optic nerve tract results in blindness in the respective side of the eye. When mydriatics are instilled and the pupils have been dilated, caution clients that vision will be blurred and they will have photophobia for one to two hours. After eye surgery teach clients to avoid activities that can increase IOP for six weeks o Stooping o Bending from the waist o Heavy lifting o Excessive fluid intake o Emotional upsets, e.g., crying, laughing o Constrictive clothing around neck o Straining during bowel movement, i.e., straining at stool o Sustained coughing or blowing of the nose Teach clients proper administration of eye drops; most importantly to wash their hands before installation. The volume of a single drop of medication can vary; the second eye drop may either wash out the first, increase the possibility of systemic toxicity, and/or increase cost. When two different types of drops are being used, they should be instilled at least 5 minutes apart. Advise the use of sunglasses for photophobia. Assist with activities of daily living as needed. When clients wear one eye patch, they lose their depth perception. Remember that this loss presents a safety risk during mobility or cooking activities. Systemic disorders that can change ocular status include diabetes mellitus, atherosclerosis, Graves' disease (hyperthyroidism), AIDS, leukemia, lupus erythematosus, rheumatoid arthritis, and sickle cell disease. If there is some problem with the pigments in the cones, the eye will not see colors in the usual way. This is called color deficiency or color blindness. o If just one pigment is missing, the eye might have trouble seeing certain colors. Red-green color blindness - where red and green might look the same - is the most common form of color blindness, followed by blue-yellow color blindness. o In some eyes, none of the pigments are present in the cones, so the eye does not see color at all. This most severe form is known as achromatopsia. o Color blindness is a genetic condition that only rarely occurs in women, but affects about 1 out of every 10 men to some degree.
Points to Remember Ear
Changes in barometric pressure will adversely affect persons with ear disorders.
Hearing loss can o be partial or total o affect one or both ears o occur in low, medium or high frequencies In the elderly the loss of high frequency sounds may require special smoke detectors with low frequency sounds. The American Medical Association formula for hearing loss: hearing is impaired 1.5% for every decibel that the pure tone average exceeds 25 decibels (dB). A hearing loss of 22.5% usually affects social functionality and requires a hearing aid. Noise exposure is the major cause of hearing loss in the United States of America. Ask clients how they communicate: lip-reading, sign language, body gestures, or writing. To gain a client's attention, raise a hand or touch the client's arm. When talking with clients who have a hearing loss, speak slowly and face them. Speak in lower tones to facilitate the hearing of clients over 50 years of age. If the client wears a hearing aid, allow him/her to show how it is inserted, turned off/on, and cleaned. Speaking toward the client's good ear is recommended; however, speaking louder will not increase his/her chances of hearing. Tell clients taking ototoxic drugs to report any signs of dizziness, loss of balance, tinnitus, or hearing loss. Ototoxic drugs include: o aminoglycosides o antimycobacterials o thiazides o loop diuretics o antineoplastics
The 6 'F' s for gallbladder disease: F air (skin and hair) F at F orty (and older) F ertile (lots of children) F emale F latulant Points to Remember
The average age at diagnosis for pernicious anemia is 60 years-old; monthly injections are prescribed to correct the deficiency. Vitamin B12 deficiency is the number one cause of nutritional dementia and one of the main causes of peripheral neuropathy in the elderly; it may be a contributing factor in depression (B12 is a cofactor in the production of serotonin). A peptic ulcer is a sore in the lining of the stomach or duodenum; treatment may include medications to block stomach acids or antibiotics. A client with esophageal varices must be monitored for bleeding, e.g., melena stools, hematemesis, tachycardia.
The rupture of esophageal varices is life threatening and associated with a high mortality rate. Ulcerative colitis and crohn's disease are chronic inflammatory intestinal diseases with unknown etiologies. When assessing a client, frequent liquid stools can be indicative of a fecal impaction or intestinal obstruction - not diarrhea! Diverticula are most common in the sigmoid colon. Clients with diverticulosis are often asymptomatic. A deficiency in dietary fiber is associated with diverticulitis. Colostomies: o Ascending colostomy drains liquid feces, is difficult to train and requires daily irrigation o Descending colostomy drains solid feces and can be controlled Bowel sounds tend to be hyperactive in the early phases of an intestinal obstruction. Most obstructions occur in the small bowel. Most large bowel obstructions are caused by cancer. Onset of cirrhosis is insidious with symptoms such as anorexia, weight loss, malaise, altered bowel habits, nausea and vomiting. Management of cirrhosis is directed towards avoiding complications, which is achieved by maintaining fluid, electrolyte and nutritional balance. Hepatitis develops in three stages: pre-icteric (pre-jaundice) or prodromal; icteric; and post-icteric (post-jaundice). Common symptoms of hepatitis include abdominal pain, dark-colored urine, pale stools and pruritus; jaundice may occur in some, but not all, cases. Pancreatitis is often associated with excessive alcohol ingestion. Pancreatic cancer is an insidious disease that often goes undetected until its later stages; it is the fourth leading cause of cancer deaths among both men and women.
Points to Remember
After a urinary catheter is removed, the client may have some burning on urination, frequency and dribbling but these symptoms should subside within 24 to 48 hours. Co-trimoxazole (Bactrim) remains the drug of choice to treat urinary tract infections (unless the client is allergic to sulfa). After a transurethral resection of the prostate (TURP), tell clients that because the threeway Foley catheter has a large diameter, they will continuously feel the urge to void for 24 to 48 hours. After prostatic surgery, it is normal for the client's urine to be blood-tinged and for them to pass medium to small blood clots and tissue debris for 24 to 48 hours. Because the prostate gland receives a rich blood supply, it is a priority to observe clients undergoing a prostatectomy for bleeding and shock. Chlamydia is the most common sexually transmitted bacterial infection in the U.S. If untreated, it can cause PID in women and epididymitis in men. HPV vaccine Gardasil® protects against types of HPV that cause most cervical cancers and can help protect against genital warts in both young men and women.
Be sure to assess the site of the AV fistula of the client receiving hemodialysis for the thrill (it feels like water running through a thin hose) and bruit (a swishing or swooshing sound heard on ausculation). Clearly communicate that no blood pressures or blood draws should be taken on the arm with the fistula. Recent studies have shown that foods high in calcium, including dairy products, may help prevent kidney (calcium) stones. At the time of diagnosis, about one-half of clients with breast cancer have regional or distant metastasis. Nerve damage and lymphedema may occur with a radical or modified radical mastectomy (when lymph nodes are removed).
Diabetes insipidus (DI) - disorder of the posterior pituitary gland
Posterior pituitary gland makes too little antidiuretic hormone (ADH) causing failure of tubular reabsorption of water in the kidneys and diuresis, resulting in increased plasma osmolality and increased sodium levels Etiology can include tumor, trauma, inflammation, or psychogenic causes Findings o excessive thirst (polydipsia) o polyuria - as much as 20 liters per day with specific gravity below 1.006 o nocturia o signs of dehydration o constipation Management o expected outcomes: to correct underlying cause and restore hormonal balance o
pharmacologic desmopressin acetate (Stimate) vasopressin (Pitressin) - antidiuretic hormone lypressin (Diapid) chloropropamide (Chloronase) clofibrate (Claripex) carbamazapine (Mazepine) o IV fluid replacement therapy o surgical removal of tumor Nursing interventions o o o o o
monitor for findings of dehydration; measure urine; specific gravity administer medications as ordered monitor fluids and give IV fluids as ordered measure intake and output weigh client daily
o o o
monitor and care for client with signs of increased intracranial pressure (ICP) care of the client undergoing surgery teach client to record intake and output
about medications and side effects
about fluids with diuretic effects to check urine specific gravity the need to wear MedicAlert® identification
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Definition: continuous secretion of ADH with water intoxication with decrease in sodium concentration Etiology: lung tumors and other cancers, central nervous system disorders, brain tumors, head trauma, and adverse drug reactions Findings o changes in level of consciousness o changes in mental status o tachycardia o hyponatremia o weight gain o hypertension Management o osmotic diuretics o CAREFUL IV administration of 3% hypertonic sodium for hyponatremia o chemotherapy Nursing interventions o monitor intake and output (I&O) o monitor vital signs o monitor for findings of fluid overload and hyponatremia o daily weights o o
monitor electrolytes restrict water intake as ordered
Diabetes mellitus (DM)
Definition: a chronic condition in which the pancreas produces too little insulin, or cells stop responding to insulin; results in hyperglycemia
Findings (S/S of DM)
hyperglycemia the 3 "polys" of diabetes mellitus: polydipsia (increased thirst), polyuria (increased urine production), polyphagia (increased hunger) fatigue weight loss (in type 1 diabetes mellitus only) blurred vision vaginal infections slow wound healing
hypoglycemia (insulin shock)
blood sugar falls below 50 mg/dL caused by too much insulin, too little food, or excessive physical activity may result from delayed meals, exercise, or vomiting rapid onset findings of insulin shock o diaphoresis; cold, clammy skin o anxiety, tremor, slurred speech o weakness o nausea o mental confusion, personality changes, altered level of consciousness o headache if client is conscious, give oral simple carbohydrate: hard candy, honey, Karo syrup, jelly, a cola beverage, juice if unconscious: give 1 mg glucagon IM, IV or subcutaneous (subQ); or 20-50 mL 50% dextrose IV push
diabetic ketoacidosis (DKA) - an acute complication
results from severe insulin deficiency sudden onset findings o blood sugar levels > 350 mg/dL o serum pH < 7.35 o elevated ketone levels - cause sweet odor to breath (may also have odor of someone drinking alcohol) o metabolic acidosis - Kussmaul's respirations, flushed appearance, dry skin o thirst o polyuria o drowsiness o anorexia, vomiting o may lead to shock and coma o usual causes: undiagnosed diabetes mellitus inadequacy of prescribed therapy for diabetes mellitus physical stress such as surgery, illness, or trauma in person with diabetes mellitus caused by increased gluconeogenesis from amino acids and glycogenolysis in the liver o management: correct fluid depletion - IV fluids correct electrolyte depletion - especially potassium correct metabolic acidosis - (regular) insulin IV hyperosmolar hyperglycemic state (formerly called: hyperglycemic hyperosmolar nonketotic coma [HHNC]) o potentially fatal o gradual onset
findings severe hyperglycemia; usually > 600 mg/dL pH > 7.4 ketones - negative plasma hyperosmolarity dehydration altered level of consciousness o usually precipitated by physical stress such as an infection o in non-diabetics can be due to tube feedings without supplemental water, or too rapid rate of infusion for parenteral nutrition o occurs more often in the elderly, typically o expected: to correct fluid depletion, insulin deficiency, and electrolyte imbalance other chronic complications o diabetic triopathy retinopathy: chronic and progressive impairment of the retinal circulation that eventually causes hemorrhage nephropathy: progressive decrease in kidney function neuropathy: general deterioration of the nervous system throughout the body with complications leading to development of nonhealing ulcers of the feet o macrovascular complications: coronary artery peripheral vascular disease
Points to Remember Endocrine System
The endocrine system controls maturation, development, growth, and regulation within the body; the functions of the endocrine and nervous systems are interrelated. Endocrine disorders may be caused by o hyper- or hyposecretion of hormones o hyporesponsiveness of hormone receptors o inflammation of glands o gland tumors
In the pancreas, the beta cells in the islets of Langerhans make insulin. Clients with type 1 diabetes typically test blood sugar 4 times a day (before meals and at bedtime); those using an insulin pump may test more frequently. Treatment for type 2 diabetes typically includes oral antidiabetic agents. Hypoglycemia, allergic reactions, lipodystrophy, and Somogyi effect are problems associated with insulin therapy. Exercise increases the body's metabolic rate that results in a decrease in blood sugar and an increase in insulin sensitivity.
Illness can disrupt metabolic control and raise blood sugar, which results in an increased need for insulin. Glycated hemoglobin (HbA1c) provides a good estimate of how well diabetes has been managed in the past 2 to 3 months. A HbA1c of 6% or less is normal; diabetics should try to keep their HbA1c below 7%. Diabetes is the leading cause of heart disease, stroke, adult blindness and nontraumatic lower limb amputations. The highest incidence of diabetes is among Native Americans. Target blood glucose levels before a meal is between 90 to 130 mg/dL; 1 to 2 hours after a meal it should be less than 180 mg/dL. Diabetic ketoacidosis (DKA) occurs more commonly in type 1 diabetes whereas hyperosmolar hyperglycemic nonketotic syndrome (HHNS) occurs most often in clients with type 2 diabetes.
Points to Remember 2 Thyroid Gland
The thyroid gland secretes thyroxine and triiodothyronine. Following neck surgery, potentially life-threatening complications such as laryngeal edema and tracheal obstruction can occur; monitor for respiratory distress. Following thyroid surgery, many clients suffer transient hypocalcemia from hypofunction or removal of the parathyroids; monitor for signs of tetany for up to three days after surgery.
The parathyroid glands secrete parathyroid hormone. Chvostek's sign and Trousseau's sign are tests for neuromuscular irritability; a positive test, i.e., hyperirritability, for either of these indicates hypocalcemia or hypomagnesemia. o Positive Chvostek's sign - contraction of facial muscle occurs when light tap is given over facial nerve in front of ear. o Positive Trousseau's sign - carpal spasm occurs when the upper arm is compressed (by a blood pressure cuff, for at least 1 minute).
The adrenal medulla produces epinephrine and norepinephrine; the adrenal cortex secretes mineralocorticoids, glucocorticoids, adrenal androgens, and estrogen. In primary disease, e.g., primary Addison's disease and primary Cushing's syndrome, destruction of the adrenal glands usually results from an autoimmune process. A client with Addison's disease may have hyperpigmentation of the skin; don't confuse this with jaundice.
The pituitary gland secretes oxytocin and antidiuretic hormone.
Diabetes insipidus is a pituitary disorder.
Points to Remember
Rheumatoid arthritis affects joints symmetrically (bilateral involvement). After hip replacements, pulmonary embolism may occur even without thrombosis in foot or leg. After a hip pinning or femoral-head prosthesis, caution client not to force hip into more than 90 degrees of flexion, into adduction or internal rotation since these will cause dislocation and severe pain. Clients should be instructed to sit in a straight, high chair, use a raised toilet seat, and never cross their legs. In hip or knee replacement, clients will need assistive devices for walking until muscle tone strengthens and they can walk without pain. After arthroscopy, outpatient rehab may be prescribed depending on procedure; health care provider may prescribe knee immobilizer. If possible, prepare the client preoperatively to reduce anxiety prior to external fixation. Device looks clumsy, but patient should be reassured that discomfort is minimal. Caution clients with a new prosthesis not to use any substances such as lotions, powders, etc. unless prescribed by the health care provider. Osteoporosis cannot be detected by conventional x-ray until more that 20% of bone calcium is lost. Eating a balanced diet with sufficient amounts of calcium phosphorous, and vitamin D can help prevent osteoporosis. Foods high in calcium include milk, cheeses, yogurt, turnip greens, cottage cheese, sardines, and spinach. When performing a musculoskeletal assessment on a client with Paget's disease, note the size and shape of the skull; the skulls of these clients will be soft, thick and enlarged. Clients at high risk for acute osteomyelitis are typically elderly, diabetics, and have peripheral vascular disease. When clients receive long-term corticosteroids, evaluate them continually for side effects. Since steroids may mask the signs of infections, client should promptly report even slight changes in temperature. Immunosuppressed clients should avoid contact with persons who have infections. Photosensitive clients should avoid the sun, limit outdoor activities during peak sun hours and wear sun block.
Points to Remember
Usually only certified nurses may administer chemotherapeutic agents. Client undergoing chemotherapy should avoid crowds and persons with infections and to report signs of infection. Radiation has local effects related to site irradiated; chemotherapy is more systemic. Ionizing radiation will damage both normal and cancerous cells, causing side effects. Clients who receive external radiation are not radioactive at any time.
Although clients receiving internal radiation are not radioactive, the implant or injection is radioactive; treat waste products and body fluids as radioactive. Although clients with cancer may experience pain at any time during their disease, pain is usually a late symptom of cancer. Be sure to test client for tuberculosis (TB) before cancer treatment using monoclonal antibodies, especially infliximab (Remicade), since they will allow TB to fulminate. Highly active antiretroviral therapy (HAART) used in the treatment of AIDS can cost up to $30,000 - $50,000 per year.
Five types of shock syndromes fall under three categories o Cardiogenic (obstructive) o Distributive septic anaphylactic neurogenic o Hypovolemic Shock and temperature o Septic shock - skin and body temperature may increase o Other shock states - body and skin temperature will decrease Shock and circulation o Early stages of shock - activate the sympathetic nervous system (which is why the client may not always be hypotensive in the early stage of shock) o Bradycardia - a very late sign in shock o Arrhythmia - another late sign is cardiac o Perfusion As the myocardium receives less perfusion, the heart pumps less blood Because less blood perfuses the brain, level of consciousness decreases Shock and urinary output o Average adult urinary output is 0.5 to 1.0 mL/kg/hour; less than 30 mL/hour reflects decreased renal blood flow o Acute renal failure can result Shock and respirations o As blood flow to lungs decreases, less gas exchange will occur o When tissues receive less oxygen, they produce more lactate, resulting in metabolic acidosis, which increases the risk of cardiac dysrhythmias Treating shock - goals o Treatment - involves increasing both available oxygen and volume of blood in vessels (unless the heart has failed) o Medications - can improve the tone of blood vessels (inotropes) or treat the cause of shock (corticosteroids, antibiotics)
Remember It Emergency trauma assessment: ABCDEFGHI A =Airway
B =Breathing C =Circulation D =Disability E =Examine/expose F =Fahrenheit (temperature) G =Get vitals H =Head-to-toe assessment/history I =Inspect the back Complications of a trauma client: TRAUMATIC T =Tissue perfusion problems R =Respiratory problems A =Anxiety U =Unstable clotting factors M =Malnutrition A =Altered body image T =Thromboembolism I =Infection C =Coping problems
Points to Remember CPR
Assess if breaths go into lungs by chest movement. Push hard and fast on the chest, without interruption, at a rate of 100 compressions a minute. For the adult victim, give 30 compressions and 2 breaths (30:2 ratio) with either 1 or 2 rescuers. For the child or infant victim, give 30 compressions and 2 breaths (30:2 ratio) when there is 1 rescuer; with 2 rescuers, infant and child CPR becomes 15 compressions and 2 breaths (15:2 ratio)
In shock, the first hour of treatment is most critical; early detection is key. There are different ways to categorize shock; basically shock presents three potential problems: o Not enough fluid in the blood vessels o Fluid has moved outside the vessels, so cannot be pumped to the organs o Heart cannot pump fluid that is present in the vascular space The major problem in shock is tissue hypoxia
If client has head injury, the most important data collection is level of consciousness, next is pupil response to light; changes in vitals signs are very late signs. When treating a trauma client, a quick check of the ABCs is the priority. After you know the client is breathing and has a pulse, vital signs can wait while any bleeding is stopped and other interventions (such as starting IVs) are started. With trauma clients, assume spine is injured until proven otherwise; while the airway is being opened, the cervical spine should be immobilized.
NCSBN Pediatrics Remember it Cyanotic defects - the 4 T's: T =Tetralogy of fallot T =Truncus arteriosus T =Transportation of the great vessels T =Tricuspid atresia
In a cardiac history, include poor weight gain, chronic respiratory infection, activity intolerance, and fatigue during eating. Oxygen is a drug that requires a prescription and frequent monitoring. Cardiac catheterization is used for diagnostic, interventional and electrophysiological purposes. It also monitors cardiac oxygen saturation, pressure changes and anatomic defects. Heart failure (HF) signs usually show either left or right sided heart disorders; these signs may include increased heart rate, adventitious lung sounds, cyanosis, edema, hepatosplenomegaly, and distended neck veins. Acquired cardiac disorders include bacterial endocarditis, acute rheumatic fever, hyperlipidemia, Kawasaki disease, and cardiomyopathy. In cyanotic heart disorders, major concerns are polycythemia or increased hemoglobin and hematocrit, which can lead to thrombus formation.
The principal functions of the respiratory tract are to allow air movement (ventilation) and exchange (diffusion) of oxygen and carbon dioxide. Children's airways are smaller, more flexible and shorter than adult's and are therefore more prone to obstruction than adults. Stridor usually indicates an upper airway concern, while wheezing indicates a lower airway disorder. Conditions that increase or decrease compliance and/or resistance will make breathing harder.
Signs of increased breathing work are tachypnea, retractions, abnormal positioning, shortness of breath and fatigue. Respiratory effort and then rate are important indicators of respiratory status. Central cyanosis in a newborn usually means severe hypoxia and possible cardiac etiology. Acrocyanosis is a common finding in a newborn. Asthma is not a disease but an inflammatory disorder. The incidence and severity of respiratory tract infections and disorders is related to the child's age, size, natural defenses, underlying disorder and agent involved. Epiglottitis, acute tracheitis and status asthmaticus are acute medical emergencies. The best way to stop the spread of respiratory syncytial virus (RSV) is meticulous hand washing; the virus is transmitted by direct contact with a fomite.
A newborn's brain is about two-thirds the size of an adult's; it reaches 80% of adult size in one year. The primary indicator of neurological status is level of consciousness (LOC). Abnormal posturing is an ominous sign. Any bleeding from the nose or ears calls for evaluation. The progression from decorticate posture to decerebrate posturing, and then to flaccid paralysis, indicates deterioration of neurologic function. A positive Babinski is normal in children until one year of age. Abnormal CSF findings include: decreased glucose, positive culture, and cloudy appearance Due to pharmacokinetics and dynamics, common side effect of the majority of anticonvulsants include drowsiness, ataxia, lethargy, anorexia, nausea. Sometimes dyscrasias or liver damage can occur; hence, these children need periodic blood tests and liver enzymes. Acute bacterial meningitis is a medical emergency and requires swift action and treatment.
Pediatric Neurology 2
The sudden appearance of a fixed or dilated pupil is an emergency. In head trauma, the primary mechanism of injury is acceleration-deceleration accidents. The care of the unconscious child focuses on respiratory management, neurological assessment, monitoring intake and output, providing appropriate medications and evaluating outcomes. Do not do any diagnostic tests that require head movement until cervical spine injury has been ruled out. Children with congenital neurological disabilities will often develop complications in other body systems. Cerebral palsy is a neuromuscular disorder and is characterized by problems with perception, language, and/or intellectual function.
Febrile seizures are generally a one-time event, although there may be a familial predisposition. Status epilepticus is an emergency situation. Do not restrain a child experiencing a tonic-clonic seizure and never place anything in the mouth.
The body secretes hormones at various times during the day (influences of diurnal and circadian rhythm). Normal hormone levels are related to age and stage of puberty. The pituitary gland stimulates target organs to produce specific hormones; when sufficient, these in return signal pituitary to stop stimulation (negative feedback loop). Untreated infant hypothyroidism will lead to mental retardation. Associated terms for hypopituitary function include: short stature, constitutional delay, dwarfism. A major concern of precocious puberty is rapid bone growth, which can result in early fusion and short stature. Children with syndrome of inappropriate antidiuretic hormone (SIADH) develop an expanded circulatory volume but not edema. Oral potassium tastes very bitter; mix it with a little strongly flavored fruit juice. For a child with an endocrine disorder, never discontinue medication abruptly. The vast majority of children with new-onset diabetes mellitus type 1 (IDDM) will experience a "honeymoon" period when their bodies secrete insulin and their need for exogenous insulin decreases. Blood glucose monitoring by finger-stick reflects glucose currently and for last several hours; glycosylated hemoglobin levels indicate long-term compliance and true diabetic status. Never freeze, heat or vigorously shake insulin. The focus of diabetic management is the interrelationship of diet, activity and insulin administration.
Infants and children have a much smaller stomach capacity than adults. Peristaltic waves may reverse occasionally during infancy; gastric esophageal reflux is very common in infants. Secretory cells don't reach adult levels until two to three years of age. The GI tract has both intake (fluid, minerals, vitamins, etc.) and output functions. Whenever a newborn coughs, chokes and turns blue with feeding, suspect tracheoesophageal fistula: note the 3 C's - cough, choke, and cyanosis. Any newborn failing to pass meconium stool within the first 24 hours of life and who is prone to constipation or or has decreased stool frequency in the first month of life, should be evaluated for Hirschsprung's disease. Dehydration can lead to shock.
Dehydrated infants and children face greater morbidity risk than adults because children differ in body composition and metabolic rate, and their fluid-regulation systems have not matured. Potassium should only be added to IV fluids when the urine output is sufficient. One gram of diaper weight equals one milliliter of urine. When assessing diarrhea or constipation, remember the acronym ACCT: amount, color, consistency, and time (duration). Bilious vomiting indicates source below the ampulla of Vater.
The kidney's function is to maintain, in equilibrium, the composition and volume of body fluids. Kidney function in an infant is nearly that of an adult by 12 months of age. Children with urine output less than one milliliter/kilogram/hour should be closely monitored for possible renal failure. Acute renal failure should be suspected in a child with decreased urine output, edema and/or lethargy, and who is dehydrated, recovering from surgery or in shock. Urinary tract infection (UTI) management aims to eliminate the underlying cause, detect and correct abnormalities, and prevent recurrences. The effects of hypokalemia or hyperkalemia can be devastating. Urinary tract infections are extremely common in young children; girls are more prone to UTIs than boys. In a child with ambiguous genitalia, the criterion for choice of gender and rearing is typically not genetic sex, but the infant's anatomy.
Since many musculoskeletal disorders begin with trauma, it is important to assess ABC (airway, breathing and circulation) first. Open fractures increase the risk of infection. Immobilization has multi-system effects. For a child with a fracture, it is important to assess the five P's of ischemia: o o o o o
Pain and point of tenderness Pulse - distal to the fracture Pallor Paresthesia Paralysis
Children with structural defects/disorders require regular follow-up evaluation until they reach skeletal maturity. Children in casts or traction need to be monitored for alterations in skin integrity routinely. Children under one year of age generally do not experience fractures. Children's soft tissues are resilient, dislocation and sprains are less common.
The extent of a burn injury is expressed as percentage of total body surface area (TBSA). The larger the percentage of TBSA that is burned, the greater the risk for burn shock. In managing alterations in skin integrity, it is necessary to individualize the type of treatment and medications to the particular causative agent. If you wouldn't put it into an eye, don't put it into a wound. Wounds heal by the process of moist wound healing and occlusion; dry wounds do not heal. Wound debridement promotes healing and prevents infection. Immediate care for a major burn is ABC: airway establishment and patency, breathing and absence of respiratory distress, and circulation with fluid initiation. Potassium should not be administered during the initial oliguric phase of a burn injury, but should be added when diuresis occurs.
Viruses are parasites that cannot reproduce or meet their own metabolic needs. Skin cells react to viruses with swelling, "vesiculation," or proliferation, sometimes warts. Most viruses are associated with rashes (characteristic of each disorder, such as chicken pox, rubella, roseola).
For a child with altered platelet function or bleeding disorder, do not administer acetylsalicylic acid (aspirin, ASA) or take rectal temperatures. Perform invasive procedures very cautiously. Children with low WBC may not exhibit common findings of infection such as purulent drainage. In a febrile client with granulocytopenia, give antibiotics immediately because this child risks developing rapid, overwhelming sepsis. Morphine is the pain medication of choice for pain in children with sickle cell disease.
Findings of pediatric malignancies vary according to the child's age, location and type of tumor, and extent of disease. Cure rate is improving for most types of pediatric malignancies; however the late effects of treatment are of increasing concern and incidence. Children typically have longer treatment plans than adults due to their increased metabolic rate and rate of cell turnover. Leukemia affects not only the blood, but can metastasize to major organ systems (extramedullary disease), including the central nervous system. Nursing care includes monitoring the child for the development of acute complications of treatment including fever, bleeding, and anemia. Pediatric oncologic emergencies include: acute tumor lysis syndrome, superior vena cava syndrome, septic shock.
NCSBN Complicated Obstetrics
Points to Remember During pregnancy
If the maternal pancreas is unable to increase insulin production sufficiently, gestational diabetes mellitus results. Maternal hyperglycemia results in glucose crossing the placenta and the fetus manufacturing insulin. Insulin in the fetus acts as a growth hormone producing a large-size, macrosomic infant. Shoulder dystocia is the most common complication of vaginal delivery in large-size infants. Maternal insulin needs are dramatically reduced following delivery. Newborns of diabetic mothers may incur birth injury, hyperbilirubinemia, hypoglycemia, and neurologic damage. Euglycemia is the most important factor in avoiding maternal/fetal complications. Anemia in pregnancy is associated with complications of abortion, infection, pregnancy induced hypertension, preterm labor and heart failure. Fetal problems from anemia of mother include growth retardation with associated morbidity and mortality. Daily logs of dietary intake may help the client focus on positive improvement. Pica is the craving by, pregnant client, for non-food substances from low serum iron levels. Failure to correct nutritional imbalances in pregnancy can result in fetal complications: intrauterine growth retardation, central nervous system malformations and fetal death. Failure to correct nutritional imbalances in pregnancy can result in maternal complications: severe dehydration, metabolic alkalosis, ketosis, cardiac dysrhythmias and death for the woman. Maternal understanding of various disease processes and recommended therapies may provide impetus for self-care. Normal pregnancy cardiovascular changes increase the heart's workload. Cardiac disease in pregnancy can deteriorate rapidly. Client must verbalize understanding of cardiac findings indicating complications. Pregnant cardiac clients must be monitored closely for decompensation. Cardiac output maximizes at approximately 28 weeks; is increased during labor and is at its highest during first hour postpartum. Class II to IV cardiac clients should labor side-lying, in semi-Fowler's position to facilitate cardiac emptying; pulse oximetry should be used to monitor tissue perfusion; and cardiac monitoring should be maintained. Class II to IV cardiac clients should have induction, regional anesthesia and should not push during birth; legs should never be higher than the heart and should be monitored intensively following delivery. Failure to detect blood incompatibility with the fetus can result in red blood cell hemolysis and severe morbidity or mortality; RhoGAM should be administered to all sensitized client's within 72 hours following delivery, miscarriage, or abortion.
Points to Remember
Complications during labor and delivery
Prolonged labor at any stage should be evaluated for fetal, pelvic or uterine dysfunction. Vaginal birth is the birth method of choice and interventions should be directed at accomplishing that goal. Cesarean birth is utilized to rescue the infant when fetal, pelvic or uterine dysfunction cannot be overcome. Efficient and effective gathering of supplies and personnel is imperative. Assist mother to birth as slowly as possible to prevent maternal/newborn trauma. With nonreassuring fetal status (fetal distress), administer oxygen, increase IV fluids and assist client to turn onto her left side; stop oxytocin (Pitocin). Anticipate predisposing factors for prolapsed cord; use gentle displacement of cord with sterile gloves to relieve pressure. Inform and support mother in emergency. Prepare for expeditious birth - usually cesarean. Surgical intervention has associated complications of increased infection, increased postoperative hemorrhage, increased morbidity and potential of increased mortality. Surgical delivery of the newborn reduces mechanical compression of the chest. It may potentiate respiratory difficulties in the newborn such as transient tachypnea of the newborn. Surgical delivery is to be avoided except to rescue the fetus or to alleviate maternal morbidity. Severe postpartum hemorrhage may result in organ failure, disseminated intravascular coagulation (DIC), and/or mortality. Estimation of bleeding is critical. Uterine massage is the first line of defense against excessive hemorrhage. Oxytocins are used to contract the uterus.