Flashcards.

WHAT IS IT?

Angina is chest pain caused by not enough blood flow to the heart muscle. If blood flow is not restored, it can lead to more heart damage. The most common cause is coronary artery disease (CAD), where atherosclerotic plaque (fatty buildup) ruptures and a clot forms. Other causes include anemia (low red blood cells), heart failure, stress or overexertion, and abnormal heart rhythms.

Quick Concept: The chest pain happens because the heart muscle is not getting enough oxygen for the work it is doing.

TYPES

• •Stable: comes with exertion (activity). Relieved by nitroglycerin.
• •Unstable: comes at rest. Lasts longer. NOT relieved by nitroglycerin.
• •Variant: unpredictable.

ASSESSMENT

• •Chest pain
• •Dyspnea on exertion (shortness of breath with activity)
• •Hypotension (low blood pressure) from decreased cardiac output (amount of blood the heart pumps)
• •Hypertension (high blood pressure) from increased stress on the heart
• •Bradycardia (slow heart rate) from decreased cardiac output
• •Supraventricular tachycardia (fast heart rate from above the ventricles) from increased stress on the heart
• •Atrial fibrillation (irregular heartbeat) from increased stress on the heart
• •Syncope (fainting)
• •Pale skin
• •Diaphoretic (sweaty)

MANAGEMENT

• •Goal: restore blood flow, decrease chest pain, and improve activity tolerance.

Medications (anticipated):

• •Thienopyridines (clopidogrel)
• •Heparin (blood thinner)
• •Renin-angiotensin blockade (ARBs or ACE inhibitors)
• •Oxygen
• •Morphine (only if indicated by facility)
• •Beta blockers
• •Nitroglycerin (per facility policy)

Monitoring and tests:

• •EKG (electrocardiogram, heart tracing) to rule out STEMI (a type of heart attack) and monitor arrhythmias (abnormal rhythms)
• •Monitor vital signs (HR, BP, SpO2) for changes
• •Cardiac enzymes to find heart muscle damage
• •Cardiac stress test to find the point of heart stress
• •Cluster care (group tasks together) so the client can rest and lower the heart's oxygen demand

WHAT IS IT?

The heart is a pump that moves blood through the body. Heart failure is pump failure. It happens when the heart cannot pump enough blood to meet the body's needs. If untreated, blood backs up (congestion) and tissues do not get enough blood (poor perfusion).

Quick Concept: Pump failure causes decreased perfusion moving forward and increased congestion backing up behind the heart.

CAUSES

• •Myocardial infarction (heart attack): dead muscle cannot pump
• •Hypertension (high blood pressure): raises afterload, which is the resistance the heart pumps against, adding stress to the heart muscle
• •Valve disorders: an inefficient pump means blood does not move in the right direction

DIAGNOSTICS

• •BNP (Brain Natriuretic Peptide): a hormone released by heart muscle cells when the ventricles stretch
• •Echocardiogram: detects ejection fraction and diagnoses valve disorders
• •Chest X-ray: detects cardiomegaly (enlarged heart) and pulmonary edema (fluid in the lungs)

COMPLICATIONS

• •Volume overload
• •Decreased perfusion

ASSESSMENT

Right-sided heart failure (decreased lung perfusion and increased body congestion):

• •Decreased oxygenation
• •Decreased activity tolerance
• •Peripheral edema (swelling in arms and legs)
• •Increased jugular venous distention (JVD, bulging neck veins)
• •Increased preload (volume returning to the heart)
• •Weight gain
• •Fatigue
• •Liver and GI congestion

Left-sided heart failure (decreased body perfusion and increased lung congestion):

• •Skin pale or dusky
• •Decreased peripheral pulses
• •Slow capillary refill
• •Decreased kidney perfusion (decreased urine output, kidney injury or failure)
• •Pulmonary edema: cough, pink or frothy sputum, crackles, wheezes, tachypnea (fast breathing), shortness of breath on exertion
• •Anxiety and restlessness

MANAGEMENT

The goal is to decrease the workload on the heart while still increasing cardiac output.

• •Decrease preload
• •Decrease afterload
• •Increase contractility

WHAT IS IT?

Heart failure means the heart cannot pump blood forward well. In left heart failure, the left ventricle (lower left pumping chamber) cannot push blood into the systemic circulation (the body). Blood backs up into the pulmonary circulation (the lungs). In right heart failure, the right ventricle cannot push blood into the lungs. Blood backs up into the venous circulation (the veins of the body).

Quick Concept: The side that fails causes a backup behind it, so left failure floods the lungs and right failure floods the body.

ASSESSMENT

Left heart failure (lung backup):

• •Shortness of breath
• •Dyspnea on exertion (trouble breathing with activity)
• •Crackles (abnormal lung sounds)
• •Pink, frothy sputum (foamy spit)
• •Cyanosis (bluish skin from low oxygen)
• •Fatigue
• •Orthopnea (trouble breathing while lying flat)
• •Tachycardia (fast heart rate)
• •Confusion
• •Restlessness

Right heart failure (body backup):

• •Jugular venous distention (bulging neck veins)
• •Fatigue
• •Ascites (fluid in the belly)
• •Anorexia (loss of appetite)
• •GI distress (stomach upset)
• •Weight gain
• •Dependent edema (swelling in the lower body)
• •Venous stasis (blood pooling in the veins)

WHAT IS IT?

Coronary artery disease is the buildup of plaque (fatty deposits) inside the main blood vessels of the heart. The main causes are high blood pressure and high cholesterol. The inner vessel walls get damaged, inflammation happens, plaque sticks to the walls, and clots form. This causes blockage and loss of blood supply to the heart. The main symptom is chest pain.

Quick Concept: When plaque and clots block a coronary artery, the heart muscle stops getting blood and starts to be damaged.

RISK FACTORS

• •Smoking
• •High blood pressure
• •Obesity
• •Diabetes
• •Hyperlipidemia (high blood fats)
• •Family history

COMPLICATIONS

• •Acute coronary syndrome: plaque breaks off and blocks a coronary artery
• •STEMI (ST-segment elevation myocardial infarction): near or complete blockage, called the "widowmaker"
• •NSTEMI (non-ST-segment elevation myocardial infarction): partial blockage
• •Unstable angina
• •Concern for cardiac arrest

ASSESSMENT

• •Chest pain
• •Arrhythmia (irregular heartbeat)
• •Shortness of breath
• •Elevated blood pressure
• •Provider orders: electrocardiogram (EKG), cholesterol levels
• •CT scan to see vessel occlusion (blockage) and stenosis (narrowing)
• •Angiogram to view inside the vessels
• •Stress test to view blood flow

MANAGEMENT

Medications:

• •Statins (cholesterol medications) to decrease plaque in the blood
• •Anticoagulants to prevent blood clotting
• •Beta-blockers to decrease the workload of the heart
• •Calcium channel blockers to relax vessels and allow blood through
• •Nitroglycerin to open arteries, allow blood through, and decrease chest pain

Procedures:

• •Angioplasty: go in through a vein to open vessels
• •Stent placement to keep the vessel open
• •Coronary artery bypass surgery to make a new vessel pathway around the blockage

WHAT IS IT?

Hypertension is high blood pressure. It is called the "silent killer" because it has no symptoms until it has already damaged organs. Over time it can lead to stroke, heart attack (MI, myocardial infarction), kidney failure, and heart failure.

ASSESSMENT

• •Often no symptoms at first (asymptomatic until end-organ damage)
• •Vision changes
• •Frequent headaches
• •Dizziness
• •Chest pain or angina (chest pain from poor blood flow to the heart)

MANAGEMENT

• •Medications: ACE inhibitors (angiotensin-converting enzyme inhibitors), beta-blockers, calcium channel blockers, diuretics (water pills)
• •Diet and lifestyle changes

Nursing priorities (perfusion):

• •Check blood pressure and heart rate FIRST before giving blood pressure medications
• •Assess for end-organ damage: check kidney and neurological status
• •Strict intake and output (I&O)
• •Assess for cardiovascular changes

WHAT IS IT?

Cardiogenic shock is complete pump failure of the heart. The heart cannot move oxygen-rich blood to the body. Causes include myocardial infarction (MI, heart attack), end-stage cardiomyopathy (weak heart muscle), papillary muscle or valve rupture, cardiac tamponade (fluid pressing on the heart), and pulmonary embolism (PE, clot in the lung).

Quick Concept: When the pump fails, blood flow forward drops and blood backs up behind the heart.

ASSESSMENT

• •Sudden, severe, extreme heart failure

Decreased perfusion (poor blood flow):

• •Decreased cardiac output (CO, blood pumped) and decreased BP (blood pressure)
• •Increased HR (heart rate) as compensation
• •Increased SVR (systemic vascular resistance, vessel tightness) as compensation
• •Weak, thready pulses (the pump is not pumping strongly)
• •Cool, diaphoretic (sweaty) skin
• •Pale, dusky, cyanotic (bluish), or mottled skin
• •Decreased urine output
• •Decreased LOC (level of consciousness), anxiety

Volume overload (blood backs up because the pump cannot pump):

• •Increased CVP (central venous pressure)
• •JVD (jugular vein distention, neck vein bulging)
• •Pulmonary edema (fluid in the lungs): crackles, pink frothy sputum, sudden severe SOB (shortness of breath)

MANAGEMENT

Treat the cause of pump failure:

• •Revascularization for MI (PCI, percutaneous coronary intervention; or CABG, coronary artery bypass graft)
• •Thrombolytics (clot busters) or surgical removal for PE
• •Pericardiocentesis (draining fluid around the heart) for cardiac tamponade

Improve contractility (squeezing strength):

• •Dopamine (may increase HR)
• •Dobutamine

Decrease afterload (pressure the heart pumps against):

• •Dobutamine

Diuretics (water pills):

• •Furosemide for pulmonary edema
• •Caution: may decrease BP

WHAT IS IT?

A myocardial infarction (heart attack) is a sudden loss of blood supply to part of the heart. This causes ischemia (lack of oxygen) and death of the heart muscle tissue.

CAUSES

• •Coronary artery disease and thrombosis (clot)

ASSESSMENT

Subjective findings (what the patient reports):

• •Chest pain not relieved by rest
• •Pale, diaphoretic (sweaty), mottled skin
• •Nausea, anxiety, shortness of breath, and palpitations that worsen with activity

Objective findings (what you measure):

• •May be hypotensive (low blood pressure) or bradycardic (slow heart rate)
• •ST-elevation on a 12-lead EKG (called STEMI)
• •Elevated troponins (most sensitive), elevated CK-MB and CK

MANAGEMENT

Anticipated medications:

• •Thienopyridines (clopidogrel)
• •Heparin
• •Renin-angiotensin blockade (ARBs or ACE inhibitors)
• •Oxygen
• •Morphine (only if indicated by facility)
• •Beta blockers
• •Nitroglycerine (per facility policy)

Nursing actions:

• •Monitor EKG
• •Rest to decrease the oxygen demand of the heart

Anticipate provider orders:

• •12-lead EKG
• •Cardiac enzymes every 3 hours times 4
• •Thrombolytics unless contraindicated
• •Percutaneous transluminal coronary angioplasty (PTCA), which opens clogged arteries

WHAT IS IT?

This is the nursing care after cardiovascular (heart and vessel) procedures. Two common procedures are PCI (Percutaneous Coronary Intervention, a catheter that opens a blocked coronary artery) and CABG (Coronary Artery Bypass Graft, surgery that reroutes blood around a blocked artery).

MANAGEMENT

Perfusion (blood flow to tissues):

• •Pulse checks
• •Vital signs
• •Pain assessment
• •Skin assessment
• •Give blood pressure medications
• •Leg positioning

Clotting:

• •Give anticoagulant (blood thinner)
• •Monitor access site (where the catheter entered)
• •Monitor for bleeding
• •Check coagulation (clotting) studies
• •Check CBC (Complete Blood Count), including H/H (hemoglobin and hematocrit)
• •Assess for DVT (Deep Vein Thrombosis, a clot in a deep vein)

Patient education:

• •Incentive spirometer (a device for deep breathing)
• •Diet and lifestyle changes
• •Medication instructions
• •Activity restrictions
• •Bleeding precautions
• •When to notify the HCP (Health Care Provider)

WHAT IS IT?

Distributive shock is caused by an immune or inflammatory response that interferes with vascular tone (the tightness of blood vessels). This leads to massive peripheral vasodilation (widening of blood vessels throughout the body). Blood pressure drops because the vessels are too wide.

TYPES

• •Anaphylactic: from an allergic reaction and inflammatory cytokines (immune signaling proteins)
• •Neurogenic: from spinal cord injury and loss of SNS (sympathetic nervous system) activity
• •Septic: from a systemic (body-wide) infection and inflammatory cytokines

ASSESSMENT

Anaphylactic:

• •Hives, rash, swelling of arms, trunk, or face/mouth
• •Exposure to an allergen
• •Decreased SpO2 (oxygen level)
• •Decreased BP (blood pressure)
• •Increased HR (heart rate)
• •Increased RR (respiratory rate), wheezes
• •Warm, flushed skin

Neurogenic:

• •Spinal cord injury in the last 24 hours
• •Warm, flushed lower extremities
• •Decreased BP
• •Decreased HR (occasional)
• •Priapism (persistent erection) due to vasodilation

Septic:

• •Decreased LOC (level of consciousness)
• •Decreased BP
• •Increased HR
• •Warm, flushed skin
• •Increased temperature
• •Signs and symptoms of infection

Decompensated shock:

• •Refractory (does not respond to treatment) low BP
• •Decreased LOC
• •Decreased SpO2
• •Decreased HR

MANAGEMENT

Anaphylactic:

• •Epinephrine to relax airway muscles
• •Corticosteroids to decrease inflammation
• •Bronchodilators to protect the airway

Neurogenic:

• •Therapeutic hypothermia (controlled cooling) for neuroprotection

Septic:

• •IV antibiotics (draw blood cultures first)
• •IV fluids to increase preload (blood returning to the heart)
• •Corticosteroids only if vasopressors are ineffective

Decompensated shock:

• •Vasopressors (drugs that tighten blood vessels)
• •Intubation for airway protection

WHAT IS IT?

Cardiomyopathy is an abnormality of the heart muscle that changes how the heart works. It can be caused by long-term untreated high blood pressure, heart failure, or congenital disorders (present at birth). There is no cure, so care is supportive.

Types:

• •Dilated: all 4 chambers enlarge, walls thin and weaken, lower contractility and lower cardiac output (CO, amount of blood the heart pumps per minute)
• •Hypertrophic: thick, stiff ventricle muscle with less space to fill, lower preload (blood filling the heart) and lower CO
• •Restrictive: ventricles become rigid and cannot stretch to fill, lower stroke volume (SV, blood pumped per beat) and lower CO

ASSESSMENT

Signs of heart failure:

• •Fatigue
• •Shortness of breath (SOB)
• •Dysrhythmias (abnormal heart rhythms)
• •Extra heart sounds (S3/S4)
• •Poor perfusion (poor blood flow to tissues)
• •Volume overload: JVD (jugular venous distension, bulging neck veins) and pulmonary edema (fluid in the lungs)
• •Echocardiogram or chest X-ray shows an enlarged or thickened heart

MANAGEMENT

• •No cure, only supportive care
• •Encourage frequent rest
• •Minimize stress
• •Manage high blood pressure with DASH diet, ACE inhibitors (angiotensin-converting enzyme inhibitors), ARBs (angiotensin receptor blockers), and beta-blockers
• •Beta-blockers lower the force of contraction, lower workload, and lower oxygen demand
• •Ventricular assist devices help eject blood from the left ventricle to the aorta

WHAT IS IT?

Atrial fibrillation is when many disorganized cells in the atria (upper heart chambers) fire extra electrical impulses. This makes the atria quiver fast instead of contracting normally. Blood pools in the atria, which creates a HIGH risk for stroke. The AV node (atrioventricular node) blocks some impulses, so the ventricles contract in a rapid, irregular way.

Quick Concept: Because the atria only quiver and do not squeeze well, blood pools and can form clots that travel to the brain.

CHARACTERISTICS

• •Rhythm: irregular
• •Atrial rate: over 300 bpm, with a wavy baseline
• •Ventricular rate: 60-100 bpm; over 100 bpm is called Rapid Ventricular Rate (RVR)
• •P:QRS ratio: no obvious P waves
• •Wavy baseline that is not measurable
• •PR interval: not measurable
• •QRS complex: 0.06-0.12 seconds

ASSESSMENT

• •Palpitations (feeling the heartbeat)
• •Fatigue
• •Lightheadedness or syncope (fainting)
• •Decreased cardiac output (blood the heart pumps): syncope, hypotension (low BP)
• •PT/INR labs if taking Coumadin (a blood thinner)

MANAGEMENT

Nursing interventions:

• •12-lead EKG (heart tracing)
• •Restore NSR (normal sinus rhythm)
• •Assess for signs and symptoms of stroke

Control ventricular rate:

• •Antiarrhythmics
• •Beta-blockers
• •Calcium channel blockers
• •Transesophageal echocardiography / cardioversion (shock to reset rhythm)
• •Ablations (destroying the tissue causing the problem)

Decrease stroke risk:

• •Anticoagulants (blood thinners): Coumadin (Warfarin), Xarelto (Rivaroxaban), Eliquis (Apixaban)

WHAT IS IT?

Thrombophlebitis is the formation of a thrombus (clot) along with inflammation in an extremity. It can dislodge and travel, so it must be managed carefully.

RISK FACTORS

Virchow's Triad:

• •Venous stasis (slow or pooling blood flow)
• •Damage to the inner lining of the vessel
• •Hypercoagulability of the blood (blood clots too easily)

Medical history:

• •History of thrombophlebitis
• •Pelvic surgery
• •Obesity
• •Heart failure, MI (heart attack)
• •A-fib (atrial fibrillation)
• •Immobility
• •Pregnancy

ASSESSMENT

Unilateral findings on the affected side:

• •Pain
• •Warm skin
• •Redness
• •Tenderness
• •Febrile state (fever)

Diagnostics to confirm:

• •Ultrasound to visualize the clot
• •D-Dimer: a product of fibrin breakdown found in the blood after a clot is broken down (a positive result suggests a clot)

MANAGEMENT

If the client has a confirmed DVT (deep vein thrombosis):

• •No SCD/TED (compression devices), no massage, bedrest, because these could dislodge the clot

Anticoagulant therapy:

• •Heparin: monitor PTT every 6 hours
• •Coumadin (warfarin): monitor PT/INR

IVC filter (sits in the inferior vena cava and collects clots before they reach the heart and lungs):

• •Monitor for signs of emboli
• •Heart (MI): chest pain
• •Lungs (pulmonary embolism): anxiety, shortness of breath, increased heart rate, increased respiratory rate, chest pain
• •Brain (stroke): facial droop, arm weakness, speech difficulty
• •Monitor distal pulses

Clotting prevention and monitoring:

• •Monitor circumference of the limb twice daily
• •SCD/TED plus enoxaparin sodium (an anticoagulant), if ordered by the provider
• •Passive range of motion
• •Early ambulation

WHAT IS IT?

Hypovolemic shock is a loss of blood volume that lowers oxygen delivery to vital organs. The body tries to compensate, but when those mechanisms fail, organs begin to shut down. If not treated, organ failure occurs.

ASSESSMENT

• •Worsening hypotension (low blood pressure) from low volume
• •Tachycardia (fast heart rate) as the body works hard to pump the volume it has
• •Weakness
• •Tachypnea (fast breathing)
• •Decreased LOC (Level Of Consciousness)
• •Inadequate urinary output from low volume
• •Weak pulse

MANAGEMENT

Treat the cause:

• •OR (operating room) for repair
• •Medications for vomiting or diarrhea
• •Common causes include vomiting or diarrhea for days, severe burns, traumatic injury, and hemorrhage (surgical or obstetric)

Replace volume:

• •Crystalloid fluids: LR (Lactated Ringer's), NS (Normal Saline)
• •Colloid: blood products
• •Rapid infuser

Support perfusion (blood flow):

• •Hemodynamic monitoring (tracking blood pressure and circulation)
• •Vasopressors (drugs that raise blood pressure)

Life support:

• •Decreased LOC may need airway protection and ventilation

WHAT IS IT?

Sinus tachycardia is a heart rhythm that starts normally in the sinus node but is faster than normal. The heart rate is over 100 beats per minute. It is usually a response to another problem in the body.

RHYTHM CHARACTERISTICS

• •Rhythm: regular
• •Heart rate: greater than 100
• •P:QRS ratio: 1:1
• •PR interval: 0.12 to 0.20 seconds
• •QRS complex: 0.06 to 0.12 seconds

ASSESSMENT

• •Stable: no concerning symptoms
• •Unstable: rapid heartbeat, palpitations, lightheaded, decreased cardiac output
• •Causes: fever, dehydration, hypotension (low blood pressure), anemia, anxiety/fear, pain

MANAGEMENT

• •Find and treat the cause
• •Determine if the client is stable or unstable

Stable:

• •Vagal maneuvers, medications (beta-blockers, calcium channel blockers, adenosine)

Unstable:

• •Synchronized cardioversion (timed electric shock to reset the rhythm)

WHAT IS IT?

A cataract is a clouding of the lens in the eye. The cloudy lens distorts the image projected onto the retina, which lowers vision. If left untreated it can lead to blindness.

ASSESSMENT

Early findings:

• •Slightly blurred vision
• •Decreased color perception

Later findings:

• •Blurred vision
• •Double vision
• •Difficulty with activities of daily living (ADLs)
• •Vision loss is gradual
• •Pupil appears white

Diagnosis:

• •Visual acuity testing shows decreased vision
• •Eye exam shows a cloudy lens

MANAGEMENT

• •Surgery is the only curative method

Post-surgery care:

• •Eye drops several times a day for 2 to 4 weeks
• •Mild itching and slight swelling are normal
• •Pain control
• •Prevent increases in intraocular pressure (pressure inside the eye)

Report these complications:

• •Significant swelling
• •Bruising
• •Infection
• •Pain
• •Bleeding or increased discharge
• •Bloodshot sclera (white of the eye)
• •Decreased vision
• •Flashes of light or floating shapes

WHAT IS IT?

Cirrhosis is chronic, irreversible liver disease. Inflammation and fibrosis (scarring) of liver cells (hepatocytes) form scar tissue in the liver. This scar tissue blocks blood flow through the liver and stops the liver from working properly.

Quick Concept: Because the sick liver cannot do its jobs, toxins, fluid, and pressure build up throughout the body.

Impaired liver function:

• •Impaired protein metabolism
• •Increased drug toxicity (the liver cannot break down drugs)
• •Decreased clotting factors, increased ammonia levels, increased bilirubin levels
• •Increased LFTs (liver function tests): ALT, AST, ALP
• •Impaired blood sugar regulation

Complications:

• •Hepatic encephalopathy: increased ammonia causes brain tissue swelling
• •Bleeding risk: decreased clotting factors
• •Portal hypertension: blocked blood flow raises pressure in the portal vein and backs up into GI (gastrointestinal) circulation
• •Esophageal varices: dilated, thin veins in the esophagus from portal hypertension that can rupture and bleed (life-threatening emergency)

ASSESSMENT

• •Malaise (feeling unwell) and general fatigue
• •Anorexia (loss of appetite)
• •Increased bilirubin: jaundice (yellow skin) with scleral icterus (yellow eyes), dark urine, clay-colored stools
• •Impaired protein metabolism: edema (swelling), ascites (fluid in the belly), increased ammonia leading to hepatic encephalopathy (disorientation, altered LOC, asterixis or flapping hand tremor)
• •Pain in the RUQ (right upper quadrant of the abdomen)
• •Hepatomegaly (enlarged liver)
• •Splenomegaly (enlarged spleen)
• •Portal hypertension: hemorrhoids, varicose veins, esophageal varices that can cause massive GI bleed and vomiting blood
• •Impaired coagulation: anemia, bleeding, easy bruising

MANAGEMENT

Medications:

• •Analgesics (pain relievers)
• •Vitamin K for clotting factors
• •Antacids to decrease esophagus irritation
• •Lactulose to decrease ammonia levels
• •Blood products if bleeding
• •Diuretics (water pills) to remove fluid

Procedures and care:

• •Paracentesis to drain abdominal fluid
• •Dietary restrictions: fluid restriction, decreased protein intake, decreased sodium (Na) intake

Esophageal varices:

• •Endoscopy to cauterize, clip, or band varices to prevent bleeding
• •Sengstaken-Blakemore OR Minnesota tube: balloon inflated in the esophagus to put pressure on bleeding varices

WHAT IS IT?

Cirrhosis is a chronic, progressive disease of the liver. Liver cells are destroyed and replaced by scar tissue. Over time the liver can no longer do its jobs, which leads to many complications.

COMPLICATIONS

• •Hepatic encephalopathy: ammonia builds up because of liver failure and can cause neurologic decline
• •Hepatorenal syndrome: kidney failure linked to liver failure
• •Coagulation defects: the liver cannot make clotting factors, so the client bleeds easily
• •Ascites: fluid builds up in the peritoneal cavity (abdomen)
• •Portal hypertension: high pressure in the portal vein because blood flow through the liver is blocked
• •Esophageal variceal bleeding: blood shunts to weaker veins in the esophagus, and these fragile veins can rupture

ASSESSMENT

• •Neurological: encephalopathy, asterixis (hand-flapping tremor)
• •GI: ascites, esophageal varices, GI bleeding, hepatomegaly (enlarged liver), pain, nausea and vomiting, malnutrition
• •Cardiopulmonary: fatigue, spider angioma, edema, portal hypertension, dyspnea, hypoxemia, hyperventilation
• •Integumentary (skin): jaundice, spider angiomas, ecchymosis and petechiae (bruising and tiny red spots)
• •Fluid and electrolyte: ascites, hypokalemia (low potassium), water retention, edema
• •Hematologic: anemia, DIC, splenomegaly (enlarged spleen), thrombocytopenia (low platelets)

MANAGEMENT

Administer:

• •Supplemental vitamins
• •Enteral feedings
• •Diuretics
• •Blood products
• •Lactulose

Monitor:

• •Edema
• •I&O (intake and output), weight
• •Level of consciousness
• •Bleeding
• •Coagulation times
• •Abdominal girth

Prepare:

• •Patient for paracentesis
• •Patient for shunting

Other:

• •Restrict sodium (Na)
• •Elevate the head of the bed (HOB)
• •Gastric intubation if indicated
• •Avoid hepatotoxic medications

WHAT IS IT?

Peptic ulcer disease is an open sore in the lining of the stomach or the first part of the small intestine. Common causes are Helicobacter pylori (a stomach bacteria), frequent use of NSAIDs (Non-Steroidal Anti-Inflammatory Drugs like ibuprofen), smoking, and alcohol use. Diagnosis is done with an upper GI (gastrointestinal) series x-ray or an EGD (Esophagogastroduodenoscopy, a scope that looks inside the upper digestive tract).

ASSESSMENT

• •Nausea and vomiting
• •Abdominal pain, usually in the upper belly
• •Pain is often burning or sharp
• •Gastric ulcer: gnawing, sharp pain 30 to 60 minutes after a meal
• •Duodenal ulcer: pain 1.5 to 3 hours after eating, may be relieved by eating
• •Hematemesis (vomiting blood), seen with gastric ulcers
• •Melena (dark black tarry stool), seen with duodenal ulcers

MANAGEMENT

• •Avoid aspirin and NSAIDs because they increase bleeding risk
• •Monitor H&H (hemoglobin and hematocrit) and assess for bleeding
• •Medications: H2 receptor antagonists, proton pump inhibitors, antacids, and sucralfate (Carafate); take sucralfate 30 to 60 minutes before meals

Surgical options:

• •Vagotomy: cut the vagus nerves to lower the parasympathetic response, which lowers gastric acid secretion
• •Gastric resection or gastrectomy: remove all or part of the stomach to remove ulcerated tissue
• •Billroth I and Billroth II: remove a portion of the stomach and reattach it to the duodenum (I) or jejunum (II)

Post-op:

• •HOB (head of bed) at 45 degrees
• •Clear liquids for 3 to 7 days
• •Assess bowel sounds
• •To lower the risk of dumping syndrome (rapid influx of stomach contents into the small intestine), avoid sugar or fatty foods, eat smaller meals, and do not drink fluids with meals

WHAT IS IT?

Cholecystitis is acute or chronic inflammation of the gallbladder. It is caused by cholelithiasis (gallstones), duct obstruction, and infection. The gallbladder stores and secretes bile into the duodenum (first part of the small intestine) to help digest fats. If not corrected, it can lead to liver damage.

ASSESSMENT

• •N/V (nausea and vomiting)
• •RUQ (right upper quadrant) pain that occurs 2 to 4 hours after high-fat meals and lasts 1 to 3 hours
• •Murphy's sign: the examiner places a hand below the costal margin on the right side at the midclavicular line. The client is asked to inspire (breathe in). If the client cannot breathe in due to pain, the test is positive.
• •Rebound tenderness over the RUQ

MANAGEMENT

• •Decrease gallbladder stimulation: NPO (nothing by mouth), nasogastric decompression, avoid gas-forming foods
• •Antiemetics (anti-nausea drugs), analgesics (pain drugs)

Cholecystectomy (removal of the gallbladder):

• •Abdominal splinting when coughing
• •Clear liquids post-op, advance as tolerated/ordered
• •T-tube drainage: maintain patency (keep the duct open), high Fowler's position, report drainage greater than 500 mL

WHAT IS IT?

Inflammatory bowel disease is a group of autoimmune inflammatory conditions that affect the GI (gastrointestinal, digestive) tract. The body attacks its own bowel. Symptoms come and go with periods of remission (calm) and exacerbation (flare-up).

Two main types:

• •Ulcerative colitis: affects the colon and rectum, poor nutrient absorption, edema (swelling) plus lesions plus ulcers, 10 to 20 stools per day with blood and mucus. Avoid foods that may worsen symptoms (raw vegetables and fruits, nuts, popcorn, whole grains, cereals, spicy foods).
• •Crohn's: affects the entire GI tract and may affect other body systems (especially skin and lymphatic system), causes thickening plus scarring plus abscesses, 5 to 6 stools per day with pus and mucus.

MANAGEMENT

Major medication classes:

• •Corticosteroids (for example methylprednisolone): decrease inflammation; chronic use raises the risk for Cushing's syndrome
• •Salicylates (for example sulfasalazine): block pro-inflammatory chemicals (prostaglandins, interleukin-I, tumor necrosis factor)
• •Immunomodulators (for example azathioprine or methotrexate): lower the immune and inflammatory response and reduce the need for corticosteroids
• •Antidiarrheals (for example loperamide): reduce loss of fluid and electrolytes

Surgical options:

• •Bowel resection or colectomy: curative for ulcerative colitis, palliative (symptom relief only) for Crohn's
• •Surgical removal of abscesses

WHAT IS IT?

A colostomy is a stoma (opening on the abdomen) where stool exits into an appliance (bag). This card covers how to care for the stoma, the skin, and the appliance, plus diet teaching.

NURSING CONSIDERATIONS

• •Assess stoma appearance. Normal color is pink to red.
• •Report a stoma that is pale, dark, purple, or brown.
• •Cut the stoma appliance (bag) 1/16 to 1/8 inch larger than the stoma.
• •Cleanse the stomal area and keep it dry.
• •Apply skin barrier before applying the appliance.
• •Empty the appliance frequently to avoid complications, generally when 1/3 full.
• •A small needle-sized hole can be made in the pouch to let flatus (gas) escape. Seal it with a bandaid.

Diet teaching:

• •Foods that increase gas: beer, broccoli, brussel sprouts, cabbage, carbonated drinks, beans, dairy, spinach
• •Foods that thicken stool: applesauce, banana, bread, cheese, yogurt, rice, pasta

WHAT IS IT?

These are two inflammatory bowel diseases. This card compares their key features side by side.

TABLE

Crohn's disease:

• •Progresses from rectum to cecum
• •Poor absorption of nutrients
• •Edema, lesions, and ulcers
• •10 to 20 stools per day

Ulcerative colitis:

• •Blood and mucus
• •Pus and mucus
• •Thickening, scarring, and abscesses
• •5 to 6 stools per day

• •[source fragment unclear, verify at source]

WHAT IS IT?

Appendicitis is inflammation of the appendix. The exact cause is unknown. The major risk is rupture, where pus and possibly fecal matter spill into the peritoneum (the lining of the belly), causing peritonitis (infection of that lining) and sepsis (a body-wide infection response).

ASSESSMENT

• •Abdominal pain at McBurney's point (a spot in the lower right belly)
• •Pain descends to the RLQ (Right Lower Quadrant)
• •Rebound tenderness (pain when pressure is released)
• •Increased WBC (White Blood Cell count)
• •Fever
• •Abdominal guarding (tensing the belly muscles)
• •SUDDEN RELIEF OF PAIN SIGNIFIES A RUPTURE: this is a medical emergency and requires immediate surgery

MANAGEMENT

• •Avoid heat application, which can lead to rupture
• •Avoid stimulating peristalsis (gut movement), so keep the client NPO (Nothing by Mouth)
• •May require an appendectomy (surgical removal of the appendix); keep NPO

Post-op:

• •NG (nasogastric) tube for decompression
• •Monitor vital signs
• •Assess for abdominal distention
• •Clear liquids, then advance diet as tolerated

WHAT IS IT?

Pancreatitis is inflammation of the pancreas. It happens when the pancreas digests itself (autodigestion) after long-term damage. Acute pancreatitis occurs suddenly, and most clients recover fully. Chronic pancreatitis is usually due to long-standing alcohol abuse with loss of pancreatic function.

CAUSES

• •Alcohol abuse
• •Gallbladder disease
• •Obstruction of the ducts
• •Hyperlipidemia (high blood fats)
• •Peptic ulcer disease (PUD)

ASSESSMENT

• •Abdominal pain with sudden onset, in the mid-epigastric area and left upper quadrant
• •N/V (nausea and vomiting)
• •Weight loss from malabsorption
• •Abdominal tenderness
• •Abnormal labs: increased WBC (white blood cells), bilirubin, ALP (alkaline phosphatase), amylase, lipase
• •Cullen's sign: bruising and edema (swelling) around the umbilicus (belly button)
• •Turner's sign: flank bruising, a sign of pancreatic autodigestion or retroperitoneal hemorrhage (bleeding behind the abdominal cavity)
• •Steatorrhea: fatty, foul-smelling stools

MANAGEMENT

• •Suppress pancreatic secretions with NPO (nothing by mouth) diet and NG (nasogastric) tube insertion to decompress the stomach
• •IV hydration
• •TPN (total parenteral nutrition, IV feeding) for prolonged exacerbations to provide adequate nutrition
• •ERCP (endoscopic retrograde cholangiopancreatography) to remove gallstones: a camera is inserted to visualize the common bile duct

Surgery:

• •Whipple: remove a portion of the pancreas (for a mass or tumor)
• •Pancreatectomy: remove the pancreas, which requires insulin, glucagon, and pancreatic enzyme supplementation
• •Cholecystectomy: if the source is gallbladder disease

Medications for pain and to control symptoms:

• •Analgesics, H2 blockers, proton pump inhibitors, insulin, and anticholinergics

WHAT IS IT?

Hepatitis is inflammation of the liver, usually from a virus. Different types spread in different ways. As the liver is damaged, bilirubin and liver enzymes rise, which leads to jaundice and other symptoms.

Types and transmission:

• •Hepatitis A (HAV): health care workers are at risk; spreads by fecal-oral route, person-to-person, and poorly washed hands or utensils. Most contagious 10 to 14 days before symptoms start and is self-limiting (resolves on its own). Prevention: strict hand washing, standard precautions, hepatitis A vaccine.
• •Hepatitis B (HBV): spreads by blood or body fluids through IV drug use, sexual contact, or needle stick. Prevention: standard precautions, hand washing, blood screening, hepatitis B vaccine, needle precautions, safe sex practices.
• •Hepatitis C (HCV): blood-borne, IV drug users, needle stick. Prevention: standard precautions, needle safety, blood screening. NO vaccine available.
• •Hepatitis D (HDV): opportunistic infection associated with hepatitis B virus (HBV).
• •Hepatitis E (HEV): fecal-oral route, common in underdeveloped countries.

ASSESSMENT

Preicteric stage:

• •Flu-like symptoms, pain, low-grade fever

Icteric stage:

• •High bilirubin causes jaundiced (yellow) skin and eyes, dark urine, and pruritus (itching)
• •Clay-colored stool (from lack of bile secretion)
• •Elevated liver function tests (LFTs): AST, ALT, ALP, and ammonia

Posticteric stage:

• •Recovery phase, lab values return to normal, pain relief, increased energy

MANAGEMENT

Supportive therapy to address symptoms:

• •Lactulose for high ammonia levels
• •Antiemetics (anti-nausea medications)
• •Antihistamines (can help treat hepatitis C virus)
• •Antiviral therapy

WHAT IS IT?

A urinary tract infection (UTI) is an infection anywhere in the urinary tract (kidneys, ureters, bladder, urethra) that causes inflammation. Pathogens (germs) enter through the perineal area or through the bloodstream. Indwelling catheters can cause a catheter-associated UTI (CAUTI). Older males are more prone due to urinary stasis (urine not draining) from an enlarged prostate.

ASSESSMENT

• •Cloudy urine with a strong odor (pyuria)
• •Burning with urination
• •Increased urinary frequency
• •Confusion (altered mental status) and lethargy, especially in the elderly
• •Increased temperature, increased WBCs (white blood cells)
• •Urine cultures reveal bacteria

MANAGEMENT

• •Get urine and blood cultures BEFORE starting antimicrobials
• •Antimicrobials
• •Antispasmodic for bladder pain: Oxybutynin
• •Analgesic: Pyridium specifically relieves pain and burning with urination

WHAT IS IT?

Acute kidney injury is a sudden onset of kidney damage. Kidney function is lost because of poor circulation or damage to kidney cells. It is usually reversible and may resolve on its own, but it can cause permanent damage if not reversed quickly.

CAUSES

• •Prerenal: decreased blood flow to the kidneys, which accounts for most cases (hypotension, hypovolemia, decreased cardiac output such as heart failure or shock)
• •Intrarenal: damage within the kidney itself (tubular necrosis, infection, obstruction, contrast dye, nephrotoxic medications)
• •Postrenal: a backup between the kidney and the urethral meatus that damages the kidneys (infection, calculi, or obstruction)

PHASES

• •Onset: a decrease from baseline urine output
• •Oliguric: decreased urine output under 400 mL/day; the sickest phase, with increased BUN/creatinine and decreased glomerular filtration rate (GFR)
• •Diuretic: beginning to recover, with a gradual increase in urine output followed by diuresis
• •Recovery: decreased edema, electrolytes normalize, and GFR increases

ASSESSMENT

• •Signs and symptoms come from the kidneys' inability to regulate fluid and electrolytes
• •Azotemia (retention of nitrogen wastes in the blood): increased BUN/creatinine
• •Decreased glomerular filtration rate (GFR)
• •Decreased urine output in the oliguric phase, which should increase in the diuretic phase
• •Signs of volume overload (hypertension, peripheral edema, pulmonary edema)
• •Signs of infection if that was the source
• •Metabolic acidosis: kidneys are not holding HCO3 (bicarbonate)
• •Electrolyte abnormalities: increased potassium, decreased sodium, increased phosphate, decreased calcium

MANAGEMENT

Oliguric phase:

• •Restrict fluid intake because of volume overload, give diuretics for volume overload, and identify and treat the cause

Diuretic phase:

• •Replace fluids and electrolytes, and watch potassium and sodium levels closely

If not recovering:

• •May need dialysis

WHAT IS IT?

Chronic kidney disease is a progressive, irreversible loss of kidney function. It comes with a decline in GFR (Glomerular Filtration Rate, how fast the kidneys filter blood) below 60 mL/min. All body systems are affected, and dialysis is required. ESRD (End-Stage Renal Disease) is a GFR below 15 mL/min. Common causes are DM (Diabetes Mellitus), HTN (Hypertension, high blood pressure), an acute kidney injury that did not reverse, glomerulonephritis (kidney filter inflammation), and autoimmune disorders.

Quick Concept: As the kidneys fail, waste, fluid, and electrolytes build up and harm every body system.

ASSESSMENT

Diagnostics:

• •GFR in mL/min, normal is above 90 mL/min
• •Ultrasound shows scarring or damage
• •Decreased urine output (could be anuric, meaning no urine)
• •Increased BUN (Blood Urea Nitrogen) and creatinine (waste products)

Body system signs (CKD affects every body system):

• •Azotemia (buildup of nitrogen waste in the blood as urea), shown by increased BUN, creatinine, and uremia
• •Cardiac (from RAAS effects): volume overload, HTN, and CHF (Congestive Heart Failure)
• •Respiratory: pulmonary edema (lung fluid) from volume overload
• •Hematologic: low erythropoietin causes anemia and thrombocytopenia (low platelets)
• •Gastrointestinal: anorexia (from azotemia) and nausea and vomiting (from metabolic acidosis)
• •Neurological (cerebral edema and uremic encephalopathy): lethargy, confusion, and coma
• •Urinary: decreased urine output and proteinuria (protein leaking into urine because the kidney is not filtering properly)
• •Skeletal: osteoporosis from an imbalance of calcium and phosphorus needed for healthy bones, because the kidneys are not filtering properly

MANAGEMENT

• •Epoetin alfa (synthetic erythropoietin)
• •Avoid aspirin or NSAIDs (risk for interstitial nephritis)

Monitor potassium levels:

• •Hyperkalemia (high potassium) causes EKG changes: peaked T waves, flat P, wide QRS, blocks, asystole
• •Continuous cardiac monitoring
• •Low potassium diet
• •Potassium lowering medications: Kayexalate, insulin with dextrose, calcium gluconate

Other:

• •Phosphate binders to lower phosphorus, given BEFORE meals
• •Calcium supplements to treat hypocalcemia (low calcium)
• •Hemodialysis or peritoneal dialysis

WHAT IS IT?

Pelvic inflammatory disease is an infection of the female reproductive tract. The infection moves into the pelvis and the bacteria move into the uterine cavity, leading to inflammation and scarring. It can be fatal if untreated.

CAUSES

• •STDs (sexually transmitted diseases), the most common cause
• •Vaginal flora overgrowth
• •Infection of pelvic structures

RISK FACTORS

• •Risky sexual practice
• •Multiple sexual partners
• •Recent IUD (intrauterine device) placement, which acts as a foreign body
• •History of STD

COMPLICATIONS

• •Infertility
• •Ectopic pregnancy (pregnancy outside the uterus)
• •Sepsis/death

ASSESSMENT

• •Abdominal pain
• •Abnormal vaginal bleeding/discharge: spotting, yellow or green discharge
• •Pain with urination and intercourse
• •Fever, chills, malaise (general feeling of being unwell)
• •Diagnosis is based on clinical history, physical exam, and lab tests including a gram stain to identify the organism and a culture and sensitivity to choose the right antibiotic

MANAGEMENT

• •Antibiotics
• •Pain control with mild analgesics: NSAIDs
• •Positioning: semi-Fowler's to help drainage of the infection

WHAT IS IT?

Dialysis filters the blood when the kidneys cannot. It clears waste and toxins (urea, creatinine, uric acid) and regulates electrolytes. The two main types are hemodialysis (filtering blood through a machine) and peritoneal dialysis (using the lining of the abdomen as a filter).

HEMODIALYSIS

Complications:

• •Hypotension or hypovolemic shock (pulling off 1 to 4 L of fluid in 2 to 4 hours)
• •Air embolus (air bubble in the blood)
• •Electrolyte imbalance
• •Sepsis (blood infection)
• •Hemorrhage from the site

Medication precautions:

• •HOLD antihypertensives and medications that might drop blood pressure (verify with the provider)
• •HOLD medications that will be removed by dialysis (contact pharmacy with questions, verify with the provider)

Nursing priorities:

• •Monitor vital signs and EKG closely throughout (risk for hypotension or EKG changes)
• •Monitor lab values closely
• •Weigh the client before and after dialysis to estimate fluid loss (1 kg = 1 L)
• •Assess for bleeding from the site

Vascular access (the connection used for hemodialysis):

• •Types: graft (artificial vessel loop), fistula (allows higher velocity or volume in veins), external dialysis catheter (usually temporary)
• •Do NOT insert IVs or take a blood pressure (NIBP, noninvasive blood pressure) on the extremity with an active fistula or graft
• •Assess pulses and capillary refill in the affected extremity
• •Monitor fistulas and grafts closely for clots: listen for a bruit (swooshing sound), feel for a thrill (vibration)
• •If bruit and thrill are absent, notify the provider
• •Protect vascular access, it is their LIFELINE

PERITONEAL DIALYSIS

• •The peritoneum (lining of the abdomen) acts as a semipermeable membrane for dialysis
• •Contraindications: peritonitis and abdominal surgery
• •Can be continuous (24/7) or intermittent and can be done at home
• •The client is at risk for peritonitis (infection of the peritoneum), which is prevented with strict sterile technique and shows as cloudy outflow

WHAT IS IT?

The source content for this card covers contrast dye and cystoscopy precautions related to genitourinary procedures.

NURSING CONSIDERATIONS

Contrast dye:

• •The dye is damaging to the kidneys, so increase fluids to flush it out after the procedure unless contraindicated.
• •Contrast dye plus glucophage (Metformin) can cause lactic acidosis, so hold Metformin before a CT scan and for 48 hours after the scan.

Cystoscopy:

• •A camera is inserted to examine the bladder and take a biopsy.
• •Assess coagulation studies (clotting labs) first.
• •After the procedure, assess the site for bleeding and apply pressure to the site.
• •[source fragment unclear, verify at source]

WHAT IS IT?

Dialysis uses a semipermeable membrane to do many of the jobs the kidneys can no longer do. This includes clearing waste and toxins, removing urea, creatinine, and uric acid, and regulating electrolytes and acid-base balance.

TABLE

Hemodialysis:

• •Pulls blood from the patient through a machine that acts as the semipermeable membrane, then returns the blood to the patient
• •Requires vascular access
• •Risk for hypovolemic shock

Hemodialysis safety:

• •Protect vascular access (limb alert: no BP or sticks on that arm)
• •Pharmacologic considerations
• •Monitor vital signs closely

Peritoneal dialysis:

• •The peritoneum acts as the semipermeable membrane
• •Can be done at home
• •Risk for peritonitis

Peritoneal dialysis safety:

• •Prevent infection (hand hygiene and sterile technique)
• •Monitor for infection (peritonitis)

WHAT IS IT?

Menopause is a drop in reproductive hormones that ends the reproductive period. It is diagnosed after 12 months of amenorrhea (no menstrual periods). The average age is around 50 years old.

ASSESSMENT

Symptoms can start up to 6 years before the final period and continue for a variable number of years after:

• •Hot flashes (most common)
• •Insomnia (trouble sleeping)
• •Weight gain, bloating
• •Mood changes, depression
• •Breast pain, headaches
• •Osteoporosis (weak, brittle bones)
• •Irregular menses (periods)
• •Vaginal dryness, painful intercourse
• •Prolapse of reproductive and urinary structures (organs dropping out of place)

Lab testing (endocrine changes):

• •Increased FSH (Follicle-Stimulating Hormone) indicates that menopause has occurred
• •Decreased estrogen and inhibin

MANAGEMENT

• •Hormone replacement therapy for severe cases
• •Symptom management

WHAT IS IT?

A blood transfusion gives a client blood products through an IV. There are four types of products: packed red blood cells (PRBCs), cryoprecipitate, fresh frozen plasma, and platelets. The product must match the donor type by ABO type, Rh status, and special antibodies.

PRODUCT TYPES

• •PRBCs (also called a "unit of blood"): given for anemia
• •FFP (fresh frozen plasma): contains clotting factors
• •Platelets: given for thrombocytopenia (low platelets) and often before a procedure for clients with platelets less than 50. Re-check 1 hour post-transfusion.
• •Cryoprecipitate: contains fibrinogen, commonly used for hemorrhage and DIC (disseminated intravascular coagulation)

PROCEDURE

Prepare to transfuse:

• •Type and crossmatch/screen
• •Pre-transfusion vitals
• •Materials: special blood IV tubing, 0.9% normal saline, access to emergency medications

Begin transfusion:

• •Independent double-check completed by two RNs
• •Start the infusion at a slow rate for the first 10 to 15 minutes
• •Monitor for reaction

ASSESSMENT

• •Transfusion reactions most commonly occur in the first 10 to 15 minutes
• •Symptoms: pruritus (itching), rash, fever, chills, low back pain, anxiety
• •Reactions present similarly to anaphylaxis and can occur up to 24 hours after transfusion
• •Delayed reactions: caused by antibody mismatch, can be potentially fatal, occur in clients who have had transfusions before or have undetectable antibodies below the screening threshold
• •Post-transfusion: redraw CBC (complete blood count)

MANAGEMENT

For a transfusion reaction:

• •Immediately STOP the transfusion and SAVE the blood product for the lab
• •Treatment is similar to anaphylaxis: notify provider, give antihistamines (diphenhydramine), give acetaminophen
• •Consider furosemide for fluid overload and to maintain kidney function
• •Monitor airway patency
• •Maintain IV access
• •Report to the blood bank

WHAT IS IT?

Acquired immune deficiency syndrome (AIDS) is the late stage of HIV (human immunodeficiency virus) infection. The virus destroys T4 lymphocytes (a type of white blood cell), so the body cannot fight infection. The person is at risk for opportunistic infections and conditions such as tuberculosis, pneumonia, cancers, and candidiasis (yeast infection).

ASSESSMENT

• •Frequent infections
• •Wasting syndrome (severe weight and muscle loss)
• •Skin breakdown
• •Stomatitis (mouth inflammation)
• •Malnutrition
• •Dehydration
• •Leukopenia (low white blood cells, WBCs)
• •Kaposi's sarcoma: a tumor that grows lesions in the skin and lymph nodes, with purple or red lesions on skin and organs
• •Candidiasis in the mouth (thrush)

MANAGEMENT

• •Respiratory support
• •Nutritional support: small frequent meals, premedicate to avoid nausea, provide favorite foods
• •Monitor fluid and electrolyte balance
• •Assess for infection
• •Start strict infection control precautions and observe hand hygiene

WHAT IS IT?

Sickle cell anemia (SCA) is a hereditary (inherited) disorder that primarily affects African Americans through a recessive trait. If both parents are carriers, each child has a 25% chance of having SCA, a 50% chance of being a carrier, and a 25% chance of no inheritance. The genetic mutation makes red blood cells (RBCs) rigid and misshapen.

Quick Concept: The misshapen RBCs cannot carry oxygen well and get stuck in blood vessels, blocking blood flow.

This can lead to Sickle Cell Crisis:

• •Vasoocclusive crisis (micro-occlusions): decreased blood flow to tissue causes hypoxia (low oxygen), ischemia, and infarction (tissue death), leading to joint pain, stroke, and acute chest syndrome
• •Sequestration: pooling of blood, usually in the spleen
• •Acute exacerbation triggered by hypoxia, exercise, high altitude, fever, or temperature extremes

ASSESSMENT

• •Pallor (pale skin) and fatigue
• •Severe pain due to micro-occlusions; the pain location matches the occlusion location

MANAGEMENT

Hemodilution (dilute the blood to wash out sickled cells):

• •Give IV fluids for hydration
• •Blood transfusions to give properly shaped, functioning RBCs

Oxygen supplementation:

• •Increase oxygen delivery to tissues if the client is hypoxic

Pain relief:

• •This pain is severe

Hydroxyurea:

• •A medication for clients with a history of frequent crisis
• •In infants, shown to increase fetal hemoglobin (a form of Hgb plentiful during gestation), which raises oxygen available to tissues and reduces complications of SCD

WHAT IS IT?

Disseminated intravascular coagulation (DIC) is widespread activation of the clotting cascade. The body clots and bleeds at the same time. The normal clotting cascade is disrupted and the clotting factors are used up. This causes severe bleeding and massive hemorrhage.

RISK FACTORS

• •Anything that triggers the clotting cascade, which then overreacts
• •The leading cause of DIC is infection

ASSESSMENT

• •Pallor, dyspnea, chest pain, anxiety, confusion
• •Ecchymosis: petechiae, purpura, and hematomas
• •Bleeding from every orifice
• •Abnormal labs: prolonged PTT, PT, and thrombin time, and decreased platelets
• •Tachycardia and hypotension

MANAGEMENT

• •Determine and treat the underlying cause immediately
• •Replace clotting factors: fresh frozen plasma, vitamin K, factor VII
• •Administer a heparin drip if excessive clotting, which stops the consumption of clotting factors

WHAT IS IT?

Anaphylaxis is a massive allergic response. Histamine is released from damaged cells, which causes swelling, inflammation, and massive vasodilation (widening of blood vessels). This can lead to distributive shock.

ASSESSMENT

• •Urticaria (hives)
• •Angioedema (facial swelling) of the lips, tongue, mouth, and throat, with a risk for airway compromise
• •Skin flushing
• •Anaphylactic shock: hypotension (low blood pressure) and cardiac arrest

MANAGEMENT

• •Monitor respiratory and cardiovascular status

Administer epinephrine IM (intramuscular) immediately:

• •Adults: 0.3 mg, 1:1000
• •Children: 0.15 mg, 1:1000
• •EpiPen auto-injector
• •Goal is to prevent life-threatening airway collapse or shock
• •Administer oxygen, antihistamines, corticosteroids, and IV fluids as needed to support hemodynamics (circulation)

WHAT IS IT?

Leukemia is the overgrowth of abnormal, undeveloped WBCs (white blood cells). WBCs are needed for infection control and immunity. It is diagnosed by blood tests and a bone marrow biopsy.

TYPES (by WBC affected)

• •ALL (acute lymphocytic leukemia): 2 to 4 years of age
• •CLL (chronic lymphocytic leukemia): 50 to 70 years of age
• •AML (acute myelogenous leukemia): peaks at 60 years of age
• •CML (chronic myelogenous leukemia): incidence increases with age

ASSESSMENT

• •Weight loss
• •Fever
• •Infections
• •Pain in bones and joints
• •Night sweats
• •Aplastic anemia: pallor (pale skin), fatigue, easy bleeding and bruising
• •Increased WBC in CLL and CML
• •Decreased WBC in ALL and AML
• •Philadelphia chromosome in the majority of CML clients
• •Mouth sores from chemotherapy

MANAGEMENT

• •Chemotherapy and radiation
• •Bone marrow biopsy: apply pressure to the biopsy site
• •Initiate neutropenic precautions: strict handwashing, limit visitation, no fresh fruits or flowers
• •Plan activities to provide time for rest
• •Instruct the client on oral hygiene: rinse mouth with saline, avoid lemon or alcohol-based mouthwashes

WHAT IS IT?

Thrombocytopenia is a decrease in circulating platelets (less than 100,000/mL). Platelets help the blood clot, so when they are low the person bleeds easily. Causes include aplastic anemia (decreased production), autoimmune disorders (increased destruction), and medications such as heparin-induced thrombocytopenia, cytotoxic drugs, and some antibiotics.

ASSESSMENT

Abnormal labs:

• •Low platelet count
• •Low hemoglobin (Hgb) and hematocrit (Hct)

Bleeding (not enough platelets to clot):

• •Petechiae (tiny red or purple spots on the skin)
• •Epistaxis (nosebleed)
• •GI (gastrointestinal) bleeding: hematemesis (vomiting blood), melena (black tarry stool), occult (hidden) blood in the stool
• •Hematuria (blood in urine)
• •Hemoptysis (coughing up blood)

MANAGEMENT

• •Platelet transfusions

Bleeding precautions:

• •Avoid invasive procedures
• •Use a soft-bristled toothbrush
• •Avoid medications that interfere with clotting (for example aspirin, heparin)

WHAT IS IT?

This chart maps donor blood types to patient (recipient) blood types.

TABLE

Donor blood types listed: O-, O+, B-, B+, A-, A+, AB-, AB+

Patient (recipient) blood types listed: O-, O+, B-, B+, A-, A+, AB-, AB+

• •[source fragment unclear, verify at source: the chart's specific donor-to-recipient matches were not legible in the source]

WHAT IS IT?

Lymphoma is cancer of the lymphatic system that affects lymphocytes (a type of white blood cell). This impairs the immune response. Because lymphocytes travel through the lymphatic system, lymphoma can spread (metastasize) through the body.

TYPES

• •Hodgkin's lymphoma: Reed-Sternberg cells are present
• •Non-Hodgkin's lymphoma: Reed-Sternberg cells are absent; this makes up 90% of lymphomas
• •Tumors may form in or around the lymph nodes

ASSESSMENT

• •Painless swelling of lymph nodes
• •Persistent fatigue
• •Fever
• •Night sweats
• •Shortness of breath
• •Unexplained weight loss
• •Enlarged liver or spleen
• •Risk for infection

MANAGEMENT

• •Official diagnosis with a lymph node biopsy; hold pressure over the biopsy site
• •Chemotherapy and radiation
• •Monitor for signs of metastasis (high risk because it travels through the lymphatic system)

WHAT IS IT?

This card lists the warning signs of cancer and the stages of cancer. The warning signs use the word CAUTION as a memory aid.

WARNING SIGNS OF CANCER (CAUTION)

• •Change in bowel pattern
• •A sore that does not heal
• •Unusual bleeding
• •Thickening of the breast, testicle, or skin
• •Indigestion
• •Obvious change in a mole
• •Nagging cough

CANCER STAGING

• •Stage 0: carcinoma in situ
• •Stage I: local tumor growth
• •Stage II: limited spreading
• •Stage III: regional spreading
• •Stage IV: metastasis to other organs

WHAT IS IT?

Burn injuries damage the skin and deeper tissues. They are classified by degree based on how deep the damage goes.

DEGREES

• •First degree: skin intact, reddened, painful
• •Second degree (partial thickness): broken skin, pain, pink/red, blisters
• •Third degree (full thickness): often painless, white/black eschar (dead tissue)
• •Fourth degree: muscle and/or bone exposed, common in electrical burns

WHAT IS IT?

This card covers how to treat burn injuries. Burns cause fluid loss and a high risk of infection, so early care focuses on replacing fluid, controlling pain, fighting infection, and healing the wound.

ASSESSMENT

• •On arrival to the ED or hospital, determine the total body surface area (TBSA) burned
• •1st and 2nd degree burns are very painful
• •3rd and 4th degree burns may be painless due to nerve damage
• •Impaired temperature regulation
• •Hypovolemia from third spacing or capillary leak (fluid leaks out of vessels), so the client will have high heart rate and low blood pressure

MANAGEMENT

Fluid resuscitation:

• •Parkland Burn Formula: 4 x TBSA (%) x kg
• •Give half over 8 hours
• •Give half over 16 hours
• •Titrate to urine output 30 to 50 mL/hr
• •Assess for edema (swelling)

Other interventions:

• •Administer antibiotics
• •Aggressive wound care
• •Pain management, typically with opioid analgesics, PCA (patient-controlled analgesia) if able
• •Optimize nutrition intake to promote healing; may require an NG (nasogastric) tube for feeds or a PICC (peripherally inserted central catheter) line for TPN (total parenteral nutrition, IV feeding)

Skin grafting:

• •Autologous: taken from healthy tissue on the client
• •Allogeneic: from another human donor
• •Meshed and stretched over the wound

WHAT IS IT?

Burn staging classifies how deep a burn goes into the skin and tissue.

TABLE

• •First degree -> Reddened, painful, intact skin
• •Second degree -> Partial thickness, broken skin, pain, pink/red, blisters
• •Third degree -> Full thickness, often painless, white/black eschar (dead tissue)
• •Fourth degree -> Muscle and/or bone exposed; common in electrical burns

WHAT IS IT?

Shingles is a viral infection caused by the herpes zoster virus. It is most common in elderly clients with a history of chickenpox or the chickenpox vaccine. It is highly contagious.

ASSESSMENT

• •Vesicular rash that follows the dermatome and is usually unilateral (on one side)
• •Painful and itchy
• •Fever, malaise, fatigue

MANAGEMENT

• •Contact isolation, or airborne isolation if the rash is disseminated (widespread)
• •Assess neurological status and signs of infection
• •Medications: antivirals, NSAIDs, and the shingles vaccine (for prevention)

WHAT IS IT?

Pressure ulcers are skin sores that vary in size and depth. They are caused by compression of tissue for an extended period of time.

Staging:

• •Stage I: skin intact, non-blanchable redness (does not turn white when pressed)
• •Stage II: partial thickness loss of skin
• •Stage III: full-thickness skin loss extending to the dermis and SubQ (subcutaneous, under the skin) tissue
• •Stage IV: full-thickness skin loss, muscle and bone undermining and tunneling, and eschar (dead tissue) or slough may be present
• •Deep tissue injury: injury to SubQ tissue under intact skin, dark purple or brown
• •Unstageable: wound completely covered by eschar or slough, so depth cannot be seen or determined

ASSESSMENT

• •Check bony prominences with every turn; if redness is present, press with a finger to check for blanching (turning white)
• •Albumin level to assess nutrition

MANAGEMENT

• •Consult a wound care specialty nurse
• •Do NOT massage a reddened area
• •Intervene as needed for malnutrition and immobility
• •Turn every 2 hours or more often
• •Keep skin clean and dry
• •Minimize sheets under the client
• •Use specialty beds or surfaces
• •Offload bony prominences with a pillow or wedge

WHAT IS IT?

A pressure ulcer is skin and tissue damage caused by pressure and/or shear (skin sliding against a surface), usually over a bony area. Nursing care focuses on prevention and treatment based on the stage.

NURSING CARE

• •Identify at-risk patients and start precautions and assessments
• •Keep skin dry and sheets wrinkle-free; turn and reposition frequently
• •Assess and document the status of the ulcer
• •Treatment may include creams, dressings, debridement (removing dead tissue), grafting, and vacuum-assisted suction

STAGING

• •Stage I: intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not show visible blanching.
• •Stage II: partial thickness loss of dermis, presenting as a shallow open ulcer with a red-pink wound. Presents as a shiny or dry shallow ulcer without slough or bruising.
• •Stage III: full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
• •Stage IV: full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
• •Unstageable: full thickness tissue loss where the actual depth is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and stage cannot be determined.
• •DTI (deep tissue injury): damage of underlying soft tissue from pressure and/or shear
• •[source fragment unclear, verify at source]

WHAT IS IT?

Addison's disease is hyposecretion (too little release) of adrenal cortex hormones. Low levels of glucocorticoids and mineralocorticoids cause electrolyte imbalances and decreased blood volume.

Quick Concept: The adrenal cortex makes glucocorticoids (for example cortisol) that control glucose, fat metabolism, and inflammation; mineralocorticoids (for example aldosterone) whose deficiency leads to hyponatremia (low sodium) and hyperkalemia (high potassium); and sex hormones (androgens such as testosterone and estrogen) that control physical features and hair. The adrenal medulla makes epinephrine and norepinephrine for the fight-or-flight response.

ASSESSMENT

• •Cardiovascular: hypotension (low blood pressure), tachycardia (fast heart rate)
• •Metabolic: weight loss
• •Integumentary: hyperpigmentation (bronzing of the skin)
• •Electrolytes: hyperkalemia (high potassium), hypercalcemia (high calcium), hyponatremia (low sodium), hypoglycemia (low blood sugar)
• •Addisonian crisis: acute exacerbation (sudden flare-up) with severe electrolyte disturbance

MANAGEMENT

Replace adrenal hormones:

• •Corticosteroids: hydrocortisone, prednisone

Addisonian crisis:

• •Monitor electrolytes and cardiovascular status closely
• •Administer adrenal hormones as ordered
• •Administer electrolyte replacement as needed

WHAT IS IT?

The adrenal glands sit on top of the kidneys. The adrenal cortex secretes glucocorticoids, mineralocorticoids, and androgen hormones. Addison's disease is too little (hypo) hormone secretion from the adrenal cortex. Cushing's disease is too much (hyper) secretion.

TABLE (by body system: Addison's hypo -> Cushing's hyper)

• •Cardiovascular: Hypotension, tachycardia (Addison's) -> Hypertension, volume overload (Cushing's)
• •Integumentary: Hyperpigmentation, bronze skin (Addison's) -> Fragile skin, striae on abdomen (Cushing's)
• •Metabolic: Weight loss (Addison's) -> Moon face (Cushing's)
• •Electrolytes (Addison's): Hypercalcemia, hypoglycemia, hyperkalemia, hyponatremia
• •Electrolytes (Cushing's): Hypocalcemia, hyperglycemia, hypokalemia, hypernatremia

WHAT IS IT?

Cushing's syndrome is hypersecretion (too much release) of glucocorticoids, which leads to an elevated cortisol level.

CAUSES

• •Adrenal or pituitary tumor (the pituitary gland controls adrenal hormones)
• •Overuse or chronic use of corticosteroids

Cushing's syndrome involves:

• •Excess cortisol
• •Excess aldosterone
• •Excess androgens

ASSESSMENT

• •Cardiovascular: hypertension, signs of heart failure
• •Metabolic: redistribution of fats, moon face, and buffalo hump
• •Integumentary (skin): excess hair, striae (stretch marks) on the abdomen, fragile skin, and peripheral edema
• •Electrolytes: hypokalemia (low potassium), hypocalcemia (low calcium), hypernatremia (high sodium), hyperglycemia (high blood sugar)
• •Decreased immune response

MANAGEMENT

• •Remove the adrenal or pituitary tumor
• •Decrease the dose or stop corticosteroid use
• •Monitor electrolytes and cardiovascular status; replace electrolytes as needed

Safety, protect from injury:

• •Risk for osteoporosis (from hypocalcemia)
• •Risk for infection
• •Risk for skin breakdown

WHAT IS IT?

Diabetic ketoacidosis (DKA) is an acute, severe flare of Type I Diabetes Mellitus with severe hyperglycemia (high blood sugar) and ketoacidosis. The body has no insulin, so it cannot get glucose into the cell. It breaks down fatty acids for energy, which makes ketones (acids).

Quick Concept: With no insulin, the body burns fat for fuel and the acid waste (ketones) builds up in the blood.

ASSESSMENT

Ketoacidosis:

• •Acidosis (pH below 7.35, HCO3- below 22)
• •Ketones in urine
• •Fruity breath (from ketones)
• •Kussmaul respirations (deep, rapid breathing to blow off CO2 and compensate for acidosis); clients can tire easily
• •Hyperkalemia (high potassium) as potassium leaves the cell to compensate for acidemia

Hyperglycemia:

• •Blood glucose 400 to 600 mg/dL
• •Severe dehydration from osmotic diuresis and polyuria (excess urination)
• •Increased BUN (Blood Urea Nitrogen) and creatinine
• •Altered LOC (Level Of Consciousness) from cellular dehydration

MANAGEMENT

• •First nursing action: begin fluid replacement and check electrolytes

Treatment priority is to correct acidosis:

• •Insulin therapy helps the body stop the breakdown of fatty acids
• •Without insulin, DKA will keep getting worse despite fluid replacement
• •Insulin therapy continues until the anion gap acidosis has fully resolved
• •Continue replacing fluids as needed for the dehydration caused by the hyperosmolarity
• •Monitor neurological status
• •Monitor and treat electrolyte imbalances

WHAT IS IT?

DKA (diabetic ketoacidosis) is a hyperglycemic (high blood sugar) crisis in Type I diabetes with metabolic acidosis and elevated serum ketones. HHNS (hyperosmolar hyperglycemic nonketotic syndrome) is a hyperglycemic crisis in Type II diabetes with no ketone formation.

DKA

• •Average serum glucose around 600 mg/dL
• •Caused by insulin deficiency; counterregulatory hormones are released (glucagon, epinephrine, growth hormone, cortisol)
• •Glycogenolysis, gluconeogenesis, and glycosuria occur
• •Lipolysis leads to ketosis and ketoacidosis
• •Protein catabolism leads to increased nitrogen loss, weight loss, decreased albumin, and immunocompromise
• •Osmotic diuresis causes loss of water, sodium, and potassium, leading to dehydration and hypovolemia
• •Signs: polyuria, polyphagia, polydipsia, altered LOC (level of consciousness), tachycardia, hypotension, decreased urine output, decreased CVP and PAOP
• •Serum potassium high initially but decreases dramatically with insulin therapy and correction of pH
• •Fruity odor to breath, positive ketones in blood and urine
• •Metabolic acidosis with increased anion gap, Kussmaul respiratory pattern, abdominal pain
• •Hypophosphatemia with insulin treatment (due to production of ATP)
• •Potential for diabetic coma, electrolyte imbalance, hypovolemic shock, and life-threatening dysrhythmias

HHNS

• •Average serum glucose around 1100 mg/dL
• •Caused by relative insulin deficiency
• •Osmotic diuresis causes loss of water, sodium, and potassium, leading to dehydration, hypovolemia, and hyperosmolality
• •Glucosuria occurs
• •Signs: polyuria, polydipsia, altered LOC, tachycardia, hypotension, decreased urine output, decreased CVP and PAOP
• •Profound hypokalemia
• •Hypophosphatemia with insulin treatment
• •Potential for vascular thrombosis, hyperosmolar coma, electrolyte imbalance, hypovolemic shock, and life-threatening dysrhythmias

WHAT IS IT?

Diabetes insipidus is hyposecretion (too little release) of, or failure to respond to, antidiuretic hormone (ADH) from the posterior pituitary. This leads to excess water loss and severe dehydration. Causes include neurogenic problems (stroke, tumor), infection, and pituitary surgery (the pituitary gland secretes ADH).

Quick Concept: ADH normally tells the kidneys to hold onto water; without it, the body loses huge amounts of dilute urine (4 L to 30 L in 24 hours).

ASSESSMENT

• •Polyuria (excessive urine output) with dilute urine, urine specific gravity less than 1.006
• •Polydipsia (extreme thirst)
• •Hypotension (low blood pressure) leading to cardiovascular collapse
• •Tachycardia (fast heart rate)
• •Hypernatremia (high sodium), neurological changes

MANAGEMENT

Water replacement:

• •PO (by mouth) free water (plain water)
• •D5W (5% dextrose in water) if IV replacement is required

Hormone replacement:

• •DDAVP (desmopressin/vasopressin), a synthetic ADH

Monitoring:

• •Monitor urine output hourly (report output greater than 200 mL/hour)
• •Monitor urine specific gravity
• •Daily weight monitoring

WHAT IS IT?

Diabetes mellitus is a pancreatic disorder with too little or no insulin production, which leads to high blood sugar. Insulin is the key that lets glucose (sugar) enter cells to be used for energy.

Quick Concept: Without enough insulin, glucose stays in the blood and cannot enter cells for energy.

TYPES

• •Type I: autoimmune disorder. The body attacks beta cells in the pancreas (the cells that make insulin). The pancreas makes NO insulin, so the client is insulin-dependent. Ketosis happens from gluconeogenesis (the body making glucose from fat) because the missing key blocks glucose use.
• •Type II: beta cells do not make enough insulin, OR the body becomes resistant to insulin. Lifestyle-related. May or may not need insulin depending on severity.

ASSESSMENT

• •Vascular and nerve damage from inflammation and hyperosmolarity (thick fluid) in vessels
• •Poor circulation because the blood is thick with glucose
• •Poor wound healing
• •Retinopathy: blurry vision
• •Neuropathy: decreased sensation, especially in feet and toes
• •Nephropathy: may lead to chronic kidney disease
• •The Three P's: polyuria (frequent urination), polydipsia (excessive thirst), polyphagia (excessive hunger)
• •Elevated HgbA1c over 7.0 (average blood sugar over the last 3 months)

Complications:

• •Dawn phenomenon: reduced insulin sensitivity between 5-8am, helped by evening insulin
• •Somogyi phenomenon: nighttime hypoglycemia (low blood sugar) causes rebound morning hyperglycemia, helped by a bedtime snack
• •Diabetic ketoacidosis (DKA): acute exacerbation of Type I (hyperglycemia spilling sugar into the urine)
• •Hyperglycemic Hyperosmolar Nonketotic State (HHNS): acute exacerbation of Type II (high blood sugar raises osmotic pressure in vessels, causing cellular dehydration)

WHAT IS IT?

This card covers how to manage diabetes mellitus with medications, insulin, diet, and exercise.

MANAGEMENT

Oral antidiabetic agents:

• •For Type II diabetics
• •Glucophage (metformin) is the most common
• •Glipizide (Glucotrol)

Insulin:

• •Required for Type I
• •Type II may require insulin if diet, exercise, and oral antidiabetic agents are not enough
• •Most at risk for hypoglycemia (low blood sugar) during insulin peak times
• •Only Regular insulin can be given by IV
• •Mixing Regular and NPH: clear before cloudy. Inject air into the cloudy vial, then inject air into the clear vial and draw up the clear, then draw up the cloudy. This avoids cross-contamination or errors in drawing up.
• •"Insulin reaction" means hypoglycemia: cool, clammy, diaphoretic (sweaty). Use the 15-15 rule: give 15 g of sugar (4 oz of juice or soda) and recheck in 15 minutes.

Diet and exercise:

• •May improve insulin response for Type II diabetics and can help stabilize blood sugars in Type I diabetics

WHAT IS IT?

HHNS is an acute, severe flare of Type II Diabetes Mellitus. The body has just enough insulin to prevent fatty acid breakdown, but there is severe hyperglycemia (high blood sugar) without ketoacidosis.

ASSESSMENT

Hyperglycemia:

• •Blood sugar above 600 mg/dL (usually higher)
• •Negative ketones
• •Glycosuria (glucose spilling into the urine)

Hyperosmolarity:

• •Profound dehydration
• •Altered LOC (Level Of Consciousness)
• •Dry mucous membranes
• •Increased BUN (Blood Urea Nitrogen) and creatinine

MANAGEMENT

• •Identify and treat the cause
• •Number one priority: replace fluids, which might also resolve the hyperglycemia
• •Insulin therapy
• •Monitor neurological status
• •Monitor and treat electrolyte imbalances

WHAT IS IT?

Hyperthyroidism is excess secretion of thyroid hormone (TH) from the thyroid gland. It results in an increased metabolic rate.

CAUSES

• •Graves disease (autoimmune)
• •Excess secretion of TSH (thyroid-stimulating hormone) from the pituitary
• •Thyroid, pituitary, or hypothalamic tumor
• •Medication reaction
• •Thyroid storm (thyroid crisis): an acute worsening due to infection, stress, or trauma

ASSESSMENT

Hormone changes:

• •Increased T3, T4, Free T4 hormones
• •Decreased TSH
• •Positive radioactive iodine uptake scan
• •Possible presence of a goiter (enlarged thyroid)

Cardiac changes:

• •Tachycardia, HTN (high blood pressure), palpitations

Neurological changes:

• •Hyperactive reflexes, hand tremor
• •Emotional instability, agitation

Sensory changes:

• •Exophthalmos (bulging eyes)
• •Blurred vision

Integumentary (skin) changes:

• •Fine, thin hair

Reproductive changes:

• •Amenorrhea (no menstrual periods)
• •Change in libido (some report increased, others decreased)

Metabolic changes:

• •Hypermetabolic
• •Increased temperature
• •Heat intolerance
• •Weight loss
• •Hypocalcemia (low calcium) due to excess calcitonin

Thyroid storm (thyroid crisis):

• •Febrile state
• •Tachycardia, HTN
• •Tremors
• •Seizures

MANAGEMENT

• •Provide rest in a cool, quiet environment
• •Cardiac monitoring as ordered
• •Maintain a patent airway
• •Provide eye protection for exophthalmos: regular eye exams, eye drops for moisture

Medications:

• •Antithyroid medications: propylthiouracil or methimazole
• •Radioactive Iodine 131: taken up by the thyroid gland, destroys some thyroid cells over 6 to 8 weeks. Avoid in pregnancy. Monitor for hypothyroidism.

Thyroidectomy (surgical removal of the thyroid):

• •Monitor airway for swelling; assess for obstruction, stridor, dysphagia (difficulty swallowing)
• •Have tracheotomy equipment available
• •Maintain an upright position
• •Assess for bleeding
• •Monitor for hypocalcemia: removal of the parathyroid glands decreases PTH (parathyroid hormone), which helps maintain blood calcium levels. Have calcium gluconate available PRN (as needed).
• •Minimal talking after surgery

WHAT IS IT?

Hypothyroidism is hyposecretion (too little release) of thyroid hormone, which lowers the metabolic rate (how fast the body uses energy). Causes include Hashimoto's thyroiditis, iodine deficiency, and thyroidectomy (removal of the thyroid). A severe, life-threatening flare-up is called myxedema coma.

Quick Concept: Myxedema coma is an acute exacerbation of very low thyroid production, triggered by acute illness, rapid stopping of medication, or hypothermia.

ASSESSMENT

• •Hypometabolic state (slowed body functions)
• •Goiter: enlarged thyroid due to iodine deficiency
• •Low T3, T4, and Free T4 hormones
• •High TSH (thyroid-stimulating hormone) levels
• •Cardiovascular: bradycardia (slow heart rate), hypotension (low blood pressure), anemia
• •Gastrointestinal: constipation
• •Neurological: lethargy, fatigue, weakness
• •Integumentary: dry skin, loss of body hair
• •Metabolic: cold intolerance, anorexia (poor appetite), weight gain, edema (swelling), hypoglycemia (low blood sugar)

MANAGEMENT

Medication therapy:

• •Levothyroxine (Synthroid)
• •Monitor for possible overdose

Other interventions:

• •Cardiac monitoring
• •Maintain an open airway, especially with a goiter; have tracheotomy supplies available
• •IV fluids to support hemodynamics (blood flow and pressure)
• •Administer glucose/dextrose as needed
• •Encourage nutrition intake
• •Assess thyroid hormone levels

WHAT IS IT?

SIADH is excess secretion of ADH (antidiuretic hormone) from the posterior pituitary. This causes hyponatremia (low sodium because excess water dilutes it) and water intoxication.

Quick Concept: Too much ADH makes the body hold onto water, which dilutes the sodium and overloads fluid volume.

ASSESSMENT

• •Fluid volume excess: hypertension (high BP), JVD (jugular vein distention, neck vein bulging), crackles
• •Hyponatremia: altered LOC (level of consciousness), coma, seizures
• •Concentrated urine: decreased urine output, urine specific gravity over 1.036
• •Diluted blood: decreased BUN (blood urea nitrogen), decreased hematocrit

MANAGEMENT

• •Frequent cardiac monitoring
• •Frequent neurological examination
• •Monitor I&O (intake and output) and fluid restriction
• •Daily weight
• •Sodium supplement
• •Medication: hypertonic saline, diuretics (water pills), electrolyte replacement

WHAT IS IT?

A fracture is a break in a bone. Fractures come in different types based on how the bone breaks. Some can cause serious complications such as fat embolism or compartment syndrome.

TYPES OF FRACTURES

• •Closed: skin is intact
• •Open/compound: bone pierces the skin
• •Transverse: broken straight across
• •Spiral: fracture from a twisting force
• •Comminuted: multiple pieces of bone
• •Impacted: from a vertical force on a long bone
• •Greenstick: incomplete fracture, common in children
• •Oblique: diagonal fracture
• •Displaced: bones no longer aligned

Related injuries:

• •Strain: excessive stretching of a muscle
• •Sprain: excessive stretching of a ligament

Complications:

• •Fat embolism (a piece of fat from bone marrow moves through the bloodstream to the lungs), a risk with long-bone fractures
• •Compartment syndrome: increased pressure within a compartment in the extremity after a fracture or crush injury cuts off circulation to muscles and nerves

ASSESSMENT

Fracture:

• •Assess distal circulation: pulses, skin temperature, color
• •Assess distal nerve function: numbness and tingling
• •May see ecchymosis (bruising) over the fractured area

Fat embolism:

• •Anxiety, restlessness
• •Tachycardia, hypotension
• •Tachypnea, dyspnea
• •Petechial rash

Compartment syndrome:

• •Pale skin
• •Extreme swelling
• •Loss of pulses or sensation distal to the injury

WHAT IS IT?

This card covers the management of fractures (broken bones), including first aid, casts, traction, and two serious complications.

MANAGEMENT

RICE:

• •Rest
• •Ice
• •Compression
• •Elevation

Cast (stabilizes the bone for healing); monitor the extremity for:

• •Swelling
• •Pain
• •Discoloration
• •Sensation
• •Circulation distal to (below) the cast

Traction (force applied in the opposite direction to realign and immobilize the fracture):

• •Ensure proper alignment of the body
• •Buck's traction: force applied to a splint
• •Skeletal traction: a pin inserted through the bone to hold the traction force
• •Weights should hang freely from the bed; do not set them on the floor, do not remove weights without a provider order, and support the weight when sliding up in bed

Fat embolism (a fat clot in the bloodstream):

• •No specific treatment
• •Support hemodynamics (circulation)
• •Corticosteroids
• •Monitor in the ICU

Compartment syndrome (dangerous pressure buildup in a muscle group):

• •Emergent intervention required to prevent loss of the limb
• •Fasciotomy (a surgical cut to relieve pressure) required

WHAT IS IT?

Osteoporosis is bone demineralization that leads to a decrease in bone mass and density. Bone resorption (breakdown) happens faster than bone formation, leading to calcium loss from bones and decreased bone density. There may be a problem absorbing calcium or vitamin D.

CAUSES AND RISK FACTORS

• •More common after menopause due to decreased estrogen
• •Steroid use, because it increases the bone resorption rate

ASSESSMENT

• •Decreased dietary calcium intake
• •Kyphosis of the spine (rounded upper back)
• •Bone pain
• •Fractures of the pelvis or hip
• •Pathological fractures: those that occur without trauma

MANAGEMENT

• •Calcium intake and supplementation
• •Vitamin D intake, because vitamin D is needed to absorb calcium
• •Weight-bearing exercises (PT/OT)
• •Medications should be taken 30 minutes before eating, for example alendronate (Fosamax) or risedronate (Actonel)

WHAT IS IT?

Parkinson's disease is a degenerative neurological disorder. The substantia nigra (a part of the brain) shrinks, which depletes dopamine (a brain chemical needed for movement). The person becomes less able to control movement. It is slow, progressive, and has no cure, so the person becomes increasingly dependent on others for self-care.

Quick Concept: Loss of dopamine in the brain causes the movement problems seen in this disease.

ASSESSMENT

Classic signs:

• •Pill rolling: tremors in the hands as if rolling a pill between the fingers
• •Shuffling gait (walk)
• •Lip smacking
• •Bradykinesia: slow movements due to muscle rigidity
• •Resting tremor
• •Akinesia: loss of voluntary movement
• •Blank facial expression
• •Stooped stance
• •Drooling
• •Dysphagia (difficulty swallowing)

MANAGEMENT

Medication therapy:

• •Dopaminergic drugs
• •Dopamine agonists (for example levodopa-carbidopa)
• •Anticholinergics
• •The goal is to increase the level of available dopamine in the CNS (central nervous system)

WHAT IS IT?

An ischemic stroke is a lack of blood flow to brain tissue caused by a blood clot in the cerebral (brain) vessels.

Quick Concept: A clot blocks a brain vessel, so no blood flows past the clot to feed that brain tissue.

Pathophysiology:

• •A blood clot forms in a brain vessel
• •No flow past the clot
• •Not immediately seen on CT scan (takes 24 hours); MRI gives a better view

ASSESSMENT

Presentation depends on where the clot is:

• •MCA (middle cerebral artery): classic FAST symptoms, contralateral (opposite side) manifestations
• •Basilar: decreased LOC (level of consciousness), loss of vision, abnormal pupil response
• •Brainstem: loss of BP (blood pressure) regulation, respiratory failure, dysphagia (trouble swallowing)

WHAT IS IT?

Multiple sclerosis is a chronic, progressive demyelination (loss of the protective myelin sheath) of neurons in the central nervous system (CNS).

Quick Concept: Memory aid: Multiple Sclerosis points to the Myelin Sheath.

ASSESSMENT

• •Fatigue
• •Tremors
• •Weakness
• •Spasticity of muscles, which can be painful
• •Bowel and bladder dysfunction: incontinence, diarrhea, or constipation
• •Decreased peripheral sensation (pain, temperature, touch), which is a high risk for injury
• •Visual disturbances
• •Emotional instability

MANAGEMENT

• •No cure; supportive therapy, analgesics, muscle relaxants
• •Energy conservation
• •Provide bowel and bladder training
• •Maintain adequate fluid intake of 2000 mL/day
• •Encourage activity independence
• •Regulate temperatures on water heaters, baths, and heating pads (risk for burns)
• •Ensure in-home safety (rugs, cords, etc.) to reduce the risk for falls

WHAT IS IT?

A hemorrhagic stroke is a bleed in or around the brain from a ruptured blood vessel. Hypertension (high blood pressure) weakens the vessel, such as an aneurysm (a bulging weak spot) that ruptures. There is no blood flow past the point of the bleed. It is visible immediately on a CT scan. It often presents as the worst headache of my life, especially with a subarachnoid hemorrhage.

Risk factors:

• •Hypertension
• •Substance abuse (cocaine)
• •Anticoagulant (blood thinner) therapy
• •Trauma

Complications:

• •Blood is an irritant to brain tissues
• •Seizures
• •Vasospasm (vessels clamp down), which causes more ischemia (lack of blood flow)

WHAT IS IT?

Meningitis is inflammation of the membranes around the brain and spinal cord. It is caused by a virus, bacteria, fungus, or protozoa.

Quick Concept: CSF (cerebrospinal fluid) is analyzed to make the diagnosis and shows cloudy fluid, increased WBC (white blood cells), and decreased glucose.

ASSESSMENT

• •Fever
• •Altered level of consciousness
• •Nuchal rigidity (neck stiffness)
• •Kernig's sign: severe stiffness of the hamstrings makes the client unable to straighten the leg when the hip is flexed to a 90-degree angle
• •Brudzinski's sign: severe neck stiffness causes the client's hips and knees to flex when the neck is flexed
• •Lethargy
• •Increased intracranial pressure
• •Photophobia (sensitivity to light)
• •Seizures

MANAGEMENT

• •Place in droplet isolation
• •Analgesics (pain drugs)
• •Antibiotics: consider the blood-brain barrier

WHAT IS IT?

A seizure is abrupt, abnormal, excessive, uncontrolled electrical activity in the neurons (nerve cells) of the brain. A persistent seizure with no breaks between episodes is called status epilepticus and is a MEDICAL EMERGENCY.

Types:

• •Generalized (both hemispheres of the brain): tonic-clonic (stiffening, then jerking or twitching, with loss of consciousness), absence (staring off into space, unaware, lasts less than 30 seconds), tonic (tensing of muscles), clonic (jerking or twitching), myoclonic (sudden jerk of muscles), atonic (all muscles suddenly go limp, high fall risk)
• •Focal (localized, one hemisphere): simple (twitching or sensory changes, client stays conscious), complex (twitching or outbursts such as laughing or crying, with loss of consciousness or awareness)

ASSESSMENT

Before the seizure:

• •Assess risk factors for medication compliance
• •Assess for an aura (a sensation that warns of an oncoming seizure); it is different for every client, some see colors, smell metal, or feel tingly

During the seizure:

• •Assess and document the type, onset, duration, and complications (biting the tongue, aspiration, or injury)

After the seizure (postictal state):

• •Some memory loss, sleepiness, impaired speech, disorientation, agitation

MANAGEMENT

EEG diagnostics:

• •Tests the types of brainwaves to find where seizures are occurring and how severe they are

Medications to stop seizures (antiepileptic drugs):

• •Lorazepam (Ativan): first-line drug, 2 mg IV push during a seizure
• •Diazepam (Valium)
• •Phenobarbital

Medications to prevent seizures:

• •Phenytoin (Dilantin), fosphenytoin (Cerebyx), levetiracetam (Keppra), lacosamide (Vimpat)

Procedures:

• •Surgical removal of a lesion
• •Cutting connections in the brain
• •Deep brain stimulation (for example corpus callosotomy surgery, extratemporal resection)

WHAT IS IT?

This card covers nursing care before, during, and after a seizure to keep the client safe.

MANAGEMENT

Before:

• •Give all medications on time
• •Use seizure precautions if at risk
• •Verify the order for PRN (as-needed) dosing and ensure medication is readily available

During (maintain airway):

• •Turn the client to the side in case of vomit
• •Have oxygen and suction equipment available
• •DO NOT force anything into the mouth during a seizure (including a bite block)

During (protect from injury):

• •Lower the bed to the lowest position
• •Use padded side rails
• •Loosen restrictive clothing
• •DO NOT try to restrain the client
• •Notify the MD of type, onset, and duration

After:

• •Keep the client safe while postictal (the recovery period after a seizure)

WHAT IS IT?

Intracranial pressure (ICP) is the pressure within the cranium (skull). Normal is 5 to 15 mmHg. Intervention is required above 20 mmHg. If pressure rises too high, brain tissue can be pushed across structures in the skull, causing permanent damage.

CAUSES

• •Tumor or mass
• •Bleeding from stroke or trauma
• •Hydrocephalus
• •Trauma leading to edema
• •Ischemic stroke leading to edema

Brain herniation:

• •ICP rises so high that brain tissue squeezes through or across a structure in the skull, which can cause permanent damage and lead to brain death

ASSESSMENT

• •Altered LOC (level of consciousness): confusion, stupor, may be subtle
• •Pupillary changes: fixed and dilated indicates prolonged increased ICP
• •Babinski reflex: a positive response is bad
• •Posturing
• •Seizures
• •Cushing's Triad (signals impending herniation): abnormal respirations, widened pulse pressure, bradycardia
• •Elevated temperature (loss of regulation)

MANAGEMENT

• •Avoid sedatives or CNS depressants
• •Hyperventilation ("permissive hypocapnia") for cerebral vasoconstriction
• •Osmotic diuretics, such as mannitol, to decrease swelling
• •Hypertonic saline (1.5% or 3%) to decrease swelling
• •Corticosteroids to decrease inflammation
• •Craniectomy (also called a "bone flap") to make room for the brain to swell
• •External ventricular drain (EVD, also called a "bolt") to drain CSF (cerebrospinal fluid) when ICP is elevated. A "bolt" only measures intracranial pressure; an EVD can measure pressure and drain CSF through the ventriculostomy.

WHAT IS IT?

This card covers the routine neurological (nervous system) assessments: level of consciousness, the Glasgow Coma Scale, and pupil assessment.

ASSESSMENT

Level of consciousness:

• •Assess alertness
• •Assess orientation to person, place, time, and situation
• •Assess response to stimuli in order: start with verbal, then light touch, then deep touch or shaking, then painful (nail beds), then deep pain (sternal rub)

Glasgow Coma Scale (GCS):

• •Can never be zero; the worst score is 3 and the best is 15
• •In each category, give the highest score, then add all three scores

Best eye opening:

• •4: spontaneous
• •3: to voice
• •2: to pain
• •1: no response

Best verbal response:

• •5: oriented
• •4: disoriented, converses
• •3: inappropriate words
• •2: incomprehensible speech
• •1: no response or intubated

Best motor response:

• •6: follows commands
• •5: localizes to pain (reaches toward the pain when pain is initiated)
• •4: withdraws from pain (reaches toward the pain but cannot cross the midline of the body)
• •3: abnormal flexion (decorticate)
• •2: abnormal extension (decerebrate)
• •1: no movement

Examples:

• •A client who opens eyes to voice (3), is disoriented (4), and follows commands (6) has a GCS of 13
• •A client who does not open eyes (1), does not respond verbally (1), and is decorticate (3) has a GCS of 5

Pupil assessment:

• •Equal, round, size
• •Reactive to light: should constrict briskly and equally on both sides when light is shined in the eyes
• •Accommodation: should constrict when focusing from far to near

WHAT IS IT?

This card covers part of a neurological assessment, including muscle strength grading in the four extremities. [source fragment unclear, verify at source]

STRENGTH GRADING (x4 extremities)

• •5: full strength
• •4: overcomes some resistance
• •3: overcomes gravity, no resistance
• •2: cannot overcome gravity
• •1: no movement at all

MANAGEMENT

• •Notify the provider of any acute changes
• •May need a STAT CT or MRI to rule out possible increased intracranial pressure or stroke

WHAT IS IT?

This card covers routine neurological (brain and nerve) assessments. PERRLA stands for Pupils Equal, Round, and Reactive to Light and Accommodation. Also document pupil size in mm.

LEVELS OF CONSCIOUSNESS

• •Normal: alert and oriented x 4 (A&O x 4), alert
• •Delirious: confused and agitated
• •Confused: alert and oriented less than x 3 (A&O x <3), unable to answer
• •Somnolent: excessively sleepy or drowsy
• •Obtunded: awake, but slow or no response to surroundings
• •Coma: NO response to stimuli, unable to arouse
• •Stuporous: sleep-like, no spontaneous activity, withdraws to pain

GLASGOW COMA SCALE

Eyes:

• •1: no opening
• •2: open to pain
• •3: open to voice
• •4: open spontaneously

Verbal:

• •1: no response
• •2: incomprehensible sounds
• •3: inappropriate words
• •4: disoriented
• •5: oriented

Motor:

• •1: no response
• •2: abnormal extension
• •3: abnormal flexion
• •4: withdraws to pain
• •5: localizes to pain
• •6: follows commands

MUSCLE STRENGTH SCORE

• •0: no muscle contraction
• •1: muscle twitch
• •2: movement without gravity
• •3: movement against gravity
• •4: movement against resistance
• •5: full strength

WHAT IS IT?

Atelectasis is the collapse of a lung or lung lobe due to the deflating of the alveoli (air sacs). It is common after surgery from shallow breathing. Excessive pulmonary (lung) secretions can also cause it.

Quick Concept: When the alveoli deflate, that part of the lung collapses.

ASSESSMENT

• •Diminished breath sounds on the affected side
• •Chest pain with breathing
• •Fever
• •Chest X-ray shows collapse (appears white)

MANAGEMENT

• •CPT (chest physiotherapy): vibrations to loosen secretions
• •IPPB (intermittent positive pressure breathing): positive pressure to open alveoli
• •IS (incentive spirometer): slow deep breaths; increased volume reinflates alveoli
• •Position changes to mobilize secretions
• •Invasive mechanical ventilation

WHAT IS IT?

COPD is a chronic obstruction of airflow caused by emphysema and chronic bronchitis.

CAUSES

Emphysema:

• •Destruction of alveoli due to chronic inflammation
• •Decreased surface area for gas exchange

Chronic bronchitis:

• •Chronic airway inflammation with a productive cough
• •Excessive sputum production

ASSESSMENT

• •Barrel chest: expanded rib cage from increased work of breathing and air trapping
• •Accessory muscle use
• •Adventitious (abnormal) breath sounds: diminished, crackles, wheezes
• •Congestion on chest X-ray
• •ABG (arterial blood gas): decreased pH, increased pCO2, decreased PaO2

MANAGEMENT

• •Do not give O2 above 2 Lpm; a low O2 level is the stimulus to breathe
• •Chest physiotherapy (CPT) to loosen secretions
• •Increase fluid intake (3 L/day) to thin secretions
• •Medications: bronchodilators, corticosteroids

WHAT IS IT?

Asthma is an inflammatory disorder of the airways. It is stimulated by triggers such as infection, allergens, exercise, and irritants. Status asthmaticus is a life-threatening condition where asthma does not respond to treatment.

ASSESSMENT

Symptoms:

• •Narrowed airways cause wheezing or crackles
• •Decreased gas exchange causes restlessness and anxiety
• •Inflammation of the airways causes diminished breath sounds and tachypnea (fast breathing)

Diagnostics:

• •Peak flow rate (the volume of expired air): stable is 80 to 100% of baseline, caution is 50 to 80% of baseline, danger is below 50% of baseline
• •Pulmonary function tests

MANAGEMENT

• •High-Fowler's or position of comfort
• •Administer O2 (oxygen)

Medications:

• •Bronchodilators
• •Corticosteroids
• •Leukotriene modulators (Montelukast/Singulair)

WHAT IS IT?

Artificial airways are devices used to keep a client's airway open. Their purpose is to protect the airway when the client cannot and to provide a route for mechanical ventilation.

ASSESSMENT

• •Assess airway
• •Assess breathing
• •Assess level of consciousness
• •Choose the correct airway
• •Call for help for an advanced airway

TYPES

• •Nasopharyngeal airway ("nasal trumpet"): for clients who cannot clear secretions, are breathing independently, and are conscious
• •Oropharyngeal airway ("oral airway"): for clients who cannot protect their airway and are unconscious
• •Endotracheal tube ("ET tube" / "intubation"): for clients who cannot protect their airway and are not breathing or require ventilation; may be conscious or unconscious before intubation
• •Tracheostomy tube ("trach"): for clients who must be weaned (slowly taken off) from the ventilator, or who have a long-term need due to neuromuscular conditions or tracheal damage

WHAT IS IT?

This card is a decision tree to choose the most appropriate artificial airway for a patient's situation. Start by checking whether the patient is conscious or unconscious.

DECISION TREE

Conscious patient:

• •Clears own secretions: apply oxygen as needed
• •Can't clear own secretions: nasopharyngeal airway plus suction
• •Requires ventilation: endotracheal tube

Unconscious patient (unprotected airway):

• •If head tilt or chin lift, or no contraindication to intubation: oropharyngeal airway plus bag/valve/mask, or endotracheal tube
• •Tracheal obstruction or damage: tracheotomy
• •[source fragment unclear, verify at source]

WHAT IS IT?

Tuberculosis (TB) is a lung infection that causes pneumonitis (lung inflammation) and granulomas (clumps of immune cells). Noncompliance with treatment can lead to multi-drug resistance (MDR-TB). It spreads by airborne transmission (infectious particles aerosolized into the air).

Risk factors:

• •Foreign travel
• •Living in tight quarters: college, prison, homeless shelters

Diagnostics:

• •Chest X-ray shows granulomas
• •TB skin test: anyone 15 mm induration (raised area); high risk 10 mm; immunocompromised 5 mm
• •Quantiferon Gold (gold standard)
• •Sputum cultures: Mycobacterium tuberculosis

ASSESSMENT

• •Night sweats
• •Weight loss
• •Chills
• •Fatigue
• •Persistent cough with hemoptysis (coughing up blood)
• •Chest pain
• •Anorexia (loss of appetite)

MANAGEMENT

• •Negative pressure room

RIPE therapy:

• •Rifampin
• •Isoniazid
• •Pyrazinamide
• •Ethambutol
• •Treatment for 6-12 months; risk of transmission reduced after 2-3 weeks of the medication regimen

WHAT IS IT?

Pneumonia is an inflammatory condition of the lungs that primarily affects the alveoli, which may fill with fluid or pus. It can be infectious (bacterial or viral) or noninfectious (aspiration).

DIAGNOSIS

• •Chest X-ray
• •Sputum culture to identify the organism

ASSESSMENT

Viral:

• •Low-grade fever
• •Nonproductive cough
• •WBCs normal to low elevation
• •Chest X-ray shows minimal changes
• •Less severe than bacterial

Bacterial:

• •High fever
• •Productive cough
• •WBCs elevated
• •Chest X-ray shows infiltrate
• •More severe than viral

Both:

• •Chills
• •Rhonchi/wheezes
• •Sputum production

MANAGEMENT

Medications:

• •Antibiotics
• •Analgesics
• •Antipyretics

Nursing actions:

• •Supplemental O2
• •Assess and maintain the respiratory status
• •Encourage activity as soon as possible
• •Instruct on chest expansion exercises: incentive spirometry; turn, cough, deep breathe
• •Encourage 3 L/day of fluids unless contraindicated, to thin secretions

WHAT IS IT?

Influenza is a virus with multiple strains and increasing severity. It is spread through droplet contact.

ASSESSMENT

Symptoms:

• •Sudden onset
• •Lasts 6 to 7 days
• •Aches in the head, muscles, and body
• •Fatigue
• •Runny nose, sore throat, cough
• •Vomiting
• •High fever (102 to 104 degrees F)

MANAGEMENT

Vaccine, indicated annually for:

• •Healthcare workers
• •Elderly
• •Children over 6 months
• •Pregnant clients
• •Immunocompromised clients: do NOT give the nasal spray vaccine to immunocompromised clients

Vaccine contraindications:

• •Severe allergy to the flu vaccine, eggs, or latex
• •History of Guillain-Barre
• •Recent bone marrow or organ transplant (less than 6 months)

Anti-virals:

• •Oseltamivir (Tamiflu): within 48 hours of onset, best within 24 hours

WHAT IS IT?

Cognitive impairment disorders include autism-spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD), dementia, and Alzheimer's disease. Dementia is a broad category of brain diseases that are gradual and long-term and result in self-care deficits, largely affecting the client's ability to function. It causes judgment impairments and problems with problem solving and behavior. Alzheimer's disease is a TYPE of dementia and is an irreversible form caused by nerve cell deterioration, with a steady, progressive decline in functional capacity.

ASSESSMENT

• •Apraxia: difficulty performing motor tasks
• •Aphasia: difficulty progressing to inability to speak and understand what is being said
• •Agnosia: does not recognize familiar people or objects
• •Amnesia: memory loss

MANAGEMENT

Caregiver stress:

• •Role strain, for example a child caring for a parent
• •Sadness due to the loved one not recognizing them

Safety:

• •Wandering can be an issue; units should be locked/secured and clients supervised
• •Watch water temperature, as clients may burn themselves
• •Remove anything toxic or hazardous from easy access
• •Watch for agitation and remove things that increase it
• •Decrease stimuli and reassure the client
• •Never argue
• •Use a calm, reassuring voice with gentle touch when appropriate
• •Watch for sundowning (increased confusion at night)

Communicate:

• •Maintain eye contact
• •Stand in front of them; be calm, firm, and direct
• •Give simple one-step tasks/directions
• •Use short, simple words
• •Always identify them and yourself
• •Reorient as needed, which may be frequent

Promote their current abilities:

• •Keep familiar things around them
• •Continually reinforce what they know and can do at this point in time
• •Promote independence and supervise to ensure ADLs (activities of daily living) are taken care of

WHAT IS IT?

This card continues care strategies for clients with cognitive impairment (problems with memory and thinking). The focus is on familiar, calming activities and a steady routine.

MANAGEMENT

• •Use familiar, simple games and activities they enjoy (coloring, reading books they enjoy)
• •Talk about their memories
• •Maintain a routine
• •Pay attention to fatigue, memory strain, and agitation, and provide ample time for rest
• •Keep a calendar and clock on the wall and refer to it when discussing the date or time

WHAT IS IT?

Mood disorders involve emotional extremes and trouble regulating moods over the long term. Mood (emotional states) is subjective and hard to define. Examples include bipolar disorder and depressive disorders.

ASSESSMENT

• •Bipolar includes periods of mania and depression with normal periods in between (extremely high highs, extremely low lows, inability to self-regulate)
• •Mania: a mood disorder marked by a hyperactive, wildly optimistic state
• •Depression: 5 or more depressive symptoms for 2 or more weeks

MANAGEMENT

Goals:

• •Manage acute episodes
• •Provide support and resources for long-term management

Medications:

• •Anti-anxiety medication can be used during manic episodes. Use caution with clients who have a history of substance abuse.
• •Antipsychotics: olanzapine (Zyprexa), aripiprazole (Abilify), risperidone (Risperdal)
• •Mood stabilizer: Lithium. Clients need regular labs to check the therapeutic level. Toxicity can result if stable sodium intake and fluid intake (2-3L/day) are not maintained.
• •Also given: sodium valproate (Depakote), lamotrigine (Lamictal), carbamazepine (Tegretol)

Interventions for mania:

• •Make sure the environment is safe; watch for dangerous hyperactivity
• •Reorient as necessary
• •Promote appropriate sleep/wake cycles
• •Use controlled, calm, focused interactions
• •Offer high-calorie finger foods because the client is manic and hyperactive
• •Set boundaries related to behaviors
• •Ensure medication compliance

WHAT IS IT?

Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behaviors, feelings, and sense of wellbeing.

SEVERITY

• •Mild: lasts 2 weeks or less
• •Moderate: more persistent, with negative thinking and possible suicidal thoughts
• •Severe: intense and pervasive, may include delusions and hallucinations

ASSESSMENT

Some combination of these symptoms may be present, especially in major depressive disorder:

• •Depressed mood most of the day
• •Diminished interest or pleasure in activities
• •Significant unintentional weight loss
• •Insomnia or hypersomnia
• •Psychomotor agitation
• •Fatigue or loss of energy
• •Feelings of worthlessness, or excessive or inappropriate guilt
• •Difficulty concentrating or making decisions
• •Recurrent thoughts of death or suicide, with or without a plan
• •Low self-esteem
• •Feelings of hopelessness
• •Poor appetite or overeating
• •Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

MANAGEMENT

• •The number one priority is assessing the risk for self-harm: "Have you had any thoughts of hurting yourself?" If they say yes, then ask, "Do you have a plan?"
• •Ensure a safe environment: remove anything from their room that they could use to harm themselves
• •Promote appropriate intake; focus on higher-calorie foods frequently, since they may go long periods without eating, so maximize intake when they do eat
• •May need reminding or encouragement to maintain basic personal hygiene (ADLs)
• •Encourage expression of feelings and focus on their strengths
• •Validate their feelings of loss, frustration, and sadness
• •Spend time with them to show they are a priority to you
• •Engage the client in activity toward progress: one-on-one situations, eventually progressing to group discussions; start with gross motor activities; suggest activities that are easy to complete, non-competitive, and offer a sense of accomplishment (coloring, drawing, playing cards, easy games)
• •Promote appropriate sleep-wake cycles

WHAT IS IT?

Suicidal behavior occurs in clients with a consistent feeling of hopelessness, guilt, and worthlessness so overwhelming that they do not want to live anymore and attempt to end their life.

At-risk clients (previous personal or family history of suicide, or mental illness history):

• •Personality disorders
• •Substance abuse
• •Psychosis
• •People with depression
• •People with terminal illness
• •People with disabilities
• •Elderly and adolescents

ASSESSMENT

Objective information:

• •Giving away important, prized possessions
• •Creating a will or changing an existing one
• •Sleep disturbances
• •Difficulty concentrating, loss of interest in things
• •Asking about methods to end one's life
• •Writing notes to loved ones
• •Sudden massive improvement in a previously very depressed client: they may have new energy or relief because they made a plan or a decision, so observe more closely for an increased chance of carrying out the plan

MANAGEMENT

• •Assess clients with a history of depression for risk of suicide and self-harm

Safety is essential:

• •Inpatients admitted with suicide attempts are not to be left alone
• •Remove any items that could be used for self-harm from their room
• •Initiate suicide precautions
• •Begin sitter or 1:1 supervision and never leave the client alone

Other therapeutic management:

• •Establish a suicide contract
• •Establish rapport and trust
• •Provide positive reinforcement
• •Involve the support system the client identifies
• •Encourage therapy (individual, group)

WHAT IS IT?

PTSD is a mental illness that results after someone experiences trauma. The client might relive the trauma, frequently dream about it, or have flashbacks. Traumatic events that cause PTSD include anything traumatic to the client, such as rape, accidents, wartime experiences, or natural disasters.

ASSESSMENT

• •Sleep issues such as insomnia, nightmares, and flashbacks
• •Mental health issues such as depression or anxiety
• •Avoiding triggers: a trigger is a situational, audible, or visual experience that invokes an anxiety-driven or fear response, similar to the original cause of the PTSD. For example, if a client experienced violence at a location, they may avoid that location or similar ones.
• •Guilt related to the event. For example, if they survived and others did not, the client might think they could have done something differently.

MANAGEMENT

• •Validate the client's feelings and promote coping mechanisms that work for them
• •Offer relaxation techniques
• •Encourage outpatient therapy and support groups
• •Therapy/service animals may help clients

WHAT IS IT?

Anxiety is a sense of worry or nervousness, usually about an upcoming event with an uncertain outcome. It is a normal part of life. It becomes concerning when it is persistent, chronic, or a response to normal daily activities.

Types:

• •Normal: healthy
• •Acute: sudden, related to an event or threat (also normal)
• •Chronic: consistent, related to normal daily activities

ASSESSMENT

Levels of anxiety:

• •Mild: can be healthy, motivating, and produce growth
• •Moderate: can still function and solve problems
• •Severe: the individual needs someone to refocus them
• •Panic: dread, impending doom, and lack of rational thoughts; this can lead to exhaustion

MANAGEMENT

Therapeutic interventions:

• •Ensure safety
• •Provide a calming and safe environment
• •Establish trust and acknowledge the anxiety
• •Encourage expression of thoughts, feelings, and problem-solving
• •Promote their coping mechanisms; do not criticize
• •Provide gross motor activities to reduce stress (movement and coordination of arms, legs, and large body parts, such as running, walking, jumping)
• •Give anti-anxiety medications PRN (as needed)

For an acute anxiety attack:

• •Decrease stimuli and maintain a calm environment (overstimulation makes it worse)
• •Encourage the client to identify and discuss feelings and their causes, which helps them see connections between behaviors and feelings
• •Listen and watch for signs of risk for self-harm such as helplessness and hopelessness; safety is the priority

WHAT IS IT?

Hemophilia is an impaired ability to control blood clotting due to a deficiency in specific clotting proteins. It is an X-linked recessive disorder (hereditary). Carrier females pass it to a male child.

Quick Concept: Missing coagulation factors prevent fibrin formation, so the person bleeds for a long time because they cannot clot.

Types:

• •Hemophilia A (deficiency of factor VIII)
• •Hemophilia B (deficiency of factor IX)
• •Hemophilia C (deficiency of factor XI)

ASSESSMENT

• •Epistaxis (nose bleeds) and prolonged bleeding from trauma
• •Frequent bruising
• •Bleeding in the brain: visual changes, headaches, change in LOC (level of consciousness), slurred speech
• •GI (gastrointestinal) bleed: hematemesis (throwing up blood), melena (black stools = upper GI bleed)
• •Normal PT and thrombin time, prolonged PTT

MANAGEMENT

Goals:

• •Replace missing clotting factors
• •Prevent bleeding
• •Prevent long-term joint problems

Medications:

• •Replace the missing factor by slow IV push
• •DDAVP increases the body's production of clotting factor and is ONLY used in mild Hemophilia A

Access:

• •Many clients have a metaport for access
• •Maintain sterility when accessed
• •Only access when following policies or orders

WHAT IS IT?

Congenital heart defects are abnormalities in the structure of the heart. They are caused by improper development during gestation (pregnancy).

RISK FACTORS

• •Associated with chromosomal abnormalities, syndromes, and congenital defects
• •Parent or sibling has a heart defect
• •Maternal diabetes
• •Maternal use of alcohol and illicit drugs
• •Exposures to infections in utero (such as rubella)

CLASSIFICATION (by how it affects hemodynamics, the blood flow patterns)

Increased pulmonary blood flow:

• •Atrial septal defect
• •Ventricular septal defect
• •Patent ductus arteriosus
• •Atrioventricular canal

Decreased pulmonary blood flow:

• •Tetralogy of Fallot
• •Tricuspid atresia

Obstruction to blood flow:

• •Coarctation of the aorta
• •Aortic stenosis
• •Pulmonic stenosis

Mixed blood flow:

• •Transposition of great arteries
• •Truncus arteriosus
• •Hypoplastic left heart

ASSESSMENT

General signs and symptoms:

• •Murmurs
• •Additional heart sounds
• •Irregular rhythms
• •Clubbing of fingers and toes
• •Failure to thrive

Signs of heart failure (poor myocardial function):

• •Tachycardia
• •Gallop rhythm
• •Sweating while feeding
• •Decreased urinary output
• •Fatigue
• •Pale, cool extremities
• •Hypotension
• •Cyanosis

Respiratory congestion (left-sided heart failure):

• •Tachypnea, dyspnea, grunting, retractions, nasal flaring
• •Exercise intolerance (older children)
• •Feeding intolerance (infants)
• •Cyanosis, cough, wheezing

Systemic congestion:

• •Weight gain
• •Enlarged liver
• •Peripheral edema (periorbital, or sacral in infants lying down)

MANAGEMENT

• •Surgery
• •Cardiac catheterization
• •Common medications: digoxin

WHAT IS IT?

This card continues the nursing care for congenital (present at birth) heart defects in infants and children, including medication safety and supportive care.

MANAGEMENT

Medications:

• •Watch for signs of toxicity
• •Medication orders must specify HR (heart rate) parameters for holding the medication, because heart rate varies with age
• •ACE inhibitors, beta-blockers, diuretics

Decrease cardiac demands:

• •Conserve energy for feeds
• •Minimize stress

Minimize respiratory distress:

• •Elevate the head of the bed
• •Administer oxygen

Support adequate nutrition:

• •Feed infants every 3 hours, and do not let feeds last longer than 30 minutes
• •High-calorie formulas

Monitor fluids and electrolytes:

• •Daily weight
• •Strict I's and O's (intake and output)
• •Potassium

WHAT IS IT?

This is a decision tree to sort congenital heart defects (heart defects present at birth). It splits defects first by whether cyanosis (bluish skin from low oxygen) is present, then by vascularity (lung blood flow) and signs of cardiac enlargement.

DECISION TREE

No cyanosis, with cardiac enlargement and normal/altered vascularity:

• •Patent ductus arteriosus (PDA)
• •Aortic stenosis
• •Pulmonic stenosis
• •Coarctation of the aorta

Cyanosis present:

• •Transposition of the great arteries (TGA)
• •Truncus arteriosus
• •TAPVC (total anomalous pulmonary venous connection)
• •Tricuspid atresia
• •Single ventricle
• •Ebstein's anomaly
• •Pulmonic atresia
• •Tetralogy of Fallot
• •Atrial septal defect
• •Ventricular septal defect
• •[source decision-tree branches partly garbled, verify branch assignments at source]

WHAT IS IT?

Gestational diabetes is high blood sugar during pregnancy. Increased weight and pregnancy hormones cause insulin resistance, which raises blood sugar. If the mother has high blood sugar, glucose crosses the placenta to the baby. The baby's body then makes more insulin, causing excessive growth.

Quick Concept: Maternal insulin does not cross the placenta, only glucose does, so the fetus responds to the mother's high sugar by making its own extra insulin.

ASSESSMENT

Maternal changes:

• •1st trimester: insulin needs are reduced
• •2nd and 3rd trimester: insulin resistance occurs as hormones increase, so insulin needs increase
• •Right after the placenta delivers: hormones and insulin requirements decrease; gestational diabetics should no longer need insulin or diet management after delivery

Newborn changes:

• •The baby grows faster and larger, but its function still reflects age, not size
• •Macrosomic (large baby) = 4000 g

Assessments:

• •Screen for glucose and protein in urine at regular prenatal visits (glucosuria and ketonuria)
• •Check blood sugar between 24 and 28 weeks with glucola testing
• •High-risk patients may be screened at the beginning of pregnancy

MANAGEMENT

• •Ideal to control with diet and exercise
• •Monitor for typical diabetes mellitus (DM) complications (signs of infection, high blood pressure, edema, proteinuria)

WHAT IS IT?

Preeclampsia is a hypertensive (high blood pressure) disorder with a BP of 140/90, plus proteinuria (protein in the urine), occurring after 20 weeks of gestation (pregnancy). A woman may or may not have symptoms but will have elevated blood pressures and proteinuria.

Diagnostic criteria:

• •Proteinuria: over 300 mg in a 24-hour urine specimen, and a protein:creatinine ratio over 0.3
• •Blood pressure: 140/90 or more on two occasions 4 hours apart, OR a systolic of 160 mmHg or more, OR a diastolic of 90 mmHg or more. Both 140/90 and 160/90 are classified as preeclamptic hypertension.

ASSESSMENT

• •Sudden increase in edema (swelling) in the hands and face
• •Sudden weight gain from excess fluid retention
• •Complaints of headache, epigastric (upper-middle abdomen), or RUQ (right upper quadrant) pain
• •Vision changes: a serious symptom, from swelling and irritation of the brain and CNS (central nervous system)
• •Proteinuria: MUST be present to be preeclampsia

Fetal assessment:

• •Intrauterine growth restriction (IUGR): placental blood flow is not at its best

MANAGEMENT

• •Delivery of the baby is the only treatment
• •Magnesium sulfate is given prophylactically (preventively) for seizure prevention
• •Some antihypertensive (BP-lowering) drugs might be given to manage BP

WHAT IS IT?

Some infections during pregnancy are concerning because they can pass to the fetus (through the placenta or during delivery) and harm the newborn. The TORCH group is a helpful memory aid for these infections.

TORCH

• •T: Toxoplasmosis
• •O: Other (such as Group B strep, HIV, syphilis)
• •R: Rubella
• •C: Cytomegalovirus
• •H: Herpes simplex

DETAILS

Toxoplasmosis:

• •A parasitic disease passed to the mother while handling cat litter, undercooked or raw meat, or gardening; passed to the fetus through the placenta
• •The mother is usually asymptomatic but may have a rash or flu-like symptoms for a few weeks to months
• •Can cause fetal death, spontaneous abortion, and neurologic complications
• •Educate the mother to never change cat litter

Other (Group B strep):

• •All women are screened during the prenatal period by a vaginal swab at 35 to 37 weeks
• •All women have the bacteria; results depend on the amount colonized
• •Prophylactic antibiotics (penicillin or ampicillin) are given during labor to women who screen positive
• •The main cause of bacterial infections in newborns, which causes sepsis

Other (HIV):

• •Delivery by c-section to limit transmission
• •Infants are given antiretrovirals

Other (Syphilis):

• •Woman is given penicillin, and the fetus receives penicillin after delivery

Rubella:

• •Passed through the placenta
• •Most dangerous if the mother gets it in the first trimester
• •Can cause brain damage, hearing loss, miscarriage, stillbirth, and various congenital defects
• •Assess the mother's immunity by drawing a titer. If non-immune, vaccinate immediately after delivery because it is a live vaccine. The vaccine protects future pregnancies.

Cytomegalovirus (CMV):

• •A very common, asymptomatic virus passed through bodily fluids
• •Passed through the placenta or during delivery; can cause intrauterine growth restriction, seizures, blindness, hepatomegaly, splenomegaly, jaundice, hearing loss, microcephaly, and/or death

Herpes Simplex:

• •Passed during birth if active lesions are present; a c-section should be done with an active lesion to prevent transmission
• •Acyclovir may be given around 36 weeks to prevent an outbreak during labor and delivery
• •Can cause serious neonatal complications (death, neurologic issues, etc.)

WHAT IS IT?

The newborn physical exam is the first physical assessment after birth. It establishes a baseline. Assess for temperature stability and note all abnormalities.

Keep the baby warm:

• •Nursing interventions must maintain temperature stability

The intrauterine to extrauterine transition period has 3 phases:

• •Reactivity: most alert and the best feeding time, in the first hour
• •Decreased responsiveness: sleepy, in the second hour
• •Reactivity: a second reactivity phase, hours 2 to 6, alert

ASSESSMENT

General observations:

• •Newborns should have a flexed posture and coordinated movements
• •Count extremities, fingers, toes
• •Check for an anus; if not patent (open), do NOT feed; if no anus is found, this is an emergent surgery
• •In males, check that the urinary meatus (opening) is on the penis; hypospadias is when the meatus is on the under portion, and NO circumcision can be performed on these clients
• •Check for hip dysplasia using the Ortolani maneuver: rotate the thighs outward and feel for clicks at the hips; no clicking or crepitus is normal; any clicking or crepitus indicates hip dysplasia; also check by placing the infant prone and looking for symmetrical buttock creases, where symmetry indicates no dysplasia

Vital signs:

• •Some newborns may have slight, subtle tremors that can be normal or due to drug withdrawal, hypocalcemia, or hypoglycemia
• •Listen to the apical pulse for 1 full minute: 120 to 160 BPM resting is normal
• •Listen to respirations for 1 full minute: 30 to 60 RR is normal
• •Axillary (armpit) temperature: 97.8 to 99 F is normal

Head:

• •Measure head, weight, length
• •Fontanels (soft spots): anterior and posterior

Eyes:

• •Weak eye muscle
• •Newborns may have strabismus or disconjugate gaze (eyes not aligned)

Ears:

• •No pits or skin tags

Mouth:

• •Assess for an intact palate, no teeth

Chest:

• •Assess for clavicular (collarbone) fractures from birth
• •Breast tissue swelling might be observed
• •May note secretions from the nipple

Umbilical cord:

• •Assess for 2 arteries and 1 vein
• •Assess for meconium staining on the cord

• •[source fragment unclear, verify at source: source lists fontanel locations as anterior "back of the head" and posterior "top of the head," which appears reversed]

WHAT IS IT?

This card continues the newborn physical exam, covering gestational age signs, the umbilical cord, genitalia, and normal skin findings in a newborn.

GESTATIONAL AGE (sole creases)

• •Preterm: typically covered
• •Term: typically only in folds
• •Postterm: absent

UMBILICAL CORD (AVA)

• •A way to remember the number of arteries and veins in the umbilical cord: 2 arteries and 1 vein
• •A = Artery, V = Vein, A = Artery

GENITALIA

• •Female: blood-stained discharge may be present due to a sudden decrease in estrogen; labia majora might be swollen and prominent
• •Male: hydrocele (excess fluid in the scrotum)

SKIN FINDINGS

• •Skin should have creases on hands and feet; more creases indicate an older gestational age
• •Stork bites: on the nape of neck, nose, eyelids; dark red to pale pink
• •Port-wine stain (nevus vasculosus): typically on the face, flat, red-purple, technically a capillary angioma below the skin
• •Mongolian spots: on the back and bottom, black to blue, flat with wavy borders and irregular shape, more common in darker races (African, Asian, Native American)
• •Erythema toxicum: normal newborn rash, red spots that pop up and move to different spots
• •Acrocyanosis: blue extremities, normal for the first few days
• •Lanugo: fine body hair
• •Harlequin sign: red/pink on one half of the body while the other half is normal or pale; indicative of cardiac issues or sepsis
• •Milia: small white sebaceous glands, typically on the face
• •Vernix caseosa: a protective, white, cheese-looking substance

WHAT IS IT?

This card covers the newborn assessment, including normal measurements, the APGAR score, medications and labs, and possible complications during delivery.

NORMAL MEASUREMENTS

• •Weight: 6 to 10 lbs
• •Length: 18 to 22 in
• •Head circumference: 33 to 35 cm
• •Chest circumference: 30 to 33 cm

MEDS AND LABS

• •Vitamin K: prevents hemorrhage
• •Optic antibiotic: prevents newborn blindness
• •PKU (phenylketonuria) level: within 24 hours after feeding begins
• •Coombs' test: if mother is Rh-negative
• •Immunizations: Hep-B (hepatitis B) can be given

PHYSICAL ASSESSMENT

• •Fontanelles (soft spots): anterior (diamond-shaped), posterior (triangular)
• •Mouth: assess for cleft lip or palate
• •Heart: assess for murmur
• •Respirations: assess breathing
• •Umbilical cord: 1 vein, 2 arteries, clamped
• •Genitalia: male, testes palpable; female, discharge of blood or mucus is normal
• •Extremities: equal length

APGAR SCORE (scored at 1 minute and 5 minutes; 8 to 10 normal, 4 to 6 moderate depression, 0 to 3 needs aggressive resuscitation)

Appearance:

• •2: pink torso and extremities
• •1: pink torso, blue extremities
• •0: blue all over

Pulse:

• •2: greater than 100
• •1: less than 100
• •0: absent

Grimace:

• •2: vigorous cry
• •1: limited cry
• •0: no response to stimulus

Activity:

• •2: actively moving
• •1: limited movement
• •0: flaccid

Respiratory effort:

• •2: strong loud cry
• •1: hypoventilation, irregular
• •0: absent

POSSIBLE COMPLICATIONS DURING DELIVERY

• •Meconium aspiration
• •Cord presentation
• •Breech presentation
• •Limb presentation
• •Postpartum hemorrhage

WHAT IS IT?

Chorioamnionitis is an intrauterine (inside the uterus) infection of the chorion, amnion, or fetal membranes. It is classified by high maternal fever, fetal tachycardia (fast fetal heart rate), maternal tachycardia, or foul smell.

Causes:

• •Intrauterine or invasive procedure: cervical exams (foreign body inserted causing infection), amniocentesis (a foreign needle inserted into the sac), prolonged rupture of membranes (more chance for bacteria to enter)
• •Can result in endometritis and sepsis (whole-body infection)

ASSESSMENT

Diagnostics: fever over 100.4 F plus two of the following:

• •Leukocytosis (high white blood cells)
• •Maternal tachycardia
• •Malodorous (foul-smelling) amniotic fluid
• •Fetal tachycardia

Monitor mother and fetus for signs of sepsis or fetal distress:

• •Maternal tachycardia
• •Maternal temperature
• •Fetal tachycardia or decelerations

MANAGEMENT

• •Draw blood cultures promptly if suspected, BEFORE antibiotics are started
• •Mother treated primarily with ampicillin and gentamicin
• •After delivery, the infant might also be treated depending on symptoms

TEST-TAKING TIPS

• •Deal with patients rather than with machines.
• •Avoid answers with: never, always, must, "why?", "I understand".
• •If two answers are opposites (for example hyper- vs. hypo-), one is usually correct.
• •Do not leave the patient alone.
• •Choose physical over psychological.
• •If you do not know the answer, pick the one with the most information.
• •Use ABC (Airway, Breathing, Circulation) except in emergencies, distress situations, and CPR.

PRIORITIZATION COMPARISONS

• •Assessment vs. Implementation
• •Acute vs. Chronic
• •Stable vs. Unstable
• •Expected vs. Unexpected
• •Real vs. Potential
• •Odd man out

DELEGATION

Do not delegate (PACET):

• •Planning
• •Assessment (initial)
• •Collaboration
• •Evaluation
• •Teaching

UAPs cannot be delegated:

• •"EAT" tasks, medication, and unstable patients

LPNs:

• •Cannot be delegated anything related to blood
• •Are assigned the most stable patients

CONVERSIONS

• •1 tsp = 5 mL
• •1 tbsp = 3 tsp (15 mL)
• •1 oz = 30 mL
• •1 cup = 8 oz
• •1 pint = 2 cups (16 oz)
• •1 quart = 2 pints (32 oz)
• •1 gr (grain) = 60 mg
• •1 kg = 2.2 lbs
• •1 g = 1 mL (diapers)
• •F = (C x 1.8) + 32

NORMAL VALUES

• •Temperature normal range: 98.6 F plus or minus 1 (37 C plus or minus 0.5)
• •MAP (mean arterial pressure): (systolic + 2 x diastolic) / 3; normal 70 to 105 mmHg (greater than 60 mmHg)
• •CVP (central venous pressure): 2 to 8 mmHg; CVP can indicate right ventricular failure or fluid volume overload

WHAT IS IT?

This card defines key ethics and legal terms in nursing.

TABLE

• •Veracity: truth, an essential part of a therapeutic relationship between a health care provider and patient
• •Beneficence: the duty to do good; an obligation to help the patient
• •Nonmaleficence: the duty to do no harm
• •Tort: litigation where one person asserts that an injury (physical, emotional, or financial) occurred because of another's actions or failure to act
• •Negligence: harm that results because a person did not act reasonably
• •Malpractice: professional negligence
• •Slander: character attacked and spoken in the presence of others
• •Assault: an act in which there is a threat or attempt to do bodily harm
• •Battery: unauthorized physical contact

WHAT IS IT?

This card lists common health and cultural considerations for several groups in the United States to help guide care. These are general patterns, not rules for every individual.

CULTURAL CONSIDERATIONS

African Americans:

• •Higher incidence of high blood pressure and obesity
• •High incidence of lactose intolerance

Arab Americans:

• •May remain silent about STIs (sexually transmitted infections), substance abuse, and mental illness
• •After death, the family may want to prepare the body; autopsy is discouraged unless required by law
• •Use same-sex family members as interpreters

Asian Americans:

• •Believe in the yin/yang "hot-cold" theory of illness
• •Sodium intake is generally high because of salted and dried foods
• •Usually refuse organ donation
• •May nod without necessarily understanding

Latino Americans:

• •Family members are typically involved in all aspects of decision making, such as terminal illness
• •May see no reason to submit to mammograms or vaccinations

Native Americans:

• •Diet may be deficient in vitamin D and calcium because many have lactose intolerance or don't drink milk
• •Obesity and diabetes are major health concerns

WHAT IS IT?

This card lists religious considerations that affect care and diet, plus the correct order of physical assessment.

RELIGIOUS DIETARY AND CARE CONSIDERATIONS

• •Jehovah's Witness: no blood products should be used
• •Hindu: no beef or items containing gelatin
• •Jewish: special dietary restrictions, use of kosher foods
• •Adventists: no pork or alcohol, and sometimes no meat
• •Muslims: no pork or alcohol; people with chronic illnesses and women who are pregnant, breastfeeding, or menstruating do not fast during Ramadan

ORDER OF ASSESSMENT

1. Inspection

2. Palpation

3. Percussion

4. Auscultation