NCLEX REVIEW PEDIATRICS - Physiological Integrity Congenital Heart Defects Cyanotic-right to left shunt Acyanotic-left to right shunt Ventricular Septal Defects-heart failure & murmur Ss: scalp sweating & sudden weight gain Surgical Repair: purse-string approach or patch sewn over the opening VSD – closes before 1 year of age Coarctation of the Aorta - Narrowing of the aorta Ss: bounding pulses Atrial Septal Defect- an opening bet the right & left atria Left atrium over powers the right atrium Ss: fatigue & dyspnea upon exertion - surgery before age 5 Patent Ductus Arteriosus- like a traffic jam of blood Ss: heart failure, machinery like murmur Asymptomatic Pulmonic and Aortic Stenosis Pulmonic - pulmonic valve located in the right ventricle - asymptomatic,heart failure - murmur & enlarge heart Aortic- decrease CO2,murmur & heart failure - opening in the left ventricle
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NCLEX REVIEW
PEDIATRICS - Physiological Integrity
Congenital Heart Defects Cyanotic-right to left shuntAcyanotic-left to right shunt
Rheumatic Fever- cause by beta hemolytic strep infectionss: tachycardia,rash,fever,chest pain migratory large joint pain,chorea & skin nodules.*administer penicillin until age 21
Kawasaki Disease- vasculitis infection of the small vesselsss: dry red cracked lips,rashes arms & legs conjunctivitis,strawberry tongue, peeling skin on the palms & soles of feet high fever, unresponsive to antibiotic,
impaired swallowing,coronaryaneurysmGamma Globulin IV 400mg/kg/day x weight in kgLive attenuated vaccine must delayed-polio,MMR
Down SyndromeSs: almond shape eyes,short broad neck protruding tongue,low set ears,broad hands w/ simian crease
GERDSs: frequent or persistent cough,heart burn abdominal pain,recurrent aspiration,anemiaMain concern: airway obstruction,fluid and Electrolyte imbalance & apnea
Pyloric StenosisSs: mild vomiting turned into vomiting that shot across the room,palpable mass RUQ, hungry,crying
Hirschprung’s Disease- part of bowel there is no nerve cells,
no peristalsis in the section of the bowelss: constipation,foul smelling ribbon like stool abdominal distention
- diagnosis established until infant is 6-12 months old- 10x more common in girls than boys
Epilepsy- chronic seizure disorder asso. w/
recurrent unprovoked seizures.
Spina Bifida- a congenital malformation of spinal column- many areas of the central nervous system may not develop or function adequately.
Ss: club feet,hip dysplexia,latex allergy or sensitivity
Scoliosis- affects female 10-13 yrs. Old- brace must be worn 16-23 hrs a day,7 days a week from 6 mos to 2 yrs to correct- after surgery flat position, log rolling
ss: assymetrical hemline,unequal leg lengths, morethan 5 degree deviation on scoliometer
Cerebral Palsy- abnormal muscle tone & coordination,spastic movement in one or more extremity, and disturbances in gait & abnormal posture.
*ORTALENIS- click hip dysplasia,head of femur displaced fromacetabulum,unequal leg lenght
Bronchiolitis- bronchioles become inflammed- cause by a Respiratory Syncytial Virus RSV- RSV- high affinity for respiratory tract mucosa- prevalence in winter & spring
*Ribavirin – antiviral used to treat bronchiolitis Caused by RSV
VIR meds means antiviral
Ss: wheezing in auscultation
Intussusception- nephrosis of bowel tissue- commonly occurs in male 3 & 5 yrs. old
Celiac Disease- poor food absorption esp. gliadin- patient unable to digest gliadin a by product of gluten*Serum anti-gliadin antibody- diagnostic test for
Celiac disease*Gluten Sensitive Eneteropathy- other name
Ss: vomiting,diarrhea pale & watery,abdominal distention,foul smelling stool
Diet: No B.R.O.W, iron supplements,vits ADEKin water soluble
Cleft Lip and Palate
- cleft lip repair at 2 months- cleft palate repair at 2 years
Sickle Cell Disease- cell halfmoon shape, blood O2 decrease- common to African-Americans- cause of anemia- an imbalance bet. Red cell destruction & production- 12 to 20 days RBC life span- avoid overheating during physical activities
Ss: hypoxia, organ dysfunction due to ischemia and infarction,painful episodes
Esophageal Atresia & Tracheoesophageal Fistula- infants do not have meconium because saliva cannot enter the stomach
ss: 3 C’s – coughing, choking & cyanosis
Tonsillitis- inflammation of tonsils, hinders swallowing and breathing
- hydrop’s fetalis a serious hemolyticreaction baby experience severe anemiacardiac decompensation,edema
- Rhogam can give to mother w/ Rh+ baby,After spontaneous or induced abortion,Amniocentesis or chronic villi sampling,Bet 28 & 32 weeks of gestation,RH- withBleeding episodes.
- Serum bilirubin normal values .2 to .6- Golden-colored amniotic fluid is severe
Fetal disease asso. w/ Rh factor- Direct Coomb’s test is done w/ the
motherto measure the number of antibodies inher bloodIndirect Coomb’s test is done on baby it tells if there are any antibodies stuck tothe red blood cells.
Newborn Care
- Ballard scale, a newborn assessmentmaturating scale
- Respiratory Rate 30 to 60 breaths/min with 10 seconds apnea
- Red reflex test serious visual defects isperformed in small dark room looking at the retina there’s a red reflex equally red to roll-out any defects of cornea.
Monitoring/testing: BNP & hemodynamic monitoring- Cardiac marker for CHFEchocardiogram & Chest X-rayAllen’s test
Myocardial Infarction
Ss: shortness of breath, crushing pain that radiates to his neck and left arm decrease CO2, increase WBC, increase temp. ST segment depression, T wave inversion,Q
waves
Laboratories/testing:CPK MB, LDH, Troponin q8 hrsCoronary arteriogram & 12 lead EKGMUGA Scan-used to measure heart function bydetermining the ejection fraction, this is thepercentage of blood ejected from the heart w/
each beat
Management:MONA- Morphine-Oxygen-Nitroglycerine-ASAFibrinolytics- are used to dissolved clots &
reduced the size of infarction- must administered 6 hrs post MI- before administered insert 2-3 large bore
peripheral IV’s - monitor for bleeding, neuro vital signs
watch rhythmPTCA- procedures performed on a double
vessel disease.
Anti-embolism stocking- to prevent venous stasisand thrombophlebitis.
Repolarization- ventricles are resting & then fill up with blood
SS: tenderness and warm to touch, increasepain with ambulation,no pulse to the affectedextremity, dull ache in calf, one side swelling,heavy sensationCauses of DVT: CHF,MI,obesity,fractures,sepsisHematological disorder,pregnancy,malignancies,Immobilization
Treatment: Doppler of the lower extremities,Venography- due to any clog artery
Hypertension
Buerger’s Disease
SS: numbness & tingling sensation of the toespale finger tips, weak peripheral pulses,ischemiculcerations, intermittent claudication
Thoracentesis- removal of fluid from pleural space 50cc
H2OProcedure: take chest x-ray & vital signs
position the client sitting up over bedside table or lying on unaffected side with HOB at 45 degree tell client not to cough,breathe deeply or move during the procedure
Chest Tubes- reestablish a negative pressure- done when there is a fluid build-up in lung- lung cllapse- spontaneous collapse- Fluctuation will occur when the suction is
working properly- bubbling becomes continous,vigorous or
excessive it means there is an air leak inthe system
- inserted at 2nd ICS at the midclavicularline
Tension Hemothorax- complete collapse of the lung- an be fatal as the accumulating pressure compresses vessels decrease venous return and decrease cardiac output
Hemothorax – is a collection of blood in the pleural cavityPneumothorax – is a collection of air/gas in the pleural
- it destroys alveoli- it narrows & collapses small airways- it causes the lungs to lose elasticity
Tx: high in carbohydrates, increase fluid intake
As alveolar wall dies, there is less surface for gasexchange
Asthma
Types of asthma:1. Emotional – cause by person2. Extrinsic – caused by dust,mold,pets3. Intrinsic – common cold, allergens
4. Mediated
PneumoniaTuberculosis
Endotracheal Tube
Goal: to position the end of ETT 2 cm above the bifurca-
-tion of the lungs or the carina
Special Double Lumen ETT – have been developed for lung -and other intrathoracic surgery -this tubes allow one lung ventilation while the -other lung can be collapsed to make surgery -easier. -ETT with a suction port are proven to decrease - the amount of bacteria which could possibly -grow in the secretions
Acute Respiratory Distress Syndrome
-alveolar spaces are filled with fluid-prone position, it makes more alveoli accessible
-ABG indicators if ARDS is improving.
NEUROLOGY – Physiological Integrity
Neurological Assessment
Frontal Lobe- damage, changes in behavior
Neurological assessment:
Mental Status- most important indicatorPupillary changes- 2-6mm normal pupilMotor strength & coordinationCorneal assessmentVital Signs- widening pulse pressure when there is
Increase ICPMovement- is the lowest move, speech is the highest
level of brain neuro function
Noxious Stimuli Reaction- the client will pull away from pain
Oculocephalic Reflex test (doll’s eye reflex) & Oculovestibular Reflex test (Ice waterCaloric test)– performed assessing Brain Stem Function
Babinski Reflex – stroked on the lateral part of foot of an infant
under 1 year old + is ok, - is bad over 1 year old + is bad, - is ok
Negative- curled downPositive – curled up
Reflex table – 0 = absent1+ = present,diminished2+ = normal3+ = increase but not necessarily
pathologic4+ = hyperactive
Computed Tomography CT Scan- identify certain lesions- takes pictures in slices- he will need to take his head still- consent due to the dye
Magnetic Resonance Imaging MRI
- identifies abnormalities in soft tissue
- using a magnet last to 1hour- client must void prior to exam- clients w/ claustrophobia cannot receive
this exam- clients can talk & hear during the scan- client will hear a thumping sound
Cerebral Angiography
- catheter inserted w/ a dye to the brain- consent due to the dye- metallic taste in mouth- warm sensation during the procedure- clients well hydrated during the
procedure.Complications:
- risk of embolus- check for pulse, hematoma & change in
LOC- 12-24 hours of bed rest
Myelogram- is an x-ray of spinal & sub arachnoid
space- air & water base- NPO 8-12 hours- Does not require a heavy sedative- Dye is injected to sub arachnoid space- Trendelenburg position for Air - 30 to 50 degrees for water- Must be flat in 6-8 hrs.
After procedure observe for the Signs:
Stiff neck & chillsBrudzinski’s sign- when neck is flexed your knee & hips is
also flexed.Kernig’s sign- flex the knee the opposite leg cannot extendPhotophobia & headache
Electroencephalogram EEG
- diagnose seizure disorder- records the electrical activity of the brain- helps in screening for a coma- 3 flat EEG reading indicate brain death
Nursing care:
- put patient in dim light & quiet room- no caffeine alter the results- no sedatives 2-3days prior alter the result
hold sedatives
Pre-procedures:- medicated w/ a mild sedative- may have not caffeine- eat a light breakfast- we may flashlights in the face
Lumbar Puncture
- performed when patient is on unexplained fever and elevated WBC
- invasive procedure- punctured site is 3rd & 4th lumbar sub-
arachnoid space- knee chest position, fetal position lie on
right side- 4-8 hours flat on bed to prevent spinal
Headache, post procedure- Fluid &blood patch- pull out blood use it &
inject at pain area- Normal CSF- clear, no RBC- Abnormal CSF- cloudy, increase protein,
& WBCPerformed when: check for blood, measure pressures,admi-
-nister drugs intrathecally.
Brain Herniation
- cause a sudden decrease of ICP
- the brain tissue is pulled down through theforamen magnum
Epidural Hematoma
- arterial bleed- gain & lost of consciousness for minutes- pts. See stars
Tx: burr holes,remove the clot and control ICP
Subdural Hematoma- venous bleed
Acute & fast – s/s bet. 24 to 72 hours after slow bleed, non- acute bleed
Tx: remove clot to control ICPSub-acute - s/s bet 72 to 2 weeks w/ rapidChronic
Scalp Laceration- infections is the problem
Skull Injury
- may or may not damage the brain
ss: Battle sign-bleeding over the mastoidRacoon eyes-peiorbital bruisingCerebrospinal rhinorrhea
Basal skull fracture- bleeding from eyes, ears, nose, throatfracture at the base of the skull
Open fracture – dura is tornDepressed fracture – is usually require surgery
Concussion
Ss: headache, dizziness, seeing spotsdiff. waking up or speaking, confusion, severeheadache & vomitting
Contusion- the brain is bruised w/ a possible surface
hemorrhageAlzheimers
- progressive disease, irreversible, loss of cerebral function due to cornical atrophy- begins 40 to 65 y.o. , 8 to 10 years onset to death
Early stage- memory loss, subtles personality,diff of abstract
thinkingMiddle stage- language is impaired, difficulty w/ motor
activity Final Stage- complete loss of languageRohin’s stage- loss of bowel & bladder control
Ss: progressive decline in recent & remote, aphasia,agnosia cannot recognized memory, cannot learn new things, recall, recognized information
Nsg. Management: promote clients independencePromote contact with realityEstablish a routine
abdomen,bruising around umbilical or flank area, ascitis, abdominaldistention
-worsen after eating & lying flat-decrease hemoglobin & hematocrit-alcohol consumption is the number one cause-no morphine can cause spasm of odi spinchter-give calcium supplements
Fecal occult blood- blue litmus paper signs of bleeding
tenden- cies,-risk for esophageal varices & portal hypertension-increase bilirubin in urine & increase SGOT & SGPT-decrease serum albumin & cholesterol-impaired aldosterone metabolism results to edema-providing thiamine & B12-bleeding precautions, avoid Im injections & aspirin-measure abdominal girth-do not give narcotics-diet must be low in protein & sodium
Diverticulitis-small inflamed protruding sacs in the colon that have ruptured-causes impacted stools, history of constipation, Low fiber & high carbohydrates
ss: left lower quadrant pain,chills,fever,nausea andvomiting
Hepatic Coma-is diagnosed by examining the serum ammonia level-prescribed lactulose (Cephulac) & Neomycin SO4-decrease protein in the diet,monitor serum ammonia
Bleeding Esophageal Varices-liver is damage and that collateral circulation has
formed into 2 of 3 places are rectum,stomach& esophagus
-portal hypertension, increase blood in the liver-coughing & straining can cause rupture of the
Varices-Sandostatin-works to lower the BP in the liver-Sengstaken Blakemore tube in the bed side-administer oxygen
Ss: black tarry stools,paleness,lightheadedness
Ulcerative Colitis-inflammation of ascending colon & rectum-condition affecting the large intestine-low fiber diet to limit motility-avoid meals that are cold-steroids to decrease the inflammation
Ss: rectal bleeding,diarrhea,bloody or mucosy stoolfever & loss of appetite,constipation,weight lossanemia,rebound tenderness
test: colonoscopy,barium enema,sigmoidoscopyCBC
Schilling Test- to test Vit. B 12 in urine
Koch’s pouch- ileostomy, there is internal reservoir(stoma & bag)
Colostomy- permanent stoma is red/pink - irrigate sametime everyday after meal
Ileostomy - temporary don’t irrigate as much- no raw vegestables,nuts,grains & peas
Chron’s Disease-iflammation or ulceration of digestive tract,chronic & relapsing
ss: blood in stool,rebound tenderness,cramping & dehydration,anemia,diarrhea w/ steatorrhea,cramping after meals,abdominal pain,vomiting& fever
Partial Bowel Resection – to allow the intestine to rest and heal
Transvers- semi-soft stoolDescending – formed stoolAscending – liquid stool
Appendicitis
-associated w/ diet low in fiber-elevate head of bed after any abdominal surgery
Ss: increased WBC,sharp pain on right side,nausea &Vomiting,rebound tenderness
Ulcers-pain that is worsenes w/ food-pain & burning worsend at night & lying down-mainly found in males-can be found in the stomach,esophagus,duodenum-avoid spicy foods & caffeine,stop smoking-avoid extreme temp hot or cold
Gastric ulcer-pain 30 mis. to 1 hour after eating mealwhen vomit the pain subsides.
Duodenal ulcers- pain 2 to 3 hrs. after eatingas long there is food in stomachtheres no pain
Gastrectomy- give vit B12 for lifeBillroth I – portion of stomach connect to duodenumBillroth II – large potion of stomach connect to
duodenum
Peritonitis-board like abdomen,low urine output,,nausea & vomiting
Dumping Syndrome-increase circulation of stomach-give complex carbohydrate,avoid simple carbohydrates, high fiber-is more common in Billroth II-recumbent position, drink bet meals-lie left side after meals,eat high fat & protein-decrease stress
Ss: cramping,diarrhea,weakness
Hiatal Hernia-the hole in the diaphragm is too large,the stomach
moves up into the thoracic cavity-small protrusion close to the navel-causes, congenital abnormality,trauma,surgery-small frequent meals,elevate head of bed,take small
bites,avoid spicy foods
Ss: abdominal mass soft can be palpate w/ out pain,fullness after eating & regurgitation
Hyperalimentation TPN
-need to change the tubing with each bag every 24 hours
-can be hung for 24 hours-taper off TPN when discontinuing-needs to be check by 2 nurses before each bag is
hung-put in pump-other medications cannot be infused, only insulin,
Lipids, K+-can be mixed daily-IV bag should never be covered-infection can be frequent complication
Laboratory values to be monitored:
Blood glucose,ketones,BMP,magnesium
Dobhoff Tube-a small bore NG feeding tube not attached to suction-more comfortable & less complications-can remain place for weeks
Central Line
-have client in trendelenburg-rolled towel to middle of back-air from getting in the line,clamp it off-cap the end of tubing,cover the end w/ syringe-position the patient on the left side in case air
will get into the line-post insertion chest xray performed to ensure
proper placement-10ml syringe use in central line
Diagnostic Tests
Barium Enema-drink clear liquids-take laxatives or enemas until clear-ensure post procedure bowel movement
Liver Biopsy-PT/INR,PTT prior to procedure-position pt supine w/ hand behind head-have client lie on affected side for 8 hours
post procedure
Paracentecis-have pt. sit in high fowlers position-have pt. empty his bladder prior to procedure-the fluid removed will be yellow-monitored for signs of shock
GENITOURINARY – Physiological Adaptation
Benign Prostatic Hyperplasia-frequent waking at night to urinate-urination
-serum PSA & urinalysis-PSA secreted by pituitary gland
Medicines:Prazosin (minipress) – helps the urination urgencyDoxazosin (Cardura) – helps the symptoms of BPH
Prostatectomy- normal to pass urine in blood tinged &blood clots & tissue debris
Percutaneous Renal Biopsy-instruct the pt to restrict food & fluids for 8 hrs
before the test-administer mild sedatives 30 to 1 hour before
procedure-check vital & inform pt. to void before procedure-place pt in prone position-observe for bleeding & hypotension
Nephrotic Syndrome-leaking of the protein into the urine-perform U/A,glucose tolerance,serum protein,
Serum albumin,renal biopsy-edema,swelling around eyes,extremities & abdomen-circulating blood volume decrease causing kidney toactivate its Renin Angiotensin cascade,aldosteroneis produce to retain sodium & H2O-Corticosteroids,prednisone & Diuretics drug of choice
Acute Glomerulonephritis-sorethroat,headache & lower back pain-protein in the urine,increase BUN & creatinine,
hematuria & hypertension-strep infection is the main cause-common bet age 6 to 7 yrs. old-antibiotics,bedrest & increase carbohydrates in diet-decrease protein & sodium in the diet and dialysis-reddish brown urine
Renal Failure-sudden loss of kidney function resulting in electrolyte
imbalance 7 retention of nitrogenous substance-during oliguric phase the patient is in a fluid volume
excess-diet should be in high carbohydrates-low protein,sodium,potassium & phosphorous
Hemodialysis-access route are: External AV shunt,fistula,femoral/
Subclavian cannulation-fistula access 3 months to mature-must be done 3-4 times a week-during treatment period monitor for: depression,
suicidal tendencies,electrolytes & BP-bruit & thrill must be assessed before accessing
hemodialysis access ports-cathflo must be used if pt allergic to heparin-decrease protein, sodium & potassium in the diet-pt. w/ unstable cardiovascular system cant tolerate hemodialysis
Peritoneal Dialysis-ambulatory-dialysate is warm to increase blood flow-patients who get peritoneal dialysis cannot tolerate hemodialysis-possible complications are: peritonitis,respi. Diff.
protein loss-cloudy drainage,there is an infection, it should be
pinktinged color
-if the fluid does not come out, turn the pt side to side
Intravenous Pyelogram-NPO 8 hrs before the test
-sitting straight up during procedure-after procedure, increase fluids,apply warm soaks if
hematoma develops
Cystoscopy-involves a lighted scope which is used to visualize the
bladder-consent, anesthesia, a sedative and enema can be
used-used to diagnosed & evaluate urinary tract disorder,
enlarged prostate,recurrent bladder infection-notify doctor if there is still blood in the urine after
3 days -expect burning on urination
Ultrafiltration-only pulls off water-has the same principles applied as hemodialysis-may be utilized w/ peritoneal dialysis or hemodialysis
Kidney Stones Renal Calculi-KUB & IVP-increase fluid intake and modify his diet,avoid high
contain of calcium & oxalate-strain his urine
Calcium Oxalate: beer,rhubarb and wheat germ, spinach
chocolateCalcium Phosphate: milk & milk products, foods high
incalcium, meats, grains &
cranberryUric Acid: avoid Vit C supplements, corn & lentils
EXtracorporeal shock wave lithotripsy (ESWL)
Pelvic Inflammatory Disease-history of menses,sexual habits, contraceptives
Used
-look for signs of hypovolemia,hypotension & fever