nclex notes from june2013 test

7/27/2019 Nclex Notes From June2013 Test

1/19

Airborne:

Measels

Chicken pox/ varicella

Herpes zoster/ shingles

TB

Bird flu

Private room, negative pressure, 6-12 air exhanges per hour with HEPA filter, respiratory protection

device N95. Talk minimum, wet mask doesnt protect.

Droplet:

Scarlet Fever

Streptoccocal Pharyngitis

Pneumonia

Pertussis

Influenza

Diptheria

Respiratory suncytial virus

Rubella

Meningicocal disease

Mumps

Private room or cohort client, mask or respirator required

Contact:

MRSA

RSV

VRE

C DIFF

Scabies

Hep A if pooping

Herpes simplex

Salmonella

Shigellosis

Staph

Private room or cohort clients, gloves, gowns

Standard:

HIV

HEP B

HEP C

Rotavirus

Protective Enviroment


2/19

Neutropenic patients

Private room , positive pressure with 12 or more air exchanges per hour, HEPA filtration, respirator mask

gloves and gowns

Dont delegate what you can EAT (Evaluate, asses, teach)

PVD- Remember DAVE- Dependent Arterial, Venous Elevated

1 gram of diaper weight= 1mL of fluid

Multiply weight in kilograms by 30 to get the amount of fluid people need daily

BMI: 18.5-25 is normal

Sterile procedure- open away from body first

Surgical asepsis- scrub nails 15 strokes and fingers with 10 strokes per side. Rinse from finger to elbow

Wash hands and rinse for 15 seconds in warm water

Koplik spots- small red spots with blue center. Measles.

Anthrax- tx with abx x 60 days

Mag Sulfate- monitor UO, dont give 2hr before delivery

Postpartum- Temp elevated x24hrs, HR decreased x1 wk

Forceps- can lead to hematoma

BPP- checks breathing, body movements, fetal tone, reactive FHR, Amniotic fluid volume

Amniocentesis- Check for fetal anomalies (down syndrome, Trisomy 13&18), Fetal maturity and LS

ration to assess fetal lung

maturity. Give rhogam if pt Rh negative

Chorionic Villi Sampling- check for fetal anomalies and genetic defects can be done at 18wks

Maternal Alphafetoprotein Samplin- Low levels= Down Syndrome, High= Neural tube defects. Done at

16-28 weeks gestation


3/19

Contractions should be 2-3min apart for 60 sec. If < 2-3 min and >90 sec d/c PIT call dr.

Birth weight doubles by 6 months and triples by 1 year

Physiological jaundice- ok noted after 25hrs, peaks on day 5

Pathological jaundice- bad- noted before 24hrs after birth

Hyperbilirubenia: = is a level >12mg/dL

Neonate FBS levels: 40-60 first 24hr, then 50-90 after 25hrs.

NL UO for infant- 1-2ml/kg/hr

Acute infectious diarrhea (infectious gastroenteritis)- is a result of various bacterial, viral, and/or

parasitic infections. The onset of gastroenteritis is often abrupt with rapid loss of fluids and electrolytes

from persistent vomiting and diarrhea

Infant born with RDS at r/f pneumothorax, give Exosurf (surfactant) to prevent

Reyes syndrome- acute encephalopathy- Dx with liver bx. Linked to aspirin in children.

Spinal bifida- neural tubes didnt close. No diapers, prone position

Bacterial meningitis- cloudy CSF with increased protein and decreased glucose.

Goodells sign- softening of cervix

Chadwicks- purpleish color of vagina

Fetal HR PMI- breech: above BB midline. Cephalic and Face presentation: lt or rt side of uterus below BB.

Transverse: below

BB midline. Vertex near symphysis pubis

Saturate 1 pad per hour= hemorrhage

Epiglottitis- secondary to flu or strep. Abrupt onset. Medical emergency. Kid drools. Tripod position. Put

Nothing in mouth. Give cool moist oxygen

Laryngotracheobronchitis- RSV. gradual onset, cool vaporizer.

Cystic fibrosis- resp failure. Deficient in Vit A,D,E,K. give lots of calories and protein


4/19

Rheumatic fever- preceded by strep

Status epilipticus- child may need intubation

Scoliosis- gradual curvature change of the vertebrae that may go unnoticed by parents.

CPT- in children should be done 1hr before meals. Give albuterol before doing it.

Rubella virus- can cause cleft lip

Cleft lip- suction stuff at bedside. Elbow restraints post op

Transesophageal fistula- 3 cs: chocking, coughing, cyanosis. Frothy saliva. R/f ASPIRATION. NPO. IV fluid

Hypertrophic pyloric stenosis- visible peristalsis. Projectile vomiting. Olive mass on right side.

Celiac disease- give iron, folic acid, vit ADEK

Appendicitis- pain in RLQ. Perforated= relief of pain then more pain. NO HEAT! Can rupture

Appendectomy- post op- no pain meds or heat and no enema or laxative. Apply ice only. Lay on R side.

NPO until BS return

Hirschprung aka megacolon- watery explosive diarrhea. Ribbony stools. No meconium. Give low fiber.

Chrons- no bleeding. Pt needs diet high in protein and calories and low in fiber

DKA- rehydration with NS!

Glomerolunephritis- STREP! Cloudy, smoky, brown urine.

Nephrotic- massive proteinuria. Dont give salt.

Sickle cell anemia- NO DEMEROL! Give morphine or dilaudid. Treat crisis with O2, hydration, pain med

and rest

Aplastic anemia- bone marrow not making WBCs, platelets, and/or RBCs. s/s: hypoxia, fatigue, pallor,

increased infection, hemorrhage, ecchymosis, petechiae, Pancytopenia. Give immunosuppressive

(prednisone and cyclosporine, or Cytoxan) and bone marrow transplant. Protective isolation.

Pernicious anemia- Vit B12 deficiency. Diagnosed through a Schillings test, measures UO of Vit B12. Will

get Vit B12 shot once a a week for 1 month then monthly for life.


5/19

Hemophilia- give factor VIII

Hodgkins disease- reed strenberg cells. Painless node near clavicle first sign.

Wilms tumor- measure abdominal girth daily. No palpation

Spider bite- ice

Snake- no ice. Level below heart. No movement of extremity

Burns- low Na and High K occurs. S/S shock. Fast HR low BP and Low CO. Hct high initially. Will gain 20lbs

the first 3 days. Antacids daily. Wt qd. Use sterile sheets

Cellulitis- warm compresses

Brachytherapy- pt emits radiation to others

Cancer- high temp is always serious!!

Mastectomy- pt should wear gloves on the affected side .

Multiple myeloma- abn plasma invades bone marrow. Produce abnormal antibody called bence jones

protein. High uric acid and Ca lead to renal failure. Get osteoporosis. Give fluids. Move carefuly.

Tumor lysis syndrome- tumor cells destroyed and uric acid and K leak into blood. Give IV fluids and

diuretics. Give allopurinol.

Give insulin and glucose to treat hyperkalemia. Emergency! Leads to electrolyte imbalance and renal

failure!

Aldosterone- always think Sodium and Water

ADH- think water only

Adrenocorticotropin Hormones (ACTH) and cortisol= same thing. Hormones of adrenal cortex.

Addisons- too little Aldosterone, pt has low sugar and Na with high K and Ca. Aldosterone makes you

retain Na and Water but they dont have any so theyre loosing Na and H2O fatigue, muscle pain,

weakness, joint pain, chronic diarrhea, N&V, diminished libido, hyperpigmentation, low BP, Pt is fluid

volume deficient. At risk for anemia need lifelong glucocorticoids(Florinef). High protein & carb.


6/19

Addisonian crisis-severe hypotension and vascular collapse. Sudden extreme weakness, severe abd,

back, & leg pain, hyperpyrexia, coma, death. Secondary to infection, trauma, surgery, stress, PG. goal is

to prevent irreversible shock and severe hypotension. May require IV steroids and respiratory support.

Cushings- too much aldosterone. pt has high sugar and Na with low K and Ca. Pt has HTN, upper body

obesity, thin extremities, moon face, buffalo hump, neck fat, hirsutism, ammenorhae, high triglycerides,

Fragile skin with purple striae, bruise easily osteoporosis. Meds: parlodel, Lysodren, Cytadren. High

protein, low carb. Put in quiet environment.

Hyperpititurism- too much GH.aka- acromegaly. Pt has lg hands, feet, deep voice. Oily skin. Need

transphenoidal hyposphectomy. Meds: sandostatin, somavert, or permax. Lower GH.

Transphenoidal Hyphospectomy- removal of pituitary tumor. Check for SIADH post op

Diabetes Insipidus-fluid volume deficit on vassopresors for life. Cant concentrate urine. have very

concentrated blood.

SIADH- s/s fluid over load. They have Low Na. give hypertonic solution. Have concentrated urine &

Diluted blood. Restrict fluids. Seizure precautions. Sodium infusions, loop or osmotic diuretics. Meds:

vasopressin receptor antagonist:s IF NA


7/19

Thyroid storm- life threatening. s/s hyperpyrexia, tachycardia, systolic hypertension. Give PTU, beta

blockers. SSKI before surgery to prevent this from happening.

Thyroidectomy- need lifetime levothyroxine and calcium. Keep trach tray, suction and O2 and IV calcium

gluconate at bed side.

Thalassemia- pt has low Hgb. Give blood transfusion. Pt is green/yellow. Has wide set eyes. Big forehead

Polycythemia vera- too many RBCs. thick blood. r/f stroke. Give fluids

Regular insulin- is the only insulin that can be give IV.

DKA- BS >300. Give IV regular insulin. Start with a bolus first then a drip. Watch K, it will drop.

Hyperosmolar hyperglycemic nonketoic syndrome- BS>800. NS alone may treat it.

Pheocromocytoma- benign tumor of adrenal medulla. The adrenal medulla produces cathecolamines epi

and norepi, with this tumor pt is producing too much which leads to- HTN!. Do 24hr urine to dx called

Vanylmandelic Test, no coffee or exercise before test. Dont palpate tumor/abdomen. Quiet

environment.

Esophageal varices- due to portal HTN. Can kill if ruptured.

Pancreatitis- NPO. Put in lying knee-chest position.

Ulcerative colitis- Vit K deficient. No milk, fiber or fruits. Patient bleeds.

Diverticulitis- give low fiber

Evisceration- put in semi fowlers position with knees bent, cover with NS gauze, call dr stat!

Dumping syndrome- early signs sweaty and pallor. Avoid sugar, salt, milk. Eat protein and fat & low carb.

Hepatic encephalopathy- eat low protein. And high cal and carb.

Barium swallow dye- causes bowel obstruction. Give lax and fluid. Chalky poop.

Gastric lavage- patient put on left side

NG insertion- pt put on high fowlers position


8/19

NG decompression or feedings- Semi fowlers position

Paracentisis- pt voids before procedure, dont want to puncture bladder.

Liver bx- put on left side during. check PT, PTT and platelets before bx. Post put on right side.

Cirrhosis- limit exercise. Limit sodium intake

Nonrebreather- gives highest concentration of O2. For pt needing ventilation.

Venturi mask- most precise

PEEP- greater than 15 can cause barotrauma or tension pneumothorax

Mechanical ventilator- pt at risk for infection esp pneumonia

ARDS- fluid in alveoli. Cardinal sign is HYPOXEMIA. treat the cause. restrict fluids. Give O2 and diuretics

Patient have Severe hypoxemia despite administration of 100% oxygen A systemic inflammatory

response injures the alveolar-capillary membrane. It becomes permeable to large molecules, and the

lung space is filled with fluid. A reduction in surfactant weakens the alveoli, which causes collapse or

filling of fluid leading to worsening edema.

COPD- ABGs show respiratory acidosis. Max O2 is 2l/min. give high cal and protein and lots of fluid.

Sever acute resp syndrome- caused by coronavirus. Contagious.

Air Embolism- treat with IV heparin

Fat embolism- early symptom: confusion. Late: petechiae over neck, upper body, chest and abdomen.

treat with heparin

Compartment- 6Ps pain, pressure, paralysis, pallor, pulselessnes, paresthesia. Meds dont help.

TB- treatment for 2-3wk then no longer contagious.

Isoniazid INH- not given to pt with liver problems

Rubeola/measles- 3Cs coryza, cough, conjunctivitis. Small red spots with blue center. Airborne pct.

Rubella /German measles- keep away from PG women. Airborne precautions

Mumps- parotid glandular swelling. Droplet/contact pct


9/19

Diptheria- bullneck-lymphadenitis. Humidified oxygen.

Mononucleosis- monitor for splenic rupture

CVP: normal 5-10= pressure in right atrium. High CVP= hypervolemia low CVP= hypovolemia. To

measure pt needs to be supine on high fowlers. You can measure CVP on patients that are receiving

bolus fluids to ensure youre not over loading them with fluid.

PAWP- NL 4-12. Measure right atrial pressure. Elevations may indicate left ventricular failure or mitral

regurgitation, intracardial shunt, or hypervolemia. Decreased means hypovolemia.

MAP- must be at least 60 for adequate organ perfusion.- SBP+2DBP/3

Pulmonary capillary wedge pressure: NL 6-12. measured when balloon inflates. Indicates Left ventricular

end-diastolic pressure. High means hypervolemia or left ventricular failure and low means hypovolemia.

Sinus bradycardia- give atropine if it doesnt work transcutaneous pacemaker. Dont give too much

atropine because pt will get tachycardia

Sinus tachycardia- HR 100-180 rhythm normal. Eliminate cause.

CD4/T4- normal levels 800-1200. 500 ok in HIV patients.


10/19

V Tach- HR 140-250, decreased CO. can lead to cardiac arrest. Tx: if pt has pulse and no s/s of decreased

CO: give O2. If pt has pulse and s/s of decreased CO give O2 and prepare for cardioversion, ask patient

to cough hard every 1-3 seconds for cough CPR. If patient has No pulse: defibrillate and CPR. Give

Amiodarone or Lido

V Fib- is fatal if not treated within 3-5 minutes, pt has no pulse, BP, heart sound or respirations. O2, CPR

and defibrillation

A fib- disorganized impulses at 350-600bpm. can lead thrombi formation causing stroke or heart failure.

No P wave visible. QRS is visible. Tx : Oxygen, Cardioversion, beta blocker, digoxin and warfarin

MI- ECG shows ST elevation and T wave inversion. Permanent abnormal Q wave.

Right ventricular failure- avoid St Johns Worth and Licorice

Cardioversion- pt on heparin 4-6 wks pre. Synchronized to R wave.

Defibrillating- turn of O2 first!

Asynchronous/fixed pacemaker- for asystole or severely bradycardic pts.

Left ventricular failure- leads to pulmonary failure- emergency!

Cardiogenic shock- failure of the heart to pump adequately. Pts BP will be lower than 90 systolic and UO


11/19

Recovery- lasts 2-3 yrs. Pees normal. Memory improves

Chronic renal failure- cardiac monitor due to high K. dont give Aldactone or Dyrenium they retain K.

Disequilibrium syndrome- decrease stimuli. Give hypertonic sol or albumin. Slow or stop infusion.

Dialysis encepholapathy- give aluminum chelating agents

Bladder trauma- pt has pain bellow umbilicus that radiated to shoulder

Glaucoma- central visual field unaffected. They lose peripheral vision, its painful. Take meds(miotics)

whole life. Meds cause pain and blurred vision.

Primary open angle glaucoma- painless, slow vision changes, tunnel vision

Primary angle closure glaucoma- blurred vision, halos, ocular erythema.

Acute angle closure glaucoma- medical emergency. Pt has N&V and pain

Cataract extraction- severe pain reported to MD stat! means hemorrhagic bleeding

Retinal detachment- pt see flashes of light and floaters, curtain drawn over eye. Painless.

Conductive hearing loss- external or middle ear obstruction. Hearing aids

Sensorineural hearing loss- pathological process of the inner ear. Usually permanent. Cochlear implants.

The hearing aids only make the sound louder not clearer

Presbycusis- a sensorinueral hearing loss that happens with age. Pts hear mumbling.

Menieres- dont give fluid or sodium. Give niacin

LP- contradicted in pt with IICP

ICP- early sign is altered LOC. Dont flex legs or knees.

Head injury- elevate HOB to prevent IICP

Spinal shock- pt has paralitic ileus

Autonomic dysreflexia- occurs after spinal shock. An emergency! s/s HA, HTN, stuffy nose,

flushing. Elevate HOB, loosen clothing, check for bladder distention. Give HTN meds. To prevent

hypertensive stroke!

Right CVA- pt has left sided neglect

CVA- keep BP at 150/100 for purfusion.

Myasthenia gravis- monitor for aspiration.

Tensilon test- puts pt at r/f Vfib or cardiac arrest. Have atropine at bed side.

Parkinson disease- depleted dopamine. Rock back and forth to move. Lay prone with pillow. Avoid vit B6

Trigeminal neuralgia- face pain. Avoid extreme temps of food.

Guillian barre- ascending paralysis. Sensitive to pain. Monitor breathing!- resp arrest is possibility.

Lou gerrighs- involves motor system. No mental changes. No cure. Leads to paralysis then Resp arrest

then death.

IICP- s/s High temp and BP, low RR and HR

Halo devices- no driving at all.

Goodpasteurs- involve lung and kidneys

Nephrostomy tube- never clamped. Report UO


12/19

LE amputation- 1st

24 hr elevate to reduce edema, bed flat to prevent contracture. After 24hr put prone

to extend/stretch and no elevation to prevent contracture.

Sprain- RICE 1st 24hrs then heat

Arthroscopic surgery- nurse can apply ice post op

Radiation- delayed until 8yo

Floater RN acts as LVN

DVT- warm moist compresses, promotes blood flow.

Pulse Ox is not accurate in CO poisoning cases because it cant distinguish between CO vs oxygen

attached to Hgb

Total protein- 6-8gm/dL

3500calories= 1 lb of weight

When pt starts on beta blocker sx of CHF will initially get worse thats ok. Ie crackles, fatigue, wt gain

COPD- caused by emphysema or chronic bronchitis. Low O2 via NC 2L/min.

K- is excreted by the kidneys so if the kidneys arent working the K cant get out so pt gets hyperkalemia

Calcitonin decreases calcium by grabing it and putting it back in the bones

Use weight to measure fluid volume adequacy, except with burns, youll measure I&O

Tetanus toxoid takes 2-4wks to develop antibodies, the immunoglobulin provides immediate protection.

Hyperkalemia happens after burns because the cells ruptured and K spills out. Monitor pt!

Electrical injury- put patient in heart monitor immediately! Pt at r/f Afib

Lobectomy- surgical side up so left over lobes can expand

Pneumonectomy- surgical side down so left over lung wont fill with water

Total laryngectomy- removal of vocal chords, epiglottis, and thyroid cartilage. Pt will have a

tracheostomy. Position in semi fowlers and provide NG feedings. Have obturater at bedside. Watch for

carotid artery rupture! Aka innominate artery, youll see the trach pulsating at the heart beat rhythm, a

medical emergency!

Tracheostomy care- suctioning is sterile and hyperoxygenate before and after. Intermittent suction on

the way out, suction for 10 seconds with 60 seconds in between times. The vagus nerve is stimulated so

the HR drops, monitor for bradycardia.

Colon cancer- diagnosed with colonoscopy. Most common signs are rectal bleeding, changes in bowel

habits and anemia

Prostate cancer- most pts will initially have s/s of BPH. The most common sign is painless hematuria.

Check PSA, should be


13/19

Developmental

2-3 months: turns head side to side

4-5 months: grasps, swith and roll

6-7 months: sits at 6 and waves bye bye

8-9 months: stands straight at eight

10-11 months: belly to butt

12-13 months: tweleve and up drink from a cup

Autonomythe right to self-determination

Beneficence taking positive actions to help others

Nonmaleficence avoidance of harm or hurt

Justice fairness

Fidelity agreement to keep promises

Veracity in general means accuracy or conformity to truth

Thiazides- not for pt with renal failure or allergies to sulfa drugs

Nicotinic acid- to lower cholesterol . causes flushing. Give NSAID 30 min before to reduce it.

TPN- used for: pancreatitis, ulcerative colitis, chrons disease, burn injury, cancer, AIDS, starvation. Its

maintained in the fridge when not in use. Hypertonic solution that should be weaned off, never shake it,

and room to warm temp priori to use

Oxazepam- Benzodiasepine given to pt with alcohol withdrawal symptoms.

Amphojel- causes constipation and tastes chalky

Amphothericin B- nephrotoxic

Adenosine- IVP 6mg FAST flush with NS. Brief asystole OK. For paroxysmal SVT

Benadryl- can be give to patients with parkinsons for tremors

Levodopa with MAOI= hypertensive crisis

Anticholinergics- contradicted in pt with glaucoma

Anticonvulsants- not taken with food or antacids

Dilantin- decreases contraceptive effect. NL level 10-20. Dont give faster than 25-50mg/min. causes

Leukopenia! Monitor WBCs

Allopurinol and colchicine- not taken with aspirin. Take lots of fluid

Synthroid- increases effects of anticoagulants

Dopamine- for shock and heart failure. Increases CO and renal perfusion. Pt will pee more.

Librium- given for alcohol withdrawal

Methadone- used to detoxify narcotic addicts.

SSKI- given pre thyroidectomy to decrease vascularity. Give in milk or juice and use a straw .

Radioactive Iodine- for hyperthyroidism. Given in 1 dose. Stay away from babies X24hr. watch for

thyroid storm as it could be a rebound effect from iodine

Tetracycline- avoid sun exposure, dont take with milk.

Carbamazepine (Tegretol)- toxic levels cause diplopia, HA, and vertigo

Metformin with alcohol= lactic acidosis


14/19

Glucocorticoids- taken with meals or antacids, may cause ulcers

Furosemide- causes ototoxicity

Priscoline- causes severe hypotension

Haldol, thorzine, mellaril are typical antipsychotics

Zyprexa, Seroquel, abilify, clozaril are atypical antypsychotics

Oral potassium should never be taken on an empty stomach

IV K should never exceed 20 mEq/hr. dont give K if pt has low UO.

Gentamycin- ototoxic, do vestibular check 4wks after discontinuation

Nitroglycerin- causes decreased preload and afterload. Pt will get a HA- give Tylenol.

Parnate- not given with Demerol

Byetta- causes pancreatitis

Isoniazid for TB should be taken for 6months

Doxycycline- should be avoided in pregnancy because it stains the neonates teeth

Salmeterol- is a maintenance drug for asthma.

Clozapine(clozaril)- causes severe tachycardia dont give if HR >140. Causes HTN and hyperglycemia.

Causes agranulocytosis so monitor WBCs

Diltiazem- IVP over 2min, can repeat in 15 min. for Afib or Aflutter

Depo-provera injection in women can cause depression if theyre already depressed

Nafcillin (Unipen)- AEs-vomitting, diarrhea, sore mouth, fever

Methimazole/Tapazole- for thyroid storm. No more than 8 wks. Causes agranulocytosis check CBCs.

Pentamidine (pentam)- causes FATAL hypoglycemia

Interferon alfa 2-a- for hep C cause flu like symptoms in the beginning.

Digoxin (in children)- dont mix with food or fluids. Signs of toxicity = poor feeding, vomiting

Sandostatin/ocreotide- for acromegaly. GI upset and gallstones.

MTX toxicity- treat with Leucovorin (wellcovorin)

Levothyroxine- on an empty stomach in the AM.

Cobalamin/ Vit B12- dose is 1000mcg Im qd x2 wks, then weekly when Hct is ok then monthly for life

Varicella Zoster immunoglobin can prevent varicella on immunocompromised pts. Usually given.

Atrovent or Spiriva not given to pts with peanut allergies.

Anticoagulants are high alert meds that need to be double checked by other nurses

Prozac doses greater then 40mg should be divided in two doses

Defroxamine- antidote for iron poisoning

Phenobarbital: 10-30mcg/mL

Vancomycin- not mixed with other medications

Neupogen- increases neutrophils WBCs in patients undergoing chemo.

Fluoroquinulones- given with lots of water to prevent crystalluria

Accutane- check triglycerides because it elevates them. Its a vit A derivative so avoid food with vit A

Cytoxan- give without food and lots of fluids to prevent cystitis

Hypokalemia ECG changes- ST depression, Inverted T wave, prominent U wave

ADH- AKA vasopressin

Ditropan- give for bladders spasms


15/19

DEFECTS WITH INCREASED PULMONARY BLOOD FLOW- CHILD SHOWS SYMPTOMS OF CHF

Atrial septal defect- opening between atria, causes too much oxygenated blood to go to rt side. So rt

atrium and ventricle get enlarged. Close with cardiac cath.

Atrioventricular canal defect- common in down syndrome. Child get cyanotic whit crying. Murmur

present. Child develops CHF.

Patent ductus arteriosus- failure for the artery connecting the aorta and pulmonary artery to close.

Machinery like murmur, wide pulse pressure and bounding pulse present. Give Indomethacin/ Indocin

to close it. Or with cardiac cath.

Ventricular Septal Defect- abn opening between lt and rt ventricles. Murmur present. Close on its own.

OBSTRUCTIVE DEFECTS- CHILD SHOWS SYMPTOMS OF CHF

Aortic stenosis- the narrowing doesnt let the blood from the lt ventricle pass through the aorta. Results

in decreased CO, lt ventricular hypertrophy and pulmonary vascular congestion. s/s of exercise

intolerance, chest pain and dizziness when standing for long. Dilation during cath or valve replacement.

Coarctation of aorta- narrowing near ductus arteriosus. BP higher in UE. s/s of CHF and decreased CO.

also headaches, dizziness, fainting, and epistaxis from HTN. Resection of coarted portion with


16/19

anastomosis or Ballon angioplasty. Restenosis can reoccur.

Pulmonary stenosis- narrow entrance of pulmonary artery. Causes right ventricular hypertrophy. NB are

cyanotic. Dilataion of the artery with cardiac cath.

DEFECTS WITH DECREASED PULMONARY BLOOD FLOW

Tetralogy of fallot- VSD, pulmonary stenosis, overriding aorta, right ventricular hypertrophy. Infants are

cyanotic at birth and progresses the 1sr year of life. They have hypercyanotic blue spells tet spells

when they cry, feed, or poop. With increasing cyanosis squatting, clubbing of fingers, and poor growth

may occur. Tx with palliative shunt, Morphine. Or complete repair after 1yo.

Tricuspid artresia- no tricuspid valve, so no communication between rt atrium and rt ventricle.

MIXED DEFECTS

Hypoplastic left heart syndrome- Underdevelopment of lt side of heart. Fatal if not treated. May need

heart transplant.

Rheumatic Fever- autoimmune inflammatory disease. Proceeds strep A infection. Can cause rheumatic

heart disease which affects cardiac valves particularly the mitral valve. Jones criteria diagnoses RF.

Major criteria: carditis, arthralgia, chorea, erythema marginatum, subQ nodules. Minor Criteria: Fever,

arthralgia, high ESR, positive CRP level . Assessment: low grade fever that spikes in the PM. High ESR,

+CRP, Aschoff bodies, + antistreptolysin O titer. Give Abx and seizure precautions.

Kawasaki disease- aka mucocutaneous lymph node syndrome. Its an acute systemic inflammatory

disease. Cause unknown. Affects the heart, aneurysms can develop. s/s ACUTE: fever, red throat, red

eye, swollen hands, lg lymph nodes. SUBACUTE: crackling lips, peeling fingers and toes, joint pain,

thmbocytosis. CONVALESCENT stage: child appears nl but signs of inflammation present. Give fluids that

are not too hot or cold. Wt daily. Monitor I&O. passive ROM. IV immunoglobulin. Avoid MMR and

varicella for 11 months after IgG therapy. Put in quiet environment. They are very irritable.

Early signs of CHF: tachycardia, especially at rest and slight exertions. Tachypnea, scalp diaphoresis,

fatigue, irritability, sudden weight gain, respiratory distress. For all these heart probs - PROVIDE REST!

Hemolytic-uremic syndrome: toxins, chemicals, viruses cause acute renal failure in children 6mos to 5yo.

S/S: triad of anemia, thrombocytopenia, renail failure, proteinuria, hematuria, urinary casts, elevated

BUN and creatnine and decreased Hgb and Hct. Do hemodyalisi or peritoneal dialysis.

Bladder Exstrophy- bladder outside the body through defect in lower abdominal wall. Cover bladder

with non-adhering plastic wrap. Surgery done.

Von Willebrands disease- hereditary. Bleeding from mucous membranes. Tx similar to hemophilia.


17/19

S/S of IICP: NL ICP= 5-15

Altered LOC- first sign

Headache

Abnormal respirations

Rise in BP with widening pulse pressure

Slowing of pulse

Elevated temperature

Vomiting

Pupil changes

Late Signs: (cushings triad- bradycardia, HTN, wide pulse pressure)

Increased systolic BP

Widened pulse pressure = increased systolic and low diastolic

Slowed heart rate

Non- reactive pupils

Positive Babinski reflex-stroke side of foot and big toe dorsiflexes and others extend

Decorticate or decerbrate posturing

Seizures

Dont give morphine sulfate. Mechanical ventilation to maintain Paco2 at 30-35mm Hg will result in

vasoconstriction of the cerebral blood vessels, decreased blood flow, and therefore decrease ICP.

Maintain BP. Prevent shivering. Decrease stimuli. Limit fluid intake. Avoid coughing and stuff. Elevate

HOB. Do a ventriculoperitoneal shunt. HOB no more then 30 degrees elevation because the hip flexion

causes an increase in ICP.

ICP increases with:

Suctioning

Coughing


18/19

Sneezing

Straining

Frequent positioning

Knees flexed

Neck flexion

CVA

Right side:

Left side paralysis (hemiplegia)

Left side neglect

Spatial-perceptual deficits

Short attentions span

Impaired judgment

Left Side:

Paralyzed on right side

Impaired speech/language-aphasias

Slow performance

Depression

Place patient in quiet environment to avoid an IICP.

Hypertensive disease in pregnancy is divided into clinical subsets of the disease based on end-organ

effects and progresses along a continuum from mild gestational hypertension, mild and severe

preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome.

Vasospasm contributing to poor tissue perfusion is the underlying mechanism for the signs and

symptoms of pregnancy hypertensive disorders.

Gestational hypertension (GH), which begins after the 20th week of pregnancy, describes hypertensive

disorders of pregnancy whereby the woman has an elevated blood pressure at 140/90 mm Hg or

greater, or a systolic increase of 30 mm Hg or a diastolic increase of 15 mm Hg from the prepregnancy

baseline. There is no proteinuria or edema. The clients blood pressure returns to baseline by 12 weeks

postpartum.

Mild preeclampsia is GH with the addition of proteinuria of 1 to 2+ and a weight gain of more than 2 kg

(4.4 lb) per week in the second and third trimesters. Mild edema will also begin to appear in the upper

extremities or face.

Severe preeclampsia consists of blood pressure that is 160/100 mm Hg or greater, proteinuria 3 to 4+,


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oliguria, elevated serum creatinine greater than 1.2 mg/dL, cerebral or visual disturbances (headache

and blurred vision), hyperreflexia with possible ankle clonus, pulmonary or cardiac involvement,

extensive peripheral edema, hepatic dysfunction, epigastric and right upper-quadrant pain, and

thrombocytopenia.

Eclampsia is severe preeclampsia symptoms along with the onset of seizure activity orcoma. Eclampsia is

usually preceded by headache, severe epigastric pain, hyperreflexia, andhemoconcentrations, which are

warning signs of probable convulsions.

HELLP syndrome is a variant of GH in which hematologic conditions coexist with severe

preeclampsia involving hepatic dysfunction. HELLP syndrome is diagnosed by laboratory

tests, not clinically.

H hemolysis resulting in anemia and jaundice

EL elevated liver enzymes resulting in elevated alanine aminotransferase (ALT) or aspartate

transaminase (AST), epigastric pain, and nausea and vomiting

LP low platelets (< 100,000/mm3), resulting in thrombocytopenia, abnormal bleeding and clotting

time, bleeding gums, petechiae, and possibly DIC

Gestational hypertensive disease and chronic hypertension may occur simultaneously Gestational

hypertensive diseases are associated with placental abruption, acute renal failure, hepatic rupture,

preterm birth, and fetal and maternal death

Administer IV magnesium sulfate, which is the medication of choice for prophylaxis or treatment. It will

lower blood pressure and depress the CNS.

Place the client on fluid restriction of 100 to 125 mL/hr, and maintain a urinary output of 30 mL/hr or

greater.

nclex notes from june2013 test

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