Detailed HESI Study Guide.

CONTENTS INCLUDE: ADVANCED CLINICAL CONCEPTS • ARDS is an unexpected, catastrophic pulmonary complication occurring in a person with no previous pulmonary problems. The mortality rate is high (50%) • In ARDS, a comm ...

CONTENTS INCLUDE: ADVANCED CLINICAL CONCEPTS • ARDS is an unexpected, catastrophic pulmonary complication occurring in a person with no previous pulmonary problems. The mortality rate is high (50%) • In ARDS, a common laboratory finding is lowered PO2. However, these clients are not very responsive to high concentrations of oxygen. • Think about the physiology of the lungs by remembering PEEP: Positive End Expiratory Pressure is the instillation and maintenance of small amounts of air into the alveolar sacs to prevent them from collapsing each time the client exhales. The amount of pressure can be set with the ventilator and is usually around 5 to 10 cm of water. • Suction only when secretions are present. • Before drawing arterial blood gases from the radial artery, perform the Allen test to assess collateral circulation. Make the client’s hand blanch by obliterating both the radial and ulnar pulses. Then release the pressure over the ulnar artery only. If flow through the ulnar artery is good, flushing will be seen immediately. The Allen test is then positive, and the radial artery can be used for puncture. If the Allen test is negative, repeat on the other arm. If this test is also negative, seek another site for arterial puncture. The Allen test ensures collateral circulation to the hand if thrombosis of the radial artery should follow the puncture. • If the client does not have O2 to his/her brain, the rest of the injuries do not matter because death will occur. However, they must be removed from any source of imminent danger, such as a fire. • PC)2 >45 or PO2 <60 on 50% O2 signifies respiratory failure. • A child in severe distress should be on 100% O2. • Early signs of shock are agitation and restlessness resulting from cerebral hypoxia. • If cardiogenic shock exists with the presence of pulmonary edema, i.e., from pump failure, position client to REDUCE venous return (HIGH FOWLER’s with legs down) in order to decrease venous return further to the left ventricle. • Severe shock leads to widespread cellular injury and impairs the integrity of the capillary membranes. Fluid and osmotic proteins seep into the extra vascular spaces, further reducing cardiac output. A vicious cycle of decreased perfusion to ALL cellular level activities ensues. All organs are damaged, and if perfusion problems exist, the damage can be permanent. • All vasopressors/vasodilator drugs are potent and dangerous and require weaning on and off. Do not change infusion rates simultaneously. • A client is brought into the hospital suffering shock symptoms as a result of a bee sting. What is the first priority? Maintaining an open airway (the allergic reaction damages the lining of the airways causing edema). Also, keep the client warm without constricting clothing; keep legs elevated (not MEDICAL –SURGICAL NURSING RESPIRATORY SYSTEM • Fever can cause dehydration from excessive fluid loss in diaphoresis. Increased temperature also increases metabolism and the demand for oxygen. • High risk for pneumonia: - Any person, who has altered level of consciousness, has depressed or absent gag reflex and cough reflexes, is susceptible to aspirating oropharyngeal secretions. (Alcoholics, anesthesized individuals, those with brain injury, drug overdose, or stroke victims). - When feeding, raise the head of the bed and position the client on side – not on back. • Bronchial breath sounds are heard over areas of density or consolidation. Sound waves are easily transmitted over consolidated tissue. • Hydration – enables liquification of mucous trapped in the bronchioles and alveoli, facilitating expectoration. Essential for the client experiencing fever. Important because 300 to 400 ml of fluid are lost daily by the lungs through evaporation. • Irritability and restlessness are early signs of cerebral hypoxia – the client is not getting enough oxygen to the brain. • Pneumonia preventatives: - Elderly: flu shots; pneumonia immunizations; avoiding sources of infection and indoor pollutants (dust, smoke, and aerosols); do not smoke. - Immunosuppressed and debilitated persons: infection avoidance, sensible nutrition, adequate intake, balance of rest and activity. - Comatose and immobile persons: elevate head of bed to feed; turn frequently. • Compensation occurs over time in clients with chronic lung disease, and arterial blood gases (ABGs) are altered. It is imperative that baseline data are obtained on the client. • Productive cough and comfort can be facilitated by SemiFowler’s or high Fowler’s positions, which lessen pressure on the diaphragm from abdominal organs. Gastric distention becomes a priority in these clients because it elevates the diaphragm and inhibits lung expansion. RENAL SYSTEM • Normally, kidney excrete approximately 1ml of urine per kg of body weight per hour, which is about 1 to 2 liters in a 24-hour period. • Electrolytes are profoundly affected by kidney problems. There must be a balance between extracellular fluid and intracellular fluid to maintain homeostasis. A change in the number of ions or in the amount of fluid will cause a shift in one direction or the other. Sodium and chloride are the primary extracellular ions. Potassium and phosphate are the primary intracellular ions. • In some cases, persons in ARF may not experience the oliguric phase but may progress directly to diuretic phase during which the urine output may be as much as 10 liters per day CARDIOVASCULAR SYSTEM • What is the relationship of the kidneys to the cardiovascular system? - The kidneys filter about a liter of blood per minute - If cardiac output is decreased, the amount of blood going through the kidneys is decreased; urinary output is decreased. Therefore, a decreased urinary output may be a sign of cardiac problems. - When the kidneys produce and excrete 0.5 ml of urine per kg of body weight or average 30 ml/hr output, the blood supply is considered to be minimally adequate to perfuse the vital organs GASTROINTESTINAL SYSTEM • A Fowler’s or semi-Fowler’s position is beneficial in reducing the amount of regurgitation as well as preventing the encroachment of the stomach tissue upward through the opening in the diaphragm. • Stress can cause or exacerbate ulcers. Teach stress reduction methods and encourage those with a family history of ulcers to obtain medical surveillance for ulcer formation. ENDOCRINE SYSTEM • Thyroid storm is a life-threatening event that occurs with uncontrolled hyperthyroidism due to Grave’s disease. Symptoms include fever, tachycardia, agitation, anxiety, and hypertension. - Primary nursing interventions include maintaining an airway and adequate aeration. - Propylthiouracil (PTU) or methimazole (Tapazole) are antithyroid drugs used to treat thyroid storm. Propanolol (Inderal) may be given to decrease excessive sympathetic stimulation. MUSCULOSKELETAL SYSTEM • A client comes to the clinic complaining of morning stiffness, weight loss, and swelling of both hands and wrists. Rheumatoid arthritis is suspected. Which methods of assessment might the nurse use and which methods would the nurse not use? - Use inspection, palpation, and strength testing. - Do not use range of motion (this activity promotes pain because ROM is limited) NEUROSENSORY SYSTEM • Glaucoma is often painless and symptom-free. It is usually picked up as part of a regular eye exam. • Eye drops are used to cause pupil constriction since movement of the muscles to constrict the pupil also allows aqueous humor to flow out, thereby decreasing the pressure in the eye. Pilocarpine is often used. Caution client that vision may be blurred 1 to 2 hours after administration o NEUROLOGICAL SYSTEM • Use of the Glasgow Coma Scale eliminates ambiguous terms to describe neurologic status such as lethargic, stuporous, or obtunded. • Almost every diagnosis in the NANDA format is applicable, as severely neurologically impaired persons require total care. HEMATOLOGY/ONCOLOGY • Physical symptoms occur as a compensatory mechanism when the body is trying to make up for a deficit somewhere in the system. For instance, cardiac output increases when hemoglobin levels drop below 7g/dl. • ONLY use normal saline to flush IV tubing or to run with blood. NEVER add medications to blood products. TWO registered nurses should simultaneously check the physician’s prescription, client’s identity, and blood bag label. REPRODUCTIVE SYSTEM • Menorrhagia (profuse or prolonged menstrual bleeding) is the most important factor relating to benign uterine tumors. Assess for signs of anemia. • What is the anatomical significance of a prolapsed uterus? When the uterus is displaced, it impinges on other structures in the lower abdomen. The bladder, rectum, and small intestine can protrude through the vaginal wall. PEDIATRIC NURSING GROWTH AND DEVELOPMENT: 1. When does birth length double? = by 4 years 2. When does the child sit unsupported? = 8 months 3. When does a child achieve 50% of adult height? = 2 years 4. When does a child throw a ball overhand? = 18 months 5. When does a child speak 2-3 word sentences? = 2 years 6. When does a child use scissors? = 4 years 7. When does a child tie his/her shoes? = 5 years RESPIRATORY DISORDERS • Child needs 150% of the usual calorie intake for normal growth and development. • Do not examine the throat of a child with epiglottis due to the risk of completely obstructing the airway, i.e., do not put a tongue blade or any object in the throat. • In planning and providing nursing care, a patent airway is always a priority of care, regardless of age! CHILD HEALTH PROMOTION • Subcutaneous injection, rather than intradermal, invalidates the Mantoux test. • The common cold is not a contraindication for immunization. CARDIOVASCULAR DISORDERS • Polycythemia is common in children with cyanotic defects. • The heart rate of a child will increase with crying or fever. • Infants may require tube feeding to conserve energy. NEUROMUSCULAR DISORDERS • The nursing goal in caring for children with Down syndrome is to help the child reach his/her OPTIMAL level of functioning. • Feed infant or child with cerebral palsy using nursing interventions aimed at preventing aspiration. Position child upright and support the lower jaw. HEMATOLOGICAL DISORDERS • Remember the Hgb norms: - Newborn: 14 to 24 g/dl - Infant: 10 to 15 g/dl - Child: 11 to 16 g/d RENAL DISORDERS • Decreased urinary output is FIRST sign of renal failure. • Surgical correction for hypospadias is usually done before preschool years due to achieving sexual identity, castration anxiety and toilet training. GASTROINTESTINAL DISORDERS • Typical parent/family reaction to a child with an obvious malformation such as cleft lip/palate are quilt, disappointment, grief, sense of loss, and anger METABOLIC AND ENDOCRINE DISORDERS • An infant with hypothyroidism is often described as a “good, quiet baby” by the parents. MATERNITY NURSING ANATOMY & PHYSIOLOGY OF REPRODUCTION • The menstrual phase varies in length for most women. • From ovulation to the beginning of the next menstrual cycle is usually exactly 14 days. In other words, ovulation occurs 14 days before the next menstrual period. SKELETAL DISORDERS • Fractures in older children are common as they fall during play and are involved in motor vehicle accidents. • Spiral fractures (caused by twisting) and fractures in infants may be related to child abuse. INTRAPARTUM NURSING CARE • Be able to differentiate true labor from false labor. • True labor: - Pain in lower back that radiates to abdomen - Accompanied by regular, rhythmic contractions - Contractions that intensify with ambulation - Progressive cervical dilation and effacement FETAL/MATERNAL ASSESSMENT TECHNIQUES • In some states, the screening for neural tube defects through either maternal serum AFP levels or amniotic fluid AFP levels is mandated by state law. This screening test is highly associated with both false positives and false negatives. NORMAL PUERPERIUM • Normal leukocytosis of pregnancy averages 12,000 to 15,000 mm3. The first 10 to 12 days post-delivery, values of 25,000 mm3 are common. Elevated WBC and the normal elevated ESR may confuse interpretation of acute postpartal infections. For example, if the nurse assesses a client’s temperature to be 101 F on the client’s second postpartum day, what THE NORMAL NEWBORN • PHYSICAL ASSESSMENT: A detailed physical assessment is performed by the nurse or physician. Regardless of who performs the physical assessment, the nurse must know normal versus abnormal variations of the newborn. Observations must be recorded and the physician and the physician notified regarding abnormalities. HIGH-RISK DISORDERS • Clients with prior traumatic delivery, history of D&C, multiple abortions (spontaneous or induced), or daughters of DES mothers may experience miscarriage or preterm labor related to INCOMPETENT CERVIX. The cervix may be surgically repaired prior to pregnancy, or DURING gestation. A CERCLAGE (McDonald’s suture) is placed around the cervix to constrict the internal os. The cerclage may be removed prior to labor if labor is planned or left in place if cesarean birth is planned POSTPARTUM HIGH-RISK DISORDERS • Nurse must be especially supportive of postpartum client with infection because it usually implies isolation from newborn until organism is identified and treatment begun. Arrange phone calls to nursery and window viewing. Involve family, spouse, significant others in teaching, and encourage other family members to continue neonatal attachment activities NEWBORN HIGH-RISK DISORDERS • “Jitteriness” is a clinical manifestation of hypoglycemia and hypocalcemia. Laboratory analysis is indicated to differentiate between two etiologies PSYCHIATRIC NURSING THERAPEUTIC COMMUNICATION / TREATMENT MODALITIES • The purpose of therapeutic interaction with clients is to allow them the autonomy to make choices when appropriate. Keep statements value free, advice free, and reassurance free. Remember, JUST THE FACTS! NO OPINIONS! ANXIETY DISORDERS • Common physiological responses to anxiety include increased heart rate and blood pressure; rapid, shallow respirations; dry mouth, tight feeling in throat; tremors, muscle tension; anorexia; urinary frequency; palmar sweating. SOMATOFORM DISORDERS • Be aware of your own feelings when dealing with this type of client. It is a challenge to be non-judgmental. The pain is real to the person experiencing it. These disorders cannot be explained medically: they result from internal conflict. The nurse should: DISSOCIATIVE DISORDERS • The nurse should be aware that ALL behavior has meaning. • Avoid giving clients with dissociative disorders too much information about past events at one time. PERSONALITY DISORDERS • Personality disorders are long-standing behavioral traits that are maladaptive responses to anxiety and cause difficulty in relating and working with other individuals. NCLEX-RN questions test personality disorder content by describing management situations EATING DISORDERS • People with Anorexia gain pleasure from providing others with food and watching them eat. These behaviors reinforce their perception of self-control. Do not allow these clients to plan or prepare food for unit-based activities MOOD DISORDERS • Depressed clients have difficulty hearing and accepting compliments because of their lowered self-concept SUBSTANCE ABUSE • Know what defense mechanisms are used by chemically dependent clients. Denial and rationalization are the two most common coping styles used – their use must be confronted so accountability for the client’s own behavior can be developed THOUGHT DISORDERS: SCHIZOPHRENIA • There are five types of schizophrenia specified under the DSM-IV-TR. The DSM-IV-TR is a diagnostic manual prepared by the American Psychiatric Association that provides diagnostic criteria for all psychiatric disorders. ABUSE • Select only one nurse to care for an abused child. Abused children have difficulty establishing trust. The child will be less anxious with one consistent caregiver. ORGANIC MENTAL DISORDERS • Confusion in the elderly is often “accepted” as part of growing old. This confusion may be due to dehydration with resulting electrolyte imbalance. Think “sudden change” when obtaining a history. Such changes are usually due to a specific stressor, and treatment for the causative stressor will usually result in correcting the confusion GERONTOLOGICAL NURSING • Changes in the heart and lungs result in less efficient utilization of O2, which reduces an individual’s capacity to maintain physical activity for long periods of time. Physical training for older persons can significantly reduce blood pressure and increase aerobic capacity. CHILDHOOD AND ADOLESCENT DISORDERS • Children also experience depression, which often presents as headaches, stomachaches, and other somatic complaints. Be sure to assess suicidal risks, especially in the adolescent