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Wednesday, May 28, 2008

Nclex Review Materials: Resource Bullet 4

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Unlocking Halo vest traction - An open-ended wrench is taped to the client's vest. This wrench provides immediate release of the bolts to remove the vest in the event the client, requires external cardiac compression. The posterior portion of vest remains in place to provide stability for the spine during CPR.

Indomethacin is NSAIDS. Bleeding may occur.

Verapamil is a calcium channel blocker, antihypertensive and antianginal.

K-Lor is a potassium supplement.

Clozaril requires weekly blood tests.

Risperdal [risperidone] - It targets both negative and positive symptoms of schizophrenia; It has fewer neurological side effects than the phenothiazines; It is unlikely to cause tardive dyskinesia.

The heparin drip has a protocol that needs to be followed, including regular PTT levels, and adjustment of the heparin drip ---- Assign to RN

Any threat to inflict harm is assault.

Shock phase (24-48 hrs after) the patient is dehydrated decrease B/P, increased P, decreased U/O.

Variable deceleration is the result of compression of umbilical cord. Nurse should change maternal position, if no improvement seen, administer oxygen, discontinue oxycitocin if infusing.

Influenza virus vaccine and the pneumococcal vaccine can be administered concomitantly; Deltoid or lateral mid-thigh is the preferred injection site; The vaccines should be administered in the dominant arm.

Check for fecal impaction on client with spinal cord injury has autonomic dysreflexia.

Family and friends around the bed, chanting and singing depicts Hindu death rituals. What the nurse should expect is that while Hindus normally bring their ill home to die, on occasion the hospital is the site of death. When death is imminent, the person is placed with his head facing east. A lamp is lit near his head and he is encouraged to concentrate on his mantra. Family members keep vigil until death comes, singing hymns, praying and reading scriptures.

Nurse should instruct the client to rinse her mouth with a normal saline and baking soda solution on a patient with painful and bleeding ulcerations in her mouth.

Good Samaritan laws shield you from liability for negligence but not gross negligence.

A health care proxy is a document appointing someone else to make medical decision.

Celiac disease - gluten free diet.

PKU patient needs to avoid protein.

Sternum and forehead are reliable sites for evaluating dehydration in elderly.

Magnesium sulfate is an anti-convulsant which can cause cardiac arrhythmias. Nurse should check for clients pulse and respiration

Tricyclic anti-depressants have anti-cholinergic s/effects (urinary retention)

Genital herpes is transmitted when lesions are present and 10 days after lesions have healed.

Counter transference reaction: The tendency of the nurse/counselor to displace feelings that are a response to people in the counselor's past onto the client.

Barbiturates decrease anti-coagulant activity. Should not be medicated along with warfarin sodum (coumadin) or other anti-coagulant meds.

S/S of adrenal insufficiency are anorexia, nausea and hypotension

Spinal shock occurs 30-60 minutes after a spinal cord injury due to disruption of nerve pathways. S/s are pulse and respirations are increasing and blood pressure is decreasing

Position of choice when caring for a client with increased intracranial pressure (IICP)? This position allows proper drainage of cerebral edema and helps decrease ICP. Anything less than 30º increases pressure (blood flow) to the brain.

Client with Bulimia has a deficit in the sense of responsibility. They feel unable to take charge of their own life.

Spinal cord patients are prone to autonomic dysreflexia which is triggered by some form of stimulus-most common is full bowel, or full bladder.

Two groups are especially susceptible - men whose testicles descended into the scrotum after age 6 and those, whose testicles never descended. Males with either of these risks are up to 17 times more likely to develop testicular cancer.

VIT D preparations are given 3 times per week during dialysis. Iron is given to treat anemia.

Aspirin prolongs bleeding time 4-7 days.

You cannot treat a minor without the permission of her parents unless she is emancipated. If she has a sexually transmitted disease, you must tell health department. Minor cannot sign for her own treatment.

Normal PT is 9.5-12 seconds.

The bronchodilator first opens the airways then the steroid can be inhaled deeply enough to reduce inflammation.

Patient with intussusception, Vomiting is an expected finding and can lead to dehydration.

MMR immunization, nurse should check the child for allergy to neomycin for prior to administering the vaccine

Coumadin takes 2-3 days to start working

A patient is on a Heparin drip and is started on Coumadin. Why she is on both not just one. The only time it is appropriate to see both anti-coagulants given is when a patient is to be sent home on Coumadin. Then they must wean the heparin and start the Coumadin in order to give it time to work.

Give simple, slow directions to patient which receptive aphasia.

disseminated intravascular coagulation (DIC) is characterized by dropping platelet count and prolonged coagulation studies.

Atenolol needs to be withheld to avoid aggravating the hypotensive effect of dialysis.

Remember that folic acid is needed to maturation of RBC .... Spinach, eggs, peanuts

Giardia is transmitted by drinking contaminated water or food. People who travel to undeveloped nations are susceptible as are those who do not travel out of the US but who drink water from mountain streams.









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Monday, May 26, 2008

State Of Vermont Nclex Application Revised

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State of Vermont
Office of the Secretary of State
Professional Regulation
Board of Nursing
National Life Bldg, North FL 2
Montpelier, VT 05620-3402
802-828-1380
Instructions For Foreign Applicants Applying For
Licensure By Examination or Endorsement

Effective March 27, 2008



Introduction: Applications must include everything listed below before they
will be reviewed. Applications which are not fully filled out will be returned
to the applicant, as will applications which do not include the fee. There is
a 3-4 Month Processing Time for Applications.

Important Note: If your Nursing Education language of instruction, and textbooks for the nursing program you attended were not in English you must apply first to CGFNS. You
may contact them at: 215-349-8767.


To complete your Vermont application you must:

1. Complete Pages 3 through 7

2. Submit the Application fee of $150.00. (Payable to: Vermont Secretary of State)
Payment Must Be In US Funds. The $150.00 must come with the application or
the application will be returned. Payment can be sent in the form of check, money
order, demand draft or travelers check. All banks must have US affiliates.
Payment is not refundable. Have your name written somewhere on the check.

3. Request the director of your school of nursing (or other authorized officer) to
complete the “Verification of Education” form (stamped), and return the form along
with a Stamped, Official, Certified copy of your Transcript and Clinical
Transcripts/related learning experience. (Not required for applicant’s applying with
CGFNS Certificate)

4. Submit one recent passport type photograph (2 X 2) in size, head and shoulders
only. Attach photo to application.

5. Submit a copy of your Current License, in good standing, which shows an
expiration date. If you do not hold a license in your country you are not eligible to
take the NCLEX through Vermont. Applicants from the Philippines may submit a
copy of their board pass letter if they have not yet received their license.

6. Submit a copy of your passport. This needs only to be a photocopy of your

Download State of Vermont Nclex Application



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Nclex Review Materials: Resource Bullet 3

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Glycosylated Hgb gives an indication of what the patient ate over the past 3 months by reporting the average blood sugar over a period of time.

MgSO4 causes vasodilatation and lowers BP. The patient could become hypotensive.

Cryptorchidism is the absence of one or both testes from the scrotum. Cryptorchidism may cause permanent damage to the testicle and interfere with either sperm production or transport of sperm.

Adoption studies of twins indicates that predisposition for schizophrenia may be inherited. Research indicates that there is a genetic vulnerability as well as other factors that contribute to the development of schizophrenia.

Low serum albumin can indicate poor nutritional status or liver failure, making patient poor candidate for surgery.

Gowns, masks and goggles or face shields are required if there is a possibility of splattering.

Stomatitis is an inflammation of the mucous lining of any of the structures in the mouth, which may involve the cheeks, gums, tongue, lips, throat, and roof or floor of the mouth.

People who drink alcohol are more susceptible to cancer of mouth, liver, pancreas, stomach.

SIADH causes water retention, which leads to edema, and weight gain. Urine output is low, Serum Na is low and urine specific gravity is high > 1.020.

Haloperidol is used in the treatment of schizophrenia and, more acutely, in the treatment of acute psychotic states and delirium.

It is preferred that cyclophosphamide (cytoxan) be given in the morning, this will permit to force fluids during the day and increase the number of times the child voids, which will help prevent hemorrhagic cystitis.

Tingling in the mouth and fingers is a sign of hyperventilation commonly occurring during the transitional phase of labor due to increased breathing patterns in response to pain. Slowing of breathing pattern will help to increase CO2 content.

Leukemia or leukaemia is a cancer of the blood or bone marrow and is characterized by an abnormal proliferation (production by multiplication) of blood cells, usually white blood cells (leukocytes). It is part of the broad group of diseases called hematological neoplasms.

In severe depression activities of daily living are ignored as self-esteem and self worth are severely impaired. The patient is showing an interest in self-care, which is a sign of improvement.

PTT normal is 35-45 seconds

Humulin R is a regular (short acting) insulin the only type that can be given IV.

Monthly self-breast exam should be done on the 7th day after the beginning of the menstrual flow.

Because the release of oxytocin during breastfeeding stimulates uterine contractions. During the first few days of involution this may feel like strong cramping. A mild analgesic will relieve the pain and will not interfere with establishing breastfeeding milk supply.

Hirschsprung's disease, or congenital aganglionic megacolon, involves an enlargement of the colon, caused by bowel obstruction resulting from an aganglionic section of bowel (the normal enteric nerves are absent) that starts at the anus and progresses upwards.

Hirschprung's disease usually includes a temporary colostomy until the dilated portion of the bowel returns to normal function.

Interfering with the completion of the ritual increases anxiety. Providing hand cream offers some protection to the skin until the rituals reduce as the patient improves.

Chicken liver is high in Tyramine.

Patient with rheumatic fever will not develop bronchitis, oliguria or nausea. He will develop polyarthritis.

Prudent nursing practice is turning bed-bound patient every 2 hours. Turning every 4 hours fails to meet nursing standards.

Green leafy vegetables are full of Vitamin K which interferes with Coumadin therapy. They may be eaten but intake should be consistent so therapy can be adequately adjusted. None of the others are contraindicated.

Patient has cirrhosis, you should be concern with itching which could indicate pruritus and liver failure.

Babies with hydrocephalus may have difficulty lifting and turning their heads due to the increased size. To prevent skin breakdown of the bony prominences it is important to turn and position the child frequently.

Hypertension with Acute Glomerulonephritis occurs during the acute phase of the disease. Normal BP range would indicate that the condition was resolving.

In the court case Rogers vs. Okin in the Federal District Court of Massachusetts, it was ruled that involuntary mental patients are competent and have the right to make treatment decisions. Forcible administration of medication is justified in an emergency if needed to prevent violence and if other alternatives have been ruled out.

Guillain-Barre Syndrome (Polyradiculitis) is a clinical syndrome which affects both cranial and peripheral nerves. Its' origin is not known, however it has been found to be preceded by either a recent Upper Respiratory Infection, Gastrointestinal Infection, or immunization against the flu (ie: Swine Flu). It is NOT hereditary.

During the acute phase of Bacterial Endocarditis the patient is usually on bed rest and the nurse must assist patient, to conserve energy and reduce cardiac workload. At the same time the nurse should be able to provide, as tolerated, activities to reduce feelings of boredom and helplessness.

Ecchymoses - The passage of blood from ruptured blood vessels into subcutaneous tissue, marked by a purple discoloration of the skin.

Patients receiving Carafate should not be given antacids for at least a half hour following the administration of this drug for the drug to exert its' maximum efficacy.

The BEST indicator of efficacy of Lasix in a patient with CHF, is the patient's CVP. The change in CVP is an indication of adequacy of venous blood volume. Along with the patient's clinical picture the improvement in breathing, weight loss, increased urine output, and reduction in edema indicate a therapeutic response to the action of this medication.

Patients on TPN must be monitored closely, and the rate of the infusion must be maintained as ordered. If the rate is too fast hyperosmolar diuresis occurs, and the patient may c/o headache, nausea, chills, and may have a fever. In this situation the nurse should suspect Hyperglycemia, and check glucose (finger stick), and urine output (Diuresis is likely) and notify M.D. Also be prepared to add Insulin to infusion.

HIB vaccine is against H influenza virus. People who have allergies to eggs often have allergic reaction to HIB vaccine.

Toxoplasmosis is a protozoa infection caused by Toxoplasma gondii, found in raw or undercooked foods and cat feces.

Celestone is corticosteroid and is used to accelerate fetal lung maturity. It has a better effect if it is given at least 24 hours prior to delivery.

Children with Tetralogy of Fallot do not have enough energy to practice gross motor skills therefore become developmentally delayed. They also may have frequent hospitalizations, which limit their activity.

Abrupt cessation of alcohol when addicted can result in seizures including status epilepticus.

Depending on the area of the brain affected, and the degree of involvement, the patients with cerebral aneurysms may exhibit one or more of the following signs/symptoms/behaviors, ie: unilateral neglect of paralyzed side, astereognosis, aphasia, emotional lability, etc. The nurse should be aware of these and be able to intervene effectively, ie. In this case use of good communication skills, and provide reassurance.

Asterixis is a tremor of the wrist when the wrist is extended (dorsiflexion), sometimes said to resemble a bird flapping its wings. Also called "liver flap", it can be a sign of hepatic encephalopathy, damage to brain cells due to the inability of the liver to metabolize ammonia to urea. The cause is thought to be related to abnormal ammonia metabolism.

Lactulose (Cephulac) is prescribed to patients with impending or actual Hepatic Coma. The drug's primary action is to reduce serum ammonia. It does this by retaining ammonia in the colon and expelling it in the stool through an osmotic laxative effect. The BEST indicator that the drug is exerting its physiological effect would be the patient having two to three soft stools per day.

Often after removal of foley, patient will have frequent sensation to void accompanied by burning sensation on first void.

The mood stabilizing effect of Lithium takes around one to two weeks based on how fast a therapeutic level can be reached and maintained.

Crutchfield tongs are cervical tongs applied for immobilization of cervical injuries. Post-procedure nursing care includes assessing the client for any changes in neurologic status. The insertion site is monitored for signs of infection.

National stroke association says 2/3 of all strokes occur in people over 65, M>F, Blacks>Whites. HTN is the No.1 risk factor.

Soft or pureed foods are easier to swallow and be controlled with a lazy tongue. Liquids increase risk of aspiration.









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Sunday, May 25, 2008

New Nclex Application Requirement: State of Vermont

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SPECIAL NOTICE: Applicants from the Philippines who have not yet been approved/denied: If your school filled out a Verification of Education form before May 5, 2008, have them fill out the updated form and send it to our office.
Due to difficulty interpreting transcripts, we are now requiring that all pending Philippine applicants submit the new form. You do NOT need to send new copies of your transcripts or any additional money. Please ask the school to send copies of your course descriptions with the new form.

We will process the applications as the new information arrives in our office in order of initial application receipt date. (2007 will be processed first, then January, February, March and April, etc.) Applicants will NOT need to wait another 3-4 months.

This new form is a requirement. Even if you did not receive correspondence from us, if you have not yet been approved or denied this applies to you. You can find this form in the Foreign Nurse Application- it is the last two pages of the application packet.

This requirement applies to ALL PENDING PHILIPPINE APPLICATIONS. Applicants are NOT exempt based on date of application. Transcripts can not be evaluated without the additional information requested on the updated form.

See: http://vtprofessionals.org/foreignnurse1.asp








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Saturday, May 24, 2008

Study Skills and Test Strategies for the New Nursing Student

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Study Skills and Test Strategies for the New Nursing Student Slide Transcript
Slide 1: Study Skills and Test Strategies for the New Nursing Student BY Caralee Bromme, RN, MSN, CCRN

Slide 2: How learners learn... Tell me and I will forget Show me and I will remember Involve me and I will understand (Confucius)

Slide 3: Critical thinking • Critical thinking is the cornerstone of one's ability to function in today's society. According to Scriven & Paul (n.d.), • it...can be seen as having two components: – a set of skills to process and generate information and beliefs, and – the habit, based on intellectual commitment, of using those skills to guide behavior. – (Scriven & Paul, nd: http://www.criticalthinking.org/University/univclass/Defining.html)

Slide 4: Critical Thinking • Critical thinking is a mental process that uses elements of reasoning to shape choices and make sound judgements. A good question is never answered. It is not a bolt to be Tightened into place But seed to be planted Towards the hope of greening And bear more seed... The landscape of ideas (John Ciardi)

Slide 5: Types of Learners • Right Brain • Left Brain – Artistic perception – Language and word use – Creativity – Logic, reasoning & – Intuitive thinking analysis – Music and rhythm – Rational thinking – Imagination and – Sequence and order abstraction – Daydreaming – Reflection – Random thinking

Slide 6: Learning Styles • Visual • Auditory • Kinesthetic • Global • Detail learning

Slide 7: Visual • Seeing is believing – Learn best by watching or reading • Resources available – Books – Demonstrations – Handouts – Internet resources – Personal notes – Periodicals – Videos

Slide 8: Auditory • Sounds like….. – You tune into the things you hear • Discussions with others • Lectures • Question and answer sessions • Reading procedures aloud • Study groups • Tape recordings

Slide 9: Kinesthetic • Can do… – If you prefer to jump right in and do something new... your motto “ Learn by doing” • Attend workshops • Give return demonstrations • Participate in individual or group projects • Take part in special or extra activities • Volunteer

Slide 10: Global Learning • The big picture… – Find the answer by looking at the big picture • Sweeping theories and over all trends fill your vision • Like to find the conclusion after considering all the options – Write summaries of your notes – Use diagrams to show relationships – Develop question lists

Slide 11: Detail Thinking • You follow instructions closely and follow logical orders and you like the teacher who follows the lessons plan closely • Create bullet summary lists from class notes • Use diagrams to connect specific ideas to larger concepts • Make specific to do lists before beginning study sessions • Write questions as they appear in the reading • Be prepared to illustrate specific details with examples

Slide 12: The Learning Process Bloom’s Learning Level (1956) Evaluation Synthesis Analysis Application Comprehension Knowledge

Slide 13: Bloom’s Learning Levels • Knowledge stage of critical thinking – Requires memorization for recall • Math formulas • Phone numbers • Comprehension – Involves converting information from the form received to your own words • Making illustrations • Describing relationships

Slide 14: Bloom’s Learning Levels • Application – You apply the information you have gained, translated or interpreted to solve problems or accomplish concrete tasks • Completing a project by following directions • Using a theory or formula to solve a problem • Analysis – You break down the concept into parts and understand how they work • Identify assumptions • Decide if data valid

Slide 15: Bloom’s Learning Levels • Synthesis – You can put parts together and find a new and larger whole • Developing your notes into presentation • Writing a poem or story • Evaluation – Most complex level of cognitive functioning • You use all the stages to determine the value and relevance of the information • Springhouse 2000

Slide 16: The Nursing Process Evaluation Implementation Planning Analysis Assessment

Slide 17: Now critical thinking and the nursing process.. • Assessment – Collect data, communicate information about assessments • Analysis/ Nursing Diagnosis – Clustering and interpreting data, identifying and communicating nursing diagnosis • Planning – Identifying goals, projecting outcomes, setting priorities, identifying interventions • Implementation – Implementing nursing care • Evaluation – Identifying patient responses, comparing outcomes to goals, modifying plan of care. “This is process of how we think about patients” Now let’s apply the same process to tests

Slide 18: The next step - Setting the stage… An action plan gives you control over your immediate future. It helps reduce stress, anxiety, frustration, and unnecessary use of time and energy. If you don’t have a plan, you jeopardize your chance to succeed and increase your chance for failure. A winner has a plan! A loser has an excuse! (Sides and Korchek)

Slide 19: The keys for success • Develop the winning attitude • Identify motivators • Set short term and long term goals • Use time management • Reward yourself

Slide 20: Time management Laundry Studying House Self Significant Other/ Spouse Kids Work Clinical School How do you handle it all?

Slide 21: Setting the stage... Do Not Disturb • Make a consistent Until 5:00pm space for yourself to study • Insure adequate lighting, and quietness • Have all your supplies • Schedule your time

Slide 22: Time management • Schedule your time – To study – For kids/ husband 8am class Test on Friday – For house 10am study Culture project • Develop weekly group Due 3 weeks 3pm baseball calendar 6pm date w/ Care study due 5 weeks • Set priorities husband get patient • Make to do lists • Don’t procrastinate

Slide 23: Breaking the procrastination habit • Identify your motivators – Make a list of self motivating statements – Recognize that negative predictions do come true • Set your goals – Establish a clear timetable – Break down large tasks to small ones – Pinpoint where your delay s typically start – Write reminders • Reward yourself – Also give up something if you fail

Slide 24: It’s time to study … • What is an objective? – Objectives are tools for describing the intended outcomes • Performance – What your supposed to do... • Conditions – How your to do it... • Criterion – How well you have to perform to be competent ...

Slide 25: An example of an objective • After listening to the lecture, the student will be able to – List in writing the three parts of an objective. – Identify why objectives are important. – Analyze the importance of objectives in future study. • Nursing courses are based on objectives

Slide 26: Study strategies for the classroom • Be prepared • During class pay attention to – Read objectives – Contents of handouts – Anything written on board – Look at and read section headings – Instructor’s response to certain questions – Look at all charts or – Anything instructor stresses or illustrations and read repeats captions – How instructor presents the – Skim main text to identify information main concepts • Big picture or details – Look at words in bold or – In the beginning and the end of Italics the lecture, the instructor often – The goal is to gain the summarizes the major points and other points there wasn’t general idea time to cover

Slide 27: The lecture notes…. • Taking notes may be the most crucial part of active listening during a lecture. – Notes trigger you memory – It makes you pay attention to new ideas – Will allow you to show your understanding by paraphrasing and condensing the notes

Slide 28: Test taking strategies • Outline your notes to each disease – With info from lecture and book • Pathophysiology of disease/ system • Signs and symptoms (including labs) – Highlight special S&S • such as RLQ pain for appy • Nursing Diagnosis • Goals • Specific Implementation plans • Patient teaching

Slide 29: Ideas on lecture notes • Shrthnd spds note tkng • After class organize – Abbreviate common words you notes – Leave out conjunctures and – Keep them personal other words not essential – Copy all board work for thought – Rewrite notes if illegible – Think before you write – Keep notes in loose leaf – Mark for emphasis binder – Vary handwriting to stay – Leave spaces to later ideas organized – Organize your notes after – Don’t write every word the class lecture says...

Slide 30: The LISAN Method • Lead , don’t follow. Anticipate what the instructor is going to say. • Ideas. What’s the main idea? • Signal Words. Listen for words that tell you the direction the instructor is taking. • Actively listen. Ask questions, be prepared. • Note taking. Write down key points. Be selective.

Slide 31: The study group • Set location and time • Have agenda • Everyone must follow the rules – Do their share – Be courteous – Attend regularly • Can be a great source of moral support

Slide 32: It’s test time… • Before the test.. – Get a good night sleep – Eat before the test • Create a study plan – Plan ahead; schedule study time . Don’t cram. – Assemble your sources. Review your material. – Make your own cheat/ summary sheet – Dress rehearse.

Slide 33: At the test… • Take one last, leisurely look at your summary sheet • Be early • Have all your supplies • Let the instructions instruct – Mark important instructions – Skim the test for an overall sense and difficulty • Budget your time – Work quickly – If you can’t answer the question right away move to the next question

Slide 34: The Objective Test • Types – Multiple choice – True/ false – Short- answer – Sentence - completion – Problem solving • Only one possible answer • Tests your ability to recall information.

Slide 35: The Test Question Test • Three parts of a question are A. – The background statement B. • Is a brief scenario that provided necessary C. information for answering the question • May provide a framework for the stem – A stem • Contains the specific problem or intent of the item – And a list of options • Are the possible answers to the questions • The corrected answered is a keyed response and the other options are distracters.

Slide 36: Types of questions • Knowledge – Recall or remembered information • Comprehension questions – Need to understand the information • Application Questions – Show, solve, use or manipulate information • Analysis – Interpret data, recognize commonalties, differences, interrelationships among presented ideas

Slide 37: The Stem • Three forms of a stem in a question – Background statement • A young woman arrived to the hospital in early labor. – Stem in question form • Which of the following signs is the best indicator of early labor? – Stem form in an incomplete statement • The best indicator that labor is progressing is...

Slide 38: Answering the question... • Read the question before looking at the options. • Identify key words in the stem – All of the following behaviors are typical of a 3 year old except • The word except directs you to behaviors not typical • If you miss the word , you will select the wrong answer • Look for key words – First , primary, initial, early, ,most important, except Haste makes waste and errors

Slide 39: Test taking strategies • Prioritization • Maslow’s Hierarchy of Needs • Biological • Safety • Belonging and love • Esteem needs • Self actualization

Slide 40: Test taking strategies • If you have to guess think physiological needs first… • Think.. • Airway • Breathing • Circulation • Disability • Safety second • Communication • Also do not forget the nursing process

Slide 41: The options… • Attempt to answer the question without looking at the responses. Identify your response in the options. • Eliminate the obviously incorrect responses first; The select the best of the remaining options. • Do not change answers without good reason or sound rational.

Slide 42: Next... • Identify the theme of the item and base it on the information given. • Don’t assume information that is not given. A husband was admitted to the ER for Delirium tremors for the third time in 3 weeks, the wife asks you what can I do to to help my husband get over the problem? a.Don’t feel guilty; I know this must be difficult for you b.Let’s go in to the lounge; so we can talk about your concerns. c.You need to convince him to seek professional help. d. How long has you husband been drinking?

Slide 43: Test taking strategies • The client has a red, raised skin rash. During the bath, the priority action of the nurse is to: • a. Assess for further inflammatory reactions • b. Discuss the body-image problems created by the presence of the rash • c. Wash the skin thoroughly with hot water and soap • d. Moisturize the skin to prevent drying.

Slide 44: Test taking strategies • To promote respiratory function in the immobilized client, the nurse should: 2. Change the client’s position q4-8 3. Encourage deep breathing and coughing every hour 4. Use oxygen and nebulizer treatments regularly 5. Suction the client every hour

Slide 45: Other tips… • Responses that use absolute words, such as “always” or “never” are less likely to be correct than “usually” or “probable”. • Funny responses are usually wrong. • “All of the above” is usually correct. • “None of the above” is usually incorrect. • Watch for double negatives. • Look for grammatical clues – If stem ends in an; the answer should start with a vowel • The longest response is often the correct one • Look for verb associations.

Slide 46: Test taking strategies • To provide for the psychosocial needs of an immobilized client, an appropriate statement by the nurse is: • a. “The staff will limit your visitors so that you will not be bothered.” • b. “A roommate can be a real bother. You’d probably rather have a private room.” • c. “Let’s discuss the routine to see if there are any changes we can make.” • d. “I think you should have your hair done and put on some make-up.”

Slide 47: More tips… • If all else falls answer B or C. • Do not hesitate to ask for clarification during the exam. • Be sure that you have the appropriate bubbles filled correctly. • Take time to check your work before handing in the answer sheet.

Slide 48: Other Objective Tests • True/ False Answers • Short Answers • Assesses recognition of • Break into 3 categories material – Know w/o hesitation • If question only part – Should be able to true , than it’s false answer if you think about it • Watch for key words – Have no idea – All, always, because • Answer the questions – Generally, never you know first than – None, only, sometimes attack the rest – usually

Slide 49: Essay tests • Read directions first • Read all the questions even if you only have to answer two. Jot down ideas about each. • Mark the time you estimate to complete each question. • Outline you answer 1. 2. • Write the answer 3. 4. 5.

Slide 50: The Essay Question 5 Paragraph Format • 1 - Introduction, in which you briefly outline the direction your argument is taking • 2 - 1st point with at least 2 supporting facts • 3- 2nd point with 2 supporting facts • 4 - 3rd point with 2 supporting facts • Conclusion, which pulls together the 3 points into one final statement

Slide 51: Reading Comprehension Tests • Read the instructions first • Read the questions next • Read the passage and A. answer the questions B. C.

Slide 52: Open Book Tests • De-emphasize memorization and encourages critical thinking • Ideas for success – Use table of contents and index. – Don’t copy from the book. – Use as many sources as allowed. – Use you note summary sheet, put as much info as possible on it. – Check your answers.

Slide 53: How can I avoid cramming? • It doesn’t work- the brain needs time to assimilate information • If you have to: – Outline the textbook – Read the objectives • Focus on chapter headings,summaries, highlighted words • First and last sentence of the paragraph • Read your notes, make flash card or summary sheet • Get at least 4 hour sleep • And review 1 hour before the test.

Slide 54: How to overcome test anxiety • Be prepared. I can do this!!! • Worry about what is real. • Arrive early and get organized. • Don’t talk about the test with your classmates. • Read over the test and plan your approach. • If a question is unclear, don.t hesitate to clarify. • Try to relax. Take slow deep breaths. • Pay attention to he test and not everyone else in the room.

Slide 55: Pulling it all together... • Learning process • Study strategies • Test taking strategies We are what we repeatedly do. Excellence, then, is not an act but a habit.




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Thursday, May 22, 2008

Reached 3000 Readers/ Subscribers!

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May 22, 2008 1:39AM, almost ready to go hit the sack when I notice that we have reached the 3000 subscribers! Just though I would brag about it :) Thanks people for you support and loyalty to our NurseReview.Org Community.

I encourage all of you to please contribute so that we can help each other. You can do so by registering in our forum @ http://Forum.NurseReview.Org and add stuff that you think will help your fellow nurses.

Thanks,
Myk


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Wednesday, May 21, 2008

Introduction to Mechanical Ventilation

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Introduction to Mechanical Ventilation Slide Transcript
Slide 1: Introduction to Mechanical Ventilation Craig A. Hawkins BS RRT RCP Respiratory Therapy Supervisor Presbyterian Hospital

Slide 2: Indications for Mechanical Ventilation  Impending Respiratory Failure  Acute Respiratory Failure/Arrest  Post-Operatively

Slide 3: Indications for Mechanical Ventilation  Impending Respiratory Failure  Progressively worsening clinical appearance.  Worsening CXR.  Hypoxemic Respiratory Failure.  Hypercapnic Respiratory Failure.

Slide 4: Indications for Mechanical Ventilation  Acute Respiratory Failure/Arrest  Acute change in ABG results  Respiratory Arrest/Status Post CPR  Acute epiglottitis/anaphylaxis

Slide 5: Indications for Mechanical Ventilation  Postoperatively  Oversedation/paralytics  Pain Control  Proper Immobilization

Slide 6: Key Terms in Mechanical Ventilation  Tidal Volume (Vt)  The volume of air inhaled and exhaled from the lungs.  Breaths per Minute (RR, f)  Also known as frequency.  Positive End Expiratory Pressure (PEEP)  Maintenance of above atmospheric pressure at the airway throughout exp. phase.

Slide 7: Key Terms in Mechanical Ventilation  Minute Ventilation (VE)  The total amount of volume moving in and out of the lung in one minute.  Fractional Inspired Oxygen (FiO2)  Correctly written with decimal place (21%- 0.21; 100%-1.0)  Inspiratory:Expiratory Ratio (I:E ratio)  Normal I:E ratio 1:2-3

Slide 8: Negative Pressure Ventilation  Rarely Used; Currently used for patients with neuromuscular diseases.  Thoracic cage is encased where negative pressure is applied across the chest wall.  Generates subatmospheric pressures creating a difference in pressure gradients.  During exhalation, negative pressure is replace by atmospheric pressure allowing the lungs to deflate.

Slide 9: Negative Pressure Ventilation  Types of Negative Pressure Ventilators

Slide 10: Iron Lung circa 1950’s

Slide 11: Modern(ized) Iron Lung

Slide 12: Chest Cuirass

Slide 13: Complications with Negative Pressure Ventilation  Limited access for patient care.  Inability to properly monitor pulmonary mechanics.  Patient discomfort.

Slide 14: Positive Pressure Ventilation  Defined as the application of pressure to the lungs in order to improve gas exchange.  The Lungs are physically filled/ventilated with air using machinery.  Multiple modes, methods, and theory.

Slide 15: Positive Pressure Ventilation  Basically broken into two categories:  Control Modes.  Supportive Modes.

Slide 16: Control Modes of Ventilation  Assist/Control (usually abbreviated A/C also known as Volume Control VC).  Tidal Volume is set and remains constant.  Respiratory Rate is set.  Airway Pressure will vary according to lung compliance.  Ventilator will deliver set volume whether patient triggers a breath or mandatory breath is being delivered.

Slide 17: Control Modes of Ventilation  Pressure Control Ventilation (usually abbreviated PCV or sometimes PCIRV).  Upper Airway Pressure Level is set and remains constant.  Respiratory Rate is set.  Tidal volumes will vary according to lung compliance.  Ventilator will deliver set pressure level whether patient triggers a breath or mandatory breath is being delivered.

Slide 18: Control Modes of Ventilation  Pressure Regulated Volume Control (usually abbreviated PRVC).  Tidal Volume is set, however may or may not remain constant.  Respiratory Rate is set.  Ventilator will deliver volume however volume may decrease according to patient’s lung compliance.  A lung protective mode.

Slide 19: Supportive Modes of Ventilation  Synchronized Intermittent Mandatory Ventilation (usually abbreviated SIMV).  Tidal Volume is set and delivered on each mandatory breath.  Respiratory Rate is set.  When a patient triggers the ventilator spontaneously , the patient receives a Pressure Supported breath.

Slide 20: Supportive Modes of Ventilation  Pressure Support Ventilation (PSV)  Is a strictly patient dependant mode; patient must be breathing spontaneously.  An upper (inspiratory) pressure level is adjusted to provide adequate tidal volumes for each patient triggered breath.  PEEP is also adjusted as an independent pressure from the upper pressure level and is active during expiration.  PSV is a weaning mode.

Slide 21: Supportive Modes of Ventilation  Volume Support (VS)  Is a strictly patient dependant mode; patient must be breathing spontaneously.  Tidal Volume is set.  Each spontaneous breath is supported with dialed volume.

Slide 22: Supportive Modes of Ventilation  Continuous (Constant) Positive Airway Pressure (CPAP)  Is a strictly patient dependant mode; patient must be breathing spontaneously.  Closely resembles Pressure Support, however CPAP is a constant set pressure that does not change during inspiration or expiration.  CPAP is a weaning mode.

Slide 23: Drager Evita II

Slide 24: Puritan Bennett 840

Slide 25: Servo 900c

Slide 26: Servo 300a

Slide 27: Servo i

Slide 28: One of the Most Famous Ventilators

Slide 29: Complications to Mechanical Ventilation  Ventilator Induced Lung Injury (VILI)  Induced by excessive pressure (barotrauma)  Induced by excessive Volume (volutrauma)  Ventilator Associated Pneumonia (VAP)  Most commonly Pseudomonas, Gram Negative Bacilli, and staphylococci.

Slide 30: Ventilatory Discontinuance  Weaning  Process of discontinuing ventilatory support, regardless of the time frame involved.  Categories  Quick removal; routine  More gradual reduction in support (trach collar trials)  Ventilator dependent patients

Slide 31: Ventilatory Discontinuance  Success in discontinuing ventilatory support is related to the patients conditions in four main areas:  Ventilatory workload  Oxygenation status  Cardiovascular function  Psychological factors.

Slide 32: Ventilatory Discontinuance  Common indices in successful weaning: FiO2 < 0.4-0.5 PaO2 > 60 PaO2/FiO2 ratio > 200 PaCO2 < 50 pH > 7.35 RSBI < 100

Slide 33: Questions?




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Tuesday, May 20, 2008

NCLEX TIPS FOR YOU

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I found this post at www.nclex-rn.net. It was posted by alex from IP 202.81.174.252 on April 25, 2007 at 20:44:17:

Bulk of my NCLEX questions are:

1. PRIORITIZATIONS.
Remember the rule of stable vs. unstable. Lagi ko itong sinasabi. Although you consider the client unstable but if it expected in him, this is stable. I just stick with this rule. Example. Asthma with wheezing- you consider this unstable at sa ABC, unstable ito. But first think na ito ay EXPECTED sa may asthma so this will be considered stable. Remember, this rule is based on what the question is being asked. PRACTICE makes PERFECT and makes you PASS. On the day before the exam and during my practice, sabi ko sa sarili ko, I’d rather answer prioritization questions rather than basic. Mas ok ako sa mga analysis and application more on basic questions. Pero as I said, LEARN THE BASIC. Read nyo daw iyong book ni Mosby na delegation and prio. Just buy it harap PRC photocopy, Php 150 lang than orig Php 1700. (laking mura no) I didn’t read the book pero highly recommended daw!

2. Delegation.

Just learn the basic- RN- newly admitted, needs assessment, pre op teaching and post op, nsg. Judgement and discharge planning ,IV meds, BT. LPN-can give meds except IV, sterile techniques like wound dressing, catheterization, insertion of NG tube, remove sutures. Also for stable expected outcome. NA/ UAP/CN/ Senior nursing student- lahat ng may “-ing” ex bathing, reading v/s in long term pt. Testing occult blood, BS monitoring, soap sud enema, testing occult blood, isolation precautions, basic hygiene ADL, Input and Output, finger stick with gestational diabetes, urinalysis, TSB, turning unconscious patient, change perineal pad, assist in ambulation, discharge tomorrow, stable v/s, pulse oximetry reading, terminally ill because of comfort only needed and Isolation. Remember: Routinary Procedure ang NA (medyo maduduming trabaho)

3. Safety Infection Control

Basic again: TB or airborne (just PARTICULATE MASK). Pnemonia or droplet (just SURGICAL mask). Read as much as possible and take note if the diseases mode of transmission is airborne, droplet or contact. PLEASE do read.

4. Pharmacology

TIP: get the suffixes of all the meds you encountered and know their side effects. Ex. –one= steroids and glucocorticoids. SE: Cushings disease. Antihypertensive meds SE: orthostatic hypotension. BAGONG BAGO ang meds at never heard before. There are only for choices in every pharmacology question.

Question: You are going to give _________. Which among these statements is correct.
a. I will take this with meals (or without meals)
b. I will take this med in the morning (or evening)
c. The side effects of these meds are:___________
d. I will notify the doctor if I felt____


Ito lang ang ang choices ng bawat pharmacology question. If you encountered this, if you really don’t know, FIRST INSTICT and PRAYER will be the best answer. Tao ka lang, hindi mo alam ang buong meds!!!!


5. Read on/ Emphasize on:
a. Triage (External)- treat first the stable before the unstable. Emergent first before urgent. But kung E.R. unstable muna before stable. ABC
b. Spinal Cord Injury
c. Reflexes
d. Cane/ Walker/ Crutches
e. LABORATORY VALUES
f. DIET DIET DIET
g. Nephrotic syndrome and Glomerulonephritis
h. Burn
i. Respi and Metabolic Acidosis and Alkalosis
j. CHEST TUBE CHEST TUBE CHEST TUBE
k. Cataract/ glaucoma/ retinal detachment
l. Defib vs. cardio version
m. Hemodialysis vs. peritoneal dialysis
n. HERBAL MEDS( just summarize their effects)
o. AUTONOMIC DYSREFLEXIA
p. DIABETES DIABETES DIABETES
q. Transcultural nsg.
r. Primary, team, functional Nsg.
s. Consent and Advance Directives!!!!
t. Glasgow coma scale
u. Traction
v. DI vs SIADH
w. FLUID VOL DEFICIT vs. OVERLAOAD
x. PEAK FLOW METER vs. METERED DOE INHALER vs. INCENTIVE SPIROMETER.
y. RENAL FAILURE ACUTE VS CHRONIC ACUTE VD. CHRONIC
z. Colostomy Irrigation/ care and Ileostomy Care
aa. Rhematoid vs. Osteoporosis vs Gouty
bb. CAST CARE
cc. DIET DIET DIET
dd. IV side effects
ee. Lung Sounds
ff. Shock
gg. NORMAL AGING PROCESS
hh. Levin vs. Salem vs. Sengstaken tube
ii. Immunizations
jj. PHEOCHROMOCYTOMA
kk. Chrons Disease
ll. ECG
mm. Breast Cancer
nn. Some OB and PEDIA ( marami rami rin ang questions ko ditto pero hindi ako masyadong nagaral nito. Know the different developmental stages)- placenta previs vs abruptio, PIH, APGAR
oo. Psychiatric: MEDS and SE and therapeutic communication., defense mechanism, SUICIDE!!!!
pp. Addisons vs. cushings; Hypothyroid vs Hyper;
qq. Computation of Meds, substitution ( Dopamine)
rr. NCLEX IS REALLY UNPREDICTABLE. JUST KNOW THE BASIC, HOW IT WORKS, PROCEDURES, NURSING INTERVENTION. Marami pa iyan!!!!
ss. KAPLAN STRATEGIES!!!!!

AVOBE ALL, PRAYER IS THE BEST TOOL. The whole exam, hindi ako kinabahan. I prayed before I answer my number 1 question. It is better to condition yourself physically, mentally and spiritually. Go to website www.vue.com/nclex then click the play the turorial para alam ninyo kung paano sumagot sa NCLEX. Ganoon din makikita ninyo sa actual exam.

Masuwerte ang mga nag265, pinagbibigyan tayo ng computer. For my readings, I just read twice my KAPLAN book ( iyong kasama sa package naming); CD’S like Saunders compre and QA (compre lang ako and not the book, just CD, wala kasi me pangbili just burn it from your friends or borrow it), mosby, QUESTION TRAINER NG KAPLAN (1-7)- I finished this twice (60-68% lang ako always), lippincott, NSNA, spring house. Focus on your weakness especially of the CD’s who has performance report after each exam. If it is in percentage, monitor it so that you can make your score higher the next time.

Goodluck and just email me for more questions. I really love to share my experience with you guys!!! Do share these also to others. Sharing is best!!!

I really gain lot of friends in here. God has really plans for me and to you as well!!!!

God Bless!!!!-Alex USRN


SOURCE: http://www.nclex-rn.net/nclex/messages2007a/173482.html


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Nursing Management of the Adult Client with Neurologic Alterations

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Nursing Management of the Adult Client with Neurologic Alterations Slide Transcript
Slide 1: Nursing Management of the Adult Client with Neurologic Alterations NURS 228 Janie Best, MSN, RN, APRN, BC

Slide 2: Objectives Relate principles of anatomy and physiology to the nursing care of individuals with common health problems of the nervous system. Analyze the common health problems that accompany alterations in cerebral circulation in the adult patient Altered Level of consciousness (LOC) Increased intracranial pressure

Slide 3: The Nervous System Central Nervous System (CNS) Brain Spinal Cord Peripheral Nervous System (PNS) Cranial nerves Spinal nerves Autonomic nervous system Sympathetic Parasympathetic

Slide 4: Anatomy Brain Cerebrum Hemispheres Lobes: Frontal, Parietal, Temporal, Occiptial Thalamus, Hypothalamus, Basal ganglia Cerebellum Brain Stem

Slide 6: Anatomy Protective Structures Dura mater Arachnoid Pia mater CSF Clear, colorless Produced by choroid plexus (ventricles/arachnoid layer) 500 mL daily; Most absorbed by body

Slide 7: Brain Requirements Blood Flow 750 ml / minute 20% of total oxygen uptake Glucose 80% of body’s glucose use Blood Flow Regulation CO2 Oxygen

Slide 8: Diagnostic Studies Skull and Spine Radiography CT (Computerized Tomography) MRI (Magnetic Resonance Imaging) PET (Positron Emission Tomography) EEG (Electroencephalogram) EMG (Electromyography)

Slide 9: Diagnostic Studies – Cerebral Angiography Post Procedure Care Pre-procedure care Bedrest x 8 hrs Assess for allergy to iodine and shellfish Increase Fluids NPO 4-6 hrs Monitor Baseline neuro assessment Neuro assessment / VS Education Peripheral pulses Immobile during / Observe following procedure for s/s altered cerebral Expect brief feeling of blood flow warmth / burning in Hematoma at femoral behind eyes, or in jaw, injection site teeth, tongue, lips Keep bed FLAT if femoral May have metallic taste artery is used

Slide 10: Diagnostic Studies – Myelography / Lumbar Puncture Pre Procedure Care Post Procedure Care NPO HOB > 300 – 450 for 3 Sedative may be given – 8 hrs Lateral recumbent position with knees Drink plenty of fluids drawn up to abdomen Monitor VS and and chin onto chest Urinary output Patient Ed. - Position of x-ray table may be changed during procedure LP is contraindicated if suspected IICP

Slide 11: Neurological Assessment Hx present illness A – associated symptoms P – what provokes / pallliates symptoms Q – Quality of pain R – region and radiation S – severity of pain on scale of 1-10 T – timing (start / stop, intermittent, constant)

Slide 12: Neurological Assessment Physical Exam Mental status Cranial Nerves Motor system Cerebellar - balance / coordination Sensory system Reflexes

Slide 14: Abnormal Findings Babinski Reflex CNS disease of pyramidal tract Clonus Hyperactive reflexes Corneal reflex Loss - dysfunction of Cranial nerve 5 Gag reflex Loss - Dysfunction of cranial nerves IX and X Text: 1839-1840

Slide 15: Abnormal Findings Battle’s sign Raccoon’s eye Rhinorrhea Otorrhea

Slide 16: Doll’s Eyes - Oculocephalic Reflex http:// connection.lww.com/Products/morton/documents/images/Ch33/jpg/Ch33-006B.jpg

Slide 18: Doll’s eyes Brainstem Eyes fail to follow normal movements Decorticate Cerebellar Internal rotation of arms &wrists, posturing function extension, internal rotation & plantar flexion of the feet Decerebrate Cerebellar Extension & external rotation of arms & posturing function wrists, extension, plantar flexion, internal rotation of feet Flacid posturing Cerebellar No motor tone or function function, limp

Slide 19: Altered LOC - Etiology Vowel TIPPS Alcohol Trauma Epilepsy Infection Insulin Psych Opiates Poisons Urates (renal failure) Shock

Slide 20: Altered LOC Arousal Alertness, response to stimuli Content Awareness of time, place, person

Slide 21: Altered LOC Level of Consciousness Continuum Terminology Alert Confusion Somnolent Lethargic Obtunded / Stupor Comatose

Slide 22: Glasgow Coma Scale Best Eye-opening Best Motor response response 1 = no response 1 = no response 6 = obeys commands 4 = spontaneously Best Verbal response 1= no response 5 = oriented Score < 7 is consistent with significant alteration in LOC (coma)

Slide 23: Assessment of Respirations Cheyne-Stokes Rhythmical pattern: waxing/ waning in depth, followed by periods of apnea Neurogenic hyperventilation Regular, rapid (> 24 / min), deep sustained respirations Apneustic Irregular respirations with pauses at the end of inspiration & expiration Ataxic Totally irregular in rhythm & depth Cluster Clusters of irregular breaths with irregularly spaced apnea

Slide 24: Assessment of other Vital Signs Vital Sign ↑/ Implications Temperature Increase CNS infection Subarachnoid hemorrhage, hypothalamic lesions, hemmorhage of hypothalamus or brainstem Temperature Decrease Spinal shock Metabolic coma Drug overdose Brainstem lesions

Slide 25: Assessment of other Vital Signs Vital Sign ↑ or  Implications Pulse Increase Poor cerebral oxygenation Decrease Late stages of IICP Blood Pressure HTN Cerebral trauma – Cushing’s triad

Slide 26: Brain Death Persistent vegetative state Brain death Rule out spinal cord injury Other causes of neurologic impairment No neuromuscular paralyzing agent effects Criteria documented in chart includes Flat EEG Absence of spontaneous respirations Pupils fixed and dilated

Slide 27: Altered LOC Nursing Interventions Airway maintenance Fluid balance and Nutrition Mouth care Skin and joint integrity Preventing injury Temperature regulation Bladder and bowel function

Slide 28: Altered LOC Nursing Interventions Sensory stimulation Family needs Preventing complications Pneumonia Aspiration Respiratory failure DVT/PE Assume the unconscious patient CAN hear! Outcomes

Slide 29: Intracranial Pressure (ICP) Pressure exerted by the combined volume of Brain tissue CSF Blood Normal ICP: 10 – 20 mmHg Normal CSF pressure 5-13 mmHg

Slide 30: Intracranial Pressure (ICP) Closed Box Brain tissue (80%) Blood (10%) CSF (10%) Brain Injury Skull may contain swollen brain tissue, blood or CSF Skull May become too full ↑ pressure on brain tissue

Slide 31: Intracranial Pressure (ICP) Compensation: Monro-Kellie Hypothesis Change in volume of one of the contents must have a change in volume of one or both of the other components in order to remain stable

Slide 32: Intracranial Pressure (ICP) Brain volume – limited expansion; controlled by Blood – brain barrier Cerebral blood volume – controlled by cerebral blood flow CSF - ↑ CSF absorption- or-  CSF production Shunting of venous blood out of the skull

Slide 33: Blood-Brain Barrier Permeable to water, oxygen, CO2, other gases, glucose and lipid soluble compounds Movement across barrier depends on: Particle size Lipid solubility Chemical dissociation Protein-binding capacity

Slide 34: Cerebral Blood Flow / Volume Increased Flow / Decreased Blood flow / volume: volume: Effects Effects Systemic hypotension Hypertension ↑ metabolic rate ↓ metabolic rate Acidosis Alkalosis Hypercapnia, Hypocapnia ischemia Cerebral edema Cerebral vasodilation Low cardiac output Cerebral vasoconstriction

Slide 35: ↑ Brain Volume Cause: Space – occupying lesions Cerebral edema Effect: Herniation http://www.uth.tmc.edu/radiology/test/ er_primer/skull_brain/skull.html

Slide 36: Cerebrospinal Fluid Functions Support / cushioning Maintain stable chemical balance of CNS Excrete toxic wastes CO2, lactate, hydrogen ions Effect: Causes of ↑CSF: ↑ cerebral blood volume ↑production Hydrocephalus Obstructed circulation ↓absorption

Slide 37: Intracranial Pressure (ICP) Compensation depends on Location of lesion Rate of expansion Compliance or volume- buffering capacity of body

Slide 38: Cycle of malignant progressive brain swelling ↑ ICP Cerebral vasodilation & edema  Cerebral brain flow ↑ pCO2  pH Tissue hypoxia From: Hudak, C.: Critical care nursing: p. 640

Slide 39: IICP CPP (Cerebral Perfusion Pressure) CPP = MAP – ICP Normal CPP – 70 to 100 mmHg IICP – CPP > 100 mmHg or < 50 mmHg < 50 mmHg – irreversible damage Cushing’s Response (Cushing’s reflex) ↑ SBP w/ widening pulse pressure ↓ pulse

Slide 40: IICP Cushing’s Triad ↑ systolic blood pressure  diastolic blood pressure Bradycardia Activation ICP ≥ Mean arterial pressure Ominous sign

Slide 42: IICP Early Indicators ∆ LOC (earliest indicator) Slowing of speech Delays in response to verbal suggestions Pupillary changes, Impaired EOMs Ipsilateral weakness Headache (constant, increasing intensity, aggravated by movement)

Slide 43: IICP Later Indicators Continued deterioration of LOC Pulse, Respiratory rate decreased/erratic BP, Temp increase Altered respiratory patterns Cheyne-Stokes respirations Ataxic breathing Projective vomiting Hemiplegia, Posturing Loss of pupillary, corneal, gag, swallowing reflexes

Slide 45: IICP - Complications Cerebral Herniation DI (Diabetes Insipidus) - ↓ secretion ADH Clinical manifestations SIADH (Syndrome of Inappropriate release of Antidiuretic Hormone) - ↑ secretion ADH Clinical manifestations

Slide 46: IICP – Complications DI DI (Diabetes Insipidus) - ↓ secretion ADH Clinical manifestations Polydipsia, polyuria, dehydration Urine output increases dramatically (up to 20 L / 24hr) Urine specific gravity falls to 1.001 – 1.005 Urine osmolality ↓ to 50 – 100 mOsm/kg.

Slide 47: IICP – Complications - DI Treatment Fluid and electrolyte management Vasopressin Thiazide diuretics Complications Cardiovascular collapse Tissue hypoxia Seizures Encephalopathy

Slide 48: IICP – Complications - SIADH SIADH (Syndrome of Inappropriate release of Antidiuretic Hormone) – Pathophysiology: ↑ secretion ADH or  production of ADH Results in ↑ in total body water Secretion continues with  osmolality of plasma Causes Pituitary tumor Head injury CNS infection Bronchogenic (oat cell), or pancreatic carcinoma

Slide 49: IICP – Complications - SIADH Clinical manifestations Signs / symptoms Water retention → Personality changes water intoxication Headache Hyponatremia Decreased mentation Lethargy N, V, diarrhea Decreased tendon reflexes Seizures, coma

Slide 50: IICP – Complications - SIADH Treatment Complications Treat underlying Seizures disease Coma Alleviate excessive Death water retention Nursing care – depressed LOC

Slide 51: IICP – Medical Management Goals Decreasing Cerebral Edema Lowering CSF Volume Decreasing Cerebral Blood Volume

Slide 52: IICP – Medical Management Neuro Exam Ventriculostomy ICP monitoring ↑ risk infection, bleeding, destruction of neurons Contraindications Coagulopathies, small or collapsed ventricles, severe generalized cerebral edema CSF Drainage Clear CSF

Slide 53: IICP – Medical Management AVOID Lumbar Puncture in IICP Risk of: Herniation of brainstem Infection Headache

Slide 54: IICP – Medical Management Medications Osmotic diuretics (cerebral edema reduction) Corticosteroids (cerebral edema reduction) Inotropics (maintain CPP) Antipyretics (fever control) Barbiturates (reduces metabolic demands)

Slide 55: Osmotic Diuretics Mannitol Increases cerebral tissue perfusion and reduces ICP Draws fluid from cerebral interstitial spaces into the vascular space Test dose Serum osmolality must be monitored Complication – acute renal failure Contraindication – active intracranial bleeding Monitor: neurologic and renal status IV site for signs of Extravasation

Slide 57: IICP – Nursing Diagnoses Ineffective cerebral tissue perfusion Ineffective airway clearance Ineffective breathing pattern Protection from injury

Slide 58: IICP Planning and Goals Maintain patent airway Adequate breathing pattern Optimal cerebral tissue perfusion Maintain negative fluid balance Absence of complications Calm, safe environment (minimal noise, dim lights)

Slide 59: IICP – Expected Outcomes Maintain patent airway Attain optimal breathing pattern Demonstrate optimal cerebral tissue perfusion Attain desired fluid balance Has no signs or symptoms of infection Absence of complications

Slide 60: Critical Thinking Case Study Chapter 6: Case Study 15, pp. 395-398.

Slide 61: References Deglin, J.H., Vallerand, A.H. (2005). Davis’s Drug Guide for Nurses, 10th Ed. Philadelphia. F.A. Davis. Pp. 739-741. Hogan, M., Madayag, T. (2004). Medical-Surgical Nursing: Reviews and rationales. Pearson Education, Inc. Upper Saddle River, NJ. Pp. 167 – 210. Hudak, C., Gallo, B, Morton, P. (1998). Patient Management: Nervous System. In: Critical Care Nursing: A holistic approach, 7th ed. Lippincott. Philadelphia. Pp. 613- 637. Hudak, C., Gallo, B, Morton, P. (1998). Patient Management: Endocrine System. In: Critical Care Nursing: A holistic approach, 7th ed. Lippincott. Philadelphia. Pp. 834- 836.

Slide 62: References LeMone, P., Burke, K. (2008). Medical Surgical Nursing: Critical thinking in client care. Pearson Education, Inc. Upper Saddle River, NJ. Pp. 1503 – 1554. Smeltzer, S., Bare, B. (2004). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Lippincott, Williams, & Wilkins. Philadelphia. Pp. 1821 -1886. Wagner, K.D., Johnson, K., Kidd, P.S. (2006). Neurologic. In: High Acuity Nursing. Upper Saddle River, N.J. pp. 402-425.





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Monday, May 19, 2008

Nursing Resource Slides: Third Spacing: Where has all the fluids gone?

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Nursing Resource Slides: Third Spacing: Where has all the fluids gone? Slide Transcript
Slide 1: Third-Spacing: Where Has All the Fluid Gone? By Marcia Bixby, RN, CS, CCRN, MS Nursing made Incredibly Easy! September/October 2006 2.5 ANCC/AACN contact hours Online: http://www.nursingcenter.com © 2006 by Lippincott Williams & Wilkins. All world rights reserved.

Slide 2: Fluids 101  Fluids bring nutrition and oxygen into the cells and remove wastes  Fluid is divided into two compartments: intracellular and extracellular  Extracellular is divided into interstitial and intravascular

Slide 3: Fluids 101  The body’s fluid should be in balance; volume entering the body = volume leaving the body  Fluid loss occurs via urine, sweat, stool, and incidental losses from respiratory effort

Slide 4: On the Move  Diffusion: Passive movement of fluid from an area of higher concentration to an area of lower concentration  Osmosis: Water movement through a selectively permeable membrane from an area of lower concentration to an area of higher concentration

Slide 5: On the Move  Active transport: Movement of molecules against a concentration as they move from an area of lower concentration to an area of higher concentration; this movement requires energy  Third spacing occurs when the fluid is “trapped” in the interstitial spaces

Slide 6: How Fluids Affect Cells: Isotonic Solutions

Slide 7: How Fluids Affect Cells: Hypertonic Solutions

Slide 8: How Fluids Affect Cells: Hypotonic Solutions

Slide 9: Decreased Oncotic Pressure  Loss of albumin or protein leads to decreased oncotic pressure, causing fluid to “leak” from the intravascular space to the interstitial space  Due to the loss in circulating fluid volume, cardiac output decreases

Slide 10: Causes of Fluid Shifts  Albumin losses can occur in liver failure, liver dysfunction, and malnutrition  Albumin losses can lead to fluid shifting into the peritoneum, causing ascites  Destruction of endothelial cells, such as in bowel surgery, can cause fluid to move and be trapped in the interstitial spaces  Fluid trapped in the lungs can lead to pulmonary edema

Slide 11: Inside the Cells  Interstitial fluid trapping can cause compression of the microvasculature, resulting in hypoperfusion and ischemia  Inflammatory “mediators” are released into the bloodstream, which can lead to systemic inflammatory response syndrome (SIRS)  Multiple organ dysfunction syndrome (MODS) occurs, leading to organ failure and death

Slide 12: Mediators of SIRS and MODS

Slide 13: What Happens When Fluids Shift?  With decreased circulating volume, baroreceptors in the aorta are activated  Sympathetic nervous system releases epinephrine and norepinephrine, causing vasoconstriction and an increased heart rate  Kidneys launch the renin-angiotensin-aldosterone system in response to a lower glomerular filtration rate  All this happens with the goal of increasing circulating volume, blood pressure, and cardiac output

Slide 14: Fluid Shift in the Bowel  Causes abdominal distention  Measure bladder pressure and abdominal girth at least every 4 to 8 hours while signs are abnormal

Slide 15: Making the Grade  A patient’s intra-abdominal pressure (IAP) determines if he has intra-abdominal hypertension.  According to the World Society of Abdominal Compartment Syndrome, there are four grades of intra- abdominal hypertension:  Grade I: IAP of 12 to 15 mm Hg  Grade II: IAP of 16 to 20 mm Hg  Grade III: IAP of 21 to 25 mm Hg  Grade IV: IAP of > 25 mm Hg

Slide 16: Complications of Abdominal Swelling  Decreased cardiac output leads to decreased blood pressure, which causes:  increased pressure on the aorta and the iliac and femoral arteries, leading to decreased cardiac output and decreased blood pressure  impaired kidney function  impaired blood flow to the bowel, liver, and spleen

Slide 17: Monitoring the Patient  Fluid shift will either resolve over the next several hours (up to 48 hours) or the patient will continue to develop bowel edema and, eventually, ischemia  Closely monitor vital signs, urine output, peripheral perfusion, mental status, ventilation/perfusion status, hematocrit/hemoglobin, serum electrolytes (elevated lactate may indicate bowel ischemia)

Slide 18: Fluid Resuscitation  Administer maintenance I.V. isotonic fluid plus intermittent colloids (i.e., albumin); pulls fluid from the interstitial spaces into the intravascular space  Small dose of a loop diuretic, such as furosemide (Lasix) may be ordered if kidneys can’t get rid of the excess fluid  If hemoglobin is low, infuse blood products, such as packed red blood cells, as ordered to help increase oxygen and pull fluid from the interstitial space

Slide 19: If Bowel Ischemia Occurs  A kidney-ureter-bladder X-ray (KUB) may be done; it will show bowel edema and any “free air,” which may indicate bowel perforation  A CT scan can detect worsening bowel edema, inadequate perfusion, and hematomas  Patient may need further surgery to repair a perforated bowel or to decrease edema





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Sunday, May 18, 2008

Medical Surgical Nursing Resource Slides: Identification of Shock

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Medical Surgical Nursing Resource Slides: Identification of Shock Slide Transcript
Slide 1: Identification of Shock States Caralee Brommé, RN, MSN, CCRN

Slide 2: Identification of Shock States „ Types of shock ƒ Hypovolemic ƒ Distributive/ Vasogenic ‚ Anaphylactic ‚ Neurogenic ‚ Septic ƒ Cardiogenic „ Clinical manifestations ƒ Compensated/Progressive ƒ Decompensated/ Nonprogressive ƒ Irreversible „ Diagnosis& treatment ƒ History ƒ Physical „ Case study Whaley and Wong (1999) 2

Slide 3: Identification of Shock States „ Shock, or circulatory failure is a complex clinical syndrome characterized by inadequate tissue perfusion to meet the metabolic demands of the body, which results in cellular dysfunction and eventual organ failure and death „ The causes are different, but the physiologic consequences are the same „ Hypotension,tissue hypoxia, and metabolic acidosis Whaley and Wong (1999) 3

Slide 4: Identification of Shock States „ Hypovolemic shock „ Characterized by a reduction in circulating volume or extra cellular loss ‚ Blood loss- trauma , GI bleeding, intracranial hemorrhage ‚ Plasma loss - increased capillary permeability associated with sepsis and acidosis, burns,peritonitis ‚ Extra cellular loss- vomiting diarrhea, glycosuric diuresis, and sunstroke Whaley and Wong (1999) 4

Slide 5: Assessment findings and classification with acute hemorrhage Assessment Class 1 Class 2 Class 3 Class 4 Blood loss <15% 15-30 30-40 >40 Blood loss <750ml 750- 1500- >2000 1500 2000 Pulse rate <100 >100 >120 >140 Blood Normal Normal Normal Normal Pressure Resp Rate 14-20 20-30 30-40 >35 Whaley and Wong (1999) 5

Slide 6: Identification of Shock States „ Distributive shock „ Characterized by systemic vasodilatation ƒ Vasogenic ‚ Anaphylaxis- allergen mediated ‚ Sepsis- overwhelming sepsis with circulating bacterial toxins ‚ Myocardial depression and peripheral dilation ƒ Neurogenic ‚ Spinal cord injury Whaley and Wong (1999) 6

Slide 7: Identification of Shock States „ Cardiogenic shock „ Results from impaired cardiac function resulting in reduced cardiac output ƒ Myocardial Infarction ƒ Primary pump failure- myocarditis, trauma, congestive heart failure ƒ Dysrhythmias- ‚ Paroxysmal atrial tachycardia, ‚ Ventricular dysrhythmias ƒ Obstructive Conditions ‚ Large Pulmonary emboli ‚ Tension Pneumothorax ‚ Pericardial Tamponade Whaley and Wong (1999) 7

Slide 8: Identification of Shock States „ Clinical manifestations ƒ Compensated/ progressive ‚ Increased heart rate/ tachycardia ‚ Vasoconstriction • Decreased perfusion of the hands and feet ‚ Irritability ‚ Thirsty ‚ Decrease urinary output - ‚ Normal BP with narrowing pulse pressure ƒ Example moderate dehydration Whaley and Wong (1999) 8

Slide 9: Identification of Shock States „ Decompensated shock ƒ Pronounced tachycardia ƒ Tachypnea ƒ Very lethargic, confused, apathetic ƒ Cool pale extremities with decreased capillary refill and skin turgor ‚ vasodilatation of the microcirculation ƒ BP might be maintained, but increasingly narrow in pulse pressure ƒ Moderate metabolic acidosis ‚ lactic acidosis from anaerobic metabolism „ Will progress to tissue hypoxia,metabolic acidosis and eventually organ dysfunction Whaley and Wong (1999) 9

Slide 10: Identification of Shock States „ Irreversible shock ƒ Pronounced vasoconstriction ƒ Severe tachycardia with progression to bradycardia- thready weak pulse ƒ Hypotension ƒ Coma ƒ Apnea ƒ Irreversibly organ damage ‚ Kidneys, brain, heart Whaley and Wong (1999) 10

Slide 11: Identification of Shock States „ Diagnosis ƒ History ‚ Type of illness- trauma vs. illness ‚ Length of illness-hours to days ‚ Find causative agent. ƒ ABG for acid/ base & oxygenation status ƒ Lactic acid level ƒ CBC, blood chemistry, full body fluid cultures ƒ EKG,CXR ƒ CVP, Arterial line Whaley and Wong (1999) 11

Slide 12: Identification of Shock States ƒ Physical exam ‚ Level of consciousness ‚ Heart rate/ Respiratory rate • O2sat (difficult d/t perfusion) ‚ Capillary refill (perfusion) ‚ BP (Art/ Doppler) ‚ Urinary output ‚ Cardiac monitoring ‚ Temperature monitoring Full hemodynamic monitoring in sever cases Whaley and Wong (1999) 12

Slide 13: Identification of Shock States „ Therapeutic Management ƒ Ventilation ‚ Establish airway- prep for intubation ‚ Administer O2 by mask ƒ Replace fluids ‚ Establish IV/ IO access ‚ Restore volume with fluid boluses • 20cc/kg isotonic solution ƒ Improve pump action ‚ Administer vasopressors • Epinephrine .01mg/ kg • Dopamine 2-20 mcg/kg/min Whaley and Wong (1999) 13

Slide 14: Identification of Shock States „ General support ƒ Keep pt flat with leg raised above level of heart ƒ Keep pt warm and dry „ Septic Shock ƒ Administer broad-spectrum antibiotics „ Anaphylaxis ƒ Remove allergen ‚ Tourniquet above injection site Whaley and Wong (1999) 14

Slide 15: Identification of Shock States in Infants and Children „ Children have an intense vasoconstrictor response: ƒ Systolic blood pressure will be maintained at the expense of peripheral perfusion ƒ Observe poor peripheral perfusion and narrow pulse pressure before hypotension is evident ƒ A decrease in heart rate below normal range will cause a significant fall in cardiac output Whaley and Wong (1999) 15

Slide 16: Identification of Shock 1. Type and degree of shock? 2. Initial intervention? 3. What signs of improvement will you see with treatment? Whaley and Wong (1999) 16

Slide 17: Identification of Shock States „ Summary ƒ The type and degree of shock must be diagnosed early and treatment started immediately. ƒ In infants and children, hypotension is a very late manifestation. ƒ Heart and respiratory rate, level of consciousness and capillary refill are essential parts of the physical exam. Whaley and Wong (1999) 17





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Saturday, May 17, 2008

Nursing Resource Slides: Thorax & Lungs

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Nursing Resource Slides: Thorax & Lungs Slide Transcript
Slide 1: Thorax and Lungs

Slide 2: Outline Structure and Function Subjective Data Objective Data Abnormal Findings

Slide 3: Structure and Function

Slide 4: Thoracic Cage /Cavity Shape- bony, conical shape, narrower at top borders – it is defined by:  Sternum – 3 parts: manubrium, body, xiphoid process  Ribs – 12 pairs, 1st seven attach to the sternum (costal cartilages) Ribs 8,9,&10 attach to the costal cartilage above, Ribs 11 & 12 are floating ribs  12 Thoracic vertebrae  Diaphragm – the floor, separates the thoracic cavity from the abdomen

Slide 5: Anterior Thoracic Landmarks Suprasternal Notch – U shaped depression Sternum – “breastbone” = 3 parts 1. Manubrium 2. Body 3. Xiphoid process  Angle of Louis – manubriosternal angle continuous with the 2nd Rib  Costal angle- usually 900 or <. (increases when rib cage is chronically overinflated)

Slide 7: Posterior Thoracic Landmarks Vertebra Prominens – Flex head, feel most prominent bony projection at base of neck = C7 next lower one is T1 Spinous Processes – spinal column- Scapula – symmetrical , lower tip at the 7 -8th Rib 12th Rib = midway b/t spine & side

Slide 9: Reference Lines Anterior Chest  Midsternal line  Midclavicular line Posterior Chest  Vertebral line – midspinal  Scapular line

Slide 10: Lateral Chest  Anterior Axillary line  Posterior Axillary line  Mid–axillary line

Slide 14: The Thoracic Cavity Mediastinum middle of the thoracic cavity & contains;  Esophagus  Trachea  Heart  Great Vessels Pleural Cavities on either side of the mediastinum contain the lungs

Slide 15: Lung Borders Anterior Chest –  Apex 3 -4 cm. ↑ inner 1/3 of the clavicles  Base – rests on the diaphragm, 6th rib, MCL Lateral Chest  Extends from Axilla apex to 7th –8th rib Posteriorly  Apex of lung is at C7 – Base T10 (on deep inspiration to T12)

Slide 16: Lobes of Lung Right Lung  3 lobes, upper, middle , lower  Shorter due to liver Left Lung  LUL = Left Upper and Lower ( 2 lobes)  Narrower due to heart

Slide 21: Lobes  Diagonal sloping segments  Oblique fissures

Slide 22: 3 Important Points • Left Lung – no middle lobe • Anterior chest contains upper & middle lobes with very little lower lobe • Posterior chest has almost all lower lobe. Rt middle lobe does not project into the posterior chest

Slide 23: Pleurae The Pleurae form an envelope b/t the lungs & chest wall Visceral pleura – lines outside of lungs Parietal pleura – lines inside of chest wall & diaphragm Pleural Cavity – the inside of the envelope- space b/t visceral & parietal pleura, lubrication. Normally has a vacuum or neg. pressure

Slide 25: Tracheal & Bronchial Tree Trachea – anterior to esophagus-  10-11 cm.long, begins at cricoid cartilage  Bifurcates just below the sternal angle ( AKA angle of Louis, manubriosternal angle) into the  Right Main Stem Bronchus – shorter, wider, more vertical ( Intubation – listen to breath sounds bilaterally)  Left Main Stem Bronchus

Slide 26: Tracheal & Bronchial Tree The trachea & bronchi provide the passage for air to get into the lungs from the environment = Dead Space (no air exchange takes place here)

Slide 27: Bronchi  Secrete mucus – captures particles  Cilia – moves the trapped particles up to be expelled or swallowed Acinus  Functional respiratory unit consisting of,  Bronchioles, alveolar ducts, alveolar sacs, & alveoli  Gaseous exchange in alveolar duct & alveoli

Slide 28: Mechanics of Respiration 4 Major Functions of the Respiratory System 1. Supply O2 for energy production 2. Remove CO2 , waste product of energy reactions 3. Homeostasis, acid-base balance of arterial blood 4. Heat exchange

Slide 29: Respiration maintains pH ( acid- base balance) of the blood by supplying O2 & eliminating CO2. Normal Range Values of Arterial Bld. Gases  pH= 7.35- 7.45  Pa CO2 = 35-45mmHg  PaO2 = 80-100mmHg  SaO2 = 94-98%

Slide 30: Lungs help to maintain the pH balance by adjusting the amt. of CO2 through:  Hypoventilation  Hyperventilation

Slide 31: Respiration = breathing Inspiration Expiration Control of Respiration  Involuntary control by respiratory center in the brain stem consisting of the pons & medulla  Hypercapnia is an ↑ in CO2 in the Bld. And provides the normal stimulus to breath  Hypoxemia

Slide 33: Subjective Data Cough SOB Chest Pain Respiratory Infections Smoking Environmental Exposure Self-care behaviors

Slide 34: Objective Data Inspect Palpate Percuss Auscultate After Posterior Thyroid Exam Posterior chest, Lateral chest, then Anterior chest

Slide 35: Remember to clean stethoscope end piece and warm prior to use on client. Quiet environment conducive to hearing lung sounds

Slide 36: Equipment for Exam Stethoscope Ruler – 15cm. Tape measure Washable marker Alcohol swabs

Slide 37: Posterior Chest Inspect Thoracic Cage  Shape and configuration  Anteroposterior Diameter should be < Transverse Diameter = Ratio 1:2 to 5:7  Note Position of Person to breathe.  ? orthopnea  Skin Color & Condition, nail color

Slide 39: Barrel Chest

Slide 40: Pectus Carinatum (Pigeon)

Slide 41: Pectus Excavatum (Funnel)

Slide 42: Posterior Chest Palpate  Symmetric Expansion- warmed hands – thumbs @ T9-T10- pinch sm. Fold of skin

Slide 44: Posterior chest  Tactile Fremitus – palpable vibration of sound from the larynx- use palmer base of fingers- “99” or Blue Moon  Symmetry important – vibration should feel the same bilaterally.  Avoid palpating over scapulae because bone dampens out sound

Slide 45: ↓ fremitus = obstructed bronchi, pleural effusion, pneumothorax or emphysema Note any barrier that is b/t the sound and your hand will↓ fremitus ↑ fremitus occurs only with gross changes (Lobar pneumonia).

Slide 47:  Entire Chest wall – gently palpate. Note  Tenderness, skin temp., moisture, lumps, lesions  Crepitus = coarse crackling sensation palpable over skin surface. (Subcutaneous emphysema when air escapes from lung into S/C tissue)

Slide 48: Posterior Chest Percuss start at the apices, across shoulders, then interspaces side to side (5cm. Intervals) Avoid scapulae & ribs  Resonance predominates in healthy lung  Hyperresonance – too much air, emphysema, pneumothorax  Dull = abnormal density, pneumonia, tumor, atelectasis

Slide 49: Expected Percussion notes

Slide 50: Diaphragmatic Expansion Lower lung borders in expiration & inspiration 1st Exhale & hold- percuss down the scapulae line until sound changes from resonant to dull. Mark with marker Estimates the level of the diaphragm separating the abd cavity. May be higher on Rt. Due to liver

Slide 51: Diaphragmatic Expansion Now take deep breath & hold. Percuss from mark to dull sound and mark. Measure the difference. Should be + bilaterally 3-5cm in adult may be 7-8 cm in well conditioned person Note hold your own breath when conducting this test!!!!!!!!!

Slide 52: Exhale Inhale

Slide 53: Posterior Chest Auscultate  Position client  Instruct to breath through mouth, little deeper than usual  Tell you if becomes light headed  Use flat diaphragm & hold firmly on chest  Must listen to at least 1 full respiration before moving stethoscope side to side  Compare both sides (lung fields)

Slide 54: Auscultation Sequence

Slide 55: Normal Breath Sounds Bronchial – Anterior Chest only = over trachea & larynx  Quality = harsh, hollow, tubular  Inspiration < Expiration  Amplitude = Loud

Slide 56: Breath Sounds Bronchovesicular both anterior & posterior  Over major bronchi, posterior b/t scapulae, anterior upper sternum, 1st & 2nd ICS  Pitch = high  Inspiration = Expiration  Moderate amplitude

Slide 57: Vesicular – Anterior & posterior  Quality = rustling, wind in trees  Inspiration > Expiration  Soft amplitude

Slide 58: Location of Breath Sounds

Slide 59: Decreased or Absent Breath Sounds  Causes =  obstruction of the bronchial tree by secretions, mucous plug, F.B  ↓ lung elasticity, emphysema = lungs hyperinflated  Pleurisy, pleural thickening, pneumothorax (air), pleural effusion (fld.) in the pleural space

Slide 60: Increased Breath Sounds = dense lung tissue enhances sound transmission as in consolidation ie. pneumonia Silent chest = ominous

Slide 61: Adventitious Sounds Not normally heard in the lungs. Caused by moving air colliding with secretions or by popping open of previously deflated airways Crackles (Rales)  Fine – high pitched popping- not cleared by coughing. Simulate sound by rolling strand of hair b/t fingers near ear or moisten thumb& index finger & separate them near your ear  Course crackles- (opening a velcro fastener) Pleural Friction Rub – coarse & low pitched, 2 pieces of leather rubbed together close to ear

Slide 62: Adventitious Sounds Wheeze (Rhonchi)  High pitched, musical squeaking = air squeezes - asthma  Low pitched musical snoring, moaning, =obstruction Stridor – high pitched, inspiratory, crowing, louder in neck = croup, acute epiglottitis

Slide 63: Coarse Crackles

Slide 64: Fine Crackles

Slide 65: Voice Sounds normal voice transmission is soft, muffled & indistinct. Pathology that ↑ lung density makes words clearer  Bronchophony – “99”  Egophony- ee-ee-ee if disease sounds like aa-aa- aa Record as “E → A changes”  Whisper pectoriloquy 1-2-3  These tests are only done if lung pathology is suspected

Slide 66: Anterior Chest Inspect  Shape & Configuration  Expression- relaxed  LOC – alert & cooperative  Skin color & condition  Quality of Respirations – reg. & even, no retraction or use of accessory muscles

Slide 67: Anterior Chest Palpate  Symmetric Chest Expansion  Tenderness, turgor, temp., moisture Tactile Fremitus  Compare both sides

Slide 68: Symmetric Expansion

Slide 69: Sequence for percussion & auscultation

Slide 70: Tactile fremitus

Slide 71: Percussion Apices in Supraclavicular Areas Interspaces = Resonance  Dullness  Female breast tissue  Liver – Rt. 5th intercostal space midclavicular  Heart – Lt. 3rd intercostal space midclavicular  Flat = muscle & bone  Tympany = stomach (Lt. Side)

Slide 72: Expected Percussion Notes

Slide 73: Auscultate Apices (supraclavicular) to 6th rib Bilateral moving down One full respiration Directly over chest wall – displace female breast tissue

Slide 74: Location Of Breath Sounds

Slide 75: Pulse Oximeter Noninvasive measurement of arterial oxygen saturation = SpO2 by measuring the relative amt. of light absorbed by oxyhemoglobin and unoxygenated hemoglobin. It compares light emitted to amt absorbed. Normally 97 -98%

Slide 76: Terms for Documentation Rate  Eupnea 12 – 20 bpm normal  Tachypnea > 24, rapid, shallow  Bradypnea < 10  Apnea = No respirations for 10 sec. or more

Slide 77: Pattern = breathing rhythm. Normal respirations are regular and even.  Cheyne – stokes = resp wax & wane in reg pattern with periods of apnea(20sec)  Biot’s or ataxisic Sim. To cheyne –stokes but pattern irreg.

Slide 78: Depth – on inspiration the normal depth is nonexaggerated and effortless.  Shallow  Sighing – purposeful to expand the alveoli

Slide 79: Symmetry – bilateral rise and fall of the chest with respiration Audibility – normally be heard by the unaided ear several centimeters from the patient’s nose/mouth

Slide 80: Patient position – healthy person breathes comfortably in supine, prone or upright position  Orthopnea Mode of Breathing – normally inhale/exhale through nose

Slide 81: Sputum  Sample  Color  Mucoid, yellow/green, rust/blood tinged, black, pink  Odor  Amount  Consistency





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Friday, May 16, 2008

Nursing Resource Slides: Vital Signs

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Nursing Resource Slides: Vital Signs Slide Transcript
Slide 1: Vital Signs Nursing 125

Slide 2: Vital Signs Temperature, pulse, respiration, blood pressure (B/P) & oxygen saturation are the most frequent measurements taken by HCP. Because of the importance of these measurements they are referred to as Vital Signs. They are important indicators of the body’s response to physical, environmental, and psychological stressors.

Slide 3: Vital Signs VS may reveal sudden changes in a client’s condition in addition to changes that occur progressively over time. A baseline set of VS are important to identify changes in the patient’s condition. VS are part of a routine physical assessment and are not assessed in isolation. Other factors such as physical signs & symptoms are also considered. Important Consideration:  A client’s normal range of vital signs may differ from the standard range.

Slide 4: When to take vital signs • On a client’s admission • According to the physician’s order or the institution’s policy or standard of practice • When assessing the client during home health visit • Before & after a surgical or invasive diagnostic procedure • Before & after the administration of meds or therapy that affect cardiovascular, respiratory & temperature control functions. • When the client’s general physical condition changes LOC, pain • Before, after & during nursing interventions influencing vital signs • When client reports symptoms of physical distress

Slide 5: Body Temperature Core temperature – temperature of the body tissues, is controlled by the hypothalamus (control center in the brain) – maintained within a narrow range. Skin temperature rises & falls in response to environmental conditions & depends on bld flow to skin & amt. of heat lost to external environment The body’s tissues & cells function best between the range from 36 deg C to 38 deg C Temperature is lowest in the morning, highest during the evening.

Slide 6: Thermometers – 3 types Glass mercury – mercury expands or contracts in response to heat. (just recently non mercury) Electronic – heat sensitive probe, (reads in seconds) there is a probe for oral/axillary use (red) & a probe for rectal use (blue). There are disposable plastic cover for each use. Relies on battery power – return to charging unit after use. Infrared Tympanic (Ear) – sensor probe shaped like an otoscope in external opening of ear canal. Ear canal must be sealed & probe sensor aimed at tympanic membrane – ret’n to charging unit after use.

Slide 7: Sites (P&P p. 216) Oral No hot or cold drinks or smoking Leave in place 3 min Posterior sublingual pocket – 20 min prior to temp. Must be under tongue (close to carotid awake & alert. artery) Not for small children (bite down) Axillary Non invasive – good for Leave in place 5-10 min. Bulb in center of axilla children. Less accurate (no Measures 0.5 C lower than oral major bld vessels nearby) temp. Lower arm position across chest Rectal When unsafe or inaccurate by Leave in place 2-3 min. Side lying with upper leg flexed, mouth (unconscious, disoriented Measures 0.5 C higher than oral insert lubricated bulb (1-11/2 or irrational) inch adult) (1/2 inch infant) Side lying position – leg flexed Ear Rapid measurement 2-3 seconds Close to hypothalmus – sensitive Easy assessibility to core temp. changes Cerumen impaction distorts Adult - Pull pinna up & back reading Child – pull pinna down & back Otitis media can distort reading

Slide 8: Assessing Radial Pulse Left ventricle contracts causing a wave of bld to surge through arteries – called a pulse. Felt by palpating artery lightly against underlying bone or muscle.  Carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis P&P p. 226 Assess: rate, rhythm, strength – can assess by using palpation & auscultation. Pulse deficit – the difference between the radial pulse and the apical pulse – indicates a decrease in peripheral perfusion from some heart conditions ie. Atrial fibrillation.

Slide 9: Procedure for Assessing Pulses Peripheral – place 2nd, 3rd & 4th fingers lightly on skin where an artery passes over an underlying bone. Do not use your thumb (feel pulsations of your own radial artery). Count 30 seconds X 2, if irregular – count radial for 1 min. and then apically for full minute. Apical – beat of the heart at it’s apex or PMI (point of maximum impulse) – 5th intercostal space, midclavicular line, just below lt. nipple – listen for a full minute “Lub-Dub”  Lub – close of atrioventricular (AV) values – tricuspid & mitral valves  Dub – close of semilunar valves – aortic & pulmonic valves

Slide 10: Assess: rate, rhythm, strength & tension Rate – N – 60-100, average 80 bpm  Tachycardia – greater than 100 bpm  Bradycardia – less than 60 bpm Rhythm – the pattern of the beats (regular or irregular) Strength or size – or amplitude, the volume of bld pushed against the wall of an artery during the ventricular contraction  weak or thready (lacks fullness)  Full, bounding (volume higher than normal)  Imperceptible (cannot be felt or heard) 0----------------- 1+ -----------------2+--------------- 3+ ----------------4+ Absent Weak NORMAL Full Bounding

Slide 11: Normal Heart Rate Age Heart Rate (Beats/min) Infants 120-160 Toddlers 90-140 Preschoolers 80-110 School agers 75-100 Adolescent 60-90 Adult 60-100

Slide 12: Assess (cont.) Tension – or elasticity, the compressibility of the arterial wall, is pulse obliterated by slight pressure (low tension or soft) Stethoscope  Diaphragm – high pitched sounds, bowel, lung & heart sounds – tight seal  Bell – low pitched sounds, heart & vascular sounds, apply bell lightly (hint think of Bell with the “L” for Low)

Slide 13: Respirations Assess by observing rate, rhythm & depth  Inspiration – inhalation (breathing in)  Expiration – exhalation (breathing out)  I&E is automatic & controlled by the medulla oblongata (respiratory center of brain)  Normal breathing is active & passive  Women breathe thoracically, while men & young children breathe diaphramatically ***usually  Asses after taking pulse, while still holding hand, so pt is unaware you are counting respiratons

Slide 14: Assessing Respiration Rate # of breathing cycles/minute (inhale/exhale-1cycle) N – 12-20 breaths/min – adult - Eupnea – normal rate & depth breathing Abnormal increase – tachypnea Abnormal decrease – bradypnea Absence of breathing – apnea Depth Amt. of air inhaled/exhaled normal (deep & even movements of chest) shallow (rise & fall of chest is minimal) SOB shortness of breath (shallow & rapid) Rhythm Regularity of inhalation/exhalation Normal (very little variation in length of pauses b/w I&E Character Digressions from normal effortless breathing Dyspnea – difficult or labored breathing Cheyne-Stokes – alternating periods of apnea and hyperventilation, gradual increase & decrease in rate & depth of resp. with period of apnea at the end of each cycle.

Slide 15: Blood Pressure Force exerted by the bld against vessel walls. Pressure of bld within the arteries of the body – lt. ventricle contracts – bld is forced out into the aorta to the lg arteries, smaller arteries & capillaries  Systolic- force exerted against the arterial wall as lt. ventricle contracts & pumps bld into the aorta – max. pressure exerted on vessel wall.  Diastolic – arterial pressure during ventricular relaxation, when the heart is filling, minimum pressure in arteries.  Factors affecting B/P  lower during sleep  Lower with bld loss  Position changes B/P  Anything causing vessels to dilate or constrict - medications

Slide 16: B/P (cont.) P&P p. 240 see table 9-3 Measured in mmHg – millimeters of mercury Normal range  syst 110-140 dias 60-90  Hypertensive - >160, >90  Hypotensive <90 Non invasive method of B/P measurement  Sphygmomanometer, stethoscope  3 types of sphygmomanometers • Aneroid – glass enclosed circular gauge with needle that registers the B/P as it descends the calibrations on the dial. • Mercury – mercury in glass tube - more reliable – read at eye level. • Electronic – cuff with built in pressure transducer reads systolic & diastolic B/P

Slide 17: B/P (cont.) Cuff – inflatable rubber bladder, tube connects to the manometer, another to the bulb, important to have correct cuff size (judge by circumference of the arm not age)  Support arm at heart level, palm turned upward - above heart causes false low reading  Cuff too wide – false low reading  Cuff too narrow – false high reading  Cuff too loose – false high reading Listen for Korotkoff sounds – series of sounds created as bld flows through an artery after it has been occluded with a cuff then cuff pressure is gradually released. P&P p. 240. Do not take B/P in  Arm with cast  Arm with arteriovenous (AV) fistula  Arm on the side of a mastectomy i.e. rt mastectomy, rt arm

Slide 18: Procedure – B/P Assessment Determine best site & baseline B/P Nursing Diagnosis Decreased cardiac output Fluid volume excess Fluid volume deficit Planning Expected outcome Have pt rest 5 min before taking B/Pa Wash hands Implementation Palpate brachial pulse Position cuff 1inch above pulse - Arm at level of heart, wrap snugly around arm Manometer at eye level

Slide 19: Procedure (cont.) Inflate cuff while palpating brachial Artery. Note Implementation reading at which pulse disappears continue to Inflate cuff 30 mmHg above this point. Deflate cuff slowly and note when reading when pulse is felt. Deflate cuff completely and wait 30 sec. With stethoscope in ears locate the brachial artery – place diaphragm over site Close valve of pressure bulb. Inflate cuff 30 mm hg above palpated systolic pressure Slowly release valve Note point on manometer when first clear sound is heard (1st phase Korotkoff) – systolic pressure Continue to deflate noting point @ which sound disappears – 5th phase Korotkoff (4th korotkoff in children Deflate & remove cuff

Slide 20: B/P Lower Extremity Best position prone – if not – supine with knee slightly flexed, locate popliteal artery (back of knee). Large cuff 1 inch above artery, same procedure as arm. Systolic pressure in legs maybe 10-40 mm hg higher If unable to palpate a pulse – you may use a doppler stethoscope

Slide 21: Oxygen Saturation (Pulse Oximetry) Non-invasive measurement of oxygen saturation Calculates SpO2 (pulse oxygen saturation) reliable estimate of arterial oxygen saturation  Probes – finger, ear, nose, toe  Patient with PVD or Raynauds syndrome – difficult to obtain. Normal – 90-100%  Remove nail polish  Wait until oximeter readout reaches constant value & pulse display reaches full strength  During continuous pulse oximetry monitoring – inspect skin under the probe routinely for skin integrity – rotate probe.

Slide 22: Procedure – Vital Signs Assessment Route of temperature – po, tympanic, axilla, rectal Determines if client has had anything hot/cold to drink or smoked (20 min) Planning Obtain equipment – thermometer, watch, stethosope, B/P cuff & graphic sheet Wash hands Implementation Explains procedure to client Temperature tympanic - thermometer Pulse - Position client’s arm @ side or across chest, palpate radial artery Resp – Keeps fingers on wrist – count respirations Documents TPR on graphic sheet B/P – correct position, client’s arm supported @ heart level Document

Slide 23: Vital Signs (cont.) Evaluation V/S within normal range Critical Thinking You are assessing a client’s pulse and the rate is irregular. How would you proceed?




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