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Thursday, November 13, 2008

Nursing Concept Outlined - How to Pass NCLEX-RN

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Epoetin alfa is erythropoietin that has been manufactured through the use of recombinant DNA technology. It is used to treat anemia in the client with chronic renal failure. The medication may be administered subcutaneously or intravenously.

The client with chronic renal failure often has dry skin, accompanied by itching (pruritus) from uremia. The client should use mild soaps, lotions, and bath water oils to reduce dryness without increasing skin irritation. Products that contain perfumes or alcohol increase dryness and pruritus, and should be avoided.

Epoetin alfa is erythropoietin that has been manufactured through the use of recombinant DNA technology. It is used to treat anemia in the client with chronic renal failure.

Many medications are dialyzable, which means they are removed from the bloodstream during dialysis. Because of this, many medications are withheld on the day of dialysis until after the procedure. It is not typical for medications to be “double-dosed,” since there is no way to be certain how much of each medication is cleared by dialysis. Clients receiving hemodialysis are not routinely taught that it is acceptable to disregard dietary and fluid restrictions.

The usual allowable daily fluid intake of the hemodialysis client is the total of the daily urine output plus 500 to 700 mL.

Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. It results from the rapid removal of solutes from the body during hemodialysis. The blood-brain barrier interferes with equally efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. It most often occurs in clients who are new to dialysis, and is prevented by dialyzing for shorter times or at reduced blood flow rates.

Aluminum intoxication can occur when there is accumulation of aluminum, an ingredient in many phosphate-binding antacids. Symptoms include mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. This complication is treated with aluminum chelating agents, which make aluminum available to be dialyzed from the body. It is prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum.

Heparin is used as an anticoagulant during hemodialysis. The hemodialysis nurse monitors the extent of anticoagulation by measuring the PTT, which measures heparin effect. The PT is measured to monitor the effect of warfarin (Coumadin) therapy. Thrombin and bleeding times are not used to measure the effect of heparin therapy, although they are useful in the diagnosis of other clotting abnormalities.

To treat hypotension during hemodialysis, a normal saline bolus of up to 500 mL may be given. The client’s feet and legs are raised to enhance cardiac return. Albumin may be given as per protocol to increase colloid oncotic pressure. The blood flow rate into the dialyzer may be decreased. All of these measures should improve the circulating volume and blood pressure. Five percent dextrose in water is not prescribed because it is less likely to improve the circulating volume and blood pressure.

Following dialysis, the client’s vital signs are monitored to determine whether the client is remaining hemodynamically stable. Weight is measured and compared to the client’s “dry weight” to determine effectiveness of fluid extraction. Laboratory studies are done as per protocol, but are not necessarily done after the hemodialysis treatment has been ended.

Steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and diminished pulse distal to the fistula and complains of pain distal to the fistula from tissue ischemia.

The typical schedule for hemodialysis is 3 to 4 hours of treatment 3 days per week. Individual adjustments may be made according to variables such as the size of the client, type of dialyzer, the rate of blood flow, personal client preferences, and others.

Because infection is a major concern with hemodialysis, the use of sterile technique and the application of a facemask for both the nurse and client are extremely important. It is also imperative that standard precautions be followed, which includes the use of goggles, mask, gloves, and an apron. The connection site should not be covered. Rather, it should be visible so that the nurse can assess for bleeding, ischemia, and infection at the site during the hemodialysis procedure.

The client monitors his or her own status between dialysis procedures by measuring intake and output and daily weight. These measures will assist the client in preventing fluid volume excess.

Since clients may be discharged immediately after cystoscopy, clients must understand home care measures. Pink-tinged urine is common, but not bright red bleeding. Increased intake of fluids helps prevent this from occurring. Clients often experience bladder spasm and bladder pain, feelings of bladder fullness and burning, and burning on urination after this procedure. Mild analgesics and warm tub baths are recommended to relieve these discomforts.

Calcium carbonate is a calcium salt that is used as a phosphate binder in the client with chronic renal failure. It has nothing to do with the treatment of anemia. Folic acid is a vitamin that is needed for RBC production, and it is usually deficient in the client with chronic renal failure. Iron supplements (ferrous sulfate) are needed to produce adequate hemoglobin. Epoetin alfa stimulates the production of RBCs because it is an exogenous source of erythropoietin.

The client taking exogenous erythropoietin may develop or have an increase in the degree of hypertension. This probably results from increased blood viscosity and the hemodynamic changes that accompany it. The nurse monitors the client’s blood pressure carefully and regularly.

Although all of the medications listed in the options are metabolized by the liver, meperidine hydrochloride is metabolized partially to normeperidine, which must be excreted by the kidneys. Seizure activity can occur in the client with chronic renal failure from accumulation of normeperidine in the client’s system. It is also generally true that dosages for all narcotic analgesics will be reduced for the client with chronic renal failure.

Apple juice and grape juice are lower in potassium, and are the better choices of juice for the client with chronic renal failure. Prune, orange, and grapefruit juices are higher in potassium and should be used cautiously or avoided in these clients.

The lungs expire about 400 mL of water per day. Therefore, if the client’s urine output for the previous day was 300 mL, then 700 mL of fluid is to be allotted (400 mL from the lungs and 300 mL urine output).

Smoking is highly detrimental to the client with thromboangiitis obliterans, and clients are recommended to stop completely. Since smoking is a form of chemical dependency, referral to a smoking cessation program may be helpful for many clients. For many clients, symptoms are relieved or alleviated once smoking stops.

Skin color is sometimes more difficult to assess in the dark-skinned client. If impaired gas exchange is suspected, the nurse would examine the lips, tongue, nail beds, conjunctivae (not sclera) of the eye, and palms of the hands and soles of the feet. In a client with cyanosis, the lips and tongue are gray, and the palms, soles, conjunctivae, and nail beds have a bluish tinge.

A Sengstaken-Blakemore tube is inserted in clients with cirrhosis who have ruptured esophageal varices. It has esophageal and gastric balloons. It is important to ensure that the gastric balloon is inflated to prevent migration of the tube. If the gastric balloon deflates with the esophageal balloon inflated, the client could develop complete or partial airway obstruction. Scissors should be available to deflate the balloons and allow for tube removal in such an emergency situation.

Clients with chronic skin disorders may have Chronic Low Self-Esteem because of the disorder itself and possible rejection by others. The nurse uses a quiet, unhurried manner, as well as appropriate visual contact, facial expression, and therapeutic touch to demonstrate acceptance of the client. Communications that are purposefully brief and formal may reinforce the feelings of rejection. These feelings may also be reinforced if the nurse obviously pretends not to notice the affected skin areas.

Several things may be done to promote hydration of the skin. The client should take tub baths or showers only every 2 to 3 days, and should use a sponge bath in between. Humidity in the home should be maintained at greater than 40%. Bath water should be between 95 and 100 degrees (tepid), not very hot or very cold. Emollients should be applied generously to the skin while it is still damp.

The artificial larynx is an electronic device that assists the client after laryngectomy to produce speech. There are two types; one is held at the side of the neck and the other is inserted into the mouth. The vibration produces a mechanical-sounding speech that is monotone in quality but is intelligible.

A rectovaginal fistula is a common type of vaginal-intestinal fistula. If the fistula is small, the only sign may be an occasional foul-smelling leukorrhea or an occasional passage of gas or fecal matter from the vagina. A vesicovaginal fistula is a genital fistula that occurs between the bladder and the vagina. The fistula is an abnormal opening between these two body parts and if this occurs, the client may experience drainage of urine through the vagina.

Allopurinol decreases uric acid production and reduces uric acid concentrations in both serum and urine. In the client receiving chemotherapy, uric acid levels elevate as a result of the massive cell destruction that occurs from the chemotherapy. This medication prevents or treats hyperuricemia secondary to chemotherapy. Although the medication is used to treat gout, that is not the purpose in this client situation.

An acidic environment in the mouth is favorable for bacterial growth, especially in an area already compromised from chemotherapy. Therefore, the client is advised to rinse the mouth at least before every meal and at bedtime with a weak sodium bicarbonate mouth rinse. This lessens the growth of bacteria and limits plaque formation.

High meat and coffee consumption plays a role in the development of other types of cancer, such as cancer of the pancreas (high meat consumption) and cancer of the bladder (high coffee consumption).

Following gastrectomy, drainage from the NG tube is normally bloody for 24 hours postoperatively and then changes to brown tinged and then to yellow or clear. The nurse would document this assessment finding. There is no need to notify the physician.

Colorectal cancer most often occurs in populations with diets low in fiber and high in refined carbohydrates, fats, and meats. Other risk factors include a family history of the disease, rectal polyps, and active inflammatory disease of at least 10 years’ duration.

Characteristic symptoms of right colon tumors include vague, dull abdominal pain exacerbated by walking, and dark red or mahogany-colored blood mixed in the stool.

To reduce the risk of contamination at the time of surgery, the bowel is emptied and cleansed. Laxatives and enemas are given to empty the bowel. Intestinal anti-infectives such as neomycin or kanamycin may be prescribed orally to decrease the bacteria in the bowel and can be administered with a sip of water 2 hours before surgery.

Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. There is no need to notify the physician at this time, but the nurse would change the dressing. A Penrose drain, if in place, should not be clamped because this action will cause the accumulation of drainage within the tissue. Both Penrose drains and packing are removed gradually over a period of 5 to 7 days. The nurse should not remove the perineal packing.

Safety precautions are required during UVL therapy. Most UVL treatments require the person to stand in a light treatment chamber for up to 15 minutes. It is best to expose to the UVL only those areas requiring treatment. Protective wraparound goggles prevent exposure of the eyes to UVL. The face should be shielded with a loosely applied pillowcase if it is unaffected. Direct contact with the light bulbs of the treatment unit should be avoided to prevent burning of the skin.

Kaposi’s sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body, then to the face and oral mucosa. It can spread to the lymphatic system, lungs, and gastrointestinal (GI) tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and GI lesions.

Aldosterone plays a major role in fluid and electrolyte balance. Hypersecretion of aldosterone leads to sodium and water retention, which can lead to fluid overload.

The use of sulfonylureas is generally contraindicated in clients who are allergic to or have adverse reactions to sulfonamides. These clients may need to take other oral antidiabetic agents such as metformin (Glucophage) or acarbose (Precose), or may require insulin therapy.

Hypoparathyroidism results from insufficient parathyroid hormone, leading to low serum calcium levels. Hypocalcemia can cause tetany, which if untreated, can lead to seizures. The nurse should institute seizure precautions in order to maintain a safe environment.

Adrenal insufficiency can occur following surgery to remove the adrenal glands. One of the effects of adrenal insufficiency is hypoglycemia. Aldosterone insufficiency also occurs, resulting in hypovolemia.

Levothyroxine sodium is a synthetically prepared thyroid hormone, which increases body metabolism. The client feels this effect as an increase in energy level. Other effects are weight loss and increased body temperature.

Clients with hyperaldosteronism should follow a low-sodium diet as an adjunct to medical management to decrease serum sodium levels. For this reason, salty foods are to be avoided. Potassium intake (oranges) needs to be maintained because the client is at risk for hypokalemia.

A 10 to 15 gram simple carbohydrate load is generally needed to increase the blood glucose level quickly and adequately.

After laser surgery removal of any type of skin lesion, the skin should be protected from direct sunlight for a minimum of 3 months.

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