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Med-surg. ANCC certification
Point in RLQ abd of appendix. Tenderness indicates appendicitis - ✔Mc burney's point Place fingers under rt coastal margin and instruct to take deep breath. Increased tenderness with sudden stop during inhalation is a positive murphy's sign - ✔Murphy's sign All assessment used to r/o appendicitis - ✔Obturator muscle, psoas sign, Rovsing's sign Out dated and not recommended to use for assessment for DVT - ✔Homan's sign Pain from a jarring movement to indicate peritonitis with appendicitis. Stand on toes and drop to heals or increaded pain with walking or running - ✔Jar sign(markle sign) Acute cardiac tamponade- pericardial effusion
- Disended neck vein's
- Distant heart sounds
- Hypotention Treatment- pericardiocentesis - ✔Beck's triad
- Nystagmas- repetitive uncontrolled movements of the eyes
- Intention tremor- tremor that worsens as approaches end of intended movement
- Scanning or staccato speech- broken speech and each syllable pronounced separately - ✔Charcot's triad for MS Inf. of bile duct caused by bacteria ascending from junction with duodenum 1.Jaundice
- Fever, usually with rigors
- RUQ ABD pain - ✔Charcot's triad for ascending cholangitis Signs of increased ICP
- HTN- widened pulse pressure
- Bradycardia
- Irregular respirations- cheyne- stokes( slow, fast, slow period of apnea then slow,fast,slow - ✔Cushing's triad Deep and labored. Presents in severe metabolic acidosis- DKA and kidney failure - ✔Kaussmaul breathing Signs of fat embolism
- Mental status changes
- Petechiae-late sign
- Dyspnea - ✔Bergman's triad
Sign of meningitis- supine flex neck will cause involuntary flexion of hips and knees - ✔Brudzinski sign Sign of meningitis- lift flexed knee and slowly extend will cause back pain if positive - ✔Kernig's sign Nerve hyperexcitability (tetany) seen with hypocalemia Abnormal reaction to stimulation of facial nerve Inflate bp cuff to greater than systolic and hand and wrist with involuntarly curl inward - ✔Chvostek's sign Trousseau' sign is positive when a patient is holding a clenched fist over his chest to describe dull, pressing chest pain consistent with the discomfort of angina pectoris. - ✔Levine sign B: Choice B would show a lateral wall MI. Choice A would show an anterior MI. Choice C would show an inferior wall MI. Choice D would show a posterior wall MI. - ✔A patient is diagnosed with a lateral wall ST segment elevation myocardial infarction (STEMI). What do you expect the EKG to show? a. ST elevation in leads V1 -V b. ST elevation in leads I, aVL, V5, V c. ST elevation in leads II, III, aVF d. ST elevation in leads V7, V8, V commonly caused by E.coli in elderly males and/or those who are not sexually active and have normal immune function. In sexually active males with a history of unprotected sex, the causative organisms are likely gonorrhea and/or chlamydia. Cases of epididymitis caused by Staph aureus are rare. Epididymitis caused by cytomegalovirus (CMV) is incredibly rare unless the patient is immunocompromised. - ✔Epididymitis Nimodipine or Nimotop is a calcium channel blocker which causes vasodilation of the blood vessels. is hypervolemia, hypertension, and hemodilution. These three factors will maintain the patency of the vessels, making it difficult for them to vasoconstrict. Vasospasm left unchecked can cause stroke, neurological compromise, and death. - ✔Triple H therapy for Subarachnoid Hemorrhage- induced Vasospasm Adverse effects caused by dx procedure or treatment - ✔Iatrogenic Dx delirium 1 Acute onset 2 Inattention 3 Disorganized thinking 4 ALOC
- Cognitive: Learning and gaining intellectual skills and mastering categories of effective learning (knowledge, comprehension, application, analysis, synthesis, and evaluation). ·
- Affective: Recognizing categories of feelings and values from simple to complex (receiving and responding to phenomena, valuing, organizing, and internalizing values). ·
- Psychomotor: Mastering motor skills necessary for independence, following a progression from simple to complex (perception, set, guided response, mechanism, complex overt response, adaptation, and origination). - ✔Bloom's Taxonomy(3 types of learning) Soften impact of longterm ,complex illness/injury - ✔Tertiary Early detection and Treatment to halt or slow progress - ✔Secondary Prevention - ✔Primary Sx to move undescended testicle or resolve testicular torsion - ✔Orchiopexy Removal of one or both testicules - ✔Orchiectomy Sensorimotor (0 -2): Infants learn about cause and effect and the permanence of objects. · Preoperational (2 -7): Thinking is concrete and tangible at the preconceptual stage, and later becomes intuitive. These children are egocentric. Concrete operational (7 -11): Children develop the concept of conservation and reasoning becomes inductive. Formal operational (11 -15): Adolescents develop the ability to use abstract thought and to develop and test hypotheses. - ✔Piaget's stages of Cognitive Development Involuntary movements. May become permanent or become worse. Treatments include stopping the drug that caused it and in some cases Botox injections may be effective - ✔Tardive dyskinesia
- Right task: The nurse determines an appropriate task to delegate for a specific patient. 2. Right circumstance: The nurse has considered all relevant information to determine appropriateness of delegation. ·
- Right Person: The nurse chooses the right person based on education and skills to perform the task. ·
- Right direction: The nurse provides a clear description of the task, purpose, limits, and expected outcomes. · 5.Right supervision: The nurse must supervise, intervene as needed, and evaluate performance. - ✔"5 rights of delegation" Autocratic leaders make decisions independently and strictly enforce rules. Bureaucratic leaders follow organizational rules exactly and expect others to do so, as well. Laissez-faire leaders exert little direct control and allow others to make decisions with little interference.
Participatory leaders present a potential decision and make a final decision based on input from team members. Consultative leaders present a decision and welcome input, but rarely change their decisions. Democratic leaders present a problem and ask the team to arrive at a solution, although these leaders make the final decision. - ✔Types of leadership stress is a body response to demands requiring positive or negative adaptation, characterized by the "generalized adaptation syndrome," which includes 3 stages: · Alarm: Fight or flight response. · Resistance: The body mobilizes to resist a threat, focusing on those organs most involved in an adaptive response. · Exhaustion: As the body is weakened and overwhelmed, organs/systems begin to deteriorate (hypertrophy/atrophy) and can no longer cope with stress, resulting in stress-related illnesses and eventual death. - ✔Selye's biological theory of stress and aging Expressive aphasia- left frontal - ✔Broca's aphasia Receptive aphasia- damage to Lt posterior temporal - ✔Wernicke's aphasia Undescended testicles - ✔Cryptorchidism Decrease in bone density - ✔Osteopenia Causes anemia - ✔Thalassemia major Rare inherited disorder that causes an amino acid called phenylalanine to build up in the body. Treated with strict diet of avoiding foods high in protein. - ✔Phenylketonuria (PKU) Assessment: Collecting data, history, and completing a physical exam. · Diagnosis: Analyzing data, determining needs and problems, and applying a nursing diagnosis. · Planning: Setting priorities, setting goals and expected outcomes, and planning interventions and strategies of care. · Implementation: Applying interventions/treatments. Evaluation: Reassessing and auditing. - ✔Nursing process Preinteraction Phase Assessment: gathering information; assessing one's feelings, fears, and anxieties about working with a particular client Goal: Explore self-perceptions Orientation (introductory) Phase nurse and client become acquainted Goal: Establish trust; Formulate contract for intervention Working Phase Goal: Promote client change
common objects, counting backward, naming, providing location, copying shapes, and following directions. The Digit Repetition Test assesses attention by asking the patient to repeat the 2 number, then 3, then 4 and so on. The Confusion Assessment Method is used to assess delirium, not dementia. - ✔Dementia assessments Dependence: The patient has an inability to make decisions, requires constant reassurance, and calls nurses/families frequently. · Depression: The patient is withdrawn and sad, fails to take treatments and/or misses appointments, and may be at risk for suicide. · Anger: The patient is belligerent, uncooperative, and blames others. · Confusion: The patient is forgetful, disoriented, and bewildered. · Passivity: The patient defers to others, feeling he/she has no control. - ✔Typical psychological responses to stress include:
- immunization,
- access to health care,
- environmental quality,
- rates of injury and violence,
- mental health care,
- responsible sexual behavior,
- rates of substance abuse and tobacco use,
- rates of overweight and obesity, and
- levels of physical activity. - ✔Leading health indicators include: often occurs with renal disease and is characterized by ventricular arrhythmia, weakness with ascending paralysis and hyperreflexia, diarrhea, and confusion. - ✔Hyperkalemia is characterized by weakness, lethargy, nausea and vomiting, paresthesias, dysrhythmias (PVCs, flattened T waves), muscle cramps with hyporeflexia, hypotension, and tetany. - ✔Hypokalemia is characterized by tetany, tingling, seizures, altered mental status, and ventricular tachycardia. - ✔Hypocalcemia is characterized by increasing muscle weakness with hypotonicity, constipation, anorexia, nausea and vomiting, and bradycardia. - ✔Hypercalcemia Self-directed: Adults prefer active involvement and responsibility. · Knowledgeable: Adults can relate new material to information with which they are familiar by life experience or education. · Relevancy-oriented: Adults like to know how they will use information. · Motivated: Adults like to see evidence of their own achievement, such as gaining a certificate. - ✔Adult learners Allowing both parties to present their side without bias. · Encouraging cooperation through negotiation and compromise. ·
Maintaining focus and avoiding arguments. · Evaluating the need for renegotiation, a formal resolution process, or a 3rd party mediator. · Utilizing humor and empathy to diffuse tension. Summarizing and outlining key arguments. · Avoiding forced resolution if possible. - ✔Conflict Resolution steps include: Signs of inhaled cocaine use include nasal irritation and nosebleeds, and signs of smoked cocaine include lip burns and a cough. Constricted pupils, headaches, and abdominal pain are also common. Most abused drugs have similar symptoms. However, heroin users would have needle tracks and would not have nasal irritation. Marijuana users may exhibit tachycardia and cough from lung irritation (similar to tobacco smokers), but usually do not develop nasal irritation or nose bleeds. Methadone abuse can cause constricted pupils and abdominal pain, but does not cause nasal symptoms. - ✔Drug users s/s DIC causes both coagulation and hemorrhage through a complex series of events. It includes trauma of a nature that causes tissue factor (transmembrane glycoprotein) to enter the circulation and bind with coagulation factors, triggering the coagulation cascade. This cascade stimulates thrombin to convert fibrinogen to fibrin, causing aggregation and destruction of platelets and forming clots that can be disseminated throughout the intravascular system. - ✔disseminated intravascular coagulation (DIC) as it is an opiate antidote. - ✔naloxone (Narcan®) intravenously an antidote for benzodiazepines. - ✔Flumazenil may be used for an oral overdose of morphine if little time has passed since ingestion but will not have an effect on morphine that was administered intravenously. - ✔Charcoal is the antidote for overdose of acetaminophen - ✔N-acetylcysteine The right to pain control,respect for patient, informed consent, advance directives, and end of life care, privacy and confidentiality, protection from abuse and neglect, protection during research, appraisal of outcomes, appeal procedures, an organizational code of ethical behaviors, and procedures for donating and procuring organs/tissues. - ✔Patients' Bill of Rights Environmental hazards: Piles of paper or junk, loose carpets, cluttered pathways. · Lighting: Adequate for reading in all rooms and stairways. · Heat and air-conditioning: Adequate to control heat and cold. · Sanitation: Rotting food, infestations of cockroaches or rodents · Animal care: Pets should have access to food, water, toileting, and veterinary care. · Smoke/chemicals in the environment: Second- hand smoke or cleaning chemicals. - ✔environmental assessment bacteremia, septicemia, sepsis, severe sepsis, septic shock, and finally MODS as the infection overwhelms the body's defenses -
✔pheochromocytoma The seven assumptions Caring can be effectively demonstrated and practiced only interpersonally. Caring consists of carative factors that result in the satisfaction of certain human needs. Effective caring promotes health and individual or family growth. Caring responses accept person not only as he or she is now but as what he or she may become. A caring environment is one that offers the development of potential while allowing the person to choose the best action for himself or herself at a given point in time. Caring is more " healthogenic" than is curing. A science of caring is complementary to the science of curing. The practice of caring is central to nursing. - ✔Watson He believed if an individual attained self-actualisation they would be a fully functioning person living "the good life". By this, he means that the individual would have a positive healthy psychological outlook, trust their own feelings and have congruence in their lives between self and experience - ✔Carl Rogers's Theory of Personality
