www.nclex-tutorial.com INTRODUCTION Dear Reader, Welcome to the 2010 edition of Dr. KarrenbergвЂ™s NCLEX-RNВ® Review Manual. We are continuing our success proven concept of our previous manuals and of our live tutorial and review classes by presenting the entire exam relevant content in a comprehensive but compact format. Based on the latest NCLEX-RNВ® Test Plan from April 1, 2010 our new manual meets the requirements of the latest passing standards. In comparison to previous versions the new exam curriculum is emphasizing clinical priorities, organizational skills, management of care as well as laws and regulations. A comparably lesser number of questions is now distributed for the category reduction of risk potential. This manual allows you to prepare for your nursing board exam with a detailed review of all exam relevant facts in just one book. Including baseline knowledge requirements as well as high scoring exam relevant content. It meets the requirements of U.S. as well as International nursing students for a successful, time and cost efficient exam preparation. Based on a review of content, NCLEX-RNВ® relevant keywords and practice questions this program enables you to acquire the necessary exam relevant knowledge, skills and confidence to pass your board exam and to start your career as a RN soon! No question remains unanswered whether you are sitting for the NCLEX-RNВ® for the first time or if you are about to prepare for a repeated attempt. In comparison to other review systems this program is based on the following three steps to assist you in acquiring the entire exam relevant knowledge as well as important test taking strategies. 1. Content Review The detailed but compact content review allows you to acquire the entire exam relevant knowledge under special consideration the most high scoring content of pathophysiology, pharmacology, nursing mathematics and other difficult subject materials that usually are the greatest challenges for the NCLEX-RNВ® candidates. 2. Keyword Review The keyword review outlines the requirements of the minimum knowledge requirements of the most current official NCLEX-RNВ® Test plan as issued by the National Council of State Boards of Nursing (NCSBN). 3. Question Review The question review of 355 well composed practice questions allows you to repeat and practice the previously acquired knowledge of the first two steps in the computer adaptive testing question style that you will encounter in the actual testing situation. I hope that this unique manual will assist you in a successful preparation for your NCLEX-RNВ® exam as it has supported many U.S. Nursing school graduates and International nurses before. We appreciate your feedback and comments about this book under [email protected]. Good Luck! Sincerely, Dr. H. A. Karrenberg January 2010 1 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Table of Content ADMINISTRATION OF THE NCLEX-RNВ® EXAMINATION Categories of the NCLEX-RNВ® curriculum Test Taking Strategies CAT Question item types CONTENT REVIEW SAFE AND EFFECTIVE CARE ENVIRONMENT Management of care Definitions of Ethics, Morals, Values and legal aspects Managed Care Settings in the United States Organizational skills Basic Principles of Leadership and Supervision Safety and infection control Rules and Definitions of Basic Life Support (BSL) Infection control HEALTH PROMOTION AND MAINTENANCE Female Reproductive System Male internal structures Infertility Assessment Treatment options in female infertility Family Planning and Contraception Antenatal Assessment and Care Sexually transmitted infections Nursing Care at neonatal visits Physiological changes in pregnancy Gestational conditions Labor and Delivery Care Electronic fetal heart rate interpretation Process of labor Pain management during labor Complicated Delivery and Care Medication Therapy in Obstetrics and Gynecology Physiological changes during the postpartum period Psychosocial changes during the postpartum period Postpartal nursing care Newborn Assessment Physiological changes in the Newborn period Complicated postpartum care Complicated newborn care Birt defects Milestones of human growth and development Vaccinations Health and physical assessments Elements of a healthy lifestyle Age related Health Screening Schedules Age related care of older adults Common adverse effects of medication in older adults Common laboratory tests Common diagnostic procedures Perioperative nursing care 2 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual 5 5 6 9 9 11 12 13 15 16 19 21 24 25 25 26 29 31 33 36 38 39 39 41 45 46 50 52 54 54 56 59 61 62 66 67 71 74 80 82 83 85 87 95 101 www.nclex-tutorial.com Basic client needs Wound care Monitoring tubes and drains Fluid and electrolyte imbalances Acid base imbalances Applied Pharmacology Dosage calculation and medication administration Intravenous therapies Red blood cell and blood component administration Total parenteral nutrition 105 118 120 123 129 133 134 139 141 143 NURSING CARE SPECIFICS - PATHOPHYSIOLOGY - MEDICAL TREATMENTS APPLIED PHARMACOLOGY AND PSYCHOSCOCIAL ASPECTS OF DISEASES AND DISORDERS Neurological Disorders and Diseases Neurological Medication Therapy Infectious Diseases Antibiotics Antiviral Medications Respiratory Disorders and Dieseases Respiratory Medications Cardiovascular Disorders and Diseases Electrocardiography Disorders of the veins Hypertension Peripheral arterial disease Cardiovascular Medications Urological Disorders and Diseases Urological Medication Therapy Gastrointestinal Tract Disorders and Diseases Gastrointestinal Tract Medication Therapy Endocrine Disorders and Diseases Musculoskeletal Disorders and Diseases Musculoskeletal Medication Therapy Dermatological Disorders and Diseases Dermatological Medication Therapy Eye Disorders and Diseases Ear Disorders and Diseases Eye and Ear Medication Therapy Mouth Disorders and Diseases Blood Disorders and Diseases Malignant Diseases Pediatric Oncology Adult Oncology Antineoplastic Chemotherapy Safety requirements for handling chemotherapeutic medication Common side effects related to chemotherapeutic agents Immune modulating medications Cell stimulating medications 3 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual 145 154 157 161 166 166 174 180 181 193 193 194 196 208 211 216 226 230 245 248 250 257 262 265 266 270 271 276 278 279 287 292 290 293 293 www.nclex-tutorial.com Psychiatric Disorders and Diseases Psychiatric Medications Normal reference ranges for laboratory test results 294 312 313 Baseline knowledge requirements of the NCLEX-RNВ® Index of content related keywords 320 NCLEX-RNВ® practice exam questions and answers Answer Key Learning Plan Recommendations 323 392 393 KEYWORD REVIEW QUESTION REVIEW 4 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Administration of the NCLEX-RNВ® examination The NCLEX-RNВ® nursing licensing examination is offered in a computer adaptive testing mode only. The duration of the exam is of variable length and depends on the average performance of the candidate during this exam. Due to its unique setting as a computer adaptive testing the NCLEX-RNВ®-Examination regularly starts with a question that targets knowledge which is slightly below average of the required overall exam base line knowledge. If the candidate answers this first question correctly then the computer will automatically pick another, more difficult question. If the candidate answers a question wrong then the computer automatically chooses a less difficult question and so on. The minimum amount of questions to be answered by every candidate is 75 within an allotted time of 6 hours. The allotted time includes any breaks as well as the time for the pretest tutorial. Depending on the individual test performance the candidate will be offered more questions but not additional testing time to reach the passing score. The maximum amount of questions will not exceed 265. Fifteen of the overall amount of questions asked will not be used for the assessment of the exam candidate since these questions are included for testing purposes for future exams. The exam stops automatically either after the minimum 75 questions or once the allotted time is over or whenever the candidate has proven a consistent satisfying or a non satisfying level of competence. It typically causes a lot of discomfort for the candidates during the test if the system keeps asking more than the 75 mandatory questions since this may be a sign of a low performance level. Although, this does not necessarily mean that the candidate is failing the overall examination. The most current 2007 NCLEX-RNВ® test plan includes four main and six subcategories of client needs in which exam candidates need to prove minimum competency. Results of the NCLEX-RN examination are scored as passed or failed only. Exam candidates receive a computerized assessment of their individual testing performance as well. Categories of the NCLEX-RNВ® curriculum I. Safe, Effective Care Environment вЂў Management of Care (16-22 %) вЂў Safety and Infection Control (8-14%) II. Health Promotion and Maintenance (6-12%) III. Psychosocial Integrity (6-12%) IV. Physiological Integrity вЂў Basic Care and Comfort(6-12%) вЂў Pharmacological and Parenteral Therapies (13-19%) вЂў Reduction of Risk Potential (10-16%) вЂў Physiological Adaptation (11-17%) Test Taking Strategies General requirements of the NCLEX-RNВ®: The NCLEX-RNВ® is considered to be an assessment test. It is specifically designed to assess the ability of a graduate nursing student to start employment as a junior RN in a 5 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com hospital or other common type of healthcare setting. All question in this exam are comprised to expose the exam candidate theoretically with a variety of common situations and regulations as they occur and apply in daily nursing practice. It is now necessary to view the question items under consideration of two or more conditioning factors. The appropriate problem solving approach is defined as вЂњcritical thinkingвЂќ in the NCLEX-RNВ® Test plan. Specific strategies for successful participation in the NCLEX-RNВ®: вЂў Thorough understanding and practice of all six different types of question items currently used in the NCLEX-RNВ®. вЂў Complete and careful reading before answering any question items. A question item may not always ask for a variety of possible outcomes. (least, most, wrong, usual, typical outcome, result). вЂў Use of a problem solving approach that considers all aspects as they are provided in the question items. вЂў Time measurement - every 10/20 questions during exam following the вЂњone question per minute ruleвЂќ. вЂў Use of common sense! All answers must also be rationally explainable! вЂў Focus on recognition of priorities for a client in a particular situation, (because other answer choices may be correct but not logical in a particular situation). Priorities examples: Maslows Hierarchy of Needs, ABC (Airway, Breathing, Circulation), Identifying and recognizing least stable /most riskful situation, time as a priority factor, priority among other clients in need (e.g. patient to be prepared for scheduled surgery). CAT Question item types: It is rather important to become familiar with the different types of questions that are used for the different items in the Nclex-RN examination before the actual exam date. This allows a faster pace by answering items and reduces insecurity. There are six alternate item format practice questions to become familiar with: 1. Single response questions (One right answer only) A single answer question typically starts with a brief description of a common situation in daily nursing practice. The candidate is then asked to make a decision based on principles of nursing practice and/or clinical knowledge by choosing one out of four answers. Example: A 40 year old male client is admitted to the hospital for acute abdominal pain. During the interview he points out to the ER Nurse on duty, that he had severe alcohol problems for many years but he has been abstinent for 5 years now. Considering this history which of the following conditions is the most likely cause for this clients chief complaints? Please select the best response. A) Ureter stones B) Pancreatitis C) Gallbladder stones D) Gastritis E) Gastroenteritis 6 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 2. Multiple response questions Compared to a single response question, test items of this type will provide more than one correct answer to choose from but it may not tell how many correct answers are there at all. Therefore, between two to four of the multiple choice answers may be correct. Example: A client who was just admitted to the Emergency Room for acute respiratory distress has a long standing history of an obstructive pulmonary disorder. Which of the following conclusions are correct in regards to this clients condition ? Please select all answers that apply. 1. This client may be suffering from Asthma. 2. The hypoxemia of this client may require respirator treatment. 3. The blood gas analysis may show a respiratory acidosis. 4. The blood gas analysis may show a significantly increased pCO2. A) 1 and 3 are correct B) 2, 3, and 4 are correct C) 3 and 4 are correct D) None of the above statements are correct E) All of the above statements are correct 3. Fill in the blank questions. (i.e. solution of a math operation) This type of question is mainly used for subjects dealing with nursing mathematics,( e. g. dosage calculation). In this case the testing computer system provides a calculator for on screen use. There are no anwsers to choose from and the appropriate answer has to be written in a defined answer field. Example: A liquid medication has a concentration of 2mg/ml and is supposed to be applied intravenously. The written physicians order states the following dosage advice. 0,5 ml / kg bodyweight / hour. How much dosage in ml will this particular client receive in 24 hours, if his weight is 78 kg? Answer: This client will receive ml of the prescribed substance. 4. вЂњHot spotвЂќ question A hotspot question allows you to answer a question by clicking on a correct area within an image 7 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Example: Please use the diagram of the female reproductive tract below to indicate the anatomical area where the fertilization takes place. A) Cervical Canal B) Fallopian tube C) Uterus D) Vagina E) None of the above 5. Chart exhibit question An exhibit question will provide a specific clinical information, (e.g. a printout of a complete blood count) followed by a question regarding its interpretation. Example: A cient on a ward suddenly develops a severe, acute respiratory distress. One of the first diagnostic steps is to obtain capillary blood for a blood gas analysis. Which is the most correct interpretation of the BGA results displayed below? A) Respiratory alkalosis B) Respiratory acidosis C) Metabolic alkalosis D) Metabolic acidosis E) None of the above pH = 7,04 pCO2 = 106 mmHg pO2= 55 mmHg BE + 8 Potassium 6. Drag and Drop Question/ Ordered Response Item Drag and drop questions are mainly used to assess knowledge concerning practical procedures. Two boxes are provided in this question item. The left hand box contains statements options for a specific question but in a non orderly manner. The right hand box is supposed to be filled with these statement options but in an orderly manner. Since all statement options have to be used to answer this type of question, there should be no statement option left in the left hand box once this question is answered. 8 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Example: To perform a cardiovascular resuscitation it is important to follow an algorithm of maneuvers. Please put the assessments and procedures described in the left hand box below in a logical sequence by putting the most basic action on top. Unordered options Airway assessment Circulation assessment Breathing Defibrillation Ordered options NCLEX-RNВ® Category I: SAFE AND EFFECTIVE CARE ENVIRONMENT 1. MANAGEMENT OF CARE - Definitons of the four Elements of Nursing Practice 1. Nursing Process: Compoments of the scientific problem solving approach in nursing practice, including: 1. 2. 3. 4. 5. Assessment of client needs Analysis of care environment Planning of care Implementation of care Evaluation of care 2. Caring: Basic requirement for a successful client вЂ“ nurse interaction to achieve desired client outcomes are mutual respect and trust. 3. Communication and Documentation: Verbal and nonverbal interaction has to be maintained with everybody involved in patient care. Documentation is a professional duty and requires written and/or electronic recording of activities and events during patient care. Proper documentation is mandatory in nursing practice and reduces liability! 4. Teaching and Learning: Goal of Client Education is the akquisition of knowledge, skills and attitudes for the client to change his behavior. - Definitions of Ethics, Morals, Values and legal aspects ANA Code of nursing ethics principles: - Autonomy, - Beneficience, - Paternalism, - Justice, - Fidelity, - Virtues, - Confidentiality. 9 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Legal regulations of nursing practice: вЂў General Law вЂў Good Samaritan Law вЂў Licensure Requirements вЂў Nurse Practice Act (Guidelines, Rules, Regulations, educational, professional standards). Basic Principles of nursing practice: вЂў Delivering a holistic and comprehensive care. вЂў Respecting a clients uniqueness. вЂў Fostering an open and honest communication. вЂў Valuing empathy. вЂў Setting appropriate limits. вЂў Promoting the independence of a client. - Definitions of Liability in Nursing Practice Negligence / Conduct = falling short of what a reasonable person would do to protect another individual from foreseeable risks of harm.= Failure to take appropriate actions. Malpractice = Failure in taking appropriate actions by disregarding specific professional standards. Assault = Threat causing fear Battery = Touching without consent Invasion of privacy = i.e. Violation of confidentiality Fraud = deliberately deceiving clients for the purpose of unlawful gains Defamation of character = Damaging a patients reputation False Imprisonment = Prohibiting discharge and give medications without need - Principles of Safeguarding Client Rights Informed Consent Agreement to undergo specific medical procedures. Typically results from a personal consultation with a healthcare provider and is based on a detailed explanation of the purpose of the particular procedure as well as of available alternatives. (exceptions: waiver, minors and legal guardianship) Confidentiality Professional obligation that counts among members of a therapeutic team and may even exclude witness in court of law (except threats to identified individuals or major crime) Advances directives Legal documents that allow to convey a clients decisions about end-of-life care ahead of time and to avoid confusion later on. (copy must be part of medical record) Health care proxy A person named in a durable power of attorney for health care document. The proxy is someone you has earned the clients trust to make health decisions if he is unable to do so. Decision making authority may also be given to medical staff. 10 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Organ / tissue donation rules вЂў Donor must be minimum of 18 years old вЂў Requires living will or advance directive or donor card вЂў Decision can be made in advance вЂў Uniform Anatomical gift Act in all 50 Stated вЂў 3 Criterias for clinical death have to be present: 1. No brainwaves 2. No spontaneous breathing 3. No sensomotoric reflexes - Legal Terms and ethical aspects Professional nursing care requires to ensure clients autonomy and liberty at all times as far as condition allows. A voluntary Admission to a hospital treatment has to be agreed on in writing by patient. An involuntary Admission is justified under the Mental Health Act in situations of self вЂ“ or public endangerment only. A Mental Health condition does not generally take the right of informed consent away! Physicians order Overall therapeutic guideline. Can and must be questioned in any case of doubt! Incident reports Have to be issued and filed for the caregivers and are not part part of the Medical Record. But incidents need to be mentioned in MRвЂ™s. Risk management Individual case and client related measures to protect client from physical injury or aggravation of the underlying condition. Considering age and condition related risks. Duties of external report are given in the following situations Communicable diseases Public Health Department Evidence of Crimes Police Suspected chemical abuse of coworker Police Sexual harassment Police Unsafe working conditions Occupational Safety and Health Administration (OSHA) - Managed Care Settings in the United States вЂ“ All managed systems are designed to control healt care costs and to optimize efficiency and quality of medical treatments. A managed Health Care Plan delivers and finances the service instead of paying a third party for it. This decreases unnecessary services and costs, maintains quality of service, facilitates management of patient care needs, promotes timely and appropriate care. Therefore all managed care systems require their own provider netwrok, unlike a regular health insurance company. Health Maintenance Organizations HMOвЂ™s Oldest and most typical managed care system among several other types. Emphasis lies on prevention and quality of care. HMO members pay a periodic fee or receive membership as a benefit by their employer. Members select a primary care physician from the list provided by the HMO. This primary care physician coordinates the 11 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com entire medical care for this member. If specialist care is needed, the primary care physician will refer the member to a specialist, usually within the HMO network. Members who go to healthcare providers outside of the network without prior approval may pay all or most of the cost of that care. A HMO is generally more restricted and has a limited capacity in comparison to PPO Networks. Copays for treatments and prescriptions may lower the monthly premium. Preferred Provider Networks PPO Network of private-practice doctors, healthcare facilities and hospitals. Network works by contract with insurance companies and PPO providers receive a set rate for their services. Less restrictive but more expensive for the patients which receive more control over their own medical needs. They do not need a referral as long as the doctor they visit is a member of the PPO. Clients may have a deductible to meet before coverage starts each year. Overall coverage may only be 80 or 90% off all healthcare costs. PPOs hire nurses and medical professionals to handle patient cases and make decisions about hospital visits and diagnostic tests. Case Management (focuses on diagnosis) Follows a guideline based care plan for defined conditions. Treats all involved professionals as equal. Managing interdisciplinary outcomes. Promotes continuity of care. - Nursing Care Delivery Systems - Functional Nursing Established in the 1940вЂ™s. Client needs are defined by necessary tasks and activities. Tasks areprovided by RN,LPN,UAP. Head nurse coordinates assignments of duties to members of the nursing staff. Nurses of different qualifications can work together therefore costefficient. Primary Nursing Nursing System to provide continuity of care for a client. A primary nurse designs, implements and is accountable for the entire client care, assisted by an associate nurse. Team Nursing Most common nursing care delivery system in the US ! Team of nurses provides total care to a team of clients. Allows non or less skilled nurses to be involved. Only one RN team leader is necessary. Shared governance models of practice Involving all delegating and supervising nursing personell within a facility. Underlying principles are partnership, equity, accountability, ownership. Characteristized by decentralized power sharing and decision making process, interdisciplinary team building, activities and conferences. Elected committees set policies and address organizational issues for nursing practice, quality improvement, education, management of specific areas. The chairperson of an overall coordinating council elects the nursing staff. - Organizational Skills вЂ“ General priority schemes in client care вЂў вЂў ABCвЂ™s MaslowвЂ™s Hierarchy of Needs o Physiological (primary) needs o Safety and security o emotional and psychosocial support 12 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂў вЂў вЂў вЂў вЂў Agency policies and procedures o Urgent response policy o Elective response policy o Delegating response policy Time o Immediate tasks o Scheduled tasks within 2 вЂ“ 4 hours o Scheduled tasks within one shift Client and family preferences o Clients and families in distress o Clients and families concerned about nursing care o Routine client and family requests Care related to client acuity Unstable client first! o Life threatening condition o Lifesaving activities o Essential activities Priorities in medication therapy o Medication for acute physical distress o Preventive Medication o Maintaining Medication Time Management Requires outcome oriented and not task oriented aspect. Goal is to provide quality care under time efficient conditions instead of caring for a larger number of clients in a circumscripted time frame. Time management strategies for nurse leaders Goal is use time wisely. Key question: Does it need to be done now / or at all ? Goal is to use the time primarily for essentials and to delegate appropriate tasks. Additional factors of efficient time management include an organized work area as well as recognition and prevention of stressors in personal life. Symptoms of poor time management Fatigue, irritability, stress, difficulty concentrating and forgetfulness. Tools to organize time efficient nursing care Efficient access to supplies, regarding shift reports, assignments to duties, shift action plans, client care rounds and self reflection. - Basic Principles of Leadership and Supervision вЂ“ Obligations that require professional judgement can not be delegated. Only authority but not ultimate responsibility can be delegated. Inappropriate delegation вЂў Underdelegation (вЂњI do it myself.вЂќ) вЂў Reverse delegation (Team member unable to fulfill task) вЂў Overdelegation (вЂњYou can do it allвЂќ) 13 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com NCSBNвЂ™s five rights of delegation 1. Right task 2. Right circumstance 3. Right person 4. Right direction/communication 5. Right supervision Assigment making requirements вЂў Clear concise directions вЂў Delegation of responsibility вЂў Delegation of authority вЂў RN retains accountability вЂў RN ensures skills are commensurate with the assignment Leadership definition Personal trait, exercise of power, influence and responsibility. Attempt to change behavior of another person. Art of getting others to do what one deems important. Coping with change. Mentoring towards higher levels. Flexible in various situations. Leadership must earn trust and respect of another! Leadership is responsibility rather than an honor! Formal leadership (Supervisor position) - Informal Leadership (Leadership by skills) Nurse Leaders first objectives: Put client first Focusing on Client Safety Enhancing care quality Improving client care outcomes - Leadership types and theories in nursing вЂ“ Autocratic leader: Makes all the decisions autonomously, is uncongenial, motivates by power and punishment. Democratic leader: Believes team members are motivated by internal drives, promotes participation and majority ruling. Laissez faire leader: Democratic leadership without direction or facilitation. Based on trust in team members to act responsibly. Everyone can operate freely as long as the expected outcome arrives. Bureaucratic leadership: Believes in external power, relying on policies and standardized procedures. Benevolent leadership: Kind to followers but not involving them in the decision making process. Consultative / participative leadership: Seeking employees advice about decisions. Contingency theories Leader adjusts leadership to the individual situation. 14 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Examples: a) Fiedler contingency theory: Task oriented or relationship oriented leadership b) Situational leadership Qantum leadership theory Contemporary. Building partnerships with followers. Leader is an influential facilitator. Transactional leadership Built on social exchange and rewards. NCLEX-RNВ® Category I: SAFE AND EFFECTIVE CARE ENVIRONMENT 2. SAFETY AND INFECTION CONTROL - Protecting Client Safety Age specific and general safety requirements. Basic Rules of Infant Safety вЂў Supine position after eating and for sleeping. вЂў Motoric development increases injury and accident risk. вЂў Rear facing restraint system to be placed in middle of backseat of car. (for children of up to 1 year or 20 pounds) вЂў Heated devices to be placed out of reach. вЂў All infant furniture have to meet safety standards. вЂў Caution for lead poisoning on antique furniture and house paint required. Lead poisoning Normal lead serum level < 10 mg/dl. Treatment with (D-Penicillinamin) from 19 mg/d required. Basic Rules of Toddlers Safety вЂў Toddler must not be in touch with potentially poisonous substances at any time. вЂў Car restraint system for toddlers has to be placed in the back seat until shoulders are above harness or ears have reached top of the seat. After child outgrows the system a booster seat with shoulder / lap belt is required. вЂў Toddlers are endangered by swallowing, electricity and drowning. Basic rules of School age safety вЂў Children have to be taught pedestrian and bicycle safety. вЂў Children under 12 years and 4вЂ™9вЂќ have to be placed in rear seat with shoulder / lap belt. вЂў Children have to be taught fire safety (вЂњstop, drop and rollвЂќ) and water safety. Basic rules f Adolescent safety вЂў Drivers education. вЂў Alcohol and substance abuse education. 15 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂў вЂў вЂў вЂў Sports injury prevention. STD information. Birth control awareness. Reviewing water safety. Basic rules of Adult safety вЂў Occupational Health Injury Prevention Programs. (musculoskeletal dysfunctions are the most common work related injuries)! вЂў OSHA Education for hazardous conditions and toxic substances. вЂў 40% of MVAвЂ™s are related to DUI (Community Programs) вЂў Firearm education. Basic rules of Elderly safety вЂў Generally increased accident risk due to reduced vision and hearing. вЂў Risk of falling. вЂў Increased risk to become crime victims. Awareness of the most common Medical errors and risks Application of wrong medication or dosage to the wrong client. Adverse reactions. Toxic effects, side effects. Idiosyncratic (individual) reactions. Common Allergies Fish Iodine Contrast Fluids! Medical history awareness. - Rules and Definitions of Basic Life Support (BSL) - * 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations Signs of cardiac arrest Rescuers should start immediate cardiopulmonary resuscitation (CPR) if the victim is unconscious (unresponsive), not moving, and not breathing. Even if the victim takes occasional gasps, rescuers should suspect that cardiac arrest has occurred and should start CPR. Airway and Ventilation management Opening the Airway Rescuers should open the airway using the head tilt-chin lift maneuver. Rescuers should use the finger sweep in the unconscious patient with a suspected airway obstruction only if solid material is visible in the oropharynx. Foreign-Body Airway Obstruction (FBAO) Chest thrusts, back blows/slaps, or abdominal thrusts are equally effective for relieving FBAO in conscious adults and children >1 year of age, although injuries have been reported with the abdominal thrust. These techniques should be applied in rapid sequence until the obstruction is relieved; more than one technique may be needed. Unconscious victims should receive CPR. The finger sweep should be used in the unconscious patient with an obstructed airway only if solid material is visible in the airway. There is insufficient evidence for a treatment recommendation for an obese or pregnant patient with FBAO. 16 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Mouth-to-Nose Ventilation Mouth-to-nose ventilation is an acceptable alternative to mouth-to-mouth ventilation. Mouth-to-Tracheal Stoma Ventilation It is reasonable to perform mouth-to-stoma breathing or to use a well-sealing, round pediatric facemask. Tidal Volumes and Ventilation Rates For mouth-to-mouth ventilation with exhaled air or bag-valve-mask ventilation with room air or oxygen, it is reasonable to give each breath within a 1-second inspiratory time to achieve chest rise. After an advanced airway (e.g., tracheal tube, Combitube, laryngeal mask airway [LMA]) is placed, ventilate the patient' s lungs with supplementary oxygen to make the chest rise. During CPR for a patient with an advanced airway in place, it is reasonable to ventilate the lungs at a rate of 8 to 10 ventilations per minute without pausing during chest compressions to deliver ventilations. Use the same initial tidal volume and rate in patients regardless of the cause of the cardiac arrest. Chest Compressions Hand Position It is reasonable for lay people and healthcare professionals to position the heel of their dominant hand in the center of the chest of an adult victim, with the nondominant hand on top. Chest Compression rates, Depth, Decompression and Duty Cycle It is reasonable for lay rescuers and healthcare providers to perform chest compressions for adults at a rate of at least 100 compressions per minute and to compress the sternum by at least 4 to 5 cm (1-1/2 to 2 inches). Rescuers should allow complete recoil of the chest after each compression. When feasible, rescuers should frequently alternate "compressor" duties, regardless of whether they feel fatigued to ensure that fatigue does not interfere with delivery of adequate chest compressions. It is reasonable to use a duty cycle (i.e., ratio between compression and release) of 50%. Firm Surface for Chest Compressions Cardiac arrest victims should be placed supine on a firm surface (i.e., backboard or floor) during chest compressions to optimize the effectiveness of compressions. Alternative Compression Techniques CPR in Prone Position CPR with the patient in a prone position is a reasonable alternative for intubated hospitalized patients who cannot be placed in the supine position. Effect of Ventilations on Compressions Interruption of Compressions Rescuers should generally minimize interruptions of chest compressions. Compression-Ventilation Ratio During CPR A single compression-ventilation ratio of 30:2 for the lone rescuer of an infant, child or adult victim is recommended. Chest Compression-Only CPR Rescuers should be encouraged to do compression-only CPR if they are unwilling to do airway and breathing maneuvers or if they are not trained in CPR or are uncertain how to do CPR. Recovery Position It is reasonable to position an unconscious adult with normal breathing on the side with the lower arm in front of the body. 17 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Cervical Spine Injury For victims of suspected spinal injury, additional time may be needed for careful assessment of breathing and circulation and it may be necessary to move the victim if he or she is found face-down. In-line spinal stabilization is an effective method of reducing risk of further spinal damage. Airway Opening Maintaining an airway and adequate ventilation is the overriding priority in managing a patient with a suspected spinal injury. In a victim with a suspected spinal injury and an obstructed airway, the head tilt-chin lift or jaw thrust (with head tilt) techniques are feasible and may be effective for clearing the airway. Both techniques are associated with cervical spinal movement. Drowning CPR for Drowning Victim in Water In-water expired-air resuscitation may be considered by trained rescuers, preferably with a flotation device, but chest compressions should not be attempted in the water. Removing Drowning Victim From Water Drowning victims should be removed from the water and resuscitated by the fastest means available. Only victims with risk factors or clinical signs of injury (history of diving, water slide use, trauma, alcohol) or focal neurologic signs should be treated as a victim with a potential spinal cord injury, with stabilization of the cervical and thoracic spine. EMS System Dispatcher instruction in CPR situations Providing telephone instruction in CPR is reasonable. Improving EMS Response Interval Administrators responsible for EMS and other systems that respond to patients with cardiac arrest should evaluate their process of delivering care and make resources available to shorten response time intervals when improvements are feasible. Risks to Victim and Rescuer Risks to Responders Providers should take appropriate safety precautions when feasible and when resources are available to do so, especially if a victim is known to have a serious infection (e.g., human immunodeficiency virus [HIV], tuberculosis, hepatitis B virus [HBV], or severe acute respiratory syndrome [SARS]). Risks for the Victim Rib fractures and other injuries are common but acceptable consequences of CPR given the alternative of death from cardiac arrest. After resuscitation all patients should be reassessed and reevaluated for resuscitation-related injuries. If available, the use of a barrier device during mouth-to-mouth ventilation is reasonable. Adequate protective equipment and administrative, environmental, and quality control measures are necessary during resuscitation attempts in the event of an outbreak of a highly transmittable microbe such as the SARS coronavirus. 18 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com -Infection ControlFactors for the development of an infection 1. Etiologic agent: Bacteria, Virus, Fungi, Protozoa, Rickettsiae, Helminths 2. Reservoir: inmate (organism) or inanimate: food, water, soil, equipment 3. Portal of exit from a reservoir 4. Method of transmission: a) direct contact (within 3ft) , b) Indirect contact , c) Airborne 5. Portal of entry to susceptible host 6. Susceptible host: Individual at increased risk for infection Standard precautions in accordance to first tier of CDC Guidelines to be used in all cases and for all clients to reduce risk of transmission. Applies to blood, body fluids, excretions, secretions, except sweat, visble or not visible, with and without intact skin and mucous membranes. Hand Hygiene To be performed before and after each contact, immediately after exposure and before and after donning gloves. Washing hands with plain soap or using waterless alcohol based hand rub has equal effect. PPE priority order: Gloves Gown Mask googles Gown mask googles gloves at last Order of applying PPE: Hand hygiene Order of removing PPE: Gloves mask gown googles hand hygiene Medical Asepsis (Clean technique) Includes hand hygiene and use of PPE. Considers вЂњcleanвЂќ and вЂњdirtyвЂќ designated objects. Disposal of contaminated equipment Linens: Handle as little as possible, contain in bag before removal from clients room. Dishes: No special considerations are needed. Syringes, needles, sharps: Avoid recapping or detaching needles, and dispose immediately in a rigid, puncture resistant container. Equipment: Discard disposable items immediately! Non disposable items have to be cleaned and decontaminated immediately after use. Lab specimens: To be placed in leak proofed container with biohazard label and placed in a sealed plastic bag. Transport of clients with infections: masks for patient, cover of wounds, information for receiving staff. Surgical Asepsis (Sterile technique) = Procedures to maintain objects and areas free of microorganisms. Considers вЂњsterileвЂќ and nonsterileвЂќ objects. Used in any invasive treatment. Principles of surgical asepsis: вЂў Items to be sterilized by chemicals, dry or moist heat, radiation. вЂў Sterile packages to be checked for intactness, dryness, expiration date. вЂў Sterilized items to be stored in clean,dry places, off the floors, away from sinks. вЂў Check of sterile indicators. 19 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў Any unsterile contact to be avoided. Areas where sterile procedures are performed need to be cleaned regularly. with damp cleaning or with detergent germicides. Hair to be kept clean and short. Surgical caps to be worn in Operating rooms, delivery rooms, burn units. Avoid sneezing and coughing. (Germs travel 3ft (= 1m))! Nurse with mild upper respiratory tract infection to refrain or wear mask when carrying out sterile procedures. Minimum conversation over sterile fields or avert the head. Sterile items ready to use have to be in view. Nursing staff not supposed to turn backs on any sterile item. Sterile part of Gown: 2 inches above elbow and front. (waist to shoulder) Sterile draped tables are sterile only at surface level. Sterile becomes unsterile by prolonged exposure to airborne microorganisms. Sterilized areas require closed doors, minimum traffic, avoidance of moving air. Do not move unsterile objects over a sterile field. Hold forceps down if no gloves are worn. Hold hands up during surgical handwash. Moisture drafts bacteria. Use sterile barrier on moist surfaces. Edges (2.5 cm) of a sterile field are considered unsterile. Skin cannot be sterilized (Wash hands prior to handscrub). Set up sterile field close to its use. Report any contamination. Questionable sterility means unsterile! Unattended items are unsterile ! Transmission based precautions. Limiting the spread off pathogenic microorganisms Airborne precautions вЂў Special air handling and ventilation are needed. Examples: Rubeola, TBC, Varicella. вЂў Place client in private, negative air pressure room w. 6 вЂ“ 12 air exchanges per hour. вЂў Air to be discharged outside or undergoes high efficiency filtration. вЂў Close doors when entering or leaving the room, clients remains in room at all times. Only cohort patients with same airborne infections but no other! Droplet precautions Examples: Diphtheria, M. Pneumonia, Rubella, Pertussis, Streptococcus. вЂў Standard precautions: Mask within 3ft. вЂў Private room or cohorted rooming. вЂў Door may remain open. Contact precautions вЂў Affects contact with client or contaminated items вЂў e. g. skin infections: Scabies, Pediculosis, Herpes, Hepatitis A, Wounds including MRSA and VRE. (Vancomycin resistant Enterococcus) 20 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂў вЂў вЂў вЂў вЂў Standard precautions: Gloves Private room or cohorted Door may remain open Limit transportation Dedicate equipment to client care MANAGEMENT OF POST-EXPOSURE PROPHYLAXIS AFTER NEEDLESTICK INJURIES Needlestick or sharps injuries or exposure to blood or other body fluid of a patient during the course work must lead to the following steps: - Wash needlesticks and cuts with soap and water. - Flush splashes to the nose, mouth, or skin with water. - Irrigate eyes with clean water, saline, or sterile irrigants. - Report the incident to your supervisor. - Immediately seek medical treatment for prescription of antiretroviral medications - Prophylaxis should begin as soon as possible after exposure and within 72 hours. - Treatment should continue for 4 weeks, if tolerated NCLEX-RNВ® Category II: HEALTH PROMOTION AND MAINTENANCE -The Female Reproductive System - Anatomy of female internal structures Vagina (birth canal) Muscular, membraneous tube. Side walls covered with rugae. Connects external genitalia and cervix. Cervix Neck of Uterus. Consists of fiber tissue. Distending during labor. Uterus (womb) Hollow muscular organ. Sheds endometrium periodically. Holds fetus. Superior part: fundus, lower part: cervix. Fallopian tubes 21 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Connects either ovary with uterus. Ciliated to transport ovum (zygote). Isthmus = part towards to the uterus. Ampulla = middle section. Indundibulum = ending Ovaries Almond sized endocrine functioning glands. Producing and secreting estrogene and progesterone. Release one mature follicle per menstrual cycle. Function of female genital structures. Oogenesis Oocytes present at birth. FSH (follicle stimulating hormone) stimulates meiosis to develop an individual ovum LH (luteinizing hormone) transforms follicle into corpus luteum Corpus luteum produces progesterone and maintains a pregnancy Estrogene and Progesterone are produced by ovaries with or without pregnancy. Ovulation FSH stimulates maturation of a follicle during follicular phase into Graaf Follicle which ruptures on the surface and becomes corpus luteum under influence of LH and FSH. Minimum body fat percentage of 14% is needed to have an ovulation! Corpus Luteum either degenerates if no fertilization occurs or produces progesterone in case of fertilization. Conception Requires a 23 Chromosom containing Spermatozzoon to meet a 23 Chromosom containing Ovum to produce a 23 Chromosom containing diploid zygote. Conception takes place in the ampulla of the fallopian tube. Development of a Pregnancy Cleavage (rapid miotic division of zygote) leads to blastocyst which develops into the 16 cell Morula Morula divides into trophoblast to be implanted into endometrium. Cervical secretions become stratified during ovulation to facilitate sperm transport Endometrial Secretions are rich in glycogen to nourish developing embryo until Placenta has developed/ Menses Begins during puberty and is stimulated by alternating estrogene and progesterone secretion. 22 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Menstrual cycle A menstruation occurs if the ovum is not fertilized and the corpus luteum disintegrates. Estrogen and progesterone levels drop in last week of menstrual cycle. Leading to sloughing of endometrium. Menstrual cycle: Follicular Phase: Day 1 вЂ“ 14 of cycle Consists of menstrual phase and proliferative phase Length of follicular phase varies and can change length of the entire cycle! Luteal Phase: Day 15 вЂ“ 28 of cycle (Always 12 вЂ“ 14 days in length)! Consisting of secretory Phase (Endometrium secrets glycogen) and ischemic phase (Endometrium breakdown) Cervical mucus as a fertility indicator вЂў During ovulation more plentiful, thinner and of stretchy consistency вЂў Forms columns to facilitate sperm transport вЂў Production can be impaired by surgical treatment for abnormal Pap smears Female sexual and reproductive hormones Estrogene characteristics вЂў Produced by ovaries and ovarian follicles during ovulation. вЂў Expresses secondary sex characteristics at puberty. вЂў Peaks in follicular phase of menstrual cycle вЂў Inhibits FSH and LH secretion. bbbbbbbbbbbbbbbbbb nnnnnnnnnnnnnnnnnnnnnnn Progesterone characterisitics вЂњ The Pregnancy HormoneвЂќ вЂў Produced by Corpus luteum. вЂў Peaks in luteal phase. вЂў Stimulates LH and FSH. вЂў Thickens endometrium. 23 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com FSH Anterior pituitary hormone, matures one ovarian cycle each cycle. LH Anterior pituitary hormone, completes maturation of ovarian follicles and stimulates ovulation which occurs 10 вЂ“ 12 hrs after LH Peaks. Menopause Defined by 1 year of amenorrhea, occurs on average around 50, leading to thinning and atrophy of internal and external genital structures. - Anatomy of male internal structures - Testes: two lobular, oval glands, conducting spermatogenesis via Meiosis Epididymis: duct from top of testis ending in vas deferens Vas deferens: connects Epididymidis and Prostate Gland Prostate Gland: encircles Urethra, producing alkaline secretion, released during ejaculation. Seminal vesicles: superior to the prostate gland, producing seminal fluid, released during ejaculation to support sperm metabolism and motility. Urethra: between Bladder and urethral meatus Semen: 2 вЂ“ 5ml , spermatozoa and secretion Spermatogenesis takes place in testes Epidydimidis stores Spermatazoa until Ejaculation occurs. b - Male sexual and reproductive hormones and fertility parameters - Semen: 2 вЂ“ 5ml , spermatozoa and secretion. Sperm Count Normal: > 20 Million Sperms / ml. 50% must have normal form and motion. Testosterone Directs libido, sperm production, building and maintenance of erection, ejaculation. Male Puberty Characterized by increased levels of Testosterone which enlarges and thickens penis testes and scrotum. Spermatozoacount and quality decrease from middle age. 24 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com - Infertility Assessment Parameters Primary Infertility = never conceived Secondary Infertility = not conceiving after previous pregnancy BBT Basal Body Temperature Morning oral temperature dips one day prior ovulation. Rises by 0.5 to 1.0 F indicate ovulation. Cervical mucus During ovulation more plentiful. Thinner and stretchy consistency. Forms columns to facilitate sperm transport. Production can be impaired after surgical treatments for abnormal Pap smears (e. g. Coniotomy). Uterine structure Abnormalities present ? (i. e. fibroids) Fertility awareness method BBT and cervical smear monitoring to detect ovulation FSH and LH Levels Assessment of ovarian function Postcoital exam of vaginal secretion 10 вЂ“ 12 hours after iintercourse, 1 or 2 days before expected ovulation Endometrial Biopsy To check for luteal phase defect (lack of progesterone) Client placed in lithotomy position under speculum adjustment. Cervical block, vaginal bleeding will occur. Vasovagal response possible. Hysterosalpingogramm HSG Detecting abnormalities within the uterus and fallopian tubes. Filling uterus with iodine based radio opaque dye via catheter. In general anaesthesia. Laparascopy Insertion of instruments in peritoneum at umbilicus and symphysis pubis to assess fallopian tubes and ovaries. Male semen analysis Sperm antibody evaluation of cervical mucus. Ejaculate testing for Agglutination with mucus. - Treatment options in female infertility - ART Assisted Reproduction Technologies Hormonal Therapy to induce ovulation and induction of ovulation with medication. (Clomiphene Citrate (Clomid, Serophene), single dose hCG) Side effects: multiple birth, ovarian cysts, Intrauterine Insemination (IUI) requires centrifugation to obtain spermatozoa concentrate. Sperm collection from Uterus for IUI has to occur within 3 hours after coitus via catheter. IVF In вЂ“ vitro fertilization Multiple ova harvested transvaginally with large bore needle after stimulation with FSH. Harvested ova is mixed with Spermatozoa Implantation of 3-4 embryos 2-3 days later 25 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Cryoconservation of remaining embryos. Clients remain under observation for 2 hours post procedure limited activity for 24 hours Prescription of progesteron supplement necessary. Variations of IVF вЂў Gamete intrafallopian transfer (GIFT) after 42-72 hours вЂў Tubal Embryo Transfer (TET) after 42 вЂ“ 72 hours. вЂў Zygote Intrafallopian Transfer (ZIFT) after 18-24 hours. вЂў Micro Epididymal Sperm Aspiration (MESA). вЂў Percutaneous Epididymal Sperm Aspiration (PESA). -Family planning and contraceptionNot every state allows provision of contraception to minors without parental consent! Termination of pregnancy (TOP) Informed consent and documentation of counseling is required in all cases. Mandatory counseling has to include: Benefits, Risks, Alternatives, Inquiries, Decisions, Explanations, Documentations. Some states require approval of spouse for a termination of pregnancy (TOP) and for sterilization procedures. Fertility awareness methods Abstinence Coitus interruptus (considered as safe) Calendar method: Least safest fertility awareness method! Based on the following facts: Ovulation occurs 14 days prior to next menses (+/- 2 days) Sperm is viable for 5 days ! Ovum is capable for fertilization for 24 hours. Method requires to maintain a menstrual calendar for 6 вЂ“ 8 month to assess shortest and longest cycle вЂў Fertile period = Between the date 18 days from the first day of the shortest cycle and the date that is 11 days from the beginning of the longest cycle. Example: 25 вЂ“ 18 = 7 / 29 вЂ“ 11 = 18 Conclusion: abstinence between 11th and 18th day of cycle. BBT method: Requires to keep chart. Daily measurement of morning temperature prior activity. No intercourse for 3 days when temperature rises significantly by 0.5 to 1.0 F. Cervical mucus method: (=ovulation or Billings method) As effective as BBT. Assessment of mucous daily for amount, color, consistency, viscosity. Abstinence for 4 days once mucuos becomes more clear, elastic, slippery. Mucus can be affected by hygiene procedures and intravaginal applications. Symptothermal method: Involves BBT and cervical mucus assessment as well as secondary indicators of ovulation = libido increase , abdominal bloating, ovulatory pelvic pain, breast and pelvic tenderness, pelvic and vulvar fullness, lightly dilated and softened cervical os. 26 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Mechanical contraceptions methods Condoms No oil based lubricants can be used alongside latex condoms. Female condoms Made of polyurethane and can be used with Latex allergy. To be inserted up to 8 hours prior to intercourse. Can be used with oil based substances. Spermicides Foams, films, suppositories. Most commonly used substance is nonoxynol-9 and octoxynol-9. Must be applied before each intercourse. Does not protect against STI. Diaphragm Needs to be inserted 4 hours before intercourse. To be replaced annually and after pregnancies and weight gain over 15lbs. Device may supports recurrent urinary tract infections due to urine retention and urethra compression! Cervical Cap Needs to be applied a minimum of 20 minutes but no longer than 4 hours prior to intercourse; Can be left in place for up to 48 hours. Spermicide does not need to be reapplied. Contraceptive Sponge Polyurethane, effectiveness highest in nulliparous women. To be moistened with water Protects for 24 hours and does not need to be reapplied within this time. Intrauterine Device IUD Immobilizing sperm on their travel into the fallopian tube, unknown how this works. Hormonal or coppered devices, Progesterone T ( Progestasert ) to be changed annually Copper T380A (ParaGard) can stay for 10 years Women should be monogam, no PID, Pain may occur for 2 вЂ“ 6 wks after insertion Irregular menstruation during the first few cycles has to be expected, Follow up after 4 вЂ“ 8 weeks, Self check for string once weekly in first month, then monthly after menses. Increased risk for PID in first 3 weeks TSS Toxic shock syndrome May be caused by Caps, Diaphraghms, Sponges, IUDвЂ™s. Early warning signs and symptoms are: 101.4 F, sore throat, weakness, achiness, sunburn rash, UTI symptoms, abdominal/ pelvic symptoms, foul smelling vaginal discharge. Hormonal Contraception Variety of effect due to inhibiting release of ovum, blocking release of gonadotropin releasing hormone, changing cervical mucus and paralyzing the fallopian tubes. 27 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Oral contraceptives: Combined = estrogen + progestin for 21 or 28 days Progestin only = вЂњmini pillвЂќ = No Estrogen and less progestin than combined pills. Preferrably used in lactation, mild hypertension and in case of Estrogene side effects. To be taken first on the first day of a new menstrual cycle but no later than the following Sunday after the onset of menstruation. (= max. 7 days delay) Missing the Mini Pill continue Pill and use extra contraceptive. Missing a Combined Pill same procedure but no extra precaution necessary if only one pill is missed. Side effects: Thromboembolic disease, headache, fluid retention, nausea = estrogen related Acne, HDL increase, depression, hirsutism, ectopic pregnancy = progestin related Combined BC Pill Benefits: Decreased Risk of Ectopic Pregnancy, fibrocystic, breast disease, ovarian and endometrial cancer, improvement of acne, protection against functional ovarian cysts. Birth control pill effect decreased by Phenytoin, Tegretol, Primidone, Topirimate, Griseofulvin, Rifampin /Ampicillin, Tetracyclines and other antibiotics. Contraindications for combined Pill: > 35 years of age, lactation, headaches and neurological problems, decreased mobility BP > 160 / 100, Diabetes, > 20 years of vascular disease. Subdermal Implants (e. g. Norplant В®) Six silastic capsules containing levanorgestrel, Subdermal implantation in upper inner arm in first 7 days of cycle, Prevent ovulation, thickening mucous, causes bleeding abnormailites, weight gain, moods and depression. Long acting progestin injections Methoxyprogesteroen (Depot Provera)150 mg, long acting progestin blocks luteinizing hormone, prevents ovulation, thickens cervical mucous. May cause bleeding abnormalities, weight gain, tenderness, depression, Intramuscular injection to be repeated after 80 вЂ“ 90 days necessary. MAP Morning after pill (Mifepristone RU 486) Progesterone antagonist, prevents Implantation of ovum. X X Surgical Contraception Vasectomy Resection of Vas deferens. Postoperatively minimal activity for 48 hours, light activity for 1 week. Ice packs help to reduce swelling, No baths until stitches are removed. Requires up to 3 semen exams prior unprotected intercourse and after the 6th and 21st month. Tubal ligation Interruption of Fallopian tubes by laparascopic surgical procedure. 28 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com -Antenatal Assessment and CareEstimation of Date of Birth (EDB) Naegeles Rule 1st day of Menstrual Period вЂ“ 3 Month (=84 days) + 7 days Rule applies in regular menstruation and in woman not being on hormonal birth control. McDonalds Method Measuring fundal height from symphysis pubis to uterine fundus. Distance correlates with weeks of gestation between 22 and 34 wks. To calculate as follow distance in cm x 8 = weeks of gestation. Not reliable in abnormal weights, multiparous and abnormal amniotic fluid. Obstetric Definitions Quickening Feeling of fetal movements between 16 and 18 weeks of gestation. Gravida Term to describe number of pregnancies = Number of infants delivered after 20 wks of Gestation, dead or alive Multiple Birth count as one. TPAL Assessment Number of children born in Term after 37 wks. Number of Preterm infants born between 20 and 37 weeks. Number of spontaneous or therapeutic Abortions prior to 20 wks. Number of Living children. Pregnancy signs, symptoms and assessments Presumptive signs Amenorrhea, nausea and vomiting, Fatigue, increased urinary frequency, breast changes and quickening. Propable signs Enlargement of abdomen, pigmentation changes, striae, ballottement, positive pregnancy test, palpation of fetal outline. Positive signs Fetal heartbeat, fetal movement palpable by examiner, visualization of fetus in ultrasound. Maternal pregnancy examination parameters: Vital signs, height, weight, thyroid, heart and breathing sounds, pelvic musculature, pelvic seize and uterus size. Laboratory pregnancy assessment parameters: Hematocrit and hemoglobin, Blood type, Rh factor, irregular antibodies, Rubella titer, tuberculin skin test, renal function tests, Urin analysis and culture , STD Screening, PAP Test, and Offer! of a HIV Test. Psychosocial pregnancy assessment parameters: Feelings about pregnancy, available support systems, stability and functional level in clients family, economic support and cultural preferences. 29 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Collaborative Antenatal Nursing Management: Client has to be instructed about physical exam, prenatal care program, setting, personnel, physiological changes and danger signs. Client has to be able to verbalize relevant knowledge from these instructions. Blood group examination: Further testings are necessary if mother is type O or Rh negative (means she carries antibodies against A, B and RH factor). May cause Erythroblastosis fetalis or Hyperbilirubinaemia which may compromise fetus in a later pregnancy. Urinalysis: Performance and interpretation: Collection from mid stream urine, clean catch specimen. An urine culture for microbiological examination is necessary if contamination is current with a number of > 100.000 bacteria / ml. Normal urine has a clear to amber color. A low Urine ph < 7 most commonly indicates Ketonbodies in fasting conditions or Diabetes. Urine glucose appears from a Blood Glucose of 160 mg/dL due to impaired renal reabsorption. The specific gravity of urine is increased in dehydration. Caused by excessive vomiting and Hyperemesis gravidarum. Proteine urine traces to + 1 in dipstick may occur in pregnancy physiologically. Higher Levels may indicate hypertension or preeclampsia. Evidence of Nitrite and WBCвЂ™s causes suspicion of an urinary tract infection. UTI in pregnancy increases risk for preterm labor! T-O-R-C- H Infection Screening Toxoplasmosis Caused by toxoplasma gondii protozoe due to consumption of undercooked, raw meat, poor hygiene after handling cat litter/ Fetus is affected if mother gets infected after conception. IgG > 1:256 = recent infection / IgM > 1:256 = acute infection Maternal symptoms: Flulike symptoms, Fetal and neonatal effects: Miscarriage, CNS defects, Hydrocephaly, Microcephaly, Chronic Retinitis, Seizures. Rubella ( = German measles, = 3 day measles) Caused by Rubella Virus. Spread by droplet infection. IgG > 1:10 = Immunity, IgG </= 1:8 = No Immunity Maternal signs: fever, rash, mild. Lymphoedema Fetal neonatal effects: congenital abnormalities, death v Cytomegalievirus CMV Caused by respiratory droplet, (Most common), semen, cervical and vaginal secretions, breast milk, placenta tissue, urine and feces. Special risk for health care workers in contact with mentally challenged! Diagnosis via viral culture most effective. CMV antibodies show recent infection, a fourfold increase within 10 вЂ“ 14 days an acute infection. Maternal symptoms: Sore Throat, Splenomegalie, cervical discharge 30 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Herpes Simplex Virus (HSV) Caused by HSV Virus. Hepatitis A / B HAV and HBV infections are the most common in a fetus. HAV spreads by Droplets or hands supported by poor hand washing HBV is transmitted to fetus via placenta but usually during labor and delivery Diagnosis of Hepatitis A: RIA for HAV Antibodies, IgG without IgM = chronic stage IgM without IgG = acute stage Diagnosis of Hepatitis B: Hepatitis B surface antigen (HbsAg) Maternal symptoms: Flu like, Fever , malaise, nausea, abdominal discomfort, liver failure. Fetal / neonatal symptoms: Preterm birth, hepatitis, intrauterine fetal death HSV II: STD, contracted via vesicular lesions on genitals. Infant gets infected in Birth Channel. Diagnosis by viral culture, Serology not accurate. Maternal symptoms: Fever, malaise, nausea, Headache, Fetal/neonatal effects: preterm, stillbirth, IUGR, (intrauterine growth restriction) Vaginal delivery indicated if no obvious lesions detectable. Sexually transmitted infections (STIвЂ™s) = STDвЂ™s = venereal diseases HPV (Genital warts) Diagnosed by inspection Maternal symptoms: Genital lesions, chronic vaginal discharge, pruritus, cervical dysplasia, some strains are asymptomatic. Juvenile symptoms: Juvenile laryngeal papillomata. HIV Transmission through all body fluids inclusive breast milk. Transplacentar transmission less likely if mother receives treatment during pregnancy. Diagnosis by EIA and positive Western Blot. P24 antigen capture assay diagnoses neonatal HIV as soon as 2 вЂ“ 6 wks after infection and before seroconversion. Cultures are best diagnostic tool fo neonates but expensive and take 4 вЂ“ 6 wks. Maternal symptoms: Opportunistic infections (p. carinii pneumonia) , candida oesophagitis, wasting syndrome, HSV, CMV. Seroconversion associated by flu like symptoms, Lymphadenopathy, nausea, diarrhea, weight loss, rash. Fetal / Neonatal symptoms: At birth asymptomatic, later as above, Hepatosplenomegalie, failure to thrive, Informed consent must be obtained prior to any HIV testing ! 31 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Group B Streptococccus (GBS) Vertically transmitted through vaginal colonisation of 10 вЂ“ 30 % of healthy women. Mandatory screening in all pregnant women between 36 вЂ“ 37 weeks gestation with GBS culture. Maternal symptoms: preterm labor, chorioamnionitis, premature rupture of membranes, UTI, postpartum infections. Fetal neonatal symproms: meningits, sepsis, septic, shock, death Syphyllis Caused by Treponema pallidum, a motile spirochete bacteria. Transmitted through microscopic abrasions on subcutaneous tissue and via placenta at any time during pregnancy. Diagnosis: Lesion tissue analysis, Serology not positive in acute infections, but in late infections. Screening in first prenatal visit and possibly again in 3rd trimester. With VDRL (Venereal Disease Research laboratories) or the RPR (Rapid plasma regain). Confirmation of positive test with fluorescent treponemal antibody absorption test (FTA ABS) Maternal symptoms: (acute) chancre on skin near infection lymphadenopathy, rash on palms and soles. Latent stage up to 5 years. third stage can affect CNS, cardiovascular system, ocular signs, miscarriage, premature labor. Fetal / neonatal effects: CNS damage, hearing loss, death. Gonorrhea Caused by infection with neisseria gonorrhea. (aerobic gramnegative diplococcus) via sexual activity and in birth canal. Screening at 1st prenatal visit. Women at risk also at 36 wks of gestation. Diagnosis: Thayer-Martin culture from smears of the endocervix, rectum and pharynx. Maternal symptoms: Asymptomatic to purulent discharge, irregular menstruation, pelvic pain Premature rupture of membranes (PROM). Fetal/ neonatal symptoms: Preterm birth, neonatal sepsis, IUGR, opthalmia neonatorum Chlamydia Caused by infection w. Chlamydia trachomatis via sexual contact. CDC recommends screening in asymptomatic high risk women. Cultures expensive , special transport required, results take up to 10 days. Maternal symptoms: Mostly asymptomatic, also bleeding, purulent discharge, PID, Dysuria. Fetal/neonaltal effects: Conjunctivitis, Opthalmia neonatorum, pneumonia. 32 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Complete Bloodcount alterations in pregnancy: Parameter Normal Results Pregnancy related alterations RBC Count 4.2-5.4 million/mm3 5-6.25 million/mm3 Hemoglobin 12-16 mg/dl > 11 grams/dl Hematocrit 37-47% > 33% Mean corpuscular 80-95/mcm3 (no changes in Pregnancy)! Volume MCV Mean corpuscular 27-31 picogram/ml (no changes in Pregnancy)! hemoglobin MCH Mean corpuscular 32-36 grams/dL (no changes in Pregnancy)! Hemoglobin concentration MCHC WBC Count 5000 вЂ“ 10000/mm3 5000-15000 / mm3 Polymorphynuclear 55вЂ“70% of WBCвЂ™s 69-85% of WBCвЂ™s Cells (Neutrophils) Lymphocytes 20-40% of WBCвЂ™s 15-40% of WBCвЂ™s Platelet Count 150000 вЂ“ 400000/mm3 postpartal changes - Nursing Care at neonatal visits Antenatal assessments вЂў Psychological well being вЂў Weight gain вЂў Vital signs вЂў Nutritional status вЂў Urine Status for Proteines/Glucose/ WBC/Nitrite w. clean catch collection. вЂў Monthly hemoglobin. вЂў Fundal height вЂў Fetal movement and heart rate, вЂў AFP Levels at 16 вЂ“ 18 wks. High AFP = Defects of neural tube, body wall, threatened abortion, fetal distress, death = Triple Screen Test. Ultasound, AFP Levels in amniotic fluid. Low AFP = s/o Trisomie 21 or fetal wastage, Glucose at 24 вЂ“ 28 weeks. Frequency of Visits Every 4 weeks during first 28 weeks Weekly until delivery. 2nd вЂ“ 9th month every 2 weeks until 36 wks. Teaching of physiological changes (Colostrum, quickening etc.) and danger signs is an essential part of the neonatal visits ! Triple Screen Test = AFP, hHCG, unconjugated Estriol UE 3 Glucose Tolerance Test GTT 50 g oral glucose load at any time of the day even with prior meals. Normal result if 1 hour venous blood glucose < = 140 mg / dl. Abnormal result: 3 hour oral glucose tolerance test. Oral Glucose Tolerance Test OGTT High Carbohydrate Diet over 3 days prior test After 8 hour fasting overnight fasting serum glucose obtained 33 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 100mg oral glucose administered Venous blood glucose readings after 1,2,3 hours 1 or more abnormal findings gestational Diabetes 1 abnormal fiding = borderline result = repeat in one month Abnormal OGTT Results Fasting > 105 mg/dL, 1hour > 190mg/dL, 2hour > 165 mg/dL, 3hour > 190 mg/dL Ultrasound Assesses gestational age, anomalies, fetal well being. Transvaginal Ultrasound: Primarily used in first trimester to assess fetal and maternal structures, fluids, bones. No full bladder needed. Contraindications: Embarassment and Latex Allergy. Viability: Assessment of fetal heart rate at 6 вЂ“ 7 weeks of gestation with real time echo scan. Fetal death Absence of heart activity, scalp edema, maceration. Assessment of gestational age via ultrasound can best be established during first 20 weeks of gestation because of fairly consistent fetal growth rate during this period. Crown - rump measurement 7 вЂ“ 14 weeks. Biparietal Parameter BPD + Femur length > 12 weeks of gestation. (= serial assessments for determination of fetal growth) Abdominal Ultrasound: Requires full bladder for best results. Warning signs in pregnancy Gush of fluids from vagina = Rupture of Membranes Vaginal bleeding = Abruptio placentae, Placenta praevia, Bloody show Abdominal pain = premature labor, abruption placentae Temperature = > 100.4 degrees Fahrenheit / 38 degrees Celsius = Infections Persistent vomiting = Hyperemesis gravidarum Visual disturbances = Hypertension Preeclampsia Severe headache and hypertension = Preeclampsia Epigastric pain = Preeclampsia Dysuria = UTI Decreased fetal movement = Compromised fetal well being Childbirth Education Needs by Trimester Trimester First Educational topic - Physical and psychosocial changes - Self care - Protecting and nurturing the fetus - Choosing a care provider and setting - Prenatal exercise - Relief of common early pregnancy discomforts Second - Planning for breast feeding - Sexuality in pregnancy - Relief of common later pregnancy discomforts 34 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Third - Preparation for childbirth - Development of a birth plan Exercise in pregnancy Women have to be encouraged to participate in regular exercise three times weekly. (pelvic tilt, partial sit ups, Kegel exercises, stretching of inner thigh muscles) Common natural birthing methods Lamaze The most widely known natural childbirth method used to be recognized for teaching of specific breathing methods which were supposed to distract the women in labor from pain. After going through several changes within the last decades this method is now founded on several other techniques that have in common to focus the attention of the women in labor elsewhere. The basic contemporary Lamaze rules of natural childbirth are as follow: вЂў вЂњLet Labor Begin on Its OwnвЂќ вЂў вЂњWalk, Move Around, and Change Positions Throughout LaborвЂќ вЂў вЂњBring a Loved One, Friend, or Doula for Continuous SupportвЂќ вЂў вЂњAvoid Interventions That Are Not Medically NecessaryвЂќ вЂў вЂњAvoid Giving Birth on Your Back, and Follow Your BodyвЂ™s Urges to PushвЂќ вЂў вЂњKeep Mother and Baby Together вЂ“ ItвЂ™s Best for Mother, Baby, and BreastfeedingвЂќ Bradley This method teaches natural childbirth and views birth in general as a natural process. Based on proper education, preparation and the help of a loving, supportive and educated coach the women can be helped to give birth naturally. Woman and coach play an active part by increasing self-awareness and teaching of how to deal with the stress of labor by tuning in to her own body. The Bradley Method encourages mothers to trust their bodies using natural breathing, relaxation, nutrition, exercise, and education. Kitzinger вЂ“ Stanislavski This method is based on the ideas of English anthropologist Sheila Kitzinger and promotes birth as a natural sexual event. In addition to education and coping skills learned in specific classes, there is a strong emphasis on the positive interaction of the parents who have conceived this baby together. Therefore this method requires an intact parent relationship since the father is supposed to вЂњcoachвЂќ the women in labor. Early Pregnancy discomfort awareness Nausea and vomiting, Breast tenderness, Urinary frequency, Fatigue, Ptyalism, Nasal stuffiness/bleeding. Late Pregnancy discomfort awareness Heartburn, constipation, hemorrhoids, backache, leg cramps varicose veins, ankle edema, faintness and flatulence. 35 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў Physiological changes in pregnancy Hypertrophy of Uterus = (increase in size of cells) from 10 mL to 5 Liter due to estrogen stimulation. Cervical secretion of thick mucus to plug opening of the cervix GoodellвЂ™s sign = softening of the uterus Chadwicks sign = bluish color of cervix during pregnancy Vagina mucosa and secretion thickening. Fiber tissue relaxing pH 3.6вЂ“6.0. Breasts: Increase in size and number of glands. Colostrum secretion, bluish white, last trimester. Cardiovascular changes: Cardiac output increases by 30- 40%. Pulse by 10вЂ“15 beats/minute. Cardiac problems most common around 28 wks. Decrease of pulmonal and peripheric vascular resistance decreases by 40вЂ“50%. BP 1st and 2nd Trimester 3rd Trimester. Vena Cava Syndrome Reduced blood flow to right atrium from midterm pregnancy leads to BP decrease and collape. Client needs to choose positioning on left side.Respiratory changes: вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў Respiratory changes: Decreased airway resistance. Increased air volume by 30вЂ“40% due to progesterone. Intrathoracic Volume remains unchanged! Musculoskeletal changes: Relaxation of pelvic and ISG Joints, Hyperlordosis Diastasis recti. Gastrointestinal: Hyperemesis gravidarum commonly occurring in 1st Trimester due to hcG production in placenta. Progesterone relaxes all smooth muscles, causing constipation. Renal: Urine frequency increased in 1st and 2nd Trimester. GFR by 50% from 2nd Trimester. Skin: Estrogen = Pigmentation in areola, nipples, vulva. Choasma in women of color around eyes and forehead aggravated by sun exposure. Linea nigra dark pigmentation from umbilicus to pubic area. Striae gravidarum. Increased activity of sebaceous glands. Endocrine changes in pregnancy: Weight gain: 3вЂ“5 lbs in first trimester , 12-15 in each following trimester (35lbs altogether) = 10вЂ“13 lbs in first 20 weeks and 1 pound weekly in last 20 weeks. Weight gain results from growth/increase of fetus, placenta, amniotic fluid, uterus, blood volume increase and breast size. Water retention due to increased levels of sexual hormones and decreased serum protein. hCG production human chorion gonasdotropin, secreted by Trophoblast in early. Pregnancy, stimulates Estrogen and Progesterone production. Urine ELISA 36 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂў вЂў вЂў вЂў вЂў вЂў pregnancy tests are developed to detect hCG in Urine. Human placental lactogen hPL = chorionic somatomammotropin. Estrogen and Progesteron. Produced by Corpus luteum for first 7 weeks. Estrogene: stimulates uterine development and lactation of breasts. Progesterone: Maintains Endometrium, relaxes uterus and smooth muscles. Relaxin: Corpus Luteum Hormon, relaxes uterus, collagen fibers, softens cervix. Prostaglandines: contribute to onset of labor Maternal Nutrition Healthy pregnant normal weight woman require additional 3000 calories per day. Proteins, Folate (Vit B 6), Vitamins, Minerals, Trace elements. Lactose Intolerance Lactase deficiency leads to a failure to break down lactose to glucose and galactose. Results in nausea, vomiting, and. Cramping and diarrhea. oral replacement via supplement before consuming dairy products (cheese, yogurt and cooked dairy products maybe tolerated) Vegetarian diet in pregnancy requires Vitamin B12 supply from whole grain fruit, legumes and nuts. Complicated antenatal care - Identification of high risk prenatal clients. Prenatal Diagnostic tests: Biophysical profile BPP = 5 factors (Score: 0 -10 8-10 normal, 4-6 possibly abnormal, < 4 abnormal) вЂў Fetal breathing movement вЂў Body movements вЂў Muscle tone вЂў FHR вЂў Amniotic fluid volume Doppler blood flow analysis Noninvasive determination of blood flow and resistance in placental circulation to detect IUGR after 15th week of pregnancy. Assessment of a systolic/diastolic pressure ratio from umbilical/uterine arteries. Ratio > after 30 weeks are considered abnormal if persisting = IUGR Nonstress test NST Assessment of FHR Velocity under provocation of fetal movements. Movement should increase FHR at least twice by min 15 bpm over min 15 seconds within 20 minutes. Contraction stress test CST Measurement of FHR Assessment under breast stimulation or IV oxytocin to stimulate uterine contractions. Indicated in situations where an IUGR is already diagnosed to find out if fetus can withstand decreased blood supply due to uterine contractions in labor. Late decelerations must not occur at all within 3 contractions in maximum 10 minutes. Amniocentesis Withdrawal of max 20ml of amniotic fluid after 14-16 wks of gestation through abdominal wall. Procedure requires RhвЂ“neg clients to receive Rhogam following procedure. Recommended for clients over 35 years of age. 37 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Tests to perform from amniotic fluid samples: вЂў Lecithin to Sphingomyelin ratio (L/S ratio) for assessement of lung maturity. Ratio must be > 2:1 вЂў Phosphatidylglycerol (PG) Presence indicates presence of surfactant = lung maturity вЂў Karyotype Assessment of genetic chromosomal disorders вЂў AFP level Indicator for spina bifida вЂў Chorionic villus sampling -Gestational conditions- Hyperemesis gravidarum Severe vomiting in first 20 weeks of pregnancy. Risk of Dehydration, Electrolyte imbalance, Ketosis, Acidosis, weight loss. Client may require hospitalization for I. V. fluid supply and I & O control. Treatment is symptom oriented, mainly based on small meals, psychological support. Pharmacological treatment with Phenothiazines and and antihistamines possible in severe cases. Ectopic pregnancy Most common site are the fallopian tubes as well as other regions within the abdominal cavity. Risk factors are PID, IUD contraception.Unilateral lower abdominal pain, radiating with abdominal tenderness. May cause uterine or abdominal bleeding. May require shock treatment. Treatment requires surgery. Preoperative test of CBC, B-HCG, Blood group and type, RhoGAM prophylaxis for rh negative mothers. Hydatiform mole (Gestational trophoblastic disease) Abnormal growth of placenta in first trimenon of pregnancy without fetal development Can result in chorioncarcinoma. Most common in Japan. May show brownish vaginal bleeding. May cause hemorrhage. For one year close follow ups for possible chorioncarcinoma (20% transformation rate!) Client to avoid pregnancy for 1 year. b Incompetent cervix Painless cervical effacement and dilation due to previous cervical injuries or infections.May cause preterm labor. Treatment may involve strict bedrest for remaining pregnancy and/or cerglage which has to be removed at onset of vaginal birth. Spontaneous abortion / Miscarriage Unintended loss of pregnancy within first 20 weeks of gestation = spontaneous abortion. After 20 weeks = miscarriage. Most commonly indicated by bleeding in first trimester Classifications: Threatened abortion: Vaginal bleeding, cervix closed, mild cramps Inevitable abortion: Cramping, bleeding, dilation, membranes may rupture Incomplete abortion: Tissue remains in uterus Complete abortion: Cervic closed uterus contracts Missed abortion: Tissue remains in utero because of risk for DIC Clots, pads and tissues may be used in all cases for further examination. RhoGAM Prophylaxis has to be considered after abortions/miscarriages. 38 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Placenta praevia Abnormally implanted placenta near to or over cervical os. Vulnerable to cervical dilation commonly causing bleddings in early pregnancy. Incidence increases with multiparity and multiple gestations. Client usually requires caesarean section. Vaginal delivery only in advanced preterm labor. Typically increasing painless bleeding after 20th week of pregnancy. Diagnosis is made by ultrasound scan. Suspicion of placenta praevia prohibits vaginal examination. All clients require bedrest with bathroom privileges. DIC risk increased. (assessment platelets, fibrinogen, fibrin degradation products, PT, PTT). Abruptio placentae Partial or full separation of the placenta from the uterine wall. More or less painful and bleeding depending if a full or partial separation occurs. Periodical Aassessment of abdominal girth at umbilicus level for baseline size to evaluate baseline size. Premature rupture of membranes PROM = Membran rupture before labor begins. Preterm rupture of amniotic membranes prior to term gestation or before 38 weeks of pregnancy. Prolonged rupture more than 12 hours before birth may require induction of labor to avoid ascending infections. (Chorioamnionitis) All membrane rupture prior to start of labor increase risk of umbilical cord prolaps. Amniotic fluid may be clear, gush or meconium filled. Differentiation to urine with nitrazine paper and microscopically detectable ferning pattern. Pregnancy induced hypertension (Preeclampsia) Refers to hypertension over 140/90 mmHg after 20 weeks of gestation. May be associated by mild to severe proteinuria, and edema depending on severity of stades. HELLP Syndrome (Hemolysis, elevated liver enzymes, low platelet count) and/or Eclampsia (includes seizures) are the eclipse of preeclampsia characterized by additional maternal tonic-clonic seizures. Commonly occurring in third trimester. Laboratory routine assessments include: haematocrit, BUN, ALT, AST, RBC and platelets Bedrest in quiet and calm environment. High protein,salt restricted diet required. Magnesium sulfate increases the seizure threshold. Condition can only be cured by labor. - Labor and Delivery care - General considerations Consider psychological safety for mother. Primigravida mostly experience longer labor. Maternal history must be assessed for abuse. Cultural awareness necessary. Education about laboring process important. Electronic fetal monitoring Used for surveillance of heart rate FHR and uterine contractions UC. External monitoring is placed over fetal back, can be disturbed by maternal obesity Internal monitoring (cervix at least 2cm, membranes ruptured)for direct ECG. Electronic Fetal heart rate interpretation Baseline fetal heart rate = heart rate between contractions, normal: 120 вЂ“ 160- bpm. Short term variability Can only be evaluated by internal monitoring = jaggedness, zickzack appearance in baseline FHR as an expression of changes in FHR between two beats. Expression of parasympathetic/sympathetic nervous system decreased by fetal tachycardia, prematurity, heart and CNS anomalies. 39 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Long Term variability Same cause. Rhythmic fluctuations of FHR 2вЂ“6 x/minute. Increased by movement, decreased by sleep. FHR may also vary spontaneously and with contractions. FHR Accelerations Nonperiodic, spontaneous. Response to fetal movement, indicate in general fetal well being. FHR Decelerations Early decelerations Starts and ends with contraction, mirrors contraction activity. Generally benign finding as long as fetus is descending and contractions do not become ineffective. Late decelerations Begin after start and end after end of contraction. Always considered ominous s/o uteroplacentar insufficiency. Order of appropriate actions in cases of suspected uteroplacentar insufficiency: 1. 2. 3. 4. 5. Oxygenation via mask 7 вЂ“ 10 L/ min., Positioning of client to left lateral side, Fluid by increased IV rate to correct hypotension. Stop Oxytocin supply. Report of incident. Variable decelerations Sudden occurrence. Varying in duration and intensity in relation to contractions. Resolve spontaneously. Caused by umbilical cord compression! Categories: mild, moderate, severe bases on lowest FHR reading. Ominous when prolonged, recurrent, more severe, slow return or overshoot of baseline = s/o fetal asphyxia. Order of appropriate actions in cases of suspected umbilical cord compression: 1. Immediate oxygene supply necessary. 2. Repositioning client to relief cord compression. 3. Vaginal exam to assess if umbilical cord has prolapsed. Intrauterine Amnio infusion of warmed saline to cushion umbilical cord may be required. Severe variable deceleration pattern deceleration of FHR to 90 bpm or less for at least 60 seconds. Uterine contraction monitoring parameters are Frequency, Duration, Intensity. External fetal monitoring: Tocodynamometer to be placed on abdomen, close to fundus. Only accurate for frequency and duration. Sensitivity of instrument depends on BMI of client. Internal fetal monitoring: Via intrauterine pressure catheter (IUPC) (pressure gauge or saline filled tube) Measures IUP in mmHg. x x 40 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com x -Process of labor- Initiating factors вЂў Distention of the uterus вЂў Release of o Prostaglandines induce mild contractions for cervical dilation. o Oxytocine induces strong uterine contractions for labor. o Fetal Cortisol increases muscular fetal activity during labor. o Estrogene levels increase towards labor. o Progesterone levels decrease towards labor. True labor is characterized by cervical effacement and dilation. Definitions of the female pelvic anatomy: gynecoid, 50% , occiput anterior most common, android, 20% , slow descent, arrest, operative birth common anthropoid, 25% , occiput anterior or posterior, vaginal delivery not favorable platypelloid, 5%, occiput posterior, vaginal delivery not favorable (type of pelvis determines delivery) False pelvis (large pelvic cavity) True pelvis (small pelvic cavity) Pelvic anatomy Obstetrics terminology: Passenger = fetus Attitude = positioning of fetal parts to one another. Normal attitude is flexion. Lie = positioning of longitudinal fetal axis to longitudinal axis of mother Types: Vertex (head first) most common lie! Breech (buttock first) Transverse / Shoulder (laterally across uterus) Oblique (diagonally across uterus) 41 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Presentation = description of fetal part entering pelvis first during labour. Types: cephalic (most common) , breech , shoulder presentation. Landmarks: acromion process, mentum, occiput, sacrum Position = position of presenting part to the pelvis. (posterior, anterior, transverse) Most common: ROA (right occiput anterior, LOA (left occiput anterior) Engagement = largest diameter of presenting part reaches pelvic inlet. Floating Engagement = part directed to pelvis but easily moveable. Ballotable Engagement = part directed to pelvis but moveable with manual pressure. Engaged Engagement = presenting part fixed, cannot be displaced. Station Position of presenting part to sciatic spines of pelvis. Measured in cm as follow: - = fetus below spines + = fetus above spines Forces of labor uterine contractions stimulated by uterine pacemaker. Contraction phases: Increment (building up phase) Acme (peak) Decrement (letting up phase) Nadir (resting phase), (necessary to facilitate perfusion and oxygenation) Frequency of contractions Intensity = strength of contraction at acme (assessed by palpation) Mild, moderate, strong palpable Duration of contraction in seconds from increment to decrement Contractions produce effacement = thinning and drawing up of internal os. Effacement may precede cervix dilation in Primigravida. Occurs simultaneously w. dilation in Multigravida. Cervical dilation is measured from 0 вЂ“ 10 cm! Psychological influences birth due to muscular contractions. Fear muscular contractions increased pain. Education about childbirth essential to reduce fear! x x x x x x xx x x x 42 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com -Stages of laborFirst stage From onset of true labor to complete dilation of cervix. Divided in three phases: latent, active, transition. Latent phase: Dilation of cervix 0 - 3 cm , Little descent. Contractions every 30 minutes, from irregular to regular with increasing intensity. Average Duration: 8.6 hours for nulliparas, 5.3 hours for multiparas. Assessments:BP, Pulse, respirations once/hour if normal. Temperature 4 hourly with intact membranes, 2 hourly with ruptured membranes. FHR hourly in low risk, per 30 minutes in high risk women. Active phase: Dilation 4 вЂ“ 7 cm Effacement and descent progressive. Contractions every 2 вЂ“ 3 minutes, of about 60 s duration, strong intensity. Client experiences increased pain. Average duration: 4.6 hours for nulliparas, 2.4 hours for multiparas. Assessments: Same as latent phase FHR per 30 min for low risk, per 15 min for high risk вЂњBloody mucus showвЂќ due to progressed cervical dilation. Transition phase: Dilation 8 вЂ“ 10 cm. Contractions every 1.5 вЂ“ 2 minutes, for 60 - 90 seconds. Communication impaired. Nausea and vomiting common. Increased anxiety, loss of control and helplessness. Average duration: 3.6 hours for nulliparas, 30 minutes for multiparas. Assessments: BP, Pulse, Respirations every 30 minutes, Contractions + FHR/15 minutes. Collaborative Management Orientation about progress and assessments. Encourage ambulation if presenting part is engaged. Provide comfort. Encourage voiding every 2 hours!. Monitoring progress and fetal well being. Ice chips, clear liquids against dehydration. Teach, reinforce breathing and relaxation. Encourage rest between contractions. Analgesia as requested and prescribed. Documentation. Second stage From full dilation of cervix to delivery of fetus. Opportunity to вЂњpressвЂќ voluntarily with contractions! 0.5 вЂ“ 3.0 hours of duration. 43 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Cardinal movements: 1. 2. 3. 4. 5. 6. 7. 8. Engagement Descent Flexion Internal Rotation Extension of fetal head under maternal symphysis. Restitution neck turns 45 degrees to untwist neck after head is delivered. External rotation further 45 degrees to bring lateral diameter of fetal shoulders in line with AP dimension of pelvis. Expulsion shoulders slip over symphysis. Crowning Expulsion of perineum and opening of vagina due to forward pressing fetal part. Assessments BP, Pulse, Breathing every 5-15 minutes. Continous palpation of contractions. FHR every 15 minutes at low risk, every 5 minutes at high risk. Monitoring of fetals descent cardinal movements and crowning. Collaborative management Urinary catheter may be necessary! Episiotomy = Perineumincision To ease birth in fetal distress or to protect perineum damage. Due to tearing which is harder to repair. Perineumlaceration 1st degree, only in epidermis, no repair necessary if no bleeding occurs. fascia muscle = suturing necessary. 2nd degree, epidermis 3rd degree, extension into rectal sphincter = surgical repair necessary 4th degree, extension through rectal mucosa = surgical repair necessary Third stage From birth of newborn to delivery of placenta on average within 30 minutes Maternal Assessment: BP,Pulse,Respiration/5minutes. Uterus tone remains increased and umbilical cord is lengthening until placenta is delivered. Fourth stage (postpartal) First 1 вЂ“ 4 hours after delivery. Client usually remains in nursing suite. Repair of episiotomy or lacerations as soon as possible. Ice administration to perineum if injured or sutured. Initiation of breast feeding. Fluid supply, resuming regular diet. Assessments: BP, Pulse, Respirations, fundus, lochia, perineum (after 15 minutes, 30 minutes, 1st hour, 2nd hour) 44 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com - Pain management during labor Nonpharmacologic methods Position changes, Hydrotherapy, Breathing techniques and Relaxation techniques. Pharmacological methods All systemic drugs cross the placenta barrier! Analgesia during birth is not to be administered to early or too late since this may cause prolonged labor. Most commonly used Intravenous narcotics: вЂў Nalbuphine Hydrochloride (NubainВ®) = narcotic agonist вЂ“ antagonist ! Not to be used for opioid dependent clients ! вЂў Butorphanol tartrate (StadolВ®) Rapid onset, short term duration, used in active phase or first phase of labor! Antidote Naloxone (Narcan) has to be available at all times! Effect and therapeutic use: Effectful pain relief during labor. Not to supply in early labor. Side effects: May prolong labor. Nubaine + Stadol may cause withdrawal in women committing Morphin abuse. Respiratory and cardial depression, hypotension, miosis, constipation, urinary retention and sedation. Newborn respiratory depression if birth 1 вЂ“ 4 hours after administration. Intrathekal narcotics: Substances: Morphin sulfate or Fentanyl citrate. Subarachnoid administration at L4/L5 or L5/S1. Sudden effect, neonatal depression rare. Easier and faster than epidural administration. Spinal headache, muscle spasms and urinary retention are common side effects. Lumbar epidural block Injection at same spinal location. Substances:Bupivacaine Hydrochloride, (Marcaine В®) or Lidocaine Hydrochloride ( Xylocaine В®) Excellent pain relief, longer lasting, no neonatal respiratory depression. Decreasing pelvic floor muscle activity and uterine contraction. May lead to failure of fetus to accomplish internal rotation caesarean section Hypotension is most considerable side effect. Meningeal anatomy of the spinal chord 45 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Paracervical Block Local anaesthesia to lateral aspect of cervix during active or transition phases Relatively easy administration, quick onset, rapid onset, no neonatal effects May lead to decreased or absent urge to push Systemic effect by infection through vascularized cervix = FHR !!!! Decreased sensation in lower extremities Pudendal Block Local anaesthetic injected into lateral walls of vagina to anaesthetize pudendus nerve. Administered in 2nd stage during preparation for episiotomy. Eliminates urge to push. Decreases sensation in lower extremities or ability to urinate. Monitoring of Morphine side effects respiratory depression may occur up to after 8 hours, nausea and vomiting after 4 hours, itching within 3 hours, urinary retention, constipation, somnolence at any time. - Complicated delivery and care Significant risk factors for intrapartal complications are high catecholamine levels due to stress, fear and labor! Factors contributing to difficult labor or dystocia Hypertonic and hypotonic uterine dysfunction Assessment with labor graph (Friedman curve) (comparing descensus and dilation of cervix over time) Malpositions and Malpresentations Fetal malpositioning (Correct position is Occiput anterior position) Occiput posterior position (OP) Occiput anterior position (OA) 46 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Fetal malpresentations вЂў Vertex presentation вЂў Brow presentation вЂў Face presentation вЂў Sincipital presentation вЂў Breech presentation (require caesarean section!) three types: 1. Frank breech (presenting sacrum) 2. Incomplete (footing) breech 3. Complete breech (presenting anus and buttocks) Shoulder presentation (transverse lie) requires caesarean section. FHR monitoring electrodes must not be placed on presenting part ! Extraction methods Vaccum delivery ( may cause cephalohematoma, retinal hemorrhage, intractranial hemaorrhage) Forceps delivery ( may cause fetal ecchymosis, edema of face) Signs and symptoms of breech positions. Fetal distress , (insufficient oxygen supply) Meconium stained amniotic fluid. FHR Tachycardia > 160, FHR Bradycardia < 110. Reduced or absent variability of HR. Late decelerations of FHR following contraction. Necessary actions Positioning mother on left side. Oxygen supply. Cephalopelvic misproportion requires caesarean birth! Shoulder dystocia is considered an obstetric emergency. - Induction of labor- Treatment methods: вЂў Prostaglandines for cervical administration (PGE2 Gel) or oral, intravaginal Misoprostol. вЂў Amniotomy/Artificial Rupture Of Membranes (AROM) вЂў Oxytocin for intravenous use over infusion pump to stimulate contractions. (Until contractions are frequent, following closer than 2 minutes and longer than 90 seconds) 47 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Contraindications for the induction of labor вЂў Abnormal pelvic structure. вЂў Prolapsed umbilical cord. вЂў Active genital herpes. вЂў Invasive cervical cancer. вЂў Prior uterine incision. вЂў Malpresentations of fetus. Causes of prolonged labor: Prolonged latent phase: > 20 hrs. for nulliparous parent, > 14 hours for multiparous parent. Protracted active phase: Dilation < 1,2 cm / hour in nulliparous or less than 1,5 in multiparous client. Protracted descent: < 1 cm/hour in nulliparous client, < 2cm in multiparous client Secondary arrest of cervical dilation: Cessation of dialatation for > 2 hours in nulliparous client and for > 1 hour in multiparous client. Arrest of descent: No fetal descent for > 1 hour. Premature labor Contractions between the 20th and the 37th week of gestation! Signs of labor Contractions frequent, every 10 minutes or less. Low abdominal cramping, with or without diarrhea. Pelvic pressure. Urinary sensation. Low backache. Increased vaginal discharge. Leaking amniotic fluid. Immediate actions to be taught to a pregnant client in case of uterine contractions: Empty bladder. Lay on left side. Administer fluids. Assess uterine contractions by abdominal palpations. Continue activity 30 min after contractions stop. Management of preterm uterine contractions: Administration of tocolytic agents. (Terbutaline (Brethine), Magnesium sulfate, Ritodrine (Yutopar). Administration of betamethasone or dexamethasone to stimulate lung maturity. - - Complications in labor - Precipitous (unattended) labor Rapid, under 3 hours. Injury in birth channel tissue may occur. Fetal risk for hypoxia, intracranial hemorrhage and birth injuries. Client not to be left alone at any time! 48 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Client blowing decreases urge to push. Support perineum with sterile towel when crowning occurs. Apply gentle pressure on fetal head to decrease velocity of delivery. Suction infants mouth first, then nose with bulb syringe. An umbilical cord around infants neck must be clamped twice and cut before delivery! Once infant is delivered assess for separation of placenta. (gushes of bright blood and lengthening of umbilical cord) Hemorrhage prevention with fundus massage or by putting infant to clients breast. Uterine prolapse May be caused by intense fundus massage and pulling on umbilical cord. Uterine inversion = inside out uterine prolapse. May occur complete or partial. Requires immediate reposition to stop blood loss! Uterine rupture Rare complication. Associated with previous caesarean or augmented birth, overstimulation of uterus resulting in intense contractions. Main symptoms are sudden cessation of uterine contractions, FHR , strong abdominal pain and massive haemorrhage. Full rupture requires hysterectomy, a partial rupture can be repaired. - Caesarean delivery Mainly indicated by CPD, fetal distress, breech presentation, previous caesarean birth. Maternal risks Injury to bowel and bladder, Hemorrhage, Thrombophlebitis, Pulmonary embolism and Aspiration. Fetal risks Prematurity, Injury at birth, Respiratory problems. Skin incision usually performed at pubic hair border (Pfannenstiel incision) or by vertical incision. Uterine incisions may be performed through upper or lower uterine segment. Common routine Pre вЂ“ and postoperative care Contraindications Inadequate pelvic or fetal size (> 4000g) Any circumstances that may require a repeated caesarean section. A previous classical uterine incision. Any fetal position that may require augmented birth. Any other than hospital birth setting. Risks Uterine rupture, especially in early period of labor. Labor failure. Benefits Experience of natural delivery for mother and child. Economic benefits. 49 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Medication Therapy in Obstetrics and Gynecology Uterine Stimulants Oxytocin (PitocinВ®) Effect and therapeutic use: Short lasting effect over 2 вЂ“ 3 minutes after administration Stimulates uterine contraction Used as labor inducing medication in: maternal diabetes, preeclampsia, eclampsia, erythroblastosis fetalis May be used carefully to support labor process after cervix has opened and presentation has occurred. Stimulates lactation by increasing let down reflex Causes post partal uterine involution Controls postpartum hemorrhage Requires dilution prior to intravenous administration Magnesiumsulphate needs to be immediately available for IV administration. May be administered as nasal spray to promote milk ejection. Side effects: Increased uterine contractions, (< 2 Minutes apart, > 90 seconds duration, around 50 mmHg in strength) Pelvic pain, Hypotension, Cardiac Dysrhythmias Ergot Alkaloids Ergonovine (ErgotartrateВ® ) Methylergonovine (Methergine В®) Effect and therapeutic use: Control of postpartum hemorrhage due to induction of uterine contractions. Side effects: Causes rebound uterine relaxation, hypertension, decreases milk production and allergenic potential. Contraindications: Pregnancy, hypertension, coronary artery disease, smokers (increased Vasoconstriction) Overdose causes Ergotism: Nausea, vomiting, weakness, muscle pain, insensitivity to cold and paraesthesia. Prostaglandines Dinoprostone (Prepidil В®, Cervidoil В®): Prostaglandin E2, Approved to support cervical opening. Carboprost promethamine (Hemabate В®): Prostaglandin F2, Approved to control postpartal bleeding Effect and therapeutic use: Stimulation of uterine myometrium To induce labor or control of postpartal bleeding Also effect to terminate pregnancy from the 12th week until the 6th month. Client to remain in supine position after administration. Side effects: Nausea, vomiting and hypertension. Uterine cramping, - tetany and rupture. Contraindications: Pelvic Inflammatory Disease (PID), Asthma and Hypertension. 50 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com - Uterine Relaxants All substances may lead to postpartal uterine hemorrhage if used shortly before delivery and may require client to receive Oxytocin as soon as possible. Terbutaline (Brethine В®) Beta-adrenergic substance. Most commonly used, not FDA approved for preterm labor. Can cause nausea and vomiting. Neonate may be delivered with Hypoglycemia. To be diluted in 1000 mL D5W for IV administration. (= 5 mcg/mL) Ritodrine (Yutopar В®) Beta-adrenergic substance. Only FDA approved substance for preterm labor! But increased risk for pulmonary edema. Nifedipine (Procardia В®) Calcium вЂ“ Antagonist. Second commonly used, not FDA approved for preterm labor. May cause Oligohydramnion. Consuming Grapefruit can interfere with effect. Hypotension or othostatic Dysregulation may occur. Indomethacin (Indocin В®) Non-steroidal anti-inflammatory drug. Third choice, Most commonly used. Short вЂ“ term treatment for up to 3 days. May cause Oligohydramnion. May cause premature closure of ductus arteriosus and/or Foramen ovale. Effect and therapeutic use: Inhibition of uterine contractions. For delay of threatened preterm labor until EDD. or until induction of surfactant with corticosteroids took effect. To allow intrauterine fetal rescuscitation during labor. Magnesium Sulfate Effect and therapeutic use: Used in treatment of preeclampsia. Reduces contractility and reliefs cramping in smooth, skeletal and cardiac muscle. Also reduction of nerve velocity in central nervous system. Common parenteral dose is 4 gram over 30 minutes via infusion pump. Antidote for side effects of Oxytocine treatment. Side effects: Generalized muscle weakness, hyponatremia, fluid and electrolyte imbalance Respiratory depression and respiratory arrest! (At risk if Patella reflex is depressed) Increased risk of pulmonary edema if used along with beta вЂ“ adrenergics Contraindications: Renal failure, Pulmonary edema, Chronic heart failure, CNS disease Fetal anomaly/death. Special considerations: Infusion rate is adjusted by urine flow of at least 30 вЂ“ 50 mL/hour Breathing rate has to be at least 16/min. prior to application of additional dosages A breathing rate < 12/min. requires physician to be notified. Serum magnesium level have to remain in normal range 4 вЂ“ 7 mEq/L 51 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Antidote calcium gluconate has to be available at bedside at all times! -RH0(D) Immune Globulin (RHOGAM) - Effect and therapeutic use: Avoidance of Anti вЂ“ D Antibody in Rhesus negative women giving birth to Rhesus positive infants. To be administered within 72 hours prior to potential contact of both blood types (labor) and at any time of a new potential contact unless mother has build up Rh вЂ“ antibodies meanwhile. Contraindications: Allergies against human immunoglobulines. -Lung SurfactantsBeractant (SurvantaВ®), Olfosceril palmitate (ExosurfВ®) Effect and therapeutic use: Lowering alveolar surface tension in preterm neonates to prevent respiratory distress. Applied by intratracheal tube. Procedure may lead to brief reduction of oxygene saturation and bradycardia. Betamethasone (Celestone В®) Effect and therapeutic use: Indution of surfactant synthesis to prevent RDS in neonatal preterm children. Administered between 28 вЂ“ 32 weeks of gestation if labor can be delayed by 48 hours. Ice daily i.m. injections. Typical steroid side effect pattern. Phytonadione Vitamin K1 (PROPHYLACTIC TREATMENT) Used for Induction of the synthesis of coagulation factors II, VII, IX, X in newborn liver to prevent neonatal hemorrhage prior to onset of own synthesis. IM injection at time of delivery. -Physiological changes during postpartum period- Involution Reduction of uterus due to ongoing contractions occluding inruterine blood vessels. Puerperium Timeframe of 6 weeks after delivery in which the uterine involution occurs under normal circumstances. Boggy uterus Interrupted contractions make it soft and relaxed, likely to cause hemorrhage. Lochia Blood and debris following delivery. Increased by exertion or fetal distress. Undergoes physiological color changes as follow: вЂў вЂў вЂў Rubra: 1 вЂ“ 3 days, musty odor, red, small clots, , nickel size), contains blood, mucus, decidua cells, epithelial cells, leukocytes, meconium, lanugo and vernix caseosa. Serosa: 4 вЂ“ 10 days, watery, pink вЂ“ brownish, odorless, also containing bacteria Alba: 11 вЂ“ 21 days (up to 6 wks in lactating women) Yellow to white, slightly stale odor. Contains Cholesterol 52 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Involution enhancing factors: Breast feeding, uncomplicated labor and delivery, early ambulation, complete expulsion of placenta and membranes. Involution inhibiting factors: Prolonged labor and delivery, anaesthesia, grand multiparity, retained placenta fragments and membranes, full blader, infections, overdistended uterus. Reoccurrence or increase of Lochia rubra is generally abnormal! Afterpains Caused by intermittent postpartal uterine contractions. More intense in multiparous and breast feeding women. Cervix soft, irregular, edematous, multiple small lacerations of 2-3 cm after 1 week, touchable after 1 week by fingertip permanent change from round, dimplelike to lateral slitlike. Vagina Smooth, edematous, multiple small lacerations. Perineal pain to resolve after 2 weeks Estrogen postpartum = lubrification = painful intercourse. Abdominal wall Soft, flabby, increased muscle tone, striae, diastasis recti. Cardiovascular system Due to Diuresis and increased GFR the first 48 hours postpartum bear the greatest risk for clients with heart diseases. BP usually remains unaltered. Temporary bradycardia occurs within first 6-10 days. Increased fibrinogen for 1st postpartal week! = ESR = DVT Risk . Temporary increase of WBC up to 30.000/mm3 considered as normal, unless fast developing (within 6 hours) or accompanied by signs of infection. Hemoglobin normalizes within 4 вЂ“ 6 weeks. Hematocrit decrease indicates an increased blood loss. Urinary tract: Generally increased UTI risk during pregnancy and postpartal period. 5 lbs weight loss due to 2000 вЂ“ 3000ml diuresis within 1st 12 вЂ“ 24 hours. Full bladder increases risk of failure of uterine involution and postpartal hemorrhage. Fluid loss also due to diaphoresis and increased perspiration. Gastrointestinal: Hunger, Thirst, Constipation (fear of defecation), Hemorrhoids. Endocrine: Delivery of Placenta causes drop of Estrogene and Progesterone. Menstruation: Mens resumes within 7 вЂ“ 12 weeks . First postpartal cycle maybe anovulatory. Ovulation and Menstruation resumes after 2 вЂ“ 18 month in lactating women. Lactation process: Nipple stimulation Oxytocin release Prolactin release production of milk and let down reflexes (expression of milk by contractions of Alveoli of breast) 53 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Colostrum, first milk secreted, rich in protein and immunoglobulins Engorgement (вЂњPre вЂ“ milkвЂќ) on 2-3rd day after delivery as supply of blood and lymph in the breast is increased and transitional milk is produced. Mature milk after 2 weeks, watery, bluish, like skim milk -Psychosocial changesBonding (Attachment) process: (3 phases) 1. Taking in phase ( 3 days) 2. Taking вЂ“ hold phase (3-10th day) 3. Letting go phase (10 days вЂ“ 6 weeks postpartum) Engrossment (fathers absorption, preoccupation, interest in infant) Postpartum blues maternal adjustment reaction. Transient depression within first 2 weeks postpartum. Related to hormonal changes. Experienced by majority of women to some extent. -Postpartal nursing care- Postpartal Assessments Temp. > 100.4 F after first 24 hrs indicates infection. Pulse 50 вЂ“ 80 bpm. Tachycardia of 100 bpm or higher needs to be reported. Respirations 16 вЂ“ 24/min. BP, orthostatic Hypotension possible. Breasts Engorgement ?, tenderness ?,nipples intact ? Uterus Firmness, height of fundus, position of fundus in relation to midline of abdomen. Wound inspection after episiotomy or caesarean section: Redness, edema, ecchymosis, discharge, gap? Bladder Voiding within 8 hours mandatory, dysuria ?, bladder palpable ? Bowel Passage of flatus ?, distension ?, auscultation ? Lochia Type ?, Quantity ?, Amount ?, Odor ? Haemorrhoids? Present, aggravated ? DVT? HomanвЂ™s sign positive ? (dorsiflexion of foot) Pedal edema ? redness ?, warmth ? Emotional status? Bonding ? Maternal depression ? 54 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com -Collaborative ManagementвЂў вЂў вЂў Keep bladder empty to ease uterine involution! Massage / self massage boggy uterus. Administer medication to support uterine involution: Oxytocin (Pitocin), Methylergonovine maleare (Methergine), Ergonovine maleate (Ergotatrate) вЂў вЂў вЂў вЂў вЂў Apply ice to perineum wounds after episiotomy or perineum lacerations. Encourage warm or cool bath within first 24 hours, as required from second day. Teach perineal care. Administer dermal anaesthetics or analgesics as required. Advice on patient controlled aneasthesia or morphine epidural for caesarian patients. Encourage stool observation and regulation. Encourage nursing on demand, alternating 10 вЂ“ 15 min per breast until infant led. Assist with positioning for breastfeeding. Assist with suppression of lactation. вЂў вЂў вЂў (snug bra/breast binder continuously for 5 вЂ“ 7 days, avoid heat and stimulation, apply ice for 20 minutes four times daily) вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў Support awakening through the day. Observe cultural specifications. Gradual return to daily activities over 4 вЂ“ 5 weeks. Muscle strengthening (Kegel exercises, chin to chest, knee rolls, lifting of buttocks) Adequate nutrition (additional 500kcal./day for lactating mothers) Administer prepregnancy diet if bottle feeding. Encourage fluid intake of 2000 mL/day. Ensure iron supply, improved with Vitamin C. Encourage and praise self and child care Encourage rooming in and presence of family members. Advice that sexual activities can resume after lochia stopped, episiotomy healed. Arrange contraception counseling prior discharge. Advice that estrogen supply interfers with lactation. Advice that refitting of mechanical contraceptives may be necessary. Rhesus Prophylaxis to prevent sensitization of a Rh negative mother Requirements: вЂў Rh negative mother not sensitized. вЂў Negative indirect Coombs Test due to lack of antibodies in maternal blood. вЂў Rh positive newborn not sensitized. Procedure: вЂў RhO(D) Immunglobuline (i. e. Rhogam) once to prevent Rh sensitization. вЂў 300mg IM within 72 hours after delivery In an acute hemolysis neonatorum an exchange transfusion with 0 neg. blood may be considered. Awareness of Neomycin Allergy if clients requires rubella vaccination! 55 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Rhogam and Rubella Vaccine need to be separated for at least 6 weeks to 3 months if both are necessary (Danger of ineraction and reduced activity of Rubella vaccine) Rhogam comes first! Clients have to avoid pregnancy for 3 months after active Rubella Vaccine ! Warning signs of the postpartal period вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў Increasing or recurrent lochia rubra with clots Temperaure > 100.4 F Chills Strong pain Redness of breast Redness of Episiotomy Offensive smelling lochia Dysuria, Urine retention Calf pain, tenderness, redness or swelling Chest pain Breathing difficulties -Newborn AssessmentApgar Score Criteria for the adaptation of a newborn after 1 and 5 minutes. Criteria: 1. Color 2. Heart Rate (Pulse) 3. Reflex Irritability (Grimace) 4. Muscle Tone (Activity) 5. Respirations The expression of each criteria is described by a score of 0 вЂ“ 2! Results: 10 = no findings, 8,9 = nasopharyngeal suction, oxygen exposure needed. 4,5,6,7 = oropharyngeal suctioning, tactile stimulation, oxygen supply needed. Collaborative Management Maintain skin Temperature at 97.7 вЂ“ 98.6 F = 36.5 вЂ“ 37.0 C, Flexed position decreases surface area,Temperature to be taken axillary and from skin. 56 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Vital signs вЂў HR 120 вЂ“ 160 bpm, irregular. вЂў Average blood pressure is 80/40 mmHg. вЂў Functional murmurs possible. вЂў Assessment of heart rate by palpating apical pulse for one full minute. вЂў Respirations 30 вЂ“ 60 breaths/minute, (more or less indicate a problem!) вЂў Temp. 97.7 вЂ“ 98.6 F = 36.5 вЂ“ 37.0 C вЂў Heat loss occurs due to o convection loss to cooler air currents o radiation from body to cooler surface o evaporation from wet skin through sweating Head Size: one quarter of body surface with molding fontanels. FOC Frontal occipital circumference: 32 вЂ“ 27 cm (12.5-14.5 inches) = 2 cm > chest circumference. Caput succedaneum: Birth trauma, swelling under scalp (disappears in days) Cephalhematoma: Blood between cranial bone and periosteum (disappears in 6 weeks) Fontanel closing: Posterior at 8 вЂ“ 12 weeks, anterior at 18 months. General assessment: Symmetric movement of face present as a sign of a facial nerve lesion? Subconjunctival hemorrhage ? (Will spontaneously disappear in weeks) Eyelids edematous ? Tear glands do not become active prior to 2 month of age. Chest clear and symmetric? Nose: Clear with flat bridge ? Mouth: Hard palate intact ? Heart Auscultation At border of left sternum. Murmurs present? Heart rate? Point of maximum pulse lateral to midclavicular line at 3rd to 4th intercostal space. Breast Nipples must be symmetrically located. White discharge or extra small nipples possible as a normal finding. Abdomen Movement with respirations? Bowel sounds present? Umbilical cord Clamped?, no foul odor? Genitalia Labia majora should cover labia minora and clitoris. Testes should be palpable in scrotum. Location of urethral meatus must be centrally located on surface of glans penis. Vernix caseosa on labia minora is indicator for term gestational age. Pseudomenstruation due to maternal hormones possible. 57 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Hips BarlowвЂ™s maneuver Adduct leg over hip leads to a snap when femur leaves actabulum OrtolaniвЂ™s maneuver Hip abducted and lifted leads to a click if femur enters acetablum Arms Grasp reflex: Grasping of object placed in hand Non movement = s/o Erb-Duchennes paralysis or ErbвЂ™s palsy. Nails present? Legs Pulses present? Back Scoliosis? Pilonidal Dimple? Skin Acrocyanosis may be present as a physiological finding. Milia, obstructed secretions of sebaceous glands may be present. Mongolian spots, bluish pigmentation buttocks in Asian, African and Hispanic children. Lanugo, fine hair on shoulders, forehead, cheeks develops from 20th gestational week. HarlequinвЂ™s Sign = one side of body red, other pale due to vasomotoric disturbance. Gestational age assessment вЂњBallard ToolвЂќ Based on six physical and six neuromuscular signs: Outcomes: Small, appropriate, large for gestational age SGA, AGA, LGA Neuromuscular assessments may need to be repeated after 24 hours since neuromuscular system may be unstable due to labor and birth. Physical maturity is always stable from birth. Lanugo is less the higher gestational age is, minimal at term birth. Plantar surface covered by 2/3 in crease in first 12 hours. Breast tissue 5 вЂ“ 10 mm between forefinger and middle finger. Nipples aised above skin level? Testes descended ? Scrotum pendulous, covered w. rugae? Labia majora cover labia minora and clitoris between 36 вЂ“ 40 weeks of gestational age. Newborn reflexes Rooting reflex: infant turns to stimulated side to suck Sucking reflex: starts when lips get stimulated EpsteinвЂ™s pearls: small white specks, cysts, tongue not protruding Tonic neck reflex: On turning of head, extremities on same side extend, opposite extremities flex. Moro reflex: Arms are extending brisk and symmetrical when newborn is loosing support in neck in a supine, vertical position. Babinski Reflex: Fanning and extension of toes if sole is stroked, disappears at 12 month. May reoccur in adults with CNS damage. 58 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com -Physiological changes and needs in the newborn periodCardiovascular lungs expand decreasing pulmonary vascular resistance. First breath Clamping of umbilical cord increase of systemic vascular resistance increasing aortic blood pressure closure of ductus arteriosus of fetal circulation between pulmonary artery and arch of thoracic aorta. Foramen ovale between left and right atrium functionally closes in 1 вЂ“ 2 hours and anatomically in few weeks to 1 year. Ductus venosus closes and forces perfusion of liver Low 02 , high PCO2, low pH immediately after birth common due to a temporary peripartal Asphyxia. Newborns are obligatory nose breathers ! Signs of respiratory distress (increased breathing rate, audible grunting, nasal flaring, intercostal retractions) color of skin, oral area, extremities ? Neurological Three Periods of reactivity 1. 2. 3. First period of reactivity: 30 вЂ“ 60 minutes after birth, awake and alert, nursing and attachment behaviours. sleep phase , sleeps minutes to 4 hours. 2nd period of reactivity: awakes from sleep, lasting 4 вЂ“ 6 hours, close observation for changes of color, heart rate and breathing necessary. Musculoscelettal Extremities with full range of symmetrical motion? Gastrointestinal Digestive enzymes active from 36 weeks of gestation No pancreatic enzymes present at birth = poor absorption of digestion and fat No proper saliva production until 3 month of age Regurgitation, spitting up due to immature lower oesophagel sphincter Meconium First stool, excreted within 24 hours. Contains bile, epithelial cells, amniotic cells. Kidney Low GFR high urinary production Redish diaper stain from uric acid. lower metabolism of drugs. Hepatic Excess of unconjugated Bilirubin derives from hemoglobin from broken down blood cells. Permeates to extravascular tissues. Binds to albumin and is eliminated in stool. Increased feeding is helpful. Collaborative care: Assessment of output (weigh diapers 2 вЂ“ 4 hourly) Monitor adequate Hydration (Specific gravity, turgor of skin) Mask for Phototherapy Bili stool 6 times in 24 hours 59 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Skin Plethora = red skin = s/o Hematocrit > 65 , should be evaluated, Polycythemia = at risk for Hypoglycaemia , cyanosis, resp. distress, jaundice, bright red, akrocyanosis due in case of immature capillary system Immune System Only IgG crosses Placenta and provides passive Immunity from mother ! Own Antibody production starts from three month of age IgA is only available in breast milk, own production starts at 4 вЂ“ 6 months. Breast fed children are protected from influenza, mumps and chickenpox ! Newborn Nutrition 90 вЂ“ 120 kcal/kg/24 hr food supply 140 вЂ“ 160 mL/kg/24 hr fluid supply 8 вЂ“ 10 wet diapers daily Formula milk does not have immunologic properties and digestibility of human milk The American Academy of Pediatrics recommends to feed breast milk or formula until 12 month of age. Soy formulas are necessary if cow milk and lactose intolerance is present! Preparation of Formula Aseptic sterilization: Supplies boiled in water for 20 minutes Terminal sterilization: poured in unsterilized bottles and sterilized together for 25 minutes Bottles are not meant to be warmed in a microwave because of hotspots and change of nutritional composition through heat ! Do not lay infant down with bottle! Breast feeding Steady milk supply until 4th postpartal week. Lactating breast never empties if stimulated continuously. Supply only increases through feedings if transfer is successful (swallowing occurs) Feeding on demand when hunger cues are displayed (rooting, sucking on fists, clenched fists, crying is last expressed sign of hunger) Night feedings necessary through first 6 вЂ“ 8 weeks. Sore nipples caused by incorrect position. Foremilk produced and stored between feedings. Hindmilk produced at the end of feedings. Weight development Normal daily weight gain 0.5 вЂ“ 1 ounces per day. Weight doubled by 6 month of age. Weight triples by 1st birthday. Eye prophylaxis Erythromycin 0.5 % and tetracycline 1 % ophthalmic ointment to be administered immediately within 1st postpartal hour to prevent ophthalmia neonatorum caused by Neisseria gonorrhea and Chlamydia trachomatis. 60 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Hemorrhagic disorder prevention 0.5 вЂ“ 1.0 mg Vitamin K IM once (Aqua-Mephyton) Phenylketonuria (PKU) Screening Child has to be fed for at least 24 hr prior to testing. Test prior discharge and within 7-14 days. Cord care - Cord care practices vary and are not evidence based! Keep dry Remove clamp after 24 hours Do not cover in diaper and submerge in water (do sponge bath) Falls off in 7 -14 days Clothes To be worn in layers and washed separately. Foreskin Does separate from Glans until 3-5 years of age Do not force for cleansing Daily retraction once separation has occurred -Complicated postpartum carePostpartum haemorrhage: Early postpartum haemorhage with over 500ml blood loss within first 24 hours due to вЂў Uterine atony Lack of contraction and descend of uterus after birth. Predisposing factors are circumstances that provide overdistention of uterus e.g. augmented birth, use of tocolytics, oxutocin induction, general anesthesia. Requires immediate intervention with Oxytocin (Pitocin) IV , Ergonovine (Methergine), Prostaglandines (Hemabate) вЂў Lacerations of birth channel. вЂў Vaginal, vulva hematoma вЂў Disseminated intravascular coagulopathy DIC Typically related to circumstances which contribute to a delayed labor as well as to placental damage in utero. Late postpartum hemorrhage 1-2 weeks after childbirth may be caused by: вЂў Subinvolution = Failure of uterus to regain previous size and position. Marked by a persistent lochia rubra. Assessments of vaginal bleeding, shock signs, amount of blood loss, bladder function, quarterly within first hour then every 30 minutes ! Postpartum infections Multiple risk factors, most common after caesarean section, PROM and any intravaginal manipulations Endometritis Parametrial cellulites Peritonitis Septic pelvic thrombophlebitis Bacteremia and septic shock 61 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Summary of possible clinical findings Temperature elevation up to 105 F, abdominal pain, uterine tenderness, subinvolution, HR , BP , offensive smelling lochia, Ileus / subileus, excessive thirst, backache, chills WBC Count, ESR, CRP , renal output Wound infections Assessments 8 -12 hourly, especially after episiotomy: Redness, edema, ecchymosis, discharge, approximation of wound edges. Breast infections (Mastitis) Most commonly caused by Streptococcus species, Staphylococcus aureus, Escherichia coli bacteria, Candida albicans along with cracked nipples, poor hygiene and tight clothing. -Complicated newborn care- Characteristics for high risk newborns Maternal Diabetes, Opiod analgesics during labor, fetal asphyxia (urges fetus to pass meconium into amniotic fluid), difficult labor, multiple gestation pregnancy, preterm or postterm delivery, congenital anomalies and infections. Small for gestational age SGA Birth weight below 10th percentile = < 2500 grams or 5 pounds and 8 ounces loose, dry skin, little scalp hair, hypoglycemia and weak cry. Large for gestational age LGA Birthweight above 90th percentile = > 4000 grams or 8 pounds and 13 ounces Primarily infants of diabetic mothers, Hyperbilirubinaemia (> 13 вЂ“ 15 mg/dL) birth injury, clavicle fracture, shoulder dytocia, Erb вЂ“ Duchenne paralysis, Hypoglycemia (Blood Glucose < 30 вЂ“ 35 mg/dL) Hypocalcemia, RDS Apgar Score < 6 at 1st minute, or 7 at 5 minutes. Preterm signs: Lanugo, Vernix caseosa, fused eyelids, crease over soles General care setting for high risk newborns include: вЂў UVL umbilical venous line вЂў UAL umbilical arterial line вЂў ABG arterial blood gas analysis вЂў Gavage tubes 5 вЂ“ 8 Fr. Maturity Problems Minimum gestation for survival is 23- 24 weeks of gestation. Respiratory distress syndrome. Maternal risk factors: smoking and placental damage. Fetal risk factors: multigestation and infections. Poor lung maturity due to surfactant deficiency. RDS within 24 вЂ“ 48 hours after birth Bronchopulmonary dysplasia (substernal retractions, inspiratory grunting, nasal flaring) Poor thermoregulation due to underweight and muscular weakness. Liver immaturity Immune incompetence Feeding problems 62 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Renal impairment Liver impairment with lack of coagulation factors and fragile cerebral capillaries leading to intraventricular hemorrhage IVH. Cardiovascular weakness Retinopathy of prematurity ROP due to high concentrations of O2 Prophylaxis by maintaining minimum PaO2 of 50 вЂ“ 70 mmHg Necrotizing Enterocolitis NEC, because of blood shunt due to neonatal distress Apnea and bradycardia due to immature circulatory regulation. Postmaturity problems For infants born after 42 weeks of gestation Caused by placental insufficiency increases risk of intrauterine asphyxia and meconium aspiration syndrome MAS Birth Trauma Facial paralyis, commonly self resolving. Erb-Duchenne paralysis Affecting brachial portion of upper arm. Infant holds arm rotated inwards with stretched elbow, Moro reflex on affected side negative and grasp reflex intact. Requires immobilization to reduce additional stress on damaged structure. Fractures, most common in descending order. (clavicle, skull, humerus, femur) Heal without surgery Asphyxia Inadequate tissue perfusion due to decrease of FHR. Signs: pH in labor < = 7,20, Apgar score 4-7, meconium passage. Requires inflation of 100 % O2 at a breathing rate of 40 вЂ“ 60/min. HR hast to be minimum 60 вЂ“ 80 or requires compressions. Withhold oral feeding in RDS if breathing rate is 60 or more. Position neonate supine or side lying to suction meconium from airways. Cerebral palsy Altered body movement due to a spastic paralysis of skeletal muscles. Most commonly caused due to a fetal intra вЂ“ or peripartal trauma causing, fetal hypoxemia or hemorrhage. Paralysis may be mildly expressed and not detectable from the beginning. Severe cerebral palsy typically shows uncontrolled athetotic (вЂњsnake likeвЂќ), movements of the affected limbs. Condition appears hemiplegic, diplegic or tetraplegic and can involve swallowing difficulties as well as speech problems. Mental retardation occurs in 25 % of children with CP. Condition is not progressive. Treatment focuses on improvement and assistive treatment of impaired functions. Congenital вЂњTORCHвЂќ infections Toxoplasmosis, Others (Hepatitis), Rubellla, Cytomegalie and HIV Common STDвЂ™s Syphillis, Gonorrhea, Chlamydia, Candidiasis and HIV Neonatal Sepsis Mainly due to Beta hemolytic streptococcal vaginosis. 63 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com -Birth Defects- Hypospadia, Epispadia Meatus of urethra in boys is not centrally located at the end of the penis but either on top (epispadia) or underneath (hypospadia) of the penile shaft. Surgical intervention is mostly performed by using praeputium kin to cover initial needs to take place prior to development of urine continence and before 18 months of age. Bladder exstrophy Exposure of urinary bladder due to a missing lover abdominal and anterior bladder wall. Commonly accompanied by an epispadia in boys. Surgical correction is immediately necessary after birth to avoid intraabdominal infections. Other defects of comparable origin are: Omphalocele Peritoneum with intraabdominal content herniates through umbilical cord due to failure of abdominal wall to close in embryonic period. Gastroschisis Bowel herniation without peritoneal sac parallel to abdominal rectus muscles. Surgical repair may not be possible in all cases. Chordee Downward curvature of the penis, mostly accompanied by a hypospadia of the penis. Treatment required prior to 18 months of age to ensure timely development of urine continence. Cryptorchism Delayed or absent descensus of testicle at term birth. Most cases require observation only and resolve spontaneously within first year of life. If persisting sexual maturity and fertility are delayed or insufficient. Clients also have a higher risk for testicular torsion. Surgical treatment is performed by orchidopexie, a ligation between the lower testicular pole and the inner lining of the scrotum. Biliary atresia Progressing inflammatory stenosis of intra вЂ“ and extrahepatic bile ducts starting from birth. Cholestasis leads to liver cirrhosis over time. Symptoms and prognosis are identical to primary biliary cholangitis. Surgical biliodigestive anastomosis between the common bile duct and the duodenal wall may lead to a temporary bile drainage. Medication treatment is not available. Only achievable cure is liver transplant. Aggravating factor is a possible early brain damage due to a constant hyperbilirubinemia. Cleft palate Birth defect of hereditary of teratogenic origin. Midline defect caused by failure of fusion of tissues in late embryonic development period. Defect may be involving or reduced to upper lip, soft palate, hard palate and nasal distortion. Condition may be uni - or bilateral expressed. Surgical correction has to take place no later than 18 months. Clients require feeding in strict upright position prior to correction to avoid aspiration of fluids and food. Postoperatively clients must not have any oral feeding, pacifiers, tooth brushing or straws. Drinking from a cup is tolerable. 64 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Congenital diaphragmatical hernia Protrusion of abdominal organs through an abnormal diaphragmatical opening into the thoracic cavity. Clinical symptoms correlate with the intensity of organ protrusion from mild to severe. Clients may appear almost asymptomatic in early childhood but will develop cardial and respiratory symptoms by further growth or failure to thrive. Main complication of an undetected CDH is a compression of heart and lungs and / or a possible life threatening bowel incarceration. Clinical outcomes can include cardail and respiratory failure as well as peritonitis. Surgical correction may require a simultaneous laparatomy and thoracotomy. Pyloric stenosis Congenital hypertrophic gastroduodenal sphincter inhibits gastric emptying. Symptoms mostly arise or worsen by increase of intake of breast or bottle milk increases and occur as sudden imperative, projectile vomiting shortly after feeding. Affected childen quickly develop dehydration and metabolic alkalosis due to repeated vomiting. Hypertrophic pylorus may be palpable through abdominal wall. Surgical sphicterotomy is required. Oral feedings can resume 6 hours after surgery. Congenital megacolon / aganglionosis (HirschsprungвЂ™s disease) Lack of ganglion cells of the parasympathetic nervous system of the colon rectosigmoideum. Absent autonomous innervation results in partial bowel paralysis with stool accumulation and disability to defecate. Surgical treatment is usually performed in two steps. Starting with an initial colostomy soon after diagnosis is made and a reanastomosis after resection of the aganglionic segment by the age of 2. Hypopituitarism Failure to thrive caused by a deficiency of growth hormone from pituitary gland. Affected children will appear with a growth retardation below third percentile by the age of 1 year. Symptoms depend on agents age at onset and severity of GH Deficiency. Primary appearance is determined by delayed or permanently interrupted physical development. Infants: Micropenis, no descend of testicles, hypoglycemia due to compensating hyperinsulinemia and jaundice. Children: Obese, hyperglycemic, retarded musculoskeletal development. Proof of diagnosis by assessment of low levels of IGF вЂ“ 1 ( insulin вЂ“ like growth factor ) Treatment requires supplemental therapy with subcutaneous growth hormone injections. Psychological support of children and parents. Phenylketonuria (PKU) Inherited autosomal recessive deficiency of the liver enzyme phenylalanine hydroxylase. Required to metabolize phenylalanine into tyrosine. Healthy appearance at birth, Musty body and urine odor, blond hair, blue eyes and fair skin. Failure to thrive, mental retardation, seizures. Laborarory findings: Phenylalanine level Tyrosine level Melanine deficiency Dopamine and Tryptophan Mandatory preventive Guthrie Test for all newborns in the United States performed after the first 24 hours of breast milk or formula nutrition but within the first seven days after birth. Main treatment is a phenylalanine free or restricted diet to keep phenylalanine blood level below 2 mg/dl. Muscular Dystrophy (MD) Inherited sex linked progressive muscular weakness from birth. Different types affect diverse muscular areas. Most common form is MD Type Duchenne. 65 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Intellectual development may not be necessarily impaired. Abnormal muscular weakness of skeletal muscles. Altered muscle tension also leads to a deforming skeletal growth. (e. g. bowed legs, hyperlordosis, hyperkyphosis) Delayed motoric development. Depending on severity of physical impairment main goal is to increase physical activity by regular physical therapy and supply of appropriate orthopedic devices. Corrective orthopedic surgery may be involved in treatment plan as well in some cases. Lethal outcomes prior to the onset of puberty are common, mostly due to affection of auxiliary breathing muscles. Clubfoot Inherited uni вЂ“ or bilateral congenital foot deformation of unknown cause but strong familial occurrence. Defect may appear with one or a combination of several of the following deformities: вЂў Plantarflexion вЂў Dorsiflexion вЂў Varus deviation вЂў Valgus deviation First line treatment is serial dressing with castings starting from newborn period over 8 вЂ“ 12 weeks. Active and passive supportive physical therapy to improve ROM. If unsuccessful, a surgical realignment of the foot bones is required. Congenital hip dysplasia Mostly unilateral congenital deformation of the acetabulum. Cause is unknown bur condition may be influenced by intrauterine breech positions or increasing size of the child. Screening examinations are performed in well child examinations in newborn period. Single sided shortened leg, inward or outward rotation of hip joint, limited abduction of hip, Ortolani sign to be assessed and positive between 2 вЂ“ 3 month of age, clicking sound during abduction of hips indicates dislocation, delayed start of walking Positive TrendelenburgвЂ™s sign: If affected hip is bearing the full body weight while client is standing on one leg only, the pelvis will tilt towards the healthy side due to insufficient gluteal muscles on the side of the affected hip. Abduction casting (Pavlik harness) for newborns and toddlers up to 3 months of age over several months to support the development of an acetabulum impression in the pelvic bone. Older childrem may require surgical intervention to rotate hip bone in an anatomical correct position towards the acetabulum space. While correcting treatment is performed motoric development of upper extremities should be supported. Untreated or undiagnosed hip dysplasia may lead to delayed and / or disturbed motoric development and early osteoarthritis of the hip. Osteogenesis imperfecta Inherited autosomal dominant congenital defect of bones and connective tissue due to an insufficient synthesis of collagen. High occurrence of pathological fractures even from birth. Clients appear with blue sclera of eyes, highly vulnerable soft skin, Highly flexible skin and joints, conductive hearing loss. Condition is incurable. 66 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Medication includes Biphosphonates, calcitonin and growth hormone to increase density and growth of bones. Main importance has avoidance of fractures by handling affected children with special care. -Milestones of Human Growth and DevelopmentPattern of Growth and Development Cephalocaudal Development, Proximodistal Development and Differentiation. Factors influencing Development Genetics, Nutrition, Prenatal factors, Family and Community and Cultural conditions. Developmental Milestones Milestones of fetal development (Prenatal Development) 4 wks: fetal heatbeat detectable 8 weeks: all organs formed 12 wks: fetal heart sounds audible by Doppler 16 wks: gender detectable 20 wks: heart audible with fetoscope, quickening, hair, eyebrows, eyelashes developed 24 wks: 1lbs 1 oz, increasing activity, respiratory movement 28 wks: Surfactant production, two thirds of final size 32 wks: finger and toenails formed 38 wks: fills uterus, gets maternal antibodies Infant Growth and Development Neonatal period ( 1Month ) Weight: 6 to 8 lbs, gaining 5 вЂ“ 7 oz weekly in first 6 months. Height: 20 in, growth 1 inch monthly for first 6 month. Head circumference: 33 вЂ“ 35 cm Growth during infancy (1 вЂ“ 12 month) Weight doubles in 6 month, triples in 1 year. Height increases 50 % 1st year Head circumference 33 вЂ“ 35 cm , greater than chest circumference Newborn Reflexes Moro (elicitated by loud noise or sudden change of position), Tonic neck (fencing position). Gag, cough, blink, papillary reflex, Grasp reflex, Rooting reflex(side of mouth touched = infant turns to this side), Babinski reflex, Parachute reflex Landau reflex,Labyrinth reflex, Body righting reflex 67 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com PiagetвЂ™s Theory on cognitive development (4 stages) 1. Sensorimotoric development (birth вЂ“ 2 years) Infant learns through senses and motor activity, Progress reflex activity simple repetitive behaviors imitative behaviors Develops sense for cause and effect, curiosity, experimentation, exploration result in learning process, Object permanence is fully developed. 2. Preoperational (2-7 years) Forms symbolic thoughts, exhibits egocentrism, language development, does not understand conservation becomes more social. Concentrates on only one characteristic of an object at a time. 3. Concrete operational (7-11 years) Thoughts increasingly logical and coherent ability to concentrate on several things simultaneously (decentralization), concrete thinkers, right or wrong, no вЂњgrayвЂќ areas problem solving skills, conservation skills. 4. Formal operations (11 years to death) Ability to logically manipulate and abstract unobservable concepts with a scientific problem solving approach. EriksonвЂ™s theory of psychosocial development Trust v. mistrust (birth вЂ“ 1 year) LOVE AND CARE Autonomy v shame and doubt (1-3 years) FREEDOM New skills used for autonomy, symbolizing independence Leads to upbuild of willpower and self вЂ“ confidence or self doubt if critized. Initiative v guilt (3-6 years) ENCOURAGEMENT Initiative is demonstrated by carrying out a plan or an action Leads to direction and purpose or guilt if inhibited. Industry v inferiority (6-12 years) INTRODUCTION Development of new interests and involvement in activities. Develops confidence and enjoys learning, being compared to others may lead to feeling inadequate and inferior if expectations are too high. Identity v role confusion (12 вЂ“ 18 years) Marked by puberty changes. Peer group very important. Self definition, definition of family, peer group and community. Leads to self identity and optimism or role confusion. Intimacy vs Isolation (early Adulthood) Strong sense of self accomplishment. Searches for meaningful relationships Generativity vs stagnation (middle Adulthood) Sense of productivity. Reaches and attains goals. Critical self вЂ“ review. Lack of success leads to stagnation. Ego integrity vs despair (older Adulthood) Acceptance that life has passed and of current stage. At peace with self. Identity apart from work and acceptance of death. 68 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Gross motor development 4 months: controls head rolls from back to side 5 months: rolls from abdomen to back 6 months: rolls from back to abdomen 8 months: sits alone without support 9 months: stands holding on 10 months: crawling 11 months: creeps 12 months: cruising, walking while holding on and sits down from upright position Fine motor development 1 month: hand predominantly closed 3 months: grasping desire 5 months: two handed grasping 6 months: holds bottle, grasps feet, 7 months: transfer from hand to hand 10 months: pincer grasp 12 months: neat pincer grasp Sensory development Birth: Hearing and touch well developed. Prefers human phase 2 months: locating sounds and smiles 6 months: taste preferences 7 months: responding to own name 1 year: four words Nutrition 6 months: starting solids, sooner start make allergies more likely. Start with iron fortified rice cereal. Eruption of lateral incisors. Weaning from breast to bottle. Introduction of 1 : 1 diluted juices, fruits, meats,vegetables, one food each week. Solids only by 12 months No more than 32 oz of formula per 24 hours for infants to avoid iron deficiency ! Toddler Period from 1 вЂ“ 3 years of age Physical Development 4 times birth weight by 2 ВЅ years 50 % of adult height by 2 years Head circumference 10.5 вЂ“ 20 inches by 2 y 90 % of adult size brain by 2 years Anterior fontanella closes by 18 month ! Gross motor development: 15 months: walks without help 18 months: jumps in place 24 months: goes upstairs (2 feet per step), Runs fairly well 69 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Fine motor development: 15 months: uses cup well and builds tower of blocks 24 вЂ“ 30 months: holds crayon with fingers 30 months: good hand finger coordination 36 months: copies a circle Sensory development: 15 months: binocular vision well developed 12 months: knows own name 2 years: follows simple directions 18 months: identifying geometric forms 18 вЂ“ 24 months: short sentences 3 years: remembers and repeats three numbers 2 years: speaks 300 words Object permanence = knowledge that a person or an object continues to exist when not seen or heard. Ritualism, toddlers need to maintain sameness and reliability. Nutrition Growth slows at 12 вЂ“ 18 months Picky and ritualistic eating habits Avoid large pieces of food Ability to feed self completely by 3 years About 20 deciduous teeth by 2.5 вЂ“ 3 years Teach good dental practice Play Imaginative, self belief play (i.e. imitation of an adult) blocks, wheels, toys, puzzles, crayons. Repetitive stories and short songs with rhythm. Preschool Period from 3 вЂ“ 5 years of age Physical Development Weight + 5 lbs/year Height + 2-3 inches / year Motor Development 3 years rides Tricycle 4 years skipping and hopping on one foot 5 years throws and catches ball, balancing on alternate feet, 2100 words, increased strgth and refinement Nutrition Similar to Toddler Food preferences, influenced by others 90 kcal/kg/day Good dental hygiene Safety Belt positioning booster seat Teach safety measures 70 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Play Imitating same sex Toys to promote motor and coordination skills Sing along songs with rhythm Schoolage Period from 6 вЂ“ 12 years of age Physical Development Weight + 5 lbs/ year Height 1-2 inch / year 20/20 vision by 7 years of age Nutrition Obesity Risk Loosing first deciduous teeth at the age of 6. All permanent teeth but the molar teeth are present at the age of 12. -Vaccinations- Active Immunity Vaccine from live, attenuated or dead and inactive viruses or bacteria induces antibody production but no infection. Not indicated for pregnant women or those who are likely to get pregnant within 3 months after vaccination. May not be indicated in HIV. Passive Immunity = administration of immunoglobulines. General considerations Vaccines have to be stored on center shelf of body of fridge to establish stable temperatures between 2 вЂ“ 8oC / 35 вЂ“ 46o F. Simultaneous vaccinations are administered contralaterally either in vastus lateralis ( newborn to preschool age) or deltoid muscle (schoolage to adulthood). Documentation necessary. Be aware of adverse reactions now and in history (VAE Report) Do not vaccinate if client is moderately or severely ill or prior to one month after immunosuppressing therapy. Delays of up to 90 days are necessary if corresponding hyperimmunglobulin has been administered. Common vaccination side effects are malaise, achiness, temperature and redness of injection site. Hepatitis B Minimum Distances of injection: 0 = Birth вЂ“ 1 Month вЂ“ 3 Months (minimum distance) 3rd dose not to be administered before 6 months of age. Intramuscular injection. Infant born by HbsAg positive mother requires simultaneous Hepatitis B Immunglobuline. Do not administer Hepatitis B vaccine in cases of Bakers yeast allergy! DPT (Diphtheria, Pertussis, Tetanus) Diptherie, Tetanus (вЂњlockjawвЂќ) = inactivated (killed) vaccine Pertussis = acellular vaccination 6 injections from 2 months to 6 years. 1 booster for adolescents and adults. Intramuscular injection. Management of acute anaphylactic reactions Epinephrine 1:1000 and resuscitation equipment has to be in reach for immediate availability. Administration of 0.01ml/kg body weight per single dose once order was obtained. To be repeated every 10 вЂ“ 20 minutes. 71 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Haemophilus influenzae Type B Used to be most common cause of meningitis in children < 1 month of age. Also causing Epiglottitis, sepsis,septic arthritis. Vaccination at 2-4-6-12-15 months of age. Intramuscular injection. Not needed over 5 years of age unless client has special health risk. Inactivated Polio Vaccine IPV Trivalent vaccine, containing all three components of Polio. Inactivated, killed vaccine, therefore requiring frequent boosters due to a less intense immune response. Vaccination at 2-4 (6-18) months and 4-6 years of age. Intramuscular injection. Do not administer IPV to clients with allergies against Neomycin, Streptomycin and Polymyxin B! MMR Vaccine Live, attenuated vaccine! Intramuscular injection. Vaccination at 12-15 months + 4-6 years of age. Yellow fluid. Advice client to avoid pregnancy for 3 months after vaccination. !Active vaccination are not supposed to be administered if immune serum globulin or blood products were administered 3-11 months earlier! Do not administer to clients with allergies against neomycin, eggs and gelatine! Varicella Vaccine (Varivax) Live, atennuated vaccine ! Vaccination at 12-18 months once or as postexposure prophylaxis. Intramuscular injection. Pneumococcal Vaccine PCV Vaccination at 2-4-6-12-15 months of age. Intramuscular injection. Active against Streptococcus pneumoniae leading cause of meningitis in the U.S ! Recommended for all children from 2 вЂ“ 23 months of age. Clear colorless liquid. Highly recommended for children in daycare, children with immunosuppression, cardiac illness, diabetes, sickle cell anemia and asplenia. Not to be administered to clients with a hypersensititivity against Diphtheria toxoids! Hepatitis A Vaccine Inactivated, killed vaccine. Can also be used as a postexposure Prophylaxis along with immune globulin. 2 doses after 24 months of age and 6 months apart. Administered by intramuscular injection. Dosage for clients < 18 years: 0.5 ml, > 18 years: 1.0 ml Influenza, trivalent inactivated vaccine Inactivated, killed vaccine. Vaccination effect lasts 1 year. To be administered once yearly in early autumn by intramuscular injection. Inranasal vaccine available for children from 5 years and older. Intramuscular 0.25 ml from 6-23 months, 0.5 ml > 3 years. For children younger than 12 years of age dosage has to be splitted in two injections 4 weeks apart. Do not administer to clients with allergy to eggs ! 72 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Meningococcal vaccine Respiratory infection can lead to meningitis, DIC, septic shock and death. No experience on safety in pregnant women. Vaccination at 2 years and at 11-12 years of age for clients at special risk due to asplenie, immune deficiencies, entering risk countries, colleges and universities. Duration of effect unknown. Intramuscular injection. Recommended Immunization Schedule for Persons aged 0 вЂ“ 6 Years United States 2010 Birth: 1 Hepatitis B 1st Month: nd 2 Hepatitis B 2nd Month: st 1 Rotavirus, Diphtheria, Pertussis, Tetanus, Pneumococcal vaccine, Inactivated Poliovirus 4th Month: nd 2 Rotavirus, Diphtheria, Pertussis, Tetanus, Pneumococcal vaccine, Inactivated Poliovirus 6th Month: rd 3 Rotavirus, Diphtheria, Pertussis, Tetanus, Pneumococcal vaccine 12th вЂ“ 15th Month: th 4 Hepatitis B, Diphtheria, Pertussis, Tetanus, Pneumococcal vaccine, 2ndInactivated Poliovirus, 1st Influenza (yearly), Mumps, Measles, Rubella, Varicella, Hepatitis A (2 doses) From 2nd to 6th year: th 5 Diphtheria, Pertussis, Tetanus, Inactivated Poliovirus, 2nd Mumps, Measles, Rubella, 1st Varicella st Recommended Immunization Schedule for Persons aged 7 вЂ“ 18 Years United States 2008 11 вЂ“ 12 years: 6th Diphtheria, Pertussis, Tetanus 1st Human Papiloma Virus HPV (3 doses), 1st Meningococcal vaccine, 1st Hepatitis B series, Inactivated Poliovirus series, Mumps, Measles, Rubella series, Varicella series. 13 вЂ“ 18 years: 7th Diphtheria, Pertussis, Tetanus, 1st Human Papiloma Virus HPV (3 doses), 2nd Meningococcal vaccine. x x x x 73 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com H1N1 Vaccination CDC Recommendations as of January 2010 вЂў вЂў вЂў All people from 6 months through 24 years of age Persons aged 25 through 64 years with health conditions associated with higher risk of medical complications from influenza. -Health and Physical AssessmentHealth History Health History Components Biographical data, chief complaint, symptom analysis, history of present illness, past health history = past history = medical history. Childhood and adult Immunization, incl. last Tetanus and Influenza shots, childhood illnesses, prior hospitalizations, surgical procedures, allergies, pregnancy history and current medication. Family Health History Increased expression of certain diseases present in family history? Known hereditary conditions? Personal/Social History Diet, activity and exercise, sleep and rest, tobacco use, substance use, living arrangements, family relationships/friendships, psychological data (stressors, appropriateness of behavior and communication style), occupation (hazards, commuting and amount of sick leave), travel (Travel abroad, Military service abroad, length, data) and healthcare resources utilized so far. Health History of Children ParentвЂ™s perception and observation vs childs perception may be different ! Birth History Length of pregnancy, mothers prenatal health and care, medication, substances taken during pregnancy, duration of labor, type of delivery, APGAR - Score, birth weight, length and head circumference. Medical History of the child Allergies, immunizations, boosters, habits and behavior, nutritional data (eating habits and diets), Family History = Genogram Family structure, community environment, occupation, education of family, cultural, religious factors and childвЂ™s personality. Preparation for Physical Examination Basic Equipment Blood pressure cuff, clean disposable gloves, penlight, stethoscope, tape measure, thermometer, watch with a second hand and weight scale. x Additional Equipment Cotton ball, Doppler, goniometer, neurologic hammer, lubricant, nasal speculum, near vision charts, skin calipers, Snellen test for visual acuity, strabismoscope, tongue 74 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com depressor, tuning fork, tympanometer, vaginal speculum, Setting: privacy, comfortable temperature, minimum distractions and adequate lighting. Systematic Physical Examination General considerations Swellings, asymmetrical, built, atypical coloration, signs of inflammation ? Skin Color, texture, wounds, scars, moles, petechiae < 0.5 cm, purpura > 0.5 cm Temperature, nails, coloration (blanch test = capillary refill < 3 s.), white bands = ? melanoma, darkening = malaria medication, hematoma, signs of fungal infection ? soft, lose, breaking skin ? Head and Neck Symmetrical features ? Conjunctives, Sclera: color, swelling, discharge, inflammation ? Nose (Nasal speculum inspection), mouth, tongue, thyroid gland (shiftable, enlarged, nodular) and lymph nodes. Eye Test PERRLA examination Extraocular movements, Pupil size, Equality, Roundness, Light, Accommodation. Fundoscopy via Ophthalmoscope (red reflex , optic disc, blood vessels, retina) Ears Otoscopy for ear canal and tympanic membrane (moveable intact, pearly white gray in colour) Rinne and Weber test for bone and air conduction. Breasts and Axillae Sitting position, symmetrical contour, skin coloration, inflammation, swelling, detect retraction by instructing client to raise arms above head, push hands together w. flexed elbows and to press hands on hips). Areola masses ? Nipples masses ? Axillary, subclavicular, supraclavicular lymph nodes. Points of palpation: lateral edge of m. pectoralis major, thoracic wall in midaxilla, upper portion of humerus, anterior edge of m. latissimus dorsi. Breast masses + tenderness present ? Chest Inspection, palpation (crepitus ?), assessing respiratory expansion normally 3 вЂ“ 6 cm Tactile fremitus вЂњninety вЂ“ nineвЂќ,вЂњblue moonвЂќ, decreased fremitus = effusion, pneumothorax, Increased fremitus = consolidation of lung tissue. Percussion Tympanic = drum = high pitch = i.e. gastric bubble Resonant = hollow = low pitch = i. e. healthy lungs Hyperresonant = booming = very loud = i. e. Emphysema Dull = Thudlike = soft to moderate pitch = substance (liver, spleen and heart) Flat = very dull = high pitch = muscle bone Auscultation From apical to base, from lateral to medial. Normal: vesicular, bronchovesicular, bronchial breathing sounds. Carotid arteries, jugular veins One at a time (contour and Amplitude) Palpation, auscultation, jugular vein distention ? 75 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Heart Auscultation sounds: S1 = Apex = closure of interventricular valves S2 = Base = closure of aortic and pulmonic valves (S3) = Apex = ventrcicle filling (S4) = Tricuspid or Mitral area = resistance to ventricular filling Pericardial friction rub = Left sternal border Cardiac auscultation scheme: Accurate heart size assessment is performed via Chest X вЂ“ Ray. Abdomen Positioning with pillow under knees, arms over chest. Contour, symmetry, bumps, bulges, masses, scars, striae, movements. Examination of all 4 quadrants singularly. Auscultation of bowel sounds before palpation and percussion for 2 minutes. (Sounds absent, present, increased, decreased ?) Do not palpate pulsating structures. Rebound tenderness ? (Peritonitis and Appendicitis signs) Groins Palpable lymph nodes and pulses. Extremities Pulsation, perfusion, motoric and sensoric nerves and muscular symmetry ? Edemas and spine curvatures ? Muscular strength: 0 = no contraction 5= Full ROM against resistance. Straight leg raising (Lasegue sign) normally not painful indicator for NP Prolaps. x Cranial nerves (CN) C I = Olfactory nerve Sense of smelling. C II = Optic nerve Visual acuity. C III , IV, VI Abducens, trochlear, occulomotorius nerve Extraocular movements. Nystagmus ? (rapid horizontal oscillating eye movements) 76 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com CV Trigeminal nerve Motor function of masseter and temporal muscles, sensitivity of face, corneal reflex. C VII Facial nerve Function of facial muscles (smile, frown,eyebrows) Sensory function of tongue for salty, sweet and sour. C VIII Vestibulocochlear nerve Hearing ability assessment by whispering from 2 ft distance. Weber Test: Tune fork in middle of scull. Is sound heard equally in both ears ? Let client indicate when sound is disappearing, then place fork on mastoid bone until sound is no longer heard. Outcome: вЂ�LateralizationвЂќ to bad ear in case ofconductive hearing loss and to good ear In case of sensoric hearing loss. No lateralization means no problem. Rinne Test: Sound heard twice as long by air conduction AC than by bone conduction BC. If AC is less or equal than BC it means conductive hearing loss. AC/BC ratio normal but overall reduced = sensorineural hearing loss. CIX and X Glossopharyngeus and vagus nerve Yawning and вЂњaahвЂќ: Innervation of uvula, soft palate and tonsilar pillars to center, gag reflex, voice quality, swallowing. C XI Spinal accessory nerve Innervation of sternocleidomastoideus and trapezius muscle. Shrug shoulders, turn head against resistance. C XII Hypoglossal nerve Protruded tongue stays centrally, вЂњLight, dynamite, tightвЂќ shows lingual speech. Cerebellar function Walking gait observation. Step length 15 inch ? heel вЂ“ heel Heel on toe on a straight line balance ?, Romberg Test, rapid alternating movement tests. Assessment of Mental Status Orientation to time, place and person. Adequate behavior, interaction and judgement. Assessment of Levels of consciousness LOC Consciousness = client is fully oriented and able to communicate Confusion = disorientation, unable to interact adequately Lethargy = slow but adequate verbal and motoric response Obtundation = brief adequate response to stimulation during sleep Stupor = poor physical response to external stimulation Coma = Loss of consciousness. 77 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Glasgow Coma Scale (Scores) Diagnostic tool used for assessment of LOC via Best verbal response Adequate and oriented = 5, Confused = 34, Inappropriate = 3 Not understandable = 2, No response = 1 Best motor response To commands = 6, To pain = 5, Flexion = 4, Atypical flexion = 3, Atypical extension = 2, No response = 1 Eye opening Spontaneous = 4, To commands = 3, To pain = 2, No response = 1 Best outcome = 15 (fully awake and oriented) Worst outcome = 3 (coma or death) Sensory system assessment Discrimination of pain (sharp and dull), temperature, vibration, discrimination of pain, sharp and dull. Temperature and vibration? Stereognosis present ? Grapheshesia Two point discrimination Deep Tendon Reflexes DTR Biceps = C5/C6, Triceps = C7/C8, Brachioradialis = C5 / C6, Quadriceps = L2/L4, Achilles=S1/S2 Superficial Reflexes Abdominal Reflexes , T8-T10 upper,T 10- T 12 lower Cremasteric Reflex L1-L2 Babinski Reflex (stroke on lateral sole and across ball of foot) Dorsiflexion of big toe and fanning of other toes. Only in infants until 12 months of age. In healthy adults negative response = Flexion of toes / foot Genital/ Rectum examination Gloves required! Blood, fissures, scars. Prolpse, hemorrhoids, discharge and blisters. Rectal exam: masses, blood ? Left testicle with longer spermatic cord. Postexamination responsibilities Assistance in cleaning, redressing, removing of dressing gown. Assure comfortable position. Immediate documentation of data. Handle specimens. Mental Status Assessment Short Assessment Mental Distress present yes or no ? Tools: Mini Mental State (Folstein), 5-10 minutes, highest score 30, average 27 Key areas of Mental Status Assessment: 1. Appearance 2. Behavior 3.Level of consciousness LOC Awake, alert, responding, aware of external and internal stimuli, or lethargic, drowsy, stupurous, unresponsive Glascow Coma Scale 4. Speech Aphasia (receptive Wernicke ; motoric Broca), mood and affect. x 78 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 5. Cognition Orientation to time, place, person, events, attention span, recent memory, remote memory, new learning (four unrelated words test), judgement. 6. Thought processes Thought content (logical, consistent), clientвЂ™s perceptions (congruent reality based) absence presence of suicidal thoughts. Specifications of children examinations General considerations: Easy understandable language, involving parents. Reassurance, distress and intrude at last, prepare for painful procedures. Assure comfortable and secure position, gentle restraint. Awareness for signs of child abuse is mandatory ! Tonsils are physiologically enlarged in children ! Epicanthal fold = Asian child or Down Syndrome. Visual acuity tests: Snellen letter chart, Snellen symbol chart and Faye symbol chart. Extraocular muscle tests Cover вЂ“ uncover test for strabismus Hirschberg test: Light shining pupils should symmetrically reflect in center of pupils or there is strabismus. Opthalmoscopic examination for PERRLA and red reflex (should be present) Permanent eye color is present at 9 Months of age! Ears Performance of otoscopy in infants requires to pull pinna down and back. In older children and adult clients pinna has to be held upward and straight. Cerumen ? Foreign bodies ? Tympanic membrane intactness, effusion. Audiometry mandatory prior school age. Heart Ausculation in children To be performed as soon as possible during encounter ! Apical pulse = 4th ICS until 7 years, 5th ICS after 7 years Sinus arrhythmia, (breathing activated) is a normal finding in children! Abdomen Prominent and supine in infants and children. Umbilical hernias common, spontaneously resolving. True and false deformities. True deformities Metatarsus varus = forefoot turned in Talipes varus = adduction of forefoot Talipes equinovarus (clubfoot) = adduction of forefoot, inversion of entire foot, Pointing downward of entire foot. Medial tibial torsion Medial femoral torsion Assessment for congenital hip dislocation To be assessed until 1 year of age several times (birth, 6weeks, 6-8 months, 15-21 months.) 79 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Ortolani sign = Child supine, flex knee and hip to 90 degree, Abduction of hip by pulling femur downwards. Click noise indcates a dislocation is present. BarlowвЂ™s maneuver = Same position but adduction of legs until thumbs touch. Equal length of legs ? Equal gluteal folds ? ROM of hips normal ? Toddlers are usually bowlegged. 2- 7 years old may be mildly knock kneed Scissoring gait ? cerebral palsy. Autonomic infant reflexes Stepping reflex Takes walking steps when feet touch ground. Disappears at 2 months of age. Moro reflex = startle reflex = parachute reflex Loud noise or sudden vertical descent in a supine or prone position lead to Flexion and abduction of legs. Lateral extension of arms while forming a C with thumb and forefinger and fanning other fingers. Immediately followed by anterior flexion and adduction of arms. Disappears by 3 months. Rooting reflex = touch of cheek or lip = infant turns head towards stimulation and opens mouth disappears by 4 months. Palmar grasp reflex Disappears by 4 months. Tonic neck reflex Child supine, head passively turned to the side = extension of arms and legs on side to which head is turned opposite extremities will flex. Appears at 2 month disappears by 6 months. Plantar grasp reflex Disappears by 10 months. Sucking reflex Disappears by 12 months. Babinski Reflex Disappears within 2 years. Persistence of newborn reflexes is suspicious for neurological disease! Hand preference develops during school years! -Elements of a healthy lifestyle- Breast self exam (BSE) Breast cancer appears in women and men. BSE monthly for males and females, women from first gyn exam or age 20. Women > 40 yearly mammogram recommended. x x x x x x 80 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Breast self exam BSE: Premenopausal women should perform BSE 5-7 days after menses each month. Standardized Instructions on how to perform a BSE: 1. Look in mirror: Arms to side, overhead and on hips = retractions ? 2. Lie down arm underhead, free arm examines opposite breast including axilla and nipple region. 3. Press tissue firmly against chest wall, from outer to inner areas, circular approach. 4. Instruct client to memorize an individual вЂ�baselineвЂ™ touch. Menstruation, breast feeding, pregnancy enlarges the breasts naturally. вЂњPersonal baselineвЂќ also has to be assessed in cystic breasts. Testicular self exam TSE Highest risk < 40 years of age. Normal finding if one testis appears larger, hanging lower with a smooth and shiftable surface. TSE during shower to assess epididymis, testis and spermatic cord. Exercise Aerobic exercise 30 minutes 3 - 5 x weekly. Maximum Heart Rate = 220 вЂ“ client age Target Heart Rate = Maximum HR вЂ“ resting HR. Walking, weight bearing prevents Osteoporosis. Physical examination prior start of exercise if chronic illness is preexisting or likely. General Recommendations* for daily nutritional supply: * www.mypyramid.govвЂќ Six ounces of grains 2.5 cups of vegetables 2 cups of fruit 3 cups milk products 5.5 ounces of meat /adult 2 grams of sodium Low fat, low sugar, balanced diets ADA Diet for diabetes patients and patients with Hyperglycemia. Vegetarian diet Vegetarians may choose Dairy products. Strict vegetarians require B12 Supplements and choose soy, tofu, dry beans, nuts for protein supply. Orange and green vegetables = Vitamins A,C,D,E and K, 8 glasses water/d. (1 ml for each kcal consumed = on average 2000 kcal/d.). Necessary dietary supplements Folic acid for childbearing women. Iron during pregnancy. Calcium after Menopause 1500 mg/d + Vit D. Religional dietary practices Orthodox Judaism Fish with scales and fins, cloven вЂ“ hoofed animals, animals that eat vegetables or slaughtered in a ritualistic manner. Milk and meat cannot be combined. 81 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Roman Catholicism No meat on Ash Wednesday and Fridays during lent. Fasting on Good Friday and Ash Wednesday optional for the rest of the lent. Russian Orthodox Meat and dairy prohibited Wednesdays and Fridays and during Lent. Fasting during Advent. Buddhism Vegetarianism, no alcohol or drugs. Hinduism Beef and veal prohibited for all. Islam Pork and meat that is not slaughtered ritually. No alcohol and drugs. JehovahвЂ™s Witness All meats to be drained of blood, no foods to which blood has been added. Cultural dietary practices Mexican Americans Mainly corn, dried beans, rice, chilli peppers. Reduced meat, papaya and mango. Hispanic / Latino Similar to Mexican diet. Dried codfish, meat, milk, vegetables used less often. Viandas, plantains, green bananas. Native American Fish (Alaskan), game, chicken, pork, mutton (Navajo) Native Alaskan Tortillas, bread, blue corn bread, corn meal mush, eggs, corn, potatoes, green beans, tomatoes and fruit. African American Breads and cereals, cooked with corn and oats, eggs, cheese, less milk. Leefy greens, okra, sweet potatoes, potatoes, corn, beans and rice. Pork, poultry, fish, organ meat, less beef and fried food. Asian American Chinese: Rice, vegetables, eggs, soybeans, tofu, small amounts of meat and green tea. Japanese: Also sushi, seafood,steamed vegetables and fresh fruit. Southeast Asian: plus chicken, duck, pork, nuts and legumes. -Age related Health Screening SchedulesHealth Screening for Children General Recommendations* for daily nutritional supply: * www.mypyramid.govвЂќ Recommendation by the US Preventive Services Task Force Yearly dental checks to start at age 4. Denver Development Assessment used from infancy to age 6. Height and weight charted annually. Well child exam schedule Birth, 1,2,4,6,9,12,15-18 month Age 2,3,4,5,6,8. Annually 10 вЂ“ 17 years. Blood Pressure = Age 3,4,5,6,8 annually 10-17 years. Vision = Age 3,4,5,6,8,10,12,15 years. 82 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Hearing = 4,5,6,8,10,12,15 years. Hereditary metabolic screening Birth to 1 months of age. Lead screening as required. Hemoglobin and Hematocrit at 12 month of age. Urinalysis: Age 5 Screening for Adults BP, BMI, Cholesterol yearly from age 20. Blood Glucose yearly from age 45. Recommendations for early cancer detection Seven warning signs as published by the American Cancer Society. 1. Altered bowel and bladder habits 2. Bleedings of unknown cause 3. Delayed healing of sores 4. Thickening tissue at any location 5. disturbances of the gastrointestinal tract 6. Skin alterations 7. Voice alteration and persistent cough Recommendations and Guidelines for early cancer detection Breast: Breast self examinations (BSE) from age 20. From age 20 вЂ“ 39 years. Gynecologic breast exam once every 3 years. From age 40 yearly mammogram and breast exam. Uterus: Yearly Pap smear from age 18. Prostate: Yearly digital rectal exam from age 50 plus. Yearly PSA test (Prostate specific antigen) Colon: From age 50 yearly stool test for occult blood. Digital rectal exam and flexible sigmoidoscopy once every 5 years. Colonoscopy with barium enema once every 10 years. -Age related care of older adultsMost Common Health Disorders in adults > 65 years. (Dept. of Health and Human Services 2003) 1. 2. 3. 4. 5. 6. Hypertension Osteoarthritis Heart Diseases Cancer Sinusitis Diabetes Characteristic age related physical changes of older adults Skin, hair and connective tissue: Loss of elastic fibers and subcutaneous tissue (affecting skin, lungs and heart) Lentigo, loss of pigmentation, thinning of hair, slower and thicker growth of nails. x x x 83 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Eyes: Presbyopia (Loss of Accommodation), weakening of color vision, delayed adaptation to light and darkeness (night lights !), increased risk of falls, cataract development, Arcus senilis of iris and dryness of eyes. Ears: Presbyacusis due to calcification of ossicles, obturating cerumen, loss of high pitch hearing , (especially w. consonants). Shouting does not help when communicating with a hearing impaired person but speaking slowly and clearly and using direct eye contact! Nose and olfactory system: Olfactory bulb decreases (Anosmia), gustatory buds decrease. Central nervous system: Decreased sensitivity to touch, temperature, slower motoric activity, requiring mind exercises, sleep decreases, proprioception (awareness for movement and position) decreases, generalized muscular atrophy, intervertebral disc atrophy, cartilage atrophy, osteoarthritis and osteoporosis risk increases. Pulmonary system: Coughing effectivity and lung expansion , oxygene diffusion decreases. Circulatory system: Heart murmurs due to stiffened valves. Blood vessel elasticity = BP Kidneys and urinary tract Renal output of minimum 30 ml/hr, GFR , Creatinine clearance BPH Syndrome may occur, Urine retention, UTIвЂ™s may occur more frequently. Metabolic and endocrine system Thirst and appettite decreasing, TSH + Thyroxine , Insulin , Insulin sensitivity . General considerations ADL = activities of daily living, IADL = instrumented activities of daily living impaired. Infections may be indicated by a fall. Shingles reoccurrence likely. Nutritional aspects in older adults BMI 20 вЂ“ 24.9 = healthy in an elderly Person. Sodium max. 2300 mg / d. Deficiencies of Vitamin A, B6 , C, E, Calcium, iron, zinc and folic acid common Potassium sources (potato, banana and fortified orange juice) Urinary incontinence Urinary incontinence is a pathologic finding at any age and not an age related finding ! 25 % of affected clients are older than 65 years. Women are more commonly affected than men. Continence requires a healthy lower urinary tract, cognitive ability, usable toileting environment, motivation. Causes of transient Incontinence may be delirium, restricted mobility, retention, infection, inflammation, impaction, polyuria, pharmaceuticals. Chronic constipation Most common cause is overuse of laxatives over years leading to an atonic colon impaction. Dehydration Hydration status may be assessed by skin tenting on abdomen, forehead and moisture of mucous membranes. Tenting on hands is normal age related process ! 84 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Mental alterations of older adults Dementia Gradually developing over years. Remains with alert consciousness. Appears w. personality changes, client becomes easily agitated. Tries to follow instructions but shows an impaired memory, looses knowledge, language and judgement. Dementia is an irreversible condition despite the underlying cause. Delirium Acute onset and brief course. Client is unable to concentrate. Poor attention and fulfillment of simple tasks. Fluctuations in memory and thoughts. Reversible. Depression Sudden or gradual development. Client appears self absorbed, apathetic, worthless but is able to follow instructions. Selective memory loss. Reversible. - Common adverse effects of medication in older adults General considerations for medication therapies in older adults: вЂў вЂў вЂў вЂў вЂў Iron is not absorbed with Calcium. Green vegetables counteract Warfarin treatment. Fluid deficiency increases orthostasis under beta вЂ“ blockers. Ciprofloxacine and Tetracycline will chelate with dairy products. Amiodarone, Lovastatin, Buspirone levels increase drastically when taken with Grapefruit juice. Inadequate Medications for older adults: ( due to a highly anticholinergic profile) Analgesics: Propoxyphene (Darvon) and combination products, Meperidine (Demerol) Hypnotics: Diazepam, Barbiturates (Phenobarbital (Luminal) is tolerable) Antiplatelet agents: Dipyridamole (Persantine) Anticoagulant: Ticlid (Ticlodipine) Antihypertensive: Methyldopa (Aldomet) Other common substancespecific side effects Delirium = acute confusion My be caused by Diazepam, Clonidin, Levodopa, Isoniazid. Monitor for oto - and nephrotoxicity Aspirin + Aminoglycosides Decreased sexual desire Antipsychotics, Ketoconazole, SSRI. Priapism Sildenafil, Alprostadil, Trazodone and Antipsychotics. -Common Laboratory TestsAdequate specimen collection: Fasting = withholding Food and Fluids for 8 вЂ“ 12 hours. (NPO Status) Observation of hygienic and antiinfective precautions. Identification of specimen with name, DOB, date of specimen, time and type of specimen. Laboratory requisition slip 85 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com requires information on diagnosis and requested tests. Shaking of vials induces hemolysis. All Specimens generally require prompt processing. Critical (panic) results have to be reported immediately. 24 hour Urine: Container may need to be stored on ice. Reminder on patients bed not to discard urine. Patient to empty bladder prior to start and at the end of the sampling period. Glucose Levels FBG Fasting Blood Glucose. (Reference range 70 вЂ“ 110 mg / dL = 3.9-6.1 mmol/l) Fasting (including medication) time 8 вЂ“ 12 hours prior sample. Assessment for Diabetes and Hypoglycemia. Antidiabetics, insulin have to be paused prior to sample. RBG Random Blood Glucose. (Reference range 60 вЂ“ 110 mg / dL = 3.3-6.1 mmol/l) Diagnostic Value: Assessment in a nonfasting state for diabetes screening and surveillance purposes of diabetes treatment. OGTT Oral Glucose Tolerance Test. Diagnostic Value: Diabetes Screening and diagnosis tool. Assessment of baseline glucose and after consumption of glucose at defined times. Requirements: High carbohydrate diet (200 вЂ“ 300 mg) for 2 days prior to the test. Avoidance of alcohol, caffeine and nicotine for 36 hours, fasting for 10 вЂ“ 16 hours. No antidiabetics or insuline for 12 hours and no exercise for 8 hours prior to test. Reference ranges: 30 minute sample 110 вЂ“ 170 mg/dL = 6.1 -9.4 mmol/l 60 minute sample 120 - 170 mg/dL = 6.6 вЂ“ 9.4 mmol/l 90 minute sample 100 вЂ“ 140 mg/dL = 5.5 вЂ“ 7.7 mmol/l 120 minute sample 70 вЂ“ 120 mg/dL = 3.9 -6.6 mmol/l Glycosylated hemoglobin A1c Diagnostic Value: Assessment of average blood glucose levels over 6 вЂ“ 12 weeks Does not require fasting sample. Normal 3.5 вЂ“ 6 5; Good diabetic control 7.5 % or lower ; Fair diabetic control 7.6 вЂ“ 8.9 % Poor diabetic control 9% or higher. Arterial Blood Gas Analysis Normal Reference Ranges Serum pH 7.35 вЂ“ 7.45 Oxygen PaO2 80 вЂ“ 100 mmHg Carbondioxide (PaCO2) 35 вЂ“ 45 mmHg Bicarbonate 22-26 mEq/L Base excess BE +3 - -3 Serum Electrolytes Normal Reference Ranges Sodium 35 вЂ“ 145 mEq/L Potassium 3.5 вЂ“ 5.1 mEq/L Chloride 98 вЂ“ 107 mEq/L Bicarbonate (venous) 23 вЂ“ 29 mEq/L 86 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Prothrombin time PT / INR International Normalized Ratio Measurement of time of fibrin clot development from prothrombin in extrinsic coagulation pathway. Interferes with Vitamin K metabolism. Diagnostic value: Assessment of effectiveness of oral anticoagulants (Warfarin type). Diagnosis of disseminated intravascular coagulopathy DIC. Vitamin K deficiency, Liver dysfunction. Normal Reference Ranges: 9.6 вЂ“ 11.8 seconds for adult females (+/- 2 seconds) 9.5 вЂ“ 11.3 seconds for adult males (+/- 2 seconds) Warfarin Therapy = 1.5 вЂ“ 2 times control value Normal: 2.0 вЂ“ 3.0 ; High dose: 3.0 вЂ“ 4.5 High values increase bleeding risk, low values show inefficient therapy. INR is considered as a standardized PT. Partial Thromboplastin Time PTT Assessment of time for fibrin clot formation over the extrinsic pathway. Normal: 60 вЂ“ 70 seconds. Activated Partial Thromboplastin Time aPTT Time needed for recalcified, citrated plasma to clot after adding activated thromboplastin reagent. Normal: 30вЂ“45 seconds. Diagnostic Value: Assessment of effectiveness of Heparin Therapy, Assessment of clotting factor deficiencies (except VII and VIII), Assessment of DIC. Sample to be taken from contralateral arm for venipuncture, if sample is taken under ongoing heparin infusion! Clotting Time Assessment of extrinsic and intrinsic clotting system. Normal 8 вЂ“ 15 minutes. Intrinsic coagulation pathway: Initiation of blood coagulation due to contact with foreign surfaces. Extrinsic coagulation pathway: Initiation of blood coagulation due to tissue damage. Bleeding Time Assessment of thrombocyte function. Normal 1 вЂ“ 4 minutes. Fibrinogen Plasma Protein required for clotting. Normal range: 150 вЂ“ 400 mg/dL. Deficiency in disseminated intravasal coagulation DIC).Increase in infections, estrogen treatments, pregnancy and hepatitis. Fibrin Degradation Products FDP Increased in FDP, fibrinolysis, thrombolysis and DIC. Normal value is 10 mcg/mL. Fibrin D-Dimer Assessment for differentiation between DIC and fibrinolysis. Most sensitive laboratory parameter for deep vein thrombosis and pulmonary embolism. Normal range is 0 вЂ“ 0,5 mcg/mL 87 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Clotting cascade Complete Blood Count CBC Hematocrit (Hct)= RBC Volume in percent of blood volume Normal reference range: 40 вЂ“ 50 % in males , 38 вЂ“ 47 % in females Diagnostic value: Assessment of hemodilution and hemolysis. Hem вЂ“ o - globin (Hgb) = CO2 and O2 binding protein of RBCвЂ™s Heme = Porphyrin and Iron ; Globin = Carrier Protein. HCT usually 3 times higher than Hgb. Nomal reference range: 13.5 вЂ“ 18 g/dL in males, 12 вЂ“ 16 d/dL in females Red Blood Cell Count RBC RBC derive from bone marrow and get eliminated by the reticulo - endothelial system RES of spleen, liver and kidneys within 120 days. Carrier of hemoglobin molecules. Nomal reference range: 4.0 вЂ“ 5.5 million cells/microliter in females, 4.5 вЂ“ 6.2 million cells/microliter in males Abnormal in anemia and blood dyscrasias. Increase in environment with low oxygen concentration. RBC Indexes MCV (mean corpuscular volume) MCH (mean corpuscular hemoglobin) MCHC (mean corpuscular hemoglobin concentration) x x x x 88 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Platelet Count Platelets initiate clotting process if traumas establish contact to body surface or altered intravascular structures such as ateriosclerotic plaques. Platelets produce Prostaglandines. Function can be inhibited by Prostanglandin synthesis blocking medication. (i.e. Aspirin) Normal range is 150.000 вЂ“ 450.000 /ml ; Life span is 10 days. Platelets decreased in bone marrow depression, leukemia, massive blood losses, infections, sepsis and uremia. Increase under Steroid treatment or as an idiopathic process. White Blood Cell Count WBC = Agranulocytes (Monocytes & Lymphocytes) + Granulocytes (Neutrophils, eosinophils, basophils) WBCвЂ™s provide humoral and cellular immune system. Normal range is 5000 вЂ“ 10000 / mm3. вЂњLeft shift WBCвЂќ occurs in massive lymphocytic immune response in viral or fungal infections or inflammations as well as in leucemias with an increased number of immature WBCвЂ™s or lymphocytes. вЂњRight shift WBCвЂќ is defined in an increased number of neutrophil granulocytes due to underlying bacterial infections, liver diseases, Down Syndrome,megaloblastic anemia. Eosinophilic increase indicates allergic or parasitic reponse. Basophilic increase indicates healing process. B Lymphocytes Stored in lymph nodes, contact with antigen Immunglobulines = antibody producing plasma cells. leads to transformation into T Lymphocytes Mature in Thymus, stored in lymph nodes, spleen and overall lymphatic tissue. Cadiovascular Function Studies Serum Lipids = Total cholesterol < 200 mg/dL ; LDL Cholesterol < 130 mg/dL ; HDL Cholesterol < 30 вЂ“ 70 mg/dL ; Triglycerides < 200 mg/dL LDL + Total Cholesterol increase increase of cardiovascular risk HDL increase has cardiopotective function Cholesterol blood test requires 12 hour fasting and 24 hours withholding of alcohol. Creatinekinase CK = creatinephosphokinase CPK Muscular enzyme with specific subtypes for skeletal and cardiac muscles and brain. Total CK rises 4-6 hours after cardial or skeletal muscle damage. Males 55/170 U/L, Females 30 вЂ“ 135 U/L. CK вЂ“ MM = originates from skeletal muscle, 94 вЂ“ 100 % of total CK , Peak 18 вЂ“ 24 hours after tissue damage. CK вЂ“ MB = originates from cardiac muscle, 0- 6 % of total CK, Increase 6 hours after tissue damge. Normalization within 3 - 4 days. CK вЂ“ BB = Brain tissue, 0-5 of total CK Alcohol to be withheld 24 hours before sample. Injections, bruises, contusion, cuts, strong physical exertion can cause false elevation of total CK. CK and LDH monitoring in MI provides additional information on progress and severity. 89 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Lactic Dehydrogenase LDH 140 вЂ“ 285 U/L, Increased from 24 hours after MI. Peaks in 48-72 hours. 5 Subtypes. Evidence for MI if LDH2 rises / flips over LDH1. Normalization in 7 вЂ“ 14 days. LDH1 LDH2 LDH3 LDH4 LDH5 14 вЂ“ 26% 29 вЂ“ 39% 20 вЂ“ 26% 8 вЂ“ 16% 6 вЂ“ 16% Troponine Proteine of cardiac and skeletal muscle cells. Troponin I < 0.1 - < 1.0 ng/ml. Rises within 3 hours after cadial muscle damage. Nomalization after 5 вЂ“ 9 days. Troponin T < 0.2 - < 1.0 ng/ml. Rises 3 hours after cadiac muscle damage. Normalization after 10 вЂ“ 14 days Thyroid Gland Function Studies Assessment of HypoвЂ“ and Hyperthyreosis. Thyroxine T4 : Normal reference range 4.5 вЂ“ 11.5 mcg/mL T4 (1.0 вЂ“ 2.3 ng/dL free T4) Triiodothyronine T3 : Normal reference range 80 вЂ“ 200 ng/dL Thyroid stimulating Hormone TSH: Released from anterior pituitary gland by negative feedback loop due to low T4 Levels. Normal reference range: 0.35 вЂ“ 5.5 mU/mL. Enables differentiation between thyroid gland and pituitary gland disorders. Low TSH and low T4 indicates pituitary gland disorder. Renal Function Studies Blood Urea Nitrogen (BUN) Product of hepatic protein catabolism. Normal reference range 8 вЂ“ 25 mg/dL = 2.9 -8.9 mmol/l. Increased in: Reduced GFR, Increased protein uptake, Starvation, Crush injuries, Feverish infections, Hemoconcentration. Decreased in: Overhydration, Poteine deficient diet. Failure of liver to convert ammonia to urea. Serum Creatinine Product of creatine metabolism in skeletal muscles. Increase indicates renal insufficiency. Sample requires withholding meat for 24 hours and leave physical exercise for 8 hours. Normal reference range is 0.6 вЂ“ 1.3 mg/dl. Urinanalysis Nitrites Presence indicates but does not proof UTI due to transformation of physiologically excreted nitrate into nitrites by gram negative bacteria. (i.e. E. coli). False negative results if urine was stored in bladder > 4 hours. No sensitivity for UTI caused by gram positive bacteria. 90 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Leucocyte Esterase Test to be done on a voided urine sample i.e. diaper. Positive results if urine contains bacteria. UTI diagnosis requires a minimum of 100.000 colonies of bacteria perhigh powerded field. Normal Urinalysis Color Pale yellow вЂ“ amber = normal Pale вЂ“ water clear = Diabetes insipidus and excessive water intake Reddish вЂ“ RBC Burgundy вЂ“ Porphyria Orange вЂ“ Phenazopyridine HCl and Rifampin (Rifadin) Green вЂ“ bile Black вЂ“ brown: mercury poisoning Milky вЂ“ pus and fat globules. Clarity Clear on excretion = normal Cloudy = infection and phosphate precipitation Odor Faintly aromated = normal Sweet = acetonuria Strong = drugs and asparagus Ammonia = produced by urea slitting bacteria in standing sample over time alkaline transformation. Specific gravity 1.005 вЂ“ 1.030 = nomal Increased = diabetes mellitus, hypovolemia, liver disease, heart failure, i.v. contast medium. Decreased = diabetes insipidus, diuretics, excessive water intake pH 4.6 вЂ“ 6.0 Acidity due to presence of ketone bodies = Diabetes, fever, starvation and dehydration. Alkaline due to citrus, salicylates, bicarbonate, uti, after standing > 4 hours. Protein Trace to none = normal Transient = Fever, stress 0.5 mg/d = chronic pyelonephritis 0.5-4.0 mg/d = multiple myeloma and diabetic nephropathy 5.0 mg/d = nephrotic syndrome and glomerulonephritis Glucose None = Normal Present = Diabetes mellitus Ketones None = Normal Pesent = Diabetes, fever, starvation and dehydration Sediment: 0-3 RBC, 0-4 WBC, occasional casts, occasional urothelial cells = normal 91 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com RBC casts: glomerulonephritis, Blood: renal bleeding, malaria, hemolysis, aanemia, transfusion reaction. WBC casts: UTI Pus: Glomerulonephritis Stool Examinations Stool samples are commonly asservated and tested for: Occult blood: Paper stripe based test retrieves pseudoperoxidase reaction of Hemoglobin. Clients have to avoid nutritional ingredients that may cause false positive results, such as fish, meat, iron, iodine, boric acid and NSAID. False negative results may be caused by: Vitamin C supply, beets, melons and horseradish. Gastrointestinal infections: Stool samples are cultivated to assess bacterial and parasitic gastrointestinal infections as well as clostridial toxins. Fecal fat Diagnostic parameter and assessed in malabsorption syndromes caused by hepato вЂ“ biliary and pancreatic gland disorders. Liver Function Studies Alanine aminotransferase (ALT) = Serum glutamic pyruvic transaminase (SGPT) Found in liver > heart, kidney, skeletal muscle. Normal reference range: 10-25 U/L Elevation > 300 U/L common in liver diseases. Sample can be obtained non-fasting. Aspartate aminotransferase (AST) = Serum glutamic oxalacetic transaminase (SGOT) Found in liver and heart muscle > skeletal muscle, kidneys and pancreas. Unspecific. Normal reference range: 8-38 U/L, Rises up to 10 times in case of liver injury. In MI rise less high in 6 вЂ“ 10 hours, peaks in 24 вЂ“ 48 hours, normalization in 4-6 days. Sample can be obtained non-fasting. Bilirubin Product of hemoglobin breakdown in liver, spleen and bone marrow. Conjugated (direct) bilirubin excreted over GI tract. Unconjugated (indirect) in blood circulating bilirubin. Normal reference ranges: Total bilirubin 0.1 вЂ“ 1.2 mg/dL = 1, 71 вЂ“ 20,52 micromol/l adults 1 - 12 mg/dL = 17.1 вЂ“ 205 micromol/l newborns Direct bilirubin 0.1-0.3 mg/dL = 17 - 51 micromol/l I Indirect bilirubin Difference between direct and total bilirubin. Elevation of total bilirubin over 2.0 mg/dL causes jaundice. Specimen is light sensitive. Sample taken fasting for 4 hours prior to test. Levels influenced by yellow vegetables if consumed 3 days prior to test. Ammonia End product of nitrogen breakdown in protein metabolism in liver. Excreted via kidneys. Normal reference range 35-65 mcg/dl. Indicator for liver disease. Increase can cause brain damage and hepatic coma. Sample to be taken fasting for 8 hours before test and after withholding nicotine for 8 hours. 92 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Pancreatic Enzymes Amylase Product of pancreatic and salivary glands. Required for digestion of Carbohydrates. Normal reference range: 25 вЂ“ 151 U/L. Increase in pancreatitis 3 вЂ“ 6 hours after pain starts. Peak after 24 hours. Normalization in 2 вЂ“ 3 days. Lipase Product of pancreatic gland. Required for breakdown of fatty acids and glycerol. Normal reference range: 10-140 units/L. Increased in pancreatic disorder from 24 hours after onset of disorder. Normalization in 14 days. Gastrointestinal Function Studies Albumin Normal reference range 3.4 вЂ“ 5.0 grams/dL Plasma protein. Maintains oncotic pressure. Transport of water insoluble substances (i.e. hormones, fatty acids, drugs, bilirubin). Indicator of nutritional status and protein synthesis in liver. Alkaline Phosphatase Present in intestines, liver, bones, placenta. Rise indicates bone growth, liver disease, bile duct obstruction. Reading may be affected by hepatotoxic drugs. Sample requires 12 hours fasting prior test. Total Protein Overall proteins functioning as carriers, hormones, coagulant factors, enzymes, tissue growth and repair. Normal reference range is 6.0 вЂ“ 8.0 grams/dL. Decreased in malnutrition, severe injuries and burns, liver disease and renal failure. Increased in Myeloma and due to all forms of dehydration by causing hemoconcentration. Uric Acid Product of purine metabolism. Affected by diet and renal function. Increase causes gout disease and kidney stone formation. Normal reference range is 3.5 вЂ“ 8.0 mg/dL in adult males and 2.8-6.8 mg/dL in females. Sample does not require fasting but withholding of high purine food. (organ meat, sardines and scallops) -Assessment of therapeutic drug levelsSamples to be taken before daily dose or as peak and though levels. (peak = 30 minutes after intake or administration, through = next to scheduled dosage) Most commonly assessed therapeutic drug levels Carbamazepine (Tegretol) 5-12 mcg/mL Digoxin (Lanoxin) 0.5 вЂ“ 2.0 ng/mL Lithium (Lithobid) 0.5 вЂ“ 1.3 mEq/L Phenytoin (Dilantin) 10-20 mcg/mL Theophylline (Theo-Dur) 10-20 mcg/mL Valproic acid (Depakene) 50 вЂ“ 100mcg/mL 93 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com - Immune Function Studies - The immune system responds to contact with antigens with its humoral and/or cell mediated immunity. The Humoral Immune System Main function is the synthesis of antibodies once an antigen has entered the system: Mediator cells are B вЂ“ Lymphocytes. 1. B Lymphocytes recognize antigen and bind it to their surface 2. B Lymphocytes differentiate into plasma cells 3. Plasma cells secrete immunoglobulins to support an antigen/antibody reaction. Lymphocytes also develop memory cells to enable the immune system for an enhanced and faster immune response once an antigen reenters the organism again. The Cell Mediated Immune System The cell mediated immune system elicits a primary immune response against viral, bacterial, parasitical, and fungal infections as well as in cases of a transplant rejection reaction (e. g. Graft versus host). The cellular immune response gets activated once BLymphocytes have bound to an invading antigen. This antigen/antibody complex is presented to the cellular immune system by expressing a specific major histocompatibility complex. (MHC). This newly build complex of BLymphocytes and antigens then bind to a specific CD receptor on the surface of a TLymphocyte. IgA IgD IgE IgG IgM Types of Immunoglobulins вЂњsessileвЂќ Antibody, not circulating in plasma. Located on all body surfaces. bound to surface of lymphocytes for antigen capture and presentation. bound to interstitial mast cells, facilitating allergic reactions circulating in entire systemic circulation. Activates systemic immune response and is able to pass placenta barrier! Immediate and primary immune response. Activates systemic immune response. Types of Hypersensitivity reactions Type I, Anaphylactic reaction Characteristics: Immediate immune response due to binding of activated IgE Immunoglobulines to mast cells leading to an allergic response. Local responses target the areas where the reaction takes place. Systemic reactions may lead to a generalized allergic reaction such as an anaphylactic shock. Symptoms and diagnostic findings: Symptoms include a variety of allergic symptoms such as wheezing, bronchospasm, hypotension, allergic dermatitis, glottis and tracheal angioedema, asphyxia, shock and death. Treatment: If possible, suspected allergen has to be eliminated instantly. Acute, life threatening anaphylactic reactions require immediate treatment with epinephrine, airway placement, oxygen and circulatory support. Further medication therapy include antihistamines and mast cell stabilisators for immediate cessation of further histamine production and release. Corticosteroids are applied to minimize immune response. 94 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Type II, Cytotoxic reaction Characteristics: Systemic humoral immune response triggered by IgA and IgM antibodies in cases of autoimmune diseases and transfusion reactions due to A,B,O incompatibility. Symptoms and diagnostic findings: See manifestation of autoimmune disorders. (e.g. Graves disease, Goodpasture Syndrome and Myasthenia gravis) Activation of hemolysis in cases of A,B,O blood incompatibility. Coombs and Gellen test positive. Treatment: Prevention of A,B,O incompatibility by thorough checks of patient identity and surveillance of transfusion for at least 15 minutes. Type III, Immune complex reaction (вЂњSerum sicknessвЂќ) Characteristics: Precipitating antigen вЂ“ antibody complexes lead to a systemic immune response with complement activation that targets specific tissues or causes a generalized unspecific immune response. Symptoms and diagnostic findings: Examples of clinical manifestations are rheumathoid arthritis (RA) systemic inflamed synovial tissues and joint cartilages. Systemic Lupus erythematodes (SLE) Generalized inflammation of internal organs and bone marrow. Sclerodermia systemic skin fibrosis. Serum sickness is characterized as generalized body ache, fever and swollen lymph nodes. Arthus reaction describes a local, only one organ targeting reaction. Treatment: Symptomoriented treatment, surveillance until reaction is exhausted. Type IV, Delayed hypersensitivity reaction Characteristics: Slow immune response of T вЂ“ Lymphocytes to substances and allergens that do not trigger a humoral immune response. Symptoms may not arise before 72 hours after allergen contact has taken place. Symptoms and diagnostic findings: Examples are positive tuberculin test reactions, contact dermatitis and graft and transplant rejections. Treatment: In order to underlying cause. Allergy testing procedures Scratch test (In vivo) Intradermal application of one or several defined testing allergens at a time. Leads in a positive testing to an immediate erythema, swelling and itching at the site of the injection due to activation of mast cells. Radio-Allergen-Absorbent-Test (RAST) (In вЂ“ vitro) Incubation of clients blood with a defined allergen leads to an accumulation of IgE antibodies in a positive case. IgE concentration can be measured by radioactively marked IgE antibodies. -Common Diagnostic Procedures- Biopsy Removal of organ tissue for the purpose of microscopical (histological) examination. Usually performed in cases of suspicion of malignant tumors. 95 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Bronchoscopy Endoscopic examination via Pharynx, Larynx and Bonchioles to reveal pathologic changes. May require premedication and general anesthesia or local anesthesia. Local anesthesia suppresses swallowing reflex which requires withholding of food until anesthetic effect wears off due to danger of aspiration ! Pulmonary function studies Assessment of physiological pulmonary function as well as of restrictive and obstructive pulmonary diseases. Main parameters are vital capacity, lung volume loop, diffusion capacity assessment, provocation studies, bodyplethysmography, pulse oximetry, ecercise studies. Clients to avoid any food and nicotine 4 вЂ“ 6 hours prior to the test. Ventilation scan Assessment of pulmonary ventilation via scan of inhaled radioactive isotopes. Used to differentiate between anatomical and cardiovascular causes of a pulmonary dysfunction. Angiography Assessment of the perfusion of the arterial and venous system via transcutaneous injection of radioactive contrast fluids. Procedure may cause allergic reaction and requires client to fast 8 вЂ“ 12 hours prior to the procedure. As any examination under administration of contrast fluid an IV access has to be maintained throughout the procedure. Angiographies on arterial blood vessels need to be observed in regards to accidential punctures or prolonged bleedings. Cardiac catheterization Angiography of the coronary arteries. Catheter device is inserted via the brachial or femoral artery and used for injections of contrast fluids into the coronary arteries. Echocardiography Ultrasound based method for examination of cardiac heart valves. May be used for transthoracic and transesophageal examinations. Transesophageal examinations are performed to assess the atrial regions of the heart. This procedure may require intravenous sedation and a fasting period of 4 hours prior to the procedure. Electrocardiography (ECG, EKG) Assessment of the autonomous electrical activity of the heart. Used to detect dysrhytmias as well as acute and chronic ischemic myocardial reactions. Commonly performed as a 12-lead ECG. Electrodes are placed on limbs and chest in a specific order Unipolar electrodes: aVR, aVL, aVF Bipolar electrodes: I,II,III Chestwall electrodes: (C) V1 вЂ“ V6 Reliable examination results require client not to move during procedure. Body hair in areas of electrode placement has to be shaved. Holter-monitoring 24-hour ECG examination under normal daily activities to assess periodical dysrhytmias. Stress / exercise tests Cardiac monitoring under physical exercise or medication induced tachycardia. Methods of assessment are treadmill and ergometer ECGвЂ™s, myocardial perfusion imaging test and dobutamine stress test. Method to establish exercise induced myocardial ischemia 96 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com and dysrhytmias. Clients are supposed to maintain NPO Status after midnight and to avoid caffeine and nicotine prior to the exam. Client instruction about acute warning signs like chest pain and dyspnea prior to the exam is mandatory. Resuscitation equipment has to be available at all times during the examination procedure. Test results may be influenced by medication, i. e. Beta-Blockers. Monitoring has to be continued for 5 вЂ“ 10 minutes after exertion has stopped and heart rate and blood pressure are normalized. Computer tomography (CT) scan Narrow X-Ray based scan of circumscripted anatomical regions for abnormalities and lesions in soft tissue, central nervous system and musculoskeletal system. May be performed with or without contrast dye. Contrast medium may cause an allergic reaction and requires assessment of kidney function prior to the examination. Use of contrast dye requires patient to dink sufficient amounts of water after procedure. Not to be performed in pregnancy. Fluoroscopy X-Ray examination of organs in motion under administration of contrast dye. (i.e. Barium Enema, coronar angiography). Contraindicated in Pregnancy. Magnetic Resonance Imaging (MRI) Imaging examination with similar results as in computer tomography. Not based on ionizing radiation. Underlying principle is the creation of a high energetic magnetic field which accelerates protones of body fluids and translates the resulting electromagnetic rays into picture producing signals. Procedure is contraindicated in any case of metal device implantation. (e. g. pacemakers). Gardolinum as a nonallergenic substance is used for contrast fluid administration and may interfere with calcium absorption for the next 24 hours. Procedure may cause claustrophobic reactions and is noisy. Nuclear scan Scan is based on the administration of radionuclides and and the assessment of their distribution into specific organs. Imaging is peformed under use of a Gamma - or scintillation camera. Radioisotopes used for these examinations are technetium 99m, iodine 123,iodine 125, thallium 201, xenon, indium 111, gallium. Client requires administration of thyroid gland blocking agent (Lugol Solution, potassium perchlorate) and san iodine restricted diet prior to the examinaton. Radionuclides are naturally discharged within 24 hours without risk of contamination for other people. Positron emission tomography (PET) Noninvasive procedure to assess perfusion and transformation of the central nervous system and within the heart muscle. Imaging is based on measurement of the density of administered positron emitting isotopes of a previously administered radionuclide. Commonly used substances are radioactive glucose, rubidium 82, oxygen 15 and nitrogen 13. Ultrasonography Ultrasound transducer produces and receives echoes from body tissues and cavities and transforms the returned echo signals into pictures. Method can detect any anatomical alterations of inner organs. Diagnostic value increases with density of the 97 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com examined tissues. Preparation usually requires fasting for abdominal examinations. Pelvic examinations have to be performed with partially filled bladder. X-ray examinations Screening and diagnostic examinations. Standard examinations are: KUB (kidneys, ureter, bladder), Flat plate (chest, heart, abdomen), skeletal and skull. Patient is required to wear protective garb for protection of reproductive organs. Contraindicated in pregnant women. Vasography (Phlebography) Flouroscopy or X-Ray of deep leg veins via intravenous injection of contrast dye. Performed for detection of deep vein thrombosis. Requires NPO Status for 4 hours. Assessment of vital signs before, during and after procedure. Client has to be handled as a DVT case until ruled out. Previously first line diagnostic tool in cases of DVT before duplex sonography was available. Cystoscopy and Cystography Direct endoscopic visualization of the bladder. May include retrograde filling of the bladder with radiopaque contrast dye. Blood tinged urine and temporary burning sensations during urination may be observed in postprocedure care within the first 2 days. Gross haematuria indicates complication. Minimum urine output has to be 200 ml / 8 hrs. Intravenous Pyelography (IP) Synonymous term for excretory urography for radiologic visualization of the entire urinary tract. Requires intravenous injection of of radiopaque contrast dye. X-rays are taken at 3,5,10,15 and 20 minutes after injection and after client has voided. Client has to remain in NPO status for up to 12 hours prior test. Preparation procedures requires a laxative in the evening and an enema in the morning. Retrograde Pyelography Not commonly used alternative for IP in cases of clients with kidney dysfunction. Contrast dye is administered via catheterization into the ureter. Barium enema Assessment of the entire large intestine (colon) to determine pathologies. Performed under use of Barium sulfate only or in combination with air as a contrast fluid. (= double contrast) Procedure requires bowel preparation with fluids, and a low residue = low fiber diet 2 вЂ“ 3 days prior to the test. Postprocedure care includes prolonged use of laxatives until barium is removed from bowels. Cholangiography Fluoroscopic and radiologic assessment of biliary ducts. Access to administer contrast fluids may be performed intravenously or via transabdominal and transhepatic puncture of biliary ducts in liver. Intraoperative cholangiography uses a t-shaped bile duct catheter (T-Tube). Assessment of LFTвЂ™s before and after procedure is mandatory. Cholecystography (oral) Orally administered contrast media concentrates in gall bladder after 12 hours. Clients are supposed to remain in NPO status for 12 hours prior to the test. Procedure requires assessment of LFT before and after. 98 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Gastrointestinal GI series Fluoroscopic and x-ray examination of the gastrointestinal tract after administering barium contrast medium. Pictures are taken over 1 вЂ“ 6 hours depending on examined area of the gastrointestinal tract. Care comparable as for other contrast media involving procedures. Lightly coloured stoll may occur for a few days after the procedure. Upper gastrointestinal tract = Mouth Intestines Lower gastrointestinal tract = Colon and Rectum Mammography X-ray examination of breasts to detect cysts or tumors. Sensitivity to detect malignancies is about 90%. Current guidelines recommend an examination every two years for every woman between 35 and 40 and yearly for women oer 40 years of age. Test does not require any specific preparation but client is supposed to avoid any external lotions or crГЁmes on the day of the examination. Procedure may cause discomfort but no actual pain. Films are usually developed instantly. Bone Densitometry X-ray based investigation to determine mineral content of the skeletal bone. Test is noninvasive and takes 30 вЂ“ 60 minutes. EEG - Electroencephalography Method to measure electrical impulses produced by brain cells. Mainly used to diagnose seizure disorders and brain death. Electrodes are placed on scalp, impulses are recorded on moving paper comparable to an ECG. May be performed und all stages of consciousness. Patient must not use oil or gels but shampoo only on hair prior to the test. Client must not remain fasting. Sedating medication has to be avoided or interrupted. Myelography Flouroscopic and radiologic exam of the subarachnoid space (spinal canal) after injection of air or contrast fluids. Procedure may require sedation of client and recurrent change of positions on the examination table. Loss of spinal fluid requires compensation with increased fluid intake. Client have to maintain bedrest for at least 8 hours after the procedure to avoid headaches due to the loss of cerebrospinal fluid. Arthroscopy Endoscopic transcutaneous surgical examination and treatment procedure for joints. May include therapeutic intervention in the same setting and / or arthrography via air or contrast media injection. Appropriate to diagnose cartilage, tendon and synovial structure damage. Most commonly used to assess and repair knee and shoulder injuries but also used for other joints. Colonoscopy Endoscopic examination of the large intestine via an rectally inserted fiberglass optic instrument. Procedure allows to perform biopsies and to remove polyps from examined tissues. Therefore medication which increases the risk for bleeding needs to be stopped 1 week prior to the procedure. Preparation requires a bowel cleansing procedure which is performed 24 hours prior to the scheduled examination and includes intake of large amounts of osmotic laxatives (i.e. GoLytely, Colyte Solution and Fleet Phosphosoda) until clear watery discharge from anus appears. Positioning of client during the examination is either on left side of body or in Sims position. Care includes monitoring of vital signs and precautions as in a surgical procedure under sedation. 99 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Esophagogastroduodenoscopy Direct visualization of the gastrointestinal tract via insertion of a fiber glass endoscope. Requires NPO Status for 8 -12 hours prior to the test or gastric lavage in case of an emergency procedure. Biopsies can and may be taken during procedure. Examination includes esophagoscopy, gastroscopy and duodenoscopy. Oral anaesthesia must loose effect before patient is allowed to eat or drink ! Endoscopic retrograde cholangiopancreatography ERCP An orally inserted endoscope is guided to the duodenal papilla where radiopaque contrast medium is injected to identify abnormalities and pathologic findings of the biliary and pancreatic duct. Preparation requires NPO status for 8 hours prior to test and insertion of an IV line. Care includes monitoring and precautions as in a surgical procedure under sedation. As for any orally or transorally performed procedure dentures have to be removed ! Gastric analysis Examination of gastric acid secretions via an inserted nasogastric tube. May be performed with or without stimulation. Increased production indicates peptic ulcers or Zollinger Ellisons Syndrome. Decreased acid production indicates pernicious anemia, gastric malignancy or atrophic gastritis. Examination usually requires four subsequent specimens every 1 minute. NPO status 8 -12 hours prior testing especially avoiding acid provocating food and coffee. Fetal Non-stress Test Used for assessment of fetal heart rate (FHR) when fetus is moving. Accomplished via a transducer. Desired rate is 15 beats per minute over 15 seconds. Test requires client to shift transducer to area where fetal movement is experienced. Fetal movement may be provocated by external stimulation. Normal outcome requires an increase of the FHR when Fetus is moving. Hysteroscopy Visualization of the uterine cavity via an endoscopic procedure. Procedure allows to take biopsies and to perform removals of polyps and other abnormal findings. Contraindicated in any case of external genital infections including cervix infections. Procedure should be undertaken in first of menstrual cycle. After menstruation and prior to ovulation. Examination is performed in Lithotomy position and on an empty bladder. Carbon dioxide is inflated to widen the uterine cavity. Care is comparable as for any surgical intervention. Client to avoid sexual intercourse and any kind of transvaginal treatment or hygienic procedure for two weeks to avoid an infection. Papanicolaou Smear (PAP Smear) Cytological smear taken from the cervix to identify atypical cells, malignancies as well as viral, fungal or bacterial infections. May also be used to evaluate effect of an ongoing radiation or chemotherapy treatment. Test does not require any specific preparation but client is supposed to avoid sexual intercourse or any transvaginal irritation 24 hours prior to the examination. Procedure requires client to lay in a lithotomy position in a gown with all clothes removed. A breast exam is typically performed after the smear. Tuberculin skin test Screening test for tuberculosis. Only for clients who were tested negative before. 100 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Not to be performed in clients with previous positive test results due to the risk of an anaphylactic reaction ! Tests are containing a purified protein derivative which is applied to the skin in two different ways. a) b) Tine test (= Mono Vac test) Multipuncture stamp needle used for mass screening purposes. Mantoux-test requires strict intradermal injection of PPD using a tuberculin 1ml needle with a 25-27 gauge needle. Results are to be read within 48 вЂ“ 72 hours. Most accurate after 72 hours. Positive test indicates contact or infection with Mycobacterium tuberculosis. Further testings include sputum cultures, gastric acid cultures and chest x-rays. Skin tests are also performed for Blastomycosis, Coccidioidomycosis, Histoplasmosis, Trichinosis and Toxoplasmosis. -Perioperative Nursing CarePreoperative Phase Checklist вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў Client identification Client assessment Identifying health problems Beginning of Postoperative teaching Interview Completion of diagnostic procedures Ensuring about availability of complete reports Reporting any abnormal findings Ask client for consent of autologous or directed blood transfusions Obtain informed consent Physical assessment Physical preparation Intraoperative phase (surgical period) Checklist (= clients transfer to operating table until admission to postanesthesia care unit PACU) вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў Client requires preparation for induction of anesthesia Maintaining aseptic conditions Assisting in providing a hazard free environment Sufficient and timely supply with materials Administering IV medications and infusions Positioning of client Applying grounding device Provide physical and emotional support Apply monitoring devices Monitor clients reaction to procedure and medications Identify nursing roles Circulating nurse = non вЂ“ sterile Scrub nurse = surgeons assistance = sterile 101 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Postoperative phase Checklist (= Discharge from PACU until follow up evaluation) вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў Requires assistance in physical adaptation, orienting back to consciousness, communication with other nursing units Assessment of effect of procedure and applied medications Monitoring of vital functions Providing comfort and pain relief Appropriate positioning Maintain hydration Monitor renal output Suctioning Wound care Education Types of treatments and procedures вЂў вЂў вЂў вЂў вЂў Diagnostic = to establish a diagnosis Curative = to remove pathological cause Ablative = to remove a diseases structure Reconstructive = to repair a dysfunction Palliative = to reduce pain Classification of surgical procedures вЂў вЂў вЂў вЂў вЂў вЂў вЂў Major surgery = prolonged, larger blood loss, vital organs involved, postoperative complications possible Minor surgery = few complications to be expected, typical for outpatient setting Emergent = immediate treatment for life threatening or dangerous condition Urgent = treatment promptly required, within 24 hours Required = treatment within weeks to month Elective = to avoid an aggravation ahead of time Optional = A non surgical treatment option exists Anesthesia Conscious sedation = minimal depression of consciousness by IV narcotics and anxiolytic medication. Regional anesthesia: 1. Accomplished by use of local anesthetics. Stages1: Drowsy,dizziness and depressed pain sensation. Stage 2: irregular breathing, involuntary movements. Stimulation may cause vomiting. Stage 3: Muscle relaxation, miosis and absence of eye lid reflex. Stage 4: Medullar depression, mydriasis, rapid pulse, decreased breathing. Factors of preoperative assessment вЂў Clients history вЂў Physical assessment 102 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Diagnostic preoperative laboratory examination screening routine Urinalysis Chest x-ray ECG CBC Blood typing Cross matching Serum electrolytes Na, K, Ca, Mg, Cl, HCO3 Fasting blood glucose BUN Creatinin ALT AST LDH Bilirubin Serum Albumin -Care specifics for surgical clients- PACU Nursing care Postanesthetic clinical assessment factors Checklist вЂў Adequacy of airway вЂў Oxygen saturation вЂў Adequacy of ventilation вЂў Cardivascular status вЂў LOC вЂў Presence of protective reflexes and motoric activity. вЂў Skin color вЂў Fluid status вЂў Condition of operative site вЂў (purulent = pus, serosanguineous (serum and blood), вЂў Patency, amount, character of drainage, вЂў Discomfort and safety. PACU unit discharge criteria 1. Vital signs sufficient, 2. Breathing spontaneously 3. Gag reflex present 4. Client easily arousable x x xx x x 103 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Postoperative nursing management duties on clinical units Assessment of: Encourage вЂў Breathing вЂў deep breathing, leg exercising вЂў Vital signs Provide вЂў i.v. sites and drains вЂў Pain management вЂў Wound conditions вЂў Call light вЂў Temperature вЂў Emesis basin вЂў Tubes вЂў Ice chips вЂў Pain вЂў Bedpan and urinal вЂў Positioning Communicate with family. вЂў IV fluid monitoring Promote вЂў Urine output monitoring вЂў GI status вЂў Discharge planning participation. Discharge instructions shall include: Diet, activity, medications, wound care and follow up care. Most common postoperative complications include вЂў Respiratory distress due to pulmonary embolism вЂў Hemorrhage and shock вЂў Thrombophlebitis вЂў Paralytic ileus, constipation, вЂў Urinary retention вЂў Wound infection вЂў Wound dehiscence and evisceration. -Postoperative care after abdominal surgery- Gastrointestinal tract: Partial gastric resection and total gastrectomy Partial or total removal of stomach for neoplastic or ulcerous diseases. Modifications of the gastrectomy procedure are: a) b) c) d) Billroth I gastrectomy ( = Gastroduodenostomy) Billroth II gastrectomy ( = Gastrojejunostomy) e) Removal of lower portion of stomach including gastrin and acid / pepsinogen secreting cells with subsequent connection to the duodenum (B I) or jejunum (B II). Common complication of these procedures is a Dumping syndrome, caused by a sudden movement of indigested food into the duodenum or jejunum. Leading to a non-resorption situation in the duodenal part as well as a sudden fluid shift into the renal cells which may cause immediate severe flushes, sweats, pallor, palpitations. Hypoglycemia may arise out of a sudden instead of a gradual insulin response. Postoperative clients after Gastrectomy and gastric resection require suctioning via a nasogastric tube which is typically placed during the procedure. Tube placement requires regular monitoring since an improper suction may lead to an overdistention of 104 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com the remaining stomach and endangers the anastomotic sutures. Tubes should not be corrected or changed blindly either. Gastrectomy procedures may also require lifelong parenteral folic acid and vitamin B12 supply due to absence of parietal cells. Clients need to be instructed how to overcome limited or absent gastric space by selecting a specific low carbohydrate, high protein and high fat diet with 4 вЂ“ 6 meals per day ! Ileostomy Stoma care requires skin protection by use of sufficient barrier systems. Special consideration has to be given to the prevention of dehydration and electrolyte imbalances of the stoma including advice on fluid and electrolye enriched diet. Colostomy Special attention has to be given to the possibility of a blockage by constipation. In general stool will appear more solid the lower the colostomy is placed. e. g. stool from a descendostomy is more solid then from an ascendostomy. Clients require education with bowel irrigation. Basic client needs -Nutritional needs- General Guidelines on Diets All current recommendations by the U.S. Department of Health and Human Services and the U. S. Department of Agriculture are valid for the NCLEX-RNВ® and can be viewed online at www.mypyramid.gov. General dieting recommendations include a balanced eating pattern, consumption of basic food groups as much as possible while keeping consumption of trans вЂ“ fats, cholesterol, added sugars, salt and alcohol low. 105 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Main nutritional elements Carbohydrates Key source of energy, providing 4 kcal/gram, mainly carried in fruits, vegetables, milk and grain. Sufficient supply of carbohydrates prevents proteine waste and muscular atrophy. Fats Concentrated sources of energy, providing 9 calories/gram. Required for absorption of fat soluble vitamins. Physiological cushion and isolation function. Sources are eggs, yolks, meats, butter, cheeses and various oils. Differentiation of fats considers Cholesterol content and molecular structure of fat acids as follow: вЂў Saturated fats Contain more carbon atoms per molecule. Carbon content is higher the more solid this fat is, e. g. butter vs. sunflower oil. Over alimentation with fats, especially saturated fats, leads to obesity, heart disease and cancer. вЂў Mono вЂ“ or polyunsaturated fats Contain less carbon atom per molecule and are mainly of herbal origin. Insufficient intake of fats leads to increased risk of infection, skin lesions, amenorrhea, hormonal imbalances and increased cold sensitivity. Minerals (Micronutrients) Part of cells, bones and hormones. Enhance cellular function and catalyze multiple physiological processes. Mainly calcium, potassium, sodium, magnesium, chloride, phophorus, zinc are required and may become deficient due to health conditions. Trace elements are required in a significant less quantitiy. Significant trace elements are iodine, copper, zinc, selenium, manganese, fluoride, chromium and molybdenom. Vitamins (Micronutrients) Vitamins function as coenzymes to support metabolic processes. Sufficient vitamin supply can be obtained by regular diet alone. Vitamin supplements are not generally necessary. The main differentiation among vitamins considers water soluble (B + C) and fat soluble (E,D,K,A) vitamins. Overview over Vitamin sources and function Thiamin = Vitamin B1 Coenzyme. In Pork, wheat and cereals. Deficiency common in chronic alcohol abuse leads to neurological symptoms. = Beri вЂ“ Beri Syndrome , Wernicke вЂ“ Korsakoff Syndrome. Riboflavin = Vitamin B2 Coenzyme. In milk and enriched grains. Deficiency = Ariboflavinosis Niacin = Vitamin B3 Coenzyme. In peanuts, legumes and grains. Defiency = Pellagra, Dermatitis, Dementia and Diarrhea. Panthotenic Acid = Vitamin B6 Coenzyme. In meat and whole grains. Deficiency = Rash and fatigue Pyridoxine = Vitamin B6 Coenzyme. In pork, organ meats, whole grains and wheat germs. Deficiency = Nutritional anemia. 106 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Cobalamin = Vitamin B12 Coenzyme. In pork, beef and poultry protein. Deficiency = Pernicious anemia Folic acid Coenzyme.In Orange juice, meat and leafy green vegetables. Deficiency = Nutritional Anemia. Neural tube defects if deficiency is current during pregnancy. Biotin Coenzyme. In eggs, yolks and liver. Deficiency = Dermatitis Ascorbic acid = Vitamin C Antioxidant, wound healing and hormone synthesis. Main source are Citrus fruits. Deficiency = Scurvy (bleeding gums). Vitamin A Vision, bone and tissue growth, immune + reproductive function. In animal foods, fruits, vegetables and fortified milk. Deficiency = Night blindness, Xeropthalmia. Toxicity possible. Vitamin D Facilitates calcium and phosphor metabolism. In dairy products, fortified food sources. Also produced by human body in kidneys and skin under the influence of sunlight. Deficiency = Ricketts, Osteomalacia. Toxicity possible. Vitamin E Antioxidant, immune function. In vegetable oil, peanuts and margarine. Deficiency = Hemolysis. Interferes with Vitamin K if taken in excess. Vitamin K Coenzyme for synthesis of clotting factors II, VII, IX, X. Deficiency = Hemorrhagic disease. In green leafy vegetables. Antidote, antagonist to warfarin. Toxicity possible. Phytochemicals Phytochemicals have no nutritional function. They are considered as functional food since their consumption appears to correlate with health benefits. Proven or suspected function as antioxidants in prevention of cancer, cardiac disease, macular degeneration and alleviation of menopausal symptoms. Types of Phytochemicals Carotenoids In colorful fruits, classified in betaвЂ“carotene and lycopene (in tomatoes and вЂ“ products) Pro вЂ“ and antioxidant function. Indoles In broccoli and cabbage. Reduce estrogen effect (less risk of non-hormone depending breast cancer). Protective against carcinogen development by influencing DNS activity. Isoflavones In soy foods, black and green tea. Cancer, osteoporosis, protection, reduction of menopausal symptoms. 107 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Phenolic acids In beans, fruits, vegetables, green tea, wine and soybeans. Binds metals to increase excretion of carcinogenic substances. Cancer protection and glycemic control. Terpones In citrus peel and menthol oil. Carcinogen protective effect. Phytoestrogens In multiple plants, especially whole grain, soy beans and berries. Breast cancer protective effect and reduction of menopausal symptoms. Catechins In teas. Rich in phenolic acid. Antioxidant activity, prevention of cancer and antihypertensive effects. Weight management and physiological nutrition The basic principle of weight management is to balance calories consumed with calories expended. Prevention of weight gain as well as weight loss therefore basically requires decrease of calorie intake and increase of calorie loss due to physical activity. Basic recommendations for adequate nutrition include the following guidelines. Vegetables Per 2000 kcal/d diet = 2 cups of fruit and 2 ВЅ cups of vegetables per day. Equal consumption of vegetable subgroups necessary (dark, green, orange, legumes, starchy). Whole grains Three or more ounces of whole grain product equivalents per day. Milk 3 cups low fat or fat free milk daily. Fats Consumption of less than 10 % of daily calories from saturated fatty acids. Consumption of less than 300 mg cholesterol / d. Trans fat consume as low as possible. Total fat intake should not over exceed 20 вЂ“ 35 % of daily calories. Preferably use of mono вЂ“ or polyunsaturated fats from fish, nuts and vegetable oils. Trans fats Trans fats are unsaturated vegetable oils which are chemically enriched with hydrogen to achieve a more aromatic taste and calories comparable to more expensive saturated fats from animals. Trans fats recognized as risk factors for diabetes, obesity, cancer and heart diseases. Widely used in fast foods and sweets although already banned in some countries and states. Carbohydrates (CHOвЂ™s) Consumption of fiber rich fruits, vegetables and whole grains often. Limit added sugar and caloric sweeteners. Practice of good oral hygiene.after consume of CHO is mandatory. 108 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Sodium Max 2300 mg / d (1 teaspoon) Potassium Choose Potassium rich food. Excess Potassium intake will be neutralized in kidneys. BMI Assessment of BMI: Asessment of nutritional status BMI = weight in kg (1kg = 2.2 lbs) Height im meters 2 Healthy = 18.5 вЂ“ 25 , Grade I Obesity= 25 вЂ“ 29.9, Grade II Obesity = 30 вЂ“ 40 Grade III Obesity = > 40. Basal Metabolic Rate (BMR) Increases with amount of lean muscle. Decreases by 2 % each decade after age 30. Hip Waist Ratio Differentiation between Truncal obesity (вЂ�appleвЂ™) = increased health risk and Pelvic obesity (вЂ�pearвЂ™) = reduced health risk. Skin fold measurements (calipers) Triceps skin fold (TSF) , Mid arm Muscle circumference (MAMC) Albumin Level Normal = 3.5 вЂ“ 5.5 g/dl Mild depletion = 2.8 вЂ“ 3.4 g/dl Moderate depetion = 2.1 вЂ“ 2.7 g/dl Severe depletion = < 2.1 g/dl Tranferrin, Albumin, Prealbumin (TPN) Parameters to check response to parenteral nutrition. Transferrin drops more rapidly than Albumin. Total Lymphocyte count depletes if protein count becomes depleted (carrying Antibodies) ! Nutritional needs across the lifespan Calorie supply in pregnancy and lactation Pregnancy = + 300 calories / d, Lactation = + 500 calories / d Weight gain in pregnancy is determined by BMI prior to the pregnancy as follow: < 19.8 = + 28 вЂ“ 40 pounds 19.8 вЂ“ 24.9 = + 25 вЂ“ 35 pounds 25 вЂ“ 29 = + 15 вЂ“ 25 pounds > 29 = + 15 pounds Infancy Weight doubles in first 6 month of life and triples by first year. Cow milk is deficient of fatty acids, iron, zinc, Vitamin E, C and has to be avoided in first year! 109 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Flouride supply to be started generally from 6 months of age, unless water supply is fluoride deficient! Solids from 4 вЂ“ 6 months by introducing one new food every week, starting with a small amount. Food has to be cooked well and cut in tiny pieces. Childhood Ritualistic and erratic eating patterns, strong food preferences in Toddlers and preschoolers. Daily multivitamin may be considered. Adolescence Male growth spurt from 12-13 , peak at 14, continue until 19. Female growth spurts at 11, peaks at 12, continues until 15. Therapeutic diets Clear liquid diet for abdominal surgery and gastroenterologic diseases. Fluid water, 500 вЂ“ 100 kcal, simple sugars, electrolytes and fiber free. To be pursued over 1 - 3 days. Only foods and fluids that are liquid at room temperature. Full liquid diet for patients with non вЂ“ neurological dysphagia or for short term postoperative, post вЂ“ surgery diet. Water calories, proteins and minerals, vitamins and dairy products. Pureed diet for patients unable to chew or swallow properly. Food has to be prepared in a way that avoids aspiration of solid particles. Dysphagia diet Thickened liquids, requires at least 30 вЂ“ 45 degrees head elevation. Soft diet for people with chewing difficulties due to oral problems as a transition diet. Mechanical soft diet Tender, soft textured, chopped foods are included in this diet. Bland diet avoiding food that stimulates the GI tract and the production of gastric acids. e. g. Spices, sweets, fat, alcohol, pepper, caffeine and fried food. High residue / high fiber diet to regulate bowel function, fat and blood sugar metabolism. 20 вЂ“ 25 g of fiber daily to add bulk to stool. Vegetable, fruits, legumes and whole grains. Low residue / low fiber diet for gastrointestinal obstruction, chronic inflammatory bowel diseases, enteritis, diarrhea. High CHO (pasta, white bread, cerals), avoiding fibers. Restricted or enhanced diets Carbohydrate controlled diets in Diabetes, Obesity, Hypoglycemia and Galactosemia, Dumping Syndrome, Consists of 55 вЂ“ 60 % CHOвЂ™s, 10 вЂ“ 20 % proteins, 10 % or less saturated fat. 20 вЂ“ 35 g fiber. 110 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Fat controlled diet in malaborption syndromes, pancreatic- , bile duct diseases and Gallbladder stones. Medium chain triglycerides (MCT) are utilized in diet because they are easily digested along with high intakes of CHOвЂ™s and proteins. Saturated fats are sparingly used. May require enzyme replacements. Gastric bypass diet Small meals several times daily with sufficient amounts of liquids in between. Multivitamin supplements may be necessary. Low fat and high protein, No carbonic acid, simple sugars and no high fiber food. Protein controlled diet in progressed liver and kidney diseases. Avoiding excess amounts of protein because of diability to metabolize and to excret metabolic products properly. Up to 0.8 g/kg of dry weight, max. 40-60 mg /d. 1.5 вЂ“ 2.0 g/kg in excess for additional need due to dialysis and liver repair. Minimum amount of 50 вЂ“ 100 grams CHO / d. Food allergy diets (Elimination diets) Gluten вЂ“ restricted diet for clients with Aprue or CoeliacвЂ™s disease. Avoidance of any prepared and commercially prepared food with sources of wheat including beer. Allowed: Cornmeal, corn flakes, popcorn, hominy, potato chips, potatos, rice, soybeans and flour. Lactose Intolerance diet Avoidance of dairy products including casein, may need supply of lactase tablets. Lactose may be part of oral medication ! Yogurt is allowed! Clients may need supply of Calcium, Vitamin B6 (Riboflavin) and Vitamin D. Purine controlled diet Indicated in gout, tumor lysis syndrome, multiple myeloma. Increased purin accummulation leads to uric acid increase. Restriction of dairy products, alcohol, anchovies, meats and seafood. Sodium controlled diet Indicated in hypertension, cardiovascular disease and heart failure. Sodium intake as low as 500mg / d. Salt restriction increases risk for potassium elevation especially under use of potassium sparing Diuretics ( e. g. Triamterene). High sodium content in canned foods , breads and salted snacks, Meats, sauces, spices, instant drinks and commercial mik. Tyramine and dopamine restricted diet Indicated in MAO treatment. Foods to avoid are cheeses, bananas, chocolate, smoked fish and meats, soy sauce and flava beans. Low Potassium diet: Indicated in renal failure and use of Potassium saving drugs. Food sources to avoid are apricots, avocados, bananas, cantaloupe, raw carrots, dried beans, dried fruits, melons, oranges and orange juice, peanuts, potatoes, prune juice, spinach, tomatoes and winter squash. High Calcium diet Indicated in osteopenia, osteoporosis, endocrine abnormalities, kidney failure. Sources are dairy products, milk and green leafy vegetables. 111 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com High protein diet Indicated for severe burns, liver disease, athletes. Preference of meat, fish, poultry and dairy products. High calorie diet Immunodeficiency, burns and wounds. Nutritious snacks and proteins. High iron diet Indicated in anemia. Iron supply, bread, egg yolks, dried fruits and legumes. x Vegetarian diet Vegan: (strict vegetarian), Ovovegetarian, Lactovegetarian and Ovolactovegetarian Lab monitoring parameters of dietary treatments Relevant parameters: TLC, BUN, Albumin, Prealbumin, Creatinine and Electrolytes. Tube feeding specific considerations To check placement of tube assess pH of aspiration fluids and auscultate stomach. Formulas must be supplied as ordered. (isotonic hypertonic) Tubes have to be assessed for remaining food particles at the end of the feeding procedure and need to be flushed regularly. Feeding supplies have to be checked for best before date. Documention of lab findings and weight is required. Obesity Starts from weight > 22 % of normal body weight in young men and > 25 % in older men or from > 35 % in women. Morbid obesity = 100 % than normal body weight. Most common cause is dietary: high fat diet and sedentary lifestyle. Rare causes: Prader willi syndrome, cushing syndrome, polycystic ovary syndrome, hypogonadism and insulinoma, growth hormone insufficiency. Supported by medication: antidepressants, estrogene, corticosteroids, antiepileptics, antihypertensives, nsaid and phenothiazines. Social and psychological factors. Nursing assessment BMI? Type of Obesity? вЂњapple or pear вЂќ? Type of body? endomorph (stocky) ectomorph (tall) mesomorph (middle range). Assesment of obesity complications: Lab findings, ECG and BP. Obesity treatment Normal safe weight loss under dietary treatment is 1 вЂ“ 2 pounds per week. Exercise should be at least 30 minutes of an aerobic activity/d. Behavioral therapy is part of the treatment as well. Surgery may be indicated in BMI > 35 and no response to other treatments, always in BMI > 40. Procedures are: gastroplasty (most common), intestinal bypass, maxillomandibular fixation and esophageal banding. Medication therapy is controversial, only in BMI > 30 or 27 with comorbidities along with diet and exercise. Anorectic medications are contraindicated, pregnancy and lactation. Liver -, kidney -, cardiac diseases. Treatment for underweight clients: Correction of underlying cause is of primary importance. 1 pound weight gain per week requires 500 additional cal./d ! = 3500 kcal per week Supportive medication therapy includes Megestrol acetate (Megace), Dronabinol (Marinol) which may be used as appettite stimulants. Treatment includes eating plans 112 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com with steady increase portion sizes and nutrient dense food. Physical activity to increase muscle tone and metabolism is part of the treatment. Supplemental feedings, tube feedings, may be necessary. Proteine deficiency in significant underweight situations may lead to: вЂў вЂў вЂў вЂў вЂў вЂў вЂў Immunodeficiency Fluid shifts to the third space (extravasal room) Ascites (Kwashiorkor) and Edema (dependant and periorbital) Electrolyte imbalances Skin, nail and hair changes Delayed wound healing Mouth sores, oral cavity changes and decreased dehydration -Hygiene needs- Common skin problems Flaky, dry, itchy skin, Abrasion of epidermis, ammonia dermatitis (diaper rash) contact dermatitis, erythema and pressure ulcers (Open lesion over bony prominences) Specific hygiene measures Partial bed bath, complete bed bath, perineal care, nail and foot care Document skin conditions! Oral care, hair and scalp care, care of eyes, ears and nose. Care of an eye Prosthesis. (wipe from inner to outer canthus) Always document ability to self care ! -Oxygenation needs- Function of the cardiorespiratory system Conditions affecting oxygenation: Altitude Increases Respiratory rate, cardiac rate, respiratory depth. Heat Causes peripheral vessel dilation, increased blood flow to skin decreased resistance to blood flow, CO , BP , HR Increase of breathing rate and depth. Causes Vasoconstriction, BP , reduced need for oxygen, HR Cold Air pollution Causes coughing, choking and difficulty breathing. Narcotics (Morphines) cause central nervous depression of breathing rate. Premature infants immature lungs, respiratory center, gag and cough reflex. Infants and toddlers are primarily endangered by aspiration. Older adults Emphysema development. Hyperventilation: increased rate , reduced depth of inspirations. Hypoventilation: inadequate alveolar ventilation. Hypoxia: (acute) rapid pulse, rapid shallow respirations, dyspnea, flaring nostrils, restlessness, intercostals / substernal retractions and cyanosis. Cyanosis: blue discoloration of skin, mucous membranes and nails. Orthopnea: Breathing difficulties while lying down Dyspnea: Difficulty breathing to air hunger. Wheezing: caused by narrowed bronchus (bronchoconstriction) Chest pain accompanied by breathing diificulties and cyanosis may be a sign of an acute pulmonary or cardial damage ! 113 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Nursing interventions to promote oxygenation 1. Providing oxygene supply 2. Suctioning of trapped mucous from airways 3. Positioning of client in FowlerвЂ™s position 4. Assessment of oxygenation with pulseoxymetry and blood gas analysis 5. Decrease of anxiety by verbal intervention 6. Turn clients with emphysema from side to side 1 вЂ“ 2 hourly 7. Chest physiotherapy: percussion, vibration, postural drainage 8. Place client in lateral position if unconscious Oxygen delivery systems Nasal cannula = 1 вЂ“ 6 l/min of 23 вЂ“ 42 oxygen concentration Oxygen mask = most effective, delivers low or up to 100 % of oxygen, Simple face mask = treatment of CO2 retention, 6-8 L / min, 40 вЂ“ 60 % Partial rebreathing mask = retains parts of exhaled air from trachea and bronchus Non rebreathing mask = fits tightly over face and designed for 80 вЂ“ 100 % oxygen supply. Oxygen tent = mainly used in infancy. Flow rate is 20 L/min, 60 % Ventimask Venturimask = for chronic alveolar hypoventilation and CO2 retention. -Meeting the need for sleep- General requirement is to assure circadian synchronization to avoid inadequate day tiredness. Stages of sleep are NREM and REM sleep. NREM sleep (non вЂ“ rapid eye movement) is deep and restful sleep, leading to decreased physiologic functions. The 4 Stages of NREM sleep: Stage 1: very light sleep, sleeper is relaxed and drowsy, floating sensations eyes roll from side to side, every few minutes. Stage 2: light sleep and easily awaken. Stage 3: medium depth sleep: less easily awaken, muscles relaxation and reflexes decrease. Stage 4: delta sleep. Deepest sleep stage, sleeper difficult to awake, rarely moving, muscle, relaxation, and dreaming. REM sleep (rapid eye movement) Every 90 minutes for 5 вЂ“ 30 minutes. Active, memorable dreaming occurs, vital signs remain regular. Hard or easy awaken. REM sleep decreases to about 20 % of overall sleep in adolescence. Changes of sleep patterns during childhood development. Neonates: 16 вЂ“ 18 hours of sleep / d, 50 % NREM Stades III + IV, 50 % REM sleep. Infants: 12 вЂ“ 22 hrs. of sleep / d, wakeful periods increase with age, at 4 month sleep through the night can be expected with naps during the day, first year, sleep 14 of 24 hours, half of time infant have light sleep and 20 вЂ“ 30 % REM sleep. Toddlers: Normal sleep вЂ“ wake cycle is established by 2 вЂ“ 3 years. Toddlers generally sleep for 10 вЂ“ 12 hours / d. Requires midafternoon nap. 20 вЂ“ 30 % REM sleep. 114 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Preschoolers: 11-12 hours sleep /d., fluctuates due to activity and growth spurts and 2 вЂ“ 30 REM sleep. School age: 8 вЂ“ 12 hours without daytime naps. REM sleep decreases to about 20 %. Adolescents: Sleep declines to 8 вЂ“ 12 hours / d. Adults: 6 вЂ“ 8 hours / night, 20 % REM sleep. Older adults: On average 6 hours of sleep a night, 20 вЂ“ 25 % REM, decrease in stage IV NREM sleep, sleep disorders are more common. Factors interfering with sleep Illness, drugs and substances, caffeine, nicotine, lifestyle, emotional stress, environment, various prescribed drugs, exercise, fatigue and food / calorie intake. Sleeping disorders and modes of treatment Insomnia Sleep inducing and sleep maintaining behaviors. Short term sedatives and correction of underlying cause. Sleep apnea Periodic cessation of breathing during sleep. From 1second to 2 minutes. Accompanied by snoring, hypertension, heart diseases, especially elder obese men. May also be caused by Adenoids and enlarged tonsils. Improvement under nasal cPAP. (continous positive airway pressure). Narcolepsia Uncontrollable desire to sleep. Treatment with stimulants (amphetamines). Parasomnias Abnormal behaviors associated with sleep. вЂў Somnambulism Episodic sleepwalking in stages III + IV NREM and 2 hours after falling asleep. вЂў Sleeptalking Occurs during NREM sleep. вЂў Nocturnal enuresis Bedwetting common in male children > 3 years of age, when arousing from stage III to stage IV NREM sleep. вЂў Nocturnal erections Start around adolescence and occur during REM sleep. вЂў Bruxism Clenching and grinding teeth during stage II NREM. Sleep deprivation REM sleep deprivation, caused by alcohol, shift work, jet lag, extended ICU hospitalizations. REM sleep deprivation has same causes as well as hypothroididm, depression, sleep apnea and age. 115 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Sleep improving factors Adjustment of environmental factors, bedtime routines, comfort promotion, activity promotion (exercise reduces stress), medications should be last resort and used on a short term basis. -Urinary elimination needs- Normal urine output is 1500 ml/d, 30 - 60 ml / hr. Characteristics of normal urine specimens (MSU): вЂў Contains 96 % water as well as urea, ammonia, uric acid, creatinine, inorganic solutes sodium, chloride, potassium, sulfate, magnesium, phosphorus. вЂў Sterile (no bacteria included) вЂў pH 4.5 вЂ“ 8 (normal H+ ion concentration in plasma and extracellular space). вЂў Specific Gravity 1.010 вЂ“ 1.025 (reflects normal concentration ability of kidneys) вЂў Glucose not present (presence indicates Diabetes, Blood Glucose > 180 mg/dl) вЂў Ketone bodies not present. (traces of breakdown of fat cells, indicates fasting or in higher concentrations poorly controlled Diabetes) вЂў Blood if present indicates inflammation, uti,damage of glomerular membranes. вЂў Aromatic odor Protein are not present in normal urine specimens. ! Traces of protein may occur as orthostatic proteinuria in tall slim people. Larger amounts of proteins, esp. Microalbumin indicates damage of glomerular membranes. ! Abnormal urination symptoms: Urgency strong unavoidable desire to void Dysuria painful voiding normal once / 3 вЂ“ 6 hours Frequency Hesitancy delay in initiating urination large volume per urination Polyuria Oliguria 100 = 500ml / 24 hr excessive and sleep interrupting urination. Nocturia Hematuria RBCвЂ™s in Urine Common urinary elimination problems Urinary retention (i.e. in cases of BPH syndrome,Urethra strictures, neoplasms, medications: anticholinergic, antidepressants, antipsychotics, antiparkinsonian and antihypertensives) Urinary tract infections Incontinence: involuntary urination Urine and urinary tract examinations Urine culture / Antibiogramm To assess number and type of bacteria and their sensitivity towards antibiotics in contaminated urine over 24 вЂ“ 72 hours. Intravenous pyelogram or urogram (IVP/IVU) Injection of radiopaque contrast media to assess kidneys, ureter and bladder. Renal Scan Radio traces or isotopes injected IV. Shows renal size, perfusion, function and position under scintillation camera. 116 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Ultrasound Imaging of the urinary system by reflected high frequency ultrasound waves. Cystoscopy Assessment of urethra and bladder via endoscopic magnifying tool with possibility to take biopsies. Bedside bladder scan Ultrasound examination tool to assess filling of bladder. Health Promotion for urinary elimination Adequate hydration of minimum 1500mL / d, proper personal hygiene, emptying bladder completely (Kegel exercises), cotton briefs for women for UTI prevention, acidification of urine for UTI prevention (cranberry juice and vitamin C products), avoidance of excess intake of dairy products. -Bowel elimination needs- Infant and toddlers have immature control of bowel function. Daytime control should be present by 2 ВЅ years with toilet training. School age children may delay elimination. Older adults are prone to constipation. In general a regulated bowel function requires adequate amount of fibers and fluids and physical activity. Constipation may be caused by Codeine, Morphine, antipsychotic, antiparkinson, antidepressant medication and any medication with anticholinergic effect. Also after abdominal surgery and general anesthesia. Bowel function disorders Constipation, impaction, diarrhea, incontinence, flatulence and hemorrhoids. Diagnostic tests X-Ray Abdomen in standing or lying position (laying on left side), upper GI barium swallow barium enema, endoscopy (EGD = esophagogastroduodenoscop, colonoscopy, proctosgmoideoscopy). Bowel diversion ostomies Terminology considers part of diverted bowel segment. Commonly performed procedures are ileostomy, cecostomy, ascending colostomy, transverse, colostomy, descending colostomy and sigmoidostomy. Ostomies may be performed in a single, loop, divided, double or barreled form. Colostomy care Colostomies rather tend to obstruct than ilestomies due to a naturally increased thickness of the stool. Adequate colostomy care requires awareness for: Odor causing food: garlic, onions, fish, eggs, beans and asparagus Gas producing food: cabbage, onions and beans. Stool thickening food: yogurt, cheese, tapioca, applesauce and bananas Stool lossening food: spices, fruits, vegetables and dried food Ileostomy care Stool is typically soft and moist. Obstructions can be solved with warm fluids, warm showers, knee chest positioning and massaging of the peristomal area. Pouch has to be removed if stoma is swollen. Clients generally require a low residue diet, limit high fiber foods. Clients with ileostomies tend to have a limited ability to digest due to a deficiency of bile acids. 117 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com -Wound Care- Layers of Epidermis Epidermis: Five layers of squameous epithelial cells deriving from basal cell layers. Dermis: Elastic cells with nerves and blood vessels, glands and hair follicles Subcutaneous tissue: Adipose tissue that provides support and blood flow to epidermis. Skin glands: sebaceous glands, soporiferous glands, cerumenous glands and secreting earwax. Wounds Break in skin or mucous membranes due to physical means. May be superficial and affecting the skin surface only or deep, involving blood vessels, nerves, fascia, tendons, ligaments and bones. b Classifications of wounds 1. Open wounds e. g. cut, lacerations, abrasions 2. Closed wounds e. g. contusion or ecchymosis 3. Full thickness burn or injury that reaches until subcutaneous tissue 4. Partial thickness burn or injury reaches epidermis and dermis 5. Noninfected / infected 6. Surgical wounds Pressure ulcers Skin lesion by unrelieved pressure. Caused by immobility, cachexia, moisture, friction, shearing, dry skin. 118 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Norton and Braden Scale for assessment of Pressure ulcer Risk Stage 1: skin intact, erythema possible, tingling or burning sensations, edema, Induration, hardness as indicators. Stage 2: superficial partial thicknes skin loss, blister, abrasionlike appearance Stage 3: full thickness skin loss, extending to fascia, Stage 4: damage beyond fascia, affection muscles, bones, tendons,\. May also build Fistulas. Phases of wound healing 1. Inflammatory phase RBC and proteines build fibers of fibrin. Increased blood perfusion of the area to assure adequate nutritional supply. Healing ends with a scab from fibrin and other proteins. Skin heals in 3 вЂ“ 4 days. 2. Proliferative phase Fibroblasts grow to form granulation tissue with new capillaries and epithelial cells. Connective tissue builds scar tissue. Excession build up of granulation tissue forms keloid. 3. Maturation / remodeling phase Weeks вЂ“ years of reorganization of collagen fibers, wound remodeling, tissue maturation. Factors affecting wound healing Age, nutrition (Vitamin C!, Proteines), Condition of injured tissue (Grade of destruction, contamination), efficiency of circulation, rest, anxiety, stress, medications. (Immunosuppressant, Cyclooxigenase inhibitors) Wound closure is either caused by primary intention (surgical repair) or by secondary intention ( scarring)! Dehiscence and Evisceration of tissues require urgent surgical repair! Wound assessment Signs of infection Redness, swelling, increased tenderness, temperature, WBC, disruption of wound edges. Treatment with wound cleaning Saline вЂ“ or diluted antimicrobial solutions. Gauze squares. Dressing types Gauze Sterile, nonsterile, antimicrobial, absorbs drainage Transparent Impermeable to bacteria and fluids, supporting autolytic debridement Composite dressing Absorbent and adhesive cover. May only require 3 changes weekly. Hydrocolloids вЂ“ Adhesives made of gelatine. Occlusive to microorganisms. Enhances autolysis of wound bed. Hydrogel Water or glycerine is primary component. Maintains moist, oxygenated surface. 119 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Calcium alginates Made of seaweed fibers to absorb larger amounts of drainage. Exudate absorbers Semiperneable polyurethane foam that absorb large amounts of exsudatives while keeping wound moist. -Monitoring of Tubes and Drains- Tracheostomy Surgically created opening in the cricothyroideum ligament between cricothyroideus cartilage and 1st tracheal cartilage. May be temporary or permanent. (Jackson tube) Variations include double or single lumen (with or without inner cannula),cuffed or cuffless, fenestrated and not fenestrated. Any procedures performed on a trachestoma require that there is a manual resuscitation bag available at all times. Replacement tracheotomy set has to be in reach in case tracheostoma is accidentialy removed and fistula opening collapses! Tracheostomy care 1. Respiratory assessments 4 hourly. 2. Suctioning prn. 3. Frequent assessment for signs of infection. 4. Tracheostomy care required every 8 hours including assessment of cuff pressure. 5. Change of tracheostomy ties daily, if soild. Change requires to have tracheostomy held in place by assistant during the procedure since patient may cough and accidentially loose it. Ensure alternate communication with patient if tracheostomy has a cuff inflation. Accidental removal of a tracheostomy tube is a medical emergency, especially if trach was inserted within the last 72 hours! Management of accidential tracheostoma tube removal hold stoma open by grasping retention sutures or using curved clamp insert obturator, insert tube, remove obturator, if problems occur call rapid response team. Long Term complications of Tracheostomy Tracheomalacia Tracheoesophagel fistula Tracheal stenosis through scar tissue Tracheal innominate artery fistula (Life threatening condition) Endotracheal tube Required for mechanical ventilation up to 14 days. Orotracheal or nasotracheal insertion. Assessment of correct placement of an endotracheal tube Ventilation with manual resuscitation bag and auscultation of epigastric area. Use of CO2 analyzer Portable Chest X-Ray (tip of tube to be placed to 1вЂ“2 cm above bifurcation (carina)) Respiratory assessments 4 hourly 120 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Suctioning prn Oral care 2 hourly Reposition tube daily Inflating cuff by minimal leak technique or minimal occluding volume technique Removal of airway tube 1. Suction trachea, 2. Adjust client to semiвЂ“fowlers or fowlers position 3. Deflate cuff 4. Remove tube at peak inspiration 5. Close monitoring for 30 minutes 6. Expect sore throat and hoarseness Closed Chest Systems Chest tubes are placed to remove air or fluids from pleural cavity by producing a vaccuum. Commonly a 3 Chamber system with water seal (vacccum), suction and collection. Management of closed chest systems: 1. All tubing connections have to be secured from dislocating with tape. 2. Collector needs to be positioned below chest. 3. Milking of the chest tube can cause organ damage. 4. Clamping of chest tube requires Physicians order. 5. No clamping when patient is mobile. Clamp must be in reach at all times. 6. Monitor drainage 1 вЂ“ 4 hourly. 7. Maintain вЂ“ 2cm water level suctioning. 8. Water level must fluctuate. 9. Continuous water bubbles indicate leak in the system. 10. Light permanent bubbling in the suction control chamber is to be expected. 11. Intermittent inspiratory water bubbles in a Pneumothoax indicate normal function. 12. Reposition client twice hourly. 13. Encourage deep breathing, and coughing. 14. Daily Chest X Ray may be necessary. 15. In accidential dislocation or damage of system insert chest tube into sterile water to maintain water seal, then replace system. 16. Accidential removal of chest tube requires immediate cover, closure of insertion wound and surgeon to be contacted. Scheduled Removal under Valsalva maneuver. Renal and urinary tract tubes Nephrostomy or ureteral tube Minimum output is 30 mL/hour. Drainage should occur at least every 15 minutes. Irrigate only if ordered with 5 ml sterile saline under sterile precautions. Action necessary if irrigation does not restore tube. Indwelling urinary catheter Specifications: Retraction foreskin in men while cleaning with soap and warm water. Repositioning after removal mandatory. Remove during exhalation. 121 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Nasogastric tubes Salem tube (common) = double lumen allows continuous suction. Levin tube (less common) intermittent suction only otherwise tube collapses. Insertion of a nasogastric tube Position client upright in Fowlers position. Measure distance tip of nose вЂ“ earlobe вЂ“ xiphoid process and mark with tape on tube. Lubricate tip with lidocaine gel or water soluble gel. Insert slowly while client swallows small sips of water. Coughing, choking indicates tracheal insertion Fixate when end of insertion is reached. Confirm placement by injecting air and auscultation of epigstric area. Chest X вЂ“ Ray prior to use with food and fluids (most reliable). Aspiring fluids for pH testing every 4 hours. (should be 4 or less in correct placement. Higher pH indicates intestina placement) Be aware of increased mouth dryness since client needs to inhale though mouth. Nasoenteric - (intestinal) tubes Miller вЂ“ Abbott or Cantor tube with tungsden weight at the terminal end. Tube forwards through peristaltic and gravity, may take hours to reach desired position. Requires X-Ray to confirm correct position. Positioning of client with head of bed elevated, laying on right side. Combined esophageal and gastric tubes Sengstaken-Blakemore tube 3-lumen tube for treatment of bleeding esophageal varicosis. Gastric and esophageal balloons with 25 вЂ“ 45 mmHg pressure. Intermittent suction tube. Needs to be maintained under traction. Can not be used if patient has esophagus lesion on history. Minnessota tube Additional 4th lumen for suctioning fluids from esophagopharyngeal area. Scissors have to be available at bedside at all times to cut tubes rapidly in case of respiratory distress. Risk of ongoing bleeding and esophagus rupture. Gastric Lavage tubes For removal of indigested toxins from stomach. 1. Ewald tube: Single lumen for one time use. 2. Lavacuator tube: Two lumen, for irrigation and suction. Unconcious clients are generally at increased risk for aspiration! Under these conditions gastric lavage tubes can only be inserted after endotracheal intubation! Wound drains Closed wound drainage system Commonly used are Jackson вЂ“ Pratt Drain, Hemovac Drain under electric or mechanical device suction. Collection chamber needs to be squeezed to reestablish suction after emptying the system. x x 122 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Penrose drain In cases of excessive serosanguineous drainage. Inserted via stab wound a few inches from surgical incision. Drains onto gauzes, lightly dressed, secured by suture. Usually removed after 3 вЂ“ 4 days. -Fluid and Electrolyte imbalances- Definitions: Intracellular space (ICS) Contains intracellular fluids which represents > 2/3 of body fluids. Extracellular space (ECS) Intravascular space and intercellular space. Constant fluid and electrolyte exchange between ics and ecs occurs by osmosis. Osmosis Shift of fuids and small particles from compartments of lower concentrations to compartments of higher concentrations through a semipermeable membrane until the concentrations of both solutions are equalized. Concentrations of solutions are defined by Osmolality and osmolarity which are determining the osmotic pressure of a fluid within a compartment. Characterizing the strength of a solution to draft water from another fluid filled compartment. Osmolarity (per liters of fluid) osmolality (per kilograms of fluid) = osmotic pressure = water intake Osmolarity and osmolality are of equal size if the solvent solution is water (1 liter = 1 kilogram). The osmolality of serum is 275 вЂ“ 295 mOsm/L. Isotonic solutions have eqal osmolarity as serum (e.g. 0,9 % NaCl, Ringers Solution, D5W) and remain in the extracellular space. Hypotonic solutions have lower osmolarity than plasma and get shifted as free water into the intracellular. (e.g. 0.45 % NaCl, 0,225 % NaCl) Hypertonic solutions have a higher osmolarity than plasma and remain in ecs to draft water from cells (e. g. 10 вЂ“ 50 % dextrose, 3 вЂ“ 5 % NaCl, 5 % dextrose + hypotonic sodium chloride solutions). Diffusion Shifting of particles (e. g. electrolytes) from solutions of higher concentrations to solutions of lower concentrations through a semipermeable membrane. Forces to facilitate movement of fluid through capillaries: Hydrostatic pressure is created in the vascular capillary system and in interstitial system by amount of intravascular fluids, cardial output and blood pressure. Oncotic pressure or colloidosmotic pressure Exists in the capillary and intersititial system. Colloids are large particles (proteines) that remain in the intravascular system and draft water into ecs) Deficiency of colloids leads to fluid loss into the third space. (e. g. Kwashiorkor, Ascites) Hydrostatic and oncotic pressure in the interstitial space are normally lower than in ecs to allow fluids to shift into the interstitial system. 123 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Hormonal regulation of the fluid and electrolyte distribution Antidiuretic Hormone ADH Increases renal water reuptake. Synthesized in hypothalamus released from the posterior lobe of the pituitary gland. ADH deficiency leads to Diabetes insipidus. Aldosterone Increases renal natrium and water reuptake and potassium excretion. Produced and excreted by adrenal glands. Activated by activation of Renin - Angiotensin System RAA once blood pressure decreases. ADH and Aldosterone release activates thirst if changes on plasma concentrations are noticed in hypothalamus. Corticosteroids Promote natrium and fluid retention in kidneys. Produced and excreted by adrenal glands. Further physiologic effects of corticosteroids include hyperglycemia, increase of blood pressure, thrombocytosis and leucopenia. ANP(F) Atrial natriuretic peptide (factor) induce reduction of blood pressure, increase of GFR, inhibition of RAA - system and ADH secretion. Cardiac hormone released by cardiac overload. Average physiological daily fluid losses: Renal 1500 ml/day Skin (perspiration, sweat) 500ml/day Lungs 350ml/day Feces 150mL/day = 2500 mL/day Dehydration conditions in regards to changes of the ECF: Isotonic Dehydration Most common due to loss of ECF. (e. g. bleedings) Hypertonic Dehydration Fluid loss requires shifting of electrolytes to recompensate ECF. Typical for any condition that mainly leads to fluid loss (e. g. sweats). Hypotonic dehydration Fluid loss is recompensated by fluid shift from ICS only. Typical for chronic ongoing fluid loss i.e. due to a chronic illness with loss of proteins (e. g. Ascites). Fluid loss into the third space Effusions of pleural space, pericard, abdomen and peripheral edema. Fluid loss into the third space is caused by any condition that leads to a loss of proteins which keeps the colloidosmotic pressure stable (e.g. trauma, burns, ulcers, sepsis, abdominal surgery, cancer, malnutrition, liver failure). Or any condition that leads to an increased vascular hydrostatic pressure due to a fluid overload that overcomes the colloidosmotic pressure (e. g. heart and renal failure). 124 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Signs and symptoms of Dehydration вЂў вЂў Reduced urine output: < 2mL / kg / hour (children) < 30 mL / kg / hour (adults) вЂў Urine specific gravity > 1.035 вЂў Serum osmolality > 300mOsmol/kg вЂў BUN,HCT,Creatinine вЂў Hypernatremia > 150 mEq/mL вЂў Dry skin and mucous membranes вЂў Sunken eyeballs вЂў Hypotension вЂў Flattened peripheral veins вЂў Hypotension вЂў Tachycardia вЂў Desorientation вЂў Neurologic defincincies (TIA, PRIND) Weight loss (Scaling more realiable than I&O) Fluid Volume Excess (FVE) Isotonic FVE due to renal failure, heart failure, excess fluid intake, high corticosteroid and aldosteron levels. Hypotonic FVE due to medical procedures (e. g. rinsing during endoscopic examinations), excessive intake of hypotonic fluids and syndrome of inadequate ADH secretion (SIADH). Hypertonic FVE due to excessive salt intake. Symptoms of fluid volume excess Edema, Bulging fontanels, CVP , pulmonary edema, fluid loss into third spaces, weight gain, HCT , BUN , Serum Osmolality < 275mOsm/kg, Serum Sodium < 125 mEq/L Treatment: Increase of diuretic activity, puncture of third spaces and restriction of fluid intake. Elecrolyte imbalances Hyponatremia Sodium < 135 mEq/L Main causes are fluid excess and hemodilution as well as sodium losses through burns, trauma, surgery, open wounds. Symptoms and diagnostic findings: Symptoms are equivalent to FVE symptoms. Also neuromuscular dysfunction, agitation, weakness, headache, confusion, seizures, lethargy, dizziness, gastrointestinal nausea, vomiting, diarrhea, cramps. Treatment: Treatment of underlying cause. Diuretics or sodium supplementation as required. Hypernatremia Sodium > 145mEq/L Sodium excess can occur in any volemic filling stade but occurs most commonly in dehydration. вЂњNatrium (sodium) always follows the water!вЂќ Symptoms and diagnostic findings: Symptoms are similar to symptoms in a dehydration stade. Tachycardia, hypertension, 125 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com dry skin and mucous membranes, increased urine output, diarrhea, neuromuscular contractions, muscle fasciculations, tremor, hyperreflexia, halluzinations. Hypernatremia can also be induced by a sodium rich diet although this appears to be a rare cause. Symptoms and diagnostic findings: Salt restrictions from 3g to 0,5 g/day, loop diuretics and fluid supply. Hypokalemia Serum Potassium < 3,5 mEq/L Caused by hyperaldosteronism, adrenal adenoma, cirrhosis of the liver, heart failure, hypertensive crisis, CushingвЂ™s syndrome, diabetes insipidus and renal dysfunction. Also possible side effect of medication therapy with loop and thiazide diuretics, corticosteroids, cardiac glycosides, penicillines, amphotericin B, gentamycin, theophyllin and tocolytic medications. Physical conditions leading to hypokalemia are vomiting and diarrhea, ileostoma, colon adenoma, laxatives, enema, sweating (Diaphoresis), dialysis, and potassium restricted diets. Symptoms and diagnostic findings: ECG: ST-Segment depression, flattened T-Wave, U Wave phenomenon, dysrhytmias, Increased Digitalis intoxicity, shallow, weak, breathing, polyuria, nocturia, urine specific gravity , anxiety, depression, confusion. Treatment: Treatment of underlying causes. Supply of Potassium under constant monitoring of serum potassium levels. Minimum urine output for supply is 0,5 mL/kg/hour. Maximum infusion rate for parenteral supply is 10mEq / hour. Potassium is to be diluted in a concentration of max. 1 mEq/10mL Higher dosages require constant ECG monitoring. Paravasation causes tissue damage. Phlebitis, veinous irritation possible. Gastric irritations possible due to oral supply, therefore supplementation after meals required. Potassium Food sources: Bananas, apricots, raisins, oranges, spinach, broccoli, green beans, carrots, tomato juice, potatoes, dairy products, meat, nuts, whole grains and legumes. Hyperkalemia Serum Potassium > 5,1 mEq/L Causes are excessive consumption of potassium rich food, decreased K+ excretion (M. Addison, renal failure, potassium sparing diuretics, ACE - inhibitors (stop aldosterone secretion), excessive hemolysis or tissue damage (K+ is mainly concentrated in the ICS), metabolic acidosis, insulin deficiency, digoxin use, blood transfusions. Symptoms and diagnostic findings: ECG: peaked T Waves, widened QRS complexes, prolonged PR Intervals, flattened P Waves, heart rhythm disorder including asystolia. Hypotension, bradycardia, respiratory failure due to generalized muscular weakness, muscular fascilations, twitching, anxiety, cramps, irritability, diarrhea and nausea. Treatment: Decrease of potassium supply and increase potassium output due to Diuretics or Insulin вЂ“ Dextrose 50/50 per infusion, Calcium Gluconate IV, Sodium bicarbonate IV. x x X x 126 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Hypocalcemia Serum calcium < 8,5 mg/dL = < Causes are dietary calcium deficiency and avoidance of dairy products. Excessive intake of oxalates which limit the intestinal calcium absorption. Post thyroidectomy/ parathroidectomy, hypoparathyroidism, crohnвЂ™s disease, laxatives, excessive use of phosphorous supplements, hypomagnesemia, blood transfusions and blood products. Diuretics, hypoalbuminemia, vitamin D deficiency, renal diseases, sepsis, burns, massive trauma, pancreatitis, corticosteroids, contrast media, biphosphonates, antacids, anticonvulsants and heparine. Symptoms and diagnostic findings: ECG: QT вЂ“ and ST - segment prolongation and cardiac arrest. Hypotension, laryngospasm, paresthesias, muscle spasm, tetany, ChvostekвЂ™s sign positive, Trousseaus sign positive, hyperreflexia, depression, amnesia, delusion, hallucinations, convulsions, diarrhea, abdominal cramping, cataracts, brittle nails and hair, increased vulnerability for fractures and bleedings. Treatment: Ca supply, treatment of underlying cause, Ca-Gluconate, Ca-Chloride, IV infusion or emergency push, oral dosages 1,0 вЂ“ 3,0 grams / day, calcitriol, vitamin D, phosphorous binding agent based on need, thiazide diuretics. Special monitoring under Ca вЂ“ supply if client is under digitalis effect because of enhanced cardiac output and contractility ! Temporary Hypocalcemia due to an induced respiratory alkalosis in a hyperventilation will be treated with sedation, verbal intervention and CO2 breathing only! Glycoside treatment under unregulated calcium and potassium levels Hypokalemia and hypercalcemia increase the toxicity of Glcosides ! (= Digoxin and Digitoxin) Hyperkalemia is rather leading to a cardiac arrest under treatment with Glycosides. As a consequence glycosides have to be withdrawn in these conditions. Hypercalcemia Serum calcium > 10,5 mg/dL = > Causes are osteolytic or other metastasis in cancer, hyperparathyroidism, hyperthyroidism, calcium rich diet (Milk alkali Synrome), sarkoidosis, thiazide diuretics, vitamin D intoxication, hypophosphatemia, lithium therapy and OTC antacids containing CaCarbonate. Symptoms and diagnostic findings: ECG: decreased ST segments, shortened QT interval, dysrhytmia, cardiac arrest. Hypertension, headache, confusion, psychotic symptoms, fatigue, increased DTRвЂ™s, amnesia, lethargy, coma, anorexia, nausea, vomiting, constipation, abdominal cramps, polyuria, polydipsia and kidney stones. Treatment: Calcium restriction, corticosteroids to limit intestinal absorption, loop diuretics, fluids 4000 mL/d, preferably high acidity juices (orange and cranberry). Parenteral fluid replacement with 0,9% NaCl in dehydration or 0,45 % if fluid volume is restored. Biphosphonates to limit Ca resorption from bone, calcitonin and dialysis. 127 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Hypomagnesemia Serum magnesium < 0,75 mmol/L Causes are alcoholism, prolonged parenteral nutrition, decreased absorption due to intestinal conditions, chronic inflammatory bowel diseases, pancreatitis, ileostomy, aminoglykosides, prolonged diarrhea, vomiting, burns and excessive trauma. Symptoms and diagnostic findings: Quite similar to hypocalcemia and hypokalemia ! Laryngeal Stridor. ECG alterations: P Wave deformation, inverted T waves, ST segment depression, Prolonged QT Interval, U waves, premature supraventricular and ventricular tachycardias вЂњTorsade des pointesвЂќ and ventricular fibrillations. Concurrent hypokalemia, increased digitalis toxicity, nausea, vomiting, anorexia, Chvostek sign, Increased DTR. DTR sensitivity is the most reliable sign to monitor the clinical improvement after supplemental magnesium therapy! Treatment: Oral replacement with Magnesium sulphate containing antacids, up to 350 mg daily. Whole grain products, cereals, nuts, green vegetable, seafood, bananas and oranges. Parenteral replacement requires at least 30ml urine output/hour. Hypermagnesemia Serum magnesium > 0,95 mmol/L Causes are decreased renal output due to renal failure, increased intake, (Antacids, enemas, parenteral nutrition), diabetic ketoacidosis, Addisons disease, lithium therapy and dehydration. Symptoms and diagnostic findings: Symptoms comparable to hyperkalemia, decreased DTR, decreased muscular tonus, hypotension, bradycardia and cardiac arrest. ECG: Peaked T Waves, widened QRS complexes, prolonged PR Intervals, flattened P Waves, heart rhythm disorder incl. asystolia and somnolence. Treatment: Limitation of Mg+ intake, diuretics, rehydration to increase urine production. Calcium gluconate intravenously is an emergency treatment in cases of cardiac and respiratory symptoms only! Concurrent shifts of electrolytes Magnesium, potassium, sodium and chloride deficiencies and overloads occur concurrently and predict each other! Hypochloremia Serum chloride < 98 mmol/L Causes are comparable to the causes of hyponatremia, hypokalemia and FVE since hypochloremia is mainly an accompanying symptom of both conditions and rarely occurring as a single finding. Other causes include increased chloride excretion in case of elevated bicarbonate levels during a respiratory acidosis in clients with COPD or other chronic pulmonary conditions leading to an increased pCO2. Diabetic ketoacidosis (increased anion gap) vomiting, diarrhea, trauma, high pitch fever, sweating, SIADH and AddisonвЂ™s syndrome. Symptoms and diagnostic findings: Muscular twitching, tremor, decreased breathing rate and hypotension. 128 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Treatment: NaCl or KCL supply (salt) , Cl- rich food are dairy products, eggs, seafood, processed and canned food. Treatment of underlying causes e.g. hypervolemia, ABG monitoring in case of acid base imbalance. Hyperchloremia Serum chloride > 106 mmol/L Causes are dehydration, hypernatremia, metabolic acidosis, NaCl supply, Diabetes insipidus, hyperaldosteronism and acute renal failure. Symptoms and diagnostic findings: Hyperventilation, dysrhythmia, accompanying hyperkalemia and hypernatremia, metabolic acidosis. Treatment: Limitation of Cl- intake, diuretics, rehydration w. hypotonic 0,45 % NaCl or D5W and correction of Acid Base imbalance. Hypophosphatemia Serum phosphorus < 2,5 mg/dL = < 0,81 mmol/l Causes are hypercalcemia, malnutrition, vitamin D deficiency, excessive use of Mg+ and Ca+ containing antacid medication due to complex building chemical reactions with phophorus, oxalate (e. g. spinach and rhubarb) or phytate (e. g. whole grains). Other causes are vomiting and diarrhea, ketoacidosis, alcoholism, hyperparathyroidism, diuretics, renal failure, hypomagnesemia, hypokalemia, glykolysis (moves phophorus into cells) respiratory alkalosis and total parenteral nutrition. Symptoms and diagnostic findings: Hemolysis (increased instability of Erythrocytes), Granulocyte dysfunction (immunosuppression), paresthesia, tremors, spasms, tetany, confusion, seizures, dysrhythmias, heart failure, shock, muscular hypoventilation, respiratory acidosis, respiratory failure due to muscular weakness and reduced gastrointestinal motility. Treatment: Oral or parenteral supplement. Phosphorus rich food (e. g. meat, dairy products, legumes and nuts) Avoiding calcium or magnesium containing antacids. Monitoring of muscular strength (hand grasps). Monitoring of neurological status. Parenteral nutrition generally requires phosphorus supply! Hyperphosphatemia Serum phosphorus > 4.5 mg/dL = > 1,45 mmol/l Causes are dietary reasons, renal failure, hypocalcemia, hypoparathyroidism (= low calcium), Vitamin D excess, blood transfusions and rhabdomyolysis.b Symptoms and diagnostic findings: Symptoms are determined by corresponding decreased Ca levels. (Hypocalcemia) Calcification of soft tissues and organs (e. g. kidneys) and constipation. Treatment: Phosphorus restriction, phosphate binding agents, calcium supply, fluid supply, antacids and stool softeners Calcium and phosphate shifts always occurs in opposite directions. e.g. Hypercalcemia = Hypophophatemia - Acid вЂ“ Base Imbalances - Definitions: Acid = releases all H+ Ions in dilution with water. Weak acids only release some H+ Ions. Base = binds fast to H+ Ions if diluted in water. Weak base reacts delayed with H+ Ions. Buffer = stabilizes pH between 7.35 вЂ“ 7.45 by either adding or releasing H+ Ions 129 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Physiological buffer exist in all tissues and compartments: вЂў вЂў вЂў вЂў Protein buffers Phosphate buffers Hemoglobin вЂ“ oxyhemoglobin system buffer Bicarbonate NaHCO3- (=renal) + carbonic acid H2CO3 (= respiratory) buffer The bicarbonate and carbonic acid buffer system The average ratio between NaHCO3 and H2CO3 is 20 : 1 ratio if pH is in normal range. All buffer systems can be activated by pH alterations of renal and respiratory causes. H2CO3 can be utilized by respiratory system for dissociation into carbondioxide CO2 for exhalation and water. HCO3 - will be excreted or retains H+ Ions from kidneys: = CO2 + H2O H2CO3 HCO3- + H+. Pulmonary pH regulation: Quick onset but not longlasting. Hypoventilation creates CO2 increase = respiratory acidosis Hyperventilation creates CO2 decrease = resp. Alkalosis Renal pH regulation: Slow onset but longlasting. Ecxretion of acidic or alkaline urine. Reuptake or diuresis of H+ amount regulates amount of HCO3- available as well as reaction between ammonia (NaH3) and hydrochloric acid (HCl) to build ammonium chloride (NH4Cl-) for excretion via urine. A metabolic pH dyregulation is primarily regulated by resiratory system. A respiratory pH dysregulation is primarily regulated by metabolic system. Monitoring of acid base status pH = negative logarithm of H+ ion concentration in mEq/ml Physiological pH range 7,35 вЂ“ 7,45 high pH = low H+ concentration, low pH = high H+ concentration Acidosis = pH < 7,35 = CNS depression ; Alkalosis = pH > 7,45 = CNS excitation PaCO2 = 35 вЂ“ 45 mmHg (partial pressure of carbon dioxide in plasma) < 35 mmHg = respiratory alkalosis = Hyperventilation > 45 mmHg = respiratory acidosis = Hypoventilation andprolonged exspiration (e.g. COPD) HCO3- = 22-26 mEq/L < 22 mEq/L = Acidosis > 26 mEq/L = Alkalosis Base excess (BE) = - 3.0 - + 3.0 (available amount of HCO3- available in ECF) > + 3.0 = metabolic alkalosis < -3.0 = metabolic acidosis Serum anion gap (AG) = 10-12 mEq/L = Na + - (Cl- + HCO3-) > 12 mEq = metabolic acidosis < 10 mEq = metabolic alkalosis 130 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com PaO2 = 80-100 mmHg (partial pressure of oxygen in plasma) SaO2 = (percentage of hemoglobin saturation with O2 ) Acidosis decreases affinity of oxygen to hemoglobin and eases its release to the peripheral tissues. = right shift of oxygen dissociation curve Alkalosis increases affinity of oxygen to hemoglobin which results in a tighter oxygen binding to hemoglobin = left shift of oxygen dissociation curve K+ ions exchange with H+ ions in case of alkalosis and acidosis In acidosis K+ shifts to ECF and H+ to ICF In Alkalosis K+ shifts to ICF and H+ to ECF Analyzing an ABG Deciding parameters 1. pH 2. pCO2 3. HCO3Interpretation: Primary imbalance always matches the direction of change of the pH! Secondary imbalance shows compensating mechanism. pCO2 and HCO3- never show acidosis or alkalosis simultaneously! Aquiring an ABG specimen from a radial artery Vital signs Allen Test Heparinized syringe Ice in collection bag Labeling Note Temp, O2 Sat, ventilator settings, clients activity Aquire sample Pressure on punctured site Immediate testing of sample required b Respiratory acidosis Causes: CO2 retention due to hypoventilation > 45 mmHg. pH decrease < 7.35 Symptoms and diagnostic findings: Hypotension, tachycardia, delayed cardiac conduction, decreased cardiac output, warm red skin, dyspnea, muscle twitching, confusion, decreased level of consciousness, hyperkalemia. Compensation: Increased breathing activity, H+ elimination and HCO3- retention in kidneys. Treatment: Any procedure that improves ventilation. Upright positioning. Medication as required to treat underlying causes (i. e. Bronchodilators). The breathing activity of the respiratory system is stimulated by the PaCO2 levels and not by oxygene levels. Therefore the oxygene supply to clients with chronic obstructive diseases can lead to a decreased repiratory stimulation and respiratory failure and has to be administered slowly and in low doses. 131 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Respiratory alkalosis Causes: pH > 7,45, paCO2 < 35 mmHg, caused by hyperventilation Symptoms and diagnostic findings: Heart rate , palpitations, hyperventilation, tetany, tingling sensations in extremities, convulsions, anxiety attack, hypokalemia, hypocalcemia, urine pH > 6 due to HCO3excretion, HCO3- , Renal H+ retention. Treatment: Rebreather mask, calm approach to client, oxygen as required, monitoring. Metabolic acidosis Causes: pH < 7,35, HCO3- < 22. Loss of HCO3- , Accumulation of acids in ECF due to starvation, diabetic ketoacidosis, malnutrition, prolonged diarrhea, sepsis, shock and trauma. Symptoms and diagnostic findings: Abdominal pain, signs of shock with peripheral vasodilation, hypotension, dysrhythmias, cold, clammy skin, deep rapid KussmaulвЂ™s breathing to release CO2, confusion, drowsiness, hyperkalemia, BE decrease, AG increases, Renal HCO3- retention leading to acidic urine pH < 6. Cardial conduction disturbances leading to dysrhythmias. Treatment: Treatment of underlyibg cause, fluid supply, alkalotic IV fluids (NaHCO3-, Cl-HCO3-) carefully and slowly, to restore reduced HCO3- levels below 18mEq/L. Monitoring of ABG, I&O, vital signs, LOC and electrolytes. Metabolic alkalosis Causes: pH > 7,45, HCO3- > 26 mEq/L, loss of H+ ions due to prolonged vomiting, indigestion of alkalotic antacids (e.g. calciumbicarbonate).n Assessments: Tachycardia, hypertension, dysrhytmias, hypoventilation to increase pCO2 may lead to respiratory failure, agitation, tremor, muscle twitching, tetany, hyperreflexia, seizures, paresthesia, hypokalemia, hypomagnesaemia, hypocalcemia (increase of pH increases Ca binding affinity), nausea and vomiting, paralytic ileus, increased renal HCO3excretion and urine pH > 6. Treatment: Supply of Cl- to enhance renal absorption of Na and excretion of HCO3- rehydration and potassium supply. Ranitidine, Famotidine Antacids to reduce secretion of H+ ions from gastrointestinal tract. Acetazolamide to increase renal HCO3- excretion. Supply of deficient electrolytes. Acidosis causes CNS depression, alkalosis stimulates the CNS ! Digitalis toxicity increases in alkalosis, hypokalemia and hypocalcemia! 132 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com -Applied PharmacologyDosage calculation and medication administration General considerations Generic names: Reflect chemical substance of a drug and do not change by manufacturer. Brand names (trade name): Proprietary name given by manufacturer. Any medication order has to be handwritten, signed and dated. Always assure correctness of illegibly written prescriptions by calling prescriber. Nurses are responsible for their own actions by law. Telephone orders must be co-signed asap. Verbal orders are only acceptable in an emergency situation. Pharmacokinetic movements Absorption, Uptake from medication from digestive tract into the bloodstream. Distribution Movement to the specific organs where medication takes effect. Metabolism Enzymatic fragmentation of a drug into molecules (metabolites) with less effect which are soluble for excretion through the biliary and urinary system. Excretion Elimination of metabolites. Principles and process of medication administration Checklist 1. Orders have to be complete, accurate and legibly written. 2. Allergies against prescribed medication have to be ruled out. 3. Clients condition needs to correspond with order? 4. Awareness of: вЂў Interactions with other medications вЂў Side effects вЂў Adverse effects вЂў Toxic effects 5. Calculation of dosage, if necessary 6. Check of expiration date 7. Labeling of medications 8. Discarding any partially used single dose containers at the end of the day Six rights of administering medication: 1. Right drug 2. Right dose 3. Right route 4. Right time 5. Right Client 6. Right documentation Do not administer medication if client is questioning correctness ! 133 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Dosage calculation medication administration Metric system Uses gram for a unit of weight and liter for an unit of liquid volume. Conversion within the metric system From a lower to the next larger unit of measure move decimal point three places to the right. e. g. 1.5 grams 1500 miligrams From a larger to the lower unit of measure move three places to the left e. g. 1000 ml 1.0 Liter Dosage calculation schemes Formula 1 вЂњDesired over haveвЂќ Dose ordered (desired) x Amount available = Amount to give Dose on hand (have) Example: Metoclopramide 15 mg is ordered, Medication is available in 10 mg/2mL 15 mg x 2 mL = 3 mg 10 mg Formula 2: Ratio and Proportion Step 1: Dose ordered (desired) = ____Dose required ____ Dose on hand (have) Amount available (have) 15 mg 10 mg = X_ 2 Step 2: Result of left Division x Amount available = Amount to have 1.5 mg x 2 = 3mg x = 3 Formula 3: Dimensional Analysis Equation: X = Amount available x Dose on hand Dose ordered X = __20__ 15 X=3 Each of these formulas works for all dosage calculation operations. Use the formula which is best for you ! Identification of extended length oral medication by additional abbreviations CR, (controlled release), CRT (controlled release tablet), LA (long acting), SA (sustained action), SR (sustained release), TR (time release) XL, XR (extended length of release) Do not crush extended length oral medication ! x x x x x 134 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Enterally administered medications For tube feeding purposes stop tube feeding 30 вЂ“ 60 minutes prior and after administering medication. Administer one medication after another. Flush tube with 30 mL water after each single dosage. Discontinue any suction for 30 minutes after administration. Maintain client for at least 30 minutes in a semi fowlers position. Injections Checklist 1. Withdrawing medication from an ampulle 2. Tap neck to move solution downwards 3. Break ampulle with a pad at marked area 4. Hold ampulle by the bottom 5. Insert filter needle 6. Dislodge air in syringe 7. Eject air in syringe 8. Recheck amount of medication in Syringe 9. Replace with appropriate injection needle Withdrawing medication from a vial Checklist Remove vial cap Cleanse rubber top with alcohol Take syringe with needle or needleless syringe Inject amount of air to be withdrawn from medication above surface of medication Invert vial and withdraw medication Only touch vial barrel and plunger Remove air while syringe is attached to vial Remove syringe once filled with desired amount of medication nn Sites, Syringes and Needles for injections Intradermal injections Used for antigen and skin testing from inner aspect of forearm or scapular area, upper chest, medial thigh. 25 вЂ“ 27 gauge needle, 10 вЂ“ 15 degree angle. Subcutaneous injections Used for slow or sustained absorption from abdomen, lateral and posterior aspects of upper arm and thigh, scapular area of back, upper ventrodorsal glutaeal area, 25 gauge needle , 45 вЂ“ 90 degree angle, depending if tissue can be grasped or not grasped. Intramuscular injections Used for rapid absorption. VentroвЂ“and dorsogluteal injections, deltoideus, vastus lateralis for children < 7 months. Inject at 90 degree angle. Modes and sites of intramuscular injections Anteroglutaeal Patient lies on one side. Use right hand for left hip or left hand for right hip. Place palm over Trochanter major. Index finger pointing to anterior superior spine of the iliac crest. Spread other finger to form a вЂњVвЂќ. Inject in 90 degree angle into the вЂњVвЂќ. 135 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Dorsogluteal Side lying position, upper knee flexed in front of lower knee. Imiginary line between greater trochanter and posterior superior spine of the iliac crest. Inject in 90 degree angle lateral and superior to this line. Vastus lateralis Place client in supine position. Antero lateral middle third of thigh between greater Trochanter and lateral femoral condyle. Inject in 90 degree angle. Deltoid 2 inches below acromion. Inject in 90 degree angle. Z-track injection Displacement of skin prior intramuscular injection to reduce loss of medication into subcutaneous tissue. Push i. v. = Bolus i. v. Injections Medication has to be injected within one minute or within the adequate injection time for the particular substance. вЂњHOW TOвЂ¦вЂќ inject IV Bolus (IV push) 1. Prepare 1 Syringe with medication, 2 Syringes with physiological saline to flush. 2. Wash hands, use gloves. 3. Clean infusion port with alcohol swab for 30 seconds. 4. Administer IV saline through needle less IV access device to flush system. 5. Administer IV Medication in recommended IV push rate. 6. Flush IV access device again. n If client has a running infusion: Stop IV Infusion while performing a bolus injection. вЂњHOW TOвЂ¦вЂќ administer a вЂњPiggybackвЂќ Infusion without interrupting an IV infusion 1. Ensure compatibility of medication that is about to be added with currently infused medications. 2. Hang existing infusion lower than вЂњPiggybackвЂќ. 3. Clean infusion port with alcohol swab for 30 seconds. 4. Connect second infusion to preexisting system. вЂњHOW TOвЂ¦вЂќ 1. 2. 3. 4. Topical medications Apply creames and ointments Use gloves after washing hands. Remove remaining topical medication from previous applications. Apply substances from container to skin using tongue depressors. вЂњHOW TOвЂ¦вЂќ Apply transdermal patches 1. Remove a previously applied patch. 2. Cleanse skin. 3. Place new patch, possibly on opposite site if indicated. 4. Record date and time of application. 136 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂњHOW TOвЂ¦вЂќ Apply nasal medications 1. 2. 3. 4. Use gloves after washing hands. Client to blow nose and bend neck lightly backwards. Occlude one nostrile. Client takes a deep breath. вЂњHOW TOвЂ¦вЂќ Apply eye drops 1. 2. 3. 4. 5. Client to extend slightly backwards. Eyedropper to be placed ВЅ - Вѕ inch above eyeball. Pull lower eyelid gently downwards to open conjunctival sack. Apply prescribed amount of drops Put light pressure on inner canthus to reduce systemic absorption. вЂњHOW TOвЂ¦вЂќ Apply ear drops 1. 2. 3. 4. 5. 6. Client is laying on his side. Put on gloves. Straighten ear canal by pulling pinna gently upward and backward in an adult. ( for a young child downward and backward) Instill medications. Cotton may вЂ“ loosely вЂ“ be inserted into ear canal. вЂњHOW TOвЂ¦вЂќ Apply vaginal suppositories / creams: 1. 2. 3. 4. 5. 6. 7. Client to be placed in dorsal recumbent or Sims (left lateral) position. Use gloves after washing hands. Remove foil wrapper and insert suppository into applicator or amount of cream. Insert applicator 4 inches into vagina. Release application. Remove applicator. Client to remain laying down for 15 minutes until medication is absorbed. вЂњHOW TOвЂ¦вЂќ Apply rectal suppositories: 1. 2. 3. 4. 5. 6. Client to be placed in dorsal recumbent or Sims (left lateral) position. Use gloves after washing hands. Remove foil wrapper from suppository. Add small amount of water soluble lubricant. insert suppository with index finger to about 4 inches. Client to remain laying down for 15 minutes until medication is absorbed. вЂњHOW TOвЂ¦вЂќ Apply metered вЂ“ dose inhaled medications: 1. 2. 3. 4. 5. 6. 7. 8. Shake canister before each use. Hold inhaler 2 inches away from mouth. Exhale through pursued lips. Depress inhalation device. Inhale slowly and deeply through mouth. Hold breath for 10 seconds. Exhale slowly through pursued lips. Wait 2 вЂ“ 5 minutes between puffs. 137 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂў вЂў вЂў вЂў вЂў вЂў вЂў use with spacer: Connect MDI Inhaler with spacer. Release inhaler medication into spacer. Open mouthpiece. Client to close lips tightly around mouthpiece. Inhalation process as with MDI only. Devices to be cleaned after use. -Dosage calculation for pediatric clientsAny pediatric medication order always has to be checked against. the safe dosage ranges of the individual medication. Dosage calculation either uses Body weight or Body surface area (BSA). BSA may be more accurate and precise. Body weight dosage order refers to mg/kg/day or mg/kg/day/order. Conversion between pounds and kilograms: 2.2 pound lb = 1 kilogram kg Calculating a single pediatric dose by body weight Order example: 10 mg of a drug per kilogram of body weight for a child that weighs 23 kg. = 10 x 23 = 230 mg The volume of a soluble medication can be calculated with one of the previously prescribed methods. If this dose is prescribed as a daily dose to be administered in two separate orders, then the daily dose needs to be divided by two, resulting in 115 mg / dose. Calculating a single pediatric dose by body surface area in m2 The size Body surface area in m2 has to be obtained from a nomogram which requires to assess the exact height and weight of the pediatric client. Administration of oral medication to children Children under 5 years may have difficulties swallowing capsules and tablets. Oral medications can be crushed and administered with juices or applesauce to disguise taste. Childs mouth has to be checked if medication has been swallowed properly. Suspensions have to be mixed well prior to administration. In infants small amounts of liquid medication should be placed around mouth at a time to prevent spitting and aspiration. Specifications of subcutaneous injections in children Usually used are 25 вЂ“ 25-gauge needles. Volumes are up to 0.5 mL for infants and 2 mL for older children. For volumes of up to 1 ml a Tuberculin syringe has to be used. Child needs to be comforted as best as possible and rewarded for any cooperation and braveness. Since medical encounters in early childhood can be traumatizing and inducing a phobia against medical treatments which may remain a stressor even into adulthood. Specifications of intramuscular injections in children Volumes are up to 0.5 mL for infants and 2 mL for larger children. Preferred injection site the vastus lateralis muscle for children up to 5 years. Dorsoglutaeal injections may be used in children after they have been walking for at least one year but not as a first choice. 138 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com -Intravenous Therapies- Indications Disability to administer sufficient amounts of fluid and nutrition orally. As well as for rapid access of medication in emergency situations or to avoid repeated intramuscular injections in a hospital environment. Also used for PPN = Partial parenteral Nutrition and TPN = Total Parenteral Nutrition. Needles and catheters are either Over-the-needle catheters or winged needles вЂњbutterfliesвЂќ. Infusion pumps and electronic delivery devices control and measure administered dosages of medication in order to adjustments made. Alarm systems indicate once a medication has been administered or if there is a blockage or disconnection of the tubing system. Regulators and controllers are electronic devices which are designed to sense and regulate the drop flow from the infusion bags. There are also mechanical devices to ensure an adequate infusion rate, such as elastomeric ballons which apply a defined and adjustable pressure to the infusion bag. Tubing system may be vented for glass bottles or nonvented for plastic bottles. In a gravity driven tubing system the drip chamber determines the size of the drop which are rated between 10 and 20 drops per mL for adult clients. Tubing systems mostly carry filters against bacterial and air contamination. Filters used in TPN require changing every 24 hours. Filters may also need to be changed at any time after the application of certain drugs, (e. g. Phenytoin and Pantoprazole). Types of intravenous infusions Peripheral Infusion via device in a peripheric vein. To be changed after 3 вЂ“ 4 days. Central Infusion via Central Venous Access Devices (CVADs / CVS) or Peripherally inserted Central venous Catheters. (PCC) Requiring a sterile dressing since catheter tip will reach into the entry of the right cardial atrium. CVCвЂ™s have one to four lumen. Insertion points are V. Subclavia, V. juguaris interna and the V. brachiocephalica. Indication for insertion of a CVC Long Term IV Therapy, need to obtain frequent blood specimens, limited access to or damaged periphereal veins, necessary CVP (central venous pressure) monitoring and TPN. Flushing with at least 10 ml syringe since smaller syringes may cause rupture of lumen. CVC Catheter types Open tip catheter: (Hickman catheter) Tip ends in blood stream and requires frequent flushing with saline followed by heparine to prevent occlusion. (Broviac catheter is a pediatric version with smaller size of lumen) Closed tip catheter: (Groshong catheter) Valve at end of tip prevents backflow of blood. Do not require heparine flush or clamping but saline solutions. Calculation of an infusion flow rate The infusion set has a given drop factor unless it is a pediatric microdrip which always has 60 drops / mL. Based on a given drip factor of 10 drops/mL the infusion rate has to be adjusted following the order. 139 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Example: An order may request to administer 1000 mL in 8 hours. The required infusion rate has to be calculated as follow: Total infusion volume x drop factor Total time of infusion in minutes = 1000 mL x 10 = 20.83 drops/minute (21 dr/min) 8 x 60 min Intravenous infusions always require constant surveillance to detect any dysfunction. Possible problems in intravenous infusion therapy Accidential disconnection of tubing system or displacement / loss of catheter. Damage or dislocation of catheter leading to fluid infiltration of interstitial tissues. Inflammation / Injection at insertion site. Blockage of catheter or tubing system. Catheter removal is necessary if infusion stops and this does not cause any blood return ! Complications of IV Therapy Air embolism Caused by air intruding accidentially into tubing system. Volumes from 10 ml may cause embolism of superior cava vein or pulmonal artery. Can be prevented by strict surveillance of catheter system and tight closure of all ports of catheter system. Clinical symptoms are sudden dyspnea, central cyanosis, tachycardia, hypotension, chest pain. In cases of suspicion for an air embolism clamp the catheter, position client in Trendelenburg position, administer oxygen and contact physician. Puncture of a central artery (e. g. A. subclavia, A. jugularis interna) Pneumothorax Due to accidental puncture of the pleural space. Infections Most common in TPN. Fever, chills, erythema, WBC , Shock ! Hydrating Solutions used in IV Therapy Isotonic Solutions Sodium chloride 0.9 %, Lactated Ringer Solution (LR) (alkalinizing effect to treat metabolic acidosis) 5 % dextrose in water (D5W) acidifying solution to treat metabolic alkalosis. Indication: Fluid replacement after shock, blood loss and dehydration. Risk: Hypervolaemia Hypotonic Solutions 0.45 % Sodium chloride, 0.33 % Sodium chloride Indication: Cellular dehydration Risk: Administration with tendency of peritoneal or pleural effusion or brain edema. Hypertonic Solutions 5 % Dextrose in normal saline D5NS, 5 % dextrose in 0.45 % sodium chloride D51/2NS 5 % Dextrose in lactated Ringers D5LR, 10,20,50 % dextrose in water D10,20,50W Indication: Dehydration, TPN, Hypoglycemia Risk: Hypervolaemia 140 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Volume Expanders Albumin 5 %, 25%, Dextran 40%, Hetastarch (HESI), Plasma Protein fraction Indication: Hypovolemic shock, Dosage to be adjusted by CVP Administered through large needle. -Red Blood Cell and Blood Product AdministrationForms of blood donation 1. Anonymous 2. Designated 3. Autologus Scheduled blood donation with client 4 вЂ“ 6 weeks prior scheduled surgery. Donation may be as frequent as every 3 days as long as hemoglobin level remains > 11 g/dL. Contraindicated in acute infections, leukemia, cardiovascular or cerebrovascular disease, hemoglobin < 11 grams/dL or hematocrit < 33 %. 4. Blood salvage Resampled blood during surgery undergoes a вЂњwashingвЂќ procedure which removes tissue and cellular debris prior to reinfusion. Blood group compatibility Blood group (=RBC surface antigen) / Antibodies present / Can donate to / Can receive 0 A,B every blood type* 0 A B A, AB 0, A B A B, AB 0, B AB No antibodies AB univ. receiver* * in regards to A,B,0 but not to Rhesus compatibility. Rhesus factor compatibility Unlike the blood group specific antibodies, rhesus factor antibodies in rhesus negative clients are not present from birth and may never be produced at all as long as a rhesus negative client does not get in contact with rhesus positive RBCвЂ™s. Since about 85 % of the overall population are rhesus factor positive it can likely happen that rhesus negative donor RBCвЂ™s are not available at the time when a rhesus negative client urgently requires blood transfusions. In these cases rhesus positive RBCвЂ™s will be supplied along with anti-D antibodies to avoid a sensitization of a rhesus negative client versus rhesus positive RBCвЂ™s. This treatment is comparable to the previously discussed treatment of a rhesus factor negative pregnant women giving birth to a rhesus positive child. In all other cases rhesus negative donor blood always has to be preferred if available. Blood group typing Involves Antibody Screening for A, B, Rhesus and other antibodies. Cross match Is ordered when a transfusion is about to be performed. Donor cells are added to recipients serum and Coombs Serum to check for agglutination. 141 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Immediately after blood is drawn for typing, client receives a wrist bracelet with an unique blood donor number that must match the blood identification tag in the units this client receives. Blood products Red blood cells (RBCвЂ™s) Replacement of lost erythrocytes. Contains 250 вЂ“ 400 ml per unit. One unit raises Hemoglobin by approximately 1 gram / dL and hematocrit by 2 вЂ“ 3 %. Assessment not prior 4 вЂ“ 6 hours after transfusion. Fresh frozen Plasma (FFP) Replacement of clotting factors and plasma proteins to extend blood volume. One Unit = 200 вЂ“ 250 mL. Requires Blood typing prior to use ! Does not contain RBC and Platelets. To be infused within 6 hours after thawing to maintain clotting factors. Assessment via coagulation studies (PTT, PT). Platelets Needed for blood coagulation. Units with variable Volumen from 70 вЂ“ 400 mL. To be administered as soon as received from blood bank. Assessment of platelet count after 1 and 24 hours. Albumin Expands blood volume and increases colloidosmotic pressure to shift fluids from interstitial space back into intravascular space. Used to treat hypovolemic shock and fluid losses into the third space. (e. g. edema). Increases albumin levels by 25 grams/100ml which equalizes amount of albumin found in 500 mL of blood. Cryoprecipitate Clotting factor replacement. Prepared from FFP. Has to be administered as soon as thawed out. Administration of Blood Products Checklist: 1. Asessment of vital signs. 2. Obtaining clients consent. 3. Finding and puncturing suitable vein. 4. Insertion of a 18 вЂ“ 20-gauge needle catheter. 5. Start Saline 0.9 % Solution using a Y вЂ“ Set. 6. Check blood from blood bank for donor number and exspiration date. 7. Compare blood donor number and patient identification with second nurse. 8. Mix cells and plasma gently by inverting back several times. 9. Hang blood unit 10. Start with transfusion rate of 2 mL per minute for first 15 minutes. 11. Check vital signs every 5 вЂ“ 15 minutes. 12. Increase transfusion rate after 15 minutes. Blood must be hung within 30 minutes of receipt from the blood bank ! Unit must be administered within four hours ! Asses vital signs half hourly until 1 hour after transfusion has stopped ! Transfusion reactions, symptoms and management Bacterial reactions Chills, tachycardia, fever. Obtain blood culture, start antibiotic therapy, fluid resuscitation, vasopressors, corticosteroids. 142 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Hypersensitivity Urticaria, fever, anaphylactic reaction. shock treatment, oxygen. Diphenhydramine, Hemolytic reaction Nausea, back pain, tachycardia, hypotension, hematuria shock treatment, oxygen. Diphenhydramine, Febrile reaction Nonspecific if not accompanied by additional physical symptoms. Most common transfusion reaction, may require premedication with Acetaminophen or Aspirin. Circulatory overload Transfusion speed to fast. Leading to tachycardia, pounding pulse, hypertension, distended neck veins, crackles upon lung auscultation, dyspnea and coughing. Procedure slow transfusion rate, maintain an upright position, supply oxygen and notify physician. Blood вЂ“ borne infection Specific risks are CMV, HIV, Hepatitis B + C, Malaria. Electrolyte imbalances Hyperkalemia, due to intravasal hemolysis. Hypocalcemia caused by citrate from blood products. Iron overload Delayed complication after multiple transfusions. Treatment with desferoxamine (Desferal) subcutaneously or intravenously which will eliminate iron via kidneys (red urine !) -Total Parenteral Nutrition (TPN)- Total parenteral nutrition via an intravenous catheter is indicated in conditions that interfere with a regular function of the gastrointestinal tract. (i. e. intestinal blockage or recent abdominal surgery) This form of treatment may be provided in a hospital as well as in a home care setting. Main goals of a TPN are prevention of weight loss, protein loss and adequate Fluid and Electrolyte supply. The TPN solutions typically consist of a mixture of amino acids and dextrose as well as electrolytes and vitamins in an amount of 2 вЂ“ 3 liters which are usually administered over 24 hours. Depending on the duration of this treatment it may be necessary to supply additional lipids, vitamins and minerals. Lipids are usually not given on a daily basis unless the primary formula solution with carbohydrates and aminoacids also includes lipids in a small concentration. Such solutions are called total nutrient admixture TNA. Single fat emulsions to be added to the TPN are called linoleic, linolenic, oleic, palmitic and stearic acids. Access sites for TPN A peripheral vein is used for up to 7 days but no longer than two weeks to administer parenteral nutrition. Access via a peripheral vein does not allow to administer dextrose 143 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com solutions of more than 10 % concentration since higher concentrated solutions cause sclerosing and phlebitis of the peripheral veins. A central vein access allows the administration of dextrose concentration of more than 10 %. TPN via a central vein access requires a catheter with at least 3 lumen where one lumen has to be reserved for administration of the TPN only. A vein catheter inserted directly into a central vein can be used for up to 4 weeks. If a TPN is required for a longer period of time, then a peripherally inserted central catheter (PICC) may be used since it can remain inserted for a longer period of time. Management of a TPN: Checklist: 1. Ensure correct function and insertion of peripheral or central vein catheter. 2. Blood glucose monitoring prior to the start of a TPN as well as every 6 hours to detect Hyperglycemia / Hypoglycemia. 3. Daily weight measurement to determine fluid balance as well as accurate 24 h input / output records. 4. (A sudden and significant increase of i.e. 1 kg per day may be rather fluid retention while a slower less significant weight of 1 вЂ“ 2 pounds weekly is rather caused by weight gain 5. Regular laboratory assessments of liver function, TLC, BUN, creatinine, albumin, prealbumin, total protein and serum electrolytes. 6. Ensure that type, concentration and amount of any ingredients of a TPN solution are complying with physicians order. 7. Assure that TPN solution has a homogenous light color and concentration without any solid particles. 8. Adjust TPN flow rate to individual conditions (usually 50 mL/hr вЂ“ 125 mL/hr). 9. Lipid concentration flow rates start from 1 mL / min. 10. Maintain Normoglycemia by using Dextrose 10 % Solution if TPN is temporarily not available. 144 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com NCLEX-RN В® Category III,IV,V: NURSING CARE SPECIFICS PATHOPHYSIOLOGY - MEDICAL TREATMENTS APPLIED PHARMACOLOGY AND PSYCHOSCOCIAL ASPECTS OF DISEASES AND DIORDERS NEUROLOGICAL DISORDERS AND DISEASES Anatomy and physiology of the nervous system Microanatomy of the nervous system The nervous system contains specific structural nerve cells (= neurons). These cells are designed to produce and process electrical impulses along the nerval fibers (= nerve axons). Each neuron communicates with an average of 1000 other neurons via functional connections which are described as synapses and dendrites. Neurons are the basic information processing units of the entire nervous system. The main cell types of the connective tissue of the central nervous system are astrocytes and oligodendrocytes. Myelin sheats Central and peripheric nerves can be differentiated in myelinated and unmyelinated nerve fibers. Myelin layers of peripheric nerves are build by specific connective tissue вЂњgliaвЂќ cells, (вЂњSwannвЂ™s cellsвЂќ) and designed to increase the speed at which nerval impulses are progressing along the myelinated fiber. Along unmyelinated fibers, impulses move continuously as waves, but, in myelinated fibers, they hop or "propagate by saltation." Myelin increases electrical resistance across the cell membrane by a factor of 5,000 and decreases capacitance by a factor of 50. Myelination also helps to prevent the electrical current from leaving the axon. When a peripheral fiber is severed, the myelin sheath provides a track along which regrowth can occur. 145 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com The compartments of the nervous system The human nervous system is functionally and anatomically divided into the following three compartments: 1. 2. 3. Central Nervous System CNS: Brain and spinal cord. Peripheric Nervous System PNS: Peripheral nerves between the spinal cord and the innervated tissues. Autonomous Nervous System ANS: Parasympathetic and enteric nervous system PSNS / ENS Sympathetic nervous system SNS The central nervous system CNS The brain and its spinal cord recognize all consciously and subconsciously received sensations that are affecting the human body. The brain transforms them into adequate responses by innervating motoric actions, inducing thought processes and memorizing important facts and experiences. The sensoric вЂњreceivingвЂќ cell areas of the brain are characterized as white matter due to their anatomical appearance while the motoric вЂњrespondingвЂќ cell areas are considered as grey matter for the same reason. All intended human actions are generally caused by sensations affecting the sensoric cortex of the brain and transformed into motoric responses that are carried out by neurons of the motoric cortex.The brain has the highest demand of oxygen and carbohydrates of all organs. An absence of oxygene for more than 3 minutes can cause an irreversible cell death of neurons. The metabolic supply of the central nervous system occurs via the blood brain barrier only, to assure that only substances of low molecular weight and lipophilic substances can be exchanged. The blood brain barrier consists of gliacells which can be considered as the connective tissue of the CNS. The peripheric nervous system PNS The PNS combines all nerval structures that are originating from the CNS to connect to the peripheral tissues. A peripheric nerve consists of multiple individual nerve fibers with afferent = sensitive, efferent = motoric and autonomous qualities. The nerval endings are classified as chemical synapses and enable nerves to connect with other nerval structures and non вЂ“ neuronal cells. Chemical synapses are designed to transform nerval signals into chemical signals by expressing neurotransmitters. Neurotransmitters are synthesized and stored in presynaptic vesicles and get discharged upon receipt of an electrical nerval stimulation. Once released neurotransmitters connect to specific receptors within the postsynaptic membrane of the chemical synapsis which is recognized as an activating or inhibiting signal by the innervated organ. In case of the PNS the main activating neurotransmitter is acetylcholine and the main inhibiting transmitter glycine. The autonomous nervous system ANS The ANS controls every willingly uncontrollable organ by specific innervation of smooth muscle cells, glandular tissue and cardiac muscle cells. Main areas of innervation are therefore the digestive and urinary tract as well as the cardiovascular and respiratory system. The ANS is functionally divided in two components with counteracting effects: The parasympathetic nervous system PSNS and the sympathetic nervous system SNS. As a descriptive characterization the PSNS is supporting every body function that supports вЂњrest and breedвЂќ while the SNS is aimed to control вЂњfight or flightвЂќ reactions. Thorough understanding of the function of the different wings and qualities of the ANS function is mandatory to understand and memorize the pathophysiology of neurologic 146 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com disorders as well as characteristic side effects of medication therapies. Atropine antagonizes acetylcholine effects only on muscarinic receptors. Neurotransmitters of main importance Acetylcholine Main neurotransmitter within the entire parasympathetic nervous system but also within the PNS and CNS. Its activating or inhibiting effect depends on the quality and distribution of muscarinic and nicotinic acetylcholine receptors within an organ tissue. Summary of parasympathomimetic = вЂњcholinergicвЂќ and sympathomimetic effects : Activating вЂњbreedвЂќ effects on: Inhibiting вЂњrestвЂќ effects on: Alpha-1 Receptors Noradrenaline (Norepinehrine) Beta-1 Receptors Adrenaline (Epinephrine) Alpha-2 Receptors Noradrenaline sensitive: Beta-2 Rceptors Adrenaline sensitive: Digestive tract Urinary tract Diaphragm Glandular functions: Salivation Enzymatic digestion Tears Hormonal glands Sexual functions Heart rate Blood Pressure Miosis Induction of sleep Bronchoconstriction sensitive: Smooth muscle contraction Skelettal muscle contraction sensitive: Heart rate Kidney function Lipolysis Digestive tract motility Urinary tract motility Glycolysis Dilation of Bronchioles Arterial vasoconstriction Uterine relaxation Pancreatic Insuline release Adrenergic effects induced by medication are described as вЂњsympathomimeticвЂќ. Glutamat, Dopamine Stimulating Neurotransmitter in the CNS GABA Main inhibiting neurotransmitter within the CNS. Injuries and diseases of the central and peripheric nervous system Spinal cord injuries and disorders Symptoms and severity of a spinal cord injury correlate with the location of the actual damage. Typical injury patterns after spinal cord injuries are: Tetraplegia Damage of the cervical spinal cord. Total paralysis from upper extremities downwards. 147 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Paraplegia Damage of the thoracic or lumbar spinal cord. Paralysis of lower extremities up to the pelvic area. Spinal shock Loss of autonomous and motoric reflexes in an area below the spinal cord injury immediately after damage has occurred. Skeletal muscle paralysis, flaccid, hypotension, bradycardia, hypesthesia for pain, temperature and touch. Bladder and bowel incontinence, autonomic dysreflexia in cases of spinal cord injury from T6 and higher. Treatment: Primary stabilization for transport with appropriate devices (e. g. halo extensions) Steroid treatment in initial injury stadium to limit spinal cord edema. Surgical stabilizations of vertebral fractures. Long Term Care: Physiotherapy, ergotherapy, bladder and bowel training, psychotherapy and supply of orthopedic devices Guillain Barre Sydrome Ascending inflammation of spinal nerves commonly starting from lower extremities resulting in a progressive motoric and sensoric paralysis. Autoimmune disorder with antibody production against myelin sheet of nerval fibers. Destruction of myelin results in loss of conduction ability of nerval fibers. Symptoms and diagnostic findings: Progressive general muscular paralysis and paresthesia, body achiness, respiratory failure due to muscular weakness, hypotension due to dysfunction of the autonomous nervous system and elevated proteins in a CSF sample. Treatment: Plasmapheresis for separation of Plasma from blood cells to eliminate autoimmune antibodies. Immunoglobulin supply and corticosteroids. Symptomoriented treatment of repiratory failure, cardiovascular problems, bowel and bladder dysfunction. x Myasthenia gravis Autoimmune disease of the peripheral nervous system. Characterized by an autoimmune disorder with antibody production against acetylcholine receptors. Results in an inhibition and destruction of the neuromuscular chemical synapses. Most cases are accompanied by autoantibody production against thymus glands. Progress can be enhanced by multiple factors such as infections, vaccinations, physical exhaustion, stress, thyroid gland disorders, menopausal hormonal disturbances and alcohol consumption. Medications with effects or side effects towards the peripheral nervous system are sedatives, anesthetics, analgesics, opioids and quinidine. Symptoms and diagnostic findings: Slowly progressing muscular weakness up to a development of a complete muscular paralysis. Diplopia, swallowing and breathing difficulties and respiratory failure. Myasthenic crisis = Respiratory failure & Aspiration. Cholinergic crisis = Overdose of cholinesterase inhibitors. Diagnosis is made via Tensilon test (leading to a temporary improvement of symptoms if positive) and Electromyography (EMG) test (poor stimulation of motoneurons if positive). Treatment: Cholinesterase inhibitors: Need to be supplied 45 minutes prior to meals, when peak concentration is needed! Neostigmine, Pyridostigmine. 148 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Immunosupressants: Corticosteroids, Azathioprin, Cyclosporine. Precautions against aspiration. Eye care/eye patch. Brain Disorders and Injuries Brain contusion Brain tissue damage due to parenchymal bleedings caused by blunt trauma. May be accompanied by a more or less significant bleeding. Brain concussion A brain contusion which leads to a temporary confusion or a loss of consciousness. Grade 1: Stade of confusion for up to 15 minutes and no loss of consciousness. Grade 2: Transient confusion for more than 15 minutes and no loss of consciousness. Grade 3: Loss of consciouness for up to several minutes. Treatment: Self limiting conditions with spontaneous improvement within hours to days if no significant brain tissue damage occurs. Clients usually require hospitalization for clinical observation for at least 24 hours. Depending on severity clients may complain of headaches, dizziness, light sensitivity, poor concentration and retrograde amnesia in regards to the circumstances prior to the trauma. Epidural Hematoma Caused by acute rupture of a meningeal artery. Leads to rapid development of a hematoma between skull and dura within minutes to hours. Subdural Hematoma Slowly developing hematoma between pia mater and dura mater over days and weeks. Caused by a rupture of small connecting bridge veins. Treatment: An epidural hematoma is a life threatening condition and always requires an emergency neurosurgical intervention via a craniotomy procedure to relief the increased intracranial pressure and to stop the intracranial bleeding. Subdural hematomas require surgery depending on their size and severity. Small circumscripted subdural hematomas may not require surgical treatment. Meningeal Anatomy 149 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Seizures Seizures are spontaneous events of unregulated electrical potentials in neurons of the brain and occur either in specific areas or generalized over the entire brain. Seizure disorders occur as idiopathic seizures with no known cause as well as related to another disorder such as hypoglycemia, acute alcohol or substance withdrawal or brain tumors. Another typical cause can be a history of severe head or brain injury or surgery because of brain irritating intracranial scar tissues. Seizures may be preceeded by a temporary specific aura stade of lethargy, lack of concentration and abnormous tiredness. Symptoms and diagnostic findings: вЂў Grand mal seizures (= tonic clonic seizures) Most common expression of a seizure. Appearance of repeated muscular tonic and clonic contractions of entire skeletal muscles, tongue bites, spontaneous uncontrolled urination and defecation, temporary cessation of breathing and loss of consciousness. Typically expression of head and muscle aches, retrograde amnesia, confusion, tiredness once client has regained consciousness. ( = Postictal period) A Status epilepticus can occur if a grand mal seizure is not improving spontaneously or remains untreated. Clients in a status epilepticus are in a potential life threatening situation, endangered by hypoxia, hypoglycemia and exhaustion. вЂў Complex partial seizures (petit mal seizures) Localized, non purposeful, unspecific movements in combination with a temporary impaired or total loss of consciousness. вЂў Simple partial seizures Expression of either motoric, sensoric, autonomic symptoms or psychic alterations but not in combination. вЂў Absence seizures Short lasting seizures for up to 30 seconds of duration. Expressed by a sudden psychic alteration and a brief cessation of motoric activity. Diagnostic tests used to detect seizure sensitivity and causes are Electroencephalography (EEG) to detect abnormous electrical activity of neurons. Skull X вЂ“ rays in search for fractures or abnormalities, CT scans, lumbar puncture and blood tests. Treatment: Most simple partial or absence seizures cessate spontaneously and do not require any acute intervention. In acute grand mal and complex partial seizures the main priority is to secure the client in a side lying position for airway maintenance and to avoid aspiration. Clients with breathing difficulties may require oxygenation. Bite sticks may be used but are not generally recommended to avoid tongue bites. Provide a safe environment by removing potential sources for injury. Drug treatment: Acute treatments may be performed via injections of short вЂ“ and midterm acting benzodiazepines such as diazepam, lorazepam or clonazepam or with phenobarbital. Long term drug treatment with phenytoin, valproic acid and carbamazepine is used to increase the seizure threshhold. Long term treatments require the ongoing daily intake of the appropriate medication at a given time to secure a sufficient blood level. Therapeutic blood levels have to be assessed on a regular basis via blood samples. In rare cases seizure disorders may not respond to drug treatments and require neurosurgical intervention. 150 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Multiple sclerosis - MS Autoimmune disease with destruction of myelin fibers and neurons of the entire central nervous system. (brain and spinal cord). The clinical course of multiple sclerosis can vary as follow: вЂў вЂў вЂў вЂў Benign (asymptomatic destruction) Relapsing вЂ“ remitting (temporary destruction) Primary progressive (repetitive destruction) Secondary progressive (permanent destruction) Production of autoantibodies against myelin and axons may be linked to viral infections. Symptoms and diagnostic findings: Earliest symptoms are visual disturbances which can be verified by neurophysiological examinations using evoked potentials. (EPвЂ™s) Gradual or sudden muscular weakness of limbs. Progressing muscle spasticity in advanced stades. Bladder incontinence, dysphagia and constipation. Appropriate diagnostic procedures and their outcomes are: Lumbar puncture (IgG bands in CSF), MRI and CT Scans (plaque formation in white matter, brain nerves and spinal chord). Histologic characteristics are Astrocytes which function as a scar tissue to replace destroyed nerve fibers. Treatment: Multiple sclerosis is primarily incurable. Treatment is mainly symptom oriented. Medications used to suppress a rapid development in stages of acute flares are immunosuppressants such as interferon вЂ“ alpha. Further treatment focuses on physical therapy, supply of orthopedic and assistive devices , adequate fluid supply, PEG вЂ“ supply to secure nutrition, assistance in ADLвЂ™s, infection control by preventive use of antibiotics and antiviral medication and psychological support. Medication therapy: Multimodal anti-inflammatory effect to the myelin structures of the central nervous system. Medications for treatment of MS are: Methylprednisolone /oral Prednisolone = Reduces exacerbation rate and severity. Interferon Beta 1a + 1b = Long term treatment to decrease severity of exacerbations. Azathioprine (Imuran) = Decreases severity of symptoms and progression of MS. Cyclophosphamide = Reduces exacerbation rate and severity. Glatiramer = Prevents destruction of brain and nerve tissue. Cyclosporine = Reduces severity of exacerbations. Morbus Parkinson / ParkinsonвЂ™s Disease Degenerative neurological disease caused by a loss of the dopamine producing substantia nigra in the hypothalamic area of the brain. Older adults from 50 years of age are mainly affected. Symptoms and diagnostic findings: Classical symptom trias results in: Rigor, Tremor and Akinesia. Slow onset of general muscle tremor at rest along with increasing muscle rigidity. Altered walking pattern with short stepped and shuffling gait, slurred speech, slow eye movements, dysphagia, constipation, depression, sweating of face and neck only. Treatment: Treatment depends on stage of disease. Treatment options include: Physical therapy, assisted and self exercise of ROM as early as possible. Supply of orthopedic mobility 151 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com devices to prevent falls. Supply of assistive devices to overcome loss motoric skills. Logopedic treatment by speech pathologist. High fiber and fluid diet and psychological support. Drug treatment options include: L-Dopa, MAO вЂ“ Inhibitors, dopamine agonists, anticholinergics, antidepressants, propranolol. Stroke/Cerebrovascular Accident CVA Definition of transient and permanent ischemic attacks to the brain: Types: 1. TIA = Transient Ischemic Attack Neurologic deficits resolve within 24 hours. 2. PRIND = Prolonged Reversible Ischemic Neurological Deficits Neurological deficits resolve within after 24 hours up to 7 days. 3. CVA = Cerebrovascular Accident Permanent neurological deficit due to either an occlusion of a cerebral artery by thrombosis or embolism or by intracranial hemorrhage. Ischemic attacks are mostly caused by arteriosclerotic degeneration of the supplying blood vessels. Other common causes include cardiac embolism, uncontrolled hypertension and aneurysms of cerebral arteries. Symptoms and diagnostic findings: вЂў Occlusion of internal carotid artery and middle cerebral artery: Paralysis and loss of sensitivity of contralateral body hemisphere. Aphasia = client unable to talk. Apraxia = client unable to perform motoric tasks. Agnosia = client unable to recognize environment. Uni or bilateral Hemianopsia = loss of half of visual field. вЂў Occlusion of vertebral artery: Dysphagia = client unable to swallow. Multiple other circumscripted losses of sensitivity can occur due to occlusion of other brain supplying arteries. Treatment: Thrombotic CVA Heparin treatment and thrombolytic drug treatment. Lysis of clot with tissue plasminogen activator within 3 hours. Hemorrhagic CVA Surgical treatment in cases of severe intracranial bleedings. Correction of blood pressure and intracranial pressure. General treatment options: Early rehabilitation, psychological support, management of underlying vascular risk factors and oral Anticoagulation. Common affections of facial nerves BellвЂ™s Palsy Unilateral paralysis of facial nerve. Cause unknown. Over 90 % experience spontaneous recovery within several months. Symptoms and diagnostic findings: Unilateral paralysis of facial muscles. Loss of taste over anterior portion of tongue. Loss of corneal reflex on affected side. Increased tearing from lacrimal gland on affected side. Treatment: Antiviral medication, steroids, eye patch, facial nerve stimulation and physiotherapy. Regular follow up examinations. 152 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Trigeminus neuralgia Nerve induced chronic recurrent or permanent pain of one half side of the face. Cause unknown. In some cases linked to underlying ear or dental disorders or tumors. Also after blunt injuries to the face. Symptoms and diagnostic findings: Unilateral pain in one, two or all three innervation areas of the trigeminus nerve branches. Most commonly occurring as a pulsating pain. Triggers of onset may be touch, light, eating or other facial an cervical movements. A paralysis of facial muscles is not involved. Treatment: Avoiding specific triggers, if known. Analgetic treatment on demand with common pain relief. In cases of recurrence in a high frequency a prophylactic treatment with carbamazepine or other antiepileptics may be tried. Surgical intervention if nerve is trapped in its compartment. Common infections of the Central Nervous System Meningitis Severe infection of the meningeal structures of the central nervous system. Most commonly caused by a hematogenic or traumatic (surgical and accident related) droplet bacterial infection with вЂў Neisseria meningitides (Meningicoccus) вЂў Streptococcus pneumoniae (Pneumococcus) вЂў Haemophilus influenzae, Type B вЂў Diverse viruses (mostly leading to a better outcome) Symptoms and diagnostic findings: Severity and duration of infections depend on causative agent. FluвЂ“like symptoms, fever, chills, bodyache, headaches, light sensitivity, photophobia, nausea and vomiting. Signs of nuchal rigidity: Brudzinski Sign (Pain on neck flexion in supine position) Kernig Sign (Pain on hip flexion in supine position), Opisthotonus (Hyperextension of neck and back), seizures and confusion. Diagnosis confirmed by growth of bacterial culture or lymphocytosis from CSF sample. Treatment: Viral meningitis: Treated by symptoms. No specific medication available. Bacterial Meningitis: Antibiotic treatment intravenously or intrathekal (=subarachnoideal) Preventive treatment due to vaccinations. Treatment and isolation of contact persons for 24 hours after onset of prophylactic treatment with Rifampicine. Upright position or LP to relief increased intracranial pressure. Encephalitis Viral infection of the brain. Most commonly caused by Herpes simplex virus type 1 (HSV1) during neonatal period. Other causes are rare. Symptoms and diagnostic findings: Symptoms are generally comparable with symptoms of meningitis. Seizures are more common. Treatment: Treatment of causative agent, symptomoriented treatment and psychological support. Poor prognosis. Clients are likely to remain with neurological disorders. 153 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Neurological Medication Therapy Migraine Medication Ergotamine Pharmaceutical effect: Alpha sympathomimetic effect on blood vessels, may lead to vasodilation or vasoconstriction depending on administered dosage. Prevention of decline of serotonine levels due to inhibition of reuptake into platelets. Physiological effect: Acute and prophylactic treatment of migraine headaches. Indication: Migraine treatment and prophylaxis. Contraindications: Pregnancy, cardiovascular disease, coronary artery disease and hypertension. Substances: Ergotamine tartrate (Ergostat), Dihydroergotamine mesilate (Migranal) and Sumatriptan (Imitrex) Medication for preventive treatment of migraines. Beta вЂ“ blockers, Ca- channel Blockers, lithium and corticosteroids. Behavioral measures for prevention of migraine attacks. Regular life style, avoidance of stress, regular meals, avoiding long fasting periods, (diets), alcohol and certain types of food (esp. Tyramine containing food, red wine etc.). Anticonvulsive medication (Antiepileptics) Diverse group of substances which are inhibiting the induction convulsive impulses of neurons of the motoric cortex. Hydantoins (Phenytoins) Acute treatment and prevention of grand mal seizures, status epilepticus (Fosphenytoine), psychomotoric seizures. Fosphenytoine is used for intravenous admnistration only. Oral Phenytoine has to be administered without food due to its high ability to bind with proteins. Long term Phenytoin treatment requires a regular assessment of medication blood levels to adjust daily dosages as well as CBC, liver and kidney function. Side effects: Paresthesias, nystagmus, diplopia, gingival hyperplasian (can be prevented by proper dental hygiene), StevensвЂ“Johnson Syndrome, hepatitis, anemia, leukopenia, thrombocytopenia and megaloblatic anemia. Barbiturates and Benzodiazepines Characteristics discussed under addictive substances. Barbiturates are used for acute treatment of seizures via intravenous administration, as well as for longterm treatment of epilepsy. Long term therapy requires regular assessment of therapeutic blood levels. Benzodiazepines are primarily used for acute intervention in a seizure rather than for a long term treatment of epilepsy. Longterm therapy requires regular assessment of blood levels. Carbamazepine Carbamazepine is used for acute treatment of seizures via intravenous administration as well as for long term treatment of epilepsy. 154 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Central Nervous System Stimulants Pharmacological effect: Alpha and Beta Receptor stimulation of the central sympathetic autonomous nervous system. Physiological Effect: Decrease of appettite and overall alertness. Obesity treatment Anorexiants Narcolepsia Amphetamines Attention deficit/hyperactivity disorder Amphetamines Side effects: Central sympathetic stimulants of different potencies share a combarable side effect pattern: hypertension, tachycardia, palpitations, restlessness, dysmenorhea. Amphetamines may also cause blood dycrasias, libido disturbances and erectile dysfunction. Special considerations: Medication has to be tapered off in any case. Client has to avoid intake of caffeine and other substances (e. g. Theobromime in tea and chocolate) with stimulating effect. Substances: Amphetamine (Adderall) Dextroamphetamine sulfate (Dexadrine) Methylphenidate hydrochloride (Ritalin) Anorexiants: Benzphetamine hydrochloride (Didrex) Diethylpropion hydrochloride (Prop/ion) Sibutramine hydrochloride (Meridia) Anti Parkinson Medication Anticholinergic Parkinson medication Pharmacological effect: Interference with acetylcholine receptors in the central parasympathetic autonomous nervous system. Physiological effect: Reduction of involuntary movements, especially tremor, in ParkinsonвЂ™s disease. Contraindications: Myasthenia gravis, narrow angle glaucoma and gastrointestinal obstruction. Side effects: (Parasympatholytic effects), Mydriasis, dry mouth, constipation, ileus and urinary retention. Intoxication occurs even due to lightest overdose! Substances: Benztropine mesilate (Cogentine) and Trihexyphenidyl hydrochloride (Artane) Dopamine-agonist Parkinson Medication Pharmacological effects depend on individual substance: Amantadine: Promotion of synthesis and release of Dopamine. L вЂ“ Dopa: Physiological precursor of Dopamine increases Dopamine synthesis. Dopamine agonists Bromocriptine / Pergolide: Direct stimulation Dopamine of receptors. Comedication to LDopa. Monoamine oxidase B inhibitor: Increase of Dopamine activity. Comedication to L-Dopa. 155 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Special considerations: Food interactions Levodopa and selegiline: Reduced absorption with high protein food. Selegiline: Tyramine containing food may establish hypertension Side effects: Amantadine: Convulsions, congestive heart failure and leukopenia Levodopa: Mental or personality changes, leucopenia and agranulocytosis. Extrapyramidal symptoms: twitches, grimacing and tongue protrusion Myasthenia Gravis Medication Pharmacological effect: Increase of acetylcholine in the chemical synapses of the peripheric nervous system. Therapeutic effect: Improvement of transmission of nervous impulses from motoneurons to skeletal muscles. Special considerations: Treatment requires a frequent dosage adaptation in accordance to the progress of the myasthenia gravis but should not be performed more than once every six weeks. Medication should be administered prior mealtimes. Atropine sulfate has to be available as an antidote at all times! Respiratory support equipment needs to be available at all times. An increasing or recurrent muscle weakness one hour after administration of the medication may lead to an overdose, resulting in a cholinergic crisis. Recurrent muscle weakness after three or more hours may be a sign of an undermedication. Medication only causes temporary relief of symptoms and does not provide a cure. Side effects: Correlate with an increased activity of the parasympathetic autonomous nervous system and can be considered as partially parasympathomimetic: Insomnia, headache, dizziness, nausea, vomiting, polyuria, diarrhea and miosis. Substances: (direct and indirect acting parasympathomimetics) Edrophonium chloride (Tensilon, Enlon), Neostigmine bromide (Prostigmin Bromide) Pyridostigmine bromide (Mestinon), Ambenonium chloride (Mytelase) (Longlasting effect)! Physostigmin (Antirilium) crosses blood/brain barrier!. Tensilon вЂ“ Test If Tensilon is given by an intravenous injection then it leads within 30 вЂ“ 60 seconds to an increased muscle tone and increased muscular strength. If this effect lasts for up to five minutes, then the tested individual is likely to suffer from Myasthenia gravis. In an already diagnosed patient under treatment receives a positive outcome of this test then this is a sign for an insufficient dosage of the current medication therapy. Skeletal muscle relaxants Pharmacological effect: Decrease of synaptic afferent response to motoneurons within the central nervous system, leading to a decreased muscular contraction. 156 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Therapeutic effect: Relief and prevention of muscle spasms and pain in musculoskeletal and neurological diseases. Indication: Spinal cord injuries, strokes, cerebral palsy and multiple sclerosis. Side effects: Drowsiness, weakness, nausea, eosinophilia and hepatic injury. Contraindications: Compromised pulmonary function, compromised cardial function, liver disease, children < 12 years of age and intermittent porphyria. Substances: Baclofen (Lioresal), Dantrolene Sodium (Dantrium), Carisoprodol (Soma), Cyclobenzaprine hydrochloride (Flexeril) and Methocarbamol (Robaxin). INFECTIOUS DISEASES Viral infections Infectious Mononucleosis (вЂњkissing diseaseвЂќ) Characteristics: Viral infection with Epstein вЂ“ Barr Virus by droplets from oral secretion or blood. Incubation period up to 6 weeks. Clients may remain contagious for 6 months. Symptoms and diagnostic findings: Fever, sore throat, pharyngitis, headache, lymphadenopathy and hepatosplenomegalie. Severe lymphocytosis in blood count. Spleen rupture may occur as a rare complication. Treatment: Symptomoriented treatment and bedrest. Assessment of lymphocytosis and size of spleen! Roseola (Exanthema subitum) Characteristics: Common viral infection with herpesvirus type 6 in children between 6 months and 3 years of age. Mode of infection is unknown. Symptoms and diagnostic findings: Sudden flare of high fever in an otherwise well child. After normalization of temperature development of maculopapoulos skin rash from trunk towards extremities and face which is typically self limiting within 24 - 48 hours. Cervical lymphadenopathy may occur briefly. Treatment: Observation and antipyretic treatment. Poliomyelitis Characteristics: Viral infection with polio virus via an oropharyngeal or fecal вЂ“ oral mode of infection. Incubation period up to 35 days. Clients may remain contagious for > 6 weeks over feces ! Symptoms and diagnostic findings: Unspecific prodromal stade with light upper respiratory tract and / or abdominal symptoms. After initial recovery progressive paralysis by destruction of motoneurons which may lead to immobility and respiratory failure. Not all polio virus species cause paralysis ! 157 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Treatment: Strict immobilization. Immunetherapy and vaccination. Treatment is oriented on individual course of infection. Prevention by vaccination from early childhood. Erythema infectiosum (Fifth disease) Characteristics: Viral infection with human parvovirus B19 via droplets from respiratory tract and blood. Incubation period up to 21 days. Aplastic crisis is most common complication. Duration of contagiosity unknown. Symptoms and diagnostic findings: Maculopapular rash, developing from face downwards over 7 вЂ“ 10 days before it disappears. If systemic symptoms such as fever, malaise, headaches and lethargy an aplastic crisis is likely to occur. Rashes can reoccur after infection has passed if triggered by traumas or extreme temperatures. If infection occurs during pregnancy abortion is likely. Treatment: Hospital admission may be necessary. Otherwise symptom oriented treatment. Mumps (Parotitis epidemica) Characteristics: Single or double sided infection of the parotid gland caused by droplet infection with Paramyxovirus. Incubation period up to 21 days. Infection is communicable from prodromal stade throughout the entire course of infection. Symptoms and diagnostic findings: Fever, jaw pain, headaches. Tender swellings of the parotid gland(s). Accompanying orchitis, myocarditis, hepatitis and encephalitis as rare complications. Treatment: Primary prevention via MMR vaccination in order to vaccination schedule or immediately after exposure. In acute uncomplicated cases symptom oriented treatment with bedrest, pain and fever relief. Fluid supply, avoidance of chewing and talking in acute stades. Measles (Rubeola) Characteristics: Infection with rubeola virus by droplets from all body excretions after an incubation period of up to 21 days. Contagiosity over entire course of infections. Symptoms and diagnostic findings: Appearance with skin rash, high fever, conjunctivitis and upper respiratory tract infection. Rash appears in a fine maculo papular expression from head downwards and may also show a typical enanthema on oral mucous membranes. So called KoplikвЂ™s spots. Complications may occur as pneumonia, otitis media, encephalitis. Treatment: Primary prevention via MMR vaccination in order to vaccination schedule or immediately after exposure. In acute uncomplicated cases symptom oriented treatment with bedrest, pain вЂ“ and fever relief. Rubella (German Measles) Characteristics: Viral infection with Rubella virus by droplets from all body excretions after an incubation period of up to 21 days. Contagiosity throughout the entire course of infection. 158 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Symptoms and diagnostic findings: In comparison to measles, a rubella infection shows only low grade fever and a rash with larger macula but less erythematic. Infection is highly teratogenic in a pregnancy. Complications may occur as arthritis or encephalitis. Treatment: Primary prevention via MMR vaccination in order to vaccination schedule or immediately after exposure. In acute uncomplicated cases symptom oriented treatment with bedrest, pain and fever relief. Chickenpox (Varicella zoster) Characteristics: Viral infections with Varicella zoster virus by droplets of oropharyngeal and respiratory origin or skin vesicules. Incubation period up to 14 days. Contagiosity persists until all skin vesicles have dried off and scarred. Symptoms and diagnostic findings: Sudden general malaise. From 2nd day maculo вЂ“ papulous rash over entire body which develops into vesicles. Vesicles rupture spontaneously and build crusts and scars. All expressions of this rash exist simultaneously and build a characteristic вЂњstar sky phenomenonвЂќ Rash usually disappears within 7 вЂ“ 10 days. Treatment: Primary prevention due to vaccination possible. Also immediately after exposure. Clients require bedrest and isolation. Treatment involves relief of temperature and pruritus as well as skin care with calamine lotion or other soothing substances to prevent scratching and bacterial infection. Bacterial infections Scarlet fever Characteristics: Bacterial infection with group A beta вЂ“ hemolytic streptococci by droplets of oropharyngeal and respiratory origin as well as foodborne. Incubation period up to 5 days. Contagiosity over entire course of infections. Symptoms and diagnostic findings: Acute swollen, tender tonsils with a white to gray exsudation that also covers the tongue which shows swollen papillae. (вЂњStrawberry tongueвЂќ) Clients may also suffer from high fever, body achiness, abdominal discomfort, nausea, vomiting and diarrhea. Within first 24 hours development of a pinpoint like maculous rash that covers the entire body but spares the face, which appears with an obvious perioral pallor. Rash disappears under scaling of the skin, especially on palms and soles. Courses without rashes are occasionally observed as well. Complications are otitis media, glomerulonephitis and endocarditis. Treatment: Immediate abticiotic treatment with penicillin or erythromycin over 14 days. In acute uncomplicated cases symptom oriented treatment with isolation, bedrest, pain and fever relief. 159 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Diptheria Characteristics: Bacterial infection with corynebacterium diptheriae by droplets of oropharyngeal, integumetary and respiratory origin . Incubation period up to 5 days. Symptoms are caused and triggered by amount of diphtheria toxin. Symptoms and diagnostic findings: Light fever, sore throat , foetor ex ore, hoarseness, progressing cover of naso and orophanrynx covered with grey вЂ“ white membranes that may cause airway obstruction. High rate of complications due to Myocarditis, Neuritis, Sepsis and respiratory failure. Treatment: Infection requires urgent hospital admission and isolation ! Treatment is accomplished with antibiotics to reduce causative bacteria and diphtheria antitoxin. Hospital discharge requires 3 negative bacterial cultures over 4 weeks to rule out persisting contagiosity. Pertussis (Whooping cough) Characteristics: Bacterial infection with Bordetella pertussis by droplets of oropharyngeal and respiratory origin. Incubation period up to 21 days. Symptoms are triggered by pertussis toxin. Contagiosity over entire course of infections. Symptoms and diagnostic findings: Stage 1: Catarrhalic stade. (1 вЂ“ 2 weeks) Symptoms of an unspecific upper respiratory tract infection with low fever and conjunctivitis.. Stage 2: Paroxysmal stade. ( approximately 4 weeks) Daily, mostly nocturnal episodes of persistent heavy cough with a whooping sound of the intermittent inspirations. Treatment: Primary prevention possible with pertussis vaccine. Antibiotic treatment with Erythromcin. Pertussis immunoglobulin against toxin effect. Humidity inhalations, fluids and bedrest. Rocky Mountain Spotted Fever Characteristics: Bacterial infection with Rickettsia ricketsii via tick bites. Incubation period up to 2 weeks. Infected humans are not contagious. Symptoms and diagnostic findings: Acute fever and overall body achiness, nausea, vomiting, headaches and confusion. Petechial rash, developing from extremities towards trunk. Treatment: Antibiotic treatment with Tetracycline. Preventive hospitalization due to increased risk of sepsis and multi organ failure. Borreliosis (Lyme Disease) Characteristics: Infectious bacterial disease caused by Borrelia burgdorferi in the several of its subtypes in Europe. The infection is transmitted by species Ixodes rhizinus. Symptoms and diagnostic findings: Early symptoms include fever, headache, fatigue, depression, (erythema migrans). Chronic courses occur if the primary infection United States and tick bites from the and a skin rash. was not diagnosed 160 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com and treated in time and may include joint pain, myocarditis, inflammation of the central nervous system. Treatment: Antibiotic treatment with ceftriaxone or doxycycline. In cases of ongoing infections treatment may need to be prolonged over month. Sepsis (Blood infection) Sepsis is usually caused by an overwhelming bacterial infection which leads to an overstimulation of the immune system. This can potentially lead to the sudden and uncontrolled development of the following symptoms: Rapid decline of blood pressure вЂ“ Tachycardia вЂ“ Tachypnea - Confusion, - Disorientation, Agitation вЂ“ Diziness - Reduced urine production вЂ“ Rashes - Joint pain - Thrombcytopenia вЂ“ Leucocytosis - CRP and ESR Elevation - Disseminated intravascular coagulation - Multi organ failure Treatment requires an ICU setting and includes i. v. antibiotic therapies based on the results blood cultures, as well as support of the circulatory symptoms with katecholamines. Antiinfective Medication Therapy Antibiotics Aminoglykosides Bactericid and antiprotozoal effect. Indications: Serious gram negative infection and sepsis. Bowel sterilization prior sugery and in cases of liver cirrhosis with hepatic encephalopathia. ( Reduction of ammonia levels) Destruction of urease producing bacteria in bowels to reduce ammonia absorption in cases of hepatic encephalopathy. Spectrum: Gram negative infections, Gram positive cocci: Acinetobacter, Citrobacter, E. coli, Klebsiella pneumoniae, Proteus, Pseudomonas, Providencia, Salmonella, Serratia and Staphylococci. Special considerations: Intravenous and intramuscular administration. Oral administration only for preventive treatments. Suitable for intrathecal/intraventricular injection. Topical periocular treatments. Assessment of therapeutic levels via peak and through drug levels. (Blood level assessment 30 minutes after and immediately before intravenous administration.) Monitoring of WBC and kidney function. May be started as empiric therapy in combination with cephalosporines in cases of sepsis prior microbiological examinations. Side effects: Ototoxicity Potentially irreversible loss of auditory and vestibular function due to affection of 8th cranial nerve. Nephrotoxicity Risk increases by co-medication, age, preexisting renal condition. Neurotoxicity Neuromuscular blockade due to inhibition of acetylcholine release. Candida infections. Skin rash, fever, paresthesias. Pseudomembranous colitis due to infection with Clostridium difficile Contraindications: Renal diseases, combination therapy with other potentially nephrotoxic substances, pregnancy and lactation 161 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Substances: Amikacin (AmikinВ®), Gentamicin (GaramycinВ®), Kanamycin (KantrexВ®), Neomycin (MycifradinВ®), Netilmicin (NetromycinВ®), Paromomycin (HumatinВ®), Streptomycin (generic) , Tobramycin (NebcinВ®) Cephalosporines Bactericidal. Chemically related to Penicillins. Identical in effect, side effects and pharmacological attributes. Cross sensitivity may occur. Spectrum: 1st Generation: Gram negative bacteria and anaerobic bacteria. 2nd Generation: additional effect against Haemophilus influenzae, Staphylococcus aureus amd Streptococcus pneumoniae. 3rd Generation: Increased effect against Beta Lactamase producing gram negative bacteria including Neiserria gonorrhoea. 4th Generation: increased activitiy against Gram positive cocci and gram negative bacilli. Indications: Bacterial sexually transmitted diseases. Upper and lower respiratory tract infections, otitis media, skin infections and Lyme disease. Prevention of postoperative bone infections (Cefazolin). Special considerations: Cefoperazone and Ceftriaxone are only cephalosporins excreted through bile. Cefuroxime passes blood/brain barrier in general. All other third generations cephalosporines only if meningeals are inflamed. Creatinine clearance under treatment is not supposed to be less than 50 mL/min. All cephalosporines cross placenta. IM injections are painful and should be avoided (except for expected Non - compliance in clients with STDвЂ™s) Medication has to be administered separately from iron and antacid medication. Treatment for streptococcal infections should be proceeded for at least 10 days. Monitoring of WBC, RBC kidney and liver functions required !. Contraindications: Pregnancy and lactation. Liver diseases (for Cefoperazone and Ceftriaxone) Side effects: Rash, allergic reactions, lethargy, hallucinations, anxiety, depression, nausea, diarrhea, liver enzyme elevation, bone marrow depression, cross sensitivity with penicillins Serum-sickness-like-illness Erythema multiforme or other skin rashes, arthralgia, fever. Treatment with corticosteroids and antihistamines. Seizures, Vitamin K deficiency, pseudomembranous colitis and alcohol intolerance for up to 72 hours after last administration. Substances: вЂў 1st Generation: Cefadroxil (DuricefВ®), Cefazolin (AncefВ®), Cephalexin (KeflexВ®), Cephapirin (CefadylВ®) and Cephradine (VelsoefВ®) вЂў 2nd Generation: Cefaclor (CeclorВ®), Cefmetazole (ZefazoneВ®), Cefonicid (MonocidВ®), Cefprozil (CefzilВ®), Cefotetan (CefotanВ®), Cefoxitin (MefoxinВ®), Cefuroxime axetil (CeftinВ®), Cefuroxime sodium (ZinacefВ®) and Loracarbef (LorabidВ®) вЂў 3rd Generation: Cefixime (SupraxВ®), Cefotaxime (ClaforanВ®), Ceftriaxon (RocephinВ®), Cefdinir (OmnicefВ®), Cefditoren (SpecracefВ®), Cefoperazone (CefobidВ®) and Ceftibuten (CedaxВ®) вЂў 4th Generation: Cefipime (MaxipimeВ®) 162 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Fluoroquinolones Bactericidic broad spectrum activity against gram positive and gram negative infections in lower respiratory tract, sinuses, bones and joints, skin and connective tissue, abdomen and urogenital tract. Oral and parenteral administration reaches same plasma levels. Treatment requires frequent and recurrent administration to secure sufficient blood levels. Medication to be separated from antacids, iron, zinc and sucralfate. May potentiate warfarin and antiepileptic medication by increasing their blood levels. Monitoring of kidney function as well as of INR, PT and drug levels of antiepileptic medication under antiepileptic treatment. Side effects: Rash, allergic reactions, lethargy, hallucinations, anxiety, depression, nausea, diarrhea, liver enzyme elevation, atrioventricular conduction impairment under sparfloxacin and moxifloxacin. Also increased light sensitivity. Adverse effects more common in elder clients. Contraindications: Impaired Kidney function. Lactation and Pregnancy. History of seizures. Substances: Ciprofloxacine (CiprolВ®) Macrolide Antibiotics Bacteriostatic effect, used in lower respiratory tract infections, skin and soft tissue infections caused by Streptococcus or Haemophilus organisms as well as gonorrhea, chlamydia, syphilis, borreliosis, mycoplasma, corynebacterium and helicobacter infections. Substances are highly bound to proteins. Administration under high protein diet necessary. Zithromax used for short term treatments only. High potential for drug interaction. Side effects: Nausea, vomiting, jaundice, diarrhea, thrombophlebitis, pseudomembranous colitis, candidiasis, hepatotoxicity, ototoxicity and nephrotoxicity. Contraindications: Pregnancy and lactation, hepatic dysfunction, kidney dysfunction and hearing impairment. Substances: Azithromycin (ZithromaxВ®),Clarithromycin (BlaxinВ®), Dirithromycin (DynabacВ®), Erythromycin (ErythrocinВ®), Troleandomycin (TaoВ®), Clindamycin (CleocinВ®), Lincomycin (LincocinВ®), Telithromycin (KetekВ®) Penicillines Bactericid beta-lactam inhibition in synthesis of cell wall. Sensitivity mainly against Gram-positive bacteria. (streptococci, pneumococci, meningococci, staphylococci and treponema pallidum). Endocarditis prophylactic treatment is preferrably performed with amoxicillin or ampicillin. Penicillins have to be taken on empty stomach, except for Amoxicillin. Strong hepatic first pass effect ( loss of effect during liver passage) requires high oral dosage. Intravenous administration is reserved for serious infections only. Monitoring of liver and kidney function necessary. Buttermilk and yogurt helps to restore destroyed colon flora in cases of diarrhea. Urine glucose may present false вЂ“ positive results. Oral suspensions of penicilline can be used for up to 14 days. Side effects: Skin rashes of diverse expressions are the most common penicillin side effects. Maculopapular rashes under ampicillin and amoxicillin are not a true allergic reaction and not necessarily a contraindication for repeated treatment! 163 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Other side effects include nausea, vomiting, diarrhea, bone marrow depression, anxiety, depression, hypokalemia/hyperkalemia, serum sickness-like reaction and high risk for acute anaphylaxia. Contraindications: Serum sickness, exfoliative dermatitis and blood dyscrasias. Substances: Amoxicillin (AmoxilВ®), Amoxicillin/clavunate (AugmentinВ®), Ampicillin (OmnipenВ®), Mezlocillin (MezlinВ®), Methicillin (StaphcillinВ®), Penicillin G (PentidsВ®) and Penicillin V (V-CillinВ®) Sulfonamides Bacteriostatic treatment of urinary tract infections caused by E. coli bacteria, also treatment of infectons with chlamydia trachomatis, toxoplasmosis (Pyrimethamine) and nocardiosis. Oral preparations have to be administered with food. Cross sensitivity with cephalosporines and penicillins possible. Sufficient fluid supply or urine alkalization required to avoid crystallization. Substance has to be stored in light resistant container. Side effects: Rash, nausea, vomiting, diarrhea, abdominal pain, jaundice, headache, depression crystalluria, peripheral neuritis, tinnitus, hepatitis, anemia and Stephens Johnson Syndrome ( exfoliative dermatitis) Contraindications: Pregnancy, lactation, children < 2 months unless treated for toxoplasmosis, porphyria blood dyscrasias, hepatic impairment, kidney impairment, glucose 6 phosphate dehydrogenase deficiency and asthma. Tetracyclines Bactericidal treatment of infections caused by chlamydiae,(PID) rickettsiae, (rocky mountain spotted fever) vibrio cholera, propionibacterium acne, shigellosis, brucellosis, mycoplasma, helicobacter pylori and typhus. Limited activity against protozoa (amebiasis). Prophylactic treatment of travelers diarrhea. Syphillis and gonorrhea treatment in cases of penicillin allergy. Sclerosing agent in pleural or pericardial effusions. Malaria treatment in combination with quinine. Inhibition of Antidiuretic Hormone. STI Prophylaxis for rape victims. To be taken on empty stomach with fluids. Dairy and calcium products decrease absorption. Not to be administered intravenously only intramuscular. Topicyclin for topical treatment can cause systemic reactions. To be stored in light resistant container. Side effects: Tooth hypoplasia, bone growth inhibition, dysphagia, nausea, vomiting, photosensitivity rash, teeth discoloration in developing teeth, nail discoloration and hepatotoxicity. Fatty liver degeneration = jaundice azotemia increased nitrogen retention hyperphosphatemia acidosis. Nephrotoxicity, pancreatitis. Decrease of cholesterol level. Allergies, blood dyscrasias Headaches due to increased intracranial pressure. Contraindications: Pregnancy and lactation. Children , < 8 years of age. Severe liver and kidney diseases. Substances: Doxycyline (VibramycinВ®), Minocycline (MinocinВ®), Tetracycline (AchromycinВ®), Oxytetracycline (TerramycinВ®) and Demeclocycline (DeclomycinВ®) 164 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Antibiotics for specific indications вЂњReserve antibioticsвЂќ Vancomycin (VancocinВ®) For treatment of bactericid Methicillin resistant Staphylococcus aureus infections (MRSA) Pseudomembranous colitis caused by Clostridium difficile Staphylococcal enterocolitis. Oral administration for colitis treatment, poorly absorbed. Parenteral treatment via infusion over 60 вЂ“ 90 minutes. Side effects: Nausea, Diarrhea, Ototoxicity, Nephrotoxicity, Thrombophlebitis if administered intravenously CVAD preferred, Bone marrow depression and hypotension (вЂњred man syndromeвЂќ). Contraindications: Severe Liver and kidney dysfunction. Imipenem/Cilastatin (PrimaxinВ®) Bactericid serious infections of any location. Only Meropenem (MerremВ®) is able to pass the blood/brain barrier and can be used for treatment of meningitis. Administration intravenously or intramuscular and diverse preparations. Side effects: Headaches, dizziness, confusion, somnolence, tremor, nausea, diarrhea, vomiting, hyperkalemia and hypernatremia. Contraindications: Penicillin and Cephalosporine allergy. Quinupristin/Dalfopristin (SynercidВ®) Bactericid treatment of Vancomycin Resistant Enterococcus Faecium. (VREF), Vancomycin resistant Staphylococcus aureus and Streptococcus pyogenes. For parenteral administration via CVAD only. Side effects: Myalgia, Arthralgia and Thrombophlebitis. Antituberculines Bactericid due to inhibition of cell wall synthesis and protein synthesis. Treatment and prevention of Mycobacterium tuberculosis, Mycobacterium avium, Mycobacterium leprae. 3rd line therapy for infections with multi resistant staphylococci, pneumococci. Antituberculines are mostly used in combination with other antituberculines to increase efficiency and reduce the risk of resistance development. Treatment requires co - administration of Vitamin B6 and B12! (rich in meats, liver soybeans, potato skin and avocado) Contraindications: Severe liver and kidney damage and pregnancy. Side effects: Generally well tolerated., Rifampicin and Rifabutin may change color of excretions, secretions of urine, tears, feces and sweat. Optic nerve neuritis, nausea, vomiting, Disulfiram-like effect (= alcohol intolerance), nephrotoxicity ,ototoxicity, hepatotoxicity (INH) and blood dyscrasias. Commonly used substances: Rifampin (RifadinВ®) Also used for for eradication of Neisseria meningitides and Haemophilus influenzae from Nasopharynx for infection prevention in Meningitis outbreaks! Streptomycin, Rifabutin (MycobutinВ®), Ethambutol HCL (MyambutolВ®) and Isoniazid INH, Kanamycin (KantrexВ®) 165 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Antiviral Medication Antiviral medication treatment has to be started as soon as possible in cases of an acute viral infection or reoccurrence of acute flares in a preexisting viral infection. Virostatic effect due to implementation of artificial nucleotides within the DNA chain. Termination of viral infections in acute phases of HSV-1, HSV-2, VZV and Eppstein-Barr Virus possible. May be used for preventive treatment only in situations of immune suppression. Treatment requires sufficient hydration and has to be started as soon as possible in case of infection. Course of treatment has to be completed to avoid development of drug resistance. Treatment of Herpes genitalis requires sexual inactivity for duration of the treatment. Medications do not cure for HSV and CMV infections. Contraindications: Hepatic or renal dysfunction, pregnancy and lactation. Side effects: Blood Dyscrasias, electrolyte dysbalance, nephrotoxicity, thrombocytopenia and pancreatitis. Commonly used substances: Aciclovir (ZoviraxВ®) HSV 1 and HSV 2 Ganciclovir (DHPGВ®) CMV infections only Famciclovir (FamvirВ®) VZV infections Trifluridine (ViropticВ®) HSV keratokonfjuntivitis Valacyclovir (ValtrexВ®) Drug of choice for genital herpes Penciclovir (DenavirВ®) topical herpes infections Cidofovir (VistideВ®) CMV retinitis in HIV infections Influenza specific antiviral substances Amantadine, Rimantadine limit duration and intensity of Influenza infections. Leukopenia is most significant side effect. RESPIRATORY DISORDERS AND DISEASES Anatomy and Physiology of the respiratory system The anatomical structure of the respiratory system is divided in the upper and lower respiratory tract. The upper respirartory tract is designed to clean, moisturize and warm the breathing air while the actual gas exchange takes place in the lower respiratory tract. Inspiration is innervated and synchronized by the autonomous nervous system which triggers the contraction of diaphraghm which pulls lungs downwards and increases of negative intrapleural pressure, while in expiration the intrapleural pressure decreases due to an upward movement of the lungs after relaxation of the diaphragm. The intrahoracic pressure is generally negative. Diagnostic tests Spirometry Pulmonary function testing and spirometry are diagnostic tests used to measure lung volumes and capacities. The interpretation of the test results allows to identify obstructive and restrictive functional pulmonary disorders by assessment of the following parameters: 166 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂў Vital Capacity (VC) - maximal amount of air exhaled steadily from full inspiration to maximal expiration. Not time dependent. вЂў Forced vital capacity (FVC) - volume of lungs from full inspiration to forced maximal expiration. Expressed as a percentage of the predicted normal for a person. Interpretation: SVC should be >80% predicted, reduced in restrictive disease. FVC is reduced in restrictive disease and also in obstructive disease if air-trapping occurs. вЂў Forced expiratory volume in one second (FEV1) Volume of air expelled in the first second of a forced expiration. Interpretation: Reduced in both obstructive and restrictive disease. вЂў Forced expiratory ratio (FER) % (FEV1/FVC)x100 Percentage of FVC expelled in the first second of a forced expiration. Interpretation: вЂў Forced expiratory flow between 25-75%(FEF 25-75%) Also known as MMEF (maximum midexpiratory flow) Definition: Average expiratory flow rate in the middle part of a forced expiration. Is a sensitive indicator of what is happening in the middle and lower airways but is not as reproducible as is happening in the middle and lower airways but is not as reproducible as FEV1. Interpretation: Normal in restrictive disease. Example of a normal, obstructive and restrictive pattern in a spirometry graph 167 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Chest XвЂ“ray Commonly anterior posterior and lateral view to inspect pulmonary structures and pleural cavity. Computer Tomography (CT) Cross sectional radiological examination of tissues with higher sensitivity for abnormalities than Chest X-ray. Magnetic Resonance Imaging (MRI) Cross sectional examination using proton signals of body fluids in a high energy magnetic field. Does not allow metal in range of scanner or as implant in client. Pulmonary angiogram Injection of radio active contrast media via a CVC into right side of heart. Pulse oxymetry Assessment of oxgen bound to hemoglobin (= oxygen saturation) in peripheric blood. Normal arterial oxygen saturation is 95% or higher in healthy clients. Method uses a light spectroscopy and can be influenced by dark skin, coloured nails and bright lights. Thoracocentesis Puncture of pleural cavity to aspire pleural fluids or effusions for diagnostic and/or therapeutic purposes. Arterial blood gas analysis вЂњAstrup вЂ“ TestвЂќ Aspiration of arterial blood from a capillary or an artery to assess oxygenation and acid вЂ“ base status. Sputum analysis For asservation of material for microbiological and cytological examination. Skin testing Intradermal testing. To measure induration from 48 вЂ“ 72 hours after injection. Indurations of 5mm diameter or greater and indicate recent tuberculosis exposure or possible HIV infection. Indurations of >10mm in diameter are significant for active tuberculosis. A positive result does not proof the diagnosis of an infection but is evidence for a previous antigen contact by the tested individual. Airway management Oropharyngeal Tubus (Guedel Tubus). Preventing posterior tongue displacement in an unconscious client. Nasopharyngeal Tubus For semiconscious clients or in situations where oropharyngeal tube is not tolerated or fittable. Endotracheal intubation Long term airway management in connection with a respirator. Tracheostomy Surgical transtracheal placement of an airway for prolonged mechanical ventilation. Cricothyrotomy Surgical placement of an intratracheal airway in an emergency situation by incision of the cricothyroid membrane between the cricothyroid cartilage and the 1st tracheal cartilage ring. Suctioning Performed to clear any patent airway from obstructive mucous. Must not be performed > 10 seconds in adults and > 5 seconds in children. Positioning Adequate positioning in a respiratory distress situation is an important factor to decrease the airway resistance. 168 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂў вЂў вЂў In any respiratory failure body position must be at least 45 degrees elevated. In a single sided pulmonary dysfunction the client may be placed in a side lying position with the affected lung upwards to improve the ventilation/perfusion matching of the damaged lung. In an Adult Respiratory Distress Syndrome ARDS the patient may need to be positioned alternating on sides and back to improve the ventilation/perfusion matching of the remaining functional pulmonary areas. Oxygen administration methods Nasal cannula: Allows 1вЂ“6 L/min O2/min provides 24вЂ“44% oxygen concentration of inspiratory volume. O2 Administration has to be performed cautiously in clients with COPD to avoid respiratory failure due to the decrease of paCO2 or under use of Venturi mask which can be adjusted to deliver exact concentrations of O2. Methods of mechanical ventilation Types of ventilators differ by trigger вЂў Positive pressure time cycled ventilator вЂў Positive pressure volume cycled ventilator вЂў Positive pressure pressure cycled ventilator вЂў Positive pressure jet ventilator вЂў Negative pressure ventilator (Iron lung) Modes of ventilation вЂў Intermittent Mandatory Ventilation IMV вЂў Assist Control Ventilation ACV вЂў Controlled mandatory Ventilation CMV вЂў Synchronized Intermittent Mandatory Ventilation SIMV Ventilator settings 1. PEEP positive end-expiratory pressure 2. FiO2 fraction = amount of O2 inhaled via ventilator 3. Tidal volume VT 4. Breathing rate per minute Indications for ventilator respiration: вЂў O2 Saturation < 80% вЂў pH < 7,35 вЂў PaCO2 > 50mmHg вЂў VT < 5mL/kg Bodyweight вЂў Minute volume < 10 L/min Client care after lung surgery After lobectomy an equal alternating positioning on back and either side is necessary to avoid atelectasis and to optimize the ventilation вЂ“ perfusion ratio for the remaining lung. After segmental resection a positioning on side of surgery can cause damage to the surgical wound. After pneumonectomy client is to be preferably positioned on back and halfway turned to side of resected lung. 169 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Obstructive pulmonary diseases Emphysema Emphysema is caused by ongoing destruction of alveoli leading to a decrease of functional pulmonary tissue surface. An emphysema is typically the terminal outcome of a long history of progressive COPD where a chronic obstruction of airways leads to a limited ability for sufficient air exhalation. Trapped air distenses the airways and leads to their systematic collapse over time which increases the airway resistance. A hereditary but rare Alpha 1вЂ“antitrypsine deficiency may also cause the development of an emphysema. Commonly occurring with emphysema are frequent pulmonary infections. A вЂ�barrel chestвЂ™ can be observed after a long lasting development of an emphysema due to the total loss of the pulmonary elastic structures. Clients may need to use auxiliary breathing muscles and pursed lip breathing. Symptoms and diagnostic findings: вЂњPink pufferвЂќ appearance in advanced stades of emphysema characterized by pursed lip breathing and barrel chest. The ability for physical exertion gradually decreases with a progressing emphysema. PO2 , PCO2 in ABG normal or elevated depending on stages. Compensatory erythrocyosis. Chest X-ray shows clear, enlarged lungs, flattened diaphraghm. VC and FEV1 Wheezes, crackles or silent chest are audible findings. Pneumothorax due to overdistended and rupturing alveoli. Treatment: Treatment or removal of underlying cause. (e. g. smoke withdrawal) Medication therapy with oral and inhalative bronchodilators. Also chest physiotherapy, intermittent positive pressure breathing (e.g. cPAP) in acute respiratory problems. Surgical removal of destructed pulmonary areas. Long term oxygene home therapy. Client education. Condition is incurable. Therapeutic goal is to slow and limit progression. Chronic Bronchitis Chronic airway inflammation. Defined by a history of chronic cough over a period of 3 consecutive months within 2 years. Mainly caused by smoking. Recurrent respiratory tract infections. Development of COPD, emphysema and pulmonary hypertension in advanced stages. Symptoms and diagnostic findings: Chest X-ray: enlarged right heart, congested lung fields and flattened diaphraghm. Pulmonary function decreased: VC , FEV1 , FEV1/FVC ratio Treatment: Smoking cessation. Otherwise comparable to emphysema treatment. Chronic Obstructive Pulmonary Disease COPD/COLD Chronic pulmonary obstruction that is not fully reversible by medication therapy. Commonly caused by a chronic inflammation of the airways of the lower respiratory tract such as a chronic bronchitis or an emphysema. Asthma Chronic recurrent obstructive lung disease with sudden onset of dyspnea. Multiple intrinsic and extrinsic causes. Flares occur unpredictably and from a variety of triggers. Generalized bronchospasm leads to ventilation perfusion mismatch under excretion of thick mucous. Symptoms and diagnostic findings: Severe breathing difficulties. Client may be unable to move or speak. Prolonged expiration. Agitation, tachypnea. Either audible wheezes or silent chest in case of 170 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com atelectasis or trapped air. Eosinophilia. Pulmonary function: RV , VC , FEV1 , peak expiratory flow . Chest X вЂ“ ray may be unsuspicious Treatment: Bronchodilators, corticosteroids, oxygen therapy in acute dyspnea. Treatment of chronic asthma involves use of short acting bronchodilators on demand as well as corticosteroids and theophylline. Client may require intravenous medication and mechanical ventilation in acute flares that do not respond to regular medication therapy. Desensitization in cases of allergic asthma. Relaxation techniques. Pleural effusion Fluid accumulation in pleural spaces may occur for multiple reasons. Depending on the consistency pleural effusions are characterized as follow: Transudate due to protein deficiency and increased hydrostatic pressure in renal and liver diseases and chronic heart failure. Contains small amounts of proteins. Exsudate Contains large amounts of protein and appears in malignancies and infections. Empyema Pus in pleural space due to underlying pneumonia, abscess, tuberculosis. Chylothorax Accumulation of lymphatic fluids in pleural space due to disease or surgery related damage of lymphatic vessels. Hemothorax due to bleeding in intrapleural space after rib fractures, lung injuries or due to lung malignancies. Symptoms and diagnostic findings: Dyspnea, limited movement of lungs, decreased breathing sounds and dull percussion over affected side. Fluid accumulations visible in pleural space ultrasound examination and chest x-ray. Chylothorax will cause malabsorption of fat from gastrointestinal tract. Treatment: Treatment of underlying cause. Acute treatment for depressurization of pleural space may involve loop diuretics and thoracocentesis as well as oxygen supply. Acquired specimen has to be asservated for microbiological and laboratory examination and for differentiation between transudate and exsudate. Pneumothorax Air filled pleural space, most commonly due to spontaneous rupture of emphysematic bullae. Affected clients are mostly slim tall young males. Other causes are trauma or pulmonary emphysema. Traumatic pneumothorax occurs due to a lung rupture or a rupture of the chest wall. Pneumothorax may lead to an intrapleural tension causing a life threatening shift of the mediastinum to the opposite side of the injury and mostly requires emergency treatment by placing a chest tube for intrapleural pressure relief. A smaller spontaneous pneumothorax may heal spontaneously and does not require any intervention. Symptoms and diagnostic findings: Dyspnea, affected side with absent breathing sounds or crepitation, dull percussion, limited chest expansion, X-ray shows collapsed lung, PO2 . Treatment: Small air accumulations in cases of spontaneous pneumothorax may not cause significant symptoms and heal without further intervention since air will be absorbed in 171 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com interpleural space. Placement of a thoracic drainage or tube is required in cases of more significant air accumulations or in a tension pneumothorax. Atelectasis Collapse of parts of pulmonary tissue or of a complete lung caused by bronchial obstruction. Typical causes are tumors, hypoventilation and longstanding COPD. An existing atelectasis is susceptible to develop pneumonia or bronchitis. Clients after immobilizing operations require chest physiotherapy for atelectasis prevention. Symptoms and diagnostic findings: Fever, Leukocytosis if accompanied by a pulmonary infection. Dyspnea, depending on size of unventilated lung tissue. Hypoxemia, diminished breathing sounds and altered percussion. Marked area of unventilated lung tissue in chest x-ray study. Treatment : Treatment of underlying cause, Treatment of hypoxemia as needed and prevention of further atelectasis.x x Pneumonia Inflammatory disease of pulmonary alveoli and bronchioles as the actual pulmonary tissue. Causes of bacterial infections are classified by community and hospital acquired infections. Streptococcus pneumoniae is the most common infectious causative agent for pneumonia overall. Community based bacterial pneumonia also arises from infections with Escherischia coli, Pseudomonas aeruginosa, Haemophilus influenzae, Klebsiella pneumoniae and influenza viruses. Also viral and fungal infections possible as well as atypical bacterial infections. Other causes include aspirations of food particles in uncontrolled vomiting or swallowing difficulties as well as inhaled chemical agents or foreign bodies. Symptoms and diagnostic findings: Fever (moderate in viral, high in bacterial infections), dyspnea, unproductive cough, leucocytosis and chest X-ray with more or less infiltrates depending on cause. Almost clear chest x-rays in cases of atypical pneumonia! Treatment: Antibiotic and fever treatment, analgetic medication, oxygen supply, upright positioning, fluid supply, mechanical ventilation as required. Tuberculosis Specific bacterial infection of pulmonary tissue. Causative agent is the gram positive Mycobacterium tuberculosis. Diagnosis is made by proof of acid fast bacteria in sputum sample or samples from fasting gastric secretion. Transmission occurs via airborne drop infection from infected individuals. Infection of otherwise healthy people usually requires a more frequent contact. Clients with immune compromising other conditions, alcoholism and / or in stades of malnutrition are at a significantly higher risk for infections. Lungs are most common sites of infection but other body tissues can be affected as well. Infection induces the upbuild of Granulomata after activation of cell mediated immune response. Symptoms and diagnostic findings: Coughing from unproductive to productive with pink sputum, weight loss, anorexia, night sweats and positive skin testing. Ghon tubercle in chest x-ray marks newly developed infection. Proof of diagnosis via acid-fast bacillus sputum samples or samples of fasting gastric secretion over three consecutive days. 172 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Treatment: CDC standards and airborne precautions: Isolation in private room, negative air room pressure, 6вЂ“12 full air exchanges per hour, personnel and visitors to wear fitted mask in patients room, client to wear mask when transferred to other departments, antimicrobial therapy and oxygen supply as needed. Antibiotic exposure prohylaxis with Isoniazid over 6 months with no clinical evidence of infection and for 12 months with clinical evidence of infection. Treatment of active disease by following one of four CDC treatment plans. Pulmonary Embolism Pulmonary embolism is caused by a sudden partial or total blockage of the pulmonal artery or multiple pulmonal arterioles by blood clots, fat or air. Blood clots mostly arise from a deep vein thrombosis or from another thrombosis and get shifted through the veinous circulation. Air or fat embolism occurs more frequently after trauma or major surgical treatments. Pulmonary embolism in general is a life threatening condition, especially if clots block the main pulmonal arteries leading to pulmonal infarction. Risk factors are comparable with risk factors for deep vein thrombosis and include immobilization, hypercoagulability, trauma and major surgery, especially joint replacement and gynecological surgery. Symptoms and diagnostic findings: Sudden chest pain, hemoptysis, hypotension, decrease of S02 and PaO2, tachycardia, anxiety, restlessness, agitation, loss of consciousness, cyanosis and lung crackles. Chest X-ray may be unsuspicious in early stages. Diagnosis is made via pulmonary angiogram or ventilation perfusion scan. Treatment: High volume oxygene supply, intravenous line, circulation support, if available thrombolytic therapy or emblectomy and sedation. Cava filter placement in vena cava inferior to prevent additional emboli. Bronchopulmonary Dysplasia BPD BPD is a chronic obstructive pulmonary dysfunction in infants which typically occurs after prolonged periods of oxygen therapy or mechanical ventilation. Commonly occurring in premature children with a history of respiratory distress syndrome at birth because the bronchial epithelium suffers damage from air pressure and high oxygen concentrations. As a consequence a generalized pulmonary fibrosis occurs and limits the gas exchange surface area. Symptoms and diagnostic findings: Hypercapnia and respiratory acidosis, hyperventilation, chronic hypoxia, poor feeding, failure to thrive, increased respiratory tract infections. Treatment: Clients require mucolytic, bronchodilating and corticosteroid medication, prophylactic antibiotic treatment may be necessary. Strict infection control practices among hospital staff and family members is mandatory as well as CPR training for parents. If children are discharged with tracheostoma precautions have to be met. Mandatory precautions for clients requiring tracheostoma care: No handling of small items in front of tracheostoma. Appplying a loose cover over tracheostoma during meals. Showering not allowed. Bathing under precautions to assure that no water is entering tracheostoma. Tracheostomy tie change with assistance only. 173 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Laryngotracheobronchitis LTB/Croup Inflammation of the upper respiratory tract due to viral infections with respiratory syncytial virus (RSB), influenza, parainfluenza and mycoplasma pneumoniae causing swelling of mucous membranes in upper airways. Typical clinical expression is an inspiratory stridor. May cause respiratory acidosis and failure. Symptoms and diagnostic findings: Barking cough, inspiratory stridor, thick bronchial secretions, increased and exhausting respiratory effort, low grade fever, muscle and body achiness and headaches. Treatment: Creating a calm environment by keeping parents at bedside. If possible accomplish cool and humidified breathing air. Oxygen supplementation. Upright positioning, bronchodilating medication. Corticosteroids to reduce airway edema. Be aware of sudden relapse after initial improvement ! Epiglottitis Most commonly caused by infection with haemophilus influenzae leading to a bright red, severe and tender swelling of the epiglottis. Mainly occurring in chidren from 2вЂ“8 years of age. Sudden onset , full obstruction within 1 to 6 hours possible. Symptoms and diagnostic findings: High fever of up to 102 F, pale facial expression, drooling saliva, altered voice, severe tender dysphagia and agitation. Proof of diagnosis via lateral neck x-ray revealing a thickened and displaced epiglottis cartilage. Treatment: Creating a calm environment, client may require intubation or tracheotomy, antibiotics antipyretics, corticosteroids, hydration and maintaining an NPO Status. Bronchiolitis Inflammation of bronchioles triggered by infection with Rhino-syncytial virus RSV. Most commonly occurring in children up to 2 years of age. Slowly developing from an upper respiratory tract infection. RSV is able to spread via airborne and drop infection. Symptoms and diagnostic findings: Low grade fever, labored breathing, severe tachypnea with nasal and thoracic retractions, thick secretions from nose and upper respiratory tract. Auscultation of wheezes and crackles. Treatment: Suctioning of secretions, rest, upright positioning, bronchodilators and steroids, fever relief with acetaminophen or ibuprofen and fluid supply. Respiratory Medication Therapy Bronchodilators Beta-agonist sympathomimetics Pharmacological effect: Sympatomimetic bronchodilators connect with betaвЂ“2 receptors on bronchial membranes and lead to release of cAMP (cyclic adenosine monophosphate) which will leads to a dilation of bronchi and bronchioles. Indication: Acute Asthma attack, acute Dyspnea in a Chronic obstructive lung disease (COPD), Long term Asthma and COPD treatment. Special considerations and side effects: вЂў The therapeutic effect of Beta-2 mimetic medication decreases with increase of 174 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com administered dose and frequency. Side-effects increase with increased dosage. Once Beta-2 receptors are saturated with Beta-mimetic medication there is no further therapeutic effect until the substance is released from receptor. вЂў This process can be enhanced by intermittent use of inhalatory corticosteroids. вЂў Increased dosage may also lead to stimulation of Beta1-sympatomimetic receptors leading to tachycardia, hypertension, palpitations, tremor and anxiety. вЂў These effects may be increased under caffeine consume which should be avoided during the treatment. вЂў Sympatomimetics have to be used with caution in patients with cardiovascular disease. вЂў Symptomimetics are contraindicated in combination with Monoamine oxidase inhibitors. (MAOIвЂ™s) вЂў Administration of inhalatory Sympatomimetics requires adequate patient education. вЂў There should be between 1вЂ“5 minutes of waiting time in between dosages вЂў If administration of a maximum dosage does not lead to a relief of the bronchospasm within minutes a physician has to be contacted. вЂў Diabetes patients may respond with hyperglycemia. вЂў During treatment of an acute dyspnea due to a flare of asthma or COPD it is very important to remain calm and reassure the patient about a positive outcome. Substances: Albuterol (ProventilВ®), Bitolterol mesylate (TornalateВ®), Formoterol (ForadiВ®) Isoprotenerol (IsuprelВ®), Metaproterenol sulfate (AlupentВ®) Pirabuterol acetate (MaxairВ®), Salmeterol (SereventВ®), Terbutaline sulfate (BrethineВ®) вЂў вЂў Salmeterol and Formoterol is not indicated for an acute treatment since its effect starts after 20 minutes and lasts for 12 hours! Albuterol, Bitolterol, Metaproterenol and Terbutaline is not indicated in children under 12 years of age! вЂњHow to ..вЂќ use a metered dose inhaler 1. Insert medication cartridge into inhaler. 2. Remove cap from mouthpiece and hold inhaler upright. 3. Shake inhaler for 3 вЂ“ 5 seconds. 4. Hold inhaler upright with mouthpiece downwards. 5. Tilt head lightly backwards. 6. Close lips tightly around mouthpiece. 7. Release dosage while taking a deep, slow breath for 3 вЂ“ 5 seconds. 8. Hold breath for 10 seconds. 9. Exhale. 10. Rinse mouth and blow nose. 11. Clean mouthpiece with mild soap. 12. Store inhaler at room temperature. Anticholinergic Bronchodilators Pharmacological effect: Blocking Acetylcholine receptors of the PNS on bronchial membranes. Indication: Acute Asthma attacks 175 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Acute Dyspnea in a Chronic obstructive lung disease (COPD) Special considerations and side effects: вЂў Lower potency than sympathomimetics. вЂў Immediate but short lasting effect. вЂў Can be used in an acute bronchoconstriction even in combination with sympathomimetics. вЂў May cause anticholinergic effects: dryness of mouth, tachycardia, hypertension, palpitations, tremor, anxiety, urinary retention, diarrhea, nausea and vomiting. Substances : Ipratropiumbromide (AtroventВ® and CombiventВ®), Tiotropium (SprivaВ®) Xanthines Pharmacological effect: Inhibition of the enzyme phosphodiesterase (PDE) Increase of cAMP in smooth muscle cells to achieve a bronchial dilation. Increase of catecholamine levels. Inhibiting synthesis of Prostaglandines. Inhibiting release of cellular mediators Prostaglandin, Histamine, Thromboxane, from leucocytes and mastcells. Indication: Status asthmaticus, mild and moderate Asthma attacks, pulmonary edema. Special considerations and side effects: вЂў Long term treatment requires monitoring of blood levels. вЂў Therapeutic range: 10 вЂ“ 20 mcg/mL вЂў Slower onset of effect than inhalers, especially if administered orally. вЂў Same stimulating effects, side effects to the cardiovascular system and central nervous system as Sympathomimetics. вЂў Euphoric effect, comparable to and increased by caffeine. вЂў Overdose may cause irritability, insomnia, restlessness, palpitations,hypertension. вЂў Not FDA approved for other pulmonary obstructive diseases than asthma. Substances: Aminophylline (TruphyllineВ®), Theophylline (Theo вЂ“ DurВ®) Inhalatory topical corticosteroids Pharmacological effect: Antiinflammatory effect on bronchial membranes. Probably due to inhibition of release and production of inflammatory mediator substances from leukocytes. Indication: Obstructive pulmonary diseases Special considerations and side effects: вЂў Used either in combination with short or long term effective bronchodilators or as a monotherapy to prevent bronchoconstrictions. вЂў Dosage has to be limited if client takes systemic corticosteroids as well. вЂў Client is supposed to rinse mouth after each use. вЂў Medication has to be tapered off, over 2 weeks. No sudden termination. вЂў Careful use in the following conditions: o Glaucoma o Congestive heart failure o Myasthenia gravis o Seizures o Inflammatory bowel diseases 176 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂў вЂў o o o o Hypertension Thromboembolic disorders Esophagitis Inflammations o o o o o Opportunistic infections Aquired immunodeficiency syndrome (AIDS) Tuberculosis Children < 2 years Thrombocytopenia o o o o o o o Risk of reduced bone growth in children Pharyngeal irritation Diarrhea, nausea and vomiting Headaches Adrenocortical suppression and AddisonвЂ™s Disease CushingвЂ™s Syndrome Weight gain Contraindications: Side effects: Substances: Beclomethasone (diproprionate) = fewest side effects, greatest anti-inflammatory effect. Budesonide (PulmicortВ®), Flunisolide (Aero-bidВ®) and Triamcinolone (AzmacortВ®) Inhalatory mast cell stabilizers Pharmacological effect: Inhibition of release of inflammatory mediator substances from mast cells. (= sessile lymphocytes). Indication: Preventive treatment of inflammatory airway diseases. Special considerations and side effects: o May help to decrease dosage of steroids and bronchodilators. o Effect may not be noticeable for treatment but flares may be rare ( = 3rd wheel of treatment). o Not suitable in acute exacerbations and breathing difficulties. o Dosage adaptation in renal or hepatic diseases necessary. o Propellants of Aerosols may aggravate symptoms of a CAD or Dysrhytmias! o Client to rinse mouth after each use. o If prescribed, bronchodilators administered 30 minutes prior to the use of inhalatory mast cell stabilizers may incease their effect. Substances: Cromolyn (IntalВ®) and Nedocromil (TiladeВ®) Leukotriene modifiers Pharmacological effect: Blocking action of leucotrienes which are released from mast cells and lymphocytes during an allergic reaction. Indication: Long term preventive treatment of Asthma in children and adults. Special considerations and side effects: Leukotriene modifiers work specifically in pulmonary tissue. Onset of effect may take up to one week. To be prescribed to children from 12 years of age and adults. May be used 177 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com singularly or in combination with corticoteroids. May cause headaches, nausea, diarrhea and dyspepsia. Substances: Montelukast (SingulairВ®), Zafirlukast (AccolateВ®), Zileuton (ZyfloВ®) Antihistamines Pharmacological effect: Blocking action of histamines by competitive block of histamine receptors. Indication: Prevention and treatment of allergic reactions, cough and sneeze relief in common colds. Therapeutic use: Prevention and relief of common allergic symptoms: (Urticaria, Quincke edema, allergic rash, itching, bronchospasm and sneezing), inhibition of oral, nasal, lacrimal, gastrointestinal and saliva glands. Not indicated in an acute asthma attack. May be given prior administration of blood products as a precaution. Onset of effect usually within 15вЂ“60 minutes, lasting for 6вЂ“12 hours. Side effects: Anticholinergic: Dry mouth, mydriasis, urine retention, constipation, nausea and vomiting. Bone marrow depression, pancytopenia and agranulocytosis. Sedation, light to deep especially in antihistamines of the 1st generation. Special considerations: Antihistamines as well as corticosteroids interfere with any diagnostic skin testing for allergies and should not be taken 72 hours prior such testing. Substances: вЂў First Generation, sedating Diphenhydramine (BenadrylВ®), Brompheniramine (DimetaneВ®), Chlorpheniramine (Chlor-TrimetonВ®), Dimenhydrinate (DramamineВ®), Clemastine (TavistВ®), Promethazine (PhenerganВ®) вЂў Second Generation, non вЂ“ sedating (can be used in children over 6 years) Loratadine (ClaritinВ®), Cetirizine (ZyrtecВ®), Fexofenadine (AllegraВ®) Nasal Decongestants Pharmacological effect: Nasal decongestants are sympathomimetics and stimulate specifically alpha1-receptors. Symptomimetic effect causes downswelling of nasal mucosal membrane due to vasoconstriction in supplying arteries. Indication: Rhinitis in upper respiratory tract infections and allergic reactions. Therapeutic use: Relief from nasal congestion. Side effects: Rebound decongestion if used longer than 3 days or repeatedly. Addictive potential leading to privinism. Sympatomimetic stimulation may lead to hypertension, tachycardia, dysrhymias. Restricted use in clients with history of cardiovascular disease. Special considerations: Nasal congestion inhibits sucking in infants. Therefore decongestant should be applied 30 minutes prior to bottle feeding. Clients have to be taught about addictive potential and very temporary benefits and alternatives (i. e. steam inhalations). Cardiovascular side effects may also occur in children. 178 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Substances: Phenylefrine (neo вЂ“ Synefrine), Pseudoephedrine (Sudafed), Ephedrine (Vicks Vatronol) Naphazoline (Privine), Oxymetazoline (Afrin), Tetrahydrozoline (Tyzine) and Xylometazoline (Otrivin) Expectorants Pharmacological effect: Not fully inestigated and questionable. Indication: Fluid secretion in respiratory tract infections. Therapeutic use: Dilution and increased secretion of fluids in repiratory tract infections of questionable effectiveness. Medication requires an adequate fluid intake. Substances : Sodium chloride solution, Acetylcyteine (Mucomyst) and Dornase alfa (Pulmozyme вЂ“ for clients with cystic fibrosis only). Antitussiva Opioids = (Codeine) and non-opioid antitussives are available. Direct inhibition of cough reflex center in brain stem. Dry, hacking unproductive cough. Non-opioid antitussiva dextrometorphan is first choice since it does not cause CNS depression. Side effects: Dependency, CNS depression with codeine. Dry mucous membranes with dextrometorphan. Oxygene therapy Pure oxygene can be directly administered in a flow rate of 1 L/min.вЂ“6 L/min. Oxygen dries mucous membranes and needs to be applied with humidifier. Prolonged supply of high concentrations of oxygene can cause damages of lung tissue. First symptoms of oxygene toxicity are cough, chest pain and gastrointestinal symptoms. Side effects: Atelectasis, alveolar collapse due to oxygene supply at a concentration of 60% over 36 hours or of 90% over 6 hours. ARDS Adult respiratory distress syndrome may occur due to 80вЂ“100% of oxygen for more than 24 hours. Outcome may be pulmonary edema and pulmonary hemorrhage. COPD patients may develop respiratory depression under supply of oxygene in rates >2 L/min. Diagnostic parameter for efficiency of oxygene supply is SaO2. Oxygene therapy must be administered under strict protection from electric sparks, friction or fire. Oxygene applications masks: VenturiвЂ“mask: max. 10 вЂ“ 100 % oxygen administration. Nonrebreather mask: 60 вЂ“ 100 % oxygen administration Partial rebreather mask: 70-90 % oxygen administration X 179 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com CARDIOVASCULAR DISORDERS AND DISEASES Anatomy and Physiology Great vessels and Coronary arteries Circulatory system Cardiac cycle вЂў Diastole: 1. Simultaneous filling of the right atrium by return of venous oxygen deficient blood via the superior and inferior cava veins and of the left atrium by return of oxygenated blood via the pulmonary veins. 2. Opening of the atioventricular valves. 3. Simultaneous filling of the right and left ventricle. 180 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂў Systole: 1. Simultaneous contraction of atrial chambers. 2. Closure of atrioventricular valves origin of 1st heart sound! 3. Simultaneous contraction of ventricular chambers. 4. Closure of pulmonalis and aortic valves origin of 2nd heart sound! Terms and Definitions Heart Rate HR = Heartbeats per minute Stroke Volume SV = amount of blood that the myocardial chambers pump per single heart beat. On average 60 вЂ“ 70 ml in healthy adults. Cardiac output CO = Heart rate (HR) x Stroke volume (SV) Contractility = Strength of the myocardial contraction Preload = Maximal ventricular enddiastolic relaxation. Afterload = Resistance caused by blood pressure in peripheric vascular system. Components of the cardiac conduction system The myocardial cells within the cardiac conduction system are also described as вЂњpacemaker cellsвЂќ since they a are specialized in conducting and progressing an electrical innervation of the myocardium. The pacemaker cells of the different compartments of the cardiac conduction system differ in the rate and strength of the electrical innervation they can induce. Pacemaker cells of the Sinus node elicite the most frequent and strongest electrical impulses. 1. Sinoatrial node Main and natural pacemaker which regulates normal heart rate between 60 вЂ“ 100 bpm. 2. Internodal conduction pathway Connecting SA node with AV node. 3. AV node Replacement pacemaker with 40 вЂ“ 60 depolarizations/minute. 4. HisвЂ™ bundle Connecting AV node with intraventricular nerve conduction fibers. (Left & right branch bundle) 5. Purkinje fibers Terminal ending of intracardial conduction system. Electrocardiography Technical principles: Graphic recording of the electric myocardial activity. Obtainable cardial information: Myocardial perfusion and ischemia, heart size, heart position, hypertrophy and dysrhythmias. 181 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Placement of 12 lead ECG Electrodes Chest: V1 = red, V2 = yellow, V3 = green, V4 = blue V5 = orange, V6 = violet (V and C leads are equivalent) Right Arm: = White Left Arm: = Black Right leg: = Green Left leg: = Red Placement of electrodes (3 вЂ“ lead ECG): One below center of each clavicle bone as well as over lowest rib in left medioclavicular line. Placement of electrodes (5 вЂ“ lead ECG): Placement of additional leads over lowest rib right medioclavicular line. As well as in one position of V1 вЂ“ V6. The standard electrocardiogram (ECG) is a representation of the heart' s electrical activity. It consists of recordings from each of the 12 electrodes on the body surface. The use of 12 recording leads is a convention and has little logical or scientific basis. The basic ECG waveform ( Regular Sinusrhythm, 60-100 bpm) The basic ECG waveform consists of three main recognizable deflections which are described as "P wave", "QRS complex" and "T wave". The P wave represents the spread of electrical activation (depolarization) through the atrial myocardium. Normally, it is a smooth rounded deflection preceeding the QRS complex. The QRS complex represents the spread of electrical activation throughout the ventricular myocardium. It is usually (not always) the largest deflection on the ECG and is "spiky" in shape. Deflections resulting from electrical activation of the ventricles are called QRS complexes, irrespective of whether they start with a positive (above the baseline) or a 182 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com negative (below the baseline) deflection and whether they have one or more recognizable deflections within them. The various components of the QRS complex however, are named on the basis of the following convention: a) The first positive wave (above the baseline) is called r or R. b) Any second positive wave is called r'or R' . c) A negative wave that follows an r or R wave is called a s or S wave. d) A negative wave that precede an r or R wave is called a q or Q wave. e) An entirely negative wave is called a qs or QS wave. f) LARGE DEFLECTIONS are named CAPITAL letters, small waves by small letters. The T wave represents electrical recovery (repolarization) of the ventricular myocardium. It is a broad rounded wave following the QRS complex. The U wave may appear due to a slow replolarization of the papillary muscles. Some causes include: Bradycardia, hypokalemia and digoxin therapies Interpretation of common ECG findings Normal 12 lead ECG Variations of normal ECG findings Sinus arrhytmia R-R Interval changes depending on respirations. Does not require treatment. 183 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Sinus tachycardia HR > 100 вЂ“ 150 bpm. May be caused by fever, hypovolemia and pain. Treatment due to relief of underlying cause. Sinus bradycardia HR < 60 bpm. Treatment is indicated if patient experiences symptoms. Atropin for immediate intervention. Premature Atrial Contractions (PAC) Usually unaltered normal atrial and ventricular heart rate. Caused by early atrial contractions leading to a compensatory break until the following contraction. Mainly caused by stress or overuse of stimulating substances like caffeine, alcohol or tobacco. Paroxysmal Supraventricular Tachycardia (PSVT) Atrial contractions > 100 - > 200 bpm. May not significantly alter the ventricular rhythm. Treatment by stimulation of the autonomous nervous system via carotis sinus stimulation, valsalva maneuver, oxygen supply, adenosine, verapamil, cardio selective beta вЂ“ blockers and ecg-triggered cardioversion. Atrial Flutter Atrial contractions between 240 and 360 bpm, regular. Ventricular response does not overexceed 150 bpm, regular. Treatment with cardioversion or drug treatment with calciumвЂ“channel blockers, betaвЂ“blockers, quinidine, amiodarone or flecainide to reduce ventricular response. 184 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Atrial Fibrillation AF Atrial contractions > 300 bpm, irregular. Ventricular response maximum 180 bpm and irregular (arrhythmia absoluta). Treatment with cardioversion or digoxin, verapamil, betablockers. Unresolvable atrial fibrillation requires anticoagulation to avoid upbuild of intracardial clots. Junctional Escape Rhythm 40вЂ“60 bpm, regular. Stimulation of myocardial tissue originates from conducting atrioventricuklar fibers. Typical replacement rhythm due to irregular or absent sinus node activity. Does require pacemaker treatment if accompanied by symptoms or if heart rate decreases. Premature Ventricular Contractions (PVC) Irregular and variable heart rate. Typically marked by a deformed widened QRS вЂ“ complex with no corresponding P вЂ“ wave. Followed by a compensatory pause. May occur singular, monotop or polytop. PVCвЂ™s can be caused by stress, overuse of stimulating substances like caffeine, alcohol or tobacco or underlying myocardial problem. Drug treatment may be performed with lidocaine, propranolol, procainamide and phenytoine. Serial PVCвЂ™s can develop into ventricular arrhytmias and ventricular fibrillation which is functionally equivalent to a cardigenic shock. Formations of triplet and quadruple premature ventricular contractions are possible as well. Ventricular Tachycardia (VT) 100 - > 200 ventricular, regular bpm. P вЂ“ waves undetectable, multiple and deformed QRS-complexes. Treatment necessary in unstable circulatory condition. Includes lidocaine, procainamide and defibrillation. x Ventricular Fibrillation (VF) Heart rate not detectable. Functional cardiac arrest. Client requires immediate defibrillation. x 185 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Atrioventricular Conduction Blocks 1st degree AV Block Prolonged P-Q interval > 0.20 seconds. Regular sinus rhythm and normal heart rate. No treatment necessary. 2nd degree AV block, type I (Mobitz I, Wenckebach) Pattern of a gradually prolonged PR вЂ“ Interval until ventricular response fails. Normal heart rate. May be a transitional stade after myocardial infarction. Therapeutic intervention is not immediately necessary and depends on symptom development. Drug therapy includes atropine or isoproterenol. 2nd degree AV block, type II, (Mobitz II) Pattern of 2:1 or higher P:QRS ratio, resulting in less than 60 ventricular regular contractions per minute. Clients require pacemaker. Intermediate drug treatment with Atropine or Isoproterenol. 3rd degree AV block Atrial and ventricular contractions are completely unlinked due to total block of the atrioventricular conduction. Ventricular heart rate regular and as low as 15 вЂ“ 60 bpm. Clients require immediate pacemaker therapy. Intraventricular conduction blocks Interruptions of the intraventricular conduction pathway may lead to an altered innervation of the ventricular myocardial innervation, which can be identified as left or right bundle branch blocks in an ECG. The affected clients may be asymptomatic in regards of clinical symptoms of heart failure or coronary heart disease. Bundle Brunch Blocks appear with a prolonged or deformed QRS complex as an incomplete or complete block in order to the following criterias: QRS complex duration < 0.12 sec. = incomplete BB / QRS complex > 0.12 sec. = complete BB Affected leads (C) V1 вЂ“ V3 = Right bundle branch block / (C) V4 вЂ“ V6 = Left bundle branch block 186 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Left bundle branch block LBB Right bundle branch block RBB Coronary Artery Diseases CAD Arteriosclerosis of the coronary arteries causes a decrease of the coronary bood flow and the nutritional and oxygen supply for the mocardium. Cinical complaints may not occur until the vascular diameter is reduced by at least 50%. Typical symptoms of coronary artery disease include congestive heart failure, dysrhytmias, Angina pectoris or myocardial infarction. Common appearance of Angina pectoris: Stable Angina pectoris Chest pain under exertion spontaneously ending when client is resting. Unstable Angina pectoris Chest pain occurs independently from physical activity. Prinzmetal Angina Benign vasospasm with no underlying cause and danger for the myocardial tissue. 187 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Symptoms and diagnostic findings of a Myocardial infarction Nitroglyzerine resistant chest pain, which may radiate to substernal, clavicular or submandibular region. Nausea, vomiting, cold sweats, dyspnea, dysrhythmias and anxiety. ECG findings in acute stades: ST вЂ“ elevations, T-Inversions. Q вЂ“ waves in post - infarction stades. Elevated myocardial enzymes in early stades: CK вЂ“ MB over 6 % of total CK. Troponine Test positive. Treatment: Monitoring of vital signs, ECG holter monitoring and 12-lead ECG, oxygen supply and creation of a calm environment. First line medication treatment includes: Nitroglycerine, Heparine supply under PTT monitoring, Aspirine, Morphine, Fibrinolytic therapy if applicapble, PTCA and CABG (if applicable). CAD specific ECG alterations Typical ECG Alterations in cases of subacute Coronary Artery Disease are ST Segment Depressions. Typical ST Depression in leads II, III, aVF in a client with Coronary Artery Disease. Heart failure (Congestive heart failure) HF Heart failure occurs as a chronically developing myocardial weakness resulting in inefficient blood supply for the cardiovascular system due to a reduced cardiac output. Heart failure typically starts as left or right sided heart failure. Contralateral sides are typically affected over time which results in a global heart failure. Common causes for 188 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com heart failure are cardiomyopathy, coronary artery disease or valvular diseases. An acute left sided heart failure mainly occurs due to a myocardial infarction. Right sided heart failure is described as cor pulmonale and develops predominantly after pulmonary diseases such as COPD, Asthma or Emphysema which cause pulmonary hypertension. Pulmonary embolism causes typically causes an acute right sided heart failure. Pathophysiology of left sided heart failure reduced cardiac output of left ventricle dilation of pulmonary veins pulmonary congestion = (вЂњpulmonary backupвЂќ) pulmonary edema diminished gas exchange moderate to severe dyspnea due to a вЂњfluid lungвЂќ hypoxia hyperkapnia peripheral and/or central cyanosis deficient metabolic supply and gas exchange in peripheral tissues general physical weakness chronic fatigue Pathophysiology of right sided heart failure: fluid retention into systemic venous circulation вЂњvenous backupвЂќ peripheral edema pleural effusions aszites fluid congestion of internal organs ( i.e. Liver, spleen) jugular vein distention in upright position. Treatment: Constant monitoring of blood pressure, heart rate and blood gas analysis, upright positioning, oxygen supply, monitoring of input/output balance, serum electrolytes, fluid restriction and weight assessment. x Pharmacological treatment of congestive heart failure: Angiotensin converting enzyme inhibitors (ACE inhibitors) Blood pressure = afterload . Diuretics (Loop and Thiazide Diuretics) cardiac preload pulmonary congestion . Diuretic medication therapy requires frequent monitoring of serum potassium levels ! Nitroglycerine cardiac preload Morphine Sedation Blood pressure . pulmonary vasodilation hypotension. 189 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Glycosides (Digoxine Digitoxine) heart rate myocardial contractility cardiac output . Digoxin is contraindicated in cases of renal failure and needs to be replaced with Digitoxin which is metabolized through a hepatic pathway only. Frequent monitoring of potassium and calcium levels under glycoside treatment is necessary throughout the course of treatment. A heart rate < 60 bpm under glycoside treatment may require physicians attention. Cardiomyopathy Dysfunction and degeneration of the heart muscle due to multiple underlying causes. Mostly fatal outcome. Common as a secondary development in alcoholism, diabetes, kidney diseases, infections or autoimmune disorders. Classifications: Dilated cardiomyopathy Myocardial degeneration leads to a weakened contractility and widening of the heart. Hypertrophic cardiomyopathy: Myocardial tissue thickens and decreases cardiac output due to a reduced stroke volume. Restrictive cardiomyopathy Loss of elasticity of the myocardial tissue which also results in a reduced stroke volume. Symptoms and diagnostic findings: Cardiomyopathy symptoms are comparable with symptoms of a left sided heart failure. A slow to rapid progression may occur. Generally poor prognosis. Treatment: Condition is incurable. Treatment is focused on underlying cause and on severity of resulting heart failure. Heart transplant may be indicated in some cases. Hereditary heart defects Rare hereditary heart defects may affect the atrial and/or ventricular cardial function but can also remain asymptomatic. Main criteria for the severity of hereditary heart defects is if the pulmonary blood oxygenation is limited leading to cyanosis. Such right left shunt heart defects result from circumstances where the intraatrial or intraventricular pressure of the right heart significantly overcomes the intracardial pressure of the left atrium or ventricle. The incidence of hereditary heart defects is significantly higher in premature children or in cases of malnutrition throughout the early childhood. Symptoms and diagnostic findings: Heart defects with left-to- right shunt: Atrial and Ventricular Septum Defect (ASD and VSD) Persisting Ductus Arteriosus Botalli. (DAB) Clients may be asymptomatic. Systolic murmur is a common significant finding. Advanced stades may lead to a global heart failure. Cyanosis unlikely. Treatment: ASD, VSD and persisting DAB may close spontaneously. Otherwise surgical treatment by insertion of a patch. DAB closure can be induced with oral administration of acetylic salicylic acid ( inhibition of prostaglandine synthesis). 190 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Heart defects with right-to-left shunt: Transposition of the great vessels Aortic vessel originates from right ventricle and pulmonal artery from left ventricle. FallotвЂ™s Tetralogy Combination of pulmonary stenosis, ventricular septum defect, right sided ventricular hypertrophy and overriding aorta. ( Aorta вЂњridesвЂќ over VSD which results in mixed aortic perfusion with oxygenated and unoxygenated blood) Symptoms and diagnostic findings: Cyanosis, вЂњ squatting childвЂќ (reduction of venous return by squatting), severe hypoxia compensatory polyglobulia. Treatment: Surgical correction. Valvular cardiac disorders Destruction and deformation of cardiac valves caused by underlying atherosclerotic degeneration, rheumatism or endocarditis. Defect results in limited opening (stenosis) or insufficient closure (regurgitation/ insuffiency) of heart walves. Most commonly affected are aortic and mitral valve. Symptoms and diagnostic findings: вЂў Aortic walve regurgitation (insufficiency): Left sided backward heart failure, diastolic murmur, enddiastolic overload of left ventricle, Palpitations and premature ventricular contractions possible. вЂў Aortic valve stenosis: Left sided forward heart failure, systolic murmur, cardiac output BP , possible angina pectoris due to insufficient diastolic filling of coronary arteries. вЂў Pulmonal valve regurgitation (insufficiency): Right sided backward heart failure, diastolic murmur, insufficient lung perfusion leading to insufficient blood oxygenation for the entire systemic circulation and enddiastolic overload of right ventricle. вЂў Pulmonal valve stenosis (occurs mostly as birth defect): Right sided forward heart failure, systolic murmur and severely impaired lung perfusion. вЂў Mitral prolapse: Left sided forward heart failure, systolic murmur, mostly asymptomatic May cause palpitatons and premature ventricular contractions. вЂў Mitral regurgitation (insufficiency): Left sided backward heart failure, systolic murmur, atrial fibrillation due to developing overdistention and increased enddiastolic pressure of left. ventricle common. вЂў Mitral stenosis: Left sided forward and backward heart failure, diastolic murmur and increased enddiastolic pressure of left ventricle. вЂў Tricuspidal regurgitation (insufficiency): Right sided backward heart failure, diastolic murmur, increased enddiastolic pressure of right ventricle and decreased lung perfusion. 191 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂў Tricuspidal stenosis: Right sided forward and backward heart failure, systolic murmur, decreased lung perfusion and fluid retention in venous system. Treatment: Treatment options include medications to improve cardiac output or to restore regular heart rhythm as well as surgical valve replacement. Every client with a valvular cardiac disorder requires prophylactic antibiotic treatment before and after valve replacement to avoid endocarditis if procedures or diseases or infections of the oropharyngeal or gastrointestinal tract are current. Materials used for valve replacement are either from a biological source (pigs) or mechanical valves made from titanium which require lifelong anticoagulation treatment with warfarin. Endocarditis Rapidly or chronically developing inflammation of the endocardial tissue due to a bacterial infection which results in a destruction of the endocardial tissue and commonly also in a damage of cardiac valves, mostly of the left sided heart. Starting point is either a predisposition and/or an abnormous high amount of bacterial toxins circulating in the blood stream. A predisposition is usually given by a preexisting cardiac valve disorder or another structural myocardial disorder such as a persisting foramen ovale. These anatomically altered surfaces function as breeding grounds for circulating bacteria. High risk clients are intravenous drug users who mostly acquire defects of the tricuspidal walve and/or the pulmonal walve. Symptoms and diagnostic findings: General malaise, fever and weakness. Elevated inflammatory parameters in blood sample ( ESR, CRP and WBC). Cardial symptoms vary from signs of moderate to severe heart failure to audible murmurs especially if valve destruction has already begun. Examination involves blood culture sample to identify type of underlying bacterial infection for specific antibiotic treatment. Acute infections are mostly caused by Staphyloccocus aureus. Treatment: Clients require strict bedrest until infection is cured. Cardiac treatment is symptom oriented and depends on severity of involvement of cardial structures. Main aspect is cure of underlying infection with intravenous antibiotic therapy. A severely damaged valve may require surgical replacement. Pericarditis Inflammation of the protective pericardial sac. Mostly caused by viral infections such as Coxsackie-, Influenza- or Ademovirus after repiratory infections. Other common causes include DresslerвЂ™s syndrome after myocardial infarction, uremia, tuberculosis and trauma. Symptoms and diagnostic findings: Symptoms of viral illness with fever and elevated inflammatory parameters along with substernal pain. Pericardial effusions may cause cardiac tamponade. Limited cardiac output, symptoms of global or single sided heart failure. ECG may show elevated ST and T waves. Audible friction noises may occur. Chronic stages lead to a restrictive heart failure due to scaring tissue. Treatment: A cardiac tamponade due to a significant pericardial effusion requires urgent pericardial puncture (Pericardiocentesis) as an emergency treatment if it leads to a restrictive heart failure. Other treatment options include pain management, oxygen supply and supportive treatment of heart failure. Anti inflammatory treatment involves non steroidal 192 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com antiinflammatories and corticosteroids. Also, if possible treatment of underlying cause. In a tuberculotic pericarditis the pericardial sac may require surgical fenestration and partial removal. Disorders of the Veins 1. Deep Vein Thrombosis DVT Sudden inhibition of blood flow in the deep vein system due to formation of an intravenous blood clot. Most commonly occurring in lower extremities. Significant risk factors for development of a DVT are: Immobility (e. g. postoperative) leading to inactivity of calf muscles, dehydration, surgical procedures, (total hip joint replacements and pelvic gynecological procedures involving the uterus), hormonal birth control, smoking, varicose veins and previous DVT in clients history. Also hereditary thrombophilia (APC resistence, Antithrombin III deficiency and thrombocytosis), diuretic medication. Paraneoplastic DVTвЂ™s in presence of a malignancy, typically in cases of pancreatic gland cancer. Symptoms and diagnostic findings: Painfull swelling of affected leg at rest and due to movement of ankle, (Hohmans sign) blue discoloration, edema, calf and thigh tender to touch. Diagnostic imaging techniques to reveal disturbed venous circulation include Doppler duplex sonography, radiologic venogram with contrast dye and MRI. Full inhibition of arterial and venous perfusion of affected leg. (Phlegmasia caerulea dolens) 2. Postthrombotic syndrome Symptoms and diagnostic findings: Chronic veinous dysfunction resulting in persistent swelling of affected leg. Treatment: Treatment has to start when a DVT is suspected. Pain relief. Strict immobilization in upright position of upper body. Elevation of affected leg and pressure bandaging (Improvement of veinous return via collateral unaffected veins) Initial administration of Heparine (e. g. 5000 IE UFH) to avoid further blood coagulation on top of existing clot. If confirmed continuation of anticoagulation with oral anticoagulants. Continuation of compression therapy with stockings. Prevention and elimination of DVT causes. 3. Thrombophlebitis Blood clot formation in superficial vein system. Most commonly due to injuries after medical vein punctures or due to varicose veins. Also common under intravenous drug users. May include a bacterial infection with Staphylococcus aureus of Streptococcus viridans bacteria if skin is injured. Symptoms and diagnostic findings: Circumscripted painful red discoloration. Affected area tender and warm to touch. Clot in superficial vein may be palpable, skin injury or puncture in affected area. Treatment: Temporary rest and limited muscular activity of affected limb. Local application of heparine gel or cool packs and pain relief. Antibiotic treatment if bacterial infection is suspected. Thrombophlebitis almost never leads to an embolism within the deep venous system! Hypertension The American Heart Association AHA defines hypertension as a blood pressure from readings of over 140/90 mmHg after ten minutes of rest, if assessed at repeated measurements on at least two different examinations. Readings from 120/80 mmHg to 193 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 139/89mmHg are classified as a prehypertension. Readings below 120/80 are unsuspicious and should be targeted in a antihypertensive therapy. Primary hypertension mainly occurs as an essential hypertension due to a primary vascular disorder of unknown cause. Secondary hypertension is less common and develops due to other underlying disorders or diseases including alcoholism, obesity, hormonal and kidney diseases. Any hypertension aggravates due to smoking, high salt intake and uncontrolled diabetes. Symptoms and diagnostic findings: Hypertension mostly develops slowly over several years without causing any physical complaints. This diagnosis is typically made by routine blood pressure measurements at rest. Other manifestations occur as a hypertensive crisis with sudden acute head or chest pain. Further assessments can reveal signs of left ventricular hypertrophy in an ECG,chronic kidney failure or retina detachments ( Fundus hypertonicus). Routine assessments in newly diagnosed clients are necessary to rule out the following most common underlying causes of secondary hypertension: вЂў Renal artery stenosis (assessed via duplex-sonography) вЂў Catecholamine producing tumors (catecholamines in 24 hour urine sample) вЂў Hyperthyreosis (TSH assessment in blood sample) Malignant hypertension is defined as hypertension that has already caused organ damages such as a MI, a stroke or kidney damage. Treatment: For primary hypertension treatment consists of usually lifelong medication therapy with single use or combination of o o o o o ACE - Inhibitors (Thiazide) вЂ“ Diuretics Beta вЂ“ Blockers Calcium channel blockers Angiotensin 1 вЂ“ inhibitors A strict cardiovascular risk factor assessment and management is necessary to control serum lipids, bodyweight, salt intake, blood sugar and kidney function. Secondary hypertension will be treated by resolving the underlying cause first. x x Periphereal Arterial Disease PAD PAD develops due to atherosclerotic damage of one or several peripheric arteries. Main risk factors are hyperlipidemia, diabetes, smoking and hypertension. Most commonly affected vessels are the aortic artery, inguinal arteries and the arteries of lower extremities. An arterial stenosis develops slowly and does not show any symptoms before the diameter of an artery is narrowed to 25% of the former diameter. Severity of a PAD - Fontaine stades I - IV: I: Narrowing arteriosclerotic process present, but no clinical symptoms. IIa: Intermittent claudication after more than 100 meters IIb: Intermittent claudication after less than 100 meters III: Pain at rest IV: Ulcers and tissue necrosis due to permanent hypoxygenation of tissues. 194 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Symptoms and diagnostic findings: Claudication pain in the affected leg is the most typical symptom observed in a PAD. Also cool and pale extremities, weak or vanished peripheric pulses, cyanosis, disturbed nail and hair growth. PAD may also lead to an acute arterial embolism where an atherosclerotic thrombus may block suddenly an artery which shows the following characteristic вЂњsix pвЂќ symptoms. Pain, Pallor, Pulselessness, Paresthesias, Paralysis and Poikilothermia Thrombi may also develop due to irregular myocardial contractions in cases of atrial fibrillation or after a myocardial infarction. Assessment of location and severity of an arterial stenosis is performed via color duplex ultrasound sonography, digital subtraction angiography (DSA) or plethysmography. Aortic Aneurysm Separation of the intima and externa layer of the aortic wall. Typically caused by atherosclerosis. Most common site is the infrarenal abdominal aorta and the ascending thoracic aorta. Aortic aneurysms may remain asymptomatic for a long time. Diagnosis is then usually made by coincidence during abdominal ultrasound examinations. Acute pain along with signs of poor arterial perfuision indicates an impending rupture and requires emergency surgical intervention with insertion of an alloplastic graft to bypass the aneurysm. Elective Surgery is performed in cases of aneurysms with more than 4 cm in diameter. (normal max. diameter is 2 cm) Treatment: Regulation of all relevant risk factors as a secondary prophylactic treatment. вЂў вЂў вЂў Medication used to inhibit aggregation of platelets: Ticlodipine (TiclidВ®), Clopidogrel (PlavixВ®) and Aspirin Vasodilating medication: Pentoxifylline (TrentalВ®) Analgetic medication. Daily repeated walks until pain occurs will help to stimulate growth of collateral arteries in Fontaine stades up to II b. x Surgical treatment options: Catheterization angioplasty, homologous or autologous bypass grafting, endarterectomy /embolectomy. In cases of acute arterial emboli also thrombolysis within 6 hours to avoid rhabdomyolysis and kidney damage. Any interventional treatment will be performed under temporary heparine therapy and requires postoperative observation of the activated partial thromboplastine time aPTT. After arterial embolism a warfarine treatment may be necessary to avoid upbuild of further thrombi. Diabetic Angiopathy Clients with a history of untreated or undiscovered Diabetes may develop comparable symptoms due to a destruction of the small arteries and capillaries only while main blood vessels may not show any evidence of advanced destruction. 195 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Cardiovascular Medication Therapy Nitrates Pharmacological effect: Dilation of blood vessels due to relaxation of smooth muscles. Physiological systemic effect: вЂў Dilation of coronary arteries вЂў Dilation of venous system = cardial preload (blood volume to return to the heart) = venous вЂњpoolingвЂќ вЂў Dilation of arterial system = cardial afterload (resistance of arterial system to blood ejected from heart) BP вЂў Reduction of myocardial oxygen demand. Indication: Coronary artery disease, pulmonary embolism and chronic heart failure. Therapeutic use: Acute intervention in Angina chest pain. Can be administered as a spray to oral mucous membranes. (most common) Also intravenous, oral (tablets) and transdermal administration (patches and paste). Special considerations: вЂў Patients with angina pectoris must have medication available at bedside for immediate treatment or self administration in case of an acute angina pectoris attack. вЂў Administration of Nitrate capsules and tablets requires adequate moisturization of oral mucous membranes. вЂў Intravenous administration is always performed as an infusion never as a bolus injection. вЂў Nitrate infusion requires dilution of medication in Sodium chloride 0.9 % or D5W. вЂў Regular PVC IV tubing may absorb up to 80 % of Nitroglycerides, especially вЂў under exposure to light. вЂў Manufacturer supplied special, darkened IV tubing and bottles may be used instead. вЂў Intravenous application requires constant monitoring of heart rate and blood pressure (every 15 Minutes). вЂў Nitrate IV solutions and aerosols can be absorbed transcutaneously. вЂў An acute angina type chest pain in a patient with a known coronary artery disease that is not improving under nitrate treatment is suspicious for a myocardial infarction. вЂў Patients with NTG Patch are allowed to swim and to take a bath. вЂў Medication has to be stored in a cool dry place. вЂў Patients with a permanent nitrate treatment must have a 12 hour administration free period within 24 hours. Otherwise the nitrate receptors of the vascular smooth muscle cells are overstimulated and become insensitive towards the medication. Contraindications: Hypersensitivity/allergies against nitrates. Combination with phosphodiesterase inhibitor medications used for treatment of erectile dysfunction (i. e. Sildenafil). May cause severe hypotension. Side effects: Nitrate related headaches, hypotension, vertigo, dizziness, nausea, vomiting, reflex вЂ“ tachycardia due to sudden hypotensive effect. 196 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Substances: Nitroglycerin, (Nitro-TabВ®, NitrstatВ®, NitrogardВ® Isosorbide mononitrate (ImdurВ®, MonoketВ®) and Isosorbide dinitrate (IsordilВ®) Beta-Adrenergic Blockers Pharmacological effect: Blockage of cardial Beta1 receptors of the Sympathetic Nervous system (SNS). In higher dosages also blocking pulmonal Beta2 Receptors. Physiological systemic effect: вЂў HR ( = negative chronotropic effect) вЂў Cardial force of contraction (= negative inotropic effect) вЂў Intracardial conduction velocity (= negative dromotrop effect) вЂў Cardial automaticity (Ability of own stimulation) вЂў Depression of sympathetic autonomous nervous system Indication: вЂў Angina pectoris вЂў Acute myocardial infarction вЂў Long term treatment after myocardial infarction вЂў Hypertension вЂў Supraventricular Tachycardia Special considerations: вЂў Treatment requires frequent monitoring of HR, BP and heart rhythm. вЂў Treatment needs to be reduced or interrupted if HR is < 60 bpm and systolic blood pressure is < 90 mmHg. вЂў Any combination with other hypotensive medication increases hypotensive effect. вЂў Combination with calcium channel blockers may increase bradycardia as well. вЂў Treatment can not be discontinued abruptly and must be tapered off. вЂў High dosages may cause bronchoconstriction. вЂў Beta blockers may disguise hypoglycemic symptoms in clients with Diabetes and may cause a limited insulin production in the pancreatic glands. вЂў Beta-blocker may cause heart block in a pre-existing Wolff-Parkinson White Syndrome. вЂў An exercise tolerance electrocardiogram may show a false negative test result under beta-blockers and should not be performed with clients receiving this treatment. Contraindications: вЂў AV вЂ“ heart blocks from first degree вЂў Valvular cardial disease вЂў Obstructive airway disease вЂў Combination with psychotropic substances вЂў During MAOI Treatment and two weeks after вЂў Severe allergic reactions ( Beta blockers would inhibit adrenaline treatment in case of anaphylaxia)! Side effects: Hypotension, dizziness, depression, psychosis, laryngo вЂ“ and bronchospasm, dry mouth, eyes, glands, agranulocytosis, hypo and hyperglycemia. Substances: Atenolol (TenorminВ®), Betaxolol (KerloneВ®), Bisoprolol (ZebetaВ®), Metoprolol (LopressorВ®) Nadolol (CorgardВ®), Propranolol (InderalВ®) and Timolol (BlocadrenВ®) 197 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Calcium channel blockers Pharmacological effect: Inhibition of calcium ion influx of myocardial and arterial smooth muscle cells avoids their stimulation. Physiological effect: вЂў Dilation of coronary arteries and arterioles вЂў Decrease of peripheric vascular resistance = decrease of afterload. вЂў Dilation of peripheric arteries вЂў Hypotonic effect вЂў Increase of myocardial O2 delivery вЂў Prevention of angina pectoris вЂў Decrease of intracardial conduction velocity (negative dromotropic effect) вЂў Reduction of heart rate (negative chronotropic effect) Indications: вЂў Essential Hypertension вЂў Prevention of Chronic stable Angina pectoris вЂў Treatment of vasospastic (PrinzmetalвЂ™s) Angina вЂў Atrial fibrillation, Atrial flutter and supraventricular Tachycardia (Verapamil + Diltiazem only) Special considerations: вЂў Not to be administered if BP is < 90/60 mmHg вЂў No alteration of serum calcium level occurs вЂў Initial BP and ECG examination prior start of treatment required вЂў Administer Verapamil and Diltiazem with food вЂў IV administration of Verapamil and Diltiazem only via infusion pump вЂў Monitoring of hepatic and renal lab test results вЂў A combination of Verapamil or Diltiazem with Beta вЂ“ blockers may lead to a cardiac arrest and is contraindicated Side effects: Hypotension, dizziness, nausea, vomiting and heart blocks (Diltiazem and Verapamil) Hyperglycemia in clients with diabetes, ankle edema and reflexвЂ“tachycardia due to hypotensive effect. Substances: Amlodipine (NorvascВ®), Felodipine (PlendilВ®), Isradipine (Dynacirc CRВ®), Nicardipine (CardeneВ®), Nifedipin (AdalatВ®) and Nisoldipine (SularВ®). Angiotensin Converting Enzyme (ACE) Inhibitors Pharmacological effect: 1. Inhibition of angiotensin-converting enzyme which catalyzes conversion of angiotensin I to angiotension II. 2. Inhibition of Renin-Aldosterone-Angiotension system RAA. Aldosterone production . Physiological effect: Hypotension due to limitation of angiotensin II. Indications: Hypertension, especially in diabetic nephropathy. Post myocardial infarction blood pressure management. Special considerations: Treatment requires ongoing monitoring of liver function, bilirubin, electrolytes, creatinine, BUN. Avoid potassium containing or elevating drugs and foods. To be taken with food, 198 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com except for Captopril and Moexipril. Medication must be tapered off to avoid rebound hypertension. Contraindications: Pregnancy and lactation, hypersensitivity and allergy. Side effects: Hypotension, palpitations, persistent nonproductive cough and dyspnea, angioedema leukopenia, agranulocytosis and thrombocytopenia. Altered taste in beginning of treatment (Dysgeusia) and rash. Impotence, Hyperkalemia and Hyponatremia. Substances : Benazepril (LotensinВ®), Captopril (CapotenВ®), Enalapril (VasotecВ®), Fosinopril (MonoprilВ®), Lisinopril (PrivinilВ®), Moexipril (UnivascВ®), Perindopril (AceonВ®), Quinapril (AccuprilВ®), Ramipril (AltaceВ®) and Trandolapril (MavikВ®). Angiotensin II Receptor Blockers (ARBS) Pharmacological effect: Blocking Angiotensin II receptor on smooth vascular muscle cells. Physiological effect: Prevention of peripheral vasoconstriction, decrease of blood pressure. Indication: Essential hypertension Special considerations: Careful use in clients with renal or hepatic diseases. Potency is higher than potency of ACE inhibitors. Side effects: Hypotension and related disorders, hyperkalemia and neutropenia. Less coughing and gastrointestinal effects than ACE inhibitors. Contraindications: Pregnancy and lactation. Substances: Candesartan (AtacandВ®), Eprosartan (TevetanВ®), Irbesartan (AvaproВ®) Direct acting Vasodilators Pharmacological effect: Direct vasodilation due to direct interaction with smooth vascular muscle cells in various ways. Physiological effect: BP , HR , Cardiac Output CO Indications: Essential Hypertension and vascular dysfunction (i. e. RaynaudвЂ™s disease). Special considerations: All substances need to be tapered off slowly to avoid rebound hypertension. IV administration requires strict monitoring of HR and BP. Nitroprussidnatrium for IV administration requires monitoring of serum thiocyanate and dilution to 200mcg/mL. Hydralazine can be administered undiluted and by bolus of 10 mg/min. IV Solutions can not be mixed with other substances and need to be stored in a light resistant container. Smoking negates effect of medication! Hot bath and hot shower may increase hypotensive effect. Side effects: Reflextachycardia, hypertension due to baroreceptor reflex, angina, palpitations nausea, vomiting, diarrhea and pancytoepenia. 199 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Thiocyanate intoxication may be caused by sodium nitroprusside! (profound hypotension, tinnitus, atigue, pink skin color,metabolic acidosis, loss of consciousness) Systemic lupus erythematodes вЂ“ like syndrome due to Hydralazine Excessive growth of body hair under Minoxidil Substances : Minoxidil (LonitenВ®), Diazoxide (HyperstatВ®), Hydralazine (ApresolineВ®) Nitroprusside (NipridВ®e) and Trimethapahan (ArfonadВ®) Central and Peripheral Alpha Receptor Blockers Pharmacological effect: Centrally acting alpha-adrenergic blockers stimulate Alpha2 receptors, leading to a lowered stimulation of the central nervous sympathetic system with an inhibition of the cardio accelerator and vasoconstrictor centers of the brainstem. Peripherally acting alpha-adrenergic blocker decrease catecholamine stores in peripheric synaptic vesicules leading to peripheric vasodilation. Physiological effect: BP , HR , CO Special considerations: Guanabenz: 1-2 weeks before maximum response and adjustment of dosage. Guanfancine: 3-4 weeks before maximum response and adjustment of dosage. Methyldopa: 2 days before maximum response and adjustment of dosage. If given orally medication should be administered without food. Methyldopa is not meant to be administered i.m. or s.c. Drowsiness may occur under centrally acting medication Regular monitoring of liver and kidney function including uric acid. Side effects: Sedation, dry mouth, nose, pharynx, parkinsonism, involuntary choreoathetotic movements, nausea, vomiting, diarrhea, peripheral edema, hepatic necrosis, myocarditis and weight gain. Cardiac Glycosides Pharmacological effect: Interaction with potassium receptors on cardial muscle cells as well as on cardiac atrioventricular conduction cells between the Sinus node and the AV node. Physiological effect: Positive inotrope and negative dromotrope. Indications: Chronic heart failure, dysrhytmia, especially absolute arrhythmia in an atrial fibrillation. Special considerations: For parenteral use, glycosids can only be administered intravenously as a push injection of the individual dose over 5 minutes. Full effect of the medication requires to establish a glycoside blood level first. Treatment requires special attention in hypokalemia, renal impairment, hypothyroidism, lung disease, cor pulmonale, heart block, organic or valvular heart diseases and coronary artery disease. Frequent assessments of glycoside and electrolyte blood levels as well as ECG вЂ“ examinations are mandatory! Therapeutic levels: Digoxine:0.5 вЂ“ 2.0 ng/mL Digitoxine 10 вЂ“ 40 mcg/mL Glycoside intoxication occurs with the following symptoms: 200 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com (Flu-like symptoms, Nausea, vomiting, diarrhea, visual disturbances) Digoxine Antidote: digoxine immune fab (Digibind) Hypokalemia through diet and medication has to be avoided. Digoxin effect increases in Hypokalemia and decreases in Hyperkalemia. Digoxin is excreted via the kidneys and should be replaced with Digitoxin in clients with an impaired kidney function. Digitoxin is excreted via the biliary system only. Heart rate assessment has to be performed via apical pulse rate over 1 minute. Side effects: Dysrhytmias, hypotension, A-V heart block, fatigue, muscle weakness, disorientation hallucinations, visual disturbances (blurred, green, yellow vision) and halo-effect. Substances : Digoxine (LanoxinВ®), Digitoxine (CrystodiginВ®) Antidysrhytmics Class I A Antidysrhythmics Fast sodium channel blockers. Pharmacological Effect: Blocking sodium ion channels in cell membranes of cardial pacemaker cells. Prolongation of the myocardial refractory period. Depression of spontaneous depolarization in myocardial pacemaker cells. Physiological Effect: Depression of contractility excitability of myocardial cells. Depression of ectopic excitability. Indications: Ventricular and supraventricular dysrhythmias, premature ventricular and supraventricular contractions. Ventricular tachycardia. Long Term treatment or treatment prior electric cardioversion. Special considerations: Assessment of blood glucose and electrolyte levels mandatory prior to and during treatment. Different types of dysrhythmic medication should not be combined. If treatment switches to another dysthythmic medication or to a contolled release formula, an appropriate time of 6 -12 hours has to elapse. Frequent ECG and BP monitoring in first days of treatment mandatory. Signs of delayed conduction that require intervention are: Prolonged QT вЂ“ Interval, QRS more than 35 % widened. HR < 60 bpm or > 120 bpm. Assessment of apical pulse prior administration of drug. Contraindications: SecondвЂ“and third degree heart block, cardiogenic shock, severe heart failure and hypotension. Side effects: Hypotension, chest pain, dysrhythmias and cardiogenic shock. Headache, fatigue, muscle weakness, paresthesias, nervousness, psychosis, peripheral neuropathy, uterine contractions and onset of myasthenia gravis. Allergic reactions, tinnitus, disorientation, drowsiness, euphoria, difficulties swallowing and speaking. Substances : Disopyramide (NorpaceВ®), Procainamide (PronestylВ®) and Quinidine (QuinagluteВ®) 201 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Class III Antidysrhythmics Local anaesthetics Pharmacological effect: Decrease of refractory period. Elevation of diastolic ventricular electrical stimulation threshold. Suppression of Replacement Rhythm by the His-Pukinje fibers. Physiological effect: Prevention of ventricular dysrhythmias. Indication: Ventricular dysrhythmias. Special considerations: Lidocaine has to be manufactured for intravenous use! First dose applied as a bolus, continuation via infusion of 1g Lidocaine to 250 вЂ“ 500mL of D5W, flow rate maximum 4 ml/min. Treatment can be discontinued as soon as normal heart rhythm occurs. Assessment of blood level of medication and creatinine necessary. Side effects: Comparable pattern as Class I a Antiarrhythmics, including parasympatholytic side effects. Substances : Lidocaine (XylocaineВ®) and Tocainide (TonocardВ®). Class I C Antidysrhythmics Strong sodium channel blockers Pharmacological effect: Down regulation of conductivity in AV node and ventricles. Physiological effect: Prevention and treatment of ventricular dysrhythmias Special considerations: Oral administration. Dosage adaptation every 4 days. Substances: Flecainide (TambocorВ®) and Propafenone (RhytmolВ®). Class II Antidysrhythmics Beta вЂ“ blockers (as previously discussed) Class III Antidysrhythmics Potassium channel blockers Pharmacological effect: Prolongation of repolarization due to limited potassium uptake into cardial pacemaker cells. Physiological effect: Decrease of intraventricular conduction. Indication: Ventricular tachycardia, ventricular fibrillation and supraventricular tachycardia. Special considerations: May aggravate hypo and hyperthyroidism. Leads to increased sensitivity of iodine. Dosage depending Gastroenteritis symptoms. Long half life of up to 55 days. Requires regular assessments of blood levels of medication including liver, kidney function parameters as well as CBC. CNS triggered tremor may occur one week after start of treatment. Requires regular ophthalmic examinations, every 6 months to 1 year. Hypersensitivity to sunlight. Side effects: Corneal microdeposits of medication. Reversible stale-blue pigmentation and rash of skin after one year. Motoric and sensoric neuropathy. Hypotension, Chest pain, Dysrhythmias and cardiogenic shock. 202 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Substances: Amiodarone (CordaroneВ®), Bretylium (BretylolВ®), Dofetilide (CorvertВ®) and Sotalol (BetaspaceВ®) Class IV V Antidysrhythmics Calcium channel blockers as previously dicussed. Class V Antidysrhythmics Adenosin (Adeonocard, Adenoscan) ( Digoxine, Digitoxine, as previously discussed) Pharmacological effect: Interruption of myocardial conductivity and reentry mechanisms. Physiological Effect: Regulation of supraventricular dysrhythmias. Indication: Supraventricular dysrhythmias and identification of heart rhythm. Specific Considerations: Applied intravenously with a bolus injection under permanent ECG montoring. Contraindications: Atrial flutter and fibrillation, hypotension, chest pain, dysrhythmias and cardiogenic shock. Sympathomimetic Antihypotensives Pharmacological Effect: Stimulation of alpha вЂ“ and beta adrenergic receptors. Physiological Effect: Vasoconstriction and increases systemic BP. Increase of heart rate and myocardial contractility. Indication: Shock treatment Specific considerations: Requires dilution and administration via infusion pump. Constant monitoring of Input & Output, vital signs and ECG necessary. May cause hypertensive reactions in clients under MAOI or TCA treatment. Requires correction of depleted blood volume prior to administration. Paravasal infiltration may cause tissue necrosis. To be treated with local injection of diluted Phentolamine mesilate (Regitine). Sympathomimetics are light sensitive are incompatible with sodium bicarbonate. Contraindications: Arrhytmias, blood volume deficit, hypoxia and vascular thrombosis. Side effects: Palpitations, bradycardia, tachycardia, hypertension, arrhytmias, cardiac arrest, bronchospasm, anxiety, restlessness and tremor. Substances : Dobutamin (DobutrexВ®), Dopamine (IntropinВ®), Isoproterenol (IsuprelВ®), Metaraminol (AramineВ®) and Norepinephrine (LevophedВ®) Oral Anticoagulants Sodium warfarin (CoumadinВ®) Pharmacological effect: 1. Prevention of conversion of Vitamin K to induce an insufficient production of the clotting factors II, VII, IX and X. 2. Vitamin K deficiency leads to the inhibition of fibrin formation within the extrinsic pathway of the clotting cascade. 203 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Physiological effect: Prevention or delay of blood coagulation. Special considerations: Coumadin has a high affinity to plasma proteins, especially Albumin and is therefore prone for drug interactions. Medication takes on average one week to reach its therapeutic effect. Daily average dosage varies between 1 and 15 mg. Effect of medication for dosage adjustment is performed by frequent assessment of the prothrombin time PT which is transferred into the international normalized ratio INR. Therapeutic INR levels: (based on indication) Average: 2.0 to 3.0 Mechanical cardiac walve replacement: 3.0 вЂ“ 4.5 Although Vitamin K is a Coumadin Antidot in urgent cases (strong bleedings) a client under warfarin treatment requires FFP (Fresh Frozen Plasma) or prothrombin concentrate. To maintain a secure therapeutic effect client has to be advised on Vitamin K containing food as a part of a general education on how to maintain this treatments and how to avoid and handle bleedings. All patients under prescribed anticoagulation medication have to avoid any medication containing acetylsalicylic acid and ibuprofen, diclofenac or any other nonsteroidal antiinflammatories. Contraindications: Pregnancy Side effects: Bleedings, rash, nausea, hair loss and hepatitis. Direct thrombine inhibitors Rivaroxaban (XareltoВ®), Dabigatran (PradaxaВ®) Altough the FDA approval of these substances is pending at the time as this manual is produced we would like to mention them since it is very likely that these medications will be part of NCLEX вЂ“ Pharmacology questions in the near future. Pharmacological effect: 1. Inhibition of Thrombin (Dabigatran, PradaxaВ®) 2. Inhibition of Factor Xa to interrupt the intrinsic and extrinsic coagulation pathway of the blood coagulation cascade as well as the inhibition of the formation of thrombi. Rivaroxaban (XareltoВ®). Physiological effect: Prevention or delay of blood coagulation. Indication: Prevention of DVTвЂ™s after knee and hip surgery. Anticoagulation in atrial fibrillation. Specific considerations: In comparison to Warfarin these substances do not require monitoring of coagulation parameters. Contraindications: Comparable to Warfarin. Side effects: Comparable to Warfarin. 204 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Heparine Pharmacological effect: Inhibition of the intrinsic, fibrin forming pathway of the clotting cascade by inhibiting the conversion of fibrinogen to fibrin and inhibiting the synthesis of thrombin. Physiological effect: Prevention or delay of blood coagulation. Special considerations: First choice of treatment and prevention of DVT, PE and embolism resulting from atrial fibrillation. Intravenous or subcutaneous administration. Antidot is Protamine sulfate, to be administered intravenously only. Low molecular weight heparin (LMWH) and unfractioned heparine (UFH) are differing in their molecular weight and bioavailability (higher in LMWH). Effect of Heparin therapy is monitored by frequent assessment of the activated partial thromboplastin time. (aPTT) Normal value = 25 вЂ“ 40 seconds. Common Heparin treatment schemes: Low dose UFH therapy for DVT prevention (not aPTT relevant) 5000 U Enoxaparin s.c. every 8 -12 hours or three postoperative dosages. High dose UFH therapy with alteration of the aPTT. Therapeutic goal is to prolong the aPTT 1.5 вЂ“ 2.0 times under intravenous infusion. The average dosage for an adult client is 20,000 вЂ“ 40,000 Units/24 hrs. Administration of subcutaneous heparin injections in a 90 degree angle by rotating the sites and without rubbing the injection areas, using a 25 вЂ“ 27 gauge needle. Side effects: Bleedings. Heparine induced platelet aggregation HITT, resulting in severe thrombocytopenia. Typically after 3rd day of treatment. Osteoporosis under long term therapy (> 6 months). Substances: Heparin (LiquaeminВ®) , Enoxaparine (LovenoxВ®), Dalteparin (FragminВ®) , Tinazaparin (InnohepВ®) and Danaparoid (OrgaranВ®) Antiplatelet Agents Pharmacological Effect: Inhibition of platelet aggregation. Physiological Effect: Prevention of blood clots. Specific considerations: Available medications use different biochemical pathways. Acetylic Salicylic Acid (AsprineВ®) Therapeutic dosages for blood clot inhibition between 81вЂ“325 mg/d. Contraindicated in Asthma, COPD, gastritis, gastric ulcers and gastrointestinal bleedings. Contraindicated in children because of risk of Reye Syndrome. Side effects include: Hemorrhage, blood dyscrasias, gastrointestinal bleedings, and ulcers. Ticlodipine (TiclidВ®) Alternative to ASA if contraindicated or not tolerated. Main side effect is serious agranulocytosis and neutropenia. Used for platelet aggragation and cardiac stress testing. Can cause gastrointestinal complaints and headaches. 205 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Clopidrogel bisulfate (PlavixВ®) Secondary prevention after strokes and MIвЂ™s, Can cause flu вЂ“ like symptoms, chest pain, edema and hypertension. Abciximab (ReoProВ®) Used after PTCA interventions. Administered intravenously. Platelet aggregation inhibitors are generally contraindicated in children, pregnancy and lactation and have to be cessated 7 days prior a scheduled surgery. Fibrinolytics Pharmocological effect: Activation of the fibrinolytic system. Conversion of plasminogen to plasmin helps to digest fibrin and degrading fibrinogen. Physiological effect: Breakdown of an already established thrombus or blood clot. Special considerations: Usually administered in an emergency treatment setting due to an acute MI, PE and DVT. Requires strict cardiac and coagulation monitoring during administration. Effect of streptokinase or urokinase can be restricted or stopped with antidote aminocaproic acid (Amicar). In an uncontrolled bleeding administration of FFP or packed cells may be necessary. Contraindications: History of CVA, Hypertension, Pregnancy, Neoplasm, recent trauma or major surgery. Side effects: Hemorhage, allergic reaction, nausea, vomiting, cardiac arrhythmias and hypotension. Substances: Strepptokinase and Urokinase Antihyperlipidemics HMG-Coenzyme A reductase inhibitors (Statins) Pharmacological effect: Inhibition of Cholesterol synthesis. Physiological effect: Reduction of LDL вЂ“ Cholesterol and light increase of HDL Cholesterol. Special considerations: Medication to be taken at bedtime. No effect on amount and synthesis of lipoproteins. Requires frequent assessment of LFT and CK under treatment. Lipid assessment not until 2 weeks of treatment have passed by. Side effects: Muscle achiness, rhabdomyolysis, elevation of liver enzymes and gastrointestinal symptoms. Substances: Atovastatin (LipitorВ®), Fluvastatin (LescolВ®), Lovastatin (MevacorВ®), Pravastatin (PravacholВ®), Rosuvastatin (CrestorВ®) and Simvastatin (ZocorВ®) Bile Acid Sequestrants Pharmacological effect: Synthetic bile acids bind cholesterol in the gastrointestinal tract. 206 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Physiological effect: Increased amounts of bile acids binding Cholesterol in the gastrointestinal tract lead to decreased Cholesterol serum level. Special considerations: Administration as powders and tablets 2вЂ“4 times/day. Tablets are not meant to be crushed and need to be taken without any other medications. Serum cholesterol starts to reduce 48 hours after start of the treatment. LDL-Cholesterol levels lower after 1 month. Contraindications: Cholestyramine is contraindicated in Phenylketonuria. Side effects: Loss of fat soluble vitamins A,D,K,E and folic acid, rash, pruritus, steatorrhea, hemorrhage after long term use and gastrointestial complaints. Substances: Colestyramine (QuestranВ®) and Colestipol (ColestidВ®). Fibric Acid Derivatives Pharmacological effect: Decrease of very low density lipoproteins VLDL and Chylomicrones, leading to a decrease of Triglycerides. Physiological effect: Lowering of Triglyceride Levels. Less intense effect on HDL and LDL levels. Special considerations: Admininistered in divided dosages twice daily. Therapy may be discontinued after three month of treatment if no improvement is detectable. Side effects: Abdominal and epigastric pain, jaundice, blurred vision, elevation of liver enzymes, cholecystitis, hypokalemia and acute appendicitis. Substances : Clofibrate (AbitrateВ®), Fenofibrate (TricorВ®) and Gemfibrozil (LopidВ®) Nicotinic Acid (Niacin, Vitamin B3) Pharmacological effect: Lowers lipoproteine levels unspecifically. Increases HDL levels. Physiological effect: Improvement of Hyperlipidemia. Peripheric vasodilation. Specific considerations: Normal dose is 500 mg/d. Cholesterol lowering effect from 300 mg/d. Niacin food sources: eggs, dairy products, meat and tuna. Side effects: Flushing, hypotension, hyperglycemia, elevation of liver enzymes, uric acid and blood glucose, dark colored urine and cardiac dysrhythmias. Contraindications: Liver disease, Peptic ulcer disease and severe hypotension. 207 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Hemostatics Pharmacological effect: Inhibition of Fibrinolysis Therapeutic effect: Inhibition of bleedings Specific considerations: Aminocaproic acid: Indicated for treatment of hemorrhage due to hyperfibrinolysis and hematologic disorders. Antidote to thrombolytic medication. (Heparine, Streptokinase and Urokinase) Tranexamic acid: Indicated in hemophilia, 1 day prior and 2 вЂ“ 8 days after dental surgery. Menadiol sodium diphosphonate, Vitamin K4: Antidote to oral anticoagulants. UROLOGICAL DISORDERS AND DISEASES Kidney and ureter stones Stone formation in the urinary tract has mutiple causes. The most common types are calcium-oxalat stones. Other types include uric acid, cystine and struvit stones. Formation of stones usually requires a chronic fluid deficiency and dehydration of the affected individual. Other common causes are excessive intake of dairy products and vitamin D, hyperparathyroidism, chronic recurrent urinary tract infection, obstruction of urinary tract and delayed oxalate metabolism or high oxalate intake. Symptoms and diagnostic findings: Kidney stones can remain asymptomatic for a long time. Sudden discharge of concrements into the ureter leads to an acute fluctuating severe flank pain. Mostly accompanied by excessive nausea and vomiting and hematuria. Pain radiates typically from flanks into scrotal area in male and labia majora area in female clients. An urinary tract infection after an ureter colic can occur. Urinalysis typically shows micro or macrohematuria, and large concentration of crystals. Routine diagnostics include assessment of blood samples to assess creatinine, BUN, calcium, phosphate and uric acid levels. 24-hour urine samples are used to assess calcium, uric acid and oxalate levels. Diagnostic procedures include intravenous pyelography, renal ultrasound and cystoscopy to localize and remove stones and possible obstructions of the ureter which may lead to a hydronephrosis. Treatment: Acute treatment is focused on pain and nausea relief. About 80% of ureter colic causing stones are discharged spontaneously. Remaining stones require intervention by an urologist surgeon for the following methods. вЂў вЂў вЂў вЂў ESWL (extracorporal shock wave lithtripsy); transurethral uroscopy with basket catheter, percutaneous nephrostomy, surgical nephrolithotomy, pyelolithotomy and ureterlithotomy. Dietary treatment for recurrence of ureter stones requires restriction of causative agents along with an alkaline вЂ“ ash diet by an increased intake of legumes, milk, green vegetables, rhubarb, fruits. Increase of fluid intake up to 3.5 liters/daily is required in all cases under consideration of pre-existing renal or heart failure. Urinary incontinence Urine incontinence is classified in the following subtypes in order to the individual causes and symptoms. 208 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Stress incontinence caused by increased intraabdomonal pressure. Reflex incontinence Ionvoluntary urination due to bladder distention. Urge incontinence shortly after urge to void appears. Functional incontinence, urgent and unpredictable. Total incontinence due to permanent urination. Symptoms and diagnostic findings: Urinary incontinence may occur temporarely or permanent and is commonly expressed as a symptom of one of the following underlying disorders. вЂў вЂў вЂў вЂў вЂў вЂў вЂў Weakened pelvic diaphragm in women Enlarged uterus Prostate gland enlargement in men Urinary tract infections Neurological diseases Tumors of the urogenital tract Menopausal vaginal atrophy Treatment: Treatment of underlying causes may include, Kegel exercises to increase muscular stability of pelvic floor, hysterectomy, prostatectomy, treatment of urinary tract infections, anticholinergic medication to support detrusor muscle, antihistamines to improve smooth muscle contractions and estrogen supply in cases of atrophic vaginitis. Urinary tract infections (UTI) Urinary tract infections are typically caused by infections of gram negative bacteria from bowel colonisation, mostly Escherischia coli. . UTIвЂ™s are more common in women than men. Infections are supported by dehydration, incontinence and urinary obstruction. A beginning UTI will start as a cystitis and may turn into a pyeolnephritis if treatment starts delayed. Pyelonephritis causes a risk for the affected kidney and for a lifethreatening urosepsis. Symptoms and diagnostic findings: Polyuria and Dysuria with burning sensations during voiding are most characteristic findings for a cystitis. Urinary retention may occur as well. Fever, chills and flank pain are indicators for an ascending urinary tract infection into a pyelonephritis. Urine samples usually appear cloudy and of strong odor. Urinalysis may show an increased count of WBC, RBC and Nitrite. Blood samples are usually showing an elevated WBC and increased inflammatory parameters in case of infection in cases of pyelonephritis but remain unsuspicious in a cystitis. Treatment: Symptom relief with analgetic and antispasmodic medication. Antibiotic treatment and increase of fluid intake up to 3 l. daily. Chronic recurrent UTIвЂ™s may require prophylactic antibiotic treatment and further diagnostic procedures to rule out other underlying pathologies of the urinary tract or systemic immunodeficiencies (e. g. diabetes mellitus). Benign tumors of the urogenital tract In most cases benign urogenital tumors arise from parenchymal tissue. Common types are kidney tumors and cysts, bladder polypes and benign prostate gland hyperplasia. Symptoms and diagnostic findings: Benign urogenital tumors may cause an acute urinary obstruction but are usually asymptomatic. 209 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Treatment: Most benign urinary tumors show a characteristic formation in the imaging diagnostic procedures and will be usually monitored in appropriate time frames, mostly every 3 вЂ“ 6 months. Invasive treatments apply in cases of suspected malignancies. Acute renal failure (ARF) Loss of kidney function. Mostly due to a shock. Three phases: Initiation Recovery Restitution. Reversible over months but also progression into terminal renal failure possible. Causes of acute renal failure: Depending on the cause three types of acute renal failure can be differentiated: Prerenal, вЂњshock kidneyвЂќ by loss of blood volume or sudden blood pressure decrease. Intrarenal, due to a parenchymal kidney damage. Postrenal, due to an obstruction of the urinary tract, e. g. stones, BPH syndrome. Pathophysiology of acute renal failure: Oliguria Anuria = urine output < 400 mL / 24 hours 0 Hypervolemia due to ECF fluid excess blood count: WBC , Platelets , RBC due to erythropoietin deficiency muscle weakness hypernatremia hyperkalemia hypermagnesemia hyperposphatemia hypocalcemia metabolic acidosis Vitamin D deficiency SG and Proteinuria Loss of consciousness Neurological symptoms NOT all symptoms are expressed from the beginning of an acute renal failure! Treatment: Intrarenal failure: Assessment of fluid retention by daily assessment of weight, input and output. Management of electrolyte imbalances. Protein, potassium and sodium restricted diet. Dialysis and medication treatment. Loop diuretics, ACE Inhibitors and Antihistamines (gastric ulcer prevention). Acute prerenal and postrenal failure will be treated by correction of underlying cause. (e.g. fluid supply in a prerenal failure caused by dehydration) Chronic renal failure (CRF) / End Stage Renal Disease (ESRD) End stage of a chronic renal failure CRF. ESRD is defined by a GFR of less than 20% than normal. Creatinine clearance and BUN rise when > 90% of nephrons are destroyed. Typical systemic causes are hypertension, diabetes and SLE. Important renal causes of CRF and ESRD are: 1. Polycystic kidney disease, Autosomal dominant and autosomal recessive hereditary disease. Causes a cystic transformation and enlargement of both kidneys in adulthood or even already in early childhood in cases of autosomal recessive inheritance. Early, asymptomatic stades are mostly discovered by routine ultrasound examinations. Symptoms occur in advanced stages with hematuria and dysuria. Cystic organ alteration causes increased resistance for renal blood supply which results in a systemic hypertension by activation of the renin вЂ“ angiotensin mechanism RAA. 210 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 2. Glomerulonephritis. Autoimmune inflammation of the capillary linings of the renal glomeruli. Caused by a antigen вЂ“ antibody reaction in a bacterial or viral disease. Most common cases are induced by an infection with group A-beta-hemolytic streptococcus. Acute Glomerulonephritis may lead untreated to a severe acute renal failure. Diagnosis requires renal biopsy. Progression leads to a damage of the glomerular membranes and to rapid a loss of plasma proteins including coagulation factors and antibodies which is considered to be a nephrotic syndrome. End stage of renal failure is considered as uremia. Pathophysiology of end stage renal disease / chronich renal failure Kidneys become unable to concentrate urine specific gravity stays 1.010, equivalent to plasma fluid retention hypernatremia hypermagnesemia hyperposphatemia hypocalcemia metabolic acidosis vitamin D deficiency SG proteinuria general weakness and fatigue nausea and vomiting Treatment: Nutritional restrictions: вЂў Sodium, Potassium max. 2g daily. вЂў Proteines max. 60g daily. вЂў Fluids as needed. Monitoring of input, output and weight. Bicarbonate buffering of acidosis. Monitoring of kidney parameters and electrolytes. Dialysis and Assessment for kidney transplant. Medication treatment includes diuretics, ACE inhibitors, electrolyte replacement, phosphate binding agents, erythropoietin and folic acid. Urological Medication Therapy Diuretics Diuretic medications are categorized in five different groups concerning their pharmacological effect within the renal tubular system. 1. 2. 3. 4. 5. Thiazide diuretics Loop diuretics Potassium sparing diuretics Carbonic anhydrase inhibitors Osmotic diuretics Characteristics of Thiazide diuretics, Loop diuretics, Potassium sparing diuretics: Indications: Chronic heart failure with fluid retention, acute and chronic renal failure 211 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com (not potassium savers)! peripheric edema, pulmonary edema, hypertension. Common diuretic side effects: Polyuria, hypotension, reflextachycardia, orthostatic dysfunction, electrolyte imbalance, hyperglycaemia, dehydration, constipation, dizziness, vertigo, abdominal pain, nausea, vomiting and blood dyscrasias. General considerations for diuretic treatment: Regular monitoring of fluid intake and output, regular weight assessment and monitoring. Diuretics should be administered between morning and lunchtime to avoid excessive Nykturia. Diuretics shall not be taken during pregnancy and lactation. A regular assessment of the kidney function including GFR rate is part of every diurtetic treatment. Thiazide Diuretics Pharmacological effects: Inhibition of reabsorption and increase of sodium and water in the renal proximal tubuli. Physiological effect: Increase of urinary output, increase of sodium output. Special considerations: Effect requires a minimum creatinine clearance of 30mL/min. No immediate antihypertensive effect; Requires regular assessment of serum electrolytes as well as assessment of body weight, fluid intake and oputput. Requires potassium supplementation and sodium restriction. (elevated sodium levels support fluid retention)! Client has to avoid habits which lead to further dehydration (i.e. alcohol consume). Specific side effects: Hyperglycemia, hyponatremia, hypokalemia, headaches and photosensitivity. Contraindications: Allergies against Sulfonamides. Substances: Hydrochlorothiazide (EsidrixВ®), Chlorothiazide (DiurilВ®) - increasing duration effect. Bendroflumethiazide (NaturetinВ®), Benzthiazide (ExnaВ®), Hydroflumethiazide (DiucardinВ®) Metolazone (ZaroxylinВ®), Quinethazone (HydromoxВ®), Chlorthalidone (HygrotonВ®, ThalitoneВ®), Indapamide (LozolВ®), Methylclothiazide (EnduronВ®), Polythiazide (MinizideВ®, ReneseВ®) Loop Diuretics Pharmacological effect: Promoting excretion of sodium, potassium, chloride and water in ascending loop of Henle within the renal tubular system. Physiological effect: Sodium , Potassium , Chloride , Fluids Special considerations: IV infusions to be mixed with Sodium chloride 0.9 %, Dextrose5W, Ringer Lactat. Strong and urgent onset of urination. Hypokalemia may occur. Surveillance of potassium levels required. Contraindications: Anuria, (Output < 400mL) Specific side вЂ“ effects: Systemic vasculitis, thrombocytopenia, agranulocytosis, photosensitivity and ototoxicity. Substances: Bumetanide (BumexВ®), Ethacrynic acid (EdecrinВ®), Furosemide (LasixВ®) and Torasemide (DemedexВ®). 212 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Potassium-sparing diuretics Pharmacological effect: Increase sodium and decrease potassium secretion within the distal convoluted tubulus. Physiological effect: Na , Potassium Special considerations: (Spironolactone) also prescribed in liver cirrhosis, primary hyperaldosteronism and premenstrual syndrome. To be taken with food or milk. Requires potassium restriction. Contraindications : Serum Potassium > 5.5 mEq/L, anuria, acute and chronic renal insufficiency. (diabetic nephropathy), impaired hepatic function (=Diminished Aldosterone breakdown) Not to be combined with other potassium saving medications. Specific side effects: Hyperkalemia = Potassium Level > 5.1 mEq/L, abdominal cramps, nausea, vomiting, tachycardia bradycardia. Hyperaldosteronism and suppression of adrenal cortex. Impotence, gynecomastia, breast soreness and muscle cramps. Substances: Spironolactone: (AldactoneВ®), Amiloride (MidamorВ®) and Triamterene (DyreniumВ®) Carbonic Anhydrase Inhibitors Pharmacological effect: Reversible, noncompetitive block of the enzyme Carbonic Anhydrase. Physiological effect: Inhibition of renal excretion of Bicarbonate, Sodium, Potassium and water. Indications: Glaucoma, epilepsy, metabolic acidosis, chronic heart failure Special considerations: Can not be administered by intramuscular injection. Further dosage increase does not lead to increased Diuresis! Side effects: Bone marrow depression, pancytopenia, sulfonamide reaction Stephens вЂ“ Johnson Syndrome toxic epidermolysis, hepatic necrosis and death. Contraindications: Allergies against sulphonamides. Narrow and wide angle glaucoma Liver and Kidney Dysfunction. Relatively contraindicated in COPD. Substances: Acetazolamide (DiamoxВ®), Dichlorphenamide (DaranideВ®) and Methazolamide (NeptazaneВ®). Osmotic Diuretics Pharmacological effect: Increase of osmotic pressure in proximale tuble and loop of Henle. Physiological effect: Inhibiting re-absorption of water and electroytes but promoting diuresis. Indication: Prevention and treatment of acute renal failure in an intensive care setting. Glaucomtherapy (Mannitol) decrease of intracranial pressure. Special considerations: All osmotic diuretics require intravenous administration. Mannitol crystalizes at low temperatures. Urea turns to ammonia over time. 213 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Antibiotics for urinary tract infections Pharmacological effect: Bacteriostatic and bactericid effect to bacteria causing urinary tract infections. Main mode of effect is to antagonize folic acid in the replication process. Physiological effects: Treatment of bacterial infections. Indications: Urinary tract infections. Special considerations: Prescribed course needs to be completed to avoid development of antibiotic resistance and recurrent infection. Medication generally requires normal liver and kidney function. Nitrofurantoin administered orally can lead to discoloration of teeth and requires rinsing of mouth immediately after dose is taken. Acidification of urine due to oral administration of vitamin C or cranberry juice is of support in treatment of an UTI. Milk, fruit juices, bicarbonate alkalizes urine and supports an urinary infection. Encourage client to drink normal amounts of fluid (eight glasses of water / d.). Highly increased fluids weaken medication due to dilution. Pyridium may be prescribed as a local analgetic medication. ( changes color of urine into orange) Side effects: Abdominal discomfort, diarrhea, leukopenia, thrombocytopenia, angioedema, drowsiness, weakness, headaches, pruritus, rash and arthralgia. Contrainidications: Folate deficiency and megaloblastic anemia Substances: Trimethoprim (ProloprimВ®), Trimethoprim / Sulfamethoxazole (BactrimВ®), Sulfamethoxazole (GantanolВ®), Sulfamethizole (Thiosufil forteВ®), Sulfisoxazole (GantrisinВ®), Methenamine (HiprexВ®) and Nalidic acid (NegGramВ®) Urinary Tract Spasmolytics Pharmacological effect: Relaxation of smooth muscles in bladder and ureter due to peripheral anticholinergic effect. Physiological effect: Spasm relief in urinary tract. Indications: Incontinence, dysuria and nocturia. Side effects: Urine retetion, constipation, palpitations, dry mouth, hypertension and mydriasis. Contraindications: Glaucoma, COPD and Asthma, gastrointestinal obstruction, myasthenia gravis, paralytic ileus, urinary tract obstruction, cardiovascular disease and drowsiness. Substances: Oxybutynin chloride (DitropanВ®), Hyoscyamine (CystospazВ®) and Tolterodine tartrate Bladder Stimulating Medication Pharmacological effect: Parasympathomimetic stimulating effect on detrusor and bladder muscle. Physiological effect: Initiation of voiding. 214 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Indications: Neurogenous bladder (MS and spinal cord injuries). Special considerations: Atropine as antidote treatment must be accessible at all times. Clients have to be monitored one hour after administration of parasympathomimetic medication. Side effects: Hypotension, blurred vision, miosis, nausea, vomiting, diarrhea and hypersalivation. Contraindications: COPD, gastrointestinal and urinary tract obstruction, peptic ulcer disease, bradycardia Parkinsonism, hypotension and AV Blocks. Substances: Bethanechol chloride (UrecholineВ®) Dopamine Pharmacological effect: Peripheric vasodilation in the gastrointestinal, urogenital and mesenterial circulatory system. Physiological effect: Increase of blood flow in kidneys. Indication: Treatment of acute renal failure. Special considerations: Effect changes by dosage. Low dosages between 2 вЂ“ 5 mcg/kg/min cause increase of renal perfusion. Widening of QRS complexes may occur. Hematopoetic Growth Factor (Erythropoetin) Pharmacological effect: Stimulation of RBC production in cases of a primary or secondary renal anemias without bone marrow defects. (i. e. Chronic renal failure, HIV, Chemotherapy) Physiological effect: Increase of RBC, Hemoglobin and Hematocrit Indications: Renal anemia and anemic conditions without bone marrow disease. Special considerations: To be administered as a bolus injection or subcutaneously. Normal HCT raise is up to 4 points in 2 weeks. Seizures may arise within first three months of treatment. Side effects: Hypertension, headaches, seizures, iron deficiency, thrombocytosis and hematocrit . Immune Suppressant Medications for treatment after kidney transplantats Cyclosporine Pharmacological effect: Suppressor of immune mediators produced by T-Lymphocytes: Interleukin-2, Gamma interferon and other cytokines. Physiological effect: Suppression of TвЂ“cell mediated immune reponse. Indications: Prevention of organ rejection after allogenic transplantation. 215 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Special considerations: Patients under treatment have limited immune response against infections. Grapefruit juice can raise Cyclosporine levels. Medication is administered orally and diluted in juices or milk. Prednisolone may be administered concurrently to limit immune suppression to the desired therapeutic effect. Client requires special education on detection of early transplant rejection symptoms, especially about the importance of fever. Clients should avoid environments that cause contraction of communicable diseases. Cyclosporine levels are affected by other medications with strong protein binding abilities and have to be assessed regularly. Side effects:(common for immune suppressants) Nausea, vomiting, increased rate of infections, bone marrow depression. (specific side effects of Cyclosporine). Hypertension, tremor, hirsutism, depression and anaphylactic shock. Substances: NeoralВ® Azathioprine Suppressor of cell mediated and humoral immune system. May be combined with Cyclosporine. Also used in rheumatoid arthritis. Bone marrow depression is main side effect. Available as ImuranВ®. Mycophenylate mofetil Used with Glucocorticoids and Cyclosporine. Available as CellCeptВ®. Tacrolimus Concurrently used with glucocorticoids. Can cause renal damage. Available as PrografВ®. Daclizumab (ZenapaxВ®), Basiliximab (SimulectВ®), Muronmonab-CD3 (Orthoclone OKT3В®) Antibodies to prevent rejection after allogenic transplant. Intravenous administration. Basiliximab for immediate treatment after transplantation. xx GASTROINTESTINAL DISORDERS AND DISEASES Gastritis Acute or inflammation of the gastric mucosa by external agents or causes e. g. NSAID food excess, alcohol excess, caffeine, stress, corticosteroids, gastroenteritis, gastroesophageal reflux disease (GERD), autoimmune diseases (Pernicious anemia), bile reflux from biliary system into the stomach and Helicobacter pylori infection. Symptoms and diagnostic findings: Acute or chronic epigastric pain, aggravating by eating, foetor ex ore, nausea, vomiting, lack of appetite and bad taste in mouth. Diagnosis in acute cases is made by physical examination. An endogastroduodenoscopy is performed in severe or recurrent cases or in cases with recurrent complaints after treatment. 216 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Treatment: Treatment of underlying cause. Medication: Antiemetics, Histamine H2 - antagonists, Proton pump inhibitors, Mucosal protective agents, Antacid and Eradication therapy for helicobacter pylori. Gastroesophageal Reflux Disease GERD Reflux of stomach content and gastric acids due to a decreased lower esophageal sphincter tonus. Condition may be caused idiopathic or by a hiatic herniation as well as obesity and external agents e. g. nicotine, caffeine, fat and fried food, estrogenes, anticholinergic drugs, calcium channel blockers and others. Long standing GERD leads to a tissue alteration of the inner mucosa from epithelial into columnal вЂњ Barretts epithelium вЂњ cells which can cause esophageal cancer. Cancer risk increases over time. Symptoms and diagnostic findings: Recurrent heartburn, aggravating in supine positions or while client is bending over as well as in long term fasting conditions or immediately after a meal. Long standing GERD may lead to a chronic inflammatory process with thickening of the esophageal mucosa causing dysphagia, regurgitation and horseness. Onset of Asthma in adults is commonly associated with GERD. Main diagnostic evidence is provided by 24hвЂ“pH monitoring. Treatment: Extinction of causative agents including: Weight management, smoking and caffeine cessation, upright positioning in bed and small meal nutrition pattern. Medication: Histamine H2 - antagonists, Proton pump inhibitors, Mucosal protective agents and Antacids. Peptic Ulcer Disease (PUD) Peptic ulcers appear in about 90% of all cases within the duodenum and in 10% as gastric ulcers. Esophageal peptic ulcers are rare. Duodenal ulcers are typically caused by an infection with Helicobacter pylori. Gastric ulcers have the same causes as seen in cases of gastritis but are strongly associated with NSAID medication which inhibit prostaglandins as the main acid protecting factor for the gastric mucosa. The severity of a PUD increases with any coexisting factor that supports a gastritis as well. Symptoms and diagnostic findings: Strong epigastric pain. Pain in duodenal ulcers aggravating especially in fasting conditions. In comparison to gastritis and gastric ulcers the intake of food provides pain relief. Helicobacter pylori test positive in > 90% of all cases of duodenal ulcers. In both cases diagnosis is made by EGD only. Perforation of ulcers can lead to acute peritonitis. Treatment: Basic treatment to decrease acid production as in cases of GERD and Gastritis. Medication: Histamine H2 - antagonists, Proton pump inhibitors, Prostaglandin analogons as mucosal protective agents, Antacids, treatment of a H. pylori infection. Chronic inflammatory bowel diseases The two most common types of chronic inflammatory bowel diseases are CrohnвЂ™s Disease and ulcerative colitis. Both diseases have in common that they are suspected to be caused by underlying autoimmune disorders. Other supporting causes like stress and infections are suspected as well. Both diseases show a chronic recurrent course and mainly start in young adulthood. Severity, intensity and recurrence rate vary individually. Extraintestinal manifestiations are linked to both types of IBD, especially arthritis and uveitis. Treatment for both types of IBD is identical. Corticosteroids in high dosages are prescribed to terminate acute flares. Depending on the affected intestinal or bowel 217 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com segments the mode to administer medication may vary from oral and intravenously to rectal suppositories. Medication for preventive treatment consists of acetylsalicylic acid compounds (e. g. sulfasalazine) or immunomodulators (e. g. azathioprine). Adequate nutrition should consist of a low fiber, high protein and high calorie diet. The psychological impact of both conditions is immense since acute flares interfere strongly with a functioning social life of the affected individual. вЂў CrohnвЂ™s disease CrohnвЂ™s disease is also described as regional enteritis which mainly affects the terminal ileum. Although this condition can potentially affect the entire gastrointestinal tract. Symptoms and diagnostic findings: Increased defecation frequency of 5 to 10 stools daily turning into a semiformed diarrhea. Severe abdominal cramping mainly in the right lower abdomen. Fever, weight loss, body achiness, intraabdominal abscess and fistulas to other segments of the intestines and bowels and other intraabdominal and intrapelvic organs. Diagnosis is made by colonoscopy which reveals a typical вЂњcobblestoneвЂќ type of lesions which are interrupted by healthy areas of the mucous membranes, so called вЂњskip lesionsвЂќ. Histological examination of biopsies typically reveals granuloma type formations of lymphocytic cells. Bowel obstruction and rigidity due to a scar tissue development after recurrent flares is common. Bowel perforations can occur as well but lead mostly to conglomerate tumors with other bowel segements. Blood examination shows elevated inflammatory parameters (WBC, ESR, CRP). Treatment: Surgical treatment is indicated if medication therapy fails or complications like bleedings or bowel perforations arise. Surgical treatment of choice is a circumscripted resection of the affected bowel area with a consecutive end вЂ“ to end anastomosis of the resection margins. A temporary Ileostomy may be necessary in cases where the acute inflammation has not come to a standstill by the time of the surgical intervention. вЂў Ulcerative Colitis Inflammation of the mucosa and submucosa from rectum over the entire colon. Other parts of the gastrointestinal tract are usually not affected. Symptoms and diagnostic findings: Sudden onset of up to 20 diarrheas per 24 hours, even nocturnal, typically with blood and mucous. Abdominal cramping, fever, weight loss and body achiness. Flares can cause acute severe intestinal bleedings, obstructions and perforations. Colon cancer risk is increased in individuals with ulcerative colitis. Diagnosis is made by colonoscopy showing an inflammated, edematous, bleeding mucosa with cryptic abscess formations. Fistulas are rarely observed in ulcerative colitis. Treatment: Surgical treatment is performed as a proctocolectomy in combination to a temporary ileostomy or colostomy. Diverticulitis Outpouchings of the intestinal wall are considered Diverticula and appear increasingly by age. Main affected area in 95% of all cases is the sigmoid colon. Diverticula do not necessarily become symptomatic. Clients with a chronic constipation tend to retain stool and bacteria within the diverticular pouches. Symptoms and diagnostic findings: Classical appearance of an acute diverticulitis is an acute pain in the lower left quadrant of the abdomen. In accordance to the clinical symptoms this condition is also called a 218 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂњleft sided appendicitisвЂќ. Fever, chills and increasing abdominal pain are indicating a developing perforation of the sigmoid colon as the most common complication of diverticulitis. As in cases of a CrohnвЂ™s Disease, a perforation can also occur вЂњcoveredвЂќ, leading to conglomerate tumors with other bowel segments and intraabdominal abscedic infections. Recurrent flares may lead to a fast growth of intraluminal fibrotic scar tissue which can cause a stenotic condition. Diagnosis is made by abdominal ultrasound and barium enema. Ileus An ileus describes the situation of an intestinal obstruction and is usually classified as either a mechanical or nonmechanical (=paralytic) ileus. Common causes for a mechanical ileus are tumors, incarcerated and trapped hernias, fibrotic rigidity after intraabdominal inflammations, adhesions, volvulus or fecal obstructions. A nonmechanical (= paralytic) ileus is caused by a disturbance of the muscular bowel function, the nerval bowel innervation or perfusion. Common causes are situations after abdominal surgery, anesthesia, peritonitis, spinal cord lesions as well as insufficient blood flow in the mesenterial arteries. A colon ileus can occur but the most common location is the terminal ileum due to its natural narrowness. Symptoms and diagnostic findings: Abdominal pain, absence of defecation, nausea, vomiting, alteration of bowel sounds from high pitched to absent, hypotension, shock due to fluid loss into bowels, signs of peritonitis, elevated inflammatory parameters, LDH and lactate elevation in blood samples. Diagnosis is made by x-ray examinations of the abdomen where dilated bowel loops with fluid entrapment can be seen. Treatment: Primary action is the insertion of a nasogastric or nasointestinal tube to reduce intraintestinal pressure. Fluid supply, analgesia under restriction of ileus supporting opioid analgetics and parenteral nutrition. Monitoring of input and output, renal function, inflammatory parameters, bowel sounds and X-rayвЂ™s. Surgical treatment by partial bowel resection and temporary or permanent ileo вЂ“ or colostomy is required if condition is not improving spontaneously or if complications arise. Acute Appendicitis The vermiform appendix is the terminal structure of the small intestines located at the end of the coecum. The appendix is a lymphoid organ and functionally comparable to tonsils and lymph nodes. Due to its anatomical configuration it is vulnerable to be obstructed by undigested food particles, hardened stool or microorganisms which can cause an acute appendicitis. The local conditions allow this inflammation to develop fast into an abscess which can potentially cause a life threatening perforation and peritonitis. Symptoms and diagnostic findings: Acute and increasing abdominal pain in the right lower abdominal quadrant. McBurney вЂ“ Trigger point, located in the center of a direct line between the umbilicus and the Crista iliaca anterior superior. Fever, chills, nausea, vomiting and anorexia. WBC count up to 20000 cell/mm3, elevation of ESR and CRP. Treatment: Acute appendicitis requires immediate appendectomy to avoid or limit a developing peritonitis. Which is an acute bacterial infection of the peritoneal cavity. Mostly caused by abdominal wall trauma or rupture of intestinal organs. Residential bowel bacteria spreading into the blood stream and leading to a septic shock by release of endotoxins. 219 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Food intolerance syndromes вЂў Celiac disease/Sprue Gluten sensitive food intolerance syndrome. Affected clients are unable to digest wheat products containing the proteins gliadine and gluteine. If condition is present from birth it is considered CeliacвЂ™s disease. A second form starts during adulthood and is described as Sprue. Symptoms and diagnostic findings: After a frequent exposure for several weeks the digestion of gluten containing products suddenly leads to an acute inflammatory reaction within the intestinal mucosa. Clients experience massive vomiting and diarrhea of fatty stool along with severe abdominal cramps. Diagnosis is made by stool analysis revealing an increased concentration of fat. Duodenal biopsies proof an acute inflammatory reaction with mucosal damage and degeneration. Antigliadin and reticulin antibodies are positive in blood samples. Treatment: Clients generally require lifelong gluten вЂ“ free diet which is accomplished by a total elimination of any sources of wheat. вЂў Lactose intolerance Caused by a steadily decreasing activity of lactase throughout childhood and early adolescent age. Clients will remain with a very limited or no lactase activity and are unable to digest lactase into glucose and galactose. Treatment requires to maintain a lactose free diet or to substitute oral lactase prior to indigestion of dairy products. Aged cheeses (e. g. camembert) and yogurts are mostly tolerated. Irritable bowel syndrome The cause of this functional disorder of the gastrointestinal tract is unknown. Affected clients experience mostly a completely disturbed bowel function. Symptoms and diagnostic findings: Cramping abdominal pain predominantly over the entire lower abdomen. Unexpected diarrhea and bloatedness especially shortly after meals. Constipation also possible. No relevant findings in routine abdominal diagnostic procedures. Mainly treated as a psychosomatic disorder after other possible causes are ruled out. Treatment: Symptom oriented treatment focuses on high fluid вЂ“ high fiber diet regulations, avoidance of stimulating substances (sweets, caffeine and processed food). Symptomatic treatment of constipation and diarrhea. Psychological support (e. g. Stress Management). Cystic fibrosis Hereditary and not primarily tumorous, malignant or cancerous disorder following an autosomal recessive trait. A chromosomal defect on chromosome 7 leads to non вЂ“ expression of the cystic fibrosis transmembrane regulator CFTR (a chloride channel). This results in a disability to move water across cell membranes and disables the Na+Clchannels as well. As a result the secretory function of any glandular cell of the body is disabled leading to a retention of glandular fluids due to thickening which is caused by a lack of water and chloride within the ICF and an increased chloride concentration in the ECF. Main symptomatic areas are the respiratory and the digestive tract. The production of large amounts of thickened mucous within the respiratory tract leads to occlusion of bronchioles which can not be cleared by coughing. Main affected organ in the digestive tract is the pancreatic gland where essential digestive enzymes can not be discharged into the duodenum. Deficiency of pancreatic 220 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com enzymes causes malabsorption of fats, proteins carbohydrates and fat soluble vitamins. Cystic fibrosis is incurable and usually causes clients to pass before the age of 40. Symptoms and diagnostic findings: Recurrent atypical respiratory infections. Growth retardation and malnutrition in children and young adults. Prenatal diagnosis via amniocentesis reveals a reduced intestinal alkaline phosphatase. Meconeum ileus is a common first sign in newborns. Diagnosis via pilocarpin induced sweat test shows an increased Cl- concentration of at least > 60 meq/L. Fatty stools in 72 hour stool sample. Chest X-rays with signs of mucous infiltrations within the parenchymateous lung tissue. Clubbing nails as a sign of chronic hypoxemia Treatment: Sincere pulmonary hygiene, Postural drainage, specific antibiotic treatments in cases of bacterial infections. Bronchodilators. High calorie and high protein diet with prefermentized ingredients or parenteral supply. Avoidance of exposure to respiratory tract infections. Frequent physical exercise to increase pulmonary function and secretion of trapped mucous. Disorders and Diseases of the Liver Hepatitis A Caused by a fecal - oral droplet infection with Hepatitis A-virus mostly from contaminated food sources or water in an non-hygienic environment. Symptoms may start after an incubation period of 15 вЂ“ 50 days. Infected clients remain infectious throughout the course of the disease, especially about two weeks prior to the onset of symptoms. Symptoms vary from minimal gastrointestinal complaints to a massive jaundice. Hepatitis A is usually a self limiting infection in otherwise healthy individuals. Treatment is oriented on symptoms. Infection leads to a lifelong immunity against Hepatitis A. Hepatitis A is vaccine preventable. Acute epidemic infections can be interrupted by mass treatments with Hepatitis A immunglobuline. Hepatitis B Caused by blood borne (= parenteral) infection with DNS containing Hepatitis B Virus. Infection requires contact between body fluids and occurs regularly either sexually or by common use of needles amongst intravenous drug users. Other sources of infection are surgical procedures with contaminated instruments, blood transfusions and dialysis treatments. Health care workers are generally endangered by accidential infections as well. The incubation period is estimated between 30 and 180 days. Clients remain infectious as long as anti вЂ“ Hbs is traceable in blood. 70% of otherwise healthy infected individuals will experience spontaneous healing within a period of 6 months. About 30% of all cases will lead to a chronic hepatitis where the virus persists in the liver parenchym, causing a more or less progressive ongoing hepatitis. In these cases anti вЂ“ Hbs, anti вЂ“ Hbe and HBV-DNA remain as diagnostic markers for the ongoing infection and its activity. Clients with a chronic persisting hepatitis b have an increased risk for the development of liver cirrhosis and liver cell carcinoma. The rate of progressive liver destruction by liver cirrhosis is 20% and 15% for the development of liver cell carcinoma. In cases of suspected fresh hepatitis b infections it is recommended to administer hepatitis b vaccine as a postexposure prophylaxis. A possibly developing chronic hepatitis will be treated with a combination of interferone and ribavirin for up to 48 weeks depending on the persistence of the infection markers. Hepatitis C (Hepatitis nonвЂ“A / nonвЂ“B) Hepatitis C is in regards to modes of infection and incubation period comparable to hepatitis b. Main difference is a comparably much more aggressive course of infection. 221 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 75% of infected individuals develop a chronic hepatitis with an increased risk for liver cirrhosis and liver cell cancer. Treatment of a chronic persisting hepatitis c is comparable to the treatment of a chronic persisting hepatitis b. Hepatitis D An infection with Hepatitis D virus requires the presence of a hepatitis b virus capsule which is needed to allow a proper replication of the hepatitis d virus. Modes of infection are comparable with hepatitis b. Acute Hepatitis with a healing rate of 95% can be observed in cases of a simultaneous infection. Superinfections in cases of an already developing course of acute hepatitis b lead to a poor prognosis with high rates of terminal liver failure. Hepatitis E Hepatitis E virus infections occur comparable to hepatitis a infections and show an almost identical outcome. Hepatitis E is currently not endemic in the United States but in South America, Africa, Asia and the Middle east. Cirrhosis of the liver Liver cirrhosis is defined as a stade of destroyed and dysfunctional liver parenchym and its replacement by connective fiber tissue. Common causes of liver cirrhosis are alcoholism, (laennecвЂ™s cirrhosis) chronic persisting hepatitis b and c, biliary diseases, autoimmune hepatitis and metabolic diseases. Course and severity of liver cirrhosis are determined by the persisting presence of its cause. Liver cirrhosis is primarily incurable but its progress can be interrupted or significantly delayed if its cause can be controlled. Total liver failure due to a cirrhosis may not occur until 90% of the organ is affected but multiple complications can derive from a reduced liver function. Symptoms and diagnostic findings: Disturbed protein synthesis and an increased blood pressure in the portal vein. Physical exhaustion, fatigue, jaundice, pruritus, weight loss, malnutrition, anorexia and enlarged liver. Delayed blood coagulation, hematomas, spider angiomata, teleangiectasia, clay colored acholic stools, altered bowel habits, pleural effusions, breathing difficulties, immunodeficiency, delayed wound healing, palmar erythema and dark urine. Umbilical caput medusa, edema, respiratory distress due to sub-diaphragmatical ascites, disturbed menstrual cycle in women, gynecomastia and erectile dysfunction in men. Testosterone/Estrogene deficiency. Pathophyiology of liver cirrhosis Portal vein hypertension Caused by an increased pressure within the portal vein due to growing resistance caused by fibrotic liver tissue as the most common cause. Other causes are portal vein thrombosis, liver vein thrombosis (Budd Chiari Syndrome), right sided heart failure. The increased pressure in the portal vein causes large connecting veins to expand, leading to the following characteristic symptoms: - Hemorrhoids - Esophageal and gastric varicosis with potential risk of hematemesis - Umbilical vein dilation вЂњcaput medusaвЂќ - Hepatospenomegaly 222 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Ascites Plasma rich fluid accumulation in the peritoneal cavity. Caused by proteine deficiency and decreased oncotic pressure. Aldosterone increase leads to sodium and water retention. Hepatic encephalopathy Neurological disorder caused by increased ammonia levels due to an altered hepatic protein metabolism. Symptoms include confusion, altered consciousness, flapping tremor and disorientation. Hepatorenal syndrome Acute renal failure in an ongoing and advanced liver failure. Oliguria, hyponatremia and fatigue. Increased creatinine and BUN parameters. Client may require dialysis to treat fluid excess and hyperkalemia. Liver transplantation is the only possible cure. Laboratory findings Bilirubin Cholinesterase Albumin Blood coagulation factors Pancytopenia Serum ammonia levels , Aldosterone leve Sodium Gamma вЂ“ globulines Fat soluble vitamines Blood Glucose due to Gycogene deficiency The final diagnosis of a liver cirrhosis always requires liver biopsy which has to be obtained by a blind liver puncture or laparascopy! Ultrasound examinations typically reveal a more or less unevenly shaped liver surface, diminished liver veins and widened portal vein. Treatment: Treatment is generally focused on resolving underlying causes. General treatment: Small frequent meals, anorectic clients require strict prevention of pressure sores, Monitoring of liver function parameters, Vitamin K supply to enhance remaining production of coagulation factors and life style change (e. g. avoiding alcohol). Ascites treatment: Paracentesis to drain ascites. Portal vein bypass by surgical procedure or catheter placement (LeVeen/TIPS) to treat portal hypertension and avoid recurrence of ascites. Fluid, sodium and protein restriction. Daily monitoring of weight, input and output. Diuretic treatment with Spironolactone and Furosemide Hepatic encephalopathy treatment: Lactulose treatment to reduce inrestinal ammonium levels produced by intestinal bacterial flora. Neomycin for bowel sterilization. Hematemesis treatment: Intervention in cases of hematemesis from a varicose esophageal bleeding by sclerotherapy or esophageal tamponade via Sengstaken вЂ“ Blakemore or Minnesota tube. Vasopressin or beta blocker intravenously (under cardiac monitoring) to cause vasoconstriction of portal vein collaterals. 223 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Gall bladder and biliary duct stones (Cholelithiasis) Gall bladder and biliary duct stones are the most common disorders of the biliary system. Gallbladder stones consist in more than 80% of all cases of cholesterol. The underlying dysfunction for the formation of these stones is mostly a disproportion between bile salts and the amount of indigested cholesterol. A deficiency of bile salts can be caused either by their disturbed hepatic production or inhibited reuptake from the terminal ileum in the digestion process. A deficit of bile salts leads to limited digestion of fats. Another possible source for cholesterol stones is a long lasting high cholesterol diet which can overcome the fat digesting capacity of the gastrointestinal tract. Multiple risk factors for the development of gallstones have been described: Obesity, hyperlipidemia, age > 40 years, caucasian ethnicity, female gender, family history of gall stones, pregnancy and estrogen supply. Affections and dysfunction of the terminal ileum (e. g. CrohnвЂ™s disease and tumors),type I diabetes. Stone formation of pigment stones occurs from a combination of hardened unconjugated bilirubin with calcium. These stones occur more often within the biliary system, mostly after a bile duct inflammation (cholangitis) or conditions of increased destruction of blood cells (e. g. leukemia). Symptoms and diagnostic findings: Gallbladder and biliary duct stones can be asymptomatic for a lifetime. Once a gallbladder got filled with gall stones its natural function as a reservoir for bile acids is limited or lost which typically results in digestive problems after fatty or spicy meals as well as larger amounts of food. A biliary colic occurs if a gallbladder stone moves into the narrow biliary duct system and gets trapped in there. As a result the affected client experiences severe fluctuating abdominal pain in the right upper quadrant. Mostly accompanied by severe nausea and vomiting. Physical examination typically reveals a sharp pain when client performs deep inspiration while examiner is palpating the RUQ. (MurphyвЂ™s sign) Jaundice, grey stools, dark urine and elevated bilirubin serum levels occur if colic leads to a total blockage of the common bile duct. Diagnosis is routinely made via abdominal ultrasound as well as by abdominal x-rays. Laboratory findings include an elevation of GPT and GOT as well as GGT and AP as cholestasis indicating parameters. WBC, ESR and CRP may be altered in cases of a developing inflammatory process. Treatment: Clients with asymptomatic gallbladder stones do not require any curative treatment. Frequent follow up examinations along with a cholesterol restricted diet are recommended. Main priority in an acute biliary colic is symptom relief with common analgetics and spasmolytics. Opiod analgetics are relatively contraindicated since they increase spasms in smooth muscles. Symptomatic cholelithiasis usually requires surgical treatment via cholecystectomy and/ or ERCP (Endoscopic Retrograde Cholangio Pancreticography). ERCP is commonly indicated in cases of bile duct blockage prior to a cholecystectomy. Cholecystectomy is usually performed as a minimal invasive laparascopic transabdominal surgery and requires a clear biliary passage. Conventional cholecystectomy via laparatomy may be indicated if a larger part of the biliary duct system has suffered damage from a colic or if biliary stones can not be captured via ERCP. In these cases surgery involves temporary placement of a TвЂ“Drain which leads biliary fluids through the abdominal wall until the biliary system has healed. Drain will be removed when bile flow subsides. Flow should not over exceed 500 mL within the first 24 hours and should gradually decrease in the following days. Other forms of treatment are Extracorporal Shock Wave Lithotripsy (ESWL). Oral Ursodesoxycholic acid (UDCA) to dissolve gall stones of less than 2cm in diameter. Treatment lasts up to several years. High recurrence rates. 224 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Cholecystitis An acute or chronic inflammation of the gall bladder. Mostly of lithogenic cause due to an obstruction of the cystic duct or the common bile duct due to an inhibited flow of biliary and pancreatic fluids as well as other digestive enzymes. Other causes are a previous gallbladder or biliary duct surgery as well as a vast overproduction of biliary fluids in cases of hyperalimentation with fats. Symptoms and diagnostic findings: Symptoms of an acute cholecystitis mostly occur during an acute biliary colic and show comparable symptoms. Advanced inflammations can lead to peritonitis. Laboratory findings are irregular liver function tests, especially elevated cholestasis parameters and inflammatory parameters. Abdominal ultrasound examination reveals an edematous gall bladder wall. Proof of inflammation in chronic stades via nuclear scans. (HIDAвЂ“ Hepatobiliary Imino Diacetic Acid). Treatment: Acute inflammation needs to be cured prior to any surgical treatment of underlying cause! Clients remain in NPO status under intravenous antibiotic treatment and analgetic medication until acute infection is under control. Emergency cholecystectomy may become necessary in case of peritonitis. Primary Sclerosing Cholangitis (PSC) Incurable autoimmune inflammatory process which leads to a progressive destruction of the entire biliary system. Symptoms and diagnostic findings: Repeated cholestasis, jaundice, abdominal pain in upper right quadrant and anorexia. Proof of diagnosis via assessment of pANCA antinuclear antibodies. Otherwise elevated GGT, AP and inflammatory parameters. Progress leads to biliary cirrhosis of liver. Up to 10% of affected individuals experience cholangiocarcinoma or colorectal cancer. Diagnosis is made by liver biopsy. Treatment: Symptom oriented treatment of cholestatic episodes including dilating procedures of biliary ducts. Only curative treatment is liver transplantation. Pancreatitis Increased amount of pancreatic enzymes in pancreatic duct leads to pancreatic inflammation and autodigestion. Inflammatory swelling of pancreatic duct occludes Sphincter oddi and ampulla Vateri and inhibits flow. Hemorrhagic organ destruction may lead to retroperitoneal hematoma. Major causes of pancreatitis are: Obstructive biliary stones leading to a reflux of digestive pancreatic enzymes. Alcohol and alimentary excess causing hypertriglyceridemia with an increased production of pancreatic enzymes lipase and amylase. Rare causes are side effects of medication e. g. NSAID, Thiazides and abdominal traumas. Symptoms and diagnostic findings: Acute epigastric abdominal pain and tenderness, increasing in supine position, Hematoma in both flanks and/or around umbilicus (Grey вЂ“ Turner sign/Cullen sign). Hemorrhagic ascites, pleural effusions, hypovolemia and shock. Also nausea, vomiting, diarrhea and fever. Abdominal ultrasound and CTвЂ“scans reveal inflammatory pancreatic edemas and bleedings, gall and biliary duct stones, ascites and pleural effusions. Laboratory findings: Blood Glucose, Lipase, Amylase , Urine Amylase , Hypocalcemia, CRP and Leucocytes . 225 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Recurrent episodes of acute pancreatitis may lead to chronic pancreatitis with a resulting exocrine pancreatic insufficiency. Main symptom is a food intolerance against fat. Treatment: Depending on the severity of an acute pancreatitis treatment includes, pain relief, antibiotic treatment, antispasmodic treatment, nasogastric tube to drain excess digestive fluids, parenteral nutrition, correction of hyperglycemia, adjustment of electrolyte status and fluid supply. Curative treatment of underlying cholelithiasis is performed after acute episode of pancreatitis is controlled. Gastrointestinal Medication Therapy Antispasmodics Pharmacological effect: Antagonizing effect on the acetylcholine receptors of the smooth muscles of the gastrointestinal tract. Therapeutic effect: Relaxation of smooth muscles to increase gastrointestinal motility. Indications: Gastrointestinal dysfunction, cramping, pylorospasms and inflammatory bowel disease. Special considerations: Medication should be taken about 30вЂ“60 min. prior mealtimes. Side effects: Dry mouth, nausea, vomiting, constipation, mydriasis,, urine retention, impotence, tachycardia, palpitations, dysphagia, hyperthermia due to inactivity of sweat glands, allergic rash and urticaria. Substances: Hyoscyamine sulfate (LevsinВ®), Dicyclomine hydrochloride (BentylВ®), Chlordiazepoxide hydrochloride (LibraxВ®) and Glycopyrrolate (RobinulВ®). Antidiarrheals Pharmacological effect: Reduction of bowel motility by interaction with intestinal motoric nerves. Therapeutic effect: Diarrhea relief Indications: Diarrhea Special considerations: Self treatment with OTC Medications is tolerable for 2 days in a case of diarrhea. Main concern is the development of dehydration, especially in elderly or pediatric clients. Adequate fluid supply and an easy digestable diet. (i. e. BRAT Diet = Banana, rice, applesauce, tea, toast is also a part of the treatment) Dairy products aggravate diarrhea. Pregnant and lactating women need to seek medical attention early! Contraindications: Bloody diarrhea, bacteria induced Diarrhea (E. Coli and Shigella), bowel obstruction. Difenoxine: Not indicated for children < 2 years and in combination with MAOI medication. Substances: Loperamide (ImodiumВ®) 226 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Categories: вЂў Stimulant laxatives вЂў Bulk forming laxatives вЂў Stool softeners вЂў Hyperosmotic laxatives вЂў Lubricants вЂў Saline Laxatives Laxatives Laxatives are indicated in the treatment of constipation only. The individual pattern on how often a human being defecates can differ widely between individuals. Therefore the individual regularity of bowel movements is of greater importance for judging about a constipation than the actual frequency. An exception from this rule is the abrupt and ongoing alteration of bowel habits which should always be further investigated since this could indicate a suspicion of bowel cancer or another intestinal or systemic disease. The main factors which regulate a normal bowel function are a fiber rich diet, daily physical activity and sufficient amount of fluids. Therefore constipation is of great concern for clients who are lacking sufficient mobility. A constipation also may occur as a side effect of certain medications and is most common for opioid analgetics of all potencies. Long term use of laxative and laxative abuse weakens the muscular bowel function and can lead into a state of bowel immobility (carthatic colon) due to a chronic ulcerative colitis. A general contraindication for laxatives are any mechanical bowel obstructions i. e. due to a tumorous or inflammatory or stenosis. Administration of laxative agents should take place separately from any other medication. Stimulant laxatives Pharmacological effect: Stimulation of parasympathic bowel innervation due to mucosa irritation. Special considerations: Effect to be expected 6вЂ“12 hours after oral administration and within 2 hours after rectal administration. Not to be taken with milk or antacids. Contraindications: Abdominal colics, pain, nausea, vomiting, rectal bleeding, gastroenteritis and intestinal obstruction. Castor oil can cause premature labor. Senna is excreted in breast milk. Side effects: Hypokalemia, hypocalcemia, abdominal cramping and colicky pain. Substances: Bisacodyl (DulcolaxВ®), Castor oil (NeoloidВ®, PurgoВ®), Senna (SenokotВ®) and Casanthranol (PericolaceВ®) Bulk forming laxatives Pharmacological effect: Non-absorbable polysaccharide molecules increase in size by binding water. The resulting bulk formation is distending the colon wall as an adequate trigger to release peristaltic action. Special considerations: Slow onset of effect within 12 hours to 3 days. Strictly requires sufficient fluid supply! Pat is otherwise endangered of bulk forming process in upper gastrointestinal tract. 227 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Substances: Calcium polycarbophil (FiberconВ®), Methylcellulose (CitrucelВ®) and Psyllium (MetamucilВ®) Hyperosmotic laxatives Pharmaceutical effect : Equivalent to bulk forming laxatives, orally or rectally administered disaccharides absorb water which leads to a softening effect without bulk formation. Special considerations: Onset of effect may be delayed by 2 вЂ“ 4 days. Substances: Lactulose (KristaloseВ®), Polyethylene glycol (MiralaxВ®) and Glycerine (GlycerolВ®) Stool softeners (emollient laxatives) Pharmaceutical effect: Anionic surfactants diluted in water penetrate into dry formations of stool. Special considerations: Effect is delayed by up to 3 days from first dosage. Main indication is the prevention of strainous defecation in clients at special risk for constipation (i. e. elderly and immobile clients with limited fluid intake). Substances: Docusate sodium (ColaceВ®), Docusate potassium (DialoseВ®) and Docusate calcium (DoxidanВ®) Saline Laxatives Pharmacological effect: Non-absorbable Magnesium sulfate or citrate salts or Sodium phosphate salts lead to a fast defecation. Special considerations: Onset of effect between 30 Minutes and 6 hours after administration. Side effects: These laxatives may get partially absorbed. (Relative)Contraindications: Renal impairment: Magnesium salts. Chronic heart failure: Sodium salts Antiemetics Antihistamines Most commonly used for treatment of motion sickness. Antiemetic effect due to anticholinergic side effect. Substances: Cyclizine HCl (MarezineВ®), Dimenhydrinate (DramamineВ®), Diphenhydramine (BenadrylВ®), Hydroxyzine (VistarilВ®) and Meclizine (AntivertВ®). Phenothiazines and Butyrophenone: Antiemetic effect due to dopamine receptor blockade. Substances: Metoclopramide (ReglanВ®), Perphenazine (PhenazineВ®), Prochlorperazine (CompazineВ®) and Promethazine HCl (PhernerganВ®). Cannabinoids Mechanism unknown. Used as an antiemetic in cancer chemotherapy. 228 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Substances: Dronabinol (MarinolВ®) and Nabilone (CesametВ®) (also used in AIDS treatment for appetite enhancement) Benzodiazepines and Glucocorticoids Antiemetics in cancer chemotherapy. Used in combination along with Metoclopromide. Substances: Diazepam (ValiumВ®) and Lorazepam (AtivanВ®) Serotoninantagonists Antiemetic effect is part of the Serotonin antagonism. Substances: Dolasetron mesylate (AnzemetВ®), Granisetron (KytrilВ®), Ondansetron (ZofranВ®), Palonosetron (AloxiВ®) Antacid medication H2 Histamine Blockers Pharmacological effect: Selective blockage of H2 - Receptors in gastric, duodenal and pancreatic secretory cells. Reduction of acid release in gastric, duodenal and external pancreatic cells. Peptic ulcer disease, reflux esophagitis and Zollinger-EllisonвЂ™s syndrome. Physiological effect: Reduction of gastric acid production. Special considerations : Reduced dosages in hepatic or renal impairment. Successful treatment requires dietary and life-style regulations. Normal oral dosage is administered once daily at bedtime. NSAID and ASA may interfere with therapeutic effect. Side effects: Dysrhytmias and blood dyscrasias. Substances: Cimetidine (TagametВ®), Famotidine (PepcidВ®), Ranitidine (ZantacВ®) and Nizatidine (AxidВ®) Protone pump inhibitors Pharmacological effect: Blockage of acid producing gastric parietal cells by inhibiting H+-K+ ATPase and removing protons from acid building process. Physiological effect: Reduction/elimination of gastric acid. Indication: GERD, gastric and duodenal ulcers. Special considerations: Used for longвЂ“and short term treatment depending on underlying conditions. Lansoprazole and Esomeprazole capsules can be crushed and administered pelletwise. Omeprazole, Rabeprazole and Pantoprazole capsules can not be opened. Medication has to provide full symptom relief. Otherwise dosage increase or change of medication is required. Intravenous administration has to be performed slow over 15 minutes. Requires reduced dosage in case of a liver impairment. Ongoing Assessment of laboratory parameters is mandatory. Contraindications: Children, pregnancy and lactating women. 229 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Side effects: Disturbed digestion due to absence of gastric acid, resulting in nausea, flatulence, constipation, diarrhea, increased liver enzymes, hepatic failure, liver necrosis, toxic epidermal necrolysis, Stevens Johnson Syndrome and Agranulocytosis. Substances: Pantoprazole (ProtonixВ®), Esomeprazole (NexiumВ®), Lansoprazole (PrevacidВ®) Rabeprazole (AciphexВ®) and Omeprazole (PrilosecВ®). Pantoprazole (Protonix), Esomeprazole (Nexium), Lansoprazole (Prevacid) Mucosa protecting substances Misoprostol (Prostaglandine) Pharmacological effect: Prostaglandine effect on gastroduodenal mucosa cells: Inhibition of gastric secretion, increase of gastric bicarbonate, increase of mucus production decrease of pepsin cells. Physiological effect: Gastric acid relief and mucosa protection. Indications: Mucosa protection Special considerations: Misoprostol has to be taken with food. Strict contraception under Misoprostol is required for up to 1 month after treatment has ended. Side effects: Dizziness, nausea, vomiting, laryngospasm, seizures, dysmenorrhea and postmenopausal bleeding. Sucralfat Pharmacological effect: Formation of a pepsin absorbing coating from albumin and fibrinogen on an gastroduodenal ulcer site. Physiological effect: Gastroduodenal ulcer protection. Indications: Gastrodudenal ulcers Special considerations: Medication to be taken 1 hour prior or 2 hours after meals and 2 hours after medication. Antacid medication Pharmacological effect: Anionic magnesium and aluminum molecules to neutralize gastric acids. Therapeutic effect: Gastric acid relief. Specific considerations: Used for symptom oriented treatment on demand only. Magnesium has to be used cautiously in cases of renal impairment ! 230 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Side effects: Magnesium may cause diarrhea, aluminum may cause constipation and hypophospatemia. Contraindications: Lactating women. Magnesium: Severe renal impairment, Ileostomy, Colostomy. Substances: Magnesium trisilicate (GavisconВ®), Magnesium hydroxide and aluminum hydroxide (MaaloxВ®) and Calcium carbonate (TumsВ®). Helicobacter pylori treatment schemes Lansoprazole + Amoxicillin + Clarithromycin (PrepakВ®) most effective! Bismuth salicylate + Metronidazol + Tetracycline (HelidacВ®) Omeprazole + Clarithromycin (Prilosec/BiaxinВ®) Ranitidine + Bismuth citrate + Clarithromycin (Titrec/BiaxinВ®) Special considerations : Course has to be completed within one week. Clarithromycin and bismuth can not be administered to pregnant women! Bismuth is contraindicated in children (Danger of Reye-Syndrome) and may change color of tongue and stool. x Gallstone-Dissolving Agents Pharmacological effect: Bile acid, inhibiting hepatic synthesis and secretion of cholesterol. Therapeutic effect: Removal of gall stones. Indication: Gallbladder stones Special considerations: Treatment requires 12вЂ“24 months and must show gradual improvement in 6 monthly frequent ultrasound investigations to be continued. Side effects: Rash, nausea, vomiting, abdominal pain, photosensitivity and anxiety. Contraindications: Calcified stones, obstruction of biliary system and liver disease. Substances: Urosodiol (ActigallВ®) Pancreatic Enzymes Pharmacological effect: Replacement of pancreatic enzymes lipase, amylase and protease. Therapeutic effect: Restoration of excretoric pancreatic function. Indication: Chronic pancreatitis Special considerations: Medication has to be linked to meals. No combination with other substances. Side effects: Nausea, diarrhea and hyperuricemia. 231 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Substances: Pancrease and Viokase (Creon 5В®) Antiprotozoal Medication Therapeutic effects: Treatment and prevention of Gardiasis, Threadwom infections, Cestodiosis and Malaria infections. Special considerations: Quinacrine: Used for treatment of tapeworm giardiasis and cestodiosis. As a sclerosing agent for injection into the pleural space used to prevent recurrence of pneumothorax. To be taken after food. Substance may cause reversible yellow blueish coloration of ears, nasal cartilage and nail beds. Chloroquine: Used for giardiasis and amebiasis treatment. To be taken with food. Prophylactic treatment once weekly during current risk and for 10 weeks afterwards. May cause bleaching of body and scalphair, bluish black skin coloration, rusty yellow or brown urine and photophobia. Side effects: Decreased visual acuity, dizziness, vertigo, headaches, nausea, vomiting, diarrhea, confusion, delirium, insomnia, cardiotoxicity, bone marrow suppression, hypotension, blackwater fever and interaction with anticonvulsive agents. Commonly used substances: Chloroquine (AalenВ®), Mefloquine (LariamВ®), Primaquine, Pyrimethamine (DaraprimВ®) Quinacrine (AtabrineВ®), Quinine sulfate (QuinammВ®), Pentamidine isethionate (Pentem 300В®) Pneumocystis carinii infection. Anthelmintic Medication Treatment of infection with Ascaris lumbricoides, trichostrongylus, enterobius vermicularis, ancystoma duodenale and necator americanus. Commonly used substances: Mebendazole (VermoxВ®), Piperazone (AnteparВ®), Pyrantel pamoate (AntiminthВ®), Thiabendazole (MintezolВ®) 232 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com ENDOCRINE DISORDERS AND DISEASES Hormonal regulation cycles Hypothalamic hormones Gonadotropine releasing hormone (Gn-RH) Dopamine Thyreoidea releasing hormone (Thyreotropin, TRH) Growth hormone releasing hormone (GH-RH) Corticotropin releasing hormone (CRH) Pituitary gland hormones Peripheric hormonal glands Peripheric hormones Follicle Stimulating Hormone Testicles Testosterone Ovarian Glands Estrogene Testicles Testosterone Ovarian Glands Progesteron None Thyroid Gland Prolaktin Thyroxin (T4) Growth hormone (GH) Liver Trijodthyronin (T3) Somatomedine Adrenocorticotropic hormone (ACTH) Adrenal cortex Glukocorticoids (FSH) LH - Luteinizing Hormone (LH) Prolaktin Thyreoidea stimulating hormone (TSH) Mineralocorticoids Androgenes Antidiuretic Hormone (ADH) Oxytocin ADH,released by pituitary gland. Oxytocin, released by pituitary gland. None None None None Adrenal cortex Adrenalin, Noradrenalin Kidney Erythropoetin, Calcitriol Pancreatic gland Somatostatin, Glukagon, Insulin Parathyroid gland Parathormone(PTH) Thyroid gland C-Cells Calcitonin Hormones initiate and support specific functions of the human body. The secretion and production process of each hormone is triggered by an endocrine feedback process. Hormonal levels are continuously measured by specific receptors within the central nervous system. Depending on the demand the hormonal production and secretion will either be halted, increased or reduced. Hypopituitarism Failure to thrive caused by a deficiency of growth hormone (GH) from pituitary gland. Affected children will appear with a characteristic growth retardation below the third percentile within the first year. 233 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Symptoms and diagnostic findings: Symptoms depend on clients age at onset of this disorder and on the severity of the GH deficiency. The primary appearance of the affected individuals is showing a delayed or permanently interrupted physical development. Infants: Micropenis, no descend of testicles, hypoglycemia due to compensating hyperinsulinemia and jaundice. Children: Obese, hyperglycemic and retarded musculoskeletal development. Proof of diagnosis by assessment of low levels of IGFвЂ“1 (insulin вЂ“ like growth factor). Treatment: Supplemental therapy with subcutaneous growth hormone injections. Psychological support of children and parents. Growth Hormone (GH) Physiological function: Pituitary gland hormone. Regulating growth of all human tissues. Therapeutic use: Supplementation in children with GH deficiency. Indication: Growth retardation. Special considerations: Only effectful by parenteral administration via subcutaneous or intramuscular injection. GH stimulates all growth specific metabolic functions epecially the protein and blood sugar metabolism. Treatment requires regular x-ray assessment of epiphyseal plates for signs of closure. Treatment has to be discontinued once epiphyseal plates are in process of closing. Treatment in first year may result in 3вЂ“5 inches additional growth but result will decrease later. Therapeutical goal is reached when normal adult height has been reached. Contraindications: Shortness of height due to other causes. Closure of epiphyseal plates. Intracranial tumors. Side effects: Glucose Intolerance, hypothyroidism, deficiency of ACTH (Adrenocorticotropic hormone). Hypercalcuria, allergies, diabetes, organ enlargement, akromegalie and hypertension. Substances : Somatrem (ProtropinВ®), Somatropin (HumatropeВ®), Sermorelin = stimulating GH release (GerefВ®), Bromocriptine = GH suppressor (ParlodelВ®), Octreotide = suppressor of intestinal peptide hormones, insuline, glucagon and growth hormone. (SandostatinВ®) Hyperpituitarism (Gigantism/Acromegalie) Abnormous physical growth by inadequate secretion of growth hormone (GH). Commonly caused by benign pituitary gland tumors. Gigantism with unlimited physical growth occurs if disorder takes place during childhood prior to the physiological epiphyseal closure. Adult hyperpituitarism results in Acromegaly. Symptoms and diagnostic findings: Abnormous enlargement of musculoskeletal system, organomegaly, hypertension and early degenerative osteoathritis. Treatment: Causative treatment is the surgical transsphenoidal removal of GH producing hypophyseal adenoma or of the entire pituitary gland. Patients who are at high risk for surgery may be treated with radiation first. 234 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Hyperthyroidism Inadequate production and secretion of thyroid gland hormones. The most common cause is an autoimmune disorder, also called GraveвЂ™s disease which leads to production of TSH Receptor autoantibodies. Hyperthyreosis is also caused by autonomous dysregulation of parts or of the entire thyroid gland. A rare cause is a dysfuntional release of the thyroid stimulating hypothalamic hypophyseal hormones TRH and TSH or an accidential overdose of thyroid gland hormones. Symptoms and diagnostic findings: Regardless of the underlying cause the following symptoms indicate hyperthyroidism. Struma (enlarged thyroid gland), tremor, nervousness, weight loss, tachycardia, hypertension, psychomototic restlessness, anxiety, panic attacks, sweats and inadequate temperature adjustment. Symptoms depend in occurrence and severity on the actual thyroid gland hormone levels. An intoxication with thyroid gland hormones can occur in severe cases and is considered a thyroid storm or thyroid crisis. This condition is a life threatening emergency, characterized by tachycardia with > 150 bpm, commonly associated by atrial fibrillation. Temperature > 102 F, nausea, vomiting Diarrhea. Clients with GraveвЂ™s disease may also develop exopthalmus (вЂњBetty DavisвЂ™ eyesвЂќ). Laboratory findings: T3, T4 , TSH , TSH receptor auto antibodies (GraveвЂ™s disease). Imaging diagnostic methods include thyroid gland ultrasound as well as technetium radionuclide uptake scan in cases of suspected thyroid gland autonomy. Treatment: Thyreostatic medication with Ethionamide to reduce secretion of thyroid gland hormones. Radioactive ablation therapy with Iodine 131. Substance is administered orally as a fluid by using a straw. Thyroid gland will be partially destroyed over six weeks time. Radioactive precautions are necessary until radiation is below 30 mCi. Partial or total thyroidectomy. Main complications of thyroidectomy are: surgical injury of the nervus laryngeus recurrens leading to a horseness, accidential removal of epithelial bodies of the parathyroid gland, leading to hypocalcemia and tetania. Special eye care may be necessary in case of exopthalmus. Hypothyroidism Comparable to the causes of hyperthyroidism the underlying problem is either a deficient TSH secretion by the pituitary gland or a primarily insufficient thyroid gland which is mainly caused by an antibody activated autoimmune disorder. (HashimotoвЂ™s disease). Symptoms and clinical findings: Weight gain, depression, intellectual retardation, hypothermia, hypotension, bradycardia, fatigue, constipation, myxedema in severe cases, not shiftable, predominantly periorbital and pretibial. Laboratory findings: (variable to cause) T3, T4 , TSH Treatment: Supply of thyroid gland hormones, mostly life long weight management. Thyroid gland medication Physiological function: Stimulation of growth, development and protein synthesis. Supplementation Treatment in hypothyroidism. Administration may be performed intravenously, intramuscular, subcutaneously or oral. An acute hypothyreosis or hyperthyreosis requires regular assessments of vital signs, mood and vigilance. Supplemental treatment requires regular 235 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com assessments of thyroid gland hormones and blood sugar levels. Supplemental treatment is in most cases life long. T3 does not cross blood brain barrier like T4 and is not useful for infantile Hypothyroidism! Side effects: Severity and characteristics of side effects depend on dosage, hypertension, weight loss, palpitations, angina pectoris, anxiety, nervousness, depression, hyperglycemia. Common substances: Levothyroxine = Tetrajodthyronine T4 (LevothroidВ®, LevoxylВ® and SynthroidВ®) Liothyronine = Trijodthyronine T3 (CytomelВ®), Liotrix = T3/T4 Mixture (ThyrolarВ®) Protirelin = TRH Hypothalamic thyroid gland releasing hormone for diagnostic use. Thyrotropin = Pituitary TSH (Thyroid gland stimulating hormone) for diagnostic puposes. Antithyroid medication Pharmacological effect: Inhibition of synthesis but not of release of thyroid hormones. Therapeutic effect: Treatment of Hyperthyreosis and Thyreotoxicosis (GraveвЂ™s disease). Specific considerations: Relevant laboratory studies under treatment with antithyroid medication. Serum T3, serum T4, serum fT3 ( вЂњfreeвЂќ = not bound to Albumine), serum fT4 T3 resin uptake, serum thyroid uptake of radioiodine, thyroid gland suppression test. No immediate onset of effect. Routine blood tests may be performed weekly. Medication is to be taken in circadian rhythm. Side effects: Hypothyroidism and related symptoms, bone marrow depression Agranulocytosis. anemia, infections, neuropathia, metallic taste Common substances: Methimazole: (TapazoleВ®) Inhibiting thyroid hormone synthesis but not hormone release. Propylthiouracil (generic) Inhibits synthesis and peripheral breakdown of T3 to T4. Hyperparathyroidism Primary hyperparathyroidism is mostly caused by a tumor or a hyperplasia of the parathyroid gland. Secondary hyperparathyroidism occurs in cases of hypocalcemia. Physiological PTH function is to restore decreased calcium levels by influencing three modalities Increasing the calcium resorption from bones, the renal calcium reabsorption and the intestinal calcium reabsorption. Symptoms and diagnostic findings: Serum calcium , Serum phosphate , nephrolithiasis, polyurie, osteopenia вЂ“ osteoporosis and gastrointestinal ulcers. Treatment: In cases of tumor or hyperplasia the first line treatment is surgical removal as early as possible in the course of disease. Medication treatment loop diuretics under sufficient fluid supply is indicated if surgical solution is not achievable or not indicated. Thiazide diuretics and digitalis are contraindicated in hypercalcemia! 236 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Hypoparathyroidism Main cause of hypoparathyroidism is the accidental surgical removal of the parathyroid gland. Symptoms and diagnostic findings: Hypocalcemic tetany: Paresthesia, hoarseness, headaches, tremor and muscle spasms. Chvostek sign positive pressure on facial nerve leads to elevation of mouth angles. Trousseau sign positive inflation of blood pressure cuff leads to cramps of forearm muscles. Laboratory findings: PTH , Serum calcium , Phosphate . Treatment: Calcium and Vitamin D supply. Parathyroid Gland Medication Calcium Supplements Pharmacological effect: Supply of calcium to meet metabolic needs. Therapeutic use: Calcium replenishment in hypocalcemia due to hypoparathyroidism. Also antacid treatment for gastric problems due to hyperacidity. Indication: Hypoparathyroidism and alimentary calcium deficiency. Special considerations: To be taken separately from dairy products and other medications with large amounts of water, with meals or after meals. Spinach, whole grain, beets, bran reduce intestinal calcium absorption due to their high concentration of oxalates. Long term treatments and severe hypocalcemia requires weekly assessments of serum and urine calcium levels. Side effects: Constipation, flatulence and hypercalcemia. Common Substances: Calcium acetate (PhosLoВ®), Calcium chloride (generic), Calcium carbonate (TumsВ®) Vitamin D Physiological effects: Controlling the calcium absorption and interaction with the skeletal calcium metabolism. Therapeutic use: Treatment and prevention of Vitamin D deficiency. Indications: Rickets, osteomalacia, hypoparathyroidism. Special considerations: Administration orally or intramuscular. Therapeutic effect requires presence of sufficient calcium serum levels. Monitoring of kidney function and electrolytes is mandatory under treatment of vitamin D deficiency. Side effects: Hypercalcemia (Constipation, gastrointestinal dysfunction, abdominal pain, hypotonia, seizures, ataxia, fatigue, somnolence, dysrhytmias and hypercalcuria) Hypervitaminosis D (Hypercalcemia, hypercalciuria, tissue calcification, lower level of consciousness. Common substances: Calcifediol (CladerolВ®), Calcitrol (CalcijexВ®), Dihydrotachysterol (HytakerolВ®), Ergocalciferol (CalciferolВ®) and Paricalcitol (ZemplarВ®). 237 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Anti-Hypercalcemia medications Pharmaceutical effect: Renal excretion of calcium , Decrease of duodenal calcium absorption , decrease of calcium mobilization from bone , complex building of free calcium ions in peripheric blood. Therapeutic effect: Normalization of calcium levels. Indications: Hypercalcemia Special considerations: Administration intravenously, intramuscular, subcutaneously or oral. Intravenous preparations require dilution. Supervision of renal function required. Sufficient fluid supply under treatment is mandatory. Contraindications: Renal impairment and ongoing calcium supply. Side effects: Mainly caused by Hypercalcemia, facial flushing, increased effect of cardiac Glycoside medication, nausea, vomiting, diarrhea. Venous irritation, thrombophlebitis and nephrotoxicity due to IV administration. Common substances: Calcitonine (MiacalcinВ®) = Inhibition of calcium resorption into bone tissue. Cinacalcet (SensiparВ®) = Increases parathyroid sensitivity to increased extracellular calcium and to decreased PTH secretion. Epedate disodium (DisotateВ®) = Building calcium chelate complexes. Etidronate (DidronelВ®), Zoledronic acid (ZometaВ®) and Pamidronate (ArediaВ®) = Inhibiting bone resorption. Gallium nitrate (GaniteВ®) = Malignant hypercalcemia. Plicamycin (MithramycineВ®) = Inhibition of malignant bone resorption. CushingвЂ™s Syndrome Inadequate secretion of cortisol from adrenal cortex or of Adrenocorticotropic Hormone (ACTH) from pituitary gland. Also caused by long term cortisol treatment in high dosages. Symptoms and diagnostic findings: Abnormal distribution of fat tissue over entire body leads to characteristic appearance including moon facies, truncal obesity, fat neck, diabetes, edema, weight gain, thin and sensitive skin with delayed wound healing. Immunodeficiency causes recurrent infections. Laboratory findings: Cortisol , ACTH decreased or increased, depending on course, natrium , glucose , 17 вЂ“ Ketosteroids in Urine Treatment: Treatment of underlying adrenal or hypophyseal dysfunction by radiation or surgery. Physical cushingoid symptoms that are established are not reversible. Clients require strict injury and infection prevention. Slow steroid dose reduction in cases of cortisol overdoses. AddisonвЂ™s Disease Mainly caused by a sudden insufficiency of the adrenal cortex due to an autoimmune disorder with antibody production against the adrenal cortex. Also due to insufficient production and release of hypophyseal adrenocorticotropic hormone (ACTH). Most commonly after severe shocks and infections. Also due to a sudden cessation of steroid treatments. 238 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Symptoms and diagnostic findings: Abnormal muscular weakness and fatigue, pigmentation of skin and mucous membranes, weight loss , dehydration, low blood pressure, abdominal pain, hyponatremia, hyperkalemia, Cortisol , ACTH (adrenocorticotropic hormone). Treatment: Supply of corticosteroids. Treatment of Gluco вЂ“ and Mineralocorticoid Metabolism Disorders Mineralocorticoids Physiological effect : Retention of sodium and water. Release of Potassium via kidneys as part of the Reninangiotensin blood pressure regulating system. Indication: Replacement therapy in dysfunction of the adrenal glands (Morbus Addison). Special considerations: Requires permanent assessment of Serum electrolytes, weight, input and output. Potassium rich and Sodium poor diet. Trauma, infections and stress require dosage adjustment. Side effects: Delayed wound healing, unusual response to infections, thromboembolism, nausea, acne and hypokalemia. Substances: Fludrocortisone (FlorinefВ®), Hydrocortisone (CortefВ®) and Cortisone (CortoneВ®) Glucocorticoides Physiological effects: Metobolic effect by stimulation of the carbohydrate, protein and fat metabolism. Anti inflammatory effect, immunosuppressive effect and thrombocytosis. Indications: Replacement in cases of disturbed or absent synthesis (i.e. M. Addison). Inflammatory diseases, allergic diseases, anaemia, thrombocytopenia, dermatological disorders and autoimmune diseases. Specific considerations: Form of administration depends on underlying indication and can be intravenous, imtramuscular, topical, oral, nasal and optical. Long Term treatment suppresses negative feedback trigger of own synthesis within the hypothalamic вЂ“ pituitary вЂ“ adrenal system. (HPA). Acute withdrawal after steroid long term treatment is contraindicated and can cause permanent depression of the entire adrenal cortex. Even in non systemic treatments. No vaccinations should be performed under treatment and three months there after. Patients under steroid treatment require thorough assessments even for common infections like colds. Each Clucocorticoid has a defined borderline dosage which is supposed to not be overcome in patients with long term steroid treatment. (e.g. the borderline dosage for Prednisolone is 7.5 mg/d). Every Glucocorticoid (besides Triamcinolon) has also mineralocorticoid effects and vice-versa. Side effects: Cushingoid appearance: moonface, weight gain, hypertension, hyperglycemia, hypertrigleridemia, striae, change of skin pigmentation, vulnerability against opportunistic infections, gastroduodenal ulcers and diabetes. Substances: (None to little mineralo corticoid action) 239 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Triamcinolone (AristacortВ®), Betamethasone (CelestoneВ®), Dexamethasone (DecadronВ®), Prednisone (DeltasoneВ®), Methylprednisolone (MedrolВ®), Prednisolone (DeltasoneВ®), Cortisone (CortoneВ®) and Hydrocortisone (CortefВ®). Adrenocorticotropic Hormone ACTH Physiological effect: Mediator hormone excreted by the pituitary gland. Direct stimulation of adrenal cortex for production of adrenal steroids. Indications: Diagnostic testing for adrenal and pituitary insufficiency. Treatment of steroid sensitive diseases but much less therapeutic potency than adrenal glucocorticoids. Specific considerations: Administration intravenously, intramuscular, subcutaneously or oral. Contraindications: (comparable to Glucocorticoids) Opportunistic infections, systemic infections and recent surgery. Substances: Corticotropin (ActharВ®), Cosyntropin (CortrosynВ®), Metyrapone (MetopironeВ®) Diabetes mellitus Caused by an insufficient function or total inability of the pancreatic gland to produce and release insuline. Diabetes Type 1 Starts from birth or until the age of 40 with a sudden or slowly developing total loss of pancreatic insulin production. Mainly caused by an autoimmune destruction of the pancreatic beta cells which can be induced by previous unspecific viral infections. Diabetes Type 2 Characterized as a slowly developing insulin resistence which leads to a hyperinsulinemia first and later to an exhaustion of the pancreatic insulin production. Intermediate stages are considered as decreased glucose tolerance. This type of diabetes strongly correlates with obesity and can occur from adolescence but mainly after the age of 40. Symptoms and diagnostic findings: Early stages: Abnormal weakness and fatigue, polydipsia, polyuria, ketonuria, polyphagia Fluid and electrolyte dysbalance, Diabetic Ketoacidosis (DKA). Advanced stages: Immunodeficiency, recurrent infections, delayed wound healing, diabetic macroangiopathy (coronary artery disease and peripheral arterial disease), diabetic microangiopathy (Diabetic foot syndrome and diabetic retinopathy), diabetic nephropathy (Microalbuminuria) and diabetic neuropathy (Paresthesia). Life threatening diabetes related conditions вЂў Diabetic ketoacidosis вЂў Hyperglycemic hyperosmolar nonketotic syndrome Laboratory findings: Hyperglycemia (Fasting blood sugar), > 126 mg/dl (= 7.0 mmol/l) Diabetes 100 вЂ“ 125 mg/dl (= 5,6 вЂ“ 6,9 mmol/l) Impaired fasting glucose IFG < 100 mg/dl (5,6 mmol/l) normal fasting glucose Glucosuria appears from blood glucose of > 180 mg/dl blood glucose levels! 240 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Treatment: Prior to any medical treatment a successful diabetes therapy requires a strong motivation of the client to learn self administration of insulin and blood glucose monitoring as well as compliance to follow dietary guidelines and to attend regular check ups to prevent or control late developing diabetes symptoms. Clients with an insuline therapy require further teaching about appropriate. Physical exercise endurance activities Foot care daily inspection of soles, avoid walking barefoot and wear appropriate Footwear. Emergency treatment of hypoglycemia 15 g Carbohydrate snack or Glucagon injection. Weight management General diet recommendations as for general public. Diabetes mellitus medication therapy Insulin Pharmocological effects: Correction of blood glucose levels due to enhanced uptake in skeletal muscles and liver. Support of the lipid synthesis and inhibition of the Glucagon secretion. Therapeutic effect: Maintaining normal blood glucose levels. Indications: Diabetes Type 1 + 2 Special considerations: Parenteral injection only via syringes, pumps and pen injectors. Mainly subcutaneous injection to abdomen, thighs, arms. Injection sites need to alter regularly. Only regular insulin can be administered intravenously! Suspension free Insulins are regular and Lispro. All others require to be dispersed prior injection. Not all insulins are compatible with each other. Unopened vials have to be stored in refrigerator. Vials in use can be stored at room temperature for up to one month. Insuline therapy schemes: 1.Conventional therapy: Injections of short acting and intermediate acting insulin as a combination twice daily at defined times. 2.Intensified therapy: Long acting insuline in the mornings and evenings in combination with short acting insuline prior to each meal. Use of Beta adrenergic Blockers can disguise hypoglycemic symptoms. Effectfulness of treatment requires frequent daily glucose monitoring as follow: вЂў вЂў For conventional therapies fasting and prior to bedtime. For intensified therapies fasting, prior each meal and at bedtime. Also whenever client experiences any physical discomfort. Assessment of glycosylated hemoglobin A1c allows judgement about adequate long term results. This assessment is most conclusive if it is performed every 3 months since renewal of RBCвЂ™s occurs within this time frame (+/- 120 days). Repeated assessments within 6 weeks provide no additional information. Required insulin dosage increases over time due to development of insuline tolerance. Clients with infections, fever 241 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com especially gastrointestinal disturbances require dosage adjustments since hypo вЂ“ and hyperglycemia can occur. Clients who are undergoing general surgery require temporary adjustments to regular insulin only. Any antidiabetic therapy but especially insulin therapy requires thorough and detailed patient education. Brand and type of insulin can not be changed without notification of client and prescriber. Vials for insulin pens contain a higher concentrated insulin than vials to be used for syringes and can not be exchanged. Pregnant and lactating clients with a diabetes that can not be maintained by dieting receive treatment with regular insulin only. Other insulin types and oral antidiabetic medication types are contraindicated in pregnancy and lactation. Side effects: Hypoglycemia ( = Blood Glucose < 50 mg/dL / 2,8 mmol/l ) cold sweats, palpitations, hunger, reduced level of consciousness, headaches, muscle weakness, seizure and coma. Allergic reactions Lipodystrophia degeneration of subcutaneous fat tissue after repeated insulin injections leads to a disturbed absorption. Weight gain due to the anabolic effect of insulin. Common Substances: Rapid acting insulin: Onset within 5 minutes, peak after 30вЂ“60 minutes, duration 2вЂ“4 hours. Types: Insulin lispro (HumalogВ®), Glulisine (ApidraВ®) modified human type. Fast acting insulin: Onset within 30 minutes, peak after 1вЂ“3 hours, duration 3вЂ“5 hours. Types: Aspart (NovologВ®) modified human type. Regular insulin: Onset within 30вЂ“60 minutes, peak after 2вЂ“4 hours, duration 5вЂ“7 hours. Types: Regular Insulin, (Humulin RВ®, Novolin RВ® , Velosulin BRВ® , human type, beef, pork insulin. Intermediate insulin: Onset within 1вЂ“2 hours, peak after 6вЂ“12 hours, duration 18вЂ“24 hours. Types: NPHВ®, HumulinВ®, NovolinВ®, Human type, beef and pork insulin. Long acting insulin: Onset within 4 вЂ“ 6 hours, peak after 16 вЂ“ 18 hours, duration 20 - 36 hours Types: LantusВ®, Humulin UВ®, UltralenteВ®, Novolin LВ®, Human type insulin. x Oral antidiabetic medication Sulfonylureas and Meglitinides Pharmacological effect: Stimulation of pancreatic beta cells for release of insulin. Therapeutic effect: Supplementation of reduced insulin production for maintenance of blood glucose levels. Indications: Diabetes mellitus type II 242 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Special considerations: Treatment is indicated when diabetes management with diets and exercise alone is not sufficient. Treatment with beta-adrenergic receptor blockers can weaken insulin release from pancreatic cells and the effect of sulfonylurea medication. Alcohol intolerance under treatment is likely to happen. Alcohol increases risk for hypoglycemia. Metabolites of sulfonylurea medication also have hypoglycemic effect and may lead to a delayed hypoglycemic reaction up to 6-12 hours after administration if no sufficient amounts of carbohydrates were consumed. Medication has to be taken 15 вЂ“ 30 minutes before meals. Available substances have equal potency. Substances: Gibencamide (EugluconВ®), Glipizide (GlucotrolВ®), Glyburide (DiabetaВ®), Glimepiride (AmarylВ®),Tolbutamide (OrinaseВ®) Metiglinides Differ to sulfonylureas in rapid onset and short duration of effect. Therefore they are better tolerable and less likely to cause side effects. Side effects: Hypoglycemia, allergies (Skin reactions), gastrointestinal disturbances and weight gain! Contraindications: Pregnancy and lactation, severe hepatic and renal dysfunction. Substances: Nateglinide (StarlixВ®) and Repaglinide (PrandinВ®) Nunsulfonylurea oral antidiabetics Alpha-glucosidase inhibitors Delay absorption of carbohydrates from intestinal tract. Biguanide medications Reduce glucose production from glycogen storages in liver and skeletal muscles by enhancing the anaerobic glycolysis. Does not cause weight gain and is primarily indicated in obese clients. Glitazones / вЂњInsulinsensitizerвЂќ (Thiazolidinediones) reduce peripheric insulin resistance and gluconeogesis in liver. Treatment in combination with biguanides or sulphonylureas. Special considerations: Medication therapy is generally indicated when diabetes management with diets and exercise alone is not sufficient. Medication has to be administered with meals. Alpha-glucose inhibitors: Used for monotherapy and in combination with insulin or sulfonylureas. Biguanides: Used for monotherapy and in combination with sulfonylureas. Alcohol increases risk of hypoglycemia and lactic acidosis. x Thiazolidinderivates: Only for therapy in combination with sulfonylureas or biguanides if they can not be combined with each other. Treatment requires strict surveillance of liver function. Side effects: Alpha-Glucosidase Inhibitors: Abdominal cramps, flatulence, diarrhea, decreased absorption of iron Anemia Biguanides: Decreased appettite, nausea, diarrhea, hypoglycemia and lactic acidosis. Thiazolidinderivates: Liver damage 243 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Contraindications: All substances: Pregnancy and lactation. Biguanides: Cardiorespiratory diseases, clients > 65 years, renal insufficiency and cachexia. Thiazolidinderivates: Liver diseases, insuline therapy. Substances: Alpha glucosidase inhibitors: Acarbose (PrecoseВ®) and Miglitol (GlysetВ®) Biguanide: Metformin (GlucophageВ®) Thiazolinediones: Pioglitazone (ActosВ®) and Rosiglitazone (AvandiaВ®) Bromocriptine (CyclosetВ®) Dopamine agonist medication. Also used for treatment of ParkinsonвЂ™s Disease. Stimulates production of Dopamin in the CNS. The substance is indicated in Diabetes Type II only and has to be taken orally in the morning with food. Either as a monotherapy or in combination with Sufonylurea and / or Metformin. Gliptines Sitagliptin (JanuviaВ®), Vildagliptin (GalvusВ®) Ora antidiabetics for treatment of Diabetes type II which do not cause hypoglycemia, weight changes or any significant side effects. Can be used as a monotherapy or in combination with Metformin, Thiazoline (вЂњInsuine sensitizerвЂќ) Sufonylurea medication and insuline. Injectable non вЂ“ insuline antidiabetics Liraglutide (VictozaВ®), Exenatide (ByettaВ®) Injectable GLP 1 - receptor agonists. Increases insulin production of the pancreatic gland in clients with Diabetes Type 2. Used as first line therapy after failure of treatment with diet, exercise and weight loss. Substance has to be injected subcutaneously once daily (Liraglutide) or twice daily (Exenatide). Anti Hypoglycemic Medication Glucagon Pharmacological effect: Promotes glucose synthesis by stimulating the breakdown of glycogen. Therapeutic effect: Correction of hypoglycemia. Indication: Emergency treatment for hypoglycemia in an unconscious client or lack of dextrose, glucose supply. Special considerations: Administration via IM, IV or subcutaneous injection. Effect expected within 5вЂ“20 minutes. Glucose/dextrose infusion has to be added under consideration of effect and measurable levels of blood glucose. Glucagon effect requires efficient glycogen storage. Every client under treatment with insulin or oral antidiabetics has to be instructed about symptoms of hypoglycemia and advised to carry oral dextrose and a glucagon kit at any time. Side effects: Nausea, vomiting, hyperglycemia and hypokalemia. 244 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com MUSCULOSKELETAL DISORDERS AND DISEASES Osteoporosis Osteoporosis is the most common bone disease among the elderly. Most common cause in > 90% of all cases is a postmenopausal osteoporosis in women. In rare cases osteoporosis may be induced by a longer lasting immobility or steroid treatment. Dietary deficits of calcium, smoking, lack of physical activity and anorexia also apply. Symptoms and diagnostic findings: Osteoporosis remains asymptomatic until the sudden occurrence of a spontaneous fracture due to an inadequate trauma, unspecific skeletal pain or reduction of body height. Most common osteoporosis induced fractures are related to spine, femur and radial bones. Preventive BMD (bone density measurements) may diagnose osteoporosis prior to the appearance of pathological fractures or other symptoms. Laboratory findings: Indicators of increased bone resorption: Serum alcalic phosphatase (AP) , calcium and phosphate levels are mostly in normal ranges. Treatment: Preventive treatment includes: Dietary daily intake of 1200mg Calcium/daily in combination with Vitamin D. Regular physical exercise and estrogene replacement therapy in postmenopausal women. PagetвЂ™s disease Second most common skeletal disease beside osteoporosis. Starts with a rapidly developing bone resorption of single bones and a hypertrophic and deforming formation of weak bone tissue. Symptoms and diagnostic findings: Diagnosis is made via x-ray. Symptoms include: Slowly increasing pain in single bones followed by a deforming bone growth. Pathological fractures due to weak new bone tissue. Arthritis, headaches and hearing loss. Laboratory findings: Increased alkaline phosphatase. Treatment: Medication therapy includes biphosphonates and calcitonin. Osteomyelitis Bacterial infection of the bone marrow. May be caused by a direct bacterial contamination in an open fracture or a surgical intervention. Other causes include a hematogenic infection from other infected tissues via the blood stream. Most common causative germ is staphylococcus areus. Symptoms and diagnostic findings: Acute, mostly feverish infection accompanied by a severe circumscripted pain of the infected area. Warmth, swelling and redness of surrounding soft tissues. Symptoms and diagnostic findings: ESR , Leucocytosis, CRP, , Imaging diagnostics via X-ray, MRI or CT scan reveals location and extent of inflammatory affection of infected bones. Treatment: Immediate high dose antibiotic treatment required. Substances with an improved resorption by bone tissues are makrolides, aminoglycosides, cephalosprines and flourchinolones. In cases of hematogenic osteomyelitis the choice of antibiotics depends on the character of the primary infections. Osteomyelitis caused by direct contamination mostly requires surgical therapy for wound debridement and local antibiotic treatment. 245 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Osteoarthritis Mostly age related degenerative joint disease. Early onset may be caused by previous joint injuries or after fractures which have healed in an anatomically deviated position. Condition causes painful progressing degeneration of joint cartilage with loss of function and deformation of the surrounding bone tissue. Every joint is affected over a life time but does not necessarily become symptomatic. Less common types of osteoarthritis are specifically effecting the distal interphalangeal finger joints (HeberdenвЂ™s nodes) or the proximal interphalangeal joints (BouchardвЂ™s nodes). Symptoms and diagnostic findings: Osteoarthritis pain in early stages typically appears as a walking through pain which starts after a resting period and gradually improves the more ROM has been performed. In later stages this condition causes ongoing pain and limits function of affected joints. Specific laboratory findings are not existing. Diagnosis is made via x-rays. Treatment: Treatment is oriented on symptomatic pain relief along with physical therapy to maintain a functional ROM of the affected joints. Medication therapy used are non-steroidal anti inflammatories and analgetics (e.g. acetaminophen). Intraarticular steroid injections are performed in acute inflammatory exacerbations. In advanced stages joint replacement surgery may be considered. Clients need to be encouraged for regular physical activity and weight management. Medication therapy for Osteoporosis and PagetвЂ™s disease Pharmacological effect: Reduction of skeletal calcium release by slowing bone resorption and remodelling process down. Therapeutic effect: Reduction of bone destruction. Prevention of Hypercalcemia Indications: Osteoporosis (disturbed bone metalbolism), PagetвЂ™s Disease (idiopathic bone destruction) Special considerations: Administration intravenously, intramuscular, subcutaneously, orally and intranasal. Interaction with calcium, vitamin D, antacids, assessments of 24 hour urinary hydroxyproline provides information on activity and speed of bone resorption. As well as bone mineral density BMD in hip , vertebrae and forearm. Reassure sufficient calcium and vitamin D supply. Side effects: Nausea and vomiting, diarrhea, dyspepsia, gastrointestinal ulcerations, gastritis, esophagitis, facial flushing due to shifting serum calcium and muscle spasms. Dry mucous membranes. Venous irritation, thrombophlebitis, nephrotoxicity due to IV administration. Hypocalcemia and hypercalcemia (temporary). Common substances: Calcitonin (human or salmon i. e. Cibacalcin), Etidronate (Didronel) and Pamidronate (Fosamax). Gout Caused by significantly increased uric acid blood levels. Most commonly caused by an excessive intake of purine containing food along with a deficient renal elimination. Rare causes are metabolic disorders with a reduced activity of the enzyme hypoxanthin вЂ“ guanin - phosphoribosyltransferase. (Lesch вЂ“ Nyhan Syndrome, Kelley вЂ“ Seegmiller Syndrome). Triggers for acute flares of gout disease are sudden alterations of uric acid 246 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com levels which can be caused by weight loss, fluid deficiency, renal insufficiency, alcohol intake or excessive consumption of purine rich food (meat and fish). Symptoms and diagnostic findings: Kidney Stones (Nephrolithiasis) Gout arthritis (Arthritis urica) mostly affecting single joints (Gonagra, Podagra) вЂњGout tophiвЂќ (Deforming joint crystallizations of uric acid and visible x-rays) Acute flares appear with significant elevations of WBCвЂ™s and ESR. Treatment: Medication therapy in acute stades is performed with non steroidal anti-inflammatories. Preventive antihyperuricemic treatment is performed with allopurinol and includes appropriate daily fluid intake, diet changes and a reduction of alcohol consume. B PertheвЂ™s Disease Perthes Disease describes an acute aseptic necrosis of the femoral head which affects children between 2 and 7 years of age only. 90% of all cases occur unilateral. The cause is unknown. This condition is generally self limiting and heals within 2вЂ“4 years if appropriate treatment takes place. The course of Perthes disease includes 4 stages: I: Avascular stage II: Revascularization stage III: Reparative stage IV: Regeneration stage Symptoms and diagnostic findings: Acute aggravating hip pain of moderate to intense severity under physical activity. Limited range of movement in affected hip joint, weakness of gluteal muscles evident by a positive Trendelenburg sign. Diagnosis is made via X-ray which show a progressing destruction of the femoral head. Treatment: Depending on the stade of an aseptic necrosis of the femoral head treatment is mainly conservative and includes strict avoidance or limitation of weight bearing while maintaining an adequate range of movement. Tutors, cast and other orthopedic devices may be necessary to avoid a luxation of the femoral head since an anatomical correct regeneration of the femoral head can only take place if the hip joint remains intact. A surgical treatment option is a rotating osteotomy of either the femoral bone or the acetabulum to ensure that the femoral head is covered by the acetabulum. Dislocation of the femoral epiphysis This condition typically occurs prior to epiphyseal closure of the longitudinal bones during puberty. During a usually slow developing process the proximal eiphyseal plate of the femoral head slips off the distal epiphyseal plate. A definite cause is unknown. Clients prone to a femoral epiphysis dislocation are usually either fast growing or show tendencies of obesity. Symptoms and diagnostic findings: Acute or gradual onset of hip pain at rest and while weight bearing, along with a developing limited range of motion. Diagnosis is made by X-ray. Treatment: Surgical treatment is mandatory. Clients require strict preoperative immobilization to avoid further damage to the epiphyseal gap which may result in a growth inhibition of the affected limb. Surgical treatment is aimed to reposition and fixate the slipped epiphyseal plate. Sporting activities which include a stop and go mechanism or contact sports have to be avoided until the skeletal growth is completed. 247 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Scoliosis Lateral deviation of the spine from its longitudinal axis. Primary cause is an idiopathic structural growth disturbance of the spine of unknown cause which mainly starts from childhood. Secondary scoliosis due to a musculoskeletal, neurological disease or osteomyelitis of the spine is comparably rare. Symptoms and diagnostic findings: A spine deformation becomes obvious during its development and is mostly not associated with pain from the beginning. Low grade scoliosis may be overlooked but are subject to the well child and school examinations. Points of orientation are equal heights of shoulders and both sides of the pelvic bone. Depending on the actual severity of the deformation internal organs may be compromised which can result in additional symptoms such as respiratory or digestive problems. Scoliosis also leads to an imbalance of the entire musculoskeletal system which may include dysfunction of limbs as well as an early developing osteoarthritis. Treatment: Treatment options are conservative or surgical depending on the actual angle of deviation. As a common rule, a scoliosis with less than 40 degrees of deviation can be treated with conservative methods which includes an intensified physical therapy to strengthen the spine and to stabilize the paravertebral muscles. Supporting braces my be used for cases of advanced scoliosis or after surgical intervention took place. Rheumatoid Arthritis RA Autoimmune disease with destructing effect to the cartilage and connective tissues of the musculoskeletal system. Inflammatory flares are triggered by environmental factors in clients with genetic predispositions. The course of the disease typically shows variable stades with exacerbations and remissions. Symptoms and diagnostic findings: Clinical manifestions mostly occur in middle aged clients but condition can be present at any age. Onset with acute flares of symmetrical inflammation of small joints, preferrably on hands and feet (PIP and DIP). Main clinical symptoms are swelling, effusions, stiffness, pain and loss of function of the affected joints. Uncontrolled flares lead to joint destructions. Symptoms and diagnostic findings: ESR , WBC , CRP , rheumatoid factor positive (in majority of cases), anemia and deformations on hands and feet. Treatment: Multimodal anti-inflammatory medication therapy. Musculoskeletal Medication Therapy Non-Ateroidal Anti-Inflammatory Drugs (NSAIDвЂ™s) Indicated in early stages of rheumatid arthritis. See discussion under musculoskeletal system. Disease Modifying Antirheumatic Drugs (DMARDвЂ™s): Auranofin (RidauraВ®) + Aurothiglucose (SolganalВ®) Reduction of rheumatoid factor and immunoglobulins to suppress arthritic symptoms. Side effect: Nephrotoxicity 248 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Gold Sodium Thiomalate (MyochrisineВ®) Inhibition of inflammatory prostaglandin effect. Side effect: Nephrotoxicity Etanercept (EnbrelВ®) Tumor necrosis factor from chinese hamsters which causes inhibition of lymphocytic inflammatory reaction. Side effect: Infections due to induced immunodeficiency Hylan G-F 20 (SynviscВ®) Preparation of hyaluronic acid from chickens which is injected in affected joints to provide lubrification. Side effect: Allergy Methotrexate (AmethopterinВ®) Inhibition of DNA synthesis, causing interruption of proliferation of inflammatory tissue. Side effects: bone marrow suppression, pulmonary fibrosis, gastrointestinal ulcerations. D-Penicillinamine (DepenВ®) Reduction of IgM - Rheumatoid factor. Side effect: skin reaction and rash. Sodium hyaluronate (HyalganВ®) Supposed to provide improved lubrification of joints and support repair of joint cartilage tissue. IV only as infusion no push. Monitoring of inflammation parameters as well as kidney and liver function required. May or may not be taken with meals but always with sufficient amounts of fluids. Non вЂ“ opioid pain management in musculoskeletal disorders Prostaglandin sysnthesis inhibitors - Nonsteroidal Anti вЂ“ Inflammatory Agents Pharmaceutical effect: Inhibition of cyclooxygenase, the key enzyme for the synthesis of the inflammation and pain mediator prostaglandin. Physiological effect: pain relief, anti inflammatory effect, inhibition of platelet aggregation, antipyretic effect Indications: Treatment of musculoskeletal pain and dysmenorrhea. Side effects: Gastric irritation, prolonged bleeding, tinnitus, hepatotoxicity, allergies, bronchospasms. Contraindications: Children, due to danger of Reye Syndrome, (Encephalopathy and fatty liver degeneration) asthma, peptic ulcer disease, history of gastrointestinal bleedings, anticoagulant therapy, hepatic diseases, kidney disease. Treatment should be pursued for up to one month at a time or as required! Substances: Celecoxib (CelebrexВ®), Diclofenac (VoltarenВ®), Ibuprofen (AdvilВ®), Indomethacin (IndocinВ®), Ketoprofen (ActronВ®), Naproxen (NaprosynВ®), Piroxicam (FeldeneВ®) 249 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com DERMATOLOGICAL DISORDERS AND DISEASES Eczema (Atopic Dermatitis) Circumscripted superficial inflammation of the skin, typically related to a wide range of allergic reactions against food, pollen or other unindentified allergic agents. Inherited sensitivity mostly occurring from childhood ages. x Symptoms and diagnostic findings: Suddenly developing superficial and itching inflammation of the skin. Mostly dry and scaly and predominantly distributed by a certain pattern over stretch or flexing sides of the limbs. Treatments: Main treatment is the elimination of the causative agent to avoid an increase and recurrence of eczemas. Mostly the causative agent is unknown and can not be revealed in an allergic test. Possible causes may be identified by stepwise elimination of any external agents other than soap and water. Possible underlying food allergies may be identified by an elimination diet. Acute medication therapy in acute cases is performed with topical steroid crГЁme such as hydrocortisone 1%. Antihistamines are used to control itching. Contact Dermatitis Acute or delayed skin reaction due to an individually specific irritating substance or allergen. An allergic reaction can also be mediated by presence IgE alone while the epidermal reaction is caused by TвЂ“lymphocytes! Reaction may appear acute or chronically. Symptoms and diagnostic findings: Expression varies from acute erythema to an eczema like and thickening skin reaction in direct range to the point of contact of the causative agent. Treatment: Main treatment is the identification and elimination of the causative agent, if possible. Skin reactions will be treated with topical steroid cremes. Smoothing external agents or systemic antipruritic medication may be used for itch relief. Urticaria Acute maculoвЂ“papulous skin transformation due to an unspecific allergic reaction or triggered by cold or hot temperature followed by an IgE mediated histamine release from mast cells. Symptoms and diagnostic findings: Raised, blanched exanthema surrounded by a red margin. Severe pruritus. May affect any area of the body. Allergic urticaria mostly appears generalized. Treatment: Medication therapy for severe allergic urticaria includes Antihistamines + corticosteroids, + epinephrine 1:1000 s. c. Any observed allergic urticaria requires an acute intervention to prevent a possible ongoing life threatening anaphylactic reactions, although an allergic urticaria may also be self limiting without any medical intervention. Treatment of other forms of urticaria depends on their underlying causes. Psoriasis Chronically recurrent eczematous skin disease which is suspected to be caused by an autoimmune disorder, mediated by TвЂ“Lymphocytes. Symptoms and diagnostic findings: Psoriasis appears with a characteristic dry rash of white вЂ“grey scales which are typically located over knee caps, elbows, scalp, palms and soles. Nails typically develop white 250 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com circumscripted dots. Psoriasis may also cause arthritis. Treatment: Medication therapy is mainly based on topical steroids in combination with systemic antihistamines. Long term treatment also includes frequent exposure to ultraviolet light under simultaneous use of psoralene containing medication to increase the light sensitivity of the skin (PUVA Therapy). Seborrhoic Dermatitis Circumscripted erythematous scaling inflammation of the skin. Acute flares mainly occur in a climate with low humidity and a lack of sunlight. The definite cause is unknown. Symptoms and diagnostic findings: Circumscripted, red (erythematic), scaly skin lesions, spreading all over the body areas which are rich of sebaceous glands: scalp, eyebrows, neck, axils, back, glutaeal and genital region, palms and soles. Treatment: Medication therapy consists of coal tar, steroids and selenium sulfide for local use only. Bacterial skin infections Acne Chronic recurrent inflammation of the sebaceous glands that are surrounding the hair follicles, commonly accompanied by a bacterial super infection with proprionibacterium acne. Course is triggered by multiple factors, such as androgen stimulation, skin type and amount of sebaceous production. Main common occurrence can be observed in male puberty. Symptoms and diagnostic findings: Lesions occur accordingly to the natural distribution of the sebaceous glands over forehead, cheeks, nose, neck, back and chest. Acne lesions follow through the following stages: Closed comedones open comedines papules pustules. Acne may heal in severe cases with extensive scarring but not necessarily. Treatment: Clients are supposed to avoid any manual destruction of lesions which could cause unnecessary scaring and to avoid any cosmetics on affected skin. Medication therapy includes: Topical scaling agents topical retinoids, benzoyl peroxide, topical antibiotics and azelaic acid. Systemic medication therapy in severe cases Oral tetracycline based antibiotics, isotretinoin 0,5вЂ“1,0 mg / kg daily. Acne caused by a hormonal overproduction of sebrum Cyproteroneacetate and estrogene supply. Impetigo Contagious bacterial skin infection with Staphylococus areus or beta hemolytic group A streptococcus. Infection occurs mainly in children through a minor injury of the skin. Symptoms and diagnostic findings: Mostly multiple erythemic vesicles which are spreading around a skin lesion and become crusted in later stages. Fever and chills are possible. Treatment: Antibiotic treatment is required. Preventive treatment requires proper hygiene. 251 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Folliculitis Bacterial infection of a hair follicle with staphylococcus areus or pseudomonas aeruginosa. Contributing factors are sweating, shaving and generally hairy skin. As in an Impetigo fever and chills can occur. Symptoms and diagnostic findings: A single follicle appears as an erythematic, very tender swelling surround a body hair. Predominant areas of infection are rich on sebacceous glands. Inflammation may progress into the following stages: x Furuncle (pus producing single inflammation of a hair follicle) Furunculosis (multiple furuncles in different areas of the skin) Carbuncle (multiple carbuncles confluating into one) Treatment: A general treatment in all forms of hair follicle infections is to apply moist heat to ease the swelling and pain. A systemic rather than local antibiotic treatment may be prescribed if pus production takes place in advanced stages. Because of the increasing pain furuncles and carbuncles may require incision and drainage to depressurize and eliminate pus. Spontaneous eruptions may occur as well. Cellulitis: (Erysipel) Bacterial infection of the subcutaneous tissue spreading along the lymphatic system. Most common cause is the invasion of Streptococcus pyogenes and Staphylococcus aureus mainly via a minor laceration of the skin. Commonly affected areas are the pretibial areas of the legs. Symptoms and diagnostic findings: Acute circumscripted and tender red discoloration of the skin. Fever, chills, malaise and body achiness may occur in severe cases. A regional tender lymphadenopathy is common. Treatment: Cellulitis requires an antibiotic therapy with penicillin. Hospitalization is required if client is endangered by a septic course of this infection which becomes more likely if the infection involves a central location in the head or neck area or another comparably large area. Supportive measures are the application of moist heat, elevation of the affected body part and analgetic treatment. Viral skin infections Herpes simplex virus infection (HSV) Target tissue of herpes simplex virus type I is the oral mucosa while herpes simplex type II is targeting the genital mucosa. Infection occurs via droplets of contaminated body fluids on the intact skin. In otherwise healthy individuals an acute flare is mostly self limiting but the infection typically takes a chronic recurrent course in all cases. An intact immune system avoids active flares by inhibiting the replication and keeping the virus in a dormant stade. New flares occur in presence of other light or severe health problems which are stimulating the immune system (e.g. common colds and gastroenteritis). HSV viruses remain in the body for life. Contagiosity of infected individuals is likely in acute flares. Symptoms and diagnostic findings: After an incubation period of an average of two weeks the outbreak occurs as a tender blister of the affected mucosa. Fever and chills may occur as well. 252 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Treatment: Rest, fluids, pain and fever relief. Prevention of spreading is accomplished by avoiding close physical contact and/or use of condoms. Acute flares can be limited in their duration and severity by medication therapy with anti retroviral agents such as aciclovir, famciclovir and others if started within 48 hours after onset of symptoms. Herpes zoster Reactivation of a previous varicella zoster infection appears as a cutaneous infection which is affecting motoric nerves. Seniors or immuno compromised individuals are at high risk. Affections of cranial nerves can endanger the eyesight. Symptoms and diagnostic findings: Circumscripted papulo вЂ“ vesicular rash, accompanied by strong pain and itching of the affected area. Overall signs of infection like fever and malaise may be present. Treatment: Treatment is directed to dry the skin lesions with superficially active substances. (e. g. BurrowвЂ™s solution). Pain and fever relief may be required. Clients have to be separated from individuals at risk, especially pregnant women, children and adults without immunity against varicella virus infection. Antiretroviral medication needs to be prescribed within the first 48 hours to limit the severity and duration of the infection. Contagiosity is current until the skin rash has completely healed. Complications may arise from a bacterial superinfection and from a neuropathy which may turn into a chronical condition as a so called вЂњZoster neuralgiaвЂќ. Zoster infections in otherwise healthy individuals should lead to further investigations of possible underlying causes for an immunodeficiency. Warts Warts are typically caused by a cutaneous infection with human papilloma virus. (HPV) Infected areas are typically palms and soles, especially in children. Symptoms and diagnostic findings: Warts do not necessarily become symptomatic and appear as flesh colored hard nodules of different forms and sizes. Classical appearances are: вЂў Plantar wart вЂў Filiform wart вЂў Flat wart вЂў Common wart Treatment: Treatment is required if wart produces symptoms like pain or aesthetical problems. Treatment options are electrotherapy, cryotherapy and surgical removal as well as external treatment with concentrated acetylic salicylic acid. Fungal skin infections Fungal infections mostly occur on grounds of an altered skin as well as due to immunodeficiency syndromes. Common supporting causes are moist, warm skin areas, antibiotic treatments, immunodeficiency in pregnancy, diabetes, steroid treatments or consuming diseases. Main fungal infections of clinical relevance are caused by Candidiasis vulgaris and Tinea corporis. Candidiasis Symptoms and diagnostic findings: Areas of infected skin appear tender, bright red, macerated and scaling. Common manifestations of cutaneous candidiasis are: 253 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Diaper rash, Balanitis, Paronychial infections, Otitis externa and Scalp infections. Mucosal candidiasis appears typically as Vulvovaginitis and oral candidiasis. Diagnosis is made from a scaling sample or smear. Tinea corporis (вЂњRingwormsвЂќ) Lesions of a ring вЂ“ like form in with an elevated border and typically spreading all over the body but spare palms and soles. Infection is caused by a number of different fungal species and can be transmitted from animals and soil. Diagnosis is made from a scaling sample or smear which requires preparation in a potassium hydrochloride for microscopic examination. Tinea pedis (вЂњAthleteвЂ™s footвЂќ) Erythematic, scaly lesions of soles caused by dermatophytes which target the epithelial keratin containing layer of the skin. Treatment: Overall recommendation is to keep affected skin dry and to change underwear and linen daily to avoid reinfection. Medication therapy: Candida infections: Nystatin Tinea corporis: Ketoconazole Tinea pedis: Nystatin, Ketoconazole for topical treatment, Griseofulvin, Fluconazole and Terbinafine for systemic oral treatment. Parasitic skin infections Pediculosis = Lice Head lice: Common among school age children and not depending on social Background. In severe cases eye lashes are affected as well. Pubic lice: Sexually transmitted affection of the pubic hair. Lice reproduce by laying eggs (nits). Symptoms and diagnostic findings: Main symptom is an ongoing and severe itching of the affected area. Diagnosis is obvious if either lice or white sesame corn size nits can be observed. Nits are typically attached to the hair roots. Treatment: Medication therapy used for Pediculosis capitis and pubis: Permethrine, Lindan shampoo for head lice. (Lindan can only be used once a week. Neurotoxicity!) External medication therapy requires an intact and uninflamed scalp! Preventive measure include washing clothes and linen of all family members of an affected individual. Scabies Infestation of the skin by scabies mites. Occurrence is increased in individuals who maintain a poor physical hygiene or do not have access to bathing facilities. Symptoms and diagnostic findings: Severe rash and pruritus. Infestation may spread over hands, wrists, elbows, axils, breasts, abdomen and genitals. Characteristic thread - like red lesions from ridges made by mites. 254 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Treatment: Prevention of spreading and reinfection by washing and hot drying of all clothes, towels and linen or by separation of clothes from host in an airtight bag for seven days. Medication therapy: Permethrin or Crotamiton cream (two treatments/48 hours from head to toe.) Lindan 1% cream (One treatment / weekly. Not for children or nursing and childbearing women). Vitiligo Acquired circumscripted white macules of different shapes and sizes due to a lack of melanocytes. Symptoms and diagnostic findings: Non - dermatomal and dermatomal form. Itching and increased UV sensitivity of the pale areas. Treatment: Not available. Progression may be stopped by oral steroid treatment. Depigmentation of normal skin for cosmetic reasons may be achieved by use of hydroquinone cream. In general strict protection from sunburns is required. Pressure ulcers (Bedsores and Decubitus ulcers) Ongoing inhibition of blood and lymphatic circulation in skin areas due to external pressure results in an ischemic ulcerous destruction of the skin and the subcutaneous, connective and muscular tissue. Pressure ulcers are a common problem for clients suffering from immobility and typically develop over prominent bone structures with little covering subcutaneous tissue such as elbows, spine, pelvic bone and heels. Supporting factors for the development of pressure ulcers are malnutrition, anorexia, low body weight, incontinence, dry or edematous skin, Vitamin C deficiency and long term steroid treatments. Symptoms and characteristic findings: Classification of pressure ulcers Stage 1: Erythematous, warm and tender Stage 2: Loss of epidermis, excoriation, erythema and swelling. Stage 3: Subcutaneous ulcer Stage 4: Ulceration beyond deep fascia decayed wound Laboratory findings: WBC , ESR , Albumine Treatment: Frequent pressure relief by repositioning client every two hours. Active and passive ROM exercises to increase circulation and muscular tonus. Supply of high protein diet, Vitamin A, C and Zinc to improve collagen sythesis. Frequent wound care including change of dressing, drainage of secretions and surgical removal of necrotizing tissue. Incontinence control. Wound assessment, classification and documentation every 12 hours. Wound care: Granulomatous and necrotizing wounds requiring topical enzymatic debriding with collagenase, fibrinolysin вЂ“ desoxyribonuklease or papaine. Secreting wounds require absorbent hydrocolloid dressings and moisture barriers. Antibiotic wound treatment: General antibiotic treatment options for Osteomyelitis are Clindamycin and Gentamycin. 255 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Burns Burns are considered as a destruction of tissues due to: вЂў Heat (open fires or contact to hot substances) вЂў Chemicals (Acids and bases) вЂў Electricity (Electrical voltage, lightning) вЂў Radiation (Ultraviolet rays and radiation) Symptoms and diagnostic findings: Assessment of burn injuries: Burns may be accompanied by respitory problems due to smoke intoxication with pulmonary edema. Possible Laboratory findings: Hemoglobin , hematocrit , sodium , potassium , creatinine , BUN Possible clinical findings: Respiratory failure, hypotension, tachycardia and shock. x Treatment: Resuscitation following the ABCD rule. Removal of rings and braces is mandatory to avoid tourniquet effect. Immediate excessive cooling of burned area with regular water may limit the after burn amount of destructed tissue significantly. Fluid resuscitation and high protein supply remains necessary until wound exsudation stops. Rule of 9вЂ™s вЂў вЂў вЂў Method to assess the approximately affected body surface area in %. In children the head is more than 9%. Description of burned body surface area equivalent to the child' s palm (= 1%) o Face & Scalp 9% o Back 18% o Perineum1% o Arm each 9% o Front18% o Lower leg each 9% Major burns are all burns involving the trunk! Classification of burn injuries by the American Burn Association epidermic painful erythema, no blisters, scarfree healing within five days. Superficial partial thickness subtotal epidermic destruction, moist, read and white areas, blisters, no loss of sensoric function, heals within 28 days with some scarring. Deep partial thickness loss of entire epidermis, dry, waxy, white wound. Skin transplant may be performed but spontaneous healing within 1 month is possible. Full thickness Destruction of more or all remaining subepidermal tissues Superficial thickness 256 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Criteria for hospital admission of burn unjuries Any burn injury that affects over 10% of BSA Burns in special areas face, neck, hands, feet, perineum Electrical burns any burn with history of smoke inhalation Chemical burns Full thickness burns where grafting is indicated. Burns may be accompanied by respitory problems due to smoke intoxication with pulmonary edema. Laboratory findings: Hemoglobin , hematocrit , sodium , potassium , creatinine , BUN Possible clinical findings: Respiratory failure, hypotension, tachycardia and shock. v Treatment: Resuscitation following the ABCD rule. Removal of rings and braces is mandatory to avoid tourniquet effect. Immediate excessive cooling of burned area with regular water may limit the after burn amount of destructed tissue significantly. Fluid resuscitation and high protein supply remains necessary until wound exsudation stops. Fluid resuscitation following the Brooke formula 2 mL/kg/%TBSA burned (3/4 crystalloid + Вј colloid) plus maintenance fluid of 2000 mL D5W within 24 hours. TBSA = Total Body Surface Area Fluid resuscitation following the Parkland/Baxter formula: 4 mL/kg/% TBSA burned (crystalloid only вЂ“ lactated Ringer) plus maintenance fluid of 2000 mL D5W within 24 hours. Medication therapy includes Opioids, Antibiotics, Tetanus booster and Albumin supply. Wound care involves use of silver ion/sulphonamid based cremes or gazes to avoid bacterial infections (e. g. Sulfadiazine). Change of dressings typically requires strong analgesia or temporary anesthesia. Escharectomy (removal of scarring tissue) may be required if wound healing results in ROM of limbs or limited thoracic or abdominal mobility. Psychosocial support may be required as well. Dermatological Medication Therapy Soaps True soaps are used for mechanical skin cleansing from bacteria, sebum and pollution. Medicated soaps and shampoos are used for skin conditions such as psoriasis or chronic dermatitis. Cleansers Preparations with bacteriostatic or bactericidal effect for preoperative skin cleansing and wound treatment. Commonly used substances are: Iodine вЂ“ cleansing effect. Povidone-iodine вЂ“ bactericidal ( i. e. Betadine and Betadone). Alcohol вЂ“ bactericidal. Hydrogen peroxide вЂ“ Germicidal and cytotoxic. Can destroy newly grown cells. 257 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Chlorhexidine вЂ“ cleansing effect. Hexachlorophene вЂ“ cleansing effect. Oxychlorosene sodium вЂ“ cleansing effect. Benzalkonium chloride вЂ“ bacteriostatic (Benza) Can support growth of pseudomonas bacteria! Lotions Liquid emulsions of thin consistency. Require thorough shaking prior to administration. Commonly used lotions are Calamine lotion (CalamoxВ®), Zinc stearate, Zinc oxide. Emollients Occluding and hydrating effect with skin repairing and protecting character. Ingredients are silicone oils, isopropyl palmitate, octyl stearate, petrolatum, lanolin and cacao butter. Common preparations are: Eucerin crГЁme, white petrolatum, lac-hydrin cream. x Protectants Ointments, creams and powders to accomplish skin protection from wetness. Prevention of rashes. Commonly used substances are lanolin, zinc oxide, petrolatum, cod liver oil. Soaks and wet dressings Weeping and crusting skin lesions respond well to aqueous drying solutions. Soaks are applied three times daily for 20 minutes at a time or continuously depending on thickness of crust. Commonly used preparations are: вЂў вЂў вЂў вЂў Self prepared salt solution for wetting purposes. Self prepared 1% acetic acid solution for pseudomonas contaminated wounds. Potassium permanaganate for antifungal treatment. BurrowвЂ™s solution (5% aluminum acetate) used in exudating wounds. Topical Antipruritics Topical treatment of pruritus may include any neutral cream or lotions as well as oral antihistamines. Examples for commonly used external anti - pruritus medications are: Aveeno lotions, creams or hydrating bath, Eucerin cremes and lotions, Zonalon cream Hydroxyzine hydrochloride (VistarilВ®) and Chlorpheniramine (Chlor-TrimetonВ®). Topical Antibiotics Antibiotic for dermatological infections may be absorbed and can cause substance specific side effects. The clients history of previous allergic reactions due to medication must be taken carefully. Antibiotics used for bacterial skin infections Tetracyclines Gram positive and gram negative bacterial skin infections. Neomycin Prevention of wound infections (e.g. MycifradinВ® topical) Mupirocin Impetigo caused by Staphylococcus aureus, Streptococcus pyogenes andbeta-hemolytic Streptococcus (e.g. BactrobanВ®) Metronidazole Broad band antibiotic treatment Meclocycline sulfosalicylate Gram positive and negative bacterial skin infections (i.e. MeclanВ® topical). Gentamycin sulfate Prevention of Pseudomonas aeruginosa infection after ear surgery (e.g. G-myticinВ® topical). 258 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Erythromycin/Benzoyl peroxide Acne vulgaris (i. e. Benzamycin) Clindamycin phosphate Vaginal infections and treatment of Acne (e.g. CleocinВ®). Chloramphenicol Broad spectrum antibiotic treatment. Can cause bone. marrow depression due to internal absorption (i. e. ChloromycetinВ®) Bacitracin, PolymyxinB, Neosporin Bacterial superinfection in other underlying skin problems (i.e. MycitracinВ® topical). Topical antiviral medications Aciclovir 5% Ointment. Solely used for Herpes simplex infections and Herpes zoster infections in early stages. Antifungal Medication Systemic antifungal medication Pharmaceutical effect: Fungicidal, fungistatic effect depending on applied dosage. Therapeutic effect: Treatment of candida, cyptococcus, blastomycosis, histoplasmosis, aspergillus fumigate and tinea. General considerations: Surveillance of liver function since elevation of liver enzymes is the most important side effect of oral antifungal medications. Regular laboratory assessments are required under treatment. Side effects: Fever, chills, headaches, nausea, vomiting, myalgia, insomnia, confusion, photosensitivity, hypokalemia, hypomagnesemia and bone marrow depression. Amphotericin: Ototoxicity and nephrotoxicity. Amphotericin therapy requires premedication with hydrocortisone, antipyretics, antihistamines as well as sufficient hydration. Substance precipitates in any sodium chloride solution. Administration has to be performed under protection from light. Ketoconazol: Gynecomastia and sexual impotency. Substances: Amphotericine B (FungizoneВ®), Amphotericin B Liposomal Complex (AmbisomeВ®) , Clotrimazole (Mycelex tocheВ®), Fluconazole (DiflucanВ®), Griseofulvin (Grifulvin VВ®), Ketoconazole (NizoralВ®) and Nystatin (MycostatinВ®). Topical antifungals Therapeutic effect: Treatment of fungal skin infections (e. g. athleteвЂ™s foot вЂњjock itchвЂќ). Special considerations: Topical antifungal treatment may be useful in limited infections of hairless skin only. All other areas of fungal skin and nail infection require systemic treatment. Usually topical antifungal medications do not cause any systemic side effects due to a low resorption rate. Topical medication always has to be administered with gloves. Nystatin spray for treatment of athleteвЂ™s foot can be applied to shoes and stockings. Vaginal suppositories can be administered during pegnancy and require to restrain from sexual intercourse or to use condoms. Infected areas are not supposed to be covered with tight clothes or dressings. Clothing with contact of infected areas require washing after treatment. 259 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Side effects: Local hypersensitivity reactions. Commonly used substances: Amphotericin B (FungizoneВ®), Ketoconazole (NizoralВ®), Miconazole (MonistatВ®), Nystatin (MycostatinВ®), Clotrimazole (MycelexВ®), Terbinafine (LamisilВ®). d Topical antiparasitic medication Main indications are Scabies and Pediculosis capitis (Lice). Common treatments: Scabies: Crotamiton (EuraxВ® cream and lotion) Pediculosis capitis: Malathion (OvideВ® lotion) Pediculosis capitis, corporis and pubis: Pyrethrin and piperonyl butoxide. Scabies and Pediculosis capitis: Permethrin (ElimiteВ® cream, Nix liquid), Lindane (KwellВ® cream, lotion) Special considerations: Scabies treatment: Permethrin and Lindane has to be left on skin for 8вЂ“12 hours. Crotamiton has to be applied twice and each time for 24 hours. Pediculosis capitis treatment: Lindan lotion stays on for 12 hours Lindan shampoo stays on for 4 minutes Side effects: Lindane may cause dizziness and seizures. Not to be used in infants and children. Topical Corticosteroids Pharmacological effect: Anti-inflammatory effect due to the inhibition of prostaglandin activity. General immunosuppressive effect.. Antiproliferative effects, vasoconstriction of epidermal capillaries. Therapeutic effect: Healing of inflammatory skin eruptions. Indications: Unspecific, non infectious skin eruptions, psoriasis, atopic dermatitis, seborrhoic dermatitis and intertrigo. Special considerations: Topical corticosteroids get absorbed systemically and can cause systemic corticosteroid side effects including suppression of adrenal cortex. Absorption rate depends on skin site and potency of the administered medication and duration of treatment. Duration of treatment should not exceed 21 days for low and medium potency agents and 14 days for high potency agents. Highest absorption occurs on face, axilla, groins and perineum where only low potency agents should be administered. Side effects: Skin atrophy, hyperpigmentations and striae. Potency of topical corticosteroids Highest potency Betamethasone Diproprionate 0.05%, Clobetasol proprionate 0.05%, Diflorasone 0.05%, Halobetasol proprionate 0.05% High potency Betamethasone diproprionate 0.05%, Desoximethasone 0.25%, Flucinolone 0.05% - 0.2 %, Halocinonide 0.1% and Triamcinolone acetonide 0.05% 260 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Intermediate potency Betamethasone benzoate 0.025%, Betamethasone valerate 0.1%, Desoximethasone 0.05%, Flucinolone acetonide 0.025%, Halocinonide 0.025%, Mometasone 0.1%, and Triamcinolone acetonide 0.1% Low potency Betamethasone valerate 0.025%, Clocortolone 0.1% , Fluocinolone acetonide 0.01% Flurandrenolide 0.025%, Hydrocortisone valerate 0.2% and Triamcinolone acetonide 0.025 %. Lowest potency Alclomethasone 0.05%, Desonide 0.05%, Dexamethasone 0.04%, Hydrocortisone 1% Hydrocortisone 2.5%, Methylprednisolone acetate 0.25% and Methylprednisolone acetate 1%. Topical acne medication Pharmacological effect: Diverse substances with antiseptic, antibiotic and keratolytic effect. Indication: Control of minor and early stages of acne. Overview: Retinoids with keratolytic effect. Tazarotene (TazoracВ®), Tretinoin (Retin вЂ“ AВ®) and Isotretinoin (Retinoic acid derivative) Antibacterials Benzoyl peroxide (BenzagelВ®) + keratolytic effect, Clindamycin (Cleocin TВ®), Sodium sulfacetamide (KlaronВ®), Tetracycline (i.e. MonodoxВ®), Erythromycin (i. e. EmgelВ®) + anti inflammatory effect. Contraindications: Retinoid medication has to be strictly avoided in pregnant women because of its high teratogenic toxicity. Women under retinoid treatment must maintain strict contraception and perform repeated pregnancy tests before and while under treatment! Retinoids, a Vitamin A metabolite, can not be combined with Vitamin A supplements to avoid intoxication. Tetracycline and Clindamycine may induce photosensitivity. Side effects: Local skin reactions. Topical Medication for Burns General considerations: Burns have to be considered as open wounds and must be treated under sterile precautions. Changing of topical substances may require administration or even sedation prior to the procedure. Regular assessment of inflammatory parameters as well as of albumine levels and kidney and liver function must be maintained in cases of larger burn wounds. Overview: Nitrofurazone (FuracinВ®) Adjunctive antibacterial effect. Contains polyethylene glycol. Use restricted in kidney impairment. Silver sulfadiazine (i. e. SilvadeneВ®) Toxic antibacterial effect of silver absorption rate 10%. Precaution in G6PDH Deficiency. May cause leukopenia, skin necrosis and Erythema multiforme. 261 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Mafenide (SulfamylonВ®) Bacteriostatic activity against Pseudomonas aeruginosa and Clostridia. May cause metabolic acidosis in clients with impaired renal function. Wound cleaning (debriding) medications A delayed or secondary healing process of skin wounds and pressure ulcers may be interrupted by cell debris, fibrinogen, damaged tissue and dirt. Substances with debriding activity contain enzymes which are able to breakdown and digest such cellular debris to facilitate reepithelisation of the wound base and further healing. Overview over commonly uses substances: Trypsin, peru balsam, castor oil (GranulexВ®), papain, urea, chlorophyllin (PanafilВ®), fibrinolysin and desoxyribonuclease (ElaseВ®), sutilains (TravaseВ®) and collagenase (santylВ®) EYE DISORDERS AND DISEASES Myopia (Shortsightedness) Condition in which light is focussed in front of the retina, resulting in a blurred vision by focusing on distant objects. Shortsighted people can often see reasonably clearly at short distances. Symptoms and diagnostic findings: Characterisitic symptoms of a myopia include the exertion of eyes to see distant objects. Affected pupils commonly experience difficulties in reading the blackboard at school. In advanced stages a limited visual - motoric coordination may lead to a lack of interest in playing outdoor games after repeated falls and accidents. Treatment: Glasses, contact lenses and refractive surgery are the currently available treatment options. Hyperopia (Farsightedness) Farsightedness or hyperopia, occurs when light entering the eye focuses behind the retina, instead of directly on it. This is caused by a cornea that is flatter or an eye that is shorter than a normal eye. Symptoms and diagnostic findings: Hyperopia can be usually well compensated during early childhood because of the compensatory lens accommodation. Clients experience primarily difficulties by focusing on close objects. In advanced stages a blurred distance vision may develop as well. Under usual circumstances the affected clients experience a severe eye fatigue when reading which may result in eye strains, headaches, pulling sensations and burning. Children may be observed with an intermittent strabism. Treatment: Glasses, contact lenses and refractive surgery are the currently available treatment options. Presbyopia Presbyopia is a physiological condition and caused by the decreasing elasticity of the eye lenses which results in a reduced ability to focus on close objects. This process is expected to develop slowly between the ages of 40 to 65 years. Symptoms and diagnostic findings: Affected clients experience difficulties to focus on close objects. Holding close objects 262 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com like a newspaper or a telephone book further away makes focusing easier. Treatment: Presbyopia is corrected by the wearing of a correct pair of glasses. Bifocal glasses allow to have one pair of glasses to improve close and farsightedness. Strabismus Affected client is unable to align eyeballs due to an uncoordinated movement of the eye muscles. Mostly inherited occurrence. Symptoms and diagnostic findings: Client appears with more or less obvious crossing eyeballs while focusing on an object. Strabismus screening is performed by cover вЂ“ uncover testing One eye is covered while client is focusing on a distant object. An unaligned eye will deviate once the cover is taken away in an attempt to readjust to the focus. Strabismus can also be detected by examining the corneal light reflex. If an examination lamp is held 12 inches away from the nasal bridge while client is focusing on a distant object the corneal light reflex is supposed to occur on symmetric spots of both eyes. Treatment: Since strabismus mostly occurs congenitally, successful treatment needs to be accomplished within the first two years to avoid amblyopia of the affected eye. Conservative treatment is based on disabling the better eye with patches to force the weaker eye to strengthen its ocular muscles. Surgical procedures can readjust the eye muscles and correct strabismus if conservative treatment is not successful. Glaucoma Pathologically increased intraocular pressure due to an overproduction and/or decreased drainage of aqueous humor. In order to the width of the anterior chamber angle between the iris and the cornea an open angle glaucoma appears to be the most common form of glaucoma. Open angle glaucoma occurs due to an obstructed canal of Schlemm. Angle closure glaucoma becomes symptomatic during mydriasis or when client is focusing on close objects which leads to a complete closure of the anterior chamber angle. Symptoms and diagnostic findings: Open angle glaucoma leads to a gradual slow increase of the intraocular pressure while an acute flare of angle closure glaucoma leads to acute eye вЂ“ and headaches with blurred vision, nausea and vomiting. Diagnoses is made via assessment of the intraocular pressure and the width of the anterior chamber angle. Treatment: Acute glaucoma is considered a medical emergency and requires immediate medication therapy with thiazide diuretics and carboanhydrase inhibitors to reduce the intraocular pressure. Miotic eye drops are used to keep the anterior chamber angle open while beta вЂ“ blocker containing eye drops reduce the production of aqueous humor. Surgical interventions are made by an iridotomy or trabeculoplasty to enhance drainage from the anterior chamber. Cataracts Gradual loss of vision due to an increased opacity of the eye lenses or lense capsules. Causes are multifactorial. Common are alcoholism, smoking, uncontrolled diabetes, steroid treatment, previous eye injuries and extended exposure to ultraviolet light. 263 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Symptoms and diagnostic findings: Vision disturbances occur independently from accommodation. Increasing blinding sensations due to light are typical first signs of cataract as well as a disturbed color vision. Treatment: Surgical replacement of eye lense with or without capsule. Retention of lens capsule provides better stability to lens implant. Retina detachment Detachment of the retina from underlying chorioid membrane. Commonly caused by age related degeneration of the vitreous humor. Less common causes are traumas and postoperative surgical complications. Symptoms and diagnostic findings: Clients produce increasing visual disturbances such as floating spots, blurred visions and gradual losses of the visual field in a way of a downing curtain or other phenomenons. Diagnosis is made via opthalmoscopy. Treatment: Treatment is mainly by performed by laser coagulation or cryotherapy in an attempt to reattach the retina after it has been repositioned and to protect the remaining retina from further detachment. Other surgical treatment options are gas or air injections into the shrinked aqueous vitreum space or вЂњbucklingвЂќ the sclera beyond the area of detachment. Acute and postoperative treatment involves supine positioning to avoid increased hydrostatic pressure to the detached area. Macular degeneration Localized degeneration of the retinal area with the most sensitive visual acuity. Age Related Macular Degeneration AMRD is considered to be the most common cause of blindness in individuals over 65 yeas of age and the most common form of macula degeneration. The exact cause of this condition is unknown. The most common form of macula degeneration is considered to be the atrophic or dry form which occurs bilaterally and leads to a gradual and significant loss of vision but only in a low percentage of all cases to a legal blindness. The exudative or wet form of macula degeneration is more aggressive and leads more often to a full legal blindness since it causes a faster degeneration due to subretinal bleedings and exudation. Symptoms and clinical findings: Characteristic symptom for a macula degeneration is a sudden and progressing loss of central vision while the peripheric vision remains intact. Other signs include distortion of objects and blurred vision. Diagnosis is made via fundoscopy which typically reveals yellow retinal spots so called вЂњDrusemвЂќ which appear around the degenerated retinal area. Treatment: Curative treatment is not available for either one form of the macular degenerations. Dry macular degeneration is untreatable. Wet macular degeneration can be limited in its progress by laser coagulation or photodynamic therapy. Photodynamic therapy is a combination of laser coagulation with a light activated drug which will be injected. Eye infections Summary of characteristics and symptoms: Blepharitis Painful infection of the eye lash follicles and eye lid glands. Hordoleum (вЂњStyвЂќ) Painful infection of the sebaceous gland of eyelid. 264 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Chalazion Granulomatous, cystic, nodular and painless inflammation of conjunctival Tissue (chronic course of a Hordeolum). Itching and tender infection or allergic reaction of the conjunctiva. Conjunctivitis Corneal ulcer Painful corneal ulcer due to infections and trauma. Keratitis Painful inflammation of the cornea. Uveitis Severly painful inflammation of the uvea with reactive papillary constriction. Treatment: Infection of the eyelids and conjunctives are treated with topical antibiotics and analgetic medication. Regular eye cleansing from bacteria and debris is mandatory. Allergic conjunctivitis is treated with local or systemic antihistamines. Topical cortisone fluids are contraindicated for use on the cornea. Suspected corneal lesions require immediate bedrest in supine position and supply of sterile dressings prior to emergency surgical repair. c EAR DISORDERS AND DISEASES Otitis externa Inflammation of the external auditory canal due to bacterial infection in a humid and moist environment or as an allergic reaction. Symptoms and diagnostic findings: Acute pain, swelling and red discoloration of the external auditory canal. May also lead to temporary hearing impairment. Treatment: Application of topical or systemical antibiotic treatment and pain relief medication. Preparations may also include topical steroids to alleviate the swelling. Otitis media Inflammation and infection of the middle ear (tympanic cavity). Most common causative bacteria in children is Escherichia coli. Other causes are infections with Streptococcus pneumoniae, Neisseria catarrhalis and Haemophilus influenzae. Symptoms and diagnostic findings: Moderate to severe ear ache. Fever. Otoscopy reveals bulging and inflamed tympanic membrane due to an effusion of the middle ear. Spontaneous rupture of the tympanic membrane can occur. In complicated courses a further development into a mastoiditis with affection of the cochlear and the vestibular organ as well as the meningeal membranes may occur. Treatment: Oral systemic antibiotic treatment is mandatory to avoid a further development into a mastoiditis with affection of the cochlear and the vestibular organ. Puncture of the tympanic membrane may be performed to avoid a spontaneous rupture. (Myringotomy) Abscedic mastoiditis requires mastoidectomy to avoid a further spreading into a meningitis and mastoiditis. Nasal decongestants may be administered briefly to ease pressure relief by dilating the Eustachian tubes. MeniereвЂ™s Disease Flares of vertigo, nausea and vomiting caused by a disturbance in the membranous labyrinth of the inner ear, where a deficient re-absorption of endolymphatic fluid causes an endolymphatic hydrops. The etiology of this condition is unknown. Flares may be triggered by stimulating substances such as caffeine or nicotine and sodium rich diets. 265 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Symptoms and diagnostic findings: Acute unilateral vertigo, accompanied by nausea, vomiting, headaches, tinnitus and partial hearing loss. Autonomous nervous symptoms may be hypotension and nystagmus. Diagnosis is made by electronystagmography with caloric testing. Ear examination and audiogram may be unsuspicious. Treatment: Atropine leads to a reduction of the parasympathetic response. Diuretics and antihistamines may be used for treatment of acute episodes. Surgical treatment options include endolymphatic decompression, vestibular neurectomy, labyrinthectomy, or cochlear implant. Epistaxis Acute bleeding of nasal mucous membranes. May occur due to a rhinitis of infectious or allergic cause or by mechanical irritation in small children or due to a trauma. Some cases are caused by abnormally located superficial blood vessels of low mechanical resistance. Symptoms and diagnostic findings: Bleeding severity varies from tissue stains to hemodynamic relevant fast and severe blood losses. Treatment: In most cases bleeding stops spontaneously by applying manual pressure to the nostriles. Clients have to bend head forward during acute bleedings while cooling pack is placed over neck. In case of prolonged or massive bleedings intranasal administration of epinephrine or thrombin may be required. Other treatment options include electrocautherization and packing of the nose (BelloqвЂ™s tamponade). Eye and Ear Medication Therapy Glaucoma Medication Beta-adrenergic antagonists (вЂњBeta вЂ“ BlockersвЂќ) Pharmacological effect: Decrease production of the intraocular aqueous humor. Therapeutic effect: Reduction of intraocular pressure. Indication: Chronic primary open angle glaucoma. Special considerations: Beta Blocker for glaucoma treatment will be absorbed into the circulatory system and cause systemic side effects, cross the placenta and appear in breast milk. Special precautions are necessary for patients with obstructive lung diseases, renal failure, diabetes, hyperthyroidism, heart blocks. Adverse effects may occur in combination with antihypertensives and antidysrhythmics. Baseline vital signs and current intraocular pressure must be obtained prior first time administration. Medical history must be explored carefully regarding cardiovascular and pulmonary diseases as well as for diabetes and hyperthyroidism. Medication of choice for treatment of open angle glaucoma in patients with obstructive pulmonary diseases is the Beta1 selective blocker betaxolol (Betoptic) Beta вЂ“ blocker medication may have to be withdrawn 48 hours prior cardiac stress testing or general surgery. Side effects: Local eye and conjunctival reaction and irritation. 266 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Allergies, hypotension, dizziness, depression, psychosis, laryngo вЂ“ and bronchospasm, dry mouth, eyes, glands, agranulocytosis, hypo вЂ“ and hyperglycemia. Contraindications: Hypotension, dizziness, depression, psychosis, laryngo вЂ“ and bronchospasm, dry mouth, eyes, glands, agranulocytosis, hypo вЂ“ and hyperglycemia. Commonly used substances: Betaxolol (BetopticВ®), Metipranolol (OptiPranololВ®), Timolol (TimopticВ®) Adrenergic agonist medications, mydriatic Pharmacological effect: Decrease of production of the intraocular aqueous humor, Mydriasis and ocular vasoconstriction Therapeutic effect: Reduction of intraocular pressure. Indications: Open angle glaucoma secondary to an uveitis. Artificial mydriasis for eye examination purposes. Hemostasis during open eye surgery. Special considerations: Adrenergic agonist medications for glaucoma treatment will be absorbed into the circulatory system but cause rarely systemic side effects. All substances cross the placenta and appear in breast milk. Baseline vital signs and current intraocular pressure must be obtained prior first time administration. Medical history must be explored carefully regarding cardiovascular and pulmonary diseases as well as diabetes and hyperthyroidism. If epinephrine is administered with miotic medication, miotic medication must be administered first. Side effects: Blurred vision, photophobia, headache, hypertension, difficulty with night vision, rebound miosis due to phenylefrine. Contraindications: Narrow angle glaucoma, corneal lesions and abrasions. Commonly used substances: Phenylefrine (Neo вЂ“ SynephrineВ®) and Hydroxyamphetamine (PredrineВ®) Sympathomimetic agents, non - mydriatic Pharmacological effect: Decrease production of aqueous humor and increase its outflow. Therapeutic effect: Reduction of intraocular pressure. Indications: Treatment of open angle glaucoma. Special considerations: Adrenergic agonist medications for glaucoma treatment will be absorbed into the circulatory system but cause rarely systemic side effects. All substances cross the placenta and appear in breast milk. Baseline vital signs and current intraocular pressure must be obtained prior first time administration. Medical history must be explored carefully regarding cardiovascular and pulmonary diseases as well as diabetes and hyperthyroidism. If epinephrine is administered with miotic medication, miotic medication must be administered first. Epinephrine: Onset of effect after 1 hour, peak effect after 4вЂ“8 hours. Dipivefrin: Onset of effect after 0.5 hours, peak effect after 1 hour. 267 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Side effects: Blurred vision, photophobia, headache, hypertension and difficulties with night vision. Contraindications: Narrow angle glaucoma, concurrent treatment with mono amino oxidase inhibitors MAOI. Commonly used substances: Dipifevrin (PropineВ®) and Epinephrine (EpifrinВ®) Cholinergic agents Pharmacological effect: Increase of outflow of aqueous humor by induced miosis. Leading to a decreased resistance of aqueous flow. Therapeutic effect: Reduction of intraocular pressure. Indications: Treatment of open angle and angle closure glaucoma. Special considerations: Cholinergic agents for glaucoma treatment will be absorbed into the circulatory system and cause systemic side effects, cross the placenta and appear in breast milk. Baseline vital signs and current intraocular pressure must be obtained prior first time administration. Medical history must be explored carefully regarding cardiovascular and pulmonary diseases as well as diabetes and hyperthyroidism. Cardiovascular reactions likely if used while under beta вЂ“ blocker medication. Side effects: (Parasympathomimetic) Blurred vision, myopia, irritation, brow pain, abdominal pain, bronchoconstriction, hypotension, ataxia, seizures, respiratory failure, bradycardia and retinal detachment after prolonged use. Contraindications: Acute Iritis and severe cardiorespiratory diseases. Commonly used substances: Carbachol (CarbopticВ®), Physostigmine sulfate (Eserine sulfateВ®), Pilocarpine (Isopto CarpineВ®) Carbonic Anhydrase Inhibitors (CAIвЂ™s) Pharmacological effect: Decrease of aqueous humor production. Therapeutic effect: Reduction of intraocular pressure. Indications: Oral preparations: Treatment of open angle, angle closure and secondary glaucoma. Ophthalmic preparations: Treatment of open angle glaucoma and ocular hypertension. Special considerations: Carbonic anhydrase inhibitors are chemically sulphonamides without antibiotic effect. Oral preparations are not indicated in acute glaucoma but for maintenance treatment. May cause diuretic effect and should be therefore taken in the morning. Client has to maintain adequate fluid supply and a high potassium/low sodium diet unless otherwise indicated. Side effects: Topical agents: Local allergic reaction, keratitis and photosensitivity. Oral agents: Diuresis, diarrhea, nausea, vomiting, lethargy, weakness, paresthesia, bone marrow depression, blood dyscrasias, Stephens Johnson syndrome and hypokalemia. 268 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Contraindications: Sulphonamide allergy. Commonly used substances: Oral agents: Acetazolamide (Diamox), Methazolamide (Neptazane) and Dichlorphenamide (Daranide) Topical agents: Brinzolamide (AzoptВ®), Dorzolamide (TrusoptВ®) Prostaglandin agonists Pharmacological effect: Increase of aqueous humor outflow. Therapeutic effect: Decrease of intraocular pressure. Indications: Open angle glaucoma and ocular hypertension Special consideration: If prescribed, Pilocarpine has to be administerd 1 hour after prostaglandin agonist eye drops. Frequency of administration in all cases only once daily. Contact lenses have to be removed for 15 minutes after use of medication. Side effects: Allergic reactions, thickening, elongation and pigmentation of eye lids. Contraindications: Allergies against Latanoprost and Benzalkonium Commonly used substances: Bimatoprost (Lumigan), Latanoprost (Xalatan), Travaprost (Travatan) and Unoprostone (Rescula) Mydriatics and Cycloplegics Pharmacological effect: Anticholinergic paralysing effect to ciliary muscle. Therapeutic effect: Mydriasis Indications: Uveitis, keratitis and preparation for intraocular surgery and fundoscopy. Special considerations: Ointment needs to be applied several hours before the examination or procedure. Cholinergic agents for glaucoma treatment will be absorbed into the circulatory system and cause systemic side effects, cross the placenta barrier and appear in breast milk. Baseline vital signs and current intraocular pressure must be obtained prior first time administration. Medical history must be explored carefully regarding cardiovascular and pulmonary diseases as well as diabetes and hyperthyroidism. Intraocular pressure needs to be monitored over full course of therapy. Side effects: Blurred vision, mydriasis may last 3 (Scopolamine)вЂ“12 days (Atropine), photophobia, tachycardia, hypertension, dry mouth. Commonly used substances: Scopolamine hydrobromide, Atropine sulfate, Tropicamide, Homatropine and Cyclopentolate. Non steroidal anti inflammatory drugs (NSAID) General description under musculoskelettal and neurological medications. If absorbed, substance can cause same side effects as under oral or parenteral administration. 269 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Indications in Ophthalmology: Ketorolac = (Acular) Treatment of Conjunctivitis , ophthalmic pruritus. Diclofenac = (Voltaren) Treatment of postoperative inflammations. Antibacterial eye medication Various antibiotics with topical activity against common eye infections: Conjunctivitis, blepharitis, keratitis, uveitis and hordeolum. Commonly used substances are: Bacitracin (BaciquentВ®), Chloramphenicol (ChloropticВ®), Ciprofloxacin (CiloxanВ®), Erythromycin (IlotycinВ®), Gentamicin (GaramycinВ®) Antiviral eye medication Indicated in treatment of herpes simplex keratitis and keratokonjunktivitis. Commonly used substances are: Idoxuridine (StoxilВ®), Trifluridine (ViropticВ®) and Vidarabine (Vira вЂ“ AВ®). Anaesthetic eye medications Indicated prior IOP assessment via tonometry and during removal of foreign bodies. Commonly used medcations are: Proparacaine hydrochloride (OphtheticВ®), Tetracaine hydrochloride (PontocaineВ®) Rapid onset for 15вЂ“20 minutes duration! Eye protection necessary until anaesthetic effect has worn off. Corticosteroid ear medication Mainly used in combination with antibacterial, antiviral or antifungal agents. Special considerations: Contraindicated in perforations of tympanic membrane. Commonly used substances are: Betamethasone, Hydrocortisone, Hydrocortisone with acetic acid, alcohol, benzethonium and Dexamethasone. MOUTH DISORDERS AND DISEASES Pharyngitis About 90% are caused by viral infections in school children. Rarely caused as a single manifestation of an infection with A beta-hemolytic streptococcus. Symptoms and diagnostic findings: Soar throat with swallowing difficulties, drooling and dry cough. Tonsils and cervical lymph nodes are mostly simultaneously enlarged as a characteristic sign of an accompanying immune response. Fever may occur. Assessment includes smears for throat cultures and strep вЂ“ testing to identify a possible bacterial infection. Treatment: Viral Pharyngitis: Pain and fever relief and smoothing of pharynx with acid free fluids. Antibiotic therapy for bacterial infections. Tonsillitis In comparison to a pharyngitis tonsillitis is typically a bacterial infection of the posterior pharyngeal tonsils. Symptoms and diagnostic findings: Symptoms are equal to symptoms in acute Pharyngitis. Throat inspection typically reveals highly enlarged tonsils with exsudation of pus. Inflammatory parameters may be elevated. Complications include paratonsillar abscess (QuinsyвЂ™s). 270 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Treatment: Antibiotic treatment is mainly required. Abscedic infections may require incision for pus relief. Cool drinks and ice cream alleviate pain. cv BLOOD DISORDERS AND DISEASES Iron Deficiency Anemia (IDA) Iron deficiency anemia is a characteristic finding in cases of acute and chronic blood losses as well as in a disturbed iron metabolism or a decreased intake. Symptoms and diagnostic findings: Most clients are elderly and may not show any significant physical symptoms if IDA has developed slowly enough for the client to adapt to it. Symptoms are determined by poor oxygenation due to a gradual loss of oxygen binding erythrocytes. Clinical findings include abnormous fatigue, physical weakness and shortness of breath. Common causes of IDA are also chronic gastrointestinal bleedings or tumor bleedings. The investigation of an IDA of unknown cause must always rule out tumors or ulcers of the gastrointestinal tract. Characteristic development of hypochromic microcytic anemia = Hemogobin, erythrocytes, MCV, MCH, MCHC , Serum iron , Serum iron binding capacity , Serum ferritin (Most significant diagnostic parameter for IDA)! Treatment: Identification and treatment of the underlying disorder. Supply of iron orally as ferrous sulphate in a dosage of 1000mg daily for six months or until normal ferritin level is established. Increase of reticulocytes occurs quickly and allows a reliable assessment of this treatment. Iron supply should be taken prior to meals with an acidic fluid. Parenteral supply in severe causes with iron dextran IV solution. Oral iron supply changes stool color into black. Megaloblastic anemia Anemia due to a deficiency of Vitamin B 12 leads to a limited proliferation of red blood cells and a low hemoglobin saturation. Vitamin B 12 deficiency is most commonly caused by a defect or a lack of the intrinsic factor producing parietal cells of the stomach due to pernicious anemia or after gastrectomy. Symptoms and diagnostic findings: Vitamin B 12 deficiency anemia is typically accompanied by defects of other fast growing tissues such as the mucous membranes. Visible alterations are a glossitis with a red and sore tongue and cracked lips (Cheilitis). Other mucous membranes may become dysfunctonial as well. Neurological complications are a disturbed proprioreception and parestesias. Laboratory findings: RBC , HCT , MCV , MCHC Achlorhydria in gastric acid analysis = pH 3,5 Diagnosis is made via Schilling test from a 24вЂ“hour urine sample to assess vitamin B 12 intake after radionuclide labeled viramin B 12 was administered. Folic acid deficiency anemia Common causes are alcoholism, malnutrition, methotrexate treatment, antiepileptic medication, oral contraceptives, parenteral nutrition and hemodialysis. Symptoms and diagnostic findings: Megaloblastic anemia without neurological symptoms. Clinical and laboratory findings otherwise comparable with Vitamin B 12 deficiency. Fragile gums and mucous membranes occur as well. 271 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Treatment: Supply of folic acid from dietary sources like fish, citrus fruits, vegetables, dried beans, green leafy, grains and liver. b Aplastic Anemia Deficiency of erythrocytes, leukocytes and platelets. Mainly caused by a toxic reaction of the bone marrow and its stem cells to external triggers such as medication, radiation, infections or toxic substances. Symptoms and diagnostic findings: Signs of anemia, infections, spontaneous bleedings, Pancytopenia in blood and no cell activity in bone marrow. Treatment: Elimination of underlying cause, General bone marrow transplant, Anemia RBC, transfusions, (leukocyte free). Thrombopenia splenectomy, leucopenia Infection precautions, Mediation therapy: Antilymphocyte globulin, antithymocyte globulin, cyclosporine, prednisone and cyclophosphamide. Neutropenia Neutrophil count of less than 2,000/mm3 due to a primary hematological disorder or caused by medication therapy, radiation or chemotherapy. Neutropenia results in a reduced phagocytotic activity for the immune system which leads to significantly higher susceptibility for bacterial infections. Symptoms and diagnostic findings: Clients in neutropenic stades may be completely asymptomatic but remain at high risk for severe bacterial infections. Neutrophil count reveals absolute amount of available cells. Treatment: First line treatment is the elimination of the underlying cause. Clients should be isolated for the duration of the immunodeficiency. Strict hygiene procedures have to be followed by clinical staff and visitors. Steroid treatment may elevate the WBC count in autoimmune related neutropenia. In decreased production due to a bone marrow suppression leucozyte stimulating growth factor may be used. Microbiological therapies should be based on specimen exams and antibiograms. Aquired Immunodeficiency Syndrome AIDS AIDS is the clinical manifestation of an infection with the Humane Immunodeficiency Virus HIV after a mostly asymptomatic latency period of up to 20 years. HIV is a RNA retrovirus which specifically targets TвЂ“lymphocytes which are expressing the CD 4 antigen and disable the cell mediated immune response. T4 cells also boost B cell mediated reactions due to inceased immunoglobulin production. HIV infections occur parenteral via blood and body fluids only. High risk sources of infection are intravenous drug use, sexual contacts and blood transfusions. Symptoms and diagnostic findings: Initial infection may lead to unspecific flu вЂ“ like symptoms like malaise, body achiness and low grade fever. Symptoms typically increase along with virus progression until latency period ends with the initiation of an aquired immunodeficiency syndrome. Additional symptoms include anorexia (unexplained вЂњwasting syndromeвЂќ) and an increased susceptibility for HIV encephalopathy, Kaposi Sarkoma and lymphomas. 272 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Opportunistic infections typically facilitated by HIV infections are: Tuberculosis, Pneumocystis carinii pneumonia, Toxoplasmosis, Mycobacterium avium pneumonia, Cryptosporidiosis, Cryptococcosis, Candidiasis and Cytomegalievirus infection. Diagnosis is made by detection of HIV antibodies via an enzymeвЂ“linked immuno absorbent assay (ELISA). Positive ELISA test results for HIV antiboides have to be confirmed by a Western blot examination to detect antibodies along with viral components. Significant markers for the couse of the infection are the CD4 count and the viral load. Unspecific markers are all inflammatory parameters. Parameters for individual risk evaluation: CD4 T cell counts T4 cells boost B cell reactions due to inceased immunoglobulin production. Normal reference range: 500-1600 cells/microliter. 200вЂ“499 cells / microliter = increasing risk < 200 cells/microliter = severe risk CD4/CD8 ratio = Helper / Suppressor cells ratio. Normal: 2:1 Ratio decreases with CD4 count if clients condition worsens. Treatment: Main importance has the continuing care and assessment of prognostic values to detect any progression or complication in time before severe further health damage can occur. Further a high protein, high calorie diet with frequent small meals is required to combat further weight loss and protein deficiency. Medication therapy: Main importance has the anti retroviral therapy to avoid a further virus replication. Substances commonly used are protesase inhibitors and nucleoside analogue medications. Additional medication therapy is based on accompanying medications. Protease inhibiting medications Pharmacological effect: Antiviral effect due to inhibition of protein synthesis. Therapeutic effect: Decrease of viral load in HIV infections and manifestations of AIDS and aids related complex including opportunistic infections. Increase of CD 4 count. Special considerations: Administration requires specific considerations: Saquinavir, Ritonavir to be taken with meals and milk. Indinavir to be taken prior or in between meals. Contraindications: Pregnancy and lactation Side effects: Nausea, vomiting, diarrhea, hyperbilirubinemia, nephrolithiasis, hepatotoxicity and blood dyscrasias. Commonly used substances: Ritonavir (Norvir), Indinavir (Crixivan) and Saquinavir (Invirase) Reverse transcriptase inhibitors: Pharmaceutical effect: Inhibition of virus replication and growth. Penetration of blood brain-barrier. Therapeutic effect: 273 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Treatment of HIV infections in clients with a CD4 count < 500/mm3. Prevention in cases of exposure and risk of maternal transmission. Special considerations: No alteration of blood cells. Substances include Nucleoside Reverse Transcriptase Inhibitors (NRTI) and Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI). Mostly used in a combination Therapy. Side effects: Neuropathy, insomnia, tremors, dizziness, diarrhea, pancreatitis, hypomagnesiaemia, discoloration of skin and nails, blood dyscrasias and dermatological side effects. Commonly used substances: NRTIвЂ™s: Zidovudine (AZT, Retrovir), Lamivudine (Epivir), Didanosine (DDI) NNRTIвЂ™s: Efavirenz (Sustiva), Nevirapine (Viramune) and Delaviridine (Rescriptor) Sickle cell disease Sickle cell disease is considered an inherited hemoglobinopathia and hemolytic anemia which is caused by the synthesis of an atypical hemoglobin S due to a mutation in the beta chain of the hemoglobin molecule. This results in both chains of the molecule for a substitution of the aminoacid valine instead of glutamine. Sickle cells disease follows a autosomal recessive inheritance and mainly occurs in clients of African origin. Symptoms occur only if the oxygen saturation of the blood declines. This leads to an immediate change of the shape of the red blood cells which interferes with proper blood flow capabilities. As a result multiple painful tissue infarctions can occur and lead to a sickle cell crisis. Symptoms and diagnostic findings: Pallor, jaundice to hemolysis, swollen joints, priapism, generalized body pain and multiple ischemic lesions throughout the entire body. Laboratory findings: Sickle cell shaped RBCвЂ™s on blood smear, hemoglobin electrophoresis shows and assesses Hemoglobin S, Bilirubin levels , Reticulocyte count . Treatment: Blood transfusions, Hydroxyurea to increase Hemoglobin F concentration. Nifedipine for priapism, hydration to decrease blood viscosity. Management of individual organ complications. Preventive vaccination against influenza, hepatitis B and pneumococcus pneumonia. Thalassemia Inherited autosomal recessive hemoglobinopathy leads to the synthesis of a fragile hemoglobin molecule which causes early hemolysis of RBCвЂ™s. Condition can be expressed in three different grades of severity: Thalassaemia minor, intermedia and major. Minor form may not require treatment but indicates a trait of the disease for the carrier. Likelihood of transmission is 25% if both parents are carriers. Mostly but not solely occuring in Mediterranean clients. Symptoms and diagnostic findings: Thalassaemia causes a progressing hemosiderosis as a result of the iron overload due to the permanent hemolysis. Affected children suffer from chronic anemia, chronic hypoxemia and failure to thrive. Hemosiderosis causes splenomegalie, cirrhosis of the liver, cardiomyopathy, diabetes, hypertrophic and increased fragility of the marrow containing bones. 274 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Treatment: Depending on the severity the main treatment includes blood supply and iron chelation therapy. Cure requires successful bone marrow transplantation. Polycythemia Polycythemia can occur as a primary disorder of the bone marrow or secondary as a reaction to another underlying disease. Polycythemia of the red blood cells is also an adaptation phenomenon that occurs during chronic hypoxia in clients with chronic pulmonary and cardial diseases or due to prolonged exposure to a low oxygen saturation, e. g. in mountain areas. Polycythaemia may affect all three cell rows of the bone marrow or only the red blood cells in cases of a polycythemia vera rubra. Main complication of a polycythemia is a significant increase of the blood viscosity which may lead to disturbed circulation and metabolism of internal organs. Symptoms and diagnostic findings: Anemia, immunodeficiency, spontaneous multiple bleedings, plethora ( red discoloration of the skin preferrably on the chest), itching and pains due to ischemic body tissues. Multiple organ failures. MI, CVA. Blood cells produced in excess are mainly dysfunctional. Diagnosis is made by bone marrow puncture. Treatment: Correction of underlying cause. Phlebotomies for multiple blood drawings to decrease hematocrit. Isolation and infection prevention for leukocytopenia. Medication therapy for myelosuppression: Melphalan, Hydroxyurea and radiation therapy. Gout prevention with Allopurinol. Thrombosis prevention with antiplatelet agents Thrombocytopenia Thrombocytopenia is defined as a platelet count of less than 100,000/mL blood. Possible causes are: Inherited autoimmune destruction of thrombocytes Idiopathic Thrombocytopenic Purpura (ITP) or conditions causing thrombocytosis (e.g. thrombosis of the liver). Increased consumption due to infectious diseases, sepsis or medication side effect. Immediate danger for spontaneous bleeding from is given from thrombocyte counts of less than 20,000/ml. Symptoms and diagnostic findings: Overall increased hemorrhagic diathesis: Pinpoint size petechial bleedings. Menorrhagia, hematuria, gastrointestinal bleedings and epistaxis. Laboratory findings: RBC , HCT , Thrombocytes (antiвЂ“platelet antibodies), bleeding time , Megakaryocytes in bone marrow absent or deficient. Treatment: Platelet transfusion if client is bleeding or at severe risk to bleed. Strict avoidance of any invasive procedures. Avoidance of NSAR medication due to risk of gastrointestinal bleedings. Steroid вЂ“ and immunosuppressant treatment in ITP. Hemophilias Hereditary coagulation disorders with a gonosomal recessive trait that leads to a prolonged bleeding time. Hemophilias are classified by their underlying genetic defect as follow: Hemophilia Type A Hemophilia Type B Deficiency of coagulation factor XIII which stabilizes fibrin clots. Most common type of hemophilia. Deficiency of coagulation factor IX, which triggers the synthesis of tromboplastin in the intrinsic system. 275 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Deficiency of von Willebrand factor vWF as a co - factor to factor VIII. Symptoms and diagnostic findings: Sudden bleedings at multiple locations. Typical are hemarthros due to joint bleedings and ecchymosis due to subcutaneous bleedings. Recurrent hemarthros leads to cartilage damage = hemarthrosis. Internal compartment syndromes. Laboratory findings: Bleeding time , aPTT in von Willebrands disease. Treatment: Supply of deficient coagulation factors which are stored and delivered as cryoprecipitiate. Von WillebrandвЂ™s disease Disseminated Intravasal Coagulation (DIC) Onset of a massive, unspecific and unregulated coagulation activity along the entire vascular system which leads to a deficiency of clotting factors with consecutive hemorrhage. Multiple underlying causes such as intoxications, sepsis, polytrauma, tumors, burns, prosthesis, medications and other health conditions. Symptoms and diagnostic findings: Clinical symptoms due to underlying causes and DIC. Start with a gradual decrease of platelets and fibrinogen. Elevation of PTT, aPPT, Thrombin time. Increased fibrin degradation products. Consumption of coagulation factors V, VII, VII, IX, XIII. D-Dimer increased. Treatment: Main aspect is the identification and treatment of the underlying cause. Controlling of severe bleedings via platelet transfusion and supply of coagulation factors (e. g. FFP). MALIGNANT DISEASES General considerations TNM Classification Tool for grading and staging of malignant tumors in regards to the therapeutic options. T = Tumor size N = Affection of lymph nodes M = Presence of metastases Scale reaches from 0вЂ“3. A rating of 0 indicates no presence of a criteria while a rating of 3 indicates its maximum development. Tumormarkers Tumormarkers are physiologically occurring substances which show alternating increasing or decreasing serum concentrations accordingly to a progression or regression of various defined types of cancer. The presence of a tumormarkers alone is not a diagnostic criteria for the presence of a tumor. Diagnosis of a malignant tumor can only be made from histology examinations of tumor biopsies. Therefore tumormarkers assessments are used as a diagnostic monitoring tool for ongoing cancer treatments. Treatment options Cancer treatment options include surgical tumor removal, radiation, chemotherapy. Main side effects of chemo and radiation therapies are the simultaneous but mostly reversible destruction of other physiologically fast growing tissues of the body such as hair follicles, mucous membranes, germ cells, blood and bone marrow cells. 276 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Clinically, these conditions are typically expressed as stomatitis, alopecia and bone marrow suppression with immunosuppression. Many more pathologies are possible and require additional treatment. Bone marrow transplantation is a treatment option specifically for leukemia and other incurable disorders of the hematopoetic system. It may also be performed if radiation or chemotherapy have destroyed healthy bone marrow irreversibly. Immunological therapies are based on substances that are able to modify the immunological response of an organism towards an antigen. Common biological reponse modifiers are: x Monoclonal antibodies artificially induced by a group of identical lymphocytes which are sensitized towards a specific antigen of a tumor. Colony stimulating factors induce proliferation of immune competent cells to achieve an enhanced immune response. Pain Management in malignant Diseases Analgesics Choice of pain medication should depend on results of pain assessment on a pain scale. Opioids Depending on their interaction with the opioid receptors of nerve cells, opioid pain relieving medications are either pure opioid agonists or mixed agonists and antagonists. The main difference between those two groups is that pure agonists show a steady increase of their analgetic effect as long as the dosage increases as well. Opioid agonist-antgonists or partial anatagonists have a limited range of effect. Even if the dosage increases further and further ceiling effect. Pure Morphin agonists Codeine (Paveral), Dihydrocdeine (Vicodin), Oxycodone (Oxycontin), Propoxyphene (Darvon), Morphine sulfate (Duramorph), Fentanylcitrate (Duragesic), Oxymorphone, (Numorphan), Hydromorphone (Dilaudid), Meperidine (Demerol) and Methadone hydrochloride (Dolophine). Mixed agonist-antagonists Pentacozine (Butorphanol), Butorphanol (Stadol), Dezocine (Dalgan) and Nalbuphine hydrochloride (Nubain) Opioid antagonists Naloxone (Narcan), Naltrexone (ReVia), Reverse effects of opioids Induction of opiate withdrawal symptoms: Tremor, convulsion, labile blood pressure, tachycardia, hyperpnea, nausea and vomiting. Need for opioide agonists depends on assessment vital signs, level of consciousness, level of respiratory and cardial depression. Assessment includes ECG and arterial blood gas analysis to assess pO2 and pCO2. Indicator for an opioide overdose is the symptom trias of Miosis, Coma and Respiratory depression! 277 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com PEDIATRIC ONCOLOGY The most common malignant tumors of Toddlers and Preschool Medication Nephroblastoma (Wilms Tumor) Malignant tumor, originating from kidneys, uni or bilateral. Main occurrence from 2 years of age. Symptoms and diagnostic findings: Symptoms occur comparably late in the course of this disease since tumor is primarily encapsuled. Children appear with abdominal pain, nausea, vomiting, hypertension, hematuria and a palpable abdominal mass. Clients under suspicion for having a WilmвЂ™s tumor have to keep strict bed rest and should receive no abdominal palpation to keep tumor capsule intact. Primary metastasizing organs are lungs and liver. Diagnosis requires intravenous pyelogram and renal ultrasound. Prognosis is generally poor due to silent, asymptomatic growth of tumor. Treatment options: Nephrectomy, radiation and chemotherapy. Neuroblastoma Most common extra cranial tumor in childhood, originating from neural crest cells. Located around the abdominal and or the thoracic paravertebral sidestring of the sympathetic autonomous nervous system. Prognosis is generally poor due to a silent and asymptomatic growth of this tumor. Symptoms and diagnostic findings: Abdominal pain , fever , weight loss , fatigue , palpable abdominal masses. Respiratory problems occur if tumor is expanding within the thoracic cavity. Diagnosis is made by thoracic and abdominal CT scans. Specific laboratory findings: Increased breakdown of catecholamines in some cases leads to excess amounts of vanillylmandelic acid (VMA) and homovanillic acid (HVA). Primary metastasis occurs in bones and bone marrow. Treatment : Nephrectomy, radiation and chemotherapy. Bone cancer in children The osteogenic sarcoma and the Ewing sarcoma are the most common osteogenic types of cancer of the childhood period and in general. вЂў Osteogenic sarcoma Tumor is typically originating from metaphyseal part of long bones but rapidly expanding in to the epiphyseal parts. Most common primary locations are femur, humerus, tibia, pelvic and jaw bones. Most common time of onset is puberty and adolescent age. Prognosis is generally poor due to the generally rapid growth of this tumor. Symptoms and diagnostic findings: Acute tender swelling with a solid and dense palpable mass. Primary metastasis occurs in lungs, often prior to diagnosis and onset of treatment. Diagnosis is made by X-rays, MRI and CT scans. Treatment: Treatment options are radical surgical resection, chemotherapy and radiation. 278 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂў Ewing sarcoma Tumor occurs in children from 4 years until young adulthood. Sarcoma is primarily originating from diaphysial part of limb bones and ribs. Symptoms and diagnostic findings: Symptoms and mode of diagnosis are comparable to osteogenic sarcoma. Primary metastasis occurs in lungs, often prior to diagnosis and onset of treatment. Treatment: Mainly radiation and chemotherapy since tumor is mostly too far advanced or clients condition already too far declined for major surgery once diagnosis is made. вЂў Testicular cancer Most common form of cancer between 15 and 35 years of age. Possible risk factors are previous cases of testicle infections (orchitis) as well as a history of maldescensus testis and cryptorchism. Tumors are mainly detected by self examination. Metastasizing occurs predominantly through the lymphatic system into the retroperitoneal lymph nodes. Symptoms and diagnostic findings: Affected clients typically experience symptoms of dull pain in one side of the scrotum along with asymmetric enlargement of one testicle. Diagnosis may also be made by assessing testicular infections or distortions with hemorrhage. Systemic symptoms include typical B-Symptoms as well as gynecomastia, lumbar back pain. Specific laboratory findings: Significant increase of Alpha вЂ“ Feto вЂ“ Protein (AFP), Beta вЂ“ human вЂ“ choriogonadotropin (Beta вЂ“ HCG), Lactatdehydrogenase (LDH). Diagnosis is made by testicular ultrasound. Metastasis is detected by CT scan. Treatment: Surgical treatment is performed by unilateral orchiectomy. In presence of signs for an advanced metastasis the surgical procedure includes retroperitoneal lymphadenectomy as well, combined with chemotherapy. Clients may preserve sperm prior to treatment for future IVF treatments. Monthly testicular self exam is mandatory on remaining testicle. Prognosis is generally well due to an usually early diagnosis. ADULT ONCOLOGY Hepatom (Hepatocellular carcinoma) and Liver metastases Primary hepatocellular carcinomas are much less common than liver meteastases. Primary liver cancer in general has a poor prognosis. Main causes are chronic progressive hepatitis b and c infections as well as alcohol induced liver cirrhosis. Tumors arise either from hepatocellular or cholangiocellular origin. Symptoms and diagnostic findings: Beside a severe pain the main symptoms are comparable to an advanced liver failure due to a cirrhosis as previously discussed. Main diagnostic tumor marker is Alpha вЂ“ Feto Proteine AFP. Diagnosis is made by imaging rechniques and biopsies. Treatment: Partial liver resection or liver transplant if indicated and clientвЂ™s condition does not interfere with these treatments. Otherwise palliative chemo and/or radiotherapy. Treatment of liver metastases is focused on underlying primary tumors. Surgical resection of single metastases may be pursued. 279 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Pancreatic cancer Adenocarcinoma, originating from the ductal epithelium of the pancreatic gland. Most commonly occurring in ages > 45 years. Possible risk factors include chronic pancreatitis, cigarette smoking and hereditary factors. Metastasis occurs mostly over the gastrointestinal lymphatic vessels into stomach, small intestines, biliary system and liver. Mostly of poor prognosis due to late diagnosis. Symptoms and diagnostic findings: Abdominal discomfort and lighter abdominal pain in early stages. Newly developing maldigestion especially of fats. Altered stool habits with infrequent diarrhea. Anorexia, diabetes and jaundice. Appropriate imaging diagnostics includes abdominal ultrasound, CT and MRI scans. Diagnosis is made via biopsy. Treatment: In rarely diagnosed early stages of the disease a total pancreatoduodenectomy (WhippleвЂ™s procedure) may be indicated. Due to the late diagnosis a palliative treatment is more common. Procedures include stent implantations into the biliary and pancreatic duct system to facilitate biliary and pancreatic secretion. Specific medication or chemotherapy is not available or of limited effect. Pain control is mandatory. Malignant tumors of the urogenital tract The most common urogenital malignancies derive from urothelial cells, which build the inner lining for the entire urogenital tract. An excemption is the prostate gland cancer which derives from a glandular parenchymal tissue alteration. Urogenital cancer may therefore occur as follows: 1. 2. 3. Urothelial kidney cancer (Hypernephroma) Urothelial cancer of the ureter and bladder Prostate gland cancer Symptoms and diagnostic findings: As an early symptom urothelial gland cancers typically present through a painless macrohematuria which usually is a turning point for the affected individual to see the doctor for further investigations. Cytologic examinations for urine samples may show cancerous epithelial cells. Pain and obstruction of the urinary tract typically occurs later in the course of the malignant disease and indicate an already advanced stade. Further investigations regularly performed in cases of suspicion of urothelial cancer are: Cysto and ureteroscopic examinations ultrasound examinations, CT, MRI scans and cytologic examinations of urine. Treatment: Main therapeutic option is the resection of the affected part of the urogenital tract if no metastasisis has been detected. Radiation and chemotherapy will be applied as an adjuvant chemotherapy in cases of an increased tumor size or metastasis. Urogenital tumor resection mostly requires an urinary diversion postoperatively. Common surgical methods of urine diversion are: вЂў Cutaneous nephrostomy and ureterostomy Ureters (or pelvic pyelon) are leading through the abdominal wall and discharge continuously into a bag. вЂў Ileal & Colon conduit Ureters are inserted into a segment of ileum or colon as an urine reservoir which can be catheterized as they end as an urostoma in the abdominal wall. вЂў Kock pouch A conduit operation where the pouch has a valve formation in the entry and the outlet which avoids dripping. Pouches and conduits require self catheterization. 280 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂў Ileocystoplasty Formation of a neo bladder which is still connected with the urethra and allows client to void. Prostate Gland Carcinoma The adenocarcinoma of the prostate gland is the most common type of prostate cancer. Clients are usually from 50 years of age or older at the time of diagnosis. Main metastasizing locations are the pelvic bone and the vertebral bones. Androgen production has stimulating effect towards the tumor growth. A second rare type of prostate cancer is a squamous cell carcinoma which typically follows a very aggressive course with predominantly hematogenic metastazition. Symptoms and characteristic findings: Early stages often remain asymptomatic. Vague symptoms include Dysura, urinary tract infections and urine retentions which can also be caused by the common benign Prostate Gland Hypertrophia (BPH) syndrome in this age group. Diagnosis is made by rectal digital examination which typically reveals a dense, enlarged and unshiftable prostate gland. Accordingly an increased PSA reading may be assessed. Proof of diagnosis occurs via transrectal biopsy. Treatment: Main surgical treatment is the prostatectomy along with orchiectomy for androgene withdrawal. Types of procedures compared by complication rate: Radical prostatectomy Removal of entire prostate gland and surrounding capsule, lymph nodes and neck of bladder. Leads to urine incontinence and impotence. Continence and potence may be maintained Suprapubic (ransvesical) prostatectomy but bladder may retain functional problems. Retropubic prostatectomy No bladder injury and least postoperative complications. Perineal prostatectomy Most minimal surgical trauma but increased risk of infections. Laser treatment may be an alternative procedure since it causes the least complications but removal of tumor tissue may remain subtotal. Hormonal ablative therapy is performed along with prostatectomy or as a single mode treatment. Prognosis of the adenocarcinoma of the prostate gland is generally well since tumor is slow in progress and rarely causes severe damage to vital organs. Clients require strong educational and psychological support to manage incontinence, self catheterization and coping with impotence and castration symptoms. Pain due to bone metastasis usually requires opioid treatment. Bronchogenic carcinoma Lung cancer arising from bronchoepithelial tissue. Cancer with highest lethality among all cancers. Main cause is cigarette smoke, especially in combination with other carcinogenic inhalatory agents and genetic predispositions. Carcinogenic agents are arsen, asbestos and aromatic hydrocarbons. Histologic classification differentiate small cell and non small cell carcinomas. Metastasing occurs hematogenic and lymphogenic. Mostly upper lobes are affected. Symptoms and diagnostic findings: Onset of symptoms typically occurs in advanced stages. Prime suspicion is given in a persistent productive or unproductive cough over three months. Other symptoms include chest pain, dyspnea , anorexia and swelling of cervical lymph nodes. Diagnostic tests that are revealing tumor build up are CT, MRI and X-Ray. Cytologic sputum samples are obtained from bronchoscopic washings. Therapeutic management: Surgical resection of the affected pulmonary tissue up to the entire lung 281 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com ( wedge resection, segmentectomy, lobectomy and pneumonectomy). Chemotherapy, radiation, laser, immunotherapy, pain management and palliative care. Laryngeal cancer A squamous cell carcinoma is the most common histological type of laryngeal cancer. A high incidence can be found in smokers and clients with a history of chronic alcoholism. A pre-existing chronic recurrent laryngitis of any etiology may be a risk factor as well by contributing to precancerous leukoplakia and erythroplakia. Metastasis mainly spreads into lungs. Symptoms and diagnostic findings: A sudden developing and persistent hoarseness or voice alteration of unknown cause is the primary suspicious finding. Swollen, nontender cervical lymph nodes and unexplained ear achecmay occur as well. Diagnostic tests: MRI, CT, X-ray and contrast paque x-ray visualization. Treatment: Laryngectomy with neck dissection of cervical lymph nodes, chemotherapy, radiation, trachestomy and patent airway supply. Oxygen supply. Pain management as required, palliative care, nutrition and hydration maintenance. Frequent suctioning of Trachesostoma especially in first postoperative period. Clients require teaching of esophageal speech by supraglottic swallowing for voice production. Colorectal carcinoma Colorectal cancer typically develops from polypes of the colorectal mucosa. Metastasizing occurs via the lymphatic system or by expansion to other organs. Symptoms and diagnostic findings: There are no specific symptoms in the early development of colorectal cancer. Unspecific signs are diffuse abdominal complaints, weight loss, altered bowel habits, rectal bleedings (вЂњtar stoolsвЂќ) positive hematest. Advanced tumors may cause obstructions, severe rectal bleedings and bowel perforations. Diagnosis is made via biopsies obtained via colonoscopy. Treatment: Primary treatment is the surgical resection of the tumor with consecutive colostomy or end to end anastomosis. Chemotherapy may be applied preoperatively to reduce tumor size or postoperative as an adjunct preventive chemotherapy to erase possible undetectable micrometastasis. Cervical cancer Most common type of cancer ot the female reproductive system. Onset commonly between 30вЂ“50 years of age. Mainly squamous cell carcinoma which shows early lymphogenic metastasis. Occurrence is strongly linked with previous Human Papilloma Virus (HPV) infections. Symptoms and diagnostic findings: Early stages are asymptomatic. Coincidential diagnosis by two consecutive abnormal results of a Papsmear. Advanced stades may show irregular but painless bleedings, especially contact bleedings or atypical cervical discharge. Diagnosis is made by biopsy from a colposopic cervical coniotomy. Treatment: In early stages surgical removal including postoperative radiation and chemotherapy. Fistulas between intrapelvin organs are common complications from radiation therapy. 282 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Prognosis is poor due to usually late diagnosis. Successful curative treatment is rare. Good response to chemotherapy and radiation therapy which results in significant life prolonging effect. Ovarian Cancer Adenocarcinoma, usually deriving from ovarian parenchyma. Mostly asymptomatic in beginning stages. Since no routine screening program is available diagnosis almost always occurs coincidential or after onset of symptoms. Risk increases significantly from age 40. Mainly lymphogenic metastasis. Symptoms and diagnostic findings: Clients usually experience abnormal pelvic heaviness or abdominal distention as a first symptom. Examination typically reveals a single sided palpable pelvic mass. Diagnosis can only be made by biopsies taken during an explorative laparatomy. Supporting diagnostic criteria is a significant increase of Carcinoembryonic antigen 125 (CA 125) as the only relevant tumormarker. Treatment: Surgery, radiation and chemotherapy. Prognosis is generally poor in regards to a cure but treatment has significant life prolonging effect. Breast cancer Adenocarcinomas are the most common histological type of breast cancer. Growth of an adenocarcinoma in females is generally hormone dependent. Other types (e. g. squamous cell carcinoma) may not be hormonsensitive. Multiple significant risk factors have been identified for the development of breast cancer, such as: Caucasian race, menarche <12 years of age, late menopause, after 50 years of age, maternity after 30 years of age, family history of breast cancer, hormonal supplemental therapy, obesity and family history of breast cancer. Most common location of occurrence is the upper, outer right quadrant of the breast. Symptoms and diagnostic findings: Asymptomatic tumors are mostly detected by a regular Breast Self Exam (BSE). Early stages are usually not tender. Corresponding enlarged axillary lymph nodes may also be detectable by affected women. Unspecific symptoms are occasional nipple discharge and unilateral tenderness. Growth are detectable by mammography, ultrasound, CT and MRI scans. Suspected tissues will be identified under application of radionuclides during PET examinations. Diagnosis is made by sentinel lymph node biopsy. Treatment: Treatment options include surgery, radiation and chemotherapy. Modes of mastectomy: Segmental only involving the tumorous tissue and the immediate surrounding area. Simple removal of breast without lymph nodes. Modified radical removal of breast and axillary lymph nodes. Radical mastectomy removal of breast, axillary lymph nodes and chest wall muscles Medication therapy for hormone receptor positive breast cancer Estrogene receptor blocker (Tamoxifen) for premenopausal women, leads to menopausal symptoms. Aromatase inhibitors for post menopausal women (Arimidex and Femara) blocks the aromatase enzyme which catalyzes the synthesis of estrogenes from its androgen precursor molecules within the adrenal cortex. Three types of aromatase inhibitors are currently used for treatment. 283 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Arimidex (anastrozole) Prescribed for early stage disease right after surgery. Femara (letrozole) Prescribed for women who have completed a five year treatment with tamoxifen. Aromasin (exemestane) As a permanent blocker of the aromatase enzyme it is prescribed for early stage diseases once three years of treatment with tamoxifen are completed. All aromatase inhibitors can be prescribed in metastatic breast cancer as an adjunct therapy. As in other malignant diseases the prognosis of breast cancer generally depends on the tumor stage that is present at the time of the diagnosis. Hormone sensitive tumors typically show better remission rates. Malignant neoplasms of the skin Malignant melanoma Highly malignant melanocytic tumor of unknown etiology. Risk factors are inceased exposure to sunlight, naturally pale skin and a history of multiple sun burns. Malignant melanomas can affect mucous membranes of the respiratory and digestive system as well. Symptoms and characteristic findings: Melanomas share the following characteristics of any suspected integumentary malignancy in comparison to common types of naevi (вЂњABCD вЂ“ RuleвЂќ). вЂў вЂў вЂў вЂў Assymmetric and fast growth. Border lacks of a surrounding clear margin to the neighboring tissue. Color changed within the same naevus. Diameter > 5mm. Diagnosis is made by histological examination of biopsy materials of suspected areas. Treatment: Surgical excision is the treatment of first choice. Chemotherapies and radiation are performed in case of metastasizing melanoma. Basal cell carcinoma (Basalioma) Slow growing malignant tumor that derives from the epidermal basal cell line. Occurrence is directly linked to a history of intense UV exposure. Most affected areas are face and head. Therefore this tumor is mostly seen in farmers and construction workers. Basaliomas mostly occur from 60 years of age and show a slow invasive growth without metastasis. Symptoms and diagnostic findings: Early stages appear as a papulous growth of skin like coloration. In advanced stages development of a keratocytic wall with a central ulceration. Treatment: Surgical excision. Alternative treatment options involve radiation or cryotherapy since the mainly elderly clients are often inoperable. 284 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Sqamous cell carcinoma Most common type of skin cancer. Likely to metastasize. Malignant skin tumor which develops from keratinocytes in areas that are frequently exposed to sunlight. Other supportive causes are exposure to chemicals and previous traumas. Symptoms and clinical findings: Early stages may appear as a basalioma but turn fast into an erythemic papule which easily starts bleeding. Treatment: Surgical removal as soon as diagnosis is made. As for other squamous cell carcinomas there is no causative medication or chemotherapy available. Mycosis fungoides (T вЂ“ cell Lymphoma) Most common lymphoma of the skin. Arising from T-lymphocytes (вЂњhelper cellsвЂќ). Classified as a Non вЂ“ Hodgkin lymphoma of low malignancy. Slowly progressing and mostly over decades. Symptoms and diagnostic findings: Main characteristic is a strong pruritus of the affected area which is mainly localized at the trunk or in the glutaeal region. Early stages start as large erythematic maculae with a sharp border to the surrounding tissue. In advanced stages the surface becomes scaly and moist. Metastasing throughout the lymphatic system into inner organs can occur in late stages. Lymph node swelling is likely at this stage. Diagnosis is made via histological examination of a biopsy or of the entire growth after surgical resection. Treatment: In early stages topical treatment with steroids, PUVA radiation and interferon may be prescribed. In advanced stages radiation therapy of the lymphatic tissue will be performed. Kaposi Sarcoma Malignant tumor that arises from endothelial cells of the vascular system. Most common in clients with HIV infections. May occur simultaneously in different areas of the body but does not metastasize. Mostly diagnosed as a skin lesion which typically occurs in the urogenital area from where it invades the integumentary blood and lymphatic vessels. Internal organs may affected as well. Symptoms and diagnostic findings: Single or multiple 5вЂ“20 mm sized unspecific erythematous macula or papula. Treatment: Single lesions are treated by excision, cryotherapy and radiation therapy. Interferon treatment is considered in advanced stages and multiple affected areas. Leukemias and Lymphomas The different types of leukemia have in common that they start with an unregulated and overwhelming proliferation of immune incompetent white blood cells within the entire bone marrow as well as in liver and spleen. As a consequence the affected clients are in a highly immunocompromised situation. The synthesis of red blood cells and platelets also becomes significantly deficient since the functioning bone marrow gets further and further eliminated throughout the course of the disease. Leukemias are classified by the origin of their underlying malignant process as follow: 285 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Acute Lymphocytic Leukemia (ALL): Occurring in childhood and most aggressive type! Chronic Lymphatic Leukemia (CLL): Occuring from 50 years of age and most benign type! Acute Myeloic Leukemia (AML): Occurring in all age groups. Chronic Myeloic Leukemia (CML): Occurring from young adulthood. Symptoms and diagnostic findings: Leukemia symptoms are anemia, thrombopenia and immunodeficiency caused by a total damage of the three main bone marrow functions. Clients appear with bleedings, infections, shortness of breath and cardiovascular symptoms. Laboratory findings: WBC or in normal ranges, depending on presence of current flares of acute leukemias, anemia and thrombopenia. Diagnosis is made by bone marrow biopsy which typically reveals irregular stem cells or an inadequate amount of premature WBC blast cells. Specific diagnostic finding for a CML is the presence of a genetic cause (Philadelphia Chromosome). Treatment: Depending on the individual leukemia classification the main treatment options involve chemotherapy and bone marrow transplantation. Deficiencies of RBCвЂ™s and platelets require transfusion therapy. A CLL may remain in remission for a long time and only requires therapeutic intervention in cases of acute flares. Malignant Lymphomas Uncontrolled proliferation of lymphocytes within the entire lymphatic system leads to a progressing immunodeficiency and a systemic destruction of inner organs. As in leukemias the actual cause is not known. Acute infections may trigger the onset of lymphomas. Malignant lymphomas are mainly classified as Hodgkin and non вЂ“ Hodgkin lymphomas. Differences between these two groups exist mainly in their diagnostic criterias but generally show a quite similar course. Characteristics of Hodkin вЂ“ Lymphomas вЂў Typical originating from TвЂ“lymphocytes. вЂў Main primary affection is an altered lymph node which is mostly cervical. вЂў Biopsy reveals multinuclear Sternberg вЂ“ Reed cells as proof of diagnosis. Symptoms and diagnostic findings: Affected lymph nodes typically appear enlarged, firm, nontender and not shiftable! Abnormous physical weakness, BвЂ“Symptoms nightsweats, fever, weight loss, jaundice, pruritus, lymphoma pain due to indigestion of alcohol, hepatosplenomegalie and mediastinal lymphadenopathy. Treatment: Invasive staging via thoracotomy and laparatomy. Treatment in order to stages IвЂ“IV by radiation and chemotherapy. Characteristics of Non вЂ“ Hodgkin Lymphomas вЂў Typical onset from BвЂ“lymphcytes within the lymphatic tissue of one organ вЂў No initial noticeable alteration of a lymph node вЂў No presence of SternbergвЂ“Reed cells Symptoms and diagnostic findings: Abnormous physical weakness, B вЂ“ Symptoms: Nightsweats, fever and weight loss. Hepatosplenomegalie, neurological deficiencies, neuropathy and lymphopenia. Diagnosis is made via lymph node biopsy. 286 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Treatment: Combination of radio вЂ“ and chemotherapy. Rituximab (monoclonal) antibody against CD 20 surface antigen of malignant lymphcocytes. Interleukin and Interferone. Antineoplastic Chemotherapy Alkylating agents Pharmacological effect: Cell cycle unspecific interference with DNA replication. Therapeutic effect: Destruction of neoplastic tissue. Indication: Chemotherapy in malignant neoplastic diseases. General considerations: Treatment requires strict contraception and is contraindicated in lactation and pregnancy. General side effects of chemotherapy include bone marrow depression, pancytopenia, blood dyscrasias and increased susceptibility for infections. Main cytotoxic effect occurs in tissues with high mitotic activity. Contraindications: Gastrointestinal tract diseases, hematopoetic system diseases, reproductive system, childbearing age and serious infections. Regular laboratory assessments under treatment required: Leukocyte count, platelet count, hematocrit, liver and kidney function initially and at least 2 weeks after completion of treatment. Neurological assessments and audiograms prior and during treatment because of neurotoxicity and ototoxicity. Substances: 1. Cyclophosphamide Administered orally on an empty stomach. 2. Busulfan Administered orally on an empty stomach. Needs to be stored in light resistant container. Myelosuppression, pancytopenia for up to 2 years after treatment, ovarian suppression, amenorrhea, nausea, vomiting, pulmonary fibrosis вЂњBusulfan lungвЂќ, hepatic dysfunction, diffuse hyperpigmentation and alopecia. 3. Cisplatin Pretreatment ECG required because of possible myocarditis. Pretreatment audiometric examination because of possible ototoxicity. Minimum urine output has to be 100mL/hour. Minimum specific gravity has to be greater than 1.030. 4. Carboplatin Store protected from light. Avoid contact with aluminum surfaces. 5. Mechlorethamine Severe tissue necrosis if extravasation occurs. Antidot for extravasation is isotonic sodium thiosulfate. 6. Procarbazine Requires avoidance of tyramine containing foods, due to danger of hypertension and hemorrhage. Causes alcohol intolerance. 287 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Antimetabolites Pharmacological effect: Cell cycle specific inhibition of DNA and protein synthesis by supplying alterated dysfunctional metabolites for the protein synthesis. Specific considerations: Regular assessments of CBC, WBC, Differential вЂ“ and platelet count. Regular assessments for infection and bleedings. Side effects: Hyperpigmentation of IV sites, including nail, veins and mucous membranes. (Rotate frequently!), myelosuppression, stomatitis, diarrhea. Substances: Flourouracil (5-FU) Side effects: Cardiotoxicity, photosensitivity, cerebellartoxicity, maculopapulous skin rash, no fever, myalgia , bone pain, malaise, , cerebellar toxicity, hepatotoxicity. Substances: Cytarabine, Methotrexate, Thioguanine, Fluouracil and Fludarabine. Antitumor Antibiotics Pharmacological effect: Cell cycle unspecific interference with RNA and DNA synthesis. Special considerations: Severe vesicants in case of extravasation. Requiring antidot treatment. Strong surveillance of infections and infusions required. Punctured veins should not be located close to nerves and blood vessels. Catheters have to be changed every 48 hours. Administration by push injections. Arterial, venous and lymphatic perfusion must not be compromised on limb chosen for injection. Substances: Doxorubicin (Adriamycin), Bleomycin (Blenoxane), Plicamycin (Mithramycin) Mitoxanthrone and Mitomycin. Side effects: Irritant on injection site, blueвЂ“green coloration of sclera and urine, myelosuppression, hepatotoxicity, renal toxicity and cardiotoxicity. Treatment of accidential paravasations Vesicant therapy antidotes and treatment Thiosulfate вЂ“ Nitrogen mustard Dactinomycin вЂ“ Apply ice Doxorubicin вЂ“ Cold pack Vinblastine вЂ“ Hyaluronidase + Warm pack for 24 hours Paclitaxel вЂ“ Hyaluronidas + Ice for 24 hours Mitose inhibitors Pharmacological effect: Inhibition or arrest of mitosis during M-Phase. Not to be used with PVC containing devices but with nitroglycerine tubing. Extravasation can cause tissue necrosis. Requires strict Anaphylaxis prevention by premedication with dexamethasone, diphenhydramine, cimetidine or ranitidine. Assessment of vital signs under treatment Side effects: Transient bradycardia, peripheral neuropathy, myelosupression and anaphylaxia. 288 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Substances: Vincristine (Vesicant) Hyaluronidase to be used as a vesicant antidote in cases of paravasation. Frequent assessment of achilles tendon reflexes for signs of polyneuropathy required! Nitrosureas Pharmacological effect: Interference with DNA replication and repair. Cell cycle non specific Crossing blood вЂ“ brain barrier. Hormonal antineoplastic therapy 1. Corticosteroids Pharmaceutical effect: Lysis of lymphoid malignancies. Special considerations: Slow intravenous infusion or oral administration with food. Requires frequent assessment of CBC, 2-hour postprandial glucose, kidney parameters, electrolytes, weight, I & O balance, mood and sleep pattern. Side effects: Euphoria, insomnia, psychosis, edema, muscle weakness and hyperglycemia. 1. Estrogens Pharmaceutical effect: Suppression of testosterone in male clients. Special considerations: Oral administration after meals. To be taken with water one hour before meals and requires that no milk, dairy products or calcium containing products are used. Side effects: Thromboembolism, nausea and severe hypercalcemia. 3. Progestins Pharmacological effect: Tumor cell regression in breast cancer. Special considerations: Palliative use. Assessment of weight, allergic symptoms, oral administration and not related to meals. Contraindicated in pregnancy, lactation, cardiac arrhythmia and combination with calcium channel blockers. Side effects: Vaginal bleeding, breast tenderness, abdominal pain and increased appetite. 4. Anti - Estrogene Pharmacological effect: Competitive blockage of estrogen receptors of malignant cells. Special considerations: Frequent CBC assessment required. Dosage may require adaptation to alleviate severe side effects. Side effects: Menopausal syndromes, thrombosis and discharge from breasts. 5. Androgens Pharmacological effect: Stimulation of androgen receptors. 289 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Special considerations: Palliative use for suppression of estrogen receptor positive neoplasia. Oral administration. Assessments of calcium levels is essential. Sufficient fluid supply necessary. Side effects: Virilization and hypercalcemia. 6. Anti вЂ“ androgens Pharmacological effect: Blockage of androgen receptors. Special considerations: Used in metastatic prostate gland cancer. Frequent assessment of liver function test. Side effects: Gynecomastia, gastrointestinal disturbances and hepatitis. Unspecific antineoplastic medication Asparaginase Pharmacological effect: Depletion of asparaginic acid for DNA protein synthesis. Special considerations: Every medication therapy that includes aminoacids and proteins carries a high risk for anaphylactic reactions! Intradermal skin testing prior to treatment with asparaginic acid is mandatory! Administration requires immediate access to emergency anaphylaxia treatment! Crash cart needs to be available at all times! Anaphylaxia occurs commonly within 30вЂ“60 minutes after administration. Mandatory assessments include kidney and liver function, clotting tests, CBC, amylase, calcium, ammonia and uric acid. Fiberlike particles in solution are common after reconstitution. Treatment is contraindicated in pregnancy and lactation. Side effects: Anaphylaxia, hyperemesis, hemorrhagia and pancreatitis. Hydroxyurea Pharmacological effect: Inhibiting incorporation of thymidine into DNA. Special considerations: Assessments of kidney, liver and bone marrow function, fluid input and output. Treatment is contraindicated in pregnancy and lactation. Side effects: Bone marrow depression, stomatitis, maculopapular rash and hyperuricemia. Common side effects related to chemotherapeutic agents Neutropenia Defined by Neutrophil count < 1500/mm3. Nadir most common 7вЂ“14 days following administration. Frequent assessment of Body temperature mandatory. Fever > 38.0 o C/100,4 o F is most significant symptom. Limit amount of visitors, avoidance of contact with individuals suffering from infections. Advice patient on good personal hygiene. Advice visitors to wash hands before touching patient. Avoid exposure to potentially contaminated fresh fruit or homemade food from 290 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com unknown sources. In case of infection determination of the infectious location involves cultures of urine, blood, tip of intravenous catheter and chest X-ray. Administration of filgrastim (Neupogen) stimulates regrowth of neutrophil colonies. (G-CSF) Substance may induce bone pain and can be self вЂ“ administered via subcutaneous injection. Thrombocytopenia Defined by platelet count < 50.000 mm3. Lifespan of Thrombocytes is 10 days. Clients are at risk for hemorrhage, prolonged bleeding time, bruising, petechiae, hypotension, tachycardia and intracranial bleedings. Advice to minimize risk of accidential injury due to falls and cuts etc. Administering stool regulators to ease defecation. Monitoring of pad count in menstruating women. Client to avoid nose blowing. Treatments with non steroidal anti-inflammatory medication or acetylic salicylic acid is contraindicated. Frequent urine and stool test for blood necessary. Hemorrhage may require platelet transfusion. Nausea and vomiting Can occur acute or delayed in clients under chemotherapy. Avoid strong aromatic odors. Encourage small frequent meals and sufficient fluid supply. Antiemetics may be administered parenteral (i. e. Metoclopramide, domperidone and ondansetron). Anticipatory nausea can be prevented with dexamethasone. Monitoring for dehydration is mandatory. Replenishment of fluids and electrolytes as required. Diarrhea Monitor client frequently for dehydration. Replenishment of fluids and electrolytes as required. Administering antidiarrhea medication. Elimination of sweets, processed sugars, caffeine and cold drinks. Avoiding milk and chocolate. Serving low fiber, high protein and high calorie diet. Client may require liquid diet or temporary fasting. Perianal area may require application of moisture barrier Constipation May occur due to intestinal polyneuropathy caused by chemotherapy. Requires monitoring of defecation frequency. Encouraging a fiber rich diet and sufficient fluid supply. Preventive treatment with stool regulators may be indicated. Sufficient regular exercise in order to clients overall physical condition. Laxatives may be used reluctantly due to side effects. Stomatitis Caused by destruction of epithelial cells of oral cavity during chemotherapy. Condition causes hypersensitivity to hot and cold temperatures, spices and alcohol. Assure thorough oral hygiene to prevent secondary infections. Antifungal/antiviral preventive treatment may be indicated. Alopecia Typical onset 2 weeks after administration of chemotherapeutic agents. May continue for up to 5 months. Condition requires careful care of persistent and regrowing hair until full consistency is achieved again. Clients may require emotional support to cope adequately. Cardiotoxicity Developing immediately or within 4вЂ“5 weeks after drug administration. Onset of symptoms requires immediate cessation of chemotherapy. Assessment parameters are the decrease of the cardiac ejection fraction, ECG вЂ“ changes, dysrhyhmias, hypotension, 291 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com chest pain, pulmonary congestion and peripheric edema. Reversibility depends on amount of administered dosage. Pulmonary toxicity More common in clients >70 years of age. Toxic reaction of alveoli and capillary endothelium. High oxygen supply increases toxicity of Bleomycin. Regular assessment of pulmonary function studies and oxygene saturation in peripheric blood required. Onset of dyspnea is the primary symptom. Management with low dose opioid medication, oxygen supply and instruction on appropriate breathing techniques. Hemorrhagic cystitis Due to damage of urothelial lining and induction of inflammation of bladder wall. Caused by acrolein, metabolit from cyclophosphamide and ifosfamide. Symptoms comparable to an urinary tract infection. Treatment with a chelatbinding agent (mesna) may lead to excretion of acrolein from bladder. Client is required to maintain adequate hydration. Hepatotoxicity Caused by metabolism of toxic chemotherapeutic agents in liver. Manifestation includes jaundice, pruritus, abdominal pain in upper right quadrant, hepatomegaly, hyperpigmentation, acholic stool and beerbrown urine. Assessment via regular liver function test. Management involves avoidance of other potentially hepatotoxic substances. Nephrotoxicity Caused by damage of nephrons leading to an obstructive nephropathy. Symptoms include elevated levels of creatinine and urea in serum and urine as well as decreased albumin levels and glomerular filtration rate. Urine specific findings are proteinuria, hematuria and hypomagnesemia. Medication may need to be cessated if BUN is > 22mg/dL and/or creatinine > 2 mg/dL. Prevention of nephrotoxicity requires hydration with minimum 3000mL fluids daily and prescription of Allopurinol to control uric acid levels. Also alkalization of urine with bicarbonate and strict avoidance of NSAID required to prevent further kidney damage. Neurotoxicity Mainly caused by cumulative dosage of vinca alkaloids passing through the blood/brain barrier to cause direct damage on cells of the central nerous system. Requires frequent neurological assessments. Neurological deficiencies allow conclusion on the affected CNS areas as follow: Confusion or impaired level of consciousness Cerebrum Tinnitus, hearing loss Auditory cortex. Digestive and urogenital dysfunction Autonomous nervous system. Paresthesias and impaired deep tendon reflexes Sensoric cortex. SAFETY REQUIREMENTS FOR HANDLING CHEMOTHERAPEUTIC MEDICATION вЂў вЂў вЂў вЂў вЂў вЂў Personnel should be specially trained for this task. Dosages have to be calculated in relation to body weight or body surface. Treatment courses are mainly intermittent and sometimes combine two or more chemotherapeutic agents. Preparation of dosages has to occur in a well air vented area with restricted access. Personal safety requires wearing of leak proof gown, disposable gloves and eye protection. 292 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Safety regulations do not allow pregnant women to get in contact with chemo вЂ“ therapeutics ! Immune modulating medication 1. Colony вЂ“ stimulating factors вЂў Granulocyte Colony-Stimulating Factors (G-CSF) вЂў Granulocyte and Macrophage stimulating factors (GM-CSF) Pharmacological effect: Reduction of neutropenia. Special considerations: Allergic reactions may occur. 2. Sargramostim (LeukineВ®) Special considerations: To be applied not any earlier than 21 days after completion of bone marrow transplantation or 11 days after completion of chemotherapy. Necessary assessments iclude CBC, liver and kidney parameters twice weekly. Thorough assessments of remaining leucemic cells are mandatory. Suspension can be reconstituted with physiological saline. Contraindications: Hypersensitivity to yeast products or E. coli products. Pregnancy, lactation. Impaired renal or hepatic function. Remaining leucemic cells in bone marrow. 3. Filgrastim (NeupogenВ®) Special considerations: Not to be administered within first 24 hours after a dose of cytotoxic chemotherapy. Necessary assessments: CBC, liver and kidney parameters twice weekly. Reconstitution in Dextrose 5%. Contraindications: Hypersensitivity to yeast products or E. coli products. Pregnancy and lactation. Impaired renal or hepatic function. Remaining leucemic cells in bone marrow. Side effects: (Substance unspecific) Headache, myalgia, malaise, stomatitis, nausea, vomiting, diarrhea, constipation, alopecia, gastrointestinal hemorrhage, renal and hepatic dysfunction, supraventricular dysrhythmias and tachycardia. Adult Respiratory Distress Syndrome (ARDS). Myocardial infarction (MI). 4. Erythropoetin (Increases RBC count only, as discussed under renal medications) Cell stimuating medication (Interleukines) Pharmacological effect: 1. Increase specifically thrombocytes, lymphocytes and T-cell immunity in peripheric blood. 2. Antitumor activity by causing cells to change to a non-proliferative type. General considerations: Frequent assessment of CBC, including differential and platelet count, electrolyte balance and vital signs. 293 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 1. Aldesleukin (ProleukinВ®) Indications: Renal carcinoma, severe thrombocytopenia. Special considerations: Treatment is administered over two times 14 single doses and requires hospital setting with availability of an ICU. Side effects: Myalgia, lethargy, fluid retention and cardiac dysrhythmias. 2. Levamisole (ErgamisolВ®) Indications: Colon cancer Duke stage C. Increase of activity of B and T cells and macrophages. Specific considerations: Treatment to be started 7вЂ“30 days after bowel resection. May be combined with 5 Fluouracil. Side effects: Flulike symptoms, bone marrow depression and gastrointestinal disturbance. 3. Oprevelkin (NeumegaВ®) Indications: Treatment of myelosuppression following chemotherapy due to an increase of megacaryocytes and thrombocyte production. Specific considerations: Treatment for 21 days or until thrombocyte count reaches 100.000 cells/mm3. To be reconstituted in physiological saline. Side effects: Cardiac dysrhytmias and fluid retention. PSYCHIATRIC DISORDERS AND DISEASES General Definitions Therapeutic Communication and Environment Elements of Communication 1. Sender initiates conversation. 2. Message is submitted. 3. Channel one of the five senses used to submit the message. 4. Receiver individual who this message is directed too. 5. Environment (context) conditions under which this message is submitted. 6. Feedback (response) Levels of communication Intrapersonal, interpersonal and public. Forms of communication Verbal and nonverbal, nonвЂ“therapeutic and therapeutic. Influencing factors of communication Pacing, intonation, clarity and brevity, timing and relevance. Factors of nonverbal communications Facial expression, eye contact, gestures, posture and gait, territoriality and personal space and personal appearance. 294 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Communication blocks (Blocks and avoids expression of clients feelings) Communication must be client centered and goal oriented. Self disclosure, inattentive listening, overuse of medical terms and personal opinions. Probing or prying questions (unless in a Mental Health Setting). Changing the subject, challenging or being defensive. False reassurance. Therapeutic relationship phases 1. Pre - interaction phase (analyzation of information prior to contact) 2. Orientation phase (pre - helping phase), opening the relationship, clarifying a problem, structuring and formulating the contract. 3. Working phase (exploring and understanding thoughts and feelings) transference and countertransference may occur and the client makes a decision. 4. Termination phase (prepare early in process, may include follow up procedures, feelings of loss and ambivalence on both sides). Health Risks under consideration of ethnicity African Americans Lactose intolerance and lactase deficiency, hypertension, sickle cell anemia, cancers, coronary heart disease, coccidioidomycosi and diabetes. Asian Americans Thalassaemia, lactase deficiency, G6PD Deficiency, hypertension, cancer (stomach and liver) and coccidioidomycosis. Latino/Hispanic Americans Diabetes, hypertension, pernicious anemia and childhood obesity. Native Americans Alcoholism, accidents, arthritis, COPD, diabetes, hypertension, heart diseases, HIV, influenza, cancer, malnutrition, maternal and infant deaths, obesity, suicide and tuberculosis. Coping Strategies and Defense Mechanisms Adaptive (healthy) coping Sustaining general homeostasis Maladaptive (unhealthy) coping General homeostasis not preserved Compensation Making up for a deficit. Denial Refusing to acknowledge an unacceptable fact. Displacement Directing feelings against a big threat towards a smaller threat. Identification Attempt to change oneself to please somebody else. Intellectualization Excessive reasoning to avoid or minimize distressing experiences. Introjection Internalizing somebody elses feelings in one self. Minimization Refusing to acknowledge the significance of somebody elses behavior. Projection Transfering unacceptable feelings to another. Rationalization Justifying unacceptable behavior by applying a false logic or applying false but acceptable motives. 295 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Reaction formation Behaving contrary to personal feelings. Regression Returning to an earlier less well developed stage of functioning. Sublimation Displacing motivation for unacceptable behavior into acceptable behavior. Substitution Replacing an unobtainable goal or unacceptable object with a less satisfying but acceptable and available one. Undoing Trying to repair previously made damage. Personality traits and response to medical illness Type A: Unhealthy response to medical illness. Irritabile, impatient, unable to relax, time conscious, low self вЂ“ esteem and highly depending on approval from others. Type B: Healthier response. Laid back, goal directed, relaxed and easygoing Behaviors that increase likelyhood of medical illness Pessimism, repression, limited social interactions, hostility and despair. Behaviors that decrease likelyhood of medical illness Energetic, questioning, humorous, inspirational and good interpersonal skills. Crisis Confrontation by a stressor a person is unable to cope with. Always time limited (4 вЂ“ 6 weeks) accompanied by: Threat to individuals well balanced self (equilibrium) Characterized by an overall hopelessness and helplessness. Crisis either leads to personal growth or increased psychological vunerability. Maturational Crisis = Developmental Crisis due to normal life transitions. Situational crisis = Due to external factors. i.e. loss and change. Adventitious crisis = Due to catastrophies or disasters. Cultural crisis = Due to being in a new cultural environment. Nursing Assessment Focus on immediate problem, determine clients perception of problem and identify current changes, assess coping mechanisms, assess support systems and assess potential for self harm. Treatment: Verbal intervention strategies. Psychopharmacological treatment during crisis. Anxiolytics: Alprozolam (Xanax), Clonazepam (Klonopin), Diazepam (Valium) and Lorazepam (Ativan) Sedatives: Zolpidem (Ambien) and Zaleplon (Sonata) Neuroleptics: Olanzapine (Zyprexa), Risperidone (Risperdal), Quetiapine (Seroquel) and Haloperidol (Haldol). Psychotic symptoms are not typical for crisis but crisis may excerbate underling Psychosis! Anger and Aggression Violence typically follows aggressive behavior of any kind. Risk factor is an appropriate history. Violence may be provocated by staff in a clinical setting. Intervention rules similar to crisis intervention! 296 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Psychosis Disorder of organic or emotional origin characterized by gross impairment in reality testing. Psychotic symptoms вЂў Delusions false beliefs that can not be altered by evidence or local reasoning. вЂў Hallucinations sensations with no real existing external stimulus. ( related to sight, sound, smell, taste or touch) вЂў Self neglect difficulty in caring for oneself. вЂў Thought disruptions Assessment of individual stress reaction Assessment of psychological factors to a clients health: Factors to explore: Source, number, duration of stressors, full mental status examination, coping strategies, adaptive and maladaptive behaviours, pre-existing psychological illness, drug, substance and alcohol abuse. Biological Assessment Assessment of impact of biological factors to a clients health. Factors to explore are: Recent and past health conditions, physical examination, neurological status, laboratory results, current physical ability, sleep pattern, nutritional pattern and pharmacological assessment. Social assessment Client history, life changing events, lifestyle patterns, cultural practices, family communication pattern, support network, spiritual concerns, occupational assessment and economic status. Anxiety Disorders (Neurosis, Psychoneurosis) Anxiety is defined as fear of the unknown and is experienced by all human beings. Anxiety is not necessarily an unhealthy reaction and it is needed to alert an individual to danger and stressors. Symptoms: Tremor, increased muscle tension and increase of BP, HR. Depression, irritability and anger. Inability to concentrate and to function on a cognitive level. Social withdrawal, excessive communication, selfвЂ“isolation and suicidal ideas. Spiritual signs, hopelessness, despair, fear of death and no meaningful aspects in life. Classification: Acute anxiety = State anxiety. Chronic anxiety = Trait anxiety. Primary anxiety = Anxiety due to psychological factors. Secondary anxiety = Response to physical health problems. Fear = A reaction to a specific danger. Stress = Imbalance between demands and fulfillment of demands. Stressor = Internal or external event that leads to feelings of anxiety. Experienced on an individual basis, but health problems are commonly an underlying stressor. Burnout = Physical and/or mental exhaustion due to prolonged stress. Anxiety levels: Mild Alert, tensed but otherwise not impaired. Moderate Focus on immediate concern, fear and tension, Perceptual field is narrowed. 297 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Severe Focus on specific details, focus directed on specific anxiety, sympathetic nervous system aroused and severe emotional distress. Reaction to dread and terror, individual is unable to function adequately. Details get blown out of proportion and overwhelming emotional reaction. General adaptation syndrome Automatic physical reaction to stress by the sympathetic nervous system. 1. 2. 3. 4. Stress = response to the demand Alarm = hormonal activity triggers fight or flight reaction Resistance = moderate to severe anxiety, psychosomatic symptoms, functioning on a suboptimal level and implementation of a coping strategy. Exhaustion = occurs when adaptational resources are depleted, disorganized functioning, hallucinations and delusions may occur. Severe anxiety to panic. Phobic Disorders Fears of specific objects, activities, situations, e.g. Agoraphobia (fear of being trapped in crowds). Frequently associated with a panic disorder. Treated with behavioral therapy. Generalized anxiety disorder GAD Triggered by common daily activities. Treated with Benzodizepines on demand and Buspirone. Client has to be taught to rethink perception of stressor (behavioral therapy). Panic Disorder Reaction to dread and terror. Individual is unable to function adequately. Details get blown out of proportion, overwhelming emotional reaction. Symptoms include desire to escape, chest pain, hot flushes and other physical symptoms. Accompanied feelings of hopelessness and despair. Obsessive Compulsive Disorder OCD Recurrent obsessive thoughts and uncontrollable compulsive behavior. Issues about controlling oneself, others and the environment. Obsessions Unwanted thoughts, impulses, images about objects, contamination, questions, sex and unacceptable impulses. Compulsions Unwanted behavioral patterns or acts i.e. counting, praying, washing hands, repeating words, controlling and seeking reassurance. Interruption of obsessive thoughts and compulsive behavior leads to increased anxiety. Treated with relaxation and cognitive behavioral techniques like flooding and thought stopping. Teach immediately after client has completed ritual. SSRI (i.e. Sertraline (Zoloft) Selective Serotonin Reuptake Inhibitors are most effective medication therapy. Electroconvulsive Therapy ECT has been used to treat depressive symptoms associated with OCD successfully. Posttraumatic Stress Disorder PTSD Associated with an extremely traumatic event. Symptoms: Apathy, social withdrawal, isolation, loss of interest, depression, hopelessness, restlessness, irritability, intrusive and unwanted memories (flashbacks). 298 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Coping with denial, repression, suppression of unwanted thoughts and impulses. To be explored about feelings of guilt, shame and grief and taught new coping strategies. Mood Disorders Mood A prolonged emotional state that affects someones life and personality. Changes of mood are generally normal. Affect Present feelings and moods Mood disorders are changes in mood ranging from depression to elation. Dysthymic Disorder Chronic disorder in which a low level depressed mood frequently fluctuates with normal mood for at least 2 years plus 3 of the following symptoms: вЂў вЂў вЂў вЂў вЂў вЂў вЂў Depressed mood daily or every 2nd day Poor appetite or overeating Insomnia or hypersomnia Low energy Low self esteem Unable to make decisions Feeling of hopelessness Therapeutic management Assure clientвЂ™s safety towards potential for self harm as a first priority since client may have limited judgement ability(self harm is more likely in phase of regaining hope)! Warning signs are a history of violence, signs of hopelessness, selfвЂ“neglect and malnutrition. Malnutrition generally requires a frequent examination of the protein metabolism including assessment of serum prealbumin, albumin, glucose, electrolytes, and nitrogen balance. Bipolar Disorder = manic depressive disorder Depression and Elation appear alternating as a Bipolar I and Bipolar II disorder. Major depression (unipolar disorder) Generally described as an overall loss of interest in life, transforming from mild to severe in at least 2 weeks. May be accompanied by delusions and hallucinations in severe stades. Suicide rate is 15%! Clients show a significantly decreased desire to participate in any social setting. Low self-esteem, feeling of incompetence, decreased motivation, вЂњWhy bother?вЂњ attitude, social withdrawal, sense of sadness and anhedonia. Guilt вЂњWhy do I feel like this?вЂќ, difficulties making decisions and self perception as unattractive. Clients may develop hallucinations. Loss of libido, altered eating pattern, increased or decreased appetite and lack of personal hygiene. Mania Clients in acute manic phases appear with high energy and productivity. Decreased ability to concentrate, increasing frustration and irritability, shortened attention span, unrealistic self confidence, poor judgement and financially risky transactions. Inadequate social behavior, increased talkativeness, cheerful to euphoric mood, irritable, 299 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com disrespecting attitude, hyperactivity, grandiosity ideas, flight of ideas. Believe to be very attractive, hallucinations possible, increased sexual activity, promiscuity, insomnia, eating disorder, constipation, exaggerated, overdressed and colorful clothing. Cyclothymic Disorder Depressive and hypomania phases last for at least 2 years each. No вЂњnormalвЂќ stage. Seasonal Affective Disorder SAD Depression in fall and winter due to reduced sunlight. Correlating with a reduced production of Melatonin and Serotonine. Schizoaffective Disorder Mood disorder accompanied with manifestations of schizophrenia. Occuring in flares of 15-20 minutes at a time. Assessment of current affect reveals restlessness, nervous anxiety and disability to concentrate. Client is socially withdrawn with dysfunctional support system and showing no personal interests. Hallucination and delusion may be present. Also signs of selfвЂ“neglect, alcoholism or drug abuse. Suicidal ideas or attempt may be revealed in medical history. Calm, respectful, honest and realistic therapeutic feedback to maintain a safe therapeutic environment. Psychotherapeutic treatment options Biologically based therapies Consider mental health problems are as biochemically induced and can be repaired with medications and other methods (i. e. ECT). Cognitive therapy Distorted conceptualization and dysfunctional beliefs will be reintegrated by reality testing. Activity therapy Considers that mental health problems are caused by social deficits. Group activity to increase self вЂ“ esteem and promote socialization. Family therapy Considers that mental health problems are caused by family problems. Members are lacking sense of вЂњIвЂќ and the problem of the affected individual serves a specific function in the family. Treatment therefore involves the entire family to gain sense of one self for each family member. Group therapy Relationship problems can be solved by learning new coping skills in a group setting. Group has to have a leader. Milieu therapy Therapeutic environment to increase self awareness of feelings and increase of reponsibilty. Setting is determined by patients leaving a high extent of autonomy. Play therapy Therapeutic setting to assist children to express thoughts and feelings unable to verbalize in play. 300 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Psychoanalytical therapy Conflicts between identity and ego lead to anxiety and ineffective and inappropriate defense mechanisms. Therapy is designed to discover unconscious thoughts, feelings, defenses and correcting them. Electro Convulsion Therapy ECT for treatment of depression in case of failure of antidepressants. Not widely used. Psychotic Disorders Schizophrenia Difficulty to think clearly, being realistic, managing feelings and relating to others in any way. Classification: вЂў Paranoid = Hallucinations. вЂў Catatonic = Stupor, Echolalia and Echopraxia. вЂў Residual = No plus symptom present but schizophrenic episode in the past. вЂў Disorganized = In speech, behavior and affect. вЂў Undifferentiated type Positive schizophrenia symptoms вЂњPlusвЂ“SymptomsвЂќ вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў Hallucinations (mostly auditory) Delusions (false beliefs) Loose associations Overactive affect Disorganized speech pattern Bizarre behaviors. Thought broadcasting = believe others can know personal information Thought insertion = believe others can put thoughts in a persons mind Psychosis = difficulty to differentiate own perceptions from reality Illusions = inaccurate perception or misinterpretation of sensory impressions Agitation and hostility Association disturbances Clang associations (rhyming words in a nonsense way) Illogical thinking patterns Neologisms and Word salads Negative schizophrenia symptoms вЂњMinus SymptomsвЂќ вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў Absence of healthy mental behavior Purposeless and ritualistic behavior Bizarre facial or body movements Ineffective social skills Isolation Lack of self care Concrete thought process Lack of ego boundaries Dependency Ineffective social skills and social withdrawal 301 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂў вЂў вЂў вЂў вЂў вЂў вЂў Affect disturbances Ambivalence Avolition = lack of motivation and goals Anergia = lack of energy Alogia = poverty of speech Anhedonia = diminished ability to experience pleasure or intimacy Sleep disturbance Intervention strategy rules in cases of acute psychosis 1. Honest supportive and consistent approach. 2. Do not argue. 3. Maintain a clear and directed communication. 4. Do not confirm hallucinations or delusions. 5. Encourage expression. 6. Do not force rest. 7. Protect from self harm. Undifferentiated psychotic disorders 1. Schizophreniform disorder Abbreviated course of schizophrenia. 2. Delusional disorder Non- bizzare delusions for at least 1 month. 3. Brief psychotic disorder One positive schizophrenia symptom for 1 day вЂ“ 1 month. May occur under specific stressor. 4. Shared psychotic disorder (folie a deux) Delusions occuring between two individuals. 5. Substance induced psychosis Psychosis induced by substance abuse or medication therapy. Personality Disorders Personality disorder patterns are inflexible, enduring, pervasive, maladaptive, causing significant functional impairment and stress. May be experienced as comfortable (egosyntonic) or uncomfortable (egodystonic) by the affected client. Condition does not cause clinical problems but problems in daily living. Commonly more than one personality disorder present at a time. Characteristics exist in four areas: вЂў вЂў вЂў вЂў Behavioral manifestations Affective manifestations Cognitive manifestations Sociocultural manifestations Personality disorders are caused by a dysfunction of the limbic system and CNS irritability. Serotonin (5 HT) levels are decreased. Norepinephrine levels are increased 302 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com (NE). Abnormal levels of Dopamine and genetic factors. Also hostility towards oneself, living up to perfectional standards, super ego rules, unsatisfied basic needs, anxiety and social oppression. Classification: Cluster A personality disorders Paranoid personality disorder Distrust and suspiciousness Schizoid personality disorder Social detachment and restricted emotions Schizotypal personality disorder Discomfort in close relationships, cognitive or perceptual distortion and eccentric behavior Cluster B personality disorders Antisocial personality disorder Disregarding others Borderline personality disorder Instability in personal relationships and impulsivity Histrionic personality disorder Excessive emotionality and attention seeking narcissistic personality disorder, grandiosity pattern and need for admiration Cluster C personality disorders Avoidant personality disorder pattern of social inhibition, feeling of inadequacy and hypersensitivity to negative evaluation. Dependent personality disorder need to be taken care of and submissive Obsessive вЂ“ compulsive personality disorder pattern of preoccupation with orderliness, perfectionism and control. Assessment guidelines Client with personality disorders are mostly not aware of this problem. Assessment includes functioning in areas of affect, cognition, behavior and sociocultural adaptation. Intervention strategy Clients may or may not change! Mirror behavior to motivate them for a more adaptive life style. Focus on a small step improvement in role functioning and decreasing distress. All clients have potential to change. Awareness of own emotional responses required! Cluster A Cluster B Cluster C requires gentle, interested and nonвЂ“intrusive approach. Patient approach when agitated and erratic. Set limits as necessary! Direct communication diminishes attention seeking behavior. Address fears of inadequacy. Treatment of personality disorders Any therapeutic intervention requires that client is aware of its need. Medication therapy include SSRI as needed to equalize mood swings. Behavioral therapy for impulse control training, setting limits (clearly stated, necessary and enforceable) and behavioral modification. Psychological comfort promotion. Encouraging independence and decision making. 303 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Dissociative Disorders Sudden disruption in clientвЂ™s consciousness, identity or memory. Using dissociation and repression as defense mechanisms. Caused by trauma (wars, natural disasters, abuse, and crime) and genetic predisposition. Dissociative Amnesia Client cannot remember personal information. Amnesia can be localized, selective, generalized and continuous. Dissociative fugue Client flees from personal environment. Unable to remember upon return. Dissociative identity disorder (Split personality) Alterating from one personality to another (вЂњDr. Jekyll and Mr. HydeвЂќ). May alter physiological characteristics of one personality as well. Client may or may not be aware of the coexisting personality. Host personality disorder Hosting other personalities than the one that is identified with persons name. Depersonalization disorder Experiencing detachment from one self as in a dreamlike state. Somatoform disorders Increased perception of physiological signals by impaired inhibitory CNS function leads to psychophysiological responses in form of physical symptoms with no underlying cause. May be reinforced by secondary gain due to increased attention within the family or cultural environment. Treatment by client education. No Psychopharmaceuticals. Somatization disorder Prior to age 30. Multiple physical complaints. Conversion disorder Client is indifferent about the loss of a motoric, sensoric or visceral function without an underlying organic cause. Clients mood may not be adequately affected. Pain disorder No organic cause but client experiences ongoing severe physical pain. Hypochondriasis disorder Development of multiple organic symptoms without an underlying cause leading to a very concerned personality. Body dysmorphic disorder Preoccupation by an imagined effect or excessive concern about a minor defect. Cognitive Impairment Disorders Delirium Acute, usually reversible brain disorder. Leading to reduced consciouness. Developing within hours to days. Caused by an underlying medical condition, intoxication or alcohol withdrawal( Delirium tremens). 304 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Dementia Chronic, irreversible brain disorder. Gradually developing. Leading to loss or weakening of memory, abstract thinking, judgement and personality. Including aphasia, apraxia and agnosia. Loss of ability to function in an organized manner. Classification: вЂў Alzheimers Type dementia вЂў Vascular dementia вЂў Substance induced dementia вЂў Multiple etiologies Amnestic disorders Unable to recall previously learned information or to learn new information. Multiple causes. Dementia screening Tools Folstein Mini Mental State Examination. Score of 9-12 indicates organical illness. Cognitive Performance Scale. Subscale from nursing home minimum data set 0 = cognitively intact 6 = cognitively impaired. Geriatric Depression Screening Tool. 0-10 = mild, 21вЂ“30 = severe depression Alzheimers Disease Stage 1: Forgetfulness and loss of higher executive functions. Losses in short вЂ“ term memory.Use of Memory Aids. Client concerned and frightened about condition. Depression worsens symptoms. Stage 2: Confusion. Progressive short term memory loss. Memory gaps (Confabulation) Performance of ADLвЂ™s seriously impaired. Social withdrawal. Inappropriate appearance. Lack of ability for adequate verbal response. Poor impulse control. Stage 3: Loosing order in ADL. Wandering and hallucinations Aphasia Stage 4: Hyperorality. Perseveration disorder and repetitive behaviors. Agraphia, Agnosia, Auditory impairment and Astereognosia (= tactile Agnosia) Alexia (=visual Agnosia). Hypermetamorphosis. Need to touch and examine every object Progressive motor deterioration. Progressive decreased response to stimuli. Progressive decline in cognitive function. Mute, scream and continous repetition of one word. Medication Therapy for Alzheimers Disease Pharmacological effect: Inhibition of the enzyme cholinesterase leads to an increase of the acetylcholine concentration in the chemical synapses in neurons of the central parasympathetic autonomous nervous system. Therapeutic effect: Progress of Alzheimers dementia slows down. Side effects: Correlate with an increased activity of the parasympathetic autonomous nervous 305 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com system and can be considered as partially parasympathomimetic: Insomnia, headache, dizziness, nausea, vomiting, polyuria, seizures and hepatotoxicity. Substances: Donezepil hydrochloride (AriceptВ®), Galantamine (RazadyneВ®), Memantine (NamendaВ®) SSRI are better tolerated in older adults than TCA! Antipsychotics hacw potential to cause tardive dyskinesia! NonвЂ“pharmacological treatment options include behavior modification, review of life therapy, validation therapy and SCU special care units. Eating Disorders Anorexia nervosa Life threatening condition. Affected clients maintain minimum nutrition to avoid obesity. Onset commonly in teenagers and triggered by life events. Mostly eager, success oriented personalities. Symptoms and diagnostic findings: Weight Loss, electrolyte imbalances, BP, Temp., HR decreased, peripheric cyanosis, constipation, tooth and gum degeneration, dry scaly skin, numbness of extremities, bone degeneration, amenorrhea over min. 3 cycles and insomnia. Bulimia Clients are concerned on body size, appearance, low self esteem, poor relationships. Overeating large amounts of low nutrient food followed by purging through vomiting, laxatives, enemas, diuretics and amphetamines. Symptoms and diagnostic findings: Weight may be normal. Electrolyte imbalances, cardiac diseases, hypertension, tooth decay, gastritis, ulcers, Boerhave Syndrome (esophagus rupture) and rectal bleedings. Pseudodementia = Depression that appears as dementia. Treatment: Main aspect is to protect client from self harm or harm to others by securing a safe care environment, assessing specific needs, building partnerships with family and finding community resources. Dependency and Addiction Substance abuse Purposeful recurrent use of a substance despite evidence of adverse consequences to oneself or others. Substance dependence Drug use is no longer under control and is continuously used despite adverse effects. Addiction Illness with compulsion, loss of control, continued pattern of abuse despite experience of negative consequences. Treatment always focuses on Abstinence. Types of addiction: Substance abuse disorder and process addiction ( i.e. gambling and shopping) Accompanied by intoxication, withdrawal, abuse, dependence and tolerance. JelinekвЂ™s four phases of Alcoholism (Can be generally applied to Substance abuse and process addiction) 306 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂў Prealcoholic symptomatic phase Drinking to cope with emotions not realizing that drinking causes tension. вЂў Prodromal symptomatic phase Six months to 5 years. Drinking in secret. Gulps first sips. Diminished emotional response. Plans activities under consideration of access to Alcohol. Feels guilty. вЂў Crucial phase Build tolerance. Disease process and psychological dependence. Loss of control during consume. Preoccupation with use. Craving triggers. Defense Mechanisms. Environment expresses concerns. ADLвЂ™s affected. Anger and alienation of nonвЂ“ drinking environment. вЂў Chronic phase Drinks to blackout, passout and incapacitation. Cognitive, physical, emotional and deterioration. Reverse tolerance. Loss of control. Model of process addiction Contact phase Serendipitous phase (discovers stress relieving effect of pursuing with addictive behavior) Instrumental phase Dependant phase. Etiology of Dependence and Addiction Addiction = chronic brain disease with a dysfunction of the brain reward system. CNS affecting substances or engaging in addictive behaviors causes increased availability of Dopamin, Serotonine, Opioid peptides and Neurotransmitters. Leads to a short term euphoric response generated by this activity. Cravings for readministration. Development of tolerance. Physical Dependence and withdrawal. Psychological Dependence. Genetic/biologic risk Developing out of multiple underlying risk factors. Hereditary tendency. Psychosocial risk for addiction development Personality traits: Antisocial, introversion and impulsiveness. Developmental failures: Abuse survivors lack of nurturance in childhood. Coping skills deficit and lack of positive coping skills. Dual disorder risk Pre-existing psychiatric disorder in clients with an alcohol or substance addiction causes an increased risk of suicide. Environmental risk Social learning theory (addiction as a learned behavior) Normalized behavior under peer pressure. 307 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Assessment of clients with addictions CAGE Question assessment for addictive behavior Have you ever tried to cut back on Alcohol? Have you ever been annoyed by comments about your drinking? Have you ever felt guilty about drinking ? Have you ever had an eye opener in the morning? 2 x yes = further assessment necessary Other Assesssment tests: Michigan Alcoholism Acreening Test (MAST). Addiction Severity Index (ASI) Physical Assessment: Changes in bowel function. Liver problems, including Wernickes Encephalopathy and KorsakoffвЂ™s Psychosis. Weight loss or weight gain. Sleep disturbances. Chronic pain? Functioning social network? Psychosocial Assessment Substance use Assessment Substance abuse in history? Medication Assessments Overuse of prescription medication? Outcome Multi specialty approach. Prognosis is mainly determined by compliance of client. Treatment: Detoxifications and Abstinence medications Disulfiram (Antabuse) Daily average dosage 250mg/d orally. Prevents breakdown of alcohol. If still consumed, appearance of severe gastrointestinal problems. May increase liver enzymes. Naltrexone (ReVia) Daily average dosage 50mg orally. Prevents and diminishes cravings/euphoric effect. Used in alcohol and opiate dependency. May increase liver enzymes. Antidepressants/Anxiolytics Enhance and stabilize mood . Gradual dosage reduction prior cessation necessary. Components of psychotherapeutic intervention Group framework key elements 1. acceptance (there is no effective cure) 2. surrender 3. processing 4. grief 5. higher power 6. power of the group Cognitive behavioral model Develop and use of positive coping skills. Identifying euphoric recall. Relapse prevention model Identify situations and factors that contribute to relapse. Components of motivational Enhancement and stages of change Reflective listening. Development of discrepancy to help clients to see themselves the way they really are. Assessments of clientвЂ™s stages of change. 308 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Substance Abuse Alcohol Effect is dose dependent and biochemically induced due to enhancement of GABA synthesis. Medication therapy for alcohol withdrawal treatments includes: Chlordiazepoxide (Librium), Diazepam (Valium) and Lorazepam (Ativan) In conjunction with Atenolol (BetaвЂ“blocker) and Disulfiram. Disulfiram effect: = Alcohol dehydrogenase enzyme inhibition leads to an increase of acetaldehyde when client consumes alcohol. Results in sudden onset of nausea, vomiting, dizziness, hypertension and flushing. Long half life of Disulfiram requires up to two weeks time to elapse before alcohol can get consumed after the last dosage of Disulfiram. Opioids Signs of toxicity and overdose are Miosis, coma and respiratory depression. Opiod antagonist Naloxone (Naran) antagonist must be administered carefully and maybe repeated because of short half life. Sudden reversal of opioid symptoms may lead to withdrawal. Nalmefene (Revex) is an opioid antagonist with a long half life and does not require repeated dosage. Methadone as a partial opioid antagonist is prescribed for withdrawal purposes only. Cocaine Stimulant, instant but short active. Depletes Norepinephrine and Dopamine by blocking its reuptake. Highly addictive, psychological and physical addiction. Treatment requires restoration of neurotransmitters by using Tyrosine and phenylalanine as amino acid catecholamine precursors as well as tricyclic antidepressants and Bromoctiptine (Dopaminagonist). Cannabis DeltaвЂ“9вЂ“tetrahydrocannabinol (THC). Produces euphoria, sedation and hallucinations. Increases sensitivity to visual and auditory stimuli. Enhanced sense of touch, taste and smell. Increased appetite. Distortion of time.Therapeutic use as an antiemetic in cancer chemotherapy. Used to stimulate appettite in HIV patients. Mainly psychological addiction and no severe physical withdrawal symptoms. Suicide Eleventh leading cause of death among all age groups. Third leading cause of death between 10 years and adolescence. A common pattern is low self esteem and isolation or a life situation that is regarded as hopeless. White, gay, male individuals are statistically at highest risk. Mood disorder is most predictive psychiatric disorder for suicide! Suspicion of suicidality requires further specialized assessment! Suicide assessment Always address any suspicion of selfвЂ“harm or suicidal tendencies directly! Ambivalence may be present. Very sudden вЂњimprovementвЂ™ may indicate that client is about to carry suicide out. Suicide watch is mandatory in case of suspected suicidal plans. Suicide watch needs to be provided in a safe environment with 15 min checks for 24 hours, if possible with roommate. 309 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Psychopharmaceutical Suicide Prevention Treatment Selective Serotonine Reuptake Inhibitors SSRI are first choice of treatment in a suicidal depression because of low risk of OD and low side effect profile. Substances: Citalopram (CelexaВ®), Paroxetine (PaxinВ®), Fluoxetine (ProzacВ®), Sertraline (ZoloftВ®) Tricyclic Antidepressants TAD Can be self administered in a lethal overdose. Treatment of suicidal patients requires a reliable supervision. Substances: Amitryptiline (ElavilВ®), Clomipramine (AnafranilВ®), Desiramine (NorpraminВ®), Doxepin (SinequanВ®), Imipramine (TofranilВ®), Nortryptiline (PamelorВ®) and Trimipramine (SurmontilВ®) Atypical and tetracyclical Antidepressants Bupropion (WellbutrinВ®), Venlafaxine (Effexor), Mirtazapine (RemeronВ®), Duloxetine (Cymbalta) Monoaminoxidase Inhibitors MAOIвЂ™s Clients need to comply to Tyramin вЂ“ free diet as previously discussed. Otherwise risk of hypertensive crisis. Substances: Tranylcypromine (ParnateВ®), Phenelzine (NardilВ®) and Isocarboxid (MarplanВ®) Mood stabilizers Prescribed in Bipolar disorders. Lithium, Valproic acid (DepakoteВ®), Carbamazepine (TegretolВ®), Lamictal (LamotrigeneВ®), Gabapentin (NeurontinВ®), Topiramate (TopamaxВ®) and Olanzapine (ZyprexaВ®). Suicidal risk increases at first improving, euphoric effect of AD! End of Life Care Goal is to create an overall positive experience for client and family by accomplishing personal goals even with suffering and loss. Caregiver led advocacy with a meaningful and dignified death. Core principles for professional end of life care вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў Respect and dignity for client and caregiver. Sensitive and respectful approach to clients and relatives wishes. Appropriate measures that are consistent with clients choices. Highest priority is alleviation of pain and other physical complaints. Continuity of care. Providing of any therapy that realistically improves clients condition. Providing access to palliative care and hospice care. Respect right to refuse treatment. Respect physicians professional judgement and recommendation. Recognition that dying is a profoundly personal experience and part of life cycle. Principles of autonomy, privacy and veracity are fundamental to nursing practice! (Veracity = determination to be truthful)! 310 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Basic ethical principles for end of life care: Beneficience = ethical principal of doing good Nonmalefficience = first do no harm Justice = being fair Advance directives Based on the 1990 Client Self Determination Act. Enables client to make decisions about their end of life care before they come in to a situation where they might be unable to enter a decision making process. Euthanasia Deliberate end to life intervention; No appropriate action in accordance with the Code of ethics for Nurses and the American Nurses position statement. A consent decision to withdraw food and fluids and to discontinue life support to let a disease take its natural course is acceptable in accordance to the American Nurses Association, The Hospice and Palliative Nurses Association and the National Hospice and Palliative Care Organization. Physiological end of life care Management of symptoms Rest periods, light exercise to support circulation, treatment of anemia and fluid supply. Recognition of physical symptoms of nearing death Changes in neurological function Weakness and fatigue Increased drowsiness and sleeping Decreased oral intake Dehydration Hypernatremia Uremia Weakened swallow reflex Terminal restlessness and agitation Fever Bowel alterations Incontinence Providing psychosocial support Provide listening, understanding and communication to patient and family members. Postmortem care Close eyes, place dentures in mouth. Clean from any fluids and secretions released at time of death Remove tubes and drains Bathe body and pad drainage areas Apply gauze pack to anal orifice Align body and fold hands Pull a sheet over the body until family leaves, Keep ID in place Documentation of time of death, depositon of the body and personal belongings. Kubler Ross stades of Bereavement Denial Anger Bargaining Depression Acceptance 311 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com RandoвЂ™s Process of Bereavement 1. Recognize loss and death 2. Expression of separation and pain 3. Reminiscence 4. Relinquish old attachments 5. Readjust to adapt to the new role 6. Reinvest Psychiatric Medication Therapy Antipsychotics Are divided in two subgroups: Phenothiazines and atypical antipsychotic drugs. Phenothiazines: ( = вЂњtypicalвЂќ antipsychotic agents) Effect and therapeutic use: Phenothiazines are also called neuroleptic medication and were the first drugs used for treatment of different types of schizophrenia. These very complex drugs are used for treatment of other psychotic disorders as well. Some Phenothiazine types also have an antihistaminic and antiemetic effect. In general Phenothiazines rarely induce a tolerance and treatments can be pursued for many years if necessary and if no side effects occur. Neuroleptic medication has to be administered in defined dosages and punctual over a circadian rhythm to establish a significant blood level of the particular substance. Phenothiazines are Dopamine antagonists as well as anticholinergic drugs. The different types of antipsychotic drugs differ in their antipsychotic and sedating effect. The weaker the antipsychotic effect is, the stronger is the sedating effect. Side effects: Anticholinergic effects - Dry mouth - Urine retention - Photophobia - Constipation - Tachycardia - Hypertension - Blurred vision Extrapyramidal side effects вЂњESPEвЂ™sвЂќ Akathisia Dystonias Disability to sit still. Torticollis, tongue and pharyngeal cramps, oculogyric crisis. Parkinsonism Picture of symptoms equivalent to ParkinsonвЂ™s disease (Tremor, rigor and akinesia) Tardive dyskinesia abnormal involuntary movements 312 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Neuroleptic malignant syndrome Rigidity - Labile blood pressure - Hyperthermia вЂ“ Sweating - DyspneaIncontinence вЂ“ Agranulocytosis вЂ“ Gynecomastia вЂ“ Galactorrhea вЂ“ Sedation вЂ“ Tradive diskinesia вЂ“ Seizures - Galactorrhea Special considerations: Occasional lack of compliance among clients with psychotic disorders may require surveillance to assure that medication is being taken. Otherwise intramuscular depot injections may be indicated. Clients also require frequent laboratory studies and neurological examinations. Antipsychotics administered as Depot injections may stabilize clients condition over long time frames. Establishment of full effect may take up to 6 weeks. Orthostatic Hypotension may occur. Urine color may change into light pink. Oral phenothiazine medication can be administered with food, milk or water. Avoid skin contact with injectable phenothiazine medication. Do not supply large amounts of medication because of possibility of lethal overdose. Substances: Chlorpromazine (ThorazineВ®), Triflupromazine (VesprinВ®), Fluphenazine (ProlixinВ®), Perphenazine (TrilafonВ®), Trifluoperazine (StelazineВ®), Thiothixene (NavaneВ®), Haloperidol (HaldolВ®), Molindone (MobanВ®) and Loxapine (LoxitaneВ®) Atypical antipsychotic drugs (Clozapine, Risperidone and Olanzapine) Effect and therapeutic use: These medications block Serotonin as well as Dopamin receptors of the cenral nervous system and show effect against positive and negative treatments of schizophrenia. Especially in early stages, as well as against other psychotic and mood disorders. In comparison to typical antipsychotics these substances show little or no extrapyramidal side effects at all! Special considerations: Olanzapine (ZyprexaВ®) Induces significant weight gain. Moderate anticholinergic side effects. Max. dosage = 15 mg/d. Clozapine (CloxarilВ®) Agranulocytosis! Clients require weekly CBC! Maximum dosage = 900 mg/d. Seizures. Risperidone (RisperdalВ®) Hypotension, Insomnia, Agitation, Headache, Anxiety and Rhinitis. Antidepressants Tricyclic Antidepressants (TCA) Effect and therapeutic use: TCAвЂ™s block the reuptake of stimulating monoamine Neurotransmitters. 313 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Therapeutic effect may take up to 3 weeks. Indicated in depression, attention deficit disorder, panic disorder and chronic insomnia. Increase appetite, regulate sleep pattern, elevate mood and increase of physical activity. All TCA substances have equal potency and effect but differ concerning their side effects. Common duration of treatments is up to 12 months. TCA can not be combined with Monoamine oxidase uptake inhibitors or with direct acting sympathomimetiscs (i. e. epinenephrine and norepinephrine). Side effects and special considerations: Orthostatic hypotension, sedation due to blockade of CNS histamin receptors, anticholinergic effect, cardiotoxicity (slowing intracardial conduction), lowering of seizure threshold, hypomania and sexual dysfunction. TCAвЂ™s weaken effect of indirect acting sympathomimetics (Ephedrine and Amphetamine) Combination with direct acting sympatomimietics (i. e. epinephrine and norepinephrine) or Monoaminoxidase Inhibitors (MAOIвЂ™s) can lead to a severe hypertensive reaction. Suicidal patients need to remain under surveillance in an inpatient setting, especially in the beginning of the treatment with TCAвЂ™s. Substances: Amitryptiline (ElavilВ®), Clomipramine (AnafranilВ®), Desipramine (NorpraminВ®), Doxepin (SinequanВ®), Imipramine (TofranilВ®), Trimipramine (SurmontilВ®), Nortryptiline (PamelorВ®). Monoaminoxidase Inhibitors MAOIвЂ™s Effect and therapeutic use: Monoaminoxdase inhibitors can cause severe side effects by food and drug interactions and are therefore not a first choice of medication. Prescribing requires a detailed instruction of the client on dietary regulations. Effect is caused by inhibition of Tyramine and other biogenic amines and monoamine transmitters. Indications are treatment of depression, bulimia, obsessiveвЂ“compulsive disorders and panic disorders. Combination with other sympathomimetic medications may lead to a hypertensive crisis. Patients under treatment with MAOIвЂ™s are required to avoid Tyramine containing food Aged cheeses: e. g. Roquefort, camembert, blue and brie cheese; aged and cured meat and fish, tofu, soy, draft beer, chianti wine, sauerkraut, yeast extracts and canned soups. Medication to avoid under MAOI treatment: Nasal decongestants, other antidepressant medication, antihistamines, asthma medication, narcotics, (mepridine), epinephrine, cocaine and amphetamines. Food to consume with caution under treatment with MAOIвЂ™s: Mozzarella, cottage, ricotta, cream, processed food, liver, meats, herring, raspberries, bananas, avocado, spinach, wine, glutamate, pizza, chocolate, caffeine, nuts and dairy products. Insulin, oral Antidiabetics, oral anticoagulants, thiazide diuretics, anticholinergic agents and muscle relaxants. Substances Phenelzine (NardilВ®) and Tranylcypromine (ParnateВ®) 314 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Selective Serotonine Reuptake Inhibitors (SSRI) Effect and therapeutic use: Shorter duration (1-3 weeks) until onset of therapeutic effect and less side effects than MAOI and TCA Antidepressants. SSRI block reuptake of Serotonine. Indications are Depression, obsessive-compulsive disorder, panic disorder and bulimia nervosa. Special considerations: Contraindicated in hepatic or renal disease. SSRI have a high tendency to bind to plasma proteins. Interaction with other medication with same characteristics have to be expected. Especially Warfarin levels may be affected. Frequent CBC and bleeding time assessments are required. Changing from SSRI to MAOI requires at least 2 weeks to elapse, before medication can be started. Changing from MAOI to SSRI require at least 5 weeks to elapse. SSRI and MAOI can not be combined since their synergetic effects may cause a Serotonine syndrome. Suicidal patients need to remain under surveillance in an inpatient setting especially in the beginning of the treatment with SSRI. Substances: Citalopram (CelexaВ®), Escitalopram (LexaproВ®), Fluoxetine (ProzacВ®), Fluvoxamine (LuvoxВ®), Paroxetine (PaxilВ®) and Sertraline (ZoloftВ®) Other Antidepressants Bupropion Effect and therapeutic use: Chemically related to amphetamines. Blocks reuptake of Dopamin in CNS. Suppressing Appetite. Well suitable for elderly patients due to less anticholinergic side effects in comparison to other antidepressants. Used for smoking cessation therapy as well. Side effects/special considerations: Agitation and insomnia are most common side effects. Especially in clients with a history of bipolar disorder. Dose related seizures also common. Dosage adaptation by age and renal or hepatic impairment necessary. Trazodone Effect and therapeutic use: Second line treatment for depression, mainly used in combination with other antidepressants. Slow onset of antidepressant effect by altering effect of Serotonin in CNS. Side effects/special considerations: May cause Dyrhytmias, cardiac assessments prior and during therapy are frequently necessary. Trazodone may cause gastrointestinal side effects and therefore has to be taken immediately after meals. Patients under Trazodone and Bupropion have to be carefully assessed for suicidal tendencies in early phase of the treatment. Antimania Medications Lithium Effect and therapeutic use: Long Term prophylaxis in recurrent manic depression. Control of manic episodes in bipolar disorders. Altering stimulating neurotransmitters in a not fully explored way. The Antimania effect appears after 5вЂ“7 days and full effect after 3 weeks. 315 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Contraindications: Dementia, dehydration, elderly clients. Preexisting hepatic or renal failure, cardiac disease, thyroid gland disorder and diabetes mellitus. Side effects/special considerations: Treatment requires close monitoring of blood level, every 1-2 month and as required. Normal Level: 0.8вЂ“1.4 mEq/L. Levels alter with sodium excretion. High sodium excretion leads to an increased lithium excretion. Loss of sodium through dehydration may cause lithium toxicity. Treatment requires at least 2000вЂ“3000 mL fluids/d. and input/output monitoring. Missed doses to be taken as soon as remembered unless 2 hours prior next dose (6 hours if MR). Clients > 40 require ECG Assessment. High amounts of Caffeine have to be avoided because of diuretic effect! Lithium toxicity Mild toxicity: (from 1.4 mEq/L) lethargy, muscle weakness, tremors, ataxia. Moderate toxicity: (1.5 вЂ“ 2.5 mEq/L) Gastrointestinal symptoms, blurred vision, tinnitus. Severe toxicity: (> 2.5 mEq/L) Nystagmus, hyperreflexia, impaired LOC, hallucinations, renal failure and death. Sedatives, Hypnotics and Anxiolytics Benzodiazepines Effect and therapeutic use: Inhibitory GABA ReceptorвЂ“Agonists. Medication has pharmacological active metabolites which ensure a longlasting effect. Indications: anxiety, insomnia, seizures, alcohol withdrawal and skeletal muscle relaxation. Contraindicated in lactation and pregnany as well as in any condition that causes hepatic impairment. Addictive potential. No abrupt withdrawal after long term treatment. Can cause paradox effects especially in elderly clients. Substances: Alprazolam (XanaxВ®) , Chlordiazepoxide (LibriumВ®), Clonazepam (KlonopinВ®) Clorazepate (TranxeneВ®), Diazepam (ValiumВ®), Flurazepam (DalmaneВ®), Lorazepam (AtivaneВ®), Midazolam (VersedВ®), Triazolam (HalcionВ®), Oxazepam (SeraxВ®) and Temazepam (RestorilВ®) Benzodiazepine Antagonist Flumazenil (RomaziconВ®) Reverses all effects of Benzodiazepines but the respiratory depression. Substance becomes immediately active after intravenous administration. Sedation can reoccur for up to two hours after administration. May cause acute Benzodiazepine withdrawal syndrome, including seizures, confusion, agitation, nausea, dizziness and paresthesias. Barbiturates Unspecific CNS Depression. Used for sedation, seizure treatment and general anesthesia. Addictive potential. Not to be administered by intramuscular because of the danger of muscle necrosis due to alkaline solution! Effect is depending on dosage in the order of sedation sleep general anesthesia. Cardiovascular depression due to effect on heart muscle and smooth vascular muscle. Overdose 316 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com symptoms are similar to Morphine overdose = Coma, Miosis and Respiratory Depression. Women require nonhormonal birth control during treatment. Can cause pain syndromes and paradox effects, esp. in elderly clients. Substances : Amobarbital (AmytalВ®), Butabarbital (ButisolВ®), Pentobarbital (NembutalВ®) Phenoparbital (Luminal) В® and Secobarbital (SeconalВ®) Buspirone Anxiolytic medication. Binds to Dopamine and Serotonine Receptors. Increases Norepinephrine metabolism in the central nervous system. Nonsedative character. No abuse or addictive potential. No CNS Depression. May cause dizziness, nausea, headaches, nervousness and dystonia. Zolpidem GABA Agonist. Used for short term and on demand treatment of insomnia. Rapid onset of action. Comparable to Benzodiazepines. 317 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Normal reference ranges for laboratory test results UNITS: Mass concentration (g/dL or g/L) is the most common measurement unit in the United States. Liters are usually given with dL (decilitres). Molar concentration (mol/L) is used to a higher degree in most of the rest of the worldincluding the United Kingdom and other parts of Europe and Australia. Laboratory Test Normal Range in US Units Normal Range in SI Units ALT (Alanine aminotransferase) W 7-30 units/liter M 10-55 units/liter W 0.12-0.50 Вµkat/liter M 0.17-0.92 Вµkat/liter Albumin 3.1 - 4.3 g/dl 31 - 43 g/liter Alkaline Phosphatase W 30-100 units/liter M 45-115 units/liter W 0.5-1.67 Вµkat/liter W 0.75-1.92 Вµkat/liter Amylase (serum) 53-123 units/liter 0.88-2.05 nkat/liter AST (Aspartate aminotransferase) W 9-25 units/liter M 10-40 units/liter W 0.15-0.42 Вµkat/liter M 0.17-0.67 Вµkat/liter Basophils 0-3% of lymphocytes 0.0-0.3 fraction of white blood cells Bilirubin - Direct 0.0-0.4 mg/dl 0-7 Вµmol/liter Bilirubin - Total 0.0-1.0 mg/dl 0-17 Вµmol/liter C peptide 0.5-2.0 ng/ml 0.17-0.66 nmol/liter Calcium, serum 8.5 -10.5 mg/dl 2.1-2.6 mmol/liter Calcium, urine 0-300 mg/24h 0.0-7.5 mmol/24h Cholesterol 200 mg/dL 5.0 mmol/liter Cholesterol, LDL 190 mg/dL 4.91 mmol/liter Cholesterol, HDL > 60 mg/dL > 1.0 mmol/l Creatine kinase W 40-150 units/liter M 60-400 units/liter W 0.67-2.50 Вµkat/liter M 1.00-6.67 Вµkat/liter Eosinophiles 0-8% of white blood cells Erythrocyte sedimentation rate W<=30 mm/h M<=20 mm/h W<=30 mm/h M<=20 mm/h Folate 3.1-17.5 ng/ml 7.0-39.7 nmol/liter Glucose, urine <0.05 g/dl <0.003 mmol/litro Glucose, plasma 70-110 mg/dl 3.9-6.1 mmol/liter GGT (Gamma glutamyl transferase) W <=45U/L M <=65 U/L W <=45U/L M <=65 U/L 318 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Hematocrit W 36.0% - 46.0% M 37.0% - 49.0% of red blood cells W 0.36-0.46 M 0.37-0.49 fraction of red blood cells Hemoglobin W 12.0-16.0 g/dl M 13.0-18.0 g/dl W 7.4-9.9 mmol/liter M 8.1-11.2 mmol/liter LDH (Lactate dehydrogenase) (total) <=270 U/L <=4.5 Вµkat/liter Lactic acid 0.5-2.2 mmol/liter 3 3 0.5-2.2 mmol/liter 4.5-11.0x109/liter Leukocytes (WBC) 4.5-11.0x10 /mm Lymphocytes 16%-46% of white blood cells 0.16-0.46 fraction of white blood cells Mean corpuscular hemoglobin (MCH) 25.0-35.0 pg/cell 25.0-35.0 pg/cell Mean corpuscular hemoglobin concentration (MCHC) 31.0-37.0 g/dl 310-370 g/liter MCV (Mean corpuscular volume) W 78-102 Вµm3 M 78-100 Вµm3 W 78-102 fl M 78-100 fl Monocytes 4-11% of white blood cells 0.04-0.11 fraction of white blood cells Neutrophils 45%-75% of white blood cells 0.45-0.75 fraction of white blood cells Phosphorus 2.5 вЂ“ 4.5 mg/dL 0.81-1.45 mmol/L Platelets (Thrombocytes) 130 вЂ“ 400 x 10 3ВµL 130 вЂ“ 400 x 10 9L Potassium 3.4-5.0 mmol/liter 3.4-5.0 mmol/liter RBC W 3.9 вЂ“ 5.2 x 106/ВµL3 M 4.4 вЂ“ 5.8 x 10 6/ВµL3 W 3.9 вЂ“ 5.2 x 1012/L M 4.4 вЂ“ 5.8 x 10 12/L Sodium 135-145 mmol/liter 135-145 mmol/liter Triglycerides 40-200 mg/dl 0.45 - 2.26 mmol/liter Urea, plasma (BUN) 8-25 mg/dl 2.9-8.9 mmol/liter Urinalysis - pH Specific gravity 5.0-9.0 1.001-1.035 5.0-9.0 1.001-1.035 WBC (White blood cells, leukocytes) 4.5-11.0x10 3 /mm 3 4.5-11.0x10 9 liter 319 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com KEYWORD REVIEW Baseline knowledge requirements of the NCLEX-RNВ® Index of content related keywords Safe and effective care environment Management of care p. 9 - 14 Advance Directives Advocacy Case Management Client Rights Collaboration with interdisciplinary Team Concepts of Management Confidentiality / Information Security Consultation Continuity of Care Delegation Establishing Priorities Ethical Practice Informed Consent Information Technology Legal Rights and Responsibilities Performance Improvement (Quality Improvement) Referrals Resource Management Staff Education Supervision Safety and infection control p. 15 - 21 Accident Prevention Disaster Planning Emergency Response Plan Ergonomic Principles Error Prevention Handling Hazardous and Infectious Materials Home Safety Injury Prevention Medical and Surgical Asepsis Reporting of Incident/Event/Irregular Occurrence/Variance Safe Use of Equipment Security Plan Standard/Transmission-based/Other Precautions 320 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com Health Promotion and Maintenance p. 21 - 74 Aging Process Ante/Intra/Postpartum and Newborn Care Developmental Stages and Transitions Disease Prevention Expected Body Image Changes Family Planning Family Systems Growth and Development Health and Wellness Health Promotion Programs Health Screening High-Risk Behaviors Human Sexuality Immunizations Psychosocial Integrity p. 294 вЂ“ 312 Abuse / Neglect Behavorial Interventions Chemical and Other Dependencies Coping Mechanisms Crisis Intervention Cultural Diversity End вЂ“ of вЂ“ Life Care Family Dynamics Grief and Loss Mental Health Concepts Psychopathology Religious and Spiritual influences on Health Sensual / Perceptual Alterations Situational Role Changes Stress Management Support Systems Therapeutic Communications Therapeutic Environment Physiological Integrity p. 105 - 177 вЂў Basic Care and Comfort p. 105 - 117 Assistive Devices Complementary and Alternative Therapies Elimination Mobility / Immobility Non вЂ“ Pharmacological Comfort Interventions Nutrition and Oral Hydration Palliative / Comfort Care Personal Hygiene Rest and Sleep 321 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com вЂў Pharmacological and Parenteral Therapies p. 133 - 144 Adverse Effects / Contraindications and Side Effects Blood and Blood Products Central Venous Access Devices Dosage Calculation Expected Effects / Outcomes Medication Administration Parenteral / Intravenous Therapies Pharmacological Agents / Actions Pharmacological Interactions Pharmacological Pain Management p. 46; 249;277 Total Parenteral Nutrition вЂў Reduction of Risk Potential p. 74 - 105 Diagnostic Tests Laboratory Values Monitoring Conscious Sedation Potential for Alterations in Body Systems Potential for Complications of Diagnostic Tests Potential for Complications from Surgical Procedures and HealthAlterations System Specific Assessments Therapeutic Procedures Vital Signs вЂў Physiological Adaptation p. 15 вЂ“ 21 Alterations in Body Systems Fluid and Electrolyte Imbalances Hemodynamics Illness Management Infectious Diseases p. 157 - 166 Medical Emergencies Pathohysiology p. 145 - 319 Radiation Therapy 322 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com QUESTION REVIEW NCLEX-RNВ® practice exam questions and answers 1. Which of the following characteristics is not part of the elements of nursing practice as defined by the National Council of State Boards of Nursing? A) B) C) D) E) Caring Communication Teaching Documentation Consideration of treatment options p. 9 2. A 30 year old female client is admitted to a hospital for a controlled alcohol withdrawal treatment. Prior to the supply of the appropriate oral medication the nurse has forgotten to collect urine for a pregnancy test. Which of the following legal terms describes this situation most accurately? A) B) C) D) Negligence Malpractice False imprisonment Battery p. 10 3. Ethics, Morals and Values of nursing practice are based on which of the following principles? A) B) C) D) E) Autonomy Beneficence Justice Confidentiality All principles apply p. 9 4. A client is admitted to the Emergency Room because of a sudden severe chest pain. The attending nurse considers his complaints as not being typical for a serious condition and delays routine diagnostic assessments. Later this client experiences a massive myocardial infarction. Which form of liability applies under the described circumstances? A) B) C) D) E) Negligence Malpractice Assault Battery Invasion of privacy p. 10 5. A client files a complaint against a nurse because of an inappropriate approach in an examination setting. He states that the nurse started a physical assessment without obtaining the clients consent first. Which form of liability applies in this case? A) B) C) D) E) Battery Invasion of privacy Fraud Defamation of character False Imprisonment p. 10 323 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 6. A nurse rejects maintaining standard infection precautions prior to the start of an intravenous therapy. The client later suffers from a severe systemic infection. The nurse may face legal charges because of: A) B) C) D) E) Defamation of character Malpractice Battery Negligence Assault p. 10 7. A doctor starts a physical examination without obtaining the patients consent first. Which form of liability applies in this case? A) B) C) D) E) Defamation of character Malpractice Battery Negligence Assault p. 10 8. Which of the following principles of professional nursing does not apply? A) B) C) D) E) Empathy Open and honest communication Personal statement about clients condition and prognosis Promotion of clients independence Holistic care p. 9 9. An unconscious adult client is admitted to a surgical unit with a life threatening injury which requires immediate surgical intervention. Which of the following statements describes the performance appropriately? A) No treatment can be performed without an informed consent from this client. B) It is necessary to find this clients relatives to obtain an informed consent prior to any treatment. C) Informed consent is not a requirement in this case. D) No treatment is necessary if this clients condition results from a suicide attempt. E) Informed consent is not required for surgical procedures. p. 10 10. Which of the following individuals in a therapeutic team is obligated to maintain confidentiality about a clientвЂ™s condition? A) Psychotherapist B) Physiotherapist C) Nurse D) Doctor E) All of these professionals p. 10 11. Which of the following statements about a health care proxy is correct? A) A competent client who has filed a health care proxy should still make healthcare decisions. B) A health care proxy requires an agent to execute the decisions that are stated in the health care proxy. C) The legal term of a health care proxy is power of attorney. D) A health care proxy has to be followed once the client loses his or her ability to communicate. E) All of the statements are correct. p. 10 324 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 12. In which of the following cases does a healthcare professional violate a clients right for confidentiality? A) Discussing a clients physical complaints with another healthcare professional who is also involved in this clients treatment and care. B) Telling a visiting colleague who is not involved in this clientвЂ™s treatment personal details about a client. C) Sharing clinical observations with other healthcare professionals on the ward during a nursing round. D) Reporting suicidal ideas of a client to the health care provider. E) Transferring a clients medical record to another department of the hospital where this client will receive treatment. p. 10 13. Please choose the statement which identifies the criteria of clinical death accurately. A) B) C) D) E) No brainwaves, no spontaneous breathing and no sensomotoric reflexes No spontaneous breathing, miosis and lack of bowel sounds No brainwaves, flat line ECG and mydriasis No arousable to any stimulus, absence of DTRвЂ™s and hypoxemia No audible heart sounds, no spontaneous breathing and midriasis p. 11 14. Which of the following statements concerning safeguarding a clients autonomy and liberty applies? A) An involuntary hospital admission under the Mental Health Act is only justified in cases of selfвЂ“or public endangerment. B) Informed consent must not be obtained at all from a client who was involuntarily admitted to a psychiatric unit. C) It is generally impossible for the average client to choose from different treatment options. D) A clients autonomy is generally restricted in a healthcare setting. E) A client is not allowed to leave a hospital without approval of the healthcare provider. p. 10 15. Which of the following incidents in a healthcare setting must not be reported to external agencies? A) Lack of health insurance coverage of a client B) Sexual harassment C) Evidence of communicable diseases D) Unsafe work conditions E) Evidence of crimes p. 11 16. A Healthcare management system offers healthcare coverage and delivers a defined package of medical services. The voluntary enrolled members are required to make periodic payments to maintain health insurance coverage and are only eligible to receive treatment within this network. Services that can not be offered within this network require a referral or can be denied. This type of health care setting is considered as a: A) Preferred Provider Organization (PPO) B) Health Maintenance Organization (HMO) C) Case Management D) Private Health Insurance E) Point of Service System (POS) p. 11/12 325 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 17. Which of the following nursing care delivery systems is considered as the most cost efficient and therefore most widely used? A) Shared governance models of practice B) Primary Nursing C) Team Nursing D) Functional Nursing E) All of the above named nursing care delivery systems have equal cost efficiency. p. 12 18. Which of the following situations requires the most immediate attention of an attending nurse? A) A client complaints about shortness of breath. B) A surgical client appears with an acute postoperative bleeding. C) A client is complaining of dysuria. D) Administering of an intravenous therapy at a defined time as ordered. E) Providing essential discharge instructions to a client with previously uncontrolled diabetes. p. 12/13 19. Please identify the activity with the least urgency. A) B) C) D) E) Providing preventive medication therapy. Following specific agency procedures. CPR treatment. Comforting a client in acute emotional distress. Assessment of a client with acute chest pain. p. 13 20. Which of the following priority of care schemes can be considered as the one with the highest priority? A) ABC B) Care related to client acuity. C) Time D) Priorities in medication therapy E) MaslowвЂ™s Hierarchy of needs p. 13 21. MaslowвЂ™s Hierarchy of Needs considers which of the following priorities in client care? A) Safety and security B) Immediate tasks C) Medication for acute physical distress D) ABCвЂ™s E) Agency specific urgent response policy p. 12 22. An obese male client with a severe and ongoing gastrointestinal bleeding is admitted to the Emergency Room. He is awake and responding on arrival. Which of the following tasks of the attending nurse has the highest priority. A) Assessment of vital signs. B) Administering intravenous fluid supply. C) Assessment of hemoglobin level. D) Obtaining informed consent for an EGD. E) Providing emotional support. p. 13 326 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 23. The nursing staff on a surgical ward suddenly experiences an unexpected amount of admissions due to a mass accident. The team leader nurse has to delegate the staff to meet which of the following priorities under any circumstances? A) Meeting the physiological needs of all clients on the ward. B) Routine client and family requests. C) Administering and maintaining medication. D) Fulfillment of scheduled tasks within one shift. E) Providing emotional and psychosocial support. p. 13 24. Which of the following clinical situations has the highest priority in terms of urgency? A) B) C) D) Insertion of an urinary catheter Administering total parenteral nutrition Bleeding from a surgical wound Pain of a fractured leg p. 13 25. Which of the following examples for the delegation of nursing care duties, applies most appropriately to the rules of delegation? A) B) C) D) Delegating nursing rounds to nurseвЂ™s aids Delegating client education to relatives Delegating the care for a client with acute pain to an intern Delegating the review of medical records to a newly qualified RN p. 14 26. A female and otherwise healthy client on a gynecological ward experienced a spontaneous abortion in the 9th gestational week and was admitted to the hospital. The attending nurse would consider which of the following care specifics as the most appropriate in order to the priorities of care for this client in an acute emotional distress? A) Providing emotional support. B) Instructing the client that an unhealthy lifestyle is the most common cause of spontaneous abortions. C) Assessment of the clients health history. D) Instructing the client about the further procedure. E) Preparing the client for immediate surgery. p. 13 27. Which of the following needs is considered as the one with the highest priority in a client care setting? A) Oxygenation need B) Nutritional need C) Bowel elimination need D) Need for sleep E) Urinary elimination need p. 13 28. Which of the following statements about appropriate delegation of nursing duties is correct? A) Delegation must reduce responsibility of the delegating nurse. B) Supervision is generally unnecessary once a task is delegated. C) Any RN is able to perform any task that a team leader RN delegates. D) Delegation requires clear and directed communication. E) Delegation includes authority and ultimate responsibility for the delegated task. p. 13/14 327 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 29. Which of the following criteria is not defined as one of the five rights of delegation in nursing care? A) Right client B) Right task C) Right supervision D) Right directions E) Right circumstances p. p. 14 30. Which of the following conditions of a client is considered mandatory to start a cardiopulmonary resuscitation (CPR) immediately? A) B) C) D) E) Shortness of breath and chest pain ECG wave suspicious for a myocardial infarction BP 50/80 mmHg, HR 45 bpm Unresponsiveness, weak pulses and shallow breathing. Unconsciousness, not moving, not breathing or taking occasional gasps p. 16 31. Which statement about correct airway management in a CPR situation is correct? A) Prior to the start of a CPR the rescuer should always perform a finger sweep of the oropharynx to detect a possible foreign body airway obstruction. B) The head tilt-chin lift maneuver is the appropriate method to open the airway of the victim. C) Mouth to Nose Ventilation is unacceptable and ineffective. D) Chest thrusts, back blows/slaps, or abdominal thrusts are appropriate to perform at any age to remove a suspected foreign body from the airways. E) Mouth to Mouth Ventilation is considered as effectful as ventilation via an advanced airway. p. 16 32. Which of the following statements about chest compressions in a CPR situation is incorrect? A) During chest compressions any position of the compressing hand is equally effective as long as the procedure leads to a significant compression of the sternum. B) Dominant and non-dominant hand should be placed in the center of the sternum. C) Victims should be placed on a firm surface. D) The effectiveness of chest compressions can be verified by palpation of the femoral pulses of the victim, if two rescuers are available. E) A compression вЂ“ ventilation ratio of 30:2 in a CPR is recommended. p. 17 33. Please check the following statements on cardiopulmonary resuscitation (CPR) for correctness and mark the appropriate correct answer. A) A CPR victim can receive chest compressions in a prone position if a supine position can not be accomplished. B) An unconscious client with normal breathing should be positioned on the side with the lower arm in front of the body. C) During CPR rescuers should limit any interruptions. D) It may be necessary to move a victim in need of CPR into an adequate position even if there is a suspicion of a spinal cord injury. E) All statements are correct. p. 17 328 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 34. Which of the following conditions requires the immediate start of a cardiorespiratory resuscitation treatment? Select all that applies. 1. 2. 3. 4. Pulselessness Unresponsiveness Weak but adequate response Occasional gasps of an unresponsive individual A) B) C) D) E) 1, 2 and 3 are correct. 1 and 4 are correct. Only 4 is correct. All statements are correct None of these situations require an immediate CPR treatment. p. 16 35. Which of the following factors is not a mandatory requirement for the development of an infection? A) B) C) D) E) Infective agent Reservoir Transmission Portal of entry Previous antibiotic medication therapy p. 19 36. Which of the following procedures is not required to maintain standard hand hygiene in order to the first tier of CDC Guidelines of infection control? A) B) C) D) E) Hand hygiene before and after each contact Hand hygiene immediately after exposure Repeated hand hygiene every ten minutes Use of waterless alcohol based hand scrub Use of plain soap p. 19 37. Which of the following orders of using personal protective equipment is correct? A) B) C) D) E) Hand hygiene first Gown mask googles gloves at last Gown first mask googles hand hygiene gloves at last Gloves first mask hand hygiene gown googles at last Hand hygiene first Gown mask gloves googles at last None of the above orders are correct. p. 19 38. Depending on the cause of infections personal protective equipment for infection control is required in the following order: A) B) C) D) E) Gloves Gown Mask Googles Gown Mask Gloves Googles Gloves Mask Gown Googles Mask Gloves Gown Googles Googles Gloves Gown Mask p. 19 39. Which of the following orders of removing personal protective equipment are correct? A) B) C) D) E) Gloves mask gown googles Mask gown googles gloves Googles gown mask gloves Gloves hand hygiene googles None of the above orders of removing p. 19 hand hygiene hand hygiene hand hygiene gown mask personal protective equipment are correct? 329 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 40. Which description does not apply to the term of medical asepsis? A) B) C) D) E) Differentiation between вЂњcleanвЂќ and вЂњdirtyвЂќ objects. Donning of gloves only in cases of infectious diseases. Hand hygiene before and after using gloves. Invasive procedures require additional sterile precautions. None of these descriptions apply for medical asepsis. p. 19 41. Which of the following statements about disposal of contaminated equipment is correct? A) B) C) D) E) Detached needles need to be recapped prior to their disposal. Any medical equipment has to be considered as a potential biohazard. Linens have to be collected in a bag prior to their removal from a clients room. Used medical equipment does not have to be discarded immediately. Used, non-disposable medical equipment can be collected throughout a shift and then cleaned and decontaminated. p. 19 42. A client on a surgical ward was diagnosed with MRSA colonization. Which of the following statements of infection control are correct? A) Prevention of contaminating nursing scrubbs with moist, wet body substances as well as with secretion from wounds and mucous membranes is of highest priority. B) Hand washing is not a primary precaution since nasal carriage is the most common mode of MRSA contamination. C) A MRSA colonized client can be placed in a room with a nonвЂ“colonized client with an open wound if no other room is available. D) Infection and Colonization with MRSA lead to identical therapeutic consequences. p. 20 43. Which of the following statements describes the term вЂњmedical asepsisвЂќ most appropriately? A) Sterility indicators are required. B) Procedures consider вЂњcleanвЂќ and вЂњdirtyвЂќ objects. C) Equipment can be used for invasive treatment. D) Surgical caps are mandatory to be worn. E) Using personal protective equipment is not required. 44. Principles of surgical asepsis include. A) B) C) D) E) p. 19 Any unsterile contact has to be avoided. Moisture drafts bacteria. Report of any contamination of sterile objects Sterile items ready to use have to be in view. All principles apply. p. 19/20 45. Airborne infection precautions apply in which of the following cases? A) B) C) D) E) Clients with Rubeola, TBC and Varicella infections Any bacterial infection Hepatitis B infections Cohorting of clients with different airborne infections Airborne precautions also include contact precautions p. 20 330 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 46. Please identify the anatomical structure where the fertilization of an ovum takes place. A) B) C) D) E) Uterus Cervix Ampulla of fallopian tube Infundibulum of fallopian tube Ovary p. 22 47. Which of the following statements about the oogenesis is correct? A) B) C) D) E) Oocytes are entirely present at birth. FSH stimulates differentiation of an oocyte into an ovum. LH supports the development of the corpus luteum. The Corpus Luteum produces progesteron. All of the above statements are correct. p. 22 48. A sexual hormone is produced and excreted by ovaries. It reaches its peak levels in the follicular phase of the menstrual cycle and inhibits the secretion of luteinizing hormone and follicle stimulating hormone. This description applies to which of the following hormones? A) B) C) D) E) Estrogene Progesterone Testosterone Gonadotropine releasing hormone None of the above named hormones p. 23/24 49. A 29 year old women was diagnosed with a Corpus Luteum insufficiency. This condition leads to a reduced production of which of the following hormones? A) B) C) D) E) Estrogene Luteinizing hormone Follicle stimulating hormone Progesterone Prolaktin p. 23 50. Which of the following characteristics describes the function of the Corpus luteum most accurately? A) B) C) D) Supply of estrogene Termination of pregnancy High levels of FSH throughout the entire menstrual cycle Maintaining an early pregnancy p. 22 51. Which of the following conditions have to be met for the development of an erythroblastosis fetalis? A) B) C) D) Mother: Rhesus negative, Child: Rhesus positive. Mother: Rhesus negative, Child: Rhesus negative. Mother: Rhesus positive, Child: Rhesus positive. Mother: Rhesus negative, Father: Rhesus negative. p. 30 331 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 52. A 36 year old and otherwise healthy women is expecting her first child. Which of the following recommendations should the attending nurse make in a first antenatal assessment? A) B) C) D) Recommendation for an Amniocentesis between in the 16th gestational week. No recommendations at all since the client is healthy. Recommendation for a Caesarean delivery under any circumstances. Recommendation to treat even severe bacterial infections during pregnancy without antibiotics. p. 37 53. Which of the following female sexual hormones is expected to produce its peak levels at the time of an ovulation? A) B) C) D) E) Luteinizing hormone Progesterone Prostaglandine Estrogen Follicle stimulating hormone p. 23 54. Please identify the most accurate description of the physiological function of the Corpus Luteum. A) The Corpus Luteum provides the production of progesterone and supports a pregnancy. B) A functioning Corpus Luteum is not mandatory for the survival of an early pregnancy. C) The persistence of the Corpus Luteum is not depending on the fertilization of an ovum. D) A Corpus Luteum weakness does not interfere with fertility. E) None of the statements describe the physiological function of the Corpus Luteum correctly. p. 22 55. Which of the sequences below describe the most immediate developments after fertilization of an ovum? A) B) C) D) E) Cleavage blastocyst morula trophoblast implantation Blastocyst morula trophoblast conception Trophoblast morula blastocyst implantation Conception trophoblast morula cleavage blastocyst Implantation cleavage conception p. 22 56. Which of the following statements about the normal menstrual cycle is incorrect? A) A menstruation occurs if the ovum is not fertilized and the Corpus Luteum disintegrates. B) Estrogen and progesterone levels drop in the last week of the menstrual cycle. C) Day 1 вЂ“ 14 of the menstrual cycle is considered as the follicular phase. D) Day 15 вЂ“ 28 of the menstrual cycle is considered as the luteal phase. E) The luteal phase can drastically vary in length and determines the overall duration of the menstrual cycle. p. 23 332 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 57. An amenorrhea for more than one year in a women of 50 years of age is suspicious for which of the following conditions? A) B) C) D) E) Uterine cancer Menopause Hypothyroidism Ovarian cysts Diabetes p. 24 58. A 27 year old man underwent a semen analysis to assess his fertility. The results are as follow: вЂў вЂў вЂў Semen 2,6 ml 8 Million Sperm /ml. 50% of normal form and motion Which of the following conclusions can be drawn from this information: A) B) C) D) E) The results show an abnormal amount of Sperm and Semen. These results are characteristic for an untreatable infertility. No relevant statement about this clientвЂ™s fertility can be made from these results. The client can be assured about a normal result of his semen analysis. This client probably produces a significant amount of estrogen. p. 24 59. Common methods of fertility assessment do not include: A) B) C) D) E) Basal Body Temperature Cervical mucus monitoring Laparascopy Male semen analysis Fallopian tube biopsies p. 25 60. Mandatory counseling as a legal requirement prior to a termination of pregnancy has to include: A) B) C) D) E) Benefits Alternatives Explanations of medical term Documentation All above named factors are required to be addressed p. 26 61. Which of the following statements about contraception methods is correct? A) B) C) D) E) All available contraceptives have the same PearlвЂ“Index. Female condoms can be used in cases of latex allergy. Diaphragm and cervical caps protect reliably against STIвЂ™s. Copper intrauterine devices have to be changed once yearly. All statement are incorrect. p. 26-28 62. A toxic shock syndrome can most likely occur due to the use of which of the following contraceptive methods? A) B) C) D) E) Condoms Cervical sponges Birth control pill Fertility awareness method Hormonal implants p. 27 333 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 63. A female client has forgotten to take her combined birth control pill for two consecutive days. Which is the most appropriate advice to give to this client? A) After missing more than one pill this client should pause the pill until a withdrawal bleeding occurs and then start a new pill cycle. Until then extra contraceptive precautions have to be met. B) Missing a combined pill for two days does not compromise its birth control effect. C) A pregnancy test should be performed immediately. D) A temporary dosage increase of the combined birth control may make up for this mistake. F) None of this advice is correct. p. 28 64. A 39 year old female client is requesting information on contraception methods. The attending nurse assesses the following relevant data: вЂў вЂў вЂў вЂў вЂў вЂў Weight: 164 lbs Height: 5вЂ™7вЂќ NonвЂ“smoker Regulated menstrual cycle History of a deep vein thrombosis at the age 22 A recent mammogram has revealed no pathology Based on the information provided which contraceptive method would be the most appropriate for this client? A) Intrauterine device B) Cervical sponge C) Cervical cap D) Combined birth control pill E) Female condom p. 27/28 65. Which of the following statements describe the main benefits of a progesterone вЂ“ only вЂњmini pillвЂќ in comparison to a combined birth control pill? A) A mini pill can be prescribed to women over 35 years of age as well as during lactation and in cases of mild hypertension and estrogen side effects. B) The main benefit of the mini pill is a reduced estrogen concentration. C) There are no major differences between a combined and a progesterone only birth control pill. D) A mini pill can also be used as a hormone replacement therapy in menopausal women. E) A mini pill makes an extrauterine gravidity less likely to occur. p. 27/28 66. A female client receives a positive result of a pregnancy test in an encounter with a nurse. The client states that her last period of her usually regulated menstrual cycle started on August 12. Please state the estimated time of delivery by using the Naegeles rule. A) B) C) D) E) May 19 April 10 June 12 March 2 April 19 p. 29 334 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 67. Which of the following descriptions of the McDonaldвЂ™s method is correct? A) B) C) D) E) The McDonaldвЂ™s method requires an ultrasound examination. The McDonaldвЂ™s method can be used in every pregnant women. The McDonaldвЂ™s method can be used from the 2nd gestational week. The McDonaldвЂ™s method is most reliable from midterm pregnancy. The McDonaldвЂ™s method is more reliable than Naegeles rule. p. 29 68. Which of the following factors are of importance for a first antenatal examination? A) Number of children born in term after 37 weeks of gestation. B) Number of preterm infants born between 20 and 37 weeks of gestation. C) Number of spontaneous or therapeutic abortions prior to the 20th gestational week. D) Number of living children. E) All of the above named factors have to be assessed at a first antenatal examination. p. 29 69. Please identify the positive signs of a pregnancy from the symptoms stated below: 1) 2) 3) 4) 5) Fetal heartbeat Fetal movement palpable by examiner Visualization of fetus in ultrasound Morning sickness Amenorrhea A) B) C) D) E) Only 4 and 5 are correct. Only 1, 2 and 3 are correct All of the above named symptoms are positive signs of a pregnancy. Only 3 is correct. Only 2 and 3 are correct p. 29 70. Parameters that are routinely assessed in a maternal pregnancy examination do not include: A) B) C) D) E) Vital signs Height Weight Tetanus vaccination status Blood type p. 29 71. Laboratory pregnancy assessment parameters are: A) B) C) D) E) Rh factor and irregular antibodies Rubella titer Tuberculin skin test Renal function tests All of the above parameters are assessed in a pregnancy p. 29 335 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 72. Which of the following maternal blood type constellations can potentially lead to an erythroblastosis fetalis? A) B) C) D) E) Rh negative Rh positive A, B and A/B A/B only None of these blood types p. 30 73. A pregnant client undergoes a routine examination at her first antenatal assessment. Her urinalysis shows the following results: вЂў вЂў вЂў вЂў вЂў вЂў > 100.000 bacteria/ml Urine ph < 7 Glucose of 160 mg/dL Specific gravity increased Protein urine traces Evidence of Nitrite and WBCвЂ™s Which of the following conclusions can be drawn from this examination result? A) B) C) D) E) Physiological finding and no action necessary. Suspicion of urinary tract infection, dehydration and gestational diabetes. Suspicion of a nephrotic syndrome in an end stage renal disease. Metabolic alkalosis. This client is at high risk to develop a HELLP syndrome. p. 30 74. Which examination is described as the TORCH Screening. A) B) C) D) E) Assessment for gestational diabetes Assessment for blood type incompatibility First gestational ultrasound examination Newborn assessment Maternal antenatal assessment for infectious diseases p. 30 75. Pregnant women have to avoid consumption of raw undercooked meat as well as contact with cats to minimize the risk for an infection with: A) Mumps B) Measles C) Rubella D) Toxoplasmosis E) Diphtheria p. 30 76. Which of the following infections carries the highest risk for congenital abnormalities if acquired during pregnancy? A) B) C) D) E) Tetanus Hepatitis A Mumps Rubella Diptheria p. 30/31 336 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 77. Please identify the most common cause of congenital fetal infections from the list below. A) B) C) D) E) Toxoplasmosis Hepatitis A and B Cytomegalievirus Herpes simplex virus Diphtheria p. 30/31 78. Please verify which of the following statements about sexually transmitted diseases are correct. 1. 2. 3. 4. 5. Hepatitis B is not primarily classified as a STI. HIV testing does not require informed consent from client. Syphillis is a viral infection. Partner treatment is not necessary in STIвЂ™s. Chlamydia infections are generally harmless. A) B) C) D) E) Only 1 is correct. Only 2 and 3 are correct Only 1, 2 and 3 are correct 1, 2, 3 and 4 are correct. All statements are correct p. 31/32 79. Which of the following statements about antenatal assessments are correct? 1. Elevated AFP levels in the amniotic fluid are suspicious for neural tube defects. 2. The triple screen test includes assessment of AFP, hHCG and Estriol concentrations in the amniotic fluid. 3. A GTT result of 162 mg/dl of venous blood glucose after 1 hour is considered as normal. 4. Antenatal visits have to be scheduled daily after the 36th gestational week. 5. A transvaginal gestational ultrasound can be performed at any time during a pregnancy. A) B) C) D) E) 1,3 and 5 are correct 1 and 2 are correct Only 1 is correct All statements are correct None of the statements are correct p. 33 80. A nurse has to instruct a female client about warnings signs during pregnancy. Which of the following statements from this client, causes doubts that the instructions are fully understood? A) I understand that only painful vaginal bleedings indicate danger for the intactness of my placenta. B) From now on I will see the doctor whenever I experience symptoms of an urinary tract infection. C) During the first 28 gestational weeks my routine antenatal assessments take place every 4 weeks. D) The spontaneous movements of my child should not decrease significantly during this pregnancy. E) Excessive vomiting may occur temporarily especially in the first trimester. p. 34 337 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 81. A female client is in her 30th gestational week. During an antenatal routine assessment she complaints about increased backache, heartburn, ankle edema and visual disturbances. What should be the most appropriate immediate action of the attending nurse? A) The nurse should assure this client that all of the described symptoms are typical discomforts in a late pregnancy. B) The nurse should take a blood pressure reading and asses this client for proteinuria. C) The nurse should give advice to limit the daily fluid intake because of the edema. D) The nurse should encourage the client to take OTC pain relief medication E) The nurse should arrange an immediate MSU exam to rule out an urinary tract infection. p. 34 82. A female client is in her 14th gestational week. During an antenatal routine assessment she complaints about recurrent nausea and vomiting, breast tenderness, increased urinary frequency, fatigue, and ptyalism. What should be the most appropriate immediate action of the attending nurse? A) The nurse should assure this client that all of the described symptoms are typical discomforts in an early pregnancy. B) The nurse should advice this client to see an ENT doctor. C) The nurse should arrange a mammogram because of the sudden breast tenderness. D) The nurse should encourage the client to take antibiotic medication since she has symptoms of an urinary tract infection. E) The nurse should arrange an immediate MSU examination. p. 38 83. Which of the following findings are considered to be physiological changes in pregnancy? A) B) C) D) E) GoodellвЂ™s sign ChadwickвЂ™s sign Hypertrophy of uterus Increase heart rate at rest All findings are considered as physiological changes during pregnancy p. 36/37 84. Which of the following statements about maternal nutrition and weight development during pregnancy is correct? A) Pregnant woman require additional 3000 calories per day as well as proteins, folate, vitamins, minerals and trace elements. B) An average weight gain of 35lbs during the entire pregnancy can be considered as normal. C) The amount of weight gained during a pregnancy is not of significance since it is mainly caused by the growing fetus. D) A significant lower weight gain during pregnancy is suspicious for gestational diabetes. E) Pregnant vegetarian women require Vitamin B12 supply from whole grain, fruits, legumes and nuts. p. 36 338 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 85. Which of the following statements about the biophysical profile is not correct? A) The BPP is a reliable tool to identify prenatal clients at high risk. B) The BPP assesses fetal breathing movement, body movements, muscle tone FHR and the amniotic fluid volume. C) A BPP score of 10 is considered as abnormal. D) The BPP score would be altered in cases of an esophageal atresia. E) A BPP score < 15 leads to further antenatal diagnostic procedures. p. 37 86. An Amniocentesis is suggested to a 37 year old nulliparous women in her first pregnancy. Diagnostic information about which of the following systems and conditions can be obtained from this procedure? 1. 2. 3. 4. 5. A) B) C) D) E) Lung maturity Chromosomal disorders Spina bifida Congenital hip dysplasia Neurological status 1, 2 and 4 are correct. 1, 2 and 3 are correct. Only 4 is correct. All statements are correct. None of the statements are correct. p. 37 87. A 27 year old women is is 24 weeks pregnant when she suddenly experiences an acute painful vaginal bleeding. Vaginal examination reveals a dilated cervix. Which is the most likely diagnosis that the receiving nurse has to consider? A) B) C) D) E) Inevitable abortion Placenta praevia Ectopic pregnancy Incompetent cervix Abruptio placentae p. 39 88. A 31 year old women arrives for her routine antenatal assessment in the 30th gestational week. During the encounter the nurse reveals the following findings: вЂў BP 175/90 mmHg вЂў Proteinuria вЂў Thrombopenia вЂў Headache Which is the most appropriate action to take for the further care of this client? A) B) C) D) E) Advise client to go home and rest. Immediate assessment of liver enzymes. Immediate referral for a transvaginal ultrasound. Immediate referral for an ECG examination. Immediate referral for a chest X-ray. p. 39 89. A 42 year old pregnant women in her 30th gestational week is referred to the obstetrics department. She is concerned that she suddenly experiences much less fetal movements than before. Further examination reveals that the cervix is closed. Uterine bleedings and contractions are not present. The fetal heart rate shows a severe variable deceleration pattern with heart rates as low as 70 bpm for more than 60 seconds. What is the most likely cause for this condition? 339 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com A) B) C) D) E) Uteroplacentar insufficiency Inevitable abortion Placenta praevia HELLP Syndrome Abruptio placentae p. 40 90. Which of the following statements about fetal heart rate monitoring are correct? A) Short term variability of the fetal heart rate is not necessarily an abnormal finding and can only be assessed by internal monitoring. B) Long Term variability of the fetal heart rate is caused by autonomous cardiac innervation. C) Nonperiodic spontaneous accelerations indicate fetal well being. D) Early decelerations are considered as normal as long as uterine contractions do not become frustraneous. E) All of the above statements about the interpretation of fetal heart rate monitoring are correct. p. 39/40 91. The first stage of labor includes which of the following steps? A) B) C) D) E) Latent, active and transition phase. Complete cervical dilation to a maximum width of 10 cm. Effacement and descent. Frequency of uterine contractions from 1/30 minutes to 1/2 minutes. All of the above steps occur in the first stage of labor. p. 43 92. Which of the following statements about the collaborative management during the second stage of labor is correct? A) It may be necessary to insert a urinary catheter and to assess the clients vital signs and the fetal heart rate every 15 minutes. B) There is no difference in the outcome if an episiotomy is performed or if a perineum laceration occurs. C) The uterine contractions during this stage are so strong that it is unnecessary to tell the client to вЂњpushвЂќ voluntarily. D) A 1st degree perineum laceration requires surgical repair. E) The 2nd stage of labor is expected to last at least five hours. p. 44 93. What are potential complications that have to be expected during the third stage of labor. 1. 2. 3. 4. 5. Atonic uterine bleeding Retention of placental parts Breech position Prolonged duration over 30 minutes Hypovolemic shock A) B) C) D) E) 1, 2 and 4 are correct. 1, 2 and 3 are correct. 1, 2 ,4 and 5 are correct. All statements are correct. None of the statements are correct. p. 44 340 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 94. The fourth stage of labor is defined as follow: A) B) C) D) E) Initial postpartal period Full uterine involution Beginning of the lactation period Discharge of white lochia A fourth stage of labor does not exist p. 44 95. Which of the following statements about pharmacological pain management during labor are correct? 1. Intravenous morphine based narcotics are most widely used. 2. The appropriate antidote in cases of a morphine overdose is naloxone. 3. Substances used for subarachnoideal administration are Bupivacaine or Lidocaine. 4. Lumbar epidural blocks are performed with morphine based analgetics as well. 5. Pharmacological pain management during labor may reduce the force of the uterine contractions. A) B) C) D) E) 1, 2 and 4 are correct. 1, 2 and 5 are correct. 1, 4 and 5 are correct. All statements are correct. None of the statements are correct. p. 45 96. What is considered to be a normal fetal position during labor? A) B) C) D) E) Occiput posterior position Occiput anterior position Occiput transverse position Breech position Face presentation p. 46 97. During the crowning process in the second stage of labor the presenting fetal part appear to be the buttocks. Which of the following terms describes this form of fetal malpresentation correctly? A) B) C) D) E) Complete breech presentation Incomplete breech presentation Frank breech presentation Sincipital presentation Transverse lie p. 47 98. Which is the most immediate action to take in a breech presentation with decelerations of the fetal heart rate? A) B) C) D) E) To apply any positioning that relieves pressure from the umbilical cord. Oxygen supply Amnio-infusion Creating a calm environment Sedating the laboring client p. 47 99. Which of the following procedures are appropriate to induce labor? 1. 2. 3. 4. 5. Applying Prostaglandine gel to cervix Amniotomy Intravenous Oxytocin therapy Transvaginal stimulation of the uterus Intravenous Terbutaline therapy 341 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com A) B) C) D) E) 1,2 and 4 are correct. 1,2 and 3 are correct. 1,2,4 and 5 are correct. All statements are correct. None of the statements are correct. p. 47 100. Premature labor is defined as A) B) C) D) E) Contractions between the 20th and the 37th gestational week. Contractions between the 28th and the 37th gestational week. Any labor prior to the 40th gestational week. Birth of child small for date of delivery. Labor prior to an established lung maturity. p. 48 101. Reliable signs for the onset of labor are: A) B) C) D) E) Frequent contractions every 10 minutes or less. Low abdominal cramping, with or without diarrhea. Pelvic pressure. Leaking amniotic fluid. All of the described symptoms are reliable signs for the onset of labor. p. 43 102. The most common indications to perform a caesarean delivery are: A) B) C) D) E) CPD Fetal distress Breech presentations Previous Caesarean birth All of the above p. 49 103. Which of the following descriptions of uterine stimulants is correct? A) Oxytocin stimulates uterine contractions as well as lactation but is only of short lasting effect. B) Ergotamines are widely used for the induction of labor. C) Prostaglandines are only used to control postpartal bleedings. D) There is no major difference between the different types of uterine stimulants. E) All descriptions are correct. p. 50 104 Which of the following substances is the most widely used uterine relaxant medication? A) B) C) D) E) Magnesium sulfate Indomethacin Terbutaline Nifedipine Ritodrine p. 51 105. A 23 year old and otherwise healthy woman experiences a spontaneous abortion. Which of the following steps is the most reasonable to detect a possible cause of a spontaneous abortion. A) To investigate a possible Rhesus incompatibility. B) Checking the clients family history for abortions. C) Questioning if the client has maintained a healthy lifestyle throughout the pregnancy. D) Telling the client to be more careful in her next pregnancy. E) To rule out underlying physical disorders. p. 52 342 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 106) A 33 year old nulliparous pregnant women experiences premature contractions in her 32nd gestational week. The attending gynecologist prescribes Terbutaline to delay the labor for at least 48 hours. What would be the appropriate answer of the attending nurse if asked by the client why this procedure was chosen. A) This treatment is necessary to have enough time to induce the lung maturity of your child. B) This is a routine procedure to see how long we can possibly delay the labor. C) We are just trying our best to save your child. D) This is one of our routine procedures. E) This is to make sure that nothing will happen to your child. p. 51 107. Which statements about the prophylactic treatment of newborns with vitamin K are correct? A) Vitamin K induces the synthesis of the coagulation factors II, VII, IX, X. B) The appropriate treatment mode is an IM injection at time of delivery. C) Newborns are generally endangered by neonatal brain hemorrhage due to a deficiency of coagulation factors. D) Vitamin K will be synthesized later by colon bacteria. E) All of the above statements are correct. p. 52 108. A nurse prepares to discharge a female client and her newborn boy. Which of the following statements is not a correct discharge instruction. A) It will take about 6 weeks until your uterus goes back to its normal size. B) You will experience some vaginal discharge for a few weeks which changes its color from red to white back and forth. C) You may detect hemorrhoids. D) There is sometimes a few days of a delay between the labor and the actual production of the breast milk. During this time it is important that you have your baby suck at your breasts. Because the stimulation of the breast nipples will help to produce the milk and your child will learn how to suck correctly. E) Please make sure you drink sufficient amounts of fluid because you may experience an urinary tract infection easier as long as the lochia production goes on. p. 54 вЂ“ 56 109. 24 - hours after a client gave birth to a healthy newborn the nurse observes the following findings during a routine postpartal assessment. вЂў вЂў вЂў вЂў Temperature 101.0 F Redness, edema and yellowish discharge from a caesarean section wound. HR 100 bpm, regular BP 125/70 mmHg Which of the following actions should the nurse take immediately? 1. To contact the healthcare provider since this client seems to have developed an infection of her surgical wound. 2. To apply an icepack to the wound. 3. To order an urgent ECG. 4. To administer antihypertensive medication. 5. To keep observing this client for further aggravation of the described symptoms. 343 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com A) B) C) D) E) 1,2 and 4 are correct. 1,2 and 3 are correct. Only 1 is correct. All statements are correct. Only 1,4 and 5 are correct. p. 56 вЂ“ 58 110. A postpartal assessment 2 hours after a vaginal delivery reveals the following findings: вЂў вЂў вЂў вЂў T 100.0 F HomanвЂ™s sign negative 25 ventilations/minute Occasional lighter and lower abdominal cramps Which of the following statements are appropriate to make based on these findings? A) B) C) D) E) Everything is fine. We may have to watch you a little closer. I am really concerned about you. We need to run a few test as soon as possible. Cramps are really unusual for this situation. p. 56 - 58 111. A client who gave birth to a healthy newborn experiences ongoing significant vaginal bleedings one hour after delivery of the placenta. Which is the most appropriate medication therapy to administer to this client. A) B) C) D) E) Amoxicillin Ergot alkaloids Oxytocin Terbutaline None of these medications p. 50 112. A newborn assessment reveals the following findings: вЂў вЂў вЂў вЂў вЂў Flexed position HR 160 bpm T 98 F BP 85/40 mmHg Head circumference 30 cm (12 inches) Which of the following statements are correct? A) B) C) D) E) All findings are considered as normal for a newborn assessment. The heart rate indicates a hereditary heart failure. This newborn appears to have an infection. A hydrocephalus is likely. Further investigation is necessary. All findings are abnormal p. 56 113. Which of the following findings are regularly assessed in newborns as an evidence of appropriate development for the gestational age. A) B) C) D) E) Completed descent of testicles into the scrotum at birth. Labia minora covered by labia majora. Thickness of breast tissue. Presence and distribution of Lanugo. All of the above findings are criterias of the Ballard tool for assessment of the gestational age of a newborn. p. 58 344 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 114. A newborn suddenly develops the following symptoms: вЂў вЂў вЂў вЂў increased breathing rate nasal flaring inter-costal retractions changing of color These symptoms are specific findings in which of the following conditions? A) B) C) D) E) Acute respiratory distress Congenital heart failure Fever Malnutrition These symptoms do not correlate to any specific findings. p. 59 115. During a newborn assessment the examiner holds the newborn vertically by stabilizing the neck and then suddenly removes the hand that is supporting the neck. The newborn responds with a sudden forward directed extension of both arms. This reaction is characteristic for which of the following newborn reflexes? A) Moro Reflex B) Babinski Reflex C) Tonic neck reflex D) Rooting reflex E) None of the above reflexes p. 58 116. Which of the following statements about newborn care is correct? A) Newborns are nose breathers. A newborn that needs to open the mouth for respiration purposes is in respiratory distress. B) A Guthrie Test must be performed immediately after delivery. C) The remains of the umbilical cord need to be removed. D) Feeding should be pursued after a fixed schedule. E) A yellowish skin color of a newborn is a normal finding. p. 59 - 67 117. The nurse assesses the vaginal blood loss of a client at 800 ml within the first 24 hours after labor. Which should be the most immediate conclusion regards to this finding? A) A postpartal blood loss of up to 1000 ml within the first 24 hours does not require any attention. B) This client may have taken aspirin during the pregnancy. C) The described finding only requires attention if the bleeding contains clots. D) The hemoglobin level of this client should be assessed. E) Further investigation is immediately necessary to rule out a severe injury of the birth channel, a coagulation disorder and an atonic uterus. p. 61 118. A newborn is assessed with the following findings: вЂў вЂў вЂў вЂў Birth weight: 4lbs, 4 ounces Blood glucose 30 mg/dl Dry skin Weak cry Which of the following conclusions are correct? 345 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com A) B) C) D) E) Abnormal birth weight, otherwise normal findings. Maternal Diabetes likely Juvenile Diabetes Type I likely Small for gestational age Renal Diabetes likely p. 62 - 63 119. A newborn is assessed with the following findings: вЂў вЂў вЂў вЂў Birthweight 4620g Bilirubin level 20 mg/dl Shoulder Dystocia Apgar score 6 at 5 minutes Which of the following conditions are likely to be present in this case? A) B) C) D) E) Inherited liver failure Hypothyreosis Large for gestational age Respiratory distress Abnormal birth weight and other findings normal p. 62 - 63 120. The minimum gestational age a fetus must have to survive preterm labor is A) B) C) D) E) 23 weeks of gestation 20 weeks of gestation 30 weeks of gestation 36 weeks of gestation 28 weeks of gestation p. 62 121. Which of the following newborn conditions can typically occur after preterm labor? A) B) C) D) E) Growth retardation Respiratory Distress Hemorrhage Retinopathy All of the above findings p. 62 122. Please review the following statements about complicated newborn care for correctness? 1. 2. 3. 4. 5. Newborn with asphyxia and a breathing rate over 60 should not be fed orally. A heart rate of less than 60 bpm may require chest compressions. A newborn with asphyxia may have aspired meconium. A facial paralysis may require immediate treatment. Cerebral palsy has hereditary causes. A) B) C) D) E) 1, 2 and 4 are correct. 1, 2 and 3 are correct. Only 1 is correct. All statements are correct. Only 1, 4 and 5 are correct. p. 62 вЂ“ 63 346 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 123. A newborn assessment of a boy reveals that the urethral opening is not located on the end but on the top of the penis. Which of the following medical terms describes this birth defect correctly? A) B) C) D) E) Epispadia Hypospadia Bladder exstrophy Gastroschisis Omphalocele p. 64 124. Which of the following birth defects is of poor prognosis? A) B) C) D) E) Chordee Epispadia Cryptorchism Cleft palate Biliary atresia p. 64 - 67 125. Two days after delivery a newborn has recurrent projectile vomiting and dehydration. These symptoms are typical for which of the following birth defects? A) B) C) D) E) Congenital diaphragmatical hernia Pyloric stenosis DownвЂ™s syndrome Cleft palate Phenylketonuria p. 65 126. Typical symptoms of muscular dystrophy do not include: A) B) C) D) E) Hypertrophic calf muscles Hyperlordosis Hyperkyphosis Bowed legs Mental retardation p. 65/66 127. The parents of a 21 month old girl are concerned since their daughter does not make any attempt to walk. Which of the following signs and symptoms indicate a congenital hip dysplasia? A) B) C) D) E) Positive Ortolani sign Positive BarlowвЂ™s maneuver Positive TrendelenburgвЂ™s sign Gluteal muscle weakness All of the above findings indicate a congenital hip dysplasia p. 66 128. Which of the following findings are expected to be observed during a routine prenatal assessment in the 16th gestational week? 1. 2. 3. 4. 5. All organs formed Gender detectable Finger and toes formed Weight: 1lb Fetal heart sound detectable 347 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com A) B) C) D) E) 1, 2 and 4 are correct. 1, 2 and 5 are correct. Only 4 is correct. All statements are correct. None of the statements are correct. p. 67 129. Quickening describes the onset of spontaneous fetal movements from which gestational week? A) B) C) D) E) 8th week 12th week 20th week 30th week 40th week p. 67 130. PiagetвЂ™s theories of development are focused on: A) B) C) D) E) Cognitive development Physical development Psychosocial development Preterm maturity None of the above p. 68 131. EriksonвЂ™s theories of development are focused on: A) B) C) D) E) ChildвЂ“parent relationship Intrauterine psychological development Social development of siblings Identity development Psychosocial development p. 68 132. PiagetвЂ™s theory defines the stages of cognitive development in the following order: A) Sensomotoric preoperational concrete operational formal operations B) Preoperational concrete operational formal operations sensomotoric development C) Formal operations concrete operational postoperational D) Physical development psychosocial development coping with stressors E) None of the above p. 68 133. In accordance to EriksonвЂ™s theory, the stages of psychosocial development appear in the following order: A) Trust vs. mistrust autonomy vs. shame and doubt Initiative vs. guilt Industry vs. inferiority Identity vs. role confusion B) Inferiority vs. Isolation generativity vs. stagnation ego integrity vs. despair C) Trust vs. mistrust industry vs. inferiority identity vs. role confusion generativity vs. stagnation ego integrity vs. despair. E) Initiative vs. guilt industry vs. role confusion generativity vs. stagnation intimacy vs. isolation. D) EriksonвЂ™s theories are not based on psychosocial development. p. 68 348 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 134. Which of the following newborn reflexes should not be present in a 10 month old child? 1. 2. 3. 4. 5. Moro reflex Landau reflex Parachute reflex Babinski reflex Body righting reflex A) B) C) D) E) 1, 2 and 4 are correct. 1, 2 and 3 are correct. 1, 2, 3 and 5 are correct. All statements are correct. Only 1, 4 and 5 are correct. p. 67 135. Which of the following summaries of skills describe an average developmental stage of a 12 month old child? A) Walking while holding on, sitting without support, neat pincer grasp, ability to speak up to four words and eating solids. B) Crawling, transferring an object from hand to hand and responding to their name. C) Walking without support, uses a cup well and builds a tower of blocks. D) Following simple directions, holding crayons and birth weight tripled. E) Identifying geometric forms, speaks short sentences and jumping. p. 67 - 69 136. Which of the following summaries of skills describe an average developmental stage of a 6 month old child? A) Rolling from back to abdomen, holding bottle, taste preferences and starting solids. B) Standing while holding on, pincer grasp and Babinski reflex present. C) Sitting without support, and binocular vision well developed. D) Slowing growth and weight gain and 50% over birth weight. E) None of the descriptions are describing a normal developmental stage of a 6 month old child. p. 67 - 69 137. Which of the following vaccinations has to be administered on the day of the childbirth? A) B) C) D) E) Hepatitis B DPT Hib IPV MMR p. 71 138. The PEERLAвЂ“examination does not include which of the following criteria? A) B) C) D) E) Pupil size Red reflex Equality of pupils Redness Light reflection p. 75 349 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 139. A percussion sound of healthy lungs is considered to be A) B) C) D) E) Tympanic Resonant Dull Flat Hyperresonant p. 75 140. Which of the following statements about auscultation sounds of the heart are correct? 1. 2. 3. 4. 5. S1 indicates the closure of the interventricular valves. S2 indicates the closure of the aortic and pulmonal valve. S2 indicates the start of the diastolic filling of the ventricles. An aortic stenosis produces a murmur at S1 + 2. Auscultation of the tricuspid and mitral valve is performed at the left sternal border. A) B) C) D) E) 1, 2 and 4 are correct. 1, 2 and 3 are correct. 1, 2,3 and 5 are correct. All statements are correct. Only 1, 4 and 5 are correct. p. 76 141. The Weber and Rinne Tests are used to detect: A) B) C) D) E) Sensorineural hearing loss Conductive hearing loss Sensorineural and conductive hearing loss Dementia Cerebrovascular diseases p. 77 142. The examination for congenital hip dislocation includes: A) B) C) D) E) OrtolaniвЂ™s sign BarlowвЂ™s maneuver ROM Test Gait pattern analysis Equality of gluteal folds 1. 2. 3. 4. 5. 1, 2 and 4 are correct. 1, 2 and 3 are correct. 1, 2, 3 and 5 are correct. Only 1, 4 and 5 are correct. All answers are correct. p. 80 143. Which of the following newborn reflexes may persist in a healthy child until the age of 1 year? A) B) C) D) E) Moro reflex Rooting reflex Plantar grasp reflex Palmar grasp reflex Babinski reflex p. 80 350 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 144. Which is the most common health disorder among adults in the US? A) B) C) D) E) Sinusitis Hypertension Diabetes Osteoarthritis Coronary artery disease p. 83 145. An older client was admitted to the hospital for the treatment of an ureter colic. During the treatment this client suddenly develops an acute confusion, is unable to concentrate and is not oriented. The situation is fully reversible within a few hours without any further treatment. What is the most likely cause of this condition? A) B) C) D) E) Pre-existing mental health disorder Delirium after a brief treatment with Benzodiazepines Stroke Hypertensive crisis Delusion in an underlying dementia p. 85 146. Food sources that contain high levels of potassium are: 1. 2. 3. 4. 5. Potatoes Milk Bananas Fortified orange juice Dried fruits A) 1, 2 and 4 are correct. B) 1, 2 and 3 are correct. C) 1, 2, 3 and 5 are correct. D) Only 1, 4 and 5 are correct. E) All answers are correct. p. 85 147. A repeated FBG sample was taken from a client over several days The results are as follow: вЂў вЂў вЂў вЂў Day 1: 126 mg/dl Day 2: 130 mg/dl Day 3: 140 mg/dl Day 4: 155 mg/dl Which of the following conclusions can be drawn from these results? A) Normal findings and no further investigation necessary. B) The results prove the diagnosis of a Diabetes. C) This client requires an insuline therapy. D) Diabetes of this severity does not require any treatment. E) The findings are related to a high carbohydrate diet. p. 86 148. A nurse is instructing a client on how to perform a 24вЂ“hour urine sample. Which of the following client statements prove that he understood the procedure? A) I understand that I need to collect as much urine as possible within the next 24 вЂ“ hours. B) I will collect all urine within the next 24вЂ“hours. C) I need to collect as much urine as needed until the container is filled up. D) I can start collecting the urine at any time and without any preparation. E) All statements show that the client did not properly understand the instructions. p. 86 351 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 149. A client receives an intravenous therapy for treatment of an acute DVT. Which of the following coagulation parameters has to be checked frequently under this treatment? A) B) C) D) E) aPTT PTT Clotting time Bleeding time Prothrombin time p. 87 150. Which of the following laboratory values is a significant parameter for the treatment of an acute myocardial infarction? A) B) C) D) E) LDH CK вЂ“ MB CK вЂ“ BB CK вЂ“ MM AST p. 89/90 151. A 25 year old women has a history of recurrent UTIвЂ™ s. She is currently not experiencing any symptoms. The result of an urinanalysis shows the following results: вЂў вЂў вЂў вЂў Nitrite negative 50.000 colonies of bacteria per high powered field pH 4,8 Specific Gravity 1.020 What advise should the attending nurse give? A) At this time no treatment is necessary but please keep drinking sufficient amounts of fluids daily. B) Another course of antibiotic medication needs to be prescribed. C) You must have terrible bladder pain. D) Any bacterial contamination of the urine is very dangerous. E) An emergency referral for a kidney examination is necessary. p. 91 152. A client is admitted to the hospital with acute abdominal pain. After reviewing the first results of a routine blood test the nurse reports to the attending physician that this client appears to have an acute pancreatitis. This statement is based on which of the following findings? A) B) C) D) E) Total Bilirubin 1,4 mg/dl ALT 25 U/L Lipase 300 U/L Ammonia 55mg/dl Uric acid 7,0 mg/l p. 92 + 225 153. Which of the following immunoglobulines is able to pass the placenta barrier? A) B) C) D) E) IgA IgD IgE IgG IgM p. 60 352 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 154. A 62 year old female client is admitted to the hospital after taking a new medication for the first time. She appears to be in an acute respiratory distress and produces a strong expiratory stridor and a significant hypotension. Which of the following immune reactions is causing these complaints? A) B) C) D) E) Type I Type II Type III Type IV All of the above reactions can apply. p. 94 155. A nurse undergoes a routine tuberculine skin test with the Occupational Health Service. The evaluation after 72 hours shows that the injection area appears significantly red and swollen. Which of the following conclusions in regards to this finding is correct? 1. The reaction does not prove an acute Tbc reaction. 2. It is possible that the nurse recently was in contact with a client with Tbc. 3. Further investigations include chest x-ray, sputum sample and gastric acid analysis. 4. The described finding does not require any further action. 5. Anti-tuberculotic treatment is immediately necessary. A) B) C) D) E) 1, 2 and 4 are correct. 1, 2 and 3 are correct. 1, 2, 3 and 5 are correct. Only 1, 4 and 5 are correct. All answers are correct. p. 100/101 156. Which of the following examination procedures is not routinely performed as part of a pre-operative assessment. A) B) C) D) E) Chest X-Ray Physical examination 24 вЂ“ hour blood pressure monitoring Blood typing and cross matching Serum electrolyte assessment p. 101 вЂ“ 104 157. A client underwent major surgery. Which of the following criterias must be met to discharge this client from the postanesthetic care unit? 1. 2. 3. 4. 5. Vital signs must be sufficient Breathing spontaneously Gag reflex must be present Client has to be easily arousable Client has to be able to maintain his personal hygiene A) B) C) D) E) 1, 2 and 4 are correct. 1, 2 and 3 are correct. 1,2,3,4 are correct All statements are correct. Only 1, 4 and 5 are correct. p. 104 353 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 158. Which of the following statements about a dumping syndrome after abdominal surgery is correct? A) A dumping syndrome is mostly caused by a Billroth I and II procedure. B) Treatment involves the adaptation of the dietary habits to the limited gastric space. C) Symptoms include palpitations, sweats, hypotension and hypoglycemia. D) A lifelong vitamin B 12 supply is most likely necessary. E) All of the above statements are correct. p. 104 159. A client with coronary artery disease underwent coronary artery bypass surgery. One of his discharge instructions is to maintain a low cholesterol diet. Which of the following statements shows that this client has understood the dietary regulations in regards to his supply with fats. A) Fats are essential for the body to maintain important metabolic functions but my diet should avoid saturate fats as they come in butter, milk and meat. B) Basically I can eat whatever I want as long as I do not gain any weight. C) Daily pure butter on bread and an egg does not make a difference. D) I can eat everything but fast food. E) Fats of herbal origin are not as nutritious as fats from animal sources. p. 106 160. The BMI is correctly calculated as follows: A) B) C) D) E) Weight in kg (1kg = 2.2 lbs) Height in meters 2 BMI = Height in meters Weight in kg Weight in kg (1kg = 2.2 lbs) BMI = Body surface area in m2 BMI = Weight in kg (1kg = 2.2 lbs) Bone density p. 109 BMI = Weight in kg вЂ“ 100 BMI = 161. A female client is 5вЂ™6вЂќ tall and weighs 190 lbs. These dimensions are relating to the following BMI. A) B) C) D) E) 23 20 30 32 24 p. 109 162. Which of the following nursing interventions is not appropriate to assist a client with orthopnea? A) B) C) D) E) Positioning the client in a Fowlers position Positioning the client in a Trendelenburg position Providing oxygen supply Performing a blood gas analysis Providing chest physiotherapy p. 113/114 354 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 163. An Urinalysis shows the following results: вЂў вЂў вЂў вЂў вЂў вЂў Sterile pH 4.5 Specific Gravity 1.010 Proteinuria Ketones negative Glucose negative The specimen was obtained from a client with an urinary output of 400 mg/d. Which of the following interpretations are correct? 1. Nephrotic syndrome 2. Urinary tract infection 3. Diabetes 4. No relevant findings 5. This client is in an oliguric stade of renal failure. A) 1, 2 and 3 are correct. B) Only 1 is correct. C) 1, 4 and 5 are correct. D) 1,2,3,4 are correct. E) None of these interpretations are correct. p. 90 164. Nursing instructions for a client with a colostomy should not include which of the following advice. A) B) C) D) E) Spices, fruits and vegetables tend to loosen the stool. Garlic, onions, eggs and beans should be consumed sparingly. A client with a colostomy does not require any dietary limitations. Cabbage, onions and beans may cause colicky pain. Beside a few limitations it is possible to maintain a healthy and well balanced diet. p. 117 165. Which of the following facts should be part of the nursing discharge instructions for a client who recently underwent an ileostomy procedure? A) An ileostomy produces generally very soft and moist stool. B) Warm fluids or the temporary use of a hot water bottle may help to improve an obstruction. C) High fiber foods should be generally limited. D) Lifelong parenteral supply of fat soluble vitamins may be necessary. E) All of the above instructions should be provided. p. 117 166. A client lives in a nursing home and is bed bound after multiple cerebrovascular accidents. The nurse notices a wound around this clients sacral area and documents it as follow: Superficial partial thickness, skin loss, blistering and abrasion - like appearance. This finding correlates to which of the following stages of the Norton and Braden scale:. A) B) C) D) E) Stage 1: Stage 2: Stage 3: Stage 4: The described wound is not a typical pressure ulcer. p. 117 355 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 167. A client has accidentially removed his tracheostoma tube. Which is the most urgent intervention necessary in this situation? A) B) C) D) E) To call for help To hold stoma open with a curved clamp or by using the retention sutures Oral suctioning Oxygen supply via face mask No urgent intervention is necessary but a new tracheostoma has to be supplied. p. 120 168. What is the correct anatomical position of an endotracheal tube? A) B) C) D) E) In between the voice membranes. In the upper half of the trachea. 2 cm above the carina. In one of the main bronchioles. Any position below the epiglottis is correct. p. 120 169. Which of the following descriptions of the osmotic process is correct? A) B) C) D) E) Shift of fluids and small particles through a semipermeable membrane. Shift of particles through a semipermeable membrane. Osmosis can only occur between two isotonic concentrations. Osmosis is not driven by any forces. None of the above statements describe the process of osmosis correctly. p. 123 170. Please identify the correct attributes of the hormone Aldosterone from the statements below: 1. 2. 3. 4. 5. Increases renal natrium and water re-uptake and potassium excretion. Decreases renal natrium and water re-uptake and potassium excretion. Secretion is inhibited by the renin вЂ“ angiotensin вЂ“ mechanism. Secretion is increased by the renin вЂ“ angiotensin вЂ“ mechanism. Aldosterone is excreted by the pituitary gland. A) B) C) D) E) 1 and 3 are correct. 1 and 4 are correct. 2 and 3 are correct. 4 and 5 are correct. Only 5 is correct. p. 124 171. Typical symptoms and diagnostic findings of Dehydration in adults do not include: A) B) C) D) E) Urine output: < 30 mL / kg / hour Urine specific gravity > 1.035 Serum osmolality > 300mOsmol/kg BUN,HCT,Creatinine Pulmonary edema p. 125 172. Signs and symptoms of a hyperkalemia do not include: A) B) C) D) E) Serum Potassium of 4,5 mEq/L ECG alterations Hypotension Bradycardia Respiratory failure p. 126 356 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 173. Concurrent findings in cases of a metabolic acidosis are: 1. 2. 3. 4. 5. Hyperkalemia Hypokalemia Shift of H+ ions into intracellular space Shift of H+ ions into the extracellular space Hypoventilation A) B) C) D) E) 1 and 3 are correct. 1 and 4 are correct. 2 and 3 are correct. 4 and 5 are correct. Only 5 is correct. p. 129 - 132 174. An arterial blood gas analysis shows the following results: вЂў вЂў вЂў pH = 7,25 PaCO2 = 55 mmHg HCO3- = 24 mEq/L A) B) C) D) Respiratory Acidosis Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis p. 129 - 132 175. An arterial blood gas analysis shows the following results: вЂў вЂў вЂў pH = 7,50 PaCO2 = 35 mmHg HCO3- = 36 mEq/L A) Respiratory Acidosis B) Respiratory Alkalosis C) Metabolic Acidosis D) Metabolic Alkalosis p. 129 - 132 176. Which of the following conditions applies in a case of isotonic dehydration? A) B) C) D) E) Sudden blood losses Profuse sweating Ascites Pleural effusion None of the above p. 124 177. Symptoms of Dehydration due to a fluid deficiency do not include: A) B) C) D) E) Serum osmolality > 300mOsmol/kg BUN,HCT,Creatinine Hyponatremia < 125 mEq/mL Dry skin and mucous membranes Sunken eyeballs p. 125 178. Which of the following statements about hypercalcemia are correct? 1. A possible cause is hyperparathyroidism. 2. Affected clients will show increased DTR. 3. Kidney stones can be caused by hypercalcemia. 357 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 4. Clients under treatment with digoxin will not experience symptoms of hypercalcemia. 5. Hypercalcemia induces hyperphosphatemia. A) B) C) D) E) 1 and 3 are correct. 1, 3 and 4 are correct. 1, 2 and 3 are correct. 4 and 5 are correct. Only 5 is correct. p. 127 179. Please verify the following information about the acid вЂ“ base regulation. 1. 2. 3. 4. 5. Respiratory alkalosis is caused by a retention of CO2. Metobolic alkalosis is defined as a CO2 > 45 mmHg. Acidosis causes CNS depression, and alkalosis stimulates the CNS. In an acidosis K+ shifts to ECF and H+ to ICF Hyperventilation does not alternate the systemic pH value. A) B) C) D) E) 1 and 3 are correct. 1, 3 and 4 are correct. 1, 2 and 3 are correct. 3 and 4 are correct. Only 5 is correct. p. 129 - 132 180. A physicianвЂ™s order states that the appropriate dosage of an intravenously administered drug is 450 mg per 24 hours. The daily dosage has to be divided and administered in three equal daily dosages. The medication is available in a concentration of 5 mg/ml. How many ml of this medication has to be administered with one single dosage? A) B) C) D) E) 30 ml 45 ml 60 ml 120 ml 150 ml p. 133 181. A single dosage of the above described substance has to be administered exactly within 30 minutes. Which of the parameters below describes the adequate hourly flow rate in ml that has to be adjusted on the infusion pump? A) B) C) D) E) 60 ml/hr 90 ml/hr 125 ml/ht 150 ml/hr 200 ml/hr p. 139/140 182. A pediatric medication is prescribed in a dosage of 125 mg/m2 BSA/day. The patient is a 30 month old boy. His height is 3вЂ™2вЂќand his weight is 28 lbs. In order to this information, this client is supposed to receive a daily dosage of how many mg of this medication? A) 250 mg B) 375 mg C) 450 mg D) 600 mg E) The information provided is not sufficient to answer this question. p. 139/140 358 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 183. Which of the following statements about infusion flow rates are correct? 1. A pediatric infusion set has a drop factor of 60 drops/ml 2. An adult infusion set has a drop factor of 60 drops/ml 3. An infusion rate has to be calculated as follows: Total infusion volume x drop factor = 1000 mL x 10 Total time of infusion in minutes 8 x 60 min 4. The required infusion rate depends on the administered substance A) 1 and 2 are correct. B) 1, 2 and 3 are correct. C) 1, 3 and 4 are correct. D) 3 and 4 are correct. E) All statements are correct. p. 139/140 184. Administering a hypotonic infusion may lead to which of the following side effects? A) Hemolysis B) Dehydration C) Hyperkalemia D) Metabolic Alkalosis E) Hypertension p. 140 185. Which of the following statements about the compatibility of blood groups are correct? 1. 2. 3. 4. 5. A Rhesus factor incompatibility has to be disregarded in cases of an emergency. Clients with blood group 0 are universal receivers. Clients with blood group AB are universal receivers. Blood group A occurs most commonly. Clients with blood group A can receive blood group 0 and A. A) 1 and 2 are correct. B) 1, 2 and 3 are correct. C) 1, 3 and 4 are correct. D) 3, 4 and 5 are correct. E) All statements are correct. p. 141 - 143 186. Regular routine laboratory assessments for a client who receives total parenteral nutrition do not include which of the following parameters? A) Liver function test B) BUN C) Creatinine D) Albumin E) C вЂ“ reactive Protein p. 143/144 187. A cholinergic effect does not cause which of the following symptoms? A) Constipation B) Stimulation of the urinary tract C) Miosis D) Bradycardia E) Hypotension p. 147 359 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 188. Nicotinic and muscarinic receptors are located on a chemical synapsis to interact with which of the following neurotransmitters? A) Adrenaline (Epinephrine) B) Noradrenaline (Norepinephrine) C) GABA D) Dopamine E) Acetylcholine p. 147 189. Which of the following synaptic neurotransmitter receptors are sensitive to adrenaline (Epinephrine)? A) B) C) D) E) Acetylcholine receptors Dopamine receptors Beta 2 receptors Alpha 1 receptors Alpha 2 receptors p. 147 190. A paraplegia was diagnosed in which of the following cases? A) B) C) D) E) Sensomotoric deficite in right arm Paralysis of left arm and leg Plexusparalysis Erb вЂ“ Duchenne Disc injury of the cervical spine Paralysis of lower extremities up to the pelvic area. p. 148 191. Which of the following statements about the GuillainвЂ“Barre Syndrome are correct? 1. The underlying cause of this disorder is an autoimmune disease. 2. The affected structures are the myelin sheets of the spinal nerve fibers. 3. The diagnosis requires a spinal tab. 4. Clients may require respirator treatment. 5. A specific medication therapy does not exist. A) 1 and 2 are correct. B) 1,2 and 3 are correct. C) 1,2, 3 and 4 are correct. D) 3 and 5 are correct. E) All statements are correct. p. 148 192. Please verify the following statements on intracranial bleedings. 1. An epidural hematoma requires urgent neurosurgical treatment. 2. Small subdural hematomas may not lead to physical complaints. 3. An epidural hematoma typically develops below the pia mater. 4. All intracranial bleedings are potentially life threatening. 5. Epidural hematomas are caused by a rupture of the meningeal artery. A) 1 and 2 are correct. B) 1, 2 and 3 are correct. C) 1, 3 and 4 are correct. D) 1,2,4 and 5 are correct. E) All statements are correct. p. 149 360 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 193. A 23 year male old client was admitted to the hospital with a sudden loss of consciousness. Accompanying friends have observed a repeated involuntary uncoordinated muscle contraction. After recovery the client is embarrassed by discovering an involuntary urination. Which of the following diagnosis is the most likely in this case? A) B) C) D) E) GrandвЂ“mal Seizure PetitвЂ“mal Seizure Multiple Sclerosis GraveвЂ™s Disease None of the above p. 150 194. Which of the following medications may be included in the treatment of multiple sclerosis? 1. 2. 3. 4. 5. Methylprednisolone Interferon Beta Azathioprine Cyclophosphamide Morphine sulfate A) 1 and 2 are correct. B) 1, 2 and 3 are correct. C) 1 2, 3 and 4 are correct. D) 3 and 5 are correct. E) All statements are correct. p. 151 195. Which of the following structures are targeted in cases of Myasthenia gravis? A) Synaptic Acetylcholine receptors B) Skeletal muscle fibers C) Beta 2 receptors D) Smooth muscle fibers E) None of the above p. 148 196. A TIA is defined as follows: A) Neurologic deficits resolving within 24 hours. B) Neurologic deficits resolving within 7 hours. C) Neurologic deficits resolving within 7 days. D) Recurrent neurologic deficits. E) Neurological deficits of unknown cause. p. 152 197. Which of the following medications is not indicated for the treatment of seizure disorders? A) B) C) D) E) Phenytoine Clonazepam Carbamazepin Magnesium Sulfate Ergotamine Alkaloids p. 150 361 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 198. The therapeutic effect of Amantadine is defined as follows: A) Promotion of synthesis and release of Dopamine. B) Blockade of Alpha 1 receptors in the CNS C) Relaxation of skeletal muscles D) Migraine relief E) None of the above p. 156 199. Which of the following statements about Scarlet fever are correct? 1. The infection is caused by beta вЂ“ hemolytic streptococci 2. The contagiosity persists over entire course of the infection 3. Scarlet fever is caused by a viral infection 4. KoplikвЂ™s Spots are typical symptoms 5. A vaccination is recommended A) 1 and 2 are correct. B) 1, 2 and 3 are correct. C) 1, 2, 3 and 4 are correct. D) 3 and 5 are correct. E) All statements are correct. p. 160 200. Which of the following statements about Rocky Mountain Spotted Fever are correct? A) It is caused by a bacterial infection with Rickettsia ricketsii. B) The infection is transmitted via tick bites. C) Antibiotic treatment with Tetracycline is required. D) The infection may require hospitalization. E) All statements are correct. p. 161 201. The four generations of Cephalosporines differ in the following way: A) Increasing effect against gram positive cocci in latest generations. B) Increasing effect against gram negative cocci in latest generations. C) Increasing effect against anaerobic bacteria in latest generations. D) Increasing antiviral effect in latest generations. E) Less cross sensitivity with Penicilline in latest generations. p. 162 202. Characteristics of Diphteria include the following symptoms: A) Light fever B) Sore throat C) Halitosis D) Grey вЂ“ white membranes in nasopharynx may cause airway obstruction E) All of the above p. 160 203. A treatment with Tetracyclines is contraindicated in which of the following cases? A) Intravenous treatment of a Cholera infection. B) Treatment of acne of a 17 year old boy. C) Treatment of a Chlamydia infection in an adult female. D) Treatment of Malaria. E) Treatment of Rocky Mountain Spotted Fever. p. 165 362 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 204. Please assess the following statements about pulmonary function testing for correctness. 1. The Vital Capacity (VC) is defined as the maximum air volume available for exhalation after a maximum inspiration. 2. The Forced Vital Capacity(FVC) is the total amount of air that can forcibly expired after full inspiration and measured in liters. 3. The Forced Expiratory Volume in 1 second. (FEV1) is defined as the Amount of air that can forcefully expired in one second and measured in liters 4. The FEV1 / FVC ration in healthy adults should be approximately 75-80%. 5. The FEV1 is increased in an obstructive pulmonary disorder. A) 1 and 3 are correct. B) 1, 3 and 4 are correct. C) 1, 2 and 3 are correct. D) 1, 2, 3 and 4 are correct. E) Only 5 is correct. p. 167 205. The diagnosis of an emphysema can include which of the following findings? A) вЂњPink pufferвЂќ appearance B) Pursed lip breathing C) Barrel chest D) VC and FEV1 E) All of the above findings correlate with a pulmonary emphysema. p. 170 206. Which of the following descriptions of pleural effusions is not correct? A) B) C) D) E) A Transudate contains small amounts of proteins. An Exsudate contains large amounts of proteins. An Empyema describes the accumulation of air in the pleural space. A Chylothorax describes the Accumulation of lymphatic fluids in the pleural space. A Hemothorax may be caused by bleedings into the intrapleural space. p. 171 207. Which of the following statements about pulmonary tuberculosis are correct? 1. Diagnosis is made via intrautaneous skin testing. 2. Diagnosis is made by proof of acid fast bacteria in sputum sample. 3. Tuberculosis is mostly accompanied by other diseases or disorders. 4. Exposure to clients with tuberculosis may require antibiotic prophylactic treatment. 5. All of the above statements are correct. A) 1 and 3 are correct. B) 1, 3 and 4 are correct. C) 1, 2 and 3 are correct. D) 2, 3 and 4 are correct. E) Only 5 is correct. p. 173 208. The treatment of clients with an inhalatory Beta 2 - mimetic has to include the following considerations. A) The therapeutic effect of Beta-2 mimetic medication decreases with increase of administered dose and frequency. B) Sympathomimetics have to be used with caution in patients with cardiovascular diseases. C) Sympathomimetics are contraindicated in combination with Monoamine Oxidase Inhibitors(MAOIвЂ™s). D) The use of inhalatory Sympathomimetics requires adequate patient education. E) All of the above facts apply under treatment with Beta-2 mimetic medication. p. 175/176 363 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 209. Specific requirements of nursing care for clients after lung surgery have to consider the following facts: 1. After lobectomy an equal alternating positioning on back and either side is necessary to avoid atelectasis. 2. After segmental resection a positioning on the side of surgical intervention can cause damage to the surgical wound. 3. After pneumonectomy client is to be preferably positioned on back and halfway turned to side of resected lung. 4. Clients should maintain a TredenlenburgвЂ™s position. 5. The pulmonary function changes significantly after a segmental pulmonary resection A) 1 and 3 are correct. B) 1, 3 and 4 are correct. C) 1, 2 and 3 are correct. D) 1, 2, 3 and 5 are correct. E) Only 5 is correct. p. 170 Which of the following ECG examinations shows the following findings? 210. Paroxysmal supraventricular Tachycardia 211. Atrial flutter 212. 1st degree AV вЂ“ Block 213. Ventricular fibrillation p. 182 - 188 214. 3rd degree AV вЂ“ Block A) B) C) D) 364 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com E) 215. Diagnostic criterias of a myocardial infarction include which of the following ECG - alterations? 1. 2. 3. 4. 5. ST вЂ“ Segment elevation Q вЂ“ waves ST вЂ“ Segment descent R вЂ“ Waves S - Waves A) 1 and 2 are correct. B) 1, 3 and 4 are correct. C) 1, 2 and 3 are correct. D) 1, 2, 3 and 5 are correct. E) Only 5 is correct. p. 189 216. Which of the following symptoms does not typically occur in a left sided heart failure? A) B) C) D) E) Pleural effusion вЂњFluid lungвЂќ Congestion of pulmonary veins Dilation of the left atrium Hypotension p. 190 217. Characteristic findings in a right sided heart failure include which of the following symptoms? 1. Tibial edema 2. Jugular vein distention in an upright position 3. Jugular vein distention in a supine position 4. Pleural effusion 5. Fluid volume excess A) 1 and 2 are correct. B) 1, 3 and 4 are correct. C) 1, 2 and 3 are correct. D) 1, 2, 3 and 4 are correct. E) All anwers are correct. p. 190 218. The medication therapy of a congestive heat failure includes which of the following pharmacological substances? A) B) C) D) E) Nitroglyzerine ACE вЂ“ Inhibitors Loop Diuretics Glycosides All of the above substances may be used for treatment of a congestive heart failure. p. 190 365 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 219. The levels of which of the following electrolytes are of most significant importance for clients under a medication therapy with Glycosides: 1. 2. 3. 4. 5. Natrium Potassium Chloride Calcium Phosphate A) B) C) D) E) 1 and 2 are correct. 1, 3 and 4 are correct. 1, 2 and 3 are correct. 1, 2, 3 and 4 are correct. Only 2 and 4 are correct. p. 191 220. A dilation of the left cardiac atrium is most likely to occur due to which of the following heart valve defects? 1. 2. 3. 4. 5. Pulmonal valve stenosis Mitral prolapse Mitral stenosis Mitral insufficiency Tricuspidal insufficiency A) B) C) D) E) 1 and 2 are correct. 1, 3 and 4 are correct. 1, 2 and 3 are correct. 1, 2, 3 and 4 are correct. Only 3 is correct. p. 192/193 221. Which of the following statements about endocarditis are correct? 1. 2. 3. 4. 5. Common causes are bacterial infections with streptococci. An antibiotic treatment with penicillin is mandatory. An immediate antibiotic treatment with tetracyclines is mandatory. A sudden destruction of heart valves is likely to occur. An endocarditis is generally a benign infection. A) B) C) D) E) 1 and 2 are correct. 1, 2 and 3 are correct. 1, 2 and 4 are correct. 1, 2, 3 and 4 are correct. Only 4 is correct. p. 193 222. Which of the following statements characterize the main difference between a thrombophlebitis and a deep vein thrombosis correctly? A. B. C. D. E. A Thrombophlebitis occurs within the superficial vein system. Both terms describe an identical pathology. A Thromboplebitis commonly leads to a pulmonary embolism. A Thrombophlebitis requires an oral anticoagulation therapy. None of the above statements describe the main difference between a thrombophlebitis and a deep vein thrombosis correctly. p. 194 366 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 223. An arterial embolism is typically accompanied by which of the following symptoms? A. B. C. D. E. Pain Pallor Pulselessness Paresthesias All of the above named symptoms can occur in an acute arterial embolim p. 196 224. Which of the following pharmacological substances is not a calcium channel blocker? A. B. C. D. E. Amlodipin Nifedipin Felodipine Verapamil Captopril p. 199 225. The pharmacological effect of an ACE вЂ“ Inhibitor is based on a direct interference with which of the following biochemical systems? A. B. C. D. E. The renal renin вЂ“ angiotensin вЂ“ aldosterone system The adrenal catecholamine synthesis The hepatic protein synthesis The pituitary synthesis of antidiuretic hormone The thyroid gland hormone synthesis p. 199 226. Which of the following statements about the medication therapy with cardiac glycosides is correct? A. Digoxin has to be replaced with digitoxin in cases of renal dysfunction. B. Frequent assessments of the serum glycoside levels are mandatory. C. Irregular serum potassium and calcium levels may cause severe glycoside side effects. D. Glycosides increase the myoacardial contractility and decrease the atrioventricular conduction. E. All of the above statements are correct. p. 201 227. Kidney and ureter stones do not cause which of the following symptoms. A. B. C. D. E. Macrohematuria Microhematuria Colicky flank pain Nausea Glomerulonephritis p. 209 228. Please state which of the following statements about urinary incontinence are correct. A. B. C. D. E. An age related urinary incontinence is not considered as an abnormal finding. Stress incontinence is caused by an increased intra-abdominal pressure. Urge incontinence occurs shortly after the urge to void appears. Postmenopausal estrogen deficiency may cause urinary incontinence. All of the above statements are correct. p. 209 367 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 229. Please identify the most common cause of acute renal failure among the following conditions: A. B. C. D. E. Hypovolemia Ureter stones Glomerulonephritis Urinary tract infections Polycystic kidney disease p. 211 230. Which of the following statements about the medication therapy with diuretics are correct? 1. 2. 3. 4. 5. Thiazide diuretics are first line medications in cases of an acute renal failure. Loop diuretics are administered in renal failure and congestive heart failure. A diuretic treatment requires a regular assessment of serum potassium levels. Loop diuretics are considered as antihypertensives. An uncontrolled therapy with diuretics can lead to dehydration. A) 1 and 2 are correct. B) 1, 2 and 3 are correct. C) 1, 2 and 4 are correct. D) 2, 3 and 5 are correct. E) Only 5 is correct. p. 212 231. A client has received a kidney transplant. Which of the following medications are expected to be part of an immunosuppressant treatment? 1. 2. 3. 4. 5. Cyclosporine Azathioprine Tacrolimus Daclizumab Interferone A) 1 and 2 are correct. B) 1, 2 and 3 are correct. C) 1, 2 and 4 are correct. D) 1, 2, 3 and 4 are correct. E) Only 4 is correct. p. 216 232. A Gastroesophageal reflux disease typically appears with which of the following symptoms? A) B) C) D) E) Flatulence Diarrhea Vomiting Heartburn Lactose intolerance p. 218 233. Which of the following statements describes the primary difference between an ulcerative colitis and a CrohnвЂ™s disease most accurately? A) B) C) D) E) Ulcerative Colitis is primarily curable by total colectomy. An ulcerative colitis typically causes constipation. CrohnвЂ™s disease affects the large bowels only. An ulcerative colitis causes a short bowel syndrome CrohnвЂ™s disease is an autoimmune disorder p. 218/219 368 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 234. Typical laboratory findings in an acute appendicitis include which of the following symptoms? A) B) C) D) E) Leucocytosis Increased erythrocyte sedimentation rate Increased c вЂ“ reactive protein Increased BUN Decreased hemoglobin p. 220 235. Which of the following statements about cystic fibrosis are correct? A) B) C) D) E) Cystic fibrosis is a hereditary disease. Cystic fibrosis causes a systemic glandular dysfunction. The condition is incurable. A heart and lung transplant may be inevitable in the course of this disease. All statements are correct. p. 221 236. A client was recently diagnosed with Hepatitis A. Which of the following statements about the expected course of this disease are correct? A) B) C) D) E) A Hepatitis A remains contagious throughout the entire course of the infection. Hepatitis A is acquired by a parenteral infection. Liver cirrhosis is likely to develop. Hepatitis A infections are of poor prognosis. Hepatitis A commonly develops into a chronic persisting hepatitis. p. 222/223 237. Which of the following descriptions of typical complications of a liver cirrhosis are correct? A) Ascites is primarily caused by a decreased colloid osmotic pressure in the extracellular space. B) A hepatic encephalopathy is caused by increased ammonia levels. C) A portal vein hypertension may cause esophageal varicosis. D) A portal vein hypertension may cause hemorrhoids. E) All of the above descriptions are correct. p. 223/224 238. Relevant laboratory diagnostic parameters in diseases and disorders of the biliary system are: A) B) C) D) E) GGT + AP AST + ALT Only AP Only AST AST + BUN p. 225/226 239. The pharmacological effect of antiemetics can be described best as: A) B) C) D) E) anticholinergic parasympathomimetic sympathomimetic sympatholytic adrenergic p. 229/230 369 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 240. Which of the following substances is considered as a stimulant laxative? A) B) C) D) E) Bisacodyl Methylcellulose Lactulose Docusate sodium Magnesium sulfate p. 228/229 241. Protone pump inhibitor medication is commonly prescribed in which of the following conditions? A) B) C) D) E) Gastroesophageal reflux disease Gastroeteritis CrohnвЂ™s disease Diverticulitis Diarrhea p. 230 242. A client was diagnosed with Gardiasis. Which of the following medications will be most likely described as an appropriate medication therapy? A) B) C) D) E) Chloroquine Clotrimazole Amantadin Trimethoprim Mebendazole p. 235 243. The synthesis and release of which of the following hormones is directly or indirectly induced by Gonadotropine? A) B) C) D) E) FSH LH Estrogene Testosteron All of the above p. 234 244. Ethionamide is frequently prescribed in which of the following endocrimologic disorders? A) B) C) D) E) Hyperthyreosis Hypothyresosis Hypopituitarism AddisonвЂ™s Disease Hyperparathreoidism p. 236 245. A secondary hyperparathyroidism is caused by which of the following conditions? A) B) C) D) E) Renal failure Liver failure Dysfunction of the adrenal cortex Hypercalcemia Hypophophatemia p. 237 370 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 246. Which of the following conditions is a typical cause of AddisonвЂ™s disease? A) B) C) D) E) Auto-immune disorder with antibody production against the adrenal cortex. Over production of Cortisol. Overdose of orally administered corticosteroids. High levels of adrenocorticotropic hormone ACTH. All of the above conditions may cause AddisonвЂ™s disease. p. 239 247. Which of the following symptoms is a characteristic finding of Diabetes mellitus Type I? A) B) C) D) E) Hyperosmolar non вЂ“ ketotic syndrome Obesity Hyperinsulinemia Diabetic keto вЂ“ acidosis Delayed Glucose tolerance p. 241/242 248. Please identify the main difference between sulfonylurea and non вЂ“ sulfonylurea oral antidiabetics among the following statements: A) Sulfonylurea medication stimulates the insulin release in the pancreatic gland. B) Non вЂ“ sulfonylurea medications stimulate the insulin release in the pancreatic gland. C) All non вЂ“ sulfonylureas show a similar effect. D) The hypoglycemic effect of sulfonylurea medication is weaker. E) None of the above statements are correct. p. 243 - 245 249. Symptoms of an advanced stage of a diabetes type II do not include which of the following findings? A) B) C) D) E) Polydipisia Diabetic nephropathy Diabetic neuropathy Diabetic angiopathy Diabetic retinopathy p. 241/242 250. A client with a pre-existing insulin dependent diabetes mellitus type II suddenly looses consciousness. An instant blood sugar monitoring reveals a blood glucose level of 30 mg/dl. Which is the most immediate and appropriate action among the following available options? A) B) C) D) E) To administer an intramuscular glucagons injection. To call for help. To inject 10 units of regular insulin subcutaneously. To wait until client regains consciousness. To administer a dextrose lozenger orally. p. 245 251. Which of the following statements about PagetвЂ™s disease are correct? 1. 2. 3. 4. 5. Symptoms include pathological fractures, headaches and hearing loss. The medication therapy is comparable to the treatment of an osteoporosis. Affected clients may experience severe musculoskeletal pain. A relevant diagnostic laboratory parameter does not exist. PagetвЂ™s disease typically results in osteomyelitis. 371 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com A) 1 and 2 are correct. B) 1, 2 and 3 are correct. C) 1, 2 and 4 are correct. D) 1, 2, 3 and 4 are correct. E) Only 4 is correct. p. 246 252. Which of the following musculoskeletal diseases develop typically during puberty? A) B) C) D) E) Rheumatoid arthritis Osteoarthritis Dislocation of the femoral epiphysis Osteoporosis Gout p. 248 253. Which of the following substances are indicated in the treatment of a rheumatoid arthritis? A) B) C) D) E) Gold Sodium Thiomalate Etanercept Hylan G-F 20 Methotrexate All of the above named substances p. 249/250 254. A client has to be educated about which of the following warning signs of common side effects of nonвЂ“steroidal anti-inflammatory medication? A) B) C) D) E) Epigastric pain Symptoms of anaphylaxia Prolonged bleeding in cases of injuries Hypertension All of the above side effects p. 250 255. A client appears with a skin rash in the Emergency Room that was caused by a limited acute allergic reaction due to medication. The exact diagnosis of this condition is most likely described as: A) B) C) D) E) Contact Dermatitis Psoriasis Erysipel Urticaria Seborrhoic Dermatitis p. 94/95 + 251 256. Which of the following dermatological disorders is not considered as a bacterial infection? A) B) C) D) E) Impetigo Folliculitis Acne Shingles Cellulitis p. 159 372 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 257. Topical treatment with Nystatin is commonly prescribed in which of the following skin infections? A) B) C) D) E) Impetigo Acne Tinea corporis Candidiasis Shingles p. 259 258. Which of the following descriptions of a superficial partial thickness burn wound is correct? A) Epidermic painful erythema, no blisters and scar free healing within five days. B) Subtotal epidermic destruction, moist, red and white areas, blisters, no loss of sensoric function and heals within 28 days with some scarring. C) Loss of entire epidermis, dry, waxy and white wound. Skin transplant may be performed but spontaneous healing within 1 month is possible. D) Destruction of more or all remaining subepidermal tissues. E) Total tissue necrosis. p. 257 259. Which of the following laboratory parameters are relevant towards the treatment and care of burn wounds? A) B) C) D) E) Serum albumin level BUN Hematocrit Serum potassium level All of the above p. 257/258 260. In order to the rule of 9вЂ™s a burn wound of the entire abdomen and chest applies to an estimated body surface area of: A) B) C) D) E) 9% 13.5% 18% 22.5% 36% p. 257/258 261. A gradual loss of visual acuity due to an increased opacity of the eye lenses is a characteristic finding in which of the following conditions? A) B) C) D) E) Strabism Cataract Glaucoma Amblyiopia Conjunctivitis p. 264 262. A client appears in the Emergency Room. He complaints about sudden and increasing visual disturbances such as floating spots, blurred visions and gradual loss of the visual field. Which of the following diagnoses is the most likely in this situation? A) B) C) D) E) Retina detachment Macular degeneration Eye infection Glaucoma None of the above p. 265 373 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 263. A nurse has to instruct a client who has just received a laser treatment for an acute retina detachment about the specifics of the post-operative treatment. Which of the following statements are correct? A) B) C) D) E) You have to remain in a supine position for the next 24 hours. We will give you a mild laxative to prevent a constipation. Even after discharge you will have to avoid heavy lifting for at least 6 weeks. You may remain without any visual impairment if this treatment was successful. All of the above statements are correct. p. 265 264. Which of the following laboratory findings in an iron deficiency anemia are typically altered in an iron deficiency anemia? A) B) C) D) E) MCV MCH MCHC Serum iron All of the above parameters are altered in an iron deficiency anemia. p. 272 265. Which of the following statements about a pernicious anemia are correct? 1. Pernicious anemia is caused by an auto-immune reaction against parietal gastric cells. 2. Pernicious anemia causes a deficiency of intrinsic factor. 3. The absorption of Vitamin B12 causes a microcytic anemia. 4. Neurological symptoms can be caused by a deficiency of Vitamin B12. 5. Diagnosis is made via the Schilling вЂ“ Test. A) 1 and 2 are correct. B) 1, 2 and 3 are correct. C) 3 and 4 are correct. D) 1, 2 and 4 are correct. E) 1, 2, 4 and 5 are correct. p. 272 266. Which of the following statements about Thalassaemia are correct? 1. 2. 3. 4. 5. Thalassaemia occurs in a major and a minor form. Thalassaemia is classified as a hemoglobinopathy. Humans of mediterranean ethnicity are immune against Thalassaemia. Thalassaemia is a synonymous term for sickle cell disease. Thalassaemia minor usually does not require any treatment. A) 1 and 2 are correct. B) 1, 2 and 3 are correct. C) 3 and 4 are correct. D) 1, 2 and 4 are correct. E) 1, 2, 4 and 5 are correct. p. 275 267. Haemophilia Type A is classified as follows: A) B) C) D) E) Deficiency of coagulation factor VIII Deficiency of coagulation factor IX Deficiency of von Willebrand factor vWF Low platelet count Microcytic anemia p. 276 374 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 268. Which of the following characteristics of a disseminated intravasal coagulation are correct? A) Common causes are intoxications, sepsis, polytrauma and other health conditions. B) PTT, aPPT and Thrombin time are elevated. C) Increased consumption of coagulation factors V,VII, IX and XIII. D) Increase of D-Dimer. E) All of the above findings are typical for a disseminated intravasal coagulation. p. 277 269. Please verify the following statements about prostate gland tumors for correctness: A) Diagnosis is made via biopsy. B) Benign tumors of the prostate gland are generally more common than malignancies. C) Prostate gland cancer typically develops bone metastasis. D) Prostate specific antigen is used as a Tumormarker for malignancies of the prostate gland. E) All of the above statements are correct. p. 282 270. A client is admitted to the hospital. His chief complaints include enlarged, firm, non - tender and non вЂ“ shiftable lymph nodes. Further diagnostic procedures reveal a hepatosplenomegalie and a mediastinal lymphadenopathy. Which is the most likely diagnosis in this case? A) B) C) D) E) Hodgkin Lymphoma NonвЂ“Hodgkin Lymphoma Chronic Lymphatic Leukemia Acute Lymphatic Leukemia None of the above p. 287 271. Which of the following side effects is not typical for a chemotherapeutic therapy? A) B) C) D) E) Bone marrow depression Nausea Vomiting Hepatotoxicity Hypertension p. 289 - 293 272. Which of the following statements about aromatase inhibitors are correct? 1. 2. 3. 4. Aromatase inhibitors are indicated in hormone receptor positive breast cancer. These substances are mainly indicated in premenopausal women. Aromatase inhibitors do not replace a necessary treatment with tamoxifen. Women with hormone receptor negative breast cancer show similar therapeutic effects. 5. Aromatase inhibitors do not change the prognosis in cases of a hormone receptor positive breast cancer. A) 1 and 2 are correct. B) 1 and 3 are correct. C) 3 and 4 are correct. D) 1, 2 and 4 are correct. E) 1, 2, 4 and 5 are correct. p. 284 375 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 273. Which of the following definitions of psychiatric symptoms is incorrect? A) B) C) D) E) Delusions = false beliefs that can not be altered by evidence or local reasoning. Hallucinations = sensations with no existing external stimulus. Self neglect = difficulty in caring for one self. Thought disruptions = difficulty in concentrating on a defined topic. Anhedonia = loss of social competence. p. 298 274. Which of the following definitions of psychiatric symptoms is incorrect? Characteristics of a major depression are defined as follows: 1. 2. 3. 4. 5. Decreased desire to participate in any social setting. Low self-esteem Feeling of incompetence Decreased motivation Sadness A) 1 and 2 are correct. B) 1 and 3 are correct. C) 3 and 4 are correct. D) 1, 2 and 4 are correct. E) All criteria are correct. p. 298 275. Which of the following psychopharmaceutical substances is also used as an anti-emetic medication? A) B) C) D) E) Phenothiazine вЂ“ type antipsychotic medication Diazepam Tricyclic anti-depressants Zopiclone Citalopram p. 313 276. Which of the following ECG вЂ“ findings can be caused by a coronary artery disease (CAD) ? 1. 2. 3. 4. 5. A) B) C) D) E) Descending ST вЂ“ Segments in leads II, III, avF. Shoulder shaped ST Elevations Left Bundle Branch Block Atrioventricular blockage 3rd degree Atrial fibrillation 2,3, and 4 are correct. 1,3, and 5 are correct Only 1 and 2 are correct None of the findings is typically caused by CAD All findings can be caused by a CAD p. 188/189 277. Which of the following rules and regulations apply for the decision making rules in nursing practice ? 1. 2. 3. 4. 5. Institutional regulations Federal law Priorities of urgent care Insurance coverage of client Power of Attorney 376 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com A) B) C) D) E) 2,3, and 4 are correct. 1,3, and 5 are correct 1,2,3 and 5 are correct None of the statements apply. All statements apply p. 8 - 11 278. Which of the following conditions of clients in an emergency room requires the least urgent medical attention ? A) Stabbing chest pain B) Suicidal ideas C) Hyperventilation D) Urinary retention D) Bleeding from a cut p. 12/13 279. ParkinsonвЂ™s Disease is caused by a deficiency of which the following neurotransmitters ? A) Dopamine B) Norepinephrine C) Epinephrine D) Serotonine E) GABA p. 152 280. Which of the following brief descriptions applies to the term HMO most accurate ? A) B) C) D) E) Preferred Provider Organization Limited services Welfare based health insurance Primary Care referrals not required Most expensive health insurance system p. 11 281. Beta вЂ“ 2 receptor stimulating medication is most commonly used in which of the following conditions. (Select all answers that apply) 1. 2. 3. 4. 5. Expected preterm labor Hypertension treatment COPD Depression Failure of uterine involution A) B) C) D) E) 2,3, and 4 are correct. 1 and 3 are correct Only 1. is correct Only 3. is correct All statements apply p. 51/176 282. Which of the following stades is not part of the Kubler Ross stages of Grief ? A) B) C) D) E) Denial (this isn' t happening to me!) Anger (why is this happening to me?) Bargaining (I promise I' ll be a better person if...) Depression (I don' t care anymore) Suicidal ideas (Life does not make anymore sense) p. 312 377 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 283. In comparison to other common birthing methods the Bradley method is based on which of the following requirements ? A) B) C) D) E) Augmented vaginal delivery Hospitalisation Distraction from pain Intact parental relationship Reduction of fear p. 35 284. Which of the following ECG Patterns is of least clinical importance ? A) B) C) D) E) Premature ventriclar contractions Premature atrial contractions Atrial fibrillation Ventricular fibrillation Shoulder shaped ST вЂ“ segment elevation p. 182 - 188 285. Which of the following criterias have to be considered by a shift leading RN who has to delegate duties to other staff members ? 1. 2. 3. 4. 5. Years of experience Qualification Skills Personal relationship Workload A) 2,3, and 4 are correct. B) 1,3, and 5 are correct C) 1,2,3 and 5 are correct D) None of the criterias above apply. E) All criterias apply p. 13/14 286. Which of the following conditions is best described as a primary restrictive pulmonary disorder ? A) B) C) D) E) COPD Asthma Emphysema Tuberculosis Whooping cough p. 167/168 287. Which of the following symptoms are common extrapyramidal side effects (ESPEвЂ™s) of an antipsychotic medication therapy ? 1. 2. 3. 4. 5. Akathisia Incontinence Diarrhea Miosis Oculogyric crisis A) 2, 3 and 4 are correct. B) 1, 3 and 5 are correct C) 1 and 5 are correct D) None of the symptoms are common expressions of ESPEвЂ™s E) All criterias apply p. 313 378 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 288. Which of the following recommendations apply for the care of a client with Diabetes ? 1. 2. 3. 4. 5. Weight gain has to be avoided Insulin treatment is mandatory Delayed wound healing is expected Gestational diabetes may heal after delivery Lack of treatment leads to Hypoglycemia A) 1, 3 and 4 are correct. B) 1, 3 and 5 are correct C) 1 and 5 are correct D) None of the statements apply E) All criterias apply p. 241 - 245 289. A nurse assesses the outcome of a tuberculine skin test a client has received 48 hours ago and recognizes a significant induration of the skin. Which of the following statements is correct ? A) 48 hours are not a sufficient time frame to allow any statement about the outcome. B) The induration is a reason to hospitalize this client instantly. C) A possible reason for this outcome is a previous BCG vaccination that this client may have received. D) The test has to be repeated. E) All statements are correct. p. 100 290. Which of the following actions in the acute care for a client with an acute pulmonary edema has the highest priority ? A) B) C) D) E) Semi FowlerвЂ™s position Oxygen supply Administering Sodium chloride 0,9% Performing an emergency ECG examination All statements are correct. p. 190 291. A nurse explains to a client the anticholinergic effects of a psychiatric medication that was prescribed to him. Which of the following symptoms have to be expected by this client ? A) B) C) D) E) Ptyalism Bradycardia Polyuria Diarrhea None of the above symptoms are anticholinergic side effects p. 313 292. Which of the following statements about psychiatric conditions are correct ? 1. 2. 3. 4. 5. rrrrr Delusional ideas are common and generally harmless Self endangerment may require hospitalization against clients will Addictive behaviour has to be anticipated and assessed Psychopharmaceutical treatment is generally mandatory Monoamineoxidase Inhibitors may be combined with trycyclic antidepressants. 379 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com A) 1, 3 and 4 are correct. B) 1, 3 and 5 are correct C) 2 and 3 are correct D) None of the statements are corrrect E) All statements are correct p. 302 293. Which of the following statements about Myelin sheets are correct. 1. 2. 3. 4. 5. Myelin is the connective tissue of the nervous system Myelin sheets increase the velocity of an electrical nerval innervation All neurons are covered in myelin sheets Myelin sheets are damaged in Myasthenia gravis Myelin sheets are damaged in Multiple sclerosis A) B) C) D) E) 1,3, and 4 are correct. 3,3, and 5 are correct Only 1, 2, 4 and 5 are correct None of the statements are correct. All statements are correct. p. 145 294. Which of the following conditions and procedures can lead to a metabolic alkalosis. 1. 2. 3. 4. 5. Myocardial infarction Hyperosmolar non вЂ“ ketotic diabetic coma Insertion of a nasogastric tube Hyperventilation Frequent use of calcium carbonate based antacids A) B) C) D) E) 1,3, and 4 are correct. 1,2, and 3 are correct Only 3 and 5 are correct None of the statements are correct All statements are correct p. 132 295. A patient has been hospitalized with pyelonephritis and is about to be discharged. A nurse provides discharge instructions to a patient and his family. Which misunderstanding by the family indicates the need for more detailed information? A) The patient may resume with normal home activities as tolerated but should avoid physical exertion and get adequate rest. B) The patient should continue to drink sufficient amounts of fluids on a daily basis. C) The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved. D) Recurrent bladder or flank pain as well as fever require immediate assessment. E) Pyelonephritis is more complicated than cystitis. p. 210 296. Which of the following signs and symptoms is not likely to occur in cases of a left sided chronic heart failure ? A) B) C) D) E) Pulmonary edema General physical weakness Hypotension Increase of BUN Ankle edema p. 190 380 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 297. An unconscious client is admitted to the Emergency room. He carries the following prescription drugs. 1. 2. 3. 4. 5. Amitryptiline Ramipril Hydrochlorothiazide Glimepirid Pantozole Which of the following assumptions can be made regarding the medical history of this client ? A) B) C) D) E) This patient may suffer from schizophrenia This patient may suffer from cancer This patient may suffer from hypothyroism This patient may suffer from diabetes This patient may suffer from COPD p. 145 298. Which of the following rules apply to a priority based clinical decision making process of a team leader RN ? 1) 2) 3) 4) 5) Acute care first Rules of delegation Oral medication first Consideration of ethnical and religious needs Institutional rules A) B) C) D) E) 1,2, and 4 are correct. 1,2, and 3 are correct Only 4and 5 are correct None of the statements are correct All statements are correct p. 12/13 299. Which of the following infection is transmitted via an enteral pathway? A) Influenza B) Hepatitis B C) Hepatitis C D) HIV E) Polio p. 157 300. Appropriate education of a client with primary hypertension should include which of the following statements. 2. A special diet is not required 3. A frequent blood pressure monitoring is recommended 4. Hypertension treatment includes frequent assessments of the kidney function 5. Smoking increases the risk to develop arterisclerosis A) B) C) D) E) 1,2, and 3 are correct. 1,2, and 4 are correct 1, 3, 4 and 5 are correct None of the statements are correct All statements are correct p. 194/195 381 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 301. A client in a psychiatric unit is frequently observed with an overeating habit, self induced vomiting, low self esteem and abuse of laxatives. Which of the following conditions may be current in this case ? A) Anorexia B) Substance abuse C) Bulimia D) Schizophrenia E) Depression p. 307 302. A client on a surgical ward complains about a reddened, warm and tender area on his left leg. The area is right above a wound that this client has suffered from a car accident. Which of the following medications are most likely to be included in this clients further care. A) Erythromycin i.v. B) Doxcyclin p.o. C) Sulfamethoxazol p.o D) Prednisolone i.v. E) Ketoconazole i.v. p. 253 303. Which of the following conditions are common risk factors for the development of a deep vein thrombosis. 1. Estrogene therapy 2. Varicose veins 3. Immobilisation 4. Smoking 5. Major surgical procedures A) B) C) D) E) 1,2, and 3 are correct. 1,2, and 4 are correct 1, 3 and 4 are correct None of the statements are correct All statements are correct p. 194 304. Which of the following rules only applies in an environment of surgical asepsis ? A) Hair has to be kept clean and short B) Designated area has clean and dirty objects C) Use of personal protective equipment required D) Hand Hygiene mandatory E) Water and soap and alcohol based hand rub are of equal effect. p. 19 305. Medical aseptic precautions apply to which of the following procedures ? A) Insertion of a Ventral veinous catheter B) Cholecystektomy C) Spinal tap D) Pleurocentesis E) Colonoscopy p. 19 382 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 306. A client complains about a sudden onset of vertigo, nausea and vomiting. The underlying condition is most likely which of the following ? A) Epistaxis B) Menieres Disease C) Uveitis D) Otitis externa E) Glaucoma p. 266 307. A client has received a lobectomy for lung cancer and is transferred to the surgical observation unit. Which of the following statements describes the appropriate positioning of this client ? A) No specific rules apply. B) Equal alternating positioning is required C) Client needs to be positioned on the side of the surgical wound D) Client is preferably positioned halfway to the side of the remaining lung E) Client is preferably positioned on back p. 170 308. Which of the following statements about a Dumping syndrome is correct ? A) It is caused by a Billroth I procedure B) It is caused by a Billroth II procedure C) It causes hypoglycemia D) It causes hot flushes and sweats E) All of the statements are correct p. 104 309. Which of the following physiological functions is a typical sympathomimetic effect ? A) Smooth muscle relaxation B) Reduction of heart rate C) Bladder stimulation D) Miosis E) Bronchoconstriction p. 147 310. Appropriate nursing care for a client with a Tracheostomy includes which of the following procedures ? 1. Respiratory assessments three times daily 2. Suctioning as required 3. Tracheostomy and Cuff pressure assessment three times daily 4. Change of soiled Tracheostomy strings asap 5. Frequent assessment of respiratory tract infections A) B) C) D) E) 1,2, and 3 are correct 1,2, and 4 are correct 2, 3,4 and 5 are correct None of the statements are correct All statements are correct p. 174 311. Which of the following actions has to be performed first when an airway tube is removed ? A) Deflation of cuff B) Adjusting client in a Fowlers position C) Suctioning of the trachea D) Removal of tube E) None of the above p. 121 383 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 312. A client receives Ergotamine for treatment of a chronic migraine. Which behavioral measures should this client be instructed on ? 1. Avoidance of stress 2. Regular meals 3. Regular life style 4. Avoidance of long fasting periods 5. Avoidance of red wine A) B) C) D) E) 1,2, and 3 are correct. 1,2, and 4 are correct 3,4 and 5 are correct None of the statements are correct All statements are correct p. 154/155 313. Which of the following criterias have to be met to diagnose a substance addiction ? A) B) C) D) E) Recurrent use of a substance despite negative consequences Controlled use Consume can be interrupted for days to weeks Compulsive use of a substance All of the above criteria are met in case of a substance addiction p. 307/308 314. Which of the following statements about Flumazenil is correct ? A) B) C) D) E) Flumazenil is administered orally. Flumazenil is an antidepressant Flumazenil may be used to treat symptoms from a Diazepam overdose Flumazenil an antipsycotic medication All statements are correct p. 317 315. Which of the following considerations apply in maintaining a central venous catheter (CVC) ? A) B) C) D) E) A closed tip (=Groshong) catheter can be flushed with physiological saline only. Flushing a CVC should be performed with a 20 ml syringe A sterile dressing of the insertion site of a CVC is not necessary A CVC only has to be inserted in cases of poor peripheral veins The tip of a CVC has to reach into the left atrium p. 139 316. Which of the following characteristics apply to CrohnвЂ™s Disease ? 1. Curable 2. Incurable 3. Infectious disease 4. Bloody diarrhea 5. Affecting the large bowels only A) B) C) D) E) 1,2, and 3 are correct. 1,2, and 4 are correct Only 2 is correct None of the statements are correct All statements are correct p. 218 384 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 317. In palliative care setting the following physical symptoms are considered to be signs of a nearing death: 1. Drowsiness 2. Dehydration 3. Restlessness and agitation 4. Incontinence 5. Pain A) B) C) D) E) 1,2, and 3 are correct 1,2, and 4 are correct Only 2 and 3 is correct 1,2,3 and 4 are correct All statements are correct p. 311 318. A pressure ulcer of a client reaches deep into the subcutameous tissue. Which of the following treatments provides the most effective support for a healing process ? A) B) C) D) E) Pressure relief Drainage of secretions Surgical debridement Frequent wound assessments Supply of zinc p. 256 319. A blood count of a female client shows the following findings: Hb 11,3 g/dl MCV 68 fL MCH 20 pg Which of the following conclusions are correct ? A) B) C) D) E) This is a normal finding This client has to e assessed for a folic acid deficiency This client requires an immediate RBC transfusion The lab results show characteristic findings for an iron deficiency anemia No statement can be made without a complete blood count p. 272 320. Which of the following findings proofs the diagnosis of a Hodgkin вЂ“ Lymphoma ? A) B) C) D) E) Enlarged, tender, shiftable lymph nodes Enlarged, nontender, non вЂ“ shiftable lymph nodes Massive production of B вЂ“ Lymphocytes Presence of Sternberg вЂ“ Reed cells in a Biopsy Weight loss p. 286 321. Which of the following criteria defines characteristics of a malignant process ? A) B) C) D) E) Enlarged, tender, shiftable lymph nodes Enlarged, nontender, non вЂ“ shiftable lymph nodes Fever Prolonged Diarrhea Weight loss p. 286 385 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 322. Which of the following actions are appropriate steps to take after a needlestick injury where the client is suspected to be infected with Hepatits and HIV ? A) B) C) D) E) Decontamination of the wound by cleaning the skin with soap and water Administering Hepatitis B вЂ“ Immunoglobulines Administering a Hepatitis B vaccination Starting an antiretroviral treatment within 72 hours All of the above actions are appropriate p. 21 323. Typical symptoms of a Hyperpituitarism are: A) B) C) D) E) Gigantism Akromegaly Cushings Syndrome Hyperthyroidism All of the above symptoms can occur p. 237 324. Which of the following symptoms are expected to occur in Hyperparathyroidism ? 1. 2. 3. 4. 5. A) B) C) D) E) Elevated blood glucose Elevated serum calcium Increased serum phosphate Increased risk of fractures Polyuria 1,2, and 3 are correct 2,3 and 4 are correct Only 2 and 3 is correct 1,2,4 and 5 are correct All statements are correct p. 237 325. Which of the following medications takes effect by blocking the Prostaglandine synthesis pathway ? A) B) C) D) E) Nitrendipine Promethazine Acetylic salicylic acid Erythromycin Metoclopramide p. 89 326. Expected complications in case of a clinical sepsis include which of the following ? 1. 2. 3. 4. 5. Fever (>38oC) Hypotension (systolic pressure<90 mm Hg) Oliguria (<20 ml/hr) Hypertension Disseminated intravascular coagulation (DIC) A) B) C) D) E) 1,3, and 4 are correct. 1,3, and 5 are correct 1,2,3 and 5 are correct None of the statements apply. All statements apply p. 161 386 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 327. Which of the following functions is not supported by an innervation of the trigeminal nerve ? A) Biting B) Chewing C) Swallowing D) Coughing E) Facial sensation p. 76/77 328. Which of the following calls made to an outpatient clinic should have the highest priority for medical intervention? A) A home health patient reports, вЂњI am running out of meds today.вЂќ B) A patient who received a forearm cast yesterday reports, вЂњI have terrible pain and numbness in my left arm.вЂќ C) A female client reports, вЂќI think I sprained my ankle about 2 weeks ago.вЂќ D) An older patient reports, вЂќMy knee is still hurting after the surgery 2 weeks ago.вЂќ E) A mother of a 2 year old girl reports that her daughter is having fever since the morning. p. 12/13 329. A patient on a surgical ward is experiencing sudden shortness of breath, chest pain and calf pain. Which of the following actions has the first priority in the further care for this client ? A) Positioning in a FowlerвЂ™s position B) Positioning in a supine position C) Assessment of vital signs D) Oxygen supply E) Request for an emergency ECG p. 12/13 330. Which of the following tasks necessary for the care of a client with a previously excerbated COPD is appropriate to delegate to a nursing assistant ? A) Transfer within the clients room B) Adjusting the flow rate of oxygen supply C) Examining the client D) Educating the cleint E) Providing discharge instructions to relatives p. 13/14 331. Which of the following patients should the nurse on duty check on first? A) A 55 year-old male who is scheduled for an EGD in 10 hours. B) A 44 year-old male who is scheduled for back surgery the next day and who has experienced an onset of urinary incontinence in the last hour. C) A 21 year-old male who had a lower extremity amputation two days ago. D) A 27 year-old female who has received a RBC transfusion two days ago. E) A 33 year-old male with headaches p. 12/13 332. A 14 year old teenager is admitted to the ER with acute lower right abdominal pain. The admitting nursing should take which the following measures first? A) Administer pain relief. B) Preparing for a blood sample C) Preparing for insertion of a central venous catheter. D) Schedule a X-Ray examination E) Assessing the menstrual cycle p. 12/13 387 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 333. Which of the following criterias have to be met to take a client with pulmonary tuberculosis off isolation restrictions ? A) Negative TBC sputum cultures B) 1 Month of tuberculostatic therapy C) Symptom relief D) Absence of fever E) Weight gain p. 173 334. An older male patient suddenly experiences abdominal pain, absent pedal pulses, chest pain, lower back pain. The attending nurse also notices a hypotensive blood pressure. Which of the following actions has the first priority in this case ? A) B) C) D) E) Scheduling an abdominal ultrasound examination Requesting an emergency ECG Oxygen supply Administering Morphine orally Inserting one or more i. v. lines p. 196 335. Which of the following actions has the highest priority in the care for a client with an acute asthma attack ? A) B) C) D) E) Administering Salbutamol by nebulizer Administering oxygen Assessment of the medical history Administering Prednisolone i. v. Administering Theophylline i. v. p. 171 336. Which of the following actions has the highest priority in the care for a client with an acute myocardial infarction after the diagnosis has been made via an ECG? A) B) C) D) E) Discussing the therapeutic options with this client Administering oxygen Administering Morphine Administerintg Metoprolol Preparing for a left heart catheterization p. 188/189 337. A client with Diabetes Type 2 receives an oral antidiabetic therapy. When he is scheduled for surgery which of the following changes of this therapy are appropriate ? A) Maintaining the pre-existing therapy throughout the surgical procedure and recovery period. B) Prescribing long acting Insulin instead of oral antidiabetics throughout the surgical procedure and recovery period. C) Cessating the oral antidiabetic therapy and replacing it with regular insulin on demand under frequent blood sugar monitoring. D) Cessating the oral antidiabetic therapy without replacement since the client will not eat as much as usual throughout the surgical procedure and recovery period. E) Reducing the dosage of the oral antidiabetic therapy by 50% throughout the surgical procedure and recovery period. p. 241 - 245 388 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 338. A client is likely to report that he feels euphorized and that he recognizes an increased pulse after taking which of his following medications ? A) B) C) D) E) Bisoprolol Candesartan Naproxen Nystatin Theophylline p. 176 339. After taking the medical history of a client the admitting nurse schould be concerned about which of the following combinations of prescribed meds ? A) B) C) D) E) Metoprolol and Verapamil Diclofenac and Pantoprazole Metoclopramide and Morphinesulfate Terbutaline and Prednisolone Ciprofloxacine and Acetaminophen p. 199 340. Which of the following clients can be cohorted ? A) B) C) D) E) A client with HIV and a client with pneumonia A client with Meningitis and a client with pneumonia A client with a pyelonephritis and a client with cellulitis Two clients with pulmonary tuberculosis A client with MRSA and a client who had an Appendectomy p. 20/21 341. Which of the following conditions may require treatment with Azathioprine ? A) B) C) D) E) Rheumatoid Arthritis Osteoarthritis Fibromyalgia Chronic heart failure Lyme disease p. 249 342. A female client is concerned about the need to receive antibiotic medication therapy and asks the attending nurse for possible side effects. The nurse should inform this client about which of the following possible side effects ? A) Diarrhea B) Cystitis C) Head cold D) Coughing E) Alopecia p. 161 343. Which of the following blood dyscrasias are likely to be observed in a client under treatment with cyclophospamide ? 1. Leukopenia 2. Anemia 3. Disseminated intravascular coagulation (DIC) 4. Thrombocytosis 5. Eosinophilia A) 1 and 2 are correct. B) 1,3, and 5 are correct C) 1,3 and 5 are correct D) 2,4, and 5 are correct E) 3,4,and 5 are correct p. 291 389 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 344. Ascites is directly caused by A) Loss of colloidosmotic pressure B) Liver enlargement C) Portal vein hypertension D) Alcoholism E) Congestion of the common bile duct p. 224 345. Pleural effusions can be caused by A) Trauma B) Tumors C) Pneumonia D) Chronic heart failure E) All of the above named conditions p. 171 346. Which of the following patients in an emergency room has the most urgent need for medical attention ? A) B) C) D) E) A pregnant female patient with sudden vaginal gosh of fluids A male patient with a BP of 195/100 mmHg A three year old child with a temperature of 100 degress Fahrenheit 38 C) A male patient with back ache and a history of an aortic aneurysm All described cases are of equal priority p. 12/13 347. Which of the following findings on a maternity ward should raise the most concern of the attending nurse ? A) A woman who has been admitted 6 hours earlier after uterine contractions have started ? B) A woman who has been admitted for her fourh vaginal delivery. C) Early decelarations of the FHR. D) Late decelarations of the FHR. E) A woman who has just competed the third stage of labor. p. 39 348. Which of the following observations of psychiatric symptoms are considered as warning signs of a psychotic disorder ? A) B) C) D) E) A client who appears to be depressed due to a job loss last year. A client who has a 10 вЂ“ year history of alcohol abuse. A client who is suffering from frequent mood changes. A client who has problems to interact socially. A client who reports to hear frequent voices. p. 302 349. Which of the following medications would be administered in an Opthalmology Department to induce a Mydriasis for an eye exam? A) B) C) D) E) Latanoprost Atropine sulfate Hydrocortisone Acetazolamide Timolol p. 268 390 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 350. HashimotoвЂ™s disease requires a medication therapy with which of the following subtances ? A) B) C) D) E) Growth hormone Prednisolone Calcitonine Thyroxine None of the above named substances p. 236 351. A client with an endstage renal disease requires a potassoium restricted diet. Which of the following food sources should be limited ? A) Beans B) Dried fruits C) Melons D) Tomatoes E) All of the above p. 126 352. Which of the following conditions is the most common health disorders in clients above 65 years of age ? A) Cancer B) Coronary Heart Disease C) Osteoarthritis D) Diabetes E) Hypertension p. 83 353. Which of the following statements about maintaining a central veinous catheter is incorrect ? A) The catheter can remain unchanged as long as necessary if no obvious signs of infections occur. B) A sterile dressing is not required. C) Insertion can be made via any visible vein. D) Correct placement of the tip of a CVC is the superior cava vein. E) All statements are incorrect. p. 139 354. Following the current 2010 CDC vaccination schedule which of the following vaccinations has to be administered at birth? A) B) C) D) E) H1N1 Influenza Tetanus Pneumococcal vaccine Hepatitis B p. 71 355. Which of the following criteria does not allow discharge from a PACU unit ? A) B) C) D) E) Vital signs sufficient No gag reflex present Spontaneous breathing Client easily arousable Immobility p. 103 391 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com ANSWER KEY 1 E 47 E 93 2 E 3 E 4 B C 139 B 185 D 231 D 48 A 49 D 94 A 140 D 186 D 232 D 95 G 141 C 187 A 233 A 50 D 96 B 142 E 188 E 234 E 5 A 51 A 97 A 143 E 189 C 235 E 6 B 52 A 98 A 144 B 190 E 236 A 7 C 53 A 99 A 145 E 191 E 237 E 8 C 54 A 100 A 146 E 192 D 238 A 9 C 55 A 101 E 147 B 193 A 239 A 10 E 56 E 102 E 148 B 194 C 240 A 11 C 57 B 103 A 149 A 195 A 241 A 12 B 58 A 104 C 150 B 196 A 242 A 13 A 59 E 105 A 151 A 197 E 243 E 14 A 60 E 106 A 152 C 198 A 244 A 15 A 61 B 107 E 153 D 199 A 245 A 16 B 62 B 108 B 154 A 200 E 246 A 17 C 63 A 109 C 155 B 201 B 247 D 18 A 64 A 110 D 156 C 202 E 248 A 19 B 65 A 111 B 157 C 203 A 249 A 20 A 66 A 112 A 158 E 204 D 250 A 21 D 67 D 113 E 159 A 205 E 251 B 22 B 68 E 114 A 160 A 206 C 252 C 23 A 69 B 115 A 161 C 207 D 253 E 24 D 70 D 116 A 162 B 208 E 254 E 25 D 71 D 117 E 163 B 209 D 255 D 26 A 72 A 118 D 164 C 210 A 256 D 27 A 73 B 119 C 165 E 211 B 257 D 28 D 74 E 120 A 166 B 212 C 258 B 29 A 75 D 121 A 167 B 213 E 259 E 30 E 76 D 122 B 168 C 214 D 260 C 31 B 77 D 123 A 169 A 215 A 261 B 32 A 78 A 124 E 170 B 216 A 262 A 33 E 79 B 125 B 171 E 217 E 263 E 34 B 80 A 126 E 172 A 218 E 264 E 35 E 81 B 127 E 173 B 219 E 265 E 36 C 82 A 128 B 174 A 220 E 266 E 37 A 83 E 129 C 175 D 221 C 267 A 38 A 84 E 130 A 176 A 222 A 268 E 39 A 85 E 131 E 177 C 223 E 269 E 40 A 86 B 132 A 178 C 224 E 270 A 41 A 87 A 133 A 179 D 225 A 271 E 42 A 88 B 134 C 180 A 226 E 272 B 43 B 89 A 135 A 181 A 227 E 273 E 44 E 90 E 136 A 182 E 228 E 274 E 45 D 91 E 137 A 183 C 229 A 275 A 46 C 92 A 138 D 184 A 230 D 392 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com 289 C 303 E 317 D 331 B 345 E 290 A 304 A 318 A 332 B 346 D 291 E 305 E 319 D 333 A 347 D 292 C 306 B 320 D 334 E 348 E 293 C 307 B 321 B 335 A 349 B 294 C 308 E 322 E 336 B 350 D B 295 C 309 A 323 E 337 C 351 E 282 E 296 E 310 C 324 D 338 E 352 E 283 D 297 D 311 A 325 C 339 A 353 E 284 B 298 B 312 E 326 C 340 C 354 E 285 C 299 E 313 A 327 D 341 A 355 B 286 C 300 C 314 C 328 B 342 A 287 C 301 C 315 A 329 A 343 A 288 A 302 A 316 C 330 A 344 A 276 E 277 C 278 C 279 A 280 B 281 Learning Plan Recommendations Depending on how soon after your college graduation you are intending to start your NCLEX-RN exam preparation process we recommend the following 3 individual learning plans below. We also recommend to schedule the exam date before you start your preparation process. Depending, if you are a full or part time student you may adapt the following time lines to your individual situation. Content Review Keyword Review Question Review Graduating Students Graduation 6 вЂ“ 12 months ago 10 days 20 days Refresher / Returner / Retaker 30 days 2 days 4 days 8 days 3 days 6 days 12 days Preparation periods over 50 days in length should be generally avoided since it becomes more difficult to retain the particular specific knowledge requirements over a longer period of time. For the individual situation you may focus on retaining as many exam relevant facts as possible instead of focusing on practice questions only. This method enables you much rather to aquire a sufficient and broad knowledge of the NCLEX-RN curriculum, which is essential to meet the passing standards. The NCLEX вЂ“ RN curriculum consists of a well defined pool of knowledge areas which we have introduced you to entirely in this manual. The challenge of passing this nursing board exam is to recognize as many known facts in the actual exam situation. 393 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual www.nclex-tutorial.com ! " # ! * *& $ , % % , $ % & # " #' ( # ) % % $ " $$ + , % % % * "* # ! ". % & % # % & & ,% & & & & $ # "$ $ # % % * $ ) * $ * # % % * % / & % $ ! " ! & & ! " $ %$ $ $ $ & 0& 1 ! " # # & ! ' $ % # " # $ # % &( '#) -% ' + " * , - # " . /- $ Register online at: www.nclex-tutorial.com and reserve your seat today, for one of our upcoming classes in your area! 394 Dr. KarrenbergвЂ™s 2010 NCLEX-RNВ® Review Manual