Exam (elaborations)
NCLEX-Day-4.
- Module
- Breathing pat. in labor
- Institution
- Breathing Pat. In Labor
Exam of 18 pages for the course Breathing pat. in labor at Breathing pat. in labor (NCLEX-Day-4.)
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Ischemic stroke- loss of brain tissue due to blockage in blood flow
- Elevated blood pressure is common and permitted after a stroke and may be a compensatory mechanism to
maintain cerebral perfusion distal to the area of blockage. This permissive hypertension usually autocorrects
within 24-48 hours and does not require treatment unless the hypertension is extreme (systolic blood pressure
>220 mm Hg or diastolic blood pressure >120 mm Hg) or contraindicated due to the presence of another illness
requiring strict blood pressure control (eg, active ischemic coronary disease, heart failure, aortic dissection). A
blood pressure of 178/95 mm Hg should be monitored, along with the client's other vital signs and status.
Cystic fibrosis
- In cystic fibrosis (CF), a defective protein responsible for transporting sodium and chloride causes the
secretions from the exocrine glands to be thicker and stickier than normal. The sticky respiratory secretions
lead to the inability to clear the airway and a chronic cough. These abnormal secretions plug smaller airway
passages and ducts in the GI tract. Secretions of impaired digestive enzymes in the GI tract result in ineffective
absorption of essential nutrients.
- The client eventually develops chronic lung disease (bronchiectasis) and is at risk for recurrent lung
infections.
- These clients are also at risk for rupture of the damaged alveoli, which results in sudden-onset
pneumothorax. Findings of pneumothorax include sudden worsening of dyspnea, tachypnea, tachycardia, and
a drop in oxygen saturation. Because many of these findings can be seen with lung infection, a sudden drop in
oxygen saturation could be the only early clue.
- The client with CF will often have a decreased pulse oximetry (reflects oxygen saturation in the blood) reading
due to the chronicity of the disease process and damage to the lungs; however, a reading of 90% requires urgent
intervention.
- Chest physiotherapy helps remove sticky secretions that cause ineffective airway clearance. Clients and
parents should receive genetic testing and counseling as CF is transmitted in an autosomal recessive
inheritance pattern. Spiritual support should be offered as clients must deal with the impact of CF on lifespan
and future pregnancies.
- As a result of these changes, the client's lifespan is shortened; most affected individuals live only into their
30s.
- Clients with cystic fibrosis should adhere to a diet high in fat and calories to combat nutrient malabsorption.
Liberal fluid intake is encouraged to loosen the thick secretions. Spiritual support should be offered to deal
with the shortened life span.
Acute pancreatitis
Supportive care for symptom relief and prevention of complications are the major goals in clients with acute
pancreatitis. These strategies include:
1. NPO status - The client is maintained on NPO status as any ingestion of food will stimulate the
excretion of pancreatic enzymes. A nasogastric tube is used to suction out gastric secretions; this will
reduce nausea and lessen stimulation of the pancreas as these juices will move to the duodenum.
2. Pain management - Intravenous opioids (eg, hydromorphone, fentanyl) are frequently utilized for pain
management. Morphine can also be used; worsening pancreatitis due to increase in sphincter of Oddi
pressure has not been proven in studies.
3. IV fluids - Aggressive fluid replacement to prevent hypovolemic shock is critical. Inflammation of the
pancreas releases chemical mediators that increase capillary permeability and cause third spacing (fluid
going into empty spaces).
- The client should maintain positions that flex the trunk and draw the knees up to the abdomen (semi-Fowler's)
to decrease tension on the abdomen. A side-lying position with the head elevated to 45 degrees will help relieve
the pain even better.
,Abdominal aortic aneurism
- An abdominal aortic aneurysm (AAA) is a blood-filled bulge in the abdominal aorta caused by weakening in
the vessel wall due to increased pressure.
- Risk factors include male sex, age >65, coronary artery and peripheral vascular diseases, hypertension, and
family and smoking history.
- AAA dissection (blood leakage into a vessel tear) or rupture may manifest as acute-onset abdominal pain
radiating to the back and is typically associated with symptoms of hemorrhagic shock (eg, decreased systolic
pressure; increased, weak pulses; pallor).
- Clients with atherosclerotic vascular disease in one system (eg, stroke, peripheral vascular disease) are more
likely to have undiagnosed, underlying atherosclerotic vascular disease in other areas (eg, coronary disease,
aortic aneurysm). Evaluation and treatment of a suspected abdominal aortic aneurysm dissection or rupture are
critical as a vascular bleed is potentially life-threatening.
Abdominal aortic aneurysm repair
- Abdominal aortic aneurysms are surgically repaired when they measure about 6 cm or are causing
symptoms. Repair can be done via femoral percutaneous placement of a stent graft (endovascular aneurysm
repair) or via an open surgical incision of the aneurysm with synthetic graft placement.
- The client must be monitored postoperatively for graft leakage and hemodynamic stability.
- Adequate blood pressure is necessary to maintain graft patency, and prolonged hypotension can lead to the
formation of graft thrombosis.
- Signs of graft leakage include a decreasing blood pressure and increasing pulse rate.
Hip replacement
- To prevent hip prosthesis dislocation following hip arthroplasty, a client must not force the hip into >90
degrees of flexion. Clients should use a chair with armrests and a high firm seat and proceed to place the hands
on the armrests for support while lowering themselves onto the seat and when rising from it. Bending forward
when getting into a chair creates excessive hip flexion (>90 degrees) and must be avoided.
- The client performs leg exercises 2-3 times a day to help strengthen the muscles surrounding the hip and
continues them for several months after discharge. These include isometric quadriceps and gluteal setting,
leg raises, and abduction exercises from the supine and standing positions.
Hypoglycemic reaction & awake
- hypoglycemic reaction (evidenced by low blood glucose <70 mg/dL [3.9 mmol/L]).
- The client who is alert enough to ingest food/liquids orally should be given 15 grams of a simple
carbohydrate such as orange juice or low-fat milk.
- The fat in whole milk slows the absorption process and will not treat hypoglycemia quickly enough. For this
reason, low-fat milk is recommended.
- Fingerstick blood glucose should be checked 10-15 minutes after this. If the client shows no improvement, the
simple carbohydrate can be readministered orally.
Hypoglycemic reaction & unable to ingest foods/liquids orally
- Dextrose (D50 IV push), a highly concentrated sugar, and glucagon (intramuscular, subcutaneous,
intravenous/gel), a hormone that stimulates glycogenolysis (conversion of glycogen to glucose), are
administered to hypoglycemic clients who are unable to ingest a simple oral carbohydrate.
- These can cause rebound hypoglycemia by stimulating additional insulin release from the body in response
to increased serum glucose levels.
, Rules of 9’s
- The rule of nines provides a quick estimate of the percentage of total body surface area (TBSA) affected by
partial- and full-thickness burns in an adult client. TBSA determines the volume of necessary fluid
resuscitation and the required level of care. The rule of nines assigns 9% per arm, 18% per leg, 36% for the
torso, 1% for the perineum, and 9% for the head and neck.
- The rule of nines is used to estimate quickly the percentage of total body surface area (TBSA) affected by
partial- and full-thickness burns in an adult client. Superficial (1st degree) burns are not included in the
calculation of affected TBSA. For a client who has sustained partial-thickness burns to all anterior body
surfaces below the neck, TBSA is calculated as follows:
TBSA = [anterior torso] + [anterior arms] + [anterior legs] + [perineum]
TBSA = [18] + [4.5 + 4.5] + [9 + 9] + [1]
TBSA = 18 + 9 + 18 + 1 = 46%
Preventing skin cancer
To prevent sunburn, instruct clients to avoid sun exposure from 10 AM to 4 PM, use protective clothing, use
sunscreen properly (daily application; minimum SPF of 15 or 30; 20-30 minutes before going outside;
reapplication when wet and every 2 hours), and avoid non-solar exposure to UV radiation (eg, tanning beds,
sunlamps).
Skin Cancer examination
1. Asymmetry (eg, one half unlike the other)
2. Border irregularity (eg, edges are notched or irregular)
3. Color changes and variation (eg, different brown or black pigmentation)
4. Diameter of 6 mm or larger (about the size of a pencil eraser)
5. Evolving (eg, appearance is changing in shape, size, color)
- Pus or purulent drainage is usually indicative of an infectious process, not cancer.
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