NCLEX

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sscott
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224449
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NCLEX
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2013-07-03 19:47:51
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NCLEX Tips
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NCLEX Tips
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  1. DELEGATION
    • Do not delegate what you can EAT!
    • E - Evaluate
    • A - Assess
    • T - Teach
  2. ADDISON'S DISEASE
    • hypoNa+
    • hypotension
    • decreased blood volume
    • hyperkalemia
    • hypoglycemia
  3. CUSHING'S DISEASE
    • ↑ hyperNa+
    • ↑ hypertension
    • ↑ increased blood volume
    • hypokalemia
    • ↑ hyperglycemia
  4. No PEE no K+!
    Never give Potassium without adequate urine output.
  5. VEIN and ARTERY perfusion.
    • EleVate Veins
    • DAngle Arteries
  6. APGAR
    • A - APPEARANCE (all pink, pink/blue, blue/pale)
    • P - PULSE (>100, <100, absent)
    • G - GRIMACE (cough, grimace, no response)
    • A - ACTIVITY (flexed, flaccid, limp)
    • R - RESPIRATIONS (strong cry, weak cry, absent)
  7. AIRBORNE PRECAUTIONS
    "MTV"
    • "MTV"
    • M - Measels
    • T - TB
    • V - Varicella (Chicken Pox/Herpes Zoster/Shingles)

    • * Private Room - Negative Pressure with 6-12 air exchanges/hr *
    • * TB - N95 Mask *
  8. DROPLET PRECAUTIONS
    "SPIDERMAN"
    • "SPIDERMAN"
    • S - Sepsis, Scarlet Fever, Strep Pharyngitis
    • P - Parvovirus B19, PNA, Pertussis
    • I - Influenza
    • D - Diphtheria (pharyngeal)
    • E - Epiglottitis
    • R - Rubella
    • M - Mumps, Meningitis, Mycoplasma pr Meningeal PNA
    • AN - Adenovirus

    • * Private Room or Cohort, Mask *
  9. CONTACT PRECAUTIONS
    "MRS. WEE"
    • "MRS. WEE"
    • M - Multidrug Resistant Organism
    • R - Respiratory Infection
    • S - Skin Infection
    • W - Wound Infection
    • E - Enteric Infection (C. Diff)
    • E - Eye Infection (Pink Eye)
  10. SKIN PRECAUTIONS
    "VCHIPS"
    • "VCHIPS"
    • V - Varicella Zoster
    • C - Cutaneous Diphtheria
    • H - Herpes Simplex
    • I - Impetigo
    • P - Pediculosis
    • S - Scabies
  11. POSITIONING:

    AIR/PULMONARY EMBOLISM
    LEFT side and ↓HOB

    (S/S: CP, Difficulty breathing, Tachycardia, Pale/Cyanotic, Sense of impending doom.)
  12. POSITIONING:

    LABOR w/ UN-REASSURING FHR
    • LEFT side
    • (Stop the Pitocin, give O2, Increase IVF)

    (S/S: Late Decels, Decreased Variability, Fetal Bradycardia.)
  13. POSITIONING:

    TUBE FEEDING w/ DECREASED LOC
    RIGHT side (promotes emptying of stomach), ↑HOB (prevent aspiration)
  14. POSITIONING:

    DURING EPIDURAL
    SIDE-lying
  15. POSITIONING:

    AFTER LP
    FLAT-SUPINE (prevent HA and leaking of CSF)
  16. POSITIONING:

    HEAT STROKE
    Lie FLAT with LEGS ELEVATED.
  17. POSITIONING:

    DURING CONTINUOUS BLADDER IRRIGATION
    Catheter is taped to thigh, so the leg should be kept STRAIGHT.

    No other positioning restrictions! :)
  18. POSITIONING:

    AFTER MYRINGOTOMY
    Position on side of AFFECTED EAR after surgery. (This allows drainage of secretions.)
  19. POSITIONING:

    AFTER CATARACT SURGERY
    Sleep on UNAFFECTED SIDE with a night shield for 1-4 weeks.
  20. POSITIONING:

    AFTER THYROIDECTOMY
    LOW or SEMI-FOWLERS

    • Support head, neck and shoulders.
  21. POSITIONING:

    INFANT w/ SPINA BIFIDA
    PRONE so that sac does not rupture.
  22. POSITIONING:

    BUCK'S TRACTION
    ELEVATE FOOT OF BED for counter-traction
  23. POSITIONING:

    AFTER TOTAL HIP REPLACEMENT
    Maintain HIP ABDUCTION by separating thighs with pillows.

    Don't sleep on operated side. Don't flex hip more than 45°-60°. Don't ↑HOB more than 45°.
  24. POSITIONING:

    INFANT w/ CLEFT LIP
    Position ON BACK or in infant seat to prevent trauma to suture line.

    While feeding, hold in UPRIGHT position.
  25. POSITIONING:

    PREVENT DUMPING SYNDROME
    Eat in RECLINING position, then LIE DOWN after meals for 20-30 minutes (also restrict fluids during meals, low CHO and fiber diet, and small frequent meals).
  26. POSITIONING:

    AKA
    ELEVATE for first 24hr on pillow.

    Position PRONE daily to provide for hip extension.
  27. POSITIONING:

    BKA
    ELEVATE foot of bed for first 24hr.

    Position PRONE daily to provide for hip extension.
  28. POSITIONING:

    DETACHED RETINA
    Area of detachment should be in DEPENDENT position.
  29. POSITIONING:

    ADMINISTRATION OF ENEMA
    LEFT SIDE-LYING (Sim's) with knees flexed.
  30. POSITIONING:

    AFTER SUPRATENTORIAL SURGERY
    (incision behind hairline)
    • ↑HOB 30°-45°
  31. POSITIONING:

    AFTER INTRATENTORIAL SURGERY
    (incision at nape of neck)
    Position patient FLAT and LATERAL on either side.
  32. POSITIONING:

    DURING INTERNAL RADIATION
    BEDREST while implant in place.
  33. POSITIONING:

    AUTONOMIC DYSREFLEXIA/HYPERREFLEXIA
    SITTING POSITION (↑HOB) first before any other implementation!

    (S/S: pounding HA, profuse sweating, nasal congestion, goose flesh, bradycardia, HTN)
  34. POSITIONING:

    SHOCK
    BEDREST with extremities ELEVATED 20°, knees straightm head slightly elevated.

    (MODIFIED TRENDELENBURG)
  35. POSITIONING:

    HEAD INJURY
    ↑HOB 30° to decrease ICP.
  36. POSITIONING:

    PERITONEAL DIALYSIS
    (when outflow is inadequate)
    Turn patient from SIDE TO SIDE before checking for kinks in tubing (according to Kaplan).
  37. POSITIONING:

    PROLAPSED CORD
    KNEE-CHEST or TRENDELENBURG
  38. PANCREATITIS
    Medication
    • DEMOROL
    • NOT Morphine Sulfate!
  39. MYASTHENIA GRAVIS
    Worsens with exercise and improves with rest.
  40. MYASTHENIA CRISIS
    A positive reaction to Tensilon - will improve symptoms.
  41. CHOLINERGIC CRISIS
    Caused by excessive medication.

    Stop medication - giving Tensilon will make it worse.
  42. HEAD INJURY
    Medication
    • Mannitol (Osmotic Diuretic)
    • Crystallizes at room temp, so ALWAYS use filter needle!
  43. LIVER BIOPSY
    Lab Result?
    Always check labs for PROTHROMBIN TIME!!!
  44. METABOLIC ACIDOSIS
    • BASE from the BUTT.
    • Diarrhea.
  45. METABOLIC ALKALOSIS
    • Lose acid from the mouth.
    • Emesis.
  46. MYEXEDEMA / HYPOTHYROIDISM
    Slowed physical and mental function, sensitivity to cold, dry skin and hair.
  47. GRAVE'S DISEASE / HYPERTHYROIDISM
    Accelerated physical and mental function, sensitivity to heat, fine/soft hair.
  48. THYROID STORM
    Increased temp, pulse, and HTN.
  49. POST-THYROIDECTOMY
    SEMI-FOWLER'S, prevent neck flexion/hyperextension, trach at bedside.
  50. HYPOPARATHYROID
    CATS (convulsions, arrhythmias, tetany, smasms, stridor)

    ↑Ca+, ↓Phosphorus diet.
  51. HYPERPARATHYROID
    Fatigue, muscle weakness, renal calculi, back and joint pain (↑Ca+).

    ↓Ca+, ↑ Phosphorus diet.
  52. HYPOVOLEMIA
    Increased temp, rapid/weak pulse, increased respirations, hypotension, anxiety, urine SG >1.030
  53. HYPERVOLEMIA
    Bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine SG <1.010, SEMI-FOWLER'S.
  54. D.I.
    (
    DECREASED ADH)
    Excessive uring output and thirst, dehydration, weakness.

    Administer Pitressin.
  55. SIADH
    (INCREASED ADH)
    Change in LOC, decreased DTR, tachycardia, N/V/A, HA.

    Administer Declomycin, diuretics.
  56. HYPONATREMIA
    Nausea, muscle cramps, increased ICP, muscular twitching, convulsion.

    Administer Osmotic Diuretics, Fluids.
  57. HYPERNATREMIA
    Increased temp, weakness, disorientation/delusions, hypotension, tachycardia.

    Administer Hypotonic Solutions.
  58. HYPOCALCEMIA
    • CATS
    • C - Convulsions
    • A - Arrhythmias
    • T - Tetany
    • S - Spasms and Stridor
  59. HYPERCALCEMIA
    Muscle weakness, lack of coordination, abd pain, confusion, absent DTR, sedative effect on CNS.
  60. HYPOMAGNESIUM
    Tremors, tetany, seizures, dysrhythmias, depression, confusion, dysphagia. Dig Toxicity.
  61. HYPERMAGNESIUM
    CNS depression, hypotension, facial flushing, muscle weakness, absent DTR, shallow respirations - EMERGENCY!!
  62. ADDISON'S
    ↓Na+, ↑K+, hypoglycemia, dark pigmentation, decreased resistance to stress, fractures, alopecia, weight loss, GI distress.
  63. CUSHING'S
    ↑Na+,↓K+, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump.
  64. ADDISONIAN CRISIS
    N/V, confusion, abd pain, extreme weakness, hypoglycemia, dehydration, decreased BP.
  65. PHEOCHROMOCYTOMA
    Hypersecretion of epi/norepi, persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA.

    Avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods, surgery to remove tumor.
  66. HYPOKALEMIA
    Muscle weakness, dysrhythmias.

    Increase K+ (raisins, bananas, apricots, oranges, beans, potatoes, carrots, celery)
  67. HYPERKALEMIA
    MURDER

    • M - Muscle weakness
    • U - Urine (oliguria/anuria)
    • R - Respiratory Depression
    • D - Decreased Cardiac Output
    • E - ECG Changes
    • R - Reflexes
  68. NEUROLEPTIC MALIGNANT SYNDROME
    (NMS)
    • NMS is like S&M:
    • You get hot (hyperpyrexia)
    • Stiff (increased muscle tone)
    • Sweaty (diaphoresis)
    • BP, Pulse and Respirations elevate
    • You start to drool.
  69. Never get PREGNANT with a GERMAN!
    GERMAN MEASLES is dangerous when pregnant. Regular measles is not.
  70. TETRALOGY OF FALLOT
    ("DROP")
    • D - Defect (septal)
    • R - Right Ventricular Hypertrophy
    • O - Overriding Aorta
    • P - Pulmonary Stenosis
  71. Pirates take MAOI's when they're depressed.
    • Pirates say "arr". MAOI's have an "arr" sound in the middle of their name:
    • Parnate, Marplan, Nardil.

    • "PANAMA"
    • PArnate NArdil MArplan
  72. AUTONOMIC DYSREFLEXIA
    POTENTIALLY LIFE-THREATENING EMERGENCY!

    • ↑HOB 90°
    • Loosen constrictive clothing
    • Assess for bladder distention and bowel impaction (triger)
    • Administer Anti-HTN meds (may cause stroke, MI, seizure)
  73. DIGOXIN
    • Check pulse: <60 - HOLD.
    • Check Dig levels and K+ levels.
  74. AMPHOJEL
    • Treatment of GERD and Kidney Stones.
    • Watch out for constipation!
  75. VISTARIL
    • Treatment of anxiety and also itching.
    • Watch for dry mouth.
    • Commonly given Pre-Op.
  76. VERSED
    • Given for Conscious Sedation.
    • Watch for resp depression and hypotension.
  77. PTU and TAPAZOLE
    Prevention of Thyroid Storm.
  78. SINEMET
    Treatment of Parkinsons.

    • Sweat, saliva, urine may turn reddish-brown occasionally.
    • Causes drowsiness.
  79. ARTANE
    • Treatment of Parkinsons.
    • Sedative Effect.
  80. COGENTIN
    Treatment of Parkinsons and Extrapyramidal Effects of other drugs.
  81. TIGAN
    Treatment of Post-Op N/V and for Nausea associated with Gastroenteritis.
  82. TIMOLOL (TIMOPTIC)
    Treatment of Glaucoma.
  83. BACTRIM
    • Antibiotic.
    • Don't take if allergic to Sulfa-Drugs!!
    • Diarrhea common side effect.
    • Drink plenty of fluids.
  84. GOUT MEDICATIONS
    • Probenecid (Benemid)
    • Colchicine
    • Allopurinol (Zyloprim)
  85. APRESOLINE (HYDRALAZINE)
    • Treatment of HTN or CHF.
    • Report flu-like sx, rise slowly from sitting/lying.
    • TAKE WITH MEALS!
  86. BENTYL
    • Treatment of IBS.
    • Assess for anticholinergic side effects.
  87. CALAN (VERAPAMIL)
    • Ca+ Channel Blocker.
    • Treatment of HTN, Angina
    • Assess for constipation.
  88. CARAFATE
    • Treatment of Duodenal Ulcers.
    • Coats the ulcer.
    • TAKE BEFORE MEALS!
  89. THEOPHYLLINE
    Treatment of Asthma or COPD.

    THERAPEUTIC DRUG LEVEL: 10-20
  90. MUCOMYST
    • Antedote to Tylenol.
    • PO.
  91. DIAMOX
    • Treatment of Glaucoma, High Altitude Sickness.
    • Don't take if allergic to Sulfa-Drugs!
  92. INDOCIN
    • NSAID
    • Treatment of Arthritis (osteo, RA, gouty), Bursitis, and Tendonitis.
  93. SYNTHROID
    • Treatment of Hypothyroidism.
    • May take several weeks to take effect.
    • Notify doctor of CP.
    • Take in the AM on EMPTY STOMACH.
    • Could cause hyperthyroidism.
  94. LIBRIUM
    • Treatment of ETOH W/D.
    • Don't take ETOH with this!!!
  95. ONCOVIN (VINCRISTINE)
    • Treatment of Leukemia.
    • Given IV only!
  96. KWELL (LINDANE)
    • Treatment of Scabies and Lice.
    • Scabies: Apply lotion once and leave on for 8-12 hours.
    • LiceL Use the shampoo and leave on for 4 minutes with hair uncovered, then rinse with warm water and comb with a fine-tooth comb.
  97. PREMARIN
    • Treatment of Menopause.
    • Estrogen Replacement.
  98. DILANTIN
    Treatment of Seizures.

    THERAPEUTIC DRUG LEVEL: 10-20
  99. NAVANE
    • Treatment of Schizophrenia.
    • Assess for EPS.
  100. RITALIN
    • Treatment of ADHD.
    • Assess for HEART-RELATED SE - report ASAP!
    • Child may need "drug holiday" - stunts growth.
  101. DOPAMINE (INTROPINE)
    • Treatment of Hypotension, Shock, Low Cardiac Output, Poor Perfusion to Vital Organs.
    • Monitor EKG for arrhythmias.
    • Monitor BP.
  102. FETAL HEART RATE PATTERNS
    "VEAL CHOP"
    • V - Var. Decel    C - Cord Comp. caused
    • E - Early Decel   H - Head Comp. caused
    • A - Accel.         O - OKAY! Not a problem!
    • L - Late Decel    P - Placental Insuff. (can't fill)
  103. CORD COMPRESSION
    • Place mother in TRENDELENBURG - this removes pressure of the presenting part off the cord.
    • (Mom's head is down - baby no longer being pulled out of body by gravity.)
  104. PROLAPSED CORD
    Cover the cord with sterile gauze to prevent drying of the cord and to minimize infection.
  105. LATE DECELERATIONS
    Turn mom on her LEFT SIDE - allows more blood flow to the placenta.
  106. ANY BAD FETAL HEART RATE PATTERN...
    Give O2, usually by mask.
  107. EPIDURAL
    HYDRATION beforehand is a priority!!
  108. NCLEX TIP:
    Monit
    ors/Machines
    • NEVER CHECK A MONITOR OR A MACHINE AS A FIRST ACTION!
    • Always assess the patient first!
  109. POSTERIOR PRESENTATION
    Sounds are heard at the sides.
  110. ANTERIOR PRESENTATION
    Sounds are heard closer to midline, between the umbilicus and where you would listen to a posterior presentation.
  111. BREECH PRESENTATION
    Sounds are high up in the fundus, near the umbilicus.
  112. VERTEX PRESENTATION
    Sounds are heard a little bit above the symphysis pubis.
  113. VENTILATOR ALARMS
    "HOLD"
    • H - HIGH Alarm
    • O - Obstruction
    • Due to increased secretions, kink, patient coughs, gags, or bites.

    • L - LOW Alarm
    • D - Disconnection
    • Or leak in vent or in patient airway cuff, pt stops spontaneous breathing.
  114. NCLEX TIP:
    Blood Sugar
    Hot and Dry - Sugar High (HYPERglycemia)

    Cold and Clammy - Need some Candy (HYPOglycemia)
  115. NCLEX TIP:
    ICP and
    SHOCK
    (opposites!)
    ICP:↑BP, ↓Pulse,↓RR


    SHOCK: ↓BP, ↑Pulse, ↑RR
  116. NCLEX TIP:
    Cor Pulmonae
    RIGHT-SIDED Heart Failure caused by LV failure (so pick edema, JVD if it's a choice.)
  117. Medication of Choice: CHF
    Ace Inhibitor
  118. Medication of Choice: Anaphylactic Shock
    Epinephrine
  119. Medication of Choice: Status Epilepticus
    Valium
  120. Medication of Choice: Bipolar Disorder
    Lithium
  121. S3
    CHF and MI
    • CHF: NORMAL
    • MI: ABnormal
  122. LOW RESIDUE
    = Low Fiber
  123. DIVERTICULITIS Pain
    Around LLQ
  124. APPENDICITIS Pain
    RLQ with Rebound Tenderness
  125. ASCITES
    Portal HTN + Albuminemia
  126. Pancreatitis and Morphine
    Morphine causes spasms in the Sphincter of Oddi, therefore Demerol is given.
  127. Semi-Fowlers
    HOB 30°

    • Gastric feedings, head injury, post-op cranial surgery, resp illness w/ dyspnea, post-op cataract removal, increased ICP
  128. Fowler's
    HOB 45°

    Head injury, post-op cranial surgery, post-op abd surgery, resp illness w/ dyspnea, cardiac problems w/ dyspnea, bleeding esophageal varices, post-op thyroidectomy, post-op cataract removal, increased ICP
  129. High-Fowler's
    HOB 90°

    Resp illness w/ dyspnea (emphysema, status asthmaticus, pneumothorax), cardiac problems w/ dyspnea, feeding, meal times, hiatial hernia, during and after meals.
  130. Supine
    (Dorsal Recumbent)
    Lying on back, head and shoulders; slightly elevated with a small pillow.

    SCI (no pillow!), urinary catheterization.
  131. Prone
    Lying on abdomen, legs extended, and head turned to the side.

    Pt who is immobilized or unconscious, post-LP 6-12°, post-myelogram 12-24° (oil-based dye), post-op tonsillectomy and adenoidectomy.
  132. Lateral
    (Side-Lying)
    Lying on side with most of the body weight borne by the lateral aspect of the lower ilium.

    Post-abd surgery, unconscious, seizures (head to side), post-op tonsillectomy and adenoidectomy, post-op pyloric stenosis of the lower scapula and the lateral (right side), post-liver biopsy (right side), rectal irrigations.
  133. Sims'
    (Semi-Prone)
    Lying on left side with most of the body weight borne by the anterior aspect of the ilium, humerus, and clavicle.

    Pt who is unconscious, enemas.
  134. Lithotomy
    Lying on back with hips and knees flexed at right angles and feet in stirrups.

    Perineal procedures, rectal procedures, vaginal procedures.
  135. Trendelenburg
    Head and body lowered while feet are elevated.

    Used for some surgeries; also may be used during labor if umbilical cord pressure is trying to be relieved.
  136. Modified Trendelenburg
    Supine with legs elevated.

    Shock
  137. Reverse Trendelenburg
    Head elevated while feet are lowered.

    • Cervical traction; also used to feed clients restricted to supine position, such as post-cardiac cath.
  138. Elevate 1 or More Extremities
    Elevate legs/feet or arms/hands by adjusting or supporting with pillows.

    Thrombophlebitis, application of cast, edema, post-op surgical procedure on extremity.
  139. Primary Prevention
    Focus is on promoting health and preventing disease.

    Immunizations, child car seat education, nutrition and fitness activities, health education programs.
  140. Secondary Prevention
    Focus is on early identification of illness, providing treatment, and conducting activities geared to prevent a worsening health status.

    Communicable disease screening and case finding, early detection and treatment of HTN, exercise programs for older adults who are frail.
  141. Tertiary Prevention
    Focus is on preventing long-term consequences of chronic illness or disability and supporting optimal functioning.

    Prevention of pressure ulcers as a complication of SCI, promoting independence for a client following a stroke.
  142. Fluid Volume Deficit
    Causes: Excessive GI loss, diaphoresis, fever, excess renal loss, hemorrhage, insufficient intake, age-related changes.

    S/S: Weight loss/poor skin turgor, dry mucus membranes, increased pulse, hyperthermia, cap refil >3, weakness, fatigue (LATE SIGNS: oliguria, decreased CVP, flattened neck veins), Elevated Hct and urine SG/osmolality.

    Dx: Lytes, BUN, Cr, Hct, Urine SG/Osmo

    Rn: Assess VS, skin turgor, strict I/O, daily weights, assess labs, replace fluids orally, initiate and maintain IVF, correct underlying cause.

    Tx: Lyte replacement, IVF
  143. Fluid Volume Excess
    Causes: Abnormal renal fxn, heart failure, hepatic failure, interstitial to plasma fluid shifts (hypertonic fluids, burns), excessive Na+ intake, age-related changes, water replacement w/o lyte replacement, excess intake of hypotonic fluid.

    S/S: Cough, dyspnea, crackles, increased BP/pulse/RR, weight gain (1L H2O=1kg weight), hemodilution of Hct and lytes (LATE SIGNS: JVD, tachycardia, pitting edema, increased CVP).

    Dx: Lytes, BUN, Cr, Hct, Urine SG/Osmo, CXR (if resp comp present).

    Rn: Assess RR/symmetry/effort, breath sounds, edema, ascites and measure abd girth, monitor I/O and VS, daily weights.

    Tx: Lyte replacement, IVF
  144. Metabolic Acidosis
    Risks: Diarrhea, fever, hypoxia, starvation, seizure, OD: salicylates or ethanol, renal fail.

    Symptoms: VS: bradycardia, weak pulses, hypotension, tachypnea. Flaccid paralysis. Confusion.

    Treatment: Treatunderlying cause. Admin fluids, lytes.
  145. Metabolic Alkalosis
    Risks: Ingestion of antacids, GI suction, hypokalemia, TPN, blood transfusion.

    Symptoms: Dizziness. Paresthesias. Hypertonic muscles. Decreased RR.

    Treatment: Treat underlying cause. Admin fluids, lytes.
  146. Respiratory Acidosis
    Risks: Respiratory depression, pneumothorax, airway obstruction, inadequate ventilation.

    Symptoms: Dizziness. Palpitations. Muscle twitching. Convulsions.

    Treatment: Maintain patent airway. Reversal agents for narcotics. Regulation ventilation therapy. Bronchodilators. Mucolytics.
  147. Respiratory Alkalosis
    • Risks: Hyperventilation, hypoxemia, altitude sickness, asphyxiation, asthma, pneumonia.
    •  
    • Symptoms: Tachypnea. Anxiety, tetany. Parresthesias. Palpitations. CP.

    Treatment: Regulate O2 therapy. Reduce anxiety. Rebreathing techniques.
  148. Asthma
    Risks: antigen-atb rxn triggered by food, meds, or inhaled substances. Pathophys abnorm within resp tract. (Older clients - beta receptors less responsive to agonist and trigger bronchospasms).

    • Symptoms: Sudden, severe dyspnea w/ use of accessory muscles. Sitting up, leaning forward. Diaphoresis, anxiety. Wheezing, gasping. Coughing. Cyanosis (late sign). Barrel chest.
    • Dx: ABGs, sputum cultures, PFT.

    Rn: Remain w/pt during attack. Position in high-Fowler's. Assess lung sounds and pulse ox. Admin O2 therapy. Maintain IV access.

    Treatment: Bronchodilators (Short-Acting: Proventil, Ventolin; Methylxanthines: Theo-Dur), Anti-Inflamm (Corticosteroids: Flovent, Prednisone; Leukotriene Antagonists: Singulair) (Combo Agents: Combivent, Advair). Therapeutic: Resp treatments, O2 therapy. Client Edu: Avoid allergens and triggers; proper use of inhaler.

    With inhaled agents, administer bronchodilators BEFORE anti-inflammatory medication.
  149. Status Asthmaticus
    Life-threatening episode of airway obstruction that is often unresponsive to treatment.

    Symptoms
    : Extreme wheezing. Labored breathing. Use of accessory muscles. Distended neck veins. High risk for cardiac and/or respiratory arrest.

    Treatment: High-Fowler's. Prep for emergency intubation. Admin O2, epinephrine, and systemic steroid as rx. Provide emotional support.

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