ATI MED SURG STUDY GUIDE – Flashcards

...Acute Kid inj: Restrict potassium, phosphate, magnesium during oliguria phase. Restrict fluids as ordered by md. (Diet high in protein) Chronic kid dis: Restrict sodium, potassium, phosphorous and magnesium. Restrict fluids as ordered by md. (Diet high in carbs, and moderate fat)

...Performed using a resectoscope, inserted through the urethra and trims away excess prostatic tissue, enlarging the passageway of the urethra through the prostate gland. Nursing Actions: Pre-op: Cardio, resp and renal systems s/b carefully assessed prior to surgery. Ensure client understands procedure and what to expect post-op. Post-op; Placement of an indwelling 3-way catheter. Drains urine and allows for installation of a continuous bladder irrigation (CBI) of normal saline (isotonic) or another prescribed irrigating solution to keep the cath free of obstruction. Cath Obstructed (bladder spasms & reduced irrigation outflow) turn off CBI and irrigate with 50ml of irrigations solutions using a large piston syringe. CONTACT surgeon if unable to free clot. Record amount of irrigating solution instilled (generally very large volumes ) and the amount of return. Th difference equals urine output (irrigating solution - amount in drain bag =total urine output) Cath has large balloon (30-45ml) that is taped tightly to the leg, creating tractions do that the balloon will apply firm pressure to the prostatic fossa to prevent bleeding. This make the client feel a continuous need to urinate. Instruct client NOT to void around the cath as this caused bladder spams. AVOID kinks in the tubing. Monitor vital signs and urinary output. MONITOR for bleeding (persistent bright red bleeding unresponsive to increase in CBI and traction on the cath or reduced HGB levels) REPORT to provider. Assist to ambulate as soon as possible to reduce risk of DVT. Medications to admin: analgesics, antispasmodics (bladder spams) , abt (prophylaxsis) , stools softener(avoid straining) REMOVAL of cath: Monitor urinary output, initially may be uncomfortable, red in color and contain clots. COLOR of urine should progress toward amble in 2-3 days. EXPECTED OUTPUT : 150-200ml every 3-4 hours. CONTACT provided if unable to void.

...Use on strong side.

...Group of manifestations that occur following eating. Shift of fluid to the abd is triggered by rapid gastric emptying or high carb ingestion.Client will have vasomotor symptoms (syncope, pallor, palpations dizziness, headache) MEDICATIONS: admin powdered pectin or octreotide (Sandostatin) sq if manifestations are severe and not effectively controlled with dietary measures. arcabose (Prandase) slows the absorption of carbs dicyclomine(Bentyl) antispasmodics Monitor I&O PREVENTION: Lying down after meals slow the movement of food within the intestines. Limit the amt of fluid ingested at one time Eliminate liquids with meals, for 1 hours prior to and following a meal Consume high protein, high fat, low fiber, low - moderate carb diet. Avoid mils, sweets or sugars (fruit juices, sweetened fruit, milk shakes hone syrup jelly. ) Consume small frequent meals rather than large meals.

...Apply pneumatic compressions stockings or elastic stocking. Early ambulating, leg exercises, SCD's

LIMIT intake of food high in animal protein(reduction of protein intake decreases calcium precipitation) LIMIT sodium intake REDUCED calcium intact (dairy products) AVOID CALCIUM OXALATE: Spinach, black tea, rhubarb, coca, beets pecans, peanuts, okra, chocolate, wheat germ, lime peel Swiss chard. AVOID STRUVITE: dairy products, red and organ meats, whole grains. AVOID URIC ACID: decrease intake of purine source (organ meats, poultry, fish, gravies, red wine, sardines MEDICATIONS: allopurinol (Zyloprim) prevent formations of uric acid Potassium or sodium citrate or sodium bircarbonate is used to alkalinize the urine. Thiazide diuretics(hydrochorothiazide) used o increase calcium reabsorption. captopril (Capoten) used to lower urine cystine alpha mercaptopropionylglycine (AMPG) used to lower urine cystine

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...AVOID nephrotoxic medication or combining 20 more will lead to nephron destruction:

S/S Hypoxia: fatigue; irritability; ALLERGIC REACTIONS: Immediate: mild/life threatening, chills, fever, low back pain, tachycardia, flushing, hypotension, chest tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria Febrile: 30-6 hours after transfusion: chills, fever, flushing, headache, anxiety, USE WBC filter ADMINISTER antipyretics. Mild Allergic: during or up to 24 hours after transfusion:itching, urticaria, flushing. ADMINISTER diphenhydramine (Benadryl) Anaphylactic: Immediate: wheezing, dyspnea, chest tightness, cyanosis ADMINISTER maintain airway, administer O2, IV Fluids, antihistamines, corticosteroids and vasopressors. STOP TRANSFUSION IMMEDIATELY if reaction is suspected. INITIATE 0.9% sodium chloride (use separate line so no more blood is infused into body) SAVE blood bag with the remaining blood and the blood tubing for testing at the lab following facility protocol

...ADMINISTERED for: increase contractility improving cardiac output Take apical pulse for 1 minute, if less than 60 beats per min or irregular, HOLD digoxin, NOTIFY provider OBSERVE for nausea and vomiting. TAKE dose at same time every day DO NOT take at same time of antacids. Separate meds by at least 2 hours apart REPORT s/s toxicity :fatigue, muscle weakness, confusion, loss of appetite, REGULARLY have digoxin and potassium levels checked ANTIDOTE for dig tox: digibind

...IMPLANTED PORTS: Port is comprised of a small reservoir covered by a thick sputum. INSERTION LOCATION: surgically implanted into chest wall pocket cath is inserted into subclavian vein with tip in superior vena cava. INDICATIONS: long term (a year or more) need for vascular access commonly used for chemo PRE-PROCEDURE: apply local anesthetic to skin if indicated, Palpate skin to locate port body septum to ensure proper insertion of the needle. Clean the skins with alcohol for at least 3 seconds and allow to dry prior to insertion of needle, Access with a non coring (Huber) needle. POST-PROCEDURE: Flush with 10ml 0.9% sodium chloride or per facility protocol ...PICC LINES(HICKMAN,GROSHONG) Inserted by a specially trained nurse. 40-65cm with single or multiple lumens. Length of use: up to 12 months Insertion Locations: basilic or cephalic vein at lest one fingers breadth below or above the antecubital fossa. CATH is advanced until the tip is positioned in the lower one third of the superior vena cava. Indications: admin of blood, long term adm of chemo agents, abt, tpn. TAKE XRAY to make sure of tip placement COVER WITH GAUZE and replace within 24hours with transparent dressing ASSESS site q8hr: redness, swelling drainage tendereness and condition of dressing Use 10ml or larger syringe to flush with

XRAY

...ADMIN SQ, rotate sites to prevent lipohypertrophy (increased swelling of fat) or lipoatrophy (loss of fat tissue) within one anatomic sit (prevents day to day changes in absorption rate) COMBO INSULIN: clear to cloudy. draw up rapid/short acting (Lispro(Humalog) aspart(Novolog) glulisine (Apidra) first, then draw up short-acting lasting regular (Hum R, Nov R)or intermediate acting (NPH) Humulan N, detemir (Levemir) (DO NOT MIX WITH INSULIN) DO NOT mix long lasting insulin glargine (Lantus) TYPE WHEN ONSET PEAK DURATION TIME Rapid ac 10-30sec Short 30/60mi 1-2hr ac Intermed between meals/nite Long 1xdaily only admin anytime, but at same time each day VISION IMPAIRED:

...SERUM MAG: less than 1.3mg/dl THERAPEUTIC RANGE:

0.8xkg

...D10 if run out of TPN WHY: weight loss 7% body wt and NPO x5days or more hyper-metabolic state NEVER abruptly stop TPN. Speeding up or slowing down is contradicted can altar bgl significantly MONITOR vs q4-8h STERILE PROCEDURES: inc mas, when change cent line dsg change tubing and solution bag q24h even if not done. filter added to collect particles from solution DO NOT USE line for other IV bolus sol (prevents contamination and interruption of flow rate) DO NOT ADD anything to the solution d/t risk of contamination and incompatibility INTERVENTIONS: check capillary glucose q4-6h for 1st 24h Clients rec tpn freq need supp reg insulin until pancreas can increase it endogenous prod of insulin keep dextrose 10% in water at bedside in case the solu unexp ruin or the next bag is not avail.

...epoeten alfa (Epogen, Procrit): hematopoietic growth factor used to increase production of WBC MONITOR: increase B/P MONITOR: Hgb and Hct twice weekly MONITOR: cardiovascular event if Hgb increases to rapidly (greater than 1g/dl in 2 weeks) REINFORCE: important to have Hgb/Hct assessed q2week

...MEDICATION S/E: Hypertensive crisis occurs when clients do not follow the medication therapy regimen CLINICAL MANIFESTATIONS: severe h/a, extremely high b/p (systolic >240mmhg, diastolic >120mmhg, blurred vision, dizziness, disorientation, epistaxis ADMINISTER IV antihypertensive therapies, nitroprusside(Nitropress), nicardipine(Cardene IV) labetalol hydrochloride as prescribed. before, during and after IV admin MONITOR b/p q5-15minutes. assess neuro, pupils, loc, muscle stregnth, ECG BE CAREFUL WITH getting OOB, driving, climbing stairs until medication effects are fully known.

...NOTIFY provider if cough, it is s/e of ace. angioedema (swelling of tissues in throat that can progress to be life threatening.

KEEP BUBBLE check ptt

Calf pain

...INADEQUATE intake of calcium and vit d stimulates parathyroid hormone to be released and triggered calcium to be pulled from bone.

...MORPHINE hypersensitivity: resp rate drops below 8/min shallow, difficult to arouse. GIVE naloxone (Narcan) to reverse effects of morphine.

...MEDICATIONS: ADH stimulants-carbamazepine (Tegretol) vasopressin (Pitressin) ADH replacement- desmopressin acetate (DDAVP) aqueaous vasopressin (Pitressing(intranasley)) Polyuria, polydypsia, nocturia, fatigue, dehydration awb extreme thirst, wt loss, muscle weakness, h/a constipation, dizziness, sunken eyes, tachycardia, hypotension, loss or absence of skin turgor, dry mucous membranes,

...DILATIN ADVERSE AFFECTS: phenytoin (Dilantin): AVOID oral contraceptives, decrease effectiveness AVOID warfarin use, decreases absorption

...Inhibits platelet formation

...Encourage clients to drink 2-3 liters daily unless restricted by provider.

...S/S AORTIC DISSECTION: Sudden onset of tearing ripping and stabbing abdominal or back pain; Hypovolemic shock; diaphoresis, nausea, vomiting, faintness, apprehension, decreased or absent peripheral pulses, neurological deficits hypotension and tachycardia (initial) S/S THORACIC OUTLET SYNDROME: Severe back pain(most common)Hoarseness, cough, shortness of breath, and difficult swallowing, decrease in urinary output, S/S PVD ANEURYSMS:

...CPM: prescribed to promote motion in the knee and prevent scar tissue formation. CPM usually placed and initiated immediately after surgery. CPM provides passive range of motion from full extension to the prescribed amount of flexion. The prescribed duration of its use should be followed, but it should be turned off during meals. Positions of flexion of the knee are limited to avoud flexion contractures. AVIOD knee gatch and pillows placed behind the knee.

...Clients blood is collected in anticipation of future transfusions(elective surgery) this blood s designated for and can be used only by the client. Clients may donate blood 5 weeks in advance up to 72 hr prior to surgery

...MODERATE AND MAJOR BURNS: Maintain airway and ventilation, A NG tube may be indicated for clients at risk for aspirations; Assist client to cough and deep breathe every hour Suction every hour or as need Keep head of bed elevated at all times Provide humidified supplemental oxygen as prescribed Monitor vital signs Maintain cardiac output: Fluid replacement within the first 24 hours RAPID fluid replacement is needed during the emergent phase to maintain tissue perfusion and prevent hypovolemeic(burn) shock Isotonic crystalloid solutions, 0.9% sodium chloride or lactated ringers solution

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...AVOID: Avoid using glycerin-based mouthwashes or mouth swabs; Nonalcoholic anesthetic mouthwashes are recommended Administer a topical anesthetic prior to meals Discourage consumption of salty, acidic, or spicy foods Offer oral hygiene before and after each meal. Use lubricating or moisturizing agents to counteract dry mouth. CLIENT EDUCATION: Encourage client to rinse mouth with a solution of half 0.9% sodium chloride and half peroxide at least twice daily, and to brush teeth using a soft bristles toothbrush. Encourage client to eat soft, bland foods and supplement that are high in calories (mash potatoes, scrambled eggs, cooked cereal, milk shakes, ice cream, frozen yogurt, bananas, and breakfast mixes) Instruct client to take medication to control infection as prescribed (nystantin(Mycostating))

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...EXPECTED FINDINGS: Macular Degen: Lack of depth perception; objects appear distorted; blurred vision; loss of central vision;blindness; DX: Opthamoscopy; Snellen test Cataracts: Decreased visual acuity(reduced night vision; blurred vision; diplopia; glare and light sensitivity; halo around lights; progressive and painless loss of vision; visible opacity; absent red reflex DX: Snellen chart; Examine ext and int eye structors; Increase amount of light in room; Provide client with adaptive devices that accommodate for reduced vision Glaucoma: Open Angle: Most common causes rise in IOP, aqueous humor decreased outflow decreased due to blockages H/A; Mild eye pain; loss of perophreal vision; decreased accomondations; elevate IOP > 21mm Hg; Angle closure: Rare; IOP rises suddenly angles closed off Rapid onset of elevate IOP; decreased of blurred vision; seein halos around lights; pupils are nonreacive to light; severe pain and nausea; photophobia DX: Tonometry;Gonioscopy

..(cant treat, assess, teach)

...Cardioversion clients at risk, :can dislodges blood clots, potentially causing: Pulmonary embolism AEB dyspnea, chest pain, air hunger, decreasing sao2 Cerebral accident AEB decreased level of consciousness, slurred speech, and muscle weakness/paraylsis MI AEB chest pain and ST segments depression of elevation

...SERUM POTASSIUM LAB VALUE: 2.5-3.5 IV potassium supplements; (NEVER administer IV bolus!(HIGH risk for cardiac arrest)) (Recommended rate is 5-10 mEq/hr) Assess for phlebitis (Tissue irritant) Monitor and maintain adequate urine output Observe for shallow ineffective respirations and diminished breath sounds Monitor client cardia rhythm and intervene approp. Monitor clients receiving digoxin(Lanoxin) Hypokaelmia increased the for for digoxin toxicity Monitor level of consciousness and maintain client safety Monitor bowel sounds, abdominal distention Monitor kidney function (BUN, GFR, creatinine) Monitor magnesium(1.3-2.1); calcium(7-10.5) phosphorous(3-4.5) Provide assistance with adl's

...Red tag: IMMEDIATE threat to life Yellow tag: immediate treatment Green tag: do not require immediate tx Black tag: expected to die

...ASSESS peritstoma skin integrity and appearance of the stoma. The stoma should appear pink and moist APPLY skin barriers and creams (adhesive paste)to peristomal skin and allow to dry before applying a new appliance. EDUCATE the client regarding dietary changes and ostomy appliance that can help manage flatus and odor FOODS that can cause odor include fish, eggs, asparagus, garlic, beans, and dark green leafy vegetables. FOODS that can cause gas include dark green leafy vegetables, beer, carbonated beverages, dairy products, and corn. YOGURT can be ingested to decrease gas. AFTER an ostomy involving the small intestine is placed, the client should be instructed to avoid high fiber foods for the first 2 months after surgery. chew food well increase fluid intact and evaluate for evidence of blockage when slowly adding high fiber foods to the diet PROPER appliance fit and maintenance prevent odor when pouch is not open. FIlters deodorizers or placement of a breath mint in the pouch can minimize odor while the pouch is open PROVIDE opportunities for the client to discuss feelings about the ostomy and concerns about its impact on the clients life. Encourage the client to look at and touch the stoma REFER the client to a local ostomy support group. EMPTY bag when 1/4 to 1/2 full

...CSF leakage from nose and ears )halo sign yellow stain surrounded by blood on a paper towel, fluid test positive for glucose.

...RIGHT SIDED: Jugular vein distention Ascending dependent edema (legs,ankles,sacrum) Abdominal distention, ascites Fatigue, weakness Nausea and anorexia Polyuria at rest (nocturnal) Liver enlargement(hepatomegaly) and tenderness Weight gain LEFT SIDED: Dyspnea, orthopnea (shortness of breath while lying down) nocturnal dyspnea Fatigue Displaced apical pulse (hypertrophy) S2 heart sound (gallop) Pulmonary congestion(dyspnea, cough, bibasilar crackles) Frothy sputum Altered mental status Manifestations of organ failure, such as oliguria (decrease in urine output)

...HEMODIALYSIS COMPLICATIONS: Clotting infection at access site Anticoagulants are given to prevent clot formation Advanced age is a risk factor for dialysis induced hypotension and access site complication r/t chronic illness and or fragile veins Hypotension Disequalibrium syndrome signs include nausea vomiting, change in level of consciousness, seizures and agitation Anemia: Infectious Disease PERITONEAL DIALYSIS COMPLICATION: Peritonitis Infection at access site Protein Loss Hyperglycemia and Hyperlipidemia Poor dialysate inflow or outflow (constipation is a common cause of poor inflow or outflow)

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...POSTOP: Keep client in high fowlers position. Support head and neck with pillows. Avoid head extension> Check surgical dressing and back of neck for excessive bleeding. Be aware that respiratory distress can occur from compression of trachea due to hemorrhage Resp distress can occur due to edema. Ensure that trachesostmy supplies are immediately available. humidify air, assist to cough and deep breath and provide oral and tracheal suction Check for laryngeal nerve damage by asking the client to speak as soon as awake from anesthesia and every 2 hours after. Administer medication to manage pain. Reassure the client that discomfort will resolve with a few days Hypocalcemia and tetany can occur if parathyroid glands are damaged or removed. Indication are tingling of toes r around mouth and muscle twitching. CHeck for positive Chvosteks and Troussea signs Ensure that IV calcium gluconate or calcium chloride are immediately avail If no drain in place, prepare the client for discarge the day following surgery as indicated. IF DRAIN is in place, the surgeon will usually remove it, along with half of the surgical clips on the second day after surgery. The remaining clips are removed the following day before discharge

...EDUCATE client to eat foods that are high in protein and calories, and LOW in fiber. ASSIST the client in identifying foods that trigger clinical manifestations INSTRUCT the client to avoid caffeine and alcohol, and take a multivitamin that contains iron ADVISE the client that small frequent meals may reduce the occurrence of manifestations. INFORM the client that dietary supplements that are high in protein and low in fiber)Elemental and semi elemental products, canned nutrition beverages) may be used

...Dumping syndrome; Pernicious anemia; pallor, glossitis, fatigue, paresthesias, perforation(presents as severe epigastric pain spreading across the abdomen; GI bleeding;

...ISP (Incentive spirometer) assist with the use of ISP at least every 2 hours to encourage expansion of the lungs and prevent atelectasis

...PURPOSE: used to detect obstructions assess for parenchymal mass and assess size of the kidneys, IV contrast dye (iodine based) is used to enhance images NURSING INTERVENTIONS: Enc increase fluids; NPO after midnight; DETERMINE client allergy to iodine, seafood, eggs, milk, chocolate or if client has asthma; HOLD metformin(Glucophage) for 24hours before procedure (risk for lactic acidosis from contrast dye with iodine) ENCOURAGE fluids the day before surgery BOWEL cleansing with laxative or enema to remove fecal contents, fluids, and gas from the colon for a more clear visualization POSTPROCEDURE: ADMINISTER parenteral fluid or encourage orla fluid to flush dye through the renal system and prevent complications DIURECTECS may be administered to increase dye excretion FOLLOW UP creatinine and BUN serum levels before metformin is resumed COMPLICATIONS: Dye can cause acute renal failure

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...Medication MUST be taken for 6-12 months. isoniaziad(Nydrazid; rifampin(Rifadin); pyrazinaide and ethambutol hydrochloride (Myambutol)

...CHRONIC KIDNEY LAB VALUES: Urinalysis (hematuria, proteinuria, and decrease in specific gravity) Serum creatinine (Gradual increase over months to years for CKD exceeding 4mg/dl. May be as high as 15 to 30mg/dl BUN ( Gradual increase with elevated serum creatinine over months to years for CKD. <ay be as high as 180-200 mg/dl Serum electrolytes ( Decease sodium (dilution-al) and calcium increased potassium, phosphorus and magnesium CBC ( Decreased hemoglobin and hematocrit from anemia secondary to the loss of erythropoietin ACUTE KIDNEY INJURY: Serum creatinine gradually increases 1-2 mg/dl every 24-48 hr, or 1-6 mg/dl in 1 week or less Blood Urea nitrogen (BUN) can increase to 80-100 mg/dl within 1 week with AKI Urine specific gravity greater than 1.000-1.010 in post renal type (1.030) in pre renal type

...COMPLICATIONS: Acute MI-complication of angina not relieved by rest or nitroglycerin Administer oxygen to pt Notify provider immediately HEART FAILURE/CARDIOGENIC SHOCK: Manifestations include: tachycardia; hypotension; inadequate urinary output; altered level of consciousness; respiratory distress (crackles and tachypnea) cool, clammy skin; decreased peripheral pulses; chest pain ISCHEMIC MITRAL REGURGITATIONS: evidence by development of a new cardiac murmur VENTRICULAR ANEURYSMS/RUPTURE: may be due to necrosis from MI, can present as sudden chest pain dysrhythmias, and sever hypotenision (THE ABOVE YOU ADMINISTER OXYGEN AND NOTIFY PROVIDER IMMEDIATLEY) DYSRHYTHMIAS: inferior wall MI may lead to aninjury to the AV node, resulting in bradycardia and second degree AV heart block. an interior wall MI may lead to an injury to the ventricle, resulting in premature ventricular contractions, bundle branch, or complete heart block (Monitor ECG and vital signs, administer oxygen, administer antidysrhythimic medication as indicated, prepar for cardiac pacemaker if needed.

...POST OP: KNEE: CPM; analgesics(opioids(epidural, PCS,IV,Oral)), NSAIDS; Antibiotics(prophylaxis and postoperatively); anticoagulants(low molecular weight heparin, ie:enoxaparin(Lovonox); Ice or cold therapy m/b applied to reduce postop swelling; HIP: monitor for DVT; Pulmonary embolism; acute dyspnea; tachycardia;pleuritic chest pain; antiembolic stocking; scd while in bed; encourage plantar flexion; dorsiflexion;circumduction exercises to prevent clot formation; hip dislocation;infection;anemia; newovascular compromise

...Complete health history and physical history assessment including client report of findings and family history of cancer or genetic disorders Provide for privacy. Consider the clients cultural preference for examinations ( a professional of the same or opposite gender) Inspect for changes in color, symmetry,movement or body function Auscualtatce for adventitious sounds that indicate altered body system function heart lungs and bowel sounds Main arters (carotid femoral renal iliac masses or areas of discomfort Palpate to detect masses or tissue abnormalities Use light medium and deep pressure as appropriate Some palpations assessments should be performed by the prover only (digital recta exam for colorectal cancer) Percuss for changes in expected sound over organs Dullness in the lungs or bowel can indicate areas of consolidation or tumor Increased liver size (noted by measurement of borders (dullness) can indicate inflammation or tumor

...Maintain resp rate and effort; auscualte breath sounds(report crackles); monitor sao2; doc ventilator settings; SPLINT the incision while deep breathing coughing; monitors client heart rate an rhythm; monitor blood pressure; monitor electrolyte imbalances espicially hyperkaemia;

... CHECK for expected finding of tidling in the water seal chamber and continuous bubbling ONLY in the suction chamber. NO bubbles in water seal chamber!!

...RISK FACTORS: Female (ages 20-40); autoimmune disorder; recent virus (children only); septicemia; cardiopulmonary arrest; hemorrhage; NURSING CARE: Take vital signs regularly and assess hemodynamic status; monitor for signs of organ failure or intracranial bleed (oliguria, decreased level of consciousness; Administer fluid volume replacement; transfuse blood, platelets, and other clotting products; monitor for complication from the administration of blood and blood products; AVOID NSAIDs; administer supplements O2; provide protection from injury; instruct client to AVOID valsavla maneuvers (could cause cerebral hemorrhage); Implement bleeding precautions(avoid use of needles) MEDICATIONS: Corticosteroids and immunosuppressants; anticoagulants (heparin) SURGICAL INTERVENTIONS: Splenectomy may be performed by the provider if client does not respond to medical management

...HGB A1C(GLYCOSYLATED HEMOGLOBIN (HbA1c): Expected reference range is 4% to 6%, but an acceptable target for clients who have diabetes may be 6.5% to 8% with a target goal of less that 7%. HbA1c: is the best indicator of the average blood glucose level for the past 120days. It assists in evaluating treatment effectiveness and compliance RECOMMENDED quarterly or twice yearly depending on hyperglycemia (exceeds 300mg/dl) is a medical emergency. FOOT CARE: Inspect feet daily; Wash feet daily with mild soap and warm water. Test water with hands before washing feet. Pat feet dry gently, especially between the toes, AVOID lotions between toes to decrease excess moisture and prevent infection Use mild foot powder (powder with cornstarch) on sweaty feet DO not use commercial remedies for the removal of calluses, corns which may increase the risk for tissue injury and infection Consult a podiatrist BEST time to perform all nail care is after bath/shower time when toenails are soft and easier to trim SEPARATE overlapping toes with cotton or lambs wool AVOID open toe open heel shoes. Leather shoes are preferred to plastic. Wear shoes that fit correctly, Wear slipper with soles. DO NOT go barefoot. WEAR clean absorbent socks or stockings that are made of cotton or wool and have not been mended. DO NOT USE water bottler or heating pads to warm feet. Wear socks for warmth AVOID prolong sitting, standing and crossing of legs Cleanse cuts with warm water and mild soap, gently dry, and apply a dry dressing. Instruct the clients to monitor healing and to seek intervention promptly TEACH the client to follow facility or podiatrist recommendations for nail care. Some protocols allow for trimming toenails straight across with clippers and filing edges with an emery board or mail file to prevent soft tissue injury. If clipper or scissors are contraindicated the client should file the nails straight across

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...EXPLAIN the procedure and its purpose to the client INSTRUCT the client that local anesthetics will be used at the insertion site EXPLAIN that there may be pressure or pain with needle insertion ASSESS the clients knowledge of the procedure

...FEEL the "thrill" and hear the bruit (this is how you know the av graft is working.

...HYPERTHYROIDISM: Serum TSH test- Decreased in the presence of Graves disease (may be elevated in secondary or tertiary hyperthyroidism) Free thyroxine index (FTI) and T3, Elevated in the presence of the disease Thyrotropin-releaseing hormone (TRH) stimulation test-Failure of expected rise in TSH HYPOTHYROIDISM: THE EXPECTED REFERENCE RANGE: T3: 70-205 mg/dl T4: 4-12mcg/dl T3- Decreased TSH - Increased with primary hypothyroidism, Decreases in secondary hypothyroidism Free thyroxin index (FTI) and thyroxin (T4 levels) Decreased T3 resin uptake-Decreased Thyroid antibodies-Increased titers Serum cholesterol- Increased CBC- Anemia

...LAB TESTS: CBC Serum Albumin Erythrocyte sedimentation rate (ESR) Occult blood stools HYDROGEN BREATH TEST: client asked to exhale into hydrogen analyzer before and after ingesting test sugar(lactose or lactulose, dependent on the suspected problem) Positive test results indicate excess hydrogen in bloodstream from bacterial overgrowth or malabsorption. CLIENT to remain NPO 12 hours prior to test except for sips of water

...LABS: Urinealysis-ruling out infection Blood type and cross match-transfusion readiness CBC-infection/immune status Hgb and Hct-fluid status, anemia Pregnancy test-fetal risk of anesthesia Clotting studies-(PT, INR, aPTT, platelet count) Electrolyte levels-electrolyte imbalances Serum creatinine and BUN-renal status ABG's-oxygenation status Chest Xray-heart and lung status 12 lead ECG-baseline heart rhythm, dysrhtyhmias, history of cardiac disease performed on ALL clients older than 40

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...Administer O2 therapy as prescribed to relieve hypoxemia and dyspnea. Position client to maximize ventilation (high fowlers=90%) Initiate and maintain IV access Provide emotional support and comfort to control client anxiety, monitor changes in level of consciousness. MEDICATIONS: anticoagulants (enoxaparin (Lovonox) heparin, warfarin (Coumidin)) to prevent clots from getting large or additional clots from forming MONITOR PTT PT INR Thrombolytic therapy: alteplase (Activase), streptokinase (Streptase)

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...Induration of 10mm or greater indicates positive skin test; An induration of 5mm is considered positive skin test for immunocompromised client. ; Positive test means client has developed an immune response to TB ; Clients who have received BCG vaccine with the past 10 years may have a false positive Mantoux test. CHEST Xray indicated for these clinets.

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...EDUCATE CLIENTS: Encourage to avoid crowds while undergoing chemotherapy Take temperature daily. Report elevated temp to provider Avoid food sources that could contain bacteria (fresh fruit and vegetables, undercooked meat, fish, and eggs, pepper and paprika) Avoid yard work, gardening, or changing a pets litter box Avoid fluids that have been sitting at room temp for longer than 1 hr Wash all dishes in hot soapy water or dishwasher. Always wash glasses and cups after one use. Wash toothbrush daily in dishwasher or rinse in bleach solution Do not share toiletry or personal hygiene items with others Report fevers greater than 37.8 celsius(100 farenheight) or other manifestations of bacterial or viral infections immediately to the provider

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...AT RISK: Genetic predisposition Acute febrile state Head trauma Cerebral edema Abrupt cessation of antieliplitic druga infection metabolic disorder exposure to toxins brain tumor hypoxia acute drug and alcohol withdrawal fluid and electrolyte imbalance TRIGGERING FACTORS: increased phy activity excessive stress hyperventialtion overwhelming fatigue acute alcohol ingestions excessive caffeine intake exposure to flashing lights specific chemicals, such as codeine, aerosols, and inhaling glue products

..Sodium (Na) 136-145 mEq/L Calcium 9.0-10 mg/dL Chloride 98-106 mEq/L Bicarb HCO 21-28 mEq/L Potassium 3.5-5.0 mg/L Phosphorus PO4 3.0-4.5 mg/dL Magnesium 1.3- 2.1 mEq/L Stomach pH 1.5-2.5 Ammonia 15-110 mg/dL Bilirubin • Total 0-1.0 • Unconjugated (indirect) 0.2 -0.8mg/dL • Conjugated (direct) 0.1 1.0 mg/dL Cholesterol • Total 40 • Triglycerides