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1. Pain/Palliative (2) 2. Metabolic/Respiratory/Acidosis/Alkalosis (2) 3. Delegation (3) RN to NA transfers responsibility only. RN still assumes accountability NA can perform: ADLs, simple, repetitive, common activities that do not require nursing judgments such as hygiene, feeding, ambulation etc. RN to RN transfers responsibility and accountability Must reevaluate to see if the nursing tasks are done properly Communicate a time frame- ask was the task done correctly?, was the task done in the proper time frame?, were the clients needs met? Right patient, right task, right instructions, right circumstance, right time, right supervision ATI in fundamentals ATI for delegation 4. Medication Administration (8) (dosage, administration, skills) 5. Blood Transfusion (3) 6. Psoriasis (1) Immune mediated, red patches of scaly skin, not contagious, chronic. Caused by stress, depression, alcohol abuse Treat with topical corticosteroids and systematic medications, phototherapy- short, non-burning exposure to sunlight, photochemotherapy, epsom salts, climatotherapy for Dead Sea, doctor fish in Turkey. 7. Herpes (2): viral infections HSV-I: Lips, mouth, face, common cold sore, fever blister HSV-II: STD, Genital ulcers, oral lesions, can lead to complications to the brain. Herpes Zoster: shingles, localized infection from varicella, painful blistering, rash (chicken pox) Treat Herpes Simplex with OTC treatments, antivirals (acyclovir, -vir), topical antibiotics ointments Treat Herpes Zoster with antivirals (acyclovir, -vir), analgesics, TCAs8. Skin Cancer (2) Basal Cell: epithelial tumor, most common, least aggressive Squamous Cell: more aggressive, has affinity for metastasis Malignant Melenoma: fair skinned Asymmetry, Borders, Color, Diameter, Elevation Treat with radiation, surgery, curettage (scrape), electrodessication, surgical excision, chemo, immunotherapy (inferons and interleukins to boost immune response), radiation therapy.9. Pressure Ulcers (2) 10. Burns (5) Set water heaters at home to >120 With chemical burns, tissue destruction can continue for 72 hours 3 types of smoke and inhalation injuries: Carbon monoxide, inhalation injury above the glottis (caused by inhaling hot air, steam, or smoke)-glottis closes and stops spread, inhalation injury below the glottis- most fatal Electrical injury can cause: fractures of long bones and vertebra, cardiac arrest or arrhythmias because of SA node, severe metabolic acidosis because the muscle contractures causes lactic acid that the kidneys cant get rid of which causes myoglobinuria (muscle enzymes cant breakdown, excreted through kidneys causing dark urine). Treat with Ringers Lactate (hypervolemic) or other fluids to flush out the kidneys or an osmotic diuretic (mannitol) to maintain urine output Cold thermal Injury (frostbite): tissue necrosis, do not massage If the client has burns to the face/neck/chest be concerned with the airways Burn percentages: 9% for entire arm. 18% entire leg. 9% head. 36% entire trunk. 1% inguineal. Lund-Browder chart is more accurate but rule of nines is used in emergent situations. Remove jewelry due to swelling Signs of airway injury is soot, singed nose hair, coughing up black sputum, blisters around oral mucosa More death with upper body burns Greatest initial threat is hypovolemic shock (loss of intravascular fluid volume) to a major burn patient. (S/S shock: dilated pupil, hypotension, tachycardia, weak thready pulse, cold and clammy) Second spacing- fluid moves into interstitial tissues from capillaries causing edema Third spacing- large amount of fluid collecting in spaces they arent suppose to such as ascites. UOP: 30-50cc/hr Wound care waits until patent airway, adequate circulation and fluid replacement is in place. Parkland Formula: 4mL x kg of pt x total body surface burned % - give half of this in first 8 hours and then the rest over 16 hours If clients respirations are shallow, they are retaining CO2, and will have respiratory acidosis Albumin holds onto fluids in the vascular space which helps correct fluid volume deficit Start pain meds low and slow via IV Tetanus toxoid immunization will be given, takes 2-4 weeks to develop immunity Manifestations of shock: confusion, increased capillary refill time, UO 200mg/dL, fasting >126 mg/dL Rapid acting: humolog, novolog; given right before means, administer with intermediate or long acting Short acting: regular (Can give IV), administer 30-60 minutes before meal Intermediate: NPH, humulin N, administers between meals and at night, only insulin to mix with regular. Clear (regular) before cloudy (NPH) Long acting: glargine insulin, administer once daily during the day at the same time everyday, dissolves slowly over 24 hours without peaks and troughs Cold and clammy needs some candy, hot and dry sugars high When hypoglycemic (300mg/dL, life-threatening, breakdowns body fat for energy, initaially give NS then give NS and add dextrose when glucose reaches 250mg/dL and regular insulin hyperglycemic hyperosmolar state (HHS): life-threatening hyperglycemia >600mg/dL, leads to dehydration, coma and death. Usually type 2. Also may have myoclonic seizures, and reversible paralysis. Dont have ketones in urine or serum, absence of acidosis. Monitor serum potassium levels for hypokalemia. For HHS administer isotonic fluids, then hypotonic fluids, glucose and regular insulin via IV. Dawn Phenomenon: rise in blood glucose between 0400-0800 Symogi: hypoglycemia at night and rebound hyperglycemia in the morning.12. Neutropenia (1): decreased neutrophils 13. Endocrine Disorders (8) (Hyper/Hypo, Cushing, Addisons, SIADH, DI) Hyperthyroidism: excessive thyroid hormones. Graves: autoimmune antibodies results in hypersecretion of thyroid hormones. S/S Hyperthyroidism: nervousness, irritability, weakness, heat intolerance, weight change, insomnia, warm skin, tremor, exopthalmus (Graves only), hair loss, goiter, tachycardia, facial flushing, fine hair, splenomegaly Toxic nodular goiter: overproduction of thyroid hormone due to the presence of thyroid nodules. Thyroid Storm: sudden surge of large amounts of thyroid hormones caused by trauma, infection, emotional stress, DKA, digitalis toxicity. Decreased TSH but increase T3, T4. S/S hyperthermia, HTN, delirium, vomiting, abdominal pain, hyperglycemia, chest pain, dyspnea, palpatations. Give antithyroid MMI (Tapazole, methamazole) drugs and Iodine then relieve respiratory distress first and stabilize cardio. Reduce fever with Tylenol, give beta-blocker for cardio stabilization, and iodine solutions. RAI therapy: radioactive precautions, such as not using the same toilet as others for 2 weeks, flush three times, wear washable clothing and was separate from others and run it before washing others clothes, dont share tooth brushes. It damages the thyroid tissues. Give with MMIs and beta-blockers. Hypothyroidism: Primary: thyroid gland is not secreting enough (Hashimotos) (TSH is increased, t3, t4 are low) Secondary: pituitary isnt secreting enough TSH (TSH is decreased, no t3,t4 low) Myexedema: accumulation of non-pitting edema in the connective tissues. First maintain airway, then do ECG monitor, do ABGs, warm them up, then give synthyroid Creatinism: caused by thyroid hormone deficiencies in the neonatal and fetal life causing mental retardation S/S: intolerance to cold, weight gain, pale skin, thinning hair, joint and muscle pain, bradycardia, constipation, dry flaky skin Return them to euthyroid state, barbituates and sedatives are contraindicated. Treat: Synthroid is treatment of choice, and monitor for CV compromise, take 1-2 hours before breakfast Hyperparathyroidism: hypercalcemia, hypophosphatemia, causes the osteoclast to break down bone for circulating calcium. Can cause kidney stones. Primary: gland is malfunctioning. Secondary: hypocalcemia all the time causes it to produce more calcitonin. Tertiary: caused by chronic renal failure. Symptoms usually related to hypercalcemia such as abdominal pain and constipation. Treat by increasing PO fluids, encourage activity (for osteoblasts), avoid thiazide diuretics, avoid Vitamin A D, avoid antacids and calcium supplements. Hypoparathyroidism: check for Trousseaus signs (hypocalcemia) and Chvosteks. Treat with calium gluconate, supplemental calcium and vitamin D Cushing: Have a cushion of excess ACTH. Advise the client to take medications as instructed, may be lifelong therapy, eat foods high in calcium and vitamin D, no alcohol and caffeine, monitor for gastric bleeding (black tarry stools, hematemesis), need to avoid infection by practicing good hygiene. BBIIG: Blood pressure, Bone formation inhibition, Decrease anti-Inflammatory, Decrease Immunity, Increase glycogenesis S/S: moon face, buffalo hump, HTN, osteoporosis, immune suppression, muscle weakness with thin extremities and trunkal obesity, hyperglycemic Treat: Aminoglutethimide and Mitotane, administer glucocorticoids to prevent abrupt drop in cortisol Adrenal cortex secretes: Mineral corticosteroids, Androgens, Cortisol Cortisol is a stress hormone and a steroid hormone Addisons: Adrenocortical insufficiency due to damage or dysfunction of the adrenal cortex. S/S: hyperpigmentation (bronze), weight loss, weakness, dehydration, hyperkalemia, hypoglycemia, hypercalcemia Primary: increase in ACTH because the gland wont work Secondary: decrease in ACTH because of pituitary tumor or abrupt withdrawal in steroids. Treat: hydrocortisone, prednisone and cortisone to replace an adrenal insufficiency and as an anti-inflammatory. Fludrocortisone is a mineralocorticoid used to replace adrenal insufficiency Adisonian Crisis: occurs when there is an acute drop in adrenocorticoids due to sudden discontinuation of glucocorticoids or trauma/stress. Administer insulin, calcium, kayexalate, loop or thiazide diuretics S/S of adisonian crisis: high fever, weakness, severe penetrating pain to abd, lower back and legs, vomiting, diarrhea, hypotension, circulatory collapse, shock and coma as well as all the symptoms of addisons disease. SIADH: Excessive ADH is released. Hold onto water. Weight gain without edema because water, not sodium, is retained. Seizures, coma and death because decreased sodium. Blood is dilute and urine is concentrated. Restrict fluids. Flush with NS to add some sodium back. Declomycin may cause drug induced DI. Lithobid is used to block the renal response to ADH, may induce DI. Lasix used to increase water excretion from the kidneys, can cause hyponatremia to worsen. Complications: water intoxication, cerebral edema, severe hyponatremia DI: deficiency of ADH from the posterior pituitary causes DI. Large quantity of diluted urine. Polydipsia and polyuria, nocturia, fatigue, dehydration, tachycardia, hypotension, decreased skin turgor. Primary (neurogenic): problems in the hypothalamus and pituitary. Nephrogenic: is inherited and the body isnt responding to ADH. Drug induced: may alter the way the kidneys respond to ADH. Need lifelong treatment of Desmopressin (DDAVP), which increases water absorption in from the kidneys and decreased urine output. Tegretol stimulates the release of ADH (central DI). Vassopressin increases water absorption form kidneys and decreased urine output. Vasopressin test determines what type of DI they have. Will only respond if they are neurogenic.14. Multiple Myeloma (1) 15. Cancer (5) 16. Thrombocytopenia (2): low platelets Platelet count less than 100,000 Idiopathic thrombocytopenia purpura (ITP) antibodies are attacking platelets prematurely, Petechiae, purpura Thrombotic thrombocytopenia purpura (TTP) platelet aggregation, multiorgan involvement HA, seizure Treat with Oral glucocorticoids (prednisone), immunosuppressive, platelet transfusion, plasmapharesis, splenectomy17. SLE (1) 18. Von Willebrands (1) 19. Hemophilia (2) Hemophilia A: problem with factor 8 Hemophilia B: Christmas disease, affects factor 9 Hemophilia C: Factor II is affected, jewish people Treat with DDAVP Hgb: 13-15 20. DIC (2) Depleted platelets and clotting factors followed by excessive clotting- if youre pregnant, cancer, poisonous snakes, head trauma or SEPTIC youre at increase risk for developing DIC. Treat with fresh frozen plasma (gives back platelets and clotting factors), platelets (give quickly), heparin (when youre clotting too much)21. Lymphoma (3) 22. Leukemia (3) 23. HIV (3): After initial infection (fever, HA, sore muscles, stomach ache, swollen lymph glands, N/V), becomes asymptomatic for 8-10 years but is still contagious. CD4+ is 500-1600 which drops dramatically in infected people