Dilantin - detoxified by liver.

The nurse cares for a client receiving IV antibiotics every 8 hours for the past 4 days. The antibiotic is mixed in D5W. The nurse determines that a post-infusion phlebitis has occurred if which of the following is observed? 1. Tenderness at the IV site. 2. Increased swelling at the insertion site. 3. Area around the IV site is reddened with red streaks. 4. Fluid is leaking around the IV catheter. a. Tenderness occurs with phlebitis but is not specific to it. b. May indicate either infiltration or phlebitis c. CORRECTreddened, warm area noted around insertion site or on path of vein; discontinue IV, apply warm, moist compresses, restart IV at new site d. Not indicative of phlebitis Ethacrynic Acid (Edecrin)are considered loop diuretics and are potassium wasting; encourage client to increase intake of potassium-rich foods. Orange juice/Bananas, etc. Aminophylline (Truphylline)is a xanthine bronchodilator; major side effects: palpitations, nervousness, rapid pulse, dysrhythmias, nausea, and vomiting. Toxic effects: confusion, headache, flushing, tachycardia, and seizure. Morphine Sulfatedecreases blood return to the right side of the heart, and decrease peripheral resistance. In other words, decreases preload and afterload pressures and cardiac workload ; causes vasodilation and pooling of fluid in extremities; provides relief from anxiety. Intropin (Dopamine)vasoactive medication are given IV to restore BP in hypotensive states; Increases blood return to the right side of the heart, and increase peripheral resistance; side effects: headache, severe hypertension, dysrhythmias; check BP q2 minutes until stabilized, then q5 minutes TPNhang no longer than 24 hours; IV tubing and filters every 24 hours; site of catheter changed every 4 weeks. Fluoxetine (Prozac)a selective serotonin reuptake inhibitor (SSRI) used to treat depression and obsessive compulsive disorder.
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Side effects: postural hypotension, dry mouth, rapid heartbeat, anorexia, weight loss, severe headache. If dose is missed, omit dose and instruct client to return to regular dosing schedule. Propanolol (inderal)a beta-adrenergic blocker used as antihypertensive; Side effects: bronchospasm, bradycardia, depression. Take pulse before administration and gradually decrease when discontinuing. Do not give to asthmatic patients. Glipizide (Glucotrol)an oral hypoglycemic that decreases blood sugar by stimulating insulin release from the beta cells of the pancreas; may cause aplastic anemia and photosensitivity. Prednisone (Deltasone)a corticosteroid. Side effects: hyperglycemia Bethanechol (Urecholine)a cholinergic or parasympathomimetic used to treat functional urinary retention; mimics action of acetylcholine. Ventricular Tachycardiacauses chest pain, dizziness, and fainting. 1 grain = 60mg Levothyroxine (Synthroid)thyroid preparation should be administered at breakfast to prevent insomnia. Carbamazepine (Tegretol)interferes with action of hormonal contraceptives. Side effects: photosensitivity; prevention of seizures and relief of pain in trigeminal neuralgia. Trigeminal neuralgia (Tic douloureux) is an agonizing pain that may result in severe depression and suicide. Aluminum Hydroxide (Amphojel)an antacid; neutralizes hydrochloric acid and reduces pepsin activity; take one hour before and hour of sleep. Antacids most effective after digestion has started, but prior to the emptying of the stomach. Isoniazid (INH)Side effects: peripheral neuropathy (administer pyridoxine), rash, urticaria, and swelling of the face, lips, and eyelids. Pyridoxine (Vitamin B6, Beesix, Doxine)required for amino acid, carbohydrate, and lipid metabolism. Used in the transport of amino acids, formation of neurotransmitters, and sythesis of heme. Prevention of neuropathy.
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Clonidine (Catapres-TTS)is a centrally acting alpha-adrenergic used to treat hypertension; Side effects: drowsiness, sedation, orthostatic hypotension, heart failure. If patch used, be cautious around microwaves, results in burns, dispose of carefully, and heat will increase medication absorption leading to toxicity. Phlebitistenderness, redness; remove iv, apply warm soaks to decrease inflammation, swelling, and discomfort. Autologous bloodmay give blood 5 weeks before surgery; can give 2 to 4 units of blood; may have to take iron pills Partial-thickness burn; only part of skin is damaged or destroyed; large, thick-walled blisters develop; underlying tissue is deep red, appears wet and shiny; painful with increased sensitivity to heat; healing occurs by evolution of undamaged basal cells, takes about 21-22 days. I.E., Redness and swelling with fluid-filled vesicles noted on right arm or Blistering and blanching of the skin noted on the back. Full-thickness burn; all skin is destroyed and muscle and bone may be involved; substance that remains is called eschar, dry to touch, doesnt heal spontaneously, requires grafting. I.E., Charred, waxy, white appearance of skin on left leg. Superficial burn; skin appears pink, increased sensitivity to heat, some swelling, healing occurs without treatment. I.E., Reddened blotchy painful areas noted on the face. Carbidopa/Levodopa (Sinemet)used to treat symptoms of Parkinsons disease. Take immediately before meals and high-protein meals may impair effectiveness of medication. Reduces rigidity and bradykinesis and facilitates clients mobility. Doxycycline (Vibramycin)a tetracycline that is taken at regular intervals but not within 1 hour of bedtime because it may cause esophageal irritation. Use another method of birth control, do not take antacids within 1-3 hours of taking medication, and may cause photosensitivity. Albuterol (Proventil)a bronchodilator. Side effects: tremors, headache, hyperactivity, tachycardia. Use first before steroid medication so opens up
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bronchioles for steroid to get in. Wait one minute between puffs of the inhalers for best effect. Beclomethasone (Vanceril)a steroid medication. Side effect: fungal infections, dry mouth, throat infections. InsulinNPH Onset: 1.5 hours Peak: 4-12 hours Regular Onset: 0.5 hours Peak: 2.5-5 hours Topiramate (Topamax)is an anticonvulsant. Should drink 2000-3000ml of fluid daily to prevent kidney stones. Side effects: orthostatic hypotension, ocular symptoms, blindness, and decrease effects of hormonal contraceptives. Propranolol (Inderal)a beta-blocker that takes up beta-adrenergic receptor sites, which prevents adrenaline from causing symptoms and glycogenolysis. Inderal may mask symptoms of hypoglycemia, removing the bodys early warning system. Phenazopyridine (Pyridium)acts on urinary tract mucosa to produce analgesic or local anesthetic effects. Side effects: bright orange urine, yellowish discoloration of skin or sclera indicates drug accumulation due to renal impairment. Trimethoprim-sulfamethoxazole (Bactrim)most common side effect mild to moderate rash (urticaria) Aminoglycosides are ototoxic. Butorphanol Tartrate (Stadol)analgesic used for moderate to severe pain; Side effects include change in BP, bradycardia, respiratory depression. Infant normal resting heart rate: 120-140 Salt substitutes contain potassium When directing a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be reported. Because the RN is responsible for all care-related decisions, only implementation tasks should be assigned because they do not require independent judgment.
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When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascular impairment can be used as a guide (pain, pulselessness, pallor, paresthesia, paralysis) READ THE QUESTIONS FIRST!!!!! READ THE QUESTIONS FIRST!!!!! DETERMINE THE QUESTION!!!!!! Rash and blood dyscrasias are side effects of anti-psychotic drugs. A history of severe depression is a contraindication to the use of neuroleptics. Children with celiac disease should eat a gluten free diet. Gluten is found mainly in grains of wheat and rye and in smaller quantities in barley and oats. Corn, rice, soybeans and potatoes are digestible in persons with celiac disease. The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk because Decadron increases the production of hydrochloric acid, which may cause gastrointestinal ulcers. The protest phase of separation anxiety is a normal response for a child this age (2 year-old hospitalized child). In toddlers, ages 1 to 3, separation anxiety is at its peak Signs of tardive dyskinesia include smacking lips, grinding of teeth and "fly catching" tongue movements. Verapamil, Bretylium, and Amiodarone increases serum dig levels, possibly causing Digitalis Toxicity Signs/Symptoms of Digital Toxicity: first signs include abdominal pain, anorexia, nausea, vomiting, visual disturbances, bradycardia, and other arrhythmias. In infants and small children, the first symptoms of overdose are usually cardiac arrhythmias. Restlessness, confusion, irritability and disorientation may be the first signs of fat embolism syndrome followed by a very high temperature. A Neologism is a new word self invented by a person and not readily understood by another that is often associated with a thought disorder. Pancreatic enzymes give before meals.
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Clinical features of delusional disorder include extreme suspiciousness, jealousy, distrust, and belief that others intend to harm. The UAP can be assigned to care for a client with a chronic condition after an initial assessment by the nurse. This client has no risk of instability of condition. Never leave your patient. For example, Ask the LPN/LVN to stay with the child and his parents while the nurse obtains phone orders from the physician. Tips for charting: dont use inflammatory words, no nurse judgments, be as specific as possible. I.E., Vital signs stable is incorrect for of charting. Restraint: frame of bed, quick release ties, document need for restraint Q4 hours Never ask WHY questions in the NCLEX! Gag Reflex: dont assess gag reflex to a client that has an absent swallow reflex Nifedipine (Procardia XL): do not crush An RN that is not assigned to a patient does not have the authority to tell a nurse what to do. Refer it to nursing supervisor. If doctor has orders it should carried out unless contraindicated in nurses decision. Physical assessment: Inspection, Percussion, Palpation, Auscultation (Except for abdomen: Inspection, Auscultation, Percussion, Palpation) Coronary artery bypass graft (CABG)halt medications before surgery, can do 5 at a time; will be on mechanical ventilations after surgery; chest tubes Acromegalymonitor blood sugar, atrium90 implant care (radioactive, nasally implanted, monitor vision) Bone marrow Aspiration---done at iliac crest; painful
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Postoperative care after Supratentorial surgery: maintain airway, elevate head 30-45 Position care after Infratentorial surgery: flat and lateral Orange juice does not help acidify urine it makes it more alkaline. Myelogram Water-soluble dyeelevate head of bed 30 degrees (not removed) Oil based dyeflat in bed (removed) Fractures: Immobilize joint above and below fracture Cover open fracture with cleanest material available Check temperature, color, sensation, capillary refill distal to fracture Close reductionmanually manipulate bone or use traction Bucks Traction Use to relieve muscle spasm of leg and back If used for muscles spasms only, they can turn to either side. If used for fracture treatment, only can turn to unaffected side. Use 8-20 lbs of weight, if used for scoliosis will use 40 lbs of weight. Elevate head of bed for countertraction or foot bed Place pillow below leg not under heel or behind knee. Russells Traction Sling is used Check for popliteal pulse Place pillow below lower leg and heel off the bed Dont turn from waist down Lift patient, not the leg Cervical Tongs Never lift the weights No pillow under head during feedings Balanced Suspension Traction For femur realignment
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 Maintain weights hanging free and not on floor Maintain continuous pull Halo Jacket Maintain pin cleansing Casts Dont rest on hard surface Dont cover until dry 48+ hours Handle with palms of hands not with fingers Keep above level of heart Check for CSM Fractured Hip Assessments Leg shortened Adducted Externally rotated Implementation Care after a total hip replacement Abduction pillows Crutch walking with 3-point gait Dont sleep on operated side Dont flex hip more than 45-60 degrees Dont elevate head of the bed more than 45 degrees Amputations Guillotine (open) Flap (closed) Delayed prosthesis fitting Residual limb covered with dressing and elastic bandage (figure eight) Figure-8 doesnt restrict blood flow, shaped to reduce edema Check for bleeding Elevated 24 hours (AKA-pillow, BKA-foot of bed elevated) Position prone daily Exercises, crutch walking
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 Phantom Pain: acknowledge feelings, that pain is real for them. Thiamin (Vit. B1)carbohydrate metabolism; deficiency will cause Beri-Beri Pyridoxine (Vit. B6)amino acid metabolism; deficiency will cause anemia, seizures Folic acidRBC formation; deficiency will cause anemia Cyanocobalamin (B12)nerve function; deficiency cause pernicious anemia Calcium deficiency causes Ricketts Cultural Food Patterns Orthodox Jewish (Kosher)milk and meat cannot be eaten at same meal Muslin30 day fast during Ramadan Japaneserice is basic food, tea is main beverage Greekbread is served with every meal Enteral feeding held if: 150 or > ccs aspirated or 50% given in the hour is aspirated If cramping, vomiting occurs decrease rate of enteral feeding or keep it warm. TPNsupply nutritions via intravenous route Peripherally or centrally Initial rate 50/hour and can be increased to 100-125ml/hour. A pump must be used to keep rate constant Prevent sepsis: maintain closed system,, dont draw blood/infuse anything in line, dry sterile dressing Verify placement of line Monitor Glucose, acetone Change IV tubing/Filter Q24 hours Solution refrigerated then warmed If solution not available, start 10% in water. 3/week check BUN, electrolytes (ca, mg) When TPN Dcd taper patient off or else will get rebound hypoglycemia (use hypotonic to do this)
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Specific gravity 1.010-1.030 Ph 4.5-8 1,000-1,500cc/day Credes Maneuverpush urine out Pernicious Anemia - monthly Vitamin B12 IM injections Metered dose inhaler - Beclomethasone (Vanceril) - Albuterol (Proventil) Guillain-Barre Syndrome - GBS often preceded by a viral infection as well as immunizations/vaccinations - Intervention is symptomatic - Acute phase: Steroids, plasmapheresis, aggressive respiratory care; prevent hazards of immobility, maintain adequate nutrition; physical therapy; pain-reducing measures; eye care, prevention of complications (UTI, aspiration); psychosocial support Organ Donation Criteria - No history of significant, disease, process in organ/tissue to be donated - No untreated sepsis - Brain death of donor - No history of extracranial malignancy - Relative hemodynamic stability - Blood group compatibility - Newborn donors must be full term (more than 200g) - Only absolute restriction to organ donation is documented case of HIV infection - Family members can give consent - Nurse can discuss organ donation with other death-related topics (funeral home to be used, autopsy request) Accurate way to verify NG tube position is to aspirate for gastric contents and check pH.
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Parkinsons disease - Activities should be scheduled for late morning when energy level is highest and patient wont be rushed - Symptoms: tremors, akinesia, rigidity, weakness, motorized propulsive gait, slurred monotonous speech, dysphagia, drooling, mask-like expression. - Nursing care: encourage finger exercises. Administer Artane, Congentin, L-Dopa, Parlodel, Sinemet, Symmetrel. - Teach: ambulation modification - Promote family understanding of disease intellect/sight/hearing not impaired, disease progressive but slow, doesnt lead to paralysis Normal urine output (1200-1500 ccs/day or 50-63 cc/hr, normal voiding pattern 5-6 times/day. Green leafy vegetables contain vitamin K. Labs HbA1c (4.5-7.6%) - indicates overall glucose control for the previous 120 days Serum Amylase / Somogyl (60-160 u/dL) - elevated in acute pancreatitis Erythrocyte Sedimentation Rate (ESR) - Men (1-15) - Women (1-20) - Rate at which RBCs settle out of unclotted blood in one hour - Indicates inflammation/neurosis Hematocrit (Hct) - Men (40-45) u/mL - Women (37-45) u/mL - Relative volume of plasma to RBC - Increased with dehydration - Decreased with volume excess Creatine Kinase (CK) - Men (12-70)
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- Women (10-55) - Enzyme specific to brain, myocardium, and skeletal muscles - Indicates tissue necrosis or injury Serum Glucose - 60-110 mg/dL Sodium (Na+) - 135-145 mEq/L - Hypernatremia o Dehydration and insufficient water intake Chloride (Cl-) - 95-105 mEq/L Potassium (K+) - 3.5-5.0 mEq/L Bicarbonate (HCO3) - 22-26 mEq/L - Decreased levels seen with starvation, renal failure, diarrhea. Blood, Urea, Nitrogen (BUN) - 6-20 mg - Elevated levels indicate rapid protein catabolism, kidney dysfunction, dehydration Creatinine Clearance Test - normal 125 ml/min. - Lower levels reflect renal insufficiency and may influence the excretion of many drugs and toxins from the body. Lithium - targeted blood level: (1-1.5 mEq/L) Tofranil and AnafranilOCD medications Pick physical needs over psychosocial needs!!!!!!!!!!!!!!! Focus on here and now!!!!!!!!!!!!!!!!!
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Oculogyric crisis: uncontrollable rolling back of eyes: side effect of Phenothiazines Moribund means dying patient. Dont leave your patients. Stay with your patients. Assess before implementation. Manic patient: decrease stimuli and increase rest period and no competition. Lithium helps control impulsive behaviors. Fluphenazine (Prolixin): antipsychotic medication Thiamine sources: organ meats, liver, whole grain, nuts, legume, egg, and milk. Dont document abuse. Report suspected abuse to nursing supervisor. Never promise a patient Not to tell. Tonometrymeasures intraocular pressure; to rule out glaucoma Myopianearsightedness (near clear, distance clear) Hyperopiafarsightedness (distance is clear, near vision blurry) Presbyopiachanges with aging Blind client: address by name, introduce self, keep furniture arrangement consistent, open or close doors walk step ahead, identify food location on tray. Instilling ear drops lie patient on unaffected ear to absorb drops. Position patient on affected ear to promote drainage. Regular Insulin only given IV.

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Sick day rules: take insulin as ordered, check blood glucose q3-4 hours, soft foods, liquids Phenylketonuriahigh blood phenylalanine (no enzyme), results in mental retardation; milk substitutes, low-protein diet Celiac Disease (SPrue)intestinal malabsorption, malnutrition (unable to digest wheat/rye/oats/barley); gluten-free diet Hepatobiliary diseasedecrease in ability of bile to absorb fat, fat malabsorption; low-fat high-protein diet, vitamins Cystic fibrosisabsence of pancreatic enzymes, malabsorption of fat, lung disease, pancreatic enzyme replacement, high-protein, high-calorie diet, respiratory care/suction Position right side to promote gastric emptying. Dumping syndrome prevention: restrict fluid with meals, lie down after eating, small, frequent meals, low-carbohydrate, low-fiber diet Sengstaken-Blakemore Tubeto treat pt. with esophageal varices. Hepatitis B Vaccine Given IM to vastus lateralis or deltoid Side effects: mild tenderness at site 1st shot Birth to 3 months 2nd shot 1 to 4 months 3rd shot 6 to 18 months DTaP (Diptheria, Tetanus, and Pertussis) Given IM anterior or lateral thigh Side effects: fever within 2448 hours, swelling, redness, soreness MMR (Mumps, Measles, and Rubella) Given SC anterior or lateral thigh Side effects: rash, fever, arthritis in 10 days to 2 weeks. 1st shot 12 to 18 months 2nd shot 4 to 6 years Varicella (Chickenpox) 12 to 18 months PCV TB
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(Pneumococcal) 1st shot 2 months 2nd shot 4 months 3rd shot 6 months 4th shot 12 to 18 months

Dont treat with aspirin, use other antipyretic. 1st shot 2 months 2nd shot 4 months 3rd shot 6 months 4th shot 15 to 18 months 5th shot 4 to 6 years Only TD shot 11 to 16 years Hib (Influenza) 1st shot 2months 2nd shot 4months 3rd shot 6 months 4th shot 12 to 18 months IPV (Inactive Polio Vaccine) Given PO, Few side effects 1st shot 2 months 2nd shot 4 months 3rd shot 6 to 18 months 4th shot 4 to 6 years Normal Vital Signs

Given intradermal Evaluated in 48 to 72 hours TD Given IM into anterior or lateral thigh Repeated every 10 years Live attenuated Rubella Given once SC into anterior or lateral thigh Given to antibody-negative women Prevent pregnancy for 3 months after receiving immunization Live attenuated mumps Given once SC Prevents orchitis

Newborn Pulse 120-140 bpm, increases with crying Respirations 30-50/min, diaphgramatic (abdomen moves), can be irregular BP 60/40 80/50 mmHg 1-4 year old Pulse: 80-140 Resp: 20-40 BP: 90-60 99/65
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5-12 year old Pulse: 70-115 Resp: 15-25 BP: 100/56 110/60 Adult Pulse: 60-100 Resp: 12-20 BP: 90/60-140/90

Aortic Valve: Right of Sternum at the 2nd intercostal space Pulmonic Valve: Left of Sternum at the 2nd intercostal space Tricuspid Valve: Immediately left of sternal border at the 5 th Intercostal Space Mitral Valve (Point of Maximal Impulse): Left of Sternum Mid-Clavicular Line at the 5th Intercostal Space Erbs Point: Left of Sternum at the 3rd intercostal space Infant (Point of Maximal Impulse): Lateral to sternum 4th intercostal space Obese person choking use Chest Thrusts. Tracheostomy tube placement of cuff maintained to prevent aspiration Care for patient first, equipment second Signs for hypoxia: restlessness, tachycardia CPR: Shake, shout, summon help, open airway, look, listen, feel for signs of breathing, pinch nose, give 2 full breaths (if no rise, reposition) Adults 12/min check carotid, chest compressions 80-100/min 1.5 inches Infants 20/min check brachial pulse, chest compression 100/min - 1 inch 15:2 Adult 4 cycles Infant 20 cycles Reassess pulse and breathing Continue CPR until:
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Victim responds Someone else takes over Victim is transferred Rescuer is unable to continue Implementation for MI Thrombolytic therapystreptokinase, t-PA Bedrest Beta-blockers, morphine sulfate, dysrhythmics, anticoagulants Do not force fluids (will give heart more to work with)

MI Chest pain radiating to arms, jaw, neck (which is unrelieved by rest or nitroglycerin) Dyspnea Indigestion Apprehension Low grade fever Elevated WBC (5-10, ESR, CK-MB, LDH)

Defibrillation Start CPR first 1st attempt 200 joules 2nd attempt 200 to 300 joules 3rd attempt 360 joules Check monitor between shocks for rhythm Cardioversion Elective procedure, Informed Consent Valium IV Synchronizer on 25-360 joules Check monitor between rhythm Epidural hematoma short period of unconsciousness, ipsilateral papillary dilation, contralateral weakness of extremities Subdural hematoma decreased LOC, ipsilateral papillary dilation, contralateral weakness of extremities, personality changes CSF leakage good place to look is behind the ears.
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Head Injury elevate bed 30 degrees, barbiturate therapy, hypothermia, glucocorticoids (Decadron) Flail Chest Affected side goes down during inspiratio n and up during expiration Sucking Chest Wound (Sucking Open Pneumothorax) Sucking sound with respiration Pain Decreased breath sounds Anxiety Pneumothorax Collapse of lung due to alteration of air in intrapleural space Dyspnea Pleuritic pain Restricted movement on affected side Decreased/absent breath sounds Cough Hypotension Implementati on Monitor for shock Humidified oxygen Thoracentesis (aspiration of fluid from pleural space) Chest Tubes

Cullens Sign ecchymosis around umbilicus Turners Sign ecchymosis around either flank Balances sign resonance over spleen (+) means rupture of spleen Shock Signs and Symptoms Cool, clammy skin Cyanosis Decreased alertness Tachycardia Hypotension Shallow, rapid respirations Oliguria Hypovolemic Decreased in intravascular volume Cardiogenic Decreased cardiac output Distributive Problem with blood flow to cells

Implementation for shock

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 Monitor CVP: <3 inadequate fluid; >11 too much fluid Increased ICP Implementations Assessments Monitor vital signs Altered LOC (Earliest Sign) Monitor Glasgow Coma Scale Glasgow coma scale <7 Elevate head 30-45 degrees indicates coma Avoid neck flexion and head Confusion rotation Restlessness Reduce environmental stimuli Pupillary changes Prevent Valsalva maneuver Vital sign changes WIDENING Restrict fluids to 1200-1500 PULSE PRESSURE cc/day Medications Osmotic diuretics, corticosteroids Seizures: do not restrain do not insert anything in mouth Electrolytes Potassium: Sodium: Calcium: Magnesium: 3.5-5.0 mEq/L 135-145 mEq/L 4.5-5.2 mEq/L 1.5-2.5 mEq/L Hypokalemia Implementations Potassium Supplements Dont give > 40 mEq/L into peripheral IV or without cardiac monitor Increase dietary intake oranges, apricots, beans, potatoes, carrots, celery, raisins Hyperkalemia Implementations Restrict oral intake Kayexalate Calcium Gluconate and Sodium
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Hypokalemia Assessments K+ < 3.5 mEq/L Muscle weakness Paresthesias Dysrhythmias Increased sensitivity to digitalis Hyperkalemia Assessments K+ >5.0 mEq/L EKG changes Paralysis

 Diarrhea Nausea

Bircarbonate IV Peritoneal or hemodialysis Diuretics Hyponatremia Implementations I&O Daily weight Increase oral intake of sodium rich foods Water restriction IV Lactated Ringers or 0.9% NaCL Hypernatremia Assessments I&O Daily Weight Give hypotonic solutions: 0.45% NaCl or 5% Dextrose in water IV

Hyponatremia Assessments Na+ < 135 mEq/L Nausea Muscle cramps Confusion Increased ICP Hypernatremia Assessments Na+ >145 mEq/L Disorientation, delusion, hallucinations Thirsty, dry, swollen tongue Sticky mucous membranes Hypotension Tachycardia Hypocalcemia Assessments Ca+ < 4.5 mEq/L Tetany Positive Trousseaus sign Positive Chvosteks sign Seizures Confusion Irritability, paresthesias

Hypocalcemia Implementations Oral calcium supplements with orange (maximizes absorption) Calcium gluconate IV Seizure precautions Meet safety needs

Hypercalcemia Assessments Ca+> 5.2 mEq/L Sedative effects on CNS Muscle weakness, lack of coordination Constipation, abdominal pain Depressed deep tendon

Hypercalcemia Implementations 0.4% NaCl or 0.9% NaCl IV Encourage fluids (acidic drinks: cranberry juice) Diuretics Calcitonin Mobilize patient
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reflexes Dysrhythmias Hypomagnesemia Assessments Mg+< 1.5 mEq/L Neuromuscular irritability Tremors Seizures Tetany Confusion Dysphagia

Surgery for hyperparathyroidism Hypomagnesemia Implementations Monitor cardiac rhythm and reflexes Test ability to swallow Seizure precautions Increase oral intakegreen vegetables, nuts, bananas, oranges, peanut butter, chocolate

Hypermagnesemia Assessments Hypermagnesemia Implementations Mg + > 2.5 mEq/L Discontinue oral and IV Hypotension magnesium Depressed cardiac impulse Monitor respirations, cardiac transmission rhythm, reflexes Absent deep tendon reflexes IV Calcium to antagonize Shallow respirations cardiac depressant activity (helps to stimulate heart) Burns Assessments Superficial partial thicknesspink to red, painful Deep partial thicknessred to white, blisters, painful Full thicknesscharred, waxy, white, painless Wound Care for Burns Never break blisters Isotonic fluids (Lactated Ringers) Closed method (Silvadene) covered with dressings Open method (Sulfamylon) that are not covered with dressings IV pain medication initially:
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Medicate patient before wound care Silver nitrate (warn patient skin will turn black) High calorie, High carbohydrate, High protein diet Vitamin B,C, and Iron TPN maybe Prevent contractures

not PO takes too long, not IM circulation impaired

Addissons Disease Assessments Fatigue Weakness Dehydration Eternal tan Decreased resistance to stress Low Sodium Low Blood Sugar High Potassium Addisonian Crisis Assessments Hypotension Extreme weakness Nausea vomiting Abdominal pain Severe hypoglycemia Dehydration Cushings Syndrome Assessments Osteoporosis Muscle wasting Hypertension Purple skin striations Moon face Truncal obesity Decreased resistance to infection Pheochromocytoma Assessmentshypersecretions

Addissons Disease Implementations High protein, High carbohydrate, high Sodium, Low potassium diet Teach life-long hormone replacement

Addisonian Crisis Implementations Administer NaCl IV, vasopressors, hydrocortisone Monitor vital signs Absolute bedrest

Cushings Syndrome Implementations Low Carbohydrate, Low Calorie, High Protein, High Potassium, Low sodium diet Monitor glucose level Postop care after adrenalectomy or hypophysectomy

Pheochromocytoma Implementations
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of the catecholamines (epinephrine/norepinephrine) Persistent hypertension Hyperglycemia Pounding headache Palpitations Visual disturbances

Histamine Test, Regitine Test, 24- hour urine VMA test Avoid emotional and physical stress Encourage rest Avoid coffee and stimulating foods Postop care after adrenalectomy and medullectomy COPD Implementations Assess airway clearance Listen to breath sounds Administer low-flow oxygen (1-2 L, not too much because your trying to prevent CO2 narcosis) Encourage fluids Small frequent feedings Use metered dose inhalers (MDI)

COPD Assessments Blue Bloaters Pink Puffers Weakness Change in postured day and hs (dont sleep laying down, have to stay erect) Use of accessory muscles of breathing Dyspnea Cough Adventitious breath sounds Pneumonia Assessments Fever Leukocytosis Productive Cough (rust, green, yellow) Dyspnea Pleuritic pain Tachycardia

Pneumonia Implementations Check breath sounds Cough and deep breath q 2 hours Chest physiotherapy Antibiotics Incentive spirometer Encourage fluids Suction PRN Provide oxygen Semi-Fowlers position Bedrest Medicationsmucolytics
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(Mucomyst), expectorants (Robitussin), Bronchodilators (Aminophylline), Antibiotics (Bacterim) Acyanotic Congenital Heart Anomalies Assessments Normal Color Possible exercise intolerance Small stature Failure to thrive Heart murmur Frequent respiratory Infections Cyanotic Congenital Heart Anomalies Assessments Cyanosis Clubbing of fingers Seizures Marked exercise intolerance Difficulty eating Squat to decrease respiratory distress Small stature Failure to thrive Characteristic murmur Frequent respiratory infection

Acyanotic Congenital Heart Anomalies Types: Ventricular Septal Defect (VSD)abnormal opening between right/left ventricles; hole size of pinhole or absence of septum; hear a loud harsh murmur, at age of 3 hole may close otherwise surgery such as purse-string suture Atrial Septal Defect (ASD)abnormal opening between the two atria; audible murmur (if defect is severe closure is done later in childhood) Patent Ductus Arteriosis (PDA)failure of fetal structure to close after birth; ductus areteriosis in the fetus connects the pulmonary artery to aorta to shunt oxygenenated blood from the placenta to systemic circulation (which bypasses the lungs). Once the child is born that structure should close because it is no longer needed because blood passes through to lungs; vascular congestion, right ventricular hypertrophy; murmur, bounding pulse, tachycardia; surgical to divide or ligate the vessel.
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 Coarctation of the Aortanarrow of aorta; high blood pressure and bounding pulse in areas that receive blood proximal to the defect. Weak and absent blood distal to aorta. Surgical end-to-end anastomosis. Pulomonic Stenosisnarrowing at entrance to pulmonary artery; causes resistance to blood flow and right ventricular hypertrophy; surgery Aortic Stenosisnarrowing of aortic valve; causes decrease cardiac output; surgery Cyanotic Congenital Heart Anomalies Types: Tetralogy of FallotVSD, pulmonic stenosis, overriding aorta, right ventricular hypertrophy; squats/knee chest position to help breath; surgery needed Transposition of great vesselspulmonary artery leaves left ventricle and aorta leaves right ventricle; oxygenated blood not going into systemic circulation Truncus arteriosusfailure of normal septation and embryonic division of the pulmonary artery and aorta; rather than two distinctly different vessels there is a single vessel that overrides both ventricles and gives rise to both pulmonary and systemic circulation; blood enters from both common artery and either goes to the lungs or to the body; cyanosis, murmur, difficult intolerance Total anomalous venous returnabsence of direct communication between pulmonary veins and left atria; pulmonary veins attach directly to right atria or drains to right atria Congenital Heart Anomalies Compensatory Mechanisms Tachycardia Polycythemia (increase formation of RBCs) Posturingsquatting, knee-chest position Congenital Heart Anomalies Implementations Prevention Recognize early symptoms
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 Monitor vital signs and heart rhythms Medicationsdigoxin, iron, diuretics, potassium Change feeding pattern Left-Side CHF Dyspnea, orthopnea Cough Pulmonary edema Weakness/Changes in mental status CHF Right-Side CHF Dependent edema Liver enlargement Abdominal pain/Nausea/Bloating Coolness of extremities

Implementations Administer digoxin, diuretics Low-sodium, low-calorie, low-residue diet Oxygen therapy Daily weight Teach about medications and diet Arterial Peripheral Vascular Disease Implementations Monitor Peripheral pulses Good foot care Stop smoking Regular exercise Medicationsvasodilators, anticoagulants

Arterial Peripheral Vascular Disease Assessments Rubor Cool shiny skin Ulcers Gangrene Intermittent Claudication (pain with exercise/walking relieved with rest) Impaired sensation Decreased peripheral pulses

Venous Peripheral Vascular Disease Assessments Cool, brown skin Edema Normal or decreased pulses

Venous Peripheral Vascular Disease Implementations Monitor peripheral pulses Elastic stockings Medicationsanticoagulants
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 Positive Homans sign

Elevate legs Warm, moist packs Bedrest 4-7 days (acute phase) Anemia Implementations Identify cause Frequent rest periods High protein, high iron, high vitamin diet Protect from infection

Anemia Assessments (reduction in hemoglobin amount/erythrocytes) Palpitations Dyspnea Diaphoresis Chronic fatigue Sensitivity to cold

Iron Deficiency Anemia Assessments Fatigue Glossitis Spoon fingernails Impaired cognition Pernicious Anemia Assessments (gastric mucosa fail to secrete enough intrinsic factor for stomach to absorb) Schillings Test Fatigue Sore, red tongue Paresthesia in hands and feet Sickle Cell Anemia Assessments Pain /Swelling/Fever Schlerae jaundiced Cardiac murmurs Tachycardia

Iron Deficiency Anemia Implementations Increase iron-rich foods (liver, green leafy vegetables) Iron supplements (stains teeth) Pernicious Anemia Assessments Vitamin B12IM Rest of life cant be absorbed PO

Sickle Cell Anemia Implementations Check for signs of infection (prevent crisis) Check joint areas for pain and swelling Encourage fluids Provide analgesics with PCA pump c crisis

Hemophilia Assessments (female to male gene

Hemophilia Implementations Administer plasma or factor VIII

27

transmission) Easy bruising Joint pain Prolonged bleeding

Analgesics Cryoprecipitated antihemophilic factor (AHF) Teach about lifestyle changes Non contact sports

Cancer Implementation: External Radiotherapy Leave markings on skin Avoid use of creams, lotions (only vitamin A&D ointment) Check for redness, cracking Wear cotton clothing Administer antiemetics Cancer Implementation: Internal Cancer Implementation: radiation sealed source Internal Radiation Lead container and long-handled Time and distance important forceps in room Private room sign on door Save all dressings, bed linen until Nurse wears dosimeter at all source removed times Urine and feces not Limit visitors and time spent radioactive in room Dont stand close or in line with Rotate staff source Self-care when can do Patient on bed rest Cancer Implementation: Internal radiation unsealed source All body fluids contaminated Greatest danger first 24-96 hours Leukemia Assessments Ulcerations of mouth Anemia Fatigue Weakness Pallor Leukemia Implementations Monitor for signs of bleeding: petechiae, ecchymosis, thrombocytopenia Infections Neutropenia (private room/limit # people, wbc done daily, no fruit, no flowers/plotted plants, clean
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toothbrush with weak bleach solution Good mouth care High calorie, high Vitamin diet (avoid salads/raw fruit/pepper/dont reuse cup/dont change litter box/digging in garden Intracranial Tumors Intracranial Tumors Implementations Assessments Preoperative: do neurological Motor deficits assessment, patient head shaved Hearing or visual Postoperative: maintain airway, disturbances elevate head 30-45 after supratentorial surgery Dizziness Flat and lateral after infratentorial Paresthesia surgery Seizures Monitor vital and neurological signs Personality disturbances Glascow coma scale Changes in LOC Therapeutic Positions Supineavoids hip flexion Dorsal recumbentsupine with knees flexed Proneextension of hip joint(after amputation) Side lateraldrainage of oral secretions Knee-chestvisualization of rectal area Simsdecreases abdominal tension (side lying with legs bent) Fowlersincreases venous return, lung expansion High Fowlers60-90 Fowlers45-60 Semi-Fowlers30-45 Low Fowlers15-30 Modified Trendelenburgused for shock;Feet elevated 20 degrees, knees straight, trunk flat, head slightly elevated Elevation of extremityincreases blood to extremity and venous return Lithotomyused for vaginal exam 4 point Gait Weight bearing 2 point Gait Bearing both legs 3 point Gait Bearing one leg Weaker leg both crutches, then stronger
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Swing-toswing through Partial

both legs RC/LF, LC/RF leg RC, LF, LC, RF

weight bearing both legs Both crutches, one or two legs

Stairs Going upgood leg first, crutches, bad leg Going downcrutches with bad leg, then good leg Up with the good, down with the bad Walker Flex elbows 20-30 degrees when hands are on grips Lift and move walker forward 8-10 inches Step forward with bad leg, support self on arms, follow with good leg Stand behind client holding onto gait belt Myelogramx-ray visualization of the spinal canal by injection of radiopaque dye. Hydration done 12 hours before procedure Cleansing enemas Avoid seizure-promoting medications Laminectomyexcision portion of lamina to expose area of affected disc Preopcare: moist heat Fowlers position Isometric exercises for abdominal muscles Muscle relaxants, NSAIDs, Analgesics Traction, TENS Post-procedure Water-soluble dyeelevate head of bed 30 degrees (not removed) Oil based dyeflat in bed (removed) Bedrest 24 hours encourage fluids Postoperative care: Assess circulation and sensation Log roll Q2 hours with pillow between leg Calf exercises, assist with ambulation keeping back straight Muscle relaxants, NSAIDS, analgesics, Teachingdaily exercises, firm mattress, avoid prone position and heavy
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lifting Avoid sitting long time Dysplasia of the Hip Assessment Uneven gluteal folds and thigh creases Limited abduction of hip Ortolanis signplace infant on back with legs flexed, clicking sound with abduction of legs Shortened limb on affected side Dysplasia of the Hip Implementations Newborn to 6 months Reduced by manipulation Pavlik harness for 3 to 6 months 6 to 18 months Bilateral Bryants traction Hip spica cast Older child Open reduction Hip Spica cast Scoliosis Implementations Exercises to strengthen abdominal muscles (if functional) Surgery: spinal fusion insertion of Herrington Rod Milwaukee brace: used with curves 30-40 degrees Wear 4-6 years, worn 23 hours of the day, wear undershirt to prevent irritation, teach isometric exercises

Scoliosis Assessmentslateral deviation of one or more of vertebrae accompanied by rotary motion of spine Uneven hips or scapulae Kyphosis lump on back Bend at waist to visualize deformity Structural (flexible deviation corrected with bending) or functional (permanent heredirary that is seen)

Cerebral Palsy Assessments Cerebral Palsy Implementations Voluntary muscles poorly Ambulation devices, PT and OT controlled due to brain damage Muscle relaxants and Spasticity, rigidity, ataxia, anticonvulsants repetitive involuntary gross Feeding: place food at back of motor movements mouth with slight downward pressure. Never tilt head backward. High calorie diet
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Muscular Dystrophy Assessments Atrophy of voluntary muscles Muscle weakness, lordosis, falls

Braces to help ambulation Balance activity and rest

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Parkinsons Disease Assessments Deficiency of dopamine Tremors, rigidity, propulsive gait Monotonous speech Mask like expression

Parkinsons Disease Implementations Teach ambulation modification: goose stepping walk (marching), ROM exercises MedicationsArtane, Cogentin, L-Dopa, Parlodel, Sinemet, Symmetrel

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Myasthenia Gravis Assessments Deficiency of acetylcholine Muscular weakness produced by repeated movement Dysphagia Respiratory distress

Myasthenia Gravis Implementations Good eye care, restful environment Medicationsanticholinesterases, corticosteroids, immunosuppressants Avoid crisis: infection Symptoms: sudden ability to swallow

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Clear liquid No milk No juice with pulp

Full liquid No jam No fruit No nuts

High Renal protein Keeps diet protein Restab , lish potassi anabol um ism to and raise sodium albumi low n No levels beans, Egg, no roast cereals beef , no sandw citrus ich, fruits No junk food

Low-fat cholestero l restricted Can eat lean meat No avoca do, milk, bacon, egg yolks butter Lowphenylala nine diet Preve nts brain dama ge from imbala nce of amino acids Fats, fruits, jams allowe d No meats eggs bread

Sodium restricte d No cheese

High roughag e, high fiber No white bread withou t fiber

Low-residue Minimize intestinal activity Buttered rice white processed food, no whole wheat corn bran

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Glomerulonephritis Assessment Fever, Chills Hematuria Proteinuria Edema Hypertension Abdominal or flank pain Occurs 10 days after beta hemolytic streptococcal throat infection Urinary Diversion: Assessments Done for: Bladder t umors, birth defects, neurogenic bladder, interstitial cystitis Ileal Conduit Koch Pouch

Glomerulonephritis Implementation Antibiotics, corticosteroids Antihypertensives, immunosuppressive agents Restrict sodium and water intake Bedrest I&O Daily weight High Calorie, Low protein

Urinary Diversion Implementations Nephrostomy: flank incision and insertion of nephrostomy tube into renal pelvis; penrose drain after surgery; surgical dressing Ureterosigmoidostomy: urters detached from bladder and anastomosed to sigmoid colon; encourage voiding via rectum q 2-4 hours;no enemas or cathartics; complicationselectrolyte imbalance, infection, obstruction; urine and stool evacuated towards anus. Cutaneous Ureterostomy: Stoma formed from ureters excised from bladder and brought to abdominal wall; stoma on right side below waist; assist with alteration in body image Illeal Conduit: Ureters replanted into portion of terminal ileum and brought to abdominal
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wall; check for obstruction; mucous threads in urine normal Koch Pouch (Continent Illeal Conduit): Ureters transplanted into pouch made from ileum with one-way valve; drainage of pouch by catheter under control of client; drain pouch at regular intervals Acute Renal Failure Assessments: Oliguric Phase Output <400 cc/day Hypertension Anemia CHF Confusion Increased K+, Ca+, Na+, BUN, Creatinine Acute Renal Failure Assessment s: Diuretic Phase Output 4-5 L/day Increased BUN Na+, K+ lost in urine Increased mental and physical activity Acute Renal Failure Causes Prerenal reduced blood volume Renal nephrotoxic drugs, glomeruloneph ritis Postrenal-obstruction Acute Renal Failure Implementations: Low-output stage: Limit fluids, Kayexalate, Dialysis High-output stage: Fluids as needed, K+ replacement, Dialysis I&O Daily Weight Monitor Electrolytes Bedrest during acute phase IV fluids Diet restrictions Oliguric phase: limit fluids, TPN maybe After Diuretic phase: high protein, high calorie diet

Hemodialysis Implementation Check for thrill and bruit q 8 hours

Peritoneal Dialysis Weight before and after treatment

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Types of Peritoneal Dialysis Continuous ambulatory

 Dont use extremity for BP, finger stick Monitor vital signs, weight, breath sounds Monitor for hemorrhage

Monitor BP Monitor breath sounds Use sterile technique If problem with outflow, reposition client Side effects: constipation

(CAPD) Automated Intermittent Continuous

Ego Defense Mechanisms Denialfailure to acknowledge thought Displacementredirect feelings to more acceptable subject Projectionattributing your feelings to someone else Undoingattempt to erase an act, thought or feeling Compensationattempt to overcome shortcoming Symbolizationless threatening object used to represent another Substitutionreplacing unacceptable or unobtainable object to one that is acceptable or attainable Introjectionsymbolic taking into oneself the characteristics of another Repressionunacceptable thoughts kept from awareness Reaction formationexpressing attitude opposite of unconscious wish or fear Regressionreturning to an earlier developmental phase Dissociationdetachment of painful emotional conflicts from consciousness Suppressionconsciously putting thought out of awareness Dying patient: Denial, Anger, Bargaining, Depression, Acceptance Bipolar Disorder Assessments Bipolar Disorder Implementations
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 Disoriented, flight of ideas Lacks inhibitions, agitated Easily stimulated by environment Sexually indiscreet Affective disorder Maintain contact with reality Elation is defense against underlying depression Manipulative behavior results from poor selfesteem

Meet physical needs first Simplify environment Distract and redirect energy Provide external controls Set limits: escalating hyperactivity Use consistent approach Administer Lithium (help Manic Phase of Bipolar, keep hydrated) Increase awareness of feelings through reflection Schizophrenia Implementations Maintain safetyprotect from erratic behavior With hallucinationdo not argue, validate reality, respond to feeling tone, never further discuss voices (dont ask to tell more about voices) With delusionsdo not argue, point out feeling tone, provide diversional activities Meet physical needs Establish therapeutic relationship Institute measures to promote trust Engage in individual,

Schizophrenia Assessments Withdrawal from relationships and world Inappropriate display of feelings Hypochondriasis Suspiciousness Inability to test reality, regression Hallucinations false sensory perceptions Delusions persistent false beliefs; grandeur (feel higher rank); persecutory (beliefs to be a victim); ideas of

Schizophrenia Types Disorganized inappropriate behavior, transient hallucinations Catatonicsudden onset mutism, stereotyped position, periods of agitation Paranoidlate onset in life, suspiciousness, ideas of persecution and delusions

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reference (see people talking think talking about them) Loose associations Short attention span Inability to meet basic needs: nutrition, hygiene Regression

group, or family therapy Encourage clients affect Accept nonverbal behavior Accept regression Provide simple activities or tasks

Paranoid Assessments Suspiciousness Cold, blunted affect Quick response with anger or rage Schizoid Assessments Shy and introverted Little verbal interaction Few friends Uses intellectualization Schizotypal Assessments Eccentric Suspicious of others Blunted affect Problems with perceiving, communicating Antisocial Assessments Disregards rights of others Lying, cheating, stealing, promiscuous Lack of guilt Immature

Paranoid Implementations Establish trust Low doses phenothiazines for anxiety Structured social situations

Schizoid Implementations Establish trust Low doses phenothiazines for anxiety Structured social situations

Schizotypal Interventions Establish trust Low doses neuroleptics to decrease psychotic symptoms Structured social situations Antisocial Implementations Firm limit-setting Confront behaviors consistently Enforce consequences Group therapy
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 Irresponsible Associated with substance abuse Borderline Assessments Brief and intense relationships Blames others for own problems Impulsive, manipulative Self-mutilation Women who have been sexually abused Suicidal when frustrated, stressed Narcissistic Assessments Arrogant lack of feelings and empathy for others Sense of entitlement Uses others to meet own needs Shallow relationships Views self as superior to others Histrionic Assessments Draws attention to self Somatic complaints Temper tantrums, outbursts Shallow, shifting emotions Cannot deal with feelings Easily influenced by others Dependent Assessments Borderline implementations Identify and verbalize feelings Use empathy Behavioral contract Journaling Consistent limit-setting Group therapy

Narcissistic Implementations Mirror what client sounds like Limit-setting Consistency Teach that mistakes are acceptable Histrionic Implementations Positive reinforcement for other centered behaviors Clarify feelings Facilitate expression of feelings

Dependent
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Implementations Passive Emphasize decision Problem working making independently Teach assertiveness Helpless when alone Assist to clarify feelings Dependent on others for and needs decisions Fears loss of support and approval Avoidant Assessments Socially uncomfortable Hypersensitive to criticism, Lacks selfconfidence Fears intimate relationships Obssessive-compulsive Assessments High personal standards for self and others Preoccupied with rules, lists, organized Perfectionists Intellectualize Avoidant Implementations Gradually confront fears Discuss feelings Teach assertiveness Increase exposure to small groups Obssessive-compulsive Implementations Explore feelings Help with decisionmaking Confront procrastination Teach that mistakes are acceptable

Manipulative behavior Assessments Unreasonable requests for time, attention, favors Divides staff against each other Intimidates others Use seductive or disingenuous approach

Manipulative Behavior Implementations Use consistent undivided staff approach Set limits Be alert for manipulation Check for destructive behavior Help client to see
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consequences of behavior Acute Alcohol Intoxication Drowsiness Slurred speech Tremors Impaired thinking Belligerence Loss of inhibitions Acute Alcohol Implementations Protect airway Assess for injuries Withdrawal assess IV glucose Counsel about alcohol use Alcohol Withdrawal Implementations Monitor vital signs, especially pulse Administer sedation, anticonvulsants, thiamine (IM or IV), glucose (IV) Seizure precautions Quiet, well-lighted environment Stay with patient

Alcohol Withdrawal Assessments Tremors insomnia anxiety hallucinations

After WithdrawalDeliriu m Tremens Assessments Disorientation Paranoia Ideas of reference Suicide attempts Grand mal convulsions

Chronic Alcohol Chronic Alcohol Dependence Dependence Assessments Implementations Persistent incapacitation Identify problems related to drinking Cyclic drinking or Help client see problem binges Establish control of problem Others in family take Alcoholics anonymous over clients role Antabuse Family violence Counsel spouse and children Wernickes Syndrome Assessments Confusion Wernickes Syndrome Implementations Thiamine (IM or IV)
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 Diplopia, nystagmus Ataxia Apathy Korsakoffs Psychosis Assessments Memory disturbances with confabulation Learning problems Altered taste and smell Loss of reality testing Retinopathy of Prematurity Assessment Demarcation line with ridge Retinal detachment

Abstinence from alcohol

Korsakoffs Psychosis Implementations Balanced diet Thiamine Abstinence from alcohol

Retinopathy of Prematurity Implementations Prevent by using minimum oxygen concentrations Monitor PO2 Eye exam (premature infants) Corrective lenses Implementations Eye exercises surgery

Strabismus (cross-eyed) Assessments Deviation of eye Diplopia Tilts head or squints Detached Retina Assessments Flashes of light Loss of vision Particles moving in line of vision confusion

Detached Retina Implementations Bedrest, affected eye in dependent position Eye patched (one or both) Surgery Sedatives and tranquilizers Avoid stooping, straining at stool, strenuous activity 3 months Cataracts Implementations
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Cataracts Assessments

 Distorted, blurred vision Milky white pupil

Postop: check for hemorrhage Check pupilconstricted with lens implanted, dilated without lens Eye drops Night shield Sleep on unaffected side Glaucoma Implementations Administer miotics (constrict pupil, allows more area for aqueous humor to flow), carbonic anhydrase inhibitors Surgery Avoid heavy lifting, straining of stool Mydriatics (dilates pupil, makes angle smaller and constrict aqueous flow) are contraindicated with glaucoma.

Glaucoma Assessments Abnormal increase in intraocular pressure that leads to blindness Blurred vision Lights with halos Decreased peripheral vision Pain Headache Trigeminal Neuralgia Assessments Stabbing, burning facial pain Twitching of facial muscles Bells Palsy Assessments Inability to close eye Increased lacrimation Distorted side of face Guillain-Barre Syndrome Assessments Paresthesia Motor losses beginning in lower extremities Altered autonomic function Meningitis Assessments

Trigeminal Neuralgia Implementations Medicationsanalgesics, Tegretol Surgery

Bells Palsy Implementations Isometric exercises for face Prevent corneal abrasions Guillain-Barre Syndrome Implementations Medicationssteroids Aggressive respiratory care Physical therapy Eye care Prevent complications: respiratory and aspiration Meningitis Implementations
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Nuchal rigidity Kernings sign Brudzinskis sign Seizures Bulging fontanels High-pitched cry

Medicationsantibiotics, antifungals Prevent complications: droplet precautions, contagious

Thoracentesis: no more than 1000cc taken at one time. Electroencephalogram (EEG) Preparation Test brains waves; seizure disorders Tranquilizer and stimulant meds withheld for 24-48 hours Stimulants (caffeine, cigarettes) withheld for 24 hours May be asked to hyperventilate during test Meals not withheld Kept awake night before test; want them to lie still Electroencephalogram (EEG) Post-test Remove paste from hair Administer medications withheld before test Observe for seizure activity Seizure prodromal signs; epigastric distress, lights before the eyes

CAT Scandye gives flushed, warm face and metallic taste during injection (if contrast dye is used) Myelogram: Post-test Supine 8-24 hours (Pantopaque oil-based dye used) Head raised 30-45degrees 8-16 hours(metrizamide water-soluble dye used) Liver Biopsy Preparation Administer vitamin K IM (decrease risk of hemorrhage) NPO 6 hours Given sedative Position supine, lateral with upper arms elevated Liver Biopsy Post-Test Position on operative side for 1-2 hours Gradually elevate head of bed 30 degrees (1st hour) and then 45 degrees (2nd 2 hours) Bedrest for 24 hours Check Vital signs
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 Asked to hold breath for 510 seconds

Check clotting time, platelets, hematocrit Report severe abdominal pain

Upper GI Series Barium Swallow: stool white from barium Tracheostomy Tube Cuff Purposeprevents aspiration of fluids Inflated o During continuous mechanical ventilation o During and after eating o During and 1 hour after tube feeding o When patient cannot handle oral secretions Oxygen Administration: assess patency of nostril, apply jelly Face mask: 5-10 l/min (40-60%) Partial rebreather mask: 6-15 l/min (70-90%); keep reservoir bag 2/3 full during inspiration Non-rebreather mask: (60-100%); keep reservoir bag 2/3 full during inspiration Venturi mask: 4-10 l/min (20-50%); provides high humidity and fixed concentrations, keep tubing free of kinks Tracheostomy collar or T-piece: (20-100%); assess for fine mist; empty condensation from tubing keep water container full Croupette or oxygen tent: o Difficulty to measure amount of oxygen delivered o Provides cooled, humidified air o Check oxygen concentration with oxygen analyzer q4 hours o Clean humidity jar and fill with distilled water daily o Cover patient with light blanket and cap for head o Raise side rails completely o Change linen frequently o Monitor patients temperature

Chest Tubes

Chest Tube
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Complications of Chest

Implementations Use to utilize negative pressure in lungs Fill water-seal chamber with sterile water to 2 cm Fill suction control chamber with sterile water to 20 cm Maintain system below level of insertion Clamp only momentarily to check for air leaks Ok to milk tubing towards drainage Observe for fluctuation in waterseal chamber Encourage patient to change position frequently

Removal: Instruct patient to do valsalva maneuver Clamp chest tube Remove quickly Occlusive dressing applied

Tubes: Constant bubbling in water-seal chamber=air leak Tube becomes dislodged from patient, apply dressing tented on one side Tube becomes disconnected from drainage system, cut off contaminated tip, insert sterile connector and reinsert Tube becomes disconnected from drainage system, immerse end in 2 cm of sterile water

CVP: measures blood volume and efficiency of cardiac work; tells us right side of heart able to manage fluid 0 on mamometer at level of right atrium at midaxilliary line Measure with patient flat in bed Open stopcock and fill manometer to 18-20 cm Turn stopcock, fluid goes to patient Level of fluid fluctuates with respirations Measure at highest level of fluctuation After insertion o Dry, sterile dressing o Change dressing, IV fluids, manometer, tubing q24 hours o Instruct patient to hold breath when inserted, withdrawn, tubing changed o Check and secure all connections
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 Normal reading3-11 cm water Elevated>11, indicates hypervolemia or poor cardiac contractility (slow down IV, notify physician) Lowered<3, hypovolemia Chest tray at bedside Eye irrigation: tilt head back and toward affected side Eye drops: drop in center of conjunctival sac; prevent systemic absorption, press on inner angle of eye; dont allow drops to go from one eye to the other; dont squeeze eyes Nasogastric Tubes: Levin-singlesingle-lumen, used for decompression or tube feeding Salem sumpdouble-lumen, used for decompression or tube feeding Sengstaken-Blakemoretriple-lumen, used for bleeding esophageal varices Linton-Nachlas4-lumen, used for bleeding esophageal varices Keofeed/Dobhoffsoft silicone, used for long-term feedings Cantorsingle lumen with mercury-filled balloon and suction port Miller-Abbottdouble-lumen with mercury-filled balloon and suction port Harrissingle lumen with mercury-filled balloon and suction port NG tube placement: BEST WAY to check is to aspirate for gastric contents and check for pH of aspirate <4 Implementation of feeding: Check residual before intermittent feeding, reinstall residual Check residual Q4 hours with continuous feeding, reinstall residual Hold feeding if >50% residual from previous hour (adults) or >25% (children) Flush tube with water before and after feeding Use pump to control rate of tube feeding Administer fluid at room temperature Change bag Q8 hours for continuous feeding Elevate head of bed while feeding is running Check patency Q4 hours
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 Good mouth care NG Irrigation Tubing: Verify placement of tube Insert 30-50 cc of normal saline into tube If feel resistance, change patient position, check for kinks Withdraw solution or record amount as input NG removal: Clamp tube Remove tape Instruct patient to exhale Remove tube with smooth, continuous pull Intestinal Tubes (Cantor, Mill-Abbott, Harris) Implementations o After tube is in stomach, have patient lie on right side, then back in Fowlers position, then left side o Gravity helps to position tube o Coil excess tube loosely on bed, do not tape o Position of tube verified by x-ray o Measure drainage QShift Removal o Clamp tube o Remove tape o Deflate balloon or aspirate contents of intestinal tube balloon o Instruct patient to exhale o Remove 6 every 10 min. until reaches the stomach, then remove completely with smooth, continuous pull T-Tube: 500-1000 cc/day, bloody first 2 hours Penrose: expect drainage on dressing Enema Implementation Position on left side Use tepid solution Hold irrigation set no more than 18 above rectum Insert tube no more than 4 Do not use if abdominal pain, nausea, vomiting, suspected appendicitis
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Catheter insertion: 2-3 into urethra then 1 after urine flows Male catheter: insert 6-7 Catheter Urine Drainage bag: do not remove more than 700 cc at one time, clamp prior to removal Ileostomy: post-op has loose, dark green, liquid drainage from stoma Tonsillectomy: post-op frequently swallowing indicates hemorrhage External contact lenses: need fine motor movements (rheumatoid arthritis prevents this). Object in eye: never remove visible glass; apply loose cover and remain quiet. Retina detached: sleep prone with affected side down; avoid jarring movements; avoid pin point movement with eye (sewing); high fluid and roughage (prevents constipation=no straining); make light sufficient for needs (75watt+); no hairwashing Glaucoma medications: Epinephrine hydrochloride (Adrenalin Chloride) and Pilocarpine Hydrochloride (Pilocar): give Pilocar (therapeutic) first then wait 2-10minutes and instill adrenalin to increase absorption of adrenalin). Tympanoplasty: remain in bed 24 hours position flat in bed with the affected ear up (helps to promote insertion). Triglycerides elevation can falsely elevate glycosalated hemoglobin test. Laparoscopic Cholecystectomy post: encourage to walk to eliminate acute right shoulder pain. Impetigo: 2 year old; honey-colored crusts, vesicles, and reddish macules around mouth; dont need to isolate; watch contact precautions. Only patient we use distractions on the NCLEX are manic patients and toddlers not for pain.
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Rhinoplasty (nose surgery) position post-op: want to promote drainage of oral secretions is to position on her right side. 1 cup= 240cc Pregnancy is a contraindication to an MRI. Raynauds disease have decreased vascularity in the extremities. Post-Parecentesis most important assessment is to obtain the blood pressure, weight the client, measure the clients abdominal girth, and check dressing in that order. Tracheostomy tube: use pre-cut/pre-made gauze pads. Suction is always intermittent never continuous. O universal donor/AB universal recipient. ABO BLOOD TYPE COMPATIBILITY Can Receive from: O A,O B,O O,A,B,AB

Blood Type O A B AB

Can donate to: O,A,B,AB A,AB B,AB AB

Autologous Transfusion: Collected 4-6 weeks before surgery Contraindicatedinfection, chronic disease, cerebrovascular or cardiovascular disease Hypotonic Solution NS (0.45% Saline) Isotonic Solution 0.9% NaCl (Normal Saline) 5% D/W (Dextrose in Water) Lactated Ringers 5% D/ NS (5% Dextrose in 0.225%
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Hypertonic Solution 10% D/W (10% Dextrose in water) D15W 5% D/NS (5% Dextrose in 0.9% Saline) 5% D/ NS (5% Dextrose in 0.45% Saline)

Saline )

3% NaCl 5% Sodium Bicarbonate

Change tubing Q72 hours Change bottle Q24 hours Infiltration Assessment: cool skin, swelling, pain, decrease in flow rate Implementation: discontinue IV, warm compresses, elevate arm, start new site proximal to infiltrated site IV Phlebitis, Thrmobophlebitis Assessmentredness, warm, tender, swelling, leukocytosis Implementationdiscontinue IV, warm moist compresses, start IV in opposite extremity Hematoma Assessmentecchymosis, swelling, leakage of blood Implementationdiscontinue IV, apply pressure, ice bag 24 hours, restart IV in opposite extremity IV Clotting Assessmentdecreased flow rate, back flow of blood into tubing Implementationdiscontinue, do not irrigate, do not milk, do not increase rate of flow or hang solution higher, do not aspirate cannula, inject Urokinase, D/C and start on other site. Insertion of Percutaneous Central Catheters: Placed supine in head-low position Turn head away from procedure Perform Valsalva maneuver Antibiotic ointment and transparent sterile dressing Verify position with x-ray Change tubing Q24 hours Nurse/patient both wear mask when dressing change 2-3x/week Adrenergics Actions: Stimulate the sympathetic nervous system: increase in peripheral resistance, increase Adrenergic Medications Levophed Dopamine Adrenalin
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Adrenergics Side effects: Dysrhythmias Tremors Anticholinergic

blood flow to heart, bronchodilation, increase blood flow to skeletal muscle, increase blood flow to uterus Stimulate beta-2 receptors in lungs Use for cardiac arrest and COPD

Dobutrex

effects Adrenergics Nursing Considerations: Monitor BP Monitor peripheral pulses Check output

Anti-Anxiety Anti-Anxiety Action: Medications: Affect Librium, neurotransmitter Xanax, s Ativan, Used for: Vistaril, Equanil Anxiety disorders, manic episodes, panic attacks

Anti-Anxiety Side effects: Sedation Confusion Hepatic dysfunction Anti-Anxiety Nursing Considerations: Potention for addiction/overdose Avoid alcohol Monitor Liver Function AST/ALT Dont discontinue abruptly, wean off Smoking/caffeine decreases effectiveness

Antacids Actions: Neutralize gastric acids Used for: Peptic ulcer Indigestion, reflex esophagitis

Antacids Medications Amphojel Milk of Magnesia Maalox

Antacids Side effects: Constipation Diarrhea Acid rebound Antacids Nursing Considerations: Interferes with absorption of antibiotics, iron preps, INH, Oral contraceptives
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 Monitor bowel function Give 1-2 hours after other medications 1-3 hours after meals and at HS Take with fluids Antiarrhythmics Action: Interfere with electrical excitability of heart Used for: Atrial fibrillation and flutter Tachycardia PVCs Aminoglycosides (Antibiotics) Action: Inhibits protein synthesis in gram-negative bacteria Used for: Pseudomonas, E.Coli Antiarrhythmics Medications: Atropine sulfate Lidocaine Pronestyl Quinidine Isuprel Antiarrhythmics Side effects: Lightheadedness Hypotension Urinary retention Antiarrhythmics Nursing Considerations: Monitor vital signs Monitor cardiac rhythm

Aminoglycosides (Antibiotics) Medications: Gentamycin Neomycin Streptomycin Tobramycin

Aminoglycosides (Antibiotics) Side effects: Ototoxicity and Nephrotoxicity Anorexia Nausea Vomiting Diarrhea Aminoglycosides (Antibiotics) Nursing Considerations: Harmful to liver and kidneys Check 8th cranial nerve (hearing) Check renal function Take for 7-10 days Encourage fluids

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 Check peak/trough level Allergy: 1st symptom SOB Cephalosporin s (Antibiotics) Action: Inhibits synthesis of bacterial cell wall Used for: Tonsillitis, otitis media, perioperative prophylaxis Meningitis Cephalospori Cephalosporins (Antibiotics) ns Side effects: (Antibiotics) Bone marrow depression: caution Medications: with anemic, thrombocytopenic Ceclor patients Ancef Superinfections Keflex Rash Rocephin Nursing Considerations: Take with food Cefoxitin Cross allergy with PCN Avoid alcohol Obtain C&S before first dose: to make sure medication is effective against disease/bacteria Can cause false-positive for proteinuria/glycosuria Fluoroquinolon Fluroquinolones es (Antibiotics) (Antibiotics) Side effects: Medications: Diarrhea Cipro Decreased WBC and Hematocrit Elevated liver enzymes (AST, ALT) Elevated alkaline phosphatase Nursing Considerations: C&S before starting therapy Encourage fluids Take 1 hour ac or 2 hour pc (food slows absorption) Dont give with antacids or iron preparation Maybe given with other medications (Probenicid: for gout)
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Fluoroquinolon es (Antibiotics) Action: Interferes with DNA replication in gramnegative bacteria Used for: E.Coli, Pseudomona s, S. Aureus

Macrolide (Antibiotics) Action: Binds to cell membrane and changes protein function Used for: Acute infections Acne URI Prophylaxis before dental procedures if allergic to PCN

Macrolide (Antibiotics) Medications: Erythromycin Clindamycin

Macrolide (Antibiotics) Side effects: Diarrhea Confusion Hepatotoxicity Superinfections Nursing Considerations: Take 1hr ac or 2-3 hr pc Monitor liver function Take with water (no fruit juice) May increase effectiveness of: Coumadin and Theophylline (bronchodilator) Penicillin Side effects: Stomatitis Diarrhea Allergic reactions Renal and Hepatic changes Nursing Considerations: Check for hypersensitivity Give 1-2 hr ac or 23 hr pc Cross allergy with cephalosporins

Penicillin Action: Inhibits synthesis of cell wall Used for: Moderate to severe infections Syphilis Gonococcal infections Lyme disease

Penicillin Medications: Amoxicillin Ampicillin Augmentin

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Sulfonamides (Antibiotics) Action: Antagonize essential component of folic acid synthesis Used for: Ulcerative colitis Crohns disease Otitis media UTIs

Sulfonamides (Antibiotics) Medications: Gantrisin Bactrim Septra Azulfidine

Sulfonamides (Antibiotics) Side effects: Peripheral Neuropathy Crystalluria Photosensitivity GI upset Stomatitis Nursing Considerations: Take with meals or foods Encourage fluids Good mouth care Antacids will interfere with absorption

Tetracyclines (Antibiotics) Action: Inhibits protein sythesis Used for: Infections Acne Prophylaxis for opthalmia neonatorum

TEtracyclines (Antibiotics) Medications: Vibramycin Panmycin

Tetracyclines (Antibiotics) Side effects: Discoloration of primary teeth if taken during pregnancy or if child takes at young age Glossitis Rash Phototoxic reactions Nursing considerations: Take 1 hr ac or 2-3 hr pc Do not take with antacids, milk, iron Note expiration date Monitor renal function Avoid sunlight

UTIs Medication: o Furadantin Action:

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o Anti-infective Side effects: o Asthma attacks o Diarrhea Nursing Considerations: o Give with food or milk o Monitor pulmonary status UTIs Medication o Mandelamine Action: o Anti-infective Side effects: o Elevated liver enzymes Nursing Considerations: o Give with cranberry juice to acidify urine o Limit alkaline foods: vegetables, milk, almonds, coconut UTIs Medication o Pyridium Side effects: o Headache o Vertigo Action o Urinary tract analgesic Nursing Consideration o Tell patient urine will be orange

Anticholinergics Action: Inhibits action of acethylcholine and blocks

Anticholinergic Medications: Pro-Banthine Atropine Scopolamine

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Anticholinergic Side Effects: Blurred vision Dry mouth Urinary retention

parasympathetic nerves (affects heart, eyes, respiratory tract, GI tract and the bladder) Dilates pupil, causes bronchodilation and decreased secretions Decrease GI motility secretions Used for: Opthalmic exam Motion sickness Pre-operative Anticoagulants Action: Blocks conversion of prothrombin to thrombin Used for: Pulmonary embolism Venous thrombosis Prophylaxis after acute MI Anticoagulant Action: Interferes with synthesis of vitamin Kdependent clotting factors Used for: Anticoagulan ts Medications: Heparin

Chage in heart rate Nursing Consideration: Monitor output Contraindicated with glaucoma Give 30 min ac, hs, or 2hr pc Contraindicated: paralytic ileus, BPH

Anticoagulants (Heparin) Side Effects: Hematuria Tissue irritation Nursing Considerations: Monitor clotting time or Partial Thromboplastin Time (PTT) Normal 20-45 sec Therapeutic level 1.5-2.5 times control AntagonistProtamine Sulfate Give SC or IV

Anticoagul Anticoagulant (Coumadin) ant Side Effects: Medication Hemorrhage, Alopecia : Nursing Considerations: Couma Monitor Prothrombin din Test (PT) Normal 9-12 sec Therapeutic level 1.5
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 Pulmonary embolism Venous thrombosis Prophylaxis after acute MI

times control AntagonistVitamin K (AquaMEPHYTON) Monitor for bleeding Give PO

Anticonvulsants Anticonvulsant Anticonvulsant Action: Medications: Side effects: Decreases flow Dilantin Respiratory depression of calcium and Luminal Aplastic anemia sodium across Depakote Gingival hypertrophy neuronal Tegretol Ataxia membranes Nursing Considerations: Klonopin Used for: Dont discontinue abruptly Seizures Monitor I&O Caution with use of medications that lower seizure threshold: MAO inhibitors & anti-psychotics Good mouth care Take with food May turn urine pinkishred/pinkish-brown

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Anti-Depressants Monoamine Oxidase Inhibitors (MAO) Action: Causes increases concentration of neurotransmitter s Used for: Depression Chronic pain

AntiDepressants (Monoamine Oxidase Inhibitors) Medications: Marplan Nardil Parnate

Anti-Depressants (Monoamine Oxidase Inhibitors) Side effects: Hypertensive Crisis (Sudden headache, diaphoretic, palpitations, stiff neck, intracranial hemorrhage) with food that contain Tyramine Nursing Considerations: Avoid foods containing Tyramine: Aged cheese, liver, yogurt, herring, beer and wine, sour cream, bologna, pepperoni, salami, bananas, raisins, and pickled products Monitor output Takes 4 weeks to work Dont combine with sympathomometics vasoconstrictors, and cold medications

62

Anti-Depressants Selective Serontonin Reuptake Inhibitors (SSRI) Action: Inhibits CNS uptake of serotonin Used for: Depression ObsessiveCompulsive Disorder Bulimia

Anti-Depressants Selective Serontonin Reuptake Inhibitors (SSRI) Side effects: Anxiety GI upset Change in appetite and bowel function Urinary retention Nursing Considerations: Suicide precautions Takes 4 weeks for full effect Take in a.m. May urine to pinkish-red or Pinkish-brown Can be taken with meals Anti-Depressants AntiAnti-Depressants (Tricyclics) Depressants (Tricyclics) Action: (Tricyclics) Side Effects: Medications: Inhibits Sedation/Confusion Norpramin reuptake of Anticholinergics neurotransmitter Elavil affects s Tofranil Postural Hypotension Used for: Urinary retention Depression Nursing Considerations: Sleep apnea Suicide precautions/26 weeks to work Take at hs/Dont abruptly halt Avoid alcohol/OTC /Photosensitivity

AntiDepressants Selective Serontonin Reuptake Inhibitors (SSRI) Medications: Paxil Prozac Zoloft

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Insulin (Regular, Humulin R) Type: Fast acting Onset: -1 hr Peak: 2-4 hr Duration: 6-8 hr

Insulin (NPH, Humulin N) Type: Intermediate acting Onset: 2hr Peak: 6-12hr Duration 18-26hr Antidiabetic Agents Medications: Diabinese Orinase Dymelor Micronase

Insulin (Ultralente, Humulin U) Type: Slow acting Onset: 4hr Peak: 8-20hr Duration: 24-36hr

Insulin (Humulin 70/30) Type: Combination Onset: hr Peak: 2-12hr Duration: 24hr

Antidiabetic Agents Action: Stimulates insulin release from beta cells in pancreas Used for: Type 2 diabetes (NIDDM)

Antidiabetic Agents Side Effects: Hypoglycemia Allergic skin reactions GI upset Nursing Considerations: Take before breakfast Monitor glucose levels Avoid alcohol, sulfonamides, Oral Contraceptives, (MAO), aspirin because they help to make drug work better Hypoglycemic Agent Side Effects: Hypotension Bronchospasm Nursing Considerations: May repeat in 15min Give carbohydrates orally to prevent secondary hypoglycemic reactions Antidiarrheals Side Effects: Constipation Anticholinergic effects (urinary retention, dry mouth) Nursing Considerations:
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Hypoglycemic Hypoglycemic Agent Agent Action: Medication: Stimulates liver Glucagon to change glycogen to glucose Used for: Hypoglycemia Antidiarrheals Action: Slows peristalsis Increases tone of Antidiarrheals Medications: Kaopectate Lomotil Imodium

sphincters Used for: Diarrhea

Paregoric

Do not use with abdominal pain Monitor for urinary retention Give 2hr before or 3 hr after other meds

Antiemetics Antiemetics Action: Medications: Increases GI Tigan motility Compazine Blocks effect Torecan of dopamine Reglan in Antivert chemorecep Dramamine tor trigger zone Used for: Vomiting Antifungals Action: Impairs cell membrane Used for: Candidiasis Oral thrush Histoplasmosi s

Antiemetics Side Effects: Sedation Anticholinergic effects Nursing Considerations: Used before chemotherapy When used with viral infections may cause Reyes syndrome (Toxic Encephalopathy)

Antifungals Medications: Amphotericin B Nystatin

Antifungals Side Effects: Hepatotoxicity Thrombocytopenia Leukopenia Pruritis Nursing Considerations: Give with food Monitor liver function Good oral hygiene Antigout Agents Side Effects: Agranulocytosis GI upset Renal calculi Nursing Considerations:

Antigout Agents Action: Decreases production and resorption of

Antigout Agents Medications: Colchicine Probenecid Zyloprim

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uric acid Used for: Gout

Monitor for renal calculi Give with food, milk, antacids

Antihistamines Action: Block effects of histamine Used for: Allergic rhinitis Allergic reactions to blood

Antihistamines Medications: Chlor-Trimeton Benadryl Phenergan

Antihistamines Side Effects: Drowsiness Dry mouth Photosensitivity Nursing Considerations: Give with food Use sunscreen Avoid alcohol Antihyperlipidemic Agents Side Effects: Constipation Fat-soluble vitamin deficiency Nursing Considerations: Take at hs or 30 min ac Administer 1hr before or 4-6 hr after other meds

Antihyperlipidemic Agents Action: Inhibits cholesterol and triglyceride synthesis Used For: Elevated cholesterol Reduce incidence of cardiovascular disease

Antihyperlipide mic Agents Medications: Questran Lipid

Antihypertensives Types: ACE Inhibitors Action: Blocks ACE in lungs Used for: Hypertension CHF

Antihypertensiv es (ACE Inhibitors) Medications: Capoten Vasotec

Antihypertensives (ACE Inhibitors) Side Effects: GI upset Orthostatic hypotension Dizziness Nursing Considerations: Give 1hr ac or 3hr pc Change position slowly

66

Antihypertensives Type: Beta-Adrenergic Blockers Action: Blocks BetaAdrenergic Receptors Decrease excitability/workload of heart, oxygen consumption Decrease Used for: Hypertension Angina SVT

Antihypertensive s Type: BetaAdrenergic Medications; Nadolol Propranolol Tenormin Timoptic

Antihypertensives Type: Beta-Adrenergic Side Effects: Changes in heart rate Hypotension Bronchospasm Nursing Considerations: Masks signs of shock and hypoglycemia Take with meals Do not discontinue abruptly

Antihypertensives Type: Calcium Channel Blockers Action: Inhibits movement of calcium across cell membranes Slow impulse conduction and depresses myocardial contractility Causes dilation of coronary arteries and decreases cardiac workload and energy consumption Used for: Angina Hypertension Interstitial cystitis

Antihypertensi ves Type: Calcium Channel Blockers Medications: Procardia Calan Cardizem

Antihypertensive s Type: Calcium Channel Blockers Side Effects: Hypotension Dizziness GI distress Nursing Consideration: Monitor vital signs Do not chew or divide sustainedrelease tablets

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Antihypertensives Type: Centrally acting alphaadrenergics Action: Stimulates alpha receptors in medulla which causes a reduction in sympathetic in the heart Used for: Hypertension Antihypertensives Type: Direct-acting vasodilators Action: Relaxes smooth muscle Used for: Hypertension

Antihypertensives Type: Centrally acting alpha-adrenergics Medications: Aldomet Catapres

Antihypertensives Type: Centrally acting alphaadrenergics Side Effects: Sedation Orthostatic Hypotension Nursing Considerations: Dont discontinue abruptly Monitor for fluid retention Change position slowly Antihypertensives Side Effects: Tachycardia Increase in body hair Nursing Considerations: Teach patient to check pulse Antihypertensives Side Effects: Depression Orthostatic Hypotension Brachycardia Nursing Considerations: Give with meals or milk Change position slowly

Antihypertensives Medications Hydralazine Minoxidil

Antihypertensives Type: Peripheral-acting alphaadrenergic blockers Action: Depletes stores of norepinephrine in sympathetic nerve endings Used for: Hypertension

Antihypertensives Medications: Reserpine

Bipolar Disorder Action: Reduces catecholamin

Bipolar Disorder Medications: Lithium (11.5meq/L)

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Bipolar Disorder Side Effects: GI upset Tremors

e release Used for: Manic episodes

Tegretol Depakote

Polydipsia Polyuria Nursing Considerations: Monitor serum levels Give with meals Increase fluid intake Antineoplastic Agents Side Effects: Hepatotoxicity Ecchymosis Alopecia Epitaxis Infertility Bone Marrow Suppression Stomatitis GI disturbances: Anorexic, N/V, diarrhea Nursing Considerations: Check hematopoietic (reproduction of RBCs by bone marrow) function Force fluids Good mouth care Antineoplastic Agents Antimetabolites Side Effects: Nausea Vomiting Oral ulceration

Antineoplastic Agents Type: Alkylating Agents Action: Interferes with rapidly reproducing DNA Used for: Leukemia Multiple myeloma

Antineoplastic Agents Medications: Cisplatin Myleran Cytoxan

Antineoplastic Agents Type: Antimetabolites Action: Inhibits DNA polymerase Used for:

Antineoplastic Agents Antimetabolites Medications: 5-FU Methotrexate Hydrea

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 Acute lymphatic leukemia Cancer of colon, breast, pancreas

Bone marrow suppression Alopecia Nursing Considerations: Monitor hematopoietic function Good mouth care Discuss body image changes Antineoplastic Antineoplastic Agents Agents Antitumor Antibiotics Antitumor Side Effects: Antibiotics Bone marrow Medications: suppression Adriamycin Alopecia Actinomycin D Stomatitis Bleomycin Nursing Considerations: Monitor vital signs Give antiemetic medications before therapy Antineoplastic Agents Type: Hormonal Agents Medications: Diethylstilbestrol Tamoxifen Testosterone Antineoplastic Agents Type: Hormonal Agents Side Effects: Leukpenia Bone pain Hypercalcemia Nursing Considerations: Check CBC Monitor serum calcium

Antineoplastic Agents Type: Antitumor Antibiotics Action: Interferes with DNA and RNA synthesis Used for: Cancer

Antineoplastic Agents Type: Hormonal Agents Action: Changes hormone input into sensitive cells Used for: Cancer Antineoplasti

Antineoplasti Antineoplastic Agents

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c Agents Type: Vinca Alkaloids Action: Interferes with cell division Used for: Cancer

c Agents Type: Vinca Alkaloids Medications: Oncovin Velban

Type: Vinca Alkaloids Side Effects: Stomatitis Alopecia Loss of reflexes Bone marrow suppression Nursing Considerations: Give antiemetic before administration Check reflexes Given with Zyloprim to decrease uric acid Antiparkinson Agents Side Effects: Dizziness Ataxia Atropine-like effects: dry mouth, urinary retention Nursing Considerations: Monitor for urinary retention Large doses of vitamin B6 reverse effects Avoid use of CNS depressants Antiplatelet Agents Side Effects: Hemorrhage Thrombocytopenia Nursing Considerations: Check for signs of bleeding Give with food or milk

Antiparkinson Agents Action: Converted to Dopamine Stimulates postsynaptic Dopamine receptors Used for: Parkinsons disease Antiplatelet Agents Action: Interferes with platelet aggregation Used for: Venous thrombosis Pulmonary embolism Antipsychotic Agents Action: Blocks

Antiparkinson Agents Medications: Artane Cogentin L-Dopa Parlodel Sinemet Symmetrel

Antiplatelet Agents Medications: Aspirin Persantine

Antipsychotic Agents Medications: Haldol

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Antipsychotic Agents Side Effects: Akathisia

dopamine receptors in basal ganglia Used for: Acute and Chronic psychoses

Thorazine Mellaril Stelazine

(inability to sit still) Dyskinesia Dystonias Parkinsons syndrome Tardive dyskinesias Leukopenia Nursing Considerations: Check CBC Monitor vital signs Avoid alcohol and caffeine Atypical Antipsychotic Side Effects: Extrapyramidal effects Anticholinergic Sedative Orthostatic hypotension Nursing Considerations: Monitor blood Change positions slowly Use sunscreen Antipyretic Agents Side Effects: GI irritation Nursing Considerations:

Atypical Antipsychotic Agents Action: Interferes with binding of dopamine in the brain Used for: Acute and Chronic psychoses

Atypical Antipsychotic Medications: Clozaril Risperdal

Antipyretic Agents Action: Antiprostaglandin activity in hypothalamus Used for:

Antipyretic Agents Medications: Tylenol (Acetaminoph en)

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 Fever

Monitor liver function Aspirin contraindicate d for younger than 21 years old due to risk of Reyes syndrome Antithyroid Agents Medications: Tapazole SSKI Antithyroid Agents Side Effects: Leukopenia Rash Thrombocytopenia Nursing Considerations: Bitter taste May cause burning in mouth Give with meals Check CBC

Antithyroid Agents Action: Reduce vascularity of thyroid Inhibits release of thyroid into circulation Used for: Hyperthyroidism

Thyroid Replacement Agents Action: Increases metabolic rate Used for: Hypothyroidism

Thyroid Replacement Medications Synthroid Cytomel

Thyroid Replacement Side Effects: Nervousness Tachycardia Weight loss Nursing Considerations: Monitor pulse and BP Monitor weight Take in a.m.

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 Enhance action of anticoagulants , antidepressant s, decrease action of insulin and digitalis Antitubercular Agents Action: Inhibits cell and protein synthesis Used for: Tuberculosis To prevent disease in person exposed to organism Antitubercular Agents Medications: INH Ethambutol Streptomycin PAS PYZ Antitubercular Agents Side Effects: Hepatitis Peripheral Neuritis Nursing Considerations: Check liver function tests Vitamin B6 given for peripheral neuritis (Pyridoxine) Used in combination Antivirals Side Effects: Headache Dizziness GI symptoms Nursing Considerations: Encourage fluids Not a cure, but relieves symptoms

Antivirals Action: Inhibits DNA and RNA replication Used for: Recurrent HSV HIV infection

Antivirals Medications: Zovirax AZT Videx Famvir Cytovene

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Attention Disorder Agents Action: Increases level of catecholamin es Used for: ADDH Narcolepsy

Attention Disorder Agents Medications: Ritalin Cylert Dexedrine

Attention Disorder Agents Side Effects: Restlessness Insomnia Tachycardia Palpitations Nursing Considerations: Monitor growth rate Monitor liver enzymes Give in A.M.

Bronchodilators Bronchodilators Action: Medications: Decreases Aminophylline activity of Atrovent phosphodiester Brethine ase Proventil Used for: Primatene COPD Preterm labor (Terbutaline)

Bronchodilators Side Effects: Tachcyardia Dysrhythmias Palpitations Anticholinergic effects Nursing Considerations: Monitor BP and HR When used with steroid inhaler, use bronchodilator first May aggravate

75

diabetes Cardiac Glycosides Medication: Lanoxin (Digoxin) Cardiac Glycosides Side Effects: Bradycardia Nausea Vomiting Visual disturbances Nursing Considerations: Take apical pulse Notify physician if adult <60, child <90-110, <70 in older children Monitor potassium level Dose: 0.5-1 milligram IV or PO over 24 hr period Average: 0.25 mg Cholinergics Side Effects: Bronchoconstriction Respiratory paralysis Hypotension Nursing Considerations: Give with food or milk Monitor vital signs, especially respirations Antidote: Atropine Sulfate Toxicity: excessive salivation, excessive sweating, abdominal cramps, flushing

ardiac ycosides tion: Increases force of myocardial contraction, slows rate ed for: Left-sided CHF

Cholinergics Cholinergics Action: Medications: Inhibits Tensilon destruction of Prostigmin acetylcholine Stimulate parasympath etic nervous system (increase bowel tone, increase bladder tone, constrict pupil) Used for: Myasthenia gravis Postoperative Postpartum urinary
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retention Diuretics Diuretics Action: Medications: Inhibits HydroDIURIL reabsorption Diamox of sodium and Aldactone water Lasix Blocks effects Hygroton of aldosterone Used for: CHF Renal disease Diuretics Side Effects: Dizziness Orthostatic Hypotension Leukopenia Nursing Considerations: Take with food or milk Take in a.m. Monitor fluid and electrolytes

Iron: Imferon/Feosol, use straw if liquid form, no milk/antacids, take on empty stomach, tachycardi Glucocorticoids Glucocorticoids Glucocorticoids Action: Medications: Side Effects: Stimulates Solu-Cortef Psychoses formation of Decadron Depression glucose Deltasone Hypokalemia Alters Stunted immune growth response Buffalo Hump Used for: Nursing Addisons Considerations: disease Monitor fluid Crohns and disease electrolyte COPD balance Leukemias Dont discontinue abruptly Monitor for signs of infection
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Mineralocorticoi Mineralocorticoi ds ds Action: Medications: Increases Florinef sodium reabsorption Potassium and hydrogen ion secretion in kidney Used for: Adrenal insufficiency Heavy Metal Antagonists Action: Forms stable complexes with metals Used for: Gold and arsenic poisoning Acute lead encephalopat hy Heavy Metal Antagonists Medications: Desferal mesylate BAL in Oil EDTA

Mineralocorticoids Side Effects: Hypertension Edema Hypokalemia Nursing Considerations: Monitor BP, I&O, Weight, and Electrolytes Give with food Low-sodium, Highprotein, Highpotassium diet Heavy Metal Antagonists Side Effects: Tachycardia Pain and induration at injection site (conjunct with Procaine in syringe) Nursing Considerations: Monitor I&O and kidney function Administered with local anesthetic Seizure precautions H2 Receptor Blockers Side Effects: Dizziness Confusion

H2 Receptor Blockers Action: Inhibits action of histamine and gastric acid

H2 Receptor Blockers Medications: Tagamet Zantac

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secretion Used for: Ulcers Gastroesophageal reflux

Hypotension Impotence Nursing Considerations: Take with meals and hs Smoking decreases effectiveness Monitor liver function and CBC

Immunosuppress ants Action: Prevents production of T cells and their response to interleukin2 Used for: Prevents rejection for transplanted organs

Immunosuppress ants Medications: Sandimmune

Immunosuppressants Side Effects: Hepatotoxicity Nephrotoxicity LeuKopenia Thrombocytopenia Nursing Considerations: Take once daily in a.m. Used with adrenal corticosteroids Monitor renal and liver function tests Miotics Side Effects: Headache Photophobia Hypotension Bronchoconstriction Nursing Considerations: Apply pressure on lacrimal sac for 1min Avoid sunlight

Miotics Miotics (Constricts Pupil) Medications: Action: Isopto Causes Carpine constriction of Eserine sphincter Carbacel muscles of iris Used for: Ocular surgery
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 Open-angle glaucoma Mydriatics (Dilates Pupil) Action: Anticholinergic actions leaves pupil under unopposed adrenergic influence Used for: Diagnostic procedures Acute iritis Uveitis Mydriatics Medications: Atropine sulfate Cyclogyl

May experience transient brow pain and myopia Mydriatics Side Effects: Tachycardia Blurred vision Photophobia Dry mouth Nursing Considerations: Contraindicated with glaucoma Apply pressure on lacrimal sac for 1min. Wear dark glasses

Narcotics Action: Acts on CNS receptor cells Used for: Moderate to severe pain Preoperative Postoperative

Narcotics Medications: Morphine Sulfate Codeine Demerol Dilaudid Percodan

Narcotics Side Effects: Dizziness Sedation Respiratory depression Hypotension Constipation Nursing Considerations: Safety precautions Avoid alcohol Monitor vital signs Use narcotic antagonist if necessary (Narcan) Antianginals Side Effects: Hypotension Tachycardia
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Antianginals Action: Relaxes smooth

Antianginals Medications: Nitroglycerine Isosorbide

muscle Decreases venous return Used for: Angina Perioperative hypertension CHF NSAIDS Action: Inhibits prostaglandin synthesis Used for: Arthritis Mild to moderate pain Fever NSAIDS Medications: Motrin Indocin Naprosyn

Headache Dizziness Nursing Considerations: Check expiration date Teach when to take medication May take Q5min x3 doses Wet with saliva and place under tongue NSAIDS Side Effects: GI upset Dizziness Headache Bleeding Fluid retention Nursing Considerations: Take with food or after meals Monitor liver and renal function Use cautiously with aspirin allergy Check for bleeding Thrombolytics Side Effects: Bleeding Bradycardia Dysrhythmias Nursing Considerations: Monitor for bleeding Have Amino Caproic Acid Available

Thrombolytics Action: Dissolves or lyses blood clots Used for: Acute Pulmonary Emboli Thrombosis MI Contraindicated in: hemophilia, CVA, Trauma, not used in

Thrombolytics Medications: Streptokinase Urokinase Tissue Plasminogen Activator

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patients over 75 years old, not used in patients taking anticoagulants

Check pulse, color, sensation of extremities Monitor EKG

Anaphylaxis Symptoms o Hives o Rash o Difficulty breathing (first sign) o Diaphoresis Nursing care o Epinephrine 0.3 ml of 1:1000 solution SQ o Massage site o May repeat in 15-20 min. Delayed Allergic Reaction Symptoms: o Rash, Hives, Swollen Joints Nursing Care o Discontinue medication o Topical Antihistamines o Corticosteroids o Comfort measures Bone Marrow Depression Symptoms: Fever, Chills, Sore Throat Back pain, Dark urine Anemia, Thrombocytopenia, Leukopenia Nursing Care: Monitor CBC Protect from infections Avoid injury Liver impairment: light stools and dark urine Renal Impairment: decrease Hematocrit Anticholinergic Effects Symptoms:
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o Dry mouth, Dysphagia, Nasal Congestion o Urinary retention, Impotence Nursing Care: o Sugarless lozenges o Good mouth care o Void before taking medication Parkinsons-like effects Symptoms: o Akinesia (temporarily paralysis of muscles) o Tremors o Drooling o Changes in gait o Rigidity o Akathisia (Extreme restlessness) o Dyskinesia (Spasms) Nursing Care: o Anticholinergic and Antiparkinsonian medications o Safety measures for gait

How long should a client with tuberculosis be on medication?

6-9 Months Inflammation of Liver Jaundice Anorexia RUQ pain Clay-colored stools, teacolored urine Pruritis (bile salts eliminated through skin) Elevated ALT, AST Prolonged PT (liver involvement with clotting factor) Fecal/Oral Consume contaminated food
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What are symptoms of hepatitis?

What is the transmission of Hepatitis A?

What is the transmission of Hepatitis B?

What is the transmission of Hepatitis C? What is the transmission of Delta Hepatitis? What nursing care are recommended for Hepatitis?

or water Travelers to developing countries at risk Clients with hepatitis A should not prepare food for others Parenteral/Sexual contact Blood or body fluids At risk individuals are the ones that abuse IV drugs, dialysis, healthcare workers Vaccine developed Blood or body fluids Can become chronic disease Seen in patients with hemophilia (unable to clot) Co-infects with hepatitis B Rest (mainly for liver) Contact and standard precautions Low-fat, High-Calorie, and High Protein diet (needed for organ healing) No alcoholic beverages Medications (Vitamin K, Aqua-Mephyton for bleeding problems, Anti-emetic no compazine, use Tigan or (Dramamine). Corticosteroids to decrease inflammatory response, and anti-histamines, will use lotions or baths than systemic ones. Multi-system infection caused by a tick bite. There are three stages. Erythematous papule develops into lesion with clear center (Bulls-eye)
84

What is Lymes Disease? What is Stage 1 of Lymes Disease?

What is Stage 2 of Lymes Disease?

What is Stage 3 of Lymes Disease?

What are some Lymes Disease teaching?

Regional lymphadenopathy Flu-like symptoms (fever, headache, conjunctivitis) Can develop over 1 to several months Develop after 1 to 6 months if disease untreated. Cardiac conduction defects Neurologic disorders (Bells palsy, temporary paralysis) Develops after 1 to several months, if reached at this stage may persist for several years. Arthralgias Enlarged, inflamed joints Cover exposed areas when in wooded areas Check exposed areas for presence of ticks Antibiotics 3-4 weeks Stage 1 use Doxicillin IV penicillin with later stages Painless chancre fades after 6 weeks Low grade fever Copper-colored rash on palms and soles of feet Spread by contact of mucous membranes, congent Treat with Penicillin G IM If patient has penicillin allergy, will use erythromycin for 10-15 days. After treatment, patient must be retested to make sure disease is gone. If female maybe asymptomatic and will be unaware of having disease.
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What are some Lymes Disease nursing care? What are the treatment, mode of transmission, care, signs and symptoms of syphillis?

What are the treatment, mode of transmission, care, signs and symptoms

of gonorrhea?

Males may have thick discharge from urethra. Some females from vagina. Spread mucous membranes, congenital IM Rocephin with Doxycycline PO, IM Aqueous Penicillin with PO Probenecid (used for gout, used with Penicillin because it delays the urinary excretion of it, makes it more effective) Complication: Pelvis Inflammatory Disease Most often affected with Chlamydia also, then treatment with PO Tetracycline No cure. Painful vesicular genital lesions Problem is exacerbations/remissions Reoccurs with stress, infection, menses Spread by contact of mucous membranes, congenital Treatment: Acyclovir, sitz bath Monitor pap smears regularly because of higher incidence of cervical cancer. Emotional support of client/significant others important because of no cure. Pregnant women with active disease will have C-section. Men: urethritis, dysuria Women: thick vaginal discharge with acrid odor
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What are the treatment, mode of transmission, care, signs and symptoms of genital herpes?

What are the treatment, mode of transmission, care, signs and symptoms

of Chlamydia?

Spread by mucous membranes, congenital Treatment with Tetracycline or Doxycycline PO Will cause sterility if left untreated. Important to notify sexually contacted. What are the treatment, Single, small papillary lesion mode of transmission, spreads into large cauliflower care, signs and symptoms cluster on perineum, vagina, of Venereal Warts? penis. May itch or burn. Spread by mucous membranes, congenital Treatment: Curettage, cryotherapy with liquid nitrogen, kerotolytic agents Avoid intimate contact until lesions heal Complication: Genital Dysplasia Cancer What is the difference HIV Positivepresence of HIV between AIDS and HIV +? in blood AIDShas significant defects in immune function associated with positive HIV evidenced by development of opportunistic infections Syndrome where CD4 counts are below 200 What are some P. Carinii Pneumonia: opportunistic infections of sob/dry-nonproductive cough AIDS? C. Albicans stomatitis: will have difficulty swalling and white exudates in back of throat C. Neoformans: debilitating form of meningitis that may suffer seizures. Cytomegalovirus (CMV): will
87

How is AIDS transmitted?

What are diagnostics test associated with AIDS?

experience lymphadenopathy and may have visual impairment and can affect any organ. Kaposis Sarcoma: most common malignancy experience with AIDS, small purplish brown, nonpainful, nonpuriitc palpable lesions on the body. Contaminated blood or body fluids Sharing IV needles Sexual contact Transplacental: across placenta Possibly by breast milk ELISA test, if positive will be confirmed by Western Blot test HIV Viral culture: Leukopenia, Thrombocytopenia, Decrease CD4 counts

What are some nursing cares for AIDS?

Prevention: avoid IV drug use, precautions regarding sexual patterns, use standard precautions Contact and standard precautions High-protein and high-calorie diet, small frequent meals rather than 3 large meals Symptomatic relief Support Dont share toothbrush/shavers What are treatments, Prevention most important. care, prevention of poison Treat patient first, and then control? the poison. Recognize signs of symptoms
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of accidental poison: changes in appearance, behavior, substances around mouth, empty containers, vomitous. What should happen when Call poison control center. someone is poisoned? Tell them: substance, time, amount and route of ingestion, childs condition, age, weight, save vomitus, stool, urine. Why should vomit not be Dont induce if: induced? Danger of aspiration, decrease LOC, Ingested petroleum distillate (lighter fluid, kerosene, paint remover) Ingested corrosive (Draino) What medication Syrup of Ipecac with small treatment is used to amount of water. Dont give induce vomiting and what large amount of fluid after other factors need to be Ipecac, will increase gastric implemented? emptying. Dont use milk. Position with head lower then chest. No universal antidote. What should happen to poison control in emergency care? Intubated if comatose Run blood gases IV fluids Cardiac Monitor Gastric Lavage (NG down to flush with NS to remove rest in stomach) Activated Charcoal May use cathartics, diuretics What are signs and Tinnitus, change in mental symptoms, treatments, status, Increased care, prevention of aspirin temperature, poisoning? hyperventilation, bleeding, nausea and vomiting.
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Nursing care: induce vomiting, maintain hydration, reduce temperature (sponge baths), monitor for bleeding. What are signs and symptoms, treatments, care, prevention of tylenol poisoning? Symptoms: nausea/vomiting, hypothermia, If no treatment, hepatic/liver involvement. If liver gets involved patient may have RUQ pain, jaundice, confusion, and coagulation abnormalities. Nursing care: induce vomiting, maintain hydration, monitor liver and kidney function with labs such as AST/ALT enzymes. Tylenol (Acetaminophen) overdosage: Antidote N-acetylcysteine (Mucomyst) Symptoms: Irritability, decreased activity, abdominal pain, Increased ICP Diagnostic tests: Blood lead levels (>9micrograms = toxic), Erythrocyte protoporphyrin (EP), X-ray long bones (lead deposits in long bones) Children engage in PICA (ingesting nonfood substances) Lead blocks formation of hemogloblin and toxic to kidneys. Nursing care: identify source, chelating agents, teaching parents
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What are signs and symptoms, treatments, care, prevention of lead toxicity?

What are nursing care goals for Hazardous wastes?

Decontaminate individual Prevent spread of contamination Clean and remove contaminuated source Monitor personnel exposed What are nursing care for If chemical poses threat to Hazardous wastes? caregiver, decontaminate patient first. If chemical poses no threat or patient has been decontaminated, begin care. If immediate threat to life, put on protective garments and provide care to stabilize patient. What type of play do Solitary play. Game is one infants (0-12months) use? sided. Like to play with body parts. Birth-3months: smile/squeal 3-6months: rattles/soft stuff toys 6-12 months: begin imitation, peek-a-boo, patty-cake What type of play do toddlers (1-3years) use? What type of play do preschoolers (3-6years) use? What type of play do school age (6-12years) use? According to Eriksons Developmental Task, explain the Infancy stage. Parallel play. Associative play. Dress up/imitating play. Talking on telephone/kitchen/tool belt Cooperative play. Conformed/organized play.

Birth-18 months. Trust vs. Mistrust Positive outcome---trusts self Negative outcome--withdrawn According to Eriksons 18months 3 years Developmental Task, Autonomy vs. Shame and explain the Toddler stage. Doubt
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According to Eriksons Developmental Task, explain the Preschool stage.

Positive outcome---exercise self-control Negative outcome---defiant and negative 3-6 years Initiative vs. Guilt Children develop conscience at this age. Positive Outcome---learns limits Negative Outcome---fearful, pessimistic 6-12years Industry vs. Inferiority Positive---sense of confidence Negative---self doubt, inadequate 12-20 years Identity vs. Role diffusion Positive outcome---coherent sense of self Negative outcome---lack of identity 20-45 years Intimacy vs. Isolation Positive outcome---intimate relationships/careers formed Negative outcome--avoidance of intimacy 45-65 years Generativity vs. Stagnation Positive Outcome---creative and productive Negative Outcome---self centered 65+ years Integrity vs. Despair No regrets in life or Regrets Positive outcome---seems life as meaningful
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According to Eriksons Developmental Task, explain the School age stage. According to Eriksons Developmental Task, explain the Adolescence stage. According to Eriksons Developmental Task, explain the young adult stage. According to Eriksons Developmental Task, explain the middle adulthood stage. According to Eriksons Developmental Task, explain the Late adulthood stage.

At what month does the head sag? At what month do you see closing of posterior fontanelle, turn from side to back, and see a social smile? What toys do you give for a 2 month old? At what month does a child bring objects to mouth and head erect? What toys do you give for a 4 month old? Which age does birth weight double? At what age does teething occur? What toys do you give for a 6 month old? What age for fears of strangers? When is fear strongest? Which month able to play peek-a-boo? What toys do you give for 7-8months? What month can a child say DADA? What month can a child crawl well? What month can a child stand erect with support? What happens in the 12th month of the child?

Negative outcome---life lacks meaning 1 month 2 months

Mobiles, wind up infant swings, soft clothes, and blankets. 3 months

Rattles, cradle gym, and stuffed animals 5 months 6 months Brightly colored, small enough to grasp, large enough for safety, teething toys 7 months 8 months is stronger 7 months Large colored, bricks, jack in the box 9 month 10 months 11 months Birth weight triples. Eats with fingers.
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Anterior Fontanelle almost close. Babinski reflex disappears. Toys: books with large pictures, push pull toys, teddy bears, a large ball, or sponge toys.

Explain introduction of solid foods.

What does a toddler do at 15 months?

One food at a time. Begin with least allergenic foods first. Cereal is usually first. (Do not use cows milk/whole milk. After six months of age cereal can be mixed with fruit juices. Fruit juices should be offered in a cup to prevent dental carries.) Vegetables Fruits Potatoes Meats Eggs Orange Juice By 12 months children should be eating table food. Dont give honey under 12 because of botulism. Walks alone. Throws object. Holds spoon. Say 4-6 words. Understand simple commands.
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What does a toddler do at 18 months?

What does a toddler do at 24 months?

What does a toddler do at 30 months?

What type of toys are included for Toddlers? How do you avoid negativism during toddler ages? What can a 3 year old do?

What can a 4 year old do?

What can a 5 year old do?

Anterior fontanelle closes. Climbs stairs. Sucks thumb. Say 10 + words. Temper Tantrums. 300 world vocabulary. Obeys easy commands. Go up/down stairs alone. Build towers. Turn doorknobs/unscrew lids. Increase independence. Walk tip toe. Stand on one foot balance. Has control for sphincter training. Birth weight quadrupled. State first/last name. Give simple commands. Cooking utensils, Dress-up clothes, rocking horses, finger paints, phonographs, cd players. Dont ask no/yes questions. Offer them choices. Make a game out of the tasks. Rides tricycle. Undresses without help. May invent imaginary friend. Vocabulary 900 words. Egocentric in thoughts/behaviors. Laces shoes Brushes teeth Throws overhand Uses sentences. Independent Runs well/Dresses without help. Beginning cooperative play. Gender-specific behavior.
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What toys are used for preschool (3-5)? Which age groups has greatest number of fears? What would you expect with a 6 year old?

Playground materials, Housekeeping toys, Coloring books, tricycle with helmet. Preschool age children.

Self-centered, show off, rude Sensitive to criticism Begins loosing temporary teeth Tends to lie. What would you expect Team games/sports. with a 7 year old? Concept of time. Playing with same sex child. What would you expect Seeks out friends. with a 8 year old? Writing replaces printing. What would you expect Conflicts between peer with a 9 year old? groups and parents. Conflicts between independence and dependence. Likes school. Able to take on job duties (housework). What toys are used for Construction toys, Pets, school age child? Games, Electronic games, reading, books, bicycles with helmets. School age potential Anuresis (encourage before problems include: bed time) Encopresis Head lice What are Thin upper lip, vertical ridge symptoms/indications of a in upper lip, short up turned fetal alcohol syndrome in nose, mental retardation, a child? motor retardation, hearing disorders, microcephaly. Avoid alcohol 3 months before conception and throughout pregnancy. What happens with 16th week detects genetic amniocentesis? What abnormality
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does it do?

What happens with an ultrasound?

What happens with a nonstress test?

What happens with a contraction stress test?

30th week detects L/S ratio: lung maturity Void before procedure Ultrasound given to determine position of placenta and fetus. Complications: premature labor, infection, Rh isommunization (if client Rh negative, will be given Rhogam) 5th week confirms pregnancy Determines position of fetus, placenta, and # of fetuses. Client must drink a lot of fluid before procedure for full bladder to have a clear image. At 28th week records FHR and fetal movement. Favorable result: 2+ FHR accelerates by 15bpm and last 15seconds in 20 minutes. Determines placentas response to labor. Done after 28th week. Fowler/Semi-Fowler. Given Oxytocin or Pitocin. Results: Positive: Late decelerations indicates potential risk to fetus. Negative: No late decelerations.

What does Torch stand for? And their

Diseases that cross placenta or other events. Produce

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importance?

significant deformities or infant born with infectious process. Toxoplasmosis: no litter box changed, no gardening, no under cooked meats. Rubella: 1-16 titer immune for rubella, titer <1-8 susceptible. Cytomegalovirus: transmitted in body fluids. Herpes Simplex: Ascending infection. During pregnancy get treated with acyclovir. Delivery through c-section. What concerns for clients UTI: may lead to that have UTI, Syphilis, pylonephritis, increase risk of Gonorrhea? premature birth. Syphillis: passes through placenta, causes 2nd trimester abortions, still birth, and congenital infection, may receive medication for her and her baby. Gonorrhea: baby gets prophylactic eydrops. What are the danger signs Gush or fluid bleeding of pregnancy? from vagina Regular uterine contractions Severe headaches, visual disturbances, abdominal pain, persistent vomiting (symptoms of PIH) Fever or chills (symptoms of infection) Swelling in face or fingers (symptoms of PIH) What are the events in Lightening: (when baby drops
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the onset of labor?

How does prolapsed umbilical cords happen?

What do you do when a client has a prolapsed cord?

What is a early/sign of fetal hypoxia? What things should you know about the Informed Consent form?

to pelvis) Primipara: occurs 2 weeks before delivery Multipara: occurs during labor Softening of cervix Expulsion of mucus plug (bloody show) pink tinged mucus secretion Uterine contractions: regular/progressive not Braxton-Hicks type. Premature rupture of membranes. Presenting part not engaged. Fetal distress. Protruding cord. Call for help. Push up against presenting part off of the cord. Place in trendenlenberg position or knee chest position. Successful if FHT left unchanged. Early sign: fetal tachycardia >160 in >10minutes Late sign: fetal bradycardia <110 in > 10 minutes Nurse can witness patient sign form. Patient has to be age of capacity/adult and confident. No confused patient/drinking/already received preoperative medications. Consent must be given voluntarily and information understandable. Nurse must make sure questions are
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What is early deceleration?

answered and form is attached to chart. Decrease in HR before peak of contraction. Indication of head compression.

What are interventions for Position mother left late decelerations? side/trendenlenberg/knee chest Increase rate of IV Administer Oxygen 7-10 l/min DC Oxytocin What do variable Cord compression. decelerations indicate? Change maternal position. Administer oxygen. DC Oyxtocin/Pitocin What are signs of True Regular contractions Labor? increasing in frequency, duration, intensity Discomfort radiates from back Contractions do not decrease with rest Cervix progressively effaced and dilated. What are characteristics Irregular contractions, no of a False Labor? change in frequency, duration, intesityDiscomfort is abdominal Contractions decrease with rest or activity No cervical changes Prior to Lumbar Epidural Void block what should the patient do? What should be Establish airway implemented during the Check Apgar at 1 and 5 delivery of a newborn? minutes Clamp umbilical cord Maintain Warmth Place ID band on mother and
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What are the types of Lochia? If fundus is displaced not centrally and off to the sides means? If client soaks pad in 15 minutes or pooling of blood? What are assessments and implementations for an Ectopic Pregnancy?

infant Rubra-bloody, day 1-3 Serosa-pink-brown, day 4-9 Alba-yellow-white, 10+ days Bladder distended. Check for hemorrhage

Unilateral lower quadrant pain. Rigid, tender abdomen Low Hct and hCG levels Bleeding Monitor for shock Administer RhoGAM Provide support What are assessments A placenta thats implanted and implementations for in the lower uterine segment Placenta Previa? near cervical os, during pregnancy placenta is torn away causing: First and second trimester spotting Third and trimester painless, profuse bleeding Bedrest side-lying or trendelenburg position, ultrasound to locate placenta, no vaginal or rectal exams, amniocentesis for lung maturity, daily Hgb, Hct, Monitor bleeding What are the assessments The premature separation of and implementation for a placenta that is implanted Abruptio Placentae? in a correct position. Painful vaginal bleeding Abdomen tender, painful, tense Possible fetal
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What are assessments and implementations for Gestational Diabetes Mellitus (GDM)?

What are assessments and implementation for a Hydatidiform Mole?

What are the newborn vital signs?

distress/Contractions Monitor for maternal and fetal distress Prepare for immediate delivery Monitor for complications: DIC, pulmonary emboli Hyperglycemia after 20 weeks Usually controlled by diet Oral hypoglycemic medications contraindicated Test for diabetes at 24-28 weeks on all women with average risk 20. Frequent monitoring of mother/fetus during pregnancy. Teach to eat prescribed amount of food daily at same times Home glucose monitoring Teach about change in insulin requirements Elevated hCG Uterine size larger than expected for dates No FHT Minimal dark red/brown vaginal bleeding with grape like clusters Nausea and vomiting Associated with PIH Curettage to remove tissue Pregnancy discouraged for 1 year Do not use IUD hCG levels monitored for 1 year Temp. 97.7-99.7 HR sleep 100, awake 120102

What are assessments and implementation for Hyperbilirubinemia?

140, 180 crying Resp 30-60 BP arm/calf 65/41 Caused by immature hepatic function Physiological Jaundice (No treatment required) Seen after 24 hours Peaks at 72 hours Lasts 5-7 days Breast-Feeding Associated Jaundice (Frequent breast feeding) Caused by poor milk intake Onset 2-3 days Peaks 2-3 days Breast Milk Jaundice (discontinue breast feeding for 24 hours) Caused by factor in breast milk Onset 4-5 days Peak 10-15 days Hemolytic Disease (Phototherapy then exchange transfusion) Caused by blood antigen incompatibility (Rh or ABO incompatibility) Onset first 24 hours Peak variable

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What are assessments Assessments and implementations for a High-pitched cry Narcotic-Addicted infant? (Hallmark sign) Hyperreflexia Decreased sleep Tachypnea (>60/min) Frequent sneezing and yawning Seen at 12-24 hours of age, up to 7-10 days Implementation Reduce environmental stimuli Administer Phenobarbital, chlorpromazine, diazepam, paregoric Wrap snugly, rock, and hold tightly Assess muscle tone, irritability, vital signs. What are the assessments Sudden-onset fever and implementations of Vomiting, diarrhea Toxic Shock Syndrome? Hypotension Erythematous rash on palms and soles Administer antibiotics Educate about use of tampons (change tampon Q3Q6 hours) What are Immunization is a primary contraindications to prevention Immunizations? Severe febrile illness Altered immune system Previous allergic response Recently acquired passive immunity What are assessments Assessment and implementations for a Urticaria, rash Latex Allergy? Wheezing, Rhinitis,
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Conjunctivitis, Bronchospasms Anaphylactic shock Implementation Screen for sensitivity Avoid latex products: gloves, catheters, brown ace bandages, band aid dressing, elastic pressure stockings, balloons, condoms What are implementations Steamy shower for Croup syndromes at Exposure to cold air home? Cool, humidified air Universal Donor Blood: Packed red blood cells (help oxygen deliver to tissue, if you use whole blood there will be a risk for fluid overload), type O, Rh-negative 5% Sodium Bicarbonatemetabolic alkalosis solution Older adults are asymptomatic when they have an infection and can lead to confusion. Mononucleosis: complication enlarged spleen; concerned for trauma if child plays dangerous sport. Lyme disease:found mainly in mid alantic states (Connecticut) Pottery is unglazed can lead to Lead Toxicity Apgar Score: normal 7-10 WBC after pregnancy? Ampicillin decreases oral contraceptives efficiency. Tricuspid area: 5th intercostals space in the left sternum area Tracheostomy care: no powder, suction trachea first then mouth, use precut gauze.
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Hip-Flexion: causes increased intra-abdominal/thoracic pressure. Injury C3 and above need respiratory ventilation. SIADH causes: lung cancer, Cisplatin (Platinol) Chest Tubes Fill water-seal chamber with sterile water to 2 cm (middle chamber) Fill suction control chamber with sterile water to 20 cm (chamber all the way to the right) Air-leak if bubbling in water-seal chamber (middle chamber) Obstruction: milk tube in direction of drainage Removal o chest tube: pt. does valsalva maneuver, clamp chest tube, remove quickly, apply occlusive dressing Dislodged: apply tented dressing Tube becomes disconnected from drainage system, cut off contaminated tip, insert sterile connector and reinsert Tube becomes disconnected from drainage system, immerse in 2cm of water Jackson-prat: Notify physician if drainage increases or becomes bright red Penrose: Expect drainage on dressing Tracheostomy Tube Cuff Prevents aspiration of fluids/separates upper and lower airways Inflated during continuous mechanical ventilation Inflated during and after eating Inflated during and 1 hour after tube feeding Inflated when patient cannot handle oral secretions NCLEX-RN exam is a here and now test; take care of problem now to prevent harm to client. Do not ask why on the licensure exam
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 Morphine Sulfate for pancreatitis causes spasms of the sphincter of Oddi; Meperidine is drug of choice. Normal Intraocular Pressure is 10-21 mm Hg Ecchymosis (faint discoloration) around the umbilicus or in either flank indicates retroperitoneal bleeding The parenteral form of Chlorpheniramine Maleate is use to relieve symptoms of anaphylaxis allergic reactions to blood or plasma.

Herbs: Toxicities and Drug Interactions Chamomile Uses: Chamomile is often used in the form of a tea as a sedative. Reactions: Allergic reactions can occur, particularly in persons allergic to ragweed. Reported reactions include abdominal cramps, tongue thickness, tightness in the throat, swelling of the lips, throat and eyes, itching all over the body, hives, and blockage of the breathing passages. Close monitoring is recommended for patients who are taking medications to prevent blood clotting (anticoagulants) such as warfarin. Echinacea Uses: Largely because white blood cells in the laboratory can be stimulated to eat particles, Echinacea has been touted to be able to boost the body's ability to fight off infection. Reactions: The most common side effect is an unpleasant taste. Echinacea can cause liver toxicity. It should be avoided in combination with other medications that can affect the liver (such as ketaconazole, leflunomide (Arava), methotrexate (Rheumatrex), isoniazide (Nizoral). St. John's Wort
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Uses: St. John's Wort is popularly used as an herbal treatment for depression, anxiety, and sleep disorders. It is technically known as Hypericum perforatum. Chemically, it is composed of at least 10 different substances that may produce its effects. The ratios of these different substances varies from plant to plant (and manufacturer). Studies of its effectiveness by the National Institutes of Health are in progress. Reactions: The most common side effect has been sun sensitivity which causes burning of the skin. It is recommended that fair- skinned persons be particularly careful while in the sun. St. John's wort may also leave nerve changes in sunburned areas. This herb should be avoided in combination with other medications that can affect sun sensitivity (such as tetracycline/Achromycin, sulfa- containing medications, piroxicam (Feldend). St. John's wort can also cause headaches, dizziness, sweating, and agitation when used in combination with serotonin reuptake inhibitor medications such as fluoxetine (Prozac) and paroxetine (Paxil). Garlic Uses: Garlic has been used to lower blood pressure and cholesterol (Dr. Lucinda Miller notes that there is "...still insufficient evidence to recommend its routine use in clinical practice.") Reactions: Allergic reactions, skin inflammation, and stomach upset have been reported. Bad breath is a notorious accompaniment. Studies in rats have shown decreases in male rats' ability to make sperm cells. Garlic may decrease normal blood clotting and should be used with caution in patients taking medications to prevent blood clotting (anticoagulants) such as warfarin /Coumadin. Feverfew Uses: Most commonly used for migraine headaches. Reactions: Feverfew can cause allergic reactions, especially in persons who are allergic to chamomile, ragweed, or yarrow. Nonsteroidal antiinflammatory drugs (NSAIDs such as ibuprofen (Advil), naproxen (Aleve) or Motrin) can reduce the effect of feverfew. A condition called "postfeverfew syndrome" features symptoms including headaches, nervousness, stiffness, joint pain, tiredness, and nervousness. Feverfew can impair the action of the normal blood clotting element (platelets). It should be avoided in patients taking medications to prevent blood clotting (anticoagulants) such as
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warfarin (Coumadin).

Ginko Biloba Uses: This herb is very popular as a treatment for dementia (a progressive brain dysfunction) and to improve thinking. Reactions: Mild stomach upset and headache have been reported. Ginko seems to have blood thinning properties. Therefore, it is not recommended to be taken with aspirin, nonsteroidal anti-inflammatory drugs (Advil), naproxen (Aleve) or Motrin), or medications to prevent blood clotting (anticoagulants) such as warfarin (Coumadin). Ginko should be avoided in patients with epilepsy taking seizure medicines, such as phenytoin (Dilantin), carbamazepine (Tegretol), and phenobarbital. Ginseng Uses: Ginseng has been used to stimulate the adrenal gland, and thereby increase energy. It also may have some beneficial effect on reducing blood sugar .in patients with diabetes mellitus. (Dr. Miller emphasized that there is substantial variation in the chemical components of substances branded as "Ginseng.") Reactions: Ginseng can cause elevation in blood pressure, headache, vomiting, insomnia, and nose bleeding. Ginseng can also cause falsely abnormal blood tests for digoxin level. It is unclear whether ginseng may affect female hormones. Its use in pregnancy is not recommended. Ginseng may affect the action of the normal blood clotting element (platelets). It should be avoided in patients taking aspirin, nonsteroidal antiinflammatory drugs (such as ibuprofen (Advil), naproxen (Aleve) or Motrin), or medications to prevent blood clotting (anticoagulants) such as warfarin (Coumadin). Ginseng may also cause headaches, tremors, nervousness, and sleeplessness. It should be avoided in persons with manic disorder and psychosis. Ginger Uses: Ginger has been used as a treatment for nausea and bowel spasms. Reactions: Ginger may lead to blood thinning. It is not recommended to be taken with medications that prevent blood clotting (anticoagulants) such as warfarin (Coumadin).
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Saw Palmetto Uses: Saw palmetto has been most commonly used for enlargement of the prostate gland. (Dr. Miller emphasized that studies verifying this assertion are necessary.) Saw palmetto has also been touted as a diuretic and urinary antiseptic to prevent bladder infections. Reactions: This herb may affect the action of the sex hormone testosterone, thereby reducing sexual drive or performance. Dr. Miller states that "While no drug-herb interactions have been documented to date, it would be prudent to avoid concomitant use with other hormonal therapies (e.g., estrogen replacement therapy and oral contraceptives...") Black Cohosh Claims, Benefits: A natural way to treat menopausal symptoms. Bottom Line: Little is known about its benefits and its risks. A child with celiac disease mustnt consume foods containing gluten and therefore should avoid prepared puddings, commercially prepared ice cream, malted milk, and all food and beverages containing wheat, rye, oats, or barley. The infant of a diabetic mother may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increases glucose amount that crosses the placenta from the mother. However, during the first 24 hours of life, this combination of high insulin production in the newborn coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. A platypelloid pelvis has a flat shape. A gynecoid pelvis is a normal female pelvis. An anthropoid pelvis has an oval shape, and an android pelvis has a heart shape. The pulse is the earliest indicator of new decreases in fluid volume.
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Adult Rickets: deficiency in vitamin D. Chronic Pain: normal blood pressure, heart rate, and respiratory rate. Normal pupils and dry skin. Acute pain: causes increased blood pressure, increased pulse, and respiratory rate, dilated pupils, and perspiration. The tip of the endotracheal tube lies 1 cm above the carina. This is positioned above the bifurcation of the right and left mainstem bronchi. Creatine Phosphokinase (CPK) is a cellular enzyme that can be fractionated into three isoenzymes. MB band reflects CPK from CARDIAC MUSCLE (This is the level that elevates with an MI.) MM band reflects CPK from SKELETAL MUSCLE BB band reflects CPK from the BRAIN ALKYLATING AGENTS: affect ALL PHASES of the reproductive cell cycle (i.e., Cyclophosphamide [Cytoxan]) ANTIMETABOLITES: are cell cycle phase-specific and affect the S PHASE (i.e., Cytarabine [Cytosar]) VINCA ALKALOIDS: are cell cycle phase-specific and act on the M PHASE Bells Palsy: is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown. Possible causes include vascular ischemia, infection, exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or a combination of these items. McBURNEYS POINT: is midway between the right anterior superior iliac crest and the umbilicus. This is usually the location of greatest pain in the child with appendicitis. MMR: administered SQ in the outer aspect of the upper arm. Watch for absolute words NOT and ONLY AIR EMBOLISM POSITIONING: Place the client on the left side in the trendelenburg position. Lying on the left side may prevent air from flowing
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into the pulmonary veins. The trendelenburg position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during inspiration. Trigeminal neuralgia pain medication: Use Carbamazepine (Tegretol) and Phenytoin (Dilantin). Narcotic analgesics (Meperidine Hydrochloride [Demerol], Codeine Sulfate , and Oxycodone) are not effective in controlling pain caused by trigeminal neuralgia. Grapefruit juice can raise cyclosporine (Sandimmune) levels by 50% to 100%, risk for toxicity. Fomepizole (Antizol): an antidote given IV to a client with Ethylene Glycol (Antifreeze) intoxication Phenotolamine (Regitine): antidote for hypertensive crisis Bromocriptine (Parlodel): an antiparkinsonian prolactin inhibitor, is used to treat NMS. Biophysical profile: assesses five parameters of fetal activity: fetal heart rate, fetal breathing movements, gross fetal movements, fetal tone, and amniotic fluid volume. In a biophysical profile, each of the five parameters contributes 0 to 2 points with a score of 8 being considered normal and a score of 10 perfect. G Gravidity, the number of pregnancie s. T Term births, the number born at term (40 weeks). P Preterm births, the number born before 40 weeks gestation. A Abortions/miscarriage s Included in gravida if before 20 weeks gestation Included in parity if past 20 weeks gestation L Live births, the number of live births or living children

Therefore a woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of preterm births is 1, and the number of term births is 0. The number of
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abortions is 0, and the number of live births is 1. Probable signs of pregnancy: Uterine enlargement Hegars sign (Softening and thinning of the lower uterine segment that occurs about week 6) Goodells sign (softening of the cervix that occurs at the beginning of the second month) Chadwicks sign (bluish coloration of the mucous membranes of the cervix, vagina, and vulva that occurs about week 6) Ballottement (rebounding of the fetus against the examiners fingers on palpation) Braxton Hicks contractions A positive pregnancy test measuring for human chorionic gonadotropin Positive signs of pregnancy: Fetal heart rate detected by electronic device (Doppler transducer) at 8-12 weeks and by nonelectronic device (Fetoscope) at 20 weeks of gestation Active fetal movements palpable by examiner An outline of fetus via radiography or ultrasound Acetazolamide (Diamox): used for management of glaucoma is a carbonic anyhdrase inhibitor that has sulfonamide properties. Watch out for absolute words ALL and ALWAYS Before NG removal: bowel sounds have to be present.

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Hyperkalemia on Electrocardiogram: Tall, peaked T waves; prolonged PR interval; widening QRS complex Hypokalemia on Electrocardiogram: ST segment depression; Flat T wave First-Degree Heart Block: Prolonged P-R interval Bundle Branch Block: Widened QRS complex Myocardial Necrosis in Area: Q waves present Ventricular Fibrillation: No visible P waves or QRS complexes, no measurable rate. Irregular, chaotic undulations of varying amplitudes. HypoCalcemia: Prolonged Q-T interval Myocardial Ischemia: ST segment elevation or depression Premature Ventricular Contractions: absence of P waves, wide and bizarre QRS complexes, and premature beats followed by a compensatory pause Ventricular Tachycardia: absence of P waves, wide QRS complexes, rate between 100 and 250 impulses per minute. Regular rhythm Atrial Fibrillation: no P waves; instead there are wavy lines, no PR interval. QRS duration is WNL and irregular ventricular rate can range from 60-160 beats/minute. ANGINA Stable Triggered by a predictable amount of effort or emotion. Unstable Triggered by an unpredictable amount of exertion or emotion and may occur at Variant Triggered by coronary artery spasm; the attacks tend to occur early in the day and at
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Intractable Chronic and incapacitating and is refractory to medical therapy.

night; the attacks increase in number, duration, and severity over time.

rest.

Cardiac Conduction System: Sinoatrial NodeInternodal/Interatrial pathwaysAV nodeBundle of HisR/L Bundle BranchesPurkinje fibers Pulse rate is the earliest indicator of decrease in fluid volume. A1-adrenergic receptors: found in the peripheral arteries and veins and cause a powerful vasoconstriction when stimulated A2-adrenergic receptors: several tissues and contract smooth muscle, inhibit lipolysis, and promote platelet aggregation. B1: Found in the heart and cause an increase in heart rate, atrioventricular node conduction, and contractility. B2: Arterial and bronchial walls and cause vasodilation and bronchodilation. PULSE PRESENT = NO DEFIBRILLATION Myxedema (a.ka. Hypothyroidism) Suggested toys a. birth to six months - mobiles, unbreakable mirrors, music boxes, rattles b. six to 12 months - blocks, nesting boxes or cups, simple take apart toys, large ball, large puzzles, jack in the box, floating toys, teething toys, activity box, push-pull toys c. Solitary play Toddlerhood (one year to three years) Play is parallel Suggested toys: push-pull toys, finger paints, thick crayons, riding toys, balls, blocks, puzzles, simple tape recorder, housekeeping toys,
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puppets, cloth picture books, large beads to string, toy telephone, water toys, sand box, play dough or clay, chalk and chalkboard Preschool age (three years to six years) Preschool play is associative and cooperative. dress-up fantasy play imaginary playmates Suggested toys: tricycle, gym and sports equipment, sandboxes, blocks, books, puzzles, computer games, dress-up clothes, blunt scissors, picture games, construction sets, musical instruments, cash registers, simple carpentry tools

School age (six years to 12 years) Play is cooperative. 1. sports and games with rules 2. fantasy play in early years 3. clubs 4. hero worship 5. cheating 6. Suggested toys/activities: board or computer games, books, collections, scrapbooks, sewing, cooking, carpentry, gardening, painting Tympany: Drumlike, loud, high pitch, moderate duration; usually found over spaces containing air such as the stomach Resonance:Hollow sound of moderate to loud intensity; low pitch, long duration; Usually heard over lungs Hyperresonance: Booming sound of very loud intensity; very low pitch, long duration; Usually heard in the presence of trapped air (such as emphysematous lung)Flatness: Flat sound of soft intensity; high pitch; short duration; Usually heard over muscle Dullness:Thud-like sound of soft intensity; high pitch; moderate duration; Usually heard over solid organs (such as heart, liver) body temperature
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range: 36 to 38 degrees Celsius (98.6 to 100.4 degrees Fahrenheit)

St. John's wort - antidepressant Garlic - antihypertensive Ginseng - Anti stress Green tea - antioxidant Echinacea - immune stimulant (6-8 weeks only) Licorice - cough and cold Ginger root - antinausea Ginkgo - improves circulation Ma huang - bronchodilator, stimulant Anatomical Landmarks of the HEART i. second right intercostal space - aortic area ii. second left intercostal space - pulmonic area iii. third left intercostal space - Erb's point iv. fourth left intercostal space - tricuspid area v. fifth left intercostal space - mitral (apical) area vi. epigastric area at tip of sternum Range of Normal Blood Pressure i. child under age two weighing at least 2700g: use flush technique,3060mg Hg ii. child over age two: 85-95/50-65 mm Hg iii. school age: 100-110/50-65 mm Hg iv. adolescent: 110-120/65-85 mm Hg v. adult: <130 mm Hg Systolic / <85 mm Hg diastolic Normal Range of Peripheral Pulses infants: 120 to 160 beats/minutes toddlers: 90 to 140 beats/minutes preschool/school-age: 75 to 110 beats/ minute adolescent/adult: 60 to 100 beats/minute Normal Rates of Respirations newborn: 35 to 40 breaths/minute infant: 30 to 50 breaths/minute toddler: 25 to 35 breaths/minute school age: 20 to 30 breaths/minute adolescent/adult: 14 to 20 breaths/minute adult: 12 to 20 breaths/minute
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CRANIAL NERVE FUNCTION 1. Olfactory (CN I)

Can identify variety of smells Deviation: Inability to identify aroma

2. Optic (CN II) Has visual acuity and full visual fields Fundoscopic exam reveals no pathology Deviation: Inability to identify full visual fields - total or partial blindness of one or both eyes 3, 4, 6. Oculomotor (CN III), trochlear (CN IV), and abducens (CN VI)

Follows up to six cardinal positions of gaze Pupils are unremarkable Exhibits no nystagmus and no ptosis Deviation: one or both eyes will deviate from its normal position

5. Trigeminal (CN V)

Clenches teeth with firm bilateral pressure Has no lateral jaw deviation with mouth open Feels a cotton wisp touched to forehead, cheek and chin Differentiates sharp and dull sensations on face Corneal reflex; blinks when cotton is touched to each cornea Deviation: Absent or one-sided blinking of eyelids

7. Facial (CN VII)

Has facial symmetry with and without a smile Can raise the eyebrows symmetrically and grimace Can shut eyes tightly Can identify sweet, sour, salt or bitter on the anterior tongue Deviation: Irregular and unequal facial movements Deviation: Inability to taste or identify taste Deviation: Inability to taste or identify salt, sweet, sour, or bitter substances on the anterior two-thirds of the tongue Deviation: Inability to smile symmetrically

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8. Acoustic (CN VIII)

Can hear a whisper at 1-2 feet Can hear a watch tick at 1-2 feet Does not lateralize the Weber test Can hear AC (air conduction) better than BC (bone conduction) in the Rinne test Deviation: Inability to hear spoken word

9, 10. Glossopharyngeal (CN IX) and Vagus (CN X)

Swallows and speaks without hoarseness Palate and uvula rise symmetrically when patient says "ah" Bilateral gag reflex Can identify taste on the posterior tongue Deviation: Unequal or absent rise of uvula and soft palate as the client says, "ah" Deviation: Absent gag reflex Deviation: inability to taste or identify taste on the posterior tongue

11. Spinal accessory (CN XI)

Resists head turning Can shrug against resistance Deviation: Weak or absent shoulder and neck movement

12. Hypoglossal (CN XII)

Can stick tongue out and move it from side to side Can push tongue strongly against resistance Deviation: Tongue deviates to side

Types of Coping Mechanisms 1. Compensation - extra effort in one area to offset real or imagined lack in another area o Example: Short man becomes assertively verbal and excels in business. 2. Conversion - A mental conflict is expressed through physical symptoms o Example: Woman becomes blind after seeing her husband with another woman.
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3. Denial - treating obvious reality factors as though they do not exist because they are consciously intolerable o Example: Mother refuses to believe her child has been diagnosed with leukemia. "She just has the flu." 4. Displacement - transferring unacceptable feelings aroused by one object to another, more acceptable substitute o Example: Adolescent lashes out at parents after not being invited to party. 5. Dissociation - walling off specific areas of the personality from consciousness o Example: Adolescent talks about failing grades as if they belong to someone else; jokes about them. 6. Fantasy - a conscious distortion of unconscious wishes and need to obtain satisfaction o Example: A student nurse fails the critical care exam and daydreams about her heroic role in a cardiac arrest. 7. Fixation - becoming stagnated in a level of emotional development in which one is comfortable o Example: A sixty year old man who dresses and acts as if he were still in the 1960's. 8. Identification - subconsciously attributing to oneself qualities of others o Example: Elvis impersonators. 9. Intellectualization - use of thinking, ideas, or intellect to avoid emotions o Example: Parent becomes extremely knowledgeable about child's diabetes. 10. Introjection - incorporating the traits of others o Example: Husband's symptoms mimic wife's before she died. 11. Projection - unconsciously projecting one's own unacceptable qualities or feelings onto others o Example: Woman who is jealous of another woman's wealth accuses her of being a gold-digger. 12. Rationalization - justifying behaviors, emotions, motives, considered intolerable through acceptable excuses o Example: "I didn't get chosen for the team because the coach plays favorites." 13. Reaction Formation - expressing unacceptable wishes or behavior by opposite overt behavior o Example: Recovered smoker preaches about the dangers of second hand smoke.
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14. Regression - retreating to an earlier and more comfortable emotional level of development o Example: Four year old insists on climbing into crib with younger sibling. 15. Repression - unconscious, deliberate forgetting of unacceptable or painful thoughts, impulses, feelings or acts o Example: Adolescent "forgets" appointment with counselor to discuss final grades. 16. Sublimation - diversion of unacceptable instinctual drives into personally and socially acceptable areas. o Example: Young woman who hated school becomes a teacher. Elizabeth Kubler-Ross: Five Stages 1. Denial a. Unconscious avoidance which varies from a brief period to the remainder of life b. Allows one to mobilize defenses to cope c. Positive adaptive responses - verbal denial; crying d. Maladaptive responses - no crying, no acknowledgement of loss 2. Anger a. Expresses the realization of loss b. May be overt or covert c. Positive adaptive responses - verbal expressions of anger d. Maladaptive responses - persistent guilt or low self esteem, aggression, self destructive ideation or behavior 3. Bargaining a. An attempt to change reality of loss; person bargains for treatment control, expresses wish to be alive for specific events in near future b. Maladaptive responses - bargains for unrealistic activities or events in distant future 4. Depression and Withdrawal a. Sadness resulting from actual and/or anticipated loss b. Positive adaptive response - crying, social withdrawal c. Maladaptive responses - self-destructive actions, despair 5. Acceptance a. Resolution of feelings about death or other loss, resulting in peaceful feelings b. Positive adaptive behaviors - may wish to be alone, limit social contacts, complete personal business FOODS HIGH IN WATER-SOLUBLE VITAMINS
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A. Vitamin C - citrus fruits, cabbage, tomatoes, strawberries, broccoli B. Thiamine (B1) - lean meat, legumes,unrefined or enriched grains and cereals C. Riboflavin (B2) - enriched grains, milk, organ meats, poultry, fish D. Niacin - peanuts, peas, beans, meat, poultry E. Pyridoxine (B6) - kidneys, liver, meats, corn, wheat, eggs, poultry, fish F. Cyanocobalamin (B12) - kidneys, lean meats,liver, dairy products, egs G. Folic acid - liver, eggs, leafy green vegetables, fruits, enriched grain products FOODS CONTAINING FAT-SOLUBLE VITAMINS A. Vitamin A - fruits, green and yellow vegetables, butter, milk, eggs, liver B. Vitamin D - milk, fish C. Vitamin E - green vegetables, vegetables oils, wheat germ, nuts D. Vitamin K - liver, cheese, leafy green vegetables, milk, green tea

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mucomyst: acetaminophen toxicity

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