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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. CORRECT—reddened, 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 Sulfate—decreases 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 TPN—hang 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.
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 Tachycardia—causes 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.
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. Phlebitis—tenderness, redness; remove iv, apply warm soaks to decrease inflammation, swelling, and discomfort. Autologous blood—may 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, doesn’t 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 Parkinson’s disease. Take immediately before meals and high-protein meals may impair effectiveness of medication. Reduces rigidity and bradykinesis and facilitates client’s 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
bradycardia. 4 . Wait one minute between puffs of the inhalers for best effect. Propranolol (Inderal)—a beta-blocker that takes up beta-adrenergic receptor sites. respiratory depression. Beclomethasone (Vanceril)—a steroid medication.bronchioles for steroid to get in. dry mouth. Inderal may mask symptoms of hypoglycemia. ocular symptoms. Should drink 2000-3000ml of fluid daily to prevent kidney stones. throat infections. Insulin—NPH Onset: 1. blindness. and decrease effects of hormonal contraceptives. Trimethoprim-sulfamethoxazole (Bactrim)—most common side effect mild to moderate rash (urticaria) Aminoglycosides are ototoxic. removing the body’s early warning system. Phenazopyridine (Pyridium)—acts on urinary tract mucosa to produce analgesic or local anesthetic effects. which prevents adrenaline from causing symptoms and glycogenolysis. Side effects: bright orange urine. Infant normal resting heart rate: 120-140 Salt substitutes contain potassium When directing a UAP.5-5 hours Topiramate (Topamax)—is an anticonvulsant.5 hours Peak: 4-12 hours Regular Onset: 0. Side effect: fungal infections. Because the RN is responsible for all care-related decisions. yellowish discoloration of skin or sclera indicates drug accumulation due to renal impairment. only implementation tasks should be assigned because they do not require independent judgment. the nurse must communicate clearly about each delegated task with specific instructions on what must be reported. Side effects include change in BP. Side effects: orthostatic hypotension.5 hours Peak: 2. Butorphanol Tartrate (Stadol)—analgesic used for moderate to severe pain.
In infants and small children. pulselessness. pallor. irritability and disorientation may be the first signs of fat embolism syndrome followed by a very high temperature. A history of severe depression is a contraindication to the use of neuroleptics. 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. the first symptoms of overdose are usually cardiac arrhythmias. anorexia. ages 1 to 3. Corn. which may cause gastrointestinal ulcers. Gluten is found mainly in grains of wheat and rye and in smaller quantities in barley and oats. 5 . assessment is the first step in providing care. Restlessness. Bretylium. Verapamil. separation anxiety is at its peak Signs of tardive dyskinesia include smacking lips. The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk because Decadron increases the production of hydrochloric acid.When applying the nursing process. possibly causing Digitalis Toxicity Signs/Symptoms of Digital Toxicity: first signs include abdominal pain. nausea. grinding of teeth and "fly catching" tongue movements. The protest phase of separation anxiety is a normal response for a child this age (2 year-old hospitalized child). In toddlers. confusion. and other arrhythmias. rice. soybeans and potatoes are digestible in persons with celiac disease. visual disturbances. paralysis) READ THE QUESTIONS FIRST!!!!! READ THE QUESTIONS FIRST!!!!! DETERMINE THE QUESTION!!!!!! Rash and blood dyscrasias are side effects of anti-psychotic drugs. paresthesia. The 5 "Ps" of vascular impairment can be used as a guide (pain. and Amiodarone increases serum dig levels. Children with celiac disease should eat a gluten free diet. vomiting. bradycardia.
Restraint: frame of bed. Percussion. 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. painful 6 . jealousy. If doctor has orders it should carried out unless contraindicated in nurse’s decision. For example. nasally implanted. chest tubes Acromegaly—monitor blood sugar. atrium—90 implant care (radioactive. Auscultation (Except for abdomen: Inspection. monitor vision) Bone marrow Aspiration---done at iliac crest. Ask the LPN/LVN to stay with the child and his parents while the nurse obtains phone orders from the physician. can do 5 at a time. distrust.Clinical features of delusional disorder include extreme suspiciousness.E. will be on mechanical ventilations after surgery. be as specific as possible.. Palpation) Coronary artery bypass graft (CABG)—halt medications before surgery. document need for restraint Q4 hours Never ask “WHY” questions in the NCLEX! Gag Reflex: don’t 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. Tips for charting: don’t use inflammatory words. “Vital signs stable” is incorrect for of charting. Palpation. quick release ties. Refer it to nursing supervisor. I. and belief that others intend to harm. Physical assessment: Inspection. Never leave your patient. Percussion. Auscultation. no nurse judgments.
If used for fracture treatment. not the leg Cervical Tongs Never lift the weights No pillow under head during feedings Balanced Suspension Traction For femur realignment 7 . elevate head 30-45 Position care after Infratentorial surgery: flat and lateral Orange juice does not help acidify urine it makes it more alkaline. capillary refill distal to fracture Close reduction—manually manipulate bone or use traction Buck’s Traction Use to relieve muscle spasm of leg and back If used for muscles spasms only.Postoperative care after Supratentorial surgery: maintain airway. Elevate head of bed for countertraction or foot bed Place pillow below leg not under heel or behind knee. Use 8-20 lbs of weight. if used for scoliosis will use 40 lbs of weight. Myelogram • Water-soluble dye—elevate head of bed 30 degrees (not removed) • Oil based dye—flat in bed (removed) Fractures: Immobilize joint above and below fracture Cover open fracture with cleanest material available Check temperature. sensation. Russell’s Traction Sling is used Check for popliteal pulse Place pillow below lower leg and heel off the bed Don’t turn from waist down Lift patient. only can turn to unaffected side. they can turn to either side. color.
Maintain weights hanging free and not on floor Maintain continuous pull Halo Jacket Maintain pin cleansing Casts Don’t rest on hard surface Don’t 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 • Don’t sleep on operated side • Don’t flex hip more than 45-60 degrees • Don’t 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 doesn’t restrict blood flow. shaped to reduce edema Check for bleeding Elevated 24 hours (AKA-pillow. crutch walking 8 . BKA-foot of bed elevated) Position prone daily Exercises.
B1)—carbohydrate metabolism. A pump must be used to keep rate constant Prevent sepsis: maintain closed system. B6)—amino acid metabolism. vomiting occurs decrease rate of enteral feeding or keep it warm. tea is main beverage Greek—bread is served with every meal Enteral feeding held if: 150 or > cc’s aspirated or 50% given in the hour is aspirated If cramping. deficiency cause pernicious anemia Calcium deficiency causes Rickett’s Cultural Food Pattern’s Orthodox Jewish (Kosher)—milk and meat cannot be eaten at same meal Muslin—30 day fast during Ramadan Japanese—rice is basic food. seizures Folic acid—RBC formation. TPN—supply nutritions via intravenous route Peripherally or centrally Initial rate 50/hour and can be increased to 100-125ml/hour. electrolytes (ca. deficiency will cause anemia. deficiency will cause anemia Cyanocobalamin (B12)—nerve function. 3/week check BUN. deficiency will cause Beri-Beri Pyridoxine (Vit. don’t draw blood/infuse anything in line. Thiamin (Vit. that pain is real for them. dry sterile dressing Verify placement of line Monitor Glucose. mg) When TPN Dc’d taper patient off or else will get rebound hypoglycemia (use hypotonic to do this) 9 . acetone Change IV tubing/Filter Q24 hours Solution refrigerated then warmed If solution not available. Phantom Pain: acknowledge feelings.. start 10% in water.
Beclomethasone (Vanceril) .Family members can give consent . aggressive respiratory care.Intervention is symptomatic .Specific gravity 1. prevent hazards of immobility. aspiration).Newborn donors must be full term (more than 200g) .monthly Vitamin B12 IM injections Metered dose inhaler .Brain death of donor . pain-reducing measures.Acute phase: Steroids.5-8 1. 10 .No history of extracranial malignancy . eye care. physical therapy. psychosocial support Organ Donation Criteria .Nurse can discuss organ donation with other death-related topics (funeral home to be used.010-1.Albuterol (Proventil) Guillain-Barre Syndrome . process in organ/tissue to be donated .Relative hemodynamic stability .Only absolute restriction to organ donation is documented case of HIV infection .Blood group compatibility .030 Ph 4. autopsy request) Accurate way to verify NG tube position is to aspirate for gastric contents and check pH. prevention of complications (UTI.GBS often preceded by a viral infection as well as immunizations/vaccinations .000-1. disease. maintain adequate nutrition.No untreated sepsis . plasmapheresis.500cc/day Crede’s Maneuver—push urine out Pernicious Anemia .No history of significant.
Promote family understanding of disease intellect/sight/hearing not impaired.5-7. akinesia. mask-like expression. weakness. Sinemet.Men (1-15) . “motorized propulsive gait. . Green leafy vegetables contain vitamin K.Parkinson’s disease .Decreased with volume excess Creatine Kinase (CK) .Women (37-45) u/mL . Labs HbA1c (4.Increased with dehydration .Rate at which RBC’s settle out of unclotted blood in one hour .indicates overall glucose control for the previous 120 days Serum Amylase / Somogyl (60-160 u/dL) .6%) .Men (12-70) 11 . normal voiding pattern 5-6 times/day. slurred monotonous speech. . rigidity. disease progressive but slow.Men (40-45) u/mL .Teach: ambulation modification . doesn’t lead to paralysis Normal urine output (1200-1500 cc’s/day or 50-63 cc/hr.Activities should be scheduled for late morning when energy level is highest and patient won’t be rushed . drooling.Relative volume of plasma to RBC . Parlodel. Administer Artane.Women (1-20) .elevated in acute pancreatitis Erythrocyte Sedimentation Rate (ESR) .Indicates inflammation/neurosis Hematocrit (Hct) . dysphagia.Nursing care: encourage finger exercises. Congentin.Symptoms: tremors. L-Dopa. Symmetrel.
3.22-26 mEq/L .normal 125 ml/min.Lower levels reflect renal insufficiency and may influence the excretion of many drugs and toxins from the body. diarrhea.Women (10-55) ..135-145 mEq/L .Elevated levels indicate rapid protein catabolism. .Decreased levels seen with starvation. Urea.5 mEq/L) Tofranil and Anafranil—OCD medications Pick physical needs over psychosocial needs!!!!!!!!!!!!!!! Focus on here and now!!!!!!!!!!!!!!!!! 12 .Hypernatremia o Dehydration and insufficient water intake Chloride (Cl-) .95-105 mEq/L Potassium (K+) .targeted blood level: (1-1. dehydration Creatinine Clearance Test .Enzyme specific to brain.60-110 mg/dL Sodium (Na+) .5-5. myocardium. Nitrogen (BUN) . Blood. renal failure.6-20 mg . Lithium . kidney dysfunction. and skeletal muscles .Indicates tissue necrosis or injury Serum Glucose .0 mEq/L Bicarbonate (HCO3) .
nuts. whole grain. Manic patient: decrease stimuli and increase rest period and no competition. 13 . Don’t document abuse. legume. egg. Lithium helps control impulsive behaviors. Instilling ear drops lie patient on unaffected ear to absorb drops. Position patient on affected ear to promote drainage. Fluphenazine (Prolixin): antipsychotic medication Thiamine sources: organ meats. Never promise a patient “Not to tell. and milk. Stay with your patients. distance clear) Hyperopia—farsightedness (distance is clear. open or close doors walk ½ step ahead. Assess before implementation. to rule out glaucoma Myopia—nearsightedness (near clear. Report suspected abuse to nursing supervisor. liver. identify food location on tray. keep furniture arrangement consistent.Oculogyric crisis: uncontrollable rolling back of eyes: side effect of Phenothiazines Moribund means dying patient. introduce self. Regular Insulin only given IV. Don’t leave your patients.” Tonometry—measures intraocular pressure. near vision blurry) Presbyopia—changes with aging Blind client: address by name.
fat malabsorption. and Pertussis) Given IM anterior or lateral thigh Side effects: fever within 2448 hours. redness. swelling.Sick day rules: take insulin as ordered. lie down after eating. fever. • 1st shot – 12 to 18 months • 2nd shot – 4 to 6 years Varicella (Chickenpox) • 12 to 18 months PCV • • • • TB 14 (Pneumococcal) 1st shot – 2 months 2nd shot – 4 months 3rd shot – 6 months 4th shot – 12 to 18 months . and Rubella) Given SC anterior or lateral thigh Side effects: rash. pancreatic enzyme replacement. frequent meals. gluten-free diet Hepatobiliary disease—decrease in ability of bile to absorb fat. Dumping syndrome prevention: restrict fluid with meals. low-fiber diet Sengstaken-Blakemore Tube—to treat pt. liquids Phenylketonuria—high blood phenylalanine (no enzyme). arthritis in 10 days to 2 weeks. small. lung disease. with esophageal varices. milk substitutes. Measles. low-protein diet Celiac Disease (SPrue)—intestinal malabsorption. malnutrition (unable to digest wheat/rye/oats/barley). vitamins Cystic fibrosis—absence of pancreatic enzymes. low-carbohydrate. low-fat high-protein diet. 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. soreness MMR (Mumps. respiratory care/suction Position right side to promote gastric emptying. malabsorption of fat. high-calorie diet. results in mental retardation. high-protein. Tetanus. check blood glucose q3-4 hours. soft foods.
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. • 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. use other antipyretic. increases with crying • Respirations 30-50/min.Don’t treat with aspirin. 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 15 .
give 2 full breaths (if no rise. summon help. equipment second Signs for hypoxia: restlessness. look.5 inches Infants 20/min check brachial pulse. listen. chest compression 100/min ½ . chest compressions 80-100/min 1. reposition) Adults 12/min check carotid. tachycardia CPR: Shake.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 Erb’s 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. open airway. feel for signs of breathing. Tracheostomy tube placement of cuff maintained to prevent aspiration Care for patient first.1 inch 15:2 Adult 4 cycles Infant 20 cycles Reassess pulse and breathing Continue CPR until: 16 . shout. pinch nose.
jaw. morphine sulfate. 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. ESR. dysrhythmics. contralateral weakness of extremities Subdural hematoma – decreased LOC. anticoagulants • Do not force fluids (will give heart more to work with) MI • Chest pain radiating to arms. ipsilateral papillary dilation. neck (which is unrelieved by rest or nitroglycerin) • Dyspnea • Indigestion • Apprehension • Low grade fever • Elevated WBC (5-10. ipsilateral papillary dilation.• • • • Victim responds Someone else takes over Victim is transferred Rescuer is unable to continue Implementation for MI • Thrombolytic therapystreptokinase. t-PA • Bedrest • Beta-blockers. personality changes CSF leakage – good place to look is behind the ears. 17 . CK-MB. contralateral weakness of extremities. Informed Consent • Valium IV • Synchronizer on • 25-360 joules • Check monitor between rhythm Epidural hematoma – short period of unconsciousness.
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 Cullen’s Sign – ecchymosis around umbilicus Turner’s Sign – ecchymosis around either flank Balance’s sign – resonance over spleen (+) means rupture of spleen Shock Signs and Symptoms • Cool. clammy skin • Cyanosis • Decreased alertness • Tachycardia • Hypotension • Shallow. hypothermia. rapid respirations • Oliguria Hypovolemic Decreased in intravascular volume Cardiogenic Decreased cardiac output Distributive Problem with blood flow to cells Implementation for shock 18 . barbiturate therapy.Head Injury – elevate bed 30 degrees.
0 mEq/L 135-145 mEq/L 4. raisins Hyperkalemia Implementations • Restrict oral intake • Kayexalate • Calcium Gluconate and Sodium 19 Hypokalemia Assessments • K+ < 3. celery.0 mEq/L • EKG changes • Paralysis . >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.2 mEq/L 1.5-2. beans. potatoes.• Monitor CVP: <3 inadequate fluid. apricots.5 mEq/L • Muscle weakness • Paresthesias • Dysrhythmias • Increased sensitivity to digitalis Hyperkalemia Assessments • K+ >5.5-5.5 mEq/L Hypokalemia Implementations • Potassium Supplements • Don’t give > 40 mEq/L into peripheral IV or without cardiac monitor • Increase dietary intake – oranges. corticosteroids Seizures: do not restrain do not insert anything in mouth Electrolytes Potassium: Sodium: Calcium: Magnesium: 3.5-5. carrots.
2 mEq/L • Sedative effects on CNS • Muscle weakness. hallucinations • Thirsty. swollen tongue • Sticky mucous membranes • Hypotension • Tachycardia Hypocalcemia Assessments • Ca+ < 4. paresthesias Hypocalcemia Implementations • Oral calcium supplements with orange (maximizes absorption) • Calcium gluconate IV • Seizure precautions • Meet safety needs Hypercalcemia Assessments • Ca+> 5.45% 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.4% NaCl or 0.9% NaCl IV • Encourage fluids (acidic drinks: cranberry juice) • Diuretics • Calcitonin • Mobilize patient 20 . delusion.• 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 Ringer’s or 0.9% NaCL Hypernatremia Assessments • I&O • Daily Weight • Give hypotonic solutions: 0. abdominal pain • Depressed deep tendon Hypercalcemia Implementations • 0. dry. lack of coordination • Constipation.5 mEq/L • Tetany • Positive Trousseau’s sign • Positive Chvostek’s sign • Seizures • Confusion • Irritability.
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 intake—green 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 thickness—pink to red, painful • Deep partial thickness—red to white, blisters, painful • Full thickness—charred, waxy, white, painless Wound Care for Burns Never break blisters Isotonic fluids (Lactated Ringer’s) Closed method (Silvadene) covered with dressings Open method (Sulfamylon) that are not covered with dressings IV pain medication initially:
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
Addisson’s 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 Cushing’s Syndrome Assessments • Osteoporosis • Muscle wasting • Hypertension • Purple skin striations • Moon face • Truncal obesity • Decreased resistance to infection Pheochromocytoma Assessments—hypersecretions
Addisson’s 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
Cushing’s Syndrome Implementations • Low Carbohydrate, Low Calorie, High Protein, High Potassium, Low sodium diet • Monitor glucose level • Postop care after adrenalectomy or hypophysectomy
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 (don’t 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-Fowler’s position • Bedrest • Medications—mucolytics
audible murmur (if defect is severe closure is done later in childhood) • Patent Ductus Arteriosis (PDA)—failure of fetal structure to close after birth. at age of 3 hole may close otherwise surgery such as purse-string suture • Atrial Septal Defect (ASD)—abnormal opening between the two atria.(Mucomyst). tachycardia. vascular congestion. hole size of pinhole or absence of septum. bounding pulse. surgical to divide or ligate the vessel. Bronchodilators (Aminophylline). Once the child is born that structure should close because it is no longer needed because blood passes through to lungs. 24 . 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. expectorants (Robitussin). right ventricular hypertrophy. murmur. 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). hear a loud harsh murmur.
difficult intolerance • Total anomalous venous return—absence of direct communication between pulmonary veins and left atria. surgery • Aortic Stenosis—narrowing of aortic valve. blood enters from both common artery and either goes to the lungs or to the body. squats/knee chest position to help breath. murmur. rather than two distinctly different vessels there is a single vessel that overrides both ventricles and gives rise to both pulmonary and systemic circulation. overriding aorta. pulmonic stenosis. oxygenated blood not going into systemic circulation • Truncus arteriosus—failure of normal septation and embryonic division of the pulmonary artery and aorta. Weak and absent blood distal to aorta. • Pulomonic Stenosis—narrowing at entrance to pulmonary artery. right ventricular hypertrophy. pulmonary veins attach directly to right atria or drains to right atria Congenital Heart Anomalies Compensatory Mechanisms • Tachycardia • Polycythemia (increase formation of RBC’s) • Posturing—squatting. high blood pressure and bounding pulse in areas that receive blood proximal to the defect. cyanosis. causes resistance to blood flow and right ventricular hypertrophy. knee-chest position Congenital Heart Anomalies Implementations • Prevention • Recognize early symptoms 25 . Surgical end-to-end anastomosis. causes decrease cardiac output. surgery Cyanotic Congenital Heart Anomalies Types: • Tetralogy of Fallot—VSD. surgery needed • Transposition of great vessels—pulmonary artery leaves left ventricle and aorta leaves right ventricle.• Coarctation of the Aorta—narrow of aorta.
diuretics. brown skin • Edema • Normal or decreased pulses Venous Peripheral Vascular Disease Implementations • Monitor peripheral pulses • Elastic stockings • Medications—anticoagulants 26 . potassium • Change feeding pattern Left-Side CHF • Dyspnea.• Monitor vital signs and heart rhythms • Medications—digoxin. iron. 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. 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-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 • Medications—vasodilators. low-calorie.
green leafy vegetables) • Iron supplements (stains teeth) Pernicious Anemia Assessments • Vitamin B12—IM • Rest of life can’t 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 .• Positive Homan’s sign • Elevate legs • Warm. 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) • Schilling’s 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. high iron. moist packs • Bedrest 4-7 days (acute phase) Anemia Implementations • Identify cause • Frequent rest periods • High protein.
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. 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. no flowers/plotted plants. lotions (only vitamin A&D ointment) • Check for redness. thrombocytopenia • Infections • Neutropenia (private room/limit # people. no fruit. ecchymosis. wbc done daily. clean 28 . bed linen until • Nurse wears dosimeter at all source removed times • Urine and feces not • Limit visitors and time spent radioactive in room • Don’t 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.
high Vitamin diet (avoid salads/raw fruit/pepper/don’t reuse cup/don’t change litter box/digging in garden Intracranial Tumors Intracranial Tumors Implementations Assessments • Preoperative: do neurological • Motor deficits assessment. head slightly elevated Elevation of extremity—increases blood to extremity and venous return Lithotomy—used for vaginal exam 4 point Gait Weight bearing 2 point Gait Bearing both legs 3 point Gait Bearing one leg Weaker leg both crutches.Feet elevated 20 degrees.toothbrush with weak bleach solution • Good mouth care • High calorie. trunk flat. knees straight. then stronger 29 Swing-toswing through Partial . 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 Supine—avoids hip flexion Dorsal recumbent—supine with knees flexed Prone—extension of hip joint(after amputation) Side lateral—drainage of oral secretions Knee-chest—visualization of rectal area Sim’s—decreases abdominal tension (side lying with legs bent) Fowler’s—increases venous return. lung expansion High Fowler’s—60-90 Fowler’s—45-60 Semi-Fowler’s—30-45 Low Fowler’s—15-30 Modified Trendelenburg—used for shock.
firm mattress. follow with “good” leg • Stand behind client holding onto gait belt Myelogram—x-ray visualization of the spinal canal by injection of radiopaque dye.both legs RC/LF. avoid prone position and heavy 30 . TENS Post-procedure • Water-soluble dye—elevate head of bed 30 degrees (not removed) • Oil based dye—flat in bed (removed) • Bedrest 24 hours encourage fluids Postoperative care: • Assess circulation and sensation • Log roll Q2 hours with pillow between leg • Calf exercises. 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. NSAIDs. assist with ambulation keeping back straight • Muscle relaxants. analgesics. • Hydration done 12 hours before procedure • Cleansing enemas • Avoid seizure-promoting medications Laminectomy—excision portion of lamina to expose area of affected disc • Preopcare: moist heat • Fowler’s position • Isometric exercises for abdominal muscles • Muscle relaxants. “bad” leg Going down—crutches with “bad” leg. LC/RF leg RC. crutches. Teaching—daily exercises. then “good” leg “Up with the good. LC. Analgesics • Traction. one or two legs Stairs Going up—“good” leg first. RF weight bearing both legs Both crutches. LF. NSAIDS.
ataxia. 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 Bryant’s 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. anticonvulsants repetitive involuntary gross • Feeding: place food at back of motor movements mouth with slight downward pressure. wear undershirt to prevent irritation. Never tilt head backward. teach isometric exercises Scoliosis Assessments—lateral 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. • High calorie diet 31 .lifting • Avoid sitting long time Dysplasia of the Hip Assessment • Uneven gluteal folds and thigh creases • Limited abduction of hip • Ortolani’s sign—place infant on back with legs flexed. worn 23 hours of the day. rigidity. PT and OT controlled due to brain damage • Muscle relaxants and • Spasticity.
Muscular Dystrophy Assessments Atrophy of voluntary muscles Muscle weakness, lordosis, falls
• Braces to help ambulation • Balance activity and rest
Parkinson’s Disease Assessments • Deficiency of dopamine • Tremors, rigidity, propulsive gait • Monotonous speech • Mask like expression
Parkinson’s Disease Implementations • Teach ambulation modification: goose stepping walk (marching), ROM exercises • Medications—Artane, Cogentin, L-Dopa, Parlodel, Sinemet, Symmetrel
Myasthenia Gravis Assessments • Deficiency of acetylcholine • Muscular weakness produced by repeated movement • Dysphagia • Respiratory distress
Myasthenia Gravis Implementations • Good eye care, restful environment • Medications—anticholinesterases, corticosteroids, immunosuppressants • Avoid crisis: infection • Symptoms: sudden ability to swallow
no roast cereals beef . bacon. egg yolks butter Lowphenylala nine diet • Preve nts brain dama ge from imbala nce of amino acids • Fats. milk. no sandw citrus ich. high fiber • No white bread withou t fiber Low-residue • Minimize intestinal activity • Buttered rice white processed food. lish potassi anabol um ism to and raise sodium albumi low n • No levels beans. fruits • No junk food Low-fat cholestero l restricted • Can eat lean meat • No avoca do. fruits.Clear liquid • No milk • No juice with pulp Full liquid • No jam • No fruit • No nuts High Renal protein • Keeps diet protein • Restab . • Egg. jams allowe d • No meats eggs bread Sodium restricte d • No cheese High roughag e. no whole wheat corn bran 35 .
penrose drain after surgery. obstruction. surgical dressing • Ureterosigmoidostomy: urters detached from bladder and anastomosed to sigmoid colon. urine and stool evacuated towards anus. encourage voiding via rectum q 2-4 hours. Low protein Urinary Diversion Implementations • Nephrostomy: flank incision and insertion of nephrostomy tube into renal pelvis. stoma on right side below waist. • Cutaneous Ureterostomy: Stoma formed from ureters excised from bladder and brought to abdominal wall. interstitial cystitis • Ileal Conduit • Koch Pouch Glomerulonephritis Implementation • Antibiotics. complications—electrolyte imbalance. 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.no enemas or cathartics.Glomerulonephritis Assessment • Fever. neurogenic bladder. corticosteroids • Antihypertensives. assist with alteration in body image • Illeal Conduit: Ureters replanted into portion of terminal ileum and brought to abdominal 36 . infection. immunosuppressive agents • Restrict sodium and water intake • Bedrest • I&O • Daily weight • High Calorie.
check for obstruction. BUN. K+ lost in urine • Increased mental and physical activity Acute Renal Failure Causes • Prerenal— reduced blood volume • Renal— nephrotoxic drugs. Dialysis • High-output stage: Fluids as needed. drain pouch at regular intervals Acute Renal Failure Assessments: Oliguric Phase • Output <400 cc/day • Hypertension • Anemia • CHF • Confusion • Increased K+. Creatinine Acute Renal Failure Assessment s: Diuretic Phase • Output 4-5 L/day • Increased BUN • Na+. drainage of pouch by catheter under control of client. K+ replacement. TPN maybe • After Diuretic phase: high protein. Na+. high calorie diet Hemodialysis Implementation • Check for thrill and bruit q 8 hours Peritoneal Dialysis • Weight before and after treatment 37 Types of Peritoneal Dialysis • Continuous ambulatory . Kayexalate. glomeruloneph ritis • Postrenal-obstruction Acute Renal Failure Implementations: • Low-output stage: Limit fluids. mucous threads in urine normal • Koch Pouch (Continent Illeal Conduit): Ureters transplanted into pouch made from ileum with one-way valve. Ca+.wall. Dialysis • I&O • Daily Weight • Monitor Electrolytes • Bedrest during acute phase • IV fluids • Diet restrictions • Oliguric phase: limit fluids.
finger stick • Monitor vital signs. breath sounds • Monitor for hemorrhage • Monitor BP • Monitor breath sounds • Use sterile technique • If problem with outflow. Depression. weight. thought or feeling Compensation—attempt to overcome shortcoming Symbolization—less threatening object used to represent another Substitution—replacing unacceptable or unobtainable object to one that is acceptable or attainable Introjection—symbolic taking into oneself the characteristics of another Repression—unacceptable thoughts kept from awareness Reaction formation—expressing attitude opposite of unconscious wish or fear Regression—returning to an earlier developmental phase Dissociation—detachment of painful emotional conflicts from consciousness Suppression—consciously putting thought out of awareness Dying patient: Denial. Acceptance Bipolar Disorder Assessments Bipolar Disorder Implementations 38 . Bargaining. reposition client • Side effects: constipation (CAPD) • Automated • Intermittent • Continuous Ego Defense Mechanisms Denial—failure to acknowledge thought Displacement—redirect feelings to more acceptable subject Projection—attributing your feelings to someone else Undoing—attempt to erase an act. Anger.• Don’t use extremity for BP.
flight of ideas • Lacks inhibitions. never further discuss voices (don’t ask to tell more about voices) • With delusions—do not argue. periods of agitation • Paranoid—late onset in life. suspiciousness. point out feeling tone. respond to feeling tone. keep hydrated) • Increase awareness of feelings through reflection Schizophrenia Implementations • Maintain safety—protect from erratic behavior • With hallucination—do not argue. grandeur (feel higher rank). Schizophrenia Assessments • Withdrawal from relationships and world • Inappropriate display of feelings • Hypochondriasis • Suspiciousness • Inability to test reality. transient hallucinations • Catatonic—sudden onset mutism. stereotyped position. provide diversional activities • Meet physical needs • Establish therapeutic relationship • Institute measures to promote trust • Engage in individual. validate reality. 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. ideas of persecution and delusions 39 .• Disoriented. persecutory (beliefs to be a victim). ideas of Schizophrenia Types • Disorganized— inappropriate behavior. regression • Hallucinations— false sensory perceptions • Delusions— persistent false beliefs.
or family therapy Encourage client’s affect Accept nonverbal behavior Accept regression Provide simple activities or tasks Paranoid Assessments • Suspiciousness • Cold. communicating Antisocial Assessments • Disregards rights of others • Lying. 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. hygiene Regression • • • • group. stealing. cheating.• • • • reference (see people talking think talking about them) Loose associations Short attention span Inability to meet basic needs: nutrition. 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 40 .
• Irresponsible • Associated with substance abuse Borderline Assessments • Brief and intense relationships • Blames others for own problems • Impulsive. 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 41 . 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.
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.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. 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 42 . attention.
especially pulse • Administer sedation. anticonvulsants. glucose (IV) • Seizure precautions • Quiet. thiamine (IM or IV).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. 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 client’s role • Antabuse • Family violence • Counsel spouse and children Wernicke’s Syndrome Assessments • Confusion Wernicke’s Syndrome Implementations • Thiamine (IM or IV) 43 .
strenuous activity 3 months Cataracts Implementations 44 Cataracts Assessments . affected eye in dependent position • Eye patched (one or both) • Surgery • Sedatives and tranquilizers • Avoid stooping. straining at stool. nystagmus • Ataxia • Apathy Korsakoff’s 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 Korsakoff’s 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.• Diplopia.
burning facial pain • Twitching of facial muscles Bell’s 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 • Medications—analgesics. dilated without lens • Eye drops • Night shield • Sleep on unaffected side Glaucoma Implementations • Administer miotics (constrict pupil. carbonic anhydrase inhibitors • Surgery • Avoid heavy lifting. allows more area for aqueous humor to flow). 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. blurred vision • Milky white pupil • Postop: check for hemorrhage • Check pupil—constricted with lens implanted. straining of stool • Mydriatics (dilates pupil. Tegretol • Surgery Bell’s Palsy Implementations • Isometric exercises for face • Prevent corneal abrasions Guillain-Barre Syndrome Implementations • Medications—steroids • Aggressive respiratory care • Physical therapy • Eye care • Prevent complications: respiratory and aspiration Meningitis Implementations 45 .• Distorted. makes angle smaller and constrict aqueous flow) are contraindicated with glaucoma.
contagious Thoracentesis: no more than 1000cc taken at one time. Electroencephalogram (EEG) Preparation • Test brains waves. cigarettes) withheld for 24 hours • May be asked to hyperventilate during test • Meals not withheld • Kept awake night before test. lights before the eyes CAT Scan—dye gives flushed. epigastric distress. antifungals • Prevent complications: droplet precautions. seizure disorders • Tranquilizer and stimulant meds withheld for 24-48 hours • Stimulants (caffeine. 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.• • • • • • Nuchal rigidity Kerning’s sign Brudzinski’s sign Seizures Bulging fontanels High-pitched cry • Medications—antibiotics. 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. 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 46 .
keep tubing free of kinks • Tracheostomy collar or T-piece: (20-100%). hematocrit • Report severe abdominal pain Upper GI Series Barium Swallow: stool white from barium Tracheostomy Tube Cuff • Purpose—prevents 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. assess for fine mist. provides high humidity and fixed concentrations.• Asked to hold breath for 510 seconds • Check clotting time. empty condensation from tubing’ keep water container full • Croupette or oxygen tent: o Difficulty to measure amount of oxygen delivered o Provides cooled. platelets. 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%). 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 patient’s temperature Chest Tubes Chest Tube 47 Complications of Chest .
immerse end in 2 cm of sterile water CVP: measures blood volume and efficiency of cardiac work. fluid goes to patient • Level of fluid fluctuates with respirations • Measure at highest level of fluctuation • After insertion o Dry. withdrawn. tubing q24 hours o Instruct patient to hold breath when inserted. IV fluids.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. tubing changed o Check and secure all connections 48 . insert sterile connector and reinsert • Tube becomes disconnected from drainage system. sterile dressing o Change dressing. cut off contaminated tip. manometer. apply dressing tented on one side • Tube becomes disconnected from drainage system. 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.
don’t squeeze eyes Nasogastric Tubes: • Levin-single—single-lumen. prevent systemic absorption. used for decompression or tube feeding • Sengstaken-Blakemore—triple-lumen. don’t allow drops to go from one eye to the other. used for bleeding esophageal varices • Keofeed/Dobhoff—soft silicone. used for bleeding esophageal varices • Linton-Nachlas—4-lumen. used for long-term feedings • Cantor—single lumen with mercury-filled balloon and suction port • Miller-Abbott—double-lumen with mercury-filled balloon and suction port • Harris—single 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 • 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 49 .• Normal reading—3-11 cm water • Elevated>11. used for decompression or tube feeding • Salem sump—double-lumen. press on inner angle of eye. hypovolemia • Chest tray at bedside Eye irrigation: tilt head back and toward affected side Eye drops: drop in center of conjunctival sac. reinstall residual • Check residual Q4 hours with continuous feeding. indicates hypervolemia or poor cardiac contractility (slow down IV. notify physician) • Lowered<3.
then back in Fowler’s position. until reaches the stomach. have patient lie on right side. nausea. Mill-Abbott. check for kinks • Withdraw solution or record amount as input NG removal: • Clamp tube • Remove tape • Instruct patient to exhale • Remove tube with smooth. then left side o Gravity helps to position tube o Coil excess tube loosely on bed. suspected appendicitis 50 . then remove completely with smooth. change patient position. Harris) • Implementations o After tube is in stomach. 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.• Good mouth care NG Irrigation Tubing: • Verify placement of tube • Insert 30-50 cc of normal saline into tube • If feel resistance. continuous pull Intestinal Tubes (Cantor. 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. vomiting.
watch contact precautions. Triglycerides elevation can falsely elevate glycosalated hemoglobin test. apply loose cover and remain quiet. avoid pin point movement with eye (sewing). avoid jarring movements. 51 . Only patient we use distractions on the NCLEX are manic patients and toddlers not for pain. don’t need to isolate. Laparoscopic Cholecystectomy post: encourage to walk to eliminate acute right shoulder pain. 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). vesicles. clamp prior to removal Ileostomy: post-op has loose. Tympanoplasty: remain in bed 24 hours position flat in bed with the affected ear up (helps to promote insertion). Object in eye: never remove visible glass. make light sufficient for needs (75watt+). honey-colored crusts. liquid drainage from stoma Tonsillectomy: post-op frequently swallowing indicates hemorrhage External contact lenses: need fine motor movements (rheumatoid arthritis prevents this). high fluid and roughage (prevents constipation=no straining). Retina detached: sleep prone with affected side down. Impetigo: 2 year old. and reddish macules around mouth.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. dark green.
9% NaCl (Normal Saline) 5% D/W (Dextrose in Water) Lactated Ringer’s 5% D/ ¼ NS (5% Dextrose in 0.45% Saline) • • • • Isotonic Solution 0. weight the client. Post-Parecentesis most important assessment is to obtain the blood pressure. cerebrovascular or cardiovascular disease Hypotonic Solution • ½ NS (0. Suction is always intermittent never continuous.Rhinoplasty (nose surgery) position post-op: want to promote drainage of oral secretions is to position on her right side. Tracheostomy tube: use pre-cut/pre-made gauze pads. 1 cup= 240cc Pregnancy is a contraindication to an MRI.O O. ABO BLOOD TYPE COMPATIBILITY Can Receive from: O A.225% 52 • • • • Hypertonic Solution 10% D/W (10% Dextrose in water) D15W 5% D/NS (5% Dextrose in 0.A.AB AB Autologous Transfusion: • Collected 4-6 weeks before surgery • Contraindicated—infection. measure the client’s abdominal girth.O B.AB A.AB Blood Type O A B AB Can donate to: O. chronic disease.B.AB B.9% Saline) 5% D/ ½ NS (5% Dextrose in 0. O universal donor/AB universal recipient. and check dressing in that order.45% Saline) .A. Raynaud’s disease have decreased vascularity in the extremities.B.
pain. warm moist compresses. do not irrigate. back flow of blood into tubing • Implementation—discontinue. do not increase rate of flow or hang solution higher.Saline ) • 3% NaCl • 5% Sodium Bicarbonate Change tubing Q72 hours Change bottle Q24 hours Infiltration • Assessment: cool skin. swelling. do not aspirate cannula. swelling. elevate arm. do not milk. tender. 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. warm. leakage of blood • Implementation—discontinue IV. ice bag 24 hours. D/C and start on other site. start new site proximal to infiltrated site IV Phlebitis. decrease in flow rate • Implementation: discontinue IV. increase Adrenergic Medications Levophed Dopamine Adrenalin 53 Adrenergics Side effects: • Dysrhythmias • Tremors • Anticholinergic . restart IV in opposite extremity IV Clotting • Assessment—decreased flow rate. swelling. inject Urokinase. Thrmobophlebitis • Assessment—redness. leukocytosis • Implementation—discontinue IV. start IV in opposite extremity Hematoma • Assessment—ecchymosis. warm compresses. apply pressure.
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. s Ativan. wean off • Smoking/caffeine decreases effectiveness Antacids Actions: • Neutralize gastric acids Used for: • Peptic ulcer • Indigestion. 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 • Don’t discontinue abruptly. reflex esophagitis Antacids Medications • Amphojel • Milk of Magnesia • Maalox Antacids Side effects: • Constipation • Diarrhea • Acid rebound Antacids Nursing Considerations: • Interferes with absorption of antibiotics. Oral contraceptives 54 . iron preps. Equanil • Anxiety disorders. bronchodilation. Used for: Vistaril.blood flow to heart. neurotransmitter Xanax. INH.
E.• 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.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 55 .
• Check peak/trough level Allergy: 1st symptom SOB Cephalosporin s (Antibiotics) Action: • Inhibits synthesis of bacterial cell wall Used for: • Tonsillitis. Pseudomona s. 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) • Don’t give with antacids or iron preparation • Maybe given with other medications (Probenicid: for gout) 56 Fluoroquinolon es (Antibiotics) Action: • Interferes with DNA replication in gramnegative bacteria Used for: • E. S.Coli. otitis media. 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 57 .
milk. iron • Note expiration date • Monitor renal function • Avoid sunlight UTIs • Medication: o Furadantin • Action: 58 .Sulfonamides (Antibiotics) Action: • Antagonize essential component of folic acid synthesis Used for: • Ulcerative colitis • Crohn’s 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.
almonds. milk. 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 59 Anticholinergic Side Effects: • Blurred vision • Dry mouth • Urinary retention .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.
respiratory tract. Alopecia : Nursing Considerations: • Couma • Monitor Prothrombin din Test (PT) • Normal 9-12 sec • Therapeutic level 1. 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. eyes. 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. hs.parasympathetic nerves (affects heart.5 times control • Antagonist—Protamine Sulfate • Give SC or IV Anticoagul Anticoagulant (Coumadin) ant Side Effects: Medication • Hemorrhage. GI tract and the bladder) • Dilates pupil. or 2hr pc • Contraindicated: paralytic ileus.5 60 .
• Pulmonary embolism • Venous thrombosis • Prophylaxis after acute MI times control • Antagonist—Vitamin 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: • Don’t 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 61 .
diaphoretic. liver. herring. sour cream.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. intracranial hemorrhage) with food that contain Tyramine Nursing Considerations: • Avoid foods containing Tyramine: Aged cheese. bologna. and cold medications 62 . yogurt. bananas. stiff neck. raisins. pepperoni. palpitations. salami. and pickled products • Monitor output • Takes 4 weeks to work • Don’t combine with sympathomometics vasoconstrictors. beer and wine.
m.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. • 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/Don’t abruptly halt • Avoid alcohol/OTC /Photosensitivity AntiDepressants Selective Serontonin Reuptake Inhibitors (SSRI) Medications: • Paxil • Prozac • Zoloft 63 .
sulfonamides. (MAO). Humulin U) Type: Slow acting Onset: 4hr Peak: 8-20hr Duration: 24-36hr Insulin (Humulin 70/30) Type: Combination Onset: ½ 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. 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. Humulin N) Type: Intermediate acting Onset: 2hr Peak: 6-12hr Duration 18-26hr Antidiabetic Agents Medications: • Diabinese • Orinase • Dymelor • Micronase Insulin (Ultralente. dry mouth) Nursing Considerations: 64 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 . Humulin R) Type: Fast acting Onset: ½ -1 hr Peak: 2-4 hr Duration: 6-8 hr Insulin (NPH. Oral Contraceptives.Insulin (Regular.
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 Reye’s 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 65 .
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 67 .
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: • Don’t 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) 68 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. diarrhea Nursing Considerations: • Check hematopoietic (reproduction of RBC’s 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 69 . N/V.
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 70 .• Acute lymphatic leukemia • Cancer of colon.
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: • Parkinson’s 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 71 Antipsychotic Agents Side Effects: • Akathisia .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.
dopamine receptors in basal ganglia Used for: • Acute and Chronic psychoses • Thorazine • Mellaril • Stelazine (inability to sit still) • Dyskinesia • Dystonias • Parkinson’s 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) 72 .
• Fever • Monitor liver function • Aspirin contraindicate d for younger than 21 years old due to risk of Reye’s 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. 73 .
• Enhance action of anticoagulants . 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 74 . antidepressant s.
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. use bronchodilator first • May aggravate 75 .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.
especially respirations • Antidote: Atropine Sulfate • Toxicity: excessive salivation. abdominal cramps. 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. <70 in older children • Monitor potassium level • Dose: 0.25 mg Cholinergics Side Effects: • Bronchoconstriction • Respiratory paralysis • Hypotension Nursing Considerations: • Give with food or milk • Monitor vital signs.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. excessive sweating.5-1 milligram IV or PO over 24 hr period • Average: 0. flushing ardiac ycosides tion: • Increases force of myocardial contraction. constrict pupil) Used for: • Myasthenia gravis • Postoperative • Postpartum urinary 76 . child <90-110.
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. 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 • Addison’s Considerations: disease • Monitor fluid • Crohn’s and disease electrolyte • COPD balance • Leukemias • Don’t discontinue abruptly • Monitor for signs of infection 77 . use straw if liquid form. • Monitor fluid and electrolytes Iron: Imferon/Feosol. take on empty stomach. no milk/antacids.
I&O. 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 78 .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. Weight. and Electrolytes • Give with food • Low-sodium. Highprotein.
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 79 .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.
• 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 80 Antianginals Action: • Relaxes smooth Antianginals Medications: • Nitroglycerine • Isosorbide .• 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.
not used in Thrombolytics Medications: • Streptokinase • Urokinase • Tissue Plasminogen Activator 81 . Trauma.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.
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:
o Dry mouth, Dysphagia, Nasal Congestion o Urinary retention, Impotence • Nursing Care: o Sugarless lozenges o Good mouth care o Void before taking medication Parkinson’s-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
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 one’s 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 (Bull’s-eye)
What is Lyme’s Disease? What is Stage 1 of Lyme’s Disease?
care. signs and symptoms . 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. temporary paralysis) Develops after 1 to several months. signs and symptoms of syphillis? What are the treatment. If female maybe asymptomatic and will be unaware of having disease. After treatment. Cardiac conduction defects Neurologic disorders (Bell’s palsy. conjunctivitis) Can develop over 1 to several months Develop after 1 to 6 months if disease untreated. patient must be retested to make sure disease is gone. if reached at this stage may persist for several years. will use erythromycin for 10-15 days. headache.What is Stage 2 of Lyme’s Disease? What is Stage 3 of Lyme’s Disease? What are some Lyme’s Disease teaching? Regional lymphadenopathy Flu-like symptoms (fever. Arthralgias Enlarged. mode of transmission. care. 85 What are some Lyme’s Disease nursing care? What are the treatment. congent Treat with Penicillin G IM If patient has penicillin allergy. mode of transmission.
care. mode of transmission. Painful vesicular genital lesions Problem is exacerbations/remissions Reoccurs with stress. menses Spread by contact of mucous membranes. congenital IM Rocephin with Doxycycline PO. Emotional support of client/significant others important because of no cure. care. infection. Men: urethritis. used with Penicillin because it delays the urinary excretion of it. signs and symptoms . signs and symptoms of genital herpes? What are the treatment.of gonorrhea? Males may have thick discharge from urethra. congenital Treatment: Acyclovir. makes it more effective) Complication: Pelvis Inflammatory Disease Most often affected with Chlamydia also. sitz bath Monitor pap smears regularly because of higher incidence of cervical cancer. mode of transmission. dysuria Women: thick vaginal discharge with acrid odor 86 What are the treatment. Some females from vagina. IM Aqueous Penicillin with PO Probenecid (used for gout. Pregnant women with active disease will have C-section. Spread mucous membranes. then treatment with PO Tetracycline No cure.
of Chlamydia? Spread by mucous membranes. of Venereal Warts? penis. Albicans stomatitis: will have difficulty swalling and white exudates in back of throat C. Cytomegalovirus (CMV): will 87 . signs and symptoms cluster on perineum. congenital Treatment: Curettage. spreads into large cauliflower care. Important to notify sexually contacted. cryotherapy with liquid nitrogen. Spread by mucous membranes. Neoformans: debilitating form of meningitis that may suffer seizures. vagina. kerotolytic agents Avoid intimate contact until lesions heal Complication: Genital Dysplasia Cancer What is the difference HIV Positive—presence of HIV between AIDS and HIV +? in blood AIDS—has 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. May itch or burn. Single. What are the treatment. congenital Treatment with Tetracycline or Doxycycline PO Will cause sterility if left untreated. Carinii Pneumonia: opportunistic infections of sob/dry-nonproductive cough AIDS? C. small papillary lesion mode of transmission.
Decrease CD4 counts What are some nursing cares for AIDS? Prevention: avoid IV drug use. Prevention most important. Recognize signs of symptoms 88 . use standard precautions Contact and standard precautions High-protein and high-calorie diet. Contaminated blood or body fluids Sharing IV needles Sexual contact Transplacental: across placenta Possibly by breast milk ELISA test. small purplish brown. and then control? the poison. Kaposi’s Sarcoma: most common malignancy experience with AIDS. nonpainful. small frequent meals rather than 3 large meals Symptomatic relief Support Don’t share toothbrush/shavers What are treatments. care. if positive will be confirmed by Western Blot test HIV Viral culture: Leukopenia.How is AIDS transmitted? What are diagnostics test associated with AIDS? experience lymphadenopathy and may have visual impairment and can affect any organ. Thrombocytopenia. nonpuriitc palpable lesions on the body. precautions regarding sexual patterns. prevention of poison Treat patient first.
nausea and vomiting. Ingested petroleum distillate (lighter fluid. Don’t give induce vomiting and what large amount of fluid after other factors need to be Ipecac. will increase gastric implemented? emptying. paint remover) Ingested corrosive (Draino) What medication Syrup of Ipecac with small treatment is used to amount of water. change in mental symptoms. amount and route of ingestion. status. No universal antidote. weight. treatments. vomitous.of accidental poison: changes in appearance. kerosene. time. prevention of aspirin temperature. Position with head lower then chest. save vomitus. Increased care. stool. decrease LOC. urine. What should happen when Call poison control center. substances around mouth. Don’t use milk. 89 . child’s condition. 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. behavior. empty containers. Why should vomit not be Don’t induce if: induced? Danger of aspiration. age. someone is poisoned? Tell them: substance. bleeding. poisoning? hyperventilation.
prevention of lead toxicity? . teaching parents 90 What are signs and symptoms.Nursing care: induce vomiting. care. If no treatment. decreased activity. prevention of tylenol poisoning? Symptoms: nausea/vomiting. 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. Increased ICP Diagnostic tests: Blood lead levels (>9micrograms = toxic). care. maintain hydration. monitor for bleeding. hypothermia. If liver gets involved patient may have RUQ pain. What are signs and symptoms. Nursing care: induce vomiting. treatments. treatments. chelating agents. monitor liver and kidney function with labs such as AST/ALT enzymes. jaundice. and coagulation abnormalities. abdominal pain. Erythrocyte protoporphyrin (EP). confusion. reduce temperature (sponge baths). hepatic/liver involvement. Nursing care: identify source. Tylenol (Acetaminophen) overdosage: Antidote N-acetylcysteine (Mucomyst) Symptoms: Irritability. maintain hydration.
Parallel play. peek-a-boo. Talking on telephone/kitchen/tool belt Cooperative play. Dress up/imitating play. Trust vs. Doubt 91 . If immediate threat to life. put on protective garments and provide care to stabilize patient. Autonomy vs. If chemical poses no threat or patient has been decontaminated. decontaminate patient first. explain the Infancy stage. Birth-3months: smile/squeal 3-6months: rattles/soft stuff toys 6-12 months: begin imitation.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. Mistrust Positive outcome---trusts self Negative outcome--withdrawn According to Erikson’s 18months – 3 years Developmental Task. Like to play with body parts. What type of play do Solitary play. begin care. Associative play. Birth-18 months. 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 Erikson’s Developmental Task. Shame and explain the Toddler stage. Conformed/organized play. Game is one infants (0-12months) use? sided.
According to Erikson’s Developmental Task. explain the School age stage. Stagnation Positive Outcome---creative and productive Negative Outcome---self centered 65+ years Integrity vs. inadequate 12-20 years Identity vs. Despair No regrets in life or Regrets Positive outcome---seems life as meaningful 92 According to Erikson’s Developmental Task. Role diffusion Positive outcome---coherent sense of self Negative outcome---lack of identity 20-45 years Intimacy vs. Guilt Children develop conscience at this age.According to Erikson’s Developmental Task. explain the Late adulthood stage. Inferiority Positive---sense of confidence Negative---self doubt. According to Erikson’s Developmental Task. . explain the Preschool stage. Positive Outcome---learns limits Negative Outcome---fearful. explain the young adult stage. According to Erikson’s Developmental Task. explain the Adolescence stage. pessimistic 6-12years Industry vs. explain the middle adulthood stage. According to Erikson’s Developmental Task. Isolation Positive outcome---intimate relationships/careers formed Negative outcome--avoidance of intimacy 45-65 years Generativity vs. Positive outcome---exercise self-control Negative outcome---defiant and negative 3-6 years Initiative vs.
large enough for safety. Eats with fingers. and stuffed animals 5 months 6 months Brightly colored. teething toys 7 months 8 months is stronger 7 months Large colored. wind up infant swings. 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. small enough to grasp. and blankets.At what month does the head sag? At what month do you see closing of posterior fontanelle. jack in the box 9 month 10 months 11 months Birth weight triples. turn from side to back. bricks. 3 months Rattles. soft clothes. cradle gym. 93 .
94 . push pull toys. Don’t give honey under 12 because of botulism. Fruit juices should be offered in a cup to prevent dental carries. After six months of age cereal can be mixed with fruit juices.Anterior Fontanelle almost close. What does a toddler do at 15 months? One food at a time. Holds spoon. or sponge toys.) • Vegetables • Fruits • Potatoes • Meats • Eggs • Orange Juice • By 12 months children should be eating table food. Explain introduction of solid foods. Walks alone. Begin with least allergenic foods first. Babinski reflex disappears. Toys: books with large pictures. teddy bears. Throws object. • Cereal is usually first. Understand simple commands. (Do not use cow’s milk/whole milk. a large ball. Say 4-6 words.
Make a game out of the tasks. Climbs stairs. State first/last name. Vocabulary 900 words. Cooking utensils. Rides tricycle. Gender-specific behavior. Obeys easy commands. cd players. Say 10 + words. finger paints. Build towers. Temper Tantrums. Laces shoes Brushes teeth Throws overhand Uses sentences. Birth weight quadrupled. Undresses without help. Give simple commands. Don’t ask no/yes questions. Turn doorknobs/unscrew lids. Dress-up clothes. Stand on one foot balance.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. rocking horses. Increase independence. Independent Runs well/Dresses without help. Walk tip toe. Beginning cooperative play. Has control for sphincter training. Sucks thumb. May invent imaginary friend. 300 world vocabulary. Go up/down stairs alone. Egocentric in thoughts/behaviors. Offer them choices. 95 . phonographs.
hearing disorders. Avoid alcohol 3 months before conception and throughout pregnancy. tricycle with helmet. mental retardation. Playing with same sex child. with a 7 year old? Concept of time. reading. What toys are used for Construction toys. bicycles with helmets. with a 8 year old? Writing replaces printing. show off. What would you expect Conflicts between peer with a 9 year old? groups and parents. school age child? Games. Coloring books. Pets.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. vertical ridge symptoms/indications of a in upper lip. What happens with 16th week detects genetic amniocentesis? What abnormality 96 . Housekeeping toys. microcephaly. books. Preschool age children. Able to take on job duties (housework). a child? motor retardation. Likes school. Electronic games. School age potential Anuresis (encourage before problems include: bed time) Encopresis Head lice What are Thin upper lip. What would you expect Seeks out friends. rude Sensitive to criticism Begins loosing temporary teeth Tends to lie. short up turned fetal alcohol syndrome in nose. Self-centered. Conflicts between independence and dependence. What would you expect Team games/sports.
Favorable result: 2+ FHR accelerates by 15bpm and last 15seconds in 20 minutes. Rh isommunization (if client Rh negative. Client must drink a lot of fluid before procedure for full bladder to have a clear image. Complications: premature labor. At 28th week records FHR and fetal movement. will be given Rhogam) 5th week confirms pregnancy Determines position of fetus. Determines placenta’s response to labor. Fowler/Semi-Fowler. placenta.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. Results: • Positive: Late decelerations indicates potential risk to fetus. Produce 97 . Done after 28th week. • Negative: No late decelerations. and # of fetuses. infection. Given Oxytocin or Pitocin. What does Torch stand for? And their Diseases that cross placenta or other events.
visual disturbances.importance? significant deformities or infant born with infectious process. Toxoplasmosis: no litter box changed. no gardening. still birth. Herpes Simplex: Ascending infection. no under cooked meats. Cytomegalovirus: transmitted in body fluids. Rubella: 1-16 titer immune for rubella. During pregnancy get treated with acyclovir. Syphillis: passes through placenta. and congenital infection. titer <1-8 susceptible. may receive medication for her and her baby. 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 98 . Gonorrhea: baby gets prophylactic eydrops. increase risk of Gonorrhea? premature birth. Delivery through c-section. What are the danger signs • Gush or fluid bleeding of pregnancy? from vagina • Regular uterine contractions • Severe headaches. Syphilis. pylonephritis. causes 2nd trimester abortions. abdominal pain. What concerns for clients UTI: may lead to that have UTI.
No confused patient/drinking/already received preoperative medications. Presenting part not engaged. Call for help. Place in trendenlenberg position or knee chest position. Successful if FHT left unchanged. Consent must be given voluntarily and information understandable. Premature rupture of membranes. Early sign: fetal tachycardia >160 in >10minutes Late sign: fetal bradycardia <110 in > 10 minutes Nurse can witness patient sign form.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-Hick’s type. Push up against presenting part off of the cord. Fetal distress. Patient has to be age of capacity/adult and confident. Nurse must make sure questions are 99 . Protruding cord.
What is early deceleration? answered and form is attached to chart. What are characteristics Irregular contractions. 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. 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 100 . duration. duration. Administer oxygen. decelerations indicate? Change maternal position. Decrease in HR before peak of contraction. intensity Discomfort radiates from back Contractions do not decrease with rest Cervix progressively effaced and dilated. no of a “False Labor”? change in frequency. DC Oyxtocin/Pitocin What are signs of “True Regular contractions Labor”? increasing in frequency.
Rigid. tense Possible fetal 101 . 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. during pregnancy placenta is torn away causing: First and second trimester spotting Third and trimester painless. day 1-3 Serosa-pink-brown. daily Hgb.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 4-9 Alba-yellow-white. amniocentesis for lung maturity. 10+ days Bladder distended. Check for hemorrhage Unilateral lower quadrant pain. tender abdomen Low Hct and hCG levels Bleeding Monitor for shock Administer RhoGAM Provide support What are assessments A placenta that’s implanted and implementations for in the lower uterine segment “Placenta Previa”? near cervical os. ultrasound to locate placenta. Hct. profuse bleeding Bedrest side-lying or trendelenburg position. no vaginal or rectal exams. Painful vaginal bleeding Abdomen tender.
97. Frequent monitoring of mother/fetus during pregnancy. 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.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.7-99.7 HR sleep 100. 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. 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 103 .
rock. vital signs. up to 7-10 days Implementation • Reduce environmental stimuli • Administer Phenobarbital. chlorpromazine. Rhinitis. rash “Latex Allergy”? Wheezing.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. 104 . and hold tightly • Assess muscle tone. What are the assessments Sudden-onset fever and implementations of Vomiting. irritability. diazepam. 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. paregoric • Wrap snugly.
catheters. use precut gauze. Rh-negative 5% Sodium Bicarbonate—metabolic alkalosis solution Older adults are asymptomatic when they have an infection and can lead to confusion. concerned for trauma if child plays dangerous sport. Tricuspid area: 5th intercostals space in the left sternum area Tracheostomy care: no powder. Bronchospasms Anaphylactic shock Implementation Screen for sensitivity Avoid latex products: gloves. 105 .Conjunctivitis. type O. condoms What are implementations Steamy shower for Croup syndromes at Exposure to cold air home? Cool. band aid dressing. suction trachea first then mouth. Mononucleosis: complication enlarged spleen. balloons. brown ace bandages. elastic pressure stockings. 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. 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).
cut off contaminated tip. • Do not ask “why” on the licensure exam 106 .Hip-Flexion: causes increased intra-abdominal/thoracic pressure. 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. apply occlusive dressing • Dislodged: apply tented dressing • Tube becomes disconnected from drainage system. 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. remove quickly. insert sterile connector and reinsert • Tube becomes disconnected from drainage system. does valsalva maneuver. clamp chest tube. Injury C3 and above need respiratory ventilation.
tightness in the throat. Reactions: The most common side effect is an unpleasant taste. and blockage of the breathing passages. hives. Echinacea has been touted to be able to boost the body's ability to fight off infection. St. throat and eyes. methotrexate (Rheumatrex). Meperidine is drug of choice. Reported reactions include abdominal cramps. tongue thickness. • 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. John's Wort 107 . Echinacea can cause liver toxicity. Close monitoring is recommended for patients who are taking medications to prevent blood clotting (anticoagulants) such as warfarin. particularly in persons allergic to ragweed. Reactions: Allergic reactions can occur. isoniazide (Nizoral). itching all over the body. Echinacea Uses: Largely because white blood cells in the laboratory can be stimulated to eat particles. It should be avoided in combination with other medications that can affect the liver (such as ketaconazole. Herbs: Toxicities and Drug Interactions Chamomile Uses: Chamomile is often used in the form of a tea as a sedative. leflunomide (Arava). swelling of the lips.• Morphine Sulfate for pancreatitis causes spasms of the sphincter of Oddi.
St. Reactions: The most common side effect has been sun sensitivity which causes burning of the skin.. piroxicam (Feldend). The ratios of these different substances varies from plant to plant (and manufacturer). John's wort may also leave nerve changes in sunburned areas. A condition called "postfeverfew syndrome" features symptoms including headaches. It is technically known as Hypericum perforatum.Uses: St. Feverfew can impair the action of the normal blood clotting element (platelets).still insufficient evidence to recommend its routine use in clinical practice. Lucinda Miller notes that there is ". dizziness.skinned persons be particularly careful while in the sun. sweating. Feverfew Uses: Most commonly used for migraine headaches. Nonsteroidal antiinflammatory drugs (NSAIDs such as ibuprofen (Advil). tiredness. John's wort can also cause headaches. it is composed of at least 10 different substances that may produce its effects. Bad breath is a notorious accompaniment. 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.. skin inflammation. Reactions: Feverfew can cause allergic reactions. Studies in rats have shown decreases in male rats' ability to make sperm cells. This herb should be avoided in combination with other medications that can affect sun sensitivity (such as tetracycline/Achromycin. Studies of its effectiveness by the National Institutes of Health are in progress. Chemically. John's Wort is popularly used as an herbal treatment for depression.containing medications. joint pain. Garlic Uses: Garlic has been used to lower blood pressure and cholesterol (Dr. ragweed. and agitation when used in combination with serotonin reuptake inhibitor medications such as fluoxetine (Prozac) and paroxetine (Paxil). and stomach upset have been reported. stiffness.") Reactions: Allergic reactions. especially in persons who are allergic to chamomile. or yarrow. It should be avoided in patients taking medications to prevent blood clotting (anticoagulants) such as 108 . It is recommended that fair. nervousness. anxiety. and sleep disorders. St. and nervousness. sulfa. naproxen (Aleve) or Motrin) can reduce the effect of feverfew.
nonsteroidal anti-inflammatory drugs (Advil). Reactions: Mild stomach upset and headache have been reported. 109 . vomiting. such as phenytoin (Dilantin). insomnia. or medications to prevent blood clotting (anticoagulants) such as warfarin (Coumadin). nervousness. headache. Ginseng may affect the action of the normal blood clotting element (platelets). naproxen (Aleve) or Motrin). and thereby increase energy. Miller emphasized that there is substantial variation in the chemical components of substances branded as "Ginseng. Ginko should be avoided in patients with epilepsy taking seizure medicines.warfarin (Coumadin).in patients with diabetes mellitus. and sleeplessness. carbamazepine (Tegretol). it is not recommended to be taken with aspirin. or medications to prevent blood clotting (anticoagulants) such as warfarin (Coumadin). Ginseng Uses: Ginseng has been used to stimulate the adrenal gland. and nose bleeding. Ginko Biloba Uses: This herb is very popular as a treatment for dementia (a progressive brain dysfunction) and to improve thinking. It is not recommended to be taken with medications that prevent blood clotting (anticoagulants) such as warfarin (Coumadin). (Dr. Reactions: Ginger may lead to blood thinning. It should be avoided in persons with manic disorder and psychosis. tremors. It is unclear whether ginseng may affect female hormones.") Reactions: Ginseng can cause elevation in blood pressure. Its use in pregnancy is not recommended. Ginko seems to have blood thinning properties. Ginseng can also cause falsely abnormal blood tests for digoxin level. Ginger Uses: Ginger has been used as a treatment for nausea and bowel spasms. naproxen (Aleve) or Motrin). Ginseng may also cause headaches. nonsteroidal antiinflammatory drugs (such as ibuprofen (Advil). Therefore. It should be avoided in patients taking aspirin. It also may have some beneficial effect on reducing blood sugar . and phenobarbital.
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. Bottom Line: Little is known about its benefits and its risks. The pulse is the earliest indicator of new decreases in fluid volume. during the first 24 hours of life. rye. Benefits: A natural way to treat menopausal symptoms. During pregnancy.. this combination of high insulin production in the newborn coupled with the loss of maternal glucose can cause severe hypoglycemia. commercially prepared ice cream. 110 .. However. (Dr.g. A gynecoid pelvis is a normal female pelvis. 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.) Saw palmetto has also been touted as a diuretic and urinary antiseptic to prevent bladder infections. thereby reducing sexual drive or performance..") Black Cohosh Claims. Miller states that "While no drug-herb interactions have been documented to date. Dr. and all food and beverages containing wheat. the fetal pancreas secretes increased levels of insulin in response to this increases glucose amount that crosses the placenta from the mother. malted milk.Saw Palmetto Uses: Saw palmetto has been most commonly used for enlargement of the prostate gland. and an android pelvis has a heart shape. Reactions: This herb may affect the action of the sex hormone testosterone. Frequent. Miller emphasized that studies verifying this assertion are necessary. A child with celiac disease mustn’t consume foods containing gluten and therefore should avoid prepared puddings. oats. or barley. estrogen replacement therapy and oral contraceptives. it would be prudent to avoid concomitant use with other hormonal therapies (e. A platypelloid pelvis has a flat shape. An anthropoid pelvis has an oval shape.
Normal pupils and dry skin.e. Watch for absolute words “NOT” and “ONLY” AIR EMBOLISM POSITIONING: Place the client on the left side in the trendelenburg position. MMR: administered SQ in the outer aspect of the upper arm. or a combination of these items.Adult Rickets: deficiency in vitamin D. This is usually the location of greatest pain in the child with appendicitis. dilated pupils. MB band reflects CPK from CARDIAC MUSCLE (This is the level that elevates with an MI. infection. Acute pain: causes increased blood pressure. Chronic Pain: normal blood pressure. McBURNEY’S POINT: is midway between the right anterior superior iliac crest and the umbilicus. Lying on the left side may prevent air from flowing 111 . Cytarabine [Cytosar]) VINCA ALKALOIDS: are cell cycle phase-specific and act on the M PHASE Bell’s Palsy: is a one-sided facial paralysis from compression of the facial nerve. This is positioned above the bifurcation of the right and left mainstem bronchi. Possible causes include vascular ischemia. The tip of the endotracheal tube lies 1 cm above the carina. exposure to viruses such as herpes zoster or herpes simplex.) 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. and respiratory rate. Creatine Phosphokinase (CPK) is a cellular enzyme that can be fractionated into three isoenzymes.. heart rate. Cyclophosphamide [Cytoxan]) ANTIMETABOLITES: are cell cycle phase-specific and affect the S PHASE (i. The exact cause is unknown. and respiratory rate. autoimmune disease.. and perspiration. increased pulse.e.
Codeine Sulfate . 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. fetal tone. 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. the number born before 40 weeks’ gestation. fetal breathing movements. the number born at term (40 weeks). Grapefruit juice can raise cyclosporine (Sandimmune) levels by 50% to 100%. and the number of term births is 0. The number of 112 . risk for toxicity. and amniotic fluid volume. each of the five parameters contributes 0 to 2 points with a score of 8 being considered normal and a score of 10 perfect. P Preterm births. G Gravidity. A Abortions/miscarriage s • Included in gravida if before 20 weeks’ gestation • Included in parity if past 20 weeks’ gestation L Live births. Biophysical profile: assesses five parameters of fetal activity: fetal heart rate. T Term births. In a biophysical profile. Narcotic analgesics (Meperidine Hydrochloride [Demerol].into the pulmonary veins. Because the child was delivered at 38 weeks. Trigeminal neuralgia pain medication: Use Carbamazepine (Tegretol) and Phenytoin (Dilantin). the number of pregnancie s. gross fetal movements. The trendelenburg position increases intrathoracic pressure. which decreases the amount of blood pulled into the vena cava during inspiration. is used to treat NMS. the number of preterm births is 1. and Oxycodone) are not effective in controlling pain caused by trigeminal neuralgia.
and vulva that occurs about week 6) • Ballottement (rebounding of the fetus against the examiner’s 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. vagina. Probable signs of pregnancy: • Uterine enlargement • Hegar’s sign (Softening and thinning of the lower uterine segment that occurs about week 6) • Goodell’s sign (softening of the cervix that occurs at the beginning of the second month) • Chadwick’s sign (bluish coloration of the mucous membranes of the cervix. and the number of live births is 1. 113 .abortions is 0.
no measurable rate. Irregular. instead there are wavy lines. Regular rhythm Atrial Fibrillation: no P waves. and premature beats followed by a compensatory pause Ventricular Tachycardia: absence of P waves. prolonged PR interval.Hyperkalemia on Electrocardiogram: Tall. . wide and bizarre QRS complexes. QRS duration is WNL and irregular ventricular rate can range from 60-160 beats/minute. 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. peaked T waves. rate between 100 and 250 impulses per minute. wide QRS complexes. Unstable Triggered by an unpredictable amount of exertion or emotion and may occur at Variant Triggered by coronary artery spasm. widening QRS complex Hypokalemia on Electrocardiogram: ST segment depression. ANGINA Stable Triggered by a predictable amount of effort or emotion. the attacks tend to occur early in the day and at 114 Intractable Chronic and incapacitating and is refractory to medical therapy. chaotic undulations of varying amplitudes. HypoCalcemia: Prolonged Q-T interval Myocardial Ischemia: ST segment elevation or depression Premature Ventricular Contractions: absence of P waves. no PR interval.
blocks. birth to six months . balls. music boxes. B2: Arterial and bronchial walls and cause vasodilation and bronchodilation. PULSE PRESENT = NO DEFIBRILLATION Myxedema (a. large ball. 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. jack in the box. large puzzles. atrioventricular node conduction. housekeeping toys. puzzles. 115 . 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. teething toys.ka.mobiles. blocks. floating toys. finger paints. simple tape recorder. unbreakable mirrors. inhibit lipolysis. simple take apart toys. rest. push-pull toys c. riding toys. B1: Found in the heart and cause an increase in heart rate. and contractility. Hypothyroidism) Suggested toys a. nesting boxes or cups. the attacks increase in number. activity box. rattles b. duration. and severity over time. Solitary play Toddlerhood (one year to three years) Play is parallel • Suggested toys: push-pull toys. and promote platelet aggregation. six to 12 months . thick crayons.night.
computer games. dress-up fantasy play imaginary playmates Suggested toys: tricycle. Usually heard over muscle Dullness:Thud-like sound of soft intensity. sewing. blocks. high pitch. construction sets. clubs 4.puppets. high pitch. Usually heard over lungs Hyperresonance: Booming sound of very loud intensity. high pitch. fantasy play in early years 3. books. gardening. scrapbooks. puzzles. play dough or clay. liver) body temperature 116 . toy telephone. Usually heard over solid organs (such as heart. moderate duration. musical instruments. large beads to string. books. long duration. sandboxes. 1. Suggested toys/activities: board or computer games. chalk and chalkboard Preschool age (three years to six years) • • • • • Preschool play is associative and cooperative. usually found over spaces containing air such as the stomach Resonance:Hollow sound of moderate to loud intensity. short duration. cloth picture books. picture games. cash registers. low pitch. sand box. gym and sports equipment. very low pitch. long duration. cheating 6. dress-up clothes. collections. simple carpentry tools School age (six years to 12 years) Play is cooperative. hero worship 5. loud. blunt scissors. Usually heard in the presence of trapped air (such as emphysematous lung)Flatness: Flat sound of soft intensity. sports and games with rules 2. water toys. cooking. moderate duration. carpentry. painting Tympany: Drumlike.
Anti stress Green tea .cough and cold Ginger root .6 to 100.antioxidant Echinacea .antinausea Ginkgo . stimulant Anatomical Landmarks of the HEART i. second left intercostal space .3060mg Hg ii.mitral (apical) area vi. epigastric area at tip of sternum Range of Normal Blood Pressure i. second right intercostal space . adolescent: 110-120/65-85 mm Hg v. child over age two: 85-95/50-65 mm Hg iii.aortic area ii.bronchodilator.Erb's point iv. school age: 100-110/50-65 mm Hg iv. John's wort .pulmonic area iii.antidepressant Garlic . child under age two weighing at least 2700g: use flush technique.tricuspid area v.improves circulation Ma huang . fifth left intercostal space .immune stimulant (6-8 weeks only) Licorice .o range: 36 to 38 degrees Celsius (98. third left intercostal space .antihypertensive Ginseng .4 degrees Fahrenheit) St. 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 117 . fourth left intercostal space .
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. Optic (CN II) • Has visual acuity and full visual fields • Fundoscopic exam reveals no pathology • Deviation: Inability to identify full visual fields . blinks when cotton is touched to each cornea Deviation: Absent or one-sided blinking of eyelids 7. or bitter substances on the anterior two-thirds of the tongue Deviation: Inability to smile symmetrically 118 . sour. 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. sweet.total or partial blindness of one or both eyes 3.CRANIAL NERVE FUNCTION 1. Trigeminal (CN V) • • • • • • Clenches teeth with firm bilateral pressure Has no lateral jaw deviation with mouth open Feels a cotton wisp touched to forehead. trochlear (CN IV). Olfactory (CN I) • • Can identify variety of smells Deviation: Inability to identify aroma 2. Oculomotor (CN III). 4. 6. cheek and chin Differentiates sharp and dull sensations on face Corneal reflex. sour. 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.
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. 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. "ah" Deviation: Absent gag reflex Deviation: inability to taste or identify taste on the posterior tongue 11. Compensation . 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. Conversion .A mental conflict is expressed through physical symptoms o Example: Woman becomes blind after seeing her husband with another woman.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.8. 10. 119 . Spinal accessory (CN XI) • • • Resists head turning Can shrug against resistance Deviation: Weak or absent shoulder and neck movement 12. 2.
Fixation . Intellectualization . "She just has the flu.transferring unacceptable feelings aroused by one object to another.use of thinking. 5." 4. 9. Introjection . Displacement .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. 120 . motives. emotions.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. 8. Fantasy . Reaction Formation . 6. 11. ideas. Identification .expressing unacceptable wishes or behavior by opposite overt behavior o Example: Recovered smoker preaches about the dangers of second hand smoke.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. Rationalization .incorporating the traits of others o Example: Husband's symptoms mimic wife's before she died." 13. or intellect to avoid emotions o Example: Parent becomes extremely knowledgeable about child's diabetes. Dissociation .subconsciously attributing to oneself qualities of others o Example: Elvis impersonators. 7. 12. Projection . 10.walling off specific areas of the personality from consciousness o Example: Adolescent talks about failing grades as if they belong to someone else. considered intolerable through acceptable excuses o Example: "I didn't get chosen for the team because the coach plays favorites. Denial .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. jokes about them. more acceptable substitute o Example: Adolescent lashes out at parents after not being invited to party.3.justifying behaviors.
person bargains for treatment control. Sadness resulting from actual and/or anticipated loss b.diversion of unacceptable instinctual drives into personally and socially acceptable areas. complete personal business FOODS HIGH IN WATER-SOLUBLE VITAMINS 121 . impulses. expresses wish to be alive for specific events in near future b.verbal denial. Regression . 15.crying.14. May be overt or covert c. aggression. crying d. self destructive ideation or behavior 3. Maladaptive responses . Acceptance a. resulting in peaceful feelings b.retreating to an earlier and more comfortable emotional level of development o Example: Four year old insists on climbing into crib with younger sibling. 16. limit social contacts. Anger a. Bargaining a.bargains for unrealistic activities or events in distant future 4. Positive adaptive responses .verbal expressions of anger d. Repression . Maladaptive responses .persistent guilt or low self esteem. Positive adaptive behaviors . Unconscious avoidance which varies from a brief period to the remainder of life b. Denial a.may wish to be alone. Expresses the realization of loss b. Sublimation . An attempt to change reality of loss. Positive adaptive response . Depression and Withdrawal a. Allows one to mobilize defenses to cope c. no acknowledgement of loss 2. o Example: Young woman who hated school becomes a teacher. Positive adaptive responses . Elizabeth Kubler-Ross: Five Stages 1. Resolution of feelings about death or other loss. despair 5.self-destructive actions.no crying. Maladaptive responses . deliberate forgetting of unacceptable or painful thoughts. social withdrawal c.unconscious. Maladaptive responses . feelings or acts o Example: Adolescent "forgets" appointment with counselor to discuss final grades.
milk.lean meat. green tea 122 . Niacin . Cyanocobalamin (B12) . Folic acid . beans. leafy green vegetables. broccoli B. leafy green vegetables. poultry. wheat germ. butter.milk. milk. Vitamin E . cabbage.unrefined or enriched grains and cereals C. peas. liver.fruits. Vitamin C .liver. eggs.peanuts. fruits. cheese. liver B. legumes. lean meats. strawberries. milk. egs G. green and yellow vegetables.liver. fish D.kidneys.citrus fruits. corn. meat. enriched grain products FOODS CONTAINING FAT-SOLUBLE VITAMINS A. Pyridoxine (B6) . dairy products. wheat. meats. fish F. poultry. poultry E.green vegetables. Riboflavin (B2) . organ meats. eggs. Vitamin D .liver.kidneys. tomatoes. vegetables oils.enriched grains. Vitamin A . Vitamin K .A. fish C. eggs. nuts D. Thiamine (B1) .
mucomyst: acetaminophen toxicity 123 .
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