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HERBAL MEDS

St. John's wort - antidepressant, photosensitive (C/I


in SULFA drugs)

Garlic - antihypertensive (avoid aspirin)

Ginseng - Anti stress (C/I in coumadin)

Green tea - antioxidant (check if risk for


calculi-oxalates)

Echinacea - immune stimulant (6-8 weeks only)(C/I in


SANDIMMUNE-Immunosuppressant)

Licorice - cough and cold

Ginger root - antinausea (C/I in Coumadin)

Ginkgo - improves circulation (C/I in anticoagulant,


headache side effect - check PT)

Ma huang - bronchodilator, stimulant (Ephedra)

Parent teaching: Use of Infant and Car Seats

Weight below 9 kg (20 lb):


Use infant or convertible seat in back seat of car in backward-facing position.
Keep infant reclined at a 45 degrees.
Never place the infant in the front passenger seat.
Fasten seat securely to car using car seat belt and following manufacturere instructions.
Adjust harness to fit snugly at shoulders and legs.
When using an infant seat, move to larger seat before the infant's head reaches the top of shell.
When using a convertable seat from birth, use one with a 5-point restraint.

Birth-18 kg (40 lb)(Some seats are designed for infants from birht to 40 lbs, others are only
designed for infants up to 20 lb, therefore there are separate instructions for each type)
When using a convertableseat, use reclined for rear-facing and upright for forward facing. (Infant
remains rear facing until they reach 20 lb as in the prior instructions)
Follow manufacturer instructions for proper positions at specfied child weights for that product
(Typcially this is the "child must face rear until they reach 20 lb)
When using a convertible seat, move to a high-backed child seat or booster seat when child's ears
are above the seat.
Always place the seat in the rear of the vehicle. (This is especially true with airbags as when they
deploy in an accident they will seriously injure or kill the child)

Above 13.6 or 18 kg-27 or 36.3 kg (30 or 40 lb-60 or 80 lb) (Most instructions agree on the 40 lb
& 40 inch-height minimum)
Use booster seat fro children who have outgrown convertible/toddler seats
Follow manufacturere instructions for use and specfied child weights for the product (NCLEX
questions will be based on the standards published in nursing textbooks which are those included
in this post)
Use booster seat until the vehicle lap and shoulder belt fit correctly
Have all children 12 years and under ride in the rear seat, whether or not in a car seat.

Air bags can seriously injure a child or cause death, when a child is in a car seat in the front
passenger seat. Even when not in a car seat, and when the vehicle is not equipped with a
passenger side air bag, the back seat is the safest for all children.

From the textbook often used to write the NCLEX pediatric questions: (Ball & Bindler)

Preschool child's need for autonomy and control can be met by allowing the child to choose
which snacks to pick or which finger to stick for glucose testing, or help the parent/caregiver
gather necessary supplies.

School-age children can learn to test blood glucose, administer insulin, and keep records. They
should be taught how to select foods appropriate for dietary management and how to plan an
exercise program. They need to learn to recognize the signs and symptoms of hypoglycemia and
hyperglycemia, and understand the importance of carrying a rapidly absorbed sugar product.

Adolescents should take on total responsibility for self-care. Although they understand
explanations about the potential complications of diabetes, they are present-time oreinted and
may rebel against the daily regimentation of insulin injections, blood glucose monitoring, and
dietary management. Successful self-care depends in part on the adolescent's adjustment to the
chronic nature of the disease and feelings of being different from peers.

This same textbook defines:

Preschool child, 3-6 years of age


School age child, 6-12 years of age
Adolescent, 12-18 years of age

Primary atypical pneumonia (Mycoplasma pneumonia) is characterized as:

Select all that apply:


O 1 Most common cause of pneumonia in children
O 2 incidence in children between the ages of 5 and 12
O 3 Occurs primarily in summer
O 4 more prevalent in crowded living conditions
O 5 caused by Borelia burdorferi

The correct answers are:


1, 2 & 4
It occurs primarily in the fall and winter months
The causative organism is M. pneumoniae
M. pneumoniae is a common cause of mild pneumonia . Various studies suggest that it causes a
higher percentage of pneumonia in school-aged children.

People at highest risk for mycoplasma pneumonia include those living or working in crowded
areas such as schools and homeless shelters, although many people who contract mycoplasma
pneumonia have no identifiable risk factor.

Symptoms
The symptoms are generally mild and appear over a period of one to three weeks. They may
progress to more severe symptoms in some people.

Common symptoms include the following:


Headache
Fever (may be high)
Chills
Excessive sweating
Cough
Usually dry
Usually without phlegm or blood
Chest pain
Sore throat
Less frequently seen symptoms include the following:
Skin lesions or rash
Eye pain or soreness
Muscle aches and joint stiffness
Neck lump
Rapid respiratory rate
Ear pain
Signs and tests
A physical examination may reveal enlarged lymph nodes and inflammation of the eardrum. An
examination of the chest with a stethoscope (auscultation) reveals crackles.

These tests help confirm the diagnosis:


Blood tests for antibodies to mycoplasma
Sputum culture
Chest x-ray

Treatment
Antibiotics may be prescribed for more serious symptoms related to mycoplasma pneumonia.
Home care includes rest and a high-protein diet with adequate fluids.

Expectations (prognosis)
Most people recover completely even without antibiotics, although antibiotics may speed
recovery. In untreated adults, cough and weakness can persist for up to a month.

EPOGEN - EPOETIN ALFA RECOMBINANT


Possible Test Item:
A client with chronic renal failure on dialysis is to receive EPOGEN. Which of the
following symptoms would warrant the nurse to hold the administration of this human
recombinant?
Select all that apply:
O 1 the client has fever
O 2 the client has hypertension
O 3 heart rate 72/minute
O 4 respiratory rate is 19
O 5 the client is pale
O 6 client has body malaise
The correct answers: 1 & 2
CNS side effect: Pyrexia, withhold the drug
CVS side effect: Hypertension, withhold the drug.
EPOGEN - recent question in the NCLEX-RN
EPOGEN - epoetin alfa recombinant
Classification
Erytrhopoietin, human recombinant
1. normally synthesized in the kidney and stimulates RBC production
2. will elevate and maintain RBC level, decreasing the need for BT
Uses:
Treatment of anemia associated with Chronic Renal Failure in adults
C/I: uncontrolled hypertension
Side effects:
CV - hypertension
CNS - pyrexia
Complication: Polycythemia
What to monitor before and after:
BP. TEMP & HEMATOCRITwater.

1)a young patient most likely to get lead poisining if?


a. he is drinking from a ceramic pitcher.
b. father referinshes old furniture at their home

> ANSWER is B. probably if he refurbishes an old furniture at home.. that is, if the
furniture has old paint on it and during 60's paints have lead content on it (heavy metals)
and if you need to remove that, chips from the old paint may be taken by a kid that leads
to Pb poisoning
2) a TB pt understands that he can reduce the risk of spreading his disease if he states?
a. i wont sleep in same room w/ my wife for 1-2 months
b. i will stay away from pregnant women and children
c. i will use plastic utensil when i eat
****>> if the patient is already taking anti-TB drugs, it will only be 2 weeks of
chemotherapy and that (+) PTB will no longer be communicable.. and 1-2 months is
long!
CHildren are more susceptible to acquire Primary complex and pregnant women are
susceptible and almost vulnerable to all type of illnesses.. There is no need for the patient
to separate their utensils since PTB is airborne and not by contact in terms of
transmission.. so i go for B answer.
3) 4 years old with salmonella what u should do?
a. private room
b. isolation
c. place in a room with 4 year old with cellulitis
d. keep door closed at all times.
*** the (+) salmonella kid may be placed in a private room. Salmonella is transmitted by
Enteric.. therefore Enteric precaution is needed and handwashing is very important and
gown and gloves, diaper or bedpan in necessary. Option B, and D are all for pulmonary
tuberculosis precautions. I suppose, the answer is A. place in a private room.

4) wot herb would help with vomiting?


a. ginko
b. ginsing.
c. ginger root
d. echinacea
****> ginger root is good for nausea.. most especially in morning sickness but in
moderation for pregnant women... Option C is the answer
5) allergic to sulfa wot not to take?
a. ma huang
b. echunacea.

...I think the answer is... geez, i forgot..i think its Echinacea..let me check again ok..
6) mother called a nurse from home stating that her child having chicken pox..which of
the following statements by the mother needs immidiate follow up?
a. father of the child with liver failure
b. sibling with anemia
c. child just had tonsillectomy
d. child has intermittent low grade fever
I think the answer is C. the child that just had tonsillectomy. i think the child is
immunocompromised. and varicella (Chicken pox) is a viral one.. we all know that
tonsils are one of the lymph defenses we have against any infection.. Im not really sure
with this answer.
7) clientwith allergy to sudafed ..which of the statments is correct?
a. i will take valerian
b. i will take ma huang
c. i will take echinacea for acute viral inf.
d. i will take black cohosh
**valerian root is for cystitis and fungal infections; ma huang is for (I forgot!!),echinacea
is for immune booster but not to be taken with patients with progressive systemic
disorders such as AIDS, PTB, HIV, etc. black cohosh is for menopause.
*** don't you think that Echinacea is the correct option??
8)food processing
a. frozen food can be defrost for up to six hours
b. frozen food which has been defrost can be return back to fridge.
c. cook perishible food should cover and cool
d. frozen food should be defrost by hot water
usually, frozen food must be thawed at cool tap water for freshness. not in the microwave
because it can be cooked outside and raw inside, not in the hotwater with same principle.
so i believe, thawing it FOR UP TO 6 HOURS would be ok. returning thawed food back
at fridge is ok but it is unsafe since salmonella can start thriving in.. Answer is OPTION
A.
9) child in a mist tent and the parents brought him a car toy...the child was clutching the
toy and the nurse refused to let him play for wot reason?
a. it will get contaminated with bacteria
b. it will accumalate moisture
c. it could cause a fire
** The answer is OPTION C. Usually car toy have friction on it for the wheels to run..
Oxygen supports combustion.. and if friction is present together with oxygen (in a mist
tent) then, fire could commence.
11) a mother reported tht her son is throwing up each time she feeds him wot would be
the best question u ask?
a. did u warm up the formula
b. wot kind of formula did u give him
c. does ur son feel hungry each time he throws up
d. does r son have a jelly like stool
***>>> CORRECT OPTION is D.. Does your son have jelly like stool.. jelly like or
currant like stool is a cardinal sign of Intussusception/ Telescoping or invagination of the
large intestines in the Ileoceccal area..
12) a patient had AIDS the nurse should advise?
a. cook ur meat very well
b. not to eat in the same table with family
c. avoid crowds
***>> if you have AIDS, u are immunocompromised.. therefore you are prone to
infection.. neutropenic precaution is advised and one that is a must is Avoiding Crowds..
Correct option is C.

Seasonal Affective Disorder (SAD) may affect over 10 million Americans.


The typical symptoms of SAD include depression, lack of energy, increased need for
sleep, a craving for sweets and weight gain. Symptoms begin in the fall, peak in the
winter and usually resolve in the spring. Some individuals experience great bursts of
energy and creativity in the spring or early summer.
Susceptible individuals who work in buildings without windows may experience SAD-
type symptoms at any time of year. Some people with SAD have mild or occasionally
severe periods of mania during the spring or summer. If the symptoms are mild, no
treatment may be necessary. If they are problematic, then a mood stabilizer such as
Lithium might be considered. There is a smaller group of individuals who suffer from
summer depression.
SAD is recognized in the DSM-IV (The American Psychiatric Association's diagnostic
manual) as a subtype of major depressive episode.
Some individuals who work long hours inside office buildings with few windows may
experience symptoms all year round. Some very sensitive individuals may note changes
in mood during long stretches of cloudy weather.

A sign of improvement from dehydration would be a decreased urine specific gravity and
a decreased/decreasing hematocrit. So the SG of 1.015 and a Hct of 46% would be the
answer. It is the best answer of the two you had in you question.
The normal urine SG is 1.003-1.035 (Usually between 1.010-1.025 with normal
hydration and volume) (different texts give a slightly different range).
SG 1.025-1.030+ (concentrated urine)
SG 1.001-1.010 (dilute urine)
SG 1.001-1.018 in infants under 2 years of age
Specific gravity is a measurement of the kidney's ability to concentrate urine. The range
of urine's SG depends on the state of hydration and varies with urine volume and the load
of solids to be excreted under standardized conditions; when fluid intake is restricted or
increased, SG measures the concentrating and diluting functions of the kidney. Loss of
these functions is an indication of renal dysfunction.
SG values usually vary inversely with amounts of urine excreated (decrease in urine
volume = increase in specific gravity). However in some conditions this is not the case.
For example:
a. Diabetes: increased urine volume, increased SG (High amount of glucose in urine)
b. Hypertension: normal volume, decreased SG
c. Early chronic renal disease: increased volume, decreased SG

Hematocrit: Percentage of packed red cells in a volume of whole blood. The hematocrit
will be increased in dehydration.

Source: A Manual of Laboratory & Diagnostic Tests (Frances Fischbach)

digitalis toxicity includes..


N - nausea
A - anorexia
V - vomiting
D - diarrhea
A - abdominal pain
kasma na changes sa vision..
Digitalis toxicity is the result of the body accumulating more digitalis than it can tolerate
at that time. Patient will complain visual change in color, and loss of appetite.

From RAG book and memory notebook


Drugs which can cause URINE DISCOLORATION
Adriamycyn------ Reddish
Rifabutin--------- Red orange
Rifampicin------- Red orange
Bactrim---------- Red orange
Robaxin--------- Brown, Black or Greenish
Azulfidine------ Orange yellow
Flagyl------------ Brownish
Dilantin---------- Pink tinged
Anti Psychotic-- Pinkish to Red brown
Early signs of hypoxia:
R-restlessness
A-anxiety
T-Tachycardia
Late signs of hypoxia:
B-bradycardia
E-extreme restlessness
D-dyspnea
In pedia-
F-feeding difficulty
I-inspiratory stridor
N-nares flare
E-expiratory grunting
S-sternal retractions
Respiratory Patterns
Kussmaul- fruity acetone breath odor
Cheyne-stokes- near death breathing pattern
CRUTCH WALKING UP STAIRS
Good goes to heaven, Bad goes to hell

CYSTITIS-Inflamation of the urinary bladder


Manifestations:
Urgency and frequency
Lab data:
Culture and sensitivity tests reveal the presence of bacteremia
Usually E.Coli
PREVENTING CYSTITIS
>Drink 8-10 glasses of fluid per day
>Women should wipe from front to back
>Urinate after intercourse
>Avoid vaginal deodorants and bubble baths
>Avoid silk underwear, cotton underwear is preferred
>Maintain acid ash diet (cheese,cranberry,prunes and plums
1.Which of the following statements made by a patient reflects a need for further
teaching?
a. I drink a lot of fluids
b. I usually go nonstop driving for 8 hours on weekends--- answer
c. I should avoid bubble baths
d. I love drinking citrus juices
2. Which of goal of nursing care takes priority for a female client with cystitis?
a. increasing urine alkalinity
b. maintaining a balanced fluid I & O
c. Providing instructions on perineal hygiene--- answer
d. screening urine for sedimentation
Muskuloskeletal Anatomical tips
TENDONS- connect muscle to bone
LIGAMENTS- connect bone to bone
CUSHING SYNDROME
Hypersecretion of Glucocorticoids by the adrenal glands
Manifestations:
central type or truncal obesity with thin extremeties
moonface
buffalo hump
hirsutism
Lab data:
Elevated serum cortisol levels
Hypernatremia,hyperglycemia,hypertension
Hypokalemia
Intervention:
High potassium, Low sodium diet
Lifelong administration of glucocorticoid synthesis inhibitors
Eg. Mitotane
Inform that there will be poor wound healing
Sample question:
When assessing a 40-year old patient with cushing’s syndrome, the nurse should expect
the person to demonstrate:
A lability of mood---- answer
B ectomorphism with a moon face
C a decrease in the growth of facial hair
D an increase resistance to bruising and bleeding

EYE ABBREVIATIONS
OU- both eyes
OR- right eye
OS- left eye
LEVELS OF CONSCIOUSNESS
A------ ALERT
V------ VERBAL STIMULI
P------ PAINFUL STIMULI
U----- UNRESPONSIVE
REASONS FOR UNCONSCIOUSNESS(SKIN COLOR)
RED----- Stroke or increase BP
WHITE---- Shock or Hemorrhage
BLUE--- Respiratory or Cardiac Arrest

CIRCULATION ASSESSMENT- 5Ps


Pain
Pallor
Pulse
Paresthesia
Paralysis

CHOLINERGIC CRISIS

S- Salivation
L-Lacrimation
U-Urination
D-Defecation
G
E

ADLs

B-Bathing
A-Ambulation
T-Toileting
T-Transfers
E-Eating
D-Dressing

Instrumental ADLs
S-shopping
C-cooking, cleaning
U-using telephone /transportation
M-managing money and medications

C cane
O opposite
A affected
L leg

IN CASE OF ABDOMINAL TENDERNESS


Inspect, auscultate, percuss, palpate

CUSHINGS (Hypersecretion of Adrenal Cortex Hormones)

C = Check VS, particularly BP


U = Urinary output & weight monitoring
S = Stress Management
H = High CHON diet
I = Infection precaution
N = Na+ restriction
G = Glucose & Electrolytes Monitoring
S = Spousal support

ADDISON'S (Hyposecretion of Adrenal Cortex Hormones)


Always Remember the 6 A's of Addison's disease

1.) Avoid Stress


2.) Avoid Strenuous
3.) Avoid Individuals with Infection
4.) Avoid OTC meds
5.) A lifelong Glucocorticoids Therapy
6.) Always wear medic alert bracelet

IF RESPIRATORY DEPRESSION OR OVERSEDATION IS SUSPECTED:


1. CEASE the PCA
2. CEASE all other infusions that could be contributing to sedation
3. Attempt to rouse the patient
4. Call 777 [MET team] if appropriate
5. If apnoeic: administer bag & mask ventilation with 100% oxygen
6. If breathing: maintain airway, monitor oxygen saturations and administer oxygen via
face mask at 8L/min
7. Check circulation. If pulseless: commence chest compressions
8. Prepare naloxone for possible administration
9. Call CPMS for urgent review

Allergic: caused by sensitivity to foreign proteins.


Clinical Manifestations: Urticaria, flushing, itching, no fever.
Treatment: Administer antihistamines as directed.
If manifestations mild and transient, transfusion may resume.
Prevention: Treat prophylactically with antihistamines.

Acute hemolytic: caused by infusion of ABO-incompatible red blood cells.


Clinical manifestations: Chills, fever, low back pain, flushing, tachycardia,
hemoglobinuria, hypotension, vascular collapse, bleeding, acute renal failure, shock,
cardiac arrest, death.
Management: Discontinue transfusion, removing/changing IV tubing down to IV
catheter.
Send blood samples for serologic testing, and send urine samples to lab. Send blood
tubing to lab/blood bank.
Maintain blood pressure.
Give diuretics as prescribed to maintain urine flow.
Insert indwelling catheter or measure hourly output.
Dialysis may be needed.
Prevention: Meticulously verify recipent from sample collection to transfusion.

Anaphylactic reaction: caused by infusion of IgA proteins to IgA-deficient recipient who


has developed anti-IgA-antibodies.
Clinical Manifestations: Anxiety, urticaria, wheezing progressing to cyanosis, shock, and
possible cardiac arrest.
Treatment: Do not transfuse additional RBC.
Initiate CPR if indicated.
Have epinephrine ready for injection (0.4 ml of a 1:1000 solution SC
Prevention: Give blood composnents from IgA-deficient donors or remove all plasma by
washing.

Hirschsprung’s diagnosed with rectal biopsy looking for absence of ganglionic cells.
Cardinal sign in infants is failure to pass meconium, and later the classic ribbon-like and
foul smelling stools.

Intussusception common in kids with CF. Obstruction may cause fecal emesis, currant
jelly-like stools (blood and mucus). A barium enema may be used to hydrostatically
reduce the telescoping. Resolution is obvious, with onset of bowel movements.

With omphalocele and gastroschisis (herniation of abdominal contents) dress with loose
saline dressing covered with plastic wrap, and keep eye on temp. Kid can lose heat
quickly.
After a hydrocele repair provide ice bags and scrotal support.

No phenylalanine with a kid positive for PKU (no meat, no dairy, no aspartame).

Second voided urine most accurate when testing for ketones and glucose.

Never give potassium if the patient is oliguric or anuric.

Nephrotic syndrome is characterized by massive proteinuria (looks dark and frothy)


caused by glomerular damage. Corticosteroids are the mainstay. Generalized edema
common.

A positive Western blot in a child <18 months (presence of HIV antibodies) indicates
only that the mother is infected. Two or more positive p24 antigen tests will confirm
HIV in kids <18 months. The p24 can be used at any age.

For HIV kids avoid OPV and Varicella vaccinations (live), but give Pneumococcal and
influenza. MMR is avoided only if the kid is severely immunocompromised. Parents
should wear gloves for care, not kiss kids on the mouth, and not share eating utensils.

Hypotension and vasoconstricting meds may alter the accuracy of o2 sats.

An antacid should be given to a mechanically ventilated patient w/ an ng tube if the ph


of the aspirate is <5.0. Aspirate should be checked at least every 12 hrs.

Ambient air (room air) contains 21% oxygen.

The first sign of ARDS is increased respirations. Later comes dyspnea, retractions, air
hunger, cyanosis.

Normal PCWP is 8-13. Readings of 18-20 are considered high.

First sign of PE (pulmonary embolism) is sudden chest pain, followed by dyspnea and
tachypnea.

High potassium is expected with carbon dioxide narcosis (hydrogen floods the cell
forcing potassium out). Carbon dioxide narcosis causes increased intracranial pressure.

Pulmonary sarcoidosis leads to right sided heart failure.

An NG tube can be irrigated with cola, and should be taught to family when a client is
going home with an NG tube.

Q&As found in the NCLEX FORUM

Question # 1 (Multiple Choice) History and exam indicates your 77 year old

female patient has digitalis toxicity. Which drugs are contraindicated in this

case? Plz provide your rationale.

A) lidocaine and atropine


B) adenosine and amiodarone
C) magnesium sulfate and sodium bicarbonate
D) bretylium and verapamil

Answer::
A) lidocaine and atropine-Don't affect dig level/dig toxicity.

B) adenosine and amiodarone-Amiodarone, increases serum dig levels, possibly

causing dig toxicity. Adenosine doesn't affect dig toxicity. Only one of these

meds is contraindicated in dig levels/toxitiy.

C) magnesium sulfate and sodium bicarbonate. Neither drug affects dig levels

D) bretylium and verapamil-BEST ANSWER: Verapamil, increases serum dig levels,

possibly causing dig toxicity. Bretylium aggravates dig toxicity and digoxin

toxic arrhytmias are exacerbated by bretylium. This answer has two meds that are

should not be given to dig toxic patients.

Question # 2(Multiple Choice) Regarding abruptio placentae

A) Blood loss is confined within the amniotic sac


B) Internal bleeding is generally minimal.
C) Blood loss may be concealed between the uterine wall and the placenta
D) There is always excessive external vagina bleeding

what's the correct one? I just don't agree with c.

Answer::

C. is the best answer because it does describe placenta previa, most correctly.

Placenta previa is premature separation of the placenta, and the blood loss can

be either apparent or concealed. If the edges of the placenta remain attached to

the uterus then there will be no apparent loss of blood. However the woman is

still have significant internal bleeding.

A. is incorect because it does not describe A.P.

B. is incorrect because blood loss is usually significant, not minimal.

D. is incorrect because blood loss can be hidden.

Question # 3 (Multiple Choice) The geriatric patient suffering from organic

brain syndrome or dementia may not be able to make a rational decisions

regarding emergency care. In these situations, you may use ____to permit you to

legally render care


A) Good Samaritan Laws
B) Standards of Care
C) Implied Consent
D) Informed Consent

c is given as correct. why?

Answer:: Implied consent means that the patient most likely has been found in

distress and it is assumed that person wants to live. Therefore, you are within

the law to treat a person who is unable to make a decision about his/her care

who is in an emergency situation.

Above answer to your question explains why C is the best answer. Let me point

out a test taking tip to further support how you would choose this answer on an

exam, like NCLEX. First look at your question and identify, the key words, i.e.

what the question is asking. This question is asking which law will permit you

to deliver care in an emergency situation, when the patient is unable to give

consent. Now define each of the possible reponses.

A) Good Samaritan Laws-This law is to protect the individual that intervene to

provide care in an emergency from litigation. In other words, if a nurse stops

at an accident scene and provides care, the nurse will not be held liable for

their actions, if the care was provided in good faith according to practice

standards. Therefore this is not the answer.

B) Standards of Care-These are established guidelines for the nurse/health care

provider that outline safe and effective nursing care/interventions for given

diagnoses, etc. So, again this is not the answer to the question.

C) Implied Consent-Best answer, the patient can't verbalize consent, due to

their OBS/dementia, but they need emergency care. Because care is required then

consent to provide life saving care is implied. The same principle applies when

giving emergency care to unconscious patients. You can't wait for them to tell

you it is OK, to save their life, the law allows you to intervene. This is

implied consent.

D) Informed Consent-This is when the physician describes the procedure that is

to be preformed. Included in this explanation is the benefits and risks


associated with the procedure. The patient is INFORMED about the procedure and

then they give their consent. Again, this is not the best answer.

Try this technique when answering NCLEX-like questions, and you will find that

you will get more correct.

Question:

1.)a person is holding their neck what do you do?

a.)ask them can they cough.


b.)immediately perform the heimlich maneuver. I got confused because I

know are suppose to ask the person can they talk.

2.) an elderly client has alzheimers and wanders through out the day. To protect
his safety what is the best thing to do?

a.) put alarms on all the doors.


b.) inform all the staff to reorient the client.
c.) have the security guards to check on him.
d.) family to sit with him.

3.)When teaching a pt.about urinary catheter. What is most important?

a.)wear sterile gloves.


b.)clean the urethra with betadine.

4.)A woman is coming in for a pap smear what is most import to follow up on
before the pap smear is performed.

a)I just started menstruating and it is very heavy.


b) my last pap smear was abnormal.
C)I never had sex before.
d)I forgot this choice.

Answer:

These are some thoughts and rationales for the possible best answers to your

questions.

1.)a person is holding their neck what do you do?

a.) ask them can they cough. BEST ANSWER, because you need to confirm/rule out an

obstructed airway. If the patient can cough, then they are encouraged to do so.

If they can't speak or cough (no airway movement/obstructed airway) then you

begin the sequence for removing an airway obstruction, in this case it would be

for a conscious patient.


b.)immediately perform the heimlich maneuver. NOT THE BEST CHOICE, because you

need to confirm whether or not the patient is able to move air effectively

before performing this maneuver. Therefore to rule out an obstructe airway you

need to select an answer that will establish if the patient can speak, cough or

some other indicator of air movement.

I got confused because I know are suppose to ask the person can they talk. This

correct, but as you know from taking the NCLEX, the answer you want is never

there. What you have to do is select the answer that best matches/fits the

principles for the answer you would expect to find. You ask if the patient can

speak to confirm/rule out airway movement. Asking if they can cough will

accomplish the same thing.

2.) an elderly client has alzheimers and wanders through out the day. to protect

his safety what is the best thing to do? Key words in this question are WANDERS,

Alzheimer's patient, and to protect HIS SAFETY.

a.) put alarms on all the doors. BEST ANSWER, this is for the patient's SAFETY,

because Alzhiemer's patients wander and if they were to leave the healthcare

facility their safety would be compromised significantly. The alarms will

immediately alert all staff and the patient can be returned to the unit

immediately.

b.) inform all the staff to reorient the client. NO, remember the question is

asking about safety. Reoriented an Alzheimer’s patient is appropriate nursing

care, but they have no short term memory, so this will not ensure that they will

remain on the unit. They can (and will ) still wander.

c.) have the security guards to check on him. NO, this is both extreme and it is

"passing the buck". On the NCLEX it is up to nursing to solve nursing

problems. The patient could be injured or leave the unit between checks by the

security guards.

d.) family to sit with him. NO, this is "passing the buck" and putting another

burden on a family that is already in crisis due to the fact they have a family
member with Alzheimer's disease.

3.)When teaching a pt.about urinary catheter. What is most important? Both

answer don't match the principles of home care for a client with a catheter, so

it would be interesting to know what the other options were.

a.)wear sterile gloves. NO, because this is a clean procedure.

b.)clean the urethra with betadine. BEST answer of the two choices, because home

catheter care is a clean procedure, so A would not be the choice. Betadine is a

good anti-infective agent but it can be irritating to tissues. Generally

cleaning with soap and water is all that is recommended for home care.

4.)A woman is coming in for a pap smear what is most import to follow up on

before the pap smear is performed.

a) I just started menstruating and it is very heavy. BEST ANSWER, the best time

to obtain a pap smear is two weeks after the first day of the last menstrual

period and DEFINITELY NOT when the patient is menstruating, as this will affect

the results.

b) my last pap smear was abnormal. No, this is important to know, but not as

significant as A. This is not a contraindication to performing the test.

C) I never had sex before. No, this is important to know, but A is more

significant

d)I forgot this choice.

Question:

1. Alzheimer's patient incontinent of urine during the night times. The nursing care
includes

a) Offers bed pan every 2 hours


b) Limit fluids during evening times
c) Foley's catheter

2. After immediate post operative hysterectomy patient to observe (or) Nursing care
includes
a) Observe vaginal bleeding
b) Urine output
c) Vital signs

3. Dilantin prescribed to the patient, instructions to patient include

a) Reticulocyte counts
b) Platelet counts

4. On the ECG found a straight line, first Nurse

a) Assess the patient


b) Cardiopulmonary resuscitation
c) IV fluids

5. 15% superficial burns, 20% partial thickness burns. If the fluids adequate

a) Urine output 30-40ml/hr


b) BP
c) Vital signs
d) Skin turgor

6. 20 week pregnant most concerned

a) Butterfly rash on both cheeks and nose


b) Uterus palpate at the level of symphysis pubis
c) Sereous fluid drain in the breasts
d) Breast enlargement

7. The sterile technique is broken when:

a) The sterile field and supplies are wet


b) Clean the area peripheral to center

8. The metal piece is embedded on the left eye

a) Pressure dressing is applied on the left eye


b) Dressing is applied on both eyes
c) Irrigate the eye with saline

9. After cerebral angiogram, patient is

a) Encourage fluids
b) obseve contrast medium in the urine
c) walking

10. Using clean, non sterile gloves, care is appropriate

a) wash the genitelia........YES/NO

Answers:-
The following possible best answers are based on the information found in nursing
textbooks, and the underlying principle for safe and effective care that NCLEX is testing
for.

1. Alzheimer's patient incontinent of urine during the night times. The nursing care
includes

a) Offers bed pan every 2 hours-NO, would be appropriate to bring the client to the toilet
or commode every 2 hours during the day, but this action means you disturb the client's
sleep.

b) Limit fluids during evening times, BEST ANSWER-(Source: Black & Hawks,
Medical-Surgical Nursing 7th edition) Specific interventions for the Alzheirmer's client
with urinary incontinence: "Sometimes the client forgets where the bathroom is located.
Having bright lights and frequently taking the client there may help control incontinence.
Fluid intake after the dinner meal can be restricted to maintain continence during the
night."

c) Foley's catheter-NO, would increase risk of lower urinary tract infection, inappropriate
and not necessary.

2. After immediate post operative hysterctomy patient to observe (or) Nursing care
includes

a) Observe vaginal bleeding


b) Urine output
c) Vital signs-BEST ANSWER, as this provides the best/most information about the
client's response to surgery and anesthesia.

3. Dilantin prescribed to the patient, to instruct the patient that includes

a) Reticulocyte counts-Yes, this will test for decreased reticulocyte count a sign that the
patient is developing aplastic anemia, a potentially life threatening side effect of Dilantin
therapy.

b) Platelet counts-No, however Dilantin can decrease the platelet count and result in
thrombocytopenia. Aplastic anemia is considered to be more serious (Davis Drug Guide)

4. On the ECG found a straight line, first Nurse

a) Assess the patient-BEST ANSWER, always assess the patient to be sure there is no
equipment malfunction, and/or to confirm the information on the monitor.

b) Cardiopulmonary resuscitation

c) IV fluids

5. 15% superficial burns, 20% partial thickness burns. If the fluids adequate

a) Urine output 30-40ml/hr BEST ANSWER, the patient's fluid balance/hydration status
is best evaluated by assessing urine output. Urine output should be between 0.5 and 1.0
mL/kg/hr, which for a 130 lb adult would be between 29.5 -59 mL/hr. Most nursing
textbooks consider 30 mL/hr of urine output to indicate appropriate fluid
balance/hydration.

b) BP
c) Vital signs
d) Skin turgor
For b, c, and d many other factors can affect these findings. Urine output directly
correlates with the patient's hydration status/fluid balance.

6. 20 week pregnant most concerned


A
) Butterfly rash on both cheeks and nose-NO this is Cholasma the "mask of pregancy",
result of hormonal changes in pregnancy.

b) Uterus palpate at the level of symphysis pubis-BEST ANSWER this correlates with 12
weeks gestation and the patient in the question is 20 weeks. This is a significant
difference.

c) Sereous fluid drain in the breasts-NO, leaking of clear fluid from the breasts during
pregnancy is not unusual.

d) Breast enlargement-NO, the breast enlarge during pregnancy.

7. The sterile technique is broke when

a) The sterile field and supplies are wet-BEST ANSWER, this would allow
microorganisms to enter the sterile field through the wet surface.

b) Clean the area peripheral to center-NO, this is inappropriate technique but response a,
specifically describes how a sterile field can be contaminated and is an important
principle in maintaining sterile fields.

8. The metal piece is embedded on the left eye

a) Pressure dressing is applied on the left eye-NO, this would "push" the object further
into the eye.
b) Dressing is applied on both eyes-BEST ANSWER, you want to keep the left eye still,
and because both eyes move together the uninjured eye must be covered to prevent
movement in the injured eye.

c) Irrigate the eye with saline-NO, the object is embedded, meaning deep within the eye.
Irrigation will not remove the object but theoretically it could cause it to move resulting
in further damage.

9. After cerebral angiogram, patient is

a) Encourage fluids-BEST ANSWER, when ever contrast medium/X-ray dyes are


administer the client is hydrated to facilitate excretion of the dye.

b) obseve contrast medium in the urine-NO, should not be observable to patient or nurse.

c) walking-NO, bedrest would be maintained for a prescribed period of time.

10. Using clean, non sterile gloves care is appropriate

a) wash the genitelia........YES/NO- YES, this is not a sterile procedure.


Question:

A patient is receiving 1,000 ml of 5% glucose and 0.45% normal saline with 40 mEq of
potassium chloride. most important for nurse to monitor the patient :

A. pulse rate
B. daily weight
C. skin turgor

Answer1:

I would say, always check for urine output before commencing anything with Potassium
because it can only be excreted in the urine. Hence if you are dehydrated & have decrease
urine output & commenced on K+ hyperkalemia will arise leading to cardiac arrythmia.

Answer2:
The answer is pulse rate

Question:

1)a young patient most likely to get lead poisining if?

a. he is drinking from a ceramic pitcher.


b. father refurnishes old furniture at their home

2) a TB pt understands that he can reduce the risk of spreading his disease if he states?

a. i wont sleep in same room w/ my wife for 1-2 months


b. i will stay away from pregnant women and children
c. i will use plastic utensil when i eat

3) 4 years old with salmonella what u should do?

a. private room
b. isolation
c. place in a room with 4 year old with cellulitis
d. keep door closed at all times.

4) wat herb would help with vomiting?

a. ginkgo
b. ginseng.
c. ginger root
d. echinacea

5) allergic to sulfa wat not to take?

a. ma huang
b. echinacea.

6) mother called a nurse from home stating that her child having chicken pox, which of
the following statements by the mother needs immediate follow up?
a. father of the child with liver failure
b. sibling with anemia
c. child just had tonsillectomy
d. child has intermittent low grade fever

7) client with allergy to sudafed ..which of the statments is correct?

a. i will take valerian


b. i will take ma huang
c. i will take echinacea for acute viral inf.
d. i will take black cohosh

8) food processing

a. frozen food can be defrost for up to six hours


b. frozen food which has been defrost can be return back to fridge.
c. cook perishable food should cover and cool
d. frozen food should be defrost by hot water

9) child in a mist tent and the parents brought him a car toy...the child was clutching the
toy and the nurse refused to let him play for wat reason?

a. it will get contaminated with bacteria


b. it will accumalate moisture
c. it could cause a fire

11) a mother reported that her son is throwing up each time she feeds him wat would be
the best question u ask?

a. did u warm up the formula


b. wot kind of formula did u give him
c. does ur son feel hungry each time he throws up
d. does ur son have a jelly like stool

12) a patient had aids the nurse should advise?

a. cook ur meat very well


b. not to eat in the same table with family
c. avoid crowds

Answer:

1)a young patient most likely to get lead poisining if?

a. he is drinking from a ceramic pitcher.


b. father refurbishes old furniture at their home

> ANSWER is B. probably if he refurbishes an old furniture at home.. that is, if the
furniture has old paint on it and during 60's paints have lead content on it (heavy metals)
and if you need to remove that, chips from the old paint may be taken by a kid that leads
to Pb poisoning

2) a TB pt understands that he can reduce the risk of spreading his disease if he states?

a. i wont sleep in same room w/ my wife for 1-2 months


b. i will stay away from pregnant women and children
c. i will use plastic utensil when i eat
****>> if the patient is already taking anti-TB drugs, it will only be 2 weeks of
chemotherapy and that (+) PTB will no longer be communicable.. and 1-2 months is
long!
CHildren are more susceptible to acquire Primary complex and pregnant women are
susceptible and almost vulnerable to all type of illnesses.. There is no need for the patient
to separate their utensils since PTB is airborne and not by contact in terms of
transmission.. so i go for B answer.

3) 4 years old with salmonella what u should do?

a. private room
b. isolation
c. place in a room with 4 year old with cellulitis
d. keep door closed at all times.

*** the (+) salmonella kid may be placed in a private room. Salmonella is transmitted by
Enteric.. therefore Enteric precaution is needed and handwashing is very important and
gown and gloves, diaper or bedpan in necessary. Option B, and D are all for pulmonary
tuberculosis precautions. I suppose, the answer is A. place in a private room.

4) wat herb would help with vomiting?

a. ginko
b. ginsing.
c. ginger root
d. echinacea

****> ginger root is good for nausea.. most especially in morning sickness but in
moderation for pregnant women... Option C is the answer

5) allergic to sulfa wat not to take?

a. ma huang
b. echinacea.

...I think the answer is... geez, i forgot..i think its Echinacea..let me check again ok..

6) mother called a nurse from home stating that her child having chicken pox..which of
the following statements by the mother needs immediate follow up?

a. father of the child with liver failure


b. sibling with anemia
c. child just had tonsillectomy
d. child has intermittent low grade fever

I think the answer is C. the child that just had tonsillectomy. i think the child is
immunocompromised. and varicella (Chicken pox) is a viral one.. we all know that
tonsils are one of the lymph defenses we have against any infection.. Im not really sure
with this answer.

7) client with allergy to sudafed ..which of the statments is correct?

a. i will take valerian


b. i will take ma huang
c. i will take echinacea for acute viral inf.
d. i will take black cohosh
**valerian root is for cystitis and fungal infections; ma huang is for (I forgot!!),echinacea
is for immune booster but not to be taken with patients with progressive systemic
disorders such as AIDS, PTB, HIV, etc. black cohosh is for menopause.

*** don't you think that Echinacea is the correct option??

8)food processing

a. frozen food can be defrost for up to six hours


b. frozen food which has been defrost can be return back to fridge.
c. cook perishible food should cover and cool
d. frozen food should be defrost by hot water

usually, frozen food must be thawed at cool tap water for freshness. not in the microwave
because it can be cooked outside and raw inside, not in the hotwater with same principle.
so i believe, thawing it FOR UP TO 6 HOURS would be ok. returning thawed food back
at fridge is ok but it is unsafe since salmonella can start thriving in.. Answer is OPTION
A.

9) child in a mist tent and the parents brought him a car toy...the child was clutching the
toy and the nurse refused to let him play for wot reason?

a. it will get contaminated with bacteria


b. it will accumalate moisture
c. it could cause a fire

** The answer is OPTION C. Usually car toy have friction on it for the wheels to run..
Oxygen supports combustion.. and if friction is present together with oxygen (in a mist
tent) then, fire could commence.

11) a mother reported that her son is throwing up each time she feeds him wat would be
the best question u ask?

a. did u warm up the formula


b. wot kind of formula did u give him
c. does ur son feel hungry each time he throws up
d. does r son have a jelly like stool

***>>> CORRECT OPTION is D.. Does your son have jelly like stool.. jelly like or
currant like stool is a cardinal sign of Intussusception/ Telescoping or invagination of the
large intestines in the Ileoceccal area..

12) a patient had AIDS the nurse should advise?

a. cook ur meat very well


b. not to eat in the same table with family
c. avoid crowds

***>> if you have AIDS, u are immunocompromised.. therefore you are prone to
infection.. neutropenic precaution is advised and one that is a must is Avoiding Crowds..
Correct option is C.

Posted by anaski from IP 203.131.185.106 on September 08, 2005 at 03:45:59:

Thank you so much English RN2B


Future USRNs, this for you:
PRIORITY QUESTIONS (WHO TO SEE FIRST)
Sample Test Item:
1. Which of the following clients should the nurse deal with FIRST?
o 1 A client who needs his daily vitamin
o 2 A client who needs to be suctioned
o 3 A client who needs diaper to be changed
o 4 A client who is being prepared for discharge

Correct Answer: 2. A client who needs to be suctioned


PRIORITY (Use ABC)
Obstruction in the airway – secretions
Need to be suctioned

2. Delegation, RN, LVN, UAP, CNA


Which of the following clients should the LPN be assigned to?
o 1 A newly diagnosed patient with MYASTHENIC CRISIS
o 2 An immediate post-op client in PACU
o 3 A client awaiting medication for vitamins
o 4 A new admission for KIDNEY Transplant Patient

Correct Answer: 3-stable, A client awaiting medication for vitamins


Myasthenic Crisis – Unstable, Acute Respiratory Failure
Immediate Post – op – Unstable, Risk for Complications,
Kidney Transplant – Unstable, needs assessment for rejection

DELEGATION: Remember the 5R's, Right Task, Right Person, Right Circumstance,
Right Communication & Right Feedback)
RN Least stable, unstable, central catheters (hickman, broviac), admission, discharge,
health teachings, patient for transfer, blood transfusion (2RNs)
LPN Technical Doer, Stable, medications, wound dressing
CNA Routine Care, Urine Dip Stix, Reporting to RN, Routine VS
UAP turning q2H, conducting group activities, ambulation

For future USRNs


This is for you... from the purkinje fibers of my heart....

Room Assignment(Who to Share Room with)


Check:
A ge
B eside the nurse's station? At the end of the hallway? Single Room/Private Room?
C hain of infection/circumstance
D iagnosis
E nviroment (dim light, darkened, red nightlapm)

Sample Test Item:


The best roommate for patient with LEUKEMIA is
O 1 A 9-year-old with ruptured appendix
O 2 A 12-year-old with chicken pox
O 3 A 2-year-old with fever of unknown origin
O 4 A 5-year-old with nephrotic syndrome

Correct Answer: 4. A 5-year-old with nephrotic syndrome.


1,2 & 3, manifest symptoms of infection. A client with leukemia is immunosuppressed
and Patients with infection shouldn't be placed in this room. Since patient with nephrotic
syndrome receives diuretics and steroids, this child will also need immunocompromised
host precaution.

INFECTION CONTROL:
Sample Test Item:
3. Which of the following methods should the RN utilize in patient with
SALMONELLA?

O 1 Airborne Precautions
O 2 Droplet Precautions
O 3 Neutropenic Precautions
O 4 Enteric Precautions

The correct answer: 4.


Salmonella mode of transmission is fecal oral (enteric)
Handwashing
Gloves must be used in handling bedpan and diapers
Gown - if soiling is likely to happen.

Source of infection:
Contaminated food and water.

Remember - Transmission Based precautions:


A ir
B orne, small particles are dispersed in the air like MTB, varicella
C ontact, drug-resistant microorganisms
D roplet, large particles are dispersed into air, resp.infections except resp syncytial
E nteric, fecal-oral like hepaA & salmonella

AGE APPROPRIATE GROWTH AND DEVELOPMENT


(HOPPING WITH ONE LEG)
Sample test Item:

4. Which of the following is NOT a characteristic of a preschooler?

O 1 predominantly "parallel play" period


O 2 balances on 1 foot with eyes closed
O 3 skips on alternate feet
O 4 jumps rope

The correct answer is: 1. Parallel play is more common in TODDLERS.

Preschooler (3-6 years)


Gross motor development

HOPS ON ONE (1) FOOT BY 4 YEARS


SKIPS & HOPS ON ALTERNATE FEET BY 5 YEARS
PLAY : ASSOCIATIVE, IMAGINATIVE, MAGICAL THINKING, SUPERHEROES
(Remember the movie: Jingle All The way!)
FEAR: Intrusive procedures, venipunctures, IM injections, body mutilation

Toxoplasmosis, where else you can contract this (thinking of cat litter but it aint there)
Sample test Item:
5. To which of the following pregnant clients will be risk for TOXOPLASMOSIS?

Select all that apply:

O 1 A pregnant client who eat raw meat.


O 2 A pregnant client handling cat litter of infected cats.
O 3 A pregnant client gardening and cultivating soil exposed to cat feces.
O 4 A pregnant client with low rubella titer
O 5 A pregnant client who have undergone external radiation.
O 6 A pregnant client with draining, painful vesicles in the external genitalia.

The correct answers: 1, 2 & 3.


TOXOPLASMOSIS
How do people get toxoplasmosis?
A Toxoplasma infection occurs by:

Accidentally swallowing cat feces from a Toxoplasma-infected cat that is shedding the
organism in its feces.
This might happen if you were to accidentally touch your hands to your mouth after
gardening,
cleaning a cat's litter box, or
touching anything that has come into contact with cat feces.
Eating contaminated raw or partly cooked meat, especially pork, lamb, or venison;
by touching your hands to your mouth after handling undercooked meat.
Contaminating food with knives, utensils, cutting boards and other foods that have had
contact with raw meat.
Drinking water contaminated with Toxoplasma.
Receiving an infected organ transplant or blood transfusion, though this is rare.
(From the internet-Division of Parasitic Disease)

Which of these statements by the nurse is incorrect if the nurse has the goal to reinforce
information about cancers to a group of young adults?
1. “You can reduce your risk of this serious type of stomach cancer by eating lots of fruits
and vegetables, limiting all meat, and avoiding nitrate-containing foods.”
2. “Prostate cancer is the most common cancer in American men with results to threaten
sexuality and life.”
3. “Colorectal cancer is the second-leading cause of cancer-related deaths in the United
States.”
4. “Lung cancer is the leading cause of cancer deaths in the United States. Yet it's the
most preventable of all cancers.

MEMORIZE MEMORIZE MEMORIZE


Tonometry: normal (10-21 mm Hg)

PR Interval: normal (0.12-0.20 seconds)

Serum Amylase: normal (25-151 units/dL)

Serum Ammonia: normal (35 to 65 mcg/dL)

Calcium: adult (8.6-10 mg/dL)


child (8 to 10.5 mg/dL)
term<1week (7 to 12 mg/dL)

Partial Thromboplastin Time (aPTT): normal (20-36 seconds) therapeutic 1.5-2.5

Prothrombin Time: normal (Male: 9.6-11.8 seconds) and


(Female: 9.5-11.3 seconds)

Platelet Count: normal (150,000-400,000 cells/uL)

Albumin level: normal (3.4 to 5 g/dL)

Serum Osmolality: normal (285 to 295 mOsm/kg)


high value indicates dehydration

Safe Suction Range: normal [Infant] 50-95 mm Hg

[Child] 95-115 mm Hg

[Adult]100-120 mm Hg)

Serum Lithium: normal (1 to 1.5 mEq/L)

acute mania (0.6 to 1.4 mEq/L) maintenance treatment

Phenytoin (Dilantin): normal serum (10 to 20 mcg/mL)

Digoxin: therapeutic blood level (0.8 to 2.0 ng/ml)

Magnesium Sulfate: Therapeutic Range (4 to 8 mg/dl)

Pregnancy Temperature: normal (36.2-37.6 celcius or 98-99.6 Farenheit)

WBC’s In Pregnancy: normal (11,000 to 15,000 cells/mm3, up to 18,000 cells/mm3).


Immediate postpartum period, (maybe as high as 25,000 to 30,000 cells/mm3)

Stomach Capacity:
 Newborn infant (10 to 20 mL)
 1-week-old (30 to 60 mL)
 2-3-week-old infant (75 to 100 mL)
 1-month-old infant (90 to 150 mL)

Left Atrial Pressure: normal (1 to 10 mm Hg)


Fibrinogen Levels: normal (male: 180 to 340 mg/dL) and

(female: 190 to 420 mg/dL)

with Disseminated Intravascular Coagulation the fibrinogen level drops because


fibrinogen is used up in the clotting process.

Insulin Insulin Insulin Insulin


(Regular, Humulin R) (NPH, Humulin N) (Ultralente, Humulin U) (Humulin 70/30)
Type: Fast acting Type: Intermediate Type: Slow acting Type: Combination
Onset: ½ -1 hr acting Onset: 4hr Onset: ½ hr
Peak: 2-4 hr Onset: 2hr Peak: 8-20hr Peak: 2-12hr
Duration: 6-8 hr Peak: 6-12hr Duration: 24-36hr Duration: 24hr
Duration 18-26hr

Central Venous Pressure:


< 3 mm Hg = inadequate fluid and >11 mm Hg = too much fluid

Potassium: 3.5-5.0 mEq/L


Sodium: 135-145 mEq/L
Calcium: 4.5-5.2 mEq/L or 8.6-10 mg/dL
Magnesium: 1.5-2.5 mEq/L
Chloride: 96-107 mEq/L
Phosphorus: 2.7 to 4.5 mg/dL

PR measurements: normal (0.12 to 0.20 second)

QRS measurements: normal (0.04 to 0.10 second)

Ammonia: 35 to 65 ug/dL
Amylase:25 to 151 IV/L

Lipase: 10 to 140 U/L

Cholesterol: 140 to 199 mg/dL


LDL: <130 mg/dL
HDL: 30 to 70 mg/dL
Triglycerides: <200 mg/dL

Bilriubin
• Direct: 0 to 0.3 mg/dL
• Indirect: 0.1 to 1.0 mg/dL
• Total: <1.5 mg/dL

Protein: 6.0 to 8.0 g/dL

Uric acid: Male 4.5 to 8 mg/dL


Female 2.5 to 6.3 mg/dL

Glycosylated Hemoglobin HbA1c: good control 7.5% or less

Serum creatinine: 0.6 to 1.3 mg/dL


BUN: 9-25 mg/dL

Normal CK is 26-174 U/L

Troponin I value: normal (<0.6 ng/mL)


Troponin T >0.1 to 0.2 ng/mL = MI

Erythrocyte studies: 0-30 mm/hour

Serum iron: Male 65-175 ug/dL


Female 50-170 ug/dL

RBC: Male 4.5 to 6.2 M/uL


Female 4.0 to 5.5 M/uL

Theophylline levels normal (10 to 20 mcg/dl)

MOTOR DEVELOPMENT

Chin up 1 month

Chest up 2 month

Knee push and “swim” 6 month

Sits alone/stands with help 7 month

Crawls on stomach 8 month

Stands holding on furniture 10 month

Walks when led 11 month

Stands alone 14 month

Walks alone 15 month

AT THE PLAY GROUND

* Stranger anxiety: 0 -1 year


* Separation anxiety: 1 - 3 years
* Solitary play: 0 – 1 year
* Parallel play: 2 – 3 years
* Group play: 3 – 4 years
PSYCHOLOGICAL DEVELOPMENT

AGE ERIKSON FREUD PIAGET


Infant Oral (trust &
0 – 1.5 Trust vs. mistrust dependence sensorimotor
Toddler Anal (holding vs.
1.5 -3 Autonomy vs. shame letting out) preoperational
Pre-school Phallic (Oedipus
3-6 Initiative vs. guilt complex) preoperational
School age Industry vs.
6 - 11 inferiority latency Concrete operational
Identity vs. role
11 - 20 confusion genital Formal operational

20 – 25 Intimacy vs. isolation


Generativity vs.
25 – 50 stagnation

50 - ? Integrity vs.despair

LABORATORY VALUES

ELECTROLYTES

Sodium (Na+): 135 – 145 meq/L


(increase-dehydration; decrease
overhydration)
Potassium (K+): 3.5 - 5.0 meq/L
Magnesium (Mg++): 1.5 – 2.5 meq/L
Calcium (Ca++): 4.5 – 5.8 meq/L
Neonate : 7.0 to 12 mg/dL
Child: 8.0 to 10.5 mg/dL
Phosphorus (PO4): 1.7 – 2.6 meq/L
Chloride (Cl-): 96 – 106 meq/L

COAGULATION STUDIES

Activated partial thromboplastin time(APTT): 20 – 36 seconds depending on the


type of activator used
Prothrombin time(PT): male: 9.6 – 11.8 seconds
Female: 9.5 – 11.3 seconds
International Normalized Ratio(INR): 2.0 - 3.0 for standard Coumadin therapy
3.0 – 4.5 for high-dose Coumadin therapy
Clotting time: 8 – 15 minutes
Platelet count: 150,000 to 400,000 cells/Ul
Bleeding time: 2.5 to 8 minutes

SERUM GASTROINTESTINAL STUDIES

Albumin: 3.4 to 5 g/dL


Alkaline phosphatase: 4.5 to 13 King-Armstrong units/dL
Ammonia: 15 to 45 ug/dL
Amylase: 50 – 180 Somogyi U/dL in adult
20 – 160 Somogyi U/dL in the older adult
Bilirubin: direct: 0 - 0.3 mg/dL
Indirect: 0.1 – 1.0 mg/dL
Total: less than 1.5 mg/dL
Cholesterol: 120 – 200mg/dL
Lipase: 31 -186 U/L
Lipids: 400 – 800 mg/dL
Triclycerides: Normal range: 10 – 190 mg/dL
Borderline high: 200 – 400 mg/dL
High: 400 – 1000mg/dL
Very high: greater than 1000mg.dL
Protien: 6.0 – 8.0 g/L
Uric acid: male: 4.5 – 8 ng/dL
Female: 2.5 – 6.2 ng/dL

GLUCOSE STUDIES

Fasting blood sugar: 70 – 105 mg/dL


Glucose monitoring (capillary Blood): 60 – 110 mg/dL

RENAL FUNCTION TEST

Creatinine: 0.6 – 1.3 mg/dL


Blood urea nitrogen (BUN): 5 – 20 mg/dL

ERYTROCYTES STUDIES

Erytrocyte sedimentation rate(ESR): 0 – 30 mm/hr depending on age


Hemoglobin: male: 14 – 16.5 g/dL
Female: 12 – 15 g/dL
Hematocrit: male: 42% - 52% (increased in hemoconcentration, fluid loss and
dehydration)
Female: 35% - 47% ( decreased in fluid retention)
Red blood cell (RBC): male: 4.5 to 6.2 million/uL
Female: 4 to 5.5 million/uL

White blood cell (WBC): 4500 to 11,000/uL


Erytrocyte Protoporthyrin (EP) : <9ug/dL
Phenylalanine Level: <2 mg/dL
PKU: >25 mg/dL

CRANIAL NERVES

MAJOR FUNCTIONS

I. Olfactory (S) smell

II. Optic (S) vision

III. Oculomotor (M) Eye movement


IV. Trochlear (M)
Facial sensation
V. Trigeminal (S-M) Jaw movement

VI. Abducent (M) Eye movement


Taste
VII. Facial (S-M) Facial expression

VIII. Acoustic (S) Hearing and balance


Taste
IX. Glossopharyngeal (S-M) Throat sensation
Gag and swallow
Gag and swallow
X. Vagus (S-M) Parasympathetic activity
Neck and back muscles
XI. Spinal Accessory (M)

XII. Hypoglossal (M) Tongue movement

On Old Olympus’ Towering Tops, A Finn And German Viewed Some Hops
Some Says Marry Money, But My Brother Says Bad Business Marry Money

ARTERIAL BLOOD GAS (ABG)

pH: 7.35 – 7.45


PCO2: 35 - 45 mmHg
PO2: 80 - 100 mmHg
HCO3: 22 - 27 mEq/L
O2 saturation: 96% - 100%
Acid-base “RAMS”(Respiratory Alternate, Metabolic Same)

GLASGOW COMA SCALE

Eye opening response


Motor response
Verbal response

AUTONOMIC NERVOUS SYSTEM

SYMPATHETIC/ PARASYMPATHETIC/
ADRENERGIC CHOLINERGIC
Increased heart rate
Heart Increased conduction Decreased heart rate
Increased force

Bronchi dilation constriction

GI tract Reduced motility Increased motility


Empties rectum
Rectum Allows filling Relaxes internal sphincter
Empties bladder
Bladder Allows filling Relaxes internal sphincter

Erection Maintains erection

Ejaculation Triggers ejaculation


Pupils of eye Big (mydriasis) Small (miosis)

Salivary glands Secretion


Depends on receptors
Blood vessels -a contrict
-b dilates

FLOW OF BLOOD THROUGH THE HEART

Inferior vena cava and superior vena cava – right atrium – tricuspid valve – right
ventricle – pulmonic valve – pulmonary artery – lungs – pulmonary veins – left atrium –
bicuspid valve (mitral) – left ventricle – aortic valve aorta – systemic circulation

CARDIAC IMPULSES

Sinoatrial (SA) node – right and left atria (atria contract) – atrioventricular (AV) node –
bundle his – bundle brabches – purjinje’s fibers – ventricles contract.

Blood volume: 5000mL


Central venous pressure: 4 to 10 cmH2O (increased in cardiac overload; decreased in
dehydration)
Pressure within the right atrium: 2 to 7 mmHg
Capillary refill time: <3 seconds
Normal sweat chloride: <40 mEq/L
Normal pupil diameter: 3 to 5mm
Normal ocular pressure: 10 to 21 mmHg
Normal Pulmonary capillary wedge pressure (PCWP): 8 to 13 mmhg
Normal cardiac output : 4 to 8 L/min.

THERAPEUTIC SERUM MEDICATION LEVELS

Acetaminopen (Tylenol) 10 – 20 ug/mL


Amikacin (Amikin) 25 – 30 ug/mL
Amitryptyline (Elavil) 120 -150 ng/mL
Carbamazepine (Tegretol) 5 -12 ug/mL
Chloramphenicol (Chloromycetin) 10 – 20 ug/mL
Desipramine (Norpramin) 150 -300 ng/mL
Digotoxin ( Crystodigin) 15- 25 ng/mL
Digoxin ( Lanoxin) 0.5 – 2.0 ng/mL
Disopyramide (Norpase) 2 -5 ug/mL
Ethosuximide ( Zarontin) 40 – 100 ug/mL
Gentamycin (Garamycin) 5 – 10 ug/mL
Imipramide (Tofranil) 150 – 300 ug/mL
Lidocaine (Xylocaine) 1.5 – 5.0 ug/mL
Lithium (Lithobid) 0.5 -1.5 ug/mL
Magnesium sulphate 4 -7 mg/dL
Nortriptyline (Aventyl) 50 – 150 ng/mL
Phenobarbital (Luminal) 10 – 30 ug/mL
Phenytoin (Dilantin) 10 -20 ug/mL
Primidone (Myoline) 5 – 20 ug/mL
Procainamide (Pronestryl) 4 – 10 ug/mL
Propranolol (Inderal) 50 – 100 ng/mL
Quinidine (Quinalaglute, Cardioquin) 2 – 5ug/mL
Salisylate 100 -250 ug/mL
Theophylline (Aminiphylline, Theo-Dur) 10 -20 ug/mL
Tobramycin (Nebcin ) 5 -10 ug/mL
Valproic acid (depakene) 50 -100 ug/mL

Pulmonary capillary wedge pressure: 5 to 13 mmHg


Pulmonary artery pressure: systolic: 16 to 30 mmHg
Diastolic: 0 to 7 mmHg
Spinal pressure: 70 to 200mmH2O
Morphine sulphate pediatric dose: 0.1mg/kg every 3 – 4 hour

SULFONYLUREAS
For treatment of NIDDM
 Sulfonylureas should not be given to patients with liver or kidney failure.
 Accummulation of drug will increase risk of hypoglycaemia.

DURATION

tolbutamide 8h

Glycburide, glipizide 20 h, most potent

chlorpropamide 48 h

Apothecary and Household System

Grain –gr 1 gr = 60 mg
Dram – dr 5 gr = 300 mg
Ounce –oz 15 gr = 1000mg or 1g
Minim – min, M, m 1/150 gr =0.4 mg
Quart – qt 1 oz = 30 mL
Pint – pt 1 dr = 4 mL
Drop – gtt 1 T = 15 mL or 3 tsp
Tablespoon – T or tbs 1 min = 1 gtt
Teaspoon – t or tsp 15 min = 1mL
Pound – lb 60 min = 1 dr
8 dr = 1 oz
1 qt = 1000mL or 1L
1 qt = 2 pt or 32 oz
1 pt = 16 oz
16 oz = 1 lb
2.2lb = 1 kg

Fahrenheit to Celcius (F – 32) divide 1.8 = C

Celcius to Fahrenheit 1.8 C + 32 = F


Formula for Calculating a Medication Dosage

D (desired ) = the dosage that the physician ordered


A (available) =the dosage strength as stated on the medication label
Q (quantity ) = the volume that the dosage strength is available in, such as tablet,
capsules, or mL

D X Q = X
A

Formulas for Intravenous Calculations

Flow Rates:
Total volume x gtt factor = gtt per min
Time in minutes

Infusion Time:
Total volume to infuse = Infusion time
mL per hour being infused

IMMUNIZATION

Birth Hepatitis B
1 months Hepatitis B
2 months OPV, DPT, HIB
4 months DPT, HIB, OPV
6 months DPT, HIB, hepatitis B
12 months HIB, OPV
15 months MMR
18 months DPT
12 – 18 months Varicella vaccine
4 -6 years DPT, OPV, MMR
11 – 12 years MMR ( if not administered at 4 -6 years)
11 – 16 TD booster

SPINAL CORD INJURY


Cervical Injury:
 C2 to C3 injury usually fatal
 C4 is the major innervation to the diaphragm by th phrenic nerve
 Involvement above th C4 causes respiratory difficulty and paralysis of
all the four extremities
 C5 or below client may have movement in the shoulder

Thoracic Level Injury:


 loss of movement of the chest, trunk, bowel, bladder, and legs, depending on the
level of injury
 Leg paralysis (paraplegia)
 Autonomic dysreflexia with lesions above T6 and in cervical lesions
 Visceral distention from a distended bladder or impacted rectum may cause
reactions such as sweating, bradycardia, hypertension, nasal stuffiness, and
gooseflesh

Lumbar and Sacral Level Injuries:


 loss of movement and sensation of the lower extremities.
 S2 and S3 center on micturation; therefore below this level, the bladder will
contract but not empty (neurogenic bladder)
 Injury above S2 in males allows them to have an erection, but they are unable to
ejaculate because of sympathetic nerve damage.
 Injury between S2 and S4 damages the sympathetic and parasympathetic
response, preventing erection and ejaculation.

RULE OF NINE

Head and neck 9%


Anterior trunk 18%
Posterior trunk 18%
Arms (9%) 18%
Legs (18%) 36%
Perineum 1%

NORMAL ADULT WHITE BLOOD CELL DIFFERENTIAL

Neutrophils 56% or 18000 – 7800/uL


Bands 3% or 0 – 700/uL
Eosinophils 2.7% or 0 – 450/uL
Basophils 0.3% or 0 – 200/uL
Lymphocytes 34% or 1000 – 4800/uL
Monocytes 4% or 0 – 800/uL

THYROID STUDIES
Thyroid –stimulating hormone (thyrotropin; THS): 0.2 to 5.4 ug/dL
Thyroxine (T4): 5.0 to 12.0 ug/dL
Thyroxine free (FT3) : 0.8 to 2.4 ng/dL
Triiodothyronine (T3): 80 to 230 ng/dL

Normal Fribrinogen level: for men: 180 to 340mg/dL


Women: 190 to 420mg/dL
Fribrinogen is used up in the clotting process.

Erythrocyte Protoporhyrin (EP): < 9ug/dL


Phenylalanine level: < 2mg/dL
PKU: >25 mg/dL
Urine specific gravity: 1.016 - 1.022 increase in SIADH; decrease in diabetes
insipidus
Normal CSF protein: 15 – 45 mg/dL increase in Guillain-Barre syndrome
Normal CSF pressure: 5 – 15 mmHg
Normal serum osmolality: 285 – 295 mOsmlkgH2O increase in dehydration;
Decrease in over hydration
Normal scalp pH: 7.26 and above
Borderline acidosis: 7.20 to 7.25
Acidosis: < 7.15
HERBAL MEDICINE

Aloe vera Gel – abrasionsand dermatologic conditions


American Ginseng (Panax quinquefolius) – boost energy, relieve stress, improve
concentration and enhance physical or cognitive performance.
Ashwagandha (Withania somnifera) – stress arthritis
Asian gingseng (Panax ginseng) – enhance health and combat stress and disease
Bilberry (Vaccinium myrtillus) – vision and peripheral vascular disorders and as
antioxidant
Black Cohosh (Cimicifuga racemosa) – menopausal
Black Currant and Borage oil (Ribes nigrum and Borago offinalis) – anti-
inflammatory, rheumatoid arthritis
Capsicum Peppers (Capsicum spp.) – arthritis, neuralgia and other painful treatment
Chamomile (Matricaria recutita) “manzanilla”- skin inflammation, colic, or dyspepsia
and anxiety
Chaste tree (Vitex agnus-castus) – menstrual related disorders, PMS, cyclical mastalgia
Chodroitin – osteoarthritis
Coenzyme Q10 – antioxidant
Coltsfoot ( Tussilago farfara ) – cough and other respiratory disoders
Cranberry (Vaccinium macrocarpon) – UTI
Devil’s Claw ( Harpagophytum procumbers) – anti inflammatory and analgesic
Echinacea (Echinacea spp.) – acute viral URI symptoms
Ederberry (Sanbacus nigra) – respiratory tract infection
Ephedra or Ma Huang (Ephedra sinica) Source of ephedrine and pseudoephedrine
Evening Primrose Oil (Oenothera biennis) – eczema, breast pain associated with PMS
and inflammatory condition
Fenugreek (Trigonella foenum-graecum) – lowering blood glucose
Feverfew ( Tanacetum parthenium) – migraine headache prophylaxis
Garlic (Allium sativaum)- help prevent cardiovascular disease and cancer
Ginger (Zingiber officinale) –nausea and motion sickness, anti-inflammatory
Ginkgo (Ginkgo biloba) – dementia and intermittent claudication, memory enhancement
and treatment of vertigo nad tinnitus
Glucosamine – osteoarthritis
Goldenseal ( Hydrastis Canadensis) – tonic and antibiotic
Gotu Kola (Centella asiatica) – mental support, wound healing and venous disorders
Hawtorn ( Crategus species) – CHF and related cardiovascular conditions
Horebound (Marribium vulgare) – primary cough suppression and expectoration
Horse Chestnut Seed (Aesculus hippocastanum) chronic venous insufficiency
Ivy (Hedera helix) – coughs, rheumatic disordes and skin disease
Kava ( piper methysticum) – mild psychoactive and antianxiety property
Lemon Balm (Melissa officinalis) – sedative and for dyspepsia
Licorice (Glycyrrhiza glabra) – respiratory disorders, hepatitis, inflammatory diseases,
and infections
Melatonin – insomia, jet lag
Milk Thistle – hepatitis, liver desease
Mints (Mentha species) – minor calcium channel antagonists, used for upper respiratory
problems, irritable bowel syndrome, dyspepsia, and colonic spasm and as a
topical counterirritant
Nettle (Urtica dioica) – arthritis pains, allergies, BPH, or as diuretic
Papaya (Carica papaya) – digestive aid, dyspepsia, and for inflammatory, topically
applied to wounds
Passion flower (Passiflora incarnata)- sedative-hypnotic or anxiolytic herb
Pokeroot (Phytolacca Americana) – inflammatory conditions also as an emetic/cathartic
Pygeum (Pygeum africanum) – mild symptoms of BPH
Red Clover (Trifolium pratense) – used as a natural estrogen substitute for women’s
health
St. John’s Wort (Hypericum perforatum) – antidepressant effect
Tea Tree Oil (Melaleuca alternifolia) – antifungal and antibacterial
Turmeric (Curuma longa ) – anti-inflammatory, anti-arthritis, anti cancer, and
antioxidant
Uva Ursi (Arctostaphylos uva ursi) – urinary antiseptic and diuretic
Yohimbe – erectile dysfunction

FOUR STRATEGIES:
1. If the question asks what you should do in the situation. Use the nursing process
to determine which step in the nursing process would be next?
2. If the question asks what the client needs. Use maslow’s hierarchy to determine
which need to address.
3. If the question indicates that the client doesn’t have urgent physiologic need,
focus on the patient safety.
4. If the question involves communicating with a patient. Use principles of
therapeutic communication.

REMEMBER:
AIRWAY, BREATHING,CIRCULATION AND SAFETY (ABCS)

The nurse in primary care clinic is caring for a 50-year-old woman. History reveals that
she had experienced on and off chest pain. After series of cardiac tests (EKG & Blood
Chem), the doctor orders for THALLIUM STRESS TEST. Which of the following
medications should the RN prepare if the patient needs an alternative exercise in thallium
test?
1.Nitroglycerin
2.Morphine
3.Aminophylline
4.Persantin
The correct answer is #4. Persantin (dipyridamole)
Persantin is use as an alternative to exercise in thallium myocardial perfusion imaging for
the evaluation of CAD in those who cannot exercise adequately.
Purpose: to determine myocardial wall viability
Other names:
1. Cardiac pooling
2. MUGA-multigated radionuclide angiographic scanning
3. nurclear scan
4. sestamibi test
5. thallium scan
6. dipyridamole or persantin stress test
7. In short, heart scan :)
Loving NCLEX-RN
URC
09178364589

Posted by Anaski from IP 203.131.183.186 on August 23, 2005 at 21:44:00:


For Future USRN's:
Cervical Cancer
Etiology:
* Early age of sexual intercourse
* Multiple sexual partners
* Sexually Transmitted Disease (Venereal Wart)
* Virus - HPV
Cancer Carcinoma in SITU - only in epithelial linings
Situ sounds like Ziru - Stage 0
Tumor marker - CEA
Signs and Symptoms (3 P's)
POST COITAL BLEEDING
PAINFUL INTERCOURSE
PROFUSE (PERIOD IRREGULARITIEs - menorrhagia and metrorrhagia)

Management:

U - pera (Surgery HYSTERECTOMY)


R - radiation (intracavitary cessium - remember STD - shielding, timing and distance))
C - chemotherapy to destroy the DNA,RNA & CHON synthesis.
MIKE’S NOTES (60 pp.)

O universal donor/AB universal recipient.

ABO BLOOD TYPE


COMPATIBILITY
Blood Type Can Receive from: Can donate to:
O O O,A,B,AB
A A,O A,AB
B B,O B,AB
AB O,A,B,AB AB

Autologous Transfusion:
• Collected 4-6 weeks before surgery
• Contraindicated—infection, chronic disease, cerebrovascular or cardiovascular
disease

Hypotonic Solution Isotonic Solution Hypertonic Solution


• ½ NS (0.45% • 0.9% NaCl (Normal Saline) • 10% D/W (10% Dextrose in water)
Saline) • 5% D/W (Dextrose in Water) • D15W
• Lactated Ringer’s • 5% D/NS (5% Dextrose in 0.9%
• 5% D/ ¼ NS (5% Dextrose in 0.225% Saline)
Saline ) • 5% D/ ½ NS (5% Dextrose in 0.45%
Saline)
• 3% NaCl
• 5% Sodium Bicarbonate

Change tubing Q72 hours

Change bottle Q24 hours


Infiltration
• Assessment: cool skin, swelling, pain, decrease in flow rate
• Implementation: discontinue IV, warm compresses, elevate arm, start new site
proximal to infiltrated site
IV Phlebitis, Thrmobophlebitis
• Assessment—redness, warm, tender, swelling, leukocytosis
• Implementation—discontinue IV, warm moist compresses, start IV in opposite
extremity
Hematoma
• Assessment—ecchymosis, swelling, leakage of blood
• Implementation—discontinue IV, apply pressure, ice bag 24 hours, restart IV in
opposite extremity

IV Clotting
• Assessment—decreased flow rate, back flow of blood into tubing
• Implementation—discontinue, do not irrigate, do not milk, do not increase rate
of flow or hang solution higher, do not aspirate cannula, inject Urokinase, D/C
and start on other site.

Insertion of Percutaneous Central Catheters:


• Placed supine in head-low position
• Turn head away from procedure
• Perform Valsalva maneuver
• Antibiotic ointment and transparent sterile dressing
• Verify position with x-ray
• Change tubing Q24 hours
• Nurse/patient both wear mask when dressing change 2-3x/week
Adrenergics Adrenergic Adrenergics Side effects:
Actions: Medications • Dysrhythmias
• Stimulate the • Levophed • Tremors
sympathetic nervous • Dopamine • Anticholinergic
system: increase in • Adrenalin effects
peripheral resistance, Adrenergics Nursing
increase blood flow to • Dobutrex Considerations:
heart, bronchodilation, • Monitor BP
increase blood flow to • Monitor peripheral
skeletal muscle, increase pulses
blood flow to uterus • Check output
• Stimulate beta-2
receptors in lungs
• Use for cardiac arrest and
COPD

Anti-Anxiety Anti-Anxiety Anti-Anxiety


Action: Medications: Side effects:
• Affect • Librium, • Sedation
neurotransmitters Xanax, Ativan, • Confusion
Used for: Vistaril, • Hepatic dysfunction
• Anxiety disorders, Equanil Anti-Anxiety
manic episodes, panic Nursing Considerations:
attacks • Potention for addiction/overdose
• Avoid alcohol
• Monitor Liver Function AST/ALT
• Don’t discontinue abruptly, wean
off
• Smoking/caffeine decreases
effectiveness

Antacids Antacids Antacids


Actions: Medications Side effects:
• Neutralize gastric • Amphojel • Constipation
acids • Milk of • Diarrhea
Used for: Magnesia • Acid rebound
• Peptic ulcer • Maalox Antacids
• Indigestion, reflex Nursing Considerations:
esophagitis • Interferes with absorption of
antibiotics, iron preps, INH, Oral
contraceptives
• Monitor bowel function
• Give 1-2 hours after other
medications
• 1-3 hours after meals and at HS
• Take with fluids

Antiarrhythmics Antiarrhythmics Antiarrhythmics


Action: Medications: Side effects:
• Interfere with • Atropine sulfate • Lightheadedness
electrical • Lidocaine • Hypotension
excitability of heart • Pronestyl • Urinary retention
Used for: • Quinidine Antiarrhythmics
• Atrial fibrillation • Isuprel Nursing Considerations:
and flutter • Monitor vital signs
• Tachycardia • Monitor cardiac
• PVCs rhythm
Aminoglycosides Aminoglycosides Aminoglycosides (Antibiotics)
(Antibiotics) (Antibiotics) Side effects:
Action: Medications: • Ototoxicity and Nephrotoxicity
• Inhibits protein • Gentamycin • Anorexia
synthesis in • Neomycin • Nausea
gram-negative • Streptomyci • Vomiting
bacteria n • Diarrhea
Used for: • Tobramycin Aminoglycosides (Antibiotics)
• Pseudomonas, Nursing Considerations:
E.Coli • Harmful to liver and kidneys
• Check 8th cranial nerve
(hearing)
• Check renal function
• Take for 7-10 days
• Encourage fluids
• Check peak/trough level

Cephalosporins Cephalosporin Cephalosporins (Antibiotics)


(Antibiotics) s (Antibiotics) Side effects:
Action: Medications: • Bone marrow depression: caution with anemic, and low
• Inhibits synthesis • Ceclor PLT px
of bacterial cell • Ancef • Superinfections
wall • Keflex • Rash
Used for: • Rocephi Nursing Considerations:
• Tonsillitis, otitis n • Take with food
media, peri- • Cefoxitin • Cross allergy with PCN
operative
• Avoid alcohol
prophylaxis
• Obtain C&S before first dose: to make sure medication
• Meningitis
is effective against disease/bacteria
• Can cause false-positive for proteinuria/glycosuria

Fluoroquinolones Fluoroquinolones Fluroquinolones


(Antibiotics) (Antibiotics) (Antibiotics)
Action: Medications: Side effects:
• Interferes with DNA • Cipro • Diarrhea
replication in gram- • Decreased WBC and Hematocrit
negative bacteria • Elevated liver enzymes (AST, ALT)
Used for: • Elevated alkaline phosphatase
• E.Coli, Nursing Considerations:
Pseudomonas, S. • C&S before starting therapy
Aureus • 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)

Macrolide (Antibiotics) Macrolide (Antibiotics) Macrolide (Antibiotics)


Action: Medications: Side effects:
• Binds to cell • Erythromycin • Diarrhea
membrane and • Clindamycin • Confusion
changes protein • Hepatotoxicity
function • Superinfections
Used for: Nursing Considerations:
• Acute infections • Take 1hr ac or 2-3 hr pc
• Acne • Monitor liver function
• URI • Take with water (no fruit juice)
• Prophylaxis before • May increase effectiveness of:
dental procedures if Coumadin and Theophylline
allergic to PCN (bronchodilator)

Penicillin Penicillin Penicillin


Action: Medications: Side effects:
• Inhibits synthesis of • Amoxicillin • Stomatitis
cell wall • Ampicillin • Diarrhea
Used for: • Augmentin • Allergic reactions
• Moderate to severe • Renal and Hepatic changes
infections Nursing Considerations:
• Syphilis • Check for hypersensitivity
• Gonococcal • Give 1-2 hr ac or 2-3 hr pc
infections • Cross allergy with
• Lyme disease cephalosporins
Sulfonamides (Antibiotics) Sulfonamides Sulfonamides (Antibiotics)
Action: (Antibiotics) Side effects:
• Antagonize essential Medications: • Peripheral Neuropathy
component of folic acid • Gantrisin • Crystalluria
synthesis • Bactrim • Photosensitivity
Used for: • Septra • GI upset
• Ulcerative colitis • Azulfidine • Stomatitis
• Crohn’s disease Nursing Considerations:
• Otitis media • Take with meals or foods
• UTIs • Encourage fluids
• Good mouth care
• Antacids will interfere with
absorption

Tetracyclines TEtracyclines Tetracyclines (Antibiotics)


(Antibiotics) (Antibiotics) Side effects:
Action: Medications: • Discoloration of primary teeth if taken during
• Inhibits protein • Vibramycin pregnancy or if child takes at young age
sythesis • Panmycin • Glossitis
Used for: • Rash
• Infections • Phototoxic reactions
• Acne Nursing considerations:
• Prophylaxis for • Take 1 hr ac or 2-3 hr pc
opthalmia • Do not take with antacids, milk, iron
neonatorum • Note expiration date
• Monitor renal function
• Avoid sunlight

UTIs
• Medication:
o Furadantin
• Action:
o Anti-infective
• Side effects:
o Asthma attacks
o Diarrhea
• Nursing Considerations:
o Give with food or milk
o Monitor pulmonary status

UTIs
• Medication
o Mandelamine
• Action:
o Anti-infective
• Side effects:
o Elevated liver enzymes
• Nursing Considerations:
o Give with cranberry juice to acidify urine
o Limit alkaline foods: vegetables, milk, almonds, coconut

UTIs
• Medication
o Pyridium
• Side effects:
o Headache
o Vertigo
• Action
o Urinary tract analgesic
• Nursing Consideration
o Tell patient urine will be orange

Anticholinergics Anticholinergic Anticholinergic


Action: Medications: Side Effects:
• Inhibits action of acethylcholine • Pro-Banthine • Blurred vision
and blocks parasympathetic nerves • Atropine • Dry mouth
(affects heart, eyes, respiratory • Scopolamine • Urinary retention
tract, GI tract and the bladder) • Chage in heart rate
• Dilates pupil, causes Nursing Consideration:
bronchodilation and decreased • Monitor output
secretions • Contraindicated with
• Decrease GI motility secretions glaucoma
Used for: • Give 30 min ac, hs, or 2hr pc
• Opthalmic exam • Contraindicated: paralytic
• Motion sickness ileus, BPH
• Pre-operative

Anticoagulants Anticoagulant Anticoagulants (Heparin)


Action: s Side Effects:
• Blocks conversion of Medications: • Hematuria
prothrombin to • Heparin • Tissue irritation
thrombin Nursing Considerations:
Used for: • Monitor clotting time or Partial
• Pulmonary embolism Thromboplastin Time (PTT)
• Venous thrombosis • Normal 20-45 sec
• Prophylaxis after
• Therapeutic level 1.5-2.5 times
acute MI
control
• Antagonist—Protamine Sulfate
• Give SC or IV

Anticoagulant Anticoagulant Anticoagulant (Coumadin)


Action: Medication: Side Effects:
• Interferes with synthesis • Coumadin • Hemorrhage, Alopecia
of vitamin K-dependent Nursing Considerations:
clotting factors • Monitor Prothrombin Test (PT)
Used for: • Normal 9-12 sec
• Pulmonary embolism • Therapeutic level 1.5 times control
• Venous thrombosis
• Antagonist—Vitamin K
• Prophylaxis after acute MI
(AquaMEPHYTON)
• Monitor for bleeding
• Give PO

Anticonvulsants Anticonvulsan Anticonvulsant


Action: t Side effects:
• Decreases flow of calcium Medications: • Respiratory depression
and sodium across neuronal • Dilantin • Aplastic anemia
membranes • Luminal • Gingival hypertrophy
Used for: • Depakot • Ataxia
• Seizures e Nursing Considerations:
• Tegretol • Don’t discontinue abruptly
• Klonopin • 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 pinkish-red/pinkish-
brown
Anti-Depressants Anti- Anti-Depressants
Monoamine Oxidase Depressants (Monoamine Oxidase Inhibitors)
Inhibitors (MAO) (Monoamine Side effects:
Action: Oxidase • Hypertensive Crisis (Sudden headache,
• Causes Inhibitors) diaphoretic, palpitations, stiff neck, intracranial
increases Medications: hemorrhage) with food that contain Tyramine
concentration of • Marplan Nursing Considerations:
neurotransmitters • Nardil • Avoid foods containing Tyramine: Aged cheese,
Used for: • Parnate liver, yogurt, herring, beer and wine, sour cream,
• Depression bologna, pepperoni, salami, bananas, raisins, and
• Chronic pain pickled products
• Monitor output
• Takes 4 weeks to work
• Don’t combine with sympathomometics
vasoconstrictors, and cold medications

Anti-Depressants Anti-Depressants Anti-Depressants


Selective Serontonin Selective Selective Serontonin Reuptake Inhibitors
Reuptake Inhibitors (SSRI) Serontonin (SSRI)
Action: Reuptake Side effects:
• Inhibits CNS uptake of Inhibitors (SSRI) • Anxiety
serotonin Medications: • GI upset
Used for: • Paxil • Change in appetite and bowel function
• Depression • Prozac • Urinary retention
• Obsessive-Compulsive • Zoloft Nursing Considerations:
Disorder • Suicide precautions
• Bulimia • Takes 4 weeks for full effect
• Take in a.m.
• May urine to pinkish-red or Pinkish-
brown
• Can be taken with meals
Anti-Depressants Anti-Depressants Anti-Depressants (Tricyclics)
(Tricyclics) (Tricyclics) Side Effects:
Action: Medications: • Sedation/Confusion
• Inhibits reuptake of • Norpramin • Anticholinergics affects
neurotransmitters • Elavil • Postural Hypotension
Used for: • Tofranil • Urinary retention
• Depression Nursing Considerations:
• Sleep apnea • Suicide precautions/2-6 weeks
to work
• Take at hs/Don’t abruptly halt
• Avoid alcohol/OTC
/Photosensitivity

Insulin Insulin Insulin Insulin


(Regular, Humulin (NPH, Humulin N) (Ultralente, Humulin (Humulin 70/30)
R) Type: Intermediate U) Type: Combination
Type: Fast acting acting Type: Slow acting Onset: ½ hr
Onset: ½ -1 hr Onset: 2hr Onset: 4hr Peak: 2-12hr
Peak: 2-4 hr Peak: 6-12hr Peak: 8-20hr Duration: 24hr
Duration: 6-8 hr Duration 18-26hr Duration: 24-36hr

Antidiabetic Agents Antidiabetic Agents Antidiabetic Agents


Action: Medications: Side Effects:
• Stimulates insulin release • Diabinese • Hypoglycemia
from beta cells in pancreas • Orinase • Allergic skin reactions
Used for: • Dymelor • GI upset
• Type 2 diabetes (NIDDM) • Micronase Nursing Considerations:
• Take before breakfast
• Monitor glucose levels
• Avoid alcohol,
sulfonamides, Oral
Contraceptives, (MAO),
aspirin because they
help to make drug
work better
Hypoglycemic Agent Hypoglycemic Agent Hypoglycemic Agent
Action: Medication: Side Effects:
• Stimulates liver to • Glucagon • Hypotension
change glycogen to • Bronchospasm
glucose Nursing Considerations:
Used for: • May repeat in
• Hypoglycemia 15min
• Give carbohydrates
orally to prevent
secondary
hypoglycemic
reactions

Antidiarrheals Antidiarrheals Antidiarrheals


Action: Medications: Side Effects:
• Slows peristalsis • Kaopectate • Constipation
• Increases tone of • Lomotil • Anticholinergic
sphincters • Imodium effects (urinary
Used for: • Paregoric retention, dry
• Diarrhea mouth)
Nursing Considerations:
• Do not use with
abdominal pain
• Monitor for urinary
retention
• Give 2hr before or 3
hr after other meds

Antiemetics Antiemetics Antiemetics


Action: Medications: Side Effects:
• Increases GI motility • Tigan • Sedation
• Blocks effect of • Compazine • Anticholinergic effects
dopamine in • Torecan Nursing Considerations:
chemoreceptor • Reglan • Used before chemotherapy
trigger zone • Antivert • When used with viral
Used for: • Dramamine infections may cause
• Vomiting Reye’s syndrome (Toxic
Encephalopathy)

Antifungals Antifungals Antifungals


Action: Medications: Side Effects:
• Impairs cell • Amphotericin B • Hepatotoxicity
membrane • Nystatin • Thrombocytopenia
Used for: • Leukopenia
• Candidiasis • Pruritis
• Oral thrush Nursing Considerations:
• Histoplasmosis • Give with food
• Monitor liver function
• Good oral hygiene

Antigout Agents Antigout Agents Antigout Agents


Action: Medications: Side Effects:
• Decreases • Colchicine • Agranulocytosis
production and • Probenecid • GI upset
resorption of uric • Zyloprim • Renal calculi
acid Nursing Considerations:
Used for: • Monitor for renal calculi
• Gout • Give with food, milk,
antacids

Antihistamines Antihistamines Antihistamines


Action: Medications: Side Effects:
• Block effects of • Chlor-Trimeton • Drowsiness
histamine • Benadryl • Dry mouth
Used for: • Phenergan • Photosensitivity
• Allergic rhinitis Nursing Considerations:
• Allergic reactions to • Give with food
blood • Use sunscreen
• Avoid alcohol

Antihyperlipidemic Antihyperlipidemic Antihyperlipidemic


Agents Agents Agents
Action: Medications: Side Effects:
• Inhibits cholesterol • Questran • Constipation
and triglyceride • Lipid • Fat-soluble vitamin
synthesis deficiency
Used For: Nursing Considerations:
• Elevated • Take at hs or 30
cholesterol min ac
• Reduce incidence • Administer 1hr
of cardiovascular before or 4-6 hr
disease after other meds

Antihypertensives Antihypertensives Antihypertensives


Types: ACE Inhibitors (ACE Inhibitors) (ACE Inhibitors)
Action: Medications: Side Effects:
• Blocks ACE in • Capoten • GI upset
lungs • Vasotec • Orthostatic hypotension
Used for: • Dizziness
• Hypertension Nursing Considerations:
• CHF • Give 1hr ac or 3hr pc
• Change position slowly
Antihypertensives Antihypertensives Antihypertensives
Type: Beta-Adrenergic Blockers Type: Beta- Type: Beta-Adrenergic
Action: Adrenergic Side Effects:
• Blocks Beta-Adrenergic Medications; • Changes in heart
Receptors • Nadolol rate
• Decrease • Propranolol • Hypotension
excitability/workload of • Tenormin • Bronchospasm
heart, oxygen • Timoptic Nursing Considerations:
consumption • Masks signs of
• Decrease shock and
Used for: hypoglycemia
• Hypertension • Take with meals
• Angina • Do not discontinue
• SVT abruptly

Antihypertensives Antihypertensives Antihypertensives


Type: Calcium Channel Blockers Type: Calcium Type: Calcium
Action: Channel Blockers Channel Blockers
• Inhibits movement of calcium across cell Medications: Side Effects:
membranes • Procardia • Hypotension
• Slow impulse conduction and depresses • Calan • Dizziness
myocardial contractility • Cardizem • GI distress
• Causes dilation of coronary arteries and Nursing Consideration:
decreases cardiac workload and energy • Monitor vital
consumption signs
Used for: • Do not chew or
• Angina divide
• Hypertension sustained-
• Interstitial cystitis release tablets

Antihypertensives Antihypertensives Antihypertensives


Type: Centrally acting Type: Centrally acting alpha- Type: Centrally acting alpha-
alpha-adrenergics adrenergics adrenergics
Action: Medications: Side Effects:
• Stimulates alpha • Aldomet • Sedation
receptors in • Catapres • Orthostatic Hypotension
medulla which Nursing Considerations:
causes a reduction • Don’t discontinue
in sympathetic in abruptly
the heart • Monitor for fluid retention
Used for: • Change position slowly
• Hypertension
Antihypertensives Antihypertensives Antihypertensives
Type: Direct-acting Medications Side Effects:
vasodilators • Hydralazine • Tachycardia
Action: • Minoxidil • Increase in body hair
• Relaxes smooth Nursing Considerations:
muscle • Teach patient to
Used for: check pulse
• Hypertension

Antihypertensives Antihypertensives Antihypertensives


Type: Peripheral-acting alpha-adrenergic Medications: Side Effects:
blockers • Reserpine • Depression
Action: • Orthostatic
• Depletes stores of norepinephrine in Hypotension
sympathetic nerve endings • Brachycardia
Used for: Nursing Considerations:
• Hypertension • Give with meals or
milk
• Change position
slowly

Bipolar Disorder Bipolar Disorder Bipolar Disorder


Action: Medications: Side Effects:
• Reduces • Lithium (1-1.5meq/L) • GI upset
catecholamine • Tegretol • Tremors
release • Depakote • Polydipsia
Used for: • Polyuria
• Manic episodes Nursing Considerations:
• Monitor serum levels
• Give with meals
• Increase fluid intake

Antineoplastic Agents Antineoplastic Antineoplastic Agents


Type: Alkylating Agents Agents Side Effects:
Action: Medications: • Hepatotoxicity
• Interferes with • Cisplatin • Ecchymosis
rapidly reproducing • Myleran • Alopecia
DNA • Cytoxan • Epitaxis
Used for: • Infertility
• Leukemia • Bone Marrow Suppression
• Multiple myeloma • Stomatitis
• GI disturbances: Anorexic, N/V,
diarrhea
Nursing Considerations:
• Check hematopoietic
(reproduction of RBC’s by bone
marrow) function
• Force fluids
• Good mouth care

Antineoplastic Agents Antineoplastic Antineoplastic Agents


Type: Antimetabolites Agents Antimetabolites
Action: Antimetabolites Side Effects:
• Inhibits DNA Medications: • Nausea
polymerase • 5-FU • Vomiting
Used for: • Methotrexate • Oral ulceration
• Acute lymphatic • Hydrea • Bone marrow
leukemia suppression
• Cancer of colon, • Alopecia
breast, pancreas Nursing Considerations:
• Monitor hematopoietic
function
• Good mouth care
• Discuss body image
changes

Antineoplastic Agents Antineoplastic Agents Antineoplastic Agents


Type: Antitumor Antitumor Antibiotics Antitumor Antibiotics
Antibiotics Medications: Side Effects:
Action: • Adriamycin • Bone marrow suppression
• Interferes with DNA • Actinomycin D • Alopecia
and RNA synthesis • Bleomycin • Stomatitis
Used for: Nursing Considerations:
• Cancer • Monitor vital signs
• Give antiemetic medications before
therapy

Antineoplastic Agents Antineoplastic Agents Antineoplastic Agents


Type: Hormonal Agents Type: Hormonal Agents Type: Hormonal Agents
Action: Medications: Side Effects:
• Changes hormone • Diethylstilbestrol • Leukpenia
input into sensitive • Tamoxifen • Bone pain
cells • Testosterone • Hypercalcemia
Used for: Nursing Considerations:
• Cancer • Check CBC
• Monitor serum
calcium

Antineoplastic Agents Antineoplastic Agents Antineoplastic Agents


Type: Vinca Alkaloids Type: Vinca Alkaloids Type: Vinca Alkaloids
Action: Medications: Side Effects:
• Interferes with cell • Oncovin • Stomatitis
division • Velban • Alopecia
Used for: • Loss of reflexes
• Cancer • Bone marrow
suppression
Nursing Considerations:
• Give antiemetic
before administration
• Check reflexes
• Given with Zyloprim
to decrease uric acid

Antiparkinson Agents Antiparkinson Agents Antiparkinson Agents


Action: Medications: Side Effects:
• Converted to • Artane • Dizziness
Dopamine • Cogentin • Ataxia
• Stimulates • L-Dopa • Atropine-like effects: dry
postsynaptic • Parlodel mouth, urinary retention
Dopamine • Sinemet Nursing Considerations:
receptors • Symmetrel • Monitor for urinary
Used for: retention
• Parkinson’s disease • Large doses of vitamin
B6 reverse effects
• Avoid use of CNS
depressants

Antiplatelet Agents Antiplatelet Agents Antiplatelet Agents


Action: Medications: Side Effects:
• Interferes with • Aspirin • Hemorrhage
platelet • Persantine • Thrombocytopenia
aggregation Nursing Considerations:
Used for: • Check for signs of
• Venous thrombosis bleeding
• Pulmonary • Give with food or
embolism milk

Antipsychotic Agents Antipsychotic Agents Antipsychotic Agents


Action: Medications: Side Effects:
• Blocks dopamine • Haldol • Akathisia (inability
receptors in basal • Thorazine to sit still)
ganglia • Mellaril • Dyskinesia
Used for: • Stelazine • Dystonias
• Acute and Chronic • Parkinson’s
psychoses syndrome
• Tardive dyskinesias
• Leukopenia
Nursing Considerations:
• Check CBC
• Monitor vital signs
• Avoid alcohol and
caffeine

Atypical Antipsychotic Atypical Antipsychotic Atypical Antipsychotic


Agents Medications: Side Effects:
Action: • Clozaril • Extrapyramidal
• Interferes with • Risperdal effects
binding of • Anticholinergic
dopamine in the • Sedative
brain • Orthostatic
Used for: hypotension
• Acute and Chronic Nursing Considerations:
psychoses • Monitor blood
• Change positions
slowly
• Use sunscreen

Antipyretic Agents Antipyretic Agents Antipyretic Agents


Action: Medications: Side Effects:
• Antiprostaglandin • Tylenol • GI irritation
activity in (Acetaminophen) Nursing Considerations:
hypothalamus • Monitor liver
Used for: function
• Fever • Aspirin
contraindicated for
younger than 21
years old due to
risk of Reye’s
syndrome

Antithyroid Agents Antithyroid Agents Antithyroid Agents


Action: Medications: Side Effects:
• Reduce vascularity • Tapazole • Leukopenia
of thyroid • SSKI • Rash
• Inhibits release of • Thrombocytopenia
thyroid into Nursing Considerations:
circulation • Bitter taste
Used for: • May cause burning
• Hyperthyroidism in mouth
• Give with meals
• Check CBC

Thyroid Replacement Thyroid Replacement Thyroid Replacement


Agents Medications Side Effects:
Action: • Synthroid • Nervousness
• Increases metabolic • Cytomel • Tachycardia
rate • Weight loss
Used for: Nursing Considerations:
• Hypothyroidism • Monitor pulse and
BP
• Monitor weight
• Take in a.m.
• Enhance action of
anticoagulants,
antidepressants,
decrease action of
insulin and digitalis

Antitubercular Agents Antitubercular Antitubercular Agents


Action: Agents Side Effects:
• Inhibits cell and Medications: • Hepatitis
protein synthesis • INH • Peripheral Neuritis
Used for: • Ethambutol Nursing Considerations:
• Tuberculosis • Streptomycin • Check liver function tests
• To prevent disease • PAS • Vitamin B6 given for
in person exposed • PYZ peripheral neuritis
to organism (Pyridoxine)
• Used in combination
Antivirals Antivirals Antivirals
Action: Medications: Side Effects:
• Inhibits DNA and • Zovirax • Headache
RNA replication • AZT • Dizziness
Used for: • Videx • GI symptoms
• Recurrent HSV • Famvir Nursing Considerations:
• HIV infection • Cytovene • Encourage fluids
• Not a cure, but
relieves symptoms

Attention Disorder Attention Disorder Attention Disorder


Agents Agents Agents
Action: Medications: Side Effects:
• Increases level of • Ritalin • Restlessness
catecholamines • Cylert • Insomnia
Used for: • Dexedrine • Tachycardia
• ADDH • Palpitations
• Narcolepsy Nursing Considerations:
• Monitor growth rate
• Monitor liver
enzymes
• Give in A.M.

Bronchodilators Bronchodilators Bronchodilators


Action: Medications: Side Effects:
• Decreases activity of • Aminophylline • Tachcyardia
phosphodiesterase • Atrovent • Dysrhythmias
Used for: • Brethine • Palpitations
• COPD • Proventil • Anticholinergic effects
• Preterm labor • Primatene Nursing Considerations:
(Terbutaline) • Monitor BP and HR
• When used with
steroid inhaler, use
bronchodilator first
• May aggravate
diabetes

Cardiac Glycosides Cardiac Cardiac Glycosides


Action: Glycosides Side Effects:
• Increases force of Medication: • Bradycardia
myocardial • Lanoxin • Nausea
contraction, slows (Digoxin) • Vomiting
rate • Visual disturbances
Used for: Nursing Considerations:
• Left-sided CHF • Take apical pulse
• Notify physician if adult <60, child <90-110, <70
in older children
• Monitor potassium level
• Dose: 0.5-1 milligram IV or PO over 24 hr period
• Average: 0.25 mg

Cholinergics Cholinergics Cholinergics


Action: Medications: Side Effects:
• Inhibits destruction of • Tensilon • Bronchoconstriction
acetylcholine • Prostigmin • Respiratory paralysis
• Stimulate • Hypotension
parasympathetic Nursing Considerations:
nervous system • Give with food or milk
(increase bowel tone, • Monitor vital signs,
increase bladder especially respirations
tone, constrict pupil) • Antidote: Atropine
Used for: Sulfate
• Myasthenia gravis • Toxicity: excessive
• Post-operative salivation, excessive
• Postpartum urinary sweating, abdominal
retention cramps, flushing

Diuretics Diuretics Diuretics


Action: Medications: Side Effects:
• Inhibits • HydroDIURIL • Dizziness
reabsorption of • Diamox • Orthostatic
sodium and water • Aldactone Hypotension
• Blocks effects of • Lasix • Leukopenia
aldosterone • Hygroton Nursing Considerations:
Used for: • Take with food or milk
• CHF • Take in a.m.
• Renal disease • Monitor fluid and
electrolytes

Iron: Imferon/Feosol, use straw if liquid form, no milk/antacids, take on empty


stomach, tachycardia
Glucocorticoids Glucocorticoids Glucocorticoids
Action: Medications: Side Effects:
• Stimulates • Solu- • Psychoses
formation of Cortef • Depression
glucose • Decadron • Hypokalemia
• Alters immune • Deltasone • Stunted growth
response • Buffalo Hump
Used for: Nursing Considerations:
• Addison’s disease • Monitor fluid and electrolyte
• Crohn’s disease balance
• COPD • Don’t discontinue abruptly
• Leukemias • Monitor for signs of infection

Mineralocorticoids Mineralocorticoid Mineralocorticoids


Action: s Side Effects:
• Increases sodium Medications: • Hypertension
reabsorption • Florinef • Edema
• Potassium and • Hypokalemia
hydrogen ion Nursing Considerations:
secretion in • Monitor BP, I&O, Weight, and Electrolytes
kidney • Give with food
Used for: • Low-sodium, High-protein, High-potassium
• Adrenal diet
insufficiency

Heavy Metal Antagonists Heavy Metal Heavy Metal Antagonists


Action: Antagonists Side Effects:
• Forms stable Medications: • Tachycardia
complexes with • Desferal mesylate • Pain and induration at
metals • BAL in Oil injection site (conjunct
Used for: • EDTA with Procaine in
• Gold and arsenic syringe)
poisoning Nursing Considerations:
• Acute lead • Monitor I&O and kidney
encephalopathy function
• Administered with local
anesthetic
• Seizure precautions

H2 Receptor Blockers H2 Receptor Blockers H2 Receptor Blockers


Action: Medications: Side Effects:
• Inhibits action of • Tagamet • Dizziness
histamine and • Zantac • Confusion
gastric acid • Hypotension
secretion • Impotence
Used for: Nursing Considerations:
• Ulcers • Take with meals
• Gastroesophageal and hs
reflux • Smoking decreases
effectiveness
• Monitor liver
function and CBC

Immunosuppressants Immunosuppressants Immunosuppressants


Action: Medications: Side Effects:
• Prevents • Sandimmune • Hepatotoxicity
production of T • Nephrotoxicity
cells and their • LeuKopenia
response to • Thrombocytopenia
interleukin-2 Nursing Considerations:
Used for: • Take once daily in
• Prevents rejection a.m.
for transplanted • Used with adrenal
organs corticosteroids
• Monitor renal and
liver function tests

Miotics (Constricts Pupil) Miotics Miotics


Action: Medications: Side Effects:
• Causes constriction • Isopto-Carpine • Headache
of sphincter • Eserine • Photophobia
muscles of iris • Carbacel • Hypotension
Used for: • Bronchoconstriction
• Ocular surgery Nursing Considerations:
• Open-angle • Apply pressure on
glaucoma lacrimal sac for 1min
• Avoid sunlight
• May experience
transient brow pain
and myopia

Mydriatics (Dilates Pupil) Mydriatics Mydriatics


Action: Medications: Side Effects:
• Anticholinergic • Atropine sulfate • Tachycardia
actions leaves pupil • Cyclogyl • Blurred vision
under unopposed • Photophobia
adrenergic • Dry mouth
influence Nursing Considerations:
Used for: • Contraindicated with
• Diagnostic glaucoma
procedures • Apply pressure on lacrimal
• Acute iritis sac for 1min.
• Uveitis • Wear dark glasses
Narcotics Narcotics Narcotics
Action: Medications: Side Effects:
• Acts on CNS • Morphine Sulfate • Dizziness
receptor cells • Codeine • Sedation
Used for: • Demerol • Respiratory depression
• Moderate to severe • Dilaudid • Hypotension
pain • Percodan • Constipation
• Preoperative Nursing Considerations:
• Postoperative • Safety precautions
• Avoid alcohol
• Monitor vital signs
• Use narcotic antagonist if
necessary (Narcan)

Antianginals Antianginals Antianginals


Action: Medications: Side Effects:
• Relaxes smooth • Nitroglycerine • Hypotension
muscle • Isosorbide • Tachycardia
• Decreases venous • Headache
return • Dizziness
Used for: Nursing Considerations:
• Angina • Check expiration date
• Peri-operative • Teach when to take medication
hypertension • May take Q5min x3 doses
• CHF • Wet with saliva and place under
tongue

NSAIDS NSAIDS NSAIDS


Action: Medications: Side Effects:
• Inhibits • Motrin • GI upset
prostaglandin • Indocin • Dizziness
synthesis • Naprosyn • Headache
Used for: • Bleeding
• Arthritis • Fluid retention
• Mild to moderate Nursing Considerations:
pain • Take with food or after meals
• Fever • Monitor liver and renal function
• Use cautiously with aspirin allergy
• Check for bleeding

Thrombolytics Thrombolytics Thrombolytics


Action: Medications: Side Effects:
• Dissolves or lyses blood clots • Streptokinase • Bleeding
Used for: • Urokinase • Bradycardia
• Acute Pulmonary Emboli • Tissue Plasminogen • Dysrhythmias
• Thrombosis Activator Nursing Considerations:
• MI • Monitor for bleeding
• Contraindicated in: hemophilia, • Have Amino Caproic
CVA, Trauma, not used in Acid Available
patients over 75 years old, not • Check pulse, color,
used in patients taking sensation of extremities
anticoagulants • 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 6-9 Months


tuberculosis be on medication?

Inflammation of Liver
Jaundice
Anorexia
RUQ pain
What are symptoms of Clay-colored stools, tea-colored urine
hepatitis? Pruritis (bile salts eliminated through skin)
Elevated ALT, AST
Prolonged PT (liver involvement with clotting
factor)
What is the transmission of Fecal/Oral
Hepatitis A? Consume contaminated food or water
Travelers to developing countries at risk
Clients with hepatitis A should not prepare food
for others
What is the transmission of Parenteral/Sexual contact
Hepatitis B? Blood or body fluids
At risk individuals are the one’s that abuse IV
drugs, dialysis, healthcare workers
Vaccine developed
What is the transmission of Blood or body fluids
Hepatitis C? Can become chronic disease
Seen in patients with hemophilia (unable to
clot)
What is the transmission of Co-infects with hepatitis B
Hepa D ?
What nursing care are Rest (mainly for liver)
recommended for Hepatitis? 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.
What is Lyme’s Disease? Multi-system infection caused by a tick bite.
There are three stages.
What is Stage 1 of Lyme’s Erythematous papule develops into lesion with
Disease? clear center (Bull’s-eye)
Regional lymphadenopathy
Flu-like symptoms (fever, headache,
conjunctivitis)
Can develop over 1 to several months
What is Stage 2 of Lyme’s Develop after 1 to 6 months if disease
Disease? untreated.
Cardiac conduction defects
Neurologic disorders (Bell’s palsy, temporary
paralysis)
What is Stage 3 of Lyme’s Develops after 1 to several months, if reached
Disease? at this stage may persist for several years.
Arthralgias
Enlarged, inflamed joints
What are some Lyme’s Disease Cover exposed areas when in wooded areas
teaching? Check exposed areas for presence of ticks

What are some Lyme’s Disease Antibiotics 3-4 weeks


nursing care? Stage 1 use Doxicillin
IV penicillin with later stages
What are the treatment, mode Painless chancre fades after 6 weeks
of transmission, care, signs and Low grade fever
symptoms of syphillis? Copper-colored rash on palms and soles of feet
Spread by contact of mucous membranes,
congent
Treat with Penicillin G IM
If patient has penicillin allergy, will use
erythromycin for 10-15 days.
After treatment, patient must be retested to
make sure disease is gone.
What are the treatment, mode If female maybe asymptomatic and will be
of transmission, care, signs and unaware of having disease.
symptoms of gonorrhea? Males may have thick discharge from urethra.
Some females from vagina.
Spread mucous membranes, congenital
IM Rocephin with Doxycycline PO, IM Aqueous
Penicillin with PO Probenecid (used for gout,
used with Penicillin because it delays the
urinary excretion of it, makes it more effective)
Complication: Pelvis Inflammatory Disease
Most often affected with Chlamydia also, then
treatment with PO Tetracycline

What are the treatment, mode No cure.


of transmission, care, signs and Painful vesicular genital lesions
symptoms of genital herpes? Problem is exacerbations/remissions
Reoccurs with stress, infection, menses
Spread by contact of mucous membranes,
congenital
Treatment: Acyclovir, sitz bath
Monitor pap smears regularly because of
higher incidence of cervical cancer.
Emotional support of client/significant others
important because of no cure.
Pregnant women with active disease will have
C-section.
What are the treatment, mode Men: urethritis, dysuria
of transmission, care, signs and Women: thick vaginal discharge with acrid odor
symptoms of Chlamydia? Spread by mucous membranes, congenital
Treatment with Tetracycline or Doxycycline PO
Will cause sterility if left untreated.
Important to notify sexually contacted.
What are the treatment, mode Single, small papillary lesion spreads into large
of transmission, care, signs and cauliflower cluster on perineum, vagina, penis.
symptoms of Venereal Warts? May itch or burn.
Spread by mucous membranes, congenital
Treatment: Curettage, cryotherapy with liquid
nitrogen, kerotolytic agents
Avoid intimate contact until lesions heal
Complication: Genital Dysplasia Cancer
What is the difference between HIV Positive—presence of HIV in blood
AIDS and HIV +? 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 opportunistic P. Carinii Pneumonia: sob/dry-nonproductive
infections of AIDS? cough
C. Albicans stomatitis: will have difficulty
swalling and white exudates in back of throat
C. Neoformans: debilitating form of meningitis
that may suffer seizures.
Cytomegalovirus (CMV): will experience
lymphadenopathy and may have visual
impairment and can affect any organ.
Kaposi’s Sarcoma: most common malignancy
experience with AIDS, small purplish brown,
nonpainful, nonpuriitc palpable lesions on the
body.
How is AIDS transmitted? Contaminated blood or body fluids
Sharing IV needles
Sexual contact
Transplacental: across placenta
Possibly by breast milk
What are diagnostics test ELISA test, if positive will be confirmed by
associated with AIDS? Western Blot test
HIV Viral culture: Leukopenia,
Thrombocytopenia, Decrease CD4 counts

What are some nursing cares Prevention: avoid IV drug use, precautions
for AIDS? regarding sexual patterns, use standard
precautions
Contact and standard precautions
High-protein and high-calorie diet, small
frequent meals rather than 3 large meals
Symptomatic relief
Support
Don’t share toothbrush/shavers
What are treatments, care, Prevention most important.
prevention of poison control? Treat patient first, and then the poison.
Recognize signs of symptoms of accidental
poison: changes in appearance, behavior,
substances around mouth, empty containers,
vomitous.
What should happen when Call poison control center.
someone is poisoned? Tell them: substance, time, amount and route
of ingestion, child’s condition, age, weight,
save vomitus, stool, urine.
Why should vomit not be Don’t induce if:
induced? Danger of aspiration, decrease LOC, Ingested
petroleum distillate (lighter fluid, kerosene,
paint remover)
Ingested corrosive (Draino)
What medication treatment is Syrup of Ipecac with small amount of water.
used to induce vomiting and Don’t give large amount of fluid after Ipecac,
what other factors need to be will increase gastric emptying.
implemented? Don’t use milk.
Position with head lower then chest.
No universal antidote.

What should happen to poison Intubated if comatose


control in emergency care? 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 symptoms, Tinnitus, change in mental status, Increased
treatments, care, prevention of temperature, hyperventilation, bleeding,
aspirin poisoning? nausea and vomiting.
Nursing care: induce vomiting, maintain
hydration, reduce temperature (sponge baths),
monitor for bleeding.
What are signs and symptoms, Symptoms: nausea/vomiting, hypothermia, If
treatments, care, prevention of no treatment, hepatic/liver involvement.
tylenol poisoning? If liver gets involved patient may have RUQ
pain, jaundice, confusion, and coagulation
abnormalities.
Nursing care: induce vomiting, maintain
hydration, monitor liver and kidney function
with labs such as AST/ALT enzymes.
Tylenol (Acetaminophen) overdosage:
Antidote N-acetylcysteine (Mucomyst)
What are signs and symptoms, Symptoms: Irritability, decreased activity,
treatments, care, prevention of abdominal pain, Increased ICP
lead toxicity? Diagnostic tests: Blood lead levels
(>9micrograms = toxic), Erythrocyte
protoporphyrin (EP), X-ray long bones (lead
deposits in long bones)
Children engage in PICA (ingesting nonfood
substances)
Lead blocks formation of hemogloblin and toxic
to kidneys.
Nursing care: identify source, chelating agents,
teaching parents
What are nursing care goals for Decontaminate individual
Hazardous wastes? Prevent spread of contamination
Clean and remove contaminuated source
Monitor personnel exposed

What are nursing care for If chemical poses threat to caregiver,


Hazardous wastes? decontaminate patient first.
If chemical poses no threat or patient has been
decontaminated, begin care.
If immediate threat to life, put on protective
garments and provide care to stabilize patient.
What type of play do infants (0- Solitary play. Game is one sided. Like to play
12months) use? with body parts.
Birth-3months: smile/squeal
3-6months: rattles/soft stuff toys
6-12 months: begin imitation, peek-a-boo,
patty-cake

Play of toddlers (1-3 years) Parallel play.


Play of pre-schoolers (3-6years) Associative play. Dress up/imitating play.
Talking on telephone/kitchen/tool belt
Play 0f school age (6-12years) Cooperative play. Conformed/organized play.
According to Erikson’s Birth-18 months.
Developmental Task, explain Trust vs. Mistrust
the Infancy stage. Positive outcome---trusts self
Negative outcome---withdrawn
According to Erikson’s 18months – 3 years
Developmental Task, explain Autonomy vs. Shame and Doubt
the Toddler stage. Positive outcome---exercise self-control
Negative outcome---defiant and negative
According to Erikson’s 3-6 years
Developmental Task, explain Initiative vs. Guilt
the Preschool stage. Children develop conscience at this age.
Positive Outcome---learns limits
Negative Outcome---fearful, pessimistic
According to Erikson’s 6-12years
Developmental Task, explain Industry vs. Inferiority
the School age stage. Positive---sense of confidence
Negative---self doubt, inadequate
According to Erikson’s 12-20 years
Developmental Task, explain Identity vs. Role diffusion
the Adolescence stage. Positive outcome---coherent sense of self
Negative outcome---lack of identity
According to Erikson’s 20-45 years
Developmental Task, explain Intimacy vs. Isolation
the young adult stage. Positive outcome---intimate
relationships/careers formed
Negative outcome---avoidance of intimacy
According to Erikson’s 45-65 years
Developmental Task, explain Generativity vs. Stagnation
the middle adulthood stage. Positive Outcome---creative and productive
Negative Outcome---self centered
According to Erikson’s 65+ years
Developmental Task, explain Integrity vs. Despair
the Late adulthood stage. No regrets in life or Regrets
Positive outcome---seems life as meaningful
Negative outcome---life lacks meaning
At what month does the head 1 month
sag?
At what month do you see 2 months
closing of posterior fontanelle,
turn from side to back, and see
a social smile?
What toys do you give for a 2 Mobiles, wind up infant swings, soft clothes,
month old? and blankets.
At what month does a child 3 months
bring objects to mouth and
head erect?

What toys do you give for a 4 Rattles, cradle gym, and stuffed animals
month old?
Which age does birth weight 5 months
double?
At what age does teething 6 months
occur?
What toys do you give for a 6 Brightly colored, small enough to grasp, large
month old? enough for safety, teething toys
What age for fears of 7 months
strangers? When is fear 8 months is stronger
strongest?
Which month able to play peek- 7 months
a-boo?
What toys do you give for 7- Large colored, bricks, jack in the box
8months?
What month can a child say 9 month
“DADA?
What month can a child crawl 10 months
well?
What month can a child stand 11 months
erect with support?
What happens in the 12th month Birth weight triples.
of the child? Eats with fingers.
Anterior Fontanelle almost close.
Babinski reflex disappears.
Toys: books with large pictures, push pull toys,
teddy bears, a large ball, or sponge toys.

Explain introduction of solid One food at a time.


foods. Begin with least allergenic foods first.
• Cereal is usually first. (Do not use
cow’s milk/whole milk. After six months
of age cereal can be mixed with fruit
juices. Fruit juices should be offered in
a cup to prevent dental carries.)
• Vegetables
• Fruits
• Potatoes
• Meats
• Eggs
• Orange Juice
• By 12 months children should be eating
table food. Don’t give honey under 12
because of botulism.
What does a toddler do at 15 Walks alone.
months? Throws object.
Holds spoon.
Say 4-6 words. Understand simple commands.
What does a toddler do at 18 Anterior fontanelle closes.
months? Climbs stairs.
Sucks thumb.
Say 10 + words.
Temper Tantrums.
What does a toddler do at 24 300 world vocabulary.
months? Obeys easy commands.
Go up/down stairs alone.
Build towers.
Turn doorknobs/unscrew lids.
Increase independence.
What does a toddler do at 30 Walk tip toe.
months? Stand on one foot balance.
Has control for sphincter training.
Birth weight quadrupled.
State first/last name.
Give simple commands.
What type of toys are included Cooking utensils, Dress-up clothes, rocking
for Toddlers? horses, finger paints, phonographs, cd players.
How do you avoid negativism Don’t ask no/yes questions.
during toddler ages? Offer them choices.
Make a game out of the tasks.
What can a 3 year old do? Rides tricycle.
Undresses without help.
May invent imaginary friend.
Vocabulary 900 words.
Egocentric in thoughts/behaviors.
What can a 4 year old do? Laces shoes
Brushes teeth
Throws overhand
Uses sentences.
Independent
What can a 5 year old do? Runs well/Dresses without help.
Beginning cooperative play.
Gender-specific behavior.
What toys are used for Playground materials, Housekeeping toys,
preschool (3-5)? Coloring books, tricycle with helmet.
Which age groups has greatest Preschool age children.
number of fears?
What would you expect with a 6 Self-centered, show off, rude
year old? Sensitive to criticism
Begins loosing temporary teeth
Tends to lie.
What would you expect with a 7 Team games/sports.
year old? Concept of time.
Playing with same sex child.
What would you expect with a 8 Seeks out friends.
year old? Writing replaces printing.
What would you expect with a 9 Conflicts between peer groups and parents.
year old? Conflicts between independence and
dependence.
Likes school.
Able to take on job duties (housework).
What toys are used for school Construction toys, Pets, Games, Electronic
age child? games, reading, books, bicycles with helmets.
School age potential problems Anuresis (encourage before bed time)
include: Encopresis
Head lice
What are symptoms/indications Thin upper lip, vertical ridge in upper lip, short
of a fetal alcohol syndrome in a up turned nose, mental retardation, motor
child? retardation, hearing disorders, microcephaly.
Avoid alcohol 3 months before conception and
throughout pregnancy.
What happens with 16th week detects genetic abnormality
amniocentesis? What does it 30th week detects L/S ratio: lung maturity
do? Void before procedure
Ultrasound given to determine position of
placenta and fetus.
Complications: premature labor, infection, Rh
isommunization (if client Rh negative, will be
given Rhogam)
What happens with an 5th week confirms pregnancy
ultrasound? Determines position of fetus, placenta, and #
of fetuses.
Client must drink a lot of fluid before procedure
for full bladder to have a clear image.
What happens with a non- At 28th week records FHR and fetal movement.
stress test? Favorable result: 2+ FHR accelerates by
15bpm and last 15seconds in 20 minutes.
What happens with a Determines placenta’s response to labor.
contraction stress test? Done after 28th week.
Fowler/Semi-Fowler.
Given Oxytocin or Pitocin.
Results:
• Positive: Late decelerations indicates
potential risk to fetus.
• Negative: No late decelerations.
What does Torch stand for? And Diseases that cross placenta or other events.
their importance? Produce significant deformities or infant born
with infectious process.
Toxoplasmosis: no litter box changed, no
gardening, no under cooked meats.
Rubella: 1-16 titer immune for rubella, titer <1-
8 susceptible.
Cytomegalovirus: transmitted in body fluids.
Herpes Simplex: Ascending infection. During
pregnancy get treated with acyclovir. Delivery
through c-section.
What concerns for clients that UTI: may lead to pylonephritis, increase risk of
have UTI, Syphilis, Gonorrhea? premature birth.
Syphillis: passes through placenta, causes 2nd
trimester abortions, still birth, and congenital
infection, may receive medication for her and
her baby.
Gonorrhea: baby gets prophylactic eydrops.
What are the danger signs of • Gush or fluid bleeding from vagina
pregnancy? • Regular uterine contractions
• Severe headaches, visual disturbances,
abdominal pain, persistent vomiting
(symptoms of PIH)
• Fever or chills (symptoms of infection)
• Swelling in face or fingers (symptoms of
PIH)
What are the events in the Lightening: (when baby drops to pelvis)
onset of labor? • 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.
How does prolapsed umbilical Premature rupture of membranes.
cords happen? Presenting part not engaged.
Fetal distress.
Protruding cord.
What do you do when a client Call for help.
has a prolapsed cord? Push up against presenting part off of the cord.
Place in trendenlenberg position or knee chest
position.
Successful if FHT left unchanged.
What is a early/sign of fetal Early sign: fetal tachycardia >160 in
hypoxia? >10minutes
Late sign: fetal bradycardia <110 in > 10
minutes
What things should you know Nurse can witness patient sign form.
about the Informed Consent Patient has to be age of capacity/adult and
form? confident. No confused
patient/drinking/already received preoperative
medications.
Consent must be given voluntarily and
information understandable. Nurse must make
sure questions are answered and form is
attached to chart.
What is early deceleration? Decrease in HR before peak of contraction.
Indication of head compression.

What are interventions for late Position mother left side/trendenlenberg/knee


decelerations? chest
Increase rate of IV
Administer Oxygen 7-10 l/min
DC Oxytocin
What do variable decelerations Cord compression.
indicate? Change maternal position.
Administer oxygen.
DC Oyxtocin/Pitocin
What are signs of “True Regular contractions increasing in frequency,
Labor”? duration, intensity
Discomfort radiates from back
Contractions do not decrease with rest
Cervix progressively effaced and dilated.
What are characteristics of a Irregular contractions, no change in frequency,
“False Labor”? duration, intesityDiscomfort is abdominal
Contractions decrease with rest or activity
No cervical changes
Prior to Lumbar Epidural block Void
what should the patient do?
What should be implemented Establish airway
during the delivery of a Check Apgar at 1 and 5 minutes
newborn? Clamp umbilical cord
Maintain Warmth
Place ID band on mother and infant
What are the types of Lochia? Rubra-bloody, day 1-3
Serosa-pink-brown, day 4-9
Alba-yellow-white, 10+ days
If fundus is displaced not Bladder distended.
centrally and off to the sides
means?
If client soaks pad in 15 Check for hemorrhage
minutes or pooling of blood?
What are assessments and Unilateral lower quadrant pain.
implementations for an Rigid, tender abdomen
“Ectopic Pregnancy”? Low Hct and hCG levels
Bleeding
Monitor for shock
Administer RhoGAM
Provide support
What are assessments and A placenta that’s implanted in the lower
implementations for “Placenta uterine segment near cervical os, during
Previa”? pregnancy placenta is torn away causing:
First and second trimester spotting
Third and trimester painless, profuse
bleeding
Bedrest side-lying or trendelenburg position,
ultrasound to locate placenta, no vaginal or
rectal exams, amniocentesis for lung maturity,
daily Hgb, Hct, Monitor bleeding
What are the assessments and The premature separation of a placenta that is
implementation for “Abruptio implanted in a correct position.
Placentae”? Painful vaginal bleeding
Abdomen tender, painful, tense
Possible fetal distress/Contractions
Monitor for maternal and fetal distress
Prepare for immediate delivery
Monitor for complications: DIC, pulmonary
emboli
What are assessments and Hyperglycemia after 20 weeks
implementations for Usually controlled by diet
Gestational Diabetes Mellitus Oral hypoglycemic medications contraindicated
(GDM)? Test for diabetes at 24-28 weeks on all women
with average risk 20.
Frequent monitoring of mother/fetus during
pregnancy.
Teach to eat prescribed amount of food daily at
same times
Home glucose monitoring
Teach about change in insulin requirements
What are assessments and Elevated hCG
implementation for a Uterine size larger than expected for dates
Hydatidiform Mole? 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
What are the newborn vital Temp. 97.7-99.7
signs? HR sleep 100, awake 120-140, 180 crying
Resp 30-60
BP arm/calf 65/41
What are assessments and Caused by immature hepatic function
implementation for Physiological Jaundice (No treatment required)
Hyperbilirubinemia? • 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

What are assessments and Assessments


implementations for a Narcotic- • High-pitched cry (Hallmark sign)
Addicted infant? • Hyperreflexia
• Decreased sleep
• Tachypnea (>60/min)
• Frequent sneezing and yawning
• Seen at 12-24 hours of age, up to 7-10
days
Implementation
• Reduce environmental stimuli
• Administer Phenobarbital,
chlorpromazine, diazepam, paregoric
• Wrap snugly, rock, and hold tightly
• Assess muscle tone, irritability, vital
signs.
What are the assessments and Sudden-onset fever
implementations of Toxic Shock Vomiting, diarrhea
Syndrome? Hypotension
Erythematous rash on palms and soles
Administer antibiotics
Educate about use of tampons (change tampon
Q3-Q6 hours)
What are contraindications to Immunization is a primary prevention
Immunizations? Severe febrile illness
Altered immune system
Previous allergic response
Recently acquired passive immunity
What are assessments and Assessment
implementations for a “Latex Urticaria, rash
Allergy”? Wheezing, Rhinitis, Conjunctivitis,
Bronchospasms
Anaphylactic shock
Implementation
Screen for sensitivity
Avoid latex products: gloves, catheters, brown
ace bandages, band aid dressing, elastic
pressure stockings, balloons, condoms
What are implementations for Steamy shower
Croup syndromes at home? Exposure to cold air
Cool, humidified air

Universal Donor Blood: Packed red blood cells (help oxygen deliver to tissue, if you
use whole blood there will be a risk for fluid overload), type O, Rh-negative

5% Sodium Bicarbonate—metabolic alkalosis solution

Older adults are asymptomatic when they have an infection and can lead to
confusion.

Mononucleosis: complication enlarged spleen; concerned for trauma if child plays


dangerous sport.

Lyme disease:found mainly in mid alantic states (Connecticut)

Pottery is unglazed can lead to “Lead Toxicity”


Apgar Score: normal 7-10

WBC after pregnancy?

Ampicillin decreases oral contraceptives efficiency.

Tricuspid area: 5th intercostals space in the left sternum area

Tracheostomy care: no powder, suction trachea first then mouth, use pre-cut gauze.

Hip-Flexion: causes increased intra-abdominal/thoracic pressure.

Injury C3 and above need respiratory ventilation.

SIADH causes: lung cancer, Cisplatin (Platinol)

Chest Tubes
• Fill water-seal chamber with sterile water to 2 cm (middle chamber)
• Fill suction control chamber with sterile water to 20 cm (chamber all the way
to the right)
• Air-leak if bubbling in water-seal chamber (middle chamber)
• Obstruction: “milk” tube in direction of drainage
• Removal o chest tube: pt. does valsalva maneuver, clamp chest tube, remove
quickly, apply occlusive dressing
• Dislodged: apply tented dressing
• Tube becomes disconnected from drainage system, cut off contaminated tip,
insert sterile connector and reinsert
• Tube becomes disconnected from drainage system, immerse in 2cm of water

Jackson-prat: Notify physician if drainage increases or becomes bright red

Penrose: Expect drainage on dressing

Tracheostomy Tube Cuff


• Prevents aspiration of fluids/separates upper and lower airways
• Inflated during continuous mechanical ventilation
• Inflated during and after eating
• Inflated during and 1 hour after tube feeding
• Inflated when patient cannot handle oral secretions

• NCLEX-RN exam is a “here and now” test; take care of problem now to
prevent harm to client.
• Do not ask “why” on the licensure exam
• Morphine Sulfate for pancreatitis causes spasms of the sphincter of Oddi;
Meperidine is drug of choice.
• Normal Intraocular Pressure is 10-21 mm Hg
• Ecchymosis (faint discoloration) around the umbilicus or in either flank
indicates retroperitoneal bleeding

The parenteral form of Chlorpheniramine Maleate is use to relieve symptoms of


anaphylaxis allergic reactions to blood or plasma.

Herbs: Toxicities and Drug Interactions

Chamomile

Uses: Chamomile is often used in the form of a tea as a sedative.

Reactions: Allergic reactions can occur, particularly in persons allergic to ragweed.


Reported reactions include abdominal cramps, tongue thickness, tightness in the
throat, swelling of the lips, throat and eyes, itching all over the body, hives, and
blockage of the breathing passages. Close monitoring is recommended for patients
who are taking medications to prevent blood clotting (anticoagulants) such as
warfarin.

Echinacea
Uses: Largely because white blood cells in the laboratory can be stimulated to eat
particles, Echinacea has been touted to be able to boost the body's ability to fight off
infection.
Reactions: The most common side effect is an unpleasant taste. Echinacea can cause
liver toxicity. It should be avoided in combination with other medications that can
affect the liver (such as ketaconazole, leflunomide (Arava), methotrexate
(Rheumatrex), isoniazide (Nizoral).

St. John's Wort

Uses: St. John's Wort is popularly used as an herbal treatment for depression,
anxiety, and sleep disorders. It is technically known as Hypericum perforatum.
Chemically, it is composed of at least 10 different substances that may produce its
effects. The ratios of these different substances varies from plant to plant (and
manufacturer). Studies of its effectiveness by the National Institutes of Health are in
progress.
Reactions: The most common side effect has been sun sensitivity which causes
burning of the skin. It is recommended that fair- skinned persons be particularly
careful while in the sun. St. John's wort may also leave nerve changes in sunburned
areas. This herb should be avoided in combination with other medications that can
affect sun sensitivity (such as tetracycline/Achromycin, sulfa- containing medications,
piroxicam (Feldend). St. John's wort can also cause headaches, dizziness, sweating,
and agitation when used in combination with serotonin reuptake inhibitor
medications such as fluoxetine (Prozac) and paroxetine (Paxil).

Garlic

Uses: Garlic has been used to lower blood pressure and cholesterol (Dr. Lucinda
Miller notes that there is "...still insufficient evidence to recommend its routine use in
clinical practice.")
Reactions: Allergic reactions, skin inflammation, and stomach upset have been
reported. Bad breath is a notorious accompaniment. Studies in rats have shown
decreases in male rats' ability to make sperm cells. Garlic may decrease normal
blood clotting and should be used with caution in patients taking medications to
prevent blood clotting (anticoagulants) such as warfarin /Coumadin.

Feverfew

Uses: Most commonly used for migraine headaches.


Reactions: Feverfew can cause allergic reactions, especially in persons who are
allergic to chamomile, ragweed, or yarrow. Nonsteroidal anti-inflammatory drugs
(NSAIDs such as ibuprofen (Advil), naproxen (Aleve) or Motrin) can reduce the effect
of feverfew. A condition called "postfeverfew syndrome" features symptoms including
headaches, nervousness, stiffness, joint pain, tiredness, and nervousness. Feverfew
can impair the action of the normal blood clotting element (platelets). It should be
avoided in patients taking medications to prevent blood clotting (anticoagulants)
such as warfarin (Coumadin).

Ginko Biloba

Uses: This herb is very popular as a treatment for dementia (a progressive brain
dysfunction) and to improve thinking.
Reactions: Mild stomach upset and headache have been reported. Ginko seems to
have blood thinning properties. Therefore, it is not recommended to be taken with
aspirin, nonsteroidal anti-inflammatory drugs (Advil), naproxen (Aleve) or Motrin), or
medications to prevent blood clotting (anticoagulants) such as warfarin (Coumadin).
Ginko should be avoided in patients with epilepsy taking seizure medicines, such as
phenytoin (Dilantin), carbamazepine (Tegretol), and phenobarbital.

Ginseng

Uses: Ginseng has been used to stimulate the adrenal gland, and thereby increase
energy. It also may have some beneficial effect on reducing blood sugar .in patients
with diabetes mellitus. (Dr. Miller emphasized that there is substantial variation in the
chemical components of substances branded as "Ginseng.")
Reactions: Ginseng can cause elevation in blood pressure, headache, vomiting,
insomnia, and nose bleeding. Ginseng can also cause falsely abnormal blood tests for
digoxin level. It is unclear whether ginseng may affect female hormones. Its use in
pregnancy is not recommended. Ginseng may affect the action of the normal blood
clotting element (platelets). It should be avoided in patients taking aspirin,
nonsteroidal antiinflammatory drugs (such as ibuprofen (Advil), naproxen (Aleve) or
Motrin), or medications to prevent blood clotting (anticoagulants) such as warfarin
(Coumadin). Ginseng may also cause headaches, tremors, nervousness, and
sleeplessness. It should be avoided in persons with manic disorder and psychosis.

Ginger

Uses: Ginger has been used as a treatment for nausea and bowel spasms.
Reactions: Ginger may lead to blood thinning. It is not recommended to be taken with
medications that prevent blood clotting (anticoagulants) such as warfarin
(Coumadin).

Saw Palmetto

Uses: Saw palmetto has been most commonly used for enlargement of the prostate
gland. (Dr. Miller emphasized that studies verifying this assertion are necessary.) Saw
palmetto has also been touted as a diuretic and urinary antiseptic to prevent bladder
infections.
Reactions: This herb may affect the action of the sex hormone testosterone, thereby
reducing sexual drive or performance. Dr. Miller states that "While no drug-herb
interactions have been documented to date, it would be prudent to avoid
concomitant use with other hormonal therapies (e.g., estrogen replacement therapy
and oral contraceptives...")

Black Cohosh

Claims, Benefits: A natural way to treat menopausal symptoms.


Bottom Line: Little is known about its benefits and its risks.

A child with celiac disease mustn’t consume foods containing gluten and therefore
should avoid prepared puddings, commercially prepared ice cream, malted milk, and
all food and beverages containing wheat, rye, oats, or barley.

The infant of a diabetic mother may be slightly hyperglycemic immediately after birth
because of the high glucose levels that cross the placenta from mother to fetus.
During pregnancy, the fetal pancreas secretes increased levels of insulin in response
to this increases glucose amount that crosses the placenta from the mother.
However, during the first 24 hours of life, this combination of high insulin production
in the newborn coupled with the loss of maternal glucose can cause severe
hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia

Stump elevation for the first 24 hours after surgery helps reduce edema and pain
by increasing venous return and decreasing venous pooling at the distal portion of
the extremity.

A platypelloid pelvis has a flat shape. A gynecoid pelvis is a normal female pelvis.
An anthropoid pelvis has an oval shape, and an android pelvis has a heart shape.

The pulse is the earliest indicator of new decreases in fluid volume.

Adult Rickets: deficiency in vitamin D.

Chronic Pain: normal blood pressure, heart rate, and respiratory rate. Normal
pupils and dry skin.

Acute pain: causes increased blood pressure, increased pulse, and respiratory rate,
dilated pupils, and perspiration.

The tip of the endotracheal tube lies 1 cm above the carina. This is positioned
above the bifurcation of the right and left mainstem bronchi.

Creatine Phosphokinase (CPK) is a cellular enzyme that can be fractionated into


three isoenzymes.
 MB band reflects CPK from CARDIAC MUSCLE (This is the level that elevates
with an MI.)
 MM band reflects CPK from SKELETAL MUSCLE
 BB band reflects CPK from the BRAIN

ALKYLATING AGENTS: affect ALL PHASES of the reproductive cell cycle


(i.e., Cyclophosphamide [Cytoxan])

ANTIMETABOLITES: are cell cycle phase-specific and affect the S PHASE


(i.e., Cytarabine [Cytosar])

VINCA ALKALOIDS: are cell cycle phase-specific and act on the M PHASE

Bell’s Palsy: is a one-sided facial paralysis from compression of the facial nerve.
The exact cause is unknown. Possible causes include vascular ischemia, infection,
exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or
a combination of these items.

McBURNEY’S POINT: is midway between the right anterior superior iliac crest
and the umbilicus. This is usually the location of greatest pain in the child with
appendicitis.

MMR: administered SQ in the outer aspect of the upper arm.

Watch for absolute words “NOT” and “ONLY”

AIR EMBOLISM POSITIONING: Place the client on the left side in the trendelenburg
position. Lying on the left side may prevent air from flowing into the pulmonary
veins. The trendelenburg position increases intrathoracic pressure, which decreases
the amount of blood pulled into the vena cava during inspiration.

Trigeminal neuralgia pain medication: Use Carbamazepine (Tegretol) and Phenytoin


(Dilantin). Narcotic analgesics (Meperidine Hydrochloride [Demerol], Codeine
Sulfate , and Oxycodone) are not effective in controlling pain caused by trigeminal
neuralgia.

Grapefruit juice can raise cyclosporine (Sandimmune) levels by 50% to 100%, risk
for toxicity.

Fomepizole (Antizol): an antidote given IV to a client with Ethylene Glycol


(Antifreeze) intoxication

Phenotolamine (Regitine): antidote for hypertensive crisis

Bromocriptine (Parlodel): an antiparkinsonian prolactin inhibitor, is used to treat


NMS.

Biophysical profile: assesses five parameters of fetal activity: fetal heart rate, fetal
breathing movements, gross fetal movements, fetal tone, and amniotic fluid volume.
In a biophysical profile, each of the five parameters contributes 0 to 2 points with a
score of 8 being considered normal and a score of 10 perfect.

G T P A L
Gravidity, the Term births, Preterm Abortions/miscarria Live births,
number of the number births, the ges the number of
pregnancies. born at term number born live births or
(40 weeks). before 40 living children
• Included in
weeks’
gravida if
gestation.
before 20
weeks’
gestation

• Included in
parity if past 20
weeks’
gestation
Therefore a woman who is pregnant with twins and has a child has a gravida of 2.
Because the child was delivered at 38 weeks, the number of preterm births is 1, and
the number of term births is 0. The number of abortions is 0, and the number of live
births is 1.

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,
vagina, 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.

Hyperkalemia on Electrocardiogram:
Tall, peaked T waves; prolonged PR interval; widening QRS complex

Hypokalemia on Electrocardiogram: ST segment depression; Flat T wave

First-Degree Heart Block: Prolonged P-R interval

Bundle Branch Block: Widened QRS complex

Myocardial Necrosis in Area: Q waves present

Ventricular Fibrillation: No visible P waves or QRS complexes, no


measurable rate. Irregular, chaotic undulations of varying amplitudes.

HypoCalcemia: Prolonged Q-T interval

Myocardial Ischemia: ST segment elevation or depression

Premature Ventricular Contractions: absence of P waves, wide and


bizarre QRS complexes, and premature beats followed by a compensatory
pause

Ventricular Tachycardia: absence of P waves, wide QRS complexes,


rate between 100 and 250 impulses per minute. Regular rhythm
Atrial Fibrillation: no P waves; instead there are wavy lines, no PR
interval. QRS duration is WNL and irregular ventricular rate can range from
60-160 beats/minute.

ANGINA
Stable Unstable Variant Intractable
Triggered by a Triggered by an Triggered by Chronic and
predictable amount unpredictable coronary artery incapacitating and
of effort or amount of exertion spasm; the attacks is refractory to
emotion. or emotion and tend to occur early medical therapy.
may occur at night; in the day and at
the attacks rest.
increase in
number, duration,
and severity over
time.

Cardiac Conduction System: Sinoatrial NodeInternodal/Interatrial


pathwaysAV nodeBundle of HisR/L Bundle BranchesPurkinje fibers

Pulse rate is the earliest indicator of decrease in fluid volume.

A1-adrenergic receptors: found in the peripheral arteries and veins and cause a
powerful vasoconstriction when stimulated

A2-adrenergic receptors: several tissues and contract smooth muscle, inhibit


lipolysis, and promote platelet aggregation.

B1: Found in the heart and cause an increase in heart rate, atrioventricular node
conduction, and contractility.

B2: Arterial and bronchial walls and cause vasodilation and bronchodilation.

PULSE PRESENT = NO DEFIBRILLATION

Myxedema (a.ka. Hypothyroidism)

Suggested toys

a. birth to six months - mobiles, unbreakable mirrors, music boxes, rattles


b. six to 12 months - blocks, nesting boxes or cups, simple take apart toys, large
ball, large puzzles, jack in the box, floating toys, teething toys, activity box,
push-pull toys
c. Solitary play

Toddlerhood (one year to three years)

Play is parallel

• Suggested toys: push-pull toys, finger paints, thick crayons, riding toys, balls,
blocks, puzzles, simple tape recorder, housekeeping toys, puppets, cloth
picture books, large beads to string, toy telephone, water toys, sand box, play
dough or clay, chalk and chalkboard

Preschool age (three years to six years)

• Preschool play is associative and cooperative.


• dress-up
• fantasy play
• imaginary playmates
• Suggested toys: tricycle, gym and sports equipment, sandboxes, blocks,
books, puzzles, computer games, dress-up clothes, blunt scissors, picture
games, construction sets, musical instruments, cash registers, simple
carpentry tools
School age (six years to 12 years)
Play is cooperative.

1. sports and games with rules


2. fantasy play in early years
3. clubs
4. hero worship
5. cheating
6. Suggested toys/activities: board or computer games, books, collections,
scrapbooks, sewing, cooking, carpentry, gardening, painting

Tympany: Drumlike, loud, high pitch, moderate duration; usually found over spaces
containing air such as the stomach

Resonance:Hollow sound of moderate to loud intensity; low pitch, long duration;


Usually heard over lungs

Hyperresonance: Booming sound of very loud intensity; very low pitch, long
duration; Usually heard in the presence of trapped air (such as emphysematous
lung)Flatness:

Flat sound of soft intensity; high pitch; short duration; Usually heard over muscle

Dullness:Thud-like sound of soft intensity; high pitch; moderate duration; Usually


heard over solid organs (such as heart, liver)

body temperature

o range: 36 to 38 degrees Celsius (98.6 to 100.4 degrees Fahrenheit)

St. John's wort - antidepressant


Garlic - antihypertensive
Ginseng - Anti stress
Green tea - antioxidant
Echinacea - immune stimulant (6-8 weeks only)
Licorice - cough and cold
Ginger root - antinausea
Ginkgo - improves circulation
Ma huang - bronchodilator, stimulant

Anatomical Landmarks of the HEART

i. second right intercostal space - aortic area


ii. second left intercostal space - pulmonic area
iii. third left intercostal space - Erb's point
iv. fourth left intercostal space - tricuspid area
v. fifth left intercostal space - mitral (apical) area
vi. epigastric area at tip of sternum

Range of Normal Blood Pressure

i. child under age two weighing at least 2700g: use flush technique,30-60mg Hg
ii. child over age two: 85-95/50-65 mm Hg
iii. school age: 100-110/50-65 mm Hg
iv. adolescent: 110-120/65-85 mm Hg
v. adult: <130 mm Hg Systolic / <85 mm Hg diastolic

Normal Range of Peripheral Pulses

• infants: 120 to 160 beats/minutes


• toddlers: 90 to 140 beats/minutes
• preschool/school-age: 75 to 110 beats/ minute
• adolescent/adult: 60 to 100 beats/minute

Normal Rates of Respirations

• newborn: 35 to 40 breaths/minute
• infant: 30 to 50 breaths/minute
• toddler: 25 to 35 breaths/minute
• school age: 20 to 30 breaths/minute
• adolescent/adult: 14 to 20 breaths/minute
• adult: 12 to 20 breaths/minute

CRANIAL NERVE FUNCTION

1. Olfactory (CN I)

• Can identify variety of smells


• Deviation: Inability to identify aroma

2. Optic (CN II)

• Has visual acuity and full visual fields


• Fundoscopic exam reveals no pathology
• Deviation: Inability to identify full visual fields - total or partial blindness of
one or both eyes

3, 4, 6. Oculomotor (CN III), trochlear (CN IV), and abducens (CN VI)

• Follows up to six cardinal positions of gaze


• Pupils are unremarkable
• Exhibits no nystagmus and no ptosis
• Deviation: one or both eyes will deviate from its normal position

5. Trigeminal (CN V)

• Clenches teeth with firm bilateral pressure


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

7. Facial (CN VII)

• Has facial symmetry with and without a smile


• Can raise the eyebrows symmetrically and grimace
• Can shut eyes tightly
• Can identify sweet, sour, salt or bitter on the anterior tongue
• Deviation: Irregular and unequal facial movements
• Deviation: Inability to taste or identify taste
• Deviation: Inability to taste or identify salt, sweet, sour, or bitter substances
on the anterior two-thirds of the tongue
• Deviation: Inability to smile symmetrically

8. Acoustic (CN VIII)

• Can hear a whisper at 1-2 feet


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

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

• Swallows and speaks without hoarseness


• Palate and uvula rise symmetrically when patient says "ah"
• Bilateral gag reflex
• Can identify taste on the posterior tongue
• Deviation: Unequal or absent rise of uvula and soft palate as the client says,
"ah"
• Deviation: Absent gag reflex
• Deviation: inability to taste or identify taste on the posterior tongue

11. Spinal accessory (CN XI)

• Resists head turning


• Can shrug against resistance
• Deviation: Weak or absent shoulder and neck movement

12. Hypoglossal (CN XII)

• Can stick tongue out and move it from side to side


• Can push tongue strongly against resistance
• Deviation: Tongue deviates to side

Types of Coping Mechanisms

1. Compensation - extra effort in one area to offset real or imagined lack in


another area
o Example: Short man becomes assertively verbal and excels in
business.
2. Conversion - A mental conflict is expressed through physical symptoms
o Example: Woman becomes blind after seeing her husband with
another woman.
3. Denial - treating obvious reality factors as though they do not exist because
they are consciously intolerable
o Example: Mother refuses to believe her child has been diagnosed with
leukemia. "She just has the flu."
4. Displacement - transferring unacceptable feelings aroused by one object to
another, more acceptable substitute
o Example: Adolescent lashes out at parents after not being invited to
party.
5. Dissociation - walling off specific areas of the personality from consciousness
o Example: Adolescent talks about failing grades as if they belong to
someone else; jokes about them.
6. Fantasy - a conscious distortion of unconscious wishes and need to obtain
satisfaction
o Example: A student nurse fails the critical care exam and daydreams
about her heroic role in a cardiac arrest.
7. Fixation - becoming stagnated in a level of emotional development in which
one is comfortable
o Example: A sixty year old man who dresses and acts as if he were still
in the 1960's.
8. Identification - subconsciously attributing to oneself qualities of others
o Example: Elvis impersonators.
9. Intellectualization - use of thinking, ideas, or intellect to avoid emotions
o Example: Parent becomes extremely knowledgeable about child's
diabetes.
10. Introjection - incorporating the traits of others
o Example: Husband's symptoms mimic wife's before she died.
11. Projection - unconsciously projecting one's own unacceptable qualities or
feelings onto others
o Example: Woman who is jealous of another woman's wealth accuses
her of being a gold-digger.
12. Rationalization - justifying behaviors, emotions, motives, considered
intolerable through acceptable excuses
o Example: "I didn't get chosen for the team because the coach plays
favorites."
13. Reaction Formation - expressing unacceptable wishes or behavior by
opposite overt behavior
o Example: Recovered smoker preaches about the dangers of second
hand smoke.
14. Regression - retreating to an earlier and more comfortable emotional level of
development
o Example: Four year old insists on climbing into crib with younger
sibling.
15. Repression - unconscious, deliberate forgetting of unacceptable or painful
thoughts, impulses, feelings or acts
o Example: Adolescent "forgets" appointment with counselor to discuss
final grades.
16. Sublimation - diversion of unacceptable instinctual drives into personally and
socially acceptable areas.
o Example: Young woman who hated school becomes a teacher.

Elizabeth Kubler-Ross: Five Stages

1. Denial
a. Unconscious avoidance which varies from a brief period to the
remainder of life
b. Allows one to mobilize defenses to cope
c. Positive adaptive responses - verbal denial; crying
d. Maladaptive responses - no crying, no acknowledgement of loss
2. Anger
a. Expresses the realization of loss
b. May be overt or covert
c. Positive adaptive responses - verbal expressions of anger
d. Maladaptive responses - persistent guilt or low self esteem, aggression,
self destructive ideation or behavior
3. Bargaining
a. An attempt to change reality of loss; person bargains for treatment
control, expresses wish to be alive for specific events in near future
b. Maladaptive responses - bargains for unrealistic activities or events in
distant future
4. Depression and Withdrawal
a. Sadness resulting from actual and/or anticipated loss
b. Positive adaptive response - crying, social withdrawal
c. Maladaptive responses - self-destructive actions, despair
5. Acceptance
a. Resolution of feelings about death or other loss, resulting in peaceful
feelings
b. Positive adaptive behaviors - may wish to be alone, limit social
contacts, complete personal business

FOODS HIGH IN WATER-SOLUBLE VITAMINS

A. Vitamin C - citrus fruits, cabbage, tomatoes, strawberries, broccoli


B. Thiamine (B1) - lean meat, legumes,unrefined or enriched grains and cereals
C. Riboflavin (B2) - enriched grains, milk, organ meats, poultry, fish
D. Niacin - peanuts, peas, beans, meat, poultry
E. Pyridoxine (B6) - kidneys, liver, meats, corn, wheat, eggs, poultry, fish
F. Cyanocobalamin (B12) - kidneys, lean meats,liver, dairy products, egs
G. Folic acid - liver, eggs, leafy green vegetables, fruits, enriched grain products

FOODS CONTAINING FAT-SOLUBLE VITAMINS

A. Vitamin A - fruits, green and yellow vegetables, butter, milk, eggs, liver
B. Vitamin D - milk, fish
C. Vitamin E - green vegetables, vegetables oils, wheat germ, nuts
D. Vitamin K - liver, cheese, leafy green vegetables, milk, green tea

mucomyst: acetaminophen toxicity


Dilantin detoxified by liver.

The nurse cares for a client receiving IV antibiotics every 8 hours for the past 4 days.
The antibiotic is mixed in D5W. The nurse determines that a post-infusion phlebitis
has occurred if which of the following is observed?
1. Tenderness at the IV site.
2. Increased swelling at the insertion site.
3. Area around the IV site is reddened with red streaks.
4. Fluid is leaking around the IV catheter.
a. Tenderness occurs with phlebitis but is not specific to it.
b. May indicate either infiltration or phlebitis
c. 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.

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.

Carbamazepine (Tegretol)—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.

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
bronchioles for steroid to get in. Wait one minute between puffs of the inhalers for
best effect.

Beclomethasone (Vanceril)—a steroid medication. Side effect: fungal infections,


dry mouth, throat infections.

Insulin—NPH Onset: 1.5 hours Peak: 4-12 hours Regular Onset: 0.5
hours Peak: 2.5-5 hours
Topiramate (Topamax)—is an anticonvulsant. Should drink 2000-3000ml of fluid
daily to prevent kidney stones. Side effects: orthostatic hypotension, ocular
symptoms, blindness, and decrease effects of hormonal contraceptives.

Propranolol (Inderal)—a beta-blocker that takes up beta-adrenergic receptor sites,


which prevents adrenaline from causing symptoms and glycogenolysis. Inderal may
mask symptoms of hypoglycemia, removing the body’s early warning system.

Phenazopyridine (Pyridium)—acts on urinary tract mucosa to produce analgesic


or local anesthetic effects. Side effects: bright orange urine, yellowish discoloration
of skin or sclera indicates drug accumulation due to renal impairment.

Trimethoprim-sulfamethoxazole (Bactrim)—most common side effect mild to


moderate rash (urticaria)
Aminoglycosides are ototoxic.
Butorphanol Tartrate (Stadol)—analgesic used for moderate to severe pain; Side
effects include change in BP, bradycardia, respiratory depression.

Infant normal resting heart rate: 120-140

Salt substitutes contain potassium

When directing a UAP, the nurse must communicate clearly about each delegated
task with specific instructions on what must be reported. Because the RN is
responsible for all care-related decisions, only implementation tasks should be
assigned because they do not require independent judgment.

When applying the nursing process, assessment is the first step in providing care.
The 5 "Ps" of vascular impairment can be used as a guide (pain, pulse, pallor,
paresthesia, paralysis)

READ THE QUESTIONS FIRST!!!!!


READ THE QUESTIONS FIRST!!!!!
DETERMINE THE QUESTION!!!!!!

Rash and blood dyscrasias are side effects of anti-psychotic drugs. A history of severe
depression is a contraindication to the use of neuroleptics.

Children with celiac disease should eat a gluten free diet. Gluten is found mainly in
grains of wheat and rye and in smaller quantities in barley and oats. Corn, rice,
soybeans and potatoes are digestible in persons with celiac disease.

The nurse instructs the client taking dexamethasone (Decadron) to take it with food
or milk because Decadron increases the production of hydrochloric acid, which may
cause gastrointestinal ulcers.

The protest phase of separation anxiety is a normal response for a child this age (2
year-old hospitalized child). In toddlers, ages 1 to 3, separation anxiety is at its peak

Signs of tardive dyskinesia include smacking lips, grinding of teeth and "fly catching"
tongue movements.

Verapamil, Bretylium, and Amiodarone increases serum dig levels, possibly causing
Digitalis Toxicity

Signs/Symptoms of Digital Toxicity: first signs include abdominal pain, anorexia,


nausea, vomiting, visual disturbances, bradycardia, and other arrhythmias. In infants
and small children, the first symptoms of overdose are usually cardiac arrhythmias.

Restlessness, confusion, irritability and disorientation may be the first signs of fat
embolism syndrome followed by a very high temperature.

A Neologism is a new word self invented by a person and not readily understood by
another that is often associated with a thought disorder.

Pancreatic enzymes give before meals.

Clinical features of delusional disorder include extreme suspiciousness, jealousy,


distrust, and belief that others intend to harm.

The UAP can be assigned to care for a client with a chronic condition after an initial
assessment by the nurse. This client has no risk of instability of condition.

Never leave your patient. For example, Ask the LPN/LVN to stay with the child and
his parents while the nurse obtains phone orders from the physician.

Tips for charting: don’t use inflammatory words, no nurse judgments, be as specific
as possible. I.E.,
“Vital signs stable” is incorrect for of charting.

Restraint: frame of bed, quick release ties, document need for restraint Q4 hours
Never ask “WHY” questions in the NCLEX!

Gag Reflex: 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. Refer it to nursing supervisor.

If doctor has orders it should carried out unless contraindicated in nurse’s decision.

Physical assessment: Inspection, Percussion, Palpation, Auscultation (Except for


abdomen: Inspection, Auscultation, Percussion, Palpation)

Coronary artery bypass graft (CABG)—halt medications before surgery, can do 5 at a


time; will be on mechanical ventilations after surgery; chest tubes

Acromegaly—monitor blood sugar, atrium—90 implant care (radioactive, nasally


implanted, monitor vision)

Bone marrow Aspiration---done at iliac crest; painful

Postoperative care after Supratentorial surgery: maintain airway, elevate head 30-45

Position care after Infratentorial surgery: flat and lateral

Orange juice does not help acidify urine it makes it more alkaline.

Myelogram
• Water-soluble 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, color, sensation, 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, they can turn to either side.
 If used for fracture treatment, only can turn to unaffected side.
 Use 8-20 lbs of weight, if used for scoliosis will use 40 lbs of weight.
 Elevate head of bed for countertraction or foot bed
 Place pillow below leg not under heel or behind knee.

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, not the leg

Cervical Tongs
 Never lift the weights
 No pillow under head during feedings

Balanced Suspension Traction


 For femur realignment
 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, BKA-foot of bed elevated)
 Position prone daily
 Exercises, crutch walking
 Phantom Pain: acknowledge feelings, that pain is real for them.

Thiamin (Vit. B1)—carbohydarte metabolism; deficiency will cause Beri-Beri

Pyridoxine (Vit. B6)—amino acid metabolism; deficiency will cause anemia, seizures

Folic acid—RBC formation; deficiency will cause anemia

Cyanocobalamin (B12)—nerve function; 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, 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, vomiting occurs decrease rate of enteral feeding or keep it warm.

TPN—supply nutritions via intravenous route


 Peripherally or centrally
 Initial rate 50/hour and can be increased to 100-125ml/hour.
 A pump must be used to keep rate constant
 Prevent sepsis: maintain closed system,, don’t draw blood/infuse anything in
line, dry sterile dressing
 Verify placement of line
 Monitor Glucose, acetone
 Change IV tubing/Filter Q24 hours
 Solution refrigerated then warmed
 If solution not available, start 10% in water.
 3/week check BUN, electrolytes (ca, mg)
 When TPN Dc’d taper patient off or else will get rebound hypoglycemia (use
hypotonic to do this)

Specific gravity 1.010-1.030


Ph 4.5-8
1,000-1,500cc/day

Crede’s Manuever—push urine out

Pernicious Anemia
- monthly Vitamin B12 IM injections

Metered dose inhaler


- Beclomethasone (Vanceril)
- Albuterol (Proventil)

Guillain-Barre Syndrome
- GBS often preceded by a viral infection as well as immunizations/vaccinations
- Intervention is symptomatic
- Acute phase: Steroids, plasmapheresis, aggressive respiratory care; prevent
hazards of immobility, maintain adequate nutrition; physical therapy; pain-
reducing measures; eye care, prevention of complications (UTI, aspiration);
psychosocial support

Organ Donation Criteria


- No history of significant, disease, process in organ/tissue to be donated
- No untreated sepsis
- Brain death of donor
- No history of extracranial malignancy
- Relative hemodynamic stability
- Blood group compatibility
- Newborn donors must be full term (more than 200g)
- Only absolute restriction to organ donation is documented case of HIV
infection
- Family members can give consent
- Nurse can discuss organ donation with other death-related topics (funeral
home to be used, autopsy request)

Accurate way to verify NG tube position is to aspirate for gastric contents and check
pH.

Parkinson’s disease
- Activities should be scheduled for late morning when energy level is highest
and patient won’t be rushed
- Symptoms: tremors, akinesia, rigidity, weakness, “motorized propulsive gait,
slurred monotonous speech, dysphagia, drooling, mask-like expression.
- Nursing care: encourage finger exercises. Administer Artane, Congentin, L-
Dopa, Parlodel, Sinemet, Symmetrel.
- Teach: ambulation modification
- Promote family understanding of disease intellect/sight/hearing not impaired,
disease progressive but slow, doesn’t lead to paralysis

Normal urine output (1200-1500 cc’s/day or 50-63 cc/hr, normal voiding pattern 5-6
times/day.

Green leafy vegetables contain vitamin K.

Labs

HbA1c (4.5-7.6%)
- indicates overall glucose control for the previous 120 days

Serum Amylase / Somogyl (60-160 u/dL)


- elevated in acute pancreatitis

Erythrocyte Sedimentation Rate (ESR)


- Men (1-15)
- Women (1-20)
- Rate at which RBC’s settle out of unclottted blood in one hour
- Indicates inflammation/neurosis

Hematocrit (Hct)
- Men (40-45) u/mL
- Women (37-45) u/mL
- Relative volume of plasma to RBC
- Increased with dehydration
- Decreased with volume excess

Creatine Kinase (CK)


- Men (12-70)
- Women (10-55)
- Enzyme specific to brain, myocardium, and skeletal muscles
- Indicates tissue necrosis or injury

Serum Glucose
- 60-110 mg/dL

Sodium (Na+)
- 135-145 mEq/L
- Hypernatremia
o Dehydration and insufficient water intake

Chloride (Cl-)
- 95-105 mEq/L

Potassium (K+)
- 3.5-5.0 mEq/L

Bicarbonate (HCO3)
- 22-26 mEq/L
- Decreased levels seen with starvation, renal failure, diarrhea.

Blood, Urea, Nitrogen (BUN)


- 6-20 mg
- Elevated levels indicate rapid protein catabolism, kidney dysfunction,
dehydration

Creatinine Clearance Test


- normal 125 ml/min.
- Lower levels reflect renal insufficiency and may influence the excretion of
many drugs and toxins from the body.

Lithium
- targeted blood level: (1-1.5 mEq/L)

Tofranil and Anafranil—OCD medications

Pick physical needs over psychosocial needs!!!!!!!!!!!!!!!

Focus on here and now!!!!!!!!!!!!!!!!!

Oculogyric crisis: uncontrollable rolling back of eyes: side effect of Phenothiazines


Moribund means dying patient.

Don’t leave your patients. Stay with your patients.

Assess before implementation.

Manic patient: decrease stimuli and increase rest period and no competition.

Lithium helps control impulsive behaviors.

Fluphenazine (Prolixin): antipsychotic medication

Thiamine sources: organ meats, liver, whole grain, nuts, legume, egg, and milk.
Don’t document abuse. Report suspected abuse to nursing supervisor.

Never promise a patient “Not to tell.”

Tonometry—measures intraocular pressure; to rule out glaucoma

Myopia—nearsightedness (near clear, distance clear)

Hyperopia—farsightedness (distance is clear, near vision blurry)

Presbyopia—changes with aging

Blind client: address by name, introduce self, keep furniture arrangement consistent,
open or close doors walk ½ step ahead, identify food location on tray.

Instilling ear drops lie patient on unaffected ear to absorb drops.

Position patient on affected ear to promote drainage.

Regular Insulin only given IV.

Sick day rules: take insulin as ordered, check blood glucose q3-4 hours, soft foods,
liquids

Phenylketonuria—high blood phenylalanine (no enzyme), results in mental


retardation; milk substitutes, low-protein diet

Celiac Disease (SPrue)—intestinal malabsorption, malnutrition (unable to digest


wheat/rye/oats/barley); gluten-free diet

Hepatobiliary disease—decrease in ability of bile to absorb fat, fat malabsorption;


low-fat high-protein diet, vitamins

Cystic fibrosis—absence of pancreatic enzymes, malabsorption of fat, lung disease,


pancreatic enzyme replacement, high-protein, high-calorie diet, respiratory
care/suction

Position right side to promote gastric emptying.

Dumping syndrome prevention: restrict fluid with meals, lie down after eating, small,
frequent meals, low-carbohydrate, low-fiber diet

Sengstaken-Blakemore Tube—to treat pt. with esophageal varices.


Hepatitis B Vaccine MMR (Mumps, Measles, and Rubella)
Given IM to vastus lateralis or deltoid Given SC anterior or lateral thigh
Side effects: mild tenderness at site Side effects: rash, fever, arthritis in 10
• 1st shot – Birth to 3 months days to 2 weeks.
• 2nd shot – 1 to 4 months • 1st shot – 12 to 18 months
• 3rd shot – 6 to 18 months • 2nd shot – 4 to 6 years

DTaP (Diptheria, Tetanus, and Pertussis) Varicella (Chickenpox)


Given IM anterior or lateral thigh • 12 to 18 months
Side effects: fever within 24-48 hours,
swelling, redness, soreness PCV (Pneumococcal)
Don’t treat with aspirin, use other • 1st shot – 2 months
antipyretic. • 2nd shot – 4 months
• 1st shot – 2 months • 3rd shot – 6 months
• 2nd shot – 4 months • 4th shot – 12 to 18 months
• 3rd shot – 6 months
• 4th shot – 15 to 18 months TB
Given intradermal
• 5th shot – 4 to 6 years
Evaluated in 48 to 72 hours
• Only TD shot – 11 to 16 years
TD
Given IM into anterior or lateral thigh
Hib (Influenza)
Repeated every 10 years
• 1st shot – 2months
• 2nd shot – 4months Live attenuated Rubella
• 3rd shot – 6 months Given once SC into anterior or lateral
thigh
• 4th shot – 12 to 18 months Given to antibody-negative women
Prevent pregnancy for 3 months after
IPV (Inactive Polio Vaccine) receiving immunization
Given PO, Few side effects
• 1st shot – 2 months Live attenuated mumps
• 2nd shot – 4 months Given once SC
• 3rd shot – 6 to 18 months Prevents orchitis
• 4th shot – 4 to 6 years

Normal Vital Signs

Newborn
• Pulse 120-160 bpm, increases with crying
• Respirations 30-50/min, diaphgramatic (abdomen moves), can
be irregular
• BP 60/40 – 80/50 mmHg

1-4 year old


• Pulse: 80-140
• Resp: 20-40
• BP: 90-60 – 99/65

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 5th Intercostal Space

Mitral Valve (Point of Maximal Impulse): Left of Sternum Mid-Clavicular Line at the 5th
Intercostal Space

Erbb’s Point: Left of Sternum at the 3rd intercostal space

Infant (Point of Maximal Impulse): Lateral to sternum 4th intercostals space

Obese person choking use Chest Thrusts.

Tracheostomy tube placement of cuff maintained to prevent aspiration

Care for patient first, equipment second


Signs for hypoxia: restlessness, tachycardia

CPR: Shake, shout, summon help, open airway, look, listen, feel for signs of
breathing, pinch nose, give 2 full breaths (if no rise, reposition)

Adults 12/min check carotid, chest compressions 80-100/min 1.5 inches


Infants 20/min check brachial pulse, chest compression 100/min ½ - 1 inch

15:2 Adult 4 cycles


Infant 20 cycles
Reassess pulse and breathing
Continue CPR until:
• Victim responds
• Someone else takes over
• Victim is transferred
• Rescuer is unable to continue
MI Implementation for MI
• Chest pain radiating to arms, jaw,
neck (which is unrelieved by rest • Thrombolytic therapy-
or nitroglycerin) streptokinase, t-PA
• Dyspnea • Bedrest
• Indigestion • Beta-blockers, morphine sulfate,
• Apprehension dysrhythmics, anticoagulants
• Low grade fever • Do not force fluids (will give heart
• Elevated WBC (5-10, ESR, CK-MB, more to work with)
LDH)

Defibrillation
• Start CPR first
• 1st attempt – 200 joules
• 2nd attempt – 200 to 300 joules
• 3rd attempt – 360 joules
• Check monitor between shocks for rhythm

Cardioversion
• Elective procedure, Informed Consent
• Valium IV
• Synchronizer on
• 25-360 joules
• Check monitor between rhythm
Epidural hematoma – short period of unconsciousness, ipsilateral papillary dilation,
contralateral weakness of extremities

Subdural hematoma – decreased LOC, ipsilateral papillary dilation, contralateral


weakness of extremities, personality changes

CSF leakage – good place to look is behind the ears.

Head Injury – elevate bed 30 degrees, barbiturate therapy, hypothermia,


glucocorticoids (Decadron)

Flail Chest Sucking Chest Wound Pneumothorax Implementati


Affected side (Sucking Open Collapse of lung due to on
goes down Pneumothorax) alteration of air in Monitor for
during • Sucking sound intrapleural space shock
inspiration with respiration • Dyspnea Humidified
and up during • Pain • Pleuritic pain oxygen
expiration • Decreased • Restricted Thoracentesis
breath sounds movement on (aspiration of
• Anxiety affected side fluid from
• Decreased/absent pleural space)
breath sounds Chest Tubes
• Cough
• Hypotension

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, rapid respirations
• Oliguria

Hypovolemic Cardiogenic Distributive


Decreased in intravascular Decreased cardiac Problem with blood flow to
volume output cells

Implementation for shock


• Monitor CVP: <3 inadequate fluid >11 too much fluid

Increased ICP Implementations


Assessments • Monitor vital signs
• Altered LOC (Earliest Sign) • Monitor Glasgow Coma Scale
• Glasgow coma scale <7 indicates • Elevate head 30-45 degrees
coma • Avoid neck flexion and head rotation
• Confusion • Reduce environmental stimuli
• Restlessness • Prevent Valsalva maneuver
• Pupillary changes • Restrict fluids to 1200-1500 cc/day
• Vital sign changes – WIDENING • Medications – Osmotic diuretics,
PULSE PRESSURE corticosteroids

Seizures:
 do not restrain
 do not insert anything in mouth
Electrolytes
Potassium: 3.5-5.0 mEq/L
Sodium: 135-145 mEq/L
Calcium: 4.5-5.2 mEq/L
Magnesium: 1.5-2.5 mEq/L
Hypokalemia Assessments Hypokalemia Implementations
• K+ < 3.5 mEq/L • Potassium Supplements
• Muscle weakness • Don’t give > 40 mEq/L into peripheral IV or
• Paresthesias without cardiac monitor
• Dysrhythmias • Increase dietary intake – oranges, apricots,
• Increased sensitivity to beans, potatoes, carrots, celery, raisins
digitalis

Hyperkalemia Assessments Hyperkalemia Implementations


• K+ >5.0 mEq/L • Restrict oral intake
• EKG changes • Kayexalate
• Paralysis • Calcium Gluconate and Sodium
• Diarrhea Bircarbonate IV
• Nausea • Peritoneal or hemodialysis
• Diuretics

Hyponatremia Assessments Hyponatremia Implementations


• Na+ < 135 mEq/L • I&O
• Nausea • Daily weight
• Muscle cramps • Increase oral intake of sodium rich
• Confusion foods
• Increased ICP • Water restriction
• IV Lactated Ringer’s or 0.9% NaCL

Hypernatremia Assessments Hypernatremia Assessments


• Na+ >145 mEq/L • I&O
• Disorientation, delusion, • Daily Weight
hallucinations • Give hypotonic solutions: 0.45%
• Thirsty, dry, swollen tongue NaCl or 5% Dextrose in water IV
• Sticky mucous membranes
• Hypotension
• Tachycardia

Hypocalcemia Assessments Hypocalcemia Implementations


• Ca+ < 4.5 mEq/L • Oral calcium supplements with
• Tetany orange (maximizes absorption)
• Positive Trousseau’s sign • Calcium gluconate IV
• Positive Chvostek’s sign • Seizure precautions
• Seizures • Meet safety needs
• Confusion
• Irritability, paresthesias

Hypercalcemia Assessments Hypercalcemia Implementations


• Ca+> 5.2 mEq/L • 0.4% NaCl or 0.9% NaCl IV
• Sedative effects on CNS • Encourage fluids (acidic drinks:
• Muscle weakness, lack of cranberry juice)
coordination • Diuretics
• Constipation, abdominal pain • Calcitonin
• Depressed deep tendon reflexes • Mobilize patient
• Dysrhythmias • Surgery for hyperparathyroidism

Hypomagnesemia Assessments Hypomagnesemia Implementations


 Mg+< 1.5 mEq/L  Monitor cardiac rhythm and
 Neuromuscular irritability reflexes
 Tremors  Test ability to swallow
 Seizures  Seizure precautions
 Tetany  Increase oral intake—green
 Confusion vegetables, nuts, bananas,
 Dysphagia oranges, peanut butter, chocolate

Hypermagnesemia Assessments Hypermagnesemia Implementations


 Mg + > 2.5 mEq/L  Discontinue oral and IV
magnesium
 Hypotension  Monitor respirations, cardiac
 Depressed cardiac impulse rhythm, reflexes
transmission  IV Calcium to antagonize
 Absent deep tendon reflexes cardiac depressant activity (helps
 Shallow respirations 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  Medicate patient before


 Never break blisters wound care
 Isotonic fluids (Lactated Ringer’s)  Silver nitrate (warn patient
 Closed method (Silvadene) skin will turn black)
covered with dressings  High calorie, High
 Open method (Sulfamylon) that carbohydrate, High protein
are not covered with dressings diet
 IV pain medication initially: not PO  Vitamin B,C, and Iron
takes too long, not IM circulation  TPN maybe
impaired  Prevent contractures

Addisson’s Disease Assessments Addisson’s Disease Implementations


 Fatigue  High protein, High carbohydrate,
 Weakness high Sodium, Low potassium diet
 Dehydration  Teach life-long hormone
 Eternal tan replacement
 Decreased resistance to stress
 Low Sodium
 Low Blood Sugar
 High Potassium
Addisonian Crisis Assessments Addisonian Crisis Implementations
• Hypotension • Administer NaCl IV, vasopressors,
• Extreme weakness hydrocortisone
• Nausea vomiting • Monitor vital signs
• Abdominal pain • Absolute bedrest
• Severe hypoglycemia
• Dehydration

Cushing’s Syndrome Assessments Cushing’s Syndrome


• Osteoporosis Implementations
• Muscle wasting • Low Carbohydrate, Low Calorie,
• Hypertension High Protein, High Potassium,
• Purple skin striations Low sodium diet
• Moon face • Monitor glucose level
• Truncal obesity • Postop care after adrenalectomy
• Decreased resistance to infection or hypophysectomy

Pheochromocytoma Assessments— Pheochromocytoma Implementations


hypersecretions of the catecholamines • Histamine Test, Regitine Test, 24-
(epinephrine/norepinephrine) hour urine VMA test
• Persistent hypertension • Avoid emotional and physical
• Hyperglycemia stress
• Pounding headache • Encourage rest
• Palpitations • Avoid coffee and stimulating foods
• Visual disturbances • Postop care after adrenalectomy
and medullectomy

COPD Assessments COPD Implementations


• “Blue Bloaters” • Assess airway clearance
• “Pink Puffers” • Listen to breath sounds
• Weakness • Administer low-flow oxygen (1-2 L,
• Change in postured day and hs not too much because your trying
(don’t sleep laying down, have to to prevent CO2 narcosis)
stay erect) • Encourage fluids
• Use of accessory muscles of • Small frequent feedings
breathing • Use metered dose inhalers (MDI)
• Dyspnea
• Cough
• Adventitious breath sounds

Pneumonia Assessments Pneumonia Implementations


• Fever • Check breath sounds
• Leukocytosis • Cough and deep breath q 2 hours
• Productive Cough (rust, green, • Chest physiotherapy
yellow) • Antibiotics
• Dyspnea • Incentive spirometer
• Pleuritic pain • Encourage fluids
• Tachycardia • Suction PRN
• Provide oxygen
• Semi-Fowler’s position
• Bedrest
• Medications—mucolytics
(Mucomyst), expectorants
(Robitussin), Bronchodilators
(Aminophylline), Antibiotics
(Bacterim)

Acyanotic Congenital Heart Cyanotic Congenital Heart Anomalies


Anomalies Assessments Assessments
• Normal Color • Cyanosis
• Possible exercise intolerance • Clubbing of fingers
• Small stature • Seizures
• Failure to thrive • Marked exercise intolerance
• Heart murmur • Difficulty eating
• Frequent respiratory Infections • Squat to decrease respiratory
distress
• Small stature
• Failure to thrive
• Characteristic murmur
• Frequent respiratory infections

Acyanotic Congenital Heart Anomalies Types:


• Ventricular Septal Defect (VSD)—abnormal opening between right/left
ventricles; hole size of pinhole or absence of septum; hear a loud harsh
murmur, at age of 3 hole may close otherwise surgery such as purse-string
suture

• Atrial Septal Defect (ASD)—abnormal opening between the two atria; audible
murmur (if defect is severe closure is done later in childhood)

• Patent Ductus Arteriosis (PDA)—failure of fetal structure to close after birth;


ductus areteriosis in the fetus connects the pulmonary artery to aorta to shunt
oxygenenated blood from the placenta to systemic circulation (which
bypasses the lungs). Once the child is born that structure should close
because it is no longer needed because blood passes through to lungs;
vascular congestion, right ventricular hypertrophy; murmur, bounding pulse,
tachycardia; surgical to divide or ligate the vessel.

• Coarctation of the Aorta—narrow of aorta; high blood pressure and bounding


pulse in areas that receive blood proximal to the defect. Weak and absent
blood distal to aorta. Surgical end-to-end anastomosis.

• Pulomonic Stenosis—narrowing at entrance to pulmonary artery; causes


resistance to blood flow and right ventricular hypertrophy; surgery
• Aortic Stenosis—narrowing of aortic valve; causes decrease cardiac output;
surgery

Cyanotic Congenital Heart Anomalies Types:


• Tetralogy of Fallot—VSD, pulmonic stenosis, overriding aorta, right ventricular
hypertrophy; squats/knee chest position to help breath; surgery needed

• Transposition of great vessels—pulmonary artery leaves left ventricle and


aorta leaves right ventricle; oxygenated blood not going into systemic
circulation
• Truncus arteriosus—failure of normal septation and embryonic division of the
pulmonary artery and aorta; rather than two distinctly different vessels there
is a single vessel that overrides both ventricles and gives rise to both
pulmonary and systemic circulation; blood enters from both common artery
and either goes to the lungs or to the body; cyanosis, murmur, difficult
intolerance
• Total anomalous venous return—absence of direct communication between
pulmonary veins and left atria; pulmonary veins attach directly to right atria or
drains to right atria

Congenital Heart Anomalies Compensatory Mechanisms


• Tachycardia
• Polycythemia (increase formation of RBC’s)
• Posturing—squatting, knee-chest position

Congenital Heart Anomalies Implementations


• Prevention
• Recognize early symptoms
• Monitor vital signs and heart rhythms
• Medications—digoxin, iron, diuretics, potassium
• Change feeding pattern

Left-Side CHF Right-Side CHF


• Dyspnea, orthopnea • Dependent edema
• Cough • Liver enlargement
• Pulmonary edema • Abdominal pain/Nausea/Bloating
• Weakness/Changes in mental • Coolness of extremities
status

CHF Implementations
• Administer digoxin, diuretics
• Low-sodium, low-calorie, low-residue diet
• Oxygen therapy
• Daily weight
• Teach about medications and diet

Arterial Peripheral Vascular Disease Arterial Peripheral Vascular Disease


Assessments Implementations
• Rubor • Monitor Peripheral pulses
• Cool shiny skin • Good foot care
• Ulcers • Stop smoking
• Gangrene • Regular exercise
• Intermittent Claudication (pain • Medications—vasodilators,
with exercise/walking relieved anticoagulants
with rest)
• Impaired sensation
• Decreased peripheral pulses

Venous Peripheral Vascular Disease Venous Peripheral Vascular Disease


Assessments Implementations
• Cool, brown skin • Monitor peripheral pulses
• Edema • Elastic stockings
• Normal or decreased pulses • Medications—anticoagulants
• Positive Homan’s sign • Elevate legs
• Warm, moist packs
• Bedrest 4-7 days (acute phase)

Anemia Assessments (reduction in Anemia Implementations


hemoglobin amount/erythrocytes) • Identify cause
• Palpitations • Frequent rest periods
• Dyspnea • High protein, high iron, high
• Diaphoresis vitamin diet
• Chronic fatigue • Protect from infection
• Sensitivity to cold

Iron Deficiency Anemia Assessments Iron Deficiency Anemia


• Fatigue Implementations
• Glossitis • Increase iron-rich foods (liver,
• Spoon fingernails green leafy vegetables)
• Impaired cognition • Iron supplements (stains teeth)
Pernicious Anemia Assessments Pernicious Anemia Assessments
(gastric mucosa fail to secrete enough • Vitamin B12—IM
intrinsic factor for stomach to absorb) • Rest of life can’t be absorbed PO
• Schilling’s Test
• Fatigue
• Sore, red tongue
• Paresthesia in hands and feet
Sickle Cell Anemia Assessments Sickle Cell Anemia Implementations
• Pain /Swelling/Fever • Check for signs of infection
• Schlerae jaundiced (prevent crisis)
• Cardiac murmurs • Check joint areas for pain and
• Tachycardia swelling
• Encourage fluids
• Provide analgesics with PCA pump
c crisis

Hemophilia Assessments (female to Hemophilia Implementations


male gene transmission) • Administer plasma or factor VIII
• Easy bruising • Analgesics
• Joint pain • Cryoprecipitated antihemophilic
• Prolonged bleeding factor (AHF)
• Teach about lifestyle changes
• Non contact sports

Cancer Implementation: External Radiotherapy


• Leave markings on skin
• Avoid use of creams, lotions (only vitamin A&D ointment)
• Check for redness, cracking
• Wear cotton clothing
• Administer antiemetics

Cancer Implementation: Internal Cancer Implementation: Internal


radiation sealed source Radiation
• Lead container and long-handled • Time and distance important
forceps in room • Private room sign on door
• Save all dressings, bed linen until • Nurse wears dosimeter at all times
source removed • Limit visitors and time spent in
• Urine and feces not room
radioactive • Rotate staff
• Don’t stand close or in line with • Self-care when can do
source
• Patient on bed rest
Cancer Implementation: Internal
radiation unsealed source
• All body fluids contaminated
• Greatest danger first 24-96 hours

Leukemia Assessments Leukemia Implementations


• Ulcerations of mouth • Monitor for signs of bleeding:
• Anemia petechiae, ecchymosis,
• Fatigue thrombocytopenia
• Weakness • Infections
• Pallor • Neutropenia (private room/limit #
people, wbc done daily, no fruit,
no flowers/plotted plants, clean
toothbrush with weak bleach
solution
• Good mouth care
• High calorie, high Vitamin diet
(avoid salads/raw
fruit/pepper/don’t reuse cup/don’t
change litter box/digging in
garden

Intracranial Tumors Assessments Intracranial Tumors Implementations


• Motor deficits • Preoperative: do neurological
• Hearing or visual disturbances assessment, patient head shaved
• Dizziness • Postoperative: maintain airway,
• Paresthesia elevate head 30-45 after
• Seizures supratentorial surgery
• Personality disturbances • Flat and lateral after infratentorial
• Changes in LOC surgery
• Monitor vital and neurological
signs
• Glascow coma scale
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;Feet elevated 20 degrees,
knees straight, trunk flat, head slightly elevated
 Elevation of extremity—increases blood to extremity and venous return
 Lithotomy—used for vaginal exam

4 point Gait 2 point Gait 3 point Gait Swing-to-swing


Weight bearing Bearing both legs Bearing one leg through
both legs RC/LF, LC/RF Weaker leg both crutches, then Partial weight
RC, LF, LC, RF stronger leg bearing both
legs
Both crutches,
one or two legs
Stairs
 Going up—“good” leg first, crutches, “bad” leg
 Going down—crutches with “bad” leg, then “good” leg
 “Up with the good, down with the bad”
Walker
• Flex elbows 20-30 degrees when hands are on grips
• Lift and move walker forward 8-10 inches
• Step forward with “bad” leg, support self on arms, follow with “good”
leg
• Stand behind client holding onto gait belt

Myelogram—x-ray visualization of the Post-procedure


spinal canal by injection of radiopaque • Water-soluble dye—elevate head
dye. of bed 30 degrees (not removed)
• Hydration done 12 hours before • Oil based dye—flat in bed
procedure (removed)
• Cleansing enemas • Bedrest 24 hours encourage fluids
• Avoid seizure-promoting
medications

Laminectomy—excision portion of Postoperative care:


lamina to expose area of affected disc • Assess circulation and sensation
• Preopcare: moist heat • Log roll Q2 hours with pillow
• Fowler’s position between leg
• Isometric exercises for abdominal • Calf exercises, assist with
muscles ambulation keeping back straight
• Muscle relaxants, NSAIDs, • Muscle relaxants, NSAIDS,
Analgesics analgesics, Teaching—daily
• Traction, TENS exercises, firm mattress, avoid
prone position and heavy lifting
• Avoid sitting long time

Dysplasia of the Hip Assessment Dysplasia of the Hip


• Uneven gluteal folds and thigh Implementations
creases Newborn to 6 months
• Limited abduction of hip • Reduced by manipulation
• Ortolani’s sign—place infant on • Pavlik harness for 3 to 6 months
back with legs flexed, clicking 6 to 18 months
sound with abduction of legs • Bilateral Bryant’s traction
• Shortened limb on affected side • Hip spica cast
Older child
• Open reduction
• Hip Spica cast

Scoliosis Assessments—lateral Scoliosis Implementations


deviation of one or more of vertebrae • Exercises to strengthen abdominal
accompanied by rotary motion of spine muscles (if functional)
• Uneven hips or scapulae • Surgery: spinal fusion insertion of
• Kyphosis lump on back Herrington Rod
• Bend at waist to visualize • Milwaukee brace: used with
deformity curves 30-40 degrees
• Structural (flexible deviation • Wear 4-6 years, worn 23 hours of
corrected with bending) or the day, wear undershirt to
functional (permanent heredirary prevent irritation, teach isometric
that is seen) exercises

Cerebral Palsy Assessments Cerebral Palsy Implementations


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

Parkinson’s Disease Assessments Parkinson’s Disease


• Deficiency of dopamine Implementations
• Tremors, rigidity, propulsive gait • Teach ambulation modification:
• Monotonous speech goose stepping walk (marching),
• Mask like expression ROM exercises
• Medications—Artane, Cogentin, L-
Dopa, Parlodel, Sinemet,
Symmetrel

Myasthenia Gravis Assessments Myasthenia Gravis Implementations


• Deficiency of acetylcholine • Good eye care, restful
• Muscular weakness produced by environment
repeated movement • Medications—anticholinesterases,
• Dysphagia corticosteroids,
• Respiratory distress immunosuppressants
• Avoid crisis: infection
• Symptoms: sudden ability to
swallow

Clear liquid Full liquid Low-fat Sodium High Low-residue


• No milk • No jam cholesterol restricte roughage, • Minimize
• No juice with • No fruit restricted d high fiber intestinal
pulp • No nuts • Can eat lean • No • No activity
meat chees white • Buttered
• No avocado, e bread rice white
milk, bacon, without processed
egg yolks fiber food, no
butter whole wheat
corn bran

High protein Renal Low-phenylalanine


diet • Keeps diet
• Restablish protein, • Prevents brain
anabolism potassium damage from
to raise and imbalance of
albumin sodium amino acids
levels low • Fats, fruits,
• Egg, roast • No beans, jams allowed
beef no • No meats
sandwich, cereals, eggs bread
• No junk no citrus
food fruits

Glomerulonephritis Assessment Glomerulonephritis Implementation


• Fever, Chills • Antibiotics, corticosteroids
• Hematuria • Antihypertensives,
• Proteinuria immunosuppressive agents
• Edema • Restrict sodium and water
• Hypertension intake
• Abdominal or flank pain • Bedrest
• Occurs 10 days after beta • I&O
hemolytic streptococcal • Daily weight
throat infection • High Calorie, Low protein
Urinary Diversion: Assessments Urinary Diversion Implementations
• Done for: Bladder t umors, birth • Nephrostomy: flank incision and insertion of
defects, neurogenic bladder, nephrostomy tube into renal pelvis; penrose drain after
interstitial cystitis surgery; surgical dressing
• Ileal Conduit • Ureterosigmoidostomy: urters detached from bladder
• Koch Pouch and anastomosed to sigmoid colon; encourage voiding
via rectum q 2-4 hours;no enemas or cathartics;
complications—electrolyte imbalance, infection,
obstruction; urine and stool evacuated towards anus.
• Cutaneous Ureterostomy: Stoma formed from ureters
excised from bladder and brought to abdominal wall;
stoma on right side below waist; assist with alteration in
body image
• Illeal Conduit: Ureters replanted into portion of terminal
ileum and brought to abdominal wall; check for
obstruction; mucous threads in urine normal
• Koch Pouch (Continent Illeal Conduit): Ureters
transplanted into pouch made from ileum with one-way
valve; drainage of pouch by catheter under control of
client; drain pouch at regular intervals

Acute Renal Acute Renal Acute Renal Failure Acute Renal Failure
Failure Failure Causes Implementations:
Assessments: Assessments: • Prerenal—reduced • Low-output stage:
Oliguric Phase Diuretic Phase blood volume Limit fluids,
• Output <400 • Output 4-5 • Renal—nephrotoxic Kayexalate, Dialysis
cc/day L/day drugs, • High-output stage:
• Hypertensio • Increased BUN glomerulonephritis Fluids as needed, K+
n • Na+, K+ lost in • Postrenal-- replacement,
• Anemia urine obstruction Dialysis
• CHF • Increased • I&O
• Confusion mental and • Daily Weight
• Increased physical • Monitor Electrolytes
K+, Ca+, activity • Bedrest during acute
Na+, BUN, phase
Creatinine • IV fluids
• Diet restrictions
• Oliguric phase: limit
fluids, TPN maybe
• After Diuretic phase:
high protein, high
calorie diet

Hemodialysis Peritoneal Dialysis Types of Peritoneal


Implementation • Weight before and after Dialysis
• Check for thrill and bruit q treatment • Continuous
8 hours • Monitor BP ambulatory (CAPD)
• Don’t use extremity for • Monitor breath sounds • Automated
BP, finger stick • Use sterile technique • Intermittent
• Monitor vital signs, • If problem with outflow, • Continuous
weight, breath sounds reposition client
• Monitor for hemorrhage • Side effects:
constipation

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, 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, Anger, Bargaining, Depression,


Acceptance

Bipolar Disorder Assessments Bipolar Disorder Implementations


• Disoriented, flight of ideas • Meet physical needs first
• Lacks inhibitions, agitated • Simplify environment
• Easily stimulated by • Distract and redirect energy
environment • Provide external controls
• Sexually indiscreet • Set limits: escalating
• Affective disorder hyperactivity
• Maintain contact with reality • Use consistent approach
• Elation is defense against • Administer Lithium (help Manic
underlying depression Phase of Bipolar, keep
• Manipulative behavior results hydrated)
from poor self-esteem • Increase awareness of feelings
through reflection

Schizophrenia Schizophrenia Types Schizophrenia


Assessments • Disorganized— Implementations
• Withdrawal from inappropriate • Maintain safety—protect
relationships and behavior, transient from erratic behavior
world hallucinations • With hallucination—do not
• Inappropriate • Catatonic—sudden argue, validate reality,
display of feelings onset mutism, respond to feeling tone,
• Hypochondriasis stereotyped position, never further discuss voices
• Suspiciousness periods of agitation (don’t ask to tell more about
• Inability to test • Paranoid—late onset voices)
reality, regression in life, • With delusions—do not
• Hallucinations— suspiciousness, ideas argue, point out feeling tone,
false sensory of persecution and provide diversional activities
perceptions delusions • Meet physical needs
• Delusions— • Establish therapeutic
persistent false relationship
beliefs; grandeur • Institute measures to
(feel higher rank); promote trust
persecutory • Engage in individual, group,
(beliefs to be a or family therapy
victim); ideas of • Encourage client’s affect
reference (see • Accept nonverbal behavior
people talking • Accept regression
think talking about • Provide simple activities or
them) tasks
• Loose associations
• Short attention
span
• Inability to meet
basic needs:
nutrition, hygiene
• Regression

Paranoid Assessments Paranoid Implementations


• Suspiciousness • Establish trust
• Cold, blunted affect • Low doses phenothiazines for
• Quick response with anger or rage anxiety
• Structured social situations
Schizoid Assessments Schizoid Implementations
• Shy and introverted • Establish trust
• Little verbal interaction • Low doses phenothiazines for
• Few friends anxiety
• Uses intellectualization • Structured social situations

Schizotypal Assessments Schizotypal Interventions


• Eccentric • Establish trust
• Suspicious of others • Low doses neuroleptics to
• Blunted affect decrease psychotic symptoms
• Problems with perceiving, • Structured social situations
communicating

Antisocial Assessments Antisocial Implementations


• Disregards rights of others • Firm limit-setting
• Lying, cheating, stealing, • Confront behaviors consistently
promiscuous • Enforce consequences
• Lack of guilt • Group therapy
• Immature
• Irresponsible
• Associated with substance abuse

Borderline Assessments Borderline implementations


• Brief and intense relationships • Identify and verbalize feelings
• Blames others for own problems • Use empathy
• Impulsive, manipulative • Behavioral contract
• Self-mutilation • Journaling
• Women who have been sexually • Consistent limit-setting
abused • Group therapy
• Suicidal when frustrated, stressed

Narcissistic Assessments Narcissistic Implementations


• Arrogant lack of feelings and • Mirror what client sounds like
empathy for others • Limit-setting
• Sense of entitlement • Consistency
• Uses others to meet own needs • Teach that mistakes are
• Shallow relationships acceptable
• Views self as superior to others

Histrionic Assessments Histrionic Implementations


• Draws attention to self • Positive reinforcement for other
• Somatic complaints centered behaviors
• Temper tantrums, outbursts • Clarify feelings
• Shallow, shifting emotions • Facilitate expression of feelings
• Cannot deal with feelings
• Easily influenced by others

Dependent Assessments Dependent Implementations


• Passive • Emphasize decision-making
• Problem working independently • Teach assertiveness
• Helpless when alone • Assist to clarify feelings and needs
• Dependent on others for decisions
• Fears loss of support and approval

Avoidant Assessments Avoidant Implementations


• Socially uncomfortable • Gradually confront fears
• Hypersensitive to criticism, Lacks • Discuss feelings
self-confidence • Teach assertiveness
• Fears intimate relationships • Increase exposure to small groups
Obssessive-compulsive Assessments Obssessive-compulsive
• High personal standards for self Implementations
and others • Explore feelings
• Preoccupied with rules, lists, • Help with decision-making
organized • Confront procrastination
• Perfectionists • Teach that mistakes are
• Intellectualize acceptable

Manipulative behavior Assessments Manipulative Behavior


• Unreasonable requests for time, Implementations
attention, favors • Use consistent undivided staff
• Divides staff against each other approach
• Intimidates others • Set limits
• Use seductive or disingenuous • Be alert for manipulation
approach • Check for destructive behavior
• Help client to see consequences of
behavior

Acute Alcohol Acute Alcohol


Intoxication Implementations
• Drowsiness • Protect airway
• Slurred speech • Assess for injuries
• Tremors • Withdrawal assess
• Impaired thinking • IV glucose
• Belligerence • Counsel about
• Loss of inhibitions alcohol use

Alcohol Withdrawal After WithdrawalDelirium Alcohol Withdrawal


Assessments Tremens Assessments Implementations
• Tremors • Disorientation • Monitor vital
• insomnia • Paranoia signs,
• anxiety • Ideas of reference especially
• hallucinations • Suicide attempts pulse
• Grand mal convulsions • Administer
sedation,
anticonvulsants
, thiamine (IM
or IV), glucose
(IV)
• Seizure
precautions
• Quiet, well-
lighted
environment
• Stay with
patient

Chronic Alcohol Dependence Chronic Alcohol Dependence


Assessments Implementations
• Persistent incapacitation • Identify problems related to
• Cyclic drinking or “binges” drinking
• Others in family take over client’s • Help client see problem
role • Establish control of problem
• Family violence • Alcoholics anonymous
• Antabuse
• Counsel spouse and children

Wernicke’s Syndrome Assessments Wernicke’s Syndrome


• Confusion Implementations
• Diplopia, nystagmus • Thiamine (IM or IV)
• Ataxia • Abstinence from alcohol
• Apathy
Korsakoff’s Psychosis Assessments Korsakoff’s Psychosis
• Memory disturbances with Implementations
confabulation • Balanced diet
• Learning problems • Thiamine
• Altered taste and smell • Abstinence from alcohol
• Loss of reality testing

Retinopathy of Prematurity Retinopathy of Prematurity


Assessment Implementations
• Demarcation line with ridge • Prevent by using minimum
• Retinal detachment oxygen concentrations
• Monitor PO2
• Eye exam (premature infants)

Strabismus (cross-eyed) Corrective lenses Implementations


Assessments • Eye exercises
• Deviation of eye • surgery
• Diplopia
• Tilts head or squints

Detached Retina Assessments Detached Retina Implementations


• Flashes of light • Bedrest, affected eye in
• Loss of vision dependent position
• Particles moving in line of vision • Eye patched (one or both)
• confusion • Surgery
• Sedatives and tranquilizers
• Avoid stooping, straining at stool,
strenuous activity 3 months

Cataracts Assessments Cataracts Implementations


• Distorted, blurred vision • Postop: check for hemorrhage
• Milky white pupil • Check pupil—constricted with lens
implanted, dilated without lens
• Eye drops
• Night shield
• Sleep on unaffected side

Glaucoma Assessments Glaucoma Implementations


• Abnormal increase in intraocular • Administer miotics (constrict pupil,
pressure that leads to blindness allows more area for aqueous humor
• Blurred vision to flow), carbonic anhydrase inhibitors
• Lights with halos • Surgery
• Decreased peripheral vision • Avoid heavy lifting, straining of stool
• Pain • Mydriatics (dilates pupil, makes angle
• Headache smaller and constrict aqueous flow)
are contraindicated with glaucoma.

Trigeminal Neuralgia Assessments Trigeminal Neuralgia


• Stabbing, burning facial pain Implementations
• Twitching of facial muscles • Medications—analgesics, Tegretol
• Surgery
Bell’s Palsy Assessments Bell’s Palsy Implementations
• Inability to close eye • Isometric exercises for face
• Increased lacrimation • Prevent corneal abrasions
• Distorted side of face
Guillain-Barre Syndrome Guillain-Barre Syndrome
Assessments Implementations
• Paresthesia • Medications—steroids
• Motor losses beginning in • Aggressive respiratory care
lower extremities • Physical therapy
• Altered autonomic function • Eye care
• Prevent complications: respiratory
and aspiration
Meningitis Assessments Meningitis Implementations
• Nuchal rigidity • Medications—antibiotics,
• Kerning’s sign antifungals
• Brudzinski’s sign • Prevent complications: droplet
• Seizures precautions, contagious
• Bulging fontanels
• High-pitched cry

Thoracentesis: no more than 1000cc taken at one time.

Electroencephalogram (EEG) Electroencephalogram (EEG)


Preparation Post-test
• Test brains waves; seizure • Remove paste from hair
disorders • Administer medications withheld
• Tranquilizer and stimulant meds before test
withheld for 24-48 hours • Observe for seizure activity
• Stimulants (caffeine, cigarettes) • Seizure prodromal signs;
withheld for 24 hours epigastric distress, lights before the
• May be asked to hyperventilate eyes
during test
• Meals not withheld
• Kept awake night before test;
want them to lie still

CAT Scan—dye gives flushed, warm face and metallic taste during injection (if
contrast dye is used)

Myelogram: Post-test
• Supine 8-24 hours (Pantopaque oil-based dye used)
• Head raised 30-45degrees 8-16 hours(metrizamide water-soluble dye used)

Liver Biopsy Preparation Liver Biopsy Post-Test


• Administer vitamin K IM • Position on operative side for 1-2
(decrease risk of hemorrhage) hours
• NPO 6 hours • Gradually elevate head of bed 30
• Given sedative degrees (1st hour) and then 45 degrees
• Position supine, lateral with (2nd 2 hours)
upper arms elevated • Bedrest for 24 hours
• Asked to hold breath for 5-10 • Check Vital signs
seconds • Check clotting time, platelets,
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, apply jelly


• Face mask: 5-10 l/min (40-60%)
• Partial rebreather mask: 6-15 l/min (70-90%); keep reservoir bag 2/3 full
during inspiration
• Non-rebreather mask: (60-100%); keep reservoir bag 2/3 full during
inspiration
• Venturi mask: 4-10 l/min (20-50%); provides high humidity and fixed
concentrations, keep tubing free of kinks
• Tracheostomy collar or T-piece: (20-100%); assess for fine mist; empty
condensation from tubing’ keep water container full
• Croupette or oxygen tent:
o Difficulty to measure amount of oxygen delivered
o Provides cooled, humidified air
o Check oxygen concentration with oxygen analyzer q4 hours
o Clean humidity jar and fill with distilled water daily
o Cover patient with light blanket and cap for head
o Raise side rails completely
o Change linen frequently
o Monitor patient’s temperature

Chest Tubes Chest Tube Complications of Chest Tubes:


Implementations Removal: • Constant bubbling in water-seal
• Use to utilize • Instruct patient to chamber=air leak
negative pressure in do valsalva • Tube becomes dislodged from
lungs maneuver patient, apply dressing tented
• Fill water-seal • Clamp chest tube on one side
chamber with sterile • Remove quickly • Tube becomes disconnected
water to 2 cm • Occlusive dressing from drainage system, cut off
• Fill suction control applied contaminated tip, insert sterile
chamber with sterile connector and reinsert
water to 20 cm • Tube becomes disconnected
• Maintain system from drainage system,
below level of immerse end in 2 cm of sterile
insertion water
• Clamp only
momentarily to check
for air leaks
• Ok to milk tubing
towards drainage
• Observe for
fluctuation in water-
seal chamber
• Encourage patient to
change position
frequently

CVP: measures blood volume and efficiency of cardiac work; tells us right side of
heart able to manage fluid
• “0” on mamometer at level of right atrium at midaxilliary line
• Measure with patient flat in bed
• Open stopcock and fill manometer to 18-20 cm
• Turn stopcock, fluid goes to patient
• Level of fluid fluctuates with respirations
• Measure at highest level of fluctuation
• After insertion
o Dry, sterile dressing
o Change dressing, IV fluids, manometer, tubing q24 hours
o Instruct patient to hold breath when inserted, withdrawn, tubing
changed
o Check and secure all connections
• Normal reading—3-11 cm water
• Elevated>11, indicates hypervolemia or poor cardiac contractility (slow
down IV, notify physician)
• Lowered<3, hypovolemia
• Chest tray at bedside
Eye irrigation: tilt head back and toward affected side

Eye drops: drop in center of conjunctival sac; prevent systemic absorption, press on
inner angle of eye; don’t allow drops to go from one eye to the other; don’t squeeze
eyes

Nasogastric Tubes:
• Levin-single—single-lumen, used for decompression or tube feeding
• Salem sump—double-lumen, used for decompression or tube feeding
• Sengstaken-Blakemore—triple-lumen, used for bleeding esophageal varices
• Linton-Nachlas—4-lumen, used for bleeding esophageal varices
• Keofeed/Dobhoff—soft silicone, 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
• Check residual Q4 hours with continuous feeding, reinstall residual
• Hold feeding if >50% residual from previous hour (adults) or >25% (children)
• Flush tube with water before and after feeding
• Use pump to control rate of tube feeding
• Administer fluid at room temperature
• Change bag Q8 hours for continuous feeding
• Elevate head of bed while feeding is running
• Check patency Q4 hours
• Good mouth care

NG Irrigation Tubing:
• Verify placement of tube
• Insert 30-50 cc of normal saline into tube
• If feel resistance, change patient position, check for kinks
• Withdraw solution or record amount as input
NG removal:
• Clamp tube
• Remove tape
• Instruct patient to exhale
• Remove tube with smooth, continuous pull

Intestinal Tubes (Cantor, Mill-Abbott, Harris)


• Implementations
o After tube is in stomach, have patient lie on right side, then back in
Fowler’s position, then left side
o Gravity helps to position tube
o Coil excess tube loosely on bed, do not tape
o Position of tube verified by x-ray
o Measure drainage QShift
• Removal
o Clamp tube
o Remove tape
o Deflate balloon or aspirate contents of intestinal tube balloon
o Instruct patient to exhale
o Remove 6” every 10 min. until reaches the stomach, then remove
completely with smooth, continuous pull
T-Tube: 500-1000 cc/day, bloody first 2 hours

Penrose: expect drainage on dressing

Enema Implementation
• Position on left side
• Use tepid solution
• Hold irrigation set no more than 18” above rectum
• Insert tube no more than 4”
• Do not use if abdominal pain, nausea, vomiting,
suspected appendicitis

Catheter insertion: 2-3” into urethra then 1” after urine flows

Male catheter: insert 6-7”

Catheter Urine Drainage bag: do not remove more than 700 cc at one time, clamp
prior to removal

Ileostomy: post-op has loose, dark green, liquid drainage from stoma

Tonsillectomy: post-op frequently swallowing indicates hemorrhage

External contact lenses: need fine motor movements (rheumatoid arthritis prevents
this).

Object in eye: never remove visible glass; apply loose cover and remain quiet.

Retina detached: sleep prone with affected side down; avoid jarring movements;
avoid pin point movement with eye (sewing); high fluid and roughage (prevents
constipation=no straining); make light sufficient for needs (75watt+); no hairwashing

Glaucoma medications: Epinephrine hydrochloride (Adrenalin Chloride) and


Pilocarpine Hydrochloride (Pilocar): give Pilocar (therapeutic) first then wait 2-
10minutes and instill adrenalin to increase absorption of adrenalin).

Tympanoplasty: remain in bed 24 hours position flat in bed with the affected ear up
(helps to promote insertion).

Triglycerides elevation can falsely elevate glycosalated hemoglobin test.

Laparoscopic Cholecystectomy post: encourage to walk to eliminate acute right


shoulder pain.

Impetigo: 2 year old; honey-colored crusts, vesicles, and reddish macules around
mouth; don’t need to isolate; watch contact precautions.

Only patient we use distractions on the NCLEX are manic patients and toddlers not
for pain.

Rhinoplasty (nose surgery) position post-op: want to promote drainage of oral


secretions is to position on her right side.

1 cup= 240cc
Pregnancy is a contraindication to an MRI.

Raynaud’s disease have decreased vascularity in the extremities.

Post-Parecentesis most important assessment is to obtain the blood pressure, weight


the client, measure the client’s abdominal girth, and check dressing in that order.

Tracheostomy tube: use pre-cut/pre-made gauze pads.

Suction is always intermittent never continuous.