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Fundamentals

- Rest and sleep: interventions to promote sleep


o Establish a routine bedtime
o Limit waking clients during the night
o Help with personal hygiene needs or a back rub prior to sleep to increase comfort
o Instruct client to:
Exercise regularly at least 2 hours before bedtime
Arrange the sleep environment for comfort
Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime.
Limit fluids 2-4 hr before bedtime
- Pharmacokinetics and routes of administration: selecting intramuscular site
o Ventrogluteal, dorsogluteal, deltoid, and vastuc lateralis (pediatric)
1-3 mL otherwise it needs to be divided into separate syringes.
- NG intubation and enteral feedings: evaluating proper function of NG tube
o Aspirate and x-ray
o pH up to 4.5
- Mobility and immobility: appropriate use of crutches
o Do not alter crutches after fitting
o Follow the prescribed crutch gait
o Support body weight at the hand grips with the elbows flexed at 30*
o Position the crutches on the unaffected side when sitting or rising from a chair
- Urinary elimination: performing closed intermittent irrigation
o 50 cc sterile solution
- Nutrition and oral hydration: findings to report
o Nausea, vomiting, diarrhea, constipation
o Flaccid muscles
o Mental status changes
o Loss of appetite
o Change in bowel pattern
o Spleen, liver enlargement
o Dry, brittle hair
o Loss of subcutaneous fat
o Dry, scaly skin
o Inflammation, bleeding of gums
o Poor dental health
o Dry, dull eyes
o Enlarged thyroid
o Poor posture
- Pressure ulcers, wounds, and wound management: preventing delays in healing
o Encourage intake of 2,000 to 3,000 mL of fluids/day
o Provide education about good resource of protein
o Lack of protein increases the risk for a delay in wound healing and infection
o Provide nutritional support
o Clean wounds from least contaminated towards the most contaminated
o Use gentle friction when cleansing or applying solution to the skin
o Use a piston syringe or a sterile straight cath for deep wounds with small openings 30-
60 mL syringe with a 19 gauge needle.
- Nursing Process Family Concerns
- Infection Control: Contact Precautions
o Person to person, object to person, fecal oral route
o Protect visitors and caregivers when they are within 3 ft of the client (Respiratory
synctytial virus, shigella, wounds, herpes simplex, impetigo, scabies.
o Private room or a room with other client with the same infection.
o Gloves and gowns
o Infectious dressing material into a single, nonporous bag without touching the outside
bag
- Mobility and Immobility: benefits of applying ice to extremity
o Decreases inflammation
o Prevents swelling
o Reduces bleeding
o Reduces fever
o Diminishes muscle spasms
o Decrease pain
o Assess every 5-10 minutes
- Vital Signs Calculating pulse pressure
o Systolic Diastolic
- Thorax, heart, abdomen: auscultating closure to the Aortic Valve
o Beginning of ventricular diastole and produces the S2 sound (Dub). Place the diaphragm
of the stethoscope at the aortic area.
Adult Med-Surg
- Cancer treatment options: Discharge teaching for myelosuppression
o Monitor the clients temperature and WBC
o Fever greater than 100*F (37.8*C) should be immediately reported to the provider.
o If WBC drops below 1000/mm3, place client in a private room and initiate neutropenic
precautions.
o Place mask during transport
o Protect client from possible sources of infection.
o Frequent hand hygiene, have no ill visitors
o Avoid invasive procedures that can cause a break in tissue unless necessary (rectal
temp, injections are a no no)
o Avoid crowds
o Avoid yard work, gardening, or changing a pets litter box
o Avoid fresh fruits
o Wash toothbrush daily in dishwasher or rinse in bleach solution
o Avoid fluids that have been sitting out for over 1 hr
- Meningitis: appropriate actions for bacterial meningitis
o Isolate the client as soon meningitis is suspected.
o Droplet precautions which requires a private room or a room with cohorts, wearing of a
surgical mask when within 3 feet of the client, appropriate hand hygiene, and the use of
designated equipment, such as blood pressure cuff and thermometer. Continue until
antibiotics have been administered for 24 hrs.
o Implement fever-reduction measures, such as cooling blanket.
o Report to the public health department.
o Decrease stimuli
o Maintain bedrest w/ head elevated at 30*
o Seizure precautions
o Replace fluid and electrolytes
- Hepatitis and cirrhosis: evaluating nutritional needs for hepatic encephalopathy
o Encourage high calorie and high carb with supplemental vitamins, folic acid, and iron.
Low protein!
- Posterior Pituitary Disorder: complications following a hypophysectomy
o Monitor glucose levels as drop can be caused by abrupt drop in cortisol
o Check weight
o ADH and oxytocin is secreted by posterior pituitary
o Secondary addisonss and hyperlipidemia can occur.
- Electrocardiography and dysthymic monitoring: Sinus tachy

- Inflammatory Disorders: Pericarditis
o Inflammation of pericardium
o Follows respiratory infection
o Findings include chest pressure/pain, friction rub auscultated in the lungs, shortness of
breath, and pain relieved when sitting and learning forward
o ECG done
o Auscultate for murmurs and friction rub
o Cardiac enzymes can be elevated with pericarditis
- Cancer treatment options providing client teaching for radiation therapy
o Do not eat any red meat
o Instruct the client about the administration of antiemetics and schedule them prior to
meals.
o Suggest that the client select foods that are served cold and do not require cooking,
which can emit odors that stimulate nausea.
o Encourage high protein, high calorie, nutrients-dense foods and avoidance of low- or
empty-calorie foods. Use meal supplements as needed.
o Encourage the use of plastic eating utensils, sucking on hard candy.
o Fatigue is common
o Wash the irradiated area with mild soap and water. Try the area using patting motions.
o Do not remove tattoos
o Do not apply powders, ointments, lotions, or perfumes to the irradiated skin.
o Wear soft clothing over the irradiated skin and avoid tight or constricting clothes.
o Do not expose it to sunlight.
- Electrocardiograpghy and dysrhythmia monitoring: indicators for use of cardioversion
o Given to those with atrial dysrhythmias, supraventricular tachycardia, and ventricular
tachycardia with pulse. They are alive and but are dropping fast! De fib is pulseless.
- Fractures: Interventions for Sprain
- Bacterial, Viral, Fungal, and Parasitic Infections: Caring for a client who has clostridium difficile
o Contact isolation
o Wash hands with soap with water
- HIV/AIDS: Caring for a client who has neutropenia
o Assess skin integrity
o Monitor vital signs (especially temperature)
o Monitor labs (CBC,WBC, LFT)
o Instruct client to practice good hygiene and frequent hand hygiene to reduce the risk of
infection
o Encourage the client to avoid raw foods, such as vegetables and meat.
- Diabetes Mellitus Management: Clinical Manifestations of Hyperglycemia
o Hot, dry skin, and fruity breath
- Chest Tube insertion and monitoring: Identifying complications
o Air leaks
Monitor water seal chamber for continuous bubbling (bad)
Suction control
- Heart failure and pulmonary edema: Decreased cardiac output
o Left sided heart failure
- Fractures: Assessing for acute compartment syndrome
o Pressure within one or more of the muscle compartments
o Pain
o Ischemia
o Tight case
o Accumulation of blood or fluid within the muscle compartment
- Esophageal Disorders: GERD
o Gastroesophageal reflux disease
- Hyperthyroidism: prioritizing care of client
o Minimize clients energy expenditure by assisting with activities as necessary and by
encouraging the client to alternate periods of activity with rest.
o Promote a calm environment
o Monitor ECG of dysrhythmias.
o Monitor I/O
- Gastrointestinal therapeutic procedures: dietary planning
o Bariatric surgery small meals, high protein ; nutrition dense foods.
- Renal Diagnostic: IV Urography
o Used to detect obstruction, assess for a parenchymal mass, assess size of the kidney.
o IV contrast dye (iodine-based) is used to enhance images.
o Encourage increasing fluids the day before procedures.
o Bowel cleansing with lax or enema to remove fecal content.
o NPO after midnight
o Hold metformin (Glucophage) for 24 hr before procedure
- DM management: Appropriate test to manage client condition
o GTT
- Fracture Priority Finding: Associated with cast
o Compartment syndrome
Mental Health
- Cognitive disorders: use of restraints
o Use only as a last resort
o Use caution when administering medications PRN for agitation or anxiety.
- Family and community violence: domestic partner abuse
o Tension-building phase
The abuser has minor episodes of anger and may be verbally abusive and
responsible for some minor physical violence. The victim is tense during this
stage and tends to accept the blame for what is happening.
o Acute battering phase
The tension becomes too much to bear and serious abuse takes place. The
victim may try to cover up the injury or may get help.
o Honeymoon Phase
The situation is defused for a while after the violent episode. The abuser
becomes loving, promises to change, and is sorry for the behavior. The victim
wants to believe this and hopes for a change. Eventually, the cycle begins again.
o Periods of escalation and de-escalation usually continue with shorter and shorter
periods of time between the two. Emotions for the abuser and victim, such as fear or
anger, increase in intensity. Repeated episodes of violence lead to feelings of
powerlessness.
o All states have mandatory reporting laws that require nurses to report suspected abuse;
there are civil and criminal penalties for not reporting suspicions of abuse.
o Help client develop a safety plan, identify behaviors and situations that might trigger
violence, and provide information regarding safe places to live.
- Suicide: appropriate nursing response
o When questioning the client about suicide, always use a follow- up question if the first
answer is negative. For example: the client says, Im feeling completely hopeless. The
nurse says, Are you thinking of suicide? Client: No, Im just sad. Nurse: I can see
youre very sad. Are you thinking about hurting yourself? Client: Well, Ive thought
about it a lot.
- Anxiety disorders: assessing the client w/ PTSD
o
- Schizophrenia: expected findings
o Hallucinations
o Delusions
o Alterations in speech
o Bizarre behavior
o Affect- blunted
o Alogia- poverty of thought or speech
o Anergia lack of energy
o Anhedonia lack of pleasure or joy
o Avolition lack of motivation in activities and hygiene
o Memory deficits
long term memory
Working memory, inability to follow directions to find an address
o Difficulty concentration to perform tasks
o Poor problem-solving ability
o Inability to make decisions
o Disordered thinking
o Hopelessness
o Suicidal ideation
- Schizophrenia: Analyzing client interpretation
- Schizophrenia: signs and symptoms
- Bipolar disorders: intervening for a client who is manic
o Abnormally elevated mood, which may also be described as expansive or irritable.
o Focus is on safety and maintaining physical health
o Therapeutic milieu (within hospital facility)
o Provide safe environment
o Assess regularly for suicidal thoughts, intentions, and escalating behavior.
o Decrease stimulation without isolating the client if possible. Beware of noise, music,
television, and other clients, all of which may lead to an escalation of the clients
behavior.
o Have rest periods
o Provide outlets for physical activity, do not involve other clients.
o Maintenance of self care
o Provide for consistency with expectations and limit setting.
- Chemical and other dependencies: clinical findings
o Blackout or loss of consciousness
o Changes in bowel movements
o Weight loss or weight gain
o Experience of stressful situation
o Sleep problems
o Chronic pain
o Concern over substance use
o Cutting down on consumption or behavior
- Chemical and other dependencies: Planning care for a client with alcohol withdrawal syndrome
o Starts within 4-12 hr of the last intake of alcohol, peak after 24-48 hours, and then
suddenly disappear.
o Manifestations include abdominal cramping, vomiting, tremors, restlessness and
inability to sleep, increased heart rate, transient hallucinations or illusions, anxiety,
increased blood pressure, respiratory rate, temperature, and tonic clonic seizures.
o Alcohol withdrawal delirium may occur 2-3 days after cessation of alcohol and may last
2-3 days. This is considered a medical emergency. Symptoms include severe
disorientation, psychotic symptoms, severe hypertension, cardiac dysrhythmias, and
delirium.
- Medications for Psychoses: Long-term adverse effects of Haldol
o Parkinsonism 1 month
o Tardive dyskinesia
Involuntary movements of the tongue and face, such as lip-smacking and tongue
fasciculation
Involuntary movement of the arms, legs, and trunk
Give medication as low as possible to control manifestations
- Medication for psychoses: Discharge teaching for clozapine
o Notify physician for indications of infection (fever, sore throat, outh lesions)
o High risk of weight gain, diabetes, and dyslipidemia
o Orthostatic hypotension
o Anticholinergic effects
o Do not take with immunosuppressive medications, such as anticancer medications, can
further suppress immune function.
o Risk for fatal agranulocytosis
Baseline and weekly monitoring of WBC
- Medications for Bipolar disorder: evaluating client understanding of Sertraline (Zoloft)
o Advise the client that adverse effects may include nausea, headache, and CNS
stimulation (agitation insomnia, anxiety)
o Instructor sexual dysfunction may occur
o Advise the clients of serotonin syndrome, withhold if it does occur
o Avoid use w/ St. Johns wort, which can increase the risk of serotonin syndrome
o Instruct the client to follow a healthy diet because weight gain can occur
- Effective communication: response to grieving client
o Dont be retarded, ask about her feelings
Nursing Care of Children
- O2 therapy- appropriate intervention with pulse ox
o Place the child in a semi-Fowler or Fowlers position to maximize ventilation
o Encourage deep breathing
o Probe site must be dry and have adequate circulation. Remove polish from nails or
remove earring if using the earlobe.
o Support arm if a finger is used as a probe site.
o Anything less than 86% is a life-threatening emergency. The lower the SaO2 value, the
less accurate the value.
- Renal disorders: intervention for chronic renal failure
o Monitor I/O. Urine for protein.
o Monitor daily weights; weigh the child on the same scale with the same amount of
clothing.
o Monitor edema and measure abdominal girth daily. Measure at the widest area, usually
at or above the umbilicus.
o Low protein, low sodium
- Gastrointestinal, structural, and inflammation disorders: cleft palate, post op
o Change the infants position frequently to facilitate breathing. The infant may be placed
on the abdomen in the immediate postoperative period.
o Maintain intravenous fluids until the infant is able to eat and drink.
o Monitor packing, which is usually removed in 2 to 3 days.
o Avoid placing objects (tongue depressor, pacifier) in the infants mouth after cleft palate
repair.
o Elbow restraints may needed to be used to prevent the infant from injuring the repair.
o There are special seats for kids
- Acute infectious gastrointestinal disorders: evaluating effectiveness of dehydration
interventions
o Hct,Hbg, BUN, creatinine, and urine-specific gravity levels are usually elevated with
dehydration.
o Obtain baseline height and weight.
o Weight the babies naked
o Weight same time everyday.
o Assess cap refill
o Oral rehydration
Mild: 50 mL/kg rehydration fluid every 4-6 hr
Moderate 100 mL/kg rehydration fluid every 4-6 hr
o Administer parenteral fluid therapy as prescribed
20 mL/kg IV bolus with repeat for isotonic and hypotonic dehydration.
Hypertonic dehydration rapid fluid replacement is contradicted because of the
risk of cerebral edema.
- Communicable disease: infectious mononucleosis
o Standard care not airbourne or droplet.
Spread through saliva
o Incubation period is 4-6 weeks
o Kinda like esptein barr virus (I think)
o S/S
Fever, sore throat, swollen lymph glands, increased WBC, atypical lymphocytes,
splenomegaly, and enlarged liver.
o Administer an antipyretic for fever. NOT ASPIRIN due to risk of Reye syndrome.
o Acyclorvir (Zovirax) is given (antiviral)
o Can complicate to ruptured spleen
o Mono spot blood test given
- Cardiovascular disorders: monitoring laboratory values
o Increased CRP and ESR indicates a response to an inflammatory reaction
o ASO titer for RF Strep
o GABHS (Group A (beta)-hemolytic strep) from the throat
- Immunization: contraindication of MMR immunization
o Pregnancy
o Allergy to gelatin and neomycin
o Immunosuppression
o Recent transfusions with blood products or immunoglobulin
o History of thrombocytopenia

Pharmacology
- Intravenous anesthetics: assess allergy to medication
- Medications affecting the reproductive tract: contraindications for use of combination oral
contraceptives
o Clients who are: smokers and over the age of 35
Has a history of thrombophlebitis and cardiovascular events
Family history or risk factors for breast cancer
Experiencing abnormal vaginal bleeding
Antibiotics, antifungals, antipsychotics, antianxiety
Use cautiously with those that have hypertension, diabetes mellitus, gall
bladder distention, seizures, and migraine headaches.
- Angina: contraindications to the use of Isosorbide mononitrate (Imdur)
o Contraindicated in clients who have hypersensitivity to nitrates.
o Contraindicated in clients who have traumatic head injury because the medication can
increase intracranial pressure
o Glaucoma
o Use cautiously in clients takes antihypertensive medications and clients who have renal
or liver dysfunction.
- Gastrointestinal Disorder: Managing side effects of metroclopramide (REGLAN)(DOPAMINE
ANTAGONIST)
o Extrapyramidal symptoms (EPS)
Inform clients of possible adverse effects (restlessness, anxiety, spasms of face
and neck)
Advise clients to stop the medication and inform the provider if EPS occur.
Administer an anticholinergic medication, such as diphenhydramine (Benadryl)
or benztropine (Cogentin), to treat symptoms.
o Hypotension
Monitor clients receiving antihypertensive medications for low blood pressure.
o Sedation
Advise clients to avoid activities that require alertness, such as driving
o Anticholinergic effects( Dry mouth, urinary retention, constipation)
Increase fluid intake
Increase physical activity by engaging in regular exercise.
Tell clients to suck on hard candy or chew gum to help relieve dry mouth
Stimulant laxative such as senna (Senokot) to counteract a decrease in bowel
motility, or stool softeners such as docusate sodium (Colace) to prevent
constipation.
Advise client to void every 4 hr. Monitor I&O and palpate the lower abdomen
area every 4 to 6 hr to assess the bladder.
- Opioid agonist and antagonist: Evaluating client understanding of methadone
o Given to patients with biliary colic
o Do not increase dosage without consulting with the provider
o Do not discontinue abruptly. Opioids should be withdrawn slowly, and the dosage
should be tapered over a period of three days.
o Do not give with kidney failure patients, will cause accumulation of normeperidine
results in seizures and neurotoxicity
o Effectiveness may be evidenced by:
Relief of moderate to severe pain
Cough suppression
Resolution of diarrhea
- Medications affecting BP: ACE inhibitors
o Blocks the conversion of angiotensin I to angiotensin II
Vasodilates
Excretion of sodium and water, and retention of potassium by actions in the
kidney
o Therapeutic use
HTN
Heart failure
MI
Diabetic and nondiabetic nephropathy
o First-dose orthostatic hypostatic
Take off diuretic 2-3s prior to the start of ace inhib
Monitor 2 hr after initial treatment
o Cough dry cough (bradykinin)
o Rash and dysgeusia (altered ngtaste)
o Angioedema
o Neutropenia
Monitor ABC every 2 weeks for 3 months
o Potassium supplements and potassium sparing diuretics increase the risk of
hyperkalemia
o NSAIDS decrease antihypertensive effect of ACE inhibit
- Medications affecting coagulation: Administration of Lovenox
o Music be given subcutaneous injection or IV infusion
o Obtain baseline vitals signs
o Obtain baseline and monitor CBC, platelet count, and hematocrit levels.
o Subcutaneous injections use a 20-22 gauge needle to withdraw medication from the
vial. Then change to a smaller needle (25-26 gauge)
o Administer deep subcutaneous injections in the abdomen; ensure a distance of 2
inches from the umbilicus. Do not aspirate.
o Do not rub the site for 1-2 after the injection.
o Soft toothbrush with electric razor!
o Do not expel the air bubble from the prefilled syringe.
- Antilipidemia agent: Atorvastatin
o Decrease LDL and increase HDL
o Adverse effects
Hepatotoxicity
Myopathy (Muscle pain)
Peripheral neuropathy
o Use cautiously w/ renal disease
o Oral route with evening meal
- Affecting Blood pressure: Indications to withhold propranolol
o Low blood pressure
o Low heart rate
o Greater than first degree heart block, bronchial asthma, cardiogenic shock, or heart
failure
- Medications affecting urinary output: evaluating clients understanding of Lasix
o Ototoxicity
o Hypokalemia
o Hypotension
- Endocrine disorders: therapeutic effects of synthroid
o Used for myxedema coma
o Thyroid hormone replacement for the treatment of hypothyroidism
o Monitor t3 and TSH levels
- Airflow disorders: Leukotrine modifiers
o Montelukast
Obtain baseline liver function test and monitor
LIVER DAMAGE
Suppressing inflammation, bronchoconstriction, airway edema, and mucus
production
Take daily at bedtime
Leadership and Management
- Coordinating client care: recognizing need for swallowing evaluation
o A speech therapist assists a client who has speech and swallowing problems.
- Clinical manifestations of small pox
o High fever
o Fatigue
o Severe headache
o Rash
o Chills
o Vomiting
o Delirium
- Indications for incident report
o Assess the individuals for injuries and institute any immediate care measures necessary
to decrease further injury.
o Forwarded to the risk management department or officer after being reviewed by a
nurse manager. NURSE MANAGER FIRST
o Medication errors
o Procedure/treatment errors
o Needlestick injuries
o Client falls/injuries
o Visitor/volunteer injuries
o Threat made to client or staff
o Loss of property
- Stages of team formation
o Forming Members of the team get to know each other. The leader defines tasks for
the team and offers direction
o Storming conflict arises, and team members begin to express polarized views. The
team establishes rules, and members begin to take on various roles.
o Norming the team establishes rules. Members show respect for one another and
begin to accomplish some of the task.
o Performing the team focuses on accomplishments of task.
- Managing client care: Delegating task to an assistive personnel
o Activities of daily living (ADLs)
Bathing
Grooming
Dressing
Toileting
Ambulating
Feeding
Positioning
Bed making
o Specimen collection
o Intake and output
o Vital signs
- Managing client care: Reassigning delegated task
- Managing client care: emergency department
- Managing client care: identifying highest priority findings to report
o Prioritize systemic before local
o Prioritize acute before chronic
o Prioritize actual problems before potential future problems
o Recognize signs of medical emergencies and complications versus expected client
findings
- Managing client care: staff development and performance improvement
- Professional responsibilities: client understanding of advanced directives
- Responsibilities: ethical consideration following a medication error
- Facility Protocols: Prioritizing care during mass casualty triage
Maternal Newborn
- Client education and discharge teaching: Engorgement
o Wear a well-fitting, supportive bra continuously for the duration of lactation
o Emphasize the importance of hand hygiene prior to breastfeeding to prevent infection
o Relieve engorgement have the client completely empty her breast at each feeding.
Allow the infant to nurse on demand, which would be about 8-12 times in 24 hr period.
Massage the breasts during feeding can help with emptying. Allow the infant to feed
until the breast softens. If the second breast not softens after the infants feeding, the
breast may be emptied with a breast pump. Alternate breast with each feeding.
o Apply cool compress between feedings and warm compress prior to breast feeding.
o Have the client apply breast creams as prescribed and wear breast shields in her bra to
soften her nipples if they are irritated and cracked.
- Infections: clinical findings w/ bacterial vaginosis
o Excessive grayish white vaginal discharge
o Fishy odor occurring after sex
- Infections: planning care for HSV-2
o Monitor fetal well being
o PAP test
o Droplet infection, virus found in semen, breast milk, urine, feces, and blood.
o Administer antibiotics
Treatment includes sulfonamides or a combination of pyrimethamine and
sulfadiazine
- Newborn assessment: manifestations of cold stress
o Increased oxygen demands
o Acidosis can occur
o Temperature above 37.2 or 98.9
o Rapidly use up brown fat reserves
o Hypoxia
o Hypoglycemia
o Respiratory distress
o Increased respiration
- Fetal assessment during labor: early decelerations
o Remember VEAL CHOP
o Compression of the fetal head resulting from uterine contraction
o No intervention required
- Labor and delivery process: latent phase
o BP, pulse, and respiratory measurements every 30-60 minutes
o Cervix 0 3 cm
o Irregular, mild to moderate contractions
o Contractions q5-30m, duration 30-45 seconds
o Talkative and eager
o Some dilation and effacement
- Bonding and integration of infant into family system: intervening
o Apathy when the infant cries
o Disgust when the infant voids, stools, or spits up
o Expresses disappointment in the infant
o Turns away from the infant
o Does not seek close physical proximity to the infant
o Does not talk about the infants unique features
o Handles the infant roughly
o Ignores the infant entirely
o Assess for signs of mood swings, conflict about maternal role, and/or personal
insecurity.
Feeling anxiety related to ineffective breastfeeding
Feeling down
Feeling of inadequacy
Flat affect and being withdrawn
Unable to care for infant
- Pain management: nonpharmacologic relaxation techniques
o Aromatherapy
o Breathing techniques
o Imagery
o Music
o Use of focal points
o Subdued lighting
o Effleurage
Gentle circular stroking of the clients abdomen with the fingertips
o Back rubs and massage
o Sacral counterpoint
o Acupressure
- Nursing care of the newborn: care and delivery
o Vital signs should be checked on admission/birth and every 30 minutes x 2, every 1 hr x
2, and then every 8 hr
- Postpartum Physiological Adaption RhoGAM administration
o Administer around 28 weeks of gestation for clients who are Rh-negative

Nutrition
- Modified diet: client who has dysphagia
o Thickened liquids
Start with nectar, then honey
o Avoid thin liquids and sticky foods
o Apple Juice
o Foods that are liquid at room temperature
o Can have all forms of milk, soups, strained fruits and vegetables, vegetable and fruit
juices, eggnog, plain ice cream and sherbet, refined or strained cereals and puddings.
- Guidelines for healthy eating: Weight reduction
o 500 calories per pound
- Managing client care: sources for nutrition
- Cultural, ethnic, and religious influences: Kosher observance
o Do not mix dairy and meet
- Enteral Nutrition: Intermittent Tube Feedings
- Parenteral Nutrition: Monitoring Client receiving TPN
o Monitor serum and urine glucose levels. Sliding scale insulin may be prescribed to
intervene for hyperglycemia
o IV 10% dextrose if TPN runs out
o Send TPN back to lab if there are two different colors in bag (separation of lipids)


12 lead
Contraceptives: miss two days- double dose for next 2 days. If more, then you have to restart