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.
1
Side effects: postural hypotension, dry mouth, rapid heartbeat, anorexia,
weight loss, severe headache. If dose is missed, omit dose and instruct
client to return to regular dosing schedule.

Propanolol (inderal)—a beta-adrenergic blocker used as antihypertensive;

Side effects: bronchospasm, bradycardia, depression. Take pulse before
administration and gradually decrease when discontinuing. Do not give to
asthmatic patients.

Glipizide (Glucotrol)—an oral hypoglycemic that decreases blood sugar

by stimulating insulin release from the beta cells of the pancreas; may
cause aplastic anemia and photosensitivity.

Prednisone (Deltasone)—a corticosteroid. Side effects: hyperglycemia

Bethanechol (Urecholine)—a cholinergic or parasympathomimetic used

to treat functional urinary retention; mimics action of acetylcholine.

Ventricular Tachycardia—causes chest pain, dizziness, and fainting.

1 grain = 60mg

Levothyroxine (Synthroid)—thyroid preparation should be administered

at breakfast to prevent insomnia.

Carbamazepine (Tegretol)—interferes with action of hormonal

contraceptives. Side effects: photosensitivity; prevention of seizures and
relief of pain in trigeminal neuralgia. Trigeminal neuralgia (Tic douloureux)
is an agonizing pain that may result in severe depression and suicide.
Aluminum Hydroxide (Amphojel)—an antacid; neutralizes hydrochloric
acid and reduces pepsin activity; take one hour before and hour of sleep.
Antacids most effective after digestion has started, but prior to the
emptying of the stomach.

Isoniazid (INH)—Side effects: peripheral neuropathy (administer

pyridoxine), rash, urticaria, and swelling of the face, lips, and eyelids.

Pyridoxine (Vitamin B6, Beesix, Doxine)—required for amino acid,

carbohydrate, and lipid metabolism. Used in the transport of amino acids,
formation of neurotransmitters, and sythesis of heme. Prevention of
neuropathy.
2
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
3
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.

4
When applying the nursing process, assessment is the first step in providing
care. The 5 "Ps" of vascular impairment can be used as a guide (pain,
pulselessness, pallor, paresthesia, paralysis)

READ THE QUESTIONS FIRST!!!!!

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

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

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

The nurse instructs the client taking dexamethasone (Decadron) to take it

with food or milk because Decadron increases the production of
hydrochloric acid, which may cause gastrointestinal ulcers.

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

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

Verapamil, Bretylium, and Amiodarone increases serum dig levels, possibly

causing Digitalis Toxicity

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

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

Restlessness, confusion, irritability and disorientation may be the first signs

of fat embolism syndrome followed by a very high temperature.

A Neologism is a new word self invented by a person and not readily

understood by another that is often associated with a thought disorder.

Pancreatic enzymes give before meals.

5
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

6
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
7
  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.
8
Thiamin (Vit. B1)—carbohydrate 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

9
Ph 4.5-8
1,000-1,500cc/day

Crede’s Maneuver—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

10
 - 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 unclotted blood in one hour
- Indicates inflammation/neurosis

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

Creatine Kinase (CK)

- Men (12-70)
- Women (10-55)
11
 - 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!!!!!!!!!!!!!!!!!

12
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.

13
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
Side effects: mild tenderness
at site
• 1st shot – Birth to 3
months
• 2nd shot – 1 to 4 months
• 3rd shot – 6 to 18
months
DTaP (Diptheria, Tetanus,
and Pertussis)
Given IM anterior or lateral
thigh
Side effects: fever within 24-
48 hours, swelling, redness,
soreness
Given SC anterior or lateral thigh
Side effects: rash, fever, arthritis in 10
days to 2 weeks.
• 1st shot – 12 to 18 months
• 2nd shot – 4 to 6 years
Varicella (Chickenpox)
• 12 to 18 months
PCV (Pneumococcal)
• 1st shot – 2 months
• 2nd shot – 4 months
• 3rd shot – 6 months
• 4th shot – 12 to 18 months
TB
Given intradermal
14
Don’t treat with aspirin, use
other antipyretic.
• 1st shot – 2 months
• 2nd shot – 4 months
• 3rd shot – 6 months
• 4th shot – 15 to 18
months
• 5th shot – 4 to 6 years
• Only TD shot – 11 to 16
years
Hib (Influenza)
• 1st shot – 2months
• 2nd shot – 4months
• 3rd shot – 6 months
• 4th shot – 12 to 18
months
Evaluated in 48 to 72 hours
TD
Given IM into anterior or lateral thigh
Repeated every 10 years
Live attenuated Rubella
Given once SC into anterior or lateral
thigh
Given to antibody-negative women
Prevent pregnancy for 3 months after
receiving immunization
Live attenuated mumps
Given once SC
Prevents orchitis

IPV (Inactive Polio Vaccine)

Given PO, Few side effects
• 1st shot – 2 months
• 2nd shot – 4 months
• 3rd shot – 6 to 18
months
• 4th shot – 4 to 6 years

Normal Vital Signs

Newborn
• Pulse 120-140 bpm, increases with crying
• Respirations 30-50/min, diaphgramatic (abdomen moves),
can be irregular
• BP 60/40 – 80/50 mmHg

1-4 year old

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

5-12 year old

• Pulse: 70-115
15
 • 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

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

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

Obese person choking use Chest Thrusts.

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
16
 • Victim is transferred
• Rescuer is unable to continue

MI Implementation for MI
• Chest pain radiating to
arms, jaw, neck (which
is unrelieved by rest or
nitroglycerin)
• Dyspnea
• Indigestion
• Apprehension
• Low grade fever
• Elevated WBC (5-10,
ESR, CK-MB, LDH)
• Thrombolytic therapy-
streptokinase, t-PA
• Bedrest
• Beta-blockers, morphine
sulfate, dysrhythmics,
anticoagulants
• Do not force fluids (will
give heart more to work
with)

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)
17
Flail Sucking Chest Pneumothorax Implementati
Chest Wound Collapse of lung due to on
Affected (Sucking Open alteration of air in Monitor for
side goes Pneumothorax) intrapleural space shock
down • Sucking • Dyspnea Humidified
during sound with • Pleuritic pain oxygen
inspiratio respiration • Restricted Thoracentesis
n and up • Pain movement on (aspiration of
during • Decreased affected side fluid from
expiration breath • Decreased/absent pleural space)
sounds breath sounds Chest Tubes
• Anxiety • 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 Decreased Problem with blood
intravascular cardiac output flow to cells
volume

Implementation for shock

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

Increased ICP Implementations

18
Assessments • Monitor vital signs
• Altered LOC (Earliest Sign) • Monitor Glasgow Coma Scale
• Glasgow coma scale <7 • Elevate head 30-45 degrees
indicates coma • Avoid neck flexion and head
• Confusion rotation
• Restlessness • Reduce environmental stimuli
• Pupillary changes • Prevent Valsalva maneuver
• Vital sign changes – WIDENING • Restrict fluids to 1200-1500
PULSE PRESSURE cc/day
• Medications – Osmotic diuretics,
corticosteroids

Seizures:
 do not restrain
 do not insert anything in mouth

Electrolytes
Potassium: 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
• Paresthesias peripheral IV or without cardiac
• Dysrhythmias monitor
• Increased sensitivity to • Increase dietary intake – oranges,
digitalis apricots, beans, potatoes, carrots,
celery, raisins

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

19
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:
• Thirsty, dry, swollen tongue 0.45% NaCl or 5% Dextrose in
• Sticky mucous membranes water IV
• 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 • Mobilize patient
reflexes • Surgery for
• Dysrhythmias hyperparathyroidism

Hypomagnesemia Assessments Hypomagnesemia

 Mg+< 1.5 mEq/L Implementations
 Monitor cardiac rhythm and
20
  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

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

Burns Assessments
• Superficial partial thickness—pink to red, painful
• Deep partial thickness—red to white, blisters, painful
• Full thickness—charred, waxy, white, painless

Wound Care for Burns  Medicate patient before

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

21
Addisson’s Disease
Assessments
 Fatigue
 Weakness
 Dehydration
 Eternal tan
 Decreased resistance to
stress
 Low Sodium
 Low Blood Sugar
 High Potassium
Addisonian Crisis Assessments
• Hypotension
• Extreme weakness
• Nausea vomiting
• Abdominal pain
• Severe hypoglycemia
• Dehydration
Cushing’s Syndrome
Assessments
• Osteoporosis
• Muscle wasting
• Hypertension
• Purple skin striations
• Moon face
• Truncal obesity
• Decreased resistance to
infection
Pheochromocytoma
Assessments—hypersecretions
of the catecholamines
(epinephrine/norepinephrine)
• Persistent hypertension
• Hyperglycemia
• Pounding headache
• Palpitations
Addisson’s Disease
Implementations
 High protein, High
carbohydrate, high Sodium, Low
potassium diet
 Teach life-long hormone
replacement
Addisonian Crisis
Implementations
• Administer NaCl IV,
vasopressors, hydrocortisone
• Monitor vital signs
• Absolute bedrest
Cushing’s Syndrome
Implementations
• Low Carbohydrate, Low Calorie,
High Protein, High Potassium,
Low sodium diet
• Monitor glucose level
• Postop care after
adrenalectomy or
hypophysectomy
Pheochromocytoma
Implementations
• Histamine Test, Regitine Test,
24- hour urine VMA test
• Avoid emotional and physical
stress
• Encourage rest
• Avoid coffee and stimulating
22
 • Visual disturbances foods
• 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
• Change in postured day and L, not too much because your
hs (don’t sleep laying down, trying to prevent CO2 narcosis)
have to stay erect) • Encourage fluids
• Use of accessory muscles of • Small frequent feedings
breathing • Use metered dose inhalers
• Dyspnea (MDI)
• Cough
• Adventitious breath sounds

Pneumonia Assessments Pneumonia Implementations

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

23
Acyanotic Congenital Heart
Anomalies Assessments
• Normal Color
• Possible exercise intolerance
• Small stature
• Failure to thrive
• Heart murmur
• Frequent respiratory
Infections
Cyanotic Congenital Heart
Anomalies Assessments
• Cyanosis
• Clubbing of fingers
• Seizures
• Marked exercise intolerance
• Difficulty eating
• Squat to decrease respiratory
distress
• Small stature
• Failure to thrive
• Characteristic murmur
• Frequent respiratory infection

Acyanotic Congenital Heart Anomalies Types:

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

• Atrial Septal Defect (ASD)—abnormal opening between the two

atria; audible murmur (if defect is severe closure is done later in
childhood)

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

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

• 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.

24
 • 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
25
 • Cough • Liver enlargement
• Pulmonary edema • Abdominal pain/Nausea/Bloating
• Weakness/Changes in • Coolness of extremities
mental 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 Arterial Peripheral Vascular

Disease 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 Venous Peripheral Vascular

Disease 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 Anemia Implementations

(reduction in hemoglobin • Identify cause
amount/erythrocytes)
26
 • Palpitations
• Dyspnea
• Diaphoresis
• Chronic fatigue
• Sensitivity to cold
• Frequent rest periods
• High protein, high iron,
high vitamin diet
• Protect from infection

Iron Deficiency Anemia Iron Deficiency Anemia

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

Hemophilia Assessments Hemophilia Implementations

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

Cancer Implementation: External Radiotherapy

• Leave markings on skin
27
 • Avoid use of creams, lotions (only vitamin A&D
ointment)
• Check for redness, cracking
• Wear cotton clothing
• Administer antiemetics

Cancer Implementation: Internal Cancer Implementation:

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

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 Intracranial Tumors Implementations

Assessments • Preoperative: do neurological
28
 • Motor deficits assessment, patient head shaved
• Hearing or visual • Postoperative: maintain airway,
disturbances elevate head 30-45 after
• Dizziness supratentorial surgery
• Paresthesia • Flat and lateral after infratentorial
• Seizures surgery
• Personality disturbances • Monitor vital and neurological signs
• Changes in LOC • 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 2 point 3 point Gait Swing-to-

Gait Gait Bearing one leg swing
Weight Bearing Weaker leg both through
bearing both legs crutches, then stronger Partial
both legs RC/LF, LC/RF leg weight
RC, LF, LC, bearing
RF both legs
Both
crutches,
one or two
legs
Stairs
 Going up—“good” leg first, crutches, “bad” leg
29
  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 Post-procedure

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

Laminectomy—excision portion of Postoperative care:

lamina to expose area of affected
disc
• Preopcare: moist heat
• Fowler’s position
• Isometric exercises for
abdominal muscles
• Muscle relaxants, NSAIDs,
Analgesics
• Traction, TENS
• Assess circulation and
sensation
• Log roll Q2 hours with pillow
between leg
• Calf exercises, assist with
ambulation keeping back
straight
• Muscle relaxants, NSAIDS,
analgesics, Teaching—daily
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
30
 back with legs flexed, clicking
sound with abduction of legs
• Shortened limb on affected
side
Scoliosis Assessments—lateral
deviation of one or more of
vertebrae accompanied by rotary
motion of spine
• Uneven hips or scapulae
• Kyphosis lump on back
• Bend at waist to visualize
deformity
• Structural (flexible deviation
corrected with bending) or
functional (permanent
heredirary that is seen)
Cerebral Palsy Assessments
• Voluntary muscles poorly
controlled due to brain damage
• Spasticity, rigidity, ataxia,
repetitive involuntary gross
motor movements
Muscular Dystrophy
Assessments
Atrophy of voluntary muscles
Muscle weakness, lordosis,
falls
Parkinson’s Disease
months
6 to 18 months
• Bilateral Bryant’s traction
• Hip spica cast
Older child
• Open reduction
• Hip Spica cast
Scoliosis Implementations
• Exercises to strengthen
abdominal muscles (if
functional)
• Surgery: spinal fusion insertion
of Herrington Rod
• Milwaukee brace: used with
curves 30-40 degrees
• Wear 4-6 years, worn 23 hours
of the day, wear undershirt to
prevent irritation, teach
isometric exercises
Cerebral Palsy Implementations
• Ambulation devices, PT and OT
• Muscle relaxants and
anticonvulsants
• Feeding: place food at back of
mouth with slight downward
pressure. Never tilt head
backward.
• High calorie diet
• Braces to help
ambulation
• Balance activity and rest
Parkinson’s Disease
31
Assessments
• Deficiency of dopamine
• Tremors, rigidity, propulsive
gait
• Monotonous speech
• Mask like expression
Implementations
• Teach ambulation modification:
goose stepping walk
(marching), ROM exercises
• Medications—Artane, Cogentin,
L-Dopa, Parlodel, Sinemet,
Symmetrel

32
Myasthenia Gravis
Assessments
• Deficiency of acetylcholine
• Muscular weakness
produced by repeated
movement
• Dysphagia
• Respiratory distress
Myasthenia Gravis Implementations
• Good eye care, restful environment
• Medications—anticholinesterases,
corticosteroids,
immunosuppressants
• Avoid crisis: infection
• Symptoms: sudden ability to
swallow
33
Clear Full Low-fat Sodium High Low-residue
liquid liquid cholestero restricte roughag • Minimize
• No milk • No jam l d e, high intestinal
• No juice • No restricted • No fiber activity
with pulp fruit • Can cheese • No • Buttered
• No eat white rice white
nuts lean bread processed
meat withou food, no
• No t fiber whole
avoca wheat corn
do, bran
milk,
bacon,
egg
yolks
butter
High Renal Low-
protein • Keeps phenylala
diet protein nine diet
• Restab , • Preve
lish potassi nts
anabol um brain
ism to and dama
raise sodium ge
albumi low from
n • No imbala
levels beans, nce of
• Egg, no amino
roast cereals acids
beef , no • Fats,
sandw citrus fruits,
ich, fruits jams
• No allowe
junk d
food • No
meats
eggs
bread

34
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 • I&O
beta hemolytic • Daily weight
streptococcal throat • High Calorie, Low protein
infection

Urinary Diversion: Urinary Diversion Implementations

Assessments • Nephrostomy: flank incision and insertion of
• Done for: Bladder t nephrostomy tube into renal pelvis; penrose
umors, birth defects, drain after surgery; surgical dressing
neurogenic bladder, • Ureterosigmoidostomy: urters detached
interstitial cystitis from bladder and anastomosed to sigmoid
• Ileal Conduit colon; encourage voiding via rectum q 2-4
• Koch Pouch 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
35
 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 Acute Renal Failure

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

Hemodialysis Peritoneal Types of

Implementation Dialysis Peritoneal
• Check for thrill • Weight before Dialysis
and bruit q 8 and after • Continuous
hours treatment ambulatory
• Don’t use • Monitor BP (CAPD)
36
 extremity for BP, • Monitor breath • Automated
finger stick sounds • Intermittent
• Monitor vital • Use sterile • Continuous
signs, weight, technique
breath sounds • If problem with
• Monitor for outflow,
hemorrhage reposition client
• 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 Bipolar Disorder

Assessments Implementations
• Disoriented, flight of • Meet physical needs
ideas first
37
 • Lacks inhibitions,
agitated
• Easily stimulated by
environment
• Sexually indiscreet
• Affective disorder
• Maintain contact with
reality
• Elation is defense
against underlying
depression
• Manipulative behavior
results from poor self-
esteem
• Simplify environment
• Distract and redirect
energy
• Provide external
controls
• Set limits: escalating
hyperactivity
• Use consistent
approach
• Administer Lithium
(help Manic Phase of
Bipolar, keep
hydrated)
• Increase awareness of
feelings through
reflection

Schizophrenia Schizophrenia Schizophrenia

Assessments Types Implementations
• Withdrawal from • Disorganized— • Maintain safety—protect
relationships and inappropriate from erratic behavior
world behavior, transient • With hallucination—do
• Inappropriate hallucinations not argue, validate
display of feelings • Catatonic—sudden reality, respond to
• Hypochondriasis onset mutism, feeling tone, never
• Suspiciousness stereotyped further discuss voices
• Inability to test position, periods of (don’t ask to tell more
reality, regression agitation about voices)
• Hallucinations— • Paranoid—late • With delusions—do not
false sensory onset in life, argue, point out feeling
perceptions suspiciousness, tone, provide
• Delusions— ideas of diversional activities
persistent false persecution and • Meet physical needs
beliefs; grandeur delusions • Establish therapeutic
(feel higher rank); relationship
persecutory • Institute measures to
(beliefs to be a promote trust
victim); ideas of • Engage in individual,
reference (see group, or family therapy
people talking • Encourage client’s affect
38
 think talking about
them)
• Loose associations
• Short attention
span
• Inability to meet
basic needs:
nutrition, hygiene
• Regression
Paranoid Assessments
• Suspiciousness
• Cold, blunted affect
• Quick response with anger or
rage
Schizoid Assessments
• Shy and introverted
• Little verbal interaction
• Few friends
• Uses intellectualization
Schizotypal Assessments
• Eccentric
• Suspicious of others
• Blunted affect
• Problems with perceiving,
communicating
Antisocial Assessments
• Disregards rights of
others
• Lying, cheating,
stealing, promiscuous
• Lack of guilt
• Immature
• Irresponsible
• Associated with
substance abuse
• Accept nonverbal
behavior
• Accept regression
• Provide simple activities
or tasks
Paranoid Implementations
• Establish trust
• Low doses phenothiazines for
anxiety
• Structured social situations
Schizoid Implementations
• Establish trust
• Low doses phenothiazines for anxiety
• Structured social situations
Schizotypal Interventions
• Establish trust
• Low doses neuroleptics to
decrease psychotic symptoms
• Structured social situations
Antisocial
Implementations
• Firm limit-setting
• Confront behaviors
consistently
• Enforce consequences
• Group therapy
39
Borderline Assessments Borderline implementations
• Brief and intense
relationships
• Blames others for own
problems
• Impulsive, manipulative
• Self-mutilation
• Women who have been
sexually abused
• Suicidal when
frustrated, stressed
• Identify and verbalize
feelings
• Use empathy
• Behavioral contract
• Journaling
• Consistent limit-setting
• Group therapy

Narcissistic Assessments Narcissistic

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

Histrionic Assessments Histrionic

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

Dependent Assessments Dependent

• Passive Implementations
• Problem working • Emphasize decision-
independently making
• Helpless when alone • Teach assertiveness
40
 • Dependent on others for • Assist to clarify feelings
decisions and needs
• Fears loss of support
and approval

Avoidant Assessments Avoidant Implementations

• Socially uncomfortable
• Hypersensitive to
criticism, Lacks self-
confidence
• Fears intimate
relationships
• Gradually confront fears
• Discuss feelings
• Teach assertiveness
• Increase exposure to
small groups

Obssessive-compulsive Obssessive-compulsive
Assessments Implementations
• High personal standards • Explore feelings
for self and others • Help with decision-
• Preoccupied with rules, making
lists, organized • Confront procrastination
• Perfectionists • Teach that mistakes are
• Intellectualize acceptable

Manipulative behavior Manipulative Behavior

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

Acute Alcohol Intoxication Acute Alcohol

• Drowsiness Implementations
41
 • Slurred speech
• Tremors
• Impaired thinking
• Belligerence
• Loss of inhibitions
• Protect airway
• Assess for injuries
• Withdrawal assess
• IV glucose
• Counsel about alcohol
use

Alcohol After Alcohol Withdrawal

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

Chronic Alcohol Chronic Alcohol Dependence

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

Wernicke’s Syndrome Wernicke’s Syndrome

Assessments Implementations
• Confusion • Thiamine (IM or IV)
• Diplopia, nystagmus • Abstinence from alcohol
• Ataxia
• Apathy

Korsakoff’s Psychosis Korsakoff’s Psychosis

Assessments Implementations
42
 • Memory disturbances with
confabulation
• Learning problems
• Altered taste and smell
• Loss of reality testing
Retinopathy of
Prematurity Assessment
• Demarcation line with
ridge
• Retinal detachment
Strabismus (cross-eyed)
Assessments
• Deviation of eye
• Diplopia
• Tilts head or squints
Detached Retina
Assessments
• Flashes of light
• Loss of vision
• Particles moving in line
of vision
• confusion
Cataracts Assessments
• Distorted, blurred vision
• Milky white pupil
• Balanced diet
• Thiamine
• Abstinence from alcohol
Retinopathy of Prematurity
Implementations
• Prevent by using minimum
oxygen concentrations
• Monitor PO2
• Eye exam (premature infants)
Corrective lenses
Implementations
• Eye exercises
• surgery
Detached Retina
Implementations
• Bedrest, affected eye in
dependent position
• Eye patched (one or
both)
• Surgery
• Sedatives and
tranquilizers
• Avoid stooping, straining
at stool, strenuous
activity 3 months
Cataracts Implementations
• Postop: check for hemorrhage
• Check pupil—constricted with lens
implanted, dilated without lens
• Eye drops
• Night shield
• Sleep on unaffected side
43
Glaucoma Assessments
• Abnormal increase in
intraocular pressure that
leads to blindness
• Blurred vision
• Lights with halos
• Decreased peripheral
vision
• Pain
• Headache
Trigeminal Neuralgia
Assessments
• Stabbing, burning facial
pain
• Twitching of facial
muscles
Bell’s Palsy Assessments
• Inability to close eye
• Increased lacrimation
• Distorted side of face
Guillain-Barre Syndrome
Assessments
• Paresthesia
• Motor losses
beginning in lower
extremities
• Altered autonomic
function
Meningitis Assessments
• Nuchal rigidity
• Kerning’s sign
• Brudzinski’s sign
• Seizures
• Bulging fontanels
• High-pitched cry
Thoracentesis: no more than 1000cc taken at one time.
Glaucoma Implementations
• Administer miotics (constrict pupil, allows
more area for aqueous humor to flow),
carbonic anhydrase inhibitors
• Surgery
• Avoid heavy lifting, straining of stool
• Mydriatics (dilates pupil, makes angle
smaller and constrict aqueous flow) are
contraindicated with glaucoma.
Trigeminal Neuralgia Implementations
• Medications—analgesics, Tegretol
• Surgery
Bell’s Palsy Implementations
• Isometric exercises for face
• Prevent corneal abrasions
Guillain-Barre Syndrome
Implementations
• Medications—steroids
• Aggressive respiratory care
• Physical therapy
• Eye care
• Prevent complications: respiratory
and aspiration
Meningitis Implementations
• Medications—antibiotics, antifungals
• Prevent complications: droplet
precautions, contagious
44
Electroencephalogram (EEG)
Preparation
• Test brains waves; seizure
disorders
• Tranquilizer and stimulant meds
withheld for 24-48 hours
• Stimulants (caffeine, cigarettes)
withheld for 24 hours
• May be asked to hyperventilate
during test
• Meals not withheld
• Kept awake night before test;
want them to lie still
Electroencephalogram (EEG)
Post-test
• Remove paste from hair
• Administer medications
withheld before test
• Observe for seizure activity
• Seizure prodromal signs;
epigastric distress, lights
before the eyes

CAT 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 hours
hemorrhage) • Gradually elevate head of bed 30
• NPO 6 hours degrees (1st hour) and then 45 degrees
• Given sedative (2nd 2 hours)
• Position supine, lateral • Bedrest for 24 hours
with upper arms elevated • Check Vital signs
• Asked to hold breath for 5- • Check clotting time, platelets,
10 seconds hematocrit
• Report severe abdominal pain

Upper GI Series Barium Swallow: stool white from barium

Tracheostomy Tube Cuff

• Purpose—prevents aspiration of fluids
• Inflated
45
 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

Implementations Removal: Tubes:
• Use to utilize negative • Instruct patient • Constant bubbling in
pressure in lungs to do valsalva water-seal chamber=air
• Fill water-seal maneuver leak
chamber with sterile • Clamp chest • Tube becomes dislodged
water to 2 cm tube from patient, apply
• Fill suction control • Remove quickly dressing tented on one
chamber with sterile • Occlusive side
water to 20 cm dressing • Tube becomes
• Maintain system applied disconnected from
46
 below level of drainage system, cut off
insertion contaminated tip, insert
• Clamp only sterile connector and
momentarily to check reinsert
for air leaks • Tube becomes
• Ok to milk tubing disconnected from
towards drainage drainage system, immerse
• Observe for end in 2 cm of sterile
fluctuation in water- 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
47
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
48
 • 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

49
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.

50
Tracheostomy tube: use pre-cut/pre-made gauze pads.

Suction is always intermittent never continuous.

O universal donor/AB universal recipient.

ABO BLOOD TYPE

COMPATIBILITY
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 Isotonic Solution Hypertonic Solution

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

Change tubing Q72 hours

Change bottle Q24 hours

Infiltration
• Assessment: cool skin, swelling, pain, decrease in flow rate
• Implementation: discontinue IV, warm compresses, elevate arm, start
new site proximal to infiltrated site
IV Phlebitis, Thrmobophlebitis
• Assessment—redness, warm, tender, swelling, leukocytosis
51
 • 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

Actions: Medications effects:
• Stimulate the sympathetic Levophed • Dysrhythmias
nervous system: increase in Dopamine • Tremors
peripheral resistance, increase Adrenalin • Anticholinergic
blood flow to heart, Dobutrex effects
bronchodilation, increase blood Adrenergics Nursing
flow to skeletal muscle, Considerations:
increase blood flow to uterus • Monitor BP
• Stimulate beta-2 receptors • Monitor peripheral
in lungs pulses
• Use for cardiac arrest and • Check output
COPD

Anti-Anxiety Anti-Anxiety Anti-Anxiety

Action: Medications: Side effects:
• Affect • Librium, • Sedation
neurotransmitter Xanax, • Confusion
52
 s Ativan, • Hepatic dysfunction
Used for: Vistaril, Anti-Anxiety
• Anxiety Equanil Nursing Considerations:
disorders, manic • Potention for
episodes, panic addiction/overdose
attacks • 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 • Amphojel • Constipation
gastric acids • Milk of • Diarrhea
Used for: Magnesia • Acid rebound
• Peptic ulcer • Maalox Antacids
• Indigestion, Nursing Considerations:
reflex • Interferes with absorption of
esophagitis 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 • Lightheadedness
electrical sulfate • Hypotension
excitability of • Lidocaine • Urinary retention
heart • Pronestyl Antiarrhythmics
Used for: • Quinidine Nursing Considerations:
• Atrial • Isuprel • Monitor vital signs
53
 fibrillation and • Monitor cardiac
flutter rhythm
• Tachycardia
• PVCs

Aminoglycosides Aminoglycosides Aminoglycosides

(Antibiotics) (Antibiotics) (Antibiotics)
Action: Medications: Side effects:
• Inhibits protein • Gentamycin • Ototoxicity and
synthesis in • Neomycin Nephrotoxicity
gram-negative • Streptomycin • Anorexia
bacteria • Tobramycin • Nausea
Used for: • Vomiting
• Pseudomonas, • Diarrhea
E.Coli Aminoglycosides
(Antibiotics)
Nursing
Considerations:
• Harmful to liver and
kidneys
• Check 8th cranial
nerve (hearing)
• Check renal function
• Take for 7-10 days
• Encourage fluids
• Check peak/trough
level

54
 Allergy: 1st symptom SOB

Cephalosporin Cephalospori Cephalosporins (Antibiotics)

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

Fluoroquinolon Fluoroquinolon Fluroquinolones

es (Antibiotics) es (Antibiotics)
Action: (Antibiotics) Side effects:
• Interferes Medications: • Diarrhea
with DNA • Cipro • Decreased WBC and Hematocrit
replication in • Elevated liver enzymes (AST, ALT)
gram- • Elevated alkaline phosphatase
negative Nursing Considerations:
bacteria
Macrolide Macrolide • C&SMacrolide (Antibiotics)
before starting therapy
Used for:
(Antibiotics) (Antibiotics) • Encourage
Side effects:
fluids
• E.Coli,
Action: Medications: • Diarrhea
• Take 1 hour ac or 2 hour pc (food
Pseudomona
• Binds to cell • Erythromycin • Confusion
slows absorption)
s,membrane
S. Aureus and • Clindamycin • Hepatotoxicity
• Don’t give with antacids or iron
changes protein • Superinfections
preparation
function Nursing
• Maybe givenConsiderations:
with other medications
Used for: • Take
(Probenicid: for1hr ac or 2-3 hr pc
gout)
• Acute infections • Monitor liver function
• Acne • Take with water (no fruit
• URI juice)
• Prophylaxis 55 • May increase effectiveness
before dental of: Coumadin and
procedures if Theophylline
allergic to PCN (bronchodilator)
 Penicillin Penicillin Penicillin
Action: Medications: Side effects:
• Inhibits • Amoxicillin • Stomatitis
synthesis of • Ampicillin • Diarrhea
cell wall • Augmentin • Allergic reactions
Used for: • Renal and Hepatic
• Moderate to changes
severe Nursing Considerations:
infections • Check for
• Syphilis hypersensitivity
• Gonococcal • Give 1-2 hr ac or 2-
infections 3 hr pc
• Lyme disease • Cross allergy with
cephalosporins

Sulfonamides Sulfonamides Sulfonamides

(Antibiotics) (Antibiotics) (Antibiotics)
Action: Medications: Side effects:
• Antagonize • Gantrisin • Peripheral
essential • Bactrim Neuropathy
component of folic • Septra • Crystalluria
acid synthesis • Azulfidine • Photosensitivity
Used for: • GI upset
• Ulcerative colitis • Stomatitis
• Crohn’s disease Nursing Considerations:
• Otitis media • Take with meals or
• UTIs foods
• Encourage fluids
• Good mouth care
• Antacids will interfere
with absorption

56
Tetracyclines TEtracyclines Tetracyclines (Antibiotics)
(Antibiotics) (Antibiotics) Side effects:
Action: Medications: • Discoloration of primary teeth if
• Inhibits • Vibramycin taken during pregnancy or if
protein • Panmycin child takes at young age
sythesis • Glossitis
Used for: • Rash
• Infections • Phototoxic reactions
• Acne Nursing considerations:
• Prophylaxis • Take 1 hr ac or 2-3 hr pc
for opthalmia • Do not take with antacids, milk,
neonatorum iron
• 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

57
 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 • Pro-Banthine • Blurred vision
acethylcholine and • Atropine • Dry mouth
blocks • Scopolamine • Urinary retention
parasympathetic • Chage in heart rate
nerves (affects Nursing
heart, eyes, Consideration:
respiratory tract, GI • Monitor output
tract and the • Contraindicated
bladder) with glaucoma
• Dilates pupil, • Give 30 min ac, hs,
causes or 2hr pc
bronchodilation and
• Contraindicated:
decreased
paralytic ileus, BPH
secretions
• Decrease GI
motility secretions
Used for:
• Opthalmic exam
• Motion sickness
• Pre-operative

58
Anticoagulants Anticoagulan Anticoagulants (Heparin)
Action: ts Side Effects:
• Blocks Medications: • Hematuria
conversion of • Heparin • Tissue irritation
prothrombin to Nursing Considerations:
thrombin • Monitor clotting time or Partial
Used for: Thromboplastin Time (PTT)
• Pulmonary • Normal 20-45 sec
embolism • Therapeutic level 1.5-2.5 times
• Venous control
thrombosis • Antagonist—Protamine Sulfate
• Prophylaxis • Give SC or IV
after acute MI

Anticoagulant Anticoagul Anticoagulant (Coumadin)

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

59
Anticonvulsants Anticonvulsant Anticonvulsant
Action: Medications: Side effects:
• Decreases flow • Dilantin • Respiratory depression
of calcium and • Luminal • Aplastic anemia
sodium across • Depakote • Gingival hypertrophy
neuronal • Tegretol • Ataxia
membranes • Klonopin Nursing Considerations:
Used for: • Don’t discontinue abruptly
• Seizures • Monitor I&O
• Caution with use of
medications that lower
seizure threshold: MAO
inhibitors & anti-psychotics
• Good mouth care
• Take with food
• May turn urine pinkish-
red/pinkish-brown

60
Anti-Depressants Anti- Anti-Depressants
Monoamine Depressants (Monoamine Oxidase
Oxidase Inhibitors (Monoamine Inhibitors)
(MAO) Oxidase Side effects:
Action: Inhibitors) • Hypertensive Crisis (Sudden
• Causes Medications: headache, diaphoretic,
increases • Marplan palpitations, stiff neck,
concentration of • Nardil intracranial hemorrhage) with
neurotransmitter • Parnate food that contain Tyramine
s Nursing Considerations:
Used for: • Avoid foods containing
• Depression Tyramine: Aged cheese, liver,
• Chronic pain yogurt, herring, beer and
Anti-Depressants Anti- wine, sour cream, bologna,
Anti-Depressants
Selective Depressants Selective pepperoni, salami, bananas,
Serontonin
Serontonin Selective raisins,Inhibitors
Reuptake and pickled products
(SSRI)
Reuptake Serontonin Side• effects:
Monitor output
Inhibitors (SSRI) Reuptake ••Anxiety
Takes 4 weeks to work
Action: Inhibitors ••GI
Don’t
upset combine with
• Inhibits CNS (SSRI) • sympathomometics
Change in appetite and
uptake of Medications: vasoconstrictors,
bowel function and cold
serotonin • Paxil medications
• Urinary retention
Used for: • Prozac Nursing Considerations:
• Depression • Zoloft • Suicide precautions
• Obsessive- • Takes 4 weeks for full effect
Compulsive • Take in a.m.
Disorder • May urine to pinkish-red or
• Bulimia Pinkish-brown
• Can be taken with meals
Anti-Depressants Anti- Anti-Depressants
(Tricyclics) Depressants (Tricyclics)
Action: (Tricyclics) Side Effects:
• Inhibits Medications: • Sedation/Confusion
reuptake of • Norpramin • Anticholinergics
neurotransmitter • Elavil affects
s • Tofranil • Postural Hypotension
Used for: • Urinary retention
• Depression Nursing Considerations:
• Sleep apnea • Suicide precautions/2-
6 weeks to work
61 • Take at hs/Don’t
abruptly halt
• Avoid alcohol/OTC
/Photosensitivity
 Insulin Insulin Insulin Insulin
(Regular, (NPH, Humulin (Ultralente, (Humulin
Humulin R) N) Humulin U) 70/30)
Type: Fast Type: Type: Slow acting Type:
acting Intermediate Onset: 4hr Combination
Onset: ½ -1 hr acting Peak: 8-20hr Onset: ½ hr
Peak: 2-4 hr Onset: 2hr Duration: 24-36hr Peak: 2-12hr
Duration: 6-8 hr Peak: 6-12hr Duration: 24hr
Duration 18-26hr

Antidiabetic Antidiabetic Antidiabetic Agents

Agents Agents Side Effects:
Action: Medications: • Hypoglycemia
• Stimulates • Diabinese • Allergic skin reactions
insulin release • Orinase • GI upset
from beta cells • Dymelor Nursing Considerations:
in pancreas • Micronase • Take before breakfast
Used for: • Monitor glucose levels
• Type 2 • Avoid alcohol, sulfonamides, Oral
diabetes Contraceptives, (MAO), aspirin
(NIDDM) because they help to make drug
work better

Hypoglycemic Hypoglycemic Hypoglycemic Agent

Agent Agent Side Effects:
Action: Medication: • Hypotension
• Stimulates liver • Glucagon • Bronchospasm
to change Nursing Considerations:
glycogen to • May repeat in 15min
glucose • Give carbohydrates orally to
Used for: prevent secondary
• Hypoglycemia hypoglycemic reactions

Antidiarrheals Antidiarrheals Antidiarrheals

Action: Medications: Side Effects:
• Slows • Kaopectate • Constipation
peristalsis • Lomotil • Anticholinergic effects
62
 • Increases • Imodium (urinary retention, dry mouth)
tone of • Paregoric Nursing Considerations:
sphincters • Do not use with abdominal
Used for: pain
• Diarrhea • Monitor for urinary retention
• Give 2hr before or 3 hr after
other meds

Antiemetics Antiemetics Antiemetics

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

Antifungals Antifungals Antifungals

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

Antigout Agents Antigout Agents Antigout Agents

Action: Medications: Side Effects:
• Decreases • Colchicine • Agranulocytosis
production • Probenecid • GI upset
63
 and • Zyloprim • Renal calculi
resorption of Nursing Considerations:
uric acid • Monitor for renal calculi
Used for: • Give with food, milk, antacids
• Gout

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 • Give with food
to blood • Use sunscreen
• Avoid alcohol

Antihyperlipidemic Antihyperlipide Antihyperlipidemic

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

Antihypertensives Antihypertensiv Antihypertensives

Types: ACE Inhibitors es (ACE Inhibitors)
Action: (ACE Inhibitors) Side Effects:
• Blocks ACE in Medications: • GI upset
lungs • Capoten • Orthostatic hypotension
Used for: • Vasotec • Dizziness
• Hypertension Nursing Considerations:
• CHF • Give 1hr ac or 3hr pc
• Change position slowly
64
Antihypertensives Antihypertensive Antihypertensives
Type: Beta-Adrenergic s Type: Beta-Adrenergic
Blockers Type: Beta- Side Effects:
Action: Adrenergic • Changes in heart
• Blocks Beta- Medications; rate
Adrenergic Receptors • Nadolol • Hypotension
• Decrease • Propranolol • Bronchospasm
excitability/workload • Tenormin Nursing Considerations:
of heart, oxygen • Timoptic • Masks signs of shock
consumption and hypoglycemia
• Decrease • Take with meals
Used for: • Do not discontinue
• Hypertension abruptly
• Angina
• SVT

Antihypertensives Antihypertensi Antihypertensive

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

65
Antihypertensives Antihypertensives Antihypertensives
Type: Centrally Type: Centrally acting Type: Centrally acting alpha-
acting alpha- alpha-adrenergics adrenergics
adrenergics Medications: Side Effects:
Action: • Aldomet • Sedation
• Stimulates • Catapres • Orthostatic
alpha Hypotension
receptors in Nursing Considerations:
medulla which • Don’t discontinue
causes a abruptly
reduction in • Monitor for fluid
sympathetic in retention
the heart • Change position slowly
Used for:
• Hypertension
Antihypertensives Antihypertensives Antihypertensives
Type: Direct-acting Medications Side Effects:
vasodilators • Hydralazine • Tachycardia
Action: • Minoxidil • Increase in body hair
• Relaxes Nursing Considerations:
smooth muscle • Teach patient to check
Used for: pulse
• Hypertension

Antihypertensives Antihypertensives Antihypertensives

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

Bipolar Disorder Bipolar Disorder Bipolar Disorder

Action: Medications: Side Effects:
• Reduces • Lithium (1- • GI upset
catecholamin 1.5meq/L) • Tremors
66
 e release • Tegretol • Polydipsia
Used for: • Depakote • Polyuria
• Manic Nursing
episodes Considerations:
• Monitor serum
levels
• Give with
meals
• Increase fluid
intake

Antineoplastic Antineoplastic Antineoplastic Agents

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

Antineoplastic Antineoplastic Antineoplastic

Agents Agents Agents
Type: Antimetabolites Antimetabolites
Antimetabolites Medications: Side Effects:
Action: • 5-FU • Nausea
• Inhibits DNA • Methotrexate • Vomiting
polymerase • Hydrea • Oral
Used for: ulceration
• Acute • Bone marrow
67
 lymphatic suppression
leukemia • Alopecia
• Cancer of Nursing
colon, breast, Considerations:
pancreas • Monitor
hematopoietic
function
• Good mouth
care
• Discuss body
image
changes

Antineoplastic Antineoplastic Antineoplastic Agents

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

Antineoplastic Antineoplastic Antineoplastic Agents

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

Antineoplasti Antineoplasti Antineoplastic Agents

c Agents c Agents Type: Vinca Alkaloids
Type: Vinca Type: Vinca Side Effects:
68
Alkaloids Alkaloids • Stomatitis
Action: Medications: • Alopecia
• Interferes • Oncovin • Loss of reflexes
with cell • Velban • Bone marrow suppression
division Nursing Considerations:
Used for: • Give antiemetic before administration
• Cancer • Check reflexes
• Given with Zyloprim to decrease uric
acid

Antiparkinson Antiparkinson Antiparkinson Agents

Agents Agents Side Effects:
Action: Medications: • Dizziness
• Converted to • Artane • Ataxia
Dopamine • Cogentin • Atropine-like effects: dry
• Stimulates • L-Dopa mouth, urinary retention
postsynaptic • Parlodel Nursing Considerations:
Dopamine • Sinemet • Monitor for urinary retention
receptors • Symmetrel • Large doses of vitamin B6
Used for: reverse effects
• Parkinson’s • Avoid use of CNS depressants
disease
Antiplatelet Antiplatelet Antiplatelet Agents
Agents Agents Side Effects:
Action: Medications: • Hemorrhage
• Interferes • Aspirin • Thrombocytopenia
with platelet • Persantine Nursing Considerations:
aggregation • Check for signs of bleeding
Used for: • Give with food or milk
• Venous
thrombosis
• Pulmonary
embolism

Antipsychotic Antipsychotic Antipsychotic

Agents Agents Agents
Action: Medications: Side Effects:
• Blocks • Haldol • Akathisia
dopamine • Thorazine (inability to sit
receptors in • Mellaril still)
69
 basal ganglia • Stelazine • Dyskinesia
Used for: • Dystonias
• Acute and • Parkinson’s
Chronic syndrome
psychoses • Tardive
dyskinesias
• Leukopenia
Nursing
Considerations:
• Check CBC
• Monitor vital
signs
• Avoid alcohol
and caffeine

Atypical Atypical Atypical

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

Antipyretic Agents Antipyretic Antipyretic

Action: Agents Agents
• Antiprostaglandin Medications: Side Effects:
activity in • Tylenol • GI irritation
hypothalamus (Acetaminoph Nursing
Used for: en) Considerations:
• Fever • Monitor liver
function
• Aspirin
70
 contraindicate
d for younger
than 21 years
old due to risk
of Reye’s
syndrome

Antithyroid Agents Antithyroid Antithyroid Agents

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

Thyroid Thyroid Thyroid

Replacement Replacement Replacement
Agents Medications Side Effects:
Action: • Synthroid • Nervousness
• Increases • Cytomel • Tachycardia
metabolic rate • Weight loss
Used for: Nursing
• Hypothyroidism Considerations:
• Monitor pulse
and BP
• Monitor weight
• Take in a.m.
• Enhance
action of
anticoagulants
,
71
 antidepressant
s, decrease
action of
insulin and
digitalis

Antitubercular Antitubercular Antitubercular

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

Attention Attention Attention

Disorder Agents Disorder Agents Disorder Agents
Action: Medications: Side Effects:
• Increases • Ritalin • Restlessness

72
 level of • Cylert • Insomnia
catecholamin • Dexedrine • Tachycardia
es • Palpitations
Used for: Nursing
• ADDH Considerations:
• Narcolepsy • Monitor
growth rate
• Monitor liver
enzymes
• Give in A.M.

Bronchodilators Bronchodilators Bronchodilators

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

ardiac Cardiac Cardiac Glycosides

ycosides Glycosides Side Effects:
73
tion: Medication: • Bradycardia
• Increases • Lanoxin • Nausea
force of (Digoxi • Vomiting
myocardial n) • Visual disturbances
contraction, Nursing Considerations:
slows rate • Take apical pulse
ed for: • Notify physician if adult <60,
• Left-sided child <90-110, <70 in older
CHF 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 • Tensilon • Bronchoconstriction
destruction of • Prostigmin • Respiratory paralysis
acetylcholine • Hypotension
• Stimulate Nursing Considerations:
parasympath • Give with food or milk
etic nervous • Monitor vital signs,
system especially respirations
(increase • Antidote: Atropine
bowel tone, Sulfate
increase • Toxicity: excessive
bladder tone, salivation, excessive
constrict sweating, abdominal
pupil) cramps, flushing
Used for:
• Myasthenia
gravis
• Post-
operative
• Postpartum
urinary
retention

Diuretics Diuretics Diuretics

Action: Medications: Side Effects:
74
 • Inhibits • HydroDIURIL • Dizziness
reabsorption • Diamox • Orthostatic
of sodium and • Aldactone Hypotension
water • Lasix • Leukopenia
• Blocks effects • Hygroton Nursing
of Considerations:
aldosterone • Take with
Used for: 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, tachycardi
Glucocorticoids Glucocorticoids Glucocorticoids
Action: Medications: Side Effects:
• Stimulates • Solu-Cortef • Psychoses
formation of • Decadron • Depression
glucose • Deltasone • Hypokalemia
• Alters • Stunted
immune growth
response • Buffalo Hump
Used for: Nursing
• Addison’s Considerations:
disease • Monitor fluid
• Crohn’s and
disease electrolyte
• COPD balance
• Leukemias • Don’t
discontinue
abruptly
• Monitor for
signs of
infection

Mineralocorticoi Mineralocorticoi Mineralocorticoids

ds ds Side Effects:
Action: Medications: • Hypertension
• Increases • Florinef • Edema
75
 sodium • Hypokalemia
reabsorption Nursing Considerations:
• Potassium • Monitor BP, I&O,
and hydrogen Weight, and
ion secretion Electrolytes
in kidney • Give with food
Used for: • Low-sodium, High-
• Adrenal protein, High-
insufficiency potassium diet

Heavy Metal Heavy Metal Heavy Metal

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

H2 Receptor Blockers H2 Receptor H2 Receptor

Action: Blockers Blockers
• Inhibits action of Medications: Side Effects:
histamine and • Tagamet • Dizziness
gastric acid • Zantac • Confusion
secretion • Hypotension
Used for: • Impotence
• Ulcers Nursing
• Gastroesophageal Considerations:
76
 reflux • Take with
meals and hs
• Smoking
decreases
effectiveness
• Monitor liver
function and
CBC

Immunosuppress Immunosuppress Immunosuppressants

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

Miotics Miotics Miotics

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

77
 Mydriatics (Dilates Mydriatics Mydriatics
Pupil) Medications: Side Effects:
Action: • Atropine • Tachycardia
• Anticholinergic sulfate • Blurred vision
actions leaves • Cyclogyl • Photophobia
pupil under • Dry mouth
unopposed Nursing Considerations:
adrenergic • Contraindicated
influence with glaucoma
Used for: • Apply pressure on
• Diagnostic lacrimal sac for
procedures 1min.
• Acute iritis • Wear dark glasses
• Uveitis

Narcotics Narcotics Narcotics

Action: Medications: Side Effects:
• Acts on CNS • Morphine • Dizziness
receptor cells Sulfate • Sedation
Used for: • Codeine • Respiratory
• Moderate to • Demerol depression
severe pain • Dilaudid • Hypotension
• Preoperative • Percodan • Constipation
• Postoperative Nursing Considerations:
• Safety precautions
• Avoid alcohol
• Monitor vital signs
• Use narcotic
antagonist if
necessary (Narcan)

Antianginals Antianginals Antianginals

Action: Medications: Side Effects:
• Relaxes • Nitroglycerine • Hypotension
smooth • Isosorbide • Tachycardia
muscle • Headache
• Decreases • Dizziness
venous Nursing Considerations:
return • Check expiration date
78
Used for: • Teach when to take
• Angina medication
• Peri- • May take Q5min x3
operative doses
hypertension • Wet with saliva and
• CHF 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 Nursing Considerations:
moderate • Take with food or after
pain 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 • Streptokinase • Bleeding
blood clots • Urokinase • Bradycardia
Used for: • Tissue • Dysrhythmias
• Acute Pulmonary Plasminogen Nursing
Emboli Activator Considerations:
• Thrombosis • Monitor for
• MI bleeding
• Contraindicated in: • Have Amino
hemophilia, CVA, Caproic Acid
Trauma, not used in Available
patients over 75 years • Check pulse,
old, not used in color, sensation
patients taking of extremities
anticoagulants • Monitor EKG

79
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
80
 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 6-9 Months

with tuberculosis be on
medication?
Inflammation of Liver
Jaundice
Anorexia
RUQ pain
What are symptoms of Clay-colored stools, tea-
hepatitis? colored urine
Pruritis (bile salts eliminated
through skin)
Elevated ALT, AST
Prolonged PT (liver
involvement with clotting
factor)
What is the transmission Fecal/Oral
of Hepatitis A? Consume contaminated food
or water
Travelers to developing
countries at risk
Clients with hepatitis A
should not prepare food for

81
 others
What is the transmission Parenteral/Sexual contact
of 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 Blood or body fluids
of Hepatitis C? Can become chronic disease
Seen in patients with
hemophilia (unable to clot)
What is the transmission Co-infects with hepatitis B
of Delta Hepatitis?
What nursing care are Rest (mainly for liver)
recommended for Contact and standard
Hepatitis? 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
Disease? develops into lesion with
clear center (Bull’s-eye)
Regional lymphadenopathy
Flu-like symptoms (fever,
headache, conjunctivitis)
Can develop over 1 to several
months
82
What is Stage 2 of Lyme’s Develop after 1 to 6 months
Disease? if disease untreated.
Cardiac conduction defects
Neurologic disorders (Bell’s
palsy, temporary paralysis)
What is Stage 3 of Lyme’s Develops after 1 to several
Disease? months, if reached at this
stage may persist for several
years.
Arthralgias
Enlarged, inflamed joints
What are some Lyme’s Cover exposed areas when in
Disease teaching? wooded areas
Check exposed areas for
presence of ticks

What are some Lyme’s Antibiotics 3-4 weeks

Disease nursing care? Stage 1 use Doxicillin
IV penicillin with later stages
What are the treatment, Painless chancre fades after
mode of transmission, 6 weeks
care, signs and symptoms Low grade fever
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, If female maybe
mode of transmission, asymptomatic and will be
care, signs and symptoms unaware of having disease.
of gonorrhea? Males may have thick
discharge from urethra.
Some females from vagina.
Spread mucous membranes,
congenital
83
 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, No cure.

mode of transmission, Painful vesicular genital
care, signs and symptoms lesions
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, Men: urethritis, dysuria
mode of transmission, Women: thick vaginal
care, signs and symptoms discharge with acrid odor
of Chlamydia? Spread by mucous
membranes, congenital
Treatment with Tetracycline
or Doxycycline PO
Will cause sterility if left
84
 untreated.
Important to notify sexually
contacted.
What are the treatment, Single, small papillary lesion
mode of transmission, spreads into large cauliflower
care, signs and symptoms cluster on perineum, vagina,
of Venereal Warts? penis.
May itch or burn.
Spread by mucous
membranes, congenital
Treatment: Curettage,
cryotherapy with liquid
nitrogen, kerotolytic agents
Avoid intimate contact until
lesions heal
Complication: Genital
Dysplasia Cancer
What is the difference HIV Positive—presence of HIV
between AIDS and HIV +? in blood
AIDS—has significant defects
in immune function
associated with positive HIV
evidenced by development of
opportunistic infections
Syndrome where CD4 counts
are below 200
What are some P. Carinii Pneumonia:
opportunistic infections of sob/dry-nonproductive cough
AIDS? C. Albicans stomatitis: will
have difficulty swalling and
white exudates in back of
throat
C. Neoformans: debilitating
form of meningitis that may
suffer seizures.
Cytomegalovirus (CMV): will
experience lymphadenopathy
and may have visual
impairment and can affect
any organ.
Kaposi’s Sarcoma: most
85
 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
associated with AIDS? confirmed by Western Blot
test
HIV Viral culture: Leukopenia,
Thrombocytopenia, Decrease
CD4 counts

What are some nursing Prevention: avoid IV drug

cares for AIDS? use, precautions regarding
sexual patterns, use standard
precautions
Contact and standard
precautions
High-protein and high-calorie
diet, small frequent meals
rather than 3 large meals
Symptomatic relief
Support
Don’t share
toothbrush/shavers
What are treatments, Prevention most important.
care, prevention of poison Treat patient first, and then
control? the poison.
Recognize signs of symptoms
of accidental poison: changes
in appearance, behavior,
substances around mouth,
empty containers, vomitous.
What should happen when Call poison control center.
86
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 Syrup of Ipecac with small
treatment is used to amount of water. Don’t give
induce vomiting and what large amount of fluid after
other factors need to be Ipecac, will increase gastric
implemented? emptying.
Don’t use milk.
Position with head lower then
chest.
No universal antidote.

What should happen to Intubated if comatose

poison control in Run blood gases
emergency care? IV fluids
Cardiac Monitor
Gastric Lavage (NG down to
flush with NS to remove rest
in stomach)
Activated Charcoal
May use cathartics, diuretics
What are signs and Tinnitus, change in mental
symptoms, treatments, status, Increased
care, prevention of aspirin temperature,
poisoning? hyperventilation, bleeding,
nausea and vomiting.
Nursing care: induce
vomiting, maintain hydration,
reduce temperature (sponge
baths), monitor for bleeding.

87
What are signs and
symptoms, treatments,
care, prevention of tylenol
poisoning?
What are signs and
symptoms, treatments,
care, prevention of lead
toxicity?
What are nursing care
goals for Hazardous
wastes?
Symptoms: nausea/vomiting,
hypothermia, If no treatment,
hepatic/liver involvement.
If liver gets involved patient
may have RUQ pain,
jaundice, confusion, and
coagulation abnormalities.
Nursing care: induce
vomiting, maintain hydration,
monitor liver and kidney
function with labs such as
AST/ALT enzymes.
Tylenol (Acetaminophen)
overdosage:
Antidote N-acetylcysteine
(Mucomyst)
Symptoms: Irritability,
decreased activity,
abdominal pain, Increased
ICP
Diagnostic tests: Blood lead
levels (>9micrograms =
toxic), Erythrocyte
protoporphyrin (EP), X-ray
long bones (lead deposits in
long bones)
Children engage in PICA
(ingesting nonfood
substances)
Lead blocks formation of
hemogloblin and toxic to
kidneys.
Nursing care: identify source,
chelating agents, teaching
parents
Decontaminate individual
Prevent spread of
contamination
Clean and remove
contaminuated source
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 Monitor personnel exposed
What are nursing care for If chemical poses threat to
Hazardous wastes? caregiver, decontaminate
patient first.
If chemical poses no threat or
patient has been
decontaminated, begin care.
If immediate threat to life,
put on protective garments
and provide care to stabilize
patient.
What type of play do Solitary play. Game is one
infants (0-12months) use? sided. Like to play with body
parts.
Birth-3months: smile/squeal
3-6months: rattles/soft stuff
toys
6-12 months: begin imitation,
peek-a-boo, patty-cake

What type of play do Parallel play.

toddlers (1-3years) use?
What type of play do pre- Associative play. Dress
schoolers (3-6years) use? up/imitating play. Talking on
telephone/kitchen/tool belt
What type of play do Cooperative play.
school age (6-12years) Conformed/organized play.
use?
According to Erikson’s Birth-18 months.
Developmental Task, Trust vs. Mistrust
explain the Infancy stage. Positive outcome---trusts self
Negative outcome---
withdrawn
According to Erikson’s 18months – 3 years
Developmental Task, Autonomy vs. Shame and
explain the Toddler stage. Doubt
Positive outcome---exercise
self-control
Negative outcome---defiant
and negative
According to Erikson’s 3-6 years
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Developmental Task, Initiative vs. Guilt
explain the Preschool Children develop conscience
stage. at this age.
Positive Outcome---learns
limits
Negative Outcome---fearful,
pessimistic

According to Erikson’s 6-12years

Developmental Task, Industry vs. Inferiority
explain the School age Positive---sense of confidence
stage. Negative---self doubt,
inadequate
According to Erikson’s 12-20 years
Developmental Task, Identity vs. Role diffusion
explain the Adolescence Positive outcome---coherent
stage. sense of self
Negative outcome---lack of
identity
According to Erikson’s 20-45 years
Developmental Task, Intimacy vs. Isolation
explain the young adult Positive outcome---intimate
stage. relationships/careers formed
Negative outcome---
avoidance of intimacy
According to Erikson’s 45-65 years
Developmental Task, Generativity vs. Stagnation
explain the middle Positive Outcome---creative
adulthood stage. and productive
Negative Outcome---self
centered
According to Erikson’s 65+ years
Developmental Task, Integrity vs. Despair
explain the Late No regrets in life or Regrets
adulthood stage. Positive outcome---seems life
as meaningful
Negative outcome---life lacks
meaning
At what month does the 1 month
head sag?
At what month do you see 2 months
90
closing of posterior
fontanelle, turn from side
to back, and see a social
smile?
What toys do you give for Mobiles, wind up infant
a 2 month old? swings, soft clothes, and
blankets.
At what month does a 3 months
child bring objects to
mouth and head erect?

What toys do you give for Rattles, cradle gym, and

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

Explain introduction of One food at a time.

solid 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 Walks alone.
15 months? Throws object.
Holds spoon.
Say 4-6 words. Understand
simple commands.
What does a toddler do at Anterior fontanelle closes.
18 months? Climbs stairs.
Sucks thumb.
Say 10 + words.
Temper Tantrums.

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What does a toddler do at 300 world vocabulary.
24 months? Obeys easy commands.
Go up/down stairs alone.
Build towers.
Turn doorknobs/unscrew lids.
Increase independence.
What does a toddler do at Walk tip toe.
30 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 Cooking utensils, Dress-up
included for Toddlers? clothes, rocking horses,
finger paints, phonographs,
cd players.
How do you avoid Don’t ask no/yes questions.
negativism during toddler Offer them choices.
ages? 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,
preschool (3-5)? Housekeeping toys, Coloring
books, tricycle with helmet.
Which age groups has Preschool age children.
greatest number of fears?
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What would you expect Self-centered, show off, rude
with a 6 year old? Sensitive to criticism
Begins loosing temporary
teeth
Tends to lie.
What would you expect Team games/sports.
with a 7 year old? Concept of time.
Playing with same sex child.
What would you expect Seeks out friends.
with a 8 year old? Writing replaces printing.
What would you expect Conflicts between peer
with a 9 year old? groups and parents.
Conflicts between
independence and
dependence.
Likes school.
Able to take on job duties
(housework).
What toys are used for Construction toys, Pets,
school age child? Games, Electronic games,
reading, books, bicycles with
helmets.
School age potential Anuresis (encourage before
problems include: bed time)
Encopresis
Head lice
What are Thin upper lip, vertical ridge
symptoms/indications of a in upper lip, short up turned
fetal alcohol syndrome in nose, mental retardation,
a child? motor retardation, hearing
disorders, microcephaly.
Avoid alcohol 3 months
before conception and
throughout pregnancy.
What happens with 16th week detects genetic
amniocentesis? What abnormality
does it do? 30th week detects L/S ratio:
lung maturity
Void before procedure
Ultrasound given to
determine position of
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 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
stress test? fetal movement.
Favorable result: 2+ FHR
accelerates by 15bpm and
last 15seconds in 20 minutes.
What happens with a Determines placenta’s
contraction stress test? response to labor.
Done after 28th week.
Fowler/Semi-Fowler.
Given Oxytocin or Pitocin.
Results:
• Positive: Late
decelerations indicates
potential risk to fetus.
• Negative: No late
decelerations.

What does Torch stand Diseases that cross placenta

for? And their or other events. Produce
importance? significant deformities or
infant born with infectious
process.
Toxoplasmosis: no litter box
changed, no gardening, no
95
 under cooked meats.
Rubella: 1-16 titer immune
for rubella, titer <1-8
susceptible.
Cytomegalovirus: transmitted
in body fluids.
Herpes Simplex: Ascending
infection. During pregnancy
get treated with acyclovir.
Delivery through c-section.
What concerns for clients UTI: may lead to
that have UTI, Syphilis, pylonephritis, increase risk of
Gonorrhea? premature birth.
Syphillis: passes through
placenta, causes 2nd trimester
abortions, still birth, and
congenital infection, may
receive medication for her
and her baby.
Gonorrhea: baby gets
prophylactic eydrops.
What are the danger signs • Gush or fluid bleeding
of pregnancy? from vagina
• Regular uterine
contractions
• Severe headaches,
visual disturbances,
abdominal pain,
persistent vomiting
(symptoms of PIH)
• Fever or chills
(symptoms of infection)
• Swelling in face or
fingers (symptoms of
PIH)
What are the events in Lightening: (when baby drops
the onset of labor? to pelvis)
• Primipara: occurs 2
weeks before delivery
• Multipara: occurs during
labor
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 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 Premature rupture of
umbilical cords happen? membranes.
Presenting part not engaged.
Fetal distress.
Protruding cord.
What do you do when a Call for help.
client has a prolapsed Push up against presenting
cord? part off of the cord.
Place in trendenlenberg
position or knee chest
position.
Successful if FHT left
unchanged.
What is a early/sign of Early sign: fetal tachycardia
fetal hypoxia? >160 in >10minutes
Late sign: fetal bradycardia
<110 in > 10 minutes
What things should you Nurse can witness patient
know about the Informed sign form.
Consent form? Patient has to be age of
capacity/adult and confident.
No confused
patient/drinking/already
received preoperative
medications.
Consent must be given
voluntarily and information
understandable. Nurse must
make sure questions are
answered and form is
attached to chart.
What is early Decrease in HR before peak
deceleration? of contraction. Indication of
head compression.
97
What are interventions for Position mother left
late decelerations? side/trendenlenberg/knee
chest
Increase rate of IV
Administer Oxygen 7-10 l/min
DC Oxytocin
What do variable Cord compression.
decelerations indicate? Change maternal position.
Administer oxygen.
DC Oyxtocin/Pitocin
What are signs of “True Regular contractions
Labor”? increasing in frequency,
duration, intensity
Discomfort radiates from
back
Contractions do not decrease
with rest
Cervix progressively effaced
and dilated.
What are characteristics Irregular contractions, no
of a “False Labor”? change in frequency,
duration, intesityDiscomfort
is abdominal
Contractions decrease with
rest or activity
No cervical changes
Prior to Lumbar Epidural Void
block what should the
patient do?
What should be Establish airway
implemented during the Check Apgar at 1 and 5
delivery of a newborn? minutes
Clamp umbilical cord
Maintain Warmth
Place ID band on mother and
infant
What are the types of Rubra-bloody, day 1-3
Lochia? Serosa-pink-brown, day 4-9
Alba-yellow-white, 10+ days
If fundus is displaced not Bladder distended.
98
centrally and off to the
sides means?
If client soaks pad in 15 Check for hemorrhage
minutes or pooling of
blood?
What are assessments Unilateral lower quadrant
and implementations for pain.
an “Ectopic Pregnancy”? Rigid, tender abdomen
Low Hct and hCG levels
Bleeding
Monitor for shock
Administer RhoGAM
Provide support
What are assessments A placenta that’s implanted
and implementations for in the lower uterine segment
“Placenta Previa”? near cervical os, during
pregnancy placenta is torn
away causing:
First and second trimester
spotting
Third and trimester
painless, profuse bleeding
Bedrest side-lying or
trendelenburg position,
ultrasound to locate placenta,
no vaginal or rectal exams,
amniocentesis for lung
maturity, daily Hgb, Hct,
Monitor bleeding
What are the assessments The premature separation of
and implementation for a placenta that is implanted
“Abruptio Placentae”? in a correct position.
Painful vaginal bleeding
Abdomen tender, painful,
tense
Possible fetal
distress/Contractions
Monitor for maternal and
fetal distress
Prepare for immediate
delivery
99
 Monitor for complications:
DIC, pulmonary emboli
What are assessments Hyperglycemia after 20
and implementations for weeks
Gestational Diabetes Usually controlled by diet
Mellitus (GDM)? Oral hypoglycemic
medications contraindicated
Test for diabetes at 24-28
weeks on all women with
average risk 20.
Frequent monitoring of
mother/fetus during
pregnancy.
Teach to eat prescribed
amount of food daily at same
times
Home glucose monitoring
Teach about change in insulin
requirements
What are assessments Elevated hCG
and implementation for a Uterine size larger than
Hydatidiform Mole? expected for dates
No FHT
Minimal dark red/brown
vaginal bleeding with grape
like clusters
Nausea and vomiting
Associated with PIH
Curettage to remove tissue
Pregnancy discouraged for 1
year
Do not use IUD
hCG levels monitored for 1
year
What are the newborn Temp. 97.7-99.7
vital signs? HR sleep 100, awake 120-
140, 180 crying
Resp 30-60
BP arm/calf 65/41
What are assessments Caused by immature hepatic
and implementation for function
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Hyperbilirubinemia? Physiological Jaundice (No
treatment required)
• Seen after 24 hours
• Peaks at 72 hours
• Lasts 5-7 days
Breast-Feeding Associated
Jaundice (Frequent breast
feeding)
• Caused by poor milk
intake
• Onset 2-3 days
• Peaks 2-3 days
Breast Milk Jaundice
(discontinue breast feeding
for 24 hours)
• Caused by factor in
breast milk
• Onset 4-5 days
• Peak 10-15 days
Hemolytic Disease
(Phototherapy then exchange
transfusion)
Caused by blood antigen
incompatibility (Rh or ABO
incompatibility)
Onset first 24 hours
Peak variable

What are assessments Assessments

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

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

5% Sodium 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)

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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.
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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
105
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),
106
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

107
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.

108
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.

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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, Term Preterm Abortions/miscarriage Live births,
the number births, the births, the s the
of number number number of
pregnancie born at born • Included in gravida live births
s. term (40 before 40 if before 20 weeks’ or living
weeks). weeks’ gestation children
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
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 • 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

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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 Triggered by Triggered by Chronic and
a predictable an coronary incapacitating
amount of unpredictable artery spasm; and is
effort or amount of the attacks refractory to
emotion. exertion or tend to occur medical
emotion and early in the therapy.
may occur at day and at
night; the rest.
attacks
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.

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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
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 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

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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

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 • 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

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 • 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

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 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
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 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
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 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

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