HERBAL MEDS

St. John's wort - antidepressant, photosensitive (C/Iin SULFA drugs)

Garlic - antihypertensive (avoid aspirin)

Ginseng - Anti stress (C/I in coumadin)

Green tea - antioxidant (check if risk forcalculi-oxalates)

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

Licorice - cough and cold

Ginger root - antinausea (C/I in Coumadin)

Ginkgo - improves circulation (C/I in anticoagulant,headache side effect - check PT)

Ma huang - bronchodilator, stimulant (Ephedra)

Parent teaching: Use of Infant and Car Seats

Weight below 9 kg (20 lb):Use infant or convertible seat in back seat of car in backward-facing position.Keep infant reclined at a 45 degrees.Never place the infant in the front passenger seat.Fasten seat securely to car using car seat belt and following manufacturere instructions.Adjust harness to fit snugly at shoulders and legs.When using an infant seat, move to larger seat before the infant's head reaches the top of shell.When using a convertable seat from birth, use one with a 5-point restraint.

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

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

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

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

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

gather necessary supplies.

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

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

This same textbook defines:

Preschool child, 3-6 years of ageSchool age child, 6-12 years of ageAdolescent, 12-18 years of age

Primary atypical pneumonia (Mycoplasma pneumonia) is characterized as:

Select all that apply:O 1 Most common cause of pneumonia in childrenO 2 incidence in children between the ages of 5 and 12O 3 Occurs primarily in summerO 4 more prevalent in crowded living conditionsO 5 caused by Borelia burdorferi

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

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

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

Common symptoms include the following:Headache Fever (may be high) Chills Excessive sweating Cough Usually dry Usually without phlegm or blood Chest pain Sore throat Less frequently seen symptoms include the following: Skin lesions or rash Eye pain or soreness Muscle aches and joint stiffness Neck lump Rapid respiratory rate Ear pain

Signs and tests

A physical examination may reveal enlarged lymph nodes and inflammation of the eardrum. An examination of the chest with a stethoscope (auscultation) reveals crackles.

These tests help confirm the diagnosis:Blood tests for antibodies to mycoplasma Sputum culture Chest x-ray

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

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

EPOGEN - EPOETIN ALFA RECOMBINANTPossible Test Item: A client with chronic renal failure on dialysis is to receive EPOGEN. Which of the following symptoms would warrant the nurse to hold the administration of this human recombinant? Select all that apply:O 1 the client has feverO 2 the client has hypertensionO 3 heart rate 72/minuteO 4 respiratory rate is 19O 5 the client is paleO 6 client has body malaise The correct answers: 1 & 2CNS side effect: Pyrexia, withhold the drugCVS side effect: Hypertension, withhold the drug.EPOGEN - recent question in the NCLEX-RNEPOGEN - epoetin alfa recombinant ClassificationErytrhopoietin, human recombinant1. normally synthesized in the kidney and stimulates RBC production2. will elevate and maintain RBC level, decreasing the need for BT Uses:Treatment of anemia associated with Chronic Renal Failure in adults C/I: uncontrolled hypertension Side effects:CV - hypertensionCNS - pyrexia Complication: Polycythemia What to monitor before and after:BP. TEMP & HEMATOCRITwater.

1)a young patient most likely to get lead poisining if?a. he is drinking from a ceramic pitcher.b. father referinshes old furniture at their home

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

2) a TB pt understands that he can reduce the risk of spreading his disease if he states?a. i wont sleep in same room w/ my wife for 1-2 monthsb. i will stay away from pregnant women and childrenc. i will use plastic utensil when i eat ****>> if the patient is already taking anti-TB drugs, it will only be 2 weeks of chemotherapy and that (+) PTB will no longer be communicable.. and 1-2 months is long!CHildren are more susceptible to acquire Primary complex and pregnant women are susceptible and almost vulnerable to all type of illnesses.. There is no need for the patient to separate their utensils since PTB is airborne and not by contact in terms of transmission.. so i go for B answer. 3) 4 years old with salmonella what u should do? a. private roomb. isolationc. place in a room with 4 year old with cellulitisd. keep door closed at all times. *** the (+) salmonella kid may be placed in a private room. Salmonella is transmitted by Enteric.. therefore Enteric precaution is needed and handwashing is very important and gown and gloves, diaper or bedpan in necessary. Option B, and D are all for pulmonary tuberculosis precautions. I suppose, the answer is A. place in a private room.

4) wot herb would help with vomiting?a. ginkob. ginsing.c. ginger rootd. echinacea ****> ginger root is good for nausea.. most especially in morning sickness but in moderation for pregnant women... Option C is the answer 5) allergic to sulfa wot not to take?a. ma huangb. echunacea.

...I think the answer is... geez, i forgot..i think its Echinacea..let me check again ok.. 6) mother called a nurse from home stating that her child having chicken pox..which of the following statements by the mother needs immidiate follow up? a. father of the child with liver failureb. sibling with anemiac. child just had tonsillectomyd. child has intermittent low grade fever I think the answer is C. the child that just had tonsillectomy. i think the child is immunocompromised. and varicella (Chicken pox) is a viral one.. we all know that tonsils are one of the lymph defenses we have against any infection.. Im not really sure with this answer. 7) clientwith allergy to sudafed ..which of the statments is correct? a. i will take valerianb. i will take ma huangc. i will take echinacea for acute viral inf.d. i will take black cohosh **valerian root is for cystitis and fungal infections; ma huang is for (I forgot!!),echinacea is for immune booster but not to be taken with patients with progressive systemic disorders such as AIDS, PTB, HIV, etc. black cohosh is for menopause. *** don't you think that Echinacea is the correct option?? 8)food processinga. frozen food can be defrost for up to six hoursb. frozen food which has been defrost can be return back to fridge.c. cook perishible food should cover and coold. frozen food should be defrost by hot water usually, frozen food must be thawed at cool tap water for freshness. not in the microwave because it can be cooked outside and raw inside, not in the hotwater with same principle.

so i believe, thawing it FOR UP TO 6 HOURS would be ok. returning thawed food back at fridge is ok but it is unsafe since salmonella can start thriving in.. Answer is OPTION A. 9) child in a mist tent and the parents brought him a car toy...the child was clutching the toy and the nurse refused to let him play for wot reason?a. it will get contaminated with bacteriab. it will accumalate moisturec. it could cause a fire ** The answer is OPTION C. Usually car toy have friction on it for the wheels to run.. Oxygen supports combustion.. and if friction is present together with oxygen (in a mist tent) then, fire could commence. 11) a mother reported tht her son is throwing up each time she feeds him wot would be the best question u ask? a. did u warm up the formulab. wot kind of formula did u give himc. does ur son feel hungry each time he throws upd. does r son have a jelly like stool ***>>> CORRECT OPTION is D.. Does your son have jelly like stool.. jelly like or currant like stool is a cardinal sign of Intussusception/ Telescoping or invagination of the large intestines in the Ileoceccal area.. 12) a patient had AIDS the nurse should advise?a. cook ur meat very wellb. not to eat in the same table with familyc. avoid crowds ***>> if you have AIDS, u are immunocompromised.. therefore you are prone to infection.. neutropenic precaution is advised and one that is a must is Avoiding Crowds.. Correct option is C.

Seasonal Affective Disorder (SAD) may affect over 10 million Americans. The typical symptoms of SAD include depression, lack of energy, increased need for sleep, a craving for sweets and weight gain. Symptoms begin in the fall, peak in the winter and usually resolve in the spring. Some individuals experience great bursts of energy and creativity in the spring or early summer. Susceptible individuals who work in buildings without windows may experience SAD-type symptoms at any time of year. Some people with SAD have mild or occasionally severe periods of mania during the spring or summer. If the symptoms are mild, no treatment may be necessary. If they are problematic, then a mood stabilizer such as Lithium might be considered. There is a smaller group of individuals who suffer from summer depression. SAD is recognized in the DSM-IV (The American Psychiatric Association's diagnostic manual) as a subtype of major depressive episode. Some individuals who work long hours inside office buildings with few windows may experience symptoms all year round. Some very sensitive individuals may note changes in mood during long stretches of cloudy weather.

A sign of improvement from dehydration would be a decreased urine specific gravity and a decreased/decreasing hematocrit. So the SG of 1.015 and a Hct of 46% would be the answer. It is the best answer of the two you had in you question. The normal urine SG is 1.003-1.035 (Usually between 1.010-1.025 with normal hydration and volume) (different texts give a slightly different range). SG 1.025-1.030+ (concentrated urine)SG 1.001-1.010 (dilute urine)SG 1.001-1.018 in infants under 2 years of age Specific gravity is a measurement of the kidney's ability to concentrate urine. The range of urine's SG depends on the state of hydration and varies with urine volume and the load of solids to be excreted under standardized conditions; when fluid intake is restricted or

increased, SG measures the concentrating and diluting functions of the kidney. Loss of these functions is an indication of renal dysfunction. SG values usually vary inversely with amounts of urine excreated (decrease in urine volume = increase in specific gravity). However in some conditions this is not the case. For example: a. Diabetes: increased urine volume, increased SG (High amount of glucose in urine) b. Hypertension: normal volume, decreased SG c. Early chronic renal disease: increased volume, decreased SG

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

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

digitalis toxicity includes.. N - nauseaA - anorexiaV - vomitingD - diarrheaA - abdominal pain kasma na changes sa vision..Digitalis toxicity is the result of the body accumulating more digitalis than it can tolerate at that time. Patient will complain visual change in color, and loss of appetite.

From RAG book and memory notebook Drugs which can cause URINE DISCOLORATION Adriamycyn------ ReddishRifabutin--------- Red orangeRifampicin------- Red orangeBactrim---------- Red orangeRobaxin--------- Brown, Black or GreenishAzulfidine------ Orange yellowFlagyl------------ BrownishDilantin---------- Pink tingedAnti Psychotic-- Pinkish to Red brown Early signs of hypoxia: R-restlessnessA-anxietyT-Tachycardia Late signs of hypoxia: B-bradycardiaE-extreme restlessnessD-dyspnea In pedia- F-feeding difficultyI-inspiratory stridorN-nares flareE-expiratory gruntingS-sternal retractions Respiratory PatternsKussmaul- fruity acetone breath odorCheyne-stokes- near death breathing pattern CRUTCH WALKING UP STAIRSGood goes to heaven, Bad goes to hell

CYSTITIS-Inflamation of the urinary bladder Manifestations: Urgency and frequency

Lab data: Culture and sensitivity tests reveal the presence of bacteremiaUsually E.ColiPREVENTING CYSTITIS>Drink 8-10 glasses of fluid per day>Women should wipe from front to back>Urinate after intercourse>Avoid vaginal deodorants and bubble baths>Avoid silk underwear, cotton underwear is preferred>Maintain acid ash diet (cheese,cranberry,prunes and plums 1.Which of the following statements made by a patient reflects a need for further teaching?a. I drink a lot of fluidsb. I usually go nonstop driving for 8 hours on weekends--- answerc. I should avoid bubble bathsd. I love drinking citrus juices 2. Which of goal of nursing care takes priority for a female client with cystitis?a. increasing urine alkalinityb. maintaining a balanced fluid I & O c. Providing instructions on perineal hygiene--- answerd. screening urine for sedimentation Muskuloskeletal Anatomical tipsTENDONS- connect muscle to boneLIGAMENTS- connect bone to bone CUSHING SYNDROMEHypersecretion of Glucocorticoids by the adrenal glands Manifestations: central type or truncal obesity with thin extremetiesmoonfacebuffalo humphirsutismLab data: Elevated serum cortisol levelsHypernatremia,hyperglycemia,hypertensionHypokalemia Intervention: High potassium, Low sodium dietLifelong administration of glucocorticoid synthesis inhibitors Eg. MitotaneInform that there will be poor wound healing Sample question:When assessing a 40-year old patient with cushing’s syndrome, the nurse should expect the person to demonstrate:A lability of mood---- answerB ectomorphism with a moon faceC a decrease in the growth of facial hairD an increase resistance to bruising and bleeding

EYE ABBREVIATIONSOU- both eyesOR- right eyeOS- left eye LEVELS OF CONSCIOUSNESSA------ ALERTV------ VERBAL STIMULIP------ PAINFUL STIMULIU----- UNRESPONSIVE REASONS FOR UNCONSCIOUSNESS(SKIN COLOR)RED----- Stroke or increase BP

WHITE---- Shock or HemorrhageBLUE--- Respiratory or Cardiac Arrest

CIRCULATION ASSESSMENT- 5PsPainPallorPulseParesthesiaParalysis

CHOLINERGIC CRISIS

S- SalivationL-LacrimationU-UrinationD-DefecationGE ADLs

B-BathingA-AmbulationT-ToiletingT-TransfersE-EatingD-Dressing

Instrumental ADLsS-shoppingC-cooking, cleaningU-using telephone /transportationM-managing money and medications

C caneO opposite A affectedL leg

IN CASE OF ABDOMINAL TENDERNESSInspect, auscultate, percuss, palpate

CUSHINGS (Hypersecretion of Adrenal Cortex Hormones)

C = Check VS, particularly BPU = Urinary output & weight monitoringS = Stress ManagementH = High CHON dietI = Infection precautionN = Na+ restrictionG = Glucose & Electrolytes MonitoringS = Spousal support

ADDISON'S (Hyposecretion of Adrenal Cortex Hormones)Always Remember the 6 A's of Addison's disease

1.) Avoid Stress2.) Avoid Strenuous3.) Avoid Individuals with Infection

4.) Avoid OTC meds5.) A lifelong Glucocorticoids Therapy6.) Always wear medic alert bracelet

IF RESPIRATORY DEPRESSION OR OVERSEDATION IS SUSPECTED:1. CEASE the PCA2. CEASE all other infusions that could be contributing to sedation3. Attempt to rouse the patient4. Call 777 [MET team] if appropriate5. If apnoeic: administer bag & mask ventilation with 100% oxygen6. If breathing: maintain airway, monitor oxygen saturations and administer oxygen via face mask at 8L/min7. Check circulation. If pulseless: commence chest compressions8. Prepare naloxone for possible administration9. Call CPMS for urgent review

Allergic: caused by sensitivity to foreign proteins.Clinical Manifestations: Urticaria, flushing, itching, no fever.Treatment: Administer antihistamines as directed.If manifestations mild and transient, transfusion may resume.Prevention: Treat prophylactically with antihistamines.

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

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

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

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

With omphalocele and gastroschisis (herniation of abdominal contents) dress with loose saline dressing covered with plastic wrap, and keep eye on temp. Kid can lose heat quickly.

After a hydrocele repair provide ice bags and scrotal support.

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

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

Never give potassium if the patient is oliguric or anuric.

Nephrotic syndrome is characterized by massive proteinuria (looks dark and frothy) caused by glomerular damage. Corticosteroids are the mainstay. Generalized edema common.

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

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

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

An antacid should be given to a mechanically ventilated patient w/ an ng tube if the ph of the aspirate is <5.0. Aspirate should be checked at least every 12 hrs.

Ambient air (room air) contains 21% oxygen.

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

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

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

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

Pulmonary sarcoidosis leads to right sided heart failure.

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

Q&As found in the NCLEX FORUM

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

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

case? Plz provide your rationale.

A) lidocaine and atropineB) adenosine and amiodaroneC) magnesium sulfate and sodium bicarbonateD) bretylium and verapamil

Answer::

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

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

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

meds is contraindicated in dig levels/toxitiy.

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

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

possibly causing dig toxicity. Bretylium aggravates dig toxicity and digoxin

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

should not be given to dig toxic patients.

Question # 2(Multiple Choice) Regarding abruptio placentae

A) Blood loss is confined within the amniotic sacB) Internal bleeding is generally minimal.C) Blood loss may be concealed between the uterine wall and the placentaD) There is always excessive external vagina bleeding

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

Answer::

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

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

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

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

still have significant internal bleeding.

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

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

D. is incorrect because blood loss can be hidden.

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

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

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

legally render care

A) Good Samaritan LawsB) Standards of CareC) Implied ConsentD) Informed Consent

c is given as correct. why?

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

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

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

who is in an emergency situation.

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

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

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

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

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

consent. Now define each of the possible reponses.

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

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

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

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

standards. Therefore this is not the answer.

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

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

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

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

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

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

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

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

implied consent.

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

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

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

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

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

you will get more correct.

Question:

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

a.)ask them can they cough.b.)immediately perform the heimlich maneuver. I got confused because I

know are suppose to ask the person can they talk.

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

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

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

a.)wear sterile gloves.b.)clean the urethra with betadine.

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

a)I just started menstruating and it is very heavy. b) my last pap smear was abnormal.C)I never had sex before.d)I forgot this choice.

Answer:

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

questions.

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

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

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

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

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

for a conscious patient.

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

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

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

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

some other indicator of air movement.

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

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

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

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

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

accomplish the same thing.

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

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

Alzheimer's patient, and to protect HIS SAFETY.

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

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

facility their safety would be compromised significantly. The alarms will

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

immediately.

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

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

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

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

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

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

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

security guards.

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

burden on a family that is already in crisis due to the fact they have a family

member with Alzheimer's disease.

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

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

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

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

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

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

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

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

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

before the pap smear is performed.

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

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

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

the results.

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

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

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

significant

d)I forgot this choice.

Question:

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

a) Offers bed pan every 2 hoursb) Limit fluids during evening timesc) Foley's catheter

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

a) Observe vaginal bleedingb) Urine outputc) Vital signs

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

a) Reticulocyte countsb) Platelet counts

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

a) Assess the patientb) Cardiopulmonary resuscitationc) IV fluids

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

a) Urine output 30-40ml/hrb) BPc) Vital signsd) Skin turgor

6. 20 week pregnant most concerned

a) Butterfly rash on both cheeks and noseb) Uterus palpate at the level of symphysis pubisc) Sereous fluid drain in the breastsd) Breast enlargement

7. The sterile technique is broken when:

a) The sterile field and supplies are wetb) Clean the area peripheral to center

8. The metal piece is embedded on the left eye

a) Pressure dressing is applied on the left eyeb) Dressing is applied on both eyesc) Irrigate the eye with saline

9. After cerebral angiogram, patient is

a) Encourage fluidsb) obseve contrast medium in the urinec) walking

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

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

Answers:-

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

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

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

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

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

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

a) Observe vaginal bleedingb) Urine outputc) Vital signs-BEST ANSWER, as this provides the best/most information about the client's response to surgery and anesthesia.

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

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

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

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

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

b) Cardiopulmonary resuscitation

c) IV fluids

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

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

b) BPc) Vital signs

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

6. 20 week pregnant most concernedA) Butterfly rash on both cheeks and nose-NO this is Cholasma the "mask of pregancy", result of hormonal changes in pregnancy.

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

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

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

7. The sterile technique is broke when

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

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

8. The metal piece is embedded on the left eye

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

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

9. After cerebral angiogram, patient is

a) Encourage fluids-BEST ANSWER, when ever contrast medium/X-ray dyes are administer the client is hydrated to facilitate excretion of the dye.

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

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

10. Using clean, non sterile gloves care is appropriate

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

Question:

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

A. pulse rateB. daily weightC. skin turgor

Answer1:

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

Answer2:The answer is pulse rate

Question:

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

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

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

a. i wont sleep in same room w/ my wife for 1-2 monthsb. i will stay away from pregnant women and childrenc. i will use plastic utensil when i eat

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

a. private roomb. isolationc. place in a room with 4 year old with cellulitisd. keep door closed at all times.

4) wat herb would help with vomiting?

a. ginkgob. ginseng.c. ginger rootd. echinacea

5) allergic to sulfa wat not to take?

a. ma huangb. echinacea.

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

a. father of the child with liver failureb. sibling with anemiac. child just had tonsillectomyd. child has intermittent low grade fever

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

a. i will take valerianb. i will take ma huangc. i will take echinacea for acute viral inf.d. i will take black cohosh

8) food processing

a. frozen food can be defrost for up to six hoursb. frozen food which has been defrost can be return back to fridge.c. cook perishable food should cover and coold. frozen food should be defrost by hot water

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

a. it will get contaminated with bacteriab. it will accumalate moisturec. it could cause a fire

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

a. did u warm up the formulab. wot kind of formula did u give himc. does ur son feel hungry each time he throws upd. does ur son have a jelly like stool

12) a patient had aids the nurse should advise?

a. cook ur meat very wellb. not to eat in the same table with familyc. avoid crowds

Answer:

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

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

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

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

a. i wont sleep in same room w/ my wife for 1-2 monthsb. i will stay away from pregnant women and childrenc. i will use plastic utensil when i eat

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

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

a. private roomb. isolationc. place in a room with 4 year old with cellulitisd. keep door closed at all times.

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

4) wat herb would help with vomiting?

a. ginkob. ginsing.c. ginger rootd. echinacea

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

5) allergic to sulfa wat not to take?

a. ma huangb. echinacea.

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

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

a. father of the child with liver failureb. sibling with anemiac. child just had tonsillectomyd. child has intermittent low grade fever

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

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

a. i will take valerianb. i will take ma huangc. i will take echinacea for acute viral inf.d. i will take black cohosh

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

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

8)food processing

a. frozen food can be defrost for up to six hoursb. frozen food which has been defrost can be return back to fridge.c. cook perishible food should cover and coold. frozen food should be defrost by hot water

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

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

a. it will get contaminated with bacteriab. it will accumalate moisturec. it could cause a fire

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

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

a. did u warm up the formulab. wot kind of formula did u give himc. does ur son feel hungry each time he throws upd. does r son have a jelly like stool

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

12) a patient had AIDS the nurse should advise?

a. cook ur meat very wellb. not to eat in the same table with familyc. avoid crowds

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

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

Thank you so much English RN2BFuture USRNs, this for you:

PRIORITY QUESTIONS (WHO TO SEE FIRST)Sample Test Item: 1. Which of the following clients should the nurse deal with FIRST?o 1 A client who needs his daily vitamino 2 A client who needs to be suctionedo 3 A client who needs diaper to be changedo 4 A client who is being prepared for discharge

Correct Answer: 2. A client who needs to be suctionedPRIORITY (Use ABC)Obstruction in the airway – secretions Need to be suctioned

2. Delegation, RN, LVN, UAP, CNAWhich of the following clients should the LPN be assigned to?o 1 A newly diagnosed patient with MYASTHENIC CRISISo 2 An immediate post-op client in PACUo 3 A client awaiting medication for vitaminso 4 A new admission for KIDNEY Transplant Patient

Correct Answer: 3-stable, A client awaiting medication for vitaminsMyasthenic Crisis – Unstable, Acute Respiratory FailureImmediate Post – op – Unstable, Risk for Complications, Kidney Transplant – Unstable, needs assessment for rejection

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

For future USRNsThis is for you... from the purkinje fibers of my heart....

Room Assignment(Who to Share Room with)Check:A geB eside the nurse's station? At the end of the hallway? Single Room/Private Room?C hain of infection/circumstanceD iagnosisE nviroment (dim light, darkened, red nightlapm)

Sample Test Item:The best roommate for patient with LEUKEMIA isO 1 A 9-year-old with ruptured appendixO 2 A 12-year-old with chicken poxO 3 A 2-year-old with fever of unknown originO 4 A 5-year-old with nephrotic syndrome

Correct Answer: 4. A 5-year-old with nephrotic syndrome.1,2 & 3, manifest symptoms of infection. A client with leukemia is immunosuppressed and Patients with infection shouldn't be placed in this room. Since patient with nephrotic syndrome receives diuretics and steroids, this child will also need immunocompromised host precaution.

INFECTION CONTROL:Sample Test Item:

3. Which of the following methods should the RN utilize in patient with SALMONELLA?

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

The correct answer: 4. Salmonella mode of transmission is fecal oral (enteric)HandwashingGloves must be used in handling bedpan and diapersGown - if soiling is likely to happen.

Source of infection:Contaminated food and water.

Remember - Transmission Based precautions:A irB orne, small particles are dispersed in the air like MTB, varicellaC ontact, drug-resistant microorganisms D roplet, large particles are dispersed into air, resp.infections except resp syncytialE nteric, fecal-oral like hepaA & salmonella

AGE APPROPRIATE GROWTH AND DEVELOPMENT(HOPPING WITH ONE LEG)Sample test Item:

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

O 1 predominantly "parallel play" periodO 2 balances on 1 foot with eyes closedO 3 skips on alternate feetO 4 jumps rope

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

Preschooler (3-6 years)Gross motor development

HOPS ON ONE (1) FOOT BY 4 YEARSSKIPS & HOPS ON ALTERNATE FEET BY 5 YEARSPLAY : ASSOCIATIVE, IMAGINATIVE, MAGICAL THINKING, SUPERHEROES (Remember the movie: Jingle All The way!)FEAR: Intrusive procedures, venipunctures, IM injections, body mutilation

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

Select all that apply:

O 1 A pregnant client who eat raw meat.O 2 A pregnant client handling cat litter of infected cats.O 3 A pregnant client gardening and cultivating soil exposed to cat feces.

O 4 A pregnant client with low rubella titerO 5 A pregnant client who have undergone external radiation.O 6 A pregnant client with draining, painful vesicles in the external genitalia.

The correct answers: 1, 2 & 3.TOXOPLASMOSISHow do people get toxoplasmosis? A Toxoplasma infection occurs by:

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

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

MEMORIZE MEMORIZE MEMORIZE

Tonometry: normal (10-21 mm Hg)

PR Interval: normal (0.12-0.20 seconds)

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

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

Calcium: adult (8.6-10 mg/dL) child (8 to 10.5 mg/dL) term<1week (7 to 12 mg/dL)

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

Prothrombin Time: normal (Male: 9.6-11.8 seconds) and (Female: 9.5-11.3 seconds)

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

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

Serum Osmolality: normal (285 to 295 mOsm/kg) high value indicates dehydration

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

[Child] 95-115 mm Hg

[Adult]100-120 mm Hg)

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

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

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

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

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

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

WBC’s In Pregnancy: normal (11,000 to 15,000 cells/mm3, up to 18,000 cells/mm3). Immediate postpartum period, (maybe as high as 25,000 to 30,000 cells/mm3)

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

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

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

(female: 190 to 420 mg/dL)

with Disseminated Intravascular Coagulation the fibrinogen level drops because fibrinogen is used up in the clotting process.

Insulin (Regular, Humulin R)Type: Fast actingOnset: ½ -1 hrPeak: 2-4 hrDuration: 6-8 hr

Insulin(NPH, Humulin N)Type: Intermediate actingOnset: 2hrPeak: 6-12hrDuration 18-26hr

Insulin(Ultralente, Humulin U)Type: Slow actingOnset: 4hrPeak: 8-20hrDuration: 24-36hr

Insulin(Humulin 70/30)Type: CombinationOnset: ½ hrPeak: 2-12hrDuration: 24hr

Central Venous Pressure: < 3 mm Hg = inadequate fluid and >11 mm Hg = too much fluid

Potassium: 3.5-5.0 mEq/LSodium: 135-145 mEq/LCalcium: 4.5-5.2 mEq/L or 8.6-10 mg/dLMagnesium: 1.5-2.5 mEq/LChloride: 96-107 mEq/LPhosphorus: 2.7 to 4.5 mg/dL

PR measurements: normal (0.12 to 0.20 second)

QRS measurements: normal (0.04 to 0.10 second)

Ammonia: 35 to 65 ug/dLAmylase:25 to 151 IV/L

Lipase: 10 to 140 U/L

Cholesterol: 140 to 199 mg/dLLDL: <130 mg/dLHDL: 30 to 70 mg/dLTriglycerides: <200 mg/dL

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

Protein: 6.0 to 8.0 g/dL

Uric acid: Male 4.5 to 8 mg/dL Female 2.5 to 6.3 mg/dL

Glycosylated Hemoglobin HbA1c: good control 7.5% or less

Serum creatinine: 0.6 to 1.3 mg/dL

BUN: 9-25 mg/dL

Normal CK is 26-174 U/L

Troponin I value: normal (<0.6 ng/mL)Troponin T >0.1 to 0.2 ng/mL = MI

Erythrocyte studies: 0-30 mm/hour

Serum iron: Male 65-175 ug/dL Female 50-170 ug/dL

RBC: Male 4.5 to 6.2 M/uL Female 4.0 to 5.5 M/uL

Theophylline levels normal (10 to 20 mcg/dl)

MOTOR DEVELOPMENT

Chin up 1 month

Chest up 2 month

Knee push and “swim” 6 month

Sits alone/stands with help 7 month

Crawls on stomach 8 month

Stands holding on furniture 10 month

Walks when led 11 month

Stands alone 14 month

Walks alone 15 month

AT THE PLAY GROUND

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

PSYCHOLOGICAL DEVELOPMENT

AGE ERIKSON FREUD PIAGET

Infant 0 – 1.5 Trust vs. mistrust

Oral (trust & dependence sensorimotor

Toddler 1.5 -3 Autonomy vs. shame

Anal (holding vs. letting out) preoperational

Pre-school 3 - 6 Initiative vs. guilt

Phallic (Oedipus complex) preoperational

School age 6 - 11

Industry vs. inferiority latency Concrete operational

11 - 20Identity vs. role confusion genital Formal operational

20 – 25 Intimacy vs. isolation

25 – 50Generativity vs. stagnation

50 - ? Integrity vs.despair

LABORATORY VALUES

ELECTROLYTES

Sodium (Na+): 135 – 145 meq/L (increase-dehydration; decrease overhydration) Potassium (K+): 3.5 - 5.0 meq/L Magnesium (Mg++): 1.5 – 2.5 meq/L Calcium (Ca++): 4.5 – 5.8 meq/L Neonate : 7.0 to 12 mg/dL Child: 8.0 to 10.5 mg/dL Phosphorus (PO4): 1.7 – 2.6 meq/L Chloride (Cl-): 96 – 106 meq/L

COAGULATION STUDIES

Activated partial thromboplastin time(APTT): 20 – 36 seconds depending on the type of activator used

Prothrombin time(PT): male: 9.6 – 11.8 seconds Female: 9.5 – 11.3 secondsInternational Normalized Ratio(INR): 2.0 - 3.0 for standard Coumadin therapy 3.0 – 4.5 for high-dose Coumadin therapyClotting time: 8 – 15 minutesPlatelet count: 150,000 to 400,000 cells/UlBleeding time: 2.5 to 8 minutes

SERUM GASTROINTESTINAL STUDIES

Albumin: 3.4 to 5 g/dLAlkaline phosphatase: 4.5 to 13 King-Armstrong units/dLAmmonia: 15 to 45 ug/dLAmylase: 50 – 180 Somogyi U/dL in adult 20 – 160 Somogyi U/dL in the older adultBilirubin: direct: 0 - 0.3 mg/dL Indirect: 0.1 – 1.0 mg/dL Total: less than 1.5 mg/dLCholesterol: 120 – 200mg/dLLipase: 31 -186 U/LLipids: 400 – 800 mg/dLTriclycerides: Normal range: 10 – 190 mg/dL Borderline high: 200 – 400 mg/dL High: 400 – 1000mg/dL Very high: greater than 1000mg.dLProtien: 6.0 – 8.0 g/LUric acid: male: 4.5 – 8 ng/dL Female: 2.5 – 6.2 ng/dL

GLUCOSE STUDIES

Fasting blood sugar: 70 – 105 mg/dLGlucose monitoring (capillary Blood): 60 – 110 mg/dL

RENAL FUNCTION TEST

Creatinine: 0.6 – 1.3 mg/dLBlood urea nitrogen (BUN): 5 – 20 mg/dL

ERYTROCYTES STUDIES

Erytrocyte sedimentation rate(ESR): 0 – 30 mm/hr depending on ageHemoglobin: male: 14 – 16.5 g/dL Female: 12 – 15 g/dLHematocrit: male: 42% - 52% (increased in hemoconcentration, fluid loss and

dehydration) Female: 35% - 47% ( decreased in fluid retention)Red blood cell (RBC): male: 4.5 to 6.2 million/uL Female: 4 to 5.5 million/uL

White blood cell (WBC): 4500 to 11,000/uLErytrocyte Protoporthyrin (EP) : <9ug/dLPhenylalanine Level: <2 mg/dLPKU: >25 mg/dL

CRANIAL NERVES

MAJOR FUNCTIONS

I. Olfactory (S) smell

II. Optic (S) vision

III. Oculomotor (M)IV. Trochlear (M)

Eye movement

V. Trigeminal (S-M)Facial sensationJaw movement

VI. Abducent (M) Eye movement

VII. Facial (S-M)Taste

Facial expression

VIII. Acoustic (S) Hearing and balance

IX. Glossopharyngeal (S-M)Taste

Throat sensationGag and swallow

X. Vagus (S-M)Gag and swallow

Parasympathetic activity

XI. Spinal Accessory (M)Neck and back muscles

XII. Hypoglossal (M) Tongue movement

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

ARTERIAL BLOOD GAS (ABG)

pH: 7.35 – 7.45 PCO2: 35 - 45 mmHg PO2: 80 - 100 mmHg HCO3: 22 - 27 mEq/L O2 saturation: 96% - 100% Acid-base “RAMS”(Respiratory Alternate, Metabolic Same)

GLASGOW COMA SCALE

Eye opening response Motor response Verbal response

AUTONOMIC NERVOUS SYSTEM

SYMPATHETIC/ ADRENERGIC

PARASYMPATHETIC/ CHOLINERGIC

HeartIncreased heart rateIncreased conductionIncreased force

Decreased heart rate

Bronchi dilation constriction

GI tract Reduced motility Increased motility

Rectum Allows fillingEmpties rectumRelaxes internal sphincter

Bladder Allows fillingEmpties bladderRelaxes internal sphincter

Erection Maintains erection

Ejaculation Triggers ejaculation

Pupils of eye Big (mydriasis) Small (miosis)

Salivary glands Secretion

Blood vesselsDepends on receptors-a contrict-b dilates

FLOW OF BLOOD THROUGH THE HEART

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

CARDIAC IMPULSES

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

Blood volume: 5000mLCentral venous pressure: 4 to 10 cmH2O (increased in cardiac overload; decreased in dehydration)Pressure within the right atrium: 2 to 7 mmHgCapillary refill time: <3 secondsNormal sweat chloride: <40 mEq/LNormal pupil diameter: 3 to 5mmNormal ocular pressure: 10 to 21 mmHgNormal Pulmonary capillary wedge pressure (PCWP): 8 to 13 mmhgNormal cardiac output : 4 to 8 L/min.

THERAPEUTIC SERUM MEDICATION LEVELS

Acetaminopen (Tylenol) 10 – 20 ug/mLAmikacin (Amikin) 25 – 30 ug/mLAmitryptyline (Elavil) 120 -150 ng/mLCarbamazepine (Tegretol) 5 -12 ug/mLChloramphenicol (Chloromycetin) 10 – 20 ug/mLDesipramine (Norpramin) 150 -300 ng/mLDigotoxin ( Crystodigin) 15- 25 ng/mLDigoxin ( Lanoxin) 0.5 – 2.0 ng/mLDisopyramide (Norpase) 2 -5 ug/mLEthosuximide ( Zarontin) 40 – 100 ug/mLGentamycin (Garamycin) 5 – 10 ug/mLImipramide (Tofranil) 150 – 300 ug/mLLidocaine (Xylocaine) 1.5 – 5.0 ug/mLLithium (Lithobid) 0.5 -1.5 ug/mLMagnesium sulphate 4 -7 mg/dLNortriptyline (Aventyl) 50 – 150 ng/mLPhenobarbital (Luminal) 10 – 30 ug/mLPhenytoin (Dilantin) 10 -20 ug/mLPrimidone (Myoline) 5 – 20 ug/mL Procainamide (Pronestryl) 4 – 10 ug/mLPropranolol (Inderal) 50 – 100 ng/mLQuinidine (Quinalaglute, Cardioquin) 2 – 5ug/mLSalisylate 100 -250 ug/mLTheophylline (Aminiphylline, Theo-Dur) 10 -20 ug/mLTobramycin (Nebcin ) 5 -10 ug/mLValproic acid (depakene) 50 -100 ug/mL

Pulmonary capillary wedge pressure: 5 to 13 mmHgPulmonary artery pressure: systolic: 16 to 30 mmHg Diastolic: 0 to 7 mmHg

Spinal pressure: 70 to 200mmH2OMorphine sulphate pediatric dose: 0.1mg/kg every 3 – 4 hour

SULFONYLUREAS For treatment of NIDDM

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

DURATION

tolbutamide 8 h

Glycburide, glipizide 20 h, most potent

chlorpropamide 48 h

Apothecary and Household System

Grain –gr 1 gr = 60 mgDram – dr 5 gr = 300 mgOunce –oz 15 gr = 1000mg or 1gMinim – min, M, m 1/150 gr =0.4 mgQuart – qt 1 oz = 30 mLPint – pt 1 dr = 4 mLDrop – gtt 1 T = 15 mL or 3 tspTablespoon – T or tbs 1 min = 1 gttTeaspoon – t or tsp 15 min = 1mLPound – lb 60 min = 1 dr 8 dr = 1 oz 1 qt = 1000mL or 1L 1 qt = 2 pt or 32 oz 1 pt = 16 oz 16 oz = 1 lb 2.2lb = 1 kg

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

Celcius to Fahrenheit 1.8 C + 32 = F

Formula for Calculating a Medication Dosage

D (desired ) = the dosage that the physician orderedA (available) =the dosage strength as stated on the medication labelQ (quantity ) = the volume that the dosage strength is available in, such as tablet,

capsules, or mL

D X Q = XA

Formulas for Intravenous Calculations

Flow Rates:

Total volume x gtt factor = gtt per min Time in minutes

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

IMMUNIZATION

Birth Hepatitis B1 months Hepatitis B2 months OPV, DPT, HIB4 months DPT, HIB, OPV6 months DPT, HIB, hepatitis B12 months HIB, OPV15 months MMR18 months DPT12 – 18 months Varicella vaccine4 -6 years DPT, OPV, MMR11 – 12 years MMR ( if not administered at 4 -6 years)11 – 16 TD booster

SPINAL CORD INJURYCervical Injury:

C2 to C3 injury usually fatal C4 is the major innervation to the diaphragm by th phrenic nerve Involvement above th C4 causes respiratory difficulty and paralysis of

all the four extremities C5 or below client may have movement in the shoulder

Thoracic Level Injury: loss of movement of the chest, trunk, bowel, bladder, and legs, depending on the

level of injury Leg paralysis (paraplegia) Autonomic dysreflexia with lesions above T6 and in cervical lesions Visceral distention from a distended bladder or impacted rectum may cause

reactions such as sweating, bradycardia, hypertension, nasal stuffiness, and gooseflesh

Lumbar and Sacral Level Injuries: loss of movement and sensation of the lower extremities. S2 and S3 center on micturation; therefore below this level, the bladder will

contract but not empty (neurogenic bladder) Injury above S2 in males allows them to have an erection, but they are unable to

ejaculate because of sympathetic nerve damage. Injury between S2 and S4 damages the sympathetic and parasympathetic

response, preventing erection and ejaculation.

RULE OF NINE

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

NORMAL ADULT WHITE BLOOD CELL DIFFERENTIAL

Neutrophils 56% or 18000 – 7800/uL Bands 3% or 0 – 700/uL Eosinophils 2.7% or 0 – 450/uL Basophils 0.3% or 0 – 200/uL Lymphocytes 34% or 1000 – 4800/uL Monocytes 4% or 0 – 800/uL

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

Normal Fribrinogen level: for men: 180 to 340mg/dL Women: 190 to 420mg/dLFribrinogen is used up in the clotting process.

Erythrocyte Protoporhyrin (EP): < 9ug/dLPhenylalanine level: < 2mg/dLPKU: >25 mg/dLUrine specific gravity: 1.016 - 1.022 increase in SIADH; decrease in diabetes insipidus Normal CSF protein: 15 – 45 mg/dL increase in Guillain-Barre syndromeNormal CSF pressure: 5 – 15 mmHgNormal serum osmolality: 285 – 295 mOsmlkgH2O increase in dehydration; Decrease in over hydrationNormal scalp pH: 7.26 and above Borderline acidosis: 7.20 to 7.25 Acidosis: < 7.15

HERBAL MEDICINE

Aloe vera Gel – abrasionsand dermatologic conditions American Ginseng (Panax quinquefolius) – boost energy, relieve stress, improve

concentration and enhance physical or cognitive performance.Ashwagandha (Withania somnifera) – stress arthritisAsian gingseng (Panax ginseng) – enhance health and combat stress and diseaseBilberry (Vaccinium myrtillus) – vision and peripheral vascular disorders and as

antioxidantBlack Cohosh (Cimicifuga racemosa) – menopausalBlack Currant and Borage oil (Ribes nigrum and Borago offinalis) – anti-

inflammatory, rheumatoid arthritisCapsicum Peppers (Capsicum spp.) – arthritis, neuralgia and other painful treatment

Chamomile (Matricaria recutita) “manzanilla”- skin inflammation, colic, or dyspepsia and anxiety

Chaste tree (Vitex agnus-castus) – menstrual related disorders, PMS, cyclical mastalgiaChodroitin – osteoarthritisCoenzyme Q10 – antioxidantColtsfoot ( Tussilago farfara ) – cough and other respiratory disodersCranberry (Vaccinium macrocarpon) – UTIDevil’s Claw ( Harpagophytum procumbers) – anti inflammatory and analgesicEchinacea (Echinacea spp.) – acute viral URI symptomsEderberry (Sanbacus nigra) – respiratory tract infectionEphedra or Ma Huang (Ephedra sinica) Source of ephedrine and pseudoephedrineEvening Primrose Oil (Oenothera biennis) – eczema, breast pain associated with PMS

and inflammatory conditionFenugreek (Trigonella foenum-graecum) – lowering blood glucoseFeverfew ( Tanacetum parthenium) – migraine headache prophylaxisGarlic (Allium sativaum)- help prevent cardiovascular disease and cancerGinger (Zingiber officinale) –nausea and motion sickness, anti-inflammatoryGinkgo (Ginkgo biloba) – dementia and intermittent claudication, memory enhancement

and treatment of vertigo nad tinnitusGlucosamine – osteoarthritisGoldenseal ( Hydrastis Canadensis) – tonic and antibioticGotu Kola (Centella asiatica) – mental support, wound healing and venous disordersHawtorn ( Crategus species) – CHF and related cardiovascular conditionsHorebound (Marribium vulgare) – primary cough suppression and expectorationHorse Chestnut Seed (Aesculus hippocastanum) chronic venous insufficiency Ivy (Hedera helix) – coughs, rheumatic disordes and skin diseaseKava ( piper methysticum) – mild psychoactive and antianxiety propertyLemon Balm (Melissa officinalis) – sedative and for dyspepsiaLicorice (Glycyrrhiza glabra) – respiratory disorders, hepatitis, inflammatory diseases,

and infectionsMelatonin – insomia, jet lagMilk Thistle – hepatitis, liver deseaseMints (Mentha species) – minor calcium channel antagonists, used for upper respiratory

problems, irritable bowel syndrome, dyspepsia, and colonic spasm and as a topical counterirritant

Nettle (Urtica dioica) – arthritis pains, allergies, BPH, or as diureticPapaya (Carica papaya) – digestive aid, dyspepsia, and for inflammatory, topically

applied to woundsPassion flower (Passiflora incarnata)- sedative-hypnotic or anxiolytic herbPokeroot (Phytolacca Americana) – inflammatory conditions also as an emetic/catharticPygeum (Pygeum africanum) – mild symptoms of BPHRed Clover (Trifolium pratense) – used as a natural estrogen substitute for women’s

healthSt. John’s Wort (Hypericum perforatum) – antidepressant effectTea Tree Oil (Melaleuca alternifolia) – antifungal and antibacterialTurmeric (Curuma longa ) – anti-inflammatory, anti-arthritis, anti cancer, and

antioxidantUva Ursi (Arctostaphylos uva ursi) – urinary antiseptic and diuretic Yohimbe – erectile dysfunction

FOUR STRATEGIES:1. If the question asks what you should do in the situation. Use the nursing process

to determine which step in the nursing process would be next?2. If the question asks what the client needs. Use maslow’s hierarchy to determine

which need to address.3. If the question indicates that the client doesn’t have urgent physiologic need,

focus on the patient safety.4. If the question involves communicating with a patient. Use principles of

therapeutic communication.

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

The nurse in primary care clinic is caring for a 50-year-old woman. History reveals that she had experienced on and off chest pain. After series of cardiac tests (EKG & Blood Chem), the doctor orders for THALLIUM STRESS TEST. Which of the following medications should the RN prepare if the patient needs an alternative exercise in thallium test? 1.Nitroglycerin2.Morphine3.Aminophylline4.Persantin The correct answer is #4. Persantin (dipyridamole)Persantin is use as an alternative to exercise in thallium myocardial perfusion imaging for the evaluation of CAD in those who cannot exercise adequately. Purpose: to determine myocardial wall viabilityOther names:1. Cardiac pooling2. MUGA-multigated radionuclide angiographic scanning3. nurclear scan4. sestamibi test5. thallium scan6. dipyridamole or persantin stress test7. In short, heart scan :) Loving NCLEX-RNURC 09178364589

Posted by Anaski from IP 203.131.183.186 on August 23, 2005 at 21:44:00: For Future USRN's:Cervical CancerEtiology:* Early age of sexual intercourse* Multiple sexual partners* Sexually Transmitted Disease (Venereal Wart)* Virus - HPV Cancer Carcinoma in SITU - only in epithelial liningsSitu sounds like Ziru - Stage 0 Tumor marker - CEASigns and Symptoms (3 P's)POST COITAL BLEEDINGPAINFUL INTERCOURSEPROFUSE (PERIOD IRREGULARITIEs - menorrhagia and metrorrhagia)

Management:

U - pera (Surgery HYSTERECTOMY)R - radiation (intracavitary cessium - remember STD - shielding, timing and distance))C - chemotherapy to destroy the DNA,RNA & CHON synthesis.

MIKE’S NOTES (60 pp.)

O universal donor/AB universal recipient.

ABO BLOOD TYPE COMPATIBILITY

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

AB O,A,B,AB AB

Autologous Transfusion: Collected 4-6 weeks before surgery

Contraindicated—infection, chronic disease, cerebrovascular or cardiovascular disease

Hypotonic Solution ½ NS (0.45%

Saline)

Isotonic Solution 0.9% NaCl (Normal Saline) 5% D/W (Dextrose in Water) Lactated Ringer’s 5% D/ ¼ NS (5% Dextrose in 0.225%

Saline )

Hypertonic Solution 10% D/W (10% Dextrose in water) D15W 5% D/NS (5% Dextrose in 0.9%

Saline) 5% D/ ½ NS (5% Dextrose in 0.45%

Saline) 3% NaCl 5% Sodium Bicarbonate

Change tubing Q72 hours

Change bottle Q24 hoursInfiltration

Assessment: cool skin, swelling, pain, decrease in flow rate Implementation: discontinue IV, warm compresses, elevate arm, start new site proximal to infiltrated site

IV Phlebitis, Thrmobophlebitis Assessment—redness, warm, tender, swelling, leukocytosis Implementation—discontinue IV, warm moist compresses, start IV in opposite extremity

Hematoma Assessment—ecchymosis, swelling, leakage of blood Implementation—discontinue IV, apply pressure, ice bag 24 hours, restart IV in opposite extremity

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

Insertion of Percutaneous Central Catheters: Placed supine in head-low position Turn head away from procedure Perform Valsalva maneuver Antibiotic ointment and transparent sterile dressing Verify position with x-ray Change tubing Q24 hours Nurse/patient both wear mask when dressing change 2-3x/week

Adrenergics Actions:

Stimulate the sympathetic nervous system: increase in peripheral resistance, increase blood flow to heart, bronchodilation, increase blood flow to skeletal muscle, increase blood flow to uterus Stimulate beta-2 receptors in lungs Use for cardiac arrest and COPD

Adrenergic Medications

Levophed Dopamine Adrenalin Dobutrex

Adrenergics Side effects: Dysrhythmias Tremors Anticholinergic effects

Adrenergics Nursing Considerations:

Monitor BP Monitor peripheral pulses Check output

Anti-AnxietyAction:

Affect neurotransmitters

Used for: Anxiety disorders, manic episodes, panic attacks

Anti-Anxiety Medications:

Librium, Xanax, Ativan, Vistaril, Equanil

Anti-Anxiety Side effects:

Sedation Confusion Hepatic dysfunction

Anti-AnxietyNursing Considerations:

Potention for addiction/overdose Avoid alcohol

Monitor Liver Function AST/ALT Don’t discontinue abruptly, wean off Smoking/caffeine decreases effectiveness

AntacidsActions:

Neutralize gastric acids

Used for: Peptic ulcer Indigestion, reflex esophagitis

Antacids Medications

Amphojel Milk of Magnesia Maalox

AntacidsSide effects:

Constipation Diarrhea Acid rebound

AntacidsNursing Considerations:

Interferes with absorption of antibiotics, iron preps, INH, Oral contraceptives Monitor bowel function Give 1-2 hours after other medications 1-3 hours after meals and at HS Take with fluids

AntiarrhythmicsAction:

Interfere with electrical excitability of heart

Used for: Atrial fibrillation and flutter Tachycardia PVCs

AntiarrhythmicsMedications:

Atropine sulfate Lidocaine Pronestyl Quinidine Isuprel

AntiarrhythmicsSide effects:

Lightheadedness Hypotension Urinary retention

AntiarrhythmicsNursing Considerations:

Monitor vital signs Monitor cardiac rhythm

Aminoglycosides (Antibiotics)Action:

Inhibits protein synthesis in gram-negative bacteria

Used for: Pseudomonas, E.Coli

Aminoglycosides (Antibiotics)Medications:

Gentamycin Neomycin Streptomycin Tobramycin

Aminoglycosides (Antibiotics)Side effects:

Ototoxicity and Nephrotoxicity Anorexia Nausea Vomiting Diarrhea

Aminoglycosides (Antibiotics)Nursing Considerations:

Harmful to liver and kidneys Check 8th cranial nerve (hearing) Check renal function Take for 7-10 days Encourage fluids Check peak/trough level

Cephalosporins (Antibiotics)Action:

Inhibits synthesis of bacterial cell wall

Used for: Tonsillitis, otitis media, peri-operative prophylaxis Meningitis

Cephalosporins (Antibiotics)Medications:

Ceclor Ancef Keflex Rocephin Cefoxitin

Cephalosporins (Antibiotics)Side effects:

Bone marrow depression: caution with anemic, and low PLT px Superinfections Rash

Nursing Considerations: Take with food Cross allergy with PCN Avoid alcohol Obtain C&S before first dose: to make sure medication is effective against disease/bacteria Can cause false-positive for proteinuria/glycosuria

Fluoroquinolones (Antibiotics)Action:

Interferes with DNA replication in gram-

Fluoroquinolones(Antibiotics)Medications:

Cipro

Fluroquinolones(Antibiotics)Side effects:

Diarrhea Decreased WBC and Hematocrit

negative bacteriaUsed for:

E.Coli, Pseudomonas, S. Aureus

Elevated liver enzymes (AST, ALT) Elevated alkaline phosphatase

Nursing Considerations: C&S before starting therapy Encourage fluids Take 1 hour ac or 2 hour pc (food slows absorption) Don’t give with antacids or iron preparation Maybe given with other medications (Probenicid: for gout)

Macrolide (Antibiotics)Action:

Binds to cell membrane and changes protein function

Used for: Acute infections Acne URI Prophylaxis before dental procedures if allergic to PCN

Macrolide (Antibiotics)Medications:

Erythromycin Clindamycin

Macrolide (Antibiotics)Side effects:

Diarrhea Confusion Hepatotoxicity Superinfections

Nursing Considerations: Take 1hr ac or 2-3 hr pc Monitor liver function Take with water (no fruit juice) May increase effectiveness of: Coumadin and Theophylline (bronchodilator)

PenicillinAction:

Inhibits synthesis of cell wall

Used for: Moderate to severe infections Syphilis Gonococcal infections Lyme disease

PenicillinMedications:

Amoxicillin Ampicillin Augmentin

PenicillinSide effects:

Stomatitis Diarrhea Allergic reactions Renal and Hepatic changes

Nursing Considerations: Check for hypersensitivity Give 1-2 hr ac or 2-3 hr pc Cross allergy with cephalosporins

Sulfonamides (Antibiotics)Action:

Antagonize essential component of folic acid synthesis

Used for: Ulcerative colitis Crohn’s disease Otitis media UTIs

Sulfonamides (Antibiotics)Medications:

Gantrisin Bactrim Septra Azulfidine

Sulfonamides (Antibiotics)Side effects:

Peripheral Neuropathy Crystalluria Photosensitivity GI upset Stomatitis

Nursing Considerations: Take with meals or foods Encourage fluids Good mouth care Antacids will interfere with absorption

Tetracyclines (Antibiotics)Action:

Inhibits protein sythesis

Used for:

TEtracyclines (Antibiotics)Medications:

Vibramycin Panmycin

Tetracyclines (Antibiotics)Side effects:

Discoloration of primary teeth if taken during pregnancy or if child takes at young age Glossitis Rash

Infections Acne Prophylaxis for opthalmia neonatorum

Phototoxic reactionsNursing considerations:

Take 1 hr ac or 2-3 hr pc Do not take with antacids, milk, iron Note expiration date Monitor renal function Avoid sunlight

UTIs Medication:

o Furadantin Action:

o Anti-infective Side effects:

o Asthma attackso Diarrhea

Nursing Considerations:o Give with food or milko 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 urineo Limit alkaline foods: vegetables, milk, almonds, coconut

UTIs Medication

o Pyridium Side effects:

o Headacheo Vertigo

Actiono Urinary tract analgesic

Nursing Considerationo Tell patient urine will be orange

AnticholinergicsAction:

Inhibits action of acethylcholine and blocks parasympathetic nerves (affects heart, eyes, respiratory tract, GI tract and the bladder) Dilates pupil, causes bronchodilation and decreased secretions Decrease GI motility secretions

Used for: Opthalmic exam Motion sickness Pre-operative

Anticholinergic Medications:

Pro-Banthine Atropine Scopolamine

AnticholinergicSide Effects:

Blurred vision Dry mouth Urinary retention Chage in heart rate

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

AnticoagulantsAction:

Blocks conversion of prothrombin to thrombin

Used for:

Anticoagulants Medications:

Heparin

Anticoagulants (Heparin)Side Effects:

Hematuria Tissue irritation

Nursing Considerations: Monitor clotting time or Partial

Pulmonary embolism Venous thrombosis Prophylaxis after acute MI

Thromboplastin Time (PTT) Normal 20-45 sec Therapeutic level 1.5-2.5 times control Antagonist—Protamine Sulfate Give SC or IV

AnticoagulantAction:

Interferes with synthesis of vitamin K-dependent clotting factors

Used for: Pulmonary embolism Venous thrombosis Prophylaxis after acute MI

AnticoagulantMedication:

Coumadin

Anticoagulant (Coumadin)Side Effects:

Hemorrhage, AlopeciaNursing Considerations:

Monitor Prothrombin Test (PT) Normal 9-12 sec Therapeutic level 1.5 times control Antagonist—Vitamin K (AquaMEPHYTON) Monitor for bleeding Give PO

AnticonvulsantsAction:

Decreases flow of calcium and sodium across neuronal membranes

Used for: Seizures

AnticonvulsantMedications:

Dilantin Luminal Depakote Tegretol Klonopin

AnticonvulsantSide effects:

Respiratory depression Aplastic anemia Gingival hypertrophy Ataxia

Nursing Considerations: Don’t discontinue abruptly Monitor I&O Caution with use of medications that lower seizure threshold: MAO inhibitors & anti-psychotics Good mouth care Take with food May turn urine pinkish-red/pinkish-brown

Anti-Depressants Monoamine Oxidase Inhibitors (MAO)Action:

Causes increases concentration of neurotransmitters

Used for: Depression Chronic pain

Anti-Depressants(Monoamine Oxidase Inhibitors)Medications:

Marplan Nardil Parnate

Anti-Depressants(Monoamine Oxidase Inhibitors)Side effects:

Hypertensive Crisis (Sudden headache, diaphoretic, palpitations, stiff neck, intracranial hemorrhage) with food that contain Tyramine

Nursing Considerations: Avoid foods containing Tyramine: Aged cheese, liver, yogurt, herring, beer and wine, sour cream, bologna, pepperoni, salami, bananas, raisins, and pickled products Monitor output Takes 4 weeks to work Don’t combine with sympathomometics vasoconstrictors, and cold medications

Anti-DepressantsSelective Serontonin Reuptake Inhibitors (SSRI)Action:

Inhibits CNS uptake of serotonin

Used for: Depression Obsessive-Compulsive Disorder Bulimia

Anti-DepressantsSelective Serontonin Reuptake Inhibitors (SSRI)Medications:

Paxil Prozac Zoloft

Anti-DepressantsSelective Serontonin Reuptake Inhibitors (SSRI)Side effects:

Anxiety GI upset Change in appetite and bowel function Urinary retention

Nursing Considerations: Suicide precautions Takes 4 weeks for full effect Take in a.m. May urine to pinkish-red or Pinkish-brown Can be taken with meals

Anti-Depressants (Tricyclics)

Anti-Depressants (Tricyclics)

Anti-Depressants (Tricyclics)Side Effects:

Action: Inhibits reuptake of neurotransmitters

Used for: Depression Sleep apnea

Medications: Norpramin Elavil Tofranil

Sedation/Confusion Anticholinergics affects Postural Hypotension Urinary retention

Nursing Considerations: Suicide precautions/2-6 weeks to work Take at hs/Don’t abruptly halt Avoid alcohol/OTC /Photosensitivity

Insulin (Regular, Humulin R)Type: Fast actingOnset: ½ -1 hrPeak: 2-4 hrDuration: 6-8 hr

Insulin(NPH, Humulin N)Type: Intermediate actingOnset: 2hrPeak: 6-12hrDuration 18-26hr

Insulin(Ultralente, Humulin U)Type: Slow actingOnset: 4hrPeak: 8-20hrDuration: 24-36hr

Insulin(Humulin 70/30)Type: CombinationOnset: ½ hrPeak: 2-12hrDuration: 24hr

Antidiabetic AgentsAction:

Stimulates insulin release from beta cells in pancreas

Used for: Type 2 diabetes (NIDDM)

Antidiabetic AgentsMedications:

Diabinese Orinase Dymelor Micronase

Antidiabetic AgentsSide Effects: Hypoglycemia Allergic skin reactions GI upsetNursing Considerations: Take before breakfast Monitor glucose levels Avoid alcohol,

sulfonamides, Oral Contraceptives, (MAO), aspirin because they help to make drug work better

Hypoglycemic AgentAction:

Stimulates liver to change glycogen to glucose

Used for: Hypoglycemia

Hypoglycemic AgentMedication:

Glucagon

Hypoglycemic AgentSide Effects:

Hypotension Bronchospasm

Nursing Considerations: May repeat in

15min Give carbohydrates

orally to prevent secondary hypoglycemic reactions

AntidiarrhealsAction:

Slows peristalsis Increases tone of

sphinctersUsed for:

Diarrhea

AntidiarrhealsMedications:

Kaopectate Lomotil Imodium Paregoric

AntidiarrhealsSide Effects:

Constipation Anticholinergic

effects (urinary retention, dry mouth)

Nursing Considerations: Do not use with

abdominal pain Monitor for urinary

retention Give 2hr before or

3 hr after other meds

AntiemeticsAction:

Increases GI motility Blocks effect of

dopamine in chemoreceptor

AntiemeticsMedications:

Tigan Compazine Torecan Reglan

AntiemeticsSide Effects:

Sedation Anticholinergic effects

Nursing Considerations: Used before chemotherapy

trigger zoneUsed for:

Vomiting

Antivert Dramamine

When used with viral infections may cause Reye’s syndrome (Toxic Encephalopathy)

AntifungalsAction:

Impairs cell membrane

Used for: Candidiasis Oral thrush Histoplasmosis

AntifungalsMedications:

Amphotericin B Nystatin

AntifungalsSide Effects:

Hepatotoxicity Thrombocytopenia Leukopenia Pruritis

Nursing Considerations: Give with food Monitor liver function Good oral hygiene

Antigout AgentsAction:

Decreases production and resorption of uric acid

Used for: Gout

Antigout AgentsMedications:

Colchicine Probenecid Zyloprim

Antigout AgentsSide Effects:

Agranulocytosis GI upset Renal calculi

Nursing Considerations: Monitor for renal calculi Give with food, milk,

antacids

AntihistaminesAction:

Block effects of histamine

Used for: Allergic rhinitis Allergic reactions to

blood

AntihistaminesMedications:

Chlor-Trimeton Benadryl Phenergan

AntihistaminesSide Effects:

Drowsiness Dry mouth Photosensitivity

Nursing Considerations: Give with food Use sunscreen Avoid alcohol

Antihyperlipidemic AgentsAction:

Inhibits cholesterol and triglyceride synthesis

Used For: Elevated

cholesterol Reduce incidence

of cardiovascular disease

Antihyperlipidemic AgentsMedications:

Questran Lipid

Antihyperlipidemic AgentsSide Effects:

Constipation Fat-soluble vitamin

deficiencyNursing Considerations:

Take at hs or 30 min ac

Administer 1hr before or 4-6 hr after other meds

AntihypertensivesTypes: ACE InhibitorsAction:

Blocks ACE in lungs

Used for: Hypertension CHF

Antihypertensives(ACE Inhibitors)Medications:

Capoten Vasotec

Antihypertensives(ACE Inhibitors)Side Effects:

GI upset Orthostatic hypotension Dizziness

Nursing Considerations: Give 1hr ac or 3hr pc Change position slowly

AntihypertensivesType: Beta-Adrenergic BlockersAction:

Blocks Beta-Adrenergic Receptors

Decrease excitability/workload of heart, oxygen

AntihypertensivesType: Beta-AdrenergicMedications;

Nadolol Propranolol Tenormin Timoptic

AntihypertensivesType: Beta-AdrenergicSide Effects:

Changes in heart rate

Hypotension Bronchospasm

Nursing Considerations:

consumption Decrease

Used for: Hypertension Angina SVT

Masks signs of shock and hypoglycemia

Take with meals Do not discontinue

abruptly

AntihypertensivesType: Calcium Channel BlockersAction:

Inhibits movement of calcium across cell membranes

Slow impulse conduction and depresses myocardial contractility

Causes dilation of coronary arteries and decreases cardiac workload and energy consumption

Used for: Angina Hypertension Interstitial cystitis

AntihypertensivesType: Calcium Channel BlockersMedications:

Procardia Calan Cardizem

AntihypertensivesType: Calcium Channel BlockersSide Effects:

Hypotension Dizziness GI distress

Nursing Consideration: Monitor vital

signs Do not chew or

divide sustained-release tablets

AntihypertensivesType: Centrally acting alpha-adrenergicsAction:

Stimulates alpha receptors in medulla which causes a reduction in sympathetic in the heart

Used for: Hypertension

AntihypertensivesType: Centrally acting alpha-adrenergicsMedications:

Aldomet Catapres

AntihypertensivesType: Centrally acting alpha-adrenergicsSide Effects:

Sedation Orthostatic Hypotension

Nursing Considerations: Don’t discontinue

abruptly Monitor for fluid retention Change position slowly

AntihypertensivesType: Direct-acting vasodilatorsAction:

Relaxes smooth muscle

Used for: Hypertension

AntihypertensivesMedications

Hydralazine Minoxidil

AntihypertensivesSide Effects:

Tachycardia Increase in body hair

Nursing Considerations: Teach patient to

check pulse

AntihypertensivesType: Peripheral-acting alpha-adrenergic blockersAction:

Depletes stores of norepinephrine in sympathetic nerve endings

Used for: Hypertension

AntihypertensivesMedications:

Reserpine

AntihypertensivesSide Effects:

Depression Orthostatic

Hypotension Brachycardia

Nursing Considerations: Give with meals or

milk Change position

slowly

Bipolar Disorder Action:

Reduces catecholamine release

Used for: Manic episodes

Bipolar Disorder Medications:

Lithium (1-1.5meq/L) Tegretol Depakote

Bipolar Disorder Side Effects:

GI upset Tremors Polydipsia Polyuria

Nursing Considerations: Monitor serum levels Give with meals Increase fluid intake

Antineoplastic AgentsType: Alkylating AgentsAction:

Antineoplastic AgentsMedications:

Antineoplastic AgentsSide Effects:

Hepatotoxicity

Interferes with rapidly reproducing DNA

Used for: Leukemia Multiple myeloma

Cisplatin Myleran Cytoxan

Ecchymosis Alopecia Epitaxis Infertility Bone Marrow Suppression Stomatitis GI disturbances: Anorexic, N/V,

diarrheaNursing Considerations:

Check hematopoietic (reproduction of RBC’s by bone marrow) function

Force fluids Good mouth care

Antineoplastic AgentsType: AntimetabolitesAction:

Inhibits DNA polymerase

Used for: Acute lymphatic

leukemia Cancer of colon,

breast, pancreas

Antineoplastic AgentsAntimetabolites Medications:

5-FU Methotrexate Hydrea

Antineoplastic AgentsAntimetabolitesSide Effects:

Nausea Vomiting Oral ulceration Bone marrow

suppression Alopecia

Nursing Considerations: Monitor hematopoietic

function Good mouth care Discuss body image

changes

Antineoplastic AgentsType: Antitumor AntibioticsAction:

Interferes with DNA and RNA synthesis

Used for: Cancer

Antineoplastic AgentsAntitumor AntibioticsMedications:

Adriamycin Actinomycin D Bleomycin

Antineoplastic AgentsAntitumor AntibioticsSide Effects:

Bone marrow suppression Alopecia Stomatitis

Nursing Considerations: Monitor vital signs Give antiemetic medications before

therapy

Antineoplastic AgentsType: Hormonal AgentsAction:

Changes hormone input into sensitive cells

Used for: Cancer

Antineoplastic AgentsType: Hormonal AgentsMedications:

Diethylstilbestrol Tamoxifen Testosterone

Antineoplastic AgentsType: Hormonal AgentsSide Effects:

Leukpenia Bone pain Hypercalcemia

Nursing Considerations: Check CBC Monitor serum

calcium

Antineoplastic AgentsType: Vinca AlkaloidsAction:

Interferes with cell division

Used for: Cancer

Antineoplastic AgentsType: Vinca AlkaloidsMedications:

Oncovin Velban

Antineoplastic AgentsType: Vinca AlkaloidsSide Effects:

Stomatitis Alopecia Loss of reflexes Bone marrow

suppressionNursing Considerations:

Give antiemetic before administration

Check reflexes Given with Zyloprim

to decrease uric acid

Antiparkinson Agents Antiparkinson Agents Antiparkinson Agents

Action: Converted to

Dopamine Stimulates

postsynaptic Dopamine receptors

Used for: Parkinson’s disease

Medications: Artane Cogentin L-Dopa Parlodel Sinemet Symmetrel

Side Effects: Dizziness Ataxia Atropine-like effects: dry

mouth, urinary retentionNursing Considerations:

Monitor for urinary retention

Large doses of vitamin B6 reverse effects

Avoid use of CNS depressants

Antiplatelet AgentsAction:

Interferes with platelet aggregation

Used for: Venous thrombosis Pulmonary

embolism

Antiplatelet AgentsMedications:

Aspirin Persantine

Antiplatelet AgentsSide Effects:

Hemorrhage Thrombocytopenia

Nursing Considerations: Check for signs of

bleeding Give with food or

milk

Antipsychotic AgentsAction:

Blocks dopamine receptors in basal ganglia

Used for: Acute and Chronic

psychoses

Antipsychotic AgentsMedications:

Haldol Thorazine Mellaril Stelazine

Antipsychotic AgentsSide Effects:

Akathisia (inability to sit still)

Dyskinesia Dystonias Parkinson’s

syndrome Tardive dyskinesias Leukopenia

Nursing Considerations: Check CBC Monitor vital signs Avoid alcohol and

caffeine

Atypical Antipsychotic AgentsAction:

Interferes with binding of dopamine in the brain

Used for: Acute and Chronic

psychoses

Atypical AntipsychoticMedications:

Clozaril Risperdal

Atypical AntipsychoticSide Effects:

Extrapyramidal effects

Anticholinergic Sedative Orthostatic

hypotensionNursing Considerations:

Monitor blood Change positions

slowly Use sunscreen

Antipyretic AgentsAction:

Antiprostaglandin activity in hypothalamus

Used for: Fever

Antipyretic AgentsMedications:

Tylenol (Acetaminophen)

Antipyretic AgentsSide Effects:

GI irritationNursing Considerations:

Monitor liver function

Aspirin contraindicated for younger than 21 years old due to risk of Reye’s syndrome

Antithyroid Agents Antithyroid Agents Antithyroid Agents

Action: Reduce vascularity

of thyroid Inhibits release of

thyroid into circulation

Used for: Hyperthyroidism

Medications: Tapazole SSKI

Side Effects: Leukopenia Rash Thrombocytopenia

Nursing Considerations: Bitter taste May cause burning

in mouth Give with meals Check CBC

Thyroid Replacement AgentsAction:

Increases metabolic rate

Used for: Hypothyroidism

Thyroid ReplacementMedications

Synthroid Cytomel

Thyroid ReplacementSide Effects:

Nervousness Tachycardia Weight loss

Nursing Considerations: Monitor pulse and

BP Monitor weight Take in a.m. Enhance action of

anticoagulants, antidepressants, decrease action of insulin and digitalis

Antitubercular AgentsAction:

Inhibits cell and protein synthesis

Used for: Tuberculosis To prevent disease

in person exposed to organism

Antitubercular AgentsMedications:

INH Ethambutol Streptomycin PAS PYZ

Antitubercular AgentsSide Effects:

Hepatitis Peripheral Neuritis

Nursing Considerations: Check liver function tests Vitamin B6 given for

peripheral neuritis (Pyridoxine)

Used in combinationAntiviralsAction:

Inhibits DNA and RNA replication

Used for: Recurrent HSV HIV infection

AntiviralsMedications:

Zovirax AZT Videx Famvir Cytovene

AntiviralsSide Effects:

Headache Dizziness GI symptoms

Nursing Considerations: Encourage fluids Not a cure, but

relieves symptoms

Attention Disorder AgentsAction:

Increases level of catecholamines

Used for: ADDH Narcolepsy

Attention Disorder AgentsMedications:

Ritalin Cylert Dexedrine

Attention Disorder AgentsSide Effects:

Restlessness Insomnia Tachycardia Palpitations

Nursing Considerations: Monitor growth rate Monitor liver

enzymes Give in A.M.

BronchodilatorsAction:

Decreases activity of phosphodiesterase

Used for: COPD

BronchodilatorsMedications:

Aminophylline Atrovent Brethine Proventil

BronchodilatorsSide Effects:

Tachcyardia Dysrhythmias Palpitations Anticholinergic effects

Preterm labor (Terbutaline)

Primatene Nursing Considerations: Monitor BP and HR When used with

steroid inhaler, use bronchodilator first

May aggravate diabetes

Cardiac GlycosidesAction:

Increases force of myocardial contraction, slows rate

Used for: Left-sided CHF

Cardiac Glycosides Medication:

Lanoxin (Digoxin)

Cardiac GlycosidesSide Effects:

Bradycardia Nausea Vomiting Visual disturbances

Nursing Considerations: Take apical pulse Notify physician if adult <60, child <90-110, <70

in older children Monitor potassium level Dose: 0.5-1 milligram IV or PO over 24 hr period Average: 0.25 mg

CholinergicsAction:

Inhibits destruction of acetylcholine

Stimulate parasympathetic nervous system (increase bowel tone, increase bladder tone, constrict pupil)

Used for: Myasthenia gravis Post-operative Postpartum urinary

retention

CholinergicsMedications:

Tensilon Prostigmin

CholinergicsSide Effects:

Bronchoconstriction Respiratory paralysis Hypotension

Nursing Considerations: Give with food or milk Monitor vital signs,

especially respirations Antidote: Atropine

Sulfate Toxicity: excessive

salivation, excessive sweating, abdominal cramps, flushing

DiureticsAction:

Inhibits reabsorption of sodium and water

Blocks effects of aldosterone

Used for: CHF Renal disease

DiureticsMedications:

HydroDIURIL Diamox Aldactone Lasix Hygroton

DiureticsSide Effects:

Dizziness Orthostatic

Hypotension Leukopenia

Nursing Considerations: Take with food or milk Take in a.m. Monitor fluid and

electrolytes

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

Stimulates formation of glucose

Alters immune response

Used for: Addison’s disease Crohn’s disease COPD Leukemias

GlucocorticoidsMedications:

Solu-Cortef

Decadron Deltasone

GlucocorticoidsSide Effects:

Psychoses Depression Hypokalemia Stunted growth Buffalo Hump

Nursing Considerations: Monitor fluid and electrolyte

balance Don’t discontinue abruptly Monitor for signs of infection

MineralocorticoidsAction:

Increases sodium

MineralocorticoidsMedications:

MineralocorticoidsSide Effects:

Hypertension

reabsorption Potassium and

hydrogen ion secretion in kidney

Used for: Adrenal

insufficiency

Florinef Edema Hypokalemia

Nursing Considerations: Monitor BP, I&O, Weight, and Electrolytes Give with food Low-sodium, High-protein, High-potassium

diet

Heavy Metal AntagonistsAction:

Forms stable complexes with metals

Used for: Gold and arsenic

poisoning Acute lead

encephalopathy

Heavy Metal AntagonistsMedications:

Desferal mesylate BAL in Oil EDTA

Heavy Metal AntagonistsSide Effects:

Tachycardia Pain and induration at

injection site (conjunct with Procaine in syringe)

Nursing Considerations: Monitor I&O and kidney

function Administered with local

anesthetic Seizure precautions

H2 Receptor BlockersAction:

Inhibits action of histamine and gastric acid secretion

Used for: Ulcers Gastroesophageal

reflux

H2 Receptor BlockersMedications:

Tagamet Zantac

H2 Receptor BlockersSide Effects:

Dizziness Confusion Hypotension Impotence

Nursing Considerations: Take with meals

and hs Smoking decreases

effectiveness Monitor liver

function and CBC

ImmunosuppressantsAction:

Prevents production of T cells and their response to interleukin-2

Used for: Prevents rejection

for transplanted organs

ImmunosuppressantsMedications:

Sandimmune

ImmunosuppressantsSide Effects:

Hepatotoxicity Nephrotoxicity LeuKopenia Thrombocytopenia

Nursing Considerations: Take once daily in

a.m. Used with adrenal

corticosteroids Monitor renal and

liver function tests

Miotics (Constricts Pupil)Action:

Causes constriction of sphincter muscles of iris

Used for: Ocular surgery Open-angle

glaucoma

Miotics Medications:

Isopto-Carpine Eserine Carbacel

MioticsSide Effects:

Headache Photophobia Hypotension Bronchoconstriction

Nursing Considerations: Apply pressure on

lacrimal sac for 1min Avoid sunlight May experience

transient brow pain and myopia

Mydriatics (Dilates Pupil)Action:

Anticholinergic

MydriaticsMedications:

Atropine sulfate

MydriaticsSide Effects:

Tachycardia

actions leaves pupil under unopposed adrenergic influence

Used for: Diagnostic

procedures Acute iritis Uveitis

Cyclogyl Blurred vision Photophobia Dry mouth

Nursing Considerations: Contraindicated with

glaucoma Apply pressure on lacrimal

sac for 1min. Wear dark glasses

NarcoticsAction:

Acts on CNS receptor cells

Used for: Moderate to severe

pain Preoperative Postoperative

Narcotics Medications:

Morphine Sulfate Codeine Demerol Dilaudid Percodan

NarcoticsSide Effects:

Dizziness Sedation Respiratory depression Hypotension Constipation

Nursing Considerations: Safety precautions Avoid alcohol Monitor vital signs Use narcotic antagonist if

necessary (Narcan)

AntianginalsAction:

Relaxes smooth muscle

Decreases venous return

Used for: Angina Peri-operative

hypertension CHF

AntianginalsMedications:

Nitroglycerine Isosorbide

AntianginalsSide Effects:

Hypotension Tachycardia Headache Dizziness

Nursing Considerations: Check expiration date Teach when to take medication May take Q5min x3 doses Wet with saliva and place under

tongue

NSAIDSAction:

Inhibits prostaglandin synthesis

Used for: Arthritis Mild to moderate

pain Fever

NSAIDSMedications:

Motrin Indocin Naprosyn

NSAIDSSide Effects:

GI upset Dizziness Headache Bleeding Fluid retention

Nursing Considerations: Take with food or after meals Monitor liver and renal function Use cautiously with aspirin allergy Check for bleeding

ThrombolyticsAction:

Dissolves or lyses blood clotsUsed for:

Acute Pulmonary Emboli Thrombosis MI Contraindicated in: hemophilia,

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

ThrombolyticsMedications:

Streptokinase Urokinase Tissue Plasminogen

Activator

ThrombolyticsSide Effects:

Bleeding Bradycardia Dysrhythmias

Nursing Considerations: Monitor for bleeding Have Amino Caproic

Acid Available Check pulse, color,

sensation of extremities Monitor EKG

Anaphylaxis Symptoms

o Hiveso Rasho Difficulty breathing (first sign)o Diaphoresis

Nursing careo Epinephrine 0.3 ml of 1:1000 solution SQo Massage siteo May repeat in 15-20 min.

Delayed Allergic Reaction Symptoms:

o Rash, Hives, Swollen Joints Nursing Care

o Discontinue medicationo Topical Antihistamineso Corticosteroidso Comfort measures

Bone Marrow DepressionSymptoms:

Fever, Chills, Sore ThroatBack pain, Dark urineAnemia, Thrombocytopenia, Leukopenia

Nursing Care:Monitor CBCProtect from infectionsAvoid injury

Liver impairment: light stools and dark urineRenal Impairment: decrease Hematocrit

Anticholinergic Effects Symptoms:

o Dry mouth, Dysphagia, Nasal Congestiono Urinary retention, Impotence

Nursing Care:o Sugarless lozengeso Good mouth careo Void before taking medication

Parkinson’s-like effects Symptoms:

o Akinesia (temporarily paralysis of muscles)o Tremorso Droolingo Changes in gaito Rigidityo Akathisia (Extreme restlessness)o Dyskinesia (Spasms)

Nursing Care:o Anticholinergic and Antiparkinsonian medicationso Safety measures for gait

How long should a client with tuberculosis be on medication?

6-9 Months

What are symptoms of hepatitis?

Inflammation of LiverJaundiceAnorexiaRUQ painClay-colored stools, tea-colored urinePruritis (bile salts eliminated through skin)Elevated ALT, ASTProlonged PT (liver involvement with clotting factor)

What is the transmission of Hepatitis A?

Fecal/OralConsume contaminated food or waterTravelers to developing countries at riskClients with hepatitis A should not prepare

food for othersWhat is the transmission of Hepatitis B?

Parenteral/Sexual contactBlood or body fluidsAt risk individuals are the one’s that abuse IV drugs, dialysis, healthcare workersVaccine developed

What is the transmission of Hepatitis C?

Blood or body fluidsCan become chronic diseaseSeen in patients with hemophilia (unable to clot)

What is the transmission of Hepa D ?

Co-infects with hepatitis B

What nursing care are recommended for Hepatitis?

Rest (mainly for liver)Contact and standard precautionsLow-fat, High-Calorie, and High Protein diet (needed for organ healing)No alcoholic beveragesMedications (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 Disease?

Erythematous papule develops into lesion with clear center (Bull’s-eye)Regional lymphadenopathyFlu-like symptoms (fever, headache, conjunctivitis)Can develop over 1 to several months

What is Stage 2 of Lyme’s Disease?

Develop after 1 to 6 months if disease untreated.Cardiac conduction defects Neurologic disorders (Bell’s palsy, temporary paralysis)

What is Stage 3 of Lyme’s Disease?

Develops after 1 to several months, if reached at this stage may persist for several years.Arthralgias Enlarged, inflamed joints

What are some Lyme’s Disease teaching?

Cover exposed areas when in wooded areasCheck exposed areas for presence of ticks

What are some Lyme’s Disease nursing care?

Antibiotics 3-4 weeksStage 1 use Doxicillin IV penicillin with later stages

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

Painless chancre fades after 6 weeksLow grade feverCopper-colored rash on palms and soles of feetSpread by contact of mucous membranes, congentTreat with Penicillin G IMIf patient has penicillin allergy, will use erythromycin for 10-15 days.After treatment, patient must be retested to make sure disease is gone.

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

If female maybe asymptomatic and will be unaware of having disease.Males may have thick discharge from urethra.Some females from vagina.Spread mucous membranes, congenitalIM 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 DiseaseMost often affected with Chlamydia also, then treatment with PO Tetracycline

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

No cure.Painful vesicular genital lesionsProblem is exacerbations/remissionsReoccurs with stress, infection, mensesSpread by contact of mucous membranes, congenitalTreatment: Acyclovir, sitz bathMonitor pap smears regularly because of higher incidence of cervical cancer.Emotional support of client/significant others important because of no cure.Pregnant women with active disease will have C-section.

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

Men: urethritis, dysuriaWomen: thick vaginal discharge with acrid odorSpread by mucous membranes, congenitalTreatment with Tetracycline or Doxycycline POWill cause sterility if left untreated.Important to notify sexually contacted.

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

Single, small papillary lesion spreads into large cauliflower cluster on perineum, vagina, penis.May itch or burn.Spread by mucous membranes, congenitalTreatment: Curettage, cryotherapy with liquid nitrogen, kerotolytic agentsAvoid intimate contact until lesions healComplication: Genital Dysplasia Cancer

What is the difference between AIDS and HIV +?

HIV Positive—presence of HIV in bloodAIDS—has significant defects in immune function associated with positive HIV evidenced by development of opportunistic infectionsSyndrome where CD4 counts are below 200

What are some opportunistic infections of AIDS?

P. Carinii Pneumonia: sob/dry-nonproductive coughC. Albicans stomatitis: will have difficulty swalling and white exudates in back of throatC. Neoformans: debilitating form of meningitis that may suffer seizures.Cytomegalovirus (CMV): will experience lymphadenopathy and may have visual impairment and can affect any organ.Kaposi’s Sarcoma: most common malignancy experience with AIDS, small purplish brown, nonpainful, nonpuriitc palpable lesions on the body.

How is AIDS transmitted? Contaminated blood or body fluidsSharing IV needlesSexual contact Transplacental: across placentaPossibly by breast milk

What are diagnostics test associated with AIDS?

ELISA test, if positive will be confirmed by Western Blot testHIV Viral culture: Leukopenia, Thrombocytopenia, Decrease CD4 counts

What are some nursing cares for AIDS?

Prevention: avoid IV drug use, precautions regarding sexual patterns, use standard precautionsContact and standard precautionsHigh-protein and high-calorie diet, small frequent meals rather than 3 large mealsSymptomatic relief SupportDon’t share toothbrush/shavers

What are treatments, care, prevention of poison control?

Prevention most important.Treat patient first, and then the poison.Recognize signs of symptoms of accidental poison: changes in appearance, behavior,

substances around mouth, empty containers, vomitous.

What should happen when someone is poisoned?

Call poison control center.Tell them: substance, time, amount and route of ingestion, child’s condition, age, weight, save vomitus, stool, urine.

Why should vomit not be induced?

Don’t induce if:Danger of aspiration, decrease LOC, Ingested petroleum distillate (lighter fluid, kerosene, paint remover)Ingested corrosive (Draino)

What medication treatment is used to induce vomiting and what other factors need to be implemented?

Syrup of Ipecac with small amount of water. Don’t give large amount of fluid after Ipecac, will increase gastric emptying. Don’t use milk. Position with head lower then chest.No universal antidote.

What should happen to poison control in emergency care?

Intubated if comatoseRun blood gasesIV fluidsCardiac MonitorGastric Lavage (NG down to flush with NS to remove rest in stomach)Activated CharcoalMay use cathartics, diuretics

What are signs and symptoms, treatments, care, prevention of aspirin poisoning?

Tinnitus, change in mental status, Increased temperature, hyperventilation, bleeding, nausea and vomiting.Nursing care: induce vomiting, maintain hydration, reduce temperature (sponge baths), monitor for bleeding.

What are signs and symptoms, treatments, care, prevention of tylenol poisoning?

Symptoms: nausea/vomiting, hypothermia, If no treatment, hepatic/liver involvement.If liver gets involved patient may have RUQ pain, jaundice, confusion, and coagulation abnormalities.Nursing care: induce vomiting, maintain hydration, monitor liver and kidney function with labs such as AST/ALT enzymes.Tylenol (Acetaminophen) overdosage: Antidote N-acetylcysteine (Mucomyst)

What are signs and symptoms, treatments, care, prevention of lead toxicity?

Symptoms: Irritability, decreased activity, abdominal pain, Increased ICPDiagnostic tests: Blood lead levels (>9micrograms = toxic), Erythrocyte protoporphyrin (EP), X-ray long bones (lead deposits in long bones)Children engage in PICA (ingesting nonfood substances)Lead blocks formation of hemogloblin and toxic to kidneys.Nursing care: identify source, chelating agents, teaching parents

What are nursing care goals for Hazardous wastes?

Decontaminate individualPrevent spread of contaminationClean and remove contaminuated sourceMonitor personnel exposed

What are nursing care for Hazardous wastes?

If chemical poses threat to 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 infants (0-12months) use?

Solitary play. Game is one sided. Like to play with body parts. Birth-3months: smile/squeal3-6months: rattles/soft stuff toys

6-12 months: begin imitation, peek-a-boo, patty-cake

Play of toddlers (1-3 years) Parallel play. Play of pre-schoolers (3-6years) Associative play. Dress up/imitating play.

Talking on telephone/kitchen/tool belt Play 0f school age (6-12years) Cooperative play. Conformed/organized play. According to Erikson’s Developmental Task, explain the Infancy stage.

Birth-18 months.Trust vs. MistrustPositive outcome---trusts selfNegative outcome---withdrawn

According to Erikson’s Developmental Task, explain the Toddler stage.

18months – 3 yearsAutonomy vs. Shame and DoubtPositive outcome---exercise self-controlNegative outcome---defiant and negative

According to Erikson’s Developmental Task, explain the Preschool stage.

3-6 yearsInitiative vs. Guilt Children develop conscience at this age.Positive Outcome---learns limitsNegative Outcome---fearful, pessimistic

According to Erikson’s Developmental Task, explain the School age stage.

6-12yearsIndustry vs. InferiorityPositive---sense of confidenceNegative---self doubt, inadequate

According to Erikson’s Developmental Task, explain the Adolescence stage.

12-20 yearsIdentity vs. Role diffusionPositive outcome---coherent sense of selfNegative outcome---lack of identity

According to Erikson’s Developmental Task, explain the young adult stage.

20-45 yearsIntimacy vs. IsolationPositive outcome---intimate relationships/careers formedNegative outcome---avoidance of intimacy

According to Erikson’s Developmental Task, explain the middle adulthood stage.

45-65 yearsGenerativity vs. StagnationPositive Outcome---creative and productiveNegative Outcome---self centered

According to Erikson’s Developmental Task, explain the Late adulthood stage.

65+ yearsIntegrity vs. DespairNo regrets in life or RegretsPositive outcome---seems life as meaningfulNegative outcome---life lacks meaning

At what month does the head sag?

1 month

At what month do you see closing of posterior fontanelle, turn from side to back, and see a social smile?

2 months

What toys do you give for a 2 month old?

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

At what month does a child bring objects to mouth and head erect?

3 months

What toys do you give for a 4 month old?

Rattles, cradle gym, and stuffed animals

Which age does birth weight double?

5 months

At what age does teething occur?

6 months

What toys do you give for a 6 month old?

Brightly colored, small enough to grasp, large enough for safety, teething toys

What age for fears of strangers? When is fear strongest?

7 months8 months is stronger

Which month able to play peek-a-boo?

7 months

What toys do you give for 7- Large colored, bricks, jack in the box

8months?What month can a child say “DADA?

9 month

What month can a child crawl well?

10 months

What month can a child stand erect with support?

11 months

What happens in the 12th month of the child?

Birth weight triples.Eats with fingers.Anterior Fontanelle almost close.Babinski reflex disappears.Toys: books with large pictures, push pull toys, teddy bears, a large ball, or sponge toys.

Explain introduction of solid foods.

One food at a time.Begin with least allergenic foods first.

Cereal is usually first. (Do not use cow’s milk/whole milk. After six months of age cereal can be mixed with fruit juices. Fruit juices should be offered in a cup to prevent dental carries.)

Vegetables Fruits Potatoes Meats Eggs Orange Juice By 12 months children should be eating

table food. Don’t give honey under 12 because of botulism.

What does a toddler do at 15 months?

Walks alone.Throws object.Holds spoon.Say 4-6 words. Understand simple commands.

What does a toddler do at 18 months?

Anterior fontanelle closes.Climbs stairs.Sucks thumb.Say 10 + words.Temper Tantrums.

What does a toddler do at 24 months?

300 world vocabulary.Obeys easy commands.Go up/down stairs alone.Build towers.Turn doorknobs/unscrew lids.Increase independence.

What does a toddler do at 30 months?

Walk tip toe.Stand on one foot balance.Has control for sphincter training.Birth weight quadrupled.State first/last name.Give simple commands.

What type of toys are included for Toddlers?

Cooking utensils, Dress-up clothes, rocking horses, finger paints, phonographs, cd players.

How do you avoid negativism during toddler ages?

Don’t ask no/yes questions.Offer them choices.Make a game out of the tasks.

What can a 3 year old do? Rides tricycle.Undresses without help.May invent imaginary friend.Vocabulary 900 words.Egocentric in thoughts/behaviors.

What can a 4 year old do? Laces shoesBrushes teethThrows overhandUses sentences.

IndependentWhat can a 5 year old do? Runs well/Dresses without help.

Beginning cooperative play.Gender-specific behavior.

What toys are used for preschool (3-5)?

Playground materials, Housekeeping toys, Coloring books, tricycle with helmet.

Which age groups has greatest number of fears?

Preschool age children.

What would you expect with a 6 year old?

Self-centered, show off, rudeSensitive to criticismBegins loosing temporary teethTends to lie.

What would you expect with a 7 year old?

Team games/sports.Concept of time.Playing with same sex child.

What would you expect with a 8 year old?

Seeks out friends.Writing replaces printing.

What would you expect with a 9 year old?

Conflicts between peer groups and parents.Conflicts between independence and dependence.Likes school.Able to take on job duties (housework).

What toys are used for school age child?

Construction toys, Pets, Games, Electronic games, reading, books, bicycles with helmets.

School age potential problems include:

Anuresis (encourage before bed time)Encopresis Head lice

What are symptoms/indications of a fetal alcohol syndrome in a child?

Thin upper lip, vertical ridge in upper lip, short up turned nose, mental retardation, motor retardation, hearing disorders, microcephaly.Avoid alcohol 3 months before conception and throughout pregnancy.

What happens with amniocentesis? What does it do?

16th week detects genetic abnormality30th week detects L/S ratio: lung maturityVoid before procedureUltrasound given to determine position of placenta and fetus.Complications: premature labor, infection, Rh isommunization (if client Rh negative, will be given Rhogam)

What happens with an ultrasound?

5th week confirms pregnancyDetermines 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-stress test?

At 28th week records FHR and fetal movement.Favorable result: 2+ FHR accelerates by 15bpm and last 15seconds in 20 minutes.

What happens with a contraction stress test?

Determines placenta’s response to labor.Done after 28th week.Fowler/Semi-Fowler.Given Oxytocin or Pitocin.Results:

Positive: Late decelerations indicates potential risk to fetus.

Negative: No late decelerations.

What does Torch stand for? And their importance?

Diseases that cross placenta or other events. Produce significant deformities or infant born with infectious process.Toxoplasmosis: no litter box changed, no gardening, no under cooked meats.Rubella: 1-16 titer immune for rubella, titer <1-8 susceptible. Cytomegalovirus: transmitted in body fluids. Herpes Simplex: Ascending infection. During pregnancy get treated with acyclovir. Delivery through c-section.

What concerns for clients that UTI: may lead to pylonephritis, increase risk of

have UTI, Syphilis, Gonorrhea? premature birth.Syphillis: passes through placenta, causes 2nd trimester abortions, still birth, and congenital infection, may receive medication for her and her baby.Gonorrhea: baby gets prophylactic eydrops.

What are the danger signs of pregnancy?

Gush or fluid bleeding 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 the onset of labor?

Lightening: (when baby drops to pelvis) Primipara: occurs 2 weeks before

delivery Multipara: occurs during labor

Softening of cervixExpulsion of mucus plug (bloody show) – pink tinged mucus secretionUterine contractions: regular/progressive not Braxton-Hick’s type.

How does prolapsed umbilical cords happen?

Premature rupture of membranes.Presenting part not engaged.Fetal distress.Protruding cord.

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

Call for help.Push up against presenting part off of the cord.Place in trendenlenberg position or knee chest position.Successful if FHT left unchanged.

What is a early/sign of fetal hypoxia?

Early sign: fetal tachycardia >160 in >10minutesLate sign: fetal bradycardia <110 in > 10 minutes

What things should you know about the Informed Consent form?

Nurse can witness patient sign form.Patient has to be age of capacity/adult and confident. No confused patient/drinking/already received preoperative medications.Consent must be given voluntarily and information understandable. Nurse must make sure questions are answered and form is attached to chart.

What is early deceleration? Decrease in HR before peak of contraction. Indication of head compression.

What are interventions for late decelerations?

Position mother left side/trendenlenberg/knee chestIncrease rate of IVAdminister Oxygen 7-10 l/minDC Oxytocin

What do variable decelerations indicate?

Cord compression.Change maternal position.Administer oxygen.DC Oyxtocin/Pitocin

What are signs of “True Labor”?

Regular contractions increasing in frequency, duration, intensityDiscomfort radiates from backContractions do not decrease with restCervix progressively effaced and dilated.

What are characteristics of a “False Labor”?

Irregular contractions, no change in frequency, duration, intesityDiscomfort is abdominalContractions decrease with rest or activityNo cervical changes

Prior to Lumbar Epidural block what should the patient do?

Void

What should be implemented Establish airway

during the delivery of a newborn?

Check Apgar at 1 and 5 minutesClamp umbilical cordMaintain WarmthPlace ID band on mother and infant

What are the types of Lochia? Rubra-bloody, day 1-3Serosa-pink-brown, day 4-9Alba-yellow-white, 10+ days

If fundus is displaced not centrally and off to the sides means?

Bladder distended.

If client soaks pad in 15 minutes or pooling of blood?

Check for hemorrhage

What are assessments and implementations for an “Ectopic Pregnancy”?

Unilateral lower quadrant pain.Rigid, tender abdomenLow Hct and hCG levelsBleedingMonitor for shock Administer RhoGAM Provide support

What are assessments and implementations for “Placenta Previa”?

A placenta that’s implanted in the lower uterine segment near cervical os, during pregnancy placenta is torn away causing:First and second trimester spottingThird and trimester painless, profuse bleedingBedrest side-lying or trendelenburg position, ultrasound to locate placenta, no vaginal or rectal exams, amniocentesis for lung maturity, daily Hgb, Hct, Monitor bleeding

What are the assessments and implementation for “Abruptio Placentae”?

The premature separation of a placenta that is implanted in a correct position.Painful vaginal bleedingAbdomen tender, painful, tensePossible fetal distress/ContractionsMonitor for maternal and fetal distressPrepare for immediate deliveryMonitor for complications: DIC, pulmonary emboli

What are assessments and implementations for Gestational Diabetes Mellitus (GDM)?

Hyperglycemia after 20 weeks Usually controlled by dietOral hypoglycemic medications contraindicatedTest 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 timesHome glucose monitoringTeach about change in insulin requirements

What are assessments and implementation for a Hydatidiform Mole?

Elevated hCGUterine size larger than expected for datesNo FHTMinimal dark red/brown vaginal bleeding with grape like clustersNausea and vomitingAssociated with PIHCurettage to remove tissuePregnancy discouraged for 1 yearDo not use IUDhCG levels monitored for 1 year

What are the newborn vital signs?

Temp. 97.7-99.7HR sleep 100, awake 120-140, 180 cryingResp 30-60 BP arm/calf 65/41

What are assessments and implementation for Hyperbilirubinemia?

Caused by immature hepatic functionPhysiological Jaundice (No treatment required)

Seen after 24 hours Peaks at 72 hours

Lasts 5-7 daysBreast-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 hoursPeak variable

What are assessments and implementations for a Narcotic-Addicted infant?

Assessments High-pitched cry (Hallmark sign) Hyperreflexia Decreased sleep Tachypnea (>60/min) Frequent sneezing and yawning Seen at 12-24 hours of age, up to 7-10

daysImplementation

Reduce environmental stimuli Administer Phenobarbital,

chlorpromazine, diazepam, paregoric Wrap snugly, rock, and hold tightly Assess muscle tone, irritability, vital

signs.What are the assessments and implementations of Toxic Shock Syndrome?

Sudden-onset feverVomiting, diarrheaHypotensionErythematous rash on palms and solesAdminister antibioticsEducate about use of tampons (change tampon Q3-Q6 hours)

What are contraindications to Immunizations?

Immunization is a primary preventionSevere febrile illnessAltered immune systemPrevious allergic responseRecently acquired passive immunity

What are assessments and implementations for a “Latex Allergy”?

AssessmentUrticaria, rashWheezing, Rhinitis, Conjunctivitis, BronchospasmsAnaphylactic shockImplementationScreen for sensitivityAvoid latex products: gloves, catheters, brown ace bandages, band aid dressing, elastic pressure stockings, balloons, condoms

What are implementations for Croup syndromes at home?

Steamy showerExposure to cold airCool, humidified air

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

5% Sodium Bicarbonate—metabolic alkalosis solution

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

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

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

Pottery is unglazed can lead to “Lead Toxicity”

Apgar Score: normal 7-10

WBC after pregnancy?

Ampicillin decreases oral contraceptives efficiency.

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

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

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

Injury C3 and above need respiratory ventilation.

SIADH causes: lung cancer, Cisplatin (Platinol)

Chest TubesFill 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 drainageRemoval o chest tube: pt. does valsalva maneuver, clamp chest tube, remove quickly, apply occlusive dressingDislodged: apply tented dressingTube becomes disconnected from drainage system, cut off contaminated tip, insert sterile connector and reinsertTube 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 CuffPrevents aspiration of fluids/separates upper and lower airwaysInflated during continuous mechanical ventilationInflated during and after eatingInflated during and 1 hour after tube feedingInflated when patient cannot handle oral secretions

NCLEX-RN exam is a “here and now” test; take care of problem now to prevent harm to client.

Do not ask “why” on the licensure exam Morphine Sulfate for pancreatitis causes spasms of the sphincter of Oddi;

Meperidine is drug of choice. Normal Intraocular Pressure is 10-21 mm Hg Ecchymosis (faint discoloration) around the umbilicus or in either flank

indicates retroperitoneal bleeding

The parenteral form of Chlorpheniramine Maleate is use to relieve symptoms of anaphylaxis allergic reactions to blood or plasma.

Herbs: Toxicities and Drug Interactions

Chamomile

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

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

Echinacea

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

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

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

Feverfew

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

Ginko Biloba

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

Ginseng

Uses: Ginseng has been used to stimulate the adrenal gland, and thereby increase energy. It also may have some beneficial effect on reducing blood sugar .in patients with diabetes mellitus. (Dr. Miller emphasized that there is substantial variation in the chemical components of substances branded as "Ginseng.")

Reactions: Ginseng can cause elevation in blood pressure, headache, vomiting, insomnia, and nose bleeding. Ginseng can also cause falsely abnormal blood tests for digoxin level. It is unclear whether ginseng may affect female hormones. Its use in pregnancy is not recommended. Ginseng may affect the action of the normal blood clotting element (platelets). It should be avoided in patients taking aspirin, nonsteroidal antiinflammatory drugs (such as ibuprofen (Advil), naproxen (Aleve) or Motrin), or medications to prevent blood clotting (anticoagulants) such as warfarin (Coumadin). Ginseng may also cause headaches, tremors, nervousness, and sleeplessness. It should be avoided in persons with manic disorder and psychosis.

Ginger

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

Saw Palmetto

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

Black Cohosh

Claims, Benefits: A natural way to treat menopausal symptoms.Bottom Line: Little is known about its benefits and its risks.

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

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

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

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

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

Adult Rickets: deficiency in vitamin D.

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

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

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

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

MB band reflects CPK from CARDIAC MUSCLE (This is the level that elevates with an MI.)

MM band reflects CPK from SKELETAL MUSCLE

BB band reflects CPK from the BRAIN

ALKYLATING AGENTS: affect ALL PHASES of the reproductive cell cycle (i.e., Cyclophosphamide [Cytoxan])

ANTIMETABOLITES: are cell cycle phase-specific and affect the S PHASE (i.e., Cytarabine [Cytosar])

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

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

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

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

Watch for absolute words “NOT” and “ONLY”

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

Trigeminal neuralgia pain medication: Use Carbamazepine (Tegretol) and Phenytoin (Dilantin). Narcotic analgesics (Meperidine Hydrochloride [Demerol], Codeine Sulfate , and Oxycodone) are not effective in controlling pain caused by trigeminal neuralgia.

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

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

Phenotolamine (Regitine): antidote for hypertensive crisis

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

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

G T P A L

Gravidity, the number of pregnancies.

Term births, the number born at term (40 weeks).

Preterm births, the number born before 40 weeks’ gestation.

Abortions/miscarriages

Included in gravida if before 20 weeks’ gestation

Included in

Live births, the number of live births or living children

parity if past 20 weeks’ gestation

Therefore a woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of preterm births is 1, and the number of term births is 0. The number of abortions is 0, and the number of live births is 1.

Probable signs of pregnancy:

Uterine enlargement Hegar’s sign (Softening and thinning of the lower uterine segment that

occurs about week 6)

Goodell’s sign (softening of the cervix that occurs at the beginning of the second month)

Chadwick’s sign (bluish coloration of the mucous membranes of the cervix, vagina, and vulva that occurs about week 6)

Ballottement (rebounding of the fetus against the examiner’s fingers on palpation)

Braxton Hicks contractions

A positive pregnancy test measuring for human chorionic gonadotropin

Positive signs of pregnancy:

Fetal heart rate detected by electronic device (Doppler transducer) at 8-12 weeks and by nonelectronic device (Fetoscope) at 20 weeks of gestation

Active fetal movements palpable by examiner

An outline of fetus via radiography or ultrasound

Acetazolamide (Diamox): used for management of glaucoma is a carbonic anyhdrase inhibitor that has sulfonamide properties.

Watch out for absolute words “ALL” and “ALWAYS”

Before NG removal: bowel sounds have to be present.

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

Hypokalemia on Electrocardiogram: ST segment depression; Flat T wave

First-Degree Heart Block: Prolonged P-R interval

Bundle Branch Block: Widened QRS complex

Myocardial Necrosis in Area: Q waves present

Ventricular Fibrillation: No visible P waves or QRS complexes, no measurable rate. Irregular, chaotic undulations of varying amplitudes.

HypoCalcemia: Prolonged Q-T interval

Myocardial Ischemia: ST segment elevation or depression

Premature Ventricular Contractions: absence of P waves, wide and bizarre QRS complexes, and premature beats followed by a compensatory pause

Ventricular Tachycardia: absence of P waves, wide QRS complexes, rate between 100 and 250 impulses per minute. Regular rhythm

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

ANGINA

Stable Unstable Variant Intractable

Triggered by a predictable amount of effort or emotion.

Triggered by an unpredictable amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time.

Triggered by coronary artery spasm; the attacks tend to occur early in the day and at rest.

Chronic and incapacitating and is refractory to medical therapy.

Cardiac Conduction System: Sinoatrial NodeInternodal/Interatrial pathwaysAV nodeBundle of HisR/L Bundle BranchesPurkinje fibers

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

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

A2-adrenergic receptors: several tissues and contract smooth muscle, inhibit lipolysis, and promote platelet aggregation.

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

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

PULSE PRESENT = NO DEFIBRILLATION

Myxedema (a.ka. Hypothyroidism)

Suggested toys a. birth to six months - mobiles, unbreakable mirrors, music boxes, rattles b. six to 12 months - blocks, nesting boxes or cups, simple take apart toys, large

ball, large puzzles, jack in the box, floating toys, teething toys, activity box, push-pull toys

c. Solitary play

Toddlerhood (one year to three years)

Play is parallel

Suggested toys: push-pull toys, finger paints, thick crayons, riding toys, balls, blocks, puzzles, simple tape recorder, housekeeping toys, 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 rules2. fantasy play in early years3. clubs4. hero worship5. cheating6. 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 - antidepressantGarlic - antihypertensiveGinseng - Anti stressGreen tea - antioxidantEchinacea - immune stimulant (6-8 weeks only)Licorice - cough and coldGinger root - antinauseaGinkgo - improves circulationMa huang - bronchodilator, stimulant

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

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

Normal Range of Peripheral Pulses

infants: 120 to 160 beats/minutes toddlers: 90 to 140 beats/minutes preschool/school-age: 75 to 110 beats/ minute adolescent/adult: 60 to 100 beats/minute

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

CRANIAL NERVE FUNCTION

1. Olfactory (CN I)

Can identify variety of smells Deviation: Inability to identify aroma

2. Optic (CN II) Has visual acuity and full visual fields Fundoscopic exam reveals no pathology Deviation: Inability to identify full visual fields - total or partial blindness of

one or both eyes

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

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

5. Trigeminal (CN V)

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

7. Facial (CN VII)

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

on the anterior two-thirds of the tongue Deviation: Inability to smile symmetrically

8. Acoustic (CN VIII)

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

test Deviation: Inability to hear spoken word

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

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

"ah" Deviation: Absent gag reflex Deviation: inability to taste or identify taste on the posterior tongue

11. Spinal accessory (CN XI)

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

12. Hypoglossal (CN XII)

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

Types of Coping Mechanisms

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

o Example: Short man becomes assertively verbal and excels in business.

2. Conversion - A mental conflict is expressed through physical symptoms o Example: Woman becomes blind after seeing her husband with

another woman.3. Denial - treating obvious reality factors as though they do not exist because

they are consciously intolerable o Example: Mother refuses to believe her child has been diagnosed with

leukemia. "She just has the flu." 4. Displacement - transferring unacceptable feelings aroused by one object to

another, more acceptable substitute o Example: Adolescent lashes out at parents after not being invited to

party.5. Dissociation - walling off specific areas of the personality from consciousness

o Example: Adolescent talks about failing grades as if they belong to someone else; jokes about them.

6. Fantasy - a conscious distortion of unconscious wishes and need to obtain satisfaction

o Example: A student nurse fails the critical care exam and daydreams about her heroic role in a cardiac arrest.

7. Fixation - becoming stagnated in a level of emotional development in which one is comfortable

o Example: A sixty year old man who dresses and acts as if he were still in the 1960's.

8. Identification - subconsciously attributing to oneself qualities of others o Example: Elvis impersonators.

9. Intellectualization - use of thinking, ideas, or intellect to avoid emotions o Example: Parent becomes extremely knowledgeable about child's

diabetes.10. Introjection - incorporating the traits of others

o Example: Husband's symptoms mimic wife's before she died.11. Projection - unconsciously projecting one's own unacceptable qualities or

feelings onto others o Example: Woman who is jealous of another woman's wealth accuses

her of being a gold-digger.12. Rationalization - justifying behaviors, emotions, motives, considered

intolerable through acceptable excuses o Example: "I didn't get chosen for the team because the coach plays

favorites."13. Reaction Formation - expressing unacceptable wishes or behavior by

opposite overt behavior o Example: Recovered smoker preaches about the dangers of second

hand smoke.

14. Regression - retreating to an earlier and more comfortable emotional level of development

o Example: Four year old insists on climbing into crib with younger sibling.

15. Repression - unconscious, deliberate forgetting of unacceptable or painful thoughts, impulses, feelings or acts

o Example: Adolescent "forgets" appointment with counselor to discuss final grades.

16. Sublimation - diversion of unacceptable instinctual drives into personally and socially acceptable areas.

o Example: Young woman who hated school becomes a teacher.

Elizabeth Kubler-Ross: Five Stages 1. Denial

a. Unconscious avoidance which varies from a brief period to the remainder of life

b. Allows one to mobilize defenses to cope c. Positive adaptive responses - verbal denial; crying d. Maladaptive responses - no crying, no acknowledgement of loss

2. Anger a. Expresses the realization of loss b. May be overt or covert c. Positive adaptive responses - verbal expressions of anger d. Maladaptive responses - persistent guilt or low self esteem, aggression,

self destructive ideation or behavior 3. Bargaining

a. An attempt to change reality of loss; person bargains for treatment control, expresses wish to be alive for specific events in near future

b. Maladaptive responses - bargains for unrealistic activities or events in distant future

4. Depression and Withdrawal a. Sadness resulting from actual and/or anticipated loss b. Positive adaptive response - crying, social withdrawal c. Maladaptive responses - self-destructive actions, despair

5. Acceptance a. Resolution of feelings about death or other loss, resulting in peaceful

feelings b. Positive adaptive behaviors - may wish to be alone, limit social

contacts, complete personal business

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

mucomyst: acetaminophen toxicity

Dilantin detoxified by liver.

The nurse cares for a client receiving IV antibiotics every 8 hours for the past 4 days. The antibiotic is mixed in D5W. The nurse determines that a post-infusion phlebitis has occurred if which of the following is observed?

1. Tenderness at the IV site.2. Increased swelling at the insertion site.3. Area around the IV site is reddened with red streaks.4. Fluid is leaking around the IV catheter.

a. Tenderness occurs with phlebitis but is not specific to it.b. May indicate either infiltration or phlebitis

c. CORRECT—reddened, warm area noted around insertion site or on path of vein; discontinue IV, apply warm, moist compresses, restart IV at new site

d. Not indicative of phlebitis

Ethacrynic Acid (Edecrin)—are considered loop diuretics and are potassium wasting; encourage client to increase intake of potassium-rich foods. Orange juice/Bananas, etc.

Aminophylline (Truphylline)—is a xanthine bronchodilator; major side effects: palpitations, nervousness, rapid pulse, dysrhythmias, nausea, and vomiting. Toxic effects: confusion, headache, flushing, tachycardia, and seizure.

Morphine Sulfate—decreases blood return to the right side of the heart, and decrease peripheral resistance. In other words, decreases preload and afterload pressures and cardiac workload; causes vasodilation and pooling of fluid in extremities; provides relief from anxiety.

Intropin (Dopamine)—vasoactive medication are given IV to restore BP in hypotensive states; Increases blood return to the right side of the heart, and increase peripheral resistance; side effects: headache, severe hypertension, dysrhythmias; check BP q2 minutes until stabilized, then q5 minutes

TPN—hang no longer than 24 hours; IV tubing and filters every 24 hours; site of catheter changed every 4 weeks.

Fluoxetine (Prozac)—a selective serotonin reuptake inhibitor (SSRI) used to treat depression and obsessive compulsive disorder. Side effects: postural hypotension, dry mouth, rapid heartbeat, anorexia, weight loss, severe headache. If dose is missed, omit dose and instruct client to return to regular dosing schedule.

Propanolol (inderal)—a beta-adrenergic blocker used as antihypertensive; Side effects: bronchospasm, bradycardia, depression. Take pulse before administration and gradually decrease when discontinuing. Do not give to asthmatic patients.

Glipizide (Glucotrol)—an oral hypoglycemic that decreases blood sugar by stimulating insulin release from the beta cells of the pancreas; may cause aplastic anemia and photosensitivity.

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

Bethanechol (Urecholine)—a cholinergic or parasympathomimetic used to treat functional urinary retention; mimics action of acetylcholine.

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

1 grain = 60mg

Levothyroxine (Synthroid)—thyroid preparation should be administered at breakfast to prevent insomnia.

Carbamazepine (Tegretol)—interferes with action of hormonal contraceptives. Side effects: photosensitivity.

Aluminum Hydroxide (Amphojel)—an antacid; neutralizes hydrochloric acid and reduces pepsin activity; take one hour before and hour of sleep. Antacids most effective after digestion has started, but prior to the emptying of the stomach.

Isoniazid (INH)—Side effects: peripheral neuropathy (administer pyridoxine), rash, urticaria, and swelling of the face, lips, and eyelids.

Pyridoxine (Vitamin B6, Beesix, Doxine)—required for amino acid, carbohydrate, and lipid metabolism. Used in the transport of amino acids, formation of neurotransmitters, and sythesis of heme. Prevention of neuropathy.

Carbamazepine (Tegretol)—prevention of seizures and relief of pain in trigeminal neuralgia. Trigeminal neuralgia (Tic douloureux) is an agonizing pain that may result in severe depression and suicide.

Clonidine (Catapres-TTS)—is a centrally acting alpha-adrenergic used to treat hypertension; Side effects: drowsiness, sedation, orthostatic hypotension, heart failure. If patch used be cautious around microwaves results in burns, dispose of carefully, and heat will increase medication absorption leading to toxicity.

Phlebitis—tenderness, redness; remove iv, apply warm soaks to decrease inflammation, swelling, and discomfort.

Autologous blood—may give blood 5 weeks before surgery; can give 2 to 4 units of blood; may have to take iron pills

Partial-thickness burn; only part of skin is damaged or destroyed; large, thick-walled blisters develop; underlying tissue is deep red, appears wet and shiny; painful with increased sensitivity to heat; healing occurs by evolution of undamaged basal cells, takes about 21-22 days. I.E., Redness and swelling with fluid-filled vesicles noted on right arm or Blistering and blanching of the skin noted on the back.

Full-thickness burn; all skin is destroyed and muscle and bone may be involved; substance that remains is called eschar, dry to touch, doesn’t heal spontaneously, requires grafting. I.E., Charred, waxy, white appearance of skin on left leg.

Superficial burn; skin appears pink, increased sensitivity to heat, some swelling, healing occurs without treatment. I.E., Reddened blotchy painful areas noted on the face.

Carbidopa/Levodopa (Sinemet)—used to treat symptoms of Parkinson’s disease. Take immediately before meals and high-protein meals may impair effectiveness of medication. Reduces rigidity and bradykinesis and facilitates client’s mobility.

Doxycycline (Vibramycin)—a tetracycline that is taken at regular intervals but not within 1 hour of bedtime because it may cause esophageal irritation. Use another method of birth control, do not take antacids within 1-3 hours of taking medication, and may cause photosensitivity.

Albuterol (Proventil)—a bronchodilator. Side effects: tremors, headache, hyperactivity, tachycardia. Use first before steroid medication so opens up bronchioles for steroid to get in. Wait one minute between puffs of the inhalers for best effect.

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

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

Propranolol (Inderal)—a beta-blocker that takes up beta-adrenergic receptor sites, which prevents adrenaline from causing symptoms and glycogenolysis. Inderal may mask symptoms of hypoglycemia, removing the body’s early warning system.

Phenazopyridine (Pyridium)—acts on urinary tract mucosa to produce analgesic or local anesthetic effects. Side effects: bright orange urine, yellowish discoloration of skin or sclera indicates drug accumulation due to renal impairment.

Trimethoprim-sulfamethoxazole (Bactrim)—most common side effect mild to moderate rash (urticaria)Aminoglycosides are ototoxic.

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

Infant normal resting heart rate: 120-140

Salt substitutes contain potassium

When directing a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be reported. Because the RN is

responsible for all care-related decisions, only implementation tasks should be assigned because they do not require independent judgment.

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

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

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

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

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

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

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

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

Signs/Symptoms of Digital Toxicity: first signs include abdominal pain, anorexia, nausea, vomiting, visual disturbances, bradycardia, and other arrhythmias. In infants and small children, the first symptoms of overdose are usually cardiac arrhythmias.

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

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

Pancreatic enzymes give before meals.

Clinical features of delusional disorder include extreme suspiciousness, jealousy, distrust, and belief that others intend to harm.

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

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

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

Restraint: frame of bed, quick release ties, document need for restraint Q4 hours

Never ask “WHY” questions in the NCLEX!

Gag Reflex: don’t assess gag reflex to a client that has an absent swallow reflex

Nifedipine (Procardia XL): do not crush

An RN that is not assigned to a patient does not have the authority to tell a nurse what to do. Refer it to nursing supervisor.

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

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

Coronary artery bypass graft (CABG)—halt medications before surgery, can do 5 at a time; will be on mechanical ventilations after surgery; chest tubes

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

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

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

Position care after Infratentorial surgery: flat and lateral

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

Myelogram Water-soluble dye—elevate head of bed 30 degrees (not removed) Oil based dye—flat in bed (removed)

Fractures: Immobilize joint above and below fracture Cover open fracture with cleanest material available Check temperature, color, sensation, capillary refill distal to fracture Close reduction—manually manipulate bone or use traction

Buck’s Traction Use to relieve muscle spasm of leg and back If used for muscles spasms only, they can turn to either side. If used for fracture treatment, only can turn to unaffected side. Use 8-20 lbs of weight, if used for scoliosis will use 40 lbs of weight. Elevate head of bed for countertraction or foot bed Place pillow below leg not under heel or behind knee.

Russell’s Traction Sling is used Check for popliteal pulse Place pillow below lower leg and heel off the bed Don’t turn from waist down Lift patient, not the leg

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

Balanced Suspension Traction For femur realignment Maintain weights hanging free and not on floor Maintain continuous pull

Halo Jacket Maintain pin cleansing

Casts Don’t rest on hard surface Don’t cover until dry 48+ hours Handle with palms of hands not with fingers Keep above level of heart Check for CSM

Fractured Hip

Assessments Leg shortened Adducted Externally rotated

Implementation Care after a total hip replacement

Abduction pillows Crutch walking with 3-point gait Don’t sleep on operated side Don’t flex hip more than 45-60 degrees Don’t elevate head of the bed more than 45 degrees

Amputations Guillotine (open) Flap (closed) Delayed prosthesis fitting

Residual limb covered with dressing and elastic bandage (figure eight)

Figure-8 doesn’t restrict blood flow, shaped to reduce edema

Check for bleeding Elevated 24 hours (AKA-pillow, BKA-foot of bed elevated) Position prone daily Exercises, crutch walking Phantom Pain: acknowledge feelings, that pain is real for them.

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

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

Folic acid—RBC formation; deficiency will cause anemia

Cyanocobalamin (B12)—nerve function; deficiency cause pernicious anemia

Calcium deficiency causes Rickett’s

Cultural Food Pattern’s Orthodox Jewish (Kosher)—milk and meat cannot be eaten at same meal Muslin—30 day fast during Ramadan Japanese—rice is basic food, tea is main beverage Greek—bread is served with every meal

Enteral feeding held if: 150 or > cc’s aspirated or 50% given in the hour is aspirated If cramping, vomiting occurs decrease rate of enteral feeding or keep it warm.

TPN—supply nutritions via intravenous route Peripherally or centrally Initial rate 50/hour and can be increased to 100-125ml/hour. A pump must be used to keep rate constant Prevent sepsis: maintain closed system,, don’t draw blood/infuse anything in

line, dry sterile dressing Verify placement of line Monitor Glucose, acetone Change IV tubing/Filter Q24 hours Solution refrigerated then warmed If solution not available, start 10% in water. 3/week check BUN, electrolytes (ca, mg) When TPN Dc’d taper patient off or else will get rebound hypoglycemia (use

hypotonic to do this)

Specific gravity 1.010-1.030Ph 4.5-81,000-1,500cc/day

Crede’s Manuever—push urine out

Pernicious Anemia- monthly Vitamin B12 IM injections

Metered dose inhaler- Beclomethasone (Vanceril)- Albuterol (Proventil)

Guillain-Barre Syndrome- GBS often preceded by a viral infection as well as immunizations/vaccinations- Intervention is symptomatic- Acute phase: Steroids, plasmapheresis, aggressive respiratory care; prevent

hazards of immobility, maintain adequate nutrition; physical therapy; pain-reducing measures; eye care, prevention of complications (UTI, aspiration); psychosocial support

Organ Donation Criteria- No history of significant, disease, process in organ/tissue to be donated- No untreated sepsis- Brain death of donor- No history of extracranial malignancy- Relative hemodynamic stability- Blood group compatibility- Newborn donors must be full term (more than 200g)- Only absolute restriction to organ donation is documented case of HIV

infection- Family members can give consent- Nurse can discuss organ donation with other death-related topics (funeral

home to be used, autopsy request)

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

Parkinson’s disease- Activities should be scheduled for late morning when energy level is highest

and patient won’t be rushed- Symptoms: tremors, akinesia, rigidity, weakness, “motorized propulsive gait,

slurred monotonous speech, dysphagia, drooling, mask-like expression.- Nursing care: encourage finger exercises. Administer Artane, Congentin, L-

Dopa, Parlodel, Sinemet, Symmetrel. - Teach: ambulation modification- Promote family understanding of disease intellect/sight/hearing not impaired,

disease progressive but slow, doesn’t lead to paralysis

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

Green leafy vegetables contain vitamin K.

Labs

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

Serum Amylase / Somogyl (60-160 u/dL)- elevated in acute pancreatitis

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

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

Creatine Kinase (CK)- Men (12-70)- Women (10-55)

- Enzyme specific to brain, myocardium, and skeletal muscles- Indicates tissue necrosis or injury

Serum Glucose- 60-110 mg/dL

Sodium (Na+)- 135-145 mEq/L- Hypernatremia

o Dehydration and insufficient water intake

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

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

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

Blood, Urea, Nitrogen (BUN)- 6-20 mg- Elevated levels indicate rapid protein catabolism, kidney dysfunction,

dehydration

Creatinine Clearance Test- normal 125 ml/min.- Lower levels reflect renal insufficiency and may influence the excretion of

many drugs and toxins from the body.

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

Tofranil and Anafranil—OCD medications

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

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

Oculogyric crisis: uncontrollable rolling back of eyes: side effect of PhenothiazinesMoribund means dying patient.

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

Assess before implementation.

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

Lithium helps control impulsive behaviors.

Fluphenazine (Prolixin): antipsychotic medication

Thiamine sources: organ meats, liver, whole grain, nuts, legume, egg, and milk.

Don’t document abuse. Report suspected abuse to nursing supervisor.

Never promise a patient “Not to tell.”

Tonometry—measures intraocular pressure; to rule out glaucoma

Myopia—nearsightedness (near clear, distance clear)

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

Presbyopia—changes with aging

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

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

Position patient on affected ear to promote drainage.

Regular Insulin only given IV.

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

Phenylketonuria—high blood phenylalanine (no enzyme), results in mental retardation; milk substitutes, low-protein diet

Celiac Disease (SPrue)—intestinal malabsorption, malnutrition (unable to digest wheat/rye/oats/barley); gluten-free diet

Hepatobiliary disease—decrease in ability of bile to absorb fat, fat malabsorption; low-fat high-protein diet, vitamins

Cystic fibrosis—absence of pancreatic enzymes, malabsorption of fat, lung disease, pancreatic enzyme replacement, high-protein, high-calorie diet, respiratory care/suction

Position right side to promote gastric emptying.

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

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

Hepatitis B VaccineGiven IM to vastus lateralis or deltoidSide 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 thighSide effects: fever within 24-48 hours, swelling, redness, sorenessDon’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

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

MMR (Mumps, Measles, and Rubella)Given SC anterior or lateral thighSide 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

TBGiven intradermal Evaluated in 48 to 72 hours

TD Given IM into anterior or lateral thighRepeated every 10 years

Live attenuated RubellaGiven once SC into anterior or lateral thighGiven to antibody-negative womenPrevent pregnancy for 3 months after receiving immunization

Live attenuated mumpsGiven once SCPrevents orchitis

Normal Vital Signs

Newborn Pulse 120-160 bpm, increases with crying Respirations 30-50/min, diaphgramatic (abdomen moves), can

be irregular BP 60/40 – 80/50 mmHg

1-4 year old Pulse: 80-140 Resp: 20-40 BP: 90-60 – 99/65

5-12 year old Pulse: 70-115 Resp: 15-25 BP: 100/56 – 110/60

Adult Pulse: 60-100 Resp: 12-20 BP: 90/60-140/90

Aortic Valve: Right of Sternum at the 2nd intercostal space

Pulmonic Valve: Left of Sternum at the 2nd intercostal space

Tricuspid Valve: Immediately left of sternal border at the 5th Intercostal Space

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

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

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

Obese person choking use Chest Thrusts.

Tracheostomy tube placement of cuff maintained to prevent aspiration

Care for patient first, equipment secondSigns 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 inchesInfants 20/min check brachial pulse, chest compression 100/min ½ - 1 inch

15:2 Adult 4 cycles Infant 20 cyclesReassess pulse and breathingContinue CPR until:

Victim responds Someone else takes over Victim is transferred Rescuer is unable to continue

MI Chest pain radiating to arms, jaw,

neck (which is unrelieved by rest or nitroglycerin)

Dyspnea Indigestion Apprehension Low grade fever

Implementation for MI

Thrombolytic therapy-streptokinase, t-PA

Bedrest Beta-blockers, morphine sulfate,

dysrhythmics, anticoagulants Do not force fluids (will give heart

Elevated WBC (5-10, ESR, CK-MB, LDH)

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)

Flail ChestAffected side goes down during inspiration and up during expiration

Sucking Chest Wound(Sucking Open Pneumothorax)

Sucking sound with respiration

Pain Decreased

breath sounds Anxiety

PneumothoraxCollapse of lung due to alteration of air in intrapleural space

Dyspnea Pleuritic pain Restricted

movement on affected side

Decreased/absent breath sounds

Cough Hypotension

ImplementationMonitor for shockHumidified oxygenThoracentesis (aspiration of fluid from pleural space)Chest Tubes

Cullen’s Sign – ecchymosis around umbilicus

Turner’s Sign – ecchymosis around either flank

Balance’s sign – resonance over spleen (+) means rupture of spleen

Shock Signs and Symptoms Cool, clammy skin Cyanosis Decreased alertness Tachycardia Hypotension Shallow, rapid respirations Oliguria

Hypovolemic Decreased in intravascular volume

CardiogenicDecreased cardiac output

DistributiveProblem with blood flow to cells

Implementation for shock Monitor CVP: <3 inadequate fluid >11 too much fluid

Increased ICPAssessments

Altered LOC (Earliest Sign)

Implementations Monitor vital signs Monitor Glasgow Coma Scale

Glasgow coma scale <7 indicates coma

Confusion Restlessness Pupillary changes Vital sign changes – WIDENING

PULSE PRESSURE

Elevate head 30-45 degrees Avoid neck flexion and head rotation Reduce environmental stimuli Prevent Valsalva maneuver Restrict fluids to 1200-1500 cc/day Medications – Osmotic diuretics,

corticosteroids

Seizures: do not restrain do not insert anything in mouth

ElectrolytesPotassium: 3.5-5.0 mEq/LSodium: 135-145 mEq/LCalcium: 4.5-5.2 mEq/LMagnesium: 1.5-2.5 mEq/L

Hypokalemia Assessments K+ < 3.5 mEq/L Muscle weakness Paresthesias Dysrhythmias Increased sensitivity to

digitalis

Hypokalemia Implementations Potassium Supplements Don’t give > 40 mEq/L into peripheral IV or

without cardiac monitor Increase dietary intake – oranges, apricots,

beans, potatoes, carrots, celery, raisins

Hyperkalemia Assessments K+ >5.0 mEq/L EKG changes Paralysis Diarrhea Nausea

Hyperkalemia Implementations Restrict oral intake Kayexalate Calcium Gluconate and

Sodium Bircarbonate IV Peritoneal or hemodialysis Diuretics

Hyponatremia Assessments Na+ < 135 mEq/L Nausea Muscle cramps Confusion Increased ICP

Hyponatremia Implementations I & O Daily weight Increase oral intake of sodium rich

foods Water restriction IV Lactated Ringer’s or 0.9% NaCL

Hypernatremia Assessments Na+ >145 mEq/L Disorientation, delusion,

hallucinations Thirsty, dry, swollen tongue Sticky mucous membranes Hypotension Tachycardia

Hypernatremia Assessments I & O Daily Weight Give hypotonic solutions: 0.45%

NaCl or 5% Dextrose in water IV

Hypocalcemia Assessments Ca+ < 4.5 mEq/L Tetany Positive Trousseau’s sign Positive Chvostek’s sign Seizures Confusion Irritability, paresthesias

Hypocalcemia Implementations Oral calcium supplements with

orange (maximizes absorption) Calcium gluconate IV Seizure precautions Meet safety needs

Hypercalcemia Assessments Ca+> 5.2 mEq/L Sedative effects on CNS Muscle weakness, lack of

coordination Constipation, abdominal pain Depressed deep tendon reflexes Dysrhythmias

Hypercalcemia Implementations 0.4% NaCl or 0.9% NaCl IV Encourage fluids (acidic drinks:

cranberry juice) Diuretics Calcitonin Mobilize patient Surgery for hyperparathyroidism

Hypomagnesemia Assessments Mg+< 1.5 mEq/L Neuromuscular irritability Tremors Seizures Tetany Confusion Dysphagia

Hypomagnesemia Implementations Monitor cardiac rhythm and

reflexes Test ability to swallow Seizure precautions Increase oral intake—green

vegetables, nuts, bananas, oranges, peanut butter, chocolate

Hypermagnesemia Assessments Mg + > 2.5 mEq/L Hypotension Depressed cardiac impulse

transmission Absent deep tendon reflexes Shallow respirations

Hypermagnesemia 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 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

Medicate patient before wound care

Silver nitrate (warn patient skin will turn black)

High calorie, High carbohydrate, High protein diet

Vitamin B,C, and Iron TPN maybe Prevent contractures

Addisson’s Disease Assessments Fatigue Weakness Dehydration Eternal tan Decreased resistance to stress Low Sodium Low Blood Sugar High Potassium

Addisson’s Disease Implementations High protein, High carbohydrate,

high Sodium, Low potassium diet Teach life-long hormone

replacement

Addisonian Crisis Assessments Hypotension Extreme weakness Nausea vomiting Abdominal pain Severe hypoglycemia Dehydration

Addisonian Crisis Implementations Administer NaCl IV, vasopressors,

hydrocortisone Monitor vital signs Absolute bedrest

Cushing’s Syndrome Assessments Osteoporosis Muscle wasting Hypertension Purple skin striations Moon face Truncal obesity Decreased resistance to infection

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 Assessments—hypersecretions of the catecholamines (epinephrine/norepinephrine)

Persistent hypertension Hyperglycemia Pounding headache

Pheochromocytoma Implementations Histamine Test, Regitine Test, 24-

hour urine VMA test Avoid emotional and physical

stress Encourage rest

Palpitations Visual disturbances

Avoid coffee and stimulating foods Postop care after adrenalectomy

and medullectomy

COPD Assessments “Blue Bloaters” “Pink Puffers” Weakness Change in postured day and hs

(don’t sleep laying down, have to stay erect)

Use of accessory muscles of breathing

Dyspnea Cough Adventitious breath sounds

COPD Implementations Assess airway clearance Listen to breath sounds Administer low-flow oxygen (1-2 L,

not too much because your trying to prevent CO2 narcosis)

Encourage fluids Small frequent feedings Use metered dose inhalers (MDI)

Pneumonia Assessments Fever Leukocytosis Productive Cough (rust, green,

yellow) Dyspnea Pleuritic pain Tachycardia

Pneumonia Implementations Check breath sounds Cough and deep breath q 2 hours Chest physiotherapy Antibiotics Incentive spirometer Encourage fluids Suction PRN Provide oxygen Semi-Fowler’s position Bedrest Medications—mucolytics

(Mucomyst), expectorants (Robitussin), Bronchodilators (Aminophylline), Antibiotics (Bacterim)

Acyanotic Congenital Heart Anomalies Assessments

Normal Color Possible exercise intolerance Small stature Failure to thrive Heart murmur Frequent respiratory Infections

Cyanotic Congenital Heart Anomalies Assessments

Cyanosis Clubbing of fingers Seizures Marked exercise intolerance Difficulty eating Squat to decrease respiratory

distress Small stature Failure to thrive Characteristic murmur Frequent respiratory infections

Acyanotic Congenital Heart Anomalies Types: Ventricular Septal Defect (VSD)—abnormal opening between right/left

ventricles; hole size of pinhole or absence of septum; hear a loud harsh murmur, at age of 3 hole may close otherwise surgery such as purse-string suture

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

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

Coarctation of the Aorta—narrow of aorta; high blood pressure and bounding pulse in areas that receive blood proximal to the defect. Weak and absent

blood distal to aorta. Surgical end-to-end anastomosis.

Pulomonic Stenosis—narrowing at entrance to pulmonary artery; causes resistance to blood flow and right ventricular hypertrophy; surgery

Aortic Stenosis—narrowing of aortic valve; causes decrease cardiac output; surgery

Cyanotic Congenital Heart Anomalies Types: Tetralogy of Fallot—VSD, pulmonic stenosis, overriding aorta, right ventricular

hypertrophy; squats/knee chest position to help breath; surgery needed

Transposition of great vessels—pulmonary artery leaves left ventricle and aorta leaves right ventricle; oxygenated blood not going into systemic circulation

Truncus arteriosus—failure of normal septation and embryonic division of the pulmonary artery and aorta; rather than two distinctly different vessels there is a single vessel that overrides both ventricles and gives rise to both pulmonary and systemic circulation; blood enters from both common artery and either goes to the lungs or to the body; cyanosis, murmur, difficult intolerance

Total anomalous venous return—absence of direct communication between pulmonary veins and left atria; pulmonary veins attach directly to right atria or drains to right atria

Congenital Heart Anomalies Compensatory Mechanisms Tachycardia Polycythemia (increase formation of RBC’s) Posturing—squatting, knee-chest position

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

Left-Side CHF Dyspnea, orthopnea Cough Pulmonary edema Weakness/Changes in mental

status

Right-Side CHF Dependent edema Liver enlargement Abdominal pain/Nausea/Bloating Coolness of extremities

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

Arterial Peripheral Vascular DiseaseAssessments

Rubor Cool shiny skin Ulcers Gangrene Intermittent Claudication (pain

with exercise/walking relieved with rest)

Impaired sensation Decreased peripheral pulses

Arterial Peripheral Vascular DiseaseImplementations

Monitor Peripheral pulses Good foot care Stop smoking Regular exercise Medications—vasodilators,

anticoagulants

Venous Peripheral Vascular DiseaseAssessments

Cool, brown skin Edema Normal or decreased pulses Positive Homan’s sign

Venous Peripheral Vascular DiseaseImplementations

Monitor peripheral pulses Elastic stockings Medications—anticoagulants Elevate legs Warm, moist packs Bedrest 4-7 days (acute phase)

Anemia Assessments (reduction in hemoglobin amount/erythrocytes)

Palpitations Dyspnea Diaphoresis Chronic fatigue Sensitivity to cold

Anemia Implementations Identify cause Frequent rest periods High protein, high iron, high

vitamin diet Protect from infection

Iron Deficiency Anemia Assessments Fatigue Glossitis Spoon fingernails Impaired cognition

Iron Deficiency Anemia Implementations

Increase iron-rich foods (liver, green leafy vegetables)

Iron supplements (stains teeth)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

Pernicious Anemia Assessments Vitamin B12—IM Rest of life can’t be absorbed PO

Sickle Cell Anemia Assessments Pain /Swelling/Fever Schlerae jaundiced Cardiac murmurs Tachycardia

Sickle Cell Anemia Implementations Check for signs of infection

(prevent crisis) Check joint areas for pain and

swelling Encourage fluids Provide analgesics with PCA pump

c crisis

Hemophilia Assessments (female to male gene transmission)

Easy bruising Joint pain Prolonged bleeding

Hemophilia Implementations Administer plasma or factor VIII Analgesics Cryoprecipitated antihemophilic

factor (AHF) Teach about lifestyle changes Non contact sports

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

Cancer Implementation: Internal 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

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

Cancer Implementation: Internal radiation unsealed source

All body fluids contaminated Greatest danger first 24-96 hours

Leukemia Assessments Ulcerations of mouth Anemia Fatigue Weakness Pallor

Leukemia Implementations Monitor for signs of bleeding:

petechiae, ecchymosis, thrombocytopenia

Infections Neutropenia (private room/limit #

people, wbc done daily, no fruit, no flowers/plotted plants, clean toothbrush with weak bleach solution

Good mouth care High calorie, high Vitamin diet

(avoid salads/raw fruit/pepper/don’t reuse cup/don’t change litter box/digging in garden

Intracranial Tumors Assessments Motor deficits Hearing or visual disturbances Dizziness Paresthesia Seizures Personality disturbances Changes in LOC

Intracranial Tumors Implementations Preoperative: do neurological

assessment, patient head shaved Postoperative: maintain airway,

elevate head 30-45 after supratentorial surgery

Flat and lateral after infratentorial surgery

Monitor vital and neurological signs

Glascow coma scaleTherapeutic 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 GaitWeight bearing both legsRC, LF, LC, RF

2 point GaitBearing both legsRC/LF, LC/RF

3 point GaitBearing one legWeaker leg both crutches, then stronger leg

Swing-to-swing throughPartial weight bearing both legsBoth crutches, one or two legs

Stairs Going up—“good” leg first, crutches, “bad” leg Going down—crutches with “bad” leg, then “good” leg “Up with the good, down with the bad”

Walker Flex elbows 20-30 degrees when hands are on grips Lift and move walker forward 8-10 inches Step forward with “bad” leg, support self on arms, follow with “good”

leg Stand behind client holding onto gait belt

Myelogram—x-ray visualization of the spinal canal by injection of radiopaque dye.

Hydration done 12 hours before procedure

Cleansing enemas Avoid seizure-promoting

medications

Post-procedure Water-soluble dye—elevate head

of bed 30 degrees (not removed) Oil based dye—flat in bed

(removed) Bedrest 24 hours encourage fluids

Laminectomy—excision portion of lamina to expose area of affected disc

Preopcare: moist heat Fowler’s position Isometric exercises for abdominal

muscles Muscle relaxants, NSAIDs,

Analgesics Traction, TENS

Postoperative care: Assess circulation and sensation Log roll Q2 hours with pillow

between leg Calf exercises, assist with

ambulation keeping back straight Muscle relaxants, NSAIDS,

analgesics, Teaching—daily exercises, firm mattress, avoid prone position and heavy lifting

Avoid sitting long time

Dysplasia of the Hip Assessment Uneven gluteal folds and thigh

creases Limited abduction of hip Ortolani’s sign—place infant on

back with legs flexed, clicking sound with abduction of legs

Shortened limb on affected side

Dysplasia of the Hip ImplementationsNewborn to 6 months

Reduced by manipulation Pavlik harness for 3 to 6 months

6 to 18 months Bilateral Bryant’s traction Hip spica cast

Older child Open reduction Hip Spica cast

Scoliosis 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)

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 Assessments Voluntary muscles poorly

controlled due to brain damage Spasticity, rigidity, ataxia,

repetitive involuntary gross motor movements

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

Muscular Dystrophy AssessmentsAtrophy of voluntary musclesMuscle weakness, lordosis, falls

Braces to help ambulationBalance activity and rest

Parkinson’s Disease Assessments Parkinson’s Disease

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

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

Clear liquidNo milkNo juice with pulp

Full liquidNo jamNo fruitNo nuts

Low-fat cholesterol restricted

Can eat lean meatNo avocado, milk, bacon, egg yolks butter

Sodium restricted

No cheese

High roughage, high fiber

No white bread without fiber

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

High protein diet

Restablish anabolism to raise albumin levelsEgg, roast beef sandwich,No junk food

RenalKeeps protein, potassium and sodium lowNo beans, no cereals, no citrus fruits

Low-phenylalanine diet

Prevents brain damage from imbalance of amino acidsFats, fruits, jams allowedNo meats eggs bread

Glomerulonephritis Assessment Fever, Chills Hematuria Proteinuria Edema Hypertension Abdominal or flank pain Occurs 10 days after beta

hemolytic streptococcal throat infection

Glomerulonephritis Implementation Antibiotics, corticosteroids Antihypertensives,

immunosuppressive agents Restrict sodium and water

intake Bedrest I&O Daily weight High Calorie, Low protein

Urinary Diversion: Assessments Done for: Bladder t umors, birth

defects, neurogenic bladder, interstitial cystitis

Ileal Conduit Koch Pouch

Urinary Diversion Implementations Nephrostomy: flank incision and insertion of

nephrostomy tube into renal pelvis; penrose drain after surgery; surgical dressing

Ureterosigmoidostomy: urters detached from bladder and anastomosed to sigmoid colon; encourage voiding via rectum q 2-4 hours;no enemas or cathartics;

complications—electrolyte imbalance, infection, obstruction; urine and stool evacuated towards anus.

Cutaneous Ureterostomy: Stoma formed from ureters excised from bladder and brought to abdominal wall; stoma on right side below waist; assist with alteration in body image

Illeal Conduit: Ureters replanted into portion of terminal ileum and brought to abdominal wall; check for obstruction; mucous threads in urine normal

Koch Pouch (Continent Illeal Conduit): Ureters transplanted into pouch made from ileum with one-way valve; drainage of pouch by catheter under control of client; drain pouch at regular intervals

Acute Renal Failure Assessments: Oliguric Phase Output <400

cc/day Hypertensio

n Anemia CHF Confusion Increased

K+, Ca+, Na+, BUN, Creatinine

Acute Renal Failure Assessments: Diuretic Phase Output 4-5

L/day Increased BUN Na+, K+ lost in

urine Increased

mental and physical activity

Acute Renal Failure Causes Prerenal—reduced

blood volume Renal—nephrotoxic

drugs, glomerulonephritis

Postrenal--obstruction

Acute Renal Failure Implementations: Low-output stage:

Limit fluids, Kayexalate, Dialysis

High-output stage: Fluids as needed, K+ replacement, Dialysis

I&O Daily Weight Monitor Electrolytes Bedrest during

acute phase IV fluids Diet restrictions Oliguric phase: limit

fluids, TPN maybe After Diuretic phase:

high protein, high calorie diet

Hemodialysis Implementation Check for thrill and bruit q

8 hours Don’t use extremity for

BP, finger stick Monitor vital signs,

weight, breath sounds Monitor for hemorrhage

Peritoneal Dialysis Weight before and after

treatment Monitor BP Monitor breath sounds Use sterile technique If problem with outflow,

reposition client Side effects:

constipation

Types of Peritoneal Dialysis Continuous

ambulatory (CAPD) Automated Intermittent Continuous

Ego Defense Mechanisms Denial—failure to acknowledge thought Displacement—redirect feelings to more acceptable subject Projection—attributing your feelings to someone else Undoing—attempt to erase an act, thought or feeling Compensation—attempt to overcome shortcoming Symbolization—less threatening object used to represent another Substitution—replacing unacceptable or unobtainable object to one that is

acceptable or attainable Introjection—symbolic taking into oneself the characteristics of another Repression—unacceptable thoughts kept from awareness Reaction formation—expressing attitude opposite of unconscious wish or fear Regression—returning to an earlier developmental phase Dissociation—detachment of painful emotional conflicts from consciousness Suppression—consciously putting thought out of awareness

Dying patient: Denial, Anger, Bargaining, Depression, Acceptance

Bipolar Disorder Assessments Disoriented, flight of ideas Lacks inhibitions, agitated Easily stimulated by

environment Sexually indiscreet Affective disorder Maintain contact with reality Elation is defense against

underlying depression Manipulative behavior results

from poor self-esteem

Bipolar Disorder Implementations Meet physical needs first Simplify environment Distract and redirect energy Provide external controls Set limits: escalating

hyperactivity Use consistent approach Administer Lithium (help Manic

Phase of Bipolar, keep hydrated)

Increase awareness of feelings through reflection

Schizophrenia Assessments

Withdrawal from relationships and world

Inappropriate display of feelings

Hypochondriasis Suspiciousness Inability to test

reality, regression Hallucinations—

false sensory perceptions

Delusions—persistent false beliefs; grandeur (feel higher rank); persecutory (beliefs to be a victim); ideas of reference (see people talking think talking about them)

Loose associations Short attention

span Inability to meet

basic needs: nutrition, hygiene

Regression

Schizophrenia Types Disorganized—

inappropriate behavior, transient hallucinations

Catatonic—sudden onset mutism, stereotyped position, periods of agitation

Paranoid—late onset in life, suspiciousness, ideas of persecution and delusions

Schizophrenia Implementations Maintain safety—protect

from erratic behavior With hallucination—do not

argue, validate reality, respond to feeling tone, never further discuss voices (don’t ask to tell more about voices)

With delusions—do not argue, point out feeling tone, provide diversional activities

Meet physical needs Establish therapeutic

relationship Institute measures to

promote trust Engage in individual, group,

or family therapy Encourage client’s affect Accept nonverbal behavior Accept regression Provide simple activities or

tasks

Paranoid AssessmentsSuspiciousnessCold, blunted affectQuick response with anger or rage

Paranoid ImplementationsEstablish trustLow doses phenothiazines for anxietyStructured social situations

Schizoid AssessmentsShy and introvertedLittle verbal interactionFew friendsUses intellectualization

Schizoid ImplementationsEstablish trustLow doses phenothiazines for anxietyStructured social situations

Schizotypal AssessmentsEccentricSuspicious of othersBlunted affectProblems with perceiving, communicating

Schizotypal InterventionsEstablish trust Low doses neuroleptics to decrease psychotic symptomsStructured social situations

Antisocial AssessmentsDisregards rights of others

Antisocial ImplementationsFirm limit-setting

Lying, cheating, stealing, promiscuousLack of guiltImmatureIrresponsibleAssociated with substance abuse

Confront behaviors consistentlyEnforce consequencesGroup therapy

Borderline Assessments Brief and intense relationshipsBlames others for own problemsImpulsive, manipulativeSelf-mutilationWomen who have been sexually abusedSuicidal when frustrated, stressed

Borderline implementationsIdentify and verbalize feelingsUse empathyBehavioral contractJournalingConsistent limit-settingGroup therapy

Narcissistic AssessmentsArrogant lack of feelings and empathy for othersSense of entitlementUses others to meet own needsShallow relationshipsViews self as superior to others

Narcissistic ImplementationsMirror what client sounds likeLimit-settingConsistencyTeach that mistakes are acceptable

Histrionic AssessmentsDraws attention to selfSomatic complaintsTemper tantrums, outburstsShallow, shifting emotionsCannot deal with feelingsEasily influenced by others

Histrionic ImplementationsPositive reinforcement for other centered behaviorsClarify feelingsFacilitate expression of feelings

Dependent AssessmentsPassiveProblem working independentlyHelpless when aloneDependent on others for decisionsFears loss of support and approval

Dependent ImplementationsEmphasize decision-makingTeach assertivenessAssist to clarify feelings and needs

Avoidant AssessmentsSocially uncomfortable Hypersensitive to criticism, Lacks self-confidenceFears intimate relationships

Avoidant ImplementationsGradually confront fearsDiscuss feelingsTeach assertivenessIncrease exposure to small groups

Obssessive-compulsive AssessmentsHigh personal standards for self and othersPreoccupied with rules, lists, organizedPerfectionistsIntellectualize

Obssessive-compulsive Implementations

Explore feelingsHelp with decision-makingConfront procrastinationTeach that mistakes are acceptable

Manipulative behavior AssessmentsUnreasonable requests for time, attention, favorsDivides staff against each otherIntimidates othersUse seductive or disingenuous approach

Manipulative Behavior Implementations

Use consistent undivided staff approachSet limitsBe alert for manipulationCheck for destructive behaviorHelp client to see consequences of behavior

Acute Alcohol Intoxication

DrowsinessSlurred speechTremorsImpaired thinkingBelligerenceLoss of inhibitions

Acute Alcohol Implementations

Protect airway Assess for injuriesWithdrawal assessIV glucoseCounsel about alcohol use

Alcohol Withdrawal Assessments

Tremors insomnia anxiety hallucinations

After WithdrawalDelirium Tremens Assessments

DisorientationParanoiaIdeas of referenceSuicide attemptsGrand mal convulsions

Alcohol Withdrawal Implementations

Monitor vital signs, especially pulseAdminister sedation, anticonvulsants, thiamine (IM or IV), glucose (IV)Seizure precautionsQuiet, well-lighted environmentStay with patient

Chronic Alcohol Dependence Assessments

Persistent incapacitation Cyclic drinking or “binges” Others in family take over client’s role Family violence

Chronic Alcohol Dependence Implementations

Identify problems related to drinking Help client see problem Establish control of problem Alcoholics anonymous Antabuse Counsel spouse and children

Wernicke’s Syndrome Assessments Confusion Diplopia, nystagmus Ataxia Apathy

Wernicke’s Syndrome Implementations

Thiamine (IM or IV) Abstinence from alcohol

Korsakoff’s Psychosis Assessments Memory disturbances with

confabulation Learning problems Altered taste and smell Loss of reality testing

Korsakoff’s Psychosis Implementations

Balanced diet Thiamine Abstinence from alcohol

Retinopathy of Prematurity Assessment

Demarcation line with ridgeRetinal detachment

Retinopathy of Prematurity Implementations

Prevent by using minimum oxygen concentrations Monitor PO2Eye exam (premature infants)

Strabismus (cross-eyed) Assessments

Deviation of eyeDiplopiaTilts head or squints

Corrective lenses ImplementationsEye exercisessurgery

Detached Retina AssessmentsFlashes of light

Detached Retina ImplementationsBedrest, affected eye in

Loss of visionParticles moving in line of visionconfusion

dependent positionEye patched (one or both)SurgerySedatives and tranquilizersAvoid stooping, straining at stool, strenuous activity 3 months

Cataracts AssessmentsDistorted, blurred visionMilky white pupil

Cataracts ImplementationsPostop: check for hemorrhageCheck pupil—constricted with lens implanted, dilated without lensEye dropsNight shieldSleep on unaffected side

Glaucoma AssessmentsAbnormal increase in intraocular pressure that leads to blindnessBlurred visionLights with halosDecreased peripheral visionPainHeadache

Glaucoma ImplementationsAdminister miotics (constrict pupil, allows more area for aqueous humor to flow), carbonic anhydrase inhibitorsSurgeryAvoid heavy lifting, straining of stoolMydriatics (dilates pupil, makes angle smaller and constrict aqueous flow) are contraindicated with glaucoma.

Trigeminal Neuralgia Assessments Stabbing, burning facial pain Twitching of facial muscles

Trigeminal Neuralgia Implementations

Medications—analgesics, Tegretol Surgery

Bell’s Palsy Assessments Inability to close eye Increased lacrimation Distorted side of face

Bell’s Palsy Implementations Isometric exercises for face Prevent corneal abrasions

Guillain-Barre Syndrome Assessments

Paresthesia Motor losses beginning in

lower extremities Altered autonomic function

Guillain-Barre Syndrome Implementations

Medications—steroids Aggressive respiratory care Physical therapy Eye care Prevent complications: respiratory

and aspiration

Meningitis Assessments Nuchal rigidity Kerning’s sign Brudzinski’s sign Seizures Bulging fontanels High-pitched cry

Meningitis Implementations Medications—antibiotics,

antifungals Prevent complications: droplet

precautions, contagious

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

Electroencephalogram (EEG) Preparation

Test brains waves; seizure disorders Tranquilizer and stimulant meds withheld for 24-48 hours Stimulants (caffeine, cigarettes) withheld for 24 hours May be asked to hyperventilate during test Meals not withheld Kept awake night before test; want them to lie still

Electroencephalogram (EEG) Post-test

Remove paste from hair Administer medications withheld before test Observe for seizure activity Seizure prodromal signs; epigastric distress, lights before the eyes

CAT 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 Administer vitamin K IM (decrease risk of hemorrhage) NPO 6 hours Given sedative Position supine, lateral with upper arms elevated Asked to hold breath for 5-10 seconds

Liver Biopsy Post-Test Position on operative side for 1-2 hours Gradually elevate head of bed 30 degrees (1st hour) and then 45 degrees (2nd 2 hours) Bedrest for 24 hours Check Vital signs Check clotting time, platelets, hematocrit Report severe abdominal pain

Upper GI Series Barium Swallow: stool white from barium

Tracheostomy Tube Cuff Purpose—prevents aspiration of fluids Inflated

o During continuous mechanical ventilationo During and after eatingo During and 1 hour after tube feedingo 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 deliveredo Provides cooled, humidified airo Check oxygen concentration with oxygen analyzer q4 hourso Clean humidity jar and fill with distilled water dailyo Cover patient with light blanket and cap for heado Raise side rails completelyo Change linen frequentlyo Monitor patient’s temperature

Chest Tubes Implementations Use to utilize

negative pressure in lungs

Fill water-seal chamber with sterile

Chest Tube Removal: Instruct patient to

do valsalva maneuver

Clamp chest tube Remove quickly

Complications of Chest Tubes: Constant bubbling in water-

seal chamber=air leak Tube becomes dislodged from

patient, apply dressing tented on one side

Tube becomes disconnected

water to 2 cm Fill suction control

chamber with sterile water to 20 cm

Maintain system below level of insertion

Clamp only momentarily to check for air leaks

Ok to milk tubing towards drainage

Observe for fluctuation in water-seal chamber

Encourage patient to change position frequently

Occlusive dressing applied

from drainage system, cut off contaminated tip, insert sterile connector and reinsert

Tube becomes disconnected from drainage system, immerse end in 2 cm of sterile water

CVP: measures blood volume and efficiency of cardiac work; tells us right side of heart able to manage fluid

“0” on mamometer at level of right atrium at midaxilliary line Measure with patient flat in bed Open stopcock and fill manometer to 18-20 cm Turn stopcock, fluid goes to patient Level of fluid fluctuates with respirations Measure at highest level of fluctuation After insertion

o Dry, sterile dressingo Change dressing, IV fluids, manometer, tubing q24 hourso Instruct patient to hold breath when inserted, withdrawn, tubing

changedo Check and secure all connections

Normal reading—3-11 cm water Elevated>11, indicates hypervolemia or poor cardiac contractility (slow down IV, notify physician) Lowered<3, hypovolemia Chest tray at bedside

Eye irrigation: tilt head back and toward affected side

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

Nasogastric Tubes: Levin-single—single-lumen, used for decompression or tube feeding Salem sump—double-lumen, used for decompression or tube feeding Sengstaken-Blakemore—triple-lumen, used for bleeding esophageal varices Linton-Nachlas—4-lumen, used for bleeding esophageal varices Keofeed/Dobhoff—soft silicone, used for long-term feedings Cantor—single lumen with mercury-filled balloon and suction port Miller-Abbott—double-lumen with mercury-filled balloon and suction port Harris—single lumen with mercury-filled balloon and suction port

NG tube placement: “BEST WAY” to check is to aspirate for gastric contents and check for pH of aspirate <4

Implementation of feeding: Check residual before intermittent feeding, reinstall residual Check residual Q4 hours with continuous feeding, reinstall residual

Hold feeding if >50% residual from previous hour (adults) or >25% (children) Flush tube with water before and after feeding Use pump to control rate of tube feeding Administer fluid at room temperature Change bag Q8 hours for continuous feeding Elevate head of bed while feeding is running Check patency Q4 hours Good mouth care

NG Irrigation Tubing: Verify placement of tube Insert 30-50 cc of normal saline into tube If feel resistance, change patient position, check for kinks Withdraw solution or record amount as input

NG removal: Clamp tube Remove tape Instruct patient to exhale Remove tube with smooth, continuous pull

Intestinal Tubes (Cantor, Mill-Abbott, Harris) Implementations

o After tube is in stomach, have patient lie on right side, then back in Fowler’s position, then left side

o Gravity helps to position tubeo Coil excess tube loosely on bed, do not tapeo Position of tube verified by x-rayo Measure drainage QShift

Removalo Clamp tubeo Remove tapeo Deflate balloon or aspirate contents of intestinal tube balloono Instruct patient to exhaleo Remove 6” every 10 min. until reaches the stomach, then remove

completely with smooth, continuous pull

T-Tube: 500-1000 cc/day, bloody first 2 hours

Penrose: expect drainage on dressing

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

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

Male catheter: insert 6-7”

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

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

Tonsillectomy: post-op frequently swallowing indicates hemorrhage

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

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

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

Glaucoma medications: Epinephrine hydrochloride (Adrenalin Chloride) and Pilocarpine Hydrochloride (Pilocar): give Pilocar (therapeutic) first then wait 2-10minutes and instill adrenalin to increase absorption of adrenalin).

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

Triglycerides elevation can falsely elevate glycosalated hemoglobin test.

Laparoscopic Cholecystectomy post: encourage to walk to eliminate acute right shoulder pain.

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

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

Rhinoplasty (nose surgery) position post-op: want to promote drainage of oral secretions is to position on her right side.

1 cup= 240ccPregnancy is a contraindication to an MRI.

Raynaud’s disease have decreased vascularity in the extremities.

Post-Parecentesis most important assessment is to obtain the blood pressure, weight the client, measure the client’s abdominal girth, and check dressing in that order.

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

Suction is always intermittent never continuous.