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22447430 compiled-nclex-tips-and-questions[1]


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  • 1. HERBAL MEDSSt. Johns 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 coldGinger 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 SeatsWeight 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 infants 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 forinfants 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 remainsrear facing until they reach 20 lb as in the prior instructions)Follow manufacturer instructions for proper positions at specfied child weights for that product (Typciallythis 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 childs ears are abovethe seat.Always place the seat in the rear of the vehicle. (This is especially true with airbags as when they deploy in anaccident 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 willbe 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 seatis the safest for all children.From the textbook often used to write the NCLEX pediatric questions: (Ball & Bindler)Preschool childs need for autonomy and control can be met by allowing the child to choose which snacks topick 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 betaught how to select foods appropriate for dietary management and how to plan an exercise program. Theyneed to learn to recognize the signs and symptoms of hypoglycemia and hyperglycemia, and understand the
  • 2. importance of carrying a rapidly absorbed sugar product.Adolescents should take on total responsibility for self-care. Although they understand explanations about thepotential complications of diabetes, they are present-time oreinted and may rebel against the dailyregimentation of insulin injections, blood glucose monitoring, and dietary management. Successful self-caredepends in part on the adolescents adjustment to the chronic nature of the disease and feelings of beingdifferent from peers.This same textbook defines:Preschool child, 3-6 years of ageSchool age child, 6-12 years of ageAdolescent, 12-18 years of agePrimary 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 burdorferiThe 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 higherpercentage of pneumonia in school-aged children.People at highest risk for mycoplasma pneumonia include those living or working in crowded areas such asschools and homeless shelters, although many people who contract mycoplasma pneumonia have noidentifiable risk factor.SymptomsThe symptoms are generally mild and appear over a period of one to three weeks. They may progress to moresevere symptoms in some people.Common symptoms include the following:HeadacheFever (may be high)ChillsExcessive sweatingCoughUsually dryUsually without phlegm or bloodChest painSore throatLess frequently seen symptoms include the following:Skin lesions or rashEye pain or sorenessMuscle aches and joint stiffnessNeck lumpRapid respiratory rateEar painSigns and testsA physical examination may reveal enlarged lymph nodes and inflammation of the eardrum. An examinationof the chest with a stethoscope (auscultation) reveals crackles.These tests help confirm the diagnosis:Blood tests for antibodies to mycoplasmaSputum cultureChest x-ray
  • 3. TreatmentAntibiotics may be prescribed for more serious symptoms related to mycoplasma pneumonia. Home careincludes rest and a high-protein diet with adequate fluids.Expectations (prognosis)Most people recover completely even without antibiotics, although antibiotics may speed recovery. Inuntreated 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 followingsymptoms 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 malaiseThe 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 recombinantClassificationErytrhopoietin, human recombinant1. normally synthesized in the kidney and stimulates RBC production2. will elevate and maintain RBC level, decreasing the need for BTUses:Treatment of anemia associated with Chronic Renal Failure in adultsC/I: uncontrolled hypertensionSide effects:CV - hypertensionCNS - pyrexiaComplication: PolycythemiaWhat 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 oldpaint on it and during 60s paints have lead content on it (heavy metals) and if you need to removethat, chips from the old paint may be taken by a kid that leads to Pb poisoning2) 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 andthat (+) 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 andalmost vulnerable to all type of illnesses.. There is no need for the patient to separate their utensilssince 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.
  • 4. *** 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. Isuppose, 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 forpregnant women... Option C is the answer5) 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 followingstatements 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 feverI think the answer is C. the child that just had tonsillectomy. i think the child isimmunocompromised. and varicella (Chicken pox) is a viral one.. we all know that tonsils are one ofthe 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 forimmune booster but not to be taken with patients with progressive systemic disorders such as AIDS,PTB, HIV, etc. black cohosh is for menopause.*** dont 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 waterusually, frozen food must be thawed at cool tap water for freshness. not in the microwave because itcan be cooked outside and raw inside, not in the hotwater with same principle. so i believe, thawingit FOR UP TO 6 HOURS would be ok. returning thawed food back at fridge is ok but it is unsafesince 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 thenurse 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.. Oxygensupports combustion.. and if friction is present together with oxygen (in a mist tent) then, fire couldcommence.11) a mother reported tht her son is throwing up each time she feeds him wot would be the bestquestion 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 likestool is a cardinal sign of Intussusception/ Telescoping or invagination of the large intestines in theIleoceccal area..
  • 5. 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 cravingfor sweets and weight gain. Symptoms begin in the fall, peak in the winter and usually resolve in thespring. Some individuals experience great bursts of energy and creativity in the spring or earlysummer.Susceptible individuals who work in buildings without windows may experience SAD-typesymptoms at any time of year. Some people with SAD have mild or occasionally severe periods ofmania during the spring or summer. If the symptoms are mild, no treatment may be necessary. Ifthey are problematic, then a mood stabilizer such as Lithium might be considered. There is a smallergroup of individuals who suffer from summer depression.SAD is recognized in the DSM-IV (The American Psychiatric Associations diagnostic manual) as asubtype of major depressive episode.Some individuals who work long hours inside office buildings with few windows may experiencesymptoms all year round. Some very sensitive individuals may note changes in mood during longstretches of cloudy weather.A sign of improvement from dehydration would be a decreased urine specific gravity and adecreased/decreasing hematocrit. So the SG of 1.015 and a Hct of 46% would be the answer. It is thebest 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 andvolume) (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 ageSpecific gravity is a measurement of the kidneys ability to concentrate urine. The range of urinesSG depends on the state of hydration and varies with urine volume and the load of solids to beexcreted under standardized conditions; when fluid intake is restricted or increased, SG measures theconcentrating and diluting functions of the kidney. Loss of these functions is an indication of renaldysfunction.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 SGc. Early chronic renal disease: increased volume, decreased SGHematocrit: Percentage of packed red cells in a volume of whole blood. The hematocrit will beincreased in dehydration.Source: A Manual of Laboratory & Diagnostic Tests (Frances Fischbach)digitalis toxicity includes..N - nauseaA - anorexiaV - vomitingD - diarrheaA - abdominal painkasma 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 notebookDrugs which can cause URINE DISCOLORATIONAdriamycyn------ ReddishRifabutin--------- Red orange
  • 6. Rifampicin------- Red orangeBactrim---------- Red orangeRobaxin--------- Brown, Black or GreenishAzulfidine------ Orange yellowFlagyl------------ BrownishDilantin---------- Pink tingedAnti Psychotic-- Pinkish to Red brownEarly signs of hypoxia:R-restlessnessA-anxietyT-TachycardiaLate signs of hypoxia:B-bradycardiaE-extreme restlessnessD-dyspneaIn pedia-F-feeding difficultyI-inspiratory stridorN-nares flareE-expiratory gruntingS-sternal retractionsRespiratory PatternsKussmaul- fruity acetone breath odorCheyne-stokes- near death breathing patternCRUTCH WALKING UP STAIRSGood goes to heaven, Bad goes to hellCYSTITIS-Inflamation of the urinary bladderManifestations:Urgency and frequencyLab 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 plums1.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 juices2. Which of goal of nursing care takes priority for a female client with cystitis?a. increasing urine alkalinityb. maintaining a balanced fluid I & Oc. Providing instructions on perineal hygiene--- answerd. screening urine for sedimentationMuskuloskeletal Anatomical tipsTENDONS- connect muscle to boneLIGAMENTS- connect bone to boneCUSHING SYNDROMEHypersecretion of Glucocorticoids by the adrenal glandsManifestations:central type or truncal obesity with thin extremetiesmoonfacebuffalo humphirsutismLab data:Elevated serum cortisol levels
  • 7. Hypernatremia,hyperglycemia,hypertensionHypokalemiaIntervention:High potassium, Low sodium dietLifelong administration of glucocorticoid synthesis inhibitorsEg. MitotaneInform that there will be poor wound healingSample question:When assessing a 40-year old patient with cushing’s syndrome, the nurse should expect the person todemonstrate:A lability of mood---- answerB ectomorphism with a moon faceC a decrease in the growth of facial hairD an increase resistance to bruising and bleedingEYE ABBREVIATIONSOU- both eyesOR- right eyeOS- left eyeLEVELS OF CONSCIOUSNESSA------ ALERTV------ VERBAL STIMULIP------ PAINFUL STIMULIU----- UNRESPONSIVEREASONS FOR UNCONSCIOUSNESS(SKIN COLOR)RED----- Stroke or increase BPWHITE---- Shock or HemorrhageBLUE--- Respiratory or Cardiac ArrestCIRCULATION ASSESSMENT- 5PsPainPallorPulseParesthesiaParalysisCHOLINERGIC CRISISS- SalivationL-LacrimationU-UrinationD-DefecationGEADLsB-BathingA-AmbulationT-ToiletingT-TransfersE-EatingD-DressingInstrumental ADLsS-shoppingC-cooking, cleaningU-using telephone /transportationM-managing money and medicationsC caneO opposite
  • 8. A affectedL legIN CASE OF ABDOMINAL TENDERNESSInspect, auscultate, percuss, palpateCUSHINGS (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 supportADDISONS (Hyposecretion of Adrenal Cortex Hormones)Always Remember the 6 As of Addisons disease1.) Avoid Stress2.) Avoid Strenuous3.) Avoid Individuals with Infection4.) Avoid OTC meds5.) A lifelong Glucocorticoids Therapy6.) Always wear medic alert braceletIF 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 at8L/min7. Check circulation. If pulseless: commence chest compressions8. Prepare naloxone for possible administration9. Call CPMS for urgent reviewAllergic: 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 tolab/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 hasdeveloped anti-IgA-antibodies.Clinical Manifestations: Anxiety, urticaria, wheezing progressing to cyanosis, shock, and possible
  • 9. 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 signin 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-likestools (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 salinedressing 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 byglomerular damage. Corticosteroids are the mainstay. Generalized edema common.A positive Western blot in a child <18 months (presence of HIV antibodies) indicates only that themother 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 forcare, 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 theaspirate 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 forcingpotassium 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 homewith an NG tube.Q&As found in the NCLEX FORUMQuestion # 1 (Multiple Choice) History and exam indicates your 77 year oldfemale patient has digitalis toxicity. Which drugs are contraindicated in this
  • 10. case? Plz provide your rationale.A) lidocaine and atropineB) adenosine and amiodaroneC) magnesium sulfate and sodium bicarbonateD) bretylium and verapamilAnswer::A) lidocaine and atropine-Dont affect dig level/dig toxicity.B) adenosine and amiodarone-Amiodarone, increases serum dig levels, possiblycausing dig toxicity. Adenosine doesnt affect dig toxicity. Only one of thesemeds is contraindicated in dig levels/toxitiy.C) magnesium sulfate and sodium bicarbonate. Neither drug affects dig levelsD) bretylium and verapamil-BEST ANSWER: Verapamil, increases serum dig levels,possibly causing dig toxicity. Bretylium aggravates dig toxicity and digoxintoxic arrhytmias are exacerbated by bretylium. This answer has two meds that areshould not be given to dig toxic patients.Question # 2(Multiple Choice) Regarding abruptio placentaeA) 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 bleedingwhats the correct one? I just dont 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 canbe either apparent or concealed. If the edges of the placenta remain attached tothe uterus then there will be no apparent loss of blood. However the woman isstill 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
  • 11. brain syndrome or dementia may not be able to make a rational decisionsregarding emergency care. In these situations, you may use ____to permit you tolegally render careA) Good Samaritan LawsB) Standards of CareC) Implied ConsentD) Informed Consentc is given as correct. why?Answer:: Implied consent means that the patient most likely has been found indistress and it is assumed that person wants to live. Therefore, you are withinthe law to treat a person who is unable to make a decision about his/her carewho is in an emergency situation.Above answer to your question explains why C is the best answer. Let me pointout a test taking tip to further support how you would choose this answer on anexam, 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 youto deliver care in an emergency situation, when the patient is unable to giveconsent. Now define each of the possible reponses.A) Good Samaritan Laws-This law is to protect the individual that intervene toprovide care in an emergency from litigation. In other words, if a nurse stopsat an accident scene and provides care, the nurse will not be held liable fortheir actions, if the care was provided in good faith according to practicestandards. Therefore this is not the answer.B) Standards of Care-These are established guidelines for the nurse/health careprovider that outline safe and effective nursing care/interventions for givendiagnoses, etc. So, again this is not the answer to the question.C) Implied Consent-Best answer, the patient cant verbalize consent, due totheir OBS/dementia, but they need emergency care. Because care is required thenconsent to provide life saving care is implied. The same principle applies whengiving emergency care to unconscious patients. You cant wait for them to tellyou it is OK, to save their life, the law allows you to intervene. This isimplied consent.
  • 12. D) Informed Consent-This is when the physician describes the procedure that isto be preformed. Included in this explanation is the benefits and risksassociated with the procedure. The patient is INFORMED about the procedure andthen they give their consent. Again, this is not the best answer.Try this technique when answering NCLEX-like questions, and you will find thatyou 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 Iknow are suppose to ask the person can they talk.2.) an elderly client has alzheimers and wanders through out the day. To protecthis 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 onbefore 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 yourquestions.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 anobstructed airway. If the patient can cough, then they are encouraged to do so.If they cant speak or cough (no airway movement/obstructed airway) then youbegin the sequence for removing an airway obstruction, in this case it would be
  • 13. for a conscious patient.b.)immediately perform the heimlich maneuver. NOT THE BEST CHOICE, because youneed to confirm whether or not the patient is able to move air effectivelybefore performing this maneuver. Therefore to rule out an obstructe airway youneed to select an answer that will establish if the patient can speak, cough orsome other indicator of air movement.I got confused because I know are suppose to ask the person can they talk. Thiscorrect, but as you know from taking the NCLEX, the answer you want is neverthere. What you have to do is select the answer that best matches/fits theprinciples for the answer you would expect to find. You ask if the patient canspeak to confirm/rule out airway movement. Asking if they can cough willaccomplish the same thing.2.) an elderly client has alzheimers and wanders through out the day. to protecthis safety what is the best thing to do? Key words in this question are WANDERS,Alzheimers patient, and to protect HIS SAFETY.a.) put alarms on all the doors. BEST ANSWER, this is for the patients SAFETY,because Alzhiemers patients wander and if they were to leave the healthcarefacility their safety would be compromised significantly. The alarms willimmediately alert all staff and the patient can be returned to the unitimmediately.b.) inform all the staff to reorient the client. NO, remember the question isasking about safety. Reoriented an Alzheimer’s patient is appropriate nursingcare, but they have no short term memory, so this will not ensure that they willremain 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 nursingproblems. The patient could be injured or leave the unit between checks by thesecurity guards.d.) family to sit with him. NO, this is "passing the buck" and putting anotherburden on a family that is already in crisis due to the fact they have a familymember with Alzheimers disease.
  • 14. 3.)When teaching a pt.about urinary catheter. What is most important? Bothanswer dont match the principles of home care for a client with a catheter, soit 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 homecatheter care is a clean procedure, so A would not be the choice. Betadine is agood anti-infective agent but it can be irritating to tissues. Generallycleaning 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 onbefore the pap smear is performed.a) I just started menstruating and it is very heavy. BEST ANSWER, the best timeto obtain a pap smear is two weeks after the first day of the last menstrualperiod and DEFINITELY NOT when the patient is menstruating, as this will affectthe results.b) my last pap smear was abnormal. No, this is important to know, but not assignificant 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 moresignificantd)I forgot this choice.Question:1. Alzheimers patient incontinent of urine during the night times. The nursing care includesa) Offers bed pan every 2 hoursb) Limit fluids during evening timesc) Foleys catheter2. After immediate post operative hysterectomy patient to observe (or) Nursing care includesa) Observe vaginal bleedingb) Urine outputc) Vital signs3. Dilantin prescribed to the patient, instructions to patient include
  • 15. a) Reticulocyte countsb) Platelet counts4. On the ECG found a straight line, first Nursea) Assess the patientb) Cardiopulmonary resuscitationc) IV fluids5. 15% superficial burns, 20% partial thickness burns. If the fluids adequatea) Urine output 30-40ml/hrb) BPc) Vital signsd) Skin turgor6. 20 week pregnant most concerneda) Butterfly rash on both cheeks and noseb) Uterus palpate at the level of symphysis pubisc) Sereous fluid drain in the breastsd) Breast enlargement7. The sterile technique is broken when:a) The sterile field and supplies are wetb) Clean the area peripheral to center8. The metal piece is embedded on the left eyea) Pressure dressing is applied on the left eyeb) Dressing is applied on both eyesc) Irrigate the eye with saline9. After cerebral angiogram, patient isa) Encourage fluidsb) obseve contrast medium in the urinec) walking10. Using clean, non sterile gloves, care is appropriatea) wash the genitelia........YES/NOAnswers:-The following possible best answers are based on the information found in nursing textbooks, andthe underlying principle for safe and effective care that NCLEX is testing for.1. Alzheimers patient incontinent of urine during the night times. The nursing care includesa) Offers bed pan every 2 hours-NO, would be appropriate to bring the client to the toilet orcommode every 2 hours during the day, but this action means you disturb the clients sleep.b) Limit fluids during evening times, BEST ANSWER-(Source: Black & Hawks, Medical-SurgicalNursing 7th edition) Specific interventions for the Alzheirmers client with urinary incontinence:"Sometimes the client forgets where the bathroom is located. Having bright lights and frequently
  • 16. taking the client there may help control incontinence. Fluid intake after the dinner meal can berestricted to maintain continence during the night."c) Foleys catheter-NO, would increase risk of lower urinary tract infection, inappropriate and notnecessary.2. After immediate post operative hysterctomy patient to observe (or) Nursing care includesa) Observe vaginal bleedingb) Urine outputc) Vital signs-BEST ANSWER, as this provides the best/most information about the clientsresponse to surgery and anesthesia.3. Dilantin prescribed to the patient, to instruct the patient that includesa) Reticulocyte counts-Yes, this will test for decreased reticulocyte count a sign that the patient isdeveloping aplastic anemia, a potentially life threatening side effect of Dilantin therapy.b) Platelet counts-No, however Dilantin can decrease the platelet count and result inthrombocytopenia. Aplastic anemia is considered to be more serious (Davis Drug Guide)4. On the ECG found a straight line, first Nursea) Assess the patient-BEST ANSWER, always assess the patient to be sure there is no equipmentmalfunction, and/or to confirm the information on the monitor.b) Cardiopulmonary resuscitationc) IV fluids5. 15% superficial burns, 20% partial thickness burns. If the fluids adequatea) Urine output 30-40ml/hr BEST ANSWER, the patients fluid balance/hydration status is bestevaluated by assessing urine output. Urine output should be between 0.5 and 1.0 mL/kg/hr, whichfor a 130 lb adult would be between 29.5 -59 mL/hr. Most nursing textbooks consider 30 mL/hr ofurine output to indicate appropriate fluid balance/hydration.b) BPc) Vital signsd) Skin turgorFor b, c, and d many other factors can affect these findings. Urine output directly correlates with thepatients 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 ofhormonal changes in pregnancy.b) Uterus palpate at the level of symphysis pubis-BEST ANSWER this correlates with 12 weeksgestation 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 isnot unusual.d) Breast enlargement-NO, the breast enlarge during pregnancy.7. The sterile technique is broke whena) The sterile field and supplies are wet-BEST ANSWER, this would allow microorganisms to enterthe sterile field through the wet surface.
  • 17. b) Clean the area peripheral to center-NO, this is inappropriate technique but response a, specificallydescribes how a sterile field can be contaminated and is an important principle in maintaining sterilefields.8. The metal piece is embedded on the left eyea) 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 becauseboth 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. Irrigationwill not remove the object but theoretically it could cause it to move resulting in further damage.9. After cerebral angiogram, patient isa) Encourage fluids-BEST ANSWER, when ever contrast medium/X-ray dyes are administer theclient 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 appropriatea) 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 potassiumchloride. most important for nurse to monitor the patient :A. pulse rateB. daily weightC. skin turgorAnswer1:I would say, always check for urine output before commencing anything with Potassium because itcan 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 rateQuestion:1)a young patient most likely to get lead poisining if?
  • 18. a. he is drinking from a ceramic pitcher.b. father refurnishes old furniture at their home2) 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 eat3) 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. echinacea5) 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 followingstatements 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 fever7) 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 cohosh8) 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 perishable food should cover and coold. frozen food should be defrost by hot water9) child in a mist tent and the parents brought him a car toy...the child was clutching the toy and thenurse refused to let him play for wat reason?a. it will get contaminated with bacteriab. it will accumalate moisturec. it could cause a fire11) a mother reported that her son is throwing up each time she feeds him wat would be the bestquestion u ask?a. did u warm up the formulab. wot kind of formula did u give him
  • 19. c. does ur son feel hungry each time he throws upd. does ur son have a jelly like stool12) a patient had aids the nurse should advise?a. cook ur meat very wellb. not to eat in the same table with familyc. avoid crowdsAnswer: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 oldpaint on it and during 60s paints have lead content on it (heavy metals) and if you need to removethat, chips from the old paint may be taken by a kid that leads to Pb poisoning2) 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 andthat (+) 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 andalmost vulnerable to all type of illnesses.. There is no need for the patient to separate their utensilssince 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. Isuppose, 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 forpregnant women... Option C is the answer5) allergic to sulfa wat not to take?a. ma huangb. echinacea.
  • 20. ...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 followingstatements 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 feverI think the answer is C. the child that just had tonsillectomy. i think the child isimmunocompromised. and varicella (Chicken pox) is a viral one.. we all know that tonsils are one ofthe 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 forimmune booster but not to be taken with patients with progressive systemic disorders such as AIDS,PTB, HIV, etc. black cohosh is for menopause.*** dont 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 waterusually, frozen food must be thawed at cool tap water for freshness. not in the microwave because itcan be cooked outside and raw inside, not in the hotwater with same principle. so i believe, thawingit FOR UP TO 6 HOURS would be ok. returning thawed food back at fridge is ok but it is unsafesince 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 thenurse 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.. Oxygensupports combustion.. and if friction is present together with oxygen (in a mist tent) then, fire couldcommence.11) a mother reported that her son is throwing up each time she feeds him wat would be the bestquestion 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
  • 21. ***>>> CORRECT OPTION is D.. Does your son have jelly like stool.. jelly like or currant likestool is a cardinal sign of Intussusception/ Telescoping or invagination of the large intestines in theIleoceccal 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 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 dischargeCorrect Answer: 2. A client who needs to be suctionedPRIORITY (Use ABC)Obstruction in the airway – secretionsNeed to be suctioned2. 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 PatientCorrect 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 rejectionDELEGATION: Remember the 5Rs, Right Task, Right Person, Right Circumstance, RightCommunication & Right Feedback)RN Least stable, unstable, central catheters (hickman, broviac), admission, discharge, healthteachings, 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, ambulationFor future USRNsThis is for you... from the purkinje fibers of my heart....Room Assignment(Who to Share Room with)Check:A geB eside the nurses station? At the end of the hallway? Single Room/Private Room?C hain of infection/circumstanceD iagnosisE nviroment (dim light, darkened, red nightlapm)
  • 22. 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 syndromeCorrect Answer: 4. A 5-year-old with nephrotic syndrome.1,2 & 3, manifest symptoms of infection. A client with leukemia is immunosuppressed and Patientswith infection shouldnt be placed in this room. Since patient with nephrotic syndrome receivesdiuretics 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 PrecautionsThe 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 microorganismsD roplet, large particles are dispersed into air, resp.infections except resp syncytialE nteric, fecal-oral like hepaA & salmonellaAGE 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 ropeThe correct answer is: 1. Parallel play is more common in TODDLERS.Preschooler (3-6 years)Gross motor developmentHOPS ON ONE (1) FOOT BY 4 YEARSSKIPS & HOPS ON ALTERNATE FEET BY 5 YEARSPLAY : ASSOCIATIVE, IMAGINATIVE, MAGICAL THINKING, SUPERHEROES (Rememberthe movie: Jingle All The way!)FEAR: Intrusive procedures, venipunctures, IM injections, body mutilation
  • 23. 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 inits feces.This might happen if you were to accidentally touch your hands to your mouth after gardening,cleaning a cats litter box, ortouching 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 withraw 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 informationabout 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 andvegetables, limiting all meat, and avoiding nitrate-containing foods.”2. “Prostate cancer is the most common cancer in American men with results to threaten sexualityand 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 its the mostpreventable of all cancers.
  • 24. MEMORIZE MEMORIZE MEMORIZETonometry: 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 1.5-2.5Prothrombin 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 dehydrationSafe 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 treatmentPhenytoin (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). Immediatepostpartum 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)
  • 25. Left Atrial Pressure: normal (1 to 10 mm Hg) Fibrinogen Levels: normal (male: 180 to 340 mg/dL) and (female: 190 to 420 mg/dL) with Disseminated Intravascular Coagulation the fibrinogen level drops because fibrinogen is used up in the clotting process.Insulin Insulin Insulin Insulin(Regular, Humulin R) (NPH, Humulin N) (Ultralente, Humulin U) (Humulin 70/30)Type: Fast acting Type: Intermediate Type: Slow acting Type: CombinationOnset: ½ -1 hr acting Onset: 4hr Onset: ½ hrPeak: 2-4 hr Onset: 2hr Peak: 8-20hr Peak: 2-12hrDuration: 6-8 hr Peak: 6-12hr Duration: 24-36hr Duration: 24hr Duration 18-26hr Central Venous Pressure: < 3 mm Hg = inadequate fluid and >11 mm Hg = too much fluid Potassium: 3.5-5.0 mEq/L Sodium: 135-145 mEq/L Calcium: 4.5-5.2 mEq/L or 8.6-10 mg/dL Magnesium: 1.5-2.5 mEq/L Chloride: 96-107 mEq/L Phosphorus: 2.7 to 4.5 mg/dL PR measurements: normal (0.12 to 0.20 second) QRS measurements: normal (0.04 to 0.10 second) Ammonia: 35 to 65 ug/dL Amylase:25 to 151 IV/L Lipase: 10 to 140 U/L Cholesterol: 140 to 199 mg/dL LDL: <130 mg/dL HDL: 30 to 70 mg/dL Triglycerides: <200 mg/dL Bilriubin • Direct: 0 to 0.3 mg/dL • Indirect: 0.1 to 1.0 mg/dL • Total: <1.5 mg/dL Protein: 6.0 to 8.0 g/dL Uric acid: Male 4.5 to 8 mg/dL Female 2.5 to 6.3 mg/dL Glycosylated Hemoglobin HbA1c: good control 7.5% or less Serum creatinine: 0.6 to 1.3 mg/dL
  • 26. BUN: 9-25 mg/dLNormal CK is 26-174 U/LTroponin I value: normal (<0.6 ng/mL)Troponin T >0.1 to 0.2 ng/mL = MIErythrocyte studies: 0-30 mm/hourSerum iron: Male 65-175 ug/dL Female 50-170 ug/dLRBC: Male 4.5 to 6.2 M/uL Female 4.0 to 5.5 M/uLTheophylline 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
  • 27. Infant Oral (trust & 0 – 1.5 Trust vs. mistrust dependence sensorimotor Toddler Anal (holding vs. 1.5 -3 Autonomy vs. shame letting out) preoperationalPre-school Phallic (Oedipus 3-6 Initiative vs. guilt complex) preoperationalSchool age Industry vs. 6 - 11 inferiority latency Concrete operational Identity vs. role 11 - 20 confusion genital Formal operational 20 – 25 Intimacy vs. isolation Generativity vs. 25 – 50 stagnation 50 - ? Integrity vs.despair LABORATORY VALUES ELECTROLYTES Sodium (Na+): 135 – 145 meq/L (increase-dehydration; decrease overhydration) Potassium (K+): 3.5 - 5.0 meq/L Magnesium (Mg++): 1.5 – 2.5 meq/L Calcium (Ca++): 4.5 – 5.8 meq/L Neonate : 7.0 to 12 mg/dL Child: 8.0 to 10.5 mg/dL Phosphorus (PO4): 1.7 – 2.6 meq/L Chloride (Cl-): 96 – 106 meq/L COAGULATION STUDIES Activated partial thromboplastin time(APTT): 20 – 36 seconds depending on the type of activator used Prothrombin time(PT): male: 9.6 – 11.8 seconds Female: 9.5 – 11.3 seconds International Normalized Ratio(INR): 2.0 - 3.0 for standard Coumadin therapy 3.0 – 4.5 for high-dose Coumadin therapy Clotting time: 8 – 15 minutes Platelet count: 150,000 to 400,000 cells/Ul Bleeding time: 2.5 to 8 minutes SERUM GASTROINTESTINAL STUDIES Albumin: 3.4 to 5 g/dL Alkaline phosphatase: 4.5 to 13 King-Armstrong units/dL Ammonia: 15 to 45 ug/dL Amylase: 50 – 180 Somogyi U/dL in adult 20 – 160 Somogyi U/dL in the older adult Bilirubin: direct: 0 - 0.3 mg/dL Indirect: 0.1 – 1.0 mg/dL Total: less than 1.5 mg/dL Cholesterol: 120 – 200mg/dL Lipase: 31 -186 U/L Lipids: 400 – 800 mg/dL Triclycerides: Normal range: 10 – 190 mg/dL Borderline high: 200 – 400 mg/dL High: 400 – 1000mg/dL Very high: greater than 1000mg.dL
  • 28. Protien: 6.0 – 8.0 g/LUric acid: male: 4.5 – 8 ng/dL Female: 2.5 – 6.2 ng/dL GLUCOSE STUDIESFasting blood sugar: 70 – 105 mg/dLGlucose monitoring (capillary Blood): 60 – 110 mg/dL RENAL FUNCTION TESTCreatinine: 0.6 – 1.3 mg/dLBlood urea nitrogen (BUN): 5 – 20 mg/dL ERYTROCYTES STUDIESErytrocyte 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/uLWhite 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) Eye movement IV. Trochlear (M) Facial sensation V. Trigeminal (S-M) Jaw movement VI. Abducent (M) Eye movement Taste VII. Facial (S-M) Facial expression VIII. Acoustic (S) Hearing and balance Taste IX. Glossopharyngeal (S-M) Throat sensation Gag and swallow Gag and swallow X. Vagus (S-M) Parasympathetic activity Neck and back muscles XI. Spinal Accessory (M)
  • 29. XII. Hypoglossal (M) Tongue movementOn 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/ PARASYMPATHETIC/ ADRENERGIC CHOLINERGIC Increased heart rateHeart Increased conduction Decreased heart rate Increased forceBronchi dilation constrictionGI tract Reduced motility Increased motility Empties rectumRectum Allows filling Relaxes internal sphincter Empties bladderBladder Allows filling Relaxes internal sphincterErection Maintains erectionEjaculation Triggers ejaculationPupils of eye Big (mydriasis) Small (miosis)Salivary glands Secretion Depends on receptorsBlood vessels -a contrict -b dilates FLOW OF BLOOD THROUGH THE HEART
  • 30. 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 IMPULSESSinoatrial (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 LEVELSAcetaminopen (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/mLProcainamide (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/mLPulmonary capillary wedge pressure: 5 to 13 mmHgPulmonary artery pressure: systolic: 16 to 30 mmHg Diastolic: 0 to 7 mmHgSpinal 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.
  • 31.  Accummulation of drug will increase risk of hypoglycaemia. DURATIONtolbutamide 8hGlycburide, glipizide 20 h, most potentchlorpropamide 48 h Apothecary and Household SystemGrain –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 kgFahrenheit to Celcius (F – 32) divide 1.8 = CCelcius to Fahrenheit 1.8 C + 32 = F Formula for Calculating a Medication DosageD (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 mLD X Q = XA Formulas for Intravenous CalculationsFlow Rates: Total volume x gtt factor = gtt per min Time in minutesInfusion Time: Total volume to infuse = Infusion time mL per hour being infused IMMUNIZATIONBirth Hepatitis B
  • 32. 1 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 shoulderThoracic 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 goosefleshLumbar 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
  • 33. 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/dLNormal 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 insipidusNormal 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 MEDICINEAloe vera Gel – abrasionsand dermatologic conditionsAmerican 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 treatmentChamomile (Matricaria recutita) “manzanilla”- skin inflammation, colic, or dyspepsia and anxietyChaste 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 disorders
  • 34. Hawtorn ( Crategus species) – CHF and related cardiovascular conditionsHorebound (Marribium vulgare) – primary cough suppression and expectorationHorse Chestnut Seed (Aesculus hippocastanum) chronic venous insufficiencyIvy (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 counterirritantNettle (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 diureticYohimbe – erectile dysfunctionFOUR 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 hadexperienced on and off chest pain. After series of cardiac tests (EKG & Blood Chem), the doctororders for THALLIUM STRESS TEST. Which of the following medications should the RN prepareif the patient needs an alternative exercise in thallium test?1.Nitroglycerin2.Morphine3.Aminophylline4.PersantinThe correct answer is #4. Persantin (dipyridamole)Persantin is use as an alternative to exercise in thallium myocardial perfusion imaging for theevaluation 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-RNURC09178364589
  • 35. Posted by Anaski from IP on August 23, 2005 at 21:44:00: For Future USRNs: Cervical Cancer Etiology: * Early age of sexual intercourse * Multiple sexual partners * Sexually Transmitted Disease (Venereal Wart) * Virus - HPV Cancer Carcinoma in SITU - only in epithelial linings Situ sounds like Ziru - Stage 0 Tumor marker - CEA Signs and Symptoms (3 Ps) POST COITAL BLEEDING PAINFUL INTERCOURSE PROFUSE (PERIOD IRREGULARITIEs - menorrhagia and metrorrhagia) Management: U - pera (Surgery HYSTERECTOMY) R - radiation (intracavitary cessium - remember STD - shielding, timing and distance)) C - chemotherapy to destroy the DNA,RNA & CHON synthesis. MIKE’S NOTES (60 pp.) O universal donor/AB universal recipient. ABO BLOOD TYPE COMPATIBILITY Blood Type Can Receive from: Can donate to: O O O,A,B,AB A A,O A,AB B B,O B,AB AB O,A,B,AB AB Autologous Transfusion: •Collected 4-6 weeks before surgery •Contraindicated—infection, chronic disease, cerebrovascular or cardiovascular disease Hypotonic Solution Isotonic Solution Hypertonic Solution• ½ NS (0.45% • 0.9% NaCl (Normal Saline) • 10% D/W (10% Dextrose in water) Saline) • 5% D/W (Dextrose in Water) • D15W • Lactated Ringer’s • 5% D/NS (5% Dextrose in 0.9% Saline) • 5% D/ ¼ NS (5% Dextrose in 0.225% • 5% D/ ½ NS (5% Dextrose in 0.45% Saline ) Saline) • 3% NaCl • 5% Sodium Bicarbonate Change tubing Q72 hours Change bottle Q24 hours Infiltration •Assessment: cool skin, swelling, pain, decrease in flow rate •Implementation: discontinue IV, warm compresses, elevate arm, start new site proximal to infiltrated site IV Phlebitis, Thrmobophlebitis •Assessment—redness, warm, tender, swelling, leukocytosis •Implementation—discontinue IV, warm moist compresses, start IV in opposite extremity Hematoma
  • 36. •Assessment—ecchymosis, swelling, leakage of blood •Implementation—discontinue IV, apply pressure, ice bag 24 hours, restart IV in opposite extremityIV Clotting •Assessment—decreased flow rate, back flow of blood into tubing •Implementation—discontinue, do not irrigate, do not milk, do not increase rate of flow or hang solution higher, do not aspirate cannula, inject Urokinase, D/C and start on other site.Insertion of Percutaneous Central Catheters: •Placed supine in head-low position •Turn head away from procedure •Perform Valsalva maneuver •Antibiotic ointment and transparent sterile dressing •Verify position with x-ray •Change tubing Q24 hours •Nurse/patient both wear mask when dressing change 2-3x/week Adrenergics Adrenergic Medications Adrenergics Side effects: Actions: •Levophed •Dysrhythmias •Stimulate the sympathetic •Dopamine •Tremors nervous system: increase in •Adrenalin •Anticholinergic effects peripheral resistance, increase •Dobutrex Adrenergics Nursing blood flow to heart, Considerations: bronchodilation, increase blood •Monitor BP flow to skeletal muscle, •Monitor peripheral pulses increase blood flow to uterus •Check output •Stimulate beta-2 receptors in lungs •Use for cardiac arrest and COPD Anti-Anxiety Anti-Anxiety Anti-Anxiety Action: Medications: Side effects: •Affect neurotransmitters •Librium, Xanax, •Sedation Used for: Ativan, Vistaril, •Confusion •Anxiety disorders, manic Equanil •Hepatic dysfunction episodes, panic attacks Anti-Anxiety Nursing Considerations: •Potention for addiction/overdose •Avoid alcohol •Monitor Liver Function AST/ALT •Don’t discontinue abruptly, wean off •Smoking/caffeine decreases effectivenessAntacids Antacids Medications AntacidsActions: •Amphojel Side effects: •Neutralize gastric acids •Milk of Magnesia •ConstipationUsed for: •Maalox •Diarrhea •Peptic ulcer •Acid rebound •Indigestion, reflex Antacids esophagitis Nursing 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 fluidsAntiarrhythmics Antiarrhythmics AntiarrhythmicsAction: Medications: Side effects: •Interfere with electrical •Atropine sulfate •Lightheadedness excitability of heart •Lidocaine •HypotensionUsed for: •Pronestyl •Urinary retention •Atrial fibrillation and •Quinidine Antiarrhythmics flutter •Isuprel Nursing Considerations: •Tachycardia •Monitor vital signs •PVCs •Monitor cardiac rhythmAminoglycosides Aminoglycosides Aminoglycosides (Antibiotics)
  • 37. (Antibiotics) (Antibiotics) Side effects: Action: Medications: •Ototoxicity and Nephrotoxicity •Inhibits protein •Gentamycin •Anorexia synthesis in gram- •Neomycin •Nausea negative bacteria •Streptomycin •Vomiting Used for: •Tobramycin •Diarrhea •Pseudomonas, Aminoglycosides (Antibiotics) E.Coli 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 levelCephalosporins Cephalosporins Cephalosporins (Antibiotics)(Antibiotics) (Antibiotics) Side effects:Action: Medications: •Bone marrow depression: caution with anemic, and low PLT •Inhibits synthesis of •Ceclor px bacterial cell wall •Ancef •SuperinfectionsUsed for: •Keflex •Rash •Tonsillitis, otitis •Rocephin Nursing Considerations: media, peri-operative •Cefoxitin •Take with food prophylaxis •Cross allergy with PCN •Meningitis •Avoid alcohol •Obtain C&S before first dose: to make sure medication is effective against disease/bacteria •Can cause false-positive for proteinuria/glycosuriaFluoroquinolones Fluoroquinolones Fluroquinolones(Antibiotics) (Antibiotics) (Antibiotics)Action: Medications: Side effects: •Interferes with DNA •Cipro •Diarrhea replication in gram- •Decreased WBC and Hematocrit negative bacteria •Elevated liver enzymes (AST, ALT)Used for: •Elevated alkaline phosphatase •E.Coli, Pseudomonas, S. Nursing Considerations: Aureus •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) Macrolide (Antibiotics) Macrolide (Antibiotics)Action: Medications: Side effects: •Binds to cell membrane •Erythromycin •Diarrhea and changes protein •Clindamycin •Confusion function •HepatotoxicityUsed for: •Superinfections •Acute infections Nursing Considerations: •Acne •Take 1hr ac or 2-3 hr pc •URI •Monitor liver function •Prophylaxis before dental •Take with water (no fruit juice) procedures if allergic to •May increase effectiveness of: Coumadin PCN and Theophylline (bronchodilator) Penicillin Penicillin Penicillin Action: Medications: Side effects: •Inhibits synthesis of cell •Amoxicillin •Stomatitis wall •Ampicillin •Diarrhea Used for: •Augmentin •Allergic reactions •Moderate to severe •Renal and Hepatic changes
  • 38. infections Nursing Considerations: •Syphilis •Check for hypersensitivity •Gonococcal infections •Give 1-2 hr ac or 2-3 hr pc •Lyme disease •Cross allergy with cephalosporins Sulfonamides (Antibiotics) Sulfonamides (Antibiotics) Sulfonamides (Antibiotics) Action: Medications: Side effects: •Antagonize essential component •Gantrisin •Peripheral Neuropathy of folic acid synthesis •Bactrim •Crystalluria Used for: •Septra •Photosensitivity •Ulcerative colitis •Azulfidine •GI upset •Crohn’s disease •Stomatitis •Otitis media Nursing Considerations: •UTIs •Take with meals or foods •Encourage fluids •Good mouth care •Antacids will interfere with absorptionTetracyclines TEtracyclines Tetracyclines (Antibiotics)(Antibiotics) (Antibiotics) Side effects:Action: Medications: •Discoloration of primary teeth if taken during pregnancy or if •Inhibits protein •Vibramycin child takes at young age sythesis •Panmycin •GlossitisUsed for: •Rash •Infections •Phototoxic reactions •Acne Nursing considerations: •Prophylaxis for •Take 1 hr ac or 2-3 hr pc opthalmia •Do not take with antacids, milk, iron neonatorum •Note expiration date •Monitor renal function •Avoid sunlight UTIs •Medication: o Furadantin •Action: o Anti-infective •Side effects: o Asthma attacks o Diarrhea •Nursing Considerations: o Give with food or milk o Monitor pulmonary status UTIs •Medication o Mandelamine •Action: o Anti-infective •Side effects: o Elevated liver enzymes •Nursing Considerations: o Give with cranberry juice to acidify urine o Limit alkaline foods: vegetables, milk, almonds, coconut UTIs •Medication o Pyridium •Side effects: o Headache o Vertigo •Action
  • 39. o Urinary tract analgesic •Nursing Consideration o Tell patient urine will be orange Anticholinergics Anticholinergic Anticholinergic Action: Medications: Side Effects: •Inhibits action of acethylcholine and •Pro-Banthine •Blurred vision blocks parasympathetic nerves (affects •Atropine •Dry mouth heart, eyes, respiratory tract, GI tract •Scopolamine •Urinary retention and the bladder) •Chage in heart rate •Dilates pupil, causes bronchodilation Nursing Consideration: and decreased secretions •Monitor output •Decrease GI motility secretions •Contraindicated with glaucoma Used for: •Give 30 min ac, hs, or 2hr pc •Opthalmic exam •Contraindicated: paralytic ileus, •Motion sickness BPH •Pre-operative Anticoagulants Anticoagulants Anticoagulants (Heparin) Action: Medications: Side Effects: •Blocks conversion of •Heparin •Hematuria prothrombin to thrombin •Tissue irritation Used for: Nursing Considerations: •Pulmonary embolism •Monitor clotting time or Partial •Venous thrombosis Thromboplastin Time (PTT) •Prophylaxis after acute MI •Normal 20-45 sec •Therapeutic level 1.5-2.5 times control •Antagonist—Protamine Sulfate •Give SC or IV Anticoagulant Anticoagulant Anticoagulant (Coumadin) Action: Medication: Side Effects: •Interferes with synthesis of •Coumadin •Hemorrhage, Alopecia vitamin K-dependent clotting Nursing Considerations: factors •Monitor Prothrombin Test (PT) Used for: •Normal 9-12 sec •Pulmonary embolism •Therapeutic level 1.5 times control •Venous thrombosis •Antagonist—Vitamin K (AquaMEPHYTON) •Prophylaxis after acute MI •Monitor for bleeding •Give PO Anticonvulsants Anticonvulsant Anticonvulsant Action: Medications: Side effects: •Decreases flow of calcium and •Dilantin •Respiratory depression sodium across neuronal •Luminal •Aplastic anemia membranes •Depakote •Gingival hypertrophy Used for: •Tegretol •Ataxia •Seizures •Klonopin 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-brownAnti-Depressants Anti-Depressants Anti-DepressantsMonoamine Oxidase (Monoamine (Monoamine Oxidase Inhibitors)Inhibitors (MAO) Oxidase Side effects:Action: Inhibitors) •Hypertensive Crisis (Sudden headache, diaphoretic, •Causes increases Medications: palpitations, stiff neck, intracranial hemorrhage) with food concentration of •Marplan that contain Tyramine
  • 40. neurotransmitters •Nardil Nursing Considerations:Used for: •Parnate •Avoid foods containing Tyramine: Aged cheese, liver, •Depression yogurt, herring, beer and wine, sour cream, bologna, •Chronic pain pepperoni, salami, bananas, raisins, and pickled products •Monitor output •Takes 4 weeks to work •Don’t combine with sympathomometics vasoconstrictors, and cold medications Anti-Depressants Anti-Depressants Anti-Depressants Selective Serontonin Reuptake Selective Serontonin Selective Serontonin Reuptake Inhibitors Inhibitors (SSRI) Reuptake Inhibitors (SSRI) Action: (SSRI) Side effects: •Inhibits CNS uptake of Medications: •Anxiety serotonin •Paxil •GI upset Used for: •Prozac •Change in appetite and bowel function •Depression •Zoloft •Urinary retention •Obsessive-Compulsive Nursing Considerations: Disorder •Suicide precautions •Bulimia •Takes 4 weeks for full effect •Take in a.m. •May urine to pinkish-red or Pinkish-brown •Can be taken with meals Anti-Depressants (Tricyclics) Anti-Depressants Anti-Depressants (Tricyclics) Action: (Tricyclics) Side Effects: •Inhibits reuptake of Medications: •Sedation/Confusion neurotransmitters •Norpramin •Anticholinergics affects Used for: •Elavil •Postural Hypotension •Depression •Tofranil •Urinary retention •Sleep apnea Nursing Considerations: •Suicide precautions/2-6 weeks to work •Take at hs/Don’t abruptly halt •Avoid alcohol/OTC /Photosensitivity Insulin Insulin Insulin Insulin (Regular, Humulin R) (NPH, Humulin N) (Ultralente, Humulin U) (Humulin 70/30) Type: Fast acting Type: Intermediate acting Type: Slow acting Type: Combination Onset: ½ -1 hr Onset: 2hr Onset: 4hr Onset: ½ hr Peak: 2-4 hr Peak: 6-12hr Peak: 8-20hr Peak: 2-12hr Duration: 6-8 hr Duration 18-26hr Duration: 24-36hr Duration: 24hr Antidiabetic Agents Antidiabetic Agents Antidiabetic Agents Action: Medications: Side Effects: •Stimulates insulin release from •Diabinese • Hypoglycemia beta cells in pancreas •Orinase • Allergic skin reactions Used for: •Dymelor • GI upset •Type 2 diabetes (NIDDM) •Micronase Nursing Considerations: • Take before breakfast • Monitor glucose levels • Avoid alcohol, sulfonamides, Oral Contraceptives, (MAO), aspirin because they help to make drug work better Hypoglycemic Agent Hypoglycemic Agent Hypoglycemic Agent Action: Medication: Side Effects: • Stimulates liver to • Glucagon • Hypotension change glycogen to • Bronchospasm glucose Nursing Considerations: Used for: • May repeat in 15min • Hypoglycemia • Give carbohydrates orally to prevent secondary hypoglycemic reactions Antidiarrheals Antidiarrheals Antidiarrheals Action: Medications: Side Effects:
  • 41. • Slows peristalsis • Kaopectate • Constipation • Increases tone of • Lomotil • Anticholinergic effects sphincters • Imodium (urinary retention, dryUsed for: • Paregoric mouth) • Diarrhea Nursing Considerations: • Do not use with abdominal pain • Monitor for urinary retention • Give 2hr before or 3 hr after other medsAntiemetics Antiemetics AntiemeticsAction: Medications: Side Effects: • Increases GI motility • Tigan • Sedation • Blocks effect of • Compazine • Anticholinergic effects dopamine in • Torecan Nursing Considerations: chemoreceptor trigger • Reglan • Used before chemotherapy zone • Antivert • When used with viralUsed for: • Dramamine infections may cause Reye’s • Vomiting syndrome (Toxic Encephalopathy)Antifungals Antifungals AntifungalsAction: Medications: Side Effects: • Impairs cell • Amphotericin B • Hepatotoxicity membrane • Nystatin • ThrombocytopeniaUsed for: • Leukopenia • Candidiasis • Pruritis • Oral thrush Nursing Considerations: • Histoplasmosis • Give with food • Monitor liver function • Good oral hygieneAntigout Agents Antigout Agents Antigout AgentsAction: Medications: Side Effects: • Decreases production • Colchicine • Agranulocytosis and resorption of uric • Probenecid • GI upset acid • Zyloprim • Renal calculiUsed for: Nursing Considerations: • Gout • Monitor for renal calculi • Give with food, milk, antacidsAntihistamines Antihistamines AntihistaminesAction: Medications: Side Effects: • Block effects of • Chlor-Trimeton • Drowsiness histamine • Benadryl • Dry mouthUsed for: • Phenergan • Photosensitivity • Allergic rhinitis Nursing Considerations: • Allergic reactions to • Give with food blood • Use sunscreen • Avoid alcoholAntihyperlipidemic Agents Antihyperlipidemic Agents Antihyperlipidemic AgentsAction: Medications: Side Effects: • Inhibits cholesterol • Questran • Constipation and triglyceride • Lipid • Fat-soluble vitamin synthesis deficiencyUsed For: Nursing Considerations: • Elevated cholesterol • Take at hs or 30 min • Reduce incidence of ac cardiovascular disease • Administer 1hr before or 4-6 hr after other medsAntihypertensives Antihypertensives Antihypertensives
  • 42. Types: ACE Inhibitors (ACE Inhibitors) (ACE Inhibitors) Action: Medications: Side Effects: • Blocks ACE in lungs • Capoten • GI upset Used for: • Vasotec • Orthostatic hypotension • Hypertension • Dizziness • CHF Nursing Considerations: • Give 1hr ac or 3hr pc • Change position slowly Antihypertensives Antihypertensives Antihypertensives Type: Beta-Adrenergic Blockers Type: Beta-Adrenergic Type: Beta-Adrenergic Action: Medications; Side Effects: • Blocks Beta-Adrenergic • Nadolol • Changes in heart rate Receptors • Propranolol • Hypotension • Decrease excitability/workload • Tenormin • Bronchospasm of heart, oxygen consumption • Timoptic Nursing Considerations: • Decrease • Masks signs of shock Used for: and hypoglycemia • Hypertension • Take with meals • Angina • Do not discontinue • SVT abruptlyAntihypertensives Antihypertensives AntihypertensivesType: Calcium Channel Blockers Type: Calcium Channel Type: Calcium ChannelAction: Blockers Blockers • Inhibits movement of calcium across cell membranes Medications: Side Effects: • Slow impulse conduction and depresses myocardial • Procardia • Hypotension contractility • Calan • Dizziness • Causes dilation of coronary arteries and decreases • Cardizem • GI distress cardiac workload and energy consumption Nursing Consideration:Used for: • Monitor vital • Angina signs • Hypertension • Do not chew or • Interstitial cystitis divide sustained- release tablets Antihypertensives Antihypertensives Antihypertensives Type: Centrally acting alpha- Type: Centrally acting alpha- Type: Centrally acting alpha- adrenergics adrenergics adrenergics Action: Medications: Side Effects: • Stimulates alpha • Aldomet • Sedation receptors in medulla • Catapres • Orthostatic Hypotension which causes a Nursing Considerations: reduction in • Don’t discontinue abruptly sympathetic in the • Monitor for fluid retention heart • Change position slowly Used for: • Hypertension Antihypertensives Antihypertensives Antihypertensives Type: Direct-acting Medications Side Effects: vasodilators • Hydralazine • Tachycardia Action: • Minoxidil • Increase in body hair • Relaxes smooth Nursing Considerations: muscle • Teach patient to check Used for: pulse • Hypertension Antihypertensives Antihypertensives Antihypertensives Type: Peripheral-acting alpha-adrenergic blockers Medications: Side Effects: Action: • Reserpine • Depression • Depletes stores of norepinephrine in • Orthostatic sympathetic nerve endings Hypotension Used for: • Brachycardia • Hypertension Nursing Considerations: • Give with meals or milk • Change position slowly Bipolar Disorder Bipolar Disorder Medications: Bipolar Disorder Action: • Lithium (1-1.5meq/L) Side Effects: • Reduces • Tegretol • GI upset catecholamine release • Depakote • Tremors
  • 43. Used for: • Polydipsia • Manic episodes • Polyuria Nursing Considerations: • Monitor serum levels • Give with meals • Increase fluid intake Antineoplastic Agents Antineoplastic Antineoplastic Agents Type: Alkylating Agents Agents Side Effects: Action: Medications: • Hepatotoxicity • Interferes with rapidly • Cisplatin • Ecchymosis reproducing DNA • Myleran • Alopecia Used for: • Cytoxan • Epitaxis • Leukemia • Infertility • Multiple myeloma • Bone Marrow Suppression • Stomatitis • GI disturbances: Anorexic, N/V, diarrhea Nursing Considerations: • Check hematopoietic (reproduction of RBC’s by bone marrow) function • Force fluids • Good mouth care Antineoplastic Agents Antineoplastic Agents Antineoplastic Agents Type: Antimetabolites Antimetabolites Antimetabolites Action: Medications: Side Effects: • Inhibits DNA • 5-FU • Nausea polymerase • Methotrexate • Vomiting Used for: • Hydrea • Oral ulceration • Acute lymphatic • Bone marrow suppression leukemia • Alopecia • Cancer of colon, Nursing Considerations: breast, pancreas • Monitor hematopoietic function • Good mouth care • Discuss body image changesAntineoplastic Agents Antineoplastic Agents Antineoplastic AgentsType: Antitumor Antibiotics Antitumor Antibiotics Antitumor AntibioticsAction: Medications: Side Effects: • Interferes with DNA • Adriamycin • Bone marrow suppression and RNA synthesis • Actinomycin D • AlopeciaUsed for: • Bleomycin • Stomatitis • Cancer Nursing Considerations: • Monitor vital signs • Give antiemetic medications before therapy Antineoplastic Agents Antineoplastic Agents Antineoplastic Agents Type: Hormonal Agents Type: Hormonal Agents Type: Hormonal Agents Action: Medications: Side Effects: • Changes hormone • Diethylstilbestrol • Leukpenia input into sensitive • Tamoxifen • Bone pain cells • Testosterone • Hypercalcemia Used for: Nursing Considerations: • Cancer • Check CBC • Monitor serum calcium Antineoplastic Agents Antineoplastic Agents Antineoplastic Agents Type: Vinca Alkaloids Type: Vinca Alkaloids Type: Vinca Alkaloids Action: Medications: Side Effects: • Interferes with cell • Oncovin • Stomatitis division • Velban • Alopecia Used for: • Loss of reflexes • Cancer • Bone marrow suppression Nursing Considerations: • Give antiemetic before
  • 44. administration • Check reflexes • Given with Zyloprim to decrease uric acidAntiparkinson Agents Antiparkinson Agents Antiparkinson AgentsAction: Medications: Side Effects: • Converted to • Artane • Dizziness Dopamine • Cogentin • Ataxia • Stimulates • L-Dopa • Atropine-like effects: dry postsynaptic • Parlodel mouth, urinary retention Dopamine receptors • Sinemet Nursing Considerations:Used for: • Symmetrel • Monitor for urinary • Parkinson’s disease retention • Large doses of vitamin B6 reverse effects • Avoid use of CNS depressantsAntiplatelet Agents Antiplatelet Agents Antiplatelet AgentsAction: Medications: Side Effects: • Interferes with platelet • Aspirin • Hemorrhage aggregation • Persantine • ThrombocytopeniaUsed for: Nursing Considerations: • Venous thrombosis • Check for signs of • Pulmonary embolism bleeding • Give with food or milkAntipsychotic Agents Antipsychotic Agents Antipsychotic AgentsAction: Medications: Side Effects: • Blocks dopamine • Haldol • Akathisia (inability to receptors in basal • Thorazine sit still) ganglia • Mellaril • DyskinesiaUsed for: • Stelazine • Dystonias • Acute and Chronic • Parkinson’s syndrome psychoses • Tardive dyskinesias • Leukopenia Nursing Considerations: • Check CBC • Monitor vital signs • Avoid alcohol and caffeineAtypical Antipsychotic Atypical Antipsychotic Atypical AntipsychoticAgents Medications: Side Effects:Action: • Clozaril • Extrapyramidal effects • Interferes with binding • Risperdal • Anticholinergic of dopamine in the • Sedative brain • OrthostaticUsed for: hypotension • Acute and Chronic Nursing Considerations: psychoses • Monitor blood • Change positions slowly • Use sunscreenAntipyretic Agents Antipyretic Agents Antipyretic AgentsAction: Medications: Side Effects: • Antiprostaglandin • Tylenol • GI irritation activity in (Acetaminophen) Nursing Considerations: hypothalamus • Monitor liver functionUsed for: • Aspirin contraindicated • Fever for younger than 21 years old due to risk of Reye’s syndromeAntithyroid Agents Antithyroid Agents Antithyroid AgentsAction: Medications: Side Effects:
  • 45. • Reduce vascularity of • Tapazole • Leukopenia thyroid • SSKI • Rash • Inhibits release of • Thrombocytopenia thyroid into circulation Nursing Considerations:Used for: • Bitter taste • Hyperthyroidism • May cause burning in mouth • Give with meals • Check CBCThyroid Replacement Thyroid Replacement Thyroid ReplacementAgents Medications Side Effects:Action: • Synthroid • Nervousness • Increases metabolic • Cytomel • Tachycardia rate • Weight lossUsed for: Nursing Considerations: • Hypothyroidism • Monitor pulse and BP • Monitor weight • Take in a.m. • Enhance action of anticoagulants, antidepressants, decrease action of insulin and digitalisAntitubercular Agents Antitubercular Agents Antitubercular AgentsAction: Medications: Side Effects: • Inhibits cell and • INH • Hepatitis protein synthesis • Ethambutol • Peripheral NeuritisUsed for: • Streptomycin Nursing Considerations: • Tuberculosis • PAS • Check liver function tests • To prevent disease in • PYZ • Vitamin B6 given for peripheral person exposed to neuritis (Pyridoxine) organism • Used in combinationAntivirals Antivirals AntiviralsAction: Medications: Side Effects: • Inhibits DNA and RNA • Zovirax • Headache replication • AZT • DizzinessUsed for: • Videx • GI symptoms • Recurrent HSV • Famvir Nursing Considerations: • HIV infection • Cytovene • Encourage fluids • Not a cure, but relieves symptomsAttention Disorder Agents Attention Disorder Agents Attention Disorder AgentsAction: Medications: Side Effects: • Increases level of • Ritalin • Restlessness catecholamines • Cylert • InsomniaUsed for: • Dexedrine • Tachycardia • ADDH • Palpitations • Narcolepsy Nursing Considerations: • Monitor growth rate • Monitor liver enzymes • Give in A.M.Bronchodilators Bronchodilators BronchodilatorsAction: Medications: Side Effects: • Decreases activity of • Aminophylline • Tachcyardia phosphodiesterase • Atrovent • DysrhythmiasUsed for: • Brethine • Palpitations • COPD • Proventil • Anticholinergic effects • Preterm labor • Primatene Nursing Considerations: (Terbutaline) • Monitor BP and HR • When used with steroid inhaler, use bronchodilator first
  • 46. • May aggravate diabetesCardiac Glycosides Cardiac Cardiac GlycosidesAction: Glycosides Side Effects: • Increases force of Medication: • Bradycardia myocardial • Lanoxin • Nausea contraction, slows rate (Digoxin) • VomitingUsed for: • Visual disturbances • Left-sided CHF 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 Cholinergics Cholinergics Cholinergics Action: Medications: Side Effects: • Inhibits destruction of • Tensilon • Bronchoconstriction acetylcholine • Prostigmin • Respiratory paralysis • Stimulate • Hypotension parasympathetic nervous Nursing Considerations: system (increase bowel • Give with food or milk tone, increase bladder • Monitor vital signs, especially tone, constrict pupil) respirations Used for: • Antidote: Atropine Sulfate • Myasthenia gravis • Toxicity: excessive • Post-operative salivation, excessive • Postpartum urinary sweating, abdominal cramps, retention flushing Diuretics Diuretics Diuretics Action: Medications: Side Effects: • Inhibits reabsorption • HydroDIURIL • Dizziness of sodium and water • Diamox • Orthostatic Hypotension • Blocks effects of • Aldactone • Leukopenia aldosterone • Lasix Nursing Considerations: Used for: • Hygroton • Take with food or milk • CHF • Take in a.m. • Renal disease • Monitor fluid and electrolytes Iron: Imferon/Feosol, use straw if liquid form, no milk/antacids, take on empty stomach, tachycardia Glucocorticoids Glucocorticoids Glucocorticoids Action: Medications: Side Effects: • Stimulates formation • Solu-Cortef • Psychoses of glucose • Decadron • Depression • Alters immune • Deltasone • Hypokalemia response • Stunted growth Used for: • Buffalo Hump • Addison’s disease Nursing Considerations: • Crohn’s disease • Monitor fluid and electrolyte balance • COPD • Don’t discontinue abruptly • Leukemias • Monitor for signs of infection Mineralocorticoids Mineralocorticoids Mineralocorticoids Action: Medications: Side Effects: • Increases sodium • Florinef • Hypertension reabsorption • Edema • Potassium and • Hypokalemia hydrogen ion Nursing Considerations: secretion in kidney • Monitor BP, I&O, Weight, and Electrolytes Used for: • Give with food • Adrenal insufficiency • Low-sodium, High-protein, High-potassium diet Heavy Metal Antagonists Heavy Metal Antagonists Heavy Metal Antagonists Action: Medications: Side Effects: • Forms stable complexes • Desferal mesylate • Tachycardia with metals • BAL in Oil • Pain and induration at Used for: • EDTA injection site (conjunct with
  • 47. • Gold and arsenic Procaine in syringe) poisoning Nursing Considerations: • Acute lead • Monitor I&O and kidney encephalopathy function • Administered with local anesthetic • Seizure precautions H2 Receptor Blockers H2 Receptor Blockers H2 Receptor Blockers Action: Medications: Side Effects: • Inhibits action of • Tagamet • Dizziness histamine and gastric • Zantac • Confusion acid secretion • Hypotension Used for: • Impotence • Ulcers Nursing Considerations: • Gastroesophageal • Take with meals and reflux hs • Smoking decreases effectiveness • Monitor liver function and CBC Immunosuppressants Immunosuppressants Immunosuppressants Action: Medications: Side Effects: • Prevents production of • Sandimmune • Hepatotoxicity T cells and their • Nephrotoxicity response to • LeuKopenia interleukin-2 • Thrombocytopenia Used for: Nursing Considerations: • Prevents rejection for • Take once daily in transplanted organs a.m. • Used with adrenal corticosteroids • Monitor renal and liver function tests Miotics (Constricts Pupil) Miotics Miotics Action: Medications: Side Effects: • Causes constriction of • Isopto-Carpine • Headache sphincter muscles of • Eserine • Photophobia iris • Carbacel • Hypotension Used for: • Bronchoconstriction • Ocular surgery Nursing Considerations: • Open-angle glaucoma • Apply pressure on lacrimal sac for 1min • Avoid sunlight • May experience transient brow pain and myopia Mydriatics (Dilates Pupil) Mydriatics Mydriatics Action: Medications: Side Effects: • Anticholinergic actions • Atropine sulfate • Tachycardia leaves pupil under • Cyclogyl • Blurred vision unopposed adrenergic • Photophobia influence • Dry mouth Used for: Nursing Considerations: • Diagnostic procedures • Contraindicated with glaucoma • Acute iritis • Apply pressure on lacrimal sac • Uveitis for 1min. • Wear dark glassesNarcotics Narcotics NarcoticsAction: Medications: Side Effects: • Acts on CNS receptor • Morphine Sulfate • Dizziness cells • Codeine • SedationUsed for: • Demerol • Respiratory depression • Moderate to severe • Dilaudid • Hypotension pain • Percodan • Constipation • Preoperative Nursing Considerations:
  • 48. • Postoperative • Safety precautions • Avoid alcohol • Monitor vital signs • Use narcotic antagonist if necessary (Narcan)Antianginals Antianginals AntianginalsAction: Medications: Side Effects: • Relaxes smooth • Nitroglycerine • Hypotension muscle • Isosorbide • Tachycardia • Decreases venous • Headache return • DizzinessUsed for: Nursing Considerations: • Angina • Check expiration date • Peri-operative • Teach when to take medication hypertension • May take Q5min x3 doses • CHF • Wet with saliva and place under tongue NSAIDS NSAIDS NSAIDS Action: Medications: Side Effects: • Inhibits prostaglandin • Motrin • GI upset synthesis • Indocin • Dizziness Used for: • Naprosyn • Headache • Arthritis • Bleeding • Mild to moderate pain • Fluid retention • Fever Nursing Considerations: • Take with food or after meals • Monitor liver and renal function • Use cautiously with aspirin allergy • Check for bleedingThrombolytics Thrombolytics ThrombolyticsAction: Medications: Side Effects: • Dissolves or lyses blood clots • Streptokinase • BleedingUsed for: • Urokinase • Bradycardia • Acute Pulmonary Emboli • Tissue Plasminogen • Dysrhythmias • Thrombosis Activator Nursing Considerations: • MI • Monitor for bleeding • Contraindicated in: hemophilia, CVA, • Have Amino Caproic Acid Trauma, not used in patients over 75 Available years old, not used in patients taking • Check pulse, color, anticoagulants sensation of extremities • Monitor EKG Anaphylaxis • Symptoms o Hives o Rash o Difficulty breathing (first sign) o Diaphoresis • Nursing care o Epinephrine 0.3 ml of 1:1000 solution SQ o Massage site o May repeat in 15-20 min. Delayed Allergic Reaction • Symptoms: o Rash, Hives, Swollen Joints • Nursing Care o Discontinue medication o Topical Antihistamines o Corticosteroids o Comfort measures Bone Marrow Depression Symptoms: Fever, Chills, Sore Throat Back pain, Dark urine Anemia, Thrombocytopenia, Leukopenia
  • 49. Nursing Care: Monitor CBC Protect from infections Avoid injuryLiver impairment: light stools and dark urineRenal Impairment: decrease HematocritAnticholinergic Effects • Symptoms: o Dry mouth, Dysphagia, Nasal Congestion o Urinary retention, Impotence • Nursing Care: o Sugarless lozenges o Good mouth care o Void before taking medicationParkinson’s-like effects • Symptoms: o Akinesia (temporarily paralysis of muscles) o Tremors o Drooling o Changes in gait o Rigidity o Akathisia (Extreme restlessness) o Dyskinesia (Spasms) • Nursing Care: o Anticholinergic and Antiparkinsonian medications o Safety measures for gait How long should a client with 6-9 Months tuberculosis be on medication? Inflammation of Liver Jaundice Anorexia RUQ pain What are symptoms of hepatitis? Clay-colored stools, tea-colored urine Pruritis (bile salts eliminated through skin) Elevated ALT, AST Prolonged PT (liver involvement with clotting factor)What is the transmission of Hepatitis Fecal/OralA? Consume contaminated food or water Travelers to developing countries at risk Clients with hepatitis A should not prepare food for othersWhat is the transmission of Hepatitis Parenteral/Sexual contactB? Blood or body fluids At risk individuals are the one’s that abuse IV drugs, dialysis, healthcare workers Vaccine developedWhat is the transmission of Hepatitis Blood or body fluidsC? Can become chronic disease Seen in patients with hemophilia (unable to clot)What is the transmission of Hepa D ? Co-infects with hepatitis BWhat nursing care are recommended Rest (mainly for liver)for Hepatitis? Contact and standard precautions Low-fat, High-Calorie, and High Protein diet (needed for organ healing) No alcoholic beverages Medications (Vitamin K, Aqua-Mephyton for bleeding problems, Anti-emetic – no compazine, use Tigan or (Dramamine). Corticosteroids to decrease inflammatory response, and anti-histamines, will use lotions or baths than systemic ones.What is Lyme’s Disease? Multi-system infection caused by a tick bite. There are three stages.What is Stage 1 of Lyme’s Disease? Erythematous papule develops into lesion with clear
  • 50. center (Bull’s-eye) Regional lymphadenopathy Flu-like symptoms (fever, headache, conjunctivitis) Can develop over 1 to several monthsWhat 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 jointsWhat are some Lyme’s Disease Cover exposed areas when in wooded areasteaching? Check exposed areas for presence of ticksWhat are some Lyme’s Disease Antibiotics 3-4 weeksnursing care? Stage 1 use Doxicillin IV penicillin with later stagesWhat are the treatment, mode of Painless chancre fades after 6 weekstransmission, care, signs and Low grade feversymptoms of syphillis? Copper-colored rash on palms and soles of feet Spread by contact of mucous membranes, congent Treat with Penicillin G IM If patient has penicillin allergy, will use erythromycin for 10-15 days. After treatment, patient must be retested to make sure disease is gone.What are the treatment, mode of If female maybe asymptomatic and will be unaware oftransmission, care, signs and having disease.symptoms of gonorrhea? Males may have thick discharge from urethra. Some females from vagina. Spread mucous membranes, congenital IM Rocephin with Doxycycline PO, IM Aqueous Penicillin with PO Probenecid (used for gout, used with Penicillin because it delays the urinary excretion of it, makes it more effective) Complication: Pelvis Inflammatory Disease Most often affected with Chlamydia also, then treatment with PO TetracyclineWhat are the treatment, mode of No cure.transmission, care, signs and Painful vesicular genital lesionssymptoms of genital herpes? Problem is exacerbations/remissions Reoccurs with stress, infection, menses Spread by contact of mucous membranes, congenital Treatment: Acyclovir, sitz bath Monitor pap smears regularly because of higher incidence of cervical cancer. Emotional support of client/significant others important because of no cure. Pregnant women with active disease will have C-section.What are the treatment, mode of Men: urethritis, dysuriatransmission, care, signs and Women: thick vaginal discharge with acrid odorsymptoms of Chlamydia? Spread by mucous membranes, congenital Treatment with Tetracycline or Doxycycline PO Will cause sterility if left untreated. Important to notify sexually contacted.What are the treatment, mode of Single, small papillary lesion spreads into large cauliflowertransmission, care, signs and cluster on perineum, vagina, penis.symptoms of Venereal Warts? May itch or burn. Spread by mucous membranes, congenital Treatment: Curettage, cryotherapy with liquid nitrogen, kerotolytic agents Avoid intimate contact until lesions heal Complication: Genital Dysplasia CancerWhat is the difference between AIDS HIV Positive—presence of HIV in bloodand HIV +? AIDS—has significant defects in immune function associated with positive HIV evidenced by development of opportunistic infections Syndrome where CD4 counts are below 200What are some opportunistic P. Carinii Pneumonia: sob/dry-nonproductive coughinfections of AIDS? C. Albicans stomatitis: will have difficulty swalling and
  • 51. white exudates in back of throat C. Neoformans: debilitating form of meningitis that may suffer seizures. Cytomegalovirus (CMV): will experience lymphadenopathy and may have visual impairment and can affect any organ. Kaposi’s Sarcoma: most common malignancy experience with AIDS, small purplish brown, nonpainful, nonpuriitc palpable lesions on the body.How is AIDS transmitted? Contaminated blood or body fluids Sharing IV needles Sexual contact Transplacental: across placenta Possibly by breast milkWhat are diagnostics test associated ELISA test, if positive will be confirmed by Western Blotwith AIDS? test HIV Viral culture: Leukopenia, Thrombocytopenia, Decrease CD4 countsWhat are some nursing cares for Prevention: avoid IV drug use, precautions regardingAIDS? sexual patterns, use standard precautions Contact and standard precautions High-protein and high-calorie diet, small frequent meals rather than 3 large meals Symptomatic relief Support Don’t share toothbrush/shaversWhat are treatments, care, Prevention most important.prevention of poison control? Treat patient first, and then the poison. Recognize signs of symptoms of accidental poison: changes in appearance, behavior, substances around mouth, empty containers, vomitous.What should happen when someone Call poison control poisoned? 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 Syrup of Ipecac with small amount of water. Don’t giveinduce vomiting and what other large amount of fluid after Ipecac, will increase gastricfactors need to be implemented? emptying. Don’t use milk. Position with head lower then chest. No universal antidote.What should happen to poison control Intubated if comatosein emergency care? Run blood gases IV fluids Cardiac Monitor Gastric Lavage (NG down to flush with NS to remove rest in stomach) Activated Charcoal May use cathartics, diureticsWhat are signs and symptoms, Tinnitus, change in mental status, Increased temperature,treatments, care, prevention of hyperventilation, bleeding, nausea and vomiting.aspirin poisoning? Nursing care: induce vomiting, maintain hydration, reduce temperature (sponge baths), monitor for bleeding.What are signs and symptoms, Symptoms: nausea/vomiting, hypothermia, If notreatments, care, prevention of treatment, hepatic/liver involvement.tylenol poisoning? If liver gets involved patient may have RUQ pain, jaundice, confusion, and coagulation abnormalities. Nursing care: induce vomiting, maintain hydration, monitor liver and kidney function with labs such as AST/ALT enzymes. Tylenol (Acetaminophen) overdosage: Antidote N-acetylcysteine (Mucomyst)What are signs and symptoms, Symptoms: Irritability, decreased activity, abdominal pain,treatments, care, prevention of lead Increased ICPtoxicity? Diagnostic tests: Blood lead levels (>9micrograms =
  • 52. 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 parentsWhat are nursing care goals for Decontaminate individualHazardous wastes? Prevent spread of contamination Clean and remove contaminuated source Monitor personnel exposedWhat are nursing care for Hazardous If chemical poses threat to caregiver, decontaminatewastes? 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 Solitary play. Game is one sided. Like to play with body(0-12months) use? parts. Birth-3months: smile/squeal 3-6months: rattles/soft stuff toys 6-12 months: begin imitation, peek-a-boo, patty-cakePlay of toddlers (1-3 years) Parallel play.Play of pre-schoolers (3-6years) Associative play. Dress up/imitating play. Talking on telephone/kitchen/tool beltPlay 0f school age (6-12years) Cooperative play. Conformed/organized play.According to Erikson’s Developmental Birth-18 months.Task, explain the Infancy stage. Trust vs. Mistrust Positive outcome---trusts self Negative outcome---withdrawnAccording to Erikson’s Developmental 18months – 3 yearsTask, explain the Toddler stage. Autonomy vs. Shame and Doubt Positive outcome---exercise self-control Negative outcome---defiant and negativeAccording to Erikson’s Developmental 3-6 yearsTask, explain the Preschool stage. Initiative vs. Guilt Children develop conscience at this age. Positive Outcome---learns limits Negative Outcome---fearful, pessimisticAccording to Erikson’s Developmental 6-12yearsTask, explain the School age stage. Industry vs. Inferiority Positive---sense of confidence Negative---self doubt, inadequateAccording to Erikson’s Developmental 12-20 yearsTask, explain the Adolescence stage. Identity vs. Role diffusion Positive outcome---coherent sense of self Negative outcome---lack of identityAccording to Erikson’s Developmental 20-45 yearsTask, explain the young adult stage. Intimacy vs. Isolation Positive outcome---intimate relationships/careers formed Negative outcome---avoidance of intimacyAccording to Erikson’s Developmental 45-65 yearsTask, explain the middle adulthood Generativity vs. Stagnationstage. Positive Outcome---creative and productive Negative Outcome---self centeredAccording to Erikson’s Developmental 65+ yearsTask, explain the Late adulthood Integrity vs. Despairstage. No regrets in life or Regrets Positive outcome---seems life as meaningful Negative outcome---life lacks meaningAt what month does the head sag? 1 monthAt what month do you see closing of 2 monthsposterior fontanelle, turn from side toback, and see a social smile?What toys do you give for a 2 month Mobiles, wind up infant swings, soft clothes, and blankets.old?At what month does a child bring 3 monthsobjects to mouth and head erect?
  • 53. What toys do you give for a 4 month Rattles, cradle gym, and stuffed animalsold?Which age does birth weight double? 5 monthsAt what age does teething occur? 6 monthsWhat toys do you give for a 6 month Brightly colored, small enough to grasp, large enough forold? safety, teething toysWhat age for fears of strangers? 7 monthsWhen is fear strongest? 8 months is strongerWhich month able to play peek-a- 7 monthsboo?What toys do you give for 7-8months? Large colored, bricks, jack in the boxWhat month can a child say “DADA? 9 monthWhat month can a child crawl well? 10 monthsWhat month can a child stand erect 11 monthswith support?What happens in the 12th month of Birth weight triples.the child? Eats with fingers. Anterior Fontanelle almost close. Babinski reflex disappears. Toys: books with large pictures, push pull toys, teddy bears, a large ball, or sponge toys.Explain introduction of solid 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 Cooking utensils, Dress-up clothes, rocking horses, fingerToddlers? paints, phonographs, cd players.How do you avoid negativism during Don’t ask no/yes questions.toddler ages? Offer them choices. Make a game out of the tasks.What can a 3 year old do? Rides tricycle. Undresses without help.
  • 54. May invent imaginary friend. Vocabulary 900 words. Egocentric in thoughts/behaviors.What can a 4 year old do? Laces shoes Brushes teeth Throws overhand Uses sentences. IndependentWhat can a 5 year old do? Runs well/Dresses without help. Beginning cooperative play. Gender-specific behavior.What toys are used for preschool Playground materials, Housekeeping toys, Coloring books,(3-5)? tricycle with helmet.Which age groups has greatest Preschool age children.number of fears?What would you expect with a 6 year Self-centered, show off, rudeold? Sensitive to criticism Begins loosing temporary teeth Tends to lie.What would you expect with a 7 year Team games/sports.old? Concept of time. Playing with same sex child.What would you expect with a 8 year Seeks out friends.old? Writing replaces printing.What would you expect with a 9 year Conflicts between peer groups and parents.old? Conflicts between independence and dependence. Likes school. Able to take on job duties (housework).What toys are used for school age Construction toys, Pets, Games, Electronic games,child? reading, books, bicycles with helmets.School age potential problems Anuresis (encourage before bed time)include: Encopresis Head liceWhat are symptoms/indications of a Thin upper lip, vertical ridge in upper lip, short up turnedfetal alcohol syndrome in a child? nose, mental retardation, motor retardation, hearing disorders, microcephaly. Avoid alcohol 3 months before conception and throughout pregnancy.What happens with amniocentesis? 16th week detects genetic abnormalityWhat does it do? 30th week detects L/S ratio: lung maturity Void before procedure Ultrasound given to determine position of placenta and fetus. Complications: premature labor, infection, Rh isommunization (if client Rh negative, will be given Rhogam)What happens with an ultrasound? 5th week confirms pregnancy Determines position of fetus, placenta, and # of fetuses. Client must drink a lot of fluid before procedure for full bladder to have a clear image.What happens with a non-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 Determines placenta’s response to labor.stress test? Done after 28th week. Fowler/Semi-Fowler. Given Oxytocin or Pitocin. Results: • Positive: Late decelerations indicates potential risk to fetus. • Negative: No late decelerations.What does Torch stand for? And their Diseases that cross placenta or other events. Produceimportance? 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.
  • 55. Herpes Simplex: Ascending infection. During pregnancy get treated with acyclovir. Delivery through c-section.What concerns for clients that have UTI: may lead to pylonephritis, increase risk of prematureUTI, Syphilis, Gonorrhea? birth. Syphillis: passes through placenta, causes 2nd trimester abortions, still birth, and congenital infection, may receive medication for her and her baby. Gonorrhea: baby gets prophylactic eydrops.What are the danger signs of • Gush or fluid bleeding from vaginapregnancy? • 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 Lightening: (when baby drops to pelvis)labor? • Primipara: occurs 2 weeks before delivery • Multipara: occurs during labor Softening of cervix Expulsion of mucus plug (bloody show) – pink tinged mucus secretion Uterine contractions: regular/progressive not Braxton- Hick’s type.How does prolapsed umbilical cords Premature rupture of membranes.happen? Presenting part not engaged. Fetal distress. Protruding cord.What do you do when a client has a Call for help.prolapsed cord? Push up against presenting part off of the cord. Place in trendenlenberg position or knee chest position. Successful if FHT left unchanged.What is a early/sign of fetal hypoxia? Early sign: fetal tachycardia >160 in >10minutes Late sign: fetal bradycardia <110 in > 10 minutesWhat things should you know about Nurse can witness patient sign form.the Informed Consent form? Patient has to be age of capacity/adult and confident. No confused patient/drinking/already received preoperative medications. Consent must be given voluntarily and information understandable. Nurse must make sure questions are answered and form is attached to chart.What is early deceleration? Decrease in HR before peak of contraction. Indication of head compression.What are interventions for late Position mother left side/trendenlenberg/knee chestdecelerations? Increase rate of IV Administer Oxygen 7-10 l/min DC OxytocinWhat do variable decelerations Cord compression.indicate? Change maternal position. Administer oxygen. DC Oyxtocin/PitocinWhat are signs of “True Labor”? Regular contractions increasing in frequency, duration, intensity Discomfort radiates from back Contractions do not decrease with rest Cervix progressively effaced and dilated.What are characteristics of a “False Irregular contractions, no change in frequency, duration,Labor”? intesityDiscomfort is abdominal Contractions decrease with rest or activity No cervical changesPrior to Lumbar Epidural block what Voidshould the patient do?What should be implemented during Establish airwaythe delivery of a newborn? Check Apgar at 1 and 5 minutes Clamp umbilical cord Maintain Warmth Place ID band on mother and infantWhat are the types of Lochia? Rubra-bloody, day 1-3 Serosa-pink-brown, day 4-9 Alba-yellow-white, 10+ daysIf fundus is displaced not centrally Bladder distended.
  • 56. and off to the sides means?If client soaks pad in 15 minutes or Check for hemorrhagepooling of blood?What are assessments and Unilateral lower quadrant pain.implementations for an “Ectopic Rigid, tender abdomenPregnancy”? Low Hct and hCG levels Bleeding Monitor for shock Administer RhoGAM Provide supportWhat are assessments and A placenta that’s implanted in the lower uterine segmentimplementations for “Placenta near cervical os, during pregnancy placenta is torn awayPrevia”? causing: First and second trimester spotting Third and trimester painless, profuse bleeding Bedrest side-lying or trendelenburg position, ultrasound to locate placenta, no vaginal or rectal exams, amniocentesis for lung maturity, daily Hgb, Hct, Monitor bleedingWhat are the assessments and The premature separation of a placenta that is implantedimplementation for “Abruptio in a correct position.Placentae”? Painful vaginal bleeding Abdomen tender, painful, tense Possible fetal distress/Contractions Monitor for maternal and fetal distress Prepare for immediate delivery Monitor for complications: DIC, pulmonary emboliWhat are assessments and Hyperglycemia after 20 weeksimplementations for Gestational Usually controlled by dietDiabetes Mellitus (GDM)? Oral hypoglycemic medications contraindicated Test for diabetes at 24-28 weeks on all women with average risk 20. Frequent monitoring of mother/fetus during pregnancy. Teach to eat prescribed amount of food daily at same times Home glucose monitoring Teach about change in insulin requirementsWhat are assessments and Elevated hCGimplementation for a Hydatidiform Uterine size larger than expected for datesMole? No FHT Minimal dark red/brown vaginal bleeding with grape like clusters Nausea and vomiting Associated with PIH Curettage to remove tissue Pregnancy discouraged for 1 year Do not use IUD hCG levels monitored for 1 yearWhat are the newborn vital signs? Temp. 97.7-99.7 HR sleep 100, awake 120-140, 180 crying Resp 30-60 BP arm/calf 65/41What are assessments and Caused by immature hepatic functionimplementation for Physiological Jaundice (No treatment required)Hyperbilirubinemia? • Seen after 24 hours • Peaks at 72 hours • Lasts 5-7 days Breast-Feeding Associated Jaundice (Frequent breast feeding) • Caused by poor milk intake • Onset 2-3 days • Peaks 2-3 days Breast Milk Jaundice (discontinue breast feeding for 24 hours) • Caused by factor in breast milk • Onset 4-5 days • Peak 10-15 days Hemolytic Disease (Phototherapy then exchange transfusion) Caused by blood antigen incompatibility (Rh or ABO incompatibility) Onset first 24 hours
  • 57. Peak variableWhat are assessments and Assessmentsimplementations for a Narcotic- • High-pitched cry (Hallmark sign)Addicted infant? • Hyperreflexia • Decreased sleep • Tachypnea (>60/min) • Frequent sneezing and yawning • Seen at 12-24 hours of age, up to 7-10 days Implementation • Reduce environmental stimuli • Administer Phenobarbital, chlorpromazine, diazepam, paregoric • Wrap snugly, rock, and hold tightly • Assess muscle tone, irritability, vital signs.What are the assessments and Sudden-onset feverimplementations of Toxic Shock Vomiting, diarrheaSyndrome? Hypotension Erythematous rash on palms and soles Administer antibiotics Educate about use of tampons (change tampon Q3-Q6 hours)What are contraindications to Immunization is a primary preventionImmunizations? Severe febrile illness Altered immune system Previous allergic response Recently acquired passive immunityWhat are assessments and Assessmentimplementations for a “Latex Urticaria, rashAllergy”? Wheezing, Rhinitis, Conjunctivitis, Bronchospasms Anaphylactic shock Implementation Screen for sensitivity Avoid latex products: gloves, catheters, brown ace bandages, band aid dressing, elastic pressure stockings, balloons, condomsWhat are implementations for Croup Steamy showersyndromes at home? Exposure to cold air Cool, humidified airUniversal Donor Blood: Packed red blood cells (help oxygen deliver to tissue, if you use whole blood therewill be a risk for fluid overload), type O, Rh-negative5% Sodium Bicarbonate—metabolic alkalosis solutionOlder 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 7-10WBC after pregnancy?Ampicillin decreases oral contraceptives efficiency.Tricuspid area: 5th intercostals space in the left sternum areaTracheostomy care: no powder, suction trachea first then mouth, use pre-cut gauze.Hip-Flexion: causes increased intra-abdominal/thoracic pressure.Injury C3 and above need respiratory ventilation.SIADH causes: lung cancer, Cisplatin (Platinol)Chest Tubes • Fill water-seal chamber with sterile water to 2 cm (middle chamber)
  • 58. • Fill suction control chamber with sterile water to 20 cm (chamber all the way to the right) • Air-leak if bubbling in water-seal chamber (middle chamber) • Obstruction: “milk” tube in direction of drainage • Removal o chest tube: pt. does valsalva maneuver, clamp chest tube, remove quickly, apply occlusive dressing • Dislodged: apply tented dressing • Tube becomes disconnected from drainage system, cut off contaminated tip, insert sterile connector and reinsert • Tube becomes disconnected from drainage system, immerse in 2cm of waterJackson-prat: Notify physician if drainage increases or becomes bright redPenrose: Expect drainage on dressingTracheostomy Tube Cuff • Prevents aspiration of fluids/separates upper and lower airways • Inflated during continuous mechanical ventilation • Inflated during and after eating • Inflated during and 1 hour after tube feeding • Inflated when patient cannot handle oral secretions • NCLEX-RN exam is a “here and now” test; take care of problem now to prevent harm to client. • Do not ask “why” on the licensure exam • Morphine Sulfate for pancreatitis causes spasms of the sphincter of Oddi; Meperidine is drug of choice. • Normal Intraocular Pressure is 10-21 mm Hg • Ecchymosis (faint discoloration) around the umbilicus or in either flank indicates retroperitoneal bleedingThe parenteral form of Chlorpheniramine Maleate is use to relieve symptoms of anaphylaxis allergic reactionsto blood or plasma.Herbs: Toxicities and Drug InteractionsChamomileUses: 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 includeabdominal cramps, tongue thickness, tightness in the throat, swelling of the lips, throat and eyes, itching allover the body, hives, and blockage of the breathing passages. Close monitoring is recommended for patientswho are taking medications to prevent blood clotting (anticoagulants) such as warfarin.EchinaceaUses: Largely because white blood cells in the laboratory can be stimulated to eat particles, Echinacea hasbeen touted to be able to boost the bodys ability to fight off infection.Reactions: The most common side effect is an unpleasant taste. Echinacea can cause liver toxicity. It shouldbe avoided in combination with other medications that can affect the liver (such as ketaconazole, leflunomide(Arava), methotrexate (Rheumatrex), isoniazide (Nizoral).St. Johns WortUses: St. Johns Wort is popularly used as an herbal treatment for depression, anxiety, and sleep disorders. Itis technically known as Hypericum perforatum. Chemically, it is composed of at least 10 different substancesthat may produce its effects. The ratios of these different substances varies from plant to plant (andmanufacturer). 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 isrecommended that fair- skinned persons be particularly careful while in the sun. St. Johns wort may alsoleave nerve changes in sunburned areas. This herb should be avoided in combination with other medicationsthat can affect sun sensitivity (such as tetracycline/Achromycin, sulfa- containing medications, piroxicam(Feldend). St. Johns wort can also cause headaches, dizziness, sweating, and agitation when used incombination with serotonin reuptake inhibitor medications such as fluoxetine (Prozac) and paroxetine (Paxil).GarlicUses: 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 anotorious accompaniment. Studies in rats have shown decreases in male rats ability to make sperm cells.
  • 59. Garlic may decrease normal blood clotting and should be used with caution in patients taking medications toprevent blood clotting (anticoagulants) such as warfarin /Coumadin.FeverfewUses: 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" featuressymptoms including headaches, nervousness, stiffness, joint pain, tiredness, and nervousness. Feverfew canimpair the action of the normal blood clotting element (platelets). It should be avoided in patients takingmedications to prevent blood clotting (anticoagulants) such as warfarin (Coumadin).Ginko BilobaUses: This herb is very popular as a treatment for dementia (a progressive brain dysfunction) and to improvethinking.Reactions: Mild stomach upset and headache have been reported. Ginko seems to have blood thinningproperties. 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 aswarfarin (Coumadin). Ginko should be avoided in patients with epilepsy taking seizure medicines, such asphenytoin (Dilantin), carbamazepine (Tegretol), and phenobarbital.GinsengUses: Ginseng has been used to stimulate the adrenal gland, and thereby increase energy. It also may havesome beneficial effect on reducing blood sugar .in patients with diabetes mellitus. (Dr. Miller emphasized thatthere 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 mayaffect female hormones. Its use in pregnancy is not recommended. Ginseng may affect the action of thenormal blood clotting element (platelets). It should be avoided in patients taking aspirin, nonsteroidalantiinflammatory drugs (such as ibuprofen (Advil), naproxen (Aleve) or Motrin), or medications to preventblood 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.GingerUses: 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 thatprevent blood clotting (anticoagulants) such as warfarin (Coumadin).Saw PalmettoUses: Saw palmetto has been most commonly used for enlargement of the prostate gland. (Dr. Milleremphasized that studies verifying this assertion are necessary.) Saw palmetto has also been touted as adiuretic and urinary antiseptic to prevent bladder infections.Reactions: This herb may affect the action of the sex hormone testosterone, thereby reducing sexual drive orperformance. Dr. Miller states that "While no drug-herb interactions have been documented to date, it wouldbe prudent to avoid concomitant use with other hormonal therapies (e.g., estrogen replacement therapy andoral contraceptives...")Black CohoshClaims, 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 preparedpuddings, 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 highglucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretesincreased levels of insulin in response to this increases glucose amount that crosses the placenta from themother. However, during the first 24 hours of life, this combination of high insulin production in the newborncoupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings withformula can prevent hypoglycemia
  • 60. Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venousreturn 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 hasan 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, andperspiration.The tip of the endotracheal tube lies 1 cm above the carina. This is positioned above the bifurcation ofthe 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 BRAINALKYLATING 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 PHASEBell’s Palsy: is a one-sided facial paralysis from compression of the facial nerve. The exact cause isunknown. Possible causes include vascular ischemia, infection, exposure to viruses such as herpes zoster orherpes 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 onthe left side may prevent air from flowing into the pulmonary veins. The trendelenburg position increasesintrathoracic pressure, which decreases the amount of blood pulled into the vena cava during inspiration.Trigeminal neuralgia pain medication: Use Carbamazepine (Tegretol) and Phenytoin (Dilantin). Narcoticanalgesics (Meperidine Hydrochloride [Demerol], Codeine Sulfate , and Oxycodone) are not effective incontrolling 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) intoxicationPhenotolamine (Regitine): antidote for hypertensive crisisBromocriptine (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 fiveparameters contributes 0 to 2 points with a score of 8 being considered normal and a score of 10 perfect. G T P A LGravidity, the Term births, the Preterm births, Abortions/miscarriages Live births, thenumber of number born at the number born number of livepregnancies. term (40 weeks). before 40 weeks’ • Included in births or living
  • 61. gestation. children gravida if before 20 weeks’ gestation • Included in parity if past 20 weeks’ gestationTherefore a woman who is pregnant with twins and has a child has a gravida of 2. Because the childwas delivered at 38 weeks, the number of preterm births is 1, and the number of term births is 0. Thenumber 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 gonadotropinPositive 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 ultrasoundAcetazolamide (Diamox): used for management of glaucoma is a carbonic anyhdrase inhibitor that hassulfonamide 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 complexHypokalemia on Electrocardiogram: ST segment depression; Flat T waveFirst-Degree Heart Block: Prolonged P-R intervalBundle Branch Block: Widened QRS complexMyocardial Necrosis in Area: Q waves presentVentricular Fibrillation: No visible P waves or QRS complexes, no measurable rate.Irregular, chaotic undulations of varying amplitudes.HypoCalcemia: Prolonged Q-T intervalMyocardial Ischemia: ST segment elevation or depressionPremature Ventricular Contractions: absence of P waves, wide and bizarre QRScomplexes, and premature beats followed by a compensatory pauseVentricular Tachycardia: absence of P waves, wide QRS complexes, rate between 100 and250 impulses per minute. Regular rhythm
  • 62. Atrial Fibrillation: no P waves; instead there are wavy lines, no PR interval. QRS duration isWNL and irregular ventricular rate can range from 60-160 beats/minute. ANGINA Stable Unstable Variant IntractableTriggered by a Triggered by an Triggered by coronary Chronic andpredictable amount of unpredictable amount artery spasm; the incapacitating and iseffort or emotion. of exertion or emotion attacks tend to occur refractory to medical and may occur at early in the day and at therapy. night; the attacks rest. increase in number, duration, and severity over time.Cardiac Conduction System: Sinoatrial NodeInternodal/Interatrial pathwaysAV nodeBundleof HisR/L Bundle BranchesPurkinje fibersPulse rate is the earliest indicator of decrease in fluid volume.A1-adrenergic receptors: found in the peripheral arteries and veins and cause a powerful vasoconstrictionwhen stimulatedA2-adrenergic receptors: several tissues and contract smooth muscle, inhibit lipolysis, and promote plateletaggregation.B1: Found in the heart and cause an increase in heart rate, atrioventricular node conduction, andcontractility.B2: Arterial and bronchial walls and cause vasodilation and bronchodilation.PULSE PRESENT = NO DEFIBRILLATIONMyxedema (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 playToddlerhood (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 chalkboardPreschool 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 toolsSchool age (six years to 12 years)Play is cooperative. 1. sports and games with rules 2. fantasy play in early years 3. clubs 4. hero worship 5. cheating
  • 63. 6. Suggested toys/activities: board or computer games, books, collections, scrapbooks, sewing, cooking, carpentry, gardening, paintingTympany: Drumlike, loud, high pitch, moderate duration; usually found over spaces containing air such asthe stomachResonance:Hollow sound of moderate to loud intensity; low pitch, long duration; Usually heard over lungsHyperresonance: Booming sound of very loud intensity; very low pitch, long duration; Usually heard in thepresence of trapped air (such as emphysematous lung)Flatness:Flat sound of soft intensity; high pitch; short duration; Usually heard over muscleDullness: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. Johns wort - antidepressantGarlic - antihypertensiveGinseng - Anti stressGreen tea - antioxidantEchinacea - immune stimulant (6-8 weeks only)Licorice - cough and coldGinger root - antinauseaGinkgo - improves circulationMa huang - bronchodilator, stimulantAnatomical Landmarks of the HEART i. second right intercostal space - aortic area ii. second left intercostal space - pulmonic area iii. third left intercostal space - Erbs point iv. fourth left intercostal space - tricuspid area v. fifth left intercostal space - mitral (apical) area vi. epigastric area at tip of sternumRange of Normal Blood Pressure i. child under age two weighing at least 2700g: use flush technique,30-60mg Hg ii. child over age two: 85-95/50-65 mm Hg iii. school age: 100-110/50-65 mm Hg iv. adolescent: 110-120/65-85 mm Hg v. adult: <130 mm Hg Systolic / <85 mm Hg diastolicNormal 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/minuteNormal 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
  • 64. CRANIAL NERVE FUNCTION1. Olfactory (CN I) • Can identify variety of smells • Deviation: Inability to identify aroma2. 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 eyes3, 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 position5. 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 eyelids7. 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 symmetrically8. 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 word9, 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 tongue11. Spinal accessory (CN XI) • Resists head turning • Can shrug against resistance • Deviation: Weak or absent shoulder and neck movement12. Hypoglossal (CN XII)
  • 65. • Can stick tongue out and move it from side to side • Can push tongue strongly against resistance • Deviation: Tongue deviates to sideTypes 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 1960s. 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 childs diabetes. 10. Introjection - incorporating the traits of others o Example: Husbands symptoms mimic wifes before she died. 11. Projection - unconsciously projecting ones own unacceptable qualities or feelings onto others o Example: Woman who is jealous of another womans wealth accuses her of being a gold- digger. 12. Rationalization - justifying behaviors, emotions, motives, considered intolerable through acceptable excuses o Example: "I didnt 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
  • 66. b. Positive adaptive response - crying, social withdrawal c. Maladaptive responses - self-destructive actions, despair 5. Acceptance a. Resolution of feelings about death or other loss, resulting in peaceful feelings b. Positive adaptive behaviors - may wish to be alone, limit social contacts, complete personal business FOODS HIGH IN WATER-SOLUBLE VITAMINS A. Vitamin C - citrus fruits, cabbage, tomatoes, strawberries, broccoli B. Thiamine (B1) - lean meat, legumes,unrefined or enriched grains and cereals C. Riboflavin (B2) - enriched grains, milk, organ meats, poultry, fish D. Niacin - peanuts, peas, beans, meat, poultry E. Pyridoxine (B6) - kidneys, liver, meats, corn, wheat, eggs, poultry, fish F. Cyanocobalamin (B12) - kidneys, lean meats,liver, dairy products, egs G. Folic acid - liver, eggs, leafy green vegetables, fruits, enriched grain products FOODS CONTAINING FAT-SOLUBLE VITAMINS A. Vitamin A - fruits, green and yellow vegetables, butter, milk, eggs, liver B. Vitamin D - milk, fish C. Vitamin E - green vegetables, vegetables oils, wheat germ, nuts D. Vitamin K - liver, cheese, leafy green vegetables, milk, green teamucomyst: acetaminophen toxicityDilantin detoxified by liver.The nurse cares for a client receiving IV antibiotics every 8 hours for the past 4 days. The antibiotic is mixedin D5W. The nurse determines that a post-infusion phlebitis has occurred if which of the following isobserved? 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 phlebitisEthacrynic Acid (Edecrin)—are considered loop diuretics and are potassium wasting; encourage clientto 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 peripheralresistance. In other words, decreases preload and afterload pressures and cardiac workload; causesvasodilation and pooling of fluid in extremities; provides relief from anxiety.Intropin (Dopamine)—vasoactive medication are given IV to restore BP in hypotensive states; Increasesblood return to the right side of the heart, and increase peripheral resistance; side effects: headache, severehypertension, dysrhythmias; check BP q2 minutes until stabilized, then q5 minutesTPN—hang no longer than 24 hours; IV tubing and filters every 24 hours; site of catheter changed every 4weeks.Fluoxetine (Prozac)—a selective serotonin reuptake inhibitor (SSRI) used to treat depression and obsessivecompulsive 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. Donot give to asthmatic patients.Glipizide (Glucotrol)—an oral hypoglycemic that decreases blood sugar by stimulating insulin release fromthe beta cells of the pancreas; may cause aplastic anemia and photosensitivity.
  • 67. Prednisone (Deltasone)—a corticosteroid. Side effects: hyperglycemiaBethanechol (Urecholine)—a cholinergic or parasympathomimetic used to treat functional urinaryretention; mimics action of acetylcholine.Ventricular Tachycardia—causes chest pain, dizziness, and fainting.1 grain = 60mgLevothyroxine (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 theemptying of the stomach.Isoniazid (INH)—Side effects: peripheral neuropathy (administer pyridoxine), rash, urticaria, and swellingof 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 ofneuropathy.Carbamazepine (Tegretol)—prevention of seizures and relief of pain in trigeminal neuralgia. Trigeminalneuralgia (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 microwavesresults 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, anddiscomfort.Autologous blood—may give blood 5 weeks before surgery; can give 2 to 4 units of blood; may have totake iron pillsPartial-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; healingoccurs 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 iscalled eschar, dry to touch, doesn’t heal spontaneously, requires grafting. I.E., Charred, waxy, whiteappearance of skin on left leg.Superficial burn; skin appears pink, increased sensitivity to heat, some swelling, healing occurs withouttreatment. I.E., Reddened blotchy painful areas noted on the face.Carbidopa/Levodopa (Sinemet)—used to treat symptoms of Parkinson’s disease. Take immediatelybefore meals and high-protein meals may impair effectiveness of medication. Reduces rigidity andbradykinesis and facilitates client’s mobility.Doxycycline (Vibramycin)—a tetracycline that is taken at regular intervals but not within 1 hour ofbedtime because it may cause esophageal irritation. Use another method of birth control, do not takeantacids within 1-3 hours of taking medication, and may cause photosensitivity.Albuterol (Proventil)—a bronchodilator. Side effects: tremors, headache, hyperactivity, tachycardia. Usefirst before steroid medication so opens up bronchioles for steroid to get in. Wait one minute between puffsof the inhalers for best effect.Beclomethasone (Vanceril)—a steroid medication. Side effect: fungal infections, dry mouth, throatinfections.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 kidneystones. Side effects: orthostatic hypotension, ocular symptoms, blindness, and decrease effects of hormonalcontraceptives.
  • 68. Propranolol (Inderal)—a beta-blocker that takes up beta-adrenergic receptor sites, which preventsadrenaline 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 anestheticeffects. Side effects: bright orange urine, yellowish discoloration of skin or sclera indicates drugaccumulation 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 changein BP, bradycardia, respiratory depression.Infant normal resting heart rate: 120-140Salt substitutes contain potassiumWhen directing a UAP, the nurse must communicate clearly about each delegated task with specificinstructions on what must be reported. Because the RN is responsible for all care-related decisions, onlyimplementation 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 vascularimpairment 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 acontraindication to the use of neuroleptics.Children with celiac disease should eat a gluten free diet. Gluten is found mainly in grains of wheat and ryeand in smaller quantities in barley and oats. Corn, rice, soybeans and potatoes are digestible in persons withceliac disease.The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk becauseDecadron 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 hospitalizedchild). In toddlers, ages 1 to 3, separation anxiety is at its peakSigns 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 ToxicitySigns/Symptoms of Digital Toxicity: first signs include abdominal pain, anorexia, nausea, vomiting, visualdisturbances, bradycardia, and other arrhythmias. In infants and small children, the first symptoms ofoverdose are usually cardiac arrhythmias.Restlessness, confusion, irritability and disorientation may be the first signs of fat embolism syndromefollowed by a very high temperature.A Neologism is a new word self invented by a person and not readily understood by another that is oftenassociated with a thought disorder.Pancreatic enzymes give before meals.Clinical features of delusional disorder include extreme suspiciousness, jealousy, distrust, and belief thatothers 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 thenurse 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.
  • 69. Restraint: frame of bed, quick release ties, document need for restraint Q4 hoursNever ask “WHY” questions in the NCLEX!Gag Reflex: don’t assess gag reflex to a client that has an absent swallow reflexNifedipine (Procardia XL): do not crushAn RN that is not assigned to a patient does not have the authority to tell a nurse what to do. Refer it tonursing 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 onmechanical ventilations after surgery; chest tubesAcromegaly—monitor blood sugar, atrium—90 implant care (radioactive, nasally implanted, monitor vision)Bone marrow Aspiration---done at iliac crest; painfulPostoperative care after Supratentorial surgery: maintain airway, elevate head 30-45Position care after Infratentorial surgery: flat and lateralOrange 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 tractionBuck’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 legCervical Tongs  Never lift the weights  No pillow under head during feedingsBalanced Suspension Traction  For femur realignment  Maintain weights hanging free and not on floor  Maintain continuous pullHalo Jacket  Maintain pin cleansingCasts  Don’t rest on hard surface  Don’t cover until dry 48+ hours
  • 70.  Handle with palms of hands not with fingers  Keep above level of heart  Check for CSMFractured 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 degreesAmputations • 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-BeriPyridoxine (Vit. B6)—amino acid metabolism; deficiency will cause anemia, seizuresFolic acid—RBC formation; deficiency will cause anemiaCyanocobalamin (B12)—nerve function; deficiency cause pernicious anemiaCalcium deficiency causes Rickett’sCultural 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 mealEnteral 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/dayCrede’s Manuever—push urine outPernicious Anemia - monthly Vitamin B12 IM injections
  • 71. 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 supportOrgan 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 paralysisNormal 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.LabsHbA1c (4.5-7.6%) - indicates overall glucose control for the previous 120 daysSerum Amylase / Somogyl (60-160 u/dL) - elevated in acute pancreatitisErythrocyte Sedimentation Rate (ESR) - Men (1-15) - Women (1-20) - Rate at which RBC’s settle out of unclottted blood in one hour - Indicates inflammation/neurosisHematocrit (Hct) - Men (40-45) u/mL - Women (37-45) u/mL - Relative volume of plasma to RBC - Increased with dehydration - Decreased with volume excessCreatine Kinase (CK) - Men (12-70) - Women (10-55) - Enzyme specific to brain, myocardium, and skeletal muscles - Indicates tissue necrosis or injury
  • 72. Serum Glucose - 60-110 mg/dLSodium (Na+) - 135-145 mEq/L - Hypernatremia o Dehydration and insufficient water intakeChloride (Cl-) - 95-105 mEq/LPotassium (K+) - 3.5-5.0 mEq/LBicarbonate (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, dehydrationCreatinine 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 medicationsPick 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 medicationThiamine 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 glaucomaMyopia—nearsightedness (near clear, distance clear)Hyperopia—farsightedness (distance is clear, near vision blurry)Presbyopia—changes with agingBlind client: address by name, introduce self, keep furniture arrangement consistent, open or close doorswalk 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.
  • 73. Sick day rules: take insulin as ordered, check blood glucose q3-4 hours, soft foods, liquidsPhenylketonuria—high blood phenylalanine (no enzyme), results in mental retardation; milk substitutes, low-protein dietCeliac Disease (SPrue)—intestinal malabsorption, malnutrition (unable to digest wheat/rye/oats/barley);gluten-free dietHepatobiliary disease—decrease in ability of bile to absorb fat, fat malabsorption; low-fat high-protein diet,vitaminsCystic fibrosis—absence of pancreatic enzymes, malabsorption of fat, lung disease, pancreatic enzymereplacement, high-protein, high-calorie diet, respiratory care/suctionPosition right side to promote gastric emptying.Dumping syndrome prevention: restrict fluid with meals, lie down after eating, small, frequent meals, low-carbohydrate, low-fiber dietSengstaken-Blakemore Tube—to treat pt. with esophageal varices.Hepatitis B Vaccine MMR (Mumps, Measles, and Rubella)Given IM to vastus lateralis or deltoid Given SC anterior or lateral thighSide effects: mild tenderness at site Side effects: rash, fever, arthritis in 10 days to • 1st shot – Birth to 3 months 2 weeks. • 2nd shot – 1 to 4 months • 1st shot – 12 to 18 months • 3rd shot – 6 to 18 months • 2nd shot – 4 to 6 yearsDTaP (Diptheria, Tetanus, and Pertussis) Varicella (Chickenpox)Given IM anterior or lateral thigh • 12 to 18 monthsSide effects: fever within 24-48 hours, swelling,redness, soreness PCV (Pneumococcal)Don’t treat with aspirin, use other antipyretic. • 1st shot – 2 months • 1st shot – 2 months • 2nd shot – 4 months • 2nd shot – 4 months • 3rd shot – 6 months • 3rd shot – 6 months • 4th shot – 12 to 18 months • 4th shot – 15 to 18 months • 5th shot – 4 to 6 years TB Given intradermal • Only TD shot – 11 to 16 years Evaluated in 48 to 72 hours TDHib (Influenza) Given IM into anterior or lateral thigh • 1st shot – 2months Repeated every 10 years • 2nd shot – 4months • 3rd shot – 6 months Live attenuated Rubella • 4th shot – 12 to 18 months Given once SC into anterior or lateral thigh Given to antibody-negative womenIPV (Inactive Polio Vaccine) Prevent pregnancy for 3 months after receivingGiven PO, Few side effects immunization • 1st shot – 2 months Live attenuated mumps • 2nd shot – 4 months Given once SC • 3rd shot – 6 to 18 months Prevents orchitis • 4th shot – 4 to 6 yearsNormal Vital Signs
  • 74. 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: 90/60-140/90Aortic Valve: Right of Sternum at the 2nd intercostal spacePulmonic Valve: Left of Sternum at the 2nd intercostal spaceTricuspid Valve: Immediately left of sternal border at the 5th Intercostal SpaceMitral Valve (Point of Maximal Impulse): Left of Sternum Mid-Clavicular Line at the 5th Intercostal SpaceErbb’s Point: Left of Sternum at the 3rd intercostal spaceInfant (Point of Maximal Impulse): Lateral to sternum 4th intercostals spaceObese person choking use Chest Thrusts.Tracheostomy tube placement of cuff maintained to prevent aspirationCare for patient first, equipment secondSigns for hypoxia: restlessness, tachycardiaCPR: Shake, shout, summon help, open airway, look, listen, feel for signs of breathing, pinch nose, give 2 fullbreaths (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 inch15:2 Adult 4 cycles Infant 20 cyclesReassess pulse and breathingContinue CPR until: • Victim responds • Someone else takes over • Victim is transferred • Rescuer is unable to continueMI Implementation for MI • Chest pain radiating to arms, jaw, neck (which is unrelieved by rest or • Thrombolytic therapy-streptokinase, t- nitroglycerin) PA • Dyspnea • Bedrest • Indigestion • Beta-blockers, morphine sulfate, • Apprehension dysrhythmics, anticoagulants • Low grade fever • Do not force fluids (will give heart • Elevated WBC (5-10, ESR, CK-MB, more to work with) LDH)Defibrillation • Start CPR first
  • 75. • 1st attempt – 200 joules • 2nd attempt – 200 to 300 joules • 3rd attempt – 360 joules • Check monitor between shocks for rhythmCardioversion • Elective procedure, Informed Consent • Valium IV • Synchronizer on • 25-360 joules • Check monitor between rhythmEpidural hematoma – short period of unconsciousness, ipsilateral papillary dilation, contralateral weakness ofextremitiesSubdural hematoma – decreased LOC, ipsilateral papillary dilation, contralateral weakness of extremities,personality changesCSF leakage – good place to look is behind the ears.Head Injury – elevate bed 30 degrees, barbiturate therapy, hypothermia, glucocorticoids (Decadron)Flail Chest Sucking Chest Wound Pneumothorax ImplementationAffected side (Sucking Open Collapse of lung due to Monitor for shockgoes down Pneumothorax) alteration of air in intrapleural Humidifiedduring • Sucking sound with space oxygeninspiration and respiration • Dyspnea Thoracentesisup during • Pain • Pleuritic pain (aspiration of fluidexpiration • Decreased breath • Restricted movement from pleural sounds on affected side space) • Anxiety • Decreased/absent Chest Tubes breath sounds • Cough • HypotensionCullen’s Sign – ecchymosis around umbilicusTurner’s Sign – ecchymosis around either flankBalance’s sign – resonance over spleen (+) means rupture of spleenShock Signs and Symptoms • Cool, clammy skin • Cyanosis • Decreased alertness • Tachycardia • Hypotension • Shallow, rapid respirations • OliguriaHypovolemic Cardiogenic DistributiveDecreased in intravascular Decreased cardiac output Problem with blood flow to cellsvolumeImplementation for shock • Monitor CVP: <3 inadequate fluid >11 too much fluidIncreased ICP ImplementationsAssessments • Monitor vital signs • Altered LOC (Earliest Sign) • Monitor Glasgow Coma Scale • Glasgow coma scale <7 indicates coma • Elevate head 30-45 degrees • Confusion • Avoid neck flexion and head rotation • Restlessness • Reduce environmental stimuli • Pupillary changes • Prevent Valsalva maneuver • Vital sign changes – WIDENING PULSE • Restrict fluids to 1200-1500 cc/day PRESSURE • Medications – Osmotic diuretics, corticosteroidsSeizures:  do not restrain  do not insert anything in mouth
  • 76. Electrolytes Potassium: 3.5-5.0 mEq/L Sodium: 135-145 mEq/L Calcium: 4.5-5.2 mEq/L Magnesium: 1.5-2.5 mEq/LHypokalemia Assessments Hypokalemia Implementations • K+ < 3.5 mEq/L • Potassium Supplements • Muscle weakness • Don’t give > 40 mEq/L into peripheral IV or • Paresthesias without cardiac monitor • Dysrhythmias • Increase dietary intake – oranges, apricots, beans, • Increased sensitivity to digitalis potatoes, carrots, celery, raisinsHyperkalemia Assessments Hyperkalemia Implementations • K+ >5.0 mEq/L • Restrict oral intake • EKG changes • Kayexalate • Paralysis • Calcium Gluconate and Sodium • Diarrhea Bircarbonate IV • Nausea • Peritoneal or hemodialysis • DiureticsHyponatremia Assessments Hyponatremia Implementations • Na+ < 135 mEq/L • I&O • Nausea • Daily weight • Muscle cramps • Increase oral intake of sodium rich • Confusion foods • Increased ICP • Water restriction • IV Lactated Ringer’s or 0.9% NaCLHypernatremia Assessments Hypernatremia Assessments • Na+ >145 mEq/L • I&O • Disorientation, delusion, hallucinations • Daily Weight • Thirsty, dry, swollen tongue • Give hypotonic solutions: 0.45% NaCl • Sticky mucous membranes or 5% Dextrose in water IV • Hypotension • TachycardiaHypocalcemia Assessments Hypocalcemia Implementations • Ca+ < 4.5 mEq/L • Oral calcium supplements with orange • Tetany (maximizes absorption) • Positive Trousseau’s sign • Calcium gluconate IV • Positive Chvostek’s sign • Seizure precautions • Seizures • Meet safety needs • Confusion • Irritability, paresthesiasHypercalcemia Assessments Hypercalcemia Implementations • Ca+> 5.2 mEq/L • 0.4% NaCl or 0.9% NaCl IV • Sedative effects on CNS • Encourage fluids (acidic drinks: • Muscle weakness, lack of coordination cranberry juice) • Constipation, abdominal pain • Diuretics • Depressed deep tendon reflexes • Calcitonin • Dysrhythmias • Mobilize patient • Surgery for hyperparathyroidismHypomagnesemia Assessments Hypomagnesemia Implementations  Mg+< 1.5 mEq/L  Monitor cardiac rhythm and reflexes  Neuromuscular irritability  Test ability to swallow  Tremors  Seizure precautions  Seizures  Increase oral intake—green vegetables,  Tetany nuts, bananas, oranges, peanut butter,  Confusion chocolate  DysphagiaHypermagnesemia Assessments Hypermagnesemia Implementations  Mg + > 2.5 mEq/L  Discontinue oral and IV magnesium  Hypotension  Monitor respirations, cardiac rhythm,  Depressed cardiac impulse reflexes
  • 77. transmission  IV Calcium to antagonize cardiac  Absent deep tendon reflexes depressant activity (helps to stimulate  Shallow respirations heart)Burns Assessments • Superficial partial thickness—pink to red, painful • Deep partial thickness—red to white, blisters, painful • Full thickness—charred, waxy, white, painlessWound Care for Burns  Medicate patient before wound  Never break blisters care  Isotonic fluids (Lactated Ringer’s)  Silver nitrate (warn patient skin  Closed method (Silvadene) covered will turn black) with dressings  High calorie, High  Open method (Sulfamylon) that are carbohydrate, High protein diet not covered with dressings  Vitamin B,C, and Iron  IV pain medication initially: not PO  TPN maybe takes too long, not IM circulation  Prevent contractures impairedAddisson’s Disease Assessments Addisson’s Disease Implementations  Fatigue  High protein, High carbohydrate, high  Weakness Sodium, Low potassium diet  Dehydration  Teach life-long hormone replacement  Eternal tan  Decreased resistance to stress  Low Sodium  Low Blood Sugar  High PotassiumAddisonian Crisis Assessments Addisonian Crisis Implementations • Hypotension • Administer NaCl IV, vasopressors, • Extreme weakness hydrocortisone • Nausea vomiting • Monitor vital signs • Abdominal pain • Absolute bedrest • Severe hypoglycemia • DehydrationCushing’s Syndrome Assessments Cushing’s Syndrome Implementations • Osteoporosis • Low Carbohydrate, Low Calorie, High • Muscle wasting Protein, High Potassium, Low sodium • Hypertension diet • Purple skin striations • Monitor glucose level • Moon face • Postop care after adrenalectomy or • Truncal obesity hypophysectomy • Decreased resistance to infectionPheochromocytoma Assessments— Pheochromocytoma Implementationshypersecretions of the catecholamines • Histamine Test, Regitine Test, 24- hour(epinephrine/norepinephrine) urine VMA test • Persistent hypertension • Avoid emotional and physical stress • Hyperglycemia • Encourage rest • Pounding headache • Avoid coffee and stimulating foods • Palpitations • Postop care after adrenalectomy and • Visual disturbances medullectomyCOPD Assessments COPD Implementations • “Blue Bloaters” • Assess airway clearance • “Pink Puffers” • Listen to breath sounds • Weakness • Administer low-flow oxygen (1-2 L, not • Change in postured day and hs (don’t too much because your trying to sleep laying down, have to stay erect) prevent CO2 narcosis) • Use of accessory muscles of breathing • Encourage fluids • Dyspnea • Small frequent feedings • Cough • Use metered dose inhalers (MDI) • Adventitious breath sounds
  • 78. Pneumonia Assessments Pneumonia Implementations • Fever • Check breath sounds • Leukocytosis • Cough and deep breath q 2 hours • Productive Cough (rust, green, yellow) • Chest physiotherapy • Dyspnea • Antibiotics • Pleuritic pain • Incentive spirometer • Tachycardia • Encourage fluids • Suction PRN • Provide oxygen • Semi-Fowler’s position • Bedrest • Medications—mucolytics (Mucomyst), expectorants (Robitussin), Bronchodilators (Aminophylline), Antibiotics (Bacterim)Acyanotic Congenital Heart Anomalies Cyanotic Congenital Heart AnomaliesAssessments Assessments • Normal Color • Cyanosis • Possible exercise intolerance • Clubbing of fingers • Small stature • Seizures • Failure to thrive • Marked exercise intolerance • Heart murmur • Difficulty eating • Frequent respiratory Infections • Squat to decrease respiratory distress • Small stature • Failure to thrive • Characteristic murmur • Frequent respiratory infectionsAcyanotic 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; surgeryCyanotic 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,
  • 79. 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 atriaCongenital Heart Anomalies Compensatory Mechanisms • Tachycardia • Polycythemia (increase formation of RBC’s) • Posturing—squatting, knee-chest positionCongenital Heart Anomalies Implementations • Prevention • Recognize early symptoms • Monitor vital signs and heart rhythms • Medications—digoxin, iron, diuretics, potassium • Change feeding patternLeft-Side CHF Right-Side CHF • Dyspnea, orthopnea • Dependent edema • Cough • Liver enlargement • Pulmonary edema • Abdominal pain/Nausea/Bloating • Weakness/Changes in mental status • Coolness of extremitiesCHF Implementations • Administer digoxin, diuretics • Low-sodium, low-calorie, low-residue diet • Oxygen therapy • Daily weight • Teach about medications and dietArterial Peripheral Vascular Disease Arterial Peripheral Vascular DiseaseAssessments Implementations • Rubor • Monitor Peripheral pulses • Cool shiny skin • Good foot care • Ulcers • Stop smoking • Gangrene • Regular exercise • Intermittent Claudication (pain with • Medications—vasodilators, exercise/walking relieved with rest) anticoagulants • Impaired sensation • Decreased peripheral pulsesVenous Peripheral Vascular Disease Venous Peripheral Vascular DiseaseAssessments Implementations • Cool, brown skin • Monitor peripheral pulses • Edema • Elastic stockings • Normal or decreased pulses • Medications—anticoagulants • Positive Homan’s sign • Elevate legs • Warm, moist packs • Bedrest 4-7 days (acute phase)Anemia Assessments (reduction in Anemia Implementationshemoglobin amount/erythrocytes) • Identify cause • Palpitations • Frequent rest periods • Dyspnea • High protein, high iron, high vitamin • Diaphoresis diet • Chronic fatigue • Protect from infection • Sensitivity to coldIron Deficiency Anemia Assessments Iron Deficiency Anemia Implementations • Fatigue • Increase iron-rich foods (liver, green • Glossitis leafy vegetables) • Spoon fingernails • Iron supplements (stains teeth) • Impaired cognitionPernicious Anemia Assessments (gastric Pernicious Anemia Assessmentsmucosa fail to secrete enough intrinsic factor • Vitamin B12—IMfor stomach to absorb) • Rest of life can’t be absorbed PO • Schilling’s Test • Fatigue • Sore, red tongue • Paresthesia in hands and feet
  • 80. Sickle Cell Anemia Assessments Sickle Cell Anemia Implementations • Pain /Swelling/Fever • Check for signs of infection (prevent • Schlerae jaundiced crisis) • Cardiac murmurs • Check joint areas for pain and swelling • Tachycardia • Encourage fluids • Provide analgesics with PCA pump c crisisHemophilia Assessments (female to male Hemophilia Implementationsgene transmission) • Administer plasma or factor VIII • Easy bruising • Analgesics • Joint pain • Cryoprecipitated antihemophilic factor • Prolonged bleeding (AHF) • Teach about lifestyle changes • Non contact sportsCancer 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 antiemeticsCancer Implementation: Internal Cancer Implementation: Internalradiation sealed source Radiation • Lead container and long-handled • Time and distance important forceps in room • Private room sign on door • Save all dressings, bed linen until • Nurse wears dosimeter at all times source removed • Limit visitors and time spent in room • Urine and feces not radioactive • Rotate staff • Don’t stand close or in line with source • Self-care when can do • Patient on bed restCancer Implementation: Internalradiation unsealed source • All body fluids contaminated • Greatest danger first 24-96 hoursLeukemia Assessments Leukemia Implementations • Ulcerations of mouth • Monitor for signs of bleeding: • Anemia petechiae, ecchymosis, • Fatigue thrombocytopenia • Weakness • Infections • Pallor • Neutropenia (private room/limit # people, wbc done daily, no fruit, no flowers/plotted plants, clean toothbrush with weak bleach solution • Good mouth care • High calorie, high Vitamin diet (avoid salads/raw fruit/pepper/don’t reuse cup/don’t change litter box/digging in gardenIntracranial Tumors Assessments Intracranial Tumors Implementations • Motor deficits • Preoperative: do neurological • Hearing or visual disturbances assessment, patient head shaved • Dizziness • Postoperative: maintain airway, elevate • Paresthesia head 30-45 after supratentorial surgery • Seizures • Flat and lateral after infratentorial • Personality disturbances surgery • Changes in LOC • 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
  • 81.  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 exam4 point Gait 2 point Gait 3 point Gait Swing-to-swingWeight bearing Bearing both legs Bearing one leg throughboth legs RC/LF, LC/RF Weaker leg both crutches, then Partial weightRC, LF, LC, RF stronger leg bearing both legs Both crutches, one or two legsStairs  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 beltMyelogram—x-ray visualization of the spinal Post-procedurecanal by injection of radiopaque dye. • Water-soluble dye—elevate head of • Hydration done 12 hours before bed 30 degrees (not removed) procedure • Oil based dye—flat in bed (removed) • Cleansing enemas • Bedrest 24 hours encourage fluids • Avoid seizure-promoting medicationsLaminectomy—excision portion of lamina to Postoperative care:expose area of affected disc • Assess circulation and sensation • Preopcare: moist heat • Log roll Q2 hours with pillow between • Fowler’s position leg • Isometric exercises for abdominal • Calf exercises, assist with ambulation muscles keeping back straight • Muscle relaxants, NSAIDs, Analgesics • Muscle relaxants, NSAIDS, analgesics, • Traction, TENS Teaching—daily exercises, firm mattress, avoid prone position and heavy lifting • Avoid sitting long timeDysplasia of the Hip Assessment Dysplasia of the Hip Implementations • Uneven gluteal folds and thigh creases Newborn to 6 months • Limited abduction of hip • Reduced by manipulation • Ortolani’s sign—place infant on back • Pavlik harness for 3 to 6 months with legs flexed, clicking sound with 6 to 18 months abduction of legs • Bilateral Bryant’s traction • Shortened limb on affected side • Hip spica cast Older child • Open reduction • Hip Spica castScoliosis Assessments—lateral deviation of Scoliosis Implementationsone or more of vertebrae accompanied by • Exercises to strengthen abdominalrotary motion of spine muscles (if functional) • Uneven hips or scapulae • Surgery: spinal fusion insertion of • Kyphosis lump on back Herrington Rod
  • 82. • Bend at waist to visualize deformity • Milwaukee brace: used with curves • Structural (flexible deviation corrected 30-40 degrees with bending) or functional (permanent • Wear 4-6 years, worn 23 hours of the heredirary that is seen) day, wear undershirt to prevent irritation, teach isometric exercises Cerebral Palsy Assessments Cerebral Palsy Implementations • Voluntary muscles poorly controlled • Ambulation devices, PT and OT due to brain damage • Muscle relaxants and anticonvulsants • Spasticity, rigidity, ataxia, repetitive • Feeding: place food at back of mouth involuntary gross motor movements with slight downward pressure. Never tilt head backward. • High calorie diet Muscular Dystrophy Assessments • Braces to help ambulation Atrophy of voluntary muscles • Balance activity and rest Muscle weakness, lordosis, falls Parkinson’s Disease Assessments Parkinson’s Disease Implementations • Deficiency of dopamine • Teach ambulation modification: goose • Tremors, rigidity, propulsive gait stepping walk (marching), ROM • Monotonous speech exercises • Mask like expression • Medications—Artane, Cogentin, L- Dopa, Parlodel, Sinemet, Symmetrel Myasthenia Gravis Assessments Myasthenia Gravis Implementations • Deficiency of acetylcholine • Good eye care, restful environment • Muscular weakness produced by • Medications—anticholinesterases, repeated movement corticosteroids, immunosuppressants • Dysphagia • Avoid crisis: infection • Respiratory distress • Symptoms: sudden ability to swallowClear liquid Full liquid Low-fat cholesterol Sodium High Low-residue• No milk • No jam restricted restricted roughage, • Minimize• No juice with pulp • No fruit • Can eat lean • No high fiber intestinal • No nuts meat cheese • No white activity • No avocado, bread • Buttered rice milk, bacon, without white egg yolks fiber processed butter food, no whole wheat corn branHigh protein diet Renal Low-phenylalanine • Restablish • Keeps diet anabolism to protein, • Prevents brain raise albumin potassium damage from levels and sodium imbalance of • Egg, roast low amino acids beef • No beans, • Fats, fruits, sandwich, no cereals, jams allowed • No junk food no citrus • No meats eggs fruits bread Glomerulonephritis Assessment Glomerulonephritis Implementation • Fever, Chills • Antibiotics, corticosteroids • Hematuria • Antihypertensives, • Proteinuria immunosuppressive agents • Edema • Restrict sodium and water • Hypertension intake
  • 83. • Abdominal or flank pain • Bedrest • Occurs 10 days after beta • I&O hemolytic streptococcal throat • Daily weight infection • High Calorie, Low proteinUrinary Diversion: Assessments Urinary Diversion Implementations• Done for: Bladder t umors, birth • Nephrostomy: flank incision and insertion of nephrostomy tube defects, neurogenic bladder, into renal pelvis; penrose drain after surgery; surgical dressing interstitial cystitis • Ureterosigmoidostomy: urters detached from bladder and• Ileal Conduit anastomosed to sigmoid colon; encourage voiding via rectum q• Koch Pouch 2-4 hours;no enemas or cathartics; complications—electrolyte imbalance, infection, obstruction; urine and stool evacuated towards anus. • Cutaneous Ureterostomy: Stoma formed from ureters excised from bladder and brought to abdominal wall; stoma on right side below waist; assist with alteration in body image • Illeal Conduit: Ureters replanted into portion of terminal ileum and brought to abdominal wall; check for obstruction; mucous threads in urine normal • Koch Pouch (Continent Illeal Conduit): Ureters transplanted into pouch made from ileum with one-way valve; drainage of pouch by catheter under control of client; drain pouch at regular intervals Acute Renal Acute Renal Acute Renal Failure Acute Renal Failure Failure Failure Causes Implementations: Assessments: Assessments: • Prerenal—reduced • Low-output stage: Limit Oliguric Phase Diuretic Phase blood volume fluids, Kayexalate, • Output <400 • Output 4-5 L/day • Renal—nephrotoxic Dialysis cc/day • Increased BUN drugs, • High-output stage: • Hypertension • Na+, K+ lost in glomerulonephritis Fluids as needed, K+ • Anemia urine • Postrenal--obstruction replacement, Dialysis • CHF • Increased mental • I&O • Confusion and physical • Daily Weight • Increased K+, activity • Monitor Electrolytes Ca+, Na+, • Bedrest during acute BUN, phase Creatinine • IV fluids • Diet restrictions • Oliguric phase: limit fluids, TPN maybe • After Diuretic phase: high protein, high calorie diet Hemodialysis Peritoneal Dialysis Types of Peritoneal Implementation • Weight before and after Dialysis • Check for thrill and bruit q 8 treatment • Continuous hours • Monitor BP ambulatory (CAPD) • Don’t use extremity for BP, • Monitor breath sounds • Automated finger stick • Use sterile technique • Intermittent • Monitor vital signs, weight, • If problem with outflow, • Continuous breath sounds reposition client • Monitor for hemorrhage • Side effects: constipation Ego Defense Mechanisms  Denial—failure to acknowledge thought  Displacement—redirect feelings to more acceptable subject  Projection—attributing your feelings to someone else  Undoing—attempt to erase an act, thought or feeling  Compensation—attempt to overcome shortcoming  Symbolization—less threatening object used to represent another  Substitution—replacing unacceptable or unobtainable object to one that is acceptable or attainable  Introjection—symbolic taking into oneself the characteristics of another  Repression—unacceptable thoughts kept from awareness
  • 84.  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 awarenessDying patient: Denial, Anger, Bargaining, Depression, AcceptanceBipolar Disorder Assessments Bipolar Disorder Implementations • Disoriented, flight of ideas • Meet physical needs first • Lacks inhibitions, agitated • Simplify environment • Easily stimulated by environment • Distract and redirect energy • Sexually indiscreet • Provide external controls • Affective disorder • Set limits: escalating hyperactivity • Maintain contact with reality • Use consistent approach • Elation is defense against • Administer Lithium (help Manic underlying depression Phase of Bipolar, keep hydrated) • Manipulative behavior results from • Increase awareness of feelings poor self-esteem through reflectionSchizophrenia Assessments Schizophrenia Types Schizophrenia Implementations • Withdrawal from • Disorganized— • Maintain safety—protect from relationships and inappropriate behavior, erratic behavior world transient hallucinations • With hallucination—do not argue, • Inappropriate display • Catatonic—sudden validate reality, respond to of feelings onset mutism, feeling tone, never further • Hypochondriasis stereotyped position, discuss voices (don’t ask to tell • Suspiciousness periods of agitation more about voices) • Inability to test • Paranoid—late onset in • With delusions—do not argue, reality, regression life, suspiciousness, point out feeling tone, provide • Hallucinations—false ideas of persecution and diversional activities sensory perceptions delusions • Meet physical needs • Delusions—persistent • Establish therapeutic relationship false beliefs; grandeur • Institute measures to promote (feel higher rank); trust persecutory (beliefs to • Engage in individual, group, or be a victim); ideas of family therapy reference (see people • Encourage client’s affect talking think talking • Accept nonverbal behavior about them) • Accept regression • Loose associations • Provide simple activities or tasks • Short attention span • Inability to meet basic needs: nutrition, hygiene • RegressionParanoid Assessments Paranoid Implementations• Suspiciousness • Establish trust• Cold, blunted affect • Low doses phenothiazines for anxiety• Quick response with anger or rage • Structured social situationsSchizoid Assessments Schizoid Implementations • Shy and introverted • Establish trust • Little verbal interaction • Low doses phenothiazines for anxiety • Few friends • Structured social situations • Uses intellectualizationSchizotypal Assessments Schizotypal Interventions • Eccentric • Establish trust • Suspicious of others • Low doses neuroleptics to decrease • Blunted affect psychotic symptoms • Problems with perceiving, • Structured social situations communicatingAntisocial Assessments Antisocial Implementations • Disregards rights of others • Firm limit-setting • Lying, cheating, stealing, promiscuous • Confront behaviors consistently • Lack of guilt • Enforce consequences • Immature • Group therapy
  • 85. • Irresponsible • Associated with substance abuseBorderline Assessments Borderline implementations • Brief and intense relationships • Identify and verbalize feelings • Blames others for own problems • Use empathy • Impulsive, manipulative • Behavioral contract • Self-mutilation • Journaling • Women who have been sexually • Consistent limit-setting abused • Group therapy • Suicidal when frustrated, stressedNarcissistic Assessments Narcissistic Implementations • Arrogant lack of feelings and empathy • Mirror what client sounds like for others • Limit-setting • Sense of entitlement • Consistency • Uses others to meet own needs • Teach that mistakes are acceptable • Shallow relationships • Views self as superior to othersHistrionic Assessments Histrionic Implementations • Draws attention to self • Positive reinforcement for other • Somatic complaints centered behaviors • Temper tantrums, outbursts • Clarify feelings • Shallow, shifting emotions • Facilitate expression of feelings • Cannot deal with feelings • Easily influenced by othersDependent Assessments Dependent Implementations • Passive • Emphasize decision-making • Problem working independently • Teach assertiveness • Helpless when alone • Assist to clarify feelings and needs • Dependent on others for decisions • Fears loss of support and approvalAvoidant Assessments Avoidant Implementations • Socially uncomfortable • Gradually confront fears • Hypersensitive to criticism, Lacks self- • Discuss feelings confidence • Teach assertiveness • Fears intimate relationships • Increase exposure to small groupsObssessive-compulsive Assessments Obssessive-compulsive Implementations • High personal standards for self and • Explore feelings others • Help with decision-making • Preoccupied with rules, lists, organized • Confront procrastination • Perfectionists • Teach that mistakes are acceptable • IntellectualizeManipulative behavior Assessments Manipulative Behavior Implementations • Unreasonable requests for time, • Use consistent undivided staff attention, favors approach • Divides staff against each other • Set limits • Intimidates others • Be alert for manipulation • Use seductive or disingenuous • Check for destructive behavior approach • Help client to see consequences of behaviorAcute Alcohol Intoxication Acute Alcohol • Drowsiness Implementations • Slurred speech • Protect airway • Tremors • Assess for injuries • Impaired thinking • Withdrawal assess • Belligerence • IV glucose
  • 86. • Loss of inhibitions • Counsel about alcohol useAlcohol Withdrawal After WithdrawalDelirium Alcohol WithdrawalAssessments Tremens Assessments Implementations • Tremors • Disorientation • Monitor vital • insomnia • Paranoia signs, especially • anxiety • Ideas of reference pulse • hallucinations • Suicide attempts • Administer • Grand mal convulsions sedation, anticonvulsants, thiamine (IM or IV), glucose (IV) • Seizure precautions • Quiet, well- lighted environment • Stay with patientChronic Alcohol Dependence Assessments Chronic Alcohol Dependence •Persistent incapacitation Implementations •Cyclic drinking or “binges” •Identify problems related to drinking •Others in family take over client’s role •Help client see problem •Family violence •Establish control of problem •Alcoholics anonymous •Antabuse •Counsel spouse and childrenWernicke’s Syndrome Assessments Wernicke’s Syndrome Implementations •Confusion •Thiamine (IM or IV) •Diplopia, nystagmus •Abstinence from alcohol •Ataxia •ApathyKorsakoff’s Psychosis Assessments Korsakoff’s Psychosis Implementations • Memory disturbances with • Balanced diet confabulation • Thiamine • Learning problems • Abstinence from alcohol • Altered taste and smell • Loss of reality testingRetinopathy of Prematurity Assessment Retinopathy of Prematurity • Demarcation line with ridge Implementations • Retinal detachment • Prevent by using minimum oxygen concentrations • Monitor PO2 • Eye exam (premature infants)Strabismus (cross-eyed) Assessments Corrective lenses Implementations • Deviation of eye • Eye exercises • Diplopia • surgery • Tilts head or squintsDetached Retina Assessments Detached Retina Implementations • Flashes of light • Bedrest, affected eye in dependent • Loss of vision position • Particles moving in line of vision • Eye patched (one or both) • confusion • Surgery • Sedatives and tranquilizers • Avoid stooping, straining at stool, strenuous activity 3 monthsCataracts Assessments Cataracts Implementations • Distorted, blurred vision • Postop: check for hemorrhage • Milky white pupil • Check pupil—constricted with lens implanted, dilated without lens • Eye drops • Night shield
  • 87. • Sleep on unaffected sideGlaucoma Assessments Glaucoma Implementations • Abnormal increase in intraocular • Administer miotics (constrict pupil, allows pressure that leads to blindness more area for aqueous humor to flow), • Blurred vision carbonic anhydrase inhibitors • Lights with halos • Surgery • Decreased peripheral vision • Avoid heavy lifting, straining of stool • Pain • Mydriatics (dilates pupil, makes angle • Headache smaller and constrict aqueous flow) are contraindicated with glaucoma.Trigeminal Neuralgia Assessments Trigeminal Neuralgia Implementations •Stabbing, burning facial pain •Medications—analgesics, Tegretol •Twitching of facial muscles •SurgeryBell’s Palsy Assessments Bell’s Palsy Implementations •Inability to close eye •Isometric exercises for face •Increased lacrimation •Prevent corneal abrasions •Distorted side of faceGuillain-Barre Syndrome Assessments Guillain-Barre Syndrome • Paresthesia Implementations • Motor losses beginning in • Medications—steroids lower extremities • Aggressive respiratory care • Altered autonomic function • Physical therapy • Eye care • Prevent complications: respiratory and aspirationMeningitis Assessments Meningitis Implementations • Nuchal rigidity • Medications—antibiotics, antifungals • Kerning’s sign • Prevent complications: droplet • Brudzinski’s sign precautions, contagious • Seizures • Bulging fontanels • High-pitched cryThoracentesis: no more than 1000cc taken at one time.Electroencephalogram (EEG) Electroencephalogram (EEG)Preparation Post-test •Test brains waves; seizure disorders •Remove paste from hair •Tranquilizer and stimulant meds •Administer medications withheld before withheld for 24-48 hours test •Stimulants (caffeine, cigarettes) •Observe for seizure activity withheld for 24 hours •Seizure prodromal signs; epigastric •May be asked to hyperventilate during distress, lights before the eyes test •Meals not withheld •Kept awake night before test; want them to lie stillCAT Scan—dye gives flushed, warm face and metallic taste during injection (if contrast dye is used)Myelogram: Post-test •Supine 8-24 hours (Pantopaque oil-based dye used) •Head raised 30-45degrees 8-16 hours(metrizamide water-soluble dye used)Liver Biopsy Preparation Liver Biopsy Post-Test •Administer vitamin K IM (decrease •Position on operative side for 1-2 hours risk of hemorrhage) •Gradually elevate head of bed 30 degrees •NPO 6 hours (1st hour) and then 45 degrees (2nd 2 hours) •Given sedative •Bedrest for 24 hours •Position supine, lateral with upper •Check Vital signs arms elevated •Check clotting time, platelets, hematocrit •Asked to hold breath for 5-10 •Report severe abdominal pain seconds
  • 88. Upper GI Series Barium Swallow: stool white from bariumTracheostomy Tube Cuff •Purpose—prevents aspiration of fluids •Inflated o During continuous mechanical ventilation o During and after eating o During and 1 hour after tube feeding o When patient cannot handle oral secretionsOxygen Administration: assess patency of nostril, apply jelly •Face mask: 5-10 l/min (40-60%) •Partial rebreather mask: 6-15 l/min (70-90%); keep reservoir bag 2/3 full during inspiration •Non-rebreather mask: (60-100%); keep reservoir bag 2/3 full during inspiration •Venturi mask: 4-10 l/min (20-50%); provides high humidity and fixed concentrations, keep tubing free of kinks •Tracheostomy collar or T-piece: (20-100%); assess for fine mist; empty condensation from tubing’ keep water container full •Croupette or oxygen tent: o Difficulty to measure amount of oxygen delivered o Provides cooled, humidified air o Check oxygen concentration with oxygen analyzer q4 hours o Clean humidity jar and fill with distilled water daily o Cover patient with light blanket and cap for head o Raise side rails completely o Change linen frequently o Monitor patient’s temperatureChest Tubes Chest Tube Removal: Complications of Chest Tubes:Implementations • Instruct patient to do • Constant bubbling in water-seal• Use to utilize negative valsalva maneuver chamber=air leak pressure in lungs • Clamp chest tube • Tube becomes dislodged from• Fill water-seal chamber • Remove quickly patient, apply dressing tented on with sterile water to 2 • Occlusive dressing one side cm applied • Tube becomes disconnected from• Fill suction control drainage system, cut off chamber with sterile contaminated tip, insert sterile water to 20 cm connector and reinsert• Maintain system below • Tube becomes disconnected from level of insertion drainage system, immerse end in 2• Clamp only momentarily cm of sterile water to check for air leaks• Ok to milk tubing towards drainage• Observe for fluctuation in water-seal chamber• Encourage patient to change position frequentlyCVP: 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
  • 89. o Dry, sterile dressing o Change dressing, IV fluids, manometer, tubing q24 hours o Instruct patient to hold breath when inserted, withdrawn, tubing changed o Check and secure all connections •Normal reading—3-11 cm water •Elevated>11, indicates hypervolemia or poor cardiac contractility (slow down IV, notify physician) •Lowered<3, hypovolemia •Chest tray at bedsideEye irrigation: tilt head back and toward affected sideEye 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 eyesNasogastric 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 portNG tube placement:“BEST WAY” to check is to aspirate for gastric contents and check for pH of aspirate <4Implementation 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 careNG 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 inputNG removal: •Clamp tube •Remove tape •Instruct patient to exhale •Remove tube with smooth, continuous pullIntestinal Tubes (Cantor, Mill-Abbott, Harris) •Implementations o After tube is in stomach, have patient lie on right side, then back in Fowler’s position, then left side o Gravity helps to position tube o Coil excess tube loosely on bed, do not tape o Position of tube verified by x-ray o Measure drainage QShift •Removal o Clamp tube o Remove tape
  • 90. o Deflate balloon or aspirate contents of intestinal tube balloon o Instruct patient to exhale o Remove 6” every 10 min. until reaches the stomach, then remove completely with smooth, continuous pullT-Tube: 500-1000 cc/day, bloody first 2 hoursPenrose: expect drainage on dressingEnema 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 appendicitisCatheter insertion: 2-3” into urethra then 1” after urine flowsMale catheter: insert 6-7”Catheter Urine Drainage bag: do not remove more than 700 cc at one time, clamp prior to removalIleostomy: post-op has loose, dark green, liquid drainage from stomaTonsillectomy: post-op frequently swallowing indicates hemorrhageExternal 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 pointmovement with eye (sewing); high fluid and roughage (prevents constipation=no straining); make lightsufficient for needs (75watt+); no hairwashingGlaucoma medications: Epinephrine hydrochloride (Adrenalin Chloride) and Pilocarpine Hydrochloride(Pilocar): give Pilocar (therapeutic) first then wait 2-10minutes and instill adrenalin to increase absorption ofadrenalin).Tympanoplasty: remain in bed 24 hours position flat in bed with the affected ear up (helps to promoteinsertion).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 toisolate; 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 onher 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 theclient’s abdominal girth, and check dressing in that order.Tracheostomy tube: use pre-cut/pre-made gauze pads.Suction is always intermittent never continuous.