Beruflich Dokumente
Kultur Dokumente
The nurse cares for a client receiving IV antibiotics every 8 hours for the
past 4 days. The antibiotic is mixed in D5W. The nurse determines that a
post-infusion phlebitis has occurred if which of the following is observed?
1. Tenderness at the IV site.
2. Increased swelling at the insertion site.
3. Area around the IV site is reddened with red streaks.
4. Fluid is leaking around the IV catheter.
a. Tenderness occurs with phlebitis but is not specific to it.
b. May indicate either infiltration or phlebitis
c. CORRECTreddened, warm area noted around insertion site or on
path of vein; discontinue IV, apply warm, moist compresses,
restart IV at new site
d. Not indicative of phlebitis
Ethacrynic Acid (Edecrin)are considered loop diuretics and are
potassium wasting; encourage client to increase intake of potassium-rich
foods. Orange juice/Bananas, etc.
Aminophylline (Truphylline)is a xanthine bronchodilator;
major side effects: palpitations, nervousness, rapid pulse, dysrhythmias,
nausea, and vomiting.
Toxic effects: confusion, headache, flushing, tachycardia, and seizure.
Morphine Sulfatedecreases blood return to the right side of the heart,
and decrease peripheral resistance. In other words, decreases preload and
afterload pressures and cardiac workload; causes vasodilation and pooling
of fluid in extremities; provides relief from anxiety.
Intropin (Dopamine)vasoactive medication are given IV to restore BP in
hypotensive states; Increases blood return to the right side of the heart, and
increase peripheral resistance;
side effects: headache, severe hypertension, dysrhythmias; check BP q2
minutes until stabilized, then q5 minutes
TPNhang no longer than 24 hours; IV tubing and filters every 24 hours;
site of catheter changed every 4 weeks.
Fluoxetine (Prozac)a selective serotonin reuptake inhibitor (SSRI) used
to treat depression and obsessive compulsive disorder.
1
bronchioles for steroid to get in. Wait one minute between puffs of the
inhalers for best effect.
Beclomethasone (Vanceril)a steroid medication. Side effect: fungal
infections, dry mouth, throat infections.
InsulinNPH Onset: 1.5 hours Peak: 4-12 hours Regular Onset: 0.5
hours Peak: 2.5-5 hours
Topiramate (Topamax)is an anticonvulsant. Should drink 2000-3000ml
of fluid daily to prevent kidney stones. Side effects: orthostatic
hypotension, ocular symptoms, blindness, and decrease effects of hormonal
contraceptives.
Propranolol (Inderal)a beta-blocker that takes up beta-adrenergic
receptor sites, which prevents adrenaline from causing symptoms and
glycogenolysis. Inderal may mask symptoms of hypoglycemia, removing
the bodys early warning system.
Phenazopyridine (Pyridium)acts on urinary tract mucosa to produce
analgesic or local anesthetic effects. Side effects: bright orange urine,
yellowish discoloration of skin or sclera indicates drug accumulation due to
renal impairment.
Trimethoprim-sulfamethoxazole (Bactrim)most common side effect
mild to moderate rash (urticaria)
Aminoglycosides are ototoxic.
Butorphanol Tartrate (Stadol)analgesic used for moderate to severe
pain; Side effects include change in BP, bradycardia, respiratory depression.
Infant normal resting heart rate: 120-140
Salt substitutes contain potassium
When directing a UAP, the nurse must communicate clearly about each
delegated task with specific instructions on what must be reported. Because
the RN is responsible for all care-related decisions, only implementation
tasks should be assigned because they do not require independent
judgment.
4
When applying the nursing process, assessment is the first step in providing
care. The 5 "Ps" of vascular impairment can be used as a guide (pain,
pulselessness, pallor, paresthesia, paralysis)
READ THE QUESTIONS FIRST!!!!!
READ THE QUESTIONS FIRST!!!!!
DETERMINE THE QUESTION!!!!!!
Rash and blood dyscrasias are side effects of anti-psychotic drugs. A history
of severe depression is a contraindication to the use of neuroleptics.
Children with celiac disease should eat a gluten free diet. Gluten is found
mainly in grains of wheat and rye and in smaller quantities in barley and
oats. Corn, rice, soybeans and potatoes are digestible in persons with celiac
disease.
The nurse instructs the client taking dexamethasone (Decadron) to take it
with food or milk because Decadron increases the production of
hydrochloric acid, which may cause gastrointestinal ulcers.
The protest phase of separation anxiety is a normal response for a child this
age (2 year-old hospitalized child). In toddlers, ages 1 to 3, separation
anxiety is at its peak
Signs of tardive dyskinesia include smacking lips, grinding of teeth and "fly
catching" tongue movements.
Verapamil, Bretylium, and Amiodarone increases serum dig levels, possibly
causing Digitalis Toxicity
Signs/Symptoms of Digital Toxicity: first signs include abdominal pain,
anorexia, nausea, vomiting, visual disturbances, bradycardia, and other
arrhythmias. In infants and small children, the first symptoms of overdose
are usually cardiac arrhythmias.
Restlessness, confusion, irritability and disorientation may be the first signs
of fat embolism syndrome followed by a very high temperature.
A Neologism is a new word self invented by a person and not readily
understood by another that is often associated with a thought disorder.
Pancreatic enzymes give before meals.
5
Ph 4.5-8
1,000-1,500cc/day
Credes Maneuverpush urine out
Pernicious Anemia
- monthly Vitamin B12 IM injections
Metered dose inhaler
- Beclomethasone (Vanceril)
- Albuterol (Proventil)
Guillain-Barre Syndrome
- GBS often preceded by a viral infection as well as
immunizations/vaccinations
- Intervention is symptomatic
- Acute phase: Steroids, plasmapheresis, aggressive respiratory care;
prevent hazards of immobility, maintain adequate nutrition; physical
therapy; pain-reducing measures; eye care, prevention of
complications (UTI, aspiration); psychosocial support
Organ Donation Criteria
- No history of significant, disease, process in organ/tissue to be donated
- No untreated sepsis
- Brain death of donor
- No history of extracranial malignancy
- Relative hemodynamic stability
- Blood group compatibility
- Newborn donors must be full term (more than 200g)
- Only absolute restriction to organ donation is documented case of HIV
infection
- Family members can give consent
- Nurse can discuss organ donation with other death-related topics
(funeral home to be used, autopsy request)
Accurate way to verify NG tube position is to aspirate for gastric contents
and check pH.
Parkinsons disease
10
12
13
Sick day rules: take insulin as ordered, check blood glucose q3-4 hours,
soft foods, liquids
Phenylketonuriahigh blood phenylalanine (no enzyme), results in mental
retardation; milk substitutes, low-protein diet
Celiac Disease (SPrue)intestinal malabsorption, malnutrition (unable to
digest wheat/rye/oats/barley); gluten-free diet
Hepatobiliary diseasedecrease in ability of bile to absorb fat, fat
malabsorption; low-fat high-protein diet, vitamins
Cystic fibrosisabsence of pancreatic enzymes, malabsorption of fat, lung
disease, pancreatic enzyme replacement, high-protein, high-calorie diet,
respiratory care/suction
Position right side to promote gastric emptying.
Dumping syndrome prevention: restrict fluid with meals, lie down after
eating, small, frequent meals, low-carbohydrate, low-fiber diet
Sengstaken-Blakemore Tubeto treat pt. with esophageal varices.
Hepatitis B Vaccine
Given IM to vastus lateralis or
deltoid
Side effects: mild tenderness
at site
1st shot Birth to 3
months
2nd shot 1 to 4 months
3rd shot 6 to 18
months
DTaP (Diptheria, Tetanus,
and Pertussis)
Given IM anterior or lateral
thigh
Side effects: fever within 2448 hours, swelling, redness,
soreness
Evaluated in 48 to 72 hours
TD
Given IM into anterior or lateral thigh
Repeated every 10 years
Live attenuated Rubella
Given once SC into anterior or lateral
thigh
Given to antibody-negative women
Prevent pregnancy for 3 months after
receiving immunization
Live attenuated mumps
Given once SC
Prevents orchitis
15
Resp: 15-25
BP: 100/56 110/60
Adult
Pulse: 60-100
Resp: 12-20
BP: 90/60-140/90
Aortic Valve: Right of Sternum at the 2nd intercostal space
Pulmonic Valve: Left of Sternum at the 2nd intercostal space
Tricuspid Valve: Immediately left of sternal border at the 5th Intercostal
Space
Mitral Valve (Point of Maximal Impulse): Left of Sternum Mid-Clavicular Line
at the 5th Intercostal Space
Erbs Point: Left of Sternum at the 3rd intercostal space
Infant (Point of Maximal Impulse): Lateral to sternum 4th intercostal space
Obese person choking use Chest Thrusts.
Tracheostomy tube placement of cuff maintained to prevent aspiration
Care for patient first, equipment second
Signs for hypoxia: restlessness, tachycardia
CPR: Shake, shout, summon help, open airway, look, listen, feel for signs of
breathing, pinch nose, give 2 full breaths (if no rise, reposition)
Adults 12/min check carotid, chest compressions 80-100/min 1.5 inches
Infants 20/min check brachial pulse, chest compression 100/min - 1 inch
15:2 Adult 4 cycles
Infant 20 cycles
Reassess pulse and breathing
Continue CPR until:
Victim responds
Someone else takes over
16
Victim is transferred
Rescuer is unable to continue
MI
Chest pain radiating to
arms, jaw, neck (which
is unrelieved by rest or
nitroglycerin)
Dyspnea
Indigestion
Apprehension
Low grade fever
Elevated WBC (5-10,
ESR, CK-MB, LDH)
Implementation for MI
Thrombolytic therapystreptokinase, t-PA
Bedrest
Beta-blockers, morphine
sulfate, dysrhythmics,
anticoagulants
Do not force fluids (will
give heart more to work
with)
Defibrillation
Start CPR first
1st attempt 200 joules
2nd attempt 200 to 300 joules
3rd attempt 360 joules
Check monitor between shocks for rhythm
Cardioversion
Elective procedure, Informed Consent
Valium IV
Synchronizer on
25-360 joules
Check monitor between rhythm
Epidural hematoma short period of unconsciousness, ipsilateral papillary
dilation, contralateral weakness of extremities
Subdural hematoma decreased LOC, ipsilateral papillary dilation,
contralateral weakness of extremities, personality changes
CSF leakage good place to look is behind the ears.
Head Injury elevate bed 30 degrees, barbiturate therapy, hypothermia,
glucocorticoids (Decadron)
17
Flail
Chest
Affected
side goes
down
during
inspiratio
n and up
during
expiration
Sucking Chest
Wound
(Sucking Open
Pneumothorax)
Sucking
sound with
respiration
Pain
Decreased
breath
sounds
Anxiety
Pneumothorax
Collapse of lung due to
alteration of air in
intrapleural space
Dyspnea
Pleuritic pain
Restricted
movement on
affected side
Decreased/absent
breath sounds
Cough
Hypotension
Implementati
on
Monitor for
shock
Humidified
oxygen
Thoracentesis
(aspiration of
fluid from
pleural space)
Chest Tubes
Cardiogenic
Decreased
cardiac output
Distributive
Problem with blood
flow to cells
Implementations
18
Assessments
Altered LOC (Earliest Sign)
Glasgow coma scale <7
indicates coma
Confusion
Restlessness
Pupillary changes
Vital sign changes WIDENING
PULSE PRESSURE
Seizures:
do not restrain
do not insert anything in mouth
Electrolytes
Potassium:
Sodium:
Calcium:
Magnesium:
3.5-5.0 mEq/L
135-145 mEq/L
4.5-5.2 mEq/L
1.5-2.5 mEq/L
Hypokalemia Assessments
K+ < 3.5 mEq/L
Muscle weakness
Paresthesias
Dysrhythmias
Increased sensitivity to
digitalis
Hypokalemia Implementations
Potassium Supplements
Dont give > 40 mEq/L into
peripheral IV or without cardiac
monitor
Increase dietary intake oranges,
apricots, beans, potatoes, carrots,
celery, raisins
Hyperkalemia Assessments
K+ >5.0 mEq/L
EKG changes
Paralysis
Diarrhea
Nausea
Hyperkalemia Implementations
Restrict oral intake
Kayexalate
Calcium Gluconate and Sodium
Bircarbonate IV
Peritoneal or hemodialysis
Diuretics
19
Hyponatremia Assessments
Na+ < 135 mEq/L
Nausea
Muscle cramps
Confusion
Increased ICP
Hyponatremia Implementations
I&O
Daily weight
Increase oral intake of sodium rich
foods
Water restriction
IV Lactated Ringers or 0.9% NaCL
Hypernatremia Assessments
Na+ >145 mEq/L
Disorientation, delusion,
hallucinations
Thirsty, dry, swollen tongue
Sticky mucous membranes
Hypotension
Tachycardia
Hypernatremia Assessments
I&O
Daily Weight
Give hypotonic solutions:
0.45% NaCl or 5% Dextrose in
water IV
Hypocalcemia Assessments
Ca+ < 4.5 mEq/L
Tetany
Positive Trousseaus sign
Positive Chvosteks sign
Seizures
Confusion
Irritability, paresthesias
Hypocalcemia Implementations
Oral calcium supplements with
orange (maximizes absorption)
Calcium gluconate IV
Seizure precautions
Meet safety needs
Hypercalcemia Assessments
Ca+> 5.2 mEq/L
Sedative effects on CNS
Muscle weakness, lack of
coordination
Constipation, abdominal pain
Depressed deep tendon
reflexes
Dysrhythmias
Hypercalcemia Implementations
0.4% NaCl or 0.9% NaCl IV
Encourage fluids (acidic drinks:
cranberry juice)
Diuretics
Calcitonin
Mobilize patient
Surgery for
hyperparathyroidism
Hypomagnesemia Assessments
Mg+< 1.5 mEq/L
Hypomagnesemia
Implementations
Monitor cardiac rhythm and
20
reflexes
Test ability to swallow
Seizure precautions
Increase oral intakegreen
vegetables, nuts, bananas,
oranges, peanut butter,
chocolate
Neuromuscular irritability
Tremors
Seizures
Tetany
Confusion
Dysphagia
21
Addissons Disease
Assessments
Fatigue
Weakness
Dehydration
Eternal tan
Decreased resistance to
stress
Low Sodium
Low Blood Sugar
High Potassium
Addisonian Crisis Assessments
Hypotension
Extreme weakness
Nausea vomiting
Abdominal pain
Severe hypoglycemia
Dehydration
Addissons Disease
Implementations
High protein, High
carbohydrate, high Sodium, Low
potassium diet
Teach life-long hormone
replacement
Cushings Syndrome
Assessments
Osteoporosis
Muscle wasting
Hypertension
Purple skin striations
Moon face
Truncal obesity
Decreased resistance to
infection
Cushings Syndrome
Implementations
Low Carbohydrate, Low Calorie,
High Protein, High Potassium,
Low sodium diet
Monitor glucose level
Postop care after
adrenalectomy or
hypophysectomy
Pheochromocytoma
Assessmentshypersecretions
of the catecholamines
(epinephrine/norepinephrine)
Persistent hypertension
Hyperglycemia
Pounding headache
Palpitations
Pheochromocytoma
Implementations
Histamine Test, Regitine Test,
24- hour urine VMA test
Avoid emotional and physical
stress
Encourage rest
Avoid coffee and stimulating
Addisonian Crisis
Implementations
Administer NaCl IV,
vasopressors, hydrocortisone
Monitor vital signs
Absolute bedrest
22
Visual disturbances
foods
Postop care after
adrenalectomy and
medullectomy
COPD Assessments
Blue Bloaters
Pink Puffers
Weakness
Change in postured day and
hs (dont sleep laying down,
have to stay erect)
Use of accessory muscles of
breathing
Dyspnea
Cough
Adventitious breath sounds
COPD Implementations
Assess airway clearance
Listen to breath sounds
Administer low-flow oxygen (1-2
L, not too much because your
trying to prevent CO2 narcosis)
Encourage fluids
Small frequent feedings
Use metered dose inhalers
(MDI)
Pneumonia Assessments
Fever
Leukocytosis
Productive Cough (rust,
green, yellow)
Dyspnea
Pleuritic pain
Tachycardia
Pneumonia Implementations
Check breath sounds
Cough and deep breath q 2
hours
Chest physiotherapy
Antibiotics
Incentive spirometer
Encourage fluids
Suction PRN
Provide oxygen
Semi-Fowlers position
Bedrest
Medicationsmucolytics
(Mucomyst), expectorants
(Robitussin), Bronchodilators
(Aminophylline), Antibiotics
(Bacterim)
23
Right-Side CHF
Dependent edema
25
Cough
Pulmonary edema
Weakness/Changes in
mental status
CHF
Liver enlargement
Abdominal pain/Nausea/Bloating
Coolness of extremities
Implementations
Administer digoxin, diuretics
Low-sodium, low-calorie, low-residue diet
Oxygen therapy
Daily weight
Teach about medications and diet
Anemia Assessments
(reduction in hemoglobin
amount/erythrocytes)
Anemia Implementations
Identify cause
26
Palpitations
Dyspnea
Diaphoresis
Chronic fatigue
Sensitivity to cold
Hemophilia Assessments
(female to male gene
transmission)
Easy bruising
Joint pain
Prolonged bleeding
Hemophilia Implementations
Administer plasma or factor VIII
Analgesics
Cryoprecipitated antihemophilic
factor (AHF)
Teach about lifestyle changes
Non contact sports
Leukemia Implementations
Monitor for signs of bleeding:
petechiae, ecchymosis,
thrombocytopenia
Infections
Neutropenia (private room/limit #
people, wbc done daily, no fruit, no
flowers/plotted plants, clean
toothbrush with weak bleach solution
Good mouth care
High calorie, high Vitamin diet (avoid
salads/raw fruit/pepper/dont reuse
cup/dont change litter box/digging in
garden
Intracranial Tumors
Assessments
2 point
Gait
Bearing
both legs
RC/LF, LC/RF
3 point Gait
Bearing one leg
Weaker leg both
crutches, then stronger
leg
Stairs
Going upgood leg first, crutches, bad leg
29
Swing-toswing
through
Partial
weight
bearing
both legs
Both
crutches,
one or two
legs
Post-procedure
Water-soluble dyeelevate
head of bed 30 degrees (not
removed)
Oil based dyeflat in bed
(removed)
Bedrest 24 hours encourage
fluids
Laminectomyexcision portion of
lamina to expose area of affected
disc
Preopcare: moist heat
Fowlers position
Isometric exercises for
abdominal muscles
Muscle relaxants, NSAIDs,
Analgesics
Traction, TENS
Postoperative care:
Assess circulation and
sensation
Log roll Q2 hours with pillow
between leg
Calf exercises, assist with
ambulation keeping back
straight
Muscle relaxants, NSAIDS,
analgesics, Teachingdaily
exercises, firm mattress, avoid
prone position and heavy
lifting
Avoid sitting long time
Scoliosis Assessmentslateral
deviation of one or more of
vertebrae accompanied by rotary
motion of spine
Uneven hips or scapulae
Kyphosis lump on back
Bend at waist to visualize
deformity
Structural (flexible deviation
corrected with bending) or
functional (permanent
heredirary that is seen)
months
6 to 18 months
Bilateral Bryants traction
Hip spica cast
Older child
Open reduction
Hip Spica cast
Scoliosis Implementations
Exercises to strengthen
abdominal muscles (if
functional)
Surgery: spinal fusion insertion
of Herrington Rod
Milwaukee brace: used with
curves 30-40 degrees
Wear 4-6 years, worn 23 hours
of the day, wear undershirt to
prevent irritation, teach
isometric exercises
Braces to help
ambulation
Balance activity and rest
Parkinsons Disease
31
Assessments
Deficiency of dopamine
Tremors, rigidity, propulsive
gait
Monotonous speech
Mask like expression
Implementations
Teach ambulation modification:
goose stepping walk
(marching), ROM exercises
MedicationsArtane, Cogentin,
L-Dopa, Parlodel, Sinemet,
Symmetrel
32
Myasthenia Gravis
Assessments
Deficiency of acetylcholine
Muscular weakness
produced by repeated
movement
Dysphagia
Respiratory distress
33
Clear
liquid
No milk
No juice
with pulp
Full
liquid
No jam
No
fruit
No
nuts
High
Renal
protein
Keeps
diet
protein
Restab
,
lish
potassi
anabol
um
ism to
and
raise
sodium
albumi
low
n
No
levels
beans,
Egg,
no
roast
cereals
beef
, no
sandw
citrus
ich,
fruits
No
junk
food
Low-fat
cholestero
l
restricted
Can
eat
lean
meat
No
avoca
do,
milk,
bacon,
egg
yolks
butter
Lowphenylala
nine diet
Preve
nts
brain
dama
ge
from
imbala
nce of
amino
acids
Fats,
fruits,
jams
allowe
d
No
meats
eggs
bread
Sodium
restricte
d
No
cheese
34
High
roughag
e, high
fiber
No
white
bread
withou
t fiber
Low-residue
Minimize
intestinal
activity
Buttered
rice white
processed
food, no
whole
wheat corn
bran
Glomerulonephritis Assessment
Fever, Chills
Hematuria
Proteinuria
Edema
Hypertension
Abdominal or flank pain
Occurs 10 days after
beta hemolytic
streptococcal throat
infection
Urinary Diversion:
Assessments
Done for: Bladder t
umors, birth defects,
neurogenic bladder,
interstitial cystitis
Ileal Conduit
Koch Pouch
Glomerulonephritis Implementation
Antibiotics, corticosteroids
Antihypertensives,
immunosuppressive agents
Restrict sodium and water
intake
Bedrest
I&O
Daily weight
High Calorie, Low protein
in urine normal
Koch Pouch (Continent Illeal Conduit):
Ureters transplanted into pouch made from
ileum with one-way valve; drainage of pouch
by catheter under control of client; drain
pouch at regular intervals
Acute Renal
Failure
Assessments:
Oliguric Phase
Output <400
cc/day
Hypertension
Anemia
CHF
Confusion
Increased
K+, Ca+,
Na+, BUN,
Creatinine
Hemodialysis
Implementation
Check for thrill
and bruit q 8
hours
Dont use
Acute Renal
Failure
Assessment
s: Diuretic
Phase
Output 4-5
L/day
Increased
BUN
Na+, K+
lost in
urine
Increased
mental
and
physical
activity
Acute Renal
Failure
Causes
Prerenal
reduced blood
volume
Renal
nephrotoxic
drugs,
glomeruloneph
ritis
Postrenal-obstruction
Peritoneal
Dialysis
Weight before
and after
treatment
Monitor BP
36
Types of
Peritoneal
Dialysis
Continuous
ambulatory
(CAPD)
Monitor breath
sounds
Use sterile
technique
If problem with
outflow,
reposition client
Side effects:
constipation
Automated
Intermittent
Continuous
Bipolar Disorder
Implementations
Meet physical needs
first
37
Lacks inhibitions,
agitated
Easily stimulated by
environment
Sexually indiscreet
Affective disorder
Maintain contact with
reality
Elation is defense
against underlying
depression
Manipulative behavior
results from poor selfesteem
Schizophrenia
Assessments
Withdrawal from
relationships and
world
Inappropriate
display of feelings
Hypochondriasis
Suspiciousness
Inability to test
reality, regression
Hallucinations
false sensory
perceptions
Delusions
persistent false
beliefs; grandeur
(feel higher rank);
persecutory
(beliefs to be a
victim); ideas of
reference (see
people talking
Simplify environment
Distract and redirect
energy
Provide external
controls
Set limits: escalating
hyperactivity
Use consistent
approach
Administer Lithium
(help Manic Phase of
Bipolar, keep
hydrated)
Increase awareness of
feelings through
reflection
Schizophrenia
Types
Disorganized
inappropriate
behavior, transient
hallucinations
Catatonicsudden
onset mutism,
stereotyped
position, periods of
agitation
Paranoidlate
onset in life,
suspiciousness,
ideas of
persecution and
delusions
38
Schizophrenia
Implementations
Maintain safetyprotect
from erratic behavior
With hallucinationdo
not argue, validate
reality, respond to
feeling tone, never
further discuss voices
(dont ask to tell more
about voices)
With delusionsdo not
argue, point out feeling
tone, provide
diversional activities
Meet physical needs
Establish therapeutic
relationship
Institute measures to
promote trust
Engage in individual,
group, or family therapy
Encourage clients affect
Accept nonverbal
behavior
Accept regression
Provide simple activities
or tasks
Paranoid Assessments
Suspiciousness
Cold, blunted affect
Quick response with anger or
rage
Schizoid Assessments
Shy and introverted
Little verbal interaction
Few friends
Uses intellectualization
Schizotypal Assessments
Eccentric
Suspicious of others
Blunted affect
Problems with perceiving,
communicating
Antisocial Assessments
Disregards rights of
others
Lying, cheating,
stealing, promiscuous
Lack of guilt
Immature
Irresponsible
Associated with
substance abuse
Paranoid Implementations
Establish trust
Low doses phenothiazines for
anxiety
Structured social situations
Schizoid Implementations
Establish trust
Low doses phenothiazines for anxiety
Structured social situations
Schizotypal Interventions
Establish trust
Low doses neuroleptics to
decrease psychotic symptoms
Structured social situations
Antisocial
Implementations
Firm limit-setting
Confront behaviors
consistently
Enforce consequences
Group therapy
39
Borderline Assessments
Brief and intense
relationships
Blames others for own
problems
Impulsive, manipulative
Self-mutilation
Women who have been
sexually abused
Suicidal when
frustrated, stressed
Borderline implementations
Identify and verbalize
feelings
Use empathy
Behavioral contract
Journaling
Consistent limit-setting
Group therapy
Narcissistic Assessments
Narcissistic
Arrogant lack of feelings Implementations
and empathy for others
Mirror what client
sounds like
Sense of entitlement
Limit-setting
Uses others to meet
own needs
Consistency
Shallow relationships
Teach that mistakes are
acceptable
Views self as superior to
others
Histrionic Assessments
Draws attention to self
Somatic complaints
Temper tantrums,
outbursts
Shallow, shifting
emotions
Cannot deal with
feelings
Easily influenced by
others
Histrionic
Implementations
Positive reinforcement
for other centered
behaviors
Clarify feelings
Facilitate expression of
feelings
Dependent Assessments
Passive
Problem working
independently
Helpless when alone
Dependent
Implementations
Emphasize decisionmaking
Teach assertiveness
40
Avoidant Assessments
Socially uncomfortable
Hypersensitive to
criticism, Lacks selfconfidence
Fears intimate
relationships
Avoidant Implementations
Gradually confront fears
Discuss feelings
Teach assertiveness
Increase exposure to
small groups
Obssessive-compulsive
Assessments
High personal standards
for self and others
Preoccupied with rules,
lists, organized
Perfectionists
Intellectualize
Obssessive-compulsive
Implementations
Explore feelings
Help with decisionmaking
Confront procrastination
Teach that mistakes are
acceptable
Manipulative behavior
Assessments
Unreasonable requests
for time, attention,
favors
Divides staff against
each other
Intimidates others
Use seductive or
disingenuous approach
Manipulative Behavior
Implementations
Use consistent
undivided staff approach
Set limits
Be alert for
manipulation
Check for destructive
behavior
Help client to see
consequences of
behavior
Acute Alcohol
Implementations
41
Slurred speech
Tremors
Impaired thinking
Belligerence
Loss of inhibitions
Alcohol
Withdrawal
Assessments
Tremors
insomnia
anxiety
hallucinations
Protect airway
Assess for injuries
Withdrawal assess
IV glucose
Counsel about alcohol
use
After
WithdrawalDeliriu
m Tremens
Assessments
Disorientation
Paranoia
Ideas of
reference
Suicide
attempts
Grand mal
convulsions
Alcohol Withdrawal
Implementations
Monitor vital signs,
especially pulse
Administer sedation,
anticonvulsants,
thiamine (IM or IV),
glucose (IV)
Seizure precautions
Quiet, well-lighted
environment
Stay with patient
Chronic Alcohol
Chronic Alcohol Dependence
Dependence Assessments Implementations
Persistent incapacitation
Identify problems related to drinking
Cyclic drinking or
Help client see problem
binges
Establish control of problem
Others in family take
Alcoholics anonymous
over clients role
Antabuse
Family violence
Counsel spouse and children
Wernickes Syndrome
Assessments
Confusion
Diplopia, nystagmus
Ataxia
Apathy
Korsakoffs Psychosis
Assessments
Wernickes Syndrome
Implementations
Thiamine (IM or IV)
Abstinence from alcohol
Korsakoffs Psychosis
Implementations
42
Balanced diet
Thiamine
Abstinence from alcohol
Retinopathy of Prematurity
Implementations
Prevent by using minimum
oxygen concentrations
Monitor PO2
Eye exam (premature infants)
Strabismus (cross-eyed)
Assessments
Deviation of eye
Diplopia
Tilts head or squints
Corrective lenses
Implementations
Eye exercises
surgery
Detached Retina
Assessments
Flashes of light
Loss of vision
Particles moving in line
of vision
confusion
Detached Retina
Implementations
Bedrest, affected eye in
dependent position
Eye patched (one or
both)
Surgery
Sedatives and
tranquilizers
Avoid stooping, straining
at stool, strenuous
activity 3 months
Cataracts Assessments
Distorted, blurred vision
Milky white pupil
Cataracts Implementations
Postop: check for hemorrhage
Check pupilconstricted with lens
implanted, dilated without lens
Eye drops
Night shield
Sleep on unaffected side
43
Glaucoma Assessments
Abnormal increase in
intraocular pressure that
leads to blindness
Blurred vision
Lights with halos
Decreased peripheral
vision
Pain
Headache
Glaucoma Implementations
Administer miotics (constrict pupil, allows
more area for aqueous humor to flow),
carbonic anhydrase inhibitors
Surgery
Avoid heavy lifting, straining of stool
Mydriatics (dilates pupil, makes angle
smaller and constrict aqueous flow) are
contraindicated with glaucoma.
Trigeminal Neuralgia
Assessments
Stabbing, burning facial
pain
Twitching of facial
muscles
Bells Palsy Assessments
Inability to close eye
Increased lacrimation
Distorted side of face
Guillain-Barre Syndrome
Assessments
Paresthesia
Motor losses
beginning in lower
extremities
Altered autonomic
function
Meningitis Assessments
Nuchal rigidity
Kernings sign
Brudzinskis sign
Seizures
Bulging fontanels
High-pitched cry
Meningitis Implementations
Medicationsantibiotics, antifungals
Prevent complications: droplet
precautions, contagious
Electroencephalogram (EEG)
Preparation
Test brains waves; seizure
disorders
Tranquilizer and stimulant meds
withheld for 24-48 hours
Stimulants (caffeine, cigarettes)
withheld for 24 hours
May be asked to hyperventilate
during test
Meals not withheld
Kept awake night before test;
want them to lie still
Electroencephalogram (EEG)
Post-test
Remove paste from hair
Administer medications
withheld before test
Observe for seizure activity
Seizure prodromal signs;
epigastric distress, lights
before the eyes
CAT Scandye gives flushed, warm face and metallic taste during injection
(if contrast dye is used)
Myelogram: Post-test
Supine 8-24 hours (Pantopaque oil-based dye used)
Head raised 30-45degrees 8-16 hours(metrizamide water-soluble dye
used)
Liver Biopsy Preparation
Administer vitamin K IM
(decrease risk of
hemorrhage)
NPO 6 hours
Given sedative
Position supine, lateral
with upper arms elevated
Asked to hold breath for 510 seconds
o
o
o
o
Chest Tubes
Implementations
Use to utilize negative
pressure in lungs
Fill water-seal
chamber with sterile
water to 2 cm
Fill suction control
chamber with sterile
water to 20 cm
Maintain system
Chest Tube
Removal:
Instruct patient
to do valsalva
maneuver
Clamp chest
tube
Remove quickly
Occlusive
dressing
applied
46
Complications of Chest
Tubes:
Constant bubbling in
water-seal chamber=air
leak
Tube becomes dislodged
from patient, apply
dressing tented on one
side
Tube becomes
disconnected from
below level of
insertion
Clamp only
momentarily to check
for air leaks
Ok to milk tubing
towards drainage
Observe for
fluctuation in waterseal chamber
Encourage patient to
change position
frequently
CVP: measures blood volume and efficiency of cardiac work; tells us right
side of heart able to manage fluid
0 on mamometer at level of right atrium at midaxilliary line
Measure with patient flat in bed
Open stopcock and fill manometer to 18-20 cm
Turn stopcock, fluid goes to patient
Level of fluid fluctuates with respirations
Measure at highest level of fluctuation
After insertion
o Dry, sterile dressing
o Change dressing, IV fluids, manometer, tubing q24 hours
o Instruct patient to hold breath when inserted, withdrawn, tubing
changed
o Check and secure all connections
Normal reading3-11 cm water
Elevated>11, indicates hypervolemia or poor cardiac contractility
(slow down IV, notify physician)
Lowered<3, hypovolemia
Chest tray at bedside
Eye irrigation: tilt head back and toward affected side
Eye drops: drop in center of conjunctival sac; prevent systemic absorption,
press on inner angle of eye; dont allow drops to go from one eye to the
other; dont squeeze eyes
47
Nasogastric Tubes:
Levin-singlesingle-lumen, used for decompression or tube feeding
Salem sumpdouble-lumen, used for decompression or tube feeding
Sengstaken-Blakemoretriple-lumen, used for bleeding esophageal
varices
Linton-Nachlas4-lumen, used for bleeding esophageal varices
Keofeed/Dobhoffsoft silicone, used for long-term feedings
Cantorsingle lumen with mercury-filled balloon and suction port
Miller-Abbottdouble-lumen with mercury-filled balloon and suction
port
Harrissingle lumen with mercury-filled balloon and suction port
NG tube placement:
BEST WAY to check is to aspirate for gastric contents and check for pH of
aspirate <4
Implementation of feeding:
Check residual before intermittent feeding, reinstall residual
Check residual Q4 hours with continuous feeding, reinstall residual
Hold feeding if >50% residual from previous hour (adults) or >25%
(children)
Flush tube with water before and after feeding
Use pump to control rate of tube feeding
Administer fluid at room temperature
Change bag Q8 hours for continuous feeding
Elevate head of bed while feeding is running
Check patency Q4 hours
Good mouth care
NG Irrigation Tubing:
Verify placement of tube
Insert 30-50 cc of normal saline into tube
If feel resistance, change patient position, check for kinks
Withdraw solution or record amount as input
NG removal:
Clamp tube
Remove tape
Instruct patient to exhale
48
Blood Type
O
A
B
AB
Autologous Transfusion:
Collected 4-6 weeks before surgery
Contraindicatedinfection, chronic disease, cerebrovascular or
cardiovascular
disease
Hypotonic
Solution
NS
(0.45%
Saline)
Isotonic Solution
0.9% NaCl (Normal
Saline)
5% D/W (Dextrose in
Water)
Lactated Ringers
5% D/ NS (5%
Dextrose in 0.225%
Saline )
Hypertonic Solution
10% D/W (10% Dextrose in
water)
D15W
5% D/NS (5% Dextrose in 0.9%
Saline)
5% D/ NS (5% Dextrose in
0.45% Saline)
3% NaCl
5% Sodium Bicarbonate
Adrenergic
Medications
Levophed
Dopamine
Adrenalin
Dobutrex
Anti-Anxiety
Anti-Anxiety
Action:
Medications:
Affect
Librium,
neurotransmitter
Xanax,
Adrenergics Side
effects:
Dysrhythmias
Tremors
Anticholinergic
effects
Adrenergics Nursing
Considerations:
Monitor BP
Monitor peripheral
pulses
Check output
Anti-Anxiety
Side effects:
Sedation
Confusion
52
s
Used for:
Anxiety
disorders, manic
episodes, panic
attacks
Antacids
Actions:
Neutralize
gastric acids
Used for:
Peptic ulcer
Indigestion,
reflex
esophagitis
Antiarrhythmics
Action:
Interfere with
electrical
excitability of
heart
Used for:
Atrial
Ativan,
Vistaril,
Equanil
Antacids
Medications
Amphojel
Milk of
Magnesia
Maalox
Hepatic dysfunction
Anti-Anxiety
Nursing Considerations:
Potention for
addiction/overdose
Avoid alcohol
Monitor Liver Function
AST/ALT
Dont discontinue
abruptly, wean off
Smoking/caffeine
decreases
effectiveness
Antacids
Side effects:
Constipation
Diarrhea
Acid rebound
Antacids
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 fluids
Antiarrhythmics
Medications:
Atropine
sulfate
Lidocaine
Pronestyl
Quinidine
Isuprel
53
Antiarrhythmics
Side effects:
Lightheadedness
Hypotension
Urinary retention
Antiarrhythmics
Nursing Considerations:
Monitor vital signs
fibrillation and
flutter
Tachycardia
PVCs
Aminoglycosides
(Antibiotics)
Action:
Inhibits protein
synthesis in
gram-negative
bacteria
Used for:
Pseudomonas,
E.Coli
Monitor cardiac
rhythm
Aminoglycosides
(Antibiotics)
Medications:
Gentamycin
Neomycin
Streptomycin
Tobramycin
54
Aminoglycosides
(Antibiotics)
Side effects:
Ototoxicity and
Nephrotoxicity
Anorexia
Nausea
Vomiting
Diarrhea
Aminoglycosides
(Antibiotics)
Nursing
Considerations:
Harmful to liver and
kidneys
Check 8th cranial
nerve (hearing)
Check renal function
Take for 7-10 days
Encourage fluids
Check peak/trough
level
Diarrhea
Take 1 hour ac or 2 hour pc (food
Pseudomona
Binds to cell
Erythromycin
Confusion
slows absorption)
s,membrane
S. Aureus and
Clindamycin
Hepatotoxicity
Dont give
with antacids or iron
changes protein
Superinfections
preparation
function
Nursing
Maybe
givenConsiderations:
with other medications
Used for:
Take
ac or 2-3 hr pc
(Probenicid:
for1hr
gout)
Acute infections
Monitor liver function
Acne
Take with water (no fruit
URI
juice)
Prophylaxis
May increase effectiveness
55
before dental
of: Coumadin and
procedures if
Theophylline
allergic to PCN
(bronchodilator)
Penicillin
Action:
Inhibits
synthesis of
cell wall
Used for:
Moderate to
severe
infections
Syphilis
Gonococcal
infections
Lyme disease
Sulfonamides
(Antibiotics)
Action:
Antagonize
essential
component of folic
acid synthesis
Used for:
Ulcerative colitis
Crohns disease
Otitis media
UTIs
Penicillin
Medications:
Amoxicillin
Ampicillin
Augmentin
Penicillin
Side effects:
Stomatitis
Diarrhea
Allergic reactions
Renal and Hepatic
changes
Nursing Considerations:
Check for
hypersensitivity
Give 1-2 hr ac or 23 hr pc
Cross allergy with
cephalosporins
Sulfonamides
(Antibiotics)
Medications:
Gantrisin
Bactrim
Septra
Azulfidine
Sulfonamides
(Antibiotics)
Side effects:
Peripheral
Neuropathy
Crystalluria
Photosensitivity
GI upset
Stomatitis
Nursing Considerations:
Take with meals or
foods
Encourage fluids
Good mouth care
Antacids will interfere
with absorption
56
Tetracyclines
(Antibiotics)
Action:
Inhibits
protein
sythesis
Used for:
Infections
Acne
Prophylaxis
for opthalmia
neonatorum
TEtracyclines
(Antibiotics)
Medications:
Vibramycin
Panmycin
Tetracyclines (Antibiotics)
Side effects:
Discoloration of primary teeth if
taken during pregnancy or if
child takes at young age
Glossitis
Rash
Phototoxic reactions
Nursing considerations:
Take 1 hr ac or 2-3 hr pc
Do not take with antacids, milk,
iron
Note expiration date
Monitor renal function
Avoid sunlight
UTIs
Medication:
o Furadantin
Action:
o Anti-infective
Side effects:
o Asthma attacks
o Diarrhea
Nursing Considerations:
o Give with food or milk
o Monitor pulmonary status
UTIs
Medication
o Mandelamine
Action:
o Anti-infective
Side effects:
o Elevated liver enzymes
Nursing Considerations:
o Give with cranberry juice to acidify urine
57
Anticholinergics
Action:
Inhibits action of
acethylcholine and
blocks
parasympathetic
nerves (affects
heart, eyes,
respiratory tract, GI
tract and the
bladder)
Dilates pupil,
causes
bronchodilation and
decreased
secretions
Decrease GI
motility secretions
Used for:
Opthalmic exam
Motion sickness
Pre-operative
Anticholinergic
Medications:
Pro-Banthine
Atropine
Scopolamine
58
Anticholinergic
Side Effects:
Blurred vision
Dry mouth
Urinary retention
Chage in heart rate
Nursing
Consideration:
Monitor output
Contraindicated
with glaucoma
Give 30 min ac, hs,
or 2hr pc
Contraindicated:
paralytic ileus, BPH
Anticoagulants
Action:
Blocks
conversion of
prothrombin to
thrombin
Used for:
Pulmonary
embolism
Venous
thrombosis
Prophylaxis
after acute MI
Anticoagulant
Action:
Interferes with
synthesis of
vitamin Kdependent
clotting factors
Used for:
Pulmonary
embolism
Venous
thrombosis
Prophylaxis
after acute MI
Anticoagulan
ts
Medications:
Heparin
Anticoagulants (Heparin)
Side Effects:
Hematuria
Tissue irritation
Nursing Considerations:
Monitor clotting time or Partial
Thromboplastin Time (PTT)
Normal 20-45 sec
Therapeutic level 1.5-2.5 times
control
AntagonistProtamine Sulfate
Give SC or IV
59
Anticonvulsants
Anticonvulsant Anticonvulsant
Action:
Medications:
Side effects:
Decreases flow
Dilantin
Respiratory depression
of calcium and
Luminal
Aplastic anemia
sodium across
Depakote
Gingival hypertrophy
neuronal
Tegretol
Ataxia
membranes
Nursing Considerations:
Klonopin
Used for:
Dont discontinue abruptly
Seizures
Monitor I&O
Caution with use of
medications that lower
seizure threshold: MAO
inhibitors & anti-psychotics
Good mouth care
Take with food
May turn urine pinkishred/pinkish-brown
60
Anti-Depressants
Monoamine
Oxidase Inhibitors
(MAO)
Action:
Causes
increases
concentration of
neurotransmitter
s
Used for:
Depression
Chronic pain
Anti-Depressants
Selective
Serontonin
Reuptake
Inhibitors (SSRI)
Action:
Inhibits CNS
uptake of
serotonin
Used for:
Depression
ObsessiveCompulsive
Disorder
Bulimia
AntiDepressants
(Monoamine
Oxidase
Inhibitors)
Medications:
Marplan
Nardil
Parnate
Anti-Depressants
(Monoamine Oxidase
Inhibitors)
Side effects:
Hypertensive Crisis (Sudden
headache, diaphoretic,
palpitations, stiff neck,
intracranial hemorrhage) with
food that contain Tyramine
Nursing Considerations:
Avoid foods containing
Tyramine: Aged cheese, liver,
yogurt, herring, beer and
wine, sour cream, bologna,
AntiAnti-Depressants
pepperoni,
salami, bananas,
Depressants Selective
Serontonin
raisins,Inhibitors
and pickled
products
Selective
Reuptake
(SSRI)
Monitor output
Serontonin
Side effects:
Takes 4 weeks to work
Reuptake
Anxiety
Dont
combine with
Inhibitors
GI
upset
(SSRI)
sympathomometics
Change in appetite and
vasoconstrictors,
and cold
Medications:
bowel function
medications
Paxil
Urinary retention
Prozac
Nursing Considerations:
Zoloft
Suicide precautions
Takes 4 weeks for full effect
Take in a.m.
May urine to pinkish-red or
Pinkish-brown
Can be taken with meals
Anti-Depressants
AntiAnti-Depressants
(Tricyclics)
Depressants
(Tricyclics)
Action:
(Tricyclics)
Side Effects:
Medications:
Inhibits
Sedation/Confusion
reuptake of
Norpramin
Anticholinergics
neurotransmitter
Elavil
affects
s
Tofranil
Postural Hypotension
Used for:
Urinary retention
Depression
Nursing Considerations:
Sleep apnea
Suicide precautions/26 weeks to work
Take at hs/Dont
61
abruptly halt
Avoid alcohol/OTC
/Photosensitivity
Insulin
(Regular,
Humulin R)
Type: Fast
acting
Onset: -1 hr
Peak: 2-4 hr
Duration: 6-8 hr
Antidiabetic
Agents
Action:
Stimulates
insulin release
from beta cells
in pancreas
Used for:
Type 2
diabetes
(NIDDM)
Insulin
(NPH, Humulin
N)
Type:
Intermediate
acting
Onset: 2hr
Peak: 6-12hr
Duration 18-26hr
Insulin
(Ultralente,
Humulin U)
Type: Slow acting
Onset: 4hr
Peak: 8-20hr
Duration: 24-36hr
Antidiabetic
Agents
Medications:
Diabinese
Orinase
Dymelor
Micronase
Antidiabetic Agents
Side Effects:
Hypoglycemia
Allergic skin reactions
GI upset
Nursing Considerations:
Take before breakfast
Monitor glucose levels
Avoid alcohol, sulfonamides, Oral
Contraceptives, (MAO), aspirin
because they help to make drug
work better
Hypoglycemic
Hypoglycemic
Agent
Agent
Action:
Medication:
Stimulates liver
Glucagon
to change
glycogen to
glucose
Used for:
Hypoglycemia
Antidiarrheals
Action:
Slows
peristalsis
Insulin
(Humulin
70/30)
Type:
Combination
Onset: hr
Peak: 2-12hr
Duration: 24hr
Antidiarrheals
Medications:
Kaopectate
Lomotil
Hypoglycemic Agent
Side Effects:
Hypotension
Bronchospasm
Nursing Considerations:
May repeat in 15min
Give carbohydrates orally to
prevent secondary
hypoglycemic reactions
Antidiarrheals
Side Effects:
Constipation
Anticholinergic effects
62
Increases
tone of
sphincters
Used for:
Diarrhea
Imodium
Paregoric
Antiemetics
Antiemetics
Action:
Medications:
Increases GI
Tigan
motility
Compazine
Blocks effect
Torecan
of dopamine
Reglan
in
Antivert
chemorecep
Dramamine
tor trigger
zone
Used for:
Vomiting
Antiemetics
Side Effects:
Sedation
Anticholinergic effects
Nursing Considerations:
Used before chemotherapy
When used with viral infections
may cause Reyes syndrome
(Toxic Encephalopathy)
Antifungals
Action:
Impairs cell
membrane
Used for:
Candidiasis
Oral thrush
Histoplasmosi
s
Antifungals
Medications:
Amphotericin B
Nystatin
Antigout Agents
Action:
Decreases
production
Antigout Agents
Medications:
Colchicine
Probenecid
63
Antifungals
Side Effects:
Hepatotoxicity
Thrombocytopenia
Leukopenia
Pruritis
Nursing Considerations:
Give with food
Monitor liver function
Good oral hygiene
Antigout Agents
Side Effects:
Agranulocytosis
GI upset
and
resorption of
uric acid
Used for:
Gout
Zyloprim
Antihistamines
Action:
Block effects of
histamine
Used for:
Allergic rhinitis
Allergic reactions
to blood
Antihyperlipidemic
Agents
Action:
Inhibits cholesterol
and triglyceride
synthesis
Used For:
Elevated cholesterol
Reduce incidence of
cardiovascular
disease
Antihypertensives
Types: ACE Inhibitors
Action:
Blocks ACE in
lungs
Used for:
Hypertension
CHF
Renal calculi
Nursing Considerations:
Monitor for renal calculi
Give with food, milk, antacids
Antihistamines
Medications:
Chlor-Trimeton
Benadryl
Phenergan
Antihistamines
Side Effects:
Drowsiness
Dry mouth
Photosensitivity
Nursing Considerations:
Give with food
Use sunscreen
Avoid alcohol
Antihyperlipide
mic Agents
Medications:
Questran
Lipid
Antihyperlipidemic
Agents
Side Effects:
Constipation
Fat-soluble vitamin
deficiency
Nursing Considerations:
Take at hs or 30 min ac
Administer 1hr before
or 4-6 hr after other
meds
Antihypertensiv
es
(ACE Inhibitors)
Medications:
Capoten
Vasotec
64
Antihypertensives
(ACE Inhibitors)
Side Effects:
GI upset
Orthostatic hypotension
Dizziness
Nursing Considerations:
Give 1hr ac or 3hr pc
Change position slowly
Antihypertensives
Type: Beta-Adrenergic
Blockers
Action:
Blocks BetaAdrenergic Receptors
Decrease
excitability/workload
of heart, oxygen
consumption
Decrease
Used for:
Hypertension
Angina
SVT
Antihypertensive
s
Type: BetaAdrenergic
Medications;
Nadolol
Propranolol
Tenormin
Timoptic
Antihypertensives
Type: Calcium Channel Blockers
Action:
Inhibits movement of calcium
across cell membranes
Slow impulse conduction and
depresses myocardial
contractility
Causes dilation of coronary
arteries and decreases cardiac
workload and energy
consumption
Used for:
Angina
Hypertension
Interstitial cystitis
Antihypertensives
Type: Beta-Adrenergic
Side Effects:
Changes in heart
rate
Hypotension
Bronchospasm
Nursing Considerations:
Masks signs of shock
and hypoglycemia
Take with meals
Do not discontinue
abruptly
Antihypertensi
ves
Type: Calcium
Channel Blockers
Medications:
Procardia
Calan
Cardizem
65
Antihypertensive
s
Type: Calcium
Channel Blockers
Side Effects:
Hypotension
Dizziness
GI distress
Nursing
Consideration:
Monitor vital
signs
Do not chew
or divide
sustainedrelease
tablets
Antihypertensives
Type: Centrally
acting alphaadrenergics
Action:
Stimulates
alpha
receptors in
medulla which
causes a
reduction in
sympathetic in
the heart
Used for:
Hypertension
Antihypertensives
Type: Direct-acting
vasodilators
Action:
Relaxes
smooth muscle
Used for:
Hypertension
Antihypertensives
Type: Centrally acting
alpha-adrenergics
Medications:
Aldomet
Catapres
Antihypertensives
Type: Centrally acting alphaadrenergics
Side Effects:
Sedation
Orthostatic
Hypotension
Nursing Considerations:
Dont discontinue
abruptly
Monitor for fluid
retention
Change position slowly
Antihypertensives
Medications
Hydralazine
Minoxidil
Antihypertensives
Side Effects:
Tachycardia
Increase in body hair
Nursing Considerations:
Teach patient to check
pulse
Antihypertensives
Type: Peripheral-acting alphaadrenergic blockers
Action:
Depletes stores of
norepinephrine in
sympathetic nerve
endings
Used for:
Hypertension
Bipolar Disorder
Action:
Reduces
catecholamin
Antihypertensives
Medications:
Reserpine
Bipolar Disorder
Medications:
Lithium (11.5meq/L)
66
Antihypertensives
Side Effects:
Depression
Orthostatic
Hypotension
Brachycardia
Nursing
Considerations:
Give with
meals or milk
Change
position slowly
Bipolar Disorder
Side Effects:
GI upset
Tremors
e release
Used for:
Manic
episodes
Tegretol
Depakote
Polydipsia
Polyuria
Nursing
Considerations:
Monitor serum
levels
Give with
meals
Increase fluid
intake
Antineoplastic
Agents
Type: Alkylating
Agents
Action:
Interferes
with rapidly
reproducing
DNA
Used for:
Leukemia
Multiple
myeloma
Antineoplastic
Agents
Medications:
Cisplatin
Myleran
Cytoxan
Antineoplastic Agents
Side Effects:
Hepatotoxicity
Ecchymosis
Alopecia
Epitaxis
Infertility
Bone Marrow
Suppression
Stomatitis
GI disturbances:
Anorexic, N/V, diarrhea
Nursing Considerations:
Check hematopoietic
(reproduction of RBCs
by bone marrow)
function
Force fluids
Good mouth care
Antineoplastic
Agents
Type:
Antimetabolites
Action:
Inhibits DNA
polymerase
Used for:
Acute
Antineoplastic
Agents
Antimetabolites
Medications:
5-FU
Methotrexate
Hydrea
67
Antineoplastic
Agents
Antimetabolites
Side Effects:
Nausea
Vomiting
Oral
ulceration
Bone marrow
lymphatic
leukemia
Cancer of
colon, breast,
pancreas
suppression
Alopecia
Nursing
Considerations:
Monitor
hematopoietic
function
Good mouth
care
Discuss body
image
changes
Antineoplastic
Agents
Type: Antitumor
Antibiotics
Action:
Interferes
with DNA and
RNA synthesis
Used for:
Cancer
Antineoplastic
Antineoplastic Agents
Agents
Antitumor Antibiotics
Antitumor
Side Effects:
Antibiotics
Bone marrow
Medications:
suppression
Adriamycin
Alopecia
Actinomycin D
Stomatitis
Bleomycin
Nursing Considerations:
Monitor vital signs
Give antiemetic
medications before
therapy
Antineoplastic
Agents
Type: Hormonal
Agents
Action:
Changes
hormone
input into
sensitive cells
Used for:
Cancer
Antineoplastic
Agents
Type: Hormonal
Agents
Medications:
Diethylstilbestrol
Tamoxifen
Testosterone
Antineoplasti
c Agents
Type: Vinca
Antineoplastic Agents
Type: Hormonal Agents
Side Effects:
Leukpenia
Bone pain
Hypercalcemia
Nursing Considerations:
Check CBC
Monitor serum calcium
Alkaloids
Action:
Interferes
with cell
division
Used for:
Cancer
Alkaloids
Medications:
Oncovin
Velban
Stomatitis
Alopecia
Loss of reflexes
Bone marrow suppression
Nursing Considerations:
Give antiemetic before administration
Check reflexes
Given with Zyloprim to decrease uric
acid
Antiparkinson
Agents
Action:
Converted to
Dopamine
Stimulates
postsynaptic
Dopamine
receptors
Used for:
Parkinsons
disease
Antiplatelet
Agents
Action:
Interferes
with platelet
aggregation
Used for:
Venous
thrombosis
Pulmonary
embolism
Antiparkinson
Agents
Medications:
Artane
Cogentin
L-Dopa
Parlodel
Sinemet
Symmetrel
Antiparkinson Agents
Side Effects:
Dizziness
Ataxia
Atropine-like effects: dry
mouth, urinary retention
Nursing Considerations:
Monitor for urinary retention
Large doses of vitamin B6
reverse effects
Avoid use of CNS depressants
Antiplatelet
Agents
Medications:
Aspirin
Persantine
Antiplatelet Agents
Side Effects:
Hemorrhage
Thrombocytopenia
Nursing Considerations:
Check for signs of bleeding
Give with food or milk
Antipsychotic
Agents
Action:
Blocks
dopamine
receptors in
Antipsychotic
Agents
Medications:
Haldol
Thorazine
Mellaril
Antipsychotic
Agents
Side Effects:
Akathisia
(inability to sit
still)
69
basal ganglia
Used for:
Acute and
Chronic
psychoses
Atypical
Antipsychotic
Agents
Action:
Interferes
with binding
of dopamine
in the brain
Used for:
Acute and
Chronic
psychoses
Stelazine
Dyskinesia
Dystonias
Parkinsons
syndrome
Tardive
dyskinesias
Leukopenia
Nursing
Considerations:
Check CBC
Monitor vital
signs
Avoid alcohol
and caffeine
Atypical
Antipsychotic
Medications:
Clozaril
Risperdal
Antipyretic Agents
Action:
Antiprostaglandin
activity in
hypothalamus
Used for:
Fever
Atypical
Antipsychotic
Side Effects:
Extrapyramidal
effects
Anticholinergic
Sedative
Orthostatic
hypotension
Nursing
Considerations:
Monitor blood
Change positions
slowly
Use sunscreen
Antipyretic
Agents
Medications:
Tylenol
(Acetaminoph
en)
70
Antipyretic
Agents
Side Effects:
GI irritation
Nursing
Considerations:
Monitor liver
function
Aspirin
contraindicate
d for younger
than 21 years
old due to risk
of Reyes
syndrome
Antithyroid Agents
Action:
Reduce
vascularity of
thyroid
Inhibits release of
thyroid into
circulation
Used for:
Hyperthyroidism
Thyroid
Replacement
Agents
Action:
Increases
metabolic rate
Used for:
Hypothyroidism
Antithyroid
Agents
Medications:
Tapazole
SSKI
Thyroid
Replacement
Medications
Synthroid
Cytomel
71
Antithyroid Agents
Side Effects:
Leukopenia
Rash
Thrombocytopenia
Nursing Considerations:
Bitter taste
May cause burning
in mouth
Give with meals
Check CBC
Thyroid
Replacement
Side Effects:
Nervousness
Tachycardia
Weight loss
Nursing
Considerations:
Monitor pulse
and BP
Monitor weight
Take in a.m.
Enhance
action of
anticoagulants
,
antidepressant
s, decrease
action of
insulin and
digitalis
Antitubercular
Agents
Action:
Inhibits cell
and protein
synthesis
Used for:
Tuberculosis
To prevent
disease in
person
exposed to
organism
Antitubercular
Agents
Medications:
INH
Ethambutol
Streptomycin
PAS
PYZ
Antivirals
Action:
Inhibits DNA
and RNA
replication
Used for:
Recurrent HSV
HIV infection
Antivirals
Medications:
Zovirax
AZT
Videx
Famvir
Cytovene
Attention
Disorder Agents
Action:
Increases
Attention
Disorder Agents
Medications:
Ritalin
72
Antitubercular
Agents
Side Effects:
Hepatitis
Peripheral
Neuritis
Nursing
Considerations:
Check liver
function tests
Vitamin B6
given for
peripheral
neuritis
(Pyridoxine)
Used in
combination
Antivirals
Side Effects:
Headache
Dizziness
GI symptoms
Nursing
Considerations:
Encourage
fluids
Not a cure,
but relieves
symptoms
Attention
Disorder Agents
Side Effects:
Restlessness
level of
catecholamin
es
Used for:
ADDH
Narcolepsy
Cylert
Dexedrine
Insomnia
Tachycardia
Palpitations
Nursing
Considerations:
Monitor
growth rate
Monitor liver
enzymes
Give in A.M.
Bronchodilators
Bronchodilators
Action:
Medications:
Decreases
Aminophylline
activity of
Atrovent
phosphodiester
Brethine
ase
Proventil
Used for:
Primatene
COPD
Preterm labor
(Terbutaline)
ardiac
ycosides
Cardiac
Glycosides
Bronchodilators
Side Effects:
Tachcyardia
Dysrhythmias
Palpitations
Anticholinergic
effects
Nursing
Considerations:
Monitor BP and
HR
When used with
steroid inhaler,
use
bronchodilator
first
May aggravate
diabetes
Cardiac Glycosides
Side Effects:
73
tion:
Increases
force of
myocardial
contraction,
slows rate
ed for:
Left-sided
CHF
Medication:
Lanoxin
(Digoxi
n)
Bradycardia
Nausea
Vomiting
Visual disturbances
Nursing Considerations:
Take apical pulse
Notify physician if adult <60,
child <90-110, <70 in older
children
Monitor potassium level
Dose: 0.5-1 milligram IV or PO
over 24 hr period
Average: 0.25 mg
Cholinergics
Cholinergics
Action:
Medications:
Inhibits
Tensilon
destruction of
Prostigmin
acetylcholine
Stimulate
parasympath
etic nervous
system
(increase
bowel tone,
increase
bladder tone,
constrict
pupil)
Used for:
Myasthenia
gravis
Postoperative
Postpartum
urinary
retention
Diuretics
Action:
Cholinergics
Side Effects:
Bronchoconstriction
Respiratory paralysis
Hypotension
Nursing Considerations:
Give with food or milk
Monitor vital signs,
especially respirations
Antidote: Atropine
Sulfate
Toxicity: excessive
salivation, excessive
sweating, abdominal
cramps, flushing
Diuretics
Medications:
Diuretics
Side Effects:
74
Inhibits
reabsorption
of sodium and
water
Blocks effects
of
aldosterone
Used for:
CHF
Renal disease
HydroDIURIL
Diamox
Aldactone
Lasix
Hygroton
Dizziness
Orthostatic
Hypotension
Leukopenia
Nursing
Considerations:
Take with
food or milk
Take in a.m.
Monitor fluid
and
electrolytes
Mineralocorticoi
ds
Medications:
Florinef
Mineralocorticoids
Side Effects:
Hypertension
Edema
75
sodium
reabsorption
Potassium
and hydrogen
ion secretion
in kidney
Used for:
Adrenal
insufficiency
Heavy Metal
Antagonists
Action:
Forms stable
complexes
with metals
Used for:
Gold and
arsenic
poisoning
Acute lead
encephalopat
hy
Hypokalemia
Nursing Considerations:
Monitor BP, I&O,
Weight, and
Electrolytes
Give with food
Low-sodium, Highprotein, Highpotassium diet
Heavy Metal
Antagonists
Medications:
Desferal
mesylate
BAL in Oil
EDTA
H2 Receptor Blockers
Action:
Inhibits action of
histamine and
gastric acid
secretion
Used for:
Ulcers
Gastroesophageal
Heavy Metal
Antagonists
Side Effects:
Tachycardia
Pain and
induration at
injection site
(conjunct with
Procaine in
syringe)
Nursing
Considerations:
Monitor I&O
and kidney
function
Administered
with local
anesthetic
Seizure
precautions
H2 Receptor
Blockers
Medications:
Tagamet
Zantac
76
H2 Receptor
Blockers
Side Effects:
Dizziness
Confusion
Hypotension
Impotence
Nursing
Considerations:
reflux
Immunosuppress
ants
Action:
Prevents
production of
T cells and
their response
to interleukin2
Used for:
Prevents
rejection for
transplanted
organs
Take with
meals and hs
Smoking
decreases
effectiveness
Monitor liver
function and
CBC
Immunosuppress
ants
Medications:
Sandimmune
Miotics
Miotics
(Constricts Pupil)
Medications:
Action:
Isopto Causes
Carpine
constriction of
Eserine
sphincter
Carbacel
muscles of iris
Used for:
Ocular
surgery
Open-angle
glaucoma
Immunosuppressants
Side Effects:
Hepatotoxicity
Nephrotoxicity
LeuKopenia
Thrombocytopenia
Nursing Considerations:
Take once daily in
a.m.
Used with adrenal
corticosteroids
Monitor renal and
liver function tests
Miotics
Side Effects:
Headache
Photophobia
Hypotension
Bronchoconstriction
Nursing Considerations:
Apply pressure on
lacrimal sac for 1min
Avoid sunlight
May experience
transient brow pain
and myopia
77
Mydriatics (Dilates
Pupil)
Action:
Anticholinergic
actions leaves
pupil under
unopposed
adrenergic
influence
Used for:
Diagnostic
procedures
Acute iritis
Uveitis
Narcotics
Action:
Acts on CNS
receptor cells
Used for:
Moderate to
severe pain
Preoperative
Postoperative
Antianginals
Action:
Relaxes
smooth
muscle
Decreases
venous
return
Mydriatics
Medications:
Atropine
sulfate
Cyclogyl
Narcotics
Medications:
Morphine
Sulfate
Codeine
Demerol
Dilaudid
Percodan
Antianginals
Medications:
Nitroglycerine
Isosorbide
Mydriatics
Side Effects:
Tachycardia
Blurred vision
Photophobia
Dry mouth
Nursing Considerations:
Contraindicated
with glaucoma
Apply pressure on
lacrimal sac for
1min.
Wear dark glasses
Narcotics
Side Effects:
Dizziness
Sedation
Respiratory
depression
Hypotension
Constipation
Nursing Considerations:
Safety precautions
Avoid alcohol
Monitor vital signs
Use narcotic
antagonist if
necessary (Narcan)
Antianginals
Side Effects:
Hypotension
Tachycardia
Headache
Dizziness
Nursing Considerations:
Check expiration date
78
Used for:
Angina
Perioperative
hypertension
CHF
NSAIDS
Action:
Inhibits
prostaglandin
synthesis
Used for:
Arthritis
Mild to
moderate
pain
Fever
NSAIDS
Side Effects:
GI upset
Dizziness
Headache
Bleeding
Fluid retention
Nursing Considerations:
Take with food or after
meals
Monitor liver and renal
function
Use cautiously with
aspirin allergy
Check for bleeding
Thrombolytics
Thrombolytics
Action:
Medications:
Dissolves or lyses
Streptokinase
blood clots
Urokinase
Used for:
Tissue
Acute Pulmonary
Plasminogen
Emboli
Activator
Thrombosis
MI
Contraindicated in:
hemophilia, CVA,
Trauma, not used in
patients over 75 years
old, not used in
patients taking
anticoagulants
79
Thrombolytics
Side Effects:
Bleeding
Bradycardia
Dysrhythmias
Nursing
Considerations:
Monitor for
bleeding
Have Amino
Caproic Acid
Available
Check pulse,
color, sensation
of extremities
Monitor EKG
Anaphylaxis
Symptoms
o Hives
o Rash
o Difficulty breathing (first sign)
o Diaphoresis
Nursing care
o Epinephrine 0.3 ml of 1:1000 solution SQ
o Massage site
o May repeat in 15-20 min.
Delayed Allergic Reaction
Symptoms:
o Rash, Hives, Swollen Joints
Nursing Care
o Discontinue medication
o Topical Antihistamines
o Corticosteroids
o Comfort measures
Bone Marrow Depression
Symptoms:
Fever, Chills, Sore Throat
Back pain, Dark urine
Anemia, Thrombocytopenia, Leukopenia
Nursing Care:
Monitor CBC
Protect from infections
Avoid injury
Liver impairment: light stools and dark urine
Renal Impairment: decrease Hematocrit
Anticholinergic Effects
Symptoms:
o Dry mouth, Dysphagia, Nasal Congestion
o Urinary retention, Impotence
Nursing Care:
o Sugarless lozenges
o Good mouth care
80
6-9 Months
Inflammation of Liver
Jaundice
Anorexia
RUQ pain
Clay-colored stools, teacolored urine
Pruritis (bile salts eliminated
through skin)
Elevated ALT, AST
Prolonged PT (liver
involvement with clotting
factor)
Fecal/Oral
Consume contaminated food
or water
Travelers to developing
countries at risk
Clients with hepatitis A
should not prepare food for
81
others
Parenteral/Sexual contact
Blood or body fluids
At risk individuals are the
ones that abuse IV drugs,
dialysis, healthcare workers
Vaccine developed
Blood or body fluids
Can become chronic disease
Seen in patients with
hemophilia (unable to clot)
Co-infects with hepatitis B
Rest (mainly for liver)
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.
Multi-system infection caused
by a tick bite. There are
three stages.
Erythematous papule
develops into lesion with
clear center (Bulls-eye)
Regional lymphadenopathy
Flu-like symptoms (fever,
headache, conjunctivitis)
Can develop over 1 to several
months
82
No cure.
Painful vesicular genital
lesions
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.
Men: urethritis, dysuria
Women: thick vaginal
discharge with acrid odor
Spread by mucous
membranes, congenital
Treatment with Tetracycline
or Doxycycline PO
Will cause sterility if left
84
untreated.
Important to notify sexually
contacted.
What are the treatment,
Single, small papillary lesion
mode of transmission,
spreads into large cauliflower
care, signs and symptoms cluster on perineum, vagina,
of Venereal Warts?
penis.
May itch or burn.
Spread by mucous
membranes, congenital
Treatment: Curettage,
cryotherapy with liquid
nitrogen, kerotolytic agents
Avoid intimate contact until
lesions heal
Complication: Genital
Dysplasia Cancer
What is the difference
HIV Positivepresence of HIV
between AIDS and HIV +? in blood
AIDShas significant defects
in immune function
associated with positive HIV
evidenced by development of
opportunistic infections
Syndrome where CD4 counts
are below 200
What are some
P. Carinii Pneumonia:
opportunistic infections of sob/dry-nonproductive cough
AIDS?
C. Albicans stomatitis: will
have difficulty swalling and
white exudates in back of
throat
C. Neoformans: debilitating
form of meningitis that may
suffer seizures.
Cytomegalovirus (CMV): will
experience lymphadenopathy
and may have visual
impairment and can affect
any organ.
Kaposis Sarcoma: most
85
common malignancy
experience with AIDS, small
purplish brown, nonpainful,
nonpuriitc palpable lesions on
the body.
Contaminated blood or body
fluids
Sharing IV needles
Sexual contact
Transplacental: across
placenta
Possibly by breast milk
ELISA test, if positive will be
confirmed by Western Blot
test
HIV Viral culture: Leukopenia,
Thrombocytopenia, Decrease
CD4 counts
someone is poisoned?
What medication
treatment is used to
induce vomiting and what
other factors need to be
implemented?
Intubated if comatose
Run blood gases
IV fluids
Cardiac Monitor
Gastric Lavage (NG down to
flush with NS to remove rest
in stomach)
Activated Charcoal
May use cathartics, diuretics
What are signs and
Tinnitus, change in mental
symptoms, treatments,
status, Increased
care, prevention of aspirin temperature,
poisoning?
hyperventilation, bleeding,
nausea and vomiting.
Nursing care: induce
vomiting, maintain hydration,
reduce temperature (sponge
baths), monitor for bleeding.
87
Symptoms: nausea/vomiting,
hypothermia, If no treatment,
hepatic/liver involvement.
If liver gets involved patient
may have RUQ pain,
jaundice, confusion, and
coagulation abnormalities.
Nursing care: induce
vomiting, maintain hydration,
monitor liver and kidney
function with labs such as
AST/ALT enzymes.
Tylenol (Acetaminophen)
overdosage:
Antidote N-acetylcysteine
(Mucomyst)
Symptoms: Irritability,
decreased activity,
abdominal pain, Increased
ICP
Diagnostic tests: Blood lead
levels (>9micrograms =
toxic), Erythrocyte
protoporphyrin (EP), X-ray
long bones (lead deposits in
long bones)
Children engage in PICA
(ingesting nonfood
substances)
Lead blocks formation of
hemogloblin and toxic to
kidneys.
Nursing care: identify source,
chelating agents, teaching
parents
Decontaminate individual
Prevent spread of
contamination
Clean and remove
contaminuated source
88
Parallel play.
Associative play. Dress
up/imitating play. Talking on
telephone/kitchen/tool belt
Cooperative play.
Conformed/organized play.
Birth-18 months.
Trust vs. Mistrust
Positive outcome---trusts self
Negative outcome--withdrawn
According to Eriksons
18months 3 years
Developmental Task,
Autonomy vs. Shame and
explain the Toddler stage. Doubt
Positive outcome---exercise
self-control
Negative outcome---defiant
and negative
According to Eriksons
3-6 years
89
Developmental Task,
explain the Preschool
stage.
According to Eriksons
Developmental Task,
explain the School age
stage.
6-12years
Industry vs. Inferiority
Positive---sense of confidence
Negative---self doubt,
inadequate
12-20 years
Identity vs. Role diffusion
Positive outcome---coherent
sense of self
Negative outcome---lack of
identity
20-45 years
Intimacy vs. Isolation
Positive outcome---intimate
relationships/careers formed
Negative outcome--avoidance of intimacy
45-65 years
Generativity vs. Stagnation
Positive Outcome---creative
and productive
Negative Outcome---self
centered
65+ years
Integrity vs. Despair
No regrets in life or Regrets
Positive outcome---seems life
as meaningful
Negative outcome---life lacks
meaning
1 month
According to Eriksons
Developmental Task,
explain the Adolescence
stage.
According to Eriksons
Developmental Task,
explain the young adult
stage.
According to Eriksons
Developmental Task,
explain the middle
adulthood stage.
According to Eriksons
Developmental Task,
explain the Late
adulthood stage.
2 months
90
closing of posterior
fontanelle, turn from side
to back, and see a social
smile?
What toys do you give for
a 2 month old?
At what month does a
child bring objects to
mouth and head erect?
What toys do you give for
a 4 month old?
Which age does birth
weight double?
At what age does teething
occur?
What toys do you give for
a 6 month old?
What age for fears of
strangers? When is fear
strongest?
Which month able to play
peek-a-boo?
What toys do you give for
7-8months?
What month can a child
say DADA?
What month can a child
crawl well?
What month can a child
stand erect with support?
What happens in the 12th
month of the child?
Explain introduction of
solid foods.
What is a early/sign of
fetal hypoxia?
What things should you
know about the Informed
Consent form?
What is early
deceleration?
Softening of cervix
Expulsion of mucus plug
(bloody show) pink tinged
mucus secretion
Uterine contractions:
regular/progressive not
Braxton-Hicks type.
Premature rupture of
membranes.
Presenting part not engaged.
Fetal distress.
Protruding cord.
Call for help.
Push up against presenting
part off of the cord.
Place in trendenlenberg
position or knee chest
position.
Successful if FHT left
unchanged.
Early sign: fetal tachycardia
>160 in >10minutes
Late sign: fetal bradycardia
<110 in > 10 minutes
Nurse can witness patient
sign form.
Patient has to be age of
capacity/adult and confident.
No confused
patient/drinking/already
received preoperative
medications.
Consent must be given
voluntarily and information
understandable. Nurse must
make sure questions are
answered and form is
attached to chart.
Decrease in HR before peak
of contraction. Indication of
head compression.
97
Hyperbilirubinemia?
Tachypnea (>60/min)
Frequent sneezing and
yawning
Seen at 12-24 hours of
age, up to 7-10 days
Implementation
Reduce environmental
stimuli
Administer
Phenobarbital,
chlorpromazine,
diazepam, paregoric
Wrap snugly, rock, and
hold tightly
Assess muscle tone,
irritability, vital signs.
What are the assessments Sudden-onset fever
and implementations of
Vomiting, diarrhea
Toxic Shock Syndrome?
Hypotension
Erythematous rash on palms
and soles
Administer antibiotics
Educate about use of
tampons (change tampon Q3Q6 hours)
What are
Immunization is a primary
contraindications to
prevention
Immunizations?
Severe febrile illness
Altered immune system
Previous allergic response
Recently acquired passive
immunity
What are assessments
Assessment
and implementations for a Urticaria, rash
Latex Allergy?
Wheezing, Rhinitis,
Conjunctivitis,
Bronchospasms
Anaphylactic shock
Implementation
Screen for sensitivity
Avoid latex products: gloves,
102
Chest Tubes
Fill water-seal chamber with sterile water to 2 cm
(middle chamber)
Fill suction control chamber with sterile water to 20 cm
(chamber all the way to the right)
Air-leak if bubbling in water-seal chamber (middle
chamber)
Obstruction: milk tube in direction of drainage
Removal o chest tube: pt. does valsalva maneuver,
clamp chest tube, remove quickly, apply occlusive
dressing
Dislodged: apply tented dressing
Tube becomes disconnected from drainage system, cut
off contaminated tip, insert sterile connector and
reinsert
Tube becomes disconnected from drainage system,
immerse in 2cm of water
Jackson-prat: Notify physician if drainage increases or becomes bright red
Penrose: Expect drainage on dressing
Tracheostomy Tube Cuff
Prevents aspiration of fluids/separates upper and lower airways
Inflated during continuous mechanical ventilation
Inflated during and after eating
Inflated during and 1 hour after tube feeding
Inflated when patient cannot handle oral secretions
NCLEX-RN exam is a here and now test; take care of problem now to
prevent harm to client.
Do not ask why on the licensure exam
Morphine Sulfate for pancreatitis causes spasms of the sphincter of
Oddi; Meperidine is drug of choice.
Normal Intraocular Pressure is 10-21 mm Hg
Ecchymosis (faint discoloration) around the umbilicus or in either flank
indicates retroperitoneal bleeding
The parenteral form of Chlorpheniramine Maleate is use to relieve
symptoms of anaphylaxis allergic reactions to blood or plasma.
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particularly careful while in the sun. St. John's wort may also leave nerve
changes in sunburned areas. This herb should be avoided in combination
with other medications that can affect sun sensitivity (such as
tetracycline/Achromycin, sulfa- containing medications, piroxicam (Feldend).
St. John's wort can also cause headaches, dizziness, sweating, and agitation
when used in combination with serotonin reuptake inhibitor medications
such as fluoxetine (Prozac) and paroxetine (Paxil).
Garlic
Uses: Garlic has been used to lower blood pressure and cholesterol (Dr.
Lucinda Miller notes that there is "...still insufficient evidence to recommend
its routine use in clinical practice.")
Reactions: Allergic reactions, skin inflammation, and stomach upset have
been reported. Bad breath is a notorious accompaniment. Studies in rats
have shown decreases in male rats' ability to make sperm cells. Garlic may
decrease normal blood clotting and should be used with caution in patients
taking medications to prevent blood clotting (anticoagulants) such as
warfarin /Coumadin.
Feverfew
Uses: Most commonly used for migraine headaches.
Reactions: Feverfew can cause allergic reactions, especially in persons who
are allergic to chamomile, ragweed, or yarrow. Nonsteroidal antiinflammatory drugs (NSAIDs such as ibuprofen (Advil), naproxen (Aleve) or
Motrin) can reduce the effect of feverfew. A condition called "postfeverfew
syndrome" features symptoms including headaches, nervousness, stiffness,
joint pain, tiredness, and nervousness. Feverfew can impair the action of the
normal blood clotting element (platelets). It should be avoided in patients
taking medications to prevent blood clotting (anticoagulants) such as
warfarin (Coumadin).
Ginko Biloba
Uses: This herb is very popular as a treatment for dementia (a progressive
brain dysfunction) and to improve thinking.
Reactions: Mild stomach upset and headache have been reported. Ginko
seems to have blood thinning properties. Therefore, it is not recommended
to be taken with aspirin, nonsteroidal anti-inflammatory drugs (Advil),
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T
Term
births, the
number
born at
term (40
weeks).
P
Preterm
births, the
number
born
before 40
weeks
gestation.
A
Abortions/miscarriage
s
Included in gravida
if before 20 weeks
gestation
L
Live births,
the
number of
live births
or living
children
Included in parity if
past 20 weeks
gestation
Therefore a woman who is pregnant with twins and has a child has a
gravida of 2. Because the child was delivered at 38 weeks, the number
of preterm births is 1, and the number of term births is 0. The number of
abortions is 0, and the number of live births is 1.
Hyperkalemia on Electrocardiogram:
Tall, peaked T waves; prolonged PR interval; widening QRS complex
Hypokalemia on Electrocardiogram: ST segment depression; Flat T
wave
First-Degree Heart Block: Prolonged P-R interval
Bundle Branch Block: Widened QRS complex
Myocardial Necrosis in Area: Q waves present
Ventricular Fibrillation: No visible P waves or QRS complexes, no
measurable rate. Irregular, chaotic undulations of varying
amplitudes.
HypoCalcemia: Prolonged Q-T interval
Myocardial Ischemia: ST segment elevation or depression
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ANGINA
Unstable
Variant
Triggered by
Triggered by
an
coronary
unpredictable artery spasm;
amount of
the attacks
exertion or
tend to occur
emotion and
early in the
may occur at day and at
night; the
rest.
attacks
increase in
number,
duration, and
severity over
time.
Intractable
Chronic and
incapacitating
and is
refractory to
medical
therapy.
B2: Arterial and bronchial walls and cause vasodilation and bronchodilation.
PULSE PRESENT = NO DEFIBRILLATION
Myxedema (a.ka. Hypothyroidism)
Suggested toys
a. birth to six months - mobiles, unbreakable mirrors, music boxes, rattles
b. six to 12 months - blocks, nesting boxes or cups, simple take apart
toys, large ball, large puzzles, jack in the box, floating toys, teething
toys, activity box, push-pull toys
c. Solitary play
Toddlerhood (one year to three years)
Play is parallel
Suggested toys: push-pull toys, finger paints, thick crayons, riding toys,
balls, blocks, puzzles, simple tape recorder, housekeeping toys,
puppets, cloth picture books, large beads to string, toy telephone,
water toys, sand box, play dough or clay, chalk and chalkboard
Preschool age (three years to six years)
vi.
child under age two weighing at least 2700g: use flush technique,3060mg Hg
child over age two: 85-95/50-65 mm Hg
school age: 100-110/50-65 mm Hg
adolescent: 110-120/65-85 mm Hg
adult: <130 mm Hg Systolic / <85 mm Hg diastolic
ii.
iii.
iv.
v.
newborn: 35 to 40 breaths/minute
infant: 30 to 50 breaths/minute
toddler: 25 to 35 breaths/minute
school age: 20 to 30 breaths/minute
adolescent/adult: 14 to 20 breaths/minute
adult: 12 to 20 breaths/minute
CRANIAL NERVE FUNCTION
1. Olfactory (CN I)
3, 4, 6. Oculomotor (CN III), trochlear (CN IV), and abducens (CN VI)
5. Trigeminal (CN V)
Deviation: Unequal or absent rise of uvula and soft palate as the client
says, "ah"
Deviation: Absent gag reflex
Deviation: inability to taste or identify taste on the posterior tongue
2.
3.
4.
5.
6.
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