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Dilantin - detoxified by liver.

The nurse cares for a client receiving IV antibiotics every 8 hours for the
past 4 days. The antibiotic is mixed in D5W. The nurse determines that a
post-infusion phlebitis has occurred if which of the following is observed?
1. Tenderness at the IV site.
2. Increased swelling at the insertion site.
3. Area around the IV site is reddened with red streaks.
4. Fluid is leaking around the IV catheter.
a. Tenderness occurs with phlebitis but is not specific to it.
b. May indicate either infiltration or phlebitis
c. 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.
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Side effects: postural hypotension, dry mouth, rapid heartbeat, anorexia,


weight loss, severe headache. If dose is missed, omit dose and instruct
client to return to regular dosing schedule.
Propanolol (inderal)a beta-adrenergic blocker used as antihypertensive;
Side effects: bronchospasm, bradycardia, depression. Take pulse before
administration and gradually decrease when discontinuing. Do not give to
asthmatic patients.
Glipizide (Glucotrol)an oral hypoglycemic that decreases blood sugar
by stimulating insulin release from the beta cells of the pancreas; may
cause aplastic anemia and photosensitivity.
Prednisone (Deltasone)a corticosteroid. Side effects: hyperglycemia
Bethanechol (Urecholine)a cholinergic or parasympathomimetic used
to treat functional urinary retention; mimics action of acetylcholine.
Ventricular Tachycardiacauses chest pain, dizziness, and fainting.
1 grain = 60mg
Levothyroxine (Synthroid)thyroid preparation should be administered
at breakfast to prevent insomnia.
Carbamazepine (Tegretol)interferes with action of hormonal
contraceptives. Side effects: photosensitivity; prevention of seizures and
relief of pain in trigeminal neuralgia. Trigeminal neuralgia (Tic douloureux)
is an agonizing pain that may result in severe depression and suicide.
Aluminum Hydroxide (Amphojel)an antacid; neutralizes hydrochloric
acid and reduces pepsin activity; take one hour before and hour of sleep.
Antacids most effective after digestion has started, but prior to the
emptying of the stomach.
Isoniazid (INH)Side effects: peripheral neuropathy (administer
pyridoxine), rash, urticaria, and swelling of the face, lips, and eyelids.
Pyridoxine (Vitamin B6, Beesix, Doxine)required for amino acid,
carbohydrate, and lipid metabolism. Used in the transport of amino acids,
formation of neurotransmitters, and sythesis of heme. Prevention of
neuropathy.
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Clonidine (Catapres-TTS)is a centrally acting alpha-adrenergic used to


treat hypertension; Side effects: drowsiness, sedation, orthostatic
hypotension, heart failure. If patch used, be cautious around microwaves,
results in burns, dispose of carefully, and heat will increase medication
absorption leading to toxicity.
Phlebitistenderness, redness; remove iv, apply warm soaks to decrease
inflammation, swelling, and discomfort.
Autologous bloodmay give blood 5 weeks before surgery; can give 2 to
4 units of blood; may have to take iron pills
Partial-thickness burn; only part of skin is damaged or destroyed; large,
thick-walled blisters develop; underlying tissue is deep red, appears wet and
shiny; painful with increased sensitivity to heat; healing occurs by evolution
of undamaged basal cells, takes about 21-22 days. I.E., Redness and
swelling with fluid-filled vesicles noted on right arm or Blistering and
blanching of the skin noted on the back.
Full-thickness burn; all skin is destroyed and muscle and bone may be
involved; substance that remains is called eschar, dry to touch, doesnt heal
spontaneously, requires grafting. I.E., Charred, waxy, white appearance of
skin on left leg.
Superficial burn; skin appears pink, increased sensitivity to heat, some
swelling, healing occurs without treatment. I.E., Reddened blotchy painful
areas noted on the face.
Carbidopa/Levodopa (Sinemet)used to treat symptoms of Parkinsons
disease. Take immediately before meals and high-protein meals may
impair effectiveness of medication. Reduces rigidity and bradykinesis and
facilitates clients mobility.
Doxycycline (Vibramycin)a tetracycline that is taken at regular
intervals but not within 1 hour of bedtime because it may cause esophageal
irritation. Use another method of birth control, do not take antacids within
1-3 hours of taking medication, and may cause photosensitivity.
Albuterol (Proventil)a bronchodilator. Side effects: tremors, headache,
hyperactivity, tachycardia. Use first before steroid medication so opens up
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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.
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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.
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Clinical features of delusional disorder include extreme suspiciousness,


jealousy, distrust, and belief that others intend to harm.
The UAP can be assigned to care for a client with a chronic condition after
an initial assessment by the nurse. This client has no risk of instability of
condition.
Never leave your patient. For example, Ask the LPN/LVN to stay with the
child and his parents while the nurse obtains phone orders from the
physician.
Tips for charting: dont use inflammatory words, no nurse judgments, be as
specific as possible. I.E., Vital signs stable is incorrect for of charting.
Restraint: frame of bed, quick release ties, document need for restraint Q4
hours
Never ask WHY questions in the NCLEX!
Gag Reflex: dont assess gag reflex to a client that has an absent swallow
reflex
Nifedipine (Procardia XL): do not crush
An RN that is not assigned to a patient does not have the authority to tell a
nurse what to do. Refer it to nursing supervisor.
If doctor has orders it should carried out unless contraindicated in nurses
decision.
Physical assessment: Inspection, Percussion, Palpation, Auscultation (Except
for abdomen: Inspection, Auscultation, Percussion, Palpation)
Coronary artery bypass graft (CABG)halt medications before surgery, can
do 5 at a time; will be on mechanical ventilations after surgery; chest tubes
Acromegalymonitor blood sugar, atrium90 implant care (radioactive,
nasally implanted, monitor vision)
Bone marrow Aspiration---done at iliac crest; painful
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Postoperative care after Supratentorial surgery: maintain airway, elevate


head 30-45
Position care after Infratentorial surgery: flat and lateral
Orange juice does not help acidify urine it makes it more alkaline.
Myelogram
Water-soluble dyeelevate head of bed 30 degrees (not removed)
Oil based dyeflat 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 reductionmanually manipulate bone or use traction
Bucks 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.
Russells Traction
Sling is used
Check for popliteal pulse
Place pillow below lower leg and heel off the bed
Dont turn from waist down
Lift patient, not the leg
Cervical Tongs
Never lift the weights
No pillow under head during feedings
Balanced Suspension Traction
For femur realignment
Maintain weights hanging free and not on floor
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Maintain continuous pull


Halo Jacket
Maintain pin cleansing
Casts
Dont rest on hard surface
Dont cover until dry 48+ hours
Handle with palms of hands not with fingers
Keep above level of heart
Check for CSM
Fractured Hip
Assessments
Leg shortened
Adducted
Externally rotated
Implementation
Care after a total hip replacement
Abduction pillows
Crutch walking with 3-point gait
Dont sleep on operated side
Dont flex hip more than 45-60 degrees
Dont elevate head of the bed more than 45 degrees
Amputations
Guillotine (open)
Flap (closed)
Delayed prosthesis fitting
Residual limb covered with dressing and elastic bandage
(figure eight)
Figure-8 doesnt 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.
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Thiamin (Vit. B1)carbohydrate metabolism; deficiency will cause Beri-Beri


Pyridoxine (Vit. B6)amino acid metabolism; deficiency will cause anemia,
seizures
Folic acidRBC formation; deficiency will cause anemia
Cyanocobalamin (B12)nerve function; deficiency cause pernicious anemia
Calcium deficiency causes Ricketts
Cultural Food Patterns
Orthodox Jewish (Kosher)milk and meat cannot be eaten at same
meal
Muslin30 day fast during Ramadan
Japaneserice is basic food, tea is main beverage
Greekbread is served with every meal
Enteral feeding held if: 150 or > ccs aspirated or 50% given in the hour is
aspirated
If cramping, vomiting occurs decrease rate of enteral feeding or keep it
warm.
TPNsupply 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,, dont 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 Dcd taper patient off or else will get rebound hypoglycemia
(use hypotonic to do this)
Specific gravity 1.010-1.030
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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
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- Activities should be scheduled for late morning when energy level is


highest and patient wont 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, doesnt lead to paralysis
Normal urine output (1200-1500 ccs/day or 50-63 cc/hr, normal voiding
pattern 5-6 times/day.
Green leafy vegetables contain vitamin K.
Labs
HbA1c (4.5-7.6%)
- indicates overall glucose control for the previous 120 days
Serum Amylase / Somogyl (60-160 u/dL)
- elevated in acute pancreatitis
Erythrocyte Sedimentation Rate (ESR)
- Men (1-15)
- Women (1-20)
- Rate at which RBCs settle out of unclotted blood in one hour
- Indicates inflammation/neurosis
Hematocrit (Hct)
- Men (40-45) u/mL
- Women (37-45) u/mL
- Relative volume of plasma to RBC
- Increased with dehydration
- Decreased with volume excess
Creatine Kinase (CK)
- Men (12-70)
- Women (10-55)
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- Enzyme specific to brain, myocardium, and skeletal muscles


- Indicates tissue necrosis or injury
Serum Glucose
- 60-110 mg/dL
Sodium (Na+)
- 135-145 mEq/L
- Hypernatremia
o Dehydration and insufficient water intake
Chloride (Cl-)
- 95-105 mEq/L
Potassium (K+)
- 3.5-5.0 mEq/L
Bicarbonate (HCO3)
- 22-26 mEq/L
- Decreased levels seen with starvation, renal failure, diarrhea.
Blood, Urea, Nitrogen (BUN)
- 6-20 mg
- Elevated levels indicate rapid protein catabolism, kidney dysfunction,
dehydration
Creatinine Clearance Test
- normal 125 ml/min.
- Lower levels reflect renal insufficiency and may influence the excretion
of many drugs and toxins from the body.
Lithium
- targeted blood level: (1-1.5 mEq/L)
Tofranil and AnafranilOCD medications
Pick physical needs over psychosocial needs!!!!!!!!!!!!!!!
Focus on here and now!!!!!!!!!!!!!!!!!

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Oculogyric crisis: uncontrollable rolling back of eyes: side effect of


Phenothiazines
Moribund means dying patient.
Dont leave your patients. Stay with your patients.
Assess before implementation.
Manic patient: decrease stimuli and increase rest period and no
competition.
Lithium helps control impulsive behaviors.
Fluphenazine (Prolixin): antipsychotic medication
Thiamine sources: organ meats, liver, whole grain, nuts, legume, egg, and
milk.
Dont document abuse. Report suspected abuse to nursing supervisor.
Never promise a patient Not to tell.
Tonometrymeasures intraocular pressure; to rule out glaucoma
Myopianearsightedness (near clear, distance clear)
Hyperopiafarsightedness (distance is clear, near vision blurry)
Presbyopiachanges with aging
Blind client: address by name, introduce self, keep furniture arrangement
consistent, open or close doors walk 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.

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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

MMR (Mumps, Measles, and Rubella)


Given SC anterior or lateral thigh
Side effects: rash, fever, arthritis in 10
days to 2 weeks.
1st shot 12 to 18 months
2nd shot 4 to 6 years
Varicella (Chickenpox)
12 to 18 months
PCV (Pneumococcal)
1st shot 2 months
2nd shot 4 months
3rd shot 6 months
4th shot 12 to 18 months
TB
Given intradermal
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Dont treat with aspirin, use


other antipyretic.
1st shot 2 months
2nd shot 4 months
3rd shot 6 months
4th shot 15 to 18
months
5th shot 4 to 6 years
Only TD shot 11 to 16
years
Hib (Influenza)
1st shot 2months
2nd shot 4months
3rd shot 6 months
4th shot 12 to 18
months

Evaluated in 48 to 72 hours
TD
Given IM into anterior or lateral thigh
Repeated every 10 years
Live attenuated Rubella
Given once SC into anterior or lateral
thigh
Given to antibody-negative women
Prevent pregnancy for 3 months after
receiving immunization
Live attenuated mumps
Given once SC
Prevents orchitis

IPV (Inactive Polio Vaccine)


Given PO, Few side effects
1st shot 2 months
2nd shot 4 months
3rd shot 6 to 18
months
4th shot 4 to 6 years
Normal Vital Signs
Newborn
Pulse 120-140 bpm, increases with crying
Respirations 30-50/min, diaphgramatic (abdomen moves),
can be irregular
BP 60/40 80/50 mmHg
1-4 year old
Pulse: 80-140
Resp: 20-40
BP: 90-60 99/65
5-12 year old
Pulse: 70-115

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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
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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)
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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

Cullens Sign ecchymosis around umbilicus


Turners Sign ecchymosis around either flank
Balances sign resonance over spleen (+) means rupture of spleen
Shock Signs and Symptoms
Cool, clammy skin
Cyanosis
Decreased alertness
Tachycardia
Hypotension
Shallow, rapid respirations
Oliguria
Hypovolemic
Decreased in
intravascular
volume

Cardiogenic
Decreased
cardiac output

Distributive
Problem with blood
flow to cells

Implementation for shock


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

Implementations
18

Assessments
Altered LOC (Earliest Sign)
Glasgow coma scale <7
indicates coma
Confusion
Restlessness
Pupillary changes
Vital sign changes WIDENING
PULSE PRESSURE

Monitor vital signs


Monitor Glasgow Coma Scale
Elevate head 30-45 degrees
Avoid neck flexion and head
rotation
Reduce environmental stimuli
Prevent Valsalva maneuver
Restrict fluids to 1200-1500
cc/day
Medications Osmotic diuretics,
corticosteroids

Seizures:
do not restrain
do not insert anything in mouth
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

Hypermagnesemia Assessments Hypermagnesemia


Mg + > 2.5 mEq/L
Implementations
Discontinue oral and IV
Hypotension
magnesium
Depressed cardiac impulse
Monitor respirations, cardiac
transmission
rhythm, reflexes
Absent deep tendon reflexes
IV Calcium to antagonize
Shallow respirations
cardiac depressant activity
(helps to stimulate heart)
Burns Assessments
Superficial partial thicknesspink to red, painful
Deep partial thicknessred to white, blisters, painful
Full thicknesscharred, waxy, white, painless
Wound Care for Burns
Never break blisters
Isotonic fluids (Lactated
Ringers)
Closed method (Silvadene)
covered with dressings
Open method (Sulfamylon)
that are not covered with
dressings
IV pain medication initially:
not PO takes too long, not
IM circulation impaired

Medicate patient before


wound care
Silver nitrate (warn patient
skin will turn black)
High calorie, High
carbohydrate, High protein
diet
Vitamin B,C, and Iron
TPN maybe
Prevent contractures

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

Acyanotic Congenital Heart


Anomalies Assessments
Normal Color
Possible exercise intolerance
Small stature
Failure to thrive
Heart murmur
Frequent respiratory
Infections

Cyanotic Congenital Heart


Anomalies Assessments
Cyanosis
Clubbing of fingers
Seizures
Marked exercise intolerance
Difficulty eating
Squat to decrease respiratory
distress
Small stature
Failure to thrive
Characteristic murmur
Frequent respiratory infection

Acyanotic Congenital Heart Anomalies Types:


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

Atrial Septal Defect (ASD)abnormal opening between the two


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

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


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

Coarctation of the Aortanarrow of aorta; high blood pressure and


bounding pulse in areas that receive blood proximal to the defect.
Weak and absent blood distal to aorta. Surgical end-to-end
anastomosis.
24

Pulomonic Stenosisnarrowing at entrance to pulmonary artery;


causes resistance to blood flow and right ventricular hypertrophy;
surgery

Aortic Stenosisnarrowing of aortic valve; causes decrease cardiac


output; surgery

Cyanotic Congenital Heart Anomalies Types:


Tetralogy of FallotVSD, pulmonic stenosis, overriding aorta, right
ventricular hypertrophy; squats/knee chest position to help breath;
surgery needed
Transposition of great vesselspulmonary artery leaves left
ventricle and aorta leaves right ventricle; oxygenated blood not
going into systemic circulation
Truncus arteriosusfailure of normal septation and embryonic
division of the pulmonary artery and aorta; rather than two distinctly
different vessels there is a single vessel that overrides both
ventricles and gives rise to both pulmonary and systemic circulation;
blood enters from both common artery and either goes to the lungs
or to the body; cyanosis, murmur, difficult intolerance
Total anomalous venous returnabsence of direct communication
between pulmonary veins and left atria; pulmonary veins attach
directly to right atria or drains to right atria

Congenital Heart Anomalies Compensatory


Mechanisms
Tachycardia
Polycythemia (increase formation of RBCs)
Posturingsquatting, knee-chest position
Congenital Heart Anomalies Implementations
Prevention
Recognize early symptoms
Monitor vital signs and heart rhythms
Medicationsdigoxin, iron, diuretics, potassium
Change feeding pattern
Left-Side CHF
Dyspnea, orthopnea

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

Arterial Peripheral Vascular


Disease
Assessments
Rubor
Cool shiny skin
Ulcers
Gangrene
Intermittent Claudication (pain
with exercise/walking relieved
with rest)
Impaired sensation
Decreased peripheral pulses

Venous Peripheral Vascular


Disease
Assessments
Cool, brown skin
Edema
Normal or decreased pulses
Positive Homans sign

Anemia Assessments
(reduction in hemoglobin
amount/erythrocytes)

Arterial Peripheral Vascular


Disease
Implementations
Monitor Peripheral pulses
Good foot care
Stop smoking
Regular exercise
Medicationsvasodilators,
anticoagulants

Venous Peripheral Vascular


Disease
Implementations
Monitor peripheral pulses
Elastic stockings
Medicationsanticoagulants
Elevate legs
Warm, moist packs
Bedrest 4-7 days (acute phase)

Anemia Implementations
Identify cause
26

Palpitations
Dyspnea
Diaphoresis
Chronic fatigue
Sensitivity to cold

Frequent rest periods


High protein, high iron,
high vitamin diet
Protect from infection

Iron Deficiency Anemia


Assessments
Fatigue
Glossitis
Spoon fingernails
Impaired cognition
Pernicious Anemia Assessments
(gastric mucosa fail to secrete
enough intrinsic factor for stomach
to absorb)
Schillings Test
Fatigue
Sore, red tongue
Paresthesia in hands and feet
Sickle Cell Anemia Assessments
Pain /Swelling/Fever
Schlerae jaundiced
Cardiac murmurs
Tachycardia

Hemophilia Assessments
(female to male gene
transmission)
Easy bruising
Joint pain
Prolonged bleeding

Iron Deficiency Anemia


Implementations
Increase iron-rich foods (liver,
green leafy vegetables)
Iron supplements (stains teeth)
Pernicious Anemia Assessments
Vitamin B12IM
Rest of life cant be absorbed
PO

Sickle Cell Anemia


Implementations
Check for signs of infection
(prevent crisis)
Check joint areas for pain and
swelling
Encourage fluids
Provide analgesics with PCA
pump c crisis

Hemophilia Implementations
Administer plasma or factor VIII
Analgesics
Cryoprecipitated antihemophilic
factor (AHF)
Teach about lifestyle changes
Non contact sports

Cancer Implementation: External Radiotherapy


Leave markings on skin
27

Avoid use of creams, lotions (only vitamin A&D


ointment)
Check for redness, cracking
Wear cotton clothing
Administer antiemetics
Cancer Implementation: Internal
Cancer Implementation:
radiation sealed source
Internal 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
source removed
times
Urine and feces not
Limit visitors and time spent
radioactive
in room
Dont stand close or in line with
Rotate staff
source
Self-care when can do
Patient on bed rest
Cancer Implementation: Internal
radiation unsealed source
All body fluids contaminated
Greatest danger first 24-96 hours
Leukemia Assessments
Ulcerations of mouth
Anemia
Fatigue
Weakness
Pallor

Leukemia Implementations
Monitor for signs of bleeding:
petechiae, ecchymosis,
thrombocytopenia
Infections
Neutropenia (private room/limit #
people, wbc done daily, no fruit, no
flowers/plotted plants, clean
toothbrush with weak bleach solution
Good mouth care
High calorie, high Vitamin diet (avoid
salads/raw fruit/pepper/dont reuse
cup/dont change litter box/digging in
garden

Intracranial Tumors
Assessments

Intracranial Tumors Implementations


Preoperative: do neurological
28

assessment, patient head shaved


Motor deficits
Postoperative: maintain airway,
Hearing or visual
elevate head 30-45 after
disturbances
supratentorial surgery
Dizziness
Flat and lateral after infratentorial
Paresthesia
surgery
Seizures
Monitor vital and neurological signs
Personality disturbances
Glascow coma scale
Changes in LOC
Therapeutic Positions
Supineavoids hip flexion
Dorsal recumbentsupine with knees flexed
Proneextension of hip joint(after amputation)
Side lateraldrainage of oral secretions
Knee-chestvisualization of rectal area
Simsdecreases abdominal tension (side lying with legs bent)
Fowlersincreases venous return, lung expansion
High Fowlers60-90
Fowlers45-60
Semi-Fowlers30-45
Low Fowlers15-30
Modified Trendelenburgused for shock;Feet elevated 20
degrees, knees straight, trunk flat, head slightly elevated
Elevation of extremityincreases blood to extremity and venous
return
Lithotomyused for vaginal exam
4 point
Gait
Weight
bearing
both legs
RC, LF, LC,
RF

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

Going downcrutches with bad leg, then good leg


Up with the good, down with the bad
Walker
Flex elbows 20-30 degrees when hands are on
grips
Lift and move walker forward 8-10 inches
Step forward with bad leg, support self on arms,
follow with good leg
Stand behind client holding onto gait belt
Myelogramx-ray visualization of
the spinal canal by injection of
radiopaque dye.
Hydration done 12 hours
before procedure
Cleansing enemas
Avoid seizure-promoting
medications

Post-procedure
Water-soluble 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

Dysplasia of the Hip Assessment Dysplasia of the Hip


Uneven gluteal folds and thigh Implementations
Newborn to 6 months
creases
Reduced by manipulation
Limited abduction of hip
Pavlik harness for 3 to 6
Ortolanis signplace infant on
30

back with legs flexed, clicking


sound with abduction of legs
Shortened limb on affected
side

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

Cerebral Palsy Assessments


Cerebral Palsy Implementations
Voluntary muscles poorly
Ambulation devices, PT and OT
controlled due to brain damage
Muscle relaxants and
Spasticity, rigidity, ataxia,
anticonvulsants
repetitive involuntary gross
Feeding: place food at back of
motor movements
mouth with slight downward
pressure. Never tilt head
backward.
High calorie diet
Muscular Dystrophy
Assessments
Atrophy of voluntary muscles
Muscle weakness, lordosis,
falls
Parkinsons Disease

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

Myasthenia Gravis Implementations


Good eye care, restful environment
Medicationsanticholinesterases,
corticosteroids,
immunosuppressants
Avoid crisis: infection
Symptoms: sudden ability to
swallow

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

Urinary Diversion Implementations


Nephrostomy: flank incision and insertion of
nephrostomy tube into renal pelvis; penrose
drain after surgery; surgical dressing
Ureterosigmoidostomy: urters detached
from bladder and anastomosed to sigmoid
colon; encourage voiding via rectum q 2-4
hours;no enemas or cathartics;
complicationselectrolyte imbalance,
infection, obstruction; urine and stool
evacuated towards anus.
Cutaneous Ureterostomy: Stoma formed
from ureters excised from bladder and
brought to abdominal wall; stoma on right
side below waist; assist with alteration in
body image
Illeal Conduit: Ureters replanted into portion
of terminal ileum and brought to abdominal
wall; check for obstruction; mucous threads
35

in urine normal
Koch Pouch (Continent Illeal Conduit):
Ureters transplanted into pouch made from
ileum with one-way valve; drainage of pouch
by catheter under control of client; drain
pouch at regular intervals
Acute Renal
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

Acute Renal Failure


Implementations:
Low-output stage:
Limit fluids,
Kayexalate,
Dialysis
High-output stage:
Fluids as needed,
K+ replacement,
Dialysis
I&O
Daily Weight
Monitor
Electrolytes
Bedrest during
acute phase
IV fluids
Diet restrictions
Oliguric phase:
limit fluids, TPN
maybe
After Diuretic
phase: high
protein, high
calorie diet

Types of
Peritoneal
Dialysis
Continuous
ambulatory
(CAPD)

extremity for BP,


finger stick
Monitor vital
signs, weight,
breath sounds
Monitor for
hemorrhage

Monitor breath
sounds
Use sterile
technique
If problem with
outflow,
reposition client
Side effects:
constipation

Automated
Intermittent
Continuous

Ego Defense Mechanisms


Denialfailure to acknowledge thought
Displacementredirect feelings to more acceptable
subject
Projectionattributing your feelings to someone else
Undoingattempt to erase an act, thought or feeling
Compensationattempt to overcome shortcoming
Symbolizationless threatening object used to represent
another
Substitutionreplacing unacceptable or unobtainable
object to one that is acceptable or attainable
Introjectionsymbolic taking into oneself the
characteristics of another
Repressionunacceptable thoughts kept from awareness
Reaction formationexpressing attitude opposite of
unconscious wish or fear
Regressionreturning to an earlier developmental phase
Dissociationdetachment of painful emotional conflicts
from consciousness
Suppressionconsciously putting thought out of
awareness
Dying patient: Denial, Anger, Bargaining,
Depression, Acceptance
Bipolar Disorder
Assessments
Disoriented, flight of
ideas

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

think talking about


them)
Loose associations
Short attention
span
Inability to meet
basic needs:
nutrition, hygiene
Regression

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

Dependent on others for


decisions
Fears loss of support
and approval

Assist to clarify feelings


and needs

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 Intoxication


Drowsiness

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

Memory disturbances with


confabulation
Learning problems
Altered taste and smell
Loss of reality testing
Retinopathy of
Prematurity Assessment
Demarcation line with
ridge
Retinal detachment

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

Trigeminal Neuralgia Implementations


Medicationsanalgesics, Tegretol
Surgery

Meningitis Assessments
Nuchal rigidity
Kernings sign
Brudzinskis sign
Seizures
Bulging fontanels
High-pitched cry

Meningitis Implementations
Medicationsantibiotics, antifungals
Prevent complications: droplet
precautions, contagious

Bells Palsy Implementations


Isometric exercises for face
Prevent corneal abrasions
Guillain-Barre Syndrome
Implementations
Medicationssteroids
Aggressive respiratory care
Physical therapy
Eye care
Prevent complications: respiratory
and aspiration

Thoracentesis: no more than 1000cc taken at one time.


44

Electroencephalogram (EEG)
Preparation
Test brains waves; seizure
disorders
Tranquilizer and stimulant meds
withheld for 24-48 hours
Stimulants (caffeine, cigarettes)
withheld for 24 hours
May be asked to hyperventilate
during test
Meals not withheld
Kept awake night before test;
want them to lie still

Electroencephalogram (EEG)
Post-test
Remove paste from hair
Administer medications
withheld before test
Observe for seizure activity
Seizure prodromal signs;
epigastric distress, lights
before the eyes

CAT 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

Liver Biopsy Post-Test


Position on operative side for 1-2
hours
Gradually elevate head of bed 30
degrees (1st hour) and then 45 degrees
(2nd 2 hours)
Bedrest for 24 hours
Check Vital signs
Check clotting time, platelets,
hematocrit
Report severe abdominal pain

Upper GI Series Barium Swallow: stool white from barium


Tracheostomy Tube Cuff
Purposeprevents aspiration of fluids
Inflated
45

o
o
o
o

During continuous mechanical ventilation


During and after eating
During and 1 hour after tube feeding
When patient cannot handle oral secretions

Oxygen Administration: assess patency of nostril, apply jelly


Face mask: 5-10 l/min (40-60%)
Partial rebreather mask: 6-15 l/min (70-90%); keep reservoir bag 2/3
full during inspiration
Non-rebreather mask: (60-100%); keep reservoir bag 2/3 full during
inspiration
Venturi mask: 4-10 l/min (20-50%); provides high humidity and fixed
concentrations, keep tubing free of kinks
Tracheostomy collar or T-piece: (20-100%); assess for fine mist; empty
condensation from tubing keep water container full
Croupette or oxygen tent:
o Difficulty to measure amount of oxygen delivered
o Provides cooled, humidified air
o Check oxygen concentration with oxygen analyzer q4 hours
o Clean humidity jar and fill with distilled water daily
o Cover patient with light blanket and cap for head
o Raise side rails completely
o Change linen frequently
o Monitor patients temperature

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

drainage system, cut off


contaminated tip, insert
sterile connector and
reinsert
Tube becomes
disconnected from
drainage system, immerse
end in 2 cm of sterile
water

CVP: measures blood volume and efficiency of cardiac work; tells us right
side of heart able to manage fluid
0 on mamometer at level of right atrium at midaxilliary line
Measure with patient flat in bed
Open stopcock and fill manometer to 18-20 cm
Turn stopcock, fluid goes to patient
Level of fluid fluctuates with respirations
Measure at highest level of fluctuation
After insertion
o Dry, sterile 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

Remove tube with smooth, continuous pull


Intestinal Tubes (Cantor, Mill-Abbott, Harris)
Implementations
o After tube is in stomach, have patient lie on right side, then back
in Fowlers position, then left side
o Gravity helps to position tube
o Coil excess tube loosely on bed, do not tape
o Position of tube verified by x-ray
o Measure drainage QShift
Removal
o Clamp tube
o Remove tape
o Deflate balloon or aspirate contents of intestinal tube balloon
o Instruct patient to exhale
o Remove 6 every 10 min. until reaches the stomach, then remove
completely with smooth, continuous pull
T-Tube: 500-1000 cc/day, bloody first 2 hours
Penrose: expect drainage on dressing
Enema Implementation
Position on left side
Use tepid solution
Hold irrigation set no more than 18 above rectum
Insert tube no more than 4
Do not use if abdominal pain, nausea, vomiting, suspected appendicitis
Catheter insertion: 2-3 into urethra then 1 after urine flows
Male catheter: insert 6-7
Catheter Urine Drainage bag: do not remove more than 700 cc at one time,
clamp prior to removal
Ileostomy: post-op has loose, dark green, liquid drainage from stoma
Tonsillectomy: post-op frequently swallowing indicates hemorrhage
49

External contact lenses: need fine motor movements (rheumatoid arthritis


prevents this).
Object in eye: never remove visible glass; apply loose cover and remain
quiet.
Retina detached: sleep prone with affected side down; avoid jarring
movements; avoid pin point movement with eye (sewing); high fluid and
roughage (prevents constipation=no straining); make light sufficient for
needs (75watt+); no hairwashing
Glaucoma medications: Epinephrine hydrochloride (Adrenalin Chloride)
and Pilocarpine Hydrochloride (Pilocar): give Pilocar (therapeutic) first then
wait 2-10minutes and instill adrenalin to increase absorption of adrenalin).
Tympanoplasty: remain in bed 24 hours position flat in bed with the
affected ear up (helps to promote insertion).
Triglycerides elevation can falsely elevate glycosalated hemoglobin test.
Laparoscopic Cholecystectomy post: encourage to walk to eliminate acute
right shoulder pain.
Impetigo: 2 year old; honey-colored crusts, vesicles, and reddish macules
around mouth; dont need to isolate; watch contact precautions.
Only patient we use distractions on the NCLEX are manic patients and
toddlers not for pain.
Rhinoplasty (nose surgery) position post-op: want to promote drainage of
oral secretions is to position on her right side.
1 cup= 240cc
Pregnancy is a contraindication to an MRI.
Raynauds disease have decreased vascularity in the extremities.
Post-Parecentesis most important assessment is to obtain the blood
pressure, weight the client, measure the clients abdominal girth, and check
dressing in that order.
50

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


Suction is always intermittent never continuous.
O universal donor/AB universal recipient.
ABO BLOOD TYPE
COMPATIBILITY
Can Receive from:
O
A,O
B,O
O,A,B,AB

Blood Type
O
A
B
AB

Can donate to:


O,A,B,AB
A,AB
B,AB
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

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
Assessmentredness, warm, tender, swelling, leukocytosis
51

Implementationdiscontinue IV, warm moist compresses, start IV in


opposite extremity
Hematoma
Assessmentecchymosis, swelling, leakage of blood
Implementationdiscontinue IV, apply pressure, ice bag 24 hours,
restart IV in opposite extremity
IV Clotting
Assessmentdecreased flow rate, back flow of blood into tubing
Implementationdiscontinue, do not irrigate, do not milk, do not
increase rate of flow or hang solution higher, do not aspirate cannula,
inject Urokinase, D/C and start on other site.
Insertion of Percutaneous Central Catheters:
Placed supine in head-low position
Turn head away from procedure
Perform Valsalva maneuver
Antibiotic ointment and transparent sterile dressing
Verify position with x-ray
Change tubing Q24 hours
Nurse/patient both wear mask when dressing change 2-3x/week
Adrenergics
Actions:

Stimulate the sympathetic


nervous system: increase in
peripheral resistance, increase
blood flow to heart,
bronchodilation, increase blood
flow to skeletal muscle,
increase blood flow to uterus

Stimulate beta-2 receptors


in lungs

Use for cardiac arrest and


COPD

Adrenergic
Medications
Levophed
Dopamine
Adrenalin
Dobutrex

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

Allergy: 1st symptom SOB


Cephalosporin
s (Antibiotics)
Action:
Inhibits
synthesis of
bacterial
cell wall
Used for:
Tonsillitis,
otitis media,
perioperative
prophylaxis
Meningitis

Cephalospori Cephalosporins (Antibiotics)


ns
Side effects:
(Antibiotics)
Bone marrow depression: caution
Medications:
with anemic, thrombocytopenic
Ceclor
patients
Ancef
Superinfections
Keflex
Rash
Rocephin Nursing Considerations:
Take with food
Cefoxitin
Cross allergy with PCN
Avoid alcohol
Obtain C&S before first dose: to
make sure medication is effective
against disease/bacteria
Can cause false-positive for
proteinuria/glycosuria

Fluoroquinolon Fluoroquinolon Fluroquinolones


es (Antibiotics) es
(Antibiotics)
Action:
(Antibiotics)
Side effects:
Medications:
Interferes
Diarrhea
with DNA
Cipro
Decreased WBC and Hematocrit
replication in
Elevated liver enzymes (AST, ALT)
gram Elevated alkaline phosphatase
negative
Nursing Considerations:
bacteria
Macrolide
Macrolide
(Antibiotics)
C&SMacrolide
before starting
therapy
Used
for:
(Antibiotics)
(Antibiotics) Encourage
Side effects:
fluids
E.Coli,
Action:
Medications:

Diarrhea
Take 1 hour ac or 2 hour pc (food
Pseudomona
Binds to cell
Erythromycin
Confusion
slows absorption)
s,membrane
S. Aureus and
Clindamycin
Hepatotoxicity
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

o Limit alkaline foods: vegetables, milk, almonds, coconut


UTIs
Medication
o Pyridium
Side effects:
o Headache
o Vertigo
Action
o Urinary tract analgesic
Nursing Consideration
o Tell patient urine will be orange

Anticholinergics
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

Anticoagul Anticoagulant (Coumadin)


ant
Side Effects:
Medication
Hemorrhage, Alopecia
:
Nursing Considerations:
Couma
Monitor Prothrombin
din
Test (PT)
Normal 9-12 sec
Therapeutic level 1.5
times control
AntagonistVitamin K
(AquaMEPHYTON)
Monitor for bleeding
Give PO

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

(urinary retention, dry mouth)


Nursing Considerations:
Do not use with abdominal
pain
Monitor for urinary retention
Give 2hr before or 3 hr after
other meds

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

Antineoplasti Antineoplastic Agents


c Agents
Type: Vinca Alkaloids
Type: Vinca
Side Effects:
68

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

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


empty stomach, tachycardi
Glucocorticoids
Glucocorticoids
Glucocorticoids
Action:
Medications:
Side Effects:
Stimulates
Solu-Cortef
Psychoses
formation of
Decadron
Depression
glucose
Deltasone
Hypokalemia
Alters
Stunted
immune
growth
response
Buffalo Hump
Used for:
Nursing
Addisons
Considerations:
disease
Monitor fluid
Crohns
and
disease
electrolyte
COPD
balance
Leukemias
Dont
discontinue
abruptly
Monitor for
signs of
infection
Mineralocorticoi
ds
Action:
Increases

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

Teach when to take


medication
May take Q5min x3
doses
Wet with saliva and
place under tongue
NSAIDS
Medications:
Motrin
Indocin
Naprosyn

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

o Void before taking medication


Parkinsons-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 tuberculosis be on
medication?

What are symptoms of


hepatitis?

What is the transmission


of Hepatitis A?

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

What is the transmission


of Hepatitis B?

What is the transmission


of Hepatitis C?
What is the transmission
of Delta Hepatitis?
What nursing care are
recommended for
Hepatitis?

What is Lymes Disease?


What is Stage 1 of Lymes
Disease?

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

What is Stage 2 of Lymes


Disease?

What is Stage 3 of Lymes


Disease?

What are some Lymes


Disease teaching?

What are some Lymes


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

What are the treatment,


mode of transmission,
care, signs and symptoms
of gonorrhea?

Develop after 1 to 6 months


if disease untreated.
Cardiac conduction defects
Neurologic disorders (Bells
palsy, temporary paralysis)
Develops after 1 to several
months, if reached at this
stage may persist for several
years.
Arthralgias
Enlarged, inflamed joints
Cover exposed areas when in
wooded areas
Check exposed areas for
presence of ticks
Antibiotics 3-4 weeks
Stage 1 use Doxicillin
IV penicillin with later stages
Painless chancre fades after
6 weeks
Low grade fever
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.
If female maybe
asymptomatic and will be
unaware of having disease.
Males may have thick
discharge from urethra.
Some females from vagina.
Spread mucous membranes,
congenital
83

IM Rocephin with Doxycycline


PO, IM Aqueous Penicillin with
PO Probenecid (used for gout,
used with Penicillin because it
delays the urinary excretion
of it, makes it more effective)
Complication: Pelvis
Inflammatory Disease
Most often affected with
Chlamydia also, then
treatment with PO
Tetracycline
What are the treatment,
mode of transmission,
care, signs and symptoms
of genital herpes?

What are the treatment,


mode of transmission,
care, signs and symptoms
of Chlamydia?

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

How is AIDS transmitted?

What are diagnostics test


associated with AIDS?

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

What are some nursing


cares for AIDS?

Prevention: avoid IV drug


use, precautions regarding
sexual patterns, use standard
precautions
Contact and standard
precautions
High-protein and high-calorie
diet, small frequent meals
rather than 3 large meals
Symptomatic relief
Support
Dont share
toothbrush/shavers
What are treatments,
Prevention most important.
care, prevention of poison Treat patient first, and then
control?
the poison.
Recognize signs of symptoms
of accidental poison: changes
in appearance, behavior,
substances around mouth,
empty containers, vomitous.
What should happen when Call poison control center.
86

someone is poisoned?

Why should vomit not be


induced?

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

Tell them: substance, time,


amount and route of
ingestion, childs condition,
age, weight, save vomitus,
stool, urine.
Dont induce if:
Danger of aspiration,
decrease LOC, Ingested
petroleum distillate (lighter
fluid, kerosene, paint
remover)
Ingested corrosive (Draino)
Syrup of Ipecac with small
amount of water. Dont give
large amount of fluid after
Ipecac, will increase gastric
emptying.
Dont use milk.
Position with head lower then
chest.
No universal antidote.

What should happen to


poison control in
emergency care?

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

What are signs and


symptoms, treatments,
care, prevention of tylenol
poisoning?

What are signs and


symptoms, treatments,
care, prevention of lead
toxicity?

What are nursing care


goals for Hazardous
wastes?

Symptoms: nausea/vomiting,
hypothermia, If no treatment,
hepatic/liver involvement.
If liver gets involved patient
may have RUQ pain,
jaundice, confusion, and
coagulation abnormalities.
Nursing care: induce
vomiting, maintain hydration,
monitor liver and kidney
function with labs such as
AST/ALT enzymes.
Tylenol (Acetaminophen)
overdosage:
Antidote N-acetylcysteine
(Mucomyst)
Symptoms: Irritability,
decreased activity,
abdominal pain, Increased
ICP
Diagnostic tests: Blood lead
levels (>9micrograms =
toxic), Erythrocyte
protoporphyrin (EP), X-ray
long bones (lead deposits in
long bones)
Children engage in PICA
(ingesting nonfood
substances)
Lead blocks formation of
hemogloblin and toxic to
kidneys.
Nursing care: identify source,
chelating agents, teaching
parents
Decontaminate individual
Prevent spread of
contamination
Clean and remove
contaminuated source
88

Monitor personnel exposed


What are nursing care for If chemical poses threat to
Hazardous wastes?
caregiver, decontaminate
patient first.
If chemical poses no threat or
patient has been
decontaminated, begin care.
If immediate threat to life,
put on protective garments
and provide care to stabilize
patient.
What type of play do
Solitary play. Game is one
infants (0-12months) use? sided. Like to play with body
parts.
Birth-3months: smile/squeal
3-6months: rattles/soft stuff
toys
6-12 months: begin imitation,
peek-a-boo, patty-cake
What type of play do
toddlers (1-3years) use?
What type of play do preschoolers (3-6years) use?
What type of play do
school age (6-12years)
use?
According to Eriksons
Developmental Task,
explain the Infancy stage.

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.

Initiative vs. Guilt


Children develop conscience
at this age.
Positive Outcome---learns
limits
Negative Outcome---fearful,
pessimistic

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.

At what month does the


head sag?
At what month do you see

2 months
90

closing of posterior
fontanelle, turn from side
to back, and see a social
smile?
What toys do you give for
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?

Mobiles, wind up infant


swings, soft clothes, and
blankets.
3 months

Rattles, cradle gym, and


stuffed animals
5 months
6 months
Brightly colored, small
enough to grasp, large
enough for safety, teething
toys
7 months
8 months is stronger
7 months
Large colored, bricks, jack in
the box
9 month
10 months
11 months
Birth weight triples.
Eats with fingers.
Anterior Fontanelle almost
close.
Babinski reflex disappears.
Toys: books with large
pictures, push pull toys,
91

teddy bears, a large ball, or


sponge toys.

Explain introduction of
solid foods.

What does a toddler do at


15 months?

What does a toddler do at


18 months?

One food at a time.


Begin with least allergenic
foods first.
Cereal is usually first.
(Do not use cows
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. Dont give honey
under 12 because of
botulism.
Walks alone.
Throws object.
Holds spoon.
Say 4-6 words. Understand
simple commands.
Anterior fontanelle closes.
Climbs stairs.
Sucks thumb.
Say 10 + words.
Temper Tantrums.
92

What does a toddler do at


24 months?

What does a toddler do at


30 months?

What type of toys are


included for Toddlers?
How do you avoid
negativism during toddler
ages?
What can a 3 year old do?

What can a 4 year old do?

What can a 5 year old do?

What toys are used for


preschool (3-5)?
Which age groups has
greatest number of fears?

300 world vocabulary.


Obeys easy commands.
Go up/down stairs alone.
Build towers.
Turn doorknobs/unscrew lids.
Increase independence.
Walk tip toe.
Stand on one foot balance.
Has control for sphincter
training.
Birth weight quadrupled.
State first/last name.
Give simple commands.
Cooking utensils, Dress-up
clothes, rocking horses,
finger paints, phonographs,
cd players.
Dont ask no/yes questions.
Offer them choices.
Make a game out of the
tasks.
Rides tricycle.
Undresses without help.
May invent imaginary friend.
Vocabulary 900 words.
Egocentric in
thoughts/behaviors.
Laces shoes
Brushes teeth
Throws overhand
Uses sentences.
Independent
Runs well/Dresses without
help.
Beginning cooperative play.
Gender-specific behavior.
Playground materials,
Housekeeping toys, Coloring
books, tricycle with helmet.
Preschool age children.
93

What would you expect


with a 6 year old?

Self-centered, show off, rude


Sensitive to criticism
Begins loosing temporary
teeth
Tends to lie.
What would you expect
Team games/sports.
with a 7 year old?
Concept of time.
Playing with same sex child.
What would you expect
Seeks out friends.
with a 8 year old?
Writing replaces printing.
What would you expect
Conflicts between peer
with a 9 year old?
groups and parents.
Conflicts between
independence and
dependence.
Likes school.
Able to take on job duties
(housework).
What toys are used for
Construction toys, Pets,
school age child?
Games, Electronic games,
reading, books, bicycles with
helmets.
School age potential
Anuresis (encourage before
problems include:
bed time)
Encopresis
Head lice
What are
Thin upper lip, vertical ridge
symptoms/indications of a in upper lip, short up turned
fetal alcohol syndrome in nose, mental retardation,
a child?
motor retardation, hearing
disorders, microcephaly.
Avoid alcohol 3 months
before conception and
throughout pregnancy.
What happens with
16th week detects genetic
amniocentesis? What
abnormality
does it do?
30th week detects L/S ratio:
lung maturity
Void before procedure
Ultrasound given to
determine position of
94

placenta and fetus.


Complications: premature
labor, infection, Rh
isommunization (if client Rh
negative, will be given
Rhogam)
What happens with an
5th week confirms pregnancy
ultrasound?
Determines position of fetus,
placenta, and # of fetuses.
Client must drink a lot of fluid
before procedure for full
bladder to have a clear
image.
What happens with a non- At 28th week records FHR and
stress test?
fetal movement.
Favorable result: 2+ FHR
accelerates by 15bpm and
last 15seconds in 20 minutes.
What happens with a
Determines placentas
contraction stress test?
response to labor.
Done after 28th week.
Fowler/Semi-Fowler.
Given Oxytocin or Pitocin.
Results:
Positive: Late
decelerations indicates
potential risk to fetus.
Negative: No late
decelerations.

What does Torch stand


for? And their
importance?

Diseases that cross placenta


or other events. Produce
significant deformities or
infant born with infectious
process.
Toxoplasmosis: no litter box
changed, no gardening, no
95

under cooked meats.


Rubella: 1-16 titer immune
for rubella, titer <1-8
susceptible.
Cytomegalovirus: transmitted
in body fluids.
Herpes Simplex: Ascending
infection. During pregnancy
get treated with acyclovir.
Delivery through c-section.
What concerns for clients UTI: may lead to
that have UTI, Syphilis,
pylonephritis, increase risk of
Gonorrhea?
premature birth.
Syphillis: passes through
placenta, causes 2nd trimester
abortions, still birth, and
congenital infection, may
receive medication for her
and her baby.
Gonorrhea: baby gets
prophylactic eydrops.
What are the danger signs
Gush or fluid bleeding
of pregnancy?
from vagina
Regular uterine
contractions
Severe headaches,
visual disturbances,
abdominal pain,
persistent vomiting
(symptoms of PIH)
Fever or chills
(symptoms of infection)
Swelling in face or
fingers (symptoms of
PIH)
What are the events in
Lightening: (when baby drops
the onset of labor?
to pelvis)
Primipara: occurs 2
weeks before delivery
Multipara: occurs during
labor
96

How does prolapsed


umbilical cords happen?

What do you do when a


client has a prolapsed
cord?

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

What are interventions for Position mother left


late decelerations?
side/trendenlenberg/knee
chest
Increase rate of IV
Administer Oxygen 7-10 l/min
DC Oxytocin
What do variable
Cord compression.
decelerations indicate?
Change maternal position.
Administer oxygen.
DC Oyxtocin/Pitocin
What are signs of True
Regular contractions
Labor?
increasing in frequency,
duration, intensity
Discomfort radiates from
back
Contractions do not decrease
with rest
Cervix progressively effaced
and dilated.
What are characteristics
Irregular contractions, no
of a False Labor?
change in frequency,
duration, intesityDiscomfort
is abdominal
Contractions decrease with
rest or activity
No cervical changes
Prior to Lumbar Epidural
Void
block what should the
patient do?
What should be
Establish airway
implemented during the
Check Apgar at 1 and 5
delivery of a newborn?
minutes
Clamp umbilical cord
Maintain Warmth
Place ID band on mother and
infant
What are the types of
Rubra-bloody, day 1-3
Lochia?
Serosa-pink-brown, day 4-9
Alba-yellow-white, 10+ days
If fundus is displaced not
Bladder distended.
98

centrally and off to the


sides means?
If client soaks pad in 15
minutes or pooling of
blood?
What are assessments
and implementations for
an Ectopic Pregnancy?

Check for hemorrhage

Unilateral lower quadrant


pain.
Rigid, tender abdomen
Low Hct and hCG levels
Bleeding
Monitor for shock
Administer RhoGAM
Provide support
What are assessments
A placenta thats implanted
and implementations for
in the lower uterine segment
Placenta Previa?
near cervical os, during
pregnancy placenta is torn
away causing:
First and second trimester
spotting
Third and trimester
painless, profuse bleeding
Bedrest side-lying or
trendelenburg position,
ultrasound to locate placenta,
no vaginal or rectal exams,
amniocentesis for lung
maturity, daily Hgb, Hct,
Monitor bleeding
What are the assessments The premature separation of
and implementation for
a placenta that is implanted
Abruptio Placentae?
in a correct position.
Painful vaginal bleeding
Abdomen tender, painful,
tense
Possible fetal
distress/Contractions
Monitor for maternal and
fetal distress
Prepare for immediate
delivery
99

What are assessments


and implementations for
Gestational Diabetes
Mellitus (GDM)?

What are assessments


and implementation for a
Hydatidiform Mole?

What are the newborn


vital signs?

What are assessments


and implementation for

Monitor for complications:


DIC, pulmonary emboli
Hyperglycemia after 20
weeks
Usually controlled by diet
Oral hypoglycemic
medications contraindicated
Test for diabetes at 24-28
weeks on all women with
average risk 20.
Frequent monitoring of
mother/fetus during
pregnancy.
Teach to eat prescribed
amount of food daily at same
times
Home glucose monitoring
Teach about change in insulin
requirements
Elevated hCG
Uterine size larger than
expected for dates
No FHT
Minimal dark red/brown
vaginal bleeding with grape
like clusters
Nausea and vomiting
Associated with PIH
Curettage to remove tissue
Pregnancy discouraged for 1
year
Do not use IUD
hCG levels monitored for 1
year
Temp. 97.7-99.7
HR sleep 100, awake 120140, 180 crying
Resp 30-60
BP arm/calf 65/41
Caused by immature hepatic
function
100

Hyperbilirubinemia?

Physiological Jaundice (No


treatment required)
Seen after 24 hours
Peaks at 72 hours
Lasts 5-7 days
Breast-Feeding Associated
Jaundice (Frequent breast
feeding)
Caused by poor milk
intake
Onset 2-3 days
Peaks 2-3 days
Breast Milk Jaundice
(discontinue breast feeding
for 24 hours)
Caused by factor in
breast milk
Onset 4-5 days
Peak 10-15 days
Hemolytic Disease
(Phototherapy then exchange
transfusion)
Caused by blood antigen
incompatibility (Rh or ABO
incompatibility)
Onset first 24 hours
Peak variable

What are assessments


Assessments
and implementations for a
High-pitched cry
Narcotic-Addicted infant?
(Hallmark sign)
Hyperreflexia
Decreased sleep
101

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

catheters, brown ace


bandages, band aid dressing,
elastic pressure stockings,
balloons, condoms
What are implementations Steamy shower
for Croup syndromes at
Exposure to cold air
home?
Cool, humidified air
Universal Donor Blood: Packed red blood cells (help oxygen deliver to
tissue, if you use whole blood there will be a risk for fluid overload), type O,
Rh-negative
5% Sodium Bicarbonatemetabolic alkalosis solution
Older adults are asymptomatic when they have an infection and can lead to
confusion.
Mononucleosis: complication enlarged spleen; concerned for trauma if child
plays dangerous sport.
Lyme disease:found mainly in mid alantic states (Connecticut)
Pottery is unglazed can lead to Lead Toxicity
Apgar Score: normal 7-10
WBC after pregnancy?
Ampicillin decreases oral contraceptives efficiency.
Tricuspid area: 5th intercostals space in the left sternum area
Tracheostomy care: no powder, suction trachea first then mouth, use precut gauze.
Hip-Flexion: causes increased intra-abdominal/thoracic pressure.
Injury C3 and above need respiratory ventilation.
SIADH causes: lung cancer, Cisplatin (Platinol)
103

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.
104

Herbs: Toxicities and Drug Interactions


Chamomile
Uses: Chamomile is often used in the form of a tea as a sedative.
Reactions: Allergic reactions can occur, particularly in persons allergic to
ragweed. Reported reactions include abdominal cramps, tongue thickness,
tightness in the throat, swelling of the lips, throat and eyes, itching all over
the body, hives, and blockage of the breathing passages. Close monitoring
is recommended for patients who are taking medications to prevent blood
clotting (anticoagulants) such as warfarin.
Echinacea
Uses: Largely because white blood cells in the laboratory can be stimulated
to eat particles, Echinacea has been touted to be able to boost the body's
ability to fight off infection.
Reactions: The most common side effect is an unpleasant taste. Echinacea
can cause liver toxicity. It should be avoided in combination with other
medications that can affect the liver (such as ketaconazole, leflunomide
(Arava), methotrexate (Rheumatrex), isoniazide (Nizoral).
St. John's Wort
Uses: St. John's Wort is popularly used as an herbal treatment for
depression, anxiety, and sleep disorders. It is technically known as
Hypericum perforatum. Chemically, it is composed of at least 10 different
substances that may produce its effects. The ratios of these different
substances varies from plant to plant (and manufacturer). Studies of its
effectiveness by the National Institutes of Health are in progress.
Reactions: The most common side effect has been sun sensitivity which
causes burning of the skin. It is recommended that fair- skinned persons be
105

particularly careful while in the sun. St. John's wort may also leave nerve
changes in sunburned areas. This herb should be avoided in combination
with other medications that can affect sun sensitivity (such as
tetracycline/Achromycin, sulfa- containing medications, piroxicam (Feldend).
St. John's wort can also cause headaches, dizziness, sweating, and agitation
when used in combination with serotonin reuptake inhibitor medications
such as fluoxetine (Prozac) and paroxetine (Paxil).
Garlic
Uses: Garlic has been used to lower blood pressure and cholesterol (Dr.
Lucinda Miller notes that there is "...still insufficient evidence to recommend
its routine use in clinical practice.")
Reactions: Allergic reactions, skin inflammation, and stomach upset have
been reported. Bad breath is a notorious accompaniment. Studies in rats
have shown decreases in male rats' ability to make sperm cells. Garlic may
decrease normal blood clotting and should be used with caution in patients
taking medications to prevent blood clotting (anticoagulants) such as
warfarin /Coumadin.
Feverfew
Uses: Most commonly used for migraine headaches.
Reactions: Feverfew can cause allergic reactions, especially in persons who
are allergic to chamomile, ragweed, or yarrow. Nonsteroidal 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),
106

naproxen (Aleve) or Motrin), or medications to prevent blood clotting


(anticoagulants) such as warfarin (Coumadin). Ginko should be avoided in
patients with epilepsy taking seizure medicines, such as phenytoin
(Dilantin), carbamazepine (Tegretol), and phenobarbital.
Ginseng
Uses: Ginseng has been used to stimulate the adrenal gland, and thereby
increase energy. It also may have some beneficial effect on reducing blood
sugar .in patients with diabetes mellitus. (Dr. Miller emphasized that there is
substantial variation in the chemical components of substances branded as
"Ginseng.")
Reactions: Ginseng can cause elevation in blood pressure, headache,
vomiting, insomnia, and nose bleeding. Ginseng can also cause falsely
abnormal blood tests for digoxin level. It is unclear whether ginseng may
affect female hormones. Its use in pregnancy is not recommended. Ginseng
may affect the action of the normal blood clotting element (platelets). It
should be avoided in patients taking aspirin, nonsteroidal antiinflammatory
drugs (such as ibuprofen (Advil), naproxen (Aleve) or Motrin), or
medications to prevent blood clotting (anticoagulants) such as warfarin
(Coumadin). Ginseng may also cause headaches, tremors, nervousness, and
sleeplessness. It should be avoided in persons with manic disorder and
psychosis.
Ginger
Uses: Ginger has been used as a treatment for nausea and bowel spasms.
Reactions: Ginger may lead to blood thinning. It is not recommended to be
taken with medications that prevent blood clotting (anticoagulants) such as
warfarin (Coumadin).
Saw Palmetto
Uses: Saw palmetto has been most commonly used for enlargement of the
prostate gland. (Dr. Miller emphasized that studies verifying this assertion
are necessary.) Saw palmetto has also been touted as a diuretic and urinary
antiseptic to prevent bladder infections.
Reactions: This herb may affect the action of the sex hormone testosterone,
thereby reducing sexual drive or performance. Dr. Miller states that "While
no drug-herb interactions have been documented to date, it would be
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prudent to avoid concomitant use with other hormonal therapies (e.g.,


estrogen replacement therapy and oral contraceptives...")
Black Cohosh
Claims, Benefits: A natural way to treat menopausal symptoms.
Bottom Line: Little is known about its benefits and its risks.
A child with celiac disease mustnt consume foods containing gluten and
therefore should avoid prepared puddings, commercially prepared ice
cream, malted milk, and all food and beverages containing wheat, rye, oats,
or barley.
The infant of a diabetic mother may be slightly hyperglycemic immediately
after birth because of the high glucose levels that cross the placenta from
mother to fetus. During pregnancy, the fetal pancreas secretes increased
levels of insulin in response to this increases glucose amount that crosses
the placenta from the mother. However, during the first 24 hours of life,
this combination of high insulin production in the newborn coupled with the
loss of maternal glucose can cause severe hypoglycemia. Frequent, early
feedings with formula can prevent hypoglycemia
Stump elevation for the first 24 hours after surgery helps reduce edema
and pain by increasing venous return and decreasing venous pooling at the
distal portion of the extremity.
A platypelloid pelvis has a flat shape. A gynecoid pelvis is a normal female
pelvis. An anthropoid pelvis has an oval shape, and an android pelvis has a
heart shape.
The pulse is the earliest indicator of new decreases in fluid volume.
Adult Rickets: deficiency in vitamin D.
Chronic Pain: normal blood pressure, heart rate, and respiratory rate.
Normal pupils and dry skin.
Acute pain: causes increased blood pressure, increased pulse, and
respiratory rate, dilated pupils, and perspiration.
The tip of the endotracheal tube lies 1 cm above the carina. This is
positioned above the bifurcation of the right and left mainstem bronchi.
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Creatine Phosphokinase (CPK) is a cellular enzyme that can be


fractionated into three isoenzymes.
MB band reflects CPK from CARDIAC MUSCLE (This is the level that

elevates with an MI.)


MM band reflects CPK from SKELETAL MUSCLE
BB band reflects CPK from the BRAIN

ALKYLATING AGENTS: affect ALL PHASES of the reproductive cell cycle


(i.e., Cyclophosphamide [Cytoxan])
ANTIMETABOLITES: are cell cycle phase-specific and affect the S PHASE
(i.e., Cytarabine [Cytosar])
VINCA ALKALOIDS: are cell cycle phase-specific and act on the M PHASE
Bells Palsy: is a one-sided facial paralysis from compression of the facial
nerve. The exact cause is unknown. Possible causes include vascular
ischemia, infection, exposure to viruses such as herpes zoster or herpes
simplex, autoimmune disease, or a combination of these items.
McBURNEYS POINT: is midway between the right anterior superior
iliac crest and the umbilicus. This is usually the location of greatest pain
in the child with appendicitis.
MMR: administered SQ in the outer aspect of the upper arm.
Watch for absolute words NOT and ONLY
AIR EMBOLISM POSITIONING: Place the client on the left side in the
trendelenburg position. Lying on the left side may prevent air from flowing
into the pulmonary veins. The trendelenburg position increases
intrathoracic pressure, which decreases the amount of blood pulled into the
vena cava during inspiration.
Trigeminal neuralgia pain medication: Use Carbamazepine (Tegretol) and
Phenytoin (Dilantin). Narcotic analgesics (Meperidine Hydrochloride
[Demerol], Codeine Sulfate , and Oxycodone) are not effective in controlling
pain caused by trigeminal neuralgia.
Grapefruit juice can raise cyclosporine (Sandimmune) levels by 50% to
100%, risk for toxicity.
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Fomepizole (Antizol): an antidote given IV to a client with Ethylene


Glycol (Antifreeze) intoxication
Phenotolamine (Regitine): antidote for hypertensive crisis
Bromocriptine (Parlodel): an antiparkinsonian prolactin inhibitor, is used
to treat NMS.
Biophysical profile: assesses five parameters of fetal activity: fetal heart
rate, fetal breathing movements, gross fetal movements, fetal tone, and
amniotic fluid volume. In a biophysical profile, each of the five parameters
contributes 0 to 2 points with a score of 8 being considered normal and a
score of 10 perfect.
G
Gravidity,
the number
of
pregnancie
s.

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.

Probable signs of pregnancy:


Uterine enlargement
Hegars sign (Softening and thinning of the lower uterine segment
that occurs about week 6)
Goodells sign (softening of the cervix that occurs at the beginning of
the second month)
Chadwicks 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 examiners fingers
on palpation)
Braxton Hicks contractions
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A positive pregnancy test measuring for human chorionic gonadotropin


Positive signs of pregnancy:
Fetal heart rate detected by electronic device (Doppler transducer) at
8-12 weeks and by nonelectronic device (Fetoscope) at 20 weeks of
gestation
Active fetal movements palpable by examiner
An outline of fetus via radiography or ultrasound
Acetazolamide (Diamox): used for management of glaucoma is a carbonic
anyhdrase inhibitor that has sulfonamide properties.
Watch out for absolute words ALL and ALWAYS
Before NG removal: bowel sounds have to be present.

Hyperkalemia on Electrocardiogram:
Tall, peaked T waves; prolonged PR interval; widening QRS complex
Hypokalemia on Electrocardiogram: ST segment depression; Flat T
wave
First-Degree Heart Block: Prolonged P-R interval
Bundle Branch Block: Widened QRS complex
Myocardial Necrosis in Area: Q waves present
Ventricular Fibrillation: No visible P waves or QRS complexes, no
measurable rate. Irregular, chaotic undulations of varying
amplitudes.
HypoCalcemia: Prolonged Q-T interval
Myocardial Ischemia: ST segment elevation or depression

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Premature Ventricular Contractions: absence of P waves, wide and


bizarre QRS complexes, and premature beats followed by a
compensatory pause
Ventricular Tachycardia: absence of P waves, wide QRS complexes,
rate between 100 and 250 impulses per minute. Regular rhythm
Atrial Fibrillation: no P waves; instead there are wavy lines, no PR
interval. QRS duration is WNL and irregular ventricular rate can
range from 60-160 beats/minute.
Stable
Triggered by
a predictable
amount of
effort or
emotion.

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.

Cardiac Conduction System: Sinoatrial NodeInternodal/Interatrial


pathwaysAV nodeBundle of HisR/L Bundle BranchesPurkinje fibers
Pulse rate is the earliest indicator of decrease in fluid volume.
A1-adrenergic receptors: found in the peripheral arteries and veins and
cause a powerful vasoconstriction when stimulated
A2-adrenergic receptors: several tissues and contract smooth muscle,
inhibit lipolysis, and promote platelet aggregation.
B1: Found in the heart and cause an increase in heart rate, atrioventricular
node conduction, and contractility.
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B2: Arterial and bronchial walls and cause vasodilation and bronchodilation.
PULSE PRESENT = NO DEFIBRILLATION
Myxedema (a.ka. Hypothyroidism)
Suggested toys
a. birth to six months - mobiles, unbreakable mirrors, music boxes, rattles
b. six to 12 months - blocks, nesting boxes or cups, simple take apart
toys, large ball, large puzzles, jack in the box, floating toys, teething
toys, activity box, push-pull toys
c. Solitary play
Toddlerhood (one year to three years)
Play is parallel
Suggested toys: push-pull toys, finger paints, thick crayons, riding toys,
balls, blocks, puzzles, simple tape recorder, housekeeping toys,
puppets, cloth picture books, large beads to string, toy telephone,
water toys, sand box, play dough or clay, chalk and chalkboard
Preschool age (three years to six years)

Preschool play is associative and cooperative.


dress-up
fantasy play
imaginary playmates
Suggested toys: tricycle, gym and sports equipment, sandboxes,
blocks, books, puzzles, computer games, dress-up clothes, blunt
scissors, picture games, construction sets, musical instruments, cash
registers, simple carpentry tools

School age (six years to 12 years)


Play is cooperative.
1.
2.
3.
4.
5.

sports and games with rules


fantasy play in early years
clubs
hero worship
cheating
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6. Suggested toys/activities: board or computer games, books,

collections, scrapbooks, sewing, cooking, carpentry, gardening,


painting
Tympany: Drumlike, loud, high pitch, moderate duration; usually found
over spaces containing air such as the stomach
Resonance:Hollow sound of moderate to loud intensity; low pitch, long
duration; Usually heard over lungs
Hyperresonance: Booming sound of very loud intensity; very low pitch,
long duration; Usually heard in the presence of trapped air (such as
emphysematous lung)Flatness:
Flat sound of soft intensity; high pitch; short duration; Usually heard over
muscle
Dullness:Thud-like sound of soft intensity; high pitch; moderate duration;
Usually heard over solid organs (such as heart, liver)
body temperature
o

range: 36 to 38 degrees Celsius (98.6 to 100.4 degrees Fahrenheit)

St. John's wort - antidepressant


Garlic - antihypertensive
Ginseng - Anti stress
Green tea - antioxidant
Echinacea - immune stimulant (6-8 weeks only)
Licorice - cough and cold
Ginger root - antinausea
Ginkgo - improves circulation
Ma huang - bronchodilator, stimulant
Anatomical Landmarks of the HEART
i.
ii.
iii.
iv.
v.

vi.

second right intercostal space - aortic area


second left intercostal space - pulmonic area
third left intercostal space - Erb's point
fourth left intercostal space - tricuspid area
fifth left intercostal space - mitral (apical) area
epigastric area at tip of sternum
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Range of Normal Blood Pressure


i.

child under age two weighing at least 2700g: use flush technique,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.

Normal Range of Peripheral Pulses

infants: 120 to 160 beats/minutes


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

Normal Rates of Respirations

newborn: 35 to 40 breaths/minute
infant: 30 to 50 breaths/minute
toddler: 25 to 35 breaths/minute
school age: 20 to 30 breaths/minute
adolescent/adult: 14 to 20 breaths/minute
adult: 12 to 20 breaths/minute
CRANIAL NERVE FUNCTION

1. Olfactory (CN I)

Can identify variety of smells


Deviation: Inability to identify aroma

2. Optic (CN II)

Has visual acuity and full visual fields


Fundoscopic exam reveals no pathology
Deviation: Inability to identify full visual fields - total or partial
blindness of one or both eyes

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

Follows up to six cardinal positions of gaze


115

Pupils are unremarkable


Exhibits no nystagmus and no ptosis
Deviation: one or both eyes will deviate from its normal position

5. Trigeminal (CN V)

Clenches teeth with firm bilateral pressure


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

7. Facial (CN VII)

Has facial symmetry with and without a smile


Can raise the eyebrows symmetrically and grimace
Can shut eyes tightly
Can identify sweet, sour, salt or bitter on the anterior tongue
Deviation: Irregular and unequal facial movements
Deviation: Inability to taste or identify taste
Deviation: Inability to taste or identify salt, sweet, sour, or bitter
substances on the anterior two-thirds of the tongue
Deviation: Inability to smile symmetrically

8. Acoustic (CN VIII)

Can hear a whisper at 1-2 feet


Can hear a watch tick at 1-2 feet
Does not lateralize the Weber test
Can hear AC (air conduction) better than BC (bone conduction) in the
Rinne test
Deviation: Inability to hear spoken word

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

Swallows and speaks without hoarseness


Palate and uvula rise symmetrically when patient says "ah"
Bilateral gag reflex
Can identify taste on the posterior tongue
116

Deviation: Unequal or absent rise of uvula and soft palate as the client
says, "ah"
Deviation: Absent gag reflex
Deviation: inability to taste or identify taste on the posterior tongue

11. Spinal accessory (CN XI)

Resists head turning


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

12. Hypoglossal (CN XII)

Can stick tongue out and move it from side to side


Can push tongue strongly against resistance
Deviation: Tongue deviates to side

Types of Coping Mechanisms


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

2.

3.

4.

5.

6.

lack in another area


o Example: Short man becomes assertively verbal and excels in
business.
Conversion - A mental conflict is expressed through physical
symptoms
o Example: Woman becomes blind after seeing her husband with
another woman.
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."
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.
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.
Fantasy - a conscious distortion of unconscious wishes and need to
obtain satisfaction
117

Example: A student nurse fails the critical care exam and


daydreams about her heroic role in a cardiac arrest.
7. Fixation - becoming stagnated in a level of emotional development in
which one is comfortable
o Example: A sixty year old man who dresses and acts as if he were
still in the 1960's.
8. Identification - subconsciously attributing to oneself qualities of
others
o Example: Elvis impersonators.
9. Intellectualization - use of thinking, ideas, or intellect to avoid
emotions
o Example: Parent becomes extremely knowledgeable about child's
diabetes.
10. Introjection - incorporating the traits of others
o Example: Husband's symptoms mimic wife's before she died.
11. Projection - unconsciously projecting one's own unacceptable
qualities or feelings onto others
o Example: Woman who is jealous of another woman's wealth
accuses her of being a gold-digger.
12. Rationalization - justifying behaviors, emotions, motives, considered
intolerable through acceptable excuses
o Example: "I didn't get chosen for the team because the coach
plays favorites."
13. Reaction Formation - expressing unacceptable wishes or behavior by
opposite overt behavior
o Example: Recovered smoker preaches about the dangers of
second hand smoke.
14. Regression - retreating to an earlier and more comfortable emotional
level of development
o Example: Four year old insists on climbing into crib with younger
sibling.
15. Repression - unconscious, deliberate forgetting of unacceptable or
painful thoughts, impulses, feelings or acts
o Example: Adolescent "forgets" appointment with counselor to
discuss final grades.
16. Sublimation - diversion of unacceptable instinctual drives into
personally and socially acceptable areas.
o Example: Young woman who hated school becomes a teacher.
o

Elizabeth Kubler-Ross: Five Stages


1. Denial
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a. Unconscious avoidance which varies from a brief period to the


remainder of life
b. Allows one to mobilize defenses to cope
c. Positive adaptive responses - verbal denial; crying
d. Maladaptive responses - no crying, no acknowledgement of loss
2. Anger
a. Expresses the realization of loss
b. May be overt or covert
c. Positive adaptive responses - verbal expressions of anger
d. Maladaptive responses - persistent guilt or low self esteem,
aggression, self destructive ideation or behavior
3. Bargaining
a. An attempt to change reality of loss; person bargains for
treatment control, expresses wish to be alive for specific events in
near future
b. Maladaptive responses - bargains for unrealistic activities or
events in distant future
4. Depression and Withdrawal
a. Sadness resulting from actual and/or anticipated loss
b. Positive adaptive response - crying, social withdrawal
c. Maladaptive responses - self-destructive actions, despair
5. Acceptance
a. Resolution of feelings about death or other loss, resulting in
peaceful feelings
b. Positive adaptive behaviors - may wish to be alone, limit social
contacts, complete personal business
FOODS HIGH IN WATER-SOLUBLE VITAMINS
A. Vitamin C - citrus fruits, cabbage, tomatoes, strawberries, broccoli
B. Thiamine (B1) - lean meat, legumes,unrefined or enriched grains and
cereals
C. Riboflavin (B2) - enriched grains, milk, organ meats, poultry, fish
D. Niacin - peanuts, peas, beans, meat, poultry
E. Pyridoxine (B6) - kidneys, liver, meats, corn, wheat, eggs, poultry, fish
F. Cyanocobalamin (B12) - kidneys, lean meats,liver, dairy products, egs
G. Folic acid - liver, eggs, leafy green vegetables, fruits, enriched grain
products
FOODS CONTAINING FAT-SOLUBLE VITAMINS
A. Vitamin A - fruits, green and yellow vegetables, butter, milk, eggs, liver
119

B. Vitamin D - milk, fish


C. Vitamin E - green vegetables, vegetables oils, wheat germ, nuts
D. Vitamin K - liver, cheese, leafy green vegetables, milk, green tea

mucomyst: acetaminophen toxicity

120

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