Guys,this is a file for NCLEX tips but I couldn't find where to attach it,so I pasted..
Good luck,
Dilantin detoxified by liver.
The nurse cares for a client receiving IV antibiotics every 8 hours for the past 4 days. The antibiotic is mixed in D5W. The nurse determines that a post-infusion phlebitis has occurred if which of the following is observed?
1. Tenderness at the IV site.
2. Increased swelling at the insertion site.
3. Area around the IV site is reddened with red streaks.
4. Fluid is leaking around the IV catheter.
a. Tenderness occurs with phlebitis but is not specific to it.
b. May indicate either infiltration or phlebitis
c. CORRECT--reddened, warm area noted around insertion site or on path of vein; discontinue IV, apply warm, moist compresses, restart IV at new site
d. Not indicative of phlebitis
Ethacrynic Acid (Edecrin)--are considered loop diuretics and are potassium wasting; encourage client to increase intake of potassium-rich foods. Orange juice/Bananas, etc.
Aminophylline (Truphylline)--is a xanthine bronchodilator; major side effects: palpitations, nervousness, rapid pulse, dysrhythmias, nausea, and vomiting. Toxic effects: confusion, headache, flushing, tachycardia, and seizure.
Morphine Sulfate--decreases blood return to the right side of the heart, and decrease peripheral resistance. In other words, decreases preload and afterload pressures and cardiac workload; causes vasodilation and pooling of fluid in extremities; provides relief from anxiety.
Intropin (Dopamine)--vasoactive medication are given IV to restore BP in hypotensive states; Increases blood return to the right side of the heart, and increase peripheral resistance; side effects: headache, severe hypertension, dysrhythmias; check BP q2 minutes until stabilized, then q5 minutes
TPN--hang no longer than 24 hours; IV tubing and filters every 24 hours; site of catheter changed every 4 weeks.
Fluoxetine (Prozac)--a selective serotonin reuptake inhibitor (SSRI) used to treat depression and obsessive compulsive disorder. Side effects: postural hypotension, dry mouth, rapid heartbeat, anorexia, weight loss, severe headache. If dose is missed, omit dose and instruct client to return to regular dosing schedule.
Propanolol (inderal)--a beta-adrenergic blocker used as antihypertensive; Side effects: bronchospasm, bradycardia, depression. Take pulse before administration and gradually decrease when discontinuing. Do not give to asthmatic patients.
Glipizide (Glucotrol)--an oral hypoglycemic that decreases blood sugar by stimulating insulin release from the beta cells of the pancreas; may cause aplastic anemia and photosensitivity.
Prednisone (Deltasone)--a corticosteroid. Side effects: hyperglycemia
Bethanechol (Urecholine)--a cholinergic or parasympathomimetic used to treat functional urinary retention; mimics action of acetylcholine.
Ventricular Tachycardia--causes chest pain, dizziness, and fainting.
1 grain = 60mg
Levothyroxine (Synthroid)--thyroid preparation should be administered at breakfast to prevent insomnia.
Carbamazepine (Tegretol)--interferes with action of hormonal contraceptives. Side effects: photosensitivity.
Aluminum Hydroxide (Amphojel)--an antacid; neutralizes hydrochloric acid and reduces pepsin activity; take one hour before and hour of sleep. Antacids most effective after digestion has started, but prior to the emptying of the stomach.
Isoniazid (INH)--Side effects: peripheral neuropathy (administer pyridoxine), rash, urticaria, and swelling of the face, lips, and eyelids.
Pyridoxine (Vitamin B6, Beesix, Doxine)--required for amino acid, carbohydrate, and lipid metabolism. Used in the transport of amino acids, formation of neurotransmitters, and sythesis of heme. Prevention of neuropathy.
Carbamazepine (Tegretol)--prevention of seizures and relief of pain in trigeminal neuralgia. Trigeminal neuralgia (Tic douloureux) is an agonizing pain that may result in severe depression and suicide.
Clonidine (Catapres-TTS)--is a centrally acting alpha-adrenergic used to treat hypertension; Side effects: drowsiness, sedation, orthostatic hypotension, heart failure. If patch used be cautious around microwaves results in burns, dispose of carefully, and heat will increase medication absorption leading to toxicity.
Phlebitis--tenderness, redness; remove iv, apply warm soaks to decrease inflammation, swelling, and discomfort.
Autologous blood--may give blood 5 weeks before surgery; can give 2 to 4 units of blood; may have to take iron pills
Partial-thickness burn; only part of skin is damaged or destroyed; large, thick-walled blisters develop; underlying tissue is deep red, appears wet and shiny; painful with increased sensitivity to heat; healing occurs by evolution of undamaged basal cells, takes about 21-22 days. I.E., Redness and swelling with fluid-filled vesicles noted on right arm or Blistering and blanching of the skin noted on the back.
Full-thickness burn; all skin is destroyed and muscle and bone may be involved; substance that remains is called eschar, dry to touch, doesn't heal spontaneously, requires grafting. I.E., Charred, waxy, white appearance of skin on left leg.
Superficial burn; skin appears pink, increased sensitivity to heat, some swelling, healing occurs without treatment. I.E., Reddened blotchy painful areas noted on the face.
Carbidopa/Levodopa (Sinemet)--used to treat symptoms of Parkinson's disease. Take immediately before meals and high-protein meals may impair effectiveness of medication. Reduces rigidity and bradykinesis and facilitates client's mobility.
Doxycycline (Vibramycin)--a tetracycline that is taken at regular intervals but not within 1 hour of bedtime because it may cause esophageal irritation. Use another method of birth control, do not take antacids within 1-3 hours of taking medication, and may cause photosensitivity.
Albuterol (Proventil)--a bronchodilator. Side effects: tremors, headache, hyperactivity, tachycardia. Use first before steroid medication so opens up bronchioles for steroid to get in. Wait one minute between puffs of the inhalers for best effect.
Beclomethasone (Vanceril)--a steroid medication. Side effect: fungal infections, dry mouth, throat infections.
Insulin--NPH Onset: 1.5 hours Peak: 4-12 hours Regular Onset: 0.5 hours Peak: 2.5-5 hours
Topiramate (Topamax)--is an anticonvulsant. Should drink 2000-3000ml of fluid daily to prevent kidney stones. Side effects: orthostatic hypotension, ocular symptoms, blindness, and decrease effects of hormonal contraceptives.
Propranolol (Inderal)--a beta-blocker that takes up beta-adrenergic receptor sites, which prevents adrenaline from causing symptoms and glycogenolysis. Inderal may mask symptoms of hypoglycemia, removing the body's early warning system.
Phenazopyridine (Pyridium)--acts on urinary tract mucosa to produce analgesic or local anesthetic effects. Side effects: bright orange urine, yellowish discoloration of skin or sclera indicates drug accumulation due to renal impairment.
Trimethoprim-sulfamethoxazole (Bactrim)--most common side effect mild to moderate rash (urticaria)
Aminoglycosides are ototoxic.
Butorphanol Tartrate (Stadol)--analgesic used for moderate to severe pain; Side effects include change in BP, bradycardia, respiratory depression.
Infant normal resting heart rate: 120-140
Salt substitutes contain potassium
When directing a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be reported. Because the RN is responsible for all care-related decisions, only implementation tasks should be assigned because they do not require independent judgment.
When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis)
READ THE QUESTIONS FIRST!!!!!
READ THE QUESTIONS FIRST!!!!!
DETERMINE THE QUESTION!!!!!!
Rash and blood dyscrasias are side effects of anti-psychotic drugs. A history of severe depression is a contraindication to the use of neuroleptics.
Children with celiac disease should eat a gluten free diet. Gluten is found mainly in grains of wheat and rye and in smaller quantities in barley and oats. Corn, rice, soybeans and potatoes are digestible in persons with celiac disease.
The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk because Decadron increases the production of hydrochloric acid, which may cause gastrointestinal ulcers.
The protest phase of separation anxiety is a normal response for a child this age (2 year-old hospitalized child). In toddlers, ages 1 to 3, separation anxiety is at its peak
Signs of tardive dyskinesia include smacking lips, grinding of teeth and "fly catching" tongue movements.
Verapamil, Bretylium, and Amiodarone increases serum dig levels, possibly causing Digitalis Toxicity
Signs/Symptoms of Digital Toxicity: first signs include abdominal pain, anorexia, nausea, vomiting, visual disturbances, bradycardia, and other arrhythmias. In infants and small children, the first symptoms of overdose are usually cardiac arrhythmias.
Restlessness, confusion, irritability and disorientation may be the first signs of fat embolism syndrome followed by a very high temperature.
A Neologism is a new word self invented by a person and not readily understood by another that is often associated with a thought disorder.
Pancreatic enzymes give before meals.
Clinical features of delusional disorder include extreme suspiciousness, jealousy, distrust, and belief that others intend to harm.
The UAP can be assigned to care for a client with a chronic condition after an initial assessment by the nurse. This client has no risk of instability of condition.
Never leave your patient. For example, Ask the LPN/LVN to stay with the child and his parents while the nurse obtains phone orders from the physician.
Tips for charting: don't use inflammatory words, no nurse judgments, be as specific as possible. I.E.,
"Vital signs stable" is incorrect for of charting.
Restraint: frame of bed, quick release ties, document need for restraint Q4 hours
Never ask "WHY" questions in the NCLEX!
Gag Reflex: don't assess gag reflex to a client that has an absent swallow reflex
Nifedipine (Procardia XL): do not crush
An RN that is not assigned to a patient does not have the authority to tell a nurse what to do. Refer it to nursing supervisor.
If doctor has orders it should carried out unless contraindicated in nurse's decision.
Physical assessment: Inspection, Percussion, Palpation, Auscultation (Except for abdomen: Inspection, Auscultation, Percussion, Palpation)
Coronary artery bypass graft (CABG)--halt medications before surgery, can do 5 at a time; will be on mechanical ventilations after surgery; chest tubes
Acromegaly--monitor blood sugar, atrium--90 implant care (radioactive, nasally implanted, monitor vision)
Bone marrow Aspiration---done at iliac crest; painful
Postoperative care after Supratentorial surgery: maintain airway, elevate head 30-45
Position care after Infratentorial surgery: flat and lateral
Orange juice does not help acidify urine it makes it more alkaline.
Myelogram
* Water-soluble dye--elevate head of bed 30 degrees (not removed)
* Oil based dye--flat in bed (removed)
Fractures:
Immobilize joint above and below fracture
Cover open fracture with cleanest material available
Check temperature, color, sensation, capillary refill distal to fracture
Close reduction--manually manipulate bone or use traction
Buck's Traction
Use to relieve muscle spasm of leg and back
If used for muscles spasms only, they can turn to either side.
If used for fracture treatment, only can turn to unaffected side.
Use 8-20 lbs of weight, if used for scoliosis will use 40 lbs of weight.
Elevate head of bed for countertraction or foot bed
Place pillow below leg not under heel or behind knee.
Russell's Traction
Sling is used
Check for popliteal pulse
Place pillow below lower leg and heel off the bed
Don't turn from waist down
Lift patient, not the leg
Cervical Tongs
Never lift the weights
No pillow under head during feedings
Balanced Suspension Traction
For femur realignment
Maintain weights hanging free and not on floor
Maintain continuous pull
Halo Jacket
Maintain pin cleansing
Casts
Don't rest on hard surface
Don't cover until dry 48+ hours
Handle with palms of hands not with fingers
Keep above level of heart
Check for CSM
Fractured Hip
* Assessments
Leg shortened
Adducted
Externally rotated
* Implementation
Care after a total hip replacement
* Abduction pillows
* Crutch walking with 3-point gait
* Don't sleep on operated side
* Don't flex hip more than 45-60 degrees
* Don't elevate head of the bed more than 45 degrees
Amputations
* Guillotine (open)
* Flap (closed)
* Delayed prosthesis fitting
Residual limb covered with dressing and elastic bandage (figure eight)
* Figure-8 doesn't restrict blood flow, shaped to reduce edema
Check for bleeding
Elevated 24 hours (AKA-pillow, BKA-foot of bed elevated)
Position prone daily
Exercises, crutch walking
Phantom Pain: acknowledge feelings, that pain is real for them.
Thiamin (Vit. B1)--carbohydarte metabolism; deficiency will cause Beri-Beri
Pyridoxine (Vit. B6)--amino acid metabolism; deficiency will cause anemia, seizures
Folic acid--RBC formation; deficiency will cause anemia
Cyanocobalamin (B12)--nerve function; deficiency cause pernicious anemia
Calcium deficiency causes Rickett's
Cultural Food Pattern's
Orthodox Jewish (Kosher)--milk and meat cannot be eaten at same meal
Muslin--30 day fast during Ramadan
Japanese--rice is basic food, tea is main beverage
Greek--bread is served with every meal
Enteral feeding held if: 150 or > cc's aspirated or 50% given in the hour is aspirated
If cramping, vomiting occurs decrease rate of enteral feeding or keep it warm.
TPN--supply nutritions via intravenous route
Peripherally or centrally
Initial rate 50/hour and can be increased to 100-125ml/hour.
A pump must be used to keep rate constant
Prevent sepsis: maintain closed system,, don't draw blood/infuse anything in line, dry sterile dressing
Verify placement of line
Monitor Glucose, acetone
Change IV tubing/Filter Q24 hours
Solution refrigerated then warmed
If solution not available, start 10% in water.
3/week check BUN, electrolytes (ca, mg)
When TPN Dc'd taper patient off or else will get rebound hypoglycemia (use hypotonic to do this)
Specific gravity 1.010-1.030
Ph 4.5-8
1,000-1,500cc/day
Crede's Manuever--push urine out
Pernicious Anemia
- monthly Vitamin B12 IM injections
Metered dose inhaler
- Beclomethasone (Vanceril)
- Albuterol (Proventil)
Guillain-Barre Syndrome
- GBS often preceded by a viral infection as well as immunizations/vaccinations
- Intervention is symptomatic
- Acute phase: Steroids, plasmapheresis, aggressive respiratory care; prevent hazards of immobility, maintain adequate nutrition; physical therapy; pain-reducing measures; eye care, prevention of complications (UTI, aspiration); psychosocial support
Organ Donation Criteria
- No history of significant, disease, process in organ/tissue to be donated
- No untreated sepsis
- Brain death of donor
- No history of extracranial malignancy
- Relative hemodynamic stability
- Blood group compatibility
- Newborn donors must be full term (more than 200g)
- Only absolute restriction to organ donation is documented case of HIV infection
- Family members can give consent
- Nurse can discuss organ donation with other death-related topics (funeral home to be used, autopsy request)
Accurate way to verify NG tube position is to aspirate for gastric contents and check pH.
Parkinson's disease
- Activities should be scheduled for late morning when energy level is highest and patient won't be rushed
- Symptoms: tremors, akinesia, rigidity, weakness, "motorized propulsive gait, slurred monotonous speech, dysphagia, drooling, mask-like expression.
- Nursing care: encourage finger exercises. Administer Artane, Congentin, L-Dopa, Parlodel, Sinemet, Symmetrel.
- Teach: ambulation modification
- Promote family understanding of disease intellect/sight/hearing not impaired, disease progressive but slow, doesn't lead to paralysis
Normal urine output (1200-1500 cc's/day or 50-63 cc/hr, normal voiding pattern 5-6 times/day.
Green leafy vegetables contain vitamin K.
Labs
HbA1c (4.5-7.6%)
- indicates overall glucose control for the previous 120 days
Serum Amylase / Somogyl (60-160 u/dL)
- elevated in acute pancreatitis
Erythrocyte Sedimentation Rate (ESR)
- Men (1-15)
- Women (1-20)
- Rate at which RBC's settle out of unclottted blood in one hour
- Indicates inflammation/neurosis
Hematocrit (Hct)
- Men (40-45) u/mL
- Women (37-45) u/mL
- Relative volume of plasma to RBC
- Increased with dehydration
- Decreased with volume excess
Creatine Kinase (CK)
- Men (12-70)
- Women (10-55)
- Enzyme specific to brain, myocardium, and skeletal muscles
- Indicates tissue necrosis or injury
Serum Glucose
- 60-110 mg/dL
Sodium (Na+)
- 135-145 mEq/L
- Hypernatremia
o Dehydration and insufficient water intake
Chloride (Cl-)
- 95-105 mEq/L
Potassium (K+)
- 3.5-5.0 mEq/L
Bicarbonate (HCO3)
- 22-26 mEq/L
- Decreased levels seen with starvation, renal failure, diarrhea.
Blood, Urea, Nitrogen (BUN)
- 6-20 mg
- Elevated levels indicate rapid protein catabolism, kidney dysfunction, dehydration
Creatinine Clearance Test
- normal 125 ml/min.
- Lower levels reflect renal insufficiency and may influence the excretion of many drugs and toxins from the body.
Lithium
- targeted blood level: (1-1.5 mEq/L)
Tofranil and Anafranil--OCD medications
Pick physical needs over psychosocial needs!!!!!!!!!!!!!!!
Focus on here and now!!!!!!!!!!!!!!!!!
Oculogyric crisis: uncontrollable rolling back of eyes: side effect of Phenothiazines
Moribund means dying patient.
Don't leave your patients. Stay with your patients.
Assess before implementation.
Manic patient: decrease stimuli and increase rest period and no competition.
Lithium helps control impulsive behaviors.
Fluphenazine (Prolixin): antipsychotic medication
Thiamine sources: organ meats, liver, whole grain, nuts, legume, egg, and milk.
Don't document abuse. Report suspected abuse to nursing supervisor.
Never promise a patient "Not to tell."
Tonometry--measures intraocular pressure; to rule out glaucoma
Myopia--nearsightedness (near clear, distance clear)
Hyperopia--farsightedness (distance is clear, near vision blurry)
Presbyopia--changes with aging
Blind client: address by name, introduce self, keep furniture arrangement consistent, open or close doors walk ½ step ahead, identify food location on tray.
Instilling ear drops lie patient on unaffected ear to absorb drops.
Position patient on affected ear to promote drainage.
Regular Insulin only given IV.
Sick day rules: take insulin as ordered, check blood glucose q3-4 hours, soft foods, liquids
Phenylketonuria--high blood phenylalanine (no enzyme), results in mental retardation; milk substitutes, low-protein diet
Celiac Disease (SPrue)--intestinal malabsorption, malnutrition (unable to digest wheat/rye/oats/barley); gluten-free diet
Hepatobiliary disease--decrease in ability of bile to absorb fat, fat malabsorption; low-fat high-protein diet, vitamins
Cystic fibrosis--absence of pancreatic enzymes, malabsorption of fat, lung disease, pancreatic enzyme replacement, high-protein, high-calorie diet, respiratory care/suction
Position right side to promote gastric emptying.
Dumping syndrome prevention: restrict fluid with meals, lie down after eating, small, frequent meals, low-carbohydrate, low-fiber diet
Sengstaken-Blakemore Tube--to treat pt. with esophageal varices.
Hepatitis B Vaccine
Given IM to vastus lateralis or deltoid
Side effects: mild tenderness at site
* 1st shot - Birth to 3 months
* 2nd shot - 1 to 4 months
* 3rd shot - 6 to 18 months
DTaP (Diptheria, Tetanus, and Pertussis)
Given IM anterior or lateral thigh
Side effects: fever within 24-48 hours, swelling, redness, soreness
Don't treat with aspirin, use other antipyretic.
* 1st shot - 2 months
* 2nd shot - 4 months
* 3rd shot - 6 months
* 4th shot - 15 to 18 months
* 5th shot - 4 to 6 years
* Only TD shot - 11 to 16 years
Hib (Influenza)
* 1st shot - 2months
* 2nd shot - 4months
* 3rd shot - 6 months
* 4th shot - 12 to 18 months
IPV (Inactive Polio Vaccine)
Given PO, Few side effects
* 1st shot - 2 months
* 2nd shot - 4 months
* 3rd shot - 6 to 18 months
* 4th shot - 4 to 6 years
MMR (Mumps, Measles, and Rubella)
Given SC anterior or lateral 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
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
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
* Resp: 15-25
* BP: 100/56 - 110/60
Adult
* Pulse: 60-100
* Resp: 12-20
* BP: 90/60-140/90
Aortic Valve: Right of Sternum at the 2nd intercostal space
Pulmonic Valve: Left of Sternum at the 2nd intercostal space
Tricuspid Valve: Immediately left of sternal border at the 5th Intercostal Space
Mitral Valve (Point of Maximal Impulse): Left of Sternum Mid-Clavicular Line at the 5th Intercostal Space
Erbb's Point: Left of Sternum at the 3rd intercostal space
Infant (Point of Maximal Impulse): Lateral to sternum 4th intercostals space
Obese person choking use Chest Thrusts.
Tracheostomy tube placement of cuff maintained to prevent aspiration
Care for patient first, equipment second
Signs for hypoxia: restlessness, tachycardia
CPR: Shake, shout, summon help, open airway, look, listen, feel for signs of breathing, pinch nose, give 2 full breaths (if no rise, reposition)
Adults 12/min check carotid, chest compressions 80-100/min 1.5 inches
Infants 20/min check brachial pulse, chest compression 100/min ½ - 1 inch
15:2 Adult 4 cycles
Infant 20 cycles
Reassess pulse and breathing
Continue CPR until:
* Victim responds
* Someone else takes over
* 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 therapy-streptokinase, t-PA
* Bedrest
* Beta-blockers, morphine sulfate, dysrhythmics, anticoagulants
* Do not force fluids (will give heart more to work with)
Defibrillation
* Start CPR first
* 1st attempt - 200 joules
* 2nd attempt - 200 to 300 joules
* 3rd attempt - 360 joules
* Check monitor between shocks for rhythm
Cardioversion
* Elective procedure, Informed Consent
* Valium IV
* Synchronizer on
* 25-360 joules
* Check monitor between rhythm
Epidural hematoma - short period of unconsciousness, ipsilateral papillary dilation, contralateral weakness of extremities
Subdural hematoma - decreased LOC, ipsilateral papillary dilation, contralateral weakness of extremities, personality changes
CSF leakage - good place to look is behind the ears.
Head Injury - elevate bed 30 degrees, barbiturate therapy, hypothermia, glucocorticoids (Decadron)
Flail Chest
Affected side goes down during inspiration 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 Implementation
Monitor for shock
Humidified oxygen
Thoracentesis (aspiration of fluid from pleural space)
Chest Tubes
Cullen's Sign - ecchymosis around umbilicus
Turner's Sign - ecchymosis around either flank
Balance's sign - resonance over spleen (+) means rupture of spleen
Shock Signs and Symptoms
* Cool, clammy skin
* Cyanosis
* Decreased alertness
* Tachycardia
* Hypotension
* Shallow, rapid respirations
* Oliguria
Hypovolemic
Decreased in intravascular volume Cardiogenic
Decreased cardiac output Distributive
Problem with blood flow to cells
Implementation for shock
* Monitor CVP: 11 too much fluid
Increased ICP
Assessments
* Altered LOC (Earliest Sign)
* Glasgow coma scale
* Confusion
* Restlessness
* Pupillary changes
* Vital sign changes - WIDENING PULSE PRESSURE Implementations
* 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: 3.5-5.0 mEq/L
Sodium: 135-145 mEq/L
Calcium: 4.5-5.2 mEq/L
Magnesium: 1.5-2.5 mEq/L
Hypokalemia Assessments
* K+
* Muscle weakness
* Paresthesias
* Dysrhythmias
* Increased sensitivity to digitalis Hypokalemia Implementations
* Potassium Supplements
* Don't give > 40 mEq/L into peripheral IV or without cardiac monitor
* Increase dietary intake - oranges, apricots, beans, potatoes, carrots, celery, raisins
Hyperkalemia Assessments
* K+ >5.0 mEq/L
* EKG changes
* Paralysis
* Diarrhea
* Nausea Hyperkalemia Implementations
* Restrict oral intake
* Kayexalate
* Calcium Gluconate and Sodium Bircarbonate IV
* Peritoneal or hemodialysis
* Diuretics
Hyponatremia Assessments
* Na+
* Nausea
* Muscle cramps
* Confusion
* Increased ICP Hyponatremia Implementations
* I & O
* Daily weight
* Increase oral intake of sodium rich foods
* Water restriction
* IV Lactated Ringer's or 0.9% NaCL
Hypernatremia Assessments
* Na+ >145 mEq/L
* Disorientation, delusion, hallucinations
* Thirsty, dry, swollen tongue
* Sticky mucous membranes
* Hypotension
* Tachycardia Hypernatremia Assessments
* I & O
* Daily Weight
* Give hypotonic solutions: 0.45% NaCl or 5% Dextrose in water IV
Hypocalcemia Assessments
* Ca+
* Tetany
* Positive Trousseau's sign
* Positive Chvostek's sign
* Seizures
* Confusion
* Irritability, paresthesias Hypocalcemia Implementations
* Oral calcium supplements with orange (maximizes absorption)
* Calcium gluconate IV
* Seizure precautions
* Meet safety needs
Hypercalcemia Assessments
* Ca+> 5.2 mEq/L
* Sedative effects on CNS
* Muscle weakness, lack of coordination
* Constipation, abdominal pain
* Depressed deep tendon reflexes
* Dysrhythmias Hypercalcemia Implementations
* 0.4% NaCl or 0.9% NaCl IV
* Encourage fluids (acidic drinks: cranberry juice)
* Diuretics
* Calcitonin
* Mobilize patient
* Surgery for hyperparathyroidism
Hypomagnesemia Assessments
Mg+
Neuromuscular irritability
Tremors
Seizures
Tetany
Confusion
Dysphagia Hypomagnesemia Implementations
Monitor cardiac rhythm and reflexes
Test ability to swallow
Seizure precautions
Increase oral intake--green vegetables, nuts, bananas, oranges, peanut butter, chocolate
Hypermagnesemia Assessments
Mg + > 2.5 mEq/L
Hypotension
Depressed cardiac impulse transmission
Absent deep tendon reflexes
Shallow respirations Hypermagnesemia Implementations
Discontinue oral and IV magnesium
Monitor respirations, cardiac rhythm, reflexes
IV Calcium to antagonize cardiac depressant activity (helps to stimulate heart)
Burns Assessments
* Superficial partial thickness--pink to red, painful
* Deep partial thickness--red to white, blisters, painful
* Full thickness--charred, waxy, white, painless
Wound Care for Burns
Never break blisters
Isotonic fluids (Lactated Ringer's)
Closed method (Silvadene) covered with dressings
Open method (Sulfamylon) that are not covered with dressings
IV pain medication initially: not PO takes too long, not IM circulation impaired
Medicate patient before wound care
Silver nitrate (warn patient skin will turn black)
High calorie, High carbohydrate, High protein diet
Vitamin B,C, and Iron
TPN maybe
Prevent contractures
Addisson's Disease Assessments
Fatigue
Weakness
Dehydration
Eternal tan
Decreased resistance to stress
Low Sodium
Low Blood Sugar
High Potassium Addisson's Disease Implementations
High protein, High carbohydrate, high Sodium, Low potassium diet
Teach life-long hormone replacement
Addisonian Crisis Assessments
* Hypotension
* Extreme weakness
* Nausea vomiting
* Abdominal pain
* Severe hypoglycemia
* Dehydration Addisonian Crisis Implementations
* Administer NaCl IV, vasopressors, hydrocortisone
* Monitor vital signs
* Absolute bedrest
Cushing's Syndrome Assessments
* Osteoporosis
* Muscle wasting
* Hypertension
* Purple skin striations
* Moon face
* Truncal obesity
* Decreased resistance to infection Cushing's Syndrome Implementations
* Low Carbohydrate, Low Calorie, High Protein, High Potassium, Low sodium diet
* Monitor glucose level
* Postop care after adrenalectomy or hypophysectomy
Pheochromocytoma Assessments--hypersecretions of the catecholamines (epinephrine/norepinephrine)
* Persistent hypertension
* Hyperglycemia
* Pounding headache
* Palpitations
* Visual disturbances Pheochromocytoma Implementations
* Histamine Test, Regitine Test, 24- hour urine VMA test
* Avoid emotional and physical stress
* Encourage rest
* Avoid coffee and stimulating foods
* Postop care after adrenalectomy and medullectomy
COPD Assessments
* "Blue Bloaters"
* "Pink Puffers"
* Weakness
* Change in postured day and hs (don't sleep laying down, have to stay erect)
* Use of accessory muscles of breathing
* Dyspnea
* Cough
* Adventitious breath sounds COPD Implementations
* Assess airway clearance
* Listen to breath sounds
* Administer low-flow oxygen (1-2 L, not too much because your trying to prevent CO2 narcosis)
* Encourage fluids
* Small frequent feedings
* Use metered dose inhalers (MDI)
Pneumonia Assessments
* Fever
* Leukocytosis
* Productive Cough (rust, green, yellow)
* Dyspnea
* Pleuritic pain
* Tachycardia Pneumonia Implementations
* Check breath sounds
* Cough and deep breath q 2 hours
* Chest physiotherapy
* Antibiotics
* Incentive spirometer
* Encourage fluids
* Suction PRN
* Provide oxygen
* Semi-Fowler's position
* Bedrest
* Medications--mucolytics (Mucomyst), expectorants (Robitussin), Bronchodilators (Aminophylline), Antibiotics (Bacterim)
Acyanotic Congenital Heart Anomalies Assessments
* Normal Color
* Possible exercise intolerance
* Small stature
* Failure to thrive
* Heart murmur
* Frequent respiratory Infections
Cyanotic Congenital Heart Anomalies Assessments
* Cyanosis
* Clubbing of fingers
* Seizures
* Marked exercise intolerance
* Difficulty eating
* Squat to decrease respiratory distress
* Small stature
* Failure to thrive
* Characteristic murmur
* Frequent respiratory infections
Acyanotic Congenital Heart Anomalies Types:
* Ventricular Septal Defect (VSD)--abnormal opening between right/left ventricles; hole size of pinhole or absence of septum; hear a loud harsh murmur, at age of 3 hole may close otherwise surgery such as purse-string suture
* Atrial Septal Defect (ASD)--abnormal opening between the two atria; audible murmur (if defect is severe closure is done later in childhood)
* Patent Ductus Arteriosis (PDA)--failure of fetal structure to close after birth; ductus areteriosis in the fetus connects the pulmonary artery to aorta to shunt oxygenenated blood from the placenta to systemic circulation (which bypasses the lungs). Once the child is born that structure should close because it is no longer needed because blood passes through to lungs; vascular congestion, right ventricular hypertrophy; murmur, bounding pulse, tachycardia; surgical to divide or ligate the vessel.
* Coarctation of the Aorta--narrow of aorta; high blood pressure and bounding pulse in areas that receive blood proximal to the defect. Weak and absent blood distal to aorta. Surgical end-to-end anastomosis.
* Pulomonic Stenosis--narrowing at entrance to pulmonary artery; causes resistance to blood flow and right ventricular hypertrophy; surgery
* Aortic Stenosis--narrowing of aortic valve; causes decrease cardiac output; surgery
Cyanotic Congenital Heart Anomalies Types:
* Tetralogy of Fallot--VSD, pulmonic stenosis, overriding aorta, right ventricular hypertrophy; squats/knee chest position to help breath; surgery needed
* Transposition of great vessels--pulmonary artery leaves left ventricle and aorta leaves right ventricle; oxygenated blood not going into systemic circulation
* Truncus arteriosus--failure of normal septation and embryonic division of the pulmonary artery and aorta; rather than two distinctly different vessels there is a single vessel that overrides both ventricles and gives rise to both pulmonary and systemic circulation; blood enters from both common artery and either goes to the lungs or to the body; cyanosis, murmur, difficult intolerance
* Total anomalous venous return--absence of direct communication between pulmonary veins and left atria; pulmonary veins attach directly to right atria or drains to right atria
Congenital Heart Anomalies Compensatory Mechanisms
* Tachycardia
* Polycythemia (increase formation of RBC's)
* Posturing--squatting, knee-chest position
Congenital Heart Anomalies Implementations
* Prevention
* Recognize early symptoms
* Monitor vital signs and heart rhythms
* Medications--digoxin, iron, diuretics, potassium
* Change feeding pattern
Left-Side CHF
* Dyspnea, orthopnea
* Cough
* Pulmonary edema
* Weakness/Changes in mental status Right-Side CHF
* Dependent edema
* Liver enlargement
* Abdominal pain/Nausea/Bloating
* Coolness of extremities
CHF Implementations
* Administer digoxin, diuretics
* Low-sodium, low-calorie, low-residue diet
* Oxygen therapy
* Daily weight
* Teach about medications and diet
Arterial Peripheral Vascular Disease
Assessments
* Rubor
* Cool shiny skin
* Ulcers
* Gangrene
* Intermittent Claudication (pain with exercise/walking relieved with rest)
* Impaired sensation
* Decreased peripheral pulses Arterial Peripheral Vascular Disease
Implementations
* Monitor Peripheral pulses
* Good foot care
* Stop smoking
* Regular exercise
* Medications--vasodilators, anticoagulants
Venous Peripheral Vascular Disease
Assessments
* Cool, brown skin
* Edema
* Normal or decreased pulses
* Positive Homan's sign Venous Peripheral Vascular Disease
Implementations
* Monitor peripheral pulses
* Elastic stockings
* Medications--anticoagulants
* Elevate legs
* Warm, moist packs
* Bedrest 4-7 days (acute phase)
Anemia Assessments (reduction in hemoglobin amount/erythrocytes)
* Palpitations
* Dyspnea
* Diaphoresis
* Chronic fatigue
* Sensitivity to cold Anemia Implementations
* Identify cause
* Frequent rest periods
* High protein, high iron, high vitamin diet
* Protect from infection
Iron Deficiency Anemia Assessments
* Fatigue
* Glossitis
* Spoon fingernails
* Impaired cognition Iron Deficiency Anemia Implementations
* Increase iron-rich foods (liver, green leafy vegetables)
* Iron supplements (stains teeth)
Pernicious Anemia Assessments (gastric mucosa fail to secrete enough intrinsic factor for stomach to absorb)
* Schilling's Test
* Fatigue
* Sore, red tongue
* Paresthesia in hands and feet Pernicious Anemia Assessments
* Vitamin B12--IM
* Rest of life can't be absorbed PO
Sickle Cell Anemia Assessments
* Pain /Swelling/Fever
* Schlerae jaundiced
* Cardiac murmurs
* Tachycardia Sickle Cell Anemia Implementations
* Check for signs of infection (prevent crisis)
* Check joint areas for pain and swelling
* Encourage fluids
* Provide analgesics with PCA pump c crisis
Hemophilia Assessments (female to male gene transmission)
* Easy bruising
* Joint pain
* Prolonged bleeding Hemophilia Implementations
* Administer plasma or factor VIII
* Analgesics
* Cryoprecipitated antihemophilic factor (AHF)
* Teach about lifestyle changes
* Non contact sports
Cancer Implementation: External Radiotherapy
* Leave markings on skin
* Avoid use of creams, lotions (only vitamin A&D ointment)
* Check for redness, cracking
* Wear cotton clothing
* Administer antiemetics
Cancer Implementation: Internal radiation sealed source
* Lead container and long-handled forceps in room
* Save all dressings, bed linen until source removed
* Urine and feces not radioactive
* Don't stand close or in line with source
* Patient on bed rest Cancer Implementation: Internal Radiation
* Time and distance important
* Private room sign on door
* Nurse wears dosimeter at all times
* Limit visitors and time spent in room
* Rotate staff
* Self-care when can do
Cancer Implementation: Internal radiation unsealed source
* All body fluids contaminated
* Greatest danger first 24-96 hours
Leukemia Assessments
* Ulcerations of mouth
* Anemia
* Fatigue
* Weakness
* Pallor Leukemia Implementations
* Monitor for signs of bleeding: petechiae, ecchymosis, thrombocytopenia
* Infections
* Neutropenia (private room/limit # people, wbc done daily, no fruit, no flowers/plotted plants, clean toothbrush with weak bleach solution
* Good mouth care
* High calorie, high Vitamin diet (avoid salads/raw fruit/pepper/don't reuse cup/don't change litter box/digging in garden
Intracranial Tumors Assessments
* Motor deficits
* Hearing or visual disturbances
* Dizziness
* Paresthesia
* Seizures
* Personality disturbances
* Changes in LOC Intracranial Tumors Implementations
* Preoperative: do neurological assessment, patient head shaved
* Postoperative: maintain airway, elevate head 30-45 after supratentorial surgery
* Flat and lateral after infratentorial surgery
* Monitor vital and neurological signs
* Glascow coma scale
Therapeutic Positions
Supine--avoids hip flexion
Dorsal recumbent--supine with knees flexed
Prone--extension of hip joint(after amputation)
Side lateral--drainage of oral secretions
Knee-chest--visualization of rectal area
Sim's--decreases abdominal tension (side lying with legs bent)
Fowler's--increases venous return, lung expansion
High Fowler's--60-90
Fowler's--45-60
Semi-Fowler's--30-45
Low Fowler's--15-30
Modified Trendelenburg--used for shock;Feet elevated 20 degrees, knees straight, trunk flat, head slightly elevated
Elevation of extremity--increases blood to extremity and venous return
Lithotomy--used for vaginal exam
4 point 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 Swing-to-swing through
Partial weight bearing both legs
Both crutches, one or two legs
Stairs
Going up--"good" leg first, crutches, "bad" leg
Going down--crutches with "bad" leg, then "good" leg
"Up with the good, down with the bad"
Walker
* Flex elbows 20-30 degrees when hands are on grips
* Lift and move walker forward 8-10 inches
* Step forward with "bad" leg, support self on arms, follow with "good" leg
* Stand behind client holding onto gait belt
Myelogram--x-ray visualization of the spinal canal by injection of radiopaque dye.
* Hydration done 12 hours before procedure
* Cleansing enemas
* Avoid seizure-promoting medications Post-procedure
* Water-soluble dye--elevate head of bed 30 degrees (not removed)
* Oil based dye--flat in bed (removed)
* Bedrest 24 hours encourage fluids
Laminectomy--excision portion of lamina to expose area of affected disc
* Preopcare: moist heat
* Fowler's position
* Isometric exercises for abdominal muscles
* Muscle relaxants, NSAIDs, Analgesics
* Traction, TENS Postoperative care:
* Assess circulation and sensation
* Log roll Q2 hours with pillow between leg
* Calf exercises, assist with ambulation keeping back straight
* Muscle relaxants, NSAIDS, analgesics, Teaching--daily exercises, firm mattress, avoid prone position and heavy lifting
* Avoid sitting long time
Dysplasia of the Hip Assessment
* Uneven gluteal folds and thigh creases
* Limited abduction of hip
* Ortolani's sign--place infant on back with legs flexed, clicking sound with abduction of legs
* Shortened limb on affected side Dysplasia of the Hip Implementations
Newborn to 6 months
* Reduced by manipulation
* Pavlik harness for 3 to 6 months
6 to 18 months
* Bilateral Bryant's traction
* Hip spica cast
Older child
* Open reduction
* Hip Spica cast
Scoliosis Assessments--lateral deviation of one or more of vertebrae accompanied by rotary motion of spine
* Uneven hips or scapulae
* Kyphosis lump on back
* Bend at waist to visualize deformity
* Structural (flexible deviation corrected with bending) or functional (permanent heredirary that is seen) Scoliosis Implementations
* Exercises to strengthen abdominal muscles (if functional)
* Surgery: spinal fusion insertion of Herrington Rod
* Milwaukee brace: used with curves 30-40 degrees
* Wear 4-6 years, worn 23 hours of the day, wear undershirt to prevent irritation, teach isometric exercises
Cerebral Palsy Assessments
* Voluntary muscles poorly controlled due to brain damage
* Spasticity, rigidity, ataxia, repetitive involuntary gross motor movements Cerebral Palsy Implementations
* Ambulation devices, PT and OT
* Muscle relaxants and anticonvulsants
* Feeding: place food at back of mouth with slight downward pressure. Never tilt head backward.
* High calorie diet
Muscular Dystrophy Assessments
Atrophy of voluntary muscles
Muscle weakness, lordosis, falls Braces to help ambulation
Balance activity and rest
Parkinson's Disease Assessments
* Deficiency of dopamine
* Tremors, rigidity, propulsive gait
* Monotonous speech
* Mask like expression Parkinson's Disease Implementations
* Teach ambulation modification: goose stepping walk (marching), ROM exercises
* Medications--Artane, Cogentin, L-Dopa, Parlodel, Sinemet, Symmetrel
Myasthenia Gravis Assessments
* Deficiency of acetylcholine
* Muscular weakness produced by repeated movement
* Dysphagia
* Respiratory distress Myasthenia Gravis Implementations
* Good eye care, restful environment
* Medications--anticholinesterases, corticosteroids, immunosuppressants
* Avoid crisis: infection
* Symptoms: sudden ability to swallow
Clear liquid
No milk
No juice with pulp Full liquid
No jam
No fruit
No nuts Low-fat cholesterol restricted
Can eat lean meat
No avocado, milk, bacon, egg yolks butter Sodium restricted
No cheese High roughage, high fiber
No white bread without fiber Low-residue
Minimize intestinal activity
Buttered rice white processed food, no whole wheat corn bran
High protein diet
Restablish anabolism to raise albumin levels
Egg, roast beef sandwich,
No junk food Renal
Keeps protein, potassium and sodium low
No beans, no cereals, no citrus fruits Low-phenylalanine diet
Prevents brain damage from imbalance of amino acids
Fats, fruits, jams allowed
No meats eggs bread
Glomerulonephritis Assessment
* Fever, Chills
* Hematuria
* Proteinuria
* Edema
* Hypertension
* Abdominal or flank pain
* Occurs 10 days after beta hemolytic streptococcal throat infection Glomerulonephritis Implementation
* Antibiotics, corticosteroids
* Antihypertensives, immunosuppressive agents
* Restrict sodium and water intake
* Bedrest
* I&O
* Daily weight
* High Calorie, Low protein
Urinary Diversion: Assessments
* Done for: Bladder t umors, birth defects, neurogenic bladder, interstitial cystitis
* Ileal Conduit
* Koch Pouch Urinary Diversion Implementations
* Nephrostomy: flank incision and insertion of nephrostomy tube into renal pelvis; penrose drain after surgery; surgical dressing
* Ureterosigmoidostomy: urters detached from bladder and anastomosed to sigmoid colon; encourage voiding via rectum q 2-4 hours;no enemas or cathartics; complications--electrolyte imbalance, infection, obstruction; urine and stool evacuated towards anus.
* Cutaneous Ureterostomy: Stoma formed from ureters excised from bladder and brought to abdominal wall; stoma on right side below waist; assist with alteration in body image
* Illeal Conduit: Ureters replanted into portion of terminal ileum and brought to abdominal wall; check for obstruction; mucous threads in urine normal
* Koch Pouch (Continent Illeal Conduit): Ureters transplanted into pouch made from ileum with one-way valve; drainage of pouch by catheter under control of client; drain pouch at regular intervals
Acute Renal Failure Assessments: Oliguric Phase
* Output
* Hypertension
* Anemia
* CHF
* Confusion
* Increased K+, Ca+, Na+, BUN, Creatinine Acute Renal Failure Assessments: Diuretic Phase
* Output 4-5 L/day
* Increased BUN
* Na+, K+ lost in urine
* Increased mental and physical activity Acute Renal Failure Causes
* Prerenal--reduced blood volume
* Renal--nephrotoxic drugs, glomerulonephritis
* Postrenal--obstruction Acute Renal Failure Implementations:
* Low-output stage: Limit fluids, Kayexalate, Dialysis
* High-output stage: Fluids as needed, K+ replacement, Dialysis
* I&O
* Daily Weight
* Monitor Electrolytes
* Bedrest during acute phase
* IV fluids
* Diet restrictions
* Oliguric phase: limit fluids, TPN maybe
* After Diuretic phase: high protein, high calorie diet
Hemodialysis Implementation
* Check for thrill and bruit q 8 hours
* Don't use extremity for BP, finger stick
* Monitor vital signs, weight, breath sounds
* Monitor for hemorrhage Peritoneal Dialysis
* Weight before and after treatment
* Monitor BP
* Monitor breath sounds
* Use sterile technique
* If problem with outflow, reposition client
* Side effects: constipation Types of Peritoneal Dialysis
* Continuous ambulatory (CAPD)
* Automated
* Intermittent
* Continuous
Ego Defense Mechanisms
Denial--failure to acknowledge thought
Displacement--redirect feelings to more acceptable subject
Projection--attributing your feelings to someone else
Undoing--attempt to erase an act, thought or feeling
Compensation--attempt to overcome shortcoming
Symbolization--less threatening object used to represent another
Substitution--replacing unacceptable or unobtainable object to one that is acceptable or attainable
Introjection--symbolic taking into oneself the characteristics of another
Repression--unacceptable thoughts kept from awareness
Reaction formation--expressing attitude opposite of unconscious wish or fear
Regression--returning to an earlier developmental phase
Dissociation--detachment of painful emotional conflicts from consciousness
Suppression--consciously putting thought out of awareness
Dying patient: Denial, Anger, Bargaining, Depression, Acceptance
Bipolar Disorder Assessments
* Disoriented, flight of ideas
* Lacks inhibitions, agitated
* Easily stimulated by environment
* Sexually indiscreet
* Affective disorder
* Maintain contact with reality
* Elation is defense against underlying depression
* Manipulative behavior results from poor self-esteem Bipolar Disorder Implementations
* Meet physical needs first
* Simplify environment
* Distract and redirect energy
* Provide external controls
* Set limits: escalating hyperactivity
* Use consistent approach
* Administer Lithium (help Manic Phase of Bipolar, keep hydrated)
* Increase awareness of feelings through reflection
Schizophrenia Assessments
* Withdrawal from relationships and world
* Inappropriate display of feelings
* Hypochondriasis
* Suspiciousness
* Inability to test reality, regression
* Hallucinations--false sensory perceptions
* Delusions--persistent false beliefs; grandeur (feel higher rank); persecutory (beliefs to be a victim); ideas of reference (see people talking think talking about them)
* Loose associations
* Short attention span
* Inability to meet basic needs: nutrition, hygiene
* Regression Schizophrenia Types
* Disorganized--inappropriate behavior, transient hallucinations
* Catatonic--sudden onset mutism, stereotyped position, periods of agitation
* Paranoid--late onset in life, suspiciousness, ideas of persecution and delusions
Schizophrenia Implementations
* Maintain safety--protect from erratic behavior
* With hallucination--do not argue, validate reality, respond to feeling tone, never further discuss voices (don't ask to tell more about voices)
* With delusions--do not argue, point out feeling tone, provide diversional activities
* Meet physical needs
* Establish therapeutic relationship
* Institute measures to promote trust
* Engage in individual, group, or family therapy
* Encourage client's affect
* Accept nonverbal behavior
* Accept regression
* Provide simple activities or tasks
Paranoid Assessments
Suspiciousness
Cold, blunted affect
Quick response with anger or rage Paranoid Implementations
Establish trust
Low doses phenothiazines for anxiety
Structured social situations
Schizoid Assessments
Shy and introverted
Little verbal interaction
Few friends
Uses intellectualization Schizoid Implementations
Establish trust
Low doses phenothiazines for anxiety
Structured social situations
Schizotypal Assessments
Eccentric
Suspicious of others
Blunted affect
Problems with perceiving, communicating Schizotypal Interventions
Establish trust
Low doses neuroleptics to decrease psychotic symptoms
Structured social situations
Antisocial Assessments
Disregards rights of others
Lying, cheating, stealing, promiscuous
Lack of guilt
Immature
Irresponsible
Associated with substance abuse Antisocial Implementations
Firm limit-setting
Confront behaviors consistently
Enforce consequences
Group therapy
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
Arrogant lack of feelings and empathy for others
Sense of entitlement
Uses others to meet own needs
Shallow relationships
Views self as superior to others Narcissistic Implementations
Mirror what client sounds like
Limit-setting
Consistency
Teach that mistakes are acceptable
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 on others for decisions
Fears loss of support and approval Dependent Implementations
Emphasize decision-making
Teach assertiveness
Assist to clarify feelings and needs
Avoidant Assessments
Socially uncomfortable
Hypersensitive to criticism, Lacks self-confidence
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 decision-making
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
Slurred speech
Tremors
Impaired thinking
Belligerence
Loss of inhibitions Acute Alcohol Implementations
Protect airway
Assess for injuries
Withdrawal assess
IV glucose
Counsel about alcohol use
Alcohol Withdrawal Assessments
Tremors
insomnia
anxiety
hallucinations After WithdrawalDelirium 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 Dependence Assessments
* Persistent incapacitation
* Cyclic drinking or "binges"
* Others in family take over client's role
* Family violence Chronic Alcohol Dependence Implementations
* Identify problems related to drinking
* Help client see problem
* Establish control of problem
* Alcoholics anonymous
* Antabuse
* Counsel spouse and children
Wernicke's Syndrome Assessments
* Confusion
* Diplopia, nystagmus
* Ataxia
* Apathy Wernicke's Syndrome Implementations
* Thiamine (IM or IV)
* Abstinence from alcohol
Korsakoff's Psychosis Assessments
* Memory disturbances with confabulation
* Learning problems
* Altered taste and smell
* Loss of reality testing Korsakoff's Psychosis Implementations
* Balanced diet
* Thiamine
* Abstinence from alcohol
Retinopathy of Prematurity Assessment
Demarcation line with ridge
Retinal detachment 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 pupil--constricted with lens implanted, dilated without lens
Eye drops
Night shield
Sleep on unaffected side
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 Trigeminal Neuralgia Implementations
* Medications--analgesics, Tegretol
* Surgery
Bell's Palsy Assessments
* Inability to close eye
* Increased lacrimation
* Distorted side of face Bell's Palsy Implementations
* Isometric exercises for face
* Prevent corneal abrasions
Guillain-Barre Syndrome Assessments
* Paresthesia
* Motor losses beginning in lower extremities
* Altered autonomic function Guillain-Barre Syndrome Implementations
* Medications--steroids
* Aggressive respiratory care
* Physical therapy
* Eye care
* Prevent complications: respiratory and aspiration
Meningitis Assessments
* Nuchal rigidity
* Kerning's sign
* Brudzinski's sign
* Seizures
* Bulging fontanels
* High-pitched cry Meningitis Implementations
* Medications--antibiotics, antifungals
* Prevent complications: droplet precautions, contagious
Thoracentesis: no more than 1000cc taken at one time.
Electroencephalogram (EEG)
Preparation
* Test brains waves; seizure disorders
* Tranquilizer and stimulant meds withheld for 24-48 hours
* Stimulants (caffeine, cigarettes) withheld for 24 hours
* May be asked to hyperventilate during test
* Meals not withheld
* Kept awake night before test; want them to lie still Electroencephalogram (EEG)
Post-test
* Remove paste from hair
* Administer medications withheld before test
* Observe for seizure activity
* Seizure prodromal signs; epigastric distress, lights before the eyes
CAT Scan--dye gives flushed, warm face and metallic taste during injection (if contrast dye is used)
Myelogram: Post-test
* Supine 8-24 hours (Pantopaque oil-based dye used)
* Head raised 30-45degrees 8-16 hours(metrizamide water-soluble dye used)
Liver Biopsy Preparation
* Administer vitamin K IM (decrease risk of hemorrhage)
* NPO 6 hours
* Given sedative
* Position supine, lateral with upper arms elevated
* Asked to hold breath for 5-10 seconds Liver Biopsy Post-Test
* Position on operative side for 1-2 hours
* Gradually elevate head of bed 30 degrees (1st hour) and then 45 degrees (2nd 2 hours)
* Bedrest for 24 hours
* Check Vital signs
* Check clotting time, platelets, hematocrit
* Report severe abdominal pain
Upper GI Series Barium Swallow: stool white from barium
Tracheostomy Tube Cuff
* Purpose--prevents aspiration of fluids
* Inflated
o During continuous mechanical ventilation
o During and after eating
o During and 1 hour after tube feeding
o When patient cannot handle oral secretions
Oxygen Administration: assess patency of nostril, apply jelly
* Face mask: 5-10 l/min (40-60%)
* Partial rebreather mask: 6-15 l/min (70-90%); keep reservoir bag 2/3 full during inspiration
* Non-rebreather mask: (60-100%); keep reservoir bag 2/3 full during inspiration
* Venturi mask: 4-10 l/min (20-50%); provides high humidity and fixed concentrations, keep tubing free of kinks
* Tracheostomy collar or T-piece: (20-100%); assess for fine mist; empty condensation from tubing' keep water container full
* Croupette or oxygen tent:
o Difficulty to measure amount of oxygen delivered
o Provides cooled, humidified air
o Check oxygen concentration with oxygen analyzer q4 hours
o Clean humidity jar and fill with distilled water daily
o Cover patient with light blanket and cap for head
o Raise side rails completely
o Change linen frequently
o Monitor patient's temperature
Chest Tubes 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 below level of insertion
* Clamp only momentarily to check for air leaks
* Ok to milk tubing towards drainage
* Observe for fluctuation in water-seal chamber
* Encourage patient to change position frequently Chest Tube Removal:
* Instruct patient to do valsalva maneuver
* Clamp chest tube
* Remove quickly
* Occlusive dressing applied 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 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 reading--3-11 cm water
* Elevated>11, indicates hypervolemia or poor cardiac contractility (slow down IV, notify physician)
* Lowered
* Chest tray at bedside
Eye irrigation: tilt head back and toward affected side
Eye drops: drop in center of conjunctival sac; prevent systemic absorption, press on inner angle of eye; don't allow drops to go from one eye to the other; don't squeeze eyes
Nasogastric Tubes:
* Levin-single--single-lumen, used for decompression or tube feeding
* Salem sump--double-lumen, used for decompression or tube feeding
* Sengstaken-Blakemore--triple-lumen, used for bleeding esophageal varices
* Linton-Nachlas--4-lumen, used for bleeding esophageal varices
* Keofeed/Dobhoff--soft silicone, used for long-term feedings
* Cantor--single lumen with mercury-filled balloon and suction port
* Miller-Abbott--double-lumen with mercury-filled balloon and suction port
* Harris--single lumen with mercury-filled balloon and suction port
NG tube placement:
"BEST WAY" to check is to aspirate for gastric contents and check for pH of aspirate
Implementation of feeding:
* Check residual before intermittent feeding, reinstall residual
* Check residual Q4 hours with continuous feeding, reinstall residual
* Hold feeding if >50% residual from previous hour (adults) or >25% (children)
* Flush tube with water before and after feeding
* Use pump to control rate of tube feeding
* Administer fluid at room temperature
* Change bag Q8 hours for continuous feeding
* Elevate head of bed while feeding is running
* Check patency Q4 hours
* Good mouth care
NG Irrigation Tubing:
* Verify placement of tube
* Insert 30-50 cc of normal saline into tube
* If feel resistance, change patient position, check for kinks
* Withdraw solution or record amount as input
NG removal:
* Clamp tube
* Remove tape
* Instruct patient to exhale
* Remove tube with smooth, continuous pull
Intestinal Tubes (Cantor, Mill-Abbott, Harris)
* Implementations
o After tube is in stomach, have patient lie on right side, then back in Fowler's position, then left side
o Gravity helps to position 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
External contact lenses: need fine motor movements (rheumatoid arthritis prevents this).
Object in eye: never remove visible glass; apply loose cover and remain quiet.
Retina detached: sleep prone with affected side down; avoid jarring movements; avoid pin point movement with eye (sewing); high fluid and roughage (prevents constipation=no straining); make light sufficient for needs (75watt+); no hairwashing
Glaucoma medications: Epinephrine hydrochloride (Adrenalin Chloride) and Pilocarpine Hydrochloride (Pilocar): give Pilocar (therapeutic) first then wait 2-10minutes and instill adrenalin to increase absorption of adrenalin).
Tympanoplasty: remain in bed 24 hours position flat in bed with the affected ear up (helps to promote insertion).
Triglycerides elevation can falsely elevate glycosalated hemoglobin test.
Laparoscopic Cholecystectomy post: encourage to walk to eliminate acute right shoulder pain.
Impetigo: 2 year old; honey-colored crusts, vesicles, and reddish macules around mouth; don't need to isolate; watch contact precautions.
Only patient we use distractions on the NCLEX are manic patients and toddlers not for pain.
Rhinoplasty (nose surgery) position post-op: want to promote drainage of oral secretions is to position on her right side.
1 cup= 240cc
Pregnancy is a contraindication to an MRI.
Raynaud's disease have decreased vascularity in the extremities.
Post-Parecentesis most important assessment is to obtain the blood pressure, weight the client, measure the client's abdominal girth, and check dressing in that order.
Tracheostomy tube: use pre-cut/pre-made gauze pads.
Suction is always intermittent never continuous.
O universal donor/AB universal recipient.
ABO BLOOD TYPE COMPATIBILITY
Blood Type Can Receive from: Can donate to:
O O O,A,B,AB
A A,O A,AB
B B,O B,AB
AB O,A,B,AB AB
Autologous Transfusion:
* Collected 4-6 weeks before surgery
* Contraindicated--infection, chronic disease, cerebrovascular or cardiovascular
disease
Hypotonic Solution
* ½ NS (0.45% Saline) Isotonic Solution
* 0.9% NaCl (Normal Saline)
* 5% D/W (Dextrose in Water)
* Lactated Ringer's
* 5% D/ ¼ NS (5% Dextrose in 0.225% Saline ) Hypertonic Solution
* 10% D/W (10% Dextrose in water)
* D15W
* 5% D/NS (5% Dextrose in 0.9% Saline)
* 5% D/ ½ NS (5% Dextrose in 0.45% Saline)
* 3% NaCl
* 5% Sodium Bicarbonate
Change tubing Q72 hours
Change bottle Q24 hours
Infiltration
* Assessment: cool skin, swelling, pain, decrease in flow rate
* Implementation: discontinue IV, warm compresses, elevate arm, start new site proximal to infiltrated site
IV Phlebitis, Thrmobophlebitis
* Assessment--redness, warm, tender, swelling, leukocytosis
* Implementation--discontinue IV, warm moist compresses, start IV in opposite extremity
Hematoma
* Assessment--ecchymosis, swelling, leakage of blood
* Implementation--discontinue IV, apply pressure, ice bag 24 hours, restart IV in opposite extremity
IV Clotting
* Assessment--decreased flow rate, back flow of blood into tubing
* Implementation--discontinue, do not irrigate, do not milk, do not increase rate of flow or hang solution higher, do not aspirate cannula, inject Urokinase, D/C and start on other site.
Insertion of Percutaneous Central Catheters:
* Placed supine in head-low position
* Turn head away from procedure
* Perform Valsalva maneuver
* Antibiotic ointment and transparent sterile dressing
* Verify position with x-ray
* Change tubing Q24 hours
* Nurse/patient both wear mask when dressing change 2-3x/week
Adrenergics
Actions:
* Stimulate the sympathetic nervous system: increase in peripheral resistance, increase blood flow to heart, bronchodilation, increase blood flow to skeletal muscle, increase blood flow to uterus
* Stimulate beta-2 receptors in lungs
* Use for cardiac arrest and COPD Adrenergic Medications
* Levophed
* Dopamine
* Adrenalin
* Dobutrex Adrenergics Side effects:
* Dysrhythmias
* Tremors
* Anticholinergic effects
Adrenergics Nursing Considerations:
* Monitor BP
* Monitor peripheral pulses
* Check output
Anti-Anxiety
Action:
* Affect neurotransmitters
Used for:
* Anxiety disorders, manic episodes, panic attacks Anti-Anxiety
Medications:
* Librium, Xanax, Ativan, Vistaril, Equanil
Anti-Anxiety
Side effects:
* Sedation
* Confusion
* Hepatic dysfunction
Anti-Anxiety
Nursing Considerations:
* Potention for addiction/overdose
* Avoid alcohol
* Monitor Liver Function AST/ALT
* Don't discontinue abruptly, wean off
* Smoking/caffeine decreases effectiveness
Antacids
Actions:
* Neutralize gastric acids
Used for:
* Peptic ulcer
* Indigestion, reflex esophagitis Antacids Medications
* Amphojel
* Milk of Magnesia
* Maalox 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
Action:
* Interfere with electrical excitability of heart
Used for:
* Atrial fibrillation and flutter
* Tachycardia
* PVCs Antiarrhythmics
Medications:
* Atropine sulfate
* Lidocaine
* Pronestyl
* Quinidine
* Isuprel Antiarrhythmics
Side effects:
* Lightheadedness
* Hypotension
* Urinary retention
Antiarrhythmics
Nursing Considerations:
* Monitor vital signs
* Monitor cardiac rhythm
Aminoglycosides (Antibiotics)
Action:
* Inhibits protein synthesis in gram-negative bacteria
Used for:
* Pseudomonas, E.Coli Aminoglycosides (Antibiotics)
Medications:
* Gentamycin
* Neomycin
* Streptomycin
* Tobramycin Aminoglycosides (Antibiotics)
Side effects:
* Ototoxicity and Nephrotoxicity
* Anorexia
* Nausea
* Vomiting
* Diarrhea
Aminoglycosides (Antibiotics)
Nursing Considerations:
* Harmful to liver and kidneys
* Check 8th cranial nerve (hearing)
* Check renal function
* Take for 7-10 days
* Encourage fluids
* Check peak/trough level
Allergy: 1st symptom SOB
Cephalosporins (Antibiotics)
Action:
* Inhibits synthesis of bacterial cell wall
Used for:
* Tonsillitis, otitis media, peri-operative prophylaxis
* Meningitis Cephalosporins (Antibiotics)
Medications:
* Ceclor
* Ancef
* Keflex
* Rocephin
* Cefoxitin Cephalosporins (Antibiotics)
Side effects:
* Bone marrow depression: caution with anemic, thrombocytopenic patients
* Superinfections
* Rash
Nursing Considerations:
* Take with food
* Cross allergy with PCN
* Avoid alcohol
* Obtain C&S before first dose: to make sure medication is effective against disease/bacteria
* Can cause false-positive for proteinuria/glycosuria
Fluoroquinolones (Antibiotics)
Action:
* Interferes with DNA replication in gram-negative bacteria
Used for:
* E.Coli, Pseudomonas, S. Aureus Fluoroquinolones
(Antibiotics)
Medications:
* Cipro Fluroquinolones
(Antibiotics)
Side effects:
* Diarrhea
* Decreased WBC and Hematocrit
* Elevated liver enzymes (AST, ALT)
* Elevated alkaline phosphatase
Nursing Considerations:
* C&S before starting therapy
* Encourage fluids
* Take 1 hour ac or 2 hour pc (food slows absorption)
* Don't give with antacids or iron preparation
* Maybe given with other medications (Probenicid: for gout)
Macrolide (Antibiotics)
Action:
* Binds to cell membrane and changes protein function
Used for:
* Acute infections
* Acne
* URI
* Prophylaxis before dental procedures if allergic to PCN Macrolide (Antibiotics)
Medications:
* Erythromycin
* Clindamycin Macrolide (Antibiotics)
Side effects:
* Diarrhea
* Confusion
* Hepatotoxicity
* Superinfections
Nursing Considerations:
* Take 1hr ac or 2-3 hr pc
* Monitor liver function
* Take with water (no fruit juice)
* May increase effectiveness of: Coumadin and Theophylline (bronchodilator)
Penicillin
Action:
* Inhibits synthesis of cell wall
Used for:
* Moderate to severe infections
* Syphilis
* Gonococcal infections
* Lyme disease 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 2-3 hr pc
* Cross allergy with cephalosporins
Sulfonamides (Antibiotics)
Action:
* Antagonize essential component of folic acid synthesis
Used for:
* Ulcerative colitis
* Crohn's disease
* Otitis media
* UTIs Sulfonamides (Antibiotics)
Medications:
* Gantrisin
* Bactrim
* Septra
* Azulfidine Sulfonamides (Antibiotics)
Side effects:
* Peripheral Neuropathy
* Crystalluria
* Photosensitivity
* GI upset
* Stomatitis
Nursing Considerations:
* Take with meals or foods
* Encourage fluids
* Good mouth care
* Antacids will interfere with absorption
Tetracyclines
(Antibiotics)
Action:
* Inhibits protein sythesis
Used for:
* 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
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 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 Anticoagulants
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
* Antagonist--Protamine Sulfate
* Give SC or IV
Anticoagulant
Action:
* Interferes with synthesis of vitamin K-dependent clotting factors
Used for:
* Pulmonary embolism
* Venous thrombosis
* Prophylaxis after acute MI Anticoagulant
Medication:
* Coumadin Anticoagulant (Coumadin)
Side Effects:
* Hemorrhage, Alopecia
Nursing Considerations:
* Monitor Prothrombin Test (PT)
* Normal 9-12 sec
* Therapeutic level 1.5 times control
* Antagonist--Vitamin K (AquaMEPHYTON)
* Monitor for bleeding
* Give PO
Anticonvulsants
Action:
* Decreases flow of calcium and sodium across neuronal membranes
Used for:
* Seizures Anticonvulsant
Medications:
* Dilantin
* Luminal
* Depakote
* Tegretol
* Klonopin Anticonvulsant
Side effects:
* Respiratory depression
* Aplastic anemia
* Gingival hypertrophy
* Ataxia
Nursing Considerations:
* Don't discontinue abruptly
* Monitor I&O
* Caution with use of medications that lower seizure threshold: MAO inhibitors & anti-psychotics
* Good mouth care
* Take with food
* May turn urine pinkish-red/pinkish-brown
Anti-Depressants Monoamine Oxidase Inhibitors (MAO)
Action:
* Causes increases concentration of neurotransmitters
Used for:
* Depression
* Chronic pain Anti-Depressants
(Monoamine Oxidase Inhibitors)
Medications:
* Marplan
* Nardil
* Parnate Anti-Depressants
(Monoamine Oxidase Inhibitors)
Side effects:
* Hypertensive Crisis (Sudden headache, diaphoretic, palpitations, stiff neck, intracranial hemorrhage) with food that contain Tyramine
Nursing Considerations:
* Avoid foods containing Tyramine: Aged cheese, liver, yogurt, herring, beer and wine, sour cream, bologna, pepperoni, salami, bananas, raisins, and pickled products
* Monitor output
* Takes 4 weeks to work
* Don't combine with sympathomometics vasoconstrictors, and cold medications
Anti-Depressants
Selective Serontonin Reuptake Inhibitors (SSRI)
Action:
* Inhibits CNS uptake of serotonin
Used for:
* Depression
* Obsessive-Compulsive Disorder
* Bulimia Anti-Depressants
Selective Serontonin Reuptake Inhibitors (SSRI)
Medications:
* Paxil
* Prozac
* Zoloft Anti-Depressants
Selective Serontonin Reuptake Inhibitors (SSRI)
Side effects:
* Anxiety
* GI upset
* Change in appetite and bowel function
* Urinary retention
Nursing Considerations:
* Suicide precautions
* Takes 4 weeks for full effect
* Take in a.m.
* May urine to pinkish-red or Pinkish-brown
* Can be taken with meals
Anti-Depressants (Tricyclics)
Action:
* Inhibits reuptake of neurotransmitters
Used for:
* Depression
* Sleep apnea Anti-Depressants (Tricyclics)
Medications:
* Norpramin
* Elavil
* Tofranil Anti-Depressants (Tricyclics)
Side Effects:
* Sedation/Confusion
* Anticholinergics affects
* Postural Hypotension
* Urinary retention
Nursing Considerations:
* Suicide precautions/2-6 weeks to work
* Take at hs/Don't abruptly halt
* Avoid alcohol/OTC /Photosensitivity
Insulin
(Regular, Humulin R)
Type: Fast acting
Onset: ½ -1 hr
Peak: 2-4 hr
Duration: 6-8 hr 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 Insulin
(Humulin 70/30)
Type: Combination
Onset: ½ hr
Peak: 2-12hr
Duration: 24hr
Antidiabetic Agents
Action:
* Stimulates insulin release from beta cells in pancreas
Used for:
* Type 2 diabetes (NIDDM) 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 Agent
Action:
* Stimulates liver to change glycogen to glucose
Used for:
* Hypoglycemia Hypoglycemic Agent
Medication:
* Glucagon Hypoglycemic Agent
Side Effects:
* Hypotension
* Bronchospasm
Nursing Considerations:
* May repeat in 15min
* Give carbohydrates orally to prevent secondary hypoglycemic reactions
Antidiarrheals
Action:
* Slows peristalsis
* Increases tone of sphincters
Used for:
* Diarrhea Antidiarrheals
Medications:
* Kaopectate
* Lomotil
* Imodium
* Paregoric Antidiarrheals
Side Effects:
* Constipation
* Anticholinergic effects (urinary retention, dry mouth)
Nursing Considerations:
* Do not use with abdominal pain
* Monitor for urinary retention
* Give 2hr before or 3 hr after other meds
Antiemetics
Action:
* Increases GI motility
* Blocks effect of dopamine in chemoreceptor trigger zone
Used for:
* Vomiting Antiemetics
Medications:
* Tigan
* Compazine
* Torecan
* Reglan
* Antivert
* Dramamine Antiemetics
Side Effects:
* Sedation
* Anticholinergic effects
Nursing Considerations:
* Used before chemotherapy
* When used with viral infections may cause Reye's syndrome (Toxic Encephalopathy)
Antifungals
Action:
* Impairs cell membrane
Used for:
* Candidiasis
* Oral thrush
* Histoplasmosis Antifungals
Medications:
* Amphotericin B
* Nystatin Antifungals
Side Effects:
* Hepatotoxicity
* Thrombocytopenia
* Leukopenia
* Pruritis
Nursing Considerations:
* Give with food
* Monitor liver function
* Good oral hygiene
Antigout Agents
Action:
* Decreases production and resorption of uric acid
Used for:
* Gout Antigout Agents
Medications:
* Colchicine
* Probenecid
* Zyloprim Antigout Agents
Side Effects:
* Agranulocytosis
* GI upset
* Renal calculi
Nursing Considerations:
* Monitor for renal calculi
* Give with food, milk, antacids
Antihistamines
Action:
* Block effects of histamine
Used for:
* Allergic rhinitis
* Allergic reactions to blood Antihistamines
Medications:
* Chlor-Trimeton
* Benadryl
* Phenergan Antihistamines
Side Effects:
* Drowsiness
* Dry mouth
* Photosensitivity
Nursing Considerations:
* Give with food
* Use sunscreen
* Avoid alcohol
Antihyperlipidemic Agents
Action:
* Inhibits cholesterol and triglyceride synthesis
Used For:
* Elevated cholesterol
* Reduce incidence of cardiovascular disease Antihyperlipidemic 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
Antihypertensives
Types: ACE Inhibitors
Action:
* Blocks ACE in lungs
Used for:
* Hypertension
* CHF Antihypertensives
(ACE Inhibitors)
Medications:
* Capoten
* Vasotec Antihypertensives
(ACE Inhibitors)
Side Effects:
* GI upset
* Orthostatic hypotension
* Dizziness
Nursing Considerations:
* Give 1hr ac or 3hr pc
* Change position slowly
Antihypertensives
Type: Beta-Adrenergic Blockers
Action:
* Blocks Beta-Adrenergic Receptors
* Decrease excitability/workload of heart, oxygen consumption
* Decrease
Used for:
* Hypertension
* Angina
* SVT Antihypertensives
Type: Beta-Adrenergic
Medications;
* Nadolol
* Propranolol
* Tenormin
* Timoptic 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
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: Calcium Channel Blockers
Medications:
* Procardia
* Calan
* Cardizem Antihypertensives
Type: Calcium Channel Blockers
Side Effects:
* Hypotension
* Dizziness
* GI distress
Nursing Consideration:
* Monitor vital signs
* Do not chew or divide sustained-release tablets
Antihypertensives
Type: Centrally acting alpha-adrenergics
Action:
* Stimulates alpha receptors in medulla which causes a reduction in sympathetic in the heart
Used for:
* Hypertension Antihypertensives
Type: Centrally acting alpha-adrenergics
Medications:
* Aldomet
* Catapres Antihypertensives
Type: Centrally acting alpha-adrenergics
Side Effects:
* Sedation
* Orthostatic Hypotension
Nursing Considerations:
* Don't discontinue abruptly
* Monitor for fluid retention
* Change position slowly
Antihypertensives
Type: Direct-acting vasodilators
Action:
* Relaxes smooth muscle
Used for:
* Hypertension Antihypertensives
Medications
* Hydralazine
* Minoxidil Antihypertensives
Side Effects:
* Tachycardia
* Increase in body hair
Nursing Considerations:
* Teach patient to check pulse
Antihypertensives
Type: Peripheral-acting alpha-adrenergic blockers
Action:
* Depletes stores of norepinephrine in sympathetic nerve endings
Used for:
* Hypertension Antihypertensives
Medications:
* Reserpine Antihypertensives
Side Effects:
* Depression
* Orthostatic Hypotension
* Brachycardia
Nursing Considerations:
* Give with meals or milk
* Change position slowly
Bipolar Disorder
Action:
* Reduces catecholamine release
Used for:
* Manic episodes Bipolar Disorder Medications:
* Lithium (1-1.5meq/L)
* Tegretol
* Depakote Bipolar Disorder
Side Effects:
* GI upset
* Tremors
* Polydipsia
* Polyuria
Nursing Considerations:
* Monitor serum levels
* Give with meals
* Increase fluid intake
Antineoplastic 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 RBC's by bone marrow) function
* Force fluids
* Good mouth care
Antineoplastic Agents
Type: Antimetabolites
Action:
* Inhibits DNA polymerase
Used for:
* Acute lymphatic leukemia
* Cancer of colon, breast, pancreas Antineoplastic Agents
Antimetabolites Medications:
* 5-FU
* Methotrexate
* Hydrea Antineoplastic Agents
Antimetabolites
Side Effects:
* Nausea
* Vomiting
* Oral ulceration
* Bone marrow 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 Agents
Antitumor Antibiotics
Medications:
* Adriamycin
* Actinomycin D
* Bleomycin Antineoplastic Agents
Antitumor Antibiotics
Side Effects:
* Bone marrow suppression
* Alopecia
* Stomatitis
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 Antineoplastic Agents
Type: Hormonal Agents
Side Effects:
* Leukpenia
* Bone pain
* Hypercalcemia
Nursing Considerations:
* Check CBC
* Monitor serum calcium
Antineoplastic Agents
Type: Vinca Alkaloids
Action:
* Interferes with cell division
Used for:
* Cancer Antineoplastic Agents
Type: Vinca Alkaloids
Medications:
* Oncovin
* Velban Antineoplastic Agents
Type: Vinca Alkaloids
Side Effects:
* 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:
* Parkinson's disease 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
Action:
* Interferes with platelet aggregation
Used for:
* Venous thrombosis
* Pulmonary embolism 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 basal ganglia
Used for:
* Acute and Chronic psychoses Antipsychotic Agents
Medications:
* Haldol
* Thorazine
* Mellaril
* Stelazine Antipsychotic Agents
Side Effects:
* Akathisia (inability to sit still)
* Dyskinesia
* Dystonias
* Parkinson's syndrome
* Tardive dyskinesias
* Leukopenia
Nursing Considerations:
* Check CBC
* Monitor vital signs
* Avoid alcohol and caffeine
Atypical Antipsychotic Agents
Action:
* Interferes with binding of dopamine in the brain
Used for:
* Acute and Chronic psychoses Atypical Antipsychotic
Medications:
* Clozaril
* Risperdal Atypical Antipsychotic
Side Effects:
* Extrapyramidal effects
* Anticholinergic
* Sedative
* Orthostatic hypotension
Nursing Considerations:
* Monitor blood
* Change positions slowly
* Use sunscreen
Antipyretic Agents
Action:
* Antiprostaglandin activity in hypothalamus
Used for:
* Fever Antipyretic Agents
Medications:
* Tylenol (Acetaminophen) Antipyretic Agents
Side Effects:
* GI irritation
Nursing Considerations:
* Monitor liver function
* Aspirin contraindicated for younger than 21 years old due to risk of Reye's syndrome
Antithyroid Agents
Action:
* Reduce vascularity of thyroid
* Inhibits release of thyroid into circulation
Used for:
* Hyperthyroidism Antithyroid Agents
Medications:
* Tapazole
* SSKI Antithyroid Agents
Side Effects:
* Leukopenia
* Rash
* Thrombocytopenia
Nursing Considerations:
* Bitter taste
* May cause burning in mouth
* Give with meals
* Check CBC
Thyroid Replacement Agents
Action:
* Increases metabolic rate
Used for:
* Hypothyroidism Thyroid Replacement
Medications
* Synthroid
* Cytomel Thyroid Replacement
Side Effects:
* Nervousness
* Tachycardia
* Weight loss
Nursing Considerations:
* Monitor pulse and BP
* Monitor weight
* Take in a.m.
* Enhance action of anticoagulants, antidepressants, decrease action of insulin and digitalis
Antitubercular 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 Antitubercular Agents
Side Effects:
* Hepatitis
* Peripheral Neuritis
Nursing Considerations:
* Check liver function tests
* Vitamin B6 given for peripheral neuritis (Pyridoxine)
* Used in combination
Antivirals
Action:
* Inhibits DNA and RNA replication
Used for:
* Recurrent HSV
* HIV infection Antivirals
Medications:
* Zovirax
* AZT
* Videx
* Famvir
* Cytovene Antivirals
Side Effects:
* Headache
* Dizziness
* GI symptoms
Nursing Considerations:
* Encourage fluids
* Not a cure, but relieves symptoms
Attention Disorder Agents
Action:
* Increases level of catecholamines
Used for:
* ADDH
* Narcolepsy Attention Disorder Agents
Medications:
* Ritalin
* Cylert
* Dexedrine Attention Disorder Agents
Side Effects:
* Restlessness
* Insomnia
* Tachycardia
* Palpitations
Nursing Considerations:
* Monitor growth rate
* Monitor liver enzymes
* Give in A.M.
Bronchodilators
Action:
* Decreases activity of phosphodiesterase
Used for:
* COPD
* Preterm labor (Terbutaline) Bronchodilators
Medications:
* Aminophylline
* Atrovent
* Brethine
* Proventil
* Primatene 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
Action:
* Increases force of myocardial contraction, slows rate
Used for:
* Left-sided CHF Cardiac Glycosides
Medication:
* Lanoxin
(Digoxin) Cardiac Glycosides
Side Effects:
* Bradycardia
* Nausea
* Vomiting
* Visual disturbances
Nursing Considerations:
* Take apical pulse
* Notify physician if adult
* Monitor potassium level
* Dose: 0.5-1 milligram IV or PO over 24 hr period
* Average: 0.25 mg
Cholinergics
Action:
* Inhibits destruction of acetylcholine
* Stimulate parasympathetic nervous system (increase bowel tone, increase bladder tone, constrict pupil)
Used for:
* Myasthenia gravis
* Post-operative
* Postpartum urinary retention Cholinergics
Medications:
* Tensilon
* Prostigmin 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
Action:
* Inhibits reabsorption of sodium and water
* Blocks effects of aldosterone
Used for:
* CHF
* Renal disease Diuretics
Medications:
* HydroDIURIL
* Diamox
* Aldactone
* Lasix
* Hygroton Diuretics
Side Effects:
* Dizziness
* Orthostatic Hypotension
* Leukopenia
Nursing Considerations:
* Take with food or milk
* Take in a.m.
* Monitor fluid and electrolytes
Iron: Imferon/Feosol, use straw if liquid form, no milk/antacids, take on empty stomach, tachycardi
Glucocorticoids
Action:
* Stimulates formation of glucose
* Alters immune response
Used for:
* Addison's disease
* Crohn's disease
* COPD
* Leukemias Glucocorticoids
Medications:
* Solu-Cortef
* Decadron
* Deltasone Glucocorticoids
Side Effects:
* Psychoses
* Depression
* Hypokalemia
* Stunted growth
* Buffalo Hump
Nursing Considerations:
* Monitor fluid and electrolyte balance
* Don't discontinue abruptly
* Monitor for signs of infection
Mineralocorticoids
Action:
* Increases sodium reabsorption
* Potassium and hydrogen ion secretion in kidney
Used for:
* Adrenal insufficiency Mineralocorticoids
Medications:
* Florinef Mineralocorticoids
Side Effects:
* Hypertension
* Edema
* Hypokalemia
Nursing Considerations:
* Monitor BP, I&O, Weight, and Electrolytes
* Give with food
* Low-sodium, High-protein, High-potassium diet
Heavy Metal Antagonists
Action:
* Forms stable complexes with metals
Used for:
* Gold and arsenic poisoning
* Acute lead encephalopathy Heavy Metal Antagonists
Medications:
* Desferal mesylate
* BAL in Oil
* EDTA 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
Action:
* Inhibits action of histamine and gastric acid secretion
Used for:
* Ulcers
* Gastroesophageal reflux H2 Receptor Blockers
Medications:
* Tagamet
* Zantac H2 Receptor Blockers
Side Effects:
* Dizziness
* Confusion
* Hypotension
* Impotence
Nursing Considerations:
* Take with meals and hs
* Smoking decreases effectiveness
* Monitor liver function and CBC
Immunosuppressants
Action:
* Prevents production of T cells and their response to interleukin-2
Used for:
* Prevents rejection for transplanted organs Immunosuppressants
Medications:
* Sandimmune 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 (Constricts Pupil)
Action:
* Causes constriction of sphincter muscles of iris
Used for:
* Ocular surgery
* Open-angle glaucoma Miotics
Medications:
* Isopto-Carpine
* Eserine
* Carbacel 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
Mydriatics (Dilates Pupil)
Action:
* Anticholinergic actions leaves pupil under unopposed adrenergic influence
Used for:
* Diagnostic procedures
* Acute iritis
* Uveitis Mydriatics
Medications:
* Atropine sulfate
* Cyclogyl 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
Action:
* Acts on CNS receptor cells
Used for:
* Moderate to severe pain
* Preoperative
* Postoperative Narcotics
Medications:
* Morphine Sulfate
* Codeine
* Demerol
* Dilaudid
* Percodan 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
Action:
* Relaxes smooth muscle
* Decreases venous return
Used for:
* Angina
* Peri-operative hypertension
* CHF Antianginals
Medications:
* Nitroglycerine
* Isosorbide Antianginals
Side Effects:
* Hypotension
* Tachycardia
* Headache
* Dizziness
Nursing Considerations:
* Check expiration date
* Teach when to take medication
* May take Q5min x3 doses
* Wet with saliva and place under tongue
NSAIDS
Action:
* Inhibits prostaglandin synthesis
Used for:
* Arthritis
* Mild to moderate pain
* Fever 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
Action:
* Dissolves or lyses blood clots
Used for:
* Acute Pulmonary Emboli
* Thrombosis
* MI
* Contraindicated in: hemophilia, CVA, Trauma, not used in patients over 75 years old, not used in patients taking anticoagulants Thrombolytics
Medications:
* Streptokinase
* Urokinase
* Tissue Plasminogen Activator 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
o Void before taking medication
Parkinson's-like effects
* Symptoms:
o Akinesia (temporarily paralysis of muscles)
o Tremors
o Drooling
o Changes in gait
o Rigidity
o Akathisia (Extreme restlessness)
o Dyskinesia (Spasms)
* Nursing Care:
o Anticholinergic and Antiparkinsonian medications
o Safety measures for gait
How long should a client with tuberculosis be on medication?
6-9 Months
What are symptoms of hepatitis?
Inflammation of Liver
Jaundice
Anorexia
RUQ pain
Clay-colored stools, tea-colored urine
Pruritis (bile salts eliminated through skin)
Elevated ALT, AST
Prolonged PT (liver involvement with clotting factor)
What is the transmission of Hepatitis A? Fecal/Oral
Consume contaminated food or water
Travelers to developing countries at risk
Clients with hepatitis A should not prepare food for others
What is the transmission of Hepatitis B? Parenteral/Sexual contact
Blood or body fluids
At risk individuals are the one's that abuse IV drugs, dialysis, healthcare workers
Vaccine developed
What is the transmission of Hepatitis C? Blood or body fluids
Can become chronic disease
Seen in patients with hemophilia (unable to clot)
What is the transmission of Delta Hepatitis? Co-infects with hepatitis B
What nursing care are recommended for Hepatitis? 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.
What is Lyme's Disease? Multi-system infection caused by a tick bite. There are three stages.
What is Stage 1 of Lyme's Disease? Erythematous papule develops into lesion with clear center (Bull's-eye)
Regional lymphadenopathy
Flu-like symptoms (fever, headache, conjunctivitis)
Can develop over 1 to several months
What is Stage 2 of Lyme's Disease? Develop after 1 to 6 months if disease untreated.
Cardiac conduction defects
Neurologic disorders (Bell's palsy, temporary paralysis)
What is Stage 3 of Lyme's Disease? Develops after 1 to several months, if reached at this stage may persist for several years.
Arthralgias
Enlarged, inflamed joints
What are some Lyme's Disease teaching? Cover exposed areas when in wooded areas
Check exposed areas for presence of ticks
What are some Lyme's Disease nursing care? Antibiotics 3-4 weeks
Stage 1 use Doxicillin
IV penicillin with later stages
What are the treatment, mode of transmission, care, signs and symptoms of syphillis? Painless chancre fades after 6 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.
What are the treatment, mode of transmission, care, signs and symptoms of gonorrhea?
If female maybe asymptomatic and will be unaware of having disease.
Males may have thick discharge from urethra.
Some females from vagina.
Spread mucous membranes, congenital
IM Rocephin with Doxycycline PO, IM Aqueous Penicillin with PO Probenecid (used for gout, used with Penicillin because it delays the urinary excretion of it, makes it more effective)
Complication: Pelvis Inflammatory Disease
Most often affected with Chlamydia also, then treatment with PO Tetracycline
What are the treatment, mode of transmission, care, signs and symptoms of genital herpes? 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.
What are the treatment, mode of transmission, care, signs and symptoms of Chlamydia? 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 untreated.
Important to notify sexually contacted.
What are the treatment, mode of transmission, care, signs and symptoms of Venereal Warts? Single, small papillary lesion spreads into large cauliflower cluster on perineum, vagina, penis.
May itch or burn.
Spread by mucous membranes, congenital
Treatment: Curettage, cryotherapy with liquid nitrogen, kerotolytic agents
Avoid intimate contact until lesions heal
Complication: Genital Dysplasia Cancer
What is the difference between AIDS and HIV +? HIV Positive--presence of HIV in blood
AIDS--has significant defects in immune function associated with positive HIV evidenced by development of opportunistic infections
Syndrome where CD4 counts are below 200
What are some opportunistic infections of AIDS? P. Carinii Pneumonia: sob/dry-nonproductive cough
C. Albicans stomatitis: will have difficulty swalling and white exudates in back of throat
C. Neoformans: debilitating form of meningitis that may suffer seizures.
Cytomegalovirus (CMV): will experience lymphadenopathy and may have visual impairment and can affect any organ.
Kaposi's Sarcoma: most common malignancy experience with AIDS, small purplish brown, nonpainful, nonpuriitc palpable lesions on the body.
How is AIDS transmitted? Contaminated blood or body fluids
Sharing IV needles
Sexual contact
Transplacental: across placenta
Possibly by breast milk
What are diagnostics test associated with AIDS? 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
Don't share toothbrush/shavers
What are treatments, care, prevention of poison control? Prevention most important.
Treat patient first, and then the poison.
Recognize signs of symptoms of accidental poison: changes in appearance, behavior, substances around mouth, empty containers, vomitous.
What should happen when someone is poisoned? Call poison control center.
Tell them: substance, time, amount and route of ingestion, child's condition, age, weight, save vomitus, stool, urine.
Why should vomit not be induced? Don't induce if:
Danger of aspiration, decrease LOC, Ingested petroleum distillate (lighter fluid, kerosene, paint remover)
Ingested corrosive (Draino)
What medication treatment is used to induce vomiting and what other factors need to be implemented? Syrup of Ipecac with small amount of water. Don't give large amount of fluid after Ipecac, will increase gastric emptying.
Don't use milk.
Position with head lower then chest.
No universal antidote.
What should happen to poison control in emergency care? Intubated if 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 symptoms, treatments, care, prevention of aspirin poisoning? Tinnitus, change in mental status, Increased temperature, hyperventilation, bleeding, nausea and vomiting.
Nursing care: induce vomiting, maintain hydration, reduce temperature (sponge baths), monitor for bleeding.
What are signs and symptoms, treatments, care, prevention of tylenol poisoning? Symptoms: nausea/vomiting, hypothermia, If no treatment, hepatic/liver involvement.
If liver gets involved patient may have RUQ pain, jaundice, confusion, and coagulation abnormalities.
Nursing care: induce vomiting, maintain hydration, monitor liver and kidney function with labs such as AST/ALT enzymes.
Tylenol (Acetaminophen) overdosage:
Antidote N-acetylcysteine (Mucomyst)
What are signs and symptoms, treatments, care, prevention of lead toxicity? Symptoms: Irritability, decreased activity, abdominal pain, Increased 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
What are nursing care goals for Hazardous wastes? Decontaminate individual
Prevent spread of contamination
Clean and remove contaminuated source
Monitor personnel exposed
What are nursing care for Hazardous wastes? If chemical poses threat to caregiver, decontaminate patient first.
If chemical poses no threat or patient has been decontaminated, begin care.
If immediate threat to life, put on protective garments and provide care to stabilize patient.
What type of play do infants (0-12months) use? Solitary play. Game is one sided. Like to play with body parts.
Birth-3months: smile/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? Parallel play.
What type of play do pre-schoolers (3-6years) use? Associative play. Dress up/imitating play. Talking on telephone/kitchen/tool belt
What type of play do school age (6-12years) use? Cooperative play. Conformed/organized play.
According to Erikson's Developmental Task, explain the Infancy stage. Birth-18 months.
Trust vs. Mistrust
Positive outcome---trusts self
Negative outcome---withdrawn
According to Erikson's Developmental Task, explain the Toddler stage. 18months - 3 years
Autonomy vs. Shame and Doubt
Positive outcome---exercise self-control
Negative outcome---defiant and negative
According to Erikson's Developmental Task, explain the Preschool stage. 3-6 years
Initiative vs. Guilt
Children develop conscience at this age.
Positive Outcome---learns limits
Negative Outcome---fearful, pessimistic
According to Erikson's Developmental Task, explain the School age stage. 6-12years
Industry vs. Inferiority
Positive---sense of confidence
Negative---self doubt, inadequate
According to Erikson's Developmental Task, explain the Adolescence stage. 12-20 years
Identity vs. Role diffusion
Positive outcome---coherent sense of self
Negative outcome---lack of identity
According to Erikson's Developmental Task, explain the young adult stage. 20-45 years
Intimacy vs. Isolation
Positive outcome---intimate relationships/careers formed
Negative outcome---avoidance of intimacy
According to Erikson's Developmental Task, explain the middle adulthood stage. 45-65 years
Generativity vs. Stagnation
Positive Outcome---creative and productive
Negative Outcome---self centered
According to Erikson's Developmental Task, explain the Late adulthood stage. 65+ years
Integrity vs. Despair
No regrets in life or Regrets
Positive outcome---seems life as meaningful
Negative outcome---life lacks meaning
At what month does the head sag? 1 month
At what month do you see closing of posterior fontanelle, turn from side to back, and see a social smile? 2 months
What toys do you give for a 2 month old? Mobiles, wind up infant swings, soft clothes, and blankets.
At what month does a child bring objects to mouth and head erect? 3 months
What toys do you give for a 4 month old? Rattles, cradle gym, and stuffed animals
Which age does birth weight double? 5 months
At what age does teething occur? 6 months
What toys do you give for a 6 month old? Brightly colored, small enough to grasp, large enough for safety, teething toys
What age for fears of strangers? When is fear strongest? 7 months
8 months is stronger
Which month able to play peek-a-boo? 7 months
What toys do you give for 7-8months? Large colored, bricks, jack in the box
What month can a child say "DADA? 9 month
What month can a child crawl well? 10 months
What month can a child stand erect with support? 11 months
What happens in the 12th month of the child? Birth weight triples.
Eats with fingers.
Anterior Fontanelle almost close.
Babinski reflex disappears.
Toys: books with large pictures, push pull toys, teddy bears, a large ball, or sponge toys.
Explain introduction of solid foods. One food at a time.
Begin with least allergenic foods first.
* Cereal is usually first. (Do not use cow's milk/whole milk. After six months of age cereal can be mixed with fruit juices. Fruit juices should be offered in a cup to prevent dental carries.)
* Vegetables
* Fruits
* Potatoes
* Meats
* Eggs
* Orange Juice
* By 12 months children should be eating table food. Don't give honey under 12 because of botulism.
What does a toddler do at 15 months? Walks alone.
Throws object.
Holds spoon.
Say 4-6 words. Understand simple commands.
What does a toddler do at 18 months? Anterior fontanelle closes.
Climbs stairs.
Sucks thumb.
Say 10 + words.
Temper Tantrums.
What does a toddler do at 24 months? 300 world vocabulary.
Obeys easy commands.
Go up/down stairs alone.
Build towers.
Turn doorknobs/unscrew lids.
Increase independence.
What does a toddler do at 30 months? Walk tip toe.
Stand on one foot balance.
Has control for sphincter training.
Birth weight quadrupled.
State first/last name.
Give simple commands.
What type of toys are included for Toddlers? Cooking utensils, Dress-up clothes, rocking horses, finger paints, phonographs, cd players.
How do you avoid negativism during toddler ages? Don't ask no/yes questions.
Offer them choices.
Make a game out of the tasks.
What can a 3 year old do? Rides tricycle.
Undresses without help.
May invent imaginary friend.
Vocabulary 900 words.
Egocentric in thoughts/behaviors.
What can a 4 year old do? Laces shoes
Brushes teeth
Throws overhand
Uses sentences.
Independent
What can a 5 year old do? Runs well/Dresses without help.
Beginning cooperative play.
Gender-specific behavior.
What toys are used for preschool (3-5)? Playground materials, Housekeeping toys, Coloring books, tricycle with helmet.
Which age groups has greatest number of fears? Preschool age children.
What would you expect with a 6 year old? Self-centered, show off, rude
Sensitive to criticism
Begins loosing temporary teeth
Tends to lie.
What would you expect with a 7 year old? Team games/sports.
Concept of time.
Playing with same sex child.
What would you expect with a 8 year old? Seeks out friends.
Writing replaces printing.
What would you expect with a 9 year old? Conflicts between peer groups and parents.
Conflicts between independence and dependence.
Likes school.
Able to take on job duties (housework).
What toys are used for school age child? Construction toys, Pets, Games, Electronic games, reading, books, bicycles with helmets.
School age potential problems include: Anuresis (encourage before bed time)
Encopresis
Head lice
What are symptoms/indications of a fetal alcohol syndrome in a child? Thin upper lip, vertical ridge in upper lip, short up turned nose, mental retardation, motor retardation, hearing disorders, microcephaly.
Avoid alcohol 3 months before conception and throughout pregnancy.
What happens with amniocentesis? What does it do? 16th week detects genetic abnormality
30th week detects L/S ratio: lung maturity
Void before procedure
Ultrasound given to determine position of placenta and fetus.
Complications: premature labor, infection, Rh isommunization (if client Rh negative, will be given Rhogam)
What happens with an ultrasound? 5th week confirms pregnancy
Determines position of fetus, placenta, and # of fetuses.
Client must drink a lot of fluid before procedure for full bladder to have a clear image.
What happens with a non-stress test? At 28th week records FHR and fetal movement.
Favorable result: 2+ FHR accelerates by 15bpm and last 15seconds in 20 minutes.
What happens with a contraction stress test? Determines placenta's response to labor.
Done after 28th week.
Fowler/Semi-Fowler.
Given Oxytocin or Pitocin.
Results:
* Positive: Late decelerations indicates potential risk to fetus.
* Negative: No late decelerations.
What does Torch stand for? And their importance? Diseases that cross placenta or other events. Produce significant deformities or infant born with infectious process.
Toxoplasmosis: no litter box changed, no gardening, no under cooked meats.
Rubella: 1-16 titer immune for rubella, titer
Cytomegalovirus: transmitted in body fluids.
Herpes Simplex: Ascending infection. During pregnancy get treated with acyclovir. Delivery through c-section.
What concerns for clients that have UTI, Syphilis, Gonorrhea? UTI: may lead to pylonephritis, increase risk of premature birth.
Syphillis: passes through placenta, causes 2nd trimester abortions, still birth, and congenital infection, may receive medication for her and her baby.
Gonorrhea: baby gets prophylactic eydrops.
What are the danger signs of pregnancy? * Gush or fluid bleeding from vagina
* Regular uterine contractions
* Severe headaches, visual disturbances, abdominal pain, persistent vomiting (symptoms of PIH)
* Fever or chills (symptoms of infection)
* Swelling in face or fingers (symptoms of PIH)
What are the events in the onset of labor? Lightening: (when baby drops to pelvis)
* Primipara: occurs 2 weeks before delivery
* Multipara: occurs during labor
Softening of cervix
Expulsion of mucus plug (bloody show) - pink tinged mucus secretion
Uterine contractions: regular/progressive not Braxton-Hick's type.
How does prolapsed umbilical cords happen? Premature rupture of membranes.
Presenting part not engaged.
Fetal distress.
Protruding cord.
What do you do when a client has a prolapsed cord? Call for help.
Push up against presenting part off of the cord.
Place in trendenlenberg position or knee chest position.
Successful if FHT left unchanged.
What is a early/sign of fetal hypoxia? Early sign: fetal tachycardia >160 in >10minutes
Late sign: fetal bradycardia 10 minutes
What things should you know about the Informed Consent form? Nurse can witness patient sign form.
Patient has to be age of capacity/adult and confident. No confused patient/drinking/already received preoperative medications.
Consent must be given voluntarily and information understandable. Nurse must make sure questions are answered and form is attached to chart.
What is early deceleration? Decrease in HR before peak of contraction. Indication of head compression.
What are interventions for late decelerations? Position mother left side/trendenlenberg/knee chest
Increase rate of IV
Administer Oxygen 7-10 l/min
DC Oxytocin
What do variable decelerations indicate? Cord compression.
Change maternal position.
Administer oxygen.
DC Oyxtocin/Pitocin
What are signs of "True Labor"? Regular contractions increasing in frequency, duration, intensity
Discomfort radiates from back
Contractions do not decrease with rest
Cervix progressively effaced and dilated.
What are characteristics of a "False Labor"? Irregular contractions, no change in frequency, duration, intesityDiscomfort is abdominal
Contractions decrease with rest or activity
No cervical changes
Prior to Lumbar Epidural block what should the patient do? Void
What should be implemented during the delivery of a newborn? Establish airway
Check Apgar at 1 and 5 minutes
Clamp umbilical cord
Maintain Warmth
Place ID band on mother and infant
What are the types of Lochia? Rubra-bloody, day 1-3
Serosa-pink-brown, day 4-9
Alba-yellow-white, 10+ days
If fundus is displaced not centrally and off to the sides means? Bladder distended.
If client soaks pad in 15 minutes or pooling of blood? Check for hemorrhage
What are assessments and implementations for an "Ectopic Pregnancy"? Unilateral lower quadrant pain.
Rigid, tender abdomen
Low Hct and hCG levels
Bleeding
Monitor for shock
Administer RhoGAM
Provide support
What are assessments and implementations for "Placenta Previa"? A placenta that's implanted in the lower uterine segment near cervical os, during pregnancy placenta is torn away causing:
First and second trimester 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 and implementation for "Abruptio Placentae"? The premature separation of a placenta that is implanted 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
Monitor for complications: DIC, pulmonary emboli
What are assessments and implementations for Gestational Diabetes Mellitus (GDM)? 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
What are assessments and implementation for a Hydatidiform Mole? 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
What are the newborn vital signs? Temp. 97.7-99.7
HR sleep 100, awake 120-140, 180 crying
Resp 30-60
BP arm/calf 65/41
What are assessments and implementation for Hyperbilirubinemia? Caused by immature hepatic function
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 and implementations for a Narcotic-Addicted infant? Assessments
* High-pitched cry (Hallmark sign)
* Hyperreflexia
* Decreased sleep
* Tachypnea (>60/min)
* Frequent sneezing and yawning
* Seen at 12-24 hours of age, up to 7-10 days
Implementation
* Reduce environmental stimuli
* Administer Phenobarbital, chlorpromazine, diazepam, paregoric
* Wrap snugly, rock, and hold tightly
* Assess muscle tone, irritability, vital signs.
What are the assessments and implementations of Toxic Shock Syndrome? Sudden-onset fever
Vomiting, diarrhea
Hypotension
Erythematous rash on palms and soles
Administer antibiotics
Educate about use of tampons (change tampon Q3-Q6 hours)
What are contraindications to Immunizations? Immunization is a primary prevention
Severe febrile illness
Altered immune system
Previous allergic response
Recently acquired passive immunity
What are assessments and implementations for a "Latex Allergy"? Assessment
Urticaria, rash
Wheezing, Rhinitis, Conjunctivitis, Bronchospasms
Anaphylactic shock
Implementation
Screen for sensitivity
Avoid latex products: gloves, catheters, brown ace bandages, band aid dressing, elastic pressure stockings, balloons, condoms
What are implementations for Croup syndromes at home? Steamy shower
Exposure to cold air
Cool, humidified air
Universal Donor Blood: Packed red blood cells (help oxygen deliver to tissue, if you use whole blood there will be a risk for fluid overload), type O, Rh-negative
5% Sodium Bicarbonate--metabolic alkalosis solution
Older adults are asymptomatic when they have an infection and can lead to confusion.
Mononucleosis: complication enlarged spleen; concerned for trauma if child plays dangerous sport.
Lyme disease:found mainly in mid alantic states (Connecticut)
Pottery is unglazed can lead to "Lead Toxicity"
Apgar Score: normal 7-10
WBC after pregnancy?
Ampicillin decreases oral contraceptives efficiency.
Tricuspid area: 5th intercostals space in the left sternum area
Tracheostomy care: no powder, suction trachea first then mouth, use pre-cut gauze.
Hip-Flexion: causes increased intra-abdominal/thoracic pressure.
Injury C3 and above need respiratory ventilation.
SIADH causes: lung cancer, Cisplatin (Platinol)
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.
Herbs: Toxicities and Drug Interactions
Chamomile
Uses: Chamomile is often used in the form of a tea as a sedative.
Reactions: Allergic reactions can occur, particularly in persons allergic to ragweed. Reported reactions include abdominal cramps, tongue thickness, tightness in the throat, swelling of the lips, throat and eyes, itching all over the body, hives, and blockage of the breathing passages. Close monitoring is recommended for patients who are taking medications to prevent blood clotting (anticoagulants) such as warfarin.
Echinacea
Uses: Largely because white blood cells in the laboratory can be stimulated to eat particles, Echinacea has been touted to be able to boost the body's ability to fight off infection.
Reactions: The most common side effect is an unpleasant taste. Echinacea can cause liver toxicity. It should be avoided in combination with other medications that can affect the liver (such as ketaconazole, leflunomide (Arava), methotrexate (Rheumatrex), isoniazide (Nizoral).
St. John's Wort
Uses: St. John's Wort is popularly used as an herbal treatment for depression, anxiety, and sleep disorders. It is technically known as Hypericum perforatum. Chemically, it is composed of at least 10 different substances that may produce its effects. The ratios of these different substances varies from plant to plant (and manufacturer). Studies of its effectiveness by the National Institutes of Health are in progress.
Reactions: The most common side effect has been sun sensitivity which causes burning of the skin. It is recommended that fair- skinned persons be particularly careful while in the sun. St. John's wort may also leave nerve changes in sunburned areas. This herb should be avoided in combination with other medications that can affect sun sensitivity (such as tetracycline/Achromycin, sulfa- containing medications, piroxicam (Feldend). St. John's wort can also cause headaches, dizziness, sweating, and agitation when used in combination with serotonin reuptake inhibitor medications such as fluoxetine (Prozac) and paroxetine (Paxil).
Garlic
Uses: Garlic has been used to lower blood pressure and cholesterol (Dr. Lucinda Miller notes that there is "...still insufficient evidence to recommend its routine use in clinical practice.")
Reactions: Allergic reactions, skin inflammation, and stomach upset have been reported. Bad breath is a notorious accompaniment. Studies in rats have shown decreases in male rats' ability to make sperm cells. Garlic may decrease normal blood clotting and should be used with caution in patients taking medications to prevent blood clotting (anticoagulants) such as warfarin /Coumadin.
Feverfew
Uses: Most commonly used for migraine headaches.
Reactions: Feverfew can cause allergic reactions, especially in persons who are allergic to chamomile, ragweed, or yarrow. Nonsteroidal anti-inflammatory drugs (NSAIDs such as ibuprofen (Advil), naproxen (Aleve) or Motrin) can reduce the effect of feverfew. A condition called "postfeverfew syndrome" features symptoms including headaches, nervousness, stiffness, joint pain, tiredness, and nervousness. Feverfew can impair the action of the normal blood clotting element (platelets). It should be avoided in patients taking medications to prevent blood clotting (anticoagulants) such as warfarin (Coumadin).
Ginko Biloba
Uses: This herb is very popular as a treatment for dementia (a progressive brain dysfunction) and to improve thinking.
Reactions: Mild stomach upset and headache have been reported. Ginko seems to have blood thinning properties. Therefore, it is not recommended to be taken with aspirin, nonsteroidal anti-inflammatory drugs (Advil), naproxen (Aleve) or Motrin), or medications to prevent blood clotting (anticoagulants) such as warfarin (Coumadin). Ginko should be avoided in patients with epilepsy taking seizure medicines, such as phenytoin (Dilantin), carbamazepine (Tegretol), and phenobarbital.
Ginseng
Uses: Ginseng has been used to stimulate the adrenal gland, and thereby increase energy. It also may have some beneficial effect on reducing blood sugar .in patients with diabetes mellitus. (Dr. Miller emphasized that there is substantial variation in the chemical components of substances branded as "Ginseng.")
Reactions: Ginseng can cause elevation in blood pressure, headache, vomiting, insomnia, and nose bleeding. Ginseng can also cause falsely abnormal blood tests for digoxin level. It is unclear whether ginseng may affect female hormones. Its use in pregnancy is not recommended. Ginseng may affect the action of the normal blood clotting element (platelets). It should be avoided in patients taking aspirin, nonsteroidal antiinflammatory drugs (such as ibuprofen (Advil), naproxen (Aleve) or Motrin), or medications to prevent blood clotting (anticoagulants) such as warfarin (Coumadin). Ginseng may also cause headaches, tremors, nervousness, and sleeplessness. It should be avoided in persons with manic disorder and psychosis.
Ginger
Uses: Ginger has been used as a treatment for nausea and bowel spasms.
Reactions: Ginger may lead to blood thinning. It is not recommended to be taken with medications that prevent blood clotting (anticoagulants) such as warfarin (Coumadin).
Saw Palmetto
Uses: Saw palmetto has been most commonly used for enlargement of the prostate gland. (Dr. Miller emphasized that studies verifying this assertion are necessary.) Saw palmetto has also been touted as a diuretic and urinary antiseptic to prevent bladder infections.
Reactions: This herb may affect the action of the sex hormone testosterone, thereby reducing sexual drive or performance. Dr. Miller states that "While no drug-herb interactions have been documented to date, it would be prudent to avoid concomitant use with other hormonal therapies (e.g., estrogen replacement therapy and oral contraceptives...")
Black Cohosh
Claims, Benefits: A natural way to treat menopausal symptoms.
Bottom Line: Little is known about its benefits and its risks.
A child with celiac disease mustn't consume foods containing gluten and therefore should avoid prepared puddings, commercially prepared ice cream, malted milk, and all food and beverages containing wheat, rye, oats, or barley.
The infant of a diabetic mother may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increases glucose amount that crosses the placenta from the mother. However, during the first 24 hours of life, this combination of high insulin production in the newborn coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia
Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity.
A platypelloid pelvis has a flat shape. A gynecoid pelvis is a normal female pelvis. An anthropoid pelvis has an oval shape, and an android pelvis has a heart shape.
The pulse is the earliest indicator of new decreases in fluid volume.
Adult Rickets: deficiency in vitamin D.
Chronic Pain: normal blood pressure, heart rate, and respiratory rate. Normal pupils and dry skin.
Acute pain: causes increased blood pressure, increased pulse, and respiratory rate, dilated pupils, and perspiration.
The tip of the endotracheal tube lies 1 cm above the carina. This is positioned above the bifurcation of the right and left mainstem bronchi.
Creatine Phosphokinase (CPK) is a cellular enzyme that can be fractionated into three isoenzymes.
MB band reflects CPK from CARDIAC MUSCLE (This is the level that elevates with an MI.)
MM band reflects CPK from SKELETAL MUSCLE
BB band reflects CPK from the BRAIN
ALKYLATING AGENTS: affect ALL PHASES of the reproductive cell cycle (i.e., Cyclophosphamide [Cytoxan])
ANTIMETABOLITES: are cell cycle phase-specific and affect the S PHASE (i.e., Cytarabine [Cytosar])
VINCA ALKALOIDS: are cell cycle phase-specific and act on the M PHASE
Bell's Palsy: is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown. Possible causes include vascular ischemia, infection, exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or a combination of these items.
McBURNEY'S POINT: is midway between the right anterior superior iliac crest and the umbilicus. This is usually the location of greatest pain in the child with appendicitis.
MMR: administered SQ in the outer aspect of the upper arm.
Watch for absolute words "NOT" and "ONLY"
AIR EMBOLISM POSITIONING: Place the client on the left side in the trendelenburg position. Lying on the left side may prevent air from flowing into the pulmonary veins. The trendelenburg position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during inspiration.
Trigeminal neuralgia pain medication: Use Carbamazepine (Tegretol) and Phenytoin (Dilantin). Narcotic analgesics (Meperidine Hydrochloride [Demerol], Codeine Sulfate , and Oxycodone) are not effective in controlling pain caused by trigeminal neuralgia.
Grapefruit juice can raise cyclosporine (Sandimmune) levels by 50% to 100%, risk for toxicity.
Fomepizole (Antizol): an antidote given IV to a client with Ethylene Glycol (Antifreeze) intoxication
Phenotolamine (Regitine): antidote for hypertensive crisis
Bromocriptine (Parlodel): an antiparkinsonian prolactin inhibitor, is used to treat NMS.
Biophysical profile: assesses five parameters of fetal activity: fetal heart rate, fetal breathing movements, gross fetal movements, fetal tone, and amniotic fluid volume. In a biophysical profile, each of the five parameters contributes 0 to 2 points with a score of 8 being considered normal and a score of 10 perfect.
G T P A L
Gravidity, the number of pregnancies. Term births, the number born at term (40 weeks). Preterm births, the number born before 40 weeks' gestation. Abortions/miscarriages
* Included in gravida if before 20 weeks' gestation
* Included in parity if past 20 weeks' gestation Live births, the number of live births or living children
Therefore a woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of preterm births is 1, and the number of term births is 0. The number of abortions is 0, and the number of live births is 1.
Probable signs of pregnancy:
* Uterine enlargement
* Hegar's sign (Softening and thinning of the lower uterine segment that occurs about week 6)
* Goodell's sign (softening of the cervix that occurs at the beginning of the second month)
* Chadwick's sign (bluish coloration of the mucous membranes of the cervix, vagina, and vulva that occurs about week 6)
* Ballottement (rebounding of the fetus against the examiner's fingers on palpation)
* Braxton Hicks contractions
* A positive pregnancy test measuring for human chorionic gonadotropin
Positive signs of pregnancy:
* Fetal heart rate detected by electronic device (Doppler transducer) at 8-12 weeks and by nonelectronic device (Fetoscope) at 20 weeks of gestation
* Active fetal movements palpable by examiner
* An outline of fetus via radiography or ultrasound
Acetazolamide (Diamox): used for management of glaucoma is a carbonic anyhdrase inhibitor that has sulfonamide properties.
Watch out for absolute words "ALL" and "ALWAYS"
Before NG removal: bowel sounds have to be present.
Hyperkalemia on Electrocardiogram: Tall, peaked T waves; prolonged PR interval; widening QRS complex
Hypokalemia on Electrocardiogram: ST segment depression; Flat T wave
First-Degree Heart Block: Prolonged P-R interval
Bundle Branch Block: Widened QRS complex
Myocardial Necrosis in Area: Q waves present
Ventricular Fibrillation: No visible P waves or QRS complexes, no measurable rate. Irregular, chaotic undulations of varying amplitudes.
HypoCalcemia: Prolonged Q-T interval
Myocardial Ischemia: ST segment elevation or depression
Premature Ventricular Contractions: absence of P waves, wide and bizarre QRS complexes, and premature beats followed by a compensatory pause
Ventricular Tachycardia: absence of P waves, wide QRS complexes, rate between 100 and 250 impulses per minute. Regular rhythm
Atrial Fibrillation: no P waves; instead there are wavy lines, no PR interval. QRS duration is WNL and irregular ventricular rate can range from 60-160 beats/minute.
ANGINA
Stable Unstable Variant Intractable
Triggered by a predictable amount of effort or emotion. Triggered by an unpredictable amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time. Triggered by coronary artery spasm; the attacks tend to occur early in the day and at rest. Chronic and incapacitating and is refractory to medical therapy.
Cardiac Conduction System: Sinoatrial NodeInternodal/Interatrial pathwaysAV nodeBundle of HisR/L Bundle BranchesPurkinje fibers
Pulse rate is the earliest indicator of decrease in fluid volume.
A1-adrenergic receptors: found in the peripheral arteries and veins and cause a powerful vasoconstriction when stimulated
A2-adrenergic receptors: several tissues and contract smooth muscle, inhibit lipolysis, and promote platelet aggregation.
B1: Found in the heart and cause an increase in heart rate, atrioventricular node conduction, and contractility.
B2: Arterial and bronchial walls and cause vasodilation and bronchodilation.
PULSE PRESENT = NO DEFIBRILLATION
Myxedema (a.ka. Hypothyroidism)
Suggested toys
a. birth to six months - mobiles, unbreakable mirrors, music boxes, rattles
b. six to 12 months - blocks, nesting boxes or cups, simple take apart toys, large ball, large puzzles, jack in the box, floating toys, teething toys, activity box, push-pull toys
c. Solitary play
Toddlerhood (one year to three years)
Play is parallel
* Suggested toys: push-pull toys, finger paints, thick crayons, riding toys, balls, blocks, puzzles, simple tape recorder, housekeeping toys, puppets, cloth picture books, large beads to string, toy telephone, water toys, sand box, play dough or clay, chalk and chalkboard
Preschool age (three years to six years)
* Preschool play is associative and cooperative.
* dress-up
* fantasy play
* imaginary playmates
* Suggested toys: tricycle, gym and sports equipment, sandboxes, blocks, books, puzzles, computer games, dress-up clothes, blunt scissors, picture games, construction sets, musical instruments, cash registers, simple carpentry tools
School age (six years to 12 years)
Play is cooperative.
1. sports and games with rules
2. fantasy play in early years
3. clubs
4. hero worship
5. cheating
6. Suggested toys/activities: board or computer games, books, collections, scrapbooks, sewing, cooking, carpentry, gardening, painting
Tympany: Drumlike, loud, high pitch, moderate duration; usually found over spaces containing air such as the stomach
Resonance:Hollow sound of moderate to loud intensity; low pitch, long duration; Usually heard over lungs
Hyperresonance: Booming sound of very loud intensity; very low pitch, long duration; Usually heard in the presence of trapped air (such as emphysematous lung)Flatness:
Flat sound of soft intensity; high pitch; short duration; Usually heard over muscle
Dullness:Thud-like sound of soft intensity; high pitch; moderate duration; Usually heard over solid organs (such as heart, liver)
body temperature
o range: 36 to 38 degrees Celsius (98.6 to 100.4 degrees Fahrenheit)
St. John's wort - antidepressant
Garlic - antihypertensive
Ginseng - Anti stress
Green tea - antioxidant
Echinacea - immune stimulant (6-8 weeks only)
Licorice - cough and cold
Ginger root - antinausea
Ginkgo - improves circulation
Ma huang - bronchodilator, stimulant
Anatomical Landmarks of the HEART
i. second right intercostal space - aortic area
ii. second left intercostal space - pulmonic area
iii. third left intercostal space - Erb's point
iv. fourth left intercostal space - tricuspid area
v. fifth left intercostal space - mitral (apical) area
vi. epigastric area at tip of sternum
Range of Normal Blood Pressure
i. child under age two weighing at least 2700g: use flush technique,30-60mg Hg
ii. child over age two: 85-95/50-65 mm Hg
iii. school age: 100-110/50-65 mm Hg
iv. adolescent: 110-120/65-85 mm Hg
v. adult:
Normal Range of Peripheral Pulses
* infants: 120 to 160 beats/minutes
* toddlers: 90 to 140 beats/minutes
* preschool/school-age: 75 to 110 beats/ minute
* adolescent/adult: 60 to 100 beats/minute
Normal Rates of Respirations
* newborn: 35 to 40 breaths/minute
* infant: 30 to 50 breaths/minute
* toddler: 25 to 35 breaths/minute
* school age: 20 to 30 breaths/minute
* adolescent/adult: 14 to 20 breaths/minute
* adult: 12 to 20 breaths/minute
CRANIAL NERVE FUNCTION
1. Olfactory (CN I)
* Can identify variety of smells
* Deviation: Inability to identify aroma
2. Optic (CN II)
* Has visual acuity and full visual fields
* Fundoscopic exam reveals no pathology
* Deviation: Inability to identify full visual fields - total or partial blindness of one or both eyes
3, 4, 6. Oculomotor (CN III), trochlear (CN IV), and abducens (CN VI)
* Follows up to six cardinal positions of gaze
* Pupils are unremarkable
* Exhibits no nystagmus and no ptosis
* Deviation: one or both eyes will deviate from its normal position
5. Trigeminal (CN V)
* Clenches teeth with firm bilateral pressure
* Has no lateral jaw deviation with mouth open
* Feels a cotton wisp touched to forehead, cheek and chin
* Differentiates sharp and dull sensations on face
* Corneal reflex; blinks when cotton is touched to each cornea
* Deviation: Absent or one-sided blinking of eyelids
7. Facial (CN VII)
* Has facial symmetry with and without a smile
* Can raise the eyebrows symmetrically and grimace
* Can shut eyes tightly
* Can identify sweet, sour, salt or bitter on the anterior tongue
* Deviation: Irregular and unequal facial movements
* Deviation: Inability to taste or identify taste
* Deviation: Inability to taste or identify salt, sweet, sour, or bitter substances on the anterior two-thirds of the tongue
* Deviation: Inability to smile symmetrically
8. Acoustic (CN VIII)
* Can hear a whisper at 1-2 feet
* Can hear a watch tick at 1-2 feet
* Does not lateralize the Weber test
* Can hear AC (air conduction) better than BC (bone conduction) in the Rinne test
* Deviation: Inability to hear spoken word
9, 10. Glossopharyngeal (CN IX) and Vagus (CN X)
* Swallows and speaks without hoarseness
* Palate and uvula rise symmetrically when patient says "ah"
* Bilateral gag reflex
* Can identify taste on the posterior tongue
* Deviation: Unequal or absent rise of uvula and soft palate as the client says, "ah"
* Deviation: Absent gag reflex
* Deviation: inability to taste or identify taste on the posterior tongue
11. Spinal accessory (CN XI)
* Resists head turning
* Can shrug against resistance
* Deviation: Weak or absent shoulder and neck movement
12. Hypoglossal (CN XII)
* Can stick tongue out and move it from side to side
* Can push tongue strongly against resistance
* Deviation: Tongue deviates to side
Types of Coping Mechanisms
1. Compensation - extra effort in one area to offset real or imagined lack in another area
o Example: Short man becomes assertively verbal and excels in business.
2. Conversion - A mental conflict is expressed through physical symptoms
o Example: Woman becomes blind after seeing her husband with another woman.
3. Denial - treating obvious reality factors as though they do not exist because they are consciously intolerable
o Example: Mother refuses to believe her child has been diagnosed with leukemia. "She just has the flu."
4. Displacement - transferring unacceptable feelings aroused by one object to another, more acceptable substitute
o Example: Adolescent lashes out at parents after not being invited to party.
5. Dissociation - walling off specific areas of the personality from consciousness
o Example: Adolescent talks about failing grades as if they belong to someone else; jokes about them.
6. Fantasy - a conscious distortion of unconscious wishes and need to obtain satisfaction
o Example: A student nurse fails the critical care exam and daydreams about her heroic role in a cardiac arrest.
7. Fixation - becoming stagnated in a level of emotional development in which one is comfortable
o Example: A sixty year old man who dresses and acts as if he were still in the 1960's.
8. Identification - subconsciously attributing to oneself qualities of others
o Example: Elvis impersonators.
9. Intellectualization - use of thinking, ideas, or intellect to avoid emotions
o Example: Parent becomes extremely knowledgeable about child's diabetes.
10. Introjection - incorporating the traits of others
o Example: Husband's symptoms mimic wife's before she died.
11. Projection - unconsciously projecting one's own unacceptable qualities or feelings onto others
o Example: Woman who is jealous of another woman's wealth accuses her of being a gold-digger.
12. Rationalization - justifying behaviors, emotions, motives, considered intolerable through acceptable excuses
o Example: "I didn't get chosen for the team because the coach plays favorites."
13. Reaction Formation - expressing unacceptable wishes or behavior by opposite overt behavior
o Example: Recovered smoker preaches about the dangers of second hand smoke.
14. Regression - retreating to an earlier and more comfortable emotional level of development
o Example: Four year old insists on climbing into crib with younger sibling.
15. Repression - unconscious, deliberate forgetting of unacceptable or painful thoughts, impulses, feelings or acts
o Example: Adolescent "forgets" appointment with counselor to discuss final grades.
16. Sublimation - diversion of unacceptable instinctual drives into personally and socially acceptable areas.
o Example: Young woman who hated school becomes a teacher.
Elizabeth Kubler-Ross: Five Stages
1. Denial
a. Unconscious avoidance which varies from a brief period to the remainder of life
b. Allows one to mobilize defenses to cope
c. Positive adaptive responses - verbal denial; crying
d. Maladaptive responses - no crying, no acknowledgement of loss
2. Anger
a. Expresses the realization of loss
b. May be overt or covert
c. Positive adaptive responses - verbal expressions of anger
d. Maladaptive responses - persistent guilt or low self esteem, aggression, self destructive ideation or behavior
3. Bargaining
a. An attempt to change reality of loss; person bargains for treatment control, expresses wish to be alive for specific events in near future
b. Maladaptive responses - bargains for unrealistic activities or events in distant future
4. Depression and Withdrawal
a. Sadness resulting from actual and/or anticipated loss
b. Positive adaptive response - crying, social withdrawal
c. Maladaptive responses - self-destructive actions, despair
5. Acceptance
a. Resolution of feelings about death or other loss, resulting in peaceful feelings
b. Positive adaptive behaviors - may wish to be alone, limit social contacts, complete personal business
FOODS HIGH IN WATER-SOLUBLE VITAMINS
A. Vitamin C - citrus fruits, cabbage, tomatoes, strawberries, broccoli
B. Thiamine (B1) - lean meat, legumes,unrefined or enriched grains and cereals
C. Riboflavin (B2) - enriched grains, milk, organ meats, poultry, fish
D. Niacin - peanuts, peas, beans, meat, poultry
E. Pyridoxine (B6) - kidneys, liver, meats, corn, wheat, eggs, poultry, fish
F. Cyanocobalamin (B12) - kidneys, lean meats,liver, dairy products, egs
G. Folic acid - liver, eggs, leafy green vegetables, fruits, enriched grain products
FOODS CONTAINING FAT-SOLUBLE VITAMINS
A. Vitamin A - fruits, green and yellow vegetables, butter, milk, eggs, liver
B. Vitamin D - milk, fish
C. Vitamin E - green vegetables, vegetables oils, wheat germ, nuts
D. Vitamin K - liver, cheese, leafy green vegetables, milk, green tea
mucomyst: acetaminophen toxicity
