Nclex Notes

Dilantin - detoxified by liver.
The nurse cares for a client receiving IV antibiotics every 8 hours for the past 4 days. The antibiotic is mixed in D5W. The nurse
determines that a post-infusion phlebitis has occurred if which of the following is observed?
1. Tenderness at the IV site.
2. Increased swelling at the insertion site.
3. Area around the IV site is reddened with red streaks.
4. Fluid is leaking around the IV catheter.
a. Tenderness occurs with phlebitis but is not specific to it.
b. May indicate either infiltration or phlebitis
c. CORRECTreddened, warm area noted around insertion site or on path of vein; discontinue IV, apply warm, moist
compresses, restart IV at new site
d. Not indicative of phlebitis
Ethacrynic Acid (Edecrin)are considered loop diuretics and are potassium wasting; encourage client to increase intake of
potassium-rich foods. Orange juice/Bananas, etc.
Aminophylline (Truphylline)is a xanthine bronchodilator;
major side effects: palpitations, nervousness, rapid pulse, dysrhythmias, nausea, and vomiting.
Toxic effects: confusion, headache, flushing, tachycardia, and seizure.
Morphine Sulfatedecreases blood return to the right side of the heart, and decrease peripheral resistance. In other words, decreases
preload and afterload pressures and cardiac workload; causes vasodilation and pooling of fluid in extremities; provides relief from
anxiety.
Intropin (Dopamine)vasoactive medication are given IV to restore BP in hypotensive states; Increases blood return to the right
side of the heart, and increase peripheral resistance;
side effects: headache, severe hypertension, dysrhythmias; check BP q2 minutes until stabilized, then q5 minutes
TPNhang no longer than 24 hours; IV tubing and filters every 24 hours; site of catheter changed every 4 weeks.
Fluoxetine (Prozac)a selective serotonin reuptake inhibitor (SSRI) used to treat depression and obsessive compulsive disorder.
Side effects: postural hypotension, dry mouth, rapid heartbeat, anorexia, weight loss, severe headache. If dose is missed, omit dose
and instruct client to return to regular dosing schedule.
Propanolol (inderal)a beta-adrenergic blocker used as antihypertensive;
Side effects: bronchospasm, bradycardia, depression. Take pulse before administration and gradually decrease when discontinuing.
Do not give to asthmatic patients.
Glipizide (Glucotrol)an oral hypoglycemic that decreases blood sugar by stimulating insulin release from the beta cells of the
pancreas; may cause aplastic anemia and photosensitivity.
Prednisone (Deltasone)a corticosteroid. Side effects: hyperglycemia
Bethanechol (Urecholine)a cholinergic or parasympathomimetic used to treat functional urinary retention; mimics action of
acetylcholine.
Ventricular Tachycardiacauses chest pain, dizziness, and fainting.
1 grain = 60mg
Levothyroxine (Synthroid)thyroid preparation should be administered at breakfast to prevent insomnia.
Carbamazepine (Tegretol)interferes with action of hormonal contraceptives. Side effects: photosensitivity; prevention of seizures
and relief of pain in trigeminal neuralgia. Trigeminal neuralgia (Tic douloureux) is an agonizing pain that may result in severe
depression and suicide.
Aluminum Hydroxide (Amphojel)an antacid; neutralizes hydrochloric acid and reduces pepsin activity; take one hour before and
hour of sleep. Antacids most effective after digestion has started, but prior to the emptying of the stomach.
Isoniazid (INH)Side effects: peripheral neuropathy (administer pyridoxine), rash, urticaria, and swelling of the face, lips, and
eyelids.
Pyridoxine (Vitamin B6, Beesix, Doxine)required for amino acid, carbohydrate, and lipid metabolism. Used in the transport of
amino acids, formation of neurotransmitters, and sythesis of heme. Prevention of neuropathy.
Clonidine (Catapres-TTS)is a centrally acting alpha-adrenergic used to treat hypertension; Side effects: drowsiness, sedation,
orthostatic hypotension, heart failure. If patch used, be cautious around microwaves, results in burns, dispose of carefully, and heat
will increase medication absorption leading to toxicity.
Phlebitistenderness, redness; remove iv, apply warm soaks to decrease inflammation, swelling, and discomfort.
Autologous bloodmay give blood 5 weeks before surgery; can give 2 to 4 units of blood; may have to take iron pills
Partial-thickness burn; only part of skin is damaged or destroyed; large, thick-walled blisters develop; underlying tissue is deep red,
appears wet and shiny; painful with increased sensitivity to heat; healing occurs by evolution of undamaged basal cells, takes about
21-22 days. I.E., Redness and swelling with fluid-filled vesicles noted on right arm or Blistering and blanching of the skin noted on
the back.
Full-thickness burn; all skin is destroyed and muscle and bone may be involved; substance that remains is called eschar, dry to touch,
doesnt heal spontaneously, requires grafting. I.E., Charred, waxy, white appearance of skin on left leg.
Superficial burn; skin appears pink, increased sensitivity to heat, some swelling, healing occurs without treatment. I.E., Reddened
blotchy painful areas noted on the face.
Carbidopa/Levodopa (Sinemet)used to treat symptoms of Parkinsons disease. Take immediately before meals and high-protein
meals may impair effectiveness of medication. Reduces rigidity and bradykinesis and facilitates clients mobility.
Doxycycline (Vibramycin)a tetracycline that is taken at regular intervals but not within 1 hour of bedtime because it may cause
esophageal irritation. Use another method of birth control, do not take antacids within 1-3 hours of taking medication, and may cause
photosensitivity.
Albuterol (Proventil)a bronchodilator. Side effects: tremors, headache, hyperactivity, tachycardia. Use first before steroid
medication so opens up bronchioles for steroid to get in. Wait one minute between puffs of the inhalers for best effect.
Beclomethasone (Vanceril)a steroid medication. Side effect: fungal infections, dry mouth, throat infections.
InsulinNPH
Onset: 1.5 hours Peak: 4-12 hours Regular Onset: 0.5 hours Peak: 2.5-5 hours
Topiramate (Topamax)is an anticonvulsant. Should drink 2000-3000ml of fluid daily to prevent kidney stones. Side effects:
orthostatic hypotension, ocular symptoms, blindness, and decrease effects of hormonal contraceptives.
Propranolol (Inderal)a beta-blocker that takes up beta-adrenergic receptor sites, which prevents adrenaline from causing
symptoms and glycogenolysis. Inderal may mask symptoms of hypoglycemia, removing the bodys early warning system.
Phenazopyridine (Pyridium)acts on urinary tract mucosa to produce analgesic or local anesthetic effects. Side effects: bright
orange urine, yellowish discoloration of skin or sclera indicates drug accumulation due to renal impairment.
Trimethoprim-sulfamethoxazole (Bactrim)most common side effect mild to moderate rash (urticaria)
Aminoglycosides are ototoxic.
Butorphanol Tartrate (Stadol)analgesic used for moderate to severe pain; Side effects include change in BP, bradycardia,
respiratory depression.
Infant normal resting heart rate: 120-140
Salt substitutes contain potassium
When directing a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be
reported. Because the RN is responsible for all care-related decisions, only implementation tasks should be assigned because they do
not require independent judgment.
When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascular impairment can be used as a
guide (pain, pulselessness, pallor, paresthesia, paralysis)
READ THE QUESTIONS FIRST!!!!!
READ THE QUESTIONS FIRST!!!!!
DETERMINE THE QUESTION!!!!!!
Rash and blood dyscrasias are side effects of anti-psychotic drugs. A history of severe depression is a contraindication to the use of
neuroleptics.
Children with celiac disease should eat a gluten free diet. Gluten is found mainly in grains of wheat and rye and in smaller quantities
in barley and oats. Corn, rice, soybeans and potatoes are digestible in persons with celiac disease.
The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk because Decadron increases the
production of hydrochloric acid, which may cause gastrointestinal ulcers.
The protest phase of separation anxiety is a normal response for a child this age (2 year-old hospitalized child). In toddlers, ages 1 to
3, separation anxiety is at its peak
Signs of tardive dyskinesia include smacking lips, grinding of teeth and "fly catching" tongue movements.
Verapamil, Bretylium, and Amiodarone increases serum dig levels, possibly causing Digitalis Toxicity
Signs/Symptoms of Digital Toxicity: first signs include abdominal pain, anorexia, nausea, vomiting, visual disturbances, bradycardia,
and other arrhythmias. In infants and small children, the first symptoms of overdose are usually cardiac arrhythmias.
Restlessness, confusion, irritability and disorientation may be the first signs of fat embolism syndrome followed by a very high
temperature.
A Neologism is a new word self invented by a person and not readily understood by another that is often associated with a thought
disorder.
Pancreatic enzymes give before meals.
Clinical features of delusional disorder include extreme suspiciousness, jealousy, distrust, and belief that others intend to harm.
The UAP can be assigned to care for a client with a chronic condition after an initial assessment by the nurse. This client has no risk of
instability of condition.
Never leave your patient. For example, Ask the LPN/LVN to stay with the child and his parents while the nurse obtains phone orders
from the physician.
Tips for charting: dont use inflammatory words, no nurse judgments, be as specific as possible. I.E., Vital signs stable is incorrect
for of charting.
Restraint: frame of bed, quick release ties, document need for restraint Q4 hours
Never ask WHY questions in the NCLEX!
Gag Reflex: dont assess gag reflex to a client that has an absent swallow reflex
Nifedipine (Procardia XL): do not crush
An RN that is not assigned to a patient does not have the authority to tell a nurse what to do. Refer it to nursing supervisor.
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If doctor has orders it should carried out unless contraindicated in nurses decision.
Physical assessment: Inspection, Percussion, Palpation, Auscultation (Except for abdomen: Inspection, Auscultation, Percussion,
Palpation)
Coronary artery bypass graft (CABG)halt medications before surgery, can do 5 at a time; will be on mechanical ventilations after
surgery; chest tubes
Acromegalymonitor blood sugar, atrium90 implant care (radioactive, nasally implanted, monitor vision)
Bone marrow Aspiration---done at iliac crest; painful
Postoperative care after Supratentorial surgery: maintain airway, elevate head 30-45
Position care after Infratentorial surgery: flat and lateral
Orange juice does not help acidify urine it makes it more alkaline.
Myelogram
Water-soluble dyeelevate head of bed 30 degrees (not removed)
Oil based dyeflat in bed (removed)
Fractures:
Immobilize joint above and below fracture

Cover open fracture with cleanest material available
Check temperature, color, sensation, capillary refill distal to fracture
Close reductionmanually manipulate bone or use traction
Bucks Traction
Use to relieve muscle spasm of leg and back
If used for muscles spasms only, they can turn to either side.
If used for fracture treatment, only can turn to unaffected side.
Use 8-20 lbs of weight, if used for scoliosis will use 40 lbs of weight.
Elevate head of bed for countertraction or foot bed
Place pillow below leg not under heel or behind knee.
Russells Traction
Sling is used
Check for popliteal pulse
Place pillow below lower leg and heel off the bed
Dont turn from waist down
Lift patient, not the leg
Cervical Tongs
Never lift the weights
No pillow under head during feedings
Balanced Suspension Traction
For femur realignment
Maintain weights hanging free and not on floor
Maintain continuous pull
Halo Jacket
Maintain pin cleansing
Casts
Dont rest on hard surface

Dont cover until dry 48+ hours
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Handle with palms of hands not with fingers

Keep above level of heart
Check for CSM
Fractured Hip
Amputations
Assessments
Leg shortened
Adducted
Externally rotated
Implementation
Care after a total hip replacement
Abduction pillows
Crutch walking with 3-point gait
Dont sleep on operated side
Dont flex hip more than 45-60 degrees
Dont elevate head of the bed more than 45 degrees
Guillotine (open)
Flap (closed)
Delayed prosthesis fitting
Residual limb covered with dressing and elastic bandage (figure eight)
Figure-8 doesnt restrict blood flow, shaped to reduce edema
Check for bleeding
Elevated 24 hours (AKA-pillow, BKA-foot of bed elevated)
Position prone daily
Exercises, crutch walking
Phantom Pain: acknowledge feelings, that pain is real for them.
Thiamin (Vit. B1)carbohydrate metabolism; deficiency will cause Beri-Beri

Pyridoxine (Vit. B6)amino acid metabolism; deficiency will cause anemia, seizures
Folic acidRBC formation; deficiency will cause anemia
Cyanocobalamin (B12)nerve function; deficiency cause pernicious anemia
Calcium deficiency causes Ricketts
Cultural Food Patterns
Orthodox Jewish (Kosher)milk and meat cannot be eaten at same meal
Muslin30 day fast during Ramadan
Japaneserice is basic food, tea is main beverage
Greekbread is served with every meal
Enteral feeding held if: 150 or > ccs aspirated or 50% given in the hour is aspirated
If cramping, vomiting occurs decrease rate of enteral feeding or keep it warm.
TPNsupply nutritions via intravenous route
Peripherally or centrally
Initial rate 50/hour and can be increased to 100-125ml/hour.
A pump must be used to keep rate constant
Prevent sepsis: maintain closed system,, dont draw blood/infuse anything in line, dry sterile dressing
Verify placement of line
Monitor Glucose, acetone
Change IV tubing/Filter Q24 hours
Solution refrigerated then warmed
If solution not available, start 10% in water.
3/week check BUN, electrolytes (ca, mg)
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When TPN Dcd 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
Credes Maneuverpush urine out
Pernicious Anemia
- monthly Vitamin B12 IM injections
Metered dose inhaler
- Beclomethasone (Vanceril)
- Albuterol (Proventil)
Guillain-Barre Syndrome
- GBS often preceded by a viral infection as well as immunizations/vaccinations
- Intervention is symptomatic
- Acute phase: Steroids, plasmapheresis, aggressive respiratory care; prevent hazards of immobility, maintain adequate
nutrition; physical therapy; pain-reducing measures; eye care, prevention of complications (UTI, aspiration); psychosocial
support
Organ Donation Criteria
- No history of significant, disease, process in organ/tissue to be donated
- No untreated sepsis
- Brain death of donor
- No history of extracranial malignancy
- Relative hemodynamic stability
- Blood group compatibility
- Newborn donors must be full term (more than 200g)
- Only absolute restriction to organ donation is documented case of HIV infection
- Family members can give consent
- Nurse can discuss organ donation with other death-related topics (funeral home to be used, autopsy request)
Accurate way to verify NG tube position is to aspirate for gastric contents and check pH.
Parkinsons disease
- Activities should be scheduled for late morning when energy level is highest and patient wont be rushed
- Symptoms: tremors, akinesia, rigidity, weakness, motorized propulsive gait, slurred monotonous speech, dysphagia,
drooling, mask-like expression.
- Nursing care: encourage finger exercises. Administer Artane, Congentin, L-Dopa, Parlodel, Sinemet, Symmetrel.
- Teach: ambulation modification
- Promote family understanding of disease intellect/sight/hearing not impaired, disease progressive but slow, doesnt lead to
paralysis
Normal urine output (1200-1500 ccs/day or 50-63 cc/hr, normal voiding pattern 5-6 times/day.
Green leafy vegetables contain vitamin K.
Labs
HbA1c (4.5-7.6%)
- indicates overall glucose control for the previous 120 days
Serum Amylase / Somogyl (60-160 u/dL)
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elevated in acute pancreatitis
Erythrocyte Sedimentation Rate (ESR)

- Men (1-15)
- Women (1-20)
- Rate at which RBCs settle out of unclotted blood in one hour
- Indicates inflammation/neurosis
Hematocrit (Hct)
- Men (40-45) u/mL
- Women (37-45) u/mL
- Relative volume of plasma to RBC
- Increased with dehydration
- Decreased with volume excess
Creatine Kinase (CK)
- Men (12-70)
- Women (10-55)
- Enzyme specific to brain, myocardium, and skeletal muscles
- Indicates tissue necrosis or injury
Serum Glucose
- 60-110 mg/dL
Sodium (Na+)
- 135-145 mEq/L
- Hypernatremia
o Dehydration and insufficient water intake
Chloride (Cl-)
- 95-105 mEq/L
Potassium (K+)
- 3.5-5.0 mEq/L
Bicarbonate (HCO3)
- 22-26 mEq/L
- Decreased levels seen with starvation, renal failure, diarrhea.
Blood, Urea, Nitrogen (BUN)
- 6-20 mg
- Elevated levels indicate rapid protein catabolism, kidney dysfunction, dehydration
Creatinine Clearance Test
- normal 125 ml/min.
- Lower levels reflect renal insufficiency and may influence the excretion of many drugs and toxins from the body.
Lithium
- targeted blood level: (1-1.5 mEq/L)
Tofranil and AnafranilOCD medications
Pick physical needs over psychosocial needs!!!!!!!!!!!!!!!
Focus on here and now!!!!!!!!!!!!!!!!!
Oculogyric crisis: uncontrollable rolling back of eyes: side effect of Phenothiazines
Moribund means dying patient.
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Dont leave your patients. Stay with your patients.

Assess before implementation.
Manic patient: decrease stimuli and increase rest period and no competition.
Lithium helps control impulsive behaviors.
Fluphenazine (Prolixin): antipsychotic medication
Thiamine sources: organ meats, liver, whole grain, nuts, legume, egg, and milk.
Dont document abuse. Report suspected abuse to nursing supervisor.
Never promise a patient Not to tell.
Tonometrymeasures intraocular pressure; to rule out glaucoma
Myopianearsightedness (near clear, distance clear)
Hyperopiafarsightedness (distance is clear, near vision blurry)
Presbyopiachanges with aging
Blind client: address by name, introduce self, keep furniture arrangement consistent, open or close doors walk step ahead, identify
food location on tray.
Instilling ear drops lie patient on unaffected ear to absorb drops.
Position patient on affected ear to promote drainage.
Regular Insulin only given IV.
Sick day rules: take insulin as ordered, check blood glucose q3-4 hours, soft foods, liquids
Phenylketonuriahigh blood phenylalanine (no enzyme), results in mental retardation; milk substitutes, low-protein diet
Celiac Disease (SPrue)intestinal malabsorption, malnutrition (unable to digest wheat/rye/oats/barley); gluten-free diet
Hepatobiliary diseasedecrease in ability of bile to absorb fat, fat malabsorption; low-fat high-protein diet, vitamins
Cystic fibrosisabsence of pancreatic enzymes, malabsorption of fat, lung disease, pancreatic enzyme replacement, high-protein,
high-calorie diet, respiratory care/suction
Position right side to promote gastric emptying.
Dumping syndrome prevention: restrict fluid with meals, lie down after eating, small, frequent meals, low-carbohydrate, low-fiber diet
Sengstaken-Blakemore Tubeto treat pt. with esophageal varices.
Hepatitis B Vaccine
Given IM to vastus lateralis or deltoid
Side effects: mild tenderness at site
1st shot Birth to 3 months
2nd shot 1 to 4 months
3rd shot 6 to 18 months
DTaP (Diptheria, Tetanus, and Pertussis)
Given IM anterior or lateral thigh
Side effects: fever within 24-48 hours, swelling,
redness, soreness
Dont treat with aspirin, use other antipyretic.
1st shot 2 months
2nd shot 4 months
3rd shot 6 months
4th shot 15 to 18 months
5th shot 4 to 6 years
Only TD shot 11 to 16 years
Hib (Influenza)
1st shot 2months
2nd shot 4months
3rd shot 6 months
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
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
Pulse: 70-115
Resp: 15-25
BP: 100/56 110/60
Pulse: 60-100
Resp: 12-20
BP: 90/60-140/90
5-12 year old
Adult
Aortic Valve: Right of Sternum at the 2nd intercostal space

Pulmonic Valve: Left of Sternum at the 2nd intercostal space
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Tricuspid Valve: Immediately left of sternal border at the 5th Intercostal Space
Mitral Valve (Point of Maximal Impulse): Left of Sternum Mid-Clavicular Line at the 5th Intercostal Space
Erbs Point: Left of Sternum at the 3rd intercostal space
Infant (Point of Maximal Impulse): Lateral to sternum 4th intercostal space
Obese person choking use Chest Thrusts.
Tracheostomy tube placement of cuff maintained to prevent aspiration
Care for patient first, equipment second
Signs for hypoxia: restlessness, tachycardia
CPR: Shake, shout, summon help, open airway, look, listen, feel for signs of breathing, pinch nose, give 2 full breaths (if no rise,
reposition)
Adults 12/min check carotid, chest compressions 80-100/min 1.5 inches
Infants 20/min check brachial pulse, chest compression 100/min - 1 inch
15:2 Adult 4 cycles
Infant 20 cycles
Reassess pulse and breathing
Continue CPR until:
Victim responds
Someone else takes over
Victim is transferred
Rescuer is unable to continue
MI
Implementation for 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)
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
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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
Cullens Sign ecchymosis around umbilicus

Turners Sign ecchymosis around either flank
Balances sign resonance over spleen (+) means rupture of spleen
Shock Signs and Symptoms
Cool, clammy skin
Cyanosis
Decreased alertness
Tachycardia
Hypotension
Shallow, rapid respirations
Oliguria
Hypovolemic
Decreased in intravascular volume
Cardiogenic
Decreased cardiac output
Distributive
Problem with blood flow to cells
Implementation for shock

Monitor CVP: <3 inadequate fluid; >11 too much fluid
Increased ICP
Assessments
Altered LOC (Earliest Sign)
Glasgow coma scale <7 indicates coma
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:
Sodium:
3.5-5.0 mEq/L
135-145 mEq/L
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Calcium:
4.5-5.2 mEq/L
Magnesium: 1.5-2.5 mEq/L
Hypokalemia Assessments
K+ < 3.5 mEq/L
Muscle weakness
Paresthesias
Dysrhythmias
Increased sensitivity to digitalis
Hypokalemia Implementations
Potassium Supplements
Dont give > 40 mEq/L into peripheral IV or without cardiac
monitor
Increase dietary intake oranges, apricots, beans, potatoes,
carrots, celery, raisins
Hyperkalemia Assessments
K+ >5.0 mEq/L
EKG changes
Paralysis
Diarrhea
Nausea
Hyperkalemia Implementations
Restrict oral intake
Kayexalate
Calcium Gluconate and Sodium Bircarbonate IV
Peritoneal or hemodialysis
Diuretics
Hyponatremia Assessments
Na+ < 135 mEq/L
Nausea
Muscle cramps
Confusion
Increased ICP
Hyponatremia Implementations
I&O
Daily weight
Increase oral intake of sodium rich foods
Water restriction
IV Lactated Ringers or 0.9% NaCL
Hypernatremia Assessments
Na+ >145 mEq/L
Disorientation, delusion, hallucinations
Thirsty, dry, swollen tongue
Sticky mucous membranes
Hypotension
Tachycardia
Hypernatremia Assessments
I&O
Daily Weight
Give hypotonic solutions: 0.45% NaCl or 5% Dextrose
in water IV
Hypocalcemia Assessments
Ca+ < 4.5 mEq/L
Tetany
Positive Trousseaus sign
Positive Chvosteks sign
Seizures
Confusion
Irritability, paresthesias
Hypocalcemia Implementations
Oral calcium supplements with orange (maximizes
absorption)
Calcium gluconate IV
Seizure precautions
Meet safety needs
Hypercalcemia Assessments
Ca+> 5.2 mEq/L
Sedative effects on CNS
Muscle weakness, lack of coordination
Constipation, abdominal pain
Depressed deep tendon reflexes
Dysrhythmias
Hypercalcemia Implementations
0.4% NaCl or 0.9% NaCl IV
Encourage fluids (acidic drinks: cranberry juice)
Diuretics
Calcitonin
Mobilize patient
Surgery for hyperparathyroidism
12
Hypomagnesemia Assessments
Mg+< 1.5 mEq/L
Neuromuscular irritability
Tremors
Seizures
Tetany
Confusion
Dysphagia
Hypomagnesemia Implementations
Monitor cardiac rhythm and reflexes
Test ability to swallow
Seizure precautions
Increase oral intakegreen 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 thicknesspink to red, painful
Deep partial thicknessred to white, blisters, painful
Full thicknesscharred, waxy, white, painless
Wound Care for Burns

Never break blisters
Isotonic fluids (Lactated Ringers)
Closed method (Silvadene) covered with
dressings
Open method (Sulfamylon) that are not covered
with dressings
IV pain medication initially: not PO takes too
long, not IM circulation impaired
Medicate patient before wound care

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

Fatigue
Weakness
Dehydration
Eternal tan
Decreased resistance to stress
Low Sodium
Low Blood Sugar
High Potassium
Addisonian Crisis Assessments
Hypotension
Extreme weakness
Nausea vomiting
Abdominal pain
Severe hypoglycemia
Dehydration
Addissons Disease Implementations

High protein, High carbohydrate, high Sodium, Low
potassium diet
Teach life-long hormone replacement
Cushings Syndrome Assessments

Osteoporosis
Muscle wasting
Hypertension
Purple skin striations
Moon face
Truncal obesity
Decreased resistance to infection
Cushings Syndrome Implementations

Low Carbohydrate, Low Calorie, High Protein, High
Potassium, Low sodium diet
Monitor glucose level
Postop care after adrenalectomy or hypophysectomy
Addisonian Crisis Implementations

Administer NaCl IV, vasopressors, hydrocortisone
Monitor vital signs
Absolute bedrest
13
Pheochromocytoma Assessmentshypersecretions 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 (dont sleep laying
down, have to stay erect)
Use of accessory muscles of breathing
Dyspnea
Cough
Adventitious breath sounds
COPD Implementations
Assess airway clearance
Listen to breath sounds
Administer low-flow oxygen (1-2 L, not too much
because your trying to prevent CO2 narcosis)
Encourage fluids
Small frequent feedings
Use metered dose inhalers (MDI)
Pneumonia Assessments
Fever
Leukocytosis
Productive Cough (rust, green, yellow)
Dyspnea
Pleuritic pain
Tachycardia
Pneumonia Implementations
Check breath sounds
Cough and deep breath q 2 hours
Chest physiotherapy
Antibiotics
Incentive spirometer
Encourage fluids
Suction PRN
Provide oxygen
Semi-Fowlers position
Bedrest
Medicationsmucolytics (Mucomyst), expectorants
(Robitussin), Bronchodilators (Aminophylline),
Antibiotics (Bacterim)
14
Acyanotic Congenital Heart Anomalies Assessments

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

Cyanosis
Clubbing of fingers
Seizures
Marked exercise intolerance
Difficulty eating
Squat to decrease respiratory distress
Small stature
Failure to thrive
Characteristic murmur
Frequent respiratory infection
Cyanotic Congenital Heart Anomalies Types:
Tetralogy of FallotVSD, pulmonic stenosis, overriding aorta, right ventricular hypertrophy; squats/knee chest position
to help breath; surgery needed
Transposition of great vesselspulmonary artery leaves left ventricle and aorta leaves right ventricle; oxygenated blood
not going into systemic circulation
Truncus arteriosusfailure of normal septation and embryonic division of the pulmonary artery and aorta; rather than
two distinctly different vessels there is a single vessel that overrides both ventricles and gives rise to both pulmonary and
systemic circulation; blood enters from both common artery and either goes to the lungs or to the body; cyanosis,
murmur, difficult intolerance
Total anomalous venous returnabsence of direct communication between pulmonary veins and left atria; pulmonary
veins attach directly to right atria or drains to right atria
Congenital Heart Anomalies Compensatory Mechanisms

Tachycardia
Polycythemia (increase formation of RBCs)
Posturingsquatting, knee-chest position
Congenital Heart Anomalies Implementations

Prevention
Recognize early symptoms
Monitor vital signs and heart rhythms
Medicationsdigoxin, iron, diuretics, potassium
Change feeding pattern
Left-Side CHF
Dyspnea, orthopnea
Cough
Pulmonary edema
Weakness/Changes in mental status
Right-Side CHF
Dependent edema
Liver enlargement
Abdominal pain/Nausea/Bloating
Coolness of extremities
15
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
Venous Peripheral Vascular Disease

Assessments
Cool, brown skin
Edema
Normal or decreased pulses
Positive Homans sign
Anemia Assessments (reduction in hemoglobin

amount/erythrocytes)
Palpitations
Dyspnea
Diaphoresis
Chronic fatigue
Sensitivity to cold
Arterial Peripheral Vascular Disease

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

Implementations
Monitor peripheral pulses
Elastic stockings
Medicationsanticoagulants
Elevate legs
Warm, moist packs
Bedrest 4-7 days (acute phase)
Anemia Implementations
Identify cause
Frequent rest periods
High protein, high iron, high vitamin diet
Protect from infection
Iron Deficiency Anemia Assessments

Fatigue
Glossitis
Spoon fingernails
Impaired cognition
Pernicious Anemia Assessments (gastric mucosa fail to
secrete enough intrinsic factor for stomach to absorb)
Schillings Test
Fatigue
Sore, red tongue
Paresthesia in hands and feet
Iron Deficiency Anemia Implementations

Increase iron-rich foods (liver, green leafy vegetables)
Iron supplements (stains teeth)
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
Pernicious Anemia Assessments

Vitamin B12IM
Rest of life cant be absorbed PO
16
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
Dont 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/dont
reuse cup/dont change litter box/digging in garden
Intracranial Tumors Assessments

Intracranial Tumors Implementations
Motor deficits
Preoperative: do neurological assessment, patient head shaved
Hearing or visual disturbances
Postoperative: maintain airway, elevate head 30-45 after
supratentorial surgery
Dizziness
Flat and lateral after infratentorial surgery
Paresthesia
Monitor vital and neurological signs
Seizures
Glascow coma scale
Personality disturbances
Changes in LOC
Therapeutic Positions
Supineavoids hip flexion
Dorsal recumbentsupine with knees flexed
Proneextension of hip joint(after amputation)
Side lateraldrainage of oral secretions
Knee-chestvisualization of rectal area
Simsdecreases abdominal tension (side lying with legs bent)
Fowlersincreases venous return, lung expansion
High Fowlers60-90
Fowlers45-60
Semi-Fowlers30-45
17
4 point Gait
Weight bearing
both legs
RC, LF, LC, RF
Low Fowlers15-30
Modified Trendelenburgused for shock;Feet elevated 20 degrees, knees straight, trunk flat, head slightly
elevated
Elevation of extremityincreases blood to extremity and venous return
Lithotomyused for vaginal exam
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 upgood leg first, crutches, bad leg
Going downcrutches with bad leg, then good leg
Up with the good, down with the bad
Walker
Flex elbows 20-30 degrees when hands are on grips
Lift and move walker forward 8-10 inches
Step forward with bad leg, support self on arms, follow with good leg
Stand behind client holding onto gait belt
Myelogramx-ray visualization of the spinal canal by injection
of radiopaque dye.
Hydration done 12 hours before procedure
Cleansing enemas
Avoid seizure-promoting medications
Post-procedure
Water-soluble dyeelevate head of bed 30 degrees
(not removed)
Oil based dyeflat in bed (removed)
Bedrest 24 hours encourage fluids
Laminectomyexcision portion of lamina to expose area of

affected disc
Preopcare: moist heat
Fowlers position
Isometric exercises for abdominal muscles
Muscle relaxants, NSAIDs, Analgesics
Traction, TENS
Postoperative care:
Assess circulation and sensation
Log roll Q2 hours with pillow between leg
Calf exercises, assist with ambulation keeping back
straight
Muscle relaxants, NSAIDS, analgesics, 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
Ortolanis signplace 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 Bryants traction
Hip spica cast
Older child
Open reduction
Hip Spica cast
Scoliosis Assessmentslateral deviation of one or more of

vertebrae accompanied by rotary motion of spine
Uneven hips or scapulae
Kyphosis lump on back
Bend at waist to visualize deformity
Structural (flexible deviation corrected with bending)
or functional (permanent heredirary that is seen)
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
18
Cerebral Palsy Assessments

Voluntary muscles poorly controlled due to brain
damage
Spasticity, rigidity, ataxia, repetitive involuntary gross
motor movements
Muscular Dystrophy Assessments

Atrophy of voluntary muscles
Muscle weakness, lordosis, falls
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
Braces to help ambulation

Balance activity and rest
Parkinsons Disease Assessments

Deficiency of dopamine
Tremors, rigidity, propulsive gait
Monotonous speech
Mask like expression
Parkinsons Disease Implementations

Teach ambulation modification: goose stepping walk
(marching), ROM exercises
MedicationsArtane, Cogentin, L-Dopa, Parlodel,
Sinemet, Symmetrel
Myasthenia Gravis Assessments

Deficiency of acetylcholine
Muscular weakness produced by repeated
movement
Dysphagia
Respiratory distress
Clear liquid
No milk
No juice with
pulp
Full liquid
No jam
No fruit
No nuts
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
Myasthenia Gravis Implementations

Good eye care, restful environment
Medicationsanticholinesterases, corticosteroids,
immunosuppressants
Avoid crisis: infection
Symptoms: sudden ability to swallow
Low-fat cholesterol
restricted
Can eat
lean meat
No
avocado,
milk,
bacon, egg
yolks butter
Low-phenylalanine
diet
Prevents
brain
damage
from
imbalance
of amino
acids
Fats, fruits,
jams
allowed
No meats
eggs bread
Sodium
restricted
No cheese
19
High roughage,
high fiber
No white
bread
without fiber
Low-residue
Minimize intestinal
activity
Buttered rice white
processed food, no
whole wheat corn
bran
Glomerulonephritis Assessment
Fever, Chills
Hematuria
Proteinuria
Edema
Hypertension
Abdominal or flank pain
Occurs 10 days after beta hemolytic
streptococcal throat infection
Urinary Diversion: Assessments
Done for: Bladder t umors, birth defects,
neurogenic bladder, interstitial cystitis
Ileal Conduit
Koch Pouch
Acute Renal Failure

Assessments: Oliguric
Phase
Output <400 cc/day
Hypertension
Anemia
CHF
Confusion
Increased K+, Ca+,
Na+, BUN, Creatinine
Urinary Diversion Implementations

Nephrostomy: flank incision and insertion of nephrostomy tube into renal
pelvis; penrose drain after surgery; surgical dressing
Ureterosigmoidostomy: urters detached from bladder and anastomosed to
sigmoid colon; encourage voiding via rectum q 2-4 hours;no enemas or
cathartics; complicationselectrolyte imbalance, infection, obstruction; urine
and stool evacuated towards anus.
Cutaneous Ureterostomy: Stoma formed from ureters excised from bladder and
brought to abdominal wall; stoma on right side below waist; assist with
alteration in body image
Illeal Conduit: Ureters replanted into portion of terminal ileum and brought to
abdominal wall; check for obstruction; mucous threads 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: Diuretic
Phase
Output 4-5 L/day
Increased BUN
Na+, K+ lost in
urine
Increased mental
and physical
activity
Hemodialysis Implementation
Check for thrill and bruit q 8
hours
Dont use extremity for BP,
finger stick
Monitor vital signs, weight,
breath sounds
Monitor for hemorrhage
Glomerulonephritis Implementation
Antibiotics, corticosteroids
Antihypertensives, immunosuppressive agents
Restrict sodium and water intake
Bedrest
I&O
Daily weight
High Calorie, Low protein
Acute Renal Failure

Causes
Prerenalreduced blood
volume
Renalnephrotoxic drugs,
glomerulonephritis
Postrenal--obstruction
Peritoneal Dialysis
Weight before and after
treatment
Monitor BP
Monitor breath sounds
Use sterile technique
If problem with outflow,
reposition client
Side effects: constipation
20
Acute Renal Failure

Implementations:
Low-output stage: Limit fluids,
Kayexalate, Dialysis
High-output stage: Fluids as
needed, K+ replacement, Dialysis
I&O
Daily Weight
Monitor Electrolytes
Bedrest during acute phase
IV fluids
Diet restrictions
Oliguric phase: limit fluids, TPN
maybe
After Diuretic phase: high
protein, high calorie diet
Types of Peritoneal
Dialysis
Continuous ambulatory
(CAPD)
Automated
Intermittent
Continuous
Ego Defense Mechanisms

Denialfailure to acknowledge thought
Displacementredirect feelings to more acceptable subject
Projectionattributing your feelings to someone else
Undoingattempt to erase an act, thought or feeling
Compensationattempt to overcome shortcoming
Symbolizationless threatening object used to represent another
Substitutionreplacing unacceptable or unobtainable object to one that is acceptable or attainable
Introjectionsymbolic taking into oneself the characteristics of another
Repressionunacceptable thoughts kept from awareness
Reaction formationexpressing attitude opposite of unconscious wish or fear
Regressionreturning to an earlier developmental phase
Dissociationdetachment of painful emotional conflicts from consciousness
Suppressionconsciously putting thought out of awareness
Dying patient: Denial, Anger, Bargaining, Depression, Acceptance
Bipolar Disorder Assessments
Disoriented, flight of ideas
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
Schizophrenia Assessments
Withdrawal from relationships
and world
Inappropriate display of feelings
Hypochondriasis
Suspiciousness
Inability to test reality, regression
Hallucinationsfalse sensory
perceptions
Delusionspersistent 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
Paranoid Assessments
Suspiciousness
Cold, blunted affect
Quick response with anger or rage
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 Types
Disorganizedinappropriate
behavior, transient hallucinations
Catatonicsudden onset mutism,
stereotyped position, periods of
agitation
Paranoidlate onset in life,
suspiciousness, ideas of
persecution and delusions
Schizophrenia Implementations
Maintain safetyprotect from erratic
behavior
With hallucinationdo not argue, validate
reality, respond to feeling tone, never
further discuss voices (dont ask to tell
more about voices)
With delusionsdo not argue, point out
feeling tone, provide diversional activities
Meet physical needs
Establish therapeutic relationship
Institute measures to promote trust
Engage in individual, group, or family
therapy
Encourage clients affect
Accept nonverbal behavior
Accept regression
Provide simple activities or tasks
Paranoid Implementations
Establish trust
Low doses phenothiazines for anxiety
Structured social situations
21
Schizoid Assessments
Shy and introverted
Little verbal interaction
Few friends
Uses intellectualization
Schizotypal Assessments
Eccentric
Suspicious of others
Blunted affect
Problems with perceiving, communicating
Schizoid Implementations
Establish trust
Low doses phenothiazines for anxiety
Schizotypal Interventions
Establish trust
Low doses neuroleptics to decrease psychotic symptoms
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 selfconfidence
Fears intimate relationships
Avoidant Implementations
Gradually confront fears
Discuss feelings
Teach assertiveness
Increase exposure to small groups
22
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 clients 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
Wernickes Syndrome Assessments

Confusion
Diplopia, nystagmus
Ataxia
Apathy
Wernickes Syndrome Implementations

Thiamine (IM or IV)
Abstinence from alcohol
Korsakoffs Psychosis Assessments

Memory disturbances with confabulation
Learning problems
Altered taste and smell
Loss of reality testing
Korsakoffs Psychosis Implementations

Balanced diet
Thiamine
Abstinence from alcohol
23
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 pupilconstricted 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
Bells Palsy Assessments
Inability to close eye
Increased lacrimation
Distorted side of face
Guillain-Barre Syndrome Assessments
Paresthesia
Motor losses beginning in lower
extremities
Altered autonomic function
Trigeminal Neuralgia Implementations

Medicationsanalgesics, Tegretol
Surgery
Bells Palsy Implementations
Isometric exercises for face
Prevent corneal abrasions
Meningitis Assessments
Nuchal rigidity
Kernings sign
Brudzinskis sign
Seizures
Bulging fontanels
High-pitched cry
Meningitis Implementations
Medicationsantibiotics, antifungals
Prevent complications: droplet precautions, contagious
Guillain-Barre Syndrome Implementations

Medicationssteroids
Aggressive respiratory care
Physical therapy
Eye care
Prevent complications: respiratory and aspiration
24
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 Scandye gives flushed, warm face and metallic taste during injection (if contrast dye is used)
Myelogram: Post-test
Supine 8-24 hours (Pantopaque oil-based dye used)
Head raised 30-45degrees 8-16 hours(metrizamide water-soluble dye used)
Liver Biopsy Preparation
Liver Biopsy Post-Test
Administer vitamin K IM (decrease risk of
Position on operative side for 1-2 hours
hemorrhage)
Gradually elevate head of bed 30 degrees (1st hour) and then 45
NPO 6 hours
degrees (2nd 2 hours)
Given sedative
Bedrest for 24 hours
Position supine, lateral with upper arms
Check Vital signs
elevated
Check clotting time, platelets, hematocrit
Asked to hold breath for 5-10 seconds
Report severe abdominal pain
Upper GI Series Barium Swallow: stool white from barium
Tracheostomy Tube Cuff
Purposeprevents 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 patients temperature
25
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 reading3-11 cm water
Elevated>11, indicates hypervolemia or poor cardiac contractility (slow down IV, notify physician)
Lowered<3, hypovolemia
Chest tray at bedside
Eye irrigation: tilt head back and toward affected side
Eye drops: drop in center of conjunctival sac; prevent systemic absorption, press on inner angle of eye; dont allow drops to go from
one eye to the other; dont squeeze eyes
Nasogastric Tubes:
Levin-singlesingle-lumen, used for decompression or tube feeding
Salem sumpdouble-lumen, used for decompression or tube feeding
Sengstaken-Blakemoretriple-lumen, used for bleeding esophageal varices
Linton-Nachlas4-lumen, used for bleeding esophageal varices
Keofeed/Dobhoffsoft silicone, used for long-term feedings
Cantorsingle lumen with mercury-filled balloon and suction port
Miller-Abbottdouble-lumen with mercury-filled balloon and suction port
Harrissingle lumen with mercury-filled balloon and suction port
NG tube placement:
BEST WAY to check is to aspirate for gastric contents and check for pH of aspirate <4
Implementation of feeding:
Check residual before intermittent feeding, reinstall residual
Check residual Q4 hours with continuous feeding, reinstall residual
Hold feeding if >50% residual from previous hour (adults) or >25% (children)
Flush tube with water before and after feeding
Use pump to control rate of tube feeding
26
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 Fowlers position, then left side
o Gravity helps to position tube
o Coil excess tube loosely on bed, do not tape
o Position of tube verified by x-ray
o Measure drainage QShift
Removal
o Clamp tube
o Remove tape
o Deflate balloon or aspirate contents of intestinal tube balloon
o Instruct patient to exhale
o Remove 6 every 10 min. until reaches the stomach, then remove completely with smooth, continuous pull
T-Tube: 500-1000 cc/day, bloody first 2 hours
Penrose: expect drainage on dressing
Enema Implementation
Position on left side
Use tepid solution
Hold irrigation set no more than 18 above rectum
Insert tube no more than 4
Do not use if abdominal pain, nausea, vomiting, suspected appendicitis
Catheter insertion: 2-3 into urethra then 1 after urine flows
Male catheter: insert 6-7
Catheter Urine Drainage bag: do not remove more than 700 cc at one time, clamp prior to removal
Ileostomy: post-op has loose, dark green, liquid drainage from stoma
Tonsillectomy: post-op frequently swallowing indicates hemorrhage
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
27
Glaucoma medications: Epinephrine hydrochloride (Adrenalin Chloride) and Pilocarpine Hydrochloride (Pilocar): give Pilocar
(therapeutic) first then wait 2-10minutes and instill adrenalin to increase absorption of adrenalin).
Tympanoplasty: remain in bed 24 hours position flat in bed with the affected ear up (helps to promote insertion).
Triglycerides elevation can falsely elevate glycosalated hemoglobin test.
Laparoscopic Cholecystectomy post: encourage to walk to eliminate acute right shoulder pain.
Impetigo: 2 year old; honey-colored crusts, vesicles, and reddish macules around mouth; dont need to isolate; watch contact
precautions.
Only patient we use distractions on the NCLEX are manic patients and toddlers not for pain.
Rhinoplasty (nose surgery) position post-op: want to promote drainage of oral secretions is to position on her right side.
1 cup= 240cc
Pregnancy is a contraindication to an MRI.
Raynauds disease have decreased vascularity in the extremities.
Post-Parecentesis most important assessment is to obtain the blood pressure, weight the client, measure the clients abdominal girth,
and check dressing in that order.
Tracheostomy tube: use pre-cut/pre-made gauze pads.
Suction is always intermittent never continuous.
O universal donor/AB universal recipient.
ABO BLOOD TYPE
COMPATIBILITY
Can Receive from:
O
A,O
B,O
O,A,B,AB
Blood Type
O
A
B
AB
Can donate to:

O,A,B,AB
A,AB
B,AB
AB
Autologous Transfusion:
Collected 4-6 weeks before surgery
Contraindicatedinfection, chronic disease, cerebrovascular or cardiovascular
disease
Hypotonic Solution
NS (0.45%
Saline)
Isotonic Solution
0.9% NaCl (Normal Saline)
5% D/W (Dextrose in Water)
Lactated Ringers
5% D/ NS (5% Dextrose in
0.225% Saline )
Hypertonic Solution
10% D/W (10% Dextrose in water)
D15W
5% D/NS (5% Dextrose in 0.9% Saline)
5% D/ NS (5% Dextrose in 0.45% Saline)
3% NaCl
5% Sodium Bicarbonate
Change tubing Q72 hours

Change bottle Q24 hours
Infiltration
Assessment: cool skin, swelling, pain, decrease in flow rate
Implementation: discontinue IV, warm compresses, elevate arm, start new site proximal to infiltrated site
28
IV Phlebitis, Thrmobophlebitis
Assessmentredness, warm, tender, swelling, leukocytosis
Implementationdiscontinue IV, warm moist compresses, start IV in opposite extremity
Hematoma
Assessmentecchymosis, swelling, leakage of blood
Implementationdiscontinue IV, apply pressure, ice bag 24 hours, restart IV in opposite extremity
IV Clotting
Assessmentdecreased flow rate, back flow of blood into tubing
Implementationdiscontinue, do not irrigate, do not milk, do not increase rate of flow or hang solution higher, do not
aspirate cannula, inject Urokinase, D/C and start on other site.
Insertion of Percutaneous Central Catheters:
Placed supine in head-low position
Turn head away from procedure
Perform Valsalva maneuver
Antibiotic ointment and transparent sterile dressing
Verify position with x-ray
Change tubing Q24 hours
Nurse/patient both wear mask when dressing change 2-3x/week
Adrenergics
Actions:
Stimulate the sympathetic nervous system:

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

Anti-Anxiety
Action:
Affect neurotransmitters
Used for:
Anxiety disorders, manic
episodes, panic attacks
Antacids
Actions:
Neutralize gastric acids
Used for:
Peptic ulcer
Indigestion, reflex
esophagitis
Adrenergic Medications
Levophed
Dopamine
Adrenalin
Dobutrex
Anti-Anxiety
Medications:
Librium, Xanax,
Ativan, Vistaril,
Equanil
Antacids Medications
Amphojel
Milk of Magnesia
Maalox
Adrenergics Side effects:

Dysrhythmias
Tremors
Anticholinergic effects
Adrenergics Nursing Considerations:
Monitor BP
Monitor peripheral pulses
Check output
Anti-Anxiety
Side effects:
Sedation
Confusion
Hepatic dysfunction
Anti-Anxiety
Nursing Considerations:
Potention for addiction/overdose
Avoid alcohol
Monitor Liver Function AST/ALT
Dont discontinue abruptly, wean off
Smoking/caffeine decreases effectiveness
Antacids
Side effects:
Constipation
Diarrhea
Acid rebound
Antacids
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
29
Antiarrhythmics
Action:
Interfere with electrical
excitability of heart
Used for:
Atrial fibrillation and
flutter
Tachycardia
PVCs
Aminoglycosides
(Antibiotics)
Action:
Inhibits protein
synthesis in gramnegative bacteria
Used for:
Pseudomonas,
E.Coli
Allergy: 1st symptom SOB

Cephalosporins
(Antibiotics)
Action:
Inhibits synthesis
of bacterial cell wall
Used for:
Tonsillitis, otitis
media, peri-operative
prophylaxis
Meningitis
Fluoroquinolones
(Antibiotics)
Action:
Interferes with DNA
replication in gramnegative bacteria
Used for:
E.Coli,
Pseudomonas, S.
Aureus
Antiarrhythmics
Medications:
Atropine sulfate
Lidocaine
Pronestyl
Quinidine
Isuprel
Aminoglycosides
(Antibiotics)
Medications:
Gentamycin
Neomycin
Streptomycin
Tobramycin
Cephalosporins
(Antibiotics)
Medications:
Ceclor
Ancef
Keflex
Rocephin
Cefoxitin
Fluoroquinolones
(Antibiotics)
Medications:
Cipro
Antiarrhythmics
Side effects:
Lightheadedness
Hypotension
Urinary retention
Antiarrhythmics
Monitor vital signs
Monitor cardiac rhythm
Aminoglycosides (Antibiotics)
Side effects:
Ototoxicity and Nephrotoxicity
Anorexia
Nausea
Vomiting
Diarrhea
Aminoglycosides (Antibiotics)
Harmful to liver and kidneys
Check 8th cranial nerve (hearing)
Check renal function
Take for 7-10 days
Encourage fluids
Check peak/trough level
Cephalosporins (Antibiotics)
Side effects:
Bone marrow depression: caution with anemic, thrombocytopenic
patients
Superinfections
Rash
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
Fluroquinolones
(Antibiotics)
Side effects:
Diarrhea
Decreased WBC and Hematocrit
Elevated liver enzymes (AST, ALT)
Elevated alkaline phosphatase
C&S before starting therapy
Encourage fluids
Take 1 hour ac or 2 hour pc (food slows absorption)
Dont give with antacids or iron preparation
Maybe given with other medications (Probenicid: for gout)
30
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
Medications:
Erythromycin
Clindamycin
Penicillin
Action:
Inhibits synthesis of cell
wall
Used for:
Moderate to severe
infections
Syphilis
Gonococcal infections
Lyme disease
Sulfonamides (Antibiotics)
Action:
Antagonize essential component
of folic acid synthesis
Used for:
Ulcerative colitis
Crohns disease
Otitis media
UTIs
Side effects:
Diarrhea
Confusion
Hepatotoxicity
Superinfections
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
Medications:
Amoxicillin
Ampicillin
Augmentin
Penicillin
Side effects:
Stomatitis
Diarrhea
Allergic reactions
Renal and Hepatic changes
Check for hypersensitivity
Give 1-2 hr ac or 2-3 hr pc
Cross allergy with cephalosporins
Medications:
Gantrisin
Bactrim
Septra
Azulfidine
Side effects:
Peripheral Neuropathy
Crystalluria
Photosensitivity
GI upset
Stomatitis
Take with meals or foods
Encourage fluids
Good mouth care
Antacids will interfere with absorption
31
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
o Give with food or milk
o Monitor pulmonary status
UTIs
Medication
o Mandelamine
Action:
o Anti-infective
Side effects:
o Elevated liver enzymes
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
32
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
Anticoagulants
Action:
Blocks conversion of
prothrombin to thrombin
Used for:
Pulmonary embolism
Venous thrombosis
Prophylaxis after acute MI
Anticoagulant
Action:
Interferes with synthesis of
vitamin K-dependent clotting
factors
Used for:
Pulmonary embolism
Venous thrombosis
Prophylaxis after acute MI
Anticonvulsants
Action:
Decreases flow of calcium
and sodium across neuronal
membranes
Used for:
Seizures
Anticholinergic Medications:
Pro-Banthine
Atropine
Scopolamine
Anticoagulants
Medications:
Heparin
Anticoagulant
Medication:
Coumadin
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 (Heparin)
Side Effects:
Hematuria
Tissue irritation
Monitor clotting time or Partial Thromboplastin Time
(PTT)
Normal 20-45 sec
Therapeutic level 1.5-2.5 times control
AntagonistProtamine Sulfate
Give SC or IV
Anticoagulant (Coumadin)
Side Effects:
Hemorrhage, Alopecia
Monitor Prothrombin Test (PT)
Normal 9-12 sec
Therapeutic level 1.5 times control
AntagonistVitamin K
(AquaMEPHYTON)
Monitor for bleeding
Give PO
Anticonvulsant
Medications:
Dilantin
Luminal
Depakote
Tegretol
Klonopin
Anticonvulsant
Side effects:
Respiratory depression
Aplastic anemia
Gingival hypertrophy
Ataxia
Dont discontinue abruptly
Monitor I&O
Caution with use of medications that lower
seizure threshold: MAO inhibitors & antipsychotics
Good mouth care
Take with food
May turn urine pinkish-red/pinkish-brown
33
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
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 (Tricyclics)
Action:
Inhibits reuptake of
neurotransmitters
Used for:
Depression
Sleep apnea
Insulin
(Regular, Humulin R)
Type: Fast acting
Onset: -1 hr
Peak: 2-4 hr
Duration: 6-8 hr
Anti-Depressants
(Monoamine Oxidase Inhibitors)
Side effects:
Hypertensive Crisis (Sudden headache, diaphoretic,
palpitations, stiff neck, intracranial hemorrhage) with
food that contain Tyramine
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
Dont combine with sympathomometics
vasoconstrictors, and cold medications
Anti-Depressants
Selective Serontonin Reuptake Inhibitors (SSRI)
Side effects:
Anxiety
GI upset
Change in appetite and bowel function
Urinary retention
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
Medications:
Side Effects:
Norpramin
Sedation/Confusion
Elavil
Anticholinergics affects
Tofranil
Postural Hypotension
Urinary retention
Suicide precautions/2-6 weeks to work
Take at hs/Dont abruptly halt
Avoid alcohol/OTC /Photosensitivity
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
34
Insulin
(Humulin 70/30)
Type: Combination
Onset: 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
Hypoglycemic Agent
Action:
Stimulates liver to change
glycogen to glucose
Used for:
Hypoglycemia
Antidiarrheals
Action:
Slows peristalsis
Increases tone of
sphincters
Used for:
Diarrhea
Antiemetics
Action:
Increases GI motility
Blocks effect of
dopamine in
chemoreceptor trigger
zone
Used for:
Vomiting
Antifungals
Action:
Impairs cell membrane
Used for:
Candidiasis
Oral thrush
Histoplasmosis
Antidiabetic Agents
Side Effects:
Hypoglycemia
Allergic skin reactions
GI upset
Take before breakfast
Monitor glucose levels
Avoid alcohol, sulfonamides, Oral Contraceptives, (MAO),
aspirin because they help to make drug work better
Hypoglycemic Agent
Medication:
Glucagon
Hypoglycemic Agent
Side Effects:
Hypotension
Bronchospasm
May repeat in 15min
Give carbohydrates orally to prevent secondary
hypoglycemic reactions
Antidiarrheals
Medications:
Kaopectate
Lomotil
Imodium
Paregoric
Antidiarrheals
Side Effects:
Constipation
Anticholinergic effects (urinary retention, dry
mouth)
Do not use with abdominal pain
Monitor for urinary retention
Give 2hr before or 3 hr after other meds
Antiemetics
Medications:
Tigan
Compazine
Torecan
Reglan
Antivert
Dramamine
Antiemetics
Side Effects:
Sedation
Used before chemotherapy
When used with viral infections may cause Reyes
syndrome (Toxic Encephalopathy)
Antifungals
Medications:
Amphotericin B
Nystatin
Antifungals
Side Effects:
Hepatotoxicity
Thrombocytopenia
Leukopenia
Pruritis
Give with food
Good oral hygiene
35
Antigout Agents
Action:
Decreases production
and resorption of uric
acid
Used for:
Gout
Antigout Agents
Medications:
Colchicine
Probenecid
Zyloprim
Antihistamines
Action:
Block effects of histamine
Used for:
Allergic rhinitis
Allergic reactions to blood
Antihyperlipidemic Agents
Action:
Inhibits cholesterol and triglyceride
synthesis
Used For:
Elevated cholesterol
Reduce incidence of cardiovascular
disease
Antihypertensives
Types: ACE Inhibitors
Action:
Blocks ACE in lungs
Used for:
Hypertension
CHF
Antigout Agents
Side Effects:
Agranulocytosis
GI upset
Renal calculi
Monitor for renal calculi
Give with food, milk, antacids
Antihistamines
Medications:
Chlor-Trimeton
Benadryl
Phenergan
Medications:
Questran
Lipid
Antihypertensives
(ACE Inhibitors)
Medications:
Capoten
Vasotec
Antihypertensives
Type: Beta-Adrenergic Blockers
Action:
Blocks Beta-Adrenergic Receptors
Decrease excitability/workload of heart,
oxygen consumption
Decrease
Used for:
Hypertension
Angina
SVT
Antihistamines
Side Effects:
Drowsiness
Dry mouth
Photosensitivity
Give with food
Use sunscreen
Avoid alcohol
Side Effects:
Constipation
Fat-soluble vitamin deficiency
Take at hs or 30 min ac
Administer 1hr before or 4-6 hr after
other meds
Antihypertensives
(ACE Inhibitors)
Side Effects:
GI upset
Orthostatic hypotension
Dizziness
Give 1hr ac or 3hr pc
Change position slowly
Antihypertensives
Type: Beta-Adrenergic
Medications;
Nadolol
Propranolol
Tenormin
Timoptic
36
Antihypertensives
Type: Beta-Adrenergic
Side Effects:
Changes in heart rate
Hypotension
Bronchospasm
Masks signs of shock and
hypoglycemia
Take with meals
Do not discontinue abruptly
Antihypertensives
Antihypertensives
Antihypertensives
Type: Centrally acting alphaType: Centrally acting alpha-adrenergics Type: Centrally acting alpha-adrenergics
adrenergics
Medications:
Side Effects:
Action:
Aldomet
Sedation
Stimulates alpha receptors
Catapres
Orthostatic Hypotension
in medulla which causes a
reduction in sympathetic
Dont discontinue abruptly
in the heart
Monitor for fluid retention
Used for:
Hypertension
Antihypertensives
Antihypertensives
Antihypertensives
Type: Direct-acting vasodilators
Medications
Side Effects:
Action:
Hydralazine
Tachycardia
Relaxes smooth muscle
Minoxidil
Increase in body hair
Used for:
Hypertension
Teach patient to check pulse
Antihypertensives
Antihypertensives
Antihypertensives
Type: Calcium Channel Blockers
Type: Calcium Channel
Type: Calcium Channel Blockers
Action:
Blockers
Side Effects:
Medications:
Inhibits movement of calcium across cell membranes
Hypotension
Procardia
Slow impulse conduction and depresses myocardial
Dizziness
contractility
Calan
GI distress
Causes dilation of coronary arteries and decreases
Cardizem
Nursing Consideration:
cardiac workload and energy consumption
Monitor vital signs
Used for:
Do not chew or divide
Angina
sustained-release tablets
Hypertension
Interstitial cystitis
Antihypertensives
Type: Peripheral-acting alpha-adrenergic blockers
Action:
Depletes stores of norepinephrine in
sympathetic nerve endings
Used for:
Hypertension
Bipolar Disorder
Action:
Reduces catecholamine
release
Used for:
Manic episodes
Antihypertensives
Medications:
Reserpine
Bipolar Disorder Medications:

Lithium (1-1.5meq/L)
Tegretol
Depakote
37
Antihypertensives
Side Effects:
Depression
Brachycardia
Give with meals or milk
Bipolar Disorder
Side Effects:
GI upset
Tremors
Polydipsia
Polyuria
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
Medications:
Cisplatin
Myleran
Cytoxan
Side Effects:
Hepatotoxicity
Ecchymosis
Alopecia
Epitaxis
Infertility
Bone Marrow Suppression
Stomatitis
GI disturbances: Anorexic, N/V, diarrhea
Check hematopoietic (reproduction of
RBCs by bone marrow) function
Force fluids
Good mouth care
Type: Antimetabolites
Action:
Inhibits DNA
polymerase
Used for:
Acute lymphatic
leukemia
Cancer of colon, breast,
pancreas
Antimetabolites Medications:
5-FU
Methotrexate
Hydrea
Type: Antitumor Antibiotics
Action:
Interferes with DNA and
RNA synthesis
Used for:
Cancer
Antitumor Antibiotics
Medications:
Adriamycin
Actinomycin D
Bleomycin
Type: Hormonal Agents
Action:
Changes hormone input
into sensitive cells
Used for:
Cancer
Medications:
Diethylstilbestrol
Tamoxifen
Testosterone
Antimetabolites
Side Effects:
Nausea
Vomiting
Oral ulceration
Bone marrow
suppression
Alopecia
Monitor hematopoietic
function
Good mouth care
Discuss body image
changes
Antitumor Antibiotics
Side Effects:
Bone marrow suppression
Alopecia
Stomatitis
Monitor vital signs
Give antiemetic medications before therapy
Side Effects:
Leukpenia
Bone pain
Hypercalcemia
Check CBC
Monitor serum calcium
38
Type: Vinca Alkaloids
Action:
Interferes with cell
division
Used for:
Cancer
Medications:
Oncovin
Velban
Antiparkinson Agents
Action:
Converted to
Dopamine
Stimulates
postsynaptic Dopamine
receptors
Used for:
Parkinsons disease
Medications:
Artane
Cogentin
L-Dopa
Parlodel
Sinemet
Symmetrel
Antiplatelet Agents
Action:
Interferes with platelet
aggregation
Used for:
Venous thrombosis
Pulmonary embolism
Antiplatelet Agents
Medications:
Aspirin
Persantine
Side Effects:
Stomatitis
Alopecia
Loss of reflexes
Bone marrow suppression
Give antiemetic before administration
Check reflexes
Given with Zyloprim to decrease uric acid
Side Effects:
Dizziness
Ataxia
Atropine-like effects: dry mouth, urinary retention
Monitor for urinary retention
Large doses of vitamin B6 reverse effects
Avoid use of CNS depressants
Antiplatelet Agents
Side Effects:
Hemorrhage
Thrombocytopenia
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
Medications:
Haldol
Thorazine
Mellaril
Stelazine
Side Effects:
Akathisia (inability to sit
still)
Dyskinesia
Dystonias
Parkinsons syndrome
Tardive dyskinesias
Leukopenia
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
Monitor blood
Change positions slowly
Use sunscreen
39
Antipyretic Agents
Action:
Antiprostaglandin
activity in hypothalamus
Used for:
Fever
Antipyretic Agents
Medications:
Tylenol
(Acetaminophen)
Antipyretic Agents
Side Effects:
GI irritation
Aspirin contraindicated
for younger than 21
years old due to risk of
Reyes syndrome
Antithyroid Agents
Action:
Reduce vascularity of
thyroid
Inhibits release of
thyroid into circulation
Used for:
Hyperthyroidism
Antithyroid Agents
Medications:
Tapazole
SSKI
Antithyroid Agents
Side Effects:
Leukopenia
Rash
Thrombocytopenia
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
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
Medications:
INH
Ethambutol
Streptomycin
PAS
PYZ
Antivirals
Action:
Inhibits DNA and RNA
replication
Used for:
Recurrent HSV
HIV infection
Antivirals
Medications:
Zovirax
AZT
Videx
Famvir
Cytovene
Side Effects:
Hepatitis
Peripheral Neuritis
Check liver function tests
Vitamin B6 given for peripheral
neuritis (Pyridoxine)
Used in combination
Antivirals
Side Effects:
Headache
Dizziness
GI symptoms
Encourage fluids
Not a cure, but relieves
symptoms
40
Attention Disorder Agents

Action:
Increases level of
catecholamines
Used for:
ADDH
Narcolepsy

Medications:
Ritalin
Cylert
Dexedrine

Side Effects:
Restlessness
Insomnia
Tachycardia
Palpitations
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
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)
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
Cardiac Glycosides
Side Effects:
Bradycardia
Nausea
Vomiting
Visual disturbances
Take apical pulse
Notify physician if adult <60,
child <90-110, <70 in older
children
Monitor potassium level
Dose: 0.5-1 milligram IV or
PO over 24 hr period
Average: 0.25 mg
Cholinergics
Side Effects:
Bronchoconstriction
Respiratory paralysis
Hypotension
Give with food or milk
Monitor vital signs, especially
respirations
Antidote: Atropine Sulfate
Toxicity: excessive salivation,
excessive sweating, abdominal
cramps, flushing
41
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
Leukopenia
Take with food or milk
Take in a.m.
Monitor fluid and
electrolytes
Iron: Imferon/Feosol, use straw if liquid form, no milk/antacids, take on empty stomach, tachycardi
Glucocorticoids
Glucocorticoids
Glucocorticoids
Action:
Medications:
Side Effects:
Stimulates formation of
Solu-Cortef
Psychoses
glucose
Decadron
Depression
Alters immune response
Deltasone
Hypokalemia
Used for:
Stunted growth
Addisons disease
Buffalo Hump
Crohns disease
COPD
Monitor fluid and
Leukemias
electrolyte balance
Dont 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
Heavy Metal Antagonists

Action:
Forms stable complexes
with metals
Used for:
Gold and arsenic
poisoning
Acute lead
encephalopathy
Mineralocorticoids
Side Effects:
Hypertension
Edema
Hypokalemia
Monitor BP, I&O, Weight, and Electrolytes
Give with food
Low-sodium, High-protein, High-potassium
diet

Medications:
Desferal mesylate
BAL in Oil
EDTA

Side Effects:
Tachycardia
Pain and induration at
injection site (conjunct with
Procaine in syringe)
Monitor I&O and kidney
function
Administered with local
anesthetic
Seizure precautions
42
H2 Receptor Blockers
Action:
Inhibits action of
histamine and gastric
acid secretion
Used for:
Ulcers
Gastroesophageal reflux
Medications:
Tagamet
Zantac
Side Effects:
Dizziness
Confusion
Hypotension
Impotence
Take with meals and hs
Smoking decreases
effectiveness
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
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
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
Contraindicated with glaucoma
Apply pressure on lacrimal sac
for 1min.
Wear dark glasses
43
Narcotics
Action:
Acts on CNS receptor
cells
Used for:
Moderate to severe pain
Preoperative
Postoperative
Antianginals
Action:
Relaxes smooth muscle
Decreases venous return
Used for:
Angina
Peri-operative
hypertension
CHF
NSAIDS
Action:
Inhibits prostaglandin
synthesis
Used for:
Arthritis
Mild to moderate pain
Fever
Narcotics
Medications:
Morphine Sulfate
Codeine
Demerol
Dilaudid
Percodan
Antianginals
Medications:
Nitroglycerine
Isosorbide
NSAIDS
Medications:
Motrin
Indocin
Naprosyn
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
Narcotics
Side Effects:
Dizziness
Sedation
Respiratory depression
Hypotension
Constipation
Safety precautions
Avoid alcohol
Monitor vital signs
Use narcotic antagonist if
necessary (Narcan)
Antianginals
Side Effects:
Hypotension
Tachycardia
Headache
Dizziness
Check expiration date
Teach when to take medication
May take Q5min x3 doses
Wet with saliva and place under tongue
NSAIDS
Side Effects:
GI upset
Dizziness
Headache
Bleeding
Fluid retention
Take with food or after meals
Monitor liver and renal function
Use cautiously with aspirin allergy
Check for bleeding
Thrombolytics
Medications:
Streptokinase
Urokinase
Tissue Plasminogen
Activator
44
Thrombolytics
Side Effects:
Bleeding
Bradycardia
Dysrhythmias
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
Parkinsons-like effects
Symptoms:
o Akinesia (temporarily paralysis of muscles)
o Tremors
o Drooling
o Changes in gait
o Rigidity
o Akathisia (Extreme restlessness)
o Dyskinesia (Spasms)
Nursing Care:
o Anticholinergic and Antiparkinsonian medications
o Safety measures for gait
45
How long should a client with tuberculosis be on

medication?
What are symptoms of hepatitis?
What is the transmission of Hepatitis A?
What is the transmission of Hepatitis B?
What is the transmission of Hepatitis C?
What is the transmission of Delta Hepatitis?

What nursing care are recommended for
Hepatitis?
What is Lymes Disease?

What is Stage 1 of Lymes Disease?
What are some Lymes Disease teaching?

What are some Lymes Disease nursing care?
What are the treatment, mode of transmission,

care, signs and symptoms of syphillis?
6-9 Months
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)
Fecal/Oral
Consume contaminated food or water
Travelers to developing countries at risk
Clients with hepatitis A should not prepare food for others
Parenteral/Sexual contact
Blood or body fluids
At risk individuals are the ones that abuse IV drugs, dialysis, healthcare
workers
Vaccine developed
Blood or body fluids
Can become chronic disease
Seen in patients with hemophilia (unable to clot)
Co-infects with hepatitis B
Rest (mainly for liver)
Contact and standard precautions
Low-fat, High-Calorie, and High Protein diet (needed for organ healing)
No alcoholic beverages
Medications (Vitamin K, Aqua-Mephyton for bleeding problems, Anti-emetic
no compazine, use Tigan or (Dramamine). Corticosteroids to decrease
inflammatory response, and anti-histamines, will use lotions or baths than
systemic ones.
Multi-system infection caused by a tick bite. There are three stages.
Erythematous papule develops into lesion with clear center (Bulls-eye)
Regional lymphadenopathy
Flu-like symptoms (fever, headache, conjunctivitis)
Can develop over 1 to several months
Develop after 1 to 6 months if disease untreated.
Cardiac conduction defects
Neurologic disorders (Bells palsy, temporary paralysis)
Develops after 1 to several months, if reached at this stage may persist for
several years.
Arthralgias
Enlarged, inflamed joints
Cover exposed areas when in wooded areas
Check exposed areas for presence of ticks
Antibiotics 3-4 weeks
Stage 1 use Doxicillin
IV penicillin with later stages
Painless chancre fades after 6 weeks
Low grade fever
Copper-colored rash on palms and soles of feet
Spread by contact of mucous membranes, congent
Treat with Penicillin G IM
If patient has penicillin allergy, will use erythromycin for 10-15 days.
After treatment, patient must be retested to make sure disease is gone.
46

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

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.
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.
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
HIV Positivepresence of HIV in blood
AIDShas significant defects in immune function associated with positive HIV
evidenced by development of opportunistic infections
Syndrome where CD4 counts are below 200
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.
Kaposis Sarcoma: most common malignancy experience with AIDS, small
purplish brown, nonpainful, nonpuriitc palpable lesions on the body.
Contaminated blood or body fluids
Sharing IV needles
Sexual contact
Transplacental: across placenta
Possibly by breast milk
ELISA test, if positive will be confirmed by Western Blot test
HIV Viral culture: Leukopenia, Thrombocytopenia, Decrease CD4 counts
Prevention: avoid IV drug use, precautions regarding sexual patterns, use
standard precautions
Contact and standard precautions
High-protein and high-calorie diet, small frequent meals rather than 3 large
meals
Symptomatic relief
Support
Dont share toothbrush/shavers

care, signs and symptoms of Chlamydia?

care, signs and symptoms of Venereal Warts?
What is the difference between AIDS and HIV

+?
What are some opportunistic infections of AIDS?
How is AIDS transmitted?
What are diagnostics test associated with AIDS?

What are some nursing cares for AIDS?
47
What are treatments, care, prevention of poison

control?
What should happen when someone is poisoned?
Why should vomit not be induced?
What medication treatment is used to induce

vomiting and what other factors need to be
implemented?
What should happen to poison control in

emergency care?
What are signs and symptoms, treatments, care,

prevention of aspirin poisoning?

prevention of tylenol poisoning?

prevention of lead toxicity?
What are nursing care goals for Hazardous

wastes?
What are nursing care for Hazardous wastes?
What type of play do infants (0-12months) use?
What type of play do toddlers (1-3years) use?

What type of play do pre-schoolers (3-6years)
use?
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.
Call poison control center.
Tell them: substance, time, amount and route of ingestion, childs condition,
age, weight, save vomitus, stool, urine.
Dont induce if:
Danger of aspiration, decrease LOC, Ingested petroleum distillate (lighter fluid,
kerosene, paint remover)
Ingested corrosive (Draino)
Syrup of Ipecac with small amount of water. Dont give large amount of fluid
after Ipecac, will increase gastric emptying.
Dont use milk.
Position with head lower then chest.
No universal antidote.
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
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.
Symptoms: nausea/vomiting, hypothermia, If no treatment, hepatic/liver

involvement.
If liver gets involved patient may have RUQ pain, jaundice, confusion, and
coagulation abnormalities.
Nursing care: induce vomiting, maintain hydration, monitor liver and kidney
function with labs such as AST/ALT enzymes.
Tylenol (Acetaminophen) overdosage:
Antidote N-acetylcysteine (Mucomyst)
Symptoms: Irritability, decreased activity, abdominal pain, Increased ICP
Diagnostic tests: Blood lead levels (>9micrograms = toxic), Erythrocyte
protoporphyrin (EP), X-ray long bones (lead deposits in long bones)
Children engage in PICA (ingesting nonfood substances)
Lead blocks formation of hemogloblin and toxic to kidneys.
Nursing care: identify source, chelating agents, teaching parents
Decontaminate individual
Prevent spread of contamination
Clean and remove contaminuated source
Monitor personnel exposed
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.
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
Parallel play.
Associative play. Dress up/imitating play. Talking on telephone/kitchen/tool
belt
48
What type of play do school age (6-12years) use?

According to Eriksons Developmental Task,
explain the Infancy stage.

explain the Toddler stage.

explain the Preschool stage.

explain the School age stage.

explain the Adolescence stage.

explain the young adult stage.

explain the middle adulthood stage.

explain the Late adulthood stage.
At what month does the head sag?

At what month do you see closing of posterior
fontanelle, turn from side to back, and see a
social smile?
What toys do you give for a 2 month old?
At what month does a child bring objects to
mouth and head erect?
Which age does birth weight double?
At what age does teething occur?
What age for fears of strangers? When is fear
strongest?
Which month able to play peek-a-boo?
What toys do you give for 7-8months?
What month can a child say DADA?
What month can a child crawl well?
What month can a child stand erect with
support?
Cooperative play. Conformed/organized play.

Birth-18 months.
Trust vs. Mistrust
Positive outcome---trusts self
Negative outcome---withdrawn
18months 3 years
Autonomy vs. Shame and Doubt
Positive outcome---exercise self-control
Negative outcome---defiant and negative
3-6 years
Initiative vs. Guilt
Children develop conscience at this age.
Positive Outcome---learns limits
Negative Outcome---fearful, pessimistic
6-12years
Industry vs. Inferiority
Positive---sense of confidence
Negative---self doubt, inadequate
12-20 years
Identity vs. Role diffusion
Positive outcome---coherent sense of self
Negative outcome---lack of identity
20-45 years
Intimacy vs. Isolation
Positive outcome---intimate relationships/careers formed
Negative outcome---avoidance of intimacy
45-65 years
Generativity vs. Stagnation
Positive Outcome---creative and productive
Negative Outcome---self centered
65+ years
Integrity vs. Despair
No regrets in life or Regrets
Positive outcome---seems life as meaningful
Negative outcome---life lacks meaning
1 month
2 months
Mobiles, wind up infant swings, soft clothes, and blankets.

3 months
Rattles, cradle gym, and stuffed animals

5 months
6 months
Brightly colored, small enough to grasp, large enough for safety, teething toys
7 months
8 months is stronger
7 months
Large colored, bricks, jack in the box
9 month
10 months
11 months
49
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 cows milk/whole milk. After six
months of age cereal can be mixed with fruit juices. Fruit juices
should be offered in a cup to prevent dental carries.)
Vegetables
Fruits
Potatoes
Meats
Eggs
Orange Juice
By 12 months children should be eating table food. Dont give honey
under 12 because of botulism.
Walks alone.
Throws object.
Holds spoon.
Say 4-6 words. Understand simple commands.
Anterior fontanelle closes.
Climbs stairs.
Sucks thumb.
Say 10 + words.
Temper Tantrums.
300 world vocabulary.
Obeys easy commands.
Go up/down stairs alone.
Build towers.
Turn doorknobs/unscrew lids.
Increase independence.
Walk tip toe.
Stand on one foot balance.
Has control for sphincter training.
Birth weight quadrupled.
State first/last name.
Give simple commands.
Cooking utensils, Dress-up clothes, rocking horses, finger paints, phonographs,
cd players.
Dont ask no/yes questions.
Offer them choices.
Make a game out of the tasks.
Rides tricycle.
Undresses without help.
May invent imaginary friend.
Vocabulary 900 words.
Egocentric in thoughts/behaviors.
Laces shoes
Brushes teeth
What does a toddler do at 15 months?
What type of toys are included for Toddlers?

How do you avoid negativism during toddler
ages?
What can a 3 year old do?
50
Throws overhand
Uses sentences.
Independent
What toys are used for preschool (3-5)?

Which age groups has greatest number of fears?
What would you expect with a 6 year old?

What toys are used for school age child?

School age potential problems include:
What are symptoms/indications of a fetal alcohol

syndrome in a child?
What happens with amniocentesis? What does it
do?
What happens with an ultrasound?
What happens with a non-stress test?
What happens with a contraction stress test?
What does Torch stand for? And their

importance?
What concerns for clients that have UTI,
Runs well/Dresses without help.

Beginning cooperative play.
Gender-specific behavior.
Playground materials, Housekeeping toys, Coloring books, tricycle with helmet.
Preschool age children.
Self-centered, show off, rude
Sensitive to criticism
Begins loosing temporary teeth
Tends to lie.
Team games/sports.
Concept of time.
Playing with same sex child.
Seeks out friends.
Writing replaces printing.
Conflicts between peer groups and parents.
Conflicts between independence and dependence.
Likes school.
Able to take on job duties (housework).
Construction toys, Pets, Games, Electronic games, reading, books, bicycles with
helmets.
Anuresis (encourage before bed time)
Encopresis
Head lice
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.
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)
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.
At 28th week records FHR and fetal movement.
Favorable result: 2+ FHR accelerates by 15bpm and last 15seconds in 20
minutes.
Determines placentas 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.
Diseases that cross placenta or other events. Produce significant deformities or
infant born with infectious process.
Toxoplasmosis: no litter box changed, no gardening, no under cooked meats.
Rubella: 1-16 titer immune for rubella, titer <1-8 susceptible.
Cytomegalovirus: transmitted in body fluids.
Herpes Simplex: Ascending infection. During pregnancy get treated with
acyclovir. Delivery through c-section.
UTI: may lead to pylonephritis, increase risk of premature birth.
51
Syphilis, Gonorrhea?
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)
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-Hicks type.
Premature rupture of membranes.
Presenting part not engaged.
Fetal distress.
Protruding cord.
Call for help.
Push up against presenting part off of the cord.
Place in trendenlenberg position or knee chest position.
Successful if FHT left unchanged.
Early sign: fetal tachycardia >160 in >10minutes
Late sign: fetal bradycardia <110 in > 10 minutes
Nurse can witness patient sign form.
Patient has to be age of capacity/adult and confident. No confused
patient/drinking/already received preoperative medications.
Consent must be given voluntarily and information understandable. Nurse must
make sure questions are answered and form is attached to chart.
Decrease in HR before peak of contraction. Indication of head compression.
What are the events in the onset of labor?
How does prolapsed umbilical cords happen?
What do you do when a client has a prolapsed

cord?
What is a early/sign of fetal hypoxia?

What things should you know about the
Informed Consent form?
What is early deceleration?

What are interventions for late decelerations?
What do variable decelerations indicate?
What are signs of True Labor?
What are characteristics of a False Labor?
Prior to Lumbar Epidural block what should the

patient do?
What should be implemented during the delivery
of a newborn?
Position mother left side/trendenlenberg/knee chest

Increase rate of IV
Administer Oxygen 7-10 l/min
DC Oxytocin
Cord compression.
Change maternal position.
Administer oxygen.
DC Oyxtocin/Pitocin
Regular contractions increasing in frequency, duration, intensity
Discomfort radiates from back
Contractions do not decrease with rest
Cervix progressively effaced and dilated.
Irregular contractions, no change in frequency, duration, intesityDiscomfort is
abdominal
Contractions decrease with rest or activity
No cervical changes
Void
Establish airway
Check Apgar at 1 and 5 minutes
Clamp umbilical cord
Maintain Warmth
Place ID band on mother and infant
52
What are the types of Lochia?
If fundus is displaced not centrally and off to the

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

Placenta Previa?
Rubra-bloody, day 1-3

Serosa-pink-brown, day 4-9
Alba-yellow-white, 10+ days
Bladder distended.
Check for hemorrhage
Unilateral lower quadrant pain.
Rigid, tender abdomen
Low Hct and hCG levels
Bleeding
Monitor for shock
Administer RhoGAM
Provide support
A placenta thats 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

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
Temp. 97.7-99.7
HR sleep 100, awake 120-140, 180 crying
Resp 30-60
BP arm/calf 65/41
What are the newborn vital signs?
53
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.
Sudden-onset fever
Vomiting, diarrhea
Hypotension
Erythematous rash on palms and soles
Administer antibiotics
Educate about use of tampons (change tampon Q3-Q6 hours)
Immunization is a primary prevention
Severe febrile illness
Altered immune system
Previous allergic response
Recently acquired passive immunity
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
Steamy shower
Exposure to cold air
Cool, humidified air
What are the assessments and implementations

of Toxic Shock Syndrome?
What are contraindications to Immunizations?
What are assessments and implementations for a

Latex Allergy?
What are implementations for Croup syndromes

at home?
54
Universal Donor Blood: Packed red blood cells (help oxygen deliver to tissue, if you use whole blood there will be a risk for fluid
overload), type O, Rh-negative
5% Sodium Bicarbonatemetabolic alkalosis solution
Older adults are asymptomatic when they have an infection and can lead to confusion.
Mononucleosis: complication enlarged spleen; concerned for trauma if child plays dangerous sport.
Lyme disease:found mainly in mid alantic states (Connecticut)
Pottery is unglazed can lead to Lead Toxicity
Apgar Score: normal 7-10
WBC after pregnancy?
Ampicillin decreases oral contraceptives efficiency.
Tricuspid area: 5th intercostals space in the left sternum area
Tracheostomy care: no powder, suction trachea first then mouth, use 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.
55
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 fairskinned 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, sulfacontaining 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
56
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 mustnt consume foods containing gluten and therefore should avoid prepared puddings, commercially
prepared ice cream, malted milk, and all food and beverages containing wheat, rye, oats, or barley.
The infant of a diabetic mother may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the
placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increases
glucose amount that crosses the placenta from the mother. However, during the first 24 hours of life, this combination of high insulin
production in the newborn coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings with
formula can prevent hypoglycemia
Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous
pooling at the distal portion of the extremity.
A platypelloid pelvis has a flat shape. A gynecoid pelvis is a normal female pelvis. An anthropoid pelvis has an oval shape, and an
android pelvis has a heart shape.
The pulse is the earliest indicator of new decreases in fluid volume.
Adult Rickets: deficiency in vitamin D.
Chronic Pain: normal blood pressure, heart rate, and respiratory rate. Normal pupils and dry skin.
Acute pain: causes increased blood pressure, increased pulse, and respiratory rate, dilated pupils, and perspiration.
The tip of the endotracheal tube lies 1 cm above the carina. This is positioned above the bifurcation of the right and left mainstem
bronchi.
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

[Cytoxan])
ANTIMETABOLITES: are cell cycle phase-specific and affect the S PHASE
57
(i.e., Cyclophosphamide
(i.e., Cytarabine [Cytosar])
VINCA ALKALOIDS: are cell cycle phase-specific and act on the M PHASE
Bells Palsy: is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown. Possible causes
include vascular ischemia, infection, exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or a
combination of these items.
McBURNEYS POINT: is midway between the right anterior superior iliac crest and the umbilicus. This is usually the location
of greatest pain in the child with appendicitis.
MMR: administered SQ in the outer aspect of the upper arm.
Watch for absolute words NOT and ONLY
AIR EMBOLISM POSITIONING: Place the client on the left side in the trendelenburg position. Lying on the left side may prevent
air from flowing into the pulmonary veins. The trendelenburg position increases intrathoracic pressure, which decreases the amount
of blood pulled into the vena cava during inspiration.
Trigeminal neuralgia pain medication: Use Carbamazepine (Tegretol) and Phenytoin (Dilantin). Narcotic analgesics (Meperidine
Hydrochloride [Demerol], Codeine Sulfate , and Oxycodone) are not effective in controlling pain caused by trigeminal neuralgia.
Grapefruit juice can raise cyclosporine (Sandimmune) levels by 50% to 100%, risk for toxicity.
Fomepizole (Antizol): an antidote given IV to a client with Ethylene Glycol (Antifreeze) intoxication
Phenotolamine (Regitine): antidote for hypertensive crisis
Bromocriptine (Parlodel): an antiparkinsonian prolactin inhibitor, is used to treat NMS.
Biophysical profile: assesses five parameters of fetal activity: fetal heart rate, fetal breathing movements, gross fetal movements, fetal
tone, and amniotic fluid volume. In a biophysical profile, each of the five parameters contributes 0 to 2 points with a score of 8 being
considered normal and a score of 10 perfect.
G
Gravidity, the
number of
pregnancies.
T
Term births, the
number born at
term (40 weeks).
P
Preterm births, the
number born
before 40 weeks
gestation.
A
Abortions/miscarriages
Included in
gravida if before
20 weeks
gestation
Included in parity
if past 20 weeks
gestation
L
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
Hegars sign (Softening and thinning of the lower uterine segment that occurs about week 6)
Goodells sign (softening of the cervix that occurs at the beginning of the second month)
Chadwicks sign (bluish coloration of the mucous membranes of the cervix, vagina, and vulva that occurs about week 6)
Ballottement (rebounding of the fetus against the examiners fingers on palpation)
Braxton Hicks contractions
58
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.
Stable
Triggered by a
predictable amount of
effort or emotion.
ANGINA
Unstable
Variant
Triggered by an
Triggered by coronary
unpredictable amount of artery spasm; the attacks
exertion or emotion and
tend to occur early in the
may occur at night; the
day and at rest.
attacks increase in
number, duration, and
severity over time.
Intractable
Chronic and
incapacitating and is
refractory to medical
therapy.
Cardiac Conduction System: Sinoatrial NodeInternodal/Interatrial pathwaysAV nodeBundle of HisR/L Bundle

BranchesPurkinje fibers
Pulse rate is the earliest indicator of decrease in fluid volume.
59
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.
b.
c.
birth to six months - mobiles, unbreakable mirrors, music boxes, rattles

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
Solitary play
Toddlerhood (one year to three years)

Play is parallel
Suggested toys: push-pull toys, finger paints, thick crayons, riding toys, balls, blocks, puzzles, simple tape recorder,
housekeeping toys, puppets, cloth picture books, large beads to string, toy telephone, water toys, sand box, play dough or
clay, chalk and chalkboard
Preschool age (three years to six years)
Preschool play is associative and cooperative.

dress-up
fantasy play
imaginary playmates
Suggested toys: tricycle, gym and sports equipment, sandboxes, blocks, books, puzzles, computer games, dress-up clothes,
blunt scissors, picture games, construction sets, musical instruments, cash registers, simple carpentry tools
School age (six years to 12 years)

Play is cooperative.
1.
2.
3.
4.
5.
6.
sports and games with rules

fantasy play in early years
clubs
hero worship
cheating
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
60
Dullness:Thud-like sound of soft intensity; high pitch; moderate duration; Usually heard over solid organs (such as heart, liver)
body temperature
o
range: 36 to 38 degrees Celsius (98.6 to 100.4 degrees Fahrenheit)
St. John's wort - antidepressant

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

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

i.
ii.
iii.
iv.
v.
child under age two weighing at least 2700g: use flush technique,30-60mg Hg
child over age two: 85-95/50-65 mm Hg
school age: 100-110/50-65 mm Hg
adolescent: 110-120/65-85 mm Hg
adult: <130 mm Hg Systolic / <85 mm Hg diastolic
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
61
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
62
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.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
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.
Conversion - A mental conflict is expressed through physical symptoms
o Example: Woman becomes blind after seeing her husband with another woman.
Denial - treating obvious reality factors as though they do not exist because they are consciously intolerable
o Example: Mother refuses to believe her child has been diagnosed with leukemia. "She just has the flu."
Displacement - transferring unacceptable feelings aroused by one object to another, more acceptable substitute
o Example: Adolescent lashes out at parents after not being invited to party.
Dissociation - walling off specific areas of the personality from consciousness
o Example: Adolescent talks about failing grades as if they belong to someone else; jokes about them.
Fantasy - a conscious distortion of unconscious wishes and need to obtain satisfaction
o Example: A student nurse fails the critical care exam and daydreams about her heroic role in a cardiac arrest.
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.
Identification - subconsciously attributing to oneself qualities of others
o Example: Elvis impersonators.
Intellectualization - use of thinking, ideas, or intellect to avoid emotions
o Example: Parent becomes extremely knowledgeable about child's diabetes.
Introjection - incorporating the traits of others
o Example: Husband's symptoms mimic wife's before she died.
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.
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."
Reaction Formation - expressing unacceptable wishes or behavior by opposite overt behavior
o Example: Recovered smoker preaches about the dangers of second hand smoke.
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.
Repression - unconscious, deliberate forgetting of unacceptable or painful thoughts, impulses, feelings or acts
o Example: Adolescent "forgets" appointment with counselor to discuss final grades.
Sublimation - diversion of unacceptable instinctual drives into personally and socially acceptable areas.
o Example: Young woman who hated school becomes a teacher.
63
Elizabeth Kubler-Ross: Five Stages

1.
2.
3.
4.
5.
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
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
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
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
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.
B.
C.
D.
E.
F.
G.
Vitamin C - citrus fruits, cabbage, tomatoes, strawberries, broccoli

Thiamine (B1) - lean meat, legumes,unrefined or enriched grains and cereals
Riboflavin (B2) - enriched grains, milk, organ meats, poultry, fish
Niacin - peanuts, peas, beans, meat, poultry
Pyridoxine (B6) - kidneys, liver, meats, corn, wheat, eggs, poultry, fish
Cyanocobalamin (B12) - kidneys, lean meats,liver, dairy products, egs
Folic acid - liver, eggs, leafy green vegetables, fruits, enriched grain products
FOODS CONTAINING FAT-SOLUBLE VITAMINS
A.
B.
C.
D.
Vitamin A - fruits, green and yellow vegetables, butter, milk, eggs, liver
Vitamin D - milk, fish
Vitamin E - green vegetables, vegetables oils, wheat germ, nuts
Vitamin K - liver, cheese, leafy green vegetables, milk, green tea
64
mucomyst: acetaminophen toxicity
65
66
Medication
-azepam (benzodiazepine)
-azine (antiemetic; phenothiazide)
-azole (proton pump inhibitor)
-barbital (barbiturate)
-cillin (penicillin)
-cycline (antibiotic)
-ipramine (Tricyclic antidepressant)
-navir (protease inhibitor)
-olol (beta antagonist)
-oxin (cardiac glycoside)
-phylline (bronchodilator)
-pril (ACE inhibitor)
-terol (Beta 2 Agonist)
-tidine (H2 Antagonist)
-trophin (Pituitary Hormone)
-zosin (alpha 1 Antagonist)
-statin (cholesterol lowering agent)
-sartan (angiotensin receptor blocker)
-sone (glucocorticoid)
-mycin (anti-infective, aminoglycosides)
-vir (anti-viral)
-coxib (cox 2 enzyme blockers)
-caine (anesthetics)
-mab (monoclonal antibiotics)
-stigmine (cholinergics)
-thiazide (diuretic)
-ase (thrombolytic)
and one prefix
ceph or cef- (cephalosporins)
-ase = thrombolytic
-coxib = cox 2 enzyme blocker
-caine = anesthetics
-dipine = CCB
-floxacin = antibiotic
-ine = reverse transcriptase inhibitors, antihistamines
-kinase = thrombolytics
-lone, pred = corticosteroid
-mab = monoclonal antibiotics
-micin = antibiotic, aminoglycoside
-navir = protease inhibitor
-nitr = nitrate/vasodilator
-olol = beta blocker
-oxin = cardiac glycoside
-osin = alpha blocker
-parin = anticoagulant
-prazole = PPI
-stigmine = colinergics
-terol = beta 2 agonist
-thiazide = diuretic
-tidine = antiulcer
-trophin = pituitary hormone
-vir = anti-viral, protease inhibitor
-zozin = alpha 1 antagonist
-zolam = benzodiazapine, sedative
-zine = antihistamine
1 heart, 2 lungs = beta 1 for cardiac, beta 2 for respiatory
67

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Dilantin - detoxified by liver.

Immobilize joint above and below fracture

Dont rest on hard surface

Handle with palms of hands not with fingers

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

Specific gravity 1.010-1.030

elevated in acute pancreatitis

Erythrocyte Sedimentation Rate (ESR)

Dont leave your patients. Stay with your patients.

MMR (Mumps, Measles, and Rubella)

Normal Vital Signs

Pulse 120-140 bpm, increases with crying

1-4 year old

5-12 year old

Aortic Valve: Right of Sternum at the 2nd intercostal space

Chest pain radiating to arms, jaw, neck

Thrombolytic therapy-streptokinase, t-PA

CSF leakage good place to look is behind the ears.

Sucking Chest Wound

Cullens Sign ecchymosis around umbilicus

Implementation for shock

Wound Care for Burns

Medicate patient before wound care

Addissons Disease Assessments

Addissons Disease Implementations

Cushings Syndrome Assessments

Cushings Syndrome Implementations

Addisonian Crisis Implementations

Pheochromocytoma Assessmentshypersecretions of the

Acyanotic Congenital Heart Anomalies Assessments

Cyanotic Congenital Heart Anomalies Assessments

Cyanotic Congenital Heart Anomalies Types:

Congenital Heart Anomalies Compensatory Mechanisms

Congenital Heart Anomalies Implementations

Venous Peripheral Vascular Disease

Anemia Assessments (reduction in hemoglobin

Arterial Peripheral Vascular Disease

Venous Peripheral Vascular Disease

Iron Deficiency Anemia Assessments

Iron Deficiency Anemia Implementations

Sickle Cell Anemia Assessments

Sickle Cell Anemia Implementations

Pernicious Anemia Assessments

Hemophilia Assessments (female to male gene

Cancer Implementation: External Radiotherapy

Cancer Implementation: Internal radiation sealed source

Cancer Implementation: Internal Radiation

Cancer Implementation: Internal radiation unsealed source

Intracranial Tumors Assessments

Laminectomyexcision portion of lamina to expose area of

Dysplasia of the Hip Assessment

Dysplasia of the Hip Implementations

Scoliosis Assessmentslateral deviation of one or more of

Cerebral Palsy Assessments

Muscular Dystrophy Assessments

Cerebral Palsy Implementations

Braces to help ambulation

Parkinsons Disease Assessments

Parkinsons Disease Implementations

Myasthenia Gravis Assessments

High protein diet

Myasthenia Gravis Implementations

Acute Renal Failure