Académique Documents
Professionnel Documents
Culture Documents
Green tea - antioxidant (check if risk for A sign of improvement from dehydration would be a decreased urine
calculi-oxalates) specific gravity and a decreased/decreasing hematocrit. So the SG of
1.015 and a Hct of 46% would be the answer. It is the best answer of
Echinacea - immune stimulant (6-8 weeks only)(C/I in the two you had in you question.
SANDIMMUNE-Immunosuppressant) The normal urine SG is 1.003-1.035 (Usually between 1.010-1.025
with normal hydration and volume) (different texts give a slightly
Licorice - cough and cold different range).
SG 1.025-1.030+ (concentrated urine)
Ginger root - antinausea (C/I in Coumadin) SG 1.001-1.010 (dilute urine)
SG 1.001-1.018 in infants under 2 years of age
Ginkgo - improves circulation (C/I in anticoagulant, Specific gravity is a measurement of the kidney's ability to concentrate
headache side effect - check PT) urine. The range of urine's SG depends on the state of hydration and
varies with urine volume and the load of solids to be excreted under
Ma huang - bronchodilator, stimulant (Ephedra) standardized conditions; when fluid intake is restricted or increased, SG
measures the concentrating and diluting functions of the kidney. Loss
of these functions is an indication of renal dysfunction.
Digitalis Toxicity includes.. SG values usually vary inversely with amounts of urine excreated
N - nausea (decrease in urine volume = increase in specific gravity). However in
A - anorexia some conditions this is not the case.
V - vomiting
D - diarrhea EYE ABBREVIATIONS
A - abdominal pain OU- both eyes
OR- right eye
OS- left eye
Drugs which can cause URINE DISCOLORATION
Adriamycyn------ Reddish
Rifabutin--------- Red orange CUSHINGS (Hypersecretion of Adrenal Cortex Hormones)
Rifampicin------- Red orange
Bactrim---------- Red orange C = Check VS, particularly BP
Robaxin--------- Brown, Black or Greenish U = Urinary output & weight monitoring
Azulfidine------ Orange yellow S = Stress Management
Flagyl------------ Brownish H = High CHON diet
Dilantin---------- Pink tinged I = Infection precaution
Anti Psychotic-- Pinkish to Red brown N = Na+ restriction
Early signs of hypoxia: G = Glucose & Electrolytes Monitoring
R-restlessness S = Spousal support
A-anxiety
T-Tachycardia ADDISON'S (Hyposecretion of Adrenal Cortex Hormones)
Late signs of hypoxia: Always Remember the 6 A's of Addison's disease
B-bradycardia
E-extreme restlessness 1.) Avoid Stress
D-dyspnea 2.) Avoid Strenuous
In pedia- 3.) Avoid Individuals with Infection
F-feeding difficulty 4.) Avoid OTC meds
I-inspiratory stridor 5.) A lifelong Glucocorticoids Therapy
N-nares flare 6.) Always wear medic alert bracelet
E-expiratory grunting
S-sternal retractions
Respiratory Patterns Hirschsprung’s diagnosed with rectal biopsy looking for absence of
Kussmaul- fruity acetone breath odor ganglionic cells. Cardinal sign in infants is failure to pass meconium,
Cheyne-stokes- near death breathing pattern and later the classic ribbon-like and foul smelling stools.
Hypotension and vasoconstricting meds may alter the accuracy of o2 INFECTION CONTROL:
sats. Sample Test Item:
3. Which of the following methods should the RN utilize in patient with
An antacid should be given to a mechanically ventilated patient w/ an SALMONELLA?
ng tube if the ph of the aspirate is <5.0. Aspirate should be checked at O 1 Airborne Precautions
least every 12 hrs. O 2 Droplet Precautions
O 3 Neutropenic Precautions
Ambient air (room air) contains 21% oxygen. O 4 Enteric Precautions
The correct answer: 4.
The first sign of ARDS is increased respirations. Later comes dyspnea, Salmonella mode of transmission is fecal oral (enteric)
retractions, air hunger, cyanosis. Handwashing
Gloves must be used in handling bedpan and diapers
Normal PCWP is 8-13. Readings of 18-20 are considered high. Gown - if soiling is likely to happen.
Source of infection:
First sign of PE (pulmonary embolism) is sudden chest pain, followed Contaminated food and water.
by dyspnea and tachypnea. Remember - Transmission Based precautions:
A ir
High potassium is expected with carbon dioxide narcosis (hydrogen B orne, small particles are dispersed in the air like MTB, varicella
floods the cell forcing potassium out). Carbon dioxide narcosis causes C ontact, drug-resistant microorganisms
increased intracranial pressure. D roplet, large particles are dispersed into air, resp.infections except
resp syncytial
Pulmonary sarcoidosis leads to right sided heart failure. E nteric, fecal-oral like hepaA & salmonella
An NG tube can be irrigated with cola, and should be taught to family AGE APPROPRIATE GROWTH AND DEVELOPMENT
when a client is going home with an NG tube. (HOPPING WITH ONE LEG)
Sample test Item:
PRIORITY QUESTIONS (WHO TO SEE FIRST) 4. Which of the following is NOT a characteristic of a preschooler?
Sample Test Item: O 1 predominantly "parallel play" period
1. Which of the following clients should the nurse deal with FIRST? O 2 balances on 1 foot with eyes closed
o 1 A client who needs his daily vitamin O 3 skips on alternate feet
o 2 A client who needs to be suctioned O 4 jumps rope
o 3 A client who needs diaper to be changed The correct answer is: 1. Parallel play is more common in
o 4 A client who is being prepared for discharge TODDLERS.
Correct Answer: 2. A client who needs to be suctioned Preschooler (3-6 years)
PRIORITY (Use ABC) Gross motor development
Obstruction in the airway – secretions HOPS ON ONE (1) FOOT BY 4 YEARS
Need to be suctioned SKIPS & HOPS ON ALTERNATE FEET BY 5 YEARS
2. Delegation, RN, LVN, UAP, CNA PLAY : ASSOCIATIVE, IMAGINATIVE, MAGICAL THINKING,
Which of the following clients should the LPN be assigned to? SUPERHEROES (Remember the movie: Jingle All The way!)
o 1 A newly diagnosed patient with MYASTHENIC CRISIS FEAR: Intrusive procedures, venipunctures, IM injections, body
o 2 An immediate post-op client in PACU mutilation
o 3 A client awaiting medication for vitamins
o 4 A new admission for KIDNEY Transplant Patient Toxoplasmosis, where else you can contract this (thinking of cat litter
Correct Answer: 3-stable, A client awaiting medication for vitamins but it aint there)
Myasthenic Crisis – Unstable, Acute Respiratory Failure Sample test Item:
Immediate Post – op – Unstable, Risk for Complications, 5. To which of the following pregnant clients will be risk for
Kidney Transplant – Unstable, needs assessment for rejection TOXOPLASMOSIS?
DELEGATION: Remember the 5R's, Right Task, Right Person, Right Select all that apply:
Circumstance, Right Communication & Right Feedback) O 1 A pregnant client who eat raw meat.
RN Least stable, unstable, central catheters (hickman, broviac), O 2 A pregnant client handling cat litter of infected cats.
admission, discharge, health teachings, patient for transfer, blood O 3 A pregnant client gardening and cultivating soil exposed to cat
transfusion (2RNs) feces.
LPN Technical Doer, Stable, medications, wound dressing O 4 A pregnant client with low rubella titer
CNA Routine Care, Urine Dip Stix, Reporting to RN, Routine VS O 5 A pregnant client who have undergone external radiation.
UAP turning q2H, conducting group activities, ambulation O 6 A pregnant client with draining, painful vesicles in the external
For future USRNs genitalia.
This is for you... from the purkinje fibers of my heart.... The correct answers: 1, 2 & 3.
Room Assignment(Who to Share Room with) TOXOPLASMOSIS
Check: How do people get toxoplasmosis?
A ge A Toxoplasma infection occurs by:
Accidentally swallowing cat feces from a Toxoplasma-infected cat that (female: 190 to 420 mg/dL)
is shedding the organism in its feces.
This might happen if you were to accidentally touch your hands to your Insulin
mouth after gardening, (Regular, Humulin R)
cleaning a cat's litter box, or Type: Fast acting
touching anything that has come into contact with cat feces. Onset: ½ -1 hr
Eating contaminated raw or partly cooked meat, especially pork, lamb, Peak: 2-4 hr
or venison; Duration: 6-8 hr Insulin
by touching your hands to your mouth after handling undercooked (NPH, Humulin N)
meat. Type: Intermediate acting
Contaminating food with knives, utensils, cutting boards and other Onset: 2hr
foods that have had contact with raw meat. Peak: 6-12hr
Drinking water contaminated with Toxoplasma. Duration 18-26hr Insulin
Receiving an infected organ transplant or blood transfusion, though this (Ultralente, Humulin U)
is rare. Type: Slow acting
(From the internet-Division of Parasitic Disease) Onset: 4hr
Which of these statements by the nurse is incorrect if the nurse has the Peak: 8-20hr
goal to reinforce information about cancers to a group of young adults? Duration: 24-36hr Insulin
1. “You can reduce your risk of this serious type of stomach cancer by (Humulin 70/30)
eating lots of fruits and vegetables, limiting all meat, and avoiding Type: Combination
nitrate-containing foods.” Onset: ½ hr
2. “Prostate cancer is the most common cancer in American men with Peak: 2-12hr
results to threaten sexuality and life.” Duration: 24hr
3. “Colorectal cancer is the second-leading cause of cancer-related
deaths in the United States.”
4. “Lung cancer is the leading cause of cancer deaths in the United Central Venous Pressure: < 3 mm Hg = inadequate fluid and >11 mm
States. Yet it's the most preventable of all cancers. Hg = too much fluid
LABORATORY VALUES
MOTOR DEVELOPMENT
ELECTROLYTES
X. Vagus (S-M) Gag and swallow FLOW OF BLOOD THROUGH THE HEART
Parasympathetic activity
Inferior vena cava and superior vena cava – right atrium – tricuspid
XI. Spinal Accessory (M) Neck and back muscles valve – right ventricle – pulmonic valve – pulmonary artery – lungs –
pulmonary veins – left atrium – bicuspid valve (mitral) – left ventricle
XII. Hypoglossal (M) – aortic valve aorta – systemic circulation
Tongue movement
CARDIAC IMPULSES
On Old Olympus’ Towering Tops, A Finn And German Viewed Some
Hops Sinoatrial (SA) node – right and left atria (atria contract) –
Some Says Marry Money, But My Brother Says Bad Business Marry atrioventricular (AV) node – bundle his – bundle brabches – purjinje’s
Money fibers – ventricles contract.
Birth Hepatitis B
1 months Hepatitis B
2 months OPV, DPT, HIB
4 months DPT, HIB, OPV
Pulmonary capillary wedge pressure: 5 to 13 mmHg 6 months DPT, HIB, hepatitis B
Pulmonary artery pressure: systolic: 16 to 30 mmHg 12 months HIB, OPV
Diastolic: 0 to 7 mmHg 15 months MMR
Spinal pressure: 70 to 200mmH2O 18 months DPT
Morphine sulphate pediatric dose: 0.1mg/kg every 3 – 4 hour 12 – 18 months Varicella vaccine
4 -6 years DPT, OPV, MMR
11 – 12 years MMR ( if not administered at 4 -6 years)
SULFONYLUREAS 11 – 16 TD booster
For treatment of NIDDM
Sulfonylureas should not be given to patients with liver or kidney
failure. SPINAL CORD INJURY
Accummulation of drug will increase risk of hypoglycaemia. Cervical Injury:
C2 to C3 injury usually fatal
C4 is the major innervation to the diaphragm by th phrenic nerve
DURATION Involvement above th C4 causes respiratory difficulty and
paralysis of all the four extremities
tolbutamide C5 or below client may have movement in the shoulder
8h
Thoracic Level Injury:
Glycburide, glipizide loss of movement of the chest, trunk, bowel, bladder, and legs,
20 h, most potent depending on the level of injury
Leg paralysis (paraplegia)
chlorpropamide Autonomic dysreflexia with lesions above T6 and in cervical
48 h lesions
Visceral distention from a distended bladder or impacted rectum
may cause reactions such as sweating, bradycardia, hypertension, nasal
Apothecary and Household System stuffiness, and gooseflesh
MAOI Drugs
Drugs That Can Cause Nephrotoxicity CRCL = creatinine clearance
CRF = chronic renal failure
• acetaminophen (high doses, acute)
CRT = capillary refill time
* acyclovir; parenteral (zovirax)
CSF = cerebrospinal fluid
* aminoglycocides
CT = computerized tomography
* amphotericin B
CVA = cerebral vascular accident, costovertebral angle
* ciprofloxacin
CVP = central venous pressure
* cisplatin (platinol)
D5W = 5% dextrose in water
* methotrexate (high doses)
DAT = diet as tolerated
* nonsteriodal anti-inflamatory drugs (NSAIDS)
DC = (dc) discontinue
* rifampicin
DIC = disseminated intravascular coagulopathy
* sulfonamides
DKA = diabetic ketoacidosis
* tetracyclines ( exceptions are doxycycline and minocycline)
DM = diabetes mellitus
* vancomycin
DNA = deoxyribonucleic acid
• DNR = do not resuscitate
DOA = dead on arrival
Basic Nursing Abbreviations DOE = dyspnea on exertion
DPT = diphtheria, pertussis, tetanus
A /G = albumin/globulin ratio DTR = deep tendon reflexes
ABG = arterial blood gases DVT = deep venous thrombosis
AC = before eating DX = diagnosis
ACE = angiotensin converting enzyme EAA = essential amino acids
ACL = anterior cruciate ligament EBL = estimated blood loss
ACLS = advanced cardiac life support EBV = Epstein-Barr Virus
ACTH = adrenocorticotropic hormone ECF = extracellular fluid, extended care facility
ad lib = as much as needed ECG = electrocardiogram
ADH = anti-diuretic hormone ECT = electroconvulsive therapy
ADL = activities of daily living EENT = eye, ear, nose and throat
AFB = acid-fast bacilli EFAD = essential fatty acid deficiency
AFP = alpha-fetoprotein EMG = electromyogram
AGA = appropriate for gestational age EMV = eyes, motor, verbal response (Glasgow coma scale)
AI = aortic insufficiency ENT = ears, nose, and throat
AIDS = acquired immune deficiency syndrome EOM = extraocular muscles
AKA = above knee amputation ESR = erythrocyte sedimentation rate
ALD = alcoholic liver disease ESRD = end stage renal disease
ALL = acute lymphocytic leukemia ET = endotracheal tube
ALP = alkaline phosphatase ETT = endotracheal tube
ALT = alanine transaminase, alanine aminotransferase EUA = examination under anesthesia
ATN = acute tubular necrosis FBS = fasting blood sugar
AU = both ears FDA = Food & Drug Administration
AV = atrioventricular FEV = forced expiratory volume
B.S. = Bachelor of Science FFP = fresh frozen plasma
B/K = below knee FNP = Family Nurse Practitioner
BM = bowel movement or breast milk GB = gallbladder
BX = biopsy GC = gonorrhea
c = with GERD = gastroesophageal reflux disease
C/O = complaining of GFR = glomerular filtration rate
CA = calcium, cancer, carcinoma GI = gastrointestinal
CAA = crystalline amino acids GSW = gun shot wound
CABG = coronary artery bypass graft GTT = glucose tolerance test
CAD = coronary artery disease GU = genitourinary
CAPD = continuous ambulatory peritoneal dialysis HB = hemoglobin
CAT = computerized axial tomography HBP = high blood pressure
CBC = complete blood count HCG = human chorionic gonadotropin
CBD = common bile duct HCO3 = bicarbonate
CBG = capillary blood gas HCT = hematocrit
CBI = continuous bladder irrigation HD = hemodialysis
CBS = capillary blood sugar HDL = high density lipoprotein
CC = chief complaint HEENT = head, eyes, ears, nose, throat
CCK = cholecystokinin
CCPD = continuous cyclic peritoneal dialysis
CCU = clean catch urine or cardiac care unit
CCV = critical closing volume Caring for the Patient on a Ventilator
CF = cystic fibrosis The nurse must be able to do the following:
CHF = congestive heart failure
CHO = carbohydrate 1. Identify the indications for mechanical ventilation.
CI = cardiac index 2. List the steps in preparing a patient for intubation.
CLT = Clinical Laboratory Technician 3. Determine the FIO2, tidal volume, rate and mode of ventilation on a
CML = chronic myelogenous leukemia given
CN = cranial nerves ventilator.
CNS = central nervous system 4. Describe the various modes of ventilation and their implications.
CO = cardiac output 5. Describe at least two complications associated with patient’s
COPD = chronic obstructive pulmonary disease response to mechanical ventilation and their signs and symptoms.
CP = chest pain, cleft palate 6. Describe the causes and nursing measures taken when trouble-
CPD = cephalo-pelvic disproportion shooting ventilator alarms.
CPK = creatinine phosphokinase 7. Describe preventative measures aimed at preventing selected other
CPP = cerebral perfusion pressure complications related to endotracheal intubation.
CPR = cardiopulmonary resuscitation
8. Give rationale for selected nursing interventions in the plan of care 2. Symptoms – may result in pneumothorax, pneumomediastinum,
for the ventilated patient. pneumoperitoneum, or subcutaneous emphysema.
9. Complete the care of the ventilated patient checklist. 3. Treatment - aimed at reducing TV, cautious use of PEEP, and
10. Complete the suctioning checklist. avoidance of high airway pressures resulting in development of auto-
PEEP in high risk patients (patients with obstructive lung diseases
1. To review indications for and basic modes of mechanical ventilation, (asthma, bronchospasm), unevenly distributed lung diseases (lobar
possible complications that can occur, and nursing observations and pneumonia), or hyperinflated lungs (emphysema).
procedures to detect and/or prevent such complications.
2. To provide a systematic nursing assessment procedure to ensure C. Nosocomial Pneumonia
early detection of complications associated with mechanical 1. Cause – invasive device in critically ill patients becomes colonized
ventilation. with pathological bacteria within 24 hours in almost all patients. 20-
60% of these, develop nosocomial pneumonia.
Indication for Intubation 2. Treatment – aimed at prevention by the following:
1. Acute respiratory failure evidenced by the lungs inability to maintain Avoid cross-contamination by frequent handwashing
arterial oxygenation or eliminate carbon dioxide leading to tissue Decrease risk of aspiration (cuff occlusion of trachea, positioning, use
hypoxia in spite of low-flow or high-flow oxygen delivery devices. of small-bore NG tubes)
(Impaired gas exchange, airway obstruction or ventilation-perfusion Suction only when clinically indicated, using sterile technique
abnormalities). Maintain closed system setup on ventilator circuitry and avoid pooling
2. In a patient with previously normal ABGs, the ABG results will be as of condensation in the tubing
follows: Ensure adequate nutrition
PaO2 > 50 mm Hg with pH < 7.25 Avoid neutralization of gastric contents with antacids and H2 blockers
PaO2 < 50 mm Hg on 60% FIO2 : restlessness, dyspnea, confusion,
anxiety, tachypnea, tachycardia, and diaphoresis D. Positive Water Balance
PaCO2 > 50 mm Hg : hypertension, irritability, somnolence (late), 1. Syndrome of Inappropriate Antidiuretic Hormone (SIADH) – due to
cyanosis (late), and LOC (late) vagal stretch receptors in right atrium sensing a decrease in venous
3. Neuromuscular or neurogenic loss of respiratory regulation. return and see it as hypovolemia, leading to a release of ADH from the
(Impaired ventilation) posterior pituitary gland and retention of sodium and water. Treatment
4. Usual reasons for intubation: Airway maintenance, Secretion control, is aimed at decreasing fluid intake.
Oxygenation and Ventilation. 2. Decrease of normal insensible water loss due to closed ventilator
circuit preventing water loss from lungs. This fluid overload evidenced
Types of intubation: Orotracheal, Nasotracheal, Tracheostomy by decreased urine specific gravity, dilutional hyponatremia, increased
Preparing for Intubation heart rate and BP.
1. Recognize the need for intubation.
2. Notify physician and respiratory therapist. Ensure consent obtained E. Decreased Renal Perfusion – can be treated with low dose dopamine
if not emergency. therapy.
3. Gather all necessary equipment:
a. Suction canister with regulator and connecting tubing F. Increased Intracranial Pressure (ICP) – reduce PEEP
b. Sterile 14 Fr. suction catheter or closed in-line suction catheter
c. Sterile gloves G. Hepatic congestion – reduce PEEP
d. Normal saline
e. Yankuer suction-tip catheter and nasogastric tube H. Worsening of intracardiac shunts –reduce PEEP
f. Intubation equipment: Manual resuscitator bag (MRB),
Laryngoscope and blade, Wire guide, Water soluble lubricant, 2. Associated with ventilator malfunction:
Cetacaine spray A. Alarms turned off or nonfunctional – may lead to apnea and
g. Endotracheal attachment device (E-tad) or tape respiratory arrest
h. Get order for initial ventilator settings Troubleshooting Ventilator Alarms
i. Sedation prn Low exhaled volume: Cuff leak, Tubing disconnect, Patient
j. Soft wrist restraints prn disconnected
k. Call for chest x-ray to confirm position of endotracheal tube Evaluate cuff; reinflate prn; if ruptured, tube will need to be replaced.
l. Provide emotional support as needed/ ensure family notified of Evaluate connections; tighten or replace as needed; check ETT
change in condition. placement, Reconnect to ventilator
High pressure: Secretions in airway, Patient biting tubing, Tube kinked,
Intubation Cuff herniation, Increased airway resistance/decreased lung compliance
(caused by bronchospasm, right mainstem bronchus intubation,
Types of Ventilators pneumothorax, pneumonia), Patient coughing and/or fighting the
Ventilator Settings ventilator; anxiety; fear; pain.
Modes of Mechanical Ventilation Suction patient, Insert bite block, Reposition patient’s head/neck; check
Complications of Mechanical Ventilation all tubing lengths, Deflate and reinflate cuff, Auscultate breath sounds,
1. Associated with patient’s response to mechanical ventilation: Evaluate compliance and tube position; stabilize tube, Explain all
procedures to patient in calm, reassuring manner, Sedate/medicate as
A. Decreased Cardiac Output necessar
1. Cause - venous return to the right atrium impeded by the Low oxygen pressure: Oxygen malfunction
dramatically increased intrathoracic pressures during inspiration from Disconnect patient from ventilator; manually bag with ambu; call R.T
positive pressure ventilation. Also reduced sympatho-adrenal
stimulation leading to a decrease in peripheral vascular resistance and 3. Other complications related to endotracheal intubation.
reduced blood pressure. A. Sinusitis and nasal injury – obstruction of paranasal sinus drainage;
2. Symptoms – increased heart rate, decreased blood pressure and pressure necrosis of nares
perfusion to vital organs, decreased CVP, and cool clammy skin. 1. Prevention: avoid nasal intubations; cushion nares from tube and
3. Treatment – aimed at increasing preload (e.g. fluid administration) tape/ties.
and decreasing the airway pressures exerted during mechanical 2. Treatment: remove all tubes from nasal passages; administer
ventilation by decreasing inspiratory flow rates and TV, or using other antibiotics.
methods to decrease airway pressures (e.g. different modes of B. Tracheoesophageal fistula – pressure necrosis of posterior tracheal
ventilation). wall resulting from overinflated cuff and rigid nasogastric tube
1. Prevention: inflate cuff with minimal amount of air necessary;
B. Barotrauma monitor cuff pressures q. 8 h.
1. Cause – damage to pulmonary system due to alveolar rupture from 2. Treatment: position cuff of tube distal to fistula; place gastrostomy
excessive airway pressures and/or overdistention of alveoli. tube for enteral feedings; place esophageal tube for secretion clearance
proximal to fistula. These signs may indicate hypoxia.
C. Mucosal lesions – pressure at tube and mucosal interface .
1. Prevention: Inflate cuff with minimal amount of air necessary; Observe skin color and capillary refill.
monitor cuff pressure q. 8 h.; use appropriate size tube. Determine adequacy of blood flow needed to carry oxygen to tissues.
2. Treatment: may resolve spontaneously; perform surgical .
interventions. Monitor CBC.
D. Laryngeal or tracheal stenosis – injury to area from end of tube or Indicates the oxygen carrying capacity available.
cuff, resulting in scar tissue formation and narrowing of airway .
1. Prevention: inflate cuff with minimal amount of air necessary; Administer oxygen as ordered.
monitor cuff pressure q. 8.h.; suction area above cuff frequently. Decreases work of breathing and supplies supplemental oxygen.
2. Treatment: perform tracheostomy; place laryngeal stint; perform .
surgical repair. Observe for tube obstruction; suction prn; ensure adequate
E. Cricoid abcess – mucosal injury with bacterial invasion humidification.
1. Prevention: inflate cuff with minimal amount of air necessary; May result in inadequate ventilation or mucous plug.
monitor cuff pressure q. 8 h.; suction area above cuff frequently. .
2. Treatment: perform incision and drainage of area; administer Reposition patient q. 1-2 h.
antibiotics. Repositioning helps all lobes of the lung to be adequately perfused and
4. Other common potential problems related to mechanical ventilation: ventilated.
Aspiration, GI bleeding, Inappropriate ventilation (respiratory acidosis
Potential altered nutritional status: less than body requirements r/t NPO
or alkalosis, Thick secretions, Patient discomfort due to pulling or status
jarring of ETT or tracheostomy, High PaO2, Low PaO2, Anxiety and Monitor lymphocytes and albumin.
fear, Dysrhythmias or vagal reactions during or after suctioning, Indicates adequate visceral protein.
Incorrect PEEP setting, Inability to tolerate ventilator mode. .
Provide nutrition as ordered, e.g. TPN, lipids or enteral feedings.
PLAN OF CARE FOR THE VENTILATED PATIENT Calories, minerals, vitamins, and protein are needed for energy and
Patient Goals: tissue repair.
Patient will have effective breathing pattern. .
Patient will have adequate gas exchange. Obtain nutrition consult.
Patient’s nutritional status will be maintained to meet body needs. Provides guidance and continued surveillance.
Patient will not develop a pulmonary infection. Potential for pulmonary infection r/t compromised tissue integrity.
Patient will not develop problems related to immobility. Secure airway and support ventialtor tubing.
Patient and/or family will indicate understanding of the purpose for Prevent mucosal damage.
mechanical ventilation. .
Provide good oral care q. 4 h.; suction when need indicated using
Nursing Diagnosis sterile technique; handwashing with antimicrobial for 30 seconds
Nursing Interventions before and after patient contact; do not empty condensation in tubing
Rationale back into cascade.
Ineffective breathing pattern r/t ____________________________. Measures aimed at prevention of nosocomial infections.
Observe changes in respiratory rate and depth; observe for SOB and .
use of accessory muscles. Use disposable saline irrigation units to rinse in-line suction; ensure
An increase in the work of breathing will add to fatigue; may indicate ventilator tubing changed q. 7 days, in-line suction changed q. 24 h.;
patient fighting ventilator. ambu bags changes between patients and whenever become soiled.
. IAW Infection Control Policy and Respiratory Therapy Standards of
Observe for tube misplacement- note and post cm. Marking at Care for CCNS.
lip/teeth/nares after x-ray confirmation and q. 2 h. Potential for complications r/t immobility.
Indicates correct position to provide adequate ventilation. Assess for psychosocial alterations.
. Dependency on ventilator with increased anxiety when weaning;
Prevent accidental extubation by taping tube securely, checking q.2h.; decreased ability to communicate; social isolation/alteration in family
restraining/sedating as needed. dynamics.
Avoid trauma from accidental extubation, prevent inadequate .
ventilation and potential respiratory arrest. Assess for GI problems. Preventative measures include relieving
. anxiety, antacids or H2 receptor antagonist therapy, adequate sleep
Inspect thorax for symmetry of movement. cycles, adequate communication system.
Determines adequacy of breathing pattern; asymmetry may indicate Most serious is stress ulcer. May develop constipation.
hemothorax or pneumothorax. .
. Observe skin integrity for pressure ulcers; preventative measures
Measure tidal volume and vital capacity. include turning patient at least q. 2 h.; keep HOB < 30 degrees with a
Indicates volume of air moving in and out of lungs. 30 degree side-lying position; use pressure relief mattress or turning
. bed if indicated; follow prevention of pressure ulcers plan of care;
Asses for pain maintain nutritional needs.
Pain may prevent patient from coughing and deep breathing. Patient is at high risk for developing pressure ulcers due to immobility
. and decreased tissue perfusion.
Monitor chest x-rays .
Shows extent and location of fluid or infiltrates in lungs. Maintain muscle strength with active/active-assistive/passive ROM and
. prevent contractures with use of span-aids or splints.
Maintain ventilator settings as ordered. Patient is at risk for developing contractures due to immobility, use of
Ventilator provides adequate ventilator pattern for the patient. paralytics and ventilator related deficiencies.
. Knowledge deficit r/t intubation and mechanical ventilation
Elevate head of bed 60-90 degrees. Explain purpose/mode/and all treatments; encourage patient to relax
This position moves the abdominal contents away from the diaphragm, and breath with the ventilator; explain alarms; teach importance of deep
which facilitates its contraction. breathing; provide alternate method of communication; keep call bell
within reach; keep informed of results of studies/progress; demonstrate
Impaired gas exchange r/t alveolar-capillary membrane changes confidence.
Monitor ABG’s. Reduce anxiety, gain cooperation and participation in plan of care.
Determines acid-base balance and need for oxygen.
.
Assess LOC, listlessness, and irritability.
Common Syndromes * Red rash followed by desquamation
DOWN SYNDROME:
Trisomy 21. Mental retardation, characteristic facial features, Simeon
CARPAL-TUNNEL SYNDROME: Compression of Median Nerve
crease in hand.
through the Carpal Tunnel - pain and parasthesia over distribution of
Median N.
MARFAN SYNDROME: Connective Tissue disorder
* Arachnodactyly: Abnormally long digits and extremities
HORNER'S SYNDROME: Loss or lesion of cervical sympathetic
* Subluxation of lens
ganglion -
* Dissecting aortic aneurism
* Ptosis, miosis, anhydrosis
* Enophthalmos (caved in eyes)
SUDDEN INFANT DEATH SYNDROME: Unexplained death in
sleeping infants.
KORSAKOFF SYNDROME: Loss of short-term memory in chronic
alcoholism, caused by degeneration of mamillary bodies.
TURNER'S SYNDROME: XO monosomy.
* Dwarfism
MALABSORPTION SYNDROME: Impaired absorption of dietary
* Webbed neck
substance - diarrhea, weakness, weight loss, or symptoms from specific
* Valgus of elbow.
deficiencies.
* Amenorrhea
Herbal Plants
AMENNORRHEA-GALACTORRHEA SYNDROME: Non-
1) ALOE VERA
physiologic lactation, resulting from endocrinologic causes or from a
Aloe vera syn. A. barbadensis (Liliaceae)
pituitary disorder.
The clear gel found inside the plant's leaf contains aloin, are both used
for medicinal and cosmetic purposes. It is a effective healer of wounds
and burns, speeding up the rate of healing and reducing the risk of
CUSHING'S SYNDROME: Hypersecretion of cortisol secondary
infection. The brownish part containing aloin is a strong laxative,
symptoms and characteristics:
useful for short-term constipation. Aloe is present in many cosmetic's
* Fatness of face and trunk with wasting of extremities
formulae because its emollient and scar preventing properties.
* Buffalo hump
* Bone decalacification
MAIN PROPERTIES: Heals wounds, emollient, laxative.
* Corticoid diabetes
* Hypertension
2) ANGELICA
Angelica arcangelica (Umbelliferae)
Angelica has been used to reduce muscular spasms in asthma and
PREMENSTRUAL SYNDROME: Abnormal sensation in breasts,
bronchitis. It has also been shown to ease rheumatic inflammation, to
abdominal pain, thirst, headache, pelvic congestion, nervous irritability.
regulate menstrual flow and as an appetite stimulant. The stems are
candied for culinary use.
Ocassionally nausea and vomiting.
MAIN PROPERTIES: Antispasmodic, promotes menstrual flow.
GUILLAN-BARRE SYNDROME: Infectious Polyneuritis of unknown
3) ANISE
cause.
Pimpinella anisum (Umbelliferae)
It has been used as a flavoring spice in recipes and as a diuretic, to treat
digestive problems and to relieve toothache. Anise seeds are known for
REYE'S SYNDROME: Loss of consciousness and seizures in kids,
their ability to reduce flatulence and colic, to settle the digestion, to
after a viral infection treated by aspirin.
relieve colic, and to ease nausea and indigestion. It also has an
expectorant and antispasmodics action that is helpful in countering
period pain, asthma, whooping cough and bronchitis. The mild
REITER'S SYNDROME: Symptom cluster. Etiology is thought to be
hormonal action of anise seeds may explain its ability to increase
Chlamydial or post-chlamydial.
breast-milk production and its reputation for easing childbirth and
Urethritis
treating impotence and frigidity. Anise essential oil is used externally to
Iridocyclitis (Conjunctivitis)
treat lice and scabies.
Arthritis
Skin lesions like karatoderma blenorrhagicum
MAIN PROPERTIES: Reduces colic and flatulence, promotes
Also can see fatty liver or liver necrosis.
digestion, antispasmodic
4) ARNICA
STEVENS-JOHNSON SYNDROME: Erythema Multiforme
Arnica montana (Compositae)
complication.
Arnica improves the local blood supply and accelerates healing. It is
Large areas of skin slough, including mouth and anogenital
anti-inflammatory and increases the rate of re-absorption of internal
membranes.
bleeding. The internal use of arnica is restricted to homeopathic
Mucous membranes: stomatitis, urethritis, conjunctivitis.
dosages as it is potentially toxic.
Headache, fever, malaise.
MAIN PROPERTIES: Anti-inflammatory, germicide, muscular
soreness, pain reliever.
TOXIC SHOCK SYNDROME: Caused by superabsorbent tampons.
Infection with Staph Aureus and subsequent toxicity of exotoxin TSST
5) ARROWROOT
systemic anaphylaxis.
Maranta arundinacea (Marantaceae)
* Fever, vomiting, diarrhea
Its root is used as a poultice for smallpox sores, and as an infusion for distillates are used extensively in perfumery. Orange flower water is a
urinary infections. It helps to relieve acidity, indigestion and colic, and by-product of distillation and is used in perfumery and to flavor sweets
is mildly laxative. It may be applied as an ointment or poultice mixed and biscuits, as well as being used medicinally to reduce heart rate and
with some other antiseptic herbs such as comfrey. palpitations, to encourage sleep and calm the digestive tract.
MAIN PROPERTIES: Anti-inflammatory, digestive, antiseptic. MAIN PROPERTIES: Anti-inflammatory, antifungal, antibacterial,
digestive.
6) ARTEMISIA, WORMWOOD
Artemisia absinthium (Compositae) 12) BOLDO
Wormwood has a marked tonic effect on the stomach, the gallbladder Peumus boldus (Umbelliferae)
and in adjusting weak digestive problems. It is used to expel It activates the secretion of saliva and gastric juices. Boldine, one of its
roundworms and threadworms. By improving the functions of the constituents, induces the flow of bile as well as the total amount of
digestive system it helps in many conditions, including anaemia. It is
solids that it excretes. Its protective action over the hepatic cells has
also a muscle relaxant occasionally used to treat rheumatism. The been demonstrated "in vitro" and "in vivo". Boldo stimulates liver
leaves of wormwood have antiseptic properties which may derive fromactivity and bile flow and is chiefly valued as a remedy for gallstones
the azulenes that the plant contains. and liver or gallbladder pain. It is normally taken for a few weeks at a
time, either as a tincture or infusion. Boldo also has antiseptic
MAIN PROPERTIES: Bitter, carminative, muscle relaxant, antiseptic. properties which help in combating cystitis.
7) BASIL, HOLY BASIL MAIN PROPERTIES: Bile and liver activity stimulant, digestive.
Ocimum sanctum (Labiatae)
The herb has very important medicinal properties - notably its ability to 13) CALENDULA, MARIGOLD
reduce blood sugar levels. It also prevents peptic ulcers and other stress Calendula officinallis (Compositae)
related conditions like hypertension, colitis and asthma. Basil is also Marigold is one of the best herbs for treating local skin problems.
used to treat cold and reduce fever, congestion and joint pain. Due to its Infusions or decoctions of Calendula petals decrease the inflammation
anti-bacterial and fungicide action, basil leaves are used on itching of sprains, stings, varicose veins and other swellings and also soothes
skin, insect biting and skin affections. burns, sunburns, rashes and skin irritations. These remedies are
excellent for inflamed and bruised skin, their antiseptic and healing
MAIN PROPERTIES: Lowers blood sugar levels, antispasmodic, properties helping to prevent the spread of infection and accelerate the
analgesic, lowers blood pressure, reduces fever, fungicidal, anti- healing. Marigold is also a cleansing and detoxifying herb, and the
inflammatory. infusion and tincture are used to treat chronic infections. Taken
internally, it has been used traditionally to promote the draining of
8) BELLADONA, DEADLY NITIGHTSHADE swollen lymph glands such as tonsillitis.
Atropa belladonna (Solanaceae)
Herba bella dona, or "herb of the beautiful lady" is known for its MAIN PROPERTIES: Anti-inflammatory, astringent, heals wounds,
poisonous effects (belladonna increases heartbeat and can lead to antiseptic, detoxifying.
death), like many other plants it is an important and beneficial remedy
when used correctly. Belladonna contains atropine used in conventional 14) CAMPHOR
medicine to dilate the pupils for eye examinations and as an anesthetic. Cinnamomum camphora syn. Laurus camphora (Lauraceae)
In herbal medicine, deadly nightshade is mainly prescribed to relieve Camphor crystals have strong antiseptic, stimulant and antispasmodic
intestinal colic, to treat peptic ulcers and to relax distended organs, properties and are applied externally as unguents or balms as a counter-
especially the stomach and intestine. Deadly nightshade is also used as irritant and analgesic liniment to relieve arthritic and rheumatic pains,
an anaesthetic in conventional medicine. neuralgia and back pain. It may also be applied to skin problems, such
as cold sores and chilblains, and used as a chest rub for bronchitis and
MAIN PROPERTIES: Smooth muscle, antispasmodic, narcotic, other chest infections.
reduces sweating, sedative.
MAIN PROPERTIES: Antiseptic, antispasmodic, analgesic,
9) BENZOIN GUM expectorant.
Styrax benzoin (Styraceae)
Its trunk exudes a gum well known for its strong astringent and 15) CARDAMOM
antiseptic action. For this reason it is used externally to fight tissue Elettaria cardamomum (Zingiberaceae)
inflammation and disinfection of wounds. When taken internally, Cardamom is an excellent remedy for many digestive problems,
benzoin gum acts to settle griping pain, to stimulate coughing, and to helping to soothe indigestion, dyspepsia, gastralgia, colon spasms and
disinfect the urinary tract. Benzoin gum is widely used in cosmetics as flatulence. It has an aromatic and pungent taste and combines well with
an antioxidant in oils, as a fixative in perfumes and as an additive to other herbs and helps to disguise the less pleasant taste of other herbs.
soaps. When steam inhaled, it helps healing sore throats, head and chest
colds, asthma and bronchitis. MAIN PROPERTIES: Eases stomach pain, carminative, aromatic,
antispasmodic.
MAIN PROPERTIES: Antiseptic, astringent, anti-inflammatory.
16) CARDUS, MILK THISTLE, MARY THISTLE
10) BERGAMOT Carduus marianus syn. Silybum marianum (Compositae)
Citrus bergamia syn. C. aurantium var. bergamia (Rutaceae) Milk thistle has been in use as a remedy for liver problems for
Bergamot oil, expressed from the peel, assists in avoiding infectious hundreds, if not thousands, of years. It is used in a whole range of liver
diseases. In cosmetics it is used in preventing oily skin, acne, psoriasis and bladder conditions including hepatitis and cirrhosis. Recent
and acne. The oil (or constituents of it) is sometimes added to sun- research has confirmed that the herb has a remarkable ability to protect
tanning oils. Bergamot oil is also used to relieve tension, relax muscle the liver from damage resulting from alcoholic and other types of
spasms and improve digestion. poisoning. Today, milk thistle is widely used in the West for the
treatment of a range of liver conditions.
MAIN PROPERTIES: Disinfectant, muscle relaxant. MAIN PROPERTIES: Digestive, liver tonic, stimulates secretion of
bile, increases breast-milk production, antidepressant.
11) BITTER ORANGE
Citrus aurantium (Rutaceae) 17) CELERY, SMALLAGE
Its oil contains flavonoids which are anti-inflammatory, antibacterial Apium graveolens (Umbelliferae)
and antifungal. Bitter orange juice is rich in vitamin C which helps the More familiar as a vegetable than as a medicine, celery find its main
immune system. As an infusion, it helps to relieve fever, soothe use in the treatment of rheumatism, arthritis and gout. Containing apiol,
headaches and lower fever. It yields neroli oil from its flowers, and the the seeds are also used as a urinary antiseptic. Celery is a good
oil known as petitgrain from its leaves and young shoots. Both cleansing, diuretic herb, and the seeds are used specifically for arthritic
complaints where there is an accumulation of waste products. The 24) CYMBOPOGON, LEMON GRASS
seeds also have a reputation as a carminative with a mild tranquilizing Cymbopogon citratus (Gramineae)
effect. The stems are less significant medicinally. Its oil is used as a culinary flavoring, a scent and medicine. Lemon
grass is principally taken as a tea to remedy digestive problems
MAIN PROPERTIES: Anti-rheumatic, antispasmodic, diuretic, urinary diarrhea and stomach ache. It relaxes the muscles of the stomach and
antiseptic. gut, relieves cramping pains and flatulence and is particularly suitable
for children. In the Caribbean, lemon grass is primarily regarded as a
18) CHAMOMILE, GERMAN CHAMOMILE fever-reducing herb. It is applied externally as a poultice or as diluted
Chamomilla recutita syn. Matricaria recutita (Compositae) essential oil to ease pain and arthritis.
Its flowers help to ease indigestion, nervousness, depressions and
headaches, being ideal for emotion related problems such as peptic MAIN PROPERTIES: Digestive, antispasmodic, analgesic.
ulcers, colitis, spastic colon and nervous indigestion. Chamomile's
essential oil have anti-inflammatory, anti-spasmodic and anti-microbial 25) DAMIANA
activity. It is an excellent herb for many digestive disorders and for Turnera diffusa syn. T. diffusa var. aphrodisiaca (Turneraceae)
nervous tension and irritability. Externally, it is used for sore skin and It has an ancient reputation as an aphrodisiac and is an excellent
eczema. Roman chamomile (Chamaemelum nobile) is a close relation, remedy for the nervous system acting as a stimulant and tonic in cases
used in a similar way. of mild depression. Damiana has a strongly aromatic, slightly bitter
taste. The leaves are used to flavor liqueurs and are taken in Mexico as
MAIN PROPERTIES: Anti-inflammatory, antispasmodic, relaxant, a substitute for tea.
carminative, bitter, nervine.
MAIN PROPERTIES: Nerve tonic, antidepressant, urinary antiseptic.
19) CHICORY
Cicorium intybus (Compositae) 26) DANDELION
As a tea or extract, chicory root is a bitter digestive tonic that also Taraxacum officinale (Compositae)
increases bile flow and decrease inflammation. Its roasted root is Known principally as a weed, dandelion has an astonishing range of
commonly used as a coffee substitute. Chicory is an excellent mild health benefits. The leaves, which can be eaten in salads, are a powerful
bitter tonic for the liver and digestive tract. The root is therapeutically diuretic. The roots act as a "blood purifier" that helps both kidneys and
similar to dandelion root supporting the action of the stomach and liver the liver to remove impurities from the blood. This effect seems to be
and cleansing the urinary tract. Chicory is also taken for rheumatic due to its potassium content. It also acts like a mild laxative and
conditions and gout, and as a mild laxative, one particularly appropriate improves appetite and digestion.
for children. An infusion of the leaves and flowers also aids the
digestion. MAIN PROPERTIES: Diuretic, digestive, antibiotic, bitter.
MAIN PROPERTIES: Antibiotic, expectorant, diaphoretic, MAIN PROPERTIES: Cardiotonic, diuretic, astringent, dilates blood
hypotensive, antispasmodic, expels worms. vessels, relaxant, antioxidant.
MAIN PROPERTIES: Sedative, relaxant, relieves muscle spasm, Find out what problems to anticipate-- and how a few simple steps can
relieves anxiety, lowers blood pressure. head them off.
75) VERBENA A clogged enteral feeding tube that can't be cleared must be replaced
Verbena officinalis (Verbenaceae) an unwelcome prospect for you and your patient. At the very least,
Verbena is used in mouth washes for infected gums and as a poultice he'll miss getting some of the fluid and nutrition he needs. At
for hemorrhoids. A tea has been used as a nerve tonic, to treat insomnia worst, if he's homebound or a nursing home resident, he'll need to
and to help digestion. It has tonic, restorative properties, and is used to travel to an appropriate facility for tube reinsertion and X-ray
relieve stress and anxiety, and to improve digestive function. confirmation of placement. The expression An ounce of prevention is
worth a pound of cure could have been coined by a nurse managing
MAIN PROPERTIES: Nervine, tonic, mild sedative, stimulates bile feeding tubes.
secretion, mild bitter.
In this article, we'll describe two simple ways you can keep feeding
76) WHITE WILLOW tubes patent: pump-assisted infusion of enteral formulas and frequent
Salix alba (Salicaceae) tube flushing. But first, let's review factors that can increase the
White willow is an excellent remedy for arthritic and rheumatic pain, risk of a clogged feeding tube.
affecting the joints like knees and hips.
Problems in the pipeline
MAIN PROPERTIES: Anti-inflammatory, analgesic, reduces fever,
anti-rheumatic, astringent. Feeding tubes can become clogged for one of these reasons:
Cranberry juice, carbonated beverages, meat tenderizers, enzymatic For Paranoid clients
solutions ... over the years, nurses have tried all sorts of remedies · Don’t argue with client (simply state that you don’t share his beliefs)
for clogged enteral tubes. But researchers who've studied various · Be reliable and consistent
preventive irrigants have learned something surprising: Nothing beats
plain water. In fact, acidic colas and cranberry juice can actually For Delusional clients
cause an obstruction by promoting formula coagulation. · Stay with client
· Don’t argue about the reality of delusions
The bottom line? Flushing the tube regularly with water remains the · Orient frequently to reality (place, situation)
most effective and practical way to prevent enteral, feeding tube · Assess potential for self harm
clogs.
For Somatization clients
Making it automatic · Respect client and his problems (client is not faking)
· Rule out physical basis for symptoms
A heavy nursing workload and lack of written policies and procedures · Help client express anxiety
for tube flushing can lead to inconsistency in tube flushing. So some
enteral pumps also have an automatic flush feature, which delivers a
preprogrammed amount of fluid, typically water, every hour. This DEFENSE MECHANISMS:
simulates the flushing action of a syringe and helps minimize residue 1. Conversion: A college student develops diarrhea on day of exam
buildup. 2. Regression: Returning to immature ways of dealing with stress:
crying, tantrums…
Automatic flushing doesn't just save nursing time--it's also more 3. Repression: Blocking of unacceptable urges and feelings from
effective. Two studies found clogging in 75% of gastrostomy tubes in awareness.
the manually flushed group, compared with only 5% in the 4. Denial: Blocking of unacceptable information or perceptions from
automatically flushed group. The results were even more dramatic for awarness.
nasogastric tubes: 91% in the manually flushed group clogged; none 5. Dissociation of affect: A girl laughs when telling about her failed
clogged in the automatic flush group. exam
6. Rationalization: Substituting an acceptable motive for attitudes or
Smooth sailing behavior for an unacceptable motive
7. Reaction formation: you want to “kick your bosses ass” but end up
By knowing which, factors predispose an enteral tube to clogging and kissing it.
taking a few preventive measures, you can keep your patient 8. Identification: A teenager dresses like Madonna and mimics her
comfortable- -and save yourself some time. behavior.
9. Projection: “ you are acting like a teenager, not I”
10. Introjection: A boy yells at his dog like his father does him
11. Displacement: Client is upset about disease and yells at nurse.
Psyche Nursing
Nurse gets upset and yells at nursing assistant
For Withdrawn clients 12. Undoing: “ magic,”
· Allow client to set pace
· Encourage social activities or games SIGNS AND SYMPTOMS
IMPLEMENTATION:
TERMS: § Support family caregivers
1. Neologisms: invents new words: Schizophrenia § Provide safe and familiar environment
2. Echolalia: echoes words or sentences: Schizophrenia § Support client’s attempts at independence
3. Word Salad: jumble of words without meaning: Schizophrenia § Continually orient client to time, date and person
4. Flight of ideas: rapid switching from topic to topic: Mania § Advance directive should be drafted as early as possible
GRIEF DEPRESSION
PERSONALITY DISORDERS:
Behavior is inflexible across a broad range of situations
Behavior is markedly deviant from cultural norms
Significant distress and impairment of functioning
Features of psychoses
ANXIETY DISORDERS:
Clients are distressed and know that their symptoms are irrational.
Palpitations, tachycardia
Fear of dying
MAJOR DEPRESSION
ASSESSMENT:
Feeling of worthlessness
Thoughts of death or suicide
Lethargy
Slow, muted speech
Anorexia, weight loss
Early morning awakening
ANALYSIS:
Risk of suicide
IMPLEMENTATION:
Dry mouth
Constipation
Urinary retention
BIPOLAR DISORDER:
Manic episodes alternate with episodes of major depression.
Some clients have only manic episodes, no depressive episodes.
ASSESSMENT:
Euphoria
Grandiose ideas
Uninhibited sexuality
Buying sprees
Psychomotor agitation
IMPLEMENTATION:
Lithium
Watch for signs of toxicity
Abdominal pain, nausea
Hand tremor
Ataxia, nystagmus
Slurred speech
SCHIZOPHRENIA:
ASSESSMENT:
Delusions
Hallucinations
“NEGATIVE SYMPTOMS”
Flat affect
Loss of interest
Ambivalence
Autism
CATATONIA:
IMPLEMENTAION:
MEDICATION:
Tongue protrusion
CLIENT EDUCATION:
DRUG ABUSE:
Abuse: recurrent use of drugs resulting in social failures at home, school or work, legal problems or hazardous situations.
Dependence: Tolerance (needs larger doses to achieve effect). Withdrawal symptoms.
INTOXICAITON WITHDRAWAL
Tremor, seizures
Epilepsy
Coma, death
Sedation Irritability
insomnia
Euphoria Dysphoria
Muscle aches
Anxiety
Paranoid ideas