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HERBAL MEDS
St. John's wort - antidepressant, photosensitive (C/I
in SULFA drugs)
Garlic - antihypertensive (avoid aspirin)
Ginseng - Anti stress (C/I in coumadin)
Green tea - antioxidant (check if risk for
calculi-oxalates)
Echinacea - immune stimulant (6-8 weeks only)(C/I in
SANDIMMUNE-Immunosuppressant)
Licorice - cough and cold
Ginger root - antinausea (C/I in Coumadin)
Ginkgo - improves circulation (C/I in anticoagulant,
headache side effect - check PT)
Ma huang - bronchodilator, stimulant (Ephedra)
Parent teaching: Use of Infant and Car Seats
Weight below 9 kg (20 lb):
Use infant or convertible seat in back seat of car in backward-facing position.
Keep infant reclined at a 45 degrees.
Never place the infant in the front passenger seat.
Fasten seat securely to car using car seat belt and following manufacturere instructions.
Adjust harness to fit snugly at shoulders and legs.
When using an infant seat, move to larger seat before the infant's head reaches the top of shell.
When using a convertable seat from birth, use one with a 5-point restraint.
Birth-18 kg (40 lb)(Some seats are designed for infants from birht to 40 lbs, others are only
designed for infants up to 20 lb, therefore there are separate instructions for each type)
When using a convertableseat, use reclined for rear-facing and upright for forward facing. (Infant
remains rear facing until they reach 20 lb as in the prior instructions)
Follow manufacturer instructions for proper positions at specfied child weights for that product
(Typcially this is the "child must face rear until they reach 20 lb)
When using a convertible seat, move to a high-backed child seat or booster seat when child's
ears are above the seat.
Always place the seat in the rear of the vehicle. (This is especially true with airbags as when they
deploy in an accident they will seriously injure or kill the child)
Above 13.6 or 18 kg-27 or 36.3 kg (30 or 40 lb-60 or 80 lb) (Most instructions agree on the 40 lb &
40 inch-height minimum)
Use booster seat fro children who have outgrown convertible/toddler seats
Follow manufacturere instructions for use and specfied child weights for the product (NCLEX
questions will be based on the standards published in nursing textbooks which are those included
in this post)
Use booster seat until the vehicle lap and shoulder belt fit correctly
Have all children 12 years and under ride in the rear seat, whether or not in a car seat.
Air bags can seriously injure a child or cause death, when a child is in a car seat in the front
passenger seat. Even when not in a car seat, and when the vehicle is not equipped with a
passenger side air bag, the back seat is the safest for all children.
From the textbook often used to write the NCLEX pediatric questions: (Ball & Bindler)
Preschool child's need for autonomy and control can be met by allowing the child to choose which
snacks to pick or which finger to stick for glucose testing, or help the parent/caregiver gather
necessary supplies.
School-age children can learn to test blood glucose, administer insulin, and keep records. They
should be taught how to select foods appropriate for dietary management and how to plan an
exercise program. They need to learn to recognize the signs and symptoms of hypoglycemia and
hyperglycemia, and understand the importance of carrying a rapidly absorbed sugar product.
Adolescents should take on total responsibility for self-care. Although they understand
explanations about the potential complications of diabetes, they are present-time oreinted and
may rebel against the daily regimentation of insulin injections, blood glucose monitoring, and
dietary management. Successful self-care depends in part on the adolescent's adjustment to the
chronic nature of the disease and feelings of being different from peers.
This same textbook defines:
Preschool child, 3-6 years of age
School age child, 6-12 years of age
Adolescent, 12-18 years of age
Primary atypical pneumonia (Mycoplasma pneumonia) is characterized as:
Select all that apply:
O 1 Most common cause of pneumonia in children
O 2 incidence in children between the ages of 5 and 12
O 3 Occurs primarily in summer
O 4 more prevalent in crowded living conditions
O 5 caused by Borelia burdorferi
The correct answers are:
1, 2 & 4
It occurs primarily in the fall and winter months
The causative organism is M. pneumoniae
M. pneumoniae is a common cause of mild pneumonia . Various studies suggest that it causes a
higher percentage of pneumonia in school-aged children.
People at highest risk for mycoplasma pneumonia include those living or working in crowded
areas such as schools and homeless shelters, although many people who contract mycoplasma
pneumonia have no identifiable risk factor.
Symptoms
The symptoms are generally mild and appear over a period of one to three weeks. They may
progress to more severe symptoms in some people.
Common symptoms include the following:
Headache
Fever (may be high)
Chills
Excessive sweating
Cough
Usually dry
Usually without phlegm or blood
Chest pain
Sore throat
Less frequently seen symptoms include the following:
Skin lesions or rash
Eye pain or soreness
Muscle aches and joint stiffness
Neck lump
Rapid respiratory rate
Ear pain
Signs and tests
A physical examination may reveal enlarged lymph nodes and inflammation of the eardrum. An
examination of the chest with a stethoscope (auscultation) reveals crackles.
These tests help confirm the diagnosis:
Blood tests for antibodies to mycoplasma
Sputum culture
Chest x-ray
Treatment
Antibiotics may be prescribed for more serious symptoms related to mycoplasma pneumonia.
Home care includes rest and a high-protein diet with adequate fluids.
Expectations (prognosis)
Most people recover completely even without antibiotics, although antibiotics may speed
recovery. In untreated adults, cough and weakness can persist for up to a month.
EPOGEN - EPOETIN ALFA RECOMBINANT
Possible Test Item:
A client with chronic renal failure on dialysis is to receive EPOGEN. Which of the following
symptoms would warrant the nurse to hold the administration of this human recombinant?
Select all that apply:
O 1 the client has fever
O 2 the client has hypertension
O 3 heart rate 72/minute
O 4 respiratory rate is 19
O 5 the client is pale
O 6 client has body malaise
The correct answers: 1 & 2
CNS side effect: Pyrexia, withhold the drug
CVS side effect: Hypertension, withhold the drug.
EPOGEN - recent question in the NCLEX-RN
EPOGEN - epoetin alfa recombinant
Classification
Erytrhopoietin, human recombinant
1. normally synthesized in the kidney and stimulates RBC production
2. will elevate and maintain RBC level, decreasing the need for BT
Uses:
Treatment of anemia associated with Chronic Renal Failure in adults
C/I: uncontrolled hypertension
Side effects:
CV - hypertension
CNS - pyrexia
Complication: Polycythemia
What to monitor before and after:
BP. TEMP & HEMATOCRITwater.
1)a young patient most likely to get lead poisining if?
a. he is drinking from a ceramic pitcher.
b. father referinshes old furniture at their home
> ANSWER is B. probably if he refurbishes an old furniture at home.. that is, if the furniture has
old paint on it and during 60's paints have lead content on it (heavy metals) and if you need to
remove that, chips from the old paint may be taken by a kid that leads to Pb poisoning
2) a TB pt understands that he can reduce the risk of spreading his disease if he states?
a. i wont sleep in same room w/ my wife for 1-2 months
b. i will stay away from pregnant women and children
c. i will use plastic utensil when i eat
****>> if the patient is already taking anti-TB drugs, it will only be 2 weeks of chemotherapy and
that (+) PTB will no longer be communicable.. and 1-2 months is long!
CHildren are more susceptible to acquire Primary complex and pregnant women are susceptible
and almost vulnerable to all type of illnesses.. There is no need for the patient to separate their
utensils since PTB is airborne and not by contact in terms of transmission.. so i go for B answer.
3) 4 years old with salmonella what u should do?
a. private room
b. isolation
c. place in a room with 4 year old with cellulitis
d. keep door closed at all times.
*** the (+) salmonella kid may be placed in a private room. Salmonella is transmitted by Enteric..
therefore Enteric precaution is needed and handwashing is very important and gown and gloves,
diaper or bedpan in necessary. Option B, and D are all for pulmonary tuberculosis precautions. I
suppose, the answer is A. place in a private room.
4) wot herb would help with vomiting?
a. ginko
b. ginsing.
c. ginger root
d. echinacea
****> ginger root is good for nausea.. most especially in morning sickness but in moderation for
pregnant women... Option C is the answer
5) allergic to sulfa wot not to take?
a. ma huang
b. echunacea.
...I think the answer is... geez, i forgot..i think its Echinacea..let me check again ok..
6) mother called a nurse from home stating that her child having chicken pox..which of the
following statements by the mother needs immidiate follow up?
a. father of the child with liver failure
b. sibling with anemia
c. child just had tonsillectomy
d. child has intermittent low grade fever
I think the answer is C. the child that just had tonsillectomy. i think the child is
immunocompromised. and varicella (Chicken pox) is a viral one.. we all know that tonsils are one
of the lymph defenses we have against any infection.. Im not really sure with this answer.
7) clientwith allergy to sudafed ..which of the statments is correct?
a. i will take valerian
b. i will take ma huang
c. i will take echinacea for acute viral inf.
d. i will take black cohosh
**valerian root is for cystitis and fungal infections; ma huang is for (I forgot!!),echinacea is for
immune booster but not to be taken with patients with progressive systemic disorders such as
AIDS, PTB, HIV, etc. black cohosh is for menopause.
*** don't you think that Echinacea is the correct option??
8)food processing
a. frozen food can be defrost for up to six hours
b. frozen food which has been defrost can be return back to fridge.
c. cook perishible food should cover and cool
d. frozen food should be defrost by hot water
usually, frozen food must be thawed at cool tap water for freshness. not in the microwave
because it can be cooked outside and raw inside, not in the hotwater with same principle. so i
believe, thawing it FOR UP TO 6 HOURS would be ok. returning thawed food back at fridge is ok
but it is unsafe since salmonella can start thriving in.. Answer is OPTION A.
9) child in a mist tent and the parents brought him a car toy...the child was clutching the toy and
the nurse refused to let him play for wot reason?
a. it will get contaminated with bacteria
b. it will accumalate moisture
c. it could cause a fire
** The answer is OPTION C. Usually car toy have friction on it for the wheels to run.. Oxygen
supports combustion.. and if friction is present together with oxygen (in a mist tent) then, fire
could commence.
11) a mother reported tht her son is throwing up each time she feeds him wot would be the best
question u ask?
a. did u warm up the formula
b. wot kind of formula did u give him
c. does ur son feel hungry each time he throws up
d. does r son have a jelly like stool
***>>> CORRECT OPTION is D.. Does your son have jelly like stool.. jelly like or currant like
stool is a cardinal sign of Intussusception/ Telescoping or invagination of the large intestines in
the Ileoceccal area..
12) a patient had AIDS the nurse should advise?
a. cook ur meat very well
b. not to eat in the same table with family
c. avoid crowds
***>> if you have AIDS, u are immunocompromised.. therefore you are prone to infection..
neutropenic precaution is advised and one that is a must is Avoiding Crowds.. Correct option is C.
Seasonal Affective Disorder (SAD) may affect over 10 million Americans.
The typical symptoms of SAD include depression, lack of energy, increased need for sleep, a
craving for sweets and weight gain. Symptoms begin in the fall, peak in the winter and usually
resolve in the spring. Some individuals experience great bursts of energy and creativity in the
spring or early summer.
Susceptible individuals who work in buildings without windows may experience SAD-type
symptoms at any time of year. Some people with SAD have mild or occasionally severe periods
of mania during the spring or summer. If the symptoms are mild, no treatment may be necessary.
If they are problematic, then a mood stabilizer such as Lithium might be considered. There is a
smaller group of individuals who suffer from summer depression.
SAD is recognized in the DSM-IV (The American Psychiatric Association's diagnostic manual) as
a subtype of major depressive episode.
Some individuals who work long hours inside office buildings with few windows may experience
symptoms all year round. Some very sensitive individuals may note changes in mood during long
stretches of cloudy weather.
A sign of improvement from dehydration would be a decreased urine 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 the two you had in you question.
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 different range).
SG 1.025-1.030+ (concentrated urine)
SG 1.001-1.010 (dilute urine)
SG 1.001-1.018 in infants under 2 years of age
Specific gravity is a measurement of the kidney's ability to concentrate 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 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.
SG values usually vary inversely with amounts of urine excreated (decrease in urine volume =
increase in specific gravity). However in some conditions this is not the case. For example:
a. Diabetes: increased urine volume, increased SG (High amount of glucose in urine)
b. Hypertension: normal volume, decreased SG
c. Early chronic renal disease: increased volume, decreased SG
Hematocrit: Percentage of packed red cells in a volume of whole blood. The hematocrit will be
increased in dehydration.
Source: A Manual of Laboratory & Diagnostic Tests (Frances Fischbach)
digitalis toxicity includes..
N - nausea
A - anorexia
V - vomiting
D - diarrhea
A - abdominal pain
kasma na changes sa vision..
Digitalis toxicity is the result of the body accumulating more digitalis than it can tolerate at that
time. Patient will complain visual change in color, and loss of appetite.
From RAG book and memory notebook
Drugs which can cause URINE DISCOLORATION
Adriamycyn------ Reddish
Rifabutin--------- Red orange
Rifampicin------- Red orange
Bactrim---------- Red orange
Robaxin--------- Brown, Black or Greenish
Azulfidine------ Orange yellow
Flagyl------------ Brownish
Dilantin---------- Pink tinged
Anti Psychotic-- Pinkish to Red brown
Early signs of hypoxia:
R-restlessness
A-anxiety
T-Tachycardia
Late signs of hypoxia:
B-bradycardia
E-extreme restlessness
D-dyspnea
In pediaF-feeding difficulty
I-inspiratory stridor
N-nares flare
E-expiratory grunting
S-sternal retractions
Respiratory Patterns
Kussmaul- fruity acetone breath odor
Cheyne-stokes- near death breathing pattern
CRUTCH WALKING UP STAIRS
Good goes to heaven, Bad goes to hell
CYSTITIS-Inflamation of the urinary bladder
Manifestations:
Urgency and frequency
Lab data:
Culture and sensitivity tests reveal the presence of bacteremia
Usually E.Coli
PREVENTING CYSTITIS
>Drink 8-10 glasses of fluid per day
>Women should wipe from front to back
>Urinate after intercourse
>Avoid vaginal deodorants and bubble baths
>Avoid silk underwear, cotton underwear is preferred
>Maintain acid ash diet (cheese,cranberry,prunes and plums
1.Which of the following statements made by a patient reflects a need for further teaching?
a. I drink a lot of fluids
b. I usually go nonstop driving for 8 hours on weekends--- answer
c. I should avoid bubble baths
d. I love drinking citrus juices
2. Which of goal of nursing care takes priority for a female client with cystitis?
a. increasing urine alkalinity
b. maintaining a balanced fluid I & O
c. Providing instructions on perineal hygiene--- answer
d. screening urine for sedimentation
Muskuloskeletal Anatomical tips
TENDONS- connect muscle to bone
LIGAMENTS- connect bone to bone
CUSHING SYNDROME
Hypersecretion of Glucocorticoids by the adrenal glands
Manifestations:
central type or truncal obesity with thin extremeties
moonface
buffalo hump
hirsutism
Lab data:
Elevated serum cortisol levels
Hypernatremia,hyperglycemia,hypertension
Hypokalemia
Intervention:
High potassium, Low sodium diet
Lifelong administration of glucocorticoid synthesis inhibitors
Eg. Mitotane
Inform that there will be poor wound healing
Sample question:
When assessing a 40-year old patient with cushing’s syndrome, the nurse should expect the
person to demonstrate:
A lability of mood---- answer
B ectomorphism with a moon face
C a decrease in the growth of facial hair
D an increase resistance to bruising and bleeding
EYE ABBREVIATIONS
OU- both eyes
OR- right eye
OS- left eye
LEVELS OF CONSCIOUSNESS
A------ ALERT
V------ VERBAL STIMULI
P------ PAINFUL STIMULI
U----- UNRESPONSIVE
REASONS FOR UNCONSCIOUSNESS(SKIN COLOR)
RED----- Stroke or increase BP
WHITE---- Shock or Hemorrhage
BLUE--- Respiratory or Cardiac Arrest
CIRCULATION ASSESSMENT- 5Ps
Pain
Pallor
Pulse
Paresthesia
Paralysis
CHOLINERGIC CRISIS
S- Salivation
L-Lacrimation
U-Urination
D-Defecation
G
E
ADLs
B-Bathing
A-Ambulation
T-Toileting
T-Transfers
E-Eating
D-Dressing
Instrumental ADLs
S-shopping
C-cooking, cleaning
U-using telephone /transportation
M-managing money and medications
C cane
O opposite
A affected
L leg
IN CASE OF ABDOMINAL TENDERNESS
Inspect, auscultate, percuss, palpate
CUSHINGS (Hypersecretion of Adrenal Cortex Hormones)
C = Check VS, particularly BP
U = Urinary output & weight monitoring
S = Stress Management
H = High CHON diet
I = Infection precaution
N = Na+ restriction
G = Glucose & Electrolytes Monitoring
S = Spousal support
ADDISON'S (Hyposecretion of Adrenal Cortex Hormones)
Always Remember the 6 A's of Addison's disease
1.) Avoid Stress
2.) Avoid Strenuous
3.) Avoid Individuals with Infection
4.) Avoid OTC meds
5.) A lifelong Glucocorticoids Therapy
6.) Always wear medic alert bracelet
IF RESPIRATORY DEPRESSION OR OVERSEDATION IS SUSPECTED:
1. CEASE the PCA
2. CEASE all other infusions that could be contributing to sedation
3. Attempt to rouse the patient
4. Call 777 [MET team] if appropriate
5. If apnoeic: administer bag & mask ventilation with 100% oxygen
6. If breathing: maintain airway, monitor oxygen saturations and administer oxygen via face mask
at 8L/min
7. Check circulation. If pulseless: commence chest compressions
8. Prepare naloxone for possible administration
9. Call CPMS for urgent review
Allergic: caused by sensitivity to foreign proteins.
Clinical Manifestations: Urticaria, flushing, itching, no fever.
Treatment: Administer antihistamines as directed.
If manifestations mild and transient, transfusion may resume.
Prevention: Treat prophylactically with antihistamines.
Acute hemolytic: caused by infusion of ABO-incompatible red blood cells.
Clinical manifestations: Chills, fever, low back pain, flushing, tachycardia, hemoglobinuria,
hypotension, vascular collapse, bleeding, acute renal failure, shock, cardiac arrest, death.
Management: Discontinue transfusion, removing/changing IV tubing down to IV catheter.
Send blood samples for serologic testing, and send urine samples to lab. Send blood tubing to
lab/blood bank.
Maintain blood pressure.
Give diuretics as prescribed to maintain urine flow.
Insert indwelling catheter or measure hourly output.
Dialysis may be needed.
Prevention: Meticulously verify recipent from sample collection to transfusion.
Anaphylactic reaction: caused by infusion of IgA proteins to IgA-deficient recipient who has
developed anti-IgA-antibodies.
Clinical Manifestations: Anxiety, urticaria, wheezing progressing to cyanosis, shock, and possible
cardiac arrest.
Treatment: Do not transfuse additional RBC.
Initiate CPR if indicated.
Have epinephrine ready for injection (0.4 ml of a 1:1000 solution SC
Prevention: Give blood composnents from IgA-deficient donors or remove all plasma by washing.
Hirschsprung’s diagnosed with rectal biopsy looking for absence of ganglionic cells. Cardinal
sign in infants is failure to pass meconium, and later the classic ribbon-like and foul smelling
stools.
Intussusception common in kids with CF. Obstruction may cause fecal emesis, currant jellylike stools (blood and mucus). A barium enema may be used to hydrostatically reduce the
telescoping. Resolution is obvious, with onset of bowel movements.
With omphalocele and gastroschisis (herniation of abdominal contents) dress with loose saline
dressing covered with plastic wrap, and keep eye on temp. Kid can lose heat quickly.
After a hydrocele repair provide ice bags and scrotal support.
No phenylalanine with a kid positive for PKU (no meat, no dairy, no aspartame).
Second voided urine most accurate when testing for ketones and glucose.
Never give potassium if the patient is oliguric or anuric.
Nephrotic syndrome is characterized by massive proteinuria (looks dark and frothy) caused by
glomerular damage. Corticosteroids are the mainstay. Generalized edema common.
A positive Western blot in a child <18 months (presence of HIV antibodies) indicates only that
the mother is infected. Two or more positive p24 antigen tests will confirm HIV in kids <18
months. The p24 can be used at any age.
For HIV kids avoid OPV and Varicella vaccinations (live), but give Pneumococcal and influenza.
MMR is avoided only if the kid is severely immunocompromised. Parents should wear gloves for
care, not kiss kids on the mouth, and not share eating utensils.
Hypotension and vasoconstricting meds may alter the accuracy of o2 sats.
An antacid should be given to a mechanically ventilated patient w/ an ng tube if the ph of the
aspirate is <5.0. Aspirate should be checked at least every 12 hrs.
Ambient air (room air) contains 21% oxygen.
The first sign of ARDS is increased respirations. Later comes dyspnea, retractions, air hunger,
cyanosis.
Normal PCWP is 8-13. Readings of 18-20 are considered high.
First sign of PE (pulmonary embolism) is sudden chest pain, followed by dyspnea and
tachypnea.
High potassium is expected with carbon dioxide narcosis (hydrogen floods the cell forcing
potassium out). Carbon dioxide narcosis causes increased intracranial pressure.
Pulmonary sarcoidosis leads to right sided heart failure.
An NG tube can be irrigated with cola, and should be taught to family when a client is going
home with an NG tube.
Q&As found in the NCLEX FORUM
Question # 1 (Multiple Choice) History and exam indicates your 77 year old
female patient has digitalis toxicity. Which drugs are contraindicated in this
case? Plz provide your rationale.
A) lidocaine and atropine
B) adenosine and amiodarone
C) magnesium sulfate and sodium bicarbonate
D) bretylium and verapamil
Answer::
A) lidocaine and atropine-Don't affect dig level/dig toxicity.
B) adenosine and amiodarone-Amiodarone, increases serum dig levels, possibly
causing dig toxicity. Adenosine doesn't affect dig toxicity. Only one of these
meds is contraindicated in dig levels/toxitiy.
C) magnesium sulfate and sodium bicarbonate. Neither drug affects dig levels
D) bretylium and verapamil-BEST ANSWER: Verapamil, increases serum dig levels,
possibly causing dig toxicity. Bretylium aggravates dig toxicity and digoxin
toxic arrhytmias are exacerbated by bretylium. This answer has two meds that are
should not be given to dig toxic patients.
Question # 2(Multiple Choice) Regarding abruptio placentae
A) Blood loss is confined within the amniotic sac
B) Internal bleeding is generally minimal.
C) Blood loss may be concealed between the uterine wall and the placenta
D) There is always excessive external vagina bleeding
what's the correct one? I just don't agree with c.
Answer::
C. is the best answer because it does describe placenta previa, most correctly.
Placenta previa is premature separation of the placenta, and the blood loss can
be either apparent or concealed. If the edges of the placenta remain attached to
the uterus then there will be no apparent loss of blood. However the woman is
still have significant internal bleeding.
A. is incorect because it does not describe A.P.
B. is incorrect because blood loss is usually significant, not minimal.
D. is incorrect because blood loss can be hidden.
Question # 3 (Multiple Choice) The geriatric patient suffering from organic
brain syndrome or dementia may not be able to make a rational decisions
regarding emergency care. In these situations, you may use ____to permit you to
legally render care
A) Good Samaritan Laws
B) Standards of Care
C) Implied Consent
D) Informed Consent
c is given as correct. why?
Answer:: Implied consent means that the patient most likely has been found in
distress and it is assumed that person wants to live. Therefore, you are within
the law to treat a person who is unable to make a decision about his/her care
who is in an emergency situation.
Above answer to your question explains why C is the best answer. Let me point
out a test taking tip to further support how you would choose this answer on an
exam, like NCLEX. First look at your question and identify, the key words, i.e.
what the question is asking. This question is asking which law will permit you
to deliver care in an emergency situation, when the patient is unable to give
consent. Now define each of the possible reponses.
A) Good Samaritan Laws-This law is to protect the individual that intervene to
provide care in an emergency from litigation. In other words, if a nurse stops
at an accident scene and provides care, the nurse will not be held liable for
their actions, if the care was provided in good faith according to practice
standards. Therefore this is not the answer.
B) Standards of Care-These are established guidelines for the nurse/health care
provider that outline safe and effective nursing care/interventions for given
diagnoses, etc. So, again this is not the answer to the question.
C) Implied Consent-Best answer, the patient can't verbalize consent, due to
their OBS/dementia, but they need emergency care. Because care is required then
consent to provide life saving care is implied. The same principle applies when
giving emergency care to unconscious patients. You can't wait for them to tell
you it is OK, to save their life, the law allows you to intervene. This is
implied consent.
D) Informed Consent-This is when the physician describes the procedure that is
to be preformed. Included in this explanation is the benefits and risks
associated with the procedure. The patient is INFORMED about the procedure and
then they give their consent. Again, this is not the best answer.
Try this technique when answering NCLEX-like questions, and you will find that
you will get more correct.
Question:
1.)a person is holding their neck what do you do?
a.)ask them can they cough.
b.)immediately perform the heimlich maneuver. I got confused because I
know are suppose to ask the person can they talk.
2.) an elderly client has alzheimers and wanders through out the day. To protect
his safety what is the best thing to do?
a.) put alarms on all the doors.
b.) inform all the staff to reorient the client.
c.) have the security guards to check on him.
d.) family to sit with him.
3.)When teaching a pt.about urinary catheter. What is most important?
a.)wear sterile gloves.
b.)clean the urethra with betadine.
4.)A woman is coming in for a pap smear what is most import to follow up on
before the pap smear is performed.
a)I just started menstruating and it is very heavy.
b) my last pap smear was abnormal.
C)I never had sex before.
d)I forgot this choice.
Answer:
These are some thoughts and rationales for the possible best answers to your
questions.
1.)a person is holding their neck what do you do?
a.) ask them can they cough. BEST ANSWER, because you need to confirm/rule out an
obstructed airway. If the patient can cough, then they are encouraged to do so.
If they can't speak or cough (no airway movement/obstructed airway) then you
begin the sequence for removing an airway obstruction, in this case it would be
for a conscious patient.
b.)immediately perform the heimlich maneuver. NOT THE BEST CHOICE, because you
need to confirm whether or not the patient is able to move air effectively
before performing this maneuver. Therefore to rule out an obstructe airway you
need to select an answer that will establish if the patient can speak, cough or
some other indicator of air movement.
I got confused because I know are suppose to ask the person can they talk. This
correct, but as you know from taking the NCLEX, the answer you want is never
there. What you have to do is select the answer that best matches/fits the
principles for the answer you would expect to find. You ask if the patient can
speak to confirm/rule out airway movement. Asking if they can cough will
accomplish the same thing.
2.) an elderly client has alzheimers and wanders through out the day. to protect
his safety what is the best thing to do? Key words in this question are WANDERS,
Alzheimer's patient, and to protect HIS SAFETY.
a.) put alarms on all the doors. BEST ANSWER, this is for the patient's SAFETY,
because Alzhiemer's patients wander and if they were to leave the healthcare
facility their safety would be compromised significantly. The alarms will
immediately alert all staff and the patient can be returned to the unit
immediately.
b.) inform all the staff to reorient the client. NO, remember the question is
asking about safety. Reoriented an Alzheimer’s patient is appropriate nursing
care, but they have no short term memory, so this will not ensure that they will
remain on the unit. They can (and will ) still wander.
c.) have the security guards to check on him. NO, this is both extreme and it is
"passing the buck". On the NCLEX it is up to nursing to solve nursing
problems. The patient could be injured or leave the unit between checks by the
security guards.
d.) family to sit with him. NO, this is "passing the buck" and putting another
burden on a family that is already in crisis due to the fact they have a family
member with Alzheimer's disease.
3.)When teaching a pt.about urinary catheter. What is most important? Both
answer don't match the principles of home care for a client with a catheter, so
it would be interesting to know what the other options were.
a.)wear sterile gloves. NO, because this is a clean procedure.
b.)clean the urethra with betadine. BEST answer of the two choices, because home
catheter care is a clean procedure, so A would not be the choice. Betadine is a
good anti-infective agent but it can be irritating to tissues. Generally
cleaning with soap and water is all that is recommended for home care.
4.)A woman is coming in for a pap smear what is most import to follow up on
before the pap smear is performed.
a) I just started menstruating and it is very heavy. BEST ANSWER, the best time
to obtain a pap smear is two weeks after the first day of the last menstrual
period and DEFINITELY NOT when the patient is menstruating, as this will affect
the results.
b) my last pap smear was abnormal. No, this is important to know, but not as
significant as A. This is not a contraindication to performing the test.
C) I never had sex before. No, this is important to know, but A is more
significant
d)I forgot this choice.
Question:
1. Alzheimer's patient incontinent of urine during the night times. The nursing care includes
a) Offers bed pan every 2 hours
b) Limit fluids during evening times
c) Foley's catheter
2. After immediate post operative hysterectomy patient to observe (or) Nursing care includes
a) Observe vaginal bleeding
b) Urine output
c) Vital signs
3. Dilantin prescribed to the patient, instructions to patient include
a) Reticulocyte counts
b) Platelet counts
4. On the ECG found a straight line, first Nurse
a) Assess the patient
b) Cardiopulmonary resuscitation
c) IV fluids
5. 15% superficial burns, 20% partial thickness burns. If the fluids adequate
a) Urine output 30-40ml/hr
b) BP
c) Vital signs
d) Skin turgor
6. 20 week pregnant most concerned
a) Butterfly rash on both cheeks and nose
b) Uterus palpate at the level of symphysis pubis
c) Sereous fluid drain in the breasts
d) Breast enlargement
7. The sterile technique is broken when:
a) The sterile field and supplies are wet
b) Clean the area peripheral to center
8. The metal piece is embedded on the left eye
a) Pressure dressing is applied on the left eye
b) Dressing is applied on both eyes
c) Irrigate the eye with saline
9. After cerebral angiogram, patient is
a) Encourage fluids
b) obseve contrast medium in the urine
c) walking
10. Using clean, non sterile gloves, care is appropriate
a) wash the genitelia........YES/NO
Answers:The following possible best answers are based on the information found in nursing textbooks, and
the underlying principle for safe and effective care that NCLEX is testing for.
1. Alzheimer's patient incontinent of urine during the night times. The nursing care includes
a) Offers bed pan every 2 hours-NO, would be appropriate to bring the client to the toilet or
commode every 2 hours during the day, but this action means you disturb the client's sleep.
b) Limit fluids during evening times, BEST ANSWER-(Source: Black & Hawks, Medical-Surgical
Nursing 7th edition) Specific interventions for the Alzheirmer's client with urinary incontinence:
"Sometimes the client forgets where the bathroom is located. Having bright lights and frequently
taking the client there may help control incontinence. Fluid intake after the dinner meal can be
restricted to maintain continence during the night."
c) Foley's catheter-NO, would increase risk of lower urinary tract infection, inappropriate and not
necessary.
2. After immediate post operative hysterctomy patient to observe (or) Nursing care includes
a) Observe vaginal bleeding
b) Urine output
c) Vital signs-BEST ANSWER, as this provides the best/most information about the client's
response to surgery and anesthesia.
3. Dilantin prescribed to the patient, to instruct the patient that includes
a) Reticulocyte counts-Yes, this will test for decreased reticulocyte count a sign that the patient is
developing aplastic anemia, a potentially life threatening side effect of Dilantin therapy.
b) Platelet counts-No, however Dilantin can decrease the platelet count and result in
thrombocytopenia. Aplastic anemia is considered to be more serious (Davis Drug Guide)
4. On the ECG found a straight line, first Nurse
a) Assess the patient-BEST ANSWER, always assess the patient to be sure there is no
equipment malfunction, and/or to confirm the information on the monitor.
b) Cardiopulmonary resuscitation
c) IV fluids
5. 15% superficial burns, 20% partial thickness burns. If the fluids adequate
a) Urine output 30-40ml/hr BEST ANSWER, the patient's fluid balance/hydration status is best
evaluated by assessing urine output. Urine output should be between 0.5 and 1.0 mL/kg/hr, which
for a 130 lb adult would be between 29.5 -59 mL/hr. Most nursing textbooks consider 30 mL/hr of
urine output to indicate appropriate fluid balance/hydration.
b) BP
c) Vital signs
d) Skin turgor
For b, c, and d many other factors can affect these findings. Urine output directly correlates with
the patient's hydration status/fluid balance.
6. 20 week pregnant most concerned
A
) Butterfly rash on both cheeks and nose-NO this is Cholasma the "mask of pregancy", result of
hormonal changes in pregnancy.
b) Uterus palpate at the level of symphysis pubis-BEST ANSWER this correlates with 12 weeks
gestation and the patient in the question is 20 weeks. This is a significant difference.
c) Sereous fluid drain in the breasts-NO, leaking of clear fluid from the breasts during pregnancy
is not unusual.
d) Breast enlargement-NO, the breast enlarge during pregnancy.
7. The sterile technique is broke when
a) The sterile field and supplies are wet-BEST ANSWER, this would allow microorganisms to
enter the sterile field through the wet surface.
b) Clean the area peripheral to center-NO, this is inappropriate technique but response a,
specifically describes how a sterile field can be contaminated and is an important principle in
maintaining sterile fields.
8. The metal piece is embedded on the left eye
a) Pressure dressing is applied on the left eye-NO, this would "push" the object further into the
eye.
b) Dressing is applied on both eyes-BEST ANSWER, you want to keep the left eye still, and
because both eyes move together the uninjured eye must be covered to prevent movement in the
injured eye.
c) Irrigate the eye with saline-NO, the object is embedded, meaning deep within the eye. Irrigation
will not remove the object but theoretically it could cause it to move resulting in further damage.
9. After cerebral angiogram, patient is
a) Encourage fluids-BEST ANSWER, when ever contrast medium/X-ray dyes are administer the
client is hydrated to facilitate excretion of the dye.
b) obseve contrast medium in the urine-NO, should not be observable to patient or nurse.
c) walking-NO, bedrest would be maintained for a prescribed period of time.
10. Using clean, non sterile gloves care is appropriate
a) wash the genitelia........YES/NO- YES, this is not a sterile procedure.
Question:
A patient is receiving 1,000 ml of 5% glucose and 0.45% normal saline with 40 mEq of potassium
chloride. most important for nurse to monitor the patient :
A. pulse rate
B. daily weight
C. skin turgor
Answer1:
I would say, always check for urine output before commencing anything with Potassium because
it can only be excreted in the urine. Hence if you are dehydrated & have decrease urine output &
commenced on K+ hyperkalemia will arise leading to cardiac arrythmia.
Answer2:
The answer is pulse rate
Question:
1)a young patient most likely to get lead poisining if?
a. he is drinking from a ceramic pitcher.
b. father refurnishes old furniture at their home
2) a TB pt understands that he can reduce the risk of spreading his disease if he states?
a. i wont sleep in same room w/ my wife for 1-2 months
b. i will stay away from pregnant women and children
c. i will use plastic utensil when i eat
3) 4 years old with salmonella what u should do?
a. private room
b. isolation
c. place in a room with 4 year old with cellulitis
d. keep door closed at all times.
4) wat herb would help with vomiting?
a. ginkgo
b. ginseng.
c. ginger root
d. echinacea
5) allergic to sulfa wat not to take?
a. ma huang
b. echinacea.
6) mother called a nurse from home stating that her child having chicken pox, which of the
following statements by the mother needs immediate follow up?
a. father of the child with liver failure
b. sibling with anemia
c. child just had tonsillectomy
d. child has intermittent low grade fever
7) client with allergy to sudafed ..which of the statments is correct?
a. i will take valerian
b. i will take ma huang
c. i will take echinacea for acute viral inf.
d. i will take black cohosh
8) food processing
a. frozen food can be defrost for up to six hours
b. frozen food which has been defrost can be return back to fridge.
c. cook perishable food should cover and cool
d. frozen food should be defrost by hot water
9) child in a mist tent and the parents brought him a car toy...the child was clutching the toy and
the nurse refused to let him play for wat reason?
a. it will get contaminated with bacteria
b. it will accumalate moisture
c. it could cause a fire
11) a mother reported that her son is throwing up each time she feeds him wat would be the best
question u ask?
a. did u warm up the formula
b. wot kind of formula did u give him
c. does ur son feel hungry each time he throws up
d. does ur son have a jelly like stool
12) a patient had aids the nurse should advise?
a. cook ur meat very well
b. not to eat in the same table with family
c. avoid crowds
Answer:
1)a young patient most likely to get lead poisining if?
a. he is drinking from a ceramic pitcher.
b. father refurbishes old furniture at their home
> ANSWER is B. probably if he refurbishes an old furniture at home.. that is, if the furniture has
old paint on it and during 60's paints have lead content on it (heavy metals) and if you need to
remove that, chips from the old paint may be taken by a kid that leads to Pb poisoning
2) a TB pt understands that he can reduce the risk of spreading his disease if he states?
a. i wont sleep in same room w/ my wife for 1-2 months
b. i will stay away from pregnant women and children
c. i will use plastic utensil when i eat
****>> if the patient is already taking anti-TB drugs, it will only be 2 weeks of chemotherapy and
that (+) PTB will no longer be communicable.. and 1-2 months is long!
CHildren are more susceptible to acquire Primary complex and pregnant women are susceptible
and almost vulnerable to all type of illnesses.. There is no need for the patient to separate their
utensils since PTB is airborne and not by contact in terms of transmission.. so i go for B answer.
3) 4 years old with salmonella what u should do?
a. private room
b. isolation
c. place in a room with 4 year old with cellulitis
d. keep door closed at all times.
*** the (+) salmonella kid may be placed in a private room. Salmonella is transmitted by Enteric..
therefore Enteric precaution is needed and handwashing is very important and gown and gloves,
diaper or bedpan in necessary. Option B, and D are all for pulmonary tuberculosis precautions. I
suppose, the answer is A. place in a private room.
4) wat herb would help with vomiting?
a. ginko
b. ginsing.
c. ginger root
d. echinacea
****> ginger root is good for nausea.. most especially in morning sickness but in moderation for
pregnant women... Option C is the answer
5) allergic to sulfa wat not to take?
a. ma huang
b. echinacea.
...I think the answer is... geez, i forgot..i think its Echinacea..let me check again ok..
6) mother called a nurse from home stating that her child having chicken pox..which of the
following statements by the mother needs immediate follow up?
a. father of the child with liver failure
b. sibling with anemia
c. child just had tonsillectomy
d. child has intermittent low grade fever
I think the answer is C. the child that just had tonsillectomy. i think the child is
immunocompromised. and varicella (Chicken pox) is a viral one.. we all know that tonsils are one
of the lymph defenses we have against any infection.. Im not really sure with this answer.
7) client with allergy to sudafed ..which of the statments is correct?
a. i will take valerian
b. i will take ma huang
c. i will take echinacea for acute viral inf.
d. i will take black cohosh
**valerian root is for cystitis and fungal infections; ma huang is for (I forgot!!),echinacea is for
immune booster but not to be taken with patients with progressive systemic disorders such as
AIDS, PTB, HIV, etc. black cohosh is for menopause.
*** don't you think that Echinacea is the correct option??
8)food processing
a. frozen food can be defrost for up to six hours
b. frozen food which has been defrost can be return back to fridge.
c. cook perishible food should cover and cool
d. frozen food should be defrost by hot water
usually, frozen food must be thawed at cool tap water for freshness. not in the microwave
because it can be cooked outside and raw inside, not in the hotwater with same principle. so i
believe, thawing it FOR UP TO 6 HOURS would be ok. returning thawed food back at fridge is ok
but it is unsafe since salmonella can start thriving in.. Answer is OPTION A.
9) child in a mist tent and the parents brought him a car toy...the child was clutching the toy and
the nurse refused to let him play for wot reason?
a. it will get contaminated with bacteria
b. it will accumalate moisture
c. it could cause a fire
** The answer is OPTION C. Usually car toy have friction on it for the wheels to run.. Oxygen
supports combustion.. and if friction is present together with oxygen (in a mist tent) then, fire
could commence.
11) a mother reported that her son is throwing up each time she feeds him wat would be the best
question u ask?
a. did u warm up the formula
b. wot kind of formula did u give him
c. does ur son feel hungry each time he throws up
d. does r son have a jelly like stool
***>>> CORRECT OPTION is D.. Does your son have jelly like stool.. jelly like or currant like
stool is a cardinal sign of Intussusception/ Telescoping or invagination of the large intestines in
the Ileoceccal area..
12) a patient had AIDS the nurse should advise?
a. cook ur meat very well
b. not to eat in the same table with family
c. avoid crowds
***>> if you have AIDS, u are immunocompromised.. therefore you are prone to infection..
neutropenic precaution is advised and one that is a must is Avoiding Crowds.. Correct option is C.
Posted by anaski from IP 203.131.185.106 on September 08, 2005 at 03:45:59:
Thank you so much English RN2B
Future USRNs, this for you:
PRIORITY QUESTIONS (WHO TO SEE FIRST)
Sample Test Item:
1. Which of the following clients should the nurse deal with FIRST?
o 1 A client who needs his daily vitamin
o 2 A client who needs to be suctioned
o 3 A client who needs diaper to be changed
o 4 A client who is being prepared for discharge
Correct Answer: 2. A client who needs to be suctioned
PRIORITY (Use ABC)
Obstruction in the airway – secretions
Need to be suctioned
2. Delegation, RN, LVN, UAP, CNA
Which of the following clients should the LPN be assigned to?
o 1 A newly diagnosed patient with MYASTHENIC CRISIS
o 2 An immediate post-op client in PACU
o 3 A client awaiting medication for vitamins
o 4 A new admission for KIDNEY Transplant Patient
Correct Answer: 3-stable, A client awaiting medication for vitamins
Myasthenic Crisis – Unstable, Acute Respiratory Failure
Immediate Post – op – Unstable, Risk for Complications,
Kidney Transplant – Unstable, needs assessment for rejection
DELEGATION: Remember the 5R's, Right Task, Right Person, Right Circumstance, Right
Communication & Right Feedback)
RN Least stable, unstable, central catheters (hickman, broviac), admission, discharge, health
teachings, patient for transfer, blood transfusion (2RNs)
LPN Technical Doer, Stable, medications, wound dressing
CNA Routine Care, Urine Dip Stix, Reporting to RN, Routine VS
UAP turning q2H, conducting group activities, ambulation
For future USRNs
This is for you... from the purkinje fibers of my heart....
Room Assignment(Who to Share Room with)
Check:
A ge
B eside the nurse's station? At the end of the hallway? Single Room/Private Room?
C hain of infection/circumstance
D iagnosis
E nviroment (dim light, darkened, red nightlapm)
Sample Test Item:
The best roommate for patient with LEUKEMIA is
O 1 A 9-year-old with ruptured appendix
O 2 A 12-year-old with chicken pox
O 3 A 2-year-old with fever of unknown origin
O 4 A 5-year-old with nephrotic syndrome
Correct Answer: 4. A 5-year-old with nephrotic syndrome.
1,2 & 3, manifest symptoms of infection. A client with leukemia is immunosuppressed and
Patients with infection shouldn't be placed in this room. Since patient with nephrotic syndrome
receives diuretics and steroids, this child will also need immunocompromised host precaution.
INFECTION CONTROL:
Sample Test Item:
3. Which of the following methods should the RN utilize in patient with SALMONELLA?
O 1 Airborne Precautions
O 2 Droplet Precautions
O 3 Neutropenic Precautions
O 4 Enteric Precautions
The correct answer: 4.
Salmonella mode of transmission is fecal oral (enteric)
Handwashing
Gloves must be used in handling bedpan and diapers
Gown - if soiling is likely to happen.
Source of infection:
Contaminated food and water.
Remember - Transmission Based precautions:
A ir
B orne, small particles are dispersed in the air like MTB, varicella
C ontact, drug-resistant microorganisms
D roplet, large particles are dispersed into air, resp.infections except resp syncytial
E nteric, fecal-oral like hepaA & salmonella
AGE APPROPRIATE GROWTH AND DEVELOPMENT
(HOPPING WITH ONE LEG)
Sample test Item:
4. Which of the following is NOT a characteristic of a preschooler?
O 1 predominantly "parallel play" period
O 2 balances on 1 foot with eyes closed
O 3 skips on alternate feet
O 4 jumps rope
The correct answer is: 1. Parallel play is more common in TODDLERS.
Preschooler (3-6 years)
Gross motor development
HOPS ON ONE (1) FOOT BY 4 YEARS
SKIPS & HOPS ON ALTERNATE FEET BY 5 YEARS
PLAY : ASSOCIATIVE, IMAGINATIVE, MAGICAL THINKING, SUPERHEROES (Remember the
movie: Jingle All The way!)
FEAR: Intrusive procedures, venipunctures, IM injections, body mutilation
Toxoplasmosis, where else you can contract this (thinking of cat litter but it aint there)
Sample test Item:
5. To which of the following pregnant clients will be risk for TOXOPLASMOSIS?
Select all that apply:
O 1 A pregnant client who eat raw meat.
O 2 A pregnant client handling cat litter of infected cats.
O 3 A pregnant client gardening and cultivating soil exposed to cat feces.
O 4 A pregnant client with low rubella titer
O 5 A pregnant client who have undergone external radiation.
O 6 A pregnant client with draining, painful vesicles in the external genitalia.
The correct answers: 1, 2 & 3.
TOXOPLASMOSIS
How do people get toxoplasmosis?
A Toxoplasma infection occurs by:
Accidentally swallowing cat feces from a Toxoplasma-infected cat that is shedding the organism
in its feces.
This might happen if you were to accidentally touch your hands to your mouth after gardening,
cleaning a cat's litter box, or
touching anything that has come into contact with cat feces.
Eating contaminated raw or partly cooked meat, especially pork, lamb, or venison;
by touching your hands to your mouth after handling undercooked meat.
Contaminating food with knives, utensils, cutting boards and other foods that have had contact
with raw meat.
Drinking water contaminated with Toxoplasma.
Receiving an infected organ transplant or blood transfusion, though this is rare.
(From the internet-Division of Parasitic Disease)
Which of these statements by the nurse is incorrect if the nurse has the goal to reinforce
information about cancers to a group of young adults?
1. “You can reduce your risk of this serious type of stomach cancer by eating lots of fruits and
vegetables, limiting all meat, and avoiding nitrate-containing foods.”
2. “Prostate cancer is the most common cancer in American men with results to threaten
sexuality and life.”
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 States. Yet it's the most
preventable of all cancers.
MEMORIZE MEMORIZE MEMORIZE
Tonometry: normal (10-21 mm Hg)
PR Interval: normal (0.12-0.20 seconds)
Serum Amylase: normal (25-151 units/dL)
Serum Ammonia: normal (35 to 65 mcg/dL)
Calcium: adult (8.6-10 mg/dL)
child (8 to 10.5 mg/dL)
term<1week (7 to 12 mg/dL)
Partial Thromboplastin Time (aPTT): normal (20-36 seconds) therapeutic 1.5-2.5
Prothrombin Time: normal (Male: 9.6-11.8 seconds) and
(Female: 9.5-11.3 seconds)
Platelet Count: normal (150,000-400,000 cells/uL)
Albumin level: normal (3.4 to 5 g/dL)
Serum Osmolality: normal (285 to 295 mOsm/kg)
high value indicates dehydration
Safe Suction Range: normal [Infant] 50-95 mm Hg
[Child] 95-115 mm Hg
[Adult]100-120 mm Hg)
Serum Lithium: normal (1 to 1.5 mEq/L)
acute mania (0.6 to 1.4 mEq/L) maintenance treatment
Phenytoin (Dilantin): normal serum (10 to 20 mcg/mL)
Digoxin: therapeutic blood level (0.8 to 2.0 ng/ml)
Magnesium Sulfate: Therapeutic Range (4 to 8 mg/dl)
Pregnancy Temperature: normal (36.2-37.6 celcius or 98-99.6 Farenheit)
WBC’s In Pregnancy: normal (11,000 to 15,000 cells/mm3, up to 18,000 cells/mm3). Immediate
postpartum period, (maybe as high as 25,000 to 30,000 cells/mm3)
Stomach Capacity:




Newborn infant (10 to 20 mL)
1-week-old (30 to 60 mL)
2-3-week-old infant (75 to 100 mL)
1-month-old infant (90 to 150 mL)
Left Atrial Pressure: normal (1 to 10 mm Hg)
Fibrinogen Levels: normal (male: 180 to 340 mg/dL) and
(female: 190 to 420 mg/dL)
with Disseminated Intravascular Coagulation the fibrinogen level drops because fibrinogen is
used up in the clotting process.
Insulin
Insulin
Insulin
Insulin
(Regular, Humulin R)
(NPH, Humulin N)
(Ultralente, Humulin U)
(Humulin 70/30)
Type: Fast acting
Type: Intermediate acting
Type: Slow acting
Type: Combination
Onset: ½ -1 hr
Onset: 2hr
Onset: 4hr
Onset: ½ hr
Peak: 2-4 hr
Peak: 6-12hr
Peak: 8-20hr
Peak: 2-12hr
Duration: 6-8 hr
Duration 18-26hr
Duration: 24-36hr
Duration: 24hr
Central Venous Pressure: < 3 mm Hg = inadequate fluid and >11 mm Hg = too much fluid
Potassium: 3.5-5.0 mEq/L
Sodium: 135-145 mEq/L
Calcium: 4.5-5.2 mEq/L or 8.6-10 mg/dL
Magnesium: 1.5-2.5 mEq/L
Chloride: 96-107 mEq/L
Phosphorus: 2.7 to 4.5 mg/dL
PR measurements: normal (0.12 to 0.20 second)
QRS measurements: normal (0.04 to 0.10 second)
Ammonia: 35 to 65 ug/dL
Amylase:25 to 151 IV/L
Lipase: 10 to 140 U/L
Cholesterol: 140 to 199 mg/dL
LDL: <130 mg/dL
HDL: 30 to 70 mg/dL
Triglycerides: <200 mg/dL
Bilriubin



Direct: 0 to 0.3 mg/dL
Indirect: 0.1 to 1.0 mg/dL
Total: <1.5 mg/dL
Protein: 6.0 to 8.0 g/dL
Uric acid: Male 4.5 to 8 mg/dL
Female 2.5 to 6.3 mg/dL
Glycosylated Hemoglobin HbA1c: good control 7.5% or less
Serum creatinine: 0.6 to 1.3 mg/dL
BUN: 9-25 mg/dL
Normal CK is 26-174 U/L
Troponin I value: normal (<0.6 ng/mL)
Troponin T >0.1 to 0.2 ng/mL = MI
Erythrocyte studies: 0-30 mm/hour
Serum iron: Male 65-175 ug/dL
Female 50-170 ug/dL
RBC: Male 4.5 to 6.2 M/uL
Female 4.0 to 5.5 M/uL
Theophylline levels normal (10 to 20 mcg/dl)
MOTOR DEVELOPMENT
Chin up
1 month
Chest up
2 month
Knee push and “swim”
6 month
Sits alone/stands with help
7 month
Crawls on stomach
8 month
Stands holding on furniture
10 month
Walks when led
11 month
Stands alone
14 month
Walks alone
15 month
AT THE PLAY GROUND
* Stranger anxiety: 0 -1 year
* Separation anxiety: 1 - 3 years
* Solitary play: 0 – 1 year
* Parallel play: 2 – 3 years
* Group play: 3 – 4 years
PSYCHOLOGICAL DEVELOPMENT
AGE
ERIKSON
FREUD
PIAGET
Infant
Trust vs. mistrust
Oral (trust & dependence sensorimotor
Autonomy vs. shame
Anal (holding vs. letting
out)
preoperational
Initiative vs. guilt
Phallic
(Oedipus complex)
preoperational
Industry vs. inferiority
latency
Concrete operational
0 – 1.5
Toddler
1.5 -3
Pre-school
3-6
School age
6 - 11
11 - 20
Identity vs. role confusion genital
20 – 25
Intimacy vs. isolation
25 – 50
Generativity vs.
stagnation
50 - ?
Integrity vs.despair
LABORATORY VALUES
Formal operational
ELECTROLYTES
Sodium (Na+): 135 – 145 meq/L
(increase-dehydration; decrease overhydration)
Potassium (K+): 3.5 - 5.0 meq/L
Magnesium (Mg++): 1.5 – 2.5 meq/L
Calcium (Ca++): 4.5 – 5.8 meq/L
Neonate : 7.0 to 12 mg/dL
Child: 8.0 to 10.5 mg/dL
Phosphorus (PO4): 1.7 – 2.6 meq/L
Chloride (Cl-): 96 – 106 meq/L
COAGULATION STUDIES
Activated partial thromboplastin time(APTT): 20 – 36 seconds depending on the type of activator
used
Prothrombin time(PT): male: 9.6 – 11.8 seconds
Female: 9.5 – 11.3 seconds
International Normalized Ratio(INR): 2.0 - 3.0 for standard Coumadin therapy
3.0 – 4.5 for high-dose Coumadin therapy
Clotting time: 8 – 15 minutes
Platelet count: 150,000 to 400,000 cells/Ul
Bleeding time: 2.5 to 8 minutes
SERUM GASTROINTESTINAL STUDIES
Albumin: 3.4 to 5 g/dL
Alkaline phosphatase: 4.5 to 13 King-Armstrong units/dL
Ammonia: 15 to 45 ug/dL
Amylase: 50 – 180 Somogyi U/dL in adult
20 – 160 Somogyi U/dL in the older adult
Bilirubin: direct: 0 - 0.3 mg/dL
Indirect: 0.1 – 1.0 mg/dL
Total: less than 1.5 mg/dL
Cholesterol: 120 – 200mg/dL
Lipase: 31 -186 U/L
Lipids: 400 – 800 mg/dL
Triclycerides: Normal range: 10 – 190 mg/dL
Borderline high: 200 – 400 mg/dL
High: 400 – 1000mg/dL
Very high: greater than 1000mg.dL
Protien: 6.0 – 8.0 g/L
Uric acid: male: 4.5 – 8 ng/dL
Female: 2.5 – 6.2 ng/dL
GLUCOSE STUDIES
Fasting blood sugar: 70 – 105 mg/dL
Glucose monitoring (capillary Blood): 60 – 110 mg/dL
RENAL FUNCTION TEST
Creatinine: 0.6 – 1.3 mg/dL
Blood urea nitrogen (BUN): 5 – 20 mg/dL
ERYTROCYTES STUDIES
Erytrocyte sedimentation rate(ESR): 0 – 30 mm/hr depending on age
Hemoglobin: male: 14 – 16.5 g/dL
Female: 12 – 15 g/dL
Hematocrit: male: 42% - 52% (increased in hemoconcentration, fluid loss and dehydration)
Female: 35% - 47% ( decreased in fluid retention)
Red blood cell (RBC): male: 4.5 to 6.2 million/uL
Female: 4 to 5.5 million/uL
White blood cell (WBC): 4500 to 11,000/uL
Erytrocyte Protoporthyrin (EP) : <9ug/dL
Phenylalanine Level: <2 mg/dL
PKU: >25 mg/dL
CRANIAL NERVES
MAJOR FUNCTIONS
I. Olfactory (S)
smell
II. Optic (S)
vision
III.
IV.
Oculomotor (M)
Trochlear (M)
V. Trigeminal (S-M)
Eye movement
Facial sensation
Jaw movement
VI. Abducent (M)
Eye movement
VII. Facial (S-M)
Taste
Facial expression
VIII. Acoustic (S)
Hearing and balance
IX. Glossopharyngeal (S-M)
Taste
Throat sensation
Gag and swallow
X. Vagus (S-M)
Gag and swallow
Parasympathetic activity
XI. Spinal Accessory (M)
Neck and back muscles
XII. Hypoglossal (M)
Tongue movement
On Old Olympus’ Towering Tops, A Finn And German Viewed Some Hops
Some Says Marry Money, But My Brother Says Bad Business Marry Money
ARTERIAL BLOOD GAS (ABG)
pH: 7.35 – 7.45
PCO2: 35 - 45 mmHg
PO2: 80 - 100 mmHg
HCO3: 22 - 27 mEq/L
O2 saturation: 96% - 100%
Acid-base “RAMS”(Respiratory Alternate, Metabolic Same)
GLASGOW COMA SCALE
Eye opening response
Motor response
Verbal response
AUTONOMIC NERVOUS SYSTEM
SYMPATHETIC/
PARASYMPATHETIC/
ADRENERGIC
CHOLINERGIC
Heart
Increased heart rate
Decreased heart rate
Increased conduction
Increased force
Bronchi
dilation
constriction
GI tract
Reduced motility
Increased motility
Rectum
Allows filling
Empties rectum
Relaxes internal sphincter
Bladder
Allows filling
Empties bladder
Relaxes internal sphincter
Erection
Maintains erection
Ejaculation
Triggers ejaculation
Pupils of eye
Big (mydriasis)
Salivary glands
Blood vessels
Small (miosis)
Secretion
Depends on receptors
-a contrict
-b dilates
FLOW OF BLOOD THROUGH THE HEART
Inferior vena cava and superior vena cava – right atrium – tricuspid valve – right ventricle –
pulmonic valve – pulmonary artery – lungs – pulmonary veins – left atrium – bicuspid valve
(mitral) – left ventricle – aortic valve aorta – systemic circulation
CARDIAC IMPULSES
Sinoatrial (SA) node – right and left atria (atria contract) – atrioventricular (AV) node – bundle his
– bundle brabches – purjinje’s fibers – ventricles contract.
Blood volume: 5000mL
Central venous pressure: 4 to 10 cmH2O (increased in cardiac overload; decreased in
dehydration)
Pressure within the right atrium: 2 to 7 mmHg
Capillary refill time: <3 seconds
Normal sweat chloride: <40 mEq/L
Normal pupil diameter: 3 to 5mm
Normal ocular pressure: 10 to 21 mmHg
Normal Pulmonary capillary wedge pressure (PCWP): 8 to 13 mmhg
Normal cardiac output : 4 to 8 L/min.
THERAPEUTIC SERUM MEDICATION LEVELS
Acetaminopen (Tylenol) 10 – 20 ug/mL
Amikacin (Amikin) 25 – 30 ug/mL
Amitryptyline (Elavil) 120 -150 ng/mL
Carbamazepine (Tegretol) 5 -12 ug/mL
Chloramphenicol (Chloromycetin) 10 – 20 ug/mL
Desipramine (Norpramin) 150 -300 ng/mL
Digotoxin ( Crystodigin) 15- 25 ng/mL
Digoxin ( Lanoxin) 0.5 – 2.0 ng/mL
Disopyramide (Norpase) 2 -5 ug/mL
Ethosuximide ( Zarontin) 40 – 100 ug/mL
Gentamycin (Garamycin) 5 – 10 ug/mL
Imipramide (Tofranil) 150 – 300 ug/mL
Lidocaine (Xylocaine) 1.5 – 5.0 ug/mL
Lithium (Lithobid) 0.5 -1.5 ug/mL
Magnesium sulphate 4 -7 mg/dL
Nortriptyline (Aventyl) 50 – 150 ng/mL
Phenobarbital (Luminal) 10 – 30 ug/mL
Phenytoin (Dilantin) 10 -20 ug/mL
Primidone (Myoline) 5 – 20 ug/mL
Procainamide (Pronestryl) 4 – 10 ug/mL
Propranolol (Inderal) 50 – 100 ng/mL
Quinidine (Quinalaglute, Cardioquin) 2 – 5ug/mL
Salisylate 100 -250 ug/mL
Theophylline (Aminiphylline, Theo-Dur) 10 -20 ug/mL
Tobramycin (Nebcin ) 5 -10 ug/mL
Valproic acid (depakene) 50 -100 ug/mL
Pulmonary capillary wedge pressure: 5 to 13 mmHg
Pulmonary artery pressure: systolic: 16 to 30 mmHg
Diastolic: 0 to 7 mmHg
Spinal pressure: 70 to 200mmH2O
Morphine sulphate pediatric dose: 0.1mg/kg every 3 – 4 hour
SULFONYLUREAS
For treatment of NIDDM


Sulfonylureas should not be given to patients with liver or kidney failure.
Accummulation of drug will increase risk of hypoglycaemia.
DURATION
tolbutamide
8h
Glycburide, glipizide
20 h, most potent
chlorpropamide
48 h
Apothecary and Household System
Grain –gr 1 gr = 60 mg
Dram – dr 5 gr = 300 mg
Ounce –oz 15 gr = 1000mg or 1g
Minim – min, M, m 1/150 gr =0.4 mg
Quart – qt 1 oz = 30 mL
Pint – pt 1 dr = 4 mL
Drop – gtt 1 T = 15 mL or 3 tsp
Tablespoon – T or tbs 1 min = 1 gtt
Teaspoon – t or tsp 15 min = 1mL
Pound – lb 60 min = 1 dr
8 dr = 1 oz
1 qt = 1000mL or 1L
1 qt = 2 pt or 32 oz
1 pt = 16 oz
16 oz = 1 lb
2.2lb = 1 kg
Fahrenheit to Celcius (F – 32) divide 1.8 = C
Celcius to Fahrenheit 1.8 C + 32 = F
Formula for Calculating a Medication Dosage
D (desired ) = the dosage that the physician ordered
A (available) =the dosage strength as stated on the medication label
Q (quantity ) = the volume that the dosage strength is available in, such as tablet, capsules, or
mL
DXQ=X
A
Formulas for Intravenous Calculations
Flow Rates:
Total volume x gtt factor = gtt per min
Time in minutes
Infusion Time:
Total volume to infuse = Infusion time
mL per hour being infused
IMMUNIZATION
Birth Hepatitis B
1 months Hepatitis B
2 months OPV, DPT, HIB
4 months DPT, HIB, OPV
6 months DPT, HIB, hepatitis B
12 months HIB, OPV
15 months MMR
18 months DPT
12 – 18 months Varicella vaccine
4 -6 years DPT, OPV, MMR
11 – 12 years MMR ( if not administered at 4 -6 years)
11 – 16 TD booster
SPINAL CORD INJURY
Cervical Injury:




C2 to C3 injury usually fatal
C4 is the major innervation to the diaphragm by th phrenic nerve
Involvement above th C4 causes respiratory difficulty and paralysis of all the four
extremities
C5 or below client may have movement in the shoulder
Thoracic Level Injury:

loss of movement of the chest, trunk, bowel, bladder, and legs, depending on the level of
injury



Leg paralysis (paraplegia)
Autonomic dysreflexia with lesions above T6 and in cervical lesions
Visceral distention from a distended bladder or impacted rectum may cause reactions
such as sweating, bradycardia, hypertension, nasal stuffiness, and gooseflesh
Lumbar and Sacral Level Injuries:




loss of movement and sensation of the lower extremities.
S2 and S3 center on micturation; therefore below this level, the bladder will contract but
not empty (neurogenic bladder)
Injury above S2 in males allows them to have an erection, but they are unable to
ejaculate because of sympathetic nerve damage.
Injury between S2 and S4 damages the sympathetic and parasympathetic response,
preventing erection and ejaculation.
RULE OF NINE
Head and neck 9%
Anterior trunk 18%
Posterior trunk 18%
Arms (9%) 18%
Legs (18%) 36%
Perineum 1%
NORMAL ADULT WHITE BLOOD CELL DIFFERENTIAL
Neutrophils 56% or 18000 – 7800/uL
Bands 3% or 0 – 700/uL
Eosinophils 2.7% or 0 – 450/uL
Basophils 0.3% or 0 – 200/uL
Lymphocytes 34% or 1000 – 4800/uL
Monocytes 4% or 0 – 800/uL
THYROID STUDIES
Thyroid –stimulating hormone (thyrotropin; THS): 0.2 to 5.4 ug/dL
Thyroxine (T4): 5.0 to 12.0 ug/dL
Thyroxine free (FT3) : 0.8 to 2.4 ng/dL
Triiodothyronine (T3): 80 to 230 ng/dL
Normal Fribrinogen level: for men: 180 to 340mg/dL
Women: 190 to 420mg/dL
Fribrinogen is used up in the clotting process.
Erythrocyte Protoporhyrin (EP): < 9ug/dL
Phenylalanine level: < 2mg/dL
PKU: >25 mg/dL
Urine specific gravity: 1.016 - 1.022 increase in SIADH; decrease in diabetes insipidus
Normal CSF protein: 15 – 45 mg/dL increase in Guillain-Barre syndrome
Normal CSF pressure: 5 – 15 mmHg
Normal serum osmolality: 285 – 295 mOsmlkgH2O increase in dehydration;
Decrease in over hydration
Normal scalp pH: 7.26 and above
Borderline acidosis: 7.20 to 7.25
Acidosis: < 7.15
HERBAL MEDICINE
Aloe vera Gel – abrasionsand dermatologic conditions
American Ginseng (Panax quinquefolius) – boost energy, relieve stress, improve concentration
and enhance physical or cognitive performance.
Ashwagandha (Withania somnifera) – stress arthritis
Asian gingseng (Panax ginseng) – enhance health and combat stress and disease
Bilberry (Vaccinium myrtillus) – vision and peripheral vascular disorders and as antioxidant
Black Cohosh (Cimicifuga racemosa) – menopausal
Black Currant and Borage oil (Ribes nigrum and Borago offinalis) – anti-inflammatory,
rheumatoid arthritis
Capsicum Peppers (Capsicum spp.) – arthritis, neuralgia and other painful treatment
Chamomile (Matricaria recutita) “manzanilla”- skin inflammation, colic, or dyspepsia and anxiety
Chaste tree (Vitex agnus-castus) – menstrual related disorders, PMS, cyclical mastalgia
Chodroitin – osteoarthritis
Coenzyme Q10 – antioxidant
Coltsfoot ( Tussilago farfara ) – cough and other respiratory disoders
Cranberry (Vaccinium macrocarpon) – UTI
Devil’s Claw ( Harpagophytum procumbers) – anti inflammatory and analgesic
Echinacea (Echinacea spp.) – acute viral URI symptoms
Ederberry (Sanbacus nigra) – respiratory tract infection
Ephedra or Ma Huang (Ephedra sinica) Source of ephedrine and pseudoephedrine
Evening Primrose Oil (Oenothera biennis) – eczema, breast pain associated with PMS and
inflammatory condition
Fenugreek (Trigonella foenum-graecum) – lowering blood glucose
Feverfew ( Tanacetum parthenium) – migraine headache prophylaxis
Garlic (Allium sativaum)- help prevent cardiovascular disease and cancer
Ginger (Zingiber officinale) –nausea and motion sickness, anti-inflammatory
Ginkgo (Ginkgo biloba) – dementia and intermittent claudication, memory enhancement and
treatment of vertigo nad tinnitus
Glucosamine – osteoarthritis
Goldenseal ( Hydrastis Canadensis) – tonic and antibiotic
Gotu Kola (Centella asiatica) – mental support, wound healing and venous disorders
Hawtorn ( Crategus species) – CHF and related cardiovascular conditions
Horebound (Marribium vulgare) – primary cough suppression and expectoration
Horse Chestnut Seed (Aesculus hippocastanum) chronic venous insufficiency
Ivy (Hedera helix) – coughs, rheumatic disordes and skin disease
Kava ( piper methysticum) – mild psychoactive and antianxiety property
Lemon Balm (Melissa officinalis) – sedative and for dyspepsia
Licorice (Glycyrrhiza glabra) – respiratory disorders, hepatitis, inflammatory diseases, and
infections
Melatonin – insomia, jet lag
Milk Thistle – hepatitis, liver desease
Mints (Mentha species) – minor calcium channel antagonists, used for upper respiratory
problems, irritable bowel syndrome, dyspepsia, and colonic spasm and as a topical counterirritant
Nettle (Urtica dioica) – arthritis pains, allergies, BPH, or as diuretic
Papaya (Carica papaya) – digestive aid, dyspepsia, and for inflammatory, topically applied to
wounds
Passion flower (Passiflora incarnata)- sedative-hypnotic or anxiolytic herb
Pokeroot (Phytolacca Americana) – inflammatory conditions also as an emetic/cathartic
Pygeum (Pygeum africanum) – mild symptoms of BPH
Red Clover (Trifolium pratense) – used as a natural estrogen substitute for women’s health
St. John’s Wort (Hypericum perforatum) – antidepressant effect
Tea Tree Oil (Melaleuca alternifolia) – antifungal and antibacterial
Turmeric (Curuma longa ) – anti-inflammatory, anti-arthritis, anti cancer, and antioxidant
Uva Ursi (Arctostaphylos uva ursi) – urinary antiseptic and diuretic
Yohimbe – erectile dysfunction
FOUR STRATEGIES:
1. If the question asks what you should do in the situation. Use the nursing process to
determine which step in the nursing process would be next?
2. If the question asks what the client needs. Use maslow’s hierarchy to determine which
need to address.
3. If the question indicates that the client doesn’t have urgent physiologic need, focus on the
patient safety.
4. If the question involves communicating with a patient. Use principles of therapeutic
communication.
REMEMBER:
AIRWAY, BREATHING,CIRCULATION AND SAFETY (ABCS)
The nurse in primary care clinic is caring for a 50-year-old woman. History reveals that she had
experienced on and off chest pain. After series of cardiac tests (EKG & Blood Chem), the doctor
orders for THALLIUM STRESS TEST. Which of the following medications should the RN prepare
if the patient needs an alternative exercise in thallium test?
1.Nitroglycerin
2.Morphine
3.Aminophylline
4.Persantin
The correct answer is #4. Persantin (dipyridamole)
Persantin is use as an alternative to exercise in thallium myocardial perfusion imaging for the
evaluation of CAD in those who cannot exercise adequately.
Purpose: to determine myocardial wall viability
Other names:
1. Cardiac pooling
2. MUGA-multigated radionuclide angiographic scanning
3. nurclear scan
4. sestamibi test
5. thallium scan
6. dipyridamole or persantin stress test
7. In short, heart scan :)
Loving NCLEX-RN
URC
09178364589
Posted by Anaski from IP 203.131.183.186 on August 23, 2005 at 21:44:00:
For Future USRN's:
Cervical Cancer
Etiology:
* Early age of sexual intercourse
* Multiple sexual partners
* Sexually Transmitted Disease (Venereal Wart)
* Virus - HPV
Cancer Carcinoma in SITU - only in epithelial linings
Situ sounds like Ziru - Stage 0
Tumor marker - CEA
Signs and Symptoms (3 P's)
POST COITAL BLEEDING
PAINFUL INTERCOURSE
PROFUSE (PERIOD IRREGULARITIEs - menorrhagia and metrorrhagia)
Management:
U - pera (Surgery HYSTERECTOMY)
R - radiation (intracavitary cessium - remember STD - shielding, timing and distance))
C - chemotherapy to destroy the DNA,RNA & CHON synthesis.
MIKE’S NOTES (60 pp.)
O universal donor/AB universal recipient.
ABO BLOOD TYPE
COMPATIBILITY
Blood Type
Can Receive from:
Can donate to:
O
O
O,A,B,AB
A
A,O
A,AB
B
B,O
B,AB
AB
O,A,B,AB
AB
Autologous Transfusion:


Collected 4-6 weeks before surgery
Contraindicated—infection, chronic disease, cerebrovascular or cardiovascular
disease
Hypotonic Solution

Saline)
½ NS (0.45% 



Isotonic Solution
Hypertonic Solution
0.9% NaCl (Normal Saline)

5% D/W (Dextrose in Water)

Lactated Ringer’s

5% D/ ¼ NS (5% Dextrose in 0.225%
Saline )

10% D/W (10% Dextrose in water)
D15W
5% D/NS (5% Dextrose in 0.9%
Saline)
5% D/ ½ NS (5% Dextrose in 0.45
Saline)


Change tubing Q72 hours
Change bottle Q24 hours
Infiltration

Assessment: cool skin, swelling, pain, decrease in flow rate
3% NaCl
5% Sodium Bicarbonate

Implementation: discontinue IV, warm compresses, elevate arm, start new site proximal
to infiltrated site
IV Phlebitis, Thrmobophlebitis


Assessment—redness, warm, tender, swelling, leukocytosis
Implementation—discontinue IV, warm moist compresses, start IV in opposite extremity
Hematoma


Assessment—ecchymosis, swelling, leakage of blood
Implementation—discontinue IV, apply pressure, ice bag 24 hours, restart IV in opposite
extremity
IV Clotting


Assessment—decreased flow rate, back flow of blood into tubing
Implementation—discontinue, do not irrigate, do not milk, do not increase rate of flow or
hang solution higher, do not aspirate cannula, inject Urokinase, D/C and start on other site.
Insertion of Percutaneous Central Catheters:







Placed supine in head-low position
Turn head away from procedure
Perform Valsalva maneuver
Antibiotic ointment and transparent sterile dressing
Verify position with x-ray
Change tubing Q24 hours
Nurse/patient both wear mask when dressing change 2-3x/week
Adrenergics


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
Actions:



Adrenergic Medications
Levophed
Dopamine
Adrenalin
Dobutrex
Adrenergics Side effects:



Dysrhythmias
Tremors
Anticholinergic effects
Adrenergics Nursing
Considerations:



Monitor BP
Monitor peripheral pulses
Check output
COPD

Anti-Anxiety
Anti-Anxiety
Anti-Anxiety
Action:
Medications:
Side effects:
Affect neurotransmitters
Used for:

Librium, Xanax,

Ativan, Vistaril, Equanil


Anxiety disorders, manic
episodes, panic attacks
Sedation
Confusion
Hepatic dysfunction
Anti-Anxiety
Nursing Considerations:





Antacids

Used for:


Antacids Medications


Neutralize gastric acids 
Actions:
Potention for addiction/overdose
Avoid alcohol
Monitor Liver Function AST/ALT
Don’t discontinue abruptly, wean off
Smoking/caffeine decreases
effectiveness
Antacids
Amphojel
Milk of Magnesia

Maalox


Peptic ulcer
Indigestion, reflex
esophagitis
Constipation
Diarrhea
Acid rebound
Antacids
Nursing Considerations:





Antiarrhythmics
Side effects:
Antiarrhythmics
Interferes with absorption of antibiotics,
iron preps, INH, Oral contraceptives
Monitor bowel function
Give 1-2 hours after other medications
1-3 hours after meals and at HS
Take with fluids
Antiarrhythmics
Action:




Medications:
Interfere with electrical

excitability of heart


Used for:


Atrial fibrillation and
flutter
Tachycardia
PVCs
Aminoglycosides
(Antibiotics)
Side effects:
Atropine sulfate
Lidocaine
Pronestyl
Quinidine
Isuprel



Lightheadedness
Hypotension
Urinary retention
Antiarrhythmics
Nursing Considerations:


Aminoglycosides
(Antibiotics)
Monitor vital signs
Monitor cardiac rhythm
Aminoglycosides (Antibiotics)
Side effects:
Action:

Medications:
Inhibits protein 
synthesis in gram-negative

bacteria


Used for:

Gentamycin
Neomycin 
Streptomycin
Tobramycin 
Ototoxicity and Nephrotoxicity
Anorexia
Nausea
Vomiting
Diarrhea
Aminoglycosides (Antibiotics)

Pseudomonas,
Nursing Considerations:
E.Coli






Cephalosporins
(Antibiotics)
Cephalosporins
(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:
Action:

Inhibits synthesis of

bacterial cell wall



Medications:

Ceclor 
Ancef 
Keflex
Rocephin
Bone marrow depression: caution with anemic, and low PLT
Superinfections
Rash
Used for:



Cefoxitin




Tonsillitis, otitis
media, peri-operative
prophylaxis
Meningitis

Fluoroquinolones
(Antibiotics)
Nursing Considerations:
Take with food
Cross allergy with PCN
Avoid alcohol
Obtain C&S before first dose: to make sure medication is
effective against disease/bacteria
Can cause false-positive for proteinuria/glycosuria
Fluoroquinolones
Fluroquinolones
(Antibiotics)
(Antibiotics)
Medications:
Side effects:
Action:

Interferes with DNA
replication in gram-negative 
bacteria
Cipro
Used for:





Diarrhea
Decreased WBC and Hematocrit
Elevated liver enzymes (AST, ALT)
Elevated alkaline phosphatase
E.Coli, Pseudomonas,
S. Aureus
Nursing Considerations:



C&S before starting therapy
Encourage fluids
Take 1 hour ac or 2 hour pc (food slows
absorption)
Don’t give with antacids or iron preparation
Maybe given with other medications (Probe
for gout)



Macrolide (Antibiotics)
Macrolide (Antibiotics)
Macrolide (Antibiotics)
Action:
Medications:
Side effects:
Binds to cell membrane 
and changes protein function 
Used for:




Acute infections
Acne
URI
Prophylaxis before dental
Erythromycin
Clindamycin




Diarrhea
Confusion
Hepatotoxicity
Superinfections
Nursing Considerations:



Take 1hr ac or 2-3 hr pc
Monitor liver function
Take with water (no fruit juice)

procedures if allergic to PCN

Penicillin
Penicillin
Penicillin
Action:
Medications:
Side effects:
Inhibits synthesis of cell



Used for:




Moderate to severe
infections
Syphilis
Gonococcal infections
Lyme disease
Stomatitis
Diarrhea
Allergic reactions
Renal and Hepatic changes
Nursing Considerations:



Check for hypersensitivity
Give 1-2 hr ac or 2-3 hr pc
Cross allergy with
cephalosporins
Sulfonamides (Antibiotics)
Sulfonamides (Antibiotics)
Sulfonamides (Antibiotics)
Action:
Medications:
Side effects:
Antagonize essential component

of folic acid synthesis


Used for:










Amoxicillin
Ampicillin
Augmentin
wall

May increase effectiveness of: Coumadin
and Theophylline (bronchodilator)
Gantrisin
Bactrim
Septra
Azulfidine
Ulcerative colitis
Crohn’s disease
Otitis media
UTIs





Peripheral Neuropathy
Crystalluria
Photosensitivity
GI upset
Stomatitis
Nursing Considerations:




Take with meals or foods
Encourage fluids
Good mouth care
Antacids will interfere with absorptio
Tetracyclines
TEtracyclines
Tetracyclines (Antibiotics)
(Antibiotics)
(Antibiotics)
Side effects:
Action:
Medications:
Inhibits protein


Vibramycin 
Discoloration of primary teeth if taken during pregnancy
child takes at young age
Glossitis

sythesis
Panmycin 

Rash
Phototoxic reactions
Used for:
Nursing considerations:



Infections
Acne
Prophylaxis for
opthalmia neonatorum





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

o

o

o
o

o
o
Medication:
Furadantin
Action:
Anti-infective
Side effects:
Asthma attacks
Diarrhea
Nursing Considerations:
Give with food or milk
Monitor pulmonary status
UTIs

o

o

o

o
o
Medication
Mandelamine
Action:
Anti-infective
Side effects:
Elevated liver enzymes
Nursing Considerations:
Give with cranberry juice to acidify urine
Limit alkaline foods: vegetables, milk, almonds, coconut
UTIs

o

o
o
Medication
Pyridium
Side effects:
Headache
Vertigo

o

o
Action
Urinary tract analgesic
Nursing Consideration
Tell patient urine will be orange
Anticholinergics
Anticholinergic
Medications:
Anticholinergic
Action:



Side Effects:

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
Pro-Banthine

Atropine
Scopolamine


Nursing Consideration:




Used for:




Opthalmic exam
Motion sickness
Pre-operative
Monitor output
Contraindicated with glaucoma
Give 30 min ac, hs, or 2hr pc
Contraindicated: paralytic ileus,
BPH
Anticoagulants
Anticoagulants
Anticoagulants (Heparin)
Action:
Medications:
Side Effects:
Blocks conversion of
prothrombin to thrombin

Heparin 

Used for:




Blurred vision
Dry mouth
Urinary retention
Chage in heart rate
Pulmonary embolism
Venous thrombosis
Prophylaxis after acute MI
Hematuria
Tissue irritation
Nursing Considerations:





Monitor clotting time or Partial
Thromboplastin Time (PTT)
Normal 20-45 sec
Therapeutic level 1.5-2.5 times control
Antagonist—Protamine Sulfate
Give SC or IV
Anticoagulant
Anticoagulant
Anticoagulant (Coumadin)
Action:
Medication:
Side Effects:
Interferes with synthesis of 
Coumadin 
Hemorrhage, Alopecia
Nursing Considerations:
vitamin K-dependent clotting factors






Used for:





Pulmonary embolism
Venous thrombosis
Prophylaxis after acute MI
Anticonvulsants
Anticonvulsant
Anticonvulsant
Action:
Medications:
Side effects:
Decreases flow of calcium and

sodium across neuronal membranes 

Used for:


Seizures
Dilantin 
Luminal 
Depakote

Tegretol 
Klonopin



Anti-Depressants
Monoamine Oxidase
Inhibitors (MAO)
Action:


Causes increases

concentration of

neurotransmitters

Used for:
Depression
Chronic pain
Respiratory depression
Aplastic anemia
Gingival hypertrophy
Ataxia
Nursing Considerations:




Monitor Prothrombin Test (PT)
Normal 9-12 sec
Therapeutic level 1.5 times control
Antagonist—Vitamin K (AquaMEPHYTON)
Monitor for bleeding
Give PO
Anti-Depressants
Don’t discontinue abruptly
Monitor I&O
Caution with use of medications that lower
seizure threshold: MAO inhibitors & anti-psychotics
Good mouth care
Take with food
May turn urine pinkish-red/pinkish-brown
Anti-Depressants
(Monoamine Oxidase (Monoamine Oxidase Inhibitors)
Inhibitors)
Side effects:
Medications:

Hypertensive Crisis (Sudden headache, diaphoretic,
Marplan
palpitations, stiff neck, intracranial hemorrhage) with food that
Nardil
contain Tyramine
Parnate
Nursing Considerations:


Avoid foods containing Tyramine: Aged cheese, liver,
yogurt, herring, beer and wine, sour cream, bologna, pepperoni,
salami, bananas, raisins, and pickled products
Monitor output


Takes 4 weeks to work
Don’t combine with sympathomometics vasoconstrictors
and cold medications
Anti-Depressants
Anti-Depressants
Anti-Depressants
Selective Serontonin Reuptake
Inhibitors (SSRI)
Selective Serontonin
Reuptake Inhibitors
(SSRI)
Selective Serontonin Reuptake Inhibitors (SSRI)
Side effects:
Action:
Medications:

Inhibits CNS uptake of
serotonin
Used for:



Paxil
Prozac
Zoloft




Anxiety
GI upset
Change in appetite and bowel function
Urinary retention
Nursing Considerations:




Depression
Obsessive-Compulsive
Disorder
Bulimia





Suicide precautions
Takes 4 weeks for full effect
Take in a.m.
May urine to pinkish-red or Pinkish-brown
Can be taken with meals
Anti-Depressants (Tricyclics)
Anti-Depressants (Tricyclics)
Anti-Depressants (Tricyclics)
Action:
Medications:
Side Effects:
Inhibits reuptake of
neurotransmitters







Norpramin
Elavil
Tofranil
Used for:


Depression
Sleep apnea
Sedation/Confusion
Anticholinergics affects
Postural Hypotension
Urinary retention
Nursing Considerations:



Suicide precautions/2-6 weeks to work
Take at hs/Don’t abruptly halt
Avoid alcohol/OTC /Photosensitivity
Insulin
Insulin
Insulin
Insulin
(Regular, Humulin R)
(NPH, Humulin N)
(Ultralente, Humulin U)
(Humulin 70/30)

Type: Fast acting
Type: Intermediate acting
Type: Slow acting
Type: Combination
Onset: ½ -1 hr
Onset: 2hr
Onset: 4hr
Onset: ½ hr
Peak: 2-4 hr
Peak: 6-12hr
Peak: 8-20hr
Peak: 2-12hr
Duration: 6-8 hr
Duration 18-26hr
Duration: 24-36hr
Duration: 24hr
Antidiabetic Agents
Antidiabetic Agents
Antidiabetic Agents
Action:
Medications:
Side Effects:
Stimulates insulin release from

beta cells in pancreas


Used for:




Diabinese
Orinase
Dymelor
Micronase
Hypoglycemia
Allergic skin reactions
GI upset
Nursing Considerations:

Type 2 diabetes (NIDDM)




Take before breakfast
Monitor glucose levels
Avoid alcohol,
sulfonamides, Oral
Contraceptives, (MAO), aspirin
because they help to make drug
work better
Hypoglycemic Agent
Hypoglycemic Agent
Hypoglycemic Agent
Action:
Medication:
Side Effects:
Stimulates liver to 
change glycogen to glucose
Glucagon


Used for:

Hypotension
Bronchospasm
Nursing Considerations:


Hypoglycemia
May repeat in 15min
Give carbohydrates
orally to prevent secondary
hypoglycemic reactions
Antidiarrheals
Antidiarrheals
Antidiarrheals
Action:
Medications:
Side Effects:


Slows peristalsis
Increases tone of
sphincters






Kaopectate
Lomotil
Imodium
Paregoric
Used for:

Nursing Considerations:

Diarrhea






Do not use with
abdominal pain
Monitor for urinary
retention
Give 2hr before or 3 hr
after other meds
Antiemetics
Antiemetics
Antiemetics
Action:
Medications:
Side Effects:
Increases GI motility

Blocks effect of dopamine

in chemoreceptor trigger zone 

Used for:


Vomiting
Tigan

Compazine 
Torecan
Reglan
Antivert
Dramamine 

Sedation
Anticholinergic effects
Nursing Considerations:
Used before chemotherapy
When used with viral infections
may cause Reye’s syndrome (Toxic
Encephalopathy)
Antifungals
Antifungals
Antifungals
Action:
Medications:
Side Effects:
Impairs cell
membrane


Amphotericin B
Nystatin
Used for:



Constipation
Anticholinergic effects
(urinary retention, dry mouth)
Candidiasis
Oral thrush
Histoplasmosis
Antigout Agents




Hepatotoxicity
Thrombocytopenia
Leukopenia
Pruritis
Nursing Considerations:



Antigout Agents
Give with food
Monitor liver function
Good oral hygiene
Antigout Agents
Action:

Medications:
Decreases production
and resorption of uric acid


Used for:
Side Effects:



Colchicine
Probenecid
Zyloprim
Agranulocytosis
GI upset
Renal calculi
Nursing Considerations:

Gout



Monitor for renal calculi
Give with food, milk,
antacids
Antihistamines
Antihistamines
Antihistamines
Action:
Medications:
Side Effects:
Block effects of
histamine



Chlor-Trimeton
Benadryl
Phenergan



Drowsiness
Dry mouth
Photosensitivity
Used for:
Nursing Considerations:


Allergic rhinitis
Allergic reactions to



blood

Give with food
Use sunscreen
Avoid alcohol
Antihyperlipidemic Agents
Antihyperlipidemic Agents
Antihyperlipidemic Agents
Action:
Medications:
Side Effects:
Inhibits cholesterol and

triglyceride synthesis

Questran
Lipid


Constipation
Fat-soluble vitamin
deficiency
Used For:
Nursing Considerations:


Elevated cholesterol
Reduce incidence of
cardiovascular disease
Antihypertensives


Antihypertensives
Take at hs or 30 min ac
Administer 1hr before or
4-6 hr after other meds
Antihypertensives
Types: ACE Inhibitors
(ACE Inhibitors)
(ACE Inhibitors)
Action:
Medications:
Side Effects:

Blocks ACE in lungs


Used for:


Hypertension
CHF
Capoten
Vasotec



GI upset
Orthostatic hypotension
Dizziness
Nursing Considerations:





Give 1hr ac or 3hr pc
Change position slowly
Antihypertensives
Antihypertensives
Type: Beta-Adrenergic Blockers
Type: Beta-Adrenergic Type: Beta-Adrenergic
Action:
Medications;
Blocks Beta-Adrenergic 
Receptors

Decrease

excitability/workload of heart, oxygen

consumption
Decrease
Antihypertensives
Side Effects:
Nadolol

Propranolol 
Tenormin 
Timoptic
Nursing Considerations:

Used for:



Hypertension
Angina
SVT
Changes in heart rate
Hypotension
Bronchospasm


Masks signs of shock and
hypoglycemia
Take with meals
Do not discontinue abruptly
Antihypertensives
Antihypertensives
Antihypertensives
Type: Calcium Channel Blockers
Type: Calcium Channel
Blockers
Type: Calcium Channel
Blockers
Medications:
Side Effects:
Action:



Inhibits movement of calcium across cell membranes
Slow impulse conduction and depresses myocardial
contractility
Causes dilation of coronary arteries and decreases



Procardia
Calan
Cardizem



Hypotension
Dizziness
GI distress
cardiac workload and energy consumption
Nursing Consideration:


Used for:




Angina
Hypertension
Interstitial cystitis
Monitor vital sig
Do not chew or
divide sustained-releas
tablets
Antihypertensives
Antihypertensives
Antihypertensives
Type: Centrally acting alphaadrenergics
Type: Centrally acting alphaadrenergics
Type: Centrally acting alphaadrenergics
Action:
Medications:
Side Effects:
Stimulates alpha

receptors in medulla which 
causes a reduction in
sympathetic in the heart


Aldomet
Catapres
Nursing Considerations:



Used for:

Hypertension
Antihypertensives
Antihypertensives



Relaxes smooth muscle
Don’t discontinue abruptly
Monitor for fluid retention
Change position slowly
Antihypertensives
Type: Direct-acting vasodilators Medications
Action:
Sedation
Orthostatic Hypotension
Side Effects:


Hydralazine
Minoxidil
Tachycardia
Increase in body hair
Nursing Considerations:
Used for:


Hypertension
pulse
Antihypertensives
Antihypertensives
Antihypertensives
Type: Peripheral-acting alpha-adrenergic blockers
Medications:
Side Effects:

Action:

Teach patient to check
Depletes stores of norepinephrine in
Reserpine


Depression
Orthostatic Hypotensio

sympathetic nerve endings
Used for:

Nursing Considerations:


Hypertension
Bipolar Disorder
Action:



Reduces catecholamine

Bipolar Disorder Medications:
Lithium (1-1.5meq/L)
Tegretol
Depakote
release
Used for:

Side Effects:




GI upset
Tremors
Polydipsia
Polyuria
Nursing Considerations:




Antineoplastic Agents
Antineoplastic Agents
Type: Alkylating Agents
Medications:
Side Effects:
Used for:


Monitor serum levels
Give with meals
Increase fluid intake
Antineoplastic Agents


Interferes with rapidly
reproducing DNA
Leukemia
Multiple myeloma
Give with meals or mil
Change position slowl
Bipolar Disorder
Manic episodes
Action:
Brachycardia
Cisplatin
Myleran
Cytoxan








Hepatotoxicity
Ecchymosis
Alopecia
Epitaxis
Infertility
Bone Marrow Suppression
Stomatitis
GI disturbances: Anorexic, N/V,
diarrhea
Nursing Considerations:



Check hematopoietic (reproduction of
RBC’s by bone marrow) function
Force fluids
Good mouth care
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Type: Antimetabolites
Antimetabolites
Medications:
Antimetabolites
Action:

Side Effects:
Inhibits DNA
polymerase



5-FU
Methotrexate
Hydrea
Used for:


Acute lymphatic
leukemia
Cancer of colon, breast,
pancreas





Nausea
Vomiting
Oral ulceration
Bone marrow suppression
Alopecia
Nursing Considerations:

Monitor hematopoietic
function



Good mouth care
Discuss body image
changes
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Type: Antitumor Antibiotics
Antitumor Antibiotics
Antitumor Antibiotics
Action:
Medications:
Side Effects:
Interferes with DNA and

RNA synthesis


Used for:
Adriamycin
Actinomycin D
Bleomycin



Bone marrow suppression
Alopecia
Stomatitis
Nursing Considerations:

Cancer


Monitor vital signs
Give antiemetic medications before
therapy

Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Type: Hormonal Agents
Type: Hormonal Agents
Type: Hormonal Agents
Action:
Medications:
Side Effects:
Changes hormone input


Diethylstilbestrol
Tamoxifen


Leukpenia
Bone pain
into sensitive cells

Testosterone

Used for:

Nursing Considerations:


Cancer
Antineoplastic Agents
Antineoplastic Agents
Type: Vinca Alkaloids
Type: Vinca Alkaloids
Type: Vinca Alkaloids
Action:
Medications:
Side Effects:
Interferes with cell
division


Oncovin
Velban
Used for:





Cancer
Stomatitis
Alopecia
Loss of reflexes
Bone marrow suppression
Nursing Considerations:




Check CBC
Monitor serum calcium
Antineoplastic Agents



Hypercalcemia
Give antiemetic before
administration
Check reflexes
Given with Zyloprim to
decrease uric acid
Antiparkinson Agents
Antiparkinson Agents
Antiparkinson Agents
Action:
Medications:
Side Effects:
Converted to Dopamine

Stimulates postsynaptic

Dopamine receptors


Used for:


Parkinson’s disease
Artane
Cogentin
L-Dopa
Parlodel
Sinemet
Symmetrel



Dizziness
Ataxia
Atropine-like effects: dry
mouth, urinary retention
Nursing Considerations:



Monitor for urinary retention
Large doses of vitamin B6
reverse effects
Avoid use of CNS
depressants

Antiplatelet Agents
Antiplatelet Agents
Antiplatelet Agents
Action:
Medications:
Side Effects:
Interferes with platelet
aggregation

Aspirin
Persantine


Used for:


Nursing Considerations:

Venous thrombosis
Pulmonary embolism


Check for signs of
bleeding
Give with food or milk
Antipsychotic Agents
Antipsychotic Agents
Antipsychotic Agents
Action:
Medications:
Side Effects:
Blocks dopamine
receptors in basal ganglia
Used for:

Hemorrhage
Thrombocytopenia




Haldol
Thorazine
Mellaril
Stelazine
Acute and Chronic
psychoses

Akathisia (inability to sit
still)





Dyskinesia
Dystonias
Parkinson’s syndrome
Tardive dyskinesias
Leukopenia
Nursing Considerations:



Check CBC
Monitor vital signs
Avoid alcohol and
caffeine

Atypical Antipsychotic Agents Atypical Antipsychotic
Atypical Antipsychotic
Action:
Side Effects:
Interferes with binding
of dopamine in the brain

Used for:

Medications:
Clozaril
Risperdal




Acute and Chronic
psychoses
Extrapyramidal effects
Anticholinergic
Sedative
Orthostatic hypotension
Nursing Considerations:

Monitor blood



Change positions slowly
Use sunscreen
Antipyretic Agents
Antipyretic Agents
Antipyretic Agents
Action:
Medications:
Side Effects:
Antiprostaglandin
activity in hypothalamus

Tylenol
(Acetaminophen)

GI irritation
Nursing Considerations:
Used for:





Fever
Monitor liver function
Aspirin contraindicated
for younger than 21 years old
due to risk of Reye’s syndrome
Antithyroid Agents
Antithyroid Agents
Antithyroid Agents
Action:
Medications:
Side Effects:
Reduce vascularity of
thyroid

Inhibits release of
thyroid into circulation
Tapazole
SSKI



Leukopenia
Rash
Thrombocytopenia
Nursing Considerations:
Used for:



Hyperthyroidism
Bitter taste
May cause burning in
mouth


Give with meals
Check CBC
Thyroid Replacement Agents Thyroid Replacement
Thyroid Replacement
Action:
Side Effects:

rate
Medications
Increases metabolic 

Synthroid
Cytomel



Nervousness
Tachycardia
Weight loss
Used for:
Nursing Considerations:

Hypothyroidism

Monitor pulse and BP






Antitubercular Agents
Antitubercular Agents
Antitubercular Agents
Action:
Medications:
Side Effects:
Inhibits cell and protein

synthesis


Used for:


Tuberculosis
To prevent disease in
person exposed to organism
INH
Ethambutol
Streptomycin
PAS
PYZ





Hepatitis
Peripheral Neuritis
Nursing Considerations:




Monitor weight
Take in a.m.
Enhance action of
anticoagulants, antidepressants,
decrease action of insulin and
digitalis
Check liver function tests
Vitamin B6 given for peripheral
neuritis (Pyridoxine)
Used in combination
Antivirals
Antivirals
Antivirals
Action:
Medications:
Side Effects:
Inhibits DNA and RNA

replication


Used for:


Recurrent HSV
HIV infection
Zovirax
AZT
Videx
Famvir
Cytovene



Headache
Dizziness
GI symptoms
Nursing Considerations:


Encourage fluids
Not a cure, but relieves
symptoms
Attention Disorder Agents
Attention Disorder Agents
Attention Disorder Agents
Action:
Medications:
Side Effects:
Increases level of
catecholamines



Ritalin
Cylert
Dexedrine



Restlessness
Insomnia
Tachycardia

Used for:


ADDH
Narcolepsy
Palpitations
Nursing Considerations:




Bronchodilators
Bronchodilators
Bronchodilators
Action:
Medications:
Side Effects:
Decreases activity of
phosphodiesterase
Used for:







Aminophylline
Atrovent
Brethine
Proventil
Primatene




COPD
Preterm labor (Terbutaline)
Tachcyardia
Dysrhythmias
Palpitations
Anticholinergic effects
Nursing Considerations:




Monitor growth rate
Monitor liver enzymes
Give in A.M.
Monitor BP and HR
When used with steroid
inhaler, use bronchodilator first
May aggravate diabetes
Cardiac Glycosides
Cardiac Glycosides Cardiac Glycosides
Action:
Medication:
Increases force of

myocardial contraction, slows
rate
Lanoxin
(Digoxin)
Side Effects:




Bradycardia
Nausea
Vomiting
Visual disturbances
Used for:
Nursing Considerations:

Left-sided CHF


Take apical pulse
Notify physician if adult <60, child <90-110, <70 in olde
children



Cholinergics
Cholinergics
Monitor potassium level
Dose: 0.5-1 milligram IV or PO over 24 hr period
Average: 0.25 mg
Cholinergics
Action:


Medications:
Inhibits destruction of 
acetylcholine

Stimulate parasympathetic
nervous system (increase bowel
tone, increase bladder tone,
constrict pupil)
Side Effects:



Tensilon
Prostigmin
Nursing Considerations:


Used for:





Bronchoconstriction
Respiratory paralysis
Hypotension


Myasthenia gravis
Post-operative
Postpartum urinary
retention
Give with food or milk
Monitor vital signs, especially
respirations
Antidote: Atropine Sulfate
Toxicity: excessive salivation,
excessive sweating, abdominal
cramps, flushing
Diuretics
Diuretics
Diuretics
Action:
Medications:
Side Effects:
Inhibits reabsorption

of sodium and water

Blocks effects of 
aldosterone


Used for:


HydroDIURIL
Diamox
Aldactone
Lasix
Hygroton



Nursing Considerations:



CHF
Renal disease
Dizziness
Orthostatic Hypotension
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,
tachycardia
Glucocorticoids
Glucocorticoids
Glucocorticoids
Action:
Medications:
Side Effects:

glucose

Stimulates formation of

Alters immune

Solu-Cortef

Decadron 
Deltasone

Psychoses
Depression
Hypokalemia
Stunted growth

response
Used for:






Nursing Considerations:



Addison’s disease
Crohn’s disease
COPD
Leukemias
Mineralocorticoids
Mineralocorticoids
Action:
Medications:
Side Effects:
Increases sodium 
reabsorption
Potassium and
hydrogen ion secretion in
kidney



Monitor fluid and electrolyte balance
Don’t discontinue abruptly
Monitor for signs of infection
Mineralocorticoids
Florinef



Hypertension
Edema
Hypokalemia
Nursing Considerations:



Used for:

Buffalo Hump
Adrenal insufficiency
Monitor BP, I&O, Weight, and Electrolytes
Give with food
Low-sodium, High-protein, High-potassium diet
Heavy Metal Antagonists
Heavy Metal Antagonists
Heavy Metal Antagonists
Action:
Medications:
Side Effects:
Forms stable complexes
with metals


Used for:
Desferal mesylate
BAL in Oil
EDTA


Gold and arsenic poisoning
Acute lead encephalopathy
Tachycardia
Pain and induration at
injection site (conjunct with Procaine
in syringe)
Nursing Considerations:

Monitor I&O and kidney
function


H2 Receptor Blockers
H2 Receptor Blockers
Administered with local
anesthetic
Seizure precautions
H2 Receptor Blockers
Action:

Medications:
Inhibits action of
histamine and gastric acid
secretion


Side Effects:




Tagamet
Zantac
Dizziness
Confusion
Hypotension
Impotence
Used for:
Nursing Considerations:


Ulcers
Gastroesophageal


reflux


Take with meals and hs
Smoking decreases
effectiveness
Monitor liver function
and CBC
Immunosuppressants
Immunosuppressants
Immunosuppressants
Action:
Medications:
Side Effects:
Prevents production of

T cells and their response to
interleukin-2




Sandimmune
Hepatotoxicity
Nephrotoxicity
LeuKopenia
Thrombocytopenia
Used for:
Nursing Considerations:

Prevents rejection for
transplanted organs



Take once daily in a.m.
Used with adrenal
corticosteroids
Monitor renal and liver
function tests
Miotics (Constricts Pupil)
Miotics
Miotics
Action:
Medications:
Side Effects:

Causes constriction of
sphincter muscles of iris


Used for:

Ocular surgery
Isopto-Carpine
Eserine
Carbacel




Headache
Photophobia
Hypotension
Bronchoconstriction
Nursing Considerations:


Open-angle glaucoma
Apply pressure on lacrimal
sac for 1min
Avoid sunlight
May experience transient
brow pain and myopia



Mydriatics (Dilates Pupil)
Mydriatics
Mydriatics
Action:
Medications:
Side Effects:
Anticholinergic actions

leaves pupil under unopposed
adrenergic influence
Atropine sulfate
Cyclogyl




Tachycardia
Blurred vision
Photophobia
Dry mouth
Used for:
Nursing Considerations:



Diagnostic procedures
Acute iritis
Uveitis







Contraindicated with glaucoma
Apply pressure on lacrimal sac
for 1min.
Wear dark glasses
Narcotics
Narcotics
Narcotics
Action:
Medications:
Side Effects:
Acts on CNS receptor
cells


Used for:


Moderate to severe
pain
Preoperative
Postoperative
Antianginals
Morphine Sulfate
Codeine
Demerol
Dilaudid
Percodan





Dizziness
Sedation
Respiratory depression
Hypotension
Constipation
Nursing Considerations:




Antianginals
Safety precautions
Avoid alcohol
Monitor vital signs
Use narcotic antagonist if necessary
(Narcan)
Antianginals
Action:


Medications:
Relaxes smooth muscle

Decreases venous 
Side Effects:
Nitroglycerine 
Isosorbide



return
Hypotension
Tachycardia
Headache
Dizziness
Used for:
Nursing Considerations:



Angina
Peri-operative
hypertension
CHF




NSAIDS
NSAIDS
NSAIDS
Action:
Medications:
Side Effects:

Inhibits prostaglandin
synthesis


Used for:



Arthritis
Mild to moderate pain
Fever
Motrin

Indocin 
Naprosyn 


GI upset
Dizziness
Headache
Bleeding
Fluid retention
Nursing Considerations:





Take with food or after meals
Monitor liver and renal function
Use cautiously with aspirin allergy
Check for bleeding
Thrombolytics
Thrombolytics
Thrombolytics
Action:
Medications:
Side Effects:
Dissolves or lyses blood clots
Used for:




Check expiration date
Teach when to take medication
May take Q5min x3 doses
Wet with saliva and place under tongue



Acute Pulmonary Emboli
Thrombosis
MI
Contraindicated in: hemophilia, CVA,
Streptokinase

Urokinase

Tissue Plasminogen 
Activator
Bleeding
Bradycardia
Dysrhythmias
Nursing Considerations:


Monitor for bleeding
Have Amino Caproic Acid
Trauma, not used in patients over 75 years old,
not used in patients taking anticoagulants


Anaphylaxis

o
o
o
o

o
o
o
Symptoms
Hives
Rash
Difficulty breathing (first sign)
Diaphoresis
Nursing care
Epinephrine 0.3 ml of 1:1000 solution SQ
Massage site
May repeat in 15-20 min.
Delayed Allergic Reaction

o

o
o
o
o
Symptoms:
Rash, Hives, Swollen Joints
Nursing Care
Discontinue medication
Topical Antihistamines
Corticosteroids
Comfort measures
Bone Marrow Depression
Symptoms:
Fever, Chills, Sore Throat
Back pain, Dark urine
Anemia, Thrombocytopenia, Leukopenia
Nursing Care:
Monitor CBC
Protect from infections
Available
Check pulse, color, sensatio
of extremities
Monitor EKG
Avoid injury
Liver impairment: light stools and dark urine
Renal Impairment: decrease Hematocrit
Anticholinergic Effects

o
o

o
o
o
Symptoms:
Dry mouth, Dysphagia, Nasal Congestion
Urinary retention, Impotence
Nursing Care:
Sugarless lozenges
Good mouth care
Void before taking medication
Parkinson’s-like effects

o
o
o
o
o
o
o

o
o
Symptoms:
Akinesia (temporarily paralysis of muscles)
Tremors
Drooling
Changes in gait
Rigidity
Akathisia (Extreme restlessness)
Dyskinesia (Spasms)
Nursing Care:
Anticholinergic and Antiparkinsonian medications
Safety measures for gait
How long should a client with
tuberculosis be on medication?
6-9 Months
What are symptoms of hepatitis?
Inflammation of Liver
Jaundice
Anorexia
RUQ pain
Clay-colored stools, tea-colored urine
Pruritis (bile salts eliminated through skin)
Elevated ALT, AST
Prolonged PT (liver involvement with clotting factor)
What is the transmission of Hepatitis
A?
Fecal/Oral
Consume contaminated food or water
Travelers to developing countries at risk
Clients with hepatitis A should not prepare food for
others
What is the transmission of Hepatitis
B?
Parenteral/Sexual contact
Blood or body fluids
At risk individuals are the one’s that abuse IV drugs,
dialysis, healthcare workers
Vaccine developed
What is the transmission of Hepatitis
C?
Blood or body fluids
Can become chronic disease
Seen in patients with hemophilia (unable to clot)
What is the transmission of Hepa D ?
Co-infects with hepatitis B
What nursing care are recommended
for Hepatitis?
Rest (mainly for liver)
Contact and standard precautions
Low-fat, High-Calorie, and High Protein diet (needed for
organ healing)
No alcoholic beverages
Medications (Vitamin K, Aqua-Mephyton for bleeding
problems, Anti-emetic – no compazine, use Tigan or
(Dramamine). Corticosteroids to decrease
inflammatory response, and anti-histamines, will use
lotions or baths than systemic ones.
What is Lyme’s Disease?
Multi-system infection caused by a tick bite. There are
three stages.
What is Stage 1 of Lyme’s Disease?
Erythematous papule develops into lesion with clear
center (Bull’s-eye)
Regional lymphadenopathy
Flu-like symptoms (fever, headache, conjunctivitis)
Can develop over 1 to several months
What is Stage 2 of Lyme’s Disease?
Develop after 1 to 6 months if disease untreated.
Cardiac conduction defects
Neurologic disorders (Bell’s palsy, temporary paralysis)
What is Stage 3 of Lyme’s Disease?
Develops after 1 to several months, if reached at this
stage may persist for several years.
Arthralgias
Enlarged, inflamed joints
What are some Lyme’s Disease
teaching?
Cover exposed areas when in wooded areas
Check exposed areas for presence of ticks
What are some Lyme’s Disease nursing Antibiotics 3-4 weeks
care?
Stage 1 use Doxicillin
IV penicillin with later stages
What are the treatment, mode of
transmission, care, signs and
symptoms of syphillis?
Painless chancre fades after 6 weeks
Low grade fever
Copper-colored rash on palms and soles of feet
Spread by contact of mucous membranes, congent
Treat with Penicillin G IM
If patient has penicillin allergy, will use erythromycin for
10-15 days.
After treatment, patient must be retested to make sure
disease is gone.
What are the treatment, mode of
If female maybe asymptomatic and will be unaware of
transmission, care, signs and
symptoms of gonorrhea?
having disease.
Males may have thick discharge from urethra.
Some females from vagina.
Spread mucous membranes, congenital
IM Rocephin with Doxycycline PO, IM Aqueous
Penicillin with PO Probenecid (used for gout, used with
Penicillin because it delays the urinary excretion of it,
makes it more effective)
Complication: Pelvis Inflammatory Disease
Most often affected with Chlamydia also, then treatment
with PO Tetracycline
What are the treatment, mode of
transmission, care, signs and
symptoms of genital herpes?
No cure.
Painful vesicular genital lesions
Problem is exacerbations/remissions
Reoccurs with stress, infection, menses
Spread by contact of mucous membranes, congenital
Treatment: Acyclovir, sitz bath
Monitor pap smears regularly because of higher
incidence of cervical cancer.
Emotional support of client/significant others important
because of no cure.
Pregnant women with active disease will have Csection.
What are the treatment, mode of
transmission, care, signs and
symptoms of Chlamydia?
Men: urethritis, dysuria
Women: thick vaginal discharge with acrid odor
Spread by mucous membranes, congenital
Treatment with Tetracycline or Doxycycline PO
Will cause sterility if left untreated.
Important to notify sexually contacted.
What are the treatment, mode of
transmission, care, signs and
symptoms of Venereal Warts?
Single, small papillary lesion spreads into large
cauliflower cluster on perineum, vagina, penis.
May itch or burn.
Spread by mucous membranes, congenital
Treatment: Curettage, cryotherapy with liquid nitrogen,
kerotolytic agents
Avoid intimate contact until lesions heal
Complication: Genital Dysplasia Cancer
What is the difference between AIDS
and HIV +?
HIV Positive—presence of HIV in blood
AIDS—has significant defects in immune function
associated with positive HIV evidenced by development
of opportunistic infections
Syndrome where CD4 counts are below 200
What are some opportunistic infections P. Carinii Pneumonia: sob/dry-nonproductive cough
of AIDS?
C. Albicans stomatitis: will have difficulty swalling and
white exudates in back of throat
C. Neoformans: debilitating form of meningitis that may
suffer seizures.
Cytomegalovirus (CMV): will experience
lymphadenopathy and may have visual impairment and
can affect any organ.
Kaposi’s Sarcoma: most common malignancy
experience with AIDS, small purplish brown, nonpainful,
nonpuriitc palpable lesions on the body.
How is AIDS transmitted?
Contaminated blood or body fluids
Sharing IV needles
Sexual contact
Transplacental: across placenta
Possibly by breast milk
What are diagnostics test associated
with AIDS?
ELISA test, if positive will be confirmed by Western Blot
test
HIV Viral culture: Leukopenia, Thrombocytopenia,
Decrease CD4 counts
What are some nursing cares for AIDS? Prevention: avoid IV drug use, precautions regarding
sexual patterns, use standard precautions
Contact and standard precautions
High-protein and high-calorie diet, small frequent meals
rather than 3 large meals
Symptomatic relief
Support
Don’t share toothbrush/shavers
What are treatments, care, prevention
of poison control?
Prevention most important.
Treat patient first, and then the poison.
Recognize signs of symptoms of accidental poison:
changes in appearance, behavior, substances around
mouth, empty containers, vomitous.
What should happen when someone is Call poison control center.
poisoned?
Tell them: substance, time, amount and route of
ingestion, child’s condition, age, weight, save vomitus,
stool, urine.
Why should vomit not be induced?
Don’t induce if:
Danger of aspiration, decrease LOC, Ingested
petroleum distillate (lighter fluid, kerosene, paint
remover)
Ingested corrosive (Draino)
What medication treatment is used to
Syrup of Ipecac with small amount of water. Don’t give
induce vomiting and what other factors large amount of fluid after Ipecac, will increase gastric
need to be implemented?
emptying.
Don’t use milk.
Position with head lower then chest.
No universal antidote.
What should happen to poison control Intubated if comatose
in emergency care?
Run blood gases
IV fluids
Cardiac Monitor
Gastric Lavage (NG down to flush with NS to remove
rest in stomach)
Activated Charcoal
May use cathartics, diuretics
What are signs and symptoms,
treatments, care, prevention of aspirin
poisoning?
Tinnitus, change in mental status, Increased
temperature, hyperventilation, bleeding, nausea and
vomiting.
Nursing care: induce vomiting, maintain hydration,
reduce temperature (sponge baths), monitor for
bleeding.
What are signs and symptoms,
treatments, care, prevention of tylenol
poisoning?
Symptoms: nausea/vomiting, hypothermia, If no
treatment, hepatic/liver involvement.
If liver gets involved patient may have RUQ pain,
jaundice, confusion, and coagulation abnormalities.
Nursing care: induce vomiting, maintain hydration,
monitor liver and kidney function with labs such as
AST/ALT enzymes.
Tylenol (Acetaminophen) overdosage:
Antidote N-acetylcysteine (Mucomyst)
What are signs and symptoms,
treatments, care, prevention of lead
Symptoms: Irritability, decreased activity, abdominal
pain, Increased ICP
toxicity?
Diagnostic tests: Blood lead levels (>9micrograms =
toxic), Erythrocyte protoporphyrin (EP), X-ray long
bones (lead deposits in long bones)
Children engage in PICA (ingesting nonfood
substances)
Lead blocks formation of hemogloblin and toxic to
kidneys.
Nursing care: identify source, chelating agents,
teaching parents
What are nursing care goals for
Hazardous wastes?
Decontaminate individual
Prevent spread of contamination
Clean and remove contaminuated source
Monitor personnel exposed
What are nursing care for Hazardous
wastes?
If chemical poses threat to caregiver, decontaminate
patient first.
If chemical poses no threat or patient has been
decontaminated, begin care.
If immediate threat to life, put on protective garments
and provide care to stabilize patient.
What type of play do infants (012months) use?
Solitary play. Game is one sided. Like to play with body
parts.
Birth-3months: smile/squeal
3-6months: rattles/soft stuff toys
6-12 months: begin imitation, peek-a-boo, patty-cake
Play of toddlers (1-3 years)
Parallel play.
Play of pre-schoolers (3-6years)
Associative play. Dress up/imitating play. Talking on
telephone/kitchen/tool belt
Play 0f school age (6-12years)
Cooperative play. Conformed/organized play.
According to Erikson’s Developmental Birth-18 months.
Task, explain the Infancy stage.
Trust vs. Mistrust
Positive outcome---trusts self
Negative outcome---withdrawn
According to Erikson’s Developmental 18months – 3 years
Task, explain the Toddler stage.
Autonomy vs. Shame and Doubt
Positive outcome---exercise self-control
Negative outcome---defiant and negative
According to Erikson’s Developmental 3-6 years
Task, explain the Preschool stage.
Initiative vs. Guilt
Children develop conscience at this age.
Positive Outcome---learns limits
Negative Outcome---fearful, pessimistic
According to Erikson’s Developmental 6-12years
Task, explain the School age stage.
Industry vs. Inferiority
Positive---sense of confidence
Negative---self doubt, inadequate
According to Erikson’s Developmental 12-20 years
Task, explain the Adolescence stage.
Identity vs. Role diffusion
Positive outcome---coherent sense of self
Negative outcome---lack of identity
According to Erikson’s Developmental 20-45 years
Task, explain the young adult stage.
Intimacy vs. Isolation
Positive outcome---intimate relationships/careers
formed
Negative outcome---avoidance of intimacy
According to Erikson’s Developmental 45-65 years
Task, explain the middle adulthood
Generativity vs. Stagnation
stage.
Positive Outcome---creative and productive
Negative Outcome---self centered
According to Erikson’s Developmental 65+ years
Task, explain the Late adulthood stage.
Integrity vs. Despair
No regrets in life or Regrets
Positive outcome---seems life as meaningful
Negative outcome---life lacks meaning
At what month does the head sag?
1 month
At what month do you see closing of
posterior fontanelle, turn from side to
back, and see a social smile?
2 months
What toys do you give for a 2 month
old?
Mobiles, wind up infant swings, soft clothes, and
blankets.
At what month does a child bring
objects to mouth and head erect?
3 months
What toys do you give for a 4 month
old?
Rattles, cradle gym, and stuffed animals
Which age does birth weight double?
5 months
At what age does teething occur?
6 months
What toys do you give for a 6 month
old?
Brightly colored, small enough to grasp, large enough
for safety, teething toys
What age for fears of strangers? When 7 months
is fear strongest?
8 months is stronger
Which month able to play peek-a-boo? 7 months
What toys do you give for 7-8months?
Large colored, bricks, jack in the box
What month can a child say “DADA?
9 month
What month can a child crawl well?
10 months
What month can a child stand erect
with support?
11 months
What happens in the 12th month of the
Birth weight triples.
child?
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.








What does a toddler do at 15 months?
Cereal is usually first. (Do not use cow’s
milk/whole milk. After six months of age cereal can be
mixed with fruit juices. Fruit juices should be offered in
a cup to prevent dental carries.)
Vegetables
Fruits
Potatoes
Meats
Eggs
Orange Juice
By 12 months children should be eating table
food. Don’t give honey under 12 because of botulism.
Walks alone.
Throws object.
Holds spoon.
Say 4-6 words. Understand simple commands.
What does a toddler do at 18 months?
Anterior fontanelle closes.
Climbs stairs.
Sucks thumb.
Say 10 + words.
Temper Tantrums.
What does a toddler do at 24 months?
300 world vocabulary.
Obeys easy commands.
Go up/down stairs alone.
Build towers.
Turn doorknobs/unscrew lids.
Increase independence.
What does a toddler do at 30 months?
Walk tip toe.
Stand on one foot balance.
Has control for sphincter training.
Birth weight quadrupled.
State first/last name.
Give simple commands.
What type of toys are included for
Toddlers?
Cooking utensils, Dress-up clothes, rocking horses,
finger paints, phonographs, cd players.
How do you avoid negativism during
toddler ages?
Don’t ask no/yes questions.
Offer them choices.
Make a game out of the tasks.
What can a 3 year old do?
Rides tricycle.
Undresses without help.
May invent imaginary friend.
Vocabulary 900 words.
Egocentric in thoughts/behaviors.
What can a 4 year old do?
Laces shoes
Brushes teeth
Throws overhand
Uses sentences.
Independent
What can a 5 year old do?
Runs well/Dresses without help.
Beginning cooperative play.
Gender-specific behavior.
What toys are used for preschool (3-5)? Playground materials, Housekeeping toys, Coloring
books, tricycle with helmet.
Which age groups has greatest number Preschool age children.
of fears?
What would you expect with a 6 year
old?
Self-centered, show off, rude
Sensitive to criticism
Begins loosing temporary teeth
Tends to lie.
What would you expect with a 7 year
old?
Team games/sports.
Concept of time.
Playing with same sex child.
What would you expect with a 8 year
old?
Seeks out friends.
Writing replaces printing.
What would you expect with a 9 year
old?
Conflicts between peer groups and parents.
Conflicts between independence and dependence.
Likes school.
Able to take on job duties (housework).
What toys are used for school age
child?
Construction toys, Pets, Games, Electronic games,
reading, books, bicycles with helmets.
School age potential problems include: Anuresis (encourage before bed time)
Encopresis
Head lice
What are symptoms/indications of a
Thin upper lip, vertical ridge in upper lip, short up
fetal alcohol syndrome in a child?
turned nose, mental retardation, motor retardation,
hearing disorders, microcephaly.
Avoid alcohol 3 months before conception and
throughout pregnancy.
16th week detects genetic abnormality
What happens with amniocentesis?
What does it do?
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
What happens with an ultrasound?
Determines position of fetus, placenta, and # of fetuses.
Client must drink a lot of fluid before procedure for full
bladder to have a clear image.
What happens with a non-stress test?
At 28th week records FHR and fetal movement.
Favorable result: 2+ FHR accelerates by 15bpm and
last 15seconds in 20 minutes.
What happens with a contraction stress Determines placenta’s response to labor.
test?
Done after 28th week.
Fowler/Semi-Fowler.
Given Oxytocin or Pitocin.
Results:


Positive: Late decelerations indicates potential
risk to fetus.
Negative: No late decelerations.
What does Torch stand for? And their
importance?
Diseases that cross placenta or other events. Produce
significant deformities or infant born with infectious
process.
Toxoplasmosis: no litter box changed, no gardening, no
under cooked meats.
Rubella: 1-16 titer immune for rubella, titer <1-8
susceptible.
Cytomegalovirus: transmitted in body fluids.
Herpes Simplex: Ascending infection. During
pregnancy get treated with acyclovir. Delivery through
c-section.
What concerns for clients that have
UTI, Syphilis, Gonorrhea?
UTI: may lead to pylonephritis, increase risk of
premature birth.
Syphillis: passes through placenta, causes 2 nd 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?





What are the events in the onset of
labor?
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 BraxtonHick’s type.
How does prolapsed umbilical cords
happen?
Premature rupture of membranes.
Presenting part not engaged.
Fetal distress.
Protruding cord.
What do you do when a client has a
prolapsed cord?
Call for help.
Push up against presenting part off of the cord.
Place in trendenlenberg position or knee chest position.
Successful if FHT left unchanged.
What is a early/sign of fetal hypoxia?
Early sign: fetal tachycardia >160 in >10minutes
Late sign: fetal bradycardia <110 in > 10 minutes
What things should you know about
the Informed Consent form?
Nurse can witness patient sign form.
Patient has to be age of capacity/adult and
confident. No confused patient/drinking/already
received preoperative medications.
Consent must be given voluntarily and information
understandable. Nurse must make sure questions are
answered and form is attached to chart.
What is early deceleration?
Decrease in HR before peak of contraction. Indication
of head compression.
What are interventions for late
decelerations?
Position mother left side/trendenlenberg/knee chest
Increase rate of IV
Administer Oxygen 7-10 l/min
DC Oxytocin
What do variable decelerations
indicate?
Cord compression.
Change maternal position.
Administer oxygen.
DC Oyxtocin/Pitocin
What are signs of “True Labor”?
Regular contractions increasing in frequency, duration,
intensity
Discomfort radiates from back
Contractions do not decrease with rest
Cervix progressively effaced and dilated.
What are characteristics of a “False
Labor”?
Irregular contractions, no change in frequency,
duration, intesityDiscomfort is abdominal
Contractions decrease with rest or activity
No cervical changes
Prior to Lumbar Epidural block what
should the patient do?
Void
What should be implemented during
the delivery of a newborn?
Establish airway
Check Apgar at 1 and 5 minutes
Clamp umbilical cord
Maintain Warmth
Place ID band on mother and infant
What are the types of Lochia?
Rubra-bloody, day 1-3
Serosa-pink-brown, day 4-9
Alba-yellow-white, 10+ days
If fundus is displaced not centrally and Bladder distended.
off to the sides means?
If client soaks pad in 15 minutes or
pooling of blood?
Check for hemorrhage
What are assessments and
implementations for an “Ectopic
Pregnancy”?
Unilateral lower quadrant pain.
Rigid, tender abdomen
Low Hct and hCG levels
Bleeding
Monitor for shock
Administer RhoGAM
Provide support
What are assessments and
A placenta that’s implanted in the lower uterine
implementations for “Placenta Previa”? segment near cervical os, during pregnancy placenta is
torn away causing:
First and second trimester spotting
Third and trimester painless, profuse bleeding
Bedrest side-lying or trendelenburg position, ultrasound
to locate placenta, no vaginal or rectal exams,
amniocentesis for lung maturity, daily Hgb, Hct, Monitor
bleeding
What are the assessments and
implementation for “Abruptio
Placentae”?
The premature separation of a placenta that is
implanted in a correct position.
Painful vaginal bleeding
Abdomen tender, painful, tense
Possible fetal distress/Contractions
Monitor for maternal and fetal distress
Prepare for immediate delivery
Monitor for complications: DIC, pulmonary emboli
What are assessments and
implementations for Gestational
Diabetes Mellitus (GDM)?
Hyperglycemia after 20 weeks
Usually controlled by diet
Oral hypoglycemic medications contraindicated
Test for diabetes at 24-28 weeks on all women with
average risk 20.
Frequent monitoring of mother/fetus during pregnancy.
Teach to eat prescribed amount of food daily at same
times
Home glucose monitoring
Teach about change in insulin requirements
What are assessments and
implementation for a Hydatidiform
Elevated hCG
Mole?
Uterine size larger than expected for dates
No FHT
Minimal dark red/brown vaginal bleeding with grape like
clusters
Nausea and vomiting
Associated with PIH
Curettage to remove tissue
Pregnancy discouraged for 1 year
Do not use IUD
hCG levels monitored for 1 year
What are the newborn vital signs?
Temp. 97.7-99.7
HR sleep 100, awake 120-140, 180 crying
Resp 30-60
BP arm/calf 65/41
What are assessments and
implementation for
Hyperbilirubinemia?
Caused by immature hepatic function
Physiological Jaundice (No treatment required)



Seen after 24 hours
Peaks at 72 hours
Lasts 5-7 days
Breast-Feeding Associated Jaundice (Frequent breast
feeding)



Caused by poor milk intake
Onset 2-3 days
Peaks 2-3 days
Breast Milk Jaundice (discontinue breast feeding for 24
hours)



Caused by factor in breast milk
Onset 4-5 days
Peak 10-15 days
Hemolytic Disease (Phototherapy then exchange
transfusion)
Caused by blood antigen incompatibility (Rh or ABO
incompatibility)
Onset first 24 hours
Peak variable
What are assessments and
implementations for a NarcoticAddicted 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




What are the assessments and
implementations of Toxic Shock
Syndrome?
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)
What are contraindications to
Immunizations?
Immunization is a primary prevention
Severe febrile illness
Altered immune system
Previous allergic response
Recently acquired passive immunity
What are assessments and
Assessment
implementations for a “Latex Allergy”?
Urticaria, rash
Wheezing, Rhinitis, Conjunctivitis, Bronchospasms
Anaphylactic shock
Implementation
Screen for sensitivity
Avoid latex products: gloves, catheters, brown
ace bandages, band aid dressing, elastic pressure
stockings, balloons, condoms
What are implementations for Croup
syndromes at home?
Steamy shower
Exposure to cold air
Cool, humidified air
Universal Donor Blood: Packed red blood cells (help oxygen deliver to tissue, if you use whole
blood there will be a risk for fluid overload), type O, Rh-negative
5% Sodium Bicarbonate—metabolic alkalosis solution
Older adults are asymptomatic when they have an infection and can lead to confusion.
Mononucleosis: complication enlarged spleen; concerned for trauma if child plays dangerous
sport.
Lyme disease:found mainly in mid alantic states (Connecticut)
Pottery is unglazed can lead to “Lead Toxicity”
Apgar Score: normal 7-10
WBC after pregnancy?
Ampicillin decreases oral contraceptives efficiency.
Tricuspid area: 5th intercostals space in the left sternum area
Tracheostomy care: no powder, suction trachea first then mouth, use pre-cut gauze.
Hip-Flexion: causes increased intra-abdominal/thoracic pressure.
Injury C3 and above need respiratory ventilation.
SIADH causes: lung cancer, Cisplatin (Platinol)
Chest Tubes








Fill water-seal chamber with sterile water to 2 cm (middle chamber)
Fill suction control chamber with sterile water to 20 cm (chamber all the way to the right)
Air-leak if bubbling in water-seal chamber (middle chamber)
Obstruction: “milk” tube in direction of drainage
Removal o chest tube: pt. does valsalva maneuver, clamp chest tube, remove quickly,
apply occlusive dressing
Dislodged: apply tented dressing
Tube becomes disconnected from drainage system, cut off contaminated tip, insert sterile
connector and reinsert
Tube becomes disconnected from drainage system, immerse in 2cm of water
Jackson-prat: Notify physician if drainage increases or becomes bright red
Penrose: Expect drainage on dressing
Tracheostomy Tube Cuff





Prevents aspiration of fluids/separates upper and lower airways
Inflated during continuous mechanical ventilation
Inflated during and after eating
Inflated during and 1 hour after tube feeding
Inflated when patient cannot handle oral secretions

NCLEX-RN exam is a “here and now” test; take care of problem now to prevent harm to
client.

Do not ask “why” on the licensure exam



Morphine Sulfate for pancreatitis causes spasms of the sphincter of Oddi; Meperidine is
drug of choice.
Normal Intraocular Pressure is 10-21 mm Hg
Ecchymosis (faint discoloration) around the umbilicus or in either flank indicates
retroperitoneal bleeding
The parenteral form of Chlorpheniramine Maleate is use to relieve symptoms of anaphylaxis
allergic reactions to blood or plasma.
Herbs: Toxicities and Drug Interactions
Chamomile
Uses: Chamomile is often used in the form of a tea as a sedative.
Reactions: Allergic reactions can occur, particularly in persons allergic to ragweed. Reported
reactions include abdominal cramps, tongue thickness, tightness in the throat, swelling of the lips,
throat and eyes, itching all over the body, hives, and blockage of the breathing passages. Close
monitoring is recommended for patients who are taking medications to prevent blood clotting
(anticoagulants) such as warfarin.
Echinacea
Uses: Largely because white blood cells in the laboratory can be stimulated to eat particles,
Echinacea has been touted to be able to boost the body's ability to fight off infection.
Reactions: The most common side effect is an unpleasant taste. Echinacea can cause liver
toxicity. It should be avoided in combination with other medications that can affect the liver (such
as ketaconazole, leflunomide (Arava), methotrexate (Rheumatrex), isoniazide (Nizoral).
St. John's Wort
Uses: St. John's Wort is popularly used as an herbal treatment for depression, anxiety, and sleep
disorders. It is technically known as Hypericum perforatum. Chemically, it is composed of at least
10 different substances that may produce its effects. The ratios of these different substances
varies from plant to plant (and manufacturer). Studies of its effectiveness by the National
Institutes of Health are in progress.
Reactions: The most common side effect has been sun sensitivity which causes burning of the
skin. It is recommended that fair- skinned persons be particularly careful while in the sun. St.
John's wort may also leave nerve changes in sunburned areas. This herb should be avoided in
combination with other medications that can affect sun sensitivity (such as
tetracycline/Achromycin, sulfa- containing medications, piroxicam (Feldend). St. John's wort can
also cause headaches, dizziness, sweating, and agitation when used in combination with
serotonin reuptake inhibitor medications such as fluoxetine (Prozac) and paroxetine (Paxil).
Garlic
Uses: Garlic has been used to lower blood pressure and cholesterol (Dr. Lucinda Miller notes that
there is "...still insufficient evidence to recommend its routine use in clinical practice.")
Reactions: Allergic reactions, skin inflammation, and stomach upset have been reported. Bad
breath is a notorious accompaniment. Studies in rats have shown decreases in male rats' ability
to make sperm cells. Garlic may decrease normal blood clotting and should be used with caution
in patients taking medications to prevent blood clotting (anticoagulants) such as warfarin
/Coumadin.
Feverfew
Uses: Most commonly used for migraine headaches.
Reactions: Feverfew can cause allergic reactions, especially in persons who are allergic to
chamomile, ragweed, or yarrow. Nonsteroidal anti-inflammatory drugs (NSAIDs such as ibuprofen
(Advil), naproxen (Aleve) or Motrin) can reduce the effect of feverfew. A condition called
"postfeverfew syndrome" features symptoms including headaches, nervousness, stiffness, joint
pain, tiredness, and nervousness. Feverfew can impair the action of the normal blood clotting
element (platelets). It should be avoided in patients taking medications to prevent blood clotting
(anticoagulants) such as warfarin (Coumadin).
Ginko Biloba
Uses: This herb is very popular as a treatment for dementia (a progressive brain dysfunction) and
to improve thinking.
Reactions: Mild stomach upset and headache have been reported. Ginko seems to have blood
thinning properties. Therefore, it is not recommended to be taken with aspirin, nonsteroidal antiinflammatory drugs (Advil), naproxen (Aleve) or Motrin), or medications to prevent blood clotting
(anticoagulants) such as warfarin (Coumadin). Ginko should be avoided in patients with epilepsy
taking seizure medicines, such as phenytoin (Dilantin), carbamazepine (Tegretol), and
phenobarbital.
Ginseng
Uses: Ginseng has been used to stimulate the adrenal gland, and thereby increase energy. It
also may have some beneficial effect on reducing blood sugar .in patients with diabetes mellitus.
(Dr. Miller emphasized that there is substantial variation in the chemical components of
substances branded as "Ginseng.")
Reactions: Ginseng can cause elevation in blood pressure, headache, vomiting, insomnia, and
nose bleeding. Ginseng can also cause falsely abnormal blood tests for digoxin level. It is unclear
whether ginseng may affect female hormones. Its use in pregnancy is not recommended.
Ginseng may affect the action of the normal blood clotting element (platelets). It should be
avoided in patients taking aspirin, nonsteroidal antiinflammatory drugs (such as ibuprofen (Advil),
naproxen (Aleve) or Motrin), or medications to prevent blood clotting (anticoagulants) such as
warfarin (Coumadin). Ginseng may also cause headaches, tremors, nervousness, and
sleeplessness. It should be avoided in persons with manic disorder and psychosis.
Ginger
Uses: Ginger has been used as a treatment for nausea and bowel spasms.
Reactions: Ginger may lead to blood thinning. It is not recommended to be taken with
medications that prevent blood clotting (anticoagulants) such as warfarin (Coumadin).
Saw Palmetto
Uses: Saw palmetto has been most commonly used for enlargement of the prostate gland. (Dr.
Miller emphasized that studies verifying this assertion are necessary.) Saw palmetto has also
been touted as a diuretic and urinary antiseptic to prevent bladder infections.
Reactions: This herb may affect the action of the sex hormone testosterone, thereby reducing
sexual drive or performance. Dr. Miller states that "While no drug-herb interactions have been
documented to date, it would be prudent to avoid concomitant use with other hormonal therapies
(e.g., estrogen replacement therapy and oral contraceptives...")
Black Cohosh
Claims, Benefits: A natural way to treat menopausal symptoms.
Bottom Line: Little is known about its benefits and its risks.
A child with celiac disease mustn’t consume foods containing gluten and therefore should avoid
prepared puddings, commercially prepared ice cream, malted milk, and all food and beverages
containing wheat, rye, oats, or barley.
The infant of a diabetic mother may be slightly hyperglycemic immediately after birth because of
the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal
pancreas secretes increased levels of insulin in response to this increases glucose amount that
crosses the placenta from the mother. However, during the first 24 hours of life, this combination
of high insulin production in the newborn coupled with the loss of maternal glucose can cause
severe hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia
Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing
venous return and decreasing venous pooling at the distal portion of the extremity.
A platypelloid pelvis has a flat shape. A gynecoid pelvis is a normal female pelvis. An anthropoid
pelvis has an oval shape, and an android pelvis has a heart shape.
The pulse is the earliest indicator of new decreases in fluid volume.
Adult Rickets: deficiency in vitamin D.
Chronic Pain: normal blood pressure, heart rate, and respiratory rate. Normal pupils and dry
skin.
Acute pain: causes increased blood pressure, increased pulse, and respiratory rate, dilated
pupils, and perspiration.
The tip of the endotracheal tube lies 1 cm above the carina. This is positioned above the
bifurcation of the right and left mainstem bronchi.
Creatine Phosphokinase (CPK) is a cellular enzyme that can be fractionated into three
isoenzymes.

MB band reflects CPK from CARDIAC MUSCLE (This is the level that elevates with an
MI.)


MM band reflects CPK from SKELETAL MUSCLE
BB band reflects CPK from the BRAIN
ALKYLATING AGENTS: affect ALL PHASES of the reproductive cell cycle (i.e.,
Cyclophosphamide [Cytoxan])
ANTIMETABOLITES: are cell cycle phase-specific and affect the S PHASE (i.e., Cytarabine
[Cytosar])
VINCA ALKALOIDS: are cell cycle phase-specific and act on the M PHASE
Bell’s Palsy: is a one-sided facial paralysis from compression of the facial nerve. The exact
cause is unknown. Possible causes include vascular ischemia, infection, exposure to viruses
such as herpes zoster or herpes simplex, autoimmune disease, or a combination of these items.
McBURNEY’S POINT: is midway between the right anterior superior iliac crest and the
umbilicus. This is usually the location of greatest pain in the child with appendicitis.
MMR: administered SQ in the outer aspect of the upper arm.
Watch for absolute words “NOT” and “ONLY”
AIR EMBOLISM POSITIONING: Place the client on the left side in the trendelenburg
position. Lying on the left side may prevent air from flowing into the pulmonary veins. The
trendelenburg position increases intrathoracic pressure, which decreases the amount of blood
pulled into the vena cava during inspiration.
Trigeminal neuralgia pain medication: Use Carbamazepine (Tegretol) and Phenytoin
(Dilantin). Narcotic analgesics (Meperidine Hydrochloride [Demerol], Codeine Sulfate , and
Oxycodone) are not effective in controlling pain caused by trigeminal neuralgia.
Grapefruit juice can raise cyclosporine (Sandimmune) levels by 50% to 100%, risk for toxicity.
Fomepizole (Antizol): an antidote given IV to a client with Ethylene Glycol (Antifreeze)
intoxication
Phenotolamine (Regitine): antidote for hypertensive crisis
Bromocriptine (Parlodel): an antiparkinsonian prolactin inhibitor, is used to treat NMS.
Biophysical profile: assesses five parameters of fetal activity: fetal heart rate, fetal breathing
movements, gross fetal movements, fetal tone, and amniotic fluid volume. In a biophysical profile,
each of the five parameters contributes 0 to 2 points with a score of 8 being considered normal
and a score of 10 perfect.
G
T
P
A
Gravidity, the
number of
pregnancies.
Term births, the Preterm births,
Abortions/miscarriages
number born at the number born

Included in
term (40 weeks). before 40 weeks’
gravida if before 20
gestation.
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
Hegar’s sign (Softening and thinning of the lower uterine segment that occurs about
week 6)





Goodell’s sign (softening of the cervix that occurs at the beginning of the second month)
Chadwick’s sign (bluish coloration of the mucous membranes of the cervix, vagina, and
vulva that occurs about week 6)
Ballottement (rebounding of the fetus against the examiner’s fingers on palpation)
Braxton Hicks contractions
A positive pregnancy test measuring for human chorionic gonadotropin
Positive signs of pregnancy:

Fetal heart rate detected by electronic device (Doppler transducer) at 8-12 weeks and by
nonelectronic device (Fetoscope) at 20 weeks of gestation


Active fetal movements palpable by examiner
An outline of fetus via radiography or ultrasound
Acetazolamide (Diamox): used for management of glaucoma is a carbonic anyhdrase inhibitor
that has sulfonamide properties.
Watch out for absolute words “ALL” and “ALWAYS”
Before NG removal: bowel sounds have to be present.
Hyperkalemia on Electrocardiogram:
widening QRS complex
Tall, peaked T waves; prolonged PR interval;
Hypokalemia on Electrocardiogram: ST segment depression; Flat T wave
First-Degree Heart Block: Prolonged P-R interval
Bundle Branch Block: Widened QRS complex
Myocardial Necrosis in Area: Q waves present
Ventricular Fibrillation: No visible P waves or QRS complexes, no measurable
rate. Irregular, chaotic undulations of varying amplitudes.
HypoCalcemia: Prolonged Q-T interval
Myocardial Ischemia: ST segment elevation or depression
Premature Ventricular Contractions: absence of P waves, wide and bizarre QRS
complexes, and premature beats followed by a compensatory pause
Ventricular Tachycardia: absence of P waves, wide QRS complexes, rate between 100 and
250 impulses per minute. Regular rhythm
Atrial Fibrillation: no P waves; instead there are wavy lines, no PR interval. QRS duration
is WNL and irregular ventricular rate can range from 60-160 beats/minute.
ANGINA
Stable
Unstable
Variant
Intractable
Triggered by a
predictable amount of
effort or emotion.
Triggered by an
unpredictable amount of
exertion or emotion and
may occur at night; the
attacks increase in
Triggered by coronary
artery spasm; the
attacks tend to occur
early in the day and at
rest.
Chronic and
incapacitating and is
refractory to medical
therapy.
number, duration, and
severity over time.
Cardiac Conduction System: Sinoatrial Node→Internodal/Interatrial pathways→AV
node→Bundle of His→R/L Bundle Branches→Purkinje fibers
Pulse rate is the earliest indicator of decrease in fluid volume.
A1-adrenergic receptors: found in the peripheral arteries and veins and cause a powerful
vasoconstriction when stimulated
A2-adrenergic receptors: several tissues and contract smooth muscle, inhibit lipolysis, and
promote platelet aggregation.
B1: Found in the heart and cause an increase in heart rate, atrioventricular node conduction, and
contractility.
B2: Arterial and bronchial walls and cause vasodilation and bronchodilation.
PULSE PRESENT = NO DEFIBRILLATION
Myxedema (a.ka. Hypothyroidism)
Suggested toys
a. birth to six months - mobiles, unbreakable mirrors, music boxes, rattles
b. six to 12 months - blocks, nesting boxes or cups, simple take apart toys, large ball, large
puzzles, jack in the box, floating toys, teething toys, activity box, push-pull toys
c. Solitary play
Toddlerhood (one year to three years)
Play is parallel

Suggested toys: push-pull toys, finger paints, thick crayons, riding toys, balls, blocks,
puzzles, simple tape recorder, housekeeping toys, puppets, cloth picture books, large beads to
string, toy telephone, water toys, sand box, play dough or clay, chalk and chalkboard
Preschool age (three years to six years)




Preschool play is associative and cooperative.
dress-up
fantasy play
imaginary playmates

Suggested toys: tricycle, gym and sports equipment, sandboxes, blocks, books, puzzles,
computer games, dress-up clothes, blunt scissors, picture games, construction sets, musical
instruments, cash registers, simple carpentry tools
School age (six years to 12 years)
Play is cooperative.
1.
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
Dullness:Thud-like sound of soft intensity; high pitch; moderate duration; Usually heard over
solid organs (such as heart, liver)
body temperature

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
CRANIAL NERVE FUNCTION
1. Olfactory (CN I)


Can identify variety of smells
Deviation: Inability to identify aroma
2. Optic (CN II)



Has visual acuity and full visual fields
Fundoscopic exam reveals no pathology
Deviation: Inability to identify full visual fields - total or partial blindness of one or both
eyes
3, 4, 6. Oculomotor (CN III), trochlear (CN IV), and abducens (CN VI)




Follows up to six cardinal positions of gaze
Pupils are unremarkable
Exhibits no nystagmus and no ptosis
Deviation: one or both eyes will deviate from its normal position
5. Trigeminal (CN V)






Clenches teeth with firm bilateral pressure
Has no lateral jaw deviation with mouth open
Feels a cotton wisp touched to forehead, cheek and chin
Differentiates sharp and dull sensations on face
Corneal reflex; blinks when cotton is touched to each cornea
Deviation: Absent or one-sided blinking of eyelids
7. Facial (CN VII)








Has facial symmetry with and without a smile
Can raise the eyebrows symmetrically and grimace
Can shut eyes tightly
Can identify sweet, sour, salt or bitter on the anterior tongue
Deviation: Irregular and unequal facial movements
Deviation: Inability to taste or identify taste
Deviation: Inability to taste or identify salt, sweet, sour, or bitter substances on the
anterior two-thirds of the tongue
Deviation: Inability to smile symmetrically
8. Acoustic (CN VIII)





Can hear a whisper at 1-2 feet
Can hear a watch tick at 1-2 feet
Does not lateralize the Weber test
Can hear AC (air conduction) better than BC (bone conduction) in the Rinne test
Deviation: Inability to hear spoken word
9, 10. Glossopharyngeal (CN IX) and Vagus (CN X)







Swallows and speaks without hoarseness
Palate and uvula rise symmetrically when patient says "ah"
Bilateral gag reflex
Can identify taste on the posterior tongue
Deviation: Unequal or absent rise of uvula and soft palate as the client says, "ah"
Deviation: Absent gag reflex
Deviation: inability to taste or identify taste on the posterior tongue
11. Spinal accessory (CN XI)



Resists head turning
Can shrug against resistance
Deviation: Weak or absent shoulder and neck movement
12. Hypoglossal (CN XII)



Can stick tongue out and move it from side to side
Can push tongue strongly against resistance
Deviation: Tongue deviates to side
Types of Coping Mechanisms
1. Compensation - extra effort in one area to offset real or imagined lack in another area
o
Example: Short man becomes assertively verbal and excels in business.
2. Conversion - A mental conflict is expressed through physical symptoms
o
Example: Woman becomes blind after seeing her husband with another woman.
3. Denial - treating obvious reality factors as though they do not exist because they are
consciously intolerable
o
Example: Mother refuses to believe her child has been diagnosed with leukemia.
"She just has the flu."
4. Displacement - transferring unacceptable feelings aroused by one object to another,
more acceptable substitute
o
Example: Adolescent lashes out at parents after not being invited to party.
5. Dissociation - walling off specific areas of the personality from consciousness
o
Example: Adolescent talks about failing grades as if they belong to someone
else; jokes about them.
6. Fantasy - a conscious distortion of unconscious wishes and need to obtain satisfaction
o
Example: A student nurse fails the critical care exam and daydreams about her
heroic role in a cardiac arrest.
7. Fixation - becoming stagnated in a level of emotional development in which one is
comfortable
o
Example: A sixty year old man who dresses and acts as if he were still in the
1960's.
8. Identification - subconsciously attributing to oneself qualities of others
o
Example: Elvis impersonators.
9. Intellectualization - use of thinking, ideas, or intellect to avoid emotions
o
Example: Parent becomes extremely knowledgeable about child's diabetes.
10. Introjection - incorporating the traits of others
o
Example: Husband's symptoms mimic wife's before she died.
11. Projection - unconsciously projecting one's own unacceptable qualities or feelings onto
others
o
Example: Woman who is jealous of another woman's wealth accuses her of
being a gold-digger.
12. Rationalization - justifying behaviors, emotions, motives, considered intolerable through
acceptable excuses
o
Example: "I didn't get chosen for the team because the coach plays favorites."
13. Reaction Formation - expressing unacceptable wishes or behavior by opposite overt
behavior
o
Example: Recovered smoker preaches about the dangers of second hand
smoke.
14. Regression - retreating to an earlier and more comfortable emotional level of
development
o
Example: Four year old insists on climbing into crib with younger sibling.
15. Repression - unconscious, deliberate forgetting of unacceptable or painful thoughts,
impulses, feelings or acts
o
Example: Adolescent "forgets" appointment with counselor to discuss final
grades.
16. Sublimation - diversion of unacceptable instinctual drives into personally and socially
acceptable areas.
o
Example: Young woman who hated school becomes a teacher.
Elizabeth Kubler-Ross: Five Stages
1. Denial
a.
b.
c.
d.
2. Anger
a.
b.
c.
d.
Unconscious avoidance which varies from a brief period to the remainder of life
Allows one to mobilize defenses to cope
Positive adaptive responses - verbal denial; crying
Maladaptive responses - no crying, no acknowledgement of loss
Expresses the realization of loss
May be overt or covert
Positive adaptive responses - verbal expressions of anger
Maladaptive responses - persistent guilt or low self esteem, aggression, self
destructive ideation or behavior
3. Bargaining
a. An attempt to change reality of loss; person bargains for treatment control,
expresses wish to be alive for specific events in near future
b. Maladaptive responses - bargains for unrealistic activities or events in distant
future
4. Depression and Withdrawal
a. Sadness resulting from actual and/or anticipated loss
b. Positive adaptive response - crying, social withdrawal
c. Maladaptive responses - self-destructive actions, despair
5. Acceptance
a. Resolution of feelings about death or other loss, resulting in peaceful feelings
b. Positive adaptive behaviors - may wish to be alone, limit social contacts,
complete personal business
FOODS HIGH IN WATER-SOLUBLE VITAMINS
A.
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
mucomyst: acetaminophen toxicity
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.
2.
3.
4.
Tenderness at the IV site.
Increased swelling at the insertion site.
Area around the IV site is reddened with red streaks.
Fluid is leaking around the IV catheter.
a. Tenderness occurs with phlebitis but is not specific to it.
b. May indicate either infiltration or phlebitis
c. CORRECT—reddened, warm area noted around insertion site or on path of vein;
discontinue IV, apply warm, moist compresses, restart IV at new site
d. Not indicative of phlebitis
Ethacrynic Acid (Edecrin)—are considered loop diuretics and are potassium wasting;
encourage client to increase intake of potassium-rich foods. Orange juice/Bananas, etc.
Aminophylline (Truphylline)—is a xanthine bronchodilator; major side effects: palpitations,
nervousness, rapid pulse, dysrhythmias, nausea, and vomiting. Toxic effects: confusion,
headache, flushing, tachycardia, and seizure.
Morphine Sulfate—decreases blood return to the right side of the heart, and decrease peripheral
resistance. In other words, decreases preload and afterload pressures and cardiac workload;
causes vasodilation and pooling of fluid in extremities; provides relief from anxiety.
Intropin (Dopamine)—vasoactive medication are given IV to restore BP in hypotensive states;
Increases blood return to the right side of the heart, and increase peripheral resistance; side
effects: headache, severe hypertension, dysrhythmias; check BP q2 minutes until stabilized, then
q5 minutes
TPN—hang no longer than 24 hours; IV tubing and filters every 24 hours; site of catheter
changed every 4 weeks.
Fluoxetine (Prozac)—a selective serotonin reuptake inhibitor (SSRI) used to treat depression
and obsessive compulsive disorder. Side effects: postural hypotension, dry mouth, rapid
heartbeat, anorexia, weight loss, severe headache. If dose is missed, omit dose and instruct
client to return to regular dosing schedule.
Propanolol (inderal)—a beta-adrenergic blocker used as antihypertensive; Side effects:
bronchospasm, bradycardia, depression. Take pulse before administration and gradually
decrease when discontinuing. Do not give to asthmatic patients.
Glipizide (Glucotrol)—an oral hypoglycemic that decreases blood sugar by stimulating insulin
release from the beta cells of the pancreas; may cause aplastic anemia and photosensitivity.
Prednisone (Deltasone)—a corticosteroid. Side effects: hyperglycemia
Bethanechol (Urecholine)—a cholinergic or parasympathomimetic used to treat functional
urinary retention; mimics action of acetylcholine.
Ventricular Tachycardia—causes chest pain, dizziness, and fainting.
1 grain = 60mg
Levothyroxine (Synthroid)—thyroid preparation should be administered at breakfast to
prevent insomnia.
Carbamazepine (Tegretol)—interferes with action of hormonal contraceptives. Side effects:
photosensitivity.
Aluminum Hydroxide (Amphojel)—an antacid; neutralizes hydrochloric acid and reduces
pepsin activity; take one hour before and hour of sleep. Antacids most effective after digestion
has started, but prior to the emptying of the stomach.
Isoniazid (INH)—Side effects: peripheral neuropathy (administer pyridoxine), rash, urticaria, and
swelling of the face, lips, and eyelids.
Pyridoxine (Vitamin B6, Beesix, Doxine)—required for amino acid, carbohydrate, and lipid
metabolism. Used in the transport of amino acids, formation of neurotransmitters, and sythesis of
heme. Prevention of neuropathy.
Carbamazepine (Tegretol)—prevention of seizures and relief of pain in trigeminal
neuralgia. Trigeminal neuralgia (Tic douloureux) is an agonizing pain that may result in severe
depression and suicide.
Clonidine (Catapres-TTS)—is a centrally acting alpha-adrenergic used to treat hypertension;
Side effects: drowsiness, sedation, orthostatic hypotension, heart failure. If patch used be
cautious around microwaves results in burns, dispose of carefully, and heat will increase
medication absorption leading to toxicity.
Phlebitis—tenderness, redness; remove iv, apply warm soaks to decrease inflammation,
swelling, and discomfort.
Autologous blood—may give blood 5 weeks before surgery; can give 2 to 4 units of blood; may
have to take iron pills
Partial-thickness burn; only part of skin is damaged or destroyed; large, thick-walled blisters
develop; underlying tissue is deep red, appears wet and shiny; painful with increased sensitivity
to heat; healing occurs by evolution of undamaged basal cells, takes about 21-22 days. I.E.,
Redness and swelling with fluid-filled vesicles noted on right arm or Blistering and blanching of
the skin noted on the back.
Full-thickness burn; all skin is destroyed and muscle and bone may be involved; substance that
remains is called eschar, dry to touch, doesn’t heal spontaneously, requires grafting. I.E.,
Charred, waxy, white appearance of skin on left leg.
Superficial burn; skin appears pink, increased sensitivity to heat, some swelling, healing occurs
without treatment. I.E., Reddened blotchy painful areas noted on the face.
Carbidopa/Levodopa (Sinemet)—used to treat symptoms of Parkinson’s disease. Take
immediately before meals and high-protein meals may impair effectiveness of
medication. Reduces rigidity and bradykinesis and facilitates client’s mobility.
Doxycycline (Vibramycin)—a tetracycline that is taken at regular intervals but not within 1 hour
of bedtime because it may cause esophageal irritation. Use another method of birth control, do
not take antacids within 1-3 hours of taking medication, and may cause photosensitivity.
Albuterol (Proventil)—a bronchodilator. Side effects: tremors, headache, hyperactivity,
tachycardia. Use first before steroid medication so opens up bronchioles for steroid to get in. Wait
one minute between puffs of the inhalers for best effect.
Beclomethasone (Vanceril)—a steroid medication. Side effect: fungal infections, dry mouth,
throat infections.
Insulin—NPH Onset: 1.5 hours Peak: 4-12 hours Regular Onset: 0.5 hours Peak: 2.5-5 hours
Topiramate (Topamax)—is an anticonvulsant. Should drink 2000-3000ml of fluid daily to prevent
kidney stones. Side effects: orthostatic hypotension, ocular symptoms, blindness, and decrease
effects of hormonal contraceptives.
Propranolol (Inderal)—a beta-blocker that takes up beta-adrenergic receptor sites, which
prevents adrenaline from causing symptoms and glycogenolysis. Inderal may mask symptoms of
hypoglycemia, removing the body’s early warning system.
Phenazopyridine (Pyridium)—acts on urinary tract mucosa to produce analgesic or local
anesthetic effects. Side effects: bright orange urine, yellowish discoloration of skin or sclera
indicates drug accumulation due to renal impairment.
Trimethoprim-sulfamethoxazole (Bactrim)—most common side effect mild to moderate rash
(urticaria)
Aminoglycosides are ototoxic.
Butorphanol Tartrate (Stadol)—analgesic used for moderate to severe pain; Side effects
include change in BP, bradycardia, respiratory depression.
Infant normal resting heart rate: 120-140
Salt substitutes contain potassium
When directing a UAP, the nurse must communicate clearly about each delegated task with
specific instructions on what must be reported. Because the RN is responsible for all care-related
decisions, only implementation tasks should be assigned because they do not require
independent judgment.
When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of
vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis)
READ THE QUESTIONS FIRST!!!!!
READ THE QUESTIONS FIRST!!!!!
DETERMINE THE QUESTION!!!!!!
Rash and blood dyscrasias are side effects of anti-psychotic drugs. A history of severe
depression is a contraindication to the use of neuroleptics.
Children with celiac disease should eat a gluten free diet. Gluten is found mainly in grains of
wheat and rye and in smaller quantities in barley and oats. Corn, rice, soybeans and potatoes are
digestible in persons with celiac disease.
The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk
because Decadron increases the production of hydrochloric acid, which may cause
gastrointestinal ulcers.
The protest phase of separation anxiety is a normal response for a child this age (2 year-old
hospitalized child). In toddlers, ages 1 to 3, separation anxiety is at its peak
Signs of tardive dyskinesia include smacking lips, grinding of teeth and "fly catching" tongue
movements.
Verapamil, Bretylium, and Amiodarone increases serum dig levels, possibly causing Digitalis
Toxicity
Signs/Symptoms of Digital Toxicity: first signs include abdominal pain, anorexia, nausea,
vomiting, visual disturbances, bradycardia, and other arrhythmias. In infants and small children,
the first symptoms of overdose are usually cardiac arrhythmias.
Restlessness, confusion, irritability and disorientation may be the first signs of fat embolism
syndrome followed by a very high temperature.
A Neologism is a new word self invented by a person and not readily understood by another that
is often associated with a thought disorder.
Pancreatic enzymes give before meals.
Clinical features of delusional disorder include extreme suspiciousness, jealousy, distrust, and
belief that others intend to harm.
The UAP can be assigned to care for a client with a chronic condition after an initial assessment
by the nurse. This client has no risk of instability of condition.
Never leave your patient. For example, Ask the LPN/LVN to stay with the child and his parents
while the nurse obtains phone orders from the physician.
Tips for charting: don’t use inflammatory words, no nurse judgments, be as specific as possible.
I.E.,
“Vital signs stable” is incorrect for of charting.
Restraint: frame of bed, quick release ties, document need for restraint Q4 hours
Never ask “WHY” questions in the NCLEX!
Gag Reflex: don’t assess gag reflex to a client that has an absent swallow reflex
Nifedipine (Procardia XL): do not crush
An RN that is not assigned to a patient does not have the authority to tell a nurse what to
do. Refer it to nursing supervisor.
If doctor has orders it should carried out unless contraindicated in nurse’s decision.
Physical assessment: Inspection, Percussion, Palpation, Auscultation (Except for abdomen:
Inspection, Auscultation, Percussion, Palpation)
Coronary artery bypass graft (CABG)—halt medications before surgery, can do 5 at a time; will
be on mechanical ventilations after surgery; chest tubes
Acromegaly—monitor blood sugar, atrium—90 implant care (radioactive, nasally implanted,
monitor vision)
Bone marrow Aspiration---done at iliac crest; painful
Postoperative care after Supratentorial surgery: maintain airway, elevate head 30-45
Position care after Infratentorial surgery: flat and lateral
Orange juice does not help acidify urine it makes it more alkaline.
Myelogram


Water-soluble dye—elevate head of bed 30 degrees (not removed)
Oil based dye—flat in bed (removed)
Fractures:
o
o
o
o
Immobilize joint above and below fracture
Cover open fracture with cleanest material available
Check temperature, color, sensation, capillary refill distal to fracture
Close reduction—manually manipulate bone or use traction
Buck’s Traction






Use to relieve muscle spasm of leg and back
If used for muscles spasms only, they can turn to either side.
If used for fracture treatment, only can turn to unaffected side.
Use 8-20 lbs of weight, if used for scoliosis will use 40 lbs of weight.
Elevate head of bed for countertraction or foot bed
Place pillow below leg not under heel or behind knee.
Russell’s Traction





Sling is used
Check for popliteal pulse
Place pillow below lower leg and heel off the bed
Don’t turn from waist down
Lift patient, not the leg
Cervical Tongs


Never lift the weights
No pillow under head during feedings
Balanced Suspension Traction



For femur realignment
Maintain weights hanging free and not on floor
Maintain continuous pull
Halo Jacket

Maintain pin cleansing
Casts





Don’t rest on hard surface
Don’t cover until dry 48+ hours
Handle with palms of hands not with fingers
Keep above level of heart
Check for CSM
Fractured Hip
o



o






Assessments
Leg shortened
Adducted
Externally rotated
Implementation
Care after a total hip replacement
Abduction pillows
Crutch walking with 3-point gait
Don’t sleep on operated side
Don’t flex hip more than 45-60 degrees
Don’t elevate head of the bed more than 45 degrees
Amputations



Guillotine (open)
Flap (closed)
Delayed prosthesis fitting

Residual limb covered with dressing and elastic bandage (figure eight)






Figure-8 doesn’t restrict blood flow, shaped to reduce edema
Check for bleeding
Elevated 24 hours (AKA-pillow, BKA-foot of bed elevated)
Position prone daily
Exercises, crutch walking
Phantom Pain: acknowledge feelings, that pain is real for them.
Thiamin (Vit. B1)—carbohydarte metabolism; deficiency will cause Beri-Beri
Pyridoxine (Vit. B6)—amino acid metabolism; deficiency will cause anemia, seizures
Folic acid—RBC formation; deficiency will cause anemia
Cyanocobalamin (B12)—nerve function; deficiency cause pernicious anemia
Calcium deficiency causes Rickett’s
Cultural Food Pattern’s




Orthodox Jewish (Kosher)—milk and meat cannot be eaten at same meal
Muslin—30 day fast during Ramadan
Japanese—rice is basic food, tea is main beverage
Greek—bread is served with every meal
Enteral feeding held if: 150 or > cc’s aspirated or 50% given in the hour is aspirated

If cramping, vomiting occurs decrease rate of enteral feeding or keep it warm.
TPN—supply nutritions via intravenous route






Peripherally or centrally
Initial rate 50/hour and can be increased to 100-125ml/hour.
A pump must be used to keep rate constant
Prevent sepsis: maintain closed system,, don’t draw blood/infuse anything in line, dry
sterile dressing
Verify placement of line
Monitor Glucose, acetone





Change IV tubing/Filter Q24 hours
Solution refrigerated then warmed
If solution not available, start 10% in water.
3/week check BUN, electrolytes (ca, mg)
When TPN Dc’d taper patient off or else will get rebound hypoglycemia (use hypotonic to
do this)
Specific gravity 1.010-1.030
Ph 4.5-8
1,000-1,500cc/day
Crede’s Manuever—push urine out
Pernicious Anemia

monthly Vitamin B12 IM injections
Metered dose inhaler


Beclomethasone (Vanceril)
Albuterol (Proventil)
Guillain-Barre Syndrome



GBS often preceded by a viral infection as well as immunizations/vaccinations
Intervention is symptomatic
Acute phase: Steroids, plasmapheresis, aggressive respiratory care; prevent hazards of
immobility, maintain adequate nutrition; physical therapy; pain-reducing measures; eye care,
prevention of complications (UTI, aspiration); psychosocial support
Organ Donation Criteria










No history of significant, disease, process in organ/tissue to be donated
No untreated sepsis
Brain death of donor
No history of extracranial malignancy
Relative hemodynamic stability
Blood group compatibility
Newborn donors must be full term (more than 200g)
Only absolute restriction to organ donation is documented case of HIV infection
Family members can give consent
Nurse can discuss organ donation with other death-related topics (funeral home to be
used, autopsy request)
Accurate way to verify NG tube position is to aspirate for gastric contents and check pH.
Parkinson’s disease





Activities should be scheduled for late morning when energy level is highest and patient
won’t be rushed
Symptoms: tremors, akinesia, rigidity, weakness, “motorized propulsive gait, slurred
monotonous speech, dysphagia, drooling, mask-like expression.
Nursing care: encourage finger exercises. Administer Artane, Congentin, L-Dopa,
Parlodel, Sinemet, Symmetrel.
Teach: ambulation modification
Promote family understanding of disease intellect/sight/hearing not impaired, disease
progressive but slow, doesn’t lead to paralysis
Normal urine output (1200-1500 cc’s/day or 50-63 cc/hr, normal voiding pattern 5-6 times/day.
Green leafy vegetables contain vitamin K.
Labs
HbA1c (4.5-7.6%)

indicates overall glucose control for the previous 120 days
Serum Amylase / Somogyl (60-160 u/dL)

elevated in acute pancreatitis
Erythrocyte Sedimentation Rate (ESR)




Men (1-15)
Women (1-20)
Rate at which RBC’s settle out of unclottted blood in one hour
Indicates inflammation/neurosis
Hematocrit (Hct)





Men (40-45) u/mL
Women (37-45) u/mL
Relative volume of plasma to RBC
Increased with dehydration
Decreased with volume excess
Creatine Kinase (CK)




Men (12-70)
Women (10-55)
Enzyme specific to brain, myocardium, and skeletal muscles
Indicates tissue necrosis or injury
Serum Glucose

60-110 mg/dL
Sodium (Na+)


o
135-145 mEq/L
Hypernatremia
Dehydration and insufficient water intake
Chloride (Cl-)

95-105 mEq/L
Potassium (K+)

3.5-5.0 mEq/L
Bicarbonate (HCO3)


22-26 mEq/L
Decreased levels seen with starvation, renal failure, diarrhea.
Blood, Urea, Nitrogen (BUN)


6-20 mg
Elevated levels indicate rapid protein catabolism, kidney dysfunction, dehydration
Creatinine Clearance Test


normal 125 ml/min.
Lower levels reflect renal insufficiency and may influence the excretion of many drugs
and toxins from the body.
Lithium

targeted blood level: (1-1.5 mEq/L)
Tofranil and Anafranil—OCD medications
Pick physical needs over psychosocial needs!!!!!!!!!!!!!!!
Focus on here and now!!!!!!!!!!!!!!!!!
Oculogyric crisis: uncontrollable rolling back of eyes: side effect of Phenothiazines
Moribund means dying patient.
Don’t leave your patients. Stay with your patients.
Assess before implementation.
Manic patient: decrease stimuli and increase rest period and no competition.
Lithium helps control impulsive behaviors.
Fluphenazine (Prolixin): antipsychotic medication
Thiamine sources: organ meats, liver, whole grain, nuts, legume, egg, and milk.
Don’t document abuse. Report suspected abuse to nursing supervisor.
Never promise a patient “Not to tell.”
Tonometry—measures intraocular pressure; to rule out glaucoma
Myopia—nearsightedness (near clear, distance clear)
Hyperopia—farsightedness (distance is clear, near vision blurry)
Presbyopia—changes with aging
Blind client: address by name, introduce self, keep furniture arrangement consistent, open or
close doors walk ½ step ahead, identify food location on tray.
Instilling ear drops lie patient on unaffected ear to absorb drops.
Position patient on affected ear to promote drainage.
Regular Insulin only given IV.
Sick day rules: take insulin as ordered, check blood glucose q3-4 hours, soft foods, liquids
Phenylketonuria—high blood phenylalanine (no enzyme), results in mental retardation; milk
substitutes, low-protein diet
Celiac Disease (SPrue)—intestinal malabsorption, malnutrition (unable to digest
wheat/rye/oats/barley); gluten-free diet
Hepatobiliary disease—decrease in ability of bile to absorb fat, fat malabsorption; low-fat highprotein diet, vitamins
Cystic fibrosis—absence of pancreatic enzymes, malabsorption of fat, lung disease, pancreatic
enzyme replacement, high-protein, high-calorie diet, respiratory care/suction
Position right side to promote gastric emptying.
Dumping syndrome prevention: restrict fluid with meals, lie down after eating, small, frequent
meals, low-carbohydrate, low-fiber diet
Sengstaken-Blakemore Tube—to treat pt. with esophageal varices.



Hepatitis B Vaccine
MMR (Mumps, Measles, and Rubella)
Given IM to vastus lateralis or deltoid
Given SC anterior or lateral thigh
Side effects: mild tenderness at site
Side effects: rash, fever, arthritis in 10 days to 2
weeks.
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






1st shot – 12 to 18 months
2nd shot – 4 to 6 years
Varicella (Chickenpox)

Side effects: fever within 24-48 hours, swelling,
redness, soreness

Don’t treat with aspirin, use other antipyretic. 

st
1 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
12 to 18 months
PCV (Pneumococcal)
1st shot – 2 months
2nd shot – 4 months
3rd shot – 6 months
4th shot – 12 to 18 months
TB
Given intradermal
Evaluated in 48 to 72 hours
Hib (Influenza)
TD

1st
shot – 2months



2nd shot – 4months
3rd shot – 6 months
4th shot – 12 to 18 months
Given IM into anterior or lateral thigh
Repeated every 10 years
IPV (Inactive Polio Vaccine)
Live attenuated Rubella
Given PO, Few side effects
Given once SC into anterior or lateral thigh




1st shot – 2 months
2nd shot – 4 months
3rd shot – 6 to 18 months
4th shot – 4 to 6 years
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 120-160 bpm, increases with crying
Respirations 30-50/min, diaphgramatic (abdomen moves), can be irregular
BP 60/40 – 80/50 mmHg
1-4 year old



Pulse: 80-140
Resp: 20-40
BP: 90-60 – 99/65
5-12 year old



Pulse: 70-115
Resp: 15-25
BP: 100/56 – 110/60
Adult

Pulse: 60-100


Resp: 12-20
BP: 90/60-140/90
Aortic Valve: Right of Sternum at the 2nd intercostal space
Pulmonic Valve: Left of Sternum at the 2nd intercostal space
Tricuspid Valve: Immediately left of sternal border at the 5th Intercostal Space
Mitral Valve (Point of Maximal Impulse): Left of Sternum Mid-Clavicular Line at the 5th Intercostal
Space
Erbb’s Point: Left of Sternum at the 3rd intercostal space
Infant (Point of Maximal Impulse): Lateral to sternum 4th intercostals space
Obese person choking use Chest Thrusts.
Tracheostomy tube placement of cuff maintained to prevent aspiration
Care for patient first, equipment second
Signs for hypoxia: restlessness, tachycardia
CPR: Shake, shout, summon help, open airway, look, listen, feel for signs of breathing, pinch
nose, give 2 full breaths (if no rise, reposition)
Adults 12/min check carotid, chest compressions 80-100/min 1.5 inches
Infants 20/min check brachial pulse, chest compression 100/min ½ - 1 inch
15:2 Adult 4 cycles
Infant 20 cycles
Reassess pulse and breathing
Continue CPR until:




Victim responds
Someone else takes over
Victim is transferred
Rescuer is unable to continue
MI
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
CSF leakage – good place to look is behind the ears.
Head Injury – elevate bed 30 degrees, barbiturate therapy, hypothermia, glucocorticoids
(Decadron)
Flail Chest
Sucking Chest Wound
(Sucking Open
Affected side
goes down during Pneumothorax)
inspiration and up

Sucking sound with
during expiration
Pneumothorax
Implementation
Collapse of lung due to
alteration of air in intrapleural
space
Monitor for shock
Humidified oxygen



respiration

Pain

Decreased breath 
sounds
Anxiety



Dyspnea
Pleuritic pain
Restricted movement
on affected side
Decreased/absent
breath sounds
Cough
Hypotension
Thoracentesis
(aspiration of fluid
from pleural space)
Chest Tubes
Cullen’s Sign – ecchymosis around umbilicus
Turner’s Sign – ecchymosis around either flank
Balance’s sign – resonance over spleen (+) means rupture of spleen
Shock Signs and Symptoms







Cool, clammy skin
Cyanosis
Decreased alertness
Tachycardia
Hypotension
Shallow, rapid respirations
Oliguria
Hypovolemic
Cardiogenic
Distributive
Decreased in intravascular
volume
Decreased cardiac output
Problem with blood flow to cells
Implementation for shock

Monitor CVP: <3 inadequate fluid >11 too much fluid
Increased ICP


Altered LOC (Earliest Sign)

Glasgow coma scale <7 indicates coma

Confusion

Restlessness

Pupillary changes

Assessments





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

Vital sign changes – WIDENING PULSE

PRESSURE
Medications – Osmotic diuretics, corticosteroids
Seizures:
o
o
do not restrain
do not insert anything in mouth
Electrolytes
Potassium: 3.5-5.0 mEq/L
Sodium: 135-145 mEq/L
Calcium: 4.5-5.2 mEq/L
Magnesium: 1.5-2.5 mEq/L
Hypokalemia Assessments





K+ < 3.5 mEq/L

Muscle weakness

Paresthesias
Dysrhythmias

Increased sensitivity to digitalis
Hypokalemia Implementations
Potassium Supplements
Don’t give > 40 mEq/L into peripheral IV or without
cardiac monitor
Increase dietary intake – oranges, apricots, beans,
potatoes, carrots, celery, raisins
Hyperkalemia Assessments





K+ >5.0 mEq/L
EKG changes
Paralysis
Diarrhea
Nausea
Hyperkalemia Implementations





Hyponatremia Assessments




Na+ < 135 mEq/L
Nausea
Muscle cramps
Confusion
Restrict oral intake
Kayexalate
Calcium Gluconate and Sodium
Bircarbonate IV
Peritoneal or hemodialysis
Diuretics
Hyponatremia Implementations




I&O
Daily weight
Increase oral intake of sodium rich foods
Water restriction

Increased ICP

Hypernatremia Assessments






Hypernatremia Assessments
Na+ >145 mEq/L

Disorientation, delusion, hallucinations
Thirsty, dry, swollen tongue

Sticky mucous membranes
Hypotension
Tachycardia
Hypocalcemia Assessments







Ca+ < 4.5 mEq/L
Tetany
Positive Trousseau’s sign
Positive Chvostek’s sign
Seizures
Confusion
Irritability, paresthesias




Ca+> 5.2 mEq/L

Sedative effects on CNS

Muscle weakness, lack of coordination
Constipation, abdominal pain


Depressed deep tendon reflexes
Dysrhythmias


Mg+< 1.5 mEq/L
Neuromuscular irritability
Tremors
Seizures
Tetany
Confusion
Dysphagia
Hypermagnesemia Assessments
Oral calcium supplements with orange
(maximizes absorption)
Calcium gluconate IV
Seizure precautions
Meet safety needs
Hypercalcemia Implementations
Hypomagnesemia Assessments







I&O
Daily Weight
Give hypotonic solutions: 0.45% NaCl or
5% Dextrose in water IV
Hypocalcemia Implementations
Hypercalcemia Assessments






IV Lactated Ringer’s or 0.9% NaCL
0.4% NaCl or 0.9% NaCl IV
Encourage fluids (acidic drinks:
cranberry juice)
Diuretics
Calcitonin
Mobilize patient
Surgery for hyperparathyroidism
Hypomagnesemia Implementations




Monitor cardiac rhythm and reflexes
Test ability to swallow
Seizure precautions
Increase oral intake—green vegetables,
nuts, bananas, oranges, peanut butter, chocolate
Hypermagnesemia Implementations





Mg + > 2.5 mEq/L

Discontinue oral and IV magnesium
Hypotension

Monitor respirations, cardiac rhythm,
Depressed cardiac impulse transmission reflexes

IV Calcium to antagonize cardiac
Absent deep tendon reflexes
Shallow respirations
depressant activity (helps to stimulate heart)
Burns Assessments



Superficial partial thickness—pink to red, painful
Deep partial thickness—red to white, blisters, painful
Full thickness—charred, waxy, white, painless
Wound Care for Burns





Never break blisters
Isotonic fluids (Lactated Ringer’s)
Closed method (Silvadene) covered with
dressings
Open method (Sulfamylon) that are not
covered with dressings
IV pain medication initially: not PO takes
too long, not IM circulation impaired
Addisson’s Disease Assessments








Fatigue
Weakness
Dehydration
Eternal tan
Decreased resistance to stress
Low Sodium
Low Blood Sugar
High Potassium
Addisson’s Disease Implementations


Addisonian Crisis Assessments





Hypotension
Extreme weakness
Nausea vomiting
Abdominal pain
Severe hypoglycemia
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
High protein, High carbohydrate, high
Sodium, Low potassium diet
Teach life-long hormone replacement
Addisonian Crisis Implementations



Administer NaCl IV, vasopressors,
hydrocortisone
Monitor vital signs
Absolute bedrest

Dehydration
Cushing’s Syndrome Assessments







Osteoporosis
Muscle wasting
Hypertension
Purple skin striations
Moon face
Truncal obesity
Decreased resistance to infection
Pheochromocytoma Assessments—
hypersecretions of the catecholamines
(epinephrine/norepinephrine)



















Persistent hypertension
Hyperglycemia
Pounding headache
Palpitations
Visual disturbances
Cushing’s Syndrome Implementations



Low Carbohydrate, Low Calorie, High
Protein, High Potassium, Low sodium diet
Monitor glucose level
Postop care after adrenalectomy or
hypophysectomy
Pheochromocytoma 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
COPD Implementations
“Blue Bloaters”

“Pink Puffers”

Weakness

Change in postured day and hs (don’t
sleep laying down, have to stay erect)
Use of accessory muscles of breathing
Dyspnea

Cough

Adventitious breath sounds
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
Pneumonia Implementations
Fever

Leukocytosis

Productive Cough (rust, green, yellow)
Dyspnea

Pleuritic pain

Tachycardia


Check breath sounds
Cough and deep breath q 2 hours
Chest physiotherapy
Antibiotics
Incentive spirometer
Encourage fluids
Suction PRN




Acyanotic Congenital Heart Anomalies
Assessments






Normal Color
Possible exercise intolerance
Small stature
Failure to thrive
Heart murmur
Frequent respiratory Infections
Provide oxygen
Semi-Fowler’s position
Bedrest
Medications—mucolytics (Mucomyst),
expectorants (Robitussin), Bronchodilators
(Aminophylline), Antibiotics (Bacterim)
Cyanotic Congenital Heart Anomalies
Assessments










Cyanosis
Clubbing of fingers
Seizures
Marked exercise intolerance
Difficulty eating
Squat to decrease respiratory distress
Small stature
Failure to thrive
Characteristic murmur
Frequent respiratory infections
Acyanotic Congenital Heart Anomalies Types:

Ventricular Septal Defect (VSD)—abnormal opening between right/left ventricles; hole size
of pinhole or absence of septum; hear a loud harsh murmur, at age of 3 hole may close otherwise
surgery such as purse-string suture

Atrial Septal Defect (ASD)—abnormal opening between the two atria; audible murmur (if
defect is severe closure is done later in childhood)

Patent Ductus Arteriosis (PDA)—failure of fetal structure to close after birth; ductus
areteriosis in the fetus connects the pulmonary artery to aorta to shunt oxygenenated blood from
the placenta to systemic circulation (which bypasses the lungs). Once the child is born that
structure should close because it is no longer needed because blood passes through to lungs;
vascular congestion, right ventricular hypertrophy; murmur, bounding pulse, tachycardia; surgical to
divide or ligate the vessel.

Coarctation of the Aorta—narrow of aorta; high blood pressure and bounding pulse in
areas that receive blood proximal to the defect. Weak and absent blood distal to aorta. Surgical
end-to-end anastomosis.

Pulomonic Stenosis—narrowing at entrance to pulmonary artery; causes resistance to
blood flow and right ventricular hypertrophy; surgery

Aortic Stenosis—narrowing of aortic valve; causes decrease cardiac output; surgery
Cyanotic Congenital Heart Anomalies Types:

Tetralogy of Fallot—VSD, pulmonic stenosis, overriding aorta, right ventricular hypertrophy;
squats/knee chest position to help breath; surgery needed

Transposition of great vessels—pulmonary artery leaves left ventricle and aorta leaves
right ventricle; oxygenated blood not going into systemic circulation
Truncus arteriosus—failure of normal septation and embryonic division of the pulmonary
artery and aorta; rather than two distinctly different vessels there is a single vessel that overrides
both ventricles and gives rise to both pulmonary and systemic circulation; blood enters from both
common artery and either goes to the lungs or to the body; cyanosis, murmur, difficult intolerance
Total anomalous venous return—absence of direct communication between pulmonary
veins and left atria; pulmonary veins attach directly to right atria or drains to right atria


Congenital Heart Anomalies Compensatory Mechanisms



Tachycardia
Polycythemia (increase formation of RBC’s)
Posturing—squatting, knee-chest position
Congenital Heart Anomalies Implementations





Prevention
Recognize early symptoms
Monitor vital signs and heart rhythms
Medications—digoxin, iron, diuretics, potassium
Change feeding pattern
Left-Side CHF




Dyspnea, orthopnea
Cough
Pulmonary edema
Weakness/Changes in mental status
Right-Side CHF




CHF Implementations



Administer digoxin, diuretics
Low-sodium, low-calorie, low-residue diet
Oxygen therapy
Dependent edema
Liver enlargement
Abdominal pain/Nausea/Bloating
Coolness of extremities


















Daily weight
Teach about medications and diet
Arterial Peripheral Vascular Disease
Arterial Peripheral Vascular Disease
Assessments
Implementations
Rubor
Cool shiny skin
Ulcers
Gangrene
Intermittent Claudication (pain with
exercise/walking relieved with rest)
Impaired sensation
Decreased peripheral pulses





Venous Peripheral Vascular Disease
Venous Peripheral Vascular Disease
Assessments
Implementations
Cool, brown skin
Edema
Normal or decreased pulses
Positive Homan’s sign






Monitor peripheral pulses
Elastic stockings
Medications—anticoagulants
Elevate legs
Warm, moist packs
Bedrest 4-7 days (acute phase)
Anemia Assessments (reduction in hemoglobin Anemia Implementations
amount/erythrocytes)

Identify cause

Frequent rest periods
Palpitations
Dyspnea

High protein, high iron, high vitamin diet
Diaphoresis

Protect from infection
Chronic fatigue
Sensitivity to cold
Iron Deficiency Anemia Assessments




Monitor Peripheral pulses
Good foot care
Stop smoking
Regular exercise
Medications—vasodilators,
anticoagulants
Fatigue
Glossitis
Spoon fingernails
Impaired cognition
Iron Deficiency Anemia Implementations


Increase iron-rich foods (liver, green
leafy vegetables)
Iron supplements (stains teeth)




Pernicious Anemia Assessments (gastric
Pernicious Anemia Assessments
mucosa fail to secrete enough intrinsic factor for

Vitamin B12—IM
stomach to absorb)

Rest of life can’t be absorbed PO
Schilling’s Test
Fatigue
Sore, red tongue
Paresthesia in hands and feet
Sickle Cell Anemia Assessments




Pain /Swelling/Fever
Schlerae jaundiced
Cardiac murmurs
Tachycardia
Sickle Cell Anemia Implementations

Check for signs of infection (prevent
crisis)



Check joint areas for pain and swelling
Encourage fluids
Provide analgesics with PCA pump c
crisis



Hemophilia Assessments (female to male gene Hemophilia Implementations
transmission)

Administer plasma or factor VIII

Analgesics
Easy bruising
Joint pain

Cryoprecipitated antihemophilic factor
Prolonged bleeding
(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
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


Don’t stand close or in line with source
Patient on bed rest
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





Intracranial Tumors Assessments







Motor deficits
Hearing or visual disturbances
Dizziness
Paresthesia
Seizures
Personality disturbances
Changes in LOC
Monitor for signs of bleeding: petechiae,
ecchymosis, thrombocytopenia
Infections
Neutropenia (private room/limit # people,
wbc done daily, no fruit, no flowers/plotted
plants, clean toothbrush with weak bleach
solution
Good mouth care
High calorie, high Vitamin diet (avoid
salads/raw fruit/pepper/don’t reuse cup/don’t
change litter box/digging in garden
Intracranial Tumors Implementations





Preoperative: do neurological
assessment, patient head shaved
Postoperative: maintain airway, elevate
head 30-45 after supratentorial surgery
Flat and lateral after infratentorial
surgery
Monitor vital and neurological signs
Glascow coma scale
Therapeutic Positions
o
o
o
o
o
o
o
Supine—avoids hip flexion
Dorsal recumbent—supine with knees flexed
Prone—extension of hip joint(after amputation)
Side lateral—drainage of oral secretions
Knee-chest—visualization of rectal area
Sim’s—decreases abdominal tension (side lying with legs bent)
Fowler’s—increases venous return, lung expansion
o
o
o
o
o
o
o
High Fowler’s—60-90
Fowler’s—45-60
Semi-Fowler’s—30-45
Low Fowler’s—15-30
Modified Trendelenburg—used for shock;Feet elevated 20 degrees, knees straight,
trunk flat, head slightly elevated
Elevation of extremity—increases blood to extremity and venous return
Lithotomy—used for vaginal exam
4 point Gait
2 point Gait
3 point Gait
Weight bearing
both legs
Bearing both legs
Bearing one leg
RC/LF, LC/RF
Weaker leg both crutches, then
stronger leg
RC, LF, LC, RF
Swing-to-swing
through
Partial weight
bearing both legs
Both crutches, one
or two legs
Stairs



Going up—“good” leg first, crutches, “bad” leg
Going down—crutches with “bad” leg, then “good” leg
“Up with the good, down with the bad”
Walker
o
o
o
o
Flex elbows 20-30 degrees when hands are on grips
Lift and move walker forward 8-10 inches
Step forward with “bad” leg, support self on arms, follow with “good” leg
Stand behind client holding onto gait belt
Myelogram—x-ray visualization of the spinal
canal by injection of radiopaque dye.
Post-procedure




Hydration done 12 hours before
procedure

Cleansing enemas

Avoid seizure-promoting medications
Laminectomy—excision portion of lamina to
expose area of affected disc


Preopcare: moist heat
Fowler’s position
Water-soluble dye—elevate head of bed
30 degrees (not removed)
Oil based dye—flat in bed (removed)
Bedrest 24 hours encourage fluids
Postoperative care:



Assess circulation and sensation
Log roll Q2 hours with pillow between leg
Calf exercises, assist with ambulation







Isometric exercises for abdominal
muscles

Muscle relaxants, NSAIDs, Analgesics
Traction, TENS

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
Dysplasia of the Hip Implementations
Uneven gluteal folds and thigh creases Newborn to 6 months
Limited abduction of hip
Reduced by manipulation
Ortolani’s sign—place infant on back 
Pavlik harness for 3 to 6 months
with legs flexed, clicking sound with abductionof
legs
6 to 18 months
Shortened limb on affected side


Bilateral Bryant’s traction
Hip spica cast
Older child






Scoliosis Assessments—lateral deviation of
Scoliosis Implementations
one or more of vertebrae accompanied by rotary

Exercises to strengthen abdominal
motion of spine
muscles (if functional)
Uneven hips or scapulae

Surgery: spinal fusion insertion of
Kyphosis lump on back
Herrington Rod
Bend at waist to visualize deformity 
Milwaukee brace: used with curves 30Structural (flexible deviation corrected
40 degrees
with bending) or functional (permanent

Wear 4-6 years, worn 23 hours of the
heredirary that is seen)
day, wear undershirt to prevent irritation, teach
isometric exercises
Cerebral Palsy Assessments


Open reduction
Hip Spica cast
Cerebral Palsy Implementations
Voluntary muscles poorly controlled due

Ambulation devices, PT and OT
to brain damage

Muscle relaxants and anticonvulsants
Spasticity, rigidity, ataxia, repetitive 
Feeding: place food at back of mouth
involuntary gross motor movements
with slight downward pressure. Never tilt head
backward.

Muscular Dystrophy Assessments
High calorie diet
Braces to help ambulation Balance activity and
rest
Atrophy of voluntary muscles
Muscle weakness, lordosis, falls
Parkinson’s Disease Assessments




Parkinson’s Disease Implementations

Deficiency of dopamine
Tremors, rigidity, propulsive gait
Monotonous speech
Mask like expression

Myasthenia Gravis Assessments






pulp


Full liquid
No milk 
No juice with


High protein diet

Myasthenia Gravis Implementations
Deficiency of acetylcholine
Muscular weakness produced by
repeated movement
Dysphagia
Respiratory distress
Clear liquid
Restablish
anabolism to raise
albumin levels
Egg, roast
beef sandwich, 
No junk food
No jam
No fruit
No nuts

Renal
Teach ambulation modification: goose
stepping walk (marching), ROM exercises
Medications—Artane, Cogentin, L-Dopa,
Parlodel, Sinemet, Symmetrel




Good eye care, restful environment
Medications—anticholinesterases,
corticosteroids, immunosuppressants
Avoid crisis: infection
Symptoms: sudden ability to swallow
Low-fat cholesterol
restricted
Can eat lean meat

No
No avocado, milk, cheese 
bacon, egg yolks butter
Low-phenylalanine diet
Keeps
Sodium
restricted
Prevents brain
protein,
damage from imbalance
potassium and
of amino acids
sodium low 
Fats, fruits, jams
No
allowed
beans, no

No meats eggs
cereals, no citrus bread
High
roughage,
high fiber 
No 
white bread
without fiber
Low-residue
Minimize
intestinal activity
Buttered
rice white
processed food, no
whole wheat corn
bran
fruits
Glomerulonephritis Assessment










Glomerulonephritis Implementation





Restrict sodium and water intake
Bedrest
I&O
Daily weight
High Calorie, Low protein
Done for: Bladder t umors, birth 
defects, neurogenic bladder, interstitial
cystitis

Ileal Conduit
Koch Pouch
Nephrostomy: flank incision and insertion of nephrostomy
tube into renal pelvis; penrose drain after surgery; surgical dressing
Ureterosigmoidostomy: urters detached from bladder and
anastomosed to sigmoid colon; encourage voiding via rectum q 2-4
hours;no enemas or cathartics; complications—electrolyte imbalance,
infection, obstruction; urine and stool evacuated towards anus.
Cutaneous Ureterostomy: Stoma formed from ureters excised
from bladder and brought to abdominal wall; stoma on right side below
waist; assist with alteration in body image
Illeal Conduit: Ureters replanted into portion of terminal ileum
and brought to abdominal wall; check for obstruction; mucous threads
in urine normal
Koch Pouch (Continent Illeal Conduit): Ureters transplanted
into pouch made from ileum with one-way valve; drainage of pouch by
catheter under control of client; drain pouch at regular intervals

Acute Renal
Failure
Assessments:
Oliguric Phase



agents
Urinary Diversion Implementations


Antibiotics, corticosteroids
Antihypertensives, immunosuppressive
Urinary Diversion: Assessments




Fever, Chills
Hematuria
Proteinuria
Edema
Hypertension
Abdominal or flank pain
Occurs 10 days after beta hemolytic
streptococcal throat infection
Acute Renal Failure
Assessments: Diuretic
Phase


Output 4-5

Output <400 L/day
cc/day

Increased BUN
Hypertensio

Na+, K+ lost in
n
urine
Anemia 
Increased
CHF
mental and physical
Confusion
Acute Renal Failure
Causes
Acute Renal Failure
Implementations:

Prerenal—reduced
blood volume
Renal—nephrotoxic
drugs, glomerulonephritis
Postrenal-obstruction



Low-output stage:
Limit fluids, Kayexalate,
Dialysis
High-output stage:
Fluids as needed, K+
replacement, Dialysis
I&O
Daily Weight
Monitor Electrolytes


Increased
activity
K+, Ca+, Na+, BUN,
Creatinine
phase




Hemodialysis Implementation




Bedrest during acute
Peritoneal Dialysis
IV fluids
Diet restrictions
Oliguric phase: limit
fluids, TPN maybe
After Diuretic phase:
high protein, high calorie diet
Types of Peritoneal
Dialysis
Check for thrill and bruit q
8
Weight before and after
hours
treatment

Continuous
Don’t use extremity for BP,

Monitor BP
ambulatory (CAPD)
finger stick

Monitor breath sounds
Automated
Monitor vital signs, weight,

Use sterile technique 
Intermittent
breath sounds

If problem with outflow,
Continuous
Monitor for hemorrhage
reposition client

Side effects: constipation
Ego Defense Mechanisms
o
o
o
o
o
o
o
o
o
o
o
o
o
Denial—failure to acknowledge thought
Displacement—redirect feelings to more acceptable subject
Projection—attributing your feelings to someone else
Undoing—attempt to erase an act, thought or feeling
Compensation—attempt to overcome shortcoming
Symbolization—less threatening object used to represent another
Substitution—replacing unacceptable or unobtainable object to one that is
acceptable or attainable
Introjection—symbolic taking into oneself the characteristics of another
Repression—unacceptable thoughts kept from awareness
Reaction formation—expressing attitude opposite of unconscious wish or fear
Regression—returning to an earlier developmental phase
Dissociation—detachment of painful emotional conflicts from consciousness
Suppression—consciously putting thought out of awareness
Dying patient: Denial, Anger, Bargaining, Depression, Acceptance
Bipolar Disorder Assessments



Disoriented, flight of ideas
Lacks inhibitions, agitated
Easily stimulated by environment
Bipolar Disorder Implementations



Meet physical needs first
Simplify environment
Distract and redirect energy
















Sexually indiscreet

Affective disorder

Maintain contact with reality

Elation is defense against underlying 
depression
Manipulative behavior results from poor

self-esteem
Provide external controls
Set limits: escalating hyperactivity
Use consistent approach
Administer Lithium (help Manic Phase of
Bipolar, keep hydrated)
Increase awareness of feelings through
reflection
Schizophrenia Assessments
Schizophrenia Types
Schizophrenia Implementations
Withdrawal from

relationships and world
Inappropriate display of
feelings

Hypochondriasis
Suspiciousness
Inability to test reality,

regression
Hallucinations—false
sensory perceptions
Delusions—persistent false
beliefs; grandeur (feel higher rank);
persecutory (beliefs to be a victim);
ideas of reference (see people
talking think talking about them)
Loose associations
Short attention span
Inability to meet basic
needs: nutrition, hygiene
Regression
Disorganized— 
inappropriate behavior,
transient hallucinations

Catatonic—sudden
onset mutism, stereotyped
position, periods of agitation
Paranoid—late onset
in life, suspiciousness, ideas

of persecution and delusions
Maintain safety—protect from
erratic behavior
With hallucination—do not
argue, validate reality, respond to
feeling tone, never further discuss
voices (don’t ask to tell more about
voices)
With delusions—do not argue,
point out feeling tone, provide
diversional activities
Meet physical needs
Establish therapeutic
relationship
Institute measures to promote
trust
Engage in individual, group, or
family therapy
Encourage client’s affect
Accept nonverbal behavior
Accept regression
Provide simple activities or
tasks








Paranoid Assessments
Paranoid Implementations
Suspiciousness

Cold, blunted affect

Quick response with anger or 
o
o
o
Establish trust
Low doses phenothiazines for anxiety
Structured social situations
rage
Schizoid Assessments

Shy and introverted
Schizoid Implementations

Establish trust



Little verbal interaction
Few friends
Uses intellectualization


Schizotypal Assessments




Eccentric
Suspicious of others
Blunted affect
Problems with perceiving,
communicating
Schizotypal Interventions



Antisocial Assessments






Disregards rights of others

Lying, cheating, stealing, promiscuous
Lack of guilt

Immature

Irresponsible
Associated with substance abuse




Brief and intense relationships

Blames others for own problems

Impulsive, manipulative

Self-mutilation

Women who have been sexually abused

Suicidal when frustrated, stressed

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
Draws attention to self
Identify and verbalize feelings
Use empathy
Behavioral contract
Journaling
Consistent limit-setting
Group therapy
Narcissistic Implementations
Histrionic Assessments

Firm limit-setting
Confront behaviors consistently
Enforce consequences
Group therapy
Borderline implementations
Narcissistic Assessments

Establish trust
Low doses neuroleptics to decrease
psychotic symptoms
Structured social situations
Antisocial Implementations
Borderline Assessments






Low doses phenothiazines for anxiety
Structured social situations
Mirror what client sounds like
Limit-setting
Consistency
Teach that mistakes are acceptable
Histrionic Implementations

Positive reinforcement for other centered





Somatic complaints
Temper tantrums, outbursts
Shallow, shifting emotions
Cannot deal with feelings
Easily influenced by others


Dependent Assessments





Dependent Implementations
Passive
Problem working independently
Helpless when alone
Dependent on others for decisions
Fears loss of support and approval



Avoidant Assessments










Socially uncomfortable

Hypersensitive to criticism, Lacks self-
confidence

Fears intimate relationships

Gradually confront fears
Discuss feelings
Teach assertiveness
Increase exposure to small groups
Obssessive-compulsive Implementations
High personal standards for self and 
others

Preoccupied with rules, lists, organized

Perfectionists

Intellectualize
Explore feelings
Help with decision-making
Confront procrastination
Teach that mistakes are acceptable
Manipulative behavior Assessments
Manipulative Behavior Implementations
Unreasonable requests for time,

attention, favors

Divides staff against each other

Intimidates others

Use seductive or disingenuous approach

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


Emphasize decision-making
Teach assertiveness
Assist to clarify feelings and needs
Avoidant Implementations
Obssessive-compulsive Assessments

behaviors
Clarify feelings
Facilitate expression of feelings
Drowsiness
Slurred speech
Acute Alcohol Implementations


Protect airway
Assess for injuries




Tremors
Impaired thinking
Belligerence
Loss of inhibitions



Withdrawal assess
IV glucose
Counsel about alcohol use
Alcohol Withdrawal
Assessments




Tremors
insomnia
anxiety
hallucinations
After Withdrawal→Delirium
Tremens Assessments





Alcohol Withdrawal
Implementations
Disorientation

Paranoia
Ideas of reference

Suicide attempts
Grand mal convulsions



Chronic Alcohol Dependence Assessments




Persistent incapacitation
Cyclic drinking or “binges”

Others in family take over client’s role 
Family violence




Wernicke’s Syndrome Assessments




Confusion
Diplopia, nystagmus
Ataxia
Apathy
Chronic Alcohol Dependence
Implementations
Identify problems related to drinking
Help client see problem
Establish control of problem
Alcoholics anonymous
Antabuse
Counsel spouse and children
Wernicke’s Syndrome Implementations


Korsakoff’s Psychosis Assessments



Monitor vital signs,
especially pulse
Administer
sedation, anticonvulsants,
thiamine (IM or IV),
glucose (IV)
Seizure
precautions
Quiet, well-lighted
environment
Stay with patient
Memory disturbances with confabulation

Learning problems

Altered taste and smell

Thiamine (IM or IV)
Abstinence from alcohol
Korsakoff’s Psychosis Implementations
Balanced diet
Thiamine
Abstinence from alcohol

Loss of reality testing
Retinopathy of Prematurity Assessment
o
o
Demarcation line with ridge
Retinal detachment
Retinopathy of Prematurity Implementations
o
o
o
Strabismus (cross-eyed) Assessments



Deviation of eye
Diplopia
Tilts head or squints
Corrective lenses Implementations


Detached Retina Assessments




Flashes of light
Loss of vision
Particles moving in line of vision
confusion
Distorted, blurred vision
Milky white pupil









Eye patched (one or both)
Surgery
Sedatives and tranquilizers
Avoid stooping, straining at stool,
strenuous activity 3 months
Cataracts Implementations


Glaucoma Assessments
Abnormal increase in intraocular
pressure that leads to blindness
Blurred vision
Lights with halos
Decreased peripheral vision
Pain
Bedrest, affected eye in dependent
position




Eye exercises
surgery
Detached Retina Implementations
Cataracts Assessments


Prevent by using minimum
oxygen concentrations
Monitor PO2
Eye exam (premature infants)
Postop: check for hemorrhage
Check pupil—constricted with lens
implanted, dilated without lens
Eye drops
Night shield
Sleep on unaffected side
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

Headache
smaller and constrict aqueous flow) are
contraindicated with glaucoma.
Trigeminal Neuralgia Assessments


Stabbing, burning facial pain
Twitching of facial muscles
Trigeminal Neuralgia Implementations


Bell’s Palsy Assessments



Inability to close eye
Increased lacrimation
Distorted side of face
Bell’s Palsy Implementations


Guillain-Barre Syndrome Assessments
o
o
extremities
o
Paresthesia

Motor losses beginning in lower


Altered autonomic function 

Nuchal rigidity
Kerning’s sign
Brudzinski’s sign
Seizures
Bulging fontanels
High-pitched cry
Isometric exercises for face
Prevent corneal abrasions
Guillain-Barre Syndrome Implementations
Meningitis Assessments






Medications—analgesics, Tegretol
Surgery
Medications—steroids
Aggressive respiratory care
Physical therapy
Eye care
Prevent complications: respiratory and
aspiration
Meningitis Implementations


Medications—antibiotics, antifungals
Prevent complications: droplet
precautions, contagious
Thoracentesis: no more than 1000cc taken at one time.



Electroencephalogram (EEG)
Electroencephalogram (EEG)
Preparation
Post-test
Test brains waves; seizure disorders 
Tranquilizer and stimulant meds withheld

for 24-48 hours
test
Stimulants (caffeine, cigarettes) withheld

Remove paste from hair
Administer medications withheld before
Observe for seizure activity



for 24 hours

Seizure prodromal signs; epigastric
May be asked to hyperventilate during
distress, lights before the eyes
test
Meals not withheld
Kept awake night before test; want them
to lie still
CAT Scan—dye gives flushed, warm face and metallic taste during injection (if contrast dye is
used)
Myelogram: Post-test







Supine 8-24 hours (Pantopaque oil-based dye used)
Head raised 30-45degrees 8-16 hours(metrizamide water-soluble dye used)
Liver Biopsy Preparation
Liver Biopsy Post-Test
Administer vitamin K IM (decrease

risk of hemorrhage)

NPO 6 hours
Given sedative

Position supine, lateral with upper
arms elevated

Asked to hold breath for 5-10

seconds
Position on operative side for 1-2 hours
Gradually elevate head of bed 30 degrees
(1st hour) and then 45 degrees (2nd 2 hours)
Bedrest for 24 hours
Check Vital signs
Check clotting time, platelets, hematocrit
Report severe abdominal pain
Upper GI Series Barium Swallow: stool white from barium
Tracheostomy Tube Cuff


o
o
o
o
Purpose—prevents aspiration of fluids
Inflated
During continuous mechanical ventilation
During and after eating
During and 1 hour after tube feeding
When patient cannot handle oral secretions
Oxygen Administration: assess patency of nostril, apply jelly


Face mask: 5-10 l/min (40-60%)
Partial rebreather mask: 6-15 l/min (70-90%); keep reservoir bag 2/3 full during
inspiration




o
o
o
o
o
o
o
o
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:
Difficulty to measure amount of oxygen delivered
Provides cooled, humidified air
Check oxygen concentration with oxygen analyzer q4 hours
Clean humidity jar and fill with distilled water daily
Cover patient with light blanket and cap for head
Raise side rails completely
Change linen frequently
Monitor patient’s temperature
Chest Tubes
Implementations








Chest Tube Removal:

Instruct patient to

Use to utilize negative do valsalva maneuver
pressure in lungs

Clamp chest tube

Fill water-seal

Remove quickly
chamber with sterile water to
 2
Occlusive dressing

cm
applied
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
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






o
o
o
o




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
Dry, sterile dressing
Change dressing, IV fluids, manometer, tubing q24 hours
Instruct patient to hold breath when inserted, withdrawn, tubing changed
Check and secure all connections
Normal reading—3-11 cm water
Elevated→>11, indicates hypervolemia or poor cardiac contractility (slow down IV, notify
physician)
Lowered→<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; don’t allow drops to go from one eye to the other; don’t squeeze eyes
Nasogastric Tubes:








Levin-single—single-lumen, used for decompression or tube feeding
Salem sump—double-lumen, used for decompression or tube feeding
Sengstaken-Blakemore—triple-lumen, used for bleeding esophageal varices
Linton-Nachlas—4-lumen, used for bleeding esophageal varices
Keofeed/Dobhoff—soft silicone, used for long-term feedings
Cantor—single lumen with mercury-filled balloon and suction port
Miller-Abbott—double-lumen with mercury-filled balloon and suction port
Harris—single lumen with mercury-filled balloon and suction port
NG tube placement:
“BEST WAY” to check is to aspirate for gastric contents and check for pH of aspirate <4
Implementation of feeding:







Check residual before intermittent feeding, reinstall residual
Check residual Q4 hours with continuous feeding, reinstall residual
Hold feeding if >50% residual from previous hour (adults) or >25% (children)
Flush tube with water before and after feeding
Use pump to control rate of tube feeding
Administer fluid at room temperature
Change bag Q8 hours for continuous feeding



Elevate head of bed while feeding is running
Check patency Q4 hours
Good mouth care
NG Irrigation Tubing:


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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:
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Clamp tube
Remove tape
Instruct patient to exhale
Remove tube with smooth, continuous pull
Intestinal Tubes (Cantor, Mill-Abbott, Harris)
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o
o
o
o
o
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o
o
o
o
o
Implementations
After tube is in stomach, have patient lie on right side, then back in Fowler’s
position, then left side
Gravity helps to position tube
Coil excess tube loosely on bed, do not tape
Position of tube verified by x-ray
Measure drainage QShift
Removal
Clamp tube
Remove tape
Deflate balloon or aspirate contents of intestinal tube balloon
Instruct patient to exhale
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
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Position on left side
Use tepid solution
Hold irrigation set no more than 18” above rectum
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Insert tube no more than 4”
Do not use if abdominal pain, nausea, vomiting, suspected
appendicitis
Catheter insertion: 2-3” into urethra then 1” after urine flows
Male catheter: insert 6-7”
Catheter Urine Drainage bag: do not remove more than 700 cc at one time, clamp prior to
removal
Ileostomy: post-op has loose, dark green, liquid drainage from stoma
Tonsillectomy: post-op frequently swallowing indicates hemorrhage
External contact lenses: need fine motor movements (rheumatoid arthritis prevents this).
Object in eye: never remove visible glass; apply loose cover and remain quiet.
Retina detached: sleep prone with affected side down; avoid jarring movements; avoid pin point
movement with eye (sewing); high fluid and roughage (prevents constipation=no straining); make
light sufficient for needs (75watt+); no hairwashing
Glaucoma medications: Epinephrine hydrochloride (Adrenalin Chloride) and Pilocarpine
Hydrochloride (Pilocar): give Pilocar (therapeutic) first then wait 2-10minutes and instill adrenalin
to increase absorption of adrenalin).
Tympanoplasty: remain in bed 24 hours position flat in bed with the affected ear up (helps to
promote insertion).
Triglycerides elevation can falsely elevate glycosalated hemoglobin test.
Laparoscopic Cholecystectomy post: encourage to walk to eliminate acute right shoulder pain.
Impetigo: 2 year old; honey-colored crusts, vesicles, and reddish macules around mouth; don’t
need to isolate; watch contact precautions.
Only patient we use distractions on the NCLEX are manic patients and toddlers not for pain.
Rhinoplasty (nose surgery) position post-op: want to promote drainage of oral secretions is to
position on her right side.
1 cup= 240cc
Pregnancy is a contraindication to an MRI.
Raynaud’s disease have decreased vascularity in the extremities.
Post-Parecentesis most important assessment is to obtain the blood pressure, weight the client,
measure the client’s abdominal girth, and check dressing in that order.
Tracheostomy tube: use pre-cut/pre-made gauze pads.
Suction is always intermittent never continuous.