A kid with Hepatitis A can return to school 1 week within the onset of jaundice.

2. After a patient has dialysis they may have a slight fever...this is normal due to the fact that the dialysis solution is warmed by the machine.

3. Hyperkalemia presents on an EKG as tall peaked T-waves

4. The antidote for Mag Sulfate toxicity is ---Calcium Gluconate

5. Impetigo is a CONTAGEOUS skin disorder and the person needs to wash ALL linens and dishes seperate from the family. They also need to wash their hands frequently and avoid contact.

positive sweat test. indicative of cystic fibrosis 1. Herbs: Black Cohosh is used to treat menopausal symptoms. When taken with an antihypertensive, it may cause hypotension. Licorice can increase potassium loss and may cause dig toxicity. 2. With acute appendicitis, expect to see pain first then nausea and vomiting. With gastroenitis, you will see nausea and vomiting first then pain. 3. If a patient is allergic to latex, they should avoid apricots, cherries, grapes, kiwi, passion fruit, bananas, avocados, chestnuts, tomatoes and peaches. 4. Do not elevate the stump after an AKA after the first 24 hours, as this may cause flexion contracture. 5. Beta Blockers and ACEI are less effective in African Americans than Caucasians.

1. for the myelogram postop positions. water based dye (lighter) bed elevated. oil based dye heavier bed flat.

2.autonomic dysreflexia- elevated bed first....then check foley or for impaction

3. any of the mycin's..check for tinnitus or hearing loss

4. cloudy dialysate...always futher assess and call doctor

5.osteoporosis prevention and mgt. choose weight bearing (walking) instead of calcium if both are choices

1. Dilantin can cause gingival hypoplasia, advise good oral hygiene and freq. dental visits, IVP 25-50 mg/min

2. Placentia Previa is painless, bright red bleed

3. Abruption is painful, board-like abdomen

4. Need MAP of 70-90 to perfuse organs

5. Vitamin C can cause false + occult blood

1. celiac disease cant have BROW! BARLEY RYE OAT WHEAT

2. any eye surgery place on pt on unaffected side

3. if pt has lung cancer, craniotomy, or some kinda pituitary surgery watch for diabetes insipidus

4. sickle cell- hydration hydration important and treat pain if in crisis

5.dont palpate a wilm's tumor on the peds pt. can cause cancer cells to be released!

oh one more:

6. terbutaline (Brethine) and mag sulfate- tx for preterm labor

Librium-antianxiety used to tx symptoms of acute alcohol withdrawal.
Cogentin-used to tx parkinsonian side effects of Thorazine (antipsychotic med)
Methadone hydrochloride-opiod analgesic; tx for narcotic withdrawal
Procardia-antianginal med (CCB) decreases myocardial O2 demand.
Digoxin-strengthens myocardial contractio0n & slows conduction thru AV node
Coumadin-inhiits prothrombin synthesis
Amicar-antifibrinolytic; prevents recurrence of subarachnoid hemorhage.
Lithium-tx manic phase of bipolar
Nimodipine-CCB; decreases spasm in cerebral blood vessels diltiazem-CCB; inhibits Ca+ influx in vascular smooth muscle; reduces myocardial O2 demand & decreases force of ventricular contraction clotrimazole-antifungal; treats rashes.

NEVER NEVER NEVER administer KCl via IV push.

The level in the water seal chamber (chest tubes) fluctuates with respiration- no fluctuation indicates an obstruction and excessive bubbling indicates an air leak.

Stay with the client for 15 minutes at the start of a blood transfusion.

Nephrotic Syndrome leads to proteinuria while Glomerulonephritis leads to hematuria.

Goodell's Sign is the softening of the cervix at the start of the 2nd month of pregnancy

Nagele's Rule is First date of last menstrual period + 7 days - 3 months + 1year.

Vinca Alkaloids (Vincristine) lead to neurotoxicity and can present with numbness and tingling in the legs or paralytic ileus.

Avoid herbal supps like ginsing, ginger, ginko, garlic (all the G's) if on any clotting drugs/products (coumadin, platelets, ASA, Plavix)

High triglycerides may cause a false HIGH Hemoglobin A1C (normal is 2.6-6)

Deer ticks transmit Lyme Disease and it is most common in the NE Atlantic states. (Go figure I thought it was down here in the South)

Think of pain last or as a psychosocial UNLESS: Burns, sickle cell crisis, or kidney stones.

Anemia of pregnancy is common in the 2nd trimester due to rapid expanding blood volume and is not a cause for concern. It can get as low as 10.5 and still be OK. 1st and 3rd trimesters can go as low as 11 and still be ok

Preterm labor--after 20 weeks and before 37

true labor INCREASES with activity and usually moves from the back to the front (according to our instructors but from personal experiance IT HURT ALL OVER THE DANG PLACE AND INCREASED WITH EVERYTHING[pic]).

Recommended weight gain for pregnancy 1.5-16 kg or 25-35 lbs HAHAHAHAHAHAHAHAH yeah right. I myself classified as Shamu's little sister by week 39[pic].

OK one more for 2nite.... normal newborn jaundice-- AFTER 24 hours of life pathologic jaundice-- BEFORE 24 hours of life

If it come out your ass...its metabolic acidosis... by vomitting...metabolic alkalosis...

1. priority unstable pt- words to look for: cyanotic, sudden, increasing pain, hypoxic, restlessness

2. when left with two choices pick the one thing you can do to make pt. comfortable, safe, and more stable

3. no narcotics to any head injury..wont be able to accurately assess LOC. so pick the narcotic if you have an order to question.

4. fluid resus. burn formula: kg X 4ml/kg X %(burn area)= total give half of total in first 8 hours

5. after thyroid surgery-maintain airway-keep emergency trach set nearby, check for blood at sides and back of dressing, teach pt to support neck

6. bucks traction-no pins tongs. skin traction

7. should not hear a bruit over anything except dialysis shunts. if so this is the unstable pt

8. DVT- elevate extremity[pic], bed rest, warm (not hot) compresses

Rubella- rash on face goes down to neck and arms then trunk and legs pregnant women should avoid contact with any child who has Rubella or just recieved the vaccine. if she does she has to get vaccine after she has delivered

mmr #1 @ 12- 15 months mmr #2 4-6 years old

before checking or measuring fundal height have the patient empty her bladder! A full bladder can throw off the measurement by 3cm.
Meniers disease= ringing in the ears and hearing damage cause from HIGH sodium levels. Need diuretics. Avoid caffeine, nicotine, and ETOH

Meningitis= look for nuchal rigidity, Kernigs sign(can't extend knee when hip is flexed) and Brudinskis sign (flex neck and knee flexes too) petichial rash. People who have been in close contact may need Rifampin as a prevention. Vaccine for meningitis after 65 years of age and every 5 years

MI=#1 pain relief, helps decrease 02 demand

Acute Asthma = diffuse expiratory wheezes

Cessation of wheeze omnimous

Infective endocarditis = murmur

Fluid overload = auscultate lungs 1st

24 hours after thyroidectomy, watch for s/s of thyroid storm not for decreased levels of thyroid hormones

1.hypoglycemia= T.I.R.E.D

T-tachycardia
I- irritability
R- restless
E- excessive hunger
D- diaphoresis

2.posturing- deceberate(brainstem problem)- hands like an "e", decorticate (cord problem)- hands pulled in toward the cord

3.tetralogy of fallot- have child squat to increase return to heart. just remember fallot=squat

4. cant sign consent after preop meds are given...call doctor if not signed

5. rubella (german measles)-airbone contact precautions, 3 day rash

6. rubeola (red measles)- droplet contact precautions, koplik spots in mouth

Amphetamine= Depression [pic], disturbed sleep, restlessness [pic], disorientation[pic]

Barbituates= nausea & vomiting, seizures, course tremors, tachy[pic] Cocaine= Sever cravings, depression[pic], hypersomnia, fatigue[pic]

Heroin= Runny nose, Yawning [pic], fever, muscle & joint pain, diarrhea (Remember Flu like symptoms)

1. When using a cane to aid ambulation: Step up on the good extremity then place the can and affected extremity on the step. Reverse when coming down. (Up with the good, down with the bad)

2. In infants, pyloric stenosis = projectile vomiting [pic]

3. Croup: seal-bark cough, dyspnea, inspiratory stridor, irritable. In children considered a medical emergency due to narrowed airway

4. Skull fracture: Battle's sign (bruising over mastoid bone) and raccoon eyes

5. Pheochromocytoma: catecholamine secreting tumor. Look for persistent hypertension, pounding headache

1. peritoneal dialysis- if outflow slow check tube for patency, turn pt side to side

2. pts with the same infection can room together or two clean non contagious disorders can room together.

3. pulse parodoxus- pulse is weak on inspiration and strong on expiration...could be a sign of CARDIAC TAMPONADE

4. fat embolism- high risk pt...fracture of long bone..greatest risk in first 48 hrs.

5. pancreatitis-elevated amylase (cardinal lab value)

6. JP DRAIN- SQUEEZE=SUCK... squeeze the bottle to let air out then repalce cap.

7.lymphocytic leukemia causes a decrease in all blood cells...hmmm i got this wrong on a test once...i didnt know it causes rbcs to be low also!

8. mannitol for ICP

Oxytocin is always given via an infusion pump and and can never be administered through the primary IV.

One of the first signs of ICP (increased intracranial pressure) in infants is a high pitched cry.

Regarding blood transfusions, a hemolytic reaction is the most dangerous kind of reaction...S & S include
NAUSEA
VOMITING
PAIN IN LOWER BSCK
HEMATURIA Treatment is to STOP blood, get a urine specimen and maintain perfusion and blood volume.

Febrile reaction S&S
FEVER
CHILLS
NAUSEA
HEADACHE

Narcan is given for to reverse respiratory depression...a rate of 8 or less is too low and requires nursing action.

Miller abbott tube is used for decompressing intestine, which relieves the small intestine by removing fluid and gas from small intestine.

If a client takes lithium the nurse should instruct the client to take in a good amount of sodium, without it causes retention of lithium and in turn leads to toxicity.

Rinne test- a vibrating tuning fork is held against the mastoid bone till pt can't hear sound...then moved to ear.

1) A subarachnoid (spinal block) for labor may cause a headache, a lumbar epidrual will not since the dura mater is not penetrated

2) Tracheoesophageal fistula: 3 C's: coughing, choking, & cyanosis

3) Hypothyroidism: Decreased T3 +T4, but increased TSH Hypertyroidism: Increased T3 + T4, but decreased TSH

4) NO tyramine containing foods if taking and MAO inhibitor ( smoked meat, brewer's yeast, aged cheese, red wine)

5)Regular insulin is the only type that can be given IV

1. Dilantin can cause gingival hyperplasia, advise good oral hygiene and freq. dental visits, IVP 25-50 mg/min

ESSR method of feeding (cleft palate)

ENLARGE nipple [pic] STIMULATE sucking [pic] SWALLOW REST

1)Immunizations
Before 1 years old:
Hep B[pic]3x):Only one that is given at birth and one month (3rd dose at 6 months)

IPV(4x), DTaP(5x), Hib(4x), PCV(4x): all given at 2, 4, & 6 months

Hib, PCV: again at 12-15month
DTaP: again at 12-18months
DTaP, IPV: last doses are given 4-6yrs

1yrs old and older:
MMR: (2x) 12-15months, then at 4-6 years* *if dose not given from 4-6 give from 11-12yrs old

Varicella Zoster: (1x) 12-18months

Td: (1x): 11-12yrs old

2)Fundal height: pt supine, measure from symphysis pubis to top of fundus, if patients is 18+ wks pregnant the height in cm will be same as weeks pregnant give or take 2 cm

3)Isolation**:

STRICT Contact: use universal precautions, gown when contact with pt., single pt. room in most situations

Used with: Any colonizing infections, MSRV, Fifths disease, RSV, infected wounds, skin, or eyes

STRICTER Droplet: include all universal precautions, gown, goggles, masks on you, on pt. if leaving room, single pt. rooms

Used with: Majority of infectious diseases

STRICTEST Airborne: include all universal precautions and negative pressure single patient rooms, gown, goggles, mask on you, mask on pt. if leaving room which should only be done if absolutely necessary

Used with:
Measles
Varicella
Disseminated Varicella Zoster
Tuberculosis

**Always check facilities policies when following isolation precautions/procedures

4) Self breast exams: do monthly, 7-10 days after menses

5) Pt's taking Monoamine Oxidase inhibitors (for depression usually) should avoid foods containing tyramine which include • Avocados, bananas • Beef/chicken liver • Caffeine • Red wine, Beer • Cheese (except cottage cheese) • Raisins • Sausages, pepperoni • Yogurt, sour cream

1. dumping syndrome-tx no fluids with meals /no high carbs /lie down after eating. they need a high fat high protien diet

2. multiple sclerosis- avoid hot showers and baths

3. parial thickness burns=blisters...... full thickness-charred, waxy

4 PKU- no nuts, meats, dry beans, eggs, dairy (basically no protein stuff) give specially prepared formula to baby because they can digest this protein well

5. introduce rice cereal to infant at 6 mos and strained veggies one at a time

6. pt must keep taking prescribed insulin on sick days, drink plenty of fluids and notify doctor. also insulin is also given when pt comes from surgery on NPO status because trauma and infection makes sugar go up!

In an infant of a diabetic mom, hypoglycemia 30-90 min after birth...then look for them to also have hypocalcemia after 24 hours

Non Stress Test on a preggo....should be REACTIVE (rise of 15 bpm above baseline for 15 sec) if it's NOT reactive they need a contraction stress test and the result that you want from it is NEGATIVE

With Diabetic Ketoacidosis don't give K+ until the patient has been hydrated and urine output is adequate.

Post-op Total Hip replacement-- abduction (toes pointing in) or patient laying on non-operative hip. Avoid adduction (letting the foot turn out)

mother/baby stuff

1. Rh negative mom gets Rhogam if baby Rh positive. Mom also gets Rhogam after aminocentesis, ectopic preganancy, or miscarriages.

2. fetus L/S Ratio less than 2= immature lungs......2-3=borderline....greater than 3=good lung maturity dude!! may give dexamethasone to speed up maturity if baby needs to be delivered soon.

3. prolasped cord position knee chest or trend..call for help!! GET THAT BOTTOM OFF THE CORD! SUPPORT CORD WITH YA HAND[pic]

4. decelerations early vs late----always good to be early but dont ever show up late. early mirrors the contraction, late comes after the contraction

5. LOCHIA SEQUENCE...lochia rubra- red, clotty....lochia serosa...pink, brown....lochia alba..white.........SHOULD NEVER HAVE A FOUL ODOR!

1. In prioritizing cardiac patients, check the pt with INDIGESTION first because that could be a sign of MI.

2. ABG's need to be placed on ice and sent to the lab ASAP.

3. If active TB is suspected, a sputum culture for acid-fast bacillus is the only metod to actually confirm active TB (NOT a mantoux skin test!)

4. Celebrex is contraindicted in pts with a history of cirrhosis.

5. In psych pts, the client most at risk for self-harm is always the pt that has stopped taking their meds.

One more! [pic] 6. Change in resp rate in a pt receiving mag sulfate could indicate toxicity.

1. dont give atropine for glaucoma. it increases intraocular pressure!

2. drug abusers at risk for heart valve disease.

3. after a liver biopsy place pt. on right side to put pressure on site.

4. end stage cirrhosis the ammonia level is elevated. doctor may order lactoluse to decrease levels.

5. dont do a vaginal exam on a pregnant cliet thats bleeding

Ulcerative colitis...3-30 stools per day WITH blood and mucus.

Pain in LLQ: relieved by defecation.

Crohns disease-NO obvious blood or mucus in stool.

Pain: Right lower quadrant pain that is steady or cramping...or pain could be in periumbilical area, tenderness and mass in the RLQ.

Rheumatoid arthritis: Pain and stiffness is on arising, lasting less than an hour...can also occur after long periods of inactivity. Joints red, hot swollen, boggy, and decreased ROM.

Osteoarthritis: Pain and stiffness occurs during activity. Joints may appear swollen, cool, and bony hard.

Hemodialysis: disequilibrium syndrome- N&V, headache, decreased LOC, rapid changes in PH, bun...

Transfusion reaction: Chills, dyspnea, itching, uticaria, back or arm pain, fever.

Peritoneal dialysis: When more dialysate drains than has been given, more fluid has been lost(output). If less is returned than given, a fluid gain has occured.

Slow dialysate instillation- increase height of container, reposition client.

Poor dialysate drainage-Lower the drainage, reposition.

If you give terbutaline and a corticosteroid together, a possible drug interaction is pulmonary edema (Smeltzer)

Rapid: (Lispro) Onset: 24 hrs

Very Long: (Lantus) Onset: 1 hr Peak: NONE Duration: 24 hr continuous

Mydriatic: with a D= Dilate pupils
Miotic:with an O= cOnstrict pupils

aniticholinergic SE: can't see can't pee can't spit can't sh*t

Hyperkalemia "MACHINE"- causes of incr serup K+
M-medications (ace inhibitors, Nsaids)
A-acidosis (Metabolic and respiratory)
C-cellular destrx-burns, traumatic injury
H-hypoaldosteronism, hemolysis
N-nephrons, renal failure
E- excretion-impaired

Signs and symptoms of incr serum K+= MURDER
M-muscle weakness
U-urine, oliguria, anuria
R-respiratory distress
D-decr cardiac contractility
E-ECG changes
R- reflexes, hyperreflexia, or flaccid

HYPERNATREMIA-you are fried
F-fever (low grade), flushed skin
R-restless (irritable)
I-incr fluid retention and incr BP
E-edema ( peripheral and pitting)
D-decr urinary output, dry mouth

Hypocalcemia-"CATS"
C-convulsions
A-arrythmias
T-tetany
S-spasms and stridor

For those of you who have trouble with mcg/kg/min problems. try this solution.

Exp: 7mg of dopamine in 500ml in NS ; pt is 110lbs

first convert 110lbsto kg =110lbs/2.2 kg=50kg then change 7 mg to mcg =7000 mcg

Now plug in the numbers. 7000* 50kg*60mins
------------------
500ml

answer is 16.8 mcg/kg/min

A way we were taught to remember which Beta Blockers are contra-indicated in patients with Resp problems are easy....
Contra-Indicated- so think.... Coreg, Corgard, Inderal

Administering ear medication... pull the ear UP and back for OLD, and down for young (Adhesions
Normal Hyper- Bi-emia after 24 hr, if before pathological. (in premature it appears after 48 hr, if before Report)
Hyperbilirubinemia- DO normal Breast feeding,q2-4hr.

RDS-basically bcoz infant cant expand lungs->cant breath normally, because of luck of surfactant in lungs. s/s:cyanosis,increased RR, nasal flaring, grunting. treatment-intratracheal surfactant, and supportive -O2-if on O2 worry about retinal damage.

if Mother-DRUGS: NEWBORN -Irritable->Swaddle&reduce stimulation aside from abcd.

FAS(fetal alcohol syndrome)-craniofascial abnormalities, growth retarded,, palmar creases. IRRITABILITY.RNs goal-nutritional balance.
When BATHIN Newborn go from CLEAN to DIRTY -eyes, face...diaper area the last.

in Diabetic mother the newborn at risk for hypoglycemia, RDS, hypo Ca emia, congenital anomal.
Diabetic mother during pregnancy-1st trimester insulin DECREASE. 2 and 3rd Trimester INCREASE INSULIN (placental hormones produce insulin resistance)
BUT after PLACENTAL DELIVERY INSULIN REQUIREMENTS DECREASE.

about Scoring

Apgar measures HR,RR,Muscle tone, Reflexes,Skin color each 0-2 point. 8-10 OK. 0-3 RESUSCITATE.

GLASGOW COMA SCALE. EYES, VERBAL,MOTOR!
It is similar to measuring dating skills...max 15 points -one can do it[pic] if below 8 you are in Coma.

So, to start dating you gotta open your EYES first, if you albe to do that spontaneously and use them correctly to SEE whom you dating you earn 4. But if she has to scream on you to make you open them it is only 3....and 1 you dont care to open even if she tries to hurt you.

if you get good EYE contact (4 points) then move to VERBAL.

talk to her/ him! if you can do that You are really ORIENTED in situation she/he uncontiously gives you 4 points! if you like her try not to be CONFUSED (3), and of cause do not use
INAPPROPRIATE WORDS (3), she will not like it)), try not to RESPOND WITH INCOMPREHENSIBLE SOUNDS (2), if you do not like her- just show no VERBAL RESPONSE(1)

Since you've got EYE and VERBAL contact you can MOVE now using your Motor Response Points.
THis is VERY important since Good moves give you 6!

filgrastim (Neupogen) - increase NEUtrophil count

epoietin alfa (Epogen) - increase RBC/erythrocytes

Cholecystectomy due to cholelithiasis and colesysthitis, WATCH for BLEEDING problems, because vit K FAT soulble, is poorly absorbed in the absence of bile. by the way T-tube used for drainage-Reason for T tube to maintain patency of common bile duct.

Chronic RF the best way to asses fluid status-WEIGHT the PATIENT daily

When NGT present mouth care ICE CHIPS but be aware not give that too much-> it becames water->stomach->NGT suck it with K and other electrolites present in stomach. LOST K

Heat cramps in hot weather-Sodium (Na) loses

Following Gastrectomy NGT drainage should NOT be BLOODY after 12 hr

Thyroid storm's main sign is FEVER

ALDOSTERONE insufficiency -Hypo-Na-emia, Hyper-K-emia, hypo-Volemia. WHEN Na decrease, K increase

easy way to remember addisons and cushings

addisons= down, down down up down cushings= up up up down up

addisons= hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia cushings= hypernatremia, hypertension, incrased blood vol, hypokalemia, hyperglycemia

everything else wouldnt be hard to remmenber> moon face, hirsutism, buffalo hump, obesity

1. prozac, zoloft, paxil- tx of depression.

2. sodium nitroprusside- sheild from light. wrap in foil

3. cephalosporins- CHECK FOR ALLERGIES TO PENICILLINS. pt could be hypersensitive.

4. pts recieving Lasix should be assessed for tinnitus and hearing loss

5. anticoagulants cant dissolve a formed thrombus but tPAs can.

1. Shock: BP 100

2. Fluid of choice in pt in shock are isotonic: NS, LR

3. PVCs: Always treat: >6 UNIFOCAL and/or >3 MULTIFOCAL with LIDOCDAINE 75mg 4:1 drip

4. SIADH Na 1.035

Diabetes Insipidus Na> 160 head injury Specific gravity 90 seconds, FHR < after contraction peak. . .turn off the pitocin [oxytocin] (if running) give O2 by tight face mask, reposition on left side, increase IV fluid rate, notify caregiver, document

use reliable form of birth control for at least 4 weeks (8 is better) after rubella immunization [of course this applies to women only]

abdominal pain, tender uterus, dark red or no bleeding = abruption

painless, bright red bleeding usually first episode in 2nd trimester = placenta previa

DO NOT give a pregnant laboring patient on methadone STADOL (precipitates withdrawal)

KVO rate is 20ml/hr

MAOIs: Nardil, Marplan, Parnate
Of course, no tyramine because of hypertensive crisis, which is treated with Procardia.

Aminoglycosides (gentamycin, etc.) affect 8th cranial nerve function (hearing) and are nephrotoxic.

Hyperparathyroid states can cause renal stones which can present with hematuria.

Bell's Palsy- facial paralysis, prevent corneal abrasions.

I teach APGARs this way

A= appearance (color all pink, pink and blue, blue [pale])
P= pulse (>100, < 100, absent)
G= grimace (cough, grimace, no response)
A= activity (flexed, flaccid, limp)
R= respirations (strong cry, weak cry, absent)

DO NOT delegate what you can EAT!

E - evaluate
A - assess
T - teach

only the RN should do this...hope that helps

macular degeneration: mac is in the middle (central vision loss)

digoxin toxicity: halos, nausea, vomiting

Fractured hip: shorter extremity and external rotation

hip replacement: teach pt not to cross legs; keep leg abducted to avoid dislocation of hip

Schillings test: measures % of B12 excreted in 24hr used to diagnose pernicious anemia

1. cardiac meds: -pine=calcium channel blockers -olol=beta blockers -pril=ACE inhibitors -artan=angiotensin II receptor blockers

2. No pee no K+

3. Before treating BPH, must restore urinary flow

4. Sign of toxic ammonia leve's is asterixis (hands flapping)

5. Diuretics: Lasix and Bumex are K+ wasting Aldacton is K+ sparing

1 - Dopamine and Lasix are incompatible

2 - Hypoglycemic jitters can be stopped by holding the limb, seizure clonus can't

3 - Normal urine output in an infant is at least 1cc/kg/hr

4 - Septic babies will often DROP their temp

5 - SE of PGE1, used to keep the ductus arteriosus open, are hypotension, fever, and apnea. The therapeutic effect is not necessarily dose-dependent, but the severity of SE is.

The adverse effects of Anti psychotics can be remembered using this: SHANCE
S-SUNLIGHT SENSITIVITY( Use hats and sunscreen)
H-HEPATOTOXICITY( Monitor LFT)
A-AGRANULOCYTOSIS( Characterised by fever and sore throat)
N-NEUROLEPTIC MALIGNANT SYNDROME( Characterised by fever and muscular rigidity)
C-CIRCULATORY PROBLEMS( Leukopenia and orthostatic hypotension)
E-EXTRA PYRAMIDAL SYMPTOMS( Administer anticholinergics and anti parkinsonian agents)

Now for some skin assessment!

ABCDEs of malignant melanoma:

A = Asymmetry;
B = Border;
C = Color;
D = Diameter;
E = Elevation

Antidote for Coumadin- Aquamephyton
Side effect of Aminophylline-head and irregular pulse
Treatment for Angina-sublingual nitro (given q5min X3)and rest
Anterior fontanel closes at-12-18mon
Posterior fontanel closes at-birth to 3mon
Classic sign of Diabetes-3 "p"s (polyuria, polydysia, polyphasia)
CVA pt with hemianopsia-approach from unaffected side
Discharge teaching after cataract surgery-avoid sneezing, coughing, straining or bending
Lyme disease-wear long sleeves clothing
Post laminectomy -flat position
Diet for cirrhosis-low protein, high calorie
Fundus displaced to right side-ask pt to void fundus is boggy-message fundus
Self breast exam-done 5-7 days after menses
SandS of Pyloric Stenosis-projectile vomit, metabolic alkalosis,olive size bulge unger the ribcage
Position for Meneries-affected side
Raynards disease-wear gloves, keep hands warm

Trigeminal neuralgia (tic douloureax) - eat warm, soft foods

Preparing to breast feed - wash braest with water and rub with a towel everyday

Ventricular gallop is the earliest sign of heart failure

Levin tube - feedings at room temperature, do not clamp between feedings

position for liver biopsy - supine with arms raised above head

rheumatoid arthritis - heat, ROM, weight reduction

Bells Palsy: avoid cold temperatures: make sure pt. closes windows when they are sleeping. Some even take eyes shut.

Nurses' priority intervention after a patient receives a skin graft is to prevent movement of the graft.

Greatest risk for postpartum hemorrhage is from distended bladder.

Herpes zoster (shingles) is from reactivation of the varicella virus.

1 grain = 60mg (I always forget this one)

Risk factors for legionnaires disease: advanced age, immunosuppression, end stage renal disease, and diabetes

Hepatitis

5 types
A,B, C, D, and E

Hep A-spread by drinking unsanitary water and uncooked foods
Hep B-spread by contact with blood or bodily fluids and is an STD
Hep C-spread by contact the same way as Hep B, can lead to cirrhosis (mostly seen with alcoholism)
Hep D-only contracted if you already have Hep B
Hep E-usually spread by contact with contaminated water

In nursing school, my instructor taught us to remember the different types like this:

VOWEL = BOWEL

Hep A and E---if your infected you will have problems with bowels...

Some Therapeutic Drug Levels

Digoxin 05-2.0 ng/ml
Lithium 0.6-1.5 mEq/L
Dilantin 10-20 mcg/dl
Theophylline 10-20 mcg/dl
Lithium 0.5-1.5 mEq/L

Coumadin PT: 12-20 sec....therapeutic range 1.5-2 times the control
INR: 2-3
Heparin PTT: 30-60 sec...therapeutic range 1.5-2 times the control

CREATININE AND CREATININE CLEARANCE

With renal impairment, serum creatinine goes up,urinary clearance goes down.

Serum Creatinine-men 0.8-1.8mg/dl women-0.5-1.5mg/dl Urinary creatinine clearance-85-135ml/min--requires a 24 hour urine specimine. Decreases with renal malfunction.

With a unilateral kidney disease, if one of the kidneys is healthy, a decrease in the creatinine clearance is not to be expected.

ATROPINE OVERDOSE

Hot as a Hare(temperature)
Mad as a hatter(confusion, delirium)
Red as a Beet(flushed face)
Dry as a bone(decreased secretions, thirsty)

CYSTIC FIBROSIS
Diet: Low in fat and high in sodium
Meds: Antibiotics, liposoluable vitamins(A D E K) Aerosol Bronchodialators, mucolytics, pancreatic enzymes.

5 A's to alzheimers
Anomia-unable to remember things
Apraxia-failure to identify objects
Agonsia-can't recognize sounds, tastes and other sensations, familiar objects.
Amnesia-memory loss
Aphasia-can't express SELF through speech.

GLOMEULONEPHRITIS-it's an antigen antibody complex from a recent strep infection which causes inflammation/ decreased glomerular filtration rate.

BETA BLOCKERS
B1-affects the heart
B2-affects lungs

EMERGENCY DRUGS TO LEAN ON
Lidocain
Epinephrine
Atropine
Narcan

AUTONOMIC DYSREFLEXIA-triggered by sustained stimuli at T6 or below. Vasodialation above injury,(flushed face, increased bp etc) vasoconstriction below injury(pale, cool, no sweating.)

AIRBORNE
My - Measles
Chicken - Chicken Pox
Hez - Herpez Zoster
TB

Private Room - negative pressure with 6-12 air exchanges/hr
Mask, N95 for TB

DROPLET think of SPIDERMAN!
S - sepsis
S - scarlet fever
S - streptococcal pharyngitis
P - parvovirus B19
P - pneumonia
P - pertussis
I - influenza
D - diptheria (pharyngeal)
E - epiglottitis
R - rubella
M - mumps
M - meningitis
M - mycoplasma or meningeal pneumonia
An - Adenovirus

Private Room or cohort
Mask

CONTACT PRECAUTION
MRS.WEE
M - multidrug resistant organism
R - respiratory infection
S - skin infections *
W - wound infxn
E - enteric infxn - clostridium difficile
E - eye infxn - conjunctivitis

SKIN INFECTIONS
VCHIPS
V - varicella zoster
C - cutaneous diphtheria
H - herpez simplex
I - impetigo
P - pediculosis
S - scabies

Private room or cohort
Gloves
Gown

Airborne
*keep door closed*

In addition to DROPLET PRECAUTION:
*Maintain spatial separation of 3 feet between infected patient and visitors. Door may remain open.

1. Widening pulse pressure is a sign of increased ICP
2.Pt taking Digoxin should eat a diet high in potassium (hypokalemia-> dig toxicity)
3.Key sign of PUD... hematemesis which can be bright red or dark red with the consistency of coffee grounds
4.Common symptom of Aluminium hydroxyde: constipation
5.In a child anemia is a the first sign of lead poisoning
6.Diuretic used for intracranial bleeding, hydrocephalus (Increased ICP,...) MANNITOL (osmotic diuretic)
7.Treatment of celiac disease: gluten free diet
8.cystis fibrosis==> excessive mucus production, respiratory infection complications,...
9.Cholelithiasis causes enlarged edematous gallbladder with multiple stones and an elevated bilirubin level.
10.Fat embolism is mostly seen in LONG BONES (femur,...)

1. Abruptio placentae may be a complication of severe preeclampsia 2. Syrup if ipecac is not administered when the ingested substance is corrosive in nature 3. Pt before liver biopsy is NPO 4-6 hours 4. Assess renal fct before giving an osmotic diuretic (mannitol) 5. Patient in addisonian crisis[pic]ecreased BP, Na, Blood glucose, Increased K 6. Amniocentesis is done as early as 14 weeks of gestation 7. Chorionic villi sampling is done as early as 10 weeks of gestation 8. Increased level of alpha fetoprotein in pregnant woman => neural tube defects 9. Insulin is safely given throughout pregnancy; oral hypoglycemic agents are contraindicated 10. Phenobarbital (Luminal) is commonly used to treat and prevent recurrent seizures in infants and young children 11. Aspirin is associated with Reye's syndrome in children with fever or viral infection 12. Glycerin suppositories are preferred agents to treat constipation in children 13. Corticosteroids may produce an altered effect of a vaccine 14. Thiazide diuretics (HCTZ,...) may induce hyperglycemia 15. Anticonvulsants INCREASE the seizures THRESHOLD!!!! 16. Hyperbilirubinemia in newborn: bilirubin levels are greater than 13-15 mg/dl

1. Postpartum period: circulating hcG disappears within 8-24 hours 2. S/S opioid withdrawl: rhinorrhea, dilated pupils, abdominal cramps 3. S/S sedative withdrawl: Increased motor activity, tachycardia 4. S/S alcohol withdrawl: tremors, N/V, diaphoresis 5. S/S stimulant withdrawl: CNS depression, fatigue, depression, confusion,... 6. Hb values: neonates have Hb higher than those of older children to sustain them until active erythropoiesis begins 7. Toclytic therapy: to arrest preterm labor 8. Child with chickenpox can be treated with oatmeal preparation baths and calamine lotion at home to relieve the itching... 9. child with rheumatoid arthritis should sleep in bag to keep joints warm and promote flexibility!!!! Wow... 10. When an eye patch is used to correct strabismus, the normal eye is patched. That forces the child to use the "lazy" eye, thereby increasing that eye's muscle strengths 11. If a chest tube accidently get disconnected, clamp it or place the open end of the tube in a container of sterile water or saline solution 12. Women should avoid pregnancy for at least 3 months after a rubella vaccine 13. Most accurate method to detect TB: sputum culture!!!
A child with KAWASAKI disease might be given a high dose of aspirin to reduce the risk of heart problems.

some respiratory

1. RSV- child in private room...CONTACT PRECAUTIONS..not droplet or airbone. (sometimes i get this mixed up because its called respiratory synctical virus..i used to pick droplet precautions but i have down now lol!

2. Elderly adults generally present with confusion rather than S/S of an illness.

3. pneumonia- droplet precautions

4. COPD pts should get low flow Oxygen b/c of the hypoxic drive. (1-3L/min) teach pursed lip breathing.

5. ARDS- this pt doesnt respond to even 100% FiO2

6. TB- hemotysis (advanced stage) v/s pulmonary edema- frothy blood tinged sputum

7. Allen's test- done b/f an ABG by applying pressure to the radial artery to determine if adequate blood flow is present.

8. INH (Isoniazid)- tx of TB. give vit B6 to prevent peripheral neuritis

9. SIMV mode on vents commonly used for weaning pt off ventilator.

10. vent alarms: high alarm (increased secretions then suction......, biting tube-need an oral airway,...... or coughing and anxiety- need a sedative) low alarm- there is a leak or break in system...check all connectors and cuff.

11. if a trach becomes accidently dislodged try to replace it with an obturator..if no luck keep the hole open with hemostats until physician arrives.

No Pee, no K (do not give potassium without adequate urine output)

Most common cause of SIADH is cancer, esp. lung cancer

IV KCL should infuse no faster than 20 mEq/hr

Valsalva maneuver is used for symptoms of SVT

Ototoxic drugs: loop diuretics (Lasix), NSAIDs, and cisplatin (Platinol-AQ)

And thank you whomever posted about Demerol being the DOC for pancreatitis! That has already come in handy on my practice tests!

1. Profile of gallbladder disease: 5Fs: fair, fat, forty, five pregnancies, flatulent(disease can occur in all ages and both sexes) 2. Hip fractures commonly hemorrhage, whereas femur fractures are at risk for fat emboli 3. Religious beliefs: Hindu- No beef or items containing gelatin 4. Renal diet- High calorie, high carbohydrate, low protein, low K, low Na, and fluid restricted to intake = output +500 ml 5. Treatment for sickle cell crises- HHOP: Heat, hydration, oxygen, pain meds 6. RN and MD institute seclusion protection 7. MD or hospice RN can pronounce the client dead 8. For hospital triage, care for the client with a life-threatening illness or injury first 9. For disaster triage, choose to triage first those clients who can be saved with the least use of resources! 10. It is contraindicated to induce vomiting if the patient has ingested gasoline, acid and alkaline!!!

MAOIs

Non-Popular Meds

Nardil
Parnate
Marplan

1. teach a pt with GERD after meals to remain upright for at least 20 min.

2.levodopa toxicity- notify physician if twitching develops.

3. Curling's ulcers or stress ulcers can cause sudden massive hemmorage.

4. 5 mm induration positive reaction (mantoux test) for HIV or immunosuppressd pts

5. Schilling test done to see how well a pt can absorb vit b12. checking to see if they have pernicious anemia.

6. Prednisone, Prograf, and Cellcept helps to prevent kidney rejection.

1. Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending doom) --> turn pt to left side and lower the head of the bed.

2. Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal bradycardia, etc) --> turn on left side (and give O2, stop Pitocin, increase IV fluids)

3. Tube Feeding w/ Decreased LOC --> position pt on right side (promotes emptying of the stomach) with the HOB elevated (to prevent aspiration)

4. During Epidural Puncture --> side-lying

5. After Lumbar Puncture (and also oil-based Myelogram)--> pt lies in flat supine (to prevent headache and leaking of CSF)

6. Pt w/ Heat Stroke --> lie flat w/ legs elevated

7. During Continuous Bladder Irrigation (CBI) --> catheter is taped to thigh so leg should be kept straight. No other positioning restrictions.

8. After Myringotomy --> position on side of affected ear after surgery (allows drainage of secretions)

9. After Cataract Surgery --> pt will sleep on unaffected side with a night shield for 1-4 weeks.

10. After Thyroidectomy --> low or semi-Fowler's, support head, neck and shoulders.

11. Infant w/ Spina Bifida --> position prone (on abdomen) so that sac does not rupture

12. Buck's Traction (skin traction) --> elevate foot of bed for counter-traction

13. After Total Hip Replacement --> don't sleep on operated side, don't flex hip more than 45-60 degrees, don't elevate HOB more than 45 degrees. Maintain hip abduction by separating thighs with pillows.

14. Prolapsed Cord --> knee-chest position or Trendelenburg

15. Infant w/ Cleft Lip --> position on back or in infant seat to prevent trauma to suture line. While feeding, hold in upright position.

16. To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) --> eat in reclining position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low CHO and fiber diet, small frequent meals)

17. Above Knee Amputation --> elevate for first 24 hours on pillow, position prone daily to provide for hip extension.

18. Below Knee Amputation --> foot of bed elevated for first 24 hours, position prone daily to provide for hip extension.

19. Detached Retina --> area of detachment should be in the dependent position

20. Administration of Enema --> position pt in left side-lying (Sim's) with knee flexed

21. After Supratentorial Surgery (incision behind hairline) --> elevate HOB 30-45 degrees

22. After Infratentorial Surgery (incision at nape of neck)--> position pt flat and lateral on either side.

23. During Internal Radiation --> on bedrest while implant in place

24. Autonomic Dysreflexia/Hyperreflexia (S&S: pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia, hypertension) --> place client in sitting position (elevate HOB) first before any other implementation.

25. Shock --> bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified Trendelenburg)

26. Head Injury --> elevate HOB 30 degrees to decrease intracranial pressure

some GI/hepatic

hepatitis--all forms standard precautions

s/s of bowel perforation--sudden diffuse abdominal pain, no bowel sounds, resp. rapid and shallow, rigid abdomen.

nursing care for undiagnosed abdominal pain--npo, no heat on stomach, no enemas, no narcotics, no laxatives.

crohns-small intestine vs ulcerative colitis-large intestine..sulfasalzine used to treat both.

pyloric stenosis- olive shaped mass felt in R. epigastric area, projectile vomiting

if a pt requires TPN and it is temp. unavailable then give D10W OR 20% DW until available.

before a Dx test of after 3 enemas, returns are not clear, notify physician

if diarrhea occurs with a colostomy. check meds (some cause diarrhea)..dont irrigate

as a general rule antacids should be taken 1-2 hours after other oral meds.

Symptothermal method of birth control - combines cervical mucus evaluation and basal body temperature evaluation, non-prescription/drug

percipitus/rapid labor - risk factor for early postpartum hemmorhage and amniotic fluid embolism

In elderly, change in mental status and confusion are often the presenting symptoms of infection

antiseizure meds - notify anesthesia prior to surgery, may need to decrease the amount of anesthetic given

neuroleptic malignant syndrome - increased temp, severe rigidity, oculogyric crises, HTN, complication of antipsychotic meds, notify MD

Dilantin - pregnancy risk category D, should investigate possibility of pregnancy (LMP) prior to administering

Transcutaneous electrical nerve stimulation (TENS) - used for localized pain (back pain, sciatica) - use gel, place electrodes over, above or below painful area, adjust voltage until pain relief/prickly "pins and needles"

1. S/S delusional thought patterns => suspiciousness and resistance to therapy 2. Use of neologism (new word self invented by a person and not readily understood by another) =>associated with thought disorders 3. Age and weight are VERY important to know after a child has ingested a toxic substance 4. Child with celiac disease can eat corn, rice, soybeans and patatoes (gluten free) 5. Anaphylactic rx => administer epinephrine first, then maintain an open airway. (Not the other way around[pic]) 6. Client with asthma => monitor peak of airflow volumes daily. Pulse ox after!!!![pic] 7. DKA pt => a HCT of 60 (way high...) (extreme dehydration) would be more critical than a pH less than 3! (Fluids first...) 8. Assess for abdominal distention after placement of a VP shunt! (You know why right?[pic]) 9. GFR is decreased in the initial response to severe burns, with fluid shift occuring. Kidney fct must be monitored closely or renal failure may follow in a few days 10. Vomiting => metabolic alkalosis (loss of stomach acid content) 11. Diarrhea => metabolic acidosis (loss of bicarbonate) 12. COPD => respiratory acidosis (CO2 retention) 13. Anxious client => hyperventilation can cause respiratory alkalosis. A paper bag will help. (Increase CO2) Right?[pic] 14. Client with low H&H after splenectomy => the initial priority is REST due to the inability of RBCs to carry O2 15. Mild to moderate diarrhea in a child => maintain a NORMAL diet with fluids to rehydrate the poor child[pic]

Don't forget Vancomycin can cause "Red man Syndrome" = decreased BP and flushing of face and neck --> give antihistamine. Also watch for liver damage with this one.

Peripheral vascular disease - patient should sit with feet flat on floor to prevent hypereflexion of the knee

Myelominigocele - baby should like on abdomen with head to the side

Tegretol - interferes with actino of hormonal contraceptives, should use alternate type of birth control

Clozapine (Clozaril) - antipsychotic, treats schizophrenia, potential to suppress bone marrow and cause agranulocytosis (look for sore throat and fever)

Bucks traction - remove foam boots 3x/day to inspect skin, turn client to unaffected side, dorsiflex foot on affected side, elevate foot of bed

phlebitis - tenderness and redness at IV insertion site and redness proximally along the vein. Remove the IV adn apply warm soaks

Cred e maneuver - apply mannual pressuer to bladder, aids in emptying the bladder completely, results in reduced risk for infeciton; if performed every day can result in bladder control for some SCI

Frequent use of nasal sprays to releive allergic symptoms can result in vasconstriction that causes atrophy of nasal membranes (frequent nosebleeds)

Lung cancer is a common cause of SIADH (abnormal secretion of ADH, increase water absorption and dilutional hyponatremia)

ginko - antiplatelet, CNS stimulant, given for dementia, increase risk of bleeding with NSAIDS

Native Americans are present oriented and do not live by the clock (will be late for appointments)

Pulmonic area - 2ICS, left of sternum

Chronic alcohol use is the most common cause of hypoMg, which ma result in cardiac arrest (increase neuromuscular irritability, tremors, tetant, seizures)

SCD - two fingers between sleeve and leg, opening at the knee and popliteal pulse point, antiembolism stockings can be applied under sleeve to decrease itching, sweating and heat buildup

Peritoneal Dialysis when Outflow is Inadequate --> turn pt from side to side BEFORE checking for kinks in tubing (according to Kaplan)

Timeouts for children - 1minute for each year of age

Temporal lobe - hearing
Frontal - personality changes
Occipital - visual brain stem - bladder/bowel

Bulemia - susceptible to tracheosophageal fistula from esophageal tear, laryngitis is a danger sign (hoarse voice that is barely audible)

mycins - if fever, notify MD

screening for HTN - two raedings, 5minutes apart

encourage geriatric patients to talk about life adn important thigns in his/her past, especially with recent memory loss

NO morphine for pancreatitis and cholecystitis.... google for the reason

1 unit of packed RBCs = 220mL

if allergic to sulfonamides dont take acetazolamide (Diamox)

VENTRICULAR FIBRILLATION: TREATMENT

"Shock, Shock, Shock, Everybody Shock, Little Shock, Big Shock, Momma Shock, Poppa Shock":

Shock= Defibrillate

Everybody= Epinephine

Little= Lidocaine

Big= Bretylium

Momma= MgSO4

Poppa= Pocainamide

methotrexate- dont take supplemental folic acid and please dont take while pregnant..can cause premature labor and bleeding.

oh dont take cytoxan while pregnant or dont handle the drug while pregnant.

infections that occur with AIDS clients are called opportunistic infections.

Pneumocystis carinii pneumonia is not contagious unless you are immunocomprimised. this infections occurs mostly with AIDS pts.

infant with HIV should NOT recieve chickenpox or oral polio vaccine. can give inactivated polio vaccine though.

Priority... if patient having allergic reaction or going into anaphilactic BUT still consious... what you do 1st action:
1. call immideately MD
2. Ensure Airway
3. Give O2 by mask
4. Epinephrine as prescribed
****

by the way who took NCSBN questions online. What score may say that you likely to pass NCLEXRN
______
answer 4

After Lumbar Puncture (and also oil-based Myelogram)--> pt lies in flat supine (to prevent headache and leaking of CSF)

not very correct. The head is usually ELEVATED if an OIL-based or water -soluble contrast agent is used.

lumbar puncture - flat

OIL based - flat

WATER soluble contrast - elevate 15-30 degrees

palpating the carotid pulses together can cause a vagal response and slow the clients heart rate

adrenal insufficiency - steroids increased prior to surgery

thyroidectomy - acess for numbness from decreased Ca

Bactrim - mild to moderate rash the most common SE

If when removing a PICC a portion of the catheter breaks - apply tournaquet to the upper arm, feel radial pulse

emptying a drainage evacuator - wash hands, don gloves, elevate bed, pour drainage itno measuring cup, compress the evacuator and replace the plug

Percodan - oxycodone and aspirin
Percocet - oxycodone and acetaminophen

low back pain, h/a and restless...cardinal of hemolytic transfusion reaction..stop transfusion..change tubing...infuse NS.

initate a blood transfusion w/i 30 min of recieving blood.

fresh frozen plasma administerd to DIC because of the clotting factors in it

cryoprecipitate given in hemophilia...also with hemophilia they tend to bleed into the joints so they may have joint problems.

Myasthenia Gravis: worsens with exercise and improves with rest.
Myasthenia Crisis: a positive reaction to Tensilon--will improve symptoms
Cholinergic Crisis: caused by excessive medication-stop med-giving Tensilon will make it worse

Head injury medication: Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use filter needle

Prior to a liver biospy its important to be aware of the lab result for prothrombin time (PT)

Pregnancy Induced Hypertension: The nurse would be MOST concerned if the patient complained of epigastric pain and a HA.

COPD: Administer low flow Oxygen! We never administer: 5L NC

1. Watery vaginal discharge and painless bleeding => endometrial cancer 2. Frothy vaginal discharge => trichomonas infection 3. Thick, white vaginal discharge => candida albicans 4. purulent vaginal discharge => PID 5. Approximately 99% of males with cystic fibrosis are sterile due to obstruction of the vas deferens 6. Lyme's disease is transmitted by ticks found on deer and mice in wooded areas 7. Children 18-24 months normally have sufficient sphincter control necessary for toilet training 8. Complications of TPN therapy are osmotic diuresis and hypovolemia!!! 9. L/S ratio => fetal lung maturity 10. Kava-kava can increase the effects of anesthesia and post-op analgesia 11. NEVER give chloride potassium by IV push[pic] 12. GINKGO interacts with many meds to increase the risk of bleeding; therefore, bruising or bleeding should be reported to MD 13. Vanco therapeutic range 10-20 mcg/mL 14. Client with disseminated herpes zoster (shingles) => AIRBORNE precautions 15. The client taking methotrexate should avoid multivitamins b/c multivitamins contain folic acid. Methotrexate is a folic acid antagonist!!! 1. Pt with increased ICP => Lumbar puncture is contraindicated b/c risk of brain herniation 2. If pt states "I have a constant throbbing headache! This is the worst headache I ever had" => may be having ICB (Intracranial bleeding); assess pt for increased ICP, and of course notify MD 3. Cardinal sign of increased ICP => change in LOC (level of consciousness) 4. Diabetes insipidous => dilute urine, concentrated plasma 5. SIADH => concentrated urine , dilute plasma

Hypovolemia and osmotic diuresis that are complications of TPN result from hyperglycmia!

Let's recapitulate TPN => Hyperglycemia => osmotic diuresis & hypovolemia...

Drooling - 4 months
Responds to own name 6-8months deliberate steps when standing 9-10months picks up bite size peices of cereal 11months

24months: kick ball w/o falling, build tower of 6blocks, 2-3 word phrases, 300 word vocab

30months: jump with both feet, run, say first and last name

36months: tricycle

Left CVA - speech, math skills, analytical thinking
Right CVA - behavior, disorientation to person, place and time

Ectopic pregnancy - LLQ pain, vaginal spotting

tricuspid valve: 5ICS left sternal border

Here are some that help me and hope they help you guys too.

1. Always identify the topic and assess before anything else!!!

2. Dont ask open ended questions and never ask a patient why!

3. With removal of the thyroid, elevated vital signs signify thyroid storm, give Inderal, PTU, and oxygen!

4. With renal calculi, sickle cell, and pancreatitis: Pain is priority...or IV hydration in sickle cell laboring patients.

5. With otitis media, a complication can be meningitis.

6. To determine HR, count the small boxes between R waves and divide by 1500.

7. For dumping syndrome: lay patient flat for an hour after meals and dont give fluids after meals.

8. Never remove traction weights!

9. For hypothermia, monitor for VFIB

10. PICC LINE complications: air embolism s/s: pale, SOB, tachy. Place pt. in trendelenberg and to their Left!

compartment syndrome...significant increase in pain not responsive to pain meds.

Plaquenil-tx of Rhem Arthritis...recommend eye exam every 3 mo.

Statins- tx of high cholesterol...ASSESS FOR MUSCLE PAIN...moniter liver enzymes.

Nicotinic Acid (Niacin)-tx of high cholesterol- flushing occurs in most pt. will diminish over several weeks.

stages of shock (its more but i made it simple "KISS" keep it simple stupid lol!) early- increase in pulse...normal urine output intermediate-RAS (renin-angioten system), low urine output, cool skin, pallor late-no urine output, low BP irreversible stage!

Myxedema/hypothyroidism: slowed physical and mental function, sensitivity to cold, dry skin and hair
Graves’ disease/hyperthyroidism: accelerated physical and mental function; sensitivity to heat, fine/soft hair
Thyroid storm: increased temp, pulse and HTN
Post-thyroidectomy: semi-Fowler’s, prevent ncek flexion/hyperextension, trach at bedside

Hypo-parathyroid: CATS – convulsions, arrhythmias, tetany, spasms, stridor (decreased calcium), high Ca, low phosphorus diet
Hyper-parathyroid: fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium), low Ca, high phosphorus diet

Hypovolemia – incrased temp, rapid/weak pulse, increase respiration, hypotension, anxiety, urine specific gravity >1.030
Hypervolemia – bounding pulse, SOB, dyspnea, rares/crackles, peripheral edema, HTN, urine specific gravity Recognizes but is fearful of strangers 5. 10-12 months infant => 3-words vocabulary1!!! 6. 12 months infant => stands alone 7. 8-12 weeks infant => can hold head up 8. Pregnant woman with "Charley horse" pain (pain in the "gastrocnemius muscle" =>the muscle in the back part of the leg that forms the greater part of the calf; responsible for the plantar flexion of the foot) is relieved by dorsiflexing the foot, which reduces the muscle spasm 9. The criteria used to distinguish TRUE from FALSE labor is "evidence of cervical change"... Wow! 10. Pediatrics... Lead poisoning primarly affects the CNS, causing increased ICP. This results in irritability and change of LOC, as well as seizure disorders, hyperactivity and learning disabilities 11. 4 months infant => palmar grasp 12. 7-9 months infant => can bang 2 cubes together 13. 9-12 months infant => can put a block in a cup 14. 10-12 months infant => can demonstrate pincer grasp 15. Hydatidiform mole => increased HCG levels, marked nausea and vomiting

A possible complication of impetigo is posstreptococcal glomerulonephritis and periorbital edema is indicative of postreptocccal glomerulonephritis.

client should weight themselves daily when taking lithium-- and after the first dose, client should have his/her levels checked within 8-12 hours and two times a week for the first month. Lithium also causes polyuria and dehydration. S&S of toxicity are, ataxia, vomiting, diarrhea, muscular weakness and drowsiness.

Gurie blood test helps determine PKU for neonate.

child can return to school with Hep A, a week after onset of jaundice

bulge test is a test for confirming fluid in the knee

it's important not to touch the bed when using defibrilator in order to prevent accidental countershock!![pic]

Extrusion reflex means is the same meaning as tongue thrust which disappears between 3- 4mos of age.

Administer oral steroids in the morning with food to prevent ulcerogenic effects!

Increased abdominal distention, nausea and vomiting are signs of paralytic ileus that should be reported to the physician!

It's important for a client with an internal radium implant to be on a low residue diet in order to prevent many bowel movements because stool can dislodge it.

Heparin is not transmitted to infant from breastfeeding.

Haldol is effective for reducing assaultive behavior, for example, a pt threatening to hurt another.

Narcotic analgesics are contraindicated for pt's with ICP because it can mask symptoms.

Pt's with SLE(lupus) should be in remission for 5 months before becoming pregnant.

Fixed and DIALATED pupil are signs of ICP and should be reported, it is an emergency.

For stabismus, the brain receives two images.

Vomiting is contraindicated for a pt/child who swallows lighter fluid(hydrocarbons) because there's a risk of aspiration.

Change IV tubing every 48-72hourse(every time I want to choose every 24 hours!)

Extreme tearing and redness are signs of viral conjunctivits and if there is a worker with these signs, make sure they are sent home because it is contagous!

For amputations after wound has healed..., assess for skin breakdown, wash, rinse and dry stump daily, alcohol dries so don't apply DARN IT![pic], no lotion. Elevate stump 24-48 hours after surgery, discourage semi fowler's position to prevent contractures of the hip.

Flush NG tube with 30ml of air before aspirating fluid.

Turp(transurethral resection of the prostate)--hemorrhage is a complication, bleeding should gradually decrease to light pink in 24 hrs.

DVT: tx with compression stockings, low dose heparin, discourage sitting for prolonged periods.

Hot and dry=sugar high(symp of hyperglycemia) cold and clammy=need some candy(hypoglycemia)

Type one diabetes is diagnosed usually before age 15. NO insulin produced

Type 2 diabetes--INSUFFICIENT insulin production. Keto acidosis not common. Affects adults over 40 mostly.

Diabetes insipidus--history of head injury or pituitary tumor or craniotomy...HYPOsecretion of ADH. Polyruria, decreased specific gravity, decreased osmolarity, HYPOvolemia, increased thirst, tachycardia, decreased bp.

SIADH--excess ADH is released. HYPERvolemia, weightgain, administer diuretics...Declomycin could be prescribed.

Adrenal crisis: Profound fatigue, dehydration, vascular collapse, renal shut down, decreased NA, increased K.

Good ol' Maslow:
1st Physiologic needs
2 Security and safety
3 Love and belonging
4 Self actualization

Sterile field and procedure facts...
For sterile field--never turn your back, avoid talking[pic], moisture barriers carries bacteria, open pack away from field, do not reach over sterile field.

Sterile procedures--Surgical procedures, biopsies, caths, injections, infusions, dressing changes.

In regards to surgery, aspirin, antidepressants, steroids, nsaids are drugs that put clients at risk!

The consent for surgery--Dr. gives client explanation, consent signed by Dr., client and witness. Signed prior to pre op meds, remains a permanent part of client chart.

For pain: PQRST
Provoking
Quality
Region
Severity
Timing

Ask if pain is stabbing, burning crushing.

Narcotics---MORPHINE, MEPERIDINE(DEMEROL), HYDROMORPHONE(DILAUDID), OXYCODONE(OXYCOTIN).
Non-narcotics--ACETOMINOPHEN(TYLENOL), SALICYLATES.
Non steroidal(NSAIDS) TYLENOL, IBPROFEN, NAPROSYN, INDOCIN.

Clozapine(Clozaril) is used for schizophrenic patient's who don't respond to other antipsychotic drugs.

(Benztropin)Congentin is used for the extrapyramidal effects associated with antipsychotic agents.

Chlorpromazine (Thorazine) is used to treat hallucinations, agitation, and thought disorders.

Adenosine(Adenocard) is an antiarrhythmic drug, this drug is good for paroxysmal atrial tachycardia...it slows conduction from av node.

Atropine for symptomatic bradycardia.

Digoxin for atrial fibrillation.

Lidocaine for ventricular ectopy.

For assessing the abdomen, correct order is INSPECTION, AUSCUTATION, PERCUSSION, PALPATION "I Am Peed PAAAAA!"[pic][pic])

Cheyne strokes respirations are periods of apnea for 10-60 seconds then slowly increasing rate and depth... occur typically with heart failure and cerebral depression.

Bulls eye rash is classic in lymes disease.

To relieve breast engorgement, pt should pump each breast for 10 minutes every 3-4 hours and during the night if she's awake.

Anticholinergic effects(drugs that block acetylcholine) cause dry mouth, constipation, urine retention.

5 rights of delegation
Right task
Right circumstance
Right communication
Right person
Right feed back

Cystic fibrosis is a recesssive trait, there is a one in four chance that each offspring will have the trait or disorder.

Cushings triad is something to look out for in patient's with increased ICP which is decreased heart rate, decreased respiratory rate BUT increased blood pressure.

Withdrawal from stimulants results in depression, fatigue and confusion.

Withdrawal from alcohol results in vomiting, nausea, tremors and diaphoresis.

Withdrawal from sedatives results in increased motor activity and tachycardia.

Withdrawal from opioids results in rhinorrhea, abdominal cramps and DIALATED pupils.

Inflammation: HIPER
Heat
Induration
Pain
Edema
Redness

Hallucinations--sensory perceptions without external stimuli.

Illusions--real stimuli is misinterpreted.

Delusions--falsed fixed belief('I am the queen of England!" for example)

Ok here is for TB drugs
Think SPRITE
S- Streptomycin (Monitor for ototoxic, nephrotoxic and neurotoxic rxn)
P-Pyrazinamide ( Photosensitivity-- so avoid sunlight or UV rays)
R- Rifampin ( Red orange urine is normal.. think about R for rifampin and R for red urine)
I- INH ( SE is Vit B6 deficiency so pt needs inj. and avoid tyramine containing foods)
T- Tubasal aka Aminosalicylate sodium ( avoid aspirin with this med)
E- Ethambutol ( E for eye problems- assess visual acuity and color discrimination esp to green)

Also for ventilator alarms
HOLD
High alarm- Obstruction due to incr. secretions, kink, pt. coughs, gag or bites
Low press alarm- Disconnection or leak in ventilatior or in pt. airway cuff, pt. stops spontaneous breathing

to remember blood sugar: hot and dry-sugar high (hyperglycemia) cold and clammy-need some candy (hypoglycemia)

2. ICP AND SHOCK HAVE OPPOSITE V/S
ICP-increased BP, decreased pulse, decreased resp. shock- decreased BP, increased pulse, increased resp.

3. cor pulmonae: right sided heart failure caused by left ventricular failure (so pick edema, jvd, if it is a choice.)

4. herion withdrawal neonate: irratable poor sucking

5. Jews: no meat and milk together

6. Brachial pulse: pulse area cpr on an infant.

7. Test child for lead poisioning around 12 months of age

8. bananas, potatoes, citrus fruits source of potassium

11. Cultures are obtained before starting IV antibiotics

12. a pt with leukemia may have epitaxis b/c of low platelets

13. best way to warm a newborn: skin to skin contact covered with a blanket on mom.

14. when a pt comes in and she is in active labor...nurse first action is to listen to fetal heart tone/rate

15. phobic disorders...use systematic desensitiztion.

1. Clients of the islam religious group might want to avoid jello, pork and alcohol 2. Most common side effect of daunorucibin (cerubidine) for a client with leukemia is cardiotoxicity 3. Patient having a surgery on the lower abdomen should be placed in the trendelenburg position 4. Flumazenil (Romazicon) is the antidote for versed (Needless to remind you that versed is used for conscious sedation... Say thank you Jean LOL) 5. Patients taking isoniazid (INH) should avoid tuna, red wine, soy sauce, and yeast extracts b/c of the side effects that can occur such as headaches and hypotension 6. A Patient with gout who is placed on a low-purine diet should avoid spinach, poultry, liver, lobster, oysters, peas, fish and otmeal 7. A patient who needs a high-iron diet should eat: sliced veal, spinach salad, and whole-wheat roll 8. Pegfilgastrin (Neulasta) is a chemotherapeutic drug given to patients to increase the white blood cells count 9. Amphoteracin B (Fungizone) should be mixed with D5W ONLY!!! 10. Pt with leukemia taking doxorubicin (Adriamycin) should be monitored for toxic effects such as rales and distended neck veins (carditoxicity manifested by change in ECG and CHF) 11. Cardidopa/levodopa (Sinemet) is given to clients with Parkinson's disease. Watch for toxic effects such as spasmodic eye winking 12. Nimotop (Nimodipine) is calcium channel blocker that is given to patients with ruptured cerebral aneurysm. Do you know why? Look it up! Vasospasm...

hope this discussion is moved to Sticky Threads soon, it is so awesome.[pic]
1. A conductive hearing loss involves interference in the transmission of sound waves to the inner ear.
2. A sensorineural hearing loss is the result of nerve impairment.
3. An acoustic neuroma is a benign Schwann cell that adversely impacts the 8th cranial nerve.
4. DKA is an acute insulin deficiency followed by a decrease in glucose in body cells and an increase production of glucose by the liver.
5. Lymphedema results from an obstruction of lymph circulation and can be aquired or can be secondary to other disorders.
6. The Reed-Sternberg cell is the malignant cell type associated with Hodgkin's Disease.
7. The incidence if Hodgkins and non - Hodgkins lymphomas are increased in those taking drugs such as phenytoin ( Dilantin ).

Necrosis is "tissue death " whereas gangrene is necrosis on a larger scale. Gangrene usually results from interruption of blood flow/supply to large areas of tissue or bone. Commonly affected areas are the extremeties ( fingers, toes, lower legs, etc ) or the bowel.
Dry Gangrene= occurs when the necrotic tissue has little blood supply and is relatively aseptic.
Wet Gangrene= is potentially life threatening due to release of toxins into the bloodstream.
Gas Gangrene= is gangrene infected with a gas bacillus, most commonly, Colstridium Perfringens.
Treatment is usually debridement of the wound, cleansing the area with an antibacterial or antiseptic, removal of the affected tissue, and possibly a course of antibiotics.[pic]

1. S/S croup (child) => hoarse voice, inspiratory stridor, barking cough 2. Client with hepatic encephalopathy => Neomycin decreases serum ammonia concentration by decreasing the number of ammonia producing bacteria in the GI tract 3. A 2 year old can remove one garment 4. A 2 and half year old can build a tower of eight cubes and point out a picture 5. A 3 year old can wash and dry his/her hands 6. S/S perforated colon => severe abdominal pain, fever, decreasing LOC 7. Hyperglycemia => b/c polyuria assess for signs of deficit fluid volume such as rapid, thready pulse, decreased BP, and rapid respirations 8. A child with nephrotic syndrome is at risk of skin breakdown from generalized edema 9. Tetracycline should be taken on an empty stomach. Avoid dairy products, Ca, Mg, Al and Fe (Iron) 10. Upper GI series => NPO 6-8 hrs b/f procedure 11. Mumps is the childhood infectious disease that most significantly affects male fertility 12. Client allergic to penicillin may be also allergic to cephalosporins 13. Infants and children up to age 7 are abdominal breathers 14. Placental transport of substances to/from the fetus begins in the 5th week 15. Duration of contractions => period from the onset of uterine tightening to uterine relaxation 16. Frequency of contractions => period b/t one contraction and the beginning of the next contraction 17. Erbs point => 3rd L ICS; pulmonic and aortic murmurs are best heard there

1. One of the CHF symptoms is S3 ventricular gallop 2. Hypertensive crisis => Priority in the first hour is brain damage due to rupture of the cerebral blood vessels. Neurologic status must be closely monitored 3. Client with A-fib => a cold, pale lower leg suggests the presence of an embolus. Peripheral pulses should be checked immediately 4. S/S anemia in a 10 months old infant => pale mucosa of eyelids and lips 5. S/S dehydration in 2 years old => sunken eyes, dry tongue, lethargy, irritability, dry skin, decreased play activity, and increased pulse 6. Pt with anaphylaxis => The entire body may turn bright red b/c massive vasodilation 7. Teaching pt with Zollinger-Ellison syndrome => Report promptly to his/her healthcare provider any finding of peptic ulcer (night time awakening with burning, cramp-like abdominal pain, vomiting and even hematemesis, and change in appetite) 8. Infant with epiglottitis : 4 D's => Drooling, Dysphagia, Dysphonia and Distress inspiratory efforts 9. Niacin (Vit B) is a lipid lowering agent. Foods high in Niacin are meats, eggs, milk, dairy products 10. Child with 3 C's (Cough-Choke-Cyanosis) should be assessed for tracheoesophagial fistula 11. Gastric lavage is a priority for an infant who has been identified as suffering from botulism 12. Viral meningitis usually does not require protective measures

Myasthenia gravis--muscle weakness that occurs mostly in the throat and face as results from the deficits of the nerve impulses conducting at the myoneural junction. Pancuronium and succinylcholine are neromuscular agents that should be used with caution because of the chance of prolonging recovery.

Clients with CRF are to be on a high carbohydrate diet to prevent protein metabolism. Pt's must limit protein, sodium and potassium and fluids because the kidneys cannot excrete an adequate amount of urine.

ABG's is the best way to monitor pulmonary status by analyzing the level of hypoxia caused by pulmonary edema and for monitoring effects of treatment.

Cardiogenic shock--there is low cardiac output from heart pump failure such as in heart failure, sever cardiomyopathy, acute MI.

Pancreatitis-high carb, low fat diet.

IV cimetidine(Tagamant) given as treatment for a bleeding peptic ulcer may experience hyptotention if given too rapidly

Watch for cardiac arrythmias when suctioning pt from an ET because of the loss of oxygen.

Chest pain and dypnea are classic signs of pulmonary embolism, typically they may have a cough with blood tinged sputum.

1. Larngotracheobronchitis: inspiratory stridor and restlessness 2. Thorazine: antidote cogentine SE: akathisia(motor restlessness) dystonia(tongue protrusion, abnormal posture) and diskinesia(stiff neck, difficulty swallowing) 3. Toddlers- parrallel play; infants enjoy company but self play. 4. IV infiltraton D/C IV and apply warm compress. 5. Urticaria= hives. 6. Graves disease: enlarged thyroid, increased metoblism and of course weight loss. 7. The goal for COPD is to improve ventilation. 8. From birth to 18 months Trust vs Mistrust 9 HbA1C- indicates BS for past 6-8 weeks(time varies with source) 2.5-6% normal. 10. myasthemia gravis: autoimmune disease of neuro jnx. destroys Acetylecholine receptors. 11. Meniere's: Inner ear disease: vertigo, tinnitus, sensorineuro hearing loss, N/V 12. Use play therapy for children d/t inability to verbalize emotions. 13. Phenergan: Check vein patency (very important) 14. Visine: contraindicated in glaucoma d/t vasocontriction

1. Autonomic Dysreflexia--asses Bladder, Bowel, Skin 2. GIVE Dantrolene to treat pt. in MH crisis 3. JOMACS (mini mental status exam)= Judgement, Orientation, Memory, Affect, Consciousness, Speech 4. -ostomy- make opening 5. -oscopy- look into or at 6. -otomy- cutting into 7. -ectomy- removal of 9. Colporrhaphy- surgical repair of the vagina (Very random[pic]) 10. Do not Palpate WILM's tumor 11. Albumin is the best indicator of nutritional status 12. In V-fib always look at pt first anything can mimic the pattern on EKG 13. V-tach is usually caused by an underlying cause treat cause 14. Percipitous delivery may cause amniotic emboli 15. Hct: Hgb approx 3:1 16. WBC= 5-10 (thousand) 17. Platlets= 150-400 (thousand) 18. PPI's stop gastric acid secretion (permanantly) 19. Vasoconsrtiction stops itching and inflamation (give cool bath) 20. Anticholinergic effects- Cant SEE, Cant PEE, Cant POOP, and dry mouth 21. Trauma to frontal may casuse Frontal Lobe disinhibition 22. Creatinine is the best indicator of renal funtion 23. Every drop of urine counts during 24hr creatinine clearence (if one sample is thrown out must start over) First void of the morning is not included but the first pee of the next morning is [pic](because it is considered Last nights urine) 24. Best position to improve resp. effort = Left Lateral, Folwer & modifications of it

1. When getting down to two answers, choose the assessment answer (assess, collect, auscultate, monitor, palpate) over the intervention except in an emergency or distress situation. If one answer has an absolute, discard it. Give priority to answers that deal directly to the patient’s body, not the machines/equipments. 2. Key words are very important. Avoid answers with absolutes for example: always, never, must, etc. 3. with lower amputations patient is placed in prone position. 4. small frequent feedings are better than larger ones. 5. Assessment, teaching, meds, evaluation, unstable patient cannot be delegated to an Unlicensed Assistive Personnel. 6. LVN/LPN cannot handle blood. 7. Amynoglycosides (like vancomycin) cause nephrotoxicity and ototoxicity. 8. IV push should go over at least 2 minutes. 9. If the patient is not a child an answer with family option can be ruled out easily. 10. In an emergency, patients with greater chance to live are treated first . 11. ARDS (fluids in alveoli), DIC (disseminated intravascular coagulaton) are always secondary to something else (another disease process). 12. Cardinal sign of ARDS is hypoxemia (low oxygen level in tissues). 13. in pH regulation the 2 organs of concern are lungs/kidneys. 14. edema is in the interstitial space not in the cardiovascular space. 15. weight is the best indicator of dehydration 16. wherever there is sugar (glucose) water follows. 17. aspirin can cause Reye’s syndrome (encephalopathy) when given to children 18. when aspirin is given once a day it acts as an antiplatelet. 19. use Cold for acute pain (eg. Sprain ankle) and Heat for chronic ( rheumatoid arthritis) 20. guided imagery is great for chronic pain. 21. when patient is in distress, medication administration is rarely a good choice. 22. with pneumonia, fever and chills are usually present. For the elderly confusion is often present. 23. Always check for allergies before administering antibiotics (especially PCN). Make sure culture and sensitivity has been done before adm. First dose of antibiotic. 24. Cor pulmonale (s/s fluid overload) is Right sided heart failure caused by pulmonary disease, occurs with bronchitis or emphysema. 25. COPD is chronic, pneumonia is acute. Emphysema and bronchitis are both COPD. 26. in COPD patients the baroreceptors that detect the CO2 level are destroyed. Therefore, O2 level must be low because high O2 concentration blows the patient’s stimulus for breathing. 27. exacerbation: acute, distress. 28. epi always given in TB syringe. 29. prednisone toxicity: cushing’s syndrome= buffalo hump, moon face, high glucose, hypertension. 30. 4 options for cancer management: chemo, radiation, surgery, allow to die with dignity. 31. no live vaccines, no fresh fruits, no flowers should be used for neutropenic patients. 32. chest tubes are placed in the pleural space. 33. angina (low oxygen to heart tissues) = no dead heart tissues. MI= dead heart tissue present. 34. mevacor (anticholesterol med) must be given with evening meal if it is QD (per day). 35. Nitroglycerine is administered up to 3 times (every 5 minutes). If chest pain does not stop go to hospital. Do not give when BP is < 90/60. 36. Preload affects amount of blood that goes to the R ventricle. Afterload is the resistance the blood has to overcome when leaving the heart.

37. Calcium channel blocker affects the afterload. 38. for a CABG operation when the great saphenous vein is taken it is turned inside out due to the valves that are inside. 39. unstable angina is not relieved by nitro. 40. dead tissues cannot have PVC’s(premature ventricular contraction. If left untreated pvc’s can lead to VF (ventricular fibrillation). 41. 1 t (teaspoon)= 5 ml 1 T(tablespoon)= 3 t = 15 ml 1 oz= 30 ml 1 cup= 8 oz 1 quart= 2 pints 1 pint= 2 cups 1 gr (grain)= 60 mg 1 g (gram)= 1000 mg 1 kg= 2.2 lbs 1 lb= 16 oz * To convert Centigrade to F. F= C+40, multiply 9/5 and substract 40 * To convert Fahrenheit to C. C= F+40, multiply 5/9 and substract 40. 42. angiotensin II in the lungs= potent vasodialator. Aldosterone attracts sodium. 43. REVERSE AGENTS FOR TOXICITY heparin= protamine sulfate coumadin= vitamin k ammonia= lactulose acetaminophen= n-Acetylcysteine. Iron= deferoxamine Digitoxin, digoxin= digibind. Alcohol withdraw= Librium. - methadone is an opioid analgesic used to detoxify/treat pain in narcotic addicts. - Potassium potentiates dig toxicity. 44. heparin prevents platelet aggregation. 45. PT/PTT are elevated when patient is on coumadin 46. cardiac output decreases with dysrythmias. Dopamine increases BP. 47. Med of choice for Vtach is lidocaine 48. Med of choice for SVT is adenosine or adenocard 49. Med of choice for Asystole (no heart beat) is atropine 50. Med of choice for CHF is Ace inhibitor. 51. Med of choice for anaphylactic shock is Epinephrine 52. Med of choice for Status Epilepticus is Valium. 53. Med of choice for bipolar is lithium. 54. Amiodorone is effective in both ventricular and atrial complications. 55. S3 sound is normal in CHF, not normal in MI. 56. give carafate (GI med) before meals to coat stomach 57. Protonix is given prophylactically to prevent stress ulcers. 58. after endoscopy check gag reflex. 59. TPN(total parenteral nutrition) given in subclavian line. 60. low residue diet means low fiver 61. diverticulitis (inflammation of the diverticulum in the colon) pain is around LL quadrant. 62. Appendicitis (inflammation of the appendix) pain is in RL quadrant with rebound tenderness. 63. portal hypotension + albuminemia= Ascites. 64. beta cells of pancreas produce insulin 65. Morphine is contraindicated in Pancreatitis. It causes spasm of the Sphincter of Oddi. Therefore Demerol should be given. 66. Trousseau and Tchovoski signs observed in hypocalcemia 67. with chronic pancreatitis, pancreatic enzymes are given with meals. 68. Never give K+ in IV push. 69. mineral corticoids are give in Addison’s disease. 70. Diabetic ketoacidosis (DKA)= when body is breaking down fat instead of sugar for energy. Fats leave ketones (acids) that cause pH to decrease. 71. DKA is rare in diabetes mellitus type II because there is enough insulin to prevent breakdown of fats. 72. Sign of fat embolism is petechiae. Treated with heparin. 73. for knee replacement use continuous passive motion machine. 74. give prophylactic antibiotic therapy before any invasive procedure. 75. glaucoma patients lose peripheral vision. Treated with meds 76. cataract= cloudy, blurry vision. Treated by lens removal-surgery 77. Co2 causes vasoconstriction. 78. most spinal cord injuries are at the cervical or lumbar regions 79. autonomic dysreflexia ( life threatening inhibited sympathetic response of nervous system to a noxious stimulus- patients with spinal cord injuries at T-7 or above) is usually caused by a full bladder. 80. spinal shock occurs immediately after spinal injury 81. Multiple sclerosis= myelin sheat destruction, disruption in nerve impulse conduction. 82. myasthenia gravis= decrease in receptor sites for acetylcholine. Since smallest concentration of ACTH receptors are in cranial nerves, expect fatigue and weakness in eye, mastication, pharyngeal muscles. 83. Tensilon test given if muscle is tense in myasthenia gravis. 84. Guillain-Barre syndrome= ascending paralysis. Keep eye on respiratory system. 85. parkinson’s = RAT: rigidity, akinesia (loss of muscle mvt), tremors. Treat with levodopa. 86. TIA (transient ischemic attack) mini stroke with no dead brain tissue 87. CVA (cerebrovascular accident) is with dead brain tissue. 88. Hodgkin’s disease= cancer of lymph is very curable in early stage. 89. Rule of NINES for burns Head and Neck= 9% Each upper ext= 9% Each lower ext= 18% Front trunk= 18% Back trunk= 18% Genitalia= 1% ?

90. Birth weight doubles by 6 month and triple by 1 year of age. 91. if HR is Patient's pupils are pinpoint 3. Neostigmine (Prostgmin) is a cholinergic and can cause bronchoconstriction in asthmatic patients 4. Native Americans have the highest incidence of cleft lip and palate 5. Prolapsed cord => Put pt in trendelenburg position 6. Latex allergies => Assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes, peaches 7. Pt with glaucoma => The priority is to prevent deterioration of the vision; vision can not be improved 8. Myelogram => Meds that lower the seizure threshold (phenothiazines, thorazine), MAO inhibitors (Marplan, Nardil, Parnate), tricyclic antidepressants (Tofranil, Elavil), CNS stimulants, psychoacive drugs (Ritalin) should be held for 48 hrs before and 24 hrs after test 9. In panic level anxiety, the pt is unable to see, hear or function 10. Double-bind communication => emotions communicated verbally are opposite of emotions communicated physically 11. Depressed client => help client to identify unrealistic behaviors 12. Benztropine (Cogentin) => treat parkinsonian side-effects of anitpsychotics meds 13. Imipramine (Tofranil) => tricyclic antidepressant used to treat panic attacks 14. CPR adults => depress sternum 1.5 to 2 inches; rescue breaths 12 times per minute 15. Pt with a dislodged trach => Priority is to hyperextend the pt neck (patent airway...) Not 100% sure about that one but you can look it up or give additional inputs... 16. Pt allergic to sulfa drugs should take Cipro 17. Vecuronium (Norcuron) (neuromuscular blocking agent) is given to a pt who is fighting the ventilator... => Pt is unable to blink! Administer complete eye care 18. Pt on dilantin => Urine may turn pink, red or brown...

Here's my share: • BRAT (Banana, rice, apple, toast/tea) - NOT recommended for a child with acute diarrhea (has low nutritional value, low protein/energy, high carbs) • SHOCK - elevate lower extremities to improve circulation to the brain and vital organs • Ct with dementia - reinforce ROUTINE, talk to ct face-to-face • Barium enema - take slow deep breaths, tell ct stool will be light-colored for 2-3 days after test • DIC - oozing blood; sepsis is most frequent cause • hospitalized school-age child = greatest fears are perceived loss of control and separation to friends/peers • Licorice - increases K+ loss, DONT take to prevent Digoxin toxicity • epiglottitis - NEVER insert a tongue blade - gag reflex can obstruct airway • Dilantin comes in a suspension, SHAKE it!!

So Many Wonderful Tips! Thanks to all who have contributed to this thread!!!!![pic]
* Active aquired immunity consists of immunologic responses that develop as the body is being defended.
* Rheumatic endocarditis results from rheumatic fever caused by group A streptococcal infection.
* People with type O blood are more susecptible to peptic ulcers.
* Tagamet is used in tx of peptic ulcers because it inhibits acid secretion.
* Diverticulitis is most often tx with diet and meds.
*The ideal tx for UTI is an antibacterial agent such as trimethoprim-sulfamethoxazole.
* A positive antibody test for HIV means you have been infected with the HIV virus & your body has produced antibodies.
* AZT ( Zidovudine ) works to fight against AIDS by inhibiting new virus production.
* Herpes Simplex Type I is the virus that causes cold sores on the lips.
* Signs of meningitis include a positive Kernig's sign, a positive Brudzinski's sign , headache , fever and nuchal rigidity.
* Varicella Zoster is transmitted by airborne contact.
* Ceftriaxone and doxycycline are used to tx gonorrhea.
* Wear gloves when in contact with excretions, secretions, blood, or any other body fluids.
* Complications of chlamydial infections significantly contributes to the incidence of ectopic pregnancy.

The secondary stage of syphilis is when the rash appears.

The medication of choice for syphilis is penicillin G benzathine.

Staphylococcous is the organism responsible for most skin infections.

The drug of choice for MRSA is vancomycin.

When assessing a pt. with diarrhea, the nurse should first determine hydration status.

Legionaire's disease is treated most often with ethromycin.

Signs & symptoms of wound sepsis include elevated pulse and temperature, elevated WBCs , swelling, warmth, and tenderness.

Lesions at the midbrain result in decerebrate posturing.

The motor cortex governs voluntary motion.

Upper motor neurons refer to motor pathways from the brain to the spinal cord.

Destruction or dysfunction of the basal ganglia leads to muscle rigidity.

Most important indicator of increased ICP is a change in LOC.

In adults, most brain tumors origionate from glial cells.

More facts:
* Tensilon is used in myesthenia gravis to confirm the diagnosis.
* Myesthenia gravis is caused by a disorder in the transmission of impulses from nerve to muscle cell.
* Amyotrophic lateral sclerosis ( ALS ) is a condition in which there is a degeneration of motor neurons in both the upper & lower motor neuron systems.
* The trend in tx of rheumatoid arthritis is with COX-2 that acts as an anti-inflammatory.
* Paget's disease is characterized by excessive bone destruction, skeletal deformities, and cortical thickening.

Chicken Pox-tx with Acylovir
Diptheria-tx with diptheria antitoxin, penicillin; erythromycin
Lyme Disease-tx with tetracycline;penicillin
Typhoid Fever-tx with chloramphenicol; ampicillin; sulphatrimethoprim

Expected patient outcomes for a patient with osteoporosis include: has positive self-esteem, experiences no new fractures, understands factors that contribute to potential injury.

Nursing management of pt.with cerebral aneurysm or intracranial hemorrhage: use gentleness in moving pt. keep room darkened keep pt. on bedrest, HOB at 30 degrees give no ice water initiate bowel program to prevent straining at stool only a few visitors at a time decrease stimuli, no tv no radio in severe cases no rectal temperatures, no enemas, no suppositories

Tips on answering nclex-rn questions

Decide What the Question is Dealing With:

Which part of the Nursing Process: Assessment; Analysis; Planning; Implementation or Evaluation?

Next, Decide the Order of Priority First you must decide what part of the nursing process the question is connected with:

ANALYSIS--is the process of identifying potential and actual health problems. Most identify pertinent assessment information and assimilate it into the nursing diagnosis. Prioritize the needs that have been identified during analysis. Some common words that are associated with ANALYSIS questions: diagnose; contrast; compare; analyze; order; prioritize; define; classify; catagorize; synthesize; sort; arrange;

ASSESSMENT--consists of a collection of data. Baseline information for pre and post procedures is included. Also included the recognition of pertinent signs and symptoms of health problems both present and potential. Verification of data and confirmation of findings are also included. Assess a situation before doing an intervention. Some common words that are associated with ASSESSMENT questions: observe; gather; collect; differentiate; assess; recognize; detect; distinguish; identify; display; indicate; describe; PLANNING--Involves formulating goals and outcomes. It also involves various members of the health care team and the patient's family. All outcome criteria must be able to be evaluated with a specific time frame. Be sure to establish priorities and modify according to question. Some common words that are associated with.

PLANNING questions: rearrange; reconstruct; determine; outcomes; formulate; include; expected; designate; plan; generate; short/long term goal; develop;

IMPLEMENTATION--Addresses the actual/direct care of a patient. Direct care entails pre, intra and postoperative management, preforming procedures, treatments, activities of daily living. Also includes the coordination of care and referral on discharge. It involves documentation and therapeutic response to intervention and patient teaching for health promotion and helping the patient maintain proper health. Some common words that are associated with IMPLEMENTATION questions: document; explain; give; inform; administer; implement; encourage; advise; provide; perform;

EVALUATION--Determines if the interventions were effective. Were goals met? Was the care delivered properly? Are modification plans needed. Addresses the effectiveness of patient teaching and understands and determines in proper care was offered. Evaluation can involve documentation, reporting issues, evaluates care given and determine the appropriateness of delegating to others. Most significantly, it finds out the response of the patient to care and the extent to which the goals we met. Some common words that are associated with EVALUATION questions: monitor; expand; evaluate; synthesize; determine; consider; question; repeat; outcomes; demonstrate; reestablish; After determining what part of the nursing process the question is concerned with, next focus your attention on determining the category of priority: Safe and effective care environment is always first. Patient safety is related to the proper preparation and delivery of nursing techniques and procedures as part of the nursing practice. It relates to every aspect of the delivery of care. Physiologic integrity is the ability to provide competent care Information that may be described as traditionally medical- surgical and pediatric nursing falls into this category. Specific questions in this area can be related to many direct-care aspects of nursing practice. The importance of this area is highlighted because it is one in which planning, implementation and evaluation of care needs can easily be identified and tested. Physiologic integrity is always a slight lower priority than safety unless it involves airway, breathing and circulation. "ABC's" always comes first! Psychosocial integrity tests the knowledge about a patients response to a disease or disorder. An understanding of stress, anxiety and ways to cope are essential. This is a lower priority the physiological integrity. Health maintenance deals with health promotion, health teaching, disease prevention and assessment of risk factors for health problems. Normal growth and development is a major theme in this category. This however, is a low priority.

In Summary, when choosing the right answer for you NCLEX exam question: 1) ask yourself, "what part of the nursing process is this question dealing with: analysis, assessment, planning, implantation or evaluation? and 2) Remember to prioritize your choices: safety always being first, second physiological integrity, third,psychosocial integrity and health maintenance always has the lowest priority when choosing an answer.

Other tidbits: avoid choices with the answers "all" "always" "never" or "none". Nothing is ever a definite in Science. look for answers that are different. If three answers say the same thing but in different words, choose the answer that is different. when given choices that are pharmacologically based or non pharmacologically based, choose the non pharmacological intervention. It is more often then not, the correct answer.

the decelerations during pregnancy get confused in my head. this is what I use to keep them straight. note the bold text.

early deceleration - fetal head compression (the ear is a part of the head)

late deceleration - uteroplacental insuffiency

variable deceleration - umbilical cord compression

• with urolithiasis avoid wearing synthetic underwear and pantyhoses. • salt substitutes shouldnt be used by clients with chronic renal failure due to risk of hyperkalemia. • s/s of epididymitis- scrotal pain and edema, n/v, and chills

SPINAL NERVES cross tracts as opposed to CRANIAL NERVES… if you are paralyzed on the left, your right brain is screwed up. HOWEVER, if your left eye doesn’t constrict it’s your LEFT BRAIN that’s screwed up (Get it? Cuz the cranial nerves don’t cross tracts but the spinal nerves that innervate your skeletal muscles do..)

Most likely for things to go down the Right Bronchus cuz it’s shorter, fatter and more vertical. If after intubation, there are decreased breath sounds/ decreased lung expansion on the left, it’s probably b/c the person who intubated put the ETTube down too far, past the carina (where it’s supposed to be) and it’s in the right bronchus.

Kids with spina bifida are more prone to latex allergies

Pregnant women can not administer Ribavarin (for RSV)

Mumps can lead to male infertility

BNP (B type natriuretic peptide) should be never stop abruptly!

Earliest sign of larynx cancer is hoarseness or change in vocal quality.

If in doubt whether a patient is hyper or hypoglycemic, treat pt for hypoglycemia.

CSF leakage through the nose (rhinorrhea) or through the ear (otorrhea) = increased ICP --> DO NOT SUCTION!

Positioning for Cleft lip and Cleft palate
Cleft lip - on side or upright in infant seat (not prone)
Cleft palate - on side or abdomen

Transesophageal Fistula (TEF) - esophagus doesn't fully develop (this is a surgical emergency)
The 3 C's of TEF in the newborn:
1) Choking
2) Coughing
3) Cyanosis

Pyloric stenosis - projectile vomiting

Intussusception - "currant jelly" stools (blood and mucus mixed)

Here's One....

A person with eczema is at greatest risk for latex allergy!

Two...

Always see difficulty breathing, swallowing, or person with pain after giving pain med an hour ago FIRST

Three...

When getting pt out of bed have open end of chair facing the foot of the bed.

Four...

Ausculate S3 and S4 extra heart sounds by turning pt on the left side and using the bell of stethoscope to listen at apex.

Five...

The more babies out.. its get loose... more prone to hemorrhage

Some pharm stuff I typed from before using the ATI review:
(hope it helps)....

• Hallmark signs of digoxin toxicity ⋄ blurred and double vision
• Guaifenesin ⋄ can cause drowsiness, so ct should avoid driving…that requires alertness
• Anticholinergic effect ⋄ urinary retention
• Safe to take with albuterol (Proventil) for a ct with cardio disease ⋄ spironolactone (aldactone) =>K+ sparing diuretic that decreases risk of hypokalemia & ECG changes)
• Supplemental thyroid hormone (Levothyroxine) for hypothyroidism will be required throughout the child’s LIFETIME.
• Severe allergic rxn to Cephalosporins ⋄ ct have high incidence of allergic rxns to PENICILLINS (avoid penicillins)
• Ct receiving Phenobarbital IV for anticonvulsant therapy, interventions include:
♣ Observing the ct for RR depression
♣ Monitoring the ct for excessive sedation
♣ Avoiding extravasation of the parental solt’n
• Sumatriptan (Imitrex) SQ therapy ⋄ take medication AS SOON AS MIGRAINE SXS APPEAR/ATTACK
• Intravenous ⋄ fastest, most effective route; deliver the medication directly into the bloodstream, allowing rapid distribution throughout the body
• Opioid antagonist (Naloxone, narcan) ⋄ increase RR, improvement of RR
• Baclofen ⋄ improved ability to perform ADLs in spinal cord injury pts (decreases frequency & severity of MUSCLE SPASMS)
• Erythromycin (Erythrocin) ⋄ contraindicated with chronic alcoholism & cirrhosis who has resp infection (liver toxicity)
• Review insulin drawing in syrine (units)
• Cts taking K+-sparing diuretics should avoid consuming foods that contain high levels of K+. Salt substitutes are high in K+ chloride content.
• A ct dx with acute MI is tx in an emergency dep’t with alteplase (Activase) which has a short half-life ⋄ must administer drug concurrently with alteplase => heparin (short half-life opens an occluded artery quicky, reduce risk of reocclusion with heparin)
• 17 yr old ct receiving testosterone (Depo-Testosterone) injections monthly to correct delayed puberty, monitor use ⋄ x-rays of the hand & wrist q 6 mos. (determine rate of bone maturation, drug can help bone mature w/o producing a compensating gain in liner growth)
• With renal impairment, there is decreased elimination of atropine => [FONT='Times New Roman','serif']↑[/font] anticholinergic effects of atropine = confusion
• A diuretic Acetazolamide (Diamox) ⋄ contraindicated with SULFONAMIDES
• Hold Metoprolol (Lopressor) dose if client develops DYSPNEA (sign of exacerbation of congestive heart failure, might precipitate it)
• Progestins (oral contraceptive) ⋄ can cause WT GAIN ⋄ can increase appetite
• How to use a metered-dose inhaler to administer albuterol (Proventil)
♣ Hold the inhaler so that drug’s metal canister is inverted
♣ Release 1 or more test sprays into the air if it’s a new inhaler
♣ Shake the inhaler before administering a dose
♣ Rinse mouth with water p the last inhalation
• A pplying a cool, damp cloth to person’s forehead, neck, wrists ⋄ helps promote comfort for pts who are N & V
• Ct taking Allopurinal (Zyloprim) to reduce uric acid level for secretion, must avoid CORN ⋄ tends to acidify urine and might increase the risk of URIC ACID STONE formation.
• Dry persistent cough ⋄ common during 1st wk of ACE inhibitor therapy d/t accumulation of bradykinin from inhibition of angiotension-converting enzymes
• Giving 2 antiHTNs together ⋄ interact synergistically (potentiation) => the effect of giving both drugs should be greater than that of either administered alone
• Lasix/furosemide ⋄ check BP (can cause a substantial drop in BP by decreasing circulatory volume and by relaxing venous smooth muscle => reduce venous bld return to the heart)
• Collagenase (Santyl) to tx leg ulcers ⋄ within about a week, this ointment will remove dead tissue so that ulcers can heal
• Immunizations with live vaccines ⋄ long-lasting active immunity
• Ct receiving Epoetin (Procrit) to tx anemia, rxn r/t this drug ⋄ HA (if hct rises too quickly, HTN & seizure can result ⋄ HA is early sign)
• 2nd cycle of Fertinex for fertility txment ⋄ verifies that today’s dose is based on the ct’s response in the preceding cycle
• Bronchospasm ⋄ SOB and hypoxia
• Interaction between Reglan & Morphine ⋄ increased SEDATION
• MANNITOL ⋄ MUST BE USED WITH EXTREME CAUTION IN CTS WHO HAVE HEART DISEASE => CHF AND PULMONARY EDEMA
• Benadryl ⋄ DON’T USE SLEEPING PILL (avoid CNS depressants to could increase sedation)
• Life-threatening rxn to GAMMA GLOBULIN = chest tightness, bronchoconstriction, angioedema, hypoTN ⋄ anaphylaxis
• Nurse to apply sulfamylon to burn injury: o Administer the PRN analgesic 30mins before applying (for pain, b/c it is painful) o Apply p daily tubbing (to remove old previously applied cream) o Monitor f&e & acid base balance o Sched wound care at least 1hr before meals (time to recover)
• Thrombocytopenia = platelet count get hgb level
• To achieve complete eradication of Hepatitis B ⋄ required immunization of all infants & children
• Family ⋄ 1 or more individuals possess some common emotional bond
• Ethnicity ⋄ group of ppl who share common, distinctive characteristics such as race, ancestry, nationality, language, religion, food preferences, hx
• Medicaid ⋄ administration falls to STATE govt’s
• Healthy ppl 2010 ⋄ set of health goals for aggregates; rationale is that our society can little afford the cost of tx preventable diseases and injuries
• Early crisis ⋄ w/c can last from moments to days, rxn is primarily emotional;cts express shock, disbelief, numb, panicky, cant cope
• Public Health Dep’t ⋄ PHN focus is the health of the community. During a home visit, will provide education & referrals for specified problems that impact the health of the community
• Occupational health nurse ⋄ work for businesses & industries to support employee health (eg; job related injury)
• Breast self-exam ⋄ 14-19yrs (must begin in high school)
• The most basic and important action for nurses in providing culturally competent care ⋄ confront own racism & ethnocentrism (if the nurse isn’t aware of his/her own culture, biases and prejudices, it’s not possible to competently assess and communicate with indiv of other cultures)
• When designing maternal-infant programs and services in a community, most important consideration ⋄ developmental level of the groups being served (to identify needs of specific aggregates for whom services are intended (adolescents, career women, migrants).
• Understanding of the developmental tasks & psychosocial issues of each population should be the cornerstone of a well-developed program.
• Compared to younger ppl, it is even more important for interventions targeted to the elderly to promote physical exercise (People aged 65yrs and older are less likely than younger ppl to exercise)
• A female student comes to the school nurse’s office to express concern about a “friend” who induces vomiting in the BR p lunch q day. ⋄ nurse must continue to assess for other signs that might indicate a mental disorder.
• The best way to evaluate the success of a campaign to increase the # of immunizations in a school district is to ⋄ compare the # of children in the district who were immunized during the past year to the # immunized in the preceding year.
• Common aspect of both elder abuse & child abuse ⋄ victims are usually dependent on the abuser
• Rural American group ⋄ have an uninsured or underinsured status
• Single most prevalent health problem among the homeless ⋄ ALCOHOLISM
• Denver II test ⋄ overall dev’t status can be appropriately screened during bith to 6 yrs (revision of the classic Denver Devt’al Screening Test)
• Highest risk of dying from severe burn injury ⋄ toddlers (1-9yrs)
• An intervention to address alcohol/drug abuse at the level of subgroups within a community would be to ⋄ provide a support group for employees who are recovering from alcohol or drug abuse (the support group constitutes a sub-group within the community; the intervention is targeted for just those ppl)
• EMPOWERMENT ⋄ CITIZEN PARTICIPATION
• Women expected to live 6yrs longer than men b/c ⋄ Men are less likely than women to obtain preventive physical exam (women more likely to engage in health maintenance)
• OSHA ⋄ regulation of potential hazards in the workplace
• Salmonella ⋄ properly store & thoroughly cook eggs and poultry
• E coli ⋄ raw beef; wash hands
C.jejuni ⋄ drink only chlorinated drinking water

ere's some more Community Facts: (sorry if they're too long.....)

• Erikson’s Generativity vs. Stagnation ⋄ middle adults (>40y) guide and care for the younger generation and assist the older one
• Neonate should gain 0.5-1 oz (15-30g/day)
• Serum lead [c] = 16mg/dL and been above 10mg/dL for several months ⋄ investigate the child’s environment
• (+) reaction to tuberculin skin test ⋄ induration (hardening) larger or equal to 15mm in a person >4yrs who has not risk factors for TB
• Pertussis ⋄ vaccine composed of INACTIVATED bacteria
• Disaster ⋄ cannot be relieved without assistance (that’s why disaster preparedness is important) o OUTSIDE AREA ⋄ area not directly affected by the disaster but can offer assistance
• Community competence ⋄ parts of community (org, groups, aggregates) collaborate effectively in identifying the problems & needs of a community, achieving similar goals and priorities
• Behavior or lifestyle ⋄ greatest effect on the health of a community as a whole. This underscores the importance of primary prevention.
• Nursing strategy for HOMELESS: o Using reflective statements that convey an understanding of situation o Accepting the political commitments essential for advocacy for homeless cts o Focus on primary prevention (identify other educational, placement, and legal services that they can’t access)
• Hospice ⋄ focus of care is COMFORT for individual facing death
• Evaluation in community assessment barrier ⋄ setting goals that are unrealistic or inappropriate tend to break down progress rapidly
• Morbidity stats ⋄ reflect the extent and distribution of illness and disability in the community
• Prevalence rate ⋄ # of old & new cases of specified disease
• Incidence rate ⋄ # of NEW cases of a specified disease within a pop
• Older smokers who try to quit smoking are MORE LIKELY to stay off cigarettes.
• Older adults might be at risk for POOR NUTRITION ⋄ loss of dentition (or poor fitting dentures interfere with biting/chewing)
• Nurse refers client to inappropriate health care provider ⋄ making negligent referral
• Secondary prevention ⋄ working with person in affected pop (ppl experiencing effects of violence and ensuring safety)
• Providing doc of physical evidence in a case of suspected physical/sexual abuse ⋄ use body mapping & photographs in addition to written doc
• Boy fell forward in the ground ⋄ Fracture of the forearm
• Physical exercise ⋄ greater energy reserve o Does NOT change person’s perception of stress
• Immunization in order: o Hepatitis B o DTaP, Hib, IPV, PCV o Influenza o MMR and varicella
• HIPAA ⋄ to protect workers from losing health care coverage with a job change or loss
• Nicotine ⋄ GATEWAY for substance abuse
• SIDS ⋄ "back to sleep"
• Tertiary prevention ⋄ helping a ct with asthma use an inhaler (long-term & chronic)
• Secondary prevention ⋄ giving first aid for injuries sustained during activities
• Enviro-mechanical hazards in the workplace: o Inadequate lifting device (risk for injury) o Excessively cluttered work areas o Slippery floors o Poor workstation-worker fit
• Ethnocentrism ⋄ belief that one’s own ways are the best, most superior

Ok for those of you who did not take Kaplan, this is their infamous Decision Tree
(Can't say I use it a lot, but some swear by it)

1. Can you identify the Topic?
Yes= proceed to step 2
No= read answers for clues, read stem, re word question identify and proceed to step 2

2. Are all answers Assessments or Implementations?
Yes= proceed to step 3
No= determine from stem if assessment needed, validation needed; if so assess
*if no assess in stem then you need to assess
*if assess in stem, do you need validation?
*if assess or validation required and there are no right assess answers, then implement

3. Does Maslows fit?
Yes= Do they make sense? Apply ABC's.
*eliminate psychosocial/pain (consider pain psychosocial for nclex)
*don't always pick airway
No= are all physical? yes..then proceed to step 4 are all psychosocial? yes..then proceed to step 5

4. Are all answers physical?
Yes= apply ABC's
No= proceed to step 5

5. What is outcome of each? do they make sense? why? and yes folks then you should have your answer!!!!

INFECTION CONTROL

Airborne Precautions:
Varicella
TB
Rubeola

pt must wear mask when transporting what else?!?

Droplet Precautions:
Mennigittis
Pneumonia
Pertussis
Rubella
Mumps

private room unless other pt has same organism maintain 3 feet distance unless giving care anything else??

Contact Precautions:
RSV
Synctial virus
C Diff
MRSA
Ecoli
Scabies
Impetigo
Room needs to be private unless same organism gloves/gown when in contact with secretions anything else??

Standard Precautions:
CF
Bronchitis
Hantavirus
Tonsillitis
Cutaneous Anthrax

For airborne, make sure the patient is in a room that has negative air pressure with at least 6-12 exchanges an hour, and N95 mask for TB.

Also remember MTV Cd for airborne: Measles (Rubeola), TB, Varicella (Shingles), Chickenpox, Disseminated varicella zoster.

Piaget is known for cognitive development.

Freud veiws anxiety as a warning to the person of impending danger.

Vitamin B1 deficiency is linked to Korsakoff's syndrome.

Korsakoff's syndrome is associated with ataxia, confabulation, and myopathy.

A liver that is tender on palpation is suggestive of viral hepatitis.

The inability of diseased liver cells to clear normal amounts of bilirubin from the blood is found in hepatocellular jaundice.

Hepatitis B has an incubation period of 2-5 months.

Patients with renal disease need to be monitored for potassium imbalances especially hyperkalemia. The primary method of treating hyperkalemia is with hemodialysis.

Here are some I've found while studying:

Approximately 2 weeks after starting pt on antidepressants, assess for increased energy, could be sign of suicidal ideation

If you believe pt to be in respiratory detress, assess lung sounds first, LOC, retractions, skin color, etc would all be late signs

if dealing with a pt that is hallucinating, ask pt what voices in head are saying to assess for presence of command hallucinations

Bi-polar pt in mania phase will be full of energy, difficulty sitting still, provide finger foods as well as private room

Chest tube water seal chamber should fluctuate with breaths, this is normal

Chest tube should not bubble, this could be sign of air leak

Trach balloon should be inflated any time there is any risk of pt aspirating (ie eating, increased secreations, when getting tube feeds, on vent, and 30 min after eating)

When changing trach ties, remove old ties with non-sterile gloves, then put on sterile gloves to apply clean ties

With a pt receiving tube feeds, only fill bag with enough feeds for 4 hrs, and assess for residuals every 4 hours

Cystic Fybrosis pt---Contact and Droplet precautions, pt must wear mask if leaving room

Avoid asking "why"

After administering Fosamax, instruct pt to remain sitting up for 30 min

Never palpate a Wihlm's Tumor, could cause cancer cells to break off

When doing adominal assessment, auscultate, then palpate, Palpating first will alter bowel sounds

When instilling eye drops into the lower conjunctival sac hold the dropper 1 to 2 cm ( 0.4 to 0.8 inches ) above the sac.

Discolored amniotic fluid such as green is a sign of fetal distress.

Placenta previa = painless bleeding. No vaginal exams.

After the rupture of membranes, the babies heart is checked then rechecked a few minutes later or after next contraction.

In the apgar score, the first time done reflects the transitional score, the second apgar score reflects the planning of care for the newborn.
Score over 7, baby is ok but score under 5 needs recussitation or intensive care.

Hep.B vaccine given within 12 hours of birth.

Anterior fontanelle closes at 12 to 15 months.

At 7-12 months they are aware of themselves and can imitate. Be sure toys have no small pieces. Should be weaning from bottle to sippy cup by 12 months ( 1 year ).

At 10 to 13 months walks while holding on to furniture and can stand ok. According to my kids pediatrician, " They are supposed to entertain themselves for periods of time ". YEAH RIGHT! Mine were calling mommy all the time.

At 2-3 months they should be able to smile and follow objects.

Anaphylactic reaction to baker's yeast is contraindication for Hep B vaccine.

** Ask for allergy to eggs before Flu shot
** Ask for anaphylactic rxn to eggs or neomycin before MMR
** When on nitroprusside, monitor thiocynate (cyanide). Normal value should be 1, >1 is heading toward toxicity
**If kid has cold, can still give immunizations
**SARS (severe acute resp syndrome) airborne + contact (just like varicella)
** Hepatitis A is contact precautions
** Tetanus, Hepatitis B, HIV are STANDARD precautions
** William's position - Semi Fowlers with knees flexed (inc. knee gatch) to relieve lower back pain.
** SIGNS of a Fractured hip: EXTERNAL ROTATION, SHORTENING, ADDUCTION
** Fat Embolism: Blood tinged sputum (r/t inflammation), inc ESR, respiratory alkalosis (not acidosis r/t tachypnea), hypocalcemia,increased serum lipids, "snow storm" effect on CXR.
**Complications of Mechanical Ventilation: Pneumothorax, Ulcers
** Paget's Disease - tinnitus, bone pain, enlargement of bone, thick bones.
** NO VITAMIN C with Allopurinol
** IVP requires bowel prep so they can visualize the bladder better
**Acid Ash diet - cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread
** Alk Ash diet- milk, veggies, rhubarb, salmon
** Orange tag in triage is non emergent Psych
** Greenstick fractures, usually seen in kids bone breaks on one side and bends on the other

Gout- a build up of crystals of uric acid (Kidney stones) depositing in tissues of the body. Tx: adequate fluid intake, reduce alcohol, medications that reduce hyperuricemia, and diet changes like decrease in foods that contain purines( organ meats, seafood etc.)

Moxifloxacin, can cause inflamed and ruptured tendons, so assess for tendon swelling and pain

Steroids can increase gastric secretions, increasing your risk of gastric ulcers and GI bleeds, so try to avoid asprin

Letrozole is used to treat advanced breast cancer, skeltal and bone pain is a common side effect

Lopressor and other Beta Adernergic blockers can commonly cause impotence

When administering chemotherapy, remember to wear gloves, eye protection, and a mask that covers both your mouth and nose

Mg toxicity, assess for loss of deep tendon reflexes, respiratory depression, drop in heart rate and blood pressure, and a sudden drop in fetal heart rate

Klonopin, pt will experience clumsiness and unsteadiness early in therapy, should disappear with long term use

Rifampin and INH, take together on empty stomach for maximum absorption

Administer Haldol and anti-Parkinson medications at same time to decrease risk of extrapyramidal effects of the Haldol

When instructing a pt on how to hold a cane, it should be at the level of the greater trochanter and femur, on the good side

When administering an enema, position the pt in a left Sims position. Do not elevate the head of bed

Tinnitus, most common symptom pts experience with inner ear disorders

Administering ear drops in a child, pull down and back on ear lobe
In adult, pull up and back on auricle. Instruct pt to keep head up for 10-15 min after administering drops

An isolated warmer area in the middle of a cast could be indicative of infection

PVC's are concerning of there are greater than 6 per min, if they occur in pairs, are multifocal, or if the fall on the T wave

Niacin, used to treat hyperlipidemia

Antiparkinson drugs, monitor for urinary retention, hypotension

Synthroid (for hypothyroidism), should only be given in the morning because of it's risk of causing insomnia if given at bedtime

Hyperthyroidism (Grave's Disease)---things speed up, monitor for tachycardia, nervousness, insomnia, weight loss, bulging eyes, diarrea, sensitive to heat

Hypothyroidism (Myexedma)--things slow down, weight gain, constipation, decreased activity level, bradycardia

Incontinence is normal with aging--not a prob

Lymes is found mostly in Conneticut

Cervical cancer--hx of many sexual partners--risk factor

Breast cancer--hx of young menstural age and oral contraceptives for 8yrs

Asthma and Arthritis--swimming best

Asthma has intercostal retractions--be concerned

Braxton hick contractions in pregnancy are normal--it's when the stomach is tensed and relaxes

Post pituitary hormones--oxytocin, vasopressin, and ADH
Ant pituitary hormones--growth, TSH, ACTH, LH, and FSH

Water heater temp should be set no higher then--120 degrees--children precautions

DKA--300-600
HHNKS--600-1200 Blood sugars

CVP normal range 3-12

Transition phase of labor--shallow resperation (pant)

PCA--patient controlled analgesics--itching is common side effect

S3 vetricular gallop is early sign of HF

Inflow and Intake recorded seperately

Cystic fibrosis--both parents carry recessive trait, an autosomal recessive trait

Nephrotic syndrome--complication--venous thrombosis

placenta previa--c-section

FVO-fluid vol overload--rales and inc Pulse

Cystic fibrosis--pos sweat test=replace enzymes and inc salt intake a resp and GI disease

Hartavirus Pulm syndrome--assess for s/s of thrombocytopenia
--caused by rodents

IOP--intra ocul pressure--10-21mm/hg

Vitamin
B-12 ==anemia
B-1 ==alcohol
B-9 == folic acid
B-6 ==TB

Synthroid in morning to prevent insomnia

Tardive Dyskinesia - irreversible - involuntary movements of the tongue, face and extremities, may happen after prolonged use of antipsychotics

Akathisia - motor restlessness, need to keep going, tx with antiparkinsons meds, can be mistaken for agitation.

Schizophrenia - disturbances in affect, mood, behavior, & thought processes. " do not go along with the delusions or hallucinations", set limits on the persons behavior when it interferes with others & becomes disruptive.

Protein and vitamin C are necessary for wound healing.

Poultry and milk are good sources of protein. ( to name a few )

Broccoli and strawberries are good sources of vitamin C. ( to name a few )

Normal serum creatinine level is 0.6 to 1.3 mg/dl. The person with mild renal insufficiency would have a slightly increased level. Levels of 3.5mg/dl means possible acute or chronic renal failure.

Theophylline increases risk of digoxin toxicity and it decreases effects of both lithium and dilantin. Barbituates decrease the effects of theophylline.

If the question asks for an immediate action/response, all options might be correct so select the answer based on priorities.

Capsules & sustained release meds are not to be crushed.

After cataract surgery the person should not sleep on the operative side.

After liver biopsy the person is instructed to lay on their right side.

When giving an enema place the patient in left laying Sim's position so the enema can flow by gravity in the natural direction of the colon.

After a craniotomy keep head of bed ( HOB ) elevated 30 degrees to 45 degrees.

When drawing an ABG, you need to put the blood in a heparinized tube, make sure there are no bubbles, put on ice immediately after drawing, with a lable indicating if the pt was on room air or how many liters of O2.

Remember to preform the Allen's Test prior to doing an ABG to check for sufficient blood flow

Before going for Pulmonary Fuction Tests (PFT's), a pt's bronchodilators will be with-held and they are not allowed to smoke for 4 hrs prior

For a lung biopsy, position pt lying on side of bed or with arms raised up on pillows over bedside table, have pt hold breath in midexpiration, chest x-ray done immediately afterwards to check for complication of pneumothorax, sterile dressing applied

For a lumbar puncture, pt is positioned in lateral recumbent fetal position, keep pt flat for 2-3 hrs afterwards, sterile dressing, frequent neuro assessments

EEG, hold meds for 24-48 hrs prior, no caffine or cigarettes for 24 hrs prior, pt can eat, pt must stay awake night before exam, pt may be asked to hyperventilate and watch a bright flashing light, after EEG, assess pt for seizures, pt's will be at increased risk

Diamox, used for glaucoma, can cause hypokalemia

Dexedrine, used for ADHD, may alter insulin needs, avoid taking with MAOI's, take in morning (insomnia possible side effect)

Cytovene, used for retinitis caused by cytomegalovirus, pt will need regular eye exams, report dizziness, confusion, or seizures immediately

INH, used to treat and prevent TB, do not give with dilantin, can cause phenytonin toxicity, monitor LFT's, give B6 along with, hypotension will occur initially, then resolve

Rifampin, for TB, dyes bodily fluids orange

If mixing antipsychotics (ie Haldol, Throazine, Prolixin) with fluids, med is incompatible with caffine and apple juice

Haldol preferred anti-psychotic in elderly, but high risk extrapyramidal side effects (dystonia, tarditive dyskinesia, tightening of jaw, stiff neck, swollen tongue, later on swollen airway), monitor for early signs of reaction and give IM Benadryl

Risperdal, antipsychotic, doses over 6mg can cause tarditive dyskinesia, first line antipsychotic in children

Levodopa, for parkinsons, contraindicated in pts with glaucoma, avoid B6

Sinemet, for parkinsons, contraindicated with MAOI's

Hydroxyurea, for sickle cell, report GI symptoms immediately, could be sign of toxicity

Zocor, for hyperlipidemia, take on empty stomach to enhance absorption, report any unexplained musle pain, especially if fever

Cushing Syndrome: salt, sugar, stress is UP

Addison's: salt, sugar, stress is down

Hypocalemia, Hypomagnesia, and Hypokaleia, all increase risk of digoxin toxicity

Ulcerative colitis, frequent liquid stools, contain blood, affects rectum and left colon

Chrohn's---diarrhea, contains fat, affects ileum and right colon

Remember McBurney's Point (pain between umbilicus and right iliac crest) when assessing pts with appendicitis

Appendicitis, no hot packs, may have ice to alleviate pain, no pain meds (may mask rupture)

Hirschsprung's disease, infant fails to pass meconium, abd distention, caused by obstruction in intestine, will get colostomy, that is usually reversed when child is 17-22 lbs.

Aside from monitoring the vital signs of a pt. post-tonsillectomy check for frequent swallowing which could be a sign of post-op bleeding.

Trach cuffs should be deflated & reinflated periodically to prevent necrosis of trachial tissues.

Post tonsillectomy/adenoidectomy no straws!

Monitor the daily weight if pt. taking Lasix.

Post-thyroidectomy, monitor for s/s of airway obstruction; hemmorhage (be sure to check behind client's neck, as bandage may appear clean when severe bleeding may be draining underneath); thyroid storm; tetany; and recurrent laryngeal nerve damage

Chvostek's Sign - Test which reveals spasm of the facial muscle when the face is tapped over the facial nerve, in the area of the parotid gland - positive results may indicate hypocalcemia, acid-base imbalance, or reaction to a blood transfusion

Trousseau's Sign - A carpopedal spasm that occurs when a blood pressure cuff is inflated above the client's SBP and left in place 2-3 minutes - an indication of latent tetany, which may indicate hypocalcemia (although it is a less sensitive test than Chvostek's)

Mannitol (Osmitrol): A hyperosmotic agent that increases intravascular pressure by drawing fluid frin the interstitial spaces and from the brain cells (monitor renal function)

Corticosteroids: Stabilize the cell membrane, reduce the leakiness in the blood-brain barrier, and decrease cerebral edema (clients must be withdrawn slowly from corticosteroids to prevent adrenal crisis)

Antihypertensives: May be required to maintain cerebral perfusion at a normal level (notify physician if BP range below 100 or above 150)

Antipyretics and Muscle Relaxants: Temperature reduction decreases metabolism, cerebral blood flow, thus ICP; muscle relaxants prevent shivering

Anticonvulsants: May be given prophylactically to prevent seizures, which increase metabolic requirements, thus increasing ICP

IV Fluids: Administered via IV infusion pump to control the amount of fluid administered (NO HYPERTONIC SOLUTIONS are given, due to the risk of promoting additional cerebral edema)

Erikson's Stages birth to 18 months = trust vs. mistrust
18 months to 3 yrs = autonomy vs. shame & doubt
3 yrs to 6 yrs = initiative vs. guilt
6yrs to 12 yrs = industry vs. inferiority
12 yrs to 20 yrs = identity vs. role confusion
20 yrs to 35 yrs = intimacy vs. isolation
35 yrs to 65 yrs = generativity vs. stagnation
65 yrs to death = integritiy vs. despair

Dumping syndrome happens most often after gastric resection. s/s occur approx. 30 minutes after eating, nausea & cramping, feeling of fullness, diarrhea, palpitations, tachycardic, sweaty, weak & dizzy, gas!
Diet 4 this is: high protein, high fat, & low carbs, tell pt to eat small frequent meals and lay down after eating & avoid sugar and salt.

Poisoning
Prevention is the key! Treat the patient, then the posion!

Contraindications to vomiting: danger of aspiration or aspiration pneumonia (diminished gag reflex), decreased LOC, ingested lighter fluid or kerosene, ingested drain cleaner

Aspirin poisoning: symptoms include tinnitus, change in mental status, increased temp, hyperventilation (resp. alkalosis), bleeding issues (decreased platelet aggregation)

Tylenol poisoning: symptoms include n/v, hypothermia (if NO treatment --> major danger-liver damage). Mucomyst is the antidote for tylenol poisoning.

Lead toxicity (AKA plumbism): symptoms include lethargy, decreased activity, increased ICP (seizures), diagnostic tests include blood lead level (>9 mcg = toxic), xray of long bones (will show lead deposits)
Lead can be ingested --> pica-eating of non-food items such as chalk, dirt, lead, paint

Hazardous wastes: if chemical poses a threat to the patient, decontaminate first! If chemical poses no threat or patient is contaminated, then begin care. If immediate threat to life, put on PPE and stabalize patient!

Disaster Planning: do greatest good for greatest number of people
Resources used for patients w/ greatest probability of survival
Triage-order treated:
Red-unstable (SOB, bleeding)
Yellow-stable, can wait (brooken bone, burn)
Green-stable can wait longer ("walking wounded"-sore back, hang nail)
Black-unstable, probably fatal (fatal injury, less likely to survive)
DOA -dead on arrival

External radiation:
Leave markings on skin, avoid use of creams, lotions, check skin for redness, cracking

Internal radiation:
Sealed source --> lead container and long-handled forceps in room, save all dressings, bed linen until radiation removed; urine and feces not radioactive, don't stand close or in line with source, patient is on bedrest while implant is in place

Unsealed source of radiation --> all bodily fluids are contaminated --> greatest danger 1st 24-96 hours. Time and distance is important, private room, sign on door, nurse wears dosimeter film badge at all times, limit visitors and time spent in patient's room, rotate staff

For an ear exam: adult --> pull up and back child --> pull back and down
(remember it like the alphabet --> b, child, d)

Cranial Nerve Disorders
Trigeminal Neuralgia--stabbing, burning facial pain, facial muscle twitching
Bell's Palsy--(7th cranial nerve)-inability to close eye, increased lacrimation, distorted side of face
Acoustic Neuroma--deafness, dizziness

Tetrology of Fallot
Tetra means four so it consists of four defects: pulmonary artery stenosis hypertrophy of right ventricle venticular septal defect overriding of aorta
Dx of Tetrology of Fallot is done by chest x-ray that shows a typical boot shaped heart. An echocardiogram, 3 dimentional echocardiography, & cardiac cath help to confirm diagnosis. s/s of TOF include: " blue spells or tet spells " relieved by having child squat. Murmur may be present. Poor growth, clubbing of fingers.

1) Detached Regina - curtain being drawn over field, floaters, must patch BOTH EYES !

2) Cataracts - decreased Color vision, Cloudy, better vision with dim light (pupil dilation)

3) Glaucoma - halo around lights, decrease peripheral vision, intraocular pressure > 22mmHg. They see better with light. COAG (chronic open angle glaucoma has little to no symptoms, pressure in the eye gradually increases 30-50mmHg), while acute closed angle glaucoma has sudden pain and the pressure in the eye is usually higher ( 50 - 70).

4) Ishihara chart - to assess color vision (specifically red -green blindness)

5) Post op stapedectomy - vertigo, nausea, vomitting is expected

Contraindications to immunizations:
Flu-= allergy to eggs
MMR=allergy to neomycin, pregnancy
HepB= allergy to yeast
IPV= allergy to strptomycin,polymycin,neomycin
Varicella=allergy to gelatin, untreated TB, HIV, pregnancy
Hep A= allergy to alum

SOme more.......
PT to be put on streptokinase ask if they had a recent strep infections, med won't be as effective

Caution with the "Mycins" for pt with Multiple Sclerosis, Myasthenia Gravis, THESE EXACERBATE MUSCLE WEAKNESS

Management for sprain:

R- Rest
I - Ice
C -Compression
E - Elevate

Management for Sickle Cell Crisis: (In order of PRIORITY)

H - Hydration
H - Heat
O - Oxygen (why? coz if you give oxygen before hydration it doesn't make sense at all since hydrating the client would prevent further clumping of RBC's thus increasing oxygenation)
P – Pain

Renal Function:Norms
BUN = 8 to 25 mg/dl
Serum Creatinine = 0.6 to 1.3 mg/dl
Creatinine Clearance = 100 to 120 mL per minute
Serum Uric Acid = 2.5 to 8.0 mg/dl
Urine Uric Acid = 250 to 750 mg/ 24 hours

Normal activated partial thromboplastin time ( APTT ) is 20-36 seconds
At theraputic levels, heparin will increase this by 1.5 to 2.5 times the normal
If the APTT is over 80, dosage needs to be reduced
Heparin is for prevention of DVT/thromboembolism

Coumadin monitored with PT & INR
Average PT is 9.6 to 11.8 seconds coumadin makes these numbers longer
The higher the number the greater the chances of bleeding
Normal INR is 1.3 to 2.0 a theraputic INR for most patients will be 2 to 3. Some pts. it may be ok to go higher

When performing a heel stick, put thumb over walking surface of the heal, strike later aspect of heal, wipe of 1st drop, don't smear, streak or sqeeze area (due to high ECF in infants)

~ Before infant feeds, insert gloved hand into mouth to assess palate.

~ Head circumference should be 2cm > than chest when born, but equal by 1 year.

~ Skin tags and low set ears in infants - suspect chromosomal abnormalities

~ Circumoral cyanosis in infants - see if it improves with crying. If it doesn't , report it cuz it might indicate cardiac pathology.

~ Toilet Training - when kid can communicate need to go (non verbal or verbal), holds on to please mom and doesn't let go to please self, sphincter control 18 months - 24 months (myelination of the cord is complete now), motor skill. Ability to stay dry for 2hours, can sit still on toilet for 5 - 10 mins without fussing, curiousity about older people's habits. No right or wrong time !

~ 1 TABLESPOON per year of age = a serving (so 2 year old's serving is 2 tablespoons or an ounce)

~ Toddlers should be drinking 3-4 cups of milk max, need to make sure they get nutrients from other foods.

~ Infants need 110kcal/kg/day

~ Breast milk has 20 kcals per ounce (so 20 kcal per 30 cc)

~ Breast milk has everything BUT slightly deficient in Vitamin D

Pleural Drainage System:
Bottle 1 = Drainage= No bubbles
Bottle 2 = Water Seal = Intermittent bubbles
Bottle 3 = Suction= Continuous bubbles

Mental Health:
Language & Communication
NEOLOGISM = a new word made up that has meaning only to the patient
ECHOLALIA = repeating of words or phrases they heard someone else say
WORD SALAD = form of speech in which words & phrases are connected without any meaning
MUTISM = absense of verbal speech
CLANG ASSOCIATION = repeating of words & phrases that are similar in sound but not in any other way ( Dr. Seuss type of speech )

Defense Mechanisms:
Compensation = putting extra effort to achive in areas of real or not-real weaknesses
Sublimation = replacing of an unacceptable need, attitude or emotion with one that is more accepted

1. Widening pulse pressure is a sign of increased ICP 2.Pt taking Digoxin should eat a diet high in potassium (hypokalemia-> dig toxicity) 3.Key sign of PUD... hematemesis which can be bright red or dark red with the consistency of coffee grounds 4.Common symptom of Aluminium hydroxyde: constipation 5.In a child anemia is a the first sign of lead poisoning 6.Diuretic used for intracranial bleeding, hydrocephalus (Increased ICP,...) MANNITOL (osmotic diuretic) 7.Treatment of celiac disease: gluten free diet 8.cystis fibrosis==> excessive mucus production, respiratory infection complications,... 9.Cholelithiasis causes enlarged edematous gallbladder with multiple stones and an elevated bilirubin level. 10.Fat embolism is mostly seen in LONG BONES (femur,...) HIV QUICK NOTES: Transmission thru contact with body and oral fluids Primary symptoms: Flu like, progressive weight loss, decreased CD4 count High risk: IV drug users,multiple sexual partners,contaminated blood prdcts, perinatal transmission

Diagnostics: 1. ELISA detects dvpt of antibodies. test is positive or negative 2. Western blot detects HIV infection and viral load. It confirms positive or negative CD4 and viral load levels indicate response to treatment. Management: Antiretroviral- taken daily and on time to avoid replication and mutation megace for apetite stimulation immunization against disease is encouraged small frequent high calori meals. PLASTIC UTENSILS USED instaed of metal ones to avoid altered food perception not to prevent spread of disease. Confidentiality a must, periodic evaluations, lab works always

Paracentisis is most commonly used to drain peritoneal fluid caused by ascites, they check the fluid for microorganisms, cell count, specific gravity, and protein. Ascites can cause abdominal discomfort/pain and may also cause some respiratory distress so the paracentisis can help alleviate that as well.

Care of T-tubes: make sure it is closed to gravity drainage system. avoid any kinks, clamping, or pulling of tube. expect 300-500 ml of bile during first 24 hours. monitor color of urine & stools which will be light colored changing gradually to normal coloring ). assess for s/s of peritonitis, assess skin around t-tube; clean often & keep dry.

Nursing mgt/teaching for home care;
1. wash hands before and after
2.use humidifier/nebulizer for extra moisture.Drink lotsa fluid
3. Avoid OTC cough meds as they dry out airway
4.For suctioning: 4-5 deep breaths before inserting sucionng catheter. do not suction more than 10 sec. Do not suction more than 3 times per session. Wait 5-10 minutes between sessions

5. CAtheter care: clean catheter in hot soapy water,rinse with tap water. soak in 50:50 water and vinegar for 1 hr and rinse with saline solution. Dry in clean covered container. Wash suction tube daily with hot,soapy water.
6. May use thin vaseline coat outside stoma t prevent crusting.
7. Stoma can be covered with ccarf, gauze when bathin, no swimming.
8. pt loses sense of smell and taste, so dental care and smoke detector are a must.

And....
Esophageal speech 101: Pt swallows air into her esophagus and she burps up the air at the moment of articulation.

Cast Care:
Nursing Assessment:
Neuro check to areas below/distal to cast and above, compare report absent or diminished pulses, cyanosis, blanching, coldness, lack of sensation, unable to move toes or fingers, any swelling check for odor that may indicate infection report all complaints of numbness/tingling or burning sensations check for bleeding and " hot spots " that can signal inflammation under the cast teach pt. to wriggle fingers/toes elevate affected extremity to reduce swelling and for pain control apply ice if ordered

The first step in decontamination is the removal of the pts clothing & jewelry & rinsing the pt with water very well.

Those with symptoms of anthrax who have been in a hot zone should be given 60 days of prophylactic antibiotic therapy.

The pt who is returning to the unit post-lumbar spinal fusion should be kept flat in bed.

Pituitary Gland = Master Gland ; the anterior lobe secretes, TSH, ACTH, FSH, LH, GH or somatotropin and LTH or prolactin.

Amputation Care:
* provide routine post op care
* prevent contractures,i.e in above the knee amps, do not keep leg up after 24 hrs
* avoid letting pt sit too long with hips flexed
* have pt lay prone several time a day & position hip in extension, unless otherwise ordered
* do not elevate stump longer than 24 hrs unless otherwise ordered
* give pain meds
* stump bandages should be tight to promote prothesis fitting
* initiate active ROM when ordered
* provide stump care: look daily for signs of skin irritation, wash daily with warm water and bacteriocide soap then rinse and dry well, do not use irritating stuff like lotions, powders or alcohol.

PACEMAKER TEACHING:
*fundamental cardiac physiology
*daily pulse check for 1 full minute
*report any sudden slowing/speeding up of the heart rate
*importance of following up with weekly monitoring during first 1-2 months after placement & at anticipated battery depletion time
*wear loose fitting clothing around area with pacemaker
*call doctor if develop pain/redness over site
*no heavy contact sports
*carry ID card/medic alert braclette with info on model of pacemaker, rate set at, and manufacturer
*remind of need for periodic hospitalization for battery changes or possible unit replacement

Blood Transfusion Reactions:
* chills * sweating * thready, rapid pulse * pallor * cyanosis * muscle aches, back pain * chest pain * headache * rash/hives * aprehension * n/v and diarrhea
Reactions that are not immediate include:
* fever, jaundice, low Hct level
If a reaction happens the pt. should be closely monitored for life-threatening symptoms. The infusion is stopped immediately & the doctor is called!!!! The blood bag and the tubing must be returned to blood bank with an explaination of the reaction. Nurse must stay with pt. during first 15 minutes of transfusion. Also, if the temperature goes up by 2 degrees from the baseline during an infusion this could be a reaction.

1) Gout : low purine diet, avoid organ meat e.g. liver. 2) Hypertension : low sodium diet. 3) Renal calculi, calcium kidney stones : follow alkaline ash diet e.g. spinach, milk, banana. Aim is to increase pH.

Before start INH for TB, usually a baseline live function test is recommended.
TB skin positive, normal 10mm, if HIV, 5mm is positive

Corticosteroids can cause stomach ulcers.
Isoniazid can cause drug induced hepatitis-look for yellow color of the skin,nausea,vomitting.

Re: Anyoone up for random FACT THROWING?? 14. 1. for the myelogram postop positions. water based dye (lighter) bed elevated. oil based dye heavier bed flat.

2. autonomic dysreflexia- elevated bed first....then check foley or for impaction

3. any of the mycin's..check for tinnitus or hearing loss

4. cloudy dialysate...always further assess and call doctor

5. osteoporosis prevention and mgt. choose weight bearing (walking) instead of calcium if both are choices.

1. Dilantin can cause gingival hyperplasia, advise good oral hygiene and freq. dental visits, IVP 25-50 mg/min

2. Placentia Previa is painless, bright red bleed

3. Abruption is painful, board-like abdomen

4. Need MAP of 70-90 to perfuse organs

5. Vitamin C can cause false + occult blood

MAP= diastolic x 2 + systolic ___________________ divided by 3 1. celiac disease can’t have BROW! BARLEY RYE OAT WHEAT

2. any eye surgery place on pt on unaffected side

3. if pt has lung cancer, craniotomy, or some kinda pituitary surgery watch for diabetes insipidus

4. sickle cell- hydration hydration important and treat pain if in crisis

5.dont palpate a wilm's tumor on the peds pt. can cause cancer cells to be released!

oh one more:

6. terbutaline (Brethine) and mag sulfate- tx for preterm labor

Librium-antianxiety used to tx symptoms of acute alcohol withdrawal. Cogentin-used to tx parkinsonian side effects of Thorazine (antipsychotic med) Methadone hydrochloride-opiod analgesic; tx for narcotic withdrawal Procardia-antianginal med (CCB) decreases myocardial O2 demand. Digoxin-strengthens myocardial contractio0n & slows conduction thru AV node Coumadin-inhibits prothrombin synthesis Amicar-antifibrinolytic; prevents recurrence of subarachnoid hemorrhage. Lithium-tx manic phase of bipolar Nimodipine-CCB; decreases spasm in cerebral blood vessels diltiazem-CCB; inhibits Ca+ influx in vascular smooth muscle; reduces myocardial O2 demand & decreases force of ventricular contraction clotrimazole-antifungal; treats rashes.

The level in the water seal chamber (chest tubes) fluctuates with respiration- no fluctuation indicates an obstruction and excessive bubbling indicates an air leak.

Stay with the client for 15 minutes at the start of a blood transfusion.

Nephrotic Syndrome leads to proteinuria while Glomerulonephritis leads to hematuria.

Goodell's Sign is the softening of the cervix at the start of the 2nd month of pregnancy

Nagele's Rule is First date of last menstrual period + 7 days - 3 months + 1year.

Vinca Alkaloids (Vincristine) lead to neurotoxicity and can present with numbness and tingling in the legs or paralytic ileus. A few more.... and forgive the spelling it is way late and my brain is turning to MUSH.

Avoid herbal supps like ginseng, ginger, ginkgo, garlic (all the G's) if on any clotting drugs/products (coumadin, platelets, ASA, Plavix)

High triglycerides may cause a false HIGH Hemoglobin A1C (normal is 2.6-6)

Deer ticks transmit Lyme Disease and it is most common in the NE Atlantic states. (Go figure I thought it was down here in the South)

Think of pain last or as a psychosocial UNLESS: Burns, sickle cell crisis, or kidney stones.

Anemia of pregnancy is common in the 2nd trimester due to rapid expanding blood volume and is not a cause for concern. It can get as low as 10.5 and still be OK. 1st and 3rd trimesters can go as low as 11 and still be ok

Preterm labor--after 20 weeks and before 37

true labor INCREASES with activity and usually moves from the back to the front (according to our instructors but from personal experience IT HURT ALL OVER THE DANG PLACE AND INCREASED WITH EVERYTHING ).

Recommended weight gain for pregnancy 1.5-16 kg or 25-35 lbs normal newborn jaundice-- AFTER 24 hours of life pathologic jaundice-- BEFORE 24 hours of life *feed orally ASAP because if it gets too high Kernicterus 5. after thyroid surgery-maintain airway-keep emergency trach set nearby, check for blood at sides and back of dressing, teach pt to support neck

6. bucks traction-no pins tongs. skin traction

7. should not hear a bruit over anything except dialysis shunts. if so this is the unstable pt

8. DVT- elevate extremity , bed rest, warm (not hot) compresses Menieres disease= ringing in the ears and hearing damage cause from HIGH sodium levels. Need diuretics. Avoid caffeine, nicotine, and ETOH

Meningitis= look for nuchal rigidity, Kerning’s sign(can't extend knee when hip is flexed) and Brudinskis sign (flex neck and knee flexes too) petichial rash. People who have been in close contact may need Rifampin as prevention. Vaccine for meningitis after 65 years of age and every 5 years MI=#1 pain relief, helps decrease 02 demand

Acute Asthma = diffuse expiratory wheezes

Cessation of wheeze ominous

Infective endocarditis = murmur

Fluid overload = auscultate lungs 1st 1.hypoglycemia= T.I.R.E.D

T-tachycardia I- irritability R- restless E- excessive hunger D- diaphoresis

2.posturing- deceberate(brainstem problem)- hands like an "e", decorticate (cord problem)- hands pulled in toward the cord

3.tetralogy of fallot- have child squat to increase return to heart. just remember fallot=squat

4. cant sign consent after preop meds are given...call doctor if not signed

5. rubella (German measles)-airborne contact precautions, 3 day rash

6. rubeola (red measles)- droplet contact precautions, koplik spots in mouth

Withdrawl Symptoms:

Amphetamine= Depression , disturbed sleep, restlessness , disorientation

Barbiturates= nausea & vomiting, seizures, course tremors, tachy

Cocaine= Sever cravings, depression , hypersomnia, fatigue

Heroin= Runny nose, Yawning , fever, muscle & joint pain, diarrhea (Remember Flu like symptoms) 1. When using a cane to aid ambulation: Step up on the good extremity then place the can and affected extremity on the step. Reverse when coming down. (Up with the good, down with the bad)

2. In infants, pyloric stenosis = projectile vomiting

3. Croup: seal-bark cough, dyspnea, inspiratory stridor, irritable. In children considered a medical emergency due to narrowed airway

4. Skull fracture: Battle's sign (bruising over mastoid bone) and raccoon eyes

5. Pheochromocytoma: catecholamine secreting tumor. Look for persistent hypertension, pounding headache

Oxytocin is always given via an infusion pump and can never be administered through the primary IV.

One of the first signs of ICP (increased intracranial pressure) in infants is a high pitched cry.

Regarding blood transfusions, a hemolytic reaction is the most dangerous kind of reaction...S & S include NAUSEA VOMITING PAIN IN LOWER BSCK HEMATURIA Treatment is to STOP blood, get a urine specimen and maintain perfusion and blood volume.

Febrile reaction S&S FEVER CHILLS NAUSEA HEADACHE

Narcan is given for to reverse respiratory depression...a rate of 8 or less is too low and requires nursing action.

Miller abbott tube is used for decompressing intestine, which relieves the small intestine by removing fluid and gas from small intestine.

If a client takes lithium the nurse should instruct the client to take in a good amount of sodium, without it causes retention of lithium and in turn leads to toxicity.

Rinne test- a vibrating tuning fork is held against the mastoid bone till pt can't hear sound...then moved to ear. 1) A subarachnoid (spinal block) for labor may cause a headache, a lumbar epidural will not since the dura mater is not penetrated

2) Tracheoesophageal fistula: 3 C's: coughing, choking, & cyanosis

3) Hypothyroidism: Decreased T3 +T4, but increased TSH Hyperthyroidism: Increased T3 + T4, but decreased TSH

4) NO tyramine containing foods if taking and MAO inhibitor ( smoked meat, brewer's yeast, aged cheese, red wine)

5)Regular insulin is the only type that can be given IV

1)Immunizations Before 1 years old: Hep B 3x):Only one that is given at birth and one month (3rd dose at 6 months)

IPV(4x), DTaP(5x), Hib(4x), PCV(4x): all given at 2, 4, & 6 months

Hib, PCV: again at 12-15month DTaP: again at 12-18months DTaP, IPV: last doses are given 4-6yrs

1yrs old and older: MMR: (2x) 12-15months, then at 4-6 years* *if dose not given from 4-6 give from 11-12yrs old

Varicella Zoster: (1x) 12-18months

Td: (1x): 11-12yrs old

2)Fundal height: pt supine, measure from symphysis pubis to top of fundus, if patients is 18+ wks pregnant the height in cm will be same as weeks pregnant give or take 2 cm

3)Isolation**:

STRICT Contact: use universal precautions, gown when contact with pt., single pt. room in most situations

Used with: Any colonizing infections, MSRV, Fifths disease, RSV, infected wounds, skin, or eyes

STRICTER Droplet: include all universal precautions, gown, goggles, masks on you, on pt. if leaving room, single pt. rooms

Used with: Majority of infectious diseases

STRICTEST Airborne: include all universal precautions and negative pressure single patient rooms, gown, goggles, mask on you, mask on pt. if leaving room which should only be done if absolutely necessary

Used with: Measles Varicella Disseminated Varicella Zoster Tuberculosis

**Always check facilities policies when following isolation precautions/procedures

4) Self breast exams: do monthly, 7-10 days after menses

5) Pt's taking Monoamine Oxidase inhibitors (for depression usually) should avoid foods containing tyramine which include · Avocados, bananas · Beef/chicken liver · Caffeine · Red wine, Beer · Cheese (except cottage cheese) · Raisins · Sausages, pepperoni · Yogurt, sour cream 1. dumping syndrome-tx no fluids with meals /no high carbs /lie down after eating. they need a high fat high protein diet

2. multiple sclerosis- avoid hot showers and baths

3. partial thickness burns=blisters...... full thickness-charred, waxy

4 PKU- no nuts, meats, dry beans, eggs, dairy (basically no protein stuff) give specially prepared formula to baby because they can digest this protein well

5. introduce rice cereal to infant at 6 mos and strained veggies one at a time

6. pt must keep taking prescribed insulin on sick days, drink plenty of fluids and notify doctor. also insulin is also given when pt comes from surgery on NPO status because trauma and infection makes sugar go up! 1. In prioritizing cardiac patients, check the pt with INDIGESTION first because that could be a sign of MI.

2. ABG's need to be placed on ice and sent to the lab ASAP.

3. If active TB is suspected, a sputum culture for acid-fast bacillus is the only method to actually confirm active TB (NOT a mantoux skin test!)

4. Celebrex is contraindicated in pts with a history of cirrhosis.

5. In psych pts, the client most at risk for self-harm is always the pt that has stopped taking their meds.

One more! 6. Change in resp rate in a pt receiving mag sulfate could indicate toxicity.

1. Cushing's Triad = HTN (widening pulse pressure, systolic rises), Bradycardia, irregular resp.

2. Tx of DIC = Heparin

3. Assessment for Cancer = C: Change in bowel or bladder habits A: A sore that doesn’t heal

U: Unusual bleeding or discharge
T: Thickening or lump
I: Indigestion or difficulty swallowing
O: Obvious changes in a wart or mole
N: Nagging cough or hoarseness.

4. Acid Base =
Respiratory
Opposite
Metabolic
Equal

5. For Injuries such as twisted ankles use RICE acronym
Rest
Ice
Compress
Elevate

Ulcerative colitis...3-30 stools per day WITH blood and mucus.

Pain in LLQ: relieved by defecation.

Crohns disease-NO obvious blood or mucus in stool.

Pain: Right lower quadrant pain that is steady or cramping...or pain could be in periumbilical area, tenderness and mass in the RLQ.

Rheumatoid arthritis: Pain and stiffness is on arising, lasting less than an hour...can also occur after long periods of inactivity. Joints red, hot swollen, boggy, and decreased ROM.

Osteoarthritis: Pain and stiffness occurs during activity. Joints may appear swollen, cool, and bony hard.

Hemodialysis: disequilibrium syndrome- N&V, headache, decreased LOC, rapid changes in PH, bun...

Transfusion reaction: Chills, dyspnea, itching, uticaria, back or arm pain, fever.

Peritoneal dialysis: When more dialysate drains than has been given, more fluid has been lost(output). If less is returned than given, a fluid gain has occurred.

Slow dialysate instillation- increase height of container, reposition client.

Poor dialysate drainage-Lower the drainage, reposition.
INSULIN:

Rapid: (Lispro) Onset: 24 hrs

Very Long: (Lantus) Onset: 1 hr Peak: NONE Duration: 24 hr continuous
Mydriatic: with a D= Dilate pupils
Miotic:with an O= cOnstrict pupils

aniticholinergic SE: can't see can't pee can't spit can't sh*t

Hyperkalemia "MACHINE"- causes of incr serum K+
M-medications (ace inhibitors, Nsaids)
A-acidosis (Metabolic and respiratory)
C-cellular destrx-burns, traumatic injury
H-hypoaldosteronism, hemolysis
N-nephrons, renal failure
E- excretion-impaired

Signs and symptoms of incr serum K+= MURDER
M-muscle weakness
U-urine, oliguria, anuria
R-respiratory distress
D-decr cardiac contractility
E-ECG changes
R- reflexes, hyperreflexia, or flaccid

HYPERNATREMIA-you are fried
F-fever (low grade), flushed skin
R-restless (irritable)
I-incr fluid retention and incr BP
E-edema ( peripheral and pitting)
D-decr urinary output, dry mouth

Hypocalcemia-"CATS"
C-convulsions
A-arrhythmias
T-tetany
S-spasms and stridor

V-FIB=DEFIB
DONT SHOCK ASYSTOLE!

EEG- MUST BE SLEEP DEPRIVED FOR THE PROCEDURE

Albumin best indicator of nutrition normal range 3.5 - 5.5

altered LOC- earliest sign of ICP

to check dehydration in an infant (inner thigh)...elderly (on top of forehead or sternum)

shift to the left when number of immature cells are increasing in the bloodstream to fight an infection
Respiratory syncytial virus- contact precautions

systemic lupus erythematosus- butterfly rash on nose and cheek. avoid sunlight

with DIC...get worried if you see blood oooze from the IV line. notify doctor

Tegratol- tx for seizures..watch for drowsiness, n/v, blurred vision, h/a.

kayexalate- may be ordered for a high potassium level

THERAPEUTIC LEVEL
10-20 mcg/ml

Theophylline
Acetaminophen
Phenytoin
Chloramphenicol

10-21 mmHg - normal intraocular pressure

1. nebulizers used by HIV patients are cleansed with warm water after each treatment and allow it to air dry. soaked in white vinegar and water for 30f min at the end of the day

2. SHARE support group for parents who have experienced miscarriage

3. RESOLVE support group for infertile clients

4. CANDLELIGHTERS families who have lost child to cancer

5 FETAL ALCOHOL SYNDROME child small head circumference, low birth wt, underdeveloped cheeks.

here is a quick one.... Dantrium (dantroline) common drug kept in the OR for us with Malignant Hyperthermia.

No birth control pills with antiseizure meds....lowers the BCP's effects filgrastim (Neupogen) - increase NEUtrophil count

epoietin alfa (Epogen) - increase RBC/erythrocytes

Apgar measures HR, RR, Muscle tone, Reflexes, Skin color each 0-2 point. 8-10 OK. 0-3 RESUSCITATE.

GLASGOW COMA SCALE. EYES, VERBAL,MOTOR!
It is similar to measuring dating skills...max 15 points -one can do it if below 8 you are in Coma.

Cholecystectomy due to cholelithiasis and cholesysthitis, WATCH for BLEEDING problems, because vit K FAT soluble, is poorly absorbed in the absence of bile. by the way T-tube used for drainage-Reason for T tube to maintain patency of common bile duct.

Chronic RF the best way to asses fluid status-WEIGHT the PATIENT daily

When NGT present mouth care ICE CHIPS but be aware not give that too much-> it becomes water->stomach->NGT suck it with K and other electrolytes present in stomach. LOST K

Heat cramps in hot weather-Sodium (Na) loses

Following Gastrectomy NGT drainage should NOT be BLOODY after 12 hr

Thyroid storm's main sign is FEVER

ALDOSTERONE insufficiency -Hypo-Na-emia, Hyper-K-emia, hypo-Volemia. WHEN Na decrease, K increase

Addison’s= hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia
Cushing’s= hypernatremia, hypertension, increased blood vol, hypokalemia, hyperglycemia
1. Prozac, Zoloft, Paxil- tx of depression.

2. sodium nitroprusside- shield from light. wrap in foil

3. cephalosporins- CHECK FOR ALLERGIES TO PENICILLINS. pt could be hypersensitive.

4. pts receiving Lasix should be assessed for tinnitus and hearing loss

5. anticoagulants cant dissolve a formed thrombus but tPAs can.
A= appearance (color all pink, pink and blue, blue [pale])
P= pulse (>100, < 100, absent)
G= grimace (cough, grimace, no response)
A= activity (flexed, flaccid, limp)
R= respirations (strong cry, weak cry, absent)

1. cardiac meds: -pine=calcium channel blockers
-olol=beta blockers
-pril=ACE inhibitors
-artan=angiotensin II receptor blockers

2. No pee no K+

3. Before treating BPH, must restore urinary flow

4. Sign of toxic ammonia level’s is asterixis (hands flapping)

5. Diuretics: Lasix and Bumex are K+ wasting Aldacton is K+ sparing

The adverse effects of Anti psychotics can be remembered using this: SHANCE
S-SUNLIGHT SENSITIVITY( Use hats and sunscreen)
H-HEPATOTOXICITY( Monitor LFT)
A-AGRANULOCYTOSIS( Characterized by fever and sore throat)
N-NEUROLEPTIC MALIGNANT SYNDROME( Characterized by fever and muscular rigidity)
C-CIRCULATORY PROBLEMS( Leukopenia and orthostatic hypotension)
E-EXTRA PYRAMIDAL SYMPTOMS( Administer anticholinergics and anti parkinsonian agents) acute renal failure-abrupt loss of kidney function, usually reversible, with minor functioning loss

prerenal (renal ischemia) intrarenal (any kidney tissue disease) postrenal (obstruction...i.e calculi, prostatic hypertrophy)

chronic renal failure- progressive, irreversible loss of renal function.

-statin = lipid lowering agents
-mycin= antibiotics; watch for oto and nephrotoxicity
-vir=antivirals
-zine=can be antipsychotics or antiemtics; watch for agranulocytosis and eps effects
-tidine=H2 blockers
-prazole=proton pump inhibitors

Bells Palsy: avoid cold temperatures: make sure pt. closes windows when they are sleeping. Some even take eyes shut.

Nurses' priority intervention after a patient receives a skin graft is to prevent movement of the graft.

Greatest risk for postpartum hemorrhage is from distended bladder.

Herpes zoster (shingles) is from reactivation of the varicella virus.

1 grain = 60mg (I always forget this one)

Risk factors for legionnaires disease: advanced age, immunosuppression, end stage renal disease, and diabetes

Heart Arrhythmias:

SVT - Adenosine
Atrial Flutter - Anticoagulants
Atrial Fibrillation - Beta Blockers, Digoxin
PVC - Amiodarone
Ventricular Tachycardia - Amiodarone
Ventricular Fibrillation - Defibrillation
Torsades de Pointes - Magnesium Sulfate
1st Degree AV Block - No treatment usually
2nd Degree AV Block Type I - Atropine
2nd Degree AV Block Type II - Pacemaker
3rd Degree AV Block Complete - Emergent Pacemaker, Atropine, Epinephrine, Dopamine
Sinus Bradycardia - Atropine or Epinephrine
Sinus Tachycardia - Beta Adrenergic or Calcium Channel Blocker
Hepatitis

5 types
A,B, C, D, and E

Hep A-spread by drinking unsanitary water and uncooked foods
Hep B-spread by contact with blood or bodily fluids and is an STD
Hep C-spread by contact the same way as Hep B, can lead to cirrhosis (mostly seen with alcoholism)
Hep D-only contracted if you already have Hep B
Hep E-usually spread by contact with contaminated water

In nursing school, my instructor taught us to remember the different types like this:

VOWEL = BOWEL

Hep A and E---if your infected you will have problems with bowels...
Some Therapeutic Drug Levels

Digoxin 0.5-2.0 ng/ml
Lithium 0.6-1.5 mEq/L
Dilantin 10-20 mcg/dl
Theophylline 10-20 mcg/dl
Lithium 0.5-1.5 mEq/L

Coumadin PT: 12-20 sec....therapeutic range 1.5-2 times the control
INR: 2-3
Heparin PTT: 30-60 sec...therapeutic range 1.5-2 times the control
CYSTIC FIBROSIS
Diet: Low in fat and high in sodium
Meds: Antibiotics, liposoluble vitamins(A D E K) Aerosol Bronchodilators, mucolytics, pancreatic enzymes.

5 A's to Alzheimer’s
Anomia-unable to remember things
Apraxia-failure to identify objects
Agonsia-can't recognize sounds, tastes and other sensations, familiar objects.
Amnesia-memory loss
Aphasia-can't express SELF through speech.

GLOMEULONEPHRITIS-it's an antigen antibody complex from a recent strep infection which causes inflammation/ decreased glomerular filtration rate.

BETA BLOCKERS
B1-affects the heart
B2-affects lungs

EMERGENCY DRUGS TO LEAN ON
Lidocaine
Epinephrine
Atropine
Narcan

AUTONOMIC DYSREFLEXIA-triggered by sustained stimuli at T6 or below. Vasodilation above injury,(flushed face, increased bp etc) vasoconstriction below injury(pale, cool, no sweating.)

4.Common symptom of Aluminum hydroxide: constipation
5.In a child anemia is a the first sign of lead poisoning
6.Diuretic used for intracranial bleeding, hydrocephalus (Increased ICP,...) MANNITOL (osmotic diuretic)
7.Treatment of celiac disease: gluten free diet
8.cystis fibrosis==> excessive mucus production, respiratory infection complications,...
9.Cholelithiasis causes enlarged edematous gallbladder with multiple stones and an elevated bilirubin level.
10.Fat embolism is mostly seen in LONG BONES (femur,...)
TRANSMISSION-BASED PRECAUTIONS:
Remember ADC - airborne, droplet, contact

AIRBORNE
My - Measles
Chicken - Chicken Pox
Hez - Herpes Zoster
TB

Private Room - negative pressure with 6-12 air exchanges/hr
Mask, N95 for TB

DROPLET think of SPIDERMAN!
S - sepsis
S - scarlet fever
S - streptococcal pharyngitis
P - parvovirus B19
P - pneumonia
P - pertussis
I - influenza
D - diphtheria (pharyngeal)
E - epiglottis
R - rubella
M - mumps
M - meningitis
M - mycoplasma or meningeal pneumonia
An - Adenovirus

Private Room or cohort
Mask

CONTACT PRECAUTION
MRS.WEE
M - multidrug resistant organism
R - respiratory infection
S - skin infections *
W - wound infxn
E - enteric infxn - clostridium difficile
E - eye infxn - conjunctivitis

SKIN INFECTIONS
VCHIPS
V - varicella zoster
C - cutaneous diphtheria
H - herpes simplex
I - impetigo
P - pediculosis
S - scabies

Private room or cohort
Gloves
Gown

1. Abruptio placentae may be a complication of severe preeclampsia
2. Syrup if ipecac is not administered when the ingested substance is corrosive in nature
3. Pt before liver biopsy is NPO 4-6 hours
4. Assess renal fct before giving an osmotic diuretic (mannitol)
5. Patient in addisonian crisis decreased BP, Na, Blood glucose, Increased K
6. Amniocentesis is done as early as 14 weeks of gestation
7. Chorionic villi sampling is done as early as 10 weeks of gestation
8. Increased level of alpha fetoprotein in pregnant woman => neural tube defects
9. Insulin is safely given throughout pregnancy; oral hypoglycemic agents are contraindicated
10. Phenobarbital (Luminal) is commonly used to treat and prevent recurrent seizures in infants and young children
11. Aspirin is associated with Reye's syndrome in children with fever or viral infection
12. Glycerin suppositories are preferred agents to treat constipation in children
13. Corticosteroids may produce an altered effect of a vaccine
14. Thiazide diuretics (HCTZ,...) may induce hyperglycemia
15. Anticonvulsants INCREASE the seizures THRESHOLD!!!!
16. Hyperbilirubinemia in newborn: bilirubin levels are greater than 13-15 mg/dl

PVD if it's arterial they are hairless dry scaly and dependent ruber; venous is edematous, weepy, and dependent cyanosis

1. Postpartum period: circulating hcG disappears within 8-24 hours
2. S/S opioid withdrawl: rhinorrhea, dilated pupils, abdominal cramps
3. S/S sedative withdrawl: Increased motor activity, tachycardia
4. S/S alcohol withdrawl: tremors, N/V, diaphoresis
5. S/S stimulant withdrawl: CNS depression, fatigue, depression, confusion,...
6. Hb values: neonates have Hb higher than those of older children to sustain them until active erythropoiesis begins
7. Toclytic therapy: to arrest preterm labor
8. Child with chickenpox can be treated with oatmeal preparation baths and calamine lotion at home to relieve the itching...
9. child with rheumatoid arthritis should sleep in bag to keep joints warm and promote flexibility!!!! Wow...
10. When an eye patch is used to correct strabismus, the normal eye is patched. That forces the child to use the "lazy" eye, thereby increasing that eye's muscle strengths
11. If a chest tube accidently get disconnected, clamp it or place the open end of the tube in a container of sterile water or saline solution
12. Women should avoid pregnancy for at least 3 months after a rubella vaccine
13. Most accurate method to detect TB: sputum culture!!!

1. RSV- child in private room...CONTACT PRECAUTIONS..not droplet or airborne. (sometimes i get this mixed up because its called respiratory synctical virus..i used to pick droplet precautions but i have down now lol!

2. Elderly adults generally present with confusion rather than S/S of an illness.

3. pneumonia- droplet precautions

4. COPD pts should get low flow Oxygen b/c of the hypoxic drive. (1-3L/min) teach pursed lip breathing.

5. ARDS- this pt doesn’t respond to even 100% FiO2

6. TB- hemolysis (advanced stage) v/s pulmonary edema- frothy blood tinged sputum

7. Allen's test- done b/f an ABG by applying pressure to the radial artery to determine if adequate blood flow is present.

8. INH (Isoniazid)- tx of TB. give vit B6 to prevent peripheral neuritis

9. SIMV mode on vents commonly used for weaning pt off ventilator.

10. vent alarms: high alarm (increased secretions then suction......, biting tube-need an oral airway,...... or coughing and anxiety- need a sedative) low alarm- there is a leak or break in system...check all connectors and cuff.

11. if a trach becomes accidently dislodged try to replace it with an obturator..if no luck keep the hole open with hemostats until physician arrives.

Dupuyten contracture - slow, progressive contracture of the palmar fascia causing flexion on the 4th and 5th fingers. Risk factors include men over 50, diabetes, gout, arthritis, alcoholism

Condom cath- remove hair on penis, apply tape in a spiral manner, 1-2in space between end of the condom and tip of the glans penis

Bulge test - confirms presence of fluid in the knee, legs should be extended and supported on the bed

Lofenalac formula - for PKU
1. Profile of gallbladder disease: 5Fs: fair, fat, forty, five pregnancies, flatulent(disease can occur in all ages and both sexes)
2. Hip fractures commonly hemorrhage, whereas femur fractures are at risk for fat emboli
3. Religious beliefs: Hindu- No beef or items containing gelatin
4. Renal diet- High calorie, high carbohydrate, low protein, low K, low Na, and fluid restricted to intake = output +500 ml
5. Treatment for sickle cell crises- HHOP: Heat, hydration, oxygen, pain meds
6. RN and MD institute seclusion protection
7. MD or hospice RN can pronounce the client dead
8. For hospital triage, care for the client with a life-threatening illness or injury first
9. For disaster triage, choose to triage first those clients who can be saved with the least use of resources!
10. It is contraindicated to induce vomiting if the patient has ingested gasoline, acid and alkaline!!!
MAOIs

Non-Popular Meds

Nardil
Parnate
Marplan

avoid Tyramine

teach a pt with GERD after meals to remain upright for at least 20 min.

2.levodopa toxicity- notify physician if twitching develops.

3. Curling's ulcers or stress ulcers can cause sudden massive hemorrhage.

4. 5 mm induration positive reaction (mantoux test) for HIV or immunosuppressd pts

5. Schilling test done to see how well a pt can absorb vit b12. checking to see if they have pernicious anemia.

6. Prednisone, Prograf, and Cellcept helps to prevent kidney rejection.

Positioning Facts:

1. Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending doom) --> turn pt to left side and lower the head of the bed.

2. Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal bradycardia, etc) --> turn on left side (and give O2, stop Pitocin, increase IV fluids)

3. Tube Feeding w/ Decreased LOC --> position pt on right side (promotes emptying of the stomach) with the HOB elevated (to prevent aspiration)

4. During Epidural Puncture --> side-lying

5. After Lumbar Puncture (and also oil-based Myelogram)--> pt lies in flat supine (to prevent headache and leaking of CSF)

6. Pt w/ Heat Stroke --> lie flat w/ legs elevated

7. During Continuous Bladder Irrigation (CBI) --> catheter is taped to thigh so leg should be kept straight. No other positioning restrictions.

8. After Myringotomy --> position on side of affected ear after surgery (allows drainage of secretions)

9. After Cataract Surgery --> pt will sleep on unaffected side with a night shield for 1-4 weeks.

10. After Thyroidectomy --> low or semi-Fowler's, support head, neck and shoulders.

11. Infant w/ Spina Bifida --> position prone (on abdomen) so that sac does not rupture

12. Buck's Traction (skin traction) --> elevate foot of bed for counter-traction

13. After Total Hip Replacement --> don't sleep on operated side, don't flex hip more than 45-60 degrees, don't elevate HOB more than 45 degrees. Maintain hip abduction by separating thighs with pillows.

14. Prolapsed Cord --> knee-chest position or Trendelenburg

15. Infant w/ Cleft Lip --> position on back or in infant seat to prevent trauma to suture line. While feeding, hold in upright position.

16. To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) --> eat in reclining position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low CHO and fiber diet, small frequent meals)

17. Above Knee Amputation --> elevate for first 24 hours on pillow, position prone daily to provide for hip extension.

18. Below Knee Amputation --> foot of bed elevated for first 24 hours, position prone daily to provide for hip extension.

19. Detached Retina --> area of detachment should be in the dependent position

20. Administration of Enema --> position pt in left side-lying (Sim's) with knee flexed

21. After Supratentorial Surgery (incision behind hairline) --> elevate HOB 30-45 degrees

22. After Infratentorial Surgery (incision at nape of neck)--> position pt flat and lateral on either side.

23. During Internal Radiation --> on bedrest while implant in place

24. Autonomic Dysreflexia/Hyperreflexia (S&S: pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia, hypertension) --> place client in sitting position (elevate HOB) first before any other implementation.

25. Shock --> bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified Trendelenburg)

26. Head Injury --> elevate HOB 30 degrees to decrease intracranial pressure some GI/hepatic

hepatitis--all forms standard precautions

s/s of bowel perforation--sudden diffuse abdominal pain, no bowel sounds, resp. rapid and shallow, rigid abdomen.

nursing care for undiagnosed abdominal pain--npo, no heat on stomach, no enemas, no narcotics, no laxatives.

crohns-small intestine vs ulcerative colitis-large intestine..sulfasalzine used to treat both.

pyloric stenosis- olive shaped mass felt in R. epigastric area, projectile vomiting

if a pt requires TPN and it is temp. unavailable then give D10W OR 20% DW until available.

before a Dx test of after 3 enemas, returns are not clear, notify physician

if diarrhea occurs with a colostomy. check meds (some cause diarrhea)..dont irrigate

as a general rule antacids should be taken 1-2 hours after other oral meds.

Symptothermal method of birth control - combines cervical mucus evaluation and basal body temperature evaluation, non-prescription/drug

percipitus/rapid labor - risk factor for early postpartum hemmorhage and amniotic fluid embolism

In elderly, change in mental status and confusion are often the presenting symptoms of infection

antiseizure meds - notify anesthesia prior to surgery, may need to decrease the amount of anesthetic given

neuroleptic malignant syndrome - increased temp, severe rigidity, oculogyric crises, HTN, complication of antipsychotic meds, notify MD

Dilantin - pregnancy risk category D, should investigate possibility of pregnancy (LMP) prior to administering

Transcutaneous electrical nerve stimulation (TENS) - used for localized pain (back pain, sciatica) - use gel, place electrodes over, above or below painful area, adjust voltage until pain relief/prickly "pins and needles"

1. S/S delusional thought patterns => suspiciousness and resistance to therapy
2. Use of neologism (new word self invented by a person and not readily understood by another) =>associated with thought disorders
3. Age and weight are VERY important to know after a child has ingested a toxic substance
4. Child with celiac disease can eat corn, rice, soybeans and potatoes (gluten free)
5. Anaphylactic rx => administer epinephrine first, then maintain an open airway. (Not the other way around )
6. Client with asthma => monitor peak of airflow volumes daily. Pulse ox after!!!!
7. DKA pt => a HCT of 60 (way high...) (extreme dehydration) would be more critical than a pH less than 3! (Fluids first...)
8. Assess for abdominal distention after placement of a VP shunt! (You know why right?)
9. GFR is decreased in the initial response to severe burns, with fluid shift occurring. Kidney fct must be monitored closely or renal failure may follow in a few days
10. Vomiting => metabolic alkalosis (loss of stomach acid content)
11. Diarrhea => metabolic acidosis (loss of bicarbonate)
12. COPD => respiratory acidosis (CO2 retention)
13. Anxious client => hyperventilation can cause respiratory alkalosis. A paper bag will help. (Increase CO2) Right?
14. Client with low H&H after splenectomy => the initial priority is REST due to the inability of RBCs to carry O2
15. Mild to moderate diarrhea in a child => maintain a NORMAL diet with fluids to rehydrate the poor child
Clozapine (Clozaril) - antipsychotic, treats schizophrenia, potential to suppress bone marrow and cause agranulocytosis (look for sore throat and fever)

Bucks traction - remove foam boots 3x/day to inspect skin, turn client to unaffected side, dorsiflex foot on affected side, elevate foot of bed

phlebitis - tenderness and redness at IV insertion site and redness proximally along the vein. Remove the IV adn apply warm soaks

Cred e maneuver - apply manual pressure to bladder, aids in emptying the bladder completely, results in reduced risk for infection; if performed every day can result in bladder control for some SCI

Frequent use of nasal sprays to relieve allergic symptoms can result in vasoconstriction that causes atrophy of nasal membranes (frequent nosebleeds)

Lung cancer is a common cause of SIADH (abnormal secretion of ADH, increase water absorption and dilutional hyponatremia)

ginkgo - antiplatelet, CNS stimulant, given for dementia, increase risk of bleeding with NSAIDS

Native Americans are present oriented and do not live by the clock (will be late for appointments)

Pulmonic area - 2ICS, left of sternum

Chronic alcohol use is the most common cause of hypoMg, which may result in cardiac arrest (increase neuromuscular irritability, tremors, tetany, seizures)

SCD - two fingers between sleeve and leg, opening at the knee and popliteal pulse point, antiembolism stockings can be applied under sleeve to decrease itching, sweating and heat buildup

if allergic to sulfonamides dont take acetazolamide (Diamox) methotrexate- dont take supplemental folic acid and please dont take while pregnant..can cause premature labor and bleeding.

oh dont take cytoxan while pregnant or dont handle the drug while pregnant.

infections that occur with AIDS clients are called opportunistic infections.

Pneumocystis carinii pneumonia is not contagious unless you are immunocompromised. this infection occurs mostly with AIDS pts.

infant with HIV should NOT receive chickenpox or oral polio vaccine. can give inactivated polio vaccine though.

Erb's point - 3ICS left of the sternum

Ambulatory electrocardiography - continuously records cardiac activity during a 24hour period, should not use electric devices, bathe or shower, no diet changes, record everything in daily log

Demerol -crosses the placenta which decreases FHR variability

Ascites management - albumin given to pull fluid back into blood vessels then diuretic given to excrete excess fluid

TB - need vitamin B6

bloody dyalasate (spelling?) - assess if patient is menstruating

placing an abductor pillow between patients legs after hip replacement prevents dislocation of the hip while turning, important especially when the client is confused

palpating the carotid pulses together can cause a vagal response and slow the clients heart rate

adrenal insufficiency - steroids increased prior to surgery

thyroidectomy - access for numbness from decreased Ca

Bactrim - mild to moderate rash the most common SE

If when removing a PICC a portion of the catheter breaks - apply tourniquet to the upper arm, feel radial pulse

emptying a drainage evacuator - wash hands, don gloves, elevate bed, pour drainage into measuring cup, compress the evacuator and replace the plug

Percodan - oxycodone and aspirin
Percocet - oxycodone and acetaminophen
Myasthenia Gravis: worsens with exercise and improves with rest.
Myasthenia Crisis: a positive reaction to Tensilon--will improve symptoms
Cholinergic Crisis: caused by excessive medication-stop med-giving Tensilon will make it worse

Head injury medication: Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use filter needle

Prior to a liver biopsy its important to be aware of the lab result for prothrombin time (PT)

1. Watery vaginal discharge and painless bleeding => endometrial cancer
2. Frothy vaginal discharge => trichomonas infection
3. Thick, white vaginal discharge => candida albicans
4. purulent vaginal discharge => PID
5. Approximately 99% of males with cystic fibrosis are sterile due to obstruction of the vas deferens
6. Lyme's disease is transmitted by ticks found on deer and mice in wooded areas
7. Children 18-24 months normally have sufficient sphincter control necessary for toilet training
8. Complications of TPN therapy are osmotic diuresis and hypovolemia!!!
9. L/S ratio => fetal lung maturity
10. Kava-kava can increase the effects of anesthesia and post-op analgesia
11. NEVER give chloride potassium by IV push
12. GINKGO interacts with many meds to increase the risk of bleeding; therefore, bruising or bleeding should be reported to MD
13. Vanco therapeutic range 10-20 mcg/mL
14. Client with disseminated herpes zoster (shingles) => AIRBORNE precautions
15. The client taking methotrexate should avoid multivitamins b/c multivitamins contain folic acid. Methotrexate is a folic acid antagonist!!!
Hypovolemia and osmotic diuresis that are complications of TPN result from hyperglycemia!

Let's recapitulate TPN => Hyperglycemia => osmotic diuresis & hypovolemia...

Drooling - 4 months
Responds to own name 6-8months deliberate steps when standing 9-10months picks up bite size pieces of cereal 11months

24months: kick ball w/o falling, build tower of 6blocks, 2-3 word phrases, 300 word vocab

30months: jump with both feet, run, say first and last name

36months: tricycle

Left CVA - speech, math skills, analytical thinking
Right CVA - behavior, disorientation to person, place and time
Ectopic pregnancy - LLQ pain, vaginal spotting tricuspid valve: 5ICS left sternal border
Meconium should be passed within 12-24 hrs transitional stools - 3rd day - thin greenish brown breastfed baby - golden yellow stools with sour milk odor compartment syndrome...significant increase in pain not responsive to pain meds.

Plaquenil-tx of Rhem Arthritis...recommend eye exam every 3 mo.

Statins- tx of high cholesterol...ASSESS FOR MUSCLE PAIN...monitor liver enzymes.

Nicotinic Acid (Niacin)-tx of high cholesterol- flushing occurs in most pt. will diminish over several weeks.

stages of shock (its more but i made it simple "KISS" keep it simple stupid lol!) early- increase in pulse...normal urine output intermediate-RAS (renin-angioten system), low urine output, cool skin, pallor late-no urine output, low BP irreversible stage!
Myxedema/hypothyroidism: slowed physical and mental function, sensitivity to cold, dry skin and hair
Graves’ disease/hyperthyroidism: accelerated physical and mental function; sensitivity to heat, fine/soft hair
Thyroid storm: increased temp, pulse and HTN
Post-thyroidectomy: semi-Fowler’s, prevent neck flexion/hyperextension, trach at bedside

Hypo-parathyroid: CATS – convulsions, arrhythmias, tetany, spasms, stridor (decreased calcium), high Ca, low phosphorus diet
Hyper-parathyroid: fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium), low Ca, high phosphorus diet

Hypovolemia – increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety, urine specific gravity >1.030
Hypervolemia – bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity Priority in the first hour is brain damage due to rupture of the cerebral blood vessels. Neurologic status must be closely monitored
3. Client with A-fib => a cold, pale lower leg suggests the presence of an embolus. Peripheral pulses should be checked immediately
4. S/S anemia in a 10 months old infant => pale mucosa of eyelids and lips
5. S/S dehydration in 2 years old => sunken eyes, dry tongue, lethargy, irritability, dry skin, decreased play activity, and increased pulse
6. Pt with anaphylaxis => The entire body may turn bright red b/c massive vasodilation
7. Teaching pt with Zollinger-Ellison syndrome => Report promptly to his/her healthcare provider any finding of peptic ulcer (night time awakening with burning, cramp-like abdominal pain, vomiting and even hematemesis, and change in appetite)
8. Infant with epiglottitis : 4 D's => Drooling, Dysphagia, Dysphonia and Distress inspiratory efforts
9. Niacin (Vit B) is a lipid lowering agent. Foods high in Niacin are meats, eggs, milk, dairy products
10. Child with 3 C's (Cough-Choke-Cyanosis) should be assessed for tracheoesophagial fistula
11. Gastric lavage is a priority for an infant who has been identified as suffering from botulism
12. Viral meningitis usually does not require protective measures
When using an inhaler, instruct the patient to exhale forcefully, use lips to form a tight seal around the inhaler, press top of inhaler and inhale deeply, hold breath as long as possible, wait 3-5 mins before taking another inhalation of the drug.

-Munchausen Syndrome is a psychiatric disorder that causes an individual to self-inflict injury or illness or to fabricate symptoms of physical or mental illness, in order to receive medical care or hospitalization. In a variation of the disorder, Munchausen by proxy (MSBP), an individual, typically a mother, intentionally causes or fabricates illness in a child or other person under her care.

-Multiple Sclerosis is a chronic, progressive disease with demyelinating lesions in the CNS which affect the white matter of the brain and spinal cord.
Motor S/S: limb weakness, paralysis, slow speech
Sensory S/S: numbness, tingling, tinnitus
Cerebral S/S: nystagmus, ataxia, dysphagia, dysarthria

Huntington's Chorea: 50% genetic, autosomal dominant disorder
S/S: chorea --> writhing, twisting, movements of face, limbs and body
-gait deteriorates to no ambulation
-no cure, just palliative care

-WBC shift to the left in a patient with pyelonephritis (neutrophils kick in to fight infection)

-Definitive diagnosis for abd. aortic aneurysm (AAA) --> CT scan

-Don't use Kayexalate if patient has hypoactive bowel sounds.

-Uremic fetor --> smell urine on the breath

-Hirschsprung’s --> bile is lower obstruction, no bile is upper obstruction; ribbon like stools.

-Pancreatic enzymes are taken with each meal! Not before, not after, but WITH each meal.
Leukemia - the main affected are: Blood, Bone mArrow, Spleen, & Lymph. The biggest problem of leukemia is the big "ANT" Anemia, Neutrepenia, and Thrombocytopenia.

ALL- problem of B & T-lymphocyte (more in children)
AML- problem of macrophage, granulocytes, RBC, & platelets (more in children)
CML & CLL - more in elderly

Note: there's 2 types- Acute and Chronic and 2 category- myeloid (myelocitic) & lymphoid (lymphocytic)

Bioterrorism

Level I- local emergency

Level II- regional aid from surrounding counties

Level III- local and regional assets are overwhelmed state or federal assistance is needed

Disaster tagging – tags are numbered and identify the triage priority; includes the name, address, age, location and description of injuries and treatment and meds given

Ethical conflicts- they arise because of the perspective of disaster nursing.

There are 4 levels of protective equipment

Level A – highest priority covered from head to toe

Level B – RESP covered but less skin and eye precautions

Level C- requires air purified respirator chemical- resistant coverall with splash hood, gloves and boots

Level D – work uniform

Decontamination – is a 2 step process
1.removal of clothing and jewelry and rinsing with water
2.thorough soap and water wash and rinse

ALL OF THESE BIOLOGICAL WARFARE AGENTS CAN BE MADE!

Anthrax – can be topical, inhaled or ingested
·topical – contact precautions
·inhaled – standard precautions
· ingested standard precautions

Smallpox – on contact precautions

Botulism - standard precautions

Tularemia- standard precautions

Types of radiation

·Alpha particles - cannot penetrate the skin but can enter through inhalation, ingestion. Localized damage
·Beta particles- can moderately penetrate the skin and cause cell damage or internal injury if penetrates the skin * exposure time is a key factor
·Gamma radiation - is penetrating and is difficult to shield against

Exposure to radiation “time, distance and shielding”

Three types of radiation induced injury can occur
1.external -pt is not radioactive does not require isolation
2.contamination – from gases, liquids or solids *requires immediate intervention to prevent incorporation
3.incorporation - uptake of radioactive material into every cell, tissue, organ

Acute radiation syndrome-
·N/V
·Bloody diarrhea
·Fever
·Cerebral edema
·Increased ICP- poor outcome and imminent death
·HA
·Skin may be red and become necrotic within day to months

Airborne Precautions

Airborne Precautions

Patients who have or may have an infectious disease that is spread by the airborne route must be placed on Airborne Precautions in addition to Standard Precautions. Airborne Precautions (formerly respiratory isolation) applies to most infections which were previously classified as requiring "Strict," "AFB," and "Respiratory" isolation under the old category-specific system of isolation precautions.

Diseases Requiring Airborne Precautions

Tuberculosis, Pulmonary (or laryngeal)
-suspected or confirmed

Criteria for Using Airborne Precautions for a Patient Suspected or Confirmed to Have Pulmonary Mycobacterium Tuberculosis

Varicella (chickenpox)
[requires use of Contact Precautions as well]

Herpes Zoster (shingles) - in an immunocompromised patient
[requires use of Contact Precautions as well]

Herpes Zoster (shingles) - disseminated
[requires the use of Contact Precautions as well]

Rubeola (Measles)

Note: Airborne Precautions require a negative pressure room in addition to a private room. Negative pressure rooms are specially designed to prevent the flow of air from the room into the corridors and common areas where susceptible persons may be exposed. This is accomplished through fans and vents that direct the airflow outside of the building and/or through HEPA filters.

Droplet Precautions

Droplet Precautions are designed to reduce the risk of droplet transmission of infectious agents. Droplet transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large particle droplets containing microorganisms generated from a person who exhibits a clinical disease or who is a carrier of the microorganism. The patient can generate these droplets from coughing, sneezing, and talking, as well as during certain procedures such as suctioning and bronchoscopy. Transmission via large droplets requires close contact (within 3 feet or less) between the source patient and the susceptible individual. Droplets (due to their large size) do not remain suspended in air and travel short distances - three feet or less. Thus, Droplet Precautions require the use of a standard surgical mask within three feet of the patient. However, it is prudent to wear a mask upon entering the room of a patient on Droplet Precautions to avoid any inadvertent exposure.
Bacterial:

Invasive Hemophilus influenzae disease: meningitis, pneumonia (in infants and small children), epiglottitis.

Invasive Neisseria meningitidis disease: meningitis, pneumonia, and bacteremia.

Mycoplasma pneumonia

Group A Streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children

Viral

Influenza

Adenovirus
(requires Contact Precautions in addition)

Mumps

Parvovirus B19

Rubella

Contact Precautions

Contact Precautions are designed to reduce the risk of transmission of organisms and specific diseases by direct or indirect contact.
Direct contact transmission involves skin to skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when personnel turn patients, bathe patients or perform other patient care activities that require physical contact. Direct contact can also occur between patients that may have physical contact with each other.
Indirect contact transmission involves a susceptible host with a contaminated intermediate object, usually inanimate, in the patient's environment.
Contact Precautions are to added to Standard Precautions for patients known or suspected to have organisms and/or diseases easily transmitted via direct or indirect contact.
Contact Precautions are required if:

A patient is colonized and/or infected with multidrug-resistant organism. A multidrug-resistant organism is an organism that is resistant to treatment with standard first-line antibiotics.

A particular organism is identified as being potentially hazardous to others and/or to the ecology of the hospital environment because of its antibiogram, pathogenicity, virulence, or epidemiologic characteristics (i.e., VRE, MRSA).

Contact Precautions Disease List

In addition to Standard Precautions, Contact Precautions must be used for patients known or suspected to have specific diseases/multidrug- resistant organisms easily transmitted by direct patient contact or contact with items in the patient's environment. Examples of such illnesses/organisms include:

Vancomycin Resistant Enterococcus (VRE)

Methicillin Resistant Staphylococcus aureus (MRSA)

Any organism deemed to be of special clinical and epidemiologic significance judged by YNHH Hospital Epidemiology and Infection Control

Clostridium difficile colitis

Respiratory Syncytial Virus (RSV)

Parainfluenza virus

Enteroviral infections in infants and young children

Pediculosis

Scabies

Escherichia coli 0157:H7, Salmonella, Shigella, Hepatitis A, Rotavirus-in diapered or incontinent patients

Diptheria (cutaneous)

Herpes Simplex virus
(neonatal, disseminated, or severe mucocutaneous)

Impetigo

Major (uncontained) abcesses or decubiti

Varicella (chickenpox), Herpes, Zoster (disseminated or in the immunocompromised host) also requires Airborne Precautions

Viral/ Hemorrhagic Conjunctivitis

Viral Hemmorrhagic Fevers
(e.g., Ebola, Lassa, or Marburg)

Nclex tips

Assess first( check the question to see if the assessment has been done)

Take care of the patient first, the machines and documentation later

Always choose the most complete answer with the least opportunity for error

In Priority question, look for acute and unstable pt to see first

Always remember your ABCs

Maslow's will usually work and pain is seen as a psychosocial need---Not a physical need

Incident or Occurrence reports--Never refer to them in the pt's chart should complete for any time there is a variance from what should have happened with Pt care should not include blame or anything but just the facts when charting, do not use the words, " Error, mistake, accident or incorrect."

Errors in charting are corrected by making one simple line through the words

If a RN comes from another unit, give that RN a pt who does not need to have a RN from specific unite care for him/her. EX. --Post op mastectomy needs an ONco nurse to take with.

Delegation--If you are assigning pt care to LPN/NA, rank order the pt as to the ones who have the least acute problems/changes to the most

Anytime a question comes up about a procedure or diagnostic test, consider the possible complications

Vital signs are a LATE signa of pt status change

Rales=CHF

Rhonchi=pneumonia

Wheezes=asthma

Hemoptysis=Lung cancer or TB

Pleural Pain=Pssible PE

Intercostal retractions=respiratory distress

Role play the situation

Read the question and answers out loud

Safety for the pt is always first, then the family, then the nurse

Never isolate a pt with Alzheimer's disease

Any time a pt has traction applied or a broken bone, consider: circulation Movement

Sensation

compartment syndrome

skin integrity

restlessness is often the first sign of hypoxia

if you chose an answer withthe word, why or check in it, make sure it is truly the best answer.

Rarely is the right answer to call the physician--Don't pass the responsibility

Psychiatric pt:

--For someone with psychosis--acknoledge the hallucination or delusion and then realityorientation
--for someone with dementia--change the subject, divert the attention

Medications to know: antipsychotics--Haldol, Thorazine, Zyprexa, Geodon\

antidepressants--Tricyclics--typically sedating so take at bedtime, cause otthostasis, dry mouth, very dangerous with OD. NEED to wean off.

MAO-I---low tyramine diet, if they eat something high tyramine--hypertensive crisis

Interact with a lot of other meds, can have hypertensive crisis with other meds

Need to be off other antidepressants for at least 2 wks before starting.

SSRI--can treat anxiety to. Typically take in the morning because they are more likely to be stimulating. Can cause diarrhea. Need to wean off.Serotonin serge.

Anti-mania--lithium--need to have levels drawn, Tend to get increased level if sweating, vomiting. Know the S/S of toxicity. Know normal Li levels( 0.6-1.2)

Anti-seizure family( Depakote, Tegretol, Lamictal, Trileptal, etc) most can lead to liver failure. Should have levels of Depakote/Tegretol done at intervals.

Anti-anxiety-Benzodiazepines----addictive and lead to seizures during withdrawl. Very dangerous if combined with alcohol. Sedating except may have paradoxical

Reaction in the elderly

Safety is always first priority if someone is losing control of her/his behavior.

--must try all other interventions before using restraints/seclusion someone must stay within arms's reach of the pt if they are restraints
Need to release one restraint or do Prom every 15 min.
Restraint to orders need to be specific and cannot be PRN and only good for 24hrs.
Chemical restraints count as restraints

The pt with Depression needs to increase interaction.

the pt with psychosis typically is very concrete in thinkgs and it not going to be able to process groups, etc

Well pt with addictive disorders use the denail as their primary coping mechanism

Manic phase pts need finger foods or calories as they burn a lot being busy

Suicidal pts --look for any phrase that implies helplessness, hopelessness, worthlessness

Post op eye surgery--don't bend at the waist, avoid straining

If someone has an object that has penetrated his/her body, leave it there until it is assessed as safe to remove.

INTERVENTIONS FOR COPD (using ABCDEF)

A-Aminophylline

B-Brochodilators

C- Chest Physiotherapy
CORTICOSTEROIDS

D- Deliver oxygen at 2 liters

E- Expectorants

F- Force Fluids

Tuberculosis ( Meds) Use RISE

R-Rifampin

I-Isoniazid (INH)

S-Streptomycin

E-Ethambutol

Care of Client After Masectomy
(BREAST)

B-Bp not on affected side

R- Reach recovery

E-Elevate affected side
Exension and flexion exercise- initialy (Squeeze a ball)

A-Abduction and external rotation should not be initial exercise

S-SBE- Once a month- about one week after period

T-To promote a positive self image

TURPS

T-Tubes

U-Urinary output

R- Red drainage

P-Pieces of clots

S-Spasms

Meniere's Disease

Administer diuretics to decrease endolymph in the cochlea, restrict sodium, lay on affected ear when in bed.
TRIAD
-vertigo
-Tinnitus
-Nausea and vomiting.

Use FIRST to help you remember

F- find hypoxia

I- Immunocompromised

R- Real bleeding ( Trauma, hemorrhage)

S-Safety

T- Try infection

Breast Cancer Risk Factors:

• >50 years of age • FIRST child born after 30 years of age • Grandmother, Mother, Sister has it • Personal history of breast cancer
Garlic has a hypoglycemic effect do not give with insulin

Eye problems do not want head in dependent position. Lie on good side and have bad eye up or elevate the head of the bed to 35 degrees.

Lay on right side after liver biopsy.

Clear fluid from head CSF medical emergency call the doctor

1 yr old with nausea, vomiting, and diarrhea is emergency because young children become dehydrated very easily

Assess pt for claustrophobia with CAT scans and MRIs, also, NO METAL.

ALPHABET NURSING FACT:

Activated charcoal - To absorb poison

AAA- Complication is hemorrhage and shock

A positive mantoux test indicate the pt has produced an immune response

Complication of warfarin- (3H) hemorrhage, hematuria and hepatitis

Colchine for treatment of gout attack

Codeine- onset- 30mins, peak- 1hr, duration 4-6hrs

COPD -use of acessory muscle for respiration indicate the pt is having difficulty breathing

Chlamydia, Genital herpes and HPV - Do not report

Crackles are heard on inspiration and dont clear with cough

Diaphramatic and purse lip breathing are the best for pt with COPD

DMD- X-linked recessive and female are carrier and male are affected.

DI- Treatment is DDAVP

Gastric lavage - To remove poison

Indomethacin - helps in closing PDA

Left sided HF- pulmonary

Myelomingocele complication - clubbfoot and hydrocephalus

Meningitis- Droplet

Osteoarthritis- Joint pain, crepitus, heberden's node, bouchard's node and enlarge joints

Pentoxifyline- hemorheologic Agent that improve blood flow and is used to treat intermittent claudication

Prostaglandin E is administerd to provide blood ming and also help to keep open the ductus arteriosus

Right side HF- systemic

Rhonchi are heard on expiration and clear with cough

Rabies- contact precaution

tPA- used to treat Acute MI

Thrombolytic- dissolve clots

To avoid falsely elevated serum digoxin, the nurse should wait @ least 8hrs after administering oral digoxin and @ least 6hrs after administering I.V digoxin to draw a blood sample.

TB- airborne

Disaster planning

A disaster plan needs to be activated when there is a life threatening situation with a large number of patients involve. A way to remember who to remove first is by using ABC

A- Ambulatory

B- Bed Ridden

C- Critical Care

You may ask why but the goal is to move the greatest number of clients.

Appendicitis- position of comfort is on the side with the legs flexed agains the abdomen. HOB should remain slightly elevated to decrease the upward spread of infection in case the rupturing of appendix occurs.

Here are a few facts I came across while doing questions.

Brown pigmentation around the ankles of patient indicates venous insufficeny

Cloudy outflow during peritoneal dialysis indication of infection and needs to be reporeted to MD

Afte colonoscopy a patient should report rebound tenderness. Abdominal cramping, fatigue and passage of liquid stool are all normal findings after colonoscopy.

A patient with pertussis should be in a private room, mask and under droplet precautions.

Hydromorhone ( Dilaudin) can Cause urinary retention.

Respite care important for caretaker of Alzheimer's patient to allow for physical and emotional rest.

Antihistamines can cause urinary retention and exacerbate symptoms of BPH.

Applying pressure to the inner cantus of the eye prevents overflow of medication into the nasolacrimal duct and possibly systemic absorption.

Ethical dilema- Determination of facts. identify possible solutions, consider patients wishes.

An Increase in peak expiratory flow rate indicates that airway restriction is resolving ( asthma patient)

Salem sum tube- turn patient every 2 hours to promote emptying of stomach contents.

Fatigue, abdominal bloating and persistent dyspnea of patient with COPD contributes to patients inability to maintain adequate nutrition.

Serosanguienous drainage beyond post-op day 5 may indicate dehiscence; therefore surgeon should be notified.

There is no need for a parent of a child who is HIV positive to notify the childs daycare provider.

INDERAL- serious side effect decrease heartrate due to blockade of betta1 receptors in the heart.

Bulima patient with bloody emesis due to esophageal tears due to purging.

Pacemaker spikes on T wave indicate that the pacemaker is not capturing appropriately and should be adjusted for this patient.

A patient who is having muscle spasm while in traction should be repositioned to see if the spasms decrease.

REASONS FOR UNCONSCIOUSNESS ( skin Color)

RED- Stroke or increase in blood pressure

BLUE- Respiratory or cardiac arrest

WHITE- Shock or Hemorrhage.

BETA BLOCKERS

B-bronchospasm( do not give to asthma, bronchial constriction patients)

E- elicits a decrease in cardiac out put and contractility.

T- treats hypertension

A- Av conduction decreases

T- tenormin ( atenolol) hypertension & angina

L- Lopressor ( metopolol) hypertension & angina

C- Corgard ( naldolol) hypertension & angina ( renally excreted)

Glomerulonephritis- fever, periorbital edema, weakness, and chills caused by grop B strep.

It is normal for a patient that has had dialysis to have a slight fever afterwards due to the dialysis solution being warmed by the machine.

Positive sweat test indicative of cystic fibrosis.

After thyroid surgery- maintain airway keep a trach kit at patients bedside, check for bleeding, be sure to check at sides and back of neck due to gravity and teach patient to support their neck.

A bit about B-Vitamins [pic]

B-1 (thiamine) and all B vitamins – Alcoholic (to prevent Wernicke’s encephalopathy and Korsakoff’s syndrome.

B-6 (pyridoxide hydrochloride) –TB patient (Pt is likely on INH which can cause peripheral neuropathy, dizziness, and ataxias, B-6 can prevent these unwanted affects).

B-9 (folic acid) – Pregnant pt to prevent neural tube defects in fetus

B-12 (cobalamine) – Pernicious anemia (autoimmune disease that attacks the parietal cells preventing intrinsic factor from being released, which is needed to absorb B-12.

1. Hep B immune globulin and Hep B vaccine are given to infants with perinatal exposure to prevent hepatitis and achieve lifelong prophylaxis; administered within 12 hours of birth.

2. Immune globulin is given to prevent Hep A.

3. Cyanocobalamin (Vit B12) is used to treat states of vit B12 deficiency; the most common manifestation of untreated cyanocobalamin deficiency is pernicious anemia.

4. Pernicious anemia is one of the risk factor for gastric cancer.

5. child with Celiac disease: dietary management is the mainstay; eliminate all wheat, rye, barley, and oats; replaced with corn and rice; vitamins supplements, especially fat-soluble vit and folate, may be needed in the early period of treatment to correct deficiencies. 1. Acid is lost from the stomach (emesis) leading to metabolic alkalosis 2. Bicarbonate is lost from diarrhea leading to metabolic acidosis 3. Irritability (rather than lethargy) is an initial finding for cerebral hypoxia which would occur from the retained fluid in the brain that results in increased ICP 4. Signs of increased ICP in infants include: bulging fontanel, irritability, high pitched cry, and continually cries when held; R more often slow, deep and irregular 5. The peak airflow volume decreases about 24 hours before clinical manifestations of exacerbation of asthma; it is the most important to monitor for asthma pts 6. the peak flow meter is used to measure peak expiratory flow volumes; provides useful info about the presence and/or severity of airway obstruction: green (good); yellow/red (caution and get help) 7. When a pregnant women is admitted with C/O painless vaginal bleeding: do abdominal ultrasound because it's the least invasive diagnostic test 8. dexamethasone (Decadron) increases the production of HCl, which often leads to GI ulcers; take it with food or milk 9. Pancreatic enzymes are to be given to pt with cyctic fibrosis; with each meal and every snack to allow for digestion of all foods that are eated 10. If the peak flow reading is 50% less of the pt's baseline reading, give a short-acting beta-agonist immediately (rather than giving oxygen because the pt's airways need to be opened up first)

NCLEX TRAPS

When you read the question ask yourself can I IDENTIFY the TOPIC of this question?

Note: NCLEX HIDES the TOPIC of a question

Example:

A nurse is evaluating the effects of medical therapy for a client with pulmonary edema. The nurse determines that the interventions that were most effective if the client exhibited which of the following?
U=urine output RR= respiratory rate BP=blood pressure P=pulse

a) BP= 96/56 mmHg; P=110 beats/min; RR=28 breaths/min; U=20 ml/hr

b) BP=88/50 mmHg; P= 116 beats/min; RR=26 breaths/min; U=25 ml/hr

c) BP=108/62 mmHg; P=98 beats/min; RR=24 breaths/min; U= 40 ml/hr

d) BP= 116/70 mmHg; P= 88 beats/min; RR= 20 breaths/min; U= 50 ml/hr

This question has been copied from another thread in which the person was inquiring why the answer she chose was not correct, and from eight responses no one could tell the person who posted this example the rationale for the correct answer. First thing: identify the topic which is client's needs- physiological integrity. The NCLEX makers want to know if you know how to apply the fifth nursing process which is evaluation within the context of physiological integrity. You need to evaluate if the set of vitals you took after giving medication therapy are withing normal limits. Eliminate first the wrong answers. Answers #a and # b are wrong (below normal limits)...just by looking at the blood pressures, you know those answers are wrong. You are just left with two choices which is better than having to choose between fours answers. Do you see the advantages of elliminating wrong answers, first? [pic]
The next step is to eliminate the last wrong answer, let's look at answer # c...everything is within normal limits except the respiratory rate (normal for an adult RR=12-20 bpm). Since you have to eliminate # c, then the right answer must be # d, which is indeed, all those numbers are within normal limits, by the way, normal urinary output is at least 30 ml/hr. That is a good example of how cleverly the NCLEX makers could hide the topic. They wanted to know if the test taker knows how to apply the nursing process of evaluation by throwing a question about evaluating a set of vitals.

IDENTIFY THE TOPIC OF THE QUESTION:

• if you have no idea what is the question asking: read the answer choices for clues to identify the topic
In some questions validation is required in order to answer the question corectly...meaning the question may ask you to assess or evaluate as opposed to implement (do some action, for example, call the doctor, start CPR, reposition the patient or give oxygen to the patient, etc.) Remember the intent of the question will be hidden to you.

• read the stem question for determining whether you should assess or implement and within that context eliminate the answers which do not fit to with what you must do, that will lead you to the right response.
If all the anwers fit in to implementation, then move on to use Maslow Hierarchy of Human Needs

--Physical needs take priority over other needs--

Pain is not a physical need--it is considered psychosocial, so it goes higher up on Maslow scheme

If all answers fit in to the physical needs apply ABC (air/blood/circulation) scheme • do not automatically select respiratory answers--remember to thow out wrong answers first
If all answers are psychosocial do not choose the answer that "sounds right": determine the outcome of each answer, throw out first the answers with negative outcome. Ask yourself "is this answer choice has a desired outcome?"

Examples of Undesirable Answers you are Looking for to Throw Out First:

a) pass the buck
b) judgmental
c) bad nursing
d) off topic
e) take the buck
f) encourage dependency
g) asking why
h) do not persuade
i) leave patient alone
J) non therapeutic
k) gives false reasurance
l) blame
m) do nothing answers
n) answers which by pass the nursing process such as implementing a particular tx before assessing the situation
o) by pass proper delegation qualifications
p) by pass priority of care
q) do not involve the patient in their own healing process
r) do not listen to the patient in a respectful manner
s) violate patient's rights
t) do not show cooperation with the health team
u) answers that contain absolute worlds such as only, always--watch for those

If Manslow and ABC does not apply: Evaluate ask yourself why, as I did in the example above, the answers presented are wrong by comparing them against the normal values, throw out first wrong ones for that will lead you to the one you are looking for: the right answer. Best wishes to all of you who are taking the NCLEX in February. feliz3

Fosamax (alendronate sodium)
-treatment for OSTEOPOROSIS
Teach the patient --FOSAMAX causesESOPAGITIS.
1)Remain upright for 30 minutes and do not eat or drink anything else for 30 minutes,to prevent delay of the drug through the esophagus
2)Take these drugs on an empty stomach, first thing in the morning, with water.Must be taken with a sufficient amount of water so it does not pass through the esophagus completely...

What I've learned today in my review [pic]
1.Tagamet- to be taken at bed time
2.Dilatin- Aside from the regular visit to the dentist, when given IV can only be given w/ normal saline,to be kept in room temperature, AE agranulocytocis and aplastic anemia, client will need freq. CBC
3.Side effect of ZYPREXA development of parkinson
4. Client taking Methotrexate should avoid multi Vitamins because they contain Folic Acid( antidote of Methotrexate)
5.Client taking Isoniazid should have negative sputum within 3 months.
3.

Nurses must assume what the physician will order first:

DKA-----Initiate fluid replacement first ( IV .9% normal saline)

Hemophilia A-------- transfuse Factor VII

Ventricular Fibrillation (UNRESPONSIVE)-----Defibrillate 200j (300j:360j) if unsuccessful ------CPR

Sickle cell anemia---------- 0xygen 100% Fi02 (HHOP)

ARDS (acute respiratory distress syndrome)-----(O2 nonrebreathing mask) if no improvement w/ nonrebreather mask----intubate /mechanical ventilator

Pulmonary edema (sx. asses breath sound--crackles)----------tx: Furosemide

MI (chest pain)----------tx.morphine

Skin test reaction(SOB,anxious,reddened blotches,dizzy)-administer epinephrine

tenision pneumothorax-----------------chest tube

Fractures:
Immobilize joint above andü below fracture
Cover open fracture with cleanest material availableüü Check temperature, color, sensation, capillary refill distal to fracture ü Close reduction—manually manipulate bone or use traction

Buck’s Traction
Use to relieve muscle spasm of leg and backü
If used forü muscles spasms only, they can turn to either side.
If used for fractureü treatment, only can turn to unaffected side.
Use 8-20 lbs of weight, ifü used for scoliosis will use 40 lbs of weight.
Elevate head of bed forü countertraction or foot bed
Place pillow below leg not under heel or behindü knee.

Russell’s Traction
Sling is usedü
Check for poplitealü pulse
Place pillow below lower leg and heel off the bedü
Don’t turnü from waist down
Lift patient, not the legü

Cervical Tongs
Neverü lift the weights
No pillow under head during feedingsü

Balanced Suspension Traction
For femur realignmentü
Maintain weights hangingü free and not on floor
Maintain continuous pullü

Halo Jacket ü Maintain pin cleansing

Casts
Don’t rest on hard surfaceü
Don’tü cover until dry 48+ hours
Handle with palms of hands not with fingersüü Keep above level of heart
Check for CSMü

Fractured Hip
• Assessments
Leg shortened§
Adducted§
Externally rotated§
• Implementation
Care after a total hip replacement§
• Abduction pillows
• Crutch walking with 3-point gait
• Don’t sleep on operated side
• Don’t flex hip more than 45-60 degrees
• Don’t elevate head of the bed more than 45 degrees

Amputations
• Guillotine (open)
• Flap (closed)
• Delayed prosthesis fitting
Residual limb covered with§ dressing and elastic bandage (figure eight)
• Figure-8 doesn’t restrict blood flow, shaped to reduce edema
Check for bleeding§
Elevated 24 hours§ (AKA-pillow, BKA-foot of bed elevated)
Position prone daily§
Exercises,§ crutch walking
Phantom Pain: acknowledge feelings, that pain is real for§ them

Isoniazid (INH)-Anti-tuberculosis
s.e.: peripheral neuropathy-watch out for signs:numbness, tingling or weakness liver damage-watch out for signs of hepatitis:yellow eyes or skin, NV, anorexia, dark urine, unusual tiredness, or weakness

Aminoglycosides: Anti-infective
Amikacin(Amikin) Gentamicin,(Garamycin) Tobramycin (Tobrax)
s.e.Ototoxicity(CN VIII)-immediately report hearing or balance problems
Nephrotoxicity -Teaching:encourage fluids 8-10 glasses daily

Antihistamine
Loratadine (Claritin),Fexofenadine (Allegra),Cetirizine HCI (Zyrtec)
s.e. Drowsiness/Dizziness -teach pt:caution in potentially hazardous activities..
-avoid use of alchohol,& other CNS depressants
Dry mouth
-*generic name ends with "zine"* cyclizine, trimeprazine, methdilazine, meclizine, and promethazine an antihistamine preventing or countering motion sickness as well as nasea and vomiting.

Heparin /-anticoagulant
s.e.: hemorrhage- watch out for:bleeding gums, nose, unusual, black tarry stools, hematuria, fall in hemacrit or bl. pressure, guaiac-positive stools teach pt:avoid ASA & NSAIDs
-antidote: protamine sulfate w/in 30 min
-injec.=deep SQ-onset 2-6- min, dur. 8-12 hrs
-IV: pk 5 min, dur. 2-6 hrs/NEVER GIVE IM
-check -therapeutic PPT (20-36) @1.5-2.5 X the control

Warfarin (Coumadin)/anticoagulant
s.e.:hemorrhage-
Caution:if pt said "I LOVE TO EAT VEGETABLE IN THE GARDEN) teach:-avoid foods high in Vit K, green leafy vegs
-antidote: vit. K
-therapeutic PT (9.6-11.8)@1.5-2.5 X control, INR @ 2.0=3.0
-onset: 12-24 hrs, pk 1-1/2 to 3 days, dur: 3-5 days

Anti-malarials
Hydrozychloroquine (Plaquenil),Quinine Sulfate
s.e.: eye disturbances, NV, Anorexia
Teach:take at same time each day to maintain blood levels

Anti-protozoals:
Metronidazole (Flagyl, Flagyl ER)
s.e.-CNS symptoms, abd cramps, metallic taste, teach pt[pic]o not drink alcohol in any form, during and 48 hrs after use, disulfiram-like reaction can occur.
-avoid hazardous activities
-dark-reddish brown urine

Opioid Analgesic-
Methadone, Hydromorphone (Dilaudid) , Propoxyphene (Darvon, Darvocet-N (propoxyphene with acetominophen),
Oxycodone (Oxy Contin; with aspirin Percodan, with acetaminophen Percoset)
Codeine,Meperidine(Demerol),Hydrocodone Bitartrate & Acetaminophen
(Lortabs)
s.e.-Drowsiness, sedation,nausea, vomiting, anorexia,Respiratory depression constipation, cramps,orthostatic hypotension,confusion, headache,rash
-do not give if RR less than 12 per min

Cephalosporins(generic name begins with "cef/cep")
Cefadroxil (Duricef) ,Cephalexin (Keflex, Keflet) ,Cephapirin (Cefadyl)
Cephradine (Velosef) ,Cefaclor (Ceclor, Ceclor CD) ,Cefamandole (Mandol)
Cefonicid (monocid) ,Cefotetan (Cefotan)
s.e. Diarrhea

*generic name ends with "phylline"*
Xanthine bronchodilator - aminophylline, dyphylline, oxtriphylline, theophylline
s.e.- nausea,vomiting,anorexia,gasstrointestinal reflux,TACHYCARDIA indication:acute asthma, chronic bronchitis, emphysema, COPD contraindicated:peptic ulcer,hyperthyroidism,cardiac dysrhythmias

Child undergoing cardiac catheterization - priority nursing Dg. is - Deficit knowledge ( parental ) related to cardiac. cath., not decreased cardiac output related to structural defect !

Planning care for child before corrective surg. for Tetralogy of Fallot - priority nursing Dg. - Deficit knowledge related to upcoming surg. and postoperative events, not impaired gas exchange related to structural cardiac def.

Kawasaki Disease - aspirin + IV gamma globulin - to reduce immune response
- steroids contraindicated - increase aneurysm formation
- dipiridamole to increase coronary vasodilatation and decrease platelet accumulation

A positive Kernig's Sign is a manifestation of meningeal irritation
2. A serum creatinine above1.4 mg/dl indicates renal failure
3. Epioglottis develops acutely and emergently
4. Bells Palsy is Cranial Nerve VII
5. Bridiging Technique ,which I had never heard of is a type os positioning of pillows used to relieve pressure on bony prominences

CARE OF A PATIENT IN TRACTION
T = Temperature
R = Ropes hang freely
A = Alignment
C = Circulation - the 5 P's - Pain, pulse, pallor, paresthesia, paralysis
T = Type and location of fracture
I = Increase fluid intake
O = Overhead trapeze
N = No weights on bed or floor

Here are my five: Knowledge Based
I am back to the drawing board with Fluids & Electrolytes
Hypovolemia: decreased urinary o/p; increased urine specific gravity
Hypervolemia: increased urinary o/p; decreased urine specific gravity

Hyponatremia: increased urinary o/p; decreased urine specific gravity (just think of dehydration-losing fluids).
Hypernatremia: decreased urinary o/p; increased specific gravity(just think of the body holding the Na+ in, and output will be decreased).

Hyponatremia: Monitor for lithium toxicity if pt is on this med. It can decrease lithium excretion, causing lithium toxicity.

Hypokalemia: Increased urinary o/p; decreased specific gravity (just think of the body losing fluids, just like with hyponatremia).
This condition is life-threatening, b/c it affects every body system.
TX: give K+ Chloride- Never give K+ IV push, IM, or SQ.
Never exceed 20 mEq/hr
If pt receives >10 mEq/hr place on cardiac monitor.
Assess renal function before administering med and monitor I/O's during tx.

Hyperkalemia:
Early sx muscle twitches, cramps, parasthesias.
Place on cardiac monitor.

Hypocalcemia: Positive Trousseau's & Chvostek's sign
Monitor cardiovascular, respiratory, neuromuscular, GI; place on cardiac monitor.
Give Ca+ supplements PO or Ca+ IV.
Ca+ IV-Warm solution to body temp. before admin. & give slowly; monitor for ECG changes.
Hypercalcemia:
early sx is increased HR. late sx: Bradycardia that can turn into cardiac arrest.
Increased urinary o/p that can lead to dehydration.
Check for urinary stones, by straining the urine. Place on cardiac monitor.
Hypoactive bowel sounds.

Don't combine aspirin with glipizide (Glucotrol) therapy or alcohol with insulin; both can cause hypoglycemia.

1. Barium swallow for 3 month old infant - NPO for three hours 2. Temporary pacemaker for MI client - increase cardiac output is the primary purpose 3. Plasma cholesterol screening - only sips of water for 12 hours 4. Reminiscing group - primary goal is to review and share their life experience with the group member 5. Miller-abbott tube - removes fluid and gas in the small intestine; provides intestinal decompression 6. Levin or salem stump - decompresses the stomach; prevent fluid and gas accumulation in the stomach 7. Promethazine Hcl (Phenergan) - check patency of the patient's vein before admin of drug, extravasation will cause necrosis 8. Insulin dependent diabetic, unable to urinate -- autonomic neuropathy 9. Overdose of aspirin will produce parkinsons dse type sx 10. Do not admin erythromycin to Multiple Sclerosis pt

Here are my five for today: NCLEX answers -
1) If you have never heard of it, nobody else probably had, so don't choose that answer.
2) If your pt. is unstable don't choose reassess in 15 min. He might be dead in 15 min - don't delay treatment. find first question that will kill or harm pt., secondly that will delay treatment and eliminate those. if there is something you can do before calling doctor, do it ( pick that question ). sometimes to call the doctor may be the only right option.
3)Maslow's hierarchy : Physiologic needs -
A) Maintaining airways and respiration
B) Maintaining circulation
C) Nutrition and elimination
D) Sleep
Safety needs - when no physiological needs exist, safety takes priority - mainatining safe and secure enviroment for pt. and nurse
4) Communication - focus on pt. feelings first
5) Teaching and learning - motivation and readiness - assess if pt. had previous experiences or any information first
How to Determine Whether to Delegate or Not

UAP= unlicensed assistive personnel

Ask yourself:

1) Are the and rules in place which support the delegation?

a) yes---go to step 2
b) no--- do not delegate

2) Is the task to be delegated within the scope of practice of the RN/LPN?

a) yes---got to step 3
b) no---do not delegate

3) Is the RN/LPN has the knowledge and experience to make delegation decisions?

a) yes---go to step 4
b) no---do not delegate. Action to take: provide education and document education provided

4) Has there been assessment of the client's needs?

a) yes---move to step 5
b) no---assess client's needs first, then proceed with considerations to delegations

5) Is the UAP competent, has the experience to accept the delegation?

a) yes---move to step 6
b) no---do not delegate. Action to take: Provide education and document the education given to the UAP

6) Does the ability of the care giver match the care needs of the client?

a) yes---go to step 7
b) no---do not delegate

7) Can the task to be delegated be performed without requiring nursing judgment?

a) yes---move to step 8
b) no---do not delegate

8) Are the results of the task reasonably predictable?

a) yes---move to step 9
b) no---do not delegate

9) Can the task be safely performed according to exact, unchanging directions?

a) yes---move to step 10
b) no---do not delegate

10) Can the task be safely performed without complex observations or decisions based on critical thinking?

a) yes---move to step 11
b) no---do not delegate

11) Can the task be performed without repeated nursing assessments?

a) yes---move to step 12
b) no---do not delegate

12) Is appropriate supervision available?

a) yes--- all other steps met, it is safe to delegate
b) no---do not delegate

Delegation= Transferring a selected nursing task in a situation to an individual who posses the knowledge, experience that makes the person competent to perform that specific task.

The Nurse Practice Act and any practice limitation, such as been unfamiliar with the particular task which needs to be delegated, define which aspects of care can be delegated and which must be performed by the registered nurse.

Only the task not the ultimate accountability may be delegated to another. The nurse who delegates maintains accountability for the overall nursing care of the client. The nurse must know what are her clients preferred outcomes in terms of health care delivery goals, so that the process of delegation is geared toward achieving desirable outcomes.

The RN must match the task to be delegated based on the Nurse Practice Act and appropriate position descriptions.

Task that which are the responsibility of the RN only:

a) unstable patients with the least predictable medical outcomes
b) central line care
c) any tasks involving teaching, observation, discharge of a patient, assessment and critical thinking based decisions
d) blood transfusions
e) parenteral nutrition
f) patient controlled analgesia
g) development of a plan of care
h) taking a medical history
i) taking phone doctor's orders for prescription and treatment
j) doing an admission assessment
K) initiate a Care Plan

Task that can be delegated to LPN/LVN only

a) patients who are stable and with predictable outcomes and common, well-defined health problems
b) give meds, oral, topical and inhalants, can administer treatments such as sterile wound care, blood sugar testing, nasogastric tube insertion, tube feedings and charting
c) LPN/LVN can start an IV of saline and superimpose IV fluids with vitamins, nutrients and electrolytes by primary or secondary infusion lines, infuse blood and blood products with IV Certification
d) give injections
e) monitor running IV
f) give enemas
g) monitor a urinary catheter
h) do simple wound dressing change
i) any task which does not require nursing judgment or complex observation, nurse can delegate to the LPN. RN must inform the parameters of what to report as abnormal
j) use sterile technique procedures such as putting a urinary catheter
K) can give intra muscular injections, subcutaneous, intradermal
l) cannot give IV Push, infuse antibiotics or other medications via secondary IV line
m) can initiate teaching and a care plan
n) cannot infuse IV fluids such as TPN or other fluids via a central line and cannot do blood withdrawal via central line
o) can do blood withdrawal via venipuncture or peripheral line with blood withdrawal certification

sources: http://www.vocationalnursingdirectorsofca.org http://www.rn.ca.gov/noa.htm http://www.bvnpt.ca.gov/pdf/vnregs.pdf

UAP

a) bathing patient
b) ambulation
c) making beds
d) routine vital signs feeding patients
e) transferring patients

SLAP---Quick Suicide Assessment

S---assess how specific is the plan: goes beyond thinking about it = suicide ideation

L---assess how lethal is the method of doing it

A---assess the availability of whatever object the person chooses to commit suicide with

P---proximity how far or close this person is from getting help or from someone to notice his/her intentions and try to stop him/her

If at least one these four items is affirmative on a patient, the patient is at risk and rising if there is no intervention in place such as placing the patient on suicide precautions.

AIRBORNE PRECAUTIONS:

a) private room with monitored negative air pressure flow with 6-12 air changes per hour
b) keep the door closed and patient in the room
c) can cohort or place the patient with another patient with the same organism but no other organism
d) care giver ware mask N-95 and respirator around mouth and nose
e) place a mask on the client if being transported

DROPLET PRECAUTIONS:

a) involves contact of conjuntive or mucous membranes of nose, mouth that happens during coughing, sneezing, talking or during procedure such as suctioning or bronchoscopy
b) private room or with patient with same infection but no other infection
c) maintain a spacial separation of three feet between infected patient and visitors or other patients
d) door may remain open
e) place mask on patient if being transported

CONTACT PRECAUTIONS:

a) needed for patient care activities that require skin-to-skin contact such as turning a patient, bathe a patient or hand contact between two patients or contact with a contaminated objects in the patient's environment
b) private room or with another patient with the same infection but no other infection
c) clean nonsterile gloves when entering the room
d) change globes after patient contact with fecal material or wound drainage
e) remove globes before leaving patient's environment and wash hands with antimicrobial agent
f) wear a gown before entering the room if clothing will have contact with patient, environment surfaces, or if patient is incontinent, has diarrhea, an ileostomy, colostomy or wound drainage
g) remove the gown before leaving the room
h) use dedicated equipment or clean and disinfect between patients

Entrance into the Isolation Room:

a) put the surgical mask or respirator around mouth and nose (type of mask depend on the type of isolation)
b) apply eyeware or goggles snugly around the face and eyes (when needed)
c) apply gown and make sure it covers all outer garments, pull sleeves down to wrist and tie the gown securely on the neck and waist
d) apply disposable globes to cover over the edge of the gown sleeves
e) enter the patient's room
f) equipment such as stethoscope, pressure cuff, thermometer--disposable--.
g) nondisposable equipment remains in the room... clean nondisposable equipment with alcohol before and after using it, place dedicated equipment on a clean surface

Leaving Isolation Room:

a) remove gloves, discard
b) untie top mask string and then bottom string pull mask away from face and do not touch the outer surface of the mask
c) untie waist and neck string of the the gown, allow the gown to fall from the shoulders
d) remove hands from sleeves without touching the outside of the gown
e) hold the gown inside at the shoulders seams and fold inside out and discard
f) remove eyeware or goggles
g) wash hands
h) leave the room and close the door if the patient is on airborne precautions

. The 3 classic signs of pre-eclampsia are: Hypertension, generalized edema and proteinuria.

2. REFLEXES
• Moro reflex- Elicited by striking a flat surface the infant is lying on. The reflex of abducting extremities and fanning fingers when a sound is heard should be gone by 3-4 months. Strongest at 2 months.
• Rooting - When the cheek of the newborn is stroked, the newborn will turn his head in the direction of the stroke.
• Tonic neck - While the n/b lies supine, his head is turned causing the extremities on the same side to straighten and those on the opposite side to flex.
• Babinski - When the sole of the foot on the side of the n/b small toe is stroked upward, the toes will fan upward and out.
• Plantar grasp - Infant’s toes will curl downward when sole of foot is touched.
• Startle - A loud noise such as a hand clap will elicit the n/b to abduct his arms and flex his elbows.
3. Terbutaline (Brethine) and Mag sulfate - treatment for preterm labor.
4. Nagele’s Rule: First day of last menstrual period + 1 year & seven days minus 3 months.

5. True labor INCREASESwith activity.

6. Normal newborn jaundice - AFTER 24 hours of life.
Pathologic jaundice - BEFORE 24 hours of life.

7. Fetal Fibronectin (FFN) test helps determine if there is pre-term labor.

8. A subarachnoid (spinal block) for labor may cause a headache, a lumbar epidural will not since the dura mater is not penetrated.

9. Tracheoesophageal fistula: 3 C's: coughing, choking, & cyanosis.

10. Pregnancy r/t: Add 300 Calories to diet when pregnant, 500 when breastfeeding.
11. Non Stress Test on a pregnant female....should be REACTIVE (rise of 15 bpm above baseline for 15 sec) if it's NOT reactive they need a contraction stress test and the result that you want from it is NEGATIVE.

12. Pregnancy Induced Hypertension: The nurse would be MOST concerned if the patient complained of epigastric pain and a headache.

13. LOCHIA SEQUENCE.: lochia rubra- red, clotty....lochia serosa...pink, brown....lochia alba..white.........SHOULD NEVER HAVE A FOUL ODOR!

14. When a pregnant women is admitted with C/O painless vaginal bleeding: do abdominal ultrasound because it's the least invasive diagnostic test

15. Calcium Gluconate can cause severe chemical burns - most important to check patency of veins when giving (given to a patient experience magnesium sulfate toxicity)

16. Take prenatal vitamins in the morning with orange juice - acid aids in absorption.

17. Fetal heart rate: 120-160 BPM
Variability: 6-10 BPM
Contractions:
Frequency - every 2-5 minutes
Duration - less than 90 secs.
Intensity - less than 100 mmHg
Amniotic fluid - 500 to 1200 ml - Nitrozene paper (litmus paper) - if urine it turns green. If amniotic fluid litmus paper turns blue.

18.FAB 9 - Folic Acid (AKA B9) B = Brain. Decreases the incidence of neural tube defects. The client should begin taking B9 three months prior to becoming pregnant.

19. AVA - The umbilical artery has 2 arteries (carries deoxygenated blood) and 1 vein (carries oxygenated blood).

20. TORCH syndrome in the neonate - A combination of diseases: Toxoplasmosis, Rubella (German measles), cytomegalovirus, herpes, and syphilis. Pregnant nurses should not be assigned to care for a client with toxoplasmosis or cytomegalovirus.

21. Android Pelvis is wedge shaped, narrow and unfavorable for birth.

22. Prenatal Visits q 4 weeks -28-32 weeks q 2 weeks -32-36 weeks q 1 week -36-40 weeks

23. Posterior fontanel close - 2-3months
Anterior close After - 12-18 months

24. Most dangerous when you're pregnant; regular measles (rubeola), or German measles (rubella), so remember: Never get pregnant with a German (rubella).

25. Apgar measures heart rate, respiratory rate, muscle tone, reflexes, and skin color.
Measured by 0 for absent, 1 for decreased, 2 for strong positive. 8-10 OK. 0-3 RESUSCITATE. Performed at 1 and 5 minutes.
A= appearance (color all pink, pink and blue, blue [pale])
P= pulse (>100, < 100, absent)
G= grimace (cough, grimace, no response)
A= activity (flexed, flaccid, limp)
R= respirations (strong cry, weak cry, absent)

26. In the Apgar score, the first time done reflects the transitional score, the second Apgar score reflects the planning of care for the newborn. Score over 7, baby is ok but score under 5 needs resuscitation or intensive care.

27. NEVER examine a bleeding gravida vaginally.

28. Maternal hypotension = STOP
Stop Pitocin (oxytocin) infusion
Turn patient on left side
Oxygen
Push IV fluids.

29. The criteria used to distinguish TRUE from FALSE labor is “EVIDENCE OF CERVICAL CHANGE“.

30. Fetal heart patterns in OB? Think VEAL CHOP

V C V = variable decels; C = cord compression caused
E H E = early decels; H = head compression caused
A O A = accels; O = okay, not a problem!
L P L = late decels P = placental insufficiency, can't fill
For any kind of bad fetal heart rate pattern, you give O2, often by mask...
Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal bradycardia, etc) --> turn on left side (and give O2, stop Pitocin, increase IV fluids)

31. For cord compression, place the mother in the TRENDELENBERG position because this removes pressure of the presenting part off the cord. (If her head is down, the baby is no longer being pulled out of the body by gravity). If the cord is prolapsed, cover it with sterile saline gauze to prevent drying of the cord and to minimize infection. Place client in knee-chest position or Trendenlenberg

32. Once the membranes rupture, important to monitor temperature hourly as risk for infection increases. First thing to do after rupture is to auscultate fetal heart tones!
Assessing for cord prolapse if decels occur.

33. For late decels, turn the mother to her left side, to allow more blood flow to the placenta.

34. Greatest risk for postpartum hemorrhage is from distended bladder.

35. Hypotension and bradypnea/bradycardia are major risks and emergencies.

36. NEVER check the monitor or a machine as a first action. Always assess the patient first; for example listen to the fetal heart tones with a stethoscope in NCLEX land. Sometimes it's hard to tell who to check on first, the mother or the baby; it's usually easy to tell the right answer if the mother or baby involves a machine. If you're not sure who to check first and one of the choices involves the machine, that's the wrong answer.

37. If the baby is a posterior presentation, the sounds are heard at the sides. the baby is anterior, the sounds are heard closer to midline, between the umbilicus and where you would listen to a posterior presentation.

If the baby is breech, the sounds are high up in the fundus near the umbilicus. If the baby is vertex, they are a little bit above the symphysis pubis.

38. Use reliable form of birth control for at least 4 weeks (8 is better) after rubella immunization [of course this applies to women only].

39. Increase calorie intake by 300 for pregnancy; 200-500 for lactation.

40. Fluid intake for pregnancy minimum 2000 mL; minimum 3000 mL for lactation.

41. Interventions for late decels: Stop Pitocin if on, turn mom to left side, increase IV fluids, O2 8-10 L/min.

42. Ways to speed delivery: Prostaglandins (Prepidil or Cervidil), Misoprostol, (Cytotec), artificial rupture of membranes, oxytocin (Pitocin).

43. Spontaneous abortion: Most commonly present Painfollowed by bleeding

44. RHoGAM : given at 28 weeks, 72 hours post partum, IM. Only given to Rh NEGATIVE mother. Also if indirect Coomb’s test is positive, don’t need to give RHoGAM cause she has antibody only give if negative Coombs

45. Discolored amniotic fluid such as green is a sign of fetal distress.

46. Placenta previa = painless bleeding. No vaginal exams.

47. After the rupture of membranes, the babies heart is checked then rechecked a few minutes later or after next contraction.

48. Hep. B vaccine given within 12 hours of birth.

49. GP-TPAL: G=#pregnancies, P=#births, T=#term pregnancies (38+ weeks), P=#preterm pregnancies (20 weeks-37 6/7 weeks), A=#abortions (spontaneous and therapeutic than chest when born, but equal by 1 year.

110. Skin tags and low set ears in infants - suspect chromosomal abnormalities

111. Circumoral cyanosis in infants - see if it improves with crying. If it doesn't , report it because it might indicate cardiac pathology.

112. Infants need 110kcal/kg/day
Breast milk has 20 kcals per ounce (so 20 kcal per 30 cc)
Breast milk has everything BUT slightly deficient in Vitamin D

113. Shoulder and Upper back lanugo is normal for term baby and vernix in deep creases and skin folds is also ok for term babies.

114. Fetal Alcohol Syndrome babies will appear with a small head circumference, low birth weight, and underdeveloped cheekbones. They may need vitamins (especially B's).

115. Pregnancy diabetes, during the first trimester, maternal insulin need decrease. During second and third trimesters, requiring an increase in the client’s insulin dose. After placental delivery, insulin requirements decrease.

116. Autosomal DOMINANT disorders :
**Marfans (prone to aneursyms, long long long people "Abe Lincoln" type folks ).
**Polydactly (too many digits)
**Achondroplastic dwarfism
** PKD polycystic kidney disease
**Huntington (doesn't show up until 40s 50s, which is why the gene is perpetuated in the gene pool because when the symptoms show up in the 40s/50s, you've probably already had kids and passed the gene along)

Autosomal Recessive
** Sickle Cell
** Cystic Fibrosis
** PKU
** Galactosemia (can't digest galactose in breast milk)

117. Spinnbarkheit: Describes the elasticity of the cervical mucus that is present at ovulation.

118. Ferning: Formation of a palm-leaf pattern by crystallization of cervical mucus as it dries at mid-cycle. Helpful in determining time of ovulation.

119. Aerocyanosis: is a bluish discoloration of the hands and feet and may be present in te first few hours after birth, but resolves as circulation improves.

120. Erythema appears: as a rash on newborns usually after 24-48 hrs of live.

121. Harlequin color results as: a vasomotor disturbance, lasting 1-20 seconds, which is transient in nature and not of clinical consequence.

122. Vernix caseosa: is a cheese like substance that protected the newborn skin while in utero.

123. Ovulation typically occurs 1to2 years after menarche.

124. To prevent anemia, females ages 10 to 55 should consume 18mg of iron daily.

125. Climacteric is the cessation of the reproductive functioning in women (menopause) and decreasing testicular action in men.

126. In Diabetic mother the newborn at risk for hypoglycemia, RDS, hypocalcemia congenital anomalies. Diabetic mother during pregnancy-1st trimester insulin DECREASE. 2 and 3rd Trimester INCREASE INSULIN (placental hormones produce insulin resistance). BUT after PLACENTAL DELIVERY INSULIN REQUIREMENTS DECREASE. Insulin is safely given throughout pregnancy; oral hypoglycemic agents are contraindicated.

MATERNITY MEDS
• Bethamethasone (celestone)=surfactant. Med for lung expansion.
• Metylergonovine- To contract uterus. before giving check BP. don’t give if vascular diseases are present.
• Terbutaline: Medication given to stop pre-term labor Methergine: Given for postpartum hemorrhage.
• Cervidil: Cervical ripening agent.
• Magnesium Sulfate: CNS depressant and Anticonvulsant = normal range 4-7.5, effective if no seizures. 4-6q IV bolus, Followed by a: 2 g/h infusion:
Magnesium Sulfate becomes toxic at levels > 8 meq/L. Respiratory arrest occurs at levels > 12 meq/L. Magnesium sulfate(used to halt preterm labor) is contraindicated if deep tendon reflexes are ineffective. If patient experiences seizure during magnesium administration. Get the baby out stat (emergency).
Adverse reactions: Inform client of these: Flushing, decrease in respiratory rate, muscle weakness. TOXICITY S/S: Absence of deep tendon reflex, Urine output < 30 ml/hour, ↓’ed LOC, respirations neural tube defects. It is not an absolute test if it is abnormal -further investigation is recommended.
• Kick counts (tests Ureteroplacental capability)
Same time every day mother records how often she feels the fetus move if minimum 3 movements are not noted within an hour's time, the mother is encouraged to call her physician immediately!
• Nonstress Test
Checks FHR and mother detects Fetal movements.
Contraction Stress Test -tests perfusion between Placenta and Uterus (basically O2 and CO2 exchange)
-IV accessed and performed in a labor and deliver unit under electronic fetal monitoring contractions initiated by Pitocin or nipple stimulation. The desired result is a "negative" test which consists of three contractions of moderate intensity in a 10 minute period without evidence of late decelerations. The test is done to detect problems so if it is Positive (persistent late decelerations) then-CS

how is done:
The electronic fetal monitor is placed on the maternal abdomen for 20-30 minutes
Each time the fetus moves, FHR should accelerate 15 beats/min above the baseline for 15 seconds. A reactive (good) test =>2 accelerations in FHR occur with associated fetal movement
• Biophysical Profile (BPP) identification of a compromised fetus and consists of 5 components:
-fetal breathing movement
-fetal movement of the body or limbs
-fetal tone (extension or flexion of the limbs)
-amniotic fluid volume index (AFI) visualized as of fluid around the fetus
-reactive non-stress test each component 0-2, 8-10-desirable.
• Percutaneous Umbilical Blood sampling -like amniocentesis but cord punctured
-chromosomal anomalies, feta karyotyping, and blood disorders

Everywhere a woman's abdomen is punctured, informed consent is needed, and risks like amnionitis, spontaneous abortion, preterm labor/delivery, and premature rupture of membranes must be explained. If she Rh--she may be given RHoGAM.

Here is a little bit on Psych for NCLEX. Hope you all like. Remember to keep those of us who havent taken it yet in your prayers.

PSYCHIATRIC

1. In psych patients, the client most at risk for self-harm is always the patient that has stopped taking their meds.

2. Hallucinations: Sensory impressions without external stimuli - Redirect patient.
Illusions: Real stimuli misinterpreted.
Delusions: False fixed beliefs. Distract the patient.

3. Bipolar Disorder
Manic Depressive
Mood elevated Anxious, hopeless
Speech loud, fast, vulgar ↓’ed interest in pleasure
Grandiose delusions negative views
Distracted Fatigue
Hyperactive ↓’ed appetite
Flight of ideas Insomnia
Inappropriate dress Suicidal

4. FIVE INTERVENTIONS FOR PSYCH PATIENTS
-safety
-setting limits
-establish trusting relationship
-meds
-least restrictive methods/environment.

5. If patients have hallucinations redirect them. In delusions distract them.

6. Language & Communication
NEOLOGISM = a new word made up that has meaning only to the patient
ECHOLALIA = repeating of words or phrases they heard someone else say
WORD SALAD = form of speech in which words & phrases are connected without any meaning
MUTISM = absence of verbal speech
CLANG ASSOCIATION = repeating of words & phrases that are similar in sound but not in any other way ( Dr. Seuss type of speech )
7. Defense Mechanisms:
Compensation = putting extra effort to achieve in areas of real or not-real weaknesses
Sublimation = replacing of an unacceptable need, attitude or emotion with one that is more accepted.
8. The adverse effects of Anti psychotics can be remembered using this: SHANCE
S-SUNLIGHT SENSITIVITY( Use hats and sunscreen)
H-HEPATOTOXICITY( Monitor LFT)
A-AGRANULOCYTOSIS( Characterized by fever and sore throat)
N-NEUROLEPTIC MALIGNANT SYNDROME( Characterized by fever and muscular rigidity)
C-CIRCULATORY PROBLEMS( Leukopenia and orthostatic hypotension)
E-EXTRA PYRAMIDAL SYMPTOMS( Administer anticholinergics and anti-parkinsonian agents)

Psychiatric emergencies
Acute alcohol intoxication

Assessment:
• Drowsiness, slurred speech, tremor, impaired thinking ,nystagmus, nausea, vomiting, hypoglycemia, increased respiration, grandiosity, loss of inhibitions, depression

Nursing diagnosis:
• Injury , risk for

Nursing :
• Quiet environment ,allow to “sleep it off”
• Monitor vital signs
• Protect airway from aspiration
• Assess for injuries

Psychiatric emergencies
Hallucinogenic drug intoxication

Assessment :
• Eye:
• red-marijuana;
• dilated-LSD, mescaline, belladonna;
• constricted-heroin and derivatives

Care plan:
1, talk down :
* keep talking ,keep eyes open
* focus on here and now, inanimate objects
* use simple, concrete , repetitive statement,
* repetitively orient to time, place
* confidentiality; don’t moralize, challenge beliefs
2. medication
* valium
* lithium
3. hospitalization: (if more than 12-18hrs)

Psychiatric emergencies
Homicidal or assaultive reaction

Cause:
* antisocial behavior, paranoid psychosis, previous violence, substance abuse, depression.

Intervention:
* physically restrain if client has a weapon
* separate from intended victims
* approach: calm and unhurried
* prevent suicidal behavior

Psychiatric emergencies
Suicidal

• suicidal ideation
• concepts and principles related to suicide
• assessment of suicide
• composite picture: male, older than 45 yrs, unemployed, divorced, living alone, depressed, history of substance abuse and suicide within family

Psychiatric emergencies----suicidal
• 10 factors to predict potential suicide and assess risk:
*age, sex and race: teenage, older age, more women make attempts, more men complete ; occurs in all races and socioeconomic groups.
*recent stress related to loss.
• clues to suicide:
* verbal clues: direct “I am going to shoot myself ”; indirect: “this is the last time you’ll ever see me”
* behavior clues: direct: pills, razor; indirect: sudden lifting of depression, buying a casket, giving away cherished belonging, writing a will.

Psychiatric emergencies----suicidal
• suicide plan: the more details, the higher risk
• previous suicidal behavior
• medical and psychiatric status
• communication: the risk reduced if the patient has talked about

Psychiatric emergencies----suicidal
• style of life: such as substance abuse
• alcohol: alcohol reinforce helpless and hopeless feeling
• resources: the fewer resources, the higher risk

Psychiatric emergencies----suicidal nursing care plan
• short-term goals
* medical : gastric lavage, respiratory and vascular support, wound care
• suicide precautions
*one to one supervision at all time
*check whereabout every 15 min
*explain to client what you will be doing, and why accompany the client for tests, procedures
*look through client’s belongs, remove any potentially harmful objects : pills, matches, belts, razors, glass, tweezers
*allow visit, but maintain one-to-one supervision
*check that visitors don’t leave potentially harmful objects
*Meal tray : contains no glass or metal silverware don’t discontinue without order

Psychiatric emergencies----suicidal
• General approaches
• Observe closely at all times
• Be available ; empathy
• Avoid : extremes in your own mood
• Focus : directly on client’s self-destructive idea
• Make a contract: no suicide within 24 hrs; or call someone
• Point out client’s self-responsibility for suicidal act
• Support the part of the client that wants to live
• Remove sources of stress : make all decision when client is severe depression

• Prove hope: problem can be solved with help
• Provide with opportunity to be useful

Psychiatric emergencies
Pseudo suicide attempts:
• Cry for help
• Desire to manipulate others
• Need attention
• Self-punishment
• Wish to punish others
• What will you do when you facing ~ ?

Crisis intervention
• definition of crisis
• Sudden event in one’s life disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem
a. maturational (internal, relate to developmental stages and associated role changes)
b. situational (external, associate with a life event )
c. adventitious (relate to a disaster)

Crisis intervention
• characteristic of crisis intervention:
a. acute, sudden onset
b. responsive to brief therapy with focus on immediate problem
c. focus shifted from the psyche in the individual to the individual in the environment; deemphasis on intrapsychic aspects
d. crisis is time limited (usually up to 6wk)

Crisis intervention nursing care plan:
• Goal:
• return to pre-crisis level
• Focus here and how

Care plan:
• Encourage expressing
• Explore past coping skill and reinforce adaptive ones
• Set limit
• Use all resource

Domestic violence

Characteristics
• 1.victims: feel helpless, powerless; blame themselves, ambivalent about leaving the relationship
• 2. abusers: often blame the victims, use power to threaten and subject victims to their assault
• 3.cycle of stages
a. buildup of tension
b. battering
c. calm

risk factors
• Learned responses
• Pregnant women and whose with one or more preschool children
• Women who Fear punishments form abuser

care plan
a. provide safe environment; refer to community resources for shelter.
b. treat physical injuries
c. document injuries
d. supportive, nonjudgmental approach
e. encourage individual and family therapy for victim and abuser.

Rape-trauma syndrome
Assessment :
• Physical trauma
• Emotional trauma: tears, hyperventilation, anxiety, self-blame, anger, fears, phobia, sleeping and eating problem.

Nursing care:
• Acknowledge feeling,
• Handle legal matters and police contact
• Medical attention
• Notify family and friends
• Remain available and supportive
• Contraception discussing
• Explore guilt and shame feeling
• Maintain confidentiality and neutrality
• Health teaching :
*avoid isolated areas and being helpful to strangers
*how to resist attack : scream , run
*Teach what to do if pregnancy or STD is outcome

Battered child
Clues in history:
• Delay in seeking medical care
• Discrepancies
• Multiple ER visits
• Vague and contradictory story

Clue in physical examination:
• Child : withdrawn, apathetic, does not cry
• Child : doesn’t turn to parents for comfort; unusual desire to please parent; fear parents
• Child: poorly nourished
• Multiple bruises, old bruises in addition to fresh one
• Burns: cigarette burs, rope marks
• Clues in parent : exaggerate care and concern

Nursing :
• Report suspected child abuse
• Conduct assessment interview in private with child and parent separated
• Be supportive and nonjudgmental

Evaluation:
• Parents have agreed to seek help

Sexual abuse children
Assessment: (characteristic)
• Relationship: filling paternal role (uncle, grandfather, cousin) with unquestioned access to the child
• Methods of pressuring victim into sexual activity: offering material good, misrepresenting moral standards (“it is ok”)
• Methods of pressuring victim to secrecy : fearing of punishment ,no being believed, rejection, being blamed for the activity, abandonment

Disclosure:
• Direct visual or verbal confrontation and observation by others
• Verbalization of act by victim
• Visible clues : excess money and candy,, new clothes, pictures
• Sings and symptoms: bed-wetting; excessive bathing ,tears, avoiding school, somatic distress
• Overly solicitous parental attitude toward child

Sexual abuse children• Child feeling:
• guilty.
• responsible for being a victim.
• powerlessness

Nursing :
• Safe environment
• Encourage child to verbalize feeling
• Observe for symptoms: phobic reaction when hearing or seeing offender; sleep pattern changes, nightmares
• Look for silent reaction

Health teaching :
* teach child that his (her) body is private
* teach family

Elder abuse
Concepts:
• Elders who are currently being abused often abused their abusers
• Victim: diminished self-esteem, feeling responsibility for the abuse, isolated
• Abuser: physical or psychosocial stressors
• Legal : most states have mandatory laws to report elder abuse

Nursing :
• Early case finding , early treatment
• Report case to law enforcement agencies
• Provide elder with phone number
• Shelter
• Self help group

Sleep disturbance

Types of sleep :
• Rapid eye movement sleep
• Non-REM sleep
• Sleep cycle (90 min)
• Adolescents spend 30% REM of total sleep time; adults : 15% ;

Nursing care:
• Obtain sleep history
• Duplicate normal bedtime rituals
• Environment : quiet , dim lights,
• Encourage daytime exercise
• Allow uninterrupted sleep cycle: 90 min
• Back rub, warm milk, relaxation
• Taper off hypnotics
• Avoid caffeine and hyperstimulation at bedtime
• What about taking a nap during daytime?

Eating Disorders

Anorexia nervosa
• Anorexia nervosa is an illness of starvation related to a severe disturbance of body image and a morbid fear of obesity; it is an eating disorder, usually seen in adolescences.

Assessment:
• Body-image disturbance
• Ambivalence: hoards food; avoids food
• Low sex drive
• Pregnancy fears
• Self-punitive behavior leading to starvation
• Physical signs:
*Weight loss
*Amenorrhea and secondary sex organ atrophy
*Hyperactivity: compulsiveness, excessive gum chewing
*Constipation
*Hypotension, bradycardia, hypothermia
*Skin: dry, poor turgor

Bulimia

• Bulimia nervosa is another type of eating disorder (binge-purge syndrome) also encountered primarily in late adolescence or early adulthood. It is characterized by at least two binge-eating episodes of large quantities of high calories food over a couple of hours followed by disparaging self-criticism and depression, self-induced vomiting, abuse of laxatives, and abuse of diuretics are commonly associated．

Eating Disorders

Analysis
• a. altered nutrition, less than body requirements, and fluid volume deficit
• b. risk for actual fluid deficit
• c. risk for self-inflicted injury
• d. altered eating
• e. body –image disturbance/chronic low self esteem
• f. compulsive behavior

Nursing care plan
• help reestablish connections between body sensations (hunger) and responses (eating).
*weigh regularly , at same time, with same amount of clothing , with back to scale
*Water drinking is avoided before weighing
*One-to-one supervision during and after mealtime to prevent attempts to vomit food
*Monitor exercise program, set limits in physical activity
• monitor physiological signs and symptoms
• health teaching
• Explain normal sexual growth and development to improve knowledge and confront sexual fear
• Behavior modification to reestablish awareness of hunger
• Teach parents skills in communication
Evaluation:
• Attains and maintains minimal normal weight for age and height
• Regular meal
• Awareness hunger, talking about being hungry
• Increase self-esteem

Most drugs especially psychotropic medications acts as CNS STIMULANTS OR CNS DEPRESSANTS. THIS strategy involves in determining which are the CNS excitations and CNS INHIBITIORS. if 3 of the options are all CNS up and 1 CNS DOWN- pick the CNS DOWN. if 3 of the options are all CNS down and 1 is CNS UP - PICK THE CNS UP.

FOR EXAMPLE.
The nurse administer WYAMINE to a client. The nurse should monitor which of the following adverse effect associated with WYAMINE.

HYPOTENSION
BRADYCARDIA
SHOCK
HYPERTENSION

THE ANSWER IS (d) HYPERTENSION BECAUSE IT IS THE ONLY ONE WITH HIGN CNS.

HERE'S A LITTLE RESPIRATORY NURSING FOR NCLEX - GOOD LUCK ALL [pic]

RESPIRATORY

1.RSV- child in private room...CONTACT PRECAUTIONS. Not droplet or airborne.

2. Elderly adults generally present with confusion rather than S/S of an illness.

3. Pneumonia- droplet precautions.

4. COPD pts should get low flow Oxygen because of the hypoxic drive. (1-3L/min) teach pursed lip breathing.

5. ARDS- this pt doesn’t respond to even 100% FiO2.

6. TB - hemoptysis (advanced stage) vital signs pulmonary edema- frothy blood tinged sputum.

7. Allen's test- done before an ABG by applying pressure to the radial artery to determine if adequate blood flow is present.
.
8. INH (Isoniazid)- treatment of TB. Give vitamin B6 to prevent peripheral neuritis.

9. SIMV mode on vents commonly used for weaning pt off ventilator.

10. Vent alarms:
A. High alarm (increased secretions then suction......, biting tube-need an oral airway,...... or coughing and anxiety- need a sedative)
B. Low alarm- there is a leak or break in system...check all connectors and cuff.

11. If a tracheostomy becomes accidentally dislodged try to replace it with an obturator..if no luck keep the hole open with hemostats until physician arrives.

12. When giving Bronchodilator & Glucocorticoids at the same time, give the bronchodilator first. Remember B before G!

13. A collection of fluid between the visceral and parietal pleura is a pleural effusion.

14. RESPIRATORS
Tidal volume is the volume of air inhaled and exhaled with a normal breath.
Inspiratory reserve volume is the maximum volume of air inspired at the end of normal inspiration.
Expiratory reserve volume is the maximum volume of air exhaled after a normal respiration.
Vital capacity is the maximum amount of air expired after maximal inspiration.
Pleurisy is an inflammation of the visceral and parietal pleura.

Mechanical Ventilators:
Can be short term, long term or in between!!! As the nurse:
1) Assess pt. first then the vent 2) assess vitals, respiratory. rate and breathing pattern 3) monitor color of lips & nail beds 4) monitor chest for symmetry 5) Assess need for suctioning & observe type, color, and amount of secretions 6) check pulse ox 7) check alarms on vent 8) empty vent tubing’s when moisture collects 9) turn pt. every 2 hours and PRN 10) have resuscitation equipment by bedside.

Causes of Alarms:
High Pressure Alarm
a) increased secretions in the airway
b) wheezing or bronchospasm
c) displaced ET tube
d) obstructed ET tube( check 4 kinks )
e) pt coughing, gagging, bites tube
f) pt. fighting vent (bucking)
Low Pressure Alarm
a) Disconnection or leak
b) Patient stops spontaneous breathing

15. TYPES OF RESPIRATIONS
Cheyne-stokes respirations: (rhythmic, with periods of apnea). May indicate a metabolic dysfunction or dysfunction in the cerebral hemisphere or basal ganglia.

Neurogenic hyperventilation(regular, rapid and deep sustained respirations). Indicates a dysfunction in the low midbrain and middle pons.

Apneustic respirations:(irregular, with pauses at the end of inspiration and expiration)
---Indicates a dysfunction in the middle or caudal pons

Ataxic Respirations: (totally irregular in rhythm and depth). Indicates a dysfunction in the medulla

Cluster respirations: (clusters of breaths with irregularly spaced pauses).. Indicates a dysfunction in the medulla and pons

16. Signs of hypoxia: restless, anxious, cyanotic tachycardia, increased respirations. (also monitor ABG's).

17. The cuff of an ET tube is for preventing aspiration and sealing the airway to prevent leaks. When the cuff deflates, aspiration is the greatest risk (due to secretions)

18. Weighted NI (Naso intestinal tubes) must float from stomach to intestine. Don't tape the tube right away after placement, may leave coiled next to patient on HOB. Position patient on RIGHT to facilitate movement through pylorus.

19. If you suspect an air embolus you must put patient in Trendenlenberg and position patient on the LEFT side because you want the air embolus to trap/dissolve/disintegrate/burst/cease to exist in the RIGHT ATRIUM.

20. Pneumonectomy- no chest tube required.

21. OXYGENATION
A. 6L Nasal Cannula is the most you can give, anything above that really doesn’t improve oxygenation. 1L NC = 24% Fi02, 2 L = 28%, 3 L = 32% …get it? Keep adding four until you get to 6L = 44% Fi02.
B. Non-rebreather give you the most Fi02, Venturi allows you to give the most precise amount, Face tent is use with facial trauma/burns
C. Incentive spirometer – tell patient to inspire, hold, get floater-thing to about 600-900 then exhale.. 10X per hour awake. Pt must be able to breathe spontaneously and make a tight seal around the mouthpiece.

22. BiPAP = CPAP and PEEP

23. ABG's is the best way to monitor pulmonary status by analyzing the level of hypoxia caused by pulmonary edema and for monitoring effects of treatment.

24. The person who hyperventilates is most likely to experience respiratory alkalosis.
25. When a pleural effusion recurs within days or weeks following a thoracentesis, this usually indicates the underlying cause is a malignancy.
26. Three lobes on the right. Two lobes on the left.
27. If you believe pt to be in respiratory distress, assess lung sounds first, LOC, retractions, skin color, etc would all be late signs.
28. KEY SIGNS/SYMPTOMS OF RESPIRATORY DISORDER
• Dyspnea
• Fatigue
• Cough
• Accessory muscle use
• Retractions
• Adventitious breath sounds: Crackles, rhonchi, wheezing, & pleural friction rub.
• Changes in mentation
• Cyanosis
29. To remember which Beta Blockers are contra-indicated in patients with Respiratory problems are easy.. Contra-Indicated- think.... Coreg, Corgard, Inderal.
30. SUCTIONING
• Encourage client to cough prior to suctioning.
• Use surgical aseptic technique when opening suction catheter kits.
• Medical aseptic technique is used for oral suctioning only. Surgical aseptic technique is used for all other types of suctioning.
• Set suction pressure to 80 to 120 mm Hg.
• Limit each suction attempt to NO LONGER THAN 10-15 SECONDS. Limit suction attempts to 2-3 times.
• Once suctioning is complete, clean tubing with water/normal saline solution.
• NASOPHARYNGEAL/NASOTRACHEAL SUCTIONING
A. Suction is performed with flexible catheter.
B. Hyperoxygenate client during equipment preparation with 100% FiO2.
C. DO NOT APPLY SUCTION WHILE INSERTING THE CATHETER.
D. Intermittent suction is only applied during catheter withdrawal, lasting no longer than 10-15 seconds.
E. Allow client time to recover between sessions, 20-30 seconds. Hyperoxygenate the client before each suctioning pass.
F. DO NOT reuse tubing.
• ENDOTRACHEAL SUCTIONING (ETS)
A. ETS performed through tracheostomy or endotracheal tube.
B. Sterility must be maintained.
C. Advance the approximate distance from nose to base of earlobe.
D. Intermittent suction is applied during catheter withdrawal lasting no longer 10-15 seconds.
E. Allow client time to recover between sessions 20-30 seconds. Hyperoxygenate client before each suctioning pass.
F. Hyperoxygenate client with 100% FiO2.
31. MECHANICAL VENTILATION
A. Assist mode: The patient initiates inspiration and receives a preset tidal volume from the machine which augments patient’s ventilator effort & lets him determine his own rate.
B. Control mode: Ventilator delivers a set tidal volume at a prescribed rate using predetermined inspiratory and expiratory times. This mode can fully regulate ventilation in a patient with paralysis or respiratory arrest.
C. Assist control mode: The patient initiates breathing and a backup control delivers a preset number of breaths at a set volume.
D. Negative pressure systems provide ventilation for patients who can’t generate adequate inspiratory pressures.
E. High-frequency ventilation (HFV) systems provide high ventilation rates with low peak airway pressures synchronized to the patient’s own inspiratory efforts.
F. NURSING INTERVENTIONS
1. Check all connections between ventilator and patient q1-2 hours. Make sure all alarms are turned on. Make sure patient can reach call bell.
2. Verify ventilator settings are correct and that ventilator is operating at those settings.
3. Check humidifier and refill as necessary.
4. Monitor fluid I&O and electrolyte balance. Monitor for stress ulcers.
5. Using sterile technique, change the humidifier, nebulizer, and ventilator tubing according to protocol.
6. Reposition patient frequently.
7. Provide emotional support to reduce stress and give antacids & medications as ordered to reduce gastric acid production and to help GI complications.
8. Check stools and NG aspirates for blood.
32. Drugs that can be given via Endotracheal tube. LANE
Lidocane
Atropine
Narcan
Epinephrine
33. When drawing an ABG, you need to put the blood in a heparinized tube, make sure there are no bubbles, put on ice immediately after drawing, with a lable indicating if the pt was on room air or how many liters of O2.
34. Remember to perform the Allen's Test prior to doing an ABG to check for sufficient blood flow
35. Before going for Pulmonary Function Tests (PFT's), a pt's bronchodilators will be with-held and they are not allowed to smoke for 4 hrs prior
36. For a lung biopsy, position pt lying on side of bed or with arms raised up on pillows over bedside table, have pt hold breath in mid-expiration, chest x-ray done immediately afterwards to check for complication of pneumothorax, sterile dressing applied

DIAGNOSTIC TEST AND PROCEDURES
BRONCHOSCOPY
• Direct visualization of the trachea and bronchial tree
• Used to obtain biopsies and deep tracheal suctioning
• Explain procedure to patient, obtain informed consent & place on chart. Without fluid and liquids.
• Check for return of gag reflex before giving anything by mouth after procedure.
• Monitor pulse oximetry.
PULMONARY ANGIOGRAPHY
• Procedure using an injection of radiopaque dye through a catheter.
• Radiographic examination of the pulmonary circulation.
• Assess patient’s allergies to iodine, seafood and radiopaque dye.
• Place written informed consent on patients chart
• Assess neurovascular status.
• Check insertion site for bleeding.
• Monitor for delayed allergic response
SPUTUM STUDIES
• Microscopic evaluation that includes culture & sensitivity, gram stain, and acid-fast bacillus
• Obtain early morning sterile specimen from suctioning or expectoration.
• Send to laboratory immediately after obtaining.
THORACENTESIS
• Surgical perforation of the chest wall and pleural space to obtain specimens, instill medication into the pleural space, remove fluid or air.
• The amount of fluid removed is limited to 1 L at a time to prevent cardiovascular collapse
• Ensure that informed consent is obtained and placed on chart.
• Apply dressing over puncture site and position client on the unaffected side for one hour.
• Encourage deep breathing to help in lung expansion.
• Obtain post procedure chest x-ray to rule out pneumothorax.
• Monitor V/S for hypotension, diaphoresis, faintness, reflex bradycardia
TUBERCULOSIS - TB
A. Lung infection caused by Mycobacterium tuberculosis
B. Any tissue can be infected.
C. Is an airborne disease caused by droplet nuclei.
D. CLINICAL MANIFESTATION:
• Night sweats
• Weight loss
• Low-grade fever, chills, flu-like symptoms
• Indigestion
• Frequent cough with copious frothy pink sputum, mucoid or mucopurulent sputum - lasts longer than 3 weeks.
E. LABORATORY
1. Positive tuberculin skin test (indicates exposure) Mantoux skin test
• Read test 48 - 72 hours after giving
• Induration of 5 mm or less, negative
• Induration of 10 mm or more indicates exposure only. Test further
2. Sputum culture
• Obtain first morning sputum for 3 consecutive days.
3. Chest X-ray
• A. Appearance of characteristic Ghon tubercle on x-ray.
• B. Shows nodular lesions and patchy infiltrates.
F. TREATMENT /NURSING INTERVENTIONS
• Antituberculotics
• IV therapy - Saline lock
• Precautions - Standard and airborne
• Activity: Bed rest.
• Place patient in a negative air pressure that has 6-12 full air exchanges per hour and is vented to the outside or has its own filtration system.
• Post precaution sign on patient’s door.
• Staff fitted for N-95 respirator masks
• Provide small frequent meals.
• Provide emotional support
• Instruct patient to cover nose and mouth when sneezing or coughing.
• Reinforce need to finish entire course of medication – 6 to 12 months.
• G. NURSING INTERVENTIONS
• Diet: High in calorie, protein, carbohydrates, vitamins
• Vitamin B6 - Potatoes, bananas, beans, seeds, nuts, red meat, poultry, fish, eggs, spinach, & fortified cereal.
• B. Vitamin C - Red berries, tomatoes, broccoli, spinach, orange and grapefruit juice, Kiwi, red & green bell pepper.
• Provide negative pressure room
• Monitor liver function test, urinary function test.
• Instruct patient to cover nose & mouth with 2-ply tissue when coughing and sneezing. Do not use bare hands.
• If patient leaves room, they must wear HEPA mask.
• Monitor I & O
• 7. After 2-4 weeks patient is usually no longer infectious.
• Tuberculosis- assessment findings: cough ( yellow mucoid sputum ) , dyspnea, hemoptysis, rales or crackles, anorexia, malaise, weight loss, afternoon low grade temperature, pallor, fatigue, pain, night sweats.
Diagnostic Tests used in TB - Chest x-ray indicates presence and extent of disease but cannot show if active or inactive. Skin test (PPD) positive; area of induration 10mm or more in diameter after 48 hrs. Sputum positive for bacillus ( 3 samples is diagnostic for TB ). Culture will be positive. WBC & ESR will be elevated. Ethambutol, Isoniazid, streptomycin, and Rifampin are first-line drugs in the treatment of TB.
• for treatment of TB and major side effects:
Rifampicin(Red-urine, tears, sweat)
INH (the N is for Neurological, H is for Hepatic)
Pyrazinamide (hyperurecimia)
Ethambutol(optic neuritis)
• The use of a multiple medication regimen destroys organisms as quickly as is possible and minimizes the emergence of medication resistant organisms.

First-line medications: Isonazid, Rifampin, Ethambutol, Streptomycin, Pyrazinamide
These provide the most effective therapy for TB.

Second-Line medications: Capreomycin, Ethionamide, Aminosalicylate sodium, Cycloserine, Kanamycin
These are used in combination with first line medications but are more toxic.

Multi-drug therapy is used because of resistant strains.
With first-line meds for TB - watch for liver function, peripheral neuritis, hepatitis, dry mouth, dizziness, hepatotoxicity, monitor CBC and blood glucose levels. Some side effect with 2nd line TB meds - nephrotoxicity, ototoxicity, neuromuscular blockade.

ANTITUBERCULOTICS
1. CYCLOSERINE
• Maximum dose is 1 gm daily.
ADVERSE REACTIONS
• Suicidal behavior, psychosis, loss of memory
• Coma, seizures.
• Hyperirritability, paresthesia.
• If taken with Isoniazid may increase risk of CNS toxicity causing dizziness or drowsiness.
D. NURSING CONSIDERATIONS
• Advise patient to avoid alcohol - increases risk for CNS toxicity.
• Give with other antituberculine drugs to prevent the development of resistant organisms.
• Monitor levels periodically for symptoms of CNS toxicity.
• Observe for psychotic symptoms.
• Monitor CBC levels and liver function tests.

2. ETHAMBUTOL - (Etibi, Myambutol)
• 0.5 to 1 gm daily
• Not given in children under the age of 13.
ADVERSE REACTIONS
• Headache, dizziness, confusion
• Optic neuritis - Causes red/green color discrimination. If this develops discontinue drug
• Joint pain.
D. NURSING CONSIDERATIONS
• Perform baseline visual acuity test and color discrimination test during therapy
• Monitor uric acid levels and for symptoms of gout.
• Give one hour before or two hours after antacids containing aluminum because they reduce absorption.
• Obtain AST and ALT levels before therapy and monitor every 3-4 weeks.
• Give drug with other antitubuculotics.
• Monitor uric acid levels; observe patient for signs and symptoms of gout.

3. ISONIAZID -( Isotamine, Nydrazid)
• Up to 300 mg daily.
• Drug of choice.
• Continued for 6 months to 18 months.
• Not for use with children under age of 15.
• Continued for 6 months up to 18 months.
F.. ADVERSE REACTIONS
• Toxic encephalopathy. Seizures.
• Optic neuritis
• Nausea, vomiting, epigastric distress.
• Hepatitis. Jaundice.
• Rheumatic and lupus-like symptoms
G. NURSING CONSIDERATIONS
• 1. Advise patient that antacids and laxatives containing aluminum may decrease absorption. Give at least one hour before antacids or laxatives.
• Demerol may increase CNS adverse reactions and hypotension. Monitor for toxicity
• If given with Rifampin monitor liver function tests. May increase risks for hepatotoxicity.
• Advise that foods containing tyramine - Beer, aged cheese, chocolate, sauerkraut, soy sauce, tofu, teriyaki sauce, avocados, eggplant, fruit - figs, oranges, raisins, plums, pineapple, prunes may cause hypertensive crisis. Advise patient to avoid such foods. Clients who are taking INH should avoid tuna, red wine, soy sauce, and yeast extracts because of the side effects that can occur, such as headaches and hypotension
• Monitor for hepatitis and liver function tests. Severe hepatitis may develop. S/S: fever, jaundice, right upper quadrant abdominal pain.
• Advise to take drug one hour before or 2 hours after meal.
• Give pyridoxine to prevent peripheral neuropathy.
• Increase intake of vitamin B-6 - potatoes, bananas, beans, seeds, nuts, red meat, poultry, eggs, spinach and fortified cereals.
• Always give with another antituberculotic.
• Patients receiving Isoniazid should be questioned about numbness, tingling, paraesthesias, and feeling of heaviness in the arms and legs as this may indicate the development of peripheral neuropathy.
• Should be taken on an empty stomach.
• Vitamin B6 (pyridoxine) is used to prevent toxicity from isonizid.
• Monitor for neurotoxicity.

4. RIFAMPIN- (Rifadin, Rimactane,Rimycin, Rofac)
• Up to 600 mg daily.
• Give one hour before or 2 hours after meal with full glass of water
• Give with at least one other antituberculotic.
• Liver abnormalities are most common side effect. Symptoms that may indicate liver dysfunction are: anorexia, malaise, jaundice, change in stools.
• If given with Isoniazid, may increase risks for hepatotoxicity.
• If patient drinks alcohol this increases risks for hepatotoxicity.
NURSING CONSIDERATIONS
• Monitor liver function tests and CBC
• Alert patient that body fluids (sweat, tears, urine, feces) may turn orange-Red
• Advise patients taking oral contraceptives, anticoagulants, oral hypoglycemic agents, or steroids that absorption is decreased. Advise with patient taking oral contraceptives the need for alternative methods for birth control.
• Give one hour before or 2 hours after a meal.
• Advise against use of alcohol.

5. STREPTOMYCIN
• Maximum dose 3 g/daily.
• Streptomycin is also an aminoglycoside.
• Second line of treatment for tuberculosis.
• Causes ototoxicity and nephrotoxicity. Monitor hearing ability and renal function.
• Monitor patient’s hearing and kidney function before starting therapy.
• Causes 8th cranial nerve damage (acoustic nerve - hearing)
• Use gloves when preparing drug to prevent skin irritation.
• Do not use a heparinized tube; heparin is incompatible with streptomycin and other aminoglycosides.
• NURSING CONSIDERATIONS
• Monitor fluid intake. Fluids should be increased 2.5 to 3 liters/day.
• Monitor for tinnitus, vertigo, deafness, renal function test - BUN, creatinine
• If patient on Lasix or other antidiuretics monitor for ototoxicity - increases risks for ototoxicity.
• Protect hands when preparing drug.
• Alternate injection sites.
• Monitor for signs of super-infection: Continued fever, chills, increased pulse rate.
• 7. Offer small frequent meals and maintain bed rest.
• 6. To decrease the development of drug resistance, newer drugs contain a combination of Rifampin and Isoniazid (rifamate) or Rifampin, Isoniazid and pyrazinamid (rifater). Drug non-compliance is a major contributing factor in the development of resistant strains of TB.

PNEUMONIA
A. Inflammatory process that produces excess fluid .
B. With pneumonia, you will hear BRONCHIAL sounds in areas of consolidation.
C. Two types of pneumonia.
• Community acquired pneumonia - Often a complication of influenza.
• Hospital acquired pneumonia - AKA nonsocomial pneumonia. High mortality rate, more likely to be resistant to antibiotics.
D. SIGNS AND SYMPTOMS
Viral
• Low grade fever
• Nonproductive cough
• WBC normal to slightly high
• Less severe than bacterial pneumonia.
Bacterial
• High fever
• Productive cough
• WBC high
• More severe than viral pneumonia.
• Crackles/wheezes
E. NURSING INTERVENTIONS
• Administer medications as ordered: Penicillin’s and cephalosporin’s, bronchodilators, steroids. Prednisone suppresses immunity!
• Obtain sputum culture before starting antibiotics
• 1. Rusty, green or bloody - Pneumococcal pneumonia.
• 2. Yellow-Green - Bronchopneumonia.
• For steroids monitor for side effects of immunosuppression, fluid retention, hyperglycemia, poor wound healing. Steroids increase blood sugar and weaken immune system. Always taper steroids if taking chronically --> never stop abruptly!
• Administer heated and humidified oxygen.
• Position high fowler’s
• Encourage coughing and deep breathing and suction
• Teach importance of flu vaccinations
• Monitor for complications o ATELECTASIS: Collapse of lung. Diminished or absent breath sounds over affected area. o ACUTE RESPIRATORY FAILURE (ARDS): Persistent hypoxemia. Monitor O2 levels and acid/base balance. Prepare for intubation and mechanical ventilation (PEEP). Cardinal sign of ARDS is hypoxemia (low oxygen level in tissues). o SEPSIS (Bacteremia) o ARDS (fluids in alveoli), DIC (disseminated intravascular coagulaton) are always secondary to something else (another disease process).
• Provide rest periods.
• Increase fluids, 3-4 L/day.
• Diet: High calorie, high protein.
• With pneumonia, fever and chills are usually present. For the elderly confusion is often present.

COPD
COPD is a group of diseases that results in persistent obstruction of the bronchial airflow.
Disease include:
Emphysema
• Stimulus to breathe is low partial pressure of arterial oxygen (PaO2). PaO2 measures oxygen in the blood.
• Characterized by loss of lung elasticity and hyperinflation of lung tissue.
Asthma
• A chronic inflammatory disorder of the airways.
• Characterized by airflow obstruction and airway hyper-responsiveness to various stimuli.
Bronchiectasis
• Chronic dilation of the bronchi and bronchioles.
• Infection destroys the bronchial mucosa which is replaced by fibrous scar tissue.
Chronic bronchitis
• Chronic inflammation of the lower respiratory tract characterized by excessive mucous section, cough, and dyspnea associated with recurrent infections of the lower respiratory tract.
• Excessive bronchial mucous production causes chronic or recurrent productive cough.
SIGNS AND SYMPTOMS
• Productive cough and sputum production lasting at least 3 months a year for 2 successive years.
• Barrel chest - due to air trapping with diaphragmatic flattening.
• Exertional dyspnea.
• D. Wheezes, crackles
• E. Use of accessory muscles.
• COPD is chronic, pneumonia is acute. Emphysema and bronchitis are both COPD.
• In COPD patients, the baroreceptors that detect the CO2 level are destroyed. Therefore, O2 level must be low because high O2 concentration blows the patient’s stimulus for breathing.

NURSING INTERVENTIONS
• Position client for maximum ventilation - high fowler’s.
• Administer medications:
• Short acting Beta2 agonists: Albuterol (proventil, ventolin) provide rapid relief.
• If patient is also using a corticosteroid inhaler, instruct them to use the
• Bronchodilator first and then wait 5 minutes before using the corticosteroid. This lets the bronchodilator open the air passages for maximum effectiveness.
• Anti-inflammatories: Decreases airway inflammation (Corticosteroids - Fluticasone (flovent) and prednisone). Monitor for serious side effects - immunosuppression, fluid retention, hyperglycemia, poor wound healing.
• Administer heated and humidified oxygen. Monitor for skin breakdown.
• Instruct patient on pursed lip breathing and diaphragmatic breathing.
• Diet: High in protein, carbohydrates, vitamin C, calories - small frequent meals.
• Encourage/Force fluids - 3000 ml/day.
• Oxygen therapy - 2-3 liters/minute. o DO NOT GIVE OXYGEN AT 100% TO PATIENTS WITH COPD because you can depress the respiratory center drive. In COPD patient’s the drive to breathe is hypoxemia.
• Nebulizer treatments should be given before meals to improve lung ventilation and reduce fatigue that accompanies eating.
• Reinforce pursed lip breathing to prolong expiration and to increase airway pressure.

PNEUMOTHORAX
A. Collapse of the lung due to loss of negative intrapleural pressure.
B. Air accumulation in the pleural space.
C. SIGNS AND SYMPTOMS
• Dyspnea. Tachycardia, tachypnea
• Subcutaneous emphysema
• Tracheal deviation to the unaffected side.
• Diminished breath sounds on the affected side and tension pneumothorax.
• Unequal chest expansion (is reduced on the affected side).
• Crepitus over the chest.
• Restlessness, anxiety
• Unequal chest expansion
• Signs of mediastinal shift.
D. MANAGEMENT
• O2 Therapy
• Needle decompression (tension pneumothorax).
• Insertion of chest tube to water seal drainage.
• Laboratory ABG values
• Position high Fowler’s
• Analgesic: Tylox
• Insertion of large bore needle into the 2nd intercostal space may be done to alleviate pressure before chest tube insertion with a tension pneumothorax.
E. NURSING INTERVENTIONS
• Assess respiratory status
• Administer oxygen
• Keep patient in high Fowler’s
• Monitor and record chest tube drainage, air leak, or subcutaneous emphysema, and labs.
• Document ventilator settings every hour.
• Monitor ABG’s, V/S, SaO2
F. MEDICATIONS
1. Lorazepam (Ativan) & Midazolam (Versed)
• Keep emergency oxygen & resuscitation equipment available.
• Monitor respirations every 5 to 15 minutes and before each IV dose.
• Refrigerate intact vials and keep from sunlight.
• Monitor for hypoventilation and hypotension

LARYNGECTOMY
A. Temporary or permanent artificial airway.
B. Partial laryngectomy: Surgical excision of a lesion on one vocal cord.
C. Total laryngectomy: Surgical removal of the larynx, hyoid bone, and tracheal rings with closure of the pharynx and formation of a permanent tracheostomy.
D. NURSING INTERVENTIONS
• Establish methods of communication: Writing, call bell, “magic slate”, and picture board.
• Maintain aseptic conditions when suctioning or cleaning tracheostomy.
• Advise clients with total laryngectomies they will lose their natural voice.
• Keep tracheostomy tube obturator at head of bed for reinsertion in case of accidental dislodgement.
• Encourage the patient to express their feelings about changes in their body and loss of their voice.
• Assess pain level, administer medications.
• Observe for hemorrhage.
• Keep a spare unused tracheostomy tube at bedside for emergency use.
• Encourage turning, coughing, deep breathing and use of incentive spirometer.
• Keep patient in semi-Fowler’s
• Assess color, amount, and consistency of sputum.
• Demonstrate ways to prevent debris from entering the stoma.
• Use thickened liquids, cut food into small pieces, and provide food that can be formed into a bolus.
• Trach balloon should be inflated any time there is any risk of pt aspirating (ie eating, increased secretions, when getting tube feeds, on vent, and 30 min after eating).
• When changing trach ties, remove old ties with non-sterile gloves, then put on sterile gloves to apply clean ties.
• If pt coughs/respiratory distress while putting in NG, pull back and wait until coughing/respiratory. Distress is resolved then attempt again. Remember pt should be in High Fowlers, when tube reaches oropharynx., neck must be flexed to cover airway and swallow sips of h20 to facilitate tube).
• If a tracheostomy tube falls out, replace it immediately (maintain airway) then check for breath sounds.

RADICAL NECK DISSECTION
1. Removal of all tissue under the skin from the ramus of the jaw down to the clavicle, from midline back to the angle of the jaw.
2. Surgical excision of the sternocleidomastoid and omohyoid muscles, muscles of the floor of the mouth, submaxillary gland, internal jugular vein, external carotid artery, and cervical chain of lymph nodes, in addition to laryngectomy.
NURSING INTERVENTIONS
• Assess for respiratory compromise – dyspnea, cyanosis, edema, dysphagia, hoarseness.
• Auscultate for decreased breath sounds, crackles, and wheezes.
• In the immediate post-op state, Auscultate over the trachea to assess for stridor indicative of edema.
• Assess vital signs, s/s of infection. Observe patient for hemorrhage.
• Keep emergency suctioning and airway equipment at bedside during meals.
• Ask if patient would prefer privacy during meals.
• Place call bell and other articles that patient may need within easy access.
• Observe for lower facial paralysis which may indicate facial nerve injury.
• Watch for shoulder dysfunction which may occur after surgery.
• Keep patient high Fowlers.
• Advise patient against swimming, showers and using aerosol sprays.
LUNG RESECTION
A. Lobectomy – Surgical removal of one lobe of the lung
B. Wedge resection – surgical removal of a wedge-shaped section of a lobe.
C. Pneumonectomy – Surgical removal of a lung.
D. NURSING INTERVENTIONS
• Maintain patient’s positioning.
1. Pneumonectomy: On back or side of surgery until stabilized.
2. Lobectomy or wedge resection: On back or side opposite surgery.
• Assess chest tube insertion for subcutaneous air & drainage.
• Reinforce turn, cough, and deep breathing, use of incentive spirometer.
• Provide suction, chest physiotherapy and postural drainage.
• Pneumonectomy usually does have a chest tube in order to let fluid collect in the lung space.
• Assess pain level, administer medication, and check effectiveness.
• Administer O2 and maintain ET tube to ventilator.
• Monitor V/S, I & O, labs, ECG.
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, shock lung)
A. Respiratory failure that occurs in critically ill patients.
B. Persistent hypoxemia. Monitor O2 levels and acid/base balance. Prepare for intubation and mechanical ventilation (PEEP). Cardinal sign of ARDS is hypoxemia (low oxygen level in tissues).
C. Lung injury causes platelets to aggregate. Alveoli collapse impairing gas exchange.
D. Oxygen and carbon dioxide levels in the blood decrease
E. Metabolic acidosis results.
F. SIGNS AND SYMPTOMS
• Dyspnea, tachypnea, tachycardia, cyanosis, and hypotension.
• Intercostal and substernal retractions
• Cough
• Crackles/rhonchi
• Anxiety
• Restlessness, altered LOC
• Decreased breath sounds
G. NURSING INTERVENTIONS
• Oxygen therapy. Intubation and mechanical ventilation using PEEP (positive end expiratory pressure). Monitor mechanical ventilation.
• Monitor V/S, I&O, CVP, ECG, etc.
• DIET: RESTRICT FLUID INTAKE
• Position: High Fowler’s
• Activity: Bed rest
• DVT prophylaxis
• Administer TPN
• Weigh patient daily
• Allow patient to express feelings.
H. MEDICATIONS
• Antibiotics: Amoxicillin (Amoxil), ampicillin (Omnipen)
• Analgesics: Morphine
• Diuretics: Lasix (furosemide), Edecrin (Ethacrynic acid)
• Anticoagulant: Heparin
• Steroids: Hydrocortisone (Solu-Cortef), solu-medrol
• Antacid: Aluminum hydroxide gel (AmternaGel)
• Sedative: Lorazepam (Ativan)
• Neuromuscular blocking agents: Pancuronium (Pavulon) Vecuronium (Norcuron)
• Mucosal barrier fortifier: Sucralfate (Carafate).
BRONCHIECTASIS
A. Chronic cough that produces copious, foul-smelling, mucopurulent sections, possibly totaling several cupfuls a day.
B. Is marked by chronic abnormal dilation of bronchi (large air passages of the lungs) and destruction of the bronchial walls.
C. It is an irreversible condition.
D. SIGNS/SYMPTOMS
• Chronic persistent cough that produces copious amounts of purulent foul smelling sputum.
• Course crackles during inspiration.
• Dyspnea, wheezes.
• Weight loss.
• Recurrent fever and bouts of pulmonary infection.
• Intermittent hemoptysis and breathlessness.
• Finger clubbing.
E. NURSING INTERVENTIONS
• Perform chest physiotherapy including postural drainage and chest percussion several times a day. BEST TO PERFORM IN EARLY AM or just before bedtime.
• Encourage increased fluids.
• Instruct patient to avoid noxious fumes, dust, smoke and other pulmonary irritants
• Teach patient to monitor sputum. Report if change in quantity or character occurs.
• Encourage regular dental care because copious sputum may affect dentition.
• Administer medications: Antibiotics and bronchodilators.
ASTHMA
A. A chronic reactive airway disorder that causes episodic, reversible airway obstruction with bronchospasm, increased mucous secretion and mucosal edema.
B. An airway disorder characterized by airflow obstruction and airway hyperresponsiveness to various stimuli.
C. Two forms of asthma
1. Extrinsic (atopic): caused by sensitivity to a specific external allergen (pollen, dust, dander, food additives).
2. Intrinsic (nonatopic): Caused by reaction to internal non-allergic factors. (Endocrine changes, noxious fumes, respiratory infections, stress, humidity/temp)
D. SIGNS AND SYMPTOMS
• Absent or diminished breath sounds during severe obstruction.
• Chest tightness
• Dyspnea, tachypnea, tachycardia, prolonged expiration.
• Productive cough with thick mucus.
• Lack of symptoms between attacks.
• Wheezes primarily on expiration but also sometimes on inspiration.
E. NURSING INTERVENTIONS
• Take appropriate measures to maintain airway, relieve bronchoconstriction.
• Administer low flow humidified O2 to reduce inflammation, ease breathing and increase SaO2.
• Administer medications
1. Bronchodilators: Terbutaline (Brethine), Aminophylline, Theophylline (Theo-Dur) Theophylline: therapeutic drug level: 10-20. via a metered dose inhaler
2. Steroids: hydrocortisone (Solu-Cortef), methylprednisolone (Solu-Medrol)
3. Beta-adrenergic drugs: Epinephrine (Adrenalin), salmeterol (Serevent)
4. Antacids
5. Antibiotics
• Auscultate lungs for improved breath sounds and effectiveness of therapy.
• Activity as tolerated.
• Keep patient in high Fowlers.
• Encourage fluids.
• Monitor and record color, amount, and consistency of sputum.
• Monitor V/S. Tachycardia may indicate worsening asthma or drug toxicity.
• Teach proper use of inhaler and taking medications correctly.
• Teach pursed lip & diaphragmatic breathing.
• Increase fluid intake to 3 qts (3L) a day.
FLAIL CHEST
A. Flail Chest= Fracture of 2 or more adjacent ribs with paradoxical movement of chest during respiration.
B. Loss of stability of the chest wall as a result of multiple rib fractures, or combined rib and sternum fractures.
C. During respiration, the detached part of the chest will be pulled in on respiration and blown out on expiration (paradoxical movement).
D. It is accompanied by severe respiratory distress.
E. Associated with lung contusion, lung laceration, and diffuse alveolar damage.
F. SIGNS AND SYMPTOMS
• Paradoxical movement of the chest
• Increased respiratory effort, pain on inspiration
• Cyanosis
• Dyspnea
G. NURSING INTERVENTIONS
• Stabilize the flail portion of the chest with hands, apply pressure dressing and turn on injured side or place a 10 lb sandbag on flail portion.
• Prepare for ET insertion and mechanical ventilation.
• Position semi-Fowler’s unless patient requires shock position.
• Analgesic: Morphine.
• Mechanical ventilation using positive pressure.
TENSION PNEUMOTHORAX
A. Occurs when air enters the pleural space during inspiration and is trapped there.
B. The increase in pressure compresses the blood vessels and limits venous return, leading to a decrease in cardiac output.
C. Relief of tension pneumothorax is considered as a medical emergency.
D. Can be converted to a simple pneumothorax by insertion of a large bore needle into the pleural space which relieves the pressure and vents the air trapped to the outside.
E. SIGNS AND SYMPTOMS
• Air hunger
• Agitation, hypotension, and cyanosis
• Asymmetrical lung expansion and tracheal deviation to the affected side.
• Cyanosis.
• Subcutaneous emphysema.
• Jugular vein distention.
F. Immediate thoracentesis is done to relieve positive pressure or tension in the lung.
CARDIAC TAMPONADE
A. Compression of the heart as a result of fluid within the pericardial sac that is usually caused by blunt or penetrating trauma to the chest.
B. SIGNS AND SYMPTOMS
• Falling blood pressure
• Distended jugular veins elevated CVP.
• Muffled heart sounds from impaired diastolic filling of the heart.
• Pulsus paradoxus (audible blood pressure fluctuation with respiration). Systolic blood pressure drops and fluctuates with respiration.
• Dyspnea, cyanosis, and shock.
• Patient may be anxious, confused and restless.
• Dyspnea, tachypnea, and precordial pain.
C. BECK’S TRIAD - 3 D’s of cardiac tamponade
• D = DISTANT HEART SOUND
• D = DECREASED BLOOD PRESSURE
• D = DISTENDED JUGULAR VEIN
D. TREATMENT
• Thoracotomy
• Pericardiocentesis – needle aspiration of fluid from the pericardium.
COR PULMONALE
A. Is the enlargement of the right ventricle that results from diseases affecting the function or the structure of the lungs. It is heart disease caused by lung disease.
B. A condition that deprives the lungs of oxygen.
C. SIGNS AND SYMPTOMS
• Increasing dyspnea and fatigue, orthopnea, paroxysmal nocturnal dyspnea.
• Distended jugular veins, peripheral edema, hepatomegaly.
• Bibasilar crackles, split second heart sound on auscultation.
• Edema of the feet and legs.
• Ascites.
• Chronic productive cough.
D. NURSING INTERVENTIONS
• Diet: Low salt with restricted fluid intake to prevent fluid retention. Provide small, frequent feedings rather than three heavy meals.
• Limit patient’s fluid intake to 1-2 qt (1-2 l/day).
• Monitor serum potassium levels. Low levels can increase risk of toxicity.
• Teach the patient to take radial pulse before taking a cardiac glycoside & to report any changes.
• Monitor Digoxin levels to prevent symptoms of cardiac glycoside toxicity (anorexia, nausea, vomiting, and yellow halos around visual images).
• Provide meticulous respiratory care, and teach pursed lip breathing.
• Monitor ABG levels.
• Avoid CNS depressants (opiods, hypnotics).
E. MEDICATIONS
• Diuretics to lower PAP by reducing total blood volume and excess fluid in lungs. Lasix (furosemide)
• Angiotension converting enzyme inhibitor – captopril (Capoten)
• Calcium channel blockers: diltiazem (Cardizem)
• Vasodilators: Diazoxide (Hyperstat), hydralazine (Apresoline), Nitroprusside (Nitropress),
PLEURAL EFFUSION & EMPYEMA
A. Pleural effusion is an excess of fluid in the pleural space.
B. Empyema is the accumulation of pus and necrotic tissue in the pleural space.
C. Pleural effusion is almost always secondary to other diseases.
D. Empyema is usually associated with infection in the pleural space.
E. SIGNS AND SYMPTOMS
• Dyspnea, pleuritic chest pain, dry cough.
• Dullness or flatness to percussion (over areas of fluid) with decreased or absent breath sounds. Decreased chest motion.
• Pleural friction rub.
• Tachycardia and tachypnea.
F. NURSING INTERVENTIONS
• Administer oxygen as ordered.
• Provide meticulous chest tube care using sterile technique for empyema. Record amount, color, and consistency of tube drainage.
• Observe patient’s breathing pattern, O2 sats, and other vital signs.
• Ensure chest tube patency by watching for bubbles in the underwater seal chamber to prevent respiratory distress resulting from chest tube obstruction.
PNEUMOCYSTIS CARINII PNEUMONIA
A. Part of the normal flora in most healthy people.
B. Pneumocystis carinii pneumonia (PCP) is an opportunistic infection strongly associated with HIV infection. Also seen in other immunocompromised patient’s – leukemic patients, cancer, organ transplants, and lymphoma.
C. SIGNS AND SYMPTOMS
• Generalized fatigue
• Low-grade, intermittent fever
• Nonproductive cough
• Shortness of breath, tachypnea. Progresses to intercostal retractions, nasal flaring and cyanosis
• Weight loss
• Insidious onset
D. NURSING INTERVENTIONS
• Assess respiratory status frequently and monitor ABG levels q4h.
• O2 therapy prn and ambulate. Deep breathing and incentive spirometry to facilitate effective gas exchange.
• Administer medications
A. Antipyretics as required.
B. Antibiotics: Co-trimoxamole (Bactrim), Clindomycin (Cleocin) with primoquine. Pentamidine.
1. If patient is receiving Bactrim watch for nausea, vomiting, rash, bone marrow suppression, thrush, fever, hepatotoxicity and anaphylaxis.
2. Never give pentamidine IM because it can cause pain and sterile abscesses. Administer the IV drug form slowly over 60 minutes to reduce the risk of hypotension.
3. If patient is receiving pentamidine monitor for hypotension, cardiac arrhythmias, dizziness, azotemia (abnormal increase in urea in blood), hypocalcemia and hepatic disturbances. These measures detect problems early to avoid crisis.
• Diet: High calorie, protein rich diet. Offer small frequent meals. Allow ample time for meals to reduce anxiety.
• Provide a relaxing environment, eliminate excessive environmental stimuli.

NEUROSENSORY SYSTEM

PARKINSON’S DISEASE
1. A progressive degenerative disease of the CNS system associated with Dopamine deficiency.
2. The lack of Dopamine impairs the area of the brain responsible for control of voluntary movement.
3. SIGNS AND SYMPTOMS
· Pill rolling tremors at rest
· Mask-like facial expression.
· Shuffling gait, dyskinesia, cogwheel rigidity, stopped posture.
• Small handwriting.
• Bradykinesia (slowness of movement)
· Nonexistent arm swing.
4.MANAGEMENT
A. Anticholinergics: To reduce transmission of cholinergic pathways. Effective in controlling tremor but causes confusion and hallucinations.
• Are more likely to cause mental problems in older patients.
• Are contraindicated in patients with glaucoma.
B.DRUGS: Artane,
A. Congentin (benztropine) – Toxic psychosis. Advise patient to avoid hot weather because of drug induced lack of sweating may cause overheating.
• Never stop drug abruptly. Reduce dosage gradually.
B. Amantadine (symmetrel)
• Increases the release of dopamine in the brain.
• Monitor for mental status changes and suicidal tendencies. Drug can worsen mental problems in patients with mental disorders.
C. Levodopa (larodopa)
• Used when other drugs cannot adequately relieve symptoms.
• Use cautiously in patients with heart disease, asthma, emphysema, glaucoma.
· Monitor for psychiatric disturbances: Dementia, hallucinations, suicide ideation, mood changes, delirium, depression.
• May cause blepharospasm – eye twitching. Early sign of toxicity.
• Antacids may decrease absorption. Give antacids 1 hour before or 2 hours after levodopa.
D. Pyridoxine (vitamin B6) may decrease the effectiveness of levodopa. Teach patient to avoid vitamins and foods high in B6.
• Advise patient to take with food to lessen GI symptoms. Avoid high protein foods.
· Advise patient and caregivers that multivitamins, fortified cereals and certain over the counter drugs may contain vitamin B6.
· Levodopa-carbidopa (sinemet) (Parcopa)
• Drug combination
• May cause suicidal tendencies.
· Do not give with iron salts. Give iron one hour before or 2 hours after sinemet.
· Do not give with MAO inhibitors – may cause severe hypertension.
• Teach patient to avoid foods high in protein. Don’t give levodopa with high protein foods.
• If patient takes levodopa, stop drug at least 8 hours before starting levodopa-carbidopa.
E. NURSING INTERVENTIONS
• Encourage patient to participate in daily exercise, stretching exercises.
• Instruct patient to use a broad-based gait. Reinforce gait training to improve mobility.
• Have patient make a conscious effort to swing arms while walking.
• Instruct patient to chew slowly.
• Monitor V/S, monitor for hypotension.
• Instruct patient to rise slowly out of bed and chair.
· TEACH PATIENT TO AVOID VITAMIN B6 PREPARATIONS AND FOODS HIGH IN B6. Eat high fiber foods.
· Teach patient to adhere to medication regimen and to not stop taking medications abruptly.
• Teach client and family for malnutrition, fall precautions and environmental hazards.

MULTIPLE SCLEROSIS
1. A progressive disease that destroys myelin in the neurons of the brain and spinal cord.
2. Degeneration of the myelin sheath results in patches of sclerotic tissue and impairs the ability of the nervous system to conduct motor nerve impulses.
3. There is no known cure for the disease.
4. Is characterized by exacerbations and remissions
5. SIGNS AND SYMPTOMS
• Fatigue and weakness.
• Abnormal reflexes – absent or exaggerated.
• Vision disturbances: Double vision, blurred, optic neuritis and nystagmus.
• Scanning speech
• Urinary and bowel disturbances. Frequency, urgency, incontinence. Frequent urinary infections.
• Intolerance to heat.
• Mood swings, irritability.
• Intention tremor
• Inability to sense of gauge body position.
6. MANAGEMENT
• Overall goal of care is to maintain as much independent function as possible.
• Include rest periods to prevent fatigue which exacerbates the symptoms.
• Maintain a fluid intake of 2,000 ml/day to maintain bladder and bowel function and to prevent impaction and urinary tract infection.
• Avoid sources of infection: Illness can act as a stressor and trigger an exacerbation.
• Advise patient on avoiding extreme temperatures which exacerbates acteric.
7. MEDICATIONS:
• Corticosteroids are used to decrease inflammation, shorten duration of relapse or exacerbation
· Prednisone (Deltasone)
A. Cause the kidney to retain sodium and water while promoting potassium loss.
B. Can cause edema and hypokalemia.
C. Monitor for hyperglycemia, hypokalemia, carbohydrate intolerance, growth suppression in children, delayed wound healing, acute adrenal insufficiency.
D. Advise against abrupt withdrawal of drug – may cause rebound inflammation, fatigue, weakness, dizziness, lethargy, depression. After prolonged use, abrupt stoppage can be fatal.
E. If taking with anticoagulants monitor PT and INR.
F. Use cautiously in patient with GI ulcer, renal disease, diabetes, hypertension, ulcerative colitis, recent MI, myasthenia gravis.
G. Give with food.
H. Diabetic may need insulin dose increased.
I. Monitor for infections. Decreases immunity.

· Interferon – Beta-1a (Avonex, Rebif) & Beta-1b (betaseron)
A. Beta interferons are derived from fibroblasts (connective tissue cells)
B. Monitor for blood toxicity- WBC, platelet count, liver function test,
C. Monitor patient closely for depression and suicidal ideation.
D. Use drug as soon as possible but must be used within 6 hours of reconstituting. Store at 36-46 degrees. Do not freeze.
E. Rotate sites of injection.
F. Inform patient that drug causes flu-like symptoms – fever, fatigue, muscle fatigue, aches, headaches, chills and joint pain occur as a side effect.
G. Advise patient to use sunscreen and avoid sun exposure.
H. Beta-1b can cause serious liver damage including liver failure requiring transplant. Monitor liver function test.
I. Inject immediately after preparing.
J. Advise patient to report signs of tissue death.

· CYCLOPHOSPHAMIDE – (Cycloblastin, Cytoxan, Endoxan, Neosar, Procytox) – SEE ONCOLOGY FOR DRUG

MYASTHENIA GRAVIS
1. Myasthenia gravis means “grave muscle weakness”.
2. A chronic progressive disorder of the peripheral nervous system affecting transmission of nerve impulses to voluntary muscles. Causes muscle weakness and fatigue that increases with exertion and improves with rest. Eventually leads to fatigue without relief from rest.
3. Onset is usually slow but can be precipitated by emotional stress, hormonal disturbances, infection, vaccinations, trauma, surgery, temperature extremes, excessive exercise, etc.
4. Myasthenia Gravis: worsens with exercise and improves with rest.
5. Myesthenia gravis is caused by a disorder in the transmission of impulses from nerve to muscle cell.
6. SIGNS AND SYMPTOMS
• Extreme muscular weakness and fatigue that decreases with rest.
• Vision disturbances: Diplopia and ptosis from ocular weakness.
• Facial muscle weakness that causes a masklike appearance.
• Dysarthria and dysphagia.
• Hanging jaw.
• Bobbing motion of the head.
• Respiratory failure.
7.DIAGNOSIS: Tensilon test. IV administration of Tensilon which allows acetylcholine to bind with its receptors which improves the symptoms of myasthenia gravis.
· Tensilon (edrophonium) also differentiates myasthenic gravis crisis from cholinergic crisis.
• In cholinergic crisis, symptoms worsen with tensilon.
• Tensilon (edrophonium) is used only for diagnostic purposes to determine whether muscular weakness is due to worsening of the disease (myasthenic crisis) or to overmedication (cholinergic crisis)
• When edrophonium is used, keep suction equipment, oxygen, mechanical ventilation and emergency drugs – atropine at bedside
8. TREATMENT:
A. ANTI-CHOLINESTERASES:
• Neostigmin (prostigmin), Pyridostigmin (Mestinon): Counteracts fatigue and muscle weakness. Promotes muscular contractions
• Anticholinesterase drugs are not effective during a myasthenic crisis so they are discontinued until respiratory function improves.
• Take with food to decrease GI symptoms.
• Advise patient to eat within 30 minutes of taking drug to strengthen chewing and reduce aspiration risk.
• Advise patient to take drug at same time every day, not to miss a dose.
· Schedule patient’s diagnostic studies around medication schedule. If patient must be off unit when drugs are to be administered, take the medication to the patient
• Observe for nausea, vomiting, cramps, facial muscle twitching and dyspnea – may indicate toxicity.
· Avoid morphine and its derivatives, curare, quinine, mycin antibiotics and drugs containing magnesium. These reduce cholinergic effects.
· Corticosteroids reduce the effects of drug, monitor patient closely.
1. IMMUNOSUPPRESSANTS (Corticosteroids)
A. Azathioprine (Imuran)
• Decrease dosage of Imuran if patient is also taking Allopurinol because it inactivates Imuran.
• Watch for clay-colored stools, dark urine, jaundice – HEPATOTOXICITY
• Monitor liver function test, WBC and CBC.
• Give after meals to minimize GI effects.
• Avoid giving IM injections if platelet count below 100,000.
• Warn patients to report even mild infections – cold, fever, sore throat, malaise because drug is a potent immunosuppressant.
• Warn patient hair may lose hair and thin.
• Cyclosphoshamide (Cytoxan) – SEE ONCOLOGY FOR MORE
• Don’t give drug at bedtime; infrequent urination during the night may increase possibility of cystitis. Test urine for blood.. Hydrate patient’s before and after dose. May cause hemorrhagic cystitis.
· Encourage patient to urinate every 1-2 hours while awake and drink at least 3 liters of fluid/daily
• Advise patient not to take tablet form before bedtime

2. NURSING MANAGEMENT
• Maintain patient’s diet: High calorie, soft foods. Encourage small frequent meals. Assess clients gag and swallow reflexes before each meal.
• Administer medications before meals to maximize muscles for swallowing.
• Determines patient’s activity tolerance.
• Teach patient to avoid exposure to infections, especially respiratory.
• Provide eye care: Instill artificial tears, use patch over eye for double vision. Sunglasses to protect eyes from too much sun.
• Instruct patient to avoid extremes of hot or cold, exposure to infections, emotional stress and OTC drugs which exacerbate symptoms. Instruct patient to avoid taking medication with fruit, coffee, tomato juice or other medications.
• Teach patient to recognize symptoms of crisis
•
MYASTHENIA CRISIS – Under-medication
A. Symptoms of myasthenia gravis are worsened.
B. Extreme fatigue.
C. Respiratory distress.
D. Symptoms improve with tensilon
CHOLINERGIC CRISIS – Overmedication
A. Respiratory distress, needs mechanical ventilation
B. Symptoms worsen with tensilon.
C. Symptoms improve with administration of anticholinergic medication – Atropine.
D. NEVER LEAVE PATIENT ALONE DURING A CRISIS

Anyone up for some pediatric info for NCLEX?

PEDIATRICS [pic]
Growth and development
1. Motor skills progress in a proximal to distal manner.
2. NEONATE (Birth to 28 days):
A. Vital signs:
1. Pulse: 110 - 160 BPM count apical for one minute
2. Respiratory rate: 32 - 60 BPM. Neonate is an obligate nose breather.
3. Blood pressure: 82/46.
4. Temperature regulation is altered because of poorly developed sweating and shivering mechanisms.
A. Limit exposure time during baths.
B. When the neonate is wet or cold cover his head.
5. Mortality rate is higher in the neonatal period than in any other growth stage.
B. Head and chest circumference are relatively equal. Head circumference may be up to ¾ greater than the chest circumference.
C. Head length is one-fourth total body length.
D. Brain growth depends on myelinization.
E. All behavior is under reflex control. Extremities are flexed.
1. Moro reflex- Elicited by striking a flat surface the infant is lying on. The reflex of abducting extremities and fanning fingers when a sound is heard should be gone by 3-4 months. Strongest at 2 months
2. Rooting - When the cheek of the newborn is stroked, the newborn will turn his head in the direction of the stroke.
3. Tonic neck - While the newborn lies supine, his head is turned causing the extremities on the same side to straighten and those on the opposite side to flex.
4. Babinski - When the sole of the foot on the side of the newborn small toe is stroked upward, the toes will fan upward and out
5. Plantar grasp - Infant’s toes will curl downward when sole of foot is touched.
6. Startle - A loud noise such as a hand clap will elicit the newborn to abduct his arms and flex his elbows.
F. Hearing and touch are well developed; a hearing screening is recommended.
G. The neonate is stimulated by being held or rocked; listening to music and watching a black-white mobile.
H. While laying prone, the neonate can lift his head.
3. INFANCY: Age 1 month to 1 year.
A. Period of rapid growth in which the head, especially the brain, grows faster than other tissues.
B. According to Erickson, the infant is in the critical stage of Trust vs. mistrust. It is important for the child to develop a trusting relationship with a consistent primary caregiver. Interference may cause failure the thrive.
C. Birth weight doubles in 6 months.
D. Birth weight triples in one year.
E. Posterior fontanel closes by 2-3 months.
F. Anterior fontanel remains open until 18 months.
G. Height increases by 50% in 1 year.
H. Head circumference > than chest circumference until 1 year.
I. Tooth eruption starts at 4 months -> 1 tooth per month.
J. AGES 1 TO 4 MONTHS
1. Instinctual smile appears at age 3 months. The social smile is the infants first social response. The social smile initiates social relationships, indicates memory traces, and signals the beginning of thought processes.
2. The infant develops binocular vision; the eyes can follow an object 180 degrees and any intermittent strabismus should be resolved by age 4 months.
3. The infant reaches out voluntarily but uncoordinatedly.
4. At age 4 months the infant laughs in response to environment.
5. Recognizes parents voices.
6. Explores his feet.
7. Appropriate toys: Music box, mobile, mirror.
K. AGES 5-6 MONTHS
1. Birth weight doubles.
2. Can sleep through the night with 1-2 naps a day.
3. Lower central incisors appear first. Results in ’ed drooling and irritability.
4. Rolls over from stomach to back.
5. Infant cries when parents leave - a normal sign of attachment. Exhibits stranger anxiety.
6. Can transfer toys from one hand to another
7. Exhibits comforting habits - sucks thumb, rubs his ears, holds a blanket or stuffed toy.
A. All these symbolize parents and security.
B. Thumb sucking in infancy doesn’t result in malocclusion of permanent teeth.
8. Appropriate toys: Bright toys, soft toys, rattle - THINK SAFETY.
L. AGES 7 - 9 MONTHS
1. Sits alone without assistance
2. Creeps on his hands and knees with his belly off of the floor.
3. Infant stands and stays up by grasping for support.
4. Develops a pincer grasp; places everything in his mouth - ‘ed risk of aspiration.
5. Self-feeds crackers; the infant who’s physically and emotionally ready can begin to be weaned to a cup.
6. Likes to look at self in mirror.
7. Develops object permanence and searches for objects outside his perceptual field.
8. Understands the word “NO”; discipline can begin. Cries when reprimanded.
9. Can verbalize consonants but speaks no intelligible words. 10. Appropriate toys: Peek-a-boo, cloth toys.
M. AGES 10 - 12 MONTHS
1. Birth weight triples and birth length increases about 50%.
2. Imitative behaviors.
3. Infant cruises (takes steps while holding on) at age 10 months, walks with support at 11 months, and stands alone and takes his first steps at 12 months.
4. Infant claps his hands, waves bye-bye and enjoys rhythm games.
5. Enjoys books and toys to build with and knock over.
6. Cooperates when dressed.
7. Can say Mama/dada and two syllable words.
8. Shows jealousy.
9. Infant explores everything by feeling, pushing, turning, pulling, biting, smelling, and testing for sound.
10. Appropriate toys: Push toys, large ball, large blocks.
N. NUTRITION
1. Introduce foods in this sequence
A. Breast milk or iron-fortified formula: According to AAP (American Academy of Pediatrics) they recommend breast feeding exclusively for the first 4-6 months of life and then in combination with infant foods until age 1.
1. Give breast fed infants iron supplements after age 4 months because iron received before birth is depleted.
2. Breast milk is a rich source of linoleum acid (essential fatty acid) and cholesterol which are needed for brain development.
3. Contains immune factors that protect infants from infection.
B. Don’t give solid foods for the first 6 months
1. Before age 6 months, the GI tract tolerates solid food poorly.
2. Because of strong extrusion reflex, the infant pushes food out of his mouth.
3. The risk of food allergy development may increase.
C. Provide rice cereal as the first solid food followed by any other cereal except wheat.
D. Give yellow or green vegetables next.
E. Provide no citrus fruits followed by citrus fruits after age 6 months.
F. Give infants teething biscuits during teething period.
G. Provide food with sufficient protein such as meat, after age 6 months.
H. After 12 months, switch from formula to regular WHOLE milk.
1. Don’t give skim milk because fatty acids are needed for myelinization.
2. Whole milk should be continued until age 2 as recommended by the AAP.
I. RULES FOR FEEDING
1. Don’t prop up baby bottle - ’s risk of aspiration & ear infections.
2. Don’t put food or cereal in a baby bottle.
3. Introduce one new food at a time; wait 4-7 days before introducing new food to determine infant’s tolerance to it and the potential for allergy.
O. SAFETY GUIDELINES
1. Place infants supine for sleep to decrease the risk of sudden infant death syndrome.
2. Keep crib rails up at all times, keep away from windows and curtain cords. Crib slats should not be more than 2” apart with mattress firmly against its rails to prevent infant falling in-between mattress and slats.
3. Use car seats properly - keep infant placed facing back of back seat.
4. Never leave infant unattended on dressing table or any other high place.
5. Don’t warm formula or breast milk in microwave. Defrosting in microwave may destroy its immune factors. Formula/food should be lukewarm.
6. Insert safety plugs in wall outlets
7. Use gates along stairways.
8. Keep soft objects and loose bedding out of the crib. Pillows, quilts, sheepskins and comforters should be kept out of infant’s sleeping environment.
9. Avoid overheating; infant should be lightly clothed for sleep.
10. ALWAYS support infants head.
11. Check temperature of bath water - should be 90-100 degrees.
P. TODDLER (Ages 1 to 3)
1. Vital signs: Pulse 100 BPM
Respiratory rate: 26 BPM
Blood pressure: 99/64
2. Period of slow growth with a weight gain of 4-6 lbs per year. Normally weighs four times birth weight.
3. Anterior fontanel closes between ages 12 and 18 months.
4. The toddler is egocentric.
5. Follows parents wherever they go.
A. Start playing peek-a-boo to develop trust.
B. Progress to playing hide and seek to reinforce the idea that his parents will return.
6. Separation anxiety arises.
A. The toddler sees bedtime as desertion.
B. Develops a fear of the dark. Nightmares begin around 2-3.
C. Separation anxiety demonstrates closeness between the toddler & his parents.
D. The parent who is leaving should say so and should promise to return.
1. Parent should leave a personal item with the toddler.
2. Prepare the parents for the toddlers reaction, and explain that this process promotes trust.
E. According to Erickson, this is the critical stage of AUTONOMY (self control & will power) VS SHAME. The child develops a sense of independence and should be allowed to explore the environment with the encouragement of the primary caregiver. Temper tantrums, negativism, and disciplinary problems are the hallmarks of this age group as the child learns to control his environment and express his will. The child should be taught to tolerate frustration through socialization and proper toilet training.
1. According to Freud, toddlers are egocentric and possessive and struggle with holding on and letting go behaviors (ANAL STAGE).
2. Toddlers usually begin to imitate sex role behavior.
3. Piaget: Sensorimotor stage the child enters the pre-operational stage in which he begins using a trial and error method of thinking and reasoning.
F. The toddler may engage in solitary play and have little interaction with others, this progresses to parallel play (toddler plays along-side but not with other children.

G. To promote development of autonomy, allow the toddler to perform tasks independently.
H. Toddler understands object permanence.
I. Discipline during this stage should be a demonstration of love, not anger. The toddler needs limits set on unacceptable demands, such limits offer security. He should be praised liberally, but only when deserved.
J. Things to expect:
1. Sphincter control begins at age 2.
2. All deciduous teeth erupt by 21 months - 2 years.
3. Pot-bellied appearance.
K. 18 months
1. Is in the “MY” stage. 2. Vocabulary of 25 words.
3. Walks independently 4. Can use a spoon.
5. Climbs.
Appropriate toys: Push/pull toys, blocks.
L. 24 months
1. Negativistic 2. Temper tantrums
3. Transitional object 4. 2-4 word sentences, 400 words
5. Walks up/down stairs 6. Turns door knobs
7. Builds tower of 6 blocks 8. Removes clothes
9. Appropriate play: Parallel play, sand, riding toys, water play, finger paints.
10. Manage temper tantrums: Ignore behavior, monitor for safety.
11. Toddler uses “NO” excessively and shows assertiveness. Is curious how parents will react to use of “NO”.
12. Overcriticizing and restricting the toddler may dampen his enthusiasm and increase shame and doubt.
13. Total sleep required is 12-14 hours. Sleep problems are common.
14. Toilet training
A. Consider emotional readiness
B. The toddler acts to please others, trusts enough to give up his body products, and begins autonomous behavior
C. Parents must be committed to establishing a toileting pattern and must communicate well with the toddler.
D. Offer PRAISE for success - NEVER punishment for any failure.
E. Don’t refer to bowel movements as being “dirty” or “yucky”. Excrement is the toddler’s first creation.
F. Introduce underpants as a badge of success and maturity.
G. Most toddlers achieve day dryness by age 18 months to 3 years and night dryness by ages 2-5. NEVER punish for “ACCIDENTS”. If toddler is not trained by age 5, seek further evaluation.
H. Toddler may fear being “sucked” into the toilet.
I. Teach proper wiping technique (front to back) and hand washing.
15. When the toddler starts climbing over the crib rails, switch to a bed.
16. Use locks on cabinets, keep handles away from edges of tables or stoves.
17. AVOID bean bag toys.
18. Appropriate toys: Nested toys, toys with parts that open and close. Toys designed for pounding such as play hammers and drums. Toy telephones, dolls. Provide the child with opportunities for positive imitative play. They enjoy simple songs with repetitive rhymes as well as moving in time to music. A musical activity should be scheduled into each day.
19. NUTRITION:
A. Toddler feeds himself, provide finger foods in small portions
B. Because of increased risk of aspiration avoid foods such as hot dogs, grapes, nuts and candy (or cut into small pieces).
C. Nutritional needs decrease because of slow growth period.
D. Child may become a picky eater. Nutritional content of food is important.
E. The toddler shouldn’t drink more than 24 ounces of milk a day in order to have room for

BURNS
1. Smoke and inhalation injuries result from inhalation of hot air or noxious chemicals.
2. The resulting effect of burns is influenced by the temperature of the burning agent, the duration of contact time, ad the tissue type burned.
3. Burn treatment is related to injury severity determined by depth. The extent is calculated by the percent of the total body surface area (TBSA), location, and patient risk factors.
4. Causes
A. Radiation: X-ray, sun, nuclear reactors
B. Mechanical: Friction
C. Chemical: Acids, alkalies, vesicants. Chemical burns alter tissue perfusion and lead to necrosis.
D. Electrical: Lightening, electrical wires. Severity depends on type and duration of current and amount of voltage - they follow the path of least resistance (muscles, bone, blood vessels and nerves)
E. Thermal: Flame, steam, frostbite, scald. These cause cellular destruction that results in vascular, bony, muscle, or nerve complications; thermal burns can also lead to inhalation injury if the head, neck or chest area is affected.
5. Burns are defined by degrees: First degree (superficial partial thickness burn), second degree (deep dermal partial thickness burn), and third degree (full-thickness burn)
A. Superficial partial-thickness burn (first degree): Sunburn type. Involves only the dermal layer. S/S: Erythema, edema, pain, blanching.

B. Deep dermal partial-thickness (2nd degree): Involves the epidermal and dermal layers. S/S; Pain, oozing, fluid filled vesicles, Erythema, Shiny wet subcutaneous layer after vesicles rupture.
C. Full-thickness burn (3rd & 4th degree): Involves epidermal, dermal, and subcutaneous layers, and nerve endings, muscle, tendons and bone. S/S: Eschar, edema, little or no pain.
6. Second and third degree burn extent can be determined using a total body surface area based on two guides: Lund-Browder chart and Rule of Nines. Burn extent is often revised after edema subsides and demarcation of injury zones occurs.
A. RULE OF NINES
Head= 9% Arms = 18%( 9% each) -
Back= 18% Legs= 36%( 18% each)
Genitalia= 1%
B. LUND-BROWDER CHART: This method accounts for changes in body proportion that occur with age. Its greater accuracy can be used to help determine a patient’s exact fluid replacement requirements after a burn injury.
7. Hands, feet, and eye burns may make jeopardize future function. Buttocks or genitalia burns are more susceptible to infection. Circumferential burns to the extremities can cause circulatory compromise distal to the burn.
8. Patient usually tetanus and immune globulin.
9. Burn management is organized chronologically into 3 phases: Emergent (resuscitative), Acute (wound healing), and rehabilitation (restorative)
A. EMERGENT: Period of time required to resolve immediate, life-threatening problems. Phase may last from time of burn to 3 or more days, but usually lasts 24- 48 hours.
1. Priority care is on ABC’s. Assess for smoke inhalation (singed nares, eyebrows, or lashes; burns on the face or neck: stridor, increasing dyspnea) and give oxygen at 100% as prescribed. Be prepared for emergency intubation and mechanical ventilation if severe inhalation injury or carbon monoxide inhalation has occurred.
2. Assess for signs of shock caused by fluid shifts (increased pulse, falling B/P and urine output, pallor, cool clammy skin, deteriorating level of consciousness.
3. Initial fluid shift/Fluid resuscitation: Occurs in first 24 hours after burn.
A. Fluid seeps out of the tissue because of increased capillary permeability. The majority of this leaking occurs within the first 24 hours. Fluid deficit = shock.
B. H & H is elevated due to loss of fluid volume and fluid shift into interstitial space (third spacing)
C. Sodium is decreased due to third spacing.
D. Potassium is increased due to cell destruction.

E. Common rule: Calculate what is needed for the first 24 hours and give ½ of the volume calculated during the first 8 hours (Parkland formula)
1. BROOKE FORMULA: Uses 2 mL/kg/% TBSA burned (¾ crystalloid plus ¼ colloid) plus maintenance fluid of 2,000 mL D5W per 24 hours.
2. PARKLAND FORMULA: Uses 4 mL formula uses 4 mL/kg/TBSA burned per 24 hours = total fluid requirements for the first 24 hours.
A. 1st 8 hours = ½ of total volume
B. 2nd 8 hours = ¼ of total volume
C. 3rd 8 hours = ¼ of total volume
3. No matter what formula the doctor uses, the formula will tell the amount of fluid the patient will get per hour.
4. Medication therapy: Pain therapy, tetanus prophylaxis, topical antimicrobial as well as systemic antibiotics.
5. Primary concern is the onset of hypovolemic shock and edema formation. Toward the end of the phase, if fluid replacement is adequate, the capillary membrane permeability is restored.
6. Fluid loss and edema formation cease. The interstitial fluid gradually returns to the vascular space.
7. Diuresis occurs with low urine specific gravities.
8. Manifestations include shock from the pain and hypovolemic. Areas of full thickness and deep partial-thickness burns are initially anesthetic because the nerve endings are destroyed. Superficial to moderate partial-thickness burns are painful.
9. Shivering occurs as a result of chilling and most patients are alert.
10. COMPLICATIONS
A. Cardiovascular system: Dysrhythmias and hypovolemic shock.
B. Respiratory system: Vulnerable to upper airway injury causing edema formation and/or obstruction of airway and inhalation injury.
C. Renal system: If patient is hypovolemic, kidney blood flow may decrease, causing renal ischemia. If it continues, acute renal failure may develop.
D. With full-thickness burns, myoglobin and hemoglobin are released into the bloodstream and occlude the renal tubules.
11. DIET: High protein, high calorie with increased fluids, high calorie high protein drinks.
12. If fingers/toes are burned, wrap each finger/toe separately.
13. Monitor urine output - if less than 30 mL/hour, assess for renal failure.
B. ACUTE PHASE
1. Begins with the start of diuresis (usually 48 to 72 hours post-burn) and ends with closure of the burn wound. Phase concludes with burned area is completely covered with skin grafts or when wounds are healed.
2. Margins of full-thickness Eschar take longer to separate. As a result, they require surgical debridement and skin grafting for healing.
3. Because the body is trying to reestablish fluid and electrolyte homeostasis, it is important for the nurse to follow the patient’s serum electrolyte levels closely (hypo - or hypernatremia, or hypo- or hyperkalemia).
4. Complications include wound infection progressing to transient bacteremia as a result of manipulation (after hydrotherapy and debridement). Same cardiovascular and respiratory system complications as in emergent phase may continue.
5. Patient can become extremely disoriented, withdraw, or be combative. This is a transient state lasting from a day to several weeks. ROM may be limited and contractures can occur. Paralytic ileus results from sepsis.
6. Management involves wound care with daily observation, assessment, cleansing, debridement, and dressing reapplication.
1. Use sterile technique when handling burn.
2. Give pain killer before dressing changes and hydrotherapy. Pain control is usually opioid analgesics required.
C. REHABILITATIVE PHASE
1. Begins with wound closure and ends when the client returns to the highest level of health restoration.
2. Goals are to assist the patient in resuming a functional role in society and accomplish functional and cosmetic reconstructive surgery.
3. Provide support and management. Use preventive measures to prevent contractures
10. NURSING INTERVENTIONS
A. Ensure airway patency and provide oxygen
B. Monitor V/S, laboratory findings, capillary refill, adequate tissue perfusion.
C. Keep patient NPO and administer H2 antagonist to prevent Curling (stress) ulcer.
D. Elevate clients extremities (increase venous return).
E. Use pressure dressings to prevent scarring and edema.
F. Give pain medication prior to any treatment and especially before dressing changes.
G. Nutritional requirements are increased with burns.
H. Encourage ROM. Neutral positions are best to prevent contractures, unless neck is burned, then hyperextend.
I. Maintain warm environment during acute phase.
J. Monitor for shock symptoms. Maintain protective precautions. Reverse isolation.
K. If client underwent grafting, keep pressure off donor side to maintain blo

Re: Anyoone up for random FACT THROWING??
Here is a little info on the thyroid gland - hope this helps

DISORDERS OF THE THYROID GLAND

1. GRAVES DISEASE - Hyperthyroidism - TOO MUCH ENERGY
A. Increased synthesis of thyroid hormone from overactivity.
B. Excessive secretion of thyroid hormone
1. Leads to increased basal metabolic rate (BMR).
2. Increased cardiovascular function, ^’ed GI function, ^’ed neuromuscular function, weight loss, and heat intolerance.
3. Thyroid hormone affects metabolism of fats, carbohydrates, and proteins.
4. Calcitonin inhibits mobilization of calcium from bone and ¯’s blood calcium levels
C. An autoimmune disorder.
D. Etiology: Excess secretion of TSH from pituitary gland. Thyroiditis, tumor, goiter. Physiological or psychological stress, infections,
F. S/S: Nervousness, weight loss despite increased appetite, sweaty/hot (heat intolerance), exophthalmus (no cure for this), hyperactivity (cant sit still), ^’ed appetite, B/P ’ed, flushed smooth skin, oliogomenorrhea or amenorrhea, palpitations, insomnia. ALL V/S ARE ^’ed - think of patient as being hyperactive.
G. DIAGNOSIS: Serum T3 and T4 are increased. Radio-iodine uptake is increased. Thyroid scan shows enlarged thyroid gland or nodules.
H. TREATMENT/NURSING INTERVENTIONS
1. Monitor V/S & I & O - determine presence of thyroid storm.
2. Lifelong antithyroid medication.
3. Surgical removal of thyroid.
A. Radioactive iodine 131
1. The thyroid gland absorbs the I-131 which destroys some of the thyroid cells over a period of 6 to 8 weeks. RULE OUT PREGNANCY FIRST.
2. Advise patient against close contact with other people, avoid kissing for 24-hours.
3. Test females for pregnancy. Pregnancy should be delayed 12 months.
4. Advise patient to drink with straw
B. Thyroidectomy or partial thyroidectomy
1. Instruct patient to hold hands behind neck when coughing, sitting, turning, or getting up/back into bed to reduce post-op pain and decrease tension on suture line.
2. Position semi-fowlers with head and neck supported. Ice collar to wound to prevent edema.
3. Monitor for hemorrhage, edema, exudates over upper chest, upper back, shoulders, back of neck.
4. Promote patent airway - keep HOB elevated 30 degrees. Keep sterile oral suction and emergency tracheotomy tray within reach. Avoid hyperextension of the neck
5. Keep phone, personal items, call bell, remote control within reach.
6. Diet: Increase calories
7. Assess for laryngeal nerve damage: assess for hoarseness. Could lead to vocal cord paralysis. If there is paralysis of both cords, airway obstruction will occur requiring immediate trach. Bilateral nerve damage = breathing difficulties and aphonia (inability to speak)
8. Instruct patient to report any signs of pressure on neck.
9. Give eye care for exophthalmus: Moisten eyes frequently with artificial tears to prevent irritation corneal infection. Protect eyes from photophobia with glasses. Sleep with HOB elevated to minimize pressure on optic nerve and eye patches to protect eyes during sleep if lids do not close. Soothe eyes with cool compresses.
10. Prevent tetany by identifying hypocalcemia - numbness or tingling of toes, extremities, and lips, muscle twitches, positive Chvostek’s & Trousseau.

I. THYROID STORM/THYROID CRISIS
1. Life threatening emergency that occurs in EXTREME hyperthyroidism.
A. Thyrotoxicosis, and thyrotoxic crisis and thyroid storm are the same.
B. It is hyperthyroidism multiplied by 100.
C. Results from a sudden surge of large amounts of thyroid hormones into the bloodstream causing a greater in body metabolism
2. S/S: Temperature > 102 up to 106 (hyperthermia). Tachycardia, systolic hypertension, abdominal pain, N/V, diarrhea, agitation, tremors, confusion, seizures, delirium to psychosis. Triad S/S of thyroid storm: Tachycardia, hyperthermia, agitation. ALL HYPERTHYROID MANIFESTATIONS ARE ^'ed.
3. May be precipitated by stress - surgery or infection, etc.
4. TREATMENT
A. Focuses on reducing circulating thyroid hormone levels by drug therapy.
B. Inhibition of thyroid hormones with propranolol (Inderal), corticosteroids, and thioamides (PTU)
C. Treat hyperthermia with cooling blankets, Tylenol (acetaminophen). Aspirin is contraindicated -it releases thyroxin, provide cool sponge baths or ice packs to axilla and groin to decrease fever.
D. Treat dehydration with IV fluids and electrolytes.
E. Treatment of precipitating event.
F. Administer insulin for hyperglycemia. B-blockers (-LOL) for tachycardia

2. MYXEDEMA - Hypothyroidism - NOT ENOUGH ENERGY/ CRETINISM
A. Occurs when there is an insufficient amount of thyroid hormone (TH) being secreted by the thyroid gland causing a ¯’ed metabolic rate, decreased heat production. CRETINISM: Hypothyroidism present at birth
B. Hyposecretion of thyroid hormone results in overall decrease in metabolism.
C. ETIOLOGY: An autoimmune disorder (Hashimoto’s thyroidism)causing destruction of the thyroid gland. External irradiation of the thyroid gland, infections, iodine deficiency. Lithium therapy.
1. Hashimoto’s thyroidism: The immune system attacks the thyroid gland.
D. S/S: Fatigue, weight gain, dry flaky skin, cold intolerance, course brittle hair, hypothermia, lethargy, diminished reflexes, periorbital edema, bradycardia, dysrhythmias, infertility, C/O cold hands and feet, hair loss, prolonged DTR-¯’ed, enlarged heart, muscle aches or weakness, constipation & ¯’ed libido.
E. CRETINISM: Hypothyroidism that is present at birth. Is very dangerous and can lead to slowed mental and physical development if undetected.
1. State of severe hypothyroidism in infants. Infants do not produce normal amounts of thyroid hormone.
2. Their skeletal maturation and CNS development are altered resulting in retardation of physical growth, mental growth, or both.
F. TREATMENT/NURSING INTERVENTIONS
1. Diet: High fiber, high protein, low calorie, ^’ed fluid intake (2000 mL/day)
2. Because of altered metabolism, patients do not tolerate barbiturates or sedatives. Therefore CNS depressants are contraindicated.
3. Give medication in the AM one hour before food or 2 hours after.
4. Do not give beta blockers to asthmatics or diabetics - hides symptoms of hypoglycemia.
5. Start thyroid medications at lowest dose and graduate to larger doses.
A. Dosage is increased every 2-3 weeks until the desired response is achieved. Advise patient that treatment is lifelong requiring constant monitoring by MD. If thyroid drug is discontinued, it must be tapered.
B. Teach patient S/S of hyperthyroidism which can occur with overmedication.
6. Caution patient against electric blankets, extra clothing because of vasodilation.

G. MYXEDEMA COMA: Life threatening crisis state of hypothyroidism.
1. Myxedema coma/crisis occurs as a result of long-standing or untreated hypothyroidism who experience significant stress as infection, medication, exposure to a cold environment or systemic disease.
A. Can be precipitated by infection, drugs - especially opioids, tranquilizers, and barbiturates.
2. Myxedema is an accumulation of hydrophilic mucopolysaccharides in the dermis and other tissues. This causes characteristic signs of hypothyroidism: puffiness, periorbital edema, and mask-like affect. Thinning eyebrows.
3. Virtually every organ system is affected.
4. S/S: Lethargy, stupor, ¯’ed oxygen & blood flow to the brain occurs. Bradycardia & ¯’ed contractility = low cardiac output. ¯’ed renal function. Unresponsiveness, edema, hypoventilation, hyponatremia, hypotension, hypothermia, Progressive stupor. Periorbital edema, non-pitting edema, puffy face and tongue. Significantly depressed respirations.
5. TREATMENT
A. The overall treatment is restoration of euthyroid state (having a normal thyroid gland as rapidly and safely as possible with hormone replacement. Levothyroxine (Synthroid) is the drug of choice - give slowly
B. Maintain airway patency.
C. Maintain circulation with IV therapy and ECG monitoring.
D. Monitor V/S, ABG, I & O, patient temperature.
E. Keep patient warm
F. Administer corticosteroids as ordered. Assess for infections.
G. Patient at risk for CAD - monitor
H. Assess for skin alterations - apply lotion, etc.
I. With rapid administration of thyroid hormone, plasma T4 levels may initiate adrenal insufficiency, hence steroid therapy may be ordered.

6. MEDICATIONS

A. SYNTHROID (thyroxin- T4) - Contraindicated in patients with MI, use cautiously in elderly and patients with diabetes, diabetes insipidus.
1. When starting thyroid replacement therapy, care must be taken with older patients and those with CAD to avoid coronary ischemia because of increased O2 demands of the heart. Start with lower doses first then .
2. Teach to take at same time each day 1 hour before meals/2 hours after. 3. Advise to take with plenty water or milk. Optimal time is before breakfast.
4. Withhold medication if heart rate above 100 or notify MD.
5. Report weight gain of 5 pounds.

B. CYTOMEL (liothyronine sodium {T3}) - Use cautiously in elderly patients and those with angina, renal insufficiency or ischemia.
1. Long term use causes bone loss.
2. Monitor B/P and pulse.
3. Do not give IM or subcutaneously.

C. PTU - Propylthiouracil (Propyl-Thyracil)
1. Inhibits oxidation of iodine in thyroid gland, blocking ability of iodine to combine with tyrosine to form T3. May prevent formation of T4
2. S/E: Headache, N/V, vertigo, paresthesia, CNS stimulation, fever, hepatotoxicity, visual disturbances, diarrhea, leukopenia, myalgia.
3. INTERVENTIONS.
1. Advise patient that iodized salt and shellfish should not be eaten because they alter drugs effectiveness.
2. Instruct patient to take with meals to reduce GI reaction.
3. Monitor lab values, especially CBC and hepatic function.

D. RADIOACTIVE IODINE (sodium iodide 131)
1. Limits thyroid hormone secretion by destroying thyroid tissue
2. S/E: N/V, skin rash, urticaria, pruritus, pain on swallowing.
3. INTERVENTIONS
A. ALL antithyroid drugs must be stopped 1 week before 1st dose.
B. Not used on patients younger than 30.
C. Institute full radiation precautions. Isolate patient, advise to avoid close contact with other people for at least 24 -48 hours
D. Advise patient to fast overnight before therapy and to force fluids
E. Monitor thyroid hormone levels

E. POTASSIUM IODIDE (SSKI, Lugol solution, ThyroSafe, Thyroshield)
1. Inhibits thyroid hormone formation, limits iodide transport into the thyroid gland and blocks thyroid hormone release.
2. Used to prepare patient for thyroidectomy: given TID after meals for ten days before surgery.
3. S/E: periorbital edema, N/V, diarrhea, inflammation of salivary glands, burning mouth and throat, sore teeth and gums, potassium toxicity, acne- type rash. DO NOT GIVE ace inhibitors or potassium sparing diuretics with drug; may cause hyperkalemia.

F. PROPRANOLOL (Inderal) "OLOL"- A adrenergic blocker. Relieves the adrenergic effects of excess thyroid hormone (sweating, palpitations, tremors)
G. INTERVENTIONS
1. Dilute oral solution in water, milk, or juice and give AFTER meals.
2. Give through straw to avoid teeth discoloration.
3. Earliest signs of delayed hypersensitivity reactions caused by iodides are irritation and swollen eyelids.
4. Signs of iodide hypersensitivity are: Angioedema, cutaneous and mucosal hemorrhage, fever, arthralgia, lymph node enlargement, and eosinophilia.
5. Monitor patient for iodism which can cause a metallic taste, burning in mouth and throat, sore teeth and gums, increased salivation, sneezing, eye irritation with swelling of eyelids, severe headache, rash or soreness of the pharynx, larynx, and tonsils, GI irritation.
6. Advise patient that sudden withdrawal may cause thyroid crisis.
7. Teach patient S/S of K+ toxicity: confusion, irregular heartbeat, numbness, tingling, pain or weakness of hands and feet & tiredness.
8. Advise patient NOT to increase potassium in diet.
9. Advise patient not to eat iodized salt or shellfish.
I. THYROIDECTOMY CARE
1. O2 therapy, suction secretions.
2. Monitor for signs of bleeding and excessive edema
3. Elevate HOB 30º. Support head and neck to avoid tension on sutures
4. Check dressing frequently, check behind the neck, shoulders for bleeding.
5. Assess for signs of respiratory distress, hoarseness (laryngeal edema or damage.
6. Keep tracheostomy set in patient’s room for emergency use.
7. Administer food and fluid with care (dysphagia is common).
8. Encourage client to gradually ROM of neck.
9. Teach about medications, frequent follow-up. If thyroidectomy - life long replacement of medication (T5, T4). Subtotal thyroidectomy - careful monitoring of return of thyroid function.
10. THINK BOW TIE:
B = Bleeding
O = open airway
W = whisper
T = trach set
I = incision
E = emergency
11. Be alert for post op complications
A. Tetany: Due to hypocalcemia caused by accidental removal of parathyroid gland. Assess for numbness, tingling, or muscle twitching. Monitor for Chvostek’s sign and Trousseau’s sign. Give calcium gluconate IV slowly.
B. Hemorrhage: Monitor for hypotension, tachycardia, other signs of hypovolemia. Irregular breathing, swelling, choking - possible hemorrhage and tracheal compression. Early signs of hemorrhage: Repeated clearing of throat, difficulty swallowing.
C. Thyroid storm: Life threatening. Sudden increased release of thyroid hormone. Assess for fever, tachycardia, ’ing restlessness, agitation, and delirium.

GROWTH AND DEVELOPMENT FOR PEDIATRICS

PEDIATRICS

1. Motor skills progress in a proximal to distal manner.
2. NEONATE (Birth to 28 days):
A. Vital signs:
1. Pulse: 110 - 160 BPM count apical for one minute
2. Respiratory rate: 32 - 60 BPM. Neonate is an obligate nose breather.
3. Blood pressure: 82/46.
4. Temperature regulation is altered because of poorly developed sweating and shivering mechanisms.
A. Limit exposure time during baths.
B. When the neonate is wet or cold cover his head.
5. Mortality rate is higher in the neonatal period than in any other growth stage.
B. Head and chest circumference are relatively equal. Head circumference may be up to ¾ greater than the chest circumference.
C. Head length is one-fourth total body length.
D. Brain growth depends on myelinization.
E. All behavior is under reflex control. Extremities are flexed.
1. Moro reflex- Elicited by striking a flat surface the infant is lying on. The reflex of abducting extremities and fanning fingers when a sound is heard should be gone by 3-4 months. Strongest at 2 months
2. Rooting - When the cheek of the newborn is stroked, the newborn will turn his head in the direction of the stroke. Usually disappears 3-4 months
3. Tonic neck - While the newborn lies supine, his head is turned causing the extremities on the same side to straighten and those on the opposite side to flex (fencing posture). Disappears at 3-4 months.
4. Babinski - When the sole of the foot on the side of the newborn small toe is stroked upward, the toes will fan upward and out
5. Plantar grasp - Infant’s toes will curl downward when sole of foot is touched.
6. Startle - A loud noise such as a hand clap will elicit the newborn to abduct his arms and flex his elbows. Best elicited after infant is at least 24 hours old and disappears within 4 months.
7. Palmar/plantar grasp - Place a finger in the palm of the newborn’s hand and then place a finger at the base of the toes, the newborn’s fingers and toes curl downward.
F. Hearing and touch are well developed; a hearing screening is recommended.
G. The neonate is stimulated by being held or rocked; listening to music and watching a black-white mobile.
H. While laying prone, the neonate can lift his head.
3. INFANCY: Age 1 month to 1 year.
A. Period of rapid growth in which the head, especially the brain, grows faster than other tissues.
B. According to Erickson, the infant is in the critical stage of Trust vs. mistrust. It is important for the child to develop a trusting relationship with a consistent primary caregiver. Interference may cause failure the thrive.
C. Birth weight doubles in 6 months.
D. Birth weight triples in one year.
E. Posterior fontanel closes by 2-3 months.
F. Anterior fontanel remains open until 18 months.
G. Height increases by 50% in 1 year.
H. Head circumference > than chest circumference until 1 year.
I. Tooth eruption starts at 4 months -> 1 tooth per month.
J. AGES 1 TO 4 MONTHS
1. Instinctual smile appears at age 3 months. The social smile is the infants first social response. The social smile initiates social relationships, indicates memory traces, and signals the beginning of thought processes.
2. The infant develops binocular vision; the eyes can follow an object 180 degrees and any intermittent strabismus should be resolved by age 4 months.
3. The infant reaches out voluntarily but uncoordinatedly.
4. At age 4 months the infant laughs in response to environment.
5. Recognizes parents voices.
6. Explores his feet.
7. Appropriate toys: Music box, mobile, mirror.
K. AGES 5-6 MONTHS
1. Birth weight doubles.
2. Can sleep through the night with 1-2 naps a day.
3. Lower central incisors appear first. Results in ’ed drooling and irritability.
4. Rolls over from stomach to back.
5. Infant cries when parents leave - a normal sign of attachment. Exhibits stranger anxiety.
6. Can transfer toys from one hand to another
7. Exhibits comforting habits - sucks thumb, rubs his ears, holds a blanket or stuffed toy.
A. All these symbolize parents and security.
B. Thumb sucking in infancy doesn’t result in malocclusion of permanent teeth.
8. Appropriate toys: Bright toys, soft toys, rattle - THINK SAFETY.
L. AGES 7 - 9 MONTHS
1. Sits alone without assistance
2. Creeps on his hands and knees with his belly off of the floor.
3. Infant stands and stays up by grasping for support.
4. Develops a pincer grasp; places everything in his mouth - ‘ed risk of aspiration.
5. Self-feeds crackers; the infant who’s physically and emotionally ready can begin to be weaned to a cup.
6. Likes to look at self in mirror.
7. Develops object permanence and searches for objects outside his perceptual field.
8. Understands the word “NO”; discipline can begin. Cries when reprimanded.
9. Can verbalize consonants but speaks no intelligible words. 10. Appropriate toys: Peek-a-boo, cloth toys.
M. AGES 10 - 12 MONTHS
1. Birth weight triples and birth length increases about 50%.
2. Imitative behaviors.
3. Infant cruises (takes steps while holding on) at age 10 months, walks with support at 11 months, and stands alone and takes his first steps at 12 months.
4. Infant claps his hands, waves bye-bye and enjoys rhythm games.
5. Enjoys books and toys to build with and knock over.
6. Cooperates when dressed.
7. Can say Mama/dada and two syllable words.
8. Shows jealousy.
9. Infant explores everything by feeling, pushing, turning, pulling, biting, smelling, and testing for sound.
10. Appropriate toys: Push toys, large ball, large blocks.
N. NUTRITION
1. Introduce foods in this sequence
A. Breast milk or iron-fortified formula: According to AAP (American Academy of Pediatrics) they recommend breast feeding exclusively for the first 4-6 months of life and then in combination with infant foods until age 1.
1. Give breast fed infants iron supplements after age 4 months because iron received before birth is depleted.
2. Breast milk is a rich source of linoleum acid (essential fatty acid) and cholesterol which are needed for brain development.
3. Contains immune factors that protect infants from infection.
B. Don’t give solid foods for the first 6 months
1. Before age 6 months, the GI tract tolerates solid food poorly.
2. Because of strong extrusion reflex, the infant pushes food out of his mouth.
3. The risk of food allergy development may increase.
C. Provide rice cereal as the first solid food followed by any other cereal except wheat.
D. Give yellow or green vegetables next.
E. Provide no citrus fruits followed by citrus fruits after age 6 months.
F. Give infants teething biscuits during teething period.
G. Provide food with sufficient protein such as meat, after age 6 months.
H. After 12 months, switch from formula to regular WHOLE milk.
1. Don’t give skim milk because fatty acids are needed for myelinization.
2. Whole milk should be continued until age 2 as recommended by the AAP.
I. RULES FOR FEEDING
1. Don’t prop up baby bottle - ’s risk of aspiration & ear infections.
2. Don’t put food or cereal in a baby bottle.
3. Introduce one new food at a time; wait 4-7 days before introducing new food to determine infant’s tolerance to it and the potential for allergy.
O. SAFETY GUIDELINES
1. Place infants supine for sleep to decrease the risk of sudden infant death syndrome.
2. Keep crib rails up at all times, keep away from windows and curtain cords. Crib slats should not be more than 2” apart with mattress firmly against its rails to prevent infant falling in-between mattress and slats.
3. Use car seats properly - keep infant placed facing back of back seat.
4. Never leave infant unattended on dressing table or any other high place.
5. Don’t warm formula or breast milk in microwave. Defrosting in microwave may destroy its immune factors. Formula/food should be lukewarm.
6. Insert safety plugs in wall outlets
7. Use gates along stairways.
8. Keep soft objects and loose bedding out of the crib. Pillows, quilts, sheepskins and comforters should be kept out of infant’s sleeping environment.
9. Avoid overheating; infant should be lightly clothed for sleep.
10. ALWAYS support infants head.
11. Check temperature of bath water - should be 90-100 degrees.
P. TODDLER (Ages 1 to 3)
1. Vital signs: Pulse 100 BPM
Respiratory rate: 26 BPM
Blood pressure: 99/64
2. Period of slow growth with a weight gain of 4-6 lbs per year. Normally weighs four times birth weight.
3. Anterior fontanel closes between ages 12 and 18 months.
4. The toddler is egocentric.
5. Follows parents wherever they go.
A. Start playing peek-a-boo to develop trust.
B. Progress to playing hide and seek to reinforce the idea that his parents will return.
6. Separation anxiety arises.
A. The toddler sees bedtime as desertion.
B. Develops a fear of the dark. Nightmares begin around 2-3.
C. Separation anxiety demonstrates closeness between the toddler & his parents.
D. The parent who is leaving should say so and should promise to return.
1. Parent should leave a personal item with the toddler.
2. Prepare the parents for the toddlers reaction, and explain that this process promotes trust.
E. According to Erickson, this is the critical stage of AUTONOMY (self control & will power) VS SHAME. The child develops a sense of independence and should be allowed to explore the environment with the encouragement of the primary caregiver. Temper tantrums, negativism, and disciplinary problems are the hallmarks of this age group as the child learns to control his environment and express his will. The child should be taught to tolerate frustration through socialization and proper toilet training.
1. According to Freud, toddlers are egocentric and possessive and struggle with holding on and letting go behaviors (ANAL STAGE).
2. Toddlers usually begin to imitate sex role behavior.
3. Piaget: Sensorimotor stage the child enters the pre-operational stage in which he begins using a trial and error method of thinking and reasoning.
F. The toddler may engage in solitary play and have little interaction with others, this progresses to parallel play (toddler plays along-side but not with other children.
G. To promote development of autonomy, allow the toddler to perform tasks independently and provide choices.
H. Toddler understands object permanence.
I. Discipline during this stage should be a demonstration of love, not anger. The toddler needs limits set on unacceptable demands, such limits offer security. He should be praised liberally, but only when deserved.
J. Things to expect:
1. Sphincter control begins at age 2.
2. All deciduous teeth erupt by 21 months - 2 years.
3. Pot-bellied appearance.
K. 18 months
1. Is in the “MY” stage. 2. Vocabulary of 25 words.
3. Walks independently 4. Can use a spoon.
5. Climbs.
Appropriate toys: Push/pull toys, blocks.
L. 24 months
1. Negativistic 2. Temper tantrums
3. Transitional object 4. 2-4 word sentences, 400 words
5. Walks up/down stairs 6. Turns door knobs
7. Builds tower of 6 blocks 8. Removes clothes
9. Appropriate play: Parallel play, sand, riding toys, water play, finger paints.
10. Manage temper tantrums: Ignore behavior, monitor for safety.
11. Toddler uses “NO” excessively and shows assertiveness. Is curious how parents will react to use of “NO”.
12. Overcriticizing and restricting the toddler may dampen his enthusiasm and increase shame and doubt.
13. Total sleep required is 12-14 hours. Sleep problems are common.
14. Toilet training
A. Consider emotional readiness
B. The toddler acts to please others, trusts enough to give up his body products, and begins autonomous behavior
C. Parents must be committed to establishing a toileting pattern and must communicate well with the toddler.
D. Offer PRAISE for success - NEVER punishment for any failure.
E. Don’t refer to bowel movements as being “dirty” or “yucky”. Excrement is the toddler’s first creation.
F. Introduce underpants as a badge of success and maturity.
G. Most toddlers achieve day dryness by age 18 months to 3 years and night dryness by ages 2-5. NEVER punish for “ACCIDENTS”. If toddler is not trained by age 5, seek further evaluation.
H. Toddler may fear being “sucked” into the toilet.
I. Teach proper wiping technique (front to back) and hand washing.
J. Toilet Training - when kid can communicate need to go (non verbal or verbal), holds on to please mom and doesn't let go to please self, sphincter control 18 months - 24 months (myelination of the cord is complete now), motor skill. Ability to stay dry for 2 hours, can sit still on toilet for 5 - 10 minutes without fussing, curiosity about older people's habits. No right or wrong time !
15. When the toddler starts climbing over the crib rails, switch to a bed.
16. Use locks on cabinets, keep handles away from edges of tables or stoves.
17. AVOID bean bag toys.
18. Appropriate toys: Nested toys, toys with parts that open and close. Toys designed for pounding such as play hammers and drums. Toy telephones, dolls. Provide the child with opportunities for positive imitative play. They enjoy simple songs with repetitive rhymes as well as moving in time to music. A musical activity should be scheduled into each day.
19. NUTRITION:
A. Toddler feeds himself, provide finger foods in small portions
B. Because of increased risk of aspiration avoid foods such as hot dogs, grapes, nuts and candy (or cut into small pieces).
C. Nutritional needs decrease because of slow growth period.
D. Child may become a picky eater. Nutritional content of food is important.
E. The toddler shouldn’t drink more than 24 ounces of milk a day in order to have room for other nutritious food.

MILESTONES
By Age 3:
Able to jump in place Able to kick a ball
Able to ride a tricycle Able to state name, age, and gender
Able to copy a cross and circle Most speech is understandable by others
By Age 4:
Able to sing simple songs Able to draw a person with 3 or more body parts
Able to distinguish between reality and fantasy
Able to state first and last name
Able to build tower with at least 10 blocks
Able to hop on one foot at least 3 times
Able to throw ball over handed All speech is understandable
By Age 5: (Enters Kindergarten)
Able to dress self without assistance
Able to state entire name (first, middle, and last)
Able to state home address and home phone number
Able to follow 2-3 step directions
Able to count to 10 on fingers
Able to copy a triangle or square
Able to draw a person with head, body, and all extremities
Able to recognize most letters of the ABC’s and able to print a few
Plays “make believe”
By Age 6:
Able to walk heel/tow forward and backwards
Able to hop on either foot
Able to catch baseball size ball with 2 hands
Able to feed self correctly using knife, fork, and spoon
Able to cut out simple shapes with scissors
Able to distinguish between right and left hand
Able to play games involving matching skills
Able to repeat simples nursery rhymes
Able to choose peers for play
Is protective of younger siblings

NCLEX QUESTIONS
1. When does birth length double - By 4 years
2. When does child sit unsupported - By 8 months
3. When does a child achieve 50% of adult height - 2 years
4. When does a child throw a ball overhand - 2 years
5. When does a child speak 2-3 word sentences - 2 years
6. When does a child use scissors - 4 years
7. When can a child tie his/her shoes - 5 years
8. Girl’s growth spurt during adolescence begins earlier than boys. May begin as early as 10 years old.
9. Temper tantrums are common in the toddler; they are considered normal or average behavior.
10. Adolescence is a time when the child forms his/her identity and that rebellion against family values is common for this age group.

Dont foget to d/c aspirin 48 hours before the pt's scheduled OR.
Page 299 on the forum

The only insulin that can be given IV is Regular which happens to be the only one of the insulins which is clear.

- bethanechol chloride (Urecholine) is used in neurogenic bladder & urinary retention, s/sx of overdose include increased salivation, sweating and flushing, when administering keep atrophine sulfate nearby as an antidote
-don't forget to give bedpan since Urecholine promotes diuresis

- avoid grapefruit juice with cyclosporine (Neoral), it raises blood levels and increases risk of toxicity

• Always administer Morphine IV push slowly,over 5 minutes to avoid cardiac arrest,cirulatory arrest. Administer diuretics in the morning Always administer Lipitor at 17:00 since the enzymes works best during the evening time. • Admisiter ACE inhibitors (prils) with food to avoid gastric upset. Give aspirin with food to avoid gastric irritation. • Aspirin causes ear toxicity,teach patient to report the tinnitus to their HCP. • Dont even admister calcium channel blockers to a patient who just drank a grapefruit juice,doing so can cause the calcium channels blockers to rise to dangerous levels. • Calcium channels blockers are contraindicated for patients with Congestive heart failure,the only calcium channel blocker that can be safely administered to a pt with CHF is Norvasc. • Do not administer NSAIDS to a pt with CHF since NSAIDS promote sodium retention and peripheral vasoconstriction-actions that can make CHF worse.Additionally they reduce the efficiency and intensify the toxicity of diuretics and ACE inhibotors. • Gingo Biloba helps to delay the progression of Alzheimer's Disease. • Dimenhydrinate (dramamine) is the most common OTC drug for motion sickeness. • Sumatriptan (Imitrex) an serotonin receptor agonist is given for migraine headache. • Antihistamines are prescribed for a variety of reasons like nausea,vomitting,dyskinesia,cough,allergy,itching, sedation. • Atropine is an antidote for wild mushroom toxicity,s/s of mushroom toxicity include increased salivation,excessive tearing,diarrhea. • Give iron preparation with orange juice,since citrus juice enhance the absorption of iron. • For cardiac meds, remember if it ends in -ine, such as Atropine...think "it can't be seen"...vasoconstrictor...if it ends in -ide, such as Nipride..think "makes them wide"..as in vasodilator.. • With insulins, remember when mixing, Regular (clear) always comes before NPH (cloudy)...R before N = RN! • Morphine is contraindicated for patients with pancreatitis and gallbladder disease because it cost spasm of the Sphincter of Odi • Sx of right sided heart failure: Shortness of breath Swelling of feet and ankles Urinating more frequently at night Pronounced neck veins Palpitations Irregular fast heartbeat Fatigue Weakness Fainting

• Sx of left sided heart failure: (I think Left with Lung-they both start with L) Cough (produces frothy or blood-tinged mucus) Decreased urine production Difficulty lying down; need to sleep with the head elevated to avoid shortness of breath Fatigue, weakness, faintness Irregular or rapid pulse Palpitations Shortness of breath Waking up due to shortness of breath (paroxysmal nocturnal dyspnea) Weight gain from fluid retention • 1) Gout : low purine diet, avoid organ meat e.g. liver. 2) Hypertension : low sodium diet. 3) Renal calculi, calcium kidney stones : follow alkaline ash diet e.g. spinach, milk, banana. Aim is to increase pH. 4) Post MI : incr troponin T, n/r : 0.1 to 0.2 ng/ml. 5) Post MI: incr isoenzyme for lactic dehydrogenase LDH1. • Always associate FRACTURES with fat embolism Always associate MAJOR SURGERIES with pulmonary embolism. • Mumps: i remember (mumps- enlarged humps on neck & enlarged testicles(orchitis) Rubella: bad for pregnant women • As far as immunization schedule for the infants and children it goes like that the newborns get their first Hepatitis B shot at birth followed by 2 more doses. • Then the babies at 2 months recieve a couple of vaccinations which include (keep in mind that they have to be at least 6 week old) Rotavirus dose (followed by two other doses at different time),DTaP (Diphteria,Tetanus,Pertussis,followed by 4 more doses at different time period),Haemophilus Influenza type b (followed by 3 other doses),Pneumoccocal vaccine (followed by 3 other doses) and finally Inactivated (dont confuse with ACTIVATED,the word can be used as great mislead in one of the NCLEX question,activated polio is no longer given to babies). • Next it is recommended for the babies to get influenza shot,however the baby must be at least 6 month of age to get this vaccine.When the baby turn one year old it is time for MMR (Measles mumps,Rubella all- in -one,remeber that the baby must be at least ONE year old or older),also at the same time the infant can get its first varicella shot and Hepatitis A shot (for both the baby must be at least one year old) • Clozaril - the "Z" in Clozaril - med for SchiZophrenia. Most worrisome complication is agranulocytosis, therefore weekly blood tests must be done • Corticosteroids can cause stomach ulcers. Isoniazid can cause drug induced hepatitis-look for yellow color of the skin,nausea,vomitting. • Before start INH for TB, usually a baseline live function test is recommended. TB skin positive, normal 10mm, if HIV, 5mm is positive • Nclex tips Assess first( check the question to see if the assessment has been done)

Take care of the patient first, the machines and documentation later

Always choose the most complete answer with the least opportunity for error

In Priority question, look for acute and unstable pt to see first

Always remember your ABCs

Maslow's will usually work and pain is seen as a psychosocial need---Not a physical need

Incident or Occurrence reports--Never refer to them in the pt's chart should complete for any time there is a variance from what should have happened with Pt care should not include blame or anything but just the facts when charting, do not use the words, " Error, mistake, accident or incorrect."

Errors in charting are corrected by making one simple line through the words

If a RN comes from another unit, give that RN a pt who does not need to have a RN from specific unite care for him/her. EX. --Post op mastectomy needs an ONco nurse to take with.

Delegation--If you are assigning pt care to LPN/NA, rank order the pt as to the ones who have the least acute problems/changes to the most

Anytime a question comes up about a procedure or diagnostic test, consider the possible complications

Vital signs are a LATE signa of pt status change

Rales=CHF

Rhonchi=pneumonia

Wheezes=asthma

Hemoptysis=Lung cancer or TB

Pleural Pain=Pssible PE

Intercostal retractions=respiratory distress

Role play the situation

Read the question and answers out loud

Safety for the pt is always first, then the family, then the nurse

Never isolate a pt with Alzheimer's disease

Any time a pt has traction applied or a broken bone, consider: Circulation

Movement

Sensation

compartment syndrome

skin integrity

restlessness is often the first sign of hypoxia

if you chose an answer withthe word, why or check in it, make sure it is truly the best answer.

Rarely is the right answer to call the physician--Don't pass the responsibility

Psychiatric pt:

--For someone with psychosis--acknoledge the hallucination or delusion and then realityorientation --for someone with dementia--change the subject, divert the attention

Medications to know: antipsychotics--Haldol, Thorazine, Zyprexa, Geodon\

antidepressants--Tricyclics--typically sedating so take at bedtime, cause otthostasis, dry mouth, very dangerous with OD. NEED to wean off.

MAO-I---low tyramine diet, if they eat something high tyramine--hypertensive crisis

Interact with a lot of other meds, can have hypertensive crisis with other meds

Need to be off other antidepressants for at least 2 wks before starting.

SSRI--can treat anxiety to. Typically take in the morning because they are more likely to be stimulating. Can cause diarrhea. Need to wean off.Serotonin serge.

Anti-mania--lithium--need to have levels drawn, Tend to get increased level if sweating, vomiting. Know the S/S of toxicity. Know normal Li levels( 0.6-1.2)

Anti-seizure family( Depakote, Tegretol, Lamictal, Trileptal, etc) most can lead to liver failure. Should have levels of Depakote/Tegretol done at intervals.

Anti-anxiety-Benzodiazepines----addictive and lead to seizures during withdrawl. Very dangerous if combined with alcohol. Sedating except may have paradoxical

Reaction in the elderly

Safety is always first priority if someone is losing control of her/his behavior.

--must try all other interventions before using restraints/seclusion someone must stay within arms's reach of the pt if they are restraints Need to release one restraint or do Prom every 15 min. Restraint to orders need to be specific and cannot be PRN and only good for 24hrs. Chemical restraints count as restraints

The pt with Depression needs to increase interaction.

the pt with psychosis typically is very concrete in thinkgs and it not going to be able to process groups, etc

Well pt with addictive disorders use the denail as their primary coping mechanism

Manic phase pts need finger foods or calories as they burn a lot being busy

Suicidal pts --look for any phrase that implies helplessness, hopelessness, worthlessness

Post op eye surgery--don't bend at the waist, avoid straining

If someone has an object that has penetrated his/her body, leave it there until it is assessed as safe to remove. • Drugs which are incompatible with INTRAVENOUS Potassium Chloride ( IV KCL)

adrenaline HCL ( this drug also interacts/incompatible with diazepam) amphotericin B ( " " " " " diazepam ) cholesteryl (interacts with ergotamine tartrate) sulfate complex (intereacts with methicillin sodium) atropine sulfate ( interacts with phenytoin sodium) cephalophin sodium ( " " phenytoin ) choramphenicol ( interacts with sulphadiazine sodium ) sodium succinate ( interacts with suxamethoniun chloride ) chlorpromazine HCL ( interacts with thiopentone sodium ) diazepam ergatamine tartarate methicilline sodium phenytoin sodium phenytoin sulphadiazine sodium suxamethonium chloride thiopentone sodium

Drugs which CANNOT be given by IVPush Route

Potassium Chloride (KCL)---never to IVPush Heparin SQ---can be given as a Drip, but no to IVP Route Ibuprofen - PO Insulin---only Regular (clear) can be given intravenous but never IVPush Keppra--PO Lovenox SQ Mestinon PO, IV Florinef PO Dobutamine IV and drip ---NO to IVPush Route Docusate PO Coumadine PO Cefazolin PO/IV/IM -------" " " " Calcium Gluconate PO/IV/IM---never to IVPush Route Atropine IV/PO/IM/SC aspirin PO/PR Albumin IV acetaminophen PO/PR • Differentiating types of Crises for NCLEX mental health related questions

Types of Crises:

Situational Crisis= from an external source

Examples:

a) divorce b) death of a love one c) mental illness d) abortion e) loss of a job f) a change in financial status g) severe physical illness

Advantageous Crisis= from an external source

Examples:

a) earthquake b) flood c) any natural disaster

Maturational Crisis= related to rites of passage

Examples:

a) retirement b) birth of a child c) kids going to college, moving out---empty nest d) marriage
Infection Control

The three bloodborne patogens of most concern to healthcare workers are:

• HIV • Hepatitis B Virus • Hepatitis C Virus
Difference between Universal Precautions and Standard Precautions:

• In 1980's the CDC created specific recommendations known as Universal Precautionsto prevent the spread of bloodborne patogens such as HIV, HBV HCV and other bloodborne diseases in the healthcare environment. • Later Universal Precautions changed from being a CDC recommendation to a workplace regulation enforced by OSHA as a Prevention of Bloodborne Patogens Standard. • Standard Precautions = A set of procedures designated by the CDC to prevent the spread of known and unknown sources of infection via body fluids, excretions and secretions of the skin and oral mucosa. Please note, that the difference for Standard Precautions include all body fluids while Universal Precautions is about bloodborne patogens only. • Memory aid for signs of potential problems for Oral Contraceptives = ACHES

A - Abdominal pain (possible liver/ gallbladder issue) C- Chest pain or SOB (possibility of pulmonary embolus) H - Headache (possibility of hypertension / brain attack) E - Eye problem (possibile hypertension / vascular attack) S - Severe leg pain (possible thromboembolic process)

Cleft Lip: nursing care plan (post OP) = CLEFT2 LIP

Crying = minimize Logan bow Elbow restraints Feed w/ Brecht feeder Teach feeding techniques; average age for repair is TWO months. Liquid (sterile water)/ rinse after feeding Impaired feeding (no sucking) Position - never on abdomen

KAWASAKI DISEASE: Unknown cause Early tx with Gamma globulin to reduce cardio damage. Abrupt onset of fever (102-106 F) lasting more than 5 days that get no better with antibiotics/antipyretics. Conjunctivitis, bilateral and nonpurulent. Peeling of the palms of the hands and feet. Generalized rash on trunk and extremeties, w/o crusts or vesicles.

Lab tests results for KAWASAKI DISEASE = elevated ESR, WBC & Platelet count. [pic] • Screening tests. -women should pay attention to their breast at the age of 20,this is the time when females should start perform self breast examination,once a month 7 days after their menstrual period beggins,they dont have to have a mammograph yet however it is recommended that women between ages 20-29 should have a professional physical examination of breast every three years. -women who are 40 and over should have a mammograph plus physical breast examination done every year. -the first pap smear should be performed at the onset of sexual relations and done annually after a woman reaches the age of 18. -men who turn 50 (or man who are 40 with a risk factors) should have a prostate specific antigen test done annually for prostate cancer. -men who turn 40 should have a rectal digital exam done yearly to screen for colon cancer. -men who turn 50 should have a a guiac test for occult blood done annually (to screen for colon cancer) -men who turn 50 should have a proctoscopy done every 3 to 5 years to screen for a colon cancer. -people especially men when they turn 45 and have a normal cholesterol level should have this test done every five years. -men (especially adolescent men) should perform self-testicular exam every month after a warm shower. -all the people above the age of 21 should have their blood pressure checked. • When drawing two different insulins Cloudy CLEAR CLEAR Cloudy

Air in cloudy air in clear, draw clear draw cloudy

GI assessment Inspect Auscultate Percuss Palpate

Antidote for Coumadin- Vitamin K Antidote for Heparin- Protamine Sulfate • Some antipsychotic drugs end in -done (like risperdone) and -zine (thorazine)

Common side effect of the antipsychotic drugs

-insomia -weight gain -agitation -extrapyramidal movements -orthostatic hypotension -sedation -diziness -headache -dry mouth -trouble urinating -constipation -decrease in WBC

Some popular antipsychotic meds; zyprexa,seroquel,haldol,molindone.geodon,risperido ne,thorazine,clozaril • Spina Bifida- allergy likely to Latex

Streptoccocal glomeruler nephritis----ask if sore throats, pr impetigo (skin condition)- normal BP

nephrotic syndrome- BP high

After pregnancy BP should b normal

What does it matter if a patient has supplement O2 if they are hemmorhaging, okay she they will be hemmorhaging oxygenated blood--ex circulation before airway

spirocyclone- is a potassium sparing diuretic--not exact spelling

Lithium--need to maintain normal sodium intake to not predispose to toxicity

Judisim- really care about pain relief at end of life care, once dead some will stay with body

Celiac Disease-- can have corn subsitutes--includes popcorn as a snack

infant with Hep A----is put on contact precautions becuase incontinent of feces

remember words::: Nance Reagan RN--for insulin adm-----put air into regular, put air into NPH, withdrawal NPH then withdrawal Regular • Blood Transfusion Reactions

Allergic- You will see rash, fever, anaphalyxis reaction as well. Treatment: Oxygen, benadryl, monitor patent airway (ABCs) Hemolytic- It means blood incompatibility. You will see pain in lower back, hypotension, decrease urinary output. Treatment: O2, benadryl, vasopressors, maintain patent airway Febrile- Most common type of reaction, especially for patients who receive a lot of blood. The blood given has antibodies that reacts with the patient's own. You will see fever, chill, nausea , tachy. Treatment: antibiotics Bacteria- gave contaminated blood. You will see hypotension, shock, fever. Treatment: IV fluids, vasopressors, steroids, antibodies.

Some meds.. Adrenergics ( Levophed, Dopamine, Adrenalin, Dobutrex) for CARDIAC ARREST, COPD Anti- Anxiety ( Librium, Xanax, Ativan, Vistaril, Equanil) for MANIC, ANXIETY, PANIC ATTACKS Antacids ( Amphojel, milk of mangnesia, maalox ) for PEPTIC ULCER, INDIGESTION, REFLEX ESOPHAGITIS. CAUTION DONT GIVE ANTACIDS WITH FOOD BECAUSE IT DELAYS GASTRIC EMPTYING. ANTIACIDS INTERFERE WITH ANTIBODIES, INH (TB MED), ORAL CONTRACEPTIVES, IRON PREPARATIONS. Glucocorticoids ( Solu-Cortex, decadron, deltasone) for ADDISON DISEASE, CROHN'S DISEASE, COPD, LEUKEMIAS Mineralcorticoids ( Florinex) for ADRENAL INSUFFICIENCY Cholinergics ( Tensilon, Prostigmin) for MYASTHENIA GRAVIS, POSTPARTUM URINARY RETENTION. Anticonvulsants ( Dilantion, Luminal, Depakote, Tegretol, Klonopin) for SEIZURES

iNFECTION CONTROL airborne- Rubeolla, Herpes zoster, Tb, chicken pox droplet- pneumonia, meningitis contact- MRSA, scabies, RSV

during seizures position patient on his or her side in a lateral position. Jaundice is best observe in sclera, nail beds and mucous membranes. If patient is getting enema and has pain= clamp tubing for 30 seconds and restart the flow at slower rate. After completing a tube feeding- patient is placed on right sie to promote emptying of stomach while preventing aspiration. First step in problem solution is to indentify the problem and generate possible solutions ( MANAGEMENT OF CARE). IOP tends to be higher in the morining, early assessment of glaucoma is good AM for that reason. Bulge test- confirms presence of fluid in the knee. TPN has a higher glucose content, monitor glucose level. Oral anticougulant therapy (coumadin) should be instituted 4 to 5 days before discontinuing heparin therapy....... • 1. Causes of Cor Pulmonale

Cor Pulmonale doesn’t need to be a jolt to think of Colt: use COLT to remember the causes of Cor pulmonale. C- COPD / and Cystic Fibrosis O- Obesity L- Living at high altitude T- Tuberculosis These all increase the heart’s workload and lead to right side hypertrophy.

----------------------------------------------------------------------------------------------------------------------------- 2. Treatment of Cor pulmonale Treatment of Cor pulmonale (right-sided heart failure) can be remembered by using the acronym SODA:

S- Sputum Culture O- O2 administration D- Digoxin A- Antibiotics: to treat any underlying respiratory infection. • Signs and Symptoms of Conjunctivitis Conjunctivitis is redness and swelling of the conjunctiva leading to redness and edema. Since the main cause for the spread of conjunctivitis is poor hand washing use the word SOAP to remember the signs and symptoms of conjunctivitis.

S- Swollen, red eyelids O- Occasional drainage from eye A- An itching or burning P- Photophobia

================================================== ================================================== =================== Rheumatic Fever Signs and Symptoms Rheumatic fever is a complication of untreated strep throat, caused by bacteria called Group A Streptococcus. It is potentially life threatening. Since one of the main symptoms of rheumatic fever is pain in the joints, use the word, JOINTS to remember the signs and symptoms. J- Joints are painful O- Over a long period it can damage the heart I- Infection may be too mild to be recognized N- Nervous system can be affected leading to chorea T- Throat that is sore S- Swollen joints • POINTS TO REMEMBER (PHYSIOLOGY)

CARDIOVASCULAR SYSTEM • Cardiovascular disease is the leading cause of death among Americans. • Take blood pressures correctly 1. Give client 5 minutes rest. 2. Take blood pressure while client is lying, sitting, and standing. 3. Ask client if he/she has recently smoked, drank a beverage containing caffeine or was emotionally upset. If so, repeat blood pressure in 30 minutes. • Rarely, the heart may lie on the right side instead of the left, this is calledDextrocardia. • Valves control the direction of the blood flow through the heart. Flow is unidirectional. • When the atria contract, the atrioventricular valves swing open, allowing the blood to flow down into the ventricles. • When the ventricles contract the valves snap shut preventing blood from flowing back up into the atria. Semilunar valves open allowing blood to eject during ventricular contraction. • If the SA node fails to generate an impulse, the AV node takes over, generating a slower rate. If the AV node fails to generate an impulse, the Bundle of His takes over, generating an even slower rate. If the Bundle of His fails to generate an impulse, the Purkinje fibers take over and generate an even slower rate. • Damaged areas of the heart may also stimulate contractions and produce arrhythmias. • Rapid, short-term control of blood pressure is achieved by cardiac and vascular reflexes that are initiated by stretch receptors (baroreceptors) in the walls of the carotid sinus and the aortic arch. • Many clients with angina or MIs benefit from involvement in a structured cardiac rehabilitation program to assist clients to increase their activity level in a monitored environment. • Current research suggests that life style and personal habits are closely related to cardiac changes once attributed to aging. • The elderly are less able to physically adapt to stressful physical and emotional conditions, because their hearts do three things less quickly: the myocardium contracts less easily, the left ventricle ejects blood less quickly, and the heart is slower to conduct the impulse for a heartbeat. • Because different enzymes are released into the blood at varying periods after a myocardial infarction, it is important to evaluate enzyme levels in relation to the onset of the physical symptoms such as chest pain. • Clients who are in postoperative recovery, on bed rest, obese, taking oral contraceptives or had knee or hip surgery should be monitored closely for thrombophlebitis.
RESPIRATORY

• Oxygen is essential for life. So, before all else, keep airways open and ease breathing. • Clients with chronic lung disease use more oxygen and energy to breathe; this can create a vicious cycle in which the client works harder, and continually requires more oxygen and more energy. • Nursing interventions for clients with lung disease should include pacing of activities, because clients have little reserve for exertion. • Quality of life for clients can be significantly improved if you teach clientsdiaphragmatic breathing and pursed-lip breathing. • Clients with asthma must understand the different types of inhalers and when to use each type. Some are rescue inhalers for acute dyspnea; others are maintenance drugs. • A finger oximeter reading is simply one element of an assessment; it's not the whole picture. • Cyanosis is determined by oxygenation and hemoglobin content; anemic clients may be severely hypoxemic and never turn blue; polycythemic clients may be cyanotic with adequate tissue oxygenation. • Control of pulmonary TB is a serious public health issue. • If a client is in respiratory distress, start out by administering oxygen by non-rebreather mask at 10-15 LPM until the client's condition is clarified or stabilizes. • When caring for a client with a chest tube, you must know whether the client has a leak from the lung. Only when you know there is no leak, should you apply an occlusive dressing. • When caring for a client on a ventilator, if an alarm sounds, first, assess the client. See if the alarm resets or if the cause is obvious. If the alarm continues to sound and the client develops distress, disconnect the client from the ventilator, use a manual resuscitation bag and page or call the respiratory therapist immediately. • To maximize therapeutic effect of inhalers, the key is technique. It is critical to teach clients the right technique and test how well they use the inhaler. • Smoking cessation is critical to reduce the risk and severity of lung disease. Second-hand smoke hurts children most. • Best treatment of pulmonary embolus is prevention by using intermittent compression stockings (with anticoagulants in extra-high risk clients) to prevent clots in deep veins. • TB clients need intensive community follow up to ensure that they continue with pharmacological treatment once discharged from the hospital. Clients who stop therapy too soon are the source for the more deadly multi-drug resistant forms of TB.
NEUROLOGICAL SYSTEM • In Multiple Sclerosis, early changes tend to be in vision and motor sensation; late changes tend to be in cognition and bowel control. • Peripheral nerves can regenerate, but nerves in the spinal cord cannot regenerate. • During a seizure, do not force anything into the client's mouth. • A major problem often associated with a left CVA is an alteration in communication. • Clients with CVAs are at high risk for aspiration. These clients must be evaluated to determine if dysphagia is present. • The rate, rhythm and depth of a client's respirations are more sensitive indicators of intracranial pressure than blood pressure and pulse. • When caring for a comatose client, remember that the hearing is the last sense to be lost. • A CVA can result in a loss of memory, emotional lability and a decreased attention span. • Communication difficulties in a CVA client usually indicate involvement of the dominant hemisphere, usually left, and is associated with right sided hemiplegia or hemiparesis. • The client with myasthenia gravis will have more severe muscle weakness in the morning due to the fact that muscles weaken with activity and regain strength with rest.
EYE
• Anything that dilates the pupil obstructs the canal of Schlemm, increases intraocular pressure. • Color blindness is caused by a deficiency in one or more types of cones and is caused by a sex-linked recessive gene. • Destruction of either the right or left optic nerve tract results in blindness in the respective side of both eyes • When mydriatics are instilled, caution clients that vision will be blurred for up to two hours • Following eye surgery teach client to avoid, for six weeks, activities that can increase IOP o Stooping o Bending from the waist o Heavy lifting o Excessive fluid intake o Emotional upsets o Constrictive clothing around neck o Straining with bowel movement (or straining at stool) • Teach client proper administration of eyedrops • Provide sunglasses for photophobia • Assist with activities of daily living as required • When clients wear eye patches, they lose depth perception. Remember that this loss presents a safety risk. • Systemic disorders that can change ocular status include diabetes mellitus,atherosclerosis, Graves' disease (hyperthyroidism), AIDS, leukemia, lupus erythematosus, rheumatoid arthritis sickle cell disease.
Ear
• Changes in barometric pressure will affect persons with ear disorders • Hearing loss o can be partial or total o can affect one or both ears o can occur in low, medium or high frequencies • AMA formula for hearing loss: hearing is impaired 1.5% for every decibel that the pure tone average exceeds 25 decibels (dB) • A hearing loss of 22.5% usually affects social functionality and requires a hearing aid • Noise exposure is the major cause of hearing loss in the United States • Ask client how he/she communicates: lip-reading, sign language, body gestures, or writing • To gain the client's attention, raise your hand or touch the client's arm • When talking with client, speak slowly and face him/her • Speak toward the client's good ear • If the client wears a hearing aid, allow him/her to show you how it's inserted • Speaking louder to a hearing impaired client does not increase his/her chances of hearing • Communicate the client's hearing loss to other staff members • Ototoxic drugs include: o Aminoglycosides o Antimyobacterials o Thiazides o Loop diuretics o Antineoplastics • Tell clients taking ototoxic drugs to report any signs of dizziness, loss of balance, tinnitus, or hearing loss
GASTRO-INTESTINAL
• Most obstructions occur in the small bowel. • Most large bowel obstructions are caused by cancer. • Onset of cirrhosis is insidious with symptoms such as anorexia, weight loss, malaise, altered bowel habits, nausea and vomiting. • Management of cirrhosis is directed towards avoiding complications. This is achieved by maintaining fluid, electrolyte and nutritional balance. • A client with esophageal varices must be monitored for bleeding (e.g., melena stools, hematemesis, and tachycardia. • The rupture of esophageal varices is life threatening and associated with a high mortality rate. • Pancreatitis is often associated with excessive alcohol ingestion. • Pancreatic cancer is an insidious disease that often goes undetected until its later stages. • Diverticula are most common in the sigmoid colon. • Clients with diverticulosis are often asymptomatic. • A deficiency in dietary fiber is associated with diverticulitis. • Colostomies: an ascending colostomy drains liquid feces, is difficult to train and requires daily irrigation; a descending colostomy drains solid feces and can be controlled. • Frequent liquid stools can be indicative of a fecal impaction or intestinal obstruction. • Bowel sounds tend to be hyperactive in the early phases of an intestinal obstruction.
GENITO-URINARY
• After a urinary catheter is removed, the client may have some burning on urination, frequency and dribbling. These symptoms should subside. • After a TUR (transurethral resection), tell the client that, because the three-way foley catheter has a large diameter, he will continuously feel the urge to void. • After prostatic surgery, it is normal for the client's urine to be blood tinged and for him to pass blood clots and tissue debris. • Because the prostate gland receives a rich blood supply, it is important to observe the client undergoing a prostatectomy for bleeding and shock. • Breast cancer starts with the alteration of a single cell and takes a minimum of two years to become palpable. • At the time of diagnosis, about 1/2 of clients with breast cancer have regional or distant metastasis. • antidisrtythmic drugs:

sodium channel blockers: Lidocaine,quinidine,procainamide-have many adverse reactions given only after other therapies have failed;

Adverse affects;prolonged Qtc or QRS,nausea,vomitting,heart block,confusion,seizures (especially with a lidocaine),rash,sedation,respiratory depression,torsades de pointes,can cause increased bleeding when combine with anticoagulants,should never be taken with potassium channel blockers,increased risk of digoxin toxicity

Potassium channel blockers: Amiodarone,sotalol,can cause hear failure,pulmonary fibrosis,heart block,sinus arrest,liver damage,use suncreen and protect your eyes

anticholinergics : Atropine-for bradycardia associated with increased vagal tone,high-alert drug,can cause flushing of the skin for 20-30 minutes when given by injection,produces anticholigergic effect such as sedation,constipation,dry mouth,urinary retention.

aceytlcholine-sensitive K-current activator:adenosine

uses:chemical conversion of supraventricular tachycardia after failure of vagal maneuver

Adverse affects;transient asystole,dysrythmias,dyspnea,chest tightness,hypotension,flushing,nausea • take tetracycline on emty stomach,do not take it with MILK products-delays absorption. Take statins with at night with meals. Do not administer calcium channel blockers with Grapefruit juice. Do not administer aspirin to people with asthma. Antilipids can cause bleeding and breakdown of skeletal muscles. Niacin is an antilipid and can cause intense flushing,increased serum uric acid (stones),abdominal pain,joint pain. Do not administer beta blockers to pt with COPD or diabetes mellitus. Beta blocker can cause depression in people. Give ampicillin on empt stomach (penicillin can be given without regards to meals) Give captopril one hour before meals.

• Some more drug endings

-zosins-alpha1 blockers,they are used for hypertension and benign prostatic hyperthrophy. -none-phosphodiesterase inhibitors for heart failure when other drugs fail or a pt is awaiting heart transplants,side effects;letal dysrtythmias dangerous drug! -kinase-thrombolytics-for MI,PE,deep vein thrombosis,for the MI must be given within 4 to 6 hr,contraindicated in brain neoplasm,cerebral hemmorage,recent major trauma or spinal surgery,high potential for bleeding.

One more facts always check K+ when administering digoxin (contraindicated in hypokalemia) and -prils (contraindicated in hyperkalemia)

• Calcium Channel Blockers are Very- Verapamil Nice- Nifedipine Drugs- Ditalizem aka Cardizem

• 1st degree heart block looks like NSR but the PR interval is 0.20 or greater 2nd Degree Heart block aka Mobitz 1 alsp aka Wenkeback the PR interval keeps getting longer and longer then suddenly drops a PR interval- remember Wenkebach=Warning (the warning, the PR interval is getting longer and longer) 2nd degree Heart block Type 2- no PR interval getting longer and longer it just suddenly drops (suddenly=serious)

• For Acute MI's remember MONA, not administered in that order : MONA Morphine, O2, Nitroglycerine, Aspirin administration is least invasive to most so that would be : O2, Aspirin, Nitro x3 q5 min, Morphine

• Meds:

---mab for Cancer: bevacizumab (Avastin) blocks the growth of blood vessels to the tumor and cetuximab (Erbitux) and panitumumab (Vectibix) both block the effects of hormone-like factors that promote cancer cell growth. Lung---No.1 Killer among cancer small cell or non-small cell and stage of cancer ; surgery, radiation therapy, chemotherapy, and targeted biological therapies such as bevacizumab (Avastin) and erlotinib (Tarceva). --mab again: for lymphoma; monoclonal antibodies, such as rituximab (Rituxan) and alemtuzumab(Campath), directed at lymphoma cells are used for initial treatment and recurrence of some types of non-Hodgkin lymphoma, as are antibodies linked to a radioactive atom, such as ibritumomab tiuxetan (Zevalin) and iodine I 131 tositumomab (Bexxar).

----"have baby" and "use oral contraceptives " both decrease risk for ovarian cancer. ( I do not know that before, then I should try first). Age is the big risk for ovarian cancer. Then I want to be young forever!!!!!!!! -----Prostate cancer most frequently diagnosed cancer in men. reasons unclear second-leading cause of cancer death in men. chemoprevention: finasteride and dutasteride

• Substance Poisoning and Antidotes Methanol =>ethanol carbon monooxide=>Oxygen Dopamine=>Phentolamine Benzo=>flumazenil Lead=>Succimer Iron=>Deferoxamine

• INTERVENTIONS FOR COPD (using ABCDEF)

A-Aminophylline B-Brochodilators C- Chest Physiotherapy CORTICOSTEROIDS D- Deliver oxygen at 2 liters E- Expectorants F- Force Fluids

Tuberculosis ( Meds) Use RISE

R-Rifampin I-Isoniazid (INH) S-Streptomycin E-Ethambutol

Care of Client After Masectomy (BREAST)

B-Bp not on affected side R- Reach recovery E-Elevate affected side Exension and flexion exercise- initialy (Squeeze a ball) A-Abduction and external rotation should not be initial exercise S-SBE- Once a month- about one week after period T-To promote a positive self image

TURPS

T-Tubes U-Urinary output R- Red drainage P-Pieces of clots S-Spasms

Meniere's Disease

Administer diuretics to decrease endolymph in the cochlea, restrict sodium, lay on affected ear when in bed. TRIAD -vertigo -Tinnitus -Nausea and vomiting.

• pheochromocytoma: neuroendocrine tumor of the medulla of the adrenal glands. This causes and increased secretion of catecholamines (epinephrine, and norepinephrine) Signs and Symptoms same as body's Sympathetic Nervous System Response:

>Elevated HR >Elevated BP >Palpitations >Anxiety >Diaphoresis >Headaches >Pallor >Wt. Loss >Elevated Blood Glucose Level (due to catecholamine stimulation of lipolysis) • Tetany tests:

Chovstek's sign- Tap facial nerve 2 cm anterior to earlobe just below zygomatic arch. Twitching of facial muscles indicates tetany.

Trousseau's sign- Inflate BP cuff to 20mmHg above Systolic. Carpal spasms w/in 2-5 mins indicates tetany.

Abnormal Breathing Patterns:

Cheyenne stokes- "Dead man breathing" Tachypnea with periods of apnea.

Kussmauls breathing- Deep and Fast, seen in pts experiencing Hyperglycemia also look for Fruity Breath.

The diabetes that isn't really a diabetes:

Diabetes Insipidus- Named diabetes b/c of the diuresis it causes similar to that which a person with diabetes would experience. The polyuria is caused by a deficiency of the ADH(Anti-diuretic hormone) causing the patient to excrete alot of urine. Check for Low Specific gravity, hypernatremia, Serum Osmolality may be low for . Pt will have to urinate frequency, have extreme thirst and may easily become dehydrated. Unlike SIADH (syndrome of inappropriate ADH) you want to increase fluid intake to hydrate the patient.

SIADH- Syndrome of Inappropriate ADH or as I like to think of it "Syndrome of IncreasedADH". Common in patients with a damaged CNS (Central Nervous System). Excessive ADH is released from the Pituitary gland resulting in hyponatremia, concentrated urine and fluid overload. • NSAIDS like Ibuprophen (Motrin) can cause GI bleeds, never take on an Empty stomach. Think"NSAIDS take with BREAD"

No milk served with meat- Jews

Clients with physical disabilities frequently respond good to support groups

Do’s and Don’ts

Don’t pass buck Don’t provide false Reassurance Don’t ask why Don’t treat psychosocial first

Do ask patient to express themselves, their concerns

INH can cause liver problems so stay away from alcohol

Risk Factors for Pneumonia Old age, bed ridden, post op, pre existing lung problems

Cane walking- Hold the cane in hand opposite of weak leg and move with weak leg. I.E. with weak right leg, advance left hand (cane) followed by right leg then left leg.

Lying prone prevents flexion contracture of hip

Poor Potassium values Call Physician. Cardiac Emergency! • Pavlik harness- is a harness applied to young children with hip dysplasia. it goes around their mid section and over their shoulders in the front looking like a pair of suspenders. It then makes and x in the back and connects to the child's feet and ankles in the front and back. The child should wear knee high socks and a under shirt to prevent skin break down. Massage the skin under the straps daily (w/out lotions, ointments) SEE HERE

JVD (jugular vein distention) is a symptom of a cardiac tamponade, a complication of CABGs caused by blood accumulating around the heart in the pericardial sac and compressing the myocardium, atrium, and ventricles.

• IF you have a female patient undergoing Peritoneal Dialysis and the output is bloody you need to determine if she is menstruating. The reason being, the dialysate is so concentrated to pull fluid from the abdominal cavity that the hypertonicity may cause blood to be pulled from the uterus through the fallopian tubes and into the effluent. • Here are a few facts:

Use FIRST to help you remember

F- find hypoxia

I- Immunocompromised

R- Real bleeding ( Trauma, hemorrhage)

S-Safety

T- Try infection

For Cardiac It use to be MOAN but the American heart Association has changed it Now it is ONAM

O- Oxygen

N-Nitoglycerine

A- Asprin

M- Morphine • Breast Cancer Risk Factors: • >50 years of age • FIRST child born after 30 years of age • Grandmother, Mother, Sister has it • Personal history of breast cancer • Garlic has a hypoglycemic effect do not give with insulin

Eye problems do not want head in dependent position. Lie on good side and have bad eye upor elevate the head of the bed to 35 degrees.

Lay on right side after liver biopsy.

Clear fluid from head CSF medical emergency call the doctor

1 yr old with nausea, vomiting, and diarrhea is emergency because young children become dehydrated very easily

Assess pt for claustrophobia with CAT scans and MRIs, also, NO METAL. • ALPHABET NURSING FACT:

Activated charcoal - To absorb poison

AAA- Complication is hemorrhage and shock

A positive mantoux test indicate the pt has produced an immune response

Complication of warfarin- (3H) hemorrhage, hematuria and hepatitis

Colchine for treatment of gout attack

Codeine- onset- 30mins, peak- 1hr, duration 4-6hrs

COPD -use of acessory muscle for respiration indicate the pt is having difficulty breathing

Chlamydia, Genital herpes and HPV - Do not report

Crackles are heard on inspiration and dont clear with cough

Diaphramatic and purse lip breathing are the best for pt with COPD

DMD- X-linked recessive and female are carrier and male are affected.

DI- Treatment is DDAVP

Gastric lavage - To remove poison

Indomethacin - helps in closing PDA

Left sided HF- pulmonary

Myelomingocele complication - clubbfoot and hydrocephalus

Meningitis- Droplet

Osteoarthritis- Joint pain, crepitus, heberden's node, bouchard's node and enlarge joints

Pentoxifyline- hemorheologic Agent that improve blood flow and is used to treat intermittent claudication

Prostaglandin E is administerd to provide blood ming and also help to keep open the ductus arteriosus

Right side HF- systemic

Rhonchi are heard on expiration and clear with cough

Rabies- contact precaution

tPA- used to treat Acute MI

Thrombolytic- dissolve clots

To avoid falsely elevated serum digoxin, the nurse should wait @ least 8hrs after administering oral digoxin and @ least 6hrs after administering I.V digoxin to draw a blood sample.

TB- airborne

• Disaster planning

A disaster plan needs to be activated when there is a life threatening situation with a large number of patients involve. A way to remember who to remove first is by using ABC

A- Ambulatory

B- Bed Ridden

C- Critical Care

You may ask why but the goal is to move the greatest number of clients.

Appendicitis- position of comfort is on the side with the legs flexed agains the abdomen. HOB should remain slightly elevated to decrease the upward spread of infection in case the rupturing of appendix occurs.

MEDS that can cause ototoxicity

Aminoglycosides bumetanide, parenteral (Bumex) cisplatin erythromycin ( renal impairment and high doses) ethacrynic acid ( Edecrin) furosemide ( Lasix) hydroxychloroquine ( Plaquenil) nonsteroidal anti-inflammatory drugs (NSAIDs) salicylates ( chronic high doses, overdose) Vancomycin, parenteral ( high doses and renal impairment)

Drugs that can cause Nephrotoxicity

Acetaminophen ( high doses, acute) Acyclovir, parenteral ( Zovirax) aminoglycocides amphotericin B, parenteral ( Fungizone) analgesic combinations containing acetaminophen, asprin, or other salicylates in high doses, chronically ciprofloxacin cisplatin ( Platinol) methotrexate ( high doses) nonsteriodal anti-inflammatory drugs ( NSAIDs) rifampin sulfonamides tetracyclines ( exceptions are doxycline and minocycline) vancomycin, parenteral (Vancocin)

Drugs that can cause Hepatotoxicity

ACE inhibitors acetaminophen alcohol iron overdose erythromycins estrogens fluconazole ( Diflucan) isoniazid ( INH) itraconazole ( Sporanox) Ketoconazole ( Nizoral) nonsterodial anti-inflammatory drugs ( NSAIDs) phenothiazines Phenytoin ( Dilantin) rifampin ( Rifadin) sulfamethooxazole and trimethoprin ( Bactrin, Septra) Sulfonamides

• Differentiating Parathyroid Hormone and Calcitonin's effect on calcium placement.

Calci-Tonin increases Calcium in the BONE

PTH- Puts The calcium in the Heme (blood) • Protease Inhibitors

indinavir ( Crixivan) nelfinavir ( Viracept) ritonavir ( Norvir) saquinvir ( Invirase)

If you notice all end in vir

Nucleoside or Reverse transcriptase inhibitors

didanosine ( Videx) lamivudine ( Epivir)) stavudine ( Zerit) zalcitabine (HIVID) zidovudine ( Retrovir)

Notice all of these end in (ine) • What helps me most with math problems is to break everything down into its lowest components. For example, if you have 3gr or 180mg in 500ml, how many ml per single mg? Divide 500 by 180. Once you know how many ml are in a single mg, you can multiply to get your answer • Pericarditis *chest pain, dry cough, fever, fatigue, anxiety. Tx w/ steriods, pericardiocentesis, antibiotics, colchicine. Myocarditis *Chest pain, CHF sx, palpitations. BPH *weak urine stream, heard to start urination, dysuria, nocturia, frequency.

Labs to look for w/ dehydration *increased specific gravity, increased urine and serum osmolarity, HYPERnatremia (think less water...so the sodium becomes very concentrated) increased HCT, BUN....Anyone think of any I have forgotten??

ACE inhib *dizziness, HA, hypotension. Pulm embolism *low grade fever, tachycardia, blood tinged sputum. COPD prolonged expiratory phase.

Tension Pneumo *trachea deviate to opposite side ( I remember it like OP-opposite=pneumo, same=atelectasis.) hypotension and bradycardia. Albuterol *tachycardia, nervousness, insomnia, anxiety. Hip fracture *Fractured leg shorter, externally rotated, adducted. Radiation *Stomatsis(irriation of mucous membrane), Xerostomia(dry mouth) and dysgeuia(decreased taste)

*protrusion of ileal conduit=stoma prolapse. *Take nystatin after meals. *lower lung sounds-vesicular close to trachea(but not directly over)=bronchial *Multiple mylomas=increased immunloglobins expected. • COMMON DRUGS THAT SHOULD NOT BE CRUSHED Trade name Generic Name

Cardizem.......................................... diltiazem hydrochlride Depakote.........................................divalproex sodium valproic acid EES............................................... .erythromycin ethylsuccinate E-mycin...........................................er ythromycin base Erythromycin ...................................erythromycin estolate Feosol............................................ .ferrous sulfate Glucotrol XL......................................glipzide Klor-con...........................................pota ssium chloride K-tab............................................... potassium chloride MS Contin.........................................mor phine sulfate Phazyme........................................... simethicone Prilosec.......................................... ...omeprazole Prozac............................................ ..fluoxetine hydrochloride Slow-K..............................................pot assium chloride Theobid........................................... ..theophylline Theo-Dur...........................................theo philline • to enhance ingestion and prevent aspiration have your patient sit up. If sitting up position is not possible, a side-lying position will also work. • when obtaining a bottle of medication you must watch for: expiration date, patient name, dose and route. • the usual gauge (size of the needle) for an IM injection is 19-23. • The greater the viscosity (thickness) of the medication the larger the gauge (circumference of the needle) needs to be. • for administering blood the usual gauge is 19 • larger gauge = smaller gauge number • for IM injections given to adults the usual needle length is 1, 1 and a half (1/2) or 2 inches • the dorsogluteal (upper, outer quadrant of the buttock) is the traditional site for IM injections • for infants under 7 months, the vastus lateralis site if preferred because that muscle is more developed than other sites. • Brown pigmentation around the ankles of patient indicates venous insufficeny

Cloudy outflow during peritoneal dialysis indication of infection and needs to be reporeted to MD

Afte colonoscopy a patient should report rebound tenderness. Abdominal cramping, fatigue and passage of liquid stool are all normal findings after colonoscopy.

A patient with pertussis should be in a private room, mask and under droplet precautions.

Hydromorhone ( Dilaudin) can Cause urinary retention.

Respite care important for caretaker of Alzheimer's patient to allow for physical and emotional rest.

Antihistamines can cause urinary retention and exacerbate symptoms of BPH.

Applying pressure to the inner cantus of the eye prevents overflow of medication into the nasolacrimal duct and possibly systemic absorption.

Ethical dilema- Determination of facts. identify possible solutions, consider patients wishes.

An Increase in peak expiratory flow rate indicates that airway restriction is resolving ( asthma patient)

Salem sum tube- turn patient every 2 hours to promote emptying of stomach contents.

Fatigue, abdominal bloating and persistent dyspnea of patient with COPD contributes to patients inability to maintain adequate nutrition.

Serosanguienous drainage beyond post-op day 5 may indicate dehiscence; therefore surgeon should be notified.

There is no need for a parent of a child who is HIV positive to notify the childs daycare provider.

INDERAL- serious side effect decrease heartrate due to blockade of betta1 receptors in the heart.

Bulima patient with bloody emesis due to esophageal tears due to purging.

Pacemaker spikes on T wave indicate that the pacemaker is not capturing appropriately and should be adjusted for this patient.

A patient who is having muscle spasm while in traction should be repositioned to see if the spasms decrease.

REASONS FOR UNCONSCIOUSNESS (skin Color)

RED- Stroke or increase in blood pressure

BLUE- Respiratory or cardiac arrest

WHITE- Shock or Hemorrhage.

BETA BLOCKERS

B-bronchospasm(do not give to asthma, bronchial constriction patients)

E- elicits a decrease in cardiac out put and contractility.

T- treats hypertension

A- Av conduction decreases

T- tenormin ( atenolol) hypertension & angina

L- Lopressor ( metopolol) hypertension & angina

C- Corgard ( naldolol) hypertension & angina ( renally excreted)

Glomerulonephritis- fever, periorbital edema, weakness, and chills caused by grop B strep.

It is normal for a patient that has had dialysis to have a slight fever afterwards due to the dialysis solution being warmed by the machine.

Positive sweat test indicative of cystic fibrosis.

After thyroid surgery- maintain airway keep a trach kit at patients bedside, check for bleeding, be sure to check at sides and back of neck due to gravity and teach patient to support their neck.

• B-1 (thiamine) and all B vitamins – Alcoholic (to prevent Wernicke’s encephalopathy and Korsakoff’s syndrome.

B-6 (pyridoxide hydrochloride) –TB patient (Pt is likely on INH which can cause peripheral neuropathy, dizziness, and ataxias, B-6 can prevent these unwanted affects).

B-9 (folic acid) – Pregnant pt to prevent neural tube defects in fetus

B-12 (cobalamine) – Pernicious anemia (autoimmune disease that attacks the parietal cells preventing intrinsic factor from being released, which is needed to absorb B-12.

• clozapine (Clozaril) can cause agranulocytosis so teach pt to watch for sore throat and fever!

phentoin (Dilantin) is EXTREMELY hepatotoxic; if liver is impaired, may cause toxicity of Dilantin b/c it can't be metabolized & builds up

• Cardiovascular toxicity is an issue that arises with the use of tricyclic antidepressants, so question such an order if the client has cardiac disease.

• Knowing Potentials Creates Meaning

K ↑ Po4↑============= Ca↓ Mg ↓============ ↑ Action Potentials seen in S/S

K ↓ Po4↓ ============= Ca↑ Mg↑ ============= ↓ Action Potentials seen in S/S

• Lung CA is a common cause of SIADH which results in an increased water absorption and dilutional hyponatremia...

• Droplet Precautions • Nurses and guests Use regular mask; clients wear surgical mask on transport • Droplets larger than 5 microns • Use standard prec within 3 feet • Private room • May be cohorted with clients with same infection without any additional infection • Diphtheria, Mycoplasma pneumonia, rubella, Pertussis, mumps, strep pharyngitis, pneumonia, scarlet fever • Door to room may remain open

• Airborne

• Negative air pressure room • N-95 respirator mask • Avoid coughing and sneezing into another person; use napkins/wipes • Tuberculosis

• Contact Isolation • Private room • Use gown, gloves and mask • Example: • Clostridium difficile B infection

• Putting Gown, Mask, Gloves • 1. Wash hands • 2. Place mask on face • 3. Put on gown • 4. Put on clean or sterile gloves

• Removing Gown, Glove, Mask 1. Remove gloves 2. Remove mask 3. Untie gown 4. Wash hands 5. Remove gown 6. Fold it inside out and discard 7. Wash hands again

• CHVOSTEK’S SIGN • Sign of hypocalcemia • Characterized by twitching when tapped on the facial muscle • hypoparathyroidism

• TB Test • Positive skin test (Mantoux test)- 10 mm induration; not redness/erythema • Indicates exposure to bacilli • Confirmatory: • Chest X-ray, 3 (+) sputum AFB

• Universal Precautions • “Everybody is infected” • Body, body fluids, secretions, excretions, • Mask, eye shields, gloves, gown • Hand hygiene

• Myocardial Infarction (MI)

• Immediate treatment: MONA Morphine, Oxygen, Nitroglycerine, ASA

• Hypoxia • Early signs: REMEMBER (RAT) • Restlessness, Anxiety,Tachycardia / Tachypnea

• • Late signs: REMEMBER (BED) • Bradycardia, Extreme restlessness, Dyspnea (severe)

• Iron Administration • REMEMBER: • Iron supplements IM or IV----iron dextran (IV route is preferred) • IM causes pain, skin staining, higher incidence of anaphylaxis • Take oral supplements with meals if experience GI upset • Then resume between meals for max absorption • Use straw if liquids are used

Depression & Suicidal

• Depression and signs and symptoms of suicide: watch for suicidal ideation. • Suicide alert: when depressed mood begins to lift and/or energy level increase.

• INH • Prevent and treat TB • Remember when taking INH • Do not drink alcohol • Take vitamin B6 to prevent peripheral neuropathy • Take with food if not tolerated on an empty stomach • Do not get pregnant

• Growth & Development • Birth weight doubles in 6 months • Pre-schooler - has imaginary friends • Infant gains head control by 4 months • Posterior fontanel closes at 2-3 months • Anterior fontanel closes by 12-18 months

• Patient on MAOI • Monoamine Oxidase Inhibitors • No tyramine containing foods. • No aged cheese, wine or pickles

• Insulin • Clear first before cloudy • Regular first before NPH

• Pneumonia • Productive cough, yellow blood streaked • Rusty sputum - infection

• Contact Precautions • While giving bath and changing linens for a client with MRSA infection the nurse should: –Wear gown and gloves when giving direct care or touching contaminated surfaces –Wear gloves before entering room and remove before leaving room –Wash hands after removing gloves

• Are you planning to kill yourself? A client who is terminally ill says to the nurse, “This is too much for me. You have been very good to me so I will give you my watch.” The nurse’s response should be: a. “Give it to your family.” b. “Keep it.” c. “Are you planning to kill yourself?” d. “Don’t worry.”

• Closed Liver Biopsy • PRE: – NPO 4-6 hours – Consent – Reinforce teaching about procedure – Baseline VS, bleeding parameter – Empty bladder – Supine position on far right side

• Liver Biopsy • DURING: – Hold breath after exhalation to keep diaphragm and liver high in abdominal cavity during insertion – Needle insertion between the 6th-7th ICS – 10 -15 seconds to obtain tissue

• Liver Biopsy • AFTER: – Apply direct pressure right after needle removal – Right side lying position – Vitals to check for bleeding – NPO for 2 more hours – No coughing, lifting, or straining for 1-2 weeks

• Myxedema • Adult form of hypothyroid crisis • Characterized by mental sluggishness, drowsiness, lethargy progressing to coma; • Hypotension

• Which among these patients need a private room? • HIV patient • Client awaiting renal transplant • Hepatitis • Scabies • Answer: Scabies is caused by sarcoptes scabei leading to skin infestation. Female mite burrows in areas between fingers and toes and warm folds of the body such as axilla, groin, to lay eggs.

• Scabies • S/S: • Burrows - visible dark lines • Mite - seen as black dot at end of burrow • Severe itching • Scratching with resulting secondary infection

• Scabies Treatment • Permethrin Cream (Elimite) • Lindane lotion • Scrub body with soap and water then apply lotion on all areas except the face • Leave permethrin on the skin for 8-12 hours and then wash off completely with warm water • All who had close contact with person within 30-60 day period should be treated

• Hearing Impaired • DO not touch patient until they are aware you’re in the room • Speak to the face • Articulate clearly but not too slowly • Move close to patient; do not cover mouth with hands • Provide alternate methods of communicating: Magic Slate, Sign

• A mother is concerned of a breastfed baby about gaining too much weight! • With adequate output (DIAPER COUNT) in infants this ensures adequacy of nutritional intake

• Which should a nurse see first among these clients in active labor? • Gravida 1 para 0 with bulging of membranes • Gravida 2 1 cm dilated • Para 4, 1 cm dilated with history of C-section • Para 5, 2cm dilated

• Answer • Para 4 with hx of c section takes priority in order monitor and prevent the occurrence of uterine rupture.

• Which one of these patient assignment for a travel nurse should be reassigned? • HIV client • Client with contagious disease • Client who just developed a rash • Patient with green purulent sputum Answer: Client with RASH as this requires

• Verbal Orders • Which of these medications need a specific written order from aprescribing physician? • Insulin • Digoxin • Coumadin • Chemotherapeutic agents • Answer: Chemotherapeutic agents as this requires also double checking with a chemo certified RN. A chemo certification is required for administration of chemo agents

• Conversion Guide • • 1tsp=5ml • 3tsp= 1 Tbsp • 0.06ml= 1 minim= 1 drop • 10z= 30ml • 1 kg=1000mg • 1mg=1000mcg • • 1kg= 2.2 pounds

• Safest site for Intramuscular injections??? • • Vastus lateralis • Deltoid • Gluteus maximus • Rectus abdominis • Answer: VASTUS LATERALIS is the safest spot because it doesn’t contain important nervous tissues that may be damaged and it is less • vascular than the other areas mentioned

• Medication Administration • • 7 Rs: • Right Drug • Right Amount • Right Route • Right time • Right patient • Right approach • • Right documentation

• Medication Administration • 2 ml= maximum volume of injection per site • Ear drops: – 1-3 years: pull pinna down and back – Above 3 years: pull pinna up and back – Rationale: shorter ear canal in children Microdrop factor for IV fluids- 60 Macrodrop factor for IV fluids- 15 Blood transfusions run for 4-6 hours

• INSULINS • Draw clear followed by cloudy insulins to avoid contamination of clear insulins by the cloudy insulins • Roll vials in between palms • Rotate injection sites to prevent lipodystrophy • Be reminded of the peak hours of insulin administered- this is the best time to provide snacks as this time hypoglycemic effect of insulin is peaks • Facilitate difusion of glucose from plasma to cells • Uses: treatment of diabetes mellitus and its acute complications • Given as subcutaneous shots or IV drip • S/E- HYPOGLYCEMIA • Lipodystrophy

• DIGOXIN • LANOXIN • Given for mild to severe heart failure • (+) inotropic effect- increases force of ventricular contraction • (-) chronotropic effect- decreases heart rate • Check pulse rate prior- do not give if below 60/min • Side effects: Halo vision, yellow vision, bradycardia • Earliest s/e: anorexia, nausea, vomiting

• Digoxin and Dudes and Babies • DO NOT GIVE IF HEART RATE • Newborn- below 100/min • 1-3 years old- below 90/min • 3-8 years old- below 70/min • 8 years old and above- below 60/min

• Bronchodilators • Review relevant history , VS, character of secretions, other conditions • Monitor VS and breath sounds • Increase fluid intake 2 to 3 Liters/day • Therapeutic levels of theophylline should be maintained • Evaluate responses to medication • S/E: CNS stimulation,Tachycradia, tremors, headache, nausea, epigastric pain, bronchospasm

• Diapers weight for volume approximation • 1 liter of fluid= I kilogram of weight assuming dry weight of the source (diaper) has been subtracted

• Head lice • S/S: severe itching in affected areas; appearance of lice on hair or clothing • Tx: Kwell/lindane shampoo Extra-fine-tooth comb • Wash all linens and clothing in hot water to destroy nits and eggs

• Potassium Rich Diet • Fruits and fruit juices • Dried fruits/plums • Apricots • Bananas • Cantaloupe • Water melon

• Sickle cell Anemia • Mgt: • Oxygenation • Hydration • Rest • Diet: High calorie High protein, increased fluids • Folic acid supplementation for anemia

• Open-angle VS Close-angle Glaucoma Open-angle- loss of peripheral vision, tunnel vison, difficulty adapting to the dark, halos around lights, difficulty focusing on near objects Vague symptoms with client unaware of them for a time; visual acuity deteriorates over time with increasing IOP Close-angle glaucoma- triggered by pupil dilationhigh emotions and darkness; S/s: severe eye and face pain, N&V, cplored halos around lights

• Crutches Use palms of the hands when crutch walking Going upstairs: “Good boys go to heaven” good leg goes first bad leg goes last

• Suppository Administration • 2 inches vaginally or rectally • Lube it!!!! • Nothing more nothing less

• Cardiac diet • Low sodium • Low cholesterol • For heart failure: low sodium • For hypertension: low na, low fat • For MI: low Na, low fat

• Opening a Sterile Package • Check label for contents, expiry date, instructions • Break seal, touching only edge of package. Open one flap away from you. Do not bend over package • Open side flap, let fall on flat surface. Repeat same with other flap. • Lift flap nearest you

• Inhalers • Hold inhaler 2 inches away from mouth • Shake canister before each puff • Exhalethrough pursed lips • Depress inhalation device slowly and deeply through the mouth • Hold breath for 10 sec and exhale slowly with pursed lips • Wait 2-5 min between puffs

• Spacers • Place lips tightly around mouthpiece so no medication will escape • Same process as any inhalers • Good care of spacer: warm water rinses

• MEDS for Hyperthyroidism • Antithyroids:Methimazole (Tapazole) • Beta-blockers: Propranolol (Inderal) • Iodine: Lugol’s solution • Radiation: Radioactive Iodine 131

• Iron Rich Foods • Red meats • Egg yolks • Leafy vegetables • Whole wheat breads • Legumes • Dried fruits

• Potassium Rich Foods • Apricots • Avocado • Banana • Cantaloupe • Raw carrots • Dried peas, beans, fruits • Melon, orange, orange juice • Peanuts, white/sweet potatoes • Prune juice, spinach • Tomatoes and tomato products, winter squash

• Insulins Peak hours: • Regular insulin- 2-4 hours • Insulin Aspart (Novolog)- 1-3 hours • Inslulin lispro (Humalog)- 1 hour • NPH/Humulin N- 6-12 hours • Insulin Zinc (Lente)- 8-12 hours • Ultralente- 18-24 hours • Insulin glargine- 5 hours • Humulin 70/30 4-8 hours

• Appendicitis • Pain: located at McBurney’s angle; right lower quadrant pain with rebound tenderness • Elevated WBCs • Surgery stat • Preop: NPO, no enemas, no pain medications,no heat applications just cold packs, IVFs, check lytes; Semi Fowler’s right side-lying to localize infection • Postop: immediate ambulation in 6-8 hours

• Hypoglycemia • • Always a priority!!!! • Can cause brain damage • Manage according to facility protocol • Glucose tabs, Orange/apple juice if awake • Dextrose 50% 1/2 amp to 1 ampule IV • Glucagon shot • Dextrose 10% IV infusion

• SLE Systemic Lupus Erythematosus • Nursing Interventions: – Emotional support in coping with prognosis – Alternative activity and planned rest periods – Avoid persons with infections, undue exposure to sunlight, and emotional stress to prevent exacerbations – Diet: high in Iron : liver, shellfish, leafy vegies, enriched bread and cereals

• Restraints • Release every 2 hours for med-surg restraints and check every 1 hour for color movement and sensation in the extremity involved • Requires order renewal every 24 hours • Siderails, medications are considered restraints

• Bone Scan • Isotope imaging of skeleton • Prep: IV injection of radioactive tracer • Empty bladder prior; hold fluids 4-6 hours prior to scan • Takes about an hour • May be asked for various positions during test • C/I: pregnancy; barium enema

• Crohn’s Disease • Inflammatory disease affecting small bowels and possibly large bowels characterized by ulcerations in intestinal linings, scar tissue formation causing narrowing and thickness in bowels • Unknown cause • May lead to perforation, stricture and obstruction

• Crohn’s Disease S/S: – Abdominal pain and cramping – Diarrhea –Weight loss – Fever – Anemia –Weakness and fatigue – Anorexia – Abdominal tenderness

• Crohn’s Disease • Meds: Sedatives, antidiarrheals, antibiotics, steroids, antispasmodics and analgesics • Hydration with IVF • High calorie, high-protein, low-residue diet

• Occult Blood Testing • Avoid red meats 3 days prior to test • May use stool specimen

• anytime your pt is taking Antabuse , you should instruct them on AVOIDING any meds that contain alcohol, such as OTC drugs

• 1.Conjuctivitis-until discharge ceases. 2.Diarrhea (with other acute symptoms)-until symptoms resolve and Salmonella infection is ruled out. 3.Hepatis A-until 7 days after the onset of jaundice. 4.Hepatits B (acute)-partial client restriction with gloves worn for procedures involving tissue trauma and mucous membrane or non-intact skin. 5.Hepatitis B (chronic) -unit antigenemia resolves. 6.Group A streptoccocal Infection-until 24 hours after the start of the treatment. 7.Herpes simplex (hands)-until lesion resolve. 8.Herpes Zoster (acute)-Exclusion from care of clients at high risk for infection with use of appropiate barriers. 9.Herpes Zoster (postexposure)-From days 10 to 21 after exposure or until all lesion dry and crust. 10.measles (active)-until 7 days after rash appear. 11.Measles (post-exposure)-from day 5 to 21 after exposure 12.Mumps(active)-Until 9 day after after onset of parotitis 13.Mumps(post exposure)-from days 12 to 26 after exposure. 14.Scabies-until treated 15.S.Aureus skin lesions-until lesion resolve. 16.Upper respiratory infections-Until acute symptoms resolve with exclusion from care of clients at high risk for infection. 17.Varicella (acute)-until all lesions dry and crust. 18.Varicella (post-exposure)-from day 10 to 21 after exposure.

Transmision based precautions

Precautions-Indications.

Airborne-private,negative airflow room with adequate filtration;mask;mask required by client during transport out of the room,transmission via airborne route;measles,TB,varicella.

Droplet-private room or cohabitation with client infected with the same organism;mask required when working within 3 feet of of client;mask worn by client during transport,transmission of large droplets through sneezing,coughing,talking,haemophilus influenza,multidrug resistant strains,neisseria meningitidis,diphtheria,rubella,mycoplasma pneumonia,mumps,scarlet fever,strep throat,epiglottis

Steps of the procedure of preparing and maintaining sterile field

Equipment: *Flat work surface *sterile drape. *sterile supplies as needed (sterile gauze,sterile basin,solutions,scissors,foreceps),packed sterile gloves.

1.Wash your hands 2.Check for the integrity of the sterile package,expiration date etc. 3.During the entire procedure,NEVER turn your back on the sterile field or lower your hands below the level of the field. 4.Open the sterile drape *start from the outer wrapper and place the inner drape in the center of the of the work surface with the outer flap facing away from you *touching the outside of the flap only,reach around rather than over the sterile field to open the flap away from you first *open the side flaps,in the same manner,using the right hand for the right flap and the left hand for the left flap. 5.Lastly ,open the inner most flap that faces you,being careful that it does not touch your clothing or any object.

Adding sterile supplies to the the field.

general rule *generally before opening the sterile package you want to assess the order in which supplies will be used during the procedure so that supplies used first can be added to the field last

1.Prepackaged sterile supplies are open by peeling back the partially sealed edges with both hands or lifting up the unsealed edge,taking care not to touch the supplies with your hands. 2.Hold supplies 10 to 12 inches above the field and allow them to fall to the middle of the sterile field.Wrapped sterile supplies are added by grasping the sterile object with one hand and unwrapping the flaps with the other hand. 3.Grasp the corners of the wrapper with the free hand and hold them against the wrists of the other hand while you carefully drop the subject onto the sterile field.

Adding sterile solutions to a sterile field 1.Read the solution label and expiration date 2.Remove cap and place it within facing up on the flat surface.Do not touch the inside of the cap or rim of the bottle. 3.Hold bottle 6 inches above the container on the sterile field and pour slowly to avoid spills. 4.Recap the solution bottle and label it with date and time of opening if the solution is to be reused. 5.Add any additonal supplies and don sterile gloves before starting the procedure.

• 7. Diltiazem ( Cardizem ) adverse reaction is Heart Failure, hypotention Calcium channel blocking agents, such as diltiazem, are used cautiously in clients with conditions that could be worsened by the medication, such as aortic stenosis, bradycardia, heart failure, acute myocardial infarction, and hypotension. 8. Furosemide adverse effect Nocturia and sleep disturbances. 9. Anticholinergic agents cause Dry mouth and urine retention. 10. Atenolol ( Tenormin ) Decrease cardiac output and systolic and diastolic blood pressure. Atenolol may cause bradycardia. 11. Dexamethasone used to decrease cerebral edema and pressure. 12. Methyldopa to reduce blood pressure. 13. Phenytoin to prevent seizure. 14. propranolol adverse effects nausea vomiting depression fatigue impotence. 15. Morphine adverse effects Sedation nausea vomiting constipation and respiratory depression. 16. Nifedipine adverse effects flushing dizziness headache and pedal edema. The client receiving a calcium channel blocking agent such as nifedipine may develop weakness and lethargy as expected effects of the medication. 17. Atrophine used to treat bradycardia. 18. Dobutamine used ti treat heart failure and low cardiac output.cardia. 19. Amiodarone used to treat ventricular fibrillation and unstable ventricular tachycardia. 20. Lidocaine used to treat ventricular ectopy ventricular tachycardia and ventricular fibrillation. 21 PTSA give antocoagulant aspirin 22. Hydrochlorothiazide is a potassium-losing diuretic, and clients are at risk for hypokalemia. Potassium is found in many foods, especially unprocessed foods, many vegetables, fruits, and fresh meats. Because potassium is very water-soluble, foods that are prepared in water are often lower in potassium than the same foods cooked another way (e.g., boiled versus baked potato). Clients who need potassium added to the diet are encouraged to take in these foods. Many salt substitutes are also high in potassium. 23. Phenazopyridine ( Pyridium)--Urine will appear orange. 24.Co trimoxazole ( trimethoprim-sulfamethoxazole) given for uti tell pt to drink at least eight 8 oz glasses of fluid daily. 25.Sulfamethoxazole (Gentanlol) adverse effect diarrhea. 26. Co trimoxazole ( Septra) Used to treat UTI and therefore absence of bacteria on urine culture indicates drug effective. 27. phenazopyridine ( pyridium) Used to treat UTI 28. Aldosterone is responsible for sodium reabsorption and potassium excreation by the kidney. 29. During oliguria phase fluids should be limit. 30. Dipyridamole ( Persantine ) to reverse effect if Dipyridamole nurse should have available Aminophyllin ( Theophylline )

• Grave disease-hyperthyroidism • Anxiety • Irritability • Difficulty sleeping • Fatigue • A rapid or irregular heartbeat • A fine tremor of your hands or fingers • An increase in perspiration • Sensitivity to heat • Weight loss, despite normal food intake • Brittle hair • Enlargement of your thyroid gland (goiter) • Change in menstrual cycles • Frequent bowel movements

• Pharm Prefix/Suffix:

-ase = thrombolytic -azepam = benzodiazepine -azine = antiemetic; phenothiazide -azole = proton pump inhibitor, antifungal -barbital = barbiturate -coxib (cox 2 enzyme blockers -cep/-cef = anti-infectives -caine = anesthetics -cillin = penicillin -cycline = antibiotic -dipine = calcium channel blocker -floxacin = antibiotic -ipramine = Tricyclic antidepressant -ine = reverse transcriptase inhibitors, antihistamines -kinase = thrombolytics -lone, pred- = corticosteroid -mab = monoclonal antibiotics -micin = antibiotic, aminoglycoside -navir = protease inhibitor nitr-, -nitr- = nitrate/vasodilator -olol = beta antagonist -oxin = cardiac glycoside -parin = anticoagulant -prazole = PPI’s -phylline = bronchodilator -pril = ACE inhibitor -statin = cholesterol lowering agent -sartan = angiotensin receptor blocker -sone = glucocorticoid -stigmine = cholinergics -terol = Beta 2 Agonist -thiazide = diuretic -tidine = antiulcer -trophin = Pituitary Hormone -vir = anti-viral, protease inhibitors -zosin = Alpha 1 Antagonist -zolam = benzo/sedative -zine = antihistamine

• Alpha vs. Beta: ABCDE

Alpha = Constricts Beta = Dilates Beta 1 = Enhances

Rennin stops the runnin' (HOH retention)

Agonist vs. Antagonist AGOnst - "A GO' - stimulates action ANTAGOnist - "ANTI "NO GO" - blocks action

Drug Overdoses - ABCD

Anti Depressants (Tricyclics) Beta Blockers Calcium Channel Blockers Digoxin

Diuretics: Lasix = Loop Mannitol = osmotic

LASIX = LAsts SIX hours

Aluminum vs. Magnesium Antacid SE's

Think aluminum can - b/c it can constipate Mag - may move bowels (diarrhea)

Give Narcan for Narcotic OD

Opioid Examples: Her Cousin Meets More Deviates - Heroin - Codeine - Methadone - Morphine - Demerol

• Pepper has bacteria in it and clients who have aids have to avoid pepper d/t being immunocompromised. Never would have though of that till it came up as a review question.

• ANTICOAGULANTS - ends in parin, rin THROMBOLYTICS - ends in ase, kinase ACE INHIBITORS - ends in pril ANGIOTENSIN II RECEPTOR BLOCKER- ends in sartan ALPHA ADRENERGIC - ends in zocin BETA-BLOCKERS - ends in olol CALCIUM CHANNEL BLOCKER - ends in dipine DIRECT ACTING VASODILATORS - starts with nitro CARDIAC GLYCOSIDES - starts with dig BRONCHODILATORS - ends in terol, terenol, phrine, phylline ANTIHISTAMINES - ends in tadine, amine, ramine H2 BLOCKER - ends in tidine ANTI-EMETICS - ends in setron PANCREATIC ENZYME REPLACEMENT - starts with pancrea ADH MEDS - ends in pressin THYROID MEDS - starts with thyro, thy, thro CALCIUM REGULATORS - ends in dronate (hypocalcemia), tonin (hypercalcemia) SULFONYLUREAS - ends in ide, amide, zide, ride NON-SULFONYLUREAS - ends in glinide, glitazone ANTIBIOTICS - ends in cillin CEPHALOSPORINS - starts with ceph, cef AMINOGLYCOSIDE - ends with mycin, micin QUINOLONES - ends in floxacin, oxacin

• *An antiacid shouldn't be taken w/ medication bcs antacid will affect the absorption of the medication.

*Lopressor---lowers blood pressure

Lo---Low

pressor---pressure

*Angiotensin-converting enzyme meds (ACE)---they end with "pril" such as Ecopril which are for treating hypertension.

• Colloidal Silver is usually excreted from the body when administered in low amounts (under 50 mg per day), but when it accumulates, it can cause "argyria" which turns the skin grey or BLUE!

• lol's -betablockers prils- ace inhibitors PTT- Heparin (because the two "tt's" make an H) INR- Warfarin

• BIOLOGICAL WARFARE: BP-AS-TOLERATED-FEVER

B - botulism > (AFW) - Air,Food,Wound contaminated P - Plague > (FleaR) - Fleas, Rodents A - anthrax > (GIS) - Gastrointestinal,Inhalation,skin S - Smallpox > Air Droplet, Materials contaminated Tolerated - tularemia > (Till death Apart) Tick,Deer flies, Animal infected Fever - hemorrhagic Fever > (MR) Mosquitoes, Roddents

• sources of potassium P - potatoes,pork,beef,veel O-oranges T-tomatoes A-avacado,banana,carrots,cantaloupe S- spinach S-strawberries,raisins I- fIsh U M-mushrooms

• Five quick facts for today. Maternity: 1) Mother's temp > 100.4 F @ 2 consecutive readings, despite increased hydration is considered febrile, report to physician. 2) Boggy uterine fungus, massage gently until firm, observe for increased bleeding or clots. 3) Normal FHR : 110-160 bpm. Pharmacology: 4) Glycerine emmolient used for dry, cracked and irritated skin. Cardiovascular: 5) Triametrene, a potassium sparing diuretic, avoid foods high in potassium, e.g. bananas, avocados, oranges, mangoes, nectarines, papayas and dried pprunes

• Maternity: clinical manifestations of cord compression is variable deceleration with brief accelaration after a gush of amniotic fluid. Perform manual sterile vaginal exam to detect the prolapsed cord. Pharmacology: Client with tachydysrythmias, dont give bronchodilators containing catacholamines, e.g. Epinephrine(Primatene Mist) and Isoproterenol HCL(Isuprel) Child Health: After pyloromyotomy, surgical treatment for hypertrophic pyloric stenosis, head of bed is elevated and the infant is placed prone to prevent aspiration.

• Infant with laryngomalacia(congenital laryngeal stridor), place in prone position with neck hyperextended to decrease stridor. • Decorticate posturing: flexion of the upper extremities and the extension of the lower extremities. Also plantar flexion of the feet. Decerebrate posturing: extension of the upper extremities with internal rotation of upper arms and wrists. The lower extremities extend with some internal rotation noted at knees and feet. Progression from decorticate to decrebrate posturing indicates deteriorating neurological function. • Hep B related jaundice: may get worse before resolving. • Client teaching: discard unused nitroglycerine tablets 3-6 months after bottle opened & obtain new prescription. • Oral intake after laryngectomy starts with semi-solid diet. • In a neonate, hypoglycemia causes central nervous system symptoms e.g. high pitched cry, also exhibited by lack of strength during feeding. • Misoprostol(cytotec) is administered to prevent gastric mucosal injury caused by regular use of NSAID's • • MAOI diet ( Tyramine restrictions) • FOODS: MUST AVOID COMPLETELY • Aged red wines (cabernet sauvignon/merlot/Chianti)

• Aged (smoked, aged, pickled, fermented, marinated, and processed) meats (pepperoni/bologna/salami, pickled herring, liver, frankfurters, bacon, ham)

• Aged/mature cheeses (blue/cheddar/provolone/Brie/ Romano/Parmesan/Swiss)

• Overripe fruits and vegetables (overripe bananas/ sauerkraut/all overripe fruit)

• Beans (fava/Italian/Chinese pea pod/fermented bean curd/ soya sauce/tofu/miso soup)

• Condiments (bouillon cubes/meat tenderizers/canned soups/gravy/sauces/soy sauce)

• Soups (prepared/canned/ frozen)

• Beverages (beer/ales/vermouth/whiskey/liqueurs/nonalcoholic wines and beers)

• FOODS: USE WITH CAUTION (MODERATION)

• Avocados (not overripe)

• Raspberries (small amounts)

• Chocolate (small amount)

• Caffeine (2– 8 oz. servings per day or less)

• Dairy products (limit to buttermilk, yogurt, and sour cream [small amounts]; cream cheese, cottage cheese, milk OK if fresh) • MEDICATIONS: MUST AVOID

• Stimulants and decongestants

• OTC medications (check with PCP/pharmacist)

Opioids (e.g., meperidine

• 1. Insertion of CVC, pt. should NOT deep breath. instead pt SHOULD do Valsalva Maneuver.

2. Sulfonamides are to treat inflammatory bowel disease, increase fluids

3. Multiple Myeloma is unique as a neoplastic condition that is better dected with a plain radiograph than with a nuclear scan. If bone scan is done then false negative result will occur. Therefore avoid bone imaginig for pt with multiple myeloma. 4.mumps s/s= HA,malaise, anorexia, earache • A nurse is preparing to administer digoxin (Lanoxin) to an infant with congestive heart failure (CHF). Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full min. and obtains a heart rate of 88beats/min. Based on this finding, what is the appropirate nursing action? • Digoxin is effective within a narrow therapeutic range (1.0 to 2.0 ng/mL). Safety in dosing is achieved by double-checking the dose and counting the apical heart rate for 1 full minute. If the heart rate is less than 100 beats/min in an infant, the nurse would withhold the dose and contact the physician. • Differentiating Gastric ulcer pain & duedonal ulcer pain: Gastric ulcer pain often occurs in the upper epigastrium, with localization to the left of the midline, and may be exacerbated by food. The pain occurs a half-hour to an hour after a meal and rarely occurs at night. Duodenal ulcer pain is usually located to the right of the epigastrium. The pain associated with a duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the client at night. • After amputations the nurse should ensure that a surgical tourniquet is in the client's room as one of the priority items. The wound and any drains are monitored closely for excessive bleeding because hemorrhage is the primary immediate complication of amputation. Therefore, a surgical tourniquet is kept at the bedside in case of acute bleeding. • Educating of a patient who has arteriovenous (AV) fistula should include following info: An AV fistula provides access to the client's bloodstream for the dialysis procedure. The client is instructed to monitor fistula patency daily by palpating for a thrill. The client is instructed to avoid compressing the fistula with tight clothing or when sleeping and that blood pressure measurements and blood draws should not be performed on the arm with the fistula. The client also is instructed to assess the fistula for signs and symptoms of infection, including pain, redness, swelling, and excessive warmth. • I like this Trend ,it has helped me alot in preparation for my test,Guys keep the ball rolling. Let me chip in this fact hopefully it will help. FLUROQUINOLONES: EXAMPLES,CIPROFLOXACIN,NORFLOXACIN,OFLOXACIN. They may increase the serum level of methylxanthines eg theophyllines causing methylxanthines toxicity. For CIPROFLOXACIN,use with caution on patients with renal disease,CNS,and seizure disoders,even those taking theophylline.It can cause nausea, vomiting, diarrhrea, constipation, dizziness, flatulence, headache and confusion.Watch out for toxic effect which can cause superinfecton • Cardio VT Ventricular tachycardia is characterized by the absence of P waves on ECG and there are wide QRS complexes (longer than 0.12 second), and typically a rate between 140 and 180 impulses/min. The rhythm is regular. • Cardio

Pericardiocentesis (a procedure which can be performed to fix cardiac tamponade problem)

-- Following pericardiocentesis, a rise in blood pressure and a fall in central venous pressure are expected.

--The client usually expresses immediate relief.

-- Heart sounds are no longer muffled or distant. • What to do when a patient comes to an ER with an insect in the ear?

-- Insects are killed before removal unless they can be coaxed out by a flashlight or by a humming noise. -- Mineral oil or diluted alcohol may be instilled into the ear to suffocate the insect, which is then removed by using ear forceps. -- When the foreign object is vegetable matter, irrigation is not used because such material may expand with hydration, thereby worsening the impaction. • How to communicate with a patient who has a hearing impairment?

-- speaking in a normal tone; avoiding shouting

-- talking directly to the client while facing the client; and speaking clearly.

-- If the client does not seem to understand what is said, the statement should be expressed differently. Moving closer to the client and toward the better ear may facilitate communication, but talking directly into the impaired ear should be avoided. • Weber's hearing test

-- In the Weber tuning fork test, the nurse places the vibrating tuning fork in the middle of the client's head, at the midline of the forehead, or above the upper lip over the teeth. Normally, the sound is heard equally in both ears by bone conduction.

-- If the client has a sensorineural hearing loss in one ear, the sound is heard in the other ear.

-- If the client has a conductive hearing loss in one ear, the sound is heard in that ear. • How to conduct an otoscopic examination on an adult patient?

In the otoscopic examination;

--the nurse tilts the client's head slightly away and holds the otoscope upside down as if it were a large pen.

--The pinna is pulled up and back and the nurse visualizes the external canal while slowly inserting the speculum.

--A small speculum is used in pediatric clients. The nurse may not be able to adequately visualize the ear canal if a small speculum is used in the adult client. • Mastoidectomy:

What is the mastoid bone? The mastoid bone is a bone located behind the ear (felt as a hard bump behind the ear). Inside it looks like a honeycomb, with the spaces filled with air. These air cells are connected to the middle ear through an air filled cavity called the mastoid antrum. Although the mastoid bone serves as a reserve air supply to allow normal movement of the eardrum, its connection to the middle ear may also result in the spread of middle ear infections to the mastoid bone (mastoiditis). What is a mastoidectomy? A mastoidectomy is a surgical procedure designed to remove infection or growths in the bone behind the ear (mastoid bone). Its purpose is to create a "safe" ear and prevent further damage to the hearing apparatus.

After mastoidectomy,

-- the nurse should monitor vital signs and inspect the dressing for drainage or bleeding.

-- The nurse also should assess for signs of facial nerve injury (cranial nerve VII).

-- The nurse also should monitor for signs of pain, dizziness, or nausea.

-- The head of the bed should be elevated at least 30 degrees, and the client should be instructed to lie on the unaffected side.

-- The client probably will have sutures, an outer ear packing, and a bulky dressing, which is removed on approximately the sixth day postoperatively. • Presbycusis

Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. • Motion sickness medications

-- To be maximally effective, medications to prevent motion sickness should be taken at least 1 hour before the triggering event.

-- Medications that are commonly used for this purpose include

** imenhydrinate (Dramamine)

**scopolamine (Transderm-Scop)

**promethazine (Phenergan)

**prochlorperazine (Compazine). • Labs

Creatine Kinase MB and Troponin - indicative of a MI if elevated Troponin is more popular... its more specific and will remain elevated for a longer period of time after pt has a MI.

C-Reactive Protein - if elevated, pt has inflammation in body... it is not specific to where the inflammation is INR - Warfarin

aPTT - Heprin

MEDS

Digoxin - works by strengthening heart contraction, give to pt who has CHF

ACE Inhibitors - be cautious of a persistent cough (contact MD if present)

COPD pts - teach pursed liped breathing - never give more than 2L of O2 • - Rubella immunization is contraindicated during pregnancy because the vaccine contains live virus which ca have teratogenic effects on the fetus. - (+) Homan's sign indicates thrombosis which is abnormal for a postpartum client - Metropolol masks the signs of hypoglycemia - Ambivalence is the most common characteristic among suicidal clients - Salicylates may interact with insulin causing hypoglycemia. - Kaposi's sarcoma is the most common cancer associated with AIDS • Valproic Acid (Depakene)- antiepileptic Lithium- dose should be adjusted when sweating, adding meds, illness with high fever Thyroid replacement- lifelong therapy Gentamycin- do not apply to large areas may cause toxicity tPa- lab values that should be examined, Hemoglobin, hematocrit, and platelet Interferon- tx of hepa B

Ulna- heals in about 12 weeks Femur- heals in 24 weeks Epstein Pearls- tiny hard white nodules found in the mouth of the neonate, normal and usually disappears without tx

Stationary bike- best for non-wt bearing exercise • Endocrine tips

In the test result for glycosylated hemoglobin A1c,

----7% or less indicates good control,

---- 7% to 8% indicates fair control,

----8% or higher indicates poor control.

**This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in the blood glucose level will cause elevations in the amount of glycosylation.

**Thus, the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes. • Endocrine

The primary goal of treatment in hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is

---to rehydrate the client to restore fluid volume and to correct electrolyte deficiency.

---Intravenous fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline.

---Regular insulin, not NPH insulin, would be administered. • ---An insulin pump provides a small continuous dose of regular insulin subcutaneously throughout the day and night

--- the client can self-administer a bolus with an additional dose from the pump before each meal as needed.

---Regular insulin is used in an insulin pump. • ---Insulin doses should not be adjusted nor increased before unusual exercise.

---If ketones are found in the urine, it possibly may indicate the need for additional insulin.

---To minimize the discomfort associated with insulin injections, insulin should be administered at room temperature.

---Injection sites should be rotated systematically within one anatomic site. • In DKA (Diabetic Ketoacidosis),

---the arterial pH is lower than 7.35,

---plasma bicarbonate is lower than 15 mEq/L,

--- the blood glucose level is higher than 250 mg/dL,

---ketones (Acids created by the process of burning body fat; if the body produces too many ketones, they are excreted in the urine) are present in the blood and urine.

---The client would be experiencing polyuria, and Kussmaul's respirations would be present.

---A comatose state may occur if DKA is not treated, but coma would not confirm the diagnosis. • ---Shakiness is a sign of hypoglycemia and would indicate the need for food or glucose.

---A fruity breath odor, blurred vision, and polyuria are signs of hyperglycemia. • During illness,

---the client should monitor blood glucose levels and should notify the physician if the level is higher than 250 mg/dL.

--- Insulin should never be stopped. In fact, insulin may need to be increased during times of illness.

---Doses should not be adjusted without the physician's advice and are usually adjusted based on blood glucose levels. • Potassium chloride

--administered intravenously must always be diluted in IV fluid and infused via a pump or controller.

--The usual concentration of IV potassium chloride is 20 to 40 mEq/L.

--Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest.

--Dilution in normal saline is recommended, but dextrose solution is avoided because this type of solution increases intracellular potassium shifting.

--The IV bag containing the potassium chloride is always gently agitated before hanging.

--The IV site is monitored closely because potassium chloride is irritating to the veins and the risk of phlebitis exists.

--The nurse monitors urinary output during administration and contacts the physician if the urinary output is less than 30 mL/hr. • After adding a medication to a bag of intravenous (IV) solution,

--the nurse should agitate or rotate the bag gently to mix the medication evenly in the solution.

--The nurse should then attach a completed medication label.

--The nurse can then prime the tubing. • --Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily.

--Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia.

--Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant.

--Conjugated estrogen (Premarin) is an estrogen used for hormone replacement therapy in postmenopausal women.

***These other three medications may be withheld before surgery without undue effects on the client. • Anticoagulants alter normal clotting factors and increase the risk of bleeding after surgery.

--Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. • Lisinopril

-- is an antihypertensive angiotensin-converting enzyme inhibitor.

--The usual dosage range is 20 to 40 mg daily.

--Adverse effects include headache, dizziness, fatigue, orthostatic hypotension, tachycardia, and angioedema.

--Specific client teaching points include taking one pill a day, not stopping the medication without consulting the physician, and monitoring for side effects and adverse reactions.

--The client should notify the physician if side effects occur. • --Polypharmacy is a concern in the geriatric population.

--Duplication of medications needs to be identified before drug-drug interactions or adverse side effects can be determined.

--The phone call to the health care provider is the intervention after all other information has been collected. • Asthma is a chronic inflammatory disease of the airways.

--Inhaled aerosolized short-acting β2 agonists are quick relief medications and recommended for clients with status asthmaticus after epinephrine has been administered.

--Leukotriene modifiers, antiallergic medications, and nonsteroidal anti-inflammatory medications are long-term control medications. • Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins.

--The primary treatment is replacement of the missing clotting factor; additional medications, such as those to relieve pain, may be prescribed depending on the source of bleeding from the disorder.

--A child with hemophilia A will be at risk for joint bleeding after a fall. Factor VIII will be prescribed intravenously (IV) to replace the missing clotting factor and minimize the bleeding. • In severe cystic acne, isotretinoin (Accutane) is used to inhibit inflammation.

--Adverse effects include elevated triglyceride levels, skin dryness, eye discomfort such as dryness and burning, and cheilitis (lip inflammation).

--Close medical follow-up is required, and dry skin and cheilitis can be decreased by the use of emollients and lip balms.

--Vitamin A supplements are stopped during this treatment. • Propylthiouracil is used to treat hyperthyroidism

---propylthiouracil (PTU) may convert the client from a hyperthyroid state to a hypothyroid state. If this occurs, the dosage should be reduced.

--Temporary administration of thyroid hormone may be required. • --Levothyroxine (Synthroid) is a synthetic thyroid hormone that increases cellular metabolism.

--Levothyroxine should be given in the morning in a single dose to prevent insomnia and should be given at the same time each day to maintain an adequate drug level. • Desmopressin acetate (DDAVP)

--is a synthetic form of antidiuretic hormone that causes increased reabsorption of water, with a resultant decrease in urine output.

--The therapeutic response to DDAVP would be a decrease in serum osmolality, because more fluid is retained, and an increase in urine osmolality, because less fluid is excreted.

--Hypotension may be apparent with diabetes insipidus and blood pressure may increase as extracellular fluid volume is restored. • Classic symptoms of hyperglycemia include

--polydipsia (Excessive thirst or drinking),

--polyuria

-- polyphagia (excessive appetite for food) • Polydipsia and polyuria are classic symptoms of diabetes insipidus. The urine is pale, and the specific gravity is low. Anorexia and weight loss occur. • Because of the hypermetabolic state, the client with hyperthyroidism needs to be provided with

--an environment that is restful physically and mentally.

--Six full meals a day that are well balanced and high in calories are required because of the accelerated metabolic rate.

--Foods that increase peristalsis, such as high-fiber foods, need to be avoided.

--These clients suffer from heat intolerance and require a cool environment. • Following thyroidectomy,

--weakness and hoarseness of the voice can occur as a result of trauma from the surgery.

--If this develops, the client should be reassured that the problem will subside in a few days.

--Unnecessary talking should be discouraged. • DKA (Diabetic ketoacidosis) tretment

--Lack (absolute or relative) of insulin is the primary cause of DKA.

--Treatment consists of insulin administration (regular insulin), IV fluid administration (normal saline initially), and potassium replacement, followed by correcting acidosis. • Hyperglycemic hyperosmolar nonketotic syndrome

-- occurs in clients with type 2 diabetes mellitus.

--The onset of symptoms may be gradual.

--The symptoms may include polyuria, polydipsia, dehydration, mental status alterations, weight loss, and weakness • To know the normal systolic for a child 1-7 years old Age +90. Example 3yo child = 93 systolic.

Here is another. Do not mix zosyn and gentamycin IV wait at least an hour to decrease the risk of gentamycin inactivation. • Coal tar

--is used to treat psoriasis and other chronic disorders of the skin.

--Coal tar suppresses DNA synthesis, mitotic activity, and cell proliferation.

--Coal tar has an unpleasant odor, frequently stains the skin and hair, and can cause phototoxicity.

--Systemic toxicity does not occur. • Mafenide acetate

--is bacteriostatic for gram-negative and gram-positive organisms and is used to treat burns to reduce bacteria present in avascular tissues.

--The client should be informed that the medication will cause local discomfort and burning. -- is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis.

-- Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation).

--If this occurs, the medication should be discontinued for 1 to 2 days. • Sodium hypochlorite

--is a solution used for irrigating and cleaning necrotic or purulent wounds. --It cannot be used to pack purulent wounds because the solution is inactivated by copious pus. --The solution should not come into contact with healing or normal tissue and should be rinsed off immediately following irrigation. --The solution loses its potency during storage, so fresh solution should be prepared frequently. • Isotretinoin (Accutane) -- can elevate triglyceride levels. --Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on the triglycerides has been evaluated. • Lindane (treatment for scabies)

--is applied in a thin layer to the body below the head. No more than 30 g (1 oz) should be used. --The medication is removed by washing 8 to 12 hours later. --In most cases, only one application is required. • Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles). • The normal platelet count is 150,000 to 450,000/mm3. When the platelets are lower than 50,000 /mm3, any small trauma can lead to episodes of prolonged bleeding. The normal white blood cell count is 5,000 to 10,000/mm3. When the white blood cell count drops, neutropenic precautions need to be implemented. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 15 to 45 mcg/dL. • Crestor=Rhabdomyolysis (muscle Weakness) PH of stomach acid lessthan 4 is good Drug catagory X=risk for fetus Colchicine=antigoout medication Lasix=K wasting=increasebananas and oranges heart failure infant=increased resp rate PIH=periorbital and facial edema Thallium stress test=allergic to Iodine should be asked Warm insulin bottle is good for 1 month only Causes of abdominal distention The 6 F's Flatus----Feces----fetus----Fluid---Fat----Fatal(Malignant) neoplasm • 1. If mishap occured like patient fell, write up an incident report and NEVER chart in the medical records that an incident report was filed. 2. If px died and was found on drivers license to be an organ donor, still have to get permission from next of kin before taking organs. order of priority is 1st ask the spouse, if none...2nd ask son or daughter, 3rd mother, 4th adult brother or sister, 5th Legal Guardian. 3. For airborne diseases measles, varicella, TB....use a particulate filter mask not a surgical mask 4. For droplet isolation patients, everyone must wear a mask if they are going wtihin 3 feet of the patient. • 5. PKU, baby born without ability to utilize essential amino acid called phenylalanine so don't give diet soda bec it contains nutrisweet, nutrisweet contains phenylalanine. • The rules of Management: Do not delegate assessment teaching or evaluation Delegate care for stable pt's with expected outcomes Delegate tasks that involve standard unchanging proceedures

Treatment for Monnucleosis= Bedrest

Amphojel=S/E Constipation Diagnostic test for cirrhosis=Liver biopsy Contaminated shellfish=Hep A Murphy's sign=On deep inspiration pain is elicited and breathing stops Abd Ultrasound=Dx for cholecystitis Pancreatitis=avoid Caffine and alcohol Pancreatitis= increased Amylase and lipase and glucose and decreased serum CA levels After liver biopsy=place client on the right side laying position with the bed flat Tensilon test=Mysthesia gravis Xerostomia=dry mouth dysgeusia=siminish sense of taste Dilantin can cause decreased HR hypotension Pyridium=Causes the urine to be red or orange Club soda=sodium chloride Gallbladder is on the right Guthrie blood test is a test for PKU Tetracycline can cause staining of the teeth Test for seizures=EEG Vit C may decrease warfarin effects Vit E may increase warfarin effects Dumping syndrome=moderate fat low carbs diet Colostomy begins to function 3-6 days after surgery Viagra=NO Nitroglycerin 250ml=I unit of PRBC (packed red blood cells) • Calcium and aluminum based antacids cause constipation Magnesium based cause diarrhea Mydriatics (big word big pupil) treats cataracts...I always picture a cat acting ( CAT ar ACTS) in a big whole ...it sound stupid I know! Miotics (small word small pupil) treats glaucoma

Maternal hypotension after an epidural anethesia: STOP S= stop pitocin if infusing T= Turn on left side O=Oxygen P= Push fluids (if hypovolemia) • HELLP= hemolysis, elevated liver enzymes, and low platelet count=elevated hepatic enzymes Chronic renal failure patients should avoid astringent cleansing pads Clients with a central venous catheter receiving TPN has an air embolus the nurse should clamp the catheter immediately and notify the physician. Crackles in the lung fileds of the peritoneal dialysis client result from overhydration or from insufficient fluid removal during dialysis. Intake grater than the output of the peritoneal dialysis fluid would overhydrate the client, resulting in lung crackles. Colonoscopy=Left sims position Normal platelets=150-400 cells mcg/l No morphine=pancreatitis it causes spasms of oddis spincter. Antineoplastic drugs=leukopenia=private room Terminal patient=Palliative care Tamoxifen increases the effects of Warfarin sodium Tachycardia commonly occurs after giving Atropine MMR Vaccine=Ask if Allergic to Gelatin, Eggs, or neomycin Pneumocystis Carinii=Fungal Vasopressin is a synthetic ADH Its used for treatment for Diabetes Insipidus which results from deficient ADH Glyburide=30 mins before breakfast Pt with Thrombus in the leg on heparin=Strict bed rest Ticlopidine (Ticlid) is used as a antiplatelet drug for Salicylate (Aspirin) sensitivity. Protamine sulfate=comes from the sperm of salmon and other fish so don't use if allergic to fish Blood drawn for APTT on heparin is in 4 hours. Early would show high Potassium is the most abundant cation in the ICP followed by Magnesium.Because Potassium isn't stored it must be replaced every day. • Rh immunization for pregnant is:

Rh immunization of Rhogam is given when an Rh incompatibility occurs, which only oocurs if the mother is Rh negative and the baby being born is Rh positive. It does NOT occur when an Rh positive mom gives birth to an RH negative baby.

If some of the baby's red blood cells leak into RH-mom's system, then her body may produce antibodies to the Rh D factor (a condition called sensitization). These antibodies can cross the placenta and destroy the red blood cells in your unborn baby or in the next Rh-positive baby you have.

***In most cases, the mom will not be exposed to the baby's blood until she gives birth....... This usually means that first baby will NOT be affected.

****HOWEVER, large amounts of the baby's blood can leak into the mother during delivery. If the mom is Rh negative, the next Rh-positive baby that she could have may have problems if the Rh-negative mom has developed antibodies

***** Occasionally, in the following situations, some of the baby's blood may leak into the mom's blood system during pregnancy:

1. After amniocentesis or other invasive procedure 2. During a miscarriage or abortion 3. During an ectopic pregnancy 4. If the mom bleeds heavily during pregnancy.

Disseminated intravascular coagulation (DIC) and s/s

Disseminated intravascular coagulation (DIC) occurs when the body's clotting mechanisms are activated throughout the body in response to an injury or a disorder, instead of being isolated to the area of initial onset. Platelets circulating throughout the body form small blood clots (thrombi) primarily in the area of the capillaries. This eventually causes the clotting factors to be used up, and none are left to form clots at the site of the injury. The presence of numerous small clots precipitates the release of clot-dissolving mechanisms, and the end result is generalized bleeding throughout the body.

This disorder can result in clots or, more often, in bleeding. The bleeding can be severe.

Risk factors for DIC include:

Blood transfusion reaction Cancer, including leukemia Infection in the blood by bacteria or fungus Pregnancy complications (such as retained placenta after delivery) Recent surgery or anesthesia Sepsis (an overwhelming infection) Severe liver disease Severe tissue injury (as in burns and head injury)

Signs & Symptoms Include:

Bleeding (possibly from multiple sites in the body), Blood clots, Drop in blood pressure, AND Sudden bruising • therapeutic level of Lithium.. I have answers from 2 different resources;

0.8 to 1.2 mEq/L ................AND ...................

0.6 to 1.2 mEq/L with therapeutic dose = 300-2700 mg/d • Risk factors for specific cancers:

Bladder = Smoking, exposure to industrial, chemicals, radiation. Prostate= African American and age 55 and older Laryngeal = Smoking, uses of tobacco and alcohol, exposure to environmental pollutants, exposure to radiation and carcinogens, nutritional deficiency (riboflavin) Lung = Smoking, exposure to environmental pollutant, vitamin A deficiency, heredity. Pancreatic= High fiber and high carb, smoking, exposure to industrial chemicals, diabetes, chronic pancreatitis. Breast = family history, early menarche and late menopause, previous cancer of the breast, uterus, or ovaries, nulliparity, obesity, high-dose radiation exposure to chest, diet high in fat, alcohol intake, the use of birth control pills and hormonal replacement. Endometrial= history of uterine polyps, nulliparity, polycystic ovary disease, estrogen stimulation, late menopause, family history. Ovarian= diet high in fat, family history of ovarian or breast cancer, alcohol use, history of breast cancer, endometrium cancer, colon cancer, nulliparity, infertility, Cervical= low socioeconomic, early first marriage, early and frequent intercourse, multiple sex partners, poor hygiene, Human papillomavirus, HIV infection, smoking during pregnancy and cervical infection. Testes= over the age of 15 and 40, infection, genetic and endocrine factors, cryptorchidism • PIH=Periorbital and facial edema Pt. intubeted and a high alarm will sound when the patient is bitting the tube. Halo traction=Sterile pin site care T-12 spinal injury=No message to the bladder. Thallium stress test=Allergic to Iodine should be asked 5 Post ops causes of fever Wind-check lungs Wound-Cl sirgoca; sote Water-I V site Walk-DVT check Whiz-Catheter Wonder drungs-drug fever Measles warrents=resp isolation Bacterial meningitis=Resp isolation Methotrexate therapy=in 2 weeks expect to see signs of bone marrow depression When pregnant increase your calories by 500 Kcals Dystonia occurs after a few days of treatment of haldol Heart failure infant=Increased resp rate Trough level=lowest level of the drug should be done immediately before administering the next dose Glycosylated hemoglobin values less than or equal to 7.5% indicates good diabetic control Preterm infant before 37 weeks Term infant older than 37 weeks post erm 42 weeks 38-41 weeks is term you should not insert a NG tube if there is a suspected skull fracture. Deferoxamine is the antidote for iron poisoning Cipro treats anthrax Cretinism=Hypothyroidism found in the neonate Nrdil (Pnenelazine) is a MAOI avoid figs, chocolate, and eggplant. It cause hypertensive crisis. Multiple sclerosis=test EEG/LP A pregnant nurse should not be assigned to any client with radioactivity present. OK for a Preg nurse to care for a client receiving liner ascelerator radiation therapy for lung cancer. Client with Cushing syndrome, with incresed level of cortisone cause the client to be immune suppressed, Pt should be put in a private room. complications of bucks traction=Weak peda pulses • 1. To check for petechiae in a dark-skinned client, assess the oral mucosa 2. Seventh-Day Adventists are usually vegetarians 3. The three types of embolism are air, fat, and thrombus 4. Before discharge, a client who has had a total laryngectomy must be able to perform tracheostomy care and suctioning and use alternative means of communication. 5. The universal blood donor is o negative 6. The universal blood donor is ab positive 7. Mucus in a colostomy bag indicates that the colon is beginning to function 8. Fatique is an adverse effect of radiation therapy. 9. celiac disease may eat rice 10. Dumping syndrome-limit liquids and high carbohydrate foods. • Addisons Disease: Hypo NA+, Hyoglycemia, Hypercalcemia and Hyperkalemia.... and the exact oppisite for Cushings syndrome! • Diabetes Insip... can concentrat urine! Addisoinan Crisis is treated with High dose steriods and Fluid replacment • for treatment of hypertension try 4,3,2,1 • ANGIOTENSIVE CONVERTING ENZYME INHIBITOR . • BETA ENVAS. • CALCIUM CANNEL BLOCKER. • DIURATICS • A 44-lb preschooler is being treated for inflammation. The physician orders 0.2 mg/kg/day of dexamethasone (Decadron) by mouth to be administered every 6 hours. The elixir comes in a strength of 0.5 mg/5 ml. How many teaspoons of dexamethasone should the nurse give this client per dose?

Answer:

• Correct Answer: 2 Your Answer: 2 RATIONALES: To perform this dosage calculation, the nurse should first convert the child's weight from pounds to kilograms:

44 lb ÷ 2.2 lb/kg = 20 kg

Then she should calculate the total daily dose for the child:

20 kg × 0.2 mg/kg/day = 4 mg

Next, the nurse should calculate the amount to be given at each dose:

4 mg ÷ 4 doses = 1 mg/dose

The available elixir contains 0.5 mg of drug per 5 ml (which is equal to 1 teaspoon). Therefore, to give 1 mg of the drug, the nurse should administer 2 teaspoons (10 ml) to the child for each dose.

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