NCLEX Cram HESI Comprehensive Review 1

Aspartate amino transferase levels in adults (AST/SGOT)

0-35 IU/l

Bilirubin total for adult

0.3-1mg/dl

Creatinine for adults

0.5-1.2mg/dl

Ensure that the daily calcium needs are met and help alleviate the occurrence of leg cramps

1 quart of milk or yogurt per day

100-150HR; 25-35RR

1-11 months normal HR & RR

Crawls

10 months

Waves bye-bye

10 months

Secondary sex characteristics develop

12-19 years

HGB for 0-2 weeks

12-20

Sodium levels in adults

136-145 mEq/l

Social smile

2 months

Achieves 50% of adult height

2 years

Daytime toilet training can be started

2 years

Feed self with spoon and cup

2 years

Two to three word sentences are spoken

2 years

Each year a child gains about 5 pounds

2.5 - 3 years

Own first and last name can be stated

2.5-3 years

Total iron binding capacity in adults

250-460mcg/dl

No nipple bud; testes in the inguinal cancal or labia majora widely separated with labia minora prominent open and equal in size; vernix over the entire body; lanugo covers the entire body; full extension of extremities in the resting posture

28 weeks gestational age assessment

Head turns to locate sounds

3 months

Three to four word sentences are spoken

3 years

Can ride a tricycle

3 years old

Handedness is established

3-5 years

Imaginary playmates and fears are common

3-5 years

Learns colors, shapes

3-5 years

Learns sexual identity (curiosity and masturbation are common)

3-5 years

Learns to run, jump, skip and hop

3-5 years

Stands erect with more slender posture

3-5 years

Uses sentences

3-5 years

Visual acuity approaches 20/20

3-5 years

80-120HR; 20-25RR

3-5 years normal HR & RR

Albumin levels for adults

3.5-5g/dl

Potassium levels for adults

3.5-5mEq/l

How many large squares on an ECG strip equals 6-seconds

30 large squares

Aggressiveness is replaced by more independence

4 & 5 years

Client should void within this many hours pose delivery; suspect retention if voiding is frequent and <100ml

4 hours

Moro reflex disappears

4 months

Uses scissors

4 years

Alanine amino transferase in adults (ALT/SGPT)

4-36IU/ml

RBC count for adults

4.2-6.1 million/mm3

Raised nipple with tissue bud underneath; descended testes with large rugae on the scrotum; labia majora large and covering the minora; vernix only increases; lanugo only over the shoulders; hypertonic flexion of extremities in resting posture

40 weeks gestational age assessment

WBC count in adults

5 000-10 000

Retractions, tachypnea, dusky color, circumoral cyanosis, expiratory grunt, flaring nares

5 symptoms of respiratory distress

Plays peek a boo

6 months

birth weight doubles

6 months

Molars erupt

6 years

70-110HR; 18-22RR

6-10 years normal HR & RR

Dress self completely

6-12 years

Each year, a child gains 4-6 pounds and 2 inches in height

6-12 years

Egocentric thinking is replaced by social awareness of others

6-12 years

Experience menarche

6-12 years

PO2 normal value

80-100mm

WBC count for newborn

9 000-30 000

Calcium levels in adults

9-10.5mg/dl

Placed around the cervix to constrict the internal os. This is removed prior to labor if labor is planned or left in place if Csection is planned; done to client with prior traumatic delivery history, history of D&C, multiple abortions

A McDonald Suture (cerclage)

Airway, breathing, circulation

ABCs of assessment

Causes the body to retain water

ADH

Common laboratory finding is a lowered pO₂; not responsive to high concentrations of oxygen and often need intubation and mechanical ventilation with PEEP

ARDS

No abnormal breath sounds are present in this disorder on auscultation because the edema occurs first in the interstitial spaces and not the airways.

ARDS

Unexpected, catastrophic pulmonary complication occurring in a person with no pervious pulmonary problems.

ARDS

A 1 hour glucose screen is routinely done on all pregnant women between 24-26 weeks gestation

Abnormal glucose screen

HGBS disease and trait

Abnormal hemoglobin

Pregnancy losses occurring before 20 weeks are counted as this; add to the clients gravidity count

Abortions

Accepting the inevitable; beginning to separate emotionally

Acceptance

Determined by hydrogen ion concentration in body fluids

Acid-base balance

TSH-secreting pituitary tumors are resected using a transnasal approach

Adenectomy

Glanduar tissue

Adeno

Loss of the ability to write

Agraphia

Perform this test before drawing an ABG from the radial artery

Allen Test

Not broken down as usual in the damaged liver; therefore this serum level rises

Ammonia

Butorphanol tartrate (stadol), nalbuphine (nubain); opioid agonist/antagonists, provision of analgesia in labor, narcotic analgesic; adverse reactions: woman with preexisting narcotic dependency will experience withdrawal symptoms immediate; give IV or IM, obtain drug history before administration; monitor RR and HR

Analgesics

Initiate CPR

Anaphylactic and severe allergic reaction nursing interventions

Sedation and drowsiness

Antianxiety drug side effects

Obstruction of blood flow from the ventricles; obstructive narrowing immediately before, at, or after the aortic valve; oxygenated blood flow from the left ventricle into systemic circulation is diminished; symptoms are caused by low cardiac output; require surgical correction

Aortic stenosis

1 and 5 minutes after birth; assesses heart rate, respiratory effort, muscle tone, reflex irritability and color; maximum score is 10 the baby is in good condition; <6 at 5 minutes needs an additional assessment at 10 minutes

Apgar assessment

Loss of the ability to speak

Aphasia

Inability to perform purposeful movements in the absence of motor problems

Apraxia

Increased pulmonary blood flow; there is a hole between the atria; oxygenated blood from the left atrium is shunted to the right atrium and lungs; do not compromise children seriously; surgical closure is recommended before school age; can lead to congestive heart failure or atrial dysrhythmias later in life if not corrected

Arterial septal defect

Feed infant or child with cerebral palsy using nursing interventions to prevent this. Position the child upright and support the lower jaw

Aspiration

Keep bulb syringe or suction immediately available: suction mouth, then nose; turn neonate on side or stomach and pat firmly on back holding the head 10-15 degrees lower than the feet

Aspiration

Macrosomia, IUGR, hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia, congenital anomalies, prematurity, infection

Assessment for diabetic insulin

Skin color, temperature, sensation, capillary refill, mobility, pain and pulses

Assessment of client with fracture/in a cast

Hand flapping tremor that often accompanies metabolic disorders

Asterixis

An inflammatory reactive airway disease that is commonly chronic; airways become edematous; airways become congested with mucus; smooth muscles of the bronchi and bronchioles constrict

Asthma

Intermittent disease that is reversible airflow obstruction and wheezing

Asthma

Dyspnea, wheezing, chest tightness, assess precipitating factors, medication history

Asthma assessment

Administer bronchodilators, administer fluids and humidification, education, ABGs, ventilator patterns

Asthma nursing interventions

Narrowing or closure of the airway due to a variety of stimulants

Asthma pathophysiology

Used for PCP in those unable to tolerate Trimethoprim/sulfamethoxazole (Bactrim)

Atovaquone (Mepron)

Produce a high incidence of thrombus formation following arrhythmia caused by turbulence of blood flow through all valves and heart chambers

Atrial flutter and fibrillation

Used to treat bradycaria; adverse reactions: chest pain, urinary retention, dry mouth; monitor HR and rhythm, assess for chest pain, assess for urinary retention, avoid use with glaucoma

Atropine sulfate (atropisol)

Anyone who has had this will have a positive skin test and must be evaluated by a chest radiograph

BCG vaccine

Making a deal with God to prolong life; usually not sharing this with anyone

Bargaining

Epithelium (sun exposed areas)

Basal cell

Relieves Myasthenia gravis symptoms; bladder and respiratory infections are recurrent problems

Bed rest

Can prevent insulin reactions due to long acting insulin peak

Bedtime snack

Should be performed in mother previously sensitized to fetal Rh+ RBC and having antibodies to the RH+ circulating cells; measures the change in optical density of the amniotic fluid caused by staining with bilirubin; done at 24 weeks gestation

Bilirubin delta optical density assessment

Determines more than 60 types of metabolic disorders

Biochemical analysis

Insufficiency oxygenation occurs with chronic bronchitis and leads to generalized cyanosis and often right-sided heart failure (cor pulmonale)

Blue bloated

Buttocks

Breech

Caregivers who are pregnant may refuse to care for a client with this

CMV (Cytomegalovirus)

A disease characertized by uncontrolled growth of abnormal cells

Cancer

Indicated for tonic-clonic, mixed seizures, drowsiness, ataxia; adverse reactions: hepatitis and agranulocytosis; monitor liver function; therapeutic level 6-12mcg/ml

Carbamazepine (tegretol)

A nonprogressive injury to the motor centers of the brain causing neuromuscular problems of spasticity or dyskinesia (involuntary movements); associated with mental retardation and seizures

Cerebral palsy

Used with spermicide; contraindicated if cervical anomalies exist; associated with cervical changes; pap smear 3 months after use

Cervical cap

Hypoxemia that persists even when 100% oxygen is given; decreased pulmonary compliance; dyspnea; non-cardiac associated bilateral pulmonary edema; dense pulmonary infiltrates on X-ray

Characteristics of ARDS

Child with headaches, stomachaches and other somatic complaints

Childhood depression

An acute inflammation of the gallbladder

Cholecystitis

IV hydration, administration of antibiotics, and pain control with meperidine or morphine

Cholecystitis treatment

The formation or presence of stones in the gall bladder

Cholelithiasis

Chronic hypertension with new onset proteinuria and worsening of the already present hypertension, thrombocytopeniam or increased liver enzyme values

Chronic hypertension superimposed on chronic hypertension

Increased production of leukocytes and lymphocytes and proliferation of cells within the bone marrow, spleen and liver; after the age of 35; most clients are asymptomatic and are not treated

Chronic lymphocytic leukemia

Place on side or upright in infant seat

Cleft lip post-op care

May not be identified until the infant has difficulty with feeding; closure is usually performed at 1 year of age to minimize speech impairment

Cleft palate

Place client on side or abdomen

Cleft palate post-op care

Characterized by suspicious, strange behavior that may be precipitated by a stressful event; paranoid personality; schizoid personality; schizotypal personality

Cluster A: paranoid personality disorder

Antisocial personality, borderline personality, histrionic personality and narcissistic personality

Cluster B: Dramatic, emotional personality disorders

Tumors occurring in the colon

Colorectal cancer

Resume regular diet gradually

Colostomy diet

Break has more than free fragments

Comminuted

Break across the entire section of bone, dividing it into distinct fragments; often displaced

Complete fracture

Bone fragments are completely separate

Complete fractures

Bone buckles and eventually cracks as the result of unusual loading force applied to its longitudinal axis

Compression fracture

Thinking based on fast vs. abstract and intellectual points

Concrete thinking

Hearing loss in which sound does not travel well to the sound organs of the inner ear. Volume of sound is less, but the sound remains clear. If volume is raise, hearing is normal; results from cerumen impaction of middle ear disorders

Conductive Hearing loss

Abnormal development of the femoral head in the acetabulum; conservative treatment consists of splinting; surgical intervention is necessary if splinting is not successful

Congenital dislocated hip

Catheter threaded into epidural space with continuous infusion of fentanyl citrate, morphine or other narcotic analgesics; risk for respiratory depression

Continuous epidural analgesia

Prematurity, placenta previa, hydramnios, multiple gestation, and previous uterine classical scar, Rupture of membranes

Contraindications of contraction stress test

Transferring a mental conflict into a physical symptom for which there is no organic cause

Conversion disorder

Pancreatic enzyme medication

Cotaztm-S pancrease

Nagele rule

Count 3 months from the first day of the LMP and add 7 days

Prepared from fresh frozen plasma with 10-20mL/bag

Cryoprepcipitates and commercial concentrates

Used in treated hemophilia; replacement of clotting factors, especially factor VII and fibrinogen

Cryoprepcipitates and commercial concentrates

Acute complication of conditions such as hypotention and septicemia; suspected when there is bloody oozing from two or more unexpected sites.

DIC

First phase involves abnormal clotting in the microcirculation, which uses up clotting factions and results in the inability to form clots, so hemorrhage occurs

DIC

Administer heparin IV during first phase to inhibit coagulation

DIC nursing intervention

Death is the last developmental task for an individual; completes the life cycle

Death

Indicated in ventricular fibrillation or pulseless ventricular tachycardia

Defibrillation

Sunken fontanels, poor skin turgor, and dry MM

Deficient fluid volume S&S in preterm

State in which the body loses water and serum sodium levels increase

Dehydration

Unreasonable wishes and wants and expresses needs in a demanding, whining manner while professing independence and denying dependent behavior; passive, without accepting responsibility for consequences of his or her own behavior; has low self-esteem, sees self as stupid, unable to make decisions; dependent on others to meet his or her needs; verbally is self depreciating, demanding in others to meet needs; nonverbally appears dull, uninterested in others, dissatisfied with self

Dependent personality disorder

Erikson's theory at 1-3 years

Developing a sense of autonomy; autonomy vs. doubt and shame

Erikson's theory at 6-12 years

Developing a sense of industry (industry vs. inferiority)

Erikson's theory at 3-5 years

Developing a sense of initiative; initiative vs. guilt

Erikson's theory from birth to one year

Developing a sense of trust; trust vs mistrust

Postpartum drug; indicated for constipation and painful defecation due to 4th degree tear; adverse reactions: abdominal cramping; increase fluid intake; effective 1-3days of continual use

Docusate sodium (colace)

Vaso-constricting agents that may be used in cardiogenic shock

Dopamine (Dopram) and norepinephrine (Levophed)

Increases the contractility

Dopamine and digitalis

The length of each contraction from beginning to end

Duration

Difficulty articulating

Dysarthris

Hysterectomy; intracavity radiation

Early carcinoma treatment

Caused by head compression and fetal descent usually occurs between 4-7cm and in the second stage. Check labor progress if these are noted

Early deceleration

Cryosurgery, electrocautery, laser, conization, hysterectomy

Early dysplasia treatment

Monitors contractions of FHR

Electronic fetal monitoring

Used to detect drainage of aqueous humor

Electronic tonometer

Cigarette smoking, environment/occupational exposure, genetics

Emphysema precipitating factors

Indicated for asystole or severe bradycardia; adverse reactions: tachyarrhythmias; make sure ventilation of newborn is adequate, do not inject directly into artery; monitor apical pulse or connect to ECG before use

Epinephrine

Indicated for cardiac arrest; adverse reactions: tachycardia and hypertension; impaired renal function can cause toxicity, monitor BUN and creatinine; monitor pulse return, monitor VS

Epinephrine (adrenaline)

Vision check before starting therapy and monthly thereafter; may have to take for 1-2 years

Ethambutol

Inhibits protein synthesis; side effects: GI disturbance, hepatotoxicity, hypersensitivity; treatment of resistant organisms; contraindicated in pregnant women.

Ethionamide (Trecator-SC)

Caused by a reaction to the environmental or external factors

Exogenous depression

Below the neck of the femur

Extracapsular fracture

The osmolarity of this is almost entirely due to sodium

Extracellular fluid

Blood is oxygenated outside the body through a bypass procedure

Extracorporeal membrane oxygenation

Used for cause pupil constriction because movement of the muscles to constrict the pupil also allows aqueous humor to flow out, thereby decreasing the pressure in the eye

Eye drops

Injury to the eye sustained as the result of sharp or blunt trauma, chemicals or heat; permanent visual impairment can occur; every eye injury should be considered an emergency

Eye trauma

Discomfort localized in abdomen; no lower back pain; contractions decrease in intensity or frequency with ambulation

False labor

Most common blood transfusion reaction; sudden chills and fever, headaches, flushing, anxiety, and muscle pain

Febrile nonhemolytic reaction

Give antipyretics

Febrile nonhemolytic reaction nursing interventions

Fruity or must breath; a distinctive breath odor of chornic liver disease; results from the damaged liver's inability to metabolize and detoxify mercaptan

Fector hepaticus

Occupies the entire uterus; activity is restricted; maternal antibodies are transferred to fetus; lecithin/sphingomyelin ratio is 2:1; weights 7+ lbs

Fetal changes at 38 weeks

Embryo becomes a fetus; heart is discernible by ultrasound; lower body develops; sex is determinable; kidneys produce urine; weight <1oz

Fetal development at 12 weeks

Vernix protects the body; lanugo covers the body and protects it; eyebrows, eyelashes, head hair develop; fetus sleeps, sucks and kicks; 11-14oz

Fetal development at 20 weeks

Performed only in the intrapartum period when the fetal blood from the presenting part can be taken; when the membranes have ruptures and the cervix is dilated 2-3cm; used to determine true acidosis when non-reassuring FHR is noted; place client in lithotomy position; sterile procedure; prepare ice in cup or emesis basin to carry pipette filled with blood to units pH machine or lab

Fetal pH blood sampling

The relationship of the point of reference on the fetal presenting part to the mothers pelvis; most common is LOA

Fetal position

From the first day of the LMP through 13 weeks

First trimester

Ambivalence, financial worries, career concerns

First trimester psychosocial responses to pregnancy

A tear that extends up the rectal mucosa

Fourth degree tear

the first 1-4 hours after delivery of the placenta

Fourth stage of labor

Firm, midline at or below the umbilicus. Massage if soft or boggy. Suspect full bladder if above umbilicus and to the right of the abdomen

Fundus

Anorexia; weight loss, sore throat, abdominal pain, diarrhea, oral lesions,

GI distress

Rarely used in today's OB units. Might be used as an emergency delivery or when regional block anesthesia is contraindicated or refused; administer drugs to reduce gastric secretions; assist with speedy delivery; assess closely for uterine atony; check fundal firmness and uterine contractions

General anesthesia

Tonic-clonic, absence (petit mal(, myoclonic

Generalized seizures

Indication: aminoglycoside antibiotic used for serious puerperal infections; adverse reactions: GI irritation, nephrotoxicty, ototoxicity, neurotoxicity, possible hypersensitivity; don't mix with any other drug; observe fro ototoxicity, ataxia, tinnitus, headache, nephrotoxicitym elevated BUN and creatinine, neurotoxicity, parenthesia, muscle weakness, I&O closely

Gentamicin sulfate (garamycin)

Assesses eye opening, motor response, and verbal response; maximum scope is 15 - minimum is 3; score of <7 indicates coma; clients with low scores have high mortality rate and poor prognosis

Glasgow coma scale

Chronic open-angle also known as adult primary and as primary open angle

Glaucoma

Positive is serum phenylalanine levels of 4mg/dl

Guthrie test

Watch this on an infant. It is difficult to oxygenate either an anemic newborn or newborn with polycythemia (HCT>80%, thick, sluggish circulation)

HCT

Characterized by hemolysis, elevated liver enzymes, and low platelets; increased risk for abruption, acute real failure, hepatic rupture, preterm birth, and fetal or maternal death or both; aside from changes that occur with preeclampsia; history of malaise, epigastric or RUQ pain, NV; normotensive and do not have proetinuria; treated prophylactically with magnesium sulfate; high risk for deloping the syndrome again in future pregnacies as well as for developing preeclampsia in other pregnancies not complicated by this

HELLP syndrome

33-35cm; normally 2cm larger than chest; tape measure placed above eyebrows and stretched around the fullest part of occiput, at posterior fontanel

Head circumference: normal newborn norms

Bulging fontanel - increased ICP; sunken fontanel - dehydration; widely separated sutures - hydrocephalus; premature suture closure - genetic disorders; cephalhematoma - blood under periosteum due to trauma and does not cross suture lines

Head: abnormal findings in newborn

Round or slightly molded, caput succedaneum that crosses suture lines; open, flat anterior and posterior fontanels, sutures slightly separated or overlapping due to molding

Head: normal newborn norms

HELLP - preeclampsia

Hemolysis, elevated liver enzymes, low platelets

More than 1 saturated pad q15min

Hemorrhage

Source of infection: contaminated blood products, needles, IV drug use and dialysis; route of infection: parenteral, sexual contact; incubation period: 14-180 days; onset: insidious; seasonal variation; all year; age group affected: any; vaccine: no; inoculation: yes; potential for chronic liver disease: no; immunity: no

Hepatitis C (non-A, non-B hepatitis)

Contributes to damage of the smallest vessels, the capillaries. Damage causes permanent capillary scarring, which inhibits the normal activity of the capillary. Causes disruption of capillary elasticity and promotes problems such as diabetic retinopathy, poor healing of breaks in the skin, cardiovascular abnormalities

High blood glucose levels

Respiratory acidosis

Hypercapnia

Polydipsia, polyuria, polyphagia, blurred vision, weight loss, weakness, syncope; encourage water intake; check BS; assess for ketoacidosis

Hyperglycemia

Polydipsia, polyuria, polyphagia, blurred vision, weakness, weight loss, syncope

Hyperglycemia S&S

Excessive activity of thyroid gland, resulting in an elevated level of circulating thyroid hormones (Graves disease, goiter)

Hyperthyroidism

Respiratory alkalosis

Hyperventilation

Side effects of digitalis are increased when the client is

Hypokalemia

Dry mouth, thirst, weakness, drowsiness, muscle aches, tachycardia

Hypokalemia symptoms

Functions on the basic instinct level and strives to meet immediate needs

ID

Onset: 30 minutes; peak: 1-3 hours; duration: 4-6 hours

IM administration

Drains liquid material

Ileostomy

Clients should chew food thoroughly; high fiber foods can cause severe diarrhea and may have to be eliminated

Ileostomy diet

Misinterpretation of external environment

Illusions

Telescoped fracture, with one fragment driven into another

Impacted fracture

Fertilization takes place in ampulla section of the fallopian tube; zygote takes 2-4 days to enter the uterus; it takes 7-10 days to complete the process of nidation/implantation

Implantation

Autism (preoccupied with self), affect is flat, associations, ambivalence

Important characteristics of schizophrenia

A break across only part of the bone

Incomplete fracture

Fracture occurs through only one cortex of the bone; usually nondisplaced

Incomplete fracture

Bone fragments remain attached

Incomplete fractures

Administration of cardiotonic drugs such as digitalis does what?

Increase Cardiac Contractility

Suctioning, coughing, straining, and turning cause ??

Increased ICP

Widening pulse pressure, tachycardia, slowing of respirations, possible decrease in pulse; temperature rise

Increased ICP signs

HR <60 or >100 indicates ICP, infection, thrombus formation or dehydration; BP rising or widening pulse pressure indicates ICP; elevation can indicate worsening condition, damage to temperature regulating area of the brain, or infection; LOC changes; papillary changes range from prompt to sluggish or may increase in size

Indications of changing condition

Big problem after joint replacement

Infection

Fever, tachycardia, lymphadenopathy, night sweats, skin infection, poor healing

Infection

Feedback about the client's observed behavior

Information giving

Acute infection that is quite similar to mononucleosis; occur within 3 weeks of first exposure to HIV then the person becomes asymptomatic

Initial S&S of HIV infection

Breaks in skin, infections on skin, diabetic dermopathy, unhealed injection sites

Integument system changes in diabetes mellitus

Measured not by external monitoring but in mmHG by internal monitoring after amniotic membranes have ruptured; ranges from 30mmhg-70mmhg

Intensity

Fracture that is harder to heal because the blood supply enters the femur below the neck of the femur; greater likelihood that necrosis will occur because the fracture is cute off from the blood supply

Intracapsular fracture

In the neck of the femur

Intracapsular fracture

The osmolarity of this is almost entirely due to potassium

Intracellular fluid

Signs of deficiency: anemia, pale conjunctiva, pale skin color, atrophy or papillae on tongue, brittle ridged spoon shaped nails, thyroid edema; food sources: infant rice cereal, liver, beef, pork, eggs, iron fortified formula, infant high protein cereal

Iron

Hemoglobin levels below normal range because of the body's inadequate supply, intake or absorption of iron; leading hematologic disorder in children; need is greater due to accelerated growth

Iron deficiency anemia

Those with descending-colon colostomies can do this to provide control over effluence; should do this at the same time each day with warm water; the area around the stoma should be cleaned with lukewarm water and a mild soap

Irrigation of a colostomy

Early signs of cerebral hypoxia; the client's brain is not receiving enough oxygen

Irritability and restlessness

With this issue, there is a problem of kernicterus (bilirubin encephalopathy) resulting from bilirubin deposition in the brain

Jaundice

A clinical manifestation of hypoglycemia and hypocalcemia; lab analysis is indicated to differentiated between the two causes

Jitteriness

Pressure dressings used

Jobst garments

Regulate bicarbonate levels by retaining and reabsorbing bicarbonate as needed; very slow compensatory mechanisms; cannot help with compensation when metabolic acidosis is created by renal failure

Kidneys

Selectively maintain and excrete body fluids; retain needed substances and excrete unneeded substances; regulate pH by excreting or maintaining hydrogen ions and bicarbonate; excrete metabolic wastes and toxic substances

Kidneys

Most accurate determination of fetal maturity. Present after 35 weeks gestation

L:S ratio and phosphatidylglycerol (PG)

Increased WBC, decreased glucoe, elevated protein, increased ICP, positive culture for meningitis

LP of bacterial meningitis

Describe the lack of concern over physical illness; conversion reactions

La belle indifference

An ominous and potentially disastrous non-reassuring sign; indicative of utero-placental insufficiency; shape of deceleration is uniform and the FHR returns to baseline after the contraction is over; depth of the deceleration is uniform and does not indicate severity; rarely falls below 100bpm

Late decelerations

Decreased alertness, lethargy, coma

Late shock mental status changes

Total separation of newborn from self; confident in care taking activities of self and newborn

Letting go phase

Malignant neoplasm of the blood-forming organs; characterized by an abnormal over production of immature forms of any of the leukocytes; interference with normal blood production that results in decreased number of RBCs and platelets

Leukemia

Provides more blood to the heart to help maintain cardiac output

Levophed, Dompamine (vasoconstrictors)

Commonly used in alcohol withdrawal patients

Librium and ativan

Clindamyzin (Cleocin); used for PCP in AIDS, severe infections resistant to penicillin and cephalosporins, used in penicillin and erythromycin sensitive clients; adverse reactions include agranulocytosis, pseudo-membrane colitis, superinfections; highly toxic drug; periodic liver/renal/blood counts; report diarrhea immediately

Lincosamides

Often accompanies a low K+

Low Magnesium

Systemic, inflammatory, connective tissue disorder; autoimmune disorder; kidney involvement is the leading cause of death

Lupus erythematosus

Lymphoid tissue

Lympho

Change in mental status, apathy, psychomotor slowing, seizures; opportunistic infection of HIV

Lymphomas of CNS

Hypertensive crisis; need dietary restrictions to prevent this

MAO inhibitor side effects

Begins giving away possessions; previously depressed client becomes happy

Major warning signs of impending suicide attempt

Edge of the placenta meets the rim of cervical os

Marginal placenta previa

Infection of the breast; sore cracked nipple; flu-like symptoms: malaise, chills, and fever; red, warm lump in breast

Mastitis

Impaired cardiac function usually results from a congential defect or history of rheumatic heart disease with valve prolapse or stenosis; dangerous because of plasma volume increase that accompanies pregnancy

Maternal cardiac disease

Uterus rises above the pelvic brim; Braxton hicks contractions are possible; potential for UTI increases; weight gain is 2.5-4lb during first trimester; placenta is fully functioning and producing hormones

Maternal changes at 12 weeks

Fundus reaches xiphoid process; breasts are full and tender; urinary frequency returns; swollen ankles may occur; sleeping problems may develop; dyspnea may develop

Maternal changes at 32 weeks

Level of pressure in the central arterial bed measured indirectly by BP; measured directly through arterial catheter insertion

Mean arterial pressure

Normal value in adults 100mmHg

Mean arterial pressure

Postpartum perineal exercises; spaced pregnancies; weight control

Measures to prevent uterine prolapse, cystocele, and rectocele

Rapid infusion of volume-expanding fluids such as whole blood, plasma, plasma substitutes; isotonic, electrolyte IV solutions; CVP artery catheters; CVP measurements, urine output, HR, clinical and mental state; immediate attendtion to improvement of perfusion; administration of drugs is withheld until circulating volume has been restores; O2 administration

Medical treatment for shock

The most common cause for increased seizure activity

Medication noncompliance

Repaglinide (prandin); lowers BS by stimulating beta cells in pancreas to release insulin closes K_ channels and opening Ca++ channels; adverse reactions: hypoglycemia, angina, chest pain, arthralgia, back pain, NV, dyspepsia, constipation or diarrhea; give before meals; monitor BS

Meglitindes

Pigmented cells of epithelium

Melano

Decreased serum chloride, increased pH and bicarbonate or CO2 content

Metabolic alkalosis

Retention of base or removal of acid from body fluids; caused by excessive gastric drainage, vomiting, potassium depletion, burns, excessive NaHCO3 administration

Metabolic alkalosis

Spread of cancer from the original sire to other parts of the body

Metastasis

Flushing, itching, hives (urticaria)

Mild allergic reaction

Give antihistamine

Mild allergic reaction nursing interventions

Appearance of a small, hard lump about the size of a pea on the front or side of the testes; manual examination should begin at 14 and done after the shower by palpating the testes and cord to look for a small lump; swelling may also be a sign of testicular cancer

Most common symptom of testicular cancer

Suction this first and then ? because stimulating the nares can initiate inspiration, which could cause aspiration of mucous

Mouth; nose

Sucralfate (carafate); indicated to treat peptic ulcers; adverse reactions include constipation and drug interactions with tetracycline, phenytoin sodium, digoxin, and cimetidine; taken 1 hour before meals; antacids interferes with absorption

Mucosal healing agents

Demyelinating disease resulting in the destruction of CNS myelin and consequent disruption in the transmission of nerve impulses; onset is insidious, increased white matter density seen on CAT scan; presence of plaques on MRI; CSF electrophoresis shows presence of oligoclonal (IGG) bands; auto immune

Multiple sclerosis

Symptoms usually begin in the upper extremities with weakness progressing to spastic paralysis

Multiple sclerosis

An inherited disease of the muscles, causing muscle atrophy and weakness; most serious and most common of the dystrophies is Duchenne

Muscular dystrophy

Associated with positive edrophonium (tensilon) test

Myasthenia crisis

Disorder affecting the neuromuscular transmission of impulses in the voluntary muscles of the body; autoimmune disease characterized by the presence of acetylcholine receptor antibodies, which interfere with neuronal transmission

Myasthenia gravis

More severe because the sac contains spinal fluid, meninges and nerves

Myelomeningocele

Narcotic antagonist used to counteract narcotic effects on mother/fetus; adverse rections: decreased RR; monitor RR closely; pain returns after administraion; 0.01mg/kg - newborn

Naloxone HCL (Narcan)

For narcotic-induced respiratory depression; 0.1mg to 0/4mg IV every 2-3 minutes as needed until 1mg is achieved

Narcan

Preferred for pain relief because they bind to the various opiate receptor sites in the CNS

Narcotic analgesics

Creating new words

Neologism

100-160HR; 30-60RR

Newborn normal HR & RR

Causes some danger because you cannot control the dose of oxytocin delivered by the posterior pituitary; change of hyper-stimulation or tetany is increased

Nipple stimulation

Used to determine fetal well being in high risk pregnancy and especially useful in postmaturity (notes response of fetus to own movements); a health fetus will usually response to its own movement by means of an FHR acceleration of 15 beats, lasting for at least 15 seconds after the movement, twice in a 20 minute period; the fetus that response with the 15/15 acceleration is considered reactive and healthy

Non stress test

2.0-4.5

Normal levels of phosphate

7.35-7.45

Normal pH range

Can be used by children 9 years of age and older

Numeric pain scale

Vaginal bleeding usually in the first trimester; size and date discrepancy (uterus larger than expected for gestational age); anemia, excessive NV, abdominal cramping, early symptoms of preeclampsia

Nursing assessment for Gestational trophoblastic disease (hydatidiform mole)

Edema that begins insidiously, becomes severe and generalized; lethargy; anorexia; pallor; frothy-appearing urine; massive proteinuria; decreased serum protein; elevated serum lipids

Nursing assessment for Nephrotic syndrome

Guthrie test; frequent vomiting, failure to gain weight; irritability, hyperactivity; musky odor of urine

Nursing assessment for PKU

Occurs in school age children; lethargy, rapidly progressive to deep coma; vomiting; elevated AGOT/AST, AGPT/ALT, LDH, serum ammonia, decreased PT; hypoglycemia

Nursing assessment for Reye Syndrome

Joint pain and decreased mobility, fever, nephritis, pleural effusion, pericarditis, abdominal pain, photosensitivity

Nursing assessment for SLE

Unconsciousness or disturbances in consciousness; vertigo; confusion, delirium, or disorientation; symptoms of increased ICP; changes in vital signs; headache; vomiting; papillary changes; seizures; ataxia; abnormal posturing; cerebral spinal fluid leakage; CAT & MRI; EEG

Nursing assessment for head injury

First red flag may be prolonged bleeding following circumcision; prolonged bleeding with minor trauma; hemarthrosis; spontaneous bleeding into muscles and tissues; loss of motion in joints; pain

Nursing assessment for hemophilia

Weight loss during pregnancy; signs of dehydration; psychological distress; fluid and electrolye imbalance; metabolic acidosis

Nursing assessment for hyperemesis gravidarum

Verbal report; as young as 3 can verbalize and report the location and degree of pain; nonverbal signs of pain such as grimacing, irritability, restlessness, and difficulty in sleeping or feeding; include the childs parents in the assessment

Nursing assessment for pain management of pediatric client

Acute pain is experienced during active labor; birth plan includes use of analgesic and anesthetic agents; decreased coping and increased anxiety are observed; VS and FHR, labor gross, last time and amount of food or fluids infested; lab values; hydration status; S&S of infection

Nursing assessment for patient Labor with analgesia or anesthesia

Plainless, bright red vaginal bleeding in third trimester; soft uterus; possible signs of shock; placenta in lower uterine segment; FHR is normal

Nursing assessment for placenta previa

Asymptomatic if confined to gland; symptoms of urinary obstruction ; with metastasis: low back pain, fatigue, aching in legs, and hip pain; elevated prostate specific antigen; elevated prostatic acid phosphatase; digital rectal examination revealing palpale nodule; transrectal ultrasound to visualize nonpalable nodule; definitive diagnosis by biopsy

Nursing assessment for prostate cancer

Chest pain, shortness of breath; tachycardia, even during sleep; migratory large joint pain; chorea; rash; subcutaneous nodules over bony prominences; fever; elevated erythrocyte edimentation rate; elevated ASO titer;

Nursing assessment for rheumatic fever

Assess disturbance of through processes; interpret content of internal and external stimuli: symbolism, delusions, ideas of reference; note form: construction of verbal communication: looseness of association, tangentital or circumstantial speech, echolalia, neologism, preservation, word salad; note process: flow of thoughts: blocking, concrete thinking; assess for disturbance in perception: hallucinations, illusions, depersonalization, delusions; assess for disturbances in affect: blunted or flat, inappropriate, incongruent with context of situation or event; assess for disturbance in behavior: incoherent and disorganized, impulsive, uninhibited, posturing, unusual mannerisms, social withdrawal, neglect of personal hygiene, exhibiting echopraxia; assess for disturbance of interpersonal relationships: difficulty establishing trust, difficulty with intimacy, fear and ambivalence toward others

Nursing assessment for schizophrenia

Postpartum hemorrhage, uterine hyperstimualtion; uterine over distension; dystocia; antepartum hemorrhage; magnesium sulfate therapy; bladder distension

Nursing assessment for the fourth stage of labor

Sore throat; fever; enlarged tonsils; breathing may be obstructed by kissing tonsils; throat culture to determine viral or bacterial causes

Nursing assessment for tonsillitis

Contains phenylalanine and should not be given to a child with PKU

Nutrasweet

Priority in substance abusers. Alcohol and drugs have superseded the intake of food

Nutrition

Anxiety associated with repetitive thoughts or irresistible impulses to perform an action; fear of losing control is a major symptom of this disorder

Obsessive compulsive disorder

Attempts to control self through the control of others or environment; shows inattention to new facts or different viewpoints; cold and rigid toward others; perfectionist, inflexible and stubborn; acts with blind conformity and obedience to rules; excessively neat and clean; preoccupied with work efficiency and productivity; verbally and nonverbally expresses disapproval of those whose behaviors and standards are different from own

Obsessive-compulsive personality disorder

Broken bone protrudes through skin or mucous membranes

Open fracture

Occurs when there is a fracture of the skill or penetration of the skill by an object

Open head injury

Assessment, management of the operative suite; PACU phase: pain management

Operative phase

Preferred method of administration; drug level peak: 1-2 hours

Oral route for analgesic

Lipid containing exfoliating sebaceous gland maturity; >20% stained orange indicates 35+ weeks

Orange staining cells

Abnormal psychological or behavioral signs and symptoms that occur as a result of cerebral disease, systemic dysfunction, or use of or exposure to exogenous substances

Organic disorders

Represents the time required for the impulse to travel from the atria (SA node), through the A-V node, to the purkinje fibers in the ventricles; represents A-V nodal function; normal is 0.12-0.20 seconds

PR interval

Relieves symptoms without curing the cause

Palliative procedure

Disorder affecting movement involving the basal ganglia and substantia nigra

Parkinson disease

Placenta lies over part of the cervical os

Partial placenta previa

Matneral pelvis, uterus, cervix, vagina, perineum

Passage

Fetus and placenta

Passenger

Causes respiratory alkalosis which causes cerebral vasoconstriction and decreased cerebral blood flow, and therefore decreased ICP

Passive hyperventilation of ventilator

Can be done during pregnancy under ultrasound for prenatal diagnosis and therapy. Hemoglobinopathies, clotting disorders, sepsis and some genetic testing can be done using this method

Percutaneous umbilical blood sampling (PUBS)

Can be used in any stage of labor

Peridural and epidural blocks

Temperature 101-104; red, swollen, very tender perineum; purulent drainage, induration

Perineal infection

Resistance to blood flow offered by the vessels in the peripheral vascular bed.

Peripheral resistance

Hair loss on extremities, indicating poor perfusion; coolness, skin shininess and thinness, weak or absent peripheral pulses, ulcerations on extremities, pallor, thick nails with ridges

Periphery changes in diabetes mellitus

Severe pain, bleeding, rectal discharge, ulceration in the rectal area; opportunistic infection of HIV

Perirectal mucocutaneous herpes simplex virus

Skin that is often prone to break down

Peristomal skin

Acute infectious respiratory disease usually occurring in infancy; gram-negative bacteria; begins with upper respiratory symptoms; paroxysmal stage characertized by prolonged coughing, and crowing or whooping upon inspiration; lasts from 4-6 weeks; transmitted by direct contact, droplet spread or freshly contaminated objects; treated by erythromycin; complications include pneumonia, hemorrhage and seizures

Pertussis (whooping cough)

Vincristine sulfate (oncovin), vinblastine sulfate (velban); indicated for ALL, Hodgkin, Wilms tumor, sarcoma, breast cancer, testicular cancer; adverse reactions: bone marrow suppression, neurotoxicity, weakness, paresthesia, jaw pain, constipation, stomatitis, alopecia, headaches, minimal NV; administer antiemetic, monitor for neurotoxicity

Plant alkaloids

Bad should be agitated periodically; used for bleeding caused by thrombocytopenia

Platelets

pooled 300mL; one unit contains single donor (200mL)

Platelets

Fever, dry cough, dyspnea at rest, chills; opportunistic infection of HIV

Pneumocystis Carinii Pneumonia

Used to differentiate between HIV infection in the neonate and antibodies the neonate receives from the mother

Polymerase chain reaction test (PCR)

After C-section, lochia is scant in the delivery room; this is normal when the patient ambulates initially.

Pooling of lochia in the vagina

Position of the laboring woman

Position

Warn not to rub or put pressure on the eye, glasses or shaded lens should be worn during waking hours; avoid lifting objects over 15 pounds, bending, straining, coughing or any other activity that can cause an increase in intraocular pressure; avoid lying on operative side; need to keep water from getting into eye; observe and report signs of increased intraocular pressure and infection

Post operative care for cataract

Fracture of the distal fibula, seriously disrupting the tibiofibular articulation; a piece of the medial malleolus may be chipped off as a result of rupture of the internal lateral ligament

Pott's fracture

Most common hypertensive disorder; develops during pregnancy and is characterized by elevated blood pressure, edema and proteinuria; characterized by an increase BP of 30mmHg systolic and/or diastolic increase of 15mmHg diastolic; 10 weeks gestation or 48 hours post delivery; major cause of maternal death, fetal hypoxia and death; predominately primigravida

Preeclampsia and eclampsia

Might influence burn recovery age, chronic illness, physical disabilities, disease, medications used routinely and drug/alcohol abuse

Preexisting conditions

Counted from the first day of the last menstrual period; 280 days, 40 weeks, 10 lunar months, 9 calendar months

Pregnancy length

Level >5mg/dl - more susceptive to kernicterus at lower bilirubin concentrations

Preterm infant

Onset of labor between 20 to 37 weeks gestation; predisposing factors to preterm labor include diabetes, cardiac disease, preeclampsia, placenta previa, infection, over distention of uterus due to multiple pregnancies, hydramnios, LGA, working outside home, 2+ children <5 years, financial stress, no social support system, smoking >10 cigarettes per day; responsible for 2/3 neonatal deaths; neonates >4.5lbs or >32 weeks have best chance for survival

Preterm labor

Exposure to tobacco smoke

Primary cause of COPD

Respiratory acidosis; necrotizing entercolitis; patent ductus arteriosus; intravascular hemorrhage

Problems associated with neonatal hypoxia

The body's response to illness and stress is what? And what does it result in

Produce glucose; resulting in hyperglycemia

Attributing ones own thoughts or impulses to another person; a student who has sexual feelings toward her teacher tells her friends the teaching is "coming on to her"

Projection

Day 5 to ovulation; endometrium is restored under primary hormone influence of estrogen; follicle stimulating hormone is secreted by the anterior pituitary; pre-ovulatory surge of leuteinizing hormone affects the follicle and ovulation occurs

Proliferation (follicular) phase

PO - 15-60 min onset; cause false decreased in urinary steroid secretion tests

Propoxyphene HCL (Darvon, Eration)

supraventricular and ventricular tachydysrhythmias; adverse reactions: hypotension, bradycardia, bronchospasm; monitor VS, contraindicated in asthma and COPD

Propranolol HCL (Inderal)

Response to labor by woman

Psyche

A sudden temporary inability to recall extensive personal information; occurs after a traumatic event; most common dissociative disorder

Psychogenic amnesia

Improves gas exchange

Pursed lip breathing

Infection of the kidney; temperature >102, chills; flank pain and costovertebral-angle tenderness; NV; dysuria, urgency, cloudy urine, hematuria, bacteriuria

Pyelonephritis

A narrowing of the pyloric canal; the sphincter hypertrophies to twice the normal size

Pyloric stenosis

Bactericidal effect; side effects: fever, skin rash, hyperuricemia, jaundice; high rate of effectiveness when used with streptomycin or capreomycin

Pyrazinamide

Don't feed infant if this occurs; anticipate gavage feedings in order to prevent further energy utilization and possible aspiration

RR>60

Decreased UOP is the first sign of ?

Renal failure

In a preterm makes the monitoring of administration of IV fluids and drug therapy crucial; closely monitor BUN and creatinine levels when administering the -mycin antibiotics to treat infections of a neonate

Renal immaturity

Should be elevated on one pillow; if elevated too high, can cause a contracture

Residual limb

Liver tissue is destroyed by hepatitis; these aspects of care are necessary for regeneration of the liver tissue being destroyed by the disease; drug therapy must be scrutinized carefully; recovery can take months, and previously taken medications should not be resumed without the health care providers directions

Rest and adequate nutrition

May indicate a return to consciousness but can also indicate anoxia, distended bladder, convert bleeding or increasing cerebral anoxia

Restlessness

Anemia results from decreased RBC production and blood loss; immunosuppression occurs because of the large number of immature WBCs or profound neutropenia; hemorrhage occurs because of thrombocytopenia

Results of leukemia

Acute, rapidly progressing encephalopathy and hepatic dysfunction; antecedent viral infections, such as influenza and chicken pox; associated with aspirin usage

Reye syndrome

Reduces effectiveness of oral contraceptives; gives body fluids orange tinge; stains soft contact lenses

Rifampin

Common viral disease that has teratogenic effects on fetus during the first trimester of pregnancy; transmitted by droplet and direct contact with infected person; discrete red macropapular rash that starts n face and rapidly spreads to entire body; rash disappears within 3 days

Rubella (German measles)

A psychiatric disorder characterized by thought disturbance, altered affect, withdrawal from reality, regressive behavior, difficulty with communication, and impaired interpersonal relationships

Schizophrenia

Productive cough and comfort can be facilitated by these positions because they lessen pressure on the diaphragm by abdominal organs.

Semi-fowler or high fowler position

Can be indicated by both a temperature increase and decrease

Sepsis

Duloxetine (Cymbalta), venlafaxine (effexor); indicated for depression, anxiety, panic disorder, anorexia, aggression, OCD; adverse reactions include nausea, dry mouth, insomnia, headache, fatigue, depressed appetite, increasing sweating, sexual dysfunction, withdrawal symptoms with abrupt cessation; should not be used with MAO inhibitors; wait at least 14 days between MAO inhibitor and starting this; baseline BP and monitor periodically; monitor for worsening of pretreatment symptoms

Serotonion/norepinephrine reuptake inhibitors

Screen for neural tube defects

Serum alphafetoprotein levels or amniotic fluid AFP levels

Widespread, serious reduction of tissue perfusion which, if prolonged, leads to generalized impairment of cellular functioning

Shock

Anger, crying, conflicting emotions, anger toward the deceased, guilt, preoccupation with loss

Shock, disbelief, rejection, or denial

Increases perfusion to the uterus, placenta, and fetus

Side lying position

PH<7.2; Po2 <50; PCO2>60

Signs of respiratory acidosis on a newborn

A malformation of the vertebrae and spinal cord resulting in varying degrees of disability and deformity; screened for latex allergies; prevented by the mother consuming 0.4mg of folic acid daily three months prior to pregnancy and 0.6mg/day during pregnancy

Spina Bifida

Involvement of two or more lymph nodes on the same side of the diaphragm or localized involvement of an extralymphatic organ site

Stage 2 Hodgkin disease

The more distal this is, the greater the chance for continence; the lower this is located, the more solid, or formed is the effluence

Stoma

Offering alternatives

Suggesting

Sore mouth, vaginal discharge, diarrhea, cough

Super infection

Major side effect of terbulatine (brethine) and ritodrine (yutopar); used to stop preterm labor; withhold if pulse >120-140

Tachycardia

97.7-99.4; measure axillary for 5 minutes; rectal approach can perforate rectum

Temperature: normal newborn norms

TPAL

Term births Preterm births Abortions Living children

Bilirubin level: >12mg/dl

Term infant

Evaluation of experience; expression of feelings ranging from anger to joy

Termination phase in group intervention

Cancer of the testes is the leading cause of death from cancer in males 15-35 years of age; death usually occurs within 2-3 years;

Testicular cancer

Hypoxic episodes; relieved by the child squatting or being placed in the knee-chest position

Tet spells

Full thickness; involves total destruction of dermis and epidermis; skin cannot regenerate; requires skin grafting; underlying tissue is involved; wound appears dry and leathery as eschar develops; painless; cannot heal on own

Third degree

Used in clients who have a resectable tumor - usually detection occurs too late to perform this

Thoracotomy

Spotting without cervical changes; treated with bed rest for 24 hours; no sex for 2 weeks

Threatened abortion

Examine legs of postpartum client daily for pain, warmth, and tenderness or a swollen vein that is tender to the touch

Thromboembolism

Propylthiouracil and methimazole act by blocking synthesis of T3 and T4; doses is based on body weight and is given over several months; take medications exactly as prescribed

Thyroid ablation

Levothyroxine (synthroid), liothyronine sodium (cytomel), desiccated thyroid (amout thyroid); indications: increase metabolic rates, synthetic T4; adverse reactions: anxiety, insomnia, tremors, tachycardia, palpitations, angina, dysrhythemias; check serum hormone levels routinely; check BP and HR; weigh daily; avoid foods and products contaiing iodine; initiate cautiously in patients with cardiac disease

Thyroid preparations

Generalized stiffness of the entire body

Tonic phase

Gestational hypertension, with no other signs of preeclampsia, is present at time of birth; resolves by 12 weeks after birth

Transient hypertension

Break occurs across the bone

Transverse

When the client is in bed, teach the client to sit with arms resting on overbed table for breathing promotion; when client is in chair, teach to lean forward with elbows resting on knees

Tripod position

Carpopedal spasm after BP cuff is inflated above systolic pressure

Trousseau's sign

Occurs 5-8 days post-op; oral fluid intake, emptying of bladder q4h-q6h, monitor I&O, avoid catheterization if possible

UTI

Calculated by subtracting the direct from the total bilirubin; dangerous bilirubin

Unconjugated indirect bilirubin

A bacterial infection anywhere along the urinary tract

Urinary tract infection

The downward displacement of the uterus

Uterine prolapsed

When this is displaced, it impinged on other structures in the lower abdomen; the bladder, rectum and small intestine can protrude through the vaginal wall

Uterus

Increased pulmonary blood flow; hole between the ventricles; oxygenated blood from left ventricle is shunted to the right ventricle and re-circulated to the lungs; small defects may close spontaneously; large defects cause Eisenmenger syndrome of congestive heart failure and require surgical closures

Ventricular septal defect

Supraventricular dysrhythmias; adverse reactions: hypotension, bradycardia, constipation; monitor BP and HR; change positions slowly

Verpamil HCL (isoptin, calan)

(Coumadin, coumain, panwarfin); blocks the formation of prothrombin from vitamin K; adverse reactions: hemorrhage, agranulocytosis, leucopenia, hepatitis; given orall, assess PTT, avoid sudden change in intake of foods high in vitamin K; antagonist: vitamin K

Warfarin sodium

Change in usual bowel and bladder function; sore that doesn't heal; unusual bleeding or discharge; thickening or a lump in the breast or elsewhere; indigestion or dysphagia; obvious changes in a wart or mole; nagging cough or hoarsenes

Warning signs of cancer

TB patient can return to work when?

When three sputum cultures have come back negative

The symptoms of anterior myocardial infarction characteristically last more than 15 minutes and are more intense than angina; if chest discomfort worsens or is unimproved 5 minutes after taking one tablet of spray of nitro.

When to seek emergency medical services

Where should the nurse place an anxious client?

Where there is reduced environmental stimuli

Speaking a jumbled mixture of real and made-up words

Word-salad

Indicated for short-term treatment of insomnia; reactions include daytime drowsiness; give with food 1-1.5 hours before bedtime

Zolpidem (ambient)

12 to 14 days after fertilization; from the time the ovum is fertilized until it is implanted in the uterus;

Zygote

Drowsiness, dizziness, weight gain, EPS, agitation

Zyprexa

Low T4 and high TSH levels; symptoms in the newborn: long gestation, large hypoactive infant, delayed meconium passage, feeding problems, prolonged physiologic jaundice, hypothermia; symptoms in early infancy: large, protruding tongue, coarse hair, lethargy, sleepiness, flat expression, constipation

assessment for congenital hypothyroidism

Twitching over tapped parotid gland

chvostek's sign

Difficulty rising to standing position; has to walk up legs using hands; occurs in Muscular dystrophy

gowers sign

Inability to control NV during pregnancy; inability to keep down fluids and solid foods for 24 hours; linked to maternal hormones

hyperemesis gravidarum

Weak, fragile capillaries of the brain

intraventricular hemorrhage

Natural humidifying pathway is gone for a client who has this

laryngectomy

Tachycardia, tachypnea, cutaneous vasoconstriction and oliguria

massive adrenergic compensatory response

Measures H+ concentrations

pH

Uncontrolled electrical discharges of neurons in the brain; more common in children <2 years; associated with immatureity of CNS, fevers, infections, neoplasms, cerebral anoxia, and metabolic disorders

seizures

Restlessness, increased RR, increased HR, diaphoresis, flaring nostrils, retractions, grunting, adventitious breath sonds, use of accessory muscles, head bobbing, alterations in blood gases: decreased PO2, elevated PCO2; respiratory failure before cardiac

signs of respiratory distress in children

80-130HR; 20-30RR

1-3 years normal HR & RR

Have less respirator depression but must be used with caution in a mother with preexisting narcotic dependency because withdrawal symptoms occur immediately

Antagonist drugs: Stadol, Nubain

If woman take these medications, expect heavy menstrual periods

Anticoagulants

Establish trust; demonstrate a nonjudgmental attitude, offer self; be empathetic, not sympathetic; use active listening; accept and support client's feelings; clarify and validate client's statements; use matter of fact approach

Basic communication principles

Continue to grow and take up space in the confined area of cranium, causing neural and vascular compromise in the rain, increased ICP and necrosis of the brain tissue; must be treated because they can have malignant effects

Benign brain tumor

A decreased serotonin is indicative of depression; a decreased norepinephrine level is also indicative of depression

Biogenic amines

Inhibits protein synthesis and is bactericidal; side effects: ototoxicity, nephrotoxicity; cautious use in older adults

Capreomycin (Capastat)

A malignant tumor arising from epithelial tissue

Carcinoma

Indicated for absence seizures, myoclonic seizures; adverse reactions: drowsiness, hyperactivity, agitation, increased salivation; therapeutic levels: 20-80mcg/ml; don't abruptly stop the drug; monitor liver function, CBC and renal function periodically

Clonazepam (klonopin)

Decrease in the oxygen carrying capacity of blood; often related to iron deficiency and reduced dietary intake; 20% of pregnant women; associated with increased incidence of abortion, preterm labor, preeclampsoa, infection, postpartum hemorrhage, and intrauterine growth retardation

Anemia

Fatigue, headache, bone and joint pain, hepatosplenomegally

Anemia

Often directing it at family or health care team members; "why me? Its not fair"

Anger

Blood vessels

Angio

Pulmonary and extrapulmonary, lymphatic and hematogenous TB are common, negative skin test doesn't rule this out; opportunistic infection of HIV

Tuberculosis

Usually diagnosed under the age of 30 years; insuling production is absent; onset is rapid; S&S polydipsia, polyphagia, polyuria, weight loss, weakness; weight is usually thin; ketosis is common; no overwhelming predisposition in regard to genetics; pathogenesis is viral, autoimmune; control is difficult with glycemia swings; meal planning and exercise is imperative; insulin is required by all; long term complications are common

Type 1 (IDDM)

Non-insulin dependent diabetes; obesity is a major factor

Type 2

Rare development of ketoacidosis; development of nonketotic hyperosmolar hyperglycemia with extreme hyperglycemia; hyperglycemia, plasma hyperosmoality; dehydration; changes mental status

Type 2 (NIDDM)

Used in bipolar disorder alone or with lithium; adverse reactions include NV, anorexia, hepatotoxicity, tremor, sedation, headache, dizziness; administer with food, monitor blood levels (should be between 50-125)

Valporic acid (depakene)

FHR is absent or minimal; short term variability is absent; long term variability is minimal; caused by hypoxia, acidosis, maternal drug ingestions, fetal sleep

Variability

Hydralazine (Apresoline), nitroprusside (Nipride), labetalol hydrochloride (Normodyne, Trandate)

Vasodilators used in shock patients

Related to allergens, spinal cord injury, or peripheral neuropathies, all resulting in venous pooling and decreased blood return to the heart, which decreases cardiac output over time

Vasogenic Shock

Potent drugs used in shock patients; dangerous and require that the client be weaned onto and off them. Don't change both infusions rates simultaneously.

Vasopressor and vasodilator drugs

Alteration in the function of consciousness, personality, memory or identity; sudden and temporary or gradual and chronic; handle stressful situations by "splitting" from the situation fantasy

Dissociative disorders

Avoid giving the patients with this disorder too much information about the past; protect from pain; too much too soon can cause decompensation

Dissociative disorders

Presence of two ro more distinct personalities within an individual; personalities emerge during stress

Dissociative identity disorder

Treatment of alcoholism; aversion therapy; interferes with the breakdown of alcohol causes accumulation of acetaldyhyde ; severe side effects occur if alcohol is consumed: NV, hypotension, headaches, rapid HR and RR, flushed face and blood shot eyes, confusion, chest pain, weakness, dizziness; persons with serious heart disease, diabetes, epilepsy, liver impairment or mental status should not take this

Disulfiram (antabuse)

Maintain aseptic technique, assess wound color and warmth, assess for wound healing, monitor for signs of infection

Dressing change for amputation

ACTH, cortisone, cytoxan, and other immunosuppressive drugs; teach prevention of infection

Drug therapy for MS

Changes in relation to uterine contractions; benign pattern caused by parasympathetic response (head compression); heart rate slowly and smoothly decelerates at beginning of contraction and returns to baseline at end of contraction

Early Decelerations

Suspect this in any women of childbearing age who presents at an emergency room, clinic or office with unilateral or bilateral abdominal pain

Ectopic pregnancy

In touch with external reality and is part of the personality that makes decisions

Ego

Prone to glaucoma and constipation - nurse should continually assess for constipation and should implement a plan of care directed at prevention of and treatment of constipation

Elderly patients with glaucoma

Measures the amount of urea nitrogen in the blood; urea is formed in the liver as the end product of protein metabolism; directly related to the metabolic function of the liver and excretory function of the kidneys

Elevated BUN

Evaluate diabetic control by reflecting blood glucose level during the previous 6-8 weeks

Elevated glycosylated hemoglobin

Lowest FIo2 possible to prevent CO2 retention, monitor for S&S of fluid overload, maintain Po2 between 55-60; pursed lip breathing and diaphragmatic breathing, teach tripod position

Emphysema nursing interventions

Reduced gas exchange surface area; increased air trapping (increased AP diameter); decreased capillary network; increased work, increased O2 consumption

Emphysema pathophysiology

Caused by an internal biologic deficiency ; biogenic amines at receptor sites in the brain

Endogenous depression

Infection of the lining of uterus; temperature 101-102; HR >100; malaise, anorexia; excess fundal tenderness long after it is expected; uterine subinvolution; lochia returning to rubra from serosa; foul smell lochia

Endometritis

Remove strong odors immediately; they can be offensive and increase nausea; encourage client to sit up for meals, this decreases the propensity to vomit; serve small, frequent meals

Environment conductive to eating for a patient who has NV

Severe, life-threatening infection of the epiglottis; progresses rapidly, causing acute airway obstruction organisms include Haemophilus influenza

Epiglottitis

Indicated as a rapid acting bronchodilator and is the drug of choice for acute asthma attack; adverse reactions: tachycardia, hypertension, tremors, nausea; give SC, IV, nebulizer; can be repeated after 20 min

Epinephrine HCL (sus-phrine)

Perineal care; fill a squeeze bottle with warm water and an ounce of povidone/iodine solution; lavage perineum with several squirts and blot dry instead of rubbing; avoid anal area

Episiotomy care

Antianemic medication; indicated for anemia due to chronic renal failure, chemotherapy, HIV related treatment; adverse reactions: seizures, hypertension, pain at injection site; don't shake vial because it can cause an inactivation of medication; monitor HCT levels; give slowly SC

Epoetin (procrit, epogen)

Acute coronary syndrome (unstable angina or non-Q wave MI, used in combination with heparin, aspirin, and in selected situations, ticlid and plavix; adverse reactions: bleeding, hypotension, thrombocytopenia, acute toxicity that presents with decreased muscle tone, dyspnea, loss of righting reflex; check drug-drug interactions, baseline PT/aPTT, H&H, platelet count and monitor; adjusted by weight for elderly; watch for bleeding; quickly reversible so emergency procedures may still be performed shortly after discontinuing

Eptifibatide (integrilin)

Indicated for Acute coronary syndrome and used in combination with heparin, aspirin, ticlid and plavix; adverse reactions: bleeding, hypotension, thrombocytopenia, acute toxicity: decreased muscle tone, dyspnea, loss of righting reflex; baseline PT/aPTT, H&H, platelet count ad monitor; watch for bleeding; quickly reversible so emergency procedures may still be performed shortly after discontinuing infusion

Eptifibatide (integrilin)

Weight dry diaper before applying. Weight the wet one after infant has voided. Calculate and record each gram of added weight as 1ml of urine

Evaluating exact urine output

Protrusion of intestinal contents and is more likely to occur in clients who are older, diabetic, obese or malnourished and have prolonged paralytic ileus

Evisceration

Edema, tachycardia, bulging fontanels, and rales in lungs

Excessive fluid volume S&S in preterm

Within 1-4 weeks after initiation of treatment; rigidity, shuffling gait, pill rolling hand movements, tremors, dyskinesia, mask like face; administer anticholingergic drugs cogentin, artane, Benadryl, symmetrel. Ativan, klonopin, inderal. Vitamin E

Extrapyramidal effects: parkinsonism

Cataracts and retinal problems

Eye changes in diabetes mellitus

Purulent discharge - gonorrhea or chlamydia; brushfield spots in iris - down syndrome; absence of red reflex - congenital cataracts; epicanthal folds - down syndrome; setting sun sign - CNS disorders; absent glabellar reflex (blink) - CNS or neuromuscular problem

Eyes: abnormal findings in newborn

Measures the balance between parasympathetic and sympathetic impulses usually produces no observable changes in the FHR during uterine contractions; most important indicator of the health of the fetal CNS

FHR

Nonverbal child can be assessed using this pain assessment tool.

FLACC

Can be utilized by children of preschool age and older for pain

Faces pain scale and poker chip scale

Sunlight, stress, pregnancy, drugs

Factors that trigger lupus

Tamoxifen citrate (nolvadex), megestrol (megace), medroxyprogesterone (provea); indicated for breast cancer; adverse reactions: hot flashes, mild nausea; administer antiemetic PRN

Female specific hormonal agents

IM - 7-15 min onset; IV - onset within 5 min; intradermal - within 12 hour onset; intrabuccal - 5 to 15 min onset; intrathecal has an immediate onset; synthetic narcotic, MSO4-like; acts quicker with a less duration

Fentanyl Citrate (Duragesic)

Used as an adjunct to anesthesia; adverse reactions: respiratory depression, apnea, bradycardia, hypotension; have resuscitation equipment readily available; don't mix with IB barbiturates

Fentanyl citrate (Sublimaze)

10-12 weeks: detectable using Doppler; 15-20 weeks: detectable using fetoscope; 110-160 is normal range

Fetal heart rate

The relationship of the long axis of the fetus to the long axis (spine) of the mother; longitudinal, transverse, or olique

Fetal lie

Determined using fundal height, fetal heart tones and rate, fetal movement, and uterine activity

Fetal well being

9 weeks after fertilization to term; few major anomalies caused by teratogens

Fetus

Pain impulses travel from the periphery to the gray matter in the dorsal horn of the spinal cord along small nerve fibers; substantia gelatinosa either opens or closes off the transmission of pain impulses to the brain; stimulation of large, fast conducting sensory fibers opposes the input from mall pain fibers, this blocking pain transmission

Gate control theory

Seeks attention by overreacting and exhibiting hyper excitable emotions; overly dramatic, seeks attention and tends to exaggerate; chaotic relationships, demonstrates angry outbursts and tantrums; verbally is loud, excitable, over reactive, attempts to draw attention o self; nonverbally is immature, self centered, dependent on attention and care from others, seductive and flirty

Histrionic personality disorder

The first and earliest signs of larynx cancer

Hoarseness or a change in vocal quality

A condition characertized by an abnormal accumulation of CSF within the ventricles of the brain; caused by an obstruction in the flow of CSF between the ventricles; most often associated with spina bifida; can be a complication of meningitis

Hydrocephalus

PO - 30 min onset; IM - 15 min onset; IV - 10-15 min onset; fast acting potent narcotic; cause appetite loss than other narcotics

Hydromorphone (Dilaudid)

Antineoplastic chemotherapeutic agents; urea-derived antineoplastic agent against solid tumors and CML. Anticancer enzyme against ALL; adverse reactions: drowsiness, renal dysfunction, NVD, hepatitis, myelosuppression; adequate H2O

Hydroxyurea (hydrea) & asparaginase (elspar)

Evaluate for RH isoimmunization and for ABO incompatibility; RH+ newborn, RH- mother; maternal RH+ antibodies are passed to the fetus and cause RBC hemolysis; RBC destruction binds to protein for excretion or metabolism; promote stolling by early feeding of milk which protein binds bilirubin for excretion; assess for the presence of jaundice; give adequate fluids; monitor bilirubin levels; phototherapy if >12mg/dl

Hyperbilirubinemia

Excessive accumulation of bilirubin (usually unconjugated) in the blood due to RBC hemolysis

Hyperbilirubinemia

Often deficient in thiamin, riboflavin, vitamin B6, Vitamin A and retinol binding proteins

Hyperemesis gravidarum

Caused by: renal failure, adrenal insufficiency, excess replacement; S&S: flushing, hypotension, drowsiness, lethargy, hypoactive reflexes, depressed respirations, bradycardia; levels above 2.5meq/l; avoid magnesium based antacids and laxatives; restrict dietary intake of foods high in this

Hypermagnesemia

Caused by renal failure or excess intake; S&S: tetany symptoms, phosphorus precipitation in nonosseus sites; level above 4.5; administer aluminum hydroxide with meals to bind; dialysis

Hyperphosphatemia

Can result from a primary disease state, replacement hormone therapy, excess TSH

Hyperthyroidism

Have osmolality higher than ECF; indicated for intravascular dehydration with interstitial or cellular overhydration; used with extreme caution; high concentrations of dextrose are given; used only when serum osmolality is dangerously low; 5% dextrose in LR, 5% dextrose in 0.45% NS, 5% dextrose in 0.9% NS; dehydration resulting from surgery because blood loss causes intravascular dehydration but the tissue cuts inflame and pull fluid into the area, causes interstitial overhydration; may also see in ascites and third spacing

Hypertonic IV solutions

Caused by renal failure, hypoparathyroidism, malabsorption, pancreatitis, alkalosis; S&S: diarrhea, numbness, tingling of extremeties, convulsions, positive trousseau sign; levels below 8.5meq/L; at risk for tetanty; administer these supplements 30 min before meals; increase intake; administer IV slowly

Hypocalcemia

Jitteriness, apnea, increased muscle tone, edema, abdominal distension, feeding intolerance, and chvostek's sign

Hypocalcemia S&S in preterm

Belief in and fear of having a disease, including misinterpretation of physical signs as "proof" of the presence of the disease

Hypochondriasis

Headache, nausea, sweating, tremors, lethargy, hunger, confusion, slurred speech, tingling around mouth, anxiety, nightmare

Hypoglycemia S&S

Jitteriness, tremors, lethargy, hypotonia, apnea, weak or high pitched cry, eye rolling, and seizures

Hypoglycemia S&S in preterm

Usually occurs rapidly and is potentially life-threatening; treat immediately with complex CHO; check blood glucose - may seize if <40

Hypoglycemia nursing actions

Caused by diuretics, diarrhea, vomiting, gastric suction, steroid administration, hyperaldosteronism, amphotericin B, bulimia, cushing syndrome; S&S: fatigue, anorexia, NV, muscle weakness, decreased GI motility, dysrhythmias, paresthesia, flat T waves on ECG; levels less than 3.5; administer this supplement (never give IV bolus), assess renal status, encourage foods high in this

Hypokalemia

Have an osmolality lower than ECF; cause fluid to move from ECF to ICF; indicated for cellular dehydration; 0.5% normal saline (HNS or 0.45%NS), 2.5% dextrose in 0.45% saline; not a common occurrence; dehydration caused by prolonged dehydration (TPN for prolonged periods of time)

Hypotonic IV solutions

Urine SG >1.020 indicates?

Hypovolemia

Related to external or internal blood or fluid loss

Hypovolemic Shock

PO2 < 50mmHg with FiO2 >60%

Hypoxemia

Usually withheld until the mid-active phase of labor; given in the early latent phase of the first stage of labor, it may retard the progress of labor; if given late in transition or in the second stage, it may depress the newborn; most drugs used for systematic pain relief and relaxation cause CNS depression; regional blocks cause a temporary interruption of nerve impulses

Labor with analgesia or anesthesia

Loss of bicarbonate; serum pH <7.33; loss of sodium and potassium through stools; elevated HCT, elevated BUN

Laboratory signs of acidosis

Ratio indicates fetal lung maturity unless mother is diabetic or has Rh disease, or fetus is septic

Lecithin:sphingomyeline

Language: aphasia, agraphia; memory: no deficit; vision: unable to discriminate words and letters, reading problems, deficits in right visual field; behavior: slow, cautious, anxious when attempting a new task, depression or catastrophic response to illness, sense of guilt, feeling of worthlessness, worries over future, quick anger and frustration; no deficit in hearing

Left hemisphere disruption in the brain

18-21 inches; 46-52.5 cm; crown to rump and rump to heel or from crown to heel at birth

Length: normal newborn norms

Abdominal palpations used to determine the fetal presentation, lie, position and engagement; supine position place both cupped hands over the fundus and palpate the determine fetal position;

Leopold maneuvers

Fracture line is intact; fracture is caused by minor to moderate force applied directly to the bone

Linear fracture

Drug that requires renal function assessment and monitoring

Lithium

Pale pinkish to brownish discharge lasting 1 week postpartum

Lochia serosa

Requires 2+ persons depending on the size of the client; carefully moved to a draw sheet to the side of the bed away from which they are going to be turned; client is then turned in a simultaneous motion, maintaining the spine in a straight position; pillows are arranged for support and comfort, and they assist the client to maintain alignment; 5 days after surgery of spine;

Log rolling

Fluphenazine decanoate (prolixin decanoate), haloperidol decanoate (haldol decanoate); indicated for clients who require supervision with medications regimes; proloxin can be given q7-28days; haldol can be given q4weeks; several months to reach steady state drug levels

Long acting Nonphenothiazines

Furosemide (lasix), torsemide (demadex), bumetanide (bumex); indicated for rapid action, potent for use when thiazides fail, cause volume depletion; adverse reactions: hypokalemia, hyperuricemia, glucose intolerance, hypercholesterolemia, hypertriglyceridemia, sexual dysfunction, weakness; volume depletion and electrolyte depletion are rapid; all nursing implications cited for thiazides

Loop diuretics

Lack of clear connection from one thought to the next

Looseness of association

Critical body areas are face, hands, feet and perineum

Lund and browder

Neoplasm occurring in the lung; cigarette smoking is responsible for 80-90%; poor prognosis

Lung cancer

Best indicator for fetal extrauterine survival

Lung maturity

Control CO2 through respirations; release excess CO2 by increasing RR; retain CO2 by decreasing RR

Lungs

CO x total peripheral resistance = systolic BP + 2/3

MAP calculation

Administered 12-15months of age and repeated at 4-6 years or by 11-12 years of age; contraindicated for persons with hx of anaphylactic reaction to neomycin or eggs, those with known altered immunodeficiency, and pregnant women; SC at different sites, may have a light transient rash for 2 weeks after administration of vaccine

MMR vaccine

Clarithromycyn (Biaxin), Azithromycin (Zithromax), Erythromycin; Indications: Biaxin (PO): URI, including strep, as adjunt treatment for H. pylori Zithromax (IV): gram-negative and gram-positive organisms; Adverse reactions: pseudo-membrane colitis, phlebitis, superinfection, dizziness, dyspnea; give biaxin XL with food, space MAO inhibitors 14 days before start and after end of Biaxin; report diarrhea, abdominal cramping; monitor liver/renal labs; PO Zithromax give on empty stomach

Macrolides

Treatment of burns, usually used with open method of wound care; adverse reactions: painful, causes mild acidosis; administer pain medication prior to dressing change; penetrates wound rapidly

Mafenide acetate (sulfamylon)

CNS: lethargy, high-pitched cry, jitteriness, seizures, bulging fontanels; Respiratory: apnea, tachypnea, flaring nares, retractions, seesaw breathing, grunting, abnormal blood gases; Cardiovascular: abnormal HR and rhythm, persistent murmurs differentials in pulse, dusky skin color, circumoral cyanosis; GI: absent feeding reflexes, vomiting, abdominal distension, changes in stool patterns, no stool; Metabolic: hypoglycemia, hypocalcemia, hyperbilirubinemia, labile temperature

Major danger signals in the newborn

Maintain utereoplacental perfusion and prevent seizures; administration of magnesium sulfate; withhold magnesium sulfate if signs of toxicity exist

Major goal for patient with patient preeclampsia

Didanosine (Videx), Lamivudine (Epivir), Abacavir (Ziagen), Zalcitabine (Hivid), Zidovudine (Retrovier); Indications are HIV infection; classification used in various combinations to reduce viral load and slow development of resistance; adverse reactions: peripheral neuropathies, pancreatitis, increase in triglycerides, fever, rash, NV, cramps; monitor for neuropathies; monitor amylase, lipase, triglycerides; give on empty stomach

NRT inhibitors

Period after pregnancy and delivery (usually 6 weeks) when the body returns to the nonpregnant state; care during this period is focused on wellness and family integrity

Normal postpartum

Excess analgesia and anesthesia may decrease peristalsis; no bowel movements are expected for 2-3 days

Normal postpartum changes: GI system

HCT rises, WBC is elevated (12,000 up to 25,000), difficult to use WBC for determination of infection; blood-clotting factors are elevated; increases risk for thromboembolism

Normal postpartum changes: hematologic system

Chloasma and hyperpigmentation areas regress; palmar erythema declines quickly; spider nevi fade

Normal postpartum changes: integumentary system

Pelvic muscles regain tone in 3-6 weeks; abdominal muscles regain tone in 6 weeks unless diastasis recti occur

Normal postpartum changes: musculoskeletal system

Fundus reaches level of umbilicus; breasts begin secreting colostrums; areolae darken; amniotic sac holds 400ml fluid; postural hypotension may occur; quickening may be felt; nasal stuffiness; leg cramps may begin; varicose veins and constipation may develop\

Maternal changes at 20 weeks

Dyspnea, hyperpnea; intercostals retractions; cyanosis, pallor; hypoxemia; diffuse pulmonary infiltrates seen on chest radiograph as "white-out" appearance; verbalized anxiety, restlessness

Nursing Assessment of ARDS

Tachycardia, tachypnea, decrease in BP (systolic <80mmHg) ; mental status changes; cool, clammy skin; diaphoresis, paleness; urine output decreases; CVP <4cm of H2O; urine SG >1.020

Nursing Assessment of patient in shock

No nursing interventions; monitor progress of labor; document process of labor

Nursing actions for early decelerations

Assess BP and pulse q5-15min; FHR with every contraction; observe perineal area for increase in bloody show, bulging perineum and anus, visibility of the presenting part; palpate bladder for distention; assess amniotic fluid for color and consistency

Nursing assessment during the second stage of labor

Bleeding: concealed or overt (dark red); uterine tenderness; persistent abdominal pain; rigid, board life abdomen; FHR abnormalities

Nursing assessment for Abruptio placenta

Pallor, tiredness, weakness, lethargy due to anemia; petechia, bleeding, bruising due to thrombocytopenia; infection, fever due to neuropenia; bone joint pain due to leukemic infiltration of bone marrow; enlarged lymph nodes; hepatosplenomegaly; headache and vomiting (signs of CNS involvement); anorexia, weight loss

Nursing assessment for Acute lymophocytic leukemia

Weight loss of at least 15% of ideal or original body weight; excessive exercise; apathy about physical condition and inordinate pleasure in weight loss; skeletal appearance; distorted body image; low self-esteem; hair loss and dry skin; irregular heart bear, decreased pulse and BP from decreased fluid volume; amenorrhea for at least 3 months; delayed psychosexual development or disinterest in sec; dehydration and electrolyte imbalance

Nursing assessment for Anorexia nervosa

Suspicion of newborn who fails to pass meconium within 24 hours; distended abdomen, chronic constipation alternating with diarrhea; nutritionally deficient child; enterocolitis that occurs as an emergency event; ribbon-like stools in the older child

Nursing assessment for Congenital aganglionic megacolon (hirschsprung disease)

Sudden onset, restlessness, high fever, sore throat, dysphagia, drooling, muffled voice, assuming upright sitting position with chin out and tongue protruding

Nursing assessment for Epiglottitis

Three C's: choking, coughing, cyanosis; excessive salivation; respiratory distress; aspiration pneumonia

Nursing assessment for Esophageal atresia with tracheoesophageal fistula

Severe anxiety; motor tension: restlessness, quickly fatigued, feelings of shakiness, tension; autonomic hyperactivity: SOB, heart palpitations, dizziness, diaphoresis, frequent urination; vigilance and scanning: difficulty concentrating, sleep disturbance, irritability, quick to become angry; on edge, appearance of being nervous; low self-esteem

Nursing assessment for Generalized anxiety disorder

History of preexisting cardiac disease; fatigue, dyspnea, feeling of smothering, dry hacking cough, racing heart, swelling of feet legs ad fingers; HR>100, crackles, orthopnea, RR>25; anemia

Nursing assessment for Maternal cardiac disease

Diplopia, ptosis; mask-like affect: sleepy appearance due to facial muscle involvement; weakness o laryngral and pharyngeal muscles: dysphagia, choking, food aspiration, difficulty speaking; muscle weakness improved by rest, worsened by activity; advanced cases: respiratory failure, bladder and bowel incontinence; myasthenic crisis and cholinergic crisis

Nursing assessment for Myasthenia gravis

Lethargy, temperature instability, difficulty breathing, subtle color changes: mottling and duskiness; just acts funny; subtle changes in behavior; respiratory distress, apnea; hyperbilirubinemia

Nursing assessment for Neonate with sepsis

Infants: vague symptoms, fever, irritability, poor food intake, diarrhea, vomiting, jaundice, strong smelling urine; children: urinary frequency, hematuria, enuresis, dysuria, fever; Escherichia coli in cultures

Nursing assessment for UTI

Recurrent UTIs; reflux; reflux noted on voiding cystourethrogram

Nursing assessment for Vesicoureteral reflex

Severe mid-epigastric pain radiating to the back, usually related to excess alcohol ingestion or a fatty meal; adominal guarding: rigid and boardlike abdomen; NV; elevated temp, tachycardia, decreased BP; bluish discoloration of the flanks or periumbilican area; elevated amylase, lipase, and glucose levels

Nursing assessment for acute pancreatitis

Assess for symptoms of peripheral vascular disease: cool extremity, absent peripheral pulses, hair loss on affected extremity, necrotic tissue or wounds, leathery skin on affected side, decrease of pain sensation; assess for inadequate circulation: arteriogram, Doppler flow studies

Nursing assessment for amputation

Fatigue, pallor; HGB<11, HCT <37% in first trimester; HGB < 10.5, HCT < 35% in second semester; HGB<10, HCT<32% in third trimester; poor nutritional intake; noncompliance with prenatal vitamin

Nursing assessment for anemia

Pallor; palmar crease; conjunctiva; fatigue, exercise intolerance, lethargy, orthostatic hypotension; tachycardia, heart murmurs, heart failure signs of bleeding; dyspnea; irritability, difficulty concentrating; cool skin and cold intolerance

Nursing assessment for anemia

History of family asthma, history of allergies; tight cough; breath sounds that are course, expiratory wheezing, rales, crackles; chest diameter enlarged; signs of respiratory distress

Nursing assessment for asthma

Signs of increased ICP; fever, chills, neck stiffness, opisthotonos; photophobia; positive kernig sign; positive brudzinski sign

Nursing assessment for bacterial meningitis for children

Determine level of depression, level of mania; assess nutrition and hydration status; assess level of fatigue; assess danger to self and others in relation to level of impulse impairment present

Nursing assessment for bipolar disorder

Pain, anorexia, vomiting, flatulence precipitated by ingestion of fried, spicy or fatty foods; fever, elevated WBC and other sigs of infection; abdominal tenderness; jaundice and clay colored stools; elevated liver enzymes, bilirubin and WBC

Nursing assessment for cholecystitis and cholelithiasis

Failure of fusion of the lip, palate or both; difficulty sucking and swallowing; parent reaction to facial deficit

Nursing assessment for cleft lip and/or cleft palate

Assess degree of social impairment degree of manipulative behavior; assess degree of anxiety; determine the risk for self or other directed violence

Nursing assessment for cluster B: dramatic, emotional and cluster C: anxiety, fearful personality disorders

Rectal bleeding, change in bowel habits, sense of incomplete evacuation, abdominal pain, nausea, vomiting, weight loss, cachexia, family history of cancer, history of polyps

Nursing assessment for colorectal cancer

Moon face; truncal obesity; buffalo hump; abdominal striae; muscle atrophy; thinning of the skin; hirsutism in females; hyperpigmentation; amenorrhea; edema, poor wound healing, easy bruising; hypertension; susceptibility to multiple infections, osteoporosis, peptic ulcer formation, hyperglycemia, hypernatremia, hypokalemia, decreased eosinophils and lymphocytes, increased plasma cortisol, increased urinary 17 hydroxycorticoids

Nursing assessment for cushing syndrome

Depression, mood swings, insomnia, potential for suicide; varying degrees of orientation; varying levels of anxiety; impairment of social and occupational functioning; alcohol or drug use

Nursing assessment for dissociative disorders

Flat, broad nasal bridge; inner epicanthal eye folds; upward, outward slant of eyes; protruding tongue; short neck; transverse palmer crease; associated with cardiac defects, respiratory infection, feeding difficulties, delated developemental skills, mental retardation

Nursing assessment for down syndrome

Bulging perineum; woman screaming that the baby is coming; presenting part visible at introitus

Nursing assessment for emergency delivery

Abnormal placement of meatus; altered voiding stream; presence of chordee; undescended testes and inguinal hernia

Nursing assessment for hypospadias

Joint pathology: arthritis, fracture, pain not relieved by medication, poor ROM

Nursing assessment for joint replacement

Tendency to bleed; anemia; infection; GI distress

Nursing assessment for leukemia

Waddling gait, lordosis; increasing clumsiness, muscle weakness; gowers sign; pseudohypertrophy of muscles; muscle degeneration especially of the thighs and fatty infiltrates; cardiac muscle is involves; delayed cognitive development; elevated CPK and SGOT/AST; scoliosis, respiratory difficulty and cardiac difficulty

Nursing assessment for muscular dystrophy

Classic dowager's hump, or kyphosis of the dorsal spine; loss of height, often 2-3 inches; back pain, often radiating around the trunk

Nursing assessment for osteoporosis

Fever, pain, infant may pull at ear; enlarged lymph nodes; discharge from ear; upper respiratory symptoms; vomiting, diarrhea

Nursing assessment for otitis media

LOC changes; irritability, vomiting; headache on awakening; motor dysfunction; unequal pupil response; seizures; decline in academics; change in personality; irritability, lethargy; increasing head circumferences; bulging fontanels; widening suture lines; sunset eyes; high pitched cry

Nursing assessment hydrocephalus

Rigidity of extremities; mask like facial expressions associated with difficulty swalling, chewing and speaking; drooling; stooped posture and slow, shuffling gait; tremors at rest, pill rolling movement; emotional lability

Nursing assessment of Parkinson disease

Pain, swelling, tenderness; deformity, loss of functional ability; discoloration, bleeding at the site through an open wound; crepitus; fracture is evident on radiograph; observe the clients use of assistive devices

Nursing assessment of a fracture

Rapid acting bronchodilators and steroids for acute attacks; maintain hydration; monitor blood gas values for signs of respiratory acidosis; oxygen or nebulizer therapy; monitor pulse oximetry; monitor theophylline levels; administer cromolyn sodium prophylactically to prevent inflammatory response

Nursing plans and interventions for asthma

Administer antibiotics and antipyretics; isolate for at least 24 hours; VS and neurologic signs frequently; keep environment quiet and darkened to prevent overstimulation; implement seizure precautions; measure head circumference daily in infants; I&O;

Nursing plans and interventions for bacterial meningitis

Maintain client's physical health; provide nutrition, rest, and hygiene; provide a safe environment; decrease stimulation; private room; consistent approach to minimize manipulative behavior; frequent, brief contacts to decrease anxiety; avoid giving attention to bizarre behavior; meet needs as soon as possible to keep client from becoming aggressive; small, frequent feedings of food that can be carried; simple, active, noncompetitive activities; avoid distracting or stimulating activities; self-control, acceptable behavior; administer lithium, sedatives and antipsychotics

Nursing plans and interventions for bipolar disorder

Identify baseline neurologic functioning; monitor I&O carefully; administer steroids and osmotic diuretics

Nursing plans and interventions for brain tumor

Similar to those with a patient who has increased ICP and head injury; elevate HOB 30-40 degrees; radiation therapy' administer chemotherapy; craniotomy

Nursing plans and interventions for brain tumors

Assess lesion by location, size, shape, consistency, fixation to surrounding tissues, lymph node involvement

Nursing plans and interventions for breast cancer

Isolate child; monitor respiratory status; observe for hypoxia; clear airway of secretions using a bulb syringe; provide care in mist tent; administer oxygen; maintain hydration; evaluate response to respiratory therapy; administer synagis (palivizumab) to provide passive immunity against RSV to high risk children

Nursing plans and interventions for bronchiolitis

Motivate learning; client to be attentive and able to focus and problem solve; dulls perceptions of sensory stimuli; client becomes hesitant; clients speech rate and volume to increase; client becomes wordy; client becomes restless; may be converted into physical symptoms, such as headaches, nausea and diarrhea

Moderate anxiety

Gradiosity, talkativeness, pressured speech, impulsiveness, excessive spending, bizarre dress and grooming

Moderate bipolar disorder

Feelings of helplessness and powerlessness; decreased energy; sleep pattern disturbances; appetite and weight changes; slowed speech, thought and movement; rumination on negative feelings

Moderate depression

Heavy, vaginal bleeding with clots; temperature on >100.4 lasting >24 hours; red, warm lump in breast; pain on urination; tenderness in calf

Mom should notify health care provider

Selegiline (eldepryl); used with dopamine agonist when client symptoms don't response; adverse reactions: confusion, dizziness, nausea, dry mouth, insomnia; not an option with antidepressants

Monoamine oxidase type B inhibitor

Azactam; indicated for pseudomonas aeruginosa and many resistant organisms, most effective against gram-negative organisms; adverse reactions include phlebitis, pseudo-membranous colitis, CNS changes, EEG changes, headache, diplopia, hypotension; monitor for renal and hepatic function, monitor for diarrhea, assess motor sensory function and cardiac rhythm

Monobactam

Trastuzumab (herceptin), rituximad (Rituxan); targets specific malignant cells with less damage to healthy cells in non-hodgkin lymphoma, breast cancer; adverse reactions: fever, chills, infection, NVD, bronchospasm, dyspnea, ARDS, hypotension, ventricular dysfunction; HF; premedicate with antiemetics

Monoclonal antibodies

PO - 60-90 min onset; IM - 10-30 min onset; IV - 10 min onset; drug of choice in relieving pain associated with MI; transient decrease in BP; drug of choice in chronic cancer pain

Morphine Sulfate

Often first choice for severe pain; adverse reactions: NV, constipation, respiratory depression, depression of cough reflexes, hypotension; chest RR and BP before administration; have narcan available just incase

Morphine sulfate

Eye contact between mom and baby; exploration of infant from head to toes; stroking, kissing, and fondling the baby; smiling, talking, singing to the neonate; use of claiming expressions; absence of negative statements; naming the newborn quickly and calling it by name

Mother-infant bonding behaviors

Maintain nutritional status; feed small, frequent feedings, provide high calorie formula; maintain hydration ; neutral thermal environment; frequent rest periods; digoxin and diuretics; monitor for signs of deteriorating condition; assist with diagnostic tests and family support; prepare child for surgery as appropriate to age

Nursing plans and interventions for children with congenital heart disease

Administer analegesic for pain; maintain NPO; maintain NG tube; IB antibiotics; Monitor I&O; electrolyte status ; avoid spic, fried, fatty foods and to reduce intake of caloiries if indicated

Nursing plans and interventions for cholecystitis and cholelithiasis

Promote family bonding and grieving during newborn period; successful corrective surgery is available; assist with feeding - feed in upright position, feed slowly with frequent bubbling, use soft large nipples lamb's nipples prosthetic palate or rubber tipped asepto synringe;

Nursing plans and interventions for cleft lip and/or cleft palate

Establish trust; protect client from injury to self and others; recognize manipulative behavior; focus on strengths and accomplishments; set limits on manipulative behaviors when necessary; reinforce independent, responsible behaviors; assist to recognize the need to respect the needs and rights of others; encourage socialization

Nursing plans and interventions for cluster B: dramatic, emotional and cluster C: anxiety, fearful personality disorders

Prepare client for surgery; prepare client for bowel preparation; provide high calorie, high protein diet; prevention of constipation with high fiber diet; early detection by screening with hemoccult tests

Nursing plans and interventions for colorectal cancer

Newborn assessment at birth; apply abduction device or splint; teach parents application and removal of the device, skin care and bathing, diapering, follow up care involves frequent adjustments;

Nursing plans and interventions for congenital dislocated hip

Newborn screening programs before discharge; assess newborn for signs; lifelong need for therapy; give child a single dose in the morning; check pulse daily before giving medication; periodic testing is necessary

Nursing plans and interventions for congenital hypothyroidism

Monitor VS frequently and report signs of increasing distress; assess respiratory functioning; elevate HOB; administer oxygen; administer digoxin and diuretics; weigh frequently; strict I&O; report any unusual weight gain; provide a low sodium diet or formula

Nursing plans and interventions for congestive heart failure

Maintain bed rest in fowler or semi fowler position with BR privileges; palpate fundus and abdomen q8h; antibiotics

Nursing plans and interventions for endometritis

Sitting position decreased intraocular pressure; remove conjunctival foreign bodies unless embedded; never attempt to remove a penetrating or embedded object; apply cold compressures to eye contusion; irrigate eye with copious amounts of water; eye medications; eye patch may be applied to rest the eye; reading and watching TV may be restricted for 3-5 days; sudden increase in eye pain should be reported

Nursing plans and interventions for eye trauma

Weigh daily; check urine 3x for ketones; monitor electrolytes and hydration status; clear liquids bland full diet; check FHR; psychological support

Nursing plans and interventions for hyperemesis gravidarum

Calm, restful atmosphere; signs of thyroid storm; high calorie, high protein, low caffeine diet; eye care for expohthalmost; treat hyperthyroidism

Nursing plans and interventions for hyperthyroidism

Prepare child and family for surgery; assess circulation to tip of penis postopertively; monitor urinary drainage after urethroplasty; restrain child; maintain hydration;

Nursing plans and interventions for hypospadias

Increased intake my 300 calories above basal and activity needs; increase protein by 30g/day; increase intake of iron (30+) and folic acid (800-1000mcg) through diet and supplements; increased intake of vitamin A, C ad calcium; 8-10 glasses of fluid per day; provide a copy of daily food guide to post on refrigerator

Nursing plans and interventions for malnutrition

C&S of breast milk; breast feed q2-3hours and make sure breasts are emptied with each feed; do not let client cease breastfeeding abruptly; mother should manually empty breasts and discard milk to maintain milk production and reduce congestion; treated at home by PO antibiotics; bed rest for 48 hours; monitor for abscess

Nursing plans and interventions for mastitis

Immediately dry infant under warmer or skin to skin with mother; suction mouth and nose with syringe; keep head slightly lower than body; assess airway status; apgar score at 1 and 5 minutes; allow maternal/parent contact; keep head covered; gestational age assessment; examine cord for presence of 2 arteries and one vein; make sure cord blood is collected for analysis and sent to lab; document passage of meconium and urine after delivery; two identity bands on neonate and one on mother; newborn footprints and maternal thumb and finger prints; physical exam of the newborn; eye prophylaxis in delivery room

Nursing plans and interventions for newborn

Ventilations are done over moth and nose, size 1 mask; 40-60 per minute; HR<60 compressions are done with thumbs side by side; 1/3 the anteroposterior chest diameter; compression/ventilation ration is 3:1 to achieve 120 events/min; IV fluids; administer sodium bicarbonate or epinephrine; glucose

Nursing plans and interventions for newborn resuscitation

24 hour recall; food diary; food frequency record; assess skin, hair, teeth, gyms, lips, tongue, and eyes; use anthrometry; obtain biochemical analysis

Nursing plans and interventions for nutrition

Provide for client's physical needs; allow performance of the compulsive activity with attention given to safety; meaning and purpose of the behavior with client; avoid punishing and criticizing; establish routine to avoid anxiety producing changes; learning alternative methods of dealing with stress; avoid reinforcing compulsive behavior; limit the amount of time for performance of ritual and encourage client to gradually decrease the tiem; anti-anxiety medications; SSRIs and tricyclic

Nursing plans and interventions for obsessive compulsive disorder

Provide and monitor O2 therapy; monitor thermoregulation; monitor fluid and electrolytes; weigh diapers daily; maintain urine output 1ml/kg/hr and SG 1.005-1.012; maintain nutrition; premie formulas; provide TPN; prevent injury resulting from hyperbilirubinemia; prevent intracranial hemorrhage

Nursing plans and interventions for preterm newborn care

Maternal BP and pulse q15 between contractions; FHR with each contraction or by continuous fetal monitoring; mouth care, linen change, positioning; decrease outside distractions; squatting, side lying or high-fowler/lithotomy for pushing; hold breath for no longer than 5 seconds during pushing; exhale when pushing or use gentle pushing technique; set up delivery table, including bulb syringe, cord clamp, and sterile supplies; at crowning, put gentle counter-pressure against the perineum. Do not allow rapid delivery over woman's perineum; record exact delivery time

Nursing plans and interventions for the second stage of labor

Determine baseline lab data for serum glucose, electrolytes, creatinine, BUN, ABGs; teach injection technique; meals should be timed sccording to medication peak times; teach diet regime: 55% - 60% carbohydrates, 12% - 15% protein, 30% less fat; teach about managing sick days; teach exercise regimen; teach S&S of hyperglycemia and hypoglycemia; teach about foot care

Nursing plans and interventions of diabetes mellitus

Administer antibiotics; reduce body temperature with tepid baths and Tylenol; position child on affected side; warm compress on affected ear; finish all antibiotics, follow up visit, monitor for hearing loss; smoking and bottle feeding when child is in supine position are predisposing factor

Nursing plans and interventions of otitis media

Retinopathy of prematurity; bronchopulmonary dysplasia

O2 toxicity results

Break occurs at an angle across the bone

Oblique

Fracture line occurs at approx. 45 degree angle across the longitudinal axis of the bone

Oblique fracture

Loss of vision or blind spots

Optic neuritis

The leading cause of death from gynecologic cancers in the US; growth is insidious so it is not recognized until it is at an advanced stage

Ovarian cancer

Zyvox; life-threatening VRE and MRSA; adverse reactions include GI disturbances, headache, pancytopenia, pseudo-membrane colitis, superinfection; monitor renal/liver labs and blood counts; may exacerbate hypertension; report diarrhea immediately

Oxazolidinone

The stimulus to breathe is hypoxia, not the usual for hypercapnia, in COPD patients - dangerous to give ?? to these patients because they may stop breathing

Oxygen

Always administer O2 at the lowest concentration possible when correcting hypoxia; use O2 analyzer to determine the exact amount; hypoxia and hyperoxia are dangerous; perscriped in percentages and represents the fraction of inspired O2 in the air; can be administered via oxy-hood (concentrations up to 100%), nasal prongs (low concentrations), continuous positive airway pressure (reduces work of breathing and keeps alveoli open

Oxygen therapy for the newborn

Most important side effect is ADH effect which can cause water intoxication

Oxytocin

Ideal method to control pain; able to prevent pain by administering to self smaller doses of the narcotic as soon as the first sign of discomfort appears; usually IV; predetermined dose and a set lockout interval are prescribed by MD; lock out mechanisms prevent overdose; pump can record number of times the client uses the pump and the cumulative dose delivered

PCA

Pain scale to be used with children 1-3 months of age

Pain rating scale

The 5 Ps of neurovascular functioning

Pain, paresthesia, pulse, pallor and paralysis

Refers to the number of deliveries that have occurred after 20 weeks of gestation

Para

Interferes with metabolism of tubercle bacillus; side effects: GI disturbance (common), hypersensitivity, hepatotoxicity; interferes with absorption of rifampin; uncommonly used

Paraaubisalicylic acid (PAS)

Absent bowel sounds, abdominal distension, tympany on percussion, NV, obstipation (intractable constipation)

Paralytic ileus

Common in comatose clients; gastric tube aids in gastric decompression

Paralytic ileus

Pelvic cellulitis; temperature 103-104l tachycardia, tachypnea; severe uterine and cervical tenderness; WBC>25,000; palpale pelvic abscess

Parametritis

Systematized delusions, hallucinations related to a single theme; ideas of reference; potential for violence if delusions are acted upon

Paranoid

Regulate calcium and phosphorus balance

Parathyroid glands

Increased pulmonary blood flow;anormal opening between the aorta and the pulmonary artery; closes within 72 hours after bith; if it remains patent, ocygenated blood from the aorta returns to the pulmonary artery; increased blood flow to the lungs causes pulmonary hypertension; medical intervention with indomethacin (indocin) or surgical closure

Patent ductus arteriosus

Generalized vasospam and vasoconstriction leading to vascular damage over time; loss of plasma protein into the interstitial spaces; Hypovolemia, which results in decreased perfusion to major organs

Pathophysiology for preeclampsia

Place this patient in Trendelenburg position (feet up 45 degrees, head flat

Patient in shock

Only used in the second stage of labor.

Pedendal block and subarachnoid (saddle) block

Commonly used eye drop for glaucoma; vision may be blurred for 1-2 hours after administration and adaptation to dark environments is difficult because of the papillary constriction it causes

Pilocarpine

Any clinical infection of the genital canal that occurs within 28 days of delivery

Post partum infection

Imbalances that are potentially life-threatening

Potassium

30-60; remember ANCs; count 1 full minute by observing abdomen or auscultating

Respirations: normal newborn norms

PCO2 > 45 or PO2 < 60 on 50% O2; a child in severe distress should be on 100% O2

Respiratory Failure

Hypoventilation; caused by COPD, primary disease, drugs, obesity, mechanical asphyxia, sleep apnea

Respiratory acidosis

An inflammatory disease; most common cause of acquired heart disease in children; usually affects the aortic and mitral valves of the heart; associated with an antecedent beta hemolytic strep-infection; a collagen disease that injures the heart, blood vessels, joints and subcutaneous tissue

Rheumatic fever

Petechiae under BP cuff; platelet decrease or increase; fibrinogen increase or decrease

Signs of coagulopathy

Result of valvular malfunction and backflow of urine into the ureters (and higher) from the bladder (severe cases are associated with hydronephrosis

Vesicoureteral reflex

BP should rise no more than 30 points systolic and no more than 15 points diastolic; HR: 60-90; RR: 16-24

Vital sign changes

Signs of deficiency: redness and fissuring of eyelid corners; burning, itching, tearing eyes, photophobita, magenta colored tongue and/or glossitis, seborrheic dermatitis, delayed wound healing; food sources: prepared infant formula, liver, enriched cereals, cow's milk, cheddar cheese, some green leafy vegetable such as broccoli, green beans and spinach

Vitamin B12 (riboflavin)

Used in bipolar disorders and as an alternative to lithium; adverse reactions include dizziness, ataxia, blood dyscrasias; serum levels between 8-12; stop if WBC < 3000 or neutrophil count < 1500; monitor hepatic and renal function

Carbamezepine (tegretol)

Meats, seafood, whole grains

Foods high in zinc

Vegetables, fruits, juices, cereals, breads, starches

Foods low in phenylalanine

Administer IV fluids and electrolytes two times maintenance levels to increase hydration and treat acidosis; mnitor I&O; administer blood products; administer analgesics; warm compressed; prescribed antibiotics

Nursing care for child in vaso-occlusive crisis

Confusion, lethargy, anorexia, rapid RR

Pneumonia in the elderly

Assess sputum for volume, color, consistency, and clarity; TCDB q2h, humidity to loosen secretions, suction airway; 3L/day unless contraindicated to liquefy lung secretions; monitor ABGs (Po2 > 80; PCO2 <44 mmHg); O2 sat > 95%

Pneumonia nursing interventions

Signifies hypoxia

Po2 < 50

Diseases that can be transmitted during intimate sexual contact; occur in adolescents and young adults

STDs

Follows a streptococcal infection; edema is mild and usually around the eyes; the blood pressure is elevated; the urine is dark, tea colored (hematuria) with slight to moderate proteinuria; blood has a normal serum protein and a positive ASO titer

Acute glomerulonephritis

Indications: Do not exhibit muscle relaxant or anticonvulsant activity, not effective for management of substance abuse; reactions include dizziness. Several weeks for antianxiety effects to become apparent

Bupirone (Buspar)

Tissue injury or necrosis caused by transfer energy from a heart source to the body; can be thermal, radiation, electrical, chemical; tissue destruction results from coagulation, protein denaturation, ionization of cellular contents; critical symptoms affected include the respiratory, integumentary, cardiovascular, renal GI, neurological

Burn

Tissue injuries caused by heat, electricity, chemicals, or radiation

Burns

Characterized by multiple pieces of bone; often occurs at bone ends or in vertebrae

Burst fracture

Can occur from the nose (rhinorrhea) or through the ear (otorrhea); carries the risk for meningitis and indicates a deteriorating condition.

CSF leakage

Motor loss, hemiparesis or hemoplegia; communication loss, dysathria, dysphasia, aphasia, or apraxis; perceptual disturbance that can be visual, spatial and sensory; change in LOC

CVA

Administer prescribed fluids until designated ?? is reached in patients with shock

CVP

When a patient is in shock, this number is usually elevated to 16-19 cm of H2O as compensation for decreased cardiac output

CVP

More often associated with acyanotic defects

Congestive heart failure

Occurs when the body retains water and electrolytes isotonically

Fluid volume excess

Multiple strains, some of which are implicated in cervical cancer; alarming rate increases in adolescent population; lesions may be small, wart life or clustered. May be flat or raised; treated with podophyllum resin, trichloracetic acid, laser, or cryotherapy

Human papillomavirus (HPV)

Enables liquefaction of mucous trapped in the bronchioles and alveoli; essential for client experiencing fever; 300-400mL of fluid are lost daily by the lungs through evaporation

Hydration

Very important in the treatment of sickle cell disease because it promotes hemodilution and circulation of RBCs through the blood vessels

Hydration

Protamine zinc (PZI), extended zinc suspension (ultralene), insulin glargine (lantus); onset: 4-8 hours; peak:: 4-20 hours (some say there is no peak); not to be given IV; give once a day; don't shake solution; don't mix other solutions with lantus

Long acting insulin

averages 6 to 10 changes per minute; evaluated by external or internal monitoring

Long term variability

Fracture line extends in the direction of the bones longitudinal axis

Longitudinal fracture

Urinary output <30ml/hour; RR<12; DTRs absent; deceleration of FHR, bradycardia

Magnesium sulfate toxicity

RR<12, urine output <100ml/4hr, absent DTRs, levels >8mg/dl

Magnesium toxicity

Change in LOC; paresthesia, paralysis, aphasia, agraphia, memory loss, vision impairment, bladder and bowel dysfunction; behavioral changes; assessment of client's functional abilities; ability to swallow, eat, and drink without aspiration

Nursing assessment for CVA

Dry, scaly rash on face or upper body (butterfly rash)

Nursing assessment for DLE

Joint pain that increases with activity and improves with rest; morning stiffness; asymmetry of affected joints; crepitus; limited movement; visible joint abnormalities; joint enlargement and bony nodules

Nursing assessment for Degenerative joint disease

Hypertonic or hypotonic uterine contractions; inability to bear down or push efficiently; prolonged labor patterns

Nursing assessment for Dystocia

Prevention of cardiac embarrassment, maintenance of uterine perfusion and alleviation of anxiety

Nursing care focus for mother with cardiac disease

Calm atmosphere; semi-fowler, side lying position; prevent valsalva maneuver; avoid hypotension; avoid stirrups in delivery room; pain relief and supportive measures because pain can contribute to cardiac distress

Nursing care for cardiac maternity client: intrapartum

STOP TRANSFUSION; change tubing, then continue saline IV; treat for shock; draw blood samples for serologic testing; monitor UOP hourly; give diuretics

Nursing interventions for acute hemolytic Reaction

Priority in planning nursing care for the confused older client; change increases anxiety and confusion

Consistent caregiver

Crackling sound between two broken bones

Crepitus

Occurs when there is digestion of the pancreas by its own enzymes, primarily trypsin; alcohol ingestion and biliary tract disease are common causes of this

Acute pancreatitis

Any traumatic damage to the head

Head injury

Decreased HBG; low serum iron level; elevated total binding capacity

Lab values for Iron deficiency anemia

Steady head control is achieved

4 months

High anxiety, superficial in interactions; testing the therapist to see if he/she can be trusted

Initial/orientation phase in group intervention

Both lower extremities flexed 90 degree at hips; rarely used because extreme elevation of lower extremities causes decreased peripheral circulation

Bryant traction

Have difficulty hearing and accepting compliments because of their lowered self concept; comment on signs of improvement by noting behavior

Depressed clients

A malignant tumor arising from nonepithelial tissue

Sarcoma

White spots in the visual field, diplopia

Scotomas

FHR below 70 lasting longer than 30-60 seconds; slow return to baseline; decreasing or absent variability

Severe variable decelerations

Determined by the extent of surface area involved

Severity

STDs in infants and children indicate ?? and should be reported; nurse is legally responsible to report suspected cases of child abuse

Sexual abuse

Should never be removed unless the MD prescribes is removal

Skin traction

Appear 12-36 hours after last drink; tachycardia, tachypnea, diaphoresis, marked tremors, hallucinations, paranoia

Delirium tremens

The exchange of oxygen for carbon dioxide in the lungs is inadequate for oxygen consumption and carbon dioxide production within the body's cells

Acute Respiratory Distress Syndrome (ARDS)

Monitor hydration status and IV therapy carefully; may be inappropriate ADH secretion causing fluid retention and dilutional hyponatremia

Meningitis

Increased HR, increased RR, diaphoresis and decreased oxygen levels

Physical assessment to pain

Bone

Osteo

Brow

Sinciput

Congenital malformation of the anorectal section of the GI tract (imperforate anus); associated with a fistula; associated with urinary tract anomalies

Anorectal malformations

If gavage tube passes into here the newborn can make no noise (gag, cough) and may become cyanotic

Trachea

Bilirubin total for newborn

1-12mg/dl

UOP for infants and children should be this

1-2 ml//kg/hour

All primary teeth are present

1-3 years

Bowlegged and potbellied

1-3 years

Involves cleaning the inner cannula, suctioning, and applying clean dressings

Tracheostomy care

Note bed position, tape, weights, pulleys, pins, pin sites, adhesive strips, ace wraps, splints and casts

Traction

Phenergan and vistaril; used in labor as analegesic potentiating drugs to decrease the amount of narcotic needed to and to decrease maternal anxiety

Tranquilizers

High incidence of fetal anomalies occurs in pregnant diabetic women; this is very important via ultrasound exam, alpha fetoprotein, non-stress and contraction stress test

Fetal surveillance

False sensory perception, usually auditory or visual

Hallucinations

Recognizing the client's opinions and statements without imposing your own values and judgment

Acknowledging

Shoulder

Acromion

From 4-7cm cervical dilatation; increased anxiety, increased discomfort, unwillingness to be left alone; contractions moderate to severe, 2-3 minutes apart lasting 30-60 seconds in duration

Active phase of the first stage of labor

Medical history, obstetric history, history of current pregnancy; determine gravidity and parity; perform physical exam; calculate EDB; VS; Lab work

Activities during first prenatal visit

No withdrawal symptoms; overdose: panic and psychosis; effects: withdrawal occurs with abrupt cessation, temporary psychosis

Hallucinogenic

Common community health strategy designed to reduce the harm of substance abuse to family, individuals, community and society

Harm reduction

Check urine; graph weight gain; check fundal height; check fetal heart rate; provide anticipatory guidance

Activities during subsequent pregnancy visits

Loss of primary teeth occurs

6-12 years

Socialization with peers becomes important

6-12 years

Partial or complete premature detachment of the placenta from its site of implantation in the uterus; 1/200 pregnancies; occurs late in the third trimester; cause of 15% of maternal deaths; ½ of infants born die; a medical emergency; cause is unknown but r/t hypertensive disorders, high gravidity, abdominal trauma, short umbilical cord; cocaine abuse

Abruptio placentae

Prepared from plasma and is available in 5% and 20% solutions

Albumin

Shortly after drinking stops, 4-6 hours; anxiety, nausea, insomnia, tremors, hyper alertness, and restlessness

Alcohol withdrawal symptoms

Very contagious and is easily transferred from client to nurse and from nurse to client

Anxiety

Socially inhibited; feels inadequate; hypersensitive to negative criticism, rejection; longs for relationships

Avoidant personality disorder

Postpartum drug; indicated for constipation; adverse reactions: abdominal cramping; insert suppository into anus past internal rectal sphincter; contact laxative that stimulates rectal mucosa directly, there may be some burning, usually effective 15minutes - 1 hour

Bisacodyl (Dulcolax suppository)

Lower extremity, legs extended, no hip flexion

Buck extension traction

Eating disorder characterized by eating excessive amounts of food followed by self-induced purging by vomiting misuse of laxatives, diuretics or other medications, fasting and/or excessive exercise; usually reports loss of control while binge eating

Bulima nervosa

Chlordiazepoxide HCL (lithium), diazepam (valium), prazepam (centrax), oxazepam (serax), alprazolam (xanx), clorazepate dipotassium (tranxene), lorazepam (ativan); indications: reduce anxiety; induce sedation, relax muscles, inhibit convulsions; safer than sedative hypnotics; reactions include sedation, drowsiness, ataxia, dizziness, irritability, blood dyscrasias, habituation and increased tolerance; administer at bed time to alleviate daytime sedation, greatest harm occurs when combined with CNS depressants and alcohol, avoid driving or working on equipment, gradually taper, short term drug

Benzodiazepines

Not to be used unless hyperkalemia, tricyclic antidepressant overdose, or preexisting metabolic acidosis is documented

Bicarbonate

Normal value is 4-6L/min

Cardiac output

All products of conception passed; cervix closed; no need for treatment

Complete abortion

May not be given during pregnancy due to its ability to cross the placenta and affect the fetus; heparin is the drug of choice

Coumadin

How to Determine the heart rate for one minute

Count the number of R-R intervals in the 30 lg. squares and multiply by 10

IM injection 300mgq3months for contraception; during the first 5 days of menstrual cycle; efficacy 99%; protection from pregnancy is immediate after injection; experience weight gain and irregular/unpredictable menstrual bleeding; monitor for S&S of thrombophlebitis; contraindications: history of brest cancer, stroke, bloot clots, liver disease; effect: nervousness, dizziness GI disturbances, headaches, and fatigue

Depo provera

Noninflammatory arthritis; degeneration of cartilage, wear and tear process; affects one or two joints; occurs symmetrically; obesity and overuse are predisposing factors

Degenerative joint disease

Characterized by suspicious, strange behavior, which may be precipitated by a stressful event

Delusional disorder

Tonometer, electronic tonometer, gonioscopy

Diagnostic tests for glaucoma

Moderate to heavy bleeding with tissue and products of conception present; open cervical os; treatment is hospitalization, dilation and curettage

Inevitable or incomplete abortion

Using reason to avoid emotional conflicts; the wide of a substance abuser describes in detail the dynamics of enabling behavior, yet continues to call her husbands workplace to report his Monday morning absence of illness

Intellectualization

Produced by the bacterial degradation of methionine

Mercaptan

Sudden, brief contactures of a muscle or group of muscles, no postictal state, may or may not be symmetric or include LOC

Myoclonic

Caries, periodontal disease, candidiasis

Oral cavity changes in diabetes mellitus

Estrogen in pills prevents pituitary secretion of FSH, preventing ovulation; woman still menstruates; lowest failure rate of methods; contraindications: history of coagulation problems, thrmoboembolism, liver disease, reproductive cancer, coronary artery disease; compliance is a problem because it must be taken every day

Oral contraceptives

Not taken during pregnancy because of the potential teratogenic effects on the fetus

Oral hypoglycemic

Signifies oxygen toxicity problems

Po2>90

Primary uterine contractions and secondary abdominal bearing down efforts

Powers

Dystocia, prolonged labor, over distended uterus, abruption placenta and infection

Risk factors for hemorrhage

Hypotension, tachycardia, fever

Signs of Hypovolemia

Indicated for correction of severe metabolic acidosis in asphyxiated infants after adequate ventilation begun; adverse reaction: fluid overload, hypernatremia, intracranial hemorrhage; don't mix with calcium solutions; pediatric concentration; infuse slowly and monitor I&O; newborn resiscitation

Sodium bicarbonate

Somatic complaints for which frequent medical attention is sought but no medical pathology is present

Somatization disorder

Involvement of single lymph node region or a single extralymphatic organ or site

Stage 1 Hodgkin disease

Not given to clients with sickle cell anmia; it is not caused by iron deficiency

Supplemental iron

Less focus on physical discomforts, beginning confidence with infant care taking; feeling inadequate caring for infant is normal; praise efforts of parents; most receptive to teaching about infant care

Taking hold phase

Life threatening event that occurs with uncontrolled hyperthyroidism due to graves disease; fever, tachycardia, agitation, anxiety and hypertension; maintain patent airway and adequate aeration

Thyroid storm

From complete expulsion of the baby to complete expulsion of the placenta; average length of this stage is 5-15 minutes; the longer this stage the greater change of uterine atony or hemorrhage to occur

Third stage of labor

27 weeks through 40 weeks

Third trimester

The trait is carried on the X chromosome; usually affects male offspring; hemophilia; child is male, has 50% chance of having hemophilia; if the child is female, she has a 50% chance of being a carrier

X-linked recessive trait

Fine princer grasp appears

10-12 months

Walks with assistance

10-12 months

HBG norms for infant

10-15

60-90HR; 16-20RR

10-16 years normal HR & RR

HGB for 2-6 months

10-17

Urea nitrogen in adults

10-20mg/dl

Lactic dehydrogenase in adults

100-190 IU/l

Prothrombin time

11-12.5 second

HBG norms for child

11-16

Calorie calculation for infant per day

110-150 calories/kg/day

Birth length increases by 50%

12 months

Birth weight triples

12 months

HGB in adults

12-18

Anterior fontanel closes

12-18 months

Family conflicts develop

12-19 years

Girls' growth spurts during adolescence begin earlier than boys

12-19 years

Between ovulation and the beginning of the next menstrual cycle there is this many days; ovulation occurs this many days before the next menstrual period

14 days

Boys catch up around this age and continue to grow

14 years

HBG norms for newborn

14-24

HGB for newborn

14-24

Milliliters for infant per day

140-160ml/kg/day

Adult thinking begins at this age; they can problem solve and use abstract thinking

15 years

Girls finish growth around this age

15 years

Platelet count in adults

150 000-400 000

Child needs this much of the usual calorie intake for normal growth and development

150%

Boys finish growth around this age

17 years

Throws a ball overhead

18 months

Shift the gravid uterus to the left by placing the woman in a 15-30 degree angled, left lateral position or by using a wedge under her right side to tilt her to her left

20 weeks pregnant and beyond CPR

HCO3 in adults

21-28mEq/l

HCO3 normal value

22-26 mEq

Premie formula calorie/oz; increases calories without increasing fluids

24 calories/oz

Kicks a ball

24 months

Egocentric and concrete

3-5 years

Birth weight quadruples

30 months

Alkaline phosphatase for adults

30-120 IU/I

Activated partial thromboplastin time

30-40 seconds

Triglyceride levels in adults

35-160 mg/dl

PCO2 normal value

35-45 mmH

HCT for adults

37-52

Tachypnea, cyanosis, flaring nares, expiratory grunt, retractions

5 symptoms of respiratory distress in newborn

Ties shoelaces

5 years

Turns over completely

5-6 months

Fine and growth motor skills mature

6-12 years

Learns cause and effect relationships

6-12 years

Learns to tell time and understands past, present and future

6-12 years

Protein total for adults

6.4-8.3 g/dl

Iron in adults

60-180mcg/dl

Partial thromboplastin time

60-70 seconds

Transfers objects from hand to hand

7 months

Develops stranger anxiety

7-9 months

PH normal value

7.35-7.45

Glucose levels for adults

70-110mg/dl

Sits unsupprted

8 months

Posterior fontanel closes

8 weeks

Able to write script

8 years

HGB for 6mo-1yr

9.5-14

90-degree flexion of hip and knee; lower extremity is in a boot cast; can also be used on upper extremities

90 degree traction

O2 normal value

95-100%

Chloride levels in adults

98-106mEq/l

HGB in pregnant women

<11

Cholesterol levels in adults

<200mg/dl

Hgb values during pregnancy

>11

HCT for pregnant women

>33

Hct values during pregnancy

>33

Elevations may be associated with neutral tube defects; low levels may indicate trisomy 21

AFP

Persons with specific, serious, opportunistic infections such as PCP, disseminated cytomegalovirus, or Kaposi sarcoma

AIDS

CD4 T-cell counts less than 200 cells/mm3; occurs when a variety of bacteria, parasites, or viruses overwhelm the body's immune system; once classified as category, the patient remains classified as that category

AIDS (CDC category C)

Dark, red vaginal bleeding; FHR 100; abdomen is rigid and board life; severe pain

Abruptio placenta

Should no undergo any abdominal or vaginal manipulation; no Leopold maneuvers; no vaginal exams; no rectal exams, enemas or suppositories; no internal monitoring

Abruptio placentae and placenta previa

Momentary loss of consciousness, posture is maintained, has minior face, eye, hand movements

Absence (petit mal)

Which is caused by the heads being in motion and deceleration injury which occurs when the head stops suddenly

Acceleration

Changes in relation to uterine contractions; caused by sympathetic fetal response; occur in response to fetal movement; indicative of a reactive healthy fetus

Accelerations

Tacrine HCL (cognex), donepezil (Aricept), rivastigmine (Exelon), galantamine (reminyl), extended release (concerta) amphetamine mixture (adderall); Alzheimer medications; adverse reactions: ND; cognex: considerable GI distress and elevated liver enzymes; should not take anticholinergic medications; should not be used in severe liver impairment; take with meals; do not stop abruptly

Acetyl cholinesterase inhibitors

Must be maintained in the body because alterations can result in alkalosis or acidosis

Acid-base balance

Do not exercise painful, swollen joints; do not exercise any joint to the point of pain; perform exercises slowly and smoothly; avoid jerky movements

Activity recommendations for RA

An immune complex response to an antecedent beta hemolytic streptococcal infection of skin or pharynx; antigen antibody complexes become trapped in the membrane of the glomeruli. Causing inflammation and decreased glomerular filtration

Acute glomerulonephritis

Chills, fever, low back pain, flushing, tachycardia, hypotension pressing to acute renal failure, shock and cardiac arrest

Acute hemolytic

A cancer of the blood forming organs; 80% of childhood leukemia; noted for the presence of lymphoblasts which replace normal cells in the bone marrow; blast cells are also see in the peripheral blood; null cell type has best prognosis

Acute lymophocytic leukemia

Classified according to whether it involves T lymphocytes, B lymphocytes, or null cells (neither T or B)

Acute lymophocytic leukemia

Four phases: induction, sanctuary, consolidation, maintenance

Acute lymophocytic leukemia treatment

Abnormal leukocytes are found in blood forming tissue; occurs in children; prognosis is favorable

Acute lymphocytic leukemia

Involves the inability of leukocytes to mature; those that do mature are abnormal; any time during the life cycle; onset is insidious; prognosis is poor; cause of death = overwhelming infection

Acute myelogenous leukemia

Pain that is located retroperitoneally; any enlargement of the pancreas causes the peritoneum to stretch tightly; sitting up or learning forward reduces pain

Acute pancreatic pain

Maintain NPO status; maintain BG tube to suction; administer meperidine or morphine; administer antacids, histamine-2, receptor blocking drugs, anticholinergics, proton pump inhibitors; assume position of comfort on side with legs drawn up to chest; avoid alcohol, caffeine, fatty and spicy foods; monitoring and regular insulin coverage may be needed temporarily

Acute pancreatitis nursing plans and interventions

Has abnormal circulation; however, all blood entering the systemic circulation is oxygenated

Acyanotic

Ventricular septal defect; atrial septal defect; patent ductus arteriosus; coarctation of the aorta; aortic stenosis; left to right shunts or increased pulmonary blood flow; obstructive defects

Acyanotic congenital heart disorders

A medical emergency that is rough on by sudden withdrawal of steroids or a stressful event; causes vascular collapse, hypoglycemia, parenteral hydrocortisone is essential to reversing the crisis; aldosterone replacement with fludrocortisones

Addison crisis

Characterized by lack of cortisol, aldosterone and androgens

Addison disease

An autoimmune process commonly found in conjunction with other endocrine diseases of an autoimmune nature; a primary disorder; sudden withdrawal of corticosteroids may precipitate symptoms of Addison's disease

Addison disease (primary adrenocortical deficiency)

VS frequently; monitor I&O and weight; rise slowly; monitor serum electrolyte; need for lifelong hormone replacement; need for close medical supervision; need for medical alert jewelry; signs and symptoms of over and under dosage; high sodium, low potassium, high carbohydrate diet; 3L of fluid/day

Addison disease nursing plans and interventions

Therapy supplemental to the primary therapy

Adjuvant therapy

Use Z track method to prevent staining of skin; do not use deltoid muscle and do not massage the site

Administration of iron parenterally

Give on empty stomach; give with citrus juices for increases absorption; use dropper or straw to avoid discoloring teeth; stools will become tarry; can be fatal if overdose; don't give with diary products

Administration of oral iron

Secrete aldosterone

Adrenal glands

Record woman's response and level of pain; monitor maternal VS, FHR and characteristics of contractions q15min for 1hr after administration; monitor bladder; decrease environmental stimuli; note time between administration of drug and delivery of baby; if baby delivers at peak, notify pediatrician or neonatologist

After administration of analgesia or anesthesia

Produce narcosis and have a higher risk for causing maternal and fetal respiratory depression.

Agonist narcotic drugs: Demerol or morphine

25g/100mL is osmotically equal to 500mL of plasma; used for hypovolemic shock and hypoalbuminemia

Albumin

No more than a trace in a normal finding in urine; related to preeclampsia

Albumin

Fetal alcohol syndrome: microcephaly, growth retardation, short palpable fissures, maxillary hypoplasia; long term complications: mental retardation, poor coordination, facial abnormalities, behavior deviations, cardiac and joint abnormalities; determine how often and how much

Alcohol intake neonate effects

Interlukin medications; indicated for metastatic renal carcinoma; adverse reactions: RF, pulmonary edema, HF, MI, arrhythmias, stroke, bowl perforation, hepatomegaly, GI disturbances, electrolyte imbalances, coagulation disorders, pancytopenia; monitor for serious side effects

Aldesleukin (proleukin, interleukin-2)

Causes sodium retention and potassium excretion

Aldosterone

Loss of the ability to read

Alexia

Cyclophosphamide (cytoxan, neosar), mechlorethamine HCL (nitrogen mustard), cisplatin (platinol), busulfan (myleran), procarbazine (matulane), imidazole carboximide (dacarbazine); indicated for Hodgkin's lymphoma, leukemia, neuroblastoma, retinoblastoma, multiple myeloma; adverse reactions: bone marrow suppression, NV, cystitis, stomatitis, alopecia, gonadal suppression, toxic effects occur slowly with high dosage, toxic to kidneys and ears, pleural effusion, seizures; use immediately after reconstitution; avoid vapors in eyes; vesicant; hydrate well and during treatment with IV fluids and mannitol; monitor renal functioning and watch for signs with cystitis; force fluids; monitor hearing and vision

Alkalating agents

An xanthine-oxidase inhibits is also administered to prevent renal damage caused by uric acid buildup and cellular lysis

Allopurinol

Acarbose (precise), miglitol (glyset); lowers BS by blunting sugar levels after meals; adverse reactions: hypoglycemia; must be taken with the first bite of each meal; taking with other classes of oral hypoglycemic; monitor blood sugar

Alpha glucosidase inhibitors

Prazosin HCL (minipress), terazosin (hytrin), phentolamine mesylate (regitine), doxazosin (Cardura); peripheral vasodilator which acts directly on the blood vessels, used in extreme hypertension of pheochromocytoma; adverse reactions: orthostatic hypotension, weakness, palpitations; use cautiously in elderly; occasional VD

Alpha-adrenergic blockers

Neuro-vital sign assessment tool; Glasgow coma scar; pupil size, limb movement, vital signs; assess skin integrity and corneal integrity; check bladder for fullness, auscultate lungs and monitor cardiac status

Altered state of consciousness assessment

Gentamicin sulfate, tobramycin sulfate (Nebcin), Amikacin sulfate, vancomycin hydrochloride, metronidazole (flagyl); used with gram negative bacteria, antiinfectives; adverse reactions include neuromuscular blockade, nephrotoxicity, ototoxicity; monitor renal function, BUN, creatinine, I&O; monitor for ototoxicity; monitor for super infection; monitor serum drug concentrations

Aminoglycocides

Removal of amniotic fluid sample from uterus as early as 14-16 weeks; fetal genetic diagnosis; fetal maturity; fetal well being; performed when uterus rises out of symphysis at 13 weeks and amniotic fluid has formed; takes 10 days to 2 weeks to develop cultured cell karyotype

Amniocentesis

VS and FHR; supine position with hands across chest; shave area and scrub with betadine; draw maternal blood sample before and after procedure to determine maternal bleeding; if bilirubin test is prescribed, darken room and immediately cover the tubes with aluminum foil; FHR for 1 hour post; report changes in fetal movement or fluid leaking from vagina

Amniocentesis nursing care

Withdrawal: Depression, fatigue, disturbed sleep; overdose: restlessness, tremors, rapid respiration, confusion, assaultive behavior, hallucinations, panic; effect is paranoid delusions

Amphetamines

Broad-spectrum antibiotic used to treat postpartum endometritis, mastitis; adverse reactions: rash, dermatitis, NV, GI irritation; don't administer to clients with penicillin; does appear in breast milk but may not cause neonate discomfort

Ampicillin (ampicin, ampilean)

Surgical removal of a diseased part or organ; causes are perpherial vascular disease, trauma, congenital deformities, malignant tumors, infection

Amputation

Meperidine HCL (Demerol, pethidine), fentanyl (sublimaze), morphine sulfate (MS contin); indicated for opiod agonists, natcotic used to produce analgesia, euphoria, and sedation in labor, analgesia during labor; adverse reactions: respiratory depression, fetal narcosis or distress, hypotension, fetus received normeperidine which is linked to fetal compromise, itching, urinary retention; store in cabinet; record use accurately; don't administer is RR<12; monitor RR, HR and BP closely

Analgesics

Anxiety, uricaria, wheezing progressive cyanosis leading to shock and possible cardiac arrest

Anaphylactic and severe allergic reaction

Testosterone (oreton), fluoxymesterone (halotestin); indicated for breast cancer in post menopausal woman; adverse reactions: fluid retention, nausea, and masculinization; low salt diet is necessary

Androgens

Deficiency of RBCs reflected as decreased HCT, HBG, RBCs

Anemia

Losartan (Cozaar), Valsartan (diovan), irbesartan (avapro); blocks the vasoconstrictor and aldosternone-producing effects of angiotensin II at various sites; adverse reactions: hypotension, fatigue, hepatitis, renal failure, hyperkalemia; monitor liver enzymes and electrolytes, monitor angrioedema in those with history of it when on ACE inhibitors previously

Angiotensin II receptor antagonists

Captopril (capoten), enalapril maleate (vasotec), lisinopril (zestril), ramipril (altace), benazepril (lotensin), quinapril (accupril); decreases BP by suppressing rennin-angiotensin aldosterone system and inhibiting conversion of angiotensin I into angiotensin II; useful with diabetics; adverse reactions: proteinuria, neutropenia, skin rash, cough; observe for acute renal failure tests, remain in bed 3 hours after first dose

Angiotensin-Converting Enzyme inhibitors

Psychiatric disorder involves a voluntary refusal to eat and maintain minimal weight for height and age; a distorted body image and fear of becoming obese drives the excessive dieting and exercise; 15-20% of those diagnosed die; associated with parent child conflicts about dependency issues; bodies and weight are their only areas of control

Anorexia nervosa

Aluminum hydroxide/magnesium hydroxide (Maalox, Mylanta, riopan, gelusil II); indicated for treatment of peptic ulcers, work by neutralizing or reducing acidity of stomach contents, differences in absorption rate; adverse reactions: drug interactions, diarrhea, constipation; take several times/day; administer after meals; assess for history of renal diseases when client is taking magnesium products; electrolyte readjustment occurs and can result in renal insufficiency and calcinosis

Antacids

Measurement of height, weight, head circumference in young children, proportion, skin fold thickness, and arm circumferences

Anthropometry

Dry mouth, blurred vision, tachycardia, nasal congestion, constipation, urinary retention, orthostatic hypotension; encourage sips of water, chewing sugarless gum or hard candy; increase fiber; change positions slowly; report urinary retention; tolerance to side effects will occur

Anticholinergic effects

Atrophine sulfate (atropisol), benztropine mesylate (cogentin), trihexyphenidyl (artane); reduces cholinergic activity; adverse reactions: increased HR, postural hypotension, dry mouth, constipation, urinary retention; warn to avoid rapid position changes; avoid extreme heat; provide gum, hard candy and frequent mouth care

Anticholinergics

Anticholinergic effects, postural hypotension

Antidepressant drug side effects

Granisteron (Kytril); indicated for NV associated with chemotherapy and abdominal radiation; adverse reactions: hypertension, CNS stimulation, elevated liver enzymes; assess for EPS, monitor liver enzymes, give one on day of chemotherapy or 1 hour before

Antiemetic

Diphenhydramine HCL (Benadryl); given with raglan and haldol to reduce EPS; adverse reactions: sedation, dizziness, hypotension, dry mouth

Antiemetics

Metoclopramide HCL (raglan), haloperidol (haldol); indicated for NV; adverse reactions: drowsiness, restlessness, fatigue, extrapyramidal symptoms; caution about decreased alertness, avoid alcohol, discontinue if EPS occurs

Antiemetics

Prochlorperazine (compazine), promethazine HCL (phenergan); indicated for NV; adverse reactions: drowsiness, dizziness, extrapyramidal symptoms, orthostatic hypotension, blurred vision, dry mouth; dilute oral solution with juice, determine baseline BP, give deep IM, monitor BP carefully

Antiemetics

Ampherotericin B (Fungizone); IV: crytococcal meningitis; PO: Oral candidiasis; adverse reactions: nephrotoxicity, hypotension, hypokalemia, febrile reaction, muscle cramps, circulatory problems; vesicant:: monitor IV site closely; premedicate with antipyretic, give slowly; swish as long as possible before swallowing PO form

Antifungals

Rarely used in preeclamptic client; given only in the event of diastolic BP >110 due to the risk of CVA; hydralazine HCL

Antihypertensive drugs

Atovaquone (Mepron), Trimethoprim/sulfamethoxazole (Bactrim)

Antiinfectives

Antineoplastic chemotherapeutic agent; flurouracil (adrucil, 5-FU), methotrexate sodium (mexate) requires leucovorin rescue to prevent toxic effects, metcaptopurine/6-MP (purinethol), cytarabine (cytosar-U, ARA-C), Gemcitabine (gemzar); indicated for ALL, AML, brain tumors, ovarian, breast, prostatic, testicular cancers; adverse reactions: NVD, myelosuppression, proctitis, stomatitis, dermatitis, renal toxicity, hepatotoxicity, anaphylaxis; adminster antiemetics PRN, wear sunscreen, toxic to liver and kidneys; avoid: aspirin, sulfonamide, tetracycline, vitamins containing folic acid; leucovorin used with methotrexate as antidotes for high doses; give allopurinol concurrently with 6-MP to inhibit uric acid production by cell destruction increases drugs potency; monitor liver function

Antimetabolites

Trihexyphenidyl HCL (artane), benztropine mesylate (cogentin), amantadine (symmetrel); indicated for action on the extrapyramidal system to reduce disturbing symptoms; adverse reactions include anticholinergic effects, drowsiness, headaches, urinary hesitancy, memory impairment; given in conjunction with antipsychotic drugs

Antiparkinsonian drugs

Ticlopidine (ticlid), dipyridamole (persantine), clopidogrel (plavix); short-term use after cardiac interventions, reduces the risk for thrombolytic stroke for those intolerant to aspirin, and prevention of thrombolytic disorders; adverse reactions: neutopenia, thrombocytopenia, agranulocytosis, leucopenia, hemorrhage, GI irritation, bleeding, pancytopenia; give PC or with food; don't take antacids w/in 2 hours; CBCq2weeks;

Antiplatelet agents

Ampicillin; ticarcillin + clavulanate (timentin); piperacillin + tazobactam (Zosyn); Ampicillin + Sulbactam (Urasyn); used as broad spectrum antibiotics and antiinfectives; adverse reactions are similar to penicillin as well as ampicillin rash; contraindicated in clients allergic to penicillin

Antipseudomonal penicillin's and combinations

Shows aggressive acting out behavior pattern without any remorse; clever and manipulative in order to meet own self centered needs; lacks social conscience and ability to feel remorse; is emotionally immature and impulsive; ineffective interpersonal skills that impair forming of close and lasting relationships; verbally is disparaging, humiliating, belligerent to threats; nonverbally is cold, callous, insensitive, socially gracious

Antisocial personality disorder

Dactinomycin (actinomycin), bleomycin sulfate (blenoxane), daunorubicin I (cerubidine), mitomycin, doxorubicin HCL (adriamycin), idarubicin (idamycin); indicated for: sarcoma, neuroblastoma, head and neck tumors, testicular, ovarian, breast cancer, Hodgkin, lymphocytic leukemia, AML; adverse reactions: bone marrow suppression, anorexia, NV, alopecia, cardiac toxicity, vesicant; monitor for cardiac dysrhythmia; urine will turn red; antiemetic PRN

Antitumor antibiotics

Prokinetic agents, antimetics, cough suppressants, stool softners; treatment of slow peristalsis and increased intraabdominal pressure in client with GERD; adverse reaction: diarrhea

Antiulcer drugs

Acyclovir sodium (Zovirax), Ganciclovir; used for herpes simplex CMV retinitis; adverse reactions: granulocytopenia, thrombocytopenia; monitor liver function tests

Antivirals

Pentamidine isethionate (Pentam 300); prophylaxis & treatment for PCP; adverse reactions: leucopenia, ECG abnormalities; Give IV or aerosol, not orally

Antoprotozoals

Compulsive acts are used in response to this; help alleviate; interfering will only increase this; acknowledge the effects that ritualistic acts have on the client; demonstrate empathy; avoid being judgmental

Anxiety

Unexplained discomfort, tension, apprehension or uneasiness, which occurs when a person feels a threat to self; very subjective experience

Anxiety

Place two on perineum; don't touch inside; do apply from front to back, being careful not to drag pad across the anus

Application of perineal pads after delivery

Apply pressure to bony prominences to blank skin. When thumb is removed, the area will look yellow before normal skin color; nose, forehead, and sternum are best for assessment

Assessing for jaundice

Mucosal edema, VQ abnormalities, increased work of breathing, beta blockers, respiratory infection, allergic reaction, emotional stress, exercise, environmental/occupational exposure, reflux esophagitis

Asthma precipitating factors

Best time to talk to a patient who has obsessive compulsive disorder. The client's anxiety is lowest at this time and is the optimal time for learning

At the completion of a performed ritual

Trazodone (Desyrel), Mitrazapine (remeron), Bupropion (wellbutrin); indicated for depression trazodone = insomnia, dementia with agitation; adverse reactions: safer than tricyclics and MAO inhibitors in terms of side effects; effective 2-4 weeks after initiation

Atypical antidepressant drugs

Riperidone (risperdal), olanzapine (zyprexa), Questiapine (seroquel), aripiprazole (ability), ziprasidone (geodon), clozapine (clozaril), aripiprazole (abilify); indicated to treat positive and negative symptoms of schizophrenia without significant EPS, in clients who haven't responded well to typical antiphychotics or have side effects to typical antiphychotics; monitor WBC weekelyx6month then biweekly; baseline VS, EEG; monitor for symptoms of NMS and EPS, teach to change positions slowly

Atypical antiphsychotic drugs

Risperidone, olanzapine, quetiapine, aripiprazole and ziprasidone

Atypical antipsychotic drugs that are also indicated for mania

Exaggerated autonomic responses to stimuli; medical emergency; occurs in clients with lesions at or above T6; occurs after spinal shock; trigged by noxious stimulus and vaginal examination; elevated BP, pounding headache, sweating, nasal congestion, goose bumps, bradycardia, bladder and bowel distention

Autonomic dysreflexia

Both parents must be heterozygous, or carriers of the recessive trait, for the disease to be expressed in their offspring; 1 in 4 chance that the infant will have the disease; all children of parents can get the disease; transmission pattern of sickle cell anemia, cystic fibrosis and phenylketouria

Autosomal recessive

Bone fragments are torn away from the body of the bone at the site of attachment of a ligament or tendon

Avulsion fracture

Bacterial inflammatory disorder of the meninges that cover the brain and spinal cord; caused by haemophilus influenza; streptococcus pneumoniae. Or neisseria meningitides; usual source of bacterial invasion is the middle ear or the nasopharynx, fractures of the skull, LP, and shunts; exudates covers the brain and cerebral edema occurs

Bacterial meningitis

Used to change ineffective behavior patterns; focused on the consequences of actions rather than on peer pressure; positive reinforcement is used to strengthen desired behavior; negative reinforcement is used to decrease or eliminate inappropriate behavior; role modeling and teaching new behaviors are important

Behavior modification

Benign tumors arising from the muscle tissue of the uterus; most common symptom is abnormal uterine bleeding; tend to disappear after menopause; rarely become malignant; intervention for severe symptoms is hysterectomy

Benign tumors of the uterus

Metoprolol tartrate (lopressor), nadolol (corgard), propranolol HCL (inderal), timolol maleate (blocadren), atenolo (tenormin), bisoprolol (zebeta), metropolol (lopressor, tropol); blocks the sympathetic nervous system esp. to the heart, produces a slower HR, lowers BP, reduces O2 consumption during myocardial contraction; adverse reactions: bradycarida, fatigue, insomnia, bizarre dreams, sexual dysfunction, hypertriglyceridemia, decreased HDL, depression; apical or radial pulse daily, monitor GI distress, don't stop abruptly, don't vary time taken, may mask symptoms of hypoglycemia or may prolong hypoglycemic reaction

Beta blockers

Timolol maleate optic (timoptic solution), carteolol (ocupress); inhibits the formation of aqueous humor; adverse reactions are insignificant and may cause hypotension; cautious use with hypersensitive, asthmatic, second or third- degree heart block, HF, congenital glaucoma, pregnancy; teach proper instillation; need for ongoing use of the drug at prescribed intervals; blurred vision tends to decrease with regular use

Beta-adrenergic receptor blocking agents

Used in renal disorders; Indicated as a cholinergic used to treat: urinary retention, neurogenic bladder, gastric reflux; adverse reactions: orthostatic hypotention, flushing, asthmatic reaction, GI distress; don't give IV or IM; monitor VS; empty stomach

Bethanechol chloride (urecholine)

Main chemical buffer; 20:1 ratio; when the ratio is altered, the pH changes

Bicarbonate-carbonic acid

Metformin (glucophage); lowers serum glucose levels by inhibiting hepatic glucose production and increasing sensitivity of peripheral tissue to insulin; adverse reactions: abdominal discomfort and diarrhea; many drug-drug interactions, extended release tablets should be taking with evening meal; use cautiously with preexisting renal or liver disease or HF; wait 48 hours to restart dosage after diagnostic studies requiring IV iodine contrast media

Biguinides

Plasma, blood cells, urine or tissues from liver, bone, hair or fingernails can be used to determine nutritional status; lab testing of HGB, HCT, albumin, creatinine, and nitrogen are also commonly used to determine nutritional status

Biochemical analysis

Ultrasonography is used to evaluate fetal health by assessing 5 variables: fetal breathing movements, gross body movement, fetal tone, reactive FHR, qualitative amniotic fluid volume

Biophysical profile

Fetal breathing movements, gross body movements, fetal tone, reactivity of fetal heart rate, and amniotic fluid volume; 10 = fetus is well

Biophysical profile (BPP)

Affective disorder that is manifested by mood swings involves euphoria, grandisotiy, and an inflated sense of self-worth. May or may not include sudden swings to depression; atleast one episode of major depression. May cycle between elevation to depression, with periods of normal activity in between

Bipolar disorder or manic depressive illness

Explores environment by motor and oral means

Birth to one year

Requirement when an amniocentesis is done early in pregnancy to help push the uterus up in the abdomen for easy access

Bladder must be full

Gap or interruption in speech due to absent thoughts

Blocking

Agranulocytosis in first weeks, thrombocytopenia (decreased platelets); characterized by sore throat, fever, chills, bruises easily, petechia; protect from infections; comfort measures; safety measures

Blood dyscrasias

Will show ?? if the bowel obstruction is in the lower bowel where base solutions are secreted

Blood gas analysis: acidic state

Will show ?? if the bowel obstruction is high in the small intestine where gastric acid is secreted

Blood gas analysis: alkalotic state

80/50

Blood pressure: normal newborn norms

Disturbances regarding self image and sexual, social and occupational roles; impulsive, self damaging behavior, makes suicidal gestures; other directed, overly dependent on others; unable to problem solve or learn from experience; view others as either all good or all bad; verbally is self critical, demanding, whiny, manipulative, and argumentative and can become verbally abusive; nonverbally has highly changeable and intense affect, impulsive behaviors

Borderline personality disorder

NPO with IV fluid and electrolyte therapy; I&O; implement NG tube; document pain; assess abdomen regulary for distention, rigidity, change in status of bowel sounds

Bowel obstruction nursing plans and interventions

Doesn't correct the spines curve in a child with scoliosis, it only stops or slows the progression

Brace

Baseline FHR <110 for 10 minutes; caused by late manifestations of fetal hypoxia, medication induced, maternal hypotension, fetal heart block, prolonged umbilical cord compression

Bradycardia

Neoplasm occurring in the brain; primary can arise in any tissue of the brain; secondary are a result of metastasis from other areas such as the lungs and breast

Brain tumor

Headache upon awakening (most common symptom of this); vomiting in the morning without nausea; loss of concentration; change in behavior or personality; vision problems, tilting of head; widening structures, I ncreasing frontal occipital circumference, tense fontanel

Brain tumor nursing assessment

The second most common cancer in children; infratentorial, maing them difficult to excise surgically; occur close to vital structures; gliomas are the most common childhood tumors

Brain tumors

Evaluates the newborn;s behavioral uniqueness; wait 2-3 days to allow the neonate to rid the body of analgesia, anesthesia, and birth trauma; six categories include habituation, orientation, motor activity, self-quieting ability, social behaviors, sleep and awake states

Brazelton Neonate behavioral assessment scale

Cancer originating in the breast; 90% are discovered through BSE; generally adenocarcinoma, originating in epthial cells and occurs in the ducts or lobes; tend to be located in the upper outer quadrant of the breast and more often in the left breast than the right; early detection is important; tumors <4cm

Breast cancer

Assess nipples for cracks, fissures, redness and tenderness; assess breasts for engorgement; palpate breasts for lumps and nodules; if not breast feeding, teach to wear a supportive bra or binder, ice packs and avoid breast stimulation; assess for change in size and shape; dimpling, puckering, scaling, redness, swelling of any part of the breast

Breast care

Deep chest, accelerated and cued; not prescribed by the stage and phase of labor but by the discomfort level of the laboring woman

Breathing techniques

Heard over areas of density or consolidation. Sound waves are easily transmitted over consolidated tissue

Bronchial breath sounds

A viral infection of the bronchioles that is characterized by thick secretions; usually caused by RSV and is found to be readily transmitted by close contact with hospital personnel, families and other children; occurs primarily in young infants

Bronchiolitis

Neck flexion causing adduction and flexion movements of the lower extremities

Brudzinski sign

Used if splinting the congenital dislocated hip was unsuccessful; maintain hips in 90 degree flexion; elevate buttocks off bed; monitor circulation to feet; meet developmental needs of immobilized infant; spica cast application

Bryant traction

Diarrhea, malabsorption of nutrients, weight loss; opportunistic infection of HIV

CMV colitis

Stroke volume (amount of blood ejected per beat) x HR

CO calculation

Performed at a 30:2 ratio of compression to ventilations; after 5 phases, reassess for breathing and pulse

CPR

Diltiazem (cardizem), nifedipine (procardia, adalat), verapamil HCL (calan, isoptin), nisoldipine (sular); inhibits calcium ion influx during cardiac depolarization; decreased SA/AV node conduction; adverse reactions: headache, hypotension, dizziness, edema, nausea, constipation, tachycardia, HF, dry cough; avoid grapefruit juice

Calcium channel blockers

Neoplasm occurring in the larynx, most commonly squamous cell in origin

Cancer of the Larynx

Of cancers occurring in the cervix; 95% are squamous cell in origin; linked to HPV; easily detected early by the papanicolaou test; precursor to cancer of the cervix is dysplasia

Cancer of the cervix

Rarely occurs rarely before 40 years of age, but it is the second leading cause of death from cancer in American men; high risk groups include those with a history of multiple sexual partners, STDs and certain viral infections

Cancer of the prostate

Laboratory diagnosis: viral culture; symptoms: females: odorless, white or yellow, cheesy discharge with itching; males: asymptomatic; treated with miconazole nitrate (monitstat), clotrimazole (gyne-lotrimin), or nystatin (mycostatin)

Candida albicans, Candidiasis

Thick white exudates in the mouth, unusual taste of food, retrosternal burning, oral ulcers; opportunistic infection of HIV

Candidiasis of Cavity and Esophagus

Passed through the nose and into the stomach; advance tube every 1-2 hours; do not secure to nose until tube reaches specified position; repositioning client q2h to assist with placement of tube; connect to suction; irrigate with air only; note amount, color, consistency and any unusual odor or drainage

Cantor, miller-Abbott or harris tubes

Acetazolamide (diamox), brinzolamide (azopt), dorzolamide (trusopt); reduces aqueous humor production; adverse reactions: numbness, tingling in hands and feet, nausea, malaise; administer orally or IV, produces dieresis, assess for Metabolic acidosis

Carbonic anhydrase inhibitors

When treating a patient with shock, the restoration of what should take priority

Cardiac Function

Volume of blood ejected by the left ventricle per unit of time

Cardiac Output

Related to ischemia or impairment in tissue perfusion resulting from MI, serious arrhythmia, or HF; all cause decrease CO

Cardiogenic Shock

Necrosis of the heart muscle aused by inadequate blood supply to the heart; usually caused by MI; MI's usually occur at rest or with moderate activity

Cardiopulmonary arrest

O2 is necessary for survival

Cardiopulmonary arrest

Angina and dyspnea

Cardiopulmonary system changes in diabetes mellitus

Administration of clotting factors, palliative treatment of the symptoms

Care of a patient with DIC - hemorrhage stage

Elevate for the first 24 hours but do not elevate 48 hours post op; keep stump extended position and turn client to prone position three times a day to prevent hip flexion contracture

Care of amputated stump

Used to treat disease by delivering high dose radiation directly to the affected tissue; not radioactive, isolation time is limited; private room and place warning on door; do not permit pregnant caretakers to care for client; discourage visits by small children; keep lead lined container in the room for disposal of the implant; remain in bed with as little movement as possivle; all client secretions have the potential of being radioactive; wear radiation badge when providing care to clients with radiation implants; plan care to limit overall time in the room

Care of the client with radiation implants

Antiemetics; monitor fluid balance; monitor for signs of infection; monitor for signs of bleeding; montiro for cumulative toxic effects of drugs such as hepatic toxicity, cardiac toxicity, renal toxicity, and neurotoxicity; small, appealing meals; increased calories and protein; promote self esteem and positive body image; prevent infection

Care toward managing side effects and toxic effects of antineoplastic agents

Condition characterized by opacity of the lens; aging accounts for 95%; other 5% is from trauma, toxic stundtances, systemic disease or are congenital; surgical removal is done under local anesthesia

Cataract

When this is removed, the lens of the eye is gone and replaced with an implant; vision is improved but not perfect; prevention of falls is important

Cataract removal

Stupor or mutism; rigidity (maintenance of a posture against efforts to be moved); posturing negativism; excitement; potential for violence of self or others during stupor or excitement

Catatonic

Inadequate stores during fetal development; deficient dietary intake; chronic blood loss; poor utilization of iron by the body

Causes of Iron deficiency anemia

Anoxic injury before, during or after birth, maternal infections, kernicterus, low birth weight

Causes of cerebral palsy

Clonidine (catapres), guanabenz acetate (wytensin), methyldopa (aldomet); decrease BP y stimulating central alpha receptors, resulting in decreased sympathetic outflow from the brain; adverse reactions: drowsiness, dry mouth, fatigue, sexual dysfunction; watch for rebound hypertension if stopped abruptly; make position changes slowly, avoid standing still and taking hot baths and shower

Central acting inhibitors

Normal values are between 4-10cm H2O

Central venous pressure

Pressure within the right atrium

Central venous pressure

First generation: cegazolin (kefzol), cephalexin (kelflex); Second generation: cefaclor (Ceclor), cefamandole (mandole), cefuroxime (ceftin-po, Zinacef-IV); Third Generation: cefotaxime (Claforan), ceftriaxone (Rocephin), ceftazidime (fortaz), cefepime (Maxipime); used as an antiinfective; adverse reactions: allergic reactions, thrombophlebitis, GI distress, Superinfection; use with caution in patients allergic to penicillin and cephalosporines

Cephalosporines

Is the cervix firm to soft

Cervical consistency

cervix opens from 0-10 cm

Cervical dilation

Cervix is taken up into the upper uterine segment; expressed in percentages from 0-100%; the thinning of the cervix

Cervical effacement

Cervix can be directly anteroir and palpated easily or posterior and difficult to palpate

Cervical position

Delivery of a fetus or fetuses through the abdomen; prone to complications such as anesthesia complications, usual abdominal surgery complications, sepsis, thromboembolism, injury of urinary tract

Cesarean birth

Laboratory diagnosis: tissue culture, chlamydiazyme, microtrak; symptoms: females: many asymptomatic, but may exhibit dysuria, urgency, vaginal discharge; males: leading cause of nongonococcal urethritis; treated with doxycycline hyclate or tetracycline HCL

Chalmydia trachomatis, Chlamydia

The chance for this increases when two or more of the parathyroid glands have been removed. Monitor serum calcium levels; check for tingling of toes and fingers and around the mouth; check for chvostek's sign; check for trousseau's sign

Chance of tetany

Act quickly to prevent major changes in body fluid pH by removing or releasing hydrogen ions

Chemical buffers

Toxic to cancer cells and normal cells in the client and caregiver; pregnant nurses should not work with these; wear gloves; check the drug with another nurse against the health care provider's prescription and the client's record to ensure it is the right medication/right patient; verify life placement and patency with another nurse; aspirated a blood return;peripheral site is used for infusion, stay with patient for the entire infusion and use a new site daily; dispose of all IV equipment in the prescribed receptacle so that personnel handing trash don't come in contact with the vesicant

Chemotherapeutic agents

Nurse must be credentialed in order to administer this; should recognize complications of this product related to administration, safety, side effects, and nursing assessment parameters and should report these to the RN and health provider

Chemotherapy

31-33cm; tape measure is stretched around scapulae over the nipple line

Chest circumference: normal newborn norms

Described as crushing, pressing, constricting, oppressive or heavy; increase in intensity for a few minutes; substernal or more diffused; may radiate to one or both shoulders and arms or to neck, jaw or back

Chest pain

Ventilations are mouth to mouth; chest compressure 1 inch with one palm at a rate of 100/min; 2 ventilations to 30 compressions; most common rhythm is asystole and bradycardia; give epinephrine at 0.01mg/kg body weight using a 1:10,000 solution

Child 1-8 resuscitation

Includes physical and mental injury, sexual abuse, and emotional and physical neglect

Child abuse

Immunization of children against communicable diseases is one of the greatest accomplishments of modern medicine. Childhood mortality and morbidity rates have greatly decreased

Child health promotion

Has a higher mortality rate due to greater central body sirface area; a greater part of their body surgace area is concentrated in the head and trunk as compared to an older child or an adult, therefore this age child is more likely to have serious effects from burns to the trunk and head; greater fluid volume; less effective cardiovascular responses to fluid

Children under 2 years

Most commonly reported communicable disease in the US

Chlamydia

Nonsurgical removal of the stones; dissolution therapy; endoscopic retrograde cholangiopancreatography, lithotripsy

Cholelithiasis treatment

Performed if stones are not removed nonsurgically and inflammation is absent

Cholescystectomy

Attributed to anticholinesterase over dosage; diaphoresis, diarrhea, fasciculations, cramps, marked worsening of symptoms resulting from overmedication; associated with negative tensilon test

Cholinergic crisis

Fasciculations, abdominal cramps, diarrhea, incontinence of stool/urine, hypotesion, bradycardia, respiratory depression, lacrimation, blurred vision

Cholinergic crisis

Removal of a small piece of villi during the period of 8-12 weeks gestation under ultrasound guidance; determines genetic diagnosis early in first trimester; obtained in 1 week; informed consent; lithotomy position using stirrups; slight sharp pain upon catheter insertion; results should not be given over the phone

Chornic villi sampling

Chronic sputum with cough production on a daily basis for a minimum of 3 months per year; chronic hypoxemia, cor pulmonale; increase in mucus, cilia production; increase in bronchial wall thickness which obstructs the airflow; reduced responsiveness of respiratory center to hypoxemic stimuli

Chronic Bronchitis Pathophysiology

Chronic lung disease includes chronic bronchitis, pulmonary emphysema, and asthmas

Chronic airflow limitation

Generalized cyanosis, blue bloaters, right-sided heart failure, distended neck veins, crackles, expiratory wheezes

Chronic bronchitis assessment

Lowest FIo2 possible and prevent CO2 retention; monitor for S&S of fluid overload; maintain Po2 between 55-60; baseline ABGs; pursed lip breathing and diaphragmatic breathing, teach tripod position

Chronic bronchitis nursing interventions

Higher incidence in smokers

Chronic bronchitis precipitating factors

Results from abnormal production of granulocytic cells; biphasic disease; chronic stage lasts 3 years; acute phase last 2-3 months; young to middle-aged adults; know causes include ionizing agents, chemical exposure; prognosis is poor; treatment is conservative and involves oral antineoplastic agents: hydroxyura, interferon, and imatinib mesylate

Chronic myelogenous leukemia

Progressive, destructive disease that causes permanent dysfunction; long term alcohol usage is the main cause of this

Chronic pancreatitis

Administer analgesics such as meperidine or porphine; administer pancreatic enzymes such as pancreatin or pancrelipase with meals or snacks. Mix powdered formed with fruit juice or applesauce; monitor stools for number and consistency to determine effectiveness of enzyme replacement; bland, low fat diet and avoid rich foods, alcohol and caffeine; S&S DM

Chronic pancreatitis nursing plans and interventions

Twitching of lip after a tap over the parotid gland

Chvostek's sign

Neonate is small; IUGR; increases with the number of substance per day; teach client that IUGR can be minimized or eliminated when smoking is stopped early

Cigarette smoking neonate effects

Cough, dyspnea, pulmonary congestion, headache, hypertension

Circulatory overload

Place client in upright position with feet in dependent position and administer diuretics, O2 and morphine

Circulatory overload nursing interventions

Clotting defects noted in lab findings: elevated bilirubin, AST, ALT, alkaline phosphatase, PT, and ammonia; decreased Hgb, Hct, electrolytes, and albumin

Cirrhosis

Degeneration of liver tissue, causing enlargement, fibrosis and scarring; caused by chronic alcohol ingestion, vital hepatitis, exposure to the hepatotoxins, infections, congenital abnormalities, biliary tree obstruction, chronic severe HF, idiopathy

Cirrhosis

The process of making sure you have understood the meaning of what was said

Clarifying

Quinidine, disopyramide phosphate (norpace), moricizine (ethmozine), lidocaine HCL (xylocaine), mexiletine (mexitil), tocainide HCL (tonocard), phenytoin sodium (dilantin), propafenone (rythmol), flecainide acetate (tambocor); indicated for premature beats, atrial flutter, atrial fibrillation, contraindicated in heart block, ventricular dysrhythmias, unlabeled use digitalis for induced arrhythmias, and ventricular dysrhythmias; adverse reactions: diarrhea, hypotension, ECG changes, cinchonism, interactions with many common drugs, hypotension, CNS effects, seizures, GI distress, bradycardia, dizziness, slurred speech, ventricular dysrhythemias; monitor HR and rhythm, monitor ECG, monitor for tinnitus an visual disturbances, lidocaine administered IV bolus and by infusion; monitor for confusion, drowsiness, slurred speech, seizures with lidocaine, administer oral drugs with foods, cause digoxin toxicity

Class I A,B,C antiarrhythmics

Unrestricted physical activity; ordinary physical activity does not cause cardiac symptomatology

Class I of cardiac disease

Ordinary activity causes fatigue, palpitations, dyspnea, and angina; physical activity is limited

Class II of cardiac disease

Bretylium tosylate (cretylol), amiodarone HCL (cordarone), milrinone (primacor), amrinone (inocor), sotalol (betapace); indicated for ventricular dysrhythmias; adverse reactions: dysrhythmias, hypertension or hypotension, muscle weakness, tremors, photophobia; amidoarone is now one of the first choice drugs, monitor VS and ECG; wear sunglasses and sunscreens

Class III antiarrhythmics

With less than ordinary activity, cardiac decompensation symptoms ensure; moderate to marked limitation or activity

Class III of cardiac disease

Symptoms of cardiac insufficiency occur even at rest; no activity is allowed

Class IV of cardiac disease

Readily apparent; initial closure of this is performed when infant weighs 10lbs and has an HGB of 10g/dl

Cleft lip

Malformation of the face and oral cavity that seem to be multifactorial in hereditary origin

Cleft lip and or Cleft palate

Recognition of distorted reality; divert focus from delusional thought to reality, do not permit rumination on false ideas; do not agree with or support delusions; avoid arguing about it; be matter of fact; avoid physically touching client, especially if delusions are persecutioal; administer antipsychotic drugs; monitor and treat side effects of psychotropic drugs; administer antiparkinsonian drugs

Client is delusional

Protect client from injury that might result from responding to commands of the voices; pay attention to the content; avoid denying or arguing with client about it; discuss observations with client; make frequent but brief remarks to interrupt; administer antipsychotic drugs; administer antiparkinsonian drugs

Client is hallucinating

Spasm followed by relaxation

Clonic phase

No break in the skin

Closed fracture

The result of blunt trauma - more serious because of chance of increased ICP in closed vault

Closed head injury

Drugs used to treat neonatal infections can be ototoxic and nephrotoxic. This is essential to monitor therapeutic levels and observations for side effects

Closing monitoring

Agranulocytosis, drowsiness, dizziness, GI symptoms, NMS

Clozaril

Avoidant personality, dependent personality, obsessive-compulsive personality

Cluster C: anxious, fearful personality disorders

Obstruction of blood flow from ventricles; there is an obstructive narrowing of the aorta; most common sites are the aortic valve and the aorta near the ductus arterisus; common finding is hypertension in the upper extremities and decreased or absent pulses in the lower extremities

Coaractation of the aorta

Withdrawal: depression, fatigue, disturbed sleep, anxiety, psychomotor agitation; overdose: tachycardia, pupillary dilatation, increased BP, cardiac arrhythmias, perspiration, chills, NV; effect: psychological dependence and occurs within hours or day

Cocaine

PO - 30-45min onset; IM or SC - 10-30 min onset; do not administer discolored injection solutions; prescribed also as an antitussive or antidiarrheal

Codeine

Directed at replacing a client's irrational beliefs and distorted attitudes; focused, problem solving therapy; work together to identify and solve problems and overcome difficulties; short term therapy of 2-3 months

Cognitive therapy

Fracture within the last inch of the distal radius; distal fragment is displaced in a position of dorsal and medial deviation

Colles fracture

HCTZ and Triamterene (maxidex), HCTZ + amiloride (moduretic), HCTZ + spinorolactone (aldactazide); decreases fluid volume while minimizing K+ loss; side effects of individual drugs offset or minimized by its partner;no to overdo K+ foods because of K+ sparing component in new drug; follow scheduling doses to avoid sleep disruptions

Combination loops and potassium sparing diuretics

Lamivudine + Zidovudine (Combivir), Zidovudine + lamivudine + abacavir (Trizivir); Indications are HIV infection; classification used in various combinations to reduce viral load and slow development of resistance; adverse reactions & monitoring : monitor for side effects/what to monitor that occur with the individual drugs

Combination products

Labetalol (normodyne), carvedilol (coreg); produces decrease in BP without reflex tachycardia or bradycardia; adverse reactions: HF, ventricular dysrhythmias, blood dyscrasias, bronchospasm, orthostatic hypotension; contraindicated with HF, COPD, block

Combined alpha beta blockers

More than one fracture line; more than two bone fragments; fragments may be splintered or crushed

Comminuted fracture

Bone fragments from the fractured shaft break free and lie in the surrounding tissue; rare in children

Comminuted fractures

Congenital heart disease; respiratory distress syndrome; infection, sepsis; neuromuscular diseases; trauma and burns; aspiration; fluid overload and dehydration; anesthesia and narcotic OD

Common cause of respiratory failure in children

COPD; pneumonia; tuberculosis; contusion; aspiration; inhaled toxins' emboli; drug OD; fluid overload; DIC; shock

Common causes of respiratory failure

Increased HR and BP; rapid, shallow RR; dry mouth and tight feeling in throat; tremors and muscle tension; anorexia; urinary frequency; palmar sweating

Common physiologic response to anxiety

Urinary retention; pulmonary problems: atelectasis, pneumonia, embolus; wound healing problems; URI; thrombophebitis; decreased GI peristalsis: constipation or paralytic ileus

Common postoperative complications

Axillary, supraclavicular, and medistinal lymph nodes, followed by spread to the lungs, liver, brain, and spine

Common sites of metastasis from breast cancer

Thyroid ablation by medication, radiation, thyroidectomy, adenectomy of portion of the anterior pituitary where TSH- producing tumor is located

Common treatment for hyperthyroidism

Results in permanent damage to the nerves and vasculature of the injured extremity due to compression

Compartment syndrome

A break across the entire cross section of the bone

Complete fracture

Placenta lies over the entire cervical os

Complete placenta previa

Unresolved grief, physical symptoms similar to those of the deceased, clinical depression, social isolation, failure to acknowledge loss

Complicated grief

Ascites, edema; portal hypertension; esophageal varices; encephalopathy; respiratory distress; ccoagulation defects

Complications of cirrhosis

Dehydration, metabolic acidosis, shock

Conditions associated with diarrhea

Postcoital test demonstrates live, motile, normal sperm preset in cervical mucus; fallopian tubes are patent; endometrial biopsy indicates adequate progesterone and secretory endometrium; semen is supportive to pregnancy which is 2mL semen or atleast 20 million sperm per ML, >60% are normal and >50% are motile

Conditions for fertilization

Used with spermicide to increase effectiveness; recommended if any suspicion of STD; penis must be withdrawn while erect or condom may fall off; petroleum jell can deteriorate rubber; water soluble jelly should be used

Condom with spermicide

Antisocial behavior characterized by violation of laws, societal norms and basic rights of others without feelings of remorse or guilt

Conduct disorders

Making up responses, stories to fill in lost memory; not lying. Used by client to decrease anxiety and protect the ego

Confabulation

Calling attention to inconsistent behavior; information shared and not shared

Confrontation

Maintaining health and safety; encouraiing self care; reinforcing reality orientation; consistent, safe environment; engaging client in simple tasks and activities to build self esteem

Confused elderly nursing interventions

In the elderly is often accepted as being part of growing old. May be due to dehydration with resulting electrolyte balance. "sudden change" when obtaining history

Confusion

Child with this condition is often described as a good, quiet baby

Congenital Hypothyroidism

Congenital absence of autonomic parasympathetic ganglion cells in a distal portion of the colon and rectum; lack of peristalsis in the area of the colon where the ganglion cells are absent; fecal contents accumulate above the aganglionic area of the bowel; correction is with a series of surgical procedures: temporary colostomy and later a reanastomosis and closure of the colostomy

Congenital aganglionic megacolon (hirschsprung disease)

Heart anomalies that develop in utero and manifest at birth or shortly thereafter

Congenital heart disease

A congenital condition resulting from inadequate thyroid tissue development in utero. Mental retardation and growth failure occur if it is not detected and treated early in infancy

Congenital hypothyroidism

Condition in which the heart is unable to pump effectively the volume of blood that is presented to it; common complications of congenital heart disease; increased workload of the heart caused by shunts or obstructions; reduce the workload of the heart and increase cardiac output

Congestive heart failure

Useful for clients who are NPO but require prolonged administration of parenteral narcotics; constant level of analgesia by continuous infusion

Continuous subcutaneous narcotic infusion

Also called oxytocin challenge test; fetus is challenged with the stress of labor by the induction of uterine contractions and the fetal response to physiologically decreased oxygen supply during uterine contractions; unhealthy fetus will develop nonreassuring FHR patterns in response to uterine contractions' late decelerations are indicative of UPI; contractions can be induced by nipple stimulation or by infusing a dilute solution of oxytocin; negative if there is no occurrence of late decelerations = negative test

Contraction stress test

Client's refusal or fear; anticoagulant therapy or presence of bleeding disorder; presence of antepartum hemorrhage causing acute Hypovolemia; infection or tumor at injection site; allergy to -caine drugs; CNS disorders, previous back surgery, or spinal anatomic abnormality

Contraindications to subarachnoid and peridural blocks

Vocal straining, chronic laryngitis, family predisposition, prolonged use of alcohol/tobacco, industrial exposure to carcinogens, nutritional deficiencies

Contributing factors to larynx cancer

Up to 48 hours post delivery

Convulsion risk

Automatic psychological processes that protect the individual against anxiety and from awareness of internal and external dangers and stressors

Coping styles (defense mechanisms)

Results in variable decelerations

Cord compression

If this is detected, the examiner should position the mother to relieve pressure on the cord or push the presenting part off the cord until immediate C-section can be accomplished

Cord prolapsed

Corticosteroids to reduce swelling; agents and osmotic diuretics to reduce secretions; agents to reduce seizures; prophylactic antibiotics

Craniotomy preoperative medications

Directly proportional to renal excretory function; affected very little by dehydration, malnutrition, or hepatic function

Creatinine

Renal maturity indicator >1.8

Creatinine

Direct at the resolution of an immediate crisis, which the individual is unable to handle alone; when previously learned coping mechanisms are ineffective in dealing with the current problem; usually in a state of disequilibrium; panic state as a result of the disorganization, be very directive; focus on the problem, not the cause; identify support system; fast coping patterns used in other stressful situations; goal is to return individual to pre-crisis level of functioning; limited to 6 weeks

Crisis intervention

Headache, changes in LOC, NV, stiff neck, blurred vision; opportunistic infection of HIV

Cryptococcal meningitis

Severe watery diarrhea (30-40 stools/day), abdominal cramps, nausea, electrolyte imbalance, malaise; opportunistic infection of HIV

Cryptosporidiosis

Excess adrenocorticoid activity; chronic administration of steroids; also caused by adrenal pituitary or hypothalamus

Cushing syndrome

Inadequate arterial oxygenation in the body is manifested by...

Cyanosis and slow Cap.refill

Has abnormal circulation with unoxygenated blood entering the systemic circulation

Cyanotic

Tetralogy of fallot, truncus arteriosus; transposition of the great vessels; right to left shunts or decreased pulmonary blood flow; mixed blood flow

Cyanotic congentical heart disorders

Inhibits cell wall synthesis; side effects: personality changes, psychosis, rash' contraindicated in individuals with histories of psychosis; used in treatment of resistant strains

Cycloserine (Seromycin)

An autosomal-recessive disease that causes dysfunction of te exocrine glands; tenacious mucus production obstructs vital structures; lung insufficiency, pancreatic insufficiency, increased loss of sodium and chloride in sweat

Cystic fibrosis

The relaxation of the anterior vaginal wall with prolapse of the bladder

Cystocele

Most common CMV infection in persons with AIDS, impaired vision in one or both eyes, can lead to blindness; opportunistic infection of HIV

Cytomegalovirus (CMV) Retinitis

Syndrome of abnormal clotting that is systematic and pathologic. Large amounts of clotting factors are depleted, causing widespread external and internal bleeding. Related to fetal demise, infection and sepsis, pregnancy induced hypertension and abruption placentae

DIC

Prothrombin time (PT): prolonged; partial thromboplastim time (PTT): prolonged; fibrinogen: decreased; platelet count: decreased; fibrin degradation products: increased

DIC diagnosis

Petechiae, purpura, hematomas; oozing from IV sites, drains, gums and wounds; GI and GU bleeding; hemoptysis; mental status changes; hypotension, tachycardia; pain

DIC nursing assessment

Bleeding gums or nose; reduced lab values for platelets, fibrinogen, and prothrombin; bleeding from injection sites, IV sites; ecchymosis

DIC signs & symptoms

Beginning at 2 months, administer 3 doses at 2 month intervals; booster doses given at 15-18 months and at 4-6 years; administer IM; not fiven to children past the 7th birthday; contraindications to P: encephalopathy within 7 days of previous vaccine, hx of seizures, neurologic symptoms after receiving vaccine, systematic allergic reactions; instructed to begin Tylenol administration after the immunization (10-15mg/kg)

DTaP vaccine

Results in late decelerations

Decrease in uteroplacental perfusion

Occurs 2-4 days post-op; NG tubing to decompress GI tract, limit use of narcotic analgesics, early ambulation

Decreased GI peristalsis: constipation, paralytic ileus

Acute process that if treated is usually reversible. Recognized by sudden onset; occurs in response to specific stressor such as infection, drug reaction, substance intoxication or withdrawal, electrolyte imbalance, head trauma, sleep deprivation; treatment is the correction of the causative disorder

Delirium

Fixed false beliefs that may be persecutory, grandose, religious, or somatic in nature

Delusions

Cognitive impairments characterized by gradual, progressive onset; irreversible. Judgment, memory, abstract thinking, and social behavior are affected. Most commonly seen in Alzheimer disease and multiinfarctions; also occurs in huntinton disease, Parkinson disease, MS and brain tumors, wernicke korsakoff syndrome

Dementia

Coping style used to protect self/ego; noncompliance, refusal to seek treatment, ignoring symptoms; changing the subject when speaking about the illness; "not me, this must be a mistake"

Denial

Unconscious failure to acknowledge an event, thought, or feeling that is too painful for conscious awareness; woman diagnosed with cancer tells her family all the tests were negative

Denial

Most common defense mechanisms used by chemically dependent clients; use must be confronted so the clients accountability for own behavior can develop

Denial and rationalization

Characterized by a temporary loss of one's reality and the ability to feel and express emotions; expresses a fear of going crazy; describes a sense of strangeness in the surrounding environment

Depersonalization

Perceives self as alienated or detached from real body

Depersonalization

The most important S&S of depression other changes include a change in appetite accompanied by a change in weight; insomnia and hypersomnia; fatigue or lack of energy; feelings of hopelessness, worthlessness, guilt or over responsibility; loss of ability to concentrate or think clearly; preoccupation with death or suicide

Depressed mood with a loss of interest in the pleasures in life

When they begin to take an interest in their appearance or begin to perform self-care activities that were previously of little or no interest to them

Depressed patient is improving

Results from the losses experienced because of health status and hospitalization; anticipating the loss of life

Depression

Pathologic grief reactions ranging from mild to severe states

Depressive disorders

The nursing intervention for phobia disorders; assist client to recognize the factors associated with feared stimuli that precipitate a phobic response; teach and practice with client alternative adaptive coping strategies such as use of thought and relaxation techniques; expose client progressively to feared stimuli, offering support with the nurse's presence; provide positive reinforcement whenever a decrease in phobic reaction occur

Desensitization

A hole or tear in, or separation of the sensory retina from, the pigmented epithelium; can be caused from blunt trauma treatment is resealing of the retina through cryotherapy (freezing), photocoagulation (Laser), diathermy (heat), sclera buckling (most often used

Detached retina

Erikson's theory 12-19 years old

Develops a sense of identity (identity vs. role confusion)

Indirect marker of depression; considered positive if post-DST cortical level is greater than 5mg/dl

Dexamethasone suppression test

A hypertonic solution and should be administered IV

Dextrose 10%

Hormonal changes during pregnancy act to increase maternal cell resistance to insulin so that an abundant supply of glucose is available to the fetus; if insulin cannot move glucose into maternal cells, the mother will begin to metabolize fat and protein for energy-producing ketones and fatty acids, which result in ketoacidosis

Diabetes mellitus

Metabolic disorder in which there is an absence of or an insufficient production of insulin; characterized by hyperglycemia; affect metabolism of protein, carbohydrate and fat, fasting glucose level of greater than 126mg/dl

Diabetes mellitus

She is more prone to preeclampsia, hemorrhage, and infection; delivery is often scheduled for 37-38weeks gestation to avoid the end of the third trimester of pregnancy because this is a very difficult time to maintain diabetic control

Diabetes mellitus in pregnant women

Family history of diabetes; history of more than 2 spontaneous abortions; previous baby with weight over 4000g; previous baby with congenital anomalies; high parity; obesity; recurrent monilial vaginitis; abnormal glucose screen; elevated glycosylated hemoglobin; polyphagia, polydipisia, and polyuria; hyperglycemia; increased incidence of preeclampsia, infection and hydramnios

Diabetes mellitus nursing assessment

Ophthalmoscope, slit lamp biomicroscope

Diagnosis for cataract

Low T3 levels <70; low T4 levels <5; presence of T4 antibody

Diagnosis for hypothyroidism

CT scan, MRI, Doppler flow studies, ultrasound imaging

Diagnosis of CVA

Made by biopsy

Diagnosis of breast cancer

Elevated erythrocyte sedimentation rate, positive rheumatoid factor, presence of antinuclear antibody, joint space narrowing indicated by arthroscopic exam, abnormal synovial fluid indicated by arthrocentesis; C-reactive protein indicated by active inflammation

Diagnosis of rheumatoid arthritis

HBG < 10; HCT<36%; RBCs<4x10^2; bone marrow positive for anemia

Diagnostic tests for anemia

Used with spermicide; must be fitted by a NP or MD; left in place for 6 hours after intercourse; refitted if excessive weight gain or loss occurs; check for integrity

Diaphragm

Increased number or decreased consistency of stools; serious, potentially fatal illness; can be caused by bacterial or viral infections, malabosption problems, inflammatory diseases, dietary factors

Diarrhea

Degree to which neoplastic tissue is different from parent tissue

Differentiation

Medication is to be withheld if HR<60

Digitalis

Increase contractility of the heart muscle

Digitalis preparations

Bradycardia, tachycardia, dysrhythmias, NV, headache

Digitalis toxicity S&S

Indicated for HF, increases contractility of heart muscle; slows HR and conduction; adverse reactions: AV block, headache, dysrhythmias, NV, blurred vision, yellow-green halos, hypotension, fatigue; monitor serum electrolytes: hypokalemia; monitor serum levels - range from 0.5-2mg; radial pulse prior to administration

Digitoxin (crystodigin, Purodigin) & Digoxin (lanoxin, lanoxicaps)

Indicated for supreventricular dysrhythemias and atrial fibrillation; adverse reactions: bradycardia, dysrhythmias, anorexia, NVD, visual disturbances; monitor HR and rhythm, report signs of toxicity, hypokalemia increases the risk for toxicity, causes hypercalecmia

Digoxin (lanoxin) and digitoxin (crystodigin)

Indicated as antidote for digitalis toxicity and bind with digitoxin or digoxin to prevent biding at their site of action; adverse reactions: decreased cardiac output, atrial tachyarrhythmias, used with caution in elderly and children; use with 0.22um filter; place client on continuous cardiac monitor; resuscitation equipment at bedside before fiving first dose

Digoxin-immune fab (digibind)

Affects skin only

Discoid Lupus erythematosus

Discontinue this the day before delivery is planed because requirements are less during labor and drop precipitously after delivery

Discontinue long acting insulin

Assess:: Length of catheter; edema, drainage, and coiling of catheter, neck distension or distended neck veins, change in patency of catheter, chest radiograph, cardiac dysrhythmias, hypotension

Dislodgement/migration/incorrect placement

Provide enough tubing length for client movement; anchor the catheter well; measure and record length of catheter

Dislodgement/migration/incorrect placement interventions

Incoherence; flat or inappropriate affect, disorganized, uninhibited behavior; unusual mannerisms; socially withdrawn; no delusions

Disorganized

Fragments out of normal position at fracture site

Displaced fracture

The transference of feelings to another person or object; after being scolded by his supervisor at work, a man comes home and kicks the dog for barking

Displacement

Malaise, fever, pancytopenia, weight loss, positive cultures from blood, urine or throat; opportunistic infection of HIV

Disseminated CMV

A coagulation disorder with paradoxic thrombosis and hemorrhage

Disseminated intravascular clotting (DIC)

Amantadine HCL (symmetrel); stimulated dopamine production or increases sensitivity of dopamine receptors; newer drugs require lower dosage; adverse reactions: involuntary movements; NV; drugs may take months to achieve desired effects; avoid sudden position changes; avoid foods high in vitamin B6 (meats, liver, high protein foods); insomnia occurs, suggest taking last dose earlier in the day; may initially cause drowsiness

Dopamine releasing agent

Levodopa (dopar), levodopa-carbidopa (sinemet); stimulated dopamine production or increases sensitivity of dopamine receptors; newer drugs require lower dosage; adverse reactions: involuntary movements; NV; drugs may take months to achieve desired effects; avoid sudden position changes; avoid foods high in vitamin B6 (meats, liver, high protein foods); insomnia occurs, suggest taking last dose earlier in the day; may initially cause drowsiness

Dopamine replacements

Bromocriptine mesylate (parlodel), praminpexole (mirapet), pergolide (permax); stimulated dopamine production or increases sensitivity of dopamine receptors; newer drugs require lower dosage; adverse reactions: involuntary movements; NV; drugs may take months to achieve desired effects; avoid sudden position changes; avoid foods high in vitamin B6 (meats, liver, high protein foods); insomnia occurs, suggest taking last dose earlier in the day; may initially cause drowsiness

Dopamine-releasing agonists

The most common chromosomal abnormality in children; evidenced by various physical characteristics and mental retardation; results from a trisomy of chromosome 21; associated with maternal age > 35

Down syndrome

Very painful; medicate client prior to procedure

Dressing change

Digitalis and vasoconstrictors preparations

Drugs of choice for shock

an x-linked recessive disease affecting primarily males; appears in the early childhood; rapidly progresses causing respiratory or cardiac complications and death usually by 25 years of age

Duchenne muscular dystrophy

Dysfunctional swallowing

Dysphagia

Impairment of speech and verbal comprehension

Dysphasia

Difficult birth resulting from any cause; can result from any one or all of the 5Ps (powers, passage, passenger, psyche, position)

Dystocia

Often requires oxytocin for augmentation or induction of labor; uterine tetany is a serious complication; want contractions q2-3 min lasting no longer than 90 seconds

Dystocia

Suspected when there is a lack of progress in cervical dilation; lack of fetal descent; lack of change in uterine contraction characteristics

Dystocia

Pressures of these are almost identical

ECF & ICF

Restless, hyper-alert

Early shock mental status changes

Agitation and restlessness that results from cerebral hypoxia

Early signs of shock

Pinna at or above level of line draw from other canthus of eye, well formed and firm with instant recoil if folded against head

Ears: normal newborn findings

Constantly repeating what is heard

Echolalia

Seizures that occur in a woman with preeclampsia

Eclampsia

Fertilized ovum is implanted outside the uterine cavity, usually in a fallopian tube; occurs in 1/200 pregnancies; occurs as a result of tubular obstruction or blockage that prevents normal transit of the fertilized ovum; considered a medical emergency

Ectopic pregnancy

Electrically induced seizures for psychiatric purposes; severely depressed clients who fail to respond to antidepressant medications and therapy. Used with extremely suicidal patients because 2 weeks are needed for antidepressants to take effect; administer anticholinergic 30 min prior to procedure; after procedure maintain airway; VSq15min until alert; reorient; common complaints are headache, muscle soreness, nausea

Electroconvulsive therapy

Should be considered prior to a digital rectal exam so that manipulation of the prostate does not give a false positive reading; rise and consistently high levels is more reliable than a single assay; can rise with inflammation, benign hypertrophy, or irritation

Elevated prostate specific antigen

Caused by a clot that has broken away from a vessel and has lodged in one of the arteries of the brain, blocking the blood supply. Related to atherosclerosis

Embolytic stroke

3-8 weeks after fertilization; most vulnerable to teratogens which can cause major congenital anomalies

Embryo

Gonads

Embryonal

Rapid, uncontrolled delivery; nonsterile or an unassisted delivery that can be managed without complications to mother or fetus

Emergency delivery

Without adequate attention to the emotional and developmental needs of the sick neonate, the following occur: failure to thrive, avoidance of eye contact with people, absent or weak crying; nurses may cuddle, swaddle, sing to and offer pacifiers to infant and put mobiles and decals in the crib of the baby

Emotional aspects related to care of high risk neonates

Terms chronic obstructive pulmonary disease; characterized by bronchospasm and dyspnea; damage is not reversible and increases in severity

Emphysema and chronic bronchitis

Pink puffers, barrel chest, pursed lip breathers, distant quiet breath sounds, wheezes, pulmonary blebs on radiograph

Emphysema assessment

Naturally occurring compounds that have morphine-like qualities; they modulate pain by preventing the conduction of pain impulses in the CNS

Endorphin theory

Specific neurotransmitters that bind with opiate receptors in the dorsal horn of the spinal cord; they modulate pain by closing the gate and stopping the pain impulse

Enkephalins theory

1:10,000; 5mL IV for severe cases of shock

Epinephrine

1:1000, 0.2-0.5mL SUBCU for mild shock cases

Epinephrine

Newborn prophylactic eye care; prevention of ophthalmia neonatorum and Chlamydia trachomatis conjunctivitis; adverse reactions: most commonly used agents and there are none known except for puffy eyes resulting from manipulation; place a thin line of ointment along the entire lower lid in conjunctival sac; one tube per baby and discard; manipulate upper lids to ensure complete eye coverage; after 1 minute, may wipe excess from around eyes

Erythromycin and/or tetracycline

Congenital anomaly in which the esophagus doesn't fully develop' upper esophagus ends in a blind pouch and the lower art of the esophagus is connected to the trachea; clinical and surgical emergency

Esophageal atresia with tracheoesophageal fistula

May rupture and cause hemorrhage. Immediate management includes insertion of an esophagogastric balloon tamponade (Blakemore-sengstaken or Minnesota tube) along with vasopressors, vitamin K, coagulation factors, and blood transfusions

Esophageal varices

Esophagogastric balloon tamponade (Blakemore tube), sclerotherapy, portal systemic shunts

Esophageal varices management

Pills affect glucose metabolism by increasing resistance to insulin

Estrogen - birth control

Inhibits RNA synthesis and its bacteriostatic for the tubercle bacillus; side effects: skin rash, GI disturbance, malaise, peripheral neuritis, optic neuritis; side effects uncommon and reversible with discontinuation of drug; most common use as substitute drug when toxicity occurs with isoniazid or rifampin

Ethambutol (Myambutol)

Hgb and Hct can do this during pregnancy

Evaluate nutritional status

Occurs within 1-6 weeks after initiation of treatment; restlessness, agitation and pacing. Sudden difficulty sitting still; rule out anxiety

Extrapyramidal effects: akathisia

Occurs within 1-2 days after initiation of treatment; limb and neck spasms, uncoordinated, jerky movements; difficulty speaking and swallowing, rigidity and muscle spasms; emergency treatment is with IM anticholinergic drugs. Have respiratory emergency equipment

Extrapyramidal effects: dystonia

Develops late in treatment; involuntary tongue and lip movements, blinking, choreiform movements of limbs and trunk; permanent side effect; drugs are of no help in decreasing symptoms; teach client and family to report side effects early

Extrapyramidal effects: tardive dyskinesia

The lens of the eye is responsible for projecting light onto the retina so that images can be discerned; without the lens, which becomes opaque with cataracts, light cannot be filtered and vision is blurred

Eye physiology

Symmetrically placed, pseudostrabismus, chemical conjunctivitis, clear cornea, white blue sclera, subconjunctival hemorrhage from pressure, absence of tears, dolls eye movement

Eyes: normal newborn norms

Identifies the entire family as the client; based on the concept of the family as a system of interrelated parts forming a whole; focused in on the patterns of interaction within the family; assist the family in identifying the roles assigned to each member based on family rules; congruent and incongruent communication patterns and behaviors are identified; decrease family conflict and anxiety and to develop appropriate role relationships

Family therapy

A syndrome in which fat migrates into the blood stream and combines with pletlets to form emboli; the greatest risk is 36 hours after a fracture; more common in clients with multiple fractures, fractures of the long bones, fractures of the pelvis. Initial symptom is confusion due to hypoxemia; assess for respiratory distress, restlessness, irritability, fever and petechiae; notify physician stat, draw ABGs, administer oxygen, assist with intubation

Fat embolism

Relationship of the fetal parts to one another; flexion or extension; flexion is desirable so that the smallest diameters of the presenting part move through the pelvis

Fetal attitude

Fetus can breathe, swallow, regulate temperature; surfactant forms in lungs; fetus can hear; fetus' eyelids open; period of greatest fetal weight gain begins; fetus weighs 2.5lbs

Fetal development at 28 weeks

Brown fat deposits develop beneath the skin to insulate baby following birth; 15-17 inches in length; storing iron, calcium and phosphorus; weights 4-5lbs

Fetal development at 32 weeks

Development is rapid; heart begins to pump blood; limb buds are well develops; facial features are discernible; major divisions of the brain are discernible; ears develop from skin folds; tiny muscles are formed beneath this skin embryo; weight is 2g

Fetal development at 8 weeks

The part of the fetus that presents to the inlet

Fetal presentation

Location of the presenting part in relation to the midpelvis or ischial spines; expressed as cm above or below the spines; station 0 is engaged, station -2 is 2 cm above the ischial spines

Fetal station

Can cause dehydration because of excessive fluid loss due to diaphoresis. Also increases metabolism and the demand for oxygen

Fever

Fibrous tissue

Fibro

Granulocyte stimulating factor; improved immune competence by increasing neutrophils; adverse reactions: medullary bone pain during initial treatment and pain at injection site; monitor WBC/diff and ANC, give SC slowly, assess bone pain and medicate with analgesics

Filgrastim (neupogen)

Deep partial thickness; sunburn; leaves the sin pink or red; dry; painful; slight edema; healing occurs in 3-6 days

First degree burn

A tear that involves only the epidermis

First degree tear

Seep into the extravascular spaces, further reducing CO

Fluid and osmotic proteins

Occurs when the body loses water and electrolytes isotonically; serum electrolyte levels remain normal; dehydration

Fluid volume deficit

Vomiting, diarrhea, GI suctioning, inadequate fluid intake, massive edema, ascites, forgetting to drink

Fluid volume deficit causes

Elevated BUN and creatinine; increased serum osmolarity; elevated HBG and HCT; urine osmolality and SG increases

Fluid volume deficit lab findings

Weight loss, decreased skin turgor, oliguria, dry/sticky mucous membranes, postural hypotension or weak, rapid pulse

Fluid volume deficit signs and symptoms

Strict I&O; replacement of fluids isotonically; water is hypotonic

Fluid volume deficit treatment

HR, renal failure, cirrhosis, liver failure, excessive ingestion of table salt, over hydration with sodium containing fluid, poorly controlled IV therapy

Fluid volume excess causes

Decreased BUN, decreased HBG&HCT, decreased serum osmolality, decreased urine osmolality and SG

Fluid volume excess lab findings

Peripheral edema, increased bounding pulse, elevated BP, distended neck and hand veins, dyspnea; moist crackles head when lungs are auscultated, attention loss, confusion, aphasia, altered LOC

Fluid volume excess symptoms

Diuretics, fluid restriction, strict I&O, sodium restricted diet, weighed daily, K+ serum monitored

Fluid volume excess treatment

Indicated to control psychotic behavior; useful in treatment of psychomotor agitation associated with thought disorders; reactions: drowsiness, orthostatic hypotension, weight fain, anticholingeric effects, extrapyramidal effects, photosensitivity, blood dyscrasias: granulocytosis, leucopenia, neuroleptic malignant syndrome; absorbed slowly; use with noncompliant clients because it can be administered IM once q14day

Fluphenazine HCL (Proloxin)

Ciprofloxacin (Cipro), levofloxacin (levaquin), gatifloxacin (tequin); used to treat the most difficult to treat respiratory infections, UTIs, skin, bone and joint infections; has been used as conjunctive treatment for TB and AIDS; adverse reactions include superinfections, CNS disturbances, arroyos and cataracts, Cipro is a vesicant; prompt onset, crosses placenta and in breast milk, can lower seizure threshold, monitor liver/renal and blood counts

Fluroquinolones

Assisting the client to explore a specific topic which may include sharing perceptions and theme identification

Focusing

Given to patients with sickle cell anemia to stimulate RBC synthesis

Folic acid

Milk, cheese, dark green vegetables, dried figs, sot, legumes

Foods high in calcium

Liver, beans, peas, spinach, yeast

Foods high in folic acid

Marine fish, shellfish, dairy products, iodized salt, some breads

Foods high in iodine

Meats, eggs, legumes, whole grains, green leafy vegetables and dried fruits

Foods high in iron

Whole grains, green leafy vegetables, tea, nuts and fruit

Foods high in magnesium

Meat, milk, dairy products, eggs, high protein foods

Foods high in phenylalanine

Milk, liver, legumes, fish, soy

Foods high in phosphorus

Citrus fruits and dried fruits, bananas, watermelon, potatoes, legumes, tea and peanut butter

Foods high in potassium

Canned vegetables, carrots, tomatoes, tomato catsup, tomato juice, bouillon cubes, mustard, pickled olives, pickles, cucumber, dill, salad dressing, soy sauce, bacon, cheeses, ready to eat breakfast cereals, peanut butter, soups, corned beef

Foods high in sodium

Liver, egg yolks, fortified margarine and butter; dark green and deep orange fruits and vegetables (apricots, broccoli, cantaloupe, carrots, pumpkin, winter squash, sweet potatoes, and spinach)

Foods high in vitamin A

Pork, beef, liver, while grains, legumes, and wheat germ

Foods high in vitamin B1

Shell fish, liver, fish and lean meat

Foods high in vitamin B12

Liver, milk, milk products, soybeans, and enriched cereals

Foods high in vitamin B2

Meat, poultry, fish, peanuts, and enriched grains

Foods high in vitamin B3

Meat, poultry, grains, seeds and seafood

Foods high in vitamin B6

Citrus fruits, cantaloupes, strawberries, tomatoes, potatoes, broccoli, green peppers and spinach

Foods high in vitamin C

Fortified and full fat dairy products; fish oil; synthesized in skin when exposed to sunlight

Foods high in vitamin D

Vegetable oils and their products such as salad oils, margarine, nuts, seeds, avocado, and mango

Foods high in vitamin E

Green leafy vegetables such as lettuce, cabbage, spinach, peas, asparagus, meat, milk, and soybean oil

Foods high in vitamin K

Phrases that should not be used when interacting with clients; avoid social interactions, clichés, and saying too much; avoid changing subjects; avoid words like good, bad, right, wrong and nice; you should..; you'll have to...; you can't...; let's...; if it were me, I would...; why don't you...; I think you...; it's the policy on this unit; don't worry; everyone...; why...; just a second; I know...

Forbidden phrases

Anticonvulsant; indicated for generalized convulsive status epilepticus, prevention and treatment of seizures during neurosurgery, short term parenteral replacement for dilatan; adverse reaction: rapid IV infusion can cause hypotension; severe: ataxia, CNS toxicity, confusion, gingival hyperplasia, irritability, lupus erythematosus, nervousness, nystagmus, paradoxic excitement, stevens-johnson syndrome, toxic epidural necrosis; used for short term parental use; always be prescribed and dispensed in phenytoin sodium equivalents; prior to IV infusion, dilute D5W or NS to administer solution of 1.2-25mg PE/ml; infuse at IV rate of no more than 150mg PE/minute

Fosphenytoin sodium (cerebyx)

A break in the continuity of the bone; caused by a firect blow, crushing force, a sudden twisting motion or a disease such as cancer or osteoporosis

Fracture

Predispose the client to anemia, especially if long bones are involved; check HCTq3-4 days to monitor erythropoiesis

Fracture

Traumatic injury to the bone; if it occurs in the epiphyseal plate, growth may be affected

Fractures

Beginning of one contraction to beginning of the next

Frequency

Liquid portion of whole blood is separated from cells and frozen

Fresh frozen plasma

The use of this is being replaced by albumin plasma expanders; used for bleeding caused by deficiency in clotting factors

Fresh frozen plasma

Must be used within 24 hours of being thawed; used as an auto transfusion; infrequently used because filters remove most of the WBCS

Frozen RBCs

Prepared from RBCs using glycerol for protection and then frozen

Frozen RBCs

One of the most common reasons for uterine atony or hemorrhage in the first 24 hours after delivery.

Full bladder

12-13 weeks: rises out of the symphysis; 20 weeks: at umbilicus; 24 weeks: measured in cm, with the number of cm above the symphysis equal to the number of weeks of gestation

Fundal height

Nutritional needs and fluid and electrolyte balance are key problems for children with these disorders

GI disorders

This is a priority in people with COPD because it elevates the diaphragm and inhibits full lung expansion

Gastric distension

Nighttime diarrhea, emesis falling into pattern; gastroparesis

Gastrointestinal changes in diabetes mellitus

Sterile feeding tube (5-8fr); calibrated syringe for formula; stethoscope; sterile syringe without needle; paper tape; formula and medications; head slightly elevated and towel under shoulders; measure distance from bridge of nose to the earlobe and then to a point halfway between the xiphoid process and umibilcus; pass tube along back of tongue, advancing as newborn swallows; aspirate and measure any residual stomach contents and reduce volume of feeding by amount of residual; attach large feeding syringe to tube with plunger removed, pour warmed formula or breast milk and allow to flow by gravity, hold 6-8 inches above newborns head for slow feeding: 20mints or 1ml/min; stop flow at neck of syringe by pinching tubing; clear tubing with small amount of sterile water; pinch tubing and withdraw quickly to avoid administering the feeding nasopharyngeally; burp; position on right side; postpone treatments for 1hr; record amount of residual

Gavage feeding in newborn client

Little subcutaneous fat - intrauterine growth problems, fetal stress; frog position - prematurity; flaccid- asphyxia, prematurity; hard to arouse - sepsis, CNS problems, asphyzia; high pitched cry - CNS damage or anomalies, hypoglycemia, drug withdrawal

General appearance: abnormal findings in the newborn

Awake, flexed extremities, moves all extremities, stong lusty cry, obvious presence of subcutaneous fat, no obvious anomalies

General appearance: normal newborn norms

Unrealistic, excessive or persistent anxiety and worry about 2 or more circumstances. Previously coping mechanisms are inadequate to deal with this level of anxiety

Generalized anxiety disorder

Pose a serious threat to unborn siblings; counsel all expectant mothers; aware of the serious consequences of exposure during pregnancy

German measles

BP elevation occurs for the first time after midpregnancy

Gestational hypertension

Chorionic villi degenerate into a bunch of clear vesicles in grape-like clusters; hydatidiform mole is a developmental anomaly; embryo is rarely present; predisposes to choriocarcinoma;

Gestational trophoblastic disease (hydatidiform mole)

Bacteria encapsulate after initial exposure of TB

Ghon Lesion

Often painless and symptom free; pick up as part of a regular exam

Glaucoma

Take a deep breathe, momentarily occlude the tracheostomy tube, cough, and simultaneously remove finger from the tube; done because the glottis is removed in laryngectomy clients

Glottal stop

betamethasone ; Enhances fetal lung maturation or surfactant production if fetus is <35 weeks gestation

Glucocorticoids

No more than 1+ in a normal finding in the urine; related to gestational diabetes

Glucose

Client does not have to fast for this test; 50g of glucose is given and blood is drawn after 1 hour; >135mg/dl a 3-hour glucose tolerance test is done

Glucose screen

Indicates glucose control over previous 120 days; is a valuable measurement of diabetes control

Glycosylated Hgb

Used to obtain a direct visualization of the lens

Gonoiscopy

Thought to be an autoimmune process; diagnosis is made on the basis of serum hormone levels

Grave's Disease

Refers to the number of times a woman has been pregnant, regardless of the outcome

Gravida

One side of the bone is broken and the other side is bent

Greenstick

Incomplete fracture in which one side of the cortex is broken and the other side is flexed but intact

Greenstick fracture

Process an individual goes through to deal with loss

Grief

Used with 2 or more client's who develop interactive relationships and share at least one common goal or issue; may be closed or open and group may be small or large; common to have nurse-led intervention groups include those that focus on medications, symptom mgmt, anger mgmt and self care.

Group intervention

Clinical syndrome of unknown origin involving peripheral and cranial nerves; preceded by a respiratory or GI infection 1-4 weeks prior to the onset of neurologic deficits; potential complication of respiratory failure; full recovery can occur within several months to a year after symptoms onset

Guillain-barre syndrome

Administered after a stroke to prevent peptic ulcers

H2 inhibitors

Choriocarcinoma may develop. Pregnancy may mask the signs and symptoms of choriocarcinoma

HCG levels that don't diminish

Measures serum bicarbonate; reflect primary metabolism disorder or compensatory mechanism to respiratory acidosis

HCO3

CD4 T cell counts more than 500 cells/mm3; no clinical problems, characterized by continuous viral replication; can last for many years (10+ years)

HIV asymptomatic (CDC category A)

Require respiratory isolation. Only real risk to non-pregnant caregivers that is not related to a break in standard precautions

HIV clients with TB

Memory loss, impaired concentration, apathy, depression, psychomotor slowing, incontinence, CT findings show diffuse atrophy and ventricular enlargement; opportunistic infection of HIV

HIV encephalopathy

Infection with human immunodeficiency virus; caused by a retrovirus, which is attracted to CD4 T cells, lymphocytes, macrophages, and cells of the CNS; destruction of the CD4 T cells causes depletion in the number of CD4 T cells and a loss of the body's ability to fight infection

HIV infection

CD4 T cell counts between 200-499 cells/mm3; persistent generalized lymphadenopathy, persistent fever, weight loss, diarrhea, peripheral neuropathy, herpes zoster, candidiasis, cervical dysplasia, hairy leukoplakia, oral

HIV symptomatic (CDC category B)

Inability to hear a whisper from 1-2 feet away; inability to respond if nurse covers mouth when talking; inability to hear a watch tick 5 inches from ear; shouting in conversation; straining to hear; turning head to favor one ear; answering questions; raising volume on radio or TV

Hearing loss nursing assessment

Speak in a low-pitched voice, slowly and distinctly; stand in front of the person with the light source behind the client; use visual aids

Hearing loss nursing interventions

110-160; 100 during sleep; 180 during crying; auscultate for 1 full minute

Heart rate: normal newborn norms

Reflect past nutrition

Height and head circumference

Another possible causative factors in hyperemesis

Helicobater pylori

Acknowledge, clarifying, confrontation, focusing, information giving, open-ended questions, reflecting/restating, silence, suggesting

Helpful techniques in communication

Inherited bleeding disorder; transmitted by an X-linked recessive chromosome (mother is the carrier, her ons may express the disease); normal individual has between 50-200% factor activity in the blood - the person with this disorder has from 0-25% activity; usually missing is either factor VIII or factor IX

Hemophilia

Give vitamin K to prevent this

Hemorrhagic disorders

Caused by a slow or fast hemorrhage into the brain tissue; often related to hypertension

Hemorrhagic stroke

Blocks the formation of thrombin

Heparin

Administered parenterally as an antagonist to thrombin and to prevent the conversion of fibrinogen to fibrin; adverse reactions; hemorrhage, agranulocytosis, leucopenia, hepatitis; assess PTT, HGB, HCT, platelets; assess stools for occult blood; avoid IM injection; antagonist protamine sulfate

Heparin sodium

A widespread inflammation of liver cells, usually caused by a virus

Hepatitis

Source of infection: contaminated food, water or shellfish; route of infection: oral, fecal, parenteral; incubation period: 15-50 days; onset: abrupt; seasonal variation; autumn, winter; age group affected: children and young adults; vaccine: yes; inoculation: yes; potential for chronic liver disease: no; immunity: yes

Hepatitis A (infectious hepatitis)

May be given to newborns prior to hospital discharge; all children up to 18 years of age should be vaccinated; contraindicated for persons with anaphylactic reaction to baker's yeast

Hepatitis B

Source of infection: contaminated blood products, needles, surgical instruments or from mother to child at birth; route of infection: oral, fecal, parenteral, direct contact, breast milk, sexual contact; incubation period: 14-180 days; onset: insidious; seasonal variation; all year; age group affected: any; vaccine: yes; inoculation: yes; potential for chronic liver disease: yes; immunity: yes

Hepatitis B (serum hepatitis)

Assess client's response to activity; assist client with care as needed; provide high calorie, high carbohydrate diet with moderate fats and proteins; small, frequent feedings; provide vitamin supplements; teach importance of personal hygiene; teach to avoid alcohol, aspirin, acetaminophen and sedatives

Hepatitis nursing plans and interventions

Symptoms: vesicles in clusters that rupture and leave painful erosions that cause painful urinary; characterized by remissions and exacerbations; may be contagious when asymptomatic; treated with acyclovir (zovirax) that partially controls symptoms and palliative care that includes viscous lidocaine topically to ease the pain, and keeping the lesions clean and dry

Herpes simplex virus 2, herpes

HgbAS - sickle cell trait

Heterozygous gene

Offers protection against bacteria that cause epiglottis, bacterial meningitis, septic arthritis; can be given beginning as early as 2 months of age. Children at high risk who were not immunized previously should be immunized >5years; IM; no contraindications

Hib (haemophilus influenze type B) vaccine

Position to reduce venous return in order to decrease further venous return to the left ventricle

High fowler position with legs down

Altered LOC, depressed or absent gag and cough reflexes, or is susceptible to aspirating oropharyngeal secretions; when feeding, raise the HOB and position the client on his or her side, not on the back

High risk for pneumonia

Debilitated by accumulated lung secretions; cigarette smokers; immobile; immunosuppressed; experiencing a depressed gag reflex; sedated; experiencing neuromuscular disorders

High risk groups for pneumonia

Ranitidine HCL (zantac), cimetidine (tagamet), famotidine (pepcid), nizatidine (axid); indicated for treatment of peptic ulcers and as a phrophylactic treatment for clients at risk for developing ulcers; there are multiple drug interactions; cigarette smoking interfers with drug action; expensive

Histamine2 antgonists

Malignancy of the lymphoid system; characterized by a generalized painless lymphadenopathy; higher in males and young adults; prognosis is good; diagnosis is made by excision of a node for biopsy with the characteristic cell being reed-sternberg

Hodgkin disease

One of the most curable of all adult malignancies; emotional support is vital; chemotherapy leaves men sterile; may bank sperm to treatment if desired

Hodgkin disease

Portable continuous monitor that can be placed o the client to provide a magnetic tape recording of the heart; keep a diary concerning activity, medications, chest pains

Holter monitor

Absolute bed rest; weigh daily and report >2lb/week; test urine daily for protein; report the following symptoms to the PCP immediately:: visual disturbances, headache, NV, hyperreflexia, convulsions, epigastric pain, oliguria, proteinuria, decreased or absent fetal activity, vaginal bleeding, abdominal pain; high protein diet with limited salt intake, maintain the minimum 35cal/kg of body weight;

Home management for patient with preeclampsia

The process of maintaining a relative state of equilibrium; occurs in relation to maintenance of the composition of fluids

Homeostasis

HbSS sickle cell disease

Homozygous gene

Prednisone (cortalone), dexamethasone (decadron); indicated for leukemia, Hodgkin, breast cancer, lymphoma, multiple myeloma, cerebral edema due to brain metastasis

Hormonal agents (corticosteroids)

If severe preeclampsia is present, hospitalization will be necessary; monitor LOC, BP, VSq4h; continuous fetal assessment; assess for vaginal bleeding and abdominal pain; bed rest in left lying position; catheter; I&O hourly; maintain quiet, slightly darkened environment and limited visitors; administer magnesium sulfate and antihypertensive drugs; assess for signs of coagulopathy; assess DTR and clonus every shift

Hospital management for patient with preeclampsia

Inject 0.5ml of air using sterile syringe while simultaneously listening for air bubble into the stomach with stethoscope over epigastrium; aspirate small amount of stomach contents and check ph (<3 acid)

How to test the placement of gavage feeding tube

Caused by: hyperparathyroidism, malignant bone disease, prolonged immobilization, excess supplementation; S&S: muscle weakness, constipation, anorexia, NV, polyuria, polydipsia, neurosis, dysrhythmias; level above 10.5meq/L; administer calcitonin; renal dialysis, avoid calcium based antacids.

Hypercalcemia

Provider may prescribe antihistamines, vitamin B6, or phenothiazines to relieve nausea; also provide metoclopramide (Reglan) to increase the rate at which the stomach moves food into the intestines or antacids to absorb stomach acid and help prevent acid reflux

Hyperemesis gravidarum

Encourage water intake, check blood glucose frequently; assess for ketoacidosis

Hyperglycemia nursing actions

Caused by hemolyzed serum sample produces pseudohyperkalemia, oliguria, acidosis, renal failure, Addison disease, multiple blood transfusions; S&S: muscle weakness, bradycardia, dysrhythmias, flaccid paralysis, intestinal colic, tall T waves, levels above 5.0meq/L; eliminate this from IC infusions and meds; administer 50% glucose with regular insulin; administer kayexalate; monitor ECG; administer calcium gluconate to protect the heart, IV loop diuretics, renal dialysis

Hyperkalemia

Caused by water deprivation, hypertonic tube feedings, diabetes insipidus, heat stroke, hyperventilation, watery diarrhea, renal failure, cushing syndrome; S&S: thirst, hyperpyrexia, stick mucous membranes, dry mouth, hallucinations, lethargy, irritability, seizures; level above 145meq/L; restrict sodium in diet, increase water intake

Hypernatremia

Results in respiratory alkalosis that is caused by blowing off too much CO2; dizziness, tingling of fingers, stiff mouth; have woman breathe into cupped hands or rebreath CO2

Hyperventilation

Headache, nausea, sweating, tremors, lethargy, hunger, confusion, slurred speech, tingling around mouth, anxiety, nightmares; occurs rapidly and is potentially life threatening; treat immediately with complex CHO; check BS

Hypoglycemia

Heel-stick blood glucose assessment on all SGA or LGA babies, on infants of diabetic mothers, on jittery babies, and on babies with high pitched cries; report any levels under 40; normal levels is 40-80; prevents cold stress which leads to this

Hypoglycemia

Caused by: alcoholism, malabsorption, DKA, prolonged gastric suction, diuretics; S&S: anorexia, distention, neuromuscular irritability, depression, disorientation; levels below 1.5meq/L; administer MgSO4 IV; encourage foods high in this

Hypomagnesemia

Caused by diuretic, GI fluid loss, hypotonic tube feedings, D5W or hypotonic IV fluids, diaphoresis; S&S: anorexia, NV, weakness, lethargy, confusion, muscle cramps, twitching, seizures; level below 135Meq/L; restrict fluids, administer IV solutions SLOW

Hyponatremia

Caused by refeeding after starvation, alcohol withdrawal, DKA, respiratory alkalosis; S&S: paresthesias, muscle weakness, muscle pain, mental changes, cardiomyopathy, respiratory failure; level below 2.0meq/L; correct underlying cause and administer oral replacements with vitamin D

Hypophosphatemia

Congenital defect of urethral meatus in males; urethra opens on ventral side of penis behind the glans

Hypospadias

Keep newborn dry and warm; place stockinette cap on the head because the head is the greatest place for heat loss through the scalp; newborn's temperature falls below 97, place the radiant warmer and apply skin temperature probe to regulate isolette temperature

Hypothermia

Leads to depletion of glucose and to the use of brown fat for energy; this results in ketoacidosis and possible shock. Prevent by keeping warm!!!

Hypothermia

Hypofunction of the thyroid gland, with resulting insufficiency of thyroid hormone; Hasimoto Disease, Myxedema

Hypothyroidism

Early detection is essential in preventing mental retardation

Hypothyroidism and PKU

Do not administer medications via these routes to a patient in shock until perfusion improves to the muscles and subcutaneous tissues

IM or Subcutaneous route

Contraindications: diabetes, anemia, abnormal pap, history of pelvic infections; high association with dysmenorrheal and infection

IUD

Onset: 5 minutes; peak: 30 minutes; Duration: 1 hour

IV administration

Preferred method for a client in labor because the onset and peak occur more quickly and the duration of the drug is shorter

IV administration of analgesics

Provides the most rapid onset (5 minutes) but has shortest duration (1 hour); useful for acute pain

IV bolus (IV push)

Belief that conversations or actions of others have reference to the client

Ideas of reference

Attempt to be like someone or emulate the personality, traits, or behaviors of another person; a teenage boy dresses and behaves like his favorite singer

Identification

Perform fundal massage; notify health care provider if the fundus does not become firm with massage; count pads to estimate blood loss; assess and record VS; increase IV fluids; oxytocin infusion

Immediate nursing actions for postpartum hemorrhage

No response, call a code; position on cardiac board; ventilate with O2 mask; initiate chest compressions; apply cardiac monitor "quick look" paddles to determine whether defibrillation is necessary; resume CPR after defibrillation

In hospital cardiac arrest

The main concern in the head injury; it is related to edema, hemorrhage, impaired cerebral autoregulation, and hydrocephalus

Increased ICP

Slight drop in temperature occurs 1 day before this; 0.5-1 degree rise occurs at ovulation and remains elevated for 10-12 days; cervical mucus is abdundant, watery, clear and more alkaline; cervical os dilates slightly, softens and rises in the vagina; spinnbarkeit (egg white stretchiness of cervical mucus) occurs; ferning is seen under microscope

Indications of ovulation

Hand washing; provide scrupulous cord care by swabbing the cord with alcohol at each diaper change or keep clean with mild soap and water; cover circumcision with petrolatum gauze and change gauze at each diaper change; don't allow visitors or personnel to attend to newborn if active infection is present or if newborn has diarrhea, open wounds and infectious, skin rash, or herpesvirus; encourage breast feeding for immunologic factors

Infection

May not be manifested with an elevated temperature in the immunocompromised patient; imperative that the nurse perform a total and thorough assessment of the client OFTEN

Infection

Assess:: site for redness, drainage, edema, or tenderness; vital signs; lab findings

Infection/phlebitis

Aseptic technique when starting IV lines; inspect all fluids and containers before use to be sure they have not been opened or contaminated; change administration sets according to policy; use a catheter that is smaller than the vein

Infection/phlebitis interventions

Hepatomegaly

Initial sign of cirrhosis

A metabolic disorder in which the insulin producing cells of the pancreas are nonfunctioning as a result of some insult; heredity, viral infections, and autoimmune processes are implicated; causes altered metabolism of carbohydrates, proteins and fats; insulin replacement, dietary management and exercise are the treatments

Insulin dependent diabetes mellitus (Type 1 diabetes)

Extreme desquamation - postmaturity; many visible veins - prematurity; meconium staining - fetal distress; cyanosis - heart disease, asphyxia; jaundice (within 24 hours) - blood incompatibilities, sepsis, drug reactions; vesicles - herpes, syphilis; café-au-lait spots -- neurofibromatosis

Integument: abnormal findings in the newborn

Smooth, elastic tugor and subcutaneous fat, superficial peeing after 24 hours; veins rarely visible; milia, vernix increases; lanugo, mottling; harlequin sign (pink-red skin o one side of body); erthema toxicum (pink popular rash), Mongolian spots, telangiectatic nevi

Integument: normal newborn norms

Interferon alpha-2a (roferon a), interferon alpha-2b (intron a); 2a - indicated for hairy cell leukemia, Kaposi sarcoma; 2b: indicated for chronic hepatitis B&C, Kaposi sarcoma, hairy cell leukemia

Interferon alpha products

Interferon beta -1a (avonex), interferon beta-1b (betaseron); indicated for relapsing multiple sclerosis, AIDS, Kaposi sarcoma, malignant melanoma, hepatitis C; adverse reactions: seizures, HA, weakness, insomnia, depression, suicidal ideation, hypertension, chest pain, vasodilation, edema, palpitations, dyspnea, NV, elevated liverfunction studies, GI disorders, myalgia, flu-like symptoms

Interferon beta products

Isophane insulin (NPH), insulin zinc suspension (humulin L); onset: 1-2 hours; peak: 6-12 hours; not to be given IV;

Intermediate acting insulin

Given in second stage of labor to deaden uterine and perineal pain; rapid onset, but highly associated with maternal hypotension which can cause maternal and fetal distress; client must remain flat for 6-8 hours after delivery

Intradural (subarachnoid, spinal) block

Acceptable method of managing acute, short-term pain; onset 30 min; peak effect 1-3 hours; duration of action: 4 hours

Intramuscular route for analgesic

Begins with true labor and consist of four stages

Intrapartum nursing care

Hypoxia causes vessel damage in the time periventricular capillaries, resulting in symptoms of increased ICP; seizures, decreased or absent reflexes, hypotonia, bulging fontanels, enlarged head circumference, setting-sun eyes, shrill cry, hypothermia, apnea, and bradycardia

Intravascular hemorrhage

Incorporation of values of qualities of an admired person or group into one's own ego structure; a young man deals with a business client in the same fashion his father deals with business clients

Introjection

Telescoping of one part of the intestine into another part of the intestine, usually the ileum into the colon; partial to complete bowel obstruction occurs; blood vessels become trapped in the telescoping bowel, causing necrosis

Intussusceptions

Telescoping of the gut within itself

Intussusceptions

treated with radiation, conization, hysterectomy or pelvic exenteration; chemotherapy is not useful for this type of cancer

Invasive cancer

Approximately 3 days before menstruation to onset of menstruation

Ischemic phase

Separation of an unacceptable feeling, idea or impulse from one's thought process; a nurse working in an ER is able to care for the seriously injured by isolating or separating her feelings and emotions related to the client's pain, injuries and death

Isolation

Increased dilantin levels

Isoniazid (INH)

Interfers with DNA metabolism of tubercle bacillus; side effects include NH, abdominal pain; rare but possible side effects include neurotoxicity, optic neuritis, and hepatoxicity; metabolism is in liver and excretion by kidneys; pyridoxine as prophylaxis; cross BBB

Isoniazid (INH)

Have an osmolality close to the ECF; don't cause RBCs to swell or shrink; normal saline (0.9%), lactated ringer (LR), 5% dextrose in water; used to treat intravascular dehydration; dehydration caused by running, labor, fever, etc.

Isotonic IV solutions

A surgical procedure in which a mechanical device, designed to act as a joint, is used to replace a diseased joint; most common joints: hip, knee, shoulder, finger; accurate fitting is essential; excellent pain relief; infection is a post-op concern

Joint replacement

Chronic inflammatory disorder of the joint synovium; single or multiple joints may be involved; systemic presentation; occurs between 2-5 years and 9-12 years

Juvenile rheumatoid arthritis/ juvenile idiopathic arthritis

Interferes with protein synthesis; side effects: ototoxicity, nephrotoxicity; use in selected treatment of resistant strains

Kanamycin (Kantex) & Amikacin

Purple-blue lesions on skin, often arms and legs; invasion of GI tract, lymphatic system, lungs and brain; opportunistic infection of HIV

Kaposi's Sarcoma

Determined down syndrome, other trisomies, and sex chromatin (sex-linked disorders)

Karyotype

Increase the integrity of the introitus and improve urine retention. Alternate contraction and relaxation of the pubococcygeal muscles

Kegal exercises

Inability to extend leg when thigh is flexed anteriorly at the hip

Kernig sign

Urine ketones; urine glucose; administer insulin as directed

Ketoacidosis assessment

Avoiding sunlight

Key management of Lupus erythematosus

Edema of the face, hands and feet; UTI; urinary retention

Kidney changes in diabetes mellitus

Bone marrow aspiration that reveals 80-90% immature blast cells

Lab data for Acute lymophocytic leukemia

Latex fixation test and elevated ESR

Lab data for Juvenile rheumatoid arthritis/ juvenile idiopathic arthritis

PTT is prolonged and factor assays less than 25%

Lab values for hemophilia

Positive enzyme-linked immunosorbent assay; confirmation by the western blot test

Laboratory testing for HIV

Ammonia detoxicant/stimulant laxative; implications are encephalopathy and used to decrease ammonia levels and bowel pH; adverse reactions: diarrhea; monitor ammonia levels

Lactulose (cephulac)

Indicated for partial seizures, tonic clonic seizures, and absence seizures; adverse reactions: dizziness, headache, nausea, rash; withhold drug if rash develops; don't discontinue abruptly

Lamotrigine (lamictal)

Used in biopolar disorder alone or with other mood stabilizers; adverse reactions include headache, dizziness, double vision, rash; give low doses initially then gradually include to 200mg/day

Lamotrigine (lamictal)

Predisposes the client to postoperative paralytic ileus. The bowel is manipulated during surgery, it creases peristalsis and this condition may persist

Laparomtomy

Used to treat cervical cancer when the lesion is small and localized

Laser therapy or cryosurgery

External beam radiation along with hysterectomy; antineoplastic chemotherapy; pelvic exenteration

Late carcinoma treatment

Associated with decreased or absent variability and tachycardia, the situation is ominous and requires immediate intervention and fetal assessment

Late or variable decelerations

From the beginning of true labor until 3-4cm cervical dilatation; mildly anxious, conversant; continue usual activities; contractions are milk, initially 10-20 minutes apart, 15-20 seconds' duration; later 5-7 minutes apart 30-40 seconds duration

Latent phase of the first stage of labor

Liver becomes large and nodular and hard

Later sign of cirrhosis

Indicated for bipolar disorders, especially manic phase; adverse reactions include nausea, fatigue, thirst, polyuria, fine hand tremors, weight gain, hypothyroidism; excreted by kidney, maintain levels 0.5-1.5; assess electrolytes esp. sodium, baseline studies of renal, cardiac and thyroid; keep salt usage consistent; use with diuretics is contraindicated

Lithium carbonate (carbolith)

Diarrhea, vomiting, drowsiness, muscle weakness, lack of coordination

Lithium toxicity

Thicker, whitish yellowish discharge with leukocytes and degenerated cells; lasts up to 4 weeks

Lochia alba

Blood tinged discharge, including shreds of tissue and deciduas; lasts 2-3 days postpartum

Lochia ruba

Prevention of thrombolytic formation (deep vein); hemorrhage, GI irritation, bleeding, thrombocytopenia; signs of bleeding, give SUBCU, monitor CBC, soft toothbrush

Low molecular weight heparin enoxaparin (lovenox)

Usually results in less postoperative pain, less bleeding and fewer incidents of ruptured uterus

Low transverse uterine incision

Placenta implants in the lower uterin segment with a placental edge lying near the cervical os

Lower lying placenta previa

Shift from the area of __ concentration to __ concentration

Lower; higher

Dry, hacking cough early, with cough turning productive as disease progresses; hoarseness; dyspnea; hemoptysis, rust colored or purulent sputum; pain in chest area; diminished breath sounds, wheezing; abnormal chest radiograph; positive sputum for cytology

Lung cancer nursing assessment

Rid the body of 300mL of fluid/day; play a role in acid-base balance; regulate CO2 concentrations

Lungs

Isocarboxazid (marplan), phenelzine sulfate (nardil), tranycypromine sulfate (parnate); indicated for depression, phobias and anxiety; adverse reactions include tachycardia, urinary hesitancy, constipation, impotence, dizziness, insomnia, muscle twitching, drowsiness, dry mouth, fluid retention, hypertensive crises; must not be used with tricyclics; dietary restrictions include restriction of high tyramine content such as aged cheese, red wine, beer, beef and chicken, liver, yeast, yogurt, soy sauce, chocolate, bananas; not to take over the counter drugs;

MAO inhibitors

1.5-2.5

Magnesium normal levels

CNS depressant administered to a preeclamptic client to prevent seizures, may be used as a tocolytic to stop preterm labor contractions; adverse reactions: CNS depression: depressed RR, depressed DTRs, decreased urine output, pulmonary edema; hold if RR <12 or urine output <100ml/4hr; DTRs absent; monitor levels; therapeutic range 5-8mg/dl; remind client of warm, flushed feeling with IV administration; keep calcium gluconate antidote

Magnesium sulfate

Given IV with loading dose of 4g in 100ml to 250ml solution; administer over 20-30 minutes to get blood level up to therapeutic serum level (5-8mg/dl);

Magnesium sulfate administration

Involves three systems: a chemical buffer system, kidneys, lungs

Maintaining acid-base balance

Position client in three quarters prone position or semiprone position to prevent tongue from obstructing airway and slightly to one side with arms away from chest wall; insert airway keep airway free of secretions; monitor arterial Po2 and PCO2; chest physiotherapy; hyperventilate before and after suctioning

Maintaining adequate respirations, airway, oxygenation

Flutamide (eulexin), Leuprolide (lupron), goserelin (zoladex); indicated for prostate cancers and testicular cancers; adverse reactions: HA, paresthesias, cardiac arrhythmias, NV, hypoglycemia, neuropathies; bone pain and voiding problems are possible

Male-specific hormonal agents

Creatine phosphokinase for adults

Male: 55-150; female: 30-135

ESR/SED rate mm/hr in adults

Male: up to 15; female up to 20

Position person supine, tap and call out are you okay?; no response = call for help, ask someone to call 911, obtain AED; extend neck with head-tilt, chin-lift; assess breathing sounds by look-listen-feel method; no breathing is noted = ventilate with 2 mouth-mouth breaths, assess circulation by palpating carotid pulse; no pulse = compressions at 100/min

Management of cardiac arrest unwitnessed; out of hospital

Acts on renal tubules by osmosis to prevent water reabsorption; in blood stream, draws fluid from the extravascular spaces into the plasma; adverse reactions: disorientation, confusion and headache, NC, convulsions and anaphylactic reactions; short term therapy only; never give to clients with cerebral hemorrhage; IV infusion is adjusted to urine output; filter urine and watch for crystals; never give to clients with no urine output, if urine output is <30ml/hr accumulation can cause pulmonary edema and water intoxication

Mannitol (osmitrol)

Osmotic diuretic used to reduce cerebral edema and postoperative swelling or trauma; adverse reactions: circulatory overlead, confusion, hypokalemia, hyponatremia; use in-line filter for IV administration, avoid extravasation; monitor I&O; lasix may also be prescribed

Mannitol (osmitrol)

Fundus is halfway between the umbilicus and xiphoid process; thoracic breathing replaces abdominal breathing; fetal outline is palpable; more introspective and concentrates interest on the unborn child; hemorrhoids and heartburn may begin

Maternal changes at 28 weeks

Lightening occurs; placenta weights 20oz; mother is eager for birth, may have burst of energy; backaches increase; urinary frequency increases; Braxton hicks contractions intensify

Maternal changes at 38 weeks

Nausea persists up to 12 weeks; uterus changes from pear to globular shape; hegar sign occurs; goodell sign occurs; cervix flexes; leucorrhea increases; ambivalence about pregnancy may occur; no noticeable weight gain; Chadwick sign occurs as early as 4 weeks

Maternal changes at 8 weeks

Due to disorders outside the bowel caused by disorders within the bowel or by blockage of the lumen in the intestine

Mechanical bowel obstruction

Yellow-green or gold yellow and may indicate fetal stress

Meconium stained fluid

Oxybutynin (ditropan), tolterodine (detrol); indicated as a GU smooth muscle relaxant (antispasmodic) used to treated uninhibited neurogenic bladder, reflex urogenic bladder - both are characterized by voiding symptoms of urgency, frequency, nocturia and incontinence; adverse reactions: increased susceptibility to UTI, GI distress, dry eyes, dry mouth, vision changes, dizziness, chest pain, drowsiness; administered orally, don't administer with other medications that have anticholinergic effects; may exacerbate reflux esophagitis; contraindicated in clients with untreated glaucoma or GI narrowing

Medications used in renal disorders

Meperidine HCL (Demerol), infliximad (remicade), methocarbamol (robaxin), cyclobenzaprine (flexeril); indicated as narcotic analgesic used to treat acute pain, non-narcotics to treat pain, stiffness and discomfort; adverse reactions: respiratory depression, NV, fever, chills, dizziness, nausea, drowsiness, chest pain, allergic response that would include rash, difficulty breathing etc. do not give if client has increased ICP, has duration of action of 2-4 hours; review history such as heart disease, thyroid disorders and use of MAOIs; remicade use can worsen TB

Medications used in skeletal disorders

Contains only meninges and spinal fluid and has less neurlogic involvement

Meningocele

A sac is present at some point along the spine

Meningocele and myelomeningocele

Profuse or prolonged menstrual bleeding; the most important factor related to benign uterine tumors; assess for signs of anemia

Menorrhagia

Composed of four phases: normal cycle is 21-45 days in length. Mean age is 12.87 years or 1-3 years after breast budding; pregnancy can occur after the very first menstrual cycle

Menstrual cycle

Days 1-5 of cycle; shedding of the endometrium occurs in the form of uterine bleeding

Menstrual phase

If fertilization did not occur, the corpus leuteum degenerates; estrogen and progesterone levels drops; endometrium becomes blood starved leading to onset of menstruation

Menstruation

Chin

Mentum

PO - 15 min onset; IM -10-15 min onset; IV - 1 min onset; use by persons allergic to morphine; extreme caution in clients with impaired renal function because its active metabolite accumulates in renal failure; Signs of toxicity such as hyperirritability; less likely to cause smooth muscle spasm than other narcotics

Meperidine HCL (Demerol)

Addition of large amounts of fixed acids to body fluids; caused by lactic acidosis (circulatory failure), ketoacidosis (diabetes, starvation), phosphates and sulfates (renal disease), acid ingestions, secondary to respiratory alkalosis, adrenal insufficiency

Metabolic acidosis

Uterine stimulant; indicated for uterine atony; adverse reactions: hypertension; usual dose: 0.2mg IM followed by tabs of 0.2mg q4-6 hours; use with caution in clients with elevated BP or preeclampsia; take BP prior to administration and if 140/90 or above, notify MD

Methylergonovine maleate (methergine)

Problem identification; beginning of problem solving; beginning of the group sense of "we"

Middle/working phase in group intervention

Associated with daily life; motivates learning; produces increased levels of sensory awareness and alertness; thoughts that are logical; able to concentrate and problem solve

Mild anxiety

Feeling of being on a high; feelings of well being; minor alterations in habits; usually doesn't seek treatment because of pleasurable effect

Mild bipolar disorder

Feelings of sadness; difficulty concentrating and performing usual activities; difficult maintaining usual activity level

Mild depression

Bp rise to 30mmHg systolic and 15mmHg diastolic over previous baseline, or 140/90 or greater; presence of associated conditions; weight gain >1+; edema around the eyes, face and fingers; hyperreflexia 3+; CNS symptoms such as possible mild headache, slight irritability; IUGR, evidence by size date discrepancy

Mild preeclampsia

Planned use of people, resources, and activities in the environment to assist in improving interpersonal skills, social functioning and performing the activities of daily living; focus on here and now; use limit setting; involves the client in making decisions about his/her own care; activities that support group sharing, cooperation and compromise

Milieu therapy

Needs to be work 23/24 hours; wear a t-shirt under the race to decrease skin irritation; check skin for areas of irritation or breakdown; clothing modifications to camouflage brace; reinforce prescribed exercise for back and abdominal muscles

Milwaukee brace

Fetus is dead; placenta atrophied but passage of products of conception has not occurred; cervix is closed; treated with watchful waiting, check clotting factors and possibly terminate pregnancy to lessen the changes for developing DIC

Missed abortion

Paclitaxel (taxol), docetaxel (taxotere); indicated for breast cancer, ovarian cancer, on-small-cell-lung cancer, Kaposi sarcoma; adverse reactions: decreased WBCs & RBCs, alopecia, NVD, joint, muscle pain; monitor for S&S of infection; administer antiemetics and antidiarrheals

Mitotic inhibitors

Muscle tissue

Myo

Can be precipitated by an acute illness, withdrawal of thyroid medication, anesthesia, use of sedatives, or hypoventilation (with the potential for respiratory acidosis and carbon dioxide narcosis). The airway must be kept patent and ventilator support is used as indicated; hypotension, hyponatremia, hypoglycemia, respiratory failure

Myxedema Coma

Inhibit prostaglandin and other chemical mediator syntheses and other chemical mediator synthesis involved in pain; antipyretic activity through action on the hypothalamic heat-regulating center to reduce fever

NSAIDS

Perceives self as all powerful and important, is critical of others, arrogant; exaggerated feeling of self importance and self-love; needs attention and admiration; preoccupied with per ad appearance; exploits others; verbally talks about self incessantly and does whatever necessary to draw attention to self; nonverbally is inattentive and indifferent to others, appears concerned only with self

Narcissistic personality disorder

Counteract narcotic effects; withdrawal symptoms if administered after client has been receiving narcotics; produce side effects including drowsiness, nausea, psychomimetic effect, hallucinations, euphoria

Narcotic agonists and antagonists

Act as opioids, binding with specific opiate receptors throughout the CNS to reduce pain perception; cause such side effects as nausea and vomiting, constipation, respiratory depression, and CNS depression

Narcotics

Irritability, hyperactivity; high-pitched cry; coarsem flapping tremors; poor feeding, frantic sucking, VD; nasal stuffiness; swaddle and minimize handling; decrease environmental stimuli; provide pacifier; prone position with sheepskin; cover elbows and knees to prevent skin breakdown; bulb syringe close at hand

Narcotics neonate effects

Attach to low suction (intermittent 80mmHg); document output every 8 hours; irrigate with normal saline

Nasogastric intubation

Hypoxic-ischemic injury to the mucosa of the intestinal tract that results in abdominal distension, sepsis, and nutritional impairment; caused by neonatal hypoxia

Necrotizing entercolitis

Laboratory diagnosis: smears, cultures; symptoms: females: majority are asymptomatic; males: dysuria, yellowish-green urethral discharge, urinary frequency; treated with ceftriaxone sodium plus doxycycline hyclate or streptomycin HCL plus doxycycline hyclate

Neisseria gonorrhoeae, Gonorrhea

Ventilations are done over the mouth and nose; palpate brachial pulse in infant <1 years; HR under 60 = compressions are done with thumbs side by side over the lower third of the sternum; compression to ventilation ratio of 3:1 (90 compressions; 30 breaths)

Neonatal resuscitation

Infections can be overwhelming in the neonate because of the immature immune system

Neonate with sepsis

A new formation

Neoplasm

A disorder in which the basement membrane of the glomeruli becomes permeable to plasma proteins; most often idiopathic in nature; occurs between the ages of 2-3; involve execration and remissions over several years

Nephrotic syndrome

The cause is usually idiopathic; edema is severe and generalized; blood pressure is normal; urine is a dark frothy yellow color with massive proteinuria; blood has a decreased serum protein and a negative ASO titer

Nephrotic syndrome

Blocks motor as well as nerve fibers. Vasodilation below the level of the block results in blood pooling in the lower extremities, causing maternal hypotension. 20 min prior to this, the client should be hydrated with 500-1000mL lactated ringers solution IV; monitor maternal vital signs and FHR q15min

Nerve block anesthesia

Treatment of acutely decompensated HF in clients who have dyspnea at rest of with minimal activity; reduces PCWP and reduces dyspnea; adverse reactions: hypotension is primary side effects and can be dose limiting, arrhythmias, HA, dizziness, insomnia, tremors, paresthesias, abdominal pain, NV; monitor BP, monitor K+; watch for over-response to treatment

Nesiritide (natrecor)

Treatment of acutely decompensated HF in clients who have dyspnea at rest or with minimal activity, and reduces PCWP and reduces dyspnea; hypotension is primary side and can be dose limiting, arrhythmias, HA, dizziness, insomnia, tremors, paresthesias, abdominal pain, NV

Nesiritide (natrecor)

Paralytic ileus and spinal cord lesion

Neurogenic causes of intestinal obstruction

Life threatening emergency: high fever, tachycardia, stupor, increased RR, severe muscle rigidity; increased risk with phenothiazines; early recognition is important; transfer to medical facility for hydration, nutritional support, and treatment of respiratory failure and renal failure

Neuroleptic malignant syndrome

Atrophy of hands and feet; neuropathies with symptoms of numbness, tingling, pain, burning

Neuromusculature changes in diabetes mellitus

Care provided to the newborn, usually performed by the nurse

Newborn care

Treatment of burns, used to prevent infections, interferes with bacterial enzymes; adverse reactions: allergic contact dermatitis; may see superinfections; administer pain medications prior to dressing change; monitor S&S of infection

Nitrofurazone (furacin)

Efavirenz (sustiva), Delavirdine (Rescriptor), Nevirapine (Viramune), Amprenavir (Agenerse); Indications are HIV infection; classification used in various combinations to reduce viral load and slow development of resistance; adverse reactions: CNS changes, nausea, rash, increase in triglycerides, hepatotoxicity; monitor liver function tests; reduce contraceptive effects

Non-NRT inhibitors

Severe variable decelerations and late decelerations

Non-reassuring (Ominous) signs

Variability, bradycardia, tachycardia, variable deceleration pattern

Non-reassuring warning signs

Aspirin, Ibuprofen, indomethacin, ketorolac tromethamine, celecoxib (celebrex), etodolac (lodine), diclofenac (voltaren), naproxen; antiinflammtory, antipyretic, analgesic; adverse reactions: GI irritation, bleeding, NV, constipation, elevated liver enzymes, prolonged coagulation time, tinnitus, thrombocytopenia, fluid retention. Nephrotoxicity, blood dyscrasias; take with food or milk to reduce GI symptoms; watch for signs of bleeding; avoid alcohol; administer corticosteroids for severe RA; reduce the effect of ACE inhibitors in hypertensive clients; check renal/liver labs and CBC routinely

Non-steroidal anti-inflammatory drugs (NSAIDs)

Fragments alinged at fracture site

Nondisplaced fracture

Due to paralytic ileus, which doesn't involve any actual physical obstruction but results from inability of the bowel itself to function

Nonmechanical bowel obstruction

Holoperidol (haldol), chlorprothizene (taractan), thiothixene HCL (navene), primodide (orap); indicated to control psychotic bejhavior, less sedative than penothiazines; adverse reactions include severe extrapyramidal reactions, leukocytosis, blurred vision, dry mouth, urinary retention; teach to avoid alcohol; orap is used only for touretts syndrome

Nonphenothiazines

Low-fat diet, medications for pain and clotting, decompression of stomach via NG tube

Nonsurgical management of a client with cholecystitis

Indicated for dilated coronary arteries and causes peripheral vasoconstriction for emergency hypotensive states not caused by blood loss, vascular thrombosis, or anesthesia using cyclopropane or halothane; adverse reactions: can cause severe tissue necrosis, sloughing and gangrene if infiltrates; rapidly inactivated by various body enzymes; use cautiously in previously hypertensive clients; check BPq2-5min; large veins to avoid complications; pressor effects potentiated by many drugs; have phentolamine diluted per protocol for local injection if infiltrates

Norepinephrine bitratrate (levophed)

22-26

Normal HCO3 range

35-45

Normal PCO2 range

8.5-10.5

Normal calcium levels

This normally occurs in postpartum period but it can pose serious problems to the new mother with cardiac disease because of increased cardiac output

Normal dieresis

At delivery: maternal vascular bed is reduced by 15%. Pulse decreases to 50, hypothesized results to shivering, BP and pulse return to pre-pregnant levels; First 72 hours: 24-48 hours postpartum, CO is elevated and will return to normal with 2-3 weeks, plasma loss> RBC loss, diaphoresis occurs at night to restore normal plasma level

Normal postpartum changes: cardiovascular system

Uterus: myometrial contractions occur for 12-24 hours post-delivery, involution occurs 1-2 cm/day, placenta site contracts and heals without scarring; Cervix: becomes parous with a transverse slit, heals within 6 weeks; vagina: rugae reappear within 3 weeks, walls are thin and dry; breasts: nonlactating: nodules are palpable, engorgement occurs 2-3 days postpartum. Lactating: milk sinuses are palpable, colostrums is expressed first then milk, breasts may feel warm, firm, tender for 48 hours

Normal postpartum changes: reproductive system

Dieresis occurs; excretes up to 3000ml/day; bladder distention and incomplete emptying are common; persistent dilatation of ureter and renal pelvis increase risk for UTI; urine glucose, creatinine and BUN levels are normal after 7 days

Normal postpartum changes: urinary system

3.5-5.0

Normal potassium levels

An isotonic solution and is used for irrigations, such as bladder irrigations or IV flush lines with intermittent IV medications

Normal saline

Use only this product to flush IV tubing or to run with blood. Never add medications to blood products; two RNs should check physicians prescription, client's identity and the blood bag label

Normal saline

9.0 to 10.5 mEq/L; the best indicator of parathyroid problems is a decrease in the client's calcium compared to the preoperative value

Normal serum calcium levels

135-145

Normal sodium levels

Sustained-release, subdermal, progestin only contraceptive; six thin, flexible capsules made of soft silastic tubing; planed in a fanline pattern just beneath the skin of the upper arm; effective within 24 hours after insertion, effective for 5 years; not dependent on clients compliance; reversible with return to previous level of fertility after removal; menstrual pattern changes, headache, nervousness; works by suppression of ovulation as well as by thickening the cervical mucus

Norplant (levonorgestrel implant)

Change maternal position; stimulate fetus if indicated; discontinue oxytocin if infusing; administer oxygen at 10 liters by tight face mask; perform a vaginal exam to check for cord prolapse

Nursing actions for variable decelerations

Turn client to the side; discontinue oxytocin if infusing; check scalp stimulation for accelerations; oxygen by 10 liters by tight face mask; fetal blood sampling; maintain IV; elevate legs to increase venous return; correct any underlying hypotension by increasing IV rate or with prescribed medications

Nursing actions of late decelerations

Recent streptococcal infection; mild to moderate edema that is often confined to the face; irritability, lethargy; hypertension; dark colored urine; slight to moderate proteinuria; elevated antistreptolysin titer, elevated BUN/creatinine

Nursing assessment for Acute glomerulonephritis

Diarrhea or constipation, abdominal pain and bloating; dental damage; sore throat and chronic inflammation of esophageal lining with possible ulceration; financial stressors r/t food budget; concerns with body shape and weight - usually not underweight

Nursing assessment for Bulima nervosa

Paresthesia, muscle weakness of legs progressing to the upper extremities, trunk and face; paralysis of the ocular, facial and oropharynheal muscles, causing marked difficulty in talking; breathlessness while talking, shallow and irregular breathing; accessory muscle usage; change in respiratory pattern; paradoxic inward movement of the upper abdominal wall ; increasing pulse rate and disturbances in rhythm; hypertension, orthostatic hypotension; pain in the back and in calves of the legs; weakness or paralysis of the intercostals and disaphragm muscles

Nursing assessment for Guillain-barre syndrome

Enlarged lymph nodes; anemia, thrombocytopenia, elevated leukocytes, decreased platelets; fever, increased susceptibility to infections; anorexia, weigh loss; malaise, bone pain; night sweats

Nursing assessment for Hodgkin disease

Polydipsia, polyphagia, polyuria, enuresis; irritability, fatigue, weight loss, abdominal complaints, nausea, and vomiting; usually occurs in school age children

Nursing assessment for IDDM

Prodomal labor signs such as lightening, Braxton hicks contractions, cervical softening and slight effacement, bloody show or expulsion of mucous plug, and burst of energy "nesting"; gravidity and parity; gestation age; FHR; maternal VS; contraction characteristics; vaginal exam to determine fetal position, cervical dilatation, effacement, position and consistency as well as fetal station; assess for status of membranes, comfort level, labor and delivery preparation, presence of support person, presence of true or false labor

Nursing assessment for Intrapartum nursing care

Pallor, paleness of mucous membranes; tiredness, fatigue; seen in infants 6-24 months and toddlers/female adolescents are more affected; overweight " milk baby"; dietary intake low; milk intake greater than 32 oz/day; pica habit;

Nursing assessment for Iron deficiency anemia

Joint swelling and stiffness; painful joints; generalized symptoms such as fever, malaise, rash; periods of exacerbations and remissions; varying severity

Nursing assessment for Juvenile rheumatoid arthritis/ juvenile idiopathic arthritis

History of symptoms, pregression of illness, types of treatment received and the responses, additional health problems; current medications; client and family's perception of illness; community resources used by client; optic neuritis; visual or swallowing difficulties; gait disturbances, intention tremors; unusual fatigue, weakness and clumsiness; numbness on one side of the face; impaired bladder and bowel control; speech disturbances; scotomas

Nursing assessment for MS

Respiratory distress: lung immaturity, lack of surfactant lining alveoli, immature respiratory center, PDA; temperature instability: insufficient SUBCU fat, larger ratio of body surface area to body weight, extended open body position, immature hypothalamus; nutrition problems: poorly developed suck, small stomach, immature digestions process, hypoglycemia, anemia, hyperbilirubinemia; fluid and electrolyte problems: limited concentration/excretion ability of kidneys, metabolic acidosis, hypocalcemia (<7mg/dl); Immunologic immaturity: no IgM antibodies, no phagocytosis, thin skin barrier, intraventricular hemorrhage

Nursing assessment for Preterm newborn

Usually occur between 4-12 years of age; last 5-10 seconds; appears to e inattentive, day dreaming; poor performance in school

Nursing assessment for absence seizures

Unusual appearing anal dimple; newborn who doesn't pass meconium within the first 24 hours; meconium appearing from perineal fistula or in urine

Nursing assessment for anorectal malformations

Headache that is more severe upon awakening; vomiting not associated with nausea; papilledema with visual changes; behavioral and personality changes; serizures; aphasia, hemiplegia, ataxia; cranial nerve dysfunction; abnormal CAT scan

Nursing assessment for brain tumors

History of upper respiratory symptoms; irritable, distressed infant; paroxysmal coughing; poor eating; nasal congestion; nasal flaring; prolonged expiratory phase of respiration; wheezing, rales can be auscultated; shallow, rapid respirations

Nursing assessment for bronchiolitis

MRI, direct laryngoscopy, hoarseness >2weeks, color changes in the mouth or tongue, radiographs of head neck and chest, CT scan of neck and biopsy; assess for dysphagia, dyspnea, cough, hemoptysis, weight loss, neck pain radiating to the eat, enlarged cervical nodes, halitosis

Nursing assessment for cancer of the larynx

Early signs: blurred vision, decreased in color perception; late signs: diplopia, reduced visual acuity, progressing to blindness; coulded pupil, progressing to a milky-white appearance

Nursing assessment for cataract

Persistent neonatal reflexes after 6 months; delayed developmental milestones; poor suck, tongue thrust; spasticity; scissoring of legs; involuntary movements; seizures

Nursing assessment for cerebral palsy

Elective or repeat cesarean birth scheduled; performed to prevent harm to mother or fetus

Nursing assessment for cesarean births

Murmur; cyanosis, clubbing of the digits; poor feeding, poor weight gain, failure to thrive; frequent regurgitation; frequent respiratory infections; activity intolerance, fatigue; assess quality and symmetry of pulses; BP of upper and lower extremities;; history of maternal infection during pregnancy

Nursing assessment for children with congenital heart disease

Changes in breathing pattern, use of accessory breathing muscles, cyanosis of lips, mucous membranes, face, nail beds; cough; higher CO2 than average; Low O2; decreased breath sounds; coarse crackles in lung fields that disappear after coughing; dyspnea, orthopnea; poor nutrition; activity intolerance

Nursing assessment for chronic airflow limitation

Determine degree of suspiciousness and mistrust of others; assess degree of anxiety; determine whether delusions are present such as reference or control, persecution, grandeur, somatic; assess degree of insecurity

Nursing assessment for cluster A: paranoid personality disorders

Physical fighting, running away from home, lying, stealing, cruelty to animals, frequent truancy, vandalism, arson, use of alcohol or drugs

Nursing assessment for conduct disorder

Infant: positive ortolani sign, unequal folds of skin on buttocks and thigh, limited abduction of the affected hip, unequal leg lengths; older child: limp on affected side and trendelenburg sign

Nursing assessment for congenital dislocated hip

Tachypnea, shortness of breath; tachycardia; difficulty feeding; cyanosis; grunting, wheezing, pulmonary congestion; edema of the face, eyes of infants, weight gain; diaphoresis; and hepatomegaly

Nursing assessment for congestive heart failure

Meconium ileus at birth in 10-20% of cases; recurrent respiratory infection; pulmonary congestion steatorrhea; foul-smelling bulky stools; delayed growth and poor weight gain; skin that tastes salty when kissed; cyanosis, nail bed clubbing and CHF

Nursing assessment for cystic fibrosis

Determine degree of suspicious and mistrust; degree of anxiety; determine if delusions are present, reference or control, persecution, grandeur, somatic; determine degree of insecurity

Nursing assessment for delusional disorder

Determine exogenous/endogenous; degree of depression; current suicide risk; arrange for lab tests such as dexamethasone suppression test and biogenic amines test

Nursing assessment for depression

History of exposure to pathogens, contaminated food, dietary changes; signs of dehydration; larboratory signs of acidosis; signs of shock

Nursing assessment for diarrhea

Possible absence of early symptoms of pregnancy; missed period; full feeling in the lower abdomen, lower quadrant tenderness; positive pregnancy test; signs of acute rupture: vaginal bleeding, adnexal or abdominal mass, sharp unilateral or bilateral pelvic pain; abdominal pain, referred shoulder pain, syncope, shock

Nursing assessment for ectopic pregnancy

Determine type of injury and symptoms; slit lamp examination; instillation of flurosecein to detect corneal injury; testing of visual acuity for medical documentation and protection

Nursing assessment for eye trauma

Early signs: increase in intraocular pressure, >22mmHg; decreased accommodation or ability to focus; late signs: loss of peripheral vision, seeing halos around lights, decreased visual acuity not correctable with glasses, headache or eye pain

Nursing assessment for glaucoma

Enlarged thyroid gland, weight loss, increased appetite, diarrhea, heat intolerance, tachycardia, palpitations, increased BP, diaphoresis, wet or moist skin, nervousness, insomnia, exophthalmost, T3>220, T4>12, low level of TSH, radioactive iodine uptake and thyroid scan indicate the presence of a goiter.

Nursing assessment for hyperthyroidism

Fatigue; thin, dry hair, dry skin; thick, brittle nails; constipation; bradycardia, hypotension; goiter; periorbital edema, facial puffiness; cold intolerance; weight gain; dull emotions and mental processes

Nursing assessment for hypothyroidism

Multiple sex partners; previous history of STD or vaginal infections; employment involving high exposure to infection; nonspecific symptoms such as fever or malaise; general symptoms of STDs such as vaginal discharge, genital lesions, dysuria, and dyspareunia; lab studies show antibody titers, TORCH, VDRL, RPR, gonorrhea screen, vaginal wet mouth

Nursing assessment for infections

Coping styles such as repression, isolation, undoing; magical thinking; destructive, hostile, aggressive and delusional thought content; difficulty with interpersonal relationships; interference with normal activities; safety issues involves in repetitive performance of the ritualistic activity; recurring intrusive thoughts; recurring, repetitive behaviors that interfere with normal function

Nursing assessment for obsessive compulsive disorder

Argumentativeness, blaming others for own problems, defying rules and authority, using obscene language, acting resentful, vindictive

Nursing assessment for oppositional defiant disorder

Limited attention span, confusion and disorientation, impaired judgment; delusions, visual hallucinations or sensory illusions, labile affect, sudden anger, anxiety and depression, loss of recent and remote memory, confabulation, impaired coordination, increased psychomotor activity, slurring speech, decreased personal hygiene, sleep deprivation, day-night pattern reversal. Incontinence and constipation

Nursing assessment for organic disorders

Tachypnea; abrupt onset of fever with shaking and chills; productive cough with pleuritic pain; rapid, bounding pulse; pain and dullness to percussion over the affected lung area; bronchial breath sounds, crackles; infiltrates with consolidation or pleural effusion; elevated WBC; ABG indication of hypoxemia.

Nursing assessment for pneumonia

Child found near source; GI disturbances such as NVD and abdominal pain, burns of mouth or pharynx, respiratory distress, seizures, changes in LOC, cyanosis, shock

Nursing assessment for poisoning

Anxiety; level of proportional to the perceived degree of threat experienced by the client; manifested by symptomatic behaviors such as intrusive thoughts, flashbacks of experience, nightmares, and emotional detachment; response such as shock, anger, panic, denial; self-destructive behavior; visible reminders of trauma

Nursing assessment for post-traumatic stress disorder

Predisposing conditions: multiparity, pelvic tearing during childbirth, vaginal muscle weakness, obesity; symptoms associated with uterine prolapse: dysmenorrheal, dragging sensation in pelvic and back, dyspareuria; symptoms associated with cystocele: incontinence or stress incontinence, urinary retention, bladder infections; symptoms associated with rectocele: cosstipation; hemorrhoids; sense of pressure; need to defecate

Nursing assessment for prolapse, cystocele, and rectocele

Usually occurs in first born males; vomiting (free of bile) usually begins after 14 days of life and becomes projectile; hungry, fretful infant; weight loss; failure to gain weight; dehydration with decreased sodium and potassium; metabolic alkalosis; palpable olive shaped mass in URQ of the abdomen; visible peristaltic waves

Nursing assessment for pyloric stenosis

No contracindications; experiencing severe pain; possible need for C-section; BP >100/70; status of maternal fetal unit

Nursing assessment for regional blocks

Preoccupation with pain or bodily function for at least 6 months' duration; frequent doctor shopping; absence of emotional concern regarding the physical impairment; report excessive dysmenorrheal; VS may be elevated as in a panic attack; fear of having serious disease; excessive use of analgesics; rumination about physical symptoms; drug abuse; depression and presence of suicidal ideation; social or occupational impairment;

Nursing assessment for somatoform disorders

Presence of sac in myelomeningocele is usually lumbar or lumbosacral; flaccid paralysis and limited or no feeling below the defect; head circumference at variance with norms on growth grids

Nursing assessment for spina bifida

Weak cry, cyanosis worsening with crying; lethargy, hypotonia and flaccidity; persistent bradycardia or tachycardia; tachypnea or other signs of respiratory distress; decreased or absent femoral pedal pulses

Nursing assessment for the newborn with congenital heart disease

Aura; loss of consciousness; generalized stiffness of entire body; apnea, cyanosis; spasms followed by relaxation; pupils dilated and nonreactive to light; incontinence; post-seizure disoriented, sleepy

Nursing assessment for toninc clonic seizures

Often asymptomatic; symptoms include: fever with night sweats, anorexia, weight loss, malaise, fatigue, cough, hemoptysis, dyspnea, pleurtic chest pain with inspiration, cavitation or calcification, positive sputum culture

Nursing assessment for tuberculosis

Fatigue, weakness; weight loss, anorexia, nausea, vomiting; postural hypotension; hypoglycemia; hyponatremia; hyperkalemia; hyperpigmentation; sighs of sock; loss of body hair; Hypovolemia

Nursing assessment of Addison disease

Absence of BS indicating paralytic ileus; radically decreased urinary output in the first 72 hours after injury, increased SG; radically increased UOP (dieresis) 72-2 weeks after initial injury; inadequate hydration; signs of inhalation burn

Nursing assessment of Burns

Risk factors: Rh incompatibility, ABO incompatibility, induction using oxytocin because of IUGR, prematurity, sepsis, perinatal asphyxia, maternal diabetes or intrauterine infections, cephalhematoma; jaundice; total bilirubin determinations increase >5mg/day; positive direct comb test; increased reticulocyte count; anemia; urine and stools are dark

Nursing assessment of Hyperbilirubinemia

Coping styles such as displacement, projection, repression, sublimation; autonomic hyperactivity; panic attacks that usually peak at 10 minutes but can past up to 30 minutes; disruption is personal life as well as work life; alcohol and drugs to decrease

Nursing assessment of Panic disorders and phobias

Mass in the flank area, confined to midline; often discovered by parents when bathing child; fever; pallor, lethargy; elevated BP; hematuria

Nursing assessment of Wilms Tumor (Nephroblastoma)

Known exposure to hepatitis; recent transfusions or hemodialysis; fatigue, malaise, weakness; anorexia, NV; jaundice, dark urine, clay-colored stools; myalgia, joint pain; dull headaches, irritability, depression; abdominal tenderness in the right upper quadrant; fever; elevations in liver enzymes and bilirubin

Nursing assessment of a patient with hepatitis

Gestational age of 20 weeks or less; fetal viability absent; uterine cramping, backache, and pelvic pressure; vaginal, bright red bleeding

Nursing assessment of a spontaneous abortion

Absence of classic signs; ill, with generalized symptoms; poor feeding; vomiting, irritability; bulging fontanel; seizures

Nursing assessment of bacterial meningitis for infants

Menorrhagia; dysmenorrheal; uterine enlargement; low back pain and pelvic pain

Nursing assessment of benign tumors of the uterus

Sudden onset of abdominal pain, tenderness or guarding; history of abdominal surgeries; history of obstruction; distention; increased peristalsis when obstruction first occurs, then peristalsis becoming absent when paralytic ileus occurs; bowel sounds that are high-pitched with early mechanical obstruction and diminished to absent with neurogenic or late mechanical obstruction

Nursing assessment of bowel obstruction

Hard lump that is not freely movable and not painful; dimpling of the skin; retraction of nipple; alterations in contour of the breast; change in skin color; change in skin texture; discharge from the nipple; pain and ulcerations; mammogram; biopsy and frozen section

Nursing assessment of breast cancer

Kid just "looks bad;" very slow or very rapid RR, dyspnea, apnea, gasping; tachycardia; cyanosis, pallor, or mottled color; irritability and lethargy; retractions, nasal flaring, poor air movement; hypoxemia, hypercapnia, respiratory acidosis

Nursing assessment of child in respiratory failure

Hx of alcohol and street drugs, work history of exposure to toxic chemicals, medication history of long term use of hepatotoxic drugs; family history

Nursing assessment of cirrhosis

Weakness, malaise, anorexia, weight loss, palpable liver, abdominal girth increases as liver enlarges, jaundice, fector hepaticus, asterixis, mental and behavioral changes, bruising, erythema, dry skin, spider angiomas, gynecomastia, testicular atrophy, ascites, peripheral neuropathy, hematemesis, palmar erythemia

Nursing assessment of cirrhosis

Child <1year; acute, intermittent abdominal pain; screaming with legs drawn up to abdomen; vomiting; "currant jelly stools: mixed with blood and mucus; sausaged shaped mass in URQ which LRQ is empty

Nursing assessment of intussusceptions

Maternal history and labor data indicating potential problems with newborn; apgar scores; brief physical examination performed in delivery room

Nursing assessment of newborn

Asymptomatic in early stages; laparotomy is the primary tool for diagnosis and staging of the disease; pelvic discomfort; low back pain; weight change; abdominal pain; NV; constipation; urinary frequency

Nursing assessment of ovarian cancer

Adolescent females 10-15 years old are more frequently affected; elevated shoulder or hip; head and hips are not aligned; a rib hump is apparent when bending forward

Nursing assessment of scoliosis

African decent, usually over 6 months; parents with trait or disease; frequent infections; tiredness; chronic hemolytic anemia; delayed physical growth; vaso-occlusive crisis; leg ulcers; cerebral vascular accidents; Hgb electrophoresis

Nursing assessment of sickle cell anemia

Assess breathing pattern, auscultate lungs; chest neuro-vital signs and cardiac status frequently; assess abdomen for girth, bowel sounds, assess lower abdomen for bladder distention; assess temperature; assess psychosocial status; hypotention and bradycardia are associated with injuries above T6

Nursing assessment of spinal cord injury

Early signs: subtle and usually go unnoticed; feeling of heaviness of dragging in lower abdomen and groin; lump or swelling on the testicle; late change: low back pain, weight loss, fatigue

Nursing assessment of testicular cancer

Review L&D report of neonatal history to determine risks during newborn transition caused by medical and obstetric complications such as C-section, prematurity, diabetic mother, prolonged rupture of membrane, Rh isoimmunization, traumatic delivery; drugs used in labor and delivery; risks during newborn transition caused by degree of birth asphyxia; apgar scores at 1and5 minutes; significant social history of mom; VS q30minx2hours then q1hrx5hours; measure the neonate; physical examination of the newborn; neuromuscular assessment; gestational age assessment; behavioral assessment

Nursing assessment of the newborn

Sigs of placental separation: lengthening of umbilical cord outside vagina, gush of blood, uterus change from oval to globular; full feeling in vagina; firm uterine contractions continue

Nursing assessment of the third stage of labor

8-10 hours of sleep; self administration of heparin; diet plan: high iron, high protein, and adequate calorie intake; notify doctor at first signs of infection

Nursing care for cardiac maternity client: antepartum

Continue semi-fowler position with side-lying position; progress ambulation: dangling, sitting, standing, short to long ambulation according to tolerance and absence of symptoms; stool softeners; watch for signs of urinary infection; report any signs of cardiac decompensation

Nursing care for cardiac maternity client: postpartum

Isolate child during period of communicability; treat fever with non-aspirin product; report occurrence to the health department; prevent child from scratching skin; administer diphenhydramine HCL (Benadryl) for itching; wash hand after caring for child and handling secretions or child's articles

Nursing care for children with communicable diseases

If planned, encourage couple to attend cesarean birth class; emergency: informed consent, including health care provider's explanation of risks, benefits, and alternatives to surgery; anesthesiologist of need for preoperative assessment; assist with anesthesia; preoperative mediations; shave abdomen from xiphoid to one quarter a way down the thigh; foley catheter; type and cross match for unit packed RBCs, CBC and chemistry; catheterized or clean catch analysis; remove: dentures, contact lenses, rings, fingernails polish and support person

Nursing care for client with cesarean births: before

Receive complete report; fundal height and consistency assessment; assess temperature q hour in recovery, then q4hx24hours; HR, RR, breath sounds, bowel sounds, and SaO2; pain medications; demonstrate splinting abdomen, coughing, deep breathing, and use of IS; aseptic technique to prevent sepsis;

Nursing care for client with cesarean births: cesarean birth

Place wedge under one hip to displace uterus laterally; keep client warm with warm blankets; monitor and document fetal heart tones continuously; grounding pad to leg; perform abdominal scrub

Nursing care for client with cesarean births: intraoperative care

Share room with others of the same age; illnesses, treatments and procedures that alter the body image can be viewed by the adolescent as being devastating; teaching about procedures should include time without the parents being present; need consent for treatment; need to maintain identity; focus should be on the here and now

Nursing implications for 12-19 years old

More support from parents than they wish to admit; contact with peers and school activities is important during hospitalization; explanation of all procedures is important; learn verbal explanations, pictures and books and by handling equipment; privacy and modesty are important and should be respected; participation in care and planning with staff fosters a sense of involvement and accomplishment

Nursing implications for 6-12 years

Emphasize understanding of the child's egocentricity; questions should be answered at the child's level, use simple words; therapeutic play and medical play that allows the child to act out his or her experiences is helpful; fear of mutilation by procedures is common; handle equipment or models of the equipment

Nursing implications for a child 3-5 years

Brief explanations before procedures; enforced separation from parents is the greatest threat to the toddlers psychological and emotional integrity; security objects or favorite toys from home should e provided for a toddler' expect regression; learning names of body parts; provide choices

Nursing implications from 1-3 years

Sit upright and bend slightly forward to promote breathing; teach diaphragmatic and pursed lip breathing; O2 at 1-2L NC; pace activities; adequate dietary intake, adequate fluid intake; prevention of secondary infections

Nursing interventions for chronic airflow limitation

Protect from infection exposure; wash hands; monitor for signs of infection; teach safety measures; low sodium diet; foods that contain vitamin D and calcium; good skin care; possibility of weaning from steroids; I&O, weigh daily, ulcer prophylaxis

Nursing plan and interventions for cushing syndrome

Gestational trophoblastic disease (hydatidiform mole) Preoperative and postoperative D&C care: VS, vaginal discharge, uterine cramping; prevent pregnancy for 1 year, obtain monthly serum human chorionic gonadotropin levels for 1 year;

Nursing plans and intervention

Establish trust; listen, use a calm approach and direct, simple questions. Remain with client; do not leave alone; provide a safe envirorment; draw clients attention away from dreaded object or situation; alternative coping strategies and encourage use of such alternatives; substitution of positive thoughts for negative ones; desensitizing client; gradually and systemically introduce the client to the anxiety producing stimuli; pair the anxiety- producing stimuli with another response such as relaxation or exercise; sharing of fears and feelings with others; anti-anxiety medications; selective serotonin reuptake inhibitors; decrease intake of caffeine and nicotine

Nursing plans and interventions

Monitor weight, VS, and electrolytes; structured supportive environment; time limit for eating; monitor food and fluid intake; express feelings of anger encouragement; positive reinforcement to build self esteem; discuss strategies to stop vomiting; antidepressant medications;

Nursing plans and interventions

Nonjudgmental approach, be straight forward when taking history; all information is condifential and reassure this to the client; complete sexual history; signs and symptoms of STDs, mode of transmission, concise written instructions; avoid sexual contact while infected; report incidents of STDs to appropriate health agencies and departments; instruct women of childbearing age about the risks to a newborn: gonorhheal conjunctivitis, neonatal herpes, congenital syphilis, oral candidiasis; teach safer sex

Nursing plans and interventions

Institute bed rest with no vaginal or rectal manipulation, notify MD immediately; monitor BP and pulse q15min; external uterine and fetal monitor; place client in side lying position to increase uterine perfusion; monitor contractions and FHR; IV infusion with 16-18 gauge catheter; review results of CBC, clotting studies, Rh factor and type/crossmatch stat; sighs for developing DIC

Nursing plans and interventions for Abruptio placenta

Supportive care; monitor VS frequently; I&O; weigh daily; low sodium diet with no added salt; low potassium if oliguric; bed rest during acute phase; administer antihypertensives; monitor for seizures (hypertensive encephalopathy); signs of CHF; signs of renal failure

Nursing plans and interventions for Acute glomerulonephritis

Private room; reverse isolation; age-appropriate explanations for diagnostic tests, treatments, and nursing care; infection of skin, needle stick sites and dental problems; administer blood products; antineoplastic chemotherapy; provide care toward managing side effects and toxic effects of antineoplastic agents

Nursing plans and interventions for Acute lymophocytic leukemia

Monitor weight, VS, and electrolytes - esp. for K+, thyroid levels, Ca/phosphorus; structured supportive environment; time limit for eating; monitor food and fluid intake; be alert to client's choosing low calorie foods; be alert to possible discarding of food though others, pockets, wastebaskets or drawers; monitor client after meals for possible vomiting; monitor activity level - prevent excessive exercise; positive reinforcement to build self esteem; behavior medication program; focus interactions away from food and eating; antidepressant mediations; family therapy; snacks between meals; monitor activity and assess for weakness, fatigue, and pathologic fractures; watch for water loading prior to weighing; safe environment

Nursing plans and interventions for Anorexia nervosa

Control hypertension to help prevent future stuff; proper body alignment; minimize edema, prevent contractures, and maintain skin integrity; full ROM exercises 4xd; personal care; set realistic goals; teach appropriate self-care activities for hemiparetic person; assist with dressing activities and modify them; analyze bladder elimination pattern; follow up speech program initiated by the speech and language therapist; do not place client in sensory overload; one instruction set at a time;

Nursing plans and interventions for CVA

Pre-operative care: begin preparation for abdominal surgery; provide bowel cleansing program; insert rectal tube; observe for symptoms of bowel perforation; post-op care: VS and axillary temperature; administer IV fluidsm; I&O; care for NG tube with connection to intermittent suction; abdominal and perineal dressings; bowel sounds

Nursing plans and interventions for Congenital aganglionic megacolon (hirschsprung disease)

Weight reduction diet; excessive use of the involved joint aggravates pain and may accelerate degeneration; correct posture and body mechanics; sleep with rolled terry cloth towel under cervical spine if neck pain is a problem' wear stretch gloves at night; keep joints in functional position

Nursing plans and interventions for Degenerative joint disease

Assist with diagnostic procedures; assist with amniotomy; initiate oxytocin

Nursing plans and interventions for Dystocia

Prevention with the Hib vaccine; maintain child in upright position; prepare for intubation or tracheostomy; IV antibiotics; hospitalization in ICU; restrain as needed

Nursing plans and interventions for Epiglottitis

Pre-op care: monitor respiratory status, remove excess secretions, elevate infant into antireflux position of 30 degrees, provide oxygen, NPO, administer IV; post-op care: NPO, IV fluids, I&O, gastrostomy tube care and feedings, pacifier to meet developmental needs

Nursing plans and interventions for Esophageal atresia with tracheoesophageal fistula

Assess client so as to recognize anxiety and label the feeling? relationship between the stressor and the level of anxiety; learn and test various adaptive coping responses; exercise, DB, visualization, relaxation, biofeedback, decrease stimuli

Nursing plans and interventions for Generalized anxiety disorder

Protect client from infection; monitor temperature; observe for signs of anemia; adequate rest; preoperative and postoperative care; high nutrient foods

Nursing plans and interventions for Hodgkin disease

Phototherapy; maintain hydration; promote excretion by feeding in order to produce more stooling; fiber optic blanket for rooming or home phototherapy

Nursing plans and interventions for Hyperbilirubinemia

Take BP between contractions, in side lying position at least every hour unless abnormal; take temperature q4h until rupture of membranes then every hour; FHR q30 minutes in latent stage; FHR q15-30 minutes in midactive stage; FHR q15 minutes in transition stage; assess urine q8h unless abnormal; assess contractions when assessing FHR; sips of clear fluid; offer anesthesia or analgesia in midactive phase

Nursing plans and interventions for Intrapartum period

Need to limit activities; provide rest periods; administer oral iron; limit milk intake; eat: meat, green leafy vegetables, fish, liver, whole grains, legumes

Nursing plans and interventions for Iron deficiency anemia

Prescribe exercise, splinting and activity; identifying adaptations in routine; support maintaining school schedule and activities; administer NSAIDS, antirheymatic drugs, corticosteroids, cytotoxic drugs; teach SE of drugs

Nursing plans and interventions for Juvenile rheumatoid arthritis/ juvenile idiopathic arthritis

Avoid prolonged exposure to the sun; clean skin with milk soap; administration of steroids

Nursing plans and interventions for Lupus erythematosus

Encourage self care and frequent rest periods; work until the point of fatigue; for muscle spascitiy and that stretch - hold- relax exercises are helpful as are riding a stationary bicycle and swimming; adequate fluid intake, high fiber foods, bowel regime for constipation; steroid therapy and chemotherapeutic drugs; interferon beta products

Nursing plans and interventions for MS

Tracheostomy kit available at bedside for possible Myasthenia crisis; administer anticholinergic drugs; schedule nursing activities to conserve energy; avoid situations that produce fatigue or physical or emotional stress; TCDB q4-6h

Nursing plans and interventions for Myasthenia gravis

Prevent infection: hand washing, triple dye antimicrobial to cord, avoid wearing rings, universal precautions, appearance of IV site q30min, watch skin integrity, maintain adequate nutrition; place in incubator; sepsis workup: blood cultures, LP, urine collection, chest x-ray, CBC with diff, chemistry; antibiotics

Nursing plans and interventions for Neonate with sepsis

Supportive care; monitor temperature, assess for signs of infection; protect from persons with infection; provide skin care; bed rest during edematous phase; administer steroids (prednisone) and cholinergics (Urecholine); I&O; abdominal girth daily; administer cytoxan; small, frequent feedings of a normal protein, low salt diet; IV albumin followed by diuretic;

Nursing plans and interventions for Nephrotic syndrome

Perform newborn screening at birth and again at 3 weeks of age; strict adherence to low phenylalanine diet; special formulas for infant such as lofenalac and/or phenex-1; phenyl free milk after 2 years; avoid foods high in phenylalanine; diet must be maintained at least until brain growth is complete

Nursing plans and interventions for PKU

Activities later in the day to allow sufficient time for client to perform self care activities; encourage activities and exercise; eliminate activities environmental noise; soft diet

Nursing plans and interventions for Parkinson disease

Suspect and assess UTI in infants who are ill; clean voided or cathertized specimen; administer antibiotics

Nursing plans and interventions for UTIs

Medication compliance, which usually leads to resolution of mild cases; provide support for children and families requiring surgey; explain the goal of ureteral reimplantation which is to stop reflux and prevent kidney damage; assess dressing and incision for drainage; maintain hydration with IV or oral fluids

Nursing plans and interventions for Vesicoureteral reflex

Support family during diagnostic period; project from injury and no abdominal palpation; prepare family and child for imminent nephrectomy; monitor for increased BP; monitor for kidney function: I&O and SG; maintain NG tube and chesck for bowel sounds

Nursing plans and interventions for Wilms Tumor (Nephroblastoma)

Bed rest, eye patch on affected eye, administer medication to inhibit accommodation and constriction; cyclopegics (mydriatic and homatropine) are given to dilate pupil before surgery; administer medication for post-op pain;

Nursing plans and interventions for a detached retina

Maintain adequate respirations, airway, oxygenation; provide nutritional, fluid and electrolyte support; prevent complications of immobility; there is a huge potential for thrombus formation, prevent this; vital signs; contractures and joint immobility, urinary calculi; prevent injury and promote safety; maintain hygiene, cleanliness, observe for bladder elimination problems; document and record bowel movements; prevent corneal injury

Nursing plans and interventions for a patient with altered LOC

Provide wound care, change dressing as needed, maintain proper body alignment in and out of bed; position the client to relieve edema and spasms at residual limb site: passive ROM

Nursing plans and interventions for amputation

Blood products; periods of rest and activity; increase iron by meating red meats, organ meats, whole wheat products, spinach, carrots; eat folic acid foods such as green vegetables, liver, citrus fruits; consume vitamin B12 foods such as glandular meats, yeasts, green leafy vegetables, milk, cheese; vitamin supplementations;

Nursing plans and interventions for anemia

Determine newborn's first temperature, typically usually a rectal thermometer to assess for imperforate anus; assess newborn for passage of meconium; after surgery position infant in side lying prone position with hips elevated

Nursing plans and interventions for anorectal malformations

Establish trust; be truthful and honest; identify situations that provoke anxiety and aggressive behaviors; avoid confrontation; help client to focus on the feelings that cause the delusions; assist in identifying thoughts, perceptions and own conclusions about reality; avoid talking and laughing where the client can see but not hear you; engage in noncompetitive activities that require concentration; involve the client in treatment plan

Nursing plans and interventions for cluster A: paranoid personality disorders

Monitor respiratory status; assess for signs of respiratory function; IV antibiotics; administer pancreatic enzymes; administer fat soluble vitamins in water soluble form; administer oxygen and nebulizer treatments; evaluate effectiveness of respiratory treatments; teach family percussion and postural-drainage techniques; diet that is high in calories, high in protein, moderate to high in fat, and moderate to low in carbohydrates

Nursing plans and interventions for cystic fibrosis

Observe for birth trauma: clavicle fracture or cerebral trauma; perform heel sticks for glucose assessment at 30minutes, 1 hour and as prescribed; hypoglycemia, hypocalcemia; small, frequent feedings at 1 hour of age

Nursing plans and interventions for diabetic insulin

Hydration status and VS frequently; I&O; do not take temperature rectally; rehydrate; calculate IV hydration to include maintenance and replacement fluids; collect specimens to aid in diagnosis; check stools for pH, glucose, and blood; administer antibiotics; check urine for SG; wash hands; teach home care: pedialyte or Lytren, lactose free diet, should not receive anti-diarrheals, do not give grape juice orange juice apple juice cola or ginger ale

Nursing plans and interventions for diarrhea

Reduce environmental stimulation to decrease anxiety; stay with client during periods of depersonalization; acceptance of client's behavior during various experiences and personalities; document emergence of different personalities; identify stressful situations; identify effective coping patterns used in other stressful situations; using new alternative coping methods

Nursing plans and interventions for dissociative disorders

Assist and support parents during the diagnostic process; assess and monitor growth and development; bulb syringe for suctioning; signs of respiratory infection; assist family with feeding problems; feed to back and side of mouth; monitor for signs of cardiac difficulty or respiratory infection; early intervention program

Nursing plans and interventions for down syndrome

VS stat; check for vaginal bleeding; IV to administer fluids; perform gentle, moderate abdominal palpation and percussion; abdominal ultrasound; prepare client or possible laparotomy; type and crossmatch for 2 units pack RBCs

Nursing plans and interventions for ectopic pregnancy

Do not leave the client alone; get precipitous delivery basin; clean towel under mothers buttocks; hee-blow or blow-blow breathing technique to slow expulsion of head over perineum; if amnion is still present, rupture with fingers; apply gentle counter pressure against presenting part; check for cord around the neck; clamp cord in 2 places cut between; placenta separation

Nursing plans and interventions for emergency delivery

Administer eye drops for rest of life and must follow regime; vision lost cannot be restored; provide safety measures; avoid activities that may increase intraocular pressure such as emotional upsets, exertion, coughing, wearing constrictive clothing, straining at stool and constipation

Nursing plans and interventions for glaucoma

Adequate ventilation and airway; keep HOB elevated 30-45 degrees to aid venous return from neck and decrease cerebral volume; neurologic vital signs q2h; avoid activities that increase ICP; take immediate measures to reduce temperature; ICP monitoring (>20mmHg report STAT); administer hyperosmotic agents and diuretics to dehydrate brain and cerebral edema; foley catheter; passive hyperventilation of ventilator; seizure precautions; prevent complications of immobility

Nursing plans and interventions for head injury

Reduce distractions; turn TV/radio off; devote full attention; look and listen' being with casual topics; progress to more critical issues slowly; face patient; speak slowly; use helpful aids

Nursing plans and interventions for hearing loss

Ice pack to perineum to decrease swelling and pain; surgical incision if hematoma is large; monitor VS closely; analgesics and antibiotics

Nursing plans and interventions for hematoma development

Administer FFP, cryoprecipitate of fresh plasma, or lyophilized concentrated as prescribed; pain medication; blood precautions; teach to recognize early bleeding into joints; local treatment for minor bleeds; administration of factor replacement; discuss dental hygiene; provide protective care; wear medic alert ID; genetic counseling

Nursing plans and interventions for hemophilia

Monitor for signs of increased ICP; seizure precautions; elevated HOB; shunt is inserted into ventricle; tubing it tunneled through skin to peritoneum where it drain excess CSF

Nursing plans and interventions for hydrocephalus

Daily dose of prescribe hormone; ongoing follow up to determine serum hormone levels; develop a bowel-elimination plan to prevent constipation

Nursing plans and interventions for hypothyroidism

Edema and douche as prescribed pre-op; not amount and character of vaginal discharge; avoid rectal thermometers or tubes; check extremities for warmth and tenderness as indicators of thrombophlebitis; pain management; encourage ambulation; monitor urinary output; assess voiding patterns; observe for incision bleeding; note abdominal distention; increase diet from liquids to general; stool softeners prior to first bowel movement; limit tampon use; avoid douching; refrain from intercourse; avoid heavy lifting; maintain adequate fluid intake; notify MD at first sign of infection

Nursing plans and interventions for hysterectomy

Monitor carefully for shock and bowel perforation; administer IV fluids; I&O; prepare family for emergency intervention; prepare child for barium enema because in 2/3 cases it will respond to this treatment

Nursing plans and interventions for intussusceptions

Monitor incision site, assess for bleeding ad drainage, assess suture line for erythema and edema, assess suction drainage apparatus, assess for signs of infection; monitor functioning of extremity - check circulation, sensation and movement of extremity distal to placement; I&O; 3Lfluid/day; work closely with health care team to increase client's mobility gradually

Nursing plans and interventions for joint replacement

Safe, consistent environment; health, nutrition, safety, hygiene, and rest; ADLs; support routine in daily activities; mark the bathroom; reorient; simple, direct statements

Nursing plans and interventions for organic disorders

Hazard-free environment; keep bed in low position; provide a safe environment; ROM exercise several times/day; proper body mechanics; diet high in protein, calcium and vitamin D; discourage use of alcohol and caffeine; hormone replacement therapy; diet high in calcium and vitamin D intake beginning in early adulthood; calcium supplementation after menopause; weight bearing exercise; bone density study as baseline

Nursing plans and interventions for osteoporosis

Provide that care required after any major abdominal surgery following laparotomy

Nursing plans and interventions for ovarian cancer

Promote lochial and uterine drainage by instructing client to use semi-fowler position; amount and odor of lochia; development of pelvic thrombophlebitis; IV antibiotics

Nursing plans and interventions for parametritis

Document baseline maternal VS and FHR prior to administration of narcotics or sedatives; assess phase and stage of labor; obtain MD orders; don't give PO medications; medications IV; push IV bolus into line slowly at the beginning of a contraction because this is when uterine blood vessels are constricted so less analgesic reaches the fetus

Nursing plans and interventions for patient Labor with analgesia or anesthesia

Suicide precautions; monitor sleep, nutrition and elimination patterns; assist with ADLs; initiate interaction with client; participation in activities; sudden elevation in mode may indicate suicide; identifying a support system; discussion of feelings of helplessness, hopelessness, loneliness, and anger; silence if client is non-talkative; spend time with client and return when promised

Nursing plans and interventions for patient with depression

Stay warm; assess site daily for decrease in redness, pain, and discharge; sitz bath and perineal lamp 2-3x/day; antibiotics and analgesics

Nursing plans and interventions for perineal infection

Use bed rest to extend the period of gestation until fetal lung maturity is achieved; then delivery is accomplished; monitor BP and pulse q15min; IV to administer fluids; review results of CBC, clotting studies, Rh factor and type/crossmatch stat; monitor contractions and FHR; side lying position; continue monitor blood loss: save pads and linens; ultrasound diagnosis; possible C-section if placenta previa is complete

Nursing plans and interventions for placenta previa

Identify the poisonous agent quickly! Assess the child's respiratory, cardiac, and neurologic status; bring any emesis, stool to ER; child's age and weight; removal may require gastric lavage, activated charcoal or naloxone HCL (narcan)

Nursing plans and interventions for poisoning

Actively listen to client's stories of experiences surrounding the traumatic event; assess suicide risk; assist client to develop objectivity about the event and problem solve regarding possible means of controlling anxiety related to the event; encourage group therapy with other clients who have experienced the same or related traumatic events

Nursing plans and interventions for post traumatic stress disorder

Consistent, nonthreatening environment; suicidal and homicidal precautions; listen to client's details of events to identify the most troubling aspect of events; develop objectivity in perceiving event and identify areas of no control; assist client to regain control by identifying past situations that have been handled successfully; anti-anxiety and antipsychotic medications to decrease anxiety, manage behavior and provide rest

Nursing plans and interventions for post traumatic stress disorder

Monitor VS, fundus, lochia, q15minx1hour, q30minx1hr, and q1hourx2hours; LOC; bladder empty; call MD if atony or bleeding continues despite message; increasing pitocin IV infusion and administering ergot preparation IM; count pads saturated and time required to saturate; I&O

Nursing plans and interventions for postpartum hemorrhage: early

Quick hospitalization and determination of cause of bleeding; type and cross match for possible blood transfusion; oxytocic drugs and possibly ergot preparations; antibiotics; keep the client warm

Nursing plans and interventions for postpartum hemorrhage: late

Teach good handwashing; record VS; manage fever by increasing fluids, providing cool baths, administering acetaminophen; assess for signs of dehydration; maintain hydration; include the four basic food groups and increase intake of foods containing vitamin C and protein

Nursing plans and interventions for postpartum infections

Early detection; preoperative bowel preparation to prevent fecal contamination of operative site; post-op care

Nursing plans and interventions for prostate cancer

Pre-op care: assess for dehydration; administer IV fluids and electrolytes as prescribed, weigh daily, monitor I&O, provide small frequent feedings; hypertrophied muscle will be split and prognosis is excellent; post-op care: continue IV fluids, provide small oral feedings with electrolyte solutions or glucose, position on right side in semi-fowler position after feeding, burp frequently to avoid stomach's becoming distended and putting pressure on surgical site, weight daily, monitor I&O

Nursing plans and interventions for pyloric stenosis

Ensure that the health care provider has explained the procedure, the risks, the benefits, and the alternatives; prehydrate to counteract possible hypotension: 500-1000mL IV fluid (isotonic) infused 20-30 minutes before initiation; sims position or sitting on the side of bed with head flexed; describe symptoms after test dose of medication is given; BO q1-2 min for 15 min after injection; BP q15min during continuous infusion; assess level of pain; report return of pain sensation; assist client with pushing technique once complete dilatation occurs

Nursing plans and interventions for regional block anesthesia

Monitor VS; assess for increasing signd of cardiac distress; encourage bed rest; assist with ambulation; chorea is temporary; administer penicillin or erythromycin and aspirin for anti-inflammatory and anticoagulant actions

Nursing plans and interventions for rheumatic fever

Establish trust; sit with mute clients; safe and secure environment; assist with physical hygiene and ADLs' use matter of fact non-judgmental approach; use clear, simple,,, concrete terms when talking with client; accept and support client's feelings; reinforce congruent thinking. Stress reality; avoid arguing and avoid agreeing with inaccurate communications; set limits; avoid stressful situations; structure time for activities as to limit time for withdrawal; identify positive characteristics related to self; socially acceptable behavior; avoid fostering a dependent relationship; promote family involvement

Nursing plans and interventions for schizophrenia

Screen all adolescent children; prepare child and family for conservative treatment

Nursing plans and interventions for scoliosis

Prevent crisis; keep child from exercising strenuously; keep away from high altitudes; avoid letting child become infected and seek care at first sig of infection; prophylactic penicillin; keep hydrated; do not withhold fluids at night; administer pneumococcal vaccine, meningococcal vaccine, and haemophilus B vaccine, Hep B vaccine

Nursing plans and interventions for sickle cell anemia

Nonjudgmental attitude; record duration and intensity of pain with attention to factors that precipitate onset; expression of angry feelings; no one medication is particularly recommended; focus interactions and activities away from self and pain; help client identify connection between pain and anxiety; increase time and attention give to client as reward for not focusing on self or physical symptoms

Nursing plans and interventions for somatoform disorders

Document the infant;s elimination pattern daily - meconium stool within the first 24 hours to transitional to milk stool, should void within 4-6 hours of birth; screen for PKU after 2-3 days of breast milk or formula ingestion; demand feeding is preferred; bottle fed infants eat q3-4hours, breast fed infant eats q2-3 hours; should gain 1oz per day; needs 50 calories/lb or 108 calories/kg of body weight for the first 6 months; teach not to submerge baby in water for bath until cord falls off

Nursing plans and interventions for the newborn

Decrease energy utilization immediately: no nippling; NICU

Nursing plans and interventions for the newborn with congenital heart disease

Collect throat culture; warm saline gargles; provide ice chips; administer antibiotics; manage fever with acetaminophen

Nursing plans and interventions for tonsillitis

Monitor WBC dailyl assess oral cavity and genital area often; monitor VS frequently; administer antibiotics; monitor blood levels of antibiotics; importance of infection control for patient, staff and family; oral hygiene regime; encourage TCDB; avoid rectal temperature and suppositories; monitor I&O, fluid status and electrolyte balance; encourage mobility; provide care for invasive catheters and lines using aseptic techniques;

Nursing plans and interventions in the client who is immunocompromised and clients with BM suppression

Monitor for respiratory distress and initiate mechanical ventilation

Nursing plans and interventions of Guillain-barre syndrome

Characterized by fluid shift from interstitial to intravascular; dieresis begins; occurs from 72 hours to 2 weeks after initial injury to near completion of wound closure; provide infection control; splint and position client to prevent contractions, avoid use of pillows; perform ROM exercises; provide fluid therapy; adequate nutrition; high-calorie, high protein, high carb; burn care

Nursing plans and interventions of a burn in the acute phase

Efforts are directed toward stabilization with ongoing assessment; assist with admission care: extinguish source of burn, provide open airway, determine baseline data, determine depth and extent of burn; administer tetanus toxoid; initiate fluid and electrolyte therapy; IV pain medication; monitor hydration status; provide wound care; monitor respiratory function

Nursing plans and interventions of a burn in the emergent phase

Characterized by the absence of infection risk; client may return home when the danger of infection has been eliminated; high protein fluids with vitamin supplements are recommended; pressure pressings may be worn continuously to prevent hypertrophic scarring and contractures

Nursing plans and interventions of a burn in the rehabilitation phase

Type of abortion and subsequent management; monitor vital signs, LOC qhour until stable; save all peripads and linens; IV with at least an 18g over the needle catheter; RhoGAM if indicated (RH-Mother);

Nursing plans and interventions of a spontaneous abortion

Maintain client in extended position with cervical collar; stabilize client when transferring between accident scene and the emergency room; maintain a patent airway; cervical injuries, skeletal traction is maintained by use of skull tongs or halo ring; high dose corticosteroids; kinetic therapy treatment table; stryker frame or very firm mattress; assess for respiratory failure; evaluate for present of spinal shock and autonomic dysreflexia; acute paralytic ileus, lack of gastric activity; suction with caution to prevent vagus nerve stimulation

Nursing plans and interventions of spinal cord injury: acute phase

Encourage deep breathing; chest physiotherapy; kinetic bed to promote blood flow to extremities; antiembolic stockings; ROM; mobilize ASAP; TCDB frequently; observe for impending skin breakdown; importance of impeccable skin care; perform intermittent catheterization q4h;I&O; acidify vitamin C; teach bladder emptying techniques; begin bowel training program; talk with client and family about permanent disability

Nursing plans and interventions of spinal cord injury: rehabilitation phase

Bed rest for 2 hours to prevent orthostatic hypotension; ass VSq15min, then q30min until stable; assess temp at the beginning of fourth stage and prior to discharge to postpartum room; assess fundal firmness, height, bladder, lochia, and perineum q15min for 1 hour then q30min for 2 hours; change perineal pads and cleanse vulva and perineum with each change; warm blanket on abdomen; analgesics; PO fluids when alert and able to swallow; ice pack to perineum to minimize edema

Nursing plans and interventions of the fourth stage of labor

Place hand under drape and palpate fundus of uterus for firmness and placement at or below the umbilicus; maternal BP before and after placental separation; check patency and site integrity of infusing IV; administer oxytocic medication immediately after delivery of the placenta; document EBL; dry and suction, perform Apgar assessment, place blanket on mother's abdomen or allow skin to skin contact with mother after delivery; place stockinette cap on the newborns head or cover head to prevent heat loss; gently cleanse vulva and apply sterile perineal pad; remove both legs simultaneously if the lefts are in stirrups; clean gown and warm blanket; lock bed before moving mother, and raise side rails during transfer

Nursing plans and interventions of the third stage of labor

Eliminate causative agent; administer vitamin supplements; observe mental status frequently; avoid initiating bleeding and observe for bleeding tendencies; provide special skin care; monitor fluid and electrolyte status; monitor dietary intake carefully, especially protein; dietary restrictions: low sodium, low potassium, low fat, high carbohydrate diet

Nursing plans and interventions with cirrhosis

Use central venous catheter or 19 gauge needle; only use blood administration tubing; run blood products with saline only; check and double check product before infusing - correct product, correct blood type and RH factor

Nursing skills for blood transfusion

Profile of the child's and family's eating habits; iron deficiency occurs most commonly in children 12-36 mohts old, in adolescents females, and in females during their childbearing years; vitamins most often consumed in less than appropriate amounts by preschool and school age children are vitamin A, B6, B12, C

Nutritional assessment

Antiemetic; indicated for prevention of NV associated with cancer as well as postoperative NV; adverse reactions: headache; administer tablets 30 min prior to chemotherapy and 1-2 hours prior to radiation therapy; dilute IV injection in 50ml of 5% dextrose or 0.9%NaCl

Ondansetron HCL (zofran)

Heroin, morphine, meperidine, codeine, opium, methadone, cocaine, amphetamines, hallucinogenic

Opiates

Characterized by behavior that fails to adhere to established norms, but doesn't violate the rights of others

Oppositional defiant disorder

Thrombotic growth factor; stimulates production of megakaryocytes and platelets; adverse reactions: dizziness, HA, insomnia, blurred vision, nervousness, pleural effusion, vasodilation, cardiac arrhythmias, bone pain, myalgia, GI upsets, fluid retention; give slowly; assess for fluid retention complications; start within 6-24 hours of chemotherapy and continue for 10-21 days; monitor CBC, H&H, platelets

Oprelvekin (Neumega)

Changes in this cause shifts in fluids

Osmolarity

Metabolic disease in which bone demineralization results in decreased density and subsequent fracture; occur prior to the client's falling; cause is unknown; postmenopausal women are at the highest risk

Osteoporosis

Inflammatory disorder of the middle ear; may be suppurative or serous; anatomic structure predisposes children to this; risk for conductive hearing loss if untreated or imcompletely treated

Otitis media

Headache, dizziness, hearing loss, tinnitus

Ototoxicity

Cancer of the ovaries can occur at all ages, including infancy and childhood. Early diagnosis is difficult because no useful screening test exists at present

Ovarian cancer

Uterine stimulant; indicated for uterine atony; adverse reactions: severe after pains in multipara and hypertension; give immediately after delivery of placenta to avoid trapped placenta; 10-20 units added to remaining IV fluid (at least 50ml); may stimulate let down milk reflex and flow of milk when engorged

Oxytocin, synthetic (pitocin, syntocinon)

Atrial systole; represents depolarization of the artial muscle

P wave

Prior to antibody-positive status this antigen assay will be positive (detects antigen of the virus)

P24 antigen

Partial pressure of CO2 in arteries; respiratory component of acid-base regulation

PCO2

The instillation and maintenance of small amounts of air into the alveolar sacs to prevent then from collapsing each time the client exhales; amount of pressure can be set and is usually around 5-10cm of water

PEEP Positive end-expiratory pressure

Less danger of fluid overload; used for acute blood loss

Packed RBC

Untreated pain may lead to complications, such as delayed recovery, alterations in sleep patterns, and alterations in nutrition; often referred to as the 5th vital sign

Pain assessment and management in the pediatric client

Nonbacterial inflammation of the pancreas

Pancreatitis

Perceptions are grossly distorted; unable to differentiate real from unreal; unable to concentrate or problem-solve; loss of rational, logical thinking; feel overwhelmed, helpless; loss of control, inability to function; elicit behavior that may be angry and aggressive or withdrawn, with clinging and crying; immediate intervention

Panic

Discrete periods of intense fear or discomfort that are unexpected and may be incapacitating; characterized by an irrational fear of an external object, activity or situation; chronic condition that has exacerbations and remissions; transfers anxiety or fear from its source to a symbolic object, idea, or situation; fear is excessive and unrealistic but can't help it

Panic disorders and phobias

Incubation: 14-21 days; symptoms are fever, headache, malaise, parotid gland swelling and tenderness; manifestations include submaxillary and sublingual infection, orchitis, and meningoencephalitis; transmitted by direct contact or droplet spread; analgesics used for pain and antiseptics for fever; bed rest maintained until swelling subsides

Paramyxovirus (mumps)

Pervasive and long standing suspiciousness; mistrusts others, is suspicious, fearful; projects blame for own problems onto others; in touch with reality; verbally uses hospital, accusatory dialogue that is reality based; non-verbally appears suspicious, tense, distant, watchful and angry

Paranoid personality disorder

Arise from specific area in the brain and cause limited symptoms; focal and psychomotor seizures

Partial seizures

Indirectly expressing aggression toward others; a facade of overt compliance masks covert resentment; an employee arrives late to a meeting and disrupts others after being reminded of the meeting earlier that day and promising to be on time

Passive-aggression

Return to fetal circulation in an attempt to provide O2 to the brain and large organs; results in worsening respiratory distress and pulmonary edema due to increased blood flow to the lungs; caused by neonatal hypoxia

Patent ductus arteriosus

Maintain a urine output of at least 30ml/hr and notify health care provider if it drops below this

Patient in shock

When client begins labor, control the amount of stimulation in the labor room; nurse to client ratio at 1:1; keep room darkened, quiet, private room; absolute bed rest, side lying with side rails up; disturb as little as possible; limit visitors except for support person; explain rationale for procedures and care; IV line with 16-18 gauge; BP q15-30min; check urine for protein q1h; DTR q1h; administer magnesium sulfate;

Patient with preeclampsia intrapartum

Evidenced by lymphoid interstitial pneumonitis, pulmonary lymphoid hyperplasia, and opportunistic infections

Pediatric HIV Client

Infection with HIV in infants and children; perinatal transmission of children born to HIV-positive mothers will be infected unless the mother is treated with Zidovudine during pregnancy and the neonate is treated after birth ; HIB infected blood products, breast milk, sexual abuse

Pediatric HIV infection

Failure to thrive, lymphadenopathy, organomegaly, neuropathy, cardiomyopathy, chronic recurrent infections, unexplained fevers

Pediatric HIV infection S&S

Administer NO live virus vaccines, IGG administration, avoid exposure to persons with infections

Pediatric HIV infection interventions

Prophylaxis for recurrence of rheumatic fever; allergic reactions ranging from rashes to anaphylactic shock and death are the adverse reactions; released very slowly over several weeks giving sustained levels of concentration; emergency equipment available whenever administered; always determine existence of allergies to penicillin and cephalosporins

Penicillin G (Bicillin)

Procraine penicillin G (Wycillin), Benzathine penicillin (Bicillin L-A), Penicillin V (Pen-Vee K); antiinfectives, used primarily for gram-positive infections; adverse reactions: allergic reactions, anaphylaxis, phlebitis at IV site, diarrhea, GI distress, superinfection; use in caution with clients allergic to cephalosporins, monitor for allergic reactions, observe all clients for at least 30 minutes, oral penicillin G should be taken on an empty stomach; alters contraceptive effectiveness

Penicillin's

Give in first or second stage of labor to block nerve impulses from T10-S5; thereby deadening pain of contractions; used in conjunction with local or pudendal block for delivery; given in single dose or continuously through catheter threaded into epidural space; moderately associated with hypotension; associated with prolonged second stage due to decreased effectiveness of pushing

Peridural (epidural, caudal) block

Chills and temperature to 105; rapid thread pulse up to 140; decreased urinary output; paralytic ileus, abdominal distension, absence of bowel sounds

Peritonitis

Long standing traits that are maladaptive responses to anxiety and cause difficulty in relating to and working w/ other individuals

Personality disorders

Persons with this are usually comfortable with their disorders and believe that they are right and the world is wrong; very little motivation to change; think of them as a challenge

Personality disorders

Anticonvulsant; tonic clonic and partial seizures; the longest acting of common barbiturates; combined with other drugs; adverse reactions: drowsiness, nystagmus, ataxia, paradoxic excitement; therapeutic levels: 15-60mcg/ml; avoid rapid infusion, monitor BP

Phenobarbital (luminal)

Chloripromazine HCL (thorzine), trifluperazine HCL (stelazine), thioridazine HCL (Mellaril), perphenazine (trilafon), triflupromazine (Vesprin), loxapine (loxitane), molidone (moban), fluphenazine HCL (prolixin); indicated to control psychotic behavior such as hallucinations, delusions and bizarre behavior; adverse reactions: drowsiness, orthostatic hypotension, weight fain, anticholingeric effects, extrapyramidal effects, photosensitivity, blood dyscrasias: granulocytosis, leucopenia, neuroleptic malignant syndrome; extrapyramidal effects are a major concern, monitor elderly, 2-3 weeks to achieve effects, keep client supine for 1hr after administration and advice to change positions slowly, avoid alcohol sedatives and antacids

Phenothiazines

Drugs that cause extrapyramidal effects; tardive dyskinesia can be permanent if client is not assessed regularly for signs of this; cause photosensitivity

Phenothiazines

An autosomal recessive disorder in which the body cannot metabolize the essential amino acid phenylalanine; the build up of serum levels of phenylalanine leads to CNS damage, most notably mental retardation; decreased melanin produces light skin and blond hair

Phenylketonuria (PKU)

Anticonvulsant; tonic clonic and partial seizures; adverse reactions: gingival hyperplasia, dermatitis, ataxia, nausea, anorexia, bone marrow depression, nystagmus; therapeutic levels: 10-20mcg/ml; monitor drug interactions; meticulous oral hygiene; monitor CBC; report to MD if any rash develops; flush IV before and after with NS only; don't administer with milk

Phenytoin (dilantin)

Sunlight: exposed skin turns blue and color changes occur in eyes, but does not cause vision impairment; teach client to stay out of sun, wear protective clothing and sunglasses; skin discoloration will disappear within 6 months after drug is stopped

Photosensitivity

Decomposes bilirubin in the skin through oxidation; place unclothed neonate 18 inches below a bank of lights for several hours or days until levels fall <12; place opague mask over eyes to prevent damage; monitor skin temperature; cover genitals with a small diaper or mask to catch urine and stool; turn q2hrs; turn off lights for 5-15 min q8hr to assess for conjunctivitis; monitor for signs of dehydration

Phototherapy

Priority when caring for a client with bulimia; increase self-esteem and develop a positive body image. Behavior modification. Family therapy is most effective because issues of control are common in these disorders

Physical assessment and nutritional support

Should concentrate on respiratory status, especially in clients with injury at C3 to C5 because of the cervical plexus innervates the diaphragm

Physical assessment of spinal cord injury

Occur as a compensatory mechanism when the body is trying to make up for a deficit somewhere in the system; CO increased when HGB drops below 7

Physical symptoms

Occurs at 2-3 days of life. If it occurs before 24 hours or persists beyond 7 days, it becomes pathologic; mainly due to the immature livers normal inability to keep up with RBC destruction and to bind bilirubin; unconjugated bilirubin causes jaundice

Physiologic jaundice

Enhances papillary constriction; adverse reactions: bronchospasm, NVD, blurred vision, twitching eye lids, eye pain with focusing; use cautiously with pregnancy, asthma, hypertension' teach proper drop instillation; need for ongoing use of the drug at prescribed intervals; blurred vision tends to decrrase with regular use; treatment of glaucoma

Pilocarpine HCL (parasympathomimetics)

A source of infection; monitor for signs of infection; cleanse and dress the sites as prescribed

Pin sites

Barrel chest is indicative of emphysema and is caused by use of accessory muscles to breath; person works harder to breath, but the amount of O2 taken in is adequate to oxygenate the tissues

Pink puffer

Secretes ADH

Pituitary gland

After the first postpartum day the most common cause of uterine atony is this. Must check for fragments in lochia

Placenta fragments

Abnormal implantation of placenta in the lower uterine segment; 1/250 pregnancies; bleeding usually begins in the third trimester; previous uterine scars, surgery and fibroid tumors are associated with this; medical emergency

Placenta previa

Removal of the entire lung; position client on operative side or back

Pneumonectomy

Inflammation of the lower respiratory tract; caused by infectious agents that reach the lungs through aspiration, inhalation, hematogenous spread

Pneumonia

Assess:: SUBCU emphysema, chest pain,dyspnea and hypoxia, tachycardia, hypotension, nausea, confusion

Pneumothorax/hemothorax/air emboli/ hydrothorax

Use clot filters when infusing blood and blood products; avoid using veins in the lower extremities; prevent fluid containers from becoming empty

Pneumothorax/hemothorax/air emboli/ hydrothorax interventions

Ingesting, inhaling, or absorbing a toxic substance; occur in children <6 with peak age being 2; due to their exploratory behavior, curiosity, and oral motor activity of early childhood place the child at risk

Poisoning

Recommended for all persons <18 years; administer at 2 months of age and again at 4 months of age. Boosters are given at 6-18 months and at 4-6 years; SB or IM; contraindicated for those with a history of anaphylactic reaction to neomycin or streptomycin; may be given with all over vaccines

Polio vaccine

Common in children with cyanotic defects

Polycythemia

Exhibited by an induration 10mm or greater in diameter 48 hour after;

Positive TB skin test

Remove oral secretions carefully; apply elbow restraints; minimize crying to prevent strain on lip suture line; maintain logan bow to lip; remove one restrain at a time and to ROM' age appropriate stimulation; resume feeding

Post-op care for cleft lip and/or cleft palate

Monitor bleeding, check under dressing, hemovac, and under client's back; position arm on operative side on a pillow, slightly elevated; avoid BP measurements, injections and venipuncture in affected arm; avoid injury to affected arms; perform activities that will use arm; post mastectomy exercises

Post-operative care of breast cancer

Severe anxiety, which results from a traumatic experience (war, earthquake, rape, incest)

Post-traumatic stress disorder

Slide-scale approach to insulin administration because of the precipitous fall in insulin requirements; continue 5% glucose infusion at 100-125; check urine for ketones; breastfeeding decreased insulin requirements; contraception: diaphragm with spermicide

Postdelivery period for diabetes mellitus in pregnant women

Prevention of complications, assessment for pain management teaching about dietary restrictions and activity levels

Postoperative phase

Be prepared for the possibility of laryngeal edema. Put oxygen and a suction machine; Ca++ gluconate should be easily accessible

Postoperative thyroidectomy

Leading cause of maternal mortality that demands prompt recognition and intervention; can be caused by uterine atony, lacerations to vagina, hematoma development in the cervix perinea or labia, retained placental fragments, and full bladder

Postpartum hemorrhage

Excessive uterine bleeding during the first hour following delivery; excessive uterine bleeding during the postpartum period; blood loss >500ml during vaginal delivery; signs of hypovolemic shock; signs of hematomas developing in perineum; signs of bleeding from un-repaired laceration; signs of uterine atony

Postpartum hemorrhage nursing assessment

Implied isolation from newborn until organism is identified and treatment begun; phone calls to nursery and viewing window

Postpartum infection

This can only be added to IV fluids when there is adequate UOP

Potassium

Spironolactone (aldactone), amiloride (midamor); volume depletion without significant potassium loss; adverse reactions: hyperkalemia, gynecomastia, sexual dysfunction; watch for hyperkalemia and renal failure in those treated with ACE inhibitors or NSAIDS; increase in serum lithium levels; give after meals to decrease GI distress

Potassium sparing diuretics

Adhesive backed opening, designed to cover the stoma, should provide about 1/8 inch clearance from the stoma; rubber band or clip is used to secure the bottom of the pouch and prevent leakage; use a squirt bottle to remove effulent from the sides of the bag; pouch system is changed every 3-7 days; pouch should be emptied when 1/3 to ½ full

Pouch care

Insert an intravenous line for infusion of insulin and a glucose-containing solution. Insulin doesn't cross the placenta; titrate regular insulin and glucose containing solution to maintain glucose levels between 60-100 during labor; determine blood glucose hourly; place on left side to avoid pressure on vena cava by large fetus or hydramnios; check urine for ketones hourly; monitor fetus continuously

Predelivery period for diabetes mellitus in pregnant women

Temperature >100.4; temperature elevation on 2 successive days or in 2 successive 4hr assessments

Predispose to puerperal morbidity

Frequently used in combination with antineoplastic drugs to reduce the mitosis of lymphocytes.

Prednisone

Used in renal disorders; Indicated as adrenocorticosteriod used to treat immunosuppression (acts as an anti-inflammatory) and edema (promotes dieresis in nephritic syndrome); adverse reactions: mood changes, increased susceptibility to infection, cushingoid appearance, acne, GI distress, thrombocytopenia, edema, potassium loss, growth failure in children; every other day administration is best to avoid growth failure; taper dose; avoid live virus vaccines

Prednisone (deltasone)

Pregnancy specific syndrome that usually occurs after 20 weeks gestation' gestational hypertension + proteinuria

Preeclampsia

Education about postoperative care, including NPO, assistance with meeting family needs

Preparation phase

Repeating the same word or phrase in response to different questions

Preservation

The use of beta-adrenergic agents such as terbutaline (brethine) and ritodrine HCL (yutopar) are contraindicated because of the risk for myocardial ischemia

Preterm labor for mothers with cardiac disease

Neonate born at <38 weeks gestation; based on the level of immaturity identified by gestational age and physical assessment

Preterm newborn care

Turn clientq2h, assess bony prominences; eggcrate or alternating pressure mattress or waterbed; minimal amount of linens and underpads

Prevent complications of immobility

Avoid unprotected intercourse for several days before the anticipated ovulation and for 3 days after ovulation; sperm live 3 days and eggs live 24 hours

Prevent pregnancy

Passive ROM q4h; elastic hose; avoid positions that decrease venous return; avoid pillows under knees and gatched bed;

Prevent thrombus formation

Remove contact lenses; irrigate eyes with sterile prescribed solution and instill ophthalmic ointment in each eye every 8 hours to prevent corneal ulceration

Prevention of corneal injury and drying

A decrease in anxiety resulting from the ability to deal with a stressful situation

Primary gain

Acute HIV infection or acute HIV syndrome; CD4 T cell counts at least 800 cells/mm3; flu-like symptoms, fever, malaise; mononucleosis-like illness, lymphadenopathy, fever, malaise, rash

Primary infection

Uterine stimulant; indicated for uterine atony; adverse reactions:headache, NV, fever, bronchospasm, wheezing; contraindicated for clients with asthma; 0.25IM q15-90min up to 8times; check temperature q1-2 hours; auscultate breasth sounds frequently

Prostaglandin F2 (hemabate)

Latanoprost (xalatan), ravoprost (travatan), bimetoprost (lumigan); lowered intraocular pressure of glaucoma by increasing outflow of aqueous humor; adverse reactions: local irritations, foreign body sensation, increased pigmentation of iris, and increased eyelash growth

Prostaglandin angonists

Indinavir (Crixivan), Amprenavir (Agenerase), Saquinavir (Invirase), Ritonavir (Norvir, Kaletra), Nelfinavir (Viracept); Indications are HIV infection; classification used in various combinations to reduce viral load and slow development of resistance; adverse reactions: depression, ketoacidosis, seizures, angioedema, steven-johnson syndrome; high-fat, high-protein foods reduce absorption; give with food; reduces contraceptive effects

Protease inhibitors

Lansoprazole (prevacid), pantoprazole (protonix), esomeprazole (nexium), omeprazole (prilosec), rabeprazole (achipex); indicated for treatment of erosive esophagitis associated with GERD; adverse reactions: constipation, hearbrn, anxiety, diarrhea, abdominal pain, hepatocellular damage, pacreatitis, gastroenteritis, tinnitus, vertigo, confusion, HA, blurred vision, hypokinesia, chest pain, dyspnea; take before meals; don't crush or chew

Proton pump inhibitors

Keep NPO until responsive; mouth care every 4 hours; maintain calorie count; administer feedings; monitor I&O; record client's weight

Provide nutritional and fluid and electrolyte support

Person suddenly leaves home or work with the inability to recall his or her identity; flight as well as loss of memory; rarely occurs; excessive use of alcoholic may contribute to this; dissociative disorder

Psychogenic fugue

Pregnancy occurring at age 19 or younger; associated with anemia, preeclampsia, cephalopelvic disproportion, STDs, IUGR, and ineffective parenting

Psychosocial concerns: teenage pregnancy

Given in second stage to deaden pudendal nerve plexus, thus deadening pain in the perineaum and vagina; has no effect on pain of uterine contractions; safe for mother and infant

Pudendal block

If shock is cardiogenic in nature, the infusion of volume-expanding fluids may result in this

Pulmonary edema

Occurs 1-2 days post-op; assist client to TCDB q2h; keep hydrated; enable early ambulation; early IS

Pulmonary problems: atelectasis, pneumonia, embolus

Search for treatment of possible contributing factors checking for Hypovolemia, hypoxia, hydrogen ion acidosis, hypo/hyper kalemia, tamponade, tension pneumothorax, thrombosis, trauma

Pulseless arrest algorithm (PALS)

Treatment for myasthenia gravis; inhibits the action of cholinesterase at the cholingeric nerve endings, promotes the accumulation of acetylcholine at zcholinergic receptor sites; adverse reactions: cholinergic crisis can occur with over dose; atropine is antidote for drug induced bradycardia; take with milk or food; dosage regulation is required; observe for symptoms of cholinergic crisis; lifelong therapy

Pyridostigmine bromide (mestinon)

Ventricular systole; represents depolarization of the ventricular muscle; normally follows a P wave; normal length is <0.11 seconds

QRS complex

Represents the time required to completely depolarize and repolarize the ventricles

QT interval

Reflects the regularity of the heart rhythm

R-R interval

Pain relief measures: moist heat; warm, moist compresses, whirlpool baths, hot showers; diversionary activities: imaging, distraction, hypnosis, biofeedback; rest after activity; avoid overexertion and to maintain proper posture and joint position; encourage use of assistive devices: elevated toilet seat, shower chair, can, walker, wheelchair, reachers, adaptive clothing with Velcro closures, straight-backed chair with elevated seat

RA nursing plans ad interventions

Iodine 131 is given to destroy thyroid cells and is very irritating to the GI tract; place client on radiation precautions

Radiation

Prompt zinc suspension insulin (semilente) onset: 0.5-1 hour peak action: 2-3 hours, human insulin lispro (humalog) onset: 0.5-1 hour peak action: 2-4 hours, insulin aspart (novolog) onset: 5-15 min peak action: 0.75- 1.5 hours; note to be given IV; give within 15 min of a meal

Rapid acting insulin

Offering acceptable, logical explanation to make unacceptable feelings and behavior acceptable' a student who did not do well in a course says it was poorly taught and the course content was not important anyways

Rationalization

Development of conscious attitudes and behaviors that are the opposite of what is really felt; a person who dislikes animals does volunteer work for the Humane society

Reaction formation

Eat more cruciferous vegetables, increase fiber intake, maintain average body weight, eat less animal fat

Recommended diet to prevent bowel cancer

Early sign of colon cancer

Rectal bleeding

Useful for clients with nausea and inability to take anything by mouth; reduced effectiveness with constipation

Rectal route for analgesic

The relaxation of the posterior vaginal wall with prolapse of the rectum

Rectocele

Loss of three or more previable pregnancies; treatment varies based on the cause; if premature cervical dilation is cause, prophylactic cerclage may be done

Recurrent abortions

Paraphrasing or repeating what the client has said

Reflecting/restating

Used for relief of perineal and uterine pain; usually safe for mother and infant unless severe hypotension occurs

Regional block anesthesia

Reverting to an earlier level of development when anxious or highly stressed; after moving to a new home, a 6 year old starts wetting the bed

Regression

When mixing insulins, which is drawn up first

Regular insulin

Visual disturbances; swelling of the face, fingers, or sacrum; severe continuous headache; persistent vomiting; infection; chills, temperature >100.4; dysuria, pain in abdomen; fluid discharge from vagina; changes in fetal movement of increased FHR

Report these changes immediately!!

The involuntary exclusion of a painful thought or memory from awareness; a young man whose mother died when he was 12 cannot tell you how old he was or the year she died

Repression

Male impotence, vaginal dryness, frequent vaginal infections, menstrual irregularities

Reproductive changes in diabetes mellitus

Socially withdrawn; inappropriate affect; eccentric or peculiar behavior; absence of prominent delusions and hallucinations; no current psychotic behavior

Residual

The amount of previous feeding still in the stomach; presence of 100 ml in adult usually indicates poor gastric emptying and feeding should be withheld

Residual feeding

Process taking up to 1+ years, renewed interest in activities

Resolution

Hyperventilation; caused by overventilation on a ventilator, response to acidosis, bacteremia, thyrotoxicosis, fever, hepatic failure, response to hypoxia, hysteria

Respiratory alkalosis

Critical care early in syndrome; neurologic status; maintain ventilation; monitor cardiac parameters; administer mannitol; monitor I&O

Reye syndrome nursing plans and interventions

Post partum drug; Indicated as prevention of Rh isoimmunization with next pregnancy; adverse reactions: none known; given to RH- woman after miscarriage, abortion or any procedure or complication that increases the risk for maternal fetal blood exchange; given at 28 weeks gestation to RH- mothers with a negative antibody titer; given postpartally to RH- mother after delivery or abortion when fetus is RH+; given within 72 hours of delivery; always give IM; is a blood product: must be checked by 2 nurses; syringe must be returned to lab with label; not given to a mother with positive indirect coombs - she has already been sensitized to fetal cells and has developed antibodies

Rh0 (D) immune globulin (RhoGam)

Chronic, systematic, progressive deterioration of the connective tissue of the joint; characterized by inflammation; exact cause is unknown; joint involvement is bilateral and symmetrical

Rheumatoid arthritis

The normal cartilage becomes soft, fissures and pitting occurs, and the cartilage thins. Spurs form and inflammation sets in. the result is deformity marked by immobility, pain and muscle spasm. Treatment is corticosteroids, splinting, immobilization

Rheumatoid arthritis

Fatigue, generalized weakness, weight loss, anorexia, morning stiffness, bilateral inflammation of joints, decreased ROM, joint pain, warmth, edema, erythema, joint deformity

Rheumatoid arthritis nursing assessment

Has broad spectrum effects, inhibits RNA polymerase of tubercule bacillus; side effects: hepatitis, febrile reaction, GI disturbance, peripheral neuropathy, hypersensitivity; used in conjunction with at least one other antitubercular agent; los incidence of side effects; suppression of effect of birth control; possible orange urine.

Rifampin (Rifadin)

Language: may be alert and oriented; memory: disoriented and cannot recognize faces; vision: visual/spatial deficits, neglect of left visual fields, loss of depth perception; behavior: impulsive, unaware of neurologic deficits, confabulates, euphoric, constantly smiles, denies illness, poor judgment, overestimates abilities, impaired sense of humor; loses ability to hear tonal variations

Right hemisphere disruption in the brain

HTN; previous TIAs; cardiac disease; advanced age; diabetes; oral contraceptives; smoking

Risk factors for Stroke: Cerebral Vascular Accident

Diet lacking in iron, folate, and/or vitamin B12; family history of genetic diseases; medication history of anemia-producing drugs, salicylates, thiazides, diuretics; exposure to toxic agents, lead or insecticides

Risk factors for anemia

Positive family history, menarche before 12 years of age and menopause after age 50; nulliparous and those breathing first child after age of 30; history of uterine cancer; daily alcohol intake

Risk factors for breast cancer

Genetic abnormalities; ionizing radiation; viral infections; exposure to benzene; alkylating chemotherapeutic agents; immunosuppreants; chloramphenicol; phenylbitazone

Risk factors for leukemia

Higher in clients who experienced problems during pregnancy and who experienced trauma during L&D

Risk for postpartum infections

Neuroleptic malignant syndrome, RPS, dizziness, nausea, constipation, anxiety

Risperdal

Postpartum drug; indicated if rubella titer of <1:20 or enzyme immunoassay of <0.10; adverse reactions: transient benign arthralgia, transient rash, hypersenivity if allergic to duck eggs; give SC before hospital discharge to non-immune women; breast feed; do not give if women or other family members are immunocompromised; informed consent; avoid pregnancy for 2-3 months after immunization

Rubella vaccine

Highly contagious viral disease that can lead to neurologic problems or death; transmitted by direct contact with droplets from infected persons; contageious mainly during the prodromal period, characertized by fever and upper respiratory symtoms; classic symptoms include photophobia, koplik spots on buccal mucosa; confluent rash that begins on the face and spreads downward

Rubeola (measles)

Head and neck 9%, upper extremities 9% each, lower extremities 18% each, front trunk 18%, back trunk 18%, perineal area 1%

Rule of nines

Nitrazine paper turns black or dark blue; vigainal fluid ferns under microscope; color and maount of amniotic fluid should be noted; allowed to ambulate as long as the FHR is normal and the fetus is engaged

Rupture of membrane

Two lines of pull on the lower extremity, one perpendicular one longitudinal

Russell traction

Extreme fatigue, loss of appetite, unexplained weight loss of more than 10 pounds in 2 months, swollen glands, leg weakness or pain, unexplained fever for more than a week, night sweats, unexplained diarrhea, dry cough, white sports in mouth and throat, painful blisters, painless purple-blue lesions on the skin, confusion, disorientation, recurrent vaginal infections that are resistant to treatment

S&S of HIV

Acute abdominal pain caused by a clot in the ovarian vein Nursing plans and interventions for peritonitis Transferred to ICU; medical emergency; O2 via mask; IV antibiotics; NG tube; assess abdomen 3xd for tympany, distension and BS

S&S of pelvic thrombophlebitis

History of malaise, epigastric or RUQ pain, NV

S&S of preeclampsia

Hypotension, narrow pulse pressure, rapid weak pulse, cold moist skin, increased CAP-REFILL time

S&S of shock and hemorrhage

Lethargy; difficulty waking; temp above 100; vomiting; green, liquid stools; refusal of two feedings in a row

S&S of sick newborn

Represents early ventricular repolarization; measured by the end of the S wave to the beginning of the T wave

ST segment

Socially detached, shy, introverted; avoids interpersonal relationships, lacks social skills; cold, quit, and aloof, has few friends; emotionally detatched, introverted, unresponsive and has autistic thinking; verbally say little, appears withdrawn and seclusive; nonverbally is dull, humorless and has little expression

Schizoid personality disorder

Has interpersonal deficits; occentricities and off beliefs; socially isolated

Schizotypal personality disorder

Lateral curvature of the spine; if severe, it can cause respiratory compromise; surgical correction by spinal fusion or instrumentation may be required if conservative treatment is ineffective

Scoliosis

Deep partial thickness destruction of the epidermis and upper layers of the dermis; injury to deeper portions of the dermis; painful; appears red, white, weeping with fluid, blisters present; hair follicles intact; very edematous; blanking followed by capillary refill; heals without surgical intervention; usually doesn't scar; healing occurs 10-21 days

Second degree burn

A tear that involves the dermis, muscle and fascia

Second degree tear

Heralded by the involuntary need to push, 10 cm dilation and rapid fetal descent and birth; averages 1 hour for a primi and 15 min for a multi; addition of the abdominal focus to the uterine contraction force enhances the cardinal movements of the fetus: engagement, descent, flexion, internal rotation, extension, restitution and external rotation

Second stage of labor

14 weeks through 26 weeks

Second trimester

Quickening occurs; pregnancy becomes real; pregnant women accepts pregnancy; ambivalence wanes

Second trimester psychosocial responses to pregnancy

Rewards obtained from the sick role

Secondary gain

Ovulation to approximately 3 days before the menstrual cycle; estrogen levels level off; progesterone levels increase

Secretory (luteal) phase

Maintain airway: turn client on side to aid ventilation; don't restrain; protect from injury; support head; document; reduce environmental stimuli; pad side rails or crib rails; have suction and oxygen nearby; tape oral airway to the HOB; EEG, CT scan; septic work up;

Seizure nursing plans and interventions

Oxacillin sodium, nafcillin sodium, cloxacillin sodium, dicloxacillin sodium; used for antiinfectives, used primarily for gram-positive infections; adverse reactions: allergic reactions, anaphylaxis, superinfections, all penicillin reactions; cannot be used in patients allergic to allergic to penicillin; caution in clients allergic to cephalosporins; monitor for superinfection

Semisynthetic drugs

A form of hearing loss in which sound passes properly through the outer and middle eat but is distorted by a defect in the inner ear; involves perceptual loss, usually progressive and bilateral; damage to the 8th cranial nerve; detected using a tuning fork; common causes are infections, ototoxic drugs, trauma, neuromas, noise, aging

Sensorineural hearing loss

Rapid onset of chills, high fever, vomiting, marked hypotension, or shock

Sepsis

Ensure patent airway, obtain blood for culture, administer prescribed antibiotics, take VS q 5 min

Sepsis nursing interventions

Related to endotoxins released by bacteria, which cause vascular pooling, diminished venous return, and reduced CO

Septic Shock

Fever, abdominal pain and tenderness; foul-smelling vaginal discharge; bleeding from scant to heavy; treated with termination of pregnancy, antibiotic therapy and monitoring for septic shock

Septic abortion

Positive on these tests occurs usually within 6 weeks to 3 months but may take as long as 12 months

Seroconversion

Drowsiness, dizziness, headache, EPS, anticholinergic effects

Seroquel

Confusion, disorientation, autonomic dysfunction; notify health care provider STAT; support system

Serotonin syndrome

Rapid onset of altered mental states, agitation, myoclonus, hyperreflexia, fever, shivering, diaphoresis, ataxia, diarrhea

Serotonin syndrome

Measures the concentration of particles in a solution

Serum osmolality

Fight-or-flight response; sensory stimuli input to be disorganized; cause perceptions to be distorted; impairs concentration and problem-solving ability; selective attention, focusing only on one detail; verbalization of emotional pain; tremors, increased motor activity

Severe anxiety

Extreme hyperactivity, flight of ideas, nonstop activity, sexual acting out, explicit language, talkativeness, over responsiveness to external stimuli, easily distracted, agitation and possible explosiveness, severe sleep disturbance, delusions of grandeur or persecution

Severe bipolar disorder

Feelings of hopelessness, worthlessness, guilt, shame; despair; flat affect; indecisiveness; lack of motivation; change in physical appearance; suicidal thoughts; possible delusions and hallucination; sleep and appetite disturbance; loss of interest in sex; constipation

Severe depression

Bp rise to 30mmHg systolic and 15mmHg diastolic over previous baseline, or 140/90 or greater; presence of associated conditions; weight gain >1+; edema around the eyes, face and fingers; hyperreflexia 3+; CNS symptoms such as severe headache, visual disturbances, and epigastric pain ; IUGR, evidence by size date discrepancy; BP of 160/110 on 2+ occasions; proteinuria 3-4+; DTRs 3+ and clonus; elevated serum creatinine, thrombocytopenia, marked liver enzyme elevation (SGOT)

Severe preeclampsia

Leads to widespread cellular injury and impairs the integrity of the capillary membranes

Severe shock

Regular insulin (human); onset: 30-60min; peak: 2-3 hours; can be given IV

Short acting insulin

Change in FHR from one beat to the next; monitored by a fetal scalp electrode; if present, the fetus is not experiences cerebral asphyxia, and therefore is not a reassuring sign

Short term variability

18months - 3 years; warn that sibling may regress; present to toddler from the newborn and encourage mother to hug toddler; plan time alone with siblings; abstain from sexual intercourse until lochia has ceased

Sibling rivalry

Keep taking insulin, monitor glucose more frequently, water for signs of hyperglycemia

Sick day rules

Inherited autosomal recessive disorder of hemoglobin; African and eastern Mediterranean descent; appears after 6 months of age; hemoglobin S replaces all or part of the normal hemoglobin, which causes red blood cells to sickle when oxygen is released to the tissues; sickled cells cannot flow through capillary beds, dehydration promote sickling; HGBS has a less than normal lifespan which leads to chronic anemia; tissue ischemia causes widespread pathologic changes in the spleen, liver, kidney, bones and CNS

Sickle cell anemia

Precipitated by hypoxia; provide pain relief, provide adequate hydration; avoid activities that cause hypoxia

Sickle cell crisis

Heroin, morphine, meperidine, codeine, opium, methadone; withdrawal: watery eyes, runny nose, dilated pupils, anxiety, diaphoresis, fever, NVD, achiness, abdominal cramps, insomnia, tachycardia; overdose: respiratory depression leading to respiratory arrest, circulatory depression leading to cardiac arrest, unconsciousness leading to coma, death. Effect is general physical and mental deterioration, rapid tolerance and impaired judgment

Side effects to opiates

Skin mottling, tachycardia, tachypnea, prolonged acrocyanosis

Signs of cold infant

Increased urine SG and oliguria

Signs of dehydration

Poor skin tugor, absence of tears, dry mucous membranes, weight loss, depressed fontanel, decreased UOP, increased SG

Signs of dehydration

Intense perineal pain; swelling and blue-black discoloration on perineum; pallor, tachycardia and hypotension; feeling of pressure in vagina, urethra and bladder; urinary retention and uterine displacement

Signs of hematomas developing in perineum

Singed nasal hairs, circumoral burns, conjunctivitis, sooty or blood sputum, hoarseness, asymmetry of chest movements with respirations and use of accessory muscles indicative of pneumonia; rales, wheezing and rhonchi denoting smoke inhalation

Signs of inhalation burn

Frequent swallowing; vomiting fresh blood; clearing throat; highest risk is during the first 24 hours and then 5-10 days after surgery

Signs of postoperative bleeding with tonsillectomy

Decreased blood pressure; rapid, weak pulse; mottled to gray skin color; changes in mental status

Signs of shock

Rapid pulse, irritability, fever, weight loss, diarrhea

Signs of thyroid medication overdose

Lethargy, fatigue, constipation, poor feeding

Signs of thyroid medication under-dose

Can be therapeutic or can be used to control interaction; use carefully with paranoid client; may be misinterpreted or could be used to support paranoid ideation

Silence

Indicated as prevention of ophthalmia neonatorus resulting from gonorrhea exposure through the birth canal in a vaginal delivery; adverse reactions: chemical conjunctivitis (red, puffy eyes), staining of the skin if contact occurs; mandatory in the US, may not kill other organisms such as Chlamydia species, 2gtt in lower conjunctival sac making sure drops spread over entire eye; don't irrigate eyes after instillation

Silver nitrate

Treatment of burns; usually used with open method of wound care; used to avoid acid=base complication; keeps eschar soft, making debridement easier; adverse reactions: penetrates wound slowly; administer pain medication prior to dressing change

Silver sulfadiazine (silvadene)

Prevent infection on burn sites

Silver sulfadiazine and mafenide acetate

Evaluation of resuscitative efforts; upper chest synchronization; lower chest retractions; xiphoid retractions; nares dilation; expiratory grunt; the lower the score, the better the respiratory status; score of 10 indicates severe respiratory distress; exact opposite of method used for apgar

Silverman-Anderson index of respiratory distress

Affect the infants or child's physical mobility

Skeletal disorders

Pin or wire applies pull directly to the distal bone fragment; 90-degree traction

Skeletal traction

Assess:: loss of tissue or separation at exit site; drainage at exit site; erythema and edema at exit site; spongy feeling at exit site; labored breathing; complaints of pain

Skin erosion/hematomas/scar tissue formation over port/infiltration/extravasation

Dilute medications; administer vesicant drugs; change IV within the timeframe outlined; provide gentle skin care; avoid selecting site over joint; anchor the catheter well

Skin erosion/hematomas/scar tissue formation over port/infiltration/extravasation interventions

Provides a measurement of the body's fat content; one half of the body's total fat stores are directly beneath the skin

Skin fold thickness

Force is applied to the skin; buck extension traction, Russell traction, Bryant traction

Skin traction

A group of disorders characterized by the expression of unexplained physical symptoms that have no physical basis; physical symptom is thought to be an unconscious expression of an internal conflict; occur more often in women and begin before 30 years of age; children may learn that physical complaints are an acceptable coping strategy and are rewarded by receiving attention for this behavior -secondary gain; may abuse analgesics without relief from pain or discomfort; accumulate prescription by doctor shopping to relieve physical symptoms

Somatoform disorders

A defect of vertebrae only; no sac is present and it is usually a benign condition; bowel and bladder problems may occur

Spina bifida occulta

Dimple with or without hair tuft at base of spine

Spina bifida occulta nursing assessment

Disruption in nervous system function which may result in complete or incomplete loss of motor and sensory function. Changes occur in the function of all physiologic systems

Spinal cord injury

Medical emergency; complete loss of all reflex, motor, sensory and autonomic activity below the lesion; hypotentsion, bradycardia; complete paralysis and lack of sensation before lesion; bladder and bowel distension

Spinal shock

Break twists around the bone

Spiral

Fracture line results from twisting force; forms a spiral encircling the bone

Spiral fracture

Indicated by bleeding between conception and 20 weeks gestation; 75% of spontaneous abortions occurs between 8-13 weeks; they are usually related to chromosomal defects; considered a medical emergency;

Spontaneous abortion

Epithelium

Squamous cell

From the beginning of regular contractions or rupture of membranes to 10cm of dilation and 100% effacement

Stage 1 of Intrapartum nursing care

Initial stage; blood loss of less than 10%; compensatory mechanisms triggered; apprehension and restlessness; increased HR; cool, pale skin; fatigue; arteriolar constriction; increased production of ADH; arterial pressure maintained; CO normal; reduction in blood flow to the skin and muscle beds

Stage 1 of hypovolemic shock

Begins at the time of injury and concludes with the restoration of capillary permeability; characterized by fluid shift from intravascular to interstitial and shock; focus of care is to preserve vital organ functioning; expect to administer large volumes of fluids

Stage 1: emergent phase

Compensatory stage; blood volume reduced by 15%-25%; decompensation begins; flattened neck veins and delayed venous filling time; increased HR&RR; pallor, diaphoresis and cool skin; decreased UP; sunken soft eyeballs; confusion; marked reduced in CO; arterial pressure decline; massive adrenergic compensatory response; decrease cerebral perfusion

Stage 2 of Hypovolemic Shock

10 cm to delivery

Stage 2 of Intrapartum nursing care

Beginning of dieresis to near completion of wound closure; characterized by fluid shift from interstitial to intravascular

Stage 2: acute phase

Involvement of lymph node areas on both sides of the diaphragm to localized involvement of one extralymphatic organ, the spleen or both

Stage 3 Hodgkin disease

Progressive stage; edema; increased blood viscosity; excessively low BP; dysrhythmia, ischemia, and MI; weak, thread, or absent peripheral pulses; rapid circulatory deterioration; decreased CO; decreased tissue perfusion; reduced blood volume

Stage 3 of Hypovolemic shock

Delivery of the placenta

Stage 3 of Intrapartum nursing care

Major wound closure to return to optimal level of physical and psychological adjustment; grafting and rehab

Stage 3: rehabilitation phase

Diffuse involvement of one or more extralymphatic organs, with or without lymph node involvement

Stage 4 Hodgkin disease

Irreversible stage; profound hypotension that is unresponsive to vasopressor drugs; severe hypoxemia that is unresponsive to O2; anuria, renal shut down; HR slows, BP falls with consequent cardiac and respiratory arrest; cell destruction so severe that death is inevitable; multiple organ system failure

Stage 4 of Hypovolemic shock

First 1-4 hours following delivery

Stage 4 of Intrapartum nursing care

Fracture lies radiate from one central point

Stellate fracture

Administered after a stroke to decrease cerebral edema and retard permanent disability

Steroids

Hydrocortisone, prednisone, dexmethasone; indicated for hormone replacement, severe rheumatoid arthritis, and autoimmune disorders; adverse reactions: emotional liability, impaired wound healing, skin fragility, abnormal fat disposition, hyperglycemia, hirsutism, moon face, osteoporosis; wean slowly; monitor serum potassium, glucose and sodium; weigh daily and report >5lb/week; administer with antiulcer drugs; prevent injurys; monitor BP and HR

Steroids

Dextroamphetamine sulfate (Dexedrine), methylphenidate HCL (Ritalin), pemoline (cylert); indicated for treatment of ADD/ADHD; methylphenidate is also used to treat narcolepsy; adverse reactions: interact with MAO inhibitors producing fever and hypertensive crisis, nervousness, insomnia, dizziness, tourette syndrome, tachycardia, palpations, angina, dysrhythmias, anorexia, weight loss, nausea and abdominal pain; short acting 2-4 hours; take last does at least 6 hours before bed time; 1-3 doses/day; with or after meals to avoid appetite suppression; monitor HR, rhythm and BP; monitor height and weight to detect growth suppression

Stimulants

The greatest chance for continence with a stoma

Stoma in the sigmoid colon on the left side of the abdomen

Most common organisms for postpartum infections

Streptococcal and anerobic organisms

Quinupristin/dalfopristin (Synercid); used for life-threatening VRE; adverse reactions: arthralgia, myalgia, severe vesicant, pseudo-membrane colitis, NVD, rash, pruritus; incompatiable with any saline solutions or heparin; monitor total bilirubin

Streptogramin

Inhibits protein synthesis and is bactericidal; side effects: ototoxicity, nephrotoxicity, hypersensitivity; cautious use in older adults, those with renal disease and pregnant women; given parenterally

Streptomycin

Sudden loss of brain function resulting from a disruption in the blood supply to a part of the brain; classified as thrombotic or hemorrhagic

Stroke: Cerebral Vascular Accident

Placental site dose not heal; lochia persists, with brisk periods of lochia rubra; D&C may be necessary

Subinvolution

Substitution of an unacceptable feeling by a more socially acceptable one; a student who feels too small to play football becomes a champion marathon swimmer

Sublimation

When providing care to a patient with ARDS, only do this when secretions are present

Suction

First generation: Tolbutamide (oranase), chlorpropamide (diabinase), second generation: Glyburide (micronase, diabeta), glipizide (glucotrol), glimeprode (amaryl); lowers blood sugar by stimulating the release of insulin by the beta cells of the pancreas + causes tissues to take up and store glucose more easily; first generation are low potency and short acting; second generation are high potency and longer acting; adverse reactions: first generations: hypoglycemia, nausea, heartburn, constipation, anorexia, agranulocytosis, allergic skin reactions; second generation reactions: weight gain, hypoglycemia; first generation: responsiveness may decrease over time; once daily with first meal; monitor blood sugar; hard to detect hypoglycemia; second generation: less likely to interact with other medications

Sulfonylureas

Intentional exclusion of feelings or ideas; when about to lose Tara, scarlet O'Hara says "ill think about it tomorrow"

Suppression

Usually done before preschool years to allow for the achievement of sexual identity, to avoid castration anxiety, ad to facilitate toilet training

Surgical correction for hypospadias

Meaning given to words by client to screen thoughts and feelings that would be difficult to handle if stated directly

Symbolism

Chest pain or discomfort at rest or with ordinary activity; change in previous angina pain; increase in frequency in CP or severity or rest angina; chest pain in a client with known coronary heart disease that is unrelieved by rest of nitroglycerin

Symptoms immediately preceding MI

Abdominal distension; vomiting; increased abdominal tenderness; irritability; dyspnea and cyansis

Symptoms of bowel perforation

Glossitis, cracked lips, dry brittle hair, dental caries, peridontitis, weight

Symptoms of malnutrition

Signs of ovulation should be taught: cervical mucus assessment, basal body temperature assessment, mittelschmerz

Symptotjermal, protjermal or fertility awareness

Line the bones of the joints. Inflammation of this lining causes destruction of tissue and bone. Early detection of RA can decrease the amount of bone and joint destruction. Often the disease goes into remission. Decreasing the amount of bone and joint destruction deduces the amount of disability

Synovial tissues

No longer recommended for poisonings; this is because inducing vomiting may cause more damage

Syrup of ipecac

Used to induce vomiting; if not vomited and is absorbed, cardiotoxicity may occur and can cause conduction disturbances, cardiac dysrhythmias, fetal myocarditis and circulatory failure; assess for edema and listen to breath sounds

Syrup of ipecac

Marked reduction in either cardiac output or peripheral vasomotor tone, without a compensatory elevation in the other results in this

System Hypotension

Can cause major body organ and system failure; more prevalent that DLE

Systemic Lupus erythematosus

If defibrillation occurs during this phase, the heart can be thrust into a life-threatening dysrhythmia

T wave

Ventricular diastole; represents repolarization of the ventricular muscle; critical time in heartbeat; resting and regrouping stage so that the next beat can occur

T wave

Baseline FHR is >180 for 10 minutes; causes are: early sign of hypoxia, fetal anemia, dehydration, maternal infection, maternal fever, maternal hyperthyroid disease, medication induced

Tachycardia

Dependency behaviors for 24-48 hours; asking for help on the simplest tasks

Taking in phase

Failing to address the orginal point, giving many nonessential details

Tangential or circumstantial speech

Advantages: low cost, distinct immunologic advantages for newborn; milk production is stimulated by decrease in postpartum estrogen production, which allows release of prolactin from the pituitary; the let down reflex is caused by action of oxytocin released from the posterior pituitary, which stimulates myoepithelial cells around milk ducts and sinuses; avoid dieting, add 500 calories to pre-pregnancy intake, drink 8 glasses of non-caffeinated beverages daily; avoid smoking, intake of drugs, alcohol or caffeine, avoid stress; should remain on first breast 10 minutes, then switch to the second breast and suckle until satisfied; use warm water, not drying soap on nipples, let nipples air dry 15 minutesx2-3/day; for engorgement: nurse more frequently, and manually express milk to soften areola before feeding, wear supportive bra, take warm or hot showers, watch for symptoms of mastitis; incorrect position is the most common reason for sore nipples, make sure the is as much areola in baby's mouth as possible, break suction with insertion of little finger into baby's mouth

Teaching breast feeding

Petechiae; nose bleeds bleeding gums; eccymosis

Tendency to bleed

Tetracycline HCL, Doxycycline hyclate (Vibramycin); used as antiinfectives; adverse reactions include photosensitivity and hypersensitivity reactions; decreased effectiveness of oral contraceptives; avoid concurrent use of antacids, milk products; inspect IV site, monitor for superinfections; avoid exposure to sunlight; avoid use in pregnant clients and children under 8 years; can cause yellow-brown discoloration of teeth and growth retardation

Tetracyclines

Decreased pulmonary blood flow; combination of 4 defects: ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy; aorta placed over and above the ventricular septal defect; cyanosis occurs because unoxygenated blood is pumped into the systemic circulation; decreased pulmonary circulation occurs because of the pulmonary stenosis; experiences tet spells; needs surgery

Tetralogy of fallot

During the immediate transitional period (6-8 hours of life) and the early newborn period (first few days of life) the nurse assesses, plans and provides nursing interventions based on the outcomes of the individual newborn's exam

The normal newborn

Indicated as a bronchodilator, used in asthma to reverse bronchospasm; adverse reactions: tachycardia, irritability, palpitations, hypotension, NV; auscultate lungs before and after administration; monitor blood levels

Theophylline (theo-dur)

Chlorthalidone (hygroton), hydrochlororthiazide (esidrix, microzide), indapamide (lozol), metolazone (zaroxolyn); indicated for decreased fluid volume, inexpensive, effective, useful in severe hypertension, effective orally, enhances other antihypertensives; adverse reactions: hypokalemia symptoms, hyperuricemia, glucose tolerance, hypercholesterolemia, sexual dysfunction; observe for postural hypotension, caution with renal failure gout and client taking lithium; hypokalemia increases risk for digitalis toxicity, administer postassium supplements

Thiazide diuretics

Rosiglitazone (avandia), pioglitazone (actos); lowers BS by decreasing insulin resistance of the tissues; adverse reactions: hypoglycemia, increased total cholesterol, weight gain, edema, anemia; skip dose if meal skipped; no known drug interactions; monitor liver function; caution with use in CAD; may precipitate HF

Thiazolidinediones

A tear that extends into the anal sphincter

Third degree tear

Becomes introverted and self-absorbed; begins to ignore partner

Third trimester psychosocial responses to pregnancy

In patient's with hip fractures, this is the most common complication; prevention includes ROM, elastic stocking, elevation of the foot, low dose heparin

Thromboembolism

Occurs 6-14 days post-op; leg exercises q8h while in bed, early ambulation, TED or SCDs, low dose heparin prophylactically

Thrombophlebitis

Deep vein thrombosis; minimal fever; positive humans sign; pain in calf or dull ache in the leg; swelling

Thromobophlebitis

Check frequently for bleeding; support the neck when moving the client; laryngeal edema damage by watching for hoarseness or inability to speak clearly; keep any drainage devices compressed and empty

Thyroidectomy

Grand mal seizure; consciousness is lost

Tonic clonic seizure

Used to measure intraocular pressure

Tonometer

Inflammation of the tonsils; viral or bacterial; related to infection by streptococcus species; treatment is very important due to the risk for developing acute glomerulonephritis or rheumatic heart disease

Tonsillitis

Irinotecan (camptosar), topotecan (hycamtin); indicated for use after failure of initial treatment of ovarian, small cell lung and colorectal cancers; adverse reactions: myelosuppression, moderate NVD; antiemetic PRN

Topoisomerase-I inhibitors

Preterm or post-surgical neonate who cannot handle or cannot metabolize enteral feedings; monitor glucose, serum and urine; IV fluids with dextrose content >12.5% through central line; calcium supplement and vitamin D to prevent rickets; vitamin E to enhance cellular integrity

Total parenteral nutrition

Hyperglycemia, electrolyte imbalance, infection, and dehydration

Total parenteral nutrition complications

Board and mallet, push-pull toys, toy telephones, stuffed animals, and story books with pictures

Toys for a 1-3 year old

Coloring books, puzzles, cutting and pasting, dolls, building blocks, clay and stuff that allows the preschooler to work out hospitalization experience

Toys for a 3-5 year old

Board games, card games, and hobbies, stamp collecting, puzzles, videogame

Toys for a 6-12 years

Mobiles, rattles, squeaking toys, pictures books, balls, colored blocks and activity boxes

Toys for a child from birth to one year

Tertralogy of fallot, truncus arteriosus, transposition of the great arteries

Traditional three T's of cyanotic heart disease

Mechanism of action, efficacy, contraindications and side effects are similar to those of oral contraceptives; continuous levels of progesterone and estradiol; applied to lower abdomen, upper outer arm, buttock or upper torso; applied on the same day ones a week for 3 weeks followed by 1 week without the patch

Transdermal contraceptive patch

Applied to the skin; deliver hormonal therapy, nitroglycerin and nicotine; document removal of old patch , site and application date and time of new patch

Transdermal patches

From 8-10cm cervical dilatation; changed behavior, sudden nausea and hiccups; extreme irritability and unwillingness to be touched; contractions are severe 1.5 minutes apart and 60-90 seconds duration

Transitions phase of the first stage of labor

Missed blood flow; the great vessles are reversed; the pulmonary circulation arises from the left ventricle, and systemic circulation arises from the right ventricle; incompatible with like unless coexisting VSD, ASD, and/or PDA is present; medical emergency; given prostaglandin E to keep the ductus open

Transposition of the great vessels

Fracture line occurs at a 90degree angle to the longitudinal axis of the bone

Transverse fracture

If in doubt whether a client is hyperglycemic or hypoglycemic, treat for this??

Treat for hypoglycemia

Radiotherapy; chemotherapy: nitrogen mustard, adriamycinm vincristine, prednisone

Treatment for Hodgkin disease

Disappear during sleep and purposeful activity

Tremors

Laboratory diagnosis: VDRL, FTA-ABS; symptoms: primary (local): up to 90 days re-exposure, chancre (red, painless lesions with indurated border), highly infectious; secondary (systematic): 6weeks- 6 months post exposure, influenze-type symptoms, generalized rash that affects palms of hands and soles of feet; lesions are contagious; tertiary: 10-30 years post exposure: cardiac and neurologic destruction; treatment is with penicillin G IM (2.4-4.8 million units)

Treponema pallidum, syphillus

Laboratory diagnosis: wet slide; symptoms: female: green, yellow or frothy foul smelling vaginal discharge with itching; males: asymptomatic; treated with metronidazole (flagyl)

Trichomanas vaginalis, trichomoniasis

Amitriptyline HCL (elavil), desorpramine HCL (norpramin), imipramine HCL (tofranil), nortiptyline HCL (aventyl), protiptyline HCL (Vivactil), maprotiline (ludiomil); indicated for depression clients with morbid fantasies don't respond to these dugs; adverse reactions: anticholinergic effects; CNS effects such as sedation, poor concentration; cardiovascular effects such as orthostatic hypotension, quindine like effect on the heart, tachycardia; administer at bedtime, 2-3 weeks to achieve effects; 1-2 weeks should elapse between discontinusing this and initiating MAO inhibitors; avoid alcohol; avoid concurrent use of antihypertensive drugs; evaluate suicide risk

Tricyclic antidepressant drugs

Pain in the lower back that radiates to the abdomen; pain accompanied y regular rhythmic contractions; contractions that intensify with ambulation; progressive cervical dilation and effacement

True labor

Pulmonary artery and aorta do not separate; one main vessel receives blood from the left and right ventricles together; blood mixes in right and left ventricales through a large ventricular septal defect, resulting in cyansis; requires surgical correction

Truncus arteriosus

Communicable lung disease caused by an infection by mycobacterium tuberculosis bacteria; airborne transmission bacteria remain dormant until a later time

Tuberculosis

Offers screening for exposure; mantoux test with PPD injected intradermally on the forearm; tine test - 4 prongs pressed into the forearm should not be used to determine the presence of infection; positive reaction represents exposure

Tuberculosis skin testing

Insulin dependent diabetes

Type 1

Hyperglycemic relatively easily; brittle diabetics; can go into ketoacidosis; serum glucose of >350; ketonuria in large amounts; venous pH of 6.8 to 7.2; serum bicarbonate below <15mEq/dl

Type 1 (IDDM)

Insulin dependent; hemoglobin A1c test

Type 1 diabetes

Usually diagnosed during school age to older adult; insulin production is present but in adequate; onset is insidious; S&S polydipsia, polyphagia, polyuria, weight loss, weakness, blurred vision - symptoms are often unnoticed; weight is usually obese; ketosis is rare; strong predisposition in regard to genetics; pathogenesis is obesity and nutrition; control is often with diet and exercise; meal planning and exercise is imperative; insulin may be required along with oral hypoglycemics; long term complications are common

Type 2 (NIDDM)

Usually with isotonic IV fluid replacement and careful monitoring potassium and glucose levels; IV insulin

Type 2 (NIDDM) treatment

Non-insulin dependent; in pregnancy, insulin is required to control maternal blood glucose levels

Type 2 diabetes

Gestational diabetes; onset during pregnancy and return to normal glucose tolerance after delivery

Type 3 diabetes

Usually with isotonic IV fluids; slow IV infusion by IV pump regular insulin; careful replacement of potassium

Type I (IDDM) treatment

Grief, guilt, disappointment, sense of loss, anger

Typical parent and family reactions to child with deformity

Not always present; most prominent in the presence of hypokalemia

U wave

High-frequency sound waves are beamed onto the abdomen; echoes are returned to a machine that records the fetus' location and size; used in first trimester to determine number of fetuses, presence of fetal cardiac movement and rhythm, uterine abnormalities, gestational age; used in the second and third trimesters to determine fetal viability and gestational age, size-date discrepancies, amniotic fluid volume, placental location and maturity, uterine anomalies and abnormalities, results of amniocentesis

Ultrasonography

FHR is apparent as early as 6-7weeks; serial evaluation of biparietal diameter and limb length can differentiate between wrong dates and true IUGR; BPP

Ultrasonography findings

Prominent delusions and hallucinations; incoherence and grossly disorganized behaviors; failure to meet any of the criteria for other types

Undifferentiated

Communication or behavior done to negate a previously unacceptable act; a young man who used to hunt wild animals now chairs a committee for the protection of animals

Undoing

Increase fluid PO via gastric tube; increase urine for high SG and balance between I&O; reposition every 2 hours; apply splints or other assistive devices to prevent foot drops, wrist drop or other improper alignment

Urinary calculi

Occurs 8-12 hours post-op; monitor hydration status and encourage oral intake; offer bedpan or assist with commode

Urinary retention

Common cause of death after spinal cord injury; bacteria grow best in alkaline media; keep dilute and acidic; keep emptied to assist in avoiding bacterial growth

Urinary tract infection

Slight or no temperaruee; dysuria, frequency, urgency, suprapubic tenderness; hematuria, bacteriuria; cloudy urine

Urinary tract infection

Useful in therapeutic interaction; keep interaction open, genuine and client centered; keep client as focus; be aware of own feelings and anxiety level; tell me about...; go on...; I'd like to discuss what you are thinking; what are your thoughts? Are you saying that...; what are you feeling...; it seems as if

Useful phrases

Preceded by antiseptic cleansing with client in modified lithotomy position; sterile gloves are worn; exams are not done routinely; prior to analgesia/anesthesia, done to determine progress of labor (dilation of cervix, cervical effacement, and cervical position), done to determine whether second stage pushing can begin

Vaginal examination

Indicated for absence seizures and myoclonic seizures; adverse reactions: hepatotoxicity, especially in children less than 2 years old; prolonged bleeding times, GI disturbances; monitor liver function; potentiated Phenobarbital and dilantin; therapeutic levels: 50-100meg/ml

Valporic acid (depakene)

Common periodic pattern; occurs in 40% of all labors and is caused mainly by cord compression but could also indicate rapid fetal descent; abrupt transitory decrease in the FHR that is variable in duration, depth of fall, and timing relative to the contraction cycle

Variable deceleration

School requirement in 33 states; safe for children with asymptomatic HIV infection; administer at 12-18 months of age; give with MMR on same day or >30 days apart in a separate site

Varicella

Viral disease characterized by skin lesions; lesions begin on the trunk and spread to the face and proximal extremities; transmitted by direct contact, droplet spread or freshly contaminated objects; communicable prodromal period to the time all lesions have crusted; progress through macular, popular, vesicular, and pustular stages

Varicella (chicken pox)

Mesenteric artery occlusions which can lead to gut infarct

Vascular causes of intestinal obstruction

Fever; severe abdominal pain; hand-foot syndrome; painful edematous hands and feet; arthralgia

Vaso-occlusive crisis

If drop in BP occurs, decrease ?? infusion rate first, then increase ?? rate

Vasodilator; Vasopressor

Hydralazine HCL (apresoline), Minoxidil (loniten); decreased BP by decreasing peripheral resistance; adverse reactions: headache, tachycardia, fluid retention (HF, pulmonary edema), postural hypotension; monitor BP and HR routinely, peripheral edema, I&O, weigh daily

Vasodilators

If BP increases, decrease ?? rate first, then increase the rate of the ??

Vasopressor; Vasodilator

When administering these medications to a patient in shock, they must be administered via a volume-controlled pump; monitor BP q 5-15 min; watch IV site carefully for extravasation and tissue damage; ask about the target mean systolic BP

Vasopressors or adrenergic stimulants

Epinephrine (Bronkaid). Dopamine (Dopram), Dobutamine (Dobutrex), norepinephrine (Levophed), isoproterenol (Isuprel)

Vasopressors or adrenergic stimulants used in shock patients

Head , cephalic

Vertex

May involve part of the fundus, resulting in more PO pain, more bleeding and an increased chance for uterine rupture

Vertical incision

Signs of deficiency: dry, rough skin, dull cornea, soft cornea, bitot spots, night blindness, defective tooth enamel, retarded growth, impaired bone formation, decreased thyroxine formation; food sources: liver, sweet potatoes, carrots, spinach, peaches, apricots

Vitamin A (retinol)

Signs of deficiency: scaly dermatitis, weight loss, anemia, irritability, convulsions, peripheral neuritis; food sources: meats, liver, cereals, yeast, soybeans, peanuts, tuna, chicken, bananas

Vitamin B6 (pyridoxine)

Signs of deficiency: scurvy, receding gums that are spongy and prone to bleeding, dry rough skin, petechiae, decreased wound healing, increased susceptibility to infection, irritability, anorexia, apprehension; food sources: strawberries, oranges and orange juice, tomatoes, broccoli, cabbage, cauliflower, spinach

Vitamin C (ascorbic acid)

Usually given to patients in shock

Volume expanding drugs

Uterine contractions q10min or more often; menstrual like cramps; low, dull backache and pelvic pressure; increase or change in vaginal discharge; rupture of membranes

Warning signs of labor

O2 must go through ?? so it can be humified if given at >4L/min or delivered directly to the trachea. When given at 1-4L/min or by mask/nasal prongs, the oropharynx and nasal pharynx provides adequate humidification

Water solution

3.5-5lb in the first trimester is recommended; 2-4 is the average; 0.9lb per week thereafter is normal (>2lb per week is related to preeclampsia edema); total should be 25-35 pounds

Weight gain

Reflect present nutritional status as well as protein and fat reserves

Weight, skinfold thickness and arm circumference

7lb 8oz; majority weight between 6-9lbs (2700-4000g); weight at birth and daily; normally loses 5%-15% of birth weight in the first week of life

Weight: normal newborn norms

Eat raw fruits or vegetables; be present in crowded areas or around people with infection; eat raw foods

What patients on chemotherapy should not do

The pain is real to the person experiencing it but it cannot be explained medically; result from internal conflict; acknowledge the symptom or complaint; reaffirm that diagnostic test results reveal no organic pathology; determine the secondary gains acquired by the client

What the nurse should do for somatoform disorders

Immediately turn client onto left side; increase IV infusion; begin O2 at 10L/min by face mask; notify health care provider stat and have ephedrine available; assess FHR

What to do if hypotension occurs

Maintain patent airway; keep client warm and free of constricting clothing; keep clients legs elevated

What to do if patient in shock arrives at the hospital

Turn off oxytocin, turn client to a side lying position, administer O2 by face mask

What to do if tetany occurs

A malignant renal tumor; embryonic in origin; encapsulated; occurs in preschool children; with early detection, surgery, adjuvant chemotherapy, as well as radiation therapy postoperatively, the prognosis is good