1 ADDISONS (TOO LITTLE CORTISOL IN THE BLOOD)==è HYPERPIGMENT SODIUM DOWN BP DOWN BLOOD VOLUME DOWN GLUCOSE DOWN POTASSIUM UP CUSHINGS (TOO MUCH CORTISOL IN THE BLOOD) SODIUM UP BP UP BLOOD VOL UP GLUCOSE UP POTASSIUM DOWN MNEMONIC: RN DELEGATION==èDON’T DELEGATE WHAT YOU CAN TAPE • T: TEACHING • A: ASSESSMENT • P: PLANNING • E: EVALUATE RN DELEGATION TO LPN: • M: MEDICATIONS (REGULAR) • R: RE-INFORCE TEACHING • S: SPECIFIC ASSESSMENT (LUNGS, NEUROVASCULAR, VITAL SIGNS) • M: MONITOR • O: OSTOMIES • R: ROUTINE PROCEDURES (FOLEY CATH) • T: TUBES (SUCTION, PENROSE, FEEDING, TPN) RN DELEGATION TO CNA/UAP/HCA===èANY ROUTINE ADLS • A: AMBULATE, ADLs • S: SHOWER OR BATHING • S: SCALE (WEIGHING) • I: INTAKE/OUTPUT RECORDING • S: SHEET OR LINEN CHANGES
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ADDISONS SODIUM BP BLOOD GLUCOSE POTASSIUM VOLUME … · nursing interventions are required right now but continue to monitor. NOT GOOD NCLEX may ask what is causing this type of
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ADDISONS (TOO LITTLE
CORTISOL IN
THE BLOOD)==è
HYPERPIGMENT
SODIUM
DOWN
BP
DOWN
BLOOD VOLUME
DOWN
GLUCOSE
DOWN
POTASSIUM
UP
CUSHINGS (TOO MUCH
CORTISOL IN
THE BLOOD)
SODIUM
UP
BP
UP
BLOOD VOL
UP
GLUCOSE
UP
POTASSIUM
DOWN
MNEMONIC: RN DELEGATION==èDON’T DELEGATE WHAT YOU CAN TAPE
BRADYCARDIA, ETC)====èMNEMONIC (LOINS)===è TURN ON LEFT SIDE (AND GIVE O2, STOP PITOCIN/OXTOCIN, INCREASE IV FLUIDS)====è
MNEMONIC:
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NO CONCERNS. MONITOR, AND DOCUMENT
NOT GOOD
WHAT IS THE NURSING PRIORITY====THINK===èLOINS: Change mom’s position (moving her
around could help relieve cord compression), administer Oxygen usually 10 L (because cord is being compressed which in turn is causing the baby to not receive enough Oxygen), stop Picotin infusion if
running, and contact the doctor. Plus you may be asked on the exam what is causing this strip to look like
this and the answer would be cord compression.
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Nothing to be alarmed about.
What is the Nursing Priority? Continue to monitor and document the process of the labor or no nursing interventions are required right now but continue to monitor.
NOT GOOD
NCLEX may ask what is causing this type of strip and the answer would be placental-uterine insufficiency. What is the nursing Priority?====èThink==èLOINS TURN MOM ONTO HER SIDE, STOP PITOCIN IF INFUSING, ADMINISTER 10 L OF O2, MAINTAIN IV ACCESS, DETERMINE THE FETAL HEART RATE VARIABILITY, AND CONTACT DOCTOR.
WHAT TYPES OF INJURIES WILL CAUSE SYSTEMIC INFLAMMATORY RESPONSE SYNDROME?
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• BURN INJURY
• CRUAH INJURY • MAJOR SURGERY
• BOWEL ISCHEMIA
3. TUBE FEEDING W/ DECREASED LOC --> POSITION PT ON RIGHT SIDE (PROMOTES EMPTYING OF THE STOMACH) WITH THE HOB ELEVATED (TO PREVENT ASPIRATION)
4. DURING EPIDURAL PUNCTURE --> SIDE-LYING
5. AFTER LUMBAR PUNCTURE (AND ALSO OIL-BASED MYELOGRAM)--> PT LIES IN FLAT SUPINE (TO PREVENT HEADACHE AND LEAKING OF CSF)
PRIORIY==èPLACE CLIENT IN SITTING POSITION (ELEVATE HOB) FIRST BEFORE ANY OTHER IMPLEMENTATION. OTHER PRIORITIES ARE===èCHECK FOR BLADDER DISTENTION; CHECK
BP; REMOVE CONSTRICTIVE CLOTHINGS; NOTIFY HCP.
25. SHOCK ===è BEDREST WITH EXTREMITIES ELEVATED 20 DEGREES, KNEES STRAIGHT, HEAD SLIGHTLY ELEVATED (MODIFIED TRENDELENBURG)
S/S OF SHOCK:
S: SOB H: HYPOTENSION, HIGH HR, HIGH RR O: OLIGURIA (LOW URINE OUTPUT) C: CONFUSION (ALTERED MENAL STATUS), COOL, CLAMMY SKIN K: KIDNEY FAILURE (HIGH SERUM CREATINE)
26. HEAD INJURY===è ELEVATE HOB 30 DEGREES TO DECREASE INTRACRANIAL PRESSURE 27. PERITONEAL DIALYSIS WHEN OUTFLOW IS INADEQUATE --> TURN PT FROM SIDE
TO SIDE BEFORE CHECKING FOR KINKS IN TUBING (ACCORDING TO KAPLAN)
28. LUMBAR PUNCTURE => AFTER THE PROCEDURE, THE CLIENT SHOULD BE PLACED IN THE SUPINE POSITION FOR 4 TO 12 HRS AS PRESCRIBED.
29. GIVE DEMOROL FOR PANCREATITIS, NOT MORPHINE SULFATE
30. MYASTHENIA GRAVIS=====AUTOIMMUNE===èEFFECT ON NEURO-MUSCULAR
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JUNCTION===èMUSCLE WEAKNESS FROM HEAD TO TOE. WORSENS WITH EXERCISE AND
IMPROVES WITH REST. NURSING PRIORTY====èMONITOR AIRWAY. OTHER PRIORITIES ARE==èADMINISTER ANTICHOLINESTERASE (PYRIDOSTIGMINE) BEFORE MEALS; ENCOURGE
SEMI-SOLID FOOD; TEACH THE IMPORTANCE OF THE NECESSARY VACCINATIONS (FLU &
PNEUMONIA SHOTS).
31. MYASTHENIA CRISIS===è A POSITIVE REACTION TO TENSILON===èWILL IMPROVE
SYMPTOMS
32. CHOLINERGIC CRISIS===è CAUSED BY EXCESSIVE MEDICATION==èSTOP MED-GIVING TENSILON WILL MAKE IT WORSE
33. HEAD INJURY MEDICATION==è MANNITOL (OSMOTIC DIURETIC)-CRYSTALLIZES AT
ROOM TEMP SO ALWAYS USE FILTER NEEDLE
34. PRIOR TO A LIVER BIOSPY ===èCHECK PROTHROMBIN TIME BEFORE THE PROCEDURE
35. FROM THE ASS (DIARRHEA)==è METABOLIC ACIDOSIS. FROM THE MOUTH
(VOMITUS)==èMETABOLIC ALKALOSIS
36. MYXEDEMA/HYPOTHYROIDISM==è SLOWED PHYSICAL AND MENTAL FUNCTION,
SENSITIVITY TO COLD, DRY SKIN AND HAIR.
37. GRAVES’ DISEASE/HYPERTHYROIDISM===è INCREASED T3 & T4. INCREASED DIFFUSED UPTAKE RAIU; BODY IS BURNING TOO MUCH ENERGY ===è S/S==èANXIETY, PALPITATION,
WEIGHT LOSS WITHOUT LOSS OF APPETITE, HEAT INTOLERANCE, SWEATING, TREMORS,
DIARRHEA, INSOMNIA, HTN, ATRIAL FIBRILLATION, LID LAG (SLOW EYE MOVEMENT), HYPER-REFLEXIA.
38. EXOPHALMOS===èCOMPLICATION OF GRAVES DISEASE. NURSING ACTION===èGIVE
ARTIFICIAL TEAR DROPS; TAPE EYELID DURING SLEEP IF EYELID CANNOT CLOSE; NEEDS EYE GLASSES TO PREVENT IRRITATION; ADVISE PT TO STOP SMOKING; RESTRICT SALT INTAKE TO
REMEMBER THAT QT INTERVAL IS INVERSELY PROPORTIONAL TO CALCIUM. NURSING
PRIORITY===èCHECK SERUM CALCIUM LEVEL; TREATMENT====èGIVE ORAL CALCIUM; FOR VIT D DEFICIENCY===èGIVE VIT D + CALCIUM.
44. OTHER CAUSES OF LOW CALCIUM
• RENAL FAILURE===èDECREASED CALCIUM & INCREASED PHOSPHORUS • VIT D DEFICIENCY====èDECREASED CALCIUM & DECREASED PHOSPHORUS
• LOW SERUM MAGNESIUM===èHAS THE SAME S/S AS LOW CALCIUM
45. PRIMARY HYPER-PARATHYROID====è MOST COMMON CAUSE OF INCREASED SERUM CALCIUM (HYPERCALCEMIA WITH SERUM Ca >10.5)===èS/S===èFATIGUE, MUSCLE WEAKNESS,
CONSTIPATION, DECREASED MENTAL ACTIVITY, KIDNEY STONE, BACK AND JOINT PAIN,
49. DIABETES INSIPIDUS (DUE TO DECREASED ADH)===è S/S===èPOLYURIA (EXCESSIVE,
DILUTED URINE OUTPUT), POLYDIPSIA (THIRST), DEHYDRATION, WEAKNESS. PATIENT WILL HAVE INCREASED SERUM SODIUM (INCREASE BLOOD SODIUM CONCENTRATION/OSMOLARITY),
DECREASED URINE SODIUM (DECREASED URINE SPECIFIC GRAVITY), THIRSTY AND WEIGHT
LOSS. NURSING PRIORITY===èREHYDRATION (FLUID REPLACEMENT TO PREVENT DEHYDRATION) AND IV DDAVP (DESMOPRESSIN). NURSING CARE PLAN====èMONITOR===è
INTAKE/OUTPUT, SPECIFIC GRAVITY WILL BE LOW, SERUM SODIUM WILL BE HIGH.
50. SIADH (INCREASED ADH)===èPATIENT WILL BE RETAINING FLUID. SIGNS====èPATIENT WILL HAVE DECREASED SERUM SODIUM, WEIGHT GAIN, DECREASE URINARY OUTPUT,
69. WHEN MIXING UP NPH & REGULAR INSULIN TOGETHER===èMNEMONIC====èNEWLY
REGISTERED-RN===èNR-RN==èINJECT AIR INTO NPH, INJECT AIR INTO REGULAR; DRAW REGULAR, DRAW NPH.
70. TETRALOGY OF FALLOT===èMURMUR IS EXPECTED====è4 DEFECTS IN THE
HEART===èMNEMONIC====èPROV.
• P==èPULMONARY STENOSIS
• R==èRIGHT VENTRICULAR HYPERTROPHY
• O==èOVERIDING OF THE AORTA • V==èVENTRICULAR SEPTAL DEFECT (VSD)
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71. TETRALOGY OF FALLOT====èIS THE MOST COMMON CYANOTIC CONGENITAL HEART
DEFECT IN CHILDREN. LOOK FOR A CHILD WITH IRRITABILITY, EXTREMELY CYANOSIS (TET SPELL) WITH EXERTION (WHEN CRYING, UPSET OR FEEDING). NURSES FIRST
ACTION===èPLACE CHILD IN KNEEL TO CHEST POSITION OR SQUATTING POSITION TO FEEL
BETTER.
72. TETRALOGY OF FALLOT====èWHAT SHOULD THE NURSE TEACH THE PARENTS TO
REPORT? =èNURSING PRIORITY TO REPORT==èELEVATED HEMOGLOBIN LEVEL HgB
>25=èPOLYCETHEMIA; REDUCTION OF NUMBER OF WET DIAPERS; PUFFINESS AROUND THE EYES; COOL EXTREMITIES; WEAK PULSES, ACTIVITY INTOLERANCE (INABILITY TO FEED), PALE
AND IRRITABLE, HYPOTENSION, TACHCARDIA, TACHYPNEA, WEIGHT GAIN, ELEVATED JVD.
73. MONOAMINE OXIDASE INHIBITORS===èMAOI'S====èARE USED AS ANTIDEPRESSANTS. NURSING PRIORITY====èPREVENT HYPERTENSIVE CRISIS====èAVOID
FOOD HIGH IN TYRAMINE (OLD CHEESE, RED WINE, BEER, CHOCOLATE, AVOCADOS, CURED
MEAT).
EASY WAY TO REMEMBER MAOI'S DRUGS===èPANAMA!
• PA - PARNATE (Tranylcypromine) • NA - NARDIL (PHENELZINE)
• MA - MARPLAN (Isocarboxazid)
74. MIXING MAOIS WITH SSRIS, TRAMADOL, ODANSETRON, DEXTROMETHORPHAN, ST JOHNS WORT====èLEAD TO====èSEROTONIN SYNDROME.
75. MAOIS====èINCREASES SUICIDAL RISK====èIN CHILDREN, ADOLESANTS AND THE
ELDERLY. NURSING PRIORITY=====èASSESS SUICIDAL RISK (FEELINGS OF HOPELESSNESS, SELF HARM).
76. WHEN SWITCHING FROM MAOI TO ANOTHER ANTIDEPRESSANT MEDICATION===èSSRI;
77. DIGOXIN===èCHECK PULSE BEFORE STARTING; LESS THAN 60 HOLD; NOTIFY HCP;
CHECK DIG LEVELS AND POTASSIUM LEVELS.
78. DIGOXIN TOXICITY====èMNEMONIC===èHAD NAUSEA/VOMITING==è (HALO AROUND OBJECT, BLINDNESS); GI SYMPTOMS (ABD PAIN, ANOREXIA, DIARRHEA, NAUSEA/VOMITING); NEUROLOGICAL SYMPTOMS (ALTERED MENTAL STATUS, WEAKNESS, LETHARGY)====èREPORT TO HCP. What is the normal digoxin level?===è 0.5-0.8 ug/ml 79. When on digoxin, too low of K+ can lead to? ===èDigoxin toxicity
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80. When on digoxin too high K+ can lead to? ===èLower therapeutic level 81. MONITOR SERUM CREATININE WHEN PATIENT IS ON DIGOXIN====èDIGOXIN IS
EXCREATED ALMOST EXCLUSIVELY BY THE KIDNEY
81. AMPHOJEL (Aluminum hydroxide)===è TX OF GERD AND KIDNEY STONES===èWATCH OUT FOR CONSTIPATION. 82. VISTARIL (HYDROXYZINE)===èANTI-HISTAMINE====èTX OF ANXIETY AND ALSO
ITCHING====èWATCH FOR DRY MOUTH.
83. VERSED===èGIVEN FOR CONSCIOUS SEDATION===èWATCH FOR RESP DEPRESSION AND HYPOTENSION
84. PTU AND METHIMAZOLE===èPREVENTION OF THYROID STORM====èREPORT S/S OF
INFECTION (AGGRANULOCYTOSIS)
85. SINEMET===èTX OF PARKINSON===èWATCH OUT FOR====èRISK FOR
FALL====èMAY CAUSE ORTHOSTATIC HYPOTENSION, DIZZINESS, INVOLUNTARY MOVEMENTS.
PATIENT SHOULD NEVER STOP MEDICATION SUDDENLY
86. ARTANE====èANTI-SPASMODIC===èTX OF PARKINSON AND ANTIPSYCHOTIC
90. APRESOLINE (HYDRALAZINE)===èTX OF HTN OR CHF====èREPORT FLU-LIKE
SYMPTOM. VASODILATOR===èRISE SLOWLY FROM SITTING/LYING POSITION; TAKE WITH MEALS.
91. BENTYL====èTX OF IRRITABLE BOWEL====èASSESS FOR ANTICHOLINERGIC SIDE
EFFECTS. CONTRA-INDICATION=====èPATIENT WITH PARALYTIC ILEU.
92. CALAN (VERAPAMIL)====èCALCIUM CHANNEL BLOCKER: TX OF HTN===èASSESS FOR
CONSTIPATION. TEACH PATIENT TO REPORT DIZZINESS; GET UP SLOWLY TO PREVENT FALL DUE
TO ORTHOSTATIC HYPOTENSION.
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93. CARAFATE===èTX OF DUODENAL ULCERS===èCOATS THE ULCER====èTAKE BEFORE
MEALS.
94. THEOPHYLLINE/AMINOPHYLLINE====è TX OF ASTHMA OR COPD===è BRONCHODILATOR===èTHERAP DRUG LEVEL: 10-20 ====èMONITOR THEOPHYLLINE TOXICITY INCLUDING===è ABDOMINAL PAIN, SEIZURES, CONFUSION, TREMORS, CHANGE IN BEHAVIOR, CONVULSIONS, DARK OR BLOODY VOMIT, DIZZINESS, DIARRHEA, ARRHYTHMIAS, HYPOTENSION, TACHYPNEA, TACHYCARDIA, NERVOUSNESS, AND RESTLESSNESS ====èNURSING PRIORITY FOR THEOPHYLINE TOXICITY====èMONITOR ====è AIRWAY, BREATHING, CIRCULATION, AND HEMODYNAMIC. OVERDOSE OF THEOPHYLLINE CAN CAUSE DEVELOPMENT OF HYPOKALEMIA. HYPERGLYCEMIA IS FOUND IN THE MAJORITY OF PATIENTS WITH ACUTE THEOPHYLLINE TOXICITY.
95. ACETYLCYSTEINE/MUCOMYST====è ANTIDOTE TO TYLENOL TOXICITY AND IS ADMINISTERED ORALLY. THE INHALER===èTO LIQUIFY SECRETION FROM THE LUNGS.
96. DIAMOX====è TX OF GLAUCOMA, HIGH ALTITUDE SICKNESS. DONT TAKE IF ALLERGIC
TO SULFA DRUGS
97. INDOCIN===è(NSAID) TX OF ARTHRITIS (OSTEO, RHEMATOID, GOUTY), BURSITIS, AND
TENDONITIS.
98. SYNTHROID/LEVOTHYROXINE====èTX OF HYPOTHYROIDISM. MAY TAKE SEVERAL WEEKS TO TAKE EFFECT. NOTIFY DOCTOR OF CHEST PAIN. TAKE IN THE AM ON EMPTY
STOMACH. COULD CAUSE HYPERTHYROIDISM.
99. LIBRIUM====è TX OF ALCOHOL W/D...DONT TAKE ALCHOL WITH THIS...VERY BAD NAUSEA AND VOMITING CAN OCCUR.
100. ONCOVIN (VINCRISTINE)===è TX OF LEUKEMIA..GIVEN IV ONLY
101. KWELL===èTX OF SCABIES AND LICE====è(SCABIES) APPLY LOTION ONCE AND LEAVE ON FOR 8-12 HOURS===è(LICE) USE THE SHAMPOO AND LEAVE ON FOR 4 MINUTES WITH HAIR
UNCOVERED THEN RINSE WITH WARM WATER AND COMB WITH A FINE TOOTH COMB
102. PREMARIN====èTX AFTER MENOPAUSE ESTROGEN REPLACEMENT
103. DILANTIN====èTX OF SEIZURES. THERA DRUG LEVEL: 10-20
104. NAVANE====è TX OF SCHIZOPHRENIA===èASSESS FOR EPS.
105. RITALIN/CONCERTA/ADDERALL===èSTIMULANT===èTX OF ADHD===èWHAT IS THE NURSING PRIORITY ACTION? ====èCHECK BP BEFORE STARTING THESE MEDICATIONS. WHAT
DO YOU TEACH THE PATIENT/PARENTS? =====èREPORT HEART RELATED SIDE EFFECTS
IMMEDIATELY; CHILD MAY NEED A DRUG HOLIDAY BECAUSE IT STUNTS GROWTH. MAJOR PROBLEMS WITH STIMULANT MEDICATIONS====èLOSS OF APPETITE, WEIGHT LOSS, ELEVATED
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BP, TACHYCARDIA, INSOMNIA, RESTLESSNESS, MOTOR/VOCAL TICS, AND ABUSE POTENTIAL.
106. CHILD WITH ADHD====èPRIORITY ASSESSMENT DURING VISIT ====èWEIGHT/HEIGHT AND BP.
107. DOPAMINE (INTROPINE)====è TX OF HYPOTENSION, SHOCK, LOW CARDIAC OUTPUT,
POOR PERFUSION TO VITAL ORGANS====èMONITOR EKG FOR ARRHYTHMIAS, MONITOR BP
108. STATINS ====èEXAMPLES====èSIMVASTATIN, ATORVASTATIN, ROSUVASTATIN, ETC. 109. WHAT ARE THE STATINS PRESCRIBED FOR?
• LOWER CHOLESTEROL 110. HOW DO THE STATINS WORK?
• HMG-COA REDUCTASE INHIBITOR (STATIN) 111. WHAT ARE THE AE OF STATINS?
• ASSESS FOR MUSCLE PAIN, TENDERNESS, OR WEAKNESS. IF URINE IS DARK BROWN, IT MAY INDICATE RHABDOMYOLYSIS. NOTIFY HCP.
• LAB VALUES TO MONITOR- CHECK LIVER (AST, ALT) AND KIDNEY (BUN, CREATININE) FUNCTION TESTS; CPK LEVELS; HDL, CHOLESTEROL, AND TRIGLYCERIDE LEVELS
• GIVE MEDICATION ON A FULL STOMACH 113. WHAT DO YOU TEACH YOU PATIENT?
• REPORT UNEXPLAINED MUSCLE PAIN, TENDERNESS, WEAKNESS, AND BROWN URINE TO DOCTOR IMMEDIATELY.
• DO NOT DRINK ALCOHOL BECAUSE IT CAN CAUSE LIVER DAMAGE. • AVOID DRINKING GRAPEFRUIT BECAUSE IT WILL SLOW DOWN THE
EFFECTIVENESS OF THE MEDICATION. • TAKE MEDICATION AT NIGHT TO INCREASE EFFECTIVENESS OF DRUG. • FOLLOW LOW CHOLESTEROL AND A LOW SATURATED FAT DIET.
114. TUBES AND DRAINAGES DEVICES NOT DRAINING? WHAT DO YOU DO FIRST? =====èCHECK PATENCY/KINK. 115. PICC LINE IS DISCONNECTED. PATIENT IS DYSPNIC, TACHYCARDIAC, AND CHEST PAIN. WHAT DO YOU DO FIRST? ======èLEFT LYING. TENDELENBERG POSITION. 116. YOUR PATIENT RECEIVES ORGAN TRANSPLANT. WHAT ARE NURSING CONCERNS?
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• INFECTION (DUE TO IMMUNOSUPRESSANTS=====èSTEROIDS) • REJECTION (ITCHING or painful rash on the palms and soles of the feet. • AVOID ANTACID. • HYPERTENSION • KIDNEY PROBLEM • HEPATITIS (NO ALCOHOL)