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- Do not delegate what you can EAT!
- E - Evaluate
- A - Assess
- T - Teach
- ↓ hypoNa+
- ↓ hypotension
- ↓ decreased blood volume
- ↑ hyperkalemia
- ↓ hypoglycemia
- ↑ hyperNa+
- ↑ hypertension
- ↑ increased blood volume
- ↓ hypokalemia
- ↑ hyperglycemia
No PEE no K+!
Never give Potassium without adequate urine output.
VEIN and ARTERY perfusion.
- EleVate Veins
- DAngle Arteries
- A - APPEARANCE (all pink, pink/blue, blue/pale)
- P - PULSE (>100, <100, absent)
- G - GRIMACE (cough, grimace, no response)
- A - ACTIVITY (flexed, flaccid, limp)
- R - RESPIRATIONS (strong cry, weak cry, absent)
- M - Measels
- T - TB
- V - Varicella (Chicken Pox/Herpes Zoster/Shingles)
- * Private Room - Negative Pressure with 6-12 air exchanges/hr *
- * TB - N95 Mask *
- S - Sepsis, Scarlet Fever, Strep Pharyngitis
- P - Parvovirus B19, PNA, Pertussis
- I - Influenza
- D - Diphtheria (pharyngeal)
- E - Epiglottitis
- R - Rubella
- M - Mumps, Meningitis, Mycoplasma pr Meningeal PNA
- AN - Adenovirus
- * Private Room or Cohort, Mask *
- "MRS. WEE"
- M - Multidrug Resistant Organism
- R - Respiratory Infection
- S - Skin Infection
- W - Wound Infection
- E - Enteric Infection (C. Diff)
- E - Eye Infection (Pink Eye)
- V - Varicella Zoster
- C - Cutaneous Diphtheria
- H - Herpes Simplex
- I - Impetigo
- P - Pediculosis
- S - Scabies
LEFT side and ↓HOB
(S/S: CP, Difficulty breathing, Tachycardia, Pale/Cyanotic, Sense of impending doom.)
LABOR w/ UN-REASSURING FHR
- LEFT side
- (Stop the Pitocin, give O2, Increase IVF)
(S/S: Late Decels, Decreased Variability, Fetal Bradycardia.
TUBE FEEDING w/ DECREASED LOC
RIGHT side (promotes emptying of stomach), ↑HOB (prevent aspiration)
FLAT-SUPINE (prevent HA and leaking of CSF)
Lie FLAT with LEGS ELEVATED.
DURING CONTINUOUS BLADDER IRRIGATION
Catheter is taped to thigh, so the leg should be kept STRAIGHT.
No other positioning restrictions! :)
Position on side of AFFECTED EAR after surgery. (This allows drainage of secretions.)
AFTER CATARACT SURGERY
Sleep on UNAFFECTED SIDE with a night shield for 1-4 weeks.
- Support head, neck and shoulders.
INFANT w/ SPINA BIFIDA
PRONE so that sac does not rupture.
ELEVATE FOOT OF BED for counter-traction
AFTER TOTAL HIP REPLACEMENT
Maintain HIP ABDUCTION by separating thighs with pillows.
Don't sleep on operated side. Don't flex hip more than 45°-60°. Don't ↑HOB more than 45°.
INFANT w/ CLEFT LIP
Position ON BACK or in infant seat to prevent trauma to suture line.
While feeding, hold in UPRIGHT position.
PREVENT DUMPING SYNDROME
Eat in RECLINING position, then LIE DOWN after meals for 20-30 minutes (also restrict fluids during meals, low CHO and fiber diet, and small frequent meals).
ELEVATE for first 24hr on pillow.
Position PRONE daily to provide for hip extension.
ELEVATE foot of bed for first 24hr.
Position PRONE daily to provide for hip extension.
Area of detachment should be in DEPENDENT position.
ADMINISTRATION OF ENEMA
LEFT SIDE-LYING (Sim's) with knees flexed.
AFTER SUPRATENTORIAL SURGERY
(incision behind hairline)
AFTER INTRATENTORIAL SURGERY
(incision at nape of neck)
Position patient FLAT and LATERAL on either side.
DURING INTERNAL RADIATION
BEDREST while implant in place.
SITTING POSITION (↑HOB) first before any other implementation!
(S/S: pounding HA, profuse sweating, nasal congestion, goose flesh, bradycardia, HTN)
BEDREST with extremities ELEVATED 20°, knees straightm head slightly elevated.
↑HOB 30° to decrease ICP.
(when outflow is inadequate)
Turn patient from SIDE TO SIDE before checking for kinks in tubing (according to Kaplan).
KNEE-CHEST or TRENDELENBURG
- NOT Morphine Sulfate!
Worsens with exercise and improves with rest.
A positive reaction to Tensilon - will improve symptoms.
Caused by excessive medication.
Stop medication - giving Tensilon will make it worse.
- Mannitol (Osmotic Diuretic)
- Crystallizes at room temp, so ALWAYS use filter needle!
Always check labs for PROTHROMBIN TIME!!!
- BASE from the BUTT.
- Lose acid from the mouth.
MYEXEDEMA / HYPOTHYROIDISM
Slowed physical and mental function, sensitivity to cold, dry skin and hair.
GRAVE'S DISEASE / HYPERTHYROIDISM
Accelerated physical and mental function, sensitivity to heat, fine/soft hair.
Increased temp, pulse, and HTN.
SEMI-FOWLER'S, prevent neck flexion/hyperextension, trach at bedside.
CATS (convulsions, arrhythmias, tetany, smasms, stridor)
↑Ca+, ↓Phosphorus diet.
Fatigue, muscle weakness, renal calculi, back and joint pain (↑Ca+).
↓Ca+, ↑ Phosphorus diet.
Increased temp, rapid/weak pulse, increased respirations, hypotension, anxiety, urine SG >1.030
Bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine SG <1.010, SEMI-FOWLER'S.
Excessive uring output and thirst, dehydration, weakness.
Change in LOC, decreased DTR, tachycardia, N/V/A, HA.
Administer Declomycin, diuretics.
Nausea, muscle cramps, increased ICP, muscular twitching, convulsion.
Administer Osmotic Diuretics, Fluids.
Increased temp, weakness, disorientation/delusions, hypotension, tachycardia.
Administer Hypotonic Solutions.
- C - Convulsions
- A - Arrhythmias
- T - Tetany
- S - Spasms and Stridor
Muscle weakness, lack of coordination, abd pain, confusion, absent DTR, sedative effect on CNS.
Tremors, tetany, seizures, dysrhythmias, depression, confusion, dysphagia. Dig Toxicity.
CNS depression, hypotension, facial flushing, muscle weakness, absent DTR, shallow respirations - EMERGENCY!!
↓Na+, ↑K+, hypoglycemia, dark pigmentation, decreased resistance to stress, fractures, alopecia, weight loss, GI distress.
↑Na+,↓K+, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump.
N/V, confusion, abd pain, extreme weakness, hypoglycemia, dehydration, decreased BP.
Hypersecretion of epi/norepi, persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA.
Avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods, surgery to remove tumor.
Muscle weakness, dysrhythmias.
Increase K+ (raisins, bananas, apricots, oranges, beans, potatoes, carrots, celery)
- M - Muscle weakness
- U - Urine (oliguria/anuria)
- R - Respiratory Depression
- D - Decreased Cardiac Output
- E - ECG Changes
- R - Reflexes
NEUROLEPTIC MALIGNANT SYNDROME
- NMS is like S&M:
- You get hot (hyperpyrexia)
- Stiff (increased muscle tone)
- Sweaty (diaphoresis)
- BP, Pulse and Respirations elevate
- You start to drool.
Never get PREGNANT with a GERMAN!
GERMAN MEASLES is dangerous when pregnant. Regular measles is not.
TETRALOGY OF FALLOT
- D - Defect (septal)
- R - Right Ventricular Hypertrophy
- O - Overriding Aorta
- P - Pulmonary Stenosis
Pirates take MAOI's when they're depressed.
- Pirates say "arr". MAOI's have an "arr" sound in the middle of their name:
- Parnate, Marplan, Nardil.
- PArnate NArdil MArplan
POTENTIALLY LIFE-THREATENING EMERGENCY
- ↑HOB 90°
- Loosen constrictive clothing
- Assess for bladder distention and bowel impaction (triger)
- Administer Anti-HTN meds (may cause stroke, MI, seizure)
- Check pulse: <60 - HOLD.
- Check Dig levels and K+ levels.
- Treatment of GERD and Kidney Stones.
- Watch out for constipation!
- Treatment of anxiety and also itching.
- Watch for dry mouth.
- Commonly given Pre-Op.
- Given for Conscious Sedation.
- Watch for resp depression and hypotension.
PTU and TAPAZOLE
Prevention of Thyroid Storm.
Treatment of Parkinsons
- Sweat, saliva, urine may turn reddish-brown occasionally.
- Causes drowsiness.
- Treatment of Parkinsons.
- Sedative Effect.
Treatment of Parkinsons and Extrapyramidal Effects of other drugs.
Treatment of Post-Op N/V and for Nausea associated with Gastroenteritis.
Treatment of Glaucoma.
- Don't take if allergic to Sulfa-Drugs!!
- Diarrhea common side effect.
- Drink plenty of fluids.
- Probenecid (Benemid)
- Allopurinol (Zyloprim)
- Treatment of HTN or CHF.
- Report flu-like sx, rise slowly from sitting/lying.
- TAKE WITH MEALS!
- Treatment of IBS.
- Assess for anticholinergic side effects.
- Ca+ Channel Blocker.
- Treatment of HTN, Angina
- Assess for constipation.
- Treatment of Duodenal Ulcers.
- Coats the ulcer.
- TAKE BEFORE MEALS!
Treatment of Asthma or COPD.
THERAPEUTIC DRUG LEVEL: 10-20
- Treatment of Glaucoma, High Altitude Sickness.Don't take if allergic to Sulfa-Drugs!
- Treatment of Arthritis (osteo, RA, gouty), Bursitis, and Tendonitis.
- Treatment of Hypothyroidism.
- May take several weeks to take effect.
- Notify doctor of CP.
- Take in the AM on EMPTY STOMACH.
- Could cause hyperthyroidism.
- Treatment of ETOH W/D.
- Don't take ETOH with this!!!
- Treatment of Leukemia.
- Given IV only!
- Treatment of Scabies and Lice.
- Scabies: Apply lotion once and leave on for 8-12 hours.
- LiceL Use the shampoo and leave on for 4 minutes with hair uncovered, then rinse with warm water and comb with a fine-tooth comb.
- Treatment of Menopause.
- Estrogen Replacement.
Treatment of Seizures.
THERAPEUTIC DRUG LEVEL: 10-20
- Treatment of Schizophrenia.
- Assess for EPS.
- Treatment of ADHD.
- Assess for HEART-RELATED SE - report ASAP!
- Child may need "drug holiday" - stunts growth.
- Treatment of Hypotension, Shock, Low Cardiac Output, Poor Perfusion to Vital Organs.
- Monitor EKG for arrhythmias.
- Monitor BP.
FETAL HEART RATE PATTERNS
- V - Var. Decel C - Cord Comp. caused
- E - Early Decel H - Head Comp. caused
- A - Accel. O - OKAY! Not a problem!
- L - Late Decel P - Placental Insuff. (can't fill)
- Place mother in TRENDELENBURG - this removes pressure of the presenting part off the cord.
- (Mom's head is down - baby no longer being pulled out of body by gravity.)
Cover the cord with sterile gauze to prevent drying of the cord and to minimize infection.
Turn mom on her LEFT SIDE - allows more blood flow to the placenta.
ANY BAD FETAL HEART RATE PATTERN...
Give O2, usually by mask.
HYDRATION beforehand is a priority!!
- NEVER CHECK A MONITOR OR A MACHINE AS A FIRST ACTION!
- Always assess the patient first!
Sounds are heard at the sides.
Sounds are heard closer to midline, between the umbilicus and where you would listen to a posterior presentation.
Sounds are high up in the fundus, near the umbilicus.
Sounds are heard a little bit above the symphysis pubis.
- H - HIGH Alarm
- O - ObstructionDue to increased secretions, kink, patient coughs, gags, or bites.
- L - LOW Alarm
- D - Disconnection
- Or leak in vent or in patient airway cuff, pt stops spontaneous breathing.
Hot and Dry - Sugar High (HYPERglycemia)
Cold and Clammy - Need some Candy (HYPOglycemia)
ICP and SHOCK
SHOCK: ↓BP, ↑Pulse, ↑RR
RIGHT-SIDED Heart Failure caused by LV failure (so pick edema, JVD if it's a choice.)
Medication of Choice: CHF
Medication of Choice: Anaphylactic Shock
Medication of Choice: Status Epilepticus
Medication of Choice: Bipolar Disorder
RLQ with Rebound Tenderness
Portal HTN + Albuminemia
Pancreatitis and Morphine
Morphine causes spasms in the Sphincter of Oddi, therefore Demerol is given.
- Gastric feedings, head injury, post-op cranial surgery, resp illness w/ dyspnea, post-op cataract removal, increased ICP
Head injury, post-op cranial surgery, post-op abd surgery, resp illness w/ dyspnea, cardiac problems w/ dyspnea, bleeding esophageal varices, post-op thyroidectomy, post-op cataract removal, increased ICP
Resp illness w/ dyspnea (emphysema, status asthmaticus, pneumothorax), cardiac problems w/ dyspnea, feeding, meal times, hiatial hernia, during and after meals.
Lying on back, head and shoulders; slightly elevated with a small pillow.
SCI (no pillow!), urinary catheterization.
Lying on abdomen, legs extended, and head turned to the side.
Pt who is immobilized or unconscious, post-LP 6-12°, post-myelogram 12-24° (oil-based dye), post-op tonsillectomy and adenoidectomy.
Lying on side with most of the body weight borne by the lateral aspect of the lower ilium.
Post-abd surgery, unconscious, seizures (head to side), post-op tonsillectomy and adenoidectomy, post-op pyloric stenosis of the lower scapula and the lateral (right side), post-liver biopsy (right side), rectal irrigations.
Lying on left side with most of the body weight borne by the anterior aspect of the ilium, humerus, and clavicle.
Pt who is unconscious, enemas.
Lying on back with hips and knees flexed at right angles and feet in stirrups.
Perineal procedures, rectal procedures, vaginal procedures.
Head and body lowered while feet are elevated.
Used for some surgeries; also may be used during labor if umbilical cord pressure is trying to be relieved.
Supine with legs elevated.
Head elevated while feet are lowered.
- Cervical traction; also used to feed clients restricted to supine position, such as post-cardiac cath.
Elevate 1 or More Extremities
Elevate legs/feet or arms/hands by adjusting or supporting with pillows.
Thrombophlebitis, application of cast, edema, post-op surgical procedure on extremity.
Focus is on promoting health and preventing disease.
Immunizations, child car seat education, nutrition and fitness activities, health education programs.
Focus is on early identification of illness, providing treatment, and conducting activities geared to prevent a worsening health status.
Communicable disease screening and case finding, early detection and treatment of HTN, exercise programs for older adults who are frail.
Focus is on preventing long-term consequences of chronic illness or disability and supporting optimal functioning.
Prevention of pressure ulcers as a complication of SCI, promoting independence for a client following a stroke.
Fluid Volume Deficit
Causes: Excessive GI loss, diaphoresis, fever, excess renal loss, hemorrhage, insufficient intake, age-related changes.
S/S: Weight loss/poor skin turgor, dry mucus membranes, increased pulse, hyperthermia, cap refil >3, weakness, fatigue (LATE SIGNS: oliguria, decreased CVP, flattened neck veins), Elevated Hct and urine SG/osmolality.
Dx: Lytes, BUN, Cr, Hct, Urine SG/Osmo
Rn: Assess VS, skin turgor, strict I/O, daily weights, assess labs, replace fluids orally, initiate and maintain IVF, correct underlying cause.
Tx: Lyte replacement, IVF
Fluid Volume Excess
Causes: Abnormal renal fxn, heart failure, hepatic failure, interstitial to plasma fluid shifts (hypertonic fluids, burns), excessive Na+ intake, age-related changes, water replacement w/o lyte replacement, excess intake of hypotonic fluid.
S/S: Cough, dyspnea, crackles, increased BP/pulse/RR, weight gain (1L H2O=1kg weight), hemodilution of Hct and lytes (LATE SIGNS: JVD, tachycardia, pitting edema, increased CVP).
Dx: Lytes, BUN, Cr, Hct, Urine SG/Osmo, CXR (if resp comp present).
Rn: Assess RR/symmetry/effort, breath sounds, edema, ascites and measure abd girth, monitor I/O and VS, daily weights.
Tx: Lyte replacement, IVF
Risks: Diarrhea, fever, hypoxia, starvation, seizure, OD: salicylates or ethanol, renal fail.
Symptoms: VS: bradycardia, weak pulses, hypotension, tachypnea. Flaccid paralysis. Confusion.
Treatment: Treatunderlying cause. Admin fluids, lytes.
Risks: Ingestion of antacids, GI suction, hypokalemia, TPN, blood transfusion.
Symptoms: Dizziness. Paresthesias. Hypertonic muscles. Decreased RR.
Treatment: Treat underlying cause. Admin fluids, lytes.
Risks: Respiratory depression, pneumothorax, airway obstruction, inadequate ventilation.
Symptoms: Dizziness. Palpitations. Muscle twitching. Convulsions.
Treatment: Maintain patent airway. Reversal agents for narcotics. Regulation ventilation therapy. Bronchodilators. Mucolytics.
- Risks: Hyperventilation, hypoxemia, altitude sickness, asphyxiation, asthma, pneumonia.
- Symptoms: Tachypnea. Anxiety, tetany. Parresthesias. Palpitations. CP.
: Regulate O2 therapy. Reduce anxiety. Rebreathing techniques.
: antigen-atb rxn triggered by food, meds, or inhaled substances. Pathophys abnorm within resp tract. (Older clients - beta receptors less responsive to agonist and trigger bronchospasms).
- Symptoms: Sudden, severe dyspnea w/ use of accessory muscles. Sitting up, leaning forward. Diaphoresis, anxiety. Wheezing, gasping. Coughing. Cyanosis (late sign). Barrel chest.
- Dx: ABGs, sputum cultures, PFT.
: Remain w/pt during attack. Position in high-Fowler's. Assess lung sounds and pulse ox. Admin O2 therapy. Maintain IV access.
(Short-Acting: Proventil, Ventolin; Methylxanthines: Theo-Dur), Anti-Inflamm
(Corticosteroids: Flovent, Prednisone; Leukotriene Antagonists: Singulair) (Combo Agents
: Combivent, Advair). Therapeutic
: Resp treatments, O2 therapy. Client Edu
: Avoid allergens and triggers; proper use of inhaler.
With inhaled agents, administer bronchodilators BEFORE anti-inflammatory medication.
Life-threatening episode of airway obstruction that is often unresponsive to treatment.
Symptoms: Extreme wheezing. Labored breathing. Use of accessory muscles. Distended neck veins. High risk for cardiac and/or respiratory arrest.
Treatment: High-Fowler's. Prep for emergency intubation. Admin O2, epinephrine, and systemic steroid as rx. Provide emotional support.