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27 Cards in this Set
- Front
- Back
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a
ac p pc c s |
before
before meals after after meals with without |
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ad lib
prn q qd qh b.i.d. q.i.d t.i.d q.o.d. q.s. Stat |
as needed, as desired
whenever necessary every every day every hour 2x / day 4x/day 3x/day every other day quantity sufficient immediately |
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ADLs
BR HOB BRP h.s. OOB ROM SOB SSE |
Activities of Daily Living
Bedrest Head of Bed Bathroom privledges hours of sleep; bedtime Out of Bed Range of motion Shortness of breath Soap suds enema |
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c
c/o hx R/O s |
c - with
complains of history rule out s - without |
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LL/LU
RL/RU E Q |
Left lower/upper
Right "/" Extremity Quadrant |
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c/o
D/C I&O T.O. V.O. |
Complains of
Discontinue Intake and output Telephone order Verbal Order |
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hx
TPR VS VSS WNL |
history
Temp, pulse, respiration Vital signs VS stable Within normal limits |
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CBC
RBC/WBC FBS Hct Hgb UA |
Complete blood count
Red/White blood count Fasting Blood Sugar Hemocrit Hemoglobin Urine Analysis |
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Os
NPO NG O.D. O.S. O.U. |
Mouth
Nothing by mouth Nasogastric Right eye Left eye Each eye |
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gtt
mL Mcg Tab IM IV SC SL |
drop
milliliter Microgram Tablet Intramuscular Intravenous Subcutanous Sublingual |
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fx.
OT PT NWB THR TJR |
fracture
Occupational therapy Physical therapy Non weight bearing Total hip replacement Total joint "" |
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CMS
CNS EEG ECG/EKG LOC |
Circulation mvmnt sensation
Central nervous system Electroencephalogram Electrocardiogram Level of consciousness or Laxitive of choice |
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LMP
MAE MI NS TPN |
Last mentstral period
Moves all extremities Myocardial infraction Normal saline Total parenteral nutrition |
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C&S
KVO LR ORIF I&D S/P URI UTI |
Culture and sensitivity
Keep vein open Lactated Ringer's Open reduction internal fixation Incision and drainage Status post Upper respiratory infection Urinary tract infection |
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HEENT
PERRLA MAE |
Head, ears, eyes, nose, throat
Pupils equal, round, react to light, accomodation Moves all extremities |
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K
NA S (degree symbol) |
Potassium
Sodium Secondary to |
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Alterations in Glucose Metabolism - HYPOGLYCEMIA
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Hypoglycemia - low blood glucose. Fatigue, hunger, anxiety, tremors, incr. P, BP
Intervention - restore thru IV...comfort measures, prevent falls |
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Alterations in Glucose Metabolism - HYPERGLYCEMIA
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Epinephrine (for asthma) can break down glyogen, lead to hi glucose
Fatigue, incr. urine, thirst, restlessness, fruity breath Admin. Insulin to decrease |
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Electrolyte Imbalances -
HYPOKALEMIA |
Hypokalemia - low potassium fr. altered renal function.
EX: Loop diuretics Weakness, tingling, nausea, diarrhea, irg. pulse Replase serum potassium, and monitor |
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Electrolyte Imbalances -
HYPERKALEMIA |
High...potassium levels...
Weakness, cramps, slow P, BP Decrease levels. Comfort. Prevent falls. |
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Sensory Effects - OCULAR
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Ocular toxicity - tiny blood vessels can be damaged
Blurry, corneal damage, blindness Carfully monitor vision if pt given oculartoxic drugs |
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Sensory Effects - AUDITORY
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Again, tiny vessels. ASPRIN
Ringing (tinitus), dizziness, loss of balance, hearing Monitor hearing! |
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Neurological Effects -
General CNS |
General CNS - drugs cross blood/brain barrier.
Confusion, insomnia, drowsiness... Provide safety measures, cars, machinery |
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Neurological Effects -
Atropine-like (Anticholinergic) |
Block cholinergic receptors...many cold drugs, antihistimines
Dry mouth, constipation, bloating, ur. retention, decr. sweating, dry skin Mouth care, aid to void, comfort, safety |
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Neurological Effects -
Parkinson's Like symptoms |
Dopamine levels affected - parkinson-like symptoms...
Anti-psychotics. Lack of activity, drooling, tremors Discontine, comfort, safety measures |
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Neurological Effects -
Neuroleptic Malignant Syndrome |
Anethesia. Generalized w/high fever.
Discontinue, comfort, safety |
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Teratogenicity
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Drugs reach fetus...abnormalities, CNS/heart defects, death
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