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390 Cards in this Set
- Front
- Back
Screening test for TB
|
Mantoux or PPD
|
|
Confirmation test for TB
|
Sputum
|
|
Screening test for Prostate Cancer
|
PSA = less than 4 is normal
|
|
Confirmation test for Prostate Cancer
|
Biopsy
|
|
Screening test for DM
|
Random BS over 125 on 2-3 consecutive tests
|
|
Confirmation of DM
|
Glucose Tolerance test with a 2 hours value over 200
Note will be NPO 8-12 hours prior to this test |
|
Screening for HIV
|
ELISA - but high rates of false +. If + repeat if + 2nd time do a Western Blot
|
|
Confirmation of HIV
|
Western Blot
|
|
If exposed to HIV
|
Do an ELISA and repeat in 6 months
|
|
What is an indirect Coombs
|
the initial test for a type and screen, the lab mixes your blood and the donor blood and if it glutinizes (clumps) cannot give it.
|
|
Labs to evaluate Dehydration and renal function
|
BUN, Creatinine, Hematocrit, Specific Gravity, Sodium
|
|
Normal BUN
|
10-20
|
|
BUN over 20
|
Dehydration
|
|
What is BUN in liver dysfunction
|
Low due to Liver cannot make BUN
|
|
Creatinine Ratio
|
20:1 = if higher renal failure
|
|
Creatinine
|
less than 1.2
|
|
If Creatinine is above 1.2
|
renal failure
|
|
Normal Hematocrit
|
36-54
|
|
Specific Gravity of Urine
|
1.005-1.030
|
|
Specific Gravity over 1.030
|
dehydration
|
|
Specific Gravity greater than 1.020 means
|
Hypovolemia and need early intervention
|
|
Sodium Na+
|
135-145
Cl- and Na+ are buddies |
|
If Sodium is above 145
|
Dehydration
|
|
Liver Function Tests
|
ALT, AST, ALP, Urobilinogen, Ammonia, Bilirubin
|
|
Billirubin max
|
1.2
Direct 0.1-0.4 Indirect 0.2-0.8 Total 0.3-1.2 Indirect is the dangerous one |
|
Potassium values
|
3.5-5.2
K+ and hydrogen exchange for each other. Also exchanges with Na+ Intracellular along with phosphate |
|
Magnesium values
|
1.5-2.5
If low risk for dysrhythmias |
|
Phosphorus values
|
2.5-4.5
found in bone and teeth |
|
Calcium values
|
8.5-10
Ca++ and Mg+ run together Phosphorus is opposite "in the absence of disease" Calcium moves out of bone with cancer, hyperparathyroid bedrest and non-weight bearing |
|
Albumin values
|
3.5-5.0
Give supplemental albumin when the level is less than 2.0 |
|
RBC values
|
4.2-6.0
|
|
RBC below 4.2
|
anemia
|
|
RBC above 6.0
|
Risk for blood clotting, thick blood
|
|
Hemoglobin
|
12-18
Critical less than 5.0 Pregos need to be greater then 11. |
|
Hemoglobin less than 7.0 what will client show
|
pallor, fatigue, dyspnea, and chest pain.
Cardiac output will increase in an attempt to compensate |
|
When hemoglobin is low, what will hematocrit be?
|
low = unless dehydrated
|
|
WBC values
|
5.0-11,000 increases in infection
During prego may be 12-15 |
|
Absolute Neutrophil Count (ANC)
|
3000-6000
Must be 500 + if below need isolation to protect from infection |
|
PT Coagulation time
|
9-12
|
|
Maintain between __________ times the baseline when on warfarin (coumadin)
|
1.5-2.5
|
|
Antidote for Warfarin (coumadin)
|
Vitamin K
Can give IV,IM, PO Safest is IV |
|
Heparin Antidote
|
Protamine Sulfate
|
|
INR therapeutic time
|
2-3
warfarin (Coumadin) |
|
Platelets if less than 80k
|
implement bleeding precautions
|
|
Platelets if less than 20k
|
risk for hemorrhage
|
|
Fasting Blood Sugar goal
|
70-125
|
|
If Fasting Blood Sugar is 100-125 then means
|
Prediabetic
|
|
Random finger stick goal is
|
70-150
|
|
Critical value of BS
|
less then 50 over 400
|
|
A1C goal is
|
7 or less
|
|
Ketonurea is generally seen in
|
Type 1 Diabetics not in Type 2
|
|
Lithium drug level
|
1.5
narrow therapeutic window Used for bipolor draw 8-12 hours after a dose Seizures with toxicity |
|
Lanoxin (digoxin) drug level
|
2.5
Used for heart failure and a fib Abnormal rhythms, blurred vision, halos, vomiting, and diarrhea with toxicity. |
|
Aminophylline
|
10-20
used for asthma status asthmaticis |
|
Phenobarbital
|
10-25
used for seizures |
|
Valproic acid
|
50-120
used for seizures |
|
Dilantin
|
10-20
used for seizures slurred speech with toxicity |
|
Trough
|
before drug
Usually 60-90 minutes before the drug is given, this is the lowest level in the body |
|
Peak
|
After the drug, Usually around 30-60 minutes after the drug is given
|
|
Guaiac test
|
same as occult blood test, looking for blood in the stool.
Betadine in the rectal area can give a false positive. AND Colchicine causes a false + in clients taking the drug for tx of gout |
|
Prior to a Guaiac Test avoid
|
red meat, poultry, fish, beets, broccoli, cauliflower, turnips, horseradish, mushrooms, foods high in vitamin C
|
|
How long will client be NPO for procedure with sedation
|
4-8 hours
|
|
How long will client be NPO for procedure with Genearl anesthetics
|
atleast 8 hours
|
|
for a flush such as a client who had a test that used dye need to give
|
3000 ml of fluids a day
if not a flush 2000 ml a day is fine |
|
Normal feelings with a dye injections
|
flutter feeling, palpitations, salty taste, flushed warm feeling, desire to cough, transient nausea
|
|
Bleeding precautions after a invasive test
|
hold pressure to the site for 10-15 minutes, bedrest for 4 hours, keep extremity straight for 6 hours
|
|
Most common complication with TPN
|
infection
|
|
When changing Central line dressing for TPN
|
wear mask and sterile gloves
|
|
Can TPN be infused alone
|
yes is must be alone
|
|
What does TPN have in it
|
protein, calories, and vitamins in that order
|
|
When on TPN must pull what lab daily
|
Electrolytes to determine whether changes are needed
|
|
Begin TPN fast or slow
|
slow, and taper down when weening due to BS problems
|
|
If TPN runs dry what can I do
|
hang 10% dextrose to avoid rebound hypoglycemia
|
|
Intralipid infusions info
|
do not refrigerate
use egg yolks to make it so assess egg allergy no filter needed if just lipids Check the solution for an oily appearance or separation of the fluids |
|
Isotonic
|
0.9% NaCl and LR
Must be used for irrigations |
|
Hypotonic
|
0.45% NS and D5W
note can cause hypotension due to it moves into cells |
|
Hypertonic
|
D5NS, D5NormM, D5LR, D10, D20, D50 and hypertonic saline and Albumin
|
|
what gauge needed for blood admin
|
20 or larger 18 is usual also for lipid admin
|
|
When changing from IV to oral med if extended release form how do I do it
|
stop the infusion, start drug immediately
|
|
When changing from IV to oral med if immediate release form how do I do it
|
Stop the infusion
Wait 4-6 hours Start the drug ex cardazim |
|
complications of IV therapy
|
Fluid overload, infiltration, extravasation, infection, phlebitis, thrombosis, air embolism
|
|
Signs of Fluid Overload
|
Crackles (left sided Heart Failure), Respirations increase, B/P increase, Pulse increase
|
|
What is infiltration of vesicant solution which will cause tissue damage and what is tx
|
Extravasation
Stop the infusion, aspirate any residual drug, give antidote, d/c IV, NO direct pressure to site |
|
May be local or systemic
|
Infection
|
|
Irritaiton of a vein
|
Phlebitis
|
|
Blood clot formation in the vein
|
Thrombosis
|
|
Rare and sudden complication where a bubble of air enters R side of heart
|
Air embolism
lungs have nothing to do with air embolism, S/S Anxiety, Dyspnea, Chest pain, Distended neck vain, CO goes down, Hypotension, Tachycardia, Decrease LOC |
|
tx of air embolism
|
place on left side with feet higher than the head and call for help
|
|
what position should client be in prior to changing tubing on a central line to decrease the risk of air embolism
|
supine
|
|
what types of central lines are there
|
triple lumen and tunneled catheters, and implanted ports
|
|
What is a major complication when a central line is inserted
|
pneumothorax
so a chest x ray is always done after all central line insertions |
|
which is better body weight or Is and Os
|
body weight
|
|
How much does 1 liter of fluid weigh
|
1 kg = 2.2 lb
|
|
What cells are affected with bone marrow suppression
|
RBC, WBC, Platelets
|
|
S/S of low RBC
|
Pale, SOB
|
|
S/S of low WBC
|
Infection
|
|
S/S of low Platelets
|
Bleeding, Bruising, Pitechia
Less than 80k risk for bleeding Less than 20k risk for hemorrage |
|
Agranulocytosis and neutropenia
|
low white blood cell count
|
|
Aplastic anemia
|
bone marrow suppresion
|
|
can I adjust the dose or dc a med without an order
|
NO
|
|
If the order is unclear or dosage does not seem correct what do I do
|
DO NOT GIVE DRUG
|
|
What is always a good idea with any med
|
take with full glass of water unless contrainidacted
note even with mylanta |
|
if med causes nausea give with
|
food,
on rare instances the dosage may need to be increased if given with food, avoid dairy products except with steroids |
|
If med causes sedation
|
give at night
|
|
can I crush any time released or enteric coated med
|
NO
K-dur do not crush |
|
If med is a syrup know that it contains
|
sugar
|
|
how do I apply a patch
|
to an intact area of skin, rotate the sites, chest and upper arms are preferred.
common side effect is pruritis |
|
When applying creams do I remove the old cream before applying the new
|
YES
|
|
When can a child go back to school after ATB ointment or eye cream has began
|
48 hours
|
|
IV onset, peak, duration
|
Onset = 5 minutes
Peak = 30 minutes Duration = 1 hour |
|
IM Onset, Peak, Duration
|
Onset = 30 minutes
Peak = 1-3 hours Duration = 4-6 hours |
|
IM injection degree, gauge, inches
|
90 degree
19-21 gauge 1-2 inches |
|
Subcutaneously (SQ) injection degree, gauge, inches
|
45 degree
25 gauge 5/8 inches |
|
Peadiatrics gauge and inches deep with injections
|
1/2 to 1 inch
22-25 gauge |
|
rules with IM injections
|
Always aspirate
massage the site slightly to promote absorption EXCEPT Z track If on anticoagulants = apply pressure after an injection, use a smaller needle if possible. Always Z track irritating drugs and use a longer needle. |
|
Vastus Lateralis
|
large muscle use for adults or kids
|
|
Deltoid
|
ok for nonirritating meds in adults. never in kids
only small amount of med into this muscle |
|
Ventrogluteal
|
must be 3 or older to use
|
|
How do I give incompatible drugs that would cause precipitate formation in the tubing when mixed
|
flush line, give drug, flush line
|
|
Epidural administration of medications
|
verify catheter placement by aspiration prior to medication admin.
Less then 1 ml clear fluid = proper epidural cath placement if greater then 1 ml clear fluid or bloody fluid = may be in the subarachnoid space or in a blood vessel. Ball of the foot or the big toe are warm and tingling when the block begins to work block cause hypotention so bolus |
|
Give nose drops when
|
before meals especially in children, opens nasal passages so they can breathe easier and taste is enhanced
|
|
How to give eye drops
|
hold above the conjunctial sac to prevent injury. In the older person their hands may shake. Safer to lie down to put drops in.
|
|
Do I give the air lock in lovenox
|
YES
Never give an air lock in kids |
|
Ear drops how to give to adult/child
|
Pull the pinna, down and back for kids.
Up and back for adults Lie on untreated side for 3-5 minutes after installation to allow the medication to move down the ear canal. Do not place a plug in the ear unless ordered All drops should be room temp for admin. Cold or warm solutions can cause dizziness when instilled in the ear. |
|
What med can you take with alcohol
|
buspirone (BuSpar) which is for anxiety.
Avoid alcohol with all other meds |
|
Give low sodium to
|
Clients with heart failure, ascites, cirrhosis, and hypertension
|
|
Give low potassium to
|
End stage renal failure
Boiling removes K+ from chicken and potatoes If broiled or baked, they are high in K+ |
|
Give high potassium to
|
Clients on diuretics except the potassium sparing
|
|
Give low calcium to
|
Hyperparathyroidism
|
|
Give high calcium to
|
Hypoparathyroidism and osteoporosis risk - Preggos should have 1 quart of milk or yogurt per day
|
|
Give low magnesium and low pohosphorus to
|
renal failure
|
|
Give Vit C to
|
Those healing, prevention of colds, smokers, and heavy alcohol consumption
|
|
Give Vit K
|
Consistent amounts in those taking warfarin (Coumadin)
|
|
Thiamine and B complex vitamins.
|
Heavy alcohol consumption
|
|
Give high fiber diet
|
Parkinson, MS, Diverticulities, Prevent constipation and coronary artery disease to decreased cholesterol. Complex carbs are high in fiber
|
|
Give low fiber diet
|
Those with bowel inflammation such as Chrons or ulcerative colitis. Reduces the amount of stool in the GI system, May be ordered the night before a colon resection.
|
|
Give high iron
|
Used in those with iron deficiency anemia
|
|
Give high protein diet
|
Any client healing. High quality proteins are the meats versus the vegetable sources. High quality is used in acute renal failure
|
|
Give low protein diet
|
Glomerulonephritis, ESRF, hepatic failure. Moderate protein in nephrotic syndrome
|
|
Tyramine Foods
|
avoid in clients taking MAOI and linezolid (Zyvox)
Can cause hyperstensive crisis tx with phenotolamine (Regitine) or nifidepine (Procardia), Includes foods containing preservatives, molds, active yeast: cheese, sour cream, yogurt, organ meats, tripe (intestine), smoked meat, pickled meat, cured or dried meat, alcohol, elixirs, tinctures, caffeine, chocolate, licorice, soy sauce |
|
Purine foods
|
Avoid in gout, shellfish
|
|
Diet low in carbs for
|
dumping syndrome
|
|
Diet high in carbs for
|
Hiatal hernia
|
|
tx of anemia
|
foods containing iron
Red meat, organ meats, oysters, eggs, green leafy veggies, whole grains, carrots, raisins, and apricots, fish is a complete protein but does not contain iron. Avoid organ meat if taking MAOI, |
|
To treat iron deficiencies other than with diet
|
iron supplements, can turn the stool black and cause constipation. Can cause nausea. Teeth will be stained from taking liquid iron and iron compounds. IM iron is very irritating, use Z track
|
|
Pesco-vegetarian
|
Will eat seafood, eggs and dairy
|
|
Vegans
|
strict vegetarians. They do not use or consume any animal products of any kind and will not use animal substances for clothing or any other purpose.
|
|
what type of food for difficulties swallowing
|
pureed foods or soft, also good for respiratory clients to decrease energy needs associated with eating
|
|
diet for nausea and vomiting
|
clear liquids
NPO status should be avoided because of the risk for dehydration. Avoid water as fluid replacement answer due to risk for hyponatremia. Carbonated beverages settle the stomach and can increase appetite Liquids should be cool or room temperature never hot |
|
Cardiac diet is
|
low in stimulents, no caffiene
|
|
What is the progressive postsurgical diet
|
progressive increase in the texture and digestibility of the food.
ex. clear to soft |
|
Person trying to lose weight
how often do we weigh them |
daily weight to monitor progress
|
|
How is BMI figured
|
used height and weight to measure the prime body size based on age
|
|
Normal BMI
|
18-25 Obesity is greater then 30.
Remember prime years 18-25. It all goes downhill after 30 |
|
Calories/kcal for carbs, protein, fat
|
Carb 4 kcal/gram
Protein 4 kcal/gram Fats 9 kcal/gram |
|
Basal energy needs
|
1800 kcal/day
|
|
Best foods to manic clients and toddlers
|
finger foods
|
|
what vitamin is good for aging because it hinders free radicals which break down body tissue
|
vitamin E
|
|
what vitamin is good to boost the natural defense mechanisms
|
A, C, E
|
|
what vitamin is good for healthier skin, excellent source is spinach and mangoes
|
Vitamin E and beta carotene
|
|
what vitamin is can cause a yellow pigmentation of the skin, joint pain, loss of hair, and an enlarged liver
|
High intake of Vitamin A
|
|
HOB for Neuro and to decrease ICP
|
30-45 degree
|
|
HOB for Cardiac, Coughing, GI, Cardiac Tamponade, Pericentisis
|
45-75 degree
|
|
HOB for Pulmonary Edema, GI, Coughing
|
High Fowlers
|
|
HOB for COPD and to enhance O2 and expand lungs
|
Leaning over the bedside table
|
|
Maslows hierachy of needs 1st priority
|
physiologic includes need for food, shelter, water, sleep, O2, sexual expression
|
|
Maslows hierachy of needs 2nd priority
|
Safety is avoiding harm, having security and order, and physical safety
|
|
Maslows hierachy of needs 3rd priority
|
Love and belonging is giving and receiving affection, companionship, identification with a group, respect of others, self estem and success in work
|
|
Maslows hierachy of needs 4th priority
|
Self-actualization is fulfillment of potential
|
|
SIMS position
|
side lying with top leg knee bent and outward and bottom leg straight.
|
|
5 rights of delegation
|
TCPDS
Right Task Right Circumstance Right Person Right Direction and Communication Right Supervision |
|
Can I witness a living will in the facility that I work
|
NO
|
|
Sudden increase in confusion of elderly what could be the cause
|
UTI, Hypoxia, Electrolyte Imbalance
|
|
To remove PPE
|
Untie gown at waist
remove gloves untie gown at neck let fall remove gown touching only the inside and fold inside out remove mask and eye wear wash hands |
|
Primary Prevention
|
Prevention
|
|
Secondary Prevention
|
Screening (early disease detection)
|
|
Tertieary Prevention
|
Total Rehabilitation
|
|
Convert C to F
|
C x 1.8 + 32
|
|
1 tsp
|
5 ml
|
|
1 tbl
|
15 ml
|
|
1 grain
|
60-65 mg
|
|
1 oz
|
30 ml
|
|
1 cup
|
8 oz
|
|
2 cups
|
1 pint
|
|
4 cups
|
1 quart = 1 liter
|
|
2.2 lb
|
1 kg
|
|
IV formula
|
Volume to be infused x drop factor divided by time in minutes for the infusion
|
|
Types of answers to target in selecting the right answer with mental health questions
|
Open ended answers and questions
Short answers which allow reflection Any answer which helps to explore feelings Any answer which requires the nurse to spend time with clinet (helps self esteem) Those which communicate empathy Answers which use parapharsing (but not negative feelings) Answers which maintain self esteem Answers which promote safety of the client, other clients and staff Answers which involve setting limits |
|
Questions which explore the "psychosocial needs" of the client are exploring their feelings or physical need
|
pick answer with feelings
|
|
Reality orientation works for
|
reality based disorder not pychotic and alzheimers
|
|
Remotivation Therapy
|
Group Therapy to stimulate social participation
|
|
Behavior Modification
|
Rewards Positive Behavior
|
|
Silence
|
Allows the client to collect thoughts, gain control of emotions or speak without hurrying
|
|
Milieu Therapy
|
Manipulating the environment to benefit the client
|
|
Common side effect with antidepressants
|
Hypotension
|
|
How to DC drugs that effect the CNS system
|
gradually these include antipsychotics, antidepressants, and anti-anxiety medications
|
|
Neuroleptic Malignant Syndrom (NLMS)
|
Potential reaction (fatal hyperpyrexia with temperature elevation to 108. to medications such as:
Phenothiazines, Cyclic antidepressants, Olanzapine (Zyprexa), Overdose of haloperidol (Haldol) tx Bromocriptine (Parlodel) antiparkinson drug Dantrolene (Dantrium) Musculoskeletal relaxant |
|
Extrapyramidal Side Effects and tardive dyskinesia what causes this
|
Antipsychotics, can stop them so it will not get worse cannot reverse
Muscle rigidity like parkinsons. Also includes lip smacking, tongue, protrusion and facial movements |
|
What do we tx EPS with
|
Amantadine (Symmetrel) Also an antiviral
Benztropine (Cogentin) These anti parkinsons drugs can induse a state of euphoria in these clients because they do not have the imbalance between dopamine and acetylcholine like parkinsons clients do |
|
Benzodiazephines
|
Antianxiety and minor tranquilizer, can be used for alcohol withdrawal, client should remain in bed for at least 3 hours following the admin of and IV formulation of a benzo.
|
|
Benzodiazephines withdrawal symptoms
|
tremors
N and V Abdominal or muscle cramps |
|
Benzodiazephines medications
|
Many end in pam or lam
Clonazepam Clorazepate (Klonopin) Diazepam (Valium) Lorazepam (Ativan) Alprazolam (Xanex) Chloridiazepoxide (Librium) Estazolam (Proscom) Flurazepam (Dalmane) Quazepam (Doral) Temazepam (Restoril) Triazolam (Halcion) |
|
Antihistamines may be used for
|
Anxiety due to side effect is sedation which is beneficial in tx anxiety
Hydroxyzine (Atarax, Vistaril) |
|
Azaspirodecanedione derivatives are used for
|
anxiety
Clients may drink alcohol BuSpar Not available in liquid form, may crush. Non sedating, not addicting, and tolerance does not develop SE Dizziness, HA, Nerviousness, Excitement, Nausea |
|
Cyclic Antidepressant Meds
|
Imipramine (Tofranil)
Amitriptyline (Elavil) Doxepin (Adapin, Sinequan) Maprotiline (Ludiomil) Mirtazapine (Remeron) Amoxapine (Ascendin) Nortriptyline (Aventyl, Pamelor) |
|
Cyclic Antidepressants Side Effects
|
Sedation
Euphoria Confusion Delirium in older clients Hyptension EPS OVERDOSE CAN BE LETHAL EASY TO OD ON Anticholinergic Effects everything slows down SLUDGE |
|
Monoamine Oxidase Inhibitors Medications
|
Mar, Nar, and Par
Marplan Nardil Parnate Numerous drug interactions and diet too |
|
MAOI Toxicity Signs
|
Anxiety
Restlessness Insomnia Hypertension Dizziness Tx hypertensive reaction with phenotolamine (Regitine) IV or nifidepine (Procardia) liquid filled capsule, bite so liquid will go into mouth |
|
SSRI Medications
|
Escitalopram (Lexapro)
Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) Fluoxetine (Prozac) - possible suicidal thoughts and insomnia |
|
SSRI Side Effects
|
Primarily GI Symptoms, sexual dysfunction, restlessness, diaphoresis, and weight gain
|
|
Miscellaneous Antidepressants
|
Bupropion (Wellbutrin, Zyban) can cause seizures
Nefazodone (Serzone) Trazodone (Desyrel) Venlafaxine (Effexor) |
|
Phenothiazines Medications
|
Zine for Zaney Clients
Chlorpromazine (Thorazine, Ormazine) Fluphenazine (Prolixin, Permitil) Trifluoperazine (Stelazine, Suprazine) |
|
Phenothiazines Side Effects
|
EPS and tardive dyskinesia
Anticholinergic effects Photosensitivity Neuroleptic Malignant Syndrome Small does are used as antiemetic Large doeses for psychosis |
|
Cholinesterase inhibitors used for
|
Alzheimers and myasthenia gravis due to we want to increase acetacholine in both of these diseases
|
|
Cholinesterase inhibitors Medications
|
Donepezil (Aricept)
Glantamine (Reminyl) Neostigmine (Prostigmin) Memantine (Namenda) Rivastigmine (Exelon) Tacrine (Cognex) |
|
Cholinesterase inhibitors
|
Take in evening before bedtime, best if taken with food, will cause nausea, keep taking will get better
|
|
Nonphenothiazines and atypical antipsychotics Medications
|
Clozapine (Clozaril)
causes severe bone marrow suppression Potential for severe drug interactions Causes sedation Haloperidol (Haldol) Neuroleptic malignant syndrome (NLMS) may occure Akathisia may occur early in therapy - occurs due to the blocking of dopamine - jittery, foot tapping, restless, and pacing - ants in your pants with akatheisia If visual disturbances occur, notify the Dr. Doses in ederly should be half the normal adult dose Olanzapine (Zyprexa) Comes in dissolving tables that prevents the client form pocketing the drug Can also cause NLMS Loxapine (Loxitane) Molindone (Moban) Quetiapine (Seroquel) Risperidone (Risperdal) Thiothixene (Navane) Ziprasidone (Geodon) |
|
Lithium is used as a
|
Mood stabilizing agent
Used for Bi Polar Manic phase |
|
SE of Lithium
|
Three Ps
Peeing - Urinary incontinent Pooping- Diarrhea Parasthesia - Tingling and Numbness |
|
If client complains of the three p's with Lithium what do we do
|
Still give the drug and notify Dr. of the side effects
|
|
Toxic side effects of Lithium
|
goal less than 1.5
Tremors Metallic Taste Severe Diarrhea |
|
Can you give Lithium to pregos
|
NO
|
|
Do we give Lithium with meals
|
YES
|
|
What does Lithium depend on for excretion
|
Sodium so push fluids to promote excretion
|
|
What type of diet with Lithium
|
Normal levels of sodium
If low client will get toxic If high lithium will be excreted more rapidly and get subtherapeutic levels. |
|
When do clients feel worse with Psychotic disorders
|
feel worse in AM improved through the day
Schitzophrenia, hullicinations |
|
When do clients feel worse with Neurotic disorders
Depression, Anxiety, OCD |
Feel worse in the PM,
Clients tend to be optimistic in the AM but worsens through the day |
|
General nursing interventions for mental health disorders
|
Provide for physical needs
Safety precautions - remove harmful objects Close observations Written contract |
|
What is meaningful socialization in mental health disorders.
|
Participation in activities, hobbies,, and group discussion.
Increases self esteem |
|
How can I promote feelings/expression in mental health disorders
|
be kind, interested approach
frequent contact cognitive therapy explores feelings Assist in decision making |
|
What is Depression
|
An illness that involves the mood, thoughts and body of a person. It affects feelings, thought processes, appetite, and the ability to sleep.
|
|
Clinical manifestation of Depression
|
withdrwan and apathetic
Poverty of expression Low energy levels Difficulty concentrating Vegetative signs where everything slows down, may sleep a lot. Feel worthlessness Poor Self Esteem Crying Episodes Anorexia |
|
If sudden imporvement in mood after a short time with a depressed client what do I watch for
|
Suicide this is called the Honeymoon phase,
Especially watchful during shift changes as staff is occupied and this could be a danger period |
|
A specific plan of suicide is
|
high risk
|
|
Nursing interventions for suicidal patient
|
regular schedule and structure
give simple info, slowly and directive Help them do tasks, comment on signs of improvement in their behavior Help the client feel comfortable with the nurse and establish trust Difficult for nurses to deal with these clients Do not perpetuate feelins of worthlessness or false beliefs |
|
Risk for suicide
|
Single, divorced or widowed have higher risk
Watch for feelins and expressions of hopelessness and helplessness Not genetic and not an attention-seeking behavior. Often give warning signs. Form of ineffective coping One on one observation of the clinet Lethality assessment is direct communicaiton between the client and the nurse concerning the clients intent. |
|
How to deal with agressive behavior
|
restraints may be needed
the best indicator that behavior is under control is when they refrain from aggression after being partially released from the restraints. Release them 1 at a time and see how they do |
|
Chronic anxiety
|
a state of uneasiness or apprehension which may be temporary or chronic
|
|
Clinical manifestations of chronic anxiety
|
fight or flight response
clenched hands heightened awareness startled response furrowed brow clining to family or staff physical lashing out |
|
what is desensitization
|
recognize situations that produce anxiety so they can cope with them
|
|
what is post traumatic stress disorder
|
precipitating factors are events that are overwhelming, unpredicatable and sometimes life threatening
|
|
How to handle PTSD
|
actively listen to their experiences, assist them to develop objectivity about the event and find ways to control anxiety related to the event. Group therapy beneficial
|
|
Clinical manifestations of PTSD
|
difficulty concentrating
sleep disturbances intrusive recollection of the event hypervigilance anxiety |
|
Stages of Grief and Coping
|
DABDA
Denial - teaching not therapeutic at this point Anger -Allow them time to release their anger with you present Bargaining Depression Acceptance May move back and forth between the stages |
|
Anticipatory grieving
|
shock, emotional numbness, disbelief, and strong emotions such as tears, screaming or anger
|
|
Ineffective coping
|
nerviousness
irritability inability to concentrate on tasks outburst of temper |
|
Repudiation in Ineffective coping
|
Refusal to recognize the loss in an attempt to protect onself.
|
|
Stocism in Ineffective coping
|
self contraol maintained and feelings hidden
|
|
Distancing in Ineffective coping
|
Distancing: will not discuss
|
|
Dependency in Ineffective coping
|
Client requires a Dr. order to perform any task or activities they are dependent upon the Dr. direction
|
|
Displacement in Ineffective coping
|
Placing feelings onto the environment instead of facing the issue. Inapproriate comments are displacement
|
|
Powerlessness in Ineffective coping
|
Feeling that personal actions will not affect an outcome in any significant way
|
|
Do elderly clients cope better then younger ones
|
NO because their physiologic coping skills are reduced
|
|
How long does grief usually take
|
1-2 years with a spouse or significant person
|
|
Projection as a Devense Mechanism
|
Finding fault with someone else or something else when a client is angry about a situation
|
|
Sublimation as a Devense Mechanism
|
Substituting acceptable feelings to replace ones that are threatening to the ego
|
|
Intellectualization as a Devense Mechanism
|
Using reasoning and facts to deny facing feelings
|
|
Reaction Formation as a Devense Mechanism
|
Unconscious replacement of opposit feelings other than those experienced in an attempt to preserve self-image
|
|
Dissociation as a Devense Mechanism
|
An attempt by the persont o detach emotional involvment or self from an interaction or the environment
|
|
Substitution as a Devense Mechanism
|
Transferring the emotions associated with an object or person to another, safer object or person in an attempt to reduce anxiety
|
|
Coalition as a Devense Mechanism
|
Combination of groups or individuals to pursue an objective
|
|
OCD
|
Anxiety disorder where they perform rituals which are a set of tasks. Manifested in a variety of forms, but is most commonly characterized by a subjects obsessive drive to perform a particular task or set of tasks and compulsions commonly termed "rituals"
|
|
Are OCD personalilits neurotic
|
Yes but they are reality based and have the potential to learn
|
|
Obsessive compulsive personality disorder (OCPD) or anankastic personality disorder
|
General psychological inflexibility
Rigid conformity to rules and procedures Perfectionism and excessive orderliness |
|
Schizophrenia
|
A type of psychosis where they lack insight and misinterpret reality. Withdraw form people and activites in the world around them and retreat into an inner world marked by psychosis
|
|
Clinical manifestation of Schizophrenia
|
cold and detached
flat affect superstitious socially anxious does not desire close relationships prefer solitary activitis |
|
Buehlers Four A's of Schizophrenia
|
Autism (Preoccupied with self)
Affect (Flat) Associations (Loose) Ambivalense (No decisions) |
|
Delusions
|
False fixed beliefs
|
|
Hulluncinations
|
Sensory impressions without external stimulus
|
|
Illusions
|
Real stimuli Misinterpreted
|
|
What increase in Schizophrenia when under stress
|
Delusions, Hallucinations, Illusions
|
|
Narrowed self concepts in Schizophrenia
|
Define themselves by where they are and what they are wearing
|
|
Ideas of reference in Schizophrenia
|
Think people are talking about them
|
|
Inappropriate affect in Schizophrenia
|
Emotions and thoughts are not congruent with the situation Ex:
Who am i Where am I What is going on What was that sound I love you I hate you Just leave me along Hear I am in my own little world |
|
Nursing Interventions in Schizophrenia
|
Acknowledge their feelings but do not acknowledge and confirm their abnormal thoughts or delusions
|
|
Catatonic excitement in Schizophrenia
|
At this time they are usually destructive and violent
|
|
Catatonic stupor in Schizophrenia
|
Usually withdrawn and must, immobile and cured up in a ball
|
|
Speech pattern abnormalities in Schizophrenia Mutism:
|
Absence of verbal speech with no physical reason for it
|
|
Speech pattern abnormalities in Schizophrenia Verbigeration
|
Purposeless speech, repetition of words or phrases
|
|
Speech pattern abnormalities in Schizophrenia Word salad:
|
Words are strung together
|
|
Speech pattern abnormalities in Schizophrenia Pressured Speech:
|
Rapidity of speech, reflecting racing thoughts
|
|
Speech pattern abnormalities in Schizophrenia Poverty of Speech:
|
Diminished amount of speech or monotonic replies
|
|
Speech pattern abnormalities in Schizophrenia Clang Association:
|
Rhyming speech patterns
|
|
Speech pattern abnormalities in Schizophrenia Neologisms:
|
Make up new words
|
|
Speech pattern abnormalities in Schizophrenia Echolalia:
|
Echos words spoken by others
|
|
Speech pattern abnormalities in Schizophrenia Loosened association and flight of ideas
|
Changes subjects frequently
|
|
Schizoid personality
|
Avoids social activities and shies away from others, described as a loner. Seems aloof and dull to others
|
|
Bipolar disorder
|
A condition which causes unusual shifst in a persons mood, energy and ability to funciton Potential to learn reality
|
|
Manic (Bipolar 1)
|
Onset before age 30
Begins suddenly and escalates over several days Extreme manic episodes can lead to delusions, such as grandiose, and hallucinations |
|
Clinical manifestation of Manic (Bipolar 1)
|
Distracted
Hyperactive Inapproprait Flight of ideas Elevated, expansive, irritable mood Loud, Rapid, and vulger speech Possible weight loss Decreased need for sleep |
|
Nursing interventions with Manic (Bipolar 1)
|
Provide a structured environment
Protect them from embarrassing themselves Solitary activities are good Activites with mild exertion help to relase tension |
|
Manic (Bipolar 1) and authority figures
|
They do not like authority figures, will put them down and make unkind remarks. Do not become defensive with them, Remember you can never WIN an argument
|
|
Manic (Bipolar 1) if agitated provide what type of activites
|
those that involve the use of hands and gross motor movements
|
|
Depressive (Bipolar II)
|
Previous manic episodes
May be agitated or have movement retardation Mood may be dysphoric, depressive or despairing |
|
Clinical manifestations with Depressive (Bipolar II)
|
Decreased interest in pleasure
Negative views Suicidal preoccupation Fatigue Decreased appetite Constipation Insomnia Decreased libido |
|
Do Anorexia believe they have a problem
|
NO
|
|
Anorexia
|
Starving due to low self concept and body image disturbance, intense fear of becoming fat
Weight down at least 25% of original body weight. Lose 15-30% of their weight in a short period of time by not eating and excercising excessively |
|
Menstral issues with Anorexia
|
Amenorrhea, and abdominal bloating due to nutritional deficiencies
|
|
Personality with Anorexia
|
Introverts and do not usually have healthy relationships
|
|
Nursing interventions with Anorexia
|
Help them identify and examine dysfunctional thoughts and beliefs is critical
Encourage mild activity Do not allow them to plan or prepary food for goup activities |
|
Bulimia
|
Recurrent binge eating and then vomiting
May use syrup of ipecac to induce vomiting, may cause toxicity to the cardiac system |
|
Do Bulimics believe they have a problem
|
They know they have a problem. They have a fear of not being about to stop eating voluntarily
|
|
What happens after bulimics vomit
|
they feel depressed, they hid the behavior, will see stained teeth due to erosion of the enamal from vomiting
|
|
PICA
|
Persistant eating of non-nutritive substances x 1 month
|
|
Infants and PICA
|
Eat paint, plaster, and cloth
|
|
Older Children and PICA
|
Bugs, rocks and sand
|
|
Adults and PICA
|
Chalk, starch and paper
|
|
General considerations with eating disorders
|
Family may be dysfunctional
Eating and weight loss become a means of control over their life when independence is discouraged and over protectiveness and intrusiveness are practiced Constipation and hypotension occur Set and maintain limits while caring for these clients ex gain 2 lbs and you can do an activity Use behavior modication approach |
|
When dealing with a violent person do you look them in the eye
|
NO
|
|
When does battering usually begin for woman in a relationship
|
during pregnancy
|
|
What type of abuse must we report
|
Elder abuse and Child abuse
|
|
What do we reinforce on discharge for any type of violent situations
|
Shelters, you are not skilled to counsel the client
|
|
What is a higher risk if the person is completely dependent on care
|
Abuse due to strain on the family
|
|
Exploitation
|
Taking over the clients bank accounts, deeds and stock portfolios
|
|
What type of environment is needed to examin child abuse
|
secure and trusting environment
|
|
When child abuse is suspected what will the Dr. do
|
Will work with the parents to admit the child to the hospital for further evaluation (and Protection)
|
|
Characteristics of abusers
|
low self esteem, immaturity, dependence, insecurity, jealousy.
Abusers will often use fear and intimidation to the point where their victims will do anything just to avoid further abuse |
|
Dependent personality disorder
|
is someone who is dependent and submissive
|
|
Antisocial personality Characteristics
|
charming
intelligent irresponsible amoral dishonest manipulative |
|
Antisocial personality Characteristics do they learn from negative experiences?
|
NO and they often become abusers
|
|
Antisocial personality Characteristics do they have remorse or guilt about their behavior
|
NO, superego or conscience is malfunctioned
|
|
Delirium
|
Confusion which may be due to many causes, short term and usually reversible
|
|
Deliruim may be due to
|
decreased sensory stimuli
Put glasses on and hearing aids in to give them more contact with the environment |
|
Alzheimers disease and dementia
|
Group of degenerative disorders involving the brain. Progressive and permanent memory loss and personality changes due to damage with in the brain structure and function
|
|
Causes of dementia
|
D - Drugs and Alcohol
E - Eyes and ear problems M - Metabolic/endocring disorders E - Emotional disorders N- Neurological disorders T - Tumors and trauma I - Infection A - Arteriosclerosis |
|
Loss of brain cells increase with
|
Alcohol
Smoking Exposure to pollution |
|
Is vascular demtentia more rapid in onset
|
Yes because it is caused by a lack of blood flow to the brain
|
|
What is vascular dementia associated with
|
stroke
|
|
Is dementia a type of psychosis where they are reality based?
|
NO
Acknowledge their feelings and redirect them |
|
Confabulation:
|
Telling stories to maintain self esteem and hide memory losses
|
|
Preservation
|
During times of stress, they may repeat phrases frequently
|
|
Additional manifestations of Dementia and Alzheimers
|
Depression, Night wandering, Aggressiveness or passiveness, Failure to recognize family members
|
|
What do Alzheimers patients need
|
Cholinergic drugs to increase the amount of acetylcholine in the brain to increase memory and thought process
|
|
Is there a sensory component to delusions
|
NO
|
|
Paranoid or persecutory delusion
|
People are out to harm you
|
|
Grandiose Delusion
|
You are superior
|
|
Somatic Delusion
|
False belief abou the body = ex anorexia
|
|
Hallucinations
|
are false fixed sensory experiences without external stimuli
|
|
Types of Hallucinations
|
Visual - See
Auditory - Hear Tactile- Feel Olfactory - Smell Gustatory - Taste |
|
How do I deal with clients who are having hallucinaitons
|
Deal with it by providing another stimulus which is stronger than the hallucinations
|
|
Illusions
|
Misinterpretation of reality
Always a sensory experience of some type. Taste, see, feel, hear, or smell something that is not true |
|
Alcoholism what is the number one problem
|
Denial is the number one problem
|
|
Can you trust an Alcoholic
|
No what they say is not what they do.
Confront them |
|
Dependency in Alcoholism
|
SO does something for alcoholic, set limits to treat it
ex buys the boos |
|
Codependency in Alcoholism
|
SO does something for the alcoholic and has an elevation of self esteem when doing it, work on self esteem of the SO for tx.
ex. I buy his boos and am a good wife for doing it |
|
Manipulation in Alcoholism
|
SO does something which is not in their best interest, to tx set limits and enforce them. Easier to tx then dependency
ex I buy his boos and he beats me when he is drunk |
|
Alcohol withdrawal is it dangerous
|
No, happens to most alcoholics
|
|
When does alcohol withdrawal begin
|
signs develop within a few hours after cessation or reduction of alcohol and peak after 24-48 hours
|
|
Early signs of alcohol withdraw
|
anxiety
anorexia insomnia temors irritability increase pulse and BP N and V Poorly formed hallucination or illusions |
|
Delirium Tremens
|
Dangerous to self and others
Need to be ICU and leather restraints due to hallucinations Occurs 12-36 hours after the last intake of alcohol |
|
tx for alcohol abuse
|
antabuse
takes 2 weeks to start to work avoid perfume, aftershave, bug spray, OTC meds such as cold meds, mouthwash, alcohol prep pads |
|
Treat alcohol withdrawal and DTs with
|
Vitamin B (thiamine, B1)
Chlordiazepoxide (Librium), and other tranquilizers |
|
Wernickes (Korsakoffs) Encephalopathy
|
Psychosis induced by vitamin B (thiamine, B1) deficiency
|
|
Wernickes (Korsakoffs) Encephalopathy signs
|
Amnesia and memory loss due to the brain injury. Will see confabulations where they fill in the blanks, just like Alzheimers
|
|
Is Wernickes (Korsakoffs) Encephalopathy irreversible
|
Yes if not treated
|
|
How to prevent Wernickes (Korsakoffs) Encephalopathy
|
Take Vit B enriched foods such as enriched cereals, whole grain, meat, organ meat, pork, fish, poultry, legumes, and nuts
|
|
How to stop Wernickes (Korsakoffs) Encephalopathy from getting worse
|
stop drinking and take Vit C
|
|
What is a priority physiologice need with Substance abuse
|
Nutrition
|
|
Uppers
|
Cocaine, speed, hallucinogens such as LCD and mushrooms, Ecstacy (MDMA), caffeine, nicotine, and ADHD drugs
Initials are usually uppers |
|
Clinical manifestations on Uppers
|
Sympathetic stimulation except GI motility
Increased HR, Pulse, BP, Respirations Pupil dilation, heightened awareness, spastic muscles, seizure activity |
|
Upper overdose everything increase or slows
|
increases
|
|
Downers
|
Depressent drugs, benzodiazepine, opioids, barbiturates, sleepers, alcohol, marijuana, and phenothiazines such as Thorazine
|
|
Clinical manifestations of downers
|
signs of parasympathetic stimulation excpet GI motility
Decreased HR, Pulse, BP, Respirations, GI Motility, Decreased LOC Pupil constriciton |
|
Which is most dangerous to OD on Uppers or Downers
|
Downers
|
|
1st thing Nurse to do to get someone off drugs is
|
sign a contract
|
|
Orientation phase
|
Discuss length of the relationship and formulate a contract
Discuss termination during orientation |
|
Working phase
|
progress is being made
|
|
Termination phase
|
Discharge plans are being made
|
|
Electroconvulsive Therapy
major side effects |
Vomiting, confusion, disorientaiton, and memory loss.
Does not affect blood pressure! Vomiting may lead to aspiration, monitor carefully |
|
during Electroconvulsive Theraphy the patient will received
|
O2 via peep due to depressed respirations during the tx. Muscle relaxants given prior to the therapy can cause depressed respirations.
|
|
What is done in the pre-operative phase?
|
teaching, maintaining NPO, give sedative 45 minutes prior to anesthesia, site marking with client involvement.
|
|
What is done in the intra-operative phase?
|
Safety is a priority, watching respiratory effort, the last physiologic function to lose with anesthesia is respiratory effort that is stage 4 we do not want to hit that stage.
|
|
What is done in the Post-operative phase?
|
Prevent complications, assess for pain, teach about dietary and activity restrictions, if they received atropine monitor for anticholinergic effects, safety, ice to decrease inflammation but remember does nothing for pain, Bleeding always a concern, if dressing becomes saturated, direct pressure is a priority tx.
|
|
What are some early complications post-operatively?
|
Hypoxia, Iieus, Hypovolemic Shock, Atelectasis
|
|
What are some late complications post-operatively?
|
Pneumonia, wound dehisence, evisceration, pulmonary embolis (takes 5-7 days to form a clot)
|
|
Signs of Atelectasis
|
Dyspnea, Tachypnea, Tachycardia, Decreased breath sounds and crackles, Asymmetrical chest movement, Increased restlessness
|
|
Signs of Pneumonia
|
Tachypnea, Shallow Respirations, Crackles, Productive Cough, Hypoxia, Asymmetrical Chest Movement, Fever, Luekocytosis, Tacycardia
|
|
Signs of Hypovolemic Shock
|
Tachypnea, Tachycardia, Weak Pulse, Cool and Clammy, Restless, Decreased Urine Output, Thirst, Increased Bleeding, Decreased CVP (normal is 2-8) Decreased BP (late sign)
|
|
Signs of a DVT
|
(takes 5-7 days to make a clot) , Unilateral Swelling, Pain in the leg, Possible Redness
|
|
Signs of a Pulmonary Embolism
|
Tachypnea, Tachycardia, Increased Anxiety, Dyspnea, CHEST PAIN, BLOOD TINGED SPUTUM, Diaphoresis, Decreased Orientation, Hypotensive, Blood Gas Chages, labe will be decreased CO2 and increasted O2 initially.
|
|
Wound Dehiscence
|
Separation of incision, usual type of incision this happens to is verticle
|
|
Wound Evisceration
|
Evidence of bowel through the incision with increased pain “Emptys out with Eviceration. Is an Emergency will go back to surgery, cover with steril saline gauze.
|
|
People at risk for Wound Evisceration
|
Elderly, Diabetic, Obese, Malnourshed, Prolonged Paralytic Ileus
|
|
Infection from surgical site
|
incision will be red due to inflammation, purulent drainage means local infection which is usually staph or strep. WBC will be increased (leukocytosis and fever indicates a systemic infection.
|
|
Bowel and Bladder events after surgery
|
Urinary retention common, Constipation often due to decreased mobility and opiods. Gastric dilatation presenting as N &V.
|
|
Bowel obstruciton and paralytic ileus is a
|
Disruption of the normal gastrointestinal motor activity.
|
|
Mechanical Bowel Obstruction
|
Caused by some type of factor involving the abdomen or the bowel. Such as Hernia, adhesions, tumors, diverticulitis, intussusception, gallstones.
|
|
Signs of a HIGH bowel obstruction
|
Gastric acid is lost and an alkalotic state results
|
|
Signs of a LOW bowel obstuction
|
Base secretions are affected and an acidotice state will result.
|
|
Nonmechanical Bowel Obstruction
|
Due to paralytic ileus. No physical obstuction. Inability of the bowel to function. Occurs in comatose and post-op clients. Gastric tube aids in decompression.
|