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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.