-Chemo Side Effects - ✔✔ o Nausea/vomiting (24-48 hr, can be delayed up to 1 week)
Meningitis first step - ✔✔ o Antibiotics - penicillin (ampi... [Show More] cillin) AND cephalosporin
o Corticosteroids
Multiple sclerosis and urinary retention - ✔✔ o Sensation of void heeded immediately (bed pan/urinal @ bedside)
o Voiding schedule (start 1/5-2hr then extend)
o Drink specific amt every 2 hour; urinate 30 min after w/ timer
o Self-catherization
Acute renal failure priority - ✔✔ o Maintain fluids
o Avoid fluid excess
o Renal replacement therapy
o Reduce metabolic rate
o Promote pulmonary function
Acute Respiratory distress priority findings - ✔✔ o Hypoxia
o Intercostal retractions
o Crackles
o BNP levels
(alveoli collapse because small airways are narrowed due to interstitial fluid and bronchial obstruction)
End of life plan of care - ✔✔ o Signs and symptoms of impending death are recognized and communicated in developmentally appropriate language for children and patients with cognitive disabilities with respect to family preference. Care appropriate to this phase of illness is proved to the patient and the family
Cushing Syndrome - ✔✔ o Can result from corticosteroids
***Attempt to reduce/taper medication while still treating underlying disease
o Alternate day therapy decrease symptoms and allows adrenal glands to recover
Valve replacement teaching - ✔✔ o Anticoagulant therapy (frequent follow-up/lab tests)
§ Pt on warfarin has specific normal ratios
o Prevent infection
o ANTIBIOTIC PROPHYALXIS FOR DETAL PROCEDURES!!!
Cancer intractable pain plan of care - ✔✔ o Pain, other symptoms and side effects are managed based on the best available evidence, with attention to disease-specific pain and symptoms, which are skillfully and systematically applied. ??????
Schizophrenia nursing diagnoses and interventions - ✔✔ - Dx: 2 or more S&S for over 6 mo (Positive= delusions, hallucinations, disorganized speech or Negative= 6 A's Anhedonia, Flat Affect, Apathy, Anergia, Algogia, Avolition)
-Establish rapport and trust, ask about hallucinations, distract, lower environmental stimuli, monitor suicidal ideation, 1st or 2nd generation antipsych
Grief process therapeutic response - ✔✔ Allow the 5 steps of grieving (DABDA), active listening and offer a supportive presence
Dementia action refusing ADLs - ✔✔ Encourage finger foods, distraction, speak therapeutically
Alcohol withdrawal - ✔✔ - Needs to be done under medical supervision b/c can be deadly
- VS Q4, onset of symptoms 4-6 hours after last drink, give lorazepam, reduce temp.
- Tremors, nausea, vomiting
Methadone overdose - ✔✔ S&S= constricted pupils, resp. depression, circul. depression, LOC decreased
Give naloxone
Domestic violence screening tool - ✔✔ - Don't probe, write evidence down verbatim, provide a safe environment
- Increase in violence during pregnancy
- Cycle of violence= tension building, violent, honeymoon
Aggression response - ✔✔ 5-phase cycle= Triggering (event), Escalation (movement toward a loss of control), Crisis (loss of control), Recovery (regain control), Postcrisis (reconciliation)
***Hx = likely to occur again
Violence handling - ✔✔ - Engage in dialogue to prevent escalation, intervene early in the cycle
- Approach as non threatening, calm manner and convey empathy
- Encourage the client to express their anger, build trust, anticipate need for meds, be consistent
Medication adverse reactions care (schizophrenia) - ✔✔ Constipation is a common side effect of antipsych meds, polydipsia occurs after years of treatment
Nurse can help minimize effects of delusions with distraction techniques, music, tv, writing and talking to friends, positive self-talk and positive thinking
Self care Maslow - ✔✔ - Physiologic, safety, love and belonging, self esteem, self-actualization
- Basic drive and needs that motivate people
Anxiety Suicide Risks: - ✔✔ Restless, difficulty concentrating, irritability
- "Have you had any suicidal thoughts since starting bupropion?"
Elder Abuse - ✔✔ Someone stating "I no longer have time to do anything for myself or anyone else" would be someone @ risk for abusing elder.
Bruising around breasts and pelvic area = abuse
Watch behavior toward family and document
Make caregiver leave room during questioning
*** include nonconsensual contact
Grief Priority - ✔✔ Priority should be based on SHOCK!
ADHD Exam/Assessment - ✔✔ - failure to listen/follow direction
- difficulty playing quietly/sitting still
- disruptive, impulsive behavior
- distractibility to external stimuli
- excessive talking
- shifting from one unfinished task to another
OCD - ✔✔ - Patient checks where car keys are 8 times
- Patient has persistent thoughts about bacteria, germs and dirt
- Help encourage participation in social activities
Questions to ask someone with OCD - ✔✔ - are there other in your family who must do things a certain way
- is it difficult to keep certain thoughts out of your awareness
- do you do certain things over and over again
Therapeutic communication abuse victim - ✔✔ 1. Physical manifestations of abuse
2. Client safety
3. Legal responsibilities of the nurse
4. For children, the nurse is legally responsible for reporting all suspected cases of abuse. In intimate-partner abuse, it is the adult's decision; the nurse should be supportive of the decision. Remember to document objective factual assessment data and the client's exact words in cases of sexual abuse and rape
Therapeutic Relationship Stages- TERMINATION - ✔✔ Unresolved feelings related to loss most likely may be recognized during this stage.
A nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task appropriate for this phase? - ✔✔ Making appropriate referrals
Which features are prominent in anorexia nervosa? - ✔✔ -Amenorrhea for three cycles
-Perfectionism
-Powerlessness [Show Less]
