Uploaded by Macy Schaum

HESI book notes

- Nurse practice law
o Pt assignments should be made with the nursing personnel’s education
preparation, skills, experience, and knowledge
o Nurse should supervise case provided by the UAP or any person for which the
nurse is administratively responsible.
o Sterile or invasive procedures should be assigned or supervised by an RN.
o Documenting care is a legal task and should be done by RN.
- Unintentional torts
o Negligence – performing an unreasonable act.
o Malpractice – professional misconduct or unreasonable lack of skill in duties that
results in an injury.
1. Duty
2. Breach of duty
3. Injury/damage (physical or mental)
4. Causation
o ****nurses can avoid negligence and malpractice by following their orgs policies
and procedures ****
o Examples of malpractice/negligence
 Burning client with heating pad
 Leaving sponges/instruments inside a client’s body after surgery
 Performing incomplete assessments
 Failing to heed warning signs of shock or impending MI
 Ignoring s/s of bleeding
 Forgetting to give a med or giving the wrong med
- Intentional torts
o Assault – mental or physical THREAT
o Battery – actual and intentional touching with or without intent to harm
 Invasion of privacy
 Exposure of a person (body or personality)
 Defamation
 Fraud
- Psychiatric nursing
 Involuntary admission:
 Requires cert by a HCP that person is a danger to self or others
 Individuals have the right to a legal hearing within a certain
number of hours or days
 Most states limit commitment is 90 days
 Extended commitment is usually no longer than 1 year
 Legal and civil rights of hospitalized clients
 Right to wear own clothes
Right to keep personal items and a reasonable amount of cash for
small purchases
 Right to have storage space for personal use
 Right to see visitors daily
 Right to have reasonable access to phone and opportunity to have
private conversations by phone
 Right to receive and send unopened mail
 Right to refuse shock treatments and lobotomy
 Persons declared incompetent have the legal status of a minor meaning
they CANNOT:
 Vote
 Make contracts or wills
 Drive a car
 Sue or be sued
 Hold a professional license
Surgical permit
o Informed consent includes
 Procedure/tx has been fully explained
 Possible complications, risks, and disfigurements explained
 Removal of any organs or parts of body explained if applicable
 Benefits and expected results explained
o HCP is the one who EXPLAINS
 **** it is NOT the nurses responsibility to explain the
procedure/complications or answer questions the patient has
o Nurse is the one who OBTAINS and DOCUMENTS
o Signature must be witnessed by a HCP or nurse
o When verbal consent is obtained, a notation should be made
 Detailing how and why verbal consent was obtained
 Placed in the client’s chart
 Witnessed and signed by 2 people
o Verbal/written consent can be given by
 Alert, coherent, competent adults
 Parent or legal guardian of a minor
 Person in loco parentis in cases of minors or incompetent adults
o Consent of minors
 Minors 14 years or older must agree to tx along with their parents or
 Emancipated minors can consent to tx themselves
Good Samaritan Act – protects HCP against malpractice claims for care provided in
emergency situations
o required to perform in a “reasonable and prudent manner”
o verbal telephone orders
 employee receiving the prescription should write the verbal order or
critical value on the chart and then READ IT BACK to the HCP
o only applied under circumstances
 emergency
 for limited time
 for purpose of protecting the pt from injury or harm
o nursing responsibility
 alert HCP
 required and imperative to accurately document the facts and client’s
behavior leading to restraint
 restraints should be the LAST option
 check frequently that restraints are not impairing circulation or causing
any kind of injury
 allow for nutrition, hydration, and stimulation at frequent intervals
 remove restraints ASAP
 document document document!!!!!!
 never leave restrained person alone
o Patient’s rights
 Pt must give written consent before HCP can use or disclose PHI
 HCP must give pt notice about providers’ responsibilities regarding
 Pt must have access to their records
 Providers who restrict access to records must explain why and must offer
pt a description of the compliant process
 Pt have the right to request that changes be made to their med records
to correct inaccuracies
 HCP must follow specific tracking procedures for any disclosures that
ensure accountability for maintenance of pt confidentiality
 Pt has the right to request that HCP restrict the use and disclosure of
their PHI, although the provider may decline to do so.
Skills of nurse manager
- Liaison between pt and others.
- Engage in conflict resolution with staff
- Plan overall strategies to address pt
- Review management outcomes.
- Identify roles/responsibilities of team
Critical thinking
- Serve as resource person to other
Characteristics of nurse manager
Commitment to quality
Classic leadership styles
o Democratic – participative, assertive personality
o Authoritarian – autocratic (doesn’t consider other points of view), aggressive
o Laissez-faire – permissive, passive personality
5 rights of delegation
o Right task
o Right circumstance
o Right person
 **any situation requiring the nursing process or nursing judgement can
NOT be delegated to a UAP
o Right direction/communication
o Right supervision
- Triage
o Black tag – expectant
 Victim unlikely to survive d/t severity of injuries, level of available care, or
 Palliative care and pain relief should be provided
o Red tag – immediate care
 Victim can be helped by immediate intervention and transport
 Requires med attention within MINUTES for survival (up to 60 minutes)
 Includes compromises to patient’s ABCs
o Yellow tag – delayed
 Victim’s transport can be delayed
 Includes serious and potentially life-threatening injuries, but status not
expected to deteriorate significantly over several hours
o Green tag – minor
 Victim with relatively minor injuries
 Status unlikely to deteriorate over days
 May be able to assist with own care – “walking wounded”
Levels of disaster management
o Disaster preparedness
o Disaster response
o Disaster recovery
Levels of prevention in disaster management
1. Primary
a. develop plan
b. train and educate personal
2. secondary
a. triage
b. treatment-shelter supervision
3. tertiary
a. follow-up
b. recovery assistance
c. prevention of future disasters
Bioterrorism agents
o Anthrax
o Pneumonic plague
o Botulism
o Smallpox
o Inhalation tularemia
o Viral hemorrhagic fever
o Ricin
o Sarin
o radiation
Infection control measures for Ebola
o Place pt in single patient room with private bathroom
o Wear full PPE
o When copious body fluids – double glove, disposable shoe covers, leg coverings
Agency to notify when providing care for pt with suspected Ebola
o Appropriate HCP and supervisors
- NG tube insertion
o Position pt in high fowlers
o Insertion may be uncomfortable for pt and may induce gagging
o Measure tube from nose, around ear, and to xiphoid process.
o Neck should only be extended back PRIOR to tube passing pharynx, then pt
should be instructed to extend neck forward.
- Nursing actions upon suspected pediatric choking:
o Note any obstruction or absence of breathing
o Place infant over arm
o Deliver 5 chest thrusts, then 5 back slaps
- Pt is on continuous enteral feedings and nurse needs to change linens – nurse should
turn off feedings 15 mins prior to linen change in order to prevent aspiration **
- Nursing actions prior to bolus tube feeding:
o Aspirate stomach contents
o Check pH of stomach content
o Assess bowel sounds
o Position pt in high fowler
o Warm feeding to room temp
- Prep for parenteral nutrition:
o Remove PN from fridge 30 mins before infusing
o Assure that the infusion time does not exceed 24 hours
o Return amber and cloudy solutions to the pharmacy
- Progressive disorder that leads to respiratory failure
- Causes an exchange of O2 for CO2 in the lungs that is inadequate for the bodies
demands for 02.
- KEY S/S – SpO2 does NOT improve when patient is on 100% O2.
- s/s
o diffuse crackles
o tachypnea
o tachycardia that can develop into respiratory distress
o acute confusion
o cyanosis
o diaphoresis
o decreased pulmonary compliance
o bilateral pulmonary edema that is NOT cardiac related
o retractions
o hypoxemia – partial pressure of Po2 < 50 with FiO2 > 60%
o pulmonary Xray shows “white-out”
o anxiety, restlessness, confusion, and agitation seen/expressed in client
medical management
o stabilize body fluids
o correct acid-base imbalances
o increase tissue perfusion
nursing management
o position for maximal lung expansion
 pronation can be helpful
o monitor for s/s of hypoxemia and oxygen toxicity
o monitor vital organ status!!!! ***POTENTIAL COMPLICATION (organ failure)***
o monitor breath sounds for pneumothorax!!!! ***POTENTIAL COMPLICATION***
o provide emotional support
o prevent complications of mechanical ventilation
 HOB to at least 30 degrees
 Sedation vacations
 Comprehensive oral hygiene program
o Monitor hemodynamic status
 Peaked T waves = hyperkalemia
 Increased PR intervals = hyperkalemia
 No P waves with ST elevations = myocardial hypoxemia
o Monitor F/E
o Monitor ABGs
 Respiratory system is the first responder – changes will be seen here first
if the pt’s status is not normal
 Metabolic system can take up to 24-48 hrs to compensate
Blood gases
Normal value
80-100 mmHg
35-45 mmHg
21-28 mEq/L
Significant differences
Elevations –alkalosis
Decreased – acidosis
Values may be lower in older adults
Decreased – asthma, anemia, RDS, lung
cancer, etc.
Elevated – PNA, asthma, COPD, anesthetic
effects, opioid usage, resp ACIDOSIS
Decreased – hyperventilation, resp
Elevated – resp ACIDOSIS or
compensation for metabolic ALKALOSIS
Decreased – resp ALKALOSIS or
compensation for metabolic ACIDOSIS
Respiratory acidosis
Too much carbonic acid
Metabolic acidosis
Too much metabolic acid
Respiratory alkalosis
Too little carbonic acid
Metabolic alkalosis
Too little metabolic acid
Lungs are retaining too
much Co2  kidneys
excrete hydrogen and
retain HCO3 to try and
Decreased LOC
Cardiac dysrhythmias
Hypotension (if severe)
Kidneys have too much
hydrogen and too little
HCO3  lungs blow off
CO2 to compensate
Lungs are losing too
much CO2  kidneys
excrete HCO3 and
retain hydrogen
Kidneys have too much
HCO3 and too little
hydrogen  lungs
retain CO2
Decreased LOC
Abdominal pain, N/V
Cardiac dysrhythmias
Unusual behaviors
Excitation then
decreased LOC
(compensatory mech)
s/s of volume depletion
Increased pH
Decreased Paco2
Decreased HCO3
Increased pH
Increased PaCo2
Increased HCO3
Decreased – hemoglobin’s impaired ability
to release O2 to tissues
Decreased pH
Increased PaCo2
Increased HCO3
Decreased pH
Decreased PaCO2
Decreased HCO3
Hyperventilating  decreased CO2  alkalosis
Hypoventilating  increased CO2  acidosis
- Lab values
o Pco2 < 45 mmHg or Po2 > 60 mmHg on 50% O2 aka HYPOXEMIA indicates failure
- *** grunting on expiration is an early s/s of respiratory failure in children***
- Hypercapnia – Pco2 > 45 mmHg
- s/s in adults
o dyspnea
o tachypnea
o intercostal and sternal retractions
o cyanosis
common causes of RF in kids
o congenital heart disease
o Infection, sepsis
o Neuromuscular diseases
Hypovolemic shock
Loss of fluid or blood
Cardiogenic shock
Damaged heart that leads to ischemia or
impairment of tissue perfusion
Anaphylactic – allergen
Neurogenic – spinal cord injury to
descending sympathetic pathways
Septic – endotoxins from bacteria
Physical obstruction of some kind:
Compartment syndrome
Distributive shock
Obstructive shock
End result
Weakened peripheral pulses
Pale cool, clammy skin
Decreased UO
Organ failure (severe)
Decreased cardiac output
Excessive vasodilation and impaired
distribution of blood flow
Impeded filling and outflow of blood
resulting in decreased cardiac output
ALL TYPES OF SHOCK CAN LEAD TO  systemic inflammatory response syndrome (SIDS) and
multiple organ dysfunction syndrome (MODS)
Shock medical management:
- Optimize O2 delivery and reduce demand on heart
- Increase O2 stats with mechanical vent and supplemental O2
- Space activities that decrease O2
- Fluid resuscitation
o ****cornerstone tx for hypovolemic and anaphylactic shock – rapid infusion of
of volume expanding fluids
- Drug therapy
o Those that increase preload – blood products, crystalloids
o Those that decrease preload – morphine, nitrates, diuretics
o Those that increase afterload – vasopressors, dopamine
o Those that decrease afterload – nitroprusside, ACE, ARB
o Those that decrease contractility – beta blockers, Ca channel blockers
o Those that increase contractility – digoxin, dobutamine
o Serial measurements of cardiopulmonary function of the pt are taken every 5-15
o Admin of meds is usually withheld until circulating volume has been restored
Nursing interventions
o Cardiogenic shock with pulmonary edema (aka pump failure) – pt should be
positioned to REDUCE VENOUS RETURN  high fowler with legs DOWN
o Assess for potential AE
o Monitor vitals every 15 minutes!!!!!
o Assess UO every hour to maintain AT LEAST 30 ML/HR
o Pt’s bed position = dependent on type of shock
o Keep pt warm!!!
o Keep side rails up during procedures ***pts in shock may experience confusion
and are high fall risk ***
o When giving vasopressors or adrenergic stimulants (epi, norepi, dopamine,
dobutamine, isoproterenol)
 Give through volume-controlled pump
 Monitor hemodynamic status every 5-15 mins
 Watch IV site carefully
 Ask HCP for target mean systolic BP ***usually 80-90 mmHg**
o When giving vasodilators (hydralazine, nitroprusside) to counteract effects of
 Wait for precipitous decrease/increase in BP, if prescribed together
 Obtain blood work as prescribed
 glucose levels should be maintained before 140-180***
 ensure that pts O2 monitor is on an earlobe or forehead **NOT on finger
d/t perfusion issues**
o provide family support
- Allopurinol
o Therapeutic outcome – reduced serum uric acid levels with a lower frequency of
gouty attacks
- Chemotherapy
o Monitor neutrophil count to assess pt’s susceptibility to infection
o Transdermal patches = BEST to maintain therapeutic level in patients in
continuous pain
o Antimetabolites – inhibit enzymes necessary for cellular function and replication.
o Daunorubicin HCl – causes urine to turn red**
o Mechlorethamine HCl and actinomycin – vesicants that can cause severe AE if
leakage into vessels so nurse should closely assess for extravasation at IV site
during infusion
o Doxorubicin HCl – ECG done prior to monitor irreversible cardiotoxic effects
o Docetaxel – can produce severe LIFE THREATENING fluid retention that can
cause pleural effusion, dyspnea at rest, cardiac tamponade, or pronounced
abdominal distention ***WATCH FOR A COUGH THAT IS NEW AND
o Cyclophosphamide – hemorrhagic cystitis is a characteristic AE **assess each
void for hematuria**
Oral vs IV
o Oral doses larger d/t passage through liver where metabolization occurs (FIRST
o Abx
o NO ALCOHOL **causes disulfiram-like reaction**
H2 Receptor Antagonist (-tidine)
o Acts on parietal cells to decrease gastric acid production
o Med usually given in the morning and at night – hydrochloric acid secreted
during the night is BLOCKED
o Used to treat ulcers AND prevent their return
o Famotidine – can cause confusion **be aware if client reports not being able to
think clearly**
Antacids (calcium carbonate [tums], etc)
o Gastric acid at night is buffered, preventing pepsin production
o Do NOT protect against development of future ulcers – provide symptomatic
relief for current ulcers
o Insulin lispro (rapid acting)
 Onset – 5-15 mins
 Peak – 45 mins -1.5 hrs
 **pt should have tray in front of them when giving**
o Regular insulin (short-acting)
 Onset – 30 mins-1 hr
 Peak – 1-5 hrs
o Intermediate acting (NPH)
 Onset – 1-2 hr
 Peak – 4-14 hrs
o Long acting (glargine)
 Onset – 1-4 hrs
 No peak
Cystic fibrosis pharm treatment
o Pancreatic enzyme replacement is VITAL** should be given with meals
o Aluminum hydroxide can be given before meals to reduce gastric acidity and
reduce enzyme destruction
o Used for steatorrhea tx -- cholestyramine resin and omeprazole
o Med should be withheld, and HCP contacted if
 < 60 pulse
 > 110 pulse
o Therapeutic levels = < 2.0 ng/dL
o Pt should be instructed to take and record pulse rate daily
o **vision change is a s/s of toxicity and should be reported ASAP
o HYPOkalemia associated with toxicity
 HR < 90 is an indication of toxicity and serum dig levels should be
o Antidote = digoxin immune fab [Digibind]
Cholinesterase inhibitors
o MOA – increase availability of acetylcholine at cholinergic synapses, which
improves nerve impulse transmission and assists in memory formation
o Anti-inflammatory used to treat and prevent gout attacks
o s/s of toxicity – N/D/V, abdominal pain
o take WITHOUT food **food inhibits absorption
o typically, pt remains on daily dose to decrease number and severity of gouty
o bronchodilator
o s/s of toxicity
 restlessness
 anorexia
 N/V
 Insomnia
 Tachycardia
 Arrhythmias
 Seizures
o Therapeutic range = 10-20 mcg/mL
o PTT is used to determine effectiveness of tx
o Antidote = protamine sulfate
o PT and INR is used to determine effectiveness of tx
o Antidote = vitamin K
o Anticonvulsant
o Expected reactions – dry mouth, dizziness
o ****blood dyscrasias are known AEs
 Pt should report flulike s/s like sore throat, pallor, fatigue, fever, etc.
 Blood lab tests down every week to watch for myelosuppression
o AE – gingival hyperplasia
 Pt should be taught to brush and floss teeth daily
o Reduces myocardial oxygen consumption  decreased ischemia and reduced
chest pain
o 1 tablet can be taken every 5 minutes (up to 3 times)
o Relief should occur in 5 mins
o Tablet should be taken at the onset of angina and activity should be STOPPED to
allow rest
o Tablets should be replaced every 3-6 months to ensure freshness
o Drug of choice for pts with positive TB skin test
o MONITOR LIVER ENZYME LEVELS – at risk for development of hepatitis **
o Activates dopamine receptors in the kidneys  dilates BV to improve renal
perfusion  increase in UO (indicates increased glomerular filtration)
o INCREASES afterload
o Given to pts who are HYPOtensive
o oral secretions during surgical procedures
o Antipsychotic
o Because this med causes CNS effects of sedation and decreased thirst, nurse
should assess for s/s of dehydration!!
o Use sunglasses and sunscreen when outdoors
 Known to cause photosensitivity
Fluphenazine decanoate
o Antipsychotic
o Given IM – has rapid onset and a long duration **DRUG OF CHOICE FOR
o CNS stimulant used for ADHD
o Med should be given in the morning at breakfast and after lunch to provide
doses that maximize attention span and helps prevent appetite suppression
 Doses should be spaced at 6 hr intervals
o Estrogen receptor blocker
o Used to treat breast carcinoma
o Common side effect – hot flashes **if these do occur, instruct that this is a
common AE and teach measures to reduce discomfort**
Pancuronium bromide
o Muscle relaxant
o Neostigmine bromide and atropine sulfate used to REVERESE respiratory muscle
paralysis that can be caused by this med
o Tricyclic antidepressant (most end in -ine)
o Antidote – sodium bicarb ***reverses QRS prolongation and CNS effects caused
by overdose***
o Stomatitis caused by thrush, can cause mouth pain
o Acidifies urine, decreasing the incidence of calcium phosphate calculi and UTIs
o Cholesterol meds
o The enzyme that metabolizes cholesterol is activated at NIGHT, so these meds
should be taken with the evening meal *****
o Bowel habits should NOT be affected
o Pt will still need to follow a low-cholesterol diet
Sulfa drugs (sulfasalazine)
o Used to treat ulcerative colitis
o Adequate hydration is important with sulfa meds because they can crystallize in
the urine **pt should drink at least 8 glasses of fluid in a day**
o Med should be taken after eating to provide longer intestinal transit time
o Treats severe acne
 HCP should be notified ASAP of pregnancy
 Before/during/after therapy two effective forms of birth control must be
used at the same time
o AE of sadness, depression, suicidal ideations, and other serious mental health
problems – if these occur alert HCP
o Initial exacerbation of acne is common when starting
o Do NOT take additional vit A **could lead to toxicity**
o Should stop this med at least 6 months before cosmetic procedures
(dermabrasion) because it can increase chances of scarring
o Used for dysrhythmias
o GI complaints common ***diarrhea***
o Ca channel blocker and antihypertensive med
o Reduces peripheral vascular resistance
o Concurrent use with nitrates can cause hypotension***
Ticarcillin disodium
o Abx
o AE – hypothrombinemia and decreased platelet adhesion ***result in presence
of petechiae***
Chlorpromazine HCl
o Antipsychotic
o BENZOTROPINE – given with chlorpromazine HCl to control EPS!!!!******
Cholinesterase inhibitors given for MG
o Develop teaching plan for pt to recognize over/undermedication so that they can
modify the dosage themselves based on a prescribed sliding scale
Tissue plasminogen activator – alteplase (t-PA)
o Clot buster that dissolves clots within a coronary artery
 Coronary specific fibrinolytic agent
Methotrexate (as used for RA)
o Administered weekly and in low doses for RA
o SAFETY -- Should have another nurse check the prescription before giving
**death can occur from an overdose**
o SE – stomitis
o Assess pts liver function and monitor I&Os
o Long term therapy:
 Daily doses of long-term therapy should be taken in the MORNING to
coincide with the body’s normal secretion of cortisol
 Increase Ca intake
 Take WITH MEAL/SNACK as can cause GI upset
o These meds depress the immune system creating a higher risk for infection
 Watch for any flulike s/s
 Report fever!!
Peak and trough levels
o Peak – give med then call lab to draw peak level STAT
o Trough –draw closest time to the next administration.
Alprazolam [Xanax]
o Antianxiety med
o Therapeutic effect – ability to sit and concentrate, show decreased levels of
o Short-duration benzo sedative
o Provides conscious sedation with local and regional anesthesia and has an
amnestic effect
o Causes profound analgesia that causes a pt to appear catatonic and amnestic
o Opioid commonly used as an analgesic during anesthesia
o Skeletal muscle anesthetic agent used to reduce spasticity to ensure a smooth
induction under general anesthesia
o Requires intubation and ventilation during onset and duration
Neuromuscular blocking agents
o Ex: succinylcholine, rocuronium, vecuronium, etc.)
o **low K levels enhance effects of these meds – HCP should be informed of client
o If solution is brown in color – admin drug if the solution’s reconstitution time is <
24 hrs ***
o Anticholinergic
o These meds have antispasmodic and antisecretory properties (relax the GI tract)
– therefore are contradicted in a pt with intestinal atony **ASSESS BOWEL
o Given to DECREASE oral secretions during surgical procedures
o If pt has experienced allergic reaction to this med, they may also be allergic to
ipratropium *****
o Antiinfective agent
o ****WATCH PLATELET COUNTS – can cause irreversible, fatal bone marrow
Pyridostigmine bromide
o Given to control s/s of myasthenia gravis
o Increases muscle strength
Anti-fungal meds (-azole)
o Mebendazole – high fat diet increases absorption
-Cycline antibiotics
o Commonly used to tx acne, blepharitis, and dry eye syndrome
o AE – superinfections, photosensitivity, and decreased efficacy of oral
 Pt report any vaginal itching/discharge
 Protect skin
 Nonhormonal contraceptives
o DO NOT TAKE ANTACIDS !!!!!!!******
o Tetracycline hydrochloride
o Minocycline
 Known to cause dizziness and ataxia so NO DRIVING until condition
o Dopamine-releasing agent – increases the amount of dopamine present in the
o Used for Parkinson’s disease
o Can also be used as an antiviral agent
o Antiviral
o ***granulocytopenia can be severe so careful monitoring of CBC’s is indicated –
pt should return to clinic Q 2WEEKS **
Levothyroxine sodium
o Hormone used to treat hypothyroidism
o Withhold med if HR > 100 bpm
o Take med early in the morning to prevent insomnia
Gentamicin sulfate
o Aminoglycoside – treats bacterial infections
o Used to prevent infection after eye injury/surgery
o Complications
 Ototoxicity
 Nephrotoxicity
 Neurotoxicity
o Thiazide diuretic that causes K wasting in the urine
o **INSTRUCT PT TO REPORT S/S OF HYPOKALEMIA (fatigue, muscle weakness)
Acyclovir sodium
o Antiviral given for herpes simplex infections
o **daily fluids should be increased to 2000-4000 mL/day – prevents precipitation
of med in the renal tubules which could lead to obstructive issues that impair
kidney function
 Acute glomerulonephritis is a possible complication of this med
o Dopamine ordered 5 mcg/kg/min
o Mixture of 400 mg in 250 mL D5W
o 5mcg/kg/hr x 105 kg x 60mins/1hr = 31,500 mcg/hr
 400mg/250mL = 1600mcg/mL
 31,5000mcg/hr / 1600mcg/mL = 20 mL/hr
o Antipsychotic
o Long term permanent and irreversible AE = tardive dyskinesia
Terbutaline sulfate
o Branded as a bronchodilator BUT also used to prevent/stop preterm labor
o ***increased maternal serum glucose levels – watch for hypoglycemia in
newborns ***
Vitamin C therapy
o AE of high dose vit C = diarrhea
o Diarrhea medication
o ASSESS FOR DEHYDRATION – any pt that has been having diarrhea is at risk for
 Ask when last void was!!!!
o Should not be given to children < 2yo except under HCP direction
o Causes anticholinergic effect of urinary retention
Darbepoetin alfa
o Bone marrow stimulant
o Therapeutic effect – increase in hemoglobin levels
Any rapid increase (more than 1g/dL in a 2-wk period) should be reported
to HCP because can lead to HTN ****
o Drug of choice for status epilepticus
o Antifungal
 Med causes cellular permeability which could lead to leakage of k
Metoclopramide HCl
o Blocks dopamine receptors in brain, which can cause EPS
 Immediate intervention****
o Antifungal
o Common SE – tingling in hands/feet, N/V, dizziness, stomach upset, tiredness,
o Antibiotic
o AE – pseudomembranous colitis leading to severe watery diarrhea
 **stool specimen should be obtained and analyzed for this complication
o Mixed agonist-antagonist analgesic that results in good analgesia with LESS
respiratory depression, nausea, and vomiting
o Good to use for discomfort and anxiety during active phase of labor
COX-2 inhibitors
o Contraindicated in those who allergic to
 Sulfas
o Contraindicated in 3rd trimester
o Antipsychotic
o Complications
 Metabolic syndrome
 Orthostatic hypotension
 Anticholinergic effects (urinary retention, dry mouth)
 Monitor and report to HCP
 Agitation, dizziness, sedation, sleep disruption
 Mild EPS (tremors)
ATI review
- Early intervention for IPV
o Make sure pt is safe psychologically and physically
Hep B
o Provide psychological first aid
o Reduce stress-related manifestations by using techniques to alleviate panic
o Provide interventions to restore rest and sleep, and connect client to social
supports and info about critical resources
PIV interprofessional collaboration
o Encourage participation in support groups
o Use case management to coordinate community, medical, criminal justice, and
social services
o Assist with client relocation, if needed to a safe house, shelter, a family/friend’s
home, or foster care
o Discuss therapies that could be beneficial
o Talk with caregivers about community agencies that could provide relief
Cord care:
o To prevent infection, keep cord dry and keep diaper folded underneath it
o Sponge baths given until cord falls off (occurs 10-14 days after birth)
o Infected cord s/s – moist, red, foul odor, purulent drainage
2 months
Hep B
4 months
6 months
Hep B
6-12 months
Seasonal flu
Schizophrenia – psychotic thinking or behavior present for at least 6 months
o Significant impairs in functioning, work/school, self-care, and interpersonal
o Positive symptoms – things that are NOT usually present
 Hallucinations
 Delusions
 Alterations in speech
 Bizarre behavior
o Negative symptoms – absence of things that are normally present
 Affect (blunted or flat)
 Alogia (poverty of thought or speech)
 Anergia (lack of energy)
 Anhedonia (lack of pleasure or joy)
 Avolition (lack of motivation in activities and hygiene)
o Alterations in speech
 Associative looseness – unconscious inability to concentrate on a single
Neologisms – made-up words that have meaning only to the client
Echolalia – repeats words spoken to them
Clang association – meaningless rhyming of words, often forceful, such as
“oh fox, box, lox”
 Word salad – words jumbled together with little meaning or significance
to the listener.
Mechanical soft diet
o Diet composition is altered for specific nutrient need
o Foods that require minimal chewing before swallowing – ground meats, canned
fruits, softly cooked veggies)
o Butter, gravies, sugar, or honey can be added to increase calorie intake
o Excludes dried fruits, most raw fruits and veggies, foods containing seeds and
o Indications include
 Limited chewing ability
 Dysphagia
 Poorly fitting dentures
 Edentulous (without teeth)
 Surgery to the head/neck/mouth
 Strictures of intestinal tract
Dysphagia diet
o When swallowing is impaired
o s/s – drooling, pocketing food, choking, or gagging.
Insulin admin
o When mixing short acting with longer acting, mix SHORT ACTING FIRST**
o Hypoglycemia – shakiness, confusion, sweating, palpitations, HA, blurry vision,
lack of coordination
o Hyper glycemia – polyuria, polyphagia, hot, dry skin, fruity breath.
Pelvic exam
o Have pt empty bladder before
o Place pt in lithotomy position
o Client should bear down during procedure
o Minimal bleeding can occur post procedure – provide perineal pads and tissues
as needed.
o s/s
 reduced visual acuity
 reduced vision at night
 decreased color perception
 blurry vision
 diplopia (double vision)
o therapeutic procedures
 surgical removal of the lens