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12-Cranial-Nerves-Nursing-Notes

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12 cranial nerves
Oh, Oh, Oh, To Touch And Feel Virgin Girls Vagina, And
Hymen/Hooters
I - Olfactory nerve
II - Optic nerve
Oculomotor nerve
IV - Trochlear nerve/pathic nerve
V - Trigeminal nerve/dentist nerve
VI - Abducens nerve
VII - Facial nerve
VIII - Vestibulocochlear nerve/Auditory nerve
IX - Glossopharyngeal nerve
X - Vagus nerve
XI - Accessory nerve/Spinal accessory nerve
XII - Hypoglossal nerve
III -
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CHOLELITHIASIS
Patients are predisposed to Cholelithiasis (aka Gallstones) by the:
4 F's (Fat, Forty, Female, and Fertile).
MOLE’S MALIGNAT
use the abcd rule to assess a mole’s malignant potential:
a: asymmetry--is the mole irregular in shape?
b: border--is the border irregular, notched, or poorly defined?
c: color--does the color vary (for example, between shades of brown, red,
white, blue, or black)?
d: diameter--is the diameter more than 6 mm?
HYPOPLASIA VS HYPERPLASIA
having difficulty distinguishing hypoplasia from hyperplasia? when you see
plasia in any word, think of "plastic." plastic, in turn, means forming or
developing. as for hypo and hyper, that’s the easy part. hypo means under, or
below normal. hyper means excessive, or above normal. thus, hypoplasia
means underdevelopment, and hyperplasia means overdevelopment.
BLOOD TYPE
to remember which blood types are compatible, visualize the letter “o” as an
orb representing the universe, because type o blood is the universal donor
blood. patients with any blood type can receive it. but o also means “odd man
out”: patients with type o blood can receive only type o blood. think beep to
remember the signs of minor bleeding:
b: bleeding gums
e: ecchymoses (bruises)
e: epistaxis (nosebleed)
p: petechiae (tiny purplish spots)
SICKLE CELL DISEASE- HOPIA
HYDRATION
OXYGENATION
PAIN
INFECTION
AVOID HIGH PLACES
CONGESTIVE HEART FAILURE- D MAD DOG
DIGOXIN
MORPHINE
AMINOPHYLLINE
DOPAMINE
DIURETICS
O2
GASSES – MONITOR (ABG)
EARLY SIGNS OF HYPOXIA
RESTLESSNESS
AGITATION
TACHYCARDIA
LATE SIGNS OF HYPOXIA
BRADYCARDIA
EXTREME RESTLESSNESS
DYSPNEA
CYANOSIS
INCREASE ICP – HYPERBRADYBRADY
CUSHINGS TRIAD:
HYPERTENSION (WIDE PULSE PRESSURE)
BRADYCARDIA
BRADYPNEA
Days of appearance of rashesVaricella(chickenpox) - "Very
Sick Patients Must Take Double Exercise"
1st dayScarlet fever
2nd dayPox(smallpox)
3rd dayMumps
4th dayTyphus
5th dayDengue
6th dayEnteric fever(typhoid)
Parkinson's Disease
Cardinal Symptoms of Parkinson's Disease - "TRAP"
Tremor
Rigidity
Akinesia and bradykinesia
Postural Instability
Spleen
Causes of huge spleen - "3M's"
Myelofibrosis
Mlaria
Myelogenous leukemia
Anti-cholinergic Crisis
Signs of anti-cholinergic crisis - "SLUD"
Salivation
Lacrimation
Urination
Defecation
Scarlet Fever
,
Six "S" in Scarlet Fever
Streptococci causal organism
Sorethroat
Swollen tonsils
Strawberry tongue
Sandpaper rash
miliary Sudamina vesicles over hands, feet, abdomen
Cor Pulmonale
Signs of cor pulmonale - "Please Read His Text"
Peripheral edema
Raised JVP
Hepatomegaly
Tricuspid incompetence
Amino acids
10 essential amino acids - "PVT. TIM HALL"
Phenylalanine
Valine
Tryptophan
Threonine
Isoleucine
Metheonine
Histidine(semi-essential)
Arginine(semi-essential)
Leucine
Lysine
Hematology
Order of prevalence of White Blood Cells, most prevalent
to least - "Never Let Monkeys Eat Bananas"
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Stages of mitosis/meiosis including interphase as a phase "In Philippines, Men Are Talented"
Interphase
Prophase
Metaphase
Anaphase
Telophase
Diarrhea
Viruses causing diarrhea - "ACNE CAR"
Adeno virus
Corana virus
Norwak virus
Entero virus
Calci virus
Astro virus
Rota virus
Skeletal System
Carpal bones of the hand (lateral to medial) - "She Looks
Too Proud, Try To Chase Her"
Proximal row:
Scaphoid
Lunate
Triquetrum
Pisiform
Distal row:
Trapezium
Trapezoid
Capitate
Hamate
Integumentary System
Layers of the scalp - "SCALP"
Skin
Connective tissue
Aponeurosis
Loose areolar tissue
Pericranium
Joints
Types of Joint movements - "FEEDPIPE CARDSHARP"
Flexion
Extension
Eversion
Dorsiflexion
Pronation
Inversion
Plantarflexion
Elevation
Circumduction
Abduction
Rotation
Depression
Supination
Hyperextension
Adduction
Retraction
Protraction
Nervous System
"Cut C4, breathe no more"
The 3rd, 4th and 5th cervical spinal nerves innervate the diaphragm.
"Point and Shoot!"
For remembering that Parasympathetics are involved with erection and
Sympathetics with ejaculation.
Cardiovascular System
Location of the heart valve from right to left - "A
Permanently Temperamental Man"
Aortic
Pulmonary
Tricuspid
Mitral
Cancer
SIGNS OF CANCER- "CAUTION US"
Change in bowel /bladder habits
A sore that doesn’t heal
Unusual bleeding/ Discharge
Thickening of lump – breast or elsewhere
Indigestion/ Dysphagia
Obvious change in wart/ mole
NAgging cough/ hoarseness
Unexplained anemia
Sudden weight loss
FOCUS OF PATIENT CARE IN CLIENTS WITH
CANCER
Chemotherapy
Assess body image disturbance (related to alopecia)
Nutritional needs when N/V present
Comfort from pain
Effective response to Tx? (Evaluate)
Rest (for patient and family)
NEUROLOGICAL FOCAL DEFICITS
NEUROLOGICAL FOCAL DEFICITS
10 S's:
Sugar (hypo, hyper)
Stroke
Seizure (Todd's paralysis)
Subdural hematoma
Subarachnoid hemorrhage
Space Occupying lesion (tumor, avm, aneurysm, abscess)
Spinal cord syndromes
Somatoform (conversion reaction)
Sclerosis (MS)
Some migraines
DIABETIC KETOACIDOSIS MANAGEMENT
KING UFC:
K+ (potassium)
Insulin (5u/hour. Note: sliding scale no longer recommended in the UK)
Nasogastic tube (if patient comatose)
Glucose (once serum levels drop to 12)
Urea (check it)
Fluids (crytalloids)
Creatinine (check it)/ Catheterize
VENTRICULAR FIBRILLATION: TREATMENT
"Shock, Shock, Shock, Everybody Shock, Little Shock, Big Shock, Momma
Shock, Poppa Shock":
Shock= Defibrillate
Everybody= Epinephine
Little= Lidocaine
Big= Bretylium
Momma= MgSO4
Poppa= Pocainamide
SHOCK: SIGNS AND SYMPTOMS
TV SPARC CUBE:
Thirst
Vomiting
Sweating
Pulse weak
Anxious
Respirations shallow/rapid
Cool
Cyanotic
Unconscious
BP low
Eyes blan
SHOCK – HYPOTACHYTACHY
HYPOTENSION
TACHYPNEA
TACHYCARDIA
--------------TRY
PULLING MY AORTA":
Tricuspid
Pulmonary
Mitral
Aorta
FEMORAL HERNIA
FEMoral hernias are more common in FEMales.
CARDIAC VALVES
"TRI before you BI":
Tricuspid valve is located in left heart and Bicuspid valve is located in right
heart. Blood flows through the tricuspid before bicuspid.
CROUP - Signs and Symptoms
SSS
S - Stridor
S - Subglottic swelling
S - Seal-bark cough
PNEUMONIA - risk factors
INSPIRATION
I - Immunosuppression
N - Neoplasia
S - Secretion retention
P - Pulmonary oedema
I - Impaired alveolar macrophages
R - RTI (prior)
A - Antibiotics & cytotoxics
T - Tracheal instrumentation
I - IV dug abuse
O - Other (general debility, immobility)
N - Neurologic impairment of cough reflex, (eg NMJ disorders)
PNEUMOTHORAX Signs and Symptoms
P-THORAX
P - Pleuritic pain
T - Trachea deviation
H - Hyper resonance
O - Onset sudden
R - Reduced breath sounds (& dypsnea)
A - Absent fremitus
X - X-ray shows collapse
inducing drugs for Respiratory Depression
STOP breathing
S - Sedatives and hypnotics
T - Trimethoprim
O - Opiates
P – Polymyxins
BLEEDING - S/Sx
BEEP
B - Bleeding gums
E - Ecchymoses (bruises)
E - Epistaxis (nosebleed)
P - Petechiae (tiny purplish spots)
Trauma care: complications—"TRAUMA"
Thromboembolism; Tissue perfusion, altered
Respiration, altered
Anxiety related to pain and prognosis
Urinary elimination, altered
Mobility impaired
Alterations in sensory-perceptual functions and skin integrity (infections)
Transient ischemic attacks: assessment—"3Ts"
Temporary unilateral visual impairment
Transient paralysis (one-sided)
Tinnitus = vertigo
Traction: nursing care plan—"TRACTION"
Trapeze bar overhead to raise and lower upper body
Requires free-hanging weights; body alignment
Analgesia for pain, prn
Circulation (check color and pulse)
Temperature (check extremity)
Infection prevention
Output (monitor)
Nutrition (alteration related to immobility)
Tracheoesophageal fistula: assessment—"3Cs"
Coughing
Choking
Cyanosis
Sprain: nursing care plan—"RICE"
Rest
Ice
Compression
Elevation
Postoperative complications: order—"4W's"
Wind (pulmonary)
Wound
Water (urinary tract infection)
Walk (thrombophlebitis)
Myocardial infarction: treatment—"MONA"
Monitor/ Morphine
Oxygen
Nitroglycerin
Aspirin
Basic MI management - "BOOMAR"
Bed rest
Oxygen
Opiate
Monitoring
Anticoagulation
Reduce clot size
Melanoma characteristics—"ABCD"
Asymmetry
Border
Color
Diameter
Hypoglycemia: signs and symptoms—"DIRE"
Diaphoresis
Increased pulse
Restless
Extra hungry
Hypertension: complications—"4 C's"
CAD (coronary artery disease)
CHF (congestive heart failure)
CRF (chronic renal failure)
CVA (cardiovascular accident; now called brain attack or stroke)
Hypertension: nursing care plan— "ITIRED"
Intake and output (urine)
Take blood pressure
Ischemia attack, transient (watch for TIAs)
Respiration, pulse
Electrolytes
Daily weight
Portal hypertension features - "ABCDE"
Ascites
Bleeding (hematemesis, piles)
Caput medusae
Diminished liver
Enlarged spleen
Diabetes
Diabetes: signs and symptoms—"3P's,"
Polydipsia (very thirsty)
Polyphagia (very hungry)
Polyuria (urinary frequency)
Cushing's Syndrome
Cushing's syndrome: symptoms—"3S's"
Sugar (hyperglycemia)
Salt (hypernatremia)
Sex (excess androgens)
Coma
Coma: causes—"A-E-I-O-U TIPS"
Alcohol, acidosis (hyperglycemic coma)
Epilepsy (also electrolyte abnormality, endocrine problem)
Insulin (hypoglycemic shock)
Overdose (or poisoning)
Uremia and other renal problems
Trauma; temperature abnormalities (hypothermia, heat
stroke)
Infection (e.g., meningitis)
Psychogenic ("hysterical coma")
Stroke or space-occupying lesions in the cranium
COMA: CONDITIONS TO EXCLUDE AS CAUSE
MIDAS:
Meningitis
Intoxication
Diabetes
Air (respiratory failure)
Subdural/ Subarachnoid hemorrhage
Cleft lip
Cleft lip: nursing care plan (postoperative)—"CLEFT LIP"
Crying, minimize
Logan bow
Elbow restraints
Feed with Brecht feeder
Teach feeding techniques; two months of age (average age at repair)
Liquid (sterile water), rinse after feeding
Impaired feeding (no sucking)
Position—never on abdomen
Cholecystitis
Cholecystitis: risk factors—"5F's"
Female
Fat
Forty
Fertile
Fair
Blood glucose
Blood glucose (rhyme)
Symptom Implication


Cold and clammy . . . give hard candy
Hot and dry . . . glucose is high
Neurovascular Occlusion
Neurovascular Occlusion: symptoms— "6 P's"
Pain
Pale
Pulseless
Paresthesia
Poikilothermic
Paralysis
Appendicitis
Appendicitis: assessment—"PAINS"
Pain (RLQ)
Anorexia
Increased temperature, WBC (15,000–20,000)
Nausea
Signs (McBurney's, Psoas)
Angina: precipitating factors—"4E's"
Eating
Emotion
Exertion (Exercise)
Extreme Temperatures (Hot or Cold weather)
Acid-base—"ROME" (Respiratory Opposite, Metabolic Equal)
Acidosis
» Respiratory (opposite): pH Pco2
» Metabolic(equal): pH HCO3
Alkalosis
» Respiratory (opposite): pH Pco2
» Metabolic(equal): pH HCO3
hypocalcemia
"cats" of "hypocalcemia"
c - convulsions
a- arrhythmias
t - tetany
s - spasms and stridor
hypocalcemia
"cats" of "hypocalcemia"
c - convulsions
a- arrhythmias
t - tetany
s - spasms and stridor
hypernatremia
hypernatremia signs and symptoms
"you are fried"
f - fever (low grade), flushed skin
r - restless (irritable)
i - increased fluid retention and increased bp
e - edema (peripheral and pitting)
d - decreased urinary output, dry mouth
can also use this one:
salt
s = skin flushed
a = agitation
l = low-grade fever
t = thirst
HYPERKALEMIA
The HYPERKALEMIA "Machine" - Causes of Increased Serum K+
M - Medications - ACE inhibitors, NSAIDS
A - Acidosis - Metabolic and respiratory
C - Cellular destruction - Burns, traumatic injury
H - Hypoaldosteronism, hemolysis
I - Intake - Excesssive
N - Nephrons, renal failure
E - Excretion - Impaired
murder
signs and symptoms of increased serum k+
m - muscle weakness
u - urine, oliguria, anuria
r- respiratory distress
d - decreased cardiac contractility
e - ecg changes
r - reflexes, hyperreflexia, or areflexia (flaccid)
MEDICAL AND SURGICAL NURSING
MNEMONICS
MR. JEFF
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