1. Charlie's
(blood) Chemistry or Comprehensive Metabolic Panel (CMP)
to detect electrolyte imbalances, myocardial damage
2. Ex
X-rays
chest x-ray is used to determine size of heart and signs of heart failure
3. PACked Ruth
Pulmonary Artery Catheter (PAC)
to detect left- or right-sided heart failure
4. In
Intake and output
to assess renal perfusion and possible fluid retention
5. Granny's
(arterial blood) Gases
to help determine O2 flow rates
6. V
Vital signs
to monitor response to therapy and detect complications
7. W
Weight
daily weight to assess possible fluid retention
A
Activities of daily living (ADLs)
Help the client with ADLs
it stresses the heart less
B
Bed rest
Maintain bed rest
it reduces the oxygen demands on the heart
C
Commode
Commode at bedside
it stresses the heart less than using a bedpan
D
Diversions
Offer diversionary activities while on bedrest
offer diversions that don't stress the heart
E
Elevate
Elevate head of bed (semi-Fowler's) or sit client up
to increase chest expansion and improve ventilation
F
Feelings
Listen to client's concerns; provide emotional support to reduce anxiety
anxiety increases oxygen demand
T
Tests and
Explain tests and treatments in simple, culturally sensitive ways
Treatments D
Drugs
Write out names and explain reason for drugs, their side effects, and how long client will take them
D
Diet
Good nutrition and restrictions, i.e., low sodium diet, reduce cholesterol levels
D
Disease
Explanation of the disorder and treatment plan
S
Smoker?
Encourage to stop smoking
Treatment for pulmonary edema: M DOG M =Morphine D =Diuretics (Lasix) O =Oxygen (100% CPAP or intubation) G =Gases (blood gasses)
C ardiogenic - ventricle loses pumping power and cardiac output becomes inadequate H ypovolemic - excessive blood loss A naphylactic - severe allergic reaction inappropriately dilates the veins to pool blood N eurogenic - sympathetic NS inappropriately dilates the veins to pool blood S eptic shock - systemic infection causes excessive capillary permeability with excess intravascular volume loss R =Respiratory O =Opposite M =Metabolic E =Equal
All of the musculoskeletal disorders - EXCEPT Guillain –Barré syndrome - feature the letter M: Myasthenia Gravis Poliomyelitis Amyotrophic Lateral Sclerosis Muscular Dystrophy
6-F’s
of gallbladder disease
F air (skin and hair) F at F orty (and older) F ertile (lots of children) F emale F latulant
After a urinary catheter is removed, the client may have some burning on urination, frequency and dribbling. These findings should subside within 24 to 48 hours. Co-trimoxazole (Bactrim) remains the drug of choice to treat uri nary tract infections (unless the client is allergic to sulfa). After a transurethral resection of the prostate (TURP), the client will continuously feel the urge to void for 24 to 48 hours because the three-way foley catheter has a large diameter. After prostatic surgery, it is normal for the client's urine to be blood tinged for 48 to 72 hours and for him to pass blood clots and tissue debris. Because the prostate gland receives a rich blood supply, it is a priority to observe the client undergoing a prostatectomy for bleeding and shock. Chlamydia is the most common sexually transmitted bacterial infection in the U.S. If untreated, it can cause PID in women and epididymitis in men. HPV vaccine Gardasil® protects against types of HPV that cause most cervical cancers and can help protect against genital warts in both young men and women. Clearly communicate that no blood pressures or blood draws should be taken on the arm with the fistula. Breast cancer starts with the alteration of a single cell and takes a minimum of 2 years to become palpable. At the time of diagnosis, about one-half of clients with breast cancer have regional or distant metastasis. Nerve damage and lymphedema may occur with a radical or modified radical mastectomy (when lymph nodes are removed).
Adrenal gland (cortex) hormones - SSS : S =Sugar (glucocorticoids) S =Salt (mineralcorticoids) S =Sex (androgens)
To help remember the glands of the endocrine system, remember: " Herman Probably Pasted The Paper To A Pot Of Tea "
H =Hypothalamus P =Pituitary P =Pineal T =Thyroid P =Parathyroid T =Thymus A =Adrenal P =Pancreas O =Ovaries T =Testes
Although it's extremely oversimplified, think of the relationship between insulin and glucose as a see-saw. When one is higher, the other tends to be lower.
After hip replacements, pulmonary embolism, often a fat embolus, may occur even without thrombosis in foot or leg. Clients, after hip replacement, should sit in a straight, high chair; use a raised toilet seat; and never cross their legs or ankles. In hip or knee replacement, clients will need assistive devices for walking until muscle tone strengthens and they can walk without pain. After an amputation, the home must be assessed for any modifications needed to ensure safety. The management of soft tissue injury can be remembered by the acronym R.I.C.E.: Rest Ice Compression Elevation Some clients will need transportation to continue rehabilitation out of the home. Amputee support groups can be helpful for clients. After arthroscopy, outpatient rehab may be prescribed depending on procedure; health care provider may prescribe knee immobilizer. Prepare client preoperatively (if possible) about external fixator device to reduce anxiety; device looks clumsy, but client should be reassured that discomfort is minimal. After a femoral-head prosthesis, caution client not to force hip into more than 90 degree of flexion, into adduction or internal rotation. Caution clients with a new prosthesis not to use any substances such as lotions, powders etc. unless prescribed by the health care provider. Osteoporosis cannot be detected by conventional x-ray until more than 30% of bone calcium is lost. Foods high in calcium include milk, yogurt, turnip greens, cottage cheese, sardines, and spinach. When collecting musculoskeletal data on a client with Paget's disease, note the size and shape of the skull; the skulls of these clients will be soft, thick and enlarged. Clients at high risk for acute osteomyelitis are: elderly, diabetics, and those with peripheral vascular disease. Immunosuppressed clients should avoid contact with persons who have infections and locations where there are crowds. Steroids may mask the signs of infections, so clients should promptly report a slight change in temperature.
Photosensitive clients should avoid the sun, limit outdoor activities during peak sun hours, wear sun block, or use clothing and hats to avoid sun exposure
CANCER Interventions: C =Comfort A =Altered body image N =Nutrition C =Chemotherapy E =Evaluate response to medications R =Respite for caretakers
Radiation has more local effects; chemotherapy has systemic effects. Only certified nurses may administer chemotherapeutic agents. Although clients with cancer may experience pain at any time during their disease, pain is usually a late symptom of cancer. Ionizing radiation will damage both normal and cancerous cells, and cause side effects. Clients who receive external radiation are not radioactive at any time. Clients receiving internal radiation are not radioactive; the implant or injection is. If the source of radiation is metabolized, the client's secretions and excretions may be radioactive for a time, based on the half-life of the isotope (usually 48 to 72 hours). Highly active antiretroviral therapy (HAART) used in the treatment of AIDS can cost up to $30,000 - $50,000 per year. THE TRAUMA CLIENT Assessment and early management of the trauma client includes the following:
Primary survey: ABCs A = airway maintenance with spinal cored control, i.e., cervical stabilization B = breathing C = circulation Assess cognitive levels: Glasgow Coma Scale Provides an objective score based on a 15 point scale (for adults) Assesses three categories of responses eye opening response verbal response motor response
Assess: A.M.P.L.E. A = allergies M = medications P = past illness L = last meal E = events preceding the injury Types of trauma
Penetrating Blunt deceleration compression
Findings of trauma Deformity/angulation of extremity Swelling Pain Paresis/paralysis Pallor Absent pulses Life threatening injuries of an extremity Massive open comminuted fractures Bilateral femoral shaft fractures Vascular injuries Crush injuries of the abdomen or pelvis Traumatic amputation of an arm or leg Predictable musculoskeletal injuries Child/pedestrian injuries Waddell's triad associated with high-velocity accidents involving children, i.e., motor vehicle, auto-pedestrian, or bicycle crashes consists of femur fracture, intra-abdominal or intrathoracic injury, and/or head injury take care to determine point of impact with the car bumper point of impact with the car hood point of impact where the body is thrown children tend to face car when incident is about to occur Adult/pedestrian injuries take care to determine point of impact with the car bumper point of impact with the car hood injuries to opposing ligaments unlike children, adults tend to turn away from car before impact Unrestrained drivers head injuries injuries to larynx and sternum knee/femur injuries posterior hip dislocation Fall from a height ("Don Juan syndrome") lands on feet and fractures ankles: bilateral calcaneal fractures falls backwards: L2-L3 injuries hyperflexion of the lumbar spine bilateral Colles' fractures compression fracture of vertebrae then may land on hands: fractured wrists Blast injuries gunshot/missile type injuries
source of infection: when energy travels it leaves a vacuum behind it, drawing in debris and body hair results in both an entry and exit wound shock waves extend throughout body
Goals of nursing care Sustain life Maintain function Preserve appearance Goals of rehabilitation Decrease pathology Prevent secondary disabilities Increase function of unaffected and affected systems
Emergency trauma assessment: ABCDEFGHI A =Airway B =Breathing C =Circulation D =Disability E =Examine/expose F =Fahrenheit (temperature) G =Get vitals H =Head-to-toe assessment/history I =Inspect the back
Complications of a trauma client: TRAUMATIC T =Tissue perfusion problems R =Respiratory problems A =Anxiety U =Unstable clotting factors M =Malnutrition A =Altered body image T =Thromboembolism I =Infection C =Coping problems
Cyanotic defects - the 4 T's: T T T T
=Tetralogy of fallot =Truncus arteriosus =Transportation of the great vessels =Tricuspid atresia
Associate Hir schsprung's with a girl ("her") who wears "ribbons" in her hair - to recall that "ribbon-like" stools are a classic finding of this disease.
Normal labor progress in active labor is 1.2 cm/hr for primiparas and 1.5 cm/hr for multiparas Prolonged labor at any stage should be evaluated for fetal, pelvic or uterine dysfunction Pain and anxiety can impede the laboring progress Vaginal birth is the birth method of choice and interventions should be directed at accomplishing that goal Cesarean birth is utilized to rescue the infant when fetal, pelvic or uterine dysfunction cannot be overcome Maintenance of a calm, soothing environment is necessary Efficient and effective gathering of supplies and personnel is imperative Maintain eye contact and verbal contact with woman to provide support Assist mother to birth as slowly as possible to prevent maternal/newborn trauma Be prepared to assist with the newborn transition to extrauterine environment Anticipate predisposing factors for prolapsed cord Inform and support mother in any emergency Prepare for expeditious birth - vaginal or cesarean Surgical interventions have associated complications of increased in fection, increased postoperative hemorrhage, increased morbidity and potential of increased mortality Surgical delivery, c-section, of the newborn reduces mechanical compression of the chest. It may potentiate respiratory difficulties in the newb orn such as transient tachypnea of the newborn. Severe postpartum hemorrhage may result in organ failure, disseminated intravascular coagulation (DIC), and/or mortality Estimation of bleeding is critical Uterine massage is the first line of defense against excessive hemorrhage Oxytocins are used to contract the uterus during the laboring process and after delivery If the maternal pancreas is unable to increase insulin production sufficiently, gestational diabetes mellitus results Maternal hyperglycemia results in glucose crossing the placenta and the fetus manufacturing insulin Insulin in the fetus acts as a growth hormone producing a large-size infant Shoulder dystocia is the most common complication of vaginal delivery in large-size infants Maternal insulin needs are dramatically reduced following delivery Newborns of diabetic mothers may incur birth injury, hyperbilirubinemia, hypoglycemia, and neurologic damage Euglycemia is the most important factor in avoiding maternal/fetal complications
Anemia in pregnancy is associated with abortion, infection, pregnancy induced hypertension, preterm labor and heart failure Fetal problems from anemia of mother include growth retardation with associated morbidity and mortality Daily logs of dietary intake may help the woman focus on positive improvement Pica is the craving by pregnant women for nonfood substances due to low iron levels Failure to correct nutritional imbalances in pregnancy can result in intrauterine growth retardation, central nervous system malformations and fetal death Failure to correct nutritional imbalances in pregnancy can result in severe dehydration, metabolic alkalosis, ketosis, cardiac dysrhythmias and death for the woman Maternal understanding of the disease process and recommended therapies may provide impetus for self-care Normal pregnancy cardiovascular changes increase the heart's workload Cardiac disease in pregnancy can deteriorate rapidly Women must verbalize understanding of cardiac findings indicating complications Pregnant cardiac clients must be monitored closely for decompensation Failure to detect blood incompatibility with the fetus can result in RBC hemolysis and severe morbidity or mortality RhoGAM should be administered to all sensitized women within 72 hours following delivery, miscarriage, or abortion
