Simple Nursing Study Guide – Flashcards
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Do not DELEGATE what you can_________.
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EAT: Evaluate, Assess, Teach
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Addison's Disease
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Hyponatremia, Hypoglycemia, Hypotension, Low blood volume(hypovolemia), and Hyperkalemia, dark pigmentation, decreased resistance to stress, fractures, alopecia, weight loss, GI distress
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Cushing's Disease
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Hypernatremia, Hyperglycemia Hypertension, Hypervolemia, and Hypokalemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump
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If your not Peeing then your not giving ________.
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K -Potassium
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Veins
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Elevate Leg
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Arteries
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Dangle Legs
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APGAR
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Appearance(Color Pink, pink and blue, or blue) Pulse (>100) (<100) or (absent) Grimace (cough, grimace, no response) Activity (Flexed, flaccid, limp) Respirations (Cry, weak cry, absent)
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Airborne Precautions (DISEASES)
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My Car Hez TB: Measles, Chicken Pox, Herpes Zoster/shingles, and Tuberculosis.
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Airborne Precautions (Nursing)
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Private room with negative air pressure with 6-12 air exchange per hour, Mask, N95 for TB.
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Droplet Precautions (DISEASES)
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SSSPPPIDERMMMAN: Sepsis, Scarlet Fever, Streptococcal pharyngitis, parvovirus b19, pneumonia, pertussis, influenza, diphtheria, epiglottis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, and adenovirus.
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Droplet Precautions (Nursing)
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Private Room or cohort mask
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Contact Precautions (DISEASES)
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MRS WEE AND VCHIPS: Multidrug resistant organism, respiratory infection, skin infection, wound infection, enteric infection (CDIFF), Eye infection (Conjunctivitis). AND Varicella Zoster, cutaneous diphtheria, herpes simplex, impetigo, pediculosis, scabies.
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S&S of Air or Pulmonary Embolism
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Chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending doom
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Nursing Intervention of Air or Pulmonary Embolism
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Turn pt. to left side and lower the head of the bed
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S&S of Women in Labor with un-reassuring FHR
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Late decels, decreased variability, fetal bradycardia.
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Nursing Intervention for Women in Labor with un-reassuring FHR
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Give O2, Stop Pitocin, Increase IV fluid
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Nursing Intervention for Tube Feeding with Decreased LOC
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Right side (prevent stomach emptying), with HOB elevated to prevent aspiration
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Nursing Intervention during Epidural puncture
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Side lying
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Nursing Intervention for heat stroke
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Flat with legs elevated
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Nursing Intervention for during continuous bladder irrigation
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Catheter is taped to thigh so leg should be kept straight. No other positioning restrictions.
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Nursing Intervention After Myringotomy
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Position on affected ear to allow for drainage.
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Nursing Intervention After Cataract Surgery
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Unaffected side with night shield for 1-4 weeks
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Nursing Intervention after thyroidectomy
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Low or Semi-fowler, support head neck and shoulders
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Nursing Interventions infant with spina bifida
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Prone on abdomen so that sac does not rupture
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Nursing interventions for bucks traction/skin traction
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Elevate foot of bed to couter traction
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Nursing Intervention after total hip replacement
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Don't sleep on operated side, don't flex hip more than 45-60 degree, don't elevate HOB more than 45 degrees. Maintain hip abduction by separating thighs with pillows
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Nursing Intervention for prolapsed cord.
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Knee chest position, or trendelenburg
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Nursing intervention for Infant with cleft lip
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Position on back or in infant seat to prevent trauma to suture line. While feeding hold in upright position
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Nursing Intervention to prevent dumping syndrome
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Post op ulcer or stomach surgery, Eat in reclining position, lie down after meal for 20-30 minute also restrict fluids during meals and low carbohydrate or Fiber diet and small frequent meals
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Nursing Intervention for above knee amputation
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elevate for first 24 hours on pillows, position prone daily to provide for hip extension
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Nursing Intervention for below knee amputation
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Foot of bed elevated for first 24 hours, position prone daily to provide for hip extension
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Nursing intervention for detached retina
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area of detachment should be in the dependent position
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Administration of enema
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Position in left side lying sims with knee flexed
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Nursing intervention after supratentorial surgery
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Incision behind the hairline, Elevate HOB 30-45 degree
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Nursing intervention after infratentorial surgery
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Incision at nape of neck, Position pt flat and lateral on either side
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Nursing intervention during internal radiation
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Bedrest while implant is in place
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S&S during autonomic dysreflexia/hyperreflexia
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pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia, hypertension
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Nursing Intervention autonomic dysreflexia/hyperreflexia
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Sitting position with HOB elevated
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Nursing intervention for shock
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Bedrest with extremities elevated 20 degrees, knee straight, head slightly elevated in modified trendelenburg
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Nursing intervention for head injury
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Elevate HOB 30 degrees to decrease ICP
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Nursing Interventions for peritoneal dialysis when outflow is decreased
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Turn pt side to side before checking tubing for kinks
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Nursing intervention after lumbar puncture
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Supine position for 4-12 hours as prescribed
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Medication for Pancreatitis
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Demerol
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Myasthenia Gravis
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Worse with exercise, better with rest
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Myasthenia Crisis
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Positive reaction to tensilon
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Cholinergic Crisis
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Stop medication, giving Tensilon will make it worse
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Head injury medication
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Mannitol -osmotic diuretic - crystallized at room temperature so use a filter needle
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Liver Biopsy watch what lab value
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Prothrombin Time
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Metabolic Acidosis
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Diarrhea (ASS)
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Metabolic Alkalosis
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Vomit (Mouth)
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Myxedema/hypothyroidism
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slowed physical and mental function, sensitive to cold, dry skin and hair
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Graves Disease/Hyperthyroidism
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accelerated physical and mental function, sensitive to heat, fine soft hair.
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Thyroid storm
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increased temperature, pulse, hypertension
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Post Thyroidectomy
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semi fowlers, prevent neck flexion/hyperextension. have trach at bedside
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Hypoparathyroid
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CATS: convulsions, arrhythmias, tetany, spasms, stridor, decreased calcium,
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Diet Hypoparathyroid
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High Calcium, High Phosphorus diet
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Diet Hyperparathyroid
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Low Calcium, Low Phosphorus Diet
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Hyperparathyroid
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fatigue, muscle weakness, renal calculi, back and joint pain, increase calcium.
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S&S Hypovolemia
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Increased temperature, rapid weak pulse, increased respiration, hypotension, anxiety, urine specific gravity >1.030
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Nursing Intervention for Hypervolemia
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Semi Fowlers
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S&S Hypervolemia
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Bounding pulse, SOB, Dyspnea, Rales/crackles, Peripheral Edema, HTN, Urine Specific Gravity <1.010
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Diabetes Insipidus (Decreased ADH)
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Excessive urine output and thirst, dehydration, weakness.
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What medication for Diabetes Insipidus
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Pitressin
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SIADH (Increase ADH)
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Change LOC, decreased deep tendon reflexes, tachycardia, n/v/a, headache,
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What medication for SIADH
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Declomycin, diuretics
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S&S Hypokalemia
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muscle weakness, dysrhythmia, increased potassium in diet
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High potassium foods
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Raisins, Bananas, apricots, oranges, beans, potatoes, carrots, celery
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S&S HyperKalemia
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MURDER: muscle weakness, urine (oliguria, anuria), respiratory depression, decreased cardiac contractility, ECG changes, reflexes
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S&S Hyponatremia
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nausea, muscle cramps, increased ICP, muscular twitching, convulsions
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Medications for Hyponatremia
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osmotic diuretics, and fluids
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S&S Hypernatremia
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increased temperature, weakness, disorientation/delusions, hypotension, tachycardia,
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Medication for Hypernatremia
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Hypotonic solution
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S&S Hypocalcemia
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CATS: Convulsions, arrhythmias, tetany, spasms, stridor
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S&S Hypercalcemia
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muscle weakness, lack of coordination, abdominal pain, confusion, absent DTR, Sedative effect on CNS
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S&S Hypomagnesaemia
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tremors, tetany, seizures, dysrhythmia, depression, confusion, dysphagia, digoxin toxicity,
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S&S Hypermagnesaemia
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depresses the CNS, hypotension, facial flushing, muscle weaknesses, absent DTR, shallow respirations, emergency
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Addisons Crisis S&S
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N/V, confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP
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Pheochromocytoma
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hypersecretion of epi/norepi, persistent HTN, Increased HR, hyperglycemia, diaphoresis, tremor, pounding headache, avoid stress, frequent bating and rest breaks, avoid cold and stimulating foods, surgery to remove tumor
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Neuroleptic Malignant Syndrome (NMS) S&S
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Hot (hyperpyrexia), Stiff (Increased muscle tone), Sweaty (diaphoresis), Increased BP, PULSE, RESP), Drooling
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Never get pregnant with _______________.
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German Measles/Rubella
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When Drawing up Regular Insulin and NPH together, Remember:
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RN: Regular before NPH
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Tetralogy of Fallot
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DROP: The child drops or squats: Defect septal, Right Ventricular Hypertrophy, Overriding aorta, pulmonary stenosis
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MAOI's used for antidepressants
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Pirates say arrrrr, Pirates are depressed. All medications have an ARRR sound in the middle (parnate, marplan, nardil,
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Autonomic Dysreflexia Nursing Interventions
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Emergency, Elevate HOB to 90 degrees, loosen restrictive cloths, Assess bladder distention, and bowel impaction which is a trigger,
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Medication of Autonomic Dysreflexia
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Antihypertensives which can cause stroke, MI, Seizures
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MAOI's
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PANAMA: Parnate, Nardil. Marplan (Metallic taste)
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Digoxin Nursing Intervention
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Check pulse, less than 60 hold, check dig level and potassium level
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Amphogel
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Treatment of GERD and Kidney stones and watch for constipation
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Vistaril
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Treatment of anxiety and also itching, watch for dry mouth and given preop commonly
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Versed
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given for conscious sedation and watch for respiratory depression and hypotension
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PTU and Tapazole
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Prevention of thyroid storm
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Sinemet
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Treatment of parkinsons, sweat, saliva, urine may turn reddish brown occasionally and can cause drowsiness
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Artane
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Treatment parkinsons with sedative effect
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Cogentin
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Treatment of parkinsons and extrapyramidal effects of other drugs
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Tigan
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Treatment of postop n/v and for nausea associated with gastroenteritis
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Timolol-Timoptic
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Treatment of glaucoma
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Bactrim
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Antibiotic (don't take if allergic to sulfa drugs) SE: diarrhea, drink plenty.
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Gout medications
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Probenecid (Benemid), colchicine, allopurinol(Zyloprim)
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Apresoline (hydralazine) (FOR, S&S, NURSING INT)
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HTN or CHF, Flu-like symptoms, Rise slowly from sitting/lying position
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Bentyl
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Irritable Bowel
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Calan (verapamil)
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Ca+ Channel Blocker, Tx of HTN Angina, Assess for Constipation
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Carafate
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Treatment of duodenal ulcers, coats the ulcer so take before meals
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Theophylline
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Treatament of asthma, COPD,
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Therapeutic Level for Theophylline
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10-20
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Mucomyst
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Antedote to Tylenol and is administered orally
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Diamox
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Treatment glaucoma, high altitude sickness. (DONT take if allergic to sulfa drugs)
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Indocin (NSAID)
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Treatment of arthritis (osteo, rheumatoid, gouty) bursitis, tendonitis,
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Synthroid
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Treatment of hypothyroidism, may take several weeks to take effect, notify doctor of chest pain, take in the am on empty stomach, could cause hyperthyroidism
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Librium
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Treatment of alcohol withdrawel (Do not take alcohol with this med can cause nausea and vomiting)
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Oncovin (Vincristine)
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Treatment of leukemia and given IV only
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Kwell
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Treatment of scabies or lice (Scabies tx with lotion once and leave on for 8-12 hours) (Lice use shampoos and leave on for 4 minutes with hair uncovered then rinse and warm water and comb with fine tooth comb.
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Premarin
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Tx of menopause estrogen replacement
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Dilantin
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treatment of seizures
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Therapeutic level Dilantin
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10-20
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Navane
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Treatment of schizophrenia assess for EPS
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Ritalin
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Treatment of ADHD assess of heart related side effects report immediately, child may need a drug holiday because it stunts growth
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Dopamine (Intropine)
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treatment of hypotension, shock, low cardiac output, poor perfusion to vital organs, monitor EKG for arrhythmia and monitor BP
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Variable Decels (VEAL CHOP)
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Cord Compression
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Early Decels (VEAL CHOP)
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Head Compression
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Accels (VEAL CHOP)
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Okay not a problem
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Late Decels (VEAL CHOP)
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Placental insufficiency
