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ons. You are looking for the MOST unstable patient. Documentation should be descriptive and objective. Dont pass the buck! Delegation o RN- Assessment, Teaching, Eval o LVN- Stable with predictable outcomes Recognize abnormal vs normal Know sterile procedure o NAP- Standard unchanging procedures. VS, O2 Sats, assist w/ ADLs, BS, etc. Light assignment- doesnt mean most stable. Bc they could be in ICU and need Assess/eval. Transfer or float nurses get LVN-like work. RN are the only ones allowed to delegate- Advise that it should not be done. Insisting is not therapeutic communication. NAP- no Myesthenia gravis pt- requires assessment. Enteral fee in NCLEX is a standard, unchanging procedure. Cannot perform a dilation and effacement test if pt has bright red discharge.-NEVER Therapeutic Communication o Respond with feeling tone o Provide information o Dont ask- WHY o Dont ask- YES/NO questions o Dont focus on Nurse o Dont explore o Dont say -Dont worry! Airway beats cardiac! Restless, agitated, and Sweating- Hypoxia! Seizures- Oxygen and suctioning. No Crash cart nor intubation needed. Meningitis- full PPE Mononucleosis- large liver, large spleen- No contact!!! Mantoux test for TB- induration >5MM--- negative unless patient is immunocompromised (AIDS, etc) Salmonellosis- you can carry the disease up to 1 yr and pass the acute phase of the illness to your family members. Stool sample is only way to verify pt is no longer contagious. PROM for >24 hrs has high potential for infection. Kaposi sarcoma!Significant lead poisoning causes constipation and growth stunting! Go over Play typeso Infant o Toddler o Pre-school
o School age o Adolescent o Adults Amniocentesis- worried about leaking (unexpected). o Worried about infection VEAL> CHOP o Late decelsHypoxia!! o Variable, Early, adequate, late Variable decels = Cord compression Early decels = Head compression Acceleration = OK Late decels = Placental insufficieny FLOP for late decels Fluids Lateral position O2 On Pitocin off Complications of Neonatal hyperbilirubinemia o Suppression of CNS. First responders are the ones who identify hazardous material. o Nurses- determine if decontamination has occurred. Risk Factors for Breast CA: o Abdominal fat increasing after menopause has increased risk for Breast CA o First degree relative (Not aunt!) You will see bright red blood loss before Vital sign changes for Postpartum!!!! - hemorrhage! Insulin---Nancy Reagan, R Nair into Nph, Air into R, then draw up R, then draw up NPH. Symptoms of heroin withdrawal occur between 12-24 hours after birth/last dose!! o Assess respiratory and cry Temp, jaundice, and vomiting--- Neonatal sepsis o Get checked right away! o Baby is cold bc immature immune system cannot respond to infection 1 saturated peri pad = 100 mL of blood -> so, 1 peri pad soaked every hour for 2 hours may indicate post-partum hemorrhage Key word--- Saturated! Smoking---- number one for issues with arthritis! Immunizations pg 5 All People Eat Tasty Meat-- Cardiac auscultation o APE TO MAN o Erbs -3rd ICS
Manic patient- provide finger food and liquids. OCD- distract. Dont focus on ritual. Risk factor for Testicular cancer o Undescended testicle/ Cryptoorchidism 3 lbs in 24hrs is dangerous for Pregnant or cardiac pt. Neuroleptic Malignant syndrome- Dangerous! Place client in dimly lit room to reduce environmental stimuli Depressed pts: try to develop a therapeutic relationship! Pt of SSRI receiving Paxil- early signs of antidepressant toxicity: o Confusion, memory loss, and disorientation not good! Lithium toxo Antagonizes ADH- dehydration o Fine tremor expected- Coarse tremor-> toxicity! o Do not restrict NA+ o Feeling faint, fast heart rate o Instruct the client to drink 8-12 glass of water daily Psychiatric- restate and reorient Ziprasidone (Geodon)- atypical antipsychotic. Used for bipolar o Potential for neuroleptic o Pt has flight of ideas- so this med helps for them to talk coherently. o Attention span is NOT a deficit with psychotic pt. Paranoia vs delusion- my neighbors dont like me can be harmful