Acid-base—"RAMS"
(Respiratory Alternate, Metabolic Same)
Or
“ROME” (Respiratory
Opposite, Metabolic Equal )
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Respiratory
(Alternate)
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Metabolic
(Same)
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Acidosis
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pH↓
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pCO2↑
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pH↓
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HCO3↓
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Alkalosis
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pH↑
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pCO2↓
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pH↑
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HCO3↑
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Alcohol withdrawal:
clinical features—"HITS"
Hallucinations (visual, tactile)
Increased vital signs and insomnia
Tremens →
delirium tremens (potentially lethal)
Shakes/Sweats/Seizures/Stomach pains (nausea, vomiting)
Angina: precipitating
factors—"three Es"
Eating
Emotion
Exertion (Exercise)
Anorexia nervosa:
clinical features—"A2 NOREXI2 C"
Adolescent women/Amenorrhea
NGT alimentation (most severe cases)
Obsession with losing weight/becoming fat though Underweight
Refusal to eat (≥
5% die)
Electrolyte abnormalities (e.g., ↓K+, cardiac arrhythmia)
↑
eXercise
Intelligence often above average/Induced vomiting
Cathartic use (and diuretic abuse)
Appendicitis: assessment—"PAINS"
Pain (RLQ)
Anorexia
Increased temperature, WBC (15,000–20,000)
Nausea
Signs (McBurney's, psoas)
Arterial occlusion:
symptoms—"six Ps"
Pain
Pale
Pulseless
Paresthesia
Poikilothermic
Paralysis
Blood glucose (rhyme)
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Symptom
|
Implication
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Cold and clammy . . .
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give hard candy
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Hot and dry . . .
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glucose is high
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Blood vessels in
umbilical cord—"AVA"
Artery
Vein
Artery
Cancer: early
signs—"CAUTION"
Change in bowel or bladder habits
A persistent sore throat
Unusual bleeding or discharge
Thickening or lump
Indigestion: dysphagia
Obvious change in a wart/mole
Nagging cough or hoarseness
Cancer: focus of
patient care—"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)
Cholecystitis: risk
factors—"five Fs"
Female
Fat
Forty
Fertile
Fair
Cleft lip: nursing care
plan (postoperative)—"CLEFT2 LIP"
Crying, minimize
Logan bow
Elbow restraints
Feed with Breck 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
Cognitive disorders:
assessment of difficulties—"JOCAM"
Judgment
Orientation
Confabulation
Affect
Memory
COMMENTS