Episiotomy
assessment—"REEDA"
Redness
Edema
Ecchymosis
Discharge
Approximation of skin
Eye medications
Mydriatic = dilated pupils
Miotic = tiny (constricted) pupils
Hypertension:
complications—"four Cs"
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—"I TIRED"
Intake and output (urine)
Take blood pressure
Ischemia attack, transient (watch for TIAs)
Respiration, pulse
Electrolytes
Daily weight
Hypoglycemia: signs
and symptoms—"DIRE" or “RIDE”
Diaphoresis
Increased pulse
Restless
Extra hungry
Infections during
pregnancy—"TORCH"
Toxoplasmosis
Other (hepatitis B, syphilis, group B beta strep)
Rubella
Cytomegalovirus
Herpes simplex virus
Infections:
signs—"INFE3 CT"
Increased—pulse, respiration, WBC
Nodes—enlarged
Function—impaired
E3: Erythema, Edema, Exudate
Complaints—discomfort, pain
Temperature—local or systemic
IUD: potential
problems with use—"PAINS"
Period (menstrual: late, spotting, bleeding)
Abdominal pain, dyspareunia
Infection (abnormal vaginal discharge)
Not feeling well, fever or chills
String missing
Manipulation: nursing
plan—promote the "three Cs"
Cooperation
Compromise
Collaboration
Medication
administration—"six rights"
RIGHT medication
RIGHT dosage
RIGHT route
RIGHT time
RIGHT client
RIGHT technique
Melanoma
characteristics—"ABCD"
Asymmetry
Border
Color
Diameter
COMMENTS