Mental retardation:
nursing care plan—"three Rs"
Regularity (provide routine and structure)
Reward (positive reinforcement)
Redundancy (repeat)
Myocardial
infarction: treatment—"M2 ONA"
MONA greets every
M.I.:
Monitor/Morphine
Oxygen
Nitroglycerin
Aspirin
Newborn assessment
components—"APGAR"
Appearance
Pulse
Grimace
Activity
Respiratory effort
Obstetric (maternity)
history—"GTPAL"
Gravida
Term
Preterm
Abortions (SAB, TAB)
Living children
Oral contraceptives:
signs of potential problems—"ACHES"
Abdominal pain (possible liver or gallbladder problem)
Chest pain or shortness of breath (possible pulmonary
embolus)
Headache (possible hypertension, brain attack)
Eye problems (possible hypertension or vascular accident)
Severe leg pain (possible thromboembolic process)
Pain:
assessment—"PQRST"
What Provokes the
pain?
What is the Quality
of the pain?
Does the pain Radiate?
What is the Severity
of the pain?
What is the Timing
of the pain?
Pain:
management—"ABCDE"
Ask about the pain
Believe when clients say they have pain
Choices—let clients know their choices
Deliver what you can, when you said you would
Empower/Enable clients' control over pain
Postoperative
complications: order—"four Ws"
Wind (pulmonary)
Wound
Water (urinary tract infection)
Walk (thrombophlebitis)
Preterm infant:
anticipated problems—"TRIES"
Temperature regulation (poor)
Resistance to infections (poor)
Immature liver
Elimination problems (necrotizing enterocolitis [NEC])
Sensory-perceptual functions (retinopathy of prematurity
[ROP])
Psychotropic medications:
common antidepressives (tricyclics)—"VENT"
Vivactil
Elavil
Norpramin
Tofranil
Schizophrenia:
primary symptoms—"four As"
Affect
Ambivalence
Associative looseness
Autism
Sprain: nursing care
plan—"RICE"
Rest
Ice
Compression
Elevation
Stool
assessment—"ACCT"
Amount
Color
Consistency
Timing
Tracheoesophageal
fistula: assessment—"three Cs"
Coughing
Choking
Cyanosis
Traction: nursing
care plan—"TRACTION"
Trapeze bar overhead to raise and lower upper body
Requires free-hanging weights; body alignment
Analgesia for pain, prn
Circulation (check color and pulse)
Temperature (check extremity)
Infection prevention
Output (monitor)
Nutrition (alteration related to immobility)
Transient ischemic
attacks: assessment—"three Ts"
Temporary unilateral visual impairment
Transient paralysis (one-sided)
Tinnitus = vertigo
Trauma care:
complications—"T2 RAUMA"
Thromboembolism; Tissue perfusion, altered
Respiration, altered
Anxiety related to pain and prognosis
Urinary elimination, altered
Mobility impaired
Alterations in sensory-perceptual functions and skin
integrity (infections)
Wernicke-Korsakoff
syndrome (alcohol-associated neurological disorder)—"COAT RACK"
Wernicke's encephalopathy (acute phase): clinical
features:
Confusion
Ophthalmoplegia
Ataxia
Thiamine is an important aspect of Tx
Korsakoff's psychosis (chronic phase): characteristic
findings:
Retrograde amnesia (↓
recall of some old memories)
Anterograde amnesia (↓ability to form new memories)
Confabulation
Korsakoff 's psychosis
COMMENTS