Feb 22, 2011

Final comprehansive notes 4


· Symptoms

o Hives

o Rash

o Difficulty breathing (first sign)

o Diaphoresis

· Nursing care

o Epinephrine 0.3 ml of 1:1000 solution SQ

o Massage site

o May repeat in 15-20 min.

Delayed Allergic Reaction

· Symptoms:

o Rash, Hives, Swollen Joints

· Nursing Care

o Discontinue medication

o Topical Antihistamines

o Corticosteroids

o Comfort measures

Bone Marrow Depression


Fever, Chills, Sore Throat

Back pain, Dark urine

Anemia, Thrombocytopenia, Leukopenia

Nursing Care:

Monitor CBC

Protect from infections

Avoid injury

Liver impairment: light stools and dark urine

Renal Impairment: decrease Hematocrit

Anticholinergic Effects

· Symptoms:

o Dry mouth, Dysphagia, Nasal Congestion

o Urinary retention, Impotence

· Nursing Care:

o Sugarless lozenges

o Good mouth care

o Void before taking medication

Parkinson’s-like effects

· Symptoms:

o Akinesia (temporarily paralysis of muscles)

o Tremors

o Drooling

o Changes in gait

o Rigidity

o Akathisia (Extreme restlessness)

o Dyskinesia (Spasms)

· Nursing Care:

o Anticholinergic and Antiparkinsonian medications

o Safety measures for gait

How long should a client with tuberculosis be on medication?

§ 6-9 Months

What are symptoms of hepatitis?

§ Inflammation of Liver

§ Jaundice

§ Anorexia

§ RUQ pain

§ Clay-colored stools, tea-colored urine

§ Pruritis (bile salts eliminated through skin)

§ Elevated ALT, AST

§ Prolonged PT (liver involvement with clotting factor)

What is the transmission of Hepatitis A?

§ Fecal/Oral

§ Consume contaminated food or water

§ Travelers to developing countries at risk

§ Clients with hepatitis A should not prepare food for others

What is the transmission of Hepatitis B?

§ Parenteral/Sexual contact

§ Blood or body fluids

§ At risk individuals are the one’s that abuse IV drugs, dialysis, healthcare workers

§ Vaccine developed

What is the transmission of Hepatitis C?

§ Blood or body fluids

§ Can become chronic disease

§ Seen in patients with hemophilia (unable to clot)

What is the transmission of Delta Hepatitis?

§ Co-infects with hepatitis B

What nursing care are recommended for Hepatitis?

§ Rest (mainly for liver)

§ Contact and standard precautions

§ Low-fat, High-Calorie, and High Protein diet (needed for organ healing)

§ No alcoholic beverages

§ Medications (Vitamin K, Aqua-Mephyton for bleeding problems, Anti-emetic – no compazine, use Tigan or (Dramamine). Corticosteroids to decrease inflammatory response, and anti-histamines, will use lotions or baths than systemic ones.

What is Lyme’s Disease?

§ Multi-system infection caused by a tick bite. There are three stages.

What is Stage 1 of Lyme’s Disease?

§ Erythematous papule develops into lesion with clear center (Bull’s-eye)

§ Regional lymphadenopathy

§ Flu-like symptoms (fever, headache, conjunctivitis)

§ Can develop over 1 to several months

What is Stage 2 of Lyme’s Disease?

§ Develop after 1 to 6 months if disease untreated.

§ Cardiac conduction defects

§ Neurologic disorders (Bell’s palsy, temporary paralysis)

What is Stage 3 of Lyme’s Disease?

§ Develops after 1 to several months, if reached at this stage may persist for several years.

§ Arthralgias

§ Enlarged, inflamed joints

What are some Lyme’s Disease teaching?

§ Cover exposed areas when in wooded areas

§ Check exposed areas for presence of ticks

What are some Lyme’s Disease nursing care?

§ Antibiotics 3-4 weeks

§ Stage 1 use Doxicillin

§ IV penicillin with later stages

What are the treatment, mode of transmission, care, signs and symptoms of syphillis?

§ Painless chancre fades after 6 weeks

§ Low grade fever

§ Copper-colored rash on palms and soles of feet

§ Spread by contact of mucous membranes, congent

§ Treat with Penicillin G IM

§ If patient has penicillin allergy, will use erythromycin for 10-15 days.

§ After treatment, patient must be retested to make sure disease is gone.

What are the treatment, mode of transmission, care, signs and symptoms of gonorrhea?

§ If female maybe asymptomatic and will be unaware of having disease.

§ Males may have thick discharge from urethra.

§ Some females from vagina.

§ Spread mucous membranes, congenital

§ IM Rocephin with Doxycycline PO, IM Aqueous Penicillin with PO Probenecid (used for gout, used with Penicillin because it delays the urinary excretion of it, makes it more effective)

§ Complication: Pelvis Inflammatory Disease

§ Most often affected with Chlamydia also, then treatment with PO Tetracycline

What are the treatment, mode of transmission, care, signs and symptoms of genital herpes?

§ No cure.

§ Painful vesicular genital lesions

§ Problem is exacerbations/remissions

§ Reoccurs with stress, infection, menses

§ Spread by contact of mucous membranes, congenital

§ Treatment: Acyclovir, sitz bath

§ Monitor pap smears regularly because of higher incidence of cervical cancer.

§ Emotional support of client/significant others important because of no cure.

§ Pregnant women with active disease will have C-section.

What are the treatment, mode of transmission, care, signs and symptoms of Chlamydia?

§ Men: urethritis, dysuria

§ Women: thick vaginal discharge with acrid odor

§ Spread by mucous membranes, congenital

§ Treatment with Tetracycline or Doxycycline PO

§ Will cause sterility if left untreated.

§ Important to notify sexually contacted.

What are the treatment, mode of transmission, care, signs and symptoms of Venereal Warts?

§ Single, small papillary lesion spreads into large cauliflower cluster on perineum, vagina, penis.

§ May itch or burn.

§ Spread by mucous membranes, congenital

§ Treatment: Curettage, cryotherapy with liquid nitrogen, kerotolytic agents

§ Avoid intimate contact until lesions heal

§ Complication: Genital Dysplasia Cancer

What is the difference between AIDS and HIV +?

§ HIV Positive—presence of HIV in blood

§ AIDS—has significant defects in immune function associated with positive HIV evidenced by development of opportunistic infections

§ Syndrome where CD4 counts are below 200

What are some opportunistic infections of AIDS?

§ P. Carinii Pneumonia: sob/dry-nonproductive cough

§ C. Albicans stomatitis: will have difficulty swalling and white exudates in back of throat

§ C. Neoformans: debilitating form of meningitis that may suffer seizures.

§ Cytomegalovirus (CMV): will experience lymphadenopathy and may have visual impairment and can affect any organ.

§ Kaposi’s Sarcoma: most common malignancy experience with AIDS, small purplish brown, nonpainful, nonpuriitc palpable lesions on the body.

How is AIDS transmitted?

§ Contaminated blood or body fluids

§ Sharing IV needles

§ Sexual contact

§ Transplacental: across placenta

§ Possibly by breast milk

What are diagnostics test associated with AIDS?

§ ELISA test, if positive will be confirmed by Western Blot test

§ HIV Viral culture: Leukopenia, Thrombocytopenia, Decrease CD4 counts

What are some nursing cares for AIDS?

§ Prevention: avoid IV drug use, precautions regarding sexual patterns, use standard precautions

§ Contact and standard precautions

§ High-protein and high-calorie diet, small frequent meals rather than 3 large meals

§ Symptomatic relief

§ Support

§ Don’t share toothbrush/shavers

What are treatments, care, prevention of poison control?

§ Prevention most important.

§ Treat patient first, and then the poison.

§ Recognize signs of symptoms of accidental poison: changes in appearance, behavior, substances around mouth, empty containers, vomitous.

What should happen when someone is poisoned?

§ Call poison control center.

§ Tell them: substance, time, amount and route of ingestion, child’s condition, age, weight, save vomitus, stool, urine.

Why should vomit not be induced?

§ Don’t induce if:

§ Danger of aspiration, decrease LOC, Ingested petroleum distillate (lighter fluid, kerosene, paint remover)

§ Ingested corrosive (Draino)

What medication treatment is used to induce vomiting and what other factors need to be implemented?

§ Syrup of Ipecac with small amount of water. Don’t give large amount of fluid after Ipecac, will increase gastric emptying.

§ Don’t use milk.

§ Position with head lower then chest.

§ No universal antidote.

What should happen to poison control in emergency care?

§ Intubated if comatose

§ Run blood gases

§ IV fluids

§ Cardiac Monitor

§ Gastric Lavage (NG down to flush with NS to remove rest in stomach)

§ Activated Charcoal

§ May use cathartics, diuretics

What are signs and symptoms, treatments, care, prevention of aspirin poisoning?

§ Tinnitus, change in mental status, Increased temperature, hyperventilation, bleeding, nausea and vomiting.

§ Nursing care: induce vomiting, maintain hydration, reduce temperature (sponge baths), monitor for bleeding.

What are signs and symptoms, treatments, care, prevention of tylenol poisoning?

§ Symptoms: nausea/vomiting, hypothermia, If no treatment, hepatic/liver involvement.

§ If liver gets involved patient may have RUQ pain, jaundice, confusion, and coagulation abnormalities.

§ Nursing care: induce vomiting, maintain hydration, monitor liver and kidney function with labs such as AST/ALT enzymes.

§ Tylenol (Acetaminophen) overdosage:

§ Antidote N-acetylcysteine (Mucomyst)

What are signs and symptoms, treatments, care, prevention of lead toxicity?

§ Symptoms: Irritability, decreased activity, abdominal pain, Increased ICP

§ Diagnostic tests: Blood lead levels (>9micrograms = toxic), Erythrocyte protoporphyrin (EP), X-ray long bones (lead deposits in long bones)

§ Children engage in PICA (ingesting nonfood substances)

§ Lead blocks formation of hemogloblin and toxic to kidneys.

§ Nursing care: identify source, chelating agents, teaching parents

What are nursing care goals for Hazardous wastes?

§ Decontaminate individual

§ Prevent spread of contamination

§ Clean and remove contaminuated source

§ Monitor personnel exposed

What are nursing care for Hazardous wastes?

§ If chemical poses threat to caregiver, decontaminate patient first.

§ If chemical poses no threat or patient has been decontaminated, begin care.

§ If immediate threat to life, put on protective garments and provide care to stabilize patient.

What type of play do infants (0-12months) use?

§ Solitary play. Game is one sided. Like to play with body parts.

§ Birth-3months: smile/squeal

§ 3-6months: rattles/soft stuff toys

§ 6-12 months: begin imitation, peek-a-boo, patty-cake

What type of play do toddlers (1-3years) use?

§ Parallel play.

What type of play do pre-schoolers (3-6years) use?

§ Associative play. Dress up/imitating play. Talking on telephone/kitchen/tool belt

What type of play do school age (6-12years) use?

§ Cooperative play. Conformed/organized play.

According to Erikson’s Developmental Task, explain the Infancy stage.

§ Birth-18 months.

§ Trust vs. Mistrust

§ Positive outcome---trusts self

§ Negative outcome---withdrawn

According to Erikson’s Developmental Task, explain the Toddler stage.

§ 18months – 3 years

§ Autonomy vs. Shame and Doubt

§ Positive outcome---exercise self-control

§ Negative outcome---defiant and negative

According to Erikson’s Developmental Task, explain the Preschool stage.

§ 3-6 years

§ Initiative vs. Guilt

§ Children develop conscience at this age.

§ Positive Outcome---learns limits

§ Negative Outcome---fearful, pessimistic

According to Erikson’s Developmental Task, explain the School age stage.

§ 6-12years

§ Industry vs. Inferiority

§ Positive---sense of confidence

§ Negative---self doubt, inadequate

According to Erikson’s Developmental Task, explain the Adolescence stage.

§ 12-20 years

§ Identity vs. Role diffusion

§ Positive outcome---coherent sense of self

§ Negative outcome---lack of identity

According to Erikson’s Developmental Task, explain the young adult stage.

§ 20-45 years

§ Intimacy vs. Isolation

§ Positive outcome---intimate relationships/careers formed

§ Negative outcome---avoidance of intimacy

According to Erikson’s Developmental Task, explain the middle adulthood stage.

§ 45-65 years

§ Generativity vs. Stagnation

§ Positive Outcome---creative and productive

§ Negative Outcome---self centered

According to Erikson’s Developmental Task, explain the Late adulthood stage.

§ 65+ years

§ Integrity vs. Despair

§ No regrets in life or Regrets

§ Positive outcome---seems life as meaningful

§ Negative outcome---life lacks meaning

At what month does the head sag?

§ 1 month

At what month do you see closing of posterior fontanelle, turn from side to back, and see a social smile?

§ 2 months

What toys do you give for a 2 month old?

§ Mobiles, wind up infant swings, soft clothes, and blankets.

At what month does a child bring objects to mouth and head erect?

§ 3 months

What toys do you give for a 4 month old?

§ Rattles, cradle gym, and stuffed animals

Which age does birth weight double?

§ 5 months

At what age does teething occur?

§ 6 months

What toys do you give for a 6 month old?

§ Brightly colored, small enough to grasp, large enough for safety, teething toys

What age for fears of strangers? When is fear strongest?

§ 7 months

§ 8 months is stronger

Which month able to play peek-a-boo?

§ 7 months

What toys do you give for 7-8months?

§ Large colored, bricks, jack in the box

What month can a child say “DADA?

§ 9 month

What month can a child crawl well?

§ 10 months

What month can a child stand erect with support?

§ 11 months

What happens in the 12th month of the child?

§ Birth weight triples.

§ Eats with fingers.

§ Anterior Fontanelle almost close.

§ Babinski reflex disappears.

§ Toys: books with large pictures, push pull toys, teddy bears, a large ball, or sponge toys.

Explain introduction of solid foods.

§ One food at a time.

§ Begin with least allergenic foods first.

§ Cereal is usually first. (Do not use cow’s milk/whole milk. After six months of age cereal can be mixed with fruit juices. Fruit juices should be offered in a cup to prevent dental carries.)

§ Vegetables

§ Fruits

§ Potatoes

§ Meats

§ Eggs

§ Orange Juice

§ By 12 months children should be eating table food. Don’t give honey under 12 because of botulism.

What does a toddler do at 15 months?

§ Walks alone.

§ Throws object.

§ Holds spoon.

§ Say 4-6 words. Understand simple commands.

What does a toddler do at 18 months?

§ Anterior fontanelle closes.

§ Climbs stairs.

§ Sucks thumb.

§ Say 10 + words.

§ Temper Tantrums.

What does a toddler do at 24 months?

§ 300 world vocabulary.

§ Obeys easy commands.

§ Go up/down stairs alone.

§ Build towers.

§ Turn doorknobs/unscrew lids.

§ Increase independence.

What does a toddler do at 30 months?

§ Walk tip toe.

§ Stand on one foot balance.

§ Has control for sphincter training.

§ Birth weight quadrupled.

§ State first/last name.

§ Give simple commands.

What type of toys are included for Toddlers?

§ Cooking utensils, Dress-up clothes, rocking horses, finger paints, phonographs, cd players.

How do you avoid negativism during toddler ages?

§ Don’t ask no/yes questions.

§ Offer them choices.

§ Make a game out of the tasks.

What can a 3 year old do?

§ Rides tricycle.

§ Undresses without help.

§ May invent imaginary friend.

§ Vocabulary 900 words.

§ Egocentric in thoughts/behaviors.

What can a 4 year old do?

§ Laces shoes

§ Brushes teeth

§ Throws overhand

§ Uses sentences.

§ Independent

What can a 5 year old do?

§ Runs well/Dresses without help.

§ Beginning cooperative play.

§ Gender-specific behavior.

What toys are used for preschool (3-5)?

§ Playground materials, Housekeeping toys, Coloring books, tricycle with helmet.

Which age groups has greatest number of fears?

§ Preschool age children.

§ Death is temporary and gradual

What would you expect with a 6 year old?

§ Self-centered, show off, rude

§ Sensitive to criticism

§ Begins loosing temporary teeth

§ Tends to lie.

What would you expect with a 7 year old?

§ Team games/sports.

§ Concept of time.

§ Playing with same sex child.

§ Death is a punishment for his/her action.

What would you expect with a 8 year old?

§ Seeks out friends.

§ Writing replaces printing.

What would you expect with a 9 year old?

§ Conflicts between peer groups and parents.

§ Conflicts between independence and dependence.

§ Likes school.

§ Able to take on job duties (housework).

§ Death is inevitable and irreversible.

What toys are used for school age child?

§ Construction toys, Pets, Games, Electronic games, reading, books, bicycles with helmets.

School age potential problems include:

§ Anuresis (encourage before bed time)

§ Encopresis

§ Head lice

What are symptoms/indications of a fetal alcohol syndrome in a child?

§ Thin upper lip, vertical ridge in upper lip, short up turned nose, mental retardation, motor retardation, hearing disorders, microcephaly.

§ Avoid alcohol 3 months before conception and throughout pregnancy.

What happens with amniocentesis? What does it do?

§ 16th week detects genetic abnormality

§ 30th week detects L/S ratio: lung maturity

§ Void before procedure

§ Ultrasound given to determine position of placenta and fetus.

§ Complications: premature labor, infection, Rh isommunization (if client Rh negative, will be given Rhogam)

What happens with an ultrasound?

§ 5th week confirms pregnancy

§ Determines position of fetus, placenta, and # of fetuses.

§ Client must drink a lot of fluid before procedure for full bladder to have a clear image.

What happens with a non-stress test?

§ At 28th week records FHR and fetal movement.

§ Favorable result: 2+ FHR accelerates by 15bpm and last 15seconds in 20 minutes.

What happens with a contraction stress test?

§ Determines placenta’s response to labor.

§ Done after 28th week.

§ Fowler/Semi-Fowler.

§ Given Oxytocin or Pitocin.

§ Results:

§ Positive: Late decelerations indicates potential risk to fetus.

Negative: No late decelerations.

What does Torch stand for? And their importance?

§ Diseases that cross placenta or other events. Produce significant deformities or infant born with infectious process.

§ Toxoplasmosis: no litter box changed, no gardening, no under cooked meats.

§ Rubella: 1-16 titer immune for rubella, titer <1-8 style="mso-spacerun:yes">

§ Cytomegalovirus: transmitted in body fluids.

§ Herpes Simplex: Ascending infection. During pregnancy get treated with acyclovir. Delivery through c-section.

What concerns for clients that have UTI, Syphilis, Gonorrhea?

§ UTI: may lead to pylonephritis, increase risk of premature birth.

§ Syphillis: passes through placenta, causes 2nd trimester abortions, still birth, and congenital infection, may receive medication for her and her baby.

§ Gonorrhea: baby gets prophylactic eydrops.

What are the danger signs of pregnancy?

§ Gush or fluid bleeding from vagina

§ Regular uterine contractions

§ Severe headaches, visual disturbances, abdominal pain, persistent vomiting (symptoms of PIH)

§ Fever or chills (symptoms of infection)

§ Swelling in face or fingers (symptoms of PIH)

What are the events in the onset of labor?

§ Lightening: (when baby drops to pelvis)

§ Primipara: occurs 2 weeks before delivery

§ Multipara: occurs during labor

§ Softening of cervix

§ Expulsion of mucus plug (bloody show) – pink tinged mucus secretion

§ Uterine contractions: regular/progressive not Braxton-Hick’s type.

How does prolapsed umbilical cords happen?

§ Premature rupture of membranes.

§ Presenting part not engaged.

§ Fetal distress.

§ Protruding cord.

What do you do when a client has a prolapsed cord?

§ Call for help.

§ Push up against presenting part off of the cord.

§ Place in trendenlenberg position or knee chest position.

§ Successful if FHT left unchanged.

What is a early/sign of fetal hypoxia?

§ Early sign: fetal tachycardia >160 in >10minutes

§ Late sign: fetal bradycardia <110> 10 minutes

What things should you know about the Informed Consent form?

§ Nurse can witness patient sign form.

§ Patient has to be age of capacity/adult and confident. No confused patient/drinking/already received preoperative medications.

§ Consent must be given voluntarily and information understandable. Nurse must make sure questions are answered and form is attached to chart.

What is early deceleration?

§ Decrease in HR before peak of contraction. Indication of head compression.

What are interventions for late decelerations?

§ Position mother left side/trendenlenberg/knee chest

§ Increase rate of IV

§ Administer Oxygen 7-10 l/min

§ DC Oxytocin

What do variable decelerations indicate?

§ Cord compression.

§ Change maternal position.

§ Administer oxygen.

§ DC Oyxtocin/Pitocin

What are signs of “True Labor”?

§ Regular contractions increasing in frequency, duration, intensity

§ Discomfort radiates from back

§ Contractions do not decrease with rest

§ Cervix progressively effaced and dilated.

What are characteristics of a “False Labor”?

§ Irregular contractions, no change in frequency, duration, intesityDiscomfort is abdominal

§ Contractions decrease with rest or activity

§ No cervical changes

Prior to Lumbar Epidural block what should the patient do?

§ Void

What should be implemented during the delivery of a newborn?

§ Establish airway

§ Check Apgar at 1 and 5 minutes

§ Clamp umbilical cord

§ Maintain Warmth

§ Place ID band on mother and infant

What are the types of Lochia?

§ Rubra-bloody, day 1-3

§ Serosa-pink-brown, day 4-9

§ Alba-yellow-white, 10+ days

If fundus is displaced not centrally and off to the sides means?

§ Bladder distended.

If client soaks pad in 15 minutes or pooling of blood?

§ Check for hemorrhage

What are assessments and implementations for an “Ectopic Pregnancy”?

§ Unilateral lower quadrant pain.

§ Rigid, tender abdomen

§ Low Hct and hCG levels

§ Bleeding

§ Monitor for shock

§ Administer RhoGAM

§ Provide support

What are assessments and implementations for “Placenta Previa”?

§ A placenta that’s implanted in the lower uterine segment near cervical os, during pregnancy placenta is torn away causing:

§ First and second trimester spotting

§ Third and trimester painless, profuse bleeding

§ Bedrest side-lying or trendelenburg position, ultrasound to locate placenta, no vaginal or rectal exams, amniocentesis for lung maturity, daily Hgb, Hct, Monitor bleeding

What are the assessments and implementation for “Abruptio Placentae”?

§ The premature separation of a placenta that is implanted in a correct position.

§ Painful vaginal bleeding

§ Abdomen tender, painful, tense

§ Possible fetal distress/Contractions

§ Monitor for maternal and fetal distress

§ Prepare for immediate delivery

§ Monitor for complications: DIC, pulmonary emboli

What are assessments and implementations for Gestational Diabetes Mellitus (GDM)?

§ Hyperglycemia after 20 weeks

§ Usually controlled by diet

§ Oral hypoglycemic medications contraindicated

§ Test for diabetes at 24-28 weeks on all women with average risk 20.

§ Frequent monitoring of mother/fetus during pregnancy.

§ Teach to eat prescribed amount of food daily at same times

§ Home glucose monitoring

§ Teach about change in insulin requirements

What are assessments and implementation for a Hydatidiform Mole?

§ Elevated hCG

§ Uterine size larger than expected for dates

§ No FHT

§ Minimal dark red/brown vaginal bleeding with grape like clusters

§ Nausea and vomiting

§ Associated with PIH

§ Curettage to remove tissue

§ Pregnancy discouraged for 1 year

§ Do not use IUD

§ hCG levels monitored for 1 year

What are the newborn vital signs?

§ Temp. 97.7-99.7

§ HR sleep 100, awake 120-140, 180 crying

§ Resp 30-60

§ BP arm/calf 65/41

What are assessments and implementation for Hyperbilirubinemia?

§ Caused by immature hepatic function

§ Physiological Jaundice (No treatment required)

§ Seen after 24 hours

§ Peaks at 72 hours

§ Lasts 5-7 days

§ Breast-Feeding Associated Jaundice (Frequent breast feeding)

§ Caused by poor milk intake

§ Onset 2-3 days

§ Peaks 2-3 days

§ Breast Milk Jaundice (discontinue breast feeding for 24 hours)

§ Caused by factor in breast milk

§ Onset 4-5 days

§ Peak 10-15 days

§ Hemolytic Disease (Phototherapy then exchange transfusion)

§ Caused by blood antigen incompatibility (Rh or ABO incompatibility)

§ Onset first 24 hours

§ Peak variable

What are assessments and implementations for a Narcotic-Addicted infant?

§ Assessments

§ High-pitched cry (Hallmark sign)

§ Hyperreflexia

§ Decreased sleep

§ Tachypnea (>60/min)

§ Frequent sneezing and yawning

§ Seen at 12-24 hours of age, up to 7-10 days

§ Implementation

§ Reduce environmental stimuli

§ Administer Phenobarbital, chlorpromazine, diazepam, paregoric

§ Wrap snugly, rock, and hold tightly

§ Assess muscle tone, irritability, vital signs.

What are the assessments and implementations of Toxic Shock Syndrome?

§ Sudden-onset fever

§ Vomiting, diarrhea

§ Hypotension

§ Erythematous rash on palms and soles

§ Administer antibiotics

§ Educate about use of tampons (change tampon Q3-Q6 hours)

What are contraindications to Immunizations?

§ Immunization is a primary prevention

§ Severe febrile illness

§ Altered immune system

§ Previous allergic response

§ Recently acquired passive immunity

What are assessments and implementations for a “Latex Allergy”?

§ Assessment

§ Urticaria, rash

§ Wheezing, Rhinitis, Conjunctivitis, Bronchospasms

§ Anaphylactic shock

§ Implementation

§ Screen for sensitivity

§ Avoid latex products: gloves, catheters, brown ace bandages, band aid dressing, elastic pressure stockings, balloons, condoms

What are implementations for Croup syndromes at home?

§ Steamy shower

§ Exposure to cold air

§ Cool, humidified air

Universal Donor Blood: Packed red blood cells (help oxygen deliver to tissue, if you use whole blood there will be a risk for fluid overload), type O, Rh-negative

5% Sodium Bicarbonate—metabolic alkalosis solution

Older adults are asymptomatic when they have an infection and can lead to confusion.

Mononucleosis: complication enlarged spleen; concerned for trauma if child plays dangerous sport.

Lyme disease:found mainly in mid alantic states (Connecticut)

Pottery is unglazed can lead to “Lead Toxicity”

Apgar Score: normal 7-10

WBC after pregnancy?

Ampicillin decreases oral contraceptives efficiency.

Tricuspid area: 5th intercostals space in the left sternum area

Tracheostomy care: no powder, suction trachea first then mouth, use pre-cut gauze.

Hip-Flexion: causes increased intra-abdominal/thoracic pressure.

Injury C3 and above need respiratory ventilation.

SIADH causes: lung cancer, Cisplatin (Platinol)

Chest Tubes

§ Fill water-seal chamber with sterile water to 2 cm (middle chamber)

§ Fill suction control chamber with sterile water to 20 cm (chamber all the way to the right)

§ Air-leak if bubbling in water-seal chamber (middle chamber)

§ Obstruction: “milk” tube in direction of drainage

§ Removal o chest tube: pt. does valsalva maneuver, clamp chest tube, remove quickly, apply occlusive dressing

§ Dislodged: apply tented dressing

§ Tube becomes disconnected from drainage system, cut off contaminated tip, insert sterile connector and reinsert

§ Tube becomes disconnected from drainage system, immerse in 2cm of water

Jackson-pratt: Notify physician if drainage increases or becomes bright red

Penrose: Expect drainage on dressing

Tracheostomy Tube Cuff

§ Prevents aspiration of fluids/separates upper and lower airways

§ Inflated during continuous mechanical ventilation

§ Inflated during and after eating

§ Inflated during and 1 hour after tube feeding

§ Inflated when patient cannot handle oral secretions

· NCLEX-RN exam is a “here and now” test; take care of problem now to prevent harm to client.

· Do not ask “why” on the licensure exam

· Morphine Sulfate for pancreatitis causes spasms of the sphincter of Oddi; Meperidine is drug of choice.

· Normal Intraocular Pressure is 10-21 mm Hg

· Ecchymosis (faint discoloration) around the umbilicus or in either flank indicates retroperitoneal bleeding

The parenteral form of Chlorpheniramine Maleate is use to relieve symptoms of anaphylaxis allergic reactions to blood or plasma.

Herbs: Toxicities and Drug Interactions


Uses: Chamomile is often used in the form of a tea as a sedative.

Reactions: Allergic reactions can occur, particularly in persons allergic to ragweed. Reported reactions include abdominal cramps, tongue thickness, tightness in the throat, swelling of the lips, throat and eyes, itching all over the body, hives, and blockage of the breathing passages. Close monitoring is recommended for patients who are taking medications to prevent blood clotting (anticoagulants) such as warfarin.


Uses: Largely because white blood cells in the laboratory can be stimulated to eat particles, Echinacea has been touted to be able to boost the body's ability to fight off infection.
Reactions: The most common side effect is an unpleasant taste. Echinacea can cause liver toxicity. It should be avoided in combination with other medications that can affect the liver (such as ketaconazole, leflunomide (Arava), methotrexate (Rheumatrex), isoniazide (Nizoral).

St. John's Wort

Uses: St. John's Wort is popularly used as an herbal treatment for depression, anxiety, and sleep disorders. It is technically known as Hypericum perforatum. Chemically, it is composed of at least 10 different substances that may produce its effects. The ratios of these different substances varies from plant to plant (and manufacturer). Studies of its effectiveness by the National Institutes of Health are in progress.
Reactions: The most common side effect has been sun sensitivity which causes burning of the skin. It is recommended that fair- skinned persons be particularly careful while in the sun. St. John's wort may also leave nerve changes in sunburned areas. This herb should be avoided in combination with other medications that can affect sun sensitivity (such as tetracycline/Achromycin, sulfa- containing medications, piroxicam (Feldend). St. John's wort can also cause headaches, dizziness, sweating, and agitation when used in combination with serotonin reuptake inhibitor medications such as fluoxetine (Prozac) and paroxetine (Paxil).


Uses: Garlic has been used to lower blood pressure and cholesterol (Dr. Lucinda Miller notes that there is "...still insufficient evidence to recommend its routine use in clinical practice.")
Reactions: Allergic reactions, skin inflammation, and stomach upset have been reported. Bad breath is a notorious accompaniment. Studies in rats have shown decreases in male rats' ability to make sperm cells. Garlic may decrease normal blood clotting and should be used with caution in patients taking medications to prevent blood clotting (anticoagulants) such as warfarin /Coumadin.


Uses: Most commonly used for migraine headaches.
Reactions: Feverfew can cause allergic reactions, especially in persons who are allergic to chamomile, ragweed, or yarrow. Nonsteroidal anti-inflammatory drugs (NSAIDs such as ibuprofen (Advil), naproxen (Aleve) or Motrin) can reduce the effect of feverfew. A condition called "postfeverfew syndrome" features symptoms including headaches, nervousness, stiffness, joint pain, tiredness, and nervousness. Feverfew can impair the action of the normal blood clotting element (platelets). It should be avoided in patients taking medications to prevent blood clotting (anticoagulants) such as warfarin (Coumadin).

Ginko Biloba

Uses: This herb is very popular as a treatment for dementia (a progressive brain dysfunction) and to improve thinking.
Reactions: Mild stomach upset and headache have been reported. Ginko seems to have blood thinning properties. Therefore, it is not recommended to be taken with aspirin, nonsteroidal anti-inflammatory drugs (Advil), naproxen (Aleve) or Motrin), or medications to prevent blood clotting (anticoagulants) such as warfarin (Coumadin). Ginko should be avoided in patients with epilepsy taking seizure medicines, such as phenytoin (Dilantin), carbamazepine (Tegretol), and phenobarbital.


Uses: Ginseng has been used to stimulate the adrenal gland, and thereby increase energy. It also may have some beneficial effect on reducing blood sugar .in patients with diabetes mellitus. (Dr. Miller emphasized that there is substantial variation in the chemical components of substances branded as "Ginseng.")
Reactions: Ginseng can cause elevation in blood pressure, headache, vomiting, insomnia, and nose bleeding. Ginseng can also cause falsely abnormal blood tests for digoxin level. It is unclear whether ginseng may affect female hormones. Its use in pregnancy is not recommended. Ginseng may affect the action of the normal blood clotting element (platelets). It should be avoided in patients taking aspirin, nonsteroidal antiinflammatory drugs (such as ibuprofen (Advil), naproxen (Aleve) or Motrin), or medications to prevent blood clotting (anticoagulants) such as warfarin (Coumadin). Ginseng may also cause headaches, tremors, nervousness, and sleeplessness. It should be avoided in persons with manic disorder and psychosis.


Uses: Ginger has been used as a treatment for nausea and bowel spasms.
Reactions: Ginger may lead to blood thinning. It is not recommended to be taken with medications that prevent blood clotting (anticoagulants) such as warfarin (Coumadin).

Saw Palmetto

Uses: Saw palmetto has been most commonly used for enlargement of the prostate gland. (Dr. Miller emphasized that studies verifying this assertion are necessary.) Saw palmetto has also been touted as a diuretic and urinary antiseptic to prevent bladder infections.
Reactions: This herb may affect the action of the sex hormone testosterone, thereby reducing sexual drive or performance. Dr. Miller states that "While no drug-herb interactions have been documented to date, it would be prudent to avoid concomitant use with other hormonal therapies (e.g., estrogen replacement therapy and oral contraceptives...")

Black Cohosh

Claims, Benefits: A natural way to treat menopausal symptoms.
Bottom Line: Little is known about its benefits and its risks.

A child with celiac disease mustn’t consume foods containing gluten and therefore should avoid prepared puddings, commercially prepared ice cream, malted milk, and all food and beverages containing wheat, rye, oats, or barley.

The infant of a diabetic mother may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increases glucose amount that crosses the placenta from the mother. However, during the first 24 hours of life, this combination of high insulin production in the newborn coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia

Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity.

A platypelloid pelvis has a flat shape. A gynecoid pelvis is a normal female pelvis. An anthropoid pelvis has an oval shape, and an android pelvis has a heart shape.

The pulse is the earliest indicator of new decreases in fluid volume.

Adult Rickets: deficiency in vitamin D.

Chronic Pain: normal blood pressure, heart rate, and respiratory rate. Normal pupils and dry skin.

Acute pain: causes increased blood pressure, increased pulse, and respiratory rate, dilated pupils, and perspiration.

The tip of the endotracheal tube lies 1 cm above the carina. This is positioned above the bifurcation of the right and left mainstem bronchi.

Creatine Phosphokinase (CPK) is a cellular enzyme that can be fractionated into three isoenzymes.

Ø MB band reflects CPK from CARDIAC MUSCLE (This is the level that elevates with an MI.)

Ø MM band reflects CPK from SKELETAL MUSCLE

Ø BB band reflects CPK from the BRAIN

ALKYLATING AGENTS: affect ALL PHASES of the reproductive cell cycle (i.e., Cyclophosphamide [Cytoxan])

ANTIMETABOLITES: are cell cycle phase-specific and affect the S PHASE

(i.e., Cytarabine [Cytosar])

VINCA ALKALOIDS: are cell cycle phase-specific and act on the M PHASE

Bell’s Palsy: is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown. Possible causes include vascular ischemia, infection, exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or a combination of these items.

McBURNEY’S POINT: is midway between the right anterior superior iliac crest and the umbilicus. This is usually the location of greatest pain in the child with appendicitis.

MMR: administered SQ in the outer aspect of the upper arm.

Watch for absolute words “NOT” and “ONLY

AIR EMBOLISM POSITIONING: Place the client on the left side in the trendelenburg position. Lying on the left side may prevent air from flowing into the pulmonary veins. The trendelenburg position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during inspiration.

Trigeminal neuralgia pain medication: Use Carbamazepine (Tegretol) and Phenytoin (Dilantin). Narcotic analgesics (Meperidine Hydrochloride [Demerol], Codeine Sulfate , and Oxycodone) are not effective in controlling pain caused by trigeminal neuralgia.

Grapefruit juice can raise cyclosporine (Sandimmune) levels by 50% to 100%, risk for toxicity.

Fomepizole (Antizol): an antidote given IV to a client with Ethylene Glycol (Antifreeze) intoxication

Phenotolamine (Regitine): antidote for hypertensive crisis

Bromocriptine (Parlodel): an antiparkinsonian prolactin inhibitor, is used to treat NMS.

Biophysical profile: assesses five parameters of fetal activity: fetal heart rate, fetal breathing movements, gross fetal movements, fetal tone, and amniotic fluid volume. In a biophysical profile, each of the five parameters contributes 0 to 2 points with a score of 8 being considered normal and a score of 10 perfect.






Gravidity, the number of pregnancies.

Term births, the number born at term (40 weeks).

Preterm births, the number born before 40 weeks’ gestation.


· Included in gravida if before 20 weeks’ gestation

· Included in parity if past 20 weeks’ gestation

Live births, the number of live births or living children

Therefore a woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of preterm births is 1, and the number of term births is 0. The number of abortions is 0, and the number of live births is 1.

Probable signs of pregnancy:

· Uterine enlargement

· Hegar’s sign (Softening and thinning of the lower uterine segment that occurs about week 6)

· Goodell’s sign (softening of the cervix that occurs at the beginning of the second month)

· Chadwick’s sign (bluish coloration of the mucous membranes of the cervix, vagina, and vulva that occurs about week 6)

· Ballottement (rebounding of the fetus against the examiner’s fingers on palpation)

· Braxton Hicks contractions

· A positive pregnancy test measuring for human chorionic gonadotropin

Positive signs of pregnancy:

· Fetal heart rate detected by electronic device (Doppler transducer) at 8-12 weeks and by nonelectronic device (Fetoscope) at 20 weeks of gestation

· Active fetal movements palpable by examiner

· An outline of fetus via radiography or ultrasound

Acetazolamide (Diamox): used for management of glaucoma is a carbonic anyhdrase inhibitor that has sulfonamide properties.

Watch out for absolute words “ALL” and “ALWAYS

Before NG removal: bowel sounds have to be present.

Hyperkalemia on Electrocardiogram:

Tall, peaked T waves; prolonged PR interval; widening QRS complex

Hypokalemia on Electrocardiogram: ST segment depression; Flat T wave

First-Degree Heart Block: Prolonged P-R interval

Bundle Branch Block: Widened QRS complex

Myocardial Necrosis in Area: Q waves present

Ventricular Fibrillation: No visible P waves or QRS complexes, no measurable rate. Irregular, chaotic undulations of varying amplitudes.

HypoCalcemia: Prolonged Q-T interval

Myocardial Ischemia: ST segment elevation or depression

Premature Ventricular Contractions: absence of P waves, wide and bizarre QRS complexes, and premature beats followed by a compensatory pause

Ventricular Tachycardia: absence of P waves, wide QRS complexes, rate between 100 and 250 impulses per minute. Regular rhythm

Atrial Fibrillation: no P waves; instead there are wavy lines, no PR interval. QRS duration is WNL and irregular ventricular rate can range from 60-160 beats/minute.






Triggered by a predictable amount of effort or emotion.

Triggered by an unpredictable amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time.

Triggered by coronary artery spasm; the attacks tend to occur early in the day and at rest.

Chronic and incapacitating and is refractory to medical therapy.

Cardiac Conduction System: Sinoatrial NodeàInternodal/Interatrial pathwaysàAV nodeàBundle of HisàR/L Bundle BranchesàPurkinje fibers

Pulse rate is the earliest indicator of decrease in fluid volume.

A1-adrenergic receptors: found in the peripheral arteries and veins and cause a powerful vasoconstriction when stimulated

A2-adrenergic receptors: several tissues and contract smooth muscle, inhibit lipolysis, and promote platelet aggregation.

B1: Found in the heart and cause an increase in heart rate, atrioventricular node conduction, and contractility.

B2: Arterial and bronchial walls and cause vasodilation and bronchodilation.


Myxedema (a.ka. Hypothyroidism)

Suggested toys

a. birth to six months - mobiles, unbreakable mirrors, music boxes, rattles

b. six to 12 months - blocks, nesting boxes or cups, simple take apart toys, large ball, large puzzles, jack in the box, floating toys, teething toys, activity box, push-pull toys

c. Solitary play

Toddlerhood (one year to three years)

Play is parallel

· Suggested toys: push-pull toys, finger paints, thick crayons, riding toys, balls, blocks, puzzles, simple tape recorder, housekeeping toys, puppets, cloth picture books, large beads to string, toy telephone, water toys, sand box, play dough or clay, chalk and chalkboard

Preschool age (three years to six years)

· Preschool play is associative and cooperative.

· dress-up

· fantasy play

· imaginary playmates

· Suggested toys: tricycle, gym and sports equipment, sandboxes, blocks, books, puzzles, computer games, dress-up clothes, blunt scissors, picture games, construction sets, musical instruments, cash registers, simple carpentry tools

School age (six years to 12 years)

Play is cooperative.

1. sports and games with rules

2. fantasy play in early years

3. clubs

4. hero worship

5. cheating

6. Suggested toys/activities: board or computer games, books, collections, scrapbooks, sewing, cooking, carpentry, gardening, painting

Tympany: Drumlike, loud, high pitch, moderate duration; usually found over spaces containing air such as the stomach

Resonance:Hollow sound of moderate to loud intensity; low pitch, long duration; Usually heard over lungs

Hyperresonance: Booming sound of very loud intensity; very low pitch, long duration; Usually heard in the presence of trapped air (such as emphysematous lung)Flatness:

Flat sound of soft intensity; high pitch; short duration; Usually heard over muscle

Dullness:Thud-like sound of soft intensity; high pitch; moderate duration; Usually heard over solid organs (such as heart, liver)

body temperature

  • range: 36 to 38 degrees Celsius (98.6 to 100.4 degrees Fahrenheit)

St. John's wort - antidepressant
Garlic - antihypertensive
Ginseng - Anti stress
Green tea - antioxidant
Echinacea - immune stimulant (6-8 weeks only)
Licorice - cough and cold
Ginger root - antinausea
Ginkgo - improves circulation
Ma huang - bronchodilator, stimulant

Anatomical Landmarks of the HEART

i. second right intercostal space - aortic area

ii. second left intercostal space - pulmonic area

iii. third left intercostal space - Erb's point

iv. fourth left intercostal space - tricuspid area

v. fifth left intercostal space - mitral (apical) area

vi. epigastric area at tip of sternum

Range of Normal Blood Pressure

i. child under age two weighing at least 2700g: use flush technique,30-60mg Hg

ii. child over age two: 85-95/50-65 mm Hg

iii. school age: 100-110/50-65 mm Hg

iv. adolescent: 110-120/65-85 mm Hg

v. adult: <130>

Normal Range of Peripheral Pulses

  • infants: 120 to 160 beats/minutes
  • toddlers: 90 to 140 beats/minutes
  • preschool/school-age: 75 to 110 beats/ minute
  • adolescent/adult: 60 to 100 beats/minute

Normal Rates of Respirations

  • newborn: 35 to 40 breaths/minute
  • infant: 30 to 50 breaths/minute
  • toddler: 25 to 35 breaths/minute
  • school age: 20 to 30 breaths/minute
  • adolescent/adult: 14 to 20 breaths/minute
  • adult: 12 to 20 breaths/minute


1. Olfactory (CN I)

  • Can identify variety of smells
  • Deviation: Inability to identify aroma

2. Optic (CN II)

  • Has visual acuity and full visual fields
  • Fundoscopic exam reveals no pathology
  • Deviation: Inability to identify full visual fields - total or partial blindness of one or both eyes

3, 4, 6. Oculomotor (CN III), trochlear (CN IV), and abducens (CN VI)

  • Follows up to six cardinal positions of gaze
  • Pupils are unremarkable
  • Exhibits no nystagmus and no ptosis
  • Deviation: one or both eyes will deviate from its normal position

5. Trigeminal (CN V)

  • Clenches teeth with firm bilateral pressure
  • Has no lateral jaw deviation with mouth open
  • Feels a cotton wisp touched to forehead, cheek and chin
  • Differentiates sharp and dull sensations on face
  • Corneal reflex; blinks when cotton is touched to each cornea
  • Deviation: Absent or one-sided blinking of eyelids

7. Facial (CN VII)

  • Has facial symmetry with and without a smile
  • Can raise the eyebrows symmetrically and grimace
  • Can shut eyes tightly
  • Can identify sweet, sour, salt or bitter on the anterior tongue
  • Deviation: Irregular and unequal facial movements
  • Deviation: Inability to taste or identify taste
  • Deviation: Inability to taste or identify salt, sweet, sour, or bitter substances on the anterior two-thirds of the tongue
  • Deviation: Inability to smile symmetrically

8. Acoustic (CN VIII)

  • Can hear a whisper at 1-2 feet
  • Can hear a watch tick at 1-2 feet
  • Does not lateralize the Weber test
  • Can hear AC (air conduction) better than BC (bone conduction) in the Rinne test
  • Deviation: Inability to hear spoken word

9, 10. Glossopharyngeal (CN IX) and Vagus (CN X)

  • Swallows and speaks without hoarseness
  • Palate and uvula rise symmetrically when patient says "ah"
  • Bilateral gag reflex
  • Can identify taste on the posterior tongue
  • Deviation: Unequal or absent rise of uvula and soft palate as the client says, "ah"
  • Deviation: Absent gag reflex
  • Deviation: inability to taste or identify taste on the posterior tongue

11. Spinal accessory (CN XI)

  • Resists head turning
  • Can shrug against resistance
  • Deviation: Weak or absent shoulder and neck movement

12. Hypoglossal (CN XII)

  • Can stick tongue out and move it from side to side
  • Can push tongue strongly against resistance
  • Deviation: Tongue deviates to side

Types of Coping Mechanisms

1. Compensation - extra effort in one area to offset real or imagined lack in another area

o Example: Short man becomes assertively verbal and excels in business.

2. Conversion - A mental conflict is expressed through physical symptoms

o Example: Woman becomes blind after seeing her husband with another woman.

3. Denial - treating obvious reality factors as though they do not exist because they are consciously intolerable

o Example: Mother refuses to believe her child has been diagnosed with leukemia. "She just has the flu."

4. Displacement - transferring unacceptable feelings aroused by one object to another, more acceptable substitute

o Example: Adolescent lashes out at parents after not being invited to party.

5. Dissociation - walling off specific areas of the personality from consciousness

o Example: Adolescent talks about failing grades as if they belong to someone else; jokes about them.

6. Fantasy - a conscious distortion of unconscious wishes and need to obtain satisfaction

o Example: A student nurse fails the critical care exam and daydreams about her heroic role in a cardiac arrest.

7. Fixation - becoming stagnated in a level of emotional development in which one is comfortable

o Example: A sixty year old man who dresses and acts as if he were still in the 1960's.

8. Identification - subconsciously attributing to oneself qualities of others

o Example: Elvis impersonators.

9. Intellectualization - use of thinking, ideas, or intellect to avoid emotions

o Example: Parent becomes extremely knowledgeable about child's diabetes.

10. Introjection - incorporating the traits of others

o Example: Husband's symptoms mimic wife's before she died.

11. Projection - unconsciously projecting one's own unacceptable qualities or feelings onto others

o Example: Woman who is jealous of another woman's wealth accuses her of being a gold-digger.

12. Rationalization - justifying behaviors, emotions, motives, considered intolerable through acceptable excuses

o Example: "I didn't get chosen for the team because the coach plays favorites."

13. Reaction Formation - expressing unacceptable wishes or behavior by opposite overt behavior

o Example: Recovered smoker preaches about the dangers of second hand smoke.

14. Regression - retreating to an earlier and more comfortable emotional level of development

o Example: Four year old insists on climbing into crib with younger sibling.

15. Repression - unconscious, deliberate forgetting of unacceptable or painful thoughts, impulses, feelings or acts

o Example: Adolescent "forgets" appointment with counselor to discuss final grades.

16. Sublimation - diversion of unacceptable instinctual drives into personally and socially acceptable areas.

o Example: Young woman who hated school becomes a teacher.

Elizabeth Kubler-Ross: Five Stages

1. Denial

a. Unconscious avoidance which varies from a brief period to the remainder of life

b. Allows one to mobilize defenses to cope

c. Positive adaptive responses - verbal denial; crying

d. Maladaptive responses - no crying, no acknowledgement of loss

2. Anger

a. Expresses the realization of loss

b. May be overt or covert

c. Positive adaptive responses - verbal expressions of anger

d. Maladaptive responses - persistent guilt or low self esteem, aggression, self destructive ideation or behavior

3. Bargaining

a. An attempt to change reality of loss; person bargains for treatment control, expresses wish to be alive for specific events in near future

b. Maladaptive responses - bargains for unrealistic activities or events in distant future

4. Depression and Withdrawal

a. Sadness resulting from actual and/or anticipated loss

b. Positive adaptive response - crying, social withdrawal

c. Maladaptive responses - self-destructive actions, despair

5. Acceptance

a. Resolution of feelings about death or other loss, resulting in peaceful feelings

b. Positive adaptive behaviors - may wish to be alone, limit social contacts, complete personal business


A. Vitamin C - citrus fruits, cabbage, tomatoes, strawberries, broccoli

B. Thiamine (B1) - lean meat, legumes,unrefined or enriched grains and cereals

C. Riboflavin (B2) - enriched grains, milk, organ meats, poultry, fish

D. Niacin - peanuts, peas, beans, meat, poultry

E. Pyridoxine (B6) - kidneys, liver, meats, corn, wheat, eggs, poultry, fish

F. Cyanocobalamin (B12) - kidneys, lean meats,liver, dairy products, egs

G. Folic acid - liver, eggs, leafy green vegetables, fruits, enriched grain products


A. Vitamin A - fruits, green and yellow vegetables, butter, milk, eggs, liver

B. Vitamin D - milk, fish

C. Vitamin E - green vegetables, vegetables oils, wheat germ, nuts

D. Vitamin K - liver, cheese, leafy green vegetables, milk, green tea