Naxlex RAT 11 6/6

1. 3개월 미만 Infant

-> Eyes to accommodate and focus due to weak eye muscles

-> Eye tracking and coordinated focusing begin improving around 2-3months

 

2. Third stage of labor 분만 3단계

-> 아기 분만 직후 시작되고 태반이 만출되면 끝이남. 

-> Placental separation : umbilical cord lengthening / Globular shape of the uterus

-> Uterine contractions continue

-> Globular uterus / Cord lengthening

-> sudden gush of blood 피분출됨.

 

3. 2~5세아동

-> TV 시청은 하루에 1시간 미만으로 제한하기. 

-> 키 : Toddler gain 5inches/year 

-> 아동에서의 excessive screen time -> Obesity (과도한 TV시청시)

 

4. DTaP vaccination -> 15~18month

 

5. 2살 -> Parallel play 

 

6. Hyperglycemia 고혈당

(증상)

: increased hunger (Polyphagia) 다식

: Polyuria 다뇨

: Fatigue

: Polydipsia 다음증 

 

7. PAD 응급 = Reactive hyperemia 반응성 출혈 

 

8. Herpes zoster (shingles) 간호 = Droplet precautions

-> Antiviral medication

-> apply moist compresses to the skin lesions

-> Cranial nerve 5 (trigeminal) - 턱관련, 저작운동관련

-> antihistamines for pruritus

 

9. Pneumocystis pneumonia 코호트 격리

 

10. Mycoplasma pneumonia -> droplet

 

 

11. Frostbite to the finger 동상

(중재) : Immerse the affected area in warm water (37~39도의 물) 

 

 

12. ACEinhibitor (~pril) = HF, HTN 치료약 

-> Dry cough

-> Avoid Potassium-containing salt 

-> 일시적인 taste disturbances

-> Renal function / K+ level (고칼륨혈증 유발)

-> Angioedema (Swelling of face, lip)

 

13. Cardiac catheterization 

합병증 : Dysrhythmia / Hemorrhage / Thromboembolism

 

14. Metronidazole 항생제 (Trichomoniasis / C.difficile)

-> Alcohol 피해야함. 

-> Drink adequate water 

-> 부작용 : Metallic taste 흔함(복용 계속하면됨)

-> 식후에 복용

 

 

15. Peptic ulcer disease 소화성 궤양질환 

(원인) : NSAID-induced peptic ulcer disease

(증상)

-> Burning epigastric pain / black / Tarry stools (melena) 

-> Pallor / tachycardia / Hypotension 

-> Low Hb / Hematocrit

(중재)

-> Hb 7, Hct 21%기준으로 수혈준비 

-> Obtain a stool specimen for occult blood 잠혈검사 

-> PPI therapy 

 

 

17. Phenazopyridine = Urinary analgesic

(흔한 부작용) : Red-orange color urine / 음식과 함께 섭취 

 

18. Cutaneous anthrax 탄저병 = Standard precautions 전염성이 없다. 

-> Put on clean gloves when obtaining the client's sputum 

 

19. MRI -> remove transdermal medication patch 

 

20. High-calcium food 칼슘함유 음식

-> Kale / Almond, soy milk / Broccoli 진한 초록 채소

-> Nut / seeds / Salmon

 

21. Paracentesis 복수천자 

-> High-Fowler position 

 

 

22. Postpartum hemorrhage 산후출혈 

-> Vaginal birth >500cc

-> C-sec >1,000cc

(중재) : IV oxytocin / Fundal massage

 

 

23. Respiratory distress syndrome (RDS) 미숙아에게 발생

(원인) : Surfactant deficiency 

(증상) : Nasal flaring / Sternal retractions / Grunting respirations

(중재) : CPAP(continuous positive airway pressure) / Intubation

 

24. Asthma에 금기약물 : Carvedilol (trigger bronchospasm)

-> beta blocker 

-> carvedilol : Liver monitor 

 

25. Anorexia nervosa 신경성 식욕부진

(증상) : Severe weight loss / Body image distortion / BMI<17

          : Lanugo (솜털) / Amenorrhea -> Osteoporosis 골다공증

          : Excessive exercise과도한 운동

(간호중재)

 : Weigh the client daily 매일 체중 1번재기

 : Sit with the client during meals 식사 시에 옆에 있기

 : Assist client in identifying areas

 : Inform the client of the harmful effects of laxative misuse

 : 음식선택 못하게하기!!!!! 음식 선택지 주지말고 Structured meal plan 제공 

 : 과도한 운동은 제한하기 

 : Refeeding syndrome 예방을 위해 1-2Ib/week 이 적당함. 

 

26. Toddler 2살

-> Picky eating -> provide calm transition period / Quiet time before meal 

 

27. Psychotic episodes (Hallucination / disorganized speech)

-> Elicit Hallucination

-> Clarify speech 

 

28. EPS 증상 -> Benztropine

 

29. Panic attack -> Staying with the client and provide reassurance 안심주기 

 

30. Opioid withdrawal 금단증상

-> Nausea / Vomit / Diarrhea / Lacrimation 눈물흘림. 

-> 자율신경 증상 : Diaphoresis / Tachycardia / HTN

(Distinctive sign 특징적인 증상 )

: Piloerection 털세우기  / Mydriasis (pupil dilation) / Yawning 하품 

 

31. Angle-closure Glaucoma 급성폐쇄각 녹내장 -> 가장 위험함. 시력잃을 수 있음. 

-> Seeing halos around lights

 

32. Volume overload = Hypervolemia sign

-> Edema / Jugular venous distention 

-> Crackles

-> bounding pulse

-> Urine Output 증가 

 

33. Open-angle glaucoma 녹내장 

금기 : Atropine -> Pupil dilation 유발 

 

34. Ileostomy -> I/O 가 가장 중요