Acid-base—"RAMS" (Respiratory Alternate, Metabolic Same)
 
 
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 E's"
Eating
Emotion
Exertion (Exercise)
 
Anorexia nervosa: clinical features—"ANOREXIC"

Adolescent women/Amenorrhea
NGT alimentation (most severe cases)
Obsession with losing weight/becoming fat though underweight
Refusal to eat (2=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 P's"

Pain
Pale
Pulseless
Paresthesia
Poikilofhermic
Paralysis
 
Blood glucose (rhyme)

Symptom                      Implication
Cold and clammy...    give hard candy.
Hot and dry...               glucose is high.
 
Blood vessels in umbilical cord—"AVA"

Artery
Vein
Artery
 
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)
 
Car seats for children
Use if under:
6 years old, or
60 pounds
 
Cholecystitis: risk factors—"five F's"

Female
Fat
Forty
Fertile
Fair
 
Cleft lip: nursing care plan (postoperative)—"CLEFT LIP"

Crying, minimize
Logan bow
Elbow restraints
Feed with Breck feeder
Tent, croup

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
 
Coma: causes— "A-E-I-O- U TIPS"

Alcohol, acidosis (hyperglycemic coma)
Epilepsy (also electrolyte abnormality, endocrine problem)
Insulin (hypoglycemic shock)
Overdose (or poisoning)

Uremia and other renal problems

Trauma; temperature abnormalities (hypothermia, heat stroke)
Infection (e.g., meningitis)
Psychogenic ("hysterical coma")
Stroke or space-occupying lesions in the cranium
 
Cushing's syndrome: symptoms—"three S's"

Sugar (hyperglycemia)
Salt (Hypernatremia)
Sex (excess androgens)
 

Diabetes: signs and symptoms—"three P's," "three poly's"

Polydipsia (very thirsty)
Polyphagia (very hungry)
Polyuria (urinary frequency)
 
Diarrhea: diet— "BRAT"

Banana
Rice (cereal)
Applesauce
Toast/Tea
 
Diet: low cholesterol—avoid the three C's:

Cake
Cookies
Cream (dairy, e.g., milk, ice cream)
 
Dystocia: etiology—"three P's"

Power
Passageway
Passenger
 

Dystocia: general aspects (maternal)—"three P's"

Psych
Placenta
Position
 

Eardrops: administering—UP/DOWN
 
 
Episiotomy assessment—"REEDA"

Redness
Edema
Ecchymosis
Discharge
Approximation of skin
 
Eye medications
Mydriatic = dilated pupils
Miotic = tiny (constricted)
 
Complication of severe preeclampsia—"HELLP" syndrome

Hemolysis
Elevated Liver enzymes
Low Platelet count
 
Hypertension: complications—"four C's"
CHF (congestive heart failure)
CVA (cardiovascular accident)
CAD (coronary artery disease)
CRF (chronic renal failure)
 
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"

Diaphoresis
Increased pulse
Restless
Extra hungry
 

Infections during pregnancy—"TORCH"

Toxoplasmosis
Other (hepatitis B, syphilis)
Rubella
Cytomegalovirus
Herpes simplex virus
 
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 C's":
Cooperation
Compromise
Collaboration
 
Medication administration—"five rights"
RIGHT medication
RIGHT dosage
RIGHT route
RIGHT time
RIGHT patient
 
Mental retardation: nursing care plan—"three R's"

Regularity (provide routine and structure)
Reward (positive reinforcement)
Redundancy (repeat)
 

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—"ABCs"

Ask about the pain
Believe when patients say they have pain
Choices—let patients know their choices
Deliver what you can, when you said you would
Empower/Enable patients' 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—"fourA's"

Associative looseness
Affect
Ambivalence
Autism
 

Sprain: nursing care plan—"ICE"

Immobilize (and rest)
Cool (with ice)
Elevate

 

Stool assessment—"ACCT"

Amount
Color
Consistency
Timing
 

Tracheoesophageal fistula: assessment—"three C's"

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 T's"

Temporary unilateral visual impairment
Transient paralysis (one-sided)
Tinnitus —» vertigo
 

Trauma care: complications—"TRAUMA"

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