ADOPTIONS for all levels of Nursing ISBN 978-0-69-78988-9 Annual subscriptions for schools to the ebook or adopt paper notebook as a required text and recieve ebook at no additional fee. Call / write today... 866.86.896 Ext. / help@nursethink.com Video tutorials available! NurseThink Notes Note Taking That Works! Tim Bristol, PhD, RN, CNE, ANEF Faculty - Walden University Minneapolis, Minnesota Karin J. Sherrill, MSN, RN, CNE, ANEF Faculty - Maricopa Community Colleges Phoenix, Arizona /adopt /samples NEW! - nd Edition SAMPLE ONLY Reproduction Prohibited Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed.
COPYRIGHT Copyright 07 by NurseTim, Inc. All rights reserved. Published by NurseTim, Inc., P.O. Box 86, Waconia, MN 5587 No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 07 or 08 of the 976 United States Copyright Act, without either the prior written permission of the publisher. Requests to publisher for permission should be addressed to the Permission Department, NurseTim, Inc., P.O. Box 86, Waconia, MN 5587, 866.86.896, fax 866.86.896, or online at www.nursetim.com. Additional copies of this publication are available at www. Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. ISBN 978-0-69-78988-9 Printed in the United States of America Second Edition 0 9 8 7 6 5 4 NCLEX is a registered trademark for the National Council of State Boards of Nursing, Inc. SAMPLE ONLY Reproduction Prohibited Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed.
PREFACE Learning how to learn is essential to every nursing student. Because there is no way to know every fact, a clear and consistent process for managing information will help students develop deep understanding that will cross all clinical situations. NurseThink Notes puts that process in an easy-to-manage tool. This unique tool is ideal for class, reading, studying, collaboration, and even clinical preparation. As students begin using NurseThink Notes, they will use critical-thinking skills to prioritize information essential to obtain desired outcomes. Through a carefully- designed process of application and analysis, long-term retention and, more importantly, the ability to adjust to a variety of situations will be facilitated. Finally, NurseThink Notes saves students and faculty time. When concepts can be clearly organized and easily accessed, students will have better outcomes. Students and faculty can do a better job of communicating about concepts (referencing key sections and analyzing the overall layout of the material). Time saving is important, as we want students more engaged in applying the information to patient care (case studies, simulations, clinical experiences, etc.) and less time involved in acquiring the knowledge. STUDENT TIPS FOR SUCCESS Best practice study tips While completing your reading, homework, and classroom activities, you will be organizing information in NurseThink Notes. Attend and actively engage in class. The classroom facilitator will offer some direction as to where to focus your study. After class (within 4 hours for best success) summarize your classroom discussions on your NurseThink Notes. Remember you only can choose priorities in each area, so select wisely. Strategies for prioritizing care Airway, breathing, circulation. Maslow hierarchy; physiologic needs first. Determine which findings/potential complications will lead to the greatest chance of mortality or morbidity. Identify least invasive interventions first Always consider safety. Use the nursing process to identify priorities (assessment, diagnosis, planning, implementation, evaluation) Encourage and support self-care with your patient Care According to the NCLEX Test Plan These categories are the emphasized areas of your licensure exam. It is important that you become familiar with them so you can best prepare. To see the details of each category, explore the Test Blueprint for the licensure exam you will be taking. (www.ncsbn.org) Quality and Safety Standards National care and safety standards guide our practice. Becoming familiar and applying each of these standards will best prepare you for practice. Consider the situation for your patient with each condition, what emphasis needs to be placed in providing quality and safety. NurseThink Notes tutorials and additional resources are available at www. Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed.
CONTENTS!= High Frequency Patient Alerts from AARP, AHRQ, CDC and Healthy People 00 Q = NurseThink Quick! ADAPTATION STRESS, COPING, ADDICTION, VIOLENCE.......................................................... Child Abuse....................................................................................................... Crisis............................................................................................................... 5 Domestic Violence................................................................................................ 7 Eating Disorders.................................................................................................. 9 Anorexia...................................................................................................... Bulimia Nervosa.............................................................................................. Elder Abuse....................................................................................................... 5 Obsessive-Compulsive Disorder................................................................................ 7 Post-Traumatic Stress Disorder (PTSD)......................................................................... 9 Rape and Sexual Assault......................................................................................... Substance Abuse................................................................................................. Alcohol Abuse................................................................................................ 5 Drug Abuse.................................................................................................. 7 Nicotine Abuse!Q........................................................................................ 9 Prescription Medication Abuse.............................................................................. 4 Workplace Violence.............................................................................................. 4 CIRCULATION PERFUSION, CLOTTING.............................................................................. 45 Arterial Disease Arteriosclerosis............................................................................................... 47 Buerger s/raynaud s Q...................................................................................... 49 Coagulation Disorders Disseminated Intravascular Coagulation (DIC).............................................................. 5 Embolic Stroke............................................................................................... 5 Hemorrhagic Stroke......................................................................................... 55 Pulmonary Embolism........................................................................................ 57 Heart Disease! Acute Coronary Syndrome.................................................................................. 59 Atherosclerosis!........................................................................................... 6 Cardiomyopathy Q.......................................................................................... 6 Heart Failure!Q........................................................................................... 65 Hypertension!Q.......................................................................................... 67 Myocardial Infarction Q..................................................................................... 69 Valve Disease Q............................................................................................. 7 Peripheral Vascular Disease Deep Vein Thrombosis....................................................................................... 7 Shock Cardiogenic.................................................................................................. 75 Hypovolemic................................................................................................. 77 Septic......................................................................................................... 79 CLIENT PREFERENCE AND PROFILE CULTURE, SPIRITUALITY, DEVELOPMENT, DYNAMICS.................... 8 Culture............................................................................................................ 8 Diversity........................................................................................................... 85 Family Dynamics................................................................................................. 87 Growth and Development Infant......................................................................................................... 89 Toddler....................................................................................................... 9 Preschool Child.............................................................................................. 9 School-Age Child............................................................................................ 95 Adolescent................................................................................................... 97 Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed. 4
CONTENTS!= High Frequency Patient Alerts from AARP, AHRQ, CDC and Healthy People 00 Q = NurseThink Quick! Health Promotion................................................................................................ 99 Spirituality....................................................................................................... 0 COGNITION FUNCTION, PSYCHOSIS.............................................................................. 0 Acute and Chronic Disorders Confusion Q................................................................................................05 Dementia and Alzheimer s!q........................................................................... 07 Psychosis.................................................................................................... 09 COMFORT PAIN, TISSUE INTEGRITY............................................................................... Pain Acute!..................................................................................................... Chronic!...................................................................................................5 Rest Fatigue...................................................................................................... 7 Sleep Disorders............................................................................................. 9 Skin Contact Dermatitis Q...................................................................................... Wounds Burns........................................................................................................ Pressure Ulcers Q.......................................................................................... 5 EMOTION MOOD, ANXIETY, GRIEF.................................................................................7 Grief Bereavement................................................................................................ 9 Loss Death and Dying............................................................................................ Psychobiological Disorders Bipolar Disorder............................................................................................. Depression.................................................................................................. 5 Psychosis.................................................................................................... 7 Schizophrenia...............................................................................................9 HOMEOSTASIS ACID-BASE, FLUID, ELECTROLYTES Q.......................................................... 4 Acid-Base Imbalance Metabolic Acidosis.......................................................................................... 4 Metabolic Alkalosis......................................................................................... 45 Respiratory Acidosis........................................................................................ 47 Respiratory Alkalosis........................................................................................49 Electrolytes Imbalance Hyper/Hypocalcemia Q....................................................................................5 Hyper/Hypokalemia Q.....................................................................................5 Hyper/Hypomagnesemia...................................................................................55 Hyper/Hyponatremia Q................................................................................... 57 Hyper/Hypophosphatemia................................................................................. 59 Fluid Imbalance Dehydration.................................................................................................6 Fluid Overload.............................................................................................. 6 MOVEMENT MOBILITY, SENSORY, NERVE CONDUCTION Q....................................................65 Musculoskeletal Disorders Amputation................................................................................................. 67 Carpal Tunnel Q............................................................................................69 Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed. 5
Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed. CONTENTS!= High Frequency Patient Alerts from AARP, AHRQ, CDC and Healthy People 00 Q = NurseThink Quick! Fractures!Q.............................................................................................. 7 Osteoarthritis!............................................................................................ 7 Osteoporosis................................................................................................ 75 Restless Leg Q..............................................................................................77 Nervous System Disorders Amyotrophic Lateral Sclerosis Q.......................................................................... 79 Attention-Deficit/Hyperactivity Disorder.................................................................. 8 Cerebral Palsy............................................................................................... 8 Guillain-Barre............................................................................................... 85 Multiple Sclerosis Q........................................................................................87 Myasthenia Gravis.......................................................................................... 89 Parkinson s Disease Q......................................................................................9 Peripheral Neuropathy......................................................................................9 Seizures Q..................................................................................................95 Spina Bifida..................................................................................................97 Trigeminal Neuralgia........................................................................................99 Sensory Cataracts Q.................................................................................................0 Conjunctivitis............................................................................................... 0 Glaucoma................................................................................................... 05 Hearing Impairment........................................................................................ 07 Labyrinthitis/Meniere s..................................................................................... 09 Macular Degeneration...................................................................................... Otitis Media................................................................................................. PROTECTION IMMUNITY, INFLAMMATION, INFECTION......................................................... 5 Gastrointestinal Disorders Appendicitis Q............................................................................................. 7 Gallbladder Disease Q..................................................................................... 9 Inflammatory Bowel Disease............................................................................... Pancreatitis.................................................................................................. General Infections and Complications Influenza.................................................................................................... 5 Septicemia!............................................................................................... 7 Healthcare Associated Infections!...........................................................................9 Methicillin-Resistant Staphylococcus Aureus.............................................................. Vancomycin-Resistant Enterococci......................................................................... Hypersensitivity Reactions Q................................................................................. 5 Immune Disorders Fibromyalgia................................................................................................ 7 HIV/AIDS!Q.............................................................................................. 9 Lupus Q.................................................................................................... 4 Rheumatoid Arthritis!Q................................................................................. 4 Kidney Urinary Disorders Cystitis.......................................................................................................45 Polycystic Kidney........................................................................................... 47 Pyelonephritis...............................................................................................49 Urinary Tract Infection!Q................................................................................5 Nervous System Disorders Meningitis/Encephalitis.....................................................................................5 Respiratory System Disorders Bronchiolitis.................................................................................................55 6
CONTENTS!= High Frequency Patient Alerts from AARP, AHRQ, CDC and Healthy People 00 Q = NurseThink Quick! Epiglottitis...................................................................................................57 Pneumonia!Q............................................................................................59 Tuberculosis Q............................................................................................. 6 Upper Respiratory Infections!............................................................................6 Skin and Bone Disorders Cellulitis!.................................................................................................. 65 Gout Q..................................................................................................... 67 REGULATION I THERMOREGULATION, CELLULAR REGULATION, INTRACRANIAL REGULATION.............69 Blood Cell Disorders! Iron Deficiency Anemia..................................................................................... 7 Polycythemia Q............................................................................................ 7 Sickle Cell Anemia.......................................................................................... 75 Thrombocytopenia Q......................................................................................77 Cancer!......................................................................................................... 79 Bone Cancer Q............................................................................................. 8 Brain Tumor................................................................................................. 8 Breast Cancer Q............................................................................................ 85 Colon Cancer Q............................................................................................ 87 Hodgkin s....................................................................................................89 Leukemia....................................................................................................9 Lung Cancer.................................................................................................9 Lymphoma Q.............................................................................................. 95 Multiple Myeloma Q....................................................................................... 97 Prostate Cancer............................................................................................. 99 Skin Cancer Q.............................................................................................. 0 Increased Intracranial Pressure Q............................................................................ 0 Thermoregulation Types Hyperthermia!............................................................................................05 Hypothermia................................................................................................ 07 REGULATION II GLUCOSE REGULATION, METABOLISM, NUTRITION, ELIMINATION..........................09 Accessory Organs Cirrhosis..................................................................................................... Hepatitis Q................................................................................................. Liver Disease Q.............................................................................................5 Adrenal Disorders Addison s Syndrome/Disease Q........................................................................... 7 Cushing s Syndrome/Disease Q........................................................................... 9 Lower Intestinal Tract Crohn s Q................................................................................................... Diverticular Disease......................................................................................... Intestinal Obstruction Q................................................................................... 5 Irritable Bowel Q........................................................................................... 7 Obesity!...................................................................................................9 Ulcerative Colitis Q......................................................................................... Metabolic Syndrome............................................................................................ Pancreas Disorders Diabetes Mellitus Insulin Dependent!Q.............................................................. 5 Diabetes Mellitus Non-Insulin Dependent............................................................... 7 Diabetic Ketoacidosis....................................................................................... 9 Hyperosmolar Hyperglycemic Nonketotic Syndrome..................................................... 4 Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed. 7
CONTENTS!= High Frequency Patient Alerts from AARP, AHRQ, CDC and Healthy People 00 Q = NurseThink Quick! Parathyroid Disorders Hyperparathyroidism....................................................................................... 4 Hypoparathyroidism........................................................................................45 Pituitary Disorders Diabetes Insipidus.......................................................................................... 47 Syndrome Inappropriate Antidiuretic Hormone Q....................................................... 49 Thyroid disorders Hyperthyroidism Q........................................................................................ 5 Hypothyroidism.............................................................................................5 Upper Intestinal Tract Cleft Lip or Palate........................................................................................... 55 Gastroesophageal Reflux/Gastritis Q......................................................................57 Peptic Ulcer................................................................................................. 59 Urinary/Renal Disorders Acute Kidney Injury!Q...................................................................................6 Benign Prostatic Hypertrophy.............................................................................. 6 Chronic Kidney Disease/End Stage Renal Disease!Q................................................... 65 Wilms Tumor................................................................................................ 67 RESPIRATION OXYGENATION, GAS EXCHANGE.................................................................. 69 Pulmonary Disease and Trauma Asthma!Q................................................................................................7 Chronic Obstructive Pulmonary Disease!Q.............................................................7 Cystic Fibrosis............................................................................................... 75 Pulmonary Hypertension................................................................................... 77 Severe Acute Respiratory Syndrome Q....................................................................79 SEXUALITY REPRODUCTION.......................................................................................8 Antepartum Abruptio Placentae and Placenta Previa................................................................... 8 First Trimester............................................................................................... 85 Second Trimester........................................................................................... 87 Third Trimester.............................................................................................. 89 Hypertensive Disorders.....................................................................................9 Spontaneous Abortion..................................................................................... 9 SAMPLE ONLY Reproduction Prohibited Erectile Dysfunction............................................................................................ 95 Intrapartum Dystocia..................................................................................................... 97 Preterm Labor...............................................................................................99 Second Stage of Labor......................................................................................40 Third Stage of Labor........................................................................................ 40 Fourth Stage of Labor.......................................................................................405 Newborn Care................................................................................................... 407 Postpartum Breastfeeding............................................................................................... 409 Hemorrhage................................................................................................ 4 Sexually Transmitted Diseases! Chlamydia...................................................................................................4 Human Papillomavirus......................................................................................45 Syphilis...................................................................................................... 47 Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed. 8
Related Exemplars Related Concepts Substance Abuse Classroom Critical Thinking Reading / Resources Critical Thinking Priority Assessments Priority Labs & Diagnostics Priority Medications Priority Potential & Actual Complications Priority Nursing Interventions Priority Collaborative Goals Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed.
NurseThink Quick Notes Substance Abuse CARE ACCORDING TO THE NCLEX TEST PLAN Safe and Effective Care: Management of Care, Coordinated Care, Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity: Basic Care and Comfort, Pharmacological and Parenteral Therapies, Reduction of Risk Potential, and Physiological Adaptation CARE ACCORDING TO QUALITY AND SAFETY STANDARDS Patient-Centered Care Teamwork and Collaboration Evidence-Based Practice Quality Improvement Safety Informatics Buddy Review: Faculty Review: Grade Tracker Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed. 4
Nicotine Abuse Related Exemplars Related Concepts Classroom Critical Thinking Reading / Resources Critical Thinking Priority Assessments Priority Labs & Diagnostics Priority Nursing Interventions Priority Medications Priority Potential & Actual Complications Priority Collaborative Goals Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed. 9
NurseThink Quick Notes Nicotinic Effects MTWThF Mydriasis/Muscle cramps Tachycardia Weakness Twitching Hypertension/Hyperglycemia Fasciculation CARE ACCORDING TO THE NCLEX TEST PLAN Safe and Effective Care: Management of Care, Coordinated Care, Safety and Infection Control Nicotine Abuse Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity: Basic Care and Comfort, Pharmacological and Parenteral Therapies, Reduction of Risk Potential, and Physiological Adaptation CARE ACCORDING TO QUALITY AND SAFETY STANDARDS Patient-Centered Care Teamwork and Collaboration Evidence-Based Practice Quality Improvement Safety Informatics Buddy Review: Grade Tracker Faculty Review: Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed. 40
Related Exemplars Concept: Circulation Perfusion, Clotting Related Concepts Classroom Critical Thinking Reading / Resources Critical Thinking Priority Assessments Priority Labs & Diagnostics Priority Nursing Interventions Priority Medications Priority Potential & Actual Complications Priority Collaborative Goals Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed. 45
NurseThink Quick Notes Abdominal Aortic Aneurism: Symptoms 4A s Asymptomatic Abdominal mass Abdominal pulse Aches in low back CARE ACCORDING TO THE NCLEX TEST PLAN Safe and Effective Care: Management of Care, Coordinated Care, Safety and Infection Control Health Promotion and Maintenance Concept: Circulation Perfusion, Clotting Psychosocial Integrity Physiological Integrity: Basic Care and Comfort, Pharmacological and Parenteral Therapies, Reduction of Risk Potential, and Physiological Adaptation CARE ACCORDING TO QUALITY AND SAFETY STANDARDS Patient-Centered Care Teamwork and Collaboration Evidence-Based Practice Quality Improvement Safety Informatics Buddy Review: Faculty Review: Grade Tracker Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed. 46
Arteriosclerosis Related Exemplars Related Concepts Classroom Critical Thinking Reading / Resources Critical Thinking Priority Assessments Priority Medications Priority Labs & Diagnostics Priority Potential & Priority Collaborative Goals Actual Complications Priority Nursing Interventions Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed. 47
NurseThink Quick Notes Arteriosclerosis CARE ACCORDING TO THE NCLEX TEST PLAN Safe and Effective Care: Management of Care, Coordinated Care, Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity: Basic Care and Comfort, Pharmacological and Parenteral Therapies, Reduction of Risk Potential, and Physiological Adaptation CARE ACCORDING TO QUALITY AND SAFETY STANDARDS Patient-Centered Care Teamwork and Collaboration Evidence-Based Practice Quality Improvement Safety Informatics Buddy Review: Faculty Review: Grade Tracker Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed. 48
Related Exemplars Abruptio Placentae and Placenta Previa Related Concepts Classroom Critical Thinking Reading / Resources Critical Thinking Priority Assessments Priority Labs & Diagnostics Priority Nursing Interventions Priority Medications Priority Potential & Actual Complications Priority Collaborative Goals Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed. 8
NurseThink Quick Notes Abruptio Placentae and Placenta Previa CARE ACCORDING TO THE NCLEX TEST PLAN Safe and Effective Care: Management of Care, Coordinated Care, Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity: Basic Care and Comfort, Pharmacological and Parenteral Therapies, Reduction of Risk Potential, and Physiological Adaptation CARE ACCORDING TO QUALITY AND SAFETY STANDARDS Patient-Centered Care Teamwork and Collaboration Evidence-Based Practice Quality Improvement Safety Informatics Buddy Review: Grade Tracker Faculty Review: Copyright 07 by NurseTim, Inc. All rights reserved. No reproduction or distribution allowed. 84