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72 Cards in this Set
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- Back
- 3rd side (hint)
Scope for LPN
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assist in implementing a defined plan of care and to perform procedures according to protocol
assessment skills are directed at differentiating normal from abnormal competence to care for physiologically stable clients with predictable conditions |
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"Scope" for UAP
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assist in a variety of direct client care activities or tasks
perform indirect activities such as housekeeping, transporting people and stocking supplies |
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Steps of Delegation
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1. Define the task
2. Match the task to the delegatee a.Within scope b. Know role expectations 3. Communicate clearly about expected outcomes and when the task should be done 4.Reach mutual agreement that all prior questions and problems are sorted and that the delegatee knows what to do 5. Supervise performance of task 6. Evaluate 7. Share feedback of delegatee |
Five rights of delegation
Right task Right circumstances Right person Right direction/communication Right supervision |
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Nursing Care Delivery System
Functional/Task Nursing |
Needs of clients are broken down into tasks
Tasks are assigned to various levels of health care workers according to licensure and skill Example: RN gives medications and UAP give bed baths for one group of clients |
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Nursing Care Delivery System Team Nursing
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Most common nursing care delivery system
A team of nursing personnel provides total care to a group of clients Team leaders supervise client care teams, which usually consist of an RN, LPN, and UAP Team leader reviews the client's plan of care and progress with team members during team conference |
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Nursing Care Delivery System Total Client Care Method
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An RN is responsible for all aspects of care of one or more clients
The LPN may be assigned to assist the RN Currently, this type of care is provided in areas requiring high level of nursing expertise, such as the critical care unit (CCU) or the post-anesthesia recovery unit (PACU) |
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Nursing Care Delivery System Primary Nursing
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The RN maintains a client load of primary clients
The primary nurse designs, implements and is accountable for the nursing care of those clients during their entire stay on the unit |
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Nursing Care Delivery System
Practice Partnerships |
An RN and an assistant (UAP, LPN, less-experienced RN, graduate nurse, or nurse intern) agree to be practice partners
Partners work together on same schedule with same group of clients Senior partner directs the work of the junior partner within the scope of each partner's practice |
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Negligence
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Legally, a breach of the duty to provide nursing care to the client
Malpractice is professional negligence The unintentional failure of an individual to perform or not perform an act that a reasonable person would or would not perform in a similar set of circumstances |
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Legal concepts of Negligence
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Duty: nurses have a legal obligation to provide nursing care to clients
must meet a reasonable and prudent standard of care under the circumstances must deliver care as any other reasonable and prudent nurse of similar education and experience would, under similar circumstances Breach of duty: failure to provide expected, reasonable standard of care under the circumstances (includes errors of omission or commission) Proximate cause: relationship between the breach of duty and the resulting injury the injured party must prove that the nurse's action or omission led to the injury Damages: the injury and the monetary award to the plaintiff |
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LIving Will
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identifies what a client wishes for their care should they become unable to communicate these wishes
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Durable Power Of Attorney for Health Care decisions
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the client has appointed a person to make decisions about their care if they are unable to do so.
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DNR
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this has been expanded to include identification of medications that may be given without any defibrillation attempts (comfort measures only)
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Ethical Principles
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Respect for others
Autonomy Nonmaleficence - "do no harm" Beneficence - do good and avoid evil Justice Veracity - the ethical duty to tell the truth Confidentiality Fidelity - loyalty, faithfulness and honoring commitments |
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Stages of Infectious Process
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Incubation period
Prodromal period Illness period Convalescent period |
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Standard Precautions
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apply to
blood all body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood non-intact skin mucous membranes |
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Contact Precautions
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gown and glove for all contact
examples of opportunities for contact transmission: epidemiologically important organisms, e.g., VRE; excessive wound damage; fecal incontinence |
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Droplet Precaution
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requires close contact (typically within 3 feet or less)
use of a standard surgical mask within 3 feet of the client is required respiratory droplets are generated when an infected person coughs, sneezes, or talks, or during procedures such as suctioning, endotracheal intubation, cough induction by chest physiotherapy and cardiopulmonary resuscitation |
examples of infectious agents transmitted through droplet route: group A streptococcus (for the first 24 hours of antimicrobial therapy), adenovirus, rhinovirus, Neisseria meningitis, pertussis, influenza virus
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Airborne Precautions
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microorganisms dispersed over long distances that remain infective over time and distance
use of special air handling and ventilation systems wearing respiratory protection with NIOSH-certified N95 or higher level respirator for all health care workers |
examples of microorganisms spread through airborne route: rubeola virus (measles), varicella-zoster virus (chickenpox), Mycobacterium tuberculosis
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Triage
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treated first: individuals who have life-threatening injuries that are readily correctable
treated last: individuals who have no injuries, or noncritical injuries, and who are ambulatory, as well as individuals who are dying or are dead |
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Erythrocyte sedimentation rate
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>15-20 mm/h indicates inflammation
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Highly C-Reactive Protein is a marker of...?
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Inflammation
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Chicken pox (varicella) incubation/transmission/S&S
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incubation: 13- 17 days
Transmission; airborne, contact, objects S/S: slight fever, malaise, anorexia, rash, macule>papule>vesicle, lymphadenopathy |
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Varicella Interventions
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isolate until vesicles crusted
avoid aspirin may lead to Rye's disease airborne and contact precautions at hospital |
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Diphtheria
incubation time |
2-5 days
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Diphtheria transmission
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direct contact with a carrier, infected client contaminated articles
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Diphtheria S/S
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Prodromal: common cold
low-rade fever, hoarseness, malaise, pharyngeal lymphadenitis;white/gray pharyngeal membrane |
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Diphtheria Interventions
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contact & droplet precautions until two successive negative nose and throat cultures
complete bedrest; watch for resp distress and obstruction; provide humidification, suctioning, and tracheostomy prn severe= sepsis and death |
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Pertussis( whooping cough) incubation
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5-21 days usually 10
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Pertussis Transmission
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direct, droplet, contaminated articles
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Pertussis S/S
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Prodromal: upper resp infection for 1-2 weeks
severe cough with high pitched whooping sound, esp at night and lasts 4-6 weeks, vomiting |
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Pertussis Interventions
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Hospital for infants; bedrest and hydration
Complications; pneumonia, wt loss, dehydration, hemorrhage, hernia, airway obstruction Maintain high humidity and restful environment; suctionl and O2 Admin erythromycin and pertussis immune globulin |
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Rubella (german measles) incubation
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14-21 days
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Rubella S/S
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Prodromal; none in children, low fever and sore throat in adolescent
Maculopapular rash appears first on face then rest of body Symptoms subside first day after rash |
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Rubella Transmission
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droplet and contaminated articles
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Rubella Interventions
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contact and droplet
risk of fetal deformity isolate child from potentially pregnant women antipyretcis and analgesics rare complications of arthritis and encephalitis |
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Rubeola Incubation
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10-20 days
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Rubeola S/S
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Prodromal: fever and malaise> Koplik's spots on buccal mucosa
Erythematous maculopapular rash with face first affected |
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Rubeola transmission
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direct contact with droplets
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Rubeola interventions
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isolate until 5th day; maintain bed rest for first 3-4 days
Airborne and seizure precautions antipyretics, dim light, humidifier clean skin and hydration |
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Scarlet Fever Incubation time
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2-4 days
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Scarlet Fever S/S
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Prodromal; high fever vomiting , chills, malaise ,enlarged tonsils covered with exudate, strawberry tongue
Rash: red tiny lesions that become generalized and desqumate; appears in 24 hrs |
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Scarlet Fever Transmission
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droplet or contaminated articles , Group A nbeta-hemolytic streptococci
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Scarlet Fever Interventions
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Droplet precautions for 24 hours after start of antibiotics
Bed rest while febrile Analgesics for sore throat Fluids and soft diet Penicillin and erythromycin |
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Mono Incubation
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4-6 weeks
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Mono S/S
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malaise, fever, enlarged lymphs, sore throat, flulike aches, low grade temp
usually in 15-30 yr/olds |
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Mono Transmission
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direct contact with oral secretions
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Mono Interventions
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Avoid sharing saliva for 3 months, treat with rest and nutrition, strenuous exercise is to be avoided or spleen will rupture
Complications: encephalitis & spleen rupture |
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Tonsillitis (Streptococcal) S/S
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fever, white exudate on tonsils
Positive culture GpA strep |
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Tonsillitis Interventions
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Antibiotics
Complications: rheumatic fever, glomerulonephritis |
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Mumps Incubation
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14-21 days
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Mumps S/S
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malaise, headache, fever, parotid gland swelling
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Mumps transmission
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direct contact with saliva, droplet
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Mumps interventions
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isolation before and after swelling
soft, bland diet Complications: deafness, meningitis, encephalitis, sterility |
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Hepatitis Diet
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Low in fat, high in calories, carbs, and protein; no alcohol
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Hepatitis Meds
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Vitamin K (Aquqa MEPHYTON)
Antivirals: interferon and lamivudine Post exposure Hep B vaccine |
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Syphilis Symptoms
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Stage 1: painless chancre that disappears in 4 weeks
Stage 2: Copper colored rash on palms and soles; low grade fever Stage 3: cardiac & CNS dysfunction |
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Syphilis Interventions
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Treat with Penicillin G IM or erythromycin if PCN allergy
Ceftriaxone and tetracyclines for non preggers Abstinence until treatment complete |
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Gonorrhea Symptoms
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Thick discharge
Females: usually asympt, but may have purulent discharge, dysuria, and dyspareunia (painful sex) Males; painful urination, yellow/green discharge |
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Gonorrhea Treatment
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IM Ceftriaxone (Rocephin)
1 time PO doxycillin BID for 1 week; azithromycin (Zithromax) Penicillin with Probenecid, Spectinomycin if allergic to rocephin monitor for PID |
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Herpes Symptoms
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painful vesicular genital lesions
difficulty voiding recurrent during stress, infection, and menses |
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Herpes treatment
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acyclovir
sitz bath |
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Chlamydia symptoms
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Men-dysuria, freq.urination, watery discharge
Women-may be asymptomatic, thick discharge with acrid odor, pelvic pain, yellow discharge; painful menses |
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Chlamydia interventions
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Notify contacts, may cause sterility, treat with azithromycin, doxycycline, erythromycin
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Genital Warts (condylomata acuminata) Symptoms
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Initially single, small papillary lesion spreads into large cauliflower like cluster on perineum and genitals; may itch or burn
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Genital warts interventions
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curettage, cryotherapy with liquid nitro or podophyllin resin
Kerotolytic agents avoid sex until lesions healed May lead to genital dysplasia or cervical carcinoma Atypical, pigmented, or persistent warts should be biopsied notify contacts |
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Aspirin (Salicylate) Poisoning Assessment
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Tinnitus, n/v, sweating , dizziness, headache
change in mental status, fever hyperventilation (resp alk) > metabolic acidosis, and resp acidosis, bleeding and hypovolemia Toxicity begins at doses of 150-200 mg/kg; 4 grams may be fatal to child |
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Aspirin poisoning interventions
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induce vomiting; initiate gastric lavage with activated charcoal
maintain IV hydration and I/O, skin turgor, fontanels reduce temp with tepid water baths or hypothermia blankets; prone to seizures Vitamin K for bleeding disorder IV sodium bicarb enhances excretion |
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Tylenol (acetminophen) Poisoning Assessment
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first 2 hours n/v, sweating, pallor, hypothermia, slow-weak pulse
Toxicity begins at 150 mg/kg |
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Tylenol poisoning treatment
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induce vomiting
N-acetylcysteine( Mucomyst) =antidote; must be effective in 8-10 hours; must be given w/in 24hrs |
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Lead toxicity assessment
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irritability, sleepiness, n/v, abd pain, poor appetite
constipation/diarrhea dec.activity, Increase ICP Blood level less than or equal to 9 mcg/dL is normal |
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Lead toxicity interventions
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chelating agents, calcium disodium, succimer, deferoxamine( desferal)
maintain hydration, id source and tell parents |
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