Do not delegate - Answers What you can EAT E-evaluate A-assess T-teach
Addison's & Cushings - Answers Addison's = down down down up down
Cushings= up up up down up
hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia
Better peripheral perfusion? - Answers EleVate Veins, DAngle Arteries
APGAR - Answers Appearance (all pink, pink and blue, blue (pale)
Pulse (>100, <100, absent)
Grimace (cough, grimace, no response)
Activity (flexed, flaccid, limp)
Respirations (strong cry, weak cry, absent)
Airborne precautions - Answers My chicken hez tb (measles, chickenpox (varicella) Herpes
zoster/shingles TB
Airborne precautions protective equip - Answers private room, neg pressure with 6-12 air
exchanges/hr mask N95 for TB
Droplet precautions - Answers spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus,
pneumonia, pertussis,
influenza,
diptheria,
epiglottitis,
rubella,
mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room or cohort
mask!)
Contact precaution - Answers MRS WEE
Multidrug resistant organism
Rresiratory infection
Skin infection
Wound infection
Enteric infection (C diff)
Eye infection (conjunctivitis)
Skin infection - Answers VCHIPS
Varicella zoster
Cutaneous diptheria
Herpes simplez
Impetigo
Peduculosis
Scabies
Air or Pulmonary Embolism - Answers S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of
impending doom. (turn pt to LEFT side and LOWER the head of bed.)
Woman in labor (un-reassuring FHR) - Answers (late decels, decreased variability, fetal bradycardia,
etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids!
Tube feeding with decreased LOC - Answers Pt on Right side (promotes emptying of the stomach)
Head of bed elevated (prevent aspiration)
After lumbar puncture and oil based myelogram - Answers pt is flat SUPINE (prevent headache and
leaking of CSF)
Pt with heat stroke - Answers flat with legs elevated
during Continuous Bladder Irrigation (CBI) - Answers catheter is taped to the thigh. leg must be kept
straight.
After Myringotomy - Answers position on the side of AFFECTED ear, allows drainage.
After Cateract surgery - Answers pt sleep on UNAFFECTED side with a night shield for 1-4 weeks
after Thyroidectomy - Answers low or semi-fowler's position, support head, neck and shoulders.
Infant with Spina Bifida - Answers Prone so that sac does not rupture
Buck's Traction (skin) - Answers elevate foot of bed for counter traction
After total hip replacement - Answers don't sleep on side of surgery, don't flex hip more than 45-60
degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating
thighs with pillows.
, Prolapsed cord - Answers Knee to chest or Trendelenburg
Cleft Lip - Answers position on back or in infant seat to prevent trauma to the suture line. while
feeding hold in upright position.
To prevent dumping syndrome - Answers (post operative ulcer/stomach surgeries) eat in reclining
position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet.
small, frequent meals.
AKA (above knee amputation) - Answers elevate for first 24 hours on pillow. position prone daily to
maintain hip extension.
BKA (below knee amputation) - Answers foot of bed elevated for first 24 hours. position prone to
provide hip extension.
detached retina - Answers area of detachment should be in the dependent position
administration of enema - Answers pt should be left side lying (Sim's) with knee flexed.
After supratentorial surgery - Answers (incision behind hairline on forhead) elevate HOB 30-40
degrees
After infratentorial surgery - Answers (incision at the nape of neck) position pt flat and lateral on
either side.
During internal radiation - Answers on bed rest while implant in place
Autonomic Dysreflexia/Hyperreflexia - Answers S/S pounding headache, profuse sweating, nasal
congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST!
Shock - Answers bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated
(modified Trendelenberg)
Head Injury - Answers elevate HOB 30 degrees to decrease ICP
Peritoneal Dialysis (when outflow is inadequate) - Answers turn pt from side to side BEFORE checking
for kinks in tubing
Lumbar Puncture - Answers After the procedure, the pt should be supine for 4-12 hours as
prescribed.
Myesthenia Gravis - Answers worsens with exercise and improves with rest
Myesthenia Gravis - Answers a positive reaction to Tensilon---will improve symptoms
Cholinergic Crisis - Answers Caused by excessive medication ---stop giving Tensilon...will make it
worse.
Liver biopsy (prior) - Answers must have lab results for prothrombin time
Myxedema/ hypothyroidism - Answers slowed physical and mental function, sensitivity to cold, dry
skin and hair.
Grave's Disease/ hyperthyroidism - Answers accelerated physical and mental function. Sensitivity to
heat. Fine/soft hair.
Thyroid storm - Answers increased temp, pulse and HTN
Post-Thyroidectomy - Answers semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside
Hypo-parathyroid - Answers CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased
calcium) give high calcium, low phosphorus diet
Hyper-parathyroid - Answers fatigue, muscle weakness, renal calculi, back and joint pain (increased
calcium) give a low calcium high phosphorous diet
Hypovolemia - Answers increased temp, rapid/weak pulse, increase respiration, hypotension,
anxiety. Urine specific gravity >1.030
Hypervolemia - Answers bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine
specific gravity <1.010. semi fowler's
Diabetes insipidus (decreased ADH) - Answers excessive urine output and thirst, dehydration,
weakness, administer Pitressin
SIADH (increased ADH) - Answers change in LOC, decreased deep tendon reflexes, tachycardia. N/V
HA administer Declomycin, diuretics
hypokalemia - Answers muscle weakness, dysrhythmias, increase K (rasins bananas apricots, oranges,
beans, potatoes, carrots, celery)
Hyperkalemia - Answers MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased
cardiac contractility, ECG changes, reflexes
Hyponatremia - Answers nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give
osmotic diuretics (Mannitol) and fluids
Hypernatremia - Answers increased temp, weakness, disorientation, dilusions, hypotension,
tachycardia. give hypotonic solution.