Summary Revised NCLEX Study Guide Latest

Revised NCLEX Study Guide 1. ABCs (Airway, Breathing, Circulation) 2. When in distress DO NOT ASSESS! Unless 2nd hand information is received. 3. Scenario • Expected outcome with Disease Process o Continue to monitor o Document finding • Unexpected finding with Disease Process o Nursing intervention that must make a difference o Call HCP 4. Mini Maslow’s 1) ABCs (& Pain unrelieved by meds) 2) Safety 3) Comfort (Pain) 4) Psychological 5) Social 6) Spiritual 5. STAT words → Pick the answer that failing to do so will kill or cause great harm ● Highest Priority ● Most Important ● Immediate Action 6. *Least Invasive First* 7. Secondhand Info → Any time you have 2nd hand info, the right answer is assess ∙ UAP ∙ Family ∙ Labs ∙ EMR ∙ EKG ∙ BP machine 8. Never ever take away the coping mechanism a patient uses during a crisis, except if the mechanism puts the patient or others @ risk 9. Eliminate answer choices & DNR 10. Never withhold Tx! If you’re left with two answer choices and the options are to Tx, or watch the patient, Pick Tx! 11. Anytime there’s a reversal from the norm, you must worry! Ex: rebound tenderness (pain after you relieve pressure) 12. Stable Patients ∙ UAP ∙ LPN ∙ New nurse ∙ Graduate Nurse ∙ Float Nurse ∙ Travel nurse 13. Anytime you see excessive findings, That’s not normal! 14. Always empower your patient 15. If a question has “ ”, pick an answer that has what they’re feeling & not what they’re saying 16. 3 R’s of Psych 1) Reality – Functional psych patient 2) Reassure – Delirium 3) Redirect – Dementia Default Answers 1. Give meds either 1 hour before meal or 2 hours after meal 2. Give antacids 1 hour before med or 4 hours after med 3. When in doubt pick K (potassium) 4. 2 – 3 L of fluids 5. When in doubt pick answer that has you stay with patient 6. Anytime you see restless & ↓ level of consciousness = early sign always pick 7. Head of Bead → 30-45 degrees for any neuro patient 8. Elderly with acute onset confusion → UTI 9. Secretions will turn Orange/Red for meds 10. Anytime you have GI problem/exacerbation = NPO 11. All surgeries 1st 24 hrs – bleeding 48 hrs – infection 12. Check daily weights if it’s a fluid problem 13. Lateral position for maternity 14. Remove answer choices that are ‘absolutes’ Kaplan NCLEX Strategies Kaplan RN Decision Tree Step 1 – Can you identify the topic of the question Step 2 – Are the answers assessment (get data) or implementation (to effect change)? Step 3 – Apply Maslow: Are the answers physical or psychosocial? (Physical trumps psychosocial) Step 4 – Are the answer choices related to ABCs? Step 5 – What is the outcome of each of the remaining answers? Rules for Delegation RN ASSIGNMENT ● Cannot delegate assessment, teaching, or nursing judgement LPN/LVN ASSIGNMENT ● Assign stable with expected outcomes UAP ASSIGNMENT ● Delegate standard, unchanging procedures Five Rights of Delegation RIGHT TASK – scope of practice, stable client RIGHT CIRCUMSTANCES – workload RIGHT PERSON – scope of practice RIGHT COMMUNICATION – specific task to be performed, expected results, follow-up communication RIGHT SUPERVISION – clear directions, intervene if necessary Therapeutic Communication Tips DO: DO NOT: ● Do respond to feeling tone ● Do provide information ● Do focus on the client ● Do use silence ● Do use presence ● Do not ask ‘why’ questions ● Do not ask ‘yes/no’ questions, except in the case of possible self-harm ● Do not focus on the nurse ● Do not explore ● Do not say, “Don’t worry!” Who Do You See First? Consider: ∙ Unstable vs. Stable ∙ Acute vs. Chronic ∙ Unexpected vs. Expected ∙ Actual vs. Potential ∙ ABCs Common NCLEX Traps ∙ Do not ask “Why?” ∙ Do not ‘do nothing.’ ∙ Do not leave the client. ∙ Do not read into the question ∙ Do not persuade the client. ∙ Do not pass the buck. ∙ Do not say, “Don’t worry!” Strategies ● Only use textbook nursing – textbook knowledge ● Pain is psychosocial, unless, it’s severe, acute, & unrelenting ● If it’s a position question, is it going to prevent or promote something – position, prevent, promote ● Teaching/learning – use T/F on each answer ● Risk Questions – use Risk Factors ● If the answers have an absolute in them, do not pick them ● Question that have the phrase ‘And Then’ – did they miss something Important Lab Values WBC 4K – 11K RBC 4 – 6 Hgb 12 – 16, 0r 12-18 Hct 36 – 48, or 37-52 Plt 150K – 400K BUN 8 – 20, or 7-22 Cr/Lithium 0.6 – 1.2 Urine Clearance 85 – 135, (GFR)=maintain above 60 Uric Acid 250 – 750 mg Na 135 – 145 Cl 98 – 106 Ca 8.5 – 10.5 K 3.5 – 5.0 PO 2.5 – 4.5g Mag 1.5 – 2.5, 4-7 if pregnant and receiving Toco Warfarin INR 2.0 – 3.5 Heparin PT 10 – 13 Seconds PTT 25 – 35 Seconds Therapeutic PTT: 1.5 – 2x the normal value (46 – 76 Seconds) Cholesterol HDL x > 50 LDL x < 100 Triglycerides x < 150 Total Cholesterol x < 200 Therapeutic Ranges Dilantin Theophylline Acetaminophen 10 – 20 Digoxin 0.5 – 2.0 Albumin level 3.5 to 5.5 Acid-Base Balance From the ass (diarrhea) –Metabolic Acidosis From the mouth (vomitus) –Metabolic Alkalosis Potassium & Alkalosis – ALKALOSIS: K is LOW – Acidosis is just the opposite: K is High Arterial Blood Gases 1. Prior to drawing an ABG, perform the Allen’s Test to check for sufficient blood flow 2. When drawing an ABG, the blood needs to be put in a heparinized tube. ● Ensuring there are no bubbles. 3. Put on ice immediately after drawing, with a label. ● The label should indicate if the pt was on room air, or how many liters of O2. General Notes ● The person who hyperventilates is most likely to experience respiratory alkalosis. Antidotes ● Aspirin → Activated Charcoal ● Coumadin (Warfarin) → Vitamin K ● Heparin → Protamine Sulfate ● Tylenol (Acetaminophen) → Mucomyst (acetylcysteine) – administered orally ● Digoxin (Lanoxin) → Digibind (immune Fab) ● Opioids → Narcan ● Iron overdose → Deferoxamine ● PCP → Activated charcoal ● Magnesium Sulfate → Calcium Gluconate ● TPA → Aminocaproic acid ● Pancuronium Br (NM blocking agent) → Neostigmine/Atropine Blood For blood types: ● "O" is the universal donor (remember "o" in donor) ● "AB" is the universal recipient Blood transfusion – sign of allergies in order: 1)Flank pain 2)Frequent swallowing 3)Rashes 4)Fever 5)Chills Thrombocytopenia – Bleeding precautions! 1)Soft bristled toothbrush 2)No insertion of anything! (c/i suppositories, douche) 3)No IM meds as much as possible! Sickle Cell Anemia During sickle cell crisis there are two interventions to prioritize: fluids and pain relief. Iron deficiency anemia – easily fatigued 1)Fe PO (Iron) - give with Vitamin C or on an empty stomach 2)Fe via IM- Interferon via Z Track -- Peds: Kids are at risk for iron deficiency anemia if they ingest too much milk; >24oz/ day. Pernicious Anemia - s/s include pallor, tachycardia, and Sore Red, Beefy tongue; will take Vit.B12 for life! Shilling Test – test for pernicious anemia/ how well one absorbs Vit b12 General Notes ● A patient with a low hemoglobin and/or hematocrit should be evaluated for signs of bleeding, such as dark stools. Burns Rule of nines, 9 = head, 18 = arms, 36 = torso, 36 =legs, and 1= perineum = 100% The Parkland formula is a formula used for calculation the total fluid requirement in 24 hours for a burn patient 4ml x TBSA % (Total Burn Surface Area) x body weight (kg) = Total amount of fluid the patient will receive in 24 hrs 50% given in first eight hours 50% given in next 16 hours. The Number #1 Priority for Burn Patients is maintaining a patent airway 1st Degree – Red and Painful
 2nd Degree – Blisters
 3rd Degree – No Pain because of blocked and burned nerves Cancer A cancer patient is getting radiation. What should the nurse be most concerned about? ● Skin irritation? No. ● Infection kills cancer patients most because of the leukopenia caused by radiation. General Notes ● A breast cancer patient treated with Tamoxifen should report changes in visual acuity, because the adverse effect could be irreversible. ● Common sites for metastasis include the liver, brain, lung, bone, and lymph. ● Bence Jones protein in the urine confirms multiple myeloma (cancer of plasma cells) ● Patients with leukemia may have epistaxis (nosebleeds) b/c of low platelets Cardiac All – Aortic Valve Physicians – Pulmonary Valve Earn – Erb’s Point Their – Tricuspid Valve Money – Mitral Valve (PMI) Or APE To Man Cardiac Catheter ● Pre-Op – NPO 8-12hr prior, empty bladder, check pulses, tell pt they may feel heat, palpitations, or desire to cough with dye injection. ● Post Op – V/S, & keep leg straight, bed rest 6-8 hrs, Sleep supine. General Notes ● Blood tests for MI: Myoglobin, CK and Troponin ● Coarctation of the aorta causes increased blood flow and bounding pulses in the arms ● Cor Pulmonale is right sided heart failure caused by left ventricular failure; (so pick edema, JVD, if it is a choice.) ● Normal PCWP (pulmonary capillary wedge pressure) is 8-13. Readings of 18-20 are considered high. ● Pulmonary sarcoidosis (an inflammatory disease) leads to right sided heart failure. ● Anytime you see fluid retention. Think heart problems first. Circulation EleVate Veins; dAngle Arteries for better perfusion For PVD remember DAVE (Legs are Dependent for Arterial & for Venous Elevated) Virchow’s Triad → Risk Factors for DVT V – Vascular Trauma I – Increased Coagulability R – Reduced Blood Flow –Definitive diagnosis for abdominal aortic aneurysm (AAA) → CT scan Fat Embolism S/S ● Blood tinged sputum (related to inflammation) <Pink frothy sputum> ● increased erthyro sedimentation rate (ESR) ● Respiratory alkalosis (related to tachypnea) ● Hypocalcemia, increased serum lipids ● "Snow Storm" effect on Chest x-ray General Notes ● Hypotension and vasoconstriction meds may alter the accuracy of O2 sats.
 ● A newly diagnosed hypertension patient should have BP assessed in both arms Cranial Nerves Sensory=S Motor=M Both=B 1. Oh (Olfactory I) Some 2. Oh (Optic II) Say 3. Oh (Oculomotor III)
 Marry 4. To (Trochlear IV)
 Money 5. Touch (Trigeminal V)
 But 6. And (Abducens VI)
 My 7. Feel (Facial VII)
 Brother 8. Very (Vestibulocochlear/Auditory VIII) Says 9. Good (Glossopharyngeal IX) Big 10. Velvet (Vagus X) Brains 11. Such (Spinal Accessory XI) Matter 12. Heaven (Hypoglossal XII) More On Old Olympus Towering Top A Finn And German Viewed Some Hopes Cultural Greek heritage - they put an amulet or any other use of protective charms around their baby's neck to avoid "evil eye" or envy of others Lyme Disease is found mostly in Connecticut Jewish Folks: no meat and milk together Diabetes Blood Sugar ~ Hyperglycemia – Hot & Dry ~ Sugar High Hypoglycemia – Cold & Clammy ~ Need some candy To remember how to draw up INSULIN think:
Nicole Richie RN <Regular is clear & don't wanna put dirty needle in clear so Regular<CLOUDY> is pulled in first> Air into NPH, then air into Regular, draw up Regular insulin then draw up NPH Oral Hypoglycemics ● Do not attempt to give an oral hypoglycemic to an unconscious pt, as this poses the risk of aspirations ● A typical adverse reaction is rash, photosensitivity.
 HbA1c – test to assess how well blood sugars have been controlled over the past 90-120 days. 4- 6 corresponds to a blood sugar of 70-110; 7 is ideal for a diabetic and corresponds to a blood sugar of 130 Fluids are the most important intervention with HHNS as well as DKA, so get fluids going first. DKA ● While treating DKA, bringing the glucose down too far and too fast can result in increased intracranial pressure due to water being pulled into the CSF. ● Serum acetone and serum ketones rise in DKA. ● As you treat the acidosis and dehydration expect the potassium to drop rapidly, so be ready, with potassium replacement.
 HHNS ● With HHNS there is no ketosis, and no acidosis. ● Potassium is low in HHNS (d/t diuresis General Notes ● Extra insulin may be needed for a patient taking Prednisone (remember, steroids cause increased glucose). ● Second voided urine most accurate when testing for ketones and glucose. Drugs General Notes ● Give NSAIDS, Corticosteroids, drugs for Bipolar, Cephalosporins, and Sulfonamides WITH food. ● Best time to take Growth Hormone PM (Octreotide), Steroids AM, Diuretics AM, Aricept (Donepezil) AM - for Alzheimer’s disease. ● Antacids are given after meals ● Remember the action of vasopressin because it sounds like “press in”, or vasoconstrict. ● If mixing antipsychotics (i.e. Haldol, Thorazine, Prolixin) with fluids, meds are incompatible with caffeine and apple juice ● The main hypersensitivity reaction seen with antiplatelet drugs is bronchospasm (anaphylaxis) - “think NSAIDS causing bronchoconstriction in asthma patients” ● Glucagon increases the effects of oral anticoagulants. ● All psych meds' (except Lithium) side effects are the same as SNS but the BP is decreased o SNS- Increase in BP, HR and RR (dilated bronchioles), dilated pupils (blurred vision), Decreased GUT (urinary retention), GIT (constipation), Constricted blood vessels and Dry mouth. Anti-Anemics ● Iron injections should be given Z-track, so they don't leak into SQ tissues. ● Take iron elixir with juice or water.... never with milk Antiarrhythmics ● Verapamil: a calcium channel blocker, used to treat hypertension, angina; assess for constipation ● Digoxin: Check pulse, if it’s less than 60, hold medication, prior to administration check both potassium and dig levels o Pick ‘do vitals’ before administering that dig. (apical pulse for one full minute). o Making sure that patients on Digoxin and Lasix are getting enough potassium, because low potassium potentiates Digoxin toxicity and can cause dysrhythmias. o Digitalis increases ventricular irritability and could convert a rhythm to v-fib following cardioversion. ● Adenosine: is the treatment of choice for paroxysmal atrial tachycardia. ● Flecainide (Tambocor): Antiarrhythmics med, limit fluids and sodium intake, because sodium increases water retention which could lead to heart failure. Antianxiety ● Diazepam is a commonly used tranquilizer given to reduce anxiety before OR ● Midazolam: an anesthetic given for conscious sedation, watch out for respiratory depression and hypotension ● Chlordiazepoxide: treatment of alcohol withdrawal; don’t take alcohol with this medication, causes nausea & vomiting ● Hydroxyzine: treatment of anxiety as well as itching, commonly administered pre-op, watch out for dry mouth ● Lorazepam: treatment of choice for status epilepticus Anti-asthmatics ● INtal<cromolyn sodium aerosol>: an inhaler used to treat allergy induced asthma may cause bronchospasm, think... INto the asthmatic lung Antibiotic ● Aminoglycocides: Adverse Effects are bean shaped - Nephrotoxic to Kidneys and Ototoxic to Ears o __Mycin (drugs that end in or have in their name); except erythromycin (have -thro- in drug name) ● Sulfamethoxazole/trimethoprim: an antibiotic; common side effect is diarrhea (drink plenty of fluids); do not take if allergic to sulfa drugs Anticholinergic---- INE ending** ● Anticholinergic effects –– assessment o dry mouth – can't spit o urinary retention – can't piss o constipated – can't shit o blurred vision – can't see ● Atropine used to decrease secretions & asystole o Atropine blocks acetylcholine (remember acetylcholine reduces secretions) o Atropine OD Hot as a Hare (Temp) Mad as a Hatter (LOC) Red as a Beet (flushed face) Dry as a Bone (Thirsty) ● Benztropine: Treats Parkinson as well as extrapyramidal side effects of other drugs Anticonvulsants ● Phenytoin <Dilantin>: treatment of seizures; therapeutic drug level: 10-20; contraindicated during pregnancy; Side effects include rash (stop med if seen), gingival hyperplasia (can be prevented w/ good hygiene). o Dilantin Toxicity → poor gait coordination, slurred speech, nausea, lethargy, & diplopia ● Phenobarbital: treatment of epilepsy; can be taken during pregnancy Antidepressants ● Zoloft/Sertraline: side effects include agitation, sleep disturb, and dry mouth (SSRI) ● MAOI’s: antidepressant o An easy way to remember MAOI'S! think of PANAMA! PA – parnate- Tranylcypromine NA – nardil- Phenelzine MA – marplan- Isocarboxazid o MAOI's used for depression all have an arrr sound in the middle (Parnate, Marplan, Nardil) – Remember that Pirates say arrr, so think “pirates take MAOI's when they're depressed” o They have metallic bitter taste Antifungal ● Amphotericin B: This medication causes hypokalemia (amongst many other side effects as well); patient will most likely get a fever; pre-medicate with acetaminophen and/or diphenhydramine (preferably both) before administering to a patient Antiemetic should ● Trimethobenzamide <Tigan>: Treatment of postop nausea and vomiting, and for nausea associated with gastroenteritis ● Promethazine <Phenergan>: an antiemetic used to reduce nausea Anti-gout Agents ● Probenecid, Colchicine, Allopurinol ● Allopurinol: Push with fluids, in order to flush the uric acid out of system; DO NOT TAKE W/ VITAMIN C Antihypertensives ● hydralazine: treatment of HTN or CHF, Report flu-like symptoms, rise slowly from sitting/lying position; take with meals. Antimanic ● Lithium: L-level of therapeutic effect is 0.5-1.5 I-indicate mania T-toxic level is 2-3 - nausea & vomiting, diarrhea, tremors H-hydrate 2-3L of water/day I-increased Urinary output and dry mouth U-uh oh; give Mannitol and Diamox if toxic signs and symptoms are present M-maintain Na intake of 2-3g/day* Antimetabolites ● Hydroxyurea: treatment of sickle cell & certain types of leukemia; when used to Tx sickle cell, report GI symptoms immediately, could be sign of toxicity Antineoplastic ● vincristine: treatment of leukemia; given IV ONLY ● Asparaginase: treatment for acute lymphoblastic leukemia; Test for hypersensitivity prior to administration Antiparkinsonian Agents ● Carbidopa-Levodopa: treatment of Parkinson; side effects include drowsiness and the patient’s sweat, saliva, urine may occasionally turn reddish brown; contraindicated with MAOI's ● Trihexyphenidyl treatment of Parkinson, causes sedation ● Levodopa: Contraindicated in patients’ w/ glaucoma, avoid B6 Antipsychotics ● Risperidone: Doses over 6mg can cause tardive dyskinesia, this is a first line antipsychotic in children ● Clozapine: Side effects include agranulocytosis, tachycardia, and seizures, WATCH FOR INFECTION* ● Thiothixene: treatment of schizophrenia; assess for EPS ● Haloperidol: preferred antipsychotic in elderly, but it has a high risk of extrapyramidal side effects (dystonia, tardive dyskinesia, tightening of jaw, stiff neck, swollen tongue, later on swollen airway) o The nurse must monitor for early signs of reaction and give IM Benadryl ● 1st generation antipsychotics are the leading cause of Akathisia o Akathisia is characterized by motor restlessness, i.e. a need to keep going o Can be mistaken for agitation o Treated with Anti Parkinson's meds Anti-rheumatics ● Indomethacin: an NSAID; treatment of arthritis (osteo, rheumatoid, gouty), bursitis, and tendonitis.
 Antispasmodics ● dicyclomine: treatment of irritable bowel; assess for anticholinergic side effects. Antitubercular ● Rifampin: Red orange tears and urine (b/c it dyes bodily fluid orange); contraceptives don't work as well ● Ethambutol: messes with your Eyes ● Isoniazid (INH): treatment & prevent TB; it can cause peripheral neuritis/neuropathy (nerve damage); do not give with Phenytoin → can cause phenytoin toxicity; monitor LFT's; give B6 along with; hypotension will occur initially, then resolve ● TB drugs are liver toxic (hepatotoxic). o An adverse reaction is peripheral neuropathy o Ask patients if they have Hep B Antithyroid ● PTU and Tapazole: Tx of hyperthyroidism & prevention of thyroid storm ● Lugol’s Solution: adjunct Tx for hyperthyroidism as well as radiation protectant. An adverse reaction: Burning sensation in the mouth, and brassy taste. Report it to the doctor. Antiulcer ● Aluminum hydroxide: treatment of GERD and kidney stones, watch out for constipation. o Long term use of amphogel (binds to phosphates, increases Ca, robs the bones...leads to increased Ca reabsorption from bones → WEAK BONES) o Amphogel and Renegal should be taken with meals ● Sucralfate: treatment of duodenal ulcers, this medication coats the ulcer by creating a mucosal barrier, so the patient should take this medication before meals; be aware of constipation as a potential side effect ● Cimetidine: an H2 antagonist taken with food; use cautiously in the elderly population; interacts with a lot of other drugs ● Peptic ulcers caused by H. pylori are treated with Flagyl, Prilosec and Biaxin. This treatment kills bacteria and stops production of stomach acid but does not heal ulcer. Antiviral ● Ganciclovir: used for retinitis caused by cytomegalovirus, patient will need regular eye exams, report dizziness, confusion, or seizures immediately Anthelmintic/Anti-worm ● Mebendazole: Administer this medication with a high fat diet as this increase’s absorption Beta Blockers ● Timolol: treatment of glaucoma Bronchodilators ● Theophylline: Tx of asthma or COPD; therapeutic drug level is 10-20; increases the risk of digoxin toxicity and decreases the effects of lithium and Phenytoin; causes GI upset, give with food CNS Stimulants ● Dexedrine: treatment of ADHD; may alter insulin needs; avoid taking with MAOI's; take in morning (insomnia possible side effect) ● Methylphenidate: Tx of ADHD; assess for heart related side effects, report them immediately; child may need a drug holiday b/c it stunts growth. Digestive Agent ● Pancrealipase: These are pancreatic enzymes, which are to be taken with each meal! Not before, not after, but W/ each meal. Diuretics ● Mannitol (osmotic diuretic): used for Head injuries; it crystallizes at room temp so ALWAYS use filter needle ● Acetazolamide: Tx of glaucoma, & high-altitude sickness; do not take if allergic to sulfa drugs; may cause hypokalemia ● Lasix: Tx of edema due to heart failure; can cause a patient to lose his appetite (anorexia) due to reduced potassium o Patients receiving Lasix and Dig, need to be getting enough potassium, b/c low potassium potentiates Dig Toxicity and can cause dysrhythmias. Hormones ● Levothyroxine: Tx of hypothyroidism, this medication may take several weeks to take effect; notify doctor of chest pain; take in the AM on empty stomach; may cause hyperthyroidism o Insomnia is a side effect of thyroid hormones (Ex: Synthroid) → Increases met. rate, your body is "too busy to sleep" as opposed to the folks with hypothyroidism who may report somnolence (dec. met rate, body is slow and sleepy). ● Conjugated estrogens: treatment occurs after menopause for estrogen replacement Hypokalemic ● Sodium Polystyrene Sulfonate: When giving administering this drug, we need to worry about dehydration (K has inverse relationship with Na) o Don’t use this medication if patient has hypoactive bowel sounds. Opioid Analgesics ● Meperidine <Demerol>: Tx for moderate to severe pain; used for patients with pancreatitis (these patients could NOT receive morphine sulfate); Do not give Demerol to pts. with sickle cell crisis Pediculocides ● Lindane <Antiparasite>: Tx of scabies and lice; o Scabies ~ apply lotion once and leave on for 8-12 hours o Lice ~ use the shampoo and leave on for 4 minutes with hair uncovered then rinse with warm water and comb with a fine-tooth comb Skeletal Muscle Relaxant ● Dantrolene: treatment for spasticity, associated w/ spinal cord injury, stroke, cerebral palsy, or MS; it may take a week or more to be effective. ● succinylcholine: is used for short-term neuromuscular blocking agent for procedures like intubation and ECT. ● Vecuronium Bromide: an adjunct medication for general anesthesia-induced muscle relaxation for endotracheal intubation/mechanical ventilation, it’s used for intermediate or long-term. Statins ● Simvastatin’s: Treatment for hyperlipidemia; take on empty stomach to enhance absorption; report any unexplained muscle pain, especially if fever is present Sympathomimetic ● Dopamine (Intropine): Tx of hypotension, shock, low cardiac output, poor perfusion to vital organs; monitor EKG for arrhythmias, and BP Vasodilators ● Nitroprusside: When the patient is on this medication, monitor thiocyanate (cyanide). The normal value should be 1, >1 is heading toward toxicity Endocrine Diseases Addison’s: hypoNa, hyperK, hypoglycemia, dark pigmentation, decreased resistance to stress, fractures, alopecia, weight loss, GI distress – Addison's disease (need to "add" hormone) Blood pressure is the most important assessment parameter in Addison’s, as it causes severe hypotension. Addisonian Crisis: Nausea & vomiting, confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP Managing stress in a patient with adrenal insufficiency (Addison’s) is paramount, because if the adrenal glands are stressed further it could result in Addisonian crisis. Cushing’s: hyperNatremia, hypoKalemia, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moon-face/buffalo hump – Cushing's syndrome (have extra "cushion" of hormones) Sex Salt Sugar Addison’s ↓ ↓ ↓ Cushing’s ↑ ↑ ↑ OR Addison’s= down, down, down, up, down Cushing’s= up, up, up, down, up Addison’s= hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia Cushing’s= hypernatremia, hypertension, increased blood vol, hypokalemia, hyperglycemia Addison's disease (need to "add" hormone) Cushing's syndrome (have extra "cushion" of hormones) Diabetes Insipidus (decreased ADH): excessive urine output and thirst, dehydration, weakness; administer Vasopressin SIADH (increased ADH): change in LOC, decreased deep tendon reflexes, tachycardia, n/v/a, HA; administer Declomycin, diuretics Hyper-parathyroid: fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium); diet should consist of low Ca, & high phosphorus diet (Calcium and phosphorus has inverse relationship) ● Polyuria is common with the hypercalcemia caused by hyperparathyroidism. Hypo-parathyroid: CATS – convulsions, arrhythmias, tetany, spasms, stridor, & decreased calcium; diet should consist of high Ca, & low phosphorus diet Hyperthyroidism/Graves’ disease: accelerated physical and mental function; sensitivity to heat, fine/soft hair For HYPERthyroidism think of MICHAEL JACKSON in THRILLER! SKINNY, NERVOUS, BULDGING EYES, up all night, heart beating fast Thyroid Storm: is HOT (hyperthermia), ↑ HR, & HTN Hypothyroidism/Myxedema: slowed physical and mental function, sensitivity to cold, hypothermia, dry skin and hair Post-thyroidectomy: Must watch for hypercortisolism and temporary diabetes insipidus. Position the patient in semi-Fowler’s, prevent neck flexion/hyperextension, and have trach at bedside Pheochromocytoma: hypersecretion of too much of epi/norepi, persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding heart; avoid stress, frequent bating and rest breaks, avoid cold and stimulating foods, surgery to remove tumor Pancreatitis: Pt is placed in fetal position, maintain NPO, gut rest, prepare antecubital site for PICC b/c will probably be receiving TPN/Lipids. After pain relief, cough and deep breathe is important because of fluid pushing up in the diaphragm. Hepatitis Hepatitis A = –ends in a VOWEL, comes from the BOWEL (Hep A) Hepatitis B = Blood and Bodily fluids ● Anaphylactic reaction to baker's yeast is contraindication for Hep B vaccine. Hepatitis C = is just like B ● During the acute stage of Hep-A gown and gloves are required. ● In the convalescent stage it is no longer contagious. Eyes & Ears Ears ● Pull pinna down and back for kids < 3 yrs. when instilling eardrops Meniere's Disease ● Tx: Admin diuretics to decrease endolymph in the cochlea ● Nursing Care: restrict Na, lay on affected ear when in bed Triad: 1)Vertigo 2)Tinnitus 3)Nausea & vomiting Strabismus Treatment is BOTOX ● Patch the GOOD eye, so that the weaker eye can get stronger. ● Botox can be used with strabismus to relax vocal cords in spasmodic dysphonia. Eyes OU – Both eyes OS – Left eye OD – Right eye (dominant Right eye – just a tip to remember) General Notes for Eyes ● Assessing extraocular eye movements check cranial nerves 3 (oculomotor), 4 (trochlear), and 6 (Abducens). ● Glaucoma intraocular pressure is greater than the normal (22 mm Hg), give miotic to constrict (pilocarpine), NO ATROPINE ● Apply eye drop to conjunctival sac and afterwards apply pressure to nasolacrimal duct / inner canthus Fluid & Electrolyte Imbalances Hypovolemia (FVD) – increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety, urine specific gravity >1.030. (More U Specificity means urine more concentrated. More particles in urine and less dilution) Hypervolemia (FVE) – bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, hypertension, urine specific gravity <1.010; Semi-Fowler’s Fluid volume overload caused by IVC fluids infusing too quickly and CHF can cause an S3 heart sound. Hyponatremia: nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic diuretics, fluids Hypernatremia (greater than 145: increased temp, weakness, disorientation/delusions, hypotension, tachycardia; hypotonic solution Remember…. Hypernatremia presents similarly to Fluid Volume Deficit Hyponatremia presents similarly to Fluid Volume Excess Remember SALT… Skin flushed Agitation Low grade fever Thirst Hypokalemia: muscle weakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges, beans, potatoes, carrots, celery) No Pee, no K (do not give potassium without adequate urine output) Hyperkalemia: MURDER – Muscle weakness, Urine (oliguria/anuria), Respiratory depression, Decreased cardiac contractility, ECG changes, Reflexes Hypocalcemia <Non sedation>: CATS – convulsions, arrhythmias, tetany, spasms and stridor Hypercalcemia <Sedative effect>: muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, sedative effect on CNS HypoMg <Non sedative effect>: tremors, tetany, seizures, dysrhythmias, depression, confusion, dysphagia; dig toxicity (not enough magnesium, everything goes up) HyperMg <Sedative effect>: depresses the CNS, hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations, emergency (More magnesium, everything goes down) Fundamental Skills Order of Assessment Order of Assessment for Abdomen/Children Inspection Inspection ∙ Bowels Sounds may be obstructed and not Auscultation Auscultation heard, if performed out of order Palpation Percussion Percussion Palpation ∙ In Kids, go from least to most invasive If your normally lucid patient starts seeing bugs you better check his respiratory status first. The first sign of hypoxia is restlessness, followed by agitation, and things go downhill from there all the way to delirium, hallucinations, and coma. So, check the o2 stat, and get ABG’s if possible. The immediate intervention after a sucking stab wound is to dress the wound and tape it on three sides which allows air to escape. Do not use an occlusive dressing, which could convert the wound from open pneumo to closed one, and a tension pneumothorax is worse situation. After that get your chest tube tray, labs, iv. An example of when you would implement before going through a bunch of assessments is when someone is experiencing anaphylaxis. Get the ordered epinephrine in them stat, especially if the stem clearly states the s/s (difficulty breathing, increasing anxiety, etc.) Radioactive iodine – The key word here is flush. Flush substance out of body w/3-4 liters/day for 2 days and flush the toilet twice after using for 2 days. Limit contact w/patient to 30 minutes/day. No pregnant visitors/nurses, and no kids. Role-Relationship Pattern, a nursing diagnosis focused on the person’s roles in the world and relationships with others. To access the role relationship pattern, focus on image, and relationships with others. Bleeding is part of the ‘circulation’ assessment of the ABCD’s in an emergent situation. ● Therefore, if airway and breathing are accounted for, a compound fracture requires assessment before Glasgow Coma Scale and a neuro check (D=disability, or neuro check) Potassium ● The vital sign you should check first with high potassium is pulse (due to dysrhythmias). ● Never give potassium if the patient is oliguric or anuric (because can’t pee out the potassium = hyperkalemia) NG Tube ● An NG tube can be irrigated with cola and should be taught to family when a client is going home with an NG tube. ● An antacid should be given to a mechanically ventilated patient with an NG tube if the pH of the aspirate is <5.0 (because pH is low, acidic) o Aspirate should be checked at least every 12 hrs. Hemovac ● Can be used after mastectomy ● How to Clean/Empty: o Empty when full or q8hr, remove plug, empty contents, place on flat surface, cleanse opening and plug with alcohol sponge, compress evacuator completely to remove air, release plug, check system for operation. Liver ● Liver Biopsy: o Prior to a liver biopsy it's important to be aware of the lab result for prothrombin time o NPO for 6 hrs morning of biopsy, & administer vitamin k (for clotting factors), as well as a sedative o Teach patient that he will be asked to hold breath for 5-10sec, supine position, lateral with upper arms elevated. o Post Op – position on right side, frequent vital signs, report severe abdominal pain stat, no heavy lifting 1 week. ● A patient with liver cirrhosis and edema may ambulate, then sit with legs elevated to try to mobilize the edema. ● For esophageal varices, a Sengstaken Blakemore tube is used, keep scissors at bedside (to cut the tube in an emergency situation) - U world question!!! ● Tylenol poisoning – liver failure possible for about 4 days. Close observation required during this timeframe, as well as treatment with Mucomist (Tylenol/acetaminophen antidote). Paracentesis: (removing a ton of fluid from abdomen from liver failure) ● Pre-Op – The patient should empty their bladder ● Post Op – Vital signs, report elevated temperature (for infection), observe for signs of hypovolemia. MRI ● Claustrophobia ● No metal ● Assess pacemaker Laparoscopy - (fiber-optic instrument is inserted through the abdominal wall to view the organs in the abdomen or to permit a surgical procedure) ● CO2 used to enhance visual ● General anesthesia is administered, and a foley is inserted ● Post Op – Walk w/ patient to decrease CO2 build up used for procedure. Compartment Syndrome ~ an EMERGENCY situation ● Paresthesia and increased pain are classic symptoms!!!! <No relief from Opioids> ● Neuromuscular damage is irreversible, 4-6 hours after onset General Notes ● For patients with Halo device; Remember safety first & have a screwdriver nearby. (Keep the pins infection free) ● Iatrogenic means it was caused by treatment, procedure, or medication. ● A 3-way occlusive dressing is used if a chest tube is accidentally pulled out of the patient. ● Cultures are obtained before starting IV antibiotics!!!! (what would you do first!?!) ● Orthostatic hypertension is verified by a drop-in pressure with increasing heart rate ● You will ask every new admission if he has an advance directive, and if not, you will explain it, and he will have the option to sign or not. ● A guy loses his house in a fire. Priority is using community resources to find shelter, before assisting with feelings about the tremendous loss. – (Maslow) ● No nasotracheal suctioning with head injury or skull fracture (increases intracranial pressure!!!) ● Feed upright to avoid otitis media. ● Water intoxication will be evidenced by drowsiness, and altered mental status, in patients with TURP syndrome, or as an adverse reaction to desmopressin (for diabetes insipidus). ● Other than initially to test tolerance, G-tube and J-tube feedings are usually given as continuous feedings. ● Four side-rails up can be considered a form of restraint. Even in LTC (long term care) facility when a client is a fall risk, keep lower rails down, and one side of bed against the wall, lowest position, wheels locked. Gastrointestinal Dumping syndrome: increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis, wait 1 hr after meals to drink!!!!! (know!!!) Weighted NI (Naso intestinal tubes) must float from stomach to intestine. Don't tape the tube right away after placement, may leave coiled next to patient on head of bed. Position patient on RIGHT to facilitate movement through pylorus. After g-tube placement the stomach contents are drained by gravity for 24 hours before it can be used for feedings. Stomach ● Mucus in ileal conduit is expected. ● Dusky Stoma = Poor blood supply ● Protruding = Prolapsed ● Sharp pain Rigidity = Peritonitis General Notes ● Don’t fall for ‘reestablishing a normal bowel pattern’ as a priority with small bowel obstruction. Because the patient can’t take in oral fluids, ‘maintaining fluid balance’ comes first. “think ABC’s!!” ● Gastric Ulcer pain occurs 30 minutes to 90 minutes after eating, not at night, and doesn't go away with food. Duodenal ulcer pain goes away with food. ● Cushing’s ulcers related BRAIN injury & increased intracranial pressure. ● When you see Coffee-brown emesis, think peptic ulcer. ● Patients should not have cantaloupe before an occult stool test; because cantaloupe is high in both vitamin C, which causes a false positive for occult blood! Glasgow Coma Scale – Eyes, Verbal, Motor Remember… < than 8 intubate It is similar to measuring dating skills...max 15 points -one can do it if below 8 you are in Coma. EYES: So, to start dating you got to open your EYES first, if you able to do that spontaneously and use them correctly to SEE whom you dating you earn 4. But if she has to scream on you to make you
open them it is only 3....and 1 you don’t care to open even if she tries to hurt you. VERBAL: If you get good EYE contact (4 points) then move to VERBAL. Talk to her/ him! If you can do that You are really ORIENTED in
situation she/he unconsciously gives you 4 points! if you like her try not to be CONFUSED (3), and of course do not use INAPPROPRIATE WORDS (3), she will not like it, try not to RESPOND WITH INCOMPREHENSIBLE SOUNDS (2), if you do not like her –
just show no VERBAL RESPONSE(1) MOTOR: Since you've got EYE and VERBAL contact you can MOVE now using your Motor Response Points. This is VERY important since Good moves give you 6! Decorticate is toward the 'core'. Decerebrate the other way (out). Decorticate positioning in response to pain = Cortex involvement Decerebrate in response to pain = Cerebellar, brain stem involvement (this is the worst one) Hallmark Signs of Symptoms 01. Pulmonary TB (pulm-TB) – low-grade afternoon fever.
 02. PNEUMONIA – rusty sputum or pink frothy sputum. 03. ASTHMA – wheezing on expiration. 04. EMPHYSEMA – barrel chest. 05. KAWASAKI SYNDROME – strawberry tongue. 06. PERNICIOUS ANEMIA – red beefy tongue (need vitamin B12). 07. DOWN SYNDROME – protruding tongue. 08. CHOLERA – rice watery stool. 09. MALARIA – step ladder like fever with chills. 10. TYPHOID – rose spots in abdomen. 11. DIPTHERIA (infection of nose and throat)– pseudo membrane formation 12. MEASLES – Koplick’s spots are red spots with blue center, usually in the mouth 13. Systemic Lupus E – butterfly rashes. 14. LIVER CIRRHOSIS – spider like varices. 15. LEPROSY – leonine face (skin lesions and nerve damage) 16. BULIMIA – chipmunk face. 17. APPENDICITIS – rebound tenderness. 18. DENGUE (fever from mosquitos) - petechiae or ( ) Herman’s sign. 19. MENINGITIS – Kernig’s sign (leg flex then leg pain on extension), Brudzinski sign (neck flex = lower leg flex). 20. TETANY – hypocalcemia ( ) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm). 21. TETANUS – risus sardonicus (grinning facial spasm). 22. PANCREATITIS – Cullen’s sign (ecchymosis of umbilicus); ( ) Grey turner's spots. 23. PYLORIC STENOSIS – olive like mass. 24. PDA – machine like murmur. 25. ADDISON’S DISEASE – bronze like skin pigmentation. 26. CUSHING’S SYNDROME – moon face appearance and buffalo hump. 27. HYPERTHYROIDISM/GRAVE’S DISEASE – exophthalmos. 28. INTUSSUSCEPTION – sausage shaped mass, Dance Sign (empty portion of RLQ) 29. Multiple Sclerosis – Charcot’s Triad (IAN)- nystagmus, intention tremor, and scanning or staccato speech. 30. Multi-Gravitis – descending muscle weakness 31. Guillain Barre Syndrome – ascending muscle weakness 32. DVT – Homan’s Sign 33. CHICKEN POX – Vesicular Rash (central to distal) dew drop on rose petal 34. ANGINA – Crushing stabbing pain relieved by NTG 35. MI – Crushing stabbing pain which radiates to left shoulder, neck, arms, unrelieved by NTG 36. Latent TB (latent-TB) – inspiratory stridor 37. TEF (trach-esoph-fist) – 4Cs’ Coughing, Choking, Cyanosis, Continuous Drooling 38. EPIGLOTTITIS – 3Ds’ Drooling, Dysphonia, Dysphagia 39. HODGKIN'S DSE/LYMPHOMA – painless, progressive enlargement of spleen & lymph tissues, Reed Sternberg Cells 40. INFECTIOUS MONONUCLEOSIS – Hallmark: sore throat, cervical lymphadenopathy, fever 41. PARKINSON’S – Pill-rolling tremors 42. FIBRIN HYALIN – Expiratory Grunt 43. CYSTIC FIBROSIS – Salty skin 44. DM – polyuria, polydipsia, polyphagia 45. DKA – Kussmaul's breathing (Deep Rapid RR) 46. BLADDER CA – painless hematuria 47. BPH – reduced size & force of urine 48. PEMPHIGUS VULGARIS – Nikolsky’s sign (separation of epidermis caused by rubbing of the skin) 49. RETINAL DETACHMENT – Visual Floaters, flashes of light, curtain vision 50. GLAUCOMA – Painful vision loss, tunnel/gun barrel/halo vision (Peripheral Vision Loss) 51. CATARACT – Painless vision loss, Opacity of the lens, blurring of vision 52. RETINOBLASTOMA – Cat’s eye reflex (grayish discoloration of pupils) 53. ACROMEGALY – Coarse facial feature (too much growth hormone) 54. DUCHENNE’S MUSCULAR DYSTROPHY – Gowers’ sign (use of hands to push one’s self from the floor) 55. GERD – Barrett's esophagus (erosion of the lower portion of the esophageal mucosa) 56. HEPATIC ENCEPHALOPATHY – Flapping tremors 57. HYDROCEPHALUS – Bossing sign (prominent forehead) 58. INCREASE ICP – HYPERtension BRADYpnea BRADYcardia (Cushing’s Triad) 59. SHOCK – HYPOtension TACHYpnea TACHYcardia 60. MENIERE’S Disease – Vertigo, Tinnitus 61. CYSTITIS – burning on urination 62. HYPOCALCEMIA – Chvostek & Trousseaus sign 63. ULCERATIVE COLITIS – recurrent bloody diarrhea 64. LYME’S Disease – Bull’s eye rash 65. Basilar Fracture – Otorrhea 66. Orbital Fracture – Battle signs & Raccoon’s Eye Immunology Sepsis and anaphylaxis (along with the obvious hemorrhaging) reduce circulating volume by way of increased capillary permeability, which leads to reduced preload (volume in the left ventricle at the end of diastole). Allergies ● Basophils release histamine during an allergic response. ● Latex allergies → Assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes, peaches ● Prior to a CT scan, assess for allergies Immunizations ● Ask for allergy to eggs before Flu shot ● Age 4 to 5 yrs child needs DPT/MMR/OPV (OPV = Polio vaccine) ● If kid has cold, can still give immunizations ● MMR and Varicella immunizations come later, around 15 months. ● MMR o The MMR vaccine is given SQ not IM. o Ask for anaphylactic reaction to eggs or neomycin before MMR vaccine ● For HIV kids avoid OPV and Varicella vaccinations (live) but give Pneumococcal and influenza. o MMR is avoided only if the kid is severely immunocompromised. ● Pneumovax 23 gets administered post splenectomy to prevent pneumococcal sepsis. ● kids can get vaccines if they have mild illness (fever <101, cold, ear infection, mild diarrhea) but should be related signs and symptoms, if it is moderate-severe. ok if they are taking antibiotics but not antivirals! Leadership If one nurse discovers another nurse has made a mistake it is always appropriate to speak to her before going to management. If the situation persists, then take it higher. Delegation DO NOT delegate what you can EAT! E – evaluate A – assess T - teach Rules for Delegation RN ASSIGNMENT ● Cannot delegate assessment, teaching, or nursing judgement LPN/LVN ASSIGNMENT ● Assign stable with expected outcomes UAP ASSIGNMENT ● Delegate standard, unchanging procedures Five Rights of Delegation RIGHT TASK – scope of practice, stable client RIGHT CIRCUMSTANCES – workload RIGHT PERSON – scope of practice RIGHT COMMUNICATION – specific task to be performed, expected results, follow-up communication RIGHT SUPERVISION – clear directions, intervene if necessary Maternity/Women’s Health Fetal Heart Rate Pattern Etiology V Variable Decels C Cord compression E Early Decels H Head compression A Accels O Okay, not a problem L Late Decels P Placental Insufficiency A= appearance (color all pink, pink and blue, blue [pale]) P= pulse (>100, < 100, absent) G= grimace (cough, grimace, no response) A= activity (flexed, flaccid, limp) R= respirations (strong cry, weak cry, absent) APGAR measures Skin color, HR, Reflexes, Muscle tone, RR; each section is scored between 0-2 points. 0–3 = Severely Depressed (RESUSCITATE) 4–6 = Moderately Depressed 7 –10 = Excellent (OK) Fetal alcohol syndrome -Upturned nose -Thin upper lip 1. ABCs (Airway, Breathing, Circulation) 2. When in distress DO NOT ASSESS! Unless 2nd hand information is received. -Flat nasal bridge -Small for Gestational Age Rhogam Factor ● Given at 28 weeks, 72 hours postpartum, IM. ● Only given to Rh NEGATIVE mother. ● If indirect Combs’ test is positive, don’t need to give Rhogam, because the mother already has the antibody ● Only administer if coombs’ test result is negative General Notes ● When a patient comes in and she is in active labor, the nurse’s first action is to listen to fetal heart tone/rate ● One way to remember which type of measles [regular measles (rubeola) or German measles (rubella)] is dangerous to pregnant mothers ~ Never get pregnant with a German (rubella) ● Placental abruptio: bleeding with pain, don't forget to monitor volume status (I&O) ● If a laboring mom’s water breaks and she is any minus station, must better know there is a risk of prolapsed cord. (because baby is inside above ischial spine and can compress the cord) ● For cord compression, place the mother in the TRENDELENBURG position because this removes pressure of the presenting part off the cord. (If her head is down, the baby is no longer being pulled out of the body by gravity) or hands and knees position. ● If the cord is prolapsed, cover it with sterile saline gauze to prevent drying of the cord and to minimize infection. ● For late decelerations, turn the mother to her left side, to allow more blood flow to the placenta (because late decelerations = placenta deficiency) ● For any kind of bad fetal heart rate pattern, you give O2, often by mask ● When doing an epidural anesthesia, hydration before-hand is a priority (because causes hypotension). ● Hypotension and bradypnea / bradycardia are major risks and emergencies. ● NEVER check the monitor or a machine as a first action. Always assess the patient first!! o For example: listen to the fetal heart tones with a stethoscope in NCLEX land. ● Sometimes it's hard to tell who to check on first, the mother or the baby; it's usually easy to tell the right answer if the mother or baby involves a machine. If you're not sure who to check first, and one of the choices involves the machine, that's the wrong answer. ● If the baby is in a posterior presentation, the sounds are heard at the sides. ● If the baby is anterior, the sounds are heard closer to midline, between the umbilicus and where you would listen to a posterior presentation (because anterior is in front/close to midline) ● If the baby is breech, the sounds are high up in the fundus near the umbilicus (because head is up, feet down first) ● If the baby is vertex, they are a little bit above the symphysis pubis. (vertex= head first, so breath sounds right above pubis bone) ● Best way to warm a newborn: skin to skin contact covered with a blanket on mom. ● Amniotic fluid is alkaline and turns nitrazine paper blue. Urine and normal vaginal discharge are acidic and turn it pink. Pink for acid and Blue for Alkaline. ● Amniotic fluid yellow with particles = meconium stained ● Cephalohematoma (caput succedaneum) resolves on its own in a few days. This is the type of edema that crosses the suture lines. ● The biggest concern with cold stress and the newborn is respiratory distress! ● Glucose Tolerance Test for preggies, a result of 140 or higher needs further evaluation. Medical (Diagnostic) Signs Murphy’s sign – pain with palpation of gallbladder area seen with cholecystitis Cullen’s sign – ecchymosis in umbilical area, seen with pancreatitis Turner’s sign – flank grayish blue (turn around to see your flanks) pancreatitis McBurney’s Point – RLQ pain indicative of appendicitis LLQ Pain – diverticulitis , low residue, no seeds, nuts, peas RLQ Pain – appendicitis, watch for peritonitis Guthrie Test – Tests for PKU, baby should have eaten source of protein first Allen’s test – Occlude both ulnar and radial artery until hand blanches then release ulnar. If the hand pinks up, ulnar artery is good, and you can carry on with ABG/radial stick as planned. ABGS must be put on ice and whisked to the lab.
 Trendelenburg Test – A tests for varicose veins. Pt is supine, and the leg is flexed at the hip and raised above the level of the heart. The veins will empty due gravity or with assistance from the examiner’s hand squeezing blood towards the heart → If they fill proximally = varicosity. Babinski Sign – Assessment for nervous system problems. Toes curl = - sign |Normal in adults & kids above 2 yrs| Abnormal in kids 2 yrs & under Toes fan = sign |Abnormal in adults & kids above 2 yrs| Normal in kids 2 yrs & under Mental Health Remember with Psych patients, SAFETY is the #1 Priority Munchausen Syndrome is a psychiatric disorder that causes an individual to self-inflict injury or illness or to fabricate symptoms of physical or mental illness, in order to receive medical care or hospitalization. In a variation of the disorder, Munchausen by proxy (MSBP), an individual, typically a mother, intentionally causes or fabricates illness in a child or other person under her care. Neuroleptic malignant syndrome (NMS): ~ rxn to antipsychotic medications -NMS is like S&M; -you get hot (hyperpyrexia) -stiff (increased muscle tone) -sweaty (diaphoresis) -BP, pulse, and respirations go up & -you start to drool General Notes ● Tardive Dyskinesia – irreversible – involuntary movements of the tongue, face and extremities, may happen after prolonged use of antipsychotics ● Depression often manifests itself in somatic ways, such as psychomotor retardation, GI complaints, and pain. ● For phobic disorders, use systematic desensitization. ● Safety over Nutrition with a severely depressed client. ● Absence of menstruation leads to osteoporosis in the anorexic. Musculoskeletal/Neurological ICP AND SHOCK HAVE OPPOSITE V/S Shock Cushing’s Triad (r/t to ICP in Brain) Blood Pressure ↓ ↑ (Widening Pulse Pressure - ↑ Systolic/ ↓ Diastolic) Pulse ↑ ↓ Respirations ↑ ↓ (Cheyne-Stokes or Irregular Respirations) Amyotrophic Lateral Sclerosis (ALS) is a condition in which there is a degeneration of motor neurons in both the upper & lower motor neuron systems. Autonomic Dysreflexia: potentially life-threatening emergency – Symptoms: HTN, Bradycardia, Pounding H/A, Severe Nasal Congestion – Elevate head of bed to 90 degree – Loosen constrictive clothing – Assess for bladder distention and bowel impaction (trigger) <TREAT THEM> – Administer antihypertensive meds (may cause stroke, MI, seizure) Multiple Sclerosis is a chronic, progressive disease with demyelinating lesions in the CNS which affect the white matter of the brain and spinal cord. Hyperactive deep tendon reflexes, vision changes, fatigue and spasticity are all symptoms of MS Motor S/S: limb weakness, paralysis, slow speech Sensory S/S: numbness, tingling, tinnitus Cerebral S/S: nystagmus, ataxia, dysphagia, dysarthria Myasthenia gravis is caused by a disorder in the transmission of impulses from nerve to muscle cell; worsens with exercise and improves with rest. ● Give neostigmine to pts w/ MG about 45 min before eating, so it can help w/ chewing & swallowing. Myasthenia Crisis: it’s used to confirm the diagnosis; a positive reaction to Tensilon – will improve symptoms Cholinergic Crisis: caused by excessive medication-stop med-giving Tensilon will make it worse Huntington's Chorea: 50% genetic, autosomal dominant disorder S/S: chorea → writhing, twisting, movements of face, limbs and body –gait deteriorates to no ambulation –no cure, just palliative care Myelogram ● Pre-Op – NPO 4-6hr, assess hx of allergies, the table will be moved to various positions during test, the following meds are withheld 48hr prior; phenothiazines, CNS depressants, and stimulants ● Post Op – Neuro checks q2-4 hrs, water soluble HOB up, oil soluble HOB down, oral analgesics for h/a, encourage PO fluids, assess for distended bladder, inspect site. Electroencephalography (EEG) ● Pre-Op – 24-48 hrs prior holds meds (especially tranquilizers and stimulants), no caffeine or cigarettes (i.e. stimulants) for 24 hrs prior, meals not withheld, no sleep the night before, pt may be asked to hyperventilate for 3-4 min and watch a bright flashing light ● Post Op – Assess pt for possible seizures, since they’re not at greater risk Cerebral Angiogram ● Pre-Op – well hydrated, lie flat, site shaved, check pulses marked ● Post Op – keep flat for 12-14hr, check site, check pulses, force fluids. Meningeal Irritation S/S ● Nuchal rigidity ● Positive Brudzinski Kernig signs ● PHOTOPHOBIA General Notes ● Lumbar Puncture Post Op – Neuro assessments q15-30 until stable, pt lays flat for 2-3hr, encourage fluids, oral analgesics for headache, observe dressing ● CSF in meningitis will have high protein, and low glucose. ● Decreased acetylcholine is related to senile dementia. ● Level of consciousness is the most important assessment parameter with status epilepticus. ● Hyper reflexes (upper motor neuron issue “your reflexes are over the top”) ● Absent reflexes (lower motor neuron issue)
 Nutrition Fat Soluble Vitamins are A, D, E, K General Notes ● Be wary of questions regarding children drinking too much milk i.e. more than 3-4 cups of milk each day. Too much milk intake reduces intake of other essential nutrients, especially iron. Watch for anemia with milk-aholics. ● Vitamin D’s presence is required by the parathyroid gland, in order for it to function. ● If the patient is taking digoxin or K-supplements, avoid salt substitutes because many are potassium based ● Potassium Sources: bananas, potatoes, citrus fruits ● No milk (as well as fresh fruit or veggies) on neutropenic precautions.
 ● Nondairy sources of calcium include RHUBARB, SARDINES, COLLARD GREENS ● Nonfat milk reduces reflux by increasing lower esophageal sphincter pressure ● Yogurt has live cultures, so do not give to immunosuppressed patients ● No phenylalanine with a kid positive for PKU (no meat, no dairy, no aspartame). ● Acid Ash diet: cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread ● Alk Ash diet: milk, veggies, rhubarb, salmon Ortho Casts: ● You can petal the rough edges of a plaster cast with tape to avoid skin irritation. ● Itching under cast area- cool air via blow dryer, ice pack for 10- 15 minutes. NEVER use Qtip or anything to scratch area Walking Devices COAL (cane walking): C – Cane O – Opposite A – Affected L – Leg The cane always moves before the weaker leg. When ascending stairs w/ a cane: 1 – Step up with the stronger leg first 2 – Move the cane next while bearing weight on the stronger leg 3 – Finally, move the weaker leg When descending stairs w/ a cane: 1. Lead with the cane 2. Bring the weaker leg down next 3. Finally, step down with the stronger leg Mnemonic – “Up with the good and down with bad.” ● Remember the phrase “step up” when picturing a person going up stairs with crutches. The good leg goes up first, followed by the crutches and then the bad leg. The opposite happens going down. The crutches go first, followed by the good leg. ● Place a wheelchair parallel to the bed on the side of weakness SIGNS of a Fractured hip ● EXTERNAL ROTATION ● SHORTENING ● ADDUCTION Paget's Disease S/S ● Tinnitus ● bone pain ● enlarged/thick bones General Notes ● Never release traction UNLESS you have an order from the MD to do so ● Osteomyelitis is an infectious bone disease → get blood cultures & antibiotics, then if necessary → surgery to drain abscess. ● Pain is usually the highest priority with RA ● Swimming is a great exercise for Arthritis ● William's position - Semi Fowlers with knees flexed (Inc. knee gatch) to relieve lower back pain. o With low back aches, bend knees to relieve ● Greenstick fractures, usually seen in kids bone breaks on one side and bends on the other Patient Positioning 1. Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending doom) → turn pt to left side and lower the head of the bed. 2. Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal bradycardia, etc) → turn on left side (and give O2, stop Pitocin, increase IV fluids) 3. Tube Feeding w/ Decreased LOC → position pt on right side (promotes emptying of the stomach) with the HOB elevated (to prevent aspiration) 4. During Epidural Puncture → side-lying 5. After Lumbar Puncture (and also oil-based Myelogram) → pt lies in flat supine (to prevent headache and leaking of CSF) for 4 to 12 hrs or 2 to 3 hrs as prescribed. Dressings must be kept sterile & frequent neuro assessments should be performed 6. Pt w/ Heat Stroke → lie flat w/ legs elevated (to get fluid to go to head to correct hypotension) 7. During Continuous Bladder Irrigation (CBI) → catheter is taped to thigh so leg should be kept straight. No other positioning restrictions. 8. After Myringotomy (surgical incision into the eardrum, to relieve pressure or drain fluid). → position on side of affected ear after surgery (allows drainage of secretions) 9. After Cataract Surgery → pt will sleep on unaffected side with a night shield for 1-4 weeks. 10. After Thyroidectomy → low or semi-Fowler’s, support head, neck and shoulders. 11. Infant w/ Spina Bifida → position prone (on abdomen) so that sac does not rupture 12. Buck’s Traction (skin traction) → elevate foot of bed for counter-traction 13. After Total Hip Replacement → don’t sleep on operated side, don’t flex hip more than 45- 60 degrees, don’t elevate HOB more than 45 degrees. Maintain hip abduction by separating thighs with pillows (use a wedge pillow) 14. Prolapsed Cord → knee-chest position or Trendelenburg 15. Infant w/ Cleft Lip → position on back or in infant seat to prevent trauma to suture line. While feeding, hold in upright position. 16. To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) → eat in reclining position or Low-fowlers (so food doesn’t empty and dump so fast), lie down after meals for 20-30 minutes (also restrict fluids during meals, low cholesterol and fiber diet, small frequent meals) 17. Above Knee Amputation → elevate for first 24 hours on pillow, position prone daily to provide for hip extension. 18. Below Knee Amputation → foot of bed elevated for first 24 hours; position prone daily to provide for hip extension. 19. Detached Retina → area of detachment should be in the dependent position 20. Administration of Enema → position pt in left side-lying (Sim’s) with knee flexed 21. After Supratentorial Surgery (incision behind hairline) → elevate HOB 30-45 degrees 22. After Infratentorial Surgery (incision at nape of neck) → position pt flat and lateral on either side. 23. During Internal Radiation → on bedrest while implant in place 24. Autonomic Dysreflexia/Hyperreflexia (S&S: pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia, hypertension) → place client in sitting position (elevate HOB) first before any other implementation 25. Shock → bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified Trendelenburg) 26. Head Injury → elevate HOB 30 degrees to decrease intracranial pressure 27. Peritoneal Dialysis when Outflow is Inadequate → turn pt from side to side BEFORE checking for kinks in tubing (reposition patient, to see if it affects the flow and output of the catheter!) 28. During a lumbar puncture → The patient is positioned in lateral recumbent fetal position 29. Lung Biopsy → Position the patient lying on the side of the bed or with arms raised up on pillows over bedside table, have the patient hold their breath in mid expiration, chest x-ray done immediately afterwards to check for complication of pneumothorax, sterile dressing applied 30. Pt w/ GERD → Patient should be lying prone on their left side, with HOB elevated 30 degrees 31. Pt w/ Pancreatitis → Patient should be place in Fetal position!! 32. After Appendectomy → Position the patient on the right side with legs flexed. (Puts pressure where appendix was) 33. Pt w/ Pneumonia → Lay the pt on the affected side to splint and reduce pain. If attempting to reduce congestion, the congested lung goes up. 34. Infant Position while Asleep → To prevent SIDS, the infant lays on their back while asleep, in a bare crib. 35. During Paracentesis → Patient should be semi-fowlers, or upright on the edge of the bed. 36. During Thoracentesis → Patient position patient with arms on pillow on over bed table or lying on side Hemoglobin Neonates 18 – 27 3 Months 10.6 – 16.5 3 yrs 9.4 – 15.5 10 yrs 10.7 – 15.5 Pediatrics Injection Sites IM ∙ Vastus Lateralis for 6 months infants