DO NOT delegate what you can EAT!
E - evaluate
A - assess
T – teach
Addison‟s disease= down, down down up down
Cushing‟s disease= up up up down up
Addison‟s= hyponatremia, hypotension, decreased blood volume, hyperkalemia, hypoglycemia
Cushing‟s= hypernatremia, hypertension, increased blood volume, hypokalemia, hyperglycemia
No Pee, no K (do not give potassium without adequate urine output)
Elevate Veins; dangle Arteries for better perfusion
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)
TRANSMISSION-BASED PRECAUTIONS:
AIRBORNE
My - Measles
Chicken - Chicken Pox/Varicella
Hez - Herpes Zoster/Shingles
TB
or remember...
MTV=Airborne
Measles
TB
Varicella-Chicken Pox/Herpes Zoster-Shingles
- Private Room - negative pressure with 6-12 air exchanges/hr
- Mask, N95 for TB
DROPLET
think of SPIDERMAN!
S - sepsis
S - scarlet fever
S - streptococcal pharyngitis
P - parvovirus B19
P - pneumonia
P - pertussis
I - influenza
D - diphtheria (pharyngeal)
E - epiglottitis
R - rubella
,M - mumps
M - meningitis
M - mycoplasma or meningeal pneumonia
An - Adenovirus
- Private Room or cohort
- Mask
CONTACT PRECAUTION
MRS.WEE
M - multidrug resistant organism
R - respiratory infection
S - skin infections *
W - wound infxn
E - enteric infxn - clostridium dificile
E - eye infxn - conjunctivitis
SKIN INFECTIONS
VCHIPS
V - varicella zoster
C - cutaneous diphtheria
H - herpes simplex
I - impetigo
P - pediculosis
S – scabies
Diagnostic Tests and Examinations
1. Air/Pulmonary Embolism
a. (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
a. (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)
6. Pt w/ Heat Stroke
--> Lie flat w/ legs elevated
7. During Continuous Bladder Irrigation (CBI)
--> Catheter is taped to thigh so leg should be kept straight. No other positioning
restrictions.
8. After Myringotomy
--> Position on side of affected ear after surgery (allows drainage of secretions)
2
,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, and don‟t
elevate HOB more than 45 degrees. Maintain hip abduction by separating thighs
with pillows.
14. Prolapsed Cord
--> Knee-chest position or Trendelenberg
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; lie down after meals for 20-30 minutes (also restrict
fluids during meals, low CHO 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 bed rest while implant in place
24. Autonomic Dysreflexia/Hyperreflexia
3
, (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
--> Bed rest with extremities elevated 20 degrees, knees straight, head slightly
elevated (modified Trendelenberg)
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 (according to
Kaplan)
28. Lumbar puncture
=> AFTER the procedure, the client should be placed in the supine position for 4 to
12 hrs as prescribed. (Saunders 3rd ed p. 229)
Demerol for pancreatitis, NOT morphine sulfate
Myasthenia Gravis: worsens with exercise and improves with rest.
Myasthenia Crisis: a positive reaction to Tensilon--will improve symptoms
Cholinergic Crisis: caused by excessive medication-stop med-giving Tensilon will make it worse
Head injury medication: Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use
filter needle
Prior to a liver biopsy its important to be aware of the lab result for prothrombin time
From the a** (diarrhea)= metabolic acidosis
From the mouth (vomitus)=metabolic alkalosis
HESI Medical Surgical Nursing
Myxedema/hypothyroidism: slowed physical and mental function, sensitivity to cold, dry skin
and hair
Graves‟ disease/hyperthyroidism: accelerated physical and mental function; sensitivity to
heat, fine/soft hair
Thyroid storm: increased temp, pulse and HTN
Post-thyroidectomy: semi-Fowler‟s, prevent neck flexion/hyperextension, trache at bedside
Hypo-parathyroid: CATS – convulsions, arrhythmias, tetany, spasms, stridor (decreased
calcium), high Ca, low phosphorus diet
4
E - evaluate
A - assess
T – teach
Addison‟s disease= down, down down up down
Cushing‟s disease= up up up down up
Addison‟s= hyponatremia, hypotension, decreased blood volume, hyperkalemia, hypoglycemia
Cushing‟s= hypernatremia, hypertension, increased blood volume, hypokalemia, hyperglycemia
No Pee, no K (do not give potassium without adequate urine output)
Elevate Veins; dangle Arteries for better perfusion
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)
TRANSMISSION-BASED PRECAUTIONS:
AIRBORNE
My - Measles
Chicken - Chicken Pox/Varicella
Hez - Herpes Zoster/Shingles
TB
or remember...
MTV=Airborne
Measles
TB
Varicella-Chicken Pox/Herpes Zoster-Shingles
- Private Room - negative pressure with 6-12 air exchanges/hr
- Mask, N95 for TB
DROPLET
think of SPIDERMAN!
S - sepsis
S - scarlet fever
S - streptococcal pharyngitis
P - parvovirus B19
P - pneumonia
P - pertussis
I - influenza
D - diphtheria (pharyngeal)
E - epiglottitis
R - rubella
,M - mumps
M - meningitis
M - mycoplasma or meningeal pneumonia
An - Adenovirus
- Private Room or cohort
- Mask
CONTACT PRECAUTION
MRS.WEE
M - multidrug resistant organism
R - respiratory infection
S - skin infections *
W - wound infxn
E - enteric infxn - clostridium dificile
E - eye infxn - conjunctivitis
SKIN INFECTIONS
VCHIPS
V - varicella zoster
C - cutaneous diphtheria
H - herpes simplex
I - impetigo
P - pediculosis
S – scabies
Diagnostic Tests and Examinations
1. Air/Pulmonary Embolism
a. (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
a. (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)
6. Pt w/ Heat Stroke
--> Lie flat w/ legs elevated
7. During Continuous Bladder Irrigation (CBI)
--> Catheter is taped to thigh so leg should be kept straight. No other positioning
restrictions.
8. After Myringotomy
--> Position on side of affected ear after surgery (allows drainage of secretions)
2
,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, and don‟t
elevate HOB more than 45 degrees. Maintain hip abduction by separating thighs
with pillows.
14. Prolapsed Cord
--> Knee-chest position or Trendelenberg
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; lie down after meals for 20-30 minutes (also restrict
fluids during meals, low CHO 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 bed rest while implant in place
24. Autonomic Dysreflexia/Hyperreflexia
3
, (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
--> Bed rest with extremities elevated 20 degrees, knees straight, head slightly
elevated (modified Trendelenberg)
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 (according to
Kaplan)
28. Lumbar puncture
=> AFTER the procedure, the client should be placed in the supine position for 4 to
12 hrs as prescribed. (Saunders 3rd ed p. 229)
Demerol for pancreatitis, NOT morphine sulfate
Myasthenia Gravis: worsens with exercise and improves with rest.
Myasthenia Crisis: a positive reaction to Tensilon--will improve symptoms
Cholinergic Crisis: caused by excessive medication-stop med-giving Tensilon will make it worse
Head injury medication: Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use
filter needle
Prior to a liver biopsy its important to be aware of the lab result for prothrombin time
From the a** (diarrhea)= metabolic acidosis
From the mouth (vomitus)=metabolic alkalosis
HESI Medical Surgical Nursing
Myxedema/hypothyroidism: slowed physical and mental function, sensitivity to cold, dry skin
and hair
Graves‟ disease/hyperthyroidism: accelerated physical and mental function; sensitivity to
heat, fine/soft hair
Thyroid storm: increased temp, pulse and HTN
Post-thyroidectomy: semi-Fowler‟s, prevent neck flexion/hyperextension, trache at bedside
Hypo-parathyroid: CATS – convulsions, arrhythmias, tetany, spasms, stridor (decreased
calcium), high Ca, low phosphorus diet
4
