ATI comprehensive

Created by josie_peebles 

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Do not delegate

What you can EAT E-evaluate A-assess T-teach

Addison's & Cushings

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?

EleVate Veins, DAngle Arteries

APGAR

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

My chicken hez tb (measles, chickenpox (varicella) Herpes zoster/shingles TB

Airborne precautions protective equip

private room, neg pressure with 6-12 air exchanges/hr mask N95 for TB

Droplet precautions

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

MRS WEE
Multidrug resistant organism
Rresiratory infection
Skin infection
Wound infection
Enteric infection (C diff)
Eye infection (conjunctivitis)

Skin infection

VCHIPS
Varicella zoster
Cutaneous diptheria
Herpes simplez
Impetigo
Peduculosis
Scabies

Air or Pulmonary Embolism

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)

(late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids!

Tube feeding with decreased LOC

Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration)

After lumbar puncture and oil based myelogram

pt is flat SUPINE (prevent headache and leaking of CSF)

Pt with heat stroke

flat with legs elevated

during Continuous Bladder Irrigation (CBI)

catheter is taped to the thigh. leg must be kept straight.

After Myringotomy

position on the side of AFFECTED ear, allows drainage.

After Cateract surgery

pt sleep on UNAFFECTED side with a night shield for 1-4 weeks

after Thyroidectomy

low or semi-fowler's position, support head, neck and shoulders.

Infant with Spina Bifida

Prone so that sac does not rupture

Buck's Traction (skin)

elevate foot of bed for counter traction

After total hip replacement

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

Knee to chest or Trendelenburg

Cleft Lip

position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position.

To prevent dumping syndrome

(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)

elevate for first 24 hours on pillow. position prone daily to maintain hip extension.

BKA (below knee amputation)

foot of bed elevated for first 24 hours. position prone to provide hip extension.

detached retina

area of detachment should be in the dependent position

administration of enema

pt should be left side lying (Sim's) with knee flexed.

After supratentorial surgery

(incision behind hairline on forhead) elevate HOB 30-40 degrees

After infratentorial surgery

(incision at the nape of neck) position pt flat and lateral on either side.

During internal radiation

on bed rest while implant in place

Autonomic Dysreflexia/Hyperreflexia

S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST!

Shock

bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg)

Head Injury

elevate HOB 30 degrees to decrease ICP

Peritoneal Dialysis (when outflow is inadequate)

turn pt from side to side BEFORE checking for kinks in tubing

Lumbar Puncture

After the procedure, the pt should be supine for 4-12 hours as prescribed.

Myesthenia Gravis

worsens with exercise and improves with rest

Myesthenia Gravis

a positive reaction to Tensilon---will improve symptoms

Cholinergic Crisis

Caused by excessive medication ---stop giving Tensilon...will make it worse.

Liver biopsy (prior)

must have lab results for prothrombin time

Myxedema/ hypothyroidism

slowed physical and mental function, sensitivity to cold, dry skin and hair.

Grave's 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. Trach at bedside

Hypo-parathyroid

CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet

Hyper-parathyroid

fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet

Hypovolemia

increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1.030

Hypervolemia

bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's

Diabetes insipidus (decreased ADH)

excessive urine output and thirst, dehydration, weakness, administer Pitressin

SIADH (increased ADH)

change in LOC, decreased deep tendon reflexes, tachycardia. N/V HA administer Declomycin, diuretics

hypokalemia

muscle weakness, dysrhythmias, increase K (rasins bananas apricots, oranges, beans, potatoes, carrots, celery)

Hyperkalemia

MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes

Hyponatremia

nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids

Hypernatremia

increased temp, weakness, disorientation, dilusions, hypotension, tachycardia. give hypotonic solution.

Hypocalcemia

CATS Convulsions, Arrythmias, Tetany, spasms and stridor

Hypercalcemia

muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, shallow respirations, emergency!

Hypo Mg

Tremors, tetany, seizures, dysthythmias, depression, confusion, dysphagia, (dig toxicity)

Hyper Mg

depresses the CNS. Hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations. EMERGENCY

Addison's

Hypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. GI stress.

Cushings

Hyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump

Addesonian crisis

N/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP

Pheochromocytoma

hypersecretion of epi/norepi. persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods (surgery to remove tumor)

Tetrology of Fallot

DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis)

Autonomic Dysreflexia

(potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure)

FHR patterns for OB

Think VEAL CHOP!
V-variable decels; C- cord compression caused
E-early decels; H- head compression caused
A-accels; O-okay, no problem
L- late decels; P- placental insufficiency, can't fill

what to check with pregnancy

Never check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope.

Position of the baby by fetal heart sounds

Posterior --heard at sides
Anterior---midline by unbilicus and side
Breech- high up in the fundus near umbilicus
Vertex- by the symphysis pubis.

Ventilatory alarms

HOLD
High alarm--Obstruction due to secretions, kink, pt cough etc
Low alarm--Disconnection, leak, etc

ICP and Shock

ICP- Increased BP, decreased pulse, decreased resp
Shock--Decreased BP, increased pulse, increased resp

Cor pumonae

Right sided heart failure caused by left ventricular failure (edema, jugular vein distention)

Heroin withdrawal neonate

irritable, poor sucking

brachial pulse

pulse area on an infant

lead poisoning

test at 12 months of age

Before starting IV antibiotics

obtain cultures!

pt with leukemia may have

epistaxis due to low platelets

when a pt comes in and is in active labor

first action of nurse is to listen to fetal heart tones/rate

for phobias

use systematic desensitization

NCLEX answer tips

choose assessment first! (assess, collect, auscultate, monitor, palpate) only choose intervention in an emergency or stress situation. If the answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment.

ARDS and DIC

are always secondary to another disease or trauma

In an emergency

patients with a greater chance to live are treated first

Cardinal sign of ARDS

hypoxemia

Edema is located

in the interstitial space, not the cardiovascular space (outside of the circulatory system)

the best indicator of dehydration?

weight---and skin turgor

heat/cold

hot for chronic pain; cold for accute pain (sprain etc)

When pt is in distress....medication administration

is rarely a good choice

pneumonia

fever and chills are usually present. For the elderly confusion is often present.

before IV antibiotics?

check allergies (esp. penicillin) make sure cultures and sensitivity has been done before first dose.

COPD and O2

with COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be low because high O2 concentration takes away the pt's stimulation to breathe.

Prednisone toxicity

Cushings (buffalo hump, moon face, high blood sugar, HTN)

Neutropenic pts

no fresh fruits or flowers

Chest tubes are placed

in the pleural space

Preload/Afterload

Preload affects the amount of blood going into Right ventricle. Afterload is the systemic resistance after leaving the heart.

CABG

Great Saphenous vein in leg is taken and turned inside out (because of valves inside) . Used for bypass surgery of the heart.

Unstable Angina

not relieved by nitro

PVC's

can turn into V fib.

1 tsp

5 mL

1 oz

30 mL

1 cup

8 oz

1 quart

2 pints

1 pint

2 cups

1 g (gram)

1000 mg

1 kg

2.2 lbs

I lb

16 oz

centigrade to Fahrenheit conversion

F= C+40 multiply 5/9 and subtract 40
C=F+40 multiply 9/5 and subtract 40

Angiotenson II

In the lungs...potent vasodialator, aldosterone attracts sodium.

Iron toxicity reversal

deferoxamine

S3 sound

normal in CHF. Not normal in MI

After endoscopy

check gag reflex

TPN given in

subclavian line

pain with diverticulitis

located in LLQ

appendicitis pain

located in RLQ

Trousseau and Chvostek's signs observed in

Hypocalcemia

never give K+ in

IV push

DKA is rare

in DM II (there is enough insulin to prevent fat breakdown)

Glaucoma patients lose

peripheral vision.

Autonomic dysreflexia

patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above)

Spinal shock occurs

immediately after injury

multiple sclerosis

myelin sheath destruction. disruptions in nerve impulse conduction

Myasthenia gravis

decrease in receptor sites for acetylcholine. weakness observed in muscles, eyes mastication and pharyngeal musles. watch for aspiration.

Gullian -Barre syndrome

ascending paralysis. watch for respiratory problems.

TIA

transient ischemic attack....mini stroke, no dead tissue.

CVA

cerebriovascular accident. brain tissue dies.

Hodgkin's disease

cancer of the lymph. very curable in early stages

burns rule of Nines

head and neck 9%
each upper ext 9%
each lower ext 9%
front trunk 18%
back trunk 18%
genitalia 1%

birth weight

doubles by 6 months
triples by 1 year

if HR is <100 (children)

Hold Dig

early sign of cystic fibrosis

meconium in ileus at birth

Meningitis--check for

Kernig's/ brudinski's signs

wilm's tumor

encapsulated above kidneys...causes flank pain

hemophilia is x linked

passed from mother to son

when phenylaline increases

brain problems occur

buck's traction

knee immobility

russell traction

femur or lower leg

dunlap traction

skeletal or skin

bryant's traction

children <3 y <35 lbs with femur fx

eclampsia is

a seizure

perform amniocentesis

before 20 weeks to check for cardiac and pulmonary abnormalities

Rh mothers receive Rhogam

to protect next baby

anterior fontanelle closes by...posterior by..

18 months, 6-8 weeks

caput succedaneum

diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days

pathological jaundice occurs:
physiological jaundice occurs:

before 24 hours (lasts 7 days)
after 24 hours

placenta previa s/s
placental abrution s/s

there is no pain, but there is bleeding
there is pain, but no bleeding (board like abd)

bethamethasone (celestone)

surfactant. premature babies

milieu therapy

taking care of pt and environmental therapy

cognitive therapy

counseling

five interventions for psych patients

safety
setting limits
establish trusting relationship
meds
least restrictive methods/environment

SSRI's

take about 3 weeks to work

patients with hallucinations
patients with delusions

redirect them
distract them

Thorazine and Haldol

can cause EPS

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