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
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)
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
spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis,
mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room or cohort mask!)
Multidrug resistant organism
Enteric infection (C diff)
Eye infection (conjunctivitis)
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.
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
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.
Knee to chest or Trendelenburg
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.
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
S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST!
bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg)
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
After the procedure, the pt should be supine for 4-12 hours as prescribed.
worsens with exercise and improves with rest
a positive reaction to Tensilon---will improve symptoms
Caused by excessive medication ---stop giving Tensilon...will make it worse.
Liver biopsy (prior)
must have lab results for prothrombin time
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.
increased temp, pulse and HTN
semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside
CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet
fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet
increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1.030
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
muscle weakness, dysrhythmias, increase K (rasins bananas apricots, oranges, beans, potatoes, carrots, celery)
MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes
nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids
increased temp, weakness, disorientation, dilusions, hypotension, tachycardia. give hypotonic solution.
CATS Convulsions, Arrythmias, Tetany, spasms and stridor
muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, shallow respirations, emergency!
Tremors, tetany, seizures, dysthythmias, depression, confusion, dysphagia, (dig toxicity)
depresses the CNS. Hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations. EMERGENCY
Hypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. GI stress.
Hyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump
N/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP
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)
(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.
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
Right sided heart failure caused by left ventricular failure (edema, jugular vein distention)
Heroin withdrawal neonate
irritable, poor sucking
pulse area on an infant
test at 12 months of age
Before starting IV antibiotics
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
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
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
hot for chronic pain; cold for accute pain (sprain etc)
When pt is in distress....medication administration
is rarely a good choice
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.
Cushings (buffalo hump, moon face, high blood sugar, HTN)
no fresh fruits or flowers
Chest tubes are placed
in the pleural space
Preload affects the amount of blood going into Right ventricle. Afterload is the systemic resistance after leaving the heart.
Great Saphenous vein in leg is taken and turned inside out (because of valves inside) . Used for bypass surgery of the heart.
not relieved by nitro
can turn into V fib.
1 g (gram)
centigrade to Fahrenheit conversion
F= C+40 multiply 5/9 and subtract 40
C=F+40 multiply 9/5 and subtract 40
In the lungs...potent vasodialator, aldosterone attracts sodium.
Iron toxicity reversal
normal in CHF. Not normal in MI
check gag reflex
TPN given in
pain with diverticulitis
located in LLQ
located in RLQ
Trousseau and Chvostek's signs observed in
never give K+ in
DKA is rare
in DM II (there is enough insulin to prevent fat breakdown)
Glaucoma patients lose
patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above)
Spinal shock occurs
immediately after injury
myelin sheath destruction. disruptions in nerve impulse conduction
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.
transient ischemic attack....mini stroke, no dead tissue.
cerebriovascular accident. brain tissue dies.
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%
doubles by 6 months
triples by 1 year
if HR is <100 (children)
early sign of cystic fibrosis
meconium in ileus at birth
Kernig's/ brudinski's signs
encapsulated above kidneys...causes flank pain
hemophilia is x linked
passed from mother to son
when phenylaline increases
brain problems occur
femur or lower leg
skeletal or skin
children <3 y <35 lbs with femur fx
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
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)
surfactant. premature babies
taking care of pt and environmental therapy
five interventions for psych patients
establish trusting relationship
least restrictive methods/environment
take about 3 weeks to work
patients with hallucinations
patients with delusions
Thorazine and Haldol
can cause EPS
60% of all dementias, chronic, progressive degenerative cognitive disorder.
draw up regular and NHP?
Air into NHP, air into Regular. Draw regular, then NHP
S=sensory M=motor B=both
Oh (Olfactory I) Some
Oh (Optic II ) Say
Oh (Oculomotor III) Marry
To (trochlear IV) Money
Touch (trigeminal V) But
And (Abducens VI ) My
Feel (facial VII) Brother
A (auditory VIII) Says
Girl's (glossopharyngeal IX) Big
Vagina (vagus X) Bras
And (accessory XI) Matter
Hymen (Hypoglossal XII) More
S (Skin flushed)
L (low grade fever )
2-3 months: turns head side to side
4-5 months: grasps, switch and roll
6-7 months: sit at 6 and waves bye bye
8-9 months: stands straight at 8
10-11 months: belly to butt
12-13 months: 12 and up, drink from a cup
Ends in a vowel, comes from the bowel
B= blood and body fluids (hep c is the same)
HR RR Muscle tone, reflexes, skin color.
Each 0-2 points. 8-10 ok, 0-3 resuscitate
Glasgow coma scale
eyes, verbal, motor
Max- 15 pts, below 8= coma
have extra "cushion" of hormone
increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis. Wait 1 hr after meals to drink
Disseminated herpes zoster
localized herpes zoster
Disseminated herpes=airborne precautions
Localized herpes= contact precautions. A nurse with localized may take care of patients as long as pts are not immunosuppressed and the lesions must be covered!
causes peripheral neuritis
Weighted NI (naso intestinal tubes)
Must float from stomach to intestine. Don't tape right away after placement. May leave coiled next to pt on HOB. Position pt on RIGHT to facilitate movement through pyloris
r/t brain injury
r/t ICP (HTN, bradycardia, irritability, sleep, widening pulse pressure)
Non Dairy calcium
Rhubarb sardines collard greens
prodomal stage of measles. Red spots with blue center, in the mouth--think kopLICK in the mouth
INH can cause peripheral neuritis
Take vitamin B6 to prevent. Hepatotoxic
put them in fetal position, NPO, gut rest, Prepare anticubital site for PICC, they are probably going to get TPN/Lipids
Pain with palplation of gall bladder (seen with cholecystitis)
ecchymosis in umbilical area, seen with pancreatitis
Flank--greyish blue. (turn around to see your flanks) Seen with pancreatitis
Pain in RLQ with appendicitis
appendicitis watch for peritonitis
Tests for PKU. Baby should have eaten protein first
Test for pernicious anemia
Its ok to have abd cramps, blood tinged outflow and leaking around site if the cath (tenkoff) was placed in the last 1-2 weeks. Cloudy outflow is never ok
upper motor neuron issue (your reflexes are over the top)
Lower motor neuron issue
assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes and peaches
used in myesthenia gravis to confirm diagnosis
(amyotrophic lateral sclerosis) degeneration of motor neurons in both upper and lower motor neuron systems
esophagus doesn't fully develop. This is a surgical emergency (3 signs in newborn: choking, coughing, cyanosis)
is given SQ not IM
codes for pt care
Red- unstable, ie.. occluded airway, actively bleeding...see first
Yellow--stable, can wait up to an hour for treatment
Green--stable can wait even longer to be seen---walking wounded
Black--unstable, probably will not make it, need comfort care
DOA--dead on arrival
Contraindication for Hep B vaccine
anaphylactic reaction to baker's yeast
what to ask before flu shot
allergy to eggs
what to ask before MMR
allergy to eggs or neomycin
when on nitroprusside monitor:
cyanide. normal value should be 1.
semi Fowler's with knees flexed to reduce low back pain
S/S of hip fx
External rotation, shortening adduction
blood tinged sputum r/t inflammations. Increase ESR, respiratory alkalosis. Hypocalcemia, increased serum lipids.
complications of mechanical ventilation
tinnitus, bone pain, elnargement of bone, thick bones
no vitamin C or warfarin!
bowel prep so bladder can be visualized
acid ash diet
cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread
alk ash diet
milk, veggies, rhubarb, salmon
orange tag in psych
is emergent psych
thyroid med side effects
insomnia. body metabolism increases
Tidal volume is
COPD patients and O2
2LNC or less. They are chronic CO2 retainers expect sats to be 90% or less
Kidney glucose threshold
Stranger anxiety is greatest at what age?
7-9 months..separation anxiety peaks in toddlerhood
when drawing an ABG
put in heparinized tube. Ice immediately, be sure there are no bubbles and label if pt was on O2
Munchausen syndrome vs munchausen by proxy
Munchausen will self inflict injury or illness to fabricate symptoms of physical or mental illness to receive medical care or hospitalization. by proxy mother or other care taker fabricates illness in child
motor s/s limb weakness, paralysis, slow speech. sensory s/s numbness, tingling, tinnitis cerebral s/s nystagmus, atazia, dysphagia, dysarthia
50% genetic autosomal dominanat disorder.. s/s uncontrolled muscle movements of face, limbs and body. no cure
WBC left shift
pt with pyelo. neutrophils kick in to fight infections
pancreatic enzymes are taken
with each meal!
infants IM site
Toddler 18 months+ IM site
IM site for children
deltoid and gluteus maximus
position pt on side or over bed table. no more than 1000 cc removed at a time. Listen for bilateral breath sounds, V.S, check leakage, sterile dressing
NPO 8-12 hours. empty bladder, pulses, tell pt may feel heat, palpitations or desire to cough with injection of dye. Post: V.S.--keep leg straight. bedrest for 6-8 hr
Cerebral angio prep
well hydrated, lie flat, site shaved, pulses marked. Post--keep flat for 12-14 hr. check site, pulses, force fluids.
fetal position. post-neuro assess q15-30 until stable. flat 2-3 hour. encourage fluids, oral analgesics for headache.
no sleep the night before, meals allowed, no stimulants/tranquilizers for 24-48 hours before. may be asked to hyperventilate 3-4 min and watch a bright flashing light. watch for seizures after the procedure.
NPO for 4-6 hours. allergy hx phenothiazines, cns depressants and stimulants withheld 48 hours prior. Table moved to various positions during test. Post--neuro assessment q2-4 hours, water soluble HOB UP. oil soluble HOB down. oralanalgesics for HA. No po fluids. assess for distended bladder. Inspect site
administer Vitamin K, NPO morning of exam 6 hrs. Give sedative. Teach pt to expect to be asked to hold breath for 5-10 sec. supide position, lateral with upper arms elevated. Post--position on RIGHT side. frequent VS. report severe ab pain STAT. no heavy lifting 1 wk
semi fowler's or upright on edge of bed. Empty bladder. post VS--report elevated temp. watch for hypovolemia
CO2 used to enhance visual. general anesthesia. foley. post--ambulate to decrease CO2 buildup
low grade afternoon fever
wheezing on expiration
red beefy tongue
rice watery stool
stepladder like fever--with chills
rose spots on the abdomen
pseudo membrane formation
sle (systemic lupus)
olive like mass
bronze like skin pigmentation
moon face, buffalo hump
hyperthyroidism/ grave's disease
descending musle weakness
ascending muscle weakness
crushing, stabbing chest pain relieved by nitro
crushing stabbing chest pain unrelieved by nitro
kussmal's breathing (deep rapid)
reduced size and force of urine
floaters and flashes of light. curtain vision
painful vision loss. tunnel vision. halo
cat's eye reflex
hypertension, bradypnea,, bradycarday (cushing's triad)
Hypotension, tachypnea, tachycardia
often used in peds when venous access can't be obtained. hand drilled through tibia where cryatalloids, colloids, blood products and meds are administered into the marrow. one med that CANNOT be administered IO is isoproterenol, a beta agonist.
sickle cell crisis
two interventions to prioritize: fluids and pain relief.
the most important assessment is blood pressure
children 5 and up
should have an explanation of what will happen a week before surgery
(inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms.
watch for abdominal distention. watch for s/s of ICP such as high pitch cry, irritability and bulging fontanels. In a toddler watch for loss of appetite and headache. After shunt is placed bed position is FLAT so fluid doesn't reduce too rapidly. If presenting s/s of ICP then raise the HOB 15-30 degrees
3-4 cups of milk a day for a child?
NO too much milk can reduce the intake of other nutrients especially iron. Watch for ANEMIA
MMR and varicella immunizaions
after 15 months!
undescended testicles! risk factor for testicular cancer later in life. Teach self exam for boys around age 12--most cases occur in adolescence
HIGH protein LOW glucose
Head injury or skull fx
no nasotracheal suctioning
feed upright to avoid otitis media!
positioning for pneumonia
lay on affected side, this will splint and reduce pain. However, if you are trying to reduce congestion, the sick lung goes up! (like when you have a stuffy nose and you lay with that side up, it clears!)
for neutropenic pts
no fresh flowers, fresh fruits or veggies and no milk
antiplatelet drug hypersensitivity
more important to maintain fluid balance than to establish a normal bowel pattern (they cant take in oral fluids)
Basophils reliease histamine
during an allergic response
means it was caused by treatment, procedure or medication
watch for visual changes--indicates toxicity
pneumovax 23 is administered to prevent pneumococcal sepsis
Alkalosis/ Acidosis and K+
ALKalosis=al K= low sis. Acidosis (K+ high)
to a kid with PKU. No meat, dairy or aspartame
never give potassium
to a pt who has low urine output!
characterized by massive proteinuria caused by glomerular damage. corticosteroids are the mainstay
the first sign of ARDS
increased respirations! followed by dyspnea and tachypnea
normal PCWC (pulmonary capillary wedge pressure)
is 8-13 readings 18-20 are considered high
first sign of PE
sudden chest pain followed by dyspnea and tachypnea
increases ventricular irritability ----could convert a rhythm to v-fib following cardioversion
Cold stress and the newborn
biggest concern resp. distress
Parathyroid relies on
vitamin D to work
Glucagon increases the effects of?
Sucking stab wound
cover wound and tape on 3 sides to allow air to escape. If you cover and occlude it--it could turn into a closed pneumo or tension pneumo!
chest tube pulled out?
acetone and keytones increase! once treated expect postassium to drop! have K+ ready
diagnosed with rectal biopsy. S/S infant-failure to pass meconium and later the classic ribbon-like/foul smelling stools
Common in kids with CF. Obstruction may cause fecal emesis, current jelly stools. enema---resolution=bowel movements
laboring mom's water breaks?
first thing--worry about prolapsed cord!
Toddlers need to express
causes sever hypotension!
first pain relief, second cough and deep breathe
CF chief concern?
a nurse makes a mistake?
take it to him/her first then take up the chain
turns blue with alkaline amniotic fluid. turns pink with other fluids
up stairs with crutches?
crutches first followed by good leg
use low fowler's to avoid. limit fluids
TB drugs are