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.
HOLD High alarm--Obstruction due to secretions, kink, pt cough etc Low alarm--Disconnection, leak, etc
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% genitalia 1%
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
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
safety setting limits establish trusting relationship meds least restrictive methods/environment
take about 3 weeks to work
patients with hallucinations patients with delusions
redirect them distract them
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) A (agitation) L (low grade fever ) T (thirst)
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
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
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
Hyper reflexes absent reflexes
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
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
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
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