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E valuate A ssess T each
Don’t delegate Unstable patients Initial Assessment, Teaching, IV drips, Evaluations only RN
AIRBORNE TRANSMISSION-BASED PRECAUTIONS: MTV M easles T B V aricella-Chicken Pox/ H erpes Zoster-Shingles Private Room: Negative pressure with 6-12 air exchanges/hr Mask: N95 for TB
DROPLET TRANSMISSION-BASED PRECAUTIONS: Think of SPIDERMAN! S epsis S carlet fever S treptococcal Pharyngitis (Streptococcus group A/ Strep Throat): Can Lead to Glomerulonephritis & Rheumatic P arvovirus B19 Fever. P neumonia P ertussis I nfluenza/ Haemophilus influenza type B D iphtheria (Pharyngeal): Serious bacterial infection. E piglottitis: Medial Emergency! No Throat Inspection. R ubella/ German measles
M umps
M eningitis/ Neisseria
NCLEX RN STUDY GUIDE
Meningitidis M ycoplasma/ Meningeal Pneumonia An - Adenovirus Private Room or Cohort Surgical mask PRN for Procedures Mask 3ft Distance
CONTACT PRECAUTION TRANSMISSION-BASED PRECAUTIONS: MRS.WEE
M ultidrug resistant organism/ MRSA/ VRE R espiratory infection S kin infections W ound infection E nteric infection - Clostridium Difficile E ye infection – Conjunctivitis *MRSA - Contact precaution ONLY. Use Chlorhexidine Wipe! *VRSA - Contact & Airborne precaution (Private room, door closed, negative pressure)
- SARS (Severe Acute Resp Syndrome) Airborne & Contact (just like Varicella)
SKIN INFECTIONS- VCHIPS- CONTACT
V aricella Zoster C utaneous Diphtheria (Bacteria Infection in the Wound) H erpes Simplex I mpetigo (Bacterial Skin Infection) P ediculosis (Lice) S cabies (Itchy Skin condition. Burrowing Trail of the Scabies Mite)
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/S: Fever, Cough, SOB, and Death. The Incubation Period is 5-6 days but can range from 2-14 days. CDC: Standard (Gloves), Contact (Gown), Eye Protection (Goggles), Airborne Precautions (N95)
Negative room: Negative disease (TB, Disseminated Herpes Zoster) Positive room: Protect the Patient (HIV, Cancer)
Addison’s = hyponatremia, hypotension, decreased blood vol, hypoglycemia, hyperKalemia, HyperCalcemia. Cushing’s = HyperNatremia, HyperTension, Incr. Blood Vol, HyperGlycemia, hypokalemia, hypocalcemia.
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. Addison’s: Remember BP is the most Important assessment parameter, as it causes Severe Hypotension. Addison’s: (need to "add" hormone): Hypoglycemia, Dark pigmentation, Decr. Resistance to Stress, fractures, Alopecia, Weight Loss, GI distress. Vitiligo. Mood swings (Normal) Need to Report S/S of Infection/ Fever (Addisonian Crisis) Tx: Mineral Corticoids. Addisonian Crisis: Hypoglycemia, Confusion, n/v, Abd Pain, Extreme Weakness, Dehydration, Decr. BP.
Cushings: (have extra "Cushion" of Hormones) : Hyperglycemia, prone to Infection, Muscle Wasting, Weakness, Edema, HTN, Hirsutism, Moonfaced/Buffalo Hump Cause: Excessive production of Corticotropin (Hyperplasia of the Adrenal Cortex) & Cortisol-secreting Adrenal Tumor. Prednisone Toxicity: Cushing’s syndrome- Buffalo Hump, Moon face, Hyperglycemia, Hypertension.
Acetaminophen: 10-20. Max 4000mg per day.
Acetaminophen Poisoning: Possible Liver Failure for about 4 days. Close observation required. Tx: (Antidote) n-AcetylCysteine/Mucomyst
NCLEX RN STUDY GUIDE
(ASA): Metabolic Acidosis. S/S: Tinnitus, Coffee Ground Emesis (Old Blood), Black tarry stools (Melena), Bruising, Tachycardia, Hypotension, GI Ulcers. Tx: Activated Charcoal, then IV Na+^ Carbonate.
Acromegaly: Coarse Facial feature. Assess Cardiac Problems (eg. S3, S4).
Acute Respiratory Distress Syndrome (ARDS): The 1st^ Sign is Incr. Respirations. Later comes Dyspnea, Retractions, Air Hunger, Cyanosis. Cardinal sign is Hypoxemia (Low O 2 level in tissues). Refractory Hypoxemia is the hallmark of ARDS, a progressive form of acute respiratory failure that has a high Mortality rate. It can develop following a Pulmonary Insult (eg, aspiration, pneumonia, toxic inhalation) or nonpulmonary insult (eg, sepsis, multiple blood transfusions, trauma) to the Lung. The Inability to improve Oxygenation With Incr. in O 2 concentration. The insult triggers a Massive Inflammatory response that causes the lung tissue to release inflammatory mediators (leukotrienes, proteases) that cause damage to the alveolar-capillary (A-C) membrane. As a result of the damage, the A-C membrane becomes more permeable, and intravascular fluid then leaks into the alveolar space, resulting in a Noncardiogenic Pulmonary Edema. The lungs become Stiff and Noncompliant, which makes Ventilation and Oxygenation less than optimal and results in increased work of breathing, tachypnea and alkalosis, atelectasis, and refractory hypoxemia. ARDS (fluids in alveoli), DIC (Disseminated Intravascular Coagulation) are always Secondary to something else (another disease process). – Impaired Gas Exchange.
PreOxygenated with 100% O 2 , and Suction should be applied for no more than 10 seconds to prevent hypoxia. The nurse must wait 1 - 2 minutes between passes to ventilate to prevent hypoxia. Deep reBreathing should be encouraged. The Suction catheter should be No more than half the width of the artificial airway and inserted without suction. Don Sterile gloves if it is not have a closed suction system.
AcetylSalicyclic Acid
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/S: Limb weakness, Dysarthria (difficulty speaking), and Dysphagia.
Iron: IM: should be given Z-track so they don't leak into SQ tissues IV: Iron Dextran (Imferon). Can cause hypersensitivity reaction (anaphylaxis), test dose needs to be given First. PO: give with Vitamin C or on an Empty stomach or Btw Meals. Place it on the back of the Month (Stain teeth). Expect Black/Green Tarry Stools. Take iron elixir with juice or water .... Never with milk (Vit D). Iron Poisoning: GI Bleed. Antidote: Deferoxamine
Iron Deficiency Anemia : Microcytic anemia. S/S: Fatigue, Pallor, Fissures at the corner of the mouth, Spooning of the fingernail, Reduced exercise tolerance
Thalassemia Major (Cooley’s Anemia) : Microcytic anemia. S/S: Maxillary Hyperplasia, Frontal Bossing. Caused by: Defects in both Beta-chains of the Hgb molecule.
Pernicious Anemia: Macrocytic anemia, Lack of required Intrinsic factor (B 12 Deficiency) S/S: Pallor, Tachycardia, Sore Red Tongue (Beefy tongue), Enlarged Liver that can lead to R-sided HF. Take Vit. B 12 for life. Shilling Test: Test for Pernicious Anemia. How well one absorbs Vit B 12
Folate (Folic Acid) Deficiency: Macrocytic anemia. Risk: Alcoholism or Diet Low in Vegetables. S/S: Stomatitis, Ulcerations on the tongue. Dysphagia, Flatulence, watery Diarrhea
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plastic Anemia: Normocytic Anemia. Decline in blood cell production r/t to Bone Marrow Depression. Can cause an Extremely Low Hgb of 7 g/dL
Severe Anemia: (Female hgb 11.7 ~ 15.5) Tachycardia. SOB (Dyspnea). Pallor. (Male hgb 13.2 ~ 17.3)
Anorexic: Absence of Menstruation leads to Osteoporosis. Bulimia: Chipmunk Face.
Antibiotic: Obtain Cultures before starting IV antibiotics. IV push should go over at least 2 Minutes. Always check for Allergies before Administering (especially PCN). Make sure Culture & Sensitivity has been done before First dose. Give Prophylactic Antibiotic therapy before any Invasive Procedure. Aminoglycocide ( _Mycin e.g. Vancomycin; except Erythromycin): Cause Nephrotoxicity and Ototoxicity. Adverse Effects are Bean Shaped - Nephrotoxic to Kidneys & Ototoxic to Ears Macrolide (Azithromycin, Erythromycin, Clarithromycin): can cause Prolonged QT interval. My lead to Torsade de Pointes (Life-threatening Arrhythmias). Antacids will Limit the Absorption of the antibiotics. Concurrent use of other prolong QT interval (Amiodarone, Sotalol, Haloperidol, Ziprasidone, Azole, Antifungals) will Incr. the risk. Risk of Hepatotoxicity: when taken in High doses. Report Elevated AST and ALT.
Sulfamethoxazole/Trimethoprim: (Tx for UTI, PJP). Don’t take if Allergic to Sulfa drugs. Drink plenty of fluids. S/S: Diarrhea
S/S: (Ascending)- Chest Pain, Radiate to the Back
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(Descending)- Abrupt in Onset, “Worst Ever” “Tearing”, Ripping Pain, Moving Back Pain, Epigastric Pain
Abdominal Aortic Aneurysm (AAA): Definitive Diagnosis- CT scan. Hypoactive BS for few days after the Surgery.
Computed Tomography (CT) Scan : Assess Allergies
Osteoarthritis: a Degenerative Disease, causing pain With Activity. Inflammation occurs, but the joint does Not usually become swollen or red. It commonly affects the Larger, weight-bearing joints and affects both genders equally.
Rheumatoid Arthritis: causes Pain and Inflammation After periods of rest. It affects the Small joints (like fingers) and is more common in women. Pain is usually the Highest Priority. Heat for Chronic (Rheumatoid Arthritis): Warm Shower/Bath in the Morning. Swimming is the Best.
Order of Assessment : Inspection, Palpation, Percussion and Auscultation. Except… Abdomen Assessment: Inspect, Auscultate, Percuss then Palpate (Last, bc it may induce pain) Assessment with Kids: Least invasive to Most invasive.
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 they clearly States the S/S (Difficulty Breathing, Increasing Anxiety, etc.) Anaphylaxis is a Medical Emergency. Epinephrine Injection is the Only option for treating anaphylaxis.
Asthma:
ADHD: Inattention, Hyperactivity, Impulsivity.
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ethylphenidate/ Ritalin: Assess for Heart related side effects report immediately. May need a Drug Holiday- it Stunts Growth. Dextroamphetamine: may alter Insulin needs, Avoid taking with MAOI's, take in Morning (Insomnia possible side effect) Atomoxetine: Norepinephrine-Specific Reuptake Inhibitor, and can be used for Depression.
Autonomic Dysreflexia/Hyperreflexia: Neuro T6 or above. Life-threatening emergency. Uncompensated SNS stimulation (Inhibited Sympathetic Response) Tigger by: Bladder distention and Bowel impaction S/S: pounding/severe HA, profuse Sweating (Diaphoresis), Nasal Congestion, Bradycardia (30~40), Flushing, Piloerection (goose bumps), Nausea, Seizure, Uncontrolled HTN. Can occur weeks to years after the injury. Tx: Place client in sitting position (Elevate Hob) first before any other implementation. High Fowler’s (90o): assist w/ventilation & prevention of HtN Stroke! Loosen constrictive clothing (Decr. skin stimulation) SBP> 300mmHg. Administer antihypertensive meds (may cause stroke, MI, seizure) Most spinal cord injuries are at the Cervical or Lumbar regions.
Spinal Shock occurs Immediately after Spinal Injury Halo: remember Safety First; have a Screwdriver nearby. Myelogram: NPO 4-6hr, allergy hx, Phenothiazine, CNS depressants, and Stimulants withheld 48hr prior, table will be moved to various positions during test. Post: Neuro q2-4, Water Soluble HOB Up. Oil Soluble HOB Down (Lie Flat Supine, to prevent HA, and Leaking of CSF) oral analgesics for HA, encourage PO fluids, assess for Distended Bladder, Inspect Site.
Benign Prostatic Hyperplasia (BPH): Enlarged Prostate. Reduced size & force of urine. Tamsulosin, Terazosin, Prazosin (Antitensive med): Alpha^1 Antagonist: Cause Orthostatic Hypotension &
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Water Intoxication will be Evidenced by Drowsiness and Altered Mental Status in a patient with TURP Syndrome, or as an Adverse Reaction to Desmopressin (for Diabetes Insipidus).
Benzodiazepine: Alprazolam/ Xanax Clonazepam/ Klonopin Diazepam/ Distat/ Valium: Status Epilepticus & to treat Anxiety. Lorazepam/ Ativan Midazolam/ Versed: Surgery Zolpidem/ Ambien
During Continuous Bladder Irrigation (CBI): Catheter is Taped to Thigh so Leg should be kept Straight. No other positioning restrictions. Maintain Urine that’s Pale Pink-Tinged. Red would indicate Active Bleeding.
Bladder Cancer: Painless Hematuria
A patient with a Low Hemoglobin and/or Hematocrit should be evaluated for Signs of Bleeding , such as Dark Stools.
Blood Transfusion: Sign of Allergies in order:
- Flank pain
- Frequent swallowing
- Rashes
- Fever
- Chills
NCLEX RN STUDY GUIDE
Patch the Good eye, so the Weaker eye can get stronger). To relax Vocal Cords in Spasmodic Dysphonia.
Bowel Sounds : Normal: High-Pitched, Gurgling sounds. Cardiovascular Bruits: (Swishing, Humming, Buzzing): usually indicate Arterial narrowing (Obstruction) or dilation (Aneurysm). After Surgery, BS are Absent first 24-48 hrs. Return to the Small intestine in 24hr; Large intestine may delayed 3~5 days. Borborygmi Sounds: are Loud, Gurgling sounds suggesting increased Peristalsis (Gastroenteritis, Diarrhea).
Obstructed Ileostomy (Bowel Obstruction): S/S: N/V, Abd Distention, Decr. Stool.
Ileostomy: Liquid Stool (Bypass the Colon). Low Fiber Diet: White rice, Pasta, Refined grains. Avoid High Fiber (Popcorn, Coconut, Brown Rice, Multigrain bread), Stringy Veg (Celery, Broccoli, Asparagus), Seeds or Pits (Strawberry, Raspberries, Olives), Edible Peels (Apple, Cucumber, Dried fruit).
Colon: Fluid & Electrolyte Absorption, Vit K Production.
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.
Small Bowel Follow-Through (SBFT): Sequential X-ray images to visualize the Structure and Function. Barium is Ingested, and X-ray images are taken every 15-60 minutes to visualize the barium as it passes through
Botox (Botulin Toxin): Used with Strabismus (
rousseau’s & Chvostek’s.
NCLEX RN STUDY GUIDE
Ca2+^ absorption is impaired when taken in excess of 500 mg per dose. Taken within an hour of meals as food incr. Ca2+^ absorption. Constipation is a frequent side effect of Ca2+^ supplements. For Chronic Kidney Disease take Ca2+^ supplements before meals, to reduce Phosphorus levels Non-dairy sources of Ca2+: Rhubarb, Sardines, Collard Greens.
Carbon Monxide (CO): More readily binds to Hemoglobin than O2. Pulse Oximeter: Can’t Differentiate between O 2 & CO. CO Poisoning: S/S: HA, Dizziness, Fatigue, Nausea, Dyspnea. Tx: 100% O 2. Serum CarboxyHemoglobin Test to Confirm Diagnosis. Normal Value: < 5% Non Smoker. < 10% Smoker.
Carbon Dioxide (CO 2 ) Narcosis: High K+^ (Expected- Hydrogen floods the cell forcing K+^ out). Causes Increased Intracranial Pressure.
Cataract: S/S: Painless Vision Loss, Cloudy, Blurry vision, Opacity of the lens. Worst at Night. Tx: Lens Removal Surgery After Cataract Surgery: Sleep on Unaffected side with a Night Shield for 1~4 weeks.
Celiac Disease: Barley, Rye, Oats, Wheat.
Cephalhematoma ( Caput Succinidanium ): Resolves on its own in a few days.
This is the type of Edema that Crosses the Suture lines.
