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Revised 37-page NCLEX Study Guide
1. ABCs (Airway, Breathing, Circulation)
2. When in distress DO NOT ASSESS! Unless 2nd hand information is received.
3. Scenario
Expected outcome with Disease Process
o Continue to monitor
o Document finding
Unexpected finding with Disease Process
o Nursing intervention that must make a difference
o Call HCP
4. Mini Maslow’s
1) ABCs (& Pain unrelieved by meds)
2) Safety
3) Comfort (Pain)
4) Psychological
5) Social
6) Spiritual
5. STAT words → Pick the answer that failing to do so will kill or cause great harm
● Highest Priority
● Most Important
● Immediate Action
6. Least Invasive First
7. Secondhand Info → Any time you have 2nd^ hand info, the right answer is assess
∙ UAP ∙ Family
∙ Labs ∙ EMR
∙ EKG ∙ BP machine
8. Never ever take away the coping mechanism a patient uses during a crisis, except if the mechanism puts the
patient or others @ risk
9. Eliminate answer choices & DNR
10. Never withhold Tx! If you’re left with two answer choices and the options are to Tx, or watch the patient,
Pick Tx!
11. Anytime there’s a reversal from the norm, you must worry!
Ex: rebound tenderness (pain after you relieve pressure)
12. Stable Patients
∙ UAP ∙ LPN ∙ New nurse
∙ Graduate Nurse ∙ Float Nurse ∙ Travel nurse
13. Anytime you see excessive findings, That’s not normal!
14. Always empower your patient
15. If a question has “ ”, pick an answer that has what they’re feeling & not what they’re saying
16. 3 R’s of Psych
1) Reality – Functional psych patient
2) Reassure – Delirium
3) Redirect – Dementia
Default Answers
1. Give meds either 1 hour before meal or 2 hours after meal
2. Give antacids 1 hour before med or 4 hours after med
3. When in doubt pick K (potassium)
4. 2 – 3 L of fluids
5. When in doubt pick answer that has you stay with patient
6. Anytime you see restless & ↓ level of consciousness = early sign always pick
7. Head of Bead → 30-45 degrees for any neuro patient
8. Elderly with acute onset confusion → UTI
9. Secretions will turn Orange/Red for meds
10. Anytime you have GI problem/exacerbation = NPO
11. All surgeries
1 st^ 24 hrs – bleeding
48 hrs – infection
12. Check daily weights if it’s a fluid problem
13. Lateral position for maternity
14. Remove answer choices that are ‘absolutes’
Kaplan NCLEX Strategies
Kaplan RN Decision Tree
Step 1 – Can you identify the topic of the question
Step 2 – Are the answers assessment (get data) or implementation (to effect change)?
Step 3 – Apply Maslow: Are the answers physical or psychosocial? (Physical trumps psychosocial)
Step 4 – Are the answer choices related to ABCs?
Step 5 – What is the outcome of each of the remaining answers?
Rules for Delegation
RN ASSIGNMENT
● Cannot delegate assessment, teaching, or nursing judgement
LPN/LVN ASSIGNMENT
● Assign stable with expected outcomes
UAP ASSIGNMENT
● Delegate standard, unchanging procedures
Five Rights of Delegation
RIGHT TASK – scope of practice, stable client
RIGHT CIRCUMSTANCES – workload
RIGHT PERSON – scope of practice
RIGHT COMMUNICATION – specific task to be performed, expected results, follow-up communication
RIGHT SUPERVISION – clear directions, intervene if necessary
Therapeutic Communication Tips
DO: DO NOT:
● Do respond to feeling tone
● Do provide information
● Do focus on the client
● Do use silence
● Do use presence
● Do not ask ‘why’ questions
● Do not ask ‘yes/no’ questions, except in the case of possible self-harm
● Do not focus on the nurse
● Do not explore
● Do not say, “Don’t worry!”
Cholesterol HDL x > 50 LDL x < 100 Triglycerides x < 150 Total Cholesterol x < 200 Therapeutic Ranges Dilantin Theophylline Acetaminophen
Digoxin 0.5 – 2. Albumin level 3.5 to 5. Acid-Base Balance From the ass (diarrhea) –Metabolic Acidosis From the mouth (vomitus) –Metabolic Alkalosis Potassium & Alkalosis – AL K A LO SIS: K is LOW
- Acidosis is just the opposite: K is High Arterial Blood Gases 1. Prior to drawing an ABG, perform the Allen’s Test to check for sufficient blood flow 2. When drawing an ABG, the blood needs to be put in a heparinized tube. ● Ensuring there are no bubbles. 3. Put on ice immediately after drawing, with a label. ● The label should indicate if the pt was on room air, or how many liters of O2. General Notes ● T he person who hyperventilates is most likely to experience respiratory alkalosis. Antidotes ● Aspirin → Activated Charcoal ● Coumadin (Warfarin) → Vitamin K ● Heparin → Protamine Sulfate ● Tylenol (Acetaminophen) → Mucomyst (acetylcysteine) – administered orally ● Digoxin (Lanoxin) → Digibind (immune Fab) ● Opioids → Narcan ● Iron overdose → Deferoxamine ● PCP → Activated charcoal ● Magnesium Sulfate → Calcium Gluconate ● TPA → Aminocaproic acid ● Pancuronium Br (NM blocking agent) → Neostigmine/Atropine
Blood
For blood types: ● "O" is the universal donor (remember "o" in donor) ● "AB" is the universal recipient
Blood transfusion – sign of allergies in order: 1)Flank pain 2)Frequent swallowing 3)Rashes 4)Fever 5)Chills Thrombocytopenia – Bleeding precautions! 1)Soft bristled toothbrush 2)No insertion of anything! (c/i suppositories, douche) 3)No IM meds as much as possible! Sickle Cell Anemia During sickle cell crisis there are two interventions to prioritize: fluids and pain relief. Iron deficiency anemia – easily fatigued 1 )Fe PO (Iron) - give with Vitamin C or on an empty stomach 2)Fe via IM- Interferon via Z Track -- Peds: Kids are at risk for iron deficiency anemia if they ingest too much milk; >24oz/ day. Pernicious Anemia - s/s include pallor, tachycardia, and Sore Red, Beefy tongue ; will take Vit.B12 for life! Shilling Test – test for pernicious anemia/ how well one absorbs Vit b General Notes ● A patient with a low hemoglobin and/or hematocrit should be evaluated for signs of bleeding , such as dark stools. Burns
Rule of nines, 9 = head, 18 = arms, 36 = torso, 36 =legs, and 1=
perineum = 100%
The Parkland formula is a formula used for calculation the
total fluid requirement in 24 hours for a burn patient
4ml x TBSA % (Total Burn Surface Area) x body weight (kg) = Total
amount of fluid the patient will receive in 24 hrs
50% given in first eight hours
50% given in next 16 hours.
The Number #1 Priority for Burn Patients is maintaining a patent
airway
1st Degree – Red and Painful
2nd Degree – Blisters
3rd Degree – No Pain because of blocked and burned nerves
Cancer A cancer patient is getting radiation. What should the nurse be most concerned about? ● Skin irritation? No. ● Infection kills cancer patients most because of the leukopenia caused by radiation. General Notes ● A breast cancer patient treated with Tamoxifen should report changes in visual acuity, because the adverse effect could be irreversible. ● Common sites for metastasis include the liver , brain, lung, bone, and lymph. ● Bence Jones protein in the urine confirms multiple myeloma (cancer of plasma cells) ● Patients with leukemia may have epistaxis (nosebleeds) b/c of low platelets
Cranial Nerves Sensory=S Motor=M Both=B
- 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
- Very (Vestibulocochlear/Auditory VIII) Says
- Good (Glossopharyngeal IX) Big
- Velvet (Vagus X) Brains
- Such (Spinal Accessory XI) Matter
- Heaven (Hypoglossal XII) More On Old Olympus Towering Top A Finn And German Viewed Some Hopes Cultural Greek heritage - they put an amulet or any other use of protective charms around their baby's neck to avoid "evil eye" or envy of others Lyme Disease is found mostly in Connecticut Jewish Folks: no meat and milk together Diabetes Blood Sugar ~ Hyperglycemia – Hot & Dry ~ Sugar High Hypoglycemia – Cold & Clammy ~ Need some candy To remember how to draw up INSULIN think: N icole R ichie RN <Regular is clear & don't wanna put dirty needle in clear so Regular is pulled in first> Air into N PH, then air into R egular, draw up R egular insulin then draw up NPH Oral Hypoglycemics ● Do not attempt to give an oral hypoglycemic to an unconscious pt, as this poses the risk of aspirations ● A typical adverse reaction is rash , photosensitivity. HbA1c – test to assess how well blood sugars have been controlled over the past 90-120 days. 4- 6 corresponds to a blood sugar of 70-110; 7 is ideal for a diabetic and corresponds to a blood sugar of 130 Fluids are the most important intervention with HHNS as well as DKA , so get fluids going first. DKA ● While treating DKA , bringing the glucose down too far and too fast can result in increased intracranial pressure due to water being pulled into the CSF. ● Serum acetone and serum ketones rise in DKA. ● As you treat the acidosis and dehydration expect the potassium to drop rapidly, so be ready, with potassium replacement.
HHNS ● With HHNS there is no ketosis, and no acidosis. ● Potassium is low in HHNS (d/t diuresis
General Notes
● Extra insulin may be needed for a patient taking Prednisone (remember, steroids cause increased glucose). ● Second voided urine most accurate when testing for ketones and glucose. Drugs
General Notes
● Give NSAIDS, Corticosteroids, drugs for Bipolar, Cephalosporins, and Sulfonamides WITH food. ● Best time to take Growth Hormone PM ( Octreotide) , Steroids AM, Diuretics AM, Aricept (Donepezil) AM - for Alzheimer’s disease. ● Antacids are given after meals ● Remember the action of vasopressin because it sounds like “press in”, or vasoconstrict. ● If mixing antipsychotics (i.e. Haldol, Thorazine, Prolixin) with fluids, meds are incompatible with caffeine and apple juice ● The main hypersensitivity reaction seen with antiplatelet drugs is bronchospasm (anaphylaxis) - “think NSAIDS causing bronchoconstriction in asthma patients” ● Glucagon increases the effects of oral anticoagulants. ● All psych meds' (except Lithium) side effects are the same as SNS but the BP is decreased o SNS - Increase in BP, HR and RR (dilated bronchioles), dilated pupils (blurred vision), Decreased GUT (urinary retention), GIT (constipation), Constricted blood vessels and Dry mouth. Anti-Anemics ● Iron injections should be given Z-track, so they don't leak into SQ tissues. ● Take iron elixir with juice or water. ... never with milk Antiarrhythmics ● Verapamil : a calcium channel blocker, used to treat hypertension, angina; assess for constipation ● Digoxin: Check pulse, if it’s less than 60, hold medication, prior to administration check both potassium and dig levels o Pick ‘do vitals’ before administering that dig. (apical pulse for one full minute). o Making sure that patients on Digoxin and Lasix are getting enough potassium , because low potassium potentiates Digoxin toxicity and can cause dysrhythmias. o Digitalis increases ventricular irritability and could convert a rhythm to v-fib following cardioversion. ● Adenosine : is the treatment of choice for paroxysmal atrial tachycardia. ● Flecainide ( Tambocor) : Antiarrhythmics med, limit fluids and sodium intake, because sodium increases water retention which could lead to heart failure. Antianxiety ● Diazepam is a commonly used tranquilizer given to reduce anxiety before OR ● Midazolam : an anesthetic given for conscious sedation, watch out for respiratory depression and hypotension ● Chlordiazepoxide : treatment of alcohol withdrawal; don’t take alcohol with this medication, causes nausea & vomiting ● Hydroxyzine: treatment of anxiety as well as itching, commonly administered pre-op, watch out for dry mouth ● Lorazepam: treatment of choice for status epilepticus
Anti-gout Agents ● Probenecid, Colchicine, Allopurinol ● Allopurinol : Push with fluids , in order to flush the uric acid out of system; DO NOT TAKE W/ VITAMIN C Antihypertensives ● hydralazine : treatment of HTN or CHF, Report flu-like symptoms, rise slowly from sitting/lying position; take with meals. Antimanic ● Lithium : L-level of therapeutic effect is 0.5-1. I-indicate mania T-toxic level is 2-3 - nausea & vomiting, diarrhea, tremors H-hydrate 2-3L of water/day I-increased Urinary output and dry mouth U-uh oh; give Mannitol and Diamox if toxic signs and symptoms are present M-maintain Na intake of 2-3g/day ***** Antimetabolites ● Hydroxyurea: treatment of sickle cell & certain types of leukemia; when used to Tx sickle cell, report GI symptoms immediately, could be sign of toxicity Antineoplastic ● vincristine: treatment of leukemia; given IV ONLY ● Asparaginase: treatment for acute lymphoblastic leukemia; Test for hypersensitivity prior to administration Antiparkinsonian Agents ● Carbidopa-Levodopa : treatment of Parkinson; side effects include drowsiness and the patient’s sweat, saliva,
urine may occasionally turn reddish brown ; contraindicated with MAOI's
● Trihexyphenidyl treatment of Parkinson, causes sedation ● Levodopa : Contraindicated in patients’ w/ glaucoma, avoid B Antipsychotics ● Risperidone : Doses over 6mg can cause tardive dyskinesia , this is a first line antipsychotic in children
● Clozapine : Side effects include agranulocytosis , tachycardia, and seizures, WATCH FOR INFECTION*
● Thiothixene : treatment of schizophrenia; assess for EPS ● Haloperidol: preferred antipsychotic in elderly , but it has a high risk of extrapyramidal side effects (dystonia, tardive dyskinesia, tightening of jaw, stiff neck, swollen tongue, later on swollen airway) o The nurse must monitor for early signs of reaction and give IM Benadryl ● 1 st^ generation antipsychotics are the leading cause of Akathisia o Akathisia is characterized by motor restlessness, i.e. a need to keep going o Can be mistaken for agitation o Treated with Anti Parkinson's meds Anti-rheumatics ● Indomethacin: an NSAID; treatment of arthritis (osteo, rheumatoid, gouty), bursitis, and tendonitis. Antispasmodics ● dicyclomine : treatment of irritable bowel; assess for anticholinergic side effects.
Antitubercular ● Rifampin : R ed orange tears and urine (b/c it dyes bodily fluid orange); contraceptives don't work as well ● Ethambutol : messes with your E yes ● Isoniazid (INH) : treatment & prevent TB; it can cause peripheral neuritis/neuropathy (nerve damage); do not give with Phenytoin → can cause phenytoin toxicity; monitor LFT's; give B6 along with ; hypotension will occur initially, then resolve ● TB drugs are liver toxic (hepatotoxic). o An adverse reaction is peripheral neuropathy o Ask patients if they have Hep B Antithyroid ● PTU and Tapazole: Tx of hyperthyroidism & prevention of thyroid storm ● Lugol’s Solution : adjunct Tx for hyperthyroidism as well as radiation protectant. An adverse reaction: Burning sensation in the mouth, and brassy taste. Report it to the doctor. Antiulcer ● Aluminum hydroxide: treatment of GERD and kidney stones, watch out for constipation. o Long term use of amphogel (binds to phosphates, increases Ca, robs the bones...leads to increased Ca reabsorption from bone s → WEAK BONES) o Amphogel and Renegal should be taken with meals ● Sucralfate : treatment of duodenal ulcers, this medication coats the ulcer by creating a mucosal barrier, so the patient should take this medication before meals; be aware of constipation as a potential side effect ● Cimetidine : an H2 antagonist taken with food; use cautiously in the elderly population; interacts with a lot of other drugs ● Peptic ulcers caused by H. pylori are treated with Flagyl, Prilosec and Biaxin. This treatment kills bacteria and stops production of stomach acid but does not heal ulcer. Antiviral ● Ganciclovir: used for retinitis caused by cytomegalovirus, patient will need regular eye exams, report dizziness, confusion, or seizures immediately Anthelmintic/Anti-worm ● Mebendazole: Administer this medication with a high fat diet as this increase’s absorption Beta Blockers ● Timolol : treatment of glaucoma Bronchodilators ● Theo phylline : Tx of asthma or COPD; therapeutic drug level is 10-20; i ncreases the risk of digoxin toxicity and decreases the effects of lithium and Phenytoin; causes GI upset, give with food CNS Stimulants ● Dexedrine : treatment of ADHD; may alter insulin needs; avoid taking with MAOI's; take in morning (insomnia possible side effect) ● Methylphenidate : Tx of ADHD; assess for heart related side effects, report them immediately; child may need a drug holiday b/c it stunts growth. Digestive Agent ● Pancrealipase : These ar e pancreatic enzymes , which are to be taken with each meal! Not before, not after, but W/ each meal.
Endocrine Diseases Addison’s : hypoNa, hyperK, hypoglycemia, dark pigmentation , decreased resistance to stress, fractures, alopecia, weight loss, GI distress – Addison's disease (need to "add" hormone) Blood pressure is the most important assessment parameter in Addison’s, as it causes severe hypotension. Addisonian Crisis : Nausea & vomiting, confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP 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. Cushing’s : hyperNatremia, hypoKalemia, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moon-face/buffalo hump – Cushing's syndrome (have extra "cushion" of hormones) Sex Salt Sugar Addison’s ↓ ↓ ↓ Cushing’s ↑ ↑ ↑ OR Addison’s = down, down, down, up, down Cushing’s = up, up, up, down, up Addison’s = hypo natremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia Cushing’s = hypernatremia, hypertension, increased blood vol, hypokalemia, hyperglycemia Addison's disease (need to "add" hormone) Cushing's syndrome (have extra "cushion" of hormones) Diabetes Insipidus (decreased ADH) : excessive urine output and thirst, dehydration, weakness; administer Vasopressin SIADH (increased ADH): change in LOC, decreased deep tendon reflexes, tachycardia, n/v/a, HA; administer Declomycin, diuretics Hyper-parathyroid : fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) ; diet should consist
of low Ca, & high phosphorus diet (Calcium and phosphorus has inverse relationship)
● Polyuria is common with the hypercalcemia caused by hyperparathyroidism. Hypo-parathyroid : CATS – convulsions, arrhythmias, tetany, spasms, stridor, & decreased calcium; diet should consist of high Ca, & low phosphorus diet Hyperthyroidism/Graves’ disease : accelerated physical and mental function; sensitivity to heat, fine/soft hair For HYPERthyroidism think of MICHAEL JACKSON in THRILLER! SKINNY, NERVOUS, BULDGING EYES , up all night, heart beating fast Thyroid Storm : is HOT (hyperthermia), ↑ HR, & HTN Hypothyroidism/Myxedema : slowed physical and mental function, sensitivity to cold, hypothermia, dry skin and hair Post-thyroidectomy : Must watch for hypercortisolism and temporary diabetes insipidus. Position the patient in semi- Fowler’s, prevent neck flexion/hyperextension, and have trach at bedside
Pheochromocytoma : hypersecretion of too much of epi/norepi, persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding heart; avoid stress, frequent bating and rest breaks, avoid cold and stimulating foods, surgery to remove tumor Pancreatitis : Pt is placed in fetal position, maintain NPO, gut rest, prepare antecubital site for PICC b/c will probably be receiving TPN/Lipids. After pain relief, cough and deep breathe is important because of fluid pushing up in the diaphragm. Hepatitis Hepatitis A = –ends in a VOWEL , comes from the BOWEL (Hep A) Hepatitis B = Blood and Bodily fluids ● Anaphylactic reaction to baker's yeast is contraindication for Hep B vaccine. Hepatitis C = is just like B ● During the acute stage of Hep-A gown and gloves are required. ● In the convalescent stage it is no longer contagious. Eyes & Ears Ears ● Pull pinna down and back for kids < 3 yrs. when instilling eardrops Meniere's Disease ● Tx: Admin diuretics to decrease endolymph in the cochlea ● Nursing Care: restrict Na, lay on affected ear when in bed Triad: 1)Vertigo 2)Tinnitus 3)Nausea & vomiting Strabismus Treatment is BOTOX ● Patch the GOOD eye , so that the weaker eye can get stronger. ● Botox can be used with strabismus to relax vocal cords in spasmodic dysphonia. Eyes OU – Both eyes OS – Left eye OD – Right eye ( dominant Right eye – just a tip to remember) General Notes for Eyes ● Assessing extraocular eye movements check cranial nerves 3 (oculomotor), 4 (trochlear), and 6 (Abducens ). ● Glaucoma intraocular pressure is greater than the normal (22 mm Hg), give miotic to constrict (pilocarpine), NO ATROPINE ● Apply eye drop to conjunctival sac and afterwards apply pressure to nasolacrimal duct / inner canthus Fluid & Electrolyte Imbalances Hypovolemia (FVD) – increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety, urine specific gravity
1.030. (More U Specificity means urine more concentrated. More particles in urine and less dilution) Hypervolemia (FVE) – bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, hypertension, urine specific gravity <1.010; Semi-Fowler’s Fluid volume overload caused by IVC fluids infusing too quickly and CHF can cause an S3 heart sound.
Bleeding is part of the ‘ circulation ’ assessment of the ABCD ’s in an emergent situation. ● Therefore, if airway and breathing are accounted for, a compound fracture requires assessment before Glasgow Coma Scale and a neuro check (D=disability, or neuro check) Potassium ● The vital sign you should check first with high potassium is pulse (due to dysrhythmias). ● Never give potassium if the patient is oliguric or anuric (because can’t pee out the potassium = hyperkalemia) NG Tube ● An NG tube can be irrigated with cola and should be taught to family when a client is going home with an NG tube. ● An antacid should be given to a mechanically ventilated patient with an NG tube if the pH of the aspirate is <5. (because pH is low, acidic) o Aspirate should be checked at least every 12 hrs. Hemovac ● Can be used after mastectomy ● How to Clean/Empty: o Empty when full or q8hr, remove plug, empty contents, place on flat surface, cleanse opening and plug with alcohol sponge, compress evacuator completely to remove air , release plug, check system for operation.
Liver
● Liver Biopsy: o Prior to a liver biopsy it's important to be aware of the lab result for prothrombin time o NPO for 6 hrs morning of biopsy, & administer vitamin k (for clotting factors), as well as a sedative o Teach patient that he will be asked to hold breath for 5-10sec, supine position, lateral with upper arms elevated. o Post Op – position on right side, frequent vital signs, report severe abdominal pain stat, no heavy lifting 1 week. ● A patient with liver cirrhosis and edema may ambulate , then sit with legs elevated to try to mobilize the edema. ● For esophageal varices, a Sengstaken Blakemore tube is used, keep scissors at bedside (to cut the tube in an emergency situation) - U world question!!! ● Tylenol poisoning – liver failure possible for about 4 days. Close observation required during this timeframe, as well as treatment with Mucomist (Tylenol/acetaminophen antidote). Paracentesis: (removing a ton of fluid from abdomen from liver failure) ● Pre-Op – The patient should empty their bladder ● Post Op – Vital signs, report elevated temperature (for infection), observe for signs of hypovolemia. MRI ● Claustrophobia ● No metal ● Assess pacemaker Laparoscopy - ( fiber-optic instrument is inserted through the abdominal wall to view the organs in the abdomen or to permit a surgical procedure) ● CO2 used to enhance visual ● General anesthesia is administered, and a foley is inserted ● Post Op – Walk w/ patient to decrease CO2 build up used for procedure. Compartment Syndrome ~ an EMERGENCY situation
● Paresthesia and increased pain are classic symptoms!!!! ● Neuromuscular damage is irreversible, 4-6 hours after onset General Notes ● For patients with Halo device; Remember safety first & have a screwdriver nearby. (Keep the pins infection free) ● Iatrogenic means it was caused by treatment, procedure, or medication. ● A 3-way occlusive dressing is used if a chest tube is accidentally pulled out of the patient. ● Cultures are obtained before starting IV antibiotics!!!! ( what would you do first!?!) ● Orthostatic hypertension is verified by a drop- in pressure with increasing heart rate ● You will ask every new admission if he has an advance directive , and if not, you will explain it, and he will have the option to sign or not. ● A guy loses his house in a fire. Priority is using community resources to find shelter, before assisting with feelings about the tremendous loss. – (Maslow) ● No nasotracheal suctioning with head injury or skull fracture (increases intracranial pressure!!!) ● Feed upright to avoid otitis media. ● Water intoxication will be evidenced by drowsiness, and altered mental status, in patients with TURP syndrome, or as an adverse reaction to desmopressin (for diabetes insipidus). ● Other than initially to test tolerance, G-tube and J-tube feedings are usually given as continuous feedings. ● Four side-rails up can be considered a form of restraint. Even in LTC (long term care) facility when a client is a fall risk, keep lower rails down, and one side of bed against the wall, lowest position, wheels locked. Gastrointestinal Dumping syndrome : increase fat and protein , small frequent meals, lie down after meal to decrease peristalsis, wait 1 hr after meals to drink!!!!! (know!!!) Weighted NI (Naso intestinal tubes) must float from stomach to intestine. Don't tape the tube right away after placement, may leave coiled next to patient on head of bed. Position patient on RIGHT to facilitate movement through pylorus. After g-tube placement the stomach contents are drained by gravity for 24 hours before it can be used for feedings. Stomach ● Mucus in ileal conduit is expected. ● Dusky Stoma = Poor blood supply ● Protruding = Prolapsed ● Sharp pain + Rigidity = Peritonitis General Notes ● 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. “think ABC’s!!” ● Gastric Ulcer pain occurs 30 minutes to 90 minutes after eating, not at night, and doesn't go away with food. Duodenal ulcer pain goes away with food. ● Cushing’s ulcers related BRAIN injury & increased intracranial pressure. ● When you see Coffee-brown emesis, think peptic ulcer. ● Patients should not have cantaloupe before an occult stool test; because cantaloupe is high in both vitamin C, which causes a false positive for occult blood! Glasgow Coma Scale – Eyes, Verbal, Motor
- DKA – Kussmaul's breathing (Deep Rapid RR)
- BLADDER CA – painless hematuria
- BPH – reduced size & force of urine
- PEMPHIGUS VULGARIS – Nikolsky’s sign (separation of epidermis caused by rubbing of the skin)
- **RETINAL DETACHMENT – Visual Floaters, flashes of light, curtain vision
- GLAUCOMA – Painful vision loss, tunnel/gun barrel/halo vision (Peripheral Vision Loss)
- CATARACT – Painless vision loss, Opacity of the lens, blurring of vision
- RETINOBLASTOMA – Cat’s eye reflex (grayish discoloration of pupils)
- ACROMEGALY – Coarse facial feature (too much growth hormone)
- DUCHENNE’S MUSCULAR DYSTROPHY – Gowers’** sign (use of hands to push one’s self from the floor) 55. GERD – Barrett's esophagus (erosion of the lower portion of the esophageal mucosa) 56. HEPATIC ENCEPHALOPATHY – Flapping tremors 57. HYDROCEPHALUS – Bossing sign (prominent forehead) 58. INCREASE ICP – HYPERtension BRADYpnea BRADYcardia (Cushing’s Triad) 59. SHOCK – HYPOtension TACHYpnea TACHYcardia 60. MENIERE’S Disease – Vertigo, Tinnitus 61. CYSTITIS – burning on urination 62. HYPOCALCEMIA – Chvostek & Trousseaus sign 63. ULCERATIVE COLITIS – recurrent bloody diarrhea 64. LYME’S Disease – Bull’s eye rash 65. Basilar Fracture – Otorrhea 66. Orbital Fracture – Battle signs & Raccoon’s Eye
Immunology
Sepsis and anaphylaxis (along with the obvious hemorrhaging) reduce circulating volume by way of increased capillary permeability, which leads to reduced preload (volume in the left ventricle at the end of diastole). Allergies ● Basophils release histamine during an allergic response. ● Latex allergies → Assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes, peaches ● Prior to a CT scan, assess for allergies Immunizations ● Ask for allergy to eggs before Flu shot ● Age 4 to 5 yrs child needs DPT/MMR/OPV (OPV = Polio vaccine) ● If kid has cold, can still give immunizations ● MMR and Varicella immunizations come later , around 15 months. ● MMR o The MMR vaccine is given SQ not IM. o Ask for anaphylactic reaction to eggs or neomycin before MMR vaccine ● For HIV kids avoid OPV and Varicella vaccinations (live) but give Pneumococcal and influenza. o MMR is avoided only if the kid is severely immunocompromised. ● Pneumovax 23 gets administered post splenectomy to prevent pneumococcal sepsis. ● kids can get vaccines if they have mild illness (fever <101, cold, ear infection, mild diarrhea) but should be related signs and symptoms, if it is moderate-severe. ok if they are taking antibiotics but not antivirals! Leadership If one nurse discovers another nurse has made a mistake it is always appropriate to speak to her before going to management. If the situation persists, then take it higher. Delegation DO NOT delegate what you can EAT! E – evaluate A – assess T - teach Rules for Delegation RN ASSIGNMENT
● Cannot delegate assessment, teaching, or nursing judgement LPN/LVN ASSIGNMENT ● Assign stable with expected outcomes UAP ASSIGNMENT ● Delegate standard, unchanging procedures Five Rights of Delegation RIGHT TASK – scope of practice, stable client RIGHT CIRCUMSTANCES – workload RIGHT PERSON – scope of practice RIGHT COMMUNICATION – specific task to be performed, expected results, follow-up communication RIGHT SUPERVISION – clear directions, intervene if necessary Maternity/Women’s Health Fetal Heart Rate Pattern Etiology V Variable Decels C Cord compression E Early Decels H Head compression A Accels O Okay, not a problem L Late Decels P Placental Insufficiency 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) APGAR measures Skin color, HR, Reflexes, Muscle tone, RR; each section is scored between 0-2 points. 0–3 = Severely Depressed (RESUSCITATE) 4–6 = Moderately Depressed 7 –10 = Excellent (OK) Fetal alcohol syndrome -Upturned nose-Thin upper lip
- ABCs (Airway, Breathing, Circulation)
- When in distress DO NOT ASSESS! Unless 2nd^ hand information is received. -Flat nasal bridge -Small for Gestational Age Rhogam Factor ● Given at 28 weeks, 72 hours postpartum, IM. ● Only given to Rh NEGATIVE mother. ● If indirect Combs’ test is positive, don’t need to give Rhogam, because the mother already has the antibody ● Only administer if coombs’ test result is negative General Notes ● When a patient comes in and she is in active labor, the nurse’s first action is to listen to fetal heart tone/rate ● One way to remember which type of measles [ regular measles (rubeola) or German measles (rubella)] is dangerous to pregnant mothers ~ Never get pregnant with a German (rubella) ● Placental abruptio: bleeding with pain, don't forget to monitor volume status (I&O) ● If a laboring mom’s water breaks and she is any minus station , must better know there is a risk of prolapsed cord.
