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This document provides a summary of key concepts for the NCLEX exam, including:
1) It outlines essential nursing concepts like Maslow's hierarchy of needs, the nursing process, and the ABCs of emergency response.
2) It lists normal lab values for important tests like complete blood count, electrolytes, and blood gases.
3) It provides information on important medications and conditions like anticoagulants, digoxin toxicity, and more.
This document provides a summary of key concepts for the NCLEX exam, including:
1) It outlines essential nursing concepts like Maslow's hierarchy of needs, the nursing process, and the ABCs of emergency response.
2) It lists normal lab values for important tests like complete blood count, electrolytes, and blood gases.
3) It provides information on important medications and conditions like anticoagulants, digoxin toxicity, and more.
This document provides a summary of key concepts for the NCLEX exam, including:
1) It outlines essential nursing concepts like Maslow's hierarchy of needs, the nursing process, and the ABCs of emergency response.
2) It lists normal lab values for important tests like complete blood count, electrolytes, and blood gases.
3) It provides information on important medications and conditions like anticoagulants, digoxin toxicity, and more.
oMaslows Hierarchy of Needs Physiologic Safety Love and Belonging Esteem Self-actualization oNursing Process Assessment Diagnosis (Analysis) Planning Implementation (treatment) Evaluation oABCs Airway Breathing Circulation
Normal Values oHgb Males 14-18 Females 12-16 oHct Males 42-52 Females 37-47 oRBCs Males 4.7-6.1 million Females 4.2-5.4 million oWBCs 4.5-11k oPlatelets 150-400k oPT (Coumadin/Warfarin) 11-12.5 sec (INR and PT TR = 1.5-2 times normal) oAPTT (Heparin) 60-70 sec (APTT and PTT TR = 1.5-2.5 times normal) oBUN 10-20 oCreatinine 0.5-1.2 oGlucose 70-110 oCholesterol < 200 oBilirubin Newborn 1-12 oPhenylalanine Newborn < 2, Adult < 6 oNa+ 136-145 oK+ 3.5-5 HypoK+ . . . Prominent U waves, Depressed ST segment, Flat T waves HyperK+ . . . Tall T-Waves, Prolonged PR interval, wide QRS oCa++ 9-10.5 Hypocalcemia muscle spasms, convulsions, cramps/tetany, + Trousseaus, + Chvosteks, prolonged ST interval, prolonged QT segment oMg+ 1.5-2.5 oCl- 96-106 oPhos 3-4.5 oAlbumin 3.5-5 oSpec Gravity 1.005-1.030 oGlycosylated Hemoglobin (Hgb A1c): 4-6% ideal, < 7.5% = OK (120 days) oDilantin TR = 10-20 oLithium TR = 0.5-1.5 oArterial Blood Gases Used for Acidosis vs. Alkalosis PH 7.35-7.45 CO2 35-45 (Respiratory driver) High = Acidosis HCO3 21-28 (Metabolic driver) High = Alkalosis O2 80-100 O2 Sat 95-100%
Antidotes oDigoxin Digiband oCoumadin Vitamin K (Keep PT and INR @ 1-1.5 X normal) oBenzodiazapines Flumzaemil (Tomazicon) oMagnesium Sulfate Calcium Gluconate? oHeparin Protamine Sulfate (Keep APTT and PTT @ 1.5-2.5 X normal) oTylenol Mucomist (17 doses + loading dose) oOpiates (narcotic analgesics, heroin, morphine) Narcan (Naloxone) oCholinergic Meds (Myesthenic Bradycardia) Atropine oMethotrexate Leucovorin
Delegation oRN Only Blood Products (2 RNs must check) Clotting Factors Sterile dressing changes and procedures Assessments that require clinical judgment Ultimately responsible for all delegated duties oUnlicensed Assistive Personnel Non-sterile procedures
Precautions & Room Assignments oUniversal (Standard) Precautions HIV initiated Wash hands Wear Gloves Gowns for splashes Masks and Eye Protection for splashes and droplets Dont recap needles Mouthpiece or Ambu-bag for resuscitation Refrain from giving care if you have skin lesion oDroplet (Respiratory) Precautions (Wear Mask) Sepsis, Scarlet Fever, Strep, Fifth Disease (Parvo B19), Pertussis, Pneumonia, Influenza, Diptheria, Epiglottitis, Rubella, Rubeola, Meningitis, Mycoplasma, Adenovirus, Rhinovirus RSV (needs contact precautions too) TB Respiratory Isolation oContact Precautions = Universal + Goggles, Mask and Gown oNo infection patients with immunosuppressed patients
Weird Miscellaneous Stuff oRifampin (for TB) Rust/orange/red urine and body fluids oPyridium (for bladder infection) Orange/red/pink urine oGlasgow Coma Scale < 8 = coma oMyesthenia Gravis Myesthenic Crisis = Weakness with change in vitals (give more meds) Cholinergic Crisis = Weakness with no change in vitals (reduce meds) oDiabetic Coma vs. Insulin Shock Give glucose first If no help, give insulin oFruity Breath = Diabetic Ketoacidosis oAcid-Base Balance If it comes out of your ass, its Acidosis. Vomiting = Alkalosis oSkin Tastes Salty = Cystic Fibrosis oLipitor (statins) in PMs only No grapefruit juice oStroke Tongue points toward side of lesion (paralysis), Uvula deviates away from the side of lesion (paralysis) oHold Digoxin if HR < 60 oStay in bed for 3 hours after first ACE Inhibitor dose oAvoid Grapefruit juice with Ca++ Channel Blockers oAnthrax = Multi-vector biohazard oPulmonary air embolism prevention = Trendelenburg (HOB down) + on left side (to trap air in right side of heart) oHead Trauma and Seizures Maintain airway = primary concern oPeptic Ulcers Feed a Duodenal Ulcer (pain relieved by food) Starve a gastric ulcer oAcute Pancreatitis Fetal position, Bluish discoloration of flanks (Turners Sign), Bluish discoloration of pericumbelical region (Cullens Sign), Board like abdomen with guarding Self digestion of pancreas by trypsin. oHold tube feeding if residual > 100mL oIn case of Fire RACE and PASS oCheck Restraints every 30 minutes 2 fingers room underneath oGullain-Barre Syndrome Weakness progresses from legs upward Resp arrest oTrough draw = ~30 min before scheduled administration Peak Draw = 30-60 min after drug administration.
Mental Health & Psychiatry oMost suicides occur after beginning of improvement with increase in energy levels oMAOIs Hypertensive Crisis with Tyramine foods Nardil, Marplan, Parnate Need 2 wk gap from SSRIs and TCAs to admin MAOIs oLithium Therapeutic Range = 0.5-1.5 oPhenothiazines (typical antipsychotics) EPS, Photosensitivity oAtypical Antipsychotics work on positive and negative symptoms, less EPS oBenzos (Ativan, Lorazepam, etc) good for Alcohol withdrawal and Status Epilepticus oAntabuse for Alcohol deterrence Makes you sick with OH intake oAlcohol Withdrawal = Delerium Tremens Tachycardia, tachypnea, anxiety, nausea, shakes, hallucinations, paranoia (DTs start 12-36 hrs after last drink) oOpiate (Heroin, Morphine, etc.) Withdrawal = Watery eyes, runny nose, dilated pupils, NVD, cramps oStimulants Withdrawal = Depression, fatigue, anxiety, disturbed sleep
Medical-Surgical oHypoventilation = Acidosis (too much CO2) oHyperventilation = Alkalosis (low CO2) oNo BP or IV on side of Mastectomy oOpiate OD = Pinpoint Pupils oLesions of Midbrain = Decerebrate Posturing (Extended elbows, head arched back) oLesions of Cortex = Decorticate Posturing (Flexion of elbows, wrists, fingers, straight legs, mummy position) oUrine Output of 30 mL/hr = minimal competency of heart and kidney function oKidney Stone = Cholelithiasis Flank pain = stone in kidney or upper ureter Abdominal/scrotal pain = stone in mid/lower ureter or bladder oRenal Failure Restrict protein intake Fluid and electrolyte problems Watch for HyperK+ (dizzy, wk, nausea, cramps, arhythmias) Pre-renal Problem = Interference with renal perfusion Intra-renal Problem= Damage to renal parenchyma Post-renal Problem = Obstruction in UT anywhere from tubules to urethral meatus. Usually 3 phases (Oligouric, Diuretic, Recovery) Monitor Body Wt and I&Os oSteroid Effects = Moon face, hyperglycemia, acne, hirsutism, buffalo hump, mood swings, weight gain Spindle shape, osteoporosis, adrenal suppression (delayed growth in kids) . . . (Cushings Syndrome symptoms) oAddisons Crisis = medical emergency (vascular collapse, hypoglycemia, tachycardia Admin IV glucose + corticosteroids) No PO corticosteroids on empty stomach oPotassium sparing diuretic = Aldactone (Spironolactone) Watch for hyperK+ with this and ACE Inhibitors. oCardiac Enzymes Troponin (1 hr), CKMB (2-4 hr), Myoglobin (1-4 hr), LDH1 (12-24 hr) oMI Tx Nitro Yes NO Digoxin, Betablockers, Atropine oFibrinolytics = Streptokinase, Tenecteplase (TNKase) oCABG = Coronary Artery Bypass Graft oPTCA = Percutaneous Transluminal Coronary Angioplasty oSex after MI okay when able to climb 2 slights of stairs without exertion (Take nitro prophylactically before sex) oBPH Tx = TURP (Transurethral Resection of Prostate) some blood for 4 days, and burning for 7 days post-TURP. oOnly isotonic sterile saline for Bladder Irrigation oPost Thyroidectomy Keep tracheostomy set by the bed with O2, suction and Calcium gluconate oPericarditis Pericardial Friction Rub, Pain relieved by leaning forward oPost Strep URI Diseases and Conditions: Acute Glomerulonephritis Rheumatic Fever Valve Disease Scarlet Fever oIf a chest-tube becomes disconnected, do not clamp Put end in sterile water oChest Tube drainage system should show bubbling and water level fluctuations (tidaling with breathing) oTB Treatment with multidrug regimen for 9 months Rifampin reduces effectiveness of OCs and turns pee orange Isoniazide (INH) increases Dilantin blood levels oUse bronchodilators before steroids for asthma Exhale completely, Inhale deeply, Hold breath for 10 seconds oVentilators Make sure alarms are on Check every 4 hours minimum oSuctioning Pre and Post oxygenate with 100% O2 No more than 3 passes No longer than 15 seconds Suction on withdrawal with rotation oCOPD: Emphysema = Pink Puffer Chronic Bronchitis = Blue Bloater (Cyanosis, Rt sided heart failure = bloating/edema) oO2 Administration Never more than 6L/min by cannula Must humidify with more than 4L/hr No more than 2L/min with COPD (CO2 Narcosis) In ascending order of delivery potency: Nasal Cannula, Simple Face Mask, Nonrebreather Mask, Partial Rebreather Mask, Venturi Mask Restlessness and Irritability = Early signs of cerebral hypoxia IVs and Blood Product Administration o18-19 gauge needle for blood with filter in tubing oRun blood with NS only and within 30 minutes of hanging oVitals and Breath Sounds before, during and after infusion (15 min after start, then 30 min later, then hourly up to 1 hr after) oCheck Blood: Exp Date, clots, color, air bubbles, leaks o2 RNs must check order, pt, blood product Ask Pt about previous transfusion Hx oStay with Pt for first 15 minutes If transfusion rxn Stop and KVO with NS oPre-medicate with Benadryl prn for previous urticaria rxns oIsotonic Solutions D5W NS (0.9% NaCl) Ringers Lactate NS only with blood products and Dilantin Diabetes and Insulin oWhen in doubt Treat for Hypoglycemia first oFirst IV for DKA = NS, then infuse regular insulin IV as Rxd oHypoglycemia confusion, HA, irritable, nausea, sweating, tremors, hunger, slurring oHyperglycemia weakness, syncope, polydipsia, polyuria, blurred vision, fruity breath oInsulin may be kept at room T for 28 days oDraw Regular (Clear) insulin into syringe first when mixing insulins oRotate Injection Sites (Rotate in 1 region, then move to new region) oRapid Acting Insulins Lispro (Humalog) and Aspart (Novolog) O: 5-15 min, P: .75-1.5 hrs oShort Acting Insulin Regular (human) O: 30-60 min, P: 2-3 hrs (IV Okay) oIntermediate Acting Insulin Isophane Insulin (NPH) O: 1-2 hrs, P: 6-12 hrs oLong Acting Insulin Insulin Glargine (Lantus) O: 1.1 hr, P: 14-20 hrs (Dont Mix) oOral Hypoglycemics decrease glucose levels by stimulating insulin production by beta cells of pancreas, increasing insulin sensitivity and decreasing hepatic glucose production Glyburide, Metformin (Glucophage), Avandia, Actos Acarbose blunts sugar levels after meals Oncology oLeukemia Anemia (reduced RBC production), Immunosuppression (neutropenia and immature WBCs), Hemorrhage and bleeding tendencies (thrombocytopenia) Acute Lymphocytic = most common type, kids, best prognosis oTesticular Cancer Painless lump or swelling testicle STE in shower > 14 yrs 15-35 = Age oProstate Cancer > 40 = Age PSA elevation DRE Mets to spine, hips, legs Elevated PAP (prostate acid phosphatase) TRUS = Transurethral US Post Op Monitor of hemorrhage and cardiovascular complication oCervical and Uterine Cancer Laser, cryotherapy, radiation, conization, hysterectomy, exenteration Chemotherapy = No help PAP smears should start within 3 years of intercourse or by age 21 oOvarian Cancer = leading cause of death from gynecological cancer oBreast Cancer = Leading cause of cancer in women Upper outer quadrant, left > right Monthly SBE Mammography Baseline @ 35, Annually after age 50 Mets to lymph nodes, then lungs, liver, brain, spine Mastectomy Radical Mastectomy = Lymph nodes too (but no mm resected) Avoid BP measurements, injections and venipuncture on surgical side oAnti-emetics given with Chemotherapy Agents (Cytoxan, Methotrexate, Interferon, etc.) Phenergan (Promethazine HCl) Compazine (Prochlorperazine) Reglan (Metocolpramide) Benadryl (Diphenhydramine) Zofran (Ondansetron HCl) Kytril (Granisetron) Sexually Transmitted Diseases oSyphilis (Treponema pallidum) Chancre + red painless lesion (Primary Stage, 90 days) ... Secondary Stage (up to 6 mo) = Rash on palms and soles + Flu-like symptoms Tertiary Stage = Neurologic and Cardiac destruction (10-30 yrs) Treated with Penicillin G IM. oGonorrhea (Neisseria Gonorrhea) Yellow green urethral discharge (The Clap) oChlamydia (Chlamydia Trachomatis) Mild vaginal discharge or urethritis Doxycyclin, Tetracycline oTrichomoniasis (Trichomonas Vaginalis) Frothy foul-smelling vaginal discharge Flagyl oCandidiasis (Candida Albicans) Yellow, cheesy discharge with itching Miconazole, Nystatin, Clomitrazole (Gyne-Lotrimin) oHerpes Simplex 2 Acyclovir oHPV (Human Pappilovirus) Acid, Laser, Cryotherapy oHIV Cocktails
Perioperative Care oBreathing Es taught in advance (before or early in pre-op) oRemove nail polish (need to see cap refill) oPre Op Meds as ordered, NPO X 8 hrs, Incentive Spirometry & Breathing Es taught in advance, Void, No NSAIDS X 48 hrs oIncreased corticosteroids for surgery (stress) May need to increase insulin too oPost Op restlessness may = hemorrhage, hypoxia oWound dehiscence or extravisation Wet sterile NS dressing + Call Dr. oCall Dr. post op if < 30 mL/hr urine, Sys BP < 90, T > 100 or < 96 oPost Op Monitoring VS and BS Every 15 minutes the first hour, Every 30 min next 2 hours, Every hour the next 4 hours, then Every 4 hours prn o1-4 hrs Post Op = Immediate Stage 2-24 hrs Post Op = Intermediate Stage 1-4 days Post Op = Extended Stage oPost Op Positioning THR No Adduction past midline, No hip flexion past 90 degrees Supratentorial Sx HOB 30-45 degrees (Semi-Fowler) Infrantentorial Sx Flat Phlebitis Supine, elevate involved leg Harris Tube Rt/back/Lt to advance tube in GI Miller Abbott Tube Right side for GI advancement into small intestine Thoracocentesis Unaffected side, HOB 30-45 degrees Enema Left Sims (flow into sigmoid) Liver Biopsy Right side with pillow/towel against puncture site Cataract Sx Opp side Semi-Fowler Cardiac Catheterization Flat (HOB no more than 30 degrees), Leg straight 4-6 hrs, bed rest 6-12 hrs Burn Autograph Elevated and Immob 3-7 days Amputation Supine, elevate stump for 48 hrs Large Brain Tumor Resection On non-operative side oIncentive Spirometry Inhale slowly and completely to keep flow at 600-900, Hold breath 5 seconds, 10 times per hr oPost Op Breathing Exercises Every 2 hours Sit up straight Breath in deeply thru nose and out slowly thru pursed lips Hold last breath 3 seconds Then cough 3 times (unless abd wound reinforce/splint if cough) oWatch for Stridor after any neck/throat Sx Keep Trach kit at bed side oStaples and sutures removed in 7-14 days Keep dry until then oNo lifting over 10 lbs for 6 weeks (in general) oIf chest tube comes disconnected, put free end in container of sterile water oRemoving Chest Tube Valsalvas, or Deep breath and hold oIf chest tube drain stops fluctuating, the lung has re-inflated (or there is a problem) oKeep scissors by bed if pt has S. Blakemore Tube (for esoph varices) Sudden respiratory distress Cut inflation tubes and remove oTracheostomy patients Keep Kelly clamp and Obturator (used to insert into trachea then removed leaving cannula) at bed side oTurn off NG suction for 30 min after PO meds oNG Tube Removal Take a deep breath and hold it oStomach contents pH = < 4 (gastric juices aspirated) oNG Tube Insertion If cough and gag, back off a little, let calm, advance again with pt sipping water from straw oNG Tube Length End of nose, to era lobe, to xyphoid (~22-26 inches) oDecubitus (pressure) Ulcer Staging Stage 1 = Erythema only Stage 2 = Partial thickness Stage 3 = Full thickness to SQ Stage 4 = Full thickness + involving mm /bone
Acute Care oCVA Hemorrhagic or Embolic A-fib and A-flutter = thrombus formation Dysarthria (verbal enunciation/articulation), Apraxia (perform purposeful movements), Dysphasia (speech and verbal comprehension), Aphasia (speaking), Agraphia (writing), Alexia (reading), Dysphagia (swallowing) Left Hemisphere Lesion aphasia, agraphia, slow, cautious, anxious, memory okay Right Hemisphere Lesion cant recognize faces, loss of depth perception, impulsive behavior, confabulates, poor judgment, constantly smiles, denies illness, loss of tonal hearing oHead Injuries Even subtle changes in mood, behavior, restlessness, irritability, confusion may indicate increased ICP Change in level of responsiveness = Most important indicator of increased ICP Watch for CSF leaks from nose or ears Leakage can lead to meningitis and mask intracranial injury since usual increased ICP symps may be absent. oSpinal Cord Injuries Respiratory status paramount C3-C5 innervates diaphragm 1 wk to know ultimate prognosis Spinal Shock = Complete loss of all reflex, motor, sensory and autonomic activity below the lesion = Medical emergency Permanent paralysis if spinal cord in compressed for 12-24 hrs Hypotension and Bradycardia with any injury above T6 Bladder Infection = Common cause of death (try to keep urine acidic) oBurns Infection = Primary concern HyperK+ due to cell damage and release of intracellular K+ Give meds before dressing changes Painful Massive volumes of IV fluid given, due to fluid shift to interstitial spaces and resultant shock First Degree = Epidermis (superficial partial thickness) Second Degree = Epidermis and Dermis (deep partial thickness) Third Degree = Epidermis, Dermis, and SQ (full thickness) Rule of 9s Head and neck = 9%, UE = 9% each, LE = 18% each, Front trunk = 18%, Back Trunk = 18% Singed nasal hair and circumoral soot/burns = Smoke inhalation burns oFractures Report abnormal assessment findings promptly Compartment Syndrome may occur = Permanent damage to nerves and vessels 5 Ps of neurovascular status (important with fractures) Pain, Pallor, Pulse, Paresthesia, Paralysis Provide age-appropriate toys for kids in traction
Special Tests and Pathognomonic Signs oTensilon Test Myesthenia Gravis (+ in Myesthenic crisis, - in Cholinergic crisis) oELISA and Western Blot HIV oSweat Test Cystic Fibrosis oCheilosis = Sores on sides of mouth Riboflavin deficiency (B2) oTrousseaus Sign (Carpal spasm induced by BP cuff) Hypocalcemia (hypoparathyroidism) oChvosteks Sign (Facial spasm after facial nerve tap) Hypocalcemia (hypoparathyroidism) oBloody Diarrhea = Ulcerative Colitis oOlive-Shaped Mass (epigastric) and Projectile Vomiting = Pyloric Stenosis oCurrent Jelly Stool (blood and mucus) and Sausage-Shaped Mass in RUQ = Intussiception oMantoux Test for TB is + if 10 mm induration 48 hrs post admin (previous BCG vaccine recipients will test +) oButterfly Rash = SLE Avoid direct sunlight o5 Ps of NV functioning Pain, paresthesia, pulse, pallor, paralysis oCullens Sign (periumbelical discoloration) and Turners Sign (blue flank) = Acute Pancreatitis oMurphys Sign (Rt. costal margin pain on palp with inspiration) = GB or Liver disease oHA more severe on wakening = Brain Tumor (remove benign and malignant) oVomiting not associated with nausea = Brain Tumor oElevated ICP = Increased BP, widened pulse pressure, increased Temp oPill-Rolling Tremor = Parkinsons (Tx with Levodopa, Cardidopa) Fall precautions, rigid, stooped, shuffling oIG Bands on Electrophoresis = MS Weakness starts in upper extremities bowel/bladder affected in 90% Demyelination - Tx with ACTH, corticosteroids, Cytoxan and other immunosuppressants oReed-Sternberg Cells = Hodgkins oKoplik Spots = Rubeola (Measles) oErythema Marginatum = Rash of Rheumatic Fever oGowers Sign = Muscular Dystrophy Like Minors sign (walks up legs with hands)
Pediatrics oBench Marks Birth wt doubles at 6 months and triples at 12 months Birth length increases by 50% at 12 months Post fontanel closes by 8 wks Ant fontanel closes by 12-18 months Moro reflex disappears at 4 months Steady head control achieved at 4 months Turns over at 5-6 months Hand to hand transfers at 7 months Sits unsupported at 8 months Crawls at 10 months Walks at 10-12 months Cooing at 2 months Monosyllabic Babbling at 3-6 months, Links syllables 6-9 mo Mama, Dada + a few words at 9-12 months Throws a ball overhand at 18 months Daytime toilet training at 18 mo - 2 years 2-3 word sentences at 2 years 50% of adult Ht at 2 years Birth Length doubles at 4 years Uses scissors at 4 years Ties shoes at 5 years Girls growth spurt as early at 10 years Boys catch up ~ Age 14 Girls finish growing at ~15 Boys ~ 17 oAutosomal Recessive Diseases CF, PKU, Sickle Cell Anemia, Tay-Sachs, Albinism, 25% chance if: AS (trait only) X AS (trait only) 50% chance if: AS (trait only) X SS (disease) oAutosomal Dominant Diseases Huntingtons, Marfans, Polydactyl, Achondroplasia, Polycystic Kidney Disease 50% if one parent has the disease/trait (trait = disease in autosomal dominant) oX-Linked Recessive Diseases Muscular Dystrophy, Hemophilia A Females are carriers (never have the disease) Males have the disease (but cant pass it on) 50% chance daughters will be carriers (cant have disease) 50% chance sons will have the disease (not a carrier = cant pass it on) This translates to an overall 25% chance that each pregnancy will result in a child that has the disease oScoliosis Milwaukee Brace 23 hrs/day, Log rolling after Sx oDown Syndrome = Trisomy 21 Simian creases on palms, hypotonia, protruding tongue, upward outward slant of eyes oCerebral Palsy Scissoring = legs extended, crossed, feet plantar-flexed oPKU leads to MR Guthrie Test Aspartame (NutraSweet) has phenylalanine in it and should not be given to PKU patient oHypothyroidism Leads to MR oPrevent Neural tube disorders with Folic Acid during PG oMyelomeningocele Cover with moist sterile water dressing and keep pressure off oHydrocephalus Signs of increased ICP are opposite of shock Shock = Increased pulse and decreased BP IICP = Decreased pulse and increased BP (+ Altered LOC = Most sensitive sign) Infants ... IICP = Bulging fontanels, high pitched cry, increased hd circum, sunset eyes, wide suture lines, lethargy Treat with peritoneal shunt dont pump shunt. Older kids IIPC = Widened pulse pressure IICP caused by suctioning, coughing, straining, and turning Try to avoid oMuscular Dystrophy X-linked Recessive, waddling gait, hyper lordosis, Gowers Sign = difficulty rising walks up legs (like Minors sign), fat pseudohypertrophy of calves. oSeizures Nothing in mouth, turn hd to side, maintain airway, dont restrain, keep safe Treat with Phenobarbitol (Luminol), Phenytoin (Dilantin: TR = 10-20 Gingival Hyperplasia), Fosphenytoin (Cerebyx), Valproic Acid (Depakene), Carbamazepine (Tegritol) oMeningitis (Bacterial) Lumbar puncture shows Increased WBC, protein, IICP and decreased glucose May lead to SIADH (Too much ADH) Water retention, fluid overload, dilutional hyponatremia oCF Kids taste salty and need enzymes sprinkled on their food oChildren with Rubella = threat to unborn siblings (may require temporary isolation from Mom during PG) oPain in young children measured with Faces pain scale oNo MMR Immunization for kids with Hx of allergic rxn to eggs or neomycin oImmunization Side Effects T < 102, redness and soreness at injection site for 3 days give Tylenol and bike pedal legs (passively) for child. oCall Physician if seizures, high fever, or high-pitched cry after immunization oAll cases of poisoning Call Poison Control Center No Ipecac! oEpiglottitis = H. influenza B Child sits upright with chin out and tongue protruding (maybe Tripod position) Prepare for intubation or trach DO NOT put anything into kids mouth oIsolate RSV patient with Contact Precautions Private room is best Use Mist Tent to provide O2 and Ribavirin Flood tent with O2 first and wipe down inside of tent periodically so you can see patient oAcute Glomerulonephritis After B strep Antigen-Antibody complexes clog up glomeruli and reduce GFR = Dark urine, proteinuria oWilms Tumor = Large kidney tumor Dont palpate oTEF = Tracheoesophageal Atresia 3 Cs of TEF = Coughing, Choking, Cyanosis oCleft Lip and Palate Post-Op Place on side, maintain Logan Bow, elbow restraints oCongenital Megacolon = Hirschsprungs Disease Lack of peristalsis due to absence of ganglionic cells in colon Suspect if no meconium w/in 24 hrs or ribbon-like foul smelling stools oIron Deficiency Anemia Give Iron on empty stomach with citrus juice (vitamin C enhances absorption), Use straw or dropper to avoid staining teeth, Tarry stools, limit milk intake < 32 oz/day oSickle Cell Disease Hydration most important SC Crisis = fever, abd pain, painful edematous hands and feet (hand-foot syndrome), arthralgia Tx + rest, hydration Avoid high altitude and strenuous activities oTonsillitis usually Strep Get PT and PTT Pre-Op (ask about Hx of bleeding) Suspect Bleeding Post- Op if frequent swallowing, vomiting blood, or clearing throat No red liquids, no straws, ice collar, soft foods Highest risk of hemorrhage = first 24 hrs and 5-10 days post-op (with sloughing of scabs) oPrimary meds for ER for respiratory distress = Sus-phrine (Epinephrine HCl) and Theophylline (Theo- dur) Bronchodilators oMust know normal respiratory rates for kids Respiratory disorders = Primary reason for most medical/ER visits for kids Newborn 30-60 1-11 mo 25-35 1-3 years 20-30 3-5 years 20-25 6-10 years 18-22 11-16 years 16-20 Cardiovascular Disorders oAcyanotic = VSD, ASD, PDA, Coarc of Aorta, Aortic Stenosis Antiprostaglandins cause closure of PDA (aorta - pulmonary artery) oCyanotic = Tetralogy of Fallot, Truncus Arteriosis (one main vessel gets mixed blood), TVG (Transposition of Great Vessels) Polycythemia common in Cyanotic disorders 3 Ts of Cyanotic Heart Disease (Tetralogy, Truncus, Transposition) oTetralogy of Fallot Unoxygenated blood pumped into aorta Pulmonary Stenosis VSD Overiding Aorta Right Ventricular Hypertrophy TET Spells Hypoxic episodes that are relieved by squatting or knee chest position oCHF can result Use Digoxin TR = 0.8-2.0 for kids oDuctus Venosus = Umbelical Vein to Inferior Vena Cava oDuctus Arteriosus = Aorta to Pulmonary Artery oRheumatic Fever Acquired Heart Disease Affects aortic and mitral valves Preceded by beta hemolytic strep infection Erythema Marginatum = Rash Elevated ASO titer and ESR Chest pain, shortness of breath (Carditis), migratory large joint pain, tachycardia (even during sleep) Treat with Penicillin G = Prophylaxis for recurrence of RF
Maternity oDay 1 of cycle = First day of menses (bleeding) Ovulation on Day 14 28 days total Sperm 3-5 days, Eggs 24 hrs Fertilization in Fallopian Tube oChadwicks Sign = Bluing of Vagina (early as 4 weeks) oHegars Sign = Softening of isthmus of cervix (8 weeks) oGoodells Sign = Softening of Cervix (8 weeks) oPregnancy Total wt gain = 25-30 lbs (11-14 kg) oIncrease calorie intake by 300 calories/day during PG Increase protein 30 g/day Increase iron, Ca++, Folic Acid, A & C oDangerous Infections with PG TORCH = Toxoplasmosis, other, Rubella, Cytomegalovirus, HPV oBraxton Hicks common throughout PG oAmniotic fluid = 800-1200 mL (< 300 mL = Oligohydramnios = fetal kidney problems) oPolyhydramnios and Macrosomia (large fetus) with Diabetes oUmbelical cord: 2 arteries, 1 vein Vein carries oxygenated blood to fetus (opposite of normal) oFHR = 120-160 oFolic Acid Deficiency = Neural tube defects oPre-term = 20-37 weeks oTerm = 38-42 weeks oPost-term = 42 weeks+ oTPAL = Term births, Pre-term births, Abortions, Living children oGravida = # of Pregnancies regardless of outcome oPara = # of Deliveries (not kids) after 20 wks gestation oNagales Rule Add 7 days to first day of last period, subtract 3 months, add 12 months = EDC oHgb and Hct a bit lower during PG due to hyperhydration oSide-lying is best position for uteroplacental perfusion (either side tho left is traditional ) o2:1 Lecithin:Sphingomyelin Ratio = Fetal lungs mature oAFP in amniotic fluid = possible neural tube defect oNeed a full bladder for Amniocentesis early in PG (but not in later PG) oLightening = Fetus drops into true pelvis oNesting Instinct = Burst of Energy just before labor oTrue Labor = Regular contractions that intensify with ambulation, LBP that radiates to abdomen, progressive dilation and effacement oStation = Negative above ischial spines, Positive below oLeopold Maneuver tries to reposition fetus for delivery oLaboring Maternal Vitals Pulse < 100 (usually a little higher than normal with PG - BP is unchanged in PG). T < 100.4 oNON-Stress Test Reactive = Healthy (FHR goes up with movements) oContraction Stress Test (Ocytocin Challenge Test) Unhealthy = Late decels noted (positive result) indicative of UPI Negative result = No late decels noted (good result) oWatch for hyporeflexia with Mag Sulfate admin . . . Diaphragmatic Inhibition Keep Calcium gluconate by the bed (antidote) oFirsts Fetal HB 8-12 weeks by Doppler, 15-20 weeks by fetoscope Fetal movement = Quickening, 14-20 weeks Showing = 14 weeks Braxton Hicks 4 months and onward oEarly Decels = Head compression = OK oVariable Decels = Cord compression = Not Good oLate Decels = Utero-placental insufficiency = BAD! oIf Variable or Late Decels Change maternal position, Stop Pitocin, Administer O2, Notify Physician oDIC Tx is with Heparin (safe in PG) Fetal Demise, Abruptio Placenta, Infection oFundal Heights 12-14 wks At level of symphysis 20 weeks 20 cm = Level of umbilicus Rises ~ 1 cm per week oStages of Labor Stage 1 = Beginning of Regular contraction to full dilation and effacement Stage 2 = 10 cm dilation to delivery Stage 3 = Delivery of Placenta Stage 4 = 1-4 Hrs following delivery oPlacenta Separation Lengthening of cord outside vagina, gush of blood, full feeling in vagina Give oxytocin after placenta is out Not before. oSchultz Presentation = Shiny side out (fetal side of placenta) oPostpartum VS Schedule Every 15 min X 1 hr Every 30 min X next 2 hours Every Hour X next 2-6 hours Then every 4 hours oNormal BM for mom within 3 days = Normal oLochia no more than 4-8 pads/day and no clots > 1 cm Fleshy smell is normal, Foul smell = infection oMassage boggy uterus to encourage involution empty bladder ASAP may need to catheterize Full bladder can lead to uterine atony and hemorrhage oTears 1st Degree = Dermis, 2nd Degree = mm/fascia, 3rd Degree = anal sphincter, 4th Degree = rectum oAPGAR = HR, R, mm tone, Reflex irritability, Color 1 and 5 minutes 7-10 = Good, 4-6 = moderate resuscitative efforts, 1-3 = mostly dead oEye care = E-mycin + Silver Nitrate for gonorrhea oPudendal Block = decreases pain in perineum and vagina No help with contraction pain oEpidural Block = T10-S5 Blocks all pain First sign = warmth or tingling in ball of foot or big toe oRegional Blocks often result in forceps or vacuum assisted births because they affect the mothers ability to push effectively oWBC counts are elevated up to 25,000 for ~10 days post partum oRho(D) immune globulin (RhoGAM) is given to Rh- mothers who deliver Rh+ kids Not given if mom has a +Coombs Test She already has developed antibodies (too late) oCaput Succedaneum = edema under scalp, crosses suture lines oCephalhematoma = blood under periosteum, does not cross suture lines oSuction Mouth first then nostrils oMoro Reflex = Startle reflex (abduction of all extremities) up to 4 months oRooting Reflex up to 4 months oBabinski Reflex up to18 months oPalmar Grasp Reflex Lessens by 4 months oBallard Scale used to estimate gestational age oHeel Stick = lateral surface of heel oPhysiologic Jaundice is normal at 2-3 days Abnormal if before 24 hours or lasting longer than 7 days Unconjugated bilirubin is the culprit. oVitamin K given to help with formation of clotting factors due to fact that the newborn gut lacks the bacteria necessary for vitamin K synthesis initially Vastus lateralis mm IM oAbrutio Placenta = Dark red bleeding with rigid board like abdomen oPlacenta Previa = Painless bright red bleeding oDIC = Disseminated Intravascular Coagulation clotting factors used up by intravascular clotting Hemorrhage and increased bleeding times result Associated with fetal demise, infection and abruptio placenta. oMagnesium Sulfate used to reduce preterm labor contractions and prevent seizures in Pre-Eclampsia Mg replaces Ca++ in the smooth mm cells resulting relaxation Can lead to hyporeflexia and respiratory depression Must keep Calcium Gluconate by bed when administering during labor = Antidote Monitor for: Absent DTRs Respirations < 12 Urinary Output < 30/hr Fetal Bradycardia oPitocin (Oxytocin) use for Dystocia If uterine tetany develops, turn off Pitocin, admin O2 by face mask, turn pt on side. Pitocin can cause water intoxication owing to ADH effects. oSuspect uterine rupture if woman complains of a sharp pain followed by cessation of contractions oPre-Eclampsia = Htn + Edema + Proteinuria oEclampsia = Htn + Edema + Proteinuria + Seizures and Coma Suspect if Severe HA + visual disturbances oNo Coumadin during PG (Heparin is OK) oHyperemesis Gravidarum = uncontrollable nausea and vomiting May be related to H. pyolori Reglan (metaclopromide) oInsulin demands drop precipitously after delivery oNo oral hypoglycemics during PG Teratogenic Insulin only for control of DM oBabies born without vaginal squeeze more likely to have respiratory difficulty initially oC-Section can lead to Paralytic Ileus Early ambulation helps oPostpartum Infection common in problem pregnancies (anemia, diabetes, traumatic birth) oPostpartum Hemorrhage = Leading cause of maternal death Risk factors include: Dystocia, prolonged labor, overdistended uterus, abrutio placenta, infection Tx includes Fundal massage, count pads, VS, IV fluids, Oxytocin, notify physician oJitteriness is a symptom of hypoglycemia and hypocalcemia in the newborn oHypoglycemia tremors, high pitched cry, seizures oHigh pitched cry + bulging fontanels = IICP oHypothermia can lead to Hypoxia and acidoisis Keep warm and use bicarbonate prn to treat acidosis in newborn. oLay on right side after feeding Move stomach contents into small intestine oJaundice and High bilirubin can cause encephalopathy < 12 = normal Phototherapy decomposes bilirubin via oxidation Protect eyes, turn every 2 hours and watch for dehydration The dangerous bilirubin is the unconjugated indirect type.
Nutrition oK+ Bananas, dried fruits, citrus, potatoes, legumes, tea, peanut butter oVitamin C Citrus, potatoes, cantaloupe oCa++ Milk, cheese, green leafy veggies, legumes oNa+ Salt, processed foods, seafood oFolic Acid Green leafy veggies, liver, citrus oFe++ Green leafy veggies, red meat, organ meat, eggs, whole wheat, carrots Use Z-track for injections to avoid skin staining oMg+ Whole grains, green leafy veggies, nuts oThiamine (B1) Pork, beef, liver, whole grains oB12 Organ meats, green leafy veggies, yeast, milk, cheese, shellfish Deficiency = Big red beefy tongue, Anemia oVitamin K Green leafy veggies, milk, meat, soy oVitamin A Liver, orange and dark green fruits and veggies oVitamin D Dairy, fish oil, sunlight oVitamin E Veggie oils, avocados, nuts, seeds oBMI 18.5-24.9 = Normal (Higher = Obese)
Gerontology oEssentially everyone goes to Hell in a progressively degenerative hand-basket Thin skin, bad sleep, mm wasting, memory loss, bladder shrinks, incontinence, delayed gastric emptying, COPD, Hypothyroidism, Diabetes
oCommon Ailments: Delerium and Dementia Cardiac Dysrhythmias Cataracts and Glaucoma CVA (usually thrombotic, TIAs common) Decubitus Ulcers Hypothyroidism Thyrotoxicosis (Graves Disease) COPD (usually combination of emphysema and CB) UTIs and Pneumonia Can cause confusion and delerium oMemory loss starts with recent progresses to full oDementia = Irreversible (Alzheimers) Depression, Sundowning, Loss of family recognition oDelerium = Secondary to another problem = Reversible (infections common cause) oMedication Alert! Due to decreased renal function, drugs metabolized by the kidneys may persist to toxic levels oWhen in doubt on NCLEX Answer should contain something about exercise and nutrition.
Advanced Clinical Concepts oErickson Psycho-Social Development 0-1 yr (Newborn) Trust vs. Mistrust 1-3 yrs (Toddler) Autonomy vs. Doubt and Shame Fear intrusive procedures - Security objects good (Blankies, stuffed animals) 3-6 yrs (Pre-school) Initiative vs. Guilt Fear mutilation Band-Aids good 6-12 yrs (School Age) Industry vs. Inferiority Games good, Peers important Fear loss of control of their bodies 12-19 yrs (Adolescent) Identity vs. Role Confusion Fear Body Image Distortion 20-35 yrs (Early Adulthood) Intimacy vs. Isolation 35-65 yrs (Middle Adulthood) Generativity vs. Stagnation Over 65 (Older Adulthood) Integrity vs. Despair oPiaget Cognitive Development Sensorimotor Stage (0-2) Learns about reality and object permanence Preoperational Stage (2-7) Concrete thinking Concrete Operational Stage (7-11) Abstract thinking Formal Operational Stage (11-adult) Abstract and logical thinking oFreud Psycho-Sexual Development Oral Stage (Birth -1 year) Self gratification, Id is in control and running wild Anal Stage (1-3) Control and pleasure wrt retention and pooping Toilet training in this stage Phallic Stage (3-6) Pleasure with genitals, Oedipus complex, SuperEgo develops Latency Stage (6-12) Sex urges channeled to culturally acceptable level, Growth of Ego Genital Stage (12 up) Gratification and satisfying sexual relations, Ego rules oKohlberg Moral Development Moral development is sequential but people do not aromatically go from one stage to the next as they mature Level 1 = Pre-conventional Reward vs. Punishment Orientation Level 2 = Conventional Morality Conforms to rules to please others Level 3 = Post- Conventional Rights, Principles and Conscience (Best for All is a concern)
Calculations Rules & Formulas oRound final answer to tenths place oRound drops to nearest drop oWhen calculating mL/hr, round to nearest full mL oMust include 0 in front of values < 1 oPediatric doses rounded to nearest 100th. Round down for peds oCalculating IV Flow Rates Total mL X Drop Factor / 60 X #Hrs = Flow Rate in gtts/min oCalculating Infusion Times Total mL X Drop Factor / Flow Rate in gtts/min X 60 = Hrs to Infuse
Conversions o1 t = 5mL o1 T = 3 t = 15 mL o1 oz = 30 cc = 30 mL = 2 T o1 gr = 60 mg o1 mg = 1000 ug (or mcg) o1 kg = 2.2 lbs o1 cup = 8 oz = 240 mL o1 pint = 16 oz o1 quart = 32 oz oDegrees F = (1.8 X C) + 32 oDegrees C = (F 32) / 1.8 37 C = 98.6 F 38 C = 100.4 F 39 C = 102.2 F 40 C = 104 F
Fall Precautions oRoom close to nurses station oAssessment and orientation to room oGet help to stand (dangle feet if light headed) oBed low with side rails up oGood lighting and reduce clutter in room oKeep consistent toileting schedule oWear proper non-slip footwear oAt home Paint edges of stairs bright color Bell on cats and dogs
Neutropenic (Immunosuppressed) Precautions oNo plants or flowers in room oNo fresh veggies Cooked foods only oAvoid crowds and infectious persons oMeticulous hand washing and hygiene to prevent infection oReport fever > 100.5 (immunosuppressed pts may not manifest fever with infection)
Bleeding Precautions (Anticoagulants, etc.) oSoft bristled tooth brush oElectric razor only (no safety razors) oHandle gently, Limit contact sports oRotate injection sites with small bore needles for blood thinners oLimit needle sticks, Use small bore needles, Maintain pressure for 5 minutes on venipuncture sites oNo straining at stool - Check stools for occult blood (Stool softeners prn) oNo salicylates, NSAIDs, or suppositories oAvoid blowing or picking nose oDo not change Vitamin K intake if on Coumadin