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HESI Hints & NCLEX Gems

Answering NCLEX Questions


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