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
1st 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 not ask ‘why’ questions
● Do provide information ● Do not ask ‘yes/no’ questions, except in the case of possible self-harm
● Do focus on the client ● Do not focus on the nurse
● Do use silence ● Do not explore
● Do use presence ● Do not say, “Don’t worry!”
Who Do You See First?

Consider:
∙ Unstable vs. Stable ∙ Acute vs. Chronic
∙ Unexpected vs. Expected ∙ Actual vs. Potential
∙ ABCs
Common NCLEX Traps
∙ Do not ask “Why?” ∙ Do not ‘do nothing.’
∙ Do not leave the client. ∙ Do not read into the question
∙ Do not persuade the client. ∙ Do not pass the buck.
∙ Do not say, “Don’t worry!”

Strategies
● Only use textbook nursing – textbook knowledge
● Pain is psychosocial, unless, it’s severe, acute, & unrelenting
● If it’s a position question, is it going to prevent or promote something – position, prevent, promote
● Teaching/learning – use T/F on each answer
● Risk Questions – use Risk Factors
● If the answers have an absolute in them, do not pick them
● Question that have the phrase ‘And Then’ – did they miss something

Important Lab Values

WBC 4K – 11K
RBC 4–6
Hgb 12 – 16, 0r 12-18
Hct 36 – 48, or 37-52
Plt 150K – 400K
BUN 8 – 20, or 7-22
Cr/Lithium 0.6 – 1.2
Urine 85 – 135,
Clearance (GFR)=maintain above
60

Uric Acid 250 – 750 mg

Na 135 – 145
Cl 98 – 106
Ca 8.5 – 10.5
K 3.5 – 5.0
PO 2.5 – 4.5g
Mag 1.5 – 2.5, 4-7 if pregnant
and receiving Toco

Warfarin INR 2.0 – 3.5

Heparin PT 10 – 13 Seconds
PTT 25 – 35 Seconds

Therapeutic PTT: 1.5 – 2x the normal value (46 – 76 Seconds)

Cholesterol
HDL x> 50
LDL x< 100
Triglycerides x< 150
Total Cholesterol x< 200

Therapeutic Ranges
Dilantin Theophylline 10 – 20
Acetaminophen
Digoxin 0.5 – 2.0

Albumin level 3.5 to 5.5

Acid-Base Balance
From the ass (diarrhea) –Metabolic Acidosis
From the mouth (vomitus) –Metabolic Alkalosis

Potassium & Alkalosis – ALKALOSIS: 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
● The 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) → Digiband\ (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 Thrombocytopenia – Bleeding precautions!
2)Frequent swallowing 1)Soft bristled toothbrush
3)Rashes 2)No insertion of anything! (c/i suppositories, douche)
4)Fever 3)No IM meds as much as possible!
5)Chills

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 b12

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
Cardiac
All – Aortic Valve
Physicians – Pulmonary Valve
Earn – Erb’s Point
Their – Tricuspid Valve
Money – Mitral Valve (PMI)
Or APE To Man

Cardiac Catheter
● Pre-Op – NPO 8-12hr prior, empty bladder, check pulses, tell pt they may feel heat, palpitations, or desire
to cough with dye injection.
● Post Op – V/S, & keep leg straight, bed rest 6-8 hrs, Sleep supine.

General Notes
● Blood tests for MI: Myoglobin, CK and Troponin
● Coarctation of the aorta causes increased blood flow and bounding pulses in the arms
● Cor Pulmonale is right sided heart failure caused by left ventricular failure; (so pick edema, JVD, if it is a
choice.)
● Normal PCWP (pulmonary capillary wedge pressure) is 8-13. Readings of 18-20 are considered high.
● Pulmonary sarcoidosis (an inflammatory disease) leads to right sided heart failure.
● Anytime you see fluid retention. Think heart problems first.

Circulation
EleVate Veins; dAngle Arteries for better perfusion
For PVD remember DAVE (Legs are Dependent for Arterial & for Venous Elevated)

Virchow’s Triad → Risk Factors for DVT

V – Vascular Trauma
I – Increased Coagulability
R – Reduced Blood Flow

–Definitive diagnosis for abdominal aortic aneurysm (AAA) → CT scan

Fat Embolism S/S

● Blood tinged sputum (related to inflammation) <Pink frothy sputum>
● increased erthyro sedimentation rate (ESR)
● Respiratory alkalosis (related to tachypnea)
● Hypocalcemia, increased serum lipids
● "Snow Storm" effect on Chest x-ray

General Notes
● Hypotension and vasoconstriction meds may alter the accuracy of O2 sats.
● A newly diagnosed hypertension patient should have BP assessed in both arms
 Cranial Nerves
Sensory=S Motor=M Both=B

1. Oh (Olfactory I) Some
2. Oh (Optic II) Say
3. Oh (Oculomotor III) Marry
4. To (Trochlear IV) Money
5. Touch (Trigeminal V) But
6. And (Abducens VI) My
7. Feel (Facial VII) Brother
8. Very (Vestibulocochlear/Auditory VIII) Says
9. Good (Glossopharyngeal IX) Big
10. Velvet (Vagus X) Brains
11. Such (Spinal Accessory XI) Matter
12. 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:Nicole Richie RN <Regular is clear & don't wanna put dirty needle in clear so Regular<CLOUDY> is pulled in first>
Air into NPH, then air into Regular, draw up Regular 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-asthmatics
● INtal<cromolyn sodium aerosol>: an inhaler used to treat allergy induced asthma may cause bronchospasm,
 think... INto the asthmatic lung

Antibiotic
● Aminoglycosides: Adverse Effects are bean shaped - Nephrotoxic to Kidneys and Ototoxic to Ears
o __Mycin (drugs that end in or have in their name); except erythromycin (have -thro- in drug name)
● Sulfamethoxazole/trimethoprim: an antibiotic; common side effect is diarrhea (drink plenty of fluids); do not
take if allergic to sulfa drugs

Anticholinergic---- INE ending**

● Anticholinergic effects –– assessment
o dry mouth – can't spit
o urinary retention – can't piss
o constipated – can't shit
o blurred vision – can't see
● Atropine used to decrease secretions & asystole
o Atropine blocks acetylcholine (remember acetylcholine reduces secretions)
o Atropine OD
Hot as a Hare (Temp)
Mad as a Hatter (LOC)
Red as a Beet (flushed face)
Dry as a Bone (Thirsty)
● Benztropine: Treats Parkinson as well as extrapyramidal side effects of other drugs

Anticonvulsants
● Phenytoin <Dilantin>: treatment of seizures; therapeutic drug level: 10-20; contraindicated during pregnancy;
Side effects include rash (stop med if seen), gingival hyperplasia (can be prevented w/ good hygiene).
o Dilantin Toxicity → poor gait + coordination, slurred speech, nausea, lethargy, & diplopia
● Phenobarbital: treatment of epilepsy; can be taken during pregnancy

Antidepressants
● Zoloft/Sertraline: side effects include agitation, sleep disturb, and dry mouth (SSRI)
● MAOI’s: antidepressant
o An easy way to remember MAOI'S! think of PANAMA!
PA – parnate- Tranylcypromine
NA – nardil- Phenelzine
MA – marplan- Isocarboxazid
o MAOI's used for depression all have an arrr sound in the middle (Parnate, Marplan, Nardil) – Remember
that Pirates say arrr, so think “pirates take MAOI's when they're depressed”
o They have metallic bitter taste

Antifungal
● Amphotericin B: This medication causes hypokalemia (amongst many other side effects as well); patient will
most likely get a fever; pre-medicate with acetaminophen and/or diphenhydramine (preferably both) before
administering to a patient

Antiemetic should
● Trimethobenzamide <Tigan>: Treatment of postop nausea and vomiting, and for nausea associated with
gastroenteritis
● Promethazine <Phenergan>: an antiemetic used to reduce nausea
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 0.5-1.5
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 B6

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
● 1st 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: Red orange tears and urine (b/c it dyes bodily fluid orange); contraceptives don't work as well
● Ethambutol: messes with your Eyes
● 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 bones → 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
● Theophylline: Tx of asthma or COPD; therapeutic drug level is 10-20; increases 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 are pancreatic enzymes, which are to be taken with each meal! Not before, not after, but
W/ each meal.
Diuretics
● Mannitol (osmotic diuretic): used for Head injuries; it crystallizes at room temp so ALWAYS use filter needle
● Acetazolamide: Tx of glaucoma, & high-altitude sickness; do not take if allergic to sulfa drugs; may cause
hypokalemia
● Lasix: Tx of edema due to heart failure; can cause a patient to lose his appetite (anorexia) due to reduced
potassium
o Patients receiving Lasix and Dig, need to be getting enough potassium, b/c low potassium potentiates
Dig Toxicity and can cause dysrhythmias.

Hormones
● Levothyroxine: Tx of hypothyroidism, this medication may take several weeks to take effect; notify doctor of
chest pain; take in the AM on empty stomach; may cause hyperthyroidism
o Insomnia is a side effect of thyroid hormones (Ex: Synthroid) → Increases met. rate, your body is "too
busy to sleep" as opposed to the folks with hypothyroidism who may report somnolence (dec. met rate,
body is slow and sleepy).
● Conjugated estrogens: treatment occurs after menopause for estrogen replacement

Hypokalemic
● Sodium Polystyrene Sulfonate: When giving administering this drug, we need to worry about dehydration (K
has inverse relationship with Na)
o Don’t use this medication if patient has hypoactive bowel sounds.

Opioid Analgesics
● Meperidine <Demerol>: Tx for moderate to severe pain; used for patients with pancreatitis (these patients
could NOT receive morphine sulfate); Do not give Demerol to pts. with sickle cell crisis

Pediculocides
● Lindane <Antiparasite>: Tx of scabies and lice;
o Scabies ~ apply lotion once and leave on for 8-12 hours
o Lice ~ use the shampoo and leave on for 4 minutes with hair uncovered then rinse with warm water and
comb with a fine-tooth comb

Skeletal Muscle Relaxant

● Dantrolene: treatment for spasticity, associated w/ spinal cord injury, stroke, cerebral palsy, or MS; it may take
a week or more to be effective.
● succinylcholine: is used for short-term neuromuscular blocking agent for procedures like intubation and ECT.
● Vecuronium Bromide: an adjunct medication for general anesthesia-induced muscle relaxation for endotracheal
intubation/mechanical ventilation, it’s used for intermediate or long-term.

Statins
● Simvastatin’s: Treatment for hyperlipidemia; take on empty stomach to enhance absorption; report any
unexplained muscle pain, especially if fever is present

Sympathomimetic
● Dopamine (Intropine): Tx of hypotension, shock, low cardiac output, poor perfusion to vital organs; monitor
EKG for arrhythmias, and BP

Vasodilators
● Nitroprusside: When the patient is on this medication, monitor thiocyanate (cyanide). The normal value
should be 1, >1 is heading toward toxicity
 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= hyponatremia, 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.
Hyponatremia: nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic diuretics, fluids
Hypernatremia (greater than 145: increased temp, weakness, disorientation/delusions, hypotension, tachycardia;
hypotonic solution
Remember…. Hypernatremia presents similarly to Fluid Volume Deficit
Hyponatremia presents similarly to Fluid Volume Excess
Remember SALT… Skin flushed
Agitation
Low grade fever
Thirst

Hypokalemia: muscle weakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges, beans, potatoes, carrots,
celery)
No Pee, no K (do not give potassium without adequate urine output)
Hyperkalemia: MURDER – Muscle weakness, Urine (oliguria/anuria), Respiratory depression, Decreased cardiac
contractility, ECG changes, Reflexes

Hypocalcemia <Non sedation>: CATS – convulsions, arrhythmias, tetany, spasms and stridor

Hypercalcemia <Sedative effect>: muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon
reflexes, sedative effect on CNS

HypoMg <Non sedative effect>: tremors, tetany, seizures, dysrhythmias, depression, confusion, dysphagia; dig toxicity
(not enough magnesium, everything goes up)
HyperMg <Sedative effect>: depresses the CNS, hypotension, facial flushing, muscle weakness, absent deep tendon
reflexes, shallow respirations, emergency (More magnesium, everything goes down)

Fundamental Skills
Order of Assessment Order of Assessment for Abdomen/Children
Inspection Inspection ∙ Bowels Sounds may be obstructed and not
Auscultation Auscultation heard, if performed out of order
Palpation Percussion
Percussion Palpation ∙ In Kids, go from least to most invasive

If your normally lucid patient starts seeing bugs you better check his respiratory status first. The first sign of hypoxia is
restlessness, followed by agitation, and things go downhill from there all the way to delirium, hallucinations, and coma.
So, check the o2 stat, and get ABG’s if possible.

The immediate intervention after a sucking stab wound is to dress the wound and tape it on three sides which allows air
to escape. Do not use an occlusive dressing, which could convert the wound from open pneumo to closed one, and a
tension pneumothorax is worse situation. After that get your chest tube tray, labs, iv.

An example of when you would implement before going through a bunch of assessments is when someone is
experiencing anaphylaxis. Get the ordered epinephrine in them stat, especially if the stem clearly states the s/s
(difficulty breathing, increasing anxiety, etc.)

Radioactive iodine – The key word here is flush. Flush substance out of body w/3-4 liters/day for 2 days and flush the
toilet twice after using for 2 days. Limit contact w/patient to 30 minutes/day. No pregnant visitors/nurses, and no kids.

Role-Relationship Pattern, a nursing diagnosis focused on the person’s roles in the world and relationships with others.
To access the role relationship pattern, focus on image, and relationships with others.
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 <5.0
(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!!!! <No relief from Opioids>
● Neuromuscular damage is irreversible, 4-6hours 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

Remember… < than 8 intubate
It is similar to measuring dating skills...max 15 points -one can do it if below 8 you are in Coma.
EYES: So, to start dating you got to open your EYES first, if you able to do that spontaneously and use them correctly to
SEE whom you dating you earn 4. But if she has to scream on you to make youopen them it is only 3....and 1 you don’t
care to open even if she tries to hurt you.
VERBAL: If you get good EYE contact (4 points) then move to VERBAL. Talk to her/ him! If you can do that You are really
ORIENTED insituation she/he unconsciously gives you 4 points! if you like her try not to be CONFUSED (3), and of course
do not use INAPPROPRIATE WORDS (3), she will not like it, try not to RESPOND WITH INCOMPREHENSIBLE SOUNDS (2), if
you do not like her –just show no VERBAL RESPONSE(1)
MOTOR: Since you've got EYE and VERBAL contact you can MOVE now using your Motor Response Points. This is VERY
important since Good moves give you 6!

Decorticate is toward the 'core'.

Decerebrate the other way (out).
Decorticate positioning in response to pain = Cortex involvement
Decerebrate in response to pain = Cerebellar, brain stem involvement (this is the worst one)

Hallmark Signs of Symptoms

01. Pulmonary TB (pulm-TB) – low-grade afternoon 24. PDA – machine like murmur.
fever. 25. ADDISON’S DISEASE – bronze like skin pigmentation.
02. PNEUMONIA – rusty sputum or pink frothy sputum. 26. CUSHING’S SYNDROME – moon face appearance
03. ASTHMA – wheezing on expiration. and buffalo hump.
04. EMPHYSEMA – barrel chest. 27. HYPERTHYROIDISM/GRAVE’S DISEASE –
05. KAWASAKI SYNDROME – strawberry tongue. exophthalmos.
06. PERNICIOUS ANEMIA – red beefy tongue (need 28. INTUSSUSCEPTION – sausage shaped mass, Dance
vitamin B12). Sign (empty portion of RLQ)
07. DOWN SYNDROME – protruding tongue. 29. Multiple Sclerosis – Charcot’s Triad (IAN)-
08. CHOLERA – rice watery stool. nystagmus, intention tremor, and scanning or
09. MALARIA – step ladder like fever with chills. staccato speech.
10. TYPHOID – rose spots in abdomen. 30. Multi-Gravitis – descending muscle weakness
11. DIPTHERIA (infection of nose and throat)– pseudo 31. Guillain Barre Syndrome – ascending muscle
membrane formation weakness
12. MEASLES – Koplick’s spots are red spots with blue 32. DVT – Homan’s Sign
center, usually in the mouth 33. CHICKEN POX – Vesicular Rash (central to distal)
13. Systemic Lupus E – butterfly rashes. dew drop on rose petal
14. LIVER CIRRHOSIS – spider like varices. 34. ANGINA – Crushing stabbing pain relieved by NTG
15. LEPROSY – leonine face (skin lesions and nerve 35. MI – Crushing stabbing pain which radiates to left
damage) shoulder, neck, arms, unrelieved by NTG
16. BULIMIA – chipmunk face. 36. Latent TB (latent-TB) – inspiratory stridor
17. APPENDICITIS – rebound tenderness. 37. TEF (trach-esoph-fist) – 4Cs’ Coughing, Choking,
18. DENGUE (fever from mosquitos) - petechiae or (+) Cyanosis, Continuous Drooling
Herman’s sign. 38. EPIGLOTTITIS – 3Ds’ Drooling, Dysphonia,
19. MENINGITIS – Kernig’s sign (leg flex then leg pain Dysphagia
on extension), Brudzinski sign (neck flex = lower leg 39. HODGKIN'S DSE/LYMPHOMA – painless,
flex). progressive enlargement of spleen & lymph tissues,
20. TETANY – hypocalcemia (+) Trousseau’s Reed Sternberg Cells
sign/carpopedal spasm; Chvostek sign (facial spasm). 40. INFECTIOUS MONONUCLEOSIS – Hallmark: sore
21. TETANUS – risus sardonicus (grinning facial spasm). throat, cervical lymphadenopathy, fever
22. PANCREATITIS – Cullen’s sign (ecchymosis of 41. PARKINSON’S – Pill-rolling tremors
umbilicus); (+) Grey turner's spots. 42. FIBRIN HYALIN – Expiratory Grunt
23. PYLORIC STENOSIS – olive like mass. 43. CYSTIC FIBROSIS – Salty skin
44. DM – polyuria, polydipsia, polyphagia
45. DKA – Kussmaul's breathing (Deep Rapid RR) sign (use of hands to push one’s self from the floor)
46. BLADDER CA – painless hematuria 55. GERD – Barrett's esophagus (erosion of the lower
47. BPH – reduced size & force of urine portion of the esophageal mucosa)
48. PEMPHIGUS VULGARIS – Nikolsky’s sign (separation 56. HEPATIC ENCEPHALOPATHY – Flapping tremors
of epidermis caused by rubbing of the skin) 57. HYDROCEPHALUS – Bossing sign (prominent
49. RETINAL DETACHMENT – Visual Floaters, flashes of forehead)
light, curtain vision 58. INCREASE ICP – HYPERtension BRADYpnea
50. GLAUCOMA – Painful vision loss, tunnel/gun BRADYcardia (Cushing’s Triad)
barrel/halo vision (Peripheral Vision Loss) 59. SHOCK – HYPOtension TACHYpnea TACHYcardia
51. CATARACT – Painless vision loss, Opacity of the 60. MENIERE’S Disease – Vertigo, Tinnitus
lens, blurring of vision 61. CYSTITIS – burning on urination
52. RETINOBLASTOMA – Cat’s eye reflex (grayish 62. HYPOCALCEMIA – Chvostek & Trousseaus sign
discoloration of pupils) 63. ULCERATIVE COLITIS – recurrent bloody diarrhea
53. ACROMEGALY – Coarse facial feature (too much 64. LYME’S Disease – Bull’s eye rash
growth hormone) 65. Basilar Fracture – Otorrhea
54. DUCHENNE’S MUSCULAR DYSTROPHY – Gowers’ 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 12-15 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

1. ABCs (Airway, Breathing, Circulation)

2. 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.
 (because baby is inside above ischial spine and can compress the cord)
● For cord compression, place the mother in the TRENDELENBURG position because this removes pressure of the
presenting part off the cord. (If her head is down, the baby is no longer being pulled out of the body by gravity) or
hands and knees position.
● If the cord is prolapsed, cover it with sterile saline gauze to prevent drying of the cord and to minimize infection.
● For late decelerations, turn the mother to her left side, to allow more blood flow to the placenta (because late
decelerations = placenta deficiency)
● For any kind of bad fetal heart rate pattern, you give O2, often by mask
● When doing an epidural anesthesia, hydration before-hand is a priority (because causes hypotension).
● Hypotension and bradypnea / bradycardia are major risks and emergencies.
● NEVER check the monitor or a machine as a first action. Always assess the patient first!!
o For example: listen to the fetal heart tones with a stethoscope in NCLEX land.
● Sometimes it's hard to tell who to check on first, the mother or the baby; it's usually easy to tell the right answer if
the mother or baby involves a machine. If you're not sure who to check first, and one of the choices involves the
machine, that's the wrong answer.
● If the baby is in a posterior presentation, the sounds are heard at the sides.
● If the baby is anterior, the sounds are heard closer to midline, between the umbilicus and where you would listen
to a posterior presentation (because anterior is in front/close to midline)
● If the baby is breech, the sounds are high up in the fundus near the umbilicus (because head is up, feet down first)
● If the baby is vertex, they are a little bit above the symphysis pubis. (vertex= head first, so breath sounds right
above pubis bone)
● Best way to warm a newborn: skin to skin contact covered with a blanket on mom.
● Amniotic fluid is alkaline and turns nitrazine paper blue. Urine and normal vaginal discharge are acidic and turn it
pink. Pink for acid and Blue for Alkaline.
● Amniotic fluid yellow with particles = meconium stained
● Cephalohematoma (caput succedaneum) resolves on its own in a few days. This is the type of edema that crosses
the suture lines.
● The biggest concern with cold stress and the newborn is respiratory distress!
● Glucose Tolerance Test for preggies, a result of 140 or higher needs further evaluation.

Medical (Diagnostic) Signs

Murphy’s sign – pain with palpation of gallbladder area seen with cholecystitis

Cullen’s sign – ecchymosis in umbilical area, seen with pancreatitis

Turner’s sign – flank grayish blue (turn around to see your flanks) pancreatitis

McBurney’s Point – RLQ pain indicative of appendicitis

LLQ Pain – diverticulitis, low residue, no seeds, nuts, peas

RLQ Pain – appendicitis, watch for peritonitis

Guthrie Test – Tests for PKU, baby should have eaten source of protein first

Allen’s test – Occlude both ulnar and radial artery until hand blanches then release ulnar. If the hand pinks up, ulnar
artery is good, and you can carry on with ABG/radial stick as planned. ABGS must be put on ice and whisked to the lab.

Trendelenburg Test – A tests for varicose veins. Pt is supine, and the leg is flexed at the hip and raised above the level of
the heart. The veins will empty due gravity or with assistance from the examiner’s hand squeezing blood towards the
heart → If they fill proximally = varicosity.

Babinski Sign – Assessment for nervous system problems.

 Toes curl = - sign |Normal in adults & kids above 2 yrs| Abnormal in kids 2 yrs & under
Toes fan = + sign |Abnormal in adults & kids above 2 yrs| Normal in kids 2 yrs & under

Mental Health
Remember with Psych patients, SAFETY is the #1 Priority

Munchausen Syndrome is a psychiatric disorder that causes an individual to self-inflict injury or illness or to fabricate
symptoms of physical or mental illness, in order to receive medical care or hospitalization.
In a variation of the disorder, Munchausen by proxy (MSBP), an individual, typically a mother, intentionally causes or
fabricates illness in a child or other person under her care.

Neuroleptic malignant syndrome (NMS): ~ rxn to antipsychotic medications

-NMS is like S&M;
-you get hot (hyperpyrexia)
-stiff (increased muscle tone)
-sweaty (diaphoresis)
-BP, pulse, and respirations go up &
-you start to drool

General Notes
● Tardive Dyskinesia – irreversible – involuntary movements of the tongue, face and extremities, may happen after
prolonged use of antipsychotics
● Depression often manifests itself in somatic ways, such as psychomotor retardation, GI complaints, and pain.
● For phobic disorders, use systematic desensitization.
● Safety over Nutrition with a severely depressed client.
● Absence of menstruation leads to osteoporosis in the anorexic.

Musculoskeletal/Neurological
ICP AND SHOCK HAVE OPPOSITE V/S
Shock Cushing’s Triad (r/t to ICP in Brain)
Blood Pressure ↓ ↑ (Widening Pulse Pressure - ↑ Systolic/ ↓ Diastolic)
Pulse ↑ ↓
Respirations ↑ ↓ (Cheyne-Stokes or Irregular Respirations)
Amyotrophic Lateral Sclerosis (ALS) is a condition in which there is a degeneration of motor neurons in both the upper &
lower motor neuron systems.

Autonomic Dysreflexia: potentially life-threatening emergency

– Symptoms: HTN, Bradycardia, Pounding H/A, Severe Nasal Congestion
– Elevate head of bed to 90 degree
– Loosen constrictive clothing
– Assess for bladder distention and bowel impaction (trigger) <TREAT THEM>
– Administer antihypertensive meds (may cause stroke, MI, seizure)

Multiple Sclerosis is a chronic, progressive disease with demyelinating lesions in the CNS which affect the white matter
of the brain and spinal cord.
Hyperactive deep tendon reflexes, vision changes, fatigue and spasticity are all symptoms of MS
Motor S/S: limb weakness, paralysis, slow speech
Sensory S/S: numbness, tingling, tinnitus
Cerebral S/S: nystagmus, ataxia, dysphagia, dysarthria
Myasthenia gravis is caused by a disorder in the transmission of impulses from nerve to muscle cell; worsens with
exercise and improves with rest.
● Give neostigmine to pts w/ MG about 45 min before eating, so it can help w/ chewing & swallowing.
Myasthenia Crisis: it’s used to confirm the diagnosis; a positive reaction to Tensilon – will improve symptoms
Cholinergic Crisis: caused by excessive medication-stop med-giving Tensilon will make it worse

Huntington's Chorea: 50% genetic, autosomal dominant disorder

S/S: chorea → writhing, twisting, movements of face, limbs and body
–gait deteriorates to no ambulation
–no cure, just palliative care

Myelogram
● Pre-Op – NPO 4-6hr, assess hx of allergies, the table will be moved to various positions during test, the following
meds are withheld 48hr prior; phenothiazines, CNS depressants, and stimulants
● Post Op – Neuro checks q2-4 hrs, water soluble HOB up, oil soluble HOB down, oral analgesics for h/a, encourage
PO fluids, assess for distended bladder, inspect site.

Electroencephalography (EEG)
● Pre-Op – 24-48 hrs prior holds meds (especially tranquilizers and stimulants), no caffeine or cigarettes (i.e.
stimulants) for 24 hrs prior, meals not withheld, no sleep the night before, pt may be asked to hyperventilate for 3-4
min and watch a bright flashing light
● Post Op – Assess pt for possible seizures, since they’re at greater risk

Cerebral Angiogram
● Pre-Op – well hydrated, lie flat, site shaved, check pulses marked
● Post Op – keep flat for 12-14hr, check site, check pulses, force fluids.

Meningeal Irritation S/S

● Nuchal rigidity
● Positive Brudzinski + Kernig signs
● PHOTOPHOBIA

General Notes
● Lumbar Puncture Post Op – Neuro assessments q15-30 until stable, pt lays flat for 2-3hr, encourage fluids, oral
analgesics for headache, observe dressing
● CSF in meningitis will have high protein, and low glucose.
● Decreased acetylcholine is related to senile dementia.
● Level of consciousness is the most important assessment parameter with status epilepticus.
● Hyper reflexes (upper motor neuron issue “your reflexes are over the top”)
● Absent reflexes (lower motor neuron issue)

Nutrition
Fat Soluble Vitamins are A, D, E, K
General Notes
● Be wary of questions regarding children drinking too much milk i.e. more than 3-4 cups of milk each day. Too much
milk intake reduces intake of other essential nutrients, especially iron. Watch for anemia with milk-aholics.
● Vitamin D’s presence is required by the parathyroid gland, in order for it to function.
● If the patient is taking digoxin or K-supplements, avoid salt substitutes because many are potassium based
● Potassium Sources: bananas, potatoes, citrus fruits
● No milk (as well as fresh fruit or veggies) on neutropenic precautions.
● Nondairy sources of calcium include RHUBARB, SARDINES, COLLARD GREENS
● Nonfat milk reduces reflux by increasing lower esophageal sphincter pressure
● Yogurt has live cultures, so do not give to immunosuppressed patients
● No phenylalanine with a kid positive for PKU (no meat, no dairy, no aspartame).
● Acid Ash diet: cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread
● Alk Ash diet: milk, veggies, rhubarb, salmon

Ortho
Casts:
● You can petal the rough edges of a plaster cast with tape to avoid skin irritation.
● Itching under cast area- cool air via blow dryer, ice pack for 10- 15 minutes. NEVER use Qtip or anything to scratch
area

Walking Devices

COAL (cane walking): When ascending stairs w/ a cane: ● Remember the phrase “step
C – Cane 1 – Step up with the stronger leg first up” when picturing a person
O – Opposite 2 – Move the cane next while bearing going up stairs with crutches.
A – Affected weight on the stronger leg The good leg goes up first,
L – Leg 3 – Finally, move the weaker leg followed by the crutches and
then the bad leg. The opposite
The cane always moves When descending stairs w/ a cane: happens going down. The
before the weaker leg. 1. Lead with the cane crutches go first, followed by
2. Bring the weaker leg down next the good leg.
3. Finally, step down with the stronger ● Place a wheelchair parallel to
leg the bed on the side of
weakness
Mnemonic – “Up with the good and
down with bad.”

SIGNS of a Fractured hip Paget's Disease S/S

● EXTERNAL ROTATION ● Tinnitus
● SHORTENING ● bone pain
● ADDUCTION ● enlarged/thick bones

General Notes
● Never release traction UNLESS you have an order from the MD to do so
● Osteomyelitis is an infectious bone disease → get blood cultures & antibiotics, then if necessary → surgery to drain
abscess.
● Pain is usually the highest priority with RA
● Swimming is a great exercise for Arthritis
● William's position - Semi Fowlers with knees flexed (Inc. knee gatch) to relieve lower back pain.
o With low back aches, bend knees to relieve
● Greenstick fractures, usually seen in kids bone breaks on one side and bends on the other

Patient Positioning
1. Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending doom)
→ turn pt to left side and lower the head of the bed.

2. Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal bradycardia, etc) → turn on left side
(and give O2, stop Pitocin, increase IV fluids)

3. Tube Feeding w/ Decreased LOC → position pt on right side (promotes emptying of the stomach) with the  HOB
elevated (to prevent aspiration)

4. During Epidural Puncture → side-lying

5. After Lumbar Puncture (and also oil-based Myelogram) → pt lies in flat supine (to prevent headache and leaking of
CSF) for 4 to 12 hrs or 2 to 3 hrs as prescribed. Dressings must be kept sterile & frequent neuro assessments should be
performed

6. Pt w/ Heat Stroke → lie flat w/ legs elevated (to get fluid to go to head to correct hypotension)

7. During Continuous Bladder Irrigation (CBI) → catheter is taped to thigh so leg should be kept straight. No other
positioning restrictions.

8. After Myringotomy (surgical incision into the eardrum, to relieve pressure or drain fluid).
 → position on side of affected ear after surgery (allows drainage of secretions)

9. After Cataract Surgery → pt will sleep on unaffected side with a night shield for 1-4 weeks.

10. After Thyroidectomy → low or semi-Fowler’s, support head, neck and shoulders.

11. Infant w/ Spina Bifida → position prone (on abdomen) so that sac does not rupture

12. Buck’s Traction (skin traction) → elevate foot of bed for counter-traction

13. After Total Hip Replacement → don’t sleep on operated side, don’t flex hip more than 45- 60 degrees, don’t elevate
HOB more than 45 degrees. Maintain hip abduction by separating thighs with pillows (use a wedge pillow)

14. Prolapsed Cord → knee-chest position or Trendelenburg

15. Infant w/ Cleft Lip → position on back or in infant seat to prevent trauma to suture line. While feeding, hold in
upright position.

16. To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) → eat in reclining position or Low-fowlers
(so food doesn’t empty and dump so fast), lie down after meals for 20-30 minutes (also restrict fluids during meals, low
cholesterol and fiber diet, small frequent meals)

17. Above Knee Amputation → elevate for first 24 hours on pillow, position prone daily to provide for hip extension.

18. Below Knee Amputation → foot of bed elevated for first 24 hours; position prone daily to provide for hip extension.
19. Detached Retina → area of detachment should be in the dependent position

20. Administration of Enema → position pt in left side-lying (Sim’s) with knee flexed

21. After Supratentorial Surgery (incision behind hairline) → elevate HOB 30-45 degrees

22. After Infratentorial Surgery (incision at nape of neck) → position pt flat and lateral on either side.

23. During Internal Radiation → on bedrest while implant in place

24. Autonomic Dysreflexia/Hyperreflexia (S&S: pounding headache, profuse sweating, nasal congestion, goose flesh,
bradycardia, hypertension) → place client in sitting position (elevate HOB) first before any other implementation

25. Shock → bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified
Trendelenburg)

26. Head Injury → elevate HOB 30 degrees to decrease intracranial pressure

27. Peritoneal Dialysis when Outflow is Inadequate → turn pt from side to side BEFORE checking for kinks in tubing
(reposition patient, to see if it affects the flow and output of the catheter!)

28. During a lumbar puncture → The patient is positioned in lateral recumbent fetal position

29. Lung Biopsy → Position the patient lying on the side of the bed or with arms raised up on pillows over bedside
table, have the patient hold their breath in mid expiration, chest x-ray done immediately afterwards to check for
complication of pneumothorax, sterile dressing applied

30. Pt w/ GERD → Patient should be lying prone on their left side, with HOB elevated 30 degrees

31. Pt w/ Pancreatitis → Patient should be place in Fetal position!!

32. After Appendectomy → Position the patient on the right side with legs flexed. (Puts pressure where appendix was)

33. Pt w/ Pneumonia → Lay the pt on the affected side to splint and reduce pain. If attempting to reduce congestion,
the congested lung goes up.

34. Infant Position while Asleep → To prevent SIDS, the infant lays on their back while asleep, in a bare crib.

35. During Paracentesis → Patient should be semi-fowlers, or upright on the edge of the bed.

36. During Thoracentesis → Patient position patient with arms on pillow on over bed table or lying on side

Hemoglobin
Neonates 18 – 27
3 Months 10.6 – 16.5
3 yrs 9.4 – 15.5
10 yrs 10.7 – 15.5
Pediatrics
Injection Sites

IM ∙ Vastus Lateralis for 6 months infants

∙ Ventrogluteal for Toddlers above 18 months
∙ Deltoid & Gluteus Maximus for Children

Developmental Stages
∙ 2-3 months: turns head side to side ∙ 8-9 months: stands straight at eight
∙ 4-5 months: grasps, switch & roll ∙ 10-11 months: belly to butt (phrase has 10 letters)
∙ 6-7 months: sit at 6 and waves bye-bye ∙ 12-13 months: twelve and up, drink from a cup

● Stranger anxiety is greatest 7 - 9 months

● Separation anxiety peaks in toddlerhood
● If you gave a toddler a choice about taking medicine and he says no, you should leave the room and come back
in five minutes, because to a toddler it is another episode. Next time don’t ask.
● School-age kids (5 and up) are old enough and should have an explanation of what will happen a week before
surgery such as tonsillectomy.

Interpersonal model (Sullivan) – Behavior motivated by need to avoid anxiety and satisfy needs

1. Infancy 0–18 months – others will satisfy needs

2. Childhood >6yrs – learn to delay need gratification
3. Juvenile 6–9 years – learn to relate to peers
4. Preadolescence 9–12 yrs – learns to relate to friends of opposite sex
5. Early adolescence 12–14 yrs – learn independence and how to relate to opposite sex
6. Late adolescence 14–21 yrs – develop intimate relationship with person of opposite sex

A child with a ventriculoperitoneal shunt will have a small upper-abdominal incision. This is where the shunt is guided
into the abdominal cavity and tunneled under the skin up to the ventricles. Assess for possible abdominal distention,
since fluid from the ventricles will be redirected to the peritoneum, as well as signs of increasing intracranial pressure.

ICP in Infants ICP in Toddlers

∙ Irritability ∙ Lack of appetite
∙ Bulging fontanels ∙ Headache
∙ High-pitched cry

Bed-position after shunt placement is flat, so fluid doesn’t reduce too rapidly. If S/S of increasing icp are present, then
raise the hob to 15-30 degrees.

Congenital Cardiac Defects

● These defects result in hypoxia which the body attempts to compensate for (influx of immature RBC’s)
o Labs supporting this would display: ↑ Hematocrit, Hemoglobin (compensating for hypoxia and
deoxygenated blood) & RBC count
● Tetralogy of Fallot;
o When children w/ Tetralogy of Fallot experience Tet spells, they’re treated with morphine.
o Think DROP (child drops to floor or squats) or Remember HOPS or POSH

D – defect, septal H – hypertrophy of right ventricle P – pulmonary stenosis

R – right ventricular hypertrophy O – overriding aorta O – overriding aorta
O – overriding aorta P – pulmonary stenosis S – septal defect (ventricle)
P – pulmonary stenosis S – septal defect (ventricle) H – hypertrophy of right ventricle

Transesophageal Fistula (TEF) – esophagus doesn't fully develop (this is a surgical emergency)
The 3 C's of TEF in the newborn:
1) Choking
2) Coughing
3) Cyanosis

Hirschsprung’s Ds. → bile is lower obstruction; no bile is upper obstruction; ribbon like stools.
● Diagnosed with rectal biopsy looking for absence of ganglionic cells.
● Cardinal sign in infants is failure to pass meconium, and later the classic ribbon-like and foul-smelling stools.

Cystic Fibrosis
● Respiratory problems are the chief concern with CF
● Give diet high fat, high sodium, fat soluble vitamins ADEK
● Intussusception common in kids with CF. Obstruction may cause fecal emesis, currant jelly- like stools (blood
and mucus). A barium enema may be used to hydrostatically reduce the telescoping. Resolution is obvious, with
onset of bowel movements.
● Treatment: Aerosol bronchodilators, mucolytics, and pancreatic enzymes.

Group-a strep precedes rheumatic fever.

● Chorea is part of this sickness (grimacing, sudden body movements, etc.) and it embarrasses kids.
● The child will have joint pain.
● Watch for elevated ant streptolysin O to be elevated.
● Treatment is Penicillin!!!! Assess for allergy

Children w/ HIV
● Parents of HIV+ should wear gloves for care, not kiss kids on the mouth, and not share eating utensils.
● Western blot
o A positive Western blot in a child <18 months (presence of HIV antibodies) indicates only that the mother is
infected.
● p24 antigen Test
o Two or more positive p24 antigen tests will confirm HIV in kids <18 months.
o The p24 can be used at any age.

Prepubescent Penis
● Hypospadias: abnormality in which urethral meatus is located on the ventral (back) surface of the penis anywhere
from the corona to the perineum (remember hypo, low (for lower side or under side)
● Epispadias: opening of the urethra on the dorsal (front) surface of the penis
● Undescended testis or cryptorchidism is a known risk factor for testicular cancer later in life.
o Start teaching boy’s testicular self-exam around 12, because most cases occur during adolescence.
● After a hydrocele repair provide ice bags and scrotal support.

There’s an association between low-set ears and renal anomalies.

● The kidneys and ears develop around the same time in utero. Hence, the kidneys & ears similarly shaped.
● When doing an assessment of a neonate, if the nurse notices low set or asymmetrical ears, there is good reason to
investigate renal functioning.

Pyloric Stenosis
● The first sign of pyloric stenosis in a baby is mild vomiting that progresses to projectile vomiting.
● Later a mass may be palpable, the baby will seem hungry often, and may spit up after feedings.
● Would expect hematocrit and BUN related to dehydration

What is an intraosseous infusion (think into to the bone = intra – osseous (bone)
● In pediatrics, it’s a temporary, life-saving measure, for life-threatening emergencies, when iv access cannot be
obtained, an osseous (bone) needle is hand-drilled into a bone (usually the tibia), where crystalloids, colloids,
blood products and drugs can be administered into the marrow.
● When venous access is achieved it can be discontinued.
● Isoproterenol (blood pressure support medication), a beta agonist, is contraindicated via intraosseous
infusion.

Children in Traction
● What traction is used in a school-age kid with a femur or tibial fracture with extensive skin damage?
o Ninety, ninety. The name refers to the angles of the joints.
▪ A pin is placed in the distal part of the broken bone, and the lower extremity is in a boot cast. The
rest are the normal pulleys and ropes commonly seen with balanced suspension.
● A child hinder should clear the bed when in Bryant’s traction (also used for femurs and congenial hip for young
kids).

General Notes
● Bottle Rot: Do NOT let the mother/father/grandma put anything but water in a child’s bottle during naps/over-
night → Juice or milk will rot the child’s teeth right out of his head
● It is essential to maintain nasal patency with children < 1 yr, b/c they are obligatory nasal breathers.
● Kawasaki disease causes a heart problem, specifically, coronary artery aneurysms due to the inflammation of blood
vessels.
● Kids with RSV; no contact lenses or pregnant nurses in rooms where ribavirin is being administered by hood, tent,
etc.
● Neonates with heroin withdrawal are irritable and are poor at suckling
● If you can remove the white patches from the mouth of a baby it is just formula. If you can’t, its candidiasis.
● Don’t pick cough over tachycardia for signs of CHF in an infant.
● When performing CPR on an infant check the brachial pulse
● Test children for lead poisoning around 12 months of age
● body surface area (BSA) is considered the most accurate method for medication dosing with kids.
● In a five-year old breath once for every 5 compressions doing CPR
● An ill child regresses in behaviors
● No aspirin with kids b/c it is associated with Reye’s Syndrome, and also no NSAID’s such as ibuprofen. Give Tylenol.
● 4-year-old kids cannot interpret TIME. Need to explain time in relationship to a known COMMON EVENT (eg: "Mom
will be back after supper").
● Toddlers need to express autonomy (independence)
● Prolonged hypoxemia is a likely cause of cardiac arrest in a child.
● With omphalocele and gastroschisis (herniation of abdominal contents) dress with loose saline dressing covered
with plastic wrap and keep eye on temperature. Kid can lose heat quickly.
● It is always the correct answer to report suspected cases of child abuse.

Reproductive Health
General Notes
● Diaphragm must stay in place 6 hours after intercourse. They are also fitted so must be re- fitted if you lose or gain
a significant amount of weight.
● Gonorrhea is a reportable disease
● Priapism: painful erection lasting longer than 6 hrs.
 Respiratory
Can’t cough=ineffective airway clearance

Incentive Spirometry steps

1) Sit upright
2) Exhale
3) Insert mouthpiece
4) Inhale for 3 seconds, and then HOLD for 10 seconds

Pulmonary Embolism
● First sign of PE is sudden chest pain, followed by dyspnea and tachypnea.
● When o2 deprived, as with PE, the body compensates by causing hyperventilation (resp alkalosis).
o Should the patient breathe into a paper bag?
▪ No. If the PaO2 is well below 80 they need oxygen.
o Look at all your ABG values. As soon as you see the words PE you should think oxygen first.

Carbon Dioxide Narcosis: a reversible state of CNS depression induced by a drug(s).

● High potassium is expected with this condition, (hydrogen floods the cell forcing potassium out).
● Causes ↑ intracranial pressure.

Asthma
● Coughing without other s/s is suggestive of asthma.
● If child who is wheezing, stops wheezing. It could mean he is worsening.
● If a pt has intercostal retractions – be concerned
● The best exercise for asthmatics is swimming (slow, long, controlled breathing)

Tuberculosis
● If a TB patient is unable/unwilling to comply with Tx they may need supervision (direct observation).
● TB is a public health risk.
PPD is positive if area of induration is:
>5 mm in an immunocompromised patient - lower parameters because immunocompromised
>10 mm in a normal patient
>15 mm in a patient who lives in an area where TB is very rare.
A positive PPD confirms infection, not just exposure. A sputum test will confirm active disease.

Ventilators
● Complications of Mechanical Ventilation: Pneumothorax, Ulcers

HO LD
High alarm – Obstruction due to increased secretions, kink, patient coughs, gag, or bites the tubing
Low press alarm – Disconnection or leak in ventilator or in pt. airway cuff, pt. stops spontaneous breathing

Thoracentesis:
● Pre-Op – Take vital signs, shave area around needle insertion, move the patient into tripod position over a bed table,
while holding a pillow
● During – Withdraw no more than 1000cc at one time
● Post Op – Listen for bilateral breath sounds, vital signs, check leakage, sterile dressing.
What could cause bronchopulmonary dysplasia? (dysplasia means abnormality or alteration)
● Mechanical ventilation is the primary cause. Other causes could be infection, pneumonia, or other conditions
that cause inflammation or scarring.
● Premature newborns with immature lungs are ventilated and over time it damages the lungs.

General Notes
● TIDAL VOLUME is 7 – 10ml / kg
● For COPD pts REMEMBER: 2L Nasal Cannula (2LNC) or less (hypoxic NOT hypercapnic drive)
o Pa02 of 60ish and Sa02 90% = normal (b/c these pts is chronic CO2 retainers)
● The first sign of ARDS is increased respirations. Later comes dyspnea, retractions, air hunger, cyanosis.
● Signs of hypoxia: restless, anxious, cyanotic, tachycardia, increased respirations. (also monitor ABG's)
● Crackles suggest pneumonia, which is likely to be accompanied by hypoxia, which would manifest itself as mental
confusion, etc.
● When using a bronchodilator inhaler conjunction with a glucocorticoid inhaler, administer the bronchodilator first
● In emphysema the stimulus to breathe is low PO2, not increased PCO2 like normal pts, so don’t slam them with
oxygen.
o Encourage pursed-lip breathing which promotes CO2 elimination, encourage up to 3000mL/day fluids, high-
fowlers and leaning forward.
● Ambient air (room air) contains 21% oxygen.
● Before going for Pulmonary Function Tests (PFT's), a pt's bronchodilators will be withheld and they are not
allowed to smoke for 4 hrs prior (so it doesn’t alter test results)
● Tension pneumothorax trachea shifts to opposite side.

Transmission-Based Precautions
● SARS (severe acute resp syndrome) → airborne + contact (just like varicella)
● Tetanus, Hepatitis B, HIV are STANDARD precautions

Airborne

My – Measles Measles
Chicken – Chicken Pox/Varicella OR remember MTV TB
Hez – Herpes Zoster/Shingles Varicella
TB-- TB
● Disseminated Herpes Zoster is AIRBORNE PRECAUTIONS
Private Room – negative pressure with 6-12 air exchanges/hr, Mask, N95 for TB

Droplet

think of SPIDERMAN!
S – sepsis
S – scarlet fever
S – streptococcal pharyngitis P - parvovirus B19
P – pneumonia
P – pertussis
I – influenza
D – diphtheria (pharyngeal)
E - epiglottitis
R – rubella
M – mumps
M – meningitis
M – mycoplasma or meningeal pneumonia
 An – Adenovirus
Private Room or cohort Mask, door open, 3 ft distance

Contact
MRS. WEE
M – multidrug resistant organism (MRSA) V – Varicella zoster
R – RAC C – Cutaneous diphtheria
S – skin infections ~ VCHIPS H – Herpes simplex
W – wound infxn I – Impetigo
E – enteric infxn – clostridium difficile P – Pediculosis
E – eye infxn – conjunctivitis S – Scabies

● Localized Herpes Zoster is CONTACT PRECAUTIONS

● A nurse with a localized herpes zoster CAN care for patients as long as the patients are NOT
immunosuppressed, and the lesions must be covered!
● Hepatitis A is contact precautions

Triage
Red- Immediate: Injuries are life threatening but survivable with minimal intervention. Ex: hemothorax, tension
pneumothorax, unstable chest and abdominal wounds, INCOMPLETE amputations, OPEN fix’s of long bones, and
2nd/3rd degree burn with 15%-40% of total body surface, etc.
∙ Red – unstable, i.e., occluded airway, actively bleeding, see first
Yellow- Delayed: Injuries are significant and require medical care but can wait hrs without threat to life or limb. Ex:
Stable abd wounds without evidence of hemorrhage, fix requiring open reduction, debridement, external fixation, most
eye and CNS injuries, etc.
∙ Yellow – stable, can wait up to an hour for treatment, i.e. burns, see second
Green- Minimal: Injuries are minor, and Tx can be delayed to hrs or days. Individuals in this group should be moved
away from the main triage area. Ex: upper extremity fix, minor burns, sprains, sm. lacerations, behavior disorders.
∙ Green – stable, can wait even longer to be seen, "walking wounded"
Black- Expectant: Injuries are extensive, and chances of survival are unlikely. Separate but don’t abandoned, comfort
measures if possible. Ex: Unresponsive, spinal cord injuries, wounds with anatomical organs, 2nd/3rd degree burn with
60% of body surface area , seizures, profound shock with multiple injuries, no pulse, b.p, pupils fixed or dilated.
∙ Black – unstable clients that will probably not make it, need comfort measures

General Notes
● DOA – Dead on Arrival
● Orange tag in triage is non-emergent Psych
● In a disaster you should triage the person who is most likely to not survive last (black code)

Urinary/Renal System
Peritoneal Dialysis
● It’s ok to have abdominal cramps, blood tinged outflow and leaking around site if the Peritoneal Dialysis cath
(tenkhoff) was placed in the last 1-2 wks.
● Cloudy outflow NEVER NORMAL - peritonitis or infection!!

Kidneys
● Low magnesium and high creatinine signal renal failure.
● Renal impairment: serum creatinine elevated, and urine clearance decreased
● Glomerulonephritis
o Take vital signs q4hrs & daily weights
o Consider blood pressure to be the most important assessment parameter.
o Dietary restrictions you can expect include fluids, protein, sodium, and potassium.
● WBC shift to the left in a patient with pyelonephritis (neutrophils kick in to fight infection)
● Nephrotic syndrome is characterized by massive proteinuria (looks dark and frothy) caused by glomerular damage.
Corticosteroids are the mainstay. Generalized edema common.
o Signs: Edema & Hypotension
o Turn and reposition (pt is @ risk for impaired skin integrity)
● A laxative/bowel prep is given the night before an IVP in order to better visualize the organs.
o IVP = Intravenous Pyelogram, an x-ray of the kidneys, ureters, and urinary bladder
o Pre-Op – Assess allergies (contrast dye)
● Kidney Glucose threshold is 180

General Notes
● Uremic fetor → smell urine on the breath
 NCLEX TIPS
1. When getting down to two answers, choose the assessment answer (assess, collect, auscultate, monitor, palpate) over
the intervention except in an emergency or distress situation. If one answer has an absolute, discard it. Give priority to
answers that deal directly to the patient’s body, not the machines/equipment.
2. Key words are very important. Avoid answers with absolutes for example: always, never, must, etc.
3. With lower amputations patient is placed in prone position.
4. Small frequent feedings are better than larger ones.
5. Assessment, teaching, meds, evaluation, unstable patient cannot be delegated to an Unlicensed Assistive Personnel.
6. LVN/LPN cannot handle blood.
7. Aminoglycosides (like vancomycin) cause nephrotoxicity and ototoxicity.
8. IV push should go over at least 2 minutes except for adenosine which goes superfast, 2-4 seconds.
9. If the patient is not a child an answer with family option can be ruled out easily.
10. In an emergency, patients with greater chance to live are treated first
11. ARDS (fluids in alveoli), DIC (disseminated intravascular coagulation) are always secondary to something else
(another disease process).
12. Cardinal sign of ARDS is hypoxemia (low oxygen level in tissues).
13. in pH regulation the 2 organs of concern are lungs/kidneys.
14. edema is in the interstitial space not in the cardiovascular space.
15. weight is the best indicator of dehydration
16. wherever there is sugar (glucose) water follows.
17. aspirin can cause Reye’s syndrome (encephalopathy) when given to children
18. when aspirin is given once a day it acts as an antiplatelet.
19. Use Cold for acute pain (e.g. Sprain ankle) and Heat for chronic (rheumatoid arthritis)
20. guided imagery is great for chronic pain.
21. when patient is in distress, medication administration is rarely a good choice.
22. with pneumonia, fever and chills are usually present. For the elderly confusion is often present.
23. Always check for allergies before administering antibiotics (especially PCN). Make sure culture and sensitivity has
been done before administering first dose of antibiotic.
24. Cor pulmonale (s/s fluid overload) is Right sided heart failure causedby pulmonary disease, occurs with bronchitis or
emphysema.
25. COPD is chronic, Pneumonia is acute. Emphysema and Bronchitis are both COPD.
26. In COPD patients the baroreceptors that detect the CO2 level are destroyed. Therefore, O2 level must be low
because high O2 concentration blows the patient’s stimulus for breathing.
27. Exacerbation: acute, distress.
28. Epi always given in TB syringe.
29. Prednisone toxicity: Cushing’s syndrome= buffalo hump, moon face, high glucose, hypertension.
30. 4 options for cancer management: chemo, radiation, surgery, allow to die with dignity.
31. No live vaccines, no fresh fruits, no flowers should be used for neutropenic patients.
32. Chest tubes are placed in the pleural space.
33. Angina (low oxygen to heart tissues) = no dead heart tissues. MI = dead heart tissue present.
34. Mevacor (anti-cholesterol med) must be given with evening meal if it is QD (per day).
35. Nitroglycerine is administered up to 3 times (every 5 minutes). If chest pain does not stop go to hospital. Do not give
when BP is < 90/60.
36. Preload affects amount of blood that goes to the right ventricle.Afterload is the resistance the blood has to
overcome when leaving the heart.
37. Calcium channel blocker affects the afterload.
38. For a CABG operation when the great saphenous vein is taken it isturned inside out due to the valves that are inside.
39. Unstable angina is not relieved by nitroglycerin.
40. Dead tissues cannot have PVC’s (premature ventricular contraction). If left untreated PVC’s can lead to VF
(ventricular fibrillation).
41. 1 t (teaspoon)= 5 ml
 1 T(tablespoon)= 3 t = 15 ml
1 oz= 30 ml
1 cup= 8 oz
1 quart= 2 pints
1 pint= 2 cups
1 gr (grain)= 60 mg
1 g (gram)= 1000 mg
1 kg= 2.2 lbs.
1 lb.= 16 oz
* To convert Centigrade to F. F= C+40, multiply 9/5 and subtract 40
* To convert Fahrenheit to C. C= F+40, multiply 5/9 and subtract 40.
42. Angiotensin II in the lungs = potent vasodilator. Aldosterone attracts sodium.
43. REVERSE AGENTS FOR TOXICITY
Heparin= protamine sulfate
Coumadin= vitamin k
Ammonia= lactulose
Acetaminophen=-Acetylcysteine
Iron= deferoxamine
Digitoxin, digoxin= Digi bind
Alcohol withdrawal= Librium
- Methadone is an opioid analgesic used to detoxify/treat pain in narcotic addicts.
- Potassium potentiates dig toxicity.
44. Heparin prevents platelet aggregation.
45. PT/PTT are elevated when patient is on Coumadin
46. Cardiac output decreases with dysrhythmias. Dopamine increases BP.
47. Med of choice for Ventricular tachycardia is lidocaine
48. Med of choice for SVT is adenosine or adenocard
49. Med of choice for Asystole (no heartbeat) is Atropine
50. Med of choice for CHF is Ace inhibitor.
51. Med of choice for anaphylactic shock is Epinephrine
52. Med of choice for Status Epilepticus is Valium.
53. Med of choice for bipolar is lithium.
54. Amiodarone is effective in both ventricular and atrial complications.
55. S3 sound is normal in CHF, not normal in MI.
56. Give Carafate (GI med) before meals to coat stomach
57. Protonix is given prophylactically to prevent stress ulcers.
58. After endoscopy check gag reflex.
59. TPN (total parenteral nutrition) given in subclavian line.
60. Low residue diet means low fiber
61. Diverticulitis (inflammation of the diverticulum in the colon) pain is around LL quadrant.
62. Appendicitis (inflammation of the appendix) pain is in RL quadrant with rebound tenderness.
63. Portal hypotension + albuminemia= Ascites.
64. Beta cells of pancreas produce insulin
65. Morphine is contraindicated in Pancreatitis. It causes spasm of the Sphincter of Oddi. Therefore, Demerol should
be given.
66. Trousseau and Chvostek signs observed in hypocalcemia
67. With chronic pancreatitis, pancreatic enzymes are given with meals, not before or after, given with meal.
68. Never give K+ in IV push.
69. Mineralocorticoids are given in Addison’s disease.

70. Diabetic ketoacidosis (DKA)= when body is breaking down fat instead of sugar for energy. Fats leave ketones (acids)
that cause pH to decrease.
71. DKA is rare in diabetes mellitus type II because there is enough insulin to prevent breakdown of fats.
72. Sign of fat embolism is petechiae. Treated with heparin.
73. For knee replacement use continuous passive motion machine.
74. Give prophylactic antibiotic therapy before any invasive procedure.
75. Glaucoma patients lose peripheral vision. Treated with meds
76. Cataract= cloudy, blurry vision. Treated by lens removal-surgery
77. Co2 causes vasoconstriction.
78. Most spinal cord injuries are at the cervical or lumbar regions
79. Autonomic dysreflexia (life threatening inhibited sympathetic responseof nervous system to a noxious stimulus-
patients with spinal cord injuriesat T-7 or above) is usually caused by a full bladder.
80. Spinal shock occurs immediately after spinal injury
81. Multiple sclerosis= myelin sheath destruction, disruption in nerveimpulse conduction.
82. Myasthenia gravis= decrease in receptor sites for acetylcholine. Since smallest concentration of ACTH receptors
are in cranial nerves, expect fatigue and weakness in eye, mastication, pharyngeal muscles.
83. Tensilon test given if muscle is tense in myasthenia gravis.
84. Guillain-Barre syndrome= ascending paralysis. Keep eye on respiratory system.
85. Parkinsons = RAT: rigidity, akinesia (loss of muscle movt), tremors.Treat with levodopa.
86. TIA (transient ischemic attack) mini stroke with no dead brain tissue
87. CVA (cerebrovascular accident) is with dead brain tissue.
88. Hodgkin’s disease= cancer of lymph is very curable in early stage.
89. Rule of NINES for burns
Head and Neck= 9%
Each upper ext= 9%
Each lower ext= 18%
Front trunk= 18%
Back trunk= 18%
Genitalia= 1%
90. Birth weight doubles by 6 month and triple by 1 year of age.
91. If HR is <100 do not give dig to children.
92. First sign of cystic fibrosis may be meconium ileus at birth. Baby is inconsolable, do not eat, not passing
meconium.
93. Heart defects. Remember for cyanotic -3T’s (ToF, Truncus arteriosus, Transposition of the great vessels). Prevent
blood from going to heart. If problem does not fix or cannot be corrected surgically, CHF will occur following by death.
94. With right side cardiac cath=look for valve problems (tricuspid valve problems)
95. With left side in adults look for coronary complications.
96. Rheumatic fever can lead to cardiac valves malfunctions.
97. Cerebral palsy = poor muscle control due to birth injuries and/or decrease oxygen to brain tissues.
98. ICP (intracranial pressure) should be <2. measure head circumference.
99. Dilantin level (10-20). Can cause gingival hyperplasia
100. for Meningitis check for Kernig’s/ Brudzinski’s signs.
101. Wilm’s tumor is usually encapsulated above the kidneys causing flank pain (don’t palpate abdomen)
102. Hemophilia is x-linked. Mother passes disease to son.
103. When phenylalanine increases, brain problems occur.
104. Buck’s traction= knee immobility
105. Russell traction= femur or lower leg
106. Dunlap traction= skeletal or skin
107. Bryant’s traction= children <3y, <35 lbs. with femur fx.
108. Place apparatus first then place the weight when putting traction
109. Placenta should be in upper part of uterus
110. Eclampsia is seizure. (hypocalcemia) - give calcium
111. A patient with a vertical c-section surgery will more likely have another c-section.
112. Perform amniocentesis before 20 weeks’ gestation to check for cardiac and pulmonary abnormalities.
113. Rh - mothers receive RhoGAM to protect next baby.
114. anterior fontanelle closes by 18 months. Posterior 6 to 8 weeks.
115. Caput succedaneum= diffuse edema of the fetal scalp that crosses the suture lines. Swelling reabsorbs within 1 to
3 days.
116. Pathological jaundice= occurs before 24hrs and lasts 7 days. Physiological jaundice occurs after 24 hours.
117. Placenta previa = there is no pain, there is bleeding. Placenta abruption = pain, bleeding.
118. Betamethasone (celestone)=surfactant. Med for lung expansion.
119. Dystocia= baby cannot make it down to canal
120. Pitocin med used for uterine stimulation
121. Magnesium sulfate (used to halt preterm labor) is contraindicated if deep tendon reflexes are ineffective. If patient
experiences seizure during magnesium adm. Get the baby out stat (emergency).
122. Do not use why or I understand statement when dealing with patients
123. Milieu therapy= taking care of patient/environment
124. cognitive therapy= counseling
125. Crisis intervention=short term.
126. FIVE INTERVENTIONS FOR PSYCH PATIENTS
-Safety
-Setting limits
-Establish trusting relationship
-Meds
-Least restrictive methods/environment.
127. SSRI’s (antidepressants) take about 3 weeks to work.
128. Obsession is to think. Compulsion is to action
129. If patients have hallucinations redirect them. In delusions distract them.
130. Thorazine, Haldol (antipsychotic) can lead to EPS (extrapyramidal side effects)
131. Alzheimer’s disease is a chronic, progressive, degenerative cognitive disorder that accounts for more than 60% of all
dementia
132. Change in color is always a LATE sign!
133. Let’s say every answer in front of you is an abnormal value. If potassium is there, you can bet it is a problem they
want you to identify, because values outside of normal can be life threatening. Normal potassium is 3.5-5.0. Even a bun
of 50 doesn’t override a potassium of 3.0 in a renal patient’s priority.
134. Look carefully when you have no idea. In a word like rhabdomyosarcoma you can easily ascertain it has something
to do with muscle (myo) cancer (sarcoma). The same thing goes for drug names. For example, if it ends in –ide it’s
probably a diuretic, as in Furosemide, and Amiloride.
135. When choosing an answer, think in this manner...if you can only do ONLY one thing to help this patient what would
it be? Pick the most important intervention.
136. An answer that delays care or treatment is ALWAYS wrong.
137. If two of the answers are the exact opposite, like bradycardia or tachycardia → one is probably the answer.
138. If two or three answers are similar or are alike, none is correct.
139. When asking patients questions NEVER use “why” questions. Eliminate all “why?” answer options.
140. If you have never heard of it → please don’t pick it!
141. Always deal with actual problems or harm, before potential problems.
142. Always select a “patient focused” answer.
143. An answer option that states "reassess in 15 minutes"is probably wrong.
144. Think positive and you can achieve great things.
145. Think of present and future, the past is gone. Forget your past mistakes and focus on your successes encouraging
yourself to greater achievements in the future.
146. Always do your best so you can be proud that you gave it your best shot.
147. Focus on your achievements rather than your failures. If you do find yourself thinking about how you failed, then
look at what you managed to do right, and how you could correct what you did for next time.