NCLEX 35 Page Random Notes

Signs & Tests

• Murphy’s sign – pain with palpation of gall bladder 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 – pain in RLQ indicative of appendicitis

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

• RLQ – appendicitis, watch for peritonitis

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

• Shilling Test – test for pernicious anemia/how well one absorbs Vit b12

• 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.

Addisons & Cushings

Na, BP, Blood, K, BSL

Addisons= down, down down up down
Cushings= up up up down up

Addisons= hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia

Cushings= hypernatremia, hypertension, incrased blood vol, hypokalemia, hyperglycemia

Mineral corticoids are given for Addison’s disease.

Addison’s: hypoNa, hyperK, hypoglycemia, dark pigmentation, decreased resistance to stress, fractures,
alopecia, weight loss, GI distress
Cushings: hyperNa, hypoK, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN,
hirsutism, moonface/buffalo hump

Addisonian crisis: n/v, confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, hypotension
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. While we’re on Addison’s, remember blood pressure is
the most important assessment parameter, as it causes severe hypotension.

Addison's disease (need to "add" hormone)

Cushing's syndrome (have extra "cushion" of hormones)

ADDISON’S DISEASE – bronze like skin pigmentation.

CUSHING’S SYNDROME – moon face appearance and buffalo hump.
Precautions
AIRBORNE DROPLET CONTACT PRECAUTION

My – Measles think of SPIDERMAN! MRS.WEE

Chicken - Chicken Pox/Varicella S - sepsis
Hez - Herpez Zoster/Shingles S - scarlet fever M - MRSA
TB S - streptococcal pharyngitis R - respiratory infection
P - parvovirus B19 S - skin infections *
or remember... P - pneumonia W - wound infxn
P - pertussis E - enteric infxn - clostridium
MTV=Airborne I - influenza difficile
Measles D - diptheria (pharyngeal) E - eye infxn - conjunctivitis
TB E - epiglottitis
Varicella-Chicken Pox/Herpes R - rubella SKIN INFECTIONS VCHIPS
Zoster-Shingles M - mumps
M - meningitis V - varicella zoster
Private Room - negative pressure M - mycoplasma or meningeal C - cutaneous diphtheria
with 6-12 air exchanges/hr pneumonia H - herpez simplex
Mask, N95 for TB An - Adenovirus I - impetigo
Private Room or cohort P - pediculosis
Mask S – scabies

Door open, 3 ft distance, private Tetanus,

room or cohort, mask Hepatitis A & B,
HIV

Disseminated Herpes Zoster is Localized Herpes Zoster is

AIRBORNE PRECAUTIONS CONTACT PRECAUTION
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!

**VRSA - Contact AND airborne precaution (Private room, door closed, negative pressure)
**SARS (Severe Acute Resp Syndrome) – Contact AND airborne (just like varicella)

Neutropenic patients = no live vaccines, no fresh fruits, no flowers/live plants

No milk (as well as fresh fruit or veggies) on neutropenic precautions.

Appendicitis
Appendicitis (inflammation of the appendix) pain is in RLQ with rebound tenderness
McBurney’s Point – pain in RLQ indicative of appendicitis

The sequence of symptoms is the most reliable when assessing for possible appendicitis;
the clinical symptoms with acute appendicitis are similar to those of many other medical conditions.
o In acute appendicitis, the pain usually comes prior to nausea and vomiting;
o Nausea and vomiting that come before abdominal pain frequently indicate gastroenteritis
Position on right side with legs flexed after appendectomy

Rheumatoid Arthritis
• Rheumatoid arthritis:
o Move your joints as much as you can each day; maintaining mobility is a physical need;
o achieved by exercises and independent ADLs;
o take warm shower or tub bath to increase blood flow, decrease pain and increase joint mobility;
(remember HOT = chronic pain, COLD = acute pain)
o walking and swimming are good exercises; Swimming is best for arthritis patients

Pain is usually the highest priority with RA

GOUT - Gout is a kind of arthritis that occurs when uric acid builds up in blood and causes joint inflammation.
Acute gout is a painful condition that typically affects one joint;
Chronic gout is repeated episodes of pain and inflammation, which may involve more than one joint.
Gout Meds: Probenecid (Benemid), Colchicine, Allopurinol (Zyloprim)

Assessment
Order of assessment: Inspection, Palpation, Percussion and Auscultation. EXCEPT with abdomen
cuz you don’t wanna mess with the bowels and their sounds so you Inspect, Auscultate, Percuss
then Palpate (same with kids)

Blood
For blood types: "O" is the universal donor (remember "o" in donor)
"AB" is the universal receipient

*Blood transfusion- sign of allergies in order:

1)Flank pain
2)Frequent swallowing
3)Rashes
4)Fever
5)Chills

Basophils release histamine during an allergic response.

During sickle cell crisis there are two interventions to prioritize: fluids and pain relief.

Hemophilia is x-linked. Mother passes disease to son.

• eleVate Veins = promotes venous return

• dAngle Arteries = increases circulation; better perfusion to extremities
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)

*Thrombocytopenia -Bleeding precautions!

1)Soft bristled toothbrush
2)No insertion of anything! (c/i suppositories, douche)
3) No injections if possible

Anemia
PERNICIOUS ANEMIA – cardinal S/S red beefy tongue

*Iron deficiency anemia - easily fatigued

1)Fe PO - give with Vitamin C or on an empty stomach
2)Fe via IM- Inferon via Ztrack

*Pernicious Anemia - Red, Beefy tongue; will take Vit.B12 for life!

Pernicious anemia s/s include pallor, tachycardia, and sore red tongue

Bone Stuff
Remember compartment syndrome is an emergency situation. Paresthesias and increased pain are classic
symptoms. Neuromuscular damage is irreversible 4-6 hours after onset.

* 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

** SIGNS of a Fractured hip: EXTERNAL ROTATION, SHORTENING, ADDUCTION

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.

** Paget's Disease - tinnitus, bone pain, enlargement of bone, thick bones.

** Greenstick fractures, usually seen in kids bone breaks on one side and bends on the other

Ottorhea s/s of basilar fracture

Battles sign and racoons eyes s/s of orbital fracture

Osteomyletitis is an infectious bone dz. Give blood cultures and antibiotics, then if necessary
surgery to drain abscess.

• Halo vest traction:

o Hurts to chew = BAD! = if pain occurs with jaw movement 24 to 48 hours after traction applied,
may indicate that skull pins have slipped onto the thin temporal plate; notify physician immediately
o Ok to be a little itchy, screws are tightened so headache is expected, give analgesic.

• Buck’s Traction
o Remove the foam boot 3x per day to inspect skin; a 2nd nurse should support the extremity during
inspection
o Turn client to unaffected side if there is a fracture, if no fracture may turn to either side
 o Provide back care q2h to prevent pressure ulcers
o Dorsiflex foot of affected leg – assess function of the peroneal nerve, weakness upon dorsiflexion
indicates pressure on the nerve
o Elevate foot of the bed – provides counter-traction

Buck’s traction= knee immobility

Russell traction= femur or lower leg
Dunlap traction= skeletal or skin
Bryant’s traction= children <3y, <35 lbs with femur fx.

Place apparatus first then place the weight when putting traction

Burns

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%

*BURNS
1st Degree - Red and Painful
2nd Degree - Blisters
3rd Degree - No Pain because of blocked and burned nerves

Cancer
4 options for cancer management: chemo, radiation, surgery, allow to die with dignity.

Your cancer patient is getting radiation. What should you be most concerned about? Skin
irritation? No. Infection kills cancer patients most because of the leukopenia caused by radiation.

During Internal Radiation --> on bedrest while implant in place

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.

A breast cancer patient treated with Tamoxifen should report changes in visual acuity, because
the adverse effect could be irreversible.

Wilm’s tumor is usually encapsulated above the kidneys causing flank pain.

BLADDER CA – cardinal S/S painless hematuria

Undescended testis or cryptorchidism is a known risk factor for testicular cancer later in life.
Start teaching boys testicular self exam around 12, because most cases occur during adolescence.

Hodgkin’s disease= cancer of lymph is very curable in early stage.

HODGKIN’S DSE/LYMPHOMA – painless, progressive enlargement of spleen & lymph tissues, Reedstenberg
Cells

A pt with leukemia may have epistaxis (nose bleed) b/c of low platelets

Common sites for metastasis include the liver, brain, lung, bone, and lymph.

Bence Jones protein in the urine confirms multiple myeloma.

Conversions

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 substract 40
* To convert Fahrenheit to C. C= F+40, multiply 5/9 and substract 40.

Diet
Jews: no meat and milk together
**Acid Ash diet - cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread
** Alk Ash diet- milk, veggies, rhubarb, salmon

low residue diet means low fiber

Yogurt has live cultures- dont give to immunosuppressed pt

TPN(total parenteral nutrition) given in subclavian line.

Latex allergies => Assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit,
avocados, chestnuts, tomatoes, peaches

Diseases- Miscellaneous

ACROMEGALY – cardinal S/S Coarse facial feature

Amyotrophic lateral sclerosis ( ALS ) is a condition in which there is a degeneration of motor neurons in both
the upper & lower motor neuron systems.

Guillain-Barre syndrome= From bottom to top. ascending paralysis. ascending muscle weakness. Keep eye on
respiratory system.

Hemophilia is x-linked. Mother passes disease to son. Bleeding disorder. No contact sports.

DOWN SYNDROME – protruding tongue.

KAWASAKI SYNDROME (autoimmune) – cardinal S/S strawberry tongue

Kawasaki's (autoimmune) leads to cardiac problems.
We know Kawasaki disease (autoimmune) causes a heart problem, but what specifically? Coronary artery
aneurysms d/t the inflammation of blood vessels.

Lupus autoimmune disease (SLE) – cardinal S/S butterfly rashes

PEMPHIGUS VULGARIS autoimmune disease – cardinal S/S Nikolsky’s sign (separation of epidermis caused
by rubbing of the skin)

Bacterial diseases cardinal S/S:

CHOLERA – rice watery stool.
MALARIA – stepladder like fever with chills.
TYPHOID – rose spots in abdomen.
DIPTHERIA – pseudo membrane formation
LEPROSY – lioning face.
TETANY – hypocalcemia (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm).
TETANUS – risus sardonicus.

Cystic Fibrosis:
First sign of cystic fibrosis may be meconium ileus at birth. Baby is inconsolable, do not eat, not passing
meconium.
CYSTIC FIBROSIS – S/S Salty skin
Cystic Fibrosis give diet low fat, high sodium, fat soluble vitamins ADEK.
Aerosal bronchodilators, mucolytics and pancreatic enzymes.
-Pancreatic enzymes are taken with each meal! Not before, not after, but WITH each meal.
Respiratory problems are the chief concern with CF

Cerebral palsy = poor muscle control due to birth injuries and/or decrease oxygen to brain tissues.

Akathisia - motor restlessness, need to keep going, tx with antiparkinsons meds, can be mistaken for agitation.
DUCHENNE’S MUSCULAR DYSTROPHY – Gowers’ sign (use of hands to push one’s self from the floor

LYME’S DISEASE – cardinal S/S Bull’s eye rash

Rheumatic fever can lead to cardiac valves malfunctions.

Group-a strep precedes rheumatic fever. Chorea is part of this sickness (grimacing, sudden body movements,
etc.) and it embarrasses kids. They have joint pain. Watch for elevated antistreptolysin O to be elevated.
Penicillin!!!

Huntington's Chorea aka Dancing Disease: 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

Viral diseases cardinal S/S:

MEASLES – cardinal S/S Koplick's spots are red spots with blue center characteristic of PRODROMAL stage
of Measles. Usually in mouth.
DENGUE – cardinal S/S petechiae or (+) Herman’s sign.
CHICKEN POX – cardinal S/S Vesicular Rash (central to distal) dew drop on rose petal

MENINGITIS – Kernig’s sign (leg flex then leg pain on extension), Brudzinski sign (neck flex = lower leg
flex).
Meningeal irritation S/S nuchal rigidity, positive Brudzinski + Kernig signs and PHOTOPHOBIA too!

CSF in bacterial meningitis will have high protein & low glucose (try to remember it by thinking the bacteria
are like ants that like sugar and eat up the sugar so low glucose)

Multiple sclerosis= myelin sheat destruction, disruption in nerve impulse conduction.

Hyperactive deep tendon reflexes, vision changes, fatigue and spasticity are all symptoms of MS
-Multiple Sclerosis is a chronic, progressive disease with demyelinating lesions in the CNS which
affect the white matter of the brain and spinal cord.
Motor S/S: limb weakness, paralysis, slow speech
Sensory S/S: numbness, tingling, tinnitus
Cerebral S/S: nystagmus, ataxia, dysphagia, dysarthria

• Multiple sclerosis – sleep on stomach as much as possible may minimize spasm of the flexor muscles of the
hips and knees of a person with multiple sclerosis; if these spasms are not relieved, joint contractions will
occur as well as pressure ulcers on the sacrum and hips from difficulty positioning the patient correctly

Myasthenia Gravis: worsens with exercise and improves with rest. descending muscle weakness.
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.
Myasthenia Gravis is caused by a disorder in the transmission of impulses from nerve to muscle
cell.

Tensilon is used in myasthenia gravis to confirm the diagnosis.

Tensilon test given if muscle is tense in myasthenia gravis.

Myasthenia Crisis: a positive reaction to Tensilon--will improve symptoms, this confirms diagnosis
Cholinergic Crisis: caused by excessive medication-stop med-giving Tensilon will make it worse

Give neostigmine to clients with Myasthenia Gravis about 45 min. before eating, so it will help with chewing
and swallowing.

Diabetes Mellitus – DKA

DM – polyuria, polydypsia, polyphagia

Beta cells of pancreas produce insulin.

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.

To remember blood sugar:

Hot and dry - sugar high (hyperglycemia)
Cold and clammy - need some candy (hypoglycemia)

Diabetic ketoacidosis (DKA)= when body is breaking down fat instead of sugar for energy. Fats leave ketones
(acids) that cause pH to decrease.

DKA is rare in diabetes mellitus type II because there is enough insulin to prevent breakdown of fats

DKA – cardinal S/S Kussmauls breathing (Deep Rapid RR)

While treating DKA, bringing the glucose down too far and too fast can result in increased intracranial
pressure d/t 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.

Fluids are the most important intervention with HHNS as well as DKA, so get fluids going first.
With HHNS there is no ketosis, and no acidosis. Potassium is low in HHNS (d/t diuresis).

Drains
Hemovac- used after mastectomy, 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.

Paracentesis- semi fowlers or upright on edge of bed, empty bladder.

Post- v.s., report elevated temp, observe for signs of hypovolemia.

Thoracentesis prep- Take v.s., shave area around needle insertion, position patient with arms
on pillow on over bed table or lying on side, no more than 1000cc at a one time. Post- listen
for bilateral breath sounds, v.s., check leakage, sterile dressing.

Ear

MENIERE’S DSE – cardinal S/S Vertigo, Tinnitus

*Meniere's Disease - Admin diuretics to decrease endolymph in the cochlea, restrict Na, lay on
affected ear when in bed. Triad:
1)Vertigo
2)Tinnitus
3)N/V

After Myringotomy --> position on side of affected ear after surgery (allows drainage of secretions)

Endocrine – ADH – DI – SIADH

The parathyroid gland relies on the presence of vitamin D to work.

Diabetes Insipidus (decreased ADH): excessive urine output and thirst, dehydration,
weakness, administer Pitressin
Water intoxication will be evidenced by drowsiness and altered mental status in a patient with TUR
syndrome, or as an adverse reaction to desmopressin (for diabetes insipidus).

SIADH (increased ADH): change in LOC, decreased deep tendon reflexes, tachycardia, n/v/a,
HA; administer Declomycin, diuretics

Pheochromocytoma: hypersecretion of epi/norepi, persistent HTN, increased HR,

hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bating and rest breaks,
avoid cold and stimulating foods, surgery to remove tumor

Eyes

OU- both eyes

OS- left eye
OD- right eye (dominant Right eye- just a tip to remember)

• IOP – Intraocular Pressure Normal = 10 -21 mm Hg

Assessing extraocular eye movements check cranial nerves 3, 4, and 6.

• Nystagmus = uncontrollable movement of the eyes

• Cataracts
o As you age, the lenses of the eyes gradually lose moisture and their density increases.
o Cataracts are partial or total opacity of the normally transparent crystalline lens; occurs because lens
becomes less hydrated and more dense
o Milky thing over eye
Cataract= cloudy, blurry vision. Treated by lens removal-surgery
CATARACT – Painless vision loss, Opacity of the lens, blurring of vision
After Cataract Surgery --> pt will sleep on unaffected side with a night shield for 1-4 weeks.

Detached Retina --> area of detachment should be in the dependent position

RETINAL DETACHMENT – Visual Floaters, flashes of light, curtain vision

Cytovene, used for retinitis caused by cytomegalovirus, pt will need regular eye exams, report
dizziness, confusion, or seizures immediately

* Ethambutol - messes with your Eyes

* Apply eye drop to conjunctival sac and after wards apply pressure to nasolacrimal duct / inner
canthus

*Glaucoma : intraocular pressure (IOP) is greater than the normal (22 mm Hg), give miotics to constrict
(pilocarpine) NO ATROPINE.
GLAUCOMA – Painfull vision loss, tunnel/gun barrel/halo vision (Peripheral Vision Loss)
Glaucoma patients lose peripheral vision. Treated with meds. Diamox, used for glaucoma, can cause
hypokalemia.
Levodopa, for parkinsons, contraindicated in pts with glaucoma, avoid B6

RETINO BLASTOMA – Cat’s eye reflex (grayish discoloration of pupils)

** BOTOX for strabismus. Patch the GOOD eye so that the weaker eye can get stronger. Found a
cool link about its use in peds pt with strabismus. I had to look it up cuz I heard it was important
*ah hem ah hem*
** BOTOX ** (Botulin Toxin) can be used with strabismus also to relax vocal cords in spasmodic
dysphonia.

Electrolytes and stuff

Aldosterone attracts sodium.

Wherever there is sugar (glucose) water follows.

Dehydration: weight is the best indicator of dehydration

Edema is in the interstitial space not in the cardiovascular space.

Hypovolemia – incrased temp, rapid/weak pulse, increase respiration, hypotension, anxiety, urine specific
gravity >1.030
Hypervolemia – bounding pulse, SOB, dyspnea, rares/crackles, peripheral edema, HTN, urine specific gravity
<1.010; Semi-Fowler’s
Fluid volume overload caused by IVC fluids infusing too quickly (or whatever reason) and CHF can cause an
S3

Calcium:
Hypocalcemia: CATS – convulsions, arrhythmias, tetany, spasms and stridor, Chvostek & Trosseaus sign
Hypercalcemia: muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes,
sedative effect on CNS
Polyuria is common with the hypercalcemia caused by hyperparathyroidism.

* Long term use of amphogel (binds to phosphates, increases Ca, robs the bones...leads to increased Ca
resortion from bones and WEAK BONES)

Non dairy sources of calcium include RHUBARB, SARDINES, COLLARD GREENS

Magnesium:
HypoMg: tremors, tetany, seizures, dyrshythmias, depression, confusion, dysphagia; dig toxicity
oHyper reflexes (upper motor neuron issue “your reflexes are over the top”)

HyperMg: depresses the CNS, hypotension, facial flushing, muscle ewakness, absent deep tendon reflexes,
shallow respirations, emergency
oAbsent reflexes (lower motor neuron issue)

Potassium:
Never give K+ in IV push.

No Pee, no K (do not give potassium without adequate urine output) ; Never give potassium if the patient is
oliguric or anuric.

Bananas, potatoes, citrus fruits source of potassium

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 in priority.

You better be making sure that patient on Dig and Lasix is getting enough potassium, because
low potassium potentiates Dig and can cause dysrrhythmias.

A little trick regarding potassium:

AlKaLOsis: K is LOW - From the mouth (vomitus) = metabolic alkalosis

Acidosis is just the opposite: K is High - From the a** (diarrhea) = metabolic acidosis

Hypokalemia: muscle ewakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges,

beans, potatoes, carrots, celery)

Hyperkalemia: MURDER – muscle weakness, urine (oliguria/anuria), respiratory depression,

decreased cardiac contractility, ECG changes, reflexes
The vital sign you should check first with high potassium is pulse (due to dysrhythmias).

Sodium:
Hyponatremia: nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic
diuretics, fluids
Hypernatremia: increased temp, weakness, disorientation/delusions, hypotension, tachycardia;
hypotonic solution
Hyper natremia (greater than 145) – SALT:
Skin flushed
Agitation
Low grade fever
Thirst

GI

Give carafate (GI med) before meals to coat stomach

Protonix is given prophylactically to prevent stress ulcers.

GERD – Barretts esophagus (erosion of the lower portion of the esophageal mucosa)
Patients with GERD should lay on their left side with the HOB elevated 30 degrees.

ULCERATIVE COLITIS – recurrent bloody diarrhea

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.
When you see Coffee-brown emesis, think peptic ulcer

*Cushings ulcers r/t BRAIN injury. A GI ulcer that occurs due to brain injury.

Diverticulitis (inflammation of the diverticulum in the colon) pain is around LL quadrant.

To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) --> eat in

reclining position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low
CHO and fiber diet, small frequent meals)
Dumping syndrome: increase fat and protein, small frequent meals, lie down after meal to
decrease peristalsis, wait 1 hr after meals to drink.

Administration of Enema --> position pt in left side-lying (Sim's) with knee flexed

Hirschsprung’s --> bile is lower obstruction, no bile is upper obstruction; ribbon like stools.
Hirschsprung’s 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.

INTUSSUSCEPTION – sausage shaped mass, Dance Sign (empty portion of RLQ)

Intussusception common in kids with CF. Obstruction may cause fecal emesis, currant jellylike stools (blood
and mucus). A barium enema may be used to hydrostatically reduce the telescoping. Resolution is obvious, with
onset of bowel movements.
PYLORIC STENOSIS – cardinal S/S olive like mass.

Nonfat milk reduces reflux by increasing lower esophageal sphincter pressure

Stomas
dusky stoma means poor blood supply, protruding means prolapsed, sharp pain + rigidity means peritonitis,
mucus in ileal conduit is expected.

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
also, 4) Continous Drooling

Head stuff
No nasotracheal suctioning with head injury or skull fracture.

Cephalhematoma (caput succinidanium) resolves on its own in a few days. This is the type of
edema that crosses the suture lines.

Level of consciousness is the most important assessment parameter with status epilepticus.

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 A Auditory VIII Says
9 Girls Glossopharyngeal IX Big
10 Vagina Vagus X Bras
11 And Accessory XI Matter
12 Hymen Hypoglassal XII More
ICP
ICP (intracranial pressure) should be <2 measure head circumference
*Cushings triad r/t increased ICP:
1 HTN
2 Bradycardia
3 Bradypnea
ICP AND SHOCK HAVE OPPOSITE V/S:
ICP-increased BP, decreased pulse, decreased resp.
Shock- decreased BP, increased pulse, increased resp.

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. You should watch
for abdominal distention, since fluid from the ventricles will be redirected to the peritoneum. You should also
watch for signs of increasing intracranial pressure, such as irritability, bulging fontanels, and high-pitched cry
in an infant. In a toddler watch lack of appetite and headache. Careful on a bed position question! Bed-position
after shunt placement is flat, so fluid doesn’t reduce too rapidly. If you see s/s of increasing icp, then raise the
hob to 15-30 degrees.

CVA (cerebrovascular accident) is with dead brain tissue.

TIA (transient ischemic attack) mini stroke with no dead brain tissue

Pt w/ Heat Stroke --> lie flat w/ legs elevated

EEG, hold meds for 24-48 hrs prior, no caffine or cigarettes for 24 hrs prior, pt can eat, pt must stay awake
night before exam, pt may be asked to hyperventilate and watch a bright flashing light, after EEG, assess pt for
seizures, pt's will be at increased risk

GLASGOW COMA SCALE. EYES, VERBAL,MOTOR!

It is similar to measuring dating skills...max 15 points -one can do it if below 8 you are in Coma.
Eyes
Verbal
Motor
So, to start dating you gotta open your EYES first, if you able to do that spontaneously and use them correctly
to SEE whom you dating you earn 4. if you get good EYE contact (4 points)
But if she has to scream on you to make you open them it is only 3....
and 1 you don’t care to open even if she tries to hurt you.
Then move to VERBAL talk to her/ him!
If you can do that You are really ORIENTED in situation she/he uncontiously gives you 4 points!
If you like her try not to be CONFUSED (3), and of course do not use INAPPROPRIATE WORDS (3),
try not to RESPOND WITH INCOMPREHENSIBLE SOUNDS (2),
if you do not like her just show no VERBAL RESPONSE(1)
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!

Questions about a halo? Remember safety first, have a screwdriver nearby.

HYDROCEPHALUS – Bossing sign (prominent forehead)

Head Injury --> elevate HOB 30 degrees to decrease intracranial pressure

Head injury medication: Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use filter needle
When phenylalanine (amino acid) increases, brain problems occur

After Supratentorial Surgery (incision behind hairline) --> elevate HOB 30-45 degrees
After Infratentorial Surgery (incision at nape of neck)--> position pt flat and lateral on either side.

Cardiac

Preload affects amount of blood that goes to the R ventricle.

Afterload is the resistance the blood has to overcome when leaving the heart.
Calcium channel blocker affects the afterload.
Cardiac output decreases with dysrythmias. Dopamine increases BP.
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). This
is a toughie…think about it.

Med of choice for Vtach is lidocaine

Med of choice for SVT is adenosine or adenocard
Med of choice for Asystole (no heart beat) is atropine
Med of choice for CHF is Ace inhibitor.
Amiodorone is effective in both ventricular and atrial complications.

S3 sound is normal in CHF, not normal in MI.

with R side cardiac cath=look for valve problems

with L side cardiac cath=look for coronary complications

Auscultate Heart Sounds:

All
Physicians
Earn
Too
Much
Money
Or APE To Man

Anytime you see fluid retention. Think heart problems first.

Fluid volume overload caused by IV fluids infusing too quickly (or whatever reason) and CHF can cause an S3

MI= dead heart tissue present

MI – Crushing stubbing pain which radiates to left shoulder, neck, arms, unrelieved by NTG
Blood tests for MI: Myoglobin, CK and Troponin

Angina:
Angina (low oxygen to heart tissues) = no dead heart tissues.
ANGINA – Crushing stubbing pain relieved by NTG
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.
Unstable angina is not relieved by nitro.

Remember the action of vasopressin because it sounds like “press in”, or vasoconstrict.
Prolonged hypoxemia is a likely cause of cardiac arrest in a child.

Coarctation of the aorta causes increased blood flow and bounding pulses in the arms

Patent Ductus Arteriosus PDA – machine like murmur.

A newly diagnosed hypertension patient should have BP assessed in both arms.

Orthostasis is verified by a drop in pressure (hypotension) with increasing heart rate.

CABG operation when the great saphenous vein is taken it is turned inside out due to the valves that are inside.

Dead tissues cannot have PVC’s (premature ventricular contraction.

If left untreated PVC’s can lead to VF (ventricular fibrillation).

Circulation
EleVate Veins; dAngle Arteries for better perfusion
DVT – positive Homan’s Sign (calf pain)
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)

Congenital cardiac defects result in hypoxia which the body attempts to compensate for (influx of immature
rbc’s)? Labs supporting this would show increased hematocrit, hemoglobin, and rbc count.

Cor Pulmonae
Cor pulmonae: right sided heart failure caused by left ventricular failure (so pick edema, jvd, if it is a choice.)
Cor pulmonale (s/s fluid overload) is Right sided heart failure caused by pulmonary disease, occurs with
bronchitis or emphysema.

Heart Meds:
Digitalis increases ventricular irritability, and could convert a rhythm to v-fib following cardioversion.

With flecainide (Tambocor), an antiarrythmic, limit fluids and sodium intake, because sodium increases water
retention which could lead to heart failure.

Adenosine is the treatment of choice for paroxysmal atrial tachycardia.

Normal PCWP (pulm capillary wedge pressure) is 8-13. Readings of 18-20 are considered high.

Pregnancy – Labor – Newborn – Peds

I kept forgetting which was dangerous when you're pregnant; regular measles (rubeola) or
German measles (rubella), so remember: -never get pregnant with a German (rubella)

Perform amniocentesis before 20 weeks gestation to check for cardiac and pulmonary abnormalities.

Rh- mothers receive rhogam to protect next baby.

Rhogam : given at 28 weeks, 72 hours post partum, IM.
Only given to Rh NEGATIVE mother.
Rhogam only given if negative indirect Coombs test.
If indirect Coomb’s test is positive, don’t need to give Rhogam cuz she has antibody

Glucose Tolerance Test for preggos result of 140 or highter needs further evaluation.

Amniotic fluid yellow with particles = meconium stained = bad because baby can swallow poop
Amniotic fluid is alkaline, and turns nitrazine paper blue.
Urine and normal vaginal discharge are acidic, and turn it pink.

For cord compression, place the mother in the TRENDELENBERG 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)

If water breaks while mom is in labor and she is any minus station you better know there is a risk of prolapsed
cord.
If the cord is prolapsed, cover it with sterile saline gauze to prevent drying of the cord and to minimize
infection.
Prolapsed Cord --> knee-chest position or Trendelenburg

FHR patterns - Think VEAL CHOP

V = variable decels; C = cord compression caused
E = early decels; H = head compression caused
A = accels; O = okay, not a problem!
L = late decels P = placental insufficiency, can't fill

For late decels, turn the mother to her left side, to allow more blood flow to the placenta.

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) 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.

During Epidural Puncture --> side-lying

Pitocin med used for uterine stimulation

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; for
exmaple 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 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.

If the baby is breech, the sounds are high up in the fundus near the umbilicus.

If the baby is vertex, they are a little bit above the symphysis pubis.
Dystocia = baby cannot make it down to canal

Placenta should be in upper part of uterus.

Placenta previa = there is no pain, there is bleeding.
Placental abruptio: bleeding with pain, don't forget to monitor volume status (I&O)

Eclampsia is seizure while pregnant.

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).

Posterior fontanelle 6 to 8 weeks.

Anterior fontanelle closes by 18 months.

Caput succedaneum= diffuse edema of the fetal scalp that crosses the suture lines. Swelling reabsorbs within 1
to 3 days.

• Pathological jaundice: pathological jaundice occurs within the first 24 hours of birth and is caused by
destruction of RBCs from an antigen-antibody reaction.
o My baby is jaundiced because of an incompatibility between my blood and the baby’s blood.
o My baby is jaundiced because I am Rh-negative and the baby is Rh-positive.
o My baby is jaundiced because this was my second pregnancy.
• Physiological jaundice: caused by immature hepatic function; occurs after 24 hours, peaks at 72 hours, and
lasts 5–7 days.
o My baby is jaundiced because the liver is unable to clear bilirubin from the blood.

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

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 HR,RR,Muscle tone, Reflexes,Skin color each 0-2 point. 8-10 OK. 0-3 RESUSCITATE.

Newborn: (+ Babinski sign): Toes fan out. [In normal adult they curl in :( - babinski)]

Newborn: heroin withdrawal neonate: irritable poor sucking

Fetal alcohol syndrome

-upturned nose
-flat nasal bridge
-thin upper lip
-SGA

Low-set ears and renal anomalies: The kidneys and ears develop around the same time in utero. Hence, they're
shaped similarly. Which is why when doing an assessment of a neonate, if the nurse notices low set or
asymmetrical ears, there is good reason to investigate renal functioning. Knowing that the kidneys and ears are
similar shapes helped me remember this

Best way to warm a newborn: skin to skin contact covered with a blanket on mom.

The biggest concern with cold stress and the newborn is respiratory distress.

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

Heart defects. Remember for cyanotic -3T’s( Tof, Truncys 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.

A positive Western blot in a child <18 months (presence of HIV antibodies) indicates only that mom is
infected.
Two or more positive p24 antigen tests will confirm HIV in kids <18 months. The p24 can be used at any age.
For HIV kids avoid OPV and Varicella vaccinations (live), but give Pneumococcal and influenza.
MMR is avoided only if the kid is severely immunocompromised.
Parents should wear gloves for care, not kiss kids on the mouth, and not share eating utensils.

What could cause bronchopulmonary dysplasia? Dysplasia means abnormality or alteration. Mechanical
ventilation can cause it. Premature newborns with immature lungs are ventilated and over time it damages the
lungs. Other causes could be infection, pneumonia, or other conditions that cause inflammation or scarring.

Infant w/ Spina Bifida --> position prone (on abdomen) so that sac does not rupture

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

With omphalocele and gastroschisis (herniation of abdominal contents) dress with loose saline dressing
covered with plastic wrap, and keep eye on temp. Kid can lose heat quickly.

The first sign of pyloric stenosis in a baby is mild vomiting that progresses to projectile vomiting. Later you
may be able to palpate a mass, the baby will seem hungry often, and may spit up after feedings.

Feed upright to avoid otitis media.

Position prone w hob elevated with gerd. In almost every other case, though, you better lay that kid on his back
(Back To Sleep - SIDS).

Kids with RSV; no contact lenses or pregnant nurses in rooms where ribavirin is being administered by
hood, tent, etc.

Birth weight doubles by 6 months and triples by 1 year of age.

If you can remove the white patches from the mouth of a baby it is just formula. If you can’t, its candidiasis.

Infant: Brachial pulse used for CPR

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

Test child for lead poisoning around 12 months of age

It is essential to maintain nasal patency with children < 1 yr. because they are obligatory nasal breathers.

Just know the MMR and Varicella immunizations come later (15 months).

** Stranger anxiety is greatest 7 - 9 months, Separation anxiety peaks in toddlerhood

Toddlers need to express autonomy (independence)

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.

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").

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.

In a five-year old breathe once for every 5 compressions doing CPR.

VACCINES: Age 4 to 5 yrs child needs DPT/MMR/OPV

An ill child regresses in behavior

Interpersonal model (Sullivan)

Behavior motivated by need to avoid anxiety and satisfy needs
Infancy 0-1 yr old others will satisfy needs
Childhood 2-6 yrs old Learn to delay need gratification
Juvenile 6-9 yrs learn to relate to peers
Pre-adolescence 9-12 yrs learns to relate to friends of opposite sex
Early adolescence 12-14 yrs learn independence and how to relate to opposite sex
Late adolescence 14-21 yes develop intimate relationship with person of opposite sex

What is an intraosseous infusion? In pediatric 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. It is a temporary, life-saving
measure, and I have seen it once! (Gruesome.) When venous access is achieved it can be d/c’d. One medication
that cannot be administered by intraosseous infusion is isoproterenol, a beta agonist. (I don’t know more about
that drug; it was just pointed out on a practice exam.)

Watch out for questions suggesting a child drinks more than 3-4 cups of milk each day. (Milks good, right?)
Too much milk reduces intake of other essential nutrients, especially iron. Watch for anemia with milk-
aholics.
And don’t let that mother put anything but water in that kid’s bottle during naps/over-night. Juice or milk will
rot that kids teeth right out of his head.

What traction is used in a school-age kid with a femur or tibial fracture with extensive skin damage? 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 is the normal pulleys and ropes you’re used to visualizing with
balanced suspension.
While we’re talking about traction, a kid’s hinder should clear the bed when in Bryant’s traction (also used
for femurs and congenial hip for young kids).

BSA Body Surface Area is considered the most accurate method for medication dosing with kids. (I though it
was weight, but apparently not)

No aspirin with kids b/c it is associated with Reye’s Syndrome, and also no nsaids such as ibuprofen. Give
Tylenol.

Eardrops: Pull pinna down and back for kids < 3 yrs. when instilling eardrops.

Injections:
for 6 month infants vastus lateralis is IM administration site
For toddlers above 18 months ventrogluteal
The deltoid and gluteus maximus are appropriate sites for children

No phenylalanine with a kid positive for PKU (no meat, no dairy, no aspartame).

LABS and Lab Values

A patient with a low hemoglobin and/or hematocrit should be evaluated for signs of
bleeding, such as dark stools.

Hemoglobin
Neonates 18-27
3 mos 10.6-16.5
3 yrs 9.4-15.5
10 yrs 10.7-15.5

Renal impairment: serum creatinine elevated and urine clearance decreased

Norm. Serum creatinine 0.8-1.8 (men), 0.5-1.5 (women)
Norm. Urine clearance 85-135
Low magnesium and high creatinine signal renal failure.

When drawing an ABG, you need to put the blood in a heparinized tube, make sure there are no bubbles, put on
ice immediately after drawing, with a label indicating if the pt was on room air or how many liters of O2.
Remember to perform the Allen's Test prior to doing an ABG to check for sufficient blood flow

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.

Second voided urine most accurate when testing for ketones and glucose.
Liver – Hepatic

Portal hypotension + albuminemia= Ascites.

Hepatitis
Hepatitis: -ends in a VOWEL, comes from the BOWEL (Hep A)
Hepatitis B=Blood and Bodily fluids
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

LIVER CIRRHOSIS – cardinal S/S spider like varices.

HEPATIC ENCEPHALOPATHY – cardinal S/S Flapping tremors

Pain

Cold for acute pain (eg. Sprain ankle)

Heat for chronic (rheumatoid arthritis)

Guided imagery is great for chronic pain.

** William's position - Semi Fowlers with knees flexed (inc. knee gatch) to relieve lower back pain. With low
back aches, bend knees to relieve.

During sickle cell crisis there are two interventions to prioritize: fluids and pain relief.

Pancreatitis

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

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

PANCREATITIS – Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots.

Demorol for pancreatitis, NOT morphine sulfate because morphine causes muscle spasm.
Morphine is contraindicated in Pancreatitis. It causes spasm of the Sphincter of Oddi. Therefore Demerol
should be given.

With chronic pancreatitis, pancreatic enzymes are given with meals.

Pancreatitis patients but them in fetal position, NPO, gut rest, prepare antecubital site for PICC cuz they'll
probably be getting TPN/Lipids.

After pain relief, cough and deep breathe is important in pancreatitis, because of fluid pushing up in the
diaphragm.
Parkinson’s = RAT: rigidity, akinesia (loss of muscle mvt), tremors. Treat with levodopa.
Sinemet, for Parkinson’s, contraindicated with MAOI's
PARKINSON’S – Pill-rolling tremors

Embolism’s

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.
First sign of PE is sudden chest pain, followed by dyspnea and tachypnea.

When o2 deprived, as with a PE, the body compensates by causing hyperventilation (resp alkalosis). Should the
patient breathe into a paper bag? No. If the pao2 is well below 80 they need oxygen. Look at all your abg
values. As soon as you see the words PE you should think oxygen first.

• Restlessness is top sign of embolism. If patient is restless and central IV has disconnected place pt on Left
side in Trendelenberg position placing the patient in this position increases the likelihood that the air will
pass into the right atrium and be dispersed by way of the pulmonary artery.
o Any other position increases the chances of the embolism traveling to the heart/brain.

Sign of fat embolism is petechiae. Treated with heparin.

** Fat Embolism: Blood tinged sputum (r/t inflammation), inc ESR, respiratory alkalosis (not acidosis r/t
tachypnea), hypocalcemia,increased serum lipids, "snow storm" effect on CXR.

Positioning

Four side-rails up can be considered a form of restraint. Even in LTC facility when a client is a fall risk, keep
lower rails down, and one side of bed against the wall, lowest position, wheels locked.

A patient with liver cirrhosis and edema may ambulate, then sit with legs elevated to try to mobilize the
edema.

Unusual positional tip - Low-fowlers recommended during meals to prevent dumping syndrome. Limit fluids
while eating.

Decorticate is toward the 'cord'. Decerebrate is the other way (out)

Decorticate positioning in response to pain = Cortex involvement.
Decerebrate in response to pain = Cerebellar, brain stem involvement

Psych stuff

Orange tag in triage is non-emergent Psych

Do not use why or I understand statement when dealing with patients. Therapeutic communication.
To access role relationship pattern focus on image and relationships with others.
Milieu therapy= taking care of patient/environment
Cognitive therapy= counseling
Crisis intervention=short term.

FIVE INTERVENTIONS FOR PSYCH PATIENTS

-safety
-setting limits
-establish trusting relationship
-meds
-leas restrictive methods/environment.

SSRI’s (antidepressants) take about 3 weeks to work.

Obsession is to thought. Compulsion is to action
If patients have hallucinations redirect them. In delusions distract them.
Thorazine, haldol (antipsychotic) can lead to EPS (extrapyramidal side effects)

If mixing antipsychotics (ie Haldol, Throazine, Prolixin) with fluids, med is incompatible with caffeine and
apple juice

Haldol preferred anti-psychotic in elderly, but high risk extrapyramidal side effects (dystonia, tarditive
dyskinesia, tightening of jaw, stiff neck, swollen tongue, later on swollen airway), monitor for early signs of
reaction and give IM Benadryl

Alzheimer  acetylcholine
Senile dementia  acetylcholine
Depression  Serotonin, Norepinephrine, Dopamine
Anxiety  GABA, Serotonin ;  Norepinephrine
Schizophrenia  Dopamine

Risperdal, antipsychotic, doses over 6mg can cause tarditive dyskinesia, first line antipsychotic in children

• Dementia
o Poor judgment, memory deficit, irritability, apathy, indifference, pacing, restlessness, and agitation
• Depression
o Weight loss, fatigue, and hopelessness.
• Delirium
o May have rapid onset due to illness
o Confusion, delirium, and hallucinations
• Dissociation
o unconscious separation of painful feelings from a difficult situation, idea, or object
• Regression
o return to an earlier level of development and the comfort measures associated with that level of
functioning
• Projection
o attributing one’s own feelings that are unacceptable to someone else, or blaming someone else for
one’s own problems
• Denial
 o unconscious refusal to admit an unacceptable idea or behavior or the feelings associated with it

Wernicke & Korsakoff usually occur together, W 1st then goes into K; Its onset is linked to chronic alcohol
abuse and/or severe malnutrition:

• Wernicke’s syndrome
o form of dementia that results from thiamine deficiency
o Confusion
o Ataxia (loss of muscle coordination)
 Leg tremor
o Vision changes
 Nystagmus (abnormal eye movement)
 Double vision
 Eyelid drooping
• Korsakoff’s psychosis
o neurological disorder caused by a lack of thiamine (vitamin B1) in the brain.
o amnesia
o confabulation (invented memories which are then taken as true due to gaps in memory sometimes
associated with blackouts)
o meager content in conversation
o lack of insight
o apathy

-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.

Alzheimer’s disease is a chronic, progressive, degenerative cognitive disorder that accounts for more than 60%
of all dementias

Med of choice for bipolar is lithium.

Depression often manifests itself in somatic ways, such as psychomotor retardation, gi complaints, and pain.
Safety over Nutrition with a severely depressed client.

Phobic disorders...use systematic desensitization.

Tardive Dyskinesia - irreversible - involuntary movements of the tongue, face and extremities, may happen
after prolonged use of antipsychotics.

Renal

Nephrotic syndrome s/s edema + hypotension. Turn and reposition (risk for impaired skin integrity)
Nephrotic syndrome s/s edema + hypotension. Turn and reposition (risk for impaired skin integrity)
Nephrotic syndrome is characterized by massive proteinuria (looks dark and frothy) caused by glomerular
damage. Corticosteroids are the mainstay. Generalized edema common.
With glomerulonephritis you should consider blood pressure to be your most important assessment
parameter. 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)

Renal impairment: serum creatinine elevated and urine clearance decreased

Low magnesium and high creatinine signal renal failure.
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 is priority.

Peritoneal Dialysis when Outflow is Inadequate --> turn pt from side to side BEFORE checking for kinks in
tubing (according to Kaplan)
It’s ok to have abdominal craps, 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.

Uremic fetor is a urine-like odor on the breath of persons with uremia. The odor occurs from the smell of
ammonia, which is created in the saliva as a breakdown product of urea. Uremic fetor is usually associated with
an unpleasant metallic taste (dysgeusia), and can be a symptom of chronic kidney disease.

Respiratory Stuff

Ambient air (room air) contains 21% oxygen.

Lung ** TIDAL VOLUME is 7 – 10ml / kg

Before going for Pulmonary Fuction Tests (PFT's), a pt's bronchodilators will be with-held and they are not
allowed to smoke for 4 hrs prior

For a lung biopsy, position pt lying on side of bed or with arms raised up on pillows over bedside table, have pt
hold breath in midexpiration, chest x-ray done immediately afterwards to check for complication of
pneumothorax, sterile dressing applied

• Normal breathing sounds:

o vesicular: soft and low-pitched breezy sounds heard over most of peripheral lung fields;
o bronchovesicular: harsh sounds heard over the mainstem bronchi;
o bronchial: loud, coarse, blowing sound heard over the trachea
• Adventitious (abnormal) breath sounds;
o caused by fluid or inflammation and include:
 rales — crackling or gurgling sounds (also known as crackles) commonly heard on
inspiration;
 rhonchi — musical sounds or vibrations commonly heard on expiration;
 wheezes — squeaky sounds heard during inspiration and expiration;
 pleural friction rub — grating sound or vibration heard during inspiration ad expiration

Can’t cough=ineffective airway clearance

The person who hyperventilates is most likely to experience respiratory alkalosis.

A positive ppd confirms infection, not just exposure. A sputum test will confirm active disease.
PPD is positive if area of induration is:
>5 mm in an immunocompromised patient
>10 mm in a normal patient
>15 mm in a patient who lives in an area where TB is very rare.

If a TB patient is unable/unwilling to comply with tx they may need supervision (direct observation). TB is a
public health risk

TB – low-grade afternoon fever. Cardinal S/S inspiratory stridor

INH, used to treat and prevent TB, do not give with dilantin, can cause phenytonin toxicity, monitor LFT's,
give B6 along with, hypotension will occur initially, then resolve
Rifampin, for TB, dyes bodily fluids orange
TB drugs are liver toxic. (Does your patient have hepB?) An adverse reaction is peripheral neuropathy.

ARDS
The first sign of ARDS is increased respirations. Later comes dyspnea, retractions, air hunger, cyanosis.
ARDS (fluids in alveoli), DIC (disseminated intravascular coagulation) are always secondary to something else
(another disease process).
Cardinal sign of ARDS is hypoxemia (low oxygen level in tissues).

Asthma
ASTHMA – wheezing on expiration.
Coughing w/o other s/s is suggestive of asthma. Speaking of asthma, watch out if your wheezer stops
wheezing. It could mean he is worsening.
Asthma --swimming best

When using a bronchodilator inhaler inconjuction with a glucocorticoid inhaler, administer the bronchodilator
first.

INtal, an inhaler used to treat allergy induced asthma may cause bronchospasm, think… INto the asthmatic lung

PNEUMONIA – rusty sputum.

Positioning with pneumonia – lay on the affected side to splint and reduce pain. But if you are
trying to reduce congestion the sick lung goes up. (Ever had a stuffy nose, and you lay with the
stuff side up and it clears?)
With pneumonia, fever and chills are usually present. For the elderly confusion is often present.
Crackles suggest pneumonia, which is likely to be accompanied by hypoxia, which would manifest itself as
mental confusion, etc.
Signs of hypoxia: restless, anxious, cyanotic tachycardia, increased resps. (also monitor ABG's)
Congenital cardiac defects result in hypoxia which the body attempts to compensate for (influx of immature
rbc’s) Labs supporting this would show increased hematocrit, hemoglobin, and rbc count.

*Incentive Spirometry steps:1) Sit upright 2) Exhale 3) Insert mouthpiece 4) Inhale for 3 seconds, and then
HOLD for 10 seconds

COPD is chronic, pneumonia is acute. Emphysema and bronchitis are both COPD.
COPD patients REMEMBER: 2LNC or less (hypoxic NOT hypercapnic drive), Pa02 of 60ish and Sa02 90% is
normal for them b/c they are chronic CO2 retainers. ...
in COPD patients the baroreceptors that detect the CO2 level are destroyed. Therefore, O2 level must be low
because high O2 concentration

EMPHYSEMA – barrel chest.

In emphysema the stimulus to breathe is low PO2, not increased PCO2 like the rest of us, so don’t slam them
with oxygen. Encourage pursed-lip breathing which promotes CO2 elimination, encourage up to
3000mL/day fluids, high-fowlers and leaning forward.

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.

EPIGLOTITIS – 3Ds’ Drooling, Dysphonia, Dysphagia

• Epiglottitis
o Is inflammation of the epiglottis and can be life-threatening;
o Never insert a tongue blade into the mouth of a child diagnosed with epiglottitis; gag reflex can
cause complete obstruction of the airway
o When working with a child be careful to not make them cry, crying can obstruct the airway

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.

Angiotensin II in the lungs= potent vasodilator.

Tension pneumothorax trachea shifts to opposite side.

Ventilators
Complications of Mechanical Ventilation: Pneumothorax, Ulcers
Bronchopulmonary dysplasia: Caused by mechanical ventilation. Premature newborns with immature lungs
are ventilated and over time it damages the lungs. Other causes could be infection, pneumonia, or other
conditions that cause inflammation or scarring.
An antacid should be given to a mechanically ventilated patient w/ a NG tube if the ph of the aspirate is <5.0.
Aspirate should be checked at least every 12 hrs.

Ventilator alarms
HOLD
High alarm- Obstruction due to incr. secretions, kink, pt. coughs, gag or bites
Low press alarm- Disconnection or leak in ventilator or in pt. airway cuff, pt. stops spontaneous breathing

Spinal Cord Injury

Most spinal cord injuries are at the cervical or lumbar regions

Spinal shock occurs immediately after spinal injury

Autonomic dysreflexia ( life threatening inhibited sympathetic response of nervous system to a noxious
stimulus- patients with spinal cord injuries at T-7 or above) is usually caused by a full bladder.

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.

Autonomic dysreflexia: potentially life threatening emergency

- elevate head of bed to 90 degree
- loosen constrictive clothing
- assess for bladder distention and bowel impaction (trigger)
- Administer antihypertensive meds (may cause stroke, MI, seizure )

Seizure
Med of choice for Status Epilepticus is Valium. // Ativan is the treatment of choice for status epilepticus

Shock
Shock --> bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified
Trendelenberg)
Shock - decreased BP, increased resp, increased pulse
SHOCK – HYPOtension TACHYpnea TACHYcardia
Med of choice for anaphylactic shock is Epinephrine

Surgeries
Above Knee Amputation --> elevate for first 24 hours on pillow, position prone daily to provide for hip
extension.
Below Knee Amputation --> foot of bed elevated for first 24 hours, position prone daily to provide for hip
extension.

For knee replacement use continuous passive motion machine.

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.

Tests

-Definitive diagnosis for abd. aortic aneurysm (AAA) --> CT scan

-CT- assess for allergies

MRI- claustrophobia, no metal, assess pacemaker

Cerebral angio prep- well hydrated, lie flat, sire shaved, pulses marked post- keep flat 12-14hr, check site,
pulses,force fluids.
Lumbar puncture- fetal position. post- neuro assess q15-30 until stable, flat 2-3hr, encourage fluids, oral
analgesics for headache, observe dressing
After Lumbar Puncture (and also oil-based Myelogram)--> pt lies in flat supine (to prevent headache and
leaking of CSF)
Lumbar puncture => AFTER the procedure, the client should be placed in the supine position for 4 to 12 hrs
as prescribed. (Saunders 3rd ed p. 229)
For a lumbar puncture, pt is positioned in lateral recumbent fetal position, keep pt flat for 2-3 hrs afterwards,
sterile dressing, frequent neuro assessments

EEG- no sleep the night before, meals not withheld, no stimulants for 24hr before, tranquilizer/stimulant meds
held 24-48hr before, may be asked to hyperventilate 3-4min and watch a bright flashing light.
EEG, hold meds for 24-48 hrs prior, no caffine or cigarettes for 24 hrs prior, pt can eat, pt must
stay awake night before exam, pt may be asked to hyperventilate and watch a bright flashing
light, after EEG, assess pt for seizures, pt's will be at increased risk

Anectine is used for short-term neuromuscular blocking agent for procedures like intubation and ECT.
Norcuron is for intermediate or long-term.

Myelogram- Npo 4-6hr, allergy hx, phenothiazines, cns depressants, and stimulants withheld 48hr prior, table
will be moved to various postions during test. Post- neuro q2-4, water soluble HOB up, oil soluble HOB
down, oral analgesics for h/a, encourage po fluids, assess for distended bladder, inspect site.

Cardiac cath- npo 8-12hr, empty bladder, pulses, tell pt may feel heat palpitations or desire to cough with dye
injection. Post- Vital signs keep leg straight bedrest 6-8hr.

Liver biopsy- Adm vit k , npo morning of exam 6hr, give sedative, Teach pt that he will be asked to hold
breath for 5-10sec, supine postion, lateral with upper arms elevated. Post- postion on right side, frequent
v.s., report severe ab pain stat, no heavy lifting 1wk.

Laparoscopy- CO2 used to enhances visual, general anesthesia, foley. Post- walk patient to decrease CO2
build up used for procedure

• Intravenous pyelogram
o Uses dye
o Caution with sensitivity to iodine, patient may develop anaphylaxis;
o assess for allergy to shellfish, iodine, chocolate, eggs, milk
o A laxative is given the night before an IVP in order to better visualize the organs.
** IVP requires bowel prep so they can visualize the bladder better

After endoscopy, check for gag reflex.

I finally realize why a person shouldn't have cantaloupe before an occult stool test, because cantaloupe is high
in vit c and vit c causes a false + for occult blood. Now I just need to figure out why they can't have fish.

Thyroid Stuff

Myxedema/hypothyroidism: slowed physical and mental function, sensitivity to cold, dry skin and hair
*Myxedema coma is COLD (hypothermia)
Give Synthroid on an empty stomach
Graves’ disease/hyperthyroidism: accelerated physical and mental function; sensitivity to heat, fine/soft hair
HYPERthyroidism think of MICHAEL JACKSON in THRILLER!
SKINNY, NERVOUS, BULDGING EYES (exopthalmus), Up all night, heart beating fast
Thyroid storm: increased temp, pulse and HTN *Thyroid storm is HOT (hyperthermia)
Burning sensation in the mouth, and brassy taste are adverse reactions to Lugol solution (for hyperthyroid).
Report it to the doc.

Post-thyroidectomy: semi-Fowler’s, prevent neck flexion/hyperextension, support head, neck and shoulders.
trach at bedside

Hypo-parathyroid: CATS – convulsions, arrhythmias, tetany, spasms, stridor (decreased calcium), high Ca,
low phosphorus diet
Hyper-parathyroid: fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium), low Ca,
high phosphorus diet

The parathyroid gland relies on the presence of vitamin D to work.

After removal of the pituitary gland you must watch for hypocortisolism and temporary diabetes insipidus.

Insomnia is a side effect of thyroid hormones. Saunders confirms it. Makes sense though!
Increased 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). Ok some more facts.

Triage

In an emergency, patients with greater chance to live are treated first.

In a disaster you should triage the person who is most likely to not survive last.

DOA---dead on arrival

Red- Immediate: Injuries are life threatening but survivable with minimal intervention. Ex:
hemothrax, tension pneumothorax, unstable chest and abdominal wounds, INCOMPLETE
amputations, OPEN fx's of long bones, and 2nd/3rd degree burn with 15%-40% of total body
surface, etc.
Red--unstable, ie, 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, fx requiring open
reduction, debridement, external fixation, most eye and CNS injuries, etc.
Yellow---stable, can wait up to an hour for treatment, ie 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 fx, 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. Seperate but dont
abandoned, comfort measures if possible. Ex: Unresponsive, spinal cord injuries, woulds with
anatomical organs, 2nd/3rd degree burn with 60% of body surface area , seizures, profound
shock with multipe injuries, no pulse, b.p, pupils fixed or dilated.
Black--unstable clients that will probably not make it, need comfort measures

Tubes

Tube Feeding w/ Decreased LOC --> position pt on right side (promotes emptying of the stomach) with the
HOB elevated (to prevent aspiration)
An NG tube can be irrigated with cola, and should be taught to family when a client is going
home with an NG tube.

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 pt on HOB. Position patient on RIGHT to facilitate movement through
pylorus.

Sengstaken blakemore tube used for tx of esophageal varices, keep scissors at bedside.

Other than initially to test tolerance, G-tube and J-tube feedings are usually given as continuous feedings.

After g-tube placement the stomach contents are drained by gravity for 24 hours before it can be used for
feedings.

Chest tubes are placed in the pleural space.

An occlusive dressing is used if a chest tube is accidentally pulled out of the patient.

Urinary – Reproductive

Absence of menstruation leads to osteoporosis in the anorexic.

Priapism: painful erection lasting longer than 6 hrs.

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.

BPH – reduced size & force of urine

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

Lasix can cause a patient to lose his appetite (anorexia) due to reduced potassium.

Gonorrhea is a reportable disease

After a hydrocele repair provide ice bags and scrotal support.

Walking – Cane – Crutches – Wheelchair

1. COAL (cane walking):

C - cane
O - opposite
A - affected
L – leg

Place a wheelchair parallel to the bed on the side of weakness.

Remember the phrase “step up” when picturing a person going up stairs with crutches. The good leg
goes up first, followed by the crutches and the bad leg. The opposite happens going down. The crutches
go first, followed by the good leg.