T H E N U R S E S C O R N E R

TABLE OF CONTENTS

Pharmacology & Need to Know Medications................Page 3-13

Fundamentals & Delegation..........................................Page 14-17
Ethical Principals & Law..................................................Page 18-20
Integumentary.................................................................Page 21-23
Respiratory Disorders & Nursing Considerations.......Page 24-32
Disorders of the Heart & Circulation...........................Page 33- 44
Musculoskeletal Disorders.............................................Page 45-47
Diabetes & Insulin.................................................................Page 48
Contact Precautions & Infectious Disease....................Page 49-53
Renal Disorders & Nursing Considerations..................Page 54-58
GI Disorders......................................................................Page 59-60
Spinal Cord Injuries..........................................................Page 61-62
Neuro & Brain..................................................................Page 63- 68
Visual/Auditory & Nursing Considerations...................Page 69- 71
Psychiatric Nursing..........................................................Page 72- 75
Endocrine Disorders........................................................Page 76- 79
Reproductive & Sexual Health........................................Page 80- 81
Maternal- Antepartum.....................................................Page 82- 88
Labor & Delivery................................................................Page 89- 92
Postpartum & Newborn...................................................Page 93- 95
Pediatric Nursing............................................................Page 96- 100
 PHARMACOLOGY

Warfarin
Vitamin k is the antagonist
used to prevent blood clots in clients with atrial fibrillation, artificial heart valves, or a
history of thrombosis
Intake of vitamin k rich foods can decrease effect ( broccoli, spinach, liver)
Monitor INR levels
Pregnant women should not take
Avoid aspirin, NSAIDS, and alcohol If recovering from a PE,
Warfarin is usually taken for 3-6 months
Antibiotics can affect INR levels
INR level 3.0-3.5
contraindicated in pregnancy
Adenosine
First line drug therapy for SVT
Administer over 1-2 minutes then flush with saline
Find a line closest to the heart
ACE Inhibitors
End with -il, controls high blood pressure
Check blood pressure before administering
Check potassium levels before administering because these medications increase
potassium levels
Can cause a dry cough and reflex tachycardia
Can have severe adverse effects of angioedema
Do not take while pregnant
Can cause orthostatic hypertension
If a client cannot tolerate ACE inhibitor then they are prescribed ARBS (-an) drugs
Calcium Channel Blockers
CCB are like valium to your heart
Help control atrial fibrillation
End in -em like diltiazem
Also end in -ine (Amlodipine)
Most severe adverse effect is dizziness
Do not drink grapefruit juice while taking this or statins
Measure blood pressure before administering, if systolic is under 100 then you hold CCB
 Clients with hypertension should not take over the counter medications for colds, these
medications have decongestants and can cause vasoconstriction
Nicardipine
Calcium channel blocker vasodilator
Brings blood pressure down, usually after stroke and patients get extremely hypertensive
(systolic over 240)
The nurse should bring the blood pressure down but not below 170 (systolic)
Priority nursing interventions are to monitor for hypotensive effects of this drug
Beta Blockers
Helps control heart rate and blood pressure (mainly heart rate)
Side effects may be bronchospasms
Do not give to people with asthma
The nurse should assess for any wheezing
May mask signs of hypoglycemia
ARBS
End with - an like Losartan (sartans)
Should not be taken while pregnant
Helps lower blood pressure
Can cause hyperkalemia
Do not take with salt substitutes
Digoxin
Increases cardiac contractility and slows the heart rate and conduction (slows the rate of
conduction through the AV node)
NOT a vasodilator
Decreases workload of the heart It is used in heart failure and atrial fibrillation
Excreted exclusively by the kidneys so need to check kidney function (creatinine and BUN)
Digoxin toxicity: N/V, GI symptoms are the earliest sign, confusion, weakness,
Toxic level above 2
visual symptoms, cardiac arrhythmias
Hypokalemia can cause digoxin toxicity
Treats A fib and heart failure
Antiplatelet Therapy Drugs
Increased risk for bleeding
Helps prevent platelet aggregation
Clients should be assessed for black tarry stools, bleeding gums, hematuria, bruising,
monitor platelets
Should not be taken with Ginko
Inhibits platelet aggregation, prevents thrombus formation, and reduces heart
inflammation
Clients can receive this when they do not have signs of bleeding or low platelet levels
!"#$%&#'()"
!"#$%& ' #()%!"#)*"*) +*,%-#)%.( )/#) 0/.1", 2* ,%0-.()%(1*, 345 ,#60 2*7.8* 0189*86
:#( %(-8*#0* 8%0; .7 2"**,%(9 0. )/* <:= 0/.1", 2* (.)%7%*, %7 ".> !"#)*"*) "*$*"0 ?@A3BBBBC
<*"!0 !8*$*() 2".., -".)0
*%+(#'",-)(%.
D*-8*#0*0 !8*".#,
E%)8#)* )/#) -#10*0 $#0.,%"#)%.(
F) 8%0; 7.8 /6!.)*(0%.(
:#( -#10* /*#,#-/*
G/* (180* 0/.1", 7."".> 1! .7 )/* -"%*() 7**"0 ,%HH6 .8 "%9/)/*#,*,
A !%"" *$*86 3 +%(1)*0 #(, 1! ). I ,.0*0 JKL 0/.1", 2* -#""*, %7 !#%( %0 (.) #""*$%#)*, 26 3
+%(1)*0 #7)*8 )/* 7%80) !%""
<*#,#-/* #(, 7"10/%(9 #8* -.++.( 0%,* *77*-)0
L%) .8 "%* ,.>( 2*7.8* )#;%(9 )/* !%""
L).8* #>#6 78.+ /*#) #(, "%9/)
/+0+%.
<*"!0 ".>*8 -/."*0)*8." #(, 8*,1-* )/* 8%0; .7 #)/*8.0-"*8.0%0 #(, -.8.(#86 #8)*86 ,%0*#0*
M*,1-*0 NDN "*$*"0' )8%9"6-*8%,*0' #(, ).)#" -/."*0)*8." "*$*"0
G#;*( #) (%9/) >%)/ *$*(%(9 +*#"0
K10-"* #-/*0 #8* # 0*8%.10 0%,* *77*-)
M*!.8) +10-"* !#%(0 .8 >*#;(*00' -.1", 2* # 0%9( .7 8/#2,.+6."60%0
N%$*8 71(-)%.( )*0) 0/.1", 2* #00*00*, 2*7.8* 9%$%(9
1+#(203+0+%.
N.>*8 NDN "%!%, "*$*"0
K.(%).8 7.8 +10-"* !#%( .8 >*#;(*00
*/145/
F"" ELFODL #8* #00.-%#)*, >%)/P QO 2"**,%(9' 2"#-; )#886 0).."0' 0).+#-/ !#%( -#( 2*
8*,1-*, %7 )#;*( >%)/ 7..,
R%,(*6 %(S186' ".(9 )*8+ 10* %0 #00.-%#)*, >%)/ )/%0
<6!*8)*(0%.( #(, /*#8) 7#%"18*
O(-8*#0* 8%0; 7.8 2"**,%(9
L/.1", 2* #$.%,*, %( -"%*()0 >%)/ ;%,(*6 ,%0*#0*' (*!/8.).&%-' :T=D
N.(9 )*8+ 10* -#( -#10* !*!)%- 1"-*80 #(, -/8.(%- ;%,(*6 ,%0*#0*' *&#-*82#)*
/6!*8)*(0%.( #(, -#8,%#- !8.2"*+0
*0$(#6).
O21!8.7*(
ELFOD
:.++.("6 !8*0-8%2*, ). 8*"%*$* S.%() !#%( #(, %(7"#++#)%.(
Keterolac
Toradol
Highly potent NSAID
Heparin
Subcutaneous or IV anticoagulation medication
Administer at 90 degrees or 45 degrees depending on how much adipose tissue they have
Administer 2 inches away from umbilicus
Works immediately
Cannot be given for longer than 3 weeks (accept for lovenox)
Antidote is protamine sulfate
Lab test that monitors heparin is PTT
PTT time should be 1.5 - 2.0 times the normal clotting time of 25-35 seconds
Too long could cause spontaneous bleeding
Can be given to pregnant women
Risk is HIT (drop in the number of platelets) Heparin should be held when there is a drop
in platelet
TPA
Must be administered in 3-4.5 hours
Surgery within 2 weeks is contraindicated
Platelet less than 100000 or coagulation disorders should not receive it
Baclofen
muscle relaxer
Side effects: Fatigue and muscle weakness
Teach: don't drink, don't drive, and don't operate heavy machinery for patients
Flexeril
Muscle relaxer
Flex = muscle
Ferrous Sulfate
Iron supplement, avoid giving with calcium supplements and antacids because that
decreases absorption
Client should increase intake of fluids because these cause constipation
Taking with vitamin c like orange juice enhances absorption
Administer 1 hour before meals or 2 hours after meals
Endocrine Medications
Levothyroxine
Medication for hypothyroidism
Used to replace thyroid hormone
Safe to take during pregnancy
Do not take with antacids, calcium or iron (avoid over the counter
multivitamins)
Take on an empty stomach, in the morning, separately from other
medications
Lifelong therapy, blood test needed
This medication will improve mood, higher energy levels, take up to 8 weeks to
work, normal heart rate
Takes 3-4 weeks for effect
Corticosteroids
Prednisone
Given to combat inflammation in the lungs to COPD patients
These medications can cause in increase in sugar
If the patient is a diabetic, anticipate giving more insulin
Started high dose then tapered slowly
Desmopressin
Treats diabetes insipidus
Mimics ADH
Increases renal water absorption and concentrates urine
Clients receiving this must have their electrolytes closely monitored for water
intoxication/ hyponatremia (headache, mental status, weakness)
Severe hyponatremia may cause seizures, neurological damage, or death
Methotrexate
Treats rheumatoid arthritis and psoriasis
Can cause bone marrow suppression, clients are at risk for infection
They should avoid large crowds and receive killed immunizations (flu,
pneumonia)
Avoid alcohol (can cause hepatotoxicity) and pregnancy with these drugs
Neurological Medications
Levetiracetam
Keppra
Anticonvulsant prescribed for seizures
Depresses the CNS and can cause drowsiness, this improves after a few weeks
Associated with suicidal ideations and should be reported to the HCP
Can trigger steven johnsons syndrome
No driving until approved by HCP
Sumatriptan
Treats migraine headaches
Work by constricting cranial blood vessels
Contraindicated in clients with coronary artery disease and uncontrolled
hypertension
Scopolamine
For motion sickness
Apply 4 hours before
Keep on for 72 hours
Apply behind ear
Phenytoin
Dilantin, is an anti seizure medication with a therapeutic index of 10-20
Tube feedings decrease phenytoin absorption which can reduce the drugs
effect and produce seizures
The nurse should pause tube feedings for 1-2 hours before and after
administration of these drug to increase absorption
Early signs of toxicity include: horizontal nystagmus and gait unsteadiness
Benzodiazepine
Commonly taken at bedtime
Antianxiety drug
Do not ever stop abruptly
Midazolam
Versed
Benzodiazepine commonly used to induce conscious sedation
Flumazenil ( Romazicon) is the antidote to reverse benzo effects
Infectious Disease Medications
Medications for CDiff
Patients are usually prescribed Flagyl ( Metronidazole)
For severe C Diff vancomycin may be used
Isoniazid (INH)
For treatment of TB
Can experience neurological effects due to the decrease in the body's ability to
utilize B6
The patient needs additional doses of B6
Linezolid
Zyvox
Should not be taken with SSRI because can cause serotonin syndrome
Macrolide Antibiotics
Azithromycin
These can cause prolonged QT intervals in patients
ECG should be monitored
Can also cause hepatotoxicity
IV Vancomycin
Draw trough prior to administration, 10-20 is a therapeutic level Infuse
medication over at least 60 minutes
Monitor blood pressure
Assess for hypersensitivity (red man syndrome)
Monitor for anaphylaxis
Check IV site every 30 minutes CVC catheter is preferred
Creatinine levels are the most important value to monitor because
vancomycin can cause nephrotoxicityIf creatinine is high this is a complication
of nephrotoxicity
Tetracycline
Helps fight bacterial infections of the skin
Take on an empty stomach
Avoid taking with dairy products, iron supplements, or antacids
Take with a full glass of water
Wear sunblock because risk of photosensitivity
Use additional contraceptive medications
Miscelleneous Drugs
Docusate Sodium
Stool softener that reduces straining during bowel movement, puts less stress on heart
Straining can also cause bradycardia due to vagal response
Furosemide
Most commonly used drug for heart failure
Lasix
Ginko
Can increase risk of bleeding
Celecoxib
COX- 2 I inhibitor
Black box warning with increased risk for cardiovascular complications
Back pain, nausea, vomiting, would need to be assessed immediately
Morphine
Decreases cardiac workload
Pain treatment and terminal dyspnea
Lidocaine
Decreases cardiac irritability
Isoniazid INH
Avoid intake of alcohol and limit use of acetaminophen
Take vitamin B6 to prevent leg tingling
Avoid aluminum containing antacids
Report changes in vision
Report jaundice, dark urine
Does not change color or urine, that is Rifampin
Adverse effects: hepatotoxicity, peripheral neuropathy
Rifampin: reduced the efficiency of oral contraceptives, changes the color of the urine,
used for TB
Codeine
Opioid and is smaller doses is a cough suppressant
Can cause constipation just like opioids do
Take medicine with food
Drink lots of water
Sit on side of bed before getting up because it can cause hypotension in patients
Transdermal Patches
Never shave before placing patch
Clonidine
Antihypertensive patch that is reapplied every 7 days
Do not remove patch if dizziness occurs
Rotate site with each use
KCL
Available in many forms
If a patient has difficulty swallowing, the nurse should consult with the pharmacist to see
if there is other forms
Maybe liquid
Fentanyl Patch
Fold when discarding
Change every 72 hours
Not cutting patches
Do not apply heat over the patch (does not aid in absorption)
Ear Drops
Over 3 years years pull ear up and back
Less than 3 pulled down and back
Children should be placed prone or supine
Warm ear drops to room temperature
Drop medication against wall of the canal
Rectal Suppository
Age appropriate distraction
Toddlers and infants toys
Preschool and older children deep breaths or count
Infant placed supine with knees and and feet raised
Other children side lying with knees bent
Use water soluble jelly
Insert using 5th finger with children under 3
Hold buttocks together after insertion
PCA PUMP
Y tubing
Connected with normal saline to keep vein open
Continuous IV fluids used PCA pumps
Children can use as long as they understanding of the device
Aminophylline
10-20, above 20 is toxic
Helps relax bronchioles
Seizures in toxicity
Isotretinoin
Do not take vitamin A supplements, can cause toxicity
Do not give blood on this medication
For severe or cystic acne
Most important to use 2 forms of contraception
IV Furosemide
May cause ototoxicity, especially in patients with kidney disease
High doses should be administered slowly to prevent this ototoxicity in patients
Sildenafil
Viagra
Nitrates and viagra are contraindicated with each other as it can cause life threatening
hypotension
The use of these should be reported to HCP
Prednisone
Glucose should be monitored in those receiving this
Thiazide Diuretics
End in -ide and -one
Treats hypertension and edema
Major side effects: hypokalemia (muscle cramps and dysrhythmias)
hyponatremia (AMS and seizures)
Hyperglycemia
Allopurinol
Used to prevent gout attacks
Inhibits uric acid production and improves solubility
Should be taken with a full glass of water and increase fluids (most important teaching)
Methotrexate
Used in the treatment of rheumatoid arthritis
Adverse effects: bone marrow suppression, hepatotoxicity, gastrointestinal irritation
Can lead to thrombocytopenia (small purple dots)
Phenytoin
Anticonvulsant for seizures
Never stop taking abruptly
Exception is the development of a rash that may indicate steven johnsons syndrome (flu
like symptoms and a painful rash)
Good dental care is a must, can cause gingival hyperplasia
Can cause suicidal ideation and depression, this an adverse effect
Aminoglycosides
-micine ending
(azithromycin, zithrominine, and clarithromycin)
Treat serious
Think “mice” think ears think ototoxic, tinnitus, vertigo, equilibrium, ringing of the ear,
dizziness
Another toxic effect is nephrotoxicity (monitor creatinine)
IM or IV PO, does not absorb
Oral micines will sterilize the bowels before surgery (neomincine and canominice)
 IV Fluids

KCL
Iv should not exceed 10 mEq/ hr
Iv should be diluted and never given at a concentrated amount, high risk
Opioids
Can cause hypotension, this side effect is not as noticeable when the client is sitting
down but when they stand up they can have orthostatic hypotension
Those at highest risk for respiratory depression due to administration: the elderly, those
with underlying pulmonary disease, snoring, obesity, smokers
Adverse effect is paralytic ileus (absent bowel sounds) also can happen with potassium
is low
Itching is a normal side effect
Opioid Analgesics
Hydromorphone, morphine
Control moderate to severe pain
Side effects: sedation, respiratory depression, hypotension, constipation
Client is at risk for falls and should not get out of bed unless with assistance
Administer daily stool softeners
Administer slowly over 2 to 3 minutes
Recheck pain 15-30 minutes after administering the medication
Transdermal Fentanyl Patch
Can take up to 72 hours for full effect
Not prescribed to patients 1 day post op or for acute pain because of the time it takes
to reach full effect
 FUNDAMENTALS & DELEGATION

PPE
Always take it off in alphabetical order
Gloves, goggles, gown, mask OFF
ON reverse for alphabetical for G but mask comes second
Gown, mask, googles, gloves
Canes
Hold the cane on the strong side
Postmortem Care
Close clients eyes
Replace dentures
Disconnect all tubes and lines
Straighten the body and limbs
Place pad under perineum
Wash body
Allow family members to assist with care
Place pillow under the head
Fold towel to put under the chin to close mouth
Speaking with an Interpreter
Address client directly
Speak in short sentences
Pre conference with interpreter
Use qualified interpreter when possible
Avoid translation through family members
The nurse should be mindful to choose interpreter with the patients prefered
age, gender
UAP
Can perform passive range of motion exercises
Take and document vital signs
No trach care or cleaning
Can collect urine specimen
Cannot document color and characteristic of it
They cannot offer orange juice to a client with hypoglycemia
Can assist 1 day post op out of bed to the bathroom
Cannot reinforce teaching
Can remind client to use incentive spirometer
Pick up blood products from the blood bank
Can take vital signs before blood transfusion and after the first 15 minutes of the
transfusion
Can perform oral suctioning (not sterile)
Report patient behavior but not monitor
Can transport body to morgue
Can give topical over the counter barrier creams
Can do vitals and accuchecks
Can delegate ADL’s Measure output in a drainage collection bag
LPN
Should be assigned stable clients with expected outcomes
Cannot perform initial teaching, assessments, or evaluate a client’s condition
Can do teaching reinforcement
Can administer anticoagulant medications
Can suction
Can perform sterile procedures (catheterizations)
Can auscultate lung sounds but cannot use that information to evaluate
Can monitor RN findings
Can monitor for bleeding
Cannot start an IV, hang or mix IV meds, push IV meds
They can maintain an IV and document the flow
They cannot administer blood or mess with central lines
Cannot plan care , the LPN can implement it
Cannot perform or develop teaching, they can reinforce it
Cannot take care of unstable patients
They cannot do the very first of anything
They can do tube feedings, but not the first
They can change dressings, but not the first
Cannot do admission, discharge, transfer, or the first assessment after a change
Can not administer or monitor blood transfusions/ products
Prioritization
Age is not a criteria for prioritization
Gender is not a criteria for prioritization
Acute beats chronic (higher priority than)
Post op is within 12 hours, beats medical or other surgical
Stable patients: indicate they are stable, chronic illness, post op greater than 12 hours,
regional anesthesia, experiencing the typical, expected signs and symptoms of the disease
with which they were diagnosed
Unstable: suspected, acute, post op less than 12 hours, general anesthesia, patient is
unstable if they are experiencing unexpected signs and symptoms
Always Unstable:Hemorrhage High fevers over 105 Hyperglycemia pulselessness/
breathlessness
Prioritizing Organs :Brain, lung, then heart, then liver, kidneys, pancreas

Assessment
Assessment is the first step in the nursing process, the nurse should assess and
then intervene
when in doubt, ASSESS FIRST
Modified Radical Mastectomy
The breast, axillary nodes, and superior apical nodes are removed, but the
muscles are preserved
Complication of this is lymphedema, can prevent by positioning each joint higher
than the proximal one
Chemotherapy
Can cause bone marrow suppression and tumor lysis syndrome
Filgrastim stimulate neutrophil production
Mastectomy
Place client in semi fowler's position
Affected side’s arm needs to be placed on several pillows to promote drainage
Staff Management
Never ignore inappropriate behavior by staff
Ask yourself if what they are doing is illegal?If yes, tell supervisor No, then ask if anyone is
in any immediate danger, if yes, then confront immediately because you don’t want to
delay to put someone at risk If behavior is legal, no harmful, but simply inappropriate,
then speak with them later on
Nursing Responsibilities Prior to Surgery
Client allergies and history are confirmed
Assessment
Confirming Informed consent has taken place
Ensuring the client has been NPO
Client voids before surgery
Witnessing that the correct surgical site has been marked
Error in Transcription
Occurs when doctor does not sign order
Doctor puts wrong amount or unit
The handwriting is not legible
Positioning Clients
High fowlers for paracentesis
Trendelenburg position and on the left lying side if suspected air embolism
Position client with arms raised above head for chest tube placements
After a liver biopsy the client should lay on the right side for at least 2 hours and then
supine for an additional 12-14 hours
Thoracentesis the patient is upright sitting position on the side of the bed leaning over on
side table with pillow
Occupational Therapy
Teaches activities of daily living (bathing, dressing, cognitive or perception issues)
Physical Therapy
Focuses on mobility, ambulation, ability to walk, use the walker or other assistive devices
Physical therapy focuses on “below the waist” rehabilitation
Radioactive Disasters
Do most good for the most people
Start with victims farthest away from the radioactive explosion
These victims are the most salvageable
Jehovah witness
Do not accept blood components of any type
DO accept normal saline, Lactated Ringer’s etc., DO accept Epoetin alfa
 ETHICAL PRINCIPALS/ LAW

Ethical Principle
Veracity: being truthful
Justice: treating every client equally regardless of background
Accountability: accepting responsibility for actions and admitting errors
Nonmaleficence: do no harm, it also relates to protecting clients who cannot
protect themselves due to mental or physical condition
Fidelity: fulfilling commitments and showing loyalty to one's self and others
Beneficence: the action of promoting good will
“Let’s talk about it”
Informed Consent
Surgeon explains the diagnosis and procedure (not the nurse)
Client indicates understanding
The client is competent and gives voluntary signature
The nurse is responsible for witnessing the signature
If the surgery requires additional procedures after the surgery has already
begun and the consent has been signed for specific procedures, then medical
power of attorney, next in kin, or legal guardian should be contacted to
discuss
Nurses role: witness client has signed, voluntarily and competently, document
in medical record that client has signed with date and time,
Physician is responsible for: explaining procedure, answering questions about
procedure, offering alternative options, reinforcing right to refuse
Incidence/ Occurrence Report
Assault and injury
Failure of treatment or intervention
Hospital equipment fail
Falls
Never document an incident report was filed
Failure to report an important lab value
Mislabeled laboratory specimens
Good Samaritan Law
Prevents civil action when helping individuals off the job
Cannot receive payment
Essential for the nurse to perform in the same way as on the job (applying
pressure if bleeding)
Must act competently
Standards of Nursing Practice and Care
Universal criteria that are used to determine if appropriate, professional care
has been delivered
Sources used to define standards of care include statements from
professional organizations, agency policies and procedures, textbooks, current
literature, the Nurse practice act, and regulatory organizations
Does not depend on good intentions
Abuse
Nurse has obligation to report abuse
Child abuse is common in all children ages
Most child abusers have low self-esteem
Abusers have history of growing up in a domestic violence
Abusers have substance abuse problems
When child is dying and parents don’t want treatment, priority is to assess
parents knowledge of situation
Advance Care Planning
This helps clients determine treatment plans and decision makers when or if
the client is unable to do so
Documents include: health care proxy (durable power of attorney or medical
power of attorney) and living will (advance directive)
Providing oxygen via nasal cannula is not considered resuscitation and can be
given
Local Organ Procurement Services
Notified for every clinical death per hospital protocol
Cardiac and respiratory support continue as organ donation is discussed or
performed
Consent is not needed by family if patient has signed to be organ donor
Organ donation does not leave the body disfigured
Reportable Instances to the Board of Nursing
Practicing outside of scope
Abandonment (leaving patients)
Stealing narcotics
Falsifying documentation
Assault
An act that threatens the client and makes them feel harm but they are not
touched
Battery
Physical contact with a client without consent
Quality Improvement Committee
Assesses process standards (guidelines, systems, and operations)
Assesses clinical issues that affect delivery of client care and client outcomes
Implements processes to improve performances
Sentinel Event
Unanticipated event in the healthcare setting that results in death serious
injury
Radiation Contamination
Radiation damages DNA, which causes cell destruction
Early manifestations of radiation contamination include: oral mucosa
ulcerations, vomiting, diarrhea, and low blood cell count
Chemical Contamination Emergency
PPE should be put on before decontamination
Victims should be decontaminated outside the facility
 INTEGUMENTARY

Pressure Injuries
- Assess risk for pressure injuries using the Braden Scale
- To prevent pressure injuries:
- Use barrier creams
- Foam pads to reduce pressure on bony prominences
- Keep skin clean and dry
- Reposition client with a turn sheet every 2 hours
- Avoid pulling or dragging client
- NO MASSAGES on bony prominences
Unstageable wounds: Full thickness skin loss with slough or eschar
Skin Cancer
Skin Cancer Screening
- Full medical workup of every mole is unnecessary
- Rapid changing mole should be evaluated immediately
- Melanomas can be any color
- Melanomas don’t always occur as a new mole
Risk factor for skin cancer:
- immunosuppressant agents,
- celtic ancestry traits
- aging
- high number of moles
Tinea Corporis (Ringworm)
- Teach about spreading the condition more
- Wash hands
- Very contagious
Allergy Skin Testing
Avoid antihistamines for 2 weeks before test and corticosteroids
Can take albuterol
Eczema
Inflammatory rash caused by an immune response
Milk, wheat, and egg whites can trigger
- Wash clothes/ bedsheets in hot water
Burns
- Urine output best indicator of fluid replacement therapy
- Lactated Ringers given for fluid volume replacement
- Administer pain medication IV
- Burns result in largest fluid shift first 24-72 hours (hypovolemia)
- Hyperkalemia occurs, Muscle weakness, EKG tall peaked T waves, Cardiac arrhythmias
hematocrit/ hemoglobin will be elevated because of fluid changes, Sodium is lost due to fluid
shift so they will be hyponatremic
- Providing proper nutrition through enteral feeding is highest priority when bowel sounds
come back and they start peeing
Psoriasis
Exposure to sun can help slow and decrease exacerbations
Poison Ivy
Most important is to wash skin and get off any excess resin
Linear appearance
Infiltration
Complication when solutions infuse into the surrounding tissues
Discontinue the IV
Assess the sight for swelling, redness, pain
Elevate the affected extremity
Apply cool or warm compress depending on the solution infiltrated
Difference between infiltration and extravasation is the fluid infusing
Extravasation
Infiltration of drug into surrounding tissues
Pain, blanching, swelling, redness
Stop infusion immediately
Elevate the extremity above the level of the heart
Treatment of Frostbite
Remove clothing and jewelry to prevent constriction
Do not massage, rub or squeeze the area
Immerse affected area in warm water
Provide pain relief as the rewarming process is extremely painful
Allow wounds to dry and then apply loose, nonadhesive dressings
Monitor for signs of compartment syndrome
Skin can appear mottled, blue or waxy yellow
IM Injection Sites
Dependent on a child’s age and muscle mass
Vastus lateralis muscle is preferred for newborns less than 1 month old and infants age
1-12 months
Vastus lateralis preferred for children less than 7 months
Infants require 1 inch needles for IM injections
Ventrogluteal not recommended until adult
IM injection needle needs to be 22-25 in size
Large bore needles for fluid resuscitation are 18
26 gauge is for subQ injections
Latex Allergy
Can develop from repeated exposure (healthcare workers)
Food allergies such as avocados, bananas, tomatoes can signal latex allergy
Warning signs of Cancer
CAUTION MNEMONIC
Change in bowel or bladder habits movement (blood)
A sore that does not heal
Unusual bleeding or discharge from body
Thickening or lump in breast
Indigestion or difficulty swallowing that does not go away
Obvious change in wart or mole
Nagging cough or hoarseness (persistent cough vs. seasonal)
Cellulitis
Inflammation from bacterial infection
Characterized by redness, edema, fever, and pain
Affected extremity should be elevated
Flat or dependent position may worsen edema
Applying a warm compress will promote circulation to the area
 RESPIRATORY DISORDERS

Atelectasis
Post op complication
Clients may have difficulty breathing, hypoxia, and basal crackles
The elderly, post op thoracic and abdominal surgery clients are at increased risk
Incentive Spirometer
Encourages clients to breath deeply with maximum inspiration
Carbon Monoxide Poisoning
Pulse ox does not correctly reflect oxygen saturation because carbon monoxide has a
stronger bond to hemoglobin
The nurses primary action is to deliver 100% oxygen through a non rebreather mask at
15 mL/hr
May have symptoms of headache, dizziness, nausea
Bronchitis
Inflammation of the upper airway after viral infection
Rhonchi are heard (low pitched wheeze)
The sound resembles snoring or moaning
Primarily heard during expiration but can be heard on inspiration
Also heard in cystic fibrosis
COPD
Encourage clients who are losing weight and having loss of appetite to avoid drinking
fluids during meals, eat small frequent meals, perform oral hygiene before meals
Chronic air trapping and reduced gas exchange in these patients by decreasing
ventilation
Avoid codeine because it is a cough suppressant
Client education:Get vaccinated for the flu
Seek medical attention for increased sputum production
Use albuterol if short of breath
Exacerbation of COPD
Characterized by acute or worsening of patients baseline symptoms
NIPPV is often prescribed short term to support gas exchange in those who have
hypercapnia ( PACO2 >45) and acidosis (pH < 7.3)
It is most important for the nurse to monitor mental status changes in these clients
Tiotropium (Spiriva)
Long acting, 24 hour inhaled medication used to control COPD
Most commonly inhaled with a capsule inhaler
The capsule should not be swallowed, but placed in the inhaler
Pneumothorax
Priority for a newly admitted patient with suspected pneumothorax is
covering the wound with a 3 sided petroleum gauze tape
This prevents inward air flow, while allowing air to escape the space
Nasopharyngeal Airway
Never place in a client with suspected head trauma
Tonsillectomy
Postoperative bleeding is uncommon but can last for up to 2 weeks
This can be indicated by continuous swallowing and cough
These patients may even develop restlessness
Teaching instruction include: avoid coughing, clearing the throat or blowing
the nose, limit physical activity, avoid milk products, avoid harsh brushing and
gargling and oral mouth rinses
Suctioning
Suctioning only should be applied when taking the catheter out, not inserting
it Pre oxygenate client for 30 seconds on 100% oxygen before suctioning
Limit suction time to 10-15 seconds
Flail Chest
Paradoxical chest movement At risk for respiratory failure
Can be caused by trauma, rib fractures
Peak Flow Meter
Used to measure peak expiratory flow rate
For patients with moderate to severe asthma
The client should exhale as quickly and forcefully as possible
The client moves the indicator to the lowest number on the scale before using
the device
Repeat 3 times
The peak flow meter is used after a short acting bronchodilator rescue MDI
PEEP
Applies a given amount of pressure at the end of mechanical ventilation
PEEP is usually kept at 5 but for ARDS it can be kept at a higher rate
A high level of PEEP (10-20) can cause rupture of the alveoli and overdistention
and can cause barotrauma, leading to pneumothorax and subcutaneous
emphysema
Ventilators
High pressure alarm is triggered by increased resistance to airflow, means the
machine has to push too hard to push air into the lungs, so alarm with sound
Obstruction may be from obstructions: kinks in the tubing, water condensing
in the tube, mucus secretions in the airway
If mucus is the cause, then you would change position, if that doesn't work
then you would suction
Low level alarm: decreased resistance, could be caused by disconnection of
main tubing, and oxygen sensing tubing
Disconnection Could signal hypotension
Nurse should assess lung sounds to check for proper endotracheal tube
placement (best way to check for tube placement)
Emphysema
Characteristics: activity intolerance, barrel chest, hyperresonance on
percussion, purse lipped breathing, tripod position (progressed)
Phlebostatic Axis
Fourth intercostal space at the midaxillary line, midway of the AP diameter
Anatomical point at the level of the chest and the heart
Used for correct placement of transducer when measuring BP, CVP, and/or
cardiopulmonary pressure invasively
Pleural Effusion
Abnormal collection of fluid >15 mL in the pleural space that prevents the
lungs from expanding
Diagnosed by a chest x-ray or CT scan
Clinical manifestations: dyspnea, non productive cough, pleural chest pain
with respirations, on assessment clients have diminished breath sounds,
dullness to percussion, decreased tactile fremitus, and decreased movement
over affected lung, chest pain during inhalation
No wheezing
Tracheostomy
Dislodgement of tracheostomy tube is a medical emergency If a mature stoma
is dislodged (>7 days) then the nurse should attempt to open the airway with a
curved hemostat If the stoma cannot be opened then cover with sterile
dressing and begin ventilation with a bag valve mask
 The priority care for a new tracheostomy is to prevent accidental
dislodgement of the tube, ties should be checked for appropriate tightness, 1
finger should be able to fit between the ties
Do not change inner cannula until 24 hours after insertion
A cuff is deflated when the patient is awake and alert, determined not to be at
risk for aspiration
Before the cuff is deflated the client is asked to cough then suction is applied
to remove any secretions
Suctioning, the catheter should be advanced even if coughing and once
resistance is met, pull back 1 cm before applying suction
Use strict sterile technique while suctioning
Humidifier should not be removed, helps facilitate secretions, even if there is
more secretions, it should not be removed
Always carry 2 tracheostomy tubes, a big and small one
Wait at least 1 minute between suction passes
BIPAP
Provides positive pressure oxygen and help expel CO2
COPD patients Hypercapnic respiratory failure
Cystic Fibrosis
Increase salt intake during hot weather
Give pancreatic enzymes with meals or snacks
Aerobic exercise is recommended
Encourage sports
Pleurisy
(pleural friction rub) characterized by stabbing chest pain that increases with
inspiration or cough
Complication of pneumonia
Bronchoscopy
Visualization of the larynx, trachea, and bronchi while under sedation
This patient should be immediately assessed upon returning from surgery
The client must be kept NPO until positive gag reflex returns
Blood tinged sputum is common but bright red blood mixed with sputum
could indicate hemoptysis and needs to be reported to HCP
Client is under mild sedation
Ventilator Acquired Pneumonia
Signs and symptoms usually present within 2-3 days of starting mechanical
ventilation
Characteristic clinical manifestations include: purulent sputum, positive
sputum culture leukocytosis, elevated temperature, or new or progressive
pulmonary infiltrates suggestive of pneumonia on a chest X ray
Best indicator would be positive sputum culture
Pneumonia
Lung infection where lungs fill with thick debris and mucus which may cause
impaired oxygenation and ventilation
Interventions to facilitate secretions removal include:
Chest physiotherapy
Huff coughing
Increase oral fluid intake and IV fluids to thin secretions
Fowler's position If patient has difficulty breathing and has left lobar
pneumonia then place them on the unaffected side to help with
oxygenation (right lateral)
People that are over the age of 65, younger than 2, central nervous system
depression, ALOC, immunosuppressant, chronic disease, inadequate nutrition,
immobility, smoking, upper airway infections, tracheal intubation are at
increased risk
Obstructive Sleep Apnea
Upper airway obstruction with multiple events of apnea and shallow breathing
CPAP is an effective treatment for OSA
It involves using a nasal or full face mask that delivers positive pressure to the
upper airways
Findings with OSA include: loud snoring, waking up gasping, sleepiness during
the day, witnessed sleep apnea, morning headaches
ARDS
Can develop following a pulmonary insult (aspiration, pneumonia) or non
pulmonary insult (trauma, sepsis, blood transfusion) to the lungs
Fluid leaks into the alveoli causing a noncardiogenic pulmonary edema
Lungs become stiff and non compliant which makes ventilation and
oxygenation difficult
 Profound hypoxia despite oxygenation, high concentrations of oxygen is a key
sign of ARDS and most important (refractory hypoxemia)
Priority nursing diagnosis is: impaired gas exchange
Can be put in the prone position: this helps to mobilize secretions, decrease
pleural pressure, decrease atelectasis
Pursed Lip Breathing
Exhale for 4 seconds through pursed lips
Inhale for 2 seconds through the nose with mouth closed
Thoracentesis
Removal of excess fluid in the lungs
After this the nurse assesses for pain and difficulty breathing, monitors vital
signs and oxygenation, looks for symmetrical chest expansion If any
abnormalities are reported then client will undergo a chest x ray
Complications from this include: pneumothorax, hemothorax, infection
Chest Tube Drainage System
Chest tube reestablishes negative pressure in pleural space
The collection chamber is where drainage from client will accumulate, the
nurse will assess amount and color
Suction control chamber it is expected to find gentle bubbling that is
continuous, this means the suction is working properly, should not be
intermittent
Air bubbles in the water seal chamber would be abnormal and would indicate
a leak and require immediate intervention (continuous)
Water seal chamber you will see tidling (up and down movement) when the
client breathes (intermittent bubbling) this is normal
Drainage should be 50-500ml first day, it is expected to be sanguineous (bright
red) then change to serosanguineous (pink) then serous (yellow) over a few
days
Bright red drainage would be of concern after 24 hours or more than
100ml/hr of drainage after the first 24 hours
When removing the patient is asked to hold breath and bear down
Post procedure chest x ray is done to ensure no fluid or air in pleural space
If drainage stops abruptly the nurse should assess for breath sounds to
determine if the lung has re expanded, have the patient cough and deep
breath, change position
 Covered with sterile, airtight petroleum jelly gauze
If drainage tube becomes disconnected from the plastic chamber, place distal
part of tube in sterile saline water
Do not clamp chest tube unless checking for air leaks or told so by the HCP
Removed when chest tube drainage is less than 200 ml/24hrs, air leak
resolved, lung expanded, absent drainage
Apical- remove air
Basilar- remove blood
Pneumonectomy - no chest tubes, trick question
If knock over collection chamber, have them take deep breaths
What if the water seal breaks? CLAMP FIRST, cut tube, put in sterile water,
unclamp it
Strategies to prevent post op pneumonia
Ambulate within 8 hours of surgery
Pain management
Coughing and splinting every hour
Deep breathing and the use of an incentive spirometer
Place in fowler's position
Turn client every 2 hours
Mouth care
CPR
100-120 per minute allowing complete chest recoil after each
Defibrillation pads are placed on the right upper chest just below the clavicle
and on the left lateral chest below nipple line
During CPR, compressions are paused every 2 minutes to check pulse for 10
seconds
Manual breaths are delivered at a rate of 2 breaths for every 30 chest
compressions
Stand clear with each shock of the defibrillator
Correct placement of hands is on the lower half of the sternum in the center
of the chest
Begin CPR before calling 911 if a home health nurse
ABG
Evaluates oxygenation and ventilation

Acid/ Base Imbalances

If the ph and bicarb are in the same direction it is metabolic(up or down)
If they are in different directions it is respiratory
Bicarb normal: 22-26
pH: 7.35-7.45
If bicarb is normal then respiratory
When ph goes up the patient gets irritable, hyperexcitable (K GOES DOWN)
When ph goes down the patient does too (K GOES UP)
Borborygmi = increased bowel sounds
Hyperventilating: alkalosis
Hypoventilating: acidosis
Metabolic alkalosis
Caused by NG tube, vomiting, prolonged suctioning
Everything that isn’t lung or vomiting or suctioning is metabolic acidosis
Metabolic Acidosis Increase in the production or retention of acid and the
depletion of bicarb via kidneys or GI tract
Common causes: diarrhea, diabetes, alcoholism, starvation, sepsis,
hypoperfusion, renal failure pH less than 7.35,
Bicarb less than 22
Hyperkalemic
Asthma
NSAIDS sensitivity
Beta blockers are contraindicated
Severe asthma exacerbation: tachycardia (>120), tachypnea (>30), saturation
<90%, use of accessory muscles to breathe, and peak expiratory flow of <40
the nurse should give oxygen, SABA inhaler(Albuterol) , and nebulizer
treatment anticholinergic (ipratropium) every 20 minutes, systemic
corticosteroids
Albuterol side effects: palpitations, tremors, difficulty sleeping, N/V
Do not give NSAIDS or beta blockers to people with asthma
 DISORDERS OF THE HEART
Pericarditis
Inflammation of the membranous sac surrounding the heart
Can cause pericardial effusion, this is excess fluid in the pericardium and it places pressure
on the heart
This can lead to cardiac tamponade- signs of this include; muffled or distant heart tones,
jugular vein distention, hypotension, narrowing pulse pressure
This requires emergency pericardiocentesis
Pericardial friction rub is an expected finding with pericarditis
Coronary Arteriogram
invasive diagnostic study of the coronary arteries, heart, and chambers, and function of the
heart, patient is awake but mildly sedated
Do not eat or drink anything for 6-12 hours
Lie flat for several hours following procedure
Client may feel warm or flushed when contrast dye is injected
Femoral or radial artery are used
Murmurs
Produced by turbulent blood flow across diseased or malformed cardiac valves, sound like
musical, blowing, swooshing sounds
Cardiac Catheterization
IV iodine contrast
No Metformin before surgery
Creatinine should be in normal range, or risk of contrast dye not being excreted by kidneys
(normal is less than 1.3)
after procedure, lay flat in low fowler's position with affected extremity straight for 4-6 hours
Femoral Popliteal Bypass
Assess pulses hourly
Keep leg straight, not elevated
Encourage client to cough and deep breathe
Implantable Cardioverter Defibrillator (ICD)
Refrain from lifting the affected arm until healthcare provider approves it
Sickle Cell Disease
Enlarged spleen needs immediate intervention
If having sickle cell crisis and vasoocclusion, adequate oxygenation and hydration can reverse,
the priority intervention is high flow IV fluids
Hemophilia
Bleeding disorder , Joint destruction is a long term complication
Monitor for bleeding
CABG Care
Wash incisions daily with soap and water
No baths
Tingling, itching, and numbness around site is NORMAL
No powders or lotions
Report any redness, swelling, increase in drainage
Wear elastic compression socks when, and elevate the legs when sitting
Severe Anemia
Symptoms include: tachycardia to maintain cardiac output, dyspnea,
shortness of breath, pallor
Cardiac and respiratory drive maintained during severe anemia to maintain
CO and respirations
Pericarditis
Inflammation of the membranous sac surrounding the heart
Can cause pericardial effusion, this is excess fluid in the pericardium and it
places pressure on the heart
This can lead to cardiac tamponade- signs of this include; muffled or distant
heart tones, jugular vein distention, hypotension, narrowing pulse pressure)
This requires emergency pericardiocentesis
Pericardial friction rub is an expected finding with pericarditis
Teach clients to relieve pain by sitting up and leaning forward, this reduces
pressure on inflamed pericardium
Coronary Arteriogram
invasive diagnostic study of the coronary arteries, heart, and chambers, and
function of the heart
Awake but mildly sedated
Do not eat or drink anything for 6-12 hours before procedure
Lie flat for several hours following procedure
Client may feel warm or flushed when contrast dye is injected
Femoral or radial artery are used
Cardiac Catheterization
IV iodine contrast
No metformin before surgery
Creatinine should be in normal range, check this lab and BUN
Nursing priority after is check distal pulses
Myocardial Infarction
Large anterior wall: affects pumping ability of ventricle
This patient at risk for heart failure and shock so monitor for pulmonary congestion
Clinical Manifestations: S3 heart sound, crackles, JVD
Meds you see post MI: Aspirin (antiplatelet), -statin(lipid lowering), docusate sodium (stool
softener reduce straining), ACE inhibitor (Prevent ventricular remodeling and HF), beta
blocker (reduce reinfarction and HF)
Nitro can worsen hypotension and cause headache
These patients are at huge risk for life threatening dysrhythmias
ALWAYS have them on cardiac monitoring
If they become hypokalemic, potassium replacement becomes priority
Complication: Pulmonary Edema: S&S: Acute onset dyspnea and productive cough with
frothy, pink sputum
You would hear bilateral crackles at lung bases
If they ask about sexual activity: they need to be able to climb 2 flights of stairs without
symptoms, and HCP needs to approve
Angina Pectoris
Chest pain brought on by myocardial ischemia (decreased blood flow to heart muscle)
Can be caused by exercise, sexual activity, anxiety, fear, hypothermia, stimulants
(amphetamine) usage, tobacco usage
Pacemaker Placement
Teaching:Report fever or any signs of redness, swelling, or drainage at incision site
Carry pacemaker identification card and wear medical alert bracelet
Take the pulse daily and report to HCP if below rate
Avoid carrying a cell phone in the pocket over the pacemaker, and when talking on cell
phone hold it in ear opposite pacemaker
Notify airport security of pacemaker
Avoid MRI scans
Clients need to be assessed for electrical capture (ECG) of heart rhythm and mechanical
capture of heart rate (apical pulse)
Allen’s Test
Radial artery is preferred site for ABG blood draws
Allen's test needs to be performed to determine the patency of the artery and ulnar artery
and sufficient circulation in the hand
Heart sounds and Locations
Apical pulse - 5th intercostal space, midclavicular line (mitral)
Pulmonic - 2nd intercostal space at the left sternal border
Mitral valve - 5th intercostal space, midclavicular line
Erb's point - 3rd intercostal space at
Chronic Venous insufficiency
Inability of the leg veins to efficiently pump blood back to the heart
Can lead to venous stasis, increased hydrostatic pressure, and venous leg
ulcers on inside of ankle
S&S: Edema, thick skin with brown pigmentation, varicose veins, and large
ulcers are expected findings
COMPRESSION stockings are crucial treatment for healing ulcers
Peripheral Arterial Disease
These patients have decreased sensations from nerve ischemia or coexisting
diabetes
S&S: intermittent claudication, hair loss, decreased peripheral pulses, cool,
dry, clammy skin, gangrene, thick, brittle nails, ulcers
Teaching: Smoking cessation, no heating pads, regular exercise, ideal body
weight, low-sodium, glucose control, antiplatelet meds, limb and foot care
(lotion)
Leg will be cold and mottled
Leg pain not relieved by rest
Deep Venous Thrombosis
Blood clot formed in large veins of lower extremities
S&S: unilateral edema, localized pain/calf pain, tenderness to touch, warmth,
erythema, and sometimes a fever
Risk factors: Trauma, major surgery, immobilization, pregnancy, oral
contraceptives, smoking, old age, malignancies, obesity and varicose veins,
myeloproliferative disorders
At risk for pulmonary embolism (cesarean birth)
Patients should NEVER massage the site- could trigger pulmonary embolism
Virchow’s Triad: Flow/stasis, endothelial damage, hypercoagulable state
Teaching: If sitting for a long time, >4 hours, use preventative measures
(compression stockings, exercise), plenty of fluids and limit alcohol, elevate
legs when sitting and flex foot often, resume normal exercise pattern, avoid
restrictive clothing, consult with dietitian if overweight
Preventing Thrombophlebitis Administer LMH (heparin)
Instruct client to flex and point toes every 2 hours
Encourage the client to drink fluids while on bedrest
Can see redness, warmth
Coronary Artery Disease
NSAIDs contraindicated, no ibuprofen or naproxen or celecoxib
They increase the risk of thrombotic events
Aortic Valve Replacement Post-Op Chest drainage >100mL/hr should be
reported to hCP immediately
Teach this client they need prophylactic antibiotics prior to dental procedures
to prevent infective endocarditis
Infective Endocarditis
IE causes the formation of vegetations on valve and endocardial surfaces.
Embolization to various organ sites can occur
Sudden onset of painful, pale, cold foot/leg could indicate embolism and
should be reported to HCP immediately
Cardioversion
Which step is most important in a patient with SVT? Synchronize button
This delivers a shock during the R-wave of the QRS complex
If the client were to become pulseless, the synchronize button should be
turned off
Orthostatic Hypotension
Clients should lay supine for 5-10 minutes and then measure BP and HR
The nurse should have the client stand for 1 minute, measure BP and HR, and
repeat measurements at 3 minutes
Findings are significant if systolic BP drops greater than 20mmHg or diastolic
drops greater than 10mmHg
Central Venous Catheter Dislodgment
Usually caused by air embolism
Client will be in respiratory distress: diaphoretic, cyanotic, tachypnea
Apply occlusive dressing over the site to prevent entry of additional air into
bloodstream
Administer 100% oxygen via non-rebreather mask to improve oxygenation
Position patient in left lateral trendelenburg position to promote venous air
pooling in heart apex
Continuously monitor vitals and respiratory effort
Notify HCP immediately
Assessing for JVD
Client should be at semi-fowler’s: 30-45 degrees
Nurse observes for distension and prominent pulsation of neck veins If
present in client with heart failure, may indicate exacerbation and possible
fluid overload
Mitral Valve Regurgitation
Back flow of blood through left ventricle through mitral valve into left atrium
Leads to reduced cardiac output and pulmonary edema
Often asymptomatic, but many clients develop heart failure
Teach to report any new symptoms of heart failure: dyspnea, orthopnea,
weight gain, cough, fatigue
Mitral Valve Prolapse
Clients will have palpitations, be dizzy, and lightheaded
Beta blockers commonly prescribed for palpitations
Teaching: Healthy eating habits, stay hydrated, avoid caffeine, reduce stress,
avoid alcohol, exercise regularly
Nitrates are not effective for chest pain in people with MVP
Aortic Stenosis
Narrowing of aortic valve, which obstructs blood flow from left ventricle to aorta this
worsens, the heart can’t overcome worsening obstruction, and ejects a smaller fraction
of blood volume each systole
Decreased ejection fraction, narrowed pulse pressure
Blood being pumped out insufficient to meet metabolic demands
Patients will have exertional dyspnea, chest pain, and syncope
Aortic Dissection
Tear in the inner lining of the aorta that allows blood to surge between layers of arterial
wall
Before surgical repair, the priority is maintaining pressure in the aorta
Administer IV beta blocker
Heart Failure
Always assess BNP in these patients
Elevated BNP indicates increased ventricular stretch and correlates with severity of heart
failure and fluid volume overload. (increased HR, Hypertension, edema, crackles)
Elevated BNP is an expected finding in HF patients
These patients will have DECREASED urine output
Patient teaching: Daily weight, sodium restriction, take own pulse if taking digoxin or
beta blockers, take BP and keep record of it, increase activity gradually, plan rest periods,
consider cardiac rehab program, avoid extreme hot/cold
Report these symptoms: weight gain of 3 lb in 2 days, or 3-5lbs in a week, difficulty
breathing when lying flat/exertion, waking up breathless at night, dry, hacky cough,
fatigue, dizziness, swelling of feet, ankles, abdomen, face
Abdominal Aortic Aneurysm
To assess for presence of this, nurse would listen with bell of stethoscope in epigastric
area slightly left of midline
Renal perfusion status monitored closely
Monitor for hypotension, dehydration, blood loss, embolism
Check BUN and creatinine, and urine output (at least 30mL/hr)
Manifestations of graft leakage: ecchymosis of the groin, penis, scrotum, or perineum,
increased abdominal girth, tachycardia, weak pulses, decreasing hct and hgb, pain in
pelvis, back, or groin, and decreased urinary output
 After AAA repair, pulses can be absent for 4-12 hours after surgery due to vasospasms
But a decrease from baseline after this time could mean an occlusion
Light palpation
Inferior Vena Cava Filter
TeachingThis filter will trap blood clots from lower extremity vessels
Promote physical exercise, report symptoms of pulmonary embolism (chest pain, SOB),
and impaired lower extremity circulation (pain, numbness), and notify the health care
team prior to having MRI’s
Cardiac Tamponade
Beck’s Triad: hypotension, muffled heart sounds, distended neck veins, narrowing pulse
pressure
Often caused by a clot in a chest tube that causes excess fluid buildup in pericardium
Warning sign: decrease in chest tube drainage
MAP
Normal MAP is between 70-105
If MAP falls below 60, vital organs can be underperfused and become ischemic
Systolic blood pressure + (diastolic blood pressure x 2)/ 3
Hypertensive Crisis
Life-threatening emergency due to the possibility of severe organ damage
If not promptly treated, can lead to intracranial hemorrhage, heart failure, myocardial
infarction, renal failure
IV Vasodilators: nitroprusside sodium
Lower BP slowly
Initial goal: decrease MAP by no more than 25% or maintain MAP at 110-115mmHg
Prioritize neurological assessment because decreased LOC can signal a hemorrhagic
stroke
Torsades de pointes
Associated with hypomagnesemia
It causes prolonged QT interval Magnesium sulfate is treatment
Arteriovenous Fistula
Surgical connection from an artery to a vein to provide vascular access for
hemodialysis
Client should perform hand exercises to mature the fistula
Thrill (vibration) needs to be palpable and an auscultated bruit
PICC Care
Aseptic technique
Sterile dressing changes every 48 hours with gauze or every 7 days with as
transparent dressing
Line should be flushed before and after medication administration
Blood pressure and venipunctures on opposite arm of PICC
All medications should be paused when blood draw occurs (except
vasopressors)
Scrub the hub for 10-15 seconds
Central Venous Access
Femoral access sites should be removed first because they have the highest
risk of infection
Preferred access sites for adults are subclavian vein or jugular veins because
less chance of infection
Subclavian Central Venous Catheter
Priority after placing subclavian cvc is to check placement in the superior vena
cava with a chest x ray
A filter should also be used when administering TPN through this site
Fluid Volume Overload
Increased respirations (dyspnea), increased pulse, increased blood pressure
S3 Heart Sound
May be a normal finding in young adults
In older adults, it could indicate fluid volume overload or heart failure so this
is a significant finding
Blood Transfusion
Blood should not be left out for more than 30 minutes, if the start of the
transfusion is delayed, then the blood should be returned to the blood bank-
hemolytic reaction: destruction of red blood cells, can see hematuria in the
urine, cyanotic, pale, back pain, hypotension
Dyspnea can indicate circulatory overload
Blood must run slowly for the first 15 minutes, no more than 2-5 ml/min
Never warm the blood and blood should be transfused within 4 hours
first 15 minutes run slow, watch for reaction, nurse should stay with patient
Do not discard blood products, keep to investigate what occurred
administer with filter tubing and normal saline
Transfusion Reactions
If a suspected transfusion reaction is occurring, the first thing to do is to stop
the transfusion
Normal saline infusion is typically started and it is important that it is
transfused through a different port
Notify HCP
Assess the client
AED
Automated external defibrillator should be used as soon as possible
AED pads for children up to 8 years, place one on chest and one on back if
only have adult AED pads (sandwich the heart)
Pads should never touchIf client is wet, dry them, remove anything on them
that may be in the way and apply the pads
Hypovolemic Shock
Most common type of shock when blood volume decreases because of
hemorrhaging or third spacing from burns
Treatment: restoring fluid and preventing further fluid loss, improving
hemodynamic stability through vasoactive medications (norepinephrine,
dopamine)
Norepinephrine causes vasoconstriction and improves heart contractility and
cardiac output but the effects end quickly, this should be tapered slowly and
never stopped abruptly
Isotonic solutions are used to restore fluid (0.9% NS, Lactated Ringers)
Ventricular Tachycardia
 Can be pulseless or with a pulse
Stable client with a pulse: treat with medication (Amiodorone)
Unstable client without a pulse: CPR and synchronized cardioversion
PPV
Positive pressure ventilation delivers positive pressure to the lungs using a
mechanical ventilator
Adverse effect of this is hypotension because it causes decreased cardiac
output and decreased venous return to the heart
Torsades De Pointes
Twisting pattern dysrhythmia First line treatment is IV Magnesium
Paroxysmal Supraventricular Tachycardia
Short, frequent attacks are first treated with vagal maneuvers
They can bear down like having a bowel movement
Regular tachycardia with a rate of 150-220
Best treatment is vagal maneuvers and Adenosine IV push
Dopamine
(Intropin) Used to improve hemodynamic status in those with shock and heart
failure
Enhances cardiac output by increasing myocardial contraction, increasing
heart rate, and elevating blood pressure through vasoconstriction Increases
renal perfusion which increases urinary output
Adverse effects: tachycardia, dysrhythmias, myocardial ischemia
Given to people with hypotension
Needs adequate fluid volume replacement
PVC
Ventricular trigeminy
Occur every third heartbeat
MI predisposes to PVC
PVC are caused or exacerbated by hypoxia, electrolyte imbalances, stress,
stimulants, fever, and exercise
Potassium replacement if low
Asystole
Cannot shock this rhythm If a patient has this rhythm, the first thing the nurse
should do is verify the monitor reading by palpating the pulse (ASSESS!)
 Priority is to provide continuous CPR and epinephrine
Epinephrine
Phentolamine is the antidote
Used to increase rate of heart and CNS
Should be given through a central line
Thrombocytopenia
Avoid IM injections to reduce client injury
Monitor neurological changes
Takes longer for these clients to clot so at risk for bleeding
Administering diuretics
Check BUN and Creatinine to make sure they don't become elevated with
use of diuretics, also check Potassium and blood pressure
Murmurs
Produced by turbulent blood flow across diseased or malformed cardiac
valves, sound like musical, blowing, swooshing sounds
Albumin
Plasma protein with normal range: 3.5-5.0
Ontonic pressure component that helps PULL water back into the
circulatory system
Plays a role in maintaining intravascular oncotic pressure and prevents
fluid from leaking out of the vessels
Liver makes albumin
Hypoalbuminemia is common in people with liver disease, can lead to
pitting edema if albumin levels are low because can not pull fluid back into
circulatory space
If a patient has protein in the urine, could indicate kidney dysfunction
Protein in the urine could be an early sign of kidney disease in patients
Third Spacing
Can occur 24-72 hours after trauma or surgery and it is where fluid shifts
from the intravascular space to the space between cells (interstitial space)
Leads to decreased circulating volume (hypovolemia) and decreased
cardiac output, weight gain, decreased urinary output, tachycardia,
hypotension
If this is suspected the FIRST thing the nurse should do is assess vital signs
 MUSKULOSKELETAL DISORDERS

Residual Limb Care

Clean limb by washing it daily with soap and water
Assess skin for redness or skin breakdown
Clean and dry socks and wraps
Perform daily range of motion exercises
Lie on stomach for 30 minutes several times each day and avoid sitting in
chair for more than 1 hour to avoid hip flexion contractures
Do not apply lotion/ powder
Should not be elevated, use ace wrap bandage instead to help with edema
Osteomalacia
Reversible bone disorder caused by lack of vitamin D
Characterized by weak, soft, and bones that hurt
These bones can easily fracture or become deformed
Halo Device Fracture
Nurse should clean pin sites with sterile solution to prevent infections
Keep the vest cool and dry and using low cool blow dryer to dry
Place foam inserts at pressure points
Placing a small pillow under clients head when supine
Only health care provider can adjust loose pins, keep wrench at bedside
though and contact HCP if pins are loose
Do not hold frame of device when moving the client
Carpal Tunnel Syndrome
Pain and paresthesia in the hand caused by the compression of the medial
nerve
IMMOBILIZE THE WRIST with a splint
Do not do repetitive wrists movements
Rhabdomyolysis
Happens when muscle fibers are released in the blood after trauma or injury
This can cause acute renal failure
The nurse’s priority action is to prevent kidney failure by filtering the kidneys
so the nurse should provide a bolus of NS
Hip Fractures
Clinical features: leg abducted, shortening of the affected limb, ecchymosis
and pain over groin and hip area and pain when weight bearing, muscle
spasms, externally rotated
Cast Care
Report foul odors or hot areas in the cast because this may indicate infection
Avoid getting the cast wet
Elevate the affected extremity above heart level for first 48 hours
Perform isometric and ROM exercises regularly
Never put anything inside of cast to itch, use air dryer
Cane Use
Cane length should be from greater trochanter to the floor
Hold cane on strong side to provide maximum support
Put can several inches in front of and to the side of unaffected foot
Move cane first then affected leg
FES
These patients will expect to have confusion, restlessness, petechiae over
chest, hypoxic, mental status, respiratory distress, fever NOT EXPECTED would
be pain in affected limb and numbness and tingling
To help prevent this from happening it is important to stabilize and immobilize
the fracture immediately , minimize movement of the fractured extremity to
help reduce the risk of FES
Bucks Traction
Client should be supine or in semi fowler's position
Do not elevate the head of the bed more than 30 degrees
Weights should be free hanging at all times and should never be placed on the
bed or floor
Never remove the weights, could be life threatening
Monitor neurovascular and skin integrity
Body should be aligned at all times
Knee Replacement Surgery
Immobilize knee, keep in straight position
Do not place anything under the knee, can put pillow on foot/heelJoint flexion
with increase the risk of fractures
Crutches
Weight should be placed on the upper arms and hand grips, not axilla of
crutches
Hand grip is right when elbow flexion is 30 degrees
Swing through - non weight bearing, amputation 2 point and 4 point gates
bilateral weakness (2 legs affected)
Odd number gate when one leg is affected
Up with the good, down with the bad Upstairs- lead with good foot, then
crutches Downstairs- lead with the bad
Increased Risk for falls
Positive orthostatic vital signs
Osteoarthritis
IV therapy
Gait abnormality
Medications
Ambulatory aid
Over age 65
Prevent Falls
Exercise programs
Wearing needed glasses
Well lit rooms
No rugs
Handrails
Non skid shoes and socks
Staff hourly rounding
Malignant Hyperthermia
Rare but life threatening inherited muscle abnormality that is triggered by
inhaled anesthetic agents
Leads to sustained muscle contraction and rigidity (early sign) then can lead to
a dangerously high temperature due to increase metabolic demands and
oxygen demands (late sign)
If the patient has never had anesthesia before, you can ask if any of their
family members have had a bad reaction to general anesthesia
 DIABETES & INSULIN

Insulin Pump
Can administer insulin through a continuous dose or or bolus administered at meal time
The client will experience fewer swings in blood glucose levels and hypoglycemic episodes
Still need to check blood sugar 4-8 times a day
Assess mental status to see if clients with insulin pumps can manage it safely
Hypokalemia
The diabetic client with hypokalemia is at risk for severe cardiac dysrhythmias
Before administering insulin to a client with hypokalemia, the nurse should contact the HCP
Insulin can worsen effects of hypokalemia, they may need supplemental potassium
Regular Insulin
Only insulin that can be administered IV Push
Regular insulin injection peaks 2-5 hours
Metformin
Clients that receive IV contrast dye for a CT procedure and receive Metformin are at
increased risk for lactic acidosis, therefore the HCP may discontinue metformin for 24-48
before the CT
Glargine
Long acting insulin has no peak and may last 24 hours or longer
Should not be mixed in same syringe with any other insulin, use seperate site
 CONTACT PRECAUTIONS

Airborne Precautions

Airborne
TB
Measles
Varicella
Chickenpox (incubation 2-3 weeks)
TB
Confirm with chest x ray before placing client in isolation
room
>15 is positive TB test in a healthy client
Latent TB infection are not contagious
Active TB are infectious and can transmit through air
TB treatment can be anywhere from 6-9 months long, crucial
for patient to finish medications
Clinical manifestations: Night sweats, weight loss, purulent or
blood tinged sputum, fatigue, low grade fever
Airborne precaution
Negative pressure room
Shingles
Shingles lesions that are open may be transmitted airborne
and contact
The client with disseminated lesions that are not crusted over
well should be put in a private room with negative airflow
pressure, contact precautions and airborne precautions
Localized shingles requires only contact precaution
Varicella
When client has open active lesions they should be on airborne precaution
Negative pressure room
N95If in contact with body fluid then contact precautions

Droplet Precaution

Droplet
Meningitis
H flu B - can cause epiglottitis
Private room, mask, gloves, no gown, no eyeshield, no negative airflow
Pertussis
Highly contagious and requires droplet precautions
Rapid coughing and vomiting
whooping cough
monitor for signs of airway obstruction
Meningitis
Droplet precaution
Care for this client includes:
Droplet precaution
Seizure precaution
Reduced stimulus environment
Bed rest, head of the bed elevated 10-30 degrees
Does not need a negative pressure room
Contact Precaution
Private room preferred, gloves, gown
RSV
C diff
Hep A
Staph infections
Herpes Infections
MRSA
Clients with this infection should be bathed with pre moistened cloths or warm clothes with
chlorhexidine
This can reduce spread of infection
Place MRSA client in a private room or semi private with a client that has the same infection
Dedicate equipment for client
Wear gloves when entering the room
Hand hygiene when exiting the room, can be soap and water or alcohol based
Wear gown with client contact
Post notification on door
Ensure client only leaves room for essential test etc.
No need to wear a mask
CDiff
Clients should be put on contact precautions (gowns and gloves) in private rooms to eliminate
spread of infection
Hand hygiene using soap and water (not alcohol based)
Diluted bleach solution must be used to clean surfaces
Manifestations:
watery diarrhea ,fever/nausea , abdominal pain
C-Dif can lead to hypovolemia (hyponatremia, hypokalemia, elevated BUN)
Preventing HCAUTI
Steps to prevent UTI in clients with urinary catheters include:
Wash hands
Wash perineal area with soap and water each shift and after bowel movement
Catheter bag below the level of the heart
Use sterile technique when collecting urine sample
Peripheral IV Sites
To reduce the risk of infections, the best IV sites would be in the forearm or hands
Sepsis
Overwhelming response to infection that causes impaired organ function
Septic shock occurs when sepsis causes cardiovascular collapse and/ or the body cannot
maintain normal metabolic function
Septic shock manifestations:
Fever or hypothermia, Hypotension , Prolonged cap refill , Tachycardia
Increased WBC count (over 11000) , Decreased urine output
HIV Infection
Infection of the CD4 Helper T cell
Low counts can increase chance of infection
To reduce the risk of infection patients should:
Get influenza vaccine
Avoid eating undercooked meals
Drink bottled water
Use condoms
Avoid cat litter
Avoid large crowds
Lyme Disease
Develops after bit from infected tick
Bulls eye rash
Flu like symptoms
migraines
UTI
Usually bacterial in origin
Classified as upper or lower depending on where the infection is
Upper UTI
Inflammation and infection in the kidneys and ureters (pyelonephritis)
Manifestations:
Become very ill
nausea/ vomiting
fever/ chills
Flank pain
Lower UTI
Inflammation and infection of bladder (cystitis)
Most common type of UTI
Manifestations:
Burning with urination
urgency/ frequency
Hematuria , Suprapubic discomfort
Thrush
Infection of the mucous membranes caused by yeast like fungus
The fungus causes pearly milk curled lesions orally
Clients who are immunocompromised are at increased risk for developing thrush,
especially those taking corticosteroids orally
Hep A
Transmitted through fecal- oral route
Priority is hand hygiene to prevent transmission
Sputum Culture Collection
Sputum culture and sensitivity test nursing considerations: teach client to rinse mouth out
with water before collecting, morning is best time to collect, inhale deeply several times
then cough forcefully, assume a sitting or upright position
Wound Culture
Always clean wound first before taking a wound culture
Clean gloves and hand hygiene to remove old dressing
Sterile gloves and hand hygiene to swab from wound center to outer margin
TB Testing
Intradermal injection
1 mL tuberculin syringe with a 27 gauge ¼ inch needle
Pull skin downward so that it is taut
Insert needle at a 10 degree angle
Outline of bevel should be visible under the skin
Inject the medication slowly and form a small bleb under the skin
Circle border
Avoid rubbing site after injection
Done in forearm
Tumor Lysis Syndrome
Life threatening complication of cancer treatment, considered an oncological emergency
When cancer treatment kills cells, it releases different intracellular components causing a
life threatening imbalance
Clinical manifestations: hyperkalemia, large amounts of nucleic acids can cause acute
kidney disease, hyperphosphatemia, hypocalcemia
 RENAL / URINARY

Creatinine Clearance
Measure of glomerular function and indicator of renal disease process
24 hour urine collection is needed for this test
First urine sample is discarded and time is noted
All other urine samples for the next 24 hours are collected and kept cool
At the end of the 24 hours the client should attempt to void one last time and
add to collection container
Blood is also drawn to collect creatinine level
Kidney Disease
Obtaining tissue sample to determine the cause of certain kidney diseases
Bleeding is the major complication for this procedure
Before the procedure the client must give informed consent and discontinue
all anticoagulants and antiplatelet medications for at least one week
The client should have well controlled blood pressure and be crossed
matched just in case of infusion
After the procedure the nurse should monitor the vital signs for the first hour
every 15 minutes and assess puncture site for bleeding
Position the client on the affected side for 30-60 minutes and bed rest for the
first 24 hours
Cystoscope
Inserted through the urethra to directly visualize the bladder wall and
urethra
Burning sensation upon urination is normal after procedure
Complications associated include: urinary retention, hemorrhaging, infection
Notify the HCP immediately if blood clots, blood tinged urine, inability to
urinate, chills, abdominal pain or fever are present
Renal Arteriogram
Radiologic test to visualize renal blood vessels
Contrast medium is injected into the femoral artery
Teach client to increase fluid intake after the exam to flush dye from the
body Increased urination after exam is expected outcome because want to
flush fluids
Benign Prostatic Hyperplasia
Abnormal prostate enlargement most commonly affecting males over the age
of 50 The prostate gradually enlarges and compresses the urethra
Clinical manifestations include: urinary urgency, frequency, and hesitancy,
dribbling urine after voiding, nighttime frequency, and urinary retention,
intermittent or weak stream, incomplete emptying sensation, straining or
difficulty starting stream
The nurse should teach about ways to control and manage these:
medications, lifestyle changes, voiding schedule, avoidance of caffeine and
antihistamine
These patients have an increased risk of UTI
If the patient is experiencing burning while urination, it could mean a UTI is
present and further assessment is required
Stress Incontinence
Nursing care plan for this includes: teaching kegel exercises, bladder training,
incontinence products, and lifestyle changes, avoid smoking, drinking,
caffeine, use of pessary
The highest priority with a client newly diagnosed with stress incontinence is
preventing skin breakdown, and UTI through bladder training, the nurse
should teach the patient to void every 2 hours
Pessary can remain in place while sexually active
Happens when there is increased abdominal pressure, from coughing,
sneezing etc
Peritoneal Dialysis
The peritoneum is used as a semipermeable membrane to dialysis clients
The tubing is clamped to let the fluid work for a specific period
Clients are closely monitored for respiratory distress while the fluid is inside
Crackles in the lungs require immediate intervention
Essential to use sterile technique when spiking the bag
Bacterial peritonitis is a potential complication and can lead to sepsis
Place the catheter bag below the client (below abdomen) and the client should
be in fowlers or semi fowler's position
Cloudy outflow, tachycardia, low grade fever are signs of peritonitis
Bloody fluid could indicate intestinal perforation
 Brown fluid could indicate fecal contamination insufficient outflow may result
from constipation, if outflow becomes sluggish, the nurse should reposition
the client (side lying), check for distention, and check for kinks in the tubing or
assist with ambulation
Never flush the tubing or pull on it
Can gently rotate the check for kinks
Bladder Cancer
Hallmark finding is painless hematuria
Primary cause is cigarette smoking
Urinary Retention
Opioids may cause urinary retention because they relax the bladder muscle
The nurse should assess the clients subprubic area for retention
Often occurs in older men with BPH
If a man is having trouble urinating after surgery, the initial action is to get
them out of bed and see if that helps, second intervention would be to
bladder scan
Chronic Kidney Disease
At risk for uncontrolled hypertension and hypertensive emergencies
Hypertensive encephalopathy is a type of hypertensive crisis characterized by
nausea, vomiting, and headache Immediate assessment and intervention
required within one hour
Are at risk for hyperkalemia and fluid overload
Clients should avoid salt substitutes which typically contain potassium
chloride
Fluid restriction, potassium restriction, sodium restriction, low protein diet,
low phosphorus diet
Acute Pyelonephritis
Upper urinary tract infection Clinical manifestations: chills, fever, vomiting,
flank pain, costovertebral tenderness
Blood and urine cultures should be obtained prior to antibiotic administration
Acute urinary Retention
Rapid, complete, bladder decompression is done
This can be associated with hematuria, hypotension and postoperative
diuresis
Complications the nurse should assess for: hypotension and bradycardia
Dialysis
Some medications should be held prior to receiving dialysis including:
antihypertensives because it could lead to hypotension also vitamins B and C,
digoxin and antibiotics
No need to give heparin before dialysis because it is given during
Dialysis equilibrium syndrome:
rare but life threatening complication that occurs during the initial stage of
dialysis creating increased intracranial pressure, slowing the rate can prevent
Symptoms include: nausea, vomiting, seizures, headache, restlessness, change
in mentation
If this is suspected the HCP should be called immediately and dialysis should
be slowed or stopped
Check weight from previous dialysis and current weight/ VS
Continuous Bladder Irrigation
3 way catheter usedInfusion rate should be sufficient to eliminate obstruction
of flowThe nurse should assess tubing and make sure there are not clots
blocking the flow
Best indicator of of productive flow rate is the output urine color (light pink)
Condom Catheters
Never pull foreskin back can cause swelling and paraphimosis
Can use elastic adhesive to spiral around to secure
Leave 1-2 inch space in catheter
Preventing UTIs
Take all antibiotics
Increase fluid intake
Wipe from front to back
Cotton underwear
Void after intercourse
Avoid douching and using feminine perineal products
Avoid spermicidal contraceptive jelly
Overflow Urinary Incontinence
Occurs due to compression of the urethra or impairment of the bladder muscles this can
lead to incomplete bladder emptying and urinary retention this can lead to urine dribbling
Nursing care includes:
scheduling a voiding pattern (every 2 hours) to prevent distention
instruct client to bear down and applying gentle pressure to the lower abdomen to
facilitate bladder emptying
assess skin for breakdown
encourage client to void 30 seconds after voiding, and check residual volume
Bladder Catheterization
If there is leakage then the nurses first action is to assess the catheter tubing
Dislodge visible obstruction by milking the tubing
Irrigation is usually avoided because puss or sediment can flow back into the bladder
Fill balloon with 5mL of saline
For males it is recommended that the catheter be inserted 7-9 inches then an additional 1
inch after urine is seen in the collection bag
Hepatic Encephalopathy
Reversible neurological complication of cirrhosis caused by primarily increased levels of
ammonia in the blood
Lactulose is the most common treatment for hepatic encephalopathy, it is a laxative but it
helps excrete ammonia
It can be given on an empty stomach and it can be given with juice, milk or water
Liver Failure
Low serum Albumin, high ammonia levels, elevated INR/ PT, increased bilirubin levels, low
platelets
May take Lactulose to excrete ammonia
Urine Collection
Given dark jug to preserve urine
Kidney Biopsy
Uncontrolled hypertension is contraindicated in these patients
Elevated creatinine is an expected finding in someone with kidney disease
Decrease hemoglobin level is expected in someone with kidney disease
Acute Kidney Injury
At risk for hyperkalemia
 GI DISORDERS

Care of Stoma
At least 3000 ml of fluid a day
Avoid eating foods that cause gas (broccoli, cauliflower, brussel sprouts,
beans)
Empty the pouch when it becomes one-third full
Pancreatitis
Acute inflammation of the pancreas that results in autodigestion
Most common causes are cholethiasis and alcoholism
Signs include severe epigastric pain radiating to the back, amylase and lipase
are ELEVATED
Complications: hypovolemia, hyperglycemia, hypocalcemia, latent hypoxia,
ARDS, cardiac arrhythmias Barium Enema Uses fluoroscopy to visualize colon
with dye
Contraindicated in patients with diverticulitis
Preprocedure instructions include: take cathartic (magnesium citrate etc.) to
empty stool from colon, Follow a clear liquid diet the day before the
procedure to aide in bowel preparation and to prevent dehydration, Do not
eat or drink anything 8 hours before the test, May experience abdominal
cramping and urge to defecate during the procedure Expect passage of chalky
white stool after procedure
Take a laxative to get rid of excess barium
Drink fluids
IBS
Keep daily record of symptoms
Exercise
Limit gas producing foods
Reduce daily caffeine intake
Do not fast, do not go on clear liquid diet when symptoms are bad
Peptic Ulcer Risk factors: H. pylori infection, stress, smoking, diet, alcohol use,
NSAID use, genetic predisposition, avoid eating meals before bedtime
Nasogastric Feeding Tubes
When administering bolus enteral feedings, the nurse should raise the head of the bed
and keep it elevated for 30-60 minutes afterwards to decrease aspiration risk
Feeding tubes should be flushed before and after feedings to keep the tubes patent
Gastric residual volumes are checked every 4 hours with continuous feeding and before
each bolus feeding
Gastric pH should be acidic (less than 5)
A pH over 6 requires chest x ray placement check of the NG tube
Newly placed tubes also require placement check
Do not remove stylet before x ray is performed
Acute Pancreatitis
These patients can develop respiratory complications due to the release of cytokines and
pancreatic enzymes that cause systemic inflammation
ARDS is most serious complication
If crackles are heard in these patients, immediate action needs to be taken
Stoma
Healthy stoma should be pink to bright red and moist
If the stoma is dusk or any color blue the HCP should be informed
Medical emergency
Botulism
GI absorption of neurotoxin
Organism found in soil and can grow in any food contaminated with the spores
Clinical manifestations: muscle paralysis, descending flaccid paralysis (starting with the
face), dysphagia, and constipation
Main source is improperly canned food or stored foods
LOOK FOR CANNED FOODS WITH SWOLLEN ENDS
No raw honey for children under age 1
Cholelithiasis
Inflammation of the gallbladder
Highest priority for a vomiting/ nauseous patient with this is NPO status so the gallbladder
is not stimulated more
Also maintain low suction for NG tube, semi-fowler position, IV fluids
PEG Tube
Tube movement of 0.5 cm when the client coughs
Should rest loosely above the skin
Resistance shouldn’t be felt when moving around
Gastric Lavage
Performed through an orogastric tube to remove ingested toxins and irritants to the
stomach
Done if the ingested toxins are considered lethal and if it can be initiated within 1 hour
 SPINAL CORD INJURIES

Neurogenic Shock
Vasodilation will occur due to loss of innervation from the spine
This will decrease venous return to the heart , signs of neurogenic shock
include: hypotension, bradycardia, and pink and dry skin from the vasodilation
Usually occurs in cervical or T6 or higher spinal injuries
Priority nursing care is administering normal saline to increase blood pressure
and perfusion to vital organs
Laminectomy
Removing the posterior of spinous process
Relieves compression of nerve root
Pain, paresthesia, paresis(muscle weakness) these are signs that the nerve
root is being pressed on so then would get a laminectomy
The location will determine the symptoms, prognosis and symptoms 3
locations: cervical, thoracic, lumbar
LOG ROLL AFTER SURGERY
Anterior thoracic will have chest tubes
Laminectomy with fusion- take bone from hip
Do not dangle, no sitting
Do not sit for longer than 30 minutes
They may walk, stand, or lay without restrictions
Discharge teaching: 6 weeks no sitting for more than 30 minutes, lie flat and
log roll for 6 weeks, no driving for 6 weeks, do not lift anything over 5 lbs for 6
weeks, cervical lams cannot lift anything over the head
Jaw Thrust Maneuver
Trauma should follow ABC
Especially true with suspected head and neck injuries
Until the spin is appropriately addressed, the patient should be placed on a
backboard
The nurse should use the jaw thrust maneuver
Acronym to help determine spine immobilization
NSAIDS
N, neurological damage
 S, significant traumatic injury
A, alertness
I, intoxication
D, distracting injury
S, spinal examination
Dumping Syndrome
Treatment: want stomach to empty slower, so lay down after eating, meals
should be small, low fluids, low carbohydrate, get fluids before or after meals,
NEVER with meals, high protein, high fiber
Electrolytes
Kalemias do the same as the prefix accept for heart rate and urine output
This is a helpful sentence to remember the symptoms of hyper and
hypokalemia
Calcemias and magnesiums do the opposite of the prefix (
everything goes down when calcium goes up)
Earliest sign of any electrolyte disorder is numbness and tingling (paresthesia)
Circumoral paresthesia (numb and tingling lips)
Fastest way to lower high potassium (give D5W with regular insulin)
TPN VS ENTERAL VS PARENTERAL
tpn and parenteral are IV feedings
Indicated for malabsorption
Enteral are tube feedings like NG
Hiatal Hernia
Stomach is pushing through the diaphragm GERD Heartburn, indigestion
Treatment: sit up after eating, want stomach to empty faster
Keep head of the bed in high position, high carb diet, fluids high and carbs
because we want things to go fast
Low protein
Scoliosis
Brace should be worn 23 hours a day
Lateral deviation
Wear shirt under
 NEURO & BRAIN
Client aging:
normal things that happen when clients age are decreased sphincter reflexes, increased
frequency, decreased peristalsis
Incontinence is not normal in the aging process, GI neurological changes are NOT normal
Hemorrhagic Stroke
Rupture of blood vessel in brain causing bleeding into brain tissue or subarachnoid space
Nursing considerations: Patient is on seizure precautions because risk of IICP
They may develop dysphagia so NPO for these patients until swallow function test is
performed
Frequent neuro checks
The nurse should prevent activities that increase ICP
How to decrease ICP:
reduce stimulation
maintain quiet and dim environment
limit visitors
stool softeners to reduce straining
strict bed rest,
assist with ADLs
maintain head in midline position to improve jugular venous return to the heart
NO anticoagulants
Meningitis
Inflammation of the meninges covering the brain and spinal cord
Clinical manifestations:
N/V
Fever
Severe headache
Nuchal rigidity
Photophobia
AMS (altered mental status)
IICP
Stiff neck
Pain with flexion
Patient should be put on droplet precautions
No negative pressure room
Bell Palsy
Peripheral, unilateral facial paralysis characterized by inflammation of the facial nerve
(CN7) in the absence of a stroke or other diseases
Flaccidity of affected side
Clinical manifestations:
Inability to close eyes of affected side
Cannot smile symmetrically
Lacrimation of the eye is decreased on affected side
Flattening of the nasal labial fold
Facial drop
Cannot close eye correctly
Aphasia Syndrome
Broca
Expressive , Impaired speech and writing
May be able to speak short phrases but has difficulty with word choice
The nurse should listen and give time for patient to speak
Easily frustrated when attempting to speak
Clients speech is limited to short phrases that require effort
Wernicke
Receptive Impaired comprehension of speech and writing
May speak full sentences but the words do not make sense
Ask simple yes or no questions
Apraxia
Loss of the ability to perform a movement due to neurological impairment
ALS
Neurodegenerative disease with no cure
Degeneration of motor neurons in the brain and spinal cord
Clinical manifestations:
Fatigue
Muscle weakness that is progressive
Twitching and muscle spasms
Difficulty swallowing, difficulty speaking
Respiratory failure
Clients usually survive 3-5 years and there is no cure
Romberg Test
Part of a focused neurological exam assessing vestibular function and body in space
Used to determine the reason for loss of coordination
Clients are asked to stand with the feet together and eyes closed
If loss of balance occurs then ataxia is considered to be sensory
These patients will have loss of balance and need assistance with ambulation
Therapeutic Hypothermia
Induced in clients who suffer neurological injury due to cardiac arrest or in comatose or
clients who do not follow commands after ressecutation
Induce 6 hours after arrest up to 24 hours
Improves neurological outcomes and decreases mortality rates
IICP
Look for signs with Cushing’s Triad as it is related to IICP
Change in LOC
Bradycardia
Widening pulse pressure
Cheyenne stokes respirations
Cushing's triad is a late sign and signals that the brain stem is compressed
Keep head of the bed at 30 degrees
Absence Seizures
Usually occurs in children
Daydreaming like episodes, usually 10 seconds and staring
No memory of the seizure
Seizures
During seizure activity, priority is client safety
Assist to lie down from a chair or whatever they are doing
Loosen restrictive clothing
Administer oxygen as needed
Never restrain and never insert anything into the mouth
During seizure activity need to stop, administer IV or rectal benzos (diazepam,
lorazepam)
Homonymous Hemianopsia
Loss of half of the visual field on the same side
May lose left side of visual field in both eyes
High risk for self neglect
Concussion
Change in LOC
Amnesia
Headache
Rest and light diet are encouraged
No strenuous activities for 1-2 days
Myasthenia Gravis
Autoimmune disease involving a decreased number of acetylcholine receptors and leads
to skeletal muscle weakness
Clinical Manifestations:
ptosis/ diplopia
 Bulbar signs (difficulty speaking or swallowing)
Difficulty breathing
Muscles are stronger in the morning and weaker in the evening
Treatment: anticholinesterase drugs before meals
Semi solid foods
Need to teach about the importance of the flu vaccine (anyone with an autoimmune
disease)
Testing Cerebellar Function
Involved in coordinating voluntary movement and balance and posture
Assessed with gate testing (heel to toe)
Finger tapping, touching nose with finger
Ischemic Stroke
Immediate CT or MRI
Thrombolytic therapy within 4.5 hours (contraindicated in bleeding, hypertensive,
aneurysm)
Neuro assessment
GCS
Highest score 15
Lowest score 3
Best indicator of decline is score decreasing in small amount of time vs. individual
component or answer
Parkinson Disease
chronic , progressive, neurodegenerative disease of the dopamine producing neurons
Characterized by:
Slow movement (bradykinesia)
Increase muscle tone (rigidity)
Resting tremor
Shuffling gait
Short steps
Stooped posture,
Masked facial expression
Caused by low levels of dopamine in the brain
Levodopa Carbidopa (Sinemet) is a medication that can help in treating
bradykinesia
Once this medication is started, it should never be stopped because it can lead to
complete loss of movement
This medication takes several weeks to reach effect
The client’s urine and saliva may turn a reddish-brown color but this is not harmful
Alzheimer’s Disease
Engaging in regular exercise decreases the risk of AD
Genetic, lifestyle, and environmental factors
Family history is a risk factor
Trauma to head is a risk factor
Usually over 65
Healthy lifestyle to reduce the risk of AD
Caring for clients with AD
Use distraction and redirecting to manage agitation (go for a walk)
Speak slowly, simple words, yes or no questions
No open ended questions
Break down complex activities into steps with simple instructions
Decrease client’s anxiety by limiting number of choices
Trigeminal Neuralgia
Sharp pain along trigeminal nerve
Primary prevention is consistent pain control
Carbamazepine is the drug of choice
This is a seizure medication and is highly effective in controlling neurological pain
This medication is associated with infection risk and leukopenia so the patient should
report any fever or sore throat
EEG
Evaluate brain electrical activity
Hair needs to be washed before procedure
Avoid caffeine, stimulants, and CNS depressants
The test is not painful and no analgesia is required
No chocolate before
Foods and liquids are not restricted before test
Not painful and not sedated
Hydrocephalus
Increased ICP
Increased head circumference, sunset eyes, bulging fontanelles
Myelomeningocele
Open spina bifida
Open area in lumbar spine
Risk for infection
Priority intervention it to cover with a sterile, moist dressing
Lumbar Puncture
The patient with be in the lateral recumbent position or sitting upright, these positions
allow for widening of the space inbetween the spinal vertebrae
Before the Procedure: Client will be asked to empty the bladder
Needle will be inserted between L3/L4 or L4/L5
Pain may be felt radiating down the leg, temporary
After the Procedure: Lie flat with no pillow for at least 4 hours to reduce the chance of
spinal fluid leak and resulting headache Increase fluid intake for the next 24 hour to
reduce dehydration
Epilepsy
Chronic seizure activity
Seizure triggers include:Avoid alcohol in excess, sleep deprivation and stress
Practice relaxation techniques
Medical alert bracelet
Phytenin may decrease oral contraceptive effectiveness so use non hormonal birth
control
Phytenin may cause fetal abnormalities Do not stop medication abruptly
Decerebrate Posturing
Sign of severe brain injury
Arms and legs will be straight out, toes pointed down, and head and neck arched back
These assessment findings indicate that severe injury has occured
Basilar Skull Fracture
CSF fluid leak from nose and ears, racoon eyes,
Battle’s sign (bruising around the ears)
Dextrose testing can be done on the fluid to confirm it is CSF
This CSF leak puts the client at risk for infection
No NG or oral tubes should be placed unless with fluoroscopic guidance
Coagulated blood surrounded by halo ring of CSF can be a positive sign (halo ring sign)
What can the nurse do to decrease IICP
Hyperventilate before suctioning
Maintain dark, quiet environment
Maintain the head of the bed in a neutral, midline position
Elevate head of the bed to 30 degrees
Administer stool softeners to decrease straining
Manage pain
Manage fever
Administer stool softeners to decrease straining
Manage pain
Manage fever
 VISUAL/ AUDITORY

Speaking with the Hearing Impaired

Speak directly to client, facing client, Use facial expressions and gestures
Post a hearing impaired sign on clients door
The nurse should ensure hearing aids are functionable and in place
Speak at a normal volume (no yelling)
Encourage client to repeat back teaching
Ocular chemical burns
Require emergency care to prevent permanent vision loss
Copious eye irrigation for all types of ocular chemical burns
Sterile saline or water irrigation should begin immediately
IV tubing used or a morgans lens, continues until the pH of eye is normal (6.5-7.5)
Cataract Surgery
Activities that may increase intraocular pressure should be avoided to decrease risk of
damage to suture site
These included: bending over, lifting more than 5lbs, sneezing, coughing, constipationIf
constipated, the nurse should encourage fluids, fiber intake, and over the counter stool
softeners
After cataract surgery it is common for the person to feel itching in the affected eye and
blurred vision
Sleeping on 2 pillows will decrease intraocular pressure
Eye Injuries If a person gets something stuck in eye (splinter, or injury) they should first
COVER BOTH EYES (since the eyes work in synchrony)
Do not flush eye is there is splinter lodged in it, may cause further injury
When a foreign body becomes lodged in the eye, both should be shielded
Retinal Detachment
Separation of the sensory retina from the underlying pigment epithelium
Clients experiencing retinal detachment may experience a gradual, curtain like, loss of
visual field
Retinal detachment is a medical emergency and interventions should happen immediately
to reduce the chance of vision loss
The injured person could have the perception of lights flashing, floaters, gnats/hairnet,
cobweb vision
Traumatic retinal detachment may result in sudden vision loss
Retinal detachment requires emergency surgery
Post Op teaching:
Avoid activities that increase intraocular pressure
No rubbing eyes (this increases intraocular pressure)
 Report sudden pain, flashes of light, vision loss or bleeding
Avoid focused activities like reading and writing
Wear eye patch
Ensure appropriate positioning instructed by the HCP
Meniere Disease
Results from excess fluid accumulating inside the inner ear
Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural
fullness, N/V, and feeling of being pulled to the ground (drop attacks)
During an attack the client is treated with sedatives such as benzodiazepines
like diazepam, antihistamines, and anticholinergics
Priority nursing care is fall precautions
Also the nurse can place patient in quiet, dark room and salt restricted diet
Macular Degeneration
Progressive, incurable disease where the center of the eyes vision begins to
deteriorate
This deterioration causes distortion (blurred or wavy visual disturbances) or
the loss of the center field of vision, but peripheral vision remains intact
They may see a blurry spot in the middle of their visual field
To decrease macular degeneration a patient can:
Stop smoking
Intake of specific supplements (carotenoids, vitamin C and E)
Laser therapyInjections of antineoplastic medications
Primary Open Angle Glaucoma
Characterized by an increase in intraocular pressure and gradual loss of
peripheral vision (tunnel vision)
Signs and symptoms develop slowly, it is painless and peripheral vision loss
with normal central vision, difficulty with vision in dim lights, increased
sensitivity to glare, and halos observed around bright lights
Can lead to blindness if left untreated
Acute Angle Closure Glaucoma
Immediate medical intervention
Characterized by increased intraocular pressure
Signs of this can include: sudden onset of eye pain, reduced central vision,
blurred vision, ocular redness, reports of seeing halos around light
Cataract
Cloudiness of the lens that may occur at birth or more commonly in older
adults
Signs and symptoms include: painless, gradual loss of visual acuity with
blurred vision, scattered light on the lens producing halos and a glare

Retinal Detachment
(curtain loss)

Macular
Degeneration

Open Angle Glaucoma

(tunnel vision)

Cataract
 PSYCHIATRIC NURSING

Need To Know NCLEX Facts

Establish a trust relationship
The nurse will examine their own feelings about…
Don't accept or give gifts
Don't give advice, rather say “what do you think you should do”
Don’t give guarantees in psych “if you cry you will feel better”
It’s never wrong to get your patient to talk
Don’t use slang
Don’t tell an upset patient to chill out
Respond to how the patient feels, not what they say
Don't ever step out of the room so they can grieve
Phobias: gradual exposure, do not take away the phobias immediately
Displacement: acting out on someone or self due to something else, cutting
self, throwing a book at a nurse
Manic Bipolar Episode
Give client finger foods, foods that they can take on the go
Reduce stimulus of environment (calm, quiet environment)
One on one interactions
No group therapy
Limit number of people that come in contact with client
Low light
Structured activities and schedules
Physical activities
Private room
Choose clothing for a client
Panic Attack
Clinical manifestations: shaking, hyperventilating, heart palpitations
The nurse should stay in the client’s room to offer support and ensure safety
Delirium
Advanced age, underlying neurodegenerative condition, acid/base imbalances,
infection, surgery, impaired mobility, inadequate pain control
Schizophrenia
Catatonic schizophrenia: does not move, remains mute, etc.
These types are unable to meet their basic needs of fluid and food intake and
are at high risk for dehydration and malnourishment
If client says the voices are saying bad things, important for the nurse to ask
what they are saying, to assess if anyone is in danger
Delirium is a positive symptom of schizophrenia
Delusion of reference believe that songs, newspapers etc. are personally
about them
Important to reinforce reality and acknowledge feelings
Depression in Adolescents
May exhibit an irritable or cranky mood rather than sad
Signs: sleeping, low self esteem, withdrawal from activities, angry outburst,
inappropriate sexual behavior, weight gain or loss
Normal for clients to voice and ask questions about appearance
Psychomotor retardation: slowed speech, decreased movement, and impaired
cognitive function
Agoraphobia
Fear of being in certain situations or physical spaces Ex: train ride
Paranoia
Belief that others desire or want to harm you (poison)
Management of this focuses on building trust and grounding the client in
reality
When the client believes food has been poisoned, the nurse can provide
unopened foods, individually packaged things
Violence
Paranoid patients that may become violent should not be put near the nurses
station, this may cause more anxiety and fear
Explain all activities clearly and calmly while facing the client
ADHD
Hyperactivity, impulsiveness, and inattention
Low self esteem and impaired social skills
Giving a written list of activities vs. explaining them is a better option for the
client
Methylphenidate is prescribed and stimulates the CNS
Domestic Abuse Victims
Priority is to remove spouse from immediate danger
Suspected clients should be assessed alone
Abuse begins or intensifies during pregnancy
Common in all socioeconomic classes
Not rare in same sex marriages
Suicide Idealation
Most important is to assess risk to determine intervention
PTSD
Difficulty concentrating
Detached
Flashbacks
Anger
Encourage client to talk about the trauma
Alcoholism
Denial
Never attack person when confronting
When dealing with problems with staff, use I, not you DABDA for death (denial,
anger, bartering,depression, acceptance)
Patient in denial about loss - support, Abuse- confront
Alcohol intoxication can cause hypoglycemia, especially in clients with
diabetes, important for nurse to assess blood glucose levels
Disulfiram - aversion therapy, therapy that promotes abstinence from alcohol,
if client consumes alcohol while taking, there are unpleasant side effects,
makes them very sick, onset and duration is 2 weeks before it starts to work, 2
weeks off drug before they can safely drink again
Teach them to avoid mouthwash,aftershaves, perfumes and colognes Insect
repellents, an over the counter that ends in the word elixir, hand sanitizers,
uncooked icings
If in emergency room, should administer thiamine IV or IV Glucose
Withdrawal symptoms: anxiety, insomnia, tremors, palpitations, diaphoresis,
hallucinations, tachycardia AWS: semi private, anywhere, no restraints
Delirium tremens: rapid onset of confusion, are dangerous, NPO, or clear
liquids, seizures, private room, near nurses station, unstable, can be fatal,
starts a few days after withdrawal , must be restrained, bedrest
Anorexia and Bulimia

Anorexia Nervosa
Clinical manifestations: fear of weight gain, fluid and electrolyte imbalances,
amenorrhea, decreased metabolic rate, lanugo, cold intolerance
Therapeutic communication
TC encourages the client and family to express feelings and thoughts, increase the
nurses understanding, and conveys support
Reflecting is a form of therapeutic communication
Then nurse provides support by expressing empathy, actively listening, and
encouraging open communications
Avoid questions that change the subject
Avoid ‘why’ questions
Avoid false assurance
Therapeutic communication will help facilitate further assessment
Chronic alcohol abuse clients
Poor nutrition
Poor thiamine can lead to Wernicke encephalopathy
Clinical manifestations of Wernicke encephalopathy:
AMS
Oculomotor dysfunction
Ataxia (tremors)
Critical these patients get Thiamine replacement
Cognitive behavior therapy
Desensitizing to specific stimulus or situation
Relaxation techniques
Self observing and monitoring
Teaching new coping skills and techniques to reframe thinking
 ENDOCRINE DISORDERS

Hypothyroidism
Low circulating T3/T4 and high TSH
Clinical features: low metabolic state features, fatigue, weakness, weight gain,
cold intolerance, bradycardia, hair loss, constipation, slow cognitively, coarse,
dry skin, hoarseness
Diabetes Insipidus
Insufficient production of ADH
ADH helps retain fluid
Polydipsia, polyuria, dilute urine (low specific gravity) Desmopressin and fluid
replacement is the preferred treatment.
SIADH
Too much ADH
complication of a head injury
Causes body to retain fluid
These patients have low urine output, high specific gravity, low serum
osmolarity, low serum sodium
Cushing Syndrome
Due to prolonged exposure to corticosteroids, most common cause is the
administration of corticosteroids such as prednisone
Clinical manifestations expected with CS: Hyperglycemia, hypertension,
truncal obesity, muscle wasting, moon face, striae in stomach area,
supraclavicular fat pads, buffalo hump, acne, muscle weakness, easy bruising
and bone loss, gynecomastia (female breasts on men), atrophy of arms and
legs, retaining sodium and water, low potassium, bruises easily, irritable,
immunosuppressed
High glucose!!!!! Hyperglycemic If you are on a steroid and diabetic, You need
more insulin because steroids increase the blood glucose
Adrenalectomy is treatment
Addison’s Disease
Adrenal glands do not produce adequate amounts of steroid hormones
Clinical Manifestations: weight loss, muscle weakness, low blood pressure,
hypocalcemia, hyperpigmentation, fluid volume deficit Hyperpigmented
They do not adapt to stress because their adrenal gland is under secreting
When they go into stress their glucose goes down, they can go into shock
Give them glucocorticoids (all steroids in sone)
Increase dose during times of stress
Diet high in calcium and protein and low in fat
Do not take on an empty stomach
Assess for cataracts, make necessary doctor appointments
Hypothyroidism
Low circulating T3/T4 and high TSH
Clinical features: low metabolic state features, fatigue, weakness, weight gain,
cold intolerance, bradycardia, hair loss, constipation, slow cognitively, coarse,
dry skin, hoarseness
Diabetes Insipidus
Insufficient production of ADHADH helps retain fluid
High serum osmolality
Polydipsia, polyuria, dilute urine (low specific gravity)
Desmopressin and fluid replacement is the preferred treatment
Dehydration due to low ADH
SIADH
Too much ADH, complication of a head injury or small lung cancer
Causes body to retain fluid
These patients have low urine output, high specific gravity, low serum
osmolarity, low serum sodium
Not thirst because they are retaining water
Gains weight suddenly
Hyperthyroidism
HYPER METABOLISM
Irritable
Heat intolerance
Cold tolerance
Exophthalmos (bulging eyes)
Graves disease is hyperthyroid
Treat with radioactive iodine (patient should be alone for 24 hours when given this, be
careful with urine, cannot touch, pregnancy test before giving)
Can also do a thyroidectomy
Do not treat all thyroid questions the same, total or sub
Total- lifelong hormone replacement, at risk for hypocalcemia (paresthesia will happen
first)
Subtotal thyroidectomy does not need lifelong hormone replacement
Subtotal are at risk for thyroid storm (thyrotoxicosis)
Thyroid storm symptoms: super high temperatures of 105 and above, hypertension,
severe tachycardia, psychotic delirium, medical emergency (treat with temperature down
and oxygen up)
Top priority is airway
Second big problem is hemorrhage
12-48 hours patient then pay attention to what type of thyroidectomy was done totals get
tetiny and subs get storm
Never pick infection in the first 72 hours
Hypothyroidism
Low metabolic rate
Obese, lethargic, cold intolerance, dull, hypotension, heat tolerance, bradycardia
Myxedema Treatment: not enough hormone, so give them thyroid hormone, synthroid
levothyroxine
Do not sedate these people because they already super slow
Myxedema coma: sedating them can cause
Do not give sleeping pill before surgery because will decrease them more
They need to get thyroid pills before surgery or they could die never hold thyroid meds
unless they told them to do it
Hyperosmolar Hyperglycemic State
Usually type 2 diabetes, older age
Altered mental status
Glucose over 600
Little to no ketones
Bicarb over 18
Osmotic diuresis
Radioactive Iodine
Treats hyperthyroidism by killing part of the thyroid
Treatment for Grave’s Disease
Requires 3 months for maximal effect Use precautions for up to1 week: stay away from
children and pregnant women, use separate bathroom, use different utensils from others
Need a negative pregnancy test
Long Term Corticosteroid Replacement
Do not discontinue abruptly (could lead to addisonian crisis)
Report signs of infection
Can cause hyperglycemia, report this to the HCP
Corticosteroids can cause osteoporosis and muscle weakness, instruct patient to have a
diet high in calcium and protein but low in fat
Cataracts are a side effect so go to yearly optometrist
Do not take on an empty stomach
Long term use of corticosteroids can mimic the the effects of cushing’s syndrome (buffalo
hump, weight gain, high blood pressure, moon shaped face, hypokalemia)
Rheumatoid Arthritis
Chronic autoimmune disorder, inflammation and damage to synovial joints, progressive
fibrosis causing pain, stiffness, and deformity
Patients should do daily ROM exercises
Apply heat to stiff joints and ice to painful joints
Plan frequent rest periods between activities
Take Methotrexate even when joints are not in pain
Take a warm shower or bath if joints are stiff, best intervention for stiff joints
Morning joint stiffness that last for more than 60 minutes
Prolonged contractions can cause contractors
Keep body aligned
OA
Degenerative disorder of the synovial joints, cushions between bones break down
Pain is exacerbated by weight bearing activity
Creptius can be heard with joint movement
Morning stiffness with subside with movement
Decreased joint mobility and range of motion
Atrophy of the muscles
Morning stiffness lasting 10-15 minutes
REPRODUCTIVE & SEXUAL HEALTH

Who is that risk for developing breast cancer

Female sex and age over 50
First degree relative (mother or sister) with history of breast cancerBRCA1 or BRCA2 gene
mutation
Personal history of endometrial or ovarian cancer
Menarche before age 12 or menopause after age 55
Modifiable Risk Factors:
Hormone therapy with estrogen or progesterone
Postmenopausal weight gain or obesity
History of smoking and alcohol consumption
Dietary fat intake
Sedentary lifestyle
STDs
Gonorrhea and chlamydia are leading causes of PID and infertility
These are referred to as silent infections
CDC recommends annual chlamydia and gonorrhea screenings for all sexual active
woman over ager 25 with risk factors
Vasectomy
Permanent male sterilization
They can still ejaculate
After procedure it can take several months for remaining sperm to ejaculate
They should use alternative methods of birth control until cleared by HCP
HPV
Most common STI
Genetial warts and cervical cancer
Often asymptomatic
Prevention: vaccine before sexual activity (age 11-12)
Transmitted vaginally, anally, orally
Clients with HPV should have annual papanicolaou test
Pap test usually initiated at age 21
Women age 21-29 should have pap test every 3 years
Copper IUD
Form of long acting, reversible contraceptive
Highly effective
Insertion causes mild discomfort, light bleeding
Heavy bleeding and increased cramping & Check for string monthly
Clients will have their period on this, Backup contraceptive is not required
Sexual Assault Victim
Emergency care
Nurse should tend to patients physical and psychosocial needs, initiate preventative and
therapeutic treatments, collect and preserve evidence
Priority nursing actions:
Determine if client has bathed, showered, or douched since the incident (evidence
compromise)
Educate on need for pelvic exam Identify birth control methods and last menstrual
cycle
Head to toe assessment
Provide prophylactic antibiotics for treatment
Cervical Cap
Do not remove the cap right away after intercourse, wait more than 6 hours for sperm to
die
Can insert it several hours before intercourse
Apply spermicide to the cap before each use
Do not use during period
Clomiphene
First line treatment for infertility by stimulating ovulation
May increase chances of twins or triplets
Frequent sexual intercourse 5 days after the medication
Testicular Self Exam
Perform during warm shower or bath
Report if there is a hard mass over the testis
Use both hands to feel each testis & perform monthly on the same day
Testicular Cancer
Most common form of cancer in patient males age 15-35
High risk for developing tumor if have a history of undescended testis
Health Promotion Strategies for Postmenopausal Women
Consult dietitian for healthy weight management
Cholesterol monitoring
Daily weight bearing exercise program
Eat green leafy vegetables and dairy products
Seek emotional support if so
Trichomoniasis
frothy , yellow, green discharge
Oral metronidazole (flagyl) is most common antibiotic
Abstain from intercourse for about 1 week after cleared
May temporarily turn urine dark
Avoid drinking alcohol for at least 3 days
 MATERNAL - ANTEPARTUM

Antepartum
The nurse should monitor blood pressure in a client that is pregnant
Normal findings is the blood pressure gradually decreases and comes back up
to normal during the third trimester
An increase of more than 15 in diastolic BP and more than 30 in systolic is a
concern before 32 weeks
Syphilis During Pregnancy
On adequate treatment is IM penicillin injection
If patient is allergic to penicillin, then they will need to be desensitized to it
Naegele's Rule
Take the first day of the last menstrual period, add 9 months, add 7 days
OR take the first day of last menstrual cycle, minus 3 months, add 7 days
Weight Gain
1 lb each month for 1st trimester
1 lb per week second and third trimester
Week of gestation and subtract by 9 is ideal weight gain
Constipation
Common discomfort of pregnancy is due to the increase hormone
progesterone, which causes decreased gastric motility Iron supplements may
also cause constipation
Can help constipation with high fiber diet, high fluid intake, regular exercise,
bulk forming fiber supplements
Do not decrease daily dairy intake, but do not take it at the same time as iron
because it decreases absorption
AVOID TEA AND SODA AND CAFFEINE this can make more
Alcohol Consumption During Pregnancy
No amount of alcohol during pregnancy is safe
The nurse should educate the client to stop drinking while trying to get
pregnant to avoid potential exposures to the embryo
Oligohydramnios
Condition with low amniotic fluid volume
Ultrasound confirms diagnosis
Anemia
Common complication of pregnancy, sometimes due to iron deficiency
Hemoglobin below 11 and 10.5 is considered low and will need iron
supplements
Or if hematocrit is below 33%
Pica
The abnormal craving for and consumption of things that may not be edible
or digestible
Pica is often accompanied by iron deficiency anemia
The HCP will order hematocrit and hemoglobin to screen for anemia
Foods to eat While Pregnant
Folic acid foods, whole grains, iron, and omega-3 fatty acids
Pregnant clients should AVOID unpasteurized milk products, unwashed fruit
and vegetables, deli meats and hot dogs and raw fish/ meat, avoid fish high in
mercury, liver
Hypertensive Disorder of Pregnancy
New onset of high blood pressure that occurs after 20 weeks gestation
>140/90
Preeclampsia
New onset of hypertension after 20 weeks gestation AND proteinuria or signs
of end stage renal disease
Patient may have headache, facial swelling, and visual disturbances
DIC
Fetal demise and patients with with placental abrupto are at high risk
Can cause bleeding
Signs of DIC: IV site bleeding, signs of internal bleeding like petechiae and
ecchymosis
Baseline laboratory test are priority to determine clotting factors
Ectopic Pregnancy
Require emergency surgical intervention
Referred shoulder pain and abdominal pain
Hypotension, dizziness, tachycardia
Fetal Heart Rate
Detected 10-12 weeks
Placenta Abruptio
Sudden onset, vaginal bleeding, abdominal pain, tender uterus, hyper
contractions
Placenta separates from the uterine wall causing hemorrhaging
Placenta Previa
Painless vaginal bleeding, ultrasound finding placenta covering cervical os
Large bore IV access in case of fluid resuscitation
No vaginal exams with active bleeding
Cesarean section is scheduled for after 36 weeks and prior to the onset of
labor
Additional ultrasounds are performed to see if the placenta has moved and
assess its location
Pelvic rest (no douching, no vaginal exams, no intercourse)
Preterm Birth Risk Factors
Preterm birth is defined by birth before 37 weeks
Biggest risk factor is previous preterm birth
Previous cervical surgery
Tobacco or drug use
Age less than 17 and over 35 is a risk factor
Black women
Periodontal disease
Infections such as UTI
Vaccines and Pregnancy
Can receive inactivated virus, no live viruses or become pregnant within 4
weeks of receiving the vaccine
Pregnant women can get: Flu vaccine, Tdap (between 27th and 36th week)
Influenza spray, Measles, mumps, varicella and rubella are NOT suggested
because they are live
Hyperemesis Gravidarum
Severe, persistent nausea and vomiting
Clinical features: weight loss, poor skin turgor, dry mucous membranes,
hypotension, tachycardia
Laboratory values: hypokalemia, hyponatremia, ketonuria, increased urine
specific gravity, hemoconcentration, metabolic alkalosis
Prenatal Teaching
HCP visits once a month until week 28
Then every 2 weeks until 37
Then every week
Week 42 c section or induction
Normal hemoglobin low11 normal for first trimester 2nd trimester it can drop
to 10.5 and be normal In the 3rd trimester it can drop to 10.5 but normal
Intrahepatic Cholestasis of Pregnancy
Liver disorder in pregnant women that results in intense itching but no rash
Involves hands and feet and worsens at night
Requires priority assessment
Indirect Coombs Test
Performed to screen for Rh sensitive Rh negative mother (o negative blood)
and an Rh positive fetus could have complications if a trauma occurs and the
blood supplies mix
Rh immune globulin is administered to all Rh negative pregnant clients at 28
weeks and within 72 hours postpartum and trauma to prevent the
development of Rh antibodies
Folic Acid
Women who are planning to become pregnant should consume 400-800 mcg
of folic acid daily
Food rich in folic acid: fortified grain products, cereals, bread, pasta and green
leafy vegetables
Measuring Fundal Height
After 20 weeks, the fundal height should be the same (in cm) with the number
of weeks pregnant
Empty the bladder before measuring fundal
Palpating The Fundus
12 weeks, right above the symphysis pubis
16 weeks, fundus is halfway between symphysis pubis and umbilicus (belly
button)
The fundus reaches the umbilicus at 20-22 weeks
Approaches the xiphoid process at 36 weeks
After 20 weeks the fundal height, measured from the symphysis pubis to the
top of the fundus, correlates the the weeks of gestation

Quickening
18-20 weeks in primigravida
14-16 weeks in multigravida
Uterine Displacement
First step to address supine hypotension
The client should be tilted laterally
This is the first thing for trauma pregnant patients who may become
hypotensive, pale
NSAIDS
Pregnancy category C in the first and second trimester and pregnancy
category D in the final trimester
NSAIDS must be avoided in final trimester
Eclampsia
Delivery is the only cure for preeclampsia and eclampsia
Hypertension, proteinuria, AND seizures after 20 weeks gestation in clients
Magnesium sulfate helps prevent/ control seizures
Therapeutic magnesium level is 4-7 mEq (2.0-3.5 mmol)
Seizure precautions should be taken
Turn client on left side during seizure
Deep tendon reflexes should be assessed
Calcium gluconate is the antidote for Magnesium toxicity
Morning Sickness
Due to rising hormone levels in the first trimester
Eat dried carbohydrates Initial intervention focuses on diet management and
trigger avoidance
Consume high protein snacks on awakening, eat several small meals during
the day (high in protein and low in fat)
Drinking fluids in between meals rather than with them (cold, carbonated)
Consuming ginger foods
Foods high in vitamin B6 (legumes, nuts, seeds)
Glucose Test for Gestational Diabetes
Test performed 24-28 weeks gestation
First is the 1 hour glucose test, no fasting required, any time of day, should be
below 140 and no further testing is needed, the patient will drink the 50 g
glucose solution then the nurse will draw blood one hour from that
Group B Staph (GBS)
May be present as normal vaginal flora in up to 30% of moms
Can be transferred to the baby during delivery
Pregnant women are tested for GBS at 35-37 weeks and receive prophylactic
antibiotics if positive
If GBS is unknown then patients antibiotics are administered
Pyrosis (Heartburn)
Common due to increase in progesterone hormone and uterine enlargement
that displaces the stomach
The client should: keep head of the bed elevated, sit upright after meals, eat
small frequent meals, eliminate fried/ fatty foods
MMR
Only give during postpartum
Avoid pregnancy 1-3 months after the vaccine is given
Cerclage
Placed to prevent preterm pregnancy
Report any signs of labor to HCP (lower back aches, contractions, pelvic pressure and
rupture of membranes)
Bed rest only required for the first few days
Stays in place 36- 37 weeks
Early removal for preterm labor or rupture of membranes
Spontaneous Abortion
“Miscarriage”
Unintentional pregnancy loss before 20 weeks gestation
Education by the nurse: avoid tampons and sex for 2 weeks, report severe pain, foul-
smelling discharge, heavy bleeding, continue prenatal vitamins, take iron, and ibprufeon
for pain
Rh immunoglobulin is indicated for Rh negative blood types
ACE Inhibitors/ ARBS
These medications should be avoided during pregnancy
WBC Count
Normal to be elevated during pregnancy, even without an infection

HELLP Syndrome
Severe form of preeclampsia
Clinical Manifestations: RUQ pain, nausea, vomiting, malaise
 LABOR/ DELIVERY

Stages of Labor

8- 10cm is the transition phase, and much anxiety for the patient
Breathing techniques are encouraged during this phase until fully dilated
3 phases in the first stage: latent, active, transition
Oxytocin
Pitocin
Can cause uterine hyperstimulation (contractions longer than 90 seconds, and closer than
every 2 minutes)
Stimulates contraction of the uterine muscle
Used to induce labor and prevent postpartum hemorrhage
High alert medication
Adverse effects: abnormal FHR (bradycardia, decelerations)
Could cause emergency caesarean birth due to abnormal FHR, postpartum hemorrhage,
water intoxication with it’s antidiuretic effect
Uerine tachysystole >5 contractions in 10 minutes Increased risk for placental abruption,
uterine rupture
Administered through a secondary IV line, not primary
Do not give with other medications that may cause contractions (Misoprostol)
Tocolytics
These medications stop labor
 Magnesium sulfate, stop labor and can cause hypermagnesemia, heart rate will decrease,
blood pressure will go down, reflexes will go down, respiratory rate will decrease, LOC will
decrease
Must monitor reflexes and respirations
Reflexes need to be +2, if the reflexes are below that slow it down, if reflexes are more
than that speed it up
Turbutoline - causes maternal tachycardia
Preterm labor
Before 34 weeks gestation the nurse should anticipate: Administer IM antenatal
glucocorticoids (-sone drugs) to mature fetal lungs
Administer antibiotics (penicillin) for GBS
Magnesium sulfate if less than 32 weeks
No artificial rupture of membrane
Umbilical Cord Prolapse
May occur after rupture of the membranes
This will cause abrupt fetal heart rate deceleration, fetal bradycardia, and disruption of
fetal oxygen supply
Priority is inspect vaginal area and perform a sterile vaginal exam
Knee to chest position or trendelenburg position
Emergency caesarean birth is usually required
Mucus Plug
Not necessarily a sign of labor
Bishop Score
Score with the likelihood of a successful induction of labor
Score of over 6-8
Pudendal Nerve Block
Best pain relief when birth is imminent (10 cm and pushing)
Amniotomy
AROM
Risk of umbilical cord prolapse
The nurse should: assess fetal heart rate before and after procedure, assessing the
characteristics of the amniotic fluid, no sharp pains, sit upright after the procedure
Shoulder Dystocia
Medical emergency when the shoulder gets stuck behind symphysis pubis
The nurse should: document times of events, verbalize passing time (5 minutes),
requesting help from staff, Mcroberts Maneuver, suprapubic pressure
Ways to Improve Fetal Perfusion and Oxygenation
Discontinue oxytocin Change position to left side
Give oxygen 8-10 L with a non rebreather mask
IV bolus of lactated ringer solution or normal saline
Epidural Block
Inhibits SNS so can cause vasodilation which can cause hypotension
If the client is experiencing lightheadedness, dizziness etc. the nurse should first assess
the client’s blood pressure
IV Opioids
Safest for clients who will give birth 2-4 hours after administration to avoid respiratory
depression in the baby
Best to give when they have well established contraction pattern
Best to give during active labor (7-8 cm with contractions)
Give pain medication during the peak of a contraction because less medication is crossed
over the barrier and less effects the fetus
True Labor vs False Labor
VEAL CHOP

Helps determine causes of fetal heart rate chances

Acceleration is high fetal heart rate
Fetal Heart Rate
Low fetal HR (under 110) stop pitocin
High fetal HR over 160, document, and take mom’s temperature, but nothing wrong
with baby
Low baseline variability - BAD -fetal heart rate just stays the same, LION, left side, IV,
oxygen, notify
High baseline variability, baby’s HR is always changing, GOOD, DOCUMENT
Early decelerations, baby’s heart slows before a contraction or at the beginning of a
contraction, NORMAL, DOCUMENT
Variable decelerations, VERY BAD, prolapsed cord, the nurse should push position
Late decelerations, bad, needs LION the worst ?
Late Decelerations
After the onset of a uterine contraction and continue beyond its end
Late decelerations occur when fetal oxygenation is compromised
The nurse should: stop oxytocin, reposition client, administer oxygen by face mask
Administer IV bolus of normal saline
Sinusoidal Fetal Heart Rate Pattern
Wavelike and no response to contractions
Suggestive of severe fetal anemia
Immediate intervention
OB MEDS
No pain medication in labor if
If baby will be born when the med peaks
Iv pain meds peak at 15-30 minutes
Surfanta (surfactant)
It is given to the neonate , given transtracheal , Given after the baby is born
 POSTPARTUM / NEWBORN
Newborn Assessment Normal Findings
Fanning of toes (Babinkis)
Creases in sole of feet
White pearl like cyst on gum margins
Avoid supplemental formula feedings unless for medical indications
Frequent vomiting could be normal
During the first 3-5 days of life, loss of 5-6% is expected finding, more than that could
indicate further evaluation
Desquamintation (peeling of the skin)
13- 14 in. head circumference
Mongolian spots (bluish dark bruise looking spots on buttocks)
The nurse should just document the findings
Babinski reflex disappears by 12 months
Moro reflex disappears by 4 months
Tonic neck disappears at 3- 4 months
Galant reflex - stroking back and baby flexes body to one side
Rooting reflex- stroking cheek and turns head
Newborn bilirubin normal under 10
Bilirubin elevated at 15
Not Normal Findings:
Decreased muscle tone, Single artery in the umbilical cord, Sacral dimple with 0.4 in skin
tag,
Meconium should happen within the first 24 hours of birth or HCP should be notified
immediately
Vomit that is green, could indicate a bowel obstruction
Sniffing position should be used for resuscitation
Grunting, chest wall retractions, nasal flaring
Jaundiced
No voiding in 24 hoursTuft of hair on sacrum
Should have no head lag by 4 months
Intussusception
Part of the intestines prolapse into another
Periodic pain and legs drawn up
Pain becomes severe and insoluble crying
Can cause occult blood and jelly like blood
Contrast enema is used for diagnostics then given air enema
Newborn Safety
Avoid bumper pads for crib
Should not share bed
Using a pacifier during sleep is appropriate after breastfeeding has been established
Can breastfeed with Hep B
Newborn Circumcision
Wash hands, Apply petroleum jelly
Yellow exudate is a normal part of the healing process
Clean with warm water (no soap)
Breast Engorgement
Clients who choose not to breastfeed: apply ice packs to breasts for 15-20 minutes for 3-4
hours to reduce blood flow and swelling
Apply chilled fresh cabbage
Take anti inflammatory (ibuprofen) to reduce pain
Wear a supportive bra or breast binder until milk flow is diminished
NO HEAT unless you want more milk production
NO MASSAGES unless you want more milk production
Mastasis
Inflammation and infection of the breast tissue
Fever, breast aches, muscle aches, and inflammation
Antibiotic treatment
The client should continue to breastfeed
Apply warm compress and cool compress between feedings for comfort
Wash handsIbuprofen and acetaminophen for pain
No tight bras Increase fluids
Breastfeeding
Additional 500 calories a day for breastfeeding mothers but same amount of protein,
calcium, and fluids are needed
Postpartum hemorrhaging
>500 mL after vaginal birth
>1000 mL after a c-section
Boggy uterus (uterine atony) is the most common cause for PPH
Risk factors for PPH: multiple gestations, macrosomic infant etc.
Can be due to large infant size, placenta accreta, uterine atony, lacerations
Order of Assessment for Infants
The steps are altered to accommodate the developmental needs of infants, minimize
stress, and increase assessment accuracy
Observe, auscultation, palpation, percussion, eyes, ears, not exam, moro reflex
Newborn Drug
When born assume intoxicated, then after 24 hours withdrawal
PKU
Lack enzyme that can cause irreversible neurological damage
Low phenylalanine diet is essential
Eliminate meats, eggs, and milk, beans, bread from the diet
Encourage fruits and vegetables
Special infant formula
Stay away from artificial sweeteners
Limiting fiber is not important
Ventricular Septal Defect
Ventricle opening causes left to right shunting of blood leading to excess blood flow to the
lungs
This places client at risk for CHF and pulmonary hypertension
If client is showing signs of grunting, tachycardia, dyspnea, diaphoresis BAD
Poor weight gain
Heart murmur
Diaphoresis during feedings
Atrial Septal Defect
Expect to hear a murmur with a fixed split second heart sound
Tetralogy of Fallot
Cyanotic congenital heart defect manifested by signs of irritability and clubbing of the
fingers due to decreased oxygen saturation chronically remaining between 65%-85%
Hypercyanotic episodes occurs when unoxygenated blood enters the system and causes
hypoxemia and cyanosis
Can place in a knees to chest position to improve pulmonary flow
Can swaddle infant, can provide quiet environment, can use pacifier, all these help with
these “TET” spells
Other signs of heart failure: puffiness around eyes, cool extremities, reduced number of
wet diapers, little to no and poor feeding
Ventricular defect, pulmonary stenosis, overriding aorta, right hypertrophy
Patent Ductus Arteriosus
Common in premature infants
The aorta is connected to the pulmonary artery
Many newborns are asymptomatic, a loud machine like systolic and diastolic murmur are
heard
Pulses
Infants under 1 year old should have their brachial artery used for assessment ( between
shoulder and elbow, inside)
Assess for 5-10 seconds
 PEDIATRIC PATIENTS

Toilet Training
Toddler Bladder training is usually achieved at age 2 ½ to 3 ½ 1
8-24 months is a good time to start
Readiness depends on developmental milestones
Bacterial Meningitis in Infants
Fever or possible hypothermia
Muscle rigidity
Irritability
Frequent seizures
Poor feeding and vomiting
High pitched cry
Bulging fontanelle
Acute hydrocephalus
Droplet precautions
Nurse should administer antibiotics as quickly as possible Important to assess
fontanelles and increased head circumference
Autism Spectrum Disorder
Sensitive to light, taste, smells, touch etc
A calming environment with limited stimulation should be provided (private
room away from the nurses station)
Nurse should not touch or try to soothe client by touching
Poison in Children
If the client is stable then the nurse can have them call poison control center
Priority would be further assessment
Lead Poisoning
Neurological impairment in children Levels higher than > 5 are dangerous in
children
Can also threaten the kidneys
Use cold water in homes for cooking and run water to get lead out
Wash hands
Home inspection
Clinical manifestations: anemia, seizures, learning disabilities
Growth & Development Overview
Reye Syndrome
Often children who have this have had a recent viral infection
Increased if aspirin therapy is used
Monitor for: (E) vomiting, lethargy, hyperventilation (L) loc and convulsions
Children recovering from flu like symptoms or chickenpox should never take
aspirin
Croup
Cough is a barking or seal like sound
Nursing action: focus on respiratory status, trach set at bedside, rest
Cool vapor is effective
Trismus
Inability to open mouth due to contraction of muscle
May indicate tonsillitis
Measles
Airborne precaution
N95 mask
Negative pressure room
Administer vitamin A
No calamine lotion
Also called rubeola
Early signs are runny nose, sneezing, and coughing
Wilms Tumor
Tumor below the kidneys in children under age 5
The abdomen should not be palpated
Acute Glomerulonephritis
Induced by strep throat
Clinical manifestations include: periorbital edema, hypertension, oliguria, tea
colored urine due to protein and blood
Priority to check blood pressure
Daily weight most accurate for daily loss or gain of fluid
Strep Throat
After 24 hours of antibiotic therapy, not contagious
Nephrotic Syndrome
Glomerular injury Proteinuria, hypoalbumin, hyperlipidemia, edema (4 signs)
 Additional symptoms include: fatigue, weight gain, pallor, decreased urine
output
Epiglottitis
Medical emergency due to haemophilus influenzae
Sitting in tripod position is a classic manifestation
Child will also drool, be restless and anxious
Do not complete throat inspection until emergency intubation is available
Keep the child calm until emergency airway equipment is available
Otitis Media
Typically occurs in infants and children under age 2
Sometimes following a respiratory infection
Tobaccos smoke exposure puts infants at risk, also using a pacifier, drinking
bottle while laying down
Infant should obtain routine vaccinations and reducing or limiting use of
pacifier by 6 months
Honey
No honey for infants less than 12 months
Risk of botulism
Iron Deficiency Anemia
Most common chronic nutritional disorder in children
One common cause is excessive milk intake
Other risk factors include: delayed introduction to solid foods, premature birth
Treatment includes oral iron supplements and increased consumption of iron
rich foods ( leafy green vegetables, meats, dried fruits, poultry, fortified
cereals)
Vitamin E is given in premature infants to prevent hemolytic anemia
Kawasaki Disease
Inflammation of arterial walls, children can develop coronary aneurysms
Not contagiousInitial treatment: IV gamma globulin and aspirin
Monitor for signs of heart failure
Monitor for gallop rhythms and decreased urine output
Monitor for fever, and report to HCP
Irritability is a hallmark sign of KD, especially in the acute phase
Bronchiolitis
Is a common viral illness of childhood that is usually caused by RSV
It typically begins with viral upper respiratory symptoms (eg, rhinorrhea,
congestion) that progress to lower respiratory tract symptoms such as
tachypnea, cough, and wheezing
Bronchiolitis is a self-limited illness and supportive care is the mainstay of
treatment
Most children can be managed in the home environment
Breastfeeding should be continued and additional fluids offered if there is a
risk of dehydration due to frequent coughing and vomiting
Parents should be instructed to use saline nose drops and then suction the
nares with a bulb syringe to remove secretions prior to feedings and at
bedtime
Medications such as cough suppressants, antihistamines, bronchodilators (eg,
albuterol), and corticosteroids have not been found to be effective and are not
recommended
Prophylactic treatment of family members is recommended for pertussis
infection but not for RSV bronchiolitis
Shaken Baby Syndrome
Abusive head trauma in infants from shaking
Shaking causes bleeding within the brain and eyes
Signs: vomiting, irritability, lethargy, crying, inability to suck to eat, and
seizures
Usually no bruises of trauma, possible small ones on arms or legs where they
have been shaken
Cleft Palate Repair
Hold baby to sooth crying
Do not place anything in mouth like tongue blade or pacifier
Restraints can be used so baby don't mess with surgical site
Sit upright after meals
Chest Compressions for Infants
Check brachial pulse for no longer than 10 seconds
Use 2 fingers or 2 thumbs for chest compressions on the sternum just below
the nipple line
30:2, 100 per minute