Nclex boot camp

Goal
To pass the NCLEX in 75 questions

Supplies
1. Qbank from a NCLEX prep of Instructions
choice 1. Pick 4 topics per day.
2. Video access: Youtube 2. Watch videos on each topic
3. Nclex prep of choice 3. Listen to audio on said topics
4. Notebook with dividers to and take notes.
write down rationales. 4. Take 150-200 questions over
5. Nclex planner avail with this these topics each day.
packet. 5. Remediate the questions you
get wrong by writing the
rationale and going back to the
videos and lecture for
clarification.

Anxiety Relief
❖ Positive daily affirmations.
❖ Mindfulness
❖ Stretching
❖ Think of it as just another General strategies
cumulative final. ❖ Take it slow
❖ Remember you have 90% ❖ Read the question and try to answer
chance at passing just it before you look at the given
because you graduated. answers.
❖ People pass everyday and ❖ Never leave the patient alone.
so will YOU! ❖ Safety first
❖ Avoid traps such as; always, never,
every.
❖ Call the HCP only when there are no
nursing interventions available.
❖ Never pass the buck
❖ Think of SATA as concept questions
and not lists. For example the
concept of Hypoxia what does a
hypoxic patient look like?
Restlessness, agitation and
confusion.
 Test Taking strategies

In NCLEX world
In NCLEX world, you are one nurse with only one patient. All the orders you need are written. The only time the nurse would need to call the doctor is
after intervention has failed and there is nothing else the nurse can do. If you call the physician about concerns, never call about something that is
expected with the disease process, which is why it is essential for nursing students to know expected signs and symptoms of the disease versus
signs and symptoms of potential complications.

TIPS
decision tree
❖ Focus on critical thinking &
memorization.
1. Identify the topic ❖ Don't cram for the exam.
2. Assessment before implementation ❖ Study the exam itself.
3. Apply maslow ❖ Take plenty of practice tests. .
4. Apply ABC rules ❖ Come prepared.
5. Evaluate, is this going to give me a positive outcome ❖ Try to visualize each situation.
STEP 1: Read each question carefully from the first word to the last word. Do not skim over ❖ Eliminate the false answers first.
❖ Keep your cool.
the words or read them too quickly.
STEP 2: Look for hints in the wording of the question stem. The adjectives most, first, best,
primary, and initial indicate that you must establish priorities. The phrase further teaching is
necessary indicates that the answer will contain incorrect information. The phrase client
understands the teaching indicates that the answer will be correct information.
STEP 3: Step 3. Reword the question stem in your own words so that it can be answered
with a yes or a no, or with a specific bit of information. Begin your questions with what, when,
or why. We will refer to this reworded version as the Reworded Question in the examples that
follow.
STEP 4: If you can’t complete step 3, read the answer choices for clues.

Simple
Use prioritization techniques
nursing
❖ Www Look at disease process, acute will beat chronic
❖ DAR Fresh post op ( under 12 hours)
❖ What is the New admit ( under 24 hours)
question really Use of the phrase "newly or just admitted" or "newly diagnosed"
asking Always a priority
❖ Hypoglycemia
❖ HEMORRHAGE
❖ High fever over 105 F
❖ Pulseless or breathless
The more vital the organ, the higher the priority
❖ - Most vital is the brain
❖ - Next is the lungs
❖ - Heart
❖ - Liver
❖ - Kidneys
❖ - Pancreas
Remember Abc isn’t always the answer!

SATA strategies
For questions regarding symptoms or presentation of
a disorder, think concept based, how is the body
going to present with this specific conditions

Food choices remember your diets, baked fish or

chicken are great scapegoats! Toddlers and manica
should have finger foods. In kidney disorders diets
should be low in protein except for nephritis.
❏
Day 1
MED SURG:Skin
The plan Day 3
❏ MED SURG: GI
❏ Fundies: ventilation ❏ Fundies: Positioning/
❏ OB: Pregnancy Med admin
❏ Pharm: Antibiotics Day 2 ❏ OB: NEWBORN
❏ MED SURG: Endocrine ❏ Pharm: GI meds
❏ Fundies: Fluids & Electrolytes
❏ OB: LABOR
❏ Pharm: Endocrine meds

Day 4 Day 5 Day 6

❏ MED SURG: Respiratory ❏ MED SURG: Cardiac ❏ MED SURG: Renal
❏ Fundies: ❏ Fundies: Hemodynamics ❏ Fundies: Elimination
❏ OB: respiratory issues of ❏ OB: Complications ❏ OB: Repeat wk 1
the newborn ❏ Pharm: cardiac meds ❏ Pharm: urinary meds
❏ Pharm: respiratory meds

Day 8 Day 9
Day 7 ❏ MED SURG:
❏ MED SURG: Eyes & ears ❏ MED SURG: Neuro
Musculoskeletal
❏ Fundies: Assessment of ears ❏ Fundies: Neuro
❏ Fundies: Traction
and eyes assessment
❏ OB: Pharm
❏ OB: Labor & Delivery ❏ OB: Neuro of the newborn
❏ Pharm: Musculoskeletal
❏ Pharma: Ophthalmic meds ❏ Pharma: CNS drugs and
neuro interventions

Day 10 Day 11 Day 12

❏ MED SURG: Immune ❏ MED SURG: Comprehensive ❏ MED SURG:
❏ Fundies: Blood tests/ ❏ Fundies: Pain management Comprehensive
disease transmission ❏ Psych : Mood disorders ❏ Fundies: Blood
❏ Psych : Grief ❏ Pharm: Antidepressants transfusion reactions
❏ Peds : Development ❏ Fundies: Ethics/ management ❏ Peds : skin/ immune
❏ Pharm: Anticoagulants ❏ Psych : Age associated disorders
disorders ❏ Psych : Stress disorders
❏ Pharm: comprehensive

Day 13 Day 14
❏ MED SURG: Comprehensive ❏ MED SURG: Comprehensive
❏ Fundies: PPE ❏ Fundies: Oxygen
❏ Psych : Personality disorders ❏ Psych : developmental disorders
❏ Pharm: Comprehensive ❏ Pharm: Comprehensive
 FUNDAMENTALS IMPORTANT FACTS

Diet and Nutrition

❖ Most of the absorption of water occurs in the large intestine.
❖ Most nutrients are absorbed in the small intestine.
PATIENT CENTERED CARE ❖ When assessing a patient’s eating habits, the nurse should ask, “What have you eaten
❖ The client is for EEG this morning. Prepare him for the in the last 24 hours?”
procedure by rendering hair shampoo, excluding caffeine ❖ A vegan diet should include an abundant supply of fiber.
from his meal and instructing the client to remain still during ❖ A hypotonic enema softens the feces, distends the colon, and stimulates peristalsis.
the procedure. ❖ First-morning urine provides the best sample to measure glucose, ketone, pH, and
❖ Primary prevention is true prevention. Examples are specific gravity values.
immunizations, weight control, and smoking cessation. ❖ 59. To induce sleep, the first step is to minimize environmental stimuli.
❖ 47. Secondary prevention is early detection. Examples ❖ Before moving a patient, the nurse should assess the patient’s physical abilities and
include purified protein derivative (PPD), breast self- ability to understand instructions as well as the amount of strength required to move the
examination, testicular self-examination, and chest X-ray. patient.
❖ Tertiary prevention is treatment to prevent long-term ❖ To lose 1 lb (0.5 kg) in 1 week, the patient must decrease his weekly intake by 3,500
complications. calories (approximately 500 calories daily). To lose 2 lb (1 kg) in 1 week, the patient
❖ On noticing religious artifacts and literature on a patient’s must decrease his weekly caloric intake by 7,000 calories (approximately 1,000 calories
night stand, a culturally aware nurse would ask the patient daily).
the meaning of the items. ❖ To avoid shearing force injury, a patient who is completely immobile is lifted on a sheet.
❖ 50. A Mexican patient may request the intervention of a ❖ 63. To insert a catheter from the nose through the trachea for suction, the nurse should
curandero, or faith healer, who involves the family in ask the patient to swallow.
healing the patient. ❖ Vitamin C is needed for collagen production.
❖ In an infant, the normal hemoglobin value is 12 g/dl. ❖ Bananas, citrus fruits, and potatoes are good sources of potassium.
❖ 52. A patient indicates that he’s coming to terms with ❖ Good sources of magnesium include fish, nuts, and grains.
having a chronic disease when he says something like: “I’m ❖ Beef, oysters, shrimp, scallops, spinach, beets, and greens are good sources of iron.
never going to get any better,” or when he exhibits ❖ The nitrogen balance estimates the difference between the intake and use of protein.
hopelessness. ❖ A Hindu patient is likely to request a vegetarian diet.
❖ No pork or pork products are allowed in a Muslim diet.
❖ In accordance with the “hot-cold” system used by some Mexicans, Puerto Ricans, and
Pain Management other Hispanic and Latino groups, most foods, beverages, herbs, and drugs are
described as “cold.”
❖ Only the patient can describe his pain accurately.
❖ Milk is high in sodium and low in iron.
❖ Cutaneous stimulation creates the release of endorphins that
❖ Discrimination is preferential treatment of individuals of a particular group. It’s usually
block the transmission of pain stimuli.
discussed in a negative sense.
❖ Patient-controlled analgesia (PCA) is a safe method to relieve
❖ Increased gastric motility interferes with the absorption of oral drugs.
acute pain caused by surgical incision, traumatic injury, labor
❖ When feeding an elderly patient, the nurse should limit high-carbohydrate foods
and delivery, or cancer.
because of the risk of glucose intolerance.
❖ An Asian-American or European-American typically places
❖ When feeding an elderly patient, essential foods should be given first.
distance between himself and others when communicating.
❖ For the patient who abides by Jewish custom, milk and meat shouldn’t be served at the
❖ Active euthanasia is actively helping a person to die.
same meal.
❖ Brain death is irreversible cessation of all brain function.
❖ Passive euthanasia is stopping the therapy that’s sustaining life.
❖ Voluntary euthanasia is actively helping a patient to die at the
patient’s request.
❖ A back rub is an example of the gate-control theory of pain.
❖ Pain threshold, of pain sensation, is the initial point at which a
patient feels pain.
❖ . The difference between acute pain and chronic pain is its
duration.
❖ Referred pain is pain that’s felt at a site other than its origin. ❖ Passive range of motion maintains joint mobility. Resistive
❖ Alleviating pain by performing a back massage is consistent exercises increase muscle mass.
with the gate control theory. ❖ Isometric exercises are performed on an extremity that’s in a cast.
❖ Pain seems more intense at night because the patient isn’t ❖ Anything that’s located below the waist is considered unsterile; a
distracted by daily activities. sterile field becomes unsterile when it comes in contact with any
❖ Older patients commonly don’t report pain because of fear of unsterile item; a sterile field must be monitored continuously; and a
treatment, lifestyle changes, or dependency. border of 1″ (2.5 cm) around a sterile field is considered unsterile.
❖ A “shift to the left” is evident when the number of immature cells
(bands) in the blood increases to fight an infection.
❖ A “shift to the right” is evident when the number of mature cells in
the blood increases, as seen in advanced liver disease and
pernicious anemia.
❖ Before administering preoperative medication, the nurse should
ensure that an informed consent form has been signed and
attached to the patient’s record.
❖ A nurse should spend no more than 30 minutes per 8-hour shift
providing care to a patient who has a radiation implant.
❖ A nurse shouldn’t be assigned to care for more than one patient
❖ Schedule I drugs, such as heroin, have a high abuse who has a radiation implant.
potential and have no currently accepted medical use ❖ Long-handled forceps and a lead-lined container should be
in the United States. available in the room of a patient who has a radiation implant.
❖ Schedule II drugs, such as morphine, opium, and ❖ 145. Usually, patients who have the same infection and are in strict
meperidine (Demerol), have a high abuse potential, isolation can share a room.
but currently have accepted medical uses. Their use ❖ 146. Diseases that require strict isolation include chickenpox,
may lead to physical or psychological dependence. diphtheria, and viral hemorrhagic fevers such as Marburg disease.
❖ Schedule III drugs, such as paregoric and According to Erik Erikson, developmental stages are:
butabarbital (Butisol), have a lower abuse potential ❖ Trust versus mistrust (birth to 18 months)
than Schedule I or II drugs. Abuse of Schedule III ❖ Autonomy versus shame and doubt (18 months to age 3)
drugs may lead to moderate or low physical or ❖ Initiative versus guilt (ages 3 to 5)
psychological dependence, or both. ❖ Industry versus inferiority (ages 5 to 12)
❖ Schedule IV drugs, such as chloral hydrate, have a ❖ Identity versus identity diffusion (ages 12 to 18)
low abuse potential compared with Schedule III drugs. ❖ Intimacy versus isolation (ages 18 to 25)
❖ Schedule V drugs, such as cough syrups that contain ❖ Generativity versus stagnation (ages 25 to 60), and
codeine, have the lowest abuse potential of the ❖ Ego integrity versus despair (older than age 60).
controlled substances. ❖ An appropriate nursing intervention for the spouse of a patient who
❖ During lumbar puncture, the nurse must note the initial has a serious incapacitating disease is to help him to mobilize a
intracranial pressure and the color of the cerebrospinal support system.
fluid. ❖ The most effective way to reduce a fever is to administer an
❖ Cold packs are applied for the first 20 to 48 hours after an antipyretic, which lowers the temperature set point.
injury; then heat is applied. During cold application, the ❖ The Controlled Substances Act designated five categories, or
pack is applied for 20 minutes and then removed for 10 to schedules, that classify controlled drugs according to their abuse
15 minutes to prevent reflex dilation (rebound phenomenon) potential.
and frostbite injury.
 PPE & Infection control
4 Points for NCLEX-RN Safety and Infection Control
❖ #1 Standard Precautions.
❖ #2 Contact Precautions.
❖ #3 Droplet Precautions.
❖ #4 Airborne Precautions.
PPE for Standard
Precautions
Droplet Precautions:– Surgical masks within 3 feet of patient
❖ Gloves – Use when touching blood, body
fluids, secretions, excretions, contaminated
S: SEPSIS, scarlet fever, strep items; for touching mucous membranes and
P: Pertussis, parvovirus, pneumonia non intact skin
I: Influenza ❖ Gowns – Use during procedures and patient
D: Diphtheria care activities when contact of clothing/
E: Epiglottitis exposed skin with blood/body fluids,
R: Rubella secretions, or excretions is anticipated
M: Mumps, meningitis, mycoplasma, meningeal pneumonia
AN: Adenovirus

❖ Pharyngeal Diphtheria
❖ Epiglottitis, (caused by Haemophilus influenzae type b)
❖ Flu (contact and droplet)
❖ Meningococcal Disease: Sepsis, Pneumonia, meningitis
❖ Mumps (infectious parotitis)
❖ Pneumonia
❖ Mycoplasma Pneumonia
❖ Parvovirus B19 (erythema infectiosum or 5th disease)
❖ Pneumonic Plague
❖ Adenovirus (contact and droplet)
❖ Streptococcal pharyngitis
❖ Whooping Cough (pertussis)
❖ Rhinovirus
❖ Scarlet fever
❖ Rubella (German Measles)

Airborne Precautions: Particulate respirator

M: Measles
T: TB
V: Varicella
❖ Chickenpox (varicella) (Airborne and Contact)
❖ Herpes Zoster (Varicella Zoster(disseminated) Shingles (Airborne and Contact)
❖ Measles (Rubeola)
❖ M. Tuberculosi

Contact Precautions: Gown and gloves for contact with patient or environment of care (e.g.,
medical equipment, environmental surfaces) • In some instances these are required for entering patient’s
environment

M: Multidrug resistant organism

R: Respiratory infection
S: Skin infections
W: wounds
E: Enteric c-diff
E: Eye infection

❖ Medication-Resistant Organisms: MRSA, VRE, extended spectrum beta lactamase

producers (ESBLs), Klebsiella pneumoniae carbapenemase (KPC)
❖ Diarrhea infections or of unknown origin: C.diff, norovirus, rotavirus…..USE SOAP AND
WATER FOR HAND WASHING NOT hand-sanitizer.
➢ NOTE: Hepatitis A. (if patient is diapered or incontinent pt)..remember
it is spread through stool
❖ Skin infection: impetigo, lice, scabies, herpes simplex, chickenpox (airborne and
contact), skin diphtheria, shingles (airborne and contact)
❖ Wound infections with excessive drainage or staphylococci
❖ Pulmonary infections: RSV, parainfluenza
❖ Eye infection: conjunctivitis
 Electrolytes Cheat Sheet
HYPO HYPER
Causes S&S Causes S&S
(135- A - Adrenal ❖ Tachycardia D - Fluid deprivation ❖ Normo/↓ HR
insufficiency ❖ Normal/↓/↑ BP I - IV hypertonic solution ❖ Normal/↓/↑ BP
145) I - H20 intoxication
D - Diuretics
❖
❖
Headache
Personality
excess
V - Vitamins “Sodium”
❖
❖
Irregular HR
↑BS
S - SIADH change supplement Thirst
Na
❖
❖ Weakness A - Amount of Na intake ❖ Restlessness
❖ Hyperactive BS excess ❖ Dyspnea
❖ Salt ❖ Seizures ❖ Muscle weakness
❖ Soy sauce
❖ Pork Interventions Interventions
❖ Cott/amer
❖ Cheese D - Diet, cheese, milk, soy sauce, salt, bacon, M - Monitor sodium intake/ Labs
❖ Spinach beef broth A - Alka-Seltzer, aspirin , and cough preps shouldn’t be
❖ Pickles R - Restrict fluids and NPO administered
G - gravity of urine monitoring
W - Weights daily I - I&O
A - Administer Iv hypertonic solutions C - Cardiac monitoring
I-I&O
T -Thiazide diuretics
G - GI loss ❖ Tachydysrhythm M- medications Ace, ❖ Bradydysrhythmi
(3.5- (Vomiting)
O – Osmotic ❖
ias
Ortho
spironolactone, NSAIDS
A- Acidosis: metabolic and ❖
as
Tall “T” waves on

5.0)
Diuresis hypotension respiratory ❖ EKG
T – Thiazides and ❖ Lethargy/fatigue C- Cell destruction (burn, ❖ Cardiac arrest
Loop diuretics ❖ ↓ BS, trauma, Injury) ❖ ↑BS Diarrhea

K
constipation H- Hypoaldosteronism ❖ Paresthesias
S – Severe Acid ❖ Anorexia I- intake excess K
Imbalance ❖ Muscle N- nephrons/ renal failure
❖ Avocados H- weakness E- excretion : impaired
❖ Raisins Hyperaldosteronism ❖ “U” waves on
❖ Cantaloupe O - Other meds EKG
❖ Bananas such as
❖ Skim milk Corticosteroids
❖ Spinach T- Transcellular
Shift
Interventions Interventions
A- Assess EKG and ABG M - Monitor EKG
I - IV Potassium Chloride D - Diet, limit green leafy veggies and avocado
D - Diet: green leafy veggies K - Kayexalate administration
***NEVER PUSH POTASSIUM IV*** I - IV sodium Bicarb, Calcium Gluconate
D - Dialysis
❖ Hypotension ❖ Dysrhythmias
(9-11) A - Antibiotics
C - Corticosteroids
❖
❖
Bradycardia
Tetany muscle
H - Hyperparathyroidism
A - Antacids
❖
❖
Pallor
HTN

Ca
I - Insulin spasm M - Malignancies cancer ❖ ↓ LOC
D - Diuretics ❖ Laryngospasm/s cells release excess ca+ Disorientation
tridor ❖ ↓ DTR
❖ Yogurt ❖ ↑ DTR, ↑ BS ❖ ↓ BS,
❖ Cheese/mil diarrhea constipation
❖ Sardines ❖ + Trousseau
❖ Rhubarb sign
❖ + Chvostek sign
Interventions Interventions
D - Diuretics F - sodium containing fluids
I- I&O I - IV phosphate
C - Calcium channel blockers /Calcium L - Lasix
Gluconate M - Monitor Labs and I&O
❖ HYPO: seizures, tetany, ❖ HYPO: muscle pain & weakness, bone
(1.3- anorexia, tachycardia,
HTN, mood changes
(2.5- ❖
pain, confusion
HYPER: circumoral & peripheral

2.1)
❖ HYPER: ↓ DTR, N/V, parenthesis, muscle spasms, tetany

4.5)
bradycardia, hypotension, ❖ FOODS: tuna, beef liver, pork, milk and
coma yogurt.

Mg
❖ FOODS: spinach,

Ph
avocado, tuna, oatmeal
and milk
 Stroke Super Sheet
Priorities in acute phase
Types of stroke Causes 1. Maintain airway & administer 02, monitor vitals
❖ Thrombosis
2. Assess the time the symptoms started
❖ Embolism
3. Focused neuro assessments
❖ TIA: May be a sign of impending ❖ Ruptured aneurysm
4. Maintain a BP of 150/100 to maintain brain
stroke. Symptoms occur
perfusion.
suddenly but do not last long.
5. Suction as needed but no longer than 10
❖ CVA: Prolonged ischemia to the
cerebral vasculature with cerebral Risks factors 6.
seconds
Monitor for ICP
anoxia lasting longer than 10 ❖ Atherosclerosis
7. Give IV fluids, prepare to administer tPa if
mins that causes long term ❖ Hypertension
indicated ( symptom onset of less than 3 hours)
irreversible damage ❖ Anticoagulation therapy : hemorrhagic
8. May be prepared for endarterectomy
❖ Hemorrhagic : Rupture of an ❖ Diabetes
existing aneurysm causing ❖ Stress
profound bleeding the cerebral ❖ Obesity
cavity. ❖ Oral contraceptives

Left side stroke

Right side
❖
stroke
Loss of control on the left side of
❖
❖
Loss of control on the right side of the body.
performs tasks that have to do with logic,
the body. such as in science and mathematics.
❖ performs tasks that have do with ❖ Impaired speech and language “ aphasia”
creativity and the arts. ❖ Slow, inhibited.
❖ Left side neglect ❖ Aware of deficits, depression, anxiety.
❖ Spatial-perceptual deficits ❖ Impaired ability to comprehend language
❖ Denies and minimizes problems and math.
❖ Rapid performance and short
attention span. May be impulsive.
❖ Unable to discern safety issues
❖ Impaired judgement
❖ Impaired concept of time

General Important to know

❖ Agnosia: inability to recognize familiar
assessment ❖
objects or persons
Apraxia: loss of ability to execute or
Long term care ❖
❖
Pulse: slow and bounding
Cheyne stokes respirations ❖
carry out skilled movements voluntarily
Hemianopia: blindness in one half of the
❖ Position every two hours ❖ Hypertension visual field
❖ Frequent range of motion to ❖ Headache, nausea & vomiting ❖ Homonymous hemianopsia: loss of
avoid contractures ❖ Facial drooping visual field on the same side in both
❖ Place antiembolism stockings ❖ Nuchal rigidity eyes
if ordered ❖ Visual changes ❖ Neglect syndrome: unaware of the
❖ Frequent skin and mouth care ❖ Ataxia affected side
❖ Monitor gag reflex ❖ Dysarthria ❖ Proprioception: altered position sense
❖ Provide soft diet ❖ Dysphagia that places the pt at increased risk of
❖ Impaired speech injury
❖ Bowel and bladder dysfunction
❖ Paralysis

Medical management
Patient goals
The major goals for the patient and family may include: ❖ Recombinant tissue plasminogen activator would
● Improve mobility. be prescribed unless contraindicated, and there
● Avoidance of shoulder pain. should be monitoring for bleeding.
● Achievement of self-care. ❖ Increased ICP. Management of increased ICP
● Relief of sensory and perceptual deprivation. includes osmotic diuretics, maintenance of PaCO2
● Prevention of aspiration. at 30-35 mmHg, and positioning to avoid hypoxia
● Continence of bowel and bladder. through elevation of the head of the bed.
● Improved thought processes. ❖ Endotracheal Tube. There is a possibility of
● Achieving a form of communication. intubation to establish patent airway if necessary.
● Maintaining skin integrity. ❖ Hemodynamic monitoring. Continuous
● Restore family functioning. hemodynamic monitoring should be implemented
● Improve sexual function. to avoid an increase in blood pressure.
● Absence of complications ❖ Neurologic assessment to determine if the stroke
is evolving and if other acute complications are
developing
 NCLEX SHOCK SHEETS
Shock is a state that is the result of inadequate tissue perfusion which creates an imbalance between the delivery
of 02 and the requirements of 02. Remember, most types of shock (hypoperfusion) are caused by dysfunction in one or more
parts of the perfusion triangle: 1. The pump (the heart) 2. The pipes, or container (blood vessels) 3. The content, or volume (blood)

Types
❖ Hypovolemic shock: decreased
Causes
Hypovolemic shock:
blood volume. A type of
❖ Bleeding from cuts
hypovolemic shock is hemorrhagic
❖ Bleeding from other injuries
shock, which results from blood
❖ Internal bleeding, such as in the
loss.
gastrointestinal tract
❖ Neurogenic shock: nervous system
❖ Burns
injury leading to vasodilation in
❖ Diarrhea
the periphery causing inadequate
❖ Excessive perspiration
perfusion to the vital organs.
❖ Vomiting
❖ Anaphylactic shock: severe
allergic reaction that leads to
Septic shock: Caused by overwhelming infection
vasodilation and
leading to vasodilation. It is treated in hospital by
bronchoconstriction.
antibiotics, fluid replacement, and vasoconstrictors.
❖ Cardiogenic shock: inadequate Anaphylactic shock: Caused by allergens that
pumping of the heart. Can be due trigger widespread vasodilation and movement of
to heart disease or heart attack. fluid out of the blood into the tissues.
Neurogenic shock : Caused by the sudden loss of
Assessment the sympathetic nervous system signals to the
Hypovolemic shock smooth muscle in vessel walls.
❖ Tachypnea
❖ Tachycardia
❖ Hypotension
❖ Confusion
❖ Loc changes Treatments for all types and stages
cardiogenic shock Hypovolemic
❖ pain of angina
❖ develop dysrhythmias ❖ Support of the respiratory system with supplemental
❖ complain of fatigue oxygen and/or mechanical ventilation to provide optimal
❖ express feelings of doom
oxygenation (see Chapter 21)
❖ hemodynamic instability.
❖ Fluid replacement to restore intravascular volume: 3;1
ratio with 0.9% NS or LR, if a colloid is prescribed is
Monitor usually albumin
Hypovolemic ❖ Vasoactive medications to restore vasomotor tone and
❖ O2 sat
❖ Lung sounds for overload improve cardiac function: Alpha adrenergic and beta
❖ Cvp blockers
❖ Urine output : voiding is the best indicator
❖ Nutritional support to address the metabolic requirements
that shock is reversed.
❖ Monitor vitals q 15 until stable when that are often dramatically increased in shock
giving vasoactive medications
❖ Initiate parenteral nutritional support Cardiogenic shock
❖ Modified trendelenburg ❖ First line treatment is oxygenation 2-6 l/min to maintain
❖ Blood transfusion o2 of 90%
❖ Lacate ❖ Fluid replacement
❖ H&H ❖ Iv morphine for chest pain to decrease preload
Cardiogenic ❖ A fluid bolus should never be given rapidly,
❖ Monitor vitals because rapid fluid administration in patients
❖ Monitor 02 and prevent ischemia with cardiac failure may result in acute
❖ Monitor ekg pulmonary edema.
❖ Dobutamine
❖ Nitroglycerin
❖ Dopamine.
❖ norepinephrine, epinephrine, milrinone,
vasopressin, and phenylephrine
❖ Antiarrhythmic Medications
❖ Mechanical ventilation
 NCLEX FLUIDS QUICK SHEET
Hypertonic Solutions Hypotonic Solutions
These are volume expanders. Think how big a party These are tricky, at first they go the vascular space then
can get when you add extras into your home “ shift to pull fluid into the cells. These rehydrate when you
space” These extra folks act like the large particles are diuresing.
in hypertonic solutions. The pull the fun from the
party to the body ( vasculature) They rehydrate but do not cause hypertension.

Hypertonic solutions pull fluid from the 3rd space Example:

into the vascular space. D.25W
½ NS Monitor
Example : 0.33% NS Watch for cellular edema
D10W because of all of the fluid
Monitor
3% NS USES shifting into the cell they could
❖ FLUID
5% NS Renal failure fill up and lyse
VOLUME
D5LR Heart failure
EXCESS
D51/2 NS Nausea
❖ CVP
D5N5 Vomiting
❖ PULSE
TPN Burns
❖ In a ICU
ALBUMIN Hemorrhage
Cellular dehydration associated with hypernatremia
USES
Hyponatremia
Ascites
Burns
Large amounts of fluids shifting into the 3rd space

Isotonic Solutions
These fluids are the well behaved fluids, why? Because they stay where you put
them! They are similar to the bodies normal fluid osmolality. Once you put them in
the vascular space they stay there!

These are usually given to elevate BP. NS is the basic solution for blood
replacement.

Examples:
NS
LR Remember
D5W Do not use these in clients
D51/4 NS with HTN,HF,Renal failure.
They can cause fluid
USES: overload and
When abundant fluid loss has occurred hyponatremia.
Hemorrhage
Excess sweating
Nausea
Vomiting
Burns
Trauma
 Drug Moa Indication Contraindicatio dose / route Nursing action
n / adverse
effects

Phytonadione Helps�prevent� Prevention and Pain, swelling, IM Monitor for frank

Vit K bleeding�by� treatment of flushing, , Subcut, IV and occult
activating� hypoprothromb (Children 1 bleeding
dizziness, rapid
clotting�factors�� inemia mo): 1– 2 mg pulse and BP
heartbeat,
single dose. frequently;. Apply
sweating pressure to all
venipuncture sites
for at least 5 min;
avoid unnecessary
IM injections.

Erythromycin Suppresses Infections infantile IV/ P.O Monitor for allergic

Erythrocin protein caused by hypertrophic PO (Neonates reaction.
synthesis at the susceptible pyloric stenosis, ):
level of the 50S organisms pancreatitis,inter Ethylsuccinate
bacterial including stitial —20– 50
ribosome nephritis.rash. mg/kg/day
benzyl alcohol divided q 6– 12
should be hr.
avoided in IV (Children 1
neonates. mo): 15– 50
mg/kg/day
divided q 6 hr,
maximum 4
g/day.

HEp B vaccine Causes a Provides Do not give if �5�mcg/0.5�mL� Assess patient

primary immunity baby is already ;�5�mcg/mL�;� anaphylaxis
immune against HEP B + 10�mcg/0.5�mL (hypotension,
response. flushing, chest
tightness,
wheezing, fever, d

HEP B IG Confers hepatitis b erythema at IM IM : 0.5 mL Assess patient

BayHep B, Nabi-HB passive infection in site, pain, within 12 hr of anaphylaxis
immunity to neonates born swelling, birth. (hypotension,
hepatitis B to HBsAg- + tenderness flushing, chest
infection post women, Hypersensitivity tightness,
exposure provides to immune wheezing, fever,
passive globulins, dizziness.
immunity. glycine, or
thimerosal.
 Drug Mode of indications Contraindications/ dose/route Nursing
Action side effects actions

Hydrocod Bind to opiate Management of Avoid chronic use ROUTE PO Monitor

one receptors in the moderate to Dizziness, sedation, —2.5– 10 mg q 3– 6 respirations
bitartrate/ CNS. severe pain. respiratory hr as needed; Do not give
acetamin depression, laxatives
ophen hypotension
(Norco)/
Lortab

Rho(d) Prevent Administered to Prior hypersensitivity ROUTE IM/IV Assess vital

immune production of Rho(D)-negative reaction to human 600 IU (120 mcg) w signs
globulin anti-Rho(D) patients who immune globulin; 40– 125 mg qid, periodically
(human) antibodies in have been Rho(D)- or Du- after meals and at during therapy
Rho(D)- exposed to positive patients. bedtime (up to 500
negative Rho(D)- positive HTN, hypotension, mg/day)
patients who blood by: anemia
were exposed Pregnancy or
to Rho(D)- delivery of a
positive blood. Rho(D)-positive
infant,

Simethico Passage of gas Relief of painful Not recommended for ROUTE 40– Assess patient
ne through the GI symptoms of infant colic 125 mg qid, after for abdominal
Gas-X tract by excess gas in the None significant meals and at pain, distention,
belching or GI tract that may bedtime (up to 500 and bowel
passing flatus occur mg/day) sounds prior to
postoperatively and periodically
throughout

Docusate Promotes Prevention of Hypersensitivity; ROUTE PO Assess for

Peri- incorporation of constipation (in Abdominal pain, : 2 tablets once daily abdominal
Colace, water into stool, patients who nausea, or vomiting, at bedtime; distention,
resulting in should avoid maximum 4 tablets presence of
softer fecal straining, such as twice daily. bowel sounds,
mass after MI or rectal and usual
surgery) pattern of bowel
function.
 Drug MOA Indication Contraindicati route/dose Nursing actions
on/ Side
effects

Surfactant Replaces Treatment of None Intratracheal: Monitor ECG, heart rate,

(beractant) surfactant respiratory O2 desaturation (4 mL/kg birth color, chest expansion, o2
in distress weight); 4 doses may sat, and ET tube patency
premature syndrome in be given in first 48 hr continuously Continuous
infants premature of life, q 6 hr apart bedside monitoring for
infants. 30min

Caffeine Decrease Short-term Hypersensitivity ROUTE necrotizing enterocolitis

citrate periods of treatment of Tachycardia, IV/PO (abdominal distension,
apnea idiopathic feeding Maintenance dose— vomiting, bloody stools,
apnea of intolerance, starting 24 hr after lethargy).
preemie gastritis loading dose 5
infants mg/kg
between 28
and 33 wk
gestational
age.

Prostaglan relaxes Temporary Respiratory ROUTE IV respiratory rate, heart

din E1 smooth maintenance distress 0.05– 0.1 sounds, and neurological
(alprostadil muscle of of patent syndrome mcg/kg/min initially; status frequently
) the ductus ductus Seizures, may be increased up
arteriosus arteriosus in cerebral to 0.4 mcg/kg/min
neonates bleeding, until satisfactory
response

ampicillin Binds to Treat bacterial Hypersen to ROUTE IM/IV Observe for anaphylaxis
bact cell infections PCN Children 40 kg): 100 (rash, pruritus, laryngeal
wall Seizures, pseud – 200 mg/kg/day in edema, wheezing).
colitis divided doses q 6– 8
hr (not to exceed 12
g/day).

HMF Increased Pancreatic Hypersen to ROUTE PO Monitor stools for high fat
(human digestion of insufficiency hog proteins (Children 1 yr): 2000 content Stools will be foul-
milk fats, carbs, Shortness of – 4000 lipase units smelling/frothy.
fortifiers) and breath, dyspnea per 120 mL of Assess patient for allergy to
enzymes proteins in formula/breast milk. pork
the GI tract.
 Assessment of Growth and Development of the Infant
Head Should measure 13.75 cm at birth
-Posterior fontanel should close by 2nd month
-Anterior fontanel should close in 12-18 months Well checkup schedule
● Second week of life
Height and weight
- In the first 6 months birth weight doubles and baby should grow 6 inches
● 2, 4, 6, 9 months of age.
- By 12 months birth weight should triple and baby should grow 10-12 in.
Skelton
- Is made up of cartilage at 3month gestation and continues to ossify and grow Vitals
throughout life. HR: 70 resting - 180 awake and crying ( accurate
HR is taken apically)
- Bone age, injury, abuse or nutritional deficits can be determined by X-Ray.
Circulation RR: 30 but can range from 20-50 with
- Hemoglobin and RBCs decrease when respiratory system takes over until increase or decrease of activity.
3 months of age BP: 85/60 mmHg
Neuro Temp: 98.6
- Nerve cells grow and coordination begins in an orderly pattern.

Physical milestones Psychological milestones

● Jerky quivering arm movements, ● Focuses 8-12 in away
● Brings hands to mouth , makes fists ● Eyes wonder and cross
● Head flops back if unprepared ● Likes black and white/ high contrast patterns.
● Strong reflexes ● Prefers human face to other patterns
● 5-8 feedings per day - 3 meals 2 snacks ● Hearing is fully mature, may turn toward sound
● Progresses from sleeping 20 hours a day to 10-12 ● Likes sweet smells, dislikes sour
hours at night and two naps by 12 months,place ● Likes soft sensations
awake child in crib to sleep ● Likes to be handled gently

Social Milestones Emotional growth

● 0-1 month: extensive sleep, dependent, eye contact ● 0-1 mo: general tension
● 0-3 months: smiles and fixes on faces,solitary play ● 1 mo: happy and sad emotions
● 3-6 mo: enjoys peekaboo, smiles at familiar faces ● 6 mo: separation anxiety
● 6-12 mo: knows name, gives and takes objects, ● 6-12 mo: stranger anxiety, shows curiosity by
understands easy commands. 12 months .

Language Nutrition
● 0-3 mo: Cries, grunts and Rapid growth causes a need for the greatest amount of nutrients
Coo ● 4-6 mo- 12mo: breast milk or commercial formula, introduction of solid foods.
● 0-6 mo: babbling, vowels, One food at a time starting with veggies.
● You may need to supplement Vit C/D iron, fluoride.
half consonants
● 6mo: iron rich foods are needed to supplement
● 12 mo: 1-2 words, imitation,
● 7-8mos: self feeding begins by grasping and bringing food to mouth. Ends with
responding to simple use of utensils
commands ● WIC program helps children and women get proper nutrition when they qualify

Age Theroist Stage Description Nursing care

Birth -18 mo Sigmund Oral Pleasure center in Encourage self

mouth feeding. Avoid putting
Freud objects in mouth

1st year Erik Erikson Trust vs Depends on Encourage bonding

parents to meet and family
mistrust needs to create relationships
trust

Birth -2 yrs Jean Piaget Sensorimotor Coordinates Plan tactile activities

sensory with use of colorful
stage experiences with materials
 Assessment of Growth and Development of the Toddler 1-3 years
Physical growth slows Discipline
Communication and mobility skills increase Training and instructing to produce positive
Stubbornness , explore, dependent Safety behavior patterns
Begin to explore Autonomy “ I DO MYSELF” ● Proper restraint in ● Self control is gradual
Bed rituals are important car seat ● 2yrs: begin accepting responsibility
● Never leave the ● Consistency and timing are key
Height and weight toddler alone in ● Calmly remove the child from the
- Gain 5 to 10 LBs per year water even buckets situation
- Grow 3 inches per year pose a drowning ● Tell child the behavior is bad, not them
- Normal to go on food jags risk
● Put away poisons
Learns to stand alone and walk, and medications Well visits
1 year Need 12-14 hours a day of sleep with locks ● 15 mo for shots
3 years need 10-12 hours ● Burns from hot ● Annually after that
appliances and ● Assess growth/ development, caregiver skill,and
water are common relationship between toddler and parent

Physical milestones Psychological milestones

● Lordosis and pot belly, organs adapt moderately to ● Well established walking
stress ● Hand eye coordination
● Well established walking ● Progressive development of fine motor skills
● Growth is slowed and stable ● They begin to draw and write
● Bones and muscles still immature requires nutrition ● Bladder control is gained , with occasional
an exercise for adequate development relapses
● Brain is 90% developed by age 5

Social Milestones Emotional growth

● Moves to parallel play, mostly imitates role models ● Many emotions in one day
● Does Not share readily until later toddler years ● Increased use of emotion language and
● Separation anxiety is overcome easily understanding of emotion
● causes/ consequence understanding

Language Nutrition
● Vocabulary begins to increase names objects, ● Require about 1000-1400 calories a day
body parts, animals, and familiar locations ● Toddlers should be active 60 min a day
● Primary method of communication ● Fruites: 1-1.5 cups
● Continuous questioning “why” ● Veggies: 1-1.5 cups
● Toys that talk are preferred ● Grains : 3-5 oz
● Brief sentences ● Protein : 2-4 oz
● Dairy : 2-2.5 cups
Allow children to eat when hungry instead of forcing meals.

Age Theroist Stage Description Nursing care

18 mo- 3 Sigmund Anal Pleasure center in Encourage the family

the anus to teach good hygiene
years Freud

1- 3 years Erik Erikson Autonomy vs Mastering Support bonding and

environment and family relationships
shame and building self
doubt esteem

2-7 Jean Piaget Pre operational Sensory / action Plan drawing and
coordination, writing, tactile
symbolic thinking. experiences. Use
Represent world colorful materials to
 Assessment of Growth and Development of the preschool child
Growth rate has slowed Well checkup schedule
-Language and play change remarkably ● Boosters and vaccines 4-6yrs
- soak up info “little sponges, let them choose their own clothes” ● Annual exams for growth and
- 3yrs still chubby faced health
- 5 yrs leaner and taller and better coordinated but can't distinguish fantasy from real life.
Height and weight
- Gains 3-5 lb a year and grows 2.5 in. a year
- By 12 months birth weight should triple and baby should grow 10-12 in.
Skelton Vision
- Gross motor skills improve by age 5 they can climb, jump, catch and throw - Still immature
A ball and ride a bicycle. - Distance judgement faulty
- 5 yrs, leaner taller and better coordinated, teach them to wash hands thoroughly - Screen for amblyopia
- Bathing and brushing teeth still need supervised, can't wash own hair.
- 20/20 vision by age 6
Dentition
- The skull is 90% of adult size by age 6 - Depth perception occurs at
- Early preschool insidious teeth have completely emerged ,you floss their teeth. 8-10 yrs old.
- End of preschool teeth have erupted w/ incisors being first.

Physical milestones Psychological milestones

● Aware of their sexuality ● Develop imagination
● May have an imaginary friend
● May be attracted to parent of the opposite sex
● Magical thinking
● Parents should teach accurate sexual info ● May be afraid of the dark or have nightmares
● Teach the difference between good and bad touch ● 4:Temper tantrums, pushing, hitting, and
● Calm matter of fact response to masturbation manipulating environment
● Teach safety and privacy regarding genitals ● Discipline: teach the child responsibility and self
control and consistency.
● Taking favorited away is more effective than hitting

Social Milestones Emotional growth

● Preschoolers use imitative play, all types of play are
● 0-1 mo: general tension
needed for development
● Dramatic play: act out situations and control it ● 1 mo: happy and sad emotions
● Cooperative play: organized groups ● 6 mo: separation anxiety
● Associative play: play together but unorganized and no ● 6-12 mo: stranger anxiety, shows curiosity by
leader 12 months .
● Solitary : playing alone away from groups

Language Nutrition
● 3-4: non communicative w/ ● Do not need large quantities of food, keep portions small.
language ● Requires high amount of protein
● 4: communicate with language ● Erratic appetite, frequent small meals are better
● 4-5: use naughty words ● Guide them when choosing food
● Converse in a way they can ● Provide healthy snacks
understand ● Rituals are important.
● Delays can be caused by:
hearing impairment, lack of
stimulation,

Age Theroist Stage Description Nursing care

3-6 yrs Sigmund Phallic Pleasure center in Explain to the family

the genitals and teach hygiene
Freud

3-5 yrs Erik Erikson Initiative vs Child develops a Monitor and protect
conscious and from injury and
guilt sense of right and poisoning. Encourage
wrong them to ask questions

2-7 yrs Jean Piaget Pre operational The child sees the Plan drawing and
world writing activities.
phase egocentrically
 Assessment of Growth and Development of the school aged child 6-10yrs
Head Should measure 13.75 cm at birth
- School starts
Well checkup schedule
- Thinking skills develop ● Annual physicals
● Booster tetanus and diphtheria
● Visit the dentist 2x a year
Height and weight ● Screening for scoliosis at 10-11
- Growth is slow and steady gains 5-6 lb a year. ● Vision and hearing screen .
- Grows 2.5 in. a year until pre-teen.
- Spine straightens and abdomen flattens
- Long bone growth is noted
Dentition
Substance abuse
- Starts to lose baby teeth at about 6 ● Teach family values
The birds and the bees
- Eruption of permanent teeth begins ● Help develop a positive
● Teach right and wrong attitude of sexuality
Neuro ● Set rules and enforce ● Sexual roles
-Refines motor and cognitive skills ● Teach facts about ● Satisfaction with being a boy
- Engages in meaningful tasks drugs and alcohol or girl
● Actively listen

Physical milestones Psychological milestones

● Slowed growth, graceful on their feet ● Displays a sense of duty and accomplishment
● Strength and abilities double ● Applies energy from play to complete tasks
● Loss of baby teeth ● Develops positive sense of self
● Structural bone changes ● Magical thinking, sit still for short periods
● Girls begin to experience secondary sex ● Understands taking turns , enjoys groups
characteristics ● Enjoys real life activities
● Give consistent rules, positive attention, and
clear expectations, questions parents
standards,

Social Milestones
● Develop confidence in family and explore Emotional growth
relationships outside of family ● Greater understanding of complex emotions
● Peers become important ● Understands they can have more than one
● Motivated by accomplishment emotion
● success/ failure have a strong impact ● Greater ability to control emotion
● Uses strategies to redirect feelings

Language Nutrition
● Language is refined vis ● Requires more food for increased energy demands
grammar education ● Choose foods from all food groups
● Ability to use words to express ● Food jags and increased appetite are normal
knowledge ● Limit fat intake, supervise snack habits
● Narrative skills improve ● Offer choices.
● Able to make inferences
● Able to evaluate speech and
messages

Age Theroist Stage Description Nursing care

6-10 yrs Sigmund Latency Preparing for Encourage sibling and

adult life but peer contact. Assess
Freud for sexual activity in
awaiting maturity
later stage

6-10 yrs Erik Erikson Industry vs Developing sense Provide activities

of self worth and based on talents and
Inferiority talent abilities

2-7 yrs Jean Piaget Pre operational The child sees the Plan drawing and
world writing activities.
phase egocentrically
 Assessment of Growth and Development of the Adolescent 11-18yrs
Early adolescents Well checkup schedule
-puberty : reproductive maturity ● 2x during teens
- starts at age 10 in girls and ends with menstruation
- starts age 12 in boys and ends sperm production
● Immunizations, hearing,
vision, scoliosis, thyroid
Growth and pelvic for sexually
- Girls achieve 98% of height of 16 active girls..
- Skeletal growth outpaces muscle growth ● BP, height and weight
- Nonvoluntary with early menses, 13-15 ovulation begins
- Boys : grow rapidly from 13-20
- Muscle strength and coordination develop rapidly
- Larynx becomes enlarged
- Both sexs : body takes on contours
- Primary sex organs develop, hormonal activity increases
- Bone growth continues until 20s
- Anorexia and bulimia can happen due to body image issues

Physical milestones Psychological milestones

● Girls : 9-11: growth spurts last 18 months ● They wonder who they are
● Grows 3 in annually until menarche ● What will they become
● Begin to develop figure ● More mobile
● Boys: 11-13: slower and steadier than girls ● Seek out intimate relationships
● Changes in penis testes and scrotum ● Most are heterosexual, homosexuality can be
● Nocturnal emissions “ wet dreams” difficult emotionally
● Body image is closely related to self esteem
● Underdevelopment causes anxiety

Social Milestones Emotional growth

● Greater focus on peers develops a separate self ● Rebellious
from parents ● Emotional highs and lows
● Moral development ● Focus on appearance
● Less egocentric ● Sexually active teens may have impaired self image
● Focused on mixed gender friendships ● Privacy becomes important. .

Language Nutrition
● Able to communicate Rapid growth causes a need for the greatest amount of nutrients
complex thoughts ● Appetite increases and teens eat frequently
● Food choices not always wise
● May skip meals
● Can have nutritional deficits of vit A, D and B. folic acid, iron and zinc. Due to
menses girls need additional iron.

Age Theroist Stage Description Nursing care

Puberty Sigmund Genital Pleasure center in Encourage safe sex,

the genitals educate on teen
Freud pregnancy and STI

10-20yrs Erik Erikson Identity vs role Integrating multiple Support self esteem,
roles, self image be honest maximize
confusion and peer pressure positive aspects of
image and minimize
defects

11- Jean Piaget Formal Reasons in more Discuss conditions

abstract idealistic openly with client.
adulthood operational ways Allow privacy to
stage discuss
 BURNS
What happens?
❖ Plasma seeps into the tissues Priorities Fluid replacement
due to increased capillary ❖ Monitoring the airway is ❖ Fluid replacement: You must
permeability usually within the your first priority. know the time the burn
first 24 hours. ❖ Look for signs of inhalation occurred because replacement
❖ Your patient may present in a injury such as; singed nasal therapy is based on 24h from
state of shock therefore you will hairs or bruns in mucosa or the injury occured.
see increased pulse, mouth, head, neck or face. ❖ Formula : Calculate the amount
respirations, and hypotension. Coughing up soot or black needed for 24h then divide by 2.
❖ Cardiac output decreases secretions. Then give the first half of the
because there is less volume to ❖ Administer 02 at 100% fluid in 8 hrs.
pump ❖ Most common airway injury
❖ The kidneys aren't being is carbon monoxide ( 4 mL * Kg* % TBSA = total fluid
perfused therefore they hold poisoning. replacement for the first 24 hrs)
onto fluids therefore causing ❖ Determine if the burn
occured in an open or
❖
decreased urine output
Initially you vasodilate. Once closed area. Emergency management
epinephrine is secreted then
you vasoconstrict and shunt ❖ Wrap the patient in a blanket to
blood to the vital organs. put out the flames to hold in
❖ ADH & Aldosterone are secreted body heat and keep out
to retain water and sodium to bacteria.
help increase blood volume. ❖ Douse in cool water
❖ Cover in a clean dry cloth
❖ Remove jewelry

Rule of 9’s
Head and neck: 9%
Trunk :18% front. 18% back
Genitals: 1%
Arms : 9% each for the whole arm
Legs : 18% each for the whole leg
Treatments
Nursing considerations ❖ Hypertonic solutions: Albumin,
Give a tetanus immunization because it keeps fluid into the
Monitor for hyperkalemia because of vascular space.
cellular destruction Albumin helps by:
Administer antacids to prevent a ❖ Increasing vascular volume
curling's ulcer ❖ Increasing blood pressure
Place an NG tube to prevent paralytic ❖ Increasing cardiac output
ileus ❖ Increased kidney perfusion
Replace calories ❖ Think shock reversal and opposites.
Monitor for contractures
Pt should be on reverse isolation Nursing considerations for
Monitor for infection
Place the patient on telemetry fluid replacement
You want to give medications IV ❖ Monitor for increased urine output.
because they work faster. This is the best way to know that
Perform frequent circulatory checks: shock is reversing and the kidneys
❖ Pulse are reprofusing.
❖ Skin temp ❖ Monitor for fluid volume excess
❖ Skin color
❖ Capillary refill
Insert a foley
Call the MD if urine is brown or red
Monitor NG tube output

Electrical burns Chemical burns

❖ Hold c spine in the field Priority is to remove the
❖ Place on cardiac chemical and rinse it off!
monitor for 24 hours
❖ At risk for Vfib
❖ Monitor renal studies :
hemoglobin and Classification of burns
myoglobin can build up ❖ First-degree burns:They result in pain and reddening
and case renal issues.
of the epidermis
❖ Second-degree burns(partial thickness burns) affect
the epidermis and the dermis (lower layer of skin). They
cause pain, redness, swelling, and blistering.
❖ Third-degree burns (full thickness burns) go through
the dermis and affect deeper tissues. They result in
white or blackened, charred skin that may be numb.
 PRIORITY AND DELEGATION
ABC’S TIPS
You can separate the tasks into categories that help you
❖ A: Airway. This category includes everything that affects a decide what to do first. I generally separate them into the
patent airway, including a foreign object, fluid from an upper following categories:
respiratory infection, and edema from trauma or an allergic ❖ Things that require action before they can happen
reaction. ❖ Things that are time sensitive
❖ B: Breathing. This category includes everything that affects ❖ Things that other people can do
the breathing pattern, including hyperventilation or ❖ Patient schedules/appointments
hypoventilation and abnormal breathing patterns, such as ❖ How many items a patient needs to have done
Korsakoff’s, Biot’s, or Cheyne-Stokes respiration.
❖ C: Circulation. This category includes everything that
affects the circulation, including fluid and electrolyte DO NOT delegate what you can EAT! or PACET
disturbances and disease processes that affect cardiac
output. P – Planning
❖ D: Disease processes. If the patient has no problem with A – Assess (Primary/Initial)
the airway, breathing, or circulation, then the nurse should C – Collaboration (with RT, OT, PT, ETC)
evaluate the disease processes, giving priority to the E – Evaluate (for trends)
disease process that poses the greatest immediate risk. For T – Teach
example, if a patient has terminal cancer and hypoglycemia,
hypoglycemia is a more immediate concern. ➢ Assessment, teaching, i.v. meds,
❖ E: Everything else. This category includes such issues as evaluation, unstable patient cannot
writing any incident report and completing the patient chart. be delegated to an Unlicensed
When evaluating needs, this category is never the highest Assistive Personnel.
priority. ➢ LVN/LPN cannot handle blood.
❖ Rule utilitarianism is known as the “greatest good for the
greatest number of people” theory.
❖ Egalitarian theory emphasizes that equal access to goods and
services must be provided to the less fortunate by an affluent
society.
 MED SURG IMPORTANT FACTS

Eyes and Ears

❖ Use of high-pitched voice is inappropriate for the client with
hearing impairment
❖ Rinne’s test compares air conduction with bone conduction.
❖ Vertigo is the most characteristic manifestation of Meniere’s
disease.
❖ . Low sodium is the diet for a client with Meniere’s disease.
❖ A client who had cataract surgery should taught to call his
MD if he has eye pain.
❖ Risk for Injury takes priority for a client with Meniere’s
disease.
❖ Irrigate the eye with sterile saline is the priority nursing
intervention when the client has a foreign body protruding
from the eye.
❖ Snellen’s Test assesses visual acuity. BONES
❖ Presbyopia is an eye disorder characterized by lessening of ❖ Bone scan is done by injecting radioisotope per IV and
the effective powers of accommodation. then x-rays are taken.
❖ The primary problem in cataract is blurring of vision. ❖ To prevent edema on the site of sprain, apply cold
❖ The primary reason for performing iridectomy after cataract compress on the area for the first 24 hours.
extraction is to prevent secondary glaucoma. ❖ To turn the client after lumbar Laminectomy, use the
❖ In acute glaucoma, the obstruction of the flow of aqueous logrolling technique.
humor is caused by displacement of the iris. ❖ Carpal tunnel syndrome occurs due to the injury of
❖ Glaucoma is characterized by irreversible blindness. median nerve.
❖ Hyperopia is corrected by convex lens. ❖ Massaging the back of the head is specifically important
❖ Pterygium is caused primarily by exposure to dust. for the client with Crutchfield tong.
❖ A sterile chronic granulomatous inflammation of the ❖ A one-year-old child has a fracture of the left femur. He is
meibomian gland is chalazion. placed in Bryant’s traction. The reason for elevation of his
❖ The surgical procedure which involves removal of the both legs at 90º angle is his weight isn’t adequate to
eyeball is enucleation. provide sufficient countertraction, so his entire body must
❖ Romberg’s test is a test for balance or gait. be used.
❖ . Swing-through crutch gait is done by advancing both
crutches together and the client moves both legs past the
level of the crutches.
❖ The appropriate nursing measure to prevent
displacement of the prosthesis after a right total hip
replacement for arthritis is to place the patient in the
position of right leg abducted.
❖ . Pain on non-use of joints, subcutaneous nodules and
elevated ESR are characteristic manifestations of
rheumatoid arthritis.
❖ Teaching program of a patient with SLE should include
emphasis on walking in shaded area.
❖ Otosclerosis is characterized by replacement of normal
bones by spongy and highly vascularized bones.

NEURO
❖ If the client with increased ICP demonstrates decorticate
posturing, observe for flexion of elbows, extension of the knees,
plantar flexion of the feet.
❖ The nursing diagnosis that would have the highest priority in the
care of the client who has become comatose following cerebral
hemorrhage is Ineffective Airway Clearance.
❖ The initial nursing action—for a client who is in the clonic phase of
a tonic-clonic seizure—is to obtain equipment for orotracheal
suctioning.
❖ The first nursing intervention in a quadriplegic client who is
experiencing autonomic dysreflexia is to elevate his head as high
as possible.
❖ Following surgery for a brain tumor near the hypothalamus, the
nursing assessment should include observing for inability to
regulate body temp.
❖ Post-myelography (using metrizamide (Omnipaque) care includes
keeping head elevated for at least 8 hours.
❖ 36. Homonymous hemianopsia is described by a client had CVA
and can only see the nasal visual field on one side and the
temporal portion on the opposite side.
❖ Ticlopidine may be prescribed to prevent thromboembolic CVA.
❖ To maintain airway patency during a stroke in evolution, have
orotracheal suction available at all times.
❖ For a client with CVA, the gag reflex must return before the client
is fed.
❖ Clear fluids draining from the nose of a client who had a head
trauma 3 hours ago may indicate basilar skull fracture.
❖ An adverse effect of gingival hyperplasia may occur during
Phenytoin (DIlantin) therapy.
❖ . Urine output increased: best shows that the mannitol is effective
in a client with increased ICP.
❖ . A client with C6 spinal injury would most likely have the symptom
of quadriplegia.
❖ Falls are the leading cause of injury in elderly people.
 COMMUNITY & ETHICS
ETHICS

❖ Veracity is truth and is an essential component of a

COMMUNITY therapeutic relationship between a health care provider
and his patient.
❖ Utilization review is performed to ❖ Beneficence is the duty to do no harm and the duty to
do good. There’s an obligation in patient care to do no
determine whether the care provided to a harm.
❖ Nonmaleficence is the duty to do no harm.
patient was appropriate and cost-effective. ❖ Frye’s ABCDE cascade provides a framework for
❖ A value cohort is a group of people who prioritizing care by identifying the most important
treatment concerns.
experienced an out-of-the-ordinary event
that shaped their values.
❖ A third-party payer is an insurance
company.
❖
❖ Intrathecal injection is administering a drug
through the spine.
❖ When a patient asks a question or makes a
statement that’s emotionally charged, the
nurse should respond to the emotion behind Communication and Patient Education
the statement or question rather than to
what’s being said or asked. ❖ Before teaching any procedure to a patient, the nurse must
assess the patient’s current knowledge and willingness to learn.
❖ Process recording is a method of evaluating one’s
communication effectiveness.
. The steps of the trajectory-nursing model are ❖ Whether the patient can perform a procedure (psychomotor
domain of learning) is a better indicator of the effectiveness of
as follows: patient teaching than whether the patient can simply state the
steps involved in the procedure (cognitive domain of learning).
❖ Step 1: Identifying the trajectory phase ❖ When communicating with a hearing impaired patient, the nurse
❖ Step 2: Identifying the problems and ❖
should face him.
. When a patient expresses concern about a health-related issue,
establishing goals before addressing the concern, the nurse should assess the
patient’s level of knowledge.
❖ Step 3: Establishing a plan to meet the
goals
❖ Step 4: Identifying factors that facilitate or
hinder attainment of the goals
❖ Step 5: Implementing interventions
❖ Step 6: Evaluating the effectiveness of
the interventions
Two goals of Healthy People 2010 are:
❖ Help individuals of all ages to increase
the quality of life and the number of years
of optimal health
❖ Eliminate health disparities among
different segments of the population.
❖ A community nurse is serving as a patient’s
advocate if she tells a malnourished patient
to go to a meal program at a local park.
❖ If a patient isn’t following his treatment plan,
the nurse should first ask why.
❖ When a patient is ill, it’s essential for the
members of his family to maintain
communication about his health needs.
❖ Ethnocentrism is the universal belief that
one’s way of life is superior to others’.
❖ When a nurse is communicating with a
patient through an interpreter, the nurse
should speak to the patient and the
interpreter.
❖ Prejudice is a hostile attitude toward
individuals of a particular group.
1. A client has come into your clinic for a psychiatric 2. Which of the following statements if made by the nurse( who)is most
follow up. They have lost 10% of her body weight
helpful in the following scenario: An elderly patient at the end of life is
since the last time you saw them. Which of the
following signs and symptoms would you find in a being visited by relatives, one of them starts crying and asks the nurse to
client suffering from anorexia nerviosa? stay with them for a few minutes, but the nurse has other patients to take
Select all that apply. care of.
A.) Fluid and electrolyte imbalances
B.) Heat intolerance A.) “ I don’t think it’s okay for me to interrupt your family time.”
C.) Amenorrhea B) “ If you would like I could stay and sit with you.”
D.) Weight loss of 25% under normal weight
C.) “ I can have the clergy come and sit with you.”
E.) Presence of lanugo
D.) “ I am busy but I think I could stay with you for a few minutes.”
Clinical manifestations of Anorexia Nervosa include several
symptoms. One can expect amenorrhea, dry skin, cold Rationale
intolerance, extreme weight loss, bradycardia and even B) The end of life process can be confusing, frightening, sad, or concerning for
dysrhythmias which can be life-threatening. It is important to family members.
keep a close eye on electrolytes in these patients. The family may inquire about the process and what to expect, some may need
comforted and reassured. The nurse should aid the family in times of grief to get
them to successfully and therapeutically pass through the grief process ,this
includes sitting with the family as needed.
3- A client was recently diagnosed with
End-Stage Kidney Disease (ESKD) and A.) Is incorrect because it is not therapeutic for the nurse to decline the family's
was informed of the necessity of request, the family could view this as dismissive and see the nurse as unconcerned
starting renal replacement therapy. This about their loved one.
morning the client was found trying to C.) Is incorrect due to the amount of time it may take for the clergy to arrive to the
bedside although this is an appropriate intervention it is not the most therapeutic.
attempt suicide by hanging himself in
D.) is incorrect because this is the least therapeutic and most dismissive, the family
the bathroom, using gown ties. He was
may already feel as though they are “bothering” the nurse. The nurse could
stabilized and relocated to the delegate tasks to other nurses and UAP
psychiatric ward. Which of the next
nursing actions should be taken first in
this patient?

A.) Deliver constant 1:1 observation

with the client
B.) Locate the client in a room close to
the nurses’ station
C.) Evaluate the client risk for a
subsequent suicide attempt
D.) encourage the client to
communicate his feelings about his
diagnosis

B) The end of life process can be confusing, frightening, sad,

or concerning for family members.
The family may inquire about the process and what to
expect, some may need comforted and reassured. The
nurse should aid the family in times of grief to get them to
successfully and therapeutically pass through the grief
process ,this includes sitting with the family as needed.

A.) Is incorrect because it is not therapeutic for the nurse to

decline the family's request, the family could view this as
dismissive and see the nurse as unconcerned about their
loved one.
C.) Is incorrect due to the amount of time it may take for
the clergy to arrive to the bedside although this is an
appropriate intervention it is not the most therapeutic.