All three of us passed the first time with 75 questions. If you know everything on this guide you will do well. Kind of long but worth studying. Best of luck to you
Please give me feedback HESI Hints & NCLEX Gems Answering NCLEX Questions Maslow's Hierarchy of Needs Physiologic Safety Love and Belonging Esteem Self-actualization Nursing Process Assessment Diagnosis (Analysis) Planning Implementation (treatment) Evaluation ABCs Airway Breathing Circulation Before we continue Watch About A Nursing Student: The Life Of A Student video... Normal Values Hgb Males 14-18 Females 12-16 Hct Males 42-52 Females 37-47 RBCs Males 4.7-6.1 million Females 4.2-5.4 million WBCs 4.5-11k Platelets 150-400k PT (Coumadin/Warfarin) 11-12.5 sec (INR and PT TR = 1.5-2 times normal) APTT (Heparin) 0-70 sec (APTT and PTT TR = 1.5-2.5 times normal) BUN 10-20
Creatinine 0.5-1.2
Glucose 70-110
Cholesterol
Bilirubin Newborn 1-12
Phenylalanine Newborn
Na+ 136-145 K+ 3.5-5 HypoK+ . . . Prominent U waves, Depressed ST segment, Flat T waves HyperK+ . . . Tall T-Waves, Prolonged PR interval, wide QRS Ca++ 9-10.5 Hypocalcemia ... muscle spasms, convulsions, cramps/tetany, + Trousseau's, + Chvostek's, prolonged ST interval, prolonged QT segment Mg+ 1.5-2.5
Cl- 96-106
Phos 3-4.5
Albumin 3.5-5
Spec Gravity 1.005-1.030
Glycosylated Hemoglobin (Hgb A1c): 4-6% ideal,
Dilantin TR = 10-20
Lithium TR = 0.5-1.5 Arterial Blood Gases ... Used for Acidosis vs. Alkalosis PH 7.35-7.45 CO2 35-45 (Respiratory driver) ... High = Acidosis HCO3 21-28 (Metabolic driver) ... High = Alkalosis O2 80-100 O2 Sat 95-100% Antidotes Digoxin ... Digiband Coumadin ... Vitamin K (Keep PT and INR @ 1-1.5 X normal) Benzodiazapines ... Flumzaemil (Tomazicon) Magnesium Sulfate ... Calcium Gluconate? Heparin ... Protamine Sulfate (Keep APTT and PTT @ 1.5-2.5 X normal) Tylenol ... Mucomist (17 doses + loading dose) Opiates (narcotic analgesics, heroin, morphine) ... Narcan (Naloxone) Cholinergic Meds (Myesthenic Bradycardia) ... Atropine Methotrexate ... Leucovorin Delegation RN Only Blood Products (2 RNs must check) Clotting Factors Sterile dressing changes and procedures Assessments that require clinical judgment Ultimately responsible for all delegated duties Unlicensed Assistive Personnel Non-sterile procedures Precautions & Room Assignments Universal (Standard) Precautions ... HIV initiated Wash hands Wear Gloves Gowns for splashes Masks and Eye Protection for splashes and droplets Don't recap needles Mouthpiece or Ambu-bag for resuscitation Refrain from giving care if you have skin lesion Droplet (Respiratory) Precautions (Wear Mask) Sepsis, Scarlet Fever, Strep, Fifth Disease (Parvo B19), Pertussis, Pneumonia, Influenza, Diptheria, Epiglottitis, Rubella, Rubeola, Meningitis, Mycoplasma, Adenovirus, Rhinovirus RSV (needs contact precautions too) TB ... Respiratory Isolation Contact Precautions = Universal + Goggles, Mask and Gown No infection patients with immunosuppressed patients Weird Miscellaneous Stuff Rifampin (for TB) ... Rust/orange/red urine and body fluids
Pyridium (for bladder infection) ... Orange/red/pink urine Glasgow Coma Scale ... Myesthenia Gravis Myesthenic Crisis = Weakness with change in vitals (give more meds) Cholinergic Crisis = Weakness with no change in vitals (reduce meds) Diabetic Coma vs. Insulin Shock ... Give glucose first - If no help, give insulin
Fruity Breath = Diabetic Ketoacidosis Acid-Base Balance If it comes out of your ***, it's Acidosis. Vomiting = Alkalosis Skin Tastes Salty = Cystic Fibrosis
Lipitor (statins) in PMs only - No grapefruit juice
Stroke ... Tongue points toward side of lesion (paralysis), Uvula deviates away from the side of lesion (paralysis)
Hold Digoxin if HR < 60
Stay in bed for 3 hours after first ACE Inhibitor dose
Avoid Grapefruit juice with Ca++ Channel Blockers
Anthrax = Multi-vector biohazard
Pulmonary air embolism prevention = Trendelenburg (HOB down) + on left side (to trap air in right side of heart)
Head Trauma and Seizures ... Maintain airway = primary concern
Peptic Ulcers ... Feed a Duodenal Ulcer (pain relieved by food) ... Starve a gastric ulcer
Acute Pancreatitis ... Fetal position, Bluish discoloration of flanks (Turner's Sign), Bluish discoloration of pericumbelical region (Cullen's Sign), Board like abdomen with guarding ... Self digestion of pancreas by trypsin.
Hold tube feeding if residual > 100mL
In case of Fire ... RACE and PASS
Check Restraints every 30 minutes ... 2 fingers room underneath
Gullain-Barre Syndrome ... Weakness progresses from legs upward - Resp arrest
Trough draw = ~30 min before scheduled administration ... Peak Draw = 30-60 min after drug administration. Mental Health & Psychiatry Most suicides occur after beginning of improvement with increase in energy levels MAOIs ... Hypertensive Crisis with Tyramine foods Nardil, Marplan, Parnate Need 2 wk gap from SSRIs and TCAs to admin MAOIs Lithium Therapeutic Range = 0.5-1.5
Phenothiazines (typical antipsychotics) - EPS, Photosensitivity
Atypical Antipsychotics - work on positive and negative symptoms, less EPS
Benzos (Ativan, Lorazepam, etc) good for Alcohol withdrawal and Status Epilepticus
Antabuse for Alcohol deterrence - Makes you sick with OH intake
Alcohol Withdrawal = Delerium Tremens - Tachycardia, tachypnea, anxiety, nausea, shakes, hallucinations, paranoia ... (DTs start 12-36 hrs after last drink)
Opiate (Heroin, Morphine, etc.) Withdrawal = Watery eyes, runny nose, dilated pupils, NVD, cramps
Stimulants Withdrawal = Depression, fatigue, anxiety, disturbed sleep Medical-Surgical Hypoventilation = Acidosis (too much CO2) Hyperventilation = Alkalosis (low CO2) No BP or IV on side of Mastectomy Opiate OD = Pinpoint Pupils Lesions of Midbrain = Decerebrate Posturing (Extended elbows, head arched back) Lesions of Cortex = Decorticate Posturing (Flexion of elbows, wrists, fingers, straight legs, mummy position) Urine Output of 30 mL/hr = minimal competency of heart and kidney function Kidney Stone = Cholelithiasis Flank pain = stone in kidney or upper ureter Abdominal/scrotal pain = stone in mid/lower ureter or bladder o Renal Failure ... Restrict protein intake Fluid and electrolyte problems ... Watch for HyperK+ (dizzy, wk, nausea, cramps, arhythmias) Pre-renal Problem = Interference with renal perfusion Intra-renal Problem= Damage to renal parenchyma Post-renal Problem = Obstruction in UT anywhere from tubules to urethral meatus. Usually 3 phases (Oligouric, Diuretic, Recovery) Monitor Body Wt and I&Os Steroid Effects = Moon face, hyperglycemia, acne, hirsutism, buffalo hump, mood swings, weight gain - Spindle shape, osteoporosis, adrenal suppression (delayed growth in kids) . . . (Cushing's Syndrome symptoms) Addison's' Crisis = medical emergency (vascular collapse, hypoglycemia, tachycardia ... Admin IV glucose + corticosteroids) ... No PO corticosteroids on empty stomach Potassium sparing diuretic = Aldactone (Spironolactone) ... Watch for hyperK+ with this and ACE Inhibitors. Cardiac Enzymes ... Troponin (1 hr), CKMB (2-4 hr), Myoglobin (1-4 hr), LDH1 (12-24 hr) MI Tx ... Nitro - Yes ... NO Digoxin, Betablockers, Atropine Fibrinolytics = Streptokinase, Tenecteplase (TNKase) CABG = Coronary Artery Bypass Graft PTCA = Percutaneous Transluminal Coronary Angioplasty Sex after MI okay when able to climb 2 slights of stairs without exertion (Take nitro prophylactically before sex) BPH Tx = TURP (Transurethral Resection of Prostate) ... some blood for 4 days, and burning for 7 days post-TURP. Only isotonic sterile saline for Bladder Irrigation Post Thyroidectomy - Keep tracheostomy set by the bed with O2, suction and Calcium gluconate Pericarditis ... Pericardial Friction Rub, Pain relieved by leaning forward Post Strep URI Diseases and Conditions: Acute Glomerulonephritis Rheumatic Fever ... Valve Disease Scarlet Fever If a chest-tube becomes disconnected, do not clamp ... Put end in sterile water Chest Tube drainage system should show bubbling and water level fluctuations (tidaling with breathing) TB ... Treatment with multidrug regimen for 9 months ... Rifampin reduces effectiveness of OCs and turns pee orange ... Isoniazide (INH) increases Dilantin blood levels Use bronchodilators before steroids for asthma ... Exhale completely, Inhale deeply, Hold breath for 10 seconds Ventilators ... Make sure alarms are on ... Check every 4 hours minimum Suctioning ... Pre and Post oxygenate with 100% O2 ... No more than 3 passes ... No longer than 15 seconds ... Suction on withdrawal with rotation COPD: Emphysema = Pink Puffer Chronic Bronchitis = Blue Bloater (Cyanosis, Rt sided heart failure = bloating/edema) o O2 Administration Never more than 6L/min by cannula Must humidify with more than 4L/hr No more than 2L/min with COPD ... (CO2 Narcosis) In ascending order of delivery potency: Nasal Cannula, Simple Face Mask, Nonrebreather Mask, Partial Rebreather Mask, Venturi Mask Restlessness and Irritability = Early signs of cerebral hypoxia IVs and Blood Product Administration 18-19 gauge needle for blood with filter in tubing Run blood with NS only and within 30 minutes of hanging Vitals and Breath Sounds ... before, during and after infusion (15 min after start, then 30 min later, then hourly up to 1 hr after) Check Blood: Exp Date, clots, color, air bubbles, leaks 2 RNs must check order, pt, blood product ... Ask Pt about previous transfusion Hx Stay with Pt for first 15 minutes ... If transfusion rxn ... Stop and KVO with NS Pre-medicate with Benadryl PRN for previous urticaria rxns Isotonic Solutions D5W NS (0.9% NaCl) Ringers Lactate NS only with blood products and Dilantin Diabetes and Insulin When in doubt - Treat for Hypoglycemia first First IV for DKA = NS, then infuse regular insulin IV as RX'd Hypoglycemia ... confusion, HA, irritable, nausea, sweating, tremors, hunger, slurring Hyperglycemia ... weakness, syncope, polydipsia, polyuria, blurred vision, fruity breath Insulin may be kept at room T for 28 days Draw Regular (Clear) insulin into syringe first when mixing insulins Rotate Injection Sites (Rotate in 1 region, then move to new region) Rapid Acting Insulins ... Lispro (Humalog) and Aspart (Novolog) ... O: 5-15 min, P: .75-1.5 hrs Short Acting Insulin ... Regular (human) ... O: 30-60 min, P: 2-3 hrs (IV Okay) Intermediate Acting Insulin ... Isophane Insulin (NPH) ... O: 1-2 hrs, P: 6-12 hrs Long Acting Insulin ... Insulin Glargine (Lantus) ... O: 1.1 hr, P: 14-20 hrs (Don't Mix) Oral Hypoglycemics decrease glucose levels by stimulating insulin production by beta cells of pancreas, increasing insulin sensitivity and decreasing hepatic glucose production Glyburide, Metformin (Glucophage), Avandia, Actos Acarbose blunts sugar levels after meals Oncology Leukemia ... Anemia (reduced RBC production), Immunosuppression (neutropenia and immature WBCs), Hemorrhage and bleeding tendencies (thrombocytopenia) Acute Lymphocytic = most common type, kids, best prognosis Testicular Cancer ... Painless lump or swelling testicle ... STE in shower > 14 yrs ... 15-35 = Age Prostate Cancer ... > 40 = Age PSA elevation DRE Mets to spine, hips, legs Elevated PAP (prostate acid phosphatase) TRUS = Transurethral US Post Op ... Monitor of hemorrhage and cardiovascular complication Cervical and Uterine Cancer Laser, cryotherapy, radiation, conization, hysterectomy, exenteration ... Chemotherapy = No help PAP smears should start within 3 years of intercourse or by age 21 Ovarian Cancer = leading cause of death from gynecological cancer Breast Cancer = Leading cause of cancer in women Upper outer quadrant, left > right Monthly SBE Mammography ... Baseline @ 35, Annually after age 50 Mets to lymph nodes, then lungs, liver, brain, spine Mastectomy ... Radical Mastectomy = Lymph nodes too (but no mm resected) Avoid BP measurements, injections and venipuncture on surgical side Anti-emetics given with Chemotherapy Agents (Cytoxan, Methotrexate, Interferon, etc.) Phenergan (Promethazine HCl) Compazine (Prochlorperazine) Reglan (Metocolpramide) Benadryl (Diphenhydramine) Zofran (Ondansetron HCl) Kytril (Granisetron) Sexually Transmitted Diseases Syphilis (Treponema pallidum) ... Chancre + red painless lesion (Primary Stage, 90 days) ... Secondary Stage (up to 6 mo) = Rash on palms and soles + Flu-like symptoms ... Tertiary Stage = Neurologic and Cardiac destruction (10-30 yrs) ... Treated with Penicillin G IM. Gonorrhea (Neisseria Gonorrhea) ... Yellow green urethral discharge (The Clap) Chlamydia (Chlamydia Trachomatis) ... Mild vaginal discharge or urethritis ... Doxycyclin, Tetracycline Trichomoniasis (Trichomonas Vaginalis) ... Frothy foul-smelling vaginal discharge ... Flagyl Candidiasis (Candida Albicans) ... Yellow, cheesy discharge with itching ... Miconazole, Nystatin, Clomitrazole (Gyne-Lotrimin) Herpes Simplex 2 ... Acyclovir HPV (Human Pappilovirus) ... Acid, Laser, Cryotherapy HIV ... Cocktails Perioperative Care Breathing Es taught in advance (before or early in pre-op) Remove nail polish (need to see cap refill) Pre Op ... Meds as ordered, NPO X 8 hrs, Incentive Spirometry & Breathing Es taught in advance, Void, No NSAIDS X 48 hrs Increased corticosteroids for surgery (stress) ... May need to increase insulin too Post Op restlessness may = hemorrhage, hypoxia Wound dehiscence or extravisation ... Wet sterile NS dressing + Call Dr. Call Dr. post op if ... 100 or Post Op Monitoring VS and BS ... Every 15 minutes the first hour, Every 30 min next 2 hours, Every hour the next 4 hours, then Every 4 hours PRN 1-4 hrs Post Op = Immediate Stage ... 2-24 hrs Post Op = Intermediate Stage ... 1-4 days Post Op = Extended Stage Post Op Positioning THR ... No Adduction past midline, No hip flexion past 90 degrees Supratentorial Sx ... HOB 30-45 degrees (Semi-Fowler) Infrantentorial Sx ... Flat Phlebitis ... Supine, elevate involved leg Harris Tube ... Rt/back/Lt - to advance tube in GI Miller Abbott Tube ... Right side for GI advancement into small intestine Thoracocentesis ... Unaffected side, HOB 30-45 degrees Enema ... Left Sims (flow into sigmoid) Liver Biopsy ... Right side with pillow/towel against puncture site Cataract Sx ... Opp side - Semi-Fowler Cardiac Catheterization ... Flat (HOB no more than 30 degrees), Leg straight 4-6 hrs, bed rest 6-12 hrs Burn Autograph ... Elevated and Immob 3-7 days Amputation ... Supine, elevate stump for 48 hrs Large Brain Tumor Resection ... On non-operative side Incentive Spirometry ... Inhale slowly and completely to keep flow at 600-900, Hold breath 5 seconds, 10 times per hr Post Op Breathing Exercises ... Every 2 hours Sit up straight Breath in deeply thru nose and out slowly thru pursed lips Hold last breath 3 seconds Then cough 3 times (unless abd wound - reinforce/splint if cough) Watch for Stridor after any neck/throat Sx ... Keep Trach kit at bed side Staples and sutures removed in 7-14 days - Keep dry until then No lifting over 10 lbs for 6 weeks (in general) If chest tube comes disconnected, put free end in container of sterile water Removing Chest Tube ... Valsalvas, or Deep breath and hold If chest tube drain stops fluctuating, the lung has re-inflated (or there is a problem) Keep scissors by bed if pt has S. Blakemore Tube (for esoph varices)... Sudden respiratory distress - Cut inflation tubes and remove Tracheostomy patients ... Keep Kelly clamp and Obturator (used to insert into trachea then removed leaving cannula) at bed side Turn off NG suction for 30 min after PO meds NG Tube Removal ... Take a deep breath and hold it Stomach contents pH = NG Tube Insertion ... If cough and gag, back off a little, let calm, advance again with pt sipping water from straw NG Tube Length ... End of nose, to era lobe, to xyphoid (~22-26 inches) Decubitus (pressure) Ulcer Staging Stage 1 = Erythema only Stage 2 = Partial thickness Stage 3 = Full thickness to SQ Stage 4 = Full thickness + involving mm /bone Acute Care VA ... Hemorrhagic or Embolic A-fib and A-flutter = thrombus formation Dysarthria (verbal enunciation/articulation), Apraxia (perform purposeful movements), Dysphasia (speech and verbal comprehension), Aphasia (speaking), Agraphia (writing), Alexia (reading), Dysphagia (swallowing) Left Hemisphere Lesion ... aphasia, agraphia, slow, cautious, anxious, memory okay Right Hemisphere Lesion ... can't recognize faces, loss of depth perception, impulsive behavior, confabulates, poor judgment, constantly smiles, denies illness, loss of tonal hearing Head Injuries ... Even subtle changes in mood, behavior, restlessness, irritability, confusion may indicate increased ICP Change in level of responsiveness = Most important indicator of increased ICP Watch for CSF leaks from nose or ears - Leakage can lead to meningitis and mask intracranial injury since usual increased ICP symps may be absent. Spinal Cord Injuries Respiratory status paramount ... C3-C5 innervates diaphragm 1 wk to know ultimate prognosis Spinal Shock = Complete loss of all reflex, motor, sensory and autonomic activity below the lesion = Medical emergency Permanent paralysis if spinal cord in compressed for 12-24 hrs Hypotension and Bradycardia with any injury above T6 Bladder Infection = Common cause of death (try to keep urine acidic) Burns Infection = Primary concern HyperK+ due to cell damage and release of intracellular K+ Give meds before dressing changes - Painful Massive volumes of IV fluid given, due to fluid shift to interstitial spaces and resultant shock First Degree = Epidermis (superficial partial thickness) Second Degree = Epidermis and Dermis (deep partial thickness) Third Degree = Epidermis, Dermis, and SQ (full thickness) Rule of 9s ... Head and neck = 9%, UE = 9% each, LE = 18% each, Front trunk = 18%, Back Trunk = 18% Singed nasal hair and circumoral soot/burns = Smoke inhalation burns o Fractures Report abnormal assessment findings promptly ... Compartment Syndrome may occur = Permanent damage to nerves and vessels 5 P's of neurovascular status (important with fractures) Pain, Pallor, Pulse, Paresthesia, Paralysis Provide age-appropriate toys for kids in traction Special Tests and Pathognomonic Signs Tensilon Test ... Myesthenia Gravis (+ in Myesthenic crisis, - in Cholinergic crisis) ELISA and Western Blot ... HIV Sweat Test ... Cystic Fibrosis Cheilosis = Sores on sides of mouth ... Riboflavin deficiency (B2) Trousseau's Sign (Carpal spasm induced by BP cuff) ... Hypocalcemia (hypoparathyroidism) Chvostek's Sign (Facial spasm after facial nerve tap) ... Hypocalcemia (hypoparathyroidism) Bloody Diarrhea = Ulcerative Colitis Olive-Shaped Mass (epigastric) and Projectile Vomiting = Pyloric Stenosis Current Jelly Stool (blood and mucus) and Sausage-Shaped Mass in RUQ = Intussiception Mantoux Test for TB is + if 10 mm induration 48 hrs post admin (previous BCG vaccine recipients will test +) Butterfly Rash = SLE ... Avoid direct sunlight 5 Ps of NV functioning ... Pain, paresthesia, pulse, pallor, paralysis Cullen's Sign (periumbelical discoloration) and Turner's Sign (blue flank) = Acute Pancreatitis Murphy's Sign (Rt. costal margin pain on palp with inspiration) = GB or Liver disease HA more severe on wakening = Brain Tumor (remove benign and malignant) Vomiting not associated with nausea = Brain Tumor Elevated ICP = Increased BP, widened pulse pressure, increased Temp Pill-Rolling Tremor = Parkinson's (Tx with Levodopa, Cardidopa) - Fall precautions, rigid, stooped, shuffling IG Bands on Electrophoresis = MS ... Weakness starts in upper extremities - bowel/bladder affected in 90% ... Demyelination - Tx with ACTH, corticosteroids, Cytoxan and other immunosuppressants Reed-Sternberg Cells = Hodgkin's Koplik Spots = Rubeola (Measles) Erythema Marginatum = Rash of Rheumatic Fever Gower's Sign = Muscular Dystrophy ... Like Minor's sign (walks up legs with hands) Pediatrics Bench Marks Birth wt doubles at 6 months and triples at 12 months Birth length increases by 50% at 12 months Post fontanel closes by 8 wks Ant fontanel closes by 12-18 months Moro reflex disappears at 4 months Steady head control achieved at 4 months Turns over at 5-6 months Hand to hand transfers at 7 months Sits unsupported at 8 months Crawls at 10 months Walks at 10-12 months Cooing at 2 months Monosyllabic Babbling at 3-6 months, Links syllables 6-9 mo Mama, Dada + a few words at 9-12 months Throws a ball overhand at 18 months Daytime toilet training at 18 mo - 2 years 2-3 word sentences at 2 years 50% of adult Ht at 2 years Birth Length doubles at 4 years Uses scissors at 4 years Ties shoes at 5 years Girls' growth spurt as early at 10 years ... Boys catch up ~ Age 14 Girls finish growing at ~15 ... Boys ~ 17 Autosomal Recessive Diseases CF, PKU, Sickle Cell Anemia, Tay-Sachs, Albinism, 25% chance if: AS (trait only) X AS (trait only) 50% chance if: AS (trait only) X SS (disease) Autosomal Dominant Diseases Huntington's, Marfans, Polydactyl, Achondroplasia, Polycystic Kidney Disease 50% if one parent has the disease/trait (trait = disease in autosomal dominant) X-Linked Recessive Diseases Muscular Dystrophy, Hemophilia A Females are carriers (never have the disease) Males have the disease (but can't pass it on) 50% chance daughters will be carriers (can't have disease) 50% chance sons will have the disease (not a carrier = can't pass it on) This translates to an overall 25% chance that each pregnancy will result in a child that has the disease Scoliosis ... Milwaukee Brace - 23 hrs/day, Log rolling after Sx Down Syndrome = Trisomy 21 ... Simian creases on palms, hypotonia, protruding tongue, upward outward slant of eyes Cerebral Palsy ... Scissoring = legs extended, crossed, feet plantar-flexed PKU ... leads to MR ... Guthrie Test ...Aspartame (NutraSweet) has phenylalanine in it and should not be given to PKU patient Hypothyroidism ... Leads to MR Prevent Neural tube disorders with Folic Acid during PG Myelomeningocele ... Cover with moist sterile water dressing and keep pressure off Hydrocephalus ... Signs of increased ICP are opposite of shock ... Shock = Increased pulse and decreased BP IICP = Decreased pulse and increased BP ... (+ Altered LOC = Most sensitive sign) Infants ... IICP = Bulging fontanels, high pitched cry, increased hd circum, sunset eyes, wide suture lines, lethargy ... Treat with peritoneal shunt - don't pump shunt. Older kids IIPC = Widened pulse pressure IICP caused by suctioning, coughing, straining, and turning - Try to avoid Muscular Dystrophy ... X-linked Recessive, waddling gait, hyper lordosis, Gower's Sign = difficulty rising walks up legs (like Minor's sign), fat pseudohypertrophy of calves. Seizures ... Nothing in mouth, turn hd to side, maintain airway, don't restrain, keep safe ... Treat with Phenobarbitol (Luminol), Phenytoin (Dilantin: TR = 10-20 ... Gingival Hyperplasia), Fosphenytoin (Cerebyx), Valproic Acid (Depakene), Carbamazepine (Tegritol) Meningitis (Bacterial) ... Lumbar puncture shows Increased WBC, protein, IICP and decreased glucose May lead to SIADH (Too much ADH) ... Water retention, fluid overload, dilutional hyponatremia CF Kids taste salty and need enzymes sprinkled on their food Children with Rubella = threat to unborn siblings (may require temporary isolation from Mom during PG) Pain in young children measured with Faces pain scale No MMR Immunization for kids with Hx of allergic rxn to eggs or neomycin Immunization Side Effects ... T Call Physician if seizures, high fever, or high-pitched cry after immunization All cases of poisoning ... Call Poison Control Center ... No Ipecac! Epiglottitis = H. influenza B ... Child sits upright with chin out and tongue protruding (maybe Tripod position) ... Prepare for intubation or trach ... DO NOT put anything into kid's mouth Isolate RSV patient with Contact Precautions ... Private room is best ... Use Mist Tent to provide O2 and Ribavirin - Flood tent with O2 first and wipe down inside of tent periodically so you can see patient Acute Glomerulonephritis ... After B strep - Antigen-Antibody complexes clog up glomeruli and reduce GFR = Dark urine, proteinuria Wilm's Tumor = Large kidney tumor ... Don't palpate TEF = Tracheoesophageal Atresia ... 3 C's of TEF = Coughing, Choking, Cyanosis Cleft Lip and Palate ... Post-Op - Place on side, maintain Logan Bow, elbow restraints Congenital Megacolon = Hirschsprung's Disease ... Lack of peristalsis due to absence of ganglionic cells in colon ... Suspect if no meconium w/in 24 hrs or ribbon-like foul smelling stools Iron Deficiency Anemia ... Give Iron on empty stomach with citrus juice (vitamin C enhances absorption), Use straw or dropper to avoid staining teeth, Tarry stools, limit milk intake Sickle Cell Disease ...Hydration most important ...SC Crisis = fever, abd pain, painful edematous hands and feet (hand-foot syndrome), arthralgia ...Tx + rest, hydration ... Avoid high altitude and strenuous activities Tonsillitis ... usually Strep ... Get PT and PTT Pre-Op (ask about Hx of bleeding) ... Suspect Bleeding Post-Op if frequent swallowing, vomiting blood, or clearing throat ... No red liquids, no straws, ice collar, soft foods ... Highest risk of hemorrhage = first 24 hrs and 5-10 days post-op (with sloughing of scabs) Primary meds for ER for respiratory distress = Sus-phrine (Epinephrine HCl) and Theophylline (Theo-dur) ... Bronchodilators Must know normal respiratory rates for kids ... Respiratory disorders = Primary reason for most medical/ER visits for kids ... Newborn ... 30-60 1-11 mo ... 25-35 1-3 years ... 20-30 3-5 years ... 20-25 6-10 years ... 18-22 11-16 years ...16-20 Cardiovascular Disorders Acyanotic = VSD, ASD, PDA, Coarc of Aorta, Aortic Stenosis Antiprostaglandins cause closure of PDA (aorta - pulmonary artery) Cyanotic = Tetralogy of Fallot, Truncus Arteriosis (one main vessel gets mixed blood), TVG (Transposition of Great Vessels) ... Polycythemia common in Cyanotic disorders 3 T's of Cyanotic Heart Disease (Tetralogy, Truncus, Transposition) Tetralogy of Fallot ... Unoxygenated blood pumped into aorta ulmonary Stenosis VSD Overiding Aorta Right Ventricular Hypertrophy TET Spells ...Hypoxic episodes that are relieved by squatting or knee chest position CHF can result ... Use Digoxin ... TR = 0.8-2.0 for kids Ductus Venosus = Umbelical Vein to Inferior Vena Cava Ductus Arteriosus = Aorta to Pulmonary Artery Rheumatic Fever ... Acquired Heart Disease ... Affects aortic and mitral valves Preceded by beta hemolytic strep infection Erythema Marginatum = Rash Elevated ASO titer and ESR Chest pain, shortness of breath (Carditis), migratory large joint pain, tachycardia (even during sleep) Treat with Penicillin G = Prophylaxis for recurrence of RF Maternity Day 1 of cycle = First day of menses (bleeding) ... Ovulation on Day 14 ... 28 days total ... Sperm 3-5 days, Eggs 24 hrs ... Fertilization in Fallopian Tube Chadwick's Sign = Bluing of Vagina (early as 4 weeks) Hegar's Sign = Softening of isthmus of cervix (8 weeks) Goodell's Sign = Softening of Cervix (8 weeks) Pregnancy Total wt gain = 25-30 lbs (11-14 kg) Increase calorie intake by 300 calories/day during PG ... Increase protein 30 g/day ... Increase iron, Ca++, Folic Acid, A & C Dangerous Infections with PG ... TORCH = Toxoplasmosis, other, Rubella, Cytomegalovirus, HPV Braxton Hicks common throughout PG Amniotic fluid = 800-1200 mL ( Polyhydramnios and Macrosomia (large fetus) with Diabetes Umbelical cord: 2 arteries, 1 vein ... Vein carries oxygenated blood to fetus (opposite of normal) FHR = 120-160 Folic Acid Deficiency = Neural tube defects Pre-term = 20-37 weeks Term = 38-42 weeks Post-term = 42 weeks+ TPAL = Term births, Pre-term births, Abortions, Living children Gravida = # of Pregnancies regardless of outcome Para = # of Deliveries (not kids) after 20 wks gestation Nagale's Rule ... Add 7 days to first day of last period, subtract 3 months, add 12 months = EDC Hgb and Hct a bit lower during PG due to hyperhydration Side-lying is best position for uteroplacental perfusion (either side tho left is traditional ) 2:1 Lecithin:Sphingomyelin Ratio = Fetal lungs mature AFP in amniotic fluid = possible neural tube defect Need a full bladder for Amniocentesis early in PG (but not in later PG) Lightening = Fetus drops into true pelvis Nesting Instinct = Burst of Energy just before labor True Labor = Regular contractions that intensify with ambulation, LBP that radiates to abdomen, progressive dilation and effacement Station = Negative above ischial spines, Positive below Leopold Maneuver tries to reposition fetus for delivery Laboring Maternal Vitals ... Pulse NON-Stress Test ... Reactive = Healthy (FHR goes up with movements) Contraction Stress Test (Ocytocin Challenge Test)... Unhealthy = Late decels noted (positive result) indicative of UPI ... "Negative" result = No late decels noted (good result) Watch for hyporeflexia with Mag Sulfate admin . . . Diaphragmatic Inhibition Keep Calcium gluconate by the bed (antidote) Firsts etal HB ... 8-12 weeks by Doppler, 15-20 weeks by fetoscope Fetal movement = Quickening, 14-20 weeks Showing = 14 weeks Braxton Hicks - 4 months and onward Early Decels = Head compression = OK Variable Decels = Cord compression = Not Good Late Decels = Utero-placental insufficiency = BAD! If Variable or Late Decels ... Change maternal position, Stop Pitocin, Administer O2, Notify Physician DIC ... Tx is with Heparin (safe in PG) ... Fetal Demise, Abruptio Placenta, Infection Fundal Heights 12-14 wks ... At level of symphysis 20 weeks ... 20 cm = Level of umbilicus Rises ~ 1 cm per week Stages of Labor Stage 1 = Beginning of Regular contraction to full dilation and effacement Stage 2 = 10 cm dilation to delivery Stage 3 = Delivery of Placenta Stage 4 = 1-4 Hrs following delivery Placenta Separation ... Lengthening of cord outside vagina, gush of blood, full feeling in vagina ... Give oxytocin after placenta is out - Not before. Schultz Presentation = Shiny side out (fetal side of placenta) Postpartum VS Schedule Every 15 min X 1 hr Every 30 min X next 2 hours Every Hour X next 2-6 hours Then every 4 hours Normal BM for mom within 3 days = Normal Lochia ... no more than 4-8 pads/day and no clots > 1 cm ... Fleshy smell is normal, Foul smell = infection Massage boggy uterus to encourage involution ... empty bladder ASAP - may need to catheterize ... Full bladder can lead to uterine atony and hemorrhage Tears ...1st Degree = Dermis, 2nd Degree = mm/fascia, 3rd Degree = anal sphincter, 4th Degree = rectum APGAR = HR, R, mm tone, Reflex irritability, Color ... 1 and 5 minutes ...7-10 = Good, 4-6 = moderate resuscitative efforts, 1-3 = mostly dead Eye care = E-mycin + Silver Nitrate ... for gonorrhea Pudendal Block = decreases pain in perineum and vagina - No help with contraction pain Epidural Block = T10-S5 ... Blocks all pain ... First sign = warmth or tingling in ball of foot or big toe Regional Blocks often result in forceps or vacuum assisted births because they affect the mother's ability to push effectively WBC counts are elevated up to 25,000 for ~10 days post partum Rho(D) immune globulin (RhoGAM) is given to Rh- mothers who deliver Rh+ kids... Not given if mom has a +Coombs Test ... She already has developed antibodies (too late) Caput Succedaneum = edema under scalp, crosses suture lines Cephalhematoma = blood under periosteum, does not cross suture lines Suction Mouth first - then nostrils Moro Reflex = Startle reflex (abduction of all extremities) - up to 4 months Rooting Reflex ... up to 4 months Babinski Reflex ... up to18 months Palmar Grasp Reflex ...Lessens by 4 months Ballard Scale used to estimate gestational age Heel Stick = lateral surface of heel Physiologic Jaundice is normal at 2-3 days ... Abnormal if before 24 hours or lasting longer than 7 days ... Unconjugated bilirubin is the culprit. Vitamin K given to help with formation of clotting factors due to fact that the newborn gut lacks the bacteria necessary for vitamin K synthesis initially ... Vastus lateralis mm IM Abrutio Placenta = Dark red bleeding with rigid board like abdomen Placenta Previa = Painless bright red bleeding DIC = Disseminated Intravascular Coagulation ... clotting factors used up by intravascular clotting - Hemorrhage and increased bleeding times result ... Associated with fetal demise, infection and abruptio placenta. Magnesium Sulfate used to reduce preterm labor contractions and prevent seizures in Pre-Eclampsia ... Mg replaces Ca++ in the smooth mm cells resulting relaxation ... Can lead to hyporeflexia and respiratory depression - Must keep Calcium Gluconate by bed when administering during labor = Antidote ... Monitor for: Absent DTR's Respirations Urinary Output Fetal Bradycardia Pitocin (Oxytocin) use for Dystocia... If uterine tetany develops, turn off Pitocin, admin O2 by face mask, turn pt on side. Pitocin can cause water intoxication owing to ADH effects. Suspect uterine rupture if woman complains of a sharp pain followed by cessation of contractions Pre-Eclampsia = Htn + Edema + Proteinuria Eclampsia = Htn + Edema + Proteinuria + Seizures and Coma ... Suspect if Severe HA + visual disturbances No Coumadin during PG (Heparin is OK) Hyperemesis Gravidarum = uncontrollable nausea and vomiting ... May be related to H. pyolori ... Reglan (metaclopromide) Insulin demands drop precipitously after delivery No oral hypoglycemics during PG - Teratogenic ... Insulin only for control of DM Babies born without vaginal squeeze more likely to have respiratory difficulty initially C-Section can lead to Paralytic Ileus ... Early ambulation helps Postpartum Infection common in problem pregnancies (anemia, diabetes, traumatic birth) Postpartum Hemorrhage = Leading cause of maternal death ... Risk factors include: Dystocia, prolonged labor, overdistended uterus, abrutio placenta, infection Tx includes ... Fundal massage, count pads, VS, IV fluids, Oxytocin, notify physician Jitteriness is a symptom of hypoglycemia and hypocalcemia in the newborn Hypoglycemia ... tremors, high pitched cry, seizures High pitched cry + bulging fontanels = IICP Hypothermia can lead to Hypoxia and acidoisis ... Keep warm and use bicarbonate PRN to treat acidosis in newborn. Lay on right side after feeding ... Move stomach contents into small intestine Jaundice and High bilirubin can cause encephalopathy ... Nutrition K+ ... Bananas, dried fruits, citrus, potatoes, legumes, tea, peanut butter Vitamin C ... Citrus, potatoes, cantaloupe Ca++ ... Milk, cheese, green leafy veggies, legumes Na+ ... Salt, processed foods, seafood Folic Acid ... Green leafy veggies, liver, citrus Fe++ ... Green leafy veggies, red meat, organ meat, eggs, whole wheat, carrots Use Z-track for injections to avoid skin staining Mg+ ... Whole grains, green leafy veggies, nuts Thiamine (B1) ... Pork, beef, liver, whole grains B12 ... Organ meats, green leafy veggies, yeast, milk, cheese, shellfish Deficiency = Big red beefy tongue, Anemia Vitamin K ... Green leafy veggies, milk, meat, soy Vitamin A ... Liver, orange and dark green fruits and veggies Vitamin D ... Dairy, fish oil, sunlight Vitamin E ... Veggie oils, avocados, nuts, seeds BMI ... 18.5-24.9 = Normal (Higher = Obese) Gerontology Essentially everyone goes to Hell in a progressively degenerative hand-basket Thin skin, bad sleep, mm wasting, memory loss, bladder shrinks, incontinence, delayed gastric emptying, COPD, Hypothyroidism, Diabetes Common Ailments: Delerium and Dementia Cardiac Dysrhythmias Cataracts and Glaucoma CVA (usually thrombotic, TIAs common) Decubitus Ulcers Hypothyroidism Thyrotoxicosis (Grave's Disease) COPD (usually combination of emphysema and CB) UTIs and Pneumonia ... Can cause confusion and delerium Memory loss starts with recent - progresses to full Dementia = Irreversible (Alzheimer's) ... Depression, Sundowning, Loss of family recognition Delerium = Secondary to another problem = Reversible (infections common cause) Medication Alert! ... Due to decreased renal function, drugs metabolized by the kidneys may persist to toxic levels When in doubt on NCLEX ... Answer should contain something about exercise and nutrition. Advanced Clinical Concepts Erickson ... Psycho-Social Development 0-1 yr (Newborn) ... Trust vs. Mistrust 1-3 yrs (Toddler)... Autonomy vs. Doubt and Shame ... Fear intrusive procedures - Security objects good (Blankies, stuffed animals) 3-6 yrs (Pre-school) ... Initiative vs. Guilt ... Fear mutilation - Band-Aids good 6-12 yrs (School Age) ... Industry vs. Inferiority... Games good, Peers important ... Fear loss of control of their bodies 12-19 yrs (Adolescent) ... Identity vs. Role Confusion ... Fear Body Image Distortion 20-35 yrs (Early Adulthood) ... Intimacy vs. Isolation 35-65 yrs (Middle Adulthood) ... Generativity vs. Stagnation Over 65 (Older Adulthood) ... Integrity vs. Despair Piaget ... Cognitive Development Sensorimotor Stage (0-2) ... Learns about reality and object permanence Preoperational Stage (2-7) ... Concrete thinking Concrete Operational Stage (7-11) ... Abstract thinking Formal Operational Stage (11-adult) ... Abstract and logical thinking Freud ... Psycho-Sexual Development Oral Stage (Birth -1 year) ... Self gratification, Id is in control and running wild Anal Stage (1-3) ... Control and pleasure wrt retention and pooping - Toilet training in this stage Phallic Stage (3-6) ... Pleasure with genitals, Oedipus complex, SuperEgo develops Latency Stage (6-12) ... Sex urges channeled to culturally acceptable level, Growth of Ego Genital Stage (12 up) ... Gratification and satisfying sexual relations, Ego rules Kohlberg ... Moral Development Moral development is sequential but people do not aromatically go from one stage to the next as they mature Level 1 = Pre-conventional ... Reward vs. Punishment Orientation Level 2 = Conventional Morality ... Conforms to rules to please others Level 3 = Post- Conventional ... Rights, Principles and Conscience (Best for All is a concern) Calculations Rules & Formulas Round final answer to tenths place Round drops to nearest drop When calculating mL/hr, round to nearest full mL Must include 0 in front of values Pediatric doses rounded to nearest 100th. Round down for peds Calculating IV Flow Rates Total mL X Drop Factor / 60 X #Hrs = Flow Rate in gtts/min Calculating Infusion Times Total mL X Drop Factor / Flow Rate in gtts/min X 60 = Hrs to Infuse Watch HESI Study Tips... Conversions 1 t = 5mL
1 T = 3 t = 15 mL
1 oz = 30 cc = 30 mL = 2 T
1 gr = 60 mg
1 mg = 1000 ug (or mcg)
1 kg = 2.2 lbs
1 cup = 8 oz = 240 mL
1 pint = 16 oz
1 quart = 32 oz
Degrees F = (1.8 X C) + 32

Degrees C = (F - 32) / 1.8 37 C = 98.6 F 38 C = 100.4 F 39 C = 102.2 F 40 C = 104 F Fall Precautions Room close to nurses station Assessment and orientation to room Get help to stand (dangle feet if light headed) Bed low with side rails up Good lighting and reduce clutter in room Keep consistent toileting schedule Wear proper non-slip footwear

At home ... Paint edges of stairs bright color Bell on cats and dogs Neutropenic (Immunosuppressed) Precautions No plants or flowers in room No fresh veggies ... Cooked foods only Avoid crowds and infectious persons Meticulous hand washing and hygiene to prevent infection Report fever > 100.5 (immunosuppressed pts may not manifest fever with infection) Bleeding Precautions (Anticoagulants, etc.) Soft bristled tooth brush Electric razor only (no safety razors) Handle gently, Limit contact sports Rotate injection sites with small bore needles for blood thinners Limit needle sticks, Use small bore needles, Maintain pressure for 5 minutes on venipuncture sites No straining at stool - Check stools for occult blood (Stool softeners PRN) No salicylates, NSAIDs, or suppositories Avoid blowing or picking nose Do not change Vitamin K intake if on Coumadin LEARN how to pass the NCLEX...
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