nclex RN notes

Published Jun 26, 2013

9 Posts

Notes:

CHF = Lasix -> watch for s/s hypokalemia (inverted T wave (ekg strip) -> increase risk for Dig (digoxin) toxicity (s/s Halo Lights)

also tx CHF = bed rest, semi to high Fowler's, low Na+ diet (no luncheon meats, no dairy (including cheese), no processed food)

keep MAP (mean arterial pressure) above 65 for adequate profusion

MAP = Systolic + (2x Diastolic - takes twice as long for heart to refill) divided by 3

this is helpful when given a series of Blood Pressures and can't decide which is worse

Kroup = (remember t's and k's) happens in Kold weather usually to Kids in Pre-K, Kindergarten, and Kids under Ten years of age, put under oxygen Tent at Ten liters of oxygen, Keep Tent Kleen so you can see the Kid, no Kombustible toys or fabrics - no wool or other materials that cause static electricity, use Kleenable Toys like cotton or plastic

Pt = Coumadin: (t in Pt is for the number ten) -> 10-15 sec (range)

Ptt = the 2 t's look like an H -> Heparin: (t + t or ten + ten in Ptt) 20-45 sec (range)

ICP = increase risk of Diabetes Insipidus

Diabetes Insipidus presents like Addison's

- hypovolemia, hypotension, hyponatremia, hypoglycemia, hyper K+

Cushing's Triad - ICP

- widening pulse pressure (increase in difference between systolic and diastolic)

- bradycardia

- irregular respirations

Rales= crackles. (*sign of fluid overload) Don't let these tricksters trip you up.

Chest Tube - Pleur Evac

Water Seal - needs to fluctuate with breathing, if not -> leak? re-inflated lung (chest x-ray)?

Suction Control - needs to be bubbling continuously (not vigorously), if not -> leak? water (20 cm)? re-inflated lung (chest x-ray)?

Drainage (collection) Chamber - document T.A.C.O. (Type/consistency, Amount, Color, Odor)

Bleeding => MOUTH: hematemesis, hemoptysis; NOSE: epistaxis; SKIN: ecchymosis, contusion (caused by trauma aka - bruise), petechia, purpura; orifice: hematochezia, melena; URINE: hematuria; HEAD: intracranial / cerebral / subarachnoid hemorrhage

if bleeding in abdomen - pt will have lower back pain

Tx = stop bleeding - vasoconstrict (cold), vasopressors, compression; stop, treat or remove causative agent; B/P is the last to go; may need to tx hypovolemia (L.R., albumin, other blood products), watch for Hyper- K+ (lysing of cells spill K+)

Antidotes:

heparin -> protamine sulfate

Koumadin (warfarin) -> vitamin K (keep same diet, don't stop green veggies)

magnesium sulfate -> calcium gluconate

most Narcotics -> Narcan

most Psych drugs -> Cogentin

Tylenol poisoning -> mucomist

Tetralogy of Fallow = Knee Chest position, O2 doesn't help - acyanotic defect - pt's suffer "tet spells"

Hyperglycemia = Cushing's, Hyperadrenalism, etc -> Poor wound healing, low K+, weight gain, increase risk for bleeding, increase risk for infection

Bradycardia = Atropine ***except if pt has or may have Glaucoma (give other CNS stimulant like Epi)

Albumin = Nutrition status, it is also used to pull the blood INto the Vasculature (ie shock) and it is also a Blood Product

if the questions gives a specific Age, please take note as it will be important when answering the question

Normally, no trendelenburg EXCEPT:

trendelenburg and on left side = central line, pt SOB, restless, etc. (possible air embolis)

rationale: keep air embolis in the lung and prevent it to go into brain

presumptive sign of pregnancy are signs Felt by the WOMEN: nausea, vomiting, breast sensitivity, fatigue, quickening

probable sign of pregnancy are Observed by the EXAMINER: uttering enlargement, soufflé and contractions, positive urine pregnancy test, Hegar's sign (dr stick hand in uterus and feels for the softening of lower part of uterus), Chadwick's sign (dark blue to purplish-red congested appearance of the lady parts, cervix, labia r/t increase blood flow - think baby Chad punched her vajayjay)