All Ncelx Systems 2023

Prepared by ABUBAKER HAMED, January 24, 2023
Fundamentals of nursing NCLEX
Lung sounds
• Wheezing = ass with narrow of the airway

• Stridor = ass with URT obstruction = medical emergency
• Coarse crackles = ass with too much fluids and sections
• Pleural friction rub = ass with inflamed pleural
• Fine crackles =
• Rhonchus = normal = cleared by cough
IV
• Too large IV canula = lead to mechanical phlebitis

• Care of central venous line
• Use sterile or aseptic technique
• Flush with heparin before de-access
• Have client to wear face mask
• Aspirate blood before medication administration
• Usually gauge size 19, 22
• If not used = access and flushed once/ month
• To remove the central line catheter, place pt in Trendelenburg position
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IV complications
Complications Notes
Extravasation A vesicant drug enters the SQ, apply pressure
Infiltration Non- vesicant drug enters into the SQ
Site ecchymosis Elevate and cold compression
Catheter embolism Apply torniquet
Mechanical phlebitis Warm compression- due to large IV catheter
Medications put pt risk for fall
Medications name or group Notes

Loop diuretics = bumetanide = lead to orthostatic hypotension
Alprazolam Drowsiness
Ca channel blocker =Verapamil Vasodilation
Opioids
Contraindications for oral TEMP
• Mouth breath
• Oral surgery
• Oral intake of hot or cold drinks
• Confusion or comatose pt
• Recently smoked
• Note= In pt with nasal cannula = nurse can take oral temp
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Contraindications of rectal TEMP
• Cardiac pt
• Rectal surgery
• Diarrhea
• Fecal impaction
• Rectal bleeding
Pulse
• 0= absent -- 4+= strong

• Apical pulse for one minute
• If radial pulse is < apical pulse = pulse deficit
Blood pressure
• 1-3 minutes after position change

• Small cuff – false high
• Big cuff = false low
• Systolic is 10-40 mmg higher in the lower extremities
Pulse oximetry = spo2
• Normal = 95-100%
• If below normal= instruct pt to take deep breathing and recheck
• Below 90% in health pt = notify physician
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Pain
• Acute
• Chronic
• Phantom
• Is subjective
• Client with cognitive problems look for non-verbal sign
• Consider culture = Asian, Arab American
• Pain management
• TENS
• Heat and cold – ice should not be left > 15-30 minutes
• Pharmacological treatment
• NSIDs = take oral dose with milk
• Taking ibuprofen with anti DM can lead to hypoglycemia
• Taking ibuprofen with Ca blocker = lead to toxicity
• Acetophenmine = not given for pt with hepatic or renal disease
Opioids
• IV route – fast effect

• Monitor RR= if < 12 don’t give and notify physician
• IF bradycardia = withhold the medication
• Monitor LOC
• Have opioid antagonist ready- naloxone
• Take oral dose with milk or snack
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Lab test
• Prolong use of tourniquet can lead to increase K+ level

• For venepuncture = Apply torniquet 5 to 10 cm above the venipuncture site
24 hours urine collection=
• 1st specimen should discarded
Taking blood glucose
• Prick side of the finger not the pad

• Turn finger down
• Disinfect finger with alcohol
• Wipe using sterile gauze
Urinary catheter
• Does not need sterile gloves

• Its important to daily clean urinary meatus with soap and water
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Urinary diversions methods
Urinary diversions methods Notes
Vesicostomy Created on abd wall

Primary for children
Kock pouch Post- pt will have catheter until pouch is healed
Catheters irrigate with NS to prevent = infection
After catheter is removed – pt teaching about how to self-catheterization
Ileal conduct Bladder removed= ileal conduct is created in the RT of the abd
Pt has no control = urine flow q second
Pt education = remove and change the device
Condom catheter External use =pt with incontinence
Ass skin breakdown
Tracheostomy
• Pre o2 use contaminated hand

• During insertion = no suction
• While withdrawing = intermittent suction
• Assess RR, skin integrity
• Suction only as needed
• Setup- sterile felid
• Remove and clean the inner canula, you may remove and replace
• Clean = 1st the stoma site 2nd the tracheostomy plate
• Secure the new ties, before remove of the old one
• One finger under the tie
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• To avoid bleeding = cuff should not be deflated and don’t manipulate

• Fenestrated tracheostomy = allow pt to speak and can be capped if the cuff is deflated
Ethical principles
Ethical principles Notes

Autonomy Right to decide = self-determination
Nurses encourage patients to make their own decision without any judgments
Beneficence is doing good and the right thing for the patient.
Non-maleficence. is doing no harm, as stated in the historical Hippocratic Oath. Harm can be intentional
or unintentional
Accountability is accepting responsibility for one's own actions.
Fidelity is keeping one's promises. The nurse must be faithful and true to their professional
justice is fairness. Nurses must be fair when they distribute care,
Veracity is being completely truthful with patients; nurses must not withhold the whole truth
from clients even when it may lead to patient distress
Nurse must follow the nurse practice act guidelines.
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Delegation
UAP tasks LPN tasks RN tasks Notes

• Do basic nursing care • Care for stable Pt Do all critical and New graduate nurse
ADLS • Work with chronic pt basic nursing care can do tracheostomy
• Turning • Work with predicable outcomes pt care
• Bathing • Do focus assessment If floated nurse
• Mouth care • Gather data, but don’t interpreted Give her most stable Can care for stable Pt
• Toileting • Does routine pt care such as Pt or pt with common
• Bed making • ECG nursing knowledge
• Weighing • Glucose check
• I&O • Wound care
• Feeding ( low risk pt) • Ostomy care
• Vital sign ( stable pt) • Give all medication except IV
• Check blood glucose • Reinforce teaching
• Implement contact
precautions • Don’t do TAPE
• Can give topical
medication o Teaching
o Assessment
o Planning
o Evaluation
• Don’t care for

• Unstable pt
• Don’t do the 1st of every things
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• Don’t care for

o New admission
o Fresh post op
• Don’t deal with CV line
• Don’t transfer or discharge
• Don’t administer blood products
Electrolytes imbalance
Electrolytes High Low Notes

imbalance
Potassium Hyperkalemia > 5.0 Hypokalemia < 3.5 Food high in K+
Causes Potassium retaining diuretics Loop Diuretics
Addison disease Cushing syndrome
Tissue damage = Burn=Hyperkalemia Metabolic alkalosis Avocado, bananas, cantaloupe,
is an expected finding for a client Vomiting / sever diarrhea Oranges
with a major burn (any full- Prolong NGT suction strawberries
thickness burn > 10% TBSA). NPO/ fasting Tomatoes
Alkalosis Carrot,
Acidosis -DKA or metabolic acidosis Mushroom
CRF spinach
Hyperuricemia Fish, pork, beef, veal
Potatoes
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Symptoms Go high except HR and UOP Go low except HR and UOP Raisins
Seizure Lethargy
Diarrhea Constipation
Increase muscle tone Paralytic ileus
Hyperreflexia Hypoactive bowel sound
Irritable, muscle weakness Muscle flaccidity
Bradycardia Hyporeflexia
Oliguria Tachycardia
Polyuria
Interventions Monitor cardiovascular system Monitor cardiovascular system Assess renal function before
Monitor for cardiac arrythmia Monitor for cardiac arrythmia administer K+
Restrict k+ diet Administer K+ supplement Assess site for phlebitis
Food high in K+
Dialysis if needed
Administer IV hypertonic glucose and
insulin
If blood transfusion= receives fresh
not storage
ECG changes Tall, peaked T wave ST depression

Widen QRS Prominent U wave
Prolong PR
Calcium Hypercalcemia > 10.5 Hypocalcaemia > 9.0 Food high in Ca++
Causes Excessive intake of Ca and VIT D Celiac sprue
Use of thiazide diuretics Crohn’s disease
Hyperparathyroidism ESRD Cheese
Hyperthyroidism Diarrhea Kale
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Immobility Acute pancreatitis Milk and milk soy

Use of glucocorticoids Removal of parathyroid gland Sardine
Adrenal insufficient Tofu
Symptoms Go opposite low Go opposite – high Yogurt
Bradycardia Agitation
Bradypnea Hyperreflexia 50-70% of serum calcium is
Hypoactive reflex Seizure ionized in the serum (Choice
Lethargy Chvostek’s sign B). Due to the protein-binding
Constipation Trousseau’s sign ability of calcium and
albumin, calcium levels can
Interventions Medication to inhibit Ca absorption= Administer Ca supplements be directly correlated
calcitonin and VIT D
Dialysis if needed Monitor for sign of
Check for urinary stones pathological fracture
Risk for fracture- move with cautions Consume food high in Ca
ECG changes Shorten ST Prolong ST

Widened T wave Prolong QT
Sodium Hypernatremia > 145 Hyponatremia <135 Food high in Na+

Causes Dehydration Diarrhea Bacon
NPO Diuretics Lunch meat
Burn Vomiting Butter, cheese
Corticosteroids Addison diseases Ketchup, mustard
Cushing syndrome SIADH Milk
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Hyperaldosteronism Hyperglycemia Processed food

DI HF Soy sauce
HHNK RF
LF
Symptoms Dehydration Overload
Hot dry skin Crackles
Thready pulse DNV
Tachycardia Can cause lithium toxicity
Interventions Administer fluids if needed Increase oral Na intake
Restrict Na Administer IV Na chloride
Administer diuretics if needed
Acid base Respiratory Respiratory Metabolic acidosis Metabolic alkalosis

acidosis alkalosis
Causes Hypoventilation Hyperventilation DKA Diuretics
Asthma Fever Excessive ingestion of Excessive vomiting
Atelectasis Hypoxia aspirin GIT suctions
Bronchitis Hysteria Malnutrition Massive transfusion of
Emphysema Pain Renal insufficient whole blood
Pneumonia Sever diarrhea High aldosterone
Pulmonary edema
Pulmonary emboli
Brain tumor
CNS depressants
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Diet
• Pt on liquid diet= increase protein

• Pt with hyponatremia, renal problem, heart problem = required fluid restrictions
• Take iron with vit c to increase absorption
• Pt with iron deficiency anemia = dark green vegetables, egg
• Pt with Malabsorption syndrome = avoid high fat diet= margarine, creamy cheese, lunch meat, eat low fat
diets = oranges, broccoli,
• Vegan pt = eat diet high in vit B12
• Liver cirrhosis = eat food high in thiamine = legumes, pork
• Pt with CRF= Low Na, low Phso, low Ca, low K+, low fluids
• Food high in Na= smoked salmon, tomato soup, instant oat meal, high processed food, processed cereal
• Food low in Na= apple, bananas, steamed vegetables
• Clear liquid diet
o Broth
o Coffee
o Gelatine
o Lemonade
o Beverage
o Water
o Tea
o bouillon
• Full liquid diet
o soup
o custard
o plain ice cream
o sherbet
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o milk
o pudding
•
• The nurse must directly monitor the client and their responses to the transfusion continuously for at
least 15 minutes after the bleeding began.
• When educating a client on providing a urine specimen, recognize the need to educate the client on
collecting the sample from the midstream portion of the client's void.
• Any urine output greater than 300 mL is alarming and the healthcare provider should be notified
immediately
• Hypersensitivity reactions occur when antibodies are formed through previous exposure to an allergen.
• A patient with B+ blood can receive blood that is B+, B-, O+, or O-.
• A patient with A+ blood can receive blood that is A+, A-, O+, or O-.
• A patient with B- blood can receive blood that is B-, O+, or O-.
• A patient with A- blood can receive blood that is A-, O+, or O-.
• A patient with AB+ blood can received from all type = universal recipient
• A patient with AB- blood can receive blood that is AB-, A-, O-
• When infusing fresh frozen plasma (FFP), the nurse should ensure that the FFP is ABO compatible with
the recipient.
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Type of blood products
Packed RBCs
• Infuse time for one unit = 1-2 hrs

• Each unit increase HB by 1g and HCT by 3%
• Blood set should be changed with each unit
• Blood must be administered as soon as possible after received from the blood bank (20-30min)- if not
administered = return to blood bank
• 18-19 IV needle is needed
• Monitor for reaction in the 1st 15 min – stay with the pt
Platelet
• Cross- matching usually is not required

• Administer immediately upon received from the blood bank
• Given over 15-30 minutes
• One unit increase = 5,000- 10,000 unit
Fresh frozen plasma
• To provide clotting factor

• Administer within 2 hours of thawing
• Infused over 15-30 min
• Rh compatibility and ABO are required
Rh- positive can received from Rh- negative, but Rh negative cannot receive from Rh positive
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Blood groups
• A = can received from A or O

• B = can received from B or O
• AB= can received from A, B, AB, or O
• O= can received from Only from O
•
• Cryoprecipitate contains fibrinogen and is used for the treatment of clotting disorders.
• Platelets are used for the treatment of a bleeding disorder and a platelet deficiency disorder.
• Packed red blood cells (PRBCs) are used for several disorders, including anemia, post-operative blood
replacement, and slow bleeding; not for a clotting disorder.
• A plasma expander is used for hypovolemic circulatory shock and not for a platelet disorder. Plasma
expanders include crystalloids and colloids. 0.9% NaCl and lactated ringers are examples of crystalloid
plasma expanders.
Albumin is indicated for clients adversely affected with the need for blood volume expansion and depleted
plasma proteins; not for an excess of plasma proteins.
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Cardiac system NCELX
Diseases Assessment Interventions Diet Notes

Coronary artery diseases Chest pain Medications Low calorie
CAD Palpation Nitrates – dilate CA Low sodium
Narrow or obt of one or more Dyspnea Ca blocker = dilate CA and Low fat
CA due to atherosclerosis Diagnostics reduce vasospasm Low cholesterol
ECG Cholesterol lowering =
Cath Beta Blocker = reduce BP High fiber
Lipid profile
Angina Pain Pain relives ECG
Chest pain due to ischemia Slowly or quickly O2 by nasal cannula ST segment
Mild to moderate Bed rest depression
Types Substernal, crushing, IV line T wave inversion
Stable angina supersizing Semi fowlers position
Exertional= occur with
activities and stress Pain radiated to If pain does not relive by
Relive with rest and nitro Shoulder, arm, jaw, nitroglycerin -= call the
neck doctor
Unstable angina Last less than 5
Pre-infraction minutes
Pain with mild activities
Last > 15 min Relive by rest or
May not be relive by nitro nitroglycerin
Variant angina
Pain occurs same time q day
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At rest
Due to CA spam
Treatment is
Ca blocker
Myocardial infarction Pain O2 = Low calorie
Sever lack of o2= ischemia- Crush substernal pain Aspirin = antiplatelet Low sodium ECG
necrosis Radiated to the jaw, Morphine = Low fat ST segment
back, left arm Nitroglycerin= vasodilator Low cholesterol elevation
Locations of MI Occur without T wave inversion
Anterior = obst LAD activities Bed rest Complications of
Posterior = obst circumflex Doesn’t relive by nitro ROM Avoid isometric MI
Inferior = obst Rt CA or by rest Ambulation 3 times/day exercise. Dysrhythmias
Last for 30 min or Stand to void or use HF
longer bedside commode Pulmonary edam
Relive by morphine Reduce stress Do aerobic Cardiogenic shock
exercise Tachycardia
SOB Treatment Hypotension
Muscle weakness – JVD
leg weakness Cardiac Cath Cool calm skin
Vomiting Dec UOP
Indigestion Cardiac surgery Priority is to
Post opt= Increase COP
Diagnostics Avoid fat and cholesterol
Increase Troponin = Avoid pushing or puling for
3-4hrs 6 weeks
Increase CK =18hrs Avoid leg crossing
Increase WBC Elevate surgical limb
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Resume sexual intercourse
after exercise tolerance =
Pt walk one block
Climb 2 fights stairs
Pt with cardiac surgery

are risk for renal
insufficient =
Dec UOP
Inc BUN and Creatinine
Heart failure S and S depends on Avoid canned HF compilations

Dec COP due to impaired the types of HF Decrease after load food Polycythemia
metabolic needs Rt HF (diastolic HF) Increase contractility Clubbing
It has systematic Reduce fluids Fluid
effect Dily wt same time, same restrictions Pt is risk to
Common cause it Lt clothes, same scale, Low Na develop pulmonary
side HF Report increase in 2-3 lb / edema
Edema day
JVD S&S
Abd distention Use diuretics at morning Extreme
Splenomegaly and monitor for breathlessness
Wt gain electrolytes imbalance Dyspnea
S4 heart sound Air hunger
Not to use NSIDs Frothy , pink tinged
Lt side HF (systolic Anula immunization sputum
HF)
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Pulmonary effect Report any wt gain of 5 Treatment for
Common cause is pounds or more / week pulmonary edema
HTN If pt has infective coping = OHDF
Dyspnea nurse encourage a O2
PND supportive group High fowler’s
Orthopnea Diuretics
Tachypnea Foley Cath
Hypertension
S3
Congestive HF (Rt +
Lt HF)
Mixed symptoms
Pericarditis Chest Pain triggers Flowers position Monitor for signs

Inflammation of the by O2 of cardiac
pericardium = lead to loss of Inspiration NSIDS tamponade.
pericardial elasticity = Coughing Administer = Tachycardia and
accumulate fluids Swallowing diuretics hypotension
Worse when lie digoxin = normal level =
supine 0.5- 2mcg
Pericardial friction sign of toxicity

rub= scratchy and dec LOC
high-pitched sound anorexia
Inc WBC
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Myocarditis Fever O2
Inflammation of the Pericardial friction Sitting position
myocardium rub NSIDs
Glop rhythm
Pulsus alternans
Murmur
Endocarditis Fever Record temp q day for 6 R/F

Inflammation of the Syncope weeks Drug users
endocardium layer Petechiae Oral hygiene = avoid Had valve
Clubbing finger flossing replacement
Too many emboli Wt loss
Murmur
Janeway lesions (flat, Monitor for emboli
reddened, non- Renal emboli
tender) Flank pain
Oster’s node Hematuria
Splinter Pyuria
hemorrhage (nail Splenic emboli
beds) Abd pain r/t Lt shoulder
Abd tenderness
Pulmonary emboli
Chest pain
Dyspnea
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Cough
CNS emboli
Confusion
Aphasia
Dysphasia
Cardia tamponade Dec COP Inc COP by given

Occur when 20-50 ml DNV Dopamine
accumulate in the heart cavity. JVD 2 liters for NS
Inc CVP
Pulsus paradoxus
Narrow pulse
pressure
Tachycardia and
hypotension
Hypertension -HTN Normal Check BP Low fat R/F

120-80 Current medication Low Na African American
BP > 130/ > 80 90-60 Avoid smoking and alcohol High K+ Old age
Reduce the wt High Ca CAD
Asymptomatic Obesity
Headache Hypertensive crisis Stress
Visual disturbance BP is over 180/120 Smoking
Epistaxis High salt intake
Immediate reduction of
BP
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Emergency medications
Airway
Catheter
Bed rest with HOB 45
degree
Monitor BP q 5 min
Valvular disease Valve replacement
Stenosis Thromboembolism is the
Regurgitation problem ass with this
surgery= lifetime
anticoagulant is required
Report any bleeding
Good oral hygiene and
avoid flossing
Avoid dental procedure
for 6 months
Avoid heavy lifting
Deep vein thrombosis Calf or groin Bed rest

tenderness Warm and moist
Positive Homans sign compression
Warm skin Elevate the extremity = q
10-20 min q few hours
Don’t massage the leg
Avoid using pillow under
the knee
Monitor aPT
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Cardiac arrhythmias
Arrhythmias Descriptions Treatment Notes

Sinus rhythm Normal Monitor for HR and rhythm
HR = 60-100
QRS < 0.12
PR interval = 0.12 – 0.20
are normal
Sinus bradycardia HR< 60 Atropine

TCP = transcutaneous
pacing
Sinus tachycardia HR> 100 -180 Digoxin Hypotension

Volume depletion
Atrial flutter HR = 250-400 Cardioversion Cardioversion
Sawtooth P wave Amiodarone Selective
No PR interval Metoprolol Hold digoxin, sedation, stop o2,
Normal QRS Diltiazem give it
Emergent
Such as pt With SVT
Synchronized
Counter shock to convert to
stable rhythm
Avoid discharge wave during T
wave
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If not synchronized
Could discharge on T wave and
cause VF
Atrial fibrillation HR = 350-600 b/m or >400 Cardioversion Can lead to thrombus formation
No P wave or wavy P O2 Immediate intervention if pt
wave ABCD report
Irregular A= Anticoagulant Light headedness
B= Beta blocker = Dizziness
diltiazem
C= Cardioversion = after =
maintain airway, o2, VS
D= Digoxin
Super ventricular Give adenosine rapid in 8
tachycardia (SVT) HR= 150-250 b/m second and push with NS
Hidden P wave
Regular rhythm Adenosine cause a systole
for seconds
Ventricular tachycardia HR= 140-180 or 140- Pt with pulse Can lead to cardiac arrest
(VT) 250b/m Amiodarone Can lead to VF
No P wave O2 Pt may experience impending
Life threating No PR interval Synchronized doom
Regular rhythm cardioversion
Wide bizarre QRS
Pt without pulse
Defibrillation In CPR
Pads = Compression is 100-120
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1st = 3rd intercostal space Depth 2-2.4 inches

to Rt Allow chest recoil
2= 5th intercostal space to Compress rotated q 2 minutes
Lt ore q 5 cycles
CPR
Epinephrine
Ventricular fibrillation Irregular chaotic Defibrillation – 120-200 Pt can develop metabolic

(VF) No visible P or QRS wave joules acidosis
Irregular rhythm CPR = for 2 minutes
Epinephrine
A systole Straight line Epinephrine IV push Priority to check monitor
No HR CPR electrode
Sinus rhythm
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Atrial fibrillation
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Pacemakers
o Use cell phone on the opposite side

o Wear loose fitting clothes
o Inform security about pacemaker
o Don’t lay your phone on your chest
o Bath and shower are not restricted
Shocks
Restless = is a sign of hypoxia – brain is not getting enough o2
• State when vital organs don’t enough o2

• Cardiovascular system consists of
o The blood
o Vascular
o Heart
• Types of shocks
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o Hypovolemic
▪ Low blood flow due to – bleeding- dehydration- vomiting/ diarrhea, loss of plasma -burn,
▪ Tachycardia
▪ Weak
▪ Pale
▪ Hypotension
▪ Dec LOC
▪ Treatment
• Stop the cause
• Give IV fluids – isotonic – NS- LR
• Administer blood products
• Administer vasopressor
▪
o Cardiogenic shock – causes – MI – PE – Cardiac tamponade.
o Heart failed to pump blood
o Sign and symptoms
▪ Hypotension
▪ Tachycardia
▪ Dec UOP
▪ Dec LOC
▪ JVD
▪ Crackles
o Treatment
▪ Treat the cause
▪ Improve contractility
• Dopamine
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• Dobutamine
▪ Decrease afterload
• Diuretics
• Dobutamine
▪ Tamponade
• thoracentesis
o Distributive shock
▪ Massive vasodilation
▪ Immune response
▪ Warm flushed skin
▪ Types
▪ Anaphylactic
• Allergic reactions
• Rash
• Swelling
• Wheezing
• Epinephrine
• Corticosteroid
• Steroid
▪ Neurogenic
• Spinal cord injury
• Priapism
• Cooling
• Supportive care
o
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▪ Septic
• Systemic infection
• High fever
• Infection
• Iv antibiotics
• Iv fluids
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Gastrointestinal NCLEX
Diseases Assessment Interventions Diets Notes
GERD Heart burn PT avoids Low fat Assess for gag reflex is
Dyspepsia Peppermint High fiber priority
N/V Chocolate
Coffee
Beverage
Smoking, use of NSIDs
Fatty or fried food
Avoid eat or drinks 2 hours
before bedtime
HOB 15-20
Wear loose fitting clothes
Gastritis Causes are

Avoid Avoid citric foods Overuse of aspirin or
Spicy food and spicy foods NSIDs e.g.,
Alcohol (indomethacin)
Caffeine Excessive use of alcohol
Monitor for sign of Radiation therapy
hemorrhagic gastritis
such as
Hematemesis
Tachycardia
Hypotension
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Peptic ulcer Pain, sharp , mid-epi Administer drugs such as Risk factor
Gastric ulcer 30- 60 minutes or 1-2 Cimetidine is H2 B, help in Stress
hours after meal heartburn, common SE is Use of NSIDs
Pain with eating confusion, take 1 hour apart Alcohol
Pain relived by hunger from antiacid, take with Complications
Hematemesis> melena food, Hemorrhage
Sucralfate, form protective Perforation
layer, give 1 hour before Pyloric obstruction
meal or 2 hours after meal
Misoprostol, coat the If gastrectomy
stomach, given for pt Place pt in fowlers position
receives NSIDs Don’t remove or irrigate
NGT
Omeprazole, proton pump B12 may be administered
inhibitor, reduce gastric
acid, increase the PH of the
stomach, take 30 minutes
before meal, mg
supplement may be used
with it,
Misoprostol is a synthetic
prostaglandin that
protects the gastric
mucosa by decreasing
gastric acid secretion and
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lining the stomach for
protection by increasing
mucus and bicarbonate
secretion. Misoprostol
reduces the risk of NSAID-
induced gastric ulcers, as
NSAIDs decrease
prostaglandin production
and predispose the client
to peptic ulceration.
The client should be

advised not to take
metronidazole with
alcohol since mixing the
two can cause abdominal
pain, nausea, vomiting,
and dizziness. The client
should wait for three days
after the prescription is
complete before drinking
any alcohol.
Monitor for signs of
perforation
Sudden sharp abd pain
Abd rigid and board like
Tachycardia
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Duodenal ulcer Pain 2-4 hours after Same as gastric ulcer
meal
Relived by food
Hunger pain
Melan > hematemesis
Dumping N/V Pt in low flower position High protein Symptoms generally

syndrome Abd fullness during meal High or moderate fat resolved within several
Rapid emptying Diarrhea After meal: lie down for 30 Low CHO- low sugar months to a year
of gastric Borborygmi ( high minutes Dry food
content into pitch bowel sound) Dumping syndrome is
the small Tachycardia not an indicator of
intestine Syncope parenteral nutrition
Vertigo because it is not an
Sweating and pallor absorption issue.
are early signs Dumping syndrome is a
potential complication
after surgical removal of a
large part of the stomach
and pyloric sphincter.
Hiatal hernia Wear loose fitting clothes Risk factors
Remain in upright position Pregnancy
for 2 hours after meal Ascites
Don’t recline for 1 hour Obesity
after meal Heavy lifting
Limit amount of liquid
taking with food
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Avoid anticholinergic
medications
Eat small frequent meal
Cholecystitis Epi pain radiated to the NPO Low fat Cholecystectomy

Inflammation RT shoulder NGT for decompress Post-opertive
of the Pain in the RUQ, trigger Administer Moitor fo resp
gallbladder ass by high fat meal and Antiemetic complications
with gallstone heavy meal Analgesics Early mobilization
N/V Anticholinergics Coughing and deep
Indigestion breathing excersie
Flatulence If pt with T-TUBE
Rebound tenderness Pt semi folwers position
Murphy’s sign (cant Monitor tube output
take breath with Color and odor
doctor fingers are Report increase in bile (
passed below hepatic) normal 750 ml -1000ml) If
more , report to the PHC
Avoid T-tube irrigation,
aspiration, clamping
without doctor order
Pancreatitis Pain in pancreatitis is NPO during acute phase Alcohol is number one
Inflammation described as severe Administer TPN and cause
of the pancreas and maximal in vitamins Lab
intensity. It begins Bed rest Increase
mid-epigastrium and NGT may be used WBC, ALP, glucose,
radiates to the back; bilirubin, lipase,
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sometimes, it radiates Opiates for pain amylase > 150 is abnormal
to the chest, flanks, (hydromorphone), don’t
and lower abdomen. give morphine if pt complins of
Abd pain LUG to the Put pt. in knee chest Abd pain, jaundice, clay
back position stool, and dark urine =
Pain increase by No alcohol notify the physician
Fatty meal
Alcohol
Lying in a recumbent
position
Steatorrhea (fatty
stool) , pancraelipase
drug used to decrease
the amount of fatty
stool
Cullen’s sign = bule

around abd and
umbilicus
Turner’s sign = blue on
the flank
Appendicitis, Pain in periumbilical Avoid use of heat Appendectomy

inflammation area decent to RLQ compression may lead to Pre-op
of the appendix Abd pain at McBurney rupture of the appendix NPO
point Use cold or ice IV fluids
Rebound tenderness Apply ice
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Low grade fever Position side lying or low
fowlers
Sudden pain relief may
indicate rupture or Post- op
perforation Monitor for V/S and sign of
infection
If rupture occurred, wound
may leave open
If pt. had paralytic ileus,
nurse may insert NGT to
compress the bowel
If pulse > 100 monitor for

hypovolemic shock
Ulcerative NPO Low fiber diet Pt is risk for colorectal
colitis Ulcerative colitis has IV fluids High protein cancer
Inflammation clinical features such Monitor = stool, bowel High vitamins
of the large as frequent bloody sound, bowel perforation, High iron
intestine stools, iron deficiency
anemia, colicky Avoid gas forming food =
abdominal pain, fever, Milk product
fatigue, and weight Nuts
loss. Raw fruits and vegetables
Anorexia Pepper
Wt loss Whole wheat grain
Sever diarrhea =
metabolic acidosis
38

Dehydration
Commonly = frequent
bloody stools or
bloody mucus
Rebound tenderness
may indicate
peritonitis
Crohn’s disease Abd pain Infliximab may be used to Avoid cold and hot May required stoma
Inflammation Diarrhea is common reduce diarrhea food May required TPN
of large and Cramp colicky pain Avoid caffeine
small intestine after meal Follow
or terminal Abd distension High protein
ileum N/V/ A High calories
Fever Low fiber during the
exacerbation
Irritable bowel Chch by chronic Chewing food slowly High fiber / bulk May need TPN
diseases diarrhea/ constipation May receives loperamide to Drink 8-10 cups of
Abd pain of floating manage chronic diarrhea liquid/ day
Diverticulosis Pain in the LLQ High fiber diet such Common ins the sigmoid
and Pain aggravated by as colon
diverticulitis coughing, straining, Bran cereal
lifting Fresh peach
Fever Cabbage soup
Blood in stool (
melena) Avoid low fiber diet
such as
39

White toast
Scrambled eggs
Liver cirrhosis Asterixis (flapping Avoid administer of Avoid high protein Serum ammonia level is –
movement of the hepatotoxic drugs such as diet 10-80 mcg/dl
finger and wrist) sedatives, opioids. Eat food high in Risk factors
thiamine such as Alcohol
If pt. develops ascites give: pork, nuts, legumes, Hepatitis c
K+ sporing diuretics wholegrain Complications:
(monitor for hyperkalemia) Portal HTN
Measure Abd grith using Decrease coagulation
the umbilicus Esophageal varices
Jaundice
If pt. develops Ascites
encephalopathy: Pt may have
Common sign is asterixis ECFV deficit
Administer: neomycin and Protein deficit
lactulose to reduce the Na deficit
ammonia level Plasma to interstitial fluid
shift
If pt develops esophageal
varices:
Bleeding is the 1st priority,
control bleeding
V/S
Hb/Hct
40

Hepatitis Hepatitis A
Crowed
Poor sanitation
Transmitted
Fecal oral route
Contaminated foods
Prevention is hand
washing
Hepatitis B and C
IV drug user
Long term HD
HCWs
Transmitted
Blood and body fluids
Infected saliva and semen
Sexual
Parental
Prevention
Hand washing
Blood screening
Hemorrhoids Bright red bleeding Appy cold packs High fiber diet Causes
Dilated anal Rectal pain Sitz bath Increase fluids intake Portal HTN
vein Rectal itching Topical anesthesia Chronic constipation
Straining
Increase abd pressure
Hemorrhoidectomy:
41

Post-op
Prone position
Ice packs
Limit sitting to short
period of time
Use sitz bath 3-4 times/day
Celiac disease Diarrhea Avoid wheat and

Flatulence bread
Abd distension
Eat free gluten diet
such as salmon beet
Anthrax is a bacterial infection treated with antibiotics such as penicillin, doxycycline, and ciprofloxacin.
42
Diagnostic test
Diagnostic test Pre Post

UGIT/ barium swallow NPO – 8 hrs Increase fluids intake
Client drink barium Use of laxative
Chalky white stool is expected (24-72 hrs)
Gastric analysis NPO – 12hrs Refrigerate sample if not tested for 4 hrs
Interest NGT q 15 /m for 1 hr Avoid use of tobacco
Chewing gum -24hrs
Medication that stimulates the
gastric secretions
UGIT endoscopy NPO- 6-8hrs NPO until gag reflex
Medication to relax sphincter Monitor for perforation such as pain,
and reduce secretions bleeding, difficult s, increase temp
Position= on Lt side
Fiberoptic colonoscopy NPO- 4-6 hrs Abd fullness and mild cramping are expected
Lt side with knee up to chest Monitor for perforation and peritonitis such
Clean the colon= enema as
Clear liquid diet guarding abd
increase temp
tachycardia
tachypnea
ERCP NPO – 6-8 hrs V/S
Check allergic to contrast Gag reflex
media Perforations
Multiple positions
CT scan NPO- 4 hrs
43
Diagnostic test Pre Post

Paracentesis for pt. with ascites Check V/S V/S – BP and Pulse
Wt Wt the pt to determine the effectiveness
Ask pt. void Apply dry dressing, not large pressure
Position = up right or fowlers dressing
Monitor for bleeding
Measure Abd girth
Mantin bed rest
Liver biopsy Assess PT, PTT, platelet count V/S

Position- supine or Lt lateral Monitor site for bleeding
Monitor for peritonitis
Position: Rt side with pillow under costal
margin for 2 hrs
Avoid coughing, straining, heavy lifting,
strenuous exercise for one week
Urea breath test Pt consume carbon capsule
Detect H. pylori Provide breath 10-20 /m after
Pt may need:
Bismuth for one month
Omeprazole for one week
Cimetidine for 24hrs
44
Ostomy and tubes
Ostomy Intervention Sites Note

Colostomy Irrigate daily DATS Pt can go back to regular diet
Irrigation use 500-1000ml of tape Descending colon= Lt U
lukewarm water abd Stoma if:
When irrigate pt can sit in toilet, if in Ascending colon= Rt U Normal= pink and moist
bed turn to side abd Retract = concave and bowel
Irrigate same time q day Transverse = mid abd shaped
One hour after meal Sigmoid = lower abd Ischemic = dry, reddish, purple
If cramping occurs – clamp the tube Stenosis= narrowed and
for a while flattened
Pouch attached to stoma and
allowed 1/16 or 1/8 inches around
the stoma
avoid gas forming food such as
Garlic
Fish
Onions
Eggs
Broccoli
Cabbage
empty when it 1/3 or ½ full
reddish appearance of the stoma

as normal.
45

Sterile gloves are not necessary
when performing ostomy care.
moisturizing soap is used, the

moisturizers will inhibit a good
seal to the skin by the wafer
Ileostomy Avoid coffee – can lead to diarrhea Located in Rt LQ Post- op , nurse assess for
Use petroleum gauze complications fluid and
low fiber diet electrolytes imbalance
small frequent meal
increase the fluids intake Post stoma pt can experience
regular diet malodorous flatus, which is
avoid gas forming food such as normal
garlic
fish
onions
eggs
broccoli
cabbage
change bag q 3-5 days

best time to empty is early morning
before breakfast
skin breakdown is possible
never give enteric coating
medications and don’t crush
medications
46
NGT NGT Feeding Lope of ear – tip of nose Goal to be free from dumping
Pt with leukemia will benefit from – xphdoid process syndrome
NGT feeding Two types of NGT
Before feeding Levin tube = Bowel sound
Check for residual, if it is less than Single lumen = used to
250 ml give it back to the client. If > remove gastric Less than 4/min = blockage
250 don’t give back. If it is more than contents by intermittent 14/ min= normal
500ml don’t give the next feeding suction or tube feeding 60/ min = hyperactive
Pt in up right position – 60-90 degree
PH should be < 5.5 Salem sump NGT tube
Change feeding containers and
tubing q 24hrs Double lumen with air
Don’t hang solution > 4 hrs vent – not to clamp the
air vent – if air vent leak –
install 30 ml of air and
irrigate main lumen with
NGT irrigation NS
Perform q 4hrs
Use 30-50 ml of NS or water Used for
Usually connected to intermittent decompression
70 mmHg pressure Intermittent continuous
suction
Disconnect from suction
Draw up to 30 ml in a syringe
Place tip of the syringe into the NGT
Put end of the NGT in irrigation tray
47

Observe for the return of the
drainage
If NGT connected to suction and

you need to give medication.
Verify placement
Turn off the suction
Clam tube for 30 minutes
Turn back the suction
Remove the NGT

Ask pt to take deep breath and hold
it
Remove over 3 –6 seconds
TPN Need for pts; Central line is preferred Not for pt with dumping
Hyperalimentation IBD syndrome
Celiac disease
Burn Complications of TPN
Negative nitrogenous balance Pneumothorax
Infection = 1st priority
Monitor for infection Hpo or hyper glycemia – in 1st
Tube dressing change q day days
Use a septic or sterile technique Hypoglycemia
Infuse 10% dextrose as the
hypo or hyperglycemia same rate as PN
monitor blood glucose q 4-6 hrs
48

don’t stop suddenly – lead to
hypoglycemia Dehydration
stop feeding gradually
administer dextrose 10% in case Air embolism – failure to clamp
there is no TPN solution the tube
Place pt in Lt side position with
usually used hypertonic solution head lower than feet
O2
home teaching:
daily wt, same time same clothes To change the tube and cap =
report wt increase = > 3lb/ week place pt in Trendelenburg
position
Pneumothorax =
PN should not be initiated until
correct verification of catheter
placement
Abdominal paracentesis is performed for clients with gross ascitic fluid due to liver cirrhosis. Nursing care for an
abdominal paracentesis includes -
➢ Witnessing informed consent that the primary healthcare provider obtains
➢ Assisting the client to void before the procedure
49
➢ Obtaining baseline vital signs
➢ Measure the abdominal girth
➢ Gather appropriate supplies (suction, tubing, paracentesis kit)
➢ Position the client per the physician's prescription. The positioning is likely upright to allow the fluid to settle in
the lower abdominal quadrants.
➢ Monitor the client and the drainage
➢ Send the initial ascitic fluid to the lab for culture and sensitivity, as prescribed
➢ Reposition the client, as needed to facilitate better drainage
➢ Monitor the client's vital signs throughout and after the procedure
➢ Administer an infusion of albumin, as prescribed for large volume (> 5 liters) paracentesis
The possibility of ruptured esophageal varices can be brought about by increasing intrathoracic pressure.
Among the activities mentioned, only lifting heavy objects can predispose the client to increased intrathoracic
pressure. The client should, therefore, avoid doing this.
When performing a physical assessment, the most often used sequence is:
1. Inspection
2. Palpation
50
3. Percussion
4. Auscultation
However, palpation and percussion can alter bowel sounds. Therefore, for abdominal assessments, the steps
should be:
1. Inspect
2. Auscultate
3. Percuss
4. Palpate
The client is four days post-op; the client is already expected to have normoactive bowel sounds. However,
the client is exhibiting hypoactive bowel sounds, which signifies a problem.
As part of the preparations for a barium enema, the client needs to be on NPO for 8 – 10 hours. The dietary
department needs to be informed about withholding meals within the NPO period.
51
Endocrine system NCLEX

Hypothyroidism
Decrease the rate Administer Priority nursing diagnosis
Low T4 and high TSH of metabolism levothyroxine Low calorie is decrease COP
S&S Best time the Low cholesterol
Hashimoto morning to avoid Low saturated fat Avoid opioids may lead to
Cold intolerance insomnia myxedema comma
Constipation Take on empty
Periorbital edema stomach Myxedema comma
Dry skin S&s
Brittle hair Warm environment Low
Fatigue BP, HR, TEMP, NA,
Libido GLUCOSE
bradycardia Hypotension
wt gain Hypothermia
anorexia Hypoglycemia
Hyponatremia
Puffiness of the Bradycardia
face and hands
Treatment for myxedema
coma
Priority maintains airway
patent
Give IV levothyroxine
IV dextrose
Corticosteroids
52

Hydrocortisone
ETT at bedside
Graves diseases
Hyperthyroidism INC metabolic rate Cool environment High protein Too much thyroid
High T3 and T4, low TSH Sedative hormones
Heat intolerance Taking medication
Diarrhea can lead to Diaphoresis
Insomnia hypothyroidism Exophthalmos
Exophthalmos Goiter
Wt loss Anti-thyroid drugs Increase appetite
Goiter Metamizole Muscle termer
Tachycardia
Iodine compound When a client is taking
Decrease size and antithyroid medication,
vascularity such as methimazole,
they should be taught
Radioactive iodin about the warning signs
therapy of hypothyroidism
Destroy thyroid cell (weight gain,
Avoid in pregnant constipation, anorexia)
women
Thyroid storm
Thyroidectomy Fever
53

Pre-op Tachycardia
Assess for glucose Hypertension
level Chest pain and SOB
Post -op Confusion
Airway – audible N/V
stridor
Monitor for
respiratory distress
Monitor laryngeal
nerve damage
Keep Tracheostomy,
o2, suction need to
be
at bedside
Monitor for sign of

hypocalcaemia and
tetany, if tetany gives
IV ca gluconate
Position = semi fowler

Avoid neck flexion
54
Hypoparathyroidism PTH functions

Low PTH= lead to = low Ca, Numbness and High calcium diet
and high PHOS tingling in the face Seizure precautions Low phosphorus Move ca from bone to
Muscle cramp diet blood stream
Anxiety Replace ca VIT D supplement
Dry skin Phosphate binders Renal reabsorption of ca
Paresthesia Renal production of VIT D
Seizure Two medications
commonly
Positive prescribed include PTH can decrease due to
Trousseau signs cholecalciferol HIGH Mg and LOW Ca
Chvostek’s sign (Vitamin D3
Hyperactive deep calcium carbonate. Following a
tendon reflexes parathyroidectomy,
aggressive calcium
replacement typically
commences. Two
medications commonly
prescribed include
cholecalciferol (Vitamin
D3) and calcium
carbonate.
Dec Ca = ECG = prolong QT
55

Hyperparathyroidism
High PTH = lead to high ca Pathological Administer High fiber PTH functions
and low phos fracture prednisone = reduce Moderate ca Move ca from bone to
Wt loss or decrease GIT High fiber diet blood stream
Renal stones – absorption of Ca Renal reabsorption of ca
nephrolithiasis Encourage to Renal production of VIT D
Polyuria Furosemide = DEC ca drink 1-2 liters of
Bone pain fluid daily PTH can increase due to
NS for hydration HIGH phos and LOW
catecholamines
Calcitonin =
increases the release PTH causes increased
of Ca by kidney phosphate to be lost in
Decrease Ca releases the urine. Therefore, a
from the bone high serum phos would
cause the release of PTH
to help the body decrease
serum phosphate
Catecholamines, such as
epinephrine, have a
direct effect on PTH.
Increased catecholamines
cause an increase in the
secretion of PTH
INC ca = ECG= shorten ST
segment
56

Diabetes insipidus (DI) Client wt him self
not enough ADH High urine output- same time q day Not consuming Causes
large amount of food promote Kidney problem
diluted urine = diuresis Pregnancy = 3rd trimester
inability to Monitor BP Watermelon Declomycin drug
concentrate urine = Fluid replacement
low specific Hourly monitor UOP = Avoid ADH
gravity (normal urinary catheter Caffeinated causes the kidneys to
1.010- 1.025) = drink release less water
Dehydration Hydrochlorothiazide Decreasing the amount of
is a thiazide diuretic urine produced
Dry skin and and has a
mucous membrane paradoxical effect Keep fluid inside body
when prescribed for
Light headache individuals with Secreted when
diabetes insipidus. Electrolytes get
Polydipsia concentrated
Vasopressin Blood pressure get low
Hypotension medication
Dibanse drug = Inhibited when
Hypernatremia increase the DH Blood volume is high
High HCT >40% Watch pt glucose level

Cover skin from sun
57

SIADH Not mention Lung cancer -most cause
Too much ADH Low urine output - Daily wt Diabinese drug
Less amount of I & O strict
urine = oliguria Monitor serum Na
Seizure precautions
high concentrated
urine= high Fluid restrictions
specific gravity (> To reduce water
1.040) = retention in a client
with SIADH, the nurse
Edema or fluid should restrict fluids.
overload
Give hypertonic
Normal BP OR solution = watch
slight worsening fluid
Hypertension overloads =
Tachycardia Hypertonic IV
solutions (3% - 5%
Hyponatremia = Normal Saline)
neuro symptoms
because increase Give docloymcin =
water inside don’t give with food
contains Ca
Confusion
Irritable Vasopressin
GIT upset
58

Anorexia Diuretics
Furosemide
Low HCT = Anemia
Water intoxication
Addison diseases Hypotension Because of High protein
Hyponatremia hyperkalemia = High CHO Causes autoimmune
Dec secretion of aldosterone Hypoglycemia continuous High or normal disease
and cortisol telemetry sodium
Dehydration Low potassium Aldosterone
Aldosterone is responsible IV hydrocortisone or Regulate BP by= RAAS
for sodium retention and Hyperkalemia prednisone, Increase release if BP or fluid volume
potassium elimination. Hypercalcemia dose during stress go low
Don’t stop sudden
Wt loss Returning sodium
Fatigue Help kidney to hold both
Postural IV fluids (normal water and sodium=
hypotension saline 0.9%) increases blood volume =
Erectile dysfunction increase blood pressure
Increase skin Fall precautions
pigmentation Help kidney to get rid of K+
Diarrhea No vigorous exercise
Depression
Striae on the Monitor for Cortisol – stress hormone,
extremities and hypoglycemia Increases glucose in the
abdomen (Purplish) bloodstream
59

Give cortisol such Break fat and regulate
hydrocortisone electrolytes
Aldosterone dugs
Make sure they
consume enough
sodium
Avoid stress
Addisonian crisis
Life threatening
S&S
Hypotension
Hyperkalemia
Hyponatremia
Sudden pain in abd

Shock
Unconscious
Sever vomiting and
diarrhea
Treatment
IV cortisol
The priority for the
nurse is to
administer the
60

prescribed
hydrocortisone to
prevent the client
from developing a
life-threatening
Addisonian crisis.
Cushing syndrome Monitor High in K+ Causes
Excess production of cortisol Hypertension BP High protein Cushing syndrome
and ACTH = act as diuretic = Hyperglycemia 1&O Low fat or fat Outside cause = medication
execrate k+ and water Hypernatremia WT restrictions on prednisone
WBC = because pt is Low Na
Hypokalemia risk for infection = Cushing diseases= inside
Hypocalcaemia because is cause= pituitary gland
(Osteoporosis)= immunocompromise produce too much
increased risk for = standard hormone
fracture precautions Dexamethasone used to
differentiate between
Acne Monitor Cushing syndrome and
Hirsutism – NA, K, CA, GLUGOSE Cushing disease
excessive hair In Cushing triad
Buffalo hump Do wt exercise Irregular heart rate
Trunk obesity Bradycardia
Round face – moon Prepare Wide pulse pressure
face Adrenalectomy
Reproductive issue Hypophysectomy:
Bruise easy
Depression Check BP
61

K+
Diabetes mellitus S & S DM In illness, infection, Low sugar Type 1 no insulin

Normal BG= 70-110 Mg/dl stress, increase the Low fat
Wt loss dose of insulin Control CHO Need insulin for treatment
Hyperglycemia
3ps Regular insulin can be Exercise Type 2 few or resistance
Polydipsia given IV injection or IV No exercise if insulin
Polyphagia push Blood glucose>
Polyuria 250 Risk factors type 2
Regular and short Urinary ketones Abd obesity
Hypoglycemia duration can be given When glucose is Increase triglyceride and
BG< 70Mg/dl IV infusion peaking low HDL
S &S Metabolic syndrome
Diaphoresis Regular insulin only Don’t inject insulin
Hunger on can be given IV to the area that Complications
Pallor Active about 6-8 will be exercised Microvascular
Shakiness hours, and peak in Retinopathy
Light headaches 2-4 hrs Exercise: Nephropathy
Irritable One hour after Neuropathy
Termers NPH, Intermittent meal
Nervousness action, peak in 4-10 Best after Macrovascular
Paresthesia hrs breakfast Hypertension
Palpation After consuming Cardiomyopathy
Cool and clammy 10-15g of CHO CVA
skin
62

Blurred vision To prevent glucose levels Pre-op DM
lipodystrophy, rotate will initially rise Withhold hypoglycemic
Administer 15 g of insulin site with exercise agent or insulin
CHO
Check BG, IF < 70, Don’t use site > once Foods to treat Long acting = withhold 24-
give a 2nd 15 g, for 2-3 weeks hypoglycemia 48hrs
check BG, IF < 70, Clean skin with 1 small box of
GIVE 3rd 15 g CHO, alcohol before injects raisins Metformin = stop = 48 hrs
check BG IF <70 1 candy par
give 50% dextrose Clients can increase ½ cup of juice
IV, if not AV, give risk for hypoglycemia 1 cup of milk
glucagon, 1 mg SQ if Hyperglycemia
or IM Has DKA and is s&s
receiving IV insulin
IF pt is not tachycardia
conscious, inject Received 10 units of increase urine Sulfisoxazole and other
50% dextrose IV OR lispro one hours a go output sulfonamides are
1mg glucagon orthostatic chemically related to oral
For client receiving hypotension antidiabetic agents and
DKA continuous infusion may precipitate
Life threatening of regular insulin hypoglycemia.
for type 1 nurse monitor
Blood glucose and K+
Priority is short level
insulin IV
AIC checked q 90 days
or 3 months
63

If BG> 250 notify The goal is < 7%
physician
Monitor for INC

ICP
S&S Hyperosmolar
Thready pulse hyperglycemic
Tachycardia syndrome (HHS)
Orthostatic Increase BG without
hypotension acidosis or ketosis
Hyperglycemia Occur with type2
Comatose state
Deep rapid Immediate action is
breathing fluid correction – IV
(Kussmaul NS
respiration)
Treatment similar to
DKA
Dehydration = Fluids
may lead to Insulin
hypovolemic shock- Electrolytes correction
keep MAP >70
DKA treatment aims
Metabolic acidosis to lower the blood
glucose by 50 to 75
Treatment for mg/dL/hr. This is
DKA accomplished by the
64

Treat dehydration prescribed regular
= rapid IV infusion insulin, which is given
of 0.9% NS, OR intravenously.
0.45% NS.
Add dextrose IV
when blood
glucose reaches
250-300 mg/dl
For
hyperglycemia= IV
insulin
Correct
electrolytes level
= hyperkalemia =
administer IV
infusion K+ =
monitor for RF and
connect pt to the
cardiac monitor
65
Glargine insulin is long-acting insulin with no peak. This insulin does not need to be withheld when a
client is NPO.
Insulin types
66
Oncology NCLEX
• When things go wrong….
• Cells start dividing uncontrollably
• They may spread (metastasize) into other tissue
• The body’s immune system doesn’t flag them like it should
• Their growth continues on unchecked
Terminology
• Benign - not cancerous

• Malignant – cancerous
• Blasts - Immature white blood cells
• Lymphoid - tissue that makes lymphocytes; lymph tissue
• Myeloid - tissue of the bone marrow
• -lymphoma - arises from the lymphoid tissue
• -myeloma - arises from the myeloid tissue
• -carcinoma - arises from the surface, or epithelium
• -sarcoma - arises from the connective tissue
Cancer stages and grading
Grading is = differentiate
• Growth
• Rate
• Spread
• Grade I= well differentiate
67
• GRADE II= moderately differentiate

• GRADE III= poorly differentiated
• GRADE IV = undifferentiated
Staging = metastasis
• Stage 0= in site – localized

• Stage 1= tissue of origin
• Stage 2= local spread
• Stage 3= extended
• Stage 4= distant spread
Treatment
Chemotherapy
• Causes immunosuppression
• Destroys cancer cells
• Stops cancer cell growth
• Prevents cancer cells from metastasizing
• But….this destroys healthy cells too.
Common side effects
• Anemia = Fatigue
• Thrombocytopenia = Bleeding risk
• Neutropenia = Immunosuppression = High infection risk
• GI upset =Loss of appetite =Nausea = Vomiting
68
• Alopecia
• Mucositis
Chemotherapy precautions
• Pregnant nurse should avoid preparation of chemotherapy

• Monitor for phlebitis
• If extravasation occur
o Stop
o Notify physician
o Apply ice or warm
o Administer antidote
• Measure pt height and weight
• Monitor ca and uric acid levels
• Chemo is administered by nurses with specialized training
o Administered with special gloves and PPE
o Oral chemo at home
▪ Only the patient and caregiver should handle the medication
▪ Wash your hands before and after handling the medication
▪ Wear gloves while handling
▪ If the medication spills, clean the spill right away.
▪ If the medication gets on the skin, wash and rinse using soap and water right away.
• Bodily fluids
o Handle anything soiled with bodily fluids with care
o Clean up any spills right away ○
o Wash anything soiled with bodily fluids separately
• Family education neutropenic
69
o Educate the family about the HH
• The neutropenic client should wear a mask when leaving their hospital room to prevent exposure to
droplets and airborne pathogens.
• Neutropenia is a condition associated with a low neutrophil count, a type of white blood cell. Neutrophils
are made in the bone marrow and fight off infections. With a low neutrophil count, the client is more
susceptible to infections, and preventive measures must be implemented.
• Avoid uncooked meats, seafood, eggs, and unwashed fruits and vegetables.
Radiation therapy
• External = teletherapy = don’t pose risk

• Internal= brachytherapy = pose risk
Internal Radiation Precautions
• Wash your laundry separately from the rest of the household, including towels and sheets.
• Sit down when using the toilet (both men and women) to avoid splashing of body waste.
• Flush the toilet twice after each use, and wash your hands well after using the toilet.
• Use separate utensils and towels.
• Drink extra fluids to flush the radioactive material out of your body.
• No kissing or sexual contact (often for at least a week).
• Keep a distance away from others in your household.
• Avoid contact with infants, children, and women who are pregnant.
• Avoid contact with pets.
• Avoid public transportation.
• Plan to stay home from work, school, and other activities.
• Don’t exposure area to the sun
70
• don’t use powder or lotion

• limit work or visit for 30 minutes
• place in private room with private bath
• rotated nurses
• wear lead shield and apron
• wear dosimeter film
• close the room door
if sealed radiation is come out
• pt stay still
• use long handle forceps
• deposit radioactive source in lead container
side effects pf radiation
• alopecia
• skin irritation
Leukemia
• Affect the bone morrow causing

• Decrease in RBCs, WBCs, and Platelet
• RBCs → anemia
o Hemoglobin levels are considered alarming and may require blood transfusions when below 8 g/dL.
Normal hemoglobin is 14-18 g/dL for males and 12-16 g/dL for females.
• Platelets → inability to clot
• WBCs → infection
71
Classifications
• Acute Lymphocytic Leukemia (ALL)

o The immature cells that the body is producing too many of are lymphoid cells.
o Most common in 2 to 5 year olds
o Treatable and more common
o 85% survival rate.
• Acute Myelogenous Leukemia (AML)
o The immature cells that the body is producing too many of are myeloid cells.
o Poor outcomes
o 27 % survival rate
Assessment
• Anemia = fatigue
• Bleeding= Bruising
• Infection = Fever
• Wt loss
Intervention
• Eliminate
o Fresh or raw fruits and vegetables
o Fresh flowers
o Standing water
• Should not receive live virus vaccine such as
o MMR= measles = mumps = rubella
o Influenzas
o Piolo
72
• Monitor for sign of internal hemorrhage

o Pain
o Rapid weak pulse
o Increase abd girth
• Pt should avoid
o Rectal temp
o Suppositories
o Enema
o Use of NSIDs
• Nutrition
o High protein
o High calories
o High CHO
Lymphoma
• Cancer of the lymphatic system

• Affects the lymphocytes
• Impairs the body’s natural immune response
Classifications
• Hodgkin’s
o Localized, single group of nodes
o Reed-Sternberg cells are present
o Extranodal involvement not common
• Non-Hodgkin’s
73
o Multiple lymph nodes are involved

o Reed-Sternberg cells are not present
o Extra nodal involvement is common
o Most common type of lymphoma
Assessment
• Painless swelling of lymph nodes

• Fatigue
• Fever
• Night sweats
• Infections
• Weight loss
• Enlarged liver of spleen
Myeloma
• Effect plasma cell in the blood

• Lead to increase in uric acid and Ca++
Assessment
• LAB = urine analysis Bence johns proteinuria

• Risk for osteoporosis = pathological fracture
• Increase fluids intake = priority
• Hypercalcemia + increase BUN level
74
Lab for multiple myeloma
• Hypercalcemia
• Anemia
• Infection
• Pathological fracture
• Renal failure
Testicular cancer
• Occurs B/ W age = 15- 40yrs

• Performed testiest exam same time q month after a warm bath
• Risk factor are
o HIV
o Family history
o Abnormal testicle development
o History of testicular cancer
o History of undescended testicle
• Post op-
o Apply ice
o Avoid heavy lifting and strenuous exercise
Treatments
• Orchiectomy =Removal of the testicle

• Radiation therapy
• Chemotherapy
75
Prostate cancer
• R/F
o Increase after age of 50
o African American
o Alcohol abuse
o High fat diet
o Farmers
o Painters
Diagnose by biopsy
Assessment
• Painless hematuria
• Pain from lumbosacral to leg
• Increase PSA = it also used to monitor response to the tt
Surgery
Post-op
• VS
• UOP
• Increase fluids to 2000-3000 L/day
• Mintor Hb and Hct
• Red urine for 24hrs – turn to amber in 3 days = normal
• Bleeding – red colour
o Increase bladder irrigation
o Notify surgeon
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• Monitor for sign for tu syndrome

o Mental status
o Brady cardia
o Confusion
o Hypertension
• Removal of the suprapubic gatherer if the residual urine is 75ml or less
Cancer of the bladder
Assessment
• Most common sign is Pain less hematuria
Intervention
• Chemotherapy = administer through urethral catheter and retained for 2hrs= and the pt position rotated
q 15- 30 minutes
• 6 hours following the chemotherapy , disinfect the toilet with beach after pt void
• Post op
• Suprapubic catheter may be left for 2 weeks
• Continuous bladder irrigation (CBI)
o If obst occurs, turn the CBI off = irrigate with 30-50 ml- if not – notify PHC
o If urine become bloody = rest and increase fluids= no improvement= notify physician
• Pt avoid for 2- 6 week
o Sex
o Stressful exercise
o Heavy lifting
o Driving
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• Female with bladder cancer may experience = vesical vaginal fistula
• Metastasis is the travel of cancerous cells from one area of the body to another. The brain is not a
common site of metastasis for bladder cancer. Cancers at risk for brain metastasis include breast
cancer and lung cancer.
• The lung, liver, and bone are all common sites of metastasis in bladder cancer. The pelvic structures
are also common sites of bladder cancer metastasis.
Cervical cancer
• R/F
o HPV
o Smoking
o Early sex and multiple sex
• Assessment
o Foul smelling
o Leakage of urine and feces
• Treatment = hysterectomy
• Post op
o Limit stairs claiming for one month
o Avoid sex for 3-6 weeks
o Monitor for vaginal bleeding = if more than 1 saturated pad / hr = excessive bleeding
•
Ovarian cancer
• Age 55-65yrs
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• Nulliparity
• advancing age
• family history
• early menarche.
Assessment
Increase tumor marker (A-125)
If advanced ovarian cancer nurse expect
• Abd distension
• Urinary frequency and urgency
• Pleural effusion
Breast cancer
R/F
• Overweight or obesity
• Nullipara
• Early menarche
LAB
• Breast biopsy
• Assessment
o BSE
o Common site = upper outer quadrant (UOQ), beneath the nipple or axilla
o BSE = performed 7-10 days after the menstrual
o Pealed orange skin
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Treatments
• Lumpectomy =Removing the tumor from the breast ●

• Mastectomy = Removing the entire breast
• Chemotherapy
• Hormone therapy
o Tamoxifen
Post op
• Client in semi fowler

• Turn to the unaffected side with arm elevated
• Elevate the arm above the heart level to prevent lymphedema
• No IV, BP check , venipuncture on the side of the mastectomy
Gastric cancer
R/F
• H. pylori
• Diet
• Smoking
• Alcohol
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Treatment
Gastrectomy
Post op
• Monitor for NGT suction = bloody in the 1st 24hrs – change to brown- change to yellow – then clear =
normal = nurse continue monitoring
• Don’t irrigate the NGT
• Before diet = make sure bowel sound , bowel movement, peristalsis returned
• Diet is – NPO- sips of water – 6 small meal
Intestinal tumor
Assessment
• Blood in stool
• Abnormal stool = ascending colon = diarrhea = descending colon= constipation
Complications
• Bowel perforation
• Peritonitis
• Hemorrhage
• Fistula formation
• Inessential Obst
Monitor for bowel perforation =
• Rapid weak pulse
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• Abd distention
Monitor for intestinal obst
• Constipation
• Pain
• Vomiting fecal
• Early sign = increase bowel sound
• Late sign = decrease bowel sound
Observe stoma color.
• Red and pink = normal

• Pale and pink = dec HCT or HB
• Purple and black = compromised circulation
• Avoid food that cause excessive gas such as
o Garlic
o Broccoli
o Cabbage
o Onion
Lung cancer
R/F =smoking
Assessment
• Hemoptysis
• Wheezing
• Hoarseness
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• Cough
• Shortness of breath
• Difficulty Swallowing
Interventions
Surgery
• Wedge resection
• Lobectomy
• Pneumonectomy
• Chemotherapy
• Airway is priority for pt with lung
• Assess for tracheal deviation
• After pneumonectomy = no use for chest tube
Diet
• Increase calories.
• Increase protein
• Increase vitamin
Expected oncological emergencies for pt with lung caner
• Sepsis
• DIC
• SIADH
• Spinal cord compression
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o Epidural spinal cord compression is a medical emergency that often causes the client to experience
back pain, a decreased range of motion, and reduced deep tendon reflexes.
• Hypercalcemia
• SVCS
Oncological emergencies
• Tumor lysis syndrome

• Superior Vena Cava syndrome
• DIC
Tumor Lysis Syndrome
• TLS is characterized by many tumor cells that are destroyed rapidly. This destruction causes an
intracellular leakage of potassium and purines. Hydration is an effective way of preventing TLS
because it causes dilutional effects in the serum.
• Hyperkalemia
• Hyperuricemia
• Hyperphosphatemia
• Hypocalcaemia
• A key intervention for the nurse is educating the client about drinking at least three to five liters of
water daily. Medications used for TLS include allopurinol which may decrease the uric acid secreted by
the lysed cancer cell.
Superior Vena Cava Syndrome
• Early sign are Cyanosis and mental status change

• Headache
• Non-pulsated DNV
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• Upper limb edema

• Blurred vision.
• Facial plethora
• Frequent clinical features of venous congestion in superior vena cava syndrome include blurred vision,
hoarse voice, stridor, dyspnea, and nasal congestion.
Infection
• Increase risk for gram negative organism
SIADH
• Hyponatremia
• Water intoxication
• Change in consciousness
• Wt gain
• Muscle weakness
• Fluid restriction
• Increase Na intake
Iron deficiency Anemia
Lack of RBCs , Hb due to blood loss or dec RBCs production, malabsorption
Assessment
• Fatigue
• SOB
• Tachycardia
• Chest pain
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• Weakness
LAB values
• Low Hb
• Low Hct
• Low MCV
• Low RBCs = microcytic and hypochromic
Foods high in iron
• Eggs
• Carrot
• Kale
• Raisin
Treatment
• IV iron = give by Z track method
Oral iron
• Take B/W meal

• Take with vit C
• Don’t take with milk and antiacid
Liquid iron
• Take through straw and brushed teeth
Iron side effect
• Constipation
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• Black stool
Vit B12 anemia
• Deficiency in vit B12

• Macrocytic
• Smooth beefy tongue
• Paresthesia of the hand and feet
Intervention
Increase diet high in vit B12
• Citrus fruits
• Dried beans
• Green leafy vegetables
• Liver
• Nuts
• Lentils
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Neurology NLCEX
lumbar puncture
❖ Between L3-L4
❖ Contraindication for patients with increase ICP
❖ Pre LP, nurse, bladder empty, the client is asked by the nurse to empty his bladder before the
procedure begins. This should be the first action of the nurse.
❖ Patient positioned in lateral recumbent position with knee up to abdomen
❖ Post LP, nurse, patient positioned flat or supine
❖ Hydration is a primary treatment for post-lumbar puncture headache. Increasing the client's fluid
intake would facilitate the restoration of the client's cerebrospinal fluid volume.
❖ Recognize the most appropriate nursing intervention for a post-lumbar puncture client experiencing a
headache is to increase the client's oral fluid intake.
hyperalgesia
❖ At risk for abnormal and irreversible pain related to hyperalgesia” is an appropriate nursing diagnosis for
a client who is affected with hyperalgesia. Hyperalgesia, which is synonymous with hyperpathia, is
abnormal pain processing that can lead to the appearance of neuropathic pain that is irreversible if
left untreated.
Pain
❖ Minimizing and challenging the client’s report of pain/pain intensity is in violation of the American
Nurses Association’s standards of care about pain/pain management.
❖ The client’s current vital signs would NOT be included in a client's pain history.
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❖ The perception of pain and its impact on our clients greatly varies among people. For example,
gender, cultural beliefs, and individuals' unique pain thresholds all impact our clients’ perceptions of
pain.
❖ To test peripheral responses to pain, health care providers should apply pressure to outer body parts
such as the toes or fingers. Pressing on the patient’s nail bed is the most appropriate action.
❖ The leading and single MOST crucial indicator of the intensity and presence of pain is the client’s
reports of pain to the nurse and other healthcare providers.
❖ Chronic pain is pain that may be limited, intermittent, or persistent that lasts beyond the average healing
period. Examples of chronic pain include pain that is related to cancer, injuries (especially those that
involve the nerves), and fibromyalgia.
❖ Acute pain is generally rapid in onset and varies in intensity from mild to severe, as occurs with an
emergency appendectomy, a ruptured aneurysm, and suffering from burns.
❖ Neuropathic pain describes constant inflammation or irritation of nerve cells. Examples of
neuropathic pain sources include CNS lesions, stroke, tumor, multiple sclerosis, sciatica, shingles, and
phantom limb pain.
❖ Nociceptive pain is typically predictable and temporary based on the injury. Examples of nociceptive
pain sources include kidney stones, menstrual cramps, muscle strain, venipuncture, and arthritic
joints.
Rehabilitation
❖ should start early in the treatment. This provides the patient with an optimistic atmosphere and makes
the transition to discharge a lot easier.
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Multiple sclerosis
❖ In clients with multiple sclerosis, an autoimmune reaction occurs.

❖ During plasmapheresis, these antibodies are removed from the client's plasma, removing the cause of
myelin sheath demyelination.
❖ Age 20-40yrs
❖ Lumbar punctures indicate increase in gamma globulin
❖ Signs and symptoms are, weakness, fatigue, depression, vision, sexual dysfunction
❖ Treatment includes corticosteroids, immunomodulators to prevent exacerbations and delay
eventual disability, antidepressants, and/or supportive care.
Guillain Barré syndrome
❖ Guillain Barré is a polyneuropathy manifested by paralysis, paresthesia, autonomic disturbances, and

depressed or absent reflexes.
❖ Respiratory failure is common, intubation tray should be ready
❖ Major concern is difficulty in breathing, nurse should monitor RR closely
❖ The paresthesia is typically found in the peripheral extremities and may persist for quite some time,
even after the return of motor function.
❖ The nurse should recognize Guillain Barré quickly and ensure a patent airway, as the ascending
paralysis may impact the diaphragm.
❖ Usually start by GIT infection or URT infection, nurse may ask patient if he or she had these infections in
the previous months.
❖ CSF increase in the protein level
❖ To help client cope with the disease, nurse should, encourage relationship, provide accurate
information, give positive feedback
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❖ When speaking with a Guillain-Barré syndrome client, recognize the importance of inquiring about
recent respiratory and/or gastrointestinal infections.
❖
Bell’s palsy.
❖ Prednisone or another corticosteroid is likely to be prescribed.

❖ Antivirals are controversial, but some studies show that the combination of antivirals with
corticosteroids may be helpful in patients with severe facial drooping.
❖ Physical therapy to massage facial muscles can help to minimize permanent damage.
❖ Eye lubricant (i.e., typically artificial tears) must be applied as often as every hour during the day to
keep the eye moist and prevent corneal drying. A moisturizing eye ointment may be used at night.
❖ Recognize that when caring for a client with Bell's palsy, the plan of care should include an order from the
health care provider (HCP) to apply eye lubricant to prevent corneal drying.
Alzheimer’s disease
❖ The client is displaying acute confusion.

❖ The best response for the nurse would be to provide the client with additional food as he requests it.
❖ There is no use in arguing with the client.
❖ Alzheimer’s patients have difficulty completing activities of daily living. However, the nurse should
prioritize client safety over other problems.
❖ Safety should be the highest priority for the client.
❖ Caregivers need to embrace a patient-centered approach that allows people with dementia to
maintain as much autonomy and control as possible, while still preserving their safety.
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❖ Nursing interventions for Alzheimer's patients with "agitation" include providing a safe environment free
of external stimulation and offering calming emotional support. Therapeutic touch (Placing an arm
around the shoulders is comforting and provides reassurance to an agitated patient.
❖ Understand that therapeutic touch is an effective modality in reducing agitation in Alzheimer's clients.
Delirium
❖ is an alteration in mental status that occurs abruptly.

❖ Delirium, unlike dementia, is reversible with treatment.
❖ Contributing factors for delirium include fever, hypoglycemia, and infection.
❖ An acute illness (fever, sepsis, infection) typically causes delirium, so delirium often has an abrupt
onset (Choice A) with rapid progression.
❖ Delirium is typically reversible when the underlying illness is resolved. Delirium typically lasts for
hours to days, whereas dementia lasts for months to years and is usually irreversible.
Spinal injury
Autonomic dysreflexia
❖ is a severe, life-threatening condition that can occur secondary to a spinal cord injury. In response to a
noxious stimulus such as full bladder, line insertion, or fecal impaction, the body mounts an exaggerated
sympathetic response that causes bradycardia, hypertension, facial flushing, nasal congestion, and
sudden headache.
❖ If left untreated, autonomic dysreflexia can cause cerebral hemorrhage, pulmonary edema, and
seizures.
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❖ When caring for pt with autonomic dysreflexia, Nurse keeps the bed linen wrinkle free, prevent
unnecessary touch on the lower limbs, turning and reposition q 2 hours, catheter q 4-6 hours,
decrease the BP, adjust the temperature of the room, maintain bowel regularity,
❖ Elevate the head of the bed is priority
❖ Dorsiflexion is the most appropriate position to prevent foot drop in a client on bed rest following a
spinal injury.
❖ Patient with spinal shock nurse will notice flaccid paralysis
❖ Client with halo device cannot drive
❖ When transferring pt with Spinal cord injury in T4 from bed to wheelchair, nurse move client upper body
first into the wheelchair
❖ C6-C7 spinal cord injury (SCI) can still retain some ability to extend shoulder, arms, and fingers with
compromised dexterity in the hands and fingers.
❖ In acute rehabilitation of C6/C7 SCI patients, the focus is on strengthening the upper extremities to the
maximal level in patients with complete paraplegia.
❖ Rehabilitation often will focus on learning to use the non-paralyzed portions of the body to regain
varying levels of autonomy. Upon successful treatment, survivors of injuries at the C6/C7 level may be
able to drive a modified car with hand controls.
❖ Post spinal surgery, the priority is logrolling the client when moving him
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Brown-Sequard Syndrome
❖ may be due to traumatic or non-traumatic injuries.

❖ However, traumatic injuries such as gunshot wounds, stab wounds, motor vehicle accidents, or
blunt trauma are more common causes than the non-traumatic etiologies.
❖ Brown-Sequard syndrome is an incomplete spinal cord injury characterized as

a weakness/paralysis (hemi-paraplegia) on the ipsilateral (same) side of the body and sensory
loss (hemianesthesia) on the contralateral (opposite) side of the body below the level of injury
❖ At the level of the injury, there is complete loss of sensation and flaccid paralysis.
❖ Below the level of the injury, there is spastic paralysis and Babinski reflex (extensor plantar
response) on the ipsilateral side.
❖
Cervical spinal surgery
❖ Difficulty swallowing liquids indicates nerve damage that requires immediate follow-up. Following
cervical spinal surgery, the client is likely placed in a cervical collar for a prescribed period.
❖ Manifestations that need to be reported following cervical spinal surgery include numbness and
tingling in the upper extremities, difficulty swallowing, decreased motor strength, and respiratory
depression.
❖ Respiratory rate is essential to monitor when a cervical spinal cord injury is sustained.
❖ The upper cervical spinal nerves innervate the diaphragm to control breathing. Thus, specific injuries to
the cervical spinal cord could be catastrophic
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Traumatic brain injury
❖ Open – torn in dura matter

❖ Closed – dura matter is intact
❖ Concussion – jarring – may or may not loss the LOC
❖ Contusion – bruising, occurs with other injury
❖ Fracture
❖ Nuchal rigidity should not be examined until spinal cord injury rolled out
Basilar skull fracture
❖ Halo's sign is an indication of a basilar skull fracture. Rhinorrhea can occur from a basilar skull
fracture. When this finding is assessed, the provider can place a drop from the nose onto a piece of gauze.
❖ CSF test positive for glucose
❖ The CSF will form a ring around the outside of the drop. This is halo’s sign.
❖ Battes sign- bruising over the mastoid bone
❖ Racoon sign- bruising in the preorbital
❖
❖ Don’t insert NG tube, orogastric tube may be inserted
❖ Impaired tactile sensation
❖ is often caused by peripheral neuropathy secondary to diabetes.
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❖ Peripheral neuropathy, a long-term complication of diabetes, is characterized by the person’s inability to

feel things like heat, cold, and a painful stimulus like the prick of a needle in their feet.
Stroke
❖ The client is manifesting signs of increased intracranial pressure. This situation warrants immediate
medical intervention to decrease the ICP. The nurse needs to notify the physician immediately.
❖ According to the AHA, the immediate general assessment and stabilization should include:
❖ assess the ABCs and vital signs, provide oxygen as needed, obtain an IV, check glucose and treat as
needed, perform an essential neurologic screening, activation of the stroke team, order an
immediate CT or MRI of the brain, and obtain an ECG. All of these actions should be included within the
first 10 minutes after arrival at the ED.
❖ The decision of whether or not to give rtPA will depend on the results of the CT scan or MRI.
❖
❖ A client with stage I dysphagia has severe difficulty swallowing. These clients must be fed puréed
foods. Stage I dysphagia clients are fed diets consisting of primarily puréed foods, including puréed
fruits, vegetables, and meats. Additional foods include gravies, puddings, egg yolks, and baby foods .
❖
❖ When providing care for a client experiencing post-CVA cognitive difficulties, nurses should adapt
communication to maximize understanding. Ideally, communication should be spoken slightly slower
than normal and include simple directions and gestures to facilitate comprehension by the client.
❖ According to the AHA's suspected stroke algorithm, the correct course for the treatment of the stroke
patient is:
• General assessment and stabilization within 10 minutes of arrival to the ED
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• Neurologic evaluation by the stroke team within 25 minutes of entry to the ED

• CT scan and determination if there is intracranial hemorrhage within 45 minutes of entry to the ED
• If ischemic stroke, determine if the patient is a candidate for fibrinolytic therapy using the fibrinolytic
checklist
• Administer rtPA within 60 minutes of entry to the ED
• Admit to the stroke unit within 3 hours of entry to the ED
Cranial nerves
Ptosis, or eye drooping, occurs with cranial nerve III (oculomotor) lesions, myasthenia gravis, and Horner
syndrome. Dysfunction of cranial nerve III is also associated with dilated pupil, absent light reflex, and impaired
extraocular muscle movement.
The twelve cranial nerves include -
CN I: Olfactory
CN II: Optic
CN III: Oculomotor
CN IV: Trochlear
CN V: Trigeminal
CN VI: Abducens
CN VII: Facial
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CN VIII: Vestibulocochlear
CN IX: Glossopharyngeal
CN X: Vagus
CN XI: Accessory
CN XII: Hypoglossal
• The hypoglossal cranial nerve (XII) is central to the skeletal muscles of the tongue and assists with
swallowing. If a client has an impairment of this cranial nerve, aspiration precautions should be
implemented. These precautions include observing the client during meals and having patent suction
at the bedside.
• The optic nerve is the second cranial nerve (CN II) responsible for transmitting visual information.
Compromise of the CN II results in visual field defects and/or visual loss. As a result, the client's vision
will be impaired, and fall risk will increase.
• "The client will remain free of falls while hospitalized" is an appropriate outcome statement for a
newly hospitalized client experiencing a CN II impairment, as the client's current visual impairment
places the client at high risk of falls, the client's safety is a priority under Maslow's hierarchy of needs, and
this nursing diagnosis includes a clear, measurable outcome.
• This statement shows compassion toward the patient. Asking where the client and her sister grew up
allows her to think about her sister and reminisce without triggering anxiety or agitation. When
communicating with a patient who has altered mental status, such as those with dementia, it is
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essential to foster therapeutic communication. Any statement that may trigger agitation or begin
the grieving process should be avoided.
• Seizure
• Lowering the side rails and using four point restraints are not appropriate actions while deploying
seizure precautions.
• Padded bed rails should remain up while the patient sleeps. Patients should be provided with a call
light so that they may call for help if needed. Four-point restraints are not appropriate for the
seizing patient and could result in injury
• these are appropriate seizure precautions. When initiating seizure precautions, the nurse should ensure
that the side rails are padded ( Choice A). All sharp objects should be removed from a patient’s bed when
instituting seizure precautions ( Choice C). Patients prone to seizures should wear a fall risk bracelet to alert
members of the health care team to the patient’s need for increased supervision (Choice E).
• Atonic seizures are drop attacks or drop seizures that cause a sudden loss of muscle tone and result
in the client collapsing. This is quite serious as this may cause a client to sustain an injury.
• Tonic-clonic seizures are characterized by stiffening the muscles (tonic), then the client has muscle
jerking (clonic).
• Absence seizures feature a brief staring gaze with an impaired level of consciousness. These are
common in children and may occur multiple times throughout the day.
• Complex partial seizures cause an impairment in consciousness, so the client may exhibit
automatisms such as lip-smacking or repeating certain words/phrases.
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• One of the major goals during a seizure is injury prevention. Caregivers should be taught about
injury prevention precautions. The wife should ensure that the furniture is moved out of the way
when her husband seizes, improving his safety.
Seizure types What is happening Notes

The petit mal (or seizure is characterized by blank staring and an Age 3-15 yrs
absence) impaired level of consciousness.
simple partial (or Pt will be in an awake state but will exhibit abnormal
Jacksonian) motor or autonomic behaviors
myoclonic seizure the patient may be awake or with short periods of abnormal motor behavior in
loss of consciousness. one or more muscle groups
that lasts a few seconds to a
few minutes.
The grand mal (or there is a rapid extension of the arms and legs with Ass with incontinence and post-
tonic-clonic) sudden jerking and eventual loss of consciousness of ictal confusion.
the patient
To assess for the Babinski reflex, stroke the lateral sole of the foot from the heel to across the base of the toes.
1. Child < 1 year of age: Babinski present --> great toe bends upward, and other toes fan out.
2. Child > 1 year of age and adults: Babinski absent --> Plantar flexion of the toes ( normal)
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Migraine headache
The most common manifestations associated with an acute migraine headache include
• Unilateral frontotemporal pain

• photophobia) and sound (phonophobia)
• Nausea and/or vomiting
• Altered mentation (drowsiness)
• Dizziness, numbness, and tingling sensations
Myasthenia gravis
❖ impairs the acetylcholine receptors.

❖ Commonly occurring more in women, this disorder impacts motor nerves which impair facial and eye
muscles. In its severe form, myasthenia gravis may impact respiratory muscles causing respiratory
failure.
❖ Key clinical features of myasthenia gravis (MG) include diplopia, ptosis, facial muscle weakness, and
may progress to respiratory failure.
vertigo
❖ Many actions should be taken for a client experiencing vertigo, but protecting the client's safety is
essential.
❖ If a client is experiencing vertigo, this raises the risk of a fall. Interventions to prioritize include
adequate lighting in the bathroom, raising the upper side rails on the bed, and providing the client
with the call bell, coupled with instructing the client to use it before getting out of bed.
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Meniere's disease
▪ is characterized by excessive endolymphatic fluid. This causes three main features of vertigo,
tinnitus, and sensorineural hearing loss.
▪ Nursing education should focus on diet medication (low salt, limiting caffeine and alcohol) and
adherence to pharmacotherapy
▪ Reducing dietary sodium intake is key to reducing attacks associated with Meniere's disease..
▪ Since Meniere’s disease causes vertigo or the feeling that one is spinning, the patient is at an increased
risk for falls. To keep this patient safe, the nurse must initiate fall risk measures.
Parkinson’s disease
▪ The classic sign of Parkinson’s disease is the “pill-rolling” tremors of the hands.
▪ Treatment is considered valid when these tremors are lessened.
▪ A common symptom often seen in Parkinson's clients is dysphagia, dysphagia places the client at an
increased risk of aspiration, and the risk of acquiring aspiration pneumonia increases.
▪ Clients taking magnesium sulfate are expected to become sleepy during the daytime as well as
experience hot flashes and lethargy. Frequent sleepiness.
sensorineural hearing loss
❖ These are all risk factors for sensorineural hearing loss. Diabetes, Meniere's disease, Exposure to loud
noise
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• Conductive hearing loss is caused by obstruction. Causes of this type of hearing loss include cerumen,
foreign body, water, edema, infection, or tumor. This type of hearing loss may be reversible.
Breathing pattern and neurological problems
1. Cluster breathing is associated with lesions of the medulla or lower pons. This breathing pattern is
characterized by clusters of breaths with irregular pauses in between.
2. Cheyne-Stokes is associated with bilateral hemispheric disease or metabolic brain dysfunction and
commonly occurs at the end of life. This breathing pattern is associated with cycles of hyperventilation
and apnea.
3. Apneustic breathing is associated with lesions of the mid or lower pons. This breathing pattern is
characterized by a prolonged inspiratory phase or pauses alternating with expiratory pauses.
4. Central neurogenic hyperventilation is associated with lesions of the brainstem between the lower
midbrain and upper pons. This breathing pattern is characterized by sustained, regular, rapid, and deep
breathing.
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Respiratory NCLEX

Asthma Insp and exp When working with Pt respond to tt if increase in
wheezing asthma patients, it is airway
Breathless essential to know the
Chest tightness risk factors for death Silent chest is an indication of
Coughing due to asthma. acute asthma
Tachypnea These risks include
Hyperresonance previous ICU admission
Use of accessory for asthma, two or
muscle more hospitalizations
Restlessness for asthma in the past
year, three or more ED
visits for asthma in the
past year,
one hospitalization or
ED visit for asthma in
the past month,
difficulty with
perception of asthma
symptoms (mainly
airflow obstruction),
inner-city residence,
low socioeconomic
status, illicit drug use,
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and comorbid
cardiovascular, lung, or
chronic psychiatric
disease.
COPD Cough VS Respiratory acidosis
Chronic Wt loss O2
bronchitis and Barrel chest = Small frequent meal High calorie R/F = smoking
emphysema emphysema High protein
Use of accessory Pursed lip breathing Increase fluids If pt on o2 and has low RR = lower
muscle intake O2 rate
Dyspnea on Diaphragmatic
exertion breathing Chest x ray (emphysema) shows
Hypoxemia Hyperinflated chest
Hypercapnia Increase fluids intake Flattened diaphragm
PFT= decrease vital Orthopnea is If pt has fever, administer

capacity shortness of breath acetaminophen or ibuprofen
that occurs when
lying flat, causing the Low blood oxygen levels, which
person to have to sleep is a clinical feature associated with
propped up in bed or COPD, cause the kidneys to
sitting in a chair. respond by releasing
Asking the client how erythropoietin (EPO), which
many pillows they use stimulates red blood cell
to sleep on is a way to production.
assess if the client has
been educated about
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measures to prevent If pt is receiving o2 through
orthopnea. nasal canula at home:
Tripod position Have pulse oximetry AV
Sitting with elbow on the Avoid open flame or heat (oven,
knee stove top, candles)
Sitting and leaning Working smoke detector
forward over table Use water soluble jell
Stand and leaning Pad the tubing in the area of skin
forward pressure
Teaching
Avoid sudden position
change
Avoid exercise in hot
and cold weather
Teaching points for
exercising in a patient
with COPD include
avoiding sudden
position changes that
may cause dizziness
and avoiding extreme
temperatures.
Pneumonia
Inflammation Lab IV line to start the High protein
of pulmonary High WBC and ESR antibiotics and High calorie
tissues Sputum administer IV fluids
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If client demonstrates
signs of acute
respiratory distress
syndrome (ARDS), a
complication of
pneumonia
(hypoxemia). The
client's inability to
oxygen is highly
concerning and is a
classic manifestation of
ARDS. An RRT should
be immediately called
to assist with
appropriate
interventions, including
intubation by a
qualified provider
Pulmonary Lead to Immediate increase O2 Freshwater and saltwater wash
edema Alveolar collapse concentration = use of out the alveolar surfactant
Decreased lung non- rebreathing mask when they enter the lungs. This
compliance = give 95% fio2 leads to alveolar collapse,
Hypoxemia intrapulmonary shunting,
decreased lung compliance, and
hypoxemia, which will eventually
result in pulmonary edema.
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Pleural Pleuritic pain = Thoracentesis
effusion increase with A thoracentesis is best
Fluid in pleural inspiration performed with the
space Dry cough client sitting upright
Fever and leaning slightly
forward with arms
supported.
Pulmonary R/F
embolism Restlessness = Priority tt DVT
hypoxemia Notify rapid response Prolong immobilization
team Surgery
Restlessness is an Reassure pt Obesity
ominous sign Elevate HOB = 60-90 Pregnancy
suggestive of degree
hypoxia. O2
Hypoxia indicates VS
pulmonary
embolism (PE) that
is advancing, and
the patient is
becoming unstable.
The nurse should
immediately follow
up on this finding.
Sudden chest pain
(most common)
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Tuberculosis Wt loss Airborne precautions Become less infectious after 2-3
TB Anorexia Negative pressure room weeks of tt
High Cough Door closed
communicable Fatigue Nurse wear AK95 or Or the contagious period is 2-3
= caused by Low grade fever particulate respirator wks
aerobic Nigh sweating If pt leaving
bacteria room=surgical mask Client who received BCG vaccine
Gold lab Room with 6 exchange will have positive tuberculin test=
QuantiFERON fresh air do x-ray
Tuberculin skin test Repository isolation is not

(TST)= administer in necessary = because family are
upper 1/3 of the exposed
inner Lt arm
According to the Centers for
Positive = indicate Disease Control (CDC), risk factors
previous exposure for TB include
immunosuppression,
TB with HIV = 7mm organ transplant
duration is positive chronic corticosteroid use,
TB without HIV= substance use,
10mm is positive diabetes mellitus,
5mm consider and residing in environments such
negative as nursing homes, prisons, and
homeless shelters.
Fracture rib Pain with chest Fowler position
movement lead to
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impaired breathing Pain medications
and coughing
Usually pain with Splint chest with hand,
inspiration arm, pillow
Shallow
respiration
Pneumothorax Diminished breath Apply dressing Chest tube
Fluid in pleural sound O2 Drainage chamber =
space Reduce breath Fowler’s position NO tidaling
Open = opening sound on the The priority treatment NO bubbling
in the chest affected side for clients unstable with
Tension= blunt Tachypnea pneumothorax is the Water seal chamber
injury Pleuritic chest pain placement of a chest Yes tidaling
tube. Intermittent bubbling
Treatment Suction chamber

Chest tube NO tidaling
Chest tube insertion is Gentle bubbling
effective if= bilateral
breath sounds are
heard upon
auscultation If blood> 100ml/h in adult and
50=> ml/h in infant = notify the
Assess crepitus by doctor
palpate skin around the
chest tube
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Tidaling in the water
seal chamber is normal
= water move up with
inspiration and down
with expiration
Absence of Tidaling –
could be -
Fibrin clot
Obst in chest tube
Kinking on the tube
lung re-expanded
If client accidently
pulled the chest tube,
1st = place Vaseline
gauze over the site and
taped on the three sides
of chest tube and call
for help= this will
prevent tension
pneumothorax
If you feel
cracking sensation
beneath fingertip
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around chest tube =
notify doctor
if chest tube
connected with wall
suction:
palpate around the
insertion site
ambulate pt with CT
under insertion site
When removing chest

tube:
Give pain medication
Ask pt to bear down as

tube removed
Ask pt to perform
Valsalva maneuver
(take deep breath,
exhale, and bear
down)
Place occlusive dressing
Prepare suture removal

kit
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Biohazard bag and

clamp
Pneumonectomy.
• Keeping the head of the bed between 30-45 degrees will minimize respiratory efforts and facilitate recovery
post pneumonectomy.
• The patient would be instructed to lie on the back or operative side only to prevent leaking of fluid into
the operative site and to allow full expansion of the remaining lung.
• The remaining lung will require 2-4 days to adjust to increased blood flow.
•
• smoking is one of the most devastating risk factors associated with peripheral arterial disease. (PAD).
• Fraction of inspired oxygen (FiO2 - the percentage of oxygen given per breath)
•
• Manifestations of a pneumothorax that are concerning include a nagging persistent cough, increased
heart and respiratory rate, dyspnea, and potentially a feeling of air hunger. The nurse must act quickly
because the client's condition may deteriorate. Depending on the size of the pneumothorax, a chest tube
may be needed.
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O2 devices
O2 devices Rates deliver Litters
Nasal cannula 24% - 44% 1 – 6 L/m
Simple face mask 40%-60% 5-8 L/m
Partial rebreather 60%- 75% 6- 11L/m
Non- rebreather mask 80% -95%
Breathing patterns
Breathing patterns Description

Neurogenic hyperventilation Regular and fast
Cheyne-stoke Rhythmic with apnea or respiratory rate and depth are irregular and alternate with
periods of apnea and hyperventilation
Kussmaul's respirations that are abnormally deep, regular, and increased in rate
Apneustic Irregular with apnea
Ataxic Irregular – rate, depth, and rhythm
Agonal breathing always concerning because the client is gasping for air and
warrants immediate intervention
Deep Breathing and coughing Sitting position
exercise Breath deeply 3 times
Inhale through nose and exhale through pursed lips
Hold the 3rd breath for 3 seconds
Incentive spirometry Siting or upright position
Place mouth tight around the mouth peace
Inhale slowly
Maintain flow rate b/w 600-900 marks on the device
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Wound eviscerations = priority
• Call for help and ask for surgeon to be notified

• Stay with the pt
• Place pt in low fowler’s with knee bent
• Cover the wound with sterile normal saline dressing
• Take VS
•
Endotracheal tube
• For pt on mechanical ventilation

• Used < 10-14
• If longer than 14 days = tracheostomy
• Chest x ray to confirm
• Auscultate chest on both side
• Suction only when needed
• Move tube to opposite side by 2 PHC
• Monitor cuff pressure q 8hrs- ensure pressure does not exceed 20mmhg
• Ambu bag need to be at bed side
Extubating
• Hyper oxygenate
• Place pt in semi-fowlers
• Deflate the cuff
• Suctioning while removing the tube
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• After remove = ask pt to deep breath and cough

•
Tracheostomy
• Pre o2 use contaminated hand

• During insertion = no suction
• While withdrawing = intermittent suction
• Assess RR, skin integrity
• Suction only as needed
• Setup- sterile felid
• Remove and clean the inner canula, you may remove and replace
• Clean = 1st the stoma site 2nd the tracheostomy plate
• Secure the new ties, before remove of the old one
• One finger under the tie
• To avoid bleeding = cuff should not be deflated and don’t manipulate
• If pt allowed to eat – sit him up and inflate the tube for 1 hour after meal
• If accidently removed = nurse ambu bag the pt and other nurse call the Rapid response team
• If accidently removed= 1st = nurse grasp the retention suture to spread the opening
Fenestrated tracheostomy =
• It has fenestration in the upper posterior wall of the outer canula

• allow pt to speak and can be capped if the cuff is deflated
• used to wean pt from tracheostomy
Cuffed Fenestrated tracheostomy
• Facilitate mechanical ventilation and speech
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• Used for pt with spinal cord paralysis who don’t require ventilation at all time
• When pt not on ventilators, cuff is deflated, and tube is capped
• Never used to wean the pt
Thoracentesis
Thoracentesis is the needle aspiration of pleural fluid or air from the pleural space for diagnostic or
management purposes.
✓ This test can be performed at the bedside and typically involves using ultrasound to guide the needle.
Nursing considerations for this procedure involve
• witnessing the informed consent,

• positioning the client over a bedside table,
• and supporting the client during the procedure.
• The provider will insert a needle (after the skin has been anesthetized) attached to a syringe and slowly
aspirate fluid.
• This fluid may be sent for laboratory analysis.
• A sterile pressure dressing will be applied, and a follow-up chest x-ray may be ordered.
• The most common complication following this procedure is pneumothorax.
Pt education
These two statements should be included in patient education about thoracentesis. A thoracentesis is a
procedure indicated for pleural effusions. The client will need to report any dyspnea after the procedure).
Shortness of breath following the thoracentesis
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Complications following a thoracentesis include:
• pneumothorax, bleeding, and infection.

• The biggest concern is pneumothorax.
Following a thoracentesis,
• the client should be assessed for increased respiratory rate,

• elevated heart rate,
• nagging cough,
• decreased oxygen saturation,
• decreased breath sounds,
• and air that makes a popping sound near the insertion site when palpated.
• These are complications and warrant an immediate chest radiograph and supportive measures.
118
Maternity NCLEX
Female pelvis
Ture = lies below pelvic rim
False = lie above pelvic rim
Gynecoid pelvis = is most favorable for vaginal birth
Fertilization occurs in = fallopian tube = stay for 3 days
Implantation occurs= 6 – 8 days after ovulation
Ovulation occurs= 2 weeks before menstrual cycle
Fetal environment
Amniotic fluids
• 800- 1200 ml normal

• Measure the fetal kidney function!
Placenta
• Nutrient and waste exchange

• O2 exchange
• In the 3rd trimester = transfer immunoglobulin and passive immunity
• Bacteria cannot cross it
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• Complete by 12 weeks
Umbilical cord
• It has 2 A / 1 V = 2 arteries and one vein

• 2 arteries = carry the de o2 blood from the fetus
• One vein = carry o2 blood and nutrient to the fetus
Family planning
• Depends on women preferences

• Sterilization = if they don’t have plan to have children
• Women taking contraceptive pills ( progestin) is at risk for tubal or ectopic pregnancy
Fetal circumcision
• If nurse observe bright blood on circumcision site = apply gentle pressure
• Ductus venosus = V+V= connect umbilical vein with inferior vena cava
• Ductus arteriosus = PA + A = connect pulmonary artery with aorta
Gestation = time from fertilization to delivery = about 280 days
• Estimated date of delivery = EDD = Women should have 28 days menstrual cycle
• assumes that all women ovulate around day 14 of their menstrual cycle
• An early ultrasound is the most accurate way to determine the estimated due date.
• Subtract 3 months and add 7 days to the last menstrual date
• Eg = LMD = DD/M/Y = 04/10/2022 = EDD= 11/07/ 2023
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Gravity = number of pregnancies
• Gravida = pregnant women

• Null gravida = never pregnant
• Primigravida = pregnant for 1st time
• Multi gravida = at her 2nd pregnancy
Parity = number of births carried past 20 weeks
• Nullipara = never give birth
GTPAL =
• Gravity
• Number of born at term > 37 weeks
• Number of born at pre-term < 37 weeks
• Number of Abortion < 20 weeks
• Number of living children
• E.g.- pregnant with twins = has health 5 yrs. Old at 38 weeks = no history of abortion
o G2 , T1, P0,A0, L1
Pregnancy signs
Presumptive signs of pregnancy
• Amenorrhea
• Nausea and vomiting
• Fatigue
• Urinary frequency
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• Quickening (slight fluttering movement usually between 16-20 weeks gestation)
Probable signs of pregnancy
• Goodell's sign (softening of the cervix)

• Chadwick's sign (bluish appearance of the cervix)
• Hegar's sign (softening of the isthmus of the cervix)
• Ballottement (sudden tap on the cervix during the vaginal examination may cause the fetus to rise in the
amniotic fluid and then rebound to its original position)
• Braxton hicks contractions
• Positive pregnancy test
• Palpation of fetal outline
Positive signs of pregnancy
• Fetal movements detected by an examiner

• Auscultation of fetal heart sounds
• Visualization of embryo or fetus
Presumptive
• Quickening = fetal movement = occur at 16- 20 weeks

• Amenorrhea
• Increase urine frequency
• Really tired
• Sore breast
• Enlarge breast
• Emesis and nausea
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Probable signs
• Enlargement of the uterus

• Soften of the cervix= Goodell’s sign
• Bluish color of the cervix = Chadwick sign
• Lower uterine segment soften = Hegar’s sign
Positive signs
• Fetal movement
• Delivery of the fetus
• Ultrasounds detect the fetus
• Feat heart rate = 10-12 weeks =by doppler = fetoscope = 20 weeks
Blood type and Rh Factor
• Important to know the mother's blood type and if they is Rh positive or negative.
• If the mother is Rh negative, and the baby is Rh positive, this is considered a ‘set up’ and puts the infant at
risk for erythroblastosis fetalis.
• Further testing needed if this is the case - after the baby is born.
• Direct Coombs test = Performed on the newborn's blood sample
• Positive = A direct Coombs test measures maternal antibodies, specifically IgG, that are present on the
infant’s red blood cells (Choice A). The presence of these antibodies is what causes erythroblastosis
fetalis; therefore, the direct Coombs test indicates erythroblastosis fetalis (Choice C).
• Indirect Coombs test = Performed on the mother’s blood sample
o measure antibodies in the maternal serum
o will check to see if the mother is at risk for Rh immunization.
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• Treatment = Rhogam
Fundal height = Evaluate the gestational age of the fetus =
• Fundal in cm = age in weeks ± 2cm = e.g., women at 28 weeks = fundal height could either be 28±2cm = 30
cm or 26 cm
•
Fundal height Weeks

B/W pubis and umbilicus 16 weeks
At the umbilicus 20-22 weeks
At the xiphoid process 36 weeks
Systems changes
CVS =
• Increase in Blood volume by 40%- 50%

• Diet for pregnancy with cardia diseases = drink adequate fluid + high fiber diet
RESP System
• Increase O2 consumption.
• Increase HR
• BP = decrease in the 2rd trimester and increase in BP 3rd trimester
Endocrine
• Gestational diabetes if FBS is > 126 and HBAIC > 6.5%

• A sugar greater than 140 indicates gestational diabetes.
124
Antepartum visits
• Women at 28-32 weeks = visit Q 4 weeks

• Women at 32-36 weeks= visit Q 2 weeks
• Women at 36-40 weeks= visit Q week
Vaccine during pregnancy
• Rubella vaccine is not given during pregnancy = because it cross the placenta
• Administer SQ
• Avoid exposure to immune comprised persons
• Avoid pregnancy for 1-3 months
• Hypersensitivity can occur
• Rubella is a maternal infection that is known to increase the risk that the fetus will have a congenital
heart defect. All mothers should be tested for rubella, and if found to be positive, should have a fetal
echocardiogram performed to evaluate the fetus' heart more closely
TORCH
Amniocentesis = removal of amniotic fluid
• Amniocentesis is a widely used antepartum test that may determine the gender of a fetus, the presence
of neural tube defects, chromosomal abnormalities, and fetal lung maturity.
• Invasive and need inform consent
• Best perform B/W 15-20 weeks
• Use to assess the feat lung maturity
• Genetic disorders = test for fetal abnormality can be done B/W= 18-40 weeks
• Metabolic disorders
125
• Client should have full bladder = if < 20 weeks and empty bladder = if > 20 weeks
Amniotomy = is artificial rupture of the membrane
• Priority is to assess FHR

• Done if fetus at 0 or plus station
• Amniotic fluids should be monitored for
• Meconium = ass with fetal distress
• Bloody = ass with abruptio placentae
• Odor= ass with infection
• Polyhydramnios = ass with DM
• Oligohydramnios = ass with intra uterine growth restriction (IUGR)
•
Kick count
• Ten kicks noticed during a 1 – 2 hour period are considered normal.

• At 28 weeks = if < 10 kicks in 2 hrs = notify doctor
• Women sit or lie on side to count them
• Fetus starts to move by =16-20 weeks
Uterine Contractions
• Braxton hick’s contractions = irregular contractions, which is normal = may occur through out the
pregnancy
126
Fetal Heart Rate Monitoring= VADRN
Variability
● Fluctuation in the fetal heart rate
• Absent= BAD
• Marked= BAD OR GOOD
• Moderate = GOOD
Acceleration
• A speeding up of the fetal heart rate = OKAY
• Episodic acceleration is sign of fetal well-being
• Ass with contractions and fetal movement
Deceleration
● A slowing down of the fetal heartrate
• Early = HEAD COMPRESSION = no intervention is needed
o Early decelerations do not need to be reported to the healthcare provider. They occur when the
fetal heart rate decreases at the same time as a contraction and are followed by a return to baseline.
They occur due to the pressure of the fetus's head on the pelvis or soft tissue and the nurse
requires no intervention after an early deceleration.
• Late= Placental Insufficiency= nurse immediately improve placenta blood flow and fetal O2 = administer O2
by facemask
• Variable= Umbilical CORD COMPRESSION OR PROLASPED = nurse – D/C oxytocin – change mother position-
O2, VS
o Amnioinfusion refers to the infusion of a warmed isotonic solution into the uterine cavity through
the IUPC. It is mostly used as a treatment to correct fetal heart rate changes caused by
umbilical cord compression, indicated by variable decelerations seen on cardiotocography. It can
help cushion the cord and relieve pressure when the membranes have ruptured.
127
Reassuring
● The baby looks healthy!
• Baseline heart rate in the normal= range: 110-160
• Moderate variability
• Accelerations
Non-reassuring
• Something is wrong with the baby.
• Fetal tachycardia = FHR> 160 = Notify the PHC
• Fetal bradycardia= FHR< 110 = Notify PHC
• Variable deceleration
• Late deceleration
Interventions: LOINDC
• Lay mother on Lt side
• O2
• Increase IV fluids
• Notify PHC
• D/C Pitocin OR oxytocin
Stress and non stress test
Nonstress test (NST)
• A nonstress test (NST) is a non-invasive test performed in pregnancies over 28 weeks gestation. During
the procedure, fetal heart rate and uterine contractions are recorded using external electronic
monitors and correlated with fetal movements as reported by the mother. This test determines the
fetus's condition during the third trimester of pregnancy
• This test assesses fetal well-being and oxygenation of the placenta
128
• Evaluates if there are changes in the fetal heart rate with movement
o Increase in fetal heart rate with movement = acceleration = good
o Decrease in fetal heart rate with movement = deceleration = bad
o This is a sign that the fetus will not tolerate labor.
Results
o Reactive = There are at least two accelerations of 15 beats per minutes for 15 seconds in a 20
minute period.
o Non-Reactive = There are NOT at least two accelerations of 15 beats per minutes for 15 seconds in a
20 minute period.
• A reactive finding indicates fetal well-being; specifically, the fetal heart rate increased by 15 beats
per minute, lasting for 15 seconds.
• A nonreactive NST is non-reassuring and indicates decreased variability with an absence in a fetal
heart rate acceleration.
• Further testing required if result is non-reactive= such as stress test
• External fetal heart rate monitor will be applied across the client's abdomen during this test, and results
that are reactive indicate fetal well-being. Abnormal testing does require additional testing, such as
a biophysical profile or a contraction stress test.
129
Contraction Stress Test
• Preformed when the non-stress test is non-reactive.

• Pitocin is administered to induce contractions and the baby is monitored to evaluate their response to
contractions. Or stimulate the nipples
• Checking to see if the baby will tolerate labor, or show signs of stress.
• Results:
o Negative = Normal = The baby did not have decelerations in response to contractive
o Positive = Bad= The baby had decelerations indicating distress in response to contractions.
o
Indications of Contraction stress test
• Maternal DM
• Post maturity
• Decrease fetal movement
• Intra uterine growth restriction = used doppler blood flow analysis
Biophysical profile ( BPP)

• Done in the 3rd trimester to assess
• Fetal breathing
• Gross body movement
• Fetal tone
• FHR
• Amniotic fluids
130
Risk related pregnancy.
Abortion =
• pregnancy end before 20 weeks

• It could be spontaneous or elective or
• Maintain bed rest
• VS
• Monitor for bleeding
• For Rho NEGTIVE = administer Rho(D)
• Threating abortion
o Bed rest for all time is not required
o Women watch for tissue and count for pads
o Avoid sexual intercourse for 2 weeks
Gestational diabetes
• Gestational diabetes if FBS is > 126 and HBAIC > 6.5%

• Glucose can cross the placenta , but insulin does not
• The baby is risk for hypoglycemia
• insulin decrease During the 1st trimester
• insulin is increase During the 2nd trimester
• screening for GD at 24 and 28 weeks
• women with type 1 DM = nonstress test done weekly until 32 weeks- done twice/ week
Ectopic pregnancy
• occur outside the uterine cavity

• most common in the ampulla of fallopian
131
• Fallopian tube ○ Cervix ○ Abdomen

• Methotrexate ○ Stops the embryo from being able to grow ○ Aborts the fetus
Hepatitis B
• limit number of vaginal exam

• remove maternal blood
• support breast feeding
• Can transmitted to the newborn
• Use contact precautions = wash hand and gloves
Hypertensive disorders of pregnancy
• Women risk for preeclampsia = increase BP or persistent HTN

o Blood pressure >140/90 ○ 2 times ○ 4 hrs apart
o Protein in the urine
o Preeclampsia occurs when a woman develops high blood pressure after 20 weeks of gestation.
• Complication of preeclampsia = DIC
• Eclampsia =
o Chch by generalized seizure
o Stay with the client
o Open airway
o Monitor FHR
o Prepare for a preterm baby
o Mag sulfate → prevent seizures in mom = Give IV slowly
o Betamethasone → Help develop baby’s lungs
o Antihypertensives….
132
o Antihypertensives during pregnancy YES ●

▪ Labetalol
▪ Nifedipine
▪ Hydralazine
o NO ●
▪ ACE- INHIBITORS
▪ ARBs ○ Can cause oligohydramnios, fetal growth restriction, and more!
• Worsen pre-eclampsia = pt complain of headache and blurred vision
• Pt with PIH may exhibit= proteinuria – headache - double vision
• Severe pre-eclampsia manifests as epigastric to right-upper quadrant pain suggestive of a liver injury.
Placenta abnormalities
Most common of placenta a adherence is = placenta accreta
Placenta abnormalities Assessment Interventions Notes

Placenta previa = Sudden onset of painless Monitor FHR Vaginal exam or use of
Bed rest = side lie manual pelvic exam is
Placenta in the lower Soft and relax uterus Monitor bleeding contraindicated
uterine segment Hydration OR
Bright red bleeding Checking the cervix for dilation
Caesarean section indicated in
Fundal height more than most cases Client is risk for hemorrhage
expected
Abruption placentae Uterine pain or tenderness Monitor FHR Can lead to DIC
Prepare y tubing
Premature separation Rigid abd Normal saline Cocaine use can lead to AP
of the placenta from IV catheter size 18
Dark vaginal bleeding
133
uterine wall after 20 Hypotension (Think shock due Bed rest – Trendelenburg
weeks to blood loss) position
Maternal tachycardia Monitor and control

hemorrhage
Fetal bradycardia (fetal
distress!!
TB
• Chest x-ray may be done after 20 weeks

• Tuberculin test is safe during pregnancy
• Treatment
o Isoniazid + Pyrazinamide + rifampin = for 9 months
o Pyridoxine = to prevent fetal neurotoxicity that caused by isoniazid
o If women not infectious = can breast feed
o
Women with HIV =
• not to breast feeding – use bottle feeding
Women at risk for developing DIC
• Abruptio placentae
• Gestational HTN or Pre-eclampsia
• HELLP syndrome
134
o HELLP syndrome stands for Hemolysis, elevated liver enzymes, and low platelets. HELLP
syndrome is a condition in which hemolysis of the red blood cells occurs creating elevated liver
enzymes and low platelets. Generally, complications are prevented by delivering the fetus as soon as
symptoms develop.
• IU fetal death
• Amniotic fluid embolism
Labor and birth
Stages of labor
• 1st stage
• LATEX
o Latent phase – uterus = 0-3cm – longest phase
▪ Contraction q 15- 30 mint.
▪ Ice chips
▪ Voiding q1-2 hrs
o Active phase = 4-7 cm
▪ Contractions q 3-5 mint
▪ Deep breathing
▪ Back rub
▪ Ice chips
o Transition phase = 8-10cm – short and difficult
▪ Contraction q 2-3 mint
▪ Rest B/W contractions
▪ Ice chips
135
o Expulsion = after birth
2nd stage
• Baby birth
• During 2nd stage of labor = monitor q 15 mint
• Cervix is completely dilated
• The Ferguson reflex
3rd stage
• Birth of the placenta
4th stage
During labor doctor order oxytocin=
o Oxytocin should always be administered intravenously as a piggyback infusion.

o nurse should monitor for fluid intake and output = because oxytocin can lead to water
intoxication
o D/C if uterine contractions is < 2 minutes
• Early stage of labor pain usually around pelvic gride
• Ture labor pain if increase in contraction and in severity
136
• Before use of electronic fetal monitoring device ( EFM) = The membrane must be rupture
• Leukorrhea is colorless vaginal drainage = is normal during 1st trimester
• Prevent breast engorgements = women should breast feed on frequent interval
• Immediate and frequent breastfeeding is the key to decreasing breast engorgement in

breastfeeding women. Also, the initial step in treating breast engorgement is encouraging the mother
to immediately breastfeed following birth and continue to do so every two hours.
• Women with nipple soreness = lubricate nipple with expressed milk
• Pregnant ask about taking castor oil for constipation= NO, this can initiate premature contraction
• Prevent newborn hypothermia by using – cool incubator wall
• Women with episiotomy = she is risk for fluid volume deficit R/T bleeding
• Episiotomy done to shorten the 2nd stage of labor
• The client should be instructed to increase their fluid and fiber intake to prevent constipation because
constipation may cause a client to experience significant pain. If the client is still experiencing constipation
as they recover from an episiotomy, the primary healthcare provider (PHCP) may prescribe a stool
softener.
137
• Transvaginal US is best for obesity women
• Women with hyperventilation = breath into her cupped hands
• Bishop score 8 and > is good
• Sign of fetal maternal compromise = persistent non-reassuring FHR
• TEMP of 100.4 is normal during the 24hrs after delivery
• Genetic test can be done by 10-12 weeks
• Sex of the baby by = 16 weeks = genital organs developed
• Yogurt is a dairy product and therefore contains lactose. Breastfeeding mothers with infants who are
lactose intolerant should avoid dairy products such as cheese, milk, and yogurt.
• Birthing centers are generally drug-free, allow women to roam around the facility to relieve
discomfort, and provide a home-like environment.
• Methylergonovine promotes vasoconstriction and uterine contraction. A firm and contracted uterus is
a sign that the medication is having its desired effect.
• The spinal change that is common in pregnancy is lordosis.
• Possible complications during pregnancy include
138
o anemia, mood changes, and nausea/vomiting.
• Prolonged bed rest can result in deep vein thrombosis (particularly of the legs), alterations in mood
due to stress and anxiety, and undesirable weight gain due to inactivity.
• Uterine atony results from the inability of the uterine muscle to contract adequately following birth,
leading to vaginal bleeding and/or postpartum hemorrhage. By performing a fundal massage, the nurse
will attempt to stimulate the client's uterus to contract.
• Physiological anemia of pregnancy occurs when there is an increase in plasma in the blood, thus
“outweighing” the number of otherwise normal red blood cell levels.
• Normal hemoglobin in a pregnant client is > 11 g/dL. Normal hematocrit in a pregnant client is > 33%.
• During pregnancy, hyperemesis gravidarum is strongly associated with hypokalemia.
• Linea nigra refers to the linear hyperpigmentation of the midline of the abdomen (from sternal notch to
pubis). This is a frequent change that occurs during the 2nd trimester.
• A displaced fundus is an indication of a distended bladder. The nurse should assess the client for
bladder distention and encourage the client to empty her bladder.
• Long-term treatment with LMWH may decrease bone mineral density (osteopenia, osteoporosis) and
increase the risk of fractures
• For a woman with a normal BMI, the average weight during pregnancy should be 25-35 pounds.
• During labor and after birth, the WBC count would rise to 25,000. This is a normal response of the
body and should not warrant any concern.
• Iron deficiency anemia is associated with an increased risk for low birth weight, preterm delivery,
and perinatal mortality.
• Prolonged QT intervals have been noted as a severe side effect of ondansetron. This medication is used
to treat hyperemesis gravidarum when the patient is losing weight and or unable to cope with pregnancy -
related nausea.
139
• A boggy uterus is a sign of subinvolution. Increased bleeding is a sign of subinvolution.
Caesarean section
• If FHR > 180 = notify physician

• Position is – supine and wedge placed under the Rt hip
• Spinal anesthesia is most preferred for cesarian section
Problem with labor and birth
Premature membrane rupture
• Risk for infection

• Chch by fetal tachycardia
• Avoid vaginal exam
• Positive nitrazine test
o Nitrazine paper is used to measure the pH of the fluid to determine if the amniotic membrane has
ruptured. Once the fluid comes into contact with nitrazine paper, the pH of the fluid will cause the
paper's color to change. The resulting color will correlate to a pH allowing the nurse to decipher
whether the fluid is amniotic fluid (i.e., PROM) or vaginal fluid.
Prolapsed umbilical cord
• Variable deceleration
• Irregular FHR
• 1st priority is to elevate presenting part
• Keep your hand on the baby’s head lifting it up and call for help
• Place women in Trendelenburg or sims position or knee chest position
140
• Wrap cord in sterile moist towel

• NEVER ATTEMPT TO PUSH THE CORD BACK IN!!!!
• Emergency delivery by C/S
Preterm labor
• After 20 weeks and before 37 weeks

• Restrict activities
• Use of 17P OR 752
• R/F= history of medical conditions, substance abuse
Fetal distress
• Prepare for C/S

• FHR < 110 OR > 160
• Severe variable deceleration
• D/C oxytocin
• Lateral position
• O2
Rupture of the uterus
• Emergency C/S
• Abd pain
• Rigid abd
• No FHR
• O2
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• IV fluids
Dystocia R/F =
• Prolonged labor with hypotonic contractions is classified as labor dystocia.

• Labor dystocia is a broad term that indicates that labor is not progressing.
• Key interventions for a client experiencing labor dystocia include
o encouraging the client to void frequently (when she feels the urge) because a full bladder will
impede uterine contractions.
o A potential infusion of oxytocin to augment uterine contractions is a plausible prescription to be
anticipated from the primary healthcare provider (PHCP).
o Frequent maternal repositioning is a key and noninvasive intervention that helps with fetal descent
and effective contractions.
• Age 54yrs
• BMI 28
• difficult with fertility
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Pediatrics NCLEX
Development
• The anterior fontanel typically closes anywhere between 12 to 18 months of age. Thus, assessing the
anterior fontanel as still being slightly open is a normal finding requiring no further action.
• Teen pregnancies are commonly denied by the teenager early in her pregnancy. The nurse must
emphasize the importance of early prenatal care to prevent complications in the teenager’s pregnancy.
• According to Freud’s psychosexual stages = OAPLG
o Oral stage
o Anal stage
o Phallic stage
o Latency stage
o Genital stage
• Adolescents need to establish their identity, which includes developing a mature sense
of responsibility/independence. Providing the patient with his schoolwork will keep him connected to
his peer group and give him a sense of accomplishment.
• The preschooler has many fears at this stage. One concern is the fear of mutilation. The nurse should
take care to prevent painful experiences in the child.
• The school-aged kids' cognitive levels are now developed to enable understanding of and adherence
to rules. They are now susceptible to instruction.
• In adolescents, they need to develop a sense of identity and belongingness, or else they develop role
confusion.
•
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• Infant: Trust versus Mistrust

• Toddler: Autonomy versus Shame and Doubt
• School-Aged Child: Industry versus Inferiority
• Young Adult: Intimacy versus Isolation
• Middle Years: Generativity versus Stagnation
Abuse and neglect

o Physical abuse is any intentional act causing injury or trauma to another person. In the child,
multiple fractures in various stages of healing are very suspicious for abuse. This points to repeated
injuries over a period of time and needs to be thoroughly investigated.
o Neglect is to fail to care for properly. This could be manifested by poor hygiene, ill-fitting clothes, or
malnourishment,
o
o Infants should triple their birth weight by 12 months of age.
o Infants should double their birth weight by 6 months of age.
o At 7 months old, the infant should be able to sit up without any support.
o At 4 months of age, the infants should have developed the fine motor skill of bringing objects to their
mouths.
CPR
o In infants, the brachial artery is the right site to check for a pulse.
o Two recues = 15:2
o One rescue = 30:2
o Compression depth 1/3 of the anterior posterior diameter
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Integumentary
Burn
• intubation and mechanical ventilation are the priority for this patient. Intubation is the A in the ABC’s
mnemonic and stands for airway. The stem of the question states that this patient has burns to her
chest.
Burn stage Description
1st degree burn • superficial
• epidermis intact
• no blister
• redness
• painful
2nd degree burn • Partial thickness
• Epidermis and dermis are affected
• Blister formation
• Very painful
• Skin moist and red
3rd degree burn • Full thickness
• Epidermis, dermis, and SQ are affected
• Destroy never ending = not painful
• Red , tan or black
• Skin dry and leathery
4th degree burn • Full thickness
• Involve bones and muscle
• Dry and dull
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Emergency management
o Fluid replacement = isotonic solution

o Lactated ringer
o Colloid
o Albumin
o Correction of the electrolytes imbalance
o Hyperkalemia
o Hyponatremia
o Monitor UOP
o Parkland burn formula
o 4 ml * % TBSA * WT (KG) = fluids to be administered
o Administer ½ of the fluids over 8 hrs
o Other ½ of the fluids over 16 hours
Rule of 9
GIT
• Celiac disease is a gastrointestinal disorder that should not affect the normal functioning and ADLs of this
patient.
• Learning to avoid gluten can be difficult for the family, so the dietician is the best resource to help them
navigate this.
• Avoid foods contain gluten such as wheat , barely , rye, and oats
• Eat rice
• Steatorrhea refers to the excretion of abnormal quantities of fecal fat due to reduced fat absorption by
the intestines. This produces pale, oily, malodorous stools and is a symptom of Celiac disease.
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• Celiac disease requires standard precautions. It is not an infectious disease and is not transmitted from
person to person; therefore, there is no reason to initiate any additional precautions.
• imperforate anus
o Toilet training for a toddler diagnosed with imperforate anus will take longer than children
who do not have this diagnosis.
o They will need to establish bowel habits and bowel management programs to achieve toilet training.
o Regular bowel habits can indeed be established for toddlers diagnosed with imperforate anus
over time. They will need to establish bowel habits and bowel management programs to achieve
toilet training.
o Bowel irrigations will help the toddler achieve normal bowel function. They may not need them
every day, but bowel irrigations will likely be needed frequently to achieve regular bowel function.
o It is not necessary to make sure the child is toilet trained before kindergarten.
o Post abdominal surgery at the pediatric:
▪ Letting the child blow bubbles will stimulate lung expansion, preventing respiratory
problems arising from surgery.
▪ Recognize that incentive spirometry is a vital intervention to help the post-surgical clients breathe
deeply and prevent lung collapse. In preschool children, blowing bubbles can be an alternative
to incentive spirometry.
intussusception.
o A gastrointestinal disease of childhood where a piece of bowel goes backward inside itself,
forming an obstruction, is called intussusception.
o Assessment intussusception
▪ Sever abd pain
▪ Vomiting
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▪ Bright bloody stool

o
o For infants ( less than one year of age), the nurse should measure the NGT distance from the
bridge of the nose to the earlobe to a point halfway between the xiphoid process and the
umbilicus.
o Measuring the NG tube length from the bridge of the nose to the earlobe to the xiphoid process is
indicated for children older than one year, not infants.
Hirschsprung's disease
o In Hirschsprung's disease, the aganglionic section of the colon is removed, and the unaffected,
functioning ends are attached to one another. In some cases, an endorectal pull-through procedure
is performed, where a surgeon removes the segment of the large intestine lacking nerve cells and
connects the first part to the anus.
o Identify a colectomy with a potential endorectal pull-through procedure as the treatment of choice
in a child with Hirschsprung's disease.
o a Pull-through procedure is a treatment option for Hirschsprung’s disease
Pyloric Stenosis
▪Hypertrophy of the circular muscle fibers of the pylorus, with a severe narrowing of the
lumen
o Assessment
o Projectile Vomiting
▪ Right after feeding
▪ Infant is still hungry and crying
o Constipation
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o Irritability
o Dehydration
o Malnutrition
o Palpable pylorus
Intussusception
o Assessment
▪ Red currant jelly
▪ Sausage-shaped mass in abdomen
Treatment
o Enema to attempt to push the intestine back out

▪ Air enema
▪ Hydrostatic enema
▪ Barium enema
o If successful a surgical repair is needed.
o Child with lactose intolerance can develop Ca and Vit D deficiency
EGRD
o To reduce emesis = feeding with thickened with rice cereal
Neurological
Client who has epilepsy= Seizure precautions
o Provide padding to the side rails

o Verify suction is at bedside and working properly.
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o Establish peripheral vascular access

o should be a face mask or Ambu bag readily available that is an appropriate size and connected to 10 L of
100% oxygen. Not nasal cannula
Seizure types What is happening Notes

The petit mal (or seizure is characterized by blank staring and an Age 3-15 yrs
absence) impaired level of consciousness.
simple partial (or Pt will be in an awake state but will exhibit
Jacksonian) abnormal motor or autonomic behaviors
myoclonic seizure the patient may be awake or with short periods of abnormal motor behavior in one
loss of consciousness. or more muscle groups that
lasts a few seconds to a few
minutes.
The grand mal (or there is a rapid extension of the arms and legs Ass with incontinence and post-
tonic-clonic) with sudden jerking and eventual loss of ictal confusion.
consciousness of the patient
BELLS PALSY
• #7, facial nerve

• facial paralysis
• not able to close his eye on the affected side
o Dark glasses
o artificial tears
o cover eye at night
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• The nurse should position the client with the head of the bed elevated at 60 – 90 degrees to prevent
aspiration
• ROM exercises prevent contractures in the child with cerebral palsy.
Hydrocephalus.
• Correct location to assess for Macewen’s sign

o used to detect hydrocephalus.
Cardiology
Heart failure
• Exercise intolerance is common for a child with heart failure because the cardiac output cannot keep up
with the demands of exercise.
• Fatigue may develop as well as irritability from the child's inability to participate in exercise-related
activities.
• Adventitious lung sounds

• Neck vein distention (this cannot be observed in infants because of their short necks)
•
• Heart failure produces abnormal heart tones such as S3 and S4, referred to as gallop rhythm.
• An S3 heart tone is heard in systolic heart failure, whereas an S4 heart tone is expected in diastolic
heart failure
• S1 and S2 heart tones are normal
• Administer digoxin
o Administer digoxin one hour before or two hours after meals.

o Call the doctor if the child starts eating poorly and vomiting frequently.
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o For the medication to be absorbed correctly, it must be taken on an empty stomach. Never
administer digoxin with food.
• Poor feeding is often one of the first signs of decreased cardiac output in an infant. It becomes harder
for the infant to breathe while feeding; they often become sweaty and pale during feedings. This is a classic
sign of decreased cardiac output (Choice A). Irritability, restlessness, or lethargy are vital signs of
decreased cardiac output in the infant
• congestive heart failure (CHF) due to the classic presenting symptoms in the infant: poor feeding,
irritability, and vomiting.
• Parents should be taught to look out for excessive sweating, especially at rest. Sudden weight gain is
due to fluid retention and edema. This indicates decreased cardiac output, increased venous congestion,
and is an early sign of heart failure.
• Hypoxia and Oliguria are also late signs of heart failure
Patent ductus arteriosus (PDA)
• due to the presence of a machine-like murmur, a hallmark sign of a PDA.

• Alprostadil will be administered to keep the ductus arteriosus open, or patent. This will allow more
pulmonary blood flow to the child with low oxygen saturations while waiting for surgery.
• Indomethacin is used to close the patent ductus arteriosus (PDA), not to keep it open.
• Morphine sulfate is the drug of choice for use during tet spells.
Tet Spell Interventions
o Comfort and calm Knee-to-chest position

o Supplemental oxygen
o Sedation - morphine
o Volume
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• Regarding aortic regurgitation

o increases preload in the left ventricle.
o increases left ventricle end diastolic pressure
o decreased cardiac output.
o Specific findings
o Upper extremities
▪ Bounding pulses
▪ Hypertensive
▪ Warm Pink
o Lower extremities
▪ Weak or absent pulses
▪ Hypotensive
▪ Pale
▪ Cool
Cleft Lip
o A congenital abnormality where there is a slip, or gap, in the upper lip on one or both sides.
Cleft Palate
o A congenital abnormality where there is a split, or gap, in the hard palate (the roof of the mouth)
• Complications
o Feeding difficulties
o Weight loss
o Failure to thrive
o Speech and language delays
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o Hearing issues
o Ear infections
o Aspiration
• Surgically corrected.
o Cleft lip first at 3-6 months of age
o Cleft palate second at 6-24 months of age
• Post-operative care
• Positioning:
o Avoid placing on surgical site
o Eg if surgery in Rt side , place in left lateral
o Position upright for feedings
o Give formula to the side and back of the mouth
o Teach patents the ESSR method of feeding
▪ Enlarged nipple
▪ Stimulate sucking reflex
▪ Swallow
▪ Rest
o Cleft palate - can be prone post op to help drain secretions
o Cleft lip should NOT be prone as this could disturb the suture line
• Elbow restraints to avoid toddler putting things in the mouth
• No hard foods, straws, pacifiers, etc.
• No oral or nasal suctioning
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Esophageal atresia
o Part of the esophagus does not form.

• Assessment = 3cs
o Choking
o Coughing
o Cyanosis
Tracheoesophageal Fistula
o A congenital abnormality in which there is an opening between the trachea and the esophagus
o Cyanosis is a notable symptom in a neonate with a tracheoesophageal fistula. The cyanosis
often results from a laryngospasm (a protective mechanism that the body has to prevent aspiration
into the trachea).
o
• Assessment = 3cs
o Choking
o Coughing
o Cyanosis
Urinary
Nocturnal enuresis
• Establishing a voiding diary/log for the client is an effective strategy as it may track the nights of the
enuresis.
• The amount of enuresis and any precipitating factors should be noted.
• Desmopressin is indicated for the treatment of diabetes insipidus and nocturnal enuresis. This
medication is a synthetic form of antidiuretic hormone.
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• Nocturnal enuresis usually starts at age five and may continue past age ten.
• The cause of this is multifactorial and may include genetic predisposition.
• Behavioral interventions are tried first and include a voiding diary to track the episodes and their
frequency, use an enuresis alarm, execute positive reinforcement, and avoid shaming the child.
• Prescriptive therapies include desmopressin or tricyclic antidepressants such as imipramine.
Renal
glomerulonephritis
o Periorbital edema
o Decreased urine output
o Gross Hematuria= resulting in dark, smoky, cola urine
o A complication of glomerulonephritis is encephalopathy caused by severe hypertension associated
with the disease process.
o A client's report of a headache should clue the nurse into checking the client's blood pressure. The client
should be monitored for this potential complication, which can be avoided by closely monitoring the client's
blood pressure.
o Nursing care aims to prevent the most common complications, including fluid volume overload and
hepatic encephalopathy.
o The client may have dietary restrictions such as fluid, sodium, and potassium. The nurse should
monitor the client's intake and output, weight, and blood pressure.
o Could be due to upper respiratory tract infection
Nephrotic syndrome
o massive proteinuria
o Hypoalbuminemia
o Edema
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o Restrict Na
Respiratory
Asthma
o Silent chest is the assessment finding of most concern.

o Epiglottitis
o Obtaining a throat culture would require immediate follow-up because this may cause acute
laryngospasm leading to respiratory obstruction.
o The culture may be obtained once an artificial airway has been established.
o In status asthmatics priority is
o Assess airway and RR
o O2 = nasal canula or face mask
o Rescue medication
o Iv line
Epiglottitis
cute epiglottitis is a medical emergency that has an abrupt onset. In epiglottitis, the epiglottis becomes
inflamed and swollen and constructs the airway. Classic symptoms of epiglottis include -
o Sore throat and pain in swallowing

o Fever
o The absence of spontaneous cough is a common feature
o The child insists on sitting upright and leaning forward (tripod position), with the chin thrust out, mouth open,
and tongue protruding.
o Drooling of saliva
o Red and inflamed mucous membranes
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o Nasal flaring
o Use of accessory muscles
o Presence of stridor
o Large, cherry red, edematous epiglottis
o The cardinal signs of epiglottitis are the "4 Ds" –
o Drooling
o Dysphonia
o Dysphagia
o Distress
o
Prevention : Key prevention for epiglottitis is immunization with H. influenzae type B conjugate beginning at
two months of age.
o Do not irritate the throat

o NO tongue depressor
o NO oral thermometer
o NO assessing the throat
o NPO
o
Tonsillitis
o Inflammation of the tonsil

o Cause by group A streptococcus
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Pre op
o Prothrombin time PT
Post op
o Prone or side lying position

o Monitor for sign of bleeding = frequent swallowing
o Provide clear, cool, non-citrus
o Avoid red, purple, brown liquid
o Avoid milk and ice cream
o Avoid use of straw and fork
o Avoid suction
o If vomiting occurs , place in side to prevent aspiration
o toddler following a tonsillectomy
o For a toddler experiencing pain resulting from a tonsillectomy, give the toddler a "magic" blanket
to take the pain away. Toddlers are magical and mystical thinkers, so this "magic" blanket may be
an effective pain management technique for children of this age.
CROUP
o Put child in cool mist tent
o Parent can hold the child
o No antibiotics unless there is a bacterial infection
o
Bronchitis
o Encourage fluids intake
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Child with RSV
o Place in private room

o One nurse to care for him only
Cystic fibrosis
o Cystic fibrosis is a multisystem disorder that is caused by a genetic defect. This disorder is inherited as an
autosomal recessive trait.
o ➢ Meconium ileus is one of the earliest manifestations in a newborn with cystic fibrosis. This may occur
within the first two weeks of life. Manifestations of a meconium ileus include abdominal distension and
failure to pass meconium, with or without vomiting.
o Treatment includes nasogastric tube (NGT) insertion, which may decompress the abdomen.
o
o What is the appearance of the stool in a client with CF? remember the 4 Fs
o Fat
o Frothy
o Foul-smelling
o Floating
o Steatorrhea
o Iontophoresis - sweat test > 60 positive = increase Na and CL

o Lung and pancreas are the most affected organs
o Diet is High calorie, High protein , Modified fat
o The major problem in CF is Increased viscosity of the secretions of exocrine glands lead to obstruction
o The most common intervention for the CF client with a diagnosis of decreased airway clearance is Postural
drainage
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Musculoskeletal
A cast is applied to a thirteen-month-old girl
o It is important to do frequent skin checks around the edges of the cast

o Pay attention if your child expresses discomfort that may suggest numbness or tingling in her toes."
o Check the temperature and color of the skin on your child’s feet.”
o Call the doctor if the child has pain unrelieved by medication.”
Hematological
Sickle cell anemia
• Hb A replaced by sickle cell Hb
R/F
• African American
Sickle crisis
• Vaso-occlusive crisis
o Fever
o Abd pain
o Pain and swelling of the hand and feet
• Splenic
• Hyper hemolytic
• Intervention
• Hydration = oral and IV
• O2
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• Blood transfusion
• Elevate the HOB
• Avoid administer of meperidine for pain
Hemophilia
• Deficiency in the clotting factors

• Hemophilia A= def in factor = VIII
• Hemophilia B= def in factor = B
• Treatment is replacing the missing factor
• Pian relive
• Assess for
• Bleeding
• Epistaxis
• Bruises
Eye and ear
Conjunctivitis
o Sharing towels should be discouraged to prevent the spread of infection to other family members.
o Rubbing the eyes can cause both injuries to the eye itself and the spreading of the infection.
o Cold compresses should be used to lessen irritation, not warm.
o It is okay to send the child back to school or daycare after just 24 hours of administration of the
antibiotic, not 48 hours.
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Mental health NCLEX

Generalized anxiety disorders
Sever
• Anti anxiety PRN
Panic = daily antianxiety
Pt education
• Avoid the triggers

• Plan what to do
• Medications - Antianxiety Agents
Short acting
• Midazolam (Versed)
• Diazepam (Valium)
Intermediate - Long acting
• Clonazepam (Klonopin)
• Alprazolam (Xanax)
• Lorazepam (Ativan)
Action:
• general CNS depression
Nursing Considerations:
• Avoid alcohol
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• Monitor for respiratory depression
Antidote
• Flumazenil
• Flumazenil is the antidote for benzodiazepine overdose.
Depression
What is Depression?
• “The feeling of severe despondency and dejection”

• A state of low mood
• Aversion to activity
• Affects their thoughts, behaviors, and feelings.
Assessment
• Anhedonia is a common symptom of depression. It is defined as the loss of pleasure in usually pleasurable
things
• Sleep disturbances are an incredibly common symptom in depression
Therapeutic management
• Safe environment - assess risk for self harm

• One to one observation
• Remove potentially harmful items
Antidepressants
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Bupropion is a medication indicated for major depressive disorder MDD and may be used for smoking
cessation.
Venlafaxine is a medication that is indicated for depression. The client's comment of not wanting to go on
anymore should concern the nurse because anti-depressants may cause thoughts of suicide.
increase the levels of ALL neurotransmitters ( dopamine, norepinephrine, epinephrine, serotonin)
MAOIs = TIPS
• Tranylcypromine
• Isocarboxazid
• Phenelzine
• Selegiline
• Avoid foods that are high in tyramine

• Aged cheeses
• Wine
• Pickled meats
Side effect
• hypertensive crisis
SSRIs =FCES
Prevent reuptake of serotonin increasing the availability of serotonin in the body.
• Fluoxetine
• Sertraline
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• Escitalopram
• Citalopram
• Monitor for serotonin syndrome

o Hypertension, confusion, anxiety, tremors, ataxia, sweating.
• Suicide precautions important for 2-3 weeks
o When the patient’s mood starts to improve, they are an increased risk for suicide
o Why? They now have the energy to follow through with a plan
TCAs =line =NAP
Prevents the reuptake of norepinephrine and serotonin increasing these neurotransmitters in the body..
• Amitriptyline
• Nortriptyline
• Protriptyline
• Monitor for anticholinergic side effects

o Dry mouth, constipation, urinary retention
Bipolar Disorder
• A mood disorder where there is difficulty regulating extreme emotions.

• There is a periods of mania, periods of depression, and the inability to self-regulate these emotions.
• Mania: “A mood disorder marked by hyperactive wildly optimistic state”
• Depression: “The feeling of severe despondency and dejection”
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Therapeutic Management
• Identify triggers to prevent future episodes of mania

• Safe environment
• Don’t argue while in a manic state
• Provide high-calorie, finger food they can eat on the go
Treatment
Lithium Indication:
Mania
• Do not administer with NSAIDS

• Monitor drug levels: Therapeutic level - 0.5-1.5mEq/L
• Encourage adequate fluid intake
• Side effects: ○ Seizures, arrhythmias, fatigue, confusion, nausea, anorexia, hypothyroidism, tremors
Haloperidol Therapeutic class:
• Antipsychotic Indication: Schizophrenia, mania, aggressive behavior, agitation

• Action: Inhibits the effects of dopamine
• Nursing Considerations:
o Monitor for extrapyramidal side effects
o Tardive dyskinesia
o Neuroleptic malignant syndrome
o Can prolong the QT interval
▪ Weekly EKG
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Schizophrenia
• A long-term mental disorder involving a breakdown in the relation between thought, emotion, and
behavior.
Assessment
Positive signs
• Hallucinations
• Delusion
• Disorganized speech
Negative
• Other than positive
Delusions
• Provide a safe environment

• Ask about the delusion to understand what they are experiencing
• Validate real aspects of the delusion
• Do not argue about the delusion
• Reflect on how it makes them feel
• Focus on FEELINGS, not the actual delusion
• Be honest
• Set limits
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Hallucinations
• Provide a safe environment ○

• Stay focused on reality
• Be direct
• Set limits
• Decreation stimulation
• Don’t touch them when experiencing a hallucination
• Auditory hallucinations
• Are they telling them to do something?
Anorexia Nervosa
“An emotional disorder characterized by an obsessive desire to lose weight by refusing to eat.”
Assessment Findings
• Low body temperature

• Bradycardia
• Hypotension
• Cyanosis
• Electrolyte abnormalities
• Hormonal imbalances
• Sleep disturbances
• Bone degeneration→ Osteoporosis
• Amenorrhea
• Lanugo
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• GI upset
Teenage clients with anorexia nervosa continually strive for perfection in all they do, exhibiting obedient
and orderly behavior at home and school.
Bulimia Nervosa
Assessment Findings
• Labile mood
• Low libido
• Esophageal varices
• Tooth enamel break down
• Helplessness
• Address medical issues

• Electrolyte imbalances
• Provide a safe environment
• Monitor for self-harm and suicidal ideations
• Validate their feelings
• Help identify triggers and avoid
• The nurse should observe the client while eating and prevent the client from using the bathroom for 90
minutes after meals to break the purging cycle.
• Bupropion is contraindicated in the treatment of bulimia because of its weight negative effects. Weight
loss is not a treatment goal for a client with bulimia nervosa, and thus, this medication should not be
utilized.
Borderline personality disorder (BPD) is a common personality disorder that features:
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• extreme emotional lability,

• impulsivity,
• self-mutilative behaviors
• manipulative mannerisms.
A borderline personality disorder is about five times more common in first-degree biological relatives with the
same disorder compared with the general population. This disorder is highly associated with genetic factors such
as hypersensitivity, impulsivity, and emotional dysregulation. A key intervention for a client with BPD is to assess
for suicidality. Parasuicide is common with this personality disorder; however, it is essential to keep this client
safe. Defense mechanisms commonly seen in this personality disorder include splitting, projective
identification, and denial.
Therapeutic Communication
• Therapeutic communication is goal-oriented, purposeful, caring, and compassionate.
• The purpose of therapeutic communication is to facilitate the achievement of optimal client outcomes.
Therefore, they must be caring and kind to achieve this goal.
• Therapeutic communication occurs after trust is established in the nurse-client relationship. The
therapeutic nurse-client relationship begins with the establishment of trust with the client, after which the
working phase of the therapeutic nurse-client relationship can continue with ongoing, open, and honest
communication.
• Therapeutic communication must be modified and altered according to the client’s culture. Many
factors, including culture, impact the therapeutic communication process. Additional factors that i mpact
the therapeutic communication process include age, level of development, perspectives, and values.
• Therapeutic communication is fully mindful of any nonverbal messages that are sent by the nurse.
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• Therapeutic communication consists of both oral communication that is understandable to the client
as well as nonverbal communication techniques that are consistent with the received message as well as
the client’s needs.
•
Open-ended questions
• Provides the patient with an opportunity to express their thoughts

• Encourages communication
• Focuses on patient centered responses
• Allows the patient to be in charge of the direction of the conversation.
• Therapeutic communication techniques and open-ended questions used to communicate with clients
allow them to express themselves while building self-esteem. Strategies involved in therapeutic
communication include clarifying the client's concern, maintaining eye contact, conveying empathy, and
periodically using silence to allow for reflection.
Never dismiss a patient’s feelings
• Important to make sure the patient knows they are heard.

• Their feelings should be validated.
Never say these
• “You have nothing to worry about”

• “It will all be okay”
• “Others have it worse off than you do”
• “I’ll just give you some medication so you can relax”
Never give false reassurance
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• These are promises you can’t always keep

• Don’t give you any chance to explore the patient’s feelings
• “Nothing bad can happen to you here”
• “It will all be alright”
• “You don’t need to worry you’re safe here”
Therapeutic Silence
• Effective for patients in the acute phase of severe depression

• Makes no demands of them
• Simply be with them
Connection
• Build rapport with the patient

• Try to remove any biases you have
Active listening
• Really listen to what the patient is telling you

• Rephrase what they have said to you so they know you are listening
• Clarify what was meant so they have the chance to correct you if you misunderstood them
• Show empathy
Never ask WHY
• Why statements are not therapeutic.

• This points the finger at the client and makes them feel as if it is their fault they are having these feelings.
• Asking why someone feels the way they do invalidates them
• It will not promote the open and honest communication that is necessary for a therapeutic environment.
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Domestic violence
• Bruises and broken bones

• Unintended pregnancies
• Alcoholism
• Depression
(including physical, emotional, and sexual abuse) occurs throughout society. It is present among all racial,
social, and economic groups.
Health issues related to domestic violence include:
physical injury from the assault and chronic health problems that may emerge, either as a complication of
traumatic injury or as a physical response to ongoing stress from violence or neglect.
Health issues related to domestic violence include physical injury from the assault itself, such as bruises and
broken bones (Choice B).
Families experiencing domestic violence/ physical abuse have more unintended pregnancies, miscarriages,
abortions, and low-birth-weight babies (Choice C).
Families experiencing domestic violence have higher rates of substance abuse and depression (Choices E and F).
Bruises and burns in a child indicate abuse. Once the nurse suspects child abuse, he/she is responsible for
notifying Child Protective Services.
Reminiscence is a therapeutic measure that enables an individual to recall past memories. Many older
adults enjoy sharing past experiences through storytelling. As a therapy, reminiscence uses the recollection of
174
the past to bring meaning and understanding to the present and resolve current conflicts. This approach also
supports an individual's self-esteem by reflecting on positive events.
Reminiscence helps support self-esteem by having an individual look back on past accomplishments and
positive life experiences. This strategy may be used one-on-one or in a group setting, facilitating rapport
building with other individuals. Finally, reminiscence is a way for an individual to express their personal
identity by reflecting on past accomplishments (college work, occupations, marriage, etc.).
client experiencing opioid withdrawal will experience symptoms such as
• abdominal cramping,
• diarrhea,
• nausea,
• rhinorrhea,
• piloerection,
• diaphoresis, tachycardia, hypertension,
• insomnia,
• agitation.
• Demonstrating altruism by a largely unconscious motivation to feel caring and concern for others.
• once the client is at risk of harming himself, other clients, or staff, the nurse should call for help and
prepare to administer a sedative/tranquilizer to calm him down. De-escalation should be continued all
the time, talking, reassuring, and negotiating. However, physical intervention should be undertaken quickly
175
in this mentally unstable patient. Physical restraint should be the minimum necessary for
the shortest period. Control is best done seated on a bed or kneeling, then restrain supine, not prone.
Physical restraint should be accompanied by rapid sedation with medications.
• The first thing that you should do is establish the client's trust. Trust is the early stage of the
therapeutic nurse-client relationship. After the trust is established, the nurse should encourage,
facilitate, and allow the client to ventilate their feelings. This ventilation of feelings is used for and enfolded
into the assessment of the client as well as their current psychosocial functioning; this is often used to
generate a nursing diagnosis that is specific to the client’s needs.
• Acamprosate is a medication intended to treat alcohol use disorder. This medication may be combined
with naltrexone to increase the chance of sobriety.
• Varenicline is a medication intended to reduce nicotine withdrawal symptoms and cravings.

Following the initiation of varenicline, the client's comments that they are not smoking cigarettes anymore
indicate varenicline has been therapeutically effective. Clients go back to resuming tobacco smoking if the
withdrawal symptoms are not appropriately treated.
References
1. Saunders comprehensive review for the NCLEX-RN examination 8th edition
2. Archer Review NCLEX-RN = 90 days combo
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Prepared by ABUBAKER HAMED, January 24, 2023

Fundamentals of nursing NCLEX

• Wheezing = ass with narrow of the airway

• Too large IV canula = lead to mechanical phlebitis

Medications put pt risk for fall

Medications name or group Notes

Contraindications for oral TEMP

Contraindications of rectal TEMP

• 0= absent -- 4+= strong

• 1-3 minutes after position change

Pulse oximetry = spo2

• IV route – fast effect

• Prolong use of tourniquet can lead to increase K+ level

24 hours urine collection=

• 1st specimen should discarded

Taking blood glucose

• Prick side of the finger not the pad

• Does not need sterile gloves

Urinary diversions methods

Urinary diversions methods Notes

Vesicostomy Created on abd wall

• Pre o2 use contaminated hand

• To avoid bleeding = cuff should not be deflated and don’t manipulate

Ethical principles Notes

Nurse must follow the nurse practice act guidelines.

UAP tasks LPN tasks RN tasks Notes

• Don’t care for

• Don’t care for

• Don’t deal with CV line

• Don’t transfer or discharge

• Don’t administer blood products

Electrolytes High Low Notes

ECG changes Tall, peaked T wave ST depression

Immobility Acute pancreatitis Milk and milk soy

ECG changes Shorten ST Prolong ST

Sodium Hypernatremia > 145 Hyponatremia <135 Food high in Na+

Hyperaldosteronism Hyperglycemia Processed food

Acid base Respiratory Respiratory Metabolic acidosis Metabolic alkalosis

• Pt on liquid diet= increase protein

Type of blood products

• Infuse time for one unit = 1-2 hrs

• Cross- matching usually is not required

Fresh frozen plasma

• To provide clotting factor

• A = can received from A or O

Cardiac system NCELX

Diseases Assessment Interventions Diet Notes

Diseases Assessment Interventions Diet Notes

Diseases Assessment Interventions Diet Notes

Pt with cardiac surgery

Heart failure S and S depends on Avoid canned HF compilations

Diseases Assessment Interventions Diet Notes

Pericarditis Chest Pain triggers Flowers position Monitor for signs

Pericardial friction sign of toxicity

Diseases Assessment Interventions Diet Notes

Endocarditis Fever Record temp q day for 6 R/F

Diseases Assessment Interventions Diet Notes

Cardia tamponade Dec COP Inc COP by given

Hypertension -HTN Normal Check BP Low fat R/F

Diseases Assessment Interventions Diet Notes

Deep vein thrombosis Calf or groin Bed rest

Arrhythmias Descriptions Treatment Notes

Sinus bradycardia HR< 60 Atropine