o This facilitates removal of fluid through gravity and enhances

circulation

Think positively and you can achieve great things!

Prior to liver biopsy it is important to check lab results for PT time (vascular
organ)

Liver biopsy- (prior) administer Vitamin K, NPO at midnight, teach patient

that he will be asked to hold breath for 5-10 sec, supine position with upper arms
elevated

Morphine is contraindicated in pancreatitis—it causes spasm of the Sphincter

of Oddi—Demerol is the pain medication of choice!
*After pain relief, it is important to cough and deep breathe in
pancreatitis—because fluid is pushing up in the diaphragm

*With chronic pancreatitis, pancreatic enzymes are given with meals

Diabetes Mellitus- pancreatic disorder resulting in insufficient or lack of

insulin production leading to elevated blood sugar
● Type I (insulin dependent) immune disorder, body attacks insulin
producing beta cells with resulting Ketosis (result of ketones in blood due
to gluconeogenesis from fat)
o Excessive thirst and weight loss are characteristic of T1DM
● Type II (insulin resistant)- beta cells do not produce enough insulin or
body becomes resistant
● NCLEX Points
o Assessment
▪ 3 P’s
● Polyuria (excessive urination), polydipsia (extreme
thirst), polyphagia (excessive hunger)
▪ Elevated blood sugar
▪ Blurred vision
▪ Elevated HbA1C
▪ Poor wound healing
▪ Neuropathy
▪ Inadequate circulation
▪ End organ damage is a major concern due to damage to
vessels
● Coronary artery disease
o HTN, cerebrovascular disease

13
 ● Retinopathy
o Therapeutic Management
▪ Insulin
● Required for Type I and for Type II when diet and
exercise do not control blood sugar
● Assess for and teach the patient regarding peak action
time for various insulins
o Only administer short acting insulins IV
● Do not use vial that appears cloudy (NPH is the
exception)
▪ Patient should monitor blood sugar before, during, and after
exercise
▪ Patient should use protective footwear to prevent injury
▪ Infections and wounds should receive meticulous care
▪ Foot Care (inspect daily)
● Feet should be kept dry
● Footwear should always be worn (cotton socks are
recommended as well as properly fitted shoes)
● Should not wear tight fitting socks
▪ Sick Day – when patients with DM become ill, glucose levels
become elevated
● Continue to check blood sugars and do not withhold
insulin
● Monitor for ketones in urine
▪ 15 Rule
● If blood sugar is low, administer 15g carbohydrates (5
lifesavers, 6 oz juice)- recheck in 15 minutes
▪ Complications
● Lipoatrophy
o Loss of subq fat at injection site (alternate
injection sites)
● Lipohypertrophy
o Fatty mass at injection site
● Dawn phenomenon
o Reduced insulin sensitivity between 5-8AM
o Evening administration may help
o Adjust evening diet, bedtime snack, insulin
dose, and exercise to prevent early morning
hyperglycemia – adjust do not eliminate
(usually intermediate acting insulin is used)
● Somogyi phenomenon
o Night time hypoglycemia results in rebound
hyperglycemia in the morning hours

14
Rapid-acting insulin should only be given if food is available and
patient is ready to eat

Repaglinide is a meglitinide analog drug—short-acting agents used to prevent

postmeal blood glucose elevation—should be given within 1 to 30 minutes before
meals and cause hypoglycemia shortly after dosing when a meal is denied or
omitted

15
Drawing up regular insulin and NPH together
Cloudy (air into NPH)
Clear (air into regular)
Clear (draw up regular)
Cloudy (draw up NPH)
Or
RN- regular before NPH

Hypoglycemia requires urgent treatment

● Signs and Symptoms
o Hunger
o Irritability
o Weakness
o Headache
o BG < 60
● Consume 10 to 15g of carbohydrate (15-Rule)
 ● Glucose should be retested in 15 min
● Patient should eat a small snack of carbohydrate and protein if the next
meal is more than an hour away
● Repeat carbohydrate treatment if symptoms do not resolve

Alcohol has the potential for causing alcohol-induced

 hypoglycemia—it is
important to know when the patient drinks alcohol and to teach the patient to
ingest it shortly after meals to prevent this complication

Guidelines for exercise are based on blood

 glucose and urine ketone
level—patients should test blood glucose before, during, and after exercise to be
sure that it is safe.
● When ketones are present the patient should not exercise because they
indicate that current insulin levels are not adequate

Diabetic Ketoacidosis (DKA)- body is breaking down fat instead of sugar for
energy—fats leave ketones (acids) that cause pH to decrease
*DKA is rare in DM Type 2 because there is enough insulin to prevent breakdown
of fats
● Serum acetone and serum ketones increase in DKA
● As you treat the acidosis and dehydration expect the potassium to drop
rapidly →
  be ready with potassium replacement
● Fluids are the most important intervention for DKA and HHNS
o NS or LR
● Second voided urine is the most accurate when testing for ketones and
glucose
● Bringing the glucose down too much too quickly can result in increased
ICP due to water being pulled into the CSF
16
 ● Urine ketone testing should be done whenever the patient’s blood glucose
is greater than 240

Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

● Potassium is low due to diuresis
● Fluids are the most important intervention
● No acidosis and no ketosis
● Weight loss is a symptom
● Often occurs in older adults with T2 Diabetes
● Risk Factors
o Diuretics
o Inadequate fluid intake (dehydration)

HbA1c- assesses how well blood sugar has been managed over 3 month period- 4
to 6% is good; 8% or greater indicates poor control
● 7% is ideal for a diabetic
Usually hold insulin prior to surgery and monitor blood glucose

To Remember Blood Sugar

Hot and dry, sugar high (hyperglycemia)
Cold and clammy, need some candy (hypoglycemia)

Laparoscopy- CO2 is used to enhance visual—general anesthesia, foley catheter

Post-op: EARLY AMBULATION to mobilize CO2

Myasthenia Gravis- decrease in receptor sites for acetylcholine- because the

smallest concentration of ACTH receptors are cranial nerves, expect fatigue and
weakness in eye, mastication/chewing, and pharyngeal muscles

Sometimes the first sign is that the patient can’t brush their hair

*Not enough receptor sites for Acetylcholine to bind to for activation—leading to

muscle weakness

*Worsens with exercise and improves with rest

● Diagnosis is made via Tensilon test- improvement in muscle weakness
(short period of time) indicates a positive reaction
● Avoid alcohol, crowded places, try to reduce stress, avoid heat (sauna, hot
tub, sunbathing), spread activities throughout the day, thicken liquids

Myasthenic Crisis:  often follows some type of infection—client is at risk for

inadequate respiratory function

17
 ● S/S: elevated temperature, tachycardia, HTN, incontinent of urine and
stool

Cholinergic Crisis: caused by excessive medication, stop med→

  Tensilon will
make it worse

Head injury Medication

● Manntiol (osmotic diuretic)—crystallizes at room temperature so
ALWAYS use a filter needle!

Endocrine System
Hormone Gland
Growth Hormone (GH) Anterior Pituitary
ADH Posterior Pituitary
T3, T4 Thyroid
PTH Parathyroid
Glucocorticoids: cortisol Adrenal gland
Insulin Pancreas

*Parathyroid gland relies on the presence of Vitamin D to work

Palpate the thyroid gently- can cause thyroid storm in a patient with
hyperthyroidism

After removal of pituitary gland- watch for hypocortisolism and

temporary Diabetes Insipidus

Myxedema/Hypothyroidism- hyposecretion of thyroid hormone (TH)

resulting in decreased metabolic rate (slowed physical and mental function)
● Myxedema coma- life threatening state of decreased thyroid
production—coma result of acute illness, rapid cessation of medication,
hypothermia
● NCLEX Points
o Assessment
▪ Think HYPOmetabolic state
▪ Cardiovascular- bradycardia, anemia, hypotension
▪ Gastrointestinal- constipation (GI motility slows)
▪ Neurological- lethargy, fatigue (due to decreased
metabolic rate—“body is slow and sleepy”), weakness, muscle
aches, paresthesias
▪ Integumentary- goiter,
 dry skin, dry hair, loss of
body hair

18
 ▪Metabolic- cold intolerance, anorexia, weight gain (due to
decreased metabolic state), edema, hypoglycemia
o Therapeutic Management
▪ Cardiac monitoring
▪ Maintain open airway
▪ Monitor medication therapy (overdose with thyroid
medications possible)
▪ Medication therapy- levothyroxine (Synthroid)
● Take in morning before breakfast to prevent
insomnia (on empty stomach)
▪ Assess thyroid hormone levels
 ▪ IV fluids
▪ Monitor and administer glucose as needed
*Myxedema is COLD (hypothermia)

Hyperthyroidism- excess secretion of thyroid hormone (TH) from thyroid

gland resulting in increased metabolic rate (accelerated physical and mental
function)
● Causes
o Graves disease (autoimmune reaction)
o Excess secretion of TSH, tumor, medication reaction
● Thyroid Storm (Thyroid Crisis)
o Extreme hyperthyroidism (life threatening) due to infection, stress,
trauma
▪ Febrile state, tachycardia, HTN, tremors, seizures
● NCLEX Points
o Assessment
▪ Elevated T3, T4, free T4, decreased TSH, positive radioactive
uptake scan
▪ Goiter
▪ Bulging eyes
▪ Cardiac- tachycardia, HTN (increased systolic, decreased
diastolic), palpitations
▪ Neurological- hyperactive reflexes, emotional instability,
agitation, hand tremor
▪ Sensory- exophthalmos (Graves disease), blurred vision,
heat intolerance
▪ Integumentary- fine, thin hair
▪ Reproductive- amenorrhea, decreased libido
▪ Metabolic- increased metabolic rate, weight loss
o Therapeutic Management
▪ Provide rest in a cool quiet environment
▪ Anti-thyroid medications (PTU, propylthiouracil)
▪ Cardiac monitoring
▪ Maintain patent airway
19
 ▪ Avoid drinks that are stimulants (increases metabolic rate)
● Caffeine- coffee, tea, soda
▪ Provide eye protection
● Regular eye exams
● Moisturize eyes
▪ Radioactive Iodine 131
● Taken up by thyroid gland and destroys some thyroid
cells over 6-8 weeks
o Avoid with pregnancy
o Monitor lab values for hypothyroidism
▪ Surgical removal
● Monitor airway
● Maintain in semi-Fowlers position
● Assess surgical site for bleeding
● Monitor for hypocalcemia
o Have calcium gluconate available
● Minimal talking during immediate post-op period
● (Partial-thyroidectomy) Monitor temperature
post-op→ elevated temp by even 1 degree may
indicate impending thyroid crisis→  report to MD
immediately

*Think of MICHAEL JACKSON IN THRILLER

-Skinny, nervous, bulging eyes, up all night, heart beating fast
(Insomnia is aside effect of excess thyroid hormones—due to increased metabolic
rate—body is “too busy to sleep”)
Hypo-parathyroid: decreased calcium (implement high calcium, low
phosphorous diet; provide Vitamin D which aids in calcium absorption)
*Trousseau’s and Chvostek’s signs
CATS (S/S):
C- convulsions
A- arrhythmias
T- tetany
S- spasms
S- stridor

Hyper-parathyroid: increased calcium (implement low calcium, high

phosphorous diet)
S/S: Fatigue, polyuria, muscle weakness, renal calculi (55% have urinary tract
calculi), back and joint pain, monitor for bone deformities

Pre-parathyroidectomy- low calcium, high phosphorous diet

20
*For patients who are not candidates for para-thyroidectomy, diuretics
(furosemide) and hydration (IV NS) in combo help reduce serum calcium →
furosemide increases kidney excretion of calcium when combined with IV saline
in large volumes

*BEST WAY TO EVALUATE FLUID STATUS (fluid volume deficit)-

daily weight

Hypovolemia: (dehydration) increased temperature, rapid/weak pulse

(tachycardia), increased respirations, hypotension, anxiety, urine SG > 1.030
(dark urine), confusion (early sign)
● Increased sodium with dehydration
● Increased BUN with dehydration
● Increased hematocrit with dehydration
Hypovolemic Shock
● Isotonic fluids – increase intravascular volume (NS or LR)
● Albumin can be given too (expander)

Hypervolemia: (fluid volume excess/overload) bounding pulse, SOB, dyspnea,

crackles, peripheral edema, HTN, urine SG <1.010 (dilute urine); Semi-Fowler’s

*D5W-body rapidly metabolizes the dextrose and the solution becomes hypotonic

Low phosphorous—patient will exhibit generalized muscle weakness→   may lead

to acute muscle breakdown (rhabdomyolysis)
● Phosphate is necessary for energy production in the form of ATP—when
not produced, leads to generalized weakness

Diabetes Insipidus (DI): hyposecretion or failure to respond to ADH from

posterior pituitary—leading to excess water loss
▪ NCLEX Points
o Assessment (S/S)
▪ Excessive urine output
● Dilute urine (USG <1.006)
▪ Hypotension leading to cardiovascular collapse
▪ Tachycardia
▪ Polydipsia (extreme thirst)
▪ Hypernatremia
▪ Neurological changes
o Therapeutic Management
▪ Water replacement
● D5W if IV replacement is required
▪ Hormone replacement
 ● Desmopressin
● Vasopressin
21

▪ Monitor urine output hourly and urine SG

● Report urine output > 200mL/hour
▪ Daily weight monitoring
Syndrome of Inappropriate Antidiuretic Hormone (SIADH): excessive
secretion of ADH (from posterior pituitary) leading to hyponatremia and
water intoxication (excessive water retention)
● Caused by trauma, tumors, infection, medications
● NCLEX Points
o Assessment (S/S)
▪ Fluid volume excess (HTN, crackles, JVD)
▪ Altered LOC
▪ Seizures
▪ Coma
▪ Urine specific gravity > 1.032
▪ Decreased BUN, hematocrit, Na (hyponatremia)
o Therapeutic Management
▪ Cardiac monitoring
▪ Frequent neuro exams
▪ Monitor I&O
▪ Fluid restriction
▪ Sodium supplement
▪ Daily weight (loss of 2.2 lbs or 1 kg = 1 L)
▪ Medication
● Hypertonic saline (D5 w/ NS)
● Diuretics (furosemide)
● Electrolyte replacement

*Water intoxication – drowsiness and altered mental status

Specific Gravity
● 1.010-1.030
● High- (concentrated/dark urine)
o Dehydration
o SIADH
o Heart failure
● Low- (dilute/water-like urine)
o CKD
o Diabetes Insipidus
o Fluid volume overload

Hypomagnesemia (low Mg): tremors, tetany, seizures, dysrhythmias (life

threatening ventricular arrhythmias), depression, confusion, dysphagia
*Low Mg may lead to digoxin toxicity

22
Hypermagnesemia (high Mg): depresses the CNS, hypotension, facial
flushing, muscle weakness, absent deep tendon reflexes, shallow respirations
*Emergency

Addison’s Disease- hyposecretion of adrenal cortex hormones; decreased

levels of glucocorticoids and mineralcorticoids leads to hyponatreamia,
hyperkalemia, hypoglycemia, decreased vascular volume—fatal if not treated
● NCLEX Points
o Assessment
▪ Hyponatremia (down)
▪ Hyperkalemia (up)
▪ Hypoglycemia (down)
▪ Decreased blood volume (down)- anemia
▪ Hypotension (down) – most important assessment
parameter
▪ Weight loss
▪ Hyperpigmentation (tanned skin)
▪ Decreased resistance to stress
o Therapeutic Management – with Addison’s you must add
hormone (teaching about steroid replacement is important)
 Monitor vital signs
▪
Monitor electrolytes
▪
Monitor glucose
▪
● Treat low blood sugar
▪ Administer replacement adrenal hormones as needed
▪ Lifelong medication therapy needed
▪ Managing stress in a patient with adrenal insufficiency is
important—if the adrenal glands are stressed further it can
result in Addisonian Crisis
o Addisonian Crisis
▪ Caused by acute exacerbation of Addison’s Disease
▪ Causes severe electrolyte disturbances
▪ Monitor electrolytes and cardiovascular status closely
▪ Administer adrenal hormones as needed
▪ S/S: N/V, confusion, abdominal pain, extreme weakness,
hypoglycemia, dehydration, decreased blood pressure
▪ During times of stress- increase sodium intake →  a
decrease in aldosterone leads to increase in excretion of
sodium)

Cushing’s Disease- hypersecretion of glucocorticoids leading to elevated

cortisol levels; greater incidence in women; life threatening if untreated
● NCLEX Points
o Assessment
▪ Hypernatremia (up)
23
 ▪ Hypokalemia (down)
▪ Hyperglycemia (up)
▪ Increased blood volume (up)
▪ Hypertension (up)
▪ Prone to infection
▪ Moon face
▪ Buffalo hump
▪ Muscle wasting
▪ Edema (signs of CHF)
▪ Risk to bruising
● Therapeutic Management – you have excess “cushion” of hormones
o Monitor electrolytes and cardiovascular status
▪ Prevent fluid overload – respirations are the first priority
▪ Cardiovascular feature- capillary fragility→
  results in
bruising and petechiae
o Provide skin care and meticulous wound care (paper thin skin that
is easily injured)
o Provide for client safety
o Adrenalectomy (surgical removal of adrenal gland)
o Protect client from infection
o Often caused by tumor on adrenal or pituitary gland

Pheochromocytoma- vascular tumor of adrenal medulla (adrenal glands)

leading to a hypersecretion of epinephrine/norepinephrine
● S/S: persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor,
pounding headache
● Management: avoid stress and frequent bathing, and take rest breaks
(limit activity), avoid stimulating foods, avoid foods high in tyramine
● Avoid palpating the abdomen as it can cause a sudden release of
catelcholamines and severe HTN
● Tx: surgery to remove tumor

Priority situation
Neuroleptic Malignant Syndrome (NMS)
NMS is like S&M
-You get hot (increased temp/hyperpyrexia)
-Stiff (increased muscle tone)
-Sweaty (diaphoresis)
-BP, pulse, and respirations go up
-You start to drool
*Flu like symptoms

*Never get pregnant with a German (German measles/rubella is the

dangerous one for pregnant women)
24
 ● Exposure to rubella for a pregnant woman—incubation is 14 to 21 days
(communicable 7 days before)

Pulmonary Embolism
● First sign- sudden chest pain, followed by dyspnea and tachypnea
● O2 deprived—first intervention is usually oxygen (check ABGs)
o Patient may be hyperventilating as a compensatory mechanism
Risk Factors
● Obesity
● Immobility
● Pooling of blood in extremities
● Trauma (MVA)

Tetralogy of Fallot
*Think DROP
 (child drops to floor or squats)
D- defect, septal
R- right ventricular hypertrophy
O- overriding aorta
P- pulmonary stenosis

For neonates with Tetralogy of Fallot- prostaglandin E1 infusion

*Give O2 and morphine, IVF for volume expansion

MAOIs
*Pirates say “arrrr”—when pirates are depressed they take MAOIs
-MAOIs used for depression have an “ar” sound in the middle (parnate, marplan,
nardil)
..or..
PANAMA
PArnate- tranylcypromine
NArdil- phenelzine
MArplan- isocarboxazid

*Avoid tyramine when taking MAOIs—aged cheese, chicken liver, avocados,

bananas, meat tenderizer, salami, bologna, wine, beer—may cause HTN crisis

Systemic Lupus Erythematous- progressive systemic inflammatory disease

resulting in major organ system failure; immune system “hyperactive” attacks
healthy tissue; no known cure
● NCLEX Points
o Assessment
▪ Assess for precipitating factors
● UV light
● Infection
● Stress
25
 ▪ Arthritis
▪ Weakness
▪ Photosensitivity
▪ Butterfly rash
▪ Elevated ESR and C Reactive Protein
o Therapeutic Management
▪ Assess respiratory status
▪ Assess end organ function
▪ Plan rest periods
▪ Identify triggers
▪ Refer to dietitian for dietary assistance
▪ Medications
● Glucocorticoids
● NSAIDs
 NSAIDs
● Cyclophosamide (immunosuppressive agent)
**Should be in remission (SLE) at least 5 months prior to conceiving
*A high number of patients with SLE develop nephropathy, so an increase in
blood urea may indicate a need for a change in therapy or for further diagnostic
testing (such as creatinine clearance)

Albumin levels are the best indicator of long-term nutritional status (normal
3.5-5.0)
● (Same range as potassium)

One of the goals for a client with anorexia is to achieve a sense of self-worth and
self-acceptance that is not based on appearance →   encourage activities that will
promote socialization and increase self-esteem

Physical S/S of anorexia

● Amenorrhea
● Constipation
● Hypotension
● Cold intolerance
● Bradycardia
● Fatigue
● Muscle weakness
● Osteoporosis

Autonomic Dysreflexia- potentially life threatening emergency (seen with

patients with spinal cord injuries)
● Elevate HOB to 90 degrees - FIRST
● Usually T6 or above spinal cord injury
● Vasoconstriction below
● Vasodilation above
● Sudden, acute onset of HTN
26
 ● Loosen constrictive clothing
● Assess for bladder distention and bowel impaction (can trigger AD)-
SECOND
● Administer anti-HTN medications (may cause stroke, MI, seizure
● Metallic bitter taste

Thrombolytic therapy- avoid injury→

  avoid activities that could cause
bleeding (NO IM injections)

*The Institute for Safe Medication Practices guidelines indicate that the use of a
trailing zero is not appropriate when writing medication orders—because it
is easily mistaken for a larger dose!

First action after medication administration error is to assess the client for
adverse outcomes

Drug Schedules
● Schedule I- no currently accepted medical use, research only (heroin, LSD,
MDMA)
● Schedule II- drugs with high potential for abuse and requires written
prescription (Ritalin, hydromorphone/Dilaudid, meperidine/Demerol,
and fentanyl)
● Schedule III- requires new prescription after 6 months or five refills
(codeine, testosterone, ketamine)
● Schedule IV- requires new prescription after 6 months (benzodiazepines)
● Schedule V- dispensed as any other prescription or without prescription
(cough preparations, laxatives)

Medication Considerations
Digoxin- assess pulse for a full minute, hold if HR less than 60, check digoxin
levels and potassium and magnesium levels (low K and Mg can lead to digoxin
toxicity)
S/S of toxicity- yellow halo, N/V
*Digoxin is given with loading doses (normally 2- 0.5mg or
higher)—maintenance dose is typically 0.25mg
**Increases ventricular irritability—can convert a rhythm to V-Fib following
cardioversion

Aluminum Hydroxide (Amphojel)- (antacid) treatment of GERD and kidney

stones- watch for constipation
*Take after meals

27
Amiodarone- treats life-threatening heart rhythm problems; watch out for
diaphoresis, dyspnea, lethargy—take missed dose any time in the day or skip it
entirely—DO NOT take double dose

Warfarin (Coumadin)- anticoagulant therapy; watch for signs of bleeding,

diarrhea, fever or rash; stress the importance of complying with prescribed
dosage and follow-up appointments
● Patients taking warfarin should not make sudden dietary changes, because
changing the oral intake of foods high in Vitamin K (green leafy
vegetables, some fruits) will impact the effectiveness of the medication

Methylphenidate (Ritalin)- treatment of ADHD; assess for heart related

side-effects and report immediately; child may need drug holiday because the
drug stunts growth; poor appetite- parents should watch for weight loss

Ethambutol (TB)- negative effect on eyes

 (blurred vision, eye pain, red-green
color blindness, any loss of vision—more common with high doses); liver
problems may occur

Gemfibrozil- lowers high cholesterol and triglycerides; monitor liver functions

– increased risk of gallstones – rhabdomyolysis

Dextroamphetamine (Dexedrine)- used for ADHD, may alter insulin needs,

avoid taking with MAOI’s, take in morning after breakfast (insomnia is a possible
side effect)

Hydroxyurea- used to help treat sickle cell, can help reduce the number of
acute chest syndrome episodes, pain crises, and need for blood
transfusions—report GI symptoms immediately—could be sign of toxicity

Hydroxyzine (Vistaril)- tx of anxiety (can also be used to help with itching)-

watch for dry mouth- commonly given pre-operatively

Haloperidol (Haldol)—preferred antipsychotic for elderly patients—high risk of

EPS (dystonia, tardive dyskinesia, tightening of jaw, stiff neck, swollen tongue,
swollen airway)—monitor early for signs of reaction (IM Diphenhydramine can
be given)
● Side Effects- galactorrhea (excessive or spontaneous flow of milk),
lactation, gynecomastia, drowsiness, insomnia, weakness, headache
● When given IM- should be given deep into large muscle mass—is very
irritating to subcutaneous tissue

*If mixing antipsychotic medications (Haloperidol, Fluphenazine,

Chlorpromazine) with fluids, incompatible with caffeine and apple
juice
 28

Risperidone (Risperdal)- antipsychotic (schizophrenia)—doses over 6mg can

cause tardive dyskinesia—first line antipsychotic in children
● Causes weight gain, impairs temperature regulation, photosensitivity,
orthostatic hypotension

Fluoxetine (Prozac)- SSRI; doses that are greater than 20mg should be given in
divided doses

Midazolam (Versed)- given for conscious sedation- watch for respiratory

depression and hypotension (benzodiazepine)
● Contraindicated in patients taking protease inhibitors

Protease Inhibitors- antiviral drugs used to treat HIV/AIDs and hepatitis C

*Decrease the metabolism of many drugs—including midazolam
Serious toxicity can occur when protease inhibitors are given with other
medications

Rifampin- (treatment of TB)- watch for red/orange tears, urine

*Decreases effectiveness of contraceptives

Propylthiouracil (PTU) and methimazole (tapazole)- prevention of thyroid

storm
*Tx: hyperthyroidisim

Oxybutynin is an anticholinergic agent—can lead to extremely dry mouth; max

dose is 20 mg/day; should be taken between meals as food interferes with
absorption

Neostigmine- treats Myasthenia Gravis—administer to clients 45 min before

eating—helps with swallowing and chewing
*Also reverses the effects of anesthesia

Procainamide HCl- given to treat PVCs- withhold if severe

hypotension—adverse signs are bradycardia and hypotension

Isoniazid (medication for TB) causes peripheral neuropathy –patients may be

instructed to take Vitamin B6 to counter; hepatotoxicity (monitor LFTs); should
not be taken with Phenytoin (Dilantin) as it can lead to toxicity; hypotension may
occur initially but should resolve

Trimethobenzamide HCl (Tigan)- tx of post-op N/V and for nausea

associated with gastroenteritis

Alendronate- used for treatment and prevention of osteoporosis

29
 ● Photosensitivity- wear sunscreen and protective clothing when outdoors
● Take in the morning
● If missed dose, wait until next day to take

Doxycyline- antibiotic; dairy products inhibit the absorption of this medication

Cholestyramine- lower cholesterol

● S/E: constipation
● Should not take with spironolactone- increases blood chloride levels
● Many interactions- anticoagulants, beta blockers, diuretics, penicillins,
hormonal contraceptives, phenobarbital

CBT- Can Block Tremors (meds for Parkinson’s)

Carbidopa/Levodopa (Sinemet)- sweat, saliva, urine may turn reddish brown,
causes drowsiness; patients should not take with MAOIs
● Levodopa- contraindicated for patients with glaucoma, avoid Vitamin B6,
avoid high protein diet (interferes with the body’s response to medication)
Benztropine (Cogentin)- can be used for Parkinson’s, as well as to treat EPS –
may lead to the inability to move specific muscle groups or weakness (too much
of an effect)—anticholinergic (may lead to blurred vision, dry mouth)
*Increase fluid intake
Biperiden- Anti-Parkinson’s used to counteract EPS
Trihexyphenidyl HCl (Artane)- sedative effect
Timolol (Beta Blocker)- eye drops, used for treatment of glaucoma

Propranolol (Beta Blocker)- decreases effectiveness of atorvastatin

Sulfamethaxozole/Trimethoprim (Bactrim)- antibiotic- do not take if

allergic to sulfa- diarrhea is a common side effect, drink plenty of fluids

Simvastatin- tx of hyperlipidemia, take on empty stomach to enhance

absorption at night, report any unexplained muscle pain (could indicate
rhabdomyolysis)—especially if fever is present

Bromocriptine- used to treat menstrual problems

*Take with meals to avoid GI upset

Dabigatran- anticoagulant with NO antidote- do not take with other

anticoagulants

Gout
Probenecid (Benemid)- increases uric acid secretion in urine
Colchicine- prevention of gout
Allopurinol- acute
30
Hydralazine- Tx of HTN or CHF, report flu-like symptoms, rise slowly from
sitting/lying positions to prevent orthostatic hypotension, take with meals

Dicycloverine- Tx of irritable bowel- assess for anticholinergic side effects

Verapamil- CCB- tx of HTN, angina, and dysrhythmias- assess for constipation

Sucralfate- tx of duodenal ulcers (coats ulcer)- take

 before meals (1 hour)-
best on empty stomach
*Protects from acid

Cimetidine- H2
*Take with meals and at bedtime
S/E: constipation

Theophylline- tx of asthma and COPD

*Therapeutic drug level: 10-20 (12 letters in theophylline—12 is in between 10
and 20, also the “1” in 10 and “2” in 20 = 12)

N-Acetylcysteine- antidote for Tylenol and is administered orally

Glipizide- effective for client diagnosed with Type 2 DM, who produces minimal
amounts of insulin (oral hypoglycemic agent)

Acetazolamide (Diamox)- tx of glaucoma, high altitude sickness, increased

ICP- DO NOT take if allergic to sulfa
*Can cause hypokalemia

Indomethacin (Indocin)- NSAID- tx of arthritis (osteo, rheumatoid, gout),

bursitis, tendonitis
*Ototoxic

Levothyroxine (synthroid)- tx of hypothyroidism- may take several weeks to

take effect, notify doctor if chest pain—take in AM on empty stomach, can lead to
hyperthyroidism
Chlordiazepoxide (Librium)- tx of alcohol withdrawal- do not take alcohol
with this (including mouth wash that contains alcohol), very bad nausea and
vomiting can occur

Terbutaline—can lead to maternal tachycardia- withhold if HR is elevated prior

to administration
31
Vincristine (oncovin)- tx of leukemia (anti-leukemic)- IV only

Ganciclovir (Cytovene)- used for retinitis caused by cytomegalovirus- patient

will need regular eye exams, report dizziness, confusion, or seizures immediately

Sertraline (Zoloft)- SSRI, depression; S/E: agitation, disruption in sleep, dry

mouth

Serotonin Syndrome
● Rare, life threatening
● S/S: abdominal pain, fever, sweating, tachycardia, HTN, delirium,
myoclonus (jerky movements), irritability, mood changes

Clozapine- schizophrenia; S/E: agranulocytosis (low WBC count), tachycardia,

seizures
*Significant toxic risk associated with clozapine is blood dyscrasia
Agranulocytosis- flu-like symptoms (fever, sore throat, lethargy)

Lindane (Kwell)- Tx of scabies (lotion) and lice (shampoo)

Scabies- apply lotion once and leave on for 8-12 hours
Lice- wash hair with shampoo and leave on for 4 minutes with hair uncovered,
then rinse with warm water and comb with a fine tooth comb

Dantrolene (Dantrium)- treats muscle spasms caused by MS—may take a

week or more to be effective

Pentamidine- helps treat and prevent pneumocystis pneumonia

● Can cause fatal hypoglycemia—monitor blood glucose (low BG may
indicate need to change treatment)

Doxepin HCl- antidepressant

*Signs of overdose: excitability and tremors

Premarin (conjugated estrogen tablets)- tx after menopause- estrogen

replacement

*Estrogen can cause dry eyes

Furosemide (Lasix)- loop diuretic

● Ototoxic especially when given with other ototoxic drugs
● Monitor BP
● Monitor U/O
32
 ● Monitor K+
● Can lead to anorexia due to reduced potassium

Phenytoin (Dilantin)- tx of seizures

*Therapeutic drug level = 10-20
S/E: rash (stop med), gingival hyperplasia (practice good dental hygiene)
Toxicity- poor gait + coordination, slurred speech, nausea, lethargy, diplopia
Can cause leukopenia (low WBC)- stop medication

Thiothixene (Navane)- tx of schizophrenia- assess for EPS

Naproxen (NSAID)- used to mild to moderate pain

● Can cause gastrointestinal bleeding- monitor stools for blood

5-Fluorouracil (5-FU)- chemotherapy agent

Sulindac (NSAID) S/E are typically GI distress (GI bleeding, ulcers,
perforation of the stomach and/or intestines)

Theophylline- used for COPD and asthma (bronchodilator)

● Causes GI upset, take with food
● Avoid use of alcohol and caffeine while taking this medication
● Watch for toxicity (10 to 20 is therapeutic range)- >20 is considered toxic
(persistent nausea and vomiting are signs)
● Many drug interactions

Dopamine- treatment of hypotension, shock, low cardiac output, poor perfusion

to vital organs (ex: kidneys)- monitor EKG for arrhythmias, monitor BP

Phenobarbital CAN be taken during pregnancy- phenytoin

 is contraindicated

*All psych meds (except Lithium) have the same side effects- SNS
(exception is hypotension)

SNS- increase BP, HR, and RR, dilated pupils (blurred vision), urinary retention,
constipation (decreased GI motility), constricted blood vessels, and dry mouth

Only specific medications require double verification

Epidural
● When doing epidural anesthesia, hydration beforehand is a priority
● Hypotension, bradypnea and bradycardia are major risks and emergencies
● Patients will have a foley catheter due to the inability to void

33
 Forget your past mistakes and focus on your
successes!

When caring for a pregnant woman who follows a vegetarian diet, the nurse
should begin with an assessment of the diet (24 hour diet recall) because
vegetarian practices vary widely—assess the diet for deficiencies before making
recommendations for supplementation

Maternity Normal Values

● Fetal Heart Rate- 120 to 160 bpm
● Amniotic fluid- 500- 1200 mL
● APGAR- 7 and above = normal; 4 to 6 fairly low; 3 and below are critically
low
o Done at 1 and 5 minutes

Prenatal vitamins should be taken with something acidic (orange juice) at

bedtime (Vitamin C increases absorption)

Pregnant women should increase calories by 300 for fetal growth, maternal
tissues and placenta

Placenta previa requires c-section

Hyperemesis gravidarum- bed rest, NPO to rest GI tract, anti-emetics, IVF

Symptoms of onset of labor

● Gush of fluid down legs
● Some blood in vaginal discharge
● Low back pain

Fetal Heart Rate Patterns

VEAL CHOP

VC
EH
AO
LP

V= variable decels, Cord compression

E = early decels, Head compression
A = accelerations, OK
L = late decels, Placental insufficiency (baby is not receiving enough oxygen and
nutrients)

34
*For c ord compression, place the mother in TRENDELENBURG position-
this removes the pressure of the presenting part from the cord (baby is no longer
being pulled out of the body by gravity)
● If the cord is prolapsed- cover it with sterile saline gauze to prevent drying
of the cord and to minimize infection
*For late decels, turn the mother on the left side to allow more blood to flow to
the placenta- give mother O2 via face mask, stop Pitocin, open IV fluids
(increase)

*Sometimes it is hard to determine who to check on first, mom or baby—it is

usually easy to tell the right answer if the mother or baby involves a machine—if
you are not sure who to check on first, and one of the choices is a machine, that’s
the wrong answer- eliminate

If the baby is in a posterior position- the sounds are heard at the sides
If the baby is in an anterior position- the sounds are heard closer to midline,
between the umbilicus and where and where you would listen to a posterior
position

*If the baby is breech- sounds are high up in the fundus (usually above or around
the umbilicus)
*If baby is vertex (head is down), they are a little above the symphysis pubis on
the left or right side

NEVER APPLY FUNDAL PRESSURE IN THE CASE OF SHOULDER

DYSTOCIA!

A newborn discharged before 72 hours of life should be seen by an RN or MD

within 2 days of discharge

A newborn should feed between 8 and 12 times in 24 hours

ALWAYS protect the newborn’s eyes when undergoing phototherapy and

monitor temperature carefully! Breastfeeding is encouraged to avoid dehydration
and increase passage of meconium (which helps excrete bilirubin)

Normal Contraction Pattern

● Contractions every 2-5 minutes for 60 seconds (<90 seconds)
o Longer lasting and shorter intervals is NOT normal (could be a
complication of Pitocin)

Palpating uterine contractions is done with fingertips

35
AVA: The umbilical cord has two arteries and one vein

Amniotic fluid is alkaline- turns nitrazine paper blue

Urine and normal vaginal discharge are acidic and turn the nitrazine paper
yellow/orange (some color charts vary)

If a woman’s water breaks and she is at a (-) station, you should be concerned
about a potential prolapsed cord
**In emergency situations where typing and cross-matching have not yet been
completed, “O“ can be given!

Medications to be given with food: NSAIDs, corticosteroids, medications for

Bipolar Disorder, cephalosporins, and sulfonamides
When using a bronchodilator in conjunction with a glucocorticoid
inhaler, administer the bronchodilator first!

Theophylline increases the risk of digoxin toxicity and decreases the

effects of lithium and phenytoin

Peptic ulcers caused by H. pylori are treated with Metronidazole (Flagyl),

Omeprazole (Prilosec), and Clarithromycin (Biaxin)—this treatment kills bacteria
and stops production of stomach acid- it does not heal the ulcer!

A board-like abdomen with shoulder pain is a symptom of a perforation,

which is the most lethal complication of peptic ulcer disease

Projectile vomiting can be a signal of obstruction in the GI tract

Diaphragm must stay in place for 6 hours after intercourse

*Also must be re-fitted if patient loses or gains a significant amount of weight!

Best time to take medications:

Growth Hormone (PM)
Steroids (AM)
Diuretics (AM) – prevent nocturia
Donepezil (Aricept) (AM)- Alzheimer’s medication
Cholesterol medications (PM)
Sulcrafate (before meals)- acts as a mucosal barrier—S/E: constipation
Cimetidine (with meals and/or at bedtime)- many interactions
Antacids (1 hour after eating or when experiencing heartburn)- large amounts of
antacid consumption can lead to osteoporosis

Glaucoma- intraocular pressure is greater than normal—give miotics

 to
constrict (pilocarpine) – NO ATROPINE
● Tonometer is used to measure IOP and diagnose glaucoma
o Normal- 10 to 21 mmHg (according to Kaplan)

Dietary calcium- dairy products, seafood, nuts, broccoli, spinach

Non-dairy sources of calcium- RHUBARB, SARDINES, COLLARD GREENS
● Daily calcium intake- 1000 to 1500mg

With low back pain/aches, bend knees for pain relief (William’s position)

61
When taking allopurinol, patients should increase fluids to flush uric acid out
of system!

Koplik’s spots are red spots (commonly found in mouth) with a bluish/whitish
center—characteristic of PRODROMAL phase of MEASLES

Tuberculosis (TB)- medications must be taken for 6 to 9 months

Endemic to Asia, Middle East, Africa, Latin America, Caribbean

A positive PPD confirms infection, not just exposure—a sputum test

confirms active disease

PPD is (+) if induration is:

● >5mm for immunocompromised patients
● >10mm for high risk populations (IV drug users, recent immigrants, lab
personnel, children <4 years)
● >15mm positive in any person (patients with no risk factors)

If a TB patient is unable/unwilling to adhere with treatment—may need

supervision (direct observation) →
  TB is a public health risk

TB medications are toxic to the liver

Adverse reaction is peripheral neuropathy

Most accidental eye injuries (90%) could be prevented by wearing eyewear for
sports and hazardous work

Eye Drop Application

Apply eye drops to the conjunctiva sac—apply pressure to lacrimal duct/inner
canthus (prevents systemic absorption)

Trendelenburg test for varicose veins—patient lies in supine position, leg is

flexed at the hip and raised above the heart, the veins will empty due to gravity
(or with the assistance of the examiner’s hand squeezing the blood towards the
heart)—a tourniquet is then applied around the upper thigh to compress the
superficial veins but not too tight as to occlude the deeper veins—the leg is then
lowered and the patient is asked to stand. If the superficial veins fill more rapidly
(than 30-35 seconds) with the tourniquet, there is valvular incompetence below
the level of the tourniquet in the “deep” veins—after 20 seconds, if there is no
rapid filling, the tourniquet is released—if there is sudden filling at this point, it
indicates that the deep veins are competent but the superficial veins are
incompetent!
*If superficial veins fill with tourniquet—deep veins are incompetent
*If there is sudden filling after tourniquet it removed—superficial
veins are incompetent
62
Precautions when giving KAYEXALATE
● Assess for dehydration (K+ has inverse relationship with Na—when you
decrease potassium, sodium increases)
● Assess patient for bowel sounds before administering—if hypoactive or
absent bowl sounds—HOLD
● Monitor for electrolyte imbalances
● Interactions
o Caution with Digoxin (hypokalemia can lead to digoxin toxicity)
o Kayexalate may decrease the absorption of lithium
o Kayexalate may decrease the absorption of thyroxine

Yogurt has live cultures- do not give to immunocompromised patients

For itching under a cast- cool air via blow dryer, ice pack on cast for 10-15
minutes—NEVER stick anything in the cast to scratch the area

After P
 ERITONEAL DIALYSIS- it is OKAY to have abdominal cramps, blood
tinged outflow, and leaking around the site IF it was placed in the last 1-2
weeks—IT IS NEVER NORMAL to have CLOUDY OUTFLOW

Amniotic fluid- yellow with particles = meconium stained (baby is stressed)

Hyper-reflexes- upper motor neuron issue (“your reflexes are over the top”)
Hypo-reflexes (absent)- lower motor neuron issue

Order of Assessment- (IPPA)  Inspection, Palpation, Percussion, and

Auscultation→ EXCEPT with abdomen—you do not want to activate the bowels
with your assessment so the order is: inspection, auscultation, percussion,
palpation (also, if patient is presenting with abdominal problem, palpation and
percussion may be painful so should be left for the end)

SIGNS
● Murphy’s Sign- pain with palpation of gall bladder area (seen with
cholecystitis)
● Cullen’s Sign- ecchymosis in umbilical area, seen with pancreatitis
(bruising)
● Turner’s Sign- ecchymosis (grayish blue) over flank areas- sign of
pancreatitis (bad sign)
● McBurney’s Point- pain in RLQ indicative of appendicitis
● Rebound tenderness in RLQ—appendicitis
● RLQ pain- appendicitis, watch for peritonitis
● LLQ pain- diverticulitis (should maintain low reside diet, no seeds, nuts,
peas)

63
 ● Guthrie Test- tests for phenylketonuria in newborns—babies should eat
source of protein first
● Allen’s Test- occlude both ulnar and radial arteries until hand blanches,
then release ulnar—if the hand returns to pink color—ulnar artery is good
and you can use for ABG/radial arterial line/stick as planned—ABGs must
be drawn in a heparinized tube, placed on ice and sent immediately to
lab—should also inform lab of how much oxygen the patient is on (and via
NC, mask, etc.)
● Schilling Test- tests for pernicious anemia—how well one absorbs
Vitamin B12

LATEX ALLERGY-

● Assess patient for allergies to bananas, apricots, cherries, grapes, kiwis,

passion fruit, avocados, chestnut, tomatoes, peaches (also see above
diagram)

Amyotrophic Lateral Sclerosis (ALS) is a condition in which there is

degeneration of motor neurons in both the upper and lower motor neuron
systems

Transesophageal Fistuala (TEF)- esophagus does not fully develop (this is a

surgical emergency)
*The 3 C’s of TEF in newborn
● Choking
● Coughing
● Cyanosis

The MMR vaccine is given SQ not IM

-First dose recommended between 12 months and 15 months
64
-Contraindicated with allergy to gelatin and neomycin (also should not be given
to immunocompromised patients because it is a live vaccine)
-Should not be given to pregnant women
-Because MMR is a live vaccine, it is not uncommon to spike a fever

Triage in Disaster/Mass-Casualty Situations

*Greatest good for the greatest number
Red- IMMEDIATE/EMERGENT: unstable, injuries are life threatening but
survivable; do not delay treatment—airway, breathing, and circulation
Ex: Airway obstruction, shock

Yellow- URGENT: major injuries that require treatment; can

 delay treatment
1-2 hours
Ex: Open fracture

Green- NONURGENT: minor injuries that do not require immediate treatment,

can delay 2 to 4 hours
Ex: “Walking wounded”, closed fracture, contusions

Black- EXPECTANT: expected and allowed to die, prepare for morgue, comfort
measures if possible
Ex: Profound hemorrhage, cardiac arrest

DOA- Dead on Arrival

Orange- psychiatric, non-urgent

Greek heritage- use of protective charms or amulet (necklace) around baby’s neck
to protect against evil

4 year old kids cannot interpret TIME—they need time to be explained in

relationship to a known common event—Ex: Mom will be back after supper

Allergies and Interactions

● Hep B Vaccine – should not receive if allergy to yeast
● Hep A Vaccine—should not receive if pregnant
● Flu shot—should not receive if allergy to eggs  (also contraindicated for
patient’s with a history of Guillain Barre)—OK to give to
immunocompromised patients
o If a child has a cold, it is okay to give immunizations
● DTaP/Tdap- contradindicated with occurrence of seizures within 3 days
of vaccine (possible adverse reaction- seizures)
o High fever 48 h after DTap is a valid contraindication for vaccine
● Rotavirus Vaccine-
 do not give if allergy to mycin drugs
(aminogylcosides)
65
 ● Varicella Vaccine- should not receive if allergy to gelatin and neomycin
or immunocompromised
● Meningococcal Vaccine- should not receive if history of Guillain Barre)
● HPV Vaccine- should not receive if allergy to yeast and/or pregnancy
● Penicillins and cephalosporins- crossover allergy (question orders of
administering med if patient has documented/known allergy to either
● Aspirin and Naproxen
 - crossover allergies with NSAIDs

Adult Immunizations Schedule

● Tetanus booster- every 10 years
● MMR- one or two doses at ages 19 to 49
● Varicella- two doses if no history of disease
● Pneumococcal (PPSV)- once after the age of 65; recommended for
immunocompromised, COPD, and living in long-term care facility
● Hepatitis A- two doses for high risk clients
● Hepatitis B and HPV- three doses for high risk clients (Hep B repeated @ 1
and 6 months)
o HPV should be given ideally before the patient is sexually active
● Seasonal influenza- annually; give to immunocompromised
● Meningococcal vaccine- students entering college, adults older than 65
repeat every 5 years for high-risk clients
● Herpes zoster- over age 60

Live Vaccines- do not give to immunocompromised and pregnant women

● MMR
● Varicella
● Nasal spray (flu)

When on nitroprusside, monitor thiocynate (cyanide)—normal value should be 1

→ >1 is heading towards toxicity

Severe Acute Respiratory Syndrome (SARS)—airborne and contact (just

like varicella)

Hepatitis A is contact precautions

● Not infectious within a week or so after onset of jaundice

Tetanus, Hepatitis B, HIV are STANDARD precautions

Avoid high fat diet for Hepatitis B

NO VITAMIN C with ALLOPURINOL

No longer contagious after 24 hours of antibiotics

66
HIV
● Medications need to be taken very consistently—failure to take the
medications daily can lead to mutations and the emergence of more
virulent forms of the virus
● Viral load testing measures the amount of HIV genetic material in the
blood, so a decrease in the viral load indicates that the HAART is effective
● Rapid HIV testing must be confirmed by another test, usually Western blot
test
● Infants born to an HIV-positive mother should receive all
immunizations on schedule
● A positive Western blot in a child < 18 months (presence of HIV
antibodies) indicates only that the mother is infected – two or more
positive P24 antigen tests will confirm HIV in children <18
months—P24 can be used at any age
● Kaposi’s sarcoma lesions should be cleaned and dressed daily to prevent
secondary infection
● Avoid OPV (polio) and varicella vaccines in HIV + (both live)→
pneumococcal and influenza are OKAY
o MMR is only avoided if severely immunocompromised
o Parents should wear gloves for care, avoid sharing utensils and
avoid kissing on the mouth (due to immunocompromised
status—not for transmission purposes)

Signs of fractured hip: external rotation, shortening of affected leg, adduction

Rotavirus- spread via fecal-oral route- contact precautions for diapered and
incontinent patient’s

Fat embolism- blood tinged sputum (related to inflammation), elevated ESR,

respiratory alkalosis (related to tachypnea), hypocalcemia, increased serum
lipids, “snow storm” effect on chest X-ray

Complications of Mechanical Ventilation- pneumothorax, ulcers,

pneumonia (ventilator associated)

Paget’s Disease-abnormal bone destruction and regrowth; cause unknown

(may be genetic or due to virus early in life)
*S/S: tinnitus, bone pain, enlargement of bone (though weak/soft), headache,
hearing loss, reduced height, bowing of the legs, hypercalcemia

Intravenous Pyleogram (IVP)- requires bowel prep in order to better

visualize the urinary tract (bladder, kidneys, ureters, urethra)

Acid Ash Diet- meat, poultry, cheese, fish, eggs, grains, cranberries, prunes,
plums
67
Greenstick fractures are commonly seen in children (also known as buckle
fractures)—bends on one side and cracks on the other

BOTOX can be used for strabismus (12 and older)—patch the GOOD
 eye to
allow the weaker eye to get stronger

COPD patients- 2L via NC or less (hypoxic not hypercapnic drive), PaO2 in 60’s
and SaO2 of 90% is normal—chronic CO2 retainers

Amphotericin B- (Amphoterrible):
 treats infection caused by a fungus
*Should only be given to patients with severe, life threatening fungal infection
Side Effects: fever (common), hypokalemia
*Must premedicate- Tylenol and Benadryl can be used

Mebendazole (Vermox) is used to treat worm infections (pinworms,

roundworms, hookworms)—increase fat in diet to increase absorption

Kidney glucose threshold is 180—when the blood glucose levels exceed

160-180 mg/dL, the proximal tubule becomes overwhelmed and begins to excrete
glucose in the urine

Glucose Tolerance Test for pregnant women- results of 140 or higher needs
further evaluation

Lymes is found mostly in Connecticut

For asthma and arthritis—swimming is best

Intercostal retractions and asthma—BE  CONCERNED – also, if the

asthma patient in the waiting room becomes silent—wheezer stops wheezing
(RED FLAG)

Coughing without other S/S is suggestive of asthma

Increased pulse rate with asthma—indicating decreased oxygenation

Tardive Dyskinesia- irreversible, involuntary movements of the tongue, face,

and extremities—may happen after prolonged use of antipsychotics

Akathisia- motor restlessness; treated with Anti-Parkinson medications—can

sometimes be mistaken for agitation

Before Pulmonary Function Tests (PFTs)—bronchodilators should be

withheld and they are not allowed to smoke for 4 days prior
68
For a lung biopsy—position patient on side of bed with arms raised up on
pillows over bedside table—have patient hold breath in mid expiration, chest
x-ray is done immediately to check for complications (pneumothorax)—sterile
dressing is applied- patient should lie on right side following biopsy

EEG- before--hold
  medications 24-48 hours prior (anti-seizure medications), no
caffeine or cigarettes for 24 hours prior, patient can eat, must stay awake the
night before the exam—during exam patient may be asked to hyperventilate and
watch a bright flashing light—after exam- assess patient for seizures, patient is at
an increased risk

Decorticate- towards the cord


Decorticate positioning in response to pain = CORtex involvement
Decerebrate- away from body
Decerebrate positioning in response to pain = CEREBellar, brain stem
involvement

*Definitive diagnosis for Abdominal Aortic Aneurysm (AAA)- CT Scan

WBC- shift to the left means there are a high number of immature white blood
cells present—most commonly this means there is an infection or inflammation
present and the bone marrow is producing more WBCs and releasing them into
the blood before they are fully mature

Chronic Kidney Disease (Renal Failure)

● Progressive, irreversible loss of renal function with associated decline in
GFR
● All body systems affected- dialysis is required
● End stage renal disease occurs with GFR <15 mL/min
69
● Causes:
o DM (leading cause)
o HTN (second cause)
o Unreversed acute kidney injury
o Glomerulonephritis
o Autoimmune disorders

● NCLEX Points
o Assessment
▪ Azotemia (elevated BUN and creatinine)
▪ Cardio- HTN, hypervolemia, CHF
▪ Hematologic- anemia, thrombocytopenia
▪ Gastrointestinal- anorexia, N/V
▪ Neurological- lethargy, confusion, coma
▪ Urinary- decreased urine output, proteinuria
▪ Skeletal- osteoporosis
o Therapeutic Management
▪ Epoetin alfa aids in countering anemia
▪ Avoid administering aspirin
▪ Monitor K levels
● Elevated potassium can lead to EKG changes (peaked
T waves, flat P, wide QRS, blocks, asystole)
● Provide low potassium diet
● Potassium lowering medications
o Kayexalate
o Insulin
o Calcium gluconate
o Continuous cardiac monitoring
▪ Phosphate binders may be required to lower phosphorous
levels
▪ Monitor daily weights
▪ Monitor for signs of heart failure
▪ Monitor electrolyte levels (will see low magnesium) and
BUN/Creatinine
▪ Assess peripheral nerve function and monitor for peripheral
neuropathy
▪ Vision can be affected- monitor and provide for a safe
environment
▪ Instruct client on dialysis and provide end of life care as
needed
● Stage I- diminished kidney reserve →   function is reduced but healthier
kidney is able to compensate (polyuria and nocturia)
o GFR >90mL/min
● Stage II
o GFR 60 to 89 mL/min
70
 ● Stage III
o GFR 30 to 59 mL/min
● Stage IV
o 15 to 29 mL/min
● Stage V (End Stage Renal Disease)
o <15 mL/min

Hemodialysis- process of cleansing the blood of accumulated waste products

and fluids—used for ESRD or for the acutely ill that require short-term treatment
● Hold meds prior to hemodialysis
● Monitor BP- concerned about BP
● Check circulation
● Weigh before and after
● AV Fistula
o Auscultate for whooshing sound over fistula (bruit and thrill),
palpate for warmth and tenderness
o No weight on extremity
o No BP or blood work from fistula side
o Do not lift heavy objects

Peritoneal Dialysis- alternative method using the peritoneum to remove

fluids, electrolyte, and waste products from the blood
● Warm dialysate
● Allow to flow in by gravity
● 5-10 min inflow time- close clamp immediately
● 30 min of equilibriation (dwell time)
● 10-30 min of drainage (should be clear and pale yellow)
● Monitor for complications: peritonitis, bleeding, respiratory difficulty,
abdominal pain, bowel or bladder perforation

Continuous Ambulatory Peritoneal Dialysis (CAPD)

● Permanent indwelling catheter inserted into peritoneum
● Fluid infused by gravity (1.5 to 3L)
● Dwell time- 4 to 8 hours
● Dialysate drains by gravity- 20 to 40 min
● Four to five exchanges daily (7 days/week)—some elect to do it at night
● Full colon can create outflow problems

Uremic Fetor- urine smelling breath (seen in patients with uremia—elevated

serum urea level)—seen in chronic kidney disease

Normal Creatinine- 0.6 to 1.2

Normal BUN- 10 to 20 (some sources say 9 to 20)
Normal GFR- 85 to 135 (<80 indicates decreased function)

71
Clients with kidney disease are susceptible to CNS effects (confusion and
dizziness)—dosage my need to be reduced
Signs and Symptoms of Kidney Rejection
● Diffuse pain over kidney (tenderness)

Congenital Gastrointestinal Disorders

Hypertrophic Pyloric Stenosis- projectile
 vomit
● Thickening of pyloric sphincter; genetic
● Manifestations: vomiting
  that occurs 30-60 min after a meal and
becomes projectile as obstruction worsens
o Constant hunger
o Olive-shaped mass in RUQ
o Peristaltic wave that moves left to right when lying supine
o Failure to gain weight and signs of dehydration
● Nursing Interventions
o Place child on side with head elevated when vomiting to prevent
aspiration
o Daily weight and I&O
o Monitor fluid and electrolyte balance to assess for deficits
o IV fluid replacement as needed
o NPO
o Monitor NG tube
● Therapeutic Management
o Surgical incision into the pyloric sphincter (pylorotomy)

Hirschsprung’s- failure to pass meconium, ribbon-like stool

● Occurs when a section of the colon is aganglionic – absence of ganglion
cells (nerves that contribute to peristalsis)—problem that prevents stool
from moving forward in the GI tract
● Manifestations
o Newborn- failure to pass meconium within 24-48 hours,
refusal to eat, episodes of bilious vomit, abdominal distention
o Infant- failure to thrive, constipation, abdominal distention,
episodes of vomiting and diarrhea
o Older child- constipation, abdominal distention, ribbon-like
stool, palpable fecal mass, malnourished

● Nursing Interventions
o Position child on side or with head elevated when vomiting to
prevent aspiration
o Monitor fluid and electrolyte balance to assess for deficits
o Provide oral care after vomiting
● Therapeutic Management
o Surgical removal of the aganglionic section (colostomy may be
temporary)
72
 o Serial rectal irrigation may be used to decompress bowel prior to
surgery

Intussusception- bloody
 stool (red currant jelly)
● Telescoping of the intestine upon itself; not a congenital condition but
often occurs with congenital conditions such as cystic fibrosis
● Manifestations
o Normal comfort interrupted by periods of sudden and acute pain
o Palpable, sausage-shaped mass in RUQ of abdomen and/or tender,
distended abdomen
o Stools that are mixed with blood and mucus (red currant jelly)
● Nursing Interventions
o Position child on side or with head elevated when vomiting to
prevent aspiration
o Monitor fluid and electrolyte balance to assess for deficits
o Assess for currant jelly stools
● Therapeutic Management
o Surgical reduction if inflating the bowel with air or administering
barium enema is not successful
o Proton Pump Inhibitors (Omeprazole)
o H2 Receptor Antagonists (Ranitidine)

Cleft Lip (CL) and Cleft Palate (CP)- aspiration

● Multifactorial, but there are strong indicators of genetic or environmental
factors
● Cleft palate is more common in males
● Cleft lip is more common in females (THINK: you are able to better
visualize cleft lip externally—females generally care more about their
appearance—therefore, cleft lip is more commonly seen in females)
● Manifestations
o Cleft lip is visible
o Cleft palate alone may only be visible when examining the mouth
o Individuals are prone to ear, nose, and throat infection
o Long-term problems include speech, hearing, and dentition
problems
● Nursing Interventions
o Assess respiratory status and ease of respiratory effort
o Keep suction equipment and bulb syringe at bedside
o Assess ability to suck and swallow
o Modify feeding techniques utilizing obturators, special nipples,
feeders
o Feed in upright position in frequent, small amounts, burp
frequently
o Daily weight and monitor I&O
● Therapeutic Management
73
 o Repair usually completed by 12 to 18 months of age to prevent
speech problems
o Surgery may be performed in stages

Avoid Vitamin C prior to occult stool test- can lead to false +

All activities that the client participated in before a colostomy may be resumed
after appropriate healing of the stoma and incisions

Hypospadias- abnormality in which the urethral meatus is located on the

ventral aspect of the penis (below)

Epispadias- abnormality in which the urethral meatus is located on the dorsal

side of the penis (top)

Priapism- painful erection lasting longer than 6 hours

Mastectomy- complaints of “wet sheets” – could indicate hemorrhage from

operative site

Thank You Mary-

Anticholinergic Effects
Can’t Spit- dry mouth
Can’t Shit- constipation
Can’t Pee- urinary retention
Can’t See- blurry vision

When you see coffee-brown emesis—think peptic ulcer

Fluid retention- think heart problems first!

Erikson’s Stages of Psychosocial Development

● Infants- 0 to 1 year
o Trust vs. Mistrust- trust develops as needs are met
● Toddlers- 1 to 3 years
o Autonomy vs. Shame and Doubt- toddlers want to make choices
● Preschooler- 3 to 6 years
o Initiative vs. Guilt- guilt may occur if unable to successfully
complete a task or if they are “punished” for an unsuccessful try
● School-Age Child- 6 to 12 years
o Industry vs. Inferiority- a sense of industry is achieved through
advancements in learning; fears of ridicule are common
● Adolescent- 12 to 20 years

74
 o Identity vs. Role Confusion- families strongly influence personal
identity, peer groups greatly influence behavior, interest in opposite
sex, career planning, may see themselves as invincible
● Young Adult- 20 to 35 years
o Intimacy vs. Isolation- ability to love deeply and commit oneself in
relationships vs. remaining uncommitted and alone
● Middle Adult- 35 to 65 years
o Generativity vs. Stagnation- ability to give and care for others vs.
self-absorption and inability to grow as a person
● Older Adult- 65 years and older
o Integrity vs. Despair- sense of accomplishment in life vs. feeling
dissatisfied with life

Fetal Alcohol Syndrome

IM administration for 6 month old infants- vastus lateralis

IM administration for toddlers (>18 months)- ventrogluteal
IM administration for children- deltoid and  gluteus maximus

Eye Abbreviations
OU-both eyes
OS- left eye
OD- right eye (dominant side is usually right side- right eye)

Ear Abbreviations
AU- both ears
AS- left ear
AD- right ear( dominant side is usually right side- right ear)

75
COAL
Cane
Opposite
Affected
Leg

Walker
Wandering- Walker

Wilma- With

Always- Affected

Late- Leg


Stand slightly behind the patient using a cane (on strong side)

For CT scan- assess for allergies to contrast (allergy to shellfish)

MRI- claustrophobia, NO METAL

● Contraindicated for patients with pacemaker, stents, cochlear implants,
surgical implants
● Titanium joint replacements CAN have MRI
● Remove transdermal patches prior to MRI

76
Cardiac Catheterization
● NPO 8-12 hours prior
● Empty bladder
● Check pulses and mark
● Tell patient he may feel palpitations or desire to cough with dye
● Post- V/S, keep leg straight (insertion site is typically in groin), maintain
bed rest 6-8 hours

Early Signs of Increased ICP

● Pupil changes
● Change in LOC/mental status changes

Increased ICP in Infants/Neonates

● High pitched cry

Intracranial Pressure (ICP) should be < 20 mmHg –measure head

circumference—Normal ICP is usually between 10-15 mmHg (opening pressure)

Early Signs of Subdural Hematoma and Cerebral Edema

● Decreased level of consciousness
● Ipsilateral pupils (same side as hematoma)
● Headache – usually the first symptom

NO MORPHINE WITH HEAD INJURY- MASKS SIGNS OF

INCREASING ICP

Fixed and dilated pupils represents a neuro emergency

Clear fluid draining out of ear indicates rupture of meninges and presents a
possible complication of meningitis

Self-catheterization (urine)- clean procedure (not sterile)

Strabismus- sign: child closes one eye to see a poster on the wall—visual axes
are not parallel so the brain receives two images

Cholecystectomy
● Do not need to restrict fat post-op

T-Tube
● Post-cholecystectomy
77
 o Used to drain bile—if change in urine color, bile is draining into the
liver
o Should not be irrigated, aspirated or clamped without a specific
order from the physician

Hemovac- closed system (requires negative pressure)

● Used often after mastectomy
● Empty when full or q8h
● Remove plug, empty contents, place on flat surface, cleanse opening and
plug with alcohol sponge, compress evacuator completely to
remove air, release plug, check system for operation

Anthrax-not spread person to person (can be spread from contaminated

clothing—so patients should undergo decontamination—removal and disposal of
clothing and showering is the initial action in possible anthrax exposure)
● According to the CDC, antibiotics should be administered only if there are
signs of infection or the contaminating substance tests positive for anthrax
(LaCharity)
o Ciprofloxacin is the antibiotic used to combat anthrax
▪ Teaching for Ciprofloxacin
● Drink plenty of fluids
● Avoid taking a multivitamin within 6 hours of taking
this medication
● Avoid exposure to sun
● Avoid caffeine
● May take with meals

Generally speaking, exposure does not mean active disease

Lactose Intolerant-
● Foods high in calcium but no dairy/milk products

Tracheostomy
● Fenestrated (cuffed) tracheostomy
o When capping a fenestrated cuff—deflate the cuff first
o 80-120 mmHg wall suction pressure

78
Vasectomy
● No permanent effect on sexual function
● Should use condom for first 6 weeks post-op

V-fib, defibrillate

You are at risk for developing cervical cancer if you have/had multiple sex
partners

Women who begin menstruating at an early age (such as 9 years old), are at risk
for breast cancer

Absence of menstruation leads to osteoporosis in the patient with anorexia

24 hour urine specimen collection

● If a woman starts menstruating during the collection—contact physician

It is not unusual for an adolescent who just started menstruating to not have a
period every month (usually expect to have around 4 in the first year)

Breast buds usually appear between 9-13 years of age—should be investigated if

they appear later

Glucagon (1mg SQ) is given when patient is unconscious with severe


hypoglycemia or those who cannot take PO fluids
*Increases the effects of anticoagulants

Crohn’s Disease
● Low fat
● Low residue (fiber)

79
 ● High protein

Priority assessment- respiratory distress

● Listen to patient’s breath sounds (most clear assessment)

Femoral angiogram- locate and note the presence of peripheral pulses (easier
to find after the procedure)
● Keep leg straight
● Check dressing
● Increase hydration to excrete dye

Breath Sounds
● Asthma
o High-pitched, musical sounds on expiration (wheezing)
● Pneumonia
o Soft, high-pitched sounds on inspiration (crackles)
● Bronchitis
o Deep, low-pitched rumbling on expiration (rhonchi)

Ileostomy- seen with spinal cord injuries, Crohn’s disease, and to rest the colon
● Clean with warm water, dry thoroughly
● Appliance should fit snugly around the opening
● Should not take laxatives
● Can take multi-vitamins
● No enteric coated meds or capsules—breakdown in large intestines
● Stoma site should be assessed at least once a day
● Bags can be changed as needed
● Liquid stool

*DO NOT CONFUSE ILEOSTOMY WITH COLOSTOMY*

Maintain bathroom schedule for incontinent patients- every 2 hours

When transferring a patient to another unit—you do not want to bring a “threat”

to the floor—clean vs. dirty patient—risk of infection to a “clean” unit is not a
good choice

For the initial dose of an ACE-Inhibitor—should not give with diuretics and other
medications that can decrease blood pressure (with the initial dose, hypotension
is concern)
80
Oral fluid intake—1500 mL in 24 hours

Patient who is agitated- reorient to place and time, assign LPN to stay with
patient

In pH regulation, two organs of concern are lungs and kidneys (lungs-

respiratory, kidneys- metabolic)

ARTERIAL BLOOD GASES

*Risk factors for acid-base imbalances include chronic kidney disease and
pulmonary disease
Metabolic Acidosis
● Low pH, Low  HCO3
● Risk Factors
o Type 1 Diabetes (at risk for DKA)
o Salicylate toxicity
o Acute renal failure (decreased production of HCO3)
o Severe diarrhea
o Hyperkalemia

Metabolic Alkalosis
● High pH, High
 HCO3
● Risk Factors
o GI losses- vomiting or gastric suctioning or drainage
▪ Nasogastric suctioning can result in a decrease in acid
components leading to metabolic alkalosis—clients decrease
in rate and depth of ventilation in an attempt to compensate
by retaining carbon dioxide
o Diuretic therapy that leads to sodium and chlorine losses
o Mineralcorticoid excess
o Hypokalemia

Respiratory Acidosis
● Low pH, High
 PaCO2
● Risk Factors
81
 o Respiratory depression (decreased respiratory rate)
o COPD and/or asthma
o Inability to ventilate properly (seen in myasthenia gravis, ALS,
muscular dystrophy, and Guillain Barre)

Respiratory Alkalosis
● High pH, Low
 PaCO2
● Risk Factors
o Hyperventilation (blowing of CO2)
o Mechanical ventilation
o Any condition that causes shortness of breath

82
From the a** (diarrhea) = metabolic acidosis
From the mouth (vomitus) = metabolic alkalosis

With hyperkalemia- pulse is the first vital sign you check (due to
dysrhythmias)

Diet for Iron-Deficiency Anemia

83
Oysters, clams, scallops are top-10 sources of iron
● Organ meats (red meats), fortified cereals, dark leafy vegetables, egg yolks
are also good sources of dietary iron

Iron supplements should be taken with orange juice (Vitamin C) as it

facilitates absorption

Documentation should be specific and factual—“Vital Signs Stable” is NOT

acceptable—what are the vital signs?

Herbal Medications
● Potency varies between medications
● Considered dietary supplements
● Not regulated by FDA
● Ma Huang should not be used by patient’s with HTN
● Ginkgo – improves cerebral circulation to treat dementia and memory
loss--increases risk of bleeding, increases effects of MAOIs, may reduce
effectiveness of insulin—discontinue 2 weeks prior to surgery, may
cause seizure with overdose
● Garlic acts as blood thinner
● Black cohosh- used to treat menopause – large doses have been known
to cause seizures, visual disturbances, increased sweating, bradycardia
● Feverfew- prevention and treatment of migraines, arthritis, and
fever--should not be taken with coumadin, aspirin, NSAIDS,
thrombolytics or antiplatelet meds—prolongs bleeding
● Ginseng- improves strength and stamina—prevents and treats cancer and
DM--it decreases the effects of anitcoagulants and
NSAIDS—contraindicated for women who are pregnant—may
increase effectiveness of antidiabetic agents and insulin
● Echinacea- prevents and treats the common cold, stimulates the immune
system, promotes wound healing—may reduce the effects of
immunosuppressants, may increase serum levels of alprazolam, CCB,
and protease inhibitors
● St. John’s Wort- depression and anxiety—may reduce the effects of
many medications—theophylline, HIV protease inhibitors, cyclosporine,
diltiazem, and nifedipine – should not be taken with other
medications

Patients with hearing loss may exhibit suspiciousness of strangers—results

from interference with communication

Nausea is a concern/priority following eye surgery—risk of increased IOP

*Patient’s undergoing eye surgery should receive flu shot before—can cause client
to sneeze, cough, or blow nose (increasing IOP)

84
Esophageal speech- (following a total laryngectomy)- swallows air & eructates
while forming words

(Organ) Transplant patients- require protective isolation following surgery

Most at risk for developing herpes zoster—immunocompromised

Cytomegalovirus- common virus –once infected, virus remains in body for life
*Standard precautions are used—eyewear worn with risk of splash

Decreased RBCs/Erythrocytopenia
S/S: fatigue and dyspnea on exertion, pallor, dizziness, malaise, tachycardia

Tetracycline- antibiotic
● Causes photosensitivity – wear sunscreen and hat outdoors
● Should be taken on an empty stomach
● Contraindicated for pregnant women

Sickle Cell Crisis

*Adequate hydration
● Dehydration perpetuates cell sickling—should be at least 200cc/hr
● Do not give cold packs—further decreases blood flow to area and increases
sickling

DO NOT GIVE DEMEROL (meperidine) TO PATIENTS WITH SICKLE

CELL CRISIS

85
Phlebitis- reddened area or red streaks at site of catheter

Blanching sign- pressing nail of big toe—indicates circulatory function

Blanching or hyperemia that does not disappear in a short time is a warning sign
of pressure ulcers

Severe to panic level of anxiety- patient is unable to process thoughts and

feelings for problem solving

Priority when managing a p

 hysically assaultive client—restore the client’s
self-control and prevent further loss of control

Reward non-attention seeking behaviors by giving client unsolicited attention

Nasogastric Tube
● Patient is nauseated and decreased flow of gastric contents—aspirate and
check pH to confirm placement (should be between 0 and 4)
● If irrigation is necessary, use normal saline
● Intermittent feeding
o Check pH of aspirated contents (normal is pH 0-4)
o Use large barreled syringe to aspirate
o Flush with 30 mL of air before aspiration

History of psych patient should include biopsychosocial data; psychosocial

and physical status are evaluated along with an assessment of the family system
and social support network; evaluation of cognitive ability is important during
physiological status assessment

Patients in seclusion should eat at regular time but remain in seclusion for
client’s safety

86
Joint legal custody with divorced parents- consent from either parent is
sufficient

Battery is harmful or offensive touching of another person unless court ordered

*For example: Patient refuses medication due to fear that it will poison
him—nurse administers medication IM
● Clients have the right to refuse medication even if psychotic

Myelogram
● NPO 4-6 hours
● History of allergies
● Phenothiazines, CNS depressants, and stimulants withheld 48 hours prior
● Table will be moved in various positions during test
● Post- neuro checks q2-4h, oral analgesics for H/A, encourage PO fluids,
assess for distended bladder, inspect insertion site
● Water soluble- HOB raised
● Oil soluble- HOB down

Common Signs and Symptoms

● Pulmonary TB- low grade afternoon fever
● Pneumonia- rusty sputum
● Asthma- wheezing on expiration
● Emphysema- barrel chest
● Kawasaki Syndrome- strawberry tongue. Peeling skin on fingers and
toes
● Pernicious Anemia- red beefy tongue, pallor, tachycardia
● Down Syndrome- protruding tongue
● Cholera- rice watery stool
● Malaria- stepladder-like fever with chills
● Typhoid- rose spots on abdomen
● Diphtheria- pseudo membrane formation
● Measles- koplik’s spots (clustered white lesions on buccal mucosa)
● Systemic Lupus Erythematous- butterfly rash
● Liver cirrhosis- spider-like varices
● Leprosy- leonine facies (thickened folded facial skin)
● Bulimia- chipmunk face (parotid gland swelling), poor dental status
● Appendicitis- rebound tenderness, psoas sign (pain from flexing the
high to the hip); Rovsing’s sign (palpation of LLQ elicits pain in RLQ)
● Meningitis- K  ernig’s sign (k
 nee flex and pain on extension), Brudzinski

sign (neck flex = lower leg flex/bend), nuchal rigidity, photosensitivity
● Tetany- hypocalcemia (+) Trousseau’s sign/carpopedal spasm, Chvostek
sign (facial spasm)
● Tetanus- risus sardonicus
● Pancreatitis- Cullen’s sign (ecchymosis of umbilicus); (+) Grey Turner’s
spots
87
● Pyloric Stenosis- olive-like mass, projectile vomiting
● Patent Ductus Arteriosus- washing machine-like murmur
● Addison’s- bronze-like skin pigmentation (tanned)
● Cushing’s- moon face and buffalo hump
● Grave’s/Hyperthyroidism
 - exophthalmos (bulging of the eyes)
● Intussusception- sausage shaped mass, Dance sign (empty portion of
RLQ), red currant jelly stools
● Multiple Sclerosis- Charcot’s Triad (nystagmus, intention tremor,
scanning speech)
● Myasthenia Gravis- descending muscle weakness, ptosis (drooping
eyelid)
● Guillain Barre- ascending muscle weakness/paralysis
● DVT- Homan’s sign
● Chicken Pox- vesicular rash (central to distal), dew drop on rose petal
● Angina- crushing stabbing pain, relieved by NTG
● Myocardial Infarction- crushing stabbing pain- radiates to left
shoulder, neck, arms, unrelieved by NTG
● Laryngotrachebronchitis- inspiratory stridor
● Transesophageal Fistula- 4 C’s- Coughing, choking, cyanosis,
continuous drooling
● Epiglottitis- 3 D’s- drooling, dysphonia, dysphagia (acute emergency)
● Hodgkin’s Lymphoma- painless, progressive enlargement of spleen
and lymph tissues, Reedstenberg cells
● Infectious Mono- sore throat, cervical lymph adenopathy, fever, fatigue
● Parkinson’s- pill-rolling tremors
● Cytomegalovirus (CMV) infection- Owl’s eye appearance of cells
(huge nucleus in cells)
● Cystic Fibrosis- salty skin, intussuception
● Diabetes Mellitus- polyuria, polydipsia, polyphagia
● DKA- Kussmaul respirations (deep, rapid RR), acetone breath
● Bladder cancer- painless hematuria
● Benign Prostatic Hyperplasia- reduced size and force of urine
● Retinal Detachment- visual floaters, flashes  of light, curtain-like
shadow vision (emergency situation)
● Glaucoma- painful
  vision loss, tunnel/gun barrel/halo vision
(peripheral vision loss)
● Cataract- painless
  vision loss, opacity of the lens, blurring of the vision,
change in color vision
● Retinoblastoma- Cat’s eye reflex (grayish discoloration of pupils)—seen
in photos
● Pregnancy Induced Hypertension- proteinuria, HTN, edema
● Acromegaly- coarse facial feature
● Duchenne’s Muscular Dystrophy- Gower’s sign (use of hands to push
one’s self from the floor)

88
 ● GERD- heartburn, Barrett’s esophagus (erosion of the lower portion of
the esophageal mucosa)
● Hepatic encephalopathy- flapping tremors (asterixis)
● Hydrocephalus- Bossing sign (prominent forehead)
● Increased ICP- HTN, Bradypnea, Bradycardia (Cushing’s Triad)
● Shock- Hypotension, Tachypnea, Tachycardia
● Meniere’s Disease- vertigo, tinnitus
● Cystitis- burning on urination
● Hypocalcemia- (+) Chvostek and Trousseau’s
● Ulcerative Colitis- recurrent bloody diarrhea
● Lyme’s Disease- Bull’s eye rash
● Buerger’s Disease- intermittent claudication (pain at buttocks or legs
from poor circulation resulting in impaired walking)
● Hirschsprung’s Disease (Toxic Megacolon)- ribbon-like stool

STIs
● Herpes Simplex Type II- painful vesicles on genitalia
● Genital Warts- warts 1-2 mm in diameter
● Syphillis- painless chancres
● Chancroid- painful chancres
● Gonorrhea- green, creamy discharges and painful urination
● Chlamydia- milky discharge and painful urination
● Candidiasis- white, cheesy, odorless vaginal discharges
● Trichomoniasis- yellow, itchy, frothy, and foul-smelling vaginal
discharges

CSF Ottorhea- sign of basilar fracture

Battle’s sign and raccoon eyes

NO Nasotracheal suctioning with head

 injury or skull
 fracture (increases
ICP)

89
Take iron elixir with juice or water- never with milk!

Therapeutic Drug Levels

Dilantin- 10 to 20
Theophylline- 10 to 20
Acetaminophen – 10 to 20 (do not excess 4000mg in one day)
Lithium- 0.4 to 1.4
Digoxin- 0.5 to 2.0

Osteomyelitis is an infectious bone disease- blood cultures and antibiotics—if

necessary, surgery to drain abscess

Nephrotic Syndrome- S/S edema (periorbital and generalized), dark, foamy

urine (indicating proteinuria), and weight gain due to excessive fluid retention;
also HTN
● Characterized by massive proteinuria
● Decreased serum albumin
● Patient will receive corticosteroids
*Risk for impaired skin integrity

Glomerulonephritis- cola colored urine, HTN, edema, proteinuria

● V/S q4h
● Daily weights

Common Diets
● Acute Renal Disease- protein-restricted, high-calorie, fluid-controlled,
sodium and potassium controlled
● Addison’s Disease- increased sodium, low potassium diet
● ADHD and Bipolar- high-calorie and provide finger foods
● Burns- high protein, high calorie, increase in Vitamin C
● Bowel Surgery- low residue
● Cancer- high-calorie, high-protein
● Celiac Disease- gluten-free diet (No BROW- barley, rye, oat, and wheat)
● Chronic Renal Disease- protein-restricted, low-sodium,
fluid-restricted, potassium-restricted, phosphorous-restricted
● Cirrhosis (stable)- normal protein
● Cirrhosis with hepatic insufficiency – restrict protein, fluids, and
sodium
● Constipation- high-fiber, increased fluids

90
 ● COPD- soft, high-calorie, low-carbohydrate, high-fat, small frequent
feedings
● Cystic Fibrosis- increase in fluids, high-sodium
● Diarrhea- liquid, low-fiber, regular, fluid and electrolyte replacement
● Gallbladder disease- low-fat, calorie-restricted, regular
● Gastritis- low fiber, bland diet
● Hepatitis- regular, high-calorie, high-protein
● Hyperlipidemias- fat controlled, calorie-restricted
● HTN, HF, CAD- low-sodium, calorie restricted, fat-controlled
● Kidney Stones- increased fluid intake, calcium-controlled, low oxalate
● Nephrotic Syndrome- sodium-restricted, high-calorie,
potassium-restricted
● Obesity, overweight- calorie restricted, high fiber
● Pancreatitis- low fat, regular, small frequent feedings, tube feeding or
TPN
● Peptic ulcer- bland diet
● Pernicious Anemia (B12)- increase B12, found in high amounts in
shellfish, beef, liver and fish
● Sickle Cell Anemia- increase fluids to maintain hydration since sickling
increases when patients become dehydrated
● Spinal Cord Injury- high fiber, low fat (prevent constipation and
straining)
● Stoke- mechanical, soft, regular, or tube-feeding
● Underweight- high-calorie, high protein
● Vomiting- fluid and electrolyte replacement

An ill child regresses in behavior

Assessing extraocular eye movements- check cranial nerves 3, 4, & 6

DVT
● Goal: promote venous return and decrease in venous pressure
● Bed rest with elevated extremity

Stomas
● Dusky- poor blood supply
● Protruding – prolapsed
● Sharp pain + rigidity- peritonitis
● Mucus in ileal conduit is expected

Tension pneumothorax – trachea shifts to opposite side

Change in color is always a LATE sign

91
Incentive Spirometer- steps: 1) sit upright 2) exhale 3) insert mouthpiece 4)
inhale for 3 seconds and then hold for 10 seconds

MRSA- contact only

VRSA- contact AND
 airborne (private room, door closed, negative pressure)

Thrombocytopenia- bleeding preacautions

● Soft bristled toothbrush
● No insertion of anything (suppositories, etc.)
● No IM meds as much as possible

Risk of MRSA
● Indwelling foley catheter
● Receiving medication through port, vascular access device, ET tube
● Immunocompromised

Iron deficiency anemia-

● Fe PO- give with vitamin C or on an empty stomach
● Fe via IM- inferon via Ztrak

Pernicious anemia (B12)- red beefy tongue, will take B12 for life

Meniere’s Disease- restrict sodium, lay on affected ear when in bed, diuretics
to decrease endolymph in cochlea
Triad: vertigo, tinnitus, N/V

Dehiscence of abdominal wound with organ  evisceration—elevate HOB

to 15 degrees →
  reduces stress on suture line
*May also be placed supine with hips/knees bent

Gastric ulcer pain- occurs 30 min to 90 min after eating, not at night and does
not go away with food

Pediatric Tips
● Intraosseous infusion- in pediatric life-threatening emergencies, when
IV access cannot be obtained, an osseous (bone) needle is hand-drilled
into a bone (usually tibia), where crystalloids, colloids, blood products and
drugs can be administered into the marrow—it is temporary- when venous
access is achieved it is d/c’d
o Only medication that CANNOT be administered IO is
isoproterenol (a beta agonist)

● With glomerulonephritis- consider blood pressure to be the most

important assessment paremeter

92
 o Dietary restrictions you can expect- fluids, protein, sodium, and
potassium

● In congenital cardiac defects that result in hypoxia- body attempts to

compensate for with an influx in immature RBCs—labs that support this:
increase Hct, Hgb, and RBC count

● There is an association between low-set ears and renal anomalies- develop

around the same time (they are also similar in shape)—if a newborn has
low-set ears, this warrants renal function tests

● School-age kids (5 and up) are old enough and should have an explanation
of what will happen a week before surgery (such as tonsillectomy)

● First sign of pyloric stenosis in a baby is mild vomiting that progresses

to projectile vomiting – later you may be able to palpate a mass, the baby
will seem hungry often, and may spit up after feedings

● Kawasaki’s Disease- causes heart problems—coronary artery

aneurysms due to inflammation of blood vessels

● A child with a VP shunt will have a small upper-abdominal incision—this

is where the shunt is guided into abdominal cavity-watch for: abdominal
distention →
  fluid from the ventricles (in brain) will be redirected to
abdomen; watch for signs of increasing ICP→ irritability, bulging
fontanels, high-pitched cry in an infant; lack of appetite and headache in a
toddler

o Bed position after shunt placement- FLAT→   do not want the

fluid to shift too rapidly (if signs of increasing ICP are
present—elevated HOB 15-30 degrees)

● Mechanical ventilation can cause bronchopulmonary

dysplasia—other causes: infection, pneumonia, or conditions that result
in inflammation and scarring

● It is essential to maintain nasal patency in a child < 1 year

because they are nose breathers

● A child should not be drinking too much milk- it reduces the intake of
other essential nutrients—especially iron (could lead to anemia)

● If you can remove the white patches from the mouth of a baby it
is formula- if you can’t it is candidiasis \

93
● MMR and Varicella
 immunizations come later (15 months)- letters
are later in alphabet

● Undescended testis or cryptorchidism is a known risk factor for

testicular cancer- start teaching boys about self testicular exams around 12
– most cases of testicular cancer occur in adolescence

● Stranger anxiety is greatest between 7-9 months

● Separation anxiety starts around 4-8 months, peaks in toddlerhood
(1-3 years)

● For a child exhibiting separation anxiety—offer favorite blanket or toy,

talk to infant when leaving room, allow to hear parent’s voice on telephone

● Children frequently set their own pace for development

● Mock run through surgery is a great way to prepare a 5 year old

● Always report suspected cases of child abuse

● Eardrop administration for kids <3 years- pinna down and back

● With omphalocele and gastroschisis (herniation of abdominal

contents) dress with loose saline dressing with plastic wrap
(non-adherent)—monitor temperature (lose heat quickly)

● After hydrocele repair, provide cold therapy (ice) and scrotal support

● NO phenylalanine with positive PKU (no meat, no dairy, no

aspartame/artificial sweetener)

o Lofenalac formula

● The biggest concern with cold stress and the newborn is respiratory
distress
● Normal RR for newborn: 30- 60

● Toddlers need to express autonomy (independence)

● Theories about bed-wetting relate it to immature bladder and deep sleep

patterns—most children stop bed-wetting by the time they start school

● Average circumference of the head ranges from 32-36 cm (increase in size

may indicate hydrocephalus or increased ICP)

94
 ● Between ages 6 and 12, children grow about 2 inches per year and gain
4.5-6.5 lbs/year

● The incidence of once-common infectious disease such as measles,

chickenpox, and mumps has been most effectively reduced by the
immunization of all school-age children

● Exposure to chemicals in the eyes→   irrigate for 20 minutes →

  another
adult, if present, should call the Poison Control Center and 911

● Children have proportionately larger heads that predispose them to head

injuries

● Hypoxemia is more likely in children because of their higher oxygen

demand

● Liver and spleen injuries are more likely because the thoracic cage of
children offers less protection

● Hypothermia is more likely because of children’s thinner skin and

proportionately larger body surface area

● Kawasaki disease is the only exception for children taking aspirin

o Important for children’s to receive immunizations

● National guidelines indicate that medication dosing for pediatric patients

should be based on the child’s weight (kg)
o Some sources say that BSA is the most accurate method for dosing
in children

Safety- Pediatrics
Infant
● Aspiration and suffocation- chop food in fine pieces, appropriate toys,
no plastic bags and balloons (latex balloons are the leading cause of
pediatric choking deaths)
● Bodily harm – keep sharp objects out of reach, keep infants away from
heavy objects they can pull down on themselves, do not leave unattended
with animals, monitor for shaken baby syndrome

95
 ● Burns- check temperature of water, working smoke detectors in home,
handles of pots and pans should be turned to back of stoves, sunscreen
should be used, electrical outlets should be covered, clothing should be
flame retardant
o Water heater should be set to no greater than 120 degrees
● Drowning- never leave infant unattended near water such as tubs,
toilets, and swimming areas
● Falls- never leave unattended, place safety gates on stairs
● Poisoning- lock or remove all toxic substances, mediations should be
stored in safety bottles and locked in cupboard, never refer to medication
as candy, poison control number handy
● Motor Vehicle Injuries- placed in approved rear-facing car seats in the
backseat- preferably in the middle (away from airbags and side
impact)—rear facing car seats until 2 years of age and they exceed the
manufacturer’s recommended weight (usually 20lbs)

Toddler
● Aspiration and suffocation- avoid common causes of choking- hot
dogs, nuts, grapes, peanut butter, raw carrots, tough meat, popcorn, no
balloons or plastic bags, no pillows in cribs, no drawstrings on clothing
● Bodily harm- firearms kept in locked boxes, stranger safety
● Burns- (same as above)
● Drowning- (same as above), taught to swim
● Falls- (same as above)
● Motor Vehicle Injuries- airbags near the child should be inactivated,
forward-facing until they exceed manufacturer’s weight limit, backseat,
booster seat after they have exceeded weight for forward-facing carseat
● Poisoning- avoid exposure to lead paint, safety locks

Preschooler (3 to 6)
● Same as above
● *Encourage safety equipment (helmet)

School-Age Child (6 to 12)

● Bodily harm- firearms should be kept in locked boxes, no trampolines,
safe areas for play, stranger safety, wear helmets
● Burns- teach fire safety and potential burn hazards
● Drowning- teach to swim
● Motor vehicle injuries- younger than 13 should be in back seat, airbags
inactivated
● Substance abuse-community resources, family involvement

Adolescent (12 to 20)

● Three leading causes of death in adolescents are homicide, suicide, and
motor vehicle accidents
96
Potassium is lost when a client is taking a thiazide diuretic – monitor K,
increase dietary K
● Should not be taken at night- prevent nocturia

Hypokalemia
● ECG changes- ST segment depression, inverted T waves, prominent U
waves—may also experience heart block
● Lethargy and muscle weakness

Neck veins are normally distended when patient is supine—veins flatten when
sitting
*Decreased plasma volume→   flattened neck veins when supine

Nurse is not required to explain delegated assignments

Migraines
● Fatigue is a trigger

Validation of a nurse having a substance abuse problem does not override quality
client care! Take care of the patient first!

Hemorrhagic shock- PRIORITY→

  identify source of bleeding and apply
direct pressure

ECT
● NPO after midnight
● General anesthesia
● Memory loss is an expected outcome

Patients with severe immunodeficiency may be unable to produce an immune

response—as a result, a negative TB skin result does not completely rule out a TB
diagnosis for this patient →
  chest x-ray and sputum culture will be ordered.

Patients taking immunosuppressive medications are at an increased risk for

development of cancer!

Cultural Considerations
● African Americans- many believe that illness is caused by supernatural
causes and seek advice and remedies from faith healers; family oriented;
higher incidence of HTN and obesity; high incidence of lactose intolerance

97
 ● Arab Americans- may remain silent about health problems such as
STIs, substance abuse and mental illness; if Muslim- many avoid pork and
alcohol
● Asian Americans- may value ability to endure pain and grief with silent
stoicism; hot/cold, yin/yang, sodium intake is generally high; may prefer
to maintain a comfortable distance; may believe prolonged eye contact is
rude and invasion of privacy
● Latino Americans- may view illness as sign of weakness, punishment
for evil doing; family members are typically involved in all aspects of
decision making such as terminal illness
● Native Americans- may turn to a medicine man to determine the true
cause of an illness, may value the ability to endure pain or grief with silent
stoicism, diet may be deficient in Vitamin D and calcium due to lactose
intolerance, obesity and diabetes are major concerns
● Western Culture- may value technology almost exclusively in the
struggle to conquer diseases; health is understood to be the absence,
minimization or control of disease process

Delegation Tips
DO NOT delegate what you can EAT

E- evaluate (nursing judgment)
A-assess (nursing judgment)
T- teach


● Delegate sterile skills to RN or LPN

● Where non-skilled care is required, delegate stable client to nursing
assistant
● Assign the most critical client to the RN
● Clients who are being discharged should have the final assessments and
teaching done by the RN
● A new nurse should receive stable patients who require routine care (same
applies to nurses that are transferred to different units for the day)
● The LPN can monitor clients with IV therapy, insert urinary catheters,
feeding tubes, and apply restraints
● LPN/LVN cannot handle blood
● LPN/LVN are given stable patients – can perform sterile procedures on
stable patients
● Experienced LPNs can use observation of patients to gather data regarding
how well they perform interventions that have already been taught
(including checking for therapeutic response/adverse effects of
medications)
● Assisting with ADLs is appropriate for assistive personnel (record I/O too)
Always check for allergies before administering antibiotics (especially
penicillin) – or any medication for that matter!

98
Neutropenic precautions- no live vaccines, no fresh fruits, no flowers, no sick
visitors, no milk
● Any temperature elevation in a neutropenic patient may indicate the
presence of a life-threatening infection
● Patients who are neutropenic should be place in a positive-airflow room

In the event of a fire- RACE→ (R) Remove the patient (A) Activate the alarm (C)
Contain the fire by closing the door (E) Extinguish the fire if it can be done safely

Informed consent- patient should know whether other treatment options are
available and should understand what will occur during the preoperative,
intraoperative, and postoperative phases; the risks involved, possible
complications—always allow patient to ask questions!

Veracity is truth and is an essential component to a therapeutic relationship

between a healthcare provider and patient

Beneficence is the action that is done to benefit others

Nonmaleficence is the duty to do no harm

Projection is the unconscious assigning of a thought, feeling, or action to

someone or something else

Sublimation is the channeling of unacceptable impulse into socially acceptable

behavior

Repression is an unconscious defense mechanism whereby unacceptable or

painful thoughts, impulses, memories, or feelings are pushed from the
consciousness or forgotten

People with obsessive-compulsive disorder realize that their behavior is

unreasonable, but are powerless to control it

Hypervigilance and déjà

 vu
 are signs of PTSD


Health Screening for Cancer

99
CAUTION
C- change in bowel or bladder habits
A- a sore that does not heal
U- unusual bleeding or discharge
T- thickening or lump in breast or elsewhere
I- indigestion or difficulty swallowing
O- obvious change in a wart or mole
N- nagging cough or hoarseness

Common sites for metastasis- liver, brain, lung, bone, lymph

When a cancer patient is receiving radiation- main concern is preventing

infection because radiation causes leukopenia

Radioactive Iodine- want to flush it out of body →   increase fluid intake for 2
days (3-4 liters unless otherwise contraindicated)—flush the toilet twice after
using
*Limit contact with patient to 30 min/day
NO PREGNANT VISITORS/NURSES and no kids

The main hypersensitivity reaction seen with antiplatelet drugs is

bronchospasm (anaphylaxis)
● Ex: clopidogrel, aspirin

Do not fall for the “reestablishing a normal bowel pattern” as a priority with small
bowel obstruction—the patient can’t take in oral fluids, “maintaining fluid
balance” comes first!

Basophils release histamine during an allergic reaction

Other than to initially test tolerance- G tube and J tube feedings are usually
given as continuous feedings

Tamoxifen (chemotherapy agent) can cause visual

 changes
 —can be
irreversible—assess visual acuity throughout treatment

You should ask every new admission if he/she has an advance directive

Succinylcholine Chloride (Anectine)- used for short-term neuromuscular

blocking agents for procedures like intubation and ECT

Typical adverse reactions to oral hypoglycemic- rash and photosensitivity

Hypotension may alter the accuracy of O2 sats

100
10-11 months- crawling, changes from a prone to a sitting position (belly to
butt), grasps rattles by its handles, finger foods
12-13 months- sits down from a standing position without assistance, starts
walking (uses furniture to cruise), tries to build a two-block tower without
success; cries when parents leave
*Twelve and up, drink from a cup

Hepatitis
-ends in a VOWEL and comes from the BOWEL (Hep A)
-Hepatitis B- Blood and Bodily fluids
-Hepatitis C is just like B
GLASGOW COMA SCALE
-Eyes, verbal, motor
*It is similar to measuring dating skills- max 15 points, one can do it!
If below 8, you are in a coma
-To start dating, you have to open your EYES
 first- if you are able to do that
spontaneously and use them correctly to SEE whom you are dating, you earn 4
points—but if she has to scream at you to make you open them it is only 3 points.
If you dare not to open your eyes, even if she kicks you, you only get 1 point!
-If you get good EYE contact (4 points) then move on to VERBAL—talk to
her/him, if you can do that you are oriented (4 points)—if you like her try not to
be CONFUSED (3 points), and of course do not use INAPPROPRIATE
WORDS (3 points) because she won’t like it—try not to respond with
INCOMPREHENSIBLE SOUNDS (2 points)—but if you just don’t like
her—do not respond at all- NO VERBAL RESPONSE (1 point)

-Since you now have EYE and VERBAL contact you can MOVE to Motor
Response- this is VERY important, because good moves give you 6 points!

You’re simply the BEST- better than all the rest!

The person who hyperventilates is likely experiencing respiratory
alkalosis

Avoid salt substitutes when taking digoxin and K-supplements—because they

contain high levels of potassium

Signs of h ypoxia: restless, anxious, cyanotic, tachycardia, increased

respirations (also monitor ABGs)

For blood types: “O” is the universal donor (remember “O” in donor)
“AB” is the universal recipient

60
**In emergency situations where typing and cross-matching have not yet been
completed, “O“ can be given!

Medications to be given with food: NSAIDs, corticosteroids, medications for

Bipolar Disorder, cephalosporins, and sulfonamides
When using a bronchodilator in conjunction with a glucocorticoid
inhaler, administer the bronchodilator first!

Theophylline increases the risk of digoxin toxicity and decreases the

effects of lithium and phenytoin

Peptic ulcers caused by H. pylori are treated with Metronidazole (Flagyl),

Omeprazole (Prilosec), and Clarithromycin (Biaxin)—this treatment kills bacteria
and stops production of stomach acid- it does not heal the ulcer!

A board-like abdomen with shoulder pain is a symptom of a perforation,

which is the most lethal complication of peptic ulcer disease

Projectile vomiting can be a signal of obstruction in the GI tract

Diaphragm must stay in place for 6 hours after intercourse

*Also must be re-fitted if patient loses or gains a significant amount of weight!

Best time to take medications:

Growth Hormone (PM)
Steroids (AM)
Diuretics (AM) – prevent nocturia
Donepezil (Aricept) (AM)- Alzheimer’s medication
Cholesterol medications (PM)
Sulcrafate (before meals)- acts as a mucosal barrier—S/E: constipation
Cimetidine (with meals and/or at bedtime)- many interactions
Antacids (1 hour after eating or when experiencing heartburn)- large amounts of
antacid consumption can lead to osteoporosis

Glaucoma- intraocular pressure is greater than normal—give miotics

 to
constrict (pilocarpine) – NO ATROPINE
● Tonometer is used to measure IOP and diagnose glaucoma
o Normal- 10 to 21 mmHg (according to Kaplan)

Dietary calcium- dairy products, seafood, nuts, broccoli, spinach

Non-dairy sources of calcium- RHUBARB, SARDINES, COLLARD GREENS
● Daily calcium intake- 1000 to 1500mg

With low back pain/aches, bend knees for pain relief (William’s position)

61
When taking allopurinol, patients should increase fluids to flush uric acid out
of system!

Koplik’s spots are red spots (commonly found in mouth) with a bluish/whitish
center—characteristic of PRODROMAL phase of MEASLES

Tuberculosis (TB)- medications must be taken for 6 to 9 months

Endemic to Asia, Middle East, Africa, Latin America, Caribbean

A positive PPD confirms infection, not just exposure—a sputum test

confirms active disease

PPD is (+) if induration is:

● >5mm for immunocompromised patients
● >10mm for high risk populations (IV drug users, recent immigrants, lab
personnel, children <4 years)
● >15mm positive in any person (patients with no risk factors)

If a TB patient is unable/unwilling to adhere with treatment—may need

supervision (direct observation) →
  TB is a public health risk

TB medications are toxic to the liver

Adverse reaction is peripheral neuropathy

Most accidental eye injuries (90%) could be prevented by wearing eyewear for
sports and hazardous work

Eye Drop Application

Apply eye drops to the conjunctiva sac—apply pressure to lacrimal duct/inner
canthus (prevents systemic absorption)

Trendelenburg test for varicose veins—patient lies in supine position, leg is

flexed at the hip and raised above the heart, the veins will empty due to gravity
(or with the assistance of the examiner’s hand squeezing the blood towards the
heart)—a tourniquet is then applied around the upper thigh to compress the
superficial veins but not too tight as to occlude the deeper veins—the leg is then
lowered and the patient is asked to stand. If the superficial veins fill more rapidly
(than 30-35 seconds) with the tourniquet, there is valvular incompetence below
the level of the tourniquet in the “deep” veins—after 20 seconds, if there is no
rapid filling, the tourniquet is released—if there is sudden filling at this point, it
indicates that the deep veins are competent but the superficial veins are
incompetent!
*If superficial veins fill with tourniquet—deep veins are incompetent
*If there is sudden filling after tourniquet it removed—superficial
veins are incompetent
62

Precautions when giving KAYEXALATE

● Assess for dehydration (K+ has inverse relationship with Na—when you
decrease potassium, sodium increases)
● Assess patient for bowel sounds before administering—if hypoactive or
 absent bowl sounds HOLD
● Monitor for electrolyte imbalances
● Interactions
o Caution with Digoxin (hypokalemia can lead to digoxin toxicity)
o Kayexalate may decrease the absorption of lithium
o Kayexalate may decrease the absorption of thyroxine

Yogurt has live cultures- do not give to immunocompromised patients

For itching under a cast- cool air via blow dryer, ice pack on cast for 10-15
minutes—NEVER stick anything in the cast to scratch the area

After PERITONEAL DIALYSIS- it is OKAY to have abdominal cramps, blood

tinged outflow, and leaking around the site IF it was placed in the last 1-2
weeks—IT IS NEVER NORMAL to have CLOUDY OUTFLOW

Amniotic fluid- yellow with particles = meconium stained (baby is stressed)

Hyper-reflexes- upper motor neuron issue (“your reflexes are over the top”)
Hypo-reflexes (absent)- lower motor neuron issue

Order of Assessment- (IPPA)  Inspection, Palpation, Percussion, and

Auscultation→ EXCEPT with abdomen—you do not want to activate the bowels
with your assessment so the order is: inspection, auscultation, percussion,
palpation (also, if patient is presenting with abdominal problem, palpation and
percussion may be painful so should be left for the end)

SIGNS
● Murphy’s Sign- pain with palpation of gall bladder area (seen with
cholecystitis)
● Cullen’s Sign- ecchymosis in umbilical area, seen with pancreatitis
(bruising)
● Turner’s Sign- ecchymosis (grayish blue) over flank areas- sign of
pancreatitis (bad sign)
● McBurney’s Point- pain in RLQ indicative of appendicitis
● Rebound tenderness in RLQ—appendicitis
● RLQ pain- appendicitis, watch for peritonitis
● LLQ pain- diverticulitis (should maintain low reside diet, no seeds, nuts,
peas)

63
 ● Guthrie Test- tests for phenylketonuria in newborns—babies should eat
source of protein first
● Allen’s Test- occlude both ulnar and radial arteries until hand blanches,
then release ulnar—if the hand returns to pink color—ulnar artery is good
and you can use for ABG/radial arterial line/stick as planned—ABGs must
be drawn in a heparinized tube, placed on ice and sent immediately to
lab—should also inform lab of how much oxygen the patient is on (and via
NC, mask, etc.)
● Schilling Test- tests for pernicious anemia—how well one absorbs
Vitamin B12

LATEX ALLERGY-
 ● Assess patient for allergies to bananas, apricots, cherries, grapes, kiwis,
passion fruit, avocados, chestnut, tomatoes, peaches (also see above
diagram)

Amyotrophic Lateral Sclerosis (ALS) is a condition in which there is

degeneration of motor neurons in both the upper and lower motor neuron
systems

Transesophageal Fistuala (TEF)- esophagus does not fully develop (this is a

surgical emergency)
*The 3 C’s of TEF in newborn
● Choking
● Coughing
● Cyanosis

The M MR vaccine is given SQ not IM

-First dose recommended between 12 months and 15 months
64
-Contraindicated with allergy to gelatin and neomycin (also should not be given
to immunocompromised patients because it is a live vaccine)
-Should not be given to pregnant women
-Because MMR is a live vaccine, it is not uncommon to spike a fever

Triage in Disaster/Mass-Casualty Situations

*Greatest good for the greatest number
Red- IMMEDIATE/EMERGENT: unstable, injuries are life threatening but
survivable; do not delay treatment—airway, breathing, and circulation
Ex: Airway obstruction, shock

Yellow- URGENT: major injuries that require treatment; can

 delay treatment
1-2 hours
Ex: Open fracture

Green- NONURGENT: minor injuries that do not require immediate treatment,

can delay 2 to 4 hours
Ex: “Walking wounded”, closed fracture, contusions

Black- EXPECTANT: expected and allowed to die, prepare for morgue, comfort
measures if possible
Ex: Profound hemorrhage, cardiac arrest

DOA- Dead on Arrival

Orange- psychiatric, non-urgent

Greek heritage- use of protective charms or amulet (necklace) around baby’s neck
to protect against evil

4 year old kids cannot interpret TIME—they need time to be explained in

relationship to a known common event—Ex: Mom will be back after supper

Allergies and Interactions

● Hep B Vaccine – should not receive if allergy to yeast
● Hep A Vaccine—should not receive if pregnant
● Flu shot—should not receive if allergy to eggs (also contraindicated for
patient’s with a history of Guillain Barre)—OK to give to
 immunocompromised patients
o If a child has a cold, it is okay to give immunizations
● DTaP/Tdap- contradindicated with occurrence of seizures within 3 days
of vaccine (possible adverse reaction- seizures)
o High fever 48 h after DTap is a valid contraindication for vaccine
● Rotavirus Vaccine-
 do not give if allergy to mycin
 drugs
(aminogylcosides)
65
 ● Varicella Vaccine- should not receive if allergy to gelatin and neomycin
or immunocompromised
● Meningococcal Vaccine- should not receive if history of Guillain Barre)
● HPV Vaccine- should not receive if allergy to yeast and/or pregnancy
● Penicillins and cephalosporins- crossover allergy (question orders of
administering med if patient has documented/known allergy to either
● Aspirin and Naproxen- crossover allergies with NSAIDs

Adult Immunizations Schedule

● Tetanus booster- every 10 years
● MMR- one or two doses at ages 19 to 49
● Varicella- two doses if no history of disease
● Pneumococcal (PPSV)- once after the age of 65; recommended for
immunocompromised, COPD, and living in long-term care facility
● Hepatitis A- two doses for high risk clients
● Hepatitis B and HPV- three doses for high risk clients (Hep B repeated @ 1
and 6 months)
o HPV should be given ideally before the patient is sexually active
● Seasonal influenza- annually; give to immunocompromised
● Meningococcal vaccine- students entering college, adults older than 65
repeat every 5 years for high-risk clients
● Herpes zoster- over age 60

Live Vaccines- do not give to immunocompromised and pregnant women

● MMR
● Varicella
● Nasal spray (flu)

When on nitroprusside, monitor thiocynate (cyanide)—normal value should be 1

→ >1 is heading towards toxicity

Severe Acute Respiratory Syndrome (SARS)—airborne and contact (just

like varicella)

Hepatitis A is contact precautions

● Not infectious within a week or so after onset of jaundice

Tetanus, Hepatitis B, HIV are STANDARD precautions

Avoid high fat diet for Hepatitis B

NO VITAMIN C with ALLOPURINOL

No longer contagious after 24 hours of antibiotics

66
HIV
● Medications need to be taken very consistently—failure to take the
medications daily can lead to mutations and the emergence of more
virulent forms of the virus
● Viral load testing measures the amount of HIV genetic material in the
blood, so a decrease in the viral load indicates that the HAART is effective
● Rapid HIV testing must be confirmed by another test, usually Western blot
test
● Infants born to an HIV-positive mother should receive all
immunizations on schedule
● A positive Western blot in a child < 18 months (presence of HIV
antibodies) indicates only that the mother is infected – two or more
positive P24 antigen tests will confirm HIV in children <18
months—P24 can be used at any age
● Kaposi’s sarcoma lesions should be cleaned and dressed daily to prevent