Simple Nursing - Completo

3 Step ABG Interpretation
Mike’s Marching Band Suit Method
Marching band suit method
A B
pH 7.35 7.45 TEST TIP
Write this chart out 5 - 10 times every day the week

B A
PaCO₂
35 45
A B of your ABG exam.

HCO₃
22 26
Side Note: Many students & instructors use the ROME or Tic-Tac-Toe method, but that can get very confusing when interpreting
partial vs. full compensation. Use the marching band suit method to make it simple & get all your ABG questions
correct!
Set Up the Chart
Phase 1 - set up the chart

pH is on 1st!
Step 1 Think pH is primary since it comes first.
pH CO2 comes 2nd.
Step 2 Look at the 2 in CO2, it comes 2nd.
PaCO₂ Lungs on top
HCO3 comes 3rd.

HCO₃ Step 3 Look at the 3 in HCO2, it comes 3nd.
Kidneys on bottom
Phase 2 - key numbers to memorize
A B
pH 7.35 7.45
B A
Top line 7.35 - 7.45
PaCO₂ Middle 35 - 45 (7 goes to heaven)
35 45
Bottom 22 - 26 (think 2+2+2 = 6)
A B
HCO₃
22 26
Phase 3 - Label it A & B
A cid
A B
pH 7.35 7.45
B A
PaCO₂
35 45
B ase HCO₃
A
22
B
26
ABG Practice Questions
ABG Practice Question 1 Example “marching band suit”
pH 7.25 , PaCO₂ 55 , HCO₃ 25 A B

pH 7.35 7.45
Draw your marching band suit here:
B A
PaCO₂
35 45
A B
HCO₃
22 26
ABG Practice Question 2

pH 7.57 , PaCO₂ 25 , HCO₃ 22

pH 7.21 , PaCO₂ 39 , HCO₃ 19
Acid Base Imbalances + ABGs
Pathophysiology Course
Pathophysiology pH
Acid base imbalances are the balance of Acid & Base in the body, Acidotic NORMAL pH
NORMAL pH Alkalotic
kind of like a tug of war the body loves to keep pH in balance. 7.35
7.35 pHpH 7.45
7.45pHpH
- Normal pH: 7.35 - 7.45

- Acidosis: Less than 7.35 pH
- Alkalosis (base): Over 7.45 pH
MEMORY TRICKS
• Full compensation = FULLY Normal pH 7.35 - 7.45 Base = Bicarbonate Carbon diACID
• Partial compensation = pH is not normal
Hydrogen ions = HIGH acid
Controlling Organs
KEY PLAYERS
Lungs control Kidneys control
Carbon Dioxide CO2 Acid Base
Breath in O2 & breath out CO2 Hydrogen H+ ions (acid)
Found in the urine
H⁺
Hypoventilation leads to
HIGHER CO2 Bicarbonate HCO3 (base)
Hyperventilation lead to Found in the intestines
Hydrogen Acid
O
lower CO2
C
C H
O O
O O
Bicarb
Carbon dioxide Acid
Metabolic Acidosis & Alkalosis - Causes MEMORY TRICKS
Metabolic
Over 7.45 pH Under 7.35 pH ALKalosis
Metabolic ALKalosis Metabolic Acidosis

H⁺
H⁺
H⁺
H⁺
Vomiting Diarrhea
NGT suction Renal Failure
Hypokalemia DKA - Diabetic Ketoacidosis
• Low K+ Potassium (below 3.5) Lactic AcidOSIS Vomiting sounds like
• LOW K+ = AlKaLOWsis • Shock (low perfusion) “ALKKK-alosis”
Compensation • Sepsis (severe infection)
• Slow Compensation
• Shallow respirations • Rapid, deep respirations Metabolic
ACIDosis
K
Memory tricks Memory tricks
Base out the Butt DKA - Diabetic Ketoacidosis
Metabolic ACIDosis
< 3.5
Diarrhea: if it comes
LOW K+ out of your a$$idosis
AlKaLOWsis Renal Failure: when the
kidneys fail, acid prevails!
ABG Compensation Questions
Full or Partial
ABG Question 1
Full or Partial compensation?
pH 7.32 , PaCO₂ 55 , HCO₃ 42
ABG Question 2
pH 7.55 , PaCO₂ 49 , HCO₃ 35
ABG Question 3
pH 7.37 , PaCO₂ 52 , HCO₃ 32
ABG Question 4
pH 7.43 , PaCO₂ 43 , HCO₃ 33
3 Step ABG Interpretation
Mike’s Marching Band Suit Method
How to Solve ABG Questions in 3 Steps

pH
A B
Step 1 - pH
pH 7.35
B
7.45
Primary
PaCO₂
pH is primary, look here first 35 45
pH below 7.35 = Acidosis A B

HCO₃
pH over 7.45 = Base (Alkalosis) 22 26
Step 2 - Match pH with partner

A B
pH
Example:
! ! 7.35 7.45
Lets say pH is under 7.35, PaCO2 is B

A
Acidosis PaCO₂
over 45 & HCO3 is normal 2 acids match: 35 45
pH & CO2 = Respiratory Acidosis ! A Normal B

HCO₃
22 26
(look at the organ icon to help you)
Step 3 - Compensated or Uncompensated

Fully Compensated
MEMORY TRICK
A Normal B
Compensation means finding common pH
7.35 7.43 7.45
ground to make the pH in normal range.
B A
PaCO₂
35 45
Fully Compensated = pH is within normal range A B
The lungs & kidneys are doing their part to HCO₃
22 26
balance the body

Uncompensated
Memory Trick A
pH
B
Uncompensated = pH is OUTSIDE normal range 7.35 7.45
The “broken home”. The body is NOT TRYING to

UNcompensated is very PaCO₂
B
A
help balance the pH. UNfriendly 35

A Normal
45
B
It’s like having a lazy partner in a relationship! HCO₃
22 25 26

Partially compensated
A
pH
B
Partially compensated = pH is OUTSIDE normal range, 7.35 7.45

but the body is trying! B
A
It is like couples counseling, sure the pH is NOT normal, PaCO₂
35 45
but at least the lungs & kidneys are TRYING to work things A
A
B
out. HCO₃
22 26 42
Acid Base Imbalances + ABGs II
Respiratory Acidosis & Alkalosis - Causes

O2 in CO2 out
Recall the patho & memory tricks
- Carbon Dioxide CO2
- Think “Carbon diACID” since it pushes the body into acidosis.
Hypoventilation (low & slow breathing) = HIGHER CO2
Hyperventilation (fast breathing) = Lower CO2
Over 7.45 pH
Under 7.35 pH Respiratory Acidosis = Low & Slow RR

Sleep apnea
Head trauma “knocked out”
Respiratory Alkalosis = Fast RR Post operative
Drugs = CNS depressants
Panic Attack • Opioid overdose NCLEX TIP
Key Manifestations • Alcohol intoxication
• Benzodiazepines (Diazepam)
• Low PaCO2 Pneumonia
• Low HCO3 COPD or Asthma attack
Compensation: Key Manifestations
• Kidneys excrete LESS H+ • Mental Status changes
& reabsorb LESS HCO3 • Elevated PaCO2
• Elevated HCO3
Compensation:
• Kidneys excrete H+ (acid)
& retain HCO3 (base)
Top Missed Exam Question

The nurse expects which client
to be in respiratory acidosis?
MEMORY TRICKS 1. Morphine overdose
2. Panic attack
pH
Respiratory ACIDosis Respiratory ALKalosis

3. Sleep apnea
Respiratory ACIDosis
4. COPD
Low & Slow RR Fast RR
5. Asthma attack
6. Alcohol intoxication
alk alk alk

alk-alooosis
CO2
Common NCLEX question
CO2 How does the nurse expect the client to

show compensation for the following
Snoring & Think of a person ABG values?
Ph 7.20, PaO2 82 mm Hg, PaCO2 37 mm
hypoventilation panting like a dog

Hg, HCO3 15 mEq/L
(metabolic acidosis)
sounds like (hyperventilation), 4

5
6 7 8 9
10
1. Decrease respiratory rate
2. Increased respiratory rate

11
“Accccccid-osis”
3
it sounds like
12
2
13 14
0 1
pH
3. Increased renal retention of H+…
“ALK, alk, alk-alosis” Acidotic

7.35 pH
NORMAL pH Alkalotic
4. Decreased renal excretion of HCO3
7.45 pH
ABG Answers Sheet
ABG Practice Question 1 A
pH
B
pH 7.25 , PaCO₂ 55 , HCO₃ 25 7.25 7.35 7.45
A
B
PaCO₂
Step 1: pH 35 45 55
7.25 is below 7.35 so it is Acid A Normal B

HCO₃
22 25 26
Step 2: Match pH with it’s partner

CO2 is 55 so it is Acid Answer:
We have a match in the lung area = respiratory acidosis Respiratory Acidosis
HCO3 25 - normal range, no match Uncompensated
Step 3: Compensated or Uncompensated?

Is the ph in normal range?
NO, it's not in balance, it did not find common ground in Acidosis
compensation
Ph is UNcompensated (not normal range)

B
pH 7.57 , PaCO₂ 25 , HCO₃ 22 pH
A
7.35 7.45 7.57
B A
Step 1: pH PaCO₂
25 35 45
7.57 is above 7.45 so it is Base (Alkalosis) A B
HCO₃
22 26
CO2 is 25 Base (Alkalosis)
Answer:
We have a match in the lung area = respiratory alkalosis
Respiratory Alkalosis
HCO3 22 - normal range, no match
Uncompensated
Is the ph in normal range? ! !
NO, it's not in balance, it did not find common ground in
Alkalosis !
compensation
Ph is UNcompensated (not normal range)

A
pH 7.21 , PaCO₂ 39 , HCO₃ 19 pH
B
7.21 7.35 7.45
A Normal B
Step 1: pH PaCO₂
35 39 45
7.21 is below 7.35 so it is Acid A B
HCO₃
19 22 26
CO2 is 39 - normal range, no match Answer:
HCO3 is 19 Acid
We have a acid match for the kidneys = Metabolic acidosis
Metabolic Acidosis
Uncompensated
Is the ph in normal range? ! !
NO, it's not in balance, it did not find common ground in
compensation Acidosis !
pH is UNcompensated (not normal range)
ABG Compensation Questions
ABG Question 1
pH 7.32 , PaCO₂ 55 , HCO₃ 42
ABG Question 2
pH 7.55 , PaCO₂ 49 , HCO₃ 35
ABG Question 3
pH 7.37 , PaCO₂ 52 , HCO₃ 32
ABG Question 4
pH 7.43 , PaCO₂ 43 , HCO₃ 33
ABG Compensation Answers
Remember:
• Full compensation = FULLY Normal pH 7.35 - 7.45
• Partial compensation = pH is not normal
pH
Remember the body will try to balance the pH

(acid & base) like a tug of war this balancing is Acidotic NORMAL pH
NORMAL pH Alkalotic
called compensation. 7.35
7.35 pHpH 7.45
7.45pHpH
Memory Trick: Compensation is like finding

Common ground (finding balance)
ABG Question 1 A
Full or Partial compensation? pH
B
7.32 7.35 7.45
A
pH 7.32 , PaCO₂ 55 , HCO₃ 42 PaCO₂
B
35 45 55
Step 1: pH A B
HCO₃
7.32 = Acid (below 7.35) 22 26 42

CO2 is 55 = Acid Answer:
We have a match in the lung area = respiratory acidosis Respiratory Acidosis
HCO3 42 = Base (alkalosis) Partially compensated
Step 3: Compensated fully or partially?
Is the pH in normal range? ! !
NO, the pH is not FULLY normal, so it is not FULLY compensated.
Partially compensated, since the pH is only still partially recovering to Acidosis !
normal. HCO3 42 = HIGH BASE, the body is trying to PULL the body OUT
of acidosis & back into balance!
ABG Question 2
B
pH
A
pH 7.55 , PaCO₂ 49 , HCO₃ 35 7.35 7.45 7.55
B
A
PaCO₂
Step 1: pH 35 45 49
7.55 = Base Alkalosis (above 7.45) A B

HCO₃
22 26 35
CO2 is 49 = Acid (no match)
HCO3 35 = Base Alkalosis Answer:
We have a match in the lung area = metabolic alkalosis Metabolic Alkalosis
Partially compensated
Is the pH in normal range? !
NO, the pH is not FULLY normal, so it is not FULLY compensated. !
Partially compensated, since the pH is only still partially recovering to Alkalosis !
normal. CO2 of 49 = High ACID, we know the body is trying to PULL the
pH back into balance!
ABG Compensation Answers II
ABG Question 3
A Normal B
pH 7.37 , PaCO₂ 52 , HCO₃ 32 pH
7.357.37 7.45
A
Step 1: pH
B
PaCO₂
35 45 52
7.37 = Normal (but pH looks closer to Acid)
A B
HCO₃
Step 2: Match pH with it’s partner 22 26 32
CO2 is 52 = Acid (no match) Respiratory
HCO3 32 = Base (no match) Metabolic
Wait a minute, can't find a match with a normal pH! Ughhh oh!
Remember it is like a tug of war, so simply ask, Who’s winning the tug of war?
pH is leaning closer to an acid side = Acid is Winning!
7.37 Answer:
pH Respiratory Acidosis
Fully compensated
Acidotic NORMAL pH
NORMAL pH Alkalotic
7.35
7.35 pHpH 7.45
7.45pHpH
! !
Acidosis
!
Is the pH in normal range?
Yes, Fully compensated, since the pH is FULLY in normal range
ABG Question 4
A B
Full or Partial compensation? pH
Normal
7.35 7.43 7.45

pH 7.43 , PaCO₂ 43 , HCO₃ 33 B Normal A
PaCO₂
35 43 45
Step 1: pH A B
7.43 = Normal (but pH looks closer to Base) HCO₃
22 26 33

CO2 is 43 = Acid (no match) Respiratory Answer:
HCO3 33 = Base Metabolic Metabolic Alkalosis
Fully compensated
pH is leaning closer to the base side = Base is Winning!
Step 3: Compensated fully or partially? ! !

Is the pH in normal range?
Alkalosis !
Yes, Fully compensated, since the pH is FULLY in normal range.
8-12
Injections : Intradermal
Purpose
To administer medications more rapidly than the oral route of administration.
Nursing considerations Needle sizes Equipment

★ Gloves.
★ Tuberculin syringe ★ PPE.
★ Can be delegated the LVN but not calculated in hundredths ★ Medication.
UAP. ★ Sterile syringe and needle of
★ Locations: Forearm and tenths
appropriate size and gauge .
★ Considerations: Consider age, ★ 25-27 gauge, ¼’’-½.’’ ★ Antimicrobial swab.
medication type, medication volume.
★ Small gauze square.
Educate the client there will be a small ★ MAR.
wheel when injected that should go
down over time. Ensure the client
knows to come back 48 hrs after
injection to assess induration. Assess
the client's risk for TB.
Procedure
1. Gather equipment and check MAR (1st
check).
2. Know the the actions, indications and
considerations of the medication to be
administered.
3. Perform hand hygiene.
4. Gather medications from the med room and
prepare meds for one client at a time.
Rights of medication
5. Check the medication with the MAR ( 2nd administration
check) and check expiration dates, perform
1. Right patient
calculations and scan the barcode.
6. Lock the medication prior to leaving it 2. Right dose
7. Transport medications, keeping them in 3. Right route
sight at all times 4. Right medication
8. Perform hand hygiene, provide privacy,
check client ID, check medications with 5. Right time
client name and DOB on the MAR ( 3rd 6. Right documentation
check) have another nurse check accuracy
of dose when giving insulin.
9. Put on clean gloves.
10. Select administration site, forearm. Documentation
11. Position the client, only exposing areas ★ Record the medications given or the
needed to perform the procedure.
12. Cleanse the area around the site with an
MAR.
antimicrobial swab and allow the area to ★ Record date.
dry. ★ Time.
13. Remove the needle cap. ★ Site.
14. The needle into the tissue at a 5-15 degree
angle. ★ If the client refused.
15. As soon as the needle is in place use the ★ If you held or omitted the medication.
thumb and forefinger of your non-dominate ★ Ongoing assessments and
hand to inject the solution. Monitor for wheel
to appear.
evaluations after admin.
16. Wait 10 seconds before withdrawing the
needle, withdraw smoothly and steadily.
17. Apply gentle pressure to the site, do not Complications
massage the area. ★ Pain and swelling at the injection
18. Engage the safety shield and do not recap
the needle.
site.
19. Discard equipment in the appropriate www.SimpleNursing.com ★ Hypersensitivity reactions to
biohazard container. medications.
20. Remove gloves and ppe. ★ Slight fever.
22. Document. ★ Monitor client for reactions.
23. Evaluate.
8-11
Injections : Intramuscular
Purpose

★ Gloves.
★ Vastus lateralis: ⅝” - 1 “ ★ PPE.
★ Can be delegated the LVN but ★ Deltoid ( child): ⅝’’- 1 ¼ “ ★ Medication.
not the UAP, ★ Deltoid ( adults) : ⅝”- 1 ½” ★ Sterile syringe and needle of
★ Locations: Ventrogluteal,
★ Ventrogluteal (adult) : 1 ½” appropriate size and gauge .
vastus lateralis, deltoid, ★ Antimicrobial swab.
dorsogluteal.
★ Considerations: Consider age, ★ MAR.
medication type, medication
volume. Patients who are obese
may require a longer needle.
Emaciated clients may need a
shorter needle.
★
★ The needle should be inserted
at a 90* angle.
Procedure
check).
administered.
3. Perform hand hygiene. Rights of medication
4. Gather medications from the med room and
administration
5. Check the medication with the MAR (2nd 1. Right patient
check) and check expiration dates, perform 2. Right dose
calculations and scan the barcode. 3. Right route
6. Lock the medication prior to leaving it.
7. Transport medications, keeping them in 4. Right medication
sight at all times. 5. Right time
8. Perform hand hygiene, provide privacy, 6. Right documentation
check client ID, check medications with
client name and DOB on the MAR ( 3rd
check).
9. Put on clean gloves. Documentation
10. Select administration site.
11. Position the client, only exposing areas ★ Record the medications given or the
needed to perform the procedure. MAR.
12. Cleanse the area around the site with an anti ★ Record date.
microbial swab and allow the area to dry.
★ Time.
13. Remove the needle cap.
14. Displace the skin in a z-track technique. ★ Site.
15. Dart the needle into the tissue perpendicular ★ If the client refused.
to the clients body. ★ If you held or omitted the medication.
16. As soon as the needle is in place use the
thumb and forefinger of your non-dominate ★ Ongoing assessments and
hand to inject the solution. evaluations after admin.
18. Apply gentle pressure to the site , do not Complications
massage the area,
19. Engage the safety shield and do not recap ★ Pain and swelling at the injection
the needle. site.
20. Discard equipment in the appropriate ★ Hypersensitivity reactions to
biohazard container.
medications.
21. Remove gloves and ppe.
22. Perform hand hygiene. ★ Slight fever.
23. Document.
www.SimpleNursing.com
★ Monitor client for reactions.
24. evaluate.
8-12 Injections : Subcutaneous
Purpose

★ Gloves.
★ 25 to 27 gauge needle 3/8
★ PPE.
to 5/8 ‘’
★ Can be delegated the LVN but ★ Medication.
★ Byetta for diabetes
not UAP. ★ Sterile syringe and needle of
recommends using 30 or
★ Locations: Abdomen, Thigh, appropriate size and gauge .
31 gauge 1/3 inch needles
Lower back, Upper Arm. ★ Antimicrobial swab.
which are ultra fine.
★ Considerations: Consider age, ★ Small gauze square.
medication type, medication ★ MAR.
volume. Educate the client to
rotate injections to avoid
hardening of the area. Ask the
client which site they would
prefer.
Procedure
check).
considerations of the medication to be Rights of medication
administered.
3. Perform hand hygiene. administration
4. Gather medications from the med room and 1. Right patient
prepare meds for one client at a time. 2. Right dose
5. Check the medication with the MAR 2nd
check) and check expiration dates, perform 3. Right route
calculations and scan the barcode. 4. Right medication
6. Lock the medication prior to leaving it. 5. Right time
7. Transport medications, keeping them in
sight at all times.
6. Right documentation
8. Perform hand hygiene, provide privacy ,
check client ID, check medications with
client name and DOB on the MAR (3rd
check) have another nurse check accuracy Documentation
of dose when giving insulin. ★ Record the medications given
9. Put on clean gloves.
10. Select administration site.
or the MAR.
11. Position the client, only exposing areas ★ Record date.
needed to perform the procedure. ★ Time.
12. Cleanse the area around the site with an anti ★ Site.
microbial swab and allow the area to dry.
13. Remove the needle cap. ★ If the client refused.
14. the needle into the tissue at a 90 or 45 ★ If you held or omitted the
degree angle. medication.
15. As soon as the needle is in place use the
thumb and forefinger of your non-dominate
★ Ongoing assessments and
hand to inject the solution. evaluations after admin.
17. Apply gentle pressure to the site, do not
massage the area. Complications
18. Engage the safety shield and do not recap ★ Pain and swelling at the
the needle. injection site
19. Discard equipment in the appropriate
biohazard container. ★ Hypersensitivity reactions to
20. Remove gloves and ppe. medications
21. Perform hand hygiene. www.SimpleNursing.com ★ Slight fever.
22. Document.
23. Evaluate.
★ Monitor client for reactions.
8-7 Blood Transfusions
Purpose
Red blood cells may be administered to treat hemorrhage, symptomatic anemia, or sickle cell crisis, and will improve oxygen delivery to the
tissues. Fresh frozen plasma can help reverse the effect of anticoagulants. Platelets transfusions may prevent bleeding with
thrombocytopenia. Compatibility must be checked by two qualified personnel before a blood product is administered to prevent a life
threatening transfusion reaction. Ask if patient has received a transfusion or organ or tissue transplant in the past and whether they had any
reaction. Note the type of reaction. Check if the patient requires irradiated blood products due to immunosuppression.
Assessment Risks Patient Teaching

★ Assess cultural and religious beliefs ( ★ Explain procedure.
★ Risk for infections.
jehovah's witness). ★ Instruct patient to report any sensation of
★ Risk for hemolytic reaction.
★ Ensure you obtain informed consent. flushing, itching, shortness of breath, or
★ Risk for sepsis.
★ Assess vital signs, including, renal, back/flank pain immediately, as these may
★ Risk for iron overload.
circulatory, respiratory status and lab be signs of a transfusion reaction.
★ Risk for disease transmission.
work. ★ Explain feelings the client will feel. Explain
★ Risk for circulatory overload.
★ Assess the client's ability to tolerate the you will maintain privacy.
★ Risk for electrolyte imbalances.
procedure. ★ Be supportive.
★ Assess client's temperature. If there is a
fever present the HCP may have you hold
Note !
off on administering the blood product.
Supplies ★ Only isotonic electrolyte solutions are
★ 0.9% normal saline, 250 mL bag approved for blood administration.
★ Blood administration set with in-line filter and a Y set for saline administration Dextrose will hemolyze RBCs and the
★ Clean gloves calcium in Lactated Ringers will
★ Blood product cause clotting.
★ IV pump (most facilities), Blood warmer, if indicated ★ Do not heat blood in hot water or a
microwave.
Procedure Documentation
1. Confirm HCP order, obtain consent. ★ Date and Time of procedure.
2. Confirm client ID and DOB. ★ Why you preformed the procedure.
3. Provide privacy and introduce yourself . ★ How many attempts, guage of the catheter.
4. Perform hand hygiene .
★ Insertion site, solution infused.
5. Insert peripheral IV access with an 18 or 19 gauge catheter
to ensure maximum flow of blood. ★ Any signs of a hemolytic reaction.
6. ALWAYS ensure patency of IV line prior to obtaining blood ★ Rate infused, client's response to the
from the lab. procedure. Continually monitor vitals every 15
7. Obtain blood product from the blood bank quickly. minutes for the first hour.
8. Visually inspect the blood for clots, sediment, or bubbles.
9. Obtain baseline vital signs. Pre-existing fever should be Complications
reported to the provider prior to proceeding with transfusion. ★ Transfusion Reaction: An immediate transfusion
10. Two RNs (one of whom will administer the blood product, reaction that manifests as, chills, hives, rash,
though this policy may vary) must confirm the blood unit, lab diaphoresis, back pain, muscle aches, chest pain, rapid
paperwork, and the blood ID band at the bedside: blood unit thready pulse, cyanosis, dyspnea, cough, wheezing,
ID number, blood and Rh type, unit expiration date, and apprehension, headache, nausea, vomiting, diarrhea. If
patient’s name and DOB confirmed with the ID band. the client experiences a transfusion/hemolytic reaction
11. Close ALL clamps on Y set tubing. Hang 0.9 % NS. the priority intervention is to STOP the transfusion
12. Prime Up: Spike the normal saline with one short end of the IMMEDIATELY!
Y tubing and open the clamps on both of the shorter Y ends ★ Septicemia: Rapid onset of chills and a high fever,
set to prime them. The descending tubing clamp remains vomiting, diarrhea, hypotension, and shock.
closed. ★ Circulatory overload: Caused by a transfusion that is
13. Prime Down: With NS clamp still open, now close the clamp too rapid. Manifestations include; Headache HTN,
on the other short end of the Y set and open main tachycardia, bounding pulse, distended neck veins.
(descending tubing) clamp to prime the rest of tubing with ★ Iron overload: A delayed transfusion reaction
NS. Close all clamps. accompanied by, vomiting diarrhea, hypotension, altered
14. Gently agitate blood bag (suspends the blood cells). Pull blood labs.
back the tabs on blood bag ports to expose them. ★ Disease Transmission: A delayed reaction that occurs
15. Prime Blood: Main tubing and NS Y arm clamps remain with contaminated blood. Symptom onset will be much
closed. Spike the blood bag with the free short end of the Y later.
tubing and open the corresponding clamp to allow blood to ★ Hypocalcemia: Monitor for signs of hypocalcemia ( F&E
flow down and prime the filter with blood. study guides)citrate binds with calcium causing calcium
16. Ensure blood product is hanging above NS solution. excretion.
17. Load tubing into the infusion pump, if used. ★ Hyperkalemia: Monitor for signs of hyperkalemia ( F&E
18. Prep injection port per facility policy, and connect the tubing study guides) can be from blood being too old.
to patient. ★ Citrate toxicity: When citrate binds with magnesium it
19. Open main clamp and begin infusion via pump or gravity. causes citrate toxicity. Citrate is the anticoagulant used
Begin the transfusion slowly. in blood products.
8-8 Central Venous Catheters
Purpose
To deliver hyperosmolar solutions, to measure central venous pressure, infuse TPN, or to administer multiple IV solutions.
★ Catheter position is determined by X-Ray after procedure.
★ Catheter may be single, double, or triple lumen.
★ Catheter is inserted peripherally into either the basilic or cephalic vein, into the superior vena cava, inserted
centrally into the internal jugular vein, or subclavian vein. They may also be surgically installed through
Subcutaneous tissue.
★ With multi lumen catheters more than one medication is able to be administered at a time.
Tunneled central venous catheter Vascular access ports ( implants)

★ More permanent and used for long ★ Surgically implanted under the
term IV therapy. skin.
★ May be single or multilumen. ★ Used for long term IV therapy.
★ Inserted in the OR. ★ Access requires palpation.
★ Fitted with an intermittent infusion ★ Accessed with a non coring
device, This allows access as needed needle.
and the system remains closed when ★ Patency is maintained with
unused. periodic flushing with heparin.
★ Patency is maintained by flushing the
catheter with diluted heparin.
PICC Line
★ Used for long term IV therapy
frequently in home.
★ The basilic vein is most commonly
used.
★ The catheter is inserted so that the
tipis terminated in the subclavian
vein or superior vena cava.
★ Small amounts of bleeding during
insertion are common, if bleeding
continues after 24 hours call the
HCP.
★ Phlebitis is common.
Epidural catheter NCLEX HINT !

★ Non central .
For central line insertion, tubing
★ Placed in the epidural space of change, and line removal, the
the spinal column. client should be placed in the
★ Used to administer analgesia. Trendelenburg's position or
★ Assess the client's vitals and supine. Also instruct the client to
respiratory status. perform the valsalva maneuver to
★ Monitor the insertion site for increase the pressure in the
infection.
central veins when the system is
★ Monitor infusion device for proper
rate and flow.
open.
★ Aspiration is performed before
injection. If more than 1 mL of
clear fluid or blood is aspirated do
not inject the medication and
notify the HCP.
8-9
IV drip rates
★
★
When calculating how many hours or how
long the infusion will run there is no need for
a drop factor.
When calculating gtt/ min you will need the
Dosage 101
Basic formula for Tablets / Capsules
drop factor.
Dose
mL l/ hr -------- x supply
Total amount to be infused Have
-------------------------------------
How many hours for the infusion to run Example : HCP orders lorazepam 50 mg / day
po. The pharmacy has it available in 100 mg
Example tablets. How many tabs would you administer?
Infuse 500mL over the next 120 minutes by infusion pump.
50mg
500mL ------ X Tablets = 0.5 tablets or ½ of a
--------- = 250 mL/ Hr tablet.
120min / 60 100 mg
( 2hr)
mL/ min
Total to be infused
Pediatric doses
--------------------------x gtt factor
★ Pediatric doses are based on
Hours x 60
body weight in Kg.
Example ★ To convert pounds to Kg divide
Calculate the IV flow rate for 1500 mL of NS to be infused in 7 by 2.2
hours. The infusion set is calibrated for a drop factor of 20
gtts/mL. Weight per Kg x dose per Kg =
amount to be administered.
1500mL
--------- x 20 gtt/Ml = 71.4 gtt/ min Rounded to 71 You use this same formula for safe dose
gtt/min range.
7 x 60 min
Example:
( 420) The HCP orders 250 mg of meropenem
to be taken by a infant weighing 15.7
Iv rate in Hr/ volume pounds, every 8 hours. The medication
amount/Hr label shows that 75-150 mg/kg per day
is the appropriate dosage range. Is this
------------ x volume order within the safe dose range for this
On hand medication?
15.7/2.2= 7.13 kg.

Example
Give patient 400 mg of vancomycin in 300 mL of D5W to
150mg x 7.13 = 1,069.5 safe per day
infuse at 10 mg/hr. Calculate the flow rate in mL/hr.
75 mg x 7.13 = 534.75 safe per day
24 hrs/8= 3 doses / day
10 mg/hr
--------x300mL = 7.5 mL/ hr 250mg x 3 doses = 750 mg/ day
400mg
This is within safe dose range.
8-10 Medication Administration
Purpose
Administration of medications whether oral, IV, injection, or transdermal is indicated to bring the clients affected body
system back to homeostasis.
Nursing considerations Needle sizes & Gauges Equipment

★ Gloves
★ Vastus lateralis: ⅝” - 1 “
★ PPE
★ Can be delegated the LVN but not UAP, ★ Deltoid ( child): ⅝’’- 1 ¼ “
★ Medication
depending on medication and ★ Deltoid ( adults) : ⅝”- 1 ½”
★ Sterile syringe and needle of
considerations ★ Ventrogluteal (adult) : 1 ½”
appropriate size and gauge .
★ Routes of administration : IV, IM,sub q, ★ 16-26 gauge.
★ Antimicrobial swab.
intradermal, PO, transdermal, intrathecal
, vaginal, ophthalmic, otic. Nasal, ★ MAR.
sublingual
★ Considerations: consider age,
medication type, medication volume.
Assess allergies, know the indications,
nursing actions,
Procedure
★ Check the client's current labs
★ Do not forget to do your 3 checks.
1. Gather equipment and check MAR ( 1st

check). Rights of medication
2. Know the the actions, indications and administration
administered. 1. Right patient
3. Perform hand hygiene. 2. Right dose
4. Gather medications from the med room and 3. Right route
4. Right medication
5. Check the medication with the MAR ( 2nd
check) and check expiration dates, perform 5. Right time
calculations and scan the barcode. 6. Right documentation
6. Lock the medication prior to leaving it.
7. Transport medications, keeping them in
sight at all times.
8. Perform hand hygiene, provide privacy,
check client ID, check medications with Documentation
client name and DOB on the MAR ( 3rd
check). ★ Record the medications given or
9. Put on clean gloves. the MAR.
10. Select administration site. ★ Record date.
11. Position the client, only exposing areas
★ Time.
needed to perform the procedure.
12. Discard equipment in the appropriate ★ Site.
biohazard container. ★ If the client refused.
13. Remove gloves and ppe. ★ If you held or omitted the
15. Document. medication.
16. Evaluate. ★ Ongoing assessments and
evaluations after admin.
Complications
★ Pain and swelling at the injection
site.
★ For IV push drugs, see each individual drug ★ Hypersensitivity reactions to
for indications, considerations and times. www.SimpleNursing.com medications.
Each IV push drug varies according to ★ Slight fever.
manufacturer and hospital policy.
★ Potassium will never be an IV push. ★ Monitor client for reactions.
8-2 Ng tube insertion
Purpose
Decompress the stomach by removing fluids or gas. This promotes abdominal comfort. To allow surgical
anastomosis to heal without distention, decrease risk of aspiration, provide nutrition as a feeding tube, to irrigate
and remove toxic substances in the stomach .
Assessment Risks
★ Determine indication for ★ Risk for placement into Patient Teaching
NG tube insertion. the airway. ★ Explain procedure and
★ Assess for previous ★ Risk for infection from indications.
insertions. not using aseptic ★ Explain feelings the client
★ Assess for latex. technique. will feel (they may gag).
★ Assess for adhesive ★ Risk for injury from ★ Explain you will maintain
allergies. insertion or removal. privacy.
★ Assess respiratory status. ★ Be supportive.
Supplies ( NG Tube Kit)

★ Clean gloves
★ Feeding tube
★ Sterile water
★ Jelly
★ Tape or marking pen
★ Syringe
★ PH tape
★ Feeding solution
1. Confirm HCP order, obtain consent.
2. Confirm client ID and DOB. ★ Date and Time of procedure.
3. Provide privacy and introduce yourself. ★ Type and size of tube.
4. Perform hand hygiene. ★ Verify method of placement and
5. Explain procedure to family and client. patency.
6. Position the client in semi fowlers with pillows ★ Type and amount of contents.
behind the shoulders. ★ PH of contents.
7. Determine the most patent nostril.
★ Type and amount of feeding given.
8. Measure the length of the tube from the bridge
of the nose to the ear lobe then the xiphoid ★ Client's response and tolerance.
process and mark this spot. ★ Position of the client post procedure.
9. Don clean gloves.
10. Give the client a drink of water, lubricate the tip
of the catheter.
11. When the tube nears the back of the throat,
have the client swallow. If resistance is met aim
the tip downward.
12. Immediately remove tube if 02 sats change.
13. Following insertion obtain an x-ray to confirm
placement.
14. Connect the tube to suction as ordered.
15. Secure the tube to the client's nose.
16. Aspirate stomach contents and check PH to
confirm placement before feeding.
17. Wash hands. Tip
18. Document. Check residual and stomach
contents prior to administration of
meds or feedings.
To avoid electrolyte and fluid
imbalances replace aspirated
www.SimpleNursing.com contents. Stomach contents PH
should be around four.
8-5 Ostomy care
Purpose
Performed to prevent infection related to stoma surgery. To monitor output, and assess client's nutritional status, and
hydration status. Usually a result of ulcerative colitis.
Risks
★ Risk for infections.
Assessment ★ Risk for impaired skin
★ Determine indication for integrity.
stoma care. ★ Risk for injury from
★ Assess stoma for color, insertion or removal of
appliance.
drainage or excoriation. Patient Teaching
★ Assess for latex allergies. ★ Explain procedure.
★ Assess for adhesive ★ Explain the stoma should
allergies. be a juicy red color not
★ Ensure you have the pale.
proper appliance. ★ Explain you will maintain
privacy.
★ Be supportive.
★ Ask if they have brought
Supplies (Ostomy Supplies) ★
their own appliance
Encourage self care.
★ Bedpan, graduated cylinder, toilet access.
★ Clean gloves, toilet tissue.
★ Washcloth, towel , waterproof pad.
★ Wash basin with warm water.
★ Gauze, skin barrier cream.
★ Stoma measuring guide.
★ Ostomy appliance and bag.
★ Clamp , trash bag.
Documentation
★ Date and Time of procedure.
★ Why you preformed the procedure or
if the client did themselves.
Procedure ★
★
Size of the stoma.
Characteristics of the stoma, color,
1. Confirm HCP order, obtain consent. odor, drainage, redness, excoriation.
2. Confirm client ID and DOB. ★ Characteristics of feces , amount,
3. Provide privacy and introduce yourself.
color, odor.
5. Help the client to a sitting position. ★ How the client tolerated the
6. Place graduated cylinder under bag for procedure.
measurement.
7. Remove the clamp and uncuff the bag and allow
contents to empty into the measuring device.
8. Wipe the end of the cuff with toilet tissue. Tip
9. To remove the appliance start at the top and move ★ Some clients have
around pushing skin away from the appliance. their own routine
10. Discard the appliance unless reusable. when it comes to
11. Gently clean the surrounding skin with a washcloth
stoma care and
and warm water.
12. Pat the skin dry and apply barrier cream no closer appliance care.
than 2 in from the stoma. Let dry completely. Allow them to
13. Remove gauze and assess and measure stoma. maintain their own
14. Cut a hole in the appliance to ⅛ inch larger than home routine if
the stoma. possible.
15. Carefully peel the backing of the appliance and lay
over the stoma.
16. Smooth out air and hold even pressure for 5
minutes.
17. Apply the clamp to the bottom of the new pouch.
18. Wash hands. www.SimpleNursing.com
19. Document.
8-6 Peripheral IV Access Insertion
Purpose
IV therapy is used to administer fluids and medications to clients who are unable to take these substances orally. It
replaces water, electrolytes and nutrients more rapidly than the oral route. It provides immediate access to the vascular
system for rapid administration of medications, blood products, and TPN.
Assessment Risks
★ Risk for infections, Patient Teaching
★ Determine indication for IV ★ Explain procedure.
insertion. ★ Risk for phlebitis,
★ Risk infiltration, and ★ Explain feelings the client
★ Assess for sites prior to insertion.
★ Assess for latex allergies. excavation. will feel ( pinch, slight pain)
★ Assess for allergies to the ★ Explain you will maintain
medications or substances to be privacy.
infused. ★ Be supportive.
★ Assess for adhesive allergies.
★ Avoid sites that are edematous, a
weak, traumatized or paralyzed
extremity. An arm that has an AV
shunt for dialysis or an area that is
infected.
Supplies ( IV Start kit)

★
★
Clean gloves
IV start Kit.
Documentation
★ Sterile Gloves ★ Date and Time of procedure.
★ Tegaderm ★ Why you preformed the procedure.
★ Tourniquet ★ How many attempts.
★ Alcohol wipe ★ Guage of the catheter.
★ Tape ★ Insertion site.
★ Solution infused.
Procedure ★ Rate infused.
1. Confirm HCP order, obtain consent. ★ Client's response to the procedure.
2. Confirm client ID and DOB. ★ If the infusion is infusing with or
3. Provide privacy and introduce yourself . without difficulty.
4. Perform hand hygiene .
5. Select vein for insertion and apply tourniquet Complications
6. Palpate vein for resilience . ★ Phlebitis: Inflammation of the vein. Signs and symptoms
7. Cleanse the skin with the provided alcohol wipe. include; pain, redness and warmth at the insertion site. If this
8. Stabilize the vein below the puncture site and occurs remove the catheter immediately and restart it in the
opposite extremity. Notify the HCP if phlebitis is suspected
insert the catheter into the bifurcation at at 10
and apply a warm, moist compress to the area.
degree angle.
9. Advance the catheter until you see a flash of ★ Infiltration: The leakage of IV fluid into the interstitial space.
blood, once you see the flashback continue Evaluate the IV site by occluding the vein proximal to the site
advancing the catheter into the vein and remove of insertion. If the infusion continues to flow the IV site has
the tourniquet. infiltrated. The site will be cool, pale, and swollen. If
10. Apply pressure above the insertion site with the infiltration occurs remove the IV catheter immediately and
apply a warm or cool compress to the site and elevate the
middle finger of the non-dominant hand and
extremity. Do not rub an infiltrated area as this can cause a
retract the needle. hematoma.
11. Connect the IV tubing to the catheter tubing.
12. Tape and secure catheter tubing to the clients ★ Air embolism: A bolus of air that enters the vein. Occurs
skin with tegaderm and begin IV flow. from inadequatly priming IV tubing. The client will experience
13. Label the tubing, primary tubing is good for 72 tachycardia, chest pain, dyspnea, hypotension, cyanosis,
hours, secondary tubing is only good for 24 hrs. and decreased LOC. If an air embolism is suspected clamp
the tubing, turn the client to the left side and place the client
DO NOT forget to label the solution bag.
in reverse trendelenburg's position to trap the air into the
14. Date, time, and initial the IV dressing. right atrium. Notify the HCP.
15. Clean up area. ★ Extravasation: Tissue damage that occurs from infiltration
16. Wash hands. of certain medications such as dopamine. Skin around the
17. Document. affected area will become discolored and slough. The client
will feel discomfort. If extravasation is suspected contact the
HCP.
8-14 Personal protective equipment
Purpose
To protect yourself and the client from infection and disease transmission.
Donning Removing
★ Hand hygiene ★ Gloves
★ Gown ★ Goggles
★ Mask ★ Gown
★ Goggles ★ Mask
★ Gloves ★ Hand hygiene
Precautions
Contact Airborne
M: Multidrug resistant
M: Measles
Droplet
organisms S: Sepsis, scarlet fever,
R: Respiratory infections T: TB
V: Varicella strep
S: Skin infections P: Parvovirus, pneumonia,
pertussis
W: Wound infections I: Influenza
E: Enteric infections D: Diphtheria
E: Eye infections E: Epiglottitis
R: Rubella
V: Varicella M: Mumps, meningitis,
C: Cutaneous diphtheria mycoplasma, meningeal
H: Herpes simplex pneumonia.
I: Impetigo A: Adenovirus, AIDS
P: Pediculosis N: Now repeat it twice!
S: Scabies
Standard precautions
★ Apply to all body fluids secretions, excretions and mucous membranes.
★ Handwashing: Before and after procedure, and when soiled, wash hands in
warm water vigorously while singing happy birthday 2x.
★ Gloves.
★ Gown.
★ Mask. www.SimpleNursing.com
★ Eye protection.
Trach care and suction
8-3
Purpose
Routine trach care is provided to aid in the healing process of the stoma and prevent skin breakdown. Frequent suction
aids in clearing the clients secretions and decreases the risk of infection and oxygen deprivation.
.
Assessment
★ Assess order.
Risks
★ Assess cannula type.
★ Risk for infection. Patient Teaching
★ Risk for decreased oxygenation.
★ Assess respiratory sounds ★ Explain procedure and indications.
★ Risk for injury from insertion or
before and after procedure. ★ Explain the procedure. Patients
removal.
should verbalize understanding of
★ Assess for secretions. ★ When performing tracheostomy
proper care.
★ Assess skin integrity and care, emergency supplies should be available
★ Explain feelings the client will feel
for signs of infection. at all times in case the tube is inadvertently
(they may gag).
dislodged, and an ambu bag to administer
★ Assess type of ★ Explain you will maintain privacy.
breaths as needed for the client on a vent.
tracheostomy and dressing. ★ Be supportive.
Supplies for trach care

★ Trach cleaning tray (includes sterile gloves, sterile basins, pipe cleaners, brush, cotton-tipped applicator, gauze).
★ Presplit non-fraying 4x4 or split drain sponge.
★ Replacement inner cannula, if applicable.
★ Sterile normal saline.
★ Clean cotton trach ties or Velcro tube holder.
Procedure
1. Confirm the patient’s ID using two identifiers.
2. Explain procedure to patient.
3. Open trach tray and put on one sterile glove in order
to set up two basins.
4. With an ungloved (non-sterile) hand, pour saline into
each basin.
5. Don the second sterile glove - both hands are now
sterile.
6. Remove inner cannula, if applicable: Secure outer
cannula neck plate with index finger and thumb.
Unlock inner cannula - usually by turning LEFT 90 Documentation
degrees. Gently pull cannula up and out - it should ★ Date and Time of procedure .
withdraw easily. ★ Any drainage, color, odor and amount
7. Soak and clean the inner cannula in sterile normal
saline or discard if disposable. Remove any secretions
of dressing.
by cleansing and wiping the lumen with moistened ★ Client's response and tolerance.
brush. ★ Position of the client post procedure.
8. Place cleaned inner cannula on sterile gauze and dry ★ If suctioned, color, type and amount
thoroughly. of secretions.
9. Replace inner cannula with care, stabilizing outer
flange with opposite hand. Lock into place (turn
RIGHT).
10. Cleanse skin around stoma with gauze or applicator
soaked in sterile saline from the clean basin (the basin
that was not used to clean inner cannula). Use a
separate gauze/applicator to clean the outer cannula.
11. Apply new dressing: Apply presplit non-fraying
gauze/split drain sponge around ostomy/trach tube
with flaps pointing up. (See picture of how to make
folded 4x4 dressing if a presplit is not available.)
12. Change trach ties/tube holder if needed. (See:
Changing tracheostomy tube ties)
13. Ask the pt if they need anything. Lock bed, put it in www.SimpleNursing.com
lowest position with call bell in reach.
8-4
Trach care and suction
Purpose
Routine trach care is provided to aid in the healing process of the stoma and prevent skin breakdown. Frequent suction aids in clearing
the clients secretions and decreases the risk of infection and oxygen deprivation.
.
Assessment Risks Patient Teaching
★ Assess order. ★ Risk for infection. ★ Explain procedure and indications.
★ Risk for decreased oxygenation. ★ Explain the procedure. Patients
★ Assess cannula type.
★ Risk for injury from insertion or should verbalize understanding of
★ Assess respiratory sounds proper care.
removal.
before and after procedure. ★ Explain feelings the client will feel
★ When performing tracheostomy
★ Assess for secretions. care, emergency supplies should be available (they may gag)
★ Assess skin integrity and at all times in case the tube is inadvertently ★ Explain you will maintain privacy.
for signs of infection. dislodged, and an ambu bag to administer ★ Be supportive.
★ Assess type of breaths as needed for
tracheostomy and dressing. the client on a vent.
Suction supplies
★ Suction tubing,trach suctioning kit or individually wrapped sterile gloves and suction catheter.
★ Bottle sterile water or normal saline (250 mL),sterile container to hold water.
★ Clean gloves.
★ PPE including gown and mask with face shield suction machine (portable or wall connection with Y connector), oxygen source
with tubing,obturator (kept at bedside for emergencies), self-inflating resuscitator bag (AMBU) with trach tube adapter.
Procedure
1. Confirm the patient’s ID using two identifiers and explain the procedure to the
patient.
2. Prepare equipment: Wall suction should have tubing connected and be set between
-80 mmHg and -120 mmHg. Higher pressures increase the risk of trauma to the
mucosa. Depending on method of delivery, the oxygen source should be set to
maximum (10-12 LPM) with the tubing connected. An AMBU bag should have a trach
tube adapter connected and should be checked for function - this can be done by
squeezing the bag. It should re-inflate spontaneously.
3. Perform hand hygiene; don clean gloves and PPE.
4. Position client for comfort. Semi-fowlers or upright is optimal for pulmonary hygiene,
but not required. Documentation
5. Hyperoxygenate: Instruct patient to take a few deep breaths while oxygen is at ★ Date and Time of
maximum, then disconnect oxygen source from the trach tube.
procedure.
6. Remove and the clean inner cannula if the patient has one. While suctioning, this can
be placed on the sterile field or in sterile water. (see: Tracheostomy Care: Removing ★ Any drainage, color, odor
and Cleaning Inner Cannula) and amount of dressing.
7. Open new suction catheter package, and ready sterile container for water. ★ Client's response and
8. Remove cap from sterile water, and pour into open sterile container. tolerance.
9. Don sterile gloves. Keeping dominant hand sterile and the other hand clean, grasp ★ Position of the client post
suction tubing with clean hand and sterile catheter with sterile hand. Estimate the procedure.
depth catheter will be advanced: 0.5 to 1 cm past the end of trach tube - and grasp
★ If suctioned, color, type
the catheter at that point.
10. Move your clean hand near the chimney valve at base of catheter (this end will not and amount of
touch the tracheostomy). The chimney valve initiates suction when it is occluded with secretions.
your thumb.
11. Insert the catheter: Without applying suction, move your sterile hand toward the
end/tip of catheter and guide the catheter into trach tube just until resistance is felt.
If patient begins coughing, withdraw catheter slightly. (Suction during insertion may
cause discomfort and injury.)
12. Suction: Using your clean thumb, occlude the chimney valve to produce intermittent
suction as catheter is rotated gently while withdrawing from the trach. Suction for no
more than 10 seconds.
13. Rinse the catheter with sterile water from the tray until the lumen is clear by using
intermittent suction. Do this between each pass with the suction.
14. Repeat the suction steps, inserting without suction and removing with intermittent
suction for no more than 10 seconds.
15. Turn off suction and replace oxygen to patient as ordered.
16. Discard catheter into appropriate receptacle after disconnecting from suction tubing.
17. Empty suction bowl with sterile water and discard.
18. Auscultate lungs and assess heart rate and breathing effort.
19. Remove (doff) all PPE before exiting room and place in appropriate receptacle. www.SimpleNursing.com
8-1 Urinary catheter insertion
Purpose
Used to remove urine from the bladder when there is an obstruction, a need for strict measurement,
retention or nerve damage. These are also used to monitor I&O’s.
Assessment
★ Determine indication for
foley insertion.
★ Assess for previous
catheterizations. Risks
★ Assess for latex and iodine ★ Risk for urinary tract
allergies. infections .
★ Assess for adhesive ★ Risk for renal
allergies. inflammation, Patient Teaching
pyelonephritis. ★ Explain procedure.
★ Risk for injury from ★ Explain feelings the client
insertion or removal. will feel (pressure the relief).
★ Explain you will maintain
privacy.
★ Be supportive.
Supplies ( Sterile Catheter Kit)
★ Clean gloves
★ Sterile Gloves
★ Wash cloth and warm water
★ Waterproof pad
★ Sterile foley Kit
Procedure
1. Confirm HCP order, obtain consent. Documentation
2. Confirm client ID and DOB.
★ Date and Time of procedure.
3. Provide privacy and introduce yourself.
4. Perform hand hygiene. ★ Why you preformed the procedure.
5. Perform peri-care. ★ Size of catheter inserted.
6. Have the client lay on their back knees flexed legs ★ How many attempts if applicable.
abducted. ★ Characteristics of urine, amount,
7. Open the sterile kit between the client's legs. color, odor.
8. Place the sterile drape under them. ★ How the client tolerated the
9. Don sterile gloves.
procedure.
10. Open all sterile supplies, remove sheath from catheter.
Squirt the lubricant into the tray. Pour the iodine over the
cotton balls.
11. Attach syringe to the lumen of the catheter and test the
balloon ( see hospital for protocol).
12. Clean the labia and urinary meatus, using your non
dominant hand ( look for the “ WINK.”
13. With three strokes downward ( outer inner outer for
females and circular motions around the glans penis for
males) front to back. Using the forceps and cotton balls
with your dominant hand.
14. With your sterile dominant hand pick up the catheter a few
inches from the tip and dip it in the lubricant.
15. Insert foley into the urethra until you see urine, then
continue advancing it another 2-3 in.
16. Inflate the balloon with the entire syringe of NS, check
Tip
placement.
17. Velcro catheter to the client's leg, initial and date the
dressing. Catheters come in a variety
18. Attach bag to bed frame, Clean up supplies. of sizes from 12 french to
19. Wash hands.
20. Document.
48 french. Be sure to check
www.SimpleNursing.com hospital policy on sizes.
BLS & CPR
Pathophysiology Instruction
Done for clients who go into cardiac arrest If NO caregivers are around to help, you must
meaning the heart has stopped pumping! initiate immediate CPR with high quality
compressions. Start Chest Compressions BEFORE
calling for help if you are the only care giver!
CARDIAC ARREST (Most students get this wrong on exams)
Causes
Immediate CPR with
Caused by a variety of factors from - Hypoxia, high quality compressions
respiratory failure, toxins, blood clots, electrolyte
imbalances & others. They are commonly
described as Hs & Ts.
#1
Hypoxia Respiratory failure Toxins
Immediate CPR with chest compressions helps to

Cl - Cl -
Cl -
+ -
provide IMMEDIATE oxygen or perfusion to the
Na+
Na+ Na+
Blood clots Electrolyte imbalances

brain & vital organs in order to prevent damage
& evene DEATH!
Adult CPR
2 2
During CPR, compressions are

min min
Chest compression Immediately paused every 2 mins to assess

pulse.
KEY Numbers 10 seconds
Rate is 100 - 120/min NCLEX TIP

Depth of at least
2 - 2.4 inches (5 - 6 cm) NCLEX TIP
AED pads (8 years & older) How to SHOCK an Adult
Hands in center of chest lower half 1. Defibrillator pads are placed
Upper right chest near
of sternum
the shoulder 2. Call out & look to make sure
Breaths: everyone is clear
Left lateral chest near
Manual: 30 compressions the anterior axillary line 3. Continue chest compression
& 2 rescue breaths below the nipple immediately after the shock
Intubation: Every 6 seconds
without interruption
Upper right chest

0 00:00:00
AED
₂
O
00:06
LOWER HALF
OF STERNUM
NO IV sedation needed.
Left lateral chest
NO synchronized button.
That is for cardioversion
BLS & CPR II
Pediatric AED Infant CPR
1. Brachial pulse for 10 seconds

How to SHOCK a Child or less NCLEX TIP
Key terms
1 AED pad on the chest & Place a roll under
2. Call for help to activate an
1 on the back the shoulders
emergency response
DO NOT overlap or touch Slightly extended neck
3. 2 Minutes of CPR
pads
100 - 120 compressions
per minute TECHNIQUE 1
MEMORY TRICK Single Rescuer 30:2 NCLEX TIP
Two Rescuers 15:2

4. Retrieve an AED after 2 minutes STERNUM
of CPR (single rescuer)

TECHNIQUE 2
STERNUM
PRIORITY
Asystole Treatment
₂
O
1. High Quality CPR Priority

2. Epinephrine every 3 - 5 minutes
Kaplan Question
3. Intubate & Ventilate
Which artery does the nurse
5
min
4. Treat the causes

EPINEPHRINE
Cl - Cl -
Cl -
+ -
use to assess the pulse rate of

Na+
Na+ Na+
an infant client during cardio-

pulmonary resuscitation?
Side Note
Brachial artery Brachial artery
NO shocking ASYSTOLE
Asystole (flat line) NCLEX TIP
PEA (pulseless electrical

activity)
Post-resuscitation Care
PEA
(pulseless electrical activity)
CPR with Pregnancy

Key terms
Comatose/
NCLEX TIP not following commands
Chest compression slightly higher Priority intervention:
on the sternum - Cold fluids for
Uterus: manually displaced to therapeutic hypothermia
6 hours
left side or place a rolled blanket
under right side
NOT SUPINE
NCLEX TIP
C C
Priority, if circulation does no return after 4 minutes then
#1 PRIORITY
an immediate C-section must take place typically within
5 minutes of starting CPR
COMATOSE COLD FLUIDS
not following Commands therapeutic hypothermia
PRIORITY
4
mins
5 mins
Burns
Types & Causes Care for Minor Burns

Burn injuries caused by direct tissue damage C C C
from exposure to: Cool water Cover the area Clothing removal
• Sun
• Chemicals
• Thermal (boiling liquids)
• Electricity
Prehospital Care
ANTIBIOTIC
C - Cool water
OINTMENT
� Briefly soak area

As you know the skin is made of 3 layers - • NO ice, creams, antibiotic
ointment to open skin
Epidermis, Dermis, & subcutaneous tissue
!
!
!
(that fatty bubble looking tissue) C - Cover area “Clean dry cloth” HCP remove anything
sticking to the skin
under the skin we find fascia, muscle, & bone.
C - Clothing & Jewelry removal
• Not adhered
Epidermis
Dermis Saunders
The nurse instructs firefighters
Subcutaneous tissue that in the event of a tar burn,
which is the immediate action?
• Cooling the injury with water
First-degree (superficial) Chemical burn injury... The nurse

REMOVING ALL
• Dry with blanchable redness instructs the employees that
which is the first consideration
Second-degree (partial thickness) in immediate care?
• Painful Blisters NCLEX TIP • Removing all clothing,
! including gloves, shoes,
• “Red, moist, shiny fluid filled vesicles” and any undergarments
Third-degree (full-thickness)
Kaplan Question
!
• Dry waxy white, leathery, or charred
black color, Non-blanchable
The nurse is caring for a client
Fourth-degree (full-thickness) with full thickness burns
covering 20% of their body.
What is the priority of care
after ensuring a patent airway:
! ! ! ! !
! !
! ! !
!
● IV fluids
! ! ! !
Notes
Major Burns
Pathophysiology
Saunders
Massive tissue damage & cellular destruction leads to
widespread systemic inflammation that increases vascular Extensive burn injury ... 45% of
total body surface area… 45%
permeability (leaky blood vessels that fill up the body like a
planning for fluid resuscitation, !
water balloon). This results in low fluid volume within the the nurse should consider that
blood vessels leading to Hypovolemic Shock & then death! fluid shifting to the interstitial !
!
spaces is greatest during which
Low fluid volume
time period?
18 - 24 hours
! • Between 18 and 24 hours
after the injury
!
!
Signs & Symptoms
First 24-hours Over 5.0

Saunders
HEMATOCRIT
K
High Potassium (Hyperkalemia)
Severe burn injury that
Over 5.0
covers 35% of the total 60% (0.60)
� Potassium Priority Pumps heart
� HIGH Potassium = HIGH Pumps body surface area (TBSA).
� Tall, Peaked T Waves on ECG The nurse is most likely to
NCLEX TIP
note which finding on the
Fluids FLOW - electrolytes GO!!!
Low Sodium (hyponatremia) HEMOGLOBIN HEMATOCRIT
laboratory report?
Below 135 NCLEX TIP 12-18 normal 36-54% normal
!
• Hematocrit 60% (0.60)
Elevated H/H
� Hemoglobin: 12 - 18 normal
! Na
!
� Hematocrit: 36 - 54% normal
Treatments 1 2 3
≥ 30 mL/hr
90
KEY Term
LACTATED RINGER’S 0.9%
Sodium Chloride
250 mL
#1 Intervention first 24-hours

IV Lactated Ringer’s (LR) solution
IV Normal Saline Saunders
A client is undergoing fluid
replacement after being burned
on 20% of her body 12-hours LACTATED RINGER’S
PRIORITY ago… blood pressure is 90/50, a

pulse rate of 110, and a urine
IV Lactated Ringer’s IV Normal Saline output of 20 mL over the past
(LR) solution (0.9% sodium Chloride) hour. The nurse ... anticipates
which prescription?
Increasing IV Lactated
LACTATED RINGER’S Ringer’s solution
NaCl 0.9%
#1
Administer enteral feedings ≥ 30 mL/hr
Once bowel sounds return
Kaplan Question
Assessment of ≥ 90 Systolic
Fluid Resuscitation
≥ 30 mL/hr
90 Patient with burns who is
immunocompromised….
1. Urine output
30 mL/hr or MORE NCLEX TIP What precautions should be
taken to prevent ... infection?
2. Blood pressure
(90/systolic Or MORE) Avoid placing fresh
3. Heart rate less than 120/min. < 120/min flowers or plants in or
near the client’s room
Burns - Rule of 9’s
& Rehabilitation Phase
Rule of 9’s Rehabilitation Phase

The Rule of 9’s is used to quickly estimate the Happens after the wounds fully heal & typically
percentage of the body affected by a burn, called takes around 12 months or so depending on the
Total Body Surface Area (TBSA). Used in order to severity of the burn.
calculate the necessary fluid resuscitation needed.
RULE OF NINES
4½% 4½%
4½%
Don’t let
4.5% anterior 9% 9%
THE NCLEX TRICK YOU

4½%
4½%
4½%
4½%
4.5% posterior
9% 9%
1%
9% 9% 9% 9% 9%
Key point
Infection is NOT a big risk
W W
RULE OF NINES
4½% 4½%
4.5% front 9% 9%
4.5% back
4½%
4½%
4½%
4½%
9% 9%
1%
9% 9% 9% 9% 9%
W W
WATER-BASED LOTION HELPS Wear PRESSURE GARMENTS
RULE OF NINES
4½% 4½%
9% front
Water based
9% 9% LOTION
9% back
4½%
4½%
4½%
4½%
9% 9%
1%
18% 9% 9% 9% 9%
RULE OF NINES
Patient Education NCLEX TIPs
4½% 4½%
W - Water-based lotion helps

1%
9% 9%
4½%
4½%
4½%
4½%
9% 9%
W - Wear pressure garments

1%
For the perineum

9% 9% 9% 9%
E - Exercise daily
(Range-of-motion)
Once the total body surface area is calculated
then the volume needed for emergency fluid
resuscitation within the FIRST 24-hours can be
calculated using the Parkland Formula
Parkland Formula
40.0
0
4 mL x kg of body weight x TBSA %
4 mL body weight %TBSA

Burns
Top Missed Question
Top MISSED Questions

Client has full thickness burns to
the all posterior body surfaces.
4½ %
Using the rule of nines, calculate

9%
4½ %
4½
%
the % of total body surface area
9%
4.5% + 18% + 9% + 18%
= 49.5% TBSA
affected.
Posterior body surfaces:
9% 9%
Head = 4.5%
Back = 18%
Right & left arm = 9% 50% of the body
Right & left leg = 18%
Answer = 49.5% TBSA
Client has partial thickness

burns to the anterior legs &
perineum.
Using the rule of nines, calculate
the % of total body surface area
4½%
affected.
9% 1% peri-area
18% Right & Left leg
4½%
4½%
9%
1% + 18%
1%
= 19% TBSA
Answer = 19% TBSA

9% 9%
.00
100
Client weighed 100 kg with 19%

TBSA… calculate the lactated 4 mL 100 Kg 19%TBSA
ringers fluid resuscitation
needed? 3,800 mL 3,800 mL
4 mL x 100 kg x 19 TBSA
LACTATED RINGER’S LACTATED RINGER’S
Answer = 7,600 ml
(within the first 24 hours)
8 hours 16 hours
Antidysrhythmics I
Cardiac Pharmacology
Class Drug Name Mainly for Image of ECG Strip

Class 1 Procainamide V Tach &
Sodium-channel blockers & Lidocaine V Fib
Class 2 Propranolol Atrial Fibrillation

Beta blockers Atrial Flutter
HTN (hypertension)
Class 3 Amiodarone V Tach &

Potassium-channel blockers V Fib
Class 4 Verapamil Atrial Fibrillation

Calcium-channel blockers Diltiazem Atrial Flutter
Nifedipine HTN (hypertension)
Others Adenosine SVT
Digoxin A Fib
(cardiac glycoside)
Atropine Symptomatic
(anticholinergic) Bradycardia
Top Missed Question
Key Points Which drugs do we teach slow

position changes due to
orthostatic hypotension?
Select all that apply.
Dizziness
?
1. Atenolol
Teach SLOW position changes 2. Atropine
3. Amiodarone
4. Amlodipine
5. Digoxin
NORMAL
HIGH
LOW
Hypotension - must reassess the BP every hour

NORMAL
6. Diltiazem
HIGH
LOW
When BP is LOW - we got to go SLOW! 7. Furosemide
MEMORY TRICK
Think ABCD start on TOP of the heart affecting atrial rhythms.
Think LAP like in your lap, since these drugs affect ventricular rhythms.
Drug Name Indication & Key Terms:

A
Atropine Symptomatic Bradycardia
L
Adenosine SVT (supraventricular tachycardia)
Lidocaine V Tach & V Fib
SE: Low BP, Low Platelets
Hypertension, SVT, Tachycardia,
B
Beta Blockers
“Propranolol” A fib & A flutter SA node
A
SE: LoL = Low BP, Low HR, bronchospasm AV node Amiodarone V Tach & V Fib
SE: Low BP, Low HR,
C
Ca Channel Blockers Hypertension, SVT, Tachycardia, Pulmonary TOXICITY!!!
“Verapamil” “Diltiazem” A fib & A flutter
SE: Low BP, Low HR, dizziness
P
Procainamide V Tach
SE: Low BP, Low Platelets
D
Digoxin A fib & Heart Failure
SE: Toxicity (NV, Vision changes)
Atropine
Symptomatic Bradycardia
Drug name: Memory tricks Side Note
AtroPINE ATROPINE
Symptomatic bradycardia
ATROPINE
If drugs do not work to fix the problem, then we

Indication: have to put the patient on external pacing:
Given to speed up a slow heart rate with
Key word 1st 2ⁿd

Correct sequence:
1. Atropine
Symptomatic ATROPINE
2. External pacing
bradycardia
MOA:
Atropine acts to increase the heart rate by blocking the
action of the vagus nerve to block the PNS (parasympathetic
Signs: Symptomatic bradycardia nervous system) REST & DIGEST, and turns ON the SNS
?
? (fight & flight) in the heart like flicking a light switch.
Mental Status changes
?
? ?
?
1. Confusion
2. Irrritability
3. Agitation
SNS
ATROPINE
PNS
Parasympathetic nervous system
Key points
Atropine is effective when we see normal Sinus
rhythm and reversal of the sympoms. They will Common NCLEX Question
show you normal sinus rhythm like this & no Atropine for a client with a heart rate of 38,
more hypoxic symptoms, like confusion, agitation, bp of 88/65, reports confusion and dizziness.
Which ECG strip would show medication
hypotension or synocope. effectiveness?
1. 60-100
Normal Sinus rhythm R peak x 10
and reversal of the symptoms 2.
8 x 10 = 80
3.
ATROPINE
4. CORRECT
Vasopressors
Alpha & Beta Physiology
VasoPRESSors - PRESS on the vessels

VasoPRESSors - PRESS on the blood vessels,
Goes back to the heart
Main Vasopressors
increasing blood pressure in order to squeeze
• Epinephrine
• Norepinephrine
oxygen rich blood back to the CORE of the body
• Vasopressin to perfuse the vital organs (sort of like
• Dobutamine squeezing a toothpaste bottle).
• Dopamine
Indication
Key Receptors: Alpha & Betas
Increase BP Cardiac Arrest Shock Mode of Action
NORMAL
They work by activating
HIGH
LOW
NORMAL
NORMAL
HIGH
LOW
Alpha & Beta receptors

HIGH
LOW
ACLS
Dobutamine
inside the heart & blood
vessels
Norepinephrine
EPINEPHRINE
EPINEPHRINE
Vasopressin
Alpha 1 - Constriction of Vessels

Alpha 1 - Anaconda (memory trick)
• Squeezing down the blood vessels so blood is pushed back to the heart.
Alpha Agonist
• think AGonists ADD to the BP to increase it (example: vasopressors)
Alpha Antagonists
• are ANTI constriction - less constriction = less pressure to lower BP (example: clonidine)
Beta 1 = 1 Heart
Beta Agonists - think AGonists ADD - Faster heart rate. (example: Vasopressors)
• Positive Chronotropic (chronos = time) more beats per minute.
• Positive INOtropic = more FORCEFUL beats, which increased Cardiac OUTPUT (increased
blood coming OUT of the heart to perfuse the body)
Beta Antagonists - are ANTI heart, used to decrease the HR & BP (example: beta blockers) NORMAL
• Negative Chronotropic - Less Beats

HIGH
LOW
• Negative Inotropic - Less force
Beta 2 = 2 Lungs Indication Alpha 1 Beta 1 Beta 2

Beta 2 Agonist Anaconda 1 heart 2 Lungs & Dilation
Constriction • Chrono - High HR Big Lungs
• think they ADD to the lungs - dilating • Inotropic - C.O. & Vessels
both the vessels & bronchi - like a big
BIG
Septic shock &
balloon or beach ball Epinephrine Cardiac arrest
Medium Small
(example: Vasopressors & Albuterol)

Norepinephrine Septic shock BIG Medium Small
Vasopressin
Desmopressin
Hypovolemic shock - - -
Dopamine Cardiogenic shock Med.
BIG Small
Dobutamine Cardiogenic shock Small BIG Medium

Antidysrhythmics II
ABCD’s - Atrial Rhythm drugs
MEMORY TRICK Notes
A
B SA node
Think ABCD start on the
TOP of the heart affecting
atrial rhythms affecting
C AV node
the SA or AV node
D L
A
P
Drug Name Indication & Key Terms: TOP MISSED Test Question
A Atropine Symptomatic Bradycardia Atropine for a client with a heart rate of 38,
bp of 88/65, reports confusion and dizziness.
Which ECG strip would show medication
effectiveness?
Puts the heart rate really HIGH like on TOP of “a PINE” tree for
60-100
atroPINE. 1.
Given for: ‘’Symptomatic Bradycardia’’ below 60 BPM with signs 8 x 10 = 80

of low oxygenation like mental status changes (confusion, 2.
Evenly Spaced
altered, agitation) or pale blue skin signs. Goal is to get back to
NORMAL sinus rhythm! 3.
<60
0₂
0₂ 4.
0₂
0₂
CORRECT
Drug Name Indication & Key Terms: 1 2
A
KEY Points
Adenosine SVT (supraventricular tachycardia)

1. Give it FAST = IV push in
1-2 seconds NCLEX TIP
2. Saline Flush immediately AFTER
DEcreases the heart rate, like putting it into a DEN (for foxes) or
Downstairs.
Given for:
SVT - Supraventricular Tachycardia
* Key points:
Know how this rhythm looks! SVT = Super Fast!
Give it FAST = IV push in 2 seconds followed by flush
Super Fast = SVT
B Beta Blockers
“Propranolol”
Hypertension, SVT, Tachycardia,
A fib & A flutter
SE: LoL = Low BP, Low HR
Common Question
What drug is causing this rhythm?
Propranolol
Beta blockers end in “-LOL”
Memory trick: Lower the 2 L’s - Low HR & Low BP
Given for: <60
Hypertension & to put the brakes on fast rhythms like SVT, tachycardia, A fib, & A flutter. 5 x 10 = 50
Side Effects: 1 2 3 4 5
• B - Bradycardia (HR below 60 BPM) & low BP
• B - Bronchospasm (avoid asthma & COPD)
• B - Blood glucose masking s/s of low sugar
• B - Bad for clients in end stage heart failure
* Orthostatic hypotension (dizziness upon standing) - teach slow position changes!
Antidysrhythmics III
ABCD’s - Atrial Rhythm Drugs
C
C C
Ca Channel Blockers Hypertension, SVT, Tachycardia, Calcium Contracts the muscles
“Verapamil” “Diltiazem” A fib & A flutter
Calcium
Ca
Since calcium contracts the muscles, when calcium blocked with CCBs, it
calms the heart
Memory Trick: CCBs lower the Couple heart vitals: HR & BP
Given for:
Hypertension, tachycardia, SVT, A Fib, & A Flutter
Side Effects:
Orthostatic hypotension (dizziness upon standing) - teach slow position changes
3 Common Questions
Q1: Intended EFFECT for Q2: Priority adverse effect Q3: Most important patient
Diltiazem? to watch for when giving teaching when giving
Amlodipine? Verapamil?
Ventricular rate decreased Dizziness Slow position changes
from 160 to 70s
Q1: Intended EFFECT for Q2: Priority adverse effect
Diltiazem? KEY WORD
to watch for when giving
Q2: Priority adverse effect Q3: Most important patient Amlodipine?
to watch for when giving teaching when giving Slow position changes
Amlodipine? Verapamil? Ventricular rate decreased Dizziness
Dizziness
160 70 beats/min Slow position changes
from 160 to 70s
Diltiazem
Drug Name Indication & Key Terms: D’s for DEEP Contraction
D Digoxin A fib & Heart Failure
SE: Toxicity (NV, Vision changes)
DIGOXIN DEEP contraction
Digoxin Digoxin
Is a TOXIN so monitor levels - under 2.0 is SAFE.
It DIGs for a deeper heart contraction to help the heart contract more
forcefully & decreases the heart rate (NOT Blood pressure), so no need
for slow position changes
Main Side Effect = Toxicity Key Sign Common NCLEX Question

Max Range 2.0 Report "dizziness & lightheaded" Q1: A client on digoxin having difficulty
1st signs of toxicity: reading a book or some type of vision
Anorexia Bradycardia problem
Nausea / Vomiting
Vision changes (difficulty reading)
Max 2.0
Digoxin
Creatinine! Over 1.3 = bad kidney
Antidysrhythmics IV
LAP - Ventricular Rhythm Drugs
L Lidocaine
SA node
Think LAP lik in your lap,
A Amiodarone AV node since these drugs affect
ventricular rhythms
L
P Procainamide A
P
Mainly give for those deadly ventricular rhythms:

• Ventricular Fibrillation (V Fib) LOW cardiac OUTput
Vfib LOW oxygen OUT to the body
• Ventricular Tachycardia (V Tach)
Vtach
0₂
Memory Trick:
Any rhythm starting with a V = VERRRY deadly.
Since the ventricles are responsible for all the Cardiac OUTPUT
meaning OXYGEN rich blood OUT TO the body, so low Cardiac OUTput
means Low oxygen OUT to the body.
Lidocaine
“Cain” Calms the ventricles. Priority
L Lidocaine Given for:
V tach, & V fib mainly, but also can work for
Key Point SVT, A fib, & A flutter.
LIDOCAINE
HYPOtension
Lidocaine Toxicity
GLASGOW COMA SCALE
EYE OPENING VERBAL RESPONSE MOTOR RESPONSE
1st
Neuro checks are a PRIORITY
Amiodarone Side Effects

A Amiodarone Typically given 2nd if Lidocaine does not
Neg. Chronotropic = Less beats
work. This is because of its life-threatening
Key Point
TOXIC effects!
<60
Pulmonary toxicity Memory trick

“dry cough & dyspnea”
“difficulty breathing while Neg. Dromo = Less Electrical impulse
ambulating”
“shortness of breath”
AMIODARONE
P Procainamide
ESTED
O NLY T
OMM
NOT C
‘’Cain’’ calms those ventricles just like Lidocaine but this drug PROCAINAMIDE
is becoming less & less popular in the hospital setting &

therefore not commonly tested.
Adenosine
Drug name: MEMORY TRICK Indication:

1st line drug to treat
- supraventricular tachycardia
AdenoSINE
Puts the HR Down 150 beats/min
in a DEN with aDENosine
MOA: SUPRAventricular tachycardia

SUPER tachy heart rate
It works by slowing impulse conduction through the AV

node to slow down the heart rate. Therefore can work too
well & stop the heart all together - soo SAFETY is the main
concern.
KEY Points
SVT ORDER of treatment

1. Vasovagal maneuver FIRST!
BEFORE adenosine (bearing down
1 2
like having a BOWEL MOVE-
Common TEST Question 2. Adenosine IV push “rapidly over 1-2

seconds” followed by a saline flush
Which drug does the nurse 3. Cardioversion to Convert the heart
anticipate the provider to order? rhythm - “Push the SYNCHRO-
SYNC
Adenosine #1 NIZE BUTTON” for Cardioversion

SYNC
Don’t let
THE NCLEX TRICK YOU
CARDIOVERSION DEFIBRILLATION
Cardioversion Defibrillation
C - Cardioversion D - Defibrillation - if you
C - Count a pulse D - Don't have a pulse
C - Controlled Rhythms D - Deadly rhythms (VFib & Vtach no pulse)
Synchronized button &sedation D - Don't Synch (shock away!)
PULSE NO PULSE
SYNC
SYNC
SYNC
Vasopressors
Top Tested Drugs
Epinephrine & Norepinephrine Kaplan Question

1st line drug Epinephrine
Epinephrine treatment is effective if ….
(Brand: Adrenaline) Answer: BP 130/67,
Apical HR 99, Cap refill
Norepinephrine HESI Question less than 2 seconds
(Brand: Levophed)
Epinephrine Less than 2s
Key difference
Initiates heart contraction
EPINEPHRINE
Epinephrine
EPINEPHRINE
Adrenaline
Cardiac Arrest during cardiac arrest
130/67 HR 99
• Asystole
• PEA (pulseless electrical Activity)
NORMAL
HIGH
LOW
Vasopressin & Desmopressin (ADH)
DI - Diabetes Insipidus
Indication DI - end up DIuresing or DraIning a lot of fluid
Vasopressin
Given for Diabetes Insipidus (DI)
Vasopressin - synthetic ADH
(AntiDiuretic Hormone)
where clients Drain a lot of fluid!
ADH is given to “Add Da H20” to
• ADH - Adds Da H20
the body, adding fluid volume &
not affecting the constriction of
Pressin - PRESSes that BP UP vessels.
Dobutamine & Dopamine

Indication
INOtropic
D’s for DEEP Contraction Given to treat cardiogenic shock - “INcreased cardiac contractility”
DEEP contraction Dopamine & Dobutamine
where the heart FAILS to pump! “INcreased forceful contraction”
These guys give a DEEPER heart
Dobutamine
DOPAMINE contraction, to increase that blood
out of the heart & to the body
(increasing cardiac output & BP)
HESI Question Kaplan Question

Dopamine Dopamine
Activates alpha 1 and beta 1 receptors Given for a patient with
hypotension, what indicates
Therapeutic Effects: effectiveness?
• Low doses act on dopamine
receptors 1 1 Answer: Increased cardiac output
• Moderate doses acts on beta 1
receptors
• High doses acts on alpha 1 and
ATI Question
beta 1 receptors
Dobutamine, Dopamine
Assess IV site hourly for s/s infiltration • Assess BP hourly
• Monitor vital signs
Notes
Inotropic, Chronotropic,
Dromotropic
D D D INOtropic
Digoxin Dopamine Dobutamine “INcreased cardiac contractility”
“INcreased forceful contraction”
3 D’s for DEEP contraction
Digoxin
DOPAMINE Dobutamine D - Digoxin
2.0 +
D - Dopamine
D - Dobutamine
Chronos
Clock
HR<60 Neg. Chronos - Neg time
Positive Chronos - Positive time
Faster HR - Positive Chronotropic
Lower HR - Negative Chronotropic
Dromo
Drums
Neg. Dromotropic -
stable heart rhythm
Inotropic Chronotropic Dromotropic

Drug Force of Heartbeat Rate of Heartbeat Rhythm of Heartbeat
A amiodarone + Pos. - Neg. - Neg.

B beta blockers
Atenolol - Neg. - Neg. - Neg.
C calcium CB - Neg. - Neg. - Neg.
C cardiac glycosides
+ Pos. - Neg. - Neg.
Digoxin
D dobutamine + Pos. X X
D dopamine + Pos. + Pos. X
E epinephrine + Pos. + Pos. X
5 Step
EKG INTERPRETATION
Heart rate Rhythm P wave PR interval QRS

(in seconds) (in seconds)
60 -100/min Regular Present before 0.10 - 0.20 Normal shape
each QRS, indentical (<5 small squares) < 0.12
P/QRS ratio 1:1
Heart Rate
8 x 10 = 80
1. Normal Sinus Rhythm
1 2 3 4 5 6 7 8
Rate - 60 -100
count the peaks - we have 8 here
multiply by 10 = 80 beats!
Rhythm
2. Rhythm - R peaks are evenly spaced apart. R R-R int. R R R R R R
To quickly measure this simply grab a paper

& mark 2 R peaks then just march it out.
The R peaks should be even every time.
P Wave
R R
3. P wave - which is our atria contracting

is it present? & does it have its buddy QRS?
P T P T
we need a P with QRS every time
Q Q
S S
PR interval (in seconds)

R
4. PR interval - basically measures the 0.2 sec
time it takes between atrial contractions

0.5 mV
5 mm
& ventricular contraction should be 5 mini P
boxes or less - or .10 - 2.0 seconds here. PR int.
QRS (in seconds) R-R int.
0.2 sec
5. QRS - Ventricles contracting

0.5 mV
5 mm
PR ST
seg. seg.
Is it present, upright & TIGHT! P T
Should NOT be wide should only be PR int. Q ST int.

S
3 boxes - .12 seconds here. QRS
int.
QT int.
9 ECG Strips on the NCLEX
1. Normal sinus rhythm
Treatment:
None - continue to monitor
Causes:
Being healthy
Memory tricks
Normal beat - evenly spaced
2. Bradycardia
Treatment:
BRADY Bunch Atropine ONLY if symptomatic
old TV show (slow times)
showing low perfusion (pale,
cool, clammy)
<60 Causes: ATROPINE
Vagal maneuver (bearing down),

Memory tricks
meds (CCB, Beta Blockers)
BRADYcardia
Below 60/min
3. Ventricular Fibrillation (V Fib)

Treatment:
1. V Fib - Defib #1 Defibrillation
immediately Stop CPR
to do it & before drugs!
*NO synchronization needed
2. Drugs: LAP - Lidocaine, L A P
Amiodarone, Procainamide
Causes:
Memory tricks Untreated V Tach, Post MI, LIDOCAINE
AMIODARONE
PROCAINAMIDE
E+ imbalance, proarrhythmic meds

Fib is flopping- squiggly line
4. Ventricular Tachycardia (V Tach) Memory tricks

Causes:
Post MI, Hypoxia,
Low potassium, Low magnesium
C
Treatment: C - Count a pulse
C - Cardiovert
1. Early Defibrillation! NCLEX TIP *Synchronize First
Apply defibrillator pads & Sedation
Call out & look for everyone to be
D
CLEAR!
Shock & IMMEDIATELY continue
chest compressions
Memory tricks D - Dead - NO PULSE
2. When to Shock? NCLEX TIP
D - DEFIB!!
V Tach with No pulse = Defibrillation
V Tach Tombstone pattern
*NO Synchronize
V Tach with Pulse = Cardioversion D - Don't wait
9 ECG Strips on the NCLEX II
5. Atrial Fibrillation (A Fib) Digoxin

Causes:
Valvular disease, Heart failure, Pulm. HTN,
COPD, after heart surg. A T
Treatment:
Max 2.0
1. Cardioversion (after TTE to rule out clots)
*Push Synch 60
2. Digoxin - Deep Contraction
Check ATP Before giving:
A - Apical pulse 60
40 kg
T - Toxicity (Max 2.0 range) visual disturbances,

N/V, Anorexia P
P - Potassium below 3.5 - HIGHER risk for
Memory tricks toxicity
< 3.5
3. Anticoagulants: Warfarin (monitor INR, Vit.
No P wave = Fibrillation FloPPing K antidote, moderate green leafy veggies)
Potassium
K+
6. Atrial Flutter (A Flutter) Causes:

Valvular disease, Heart failure, Pulm. HTN,
COPD, after heart surg.
Treatment:
DIGOXIN
1. Cardioversion (after TTE to rule out clots)

*Push Synch
2. Digoxin - Deep Contraction
Max 2.0
Check ATP Before giving: 60
A - Apical pulse 60 40 kg
T - Toxicity (Max 2.0 range) visual disturbances,

N/V, Anorexia < 3.5
K
P - Potassium below 3.5 - HIGHER risk for
Memory tricks
Potasssium
toxicity
3. Anticoagulants: Warfarin (monitor INR, Vit.
K+
A FluTTer = sawTooTh K antidote, moderate green leafy veggies)
7. SVT - Supraventricular Tachycardia KAPLAN

Which medication should be held 48-hours
Causes: prior to an elective cardioversion for SVT?
Stimulants, Strenuous exercise, hypoxia, Digoxin due to increased ventricular
irritability
heart disease
Client with SVT has the following
Treatment: assessment data: HR 200, BP 78/40, RR 30
1. Vagal Maneuver (bear down like Priority action: Synchronized

cardioversion
having a bowel movement, ice cold
stimulation)
PRIORITY
2. Adenosine - RAPID PUSH & flush
Memory tricks with NS - HR may stop
3. Cardioversion - *Push Synch
Super Fast = Supraventricular
8. Torsades de Pointes Memory tricks
M
Magnesium
Causes: Magnesium
Post MI, Hypoxia, Low magnesium Mg+

Treatment:
Magnesium Sulfate NCLEX TIP
M
Mellows out the heart
Memory tricks
Tornado Pointes
9 ECG Strips on the NCLEX III
9. Asystole - Flatline
Epinephrine, Atropine, & CPR

*NO Defibrillation
(NO shock) NCLEX TIP
Memory tricks
Assist Fully! … patient is flatlined
R R
R NCLEX Key Terms
PP PP P
Q
Q Q S
S S
1. P wave = Atrial rhythm 4. “Bizarre” - Tachycardia

3.
Question:
Asystole
2. QRS wave -Ventricular rhythm Ventricular Tachycardia
Question: “Bizarre rhythm with wide QRS complex”

Answer: Ventricular Tachycardia
“Lack of QRS complexes”
R
Q
Answer: Asystole 5. “Sawtooth” - Atrial Flutter
“Wide bizarre QRS complexes”
S
3.
Answer: V Tach
3. “Chaotic or unorganized” - Fibrillation

V Tach
Question:
A FluTTer = sawTooTh
“Chaotic rhythm with no P waves”

Answer: Atrial Fibrillation
Atrial Flutter
“CHAOTIC rhythm without QRS complexes”

Answer: Ventricular Fibrillation
Atrial Fibrillation
If you know these, you will pass the NCLEX! NCLEX TIP
Normal sinus rhythm Bradycardia Ventricular Fibrillation (V Fib)
Ventricular Tachycardia (V Tach) Atrial Fibrillation (A Fib) Atrial Flutter (A Flutter)
3.
SVT - Supraventricular Tachycardia Torsades de Pointes Asystole - flatline

EKG Quick view
9 strips to know for the Nclex
Normal sinus rhythm
Bradycardia
Ventricular Fibrillation (V Fib)
Ventricular Tachycardia (V Tach)
Atrial Fibrillation (A Fib)
Atrial Flutter (A Flutter)
SVT - Supraventricular Tachycardia
Torsades de Pointes
Asystole - flatline
Heart Sounds &
5 EKG Lead Placement
Memory Trick
APETM
Heart Sounds
“All Pigs Eat Too Much”
AORTIC PULMONIC
A - Aortic (2nd Intercostal Space
(2 Intercostal Space
nd
P - Pulmonic L Sternal Border)
R Sternal Border)
E - Erb’s point
T - Tricuspid
M - Mitral
TRICUSPID
(3nd or 4th Intercostal Space
L Sternal Border)
ERB’S POINT
(3rd Intercostal Space MITRAL
L Sternal Border) (5th Intercostal Space
Midclavicular Line)
5 EKG Lead Placement

QRS Complex
R
Memory Trick
P PR Segment ST Segment T White on Right
Smoke over Fire
Brown in the Middle
PR Interval
Grass under sky (white)
Q
S
QT Interval
Proper 12-Lead Placement for Left Side of Chest

v1 4th intercostal space to the right of the sternum
v2 4th intercostal space to the left of the sternum
v3 directly between the leads V2 & V4
v4 5th intercostal space at midclavicular line

v1 v2 v
3
v5 level with V4 at left anterior axillary line v4R v6
v4 v5
v6 level with V5 at left midaxilary line

(directly under the midpoint of the armpit)
v4R 5th intercostal space, right midclavicular line
Hypothermia
Pathophysiology
Occurs when core body temp is less than 95oF (35oC).

The body basically becomes like a popsicle with all the
organs freezing over & shutting down being unable to
compensate for heat loss! The nearly frozen heart muscles
(myocardium) becomes very irritable leading to DEADLY Ventricular Fibrillation (V Fib)
cardiac arrhythmias like Ventricular Fibrillation (V Fib)
Priority action: NCLEX TIP #1 #2
1. Attach cardiac monitor

2. Anticipate defibrillation
Signs & Symptoms
Everything is super cold & nearly frozen here!

Heart:
- Pulses are weak and thready from the cold heart muscles
Lungs:
- Wheezing may be heard indicating bronchospasms
- Crackles at bases of lungs indicating pulmonary edema
from fluid buildup!
Interventions
NCLEX TIP
1st 2 nd Airway: Anticipate Mechanical Ventilation
Circulation: Attach the cardiac monitor
(anticipate defibrillation)
Rewarming Process:
Airway Breathing Circulation Passive methods
Active internal warming
Warmed IV fluids via 2 large bore IV’s
Cover with warm blankets (head & trunk)
1st
2 nd
Frostbite
Pathophysiology
Tissue in the body basically freezes like a popsicle

Ice crystal formation
resulting in ice crystal formation within the cells of the body!
It’s like every cell becomes a little snowball.
There will be Vasoconstriction as the vessels contract
from the cold, leading to decreased blood flow
- vascular stasis
Signs & Symptoms
Superficial frostbite:
Skin blue, mottled, or waxy yellow
Deep frostbite:
Skin white, hard → Gangrene
Treatment
Rewarming PRIORITY NCLEX TIP

Warm water soaks (whirlpool)
Elevate affected extremity after
rewarming
Provide analgesic pain meds
NO pressure to the site
NO heavy clothing, blankets
NO massaging, rubbing
NO occlusive dressings on wounds
NCLEX TIP
Shock
Memory trick
Pathophysiology S S
Shock is a critical condition 0₂ 0₂ Shock Severely low 0₂ 0₂

blood pressure
NORMAL
where the body has decreased 0₂ 0₂ 0₂
HIGH
LOW
0₂ 0₂
0₂
0₂
tissue perfusion evenetually NORMAL
leading to organ failure and
HIGH
LOW
death
4 Stages of Shock
5 TYPES OF SHOCK
1 2 3 4
I. Initial II. Compensatory III. Progressive IV. Irreversible 1. Septic shock
Septic shock caused by widespread Sepsis Septic shock
bloodborne infection - think Sepsis

I. Initial infection causes Septic shock
There is too little oxygen in the blood Anaerobic metabolism
to feed the organs, resulting in 2. Neurogenic shock

0₂
anaerobic metabolism, meaning

0₂
0₂
metabolism without oxygen - Neurogenic shock caused by spinal

Blood glucose
T-6
BUT s/s are absent in this stage cord injury T-6 or higher.
II. Compensatory
3. Hypovolemic shock (hemorrhagic)
The body is trying to compensate for the LOW oxygen,
So the heart will pump faster (tachycardia) & RR Hypovolemic shock (hemorrhagic) caused by blood
increases to get more oxygen (tachypnea) body loss like from a trauma or a gunshot wound or even
compensates with the sympathetic nervous system from surgery or burns
to speed up the vital signs & renin-angiotensin
activation to maintain BP and oxygenation to keep the
organs perfused
III. Progressive
Key sign 4. Cardiogenic shock
Cold and clammy skin Cardiogenic shock where the heart fails to pump like
PRIORITY NCLEX TIP in heart failure exacerbation or an MI heart attack
heart muslces are weak & fail to pump
IV. Irreversible
5. Anaphylactic shock
Death is imminent
Anaphylactic shock from a severe allergic reaction like
from a bee sting, eating seafood or something you
have an allergy to
Septic Shock
Pathophysiology
Septic shock Pathophysiology results from a sepsis widespread
bloodborne infection that overwhelms the body typically caused
by a bacterial infection like Pneumonia - infection in the lungs or
even UTI or kidney infection that gets worse. A systemic cytokine
release inside the bloodstream causes extreme vasodilation & fluid
Lorem
leakage from capillaries
Signs & Symptoms Memory trick
S S
Severely low blood pressure Severely low
Shock 0₂ 0₂
blood pressure
0₂ 0₂
0₂
0₂
0₂
NORMAL
NORMAL
HIGH
LOW
HIGH
LOW
Low Blood pressure

(Less than 80/systolic)
Cold, Clammy skin
(pale & cool extremities)
Delayed capillary refill ?
?
?
? ?
Mental Status change NCLEX TIP ?
Confusion ?
Disorientation
High WBC (over 10,000) <96oF
Temp. High or very low (96°F)

NCLEX TIP
>10,000
Treatment
Emergency treatment may include supplemental

oxygen, intravenous fluids, antibiotics, and
other medications.
Neurogenic Shock
Pathophysiology
The Autonomic nervous system is damaged resulting in the blockage Spinal Cord Injury
of the sympathetic nervous system which is supposed to Speed up
(T-6 or higher) NCLEX TIP
the vitals & vasoconstriction Only the parasympathetic system is
intact - which puts the breaks on the Vitals causing widespread
vasodilation & hypotension aturally, we see Low & slow vital signs
like low heart rate & low BP as Vasodilation occurs making it difficult
for blood to return BACK to the heart. This decreased blood flow
BACK to the heart leads to decreased blood flow OUT of the heart
asically decreased cardiac OUTput - meaning less oxygenated blood
OUT of the heart to the body & this Leads to poor tissue perfusion
T-6
from the lack of oxygen & impaired cell metabolism esulting in organ
failure & death.
Signs & Symptoms Interventions
Bradycardia NCLEX TIP PRIORITY

NORMAL
● IV Normal Saline
HIGH
LOW
P P (0.9% sodium chloride)
PNS Parasympathetic Puts the breaks Increase the blood pressure
on the vitals
<60
PNS
PNS
SIDE NOTE
● Spinal cord injury ABOVE T-6
Autonomic dysreflexia T-6
Saunder’s
A client is admitted to the hospital with Triggered by a full bladder, constipation, or tight
a diagnosis of neurogenic shock after a
traumatic motor vehicle collision.
fitting clothes - anything with constriction thus
Which manifestation best characterizes place Foley in spinal trauma patients to keep the
this diagnosis?
bladder empty and offer laxatives & loose clothes
Bradycardia can save a client with a Spinal cord injury
ABOVE T-6
<60
NCLEX TIPS
Low HR (bradycardia) Less than 60
Low BP (hypotension) Less than 80/systolic
Skin: Warm, Pink, & Dry
Hypovolemic Shock
Pathophysiology
Caused by anything that can lower blood volume - Think HYPO

- LOW blood or fluid volume from excessive fluid volume loss
through diarrhea, vomiting, or fluid shifts as in burn patients
& from bleeding (hemorrhage) from trauma like gunshot or
knife injury, or even surgery & GI bleed. HYPOvolemic shock
LOW blood volume
Signs & Symptoms
III. Progressive
Key Point
1. Hypotension (less than 80/systolic)
2. Tachycardia
Hypovolemic shock - As mentioned before -
3. Low central venous pressure
this is often seen in progressive stage & is an (normal 2-6 mmHg)
indication that the client is GETTING WORSE!
So you must Notify the healthcare provider
<80/systolic
Cold and clammy skin immediately & get some IV normal saline
PRIORITY NCLEX TIP started quickly! NORMAL
HIGH
KAPLAN LOW
Saunder’s
A client in shock develops a central
Which vital sign would alert the nurse venous pressure (CVP) of less than 2 1
st
to potential hemorrhage following a mm Hg. Which prescribed intervention

nephrectomy: should the nurse implement first?
HR 110
110 Increase the rate of intravenous
IV fluids
Interventions
Norepinephrine Norepinephrine
MAP >65 mmHG
88%
NORMAL
HIGH
LOW
PRIORITY = Hemodynamic stability

CRITICAL! DO NOT delay a new
1. LOWER head of bed right
bag of norepinephrine NCLEX TIP
away NCLEX TIP
NEVER place the HOB in MAP (mean arterial pressure) SpO2 = the sensor should be
High Fowler’s position Over 65 mmHg placed on the forehead instead
2. IV Normal Saline CVP (Central venous pressure) of extremities
(0.9% sodium chloride) 2 - 6 mm Hg
3. IV norepinephrine / dopamine
2-6 mmHG
Memory trick
1
st
Put the Head LOW in

2
nd
HYPOvolemic (hypotension)
NORMAL
HIGH
LOW
Cardiogenic &
Anaphylactic Shock
Pathophysiology Signs & Symptoms

Cardiogenic shock Saunder’s
The heart fails to pump blood out of the heart & to A client having a… myocardial infarction
the body like in a heart attack where heart muscles based on elevated troponin levels … the
nurse should alert the primary health
die or heart failure exacerbation - where the heart care provider because the vital sign
fails to pump C C
changes … are most consistent with
which complication? Refer to the exhibit.
CARDIOgenic shock CARDIAC fails Cardiogenic shock
Cardiogenic shock - Cardiac problem - Heart attack - MI heart

tissue DIES - heart FAILS to pump adequately. So just look at
the BLOOD Pressure here when clicking on the exhibit the low
Blood pressure lower & lower it goes!
Treatment Client’s Chart

Positive INOtropic = more FORCEFUL beats Time 11:00 a.m. 11:15 a.m. 11:30 a.m. 11:45 a.m.
Pulse 92 beats/min 96 beats/min 104 beats/min 118 beats/min

Dopamine
Digoxin
Resp. rate 24 breaths/min 26 breaths/min 28 breaths/min 32 breaths/min
BP 140/88 mm Hg 128/82 mm Hg 104/68 mm Hg 88/58 mm Hg
Dopamine & Digoxin which both have INOtropic

properties meaning it helps the heart to pump Saunder’s
more forcefully!
Client with heart failure exacerbation…
and suspected state of shock. The nurse
knows which intervention is the priority
for this client?
D - Dopamine (vasopressor) Administration of Digoxin
Caution:
Tachycardia D’s for DEEP Contraction
(over 100/min) NCLEX TIP DIGOXIN DEEP contraction
Arrhythmias
D - Digoxin Digoxin
Anaphylactic Shock Treatment

Severe allergic reaction - like from a
bee sting or peanut allergy.
NCLEX TIP
Anaphylactic shock - severe ALLERGIC reaction
Epinephrine
EPINEPHRINE
EPINEPHRINE
Adrenaline
EpiPen Auto Injector

Cardiovascular
• Thready, increased pulse rate, decreased blood pressure and orthostatic
hypotension, flat neck and hand in veins in dependent positions, diminished
Fluid Volume peripheral pulses, decreased central venous pressure, dysrhythmias

Respiratory
Deficit • Increased rate and depth of respirations, dyspnea
Neuromuscular
• Decreased central nervous system activity, from lethargy to coma, fever,
“HypOvolemia” depending on the amount of fluid loss, skeletal muscle weakness
(Low fluid volume) Renal
• Decreased urine output
Integumentary
• Dry skin, poor turgor, tenting, dry mouth
Gastrointestinal
• Decreased motility and diminished bowel sounds, constipation, thirst,
decreased body weight
Serum Blood Lab Findings
25%
• Increased serum osmolality, increased hematocrit
• Increased blood urea nitrogen (BUN)
• Increased serum sodium level
• Increased urinary specific gravity
Memory Trick:
• If Osmolality is HIGH = Body is DRY
• If Specific gravity is HIGH = Body is DRY
Cardiovascular
• Bouding, increased pulse rate, elevated blood pressure, distended neck
and hand veins, elevated central venous pressure, dysrhythmias
Fluid Volume Respiratory

• Increased respiratory rate (shallow respirations), dyspnea, moist crackles
Excess on auscultation
Neuromuscular
• Altered level of consciousness, headache, visual disturbances, skeletal
“Hypervolemia” muscle weakness, paresthesias
(High fluid volume) Renal & Urinary
• Increased urine output if kidneys cannot compensate
• Decreased urine output if kidney damage is the cause
Integumentary
• Pitting edema in independent areas, pale cool skin
Gastrointestinal
• Increased motility in gastrointestinal tract, diarrhea
• Increased body weight, liver enlargement, ascites
100%
• Decreased serum osmolality, decreased hematocrit, decreased BUN level
• Decreased serum sodium level
• Decreased urine specific gravity
Memory Trick:
• If Osmolality is Low = Body is Liquidy
• If Specific gravity is Low = Body is Liquidy
F&L Quick Notes: IV Solutions
Isotonic solutions
• Definition: when solutions on both sides of a selectively permeable membrane have
established equilibrium or are equal in concentration, they are isotonic.
• Human blood is isotonic thus very little osmosis occurs since isotonic solutions have
the same osmolality as body fluids & thus increase extracellular fluid volume.
Memory Trick:
• Iso-tonic Solutions
• I-so-Perfect (no fluid shift, “I’m so perfect” perfect balance)
• List of fluids:
• 0.9% sódio, chloride (normal saline)
• 5% dextrose in water (DWS)
• 5% dextrose in 0.225% saline (DSW/ 1/4 NS)
• Lactated Ringer’s (LR)
Hypotonic solutions
• Definition: when a solution contains a lower concentration of solute than another
more concentrated solution, then it is a hypotonic solution.
• These solutions have lower osmolality than body fluids.
• They cause the movement of water into cells by osmosis, swelling the cells like a BIG
fat hippo, and therefore should be administered slowly to prevent cellular edema
Memory Trick:
• HypO - tonic
• HippO - tonic = fluid swells the cell like a big hippo
• 0.45% sodium chloride (1/2 NS)
• 0.33% sodium chloride (1.3 NS)
Hypertonic solutions
• Definition: when a solution contains a higher concentration of solutes than
another less concentrated solution, then it is a hypertonic solution.
• These solutions have higher osmolality than body fluids
• They cause the movement of water outside the cells by osmosis, making the
cells skinny like a hyper person.
Memory Trick:
• Hyper - tonic
• Hyper person = very skinny cells like a hyper person is skinny
• 3% sodium chloride (3% NS)
• 10% dextrose in water (D10W)
• 5% dextrose in 0.9% sodium chloride (D5W/NS)
• 5% dextrose in 0.45% sodium chloride (D5W/ 1/2 NS)
• 5% dextrose in Lactated Ringer’s (D5LR)
5-11 Pain management
Patho Factors that influence pain
Nociceptors: Pain receptors on nerve endings
❖ Past experience.
that respond selectively to painful stimuli.
❖ Anxiety: decreases pain threshold.
Nociception: The transmission of pain.
❖ Depression: decreases pain threshold.
Chemical substances: some increase pain
❖ Age.
sensitivity some decrease pain sensitivity.
❖ Gender.
Cox 1: Mediates prostaglandin formation, platelet
❖ Culture: different cultures respond to pain differently
formation, provides gut protection from ulcers.
based on what they were taught to be appropriate.
Cox 2: Present in inflammation, pain and fever.
Inhibition will reduce symptoms of fever
inflammation and pain. Inhibits substance P.
Decrease pain sensation: Endorphins and
enkephalins, act as endogenous opioids. Effects of pain
Acute: Increased cardiac output, impaired insulin response, immune
supression, increased cortisol production, and increased fluid
Types of pain retention.
Chronic : Persistent malignant pain that
Chronic: Immune suppression, depression, disability, fatigue,
lasts longer than six months.
anger, inability to perform ADL’s.
Acute pain: Sudden onset of pain, specific
to injury. Lasts from seconds to six months.
Pharmacologic treatments
Non opioids
❖ NSAIDS: Mild pain. Ketorolac, sprix,
calador, ibuprofen.
❖ Acetaminophen: Can cause hepatotoxicity
can be given with NSAIDs.
Non pharmacologic treatments
❖ Ofirmev: IV acetaminophen, newly ❖ Cutaneous stimulation: TENS machine
approved for short term use IV piggyback. ❖ Massage
❖ Thermal therapies: Heat and cold
Opioids ❖ Distraction
❖ Tramadol ❖ Relaxation
❖ Tylenol 3 ❖ Guided imagery
❖ Meperidine ❖ Hypnosis
❖ Propoxyphene with tylenol ❖ Music therapy
❖ Oxycodone ❖ Alternative therapy: Acupuncture
❖ Fetanyl
❖
❖
Morphine
Dauladid Focused pain assessment
❖ Scale: 0-10
Other ❖ Timing: When did the pain start, what was happening
❖ PCA pump when it started?
❖ PRN medications ❖ Location: Where is the pain? Is it radiating?
❖ Multi modal: use of one or more drug ❖ Duration: How long have you had the pain?
❖ Routine admin: admin around the clock ❖ Quality: Is it dull, sharp, or stabbing?
❖ Topical ❖ Aggravating and alleviating factors: What makes it
❖ Local anesthesia worse? What makes it better?
❖ Intraspinal
5-11
www.Simplenursing.com
5-1
Fundamentals : Positioning
Purpose
To ensure client comfort and safety, while preventing complications related to the client's condition, treatment, or
procedure.
Fowler's position Lateral Lithotomy

Includes semi fowler's position Can be right or left sided. Most commonly seen in OB.
which is between 30-40 degrees What am i? What am I ?
and high fowler's which is 90 Right lateral means the right Patient is lying flat on their back
degrees. side of the patient is touching with knees elevated and hips
What am i? the bed, left lateral indicates level, often supported by
A position in which the head and the left side of the patient is stirrups.
trunk are raised 40-90 degrees. touching the bed.
Indications
Indications Gynecological procedures and
Indications GI issues, and rectal surgery. childbirth.
Cardiac issues, SOB, or NG tube.
placement.
Sim’s Position
A prone/lateral.
Prone Supine
What AM I?
Prone your on your tummy. You’re on your spine.
A position in which the patient

What am I? Supine is considered the most
The patient lies on his stomach natural “at rest” position.
lies on his side with his upper
leg flexed and drawn in towards
with his back up. The head is What am i?
typically turned to one side. A position where the patient is
the chest, and the upper arm
flexed at the elbow. Indications flat on his back.
Indications Drainage of the mouth after oral Indications

or neck surgery. It also allows Used in surgery for abdominal,
Administering enemas, perineal
for full flexion of knee and hip facial, and extremity procedures.
examinations, and for comfort in
joints.
pregnancy.
Trendelenburg Reverse Trendelenburg

“Upside Down.” What am i?
What AM I? Patient is in the supine position with the head of the
This position involves a supine patient and sharply bed elevated and the foot of the bed down
lowering the head of the bed and raising the foot. Indications.
Indications Indications
Used to treat hypotension, during gynecological Used in surgery to help promote perfusion in obese
and abdominal hernia surgeries, and in the patients. It can also be helpful in treating venous air
placement of central lines. embolism and preventing pulmonary aspiration.
5-1
www.Simplenursing.com
5-8
Sterile Technique
Purpose
Sterile technique is performed to drastically reduce and hopefully eliminate the threat of bacteria being introduced into a
wound, or catheter site. Thus reducing the risk for post procedure or post care infections, also called Nosocomial
infections, “meaning hospitals acquired.”
Education
Assessment Risks
❖ Educate the client to practice
good hygiene.
❖ Asses the need to perform ❖ Educate the client to ask for
❖ Risk for infection.
the procedure. analgesia before the pain
❖ Risk for impaired.
❖ Assess the site you will be becomes unbearable.
tissue integrity.
working on for presence of ❖ Educate the client on the signs
❖ Risk for pain.
current infection. and symptoms of infection and
❖ Risk for
❖ Assess for latex allergies, when to notify the HCP.
hypersensitivity
iodine or adhesive allergies.
reaction.
❖
Supplies
Assess pain level, and
administer analgesia
30-45mins prior to the ❖ Sterile kit
procedure for client comfort. ❖ Running water and soap
❖ Gloves (sometimes these are in your
kit)
Procedure
❖ A clean, dry surface
❖ Clean paper towels
❖ Check expiration date on package and perform hand hygiene.
❖ Open the kit with the special flap so that you are opening your kit away
from you.
❖ Pinch the other sections on the outside, and pull them back gently. DO
NOT touch the inside. Everything inside the pad or kit is sterile except
for the 1-inch border around it.
❖ Throw the wrapper away.
❖ Get sterile gloves ready
❖ Wash your hands again the same way you did the first time. Dry with a
clean paper towel.
❖ If the gloves are in your kit, pinch the glove wrapper to pick it up, and
place it on a clean, dry surface next to the pad.
Documentation
❖ If the gloves are in a separate package, open the outer wrapper and ❖ Date and time of procedure.
❖ Type of procedure.
place the open package on a clean, dry surface next to the pad.
❖ Any fluids or exudate on the site
❖ Put your gloves on carefully. you are working with. Also note
❖ Wash your hands again the same way you did the first time. Dry with a color of exudate or fluids, amount,
clean paper towel. and if there is any odor.
❖ Open the wrapper so that the gloves are laying out in front of you. But ❖ Follow hospital policy on dating,
timing and initialing dressing,
DO NOT touch them.
specimen, or catheter site.
❖ With your writing hand, grab the other glove by the folded wrist cuff. ❖ Document the client's tolerance to
❖ Slide the glove onto your hand. the procedure.
❖ Leave the cuff folded. Be careful not to touch the outside of the glove.
❖ Pick up the other glove by sliding your fingers into the cuff.
❖ Slip the glove over the fingers of this hand. Keep your hand flat and do
not let your thumb touch your skin.
❖ Both gloves will have a folded-over cuff. Reach under the cuffs and pull
back towards your elbow.
❖ Once your gloves are on, do not touch anything except your sterile
supplies. If you do touch something else, remove the gloves, wash your
hands again, and go through the steps to open and put on a new pair of www.simplenursing.com 5-8
gloves.
5-9
Wound care: wet to dry dressing change
Purpose
To maintain skin integrity, to prevent infection,provide comfort, maintain a moist environment, remove necrotic tissue if
appropriate, and prevention of complications associated with injury or surgery.
Assessment Risks Education

❖ Assess the wound for color, ❖ Educate the client to
excoriation, order, exudate or ❖ Risk for infection.
practice good hygiene.
drainage, sinus tracts to tunneling. ❖ Risk for impaired
❖ Educate the client to ask for
❖ Assess client's pain level and tissue integrity.
analgesia before the pain
administer analgesia 30-45 minutes ❖ Risk for pain.
prior to dressing change. becomes unbearable.
❖ Risk for
❖ Assess for allergies to latex, ❖ Educate the client on the
hypersensitivity
adhesive and iodine. signs and symptoms of
reaction.
infection and when to notify
the HCP.
Dressing removal
❖ Date and time dressing change was
performed.
❖ Perform hand hygiene.
❖ Why you changed the dressing.
❖ Put on a pair of non-sterile gloves.
❖ Carefully remove the tape. ❖ Document dressing assessment
❖ Remove the old dressing. If it is sticking to your skin, wet it with warm and wound location.
water to loosen it. ❖ Color, odor, exudate, drainage.
❖ Remove the gauze pads or packing tape from inside the wound. ❖ Document size of the wound, any
❖ Measure the wound in diameter and depth, also note any tunneling and tunneling, or sinus tracts, and
sinus tracts. Document these findings. approximation.
❖ Put the old dressing, packing material, and your gloves in a plastic bag.
❖ Document pain assessment before
and after dressing change.
Wound irrigation
❖ Put on a new pair of clean gloves.

❖ Use a clean, sterile gauze to gently clean the wound with warm water
and soap. From the top of the wound to the bottom of the wound and
outward from the incision in lines parallel. Wipe from the clean area to
less clean area.
Debridement
❖ Gently irrigate wound from top to bottom.
❖ Check the wound for increased redness, swelling, or a bad odor.
❖ Pay attention to the color and amount of drainage from your wound. Look ❖ Mechanical: Done during hydrotherapy,
for drainage that has become darker or thicker. with washcloths or sponges to remove
❖ After cleaning your wound, remove your gloves and put them in the eschar. May include wet to dry dressing
plastic bag with the old dressing and gloves. changes. Painful and may cause bleeding.
❖ Wash your hands again. ❖ Enzymatic: Application of a topical enzyme
ointment such as santyl directly on the
wound to remove necrotic tissue.
Dressing replacement ❖ Surgical: Excision/ removal of eschar and
necrotic tissue, via surgery in a sterile OR.
❖ Tangential: Excising very thin layers of
❖ Put on a new pair of non-sterile gloves. necrotic skin until bleeding occurs.
❖ Pour saline into sterile container.. Place gauze pads and any packing ❖ Fascial: Necrotic tissue is removed down
tape you will use in the container. to the superficial fascia, usually reserved
❖ Apply barrier cream. for very deep and severe burns.
❖ Squeeze the saline from the gauze pads or packing tape until it is no
longer dripping.
❖ Place the gauze pads or packing tape in the wound. Carefully fill in the
wound and any spaces under the skin.
❖ Cover the wet gauze or packing tape with a large dry dressing pad. Use
tape or rolled gauze to hold this dressing in place.
❖ Put all used supplies in the plastic bag. Close it securely, then put it in a
second plastic bag, and close that bag securely. Put it in the trash.
❖ Time, date and initial new dressing.
❖ Wash your hands again when you are finished. 5-9
❖ Document. www.Simplenursing.com
Labs
BMP Panel & Electrolytes
BMP Basic Metabolic Panel

Sodium (Na+) Swells the body
Potassium (K+) Potassium pumps the heart muscles
Na Cl BUN
Chloride (Cl-) Helps to maintain acid base balance
CO2 Helps to maintain acid base pH balance (too much can
(Carbon Dioxide)
HCO3
put the body in Acidosis) Memory trick: Carbon DiACID
Pushes the body into an alkalotic state
Glucose
(Bicarbonate) Memory trick: Bicarb Base
2 labs for 2 kidneys. High BUN over 20, usually means
K CO2/ HCO3 Cr
BUN & Creatinine dehydration. Creatinine over 1.3 = Bad Kidney (kidney injury)
70 - 110 Normal
Glucose Hyperglycemia (over 120) usually clients with uncontrolled diabetes,
Hypoglycemia (60 or less) brain will DIE! Very deadly
Electrolytes Labs Treatment
K+ 3.5 - 5.0 mEq/L Hyperkalemia Hypokalemia

P P P PHARMACOLOGY FOR HIGH K+ Potassium IV (Normal 3.5-5.0)
NCLEX TIP 1. IV Calcium Gluconate = Dysrhythmias 1. First Action = Heart monitor
Potassium Priority Pumps the heart 2. IV 50% Dextrose + Regular INsulin 2. Never push = DEATH
LAB: High or Low
3. Kayexalate (polystyrene sulfonate) 3. Only 10-20 mEq MAX per HOUR
Potassium (K+)
4. Dialysis IV!!! (IV Pump)
3.5-5.0 (normal)
Potassium 4. Slow infusion (if arm burns)
RITY
K+ PRIO
Common NCLEX Question

HIGH Potassium (5.0+) LOW Potassium (Below 3.5)
HIGH Pump LOW Pump Patient with chronic kidney disease missed 3 dialysis End stage renal disease… potassium 7.2, BUN 35,
sessions… potassium level of 8.1 … creatinine of 3.8, and urine output of 300 ml in 24
Peaked T waves, ST elevation Flat T wave, ST depress, U wave wide QRS complexes, heart rate of 58 & lethargy. hours. Which order is PRIORITY?
Which order should the nurse implement first?
1. IV Regular insulin R & 50% Dextrose

1. IV 50% Dextrose & regular insulin
2. IV loop diuretic
2. Sodium polystyrene sulfonate
O2 3. Dialysis
3. Hemodialysis
4. Put in for vacation time?
4. IV calcium gluconate
Normal ST elevation ST Depression
Na 135 - 145 mEq/L Ca 9.0 - 10.5 mEq/L Mg+ 1.3 - 2.1 mEq/L
S S C C M M
Sodium Swells the body with FLUID Calcium Contracts the muscles Magnesium Mellows the muscles
Sodium Calcium Magnesium
Na+ Ca Mg+
Ca 9.0 - 10.5 mEq/L Mg+ 1.3 - 2.1 mEq/L

Low calcium
Diarrhea
Low magnesium
Na 135 - 145 mEq/L 2 dance moves:
T&C
• Torsades De Pointes
& V Fib! NCLEX TIP
• T - Trousseau's • Hyperreflexia
Low Sodium - Low & Slow
Twerking arm when BP cuff on
• C - Chvostek’s • Increased DTR
Cheek smile when stroking face
• “Mental Status change” = PRIORITY
• Seizures & Coma HIGH magnesium
HIGH Calcium • Decreased DTR
• Respiratory Arrest Stones, moans & groans
Kidney Stones • Hyporeflexia
Constipation
HIGH sodium = Big & Bloated
Torsades de pointes
• Edema (swollen body) T C
• Increased muscle tone Trousseau's Chvostek’s
Twerking arm when BP cuff on Cheek smile when stroking face
• Flushed “red & rosey” skin
Ventricular Fibrillation
LABS NORMAL RANGE
Na+ 135 - 145 Sodium Swells the body
K+ 3.5 - 5.0 Potassium Pumps Heart
Cl- 97 - 107
Ca 9.0 - 10.5 Calcium Contracts Muscles
Mg+ 1.3 - 2.1 Mag. Mellows Muscles
Albumin 3.5 - 5.0 Liver
Creatinine Over 1.3 Bad Kidney
BUN 10 - 20 Kidney
Glucose 70 - 110 Hypogly = Brain Die
WBC 5,000 - 10,000 High = Infection
RBC (M) 4.7 - 6.1 (F) 4.2 - 5.4 Low = Anemia
Hgb (M) 14 - 18 (F) 12 - 16 Below 7 = Blood Trans
Hct (M) 42 - 52 (F) 37 - 47
PLTS 150k - 400k AsaParin, CloPidogrel
PT 11 - 12.5
aPTT 30 - 40
INR 0.9 - 1.2
Therapeutic Range while on Anticoags
aPTT 46 - 70
INR 2-3
* 3 x MAX range
Labs II
CBC - Complete Blood Count
Immunity - the defense system of the body to fight infection.

White Blood Cells
Normal: 5,000 - 10,000
(WBC)
Hgb
CBC Test
The whole blood in the blood vessels.

WBC PLT
Hemoglobin & Hematocrit
Hemoglobin: Oxygen carriers on the red blood cells.
(H & H)
HCT Hematocrit: the ratio of RBC & total blood volume.
Blood clotting proteins that help to stop bleeding by

Platelets
forming scabs, but also creates blood clots which can KILL!
(PLT)
Trick: Platelets Plug the bleeding
MemoryTRICK:
MEMORY
Hemoglobin Normal 12 - 18
Normal: 12 - 18
Risky: 8 - 11
• REPORT to HCP & Surgeon
02 Risky 8 - 11
(if before surgery)
• Bleeding & Anemia
Below 7
Malnutrition, Cancers
Below 7 = Heaven or blood transfusion

• Top S/S: NCLEX TIP
1. Pale skin: pallor, dusky skin tones
2. Cool Clammy skin
3. Fatigue, Weakness
Hematocrit - hemato creek

Hematocrit H/H: Ratio
Normal: 36 - 54% 1/3 ratio 12/36 ratio 18/54 ratio
Elevated Hct = Dehydration
Decreased Hct =
• Fluid Volume overload
1:3 12:36 18:54
• Bleeding, Anemia, Malnutrition
Saunder’s
Client with gastrointestinal (GI)
bleeding… laboratory results
hematocrit level of 30%. Which
RBC - Red blood cell count

action should the nurse take?
10 Hemoglobin
Report the abnormally
4 - 6 million
! !
low level
Low = Anemia, Renal Failure

• Iron (Fe+) 1
Abnormally low level
• Erythropoietin
High = Dehydration
! 10
• High Labs = Dry body
30%
Top 5 Toxic Drug Levels
1. Lithium 1.5 +
NCLEX TIP
2. Digoxin 2.0 +
HIGHEST risk for toxicity
3. Theophylline 20 +
Decreased renal function
4. Phenytoin 20 +
Creatinine Over 1.3 = Bad Kidney
(brand: Dilantin)
• Renal Failure
5. Kidney Killers: • Older Age
Creatinine Over 1.3 = dead kidney
� CT contrast Creatinine > 1.3
� Antibiotics: Vancomycin
& Gentamicin
CREATININE
Digoxin 2.0 +
Lithium: 1.5 + Top Signs of toxicity
Theophylline 20+
Top Signs leading to toxicity • Nausea & Vomiting Top Signs of toxicity
1. Extreme thirst • Vision changes • Seizures
2. Excessive urination “difficulty reading” T - Theophylline
3. Vomiting / diarrhea D - Digoxin T - Tonic Clonic seizures
D - Difficulty reading
D D T T
Digoxin Difficulty reading Theophylline Tonic Clonic seizures
A WB I
DIGOXIN
Theophylline
20+
Phenytoin 2.0 + Kidney Killers

Top Signs of toxicity (creatinine over 1.3 = bad kidney)
1. Ataxia - unsteady gait • CT Contrast
2. Hand tremors
Vancomycin
Gentamicin
• Mycin Antibiotics
3. Slurred speech
Notes
Labs III
WBC’s & Coagulation Panel
WBC - White Blood Cells
1. WBC Total Count

Normal: 5,000-10,000 Common Exam Question
Higher = Leukocytosis
• Which blood laboratory test results should the nurse report to the HCP?
• Steroids (prednisone) Select all that apply
Low = “Leukopenia”
1. Hemoglobin 6 g/dL
• Chemotherapy
• 2. Potassium 6.5 mEq/L 5,000 - 10,000
• Immunosuppressant Drugs
3. Sodium 150 mEq/L
• Lupus - Autoimmune Diseases
PRIORITY 4. White blood cells,
- Low Grade Fever = Priority 2,000 mm3
- Private Room
- No fresh fruits / flowers 100.4
5. Platelets 45,000 mm3
- Avoid crowds & sick people
- NO
2. CD4 Count
Norm: Over 200
Coagulation Panel
Never be more than
PLATELETS PTT INR these max ranges!
150k - 400k 30 - 40 0.9 - 1.2
!
!
HeParin WarfarIN
PTT
P P P
AsPirin CloPidogrel EnoxaParin
46 - 70 2-3
INR !
CLOPIDOGREL WARFARIN
ASPIRIN
<150k <50k
! NCLEX Question
! Client is on Warfarin with an INR of 4.5 …
Client on Heparin PTT of 100
! 1. Stop or Hold drug
2. Assess - bleeding
NCLEX 3.
STOP Assess Prep Report
4. Report to HCP
SAFETY FIRST! 1
ANTIDOTE
Focus on things that WILL KILL FIRST!
Notes
Labs IV
Cardiac Labs & Acid Base ABG
Cardiac Labs
T T B B
T - Troponin Over 0.5
TROPONIN > 0.5 TRAUMA TO HEART T - Trauma to heart muscles BNP >100 BIG STRETCHED
MUSCLES (CELL DEATH) OUT VENTRICLES
100
BNP - TEST
B - BNP - Over 100
10
B - Big stretched out ventricles

0.1
0.01
0 1 2 3
Acid Base ABG

A B
pH
pH
Acid “acidosis” Base “alkalosis”
7.35 7.45
B A NORMAL pH
Carbon Di-ACID PaCO₂ 7.35 pH 7.35 pH 7.45 pH 7.45 pH
35 45
A B
Alkalosis (Base) HCO₃
22 26
Respiratory Acidosis = Low & Slow Kaplan

breathing
Respiratory ALKalosis = FAST
Most Tested Cause for respiratory
breathing
Overdose (Low & slow RR)
alkalosis?
Opioids / Benzos (diazepam)
C - COPD Hyper
C - CO2 retained A - Alkalosis
Sleep apnea
Treatment: Breathing into a
Head Trauma PaCO2 35 - 45
paper bag- slow down breathing
Treatment:
lip breathing to blow off the CO2
alk alk alk & retain CO2
alk-alooosis
CO2
Alk alk alkalosis”
Severe Acidosis = HyperCapnic Hypoxia earliest sign

respiratory failure Mental Status changes:
Metabolic ALKalosis
Example: 1. Restlessness
Client with a Ph of 6 & CO2 of 65
2. Confusion
Treatment: 3.
1. HyperCap = Give BiPAP
Metabolic Acidosis:
PaO2 80 -100%
Diarrhea
PaO₂
HIGH CO2 80 100
HyperCapnic #1
Renal Failure
4
5
6 7 8 9
10
CO₂ 0₂
0₂
0₂
11
3
12
2
13 14
0 1
0₂
Labs V
Highest Priority - Safety
Who to see first

Infection PRIORITY
ABCS Priority: Less than 5,000 WBC

Airway, Breathing = Oxygenation “Leukopenia”
Low PaO2 norm: 80 -100
Kidney Labs
High CO2 OVER 45 < 5000
Creatinine OVER 1.3 = Bad kidney! Leukopenia
Mental changes: Restless, agitation
Skin: Pale, dusky, cool & clammy Pain
Circulation Lose life or limb Creatinine > 1.3
Bleeding - High PTT / INR T
▪ Chest Pain = #1 priority
INR & PT
Shock - Severe low BP ▪ Compartment Syndrome
Chest pain (any kind) Cast / broken limb pain
BUN/Creatinine
HTN crisis (over 180 sys) = Unrelieved with pain meds

PTT & INR
ABG’s (not pulse oximeter)

Abnormal blood gases (ABGs)
PaO₂
60 or less
60 80 100
PaO2: 80 - 100 normal
= HypOXemic Respiratory
failure LOW O2
PaCO2: 35 - 45 50 or MORE
ABG HCO3 pCO2 pH 0₂
= HyperCapnic Respiratory Respiratory Acidosis Normal
failure HIGH CO2
Respiratory Alkalosis Normal
1. HyperCap = Give BiPAP
2. Intubate & ventilate
INR > 1.3 aPTT > 100 PRIORITY
Bleeding
TT
INR & P
INR - Over 4
Infection
aPTT - Over 100 Priority: Less than 5,000 WBC

“Leukopenia” < 5000
1. STOP / Hold drug Leukopenia
Low Grade FEVER = KILL!
2. Assess - bleeding Memory tricks
3. Prep antidote ● Immunocompromised Low Grade FEVER <100.4 F
WarKin HePTT
Warfarin - Vitamin K ● Chemotherapy
K
● Taking Immunosuppressants
Heparin - Protamine Sulfate
4. Report to HCP
Common NCLEX Question

An emergency room nurse is presented with
four clients at the same time. Which of the
following clients should the nurse see FIRST?
1. A client with a low-grade fever, headache, and fatigue

for the past 72-hours.
2. A client with swelling and bruising to the left foot
following a running accident.
3. A client with abdominal and chest pain following a
large, spicy meal.
4. A child with a 10 cm laceration to the chin
Cardiovascular
• Thready, increased pulse rate, decreased blood pressure and orthostatic
hypotension, flat neck and hand in veins in dependent positions, diminished
Fluid Volume peripheral pulses, decreased central venous pressure, dysrhythmias

Respiratory
Deficit • Increased rate and depth of respirations, dyspnea
Neuromuscular
• Decreased central nervous system activity, from lethargy to coma, fever,
“HypOvolemia” depending on the amount of fluid loss, skeletal muscle weakness
(Low fluid volume) Renal
• Decreased urine output
Integumentary
• Dry skin, poor turgor, tenting, dry mouth
Gastrointestinal
• Decreased motility and diminished bowel sounds, constipation, thirst,
decreased body weight
25%
• Increased serum osmolality, increased hematocrit
• Increased blood urea nitrogen (BUN)
• Increased serum sodium level
• Increased urinary specific gravity
Memory Trick:
• If Osmolality is HIGH = Body is DRY
• If Specific gravity is HIGH = Body is DRY
Cardiovascular
• Bouding, increased pulse rate, elevated blood pressure, distended neck
and hand veins, elevated central venous pressure, dysrhythmias
Fluid Volume Respiratory

• Increased respiratory rate (shallow respirations), dyspnea, moist crackles
Excess on auscultation
Neuromuscular
• Altered level of consciousness, headache, visual disturbances, skeletal
“Hypervolemia” muscle weakness, paresthesias
(High fluid volume) Renal & Urinary
• Increased urine output if kidneys cannot compensate
• Decreased urine output if kidney damage is the cause
Integumentary
• Pitting edema in independent areas, pale cool skin
Gastrointestinal
• Increased motility in gastrointestinal tract, diarrhea
• Increased body weight, liver enlargement, ascites
100%
• Decreased serum osmolality, decreased hematocrit, decreased BUN level
• Decreased serum sodium level
• Decreased urine specific gravity
Memory Trick:
• If Osmolality is Low = Body is Liquidy
• If Specific gravity is Low = Body is Liquidy
Fluid & Electroly Quick Notes IV Solutions
Isotonic solutions
• Definition: when solutions on both sides of a selectively permeable membrane have
established equilibrium or are equal in concentration, they are isotonic.
• Human blood is isotonic thus very little osmosis occurs since isotonic solutions have
the same osmolality as body fluids & thus increase extracellular fluid volume.
Memory Trick:
• Iso-tonic Solutions
• I-so-Perfect (no fluid shift, “I’m so perfect” perfect balance)
• 0.9% sódio, chloride (normal saline)
• 5% dextrose in water (DWS)
• 5% dextrose in 0.225% saline (DSW/ 1/4 NS)
• Lactated Ringer’s (LR)
Hypotonic solutions
• Definition: when a solution contains a lower concentration of solute than another
more concentrated solution, then it is a hypotonic solution.
• These solutions have lower osmolality than body fluids.
• They cause the movement of water into cells by osmosis, swelling the cells like a BIG
fat hippo, and therefore should be administered slowly to prevent cellular edema
Memory Trick:
• HypO - tonic
• HippO - tonic = fluid swells the cell like a big hippo
• 0.33% sodium chloride (1.3 NS)
Hypertonic solutions
• Definition: when a solution contains a higher concentration of solutes than
another less concentrated solution, then it is a hypertonic solution.
• These solutions have higher osmolality than body fluids
• They cause the movement of water outside the cells by osmosis, making the
cells skinny like a hyper person.
Memory Trick:
• Hyper - tonic
• Hyper person = very skinny cells like a hyper person is skinny
• 10% dextrose in water (D10W)
• 5% dextrose in 0.9% sodium chloride (D5W/NS)
• 5% dextrose in 0.45% sodium chloride (D5W/ 1/2 NS)
• 5% dextrose in Lactated Ringer’s (D5LR)
Reproductive System
Female
MALE External genitalia
External genitalia ❖ mons pubis
❖ Penis: reproductive and urinary elimination. ❖ labia majora and minora
❖ Scrotum: External sac that houses testes. ❖ Clitoris
Protects the testes from trauma & testicular ❖ Vestibule
temperature regulation. ❖ perineum
Internal reproductive organs
Internal reproductive organs ❖ Vagina: muscular tube that leads from the vulva to the
❖ Testes: produce male sex hormone and from uterus
spermatozoa ❖ Cervix: dips into the vagina and forms fornices, which are
❖ Ductal system: “ vas deferens” the tube in which arch-like structures or pockets.
sperm begin the journey out of the body. ❖ Ovaries :two sex glands homologous to the male testes,
❖ Accessory glands: The seminal vesicles are are located on either side of the uterus. (Hatfield 55)
paired glands that empty an alkaline, fructose-rich Fallopian tubes: The paired fallopian tubes (also known as oviducts)
fluid into the ejaculatory ducts during ejaculation. are tiny, muscular corridors that arise from the superior surface of the
Prostate: muscular gland that surrounds the first part of the uterus near the fundus and extend laterally on either side toward the
urethra as it exits the urinary bladder. The alkaline fluids ovaries. The fallopian tubes have three sections
secreted by these glands are nutrient plasmas with several ❖ Isthmus
key functions, including the following: ❖ Ampulla
❖ Enhancement of sperm motility (i.e., ability to ❖ infundibulum
move) Uterus: uterus, or womb, is a hollow, pear-shaped, muscular
❖ Nourishment of sperm (i.e., provides a ready structure located within the pelvic cavity between the bladder and
source of energy with the simple sugar fructose) the rectum.
❖ Protection of sperm (i.e., sperm are maintained in The uterus is divided into four sections.
an alkaline environment to protect them from the ❖ cervix
acidic environment of the vagina) (Hatfield 51) ❖ uterine isthmus
❖ corpus
❖ fundus (Hatfield 53)
Cellular development
Menstrual cycle Soma cells:
❖ Makeup organs and bodily tissue of the human body.
Two main components : Ovarian cycle and Uterine cycle ❖ Gametes: germ cells/ sex cells found only in the reproductive
Ovarian cycle : Cyclical changes in the ovaries occur in glands
response to two anterior pituitary hormones: ❖ Nucleus: contains 23 pairs of chromosomes
follicle-stimulating hormone (FSH) and luteinizing hormone ❖ Each parent donates 1 par of chromosomes ( 46 Chromosomes
(LH). There are two phases of the ovarian cycle, each equals little Mikey)
named for the hormone that has the most control over that ❖ Each parent donates 22 pairs of autosomes: genetic traits such
particular phase. The follicular phase, controlled by FSH, as eye color, hair color, ear wax consistency.
encompasses days 1 to 14 of a 28-day cycle. LH controls ❖ One pair of sex chromosomes
the luteal phase, which includes days 15 to 28
❖ Follicular phase
❖
Fetal development
Luteal phase
Uterine cycle: changes that occur in the inner lining of the

uterus. These changes happen in response to the ovarian Pre-embryonic stage : 3-4 weeks
hormones estrogen and progesterone. gestation
There are four phases to this cycle: Embryonic: 5-10 weeks gestation
❖ Menstrual Fetal: 11-40 weeks gestation
❖ Proliferative
❖ Secretory
❖ ischemic.
Signs of pregnancy
❖ Presumptive: subjective data the
woman reports to the HCP for
example, “ My breasts hurt”
❖ Probable : objective data such as
cervical changes
❖ Positive : diagnostic confirmation
such as, fetal heartbeat & ultrasound
Hematologic Changes
❖ Blood volume increases by
45-50%
PREGNANCY ❖
Weight gain
A woman should increase her
❖ Red blood cell count caloric intake by 300 kcal/day
during 2nd & 3rd trimesters.
Signs of pregnancy
increases up to 30%
❖ Recommended weight gain
❖ Plasma increases up tp 50%
depends on pre pregnancy BMI.
❖ Hemoglobin decreases ❖ Presumptive: subjective data ❖ FIRST TRIMESTER : 3-4 lb total
❖ Hematocrit decreases the woman reports to the HCP ❖ REMAINDER OF PREGNANCY: 1
❖ for example, “ My breasts hurt” lb per week.
❖ Total weight gain: 25-35 lb for a
Cardiac changes
❖ Probable : objective data such
as cervical changes woman with a normal BMI
❖ Positive : diagnostic
❖ Blood pressure slightly
confirmation such as, fetal
decreases
heartbeat & ultrasound
Nutrition
❖ Heart rate increases by
10-15 BPM
❖ Cardiac output increases ❖ When a woman isn't getting the proper nutrients this can cause
Amenorrhea which can inhibit the ability to become pregnant.
❖ Lack of folic acid can cause neural tube defects( spina bifida) and cause
damage to the growing fetus.
❖ Deficits in Vit C have been shown to also cause birth defects and
Integumentary changes
cancer.
❖ Pica:
❖ Chloasma : “ pregnancy mask” ❖ persistent ingestion of nonfood substances such as clay, laundry
brown blotchy areas on the skin of starch, freezer frost, or dirt.It results from a craving for these
substances that some women develop during pregnancy.
the face, cheeks, nose and
❖ These cravings disappear when the woman is no longer pregnant.
forehead.
❖ Pica is associated with iron-deficiency anemia, but it is unknown
❖ Linea nigra: a dark line down the whether iron deficiency is the cause or the result
middle of the skin on the abdomen
Nutritional requirements
❖ Striae: develop in response to
increased glucocorticoid levels.
Also known as stretch marks ❖ Proteins: Growth and repair of fetal tissue, placenta, uterus,
breasts, and maternal blood volume
❖ Minerals: Prevent deficiencies in the growing fetus and maternal
stores
Musculoskeletal changes
❖ Iron : Formation of hemoglobin; essential to the oxygen-carrying
capacity of the blood
❖ Calcium: Nerve cell transmission, muscle contraction, bone
❖ Lordosis: Excessive inward building, and blood clotting
curvature of the spine ❖ Phosphorus: Promotes strong bone growth
❖ Diastasis rectus abdominis: ❖ Zinc: Fetal growth and maternal milk production
tearing of the rectus abdominis ❖ Iodine : Promotes normal thyroid activity, preventing specific birth
muscles defects
Vitamin requirements
Respiratory changes Folic acid (Vitamin B9)
❖ Nasal mucosa edematous due to ❖ Necessary for formation of the nervous system
vasocongestion ❖ Prevents up to 70% neural tube defects
❖ Nasal congestion and voice ❖ Diet should include at least 400 mcg of folic acid per day
changes possible
❖ Accommodations to maintain lung Vitamin A
capacity ❖ Recommended intake via beta-carotene
❖ May feel short of breath when ❖ Too much can be toxic to the fetus
❖ Too little can stunt fetal growth and cause impaired dark adaptation
eupneic
and night blindness
❖ Third trimester diaphragm pressure
Vitamin C
❖ Essential in the formation of collagen, a necessary ingredient to
GI changes
wound healing
Vitamin B6
❖ Necessary for the healthy development of the
❖ Intestines are displaced fetus’s nervous system
upwards & to the side. Vitamin B12
❖ Pressure changes in the ❖ Needed to maintain healthy nerve cells, RBCs, form DNA
esophagus & stomach
which leads to heartburn.
❖ constipation
FETAL HEART TONES
CONDITION CAUSE GRADE
Fetal Tachycardia ❖ Infection ❖ Mild : > 5 BPM from baseline

❖ Dehydration ❖ Moderate: 6-25 BPM from baseline
❖ Fever ❖ Severe: < 25 BPM from baseline
❖ Fetal hypoxemia ❖ Absent : No fluctuation in fetal heart rate
❖ Anemia
❖ Prematurity
❖ Terbutaline
❖ Caffeine
❖ Epinephrine
❖ Theophylline
❖ illicit drugs
Fetal bradycardia ❖ Maternal hypotension ❖ Mild : > 5 BPM from baseline

❖ Supine hypotensive syndrome ❖ Moderate: 6-25 BPM from baseline
❖ Fetal decompression ❖ Severe: < 25 BPM from baseline
❖ Late fetal hypoxia ❖ Absent : No fluctuation in fetal heart rate
❖ Cord compression
❖ Abruptio placenta
❖ Vagal stimulation
Accelerations & Decelerations

Variability Accelerations: must be 15 BPM above the FHR baseline for 15
seconds 15x15 window
FHR drops from baseline then recovers, usually jagged and Decelerations : A decrease in FHR during uterine contraction ”
erratically shaped. Can happen at anytime during contraction mirrors contractions usually a U shape
Periodic changes : variations that occur during a contraction.
Nursing interventions : Left Side. IV bolus of fluids, O2 6l mask, ❖ Reassuring periodic changes : must be 15 BPM
Notify HCP above the FHR baseline for 15 seconds ( 15x15 window)
❖ Benign periodic changes: Early decelerations
A great way to remember this is L.I.O.N
Decreased or absent variability: Non reassuring, acute treatment Episodic changes: occur in association with medication
and monitoring are indicated. administration or analgesia
Decreased or absent variability: medications, narcotics, mag
Wandering baselines with no variability could indicate
sulfate ( preeclampsia, preterm), terbutaline, fetal sleep (
❖ Congenital defects normally 20 minute cycles), prematurity, fetal hypoxemia.
❖ Metabolic acidosis
Fetal decelerations
The nurse should administer 02 and the baby needs to be
delivered as quickly as possible.
Memory trick
Early decelerations : A decrease in FHR during uterine contraction mirrors
uterine contractions . caused by uterine squeeze
❖ FHR slows as the contraction begins
V: variable deceleration C: cord compression ❖ Lowest point coincides with the highest point ACME of the
E:early deceleration H: head compression contraction
A: acceleration O: ok ❖ Deceleration ends with the contraction
Late deceleration Placental insufficiency Late deceleration: occurs after the peak of contraction due to uteroplacental
insufficiency, pitocin, HTN, diabetes, placental abruption.
❖ Too many decelerations will indicate a need for C-section
❖ Prepare for fetal resuscitation
Variable decelerations: may indicate cord compression. Occur at different
times during a contraction, resulting in fetal HTN that causes the aortic arch
to slow the FHR. usually abrupt and sudden.
Measures to clarify NONreassuring FHR patterns
❖ Fetal stimulation
❖ Fetal scalp sampling
❖ Fetal scalp oximetry
Assessment
Admission
❖ Birth imminence Components of assessment
❖ Fetal status Obstetric History
❖ Maternal status ❖ Number and outcomes of previous pregnancies in
❖ Risk assessment GTPAL (gravida, term, preterm, abortions, living)
format (see Chapter 7 for a detailed explanation of
these terms)
❖ Estimated delivery date
❖ History of prenatal care for current pregnancy
Assessment of reproductive history

❖ Complications during pregnancy
❖ Dates and results of fetal surveillance studies, such
as ultrasound or nonstress test (NST)
Gravida: Number of pregnancies the woman has had regardless
❖ Childbirth preparation classes
of outcome
❖ Previous labor and birth experiences
Nulligravida: never been pregnant
Current Labor Status
Multigravida: more than one pregnancy
❖ Time of contraction onset
Parity: the client communicates outcome of previous pregnancies
❖ Contraction pattern including frequency, duration,
GTPAL :
and intensity
G: Gravida – the total number of pregnancies regardless of
❖ Status of membranes
outcome
❖ Description of bloody show or bleeding
T: Term – the number of pregnancies that ended at term (at or
❖ Fetal movements during the past 24 hours
beyond 38 weeks’ gestation)
Medical–Surgical History
P: Preterm – the number of pregnancies that ended after 20
❖ Chronic illnesses
weeks and before the end of 37 weeks’ gestation either
❖ Current medications
A : Abortions – the number of pregnancies that ended before 20
❖ Prescribed
weeks’ gestation either spontaneous or induced
❖ Over-the-counter
L: Living – the number of children delivered who are alive when
❖ Herbal remedies
the history is taken
Social History
❖ Marital status
❖ Support system
❖ Domestic violence screen
❖ Cultural/religious considerations that affect care
Prenatal visits
❖ Amount of smoking during pregnancy
❖ Drug and alcohol use during pregnancy
Ist visit : Desires/Plans for Labor and Birth
❖ Presence of a partner, coach, and/or doula (see
❖ Family History, Medical Surgical History,
Chapter 7 for discussion of doulas)
Social History, Teaching, Avoiding
❖ Pain management preferences
teratogenic, substance ingestion, Alcohol, ❖ Other personal preferences affecting intrapartum
tobacco, illegal drugs, etc., Diet, nutrition, and nursing care
exercise, Infection control ❖ Presence of a birth plan
❖ Medication use ❖ Desires/Plans for Newborn
❖ Determining due dates ❖ Plans for feeding—breast or formula
❖ Naegele's rule ❖ Choice of pediatrician
❖ Add seven days to the date of the first day of ❖ Circumcision preference, if the infant is male
the LMP, then subtract three months (and ❖ Rooming-in preference (Hatfield 208)
add a year)
❖ Pelvic examination
❖ Practitioner sizes the uterus to estimate term
❖ Obstetric sonogram: High frequency sound
waves reflect off fetal and maternal pelvic
Tips
structures, allowing structure measurement If a woman presents with ℅
bleeding ask her how man
sanitary napkins she has
saturated in an hour.
Complications: Abruptio Placenta
What Am I? Assessment
❖ Premature separation of the ❖
❖
Rigid board-like abdomen
Abdominal pain
Priorities
placenta from the uterine wall ❖ Keep baby safe,
❖ Difficulty palpating baby.
❖ Usually occurs after 20 weeks' ❖ Signs of fetal distress: prolonged continuous monitoring
gestation, most commonly during fetal bradycardia, repetitive late ❖ Manage maternal shock
the third trimester, and peaks at decelerations, and decreased
24 to 26 weeks' gestation short-term variability; absent fetal
heart tones
Complications
❖ Common cause of bleeding
❖ Uterine hypertonicity
during the second half of ❖ Abdominal tenderness
pregnancy
❖ Cesarean delivery
PATHo ❖ Hemorrhage/coagulopathy
Improperly implanted placenta ❖ Retroperitoneal
separates before the pregnancy bleed/bleeding into the
reches term. If the abruption is abdomen
classified as concealed it is bleeding ❖ Shock
into the uterus.
Can be classified on scale of 0-3, 3
❖ Acute kidney injury
Causes
being the worst prognosis. ❖ Disseminated intravascular
coagulation (DIC)
❖ Car accidents ❖ Adult respiratory distress
❖ Domestic or IPV
syndrome
❖ Previous C-section
❖ Rupture of membranes ❖ Multisystem organ failure
❖ Cocaine use ❖ Maternal death
❖ Smoking ❖ Fetal hypoxia or asphyxia
❖ Pregnancy induced ❖ Precipitous labor and
hypertension
delivery
❖ Prematurity
❖ Fetal death
❖ Sepsis
Interventions
❖ Insert an indwelling urinary : monitor urine Labs
output.
❖ Obtain blood specimens for Hb level and ❖ Serum hemoglobin level test and
hematocrit, coagulation studies, and typing and platelet count are decreased.
crossmatching. ❖ Fibrin degradation products test
❖ Evaluate the extent and amount of bleeding; shows progression of abruptio
perform a pad count, placentae and indicates the
❖ Provide continuous external electronic fetal presence of DIC.
monitoring if the fetus is viable. ❖ Hypofibrinogenemia suggests
severe abruption (fibrinogen
❖ Give I.V. fluids and blood products. Maintain
levels less than or equal to 200
one to two large-bore I.V. lines; inspect I.V.
mg/dL).
insertion sites frequently for signs and
❖ Kleihauer-Betke test is positive if
symptoms of inflammation or infiltration.
fetal-maternal transfusion has
Provide I.V. site care according to your facility's occurred.
policy. ❖ Rho(D) antibody screening is
❖ Position the patient on her left side to enhance positive if isoimmunization has
uteroplacental perfusion. occurred.
❖ Administer oxygen, as ordered, on the basis of
pulse oximetry levels and respiratory status.
❖ Prepare the patient for emergency delivery, as
appropriate.
Complications: Ectopic pregnancy
What Am I ? ASSESSMENT Diagnostics
❖ Pain ❖ H&H: Low if rupture occurs.
Fetal growth somewhere
❖ Referred shoulder pain ❖ Diagnosable with ultrasound.
outside of the uterus, usually
❖ Spotting ❖ Human chorionic gonadotropin
within the fallopian tubes.
❖ Bleeding into the peritoneum level (serum) (hCG) is abnormally
❖ Bleeding from vagina if rupture low; when the test is repeated in
occurs 48 hours, the level remains lower
Causes ❖ Normal signs/ symptoms of
pregnancy
than usual for a normal
(intrauterine) pregnancy.
❖ Congenital defects in reproductive tract ❖ Progesterone level (plasma) is
❖ Diverticula lower than expected for an
❖ Ectopic endometrial implants in the tubal
intrauterine pregnancy.
mucosa
Risk Factors
❖ Endosalpingitis
❖ History of multiple elective abortions
❖ Intrauterine device
❖ Previous surgery, such as tubal ligation ❖ History of tubal surgery
or resection ❖ Previous ectopic pregnancy
❖ Sexually transmitted tubal infection ❖ History of pelvic inflammatory disease
❖ Transmigration of the ovum ❖ Pelvic adhesions
❖ Tumor pressing against the tube ❖ Use of intrauterine device
❖ Hormonal imbalance ❖ History of endometritis
❖ Progesterone-only contraceptive use
❖ Use of assisted reproductive technologies
❖
Complications
Diethylstilbestrol exposure in utero
❖ Cigarette smoking
❖ Age between 35 and 44
❖ Rupture of fallopian tube ❖ Multiple sexual partners
❖ Hemorrhage ❖ Vaginal douching
❖ Shock ❖ Young age at first sexual intercourse
❖ Peritonitis
❖ Infertility
Interventions
❖ Disseminated intravascular
coagulation
❖ Death
❖ Vital signs
Treatments
❖ Vaginal bleeding
❖ Pain level and effectiveness of
❖ Transfusion with whole blood or packed red blood interventions
cells to treat hypovolemic shock if the tube has ❖ Fluid balance status
ruptured. ❖ Intake and output
❖ IV fluid replacement ❖ Signs and symptoms of hypovolemia and
❖ Supplemental iron if anemia occurs from blood loss impending shock
❖ Methotrexate sodium (Trexall) as primary treatment ❖ Surgical site (postoperatively)
for unruptured ectopic pregnancy (single I.M. dose
or multidose treatment via I.M. or IV route)
❖ Leucovorin I.N. between doses of multi dose
methotrexate therapy
❖ Rho(D) immune globulin, human, if the patient is
Rh-negative
What is it?
Hyperemesis gravidarum
Excessive vomiting that
leads to dehydration,
starvation, and even Assessment Interventions
death among pregnant ❖ Hypotension ❖ 48 hours of NPO status
populations ❖ Elevated H&H ❖ IV fluids
Related to increased ❖ Decreased urine ❖ Antiemetics as ordered
estrogen levels output ❖ Vitamins
❖ Hypokalemia ❖ Decrease environmental
❖ Weight loss stimuli
❖ Ketonuria ❖ Clear liquids and small dry
feedings as tolerated.
❖ Give either cold or hot food,
nothing room temp.
Critical labs
❖ Potassium
❖ Have the patient on tele
❖ Monitor for symptoms of
shock and fluid volume
deficit.
Complications
❖ Dehydration
❖ Wernicke's encephalopathy from
vitamin B1 deficiency
❖ Mallory-Weiss tears (esophageal
tears and bleeding)
❖ Esophageal bleeding
❖ Pneumothorax
❖ Acute tubular necrosis
❖ Electrolyte and acid‑base
imbalances
Diagnostic studies
❖ Potassium, sodium, chloride, and protein levels
are decreased due to losses from vomiting.
❖ Blood urea nitrogen, non protein nitrogen, and
uric acid levels are increased due to renal
compromise and hemoconcentration.
Hemoglobin (Hb) level and hematocrit (HCT) are
increased due to hemoconcentration.
❖ Urinalysis reveals ketones and, possibly, protein;
urine specific gravity increases.
❖ Vitamin B1 and B6 levels are decreased due to
impaired intake.
❖ Thyroid-stimulating hormone, thyroxine, and
triiodothyronine levels may be mildly increased.
Complications:Miscarriage
What is it? Assessment
❖ Cardinal signs are
Can be elective or spontaneous
❖ Spotting and cramping together
❖ Tissue expulsion from the vagina
❖ Elective: The choice to terminate the
pregnancy.
❖ Spontaneous: spontaneous abortion
and pregnancy loss, is the natural death
of an embryo or fetus before it is able to
survive independently. Some use the
cutoff of 20 weeks of gestation, after Risks
which fetal death is known as a stillbirth. ❖ Age. Women older than age 35 have a higher risk of
miscarriage than do younger women. At age 35, you
have about a 20 percent risk. At age 40, the risk is
about 40 percent. And at age 45, it's about 80
percent.
❖ Previous miscarriages. Women who have had two
or more consecutive miscarriages are at higher risk of
Causes
miscarriage.
❖ Chronic conditions. Women who have a chronic
Chromosomal abnormalities might lead to: condition, such as uncontrolled diabetes, have a
higher risk of miscarriage.
❖ Blighted ovum. Blighted ovum occurs when no ❖ Uterine or cervical problems. Certain uterine
embryo forms. abnormalities or weak cervical tissues (incompetent
❖ Intrauterine fetal demise. In this situation, an cervix) might increase the risk of miscarriage.
embryo forms but stops developing and dies ❖ Smoking, alcohol and illicit drugs. Women who
before any symptoms of pregnancy loss occur. smoke during pregnancy have a greater risk of
❖ Molar pregnancy and partial molar pregnancy. miscarriage than do nonsmokers. Heavy alcohol use
With a molar pregnancy, both sets of and illicit drug use also increase the risk of
chromosomes come from the father. A molar miscarriage.
pregnancy is associated with abnormal growth of ❖ Weight. Being underweight or being overweight has
the placenta; there is usually no fetal been linked with an increased risk of miscarriage.
development. ❖ Invasive prenatal tests. Some invasive prenatal
❖ Uncontrolled diabetes genetic tests, such as chorionic villus sampling and
❖ Infections amniocentesis, carry a slight risk of miscarriage.
❖ Hormonal problems ❖
❖ Uterus or cervix problems
Treatment
❖ Thyroid disease
❖ Monitor HcG Levels, a decrease is

indicative of miscarriage.
❖ Pelvic rest
Prevention
❖ Bed rest
❖ If it is sure that a miscarriage is
❖ Seek regular prenatal care. happening : prepare to start an IV,
administer blood & D&C
❖ Avoid known miscarriage risk factors
— such as smoking, drinking alcohol
and illicit drug use.
❖ Take a daily multivitamin.
❖ Limit your caffeine intake. A recent
study found that drinking more than
two caffeinated beverages a day
appeared to be associated with a
higher risk of miscarriage.
Complications : Placenta Previa
Assessment complications
What am i? ❖ Cord being the presenting part, possible
❖ Three types: Marginal, partial,
❖ Painless bleeding cord prolapse
and total
❖ Soft, nontender uterus ❖ Fetal hypoxia or blood loss
❖ Common cause of bleeding during
❖ Fetal malpresentation ❖ Preterm delivery
the second half of pregnancy
❖ Minimal descent of fetal ❖ Dystocia
❖ Good maternal prognosis if
presenting part ❖ Anemia
hemorrhage can be controlled
❖ Good fetal heart tones ❖ Hemorrhage
❖ Usually necessitates pregnancy
❖ Possible contractions ❖ Abruptio placentae
termination if bleeding is heavy
❖ Disseminated intravascular coagulation
❖ Fetal prognosis dependent on
❖ Shock
gestational age and amount of
❖ Placenta accreta, increta, percreta
blood lost; risk of death greatly
❖ Intrauterine growth restriction
reduced by frequent monitoring
❖ Abnormal fetal presentation
and prompt management
❖ Kidney damage
❖ Cerebral ischemia
❖ Maternal or fetal death
Patho
Improper implantation of the placenta
in the lower uterine segment has Medications
caused partial or total coverage of the
cervical os.With development of the ❖ I.V. fluids, such as lactated Ringer solution
lower uterine segment and gradual or normal saline solution, using a large-bore
changes in the cervix during the third catheter
trimester, shearing forces at the ❖ Oxygen
attachment site lead to partial
❖ Fresh frozen plasma and platelets, as
detachment and bleeding.
necessary, for coagulation problems
❖ Tocolytics, such as terbutaline sulfate,
Risk Factors
calcium channel blockers, or magnesium
sulfate short-term to halt preterm labor and
to allow time for doses of betamethasone
❖ Advanced maternal age (over age 35) dipropionate (Diprolene)
❖ Defective vascularization of the decidua ❖ Betamethasone dipropionate to enhance
❖ Endometriosis fetal lung maturity if less than 34 weeks'
❖ Multiparity Interventions
gestation
❖ Infertility treatments ❖ Pad counts, the patient should not saturate
❖ Multiple pregnancy more than one pad an hour.
❖ Previous uterine surgery or cesarean birth ❖ Monitor blood counts
❖ Monitor fetal heart tones
❖ Smoking
❖ Monitor contractions
❖ Male fetus ❖ Prepare for c-section
❖ Cocaine use ❖ Do not perform cervical exams
❖ History of placenta previa
❖ High altitudes
❖ Uterine abnormalities inhibiting normal
embryonic implantation (such as prior
curettage or the presence of uterine
fibroids)
What is it?
Extreme elevation in
blood pressure during
preeclampsia
pregnancy with the
presence of protein in the Assessment Types
urine after 20 weeks of ❖ Sudden weight gain ❖ Mild : 30/15 mmhg off of baseline
❖ Swelling of the face and six hours apart. Increase the
gestation.
hands amount of protein in the diet
❖ Headache
because they are spilling it into the
❖ Blurry vision
❖ Hyperreflexia urine. Glomerular damage is
❖ Clonus ( seizures) present.
❖ Severe: 160/110 mmHg 6 hours
apart. May have an episode of
seizure activity. Have mag sulfate
ready.
Interventions
Magnesium sulfate ❖ Magnesium sulfate : have
calcium gluconate at
❖ Vasodilator & sedative bedside.
❖ Monitor for pulmonary ❖ Monitor for sedation and
edema hyporeflexia.
❖ Seizure precautions
❖ Monitor for signs of mag
❖ Safety checks
toxicity: decreased
DTRS, BP, respiration,
Risk factors
decreased LOC.
❖ Labor will halt: have
oxytocin ready if ❖ History of preeclampsia.
indicated. ❖ Chronic hypertension.
❖ First pregnancy.
❖ New paternity
Care
❖ Age. The risk of preeclampsia is higher for very
young pregnant women as well as pregnant
❖ Decrease environmental
women older than 40.
stimuli. This decreases the
risk of seizures. ❖ Obesity.
❖ Initiate seizure precautions ❖ Multiple pregnancy. Preeclampsia is more
❖ Monitor mom and baby common in women who are carrying twins,
triplets or other multiples.
❖ Interval between pregnancies. Having babies
less than two years or more than 10 years apart
leads to a higher risk of preeclampsia.
❖ In vitro fertilization. Your risk of preeclampsia is
increased if your baby was conceived with in
vitro fertilization.
Nclex tip!
Blood pressure that exceeds
140/90 millimeters of mercury
(mm Hg) or
greater,documented on two
occasions, at least four hours
apart , is abnormal.
Respiratory syncytial virus: Bronchiolitis
What am I ? Assessment Diagnostics
Respiratory syncytial virus (RSV) ❖ Sneezing ❖ Secretions from the
is a very common virus that leads ❖ Rhinorrhea nose and throat are
to mild, cold-like symptoms in ❖ Low grade fever cultured.
adults and older healthy children. ❖ Coughing ❖ ELISA test
It can be more serious in young ❖ Wheezing ❖ IFA test
babies, especially those in certain ❖ Retractions
high-risk groups ❖ Nasal flaring
❖ Dyspnea
❖ Prolonged expiratory phase
❖ Intermittent cyanosis
Patho R: Rhinorrhea, retractions

The inflammatory process leads
U: Unable to expire Treatments
N: Nasal flaring ❖ Suction
to airway edema and
N: Not a high fever ❖ Possible mechanical
accumulation of mucus and
Y: Yes they may be blue ventilation
cellular debris. Obstruction of the
airway leads to overinflation of the ❖ Iv fluids
N: Not able to breathe ❖ High humidity and fluids
alveoli or atelectasis in some
O: Overloaded, crackles ❖ Rest
instances.
S: Some wheezing ❖ Mist therapy with oxygen
Expiratory phase is prolonged via hood or tent to
alleviate dyspnea and
hypoxia
Risk factors ❖ Ribavirin for severely ill:
aerosol mist
❖ Palivizumab
❖ Prematurity ❖ Albuterol
❖ Crowded places with people who ❖ Antipyretics
may be infected
❖ Exposure to other children (e.g., in
daycare) or to older siblings
attending school
❖ Infants younger than 6 months of
age Interventions
❖ Smoke ❖ Continuous respiratory
❖ Congenital disorders assessments
❖ Young children, especially those ❖ Hand washing
under 1 year of age, who were ❖ Place the client on
born prematurely or who have an isolation: Droplet
underlying condition, such as ❖ Do not care for other
congenital heart or lung disease high risks clients.
❖ Children with weakened immune ❖ Do not care for this
systems client if pregnant.
❖ Adults with asthma, congestive
heart failure, or chronic obstructive
pulmonary disease (COPD)
❖ People with immunodeficiency,
including those with certain
transplanted organs, leukemia, or
HIV/AIDS
Uterine rupture
Assessment
What is it? ❖ Dramatic onset of fetal bradycardia
A serious but rare complication
of childbirth. Characterized by ❖
or deep variable decelerations
Reports by the woman of a Types
tearing of a previous uterine scar “popping” sensation in her ❖ Incomplete: rupture only goes
abdomen through the endometrium and
from cesarean section. The ❖ Excessive maternal (possibly
myometrial wall becomes referred) pain the myometrium only, with the
breached causing hemorrhage ❖ Unrelenting uterine contraction peritoneum still intact.
into the peritoneum. followed by a disorganized uterine ❖ Complete: rupture goes
pattern through the endometrium,
❖ Increased fetal station felt upon myometrium, and peritoneum,
vaginal examination and then the contractions
❖ Vaginal bleeding or increased
bloody show would immediately stop.
❖ Easily palpable fetal parts through
the abdominal wall
❖ Signs of maternal shock
Causes
❖ Pressure of baby moving
through the birth canal against
a previous uterine scar.
❖
❖
abnormal presentation
prolonged labor Nursing interventions
❖ multiple gestation
❖ improper use of oxytocin
❖ traumatic effects of forceps use ❖ The nurse should prepare IV fluid
or traction.
replacement.
❖ IV oxytocin administration .
❖ Laparotomy to control the
bleeding and repair the rupture.
❖ Cesarean hysterectomy or tubal
ligation
Cesarean section delivery
Indication
❖ History of previous cesarean Cesarean Birth
birth or other uterine incision Maternal risks
❖ Labor dystocia (failure to ❖ Major surgery risks and risks of birth itself
progress in labor) ❖ Increases maternal risk of death
❖ Nonreassuring fetal status ❖ Thrombophlebitis, laceration of uterine artery,
❖ Fetal malpresentation bladder, ureter, bowel
❖ Active herpes, prolapsed cord( ❖ Hemorrhage, infection, pneumonia, etc.
emergency)
❖ ruptured uterus(emergency)
❖ placenta previa Fetal risks
❖ abruptio placenta. ❖ Inadvertent delivery of premature fetus
(miscalculation of dates)
❖ Increases incidence of neonatal respiratory
the rise of C-sections

distress
❖ Scalpel cutting through the uterine wall can nick
the baby.
❖ Change in perception of risk by physicians ❖ The fetus can become wedged in
and patients ❖ the pelvis after a prolonged second stage with
❖ Increase in the percentage of pregnant the woman pushing, which can make for a
women who are carrying their first child difficult extraction leading to bruising and
❖ Rise in the number of older pregnant women possibly other injuries.
❖ ❖ National goal to decrease the cesarean delivery
Cesarean delivery procedures
More labor inductions for nonmedical
reasons rate
❖ Almost universal use of continuous electronic
perioperative period
fetal monitoring, which carries with it high
❖ Preoperative phase: Team approach, 2 MD or
false-positive indications of fetal compromise
1 MD and 1 first assist R.N and one
❖ Return to the adage “once a cesarean, pediatrician.
always a cesarean” ❖ LVN cannot care for this client until they have
❖ A decrease in VBAC attempts fully recovered from Anesthesia.
Increasing concerns regarding malpractice ❖ informed consent must be obtained by the MD
litigation and the anesthesiologist prior to the
❖ Increased prevalence of multiple gestations procedure.
❖ Increased prevalence of maternal obesity
❖ New phenomenon of cesarean by demand
(women asking for planned cesarean without
medical indications)
indications for induced labor Contraindications for induced

❖ Postdate pregnancy: pregnancy that has gone
past the due date labor
❖ Premature rupture of membranes (PROM) Maternal contraindications for induced labor
❖ Chorioamnionitis: infection of the fetal ❖ Complete placenta previa: placenta covers the
membranes cervix
❖ Gestational hypertension ❖ History of vertical uterine incision: This mom will
❖ Preeclampsia never have a vaginal birth due to risks of uterine
❖ Severe intrauterine fetal growth restriction rupture and risk of hernia. this incision carries an
increased risk of dehiscence
❖ Maternal medical conditions ❖ Structural abnormalities of the pelvis
❖ Invasive cervical cancer
❖ Medical conditions (e.g., active genital herpes): A
herpes outbreak can cause the baby to go blind
and/ or cause sores of the mouth
Fetal contraindications for induced labor
❖ Certain anomalies, such as hydrocephalus
❖ Certain fetal malpresentations
❖ Fetal compromise
DELIVERY
Getting ready for the newborn Birthing the placenta
❖ If the urinary bladder is full, the birth
attendant may request that you perform a ❖ nursing care focuses on monitoring for
straight cath placental separation and providing
❖ bed is “broken”—the lower part of the bed
physical and psychological care to the
is removed to allow room for the birth
attendant to control the delivery. woman.
❖ place the woman’s feet on foot pedals or ❖ the fundus rises in the abdomen, the
stirrups uterus takes on a globular shape,
❖ clean the woman’s perineum with an blood begins to trickle steadily from
antiseptic solution
the vagina, and the umbilical cord
❖ Position the instrument table close to the
birthing bed and uncover it. lengthens as the placenta separates
❖ Eye shields, gowns, and gloves may be from the uterine wall.
necessary for protection from contact with
bodily fluids.
Recovery
❖ The new mother is at highest risk for hemorrhage during the
first two to four hours of the postpartum period.
❖ Monitor the woman’s vital signs, and palpate the fundus for
position and firmness.
❖ The fundus should be well contracted, at the midline, and
approximately one fingerbreadth below the umbilicus
immediately after delivery.
❖ Assess the lochia (vaginal discharge after birth) for color and
quantity. The lochia should be dark red and of a small to
moderate amount. If she saturates more than one perineal pad
in an hour, palpate and massage the fundus,
❖ Monitor for signs of infection. The temperature may be
elevated slightly, as high as 100.4°F, because of mild
dehydration and the stress of delivery.
❖ The woman should void within six hours after delivery.
❖ Assess cramping from uterine contractions (referred to as
“afterbirth pains”) and perineal pain from edema or episiotomy
repair
❖ ibuprofen to be given every six to eight hours
❖ ice pack to the perineum.
Pain management during labor
Pain General concepts of pain
❖ Individual &
❖ Pain threshold: Level of pain
Factors influencing pain

subjective
necessary for an individual to perceive
❖ Sensory experience
pain
❖ Physiologic ❖ Pain tolerance: Ability of an individual
❖ Psychological to withstand pain, once recognized
❖ Emotional
❖ Environmental
Non Pharmacological pain

❖ Sociocultural
interventions
Principles of pain relief ❖ Continuous labor support
during labor ❖ Comfort measures
❖ Women are more satisfied when Relaxation techniques

they have control over the pain ❖ Patterned breathing
experience ❖ Attention focusing/concentration
❖ Caregivers commonly underrate ❖ Movement and positioning
the severity of pain ❖ Touch and massage
❖ Women who are prepared for ❖ Water therapy;
labor usually report a more hypnosis,Intradermal water
satisfying experience than do injections
women who are not prepared ❖ Acupressure and acupuncture
Opioids Anesthesia
❖ Local: Used to numb the perineum just before birth,
Medications with opium-like properties (also
allowing for episiotomy and repair
known as narcotic analgesics); the most ❖ Regional: Blocks a group of sensory nerves, supplying
frequently administered medications to provide a particular organ or body area
analgesia during labor. (ex.:Demerol IV, IM) ❖ General :Not frequently used in OB due to risks
Advantages involved
❖ Increased ability for a woman to cope Complications of anesthesia
with labor ❖ Hypotension
❖ Total spinal blockade (rare)
❖ Medications may be
❖ Inadvertent injection into the bloodstream
nurse-administered ❖ Spinal headache
Disadvantages ❖ Pruritus
❖ Frequent occurrence of uncomfortable ❖ Respiratory distress
side effects ❖
Fatal complications of anesthesia
❖ Nausea and vomiting; pruritus;
❖ Failed intubation
drowsiness; neonatal depression ❖ Aspiration
❖ Pain not completely eliminated ❖ Malignant hyperthermia: is a disease that causes a
❖ Possible overdose fast rise in body temperature and severe muscle
contractions when someone with the disease gets
general anesthesia. It is passed down through families(
google)
Labor positions
Anticipatory signs of labor
The Four P’s of Labor
❖ Lightening or sense that the baby has
❖ “dropped”
❖ Increased frequency, intensity of
❖ Passageway: Pelvic shape
Braxton Hicks contractions
❖ Passenger: fetus
❖ Gastrointestinal disturbances
❖ Powers: contractions
❖ Expelling the mucus plug
❖ Psyche
❖ Feeling a burst of energy
Clinical signs
❖ Ripening (softening)
❖ effacement (thinning) of the cervix
Fetal lie
❖ Longitudinal lie: Long axis of the fetus is parallel to
maternal long axis
❖ Oblique lie: Between longitudinal and transverse lie
❖ Transverse lie: Long axis of fetus is perpendicular to
Maternal adaptation to maternal long axis
labor
❖ Maternal physiologic adaptation
Fetal presentation
❖ Increased demand for oxygen Foremost part of the fetus that enters the pelvic inlet
during the first stage of labor Three main presentations
❖ Increased heart rate ❖ Head: Cephalic presentation
❖ Increased cardiac output ❖ Feet or buttocks: Breech presentation
❖ Increased respiratory rate ❖ Shoulder: Shoulder presentation
❖ Gastrointestinal and urinary
systems are affected Fetal attitude
❖ Laboratory values impact Relationship of fetal parts to one another
❖ Flexion (ovoid shape):Most favorable for
Fetal adaptation to labor ❖

vaginal delivery
Military (no flexion or extension)
❖ Increase in intracranial pressure
❖ Brow or frontum (partial extension)
❖ Placental blood flow temporarily interrupted at peak of
uterine contractions ❖ Face (full extension)
❖ Stresses cardiovascular system; results in slowly
decreasing pH throughout labor
❖ Passing through the birth canal is beneficial in two ways
❖ Stimulates surfactant production; helps clear respiratory
passageways
❖ Ecchymosis :a discoloration of the skin resulting from
bleeding underneath, typically caused by bruising.(GOOGLE)
❖ Edema: swelling
❖ Caput succedaneum:serosanguinous, subcutaneous,
extraperiosteal fluid collection with poorly defined margins
caused by the pressure of the presenting part of the scalp
against the dilating cervix (tourniquet effect of the cervix)
during delivery.(GOOGLE)
❖ Cephalohematoma: is a traumatic subperiosteal
haematoma that occurs underneath the skin, in the
periosteum of the infant's skull bone. Cephalohematoma
does not pose any risk to the brain cells, but it causes
unnecessary pooling of the blood from damaged blood
vessels between the skull and inner layers of the skin.
Labor Readiness
RIPENING OF THE CERVIX Fetal readiness labor indicators
A “Ripe” cervix: Prerequisite for successful The Fetus should be mature. There are several ways to assess
induced labor. Bishop score is most often maturity:
used to determine readiness for labor ❖ ≥38 weeks’ gestation
❖ Five factors evaluated, each factor ❖ Fetal lung maturity is major point of consideration
scored 0 to 3 ❖ Measuring the lecithin/sphingomyelin (L/S) ratio via
❖ Score ≥8: Associated with amniocentesis assesses lung maturity. An L/S ratio greater
successful oxytocin-induced labor than 2 indicates fetal lung maturity.
❖ Score ≤5: “Unripe” cervix or
Induction of Labor
unfavorable
Never schedule an induction without
asking the bishop score.
Artificial rupture of membranes (AROM) – amniotomy
❖ Causes release of prostaglandins, which enhance
Methods of Cervical Ripening

labor
Nursing interventions
❖ Observing, documenting amniotic fluid color
Mechanical methods ❖ Monitoring fetal heart rate
Oxytocin induction of labor
❖ Membrane stripping ❖ IV oxytocin (Pitocin) is the most common agent
❖ Inserting a catheter into the cervix and used
inflating the balloon holds 30-80cc of fluid ❖ IV line initiated: Infusion pump required
❖ Laminaria: Cervical dilators “seaweed” ❖ Baseline fetal heart assessment before induction .
Pharmacologic methods The RN can titrate the PIT until fetal distress
occurs, however they must call the HCP to obtain
❖ Prostaglandin E2 (dinoprostone) an order to decrease the PIT
❖ Cervidil (string)( tampon like)
❖ Prepidil (gel)
❖ Prostaglandin E1 (misoprostol) ( can cause
rough labor)
❖ Cytotec
Assisted Delivery Potential complications of

Episiotomy: Perineal surgical incision to enlarge the vaginal
opening immediately pre birth
oxytocin induction IV Pitocin
Forceps: Instruments with curved, blunted blades are placed Potential risk for C-section doubles
around the head of fetus to facilitate rapid delivery ❖ Primigravidas versus multi gravidas
❖ Low, outlet forceps are more common than mid ❖ Hyperstimulation of uterus leading to one
forceps contraction after another without substantial rest
❖ Maternal indications: Fatigue; certain chronic periods in between : can blow the uterus. Give 02
conditions; prolonged second stage of labor 10-12L via mask. IV bolus
❖ Nonreassuring fetal strip Water retention may cause
❖ monitor for skull fracture, bruising, and hypoxia ❖ Hyponatremia
Vacuum-assisted delivery: RN assisted: Suction cup ❖ Confusion; convulsions
connected to fetal head; suction is applied, used to guide
delivery ❖ Coma
❖ Can be hazardous to infant, causing ❖ Congestive heart failure; death
❖ Scalp trauma, stop vacuum after 3 pop offs Nursing actions
❖ Subgaleal and intracranial hemorrhage
❖ Death ❖ monitoring mother and baby during
pharmacologic induction interventions
❖ Assist with pelvic examination in mechanical
ripening of cervix or ROM
❖ Document fetal heart rate before and after ROM
❖ Communicate changes as needed
Potential complications of operative vaginal delivery

❖ Neonatal cephalohematoma; retinal, subdural, and subgaleal hemorrhage occur more
frequently with vacuum extraction than with forceps
❖ Facial bruising, facial nerve injury, skull fractures, and seizures: More common with forceps
❖ Potential maternal complications
❖ Extension of episiotomy into anal sphincter
❖ Uterine rupture, perineal pain, lacerations, hematomas, urinary retention, anemia, and
rehospitalization
PRETERM LABOR Assessment
What is it? ❖ Regular or frequent sensations of
abdominal tightening (contractions)
Onset of labor anywhere
between 20-37 weeks ❖ Constant low, dull backache
gestation. ❖ A sensation of pelvic or lower abdominal
pressure
❖ Mild abdominal cramps
❖ Vaginal spotting or light bleeding
❖ Preterm rupture of membranes — in a
gush or a continuous trickle of fluid after
the membrane around the baby breaks
Risk factors or tears
❖ Previous preterm labor or premature birth, ❖ A change in type of vaginal discharge —
particularly in the most recent pregnancy or watery, mucus-like or bloody
in more than one previous pregnancy
❖ Pregnancy with twins, triplets or other
multiples
❖ Problems with the uterus, cervix or placenta
❖ Smoking cigarettes or using illicit drugs Prevention
❖ Certain infections, particularly of the ❖ Seek regular prenatal care.
amniotic fluid and lower genital tract ❖ Eat a healthy diet
❖ Some chronic conditions, such as high ❖ Avoid risky substances.
blood pressure and diabetes ❖ Consider pregnancy spacing.
❖ Stressful life events, such as the death of a ❖ Be cautious when using assisted reproductive
loved one technology (ART).
❖ Too much amniotic fluid (polyhydramnios)
❖ Vaginal bleeding during pregnancy
❖ Presence of a fetal birth defect
❖ An interval of less than six months between
pregnancies
❖ Infection of tissues that surround and
support your teeth (periodontal disease)
Treatment
❖ Terbutaline: Tocolytic
❖ Magnesium sulfate
❖ Betamethasone : to stimulate maturation of
babies lungs.
❖ Hydration
❖ Treatment of UTI
Prolapsed cord
Diagnosis
What is it Umbilical cord prolapse should always be
Umbilical cord prolapse considered a possibility when there is a
occurs when the umbilical sudden decrease in fetal heart rate or
cord comes out of the uterus variable decelerations, particularly after the
with or before the presenting rupture of membranes. With overt
part of the fetus. It is a prolapses, the diagnosis can be confirmed
relatively rare condition and if the cord can be palpated on vaginal
occurs in fewer than 1% of examination. Without overt prolapse, the
pregnancies. Cord prolapse is diagnosis can only be confirmed after a
more common in women who cesarean section, though even then it will
have had rupture of their not always be evident at time of procedure
amniotic sac
Treatments
❖ Lift the baby's head off the cord.
❖ Trendelenburg or knee chest
position
❖
Causes
Hyperoxygenate mom
❖ Never push the cord back in
❖ Premature delivery of the baby
❖ Delivering more than one baby
per pregnancy (twins, triplets,
etc.)
❖ Excessive amniotic fluid
❖ Breech delivery (the baby comes
❖
through the birth canal feet first)
An umbilical cord that is longer
Management
than usual ❖ Monitor fetal heart tones
❖ manual elevation of the presenting fetal part
❖ repositioning of the mother to be head down
with feet elevated
❖ filling of the bladder with a foley catheter, or
tube through the urethra to elevate the
presenting fetal part
NCLEX Tip
❖ use of tocolytics (medications to suppress labor)
have been proposed, usually in addition to
If the cord stops pulsating fetal bladder filling rather than a standalone
death has occured.
intervention
Stages of labor
First stage: Begins with the onset of true labor and
Second Stage of Labor: Expulsion of the Fetus
ends with full dilation of the cervix at 10 cm.
Assessment
1. Early labor
❖ Monitor the blood pressure, pulse, and respirations every 15
2. Active labor
to 30 minutes
3. Transition
❖ Assess the contraction pattern every 15 minutes
Latent Phase (Early Labor): Contractions during
❖ Assess fetal status
early labor are typically five to 10 minutes apart, last
❖ Assess the woman’s report of an uncontrollable urge to
30 to 45 seconds, and are of mild intensity. The
push
cervix is dilated from 1 to 3 cm, and effacement has
❖ Check the FHR every 15 minutes for the low-risk woman,
begun. Possible spontaneous rupture of membranes
every five minutes for woman at risk for labor complications
Assessment
❖ Assess FHR and contractions at least once
every hour
❖ Assess maternal status
❖ Assess status of fetal membranes
❖ Assess the woman’s psychosocial state
Goals, expected outcomes
❖ Goal: The woman and fetus remain free
from injury
❖ Goal: The woman’s anxiety is reduced
❖ Goal: The woman’s pain is manageable
Third Stage of Labor: Delivery of Placenta
❖ Goal: The woman and partner have
adequate knowledge of labor process Assessment
Active Labor: contractions occur every two to five ❖ Assess the woman’s psychosocial
minutes, last 45 to 60 seconds, and are of moderate state after she gives birth
to strong intensity. The cervix should dilate ❖ Monitor for signs of placental
progressively from 4 to 8 cm.contractions are regular separation
moderate and strong. Rapid effacement. Fetal
Selected nursing diagnoses
descent begins.
Assessment ❖ Risk for deficient fluid volume related
to blood loss in the intrapartum period
❖ Assess woman’s psychosocial
❖ Risk for trauma: Hemorrhage, amniotic
state
fluid embolism, retained placenta, or
❖ Assess labor progress
uterine inversion related to delivery of
the placenta
Transition Phase of Labor: contractions should

occur every two to three minutes, last 60 to 90 Fourth Stage of Labor: Recovery
seconds, and be of strong intensity. The uterus Assessment
should relax completely between uterine ❖ Continue to assess for hemorrhage
contractions. Cervical examination during transition ❖ Assess the lochia: Color, quantity
reveals dilation between 8 and 10 cm. ❖ Monitor for signs of infection
The client may be nauseous, vomiting or reporting ❖ Monitor for suprapubic distention
the need to have a bowel movement. Urge to push ❖ Assess comfort level
and bloody show. ❖ Assess mother’s psychosocial state during the
Assessment
fourth stage
❖ Assess for signs that woman has reached
transition phase ❖ Assess initial bonding behaviors of the new
Pushing
❖ Assess woman’s ability to cope family
❖ She will often express irritability, ❖ Vigorous pushing: take a deep breath, hold the breath, and push while
restlessness, and will feel out of control. counting to 10. She is encouraged to complete three “good” pushes in
She may tremble, vomit, or cry. It is this manner with each contraction.
important to assess for hyperventilation ❖ open-glottis pushing: method of expelling the fetus that is
during this phase. characterized by pushing with contractions using an open glottis so that
air is released during the pushing effort.
❖ urge-to-push method, in which the woman bearsdown only when she
feels the urge to do so using any technique that feels right for her
Newborn adaptation
Respiratory system
The Birth process:
❖ Helps expel fetal lung fluid
❖
Thermoregulatory adaptation
Stimulates lung inflation
❖ Stimulates surfactant
production
❖ Surfactant keeps alveoli from ❖ Thermoregulation is the physiologic process
collapsing after expansion of balancing heat production with heat loss
to maintain adequate body temperature
Circulation through the heart ❖ Newborn thermoregulation difficulties
❖ Fetal circulation ❖ Prone to heat loss due to lower proportion of
❖ High pressure in the lungs heat-producing tissue
causes pressure in right atrium ❖ Not readily able to produce heat
> left atrium ❖ Vulnerable to cold stress
Pressure differences help route
blood:
❖ Through the foramen ovale, Newborn loses heat in four ways:
❖ Conduction—body heat transfers to cold
ductus arteriosus object, infant placed in cold scale
❖ Away from non functioning ❖ Convection—air currents blow over infant’s
lungs body, infant susceptible to draft
❖ Back into general circulation ❖ Evaporation—wet skin dries and
❖ Ductus venosus shunts fetal evaporates
❖ Radiation—cold object close but not
blood away from the liver touching, infant close to cold windowpane
causing body heat to radiate to window
Newborn Metabolic adaptation

Newborn compensation
❖ Flexed posture conserves heat
❖ Burning brown fat produces heat
Neonatal hypoglycemia: Blood glucose falls to ≤50
mg/dL
(Differs at facilities)
Early signs of hypoglycemia Late signs of hypoglycemia
❖
Newborn Hepatic adaptation
❖ jitteriness Respiratory distress
❖ poor feeding ❖ Apnea
❖ listlessness ❖ Seizures
❖ Coma Liver immature at birth
❖ irritability Bilirubin
❖ low temperature Conjugated
❖ weak or high-pitched cry ❖ Water-soluble
❖ hypotonia ❖ Excreted in feces
❖ Unconjugated
Apgar score ❖
❖
Fat-soluble
Enters cells causing jaundice
Five parameters Hyperbilirubinemia
❖ Heart rate ❖ High levels of unconjugated
❖ Respiratory effort ❖ bilirubin in the bloodstream
❖ Muscle tone
❖ Reflex irritability ❖ serum levels ≥4 to 6 mg/dL
❖ Color Physiologic jaundice
Scored 0 to 2 points each ❖ Jaundice that occurs after first 24 hours of life
❖ Assessed @ 1 & 5 min of life (usually on days 2 or 3 after birth)
❖ Scores 7 to 10 at five minutes: Doing ❖ Bilirubin levels that peak between days 3 and 5
well ❖ Bilirubin levels that do not rise rapidly (no
❖ Scores 4 to 6 at five minutes: Needs greater than 5 mg/dL per day)
close observation ❖ First appears on head
❖ Score 0 to 3 at five minutes: In The liver manufactures clotting factors necessary for
severe distress normal blood coagulation. Several of the factors require
vitamin K in their production.
❖ Bacteria that produce vitamin K are normally
present in the gastrointestinal tract. However,
the newborn’s gut is sterile because normal
flora have not yet been introduced and colonized
in the infant’s gastrointestinal tract.
❖ Newborns receive vitamin K (AquaMEPHYTON)
intramuscularly shortly after birth
******Prevent hemorrhage *******
If parents refuse, additional paperwork must be
signed by parents.
Principles
Newborn nutrition
Feeding types
❖ At birth, the passive intake of nutrition
ends and the newborn must actively Two main types of nourishment suitable for the healthy
consume and digest food term newborn:
❖ Newborn has unique nutritional needs
❖ Breast milk
❖ Healthy term newborn requires ❖ Commercial formula
❖ 80 to 100 mL/kg/day of water to maintain
fluid balance and growth Two delivery methods:
❖ 100 to 115 kcal/kg/day to meet energy
needs for growth and development ❖ Breast
❖ Bottle
Breastfeeding
Feeding method choices:
❖ Breastfeed exclusively
● Recommended method for feeding newborns
❖ Breastfeed and supplement with expressed breast
● Breast milk is nutritionally superior to commercial formulas
milk in a bottle
❖ Breastfeed and supplement with formula
● The American Academy of Pediatrics (AAP) recommends
❖ Formula-feed exclusively
● Exclusive breast-feeding until 6 months of age
● Continuation of breast-feeding until at least 12 months of
age
● Healthy People 2020 goals
● Increase proportion of women who breastfeed their babies
Maternal advantages Factors that affect feeding

Culture
❖ More rapid uterine involution, less bleeding in the
❖ Acceptability of breast-feeding in public
postpartum period ❖ Amount and quality of family and community
❖ Stress levels decrease; may enhance immune function support for breast-feeding
❖ More sleep at night; weight loss is faster on average ❖ When a woman initiates breast-feeding
❖ Long-term advantages ❖ How many times per day a woman breast-feeds
❖ Whether or not a woman supplements
❖ Decreased incidence of ovarian and premenopausal breast ❖ When a woman stops breast-feeding
cancers ❖ –In the United States
❖ Potential osteoporosis protection ❖ –83% (highest): Asian or Pacific Islander descent
❖ Additional research needed ❖ –59% (lowest): Non-Hispanic African American
women
❖ –Hispanic or Latino: Higher initiation rates (81%)
Newborn advantages than white women at 77%
❖ –Hispanic women are more likely to breastfeed if
❖ Breast milk contains substances that facilitate critical they are of Mexican descent and have not
periods of growth and development, particularly in the
completely acculturated
brain, immune system, and gastrointestinal tract Sociodemographic
❖ Breast milk provides immunologic properties
❖ Breast-feeding rates differ by age, amount of
❖ Lower incidences of otitis media, diarrhea, and lower
education, and socioeconomic status
respiratory tract infections ❖ Past experiences of a woman and her support
❖ No physiologic disadvantages to either the woman or the system
newborn ❖ The feeding experiences and attitudes of the
individuals who compose a woman’s support
Disadvantages system strongly influence a woman’s choice of
feeding method
Maternal conditions or situations in which breast-feeding is ❖ Intent to return to work or school
contraindicated ❖ Plays an important role in a woman’s feeding
choice
❖ Illegal drug use ❖ Nursing considerations
❖ Active untreated tuberculosis ❖ Provide education
❖ Human immunodeficiency virus (HIV) infection ❖ Support the woman
❖ Chemotherapy treatment
❖ Herpetic lesions on the breast
❖ Newborn contraindications
❖ Galactosemia
❖ Phenylketonuria
❖ Other medical conditions
❖ Mother producing insufficient breast milk
The newborn
Complications
Neonatal resuscitation
❖ If the newborn doesn't cry immediately: Transport him or
❖ Neonatal Resuscitation Program (NRP) her to a preheated radiant warmer for prompt resuscitation
❖ Must be able to initiate resuscitation and ❖ Dry him or her quickly to prevent heat loss
assist throughout process ❖ Bag and mask connected to 100% oxygen are used to
❖ First 6 to 12 hours after birth are a critical provide respiratory support
transition period for the newborn ❖ Most newborns do not require resuscitation, and the ones
❖ Must be alert to early signs of distress: who do generally respond well to a short period of positive
Bluish color of the skin and mucous pressure ventilation with a bag and mask.
membranes (cyanosis),Brief stop in ❖ However, a very small number of infants require chest
breathing (apnea), Decreased urine output. compressions, intubation, and medications
Nasal flaring. Rapid breathing.,Shallow ❖ Give constant attention to the airway
breathing.Shortness of breath and grunting ❖ Position newborn on side; bulb syringe is used to suction
sounds while breathing. mouth first, then nose
❖ Must be ready to intervene quickly to
Thermoregulation
Assessment
prevent complications and poor outcomes
❖ Critical to protecting the newborn from chilling
❖ Cold stress increases amount of oxygen and glucose
needed
❖ Heart and respiratory rates at least every 30 ❖ Can quickly deplete body’s glucose and develop
minutes during the first two hours of transition. hypoglycemia( < 40 mg/ dl )
❖ Monitor the axillary temperature every 30 ❖ Easily develop respiratory distress and metabolic
minutes until it stabilizes in the expected range acidosis if exposed to prolonged chilling ( PH < 7.20 )
❖ Dry the newborn while on the mother’s abdomen
between 97.7°F and 99.5°F ❖ Swaddle him snugly, and apply a cap to prevent heat
❖ Be alert for signs of hypoglycemia. loss
❖ A full physical assessment including gestational ❖ Kangaroo care
age assessment is completed within the first few
Hypoglycemia
hours of life.
❖ Ideal glucose range 40-60 mg/dL

Birth ❖ Perform a heel stick Glucose level of less than 50 mg/dL
requires confirmation (see hospital protocol)Immediately initiate
❖ If the newborn cries vigorously: Palpate the treatment ( 20-30 mg/dl start a line, 30-40 mg/dl give sugar
base of the umbilical cord and count the pulse bottle)
for six seconds and multiply x 10 ❖ If the mother is breast-feeding, encourage early and frequent
❖ Pulse above 100 bpm and a vigorous cry are feedings.
reassuring signs ❖ If the newborn is to be bottle-fed, initiate early feedings.
❖ Give constant attention to the airway.
❖ Newborns often have abundant secretions.
❖ A bulb syringe is used to suction the mouth
❖
first and then the nose.
Keep the bulb syringe with the newborn, and
INFECTION CONTROL OF THE NEONATE
teach the parents how and when to suction
❖ UMBILICAL CORD STUMP: Use strict aseptic technique
the baby. when caring for the cord
❖ Triple dye, bacitracin ointment, or povidone-iodine used
initially to paint the cord to help prevent the development
of infection.
❖ PREVENT OPHTHALMIA NEONATORUM: a severe eye
infection contracted in the birth canal of a woman with
gonorrhea or chlamydia.
❖ 0.5% erythromycin
Breastfeeding
Physical control of breastfeeding
Newborn features that facilitate ❖ When the breast is emptied, it responds by
breast-feeding ❖
replenishing the milk supply
If emptied incompletely, it will decrease milk supply
❖ Hormonal control of lactation
❖ Newborn facial anatomy ❖ Pituitary gland releases prolactin and oxytocin
❖ Designed uniquely for breast-feeding ❖ Lactogen
Nose breathers
❖ Rooting and sucking reflex

❖ Present at birth
What is breast Milk

The breast and lactation
Unique organ designed to provide newborn nourishment

via lactation ❖ Unique substance that commercial formulas cannot
duplicate, especially immunologic factors
Consists of 15 to 20 lobes containing milk-producing
alveoli ❖ Colostrum
❖ Higher in antibodies; lower in fat; higher in protein
❖ Makes milk in response to several different stimuli ❖ Milk appears approximately three to five days after birth
❖ Physical emptying of breast
❖ Hormonal stimulation Breast milk supplies 20 calories per ounce
❖ Sensory stimulation
Nutrition requirements for ❖ Foremilk: the breast milk your baby gets at the
breastfeeding beginning of each feeding when your breasts are full.

Foremilk is high in lactose (milk sugar) and low in fat and
calories. It's thin, watery, and it looks white or bluish.
❖ Approximately 500 kcal/day above her prepregnant
❖ Hindmilk: the high-fat, high-calorie breast milk that your
needs
baby gets toward the end of a feeding. It's richer,
❖ Plenty of fluids
thicker, and creamier than foremilk, the breast milk that
❖ Rest
your baby gets when he first starts to breastfeed. The
❖ Eat a balanced diet
color of hindmilk is creamy white.
❖ Multivitamin each day
Positioning for breastfeeding

❖ Assessing breast-feeding readiness
❖ Flat or inverted nipples
❖ History of breast surgery
❖ Attitudes toward breast-feeding ❖ Cradle hold
❖ Quality of support for breast-feeding ❖ football hold
❖ Refer to lactation consultant if special needs exist ❖ side-lying position
Education
Relieving common maternal breast-feeding problems
WHEN THE BABY ISN'T FEEDING WELL
❖ Sore nipples
❖ Engorgement ❖ Dry mouth
❖ Plugged milk ducts
❖ Mastitis ❖ Not enough wet diapers per day
❖ Breastfeeding amenorrhea ❖ Difficulty rousing the newborn for feeding
❖ Return of woman’s menstrual cycle occurs between ❖ Not enough feedings per day
six and 10 weeks post delivery
❖ Ovulation can occur in absence of a menstrual ❖ Difficulty with latching on or sucking
period, and she can become pregnant
❖ By end of third day of life at least six wet diapers and
about three bowel movements per day
❖ Monitor the newborn’s weight daily during the
hospital stay
Postpartum care
Maternal Adaptation During
Postpartum Period Weight loss
Physiologic adaptation
Reproductive system ❖ Immediate 12 to 14 lb = baby, placenta, and
❖ Uterine contraction leads to amniotic fluid
involution(shrinking of the uterus ❖ 5 to 15 lb (early postpartum) = fluid loss from
❖ Measured by assessing fundal height diaphoresis, urinary excretion
❖ Factors promote, inhibit involution ❖ Return to prepregnancy weight six months after
❖ Afterpains childbirth (if within recommended weight gain
range)
assessment/ education ❖ In general, the breastfeeding woman tends to

lose weight faster than the woman who does not
Assess fundal height: Assess the location, breastfeed because of increased caloric
consistency, and height of the fundus through palpation. demands.
❖ If the uterus is not firm upon palpation,
massage it gently. Placing the infant on the
mother’s breast also aids in stimulating
Nursing interventions for
contractions.
postpartum care after cesarean birth
Assessment
Lochia: blood, mucus, tissue, WBC compose uterine Primary causes of maternal mortality post cesarean
discharge ❖ Anesthesia complications
❖ Rubra: first 3-4 days, small-mod amount, ❖ Postpartum infection
mostly blood and dark red with fleshy odor ❖ Hemorrhage
❖ Serosa: days 4-10, decreases to small amount, ❖ Thromboembolism
brownish/pink color Monitor
❖ Alba: after day 10, white-pale yellow, mostly ❖ Lungs; signs of respiratory depression
❖ IV for Sources of pain
WBCs ❖ PCA
Ovaries ❖ discomfort
❖ Ovulation can occur as soon as three weeks ❖ Incision; bowel sounds; urinary output
❖ Signs of thrombus formation
post-delivery
Cervix
❖ Vagina, perineum
❖ Never fully return to pregravid state; Kegel
❖
exercises
Lactation can lead to vaginal dryness, Nursing management & Discharge
Breasts
dyspareunia (painful intercourse)
planning
❖ Colostrum; prolactin ❖ Preventing injury from Rh-negative blood type or non immunity
Cardiovascular system to rubella
❖ High plasma fibrinogen levels and other ❖ Is the woman a candidate for Rho(D) immune globulin
coagulation factors mark postpartum period (RhoGAM) I'M within 24 hours of delivery. Given and checked
Vital signs as if you were administering a blood product.
❖ Temperature may be slightly elevated first 24 ❖ Providing patient teaching
❖ Breast care; fundal massage
hours
❖ Perineum and vaginal care
❖ Slow pulse a first, then WNL first week post
❖ Pain management
delivery ❖ Nutrition; constipation
❖ Blood pressure should not be elevated ❖ Proper rest
For every 250 mL of blood loss, the hemoglobin and ❖ Stress importance of prioritizing self-care
hematocrit (H&H) fall by one and two points, ❖ MMR (subq) right before DC if needed
respectively. So, if the woman’s H&H were 12 and 34, ❖ Evaluation: Goals and expected outcomes
then fall to 10 and 30, the approximate blood loss is
500 mL.
❖ Musculoskeletal system: Abdomen is soft,
sagging immediately postpartum
❖ Gastrointestinal system: Very hungry;
constipation
❖ Urinary system: Transient glycosuria,
proteinuria, and ketonuria are normal
immediately postpartum
❖ Voiding issues
❖ Integumentary system: Copious diaphoresis
common
❖ Striae (stretch marks) on abdomen and breasts
Drug Moa Indication Contraindication / dose / route Nursing action
adverse effects
Phytonadione Helps prevent bleeding by Prevention and treatment IM Monitor for frank and occult
Vit K activating clotting factors of hypoprothrombinemia Pain, swelling, flushing, , Subcut, IV (Children 1 bleeding
dizziness, rapid heartbeat, mo): 1– 2 mg single dose. pulse and BP frequently;. Apply
sweating pressure to all venipuncture
sites for at least 5 min; avoid
unnecessary IM injections.
Erythromycin Suppresses protein Infections caused by infantile hypertrophic pyloric IV/ P.O Monitor for allergic reaction.
Erythrocin synthesis at the level of the susceptible organisms stenosis, PO (Neonates ):
50S bacterial ribosome including pancreatitis,interstitial Ethylsuccinate—20– 50
nephritis.rash. mg/kg/day divided q 6– 12
benzyl alcohol should be hr.
avoided in neonates. IV (Children 1 mo): 15–
50 mg/kg/day divided q 6
hr, maximum 4 g/day.
HEp B vaccine Causes a primary immune Provides immunity against Do not give if baby is already 5 mcg/0.5 mL ; 5 mcg/mL Assess patient anaphylaxis
response. HEP B + ; 10 mcg/0.5 mL (hypotension, flushing, chest
tightness, wheezing, fever, d
HEP B IG Confers passive immunity hepatitis b infection in erythema at IM site, pain, IM : 0.5 mL within 12 hr of Assess patient anaphylaxis
BayHep B, Nabi-HB to hepatitis B infection post neonates born to HBsAg- swelling, tenderness birth. (hypotension, flushing, chest
exposure + women, provides Hypersensitivity to immune tightness, wheezing, fever,
passive immunity. globulins, glycine, or dizziness.
thimerosal.
Drug Mode of Action indications Contraindications/ side dose/route Nursing actions
effects
Hydrocodone Bind to opiate receptors in Management of moderate to Avoid chronic use ROUTE PO Monitor respirations
bitartrate/ the CNS. severe pain. ● Dizziness, sedation, —2.5– 10 mg q 3– 6 hr as needed; Do not give laxatives
acetaminophen respiratory depression,
(Norco)/ Lortab hypotension
Rho(d) immune Prevent production of Administered to Prior hypersensitivity reaction to ROUTE IM/IV Assess vital signs
globulin (human) anti-Rho(D) antibodies in Rho(D)-negative patients who human immune globulin; Rho(D)- or 600 IU (120 mcg) w periodically during therapy
Rho(D)-negative patients have been exposed to Rho(D)- Du-positive patients. 40– 125 mg qid, after meals and at
who were exposed to positive blood by: Pregnancy or ● HTN, hypotension, bedtime (up to 500 mg/day)
Rho(D)-positive blood. delivery of a Rho(D)-positive anemia
infant,
Simethicone Passage of gas through Relief of painful symptoms of Not recommended for infant colic ROUTE 40– 125 mg qid, after Assess patient for
Gas-X the GI tract by belching or excess gas in the GI tract that ● None significant meals and at bedtime (up to 500 abdominal pain, distention,
passing flatus may occur postoperatively mg/day) and bowel sounds prior to
and periodically throughout
Docusate Promotes incorporation of Prevention of constipation (in Hypersensitivity; Abdominal pain, ROUTE PO Assess for abdominal
Peri-Colace, water into stool, resulting in patients who should avoid nausea, or vomiting, : 2 tablets once daily at bedtime; distention, presence of
softer fecal mass straining, such as after MI or maximum 4 tablets twice daily. bowel sounds, and usual
rectal surgery) pattern of bowel function.
Drug MOA Indication Contraindication/ route/dose Nursing actions
Side effects
Surfactant Replaces surfactant Treatment of respiratory None Intratracheal: Monitor ECG, heart rate, color, chest expansion,
(beractant) in premature infants distress syndrome in ● O2 desaturation (4 mL/kg birth weight); 4 doses may o2 sat, and ET tube patency continuously
premature infants. be given in first 48 hr of life, q 6 hr Continuous bedside monitoring for 30min
apart
Caffeine citrate Decrease periods of Short-term treatment of Hypersensitivity ROUTE IV/PO necrotizing enterocolitis (abdominal distension,
apnea idiopathic apnea of ● Tachycardia, Maintenance dose—starting 24 hr vomiting, bloody stools, lethargy).
preemie infants between feeding after loading dose 5 mg/kg
28 and 33 wk gestational intolerance,
age. gastritis
Prostaglandin E1 relaxes smooth Temporary maintenance Respiratory distress ROUTE IV respiratory rate, heart sounds, and neurological
(alprostadil) muscle of the of patent ductus arteriosus syndrome 0.05– 0.1 mcg/kg/min initially; may status frequently
ductus arteriosus in neonates ● Seizures, be increased up to 0.4 mcg/kg/min
cerebral bleeding, until satisfactory response
ampicillin Binds to bact cell Treat bacterial infections Hypersen to PCN ROUTE IM/IV Observe for anaphylaxis (rash, pruritus,
wall ● Seizures, pseud Children 40 kg): 100– 200 mg/kg/day laryngeal edema, wheezing).
colitis in divided doses q 6– 8 hr (not to
exceed 12 g/day).
HMF (human milk Increased digestion Pancreatic insufficiency Hypersen to hog proteins ROUTE PO Monitor stools for high fat content Stools will be
fortifiers) of fats, carbs, and ● Shortness of (Children 1 yr): 2000– 4000 lipase foul-smelling/frothy.
enzymes proteins in the GI breath, dyspnea units per 120 mL of formula/breast Assess patient for allergy to pork
tract. milk.
Autism Spectrum Disorder
Mental Health "Psychiatric Care"
Pathophysiology Risk Factors

MOST tested
ASD is a developmental disorder that impairs a child’s

ability to communicate and interact. Cause of autism is
Highest risk factor
unknown.
= sibling with autism
?
C
T
HESI
U
C
B
A
For example - while performing a developmental

?
Delayed developmental milestones
screening on 2 siblings. If the older sibling has autism
? T
U
C
? ATI
Autism can usually be diagnosed when
then the younger sibling is at highest risk for having it too.
Don’t let NCLEX trick you

C the child is approximately:
B Highest risk factors are NOT having early vaccinations
2 years of age
A & NOT having parents of older age - this is according to
the NCLEX.
Signs & Symptoms
Does NOT T
U
C
Maintain eye contact NCLEX TIP

B
A
Interact with gestures

Like being cuddled & plays alone
Education
Does NOT
Respond to questions NCLEX TIP
Routines & Consistency
Are
Display nonverbal behavior you

hungry?
Delay in language development Give a schedule of daily activities NCLEX TIP

C C
B B
A A
A
Maintain daily routines when possible HESI
Repetitive
Avoid making acute changes in their environment
Actions “Ritualistic behavior”
Words (echolalia)
HESI HESI
HESI Q1: Child with autism spectrum disorder (ASD).
Limit
Q2: Child with autism spectrum disorder. Which

The parents say, “We are going to move our child statements by the parents indicate … that they
Child who plays alone, does not maintain eye to a different bedroom in our home.” understand the teaching?
contact, repeatedly twists fingers, has inadequate Select the nurse’s therapeutic response. Select all that apply.
ASD - Autism Spectrum Disorder C
A
B
C
A
B
speech, and does not interact with gestures? “Children with autism spectrum disorder Repetitive movements are common
usually prefer for things to stay the same.” Non-verbal communication is limited
Autism spectrum disorder (ASD) Maintain a daily routine whenever possible
T
C Kaplan
U
C Child with autism is admitted to the pediatric
A
B unit ... Which response by the nurse is best? Prevent Overstimulation
“The inability to maintain eye contact
is a characteristic of autism.” Limit number of visitors & choices
Private room away from the
ATI nurse’s station NCLEX TIP
1... 2... 3...
4... 5... 6... C
Which of the following manifestations …

B
A
are indications of autism spectrum disorder?

Select all that apply. ATI
A
A
A
Nonverbal behavior What is the most important intervention when

Repetitive counting I
W
A admitting a child with autism spectrum disorder?
B
Spins a toy repetitively
Placement in a private room down the
Delayed language development
corridor from the nurses’ station
Exhibits ritualistic behavior
ADD/ADHD
Pathophysiology Management
ADD - Attention Deficit Disorder Give a written schedule

ADHD - Attention Deficit Hyperactivity Disorder of daily activities NCLEX TIP M T W TH F SA S
Aggressive behavior:
The brain has low levels of the neurotransmitters dopamine &
distract the child & ask
norepinephrine which help the brain focus on reward vs. risk and
them to blow up a balloon
control impulsivity & mood, making client with ADHD more likely
to have anxiety & substance abuse problems. Increased risk for injury
Always think calm with ADHD ATI Question

9 year old hospitalized
client on bedrest who has
attention deficit disorder…
Which of the following
should the nurse prioritize?
Dopamine Norepinephrine
● Provide the child with
a daily schedule that
is typed or written
Signs & Symptoms

HESI Question
A nursing diagnosis that should be
considered for a child with attention
deficit hyperactivity disorder is
1. Hyperactivity “restless”
● Risk for injury
2. Inattention “reduced ability to focus”
ATI Question
3. Impulsiveness “excessive talking”
… new diagnosis of ADHD… which
4. Low self-esteem & impaired social of the following statements should
the nurse include in the teaching?
skills NCLEX TIP ● Your child is at an
increased risk for injury
Communication ATI Question

6 year old client with … ADHD. What
techniques should the nurse use to
communicate most effectively with the client
when asking the client to complete a task?
1. Eye contact first (before speaking) ● Obtain eye contact before speaking
● Use simple language
2. Simple language ● Have him repeat what was said
● Praise him if he completes a task
3. Child repeats back what was said

Kaplan Question
4. Offer praise upon task completion ... child with attention deficit disorder. Which
statement by the nurse is most appropriate?
● “Hug your child after a task is completely
performed.”
Causes & Risk Factors

Classroom Strategies
• Head trauma: TBI (traumatic brain injury)
ATI Question
Children who have had a serious head injury are more
… classroom strategies for
likely to develop ADHD later on in age. children who have ADHD. Which
of the following information
should the nurse plan to discuss
with the teachers?
ATI Question Select all that apply.

CLASSROOM
RULES
● Allow for regular breaks

Risk factors of ADHD… ● Combine verbal instruction
Which of the following with visual cues
should the nurse include ● Establish consistent
in the teaching? classroom rules
● History of head trauma ● Decrease the amount of
homework assigned
Abuse & Neglect
Elder
Elder neglect is a form of abuse that happens when the caregiver fails to provide for the needs of the elderly client
either emotionally, physically, or socially.
Key signs Caregiver Role Strain (CRS) HESI Question

Poor eye contact NCLEX TIP
Assess stressors & A 79-year old … weighs 93 lbs,
“Client breaks eye contact when NCLEX TIP and is wearing old, dirty clothes …
talking with a caregiver” Unmet needs
diagnosed with pneumonia.
Broken assistive devices Ask about the nature & requirements Which comment by this patient
Glasses, hearing aids of providing daily care suggests a significant risk for
Expired medication abuse?
Physical KEY WORD
Our family is poor, so my daughter
Weight loss, dehydration & malnutrition What is the nature & requirements
gets my monthly retirement and
Pressure ulcers
of providing daily care? Social Security checks
Poor Hygiene: orally, soiled clothing
Intimate Partner Violence

Intimate partner violence is domestic violence or abusive behavior inflicted by one partner against the other
- be it physically, emotionally, verbally, sexually, or economically.
HESI Question
HESI Question The clinic nurse notes bruises in various
Abusive partner: extreme jealousy & ... expect the abuse to worsen?
stages of healing... What questions must the
nurse include?
possessiveness NCLEX TIP When the victim moves toward Select all that apply.
Is anyone hurting you?
Abuse gets more intense during pregnancy independence from the abuser
When you and your spouse disagree, what
happens to you?
Victim stays: Financial, Fear of harm, Has your spouse ever threatened you
Please,
Child custody, Religion, etc., i need help!
verbally or with violence?
ATI Question
Interventions Which of the following ... should the nurse
implement … client in a domestic violence
Priority Action: situation?
Have partner leave the room to speak with Assure the victim that he/she is not alone
Preserve any physical evidence, if applicable
& examine client in private
Convey an attitude of concern and respect
for the client
Treatment HESI Question

Victim … injuries associated with intimate partner violence.
The patient plans to return home. Which action by
Affirm that the patient did not HESI the nurse has priority? Local shelter
deserve or cause the abuse Provide the patient with contact information
for the local shelter.
Developing a plan to assure safety: Local shelter
ATI Question
Psychotherapy (Talk Therapy)
… coping strategies … clients who are
Identity triggers experiencing intimate partner violence...under-
standing of the teaching?
Recognize destructive patterns of behavior &
“I should try to identify issues that increased my
learn alternative responses partner’s stress level.”
CBT - Cognitive Behavior Therapy
Pathophysiology
Kaplan Question
CBT is a common type of psychotherapy (talk therapy). It helps clients reframe
A client states ... “I travel only
their thought processes in order to slowly cope with stress & anxiety, helping by train because I am terrified
of flying.” ... the phobic client
to treat many disorders from PTSD & OCD, to eating disorders like anorexia & is most likely to respond to
bulimia, and even depressive disorders. which intervention?
• Systematic desensitization
5 CBT Strategies NCLEX TIP Systematic desensitization

1. Learn about the disorder HESI Question
Q1: A nurse teaches ... examining
2. Exposure: Desensitization negative thoughts and
to situations & events restating them in positive
(behavioral strategies) ways. The technique is call:
• Cognitive reframing
3. Self-observation & monitor
Q2: The nurse is teaching
4. Relaxation techniques
Gradual exposure to a phobia or traumatic event cognitive reframing ... to
5. Teaching new coping skills & counteract depression.
which helps to desensitize the client to the major Which response by the
Techniques to reframe thinking patient indicates effective
(Cognitive restructuring) stress & anxiety & at the same time administer teaching by the nurse?
Systematic desensitization relaxation techniques. • “I have many friends who
love me and care for me.”
Guided Imagery Biofeedback

Guided imagery is a mind-body intervention where Biofeedback is just like guided imagery, but the key
clients concentrate on mental images to help reduce difference is that machines are used to help the mind
stress, anxiety, & improve concentration. focus, sort of like virtual reality
ATI Question
Q1: Which of the following have been
ATI Question
shown to be advantages of using
guided imagery? A nurse is providing
Select all that apply. education to student nurses
• Finding relaxation and inner peace about non-pharmacological
• Solving complicated problems
• Improving concentration
modalities of pain control.
Which best describes
Q2: Which of the following information biofeedback?
should the nurse include about
guided imagery? • Teaching the body to
• It concentrates on descriptive respond differently to
mental pictures to treat stress of other stimuli
pathological conditions
Therapeutic Milieu Group Therapy KAPLAN Question

Q1: The nurse understands which is the
This provides a safe & secure environment for clients that Goal primary benefit of group therapy?
• Groups reduce isolation in structured,
are in therapy. It’s basically the goal of every behavioral Reduce isolation &
controlled environments
Q2: The client with depression joins an
health or psych unit in the clinical setting. Clients are Communicate acceptance ongoing therapy group. Which is the
goal of group therapy?
encouraged to freely roam around in the social • To communicate acceptance to
environment. Problem? the client
• Allow the group to handle it HESI Question

• Silent member: encourage ... one participant ... interrupts others
Kaplan Question interaction, then divide
when they are talking. What is the best
action ... to take in this situation?
Psychiatric inpatient setting: which
description is the best for milieu therapy?
groups into pairs • Allow the group to handle the problem
• Aggressive member:
• Providing a therapeutic physical and
social environment address the anger & separate ATI Question
in another room
HESI Question Q1: Group therapy: Which of
the following is the primary
Primary goal of milieu therapy for patients focus of group therapy?
diagnosed with personality disorders? • Personal feelings that
• Managing the effect of the behavior on
affect behavior
the entire group
ATI Question
Q2: Group therapy: Which
response should the nurse
... how to establish a therapeutic milieu on make to a client’s
the unit? aggressive statement?
• Orient new clients to their environments,
rights, and responsibilities • “You seem very upset.”
Crisis Management
ATI Question
4 Phases … which of the following best
1. Trigger event: anxiety in describes what should be in
the first box?
response to threat ● The triggering event
2. Escalation: increasing The
anxiety & agitation Kaplan Question triggering
event
Escalation Crisis Disorganization
3. CRISIS: outburst, The client states, “I feel like I

can barely get out of bed in
violence, or shouting
the morning.” The nurse
4. Post Crisis Disorganization recognizes the client is in
which stage of crisis?
& Depression
● Disorganization & depression
Interventions 1st 2nd 3rd
...
...
HESI Question ATI Question HESI Question

Communication
The patient becomes agitated and Q1: A client becomes agitated and threatens
Q1: A client … bursts out in a verbal
threatens to harm a staff person. Which to punch the other client. What is the
priority action by the nurse? tirade in the dayroom. The client
nursing intervention is appropriate?
● Eliminate the trigger using nursing has a history of poor impulse
● Address the patient with simple
measures and interventions control. What is the nurse’s
1. Explain all activities of care clearly directions and a calming voice
Q2: … yelling and screaming at the staff…
priority action?
Kaplan Question
● Remove any other clients from
& calmly NCLEX TIP which actions should the nurse take?
● Determine the true source of the
the day room
When intervening with a violent client, client’s anger Q2: When approaching an angry
2. Eliminate the trigger the nurse takes which action?
● Identifies the nurse to the client and
Q3: angry and throws a chair in the dayroom.
Which of the following interventions
patient, which safety
considerations should be taken?
remains calm should the nurse perform first?
3. Low-stimulation environment
● Have other staff as backup,
● Acknowledge the client’s emotions and stand far enough away
- NOT near nurses station

to avoid injury
4. Determine the source of anger

I'm Lily and
I'm here to help
I see you
are upset
5. Acknowledge the client's emotions
Pharmacology
Anxiolytics
HESI Question LORAZEPAM
A client who is displaying violent behavior.
Benzos: “-pam” “-lam” Which of the following medications
Lorazepam (brand: Ativan) should the nurse expect the provider to
prescribe? Select all that apply. HALOPERIDOL Ziprasidone
hydrochloride
Antipsychotics: ● Lorazepam Geodon
● Haloperidol
Haloperidol (brand: Haldol) ● Ziprasidone
Ziprasidone (brand: Geodon)
Physical Restraints
1. Get an order for restraints
HESI Question
Physical restraints are placed on the client,
(Renewed every 4 hours Adults) and then the client is put into a seclusion
2. Must be assessed by HCP within room. Which actions must the nurse take in
the next hour?
1 hour of order
● Meet the physical needs of the client
3. Document every 15 minutes ● Obtain a prescription for the restraints
● Objectively document the client’s behavior
4. Monitor & meet physical needs
Death & Dying
5 Stages of Grief Bowlby’s 4 Stages of Grief

KAPLAN
Q1: The client appears angry and demanding following a
1. Denial below-the-knee amputation.

The client is having difficulty accepting the new
Numbness or protest
body image
Q2: After being told the feet will need to be amputated,
2. Anger the client states, “I’m sure if I start taking my medication

my feet will heal.”... example of which behavior?
Denial
? ?
? ? Disequilibrium
3. Bargaining ATI
… acute grief process. Which of the
following statements made by the client
4. Depression indicates understanding of feelings? Disorganization and despair
Select all that apply
I might experience feelings of resentment
I might have some guilt over how my
5. Acceptance partner died
I might have angry feelings that I Reorganization
should express
Defense Mechanisms
Type of Loss HESI
A client on the psychiatric unit seeks out
Perceived loss a particular nurse and imitates her
mannerisms. Which defense mechanism?
1. Disaplacement NCLEX TIP
The type of loss that is felt by the person, but is
intangible to others. For example loss of financial
independence or a valued personal item. Identification
shifting of anger or impulses from an outside situation toward another person.
Situational Loss
2. Repression Unexpected loss caused by an external event, like HESI
cancer in a family member.
Choosing to hide or ignore painful memories instead .. an adolescent with a history of violence
Maturational Loss ... sublimation?
of facing them in hopes of forgetting. Loss that is expected with normal life transitions, like Joined a competitive boxing team
graduating from high school & leaving your friends
3. Compensation behind.
KAPLAN
Overachieving in one area to compensate for failures in another.
The client is told ... she cannot have
ATI
4. Undoing … best describes an instance when
children.... forms a close attachment to the
niece and nephew … example of which
A person tries to cancel out an unhealthy memory, by doing good acts. displacement is used as a defense defense mechanism?
mechanism? Sublimation
5. Sublimation A man who loses his job goes
home and yells at his wife ATI
A person channels unacceptable desires into an activity that is appropriate & safe.
… a client who was bullied about his
HESI interest in chemistry now tutors students
6. Projection having difficulty with science. Which of the
A 20 year old was sexually molested at age following defense mechanisms?
Taking unacceptable qualities or feelings & pinning them on other people. 10, but can no longer remember the Sublimation
incident... defense mechanism used:
7. Rationalization Repression
IDENTIFICATION
Justify illogical or irrational ideas & feelings
KAPLAN
8. Identification … a client with alcoholism… states, “I
need a drink or two to relax after a busy
A person adopts the behavior of a person who is perceived to be more powerful
day at work. I have an incredibly high
stress job.” ...which defense mechanism?
Rationalization
Interventions - Pediatric Interventions - Adult
• Therapeutic communication
1. Play therapy I feel sad
• Sit with the client
• Support Groups
2. Honestly answer questions • Focus on good memories
3. Therapeutic touch ATI Saunders

A nurse is caring for a client who just … an older client whose spouse died 6
delivered a stillborn fetus at 36 weeks months ago. Which behaviors by the client
of gestation. Which of the following
KAPLAN HESI statements should the nurse make?
indicates effective coping?
The parent of the younger child asks the A 6 year old learns about the death of a You may hold your baby as long as Looking at old snapshots of the family
nurse why the child is involved in play grandparent… What will the nurse you want NCLEX TIP
therapy. Which statement is best? Participating in a senior citizens program
include in the parent’s teaching plan?
Select all that apply. Visiting the spouse’s grave once a month
“Young children have difficulty
verbalizing emotions.” NCLEX Decorating a wall with the spouse’s
Promote activities that the child enjoys pictures and awards
You may hold your baby
Encourage the child to express feeling as long as you want
through coloring
Young children have difficulty
verbalizing emotions
Answer the child’s questions honestly

Hold and cuddle the child to rein
force closeness
Dissociative Identity Disorder
Pathophysiology
Dissociative identity disorder occurs when 2 or more identities rotate control over the client’s behavior.
Clients will typically have amnesia or lack of memory, not aware that the alternate identities exist, & often
confused by the big gaps in their memory.
How does this happen? Ususally originated by a traumatic event like abuse or rape, the various identities
& memory gaps serve as protective mechanisms helping to shield the client from the traumatic memories.
Naturally, stress & anxiety that remind the client can trigger the identities into play.
HESI Question
Dissociative episode: .....
Select all that apply. .....
Dissociation is a method for
coping with severe stress
Dissociative symptoms are not under
the person’s conscious control
The existence of two or more
subpersonalities, each with its
own patterns of thinking
Treatment
The goal of care is to help the client merge the various identities into 1 personality by integrating past events.
5 NCLEX TIPS HESI Question HESI Question

grounding techniques...
to alleviate symptoms? Which factor would indicate
1. Grounding techniques: Hold an ice cube in your hand successful treatment?
Deep breathing, counting coins,
The patient has integrated
holding an ice cube past events
2. Journal about feelings & triggers
3. Trust: Develop a trusting Remember?
relationship with each identity
4. Self-harm: Monitor & listen for
expressions of self-harm
5. NEVER ask the client to
recall memories
Notes
OCD
Pathophysiology
ATI Question
Client with OCD ... constantly reorganizing
Obsessions = books ... the client uses this behavior to do
Excessive thoughts & impulses which of the following?
You should
Compulsions = take a break. Decrease anxiety to a tolerable level
Repetitive “ritualistic behaviors” 1 2 3 4
Kaplan Question
.. client with OCD must wash, rinse, and dry
Key term door handles before entering or leaving a
Give a reminder that it’s time to take a break, room. Which action by the nurse is best?
since the client has been cleaning for hours. Provide time for the client to complete
the ritual
Treatment You should spend only
HESI Question 5 minutes on this.
Initial Plan of Care 5 NCLEX TIPS ... priority nursing action 3 days
after the admission of a client
1. Decrease ritual time slowly diagnosed with OCD? This time try to spend
only 4 minutes.
NEVER “suddenly” deny ritualistic gradually decrease the

activity (initially) compulsive behaviors
Gradually limit the time of the activity
2. Identify triggers that increase anxiety
3. CBT: thought stopping techniques
TOP Missed NCLEX QUESTION
While evaluating a client with obsessive-compulsive disorder, the nurse
knows which of the following indicates an improvement in effective
4. Relaxation / Redirection coping?
Deep-breathing CBT In the morning when I feel anxiety building, I have been able to
attend an exercise class to decompress.
Exercise (take a short walk)
Completing rituals of handwashing effectively helps me cope with
my anxiety and ensures that I am clean.
5. Communication
My mom helps disinfect my house everyday when I am at work, so
NEVER say judgemental comments I can have peace of mind everything is clean.
about OCD habits My boss gave me a large project which has increased my stress,
but I will use deep-breathing to decrease my anxiety.
Give positive feedback during group
I used to wash door handles 10 times before opening, but for
activities & non ritualistic behavior 2 weeks now I can open doors without washing them.
OCPD - Obsessive Compulsive Personality Disorder Pharmacology
Clients will have their Antidepressants

whole day planned out NCLEX TIP
SSRI: Sertraline & Paroxetine
SNRI: Duloxetine
MEMORY TRICK
Anxiolytics
OCPD Benzodiazepines
Punctual NCLEX TIP Barbiturates
Perfectionism Buspirone
I have to do this way. ATI Question

… client with obsessive-compulsive
personality disorder (OCPD)...
I don’t want change!
information about the diagnosis.
Select all that apply. PAROXETINE
SERTRALINE
Perfectionism and
overemphasis on tasks
This disorder typically involves
inflexibility and a need to be
in control
Personality Disorders
HESI
Which behaviors are demonstrated characteristically
Narcissistic Personality Disorder by a patient diagnosed with narcissism?
Grandiose, exploitive, and rage-filled behavior
Believes they are perfect Exploitation of others
Acts entitled, arrogant, & grandiose ATI

Relies on constant reinforcement & need for admiration Narcissistic personality disorder: Which of the
= attempt to maintain self-esteem NCLEX TIP following manifestations should the nurse expect?
Lack of empathy
Feelings of entitlement
HESI
Which behavior indicates... that a client with paranoid
ideas is improving?
Paranoid Personality Disorder Discusses his feelings of anxiety with the nurse
ATI
Distrust & suspicion of others
A client with a paranoid personality disorder sees some
Intense need to control the environment NCLEX TIP clients laughing … asks the nurse, “Why are they laughing
at me? I bet they are making fun of me.” Which of the
following responses… is most appropriate?
“They are laughing at a joke another client told.
They are not laughing at you.”
HESI
Histrionic Personality Disorder … a patient behaves in a melodramatic way and acts
flirtatiously. What possible personality disorder
4 NCLEX TIPS does the patient have?
1. Center of attention Histrionic personality disorder
2. Exaggerated or shallow emotional expression
ATI
3. Little tolerance for frustration & demands gratification Histrionic personality disorder: Which of the following
4. Overly friendly & flirtatious findings should the nurse expect?
Lack of insight
Dependent Personality Disorder

ATI
Extreme dependency in a relationship
& fear separation. Dependent personality disorder:
Which of the following actions should the
PROGRESS
nurse plan to take?
2 NCLEX TIPS
Give positive feedback when the client is
1. “My sister could not drive me here, so I took the bus.” assertive with staff or clients
2. “I am planning which plants I wish to cultivate this spring”
HESI
Q1: Priority nursing intervention... borderline personality disorder:
Borderline Personality Disorder Assess for suicidal and self-mutilating behaviors
Q2: Primary coping style of persons with borderline personality disorder?
Fear of being abandoned & uses manipulative behavior “Last night the nurse let me go outside and smoke. I can’t believe you
1. Cling to 1 favorite staff aren’t letting me. I used to think you were the best nurse here”
2. Self-harm to draw attention = HIGH risk for suicide ATI

Priority action: 2 NCLEX TIPS Q1: Client with borderline personality disorder … makes numerous minor
1. Assign different staff members to the client each day requests & spends a lot of time near the nurses station. How should the
nurse interpret these behaviors?
2. Assess immediately: any self-harm behavior “superficial cuts” Fear of abandonment and attention-seeking
Q2: Client at greatest risk for suicide?
Personality disorder
KAPLAN
I'm not guilty!
Q1: The client shoves another client out of the way …Which action
Antisocial Personality Disorder should the nurse take?
Calmly confront the behavior and remind the client of consequences for
negative behavior
Impulsive, manipulates others for personal gain & lacks empathy Q2: Which statement best indicates improvement in the client’s condition?
“I get into trouble because I don’t think before I act.”
HESI
ATI
... antisocial personality may present with which characteristic?
1 2 8 4 8 … demonstrating manipulative behavior. Which of the following actions
Lack of remorse
should the nurse take?
Institute consequences for manipulative behavior
HESI
Schizotypal Personality Disorder A patient is withdrawn and suspicious ...
prefers to be alone… patient describes themself
Withdrawn & alone as having “special powers” and states, “I believe
we can all read each other’s thoughts at times.”
“Special powers” & Magical thinking … which personality disorder?
Schizotypal (STPD)
Phobias
Pathophysiology
Phobias are excessive fear of an object or situation.
HESI Question
The inability to leave one’s home
because of severe anxiety
Phobias disorder • Panic attacks with agoraphobia
Arachnophobia: fear of spiders

Zoophobia: fear of animals ATI Question
Q1: “I am terrified of being
Claustrophobia: fear of being
outside alone.” The nurse
closed in should identify that the
Agoraphobia: NCLEX TIP client is experiencing which
of the following phobias?
Fear of leaving a safe place
“riding on trains or buses”
• Agoraphobia
Q2: Phobias can be
manifestations of PTSD
Therapeutic Communication
You always want to assess first, & reinforce the facts,

simply state what the client has just stated, for example:
You feel like your

KAPLAN Question fear does not make
Q1: Phobic disorder: “I am so
terrified of heights that the sense, but it is very
thought of going up my stairs
makes me feel like I am going real to you
to hyperventilate. I know it
sounds ridiculous.” Which
response is best?
• “You feel like your fear does
not make sense, but it is
very real to you.”
Effective Coping
This is demonstrated as clients increase their comfort

levels little by little when exposed to their phobias. 3 NCLEX TIPS
This is done via systematic desensitization:
meaning the clients gradually get exposed to their phobia 1. Increased comfort while
little by little - to decrease the anxiety over all. exposed to the phobia
Systematic desensitization 2. Verbalizing feelings &
insight about anxiety
KAPLAN Question (self observation)
“I travel only by train because I
am terrified of flying.” … phobic
client is most likely to respond
to which intervention?
3. Self distraction: focusing
• Systematic desensitization on something other
than the phobia
PTSD & Acute Stress Disorder
Pathophysiology
PTSD - Post Traumatic Stress Disorder
Acute stress disorder ASD is a mental disorder that can

occur within the first month following a traumatic event
- typically a near death experience like war, sexual assault,
a car accident, physical abuse, & others, it becomes
PTSD - Post Traumatic Stress Disorder if symptoms
persist over 1 month.
1st month
Signs & Symptoms

NCLEX TIPS
Increased anxiety
• Sweating, pounding heart
• Persistent anger
• Hypervigilance & restless
Flashbacks & Reliving the event
Feeling detached from others
Sleep disturbance:
• Insomnia
• Recurring nightmares
AVOIDing reminders of trauma
Assessments
1. Self-harm: thoughts or plans HESI Question Kaplan Question

2. Substance abuse (drugs & alcohol) Q1: … “The war was years ago, but I victim of bank robbery
still remember my friends who
…. reports daily
3. Relationships with family & friends You could not were killed. I don’t know why I
have anticipated
lived and they died.” What is the flashbacks … Which
rape & you did
4. Explain that difficult symptoms not deserve it
nurse’s priority response? action is best?
after the trauma are normal • Are you having any thoughts
of harming yourself? • Offer assurance of
5. Rape Victim: Assess for guilt Q2: PTSD … first stage of the safety, & tell the
& shame NCLEX TIP treatment? client these feelings
• Reinforce the client could not • Stopping self-destructive
behavior of the patient are normal
have anticipated rape
& did NOT deserve it
Interventions Pharmacology
HESI Question
Q1: war veteran … says, “Sometimes I
still hear explosions but I know I am
safe in my home.” What is the
Antidepressants
nurse’s best response?
• You are experiencing flashbacks. I’d
1. Priority Action: NCLEX TIP like to arrange for you to talk more SERTRALINE
about your feelings and reactions
Encourage the client to talk about SSRI: Sertraline & Paroxetine
Q2: Which actions will the nurse include
the traumatic experience at their in the war veteran’s plan of care? TCA: Amitriptyline & Imipramine
own pace • With each session, explore each
traumatic experience more deeply
2. Exposure therapy
Anxiolytics
3. Group therapy PAROXETINE
• Benzodiazepines
4. CBT: thought stopping techniques • Barbiturates
• Buspirone
Somatic System Disorders
Pathophysiology
SDD is a psychological disorder where clients have unexplained physical symptoms like abdominal pain, weakness,
chest pain, shortness of breath, & others. The key point is that there is NO medical cause of the physical symptoms!
All diagnostic tests come back negative. These physical symptoms are real & clients are not making them up or faking it.
Unexplained physical symptoms

NO medical cause
?
IVE
NEGAT
Causes
Clients will often obsessively focus their time & energy on the symptoms, often going to many different doctors &
practitioners in order to get a medical diagnosis that does not exist. All the pain in the body is typically caused by stress.
FIRED
Interventions
Limiting focus on being sick

Limit time discussing
NCLEX TIP
physical symptoms
Promote insight
FIRED
Don’t let
Identify stressors that THE EXAMS TRICK YOU
intensify symptoms
- DO NOT reinforce negative exam
Coping mechanisms results when the client wants pain
meds.
(Stress reducing techniques)
- NEVER debunk or dispute the clients
Deep-breathing symptoms saying they are not real!
Meditation - DO NOT advocate for more diagnostic
tests or a new diet plan, since it is a
Exercise psychological disorder.
Open-ended questions I don’t hear any voices,

but I know this is frightening for you. HESI
These are NOT simply “Yes” or “No” Open-ended questions?
questions, rather it requires an in Select all that apply.
depth response. “How do you cope with anxiety? ”
“What event in your life has been
Closed-ended comments the most stressful?”
“Can you please tell me more about
what was happening to you that led
Stating facts used portray empathy,
you to be hospitalized here?”
builds trust & assess further.
Top Missed NCLEX Question

Elderly client losing their spouse to pancreatic cancer. Choose the most therapeutic response.
Build TRUST 2 NCLEX TIPS AVOID Select All That Apply
1. Leave the room to allow the client to grieve in private.

1. Ask & Assess Emotions “Non-Therapeutic” Communication 2. “I recently lost my grandfather to cancer, so I understand what you are going through.”
“Tell me when you started noticing ...”
NEVER: Offer opinions, advice, or 3. “I know this is a difficult time for you. Tell me how you have been coping with this loss.”
“Tell me what concerns you have ...” personal experiences
“What are you feeling right now?” NEVER: Minimize client’s feelings 4. “What are your feelings & thoughts about attending a support group.”
“How are you feeling about your baby?”

NEVER: Leave the room! 5. “It takes time to deal with & come to terms with a lost spouse, but it will be ok”
2. State Facts
NEVER: Give false reassurance NCLEX TIP 6. “Why do you feel sad when you are alone?”
“We have the vital signs under control”
“You must be very upset after “Everything is going to be alright”
experiencing this”
“I’m sure you will do the correct thing”
“I understand you are worried” Why do you feel sad when you are alone?
NEVER: Ask “WHY?” NCLEX TIP
“You sound very discouraged & scared.”
“You sound angry. Anger is a normal “WHY do you feel angry when…”
feeling associated with loss.”
“WHY do you act this way?”
Combo:
“This experience has been overwhelming “WHY did you leave your child alone”
for you. What are you feeling right now?”
“Client’s with cancer experience fear of
dying, tell me about your concerns.”
Practice Questions
Ask Questions ATI
HESI
Exploring emotions: Q1: What is the most helpful nursing response to a
Q1: “I am really concerned about my mom.” Which of the
following responses should the nurse make?
gather more information patient who reports thinking of dropping out of college
because it is too stressful?
“Tell me what is troubling you.”
Restating: repeating patient words “School is stressful. What do you find most stressful?” “Tell me about what you are feeling right now.
What is upsetting you?”
Q2: Which statements will the nurse indicate as
to confirm what you understand therapeutic? Select all that apply. “It seems that you feel responsible for what happened to
your mother.”
“Am I correct in restating that you are feeling less
Reflecting: return focus on client
Q2: Client who has cancer is scheduled to receive
anxious today?”
chemotherapy ... she wants to try homeopathic treatments
“In looking back at what you said, you stated you are first. Which of the following responses should the nurse make?
feeling better.” “Tell me more about your concerns about taking chemotherapy.”
Stating Facts “Help me understand what you are feeling today?”
Q3: A man was killed during a robbery 10 days ago. His

Q3: A parent who recently lost her child … states she cries
frequently and can't bear the loss … therapeutic statements
should the nurse make?
Voicing doubt & presenting reality: widow… cries spontaneously when talking to the nurse.
What is the nurse’s most therapeutic response?
“You are feeling great pain at the loss of your child.”
refutes misconceptions or delusions “The sudden death of your husband is hard to accept.
Tell me about how you are feeling?”
Suggesting resources or strategies:

SAUNDERS
helps offer guidance KAPLAN
Q1: … “I can’t believe that my wife died yesterday. I keep
Q1: Client with ... end stage heart failure, says “Why can’t expecting to see her everywhere I go in this house.” …
this just end? I’m no good to anyone anymore.” Which therapeutic nurse response?
response is best?
“It must be hard to accept that she has passed away”
“This must be difficult. Please tell me about your feelings?”
Q2: ... “This condition is just another nail in my coffin.”
Q2: The nurse finds the client crying … & says, “What do Which response by the nurse is therapeutic?
you want? Go away, you can’t help me. I hate you and I
“You seem very distressed over learning you have
hate myself.” Which response by the nurse is best? asthma.”
“You seem to be in pain; I’ll stay with you for a while.” Q3: A client diagnosed with terminal cancer says to the
nurse, “I wish my family would stop hoping for a cure! I get
Q3: Client’s spouse has been unemployed for more than
so angry when they carry on like this.” Which response by
six months, and is afraid of not being able to pay the rent.
the nurse is most therapeutic?
Which response is most appropriate?
“You’re feeling angry that your family continues to hope
“You’re worried that you won’t be able to pay the rent?” for you to be cured?”
Alcohol & Drug Abuse
6 Key Definitions
1. Tolerance: decreased response Enabling & Codependence ATI

to a drug / alcohol …client who abuses alcohol & illicit drugs...
spouse tells the nurse: “have lied to his
2. Withdrawal: symptoms that 3 NCLEX TIPS boss, his children, and his friends and I just
don’t think I can do this anymore.” Which of
develop after abruptly stopping
drugs / alcohol
“It is my fault that my spouse the following best describes this behavior?
Enabling
drinks so much”
3. Dependance: the body’s physical
addiction to a drug / alcohol “I will take care of the children HESI
4. Relapse: the recurrence of drug/ so that my spouse can drink” Patient with chronic pain... A regular dose
alcohol use after remission “I have lied to my spouse’s boss of analgesic medication is ineffective in
reducing the patient’s pain?
5. Denial & projection about why he missed work” The patient is showing signs of tolerance
6. Enabling & codependence
Cocaine & Meth. Or Methamphetamines

Cocaine
NORMAL
are both stimulants that act on the brain
HIGH
LOW
Methamphetamines to increase the heart rate & blood pressure.
HESI HESI
Symptoms Q1: ... significant dental problems. The A nurse is learning how to manage patients
with substance abuse disorders. Which step
nurse expects that this patient abuses
should the nurse apply as a first-line
which substance?
Meth = dental problems Methamphetamines
intervention in such cases?
Providing safety and sleep
Q2: The nurse finds that a patient who is a
Cocaine = nasal damage drug addict has nasal damage. Which
substance does the nurse suspect? KAPLAN
Cocaine The client is agitated and fights against the
Nursing Interventions nurse ... positive for cocaine... priority
intervention?
Provide a calm atmosphere and monitor
respiratory and cardiac status
1st
Opioids HESI
Which vital sign would be most concerning
to the nurse?
Signs & Symptoms
aaa...
bbb...
ooo... Respirations 10 breaths/min
Slurred incoherent speech

KAPLAN
aaa...
Decreased respiratory rate A client uses heroin several times a day. bbb...
(norm: 12 - 20) Which signs and symptoms does the nurse ooo...
expect to observe? Select all that apply.
Narrowed “constricted” pupils Constricted pupils
Depressed respirations
Sedation & coma
Drowsiness or sedation
Slurred incoherent speech
Opioids Withdrawal ATI

Treatment for opioid dependence... which of
the following medications is used for
Signs & Symptoms Treatment treatment of opiate withdrawal?
Naltrexone = Prevents relapse
Runny nose Clonidine
Opioid by reducing cravings
Methadone
Diaphoresis (sweating)
STOP Clonidine = Lowers BP
HESI
Insomnia
Methadone = Low dose opioid ... teaching a patient with a new prescription
Dilated pupils (wean off addiction) NCLEX TIP for naltrexone?
It helps prevent relapse by reducing your
drug cravings
Alcohol & Drug Abuse II
Alcohol Abuse
Big Key Point
Alcohol is a toxin that causes central nervous
system depression, making the vitals signs
<70 Hypoglycemia PRIORITY
low & slow, causing coordination & balance
problems.
Alcohol intoxication & Diabetic

Monitor blood glucose
levels at night NCLEX TIP
Psychosocial Assessments KAPLAN

Identify triggers Q1: The nurse prepares to lead a group
session for ... dependence on alcohol. The
nurse knows that a client with a diagnosis
of alcoholism drinks because of which
Escape from problems reason?
Cover up depression & anxiety
Escape from problems
Primary goal of counseling: Cover up depression or anxiety
identify triggers Q2: The nurse provides care for a client
diagnosed with alcohol abuse ... Which is
the primary goal of counseling?
Assist the client to identify factors that
trigger alcohol use
Recovery Teaching
After detox the primary goal of recovery is total abstinence -
meaning NO alcohol forever!
HESI
3 NCLEX TIPS ... patient with alcohol misuse. What
intervention does the nurse plan for
Expressed accountability: taking rehabilitation of this patient?
responsibility & acknowledging Develop motivation and self-help skills
2. Coping skills
3. Setting Goals: develop
motivation & self help skills
Alcohol Withdrawal & DT HESI KAPLAN

Signs of alcohol withdrawal. What
Q1: The client reports drinking socially ...
assessments will the nurse include when >100.30F 120 bpm 24/min 130/90 mmHG
states, “I am anxious and shaking inside.” ...
providing care to this client?
Alcohol, Benzodiazepines, Barbiturates vital signs are Temp. 100 F (38 C), HR 120
NORMAL

HIGH
LOW
bpm, RR 24/min, BP 130/90 mm Hg.

Anxiety
Which conclusion does the nurse make?
24 hours: anxiety, insomnia, palpitations Tachycardia
The client has early signs of alcohol
Irritability
48 hours: Seizures & unstable vitals Tremors
withdrawal
Q2: The nurse admits a client for possible
48 - 72 hours: appendicitis... client states, “Most days I STOP
ATI drink about one pint of vodka.”... alcohol
Delirium Tremens NCLEX TIP ... result of sudden withdrawal from
withdrawal delirium time frame?
48-72 hours after last consumption
barbiturate use?
1. HYPERreflexia “Hand Tremors” Seizures
2. Diaphoresis (sweating)
3. Hallucinations Nursing Care
Increased Vitals:
Tachycardia (HR over 100 BPM) Implement seizure precautions
Hypertension
Fever Kaplan
The nurse admits a client who has a diagnosis
Mood: Agitation & Anxiety of alcoholism and admits to drinking a pint of
Mental: Confused & restless vodka a day.... which intervention is
appropriate?
Seizures!
Ensure seizure precautions are in place
Anorexia Nervosa
Pathophysiology
Anorexia nervosa is an eating disorder causing clients to obsess about their weight & what they eat.
Risk Factors:
Distorted body image - Adolescent females are the most affected
- Anorexia also has the highest death rate of all
& fear of being overweight mental disorders due to suicide
KAPLAN
ATI 1st Which statements are true regarding

anorexia nervosa?
Anorexia nervosa: The client has an
Clients see themselves as overweight
unrealistic fear of obesity
Adolescent females are most affected
Anorexia nervosa has the highest
mortality rate of all mental disorders
Signs & Symptoms
HESI
SEVERE 6 NCLEX TIPS
Starvation → Malnutrition Q1: adolescent female with anorexia
1. Extreme weight loss nervosa. Which physical findings
Vigorous Exercise Less than 75% of expected weight support the diagnosis?
“25% below normal weight” NCLEX TIP Select all that apply
2. Fluid & electrolyte imbalance Lanugo
Hypokalemia: potassium below 3.5 (cardiac dysrhythmias) Irregular heart rate
Pulse rate 48 bpm
3. Lanugo (thin hair)
4. Amenorrhea (no menstruation) Q2: ... which assessment finding
5. Cold intolerance meets the criteria for hospitalization?
Serum potassium level 2.6 mEq/L
6. Low Vitals: Low temp., Low BP,
Low HR (below 60)
Treatment
Typically done in an outpatient clinic (outside the hospital), but hospitalization may be needed if the client's
body weight is below 75% ideal.
Priority short-term goal HESI Admitted for Malnutrition 5 NCLEX TIPS HESI
Q1: What is the focus for the acute
2 NCLEX TIPS phase of treatment for anorexia 1. Strict record: protein & calorie intake What is a subjective symptom ... with
anorexia nervosa?
nervosa? Fear of gaining weight
1. Increase caloric intake for Weight restoration
2. Stay with the client during each meal
gradual weight gain & 1 hour after
Saunder’s
2. One-on-one supervision Q2: … anorexia nervosa presents with 3. Morning weights prior to oral intake … cognitive behavioral approach
during feedings severe dehydration and rapid weight
loss in the last week:
4. Help the client identify triggers ● Help the client to examine
Suggest hospital admission dysfunctional thoughts and
5. NO exercise! beliefs
Communication
Let sort out your
Encourage & reinforce: NCLEX TIP emotions together
“Progress toward healthy weight”
35 kg
Bulimia
Pathophysiology
Bulimia is an eating disorder that involves 2 cycles:

1. Episodes of uncontrolled binge eating in secret (eating a lot of
food at once)
2. Followed by self-induced vomiting or purging. Also the use of
laxatives, diuretics, and fasting to prevent weight gain, along
with even excessive exercise.
Clients have a distorted view of body image & an obsessive desire to lose weight.
Signs & Symptoms HESI

… assessment finding with bulimia
nervosa?
Binge eating Dental erosion

Patients with bulimia often appear
then compensatory behavior: to have a normal weight
purging, exercise, fasting, laxatives

Tooth & gum deterioration
Scaly skin
Normal body weight 70 kg
Interventions
HESI ATI
1 - 2 hours after each meal NCLEX TIP
Q1: A nurse is teaching a patient with … a client with bulimia nervosa… states
One-on-one supervision during meals bulimia nervosa about scheduling that at times she feels helpless... The
healthy, balanced meals: most appropriate short-term goal:
Monitor for fluid & electrolyte imbalances Mg
hypokalemia: potassium below 3.5 (cardiac dysrhythmias) To avoid binge-purge cycles
Verbalizing the desire to increase
Check for hidden binging or purging

NCLEX TIP
Q2: A patient with bulimia nervosa

Na Ca
control over stressful situations
“Hidden or trashed food wrappers” uses ememas and laxatives to purge K

“Laxative boxes in the trash” ... which imbalance should the nurse I want to
control myself...
assess?
Food diary during hospitalization Disrupted fluid and electrolyte balance
Let me
help you!
Pharmacology
HESI
The nurse is caring for a patient with

Bupropion bulimia nervosa who overuses
Bupropion
laxatives but does not purge. Which
Wellbutrin
Not recommended Bupropion drug is known to be effective to treat

Wellbutrin the patient?
NOT recommended for purge bulimia
Bupropion
Notes
Anxiety Disorders
TYPES HESI Question

GAD: General Anxiety Disorder Client states... “every time I
SAD: Social Anxiety Disorder need to leave the house for Separation
anxiety
Panic disorder work ... Mom becomes disorder
Separation Anxiety extremely anxious and cries

that something terrible is going
Phobias NCLEX EXAMS to happen to me.” ... supports
which psychiatric diagnosis?
OCD: Obsessive Compulsive Disorder
PTSD: Post-traumatic Stress Disorder ● Separation anxiety disorder
Pathophysiology ATI Question

Which of the following are
During severe anxiety the mind goes into a state of panic & so the body physiological signs of anxiety?
goes into fight or flight mode turning on the SNS - sympathetic nervous system.
● Increased pulse rate
The SNS tells the body to shunt blood flow away from the extremities & toward
● Hyperglycemia
the core of the body for the vital organs & to increase the vital signs. ● Dilated pupils
● Dilated bronchioles
MEMORY TRICK ● Peripheral vasoconstriction
SNS - Sssspeeds Up the Vital Signs

Increasing the HR, BP, RR, sugar levels, & dilating the pupils! 120
Classifications
Small Medium Large EXTRA Large

Mild Anxiety Moderate Anxiety Severe Anxiety Panic Attacks!
Signs & Symptoms
ATI Question HESI Question

Mild Anxiety ...clinical manifestations ...
expected in a client with Q1: ... a patient tells the nurse, “I feel
Restless, irritability severe anxiety? like I am going to die.” Based on
The client is pacing the the statement the patient made,
Moderate Anxiety hallway and tells the what level of anxiety is the
Increased RR & HR nurse he has a feeling of patient experiencing?
Pacing back & forth impending doom � Severe
Slightly reduced perception
Q2: A male patient is running ... and
keeps repeating, “They are
Severe Anxiety
coming!” ... neither follows staff
Increased RR & HR “hyperventilation” directions nor responds to verbal
Pacing back & forth efforts to calm him. The level of
Feeling of “Impending Doom” anxiety can be assessed as:
Perception is GREATLY reduced: � Severe
Can NOT respond to directions
Anxiety Disorders II
Signs & Symptoms
HESI Questions
Panic Attack Q1: A symptom associated with panic Panic
attacks is: disorder
Fear of death “Impending doom” � Fear of impending doom
Feeling detachment “Hallucinations”
Q2: A patient who has to undergo
Physical s/s:
surgery ... complains of chest
• Chest Pain & heart palpitations pain, feelings of choking, and hot
• Trembling & Numbness flashes. What appropriate
• Hyperventilation diagnosis does the nurse make
• Sweating & Hot flashes from the patient’s symptoms?
• Nausea & choking sensations � The patient has panic disorder
Interventions
Severe Anxiety HESI Questions ATI Questions Kaplan Questions

Q1: ... a client with a severe level of Q1: Client with anxiety disorder…
& Panic Attacks
Q1: Client ... becoming increasingly
anxious. What initial actions should anxiety is rocking back and forth begins to sweat profusely and
the nurse take for this client? … stating, “Something bad is going breathe rapidly.. & states “I feel like
Select all that apply. to happen.” Which action should I am having a panic attack.” Which
the nurse take? response by the nurse is best?
1. REMAIN with the client � Stay by the client’s side
� Sit in a chair next the client’s bed
� Escort the client to a quiet place � “I’m going to help you back to
#1 Priority NCLEX TIP � Use a comforting tone of voice your room.”
when speaking to the client Q2: ... client who has generalized
anxiety disorder and is trembling Q2: … client reporting dizziness and a
2. Place client in a quiet room and pacing during a group ‘racing heart’.... extremely
Q2: ... new client ... spontaneous onset
“Sit with client” “remain at bedside” of hyperventilation, trembling, and
activity... Which of the following anxious. Which response by the
statements should the nurse make nurse is best?
an inability to concentrate. What is to the client?
3. Speaking calmly with simple the nurse’s priority action? � “When did you first notice that
� Come with me to an area where you were feeling anxious?”
clear words � Stay with the new client
we can talk without interruption
Pharmacology Effective Coping
Beta blockers “-lol” 3 NCLEX TIPS

• Atenolol
1. Increased comfort while exposed NCLEX TIP
Antidepressants to the phobia
• SSRI: Sertraline & Paroxetine Resilience:
• TCA: Amitriptyline & Imipramine 2. Verbalizing feelings & insight
• MAOI: Phenelzine & Isocarboxazid about anxiety (self observation)
Practicing stress reduction
techniques daily
Anxiolytics MOST TESTED 3. Self distraction: focusing on
• Benzodiazepines something other than the phobia
• Barbiturates
• Buspirone
Top Missed NCLEX Questions
A client with social anxiety disorder has been struggling with his new job when coworkers invite him to
lunch. Which of the following statements indicates the client is improving in coping mechanisms?
1. I went to a restaurant with a few

coworkers & focused on our
conversation rather than my phobia.
2. I planned to go out of town rather than
attend our company’s christmas party.
3. I must admit that I am still very nervous

Benzodiazepines Buspirone about eating in front of my coworkers,
but I am working through it.
4. I went to a coffee shop by myself and

sat to watch people.
5. I will make excuses to avoid going to

eat with my boss.
Cognitive Behavior Therapy (CBT)
CBT is a type of talk therapy that helps clients reframe their thought processes to
prevent negative thought patterns in order to adapt to stress & anxiety.
Bipolar Disorder
Pathophysiology
Bipolar is a mood disorder with cycling periods of lows with Depression followed by highs with Acute Mania.
During depression: clients have low mood, low energy, & motivation & high risk for suicide.
During acute mania: high energy, hyperactivity, elevated mood, & even aggression with violence.
HESI Question
Four or more mood MEMORY TRICK
Depression Acute Mania
episodes in a
12-month period, the Depression Mania
Declined mood More energy + Maniac
patient is said to be
Rapid cycling
ATI Question
Five acute manic
episodes in one year
Rapid cycling
Types of Bipolar Disorders
Bipolar 1 - 1 episode of mania that lasts over 1 week or need for hospitalization
Bipolar 2 - 2 episodes of milder high hypomania, which can last longer
Cyclothymia - milder lows & milder highs cycling over a period of 2 years
Rapid Cycling - 4 episodes of depression & mania within a 12 month period
The cause is unknown but what does play a big part is:
• Genetics - having a family member with bipolar, clients are 10x more likely to have it.
• SSRIs (antidepressants) can trigger a manic episode
SSRIs can trigger a manic episode
Genetics SSRI
10x
Signs & Symptoms
M
More energy & Mood Swings
Euphoric energy, impulsive, grandiosity
ATI Question Kaplan Question
Hallucinations & delusions of grandeur
Q1: Acute manic phase: Which symptom
symptoms with manic behavior? does the nurse expect?
A Agitation
Set limits & structured environment
• More talkative than usual
• Easily distracted
• Hyperactivity & irritable
Q2: “I just bought myself a home

• Intense need for activity computer and a large screen TV for
N
the family.” Which interpretation is
Non-stop talking & Flight of ideas most accurate?
Colorful bizarre clothing choices
HESI Question • Mood disturbance and judgement
that is poor at this time
manic phase?
I Insomnia
Cannot sleep for days
• The client is quickly angered
• Flight of ideas
Saunders
Assessment finding that requires
A
• Going rapidly from one activity immediate intervention?
Attention span POOR to another • Nonstop physical activity and poor
Easily distracted = reduce stimuli
• Colorful & outlandish clothing nutritional intake
• Constant delusions
Bipolar Disorder II
Interventions
Acute Manic Episode Acute Manic Episode

1. Reduce Stimulation: Acute Manic Episode
4. Diet:
Quiet, calm environment 2. Physical exercise HIGH calories & protein
“Private Room near the - Alternating aerobic exercise with scheduled
nurses station” NCLEX TIP periods of rest ATI HIGH FLUID intake
- Manic episode? A single room near the
- Assist the client with sweeping the floor of Foods “on the go”: NCLEX TIP
the unit HESI
nurses’ station HESI Hamburgers, Sandwiches, Burritos
- Manic phase of bipolar disorder? A 3. Set structure & limits on aggression Milkshake, protein shake
private room across from the nurses’ station ATI “Choose clothes for the client” NCLEX TIP Hand held: fruits & veggies
- Take the client to a quiet area with low Set limits & be consistent with consequences
stimulation ATI - “If you throw that lamp, you will need to stay in Provide the client with a chicken leg and
your room for 1 hour” HESI carrot sticks HESI
Limit group contact: - “Swearing & profanity are unacceptable here” ATI
NO dining room NO caffeine (coffee, tea, soda)
NO group activities (1-on-1 activity)
Top Missed NCLEX Questions

Interventions for a client with bipolar disorder who is admitted to the hospital for an acute
manic episode? Select all the apply
1. Encourage physical
exercise with staff
2. Private room near the
nurses station
3. Pick out clothing for

the client
4. Avoid group activities
5. Eat meals in the dining

area with other
patients
Pharmacology
Valporic Acid Lithium
Mania Kaplan Question

ATI Question HESI Question Lithium carbonate …
Anxiolytics: Q1: What action should the The nurse understands
Clonazepam Valproic acid… monitor: nurse take ... lithium level which other medication
Alprazolam Liver function is 1.8 mEq/L
is contraindicated?
• Withhold medication
and notify the healthcare • Diuretic
Depression provider (HCP)
Antidepressants
HESI Question Q2: Taken lithium for 1 year …
nurse’s priority attention?
Mood Stabilizers: Valproic acid…. Which • “I’ve had very bad
- Carbamazepine laboratory finding is diarrhea for 3 days.” ATI Question
- Valproic acid most important? Q1: Scheduled to begin lithium therapy…
priority to report to the provider?
- Lithium Liver function • I am currently taking furosemide for
test results congestive heart failure
L Levels OVER 1.5 mEq/L = TOXIC!

Q2: Manifestations of lithium toxicity?
• Nausea & vomiting
• Diarrhea
I
Increase FLUID & Sodium (Na+) • Polyuria
VaLproic acid
HIGH RISK Toxicity
= Dehydration & Hyponatremia < 135 mEq/L • Muscle weakness
Liver Toxic Do NOT limit sodium or water intake
Q3: Lithium for treatment of bipolar
T
TOXIC Signs to REPORT: disorder… teaching:
Excessive urination and extreme thirst!
Vomiting & diarrhea • Aspirin is better to use than ibuprofen
• Report excessive thirst & increased
H
urination
HOLD NSAIDS – (Ibuprofen, Naproxen)
NSAIDS decrease renal blood flow = toxicity risk • Avoid exercising outdoors on hot days
• Regular laboratory tests to monitor
lithium level
Depression
Pathophysiology
Major Depressive Disorder (MDD) also called clinical depression is when a client experiences a severe depressed mood,
loss of enjoyment in life, low energy & few other critical signs and symptoms. Everything is low & slow, it is thought to
be from low levels of neurotransmitters within the brain.
O
Serotonin N O
Neurotransmitters O
Low Serotonin O
Dopamine
Blah... Low Dopamine N O
Low Norepinephrine N
Norepinephrine N N
Risk Factors
ATI Question
a risk factor for depression?
Stressful life event
Stressful life events
Chronic illness
Genetics: Family history KAPLAN Question
recently become unemployed and the
Females client reports feeling depressed. The nurse
Substance abuse disorders understands which statement to be true?
unemployment is a significant
potential stressor
Signs & Symptoms

HESI Question
Q1: “Life just doesn’t have any joy in it
Diagnosis: 5 or more symptoms anymore. Things I once did for pleasure
aren’t fun.”
1. Depressed mood Anhedonia
Diagnosis
(hopeless, empty) Q2: Which complaint regarding sleep
2. Anhedonia HESI & ATI would the nurse expect from a patient
5/9 symptoms
MDD? diagnosed with major depression?
(loss of joy/ interest in life)
I wake up about 4 am and cannot go
3. Weight loss (anorexia) or Wt. Gain back to sleep. I feel tired all the time
4. Psychomotor retardation NCLEX TIP
Slower speech, response time, ATI Question
& Decreased movement A nurse is assessing an adolescent who has
5. Insomnia depression. Which of the following findings
or hypersomnia (sleeping too much) should the nurse expect?
6. Fatigue (Anergia)
Irritability Anhedonia
7. Feelings of worthlessness or Guilt Anergia Appetite changes
8. Difficulty concentration
9. Suicidal thoughts (Recurrent)
TOP Missed NCLEX QUESTION
Which of the following pediatric clients
Side Note Pediatrics: should the nurse screen for depression?
Select all that apply. 4 weeks
Adolescents 10 - 19 years NCLEX TIP
10 year old taking frequent naps
Angry, aggressive outbursts & during class time
vandalism / skipping class 16 year old quit the chess team
despite being the team captain
Weight loss or gain “suddenly” “rapidly”
14 year old sent home from school due 48.2
kg
Napping during day to angry outbursts & skipping class

17 year old suddenly lost 15 lbs (6.8 kg)
Low self-esteem (withdrawal)
in 4 weeks
Depression II
Treatment Types
3 Phases HESI Question

Dysthymia
Mild symptoms … seasonal affective disorder.
1. Acute Phase What appropriate action...?
Seasonal affective disorder
2. Continuation Phase Use of light therapy
Instruct the patient to be
exposed to a light source
3. Maintenance phase Pre & Postpartum baby blues for 30 to 45 minutes daily
Nursing Care
Priority: Suicide Risk

ATI Question
Assessment:
... major depression and suicidal Saunder’s Question
Calmer or MORE Energetic ideation who is suddenly calmer and Q1: … a depressed client ... suddenly begins
= INCREASED suicide risk more energetic. Which of the following smiling and reporting that the crisis is over.
Sudden, abrupt, rapid change in energy should the nurse consider? The client says to the nurse, “I’m finally
Giving away possessions (cherished / valued) The client is suicidal cured.” Intervention?
Increasing the level of suicide
Statements: “I can’t go on” “I do not want
precautions
to live”
Q2: Which behavior ... indicates an
“I won’t be a problem much longer” HESI HESI Question adolescent client may be suicidal?
“This will all be over soon” Kaplan
A man tells the nurse … he has no Gives away a DVD and a
Questions: Suicide risk assessment reason to continue living. What should cherished autographed picture of
“Have you had any thoughts of the nurse ask him first? their favorite performer
NCLEX TIP
hurting yourself?” Do you have any plans to end
your life right now?
“Do you have a plan to kill yourself?”
“Do you want to die?
NCLEX TIPS HESI Question

1. Continuous one-to-one observation Kaplan Question Q1: A client .. admits to a plan for suicide ..
2. Semi-private room (near nurses’ station) ... client states, “I don’t want to live anymore. What is the nurse’s priority action?
I’ll find something else to kill myself with.” Provide one on one supervision
Remove harmful objects from room
Which nursing intervention is important to Q2: One week ago, a patient attempted
Supervise during meals perform next? suicide…. which comment by the nurse is
Reassess: changes in suicidal thoughts Provide direct one-to-one observation most therapeutic?
Clear plans of the future involving personal to the client at all times “I’d like to hear about how you are
feeling now”
goals, family, & friends NCLEX TIP
ATI Question Kaplan Question

Q1: … newly admitted client who has
Q1: Client diagnosed with depression … Which
severe depression.
approach by the nurse is best?
Sit with the client and offer
Invite the client to join in group activities
Interventions simple, direct information
Q2: … client seems more withdrawn and
Encourage & Invite client to participate Q2: … crying alone in the room. The client has
depressed than usual. refused to eat breakfast or have morning care.
Assist with ADLs Say to the client, “I would like to Which intervention by the nurse is best?
Help the client get ready NCLEX TIP spend some time with you.” Offer to sit with the client and help the
client get dressed
Spend time with client
“Sit with the client”
Communication with simple & direct language
HESI Question
Reevaluation Which comment … shows Saunder’s Question
improvement in depression?
...diagnosis of depression … plan of care that
“I talked with my family includes which intervention?
about ways we can celebrate A structured program of activities in
holidays together.” which the client can participate
Depression III
Diet
Remember a big symptom of depression is rapid weight loss or weight gain, typically weight loss is the most tested,
since it is more common. Clients lose appetite & refuse to eat.
HESI Question Saunder’s Question

Poor nutritional intake ... imbalanced nutrition, less than body Client with depression ... poor nutritional intake.
requirements … with severe depression. The … which interventions in the plan of care?
1. Small “frequent” meals most reliable evaluation of outcomes? Select all that apply.
Weekly weights Assist the client in selecting foods from
2. High calorie foods & fluids the food menu
Offer high-calorie fluids throughout
3. Stay with client during meals the day and evening
Offer small high-calorie, high-protein
4. Weekly weights snacks during the day and evening
g
30 k
Procedures
MOST tested
MOST TESTED
Vagus nerve
1. ECT - Electroconvulsive therapy stimulator
2. TMS - Transcranial magnetic stimulation

3. Vagus nerve stimulation
ECT TMS
ECT - Electroconvulsive Therapy
ECT induces electrical activity on the scalp to create a

BEFORE
generalized seizure. Think of this as jump starting the
1. Screen for Medical History & Report to HCP brain like jump starting a car or doing a hard reset on
Recent myocardial infarction Saunder’s your iphone. Each seizure lasts around 15 - 20 seconds,
done 2-3 times a week for 6-12 treatments total.
Cerebral neoplasm ATI
2. Assess Concerns: ATI Question HESI Question
What are your concerns about ECT? NCLEX TIP Which of the following is a side effect … electroconvulsive therapy (ECT),
of ECT? which equipment should the nurse make
3. NPO x 6 - 8 hours NCLEX TIP Memory loss sure is available?
4. NO anticonvulsant meds NCLEX TIP Oxygen
Kaplan Question
Valproic Acid, Carbamazepine after ECT… It is most important for the
Suction equipment
Crash cart
5. Remove: dentures & contacts nurse to take which action?
Remind the client that memory loss Saunder’s Question
6. Side Effect: is temporary
ECT ... interventions before procedure?
Memory loss ATI & Kaplan Have the client void
Equipment: Obtain an informed consent
Remove dentures and contact lenses
Cardiac monitor Oxygen Temporary
Withhold food and fluids for 6 hours
Crash cart Suction
Informed Consent signed
REMOVE
AFTER
NO driving (during course of ECT treatment) NCLEX TIP
Temporary confusion & memory loss common after
Schizophrenia
Pathophysiology Memory trick

Abnormal scattered pattern of thinking for about 6 months or more. S - Schizophrenia
It often starts to affect relationships as well as school & work flow as S - Scattered pattern of thinking
clients cannot concentrate. S - Suicide Risk HIGH

Children are more likely to have schizophrenia when parents have the
condition. It is thought to be caused by a decrease in dopamine within
Genetics the brain.
Signs & Symptoms

Positive Symptoms = Psychotic
Hallucinations ? ?
Delusions ?
Thought Disturbance
Negative Symptoms = Negative State
Cognitive Symptoms = Capacity of Memory
Positive Symptoms
Hallucinations Delusions
Delusions of Reference: NCLEX TIP
Tactile Hallucination:
P P sensation of being touched
“This song has a secret message just for me”
Delusions of Control:
Auditory Hallucination: “I do not go online, that's how the FBI controls you”
Positive Symptom Psychotic Symptoms hearing voices & sounds not there Delusions of Grandeur:
”I have a very important meeting with the Queen today”
Best action: Provide earphones
Persecutory (paranoid) delusions:
& music NCLEX TIP “The hospital food is trying to poison me”
HESI HESI
Hearing voices that tell him or her to Schizophrenia: positive symptom?
stay home: Delusions
Positive symptoms of schizophrenia
Memory trick This song has a secret message just for me
P - Positive Symptoms
P - Psychotic Symptoms
Disorganized Speech & Thought

1. Loose associations “flight of ideas”: rapid 3. Clang associations: listing rhyming words 5. Concrete thinking: taking a statement literally. 7. Echolalia: repetition of words they hear from
shift of thought with no logical connection together that make no sense “Grass is greener on the other side” or “don't put all someone else NCLEX TIP
NCLEX TIP “Lets go to the bay, hit the hay, what do you say, your eggs in one basket” Nurse says “we will take your vitals”
“The universe is like a raisin, but the the moon we can go today” Thinking there is actual grass & eggs. Client repeats this phrase over & over
is a home & I rode my bike”
4. Word Salad: mixing words together that 6. Tangentiality: speaking of unrelated topics 8. Perseveration: repeating the same words /
“Glass breaks if you throw stones .. My cousin
have no meaning except to the client that do not correlate to the main discussion. phrases when answering different questions
shoots guns. I live in glass houses Saunders
“Here is the chair, moon, orange, drank too much” Nurse asks “how was your sleep?” Nurse says “how do you feel today?”
2. Neologisms: made up imaginary words Client says “When I was five, my cat was killed, Client says “Absolutely splendid”
“I have to get away. The vomers are coming to I love dogs”
Nurse says “do you know today's date?”
execute me.” HESI
Client says “Absolutely splendid”
?
@#% Grass is greener
LCENA
MO on the other side We will take your vitals
NO Don't put all your eggs

Vitals
Vitals
in one basket
We will take your vitals

Schizophrenia II
Negative Symptoms Saunders

negative symptoms associated with
The 5 A’s schizophrenia? Select all that apply.
Verbal communication is almost nonexistent
A - Affect Flat The client needs frequent redirection
(expressionless, blank look) Saunders because of short attention span
A - Anhedonia
(inability to experience pleasure) ATI
I wanna be alone
client mood turned off like a light switch aaa... negative symptoms?
bbb... Anhedonia
A - Apathy & Avolition ooo...
Blunt affect
(lack of interest or motivation)
HESI
A - Alogia
NOT a positive symptom of schizophrenia?
(poor speech)
Affective flattening
A - Anxiety & Avoids
social interaction NCLEX TIP
Cognitive Symptoms
Top Missed NCLEX Question
Client with schizophrenia leaves the
room as soon as the nurse enters & asks C C Affects memory, learning,
about the client’s day. Best action?
Let the client leave & sit quietly Cognitive symptoms Capacity to remember & understanding
? Memory trick
C - Cognitive symptoms
C - Capacity to remember
NCLEX Key Points ATI

… catatonia with catalepsy. Which of the
Cataonic Schizophrenia following findings should the nurse expect?
+ 2 more features: Muscle rigidity
Immobility
Bizarre postures “muscle rigidity”
Prodromal Active Mute (no speech)
HESI
Severe Negativism “I understand that the voices are very real
S NCLEX TIPS
withdrawn socially extreme symptoms
U Staring to you, but I do not hear them.”
FOC
NOT
Priority:
Fluid & nutritional intake NCLEX TIP 1. Focus on reality KAPLAN
Paranoid schizophrenia & reinforce it verbally “That must be an unpleasant experience for
“Persecutory Delusions” you. Have you had these feelings before?”
Residual Plan of care: NCLEX TIP
2. Acknowledge client’s
cognitive symptoms
1. Focus on reality & reinforce it verbally
feelings Saunders
2. Acknowledge client’s feelings
Facilitate awareness that hallucination is
not the reality of the world.
HESI
… paranoid schizophrenia refuses food,
stating the voices are saying the food is
Assessment: State the Facts: contaminated and deadly. A therapeutic

(open-ended questions) response for the nurse would be:
“I understand that the voices are very
What are the voices saying? What do you see? NCLEX I see you are frightened, let's go to real to you, but I do not hear them.”
Tell me what you are feeling at this moment HESI your room & talk about this NCLEX KAPLAN
Describe what you are seeing now HESI It might be frightening to think that “There are really strange people in the
corner of my room laughing at me and
How does it feel to think you are being watched? Kaplan others want to hurt you Saunders saying horrible things.”Which response by
the nurse is best?
What activities did you enjoy in the past? ATI I don’t hear any voices, but I know “I don’t hear any voices, but I know this is
they are scary for you Kaplan frightening for you.”
I understand the voices are real

What do you see?
to you, but I do not hear them HESI
I don’t hear any voices,
KAPLAN
What are the voices saying?
You see yourself as the savior but I know this is frightening for you.
“Do you see those cameras in the ceiling? I am being

I see you as my client HESI
watched all the time.” Which response by the nurse is
most appropriate?
“Those are sprinklers in the ceiling that come on if there
is a fire. How does it feel to think you are being watched?”
Schizophrenia III
Interventions
• Provide safe & structured environment and promote trust

• Decrease environmental stimuli
• Always MONITOR for suicide risk
Delusions & hallucinations

Never label voices or argue
Always present reality
Pharmacology
Antipsychotics:
Haloperidol (brand: Haldol) HALOPERIDOL
CLOZAPINE -
Clozapine Life-threatening reaction to antipsychotic
drugs characterized by fever, altered
Risperidone RISPERIDONE
Ziprasidone
hydrochloride
Geodon mental status, muscle rigidity, and
dizziness.
Ziprasidone (brand: Geodon)
Clozapine Adverse Reactions
NCLEX Question
Clozapine: Priority to monitor? PRIORITY
Complete blood count

& absolute neutrophil count
ATI
Q1: ... a client prescribed multiple
antipsychotic medications... has rigid
extremities, hypertension, hyperpyrexia,
and diaphoresis.
Neuroleptic malignant syndrome NMS
Q2: Antipsychotic meds further teaching

is necessary?
“I should not be concerned about
fever and muscle stiffness.”
Key terms
NORMAL
HIGH
LOW
Prioritization Beyond ABCs
ABC’s Highest Breathing = RR & Oxygenation Circulation

PRIORITY Low PaO2 (Norm: 80 - 100) Bleeding:
60 or less = HypOXemic Internal:
Respiratory failure Hypotension “Low BP”
Airway = blockage High CO2 Hard stiff “board-like” abdomen
Stridor “squeak” - Postoperative 50 or MORE = HyperCapnic Skin: Pale, dusky, cool & clammy
Thyroid / Parathyroid Respiratory failure Coagulation:
Anaphylaxis: throat swelling - Hypoxia Platelets (norm: 150k - 400k)
Epipen 1st! Change LOC: Level of consciousness Less than 150k - Thrombocytopenia
Ruptured esophageal varices - Mental changes: Restless, agitation Less than 50k - VERY RISKY!
Turn to side lying position Skin: Pale, dusky, cool & clammy Heparin: PTT 46 - 70
SpO2% (Norm: 95 - 100%) Warfarin: INR 2 - 3
COPD - Low 90% is normal 3 x MAX range
1st
HIGH CO2 HeParin WarfarIN
HyperCapnic 46 - 70 2-3
CO₂
PTT
CO₂
CO₂
CO₂ CO₂
CO₂
6 7 8 9
5
4 10
11
3
12
2
13 14
0 1
S S T
Circulation TROPONIN > 0.5
Shock Severely low Shock - Severe low BP 100
blood pressure Urine output 30ml/hr or less

10
0.1
0.01
0 1 2 3
Skin: Pale, dusky, cool & clammy

Chest pain (any kind)
NORMAL
> 180 sys
Troponin Over 0.5
HIGH
LOW
HTN crisis (over 180 systolic) NORMAL
HIGH
LOW
Infection Labs Pain
Low Glucose
Infection After any surgery! Less than 70 “Hypoglycemia” Lose life or limb
Red, warm, smelly drainage at Hypogly = Brain will DIE!
Chest Pain = #1 priority
surgical site Kidney problem Cast / broken limb pain
WBC over 10,000 Creatinine OVER 1.3 = Bad kidney!
Priority: Neutropenia Urine output 30 ml/hr or less = = Pain Unrelieved with pain meds
(Less than 1,500 WBC) Kidneys in distress
Chemotherapy, Side note Kidney Killers

Immunosuppressants CT contrast
Antibiotics: Vancomycin & Gentamicin
Low grade fever will KILL!
Toxic lab levels #1 PRIORITY
Lithium 1.5 + LIMB
Neutropenia Low Grade FEVER <100.4 F Digoxin 2.0 +
Theophylline 20 +
Phenytoin 20 + (brand: Dilantin)
Creatinine > 1.3 Urine Output < 30ml/hr
Compartment Syndrome
<1,500 BUN/Creatinine
Notes
Delegation
RN’s do NOT Delegate below
• New admission
• Returning to floor after procedure
NO Delegating: RN ONLY
U Unstable
clients
• “Post-Operative” after surgery
• Unstable blood sugar, vitals, Lab values
1st
2nd
LVN LPN
• Sudden change RR, neuro status. • IV PUSH (IV piggy back varies state to state)
• Blood transfusion & blood products
E Evaluation
Trending / Interpreting data
• Lab Values, Pain, Vital Signs • Central line drugs: Chemo, TPN
A Assessments Initial, First, Primary assessments

• New admission, “Post-Operative”
T Teaching Initial, First, Primary education
RN’s
Can NOT Delegate
Never delegate
Key terms U E A T
LVN / LPN LVN LPN Secondary CNA, UAP NCLEX

Assess, Teach, Monitor Re-inforce
Secondary, Re-inforce, Follow-up

Follow-up
V - Vitals
NOT initial, first or primary
A - Ambulation
Meds:
NO IV push! P - Position changes / Bathing
• Yes: Monitor blood transfusion
• Yes: Administer IVPB meds,
but NO titrating (changing) rate
LVN LPN
E - Eating
• Yes: Maintain IVs
• Yes: Calc. & monitor IV flow rates R - Recording I & O
Yes - PO, SQ, IM NO Teaching
NO Assessment
NO Meds
Yes No
• Long-term patient • NO newly admitted
• Going to be discharged • NO new post-op
• NO evaluation (labs, vitals)
• Initial assessment
• First teaching
Top Missed NCLEX Questions Top Missed NCLEX Questions

Which of the following should the registered nurse delegate to the LPN (LVN)? A client newly admitted for an myocardial infarction. Appropriate activities to assign
Select all that apply. to unlicensed assistive personnel (UAP) would include all the following except:
1. Administering subcutaneous insulin Secondary assessment 1. Teaching about what foods

NEVER teaching
are high in sodium
2. Assessment of client returning after
a ERCP procedure 2. Recording input & output
High in sodium
3. Initiating a primary IV medication 3. Assisting with ambulation IV piggyback
4. Reinforce teaching for a client to the restroom

recovering from surgery 4. Reporting to the nurse that
5. Urinary catheterization the patient complained of
chest pain
6. Secondary assessment of clients
chest pain

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3 Step ABG Interpretation

Mike’s Marching Band Suit Method

Marching band suit method

Write this chart out 5 - 10 times every day the week

A B of your ABG exam.

Set Up the Chart

Phase 1 - set up the chart

HCO3 comes 3rd.

Phase 2 - key numbers to memorize

Phase 3 - Label it A & B

pH 7.25 , PaCO₂ 55 , HCO₃ 25 A B

ABG Practice Question 2

ABG Practice Question 3

- Normal pH: 7.35 - 7.45

Metabolic Acidosis & Alkalosis - Causes MEMORY TRICKS

Metabolic ALKalosis Metabolic Acidosis

How to Solve ABG Questions in 3 Steps

pH below 7.35 = Acidosis A B

Step 2 - Match pH with partner

Lets say pH is under 7.35, PaCO2 is B

pH & CO2 = Respiratory Acidosis ! A Normal B

Step 3 - Compensated or Uncompensated

balance the body

Step 3 - Compensated or Uncompensated

Uncompensated = pH is OUTSIDE normal range 7.35 7.45

The “broken home”. The body is NOT TRYING to

help balance the pH. UNfriendly 35

Step 3 - Compensated or Uncompensated

Partially compensated = pH is OUTSIDE normal range, 7.35 7.45

Respiratory Acidosis & Alkalosis - Causes

Under 7.35 pH Respiratory Acidosis = Low & Slow RR

Top Missed Exam Question

Respiratory ACIDosis Respiratory ALKalosis

alk alk alk

Common NCLEX question

CO2 How does the nurse expect the client to

hypoventilation panting like a dog

sounds like (hyperventilation), 4

2. Increased respiratory rate

“ALK, alk, alk-alosis” Acidotic

pH 7.25 , PaCO₂ 55 , HCO₃ 25 7.25 7.35 7.45

7.25 is below 7.35 so it is Acid A Normal B

Step 2: Match pH with it’s partner

Step 3: Compensated or Uncompensated?

ABG Practice Question 2

7.35 7.45 7.57

ABG Practice Question 3

7.21 7.35 7.45

Remember the body will try to balance the pH

Memory Trick: Compensation is like ﬁnding

7.32 7.35 7.45

Step 2: Match pH with it’s partner

pH 7.55 , PaCO₂ 49 , HCO₃ 35 7.35 7.45 7.55

7.55 = Base Alkalosis (above 7.45) A B

7.35 7.43 7.45

Step 2: Match pH with it’s partner

Step 3: Compensated fully or partially? ! !

Nursing considerations Needle sizes Equipment

Nursing considerations Needle sizes Equipment

Nursing considerations Needle sizes Equipment

Assessment Risks Patient Teaching

Tunneled central venous catheter Vascular access ports ( implants)

Epidural catheter NCLEX HINT !

15.7/2.2= 7.13 kg.