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PRIORITIZING 4 CLIENTS
Factors
1. Age (have bearing if pedia)
2. Sex (A&S remove if priority of 4 pt)
3. Diagnosis (choose acute ex MI)
4. Modifying Phrase (if present, choose
this; ex. Unstable v/s)
BEST TO USE
Modifying Phrase “Sure answer”
1. Hemorrhage
2. Fever >105 deg F
3. Hypoglycemia
4. Pulseless/Breathless
SECOND TO USE
***If no modifying phrase
1. Post op less than 12 hrs
2. Abnormal labs
3. General Anesthesia
4. Not ready for discharge
5. New/changed assessment (ex.
New edema; not expected s/sx;
even mild or moderate; newly
admitted/diagnosed)
THIRD TO USE
Use Vital Organs (to break choices)
1. Brain
2. Lungs
3. Heart
4. Liver
5. Kidney
6. Pancreas
HENNAJANECE
TEST TAKING STRATEGIES
SATA PRIORITIZATION PRIORITIZATION
- 25-38 points out over 75 GUIDELINES 1. Maslow 4 steps Process
- Scored right or wrong (no partial credit) ❖ Maslow’s Hierarchy of Needs • Step 1
- (Physiological; Safety; - Look at the choices; identify
STRATEGIES:
1. Apply strategy number 1 in analyzing Psychosocial; Love & belonging) Physical vs. Psychosocial
(keywords, important phrase)4 ❖ ABC • Step 2
❖ Knowing the Issue - Airway, Breathing, Cardiac & - Eliminate Psychosocial
- Read situation carefully and identify Circulation, V/S, Lab Values (life - Ex. Pain as shown in change in
issue threatening) V/S (Physical)
o Keywords/phrase (subject)
o Positive or negative question
❖ Nursing Process - Pt verbalized pain (Psychosocial)
2. True or false (identify if question is looking - Assessment always comes first • Step 3
for right or wrong answers) - Look at the remaining choices
3. Go over each option (finalize if the option is ➢ 1st Technique - Which is related to the issue
right or wrong before proceeding to next - ABCC vs Lab Values • Step 4
option; stick on it and never go back)
- Can you apply ABC, V/S,
4. Avoid over analyzing and comparing
similarities in options (only compare in ➢ 2nd Technique: Maslow Abnormal Labs
prioritizing 4 clients) (never add situation; - Physiologic (Oxygen, Nutrition, - If not, use Maslow HN
don’t ask what if?) Electrolyte, Fluids, Shelter, Rest,
5. Watch out for absolute/close ended words Sex) 2. Nursing Process
(all, only, always, never, every, must, none) - Safety (Physical- illness, - Assessment (based on normal
80% accuracy that it is wrong- but still use
accidents, environment/ values)
common sense
6. Options must be related to the issue (avoid Psychological) - Intervention
correct/true statements that’s not related to
the issue) ➢ 3rd Technique: Assess 3. Safety
7. WOF key terms o Step 1 – if all implementation,
o Lab values use SAFETY Strategy
o Measurable nursing intervention (ex.
Turning the pt every 2 hrs)
o Step 2 – if no knowledge,
o Measurable changes in pt status ESTABLISH PRIORITIES proceed to next
(expected; something that would 1. Maslow Strategy o Step 3 – which choice will cause
happen w/n the disease process) 2. Nursing Process Strategy more harm if not address/done
8. Stick on your 1st decision 3. Safety Strategy (use this if all
9. Increase knowledge on concepts
choices are intervention)
10. Practice more SATA’s
MY NCLEX NOTES 2021 1|Page
 PSYCHE NOTES
TOXICITY SYNDROME SUICIDE COMMUNICATION ADMISSION
NEUROLEPTIC MALIGNANT SYNDROME Suicidal Characteristics If ask for response, statement, say: Involuntary:
Toxic side effects of Typical antipsychotic • Sex (M-successful/ F-attempt) • Danger towards self and others
Cause: severed drop on Dopamine • Age (18-27 yo and 40 above) 1. Explore/acknowledge feelings • Grave disability (basic needs)
• Depression 2. Explore anxiety, sad ***no need to sign consent
s/sx (helpless/hopeless/worthless) 3. Offer self ***can’t refuse treatment
• ↑ Fever >38 • Prior history of Suicide ***make sure its related to issue ***can’t do home against med advice
• Muscle Prob (tremors, rigidity) • Ethanol and Drugs ***not for suicidal/panic pt ***can’t be discharge <72 hrs
• ↓ LOC (Lethargic, stupor) • Rational thinking is loss
• ↑ V/S • Support system absent (alone) BAD BEHAVIOR Voluntary:
• Diaphoresis • Organized Plan of suicide ***Needs consent
• No significant others • Set limit
• Dysrythmia ***Has right to refuse
• Sickness (terminal) • Firm ***Home against med advice w/
Mgt • Consistent consent
Signs of Suicide:
1. HOLD meds ***Pt should be aware of good behavior
1. Sudden mood change
2. Cover with blanket 2. Give priced belongings
3. Report to HCP DEATH Situation
3. Verbalize plan of suicide
4. Make will and testament • Be truthful
***Bromocriptine (Parlodel) | Dantolene 5. ↓self esteem (feel worthless) • STAY with patient and family
--- meds for muscle rigidity and antiparkinsons • Offer Self
Prevention:
SEROTONIN SYNDROME ***KEEP SAFE Therapeutic Communication
Overdose, increase level serotonin 1. STAY with pt (cont one-on-one • Therapeutic Eye contact
s/sx observation) • Open ended
• Sweaty hot fever 2. Unscheduled rounds • Avoid WHY
• Rigidity/tremors/restless/agitation(↓ 3. Remove pointed obj • Avoid cliché (overuse phrase)
4. Verbalize direct statement
LOC Disoriented) (Muscle Prob- • Never argue, advise
5. Make contract for safety
Hyper reflexes) • Don’t “Pass the back”
• Increase V/S (High Temp, shivering) • Never negate “I don’t believe”
***Ask directly “Do you have thoughts of
• Diarrhea • Don’t reject or agree
hurting yourself?”
***Always verify if pt says they hear voices • Never threat or insist
***SS will also lead to Hypertensive Crisis (ex. Voices saying they are worthless)
***Wait for 2 weeks and wait for the half life ***Concerning during failed suicide- “Very
of meds before changing to other anti dep soon everything will be much better”
meds

HENNAJANECE MY NCLEX NOTES 2021 2|Page

 PERSONALITY DISORDERS
− Poor social interaction; Inflexible
behavior; Inappropriate view of self
towards others; Not mental illness/ Not
aware; Have low self esteem
Class A: off, eccentric
• Schizoid- last to catch up with fashion,
solitary
• Paranoid-suspicious (wants to control
people/envi) (mistrust) (can’t control
anger; impulsive)
• Schizotypal- magical thinking
Class B: erratic (very bad)
• Borderline D/O-
-Self mutilating (highly suicidal);
Common in females; Manipulative;
Impulsive; Projection; Intense
relationship; Never have successful
relationship; Splitting attitude; Sexually
provocative; Impulsive
-SAFETY (Assign diff staff every day)
• Anti Social PD- always break rules, no
remorse, conscience
• Narcissistic-love self, grandiose and
entitled, believes perfect, relies on
constant reinforcement and admiration
from people perceived as ideal to
maintain self-esteem
• Histrionic-attention seeking
• Passive Aggressive-back fighter
Class C: Anxious, fearful
− OCD- perfectionist; decision conflict
− Dependent PD-always w/ others
− Avoidant-↑inferiority complex
HENNAJANECE
DISSOCIATIVE IDENTITY D/O
− Formerly called Multiple
Personality Disorder
− 2 or more identities
− Alternate personalities
− Response to abuse/trauma
− Original self is not aware of their
identities (the alternate identity
knows about the original &
other identities)
− Lost time; gaps of memory
− Switch identities (due to
stressful memories/trigger
exposure)
Goal:
1. SAFETY
2. One Personality
Mgt
• Daily diary/ journal (feelings and
disassociation triggers)
• Grounding
• Assess self harm
• Promote trust with all the
identities
• Allow recall in her own pace
ANXIETY ACUTE STRESS DISORDER
POST TRAUMATIC STRESS D/O Due to trauma/severe stress
Diagnosis: Anxiety severe
• Flashback- (reliving event) cause panic and s/sx
palpitate • Intrusive memories
• Nightmare
• Reactivity/arousal (easily startle,
• Conversion (claiming blind, but not)
sleep disturbance, poor
(La belle Indifference- lack concern of symptoms)
concentration
• Depression
S/sx
• ↑anxiety Mgt
• Reliving the event • Safety (suicidal)
• Feeling detach from others • Assess for ineffective coping
Mgt
• Cognitive Behavioral Therapy- correct a
“How this situation affected your
wrong belief
relationship with family and friends?”
• Flooding- *prank (exposure to fake event)
“It is normal to experience diff symptoms
• If confused/ disoriented/ restless (make client
after traumatic event”
feel SAFE)
“Please tell me about your current use of
alcohol and any drugs”
PHOBIA
Irrational fear of specific object “Share with me any thoughts or plan of self
• Agora-public places harm”
• Social-people (Ex. Xenophobia-fear of stranger)
• Simple-places PANIC ATTACK
Mgt Intense fear of something about to happen
Systematic Desensitization (do deep
breathing/relaxation tech to prevent attack Mgt
during SD) • SAFETY (STAY with pt)
1. Image (SLOWLY) • Anxiolytics
2. Video
• Decrease the stimuli
3. Slowly exposure to phobia
• Slow deep breathing
• Calm
OBSESSIVE COMPULSIVE D/O
− perfectionist; decision conflict -----------------------------------------------------------
Obsession (persistent, intrusive thought) -
Compulsion (coping, uncontrolled rituals)
Diagnosis: Anxiety severe PHOBIAS
Goal: Limit, Control, Schedule Acrophobia- heights
Mgt: Astraphobia-electrical storms
Clomipramine (Anafranil)-TCA Claustrophobia- close space
Group therapy (support) Hematophobia- blood
Hydrophobia- water
GENERALIZED ANXIETY DISODER Monophobia- being alone
Excessive worrying; last 6 mos or more Mysophobia-dirt/germs
Characteristics: Tension (Headache; ↑V/S; HPN; Nyctophobia- darkness
Disorganized/confused; Irritable/Restless; Pyrophobia – fires
Tremors; Slurred Speech Zoophobia- animals
Mgt: Anxiety Mgt
MY NCLEX NOTES 2021 3|Page
 SCHIZOPHRENIA SCHIZOPHRENIA DEPRESSION MANIC (BIPOLAR DISORDER)
Split of mind, not personality; impaired reality; How to start socializing: 2 major keys of Depression Characteristics:
Elevated Dopamine ***Socialize first with staff/nurse, not right 1. Depress mood • Manipulative
away with a group 2. Loss of interest/ • Impulsive, aggressive, hostile
Criteria (2/ more, atleast one major) pleasure(anhedonia) • Threat; danger to society
1. Hallucination (Major) ***TWINS- 50% will have the ds • Hyperactive; insomnia
2. Delusion (Major) Characteristic Signs of Depression • Talkative; flight of ideas
Paranoid Schizo (suspicious, hostile) • Sleep (insomnia/hypersomnia • Colorful; extravagant
3. Disorganized speech
Don’t touch (assault)-ask /inform first • Interest deficit (anhedonia) • Sexually provocative
4. Disorganized/catatonic behavior
Maintain distance- safety (put table in • Guilt (worthless/hopeless/low self
5. Negative symptoms
between) esteem) Defense Mech: Reaction Formation (act
All are Suicidal • Energy decrease opposite to what they truly feel)
Hallucinations Nx Diagnosis: Risk for Injury Directed to • Concentration decrease
Touch – “these bugs crawling under my skin” self/others • Appetite decrease/increase
Auditory-“hear that? She told me to kill you” Mgt
Defense Mech: Projection • Psychomotor Retardation (slow)/Agitation 1. SAFETY (↓stimuli, make
PRIORITY: SAFETY; Nutrition (hard to feed, • Suicidal command, restraint)
***PRIORITY- need to know the hallucinations; open sealed food in front of pt or involve in 2. Diet/Nutrition- ↑calories (Foods
then orient to reality preparation on the go / finger food (can eat
Mgt (MAJOR Depression) and hold with hands even while
Catatonic Schizo (excitement/stupor) 1. Anti Depressants (effective after 2-4 walking)
Positive Symptoms (absent to mentally healthy Nx Diagnosis: Impaired Motor weeks) 3. Set limits/ Matter of Fact
individual, major & hard s/sx) Catatonic Stupor SAFETY (suicidal-highest risk to suicide (consistent)
• Hallucination − Psychomotor retardation (waxy during less than 2 weeks of taking the 4. Anti Manic (mood stabilizer)
• Illusion flexibility) meds due to increase energy) 5. Group Therapy
• Delusion − Major depressive disorder − Encourage to ventilate feelings (don’t 6. Solitary play (non competitive,
• Echopraxia (imitate movt of others) − Not moving for long time say tell me how you feel) (DIRECT short span, mild exertion)
− Respond slowly or doesn’t respond QUESTION Yes/No) Arrange chair; painting, wood
• Insomnia
Defense Mech: Repression − Grounding (familiarize to surrounding works, writing, walking
• Ambivalence ex. Stepping on sand, Sunrise
PRIORITY: Circulation; Nutrition
• Poor Hygiene exposure, Gardening) ❖ SECLUSION
• Bizarre Behavior Disorganized Schizo (worst type; disorganized 2. ECT- if highly suicidal, even if not yet Determinant: When less restrictive methods
thoughts &behavior, mumbling) started with Anti-dep are insufficient
Negative Symptoms (can be present in mentally Nx Diagnosis: Poor Social Interaction
healthy indv; minor & soft s/sx) Defense Mech: Regression Mgt: Dysthymic Depression (chronic type) • Check restraints
• Avolition- no plans of doing PRIORITY: Physiologic needs; SAFETY 1. No Anti-depressants • Every 15-30 mins (leather)
• Anergia-lack of energy 2. Perform psychotherapy (music, art) • Every 1-2 hrs (cloth)
• Asocial- don’t want to socialize 3. Encourage to ventilate feelings • Can do seclusion even w/o doctor’s
• Anhedonia- cant appreciate pleasure orders (If high risk of harm to pt &
***CLOZAPINE – antipsychotic Mgt (insomnia)
• Apathy-no emotion others
Immunosuppressant (Monitor CBC & • Sunrise exposure
• Alogia-poverty of speech - Need to obtain doctor’s orders
Neutrophil count) • Small amnt of carbs before bed (ex. Cheese) IMMEDIATELY after
• Affect is inappropriate • Spend time with pt in quiet envi before bed
• Catatonia-hyper/waxy • Suggest warm bath before bed
• Exercise at least 5 hrs before bed

HENNAJANECE MY NCLEX NOTES 2021 4|Page

ELECTROCONVULSIVE THERAPY
− Needs consent (pt/ nearest kin or court)
– very important to obtain before ECT
Indications:
1. Pt w/ Acute/Major Depression (not for
Chronic) that doesn’t respond w/ Anti
Dep meds and highly suicidal
2. Mania & Bipolar
3. Schizophrenia Catatonic Excitement
Voltage: 70-150 volts
Time: atleast 6x-12x
Interval: every 48 hrs/ 3x a week
Duration: 0.5-2 secs
Effective Signs: Tonic Clonic Seizure
Major Contraindication
1. ↑ICP (brain tumor, trauma, stroke)
2. Fever, fracture, HPN
3. PRESENT Resp/Cardiac Probs
4. Underwent organ transplant
Not Contraindicated to
1. Pregnancy (↓100 volts) (must be
normal pregnancy, no complications)
2. Liver/Kidney Problem
HENNAJANECE
ELECTROCONVULSIVE THERAPY (ECT)
Preparation: (same w/ pre op or general
anesthesia procedure)
− NPO 6-8 hrs
− Consent
− Remove dentures
− Hold
anticonvulsant/Benzodiazepine the
night prior (will contradict the
normal side effect of ECT)
− Remove nail polish/dentures
− Give pre-op meds
1. ***Atropine sulfate(aspiration)-
promote safety (IMPORTANT)
2. Succinyl choline (muscle relaxant
because ECT causes tonic clonic)
3. Methohexital Sodium (Brevital)-
anesthetic agent (the pt will not
feel the ECT; pt must be asleep
prior to ECT)
Minor tranquilizers (↓anxiety)
Antibiotic prophylaxis
Expected S/E:
• Temporary memory lost (mgt:
orient once awake)
• Severe headache
• Asleep
• Muscle weakness (due to the
Succinyl Choline) (SAFETY!!)
Post-op:
− Airway (1st)- position side lying;
Oxygen
− Siderails Raise (padded) (not all
4) or lower height of bed
− Orient once pt awake
− Monitor V/S and LOC
THERAPIES
COGNITIVE BEHAVIORAL THERAPY
− Correct a wrong belief
• Desensitization to specific
stimuli/situation
• Relaxation technique
• Self observation and monitoring
• Teaching new coping skills and
technique to reframe thinking
BEHAVIORAL MODIFICATION THERAPY
• Establish trust and rapport
• Make contract of positive
behavior
• Set limit, firm, consistent
• Token of economy
(reward/punish)
GROUP THERAPY
To test mood of pt during therapy
Members: 6/7 – 10/12
Nurse: facilitator
MY NCLEX NOTES 2021
EATING DISORDERS
• Anorexia Nervosa (not aware, wt loss;
very thin; odd bizarre behavior;
hypothermia; lanugo; amenorrhea; dry
scaly skin; brown brittle hair)
***Purge (vomit, diuretic, laxative)
• Bulimia Nervosa (aware, normal wt)
***binge eating
***Purge (causes dental enamel
erosion, stained teeth, dental
carries)
Rupture esophagus
Signs of excessive exercise (callus in
hands)
− Assess electrolyte imbalance
− Be alert to hidden/discarded food
wrappers
− Allow Food Diary to monitor intake
− Monitor 1-2 hrs after meal
General Mgt
• Cognitive Behavioral Therapy- help
pt realize the truth
• Behavioral Modification Therapy
• Involve patient with meal planning
• Always weigh daily (same clothes,
time)
• Monitor while eating and 1-2 hrs
after meal
• Anti-Depressants
Nursing Diagnosis
Altered Nutrition: less than body req
Altered Body Image
Low Self Esteem
Ineffective Individual Coping
5|Page
 DELIRIUM VS DEMENTIA ALZHEIMER’S DISEASE ALZHEIMER’S DISEASE ADHD
Delirium Most common type of Dementia; Mgt Common in 7 yo male children; present
Common in adult Irreversible; ↓acethylcholine ; Life span: • SAFETY (well lighted room; until adult/elderly (they will learn to
Easily reversible/ acute 10 yrs alternated colors of stairs; arrange control as they grow older)
furniture; keep items w/n reach;
Causes:
Goal: lock doors leading to stairs & s/sx
1. Substance abuse
2. Illness (Hepatic Encephalopathy & Liver Teach how they accomplish task outside; place identifying symbol on • Impulsive (Destructive)
Cirrhosis-ammonia) (Chronic Kidney Ds-urea Give them enough time bathroom door) • Hyperactive (Fidget)
nitrogen) Defense Mech: Denial • Provide daily routine/structured • Inattention
3. Threat activities same time and task
4 Classic Signs: everyday; provide lesser choices; Mgt
Diagnostic Test: 1. Aphasia- hard to speak and interact as an adult; use close ended 1. CNS Stimulant (Methylphenidate)
1. EEG(Electroencephalography) understand like yes or no methamphetamine
Light breakfast
Shampoo head before & after
(Mgt: speak slowly, and use simple • Orient to time, place, person (digital ***METHYLPHENIDATE (RITALIN)
words) clock and big number calendar) - CNS Stimulant (Quick
Pt must be tired after
2. Anomia- difficult to remember • Nutrition response)
Dementia names • Assist& involve pt in ADLs - Give in the morning (avoid
Common in elderly 3. Agnosia- difficulty recognize people/ • Allow pt to socialize insomnia)
Irreversible; chronic things • Meds to slow progress (cholinergic) - Help them complete school
L 4. Apraxia- slow movement tasks and (↑Focus)
• Tacrine (Cognex)
Causes: - Causes weight loss (due to loss
1. Ageing • Donepezil (Aricept)
End Stage of Alzheimer’s s/e DHN (hydration is important) of appetite) and growth
2. Organic factors (trauma, stroke, bacteria,
(Immobility problem) retardation (monitor
viral infxn in brain like Huntington’s Ds-lesion
Complications: Bed sore; Pneumonia; If agitated: musculoskeletal) – Mgt:
in brain)
forget to swallow food (attach NGT) “Drug Holiday” (skip med)
• Distract and redirect the pt by asking
Diagnostic Test (also for Alzheimer’s): help to do something - May cause restlessness
1. Positron Emetron Scan (PET) • Use direct therapeutic eye contact
2. Autopsy (post mortem)-for confirmation MEALS: 2. Safety
and say “I can see that you are upset,
Serve half meal (divide into two) the offer 3. Nutrition (↑Calories)
Sundowning-wandering at night (happen during this is a safe place”
other half later 4. Structure activities- give 2 at a time
active stage) (lock doors above and below eye • EARLY Stage (claim didn’t eat) (give written schedule)
level/exterior; keyed deadbolts on all exterior
• MODERATE Stage (Forget) 5. Play (safe)
doors; grab bars in the shower & bedside; safe
• LATE Stage (NGT) 6. Behavioral Modification Therapy
return bracelet; no clutter)

***Pt is active, redirect to what the pt needs to do *** Myth- sugar and food additives (not
***If mild symptoms (memory disturbance)-orient true triggers of ADHD)
the pt ***If destructive, teach the child
relaxation deep breathing

HENNAJANECE MY NCLEX NOTES 2021 6|Page

 CHILD ABUSE ABUSE RAPE / SEXUAL ASSAULT RAPE / SEXUAL ASSAULT
Mgt Forcible insertion of penis/objects into the
• Assess the child Battered Wife vagina, mouth or anus EMERGENCY POST COITAL
• Observe the parent-child behavior − Due to jealousy, possessive partner CONTRACEPTIVE
Types
• REPORT (PRIORITY) − ↑abuse during pregnancy
1. Incest (related)
− Victim stays (due to fear of life, 2. Acquaintance (someone you know)
Morning After Pills (w/n 72 hrs)
Signs of Child Abuse financial, religion, children) 3. Statutory (w/consent; minor <15 yo)
• Injuries at different stages of healing − Can occur to ALL status 4. Blitz (unknown suspect) ❖ Ethinyl + Levonorgestrel (Plan
(common site: buttocks/thighs) 5. Accessory (can’t give consent; autistic, A)
• Aloft/uncomfortable Characteristic of Victim schizo) 1. Take 2 pills w/n 72 hrs
• Unequal hair growth Dependence – can’t live abusive 6. Confidential (unreported) 2. Take next 2 pills after 12 hrs of
7. Date (during date) 1st dose
• Nightmare husband; may be financially dependent
• Knowledge with sex Co-dependence – blaming self not the
Mgt
• Depression- abuser ❖ Levonorgestrel (Plan B)
• Preserve evidence
Low self esteem Commonly use
hopelessness/powerlessness • SAFETY (Stay with pt)
• Educate victim the need for pelvic
1. Take 2 pills w/n 72 hrs
Mgt Mgt exam (to check injury) 2. Take next 2 pills after 12 hrs of
1. SAFETY (Call 911, Teach nearest place to 1. SAFETY (Call 911, Teach nearest • Obtain LMP & method of birth 1st dose
go, provide shelter) place to go, provide shelter) control
2. Family Therapy 2. Ask direct question • Perform head to toe assessment
3. Play Therapy “Did anyone hit you?” • Proper documentation
(confidential, organize subj&obj)
4. REPORT
Characteristics of Perpetrator • Report (supervisor then police)
• When undressing, use scissors
***Tell them its not their fault or to be blame − Have hx of growing up in envi
• Provide Prophylactic antibiotic
“You did the right thing by telling me. You are with domestic violence
not in trouble” − Abused before
− Have hx of substance abuse Rape Trauma Syndrome
Assess (Example questions): − Have low self esteem/ high − Develop immediately after the rape
− Ask parent about child’s behavior at insecurity − Victim is disorganized, shocked, numb,
home − Teenager/ immaturity disbelief, have ↑anxiety (fear of death)
− Forms of discipline parent use − Denial (don’t talk about the rape or may
talk but w/o feelings)
− Coping mechanism of parents
− Who watch their child in behalf of ***PTSD-develops after 2-3 mos
them Causes of ABUSE/RAPE ***Clearly communicate to prevent rape
1. Power
2. Anger (revenge)
3. Sadism (most common)

HENNAJANECE MY NCLEX NOTES 2021 7|Page

MAJOR PSYCHOTIC SX & DIAGNOSIS
Altered Sensory Perception (senses)
1. Hallucination- no external stimuli
2. Illusion- w/ external stimuli
Altered Thought Process (Beliefs/speech)
1. Delusion-false belief based on thought
• Grandeur- VIP feeling
• Persecution- someone will harm them
(***give pack/sealed food)
- understand feeling secondary to
the delusion
- focus on reality and verbally
reinforce it
- never confront/argue/explore the
delusion
• Control- feeling of posses
• Religion- prophet
• Ideas of Reference
- Relate self with what is happening
around (tv, media, code)
- Feeling that 2 people talking about
you
2. Echolalia-repeat words of others
3. Word Salad- mix words
4. Neologism- coining new words
5. Alogia- poverty of speech (ahhmm)
6. Circumstantiality- add unnecessary
details but relevant details is achieved;
flowery words
7. Tangentiality-digress from
topic/question; never reach the point of
the question
8. Clang Association-rhyme words
9. Dissociation-detach from normal
function; disconnected
10. Flight of Ideas-shift from one topic to
another related topic (talkative)
(ex.manic pt)
11. Loose of Association-sequence of
unrelated ideas (schizo pt)
HENNAJANECE
MAJOR PSYCHOTIC SIGNS&SYMPTOMS
Inappropriate Affect (feelings/emotions)
1. Blunted affect-delayed response
2. Flat affect-no facial expression/
no response
3. Apathy- no emotion/feelings
4. Anhedonia-inability to exp
pleasure (don’t appreciate)
5. Ambivalence- opposing feelings
6. Labile- sudden mood swing
Impaired Motor
1. Echopraxia- repeat movt
2. Waxy flexibility-hold position for
so long
Memory Disturbance
1. Amnesia- forgetfulness
•
Anterograde-forgetting
recent/immediate past; short
term (ex.Alzheimers)
• Retrograde-forgetting distant
past; long term
2. Confabulation- creation of
fantasy to fill in gaps
***In delusion, focus on feelings &
present reality (don’t explore, don’t
confront & don’t present logical
explanation to discredit)
DEFENSE MECHANISM
• Denial-failure to accept reality
• Displacement-shift emotion to less
threat (ex.your boss fired you, at
home, you hit your dog)
• Projection- assimilate self to others
(ex. You said your friend is hungry,
but actually, you are the one
hungry)
• Substitution-replace unattainable
goal to attainable
• Sublimation-channel unacceptable
behavior towards something
acceptable (ex.angry then play
piano)
• Symbolization-use to represent
another (ex. Social climber)
• Undoing- attempt to erase wrong
act
• Repression-involuntary forgetting
• Suppression-voluntary forgetting
• Identification-conscious patterning
of behavior(impt in growth&devpt)
• Introjection-unconscious patterning
of behavior
• Rationalization-justify unacceptable
behavior
• Intellectualization-explain things in
detail based on books or studies
• Regression-reversion to earlier
stage of development to ↓anxiety
(ex.nail biting, bed wetting)
• Compensation-weakness in one
area through gratification in another
area
• Acting out- performing extreme
behavior in order to express
though/feelings
• Reaction formation-act opposite to
what you truly feel
MY NCLEX NOTES 2021
AUTISM SPECTRUM DISORDER
Common in 2-3 yo (3 yo) mostly male
S/sx wild and smart child
Major characteristics
• Poor social interaction-
unresponsive
• No eye contact, not cuddly
• Echolalia
• Spin objects (Offer Block Toys)
• Love music
• Tantrums (Headbang)-
safety(helmet)
• Don’t like changes
Mgt
• SAFETY
• Nutrition
• Behavioral Modification
• Repetition
• Role model
• Refer with resources (not in
regular school)
***During hospitalizations
• Avoid overstimulation
• Give lesser choices
• Only one or limited visitors
• Give schedule of daily activity
8|Page

OB ASSESSMENT
1. OB SCORE “GPTPAL”
Gravida – # of pregnancy
Para – # of deliveries
Term – 37-42 wks
Preterm – 20-36 wks (Age of Viability)
(either dead or alive w/n 20-36 wks)
Abortion – death before 20 wks
Living – alive
Null (none)
Primi (1st)
Multi (2 or more)
***Multiples- considered as one for G;
multiples for PTPAL
***Living- count individually
***Twins (Preterm 2)
***Abortion not counted as Para/delivery
*** Preterm is counted as Para/delivery
Ex. A mother claims that this is her 2nd
pregnancy, her 1st was abortion. (G1P0)
***the current pregnancy is not yet counted as
Gravida, because only “claim”
Ex. A pregnant mother reports to clinic she has
12 yo son born @ 29 wks, her 1st delivered
dead at 24 wks (G3P2T0P2A0L1)
***Toxoplasmosis – from soil of home-
grown vegetables
HENNAJANECE
OB MATERNAL NOTES
OB ASSESSMENT
2. NAEGELE’S RULE
(Expected date of delivery/expected
date of confinement)
LMP Calculation
-3 months
+7 days
Ex. LMP July 25 (A: May 2)
Ex. LMP Mar 10,19 (A: Dec 17,19)
Ex. LMP May 25,19 (March 3 2020-
2020 is a leap year so Feb has 29 days;
leap year is every 4 yrs)
3. BABY LENGTH DURING PREGNANCY
(Haise’s)
• 1-5 mos = Month squared2
• 6-10 mos = Month x 5
4. CALORIC INTAKE
Normal Caloric Intake: 2300 Kcal/day
or
Add 300 kcal/day (ex. 1800 kcal/day
pre-pregnancy + 300= 2100 kcal/day)
OB ASSESSMENT
5. FUNDAL HEIGHT & AOG
- check at 12 wks or 2nd trimester
- ask mother to void prior
- use tape measure
- Position: Supine
- Not accurate result: full bladder;
polyhydramnios; obese mother;
multiple gestation
- Start at Symphysis pubis - 12cm
- ***Lightening- happens 2 wks before
delivery, the fundus will go down to
34-35 cm
Xyphoid Process
Umbilicus
Symphysis Pubis
Bartholomew’s Rule – Age of Gestation
1 cm= 1 wk (+2-2)
Ex. 16 cm = 16wks +2-2 (AOG 14-18 wks)
McDonald’s – Age of Gestation (weeks)
• Week: FH x 8 / 7
Ex. 16 cm x 8 / 7 = 18.29 (18-19 wks)
• Months: FH x 2 / 7
Ex. 16 cm x 2 / 7= 4.57 (4 ½ mos)
MY NCLEX NOTES 2021
OB ASSESSMENT
FUNDAL HEIGHT POSTPARTUM
Normal Fundus: Firm; Contracted
***If fundus is at the side-assist to
void/straight cath if pt had epidural
Level
Immediately after birth-midway between
symphysis pubis and umbilical cord
12 -24 hrs – Umbilicus
After 1 day- 1 line below umbilicus
(succeeding line below is another day)
2nd day – 1 finger breath below umbilicus
6th day – level of symphysis pubis
UTERINE ATONY
- Hemorrhage; soft & boggy fundus
Mgt
1. Creed’s Maneuver-Massage fundus
until firm
2. Report to start oxytocin for uterine
contraction and prevent bleeding
9|Page
 OB ASSESSMENT SIGNS OF PREGNANCY SIGNS OF PREGNANCY EMOTIONAL ADAPTATION

6. WEIGHT GAIN ➢ POSITIVE SIGNS OF PREGNANCY ➢ MORNING SICKNESS 1st Trimester: Accept Pregnancy/
• Normal: 28 lbs -3+3 (25-31 lbs) or 40 Appears from 1st trimester until 2nd tri Dial/Ambivalence
lbs if twins for the whole pregnancy • Fetal Heart Rate Cause: ↑ HCG hormones
1st Trimester: 1 lb/month (3 lbs in total) o Earliest to detect @ 8wks using Triggers: 2nd Trimester: Accept Baby/ Fantasy &
2nd – 3rd: 1 lb/week Doppler UTZ • Fatty/oil/spicy foods daydreaming of baby
o @10-12 wks using Doppler • Water w/ meal (it should be
1mon= 4 wks (1lb) o @16 wks fetoscope water in between meal/ 30 mins 3rd Trimester: Accept role of a mother/
2mos= 8 wks (1lb) o 18-20 wks using stethoscope before or after meals) Anxiety/Fear/Nesting behavior/Clumsy
3mos= 12 wks(1lb) • Fetal Movement Mgt (risk for fall)/feels ugly
4mos= 16 wks(4lb) • Fetal Outline via UTZ or Xray (can • Dry carbohydrates (crackers)
5mos= 20 wks(4lb) perform xray 16 wks & above) - Take before arising
6mos= 24 wks(4lb) • Fetal body parts (felt by examiner) • High protein diet (best answer) COUVAIDE SYNDROME
7mos= 28 wks(4lb) • Encourage to take Ginger (mgt of - Father also experience these
PRESUMPTIVE Subjective by mother nausea & vomiting) emotional adaptation
Ex. 22 wks (13 lbs)
1st Trimester 2nd Trimester ➢ URINARY FREQUENCY
*** WEIGHT GAIN PER WEEK • Breast changes • Chloasma Happens on 1st & 3rd Trimester (not on 2nd
AOG in weeks – 9 (+2-2) • Urinary • Linea Negra trimester because fundus is at abdomen)
Ex. AOG 20 wks frequency • Increase skin
20-9 +2-2 (9-13 lbs) • Fatigue pigment Mgt (during pregnancy & postpartum)
• Amenorrhea • Striae - Void every 2 hrs
• Morning sickness gravidarum
• Enlargement of • Quickening
7. PRE-NATAL uterus ➢ SEQUENCE (alphabetical)
• Earliest time to seek prenatal: • Latitude 1. Chadwick- bluish discoloration
when the mother suspect she is of vagina & cervix
pregnant 2. Goodell’s sign – soft cervix (as
• Schedule: PROBABLE Objective (nurse assess/can soft as earlobe); if soft as butter
1. Once/mo until 28 wks (7 mos) see) means almost delivery of baby
2. Every 2 wks until 36 wks 1st Trimester 2nd Trimester 3. Hegar’s sign – softening of
3. Every wk until 42 wks • Goodell’s sign • Braxton’s hick lower uterus
4. After 42 wks (induced labor) • Chadwick • Elevated fundus
• Hegar’s Sign • Ballottement- a
Ex. Prenatal at 21 wks, when is next? • Elevation of basal sharp upward ➢ DYSPNEA
A: Next month @ 25 wks body temp pushing against the Mgt
• Positive test uterine wall with a - Position: Tripod/Orthopneic
Ex. 28 wks (A: 30 wks) finger inserted into (leaning forward
Ex. 37 wks (A: 38 wks) the vagina

HENNAJANECE MY NCLEX NOTES 2021 10 | P a g e

 PHYSIOLOGIC CHANGES
➢ CARDIOVASCULAR
• Physiologic Anemia (normal during
pregnancy)- due to ↑plasma
- Normal Hgb during pregnancy
o 1st Tri: 11 g/dL
o 2nd Tri: 10.5 g/dL
o 3rd Tri: 11g/dL
- ***If below these numbers, its
diagnose as general anemia
• WBC
- N: 5000-1000mm3
- If pregnant: Elevated
- High WBC- normal upto 1 wk
postpartum
• Supine Hypotension – due to decrease
blood flow back to the heart
- Mgt: Left Lateral Position
• Orthostatic Hypotension
- Mgt: move slowly
• Varicose
- Mgt: support stockings/anti embolic
stocking; elevate legs not more than
30 mins
➢ SKELETAL
• Back Pain (lumbosacral curvature)
- Common in 2nd to 3rd trimester
- Mgt: Position then Pelvic Tilt/Rock
exercise; counter pressure massage
• Walk
- ***Waddling Gait (due to presence
of Relaxin hormone
• Posture
- Wear low heeled shoes <1 in
➢ RESPIRATORY
• Hyperventilation (slight Respiratory
Alkalosis)
- Mgt: document no need to report
HENNAJANECE
FETAL HEART DECELERATION
Normal FHR= 120-160 bpm
Normal Fetal Kick counts (10 & ↑/hr or
after meal)
1. Early Deceleration- due to head
compression due to crowning; may lead
to caput succedaneum; Normal (no
report)
2. Late Deceleration-due to placenta
insufficiency due to HPN/DM/Abruptio P
(Maternal hypoxia); Abnormal (report)
Goal: Identify and treat the cause of
maternal hypoxia
Mgt: STOP Oxytocin drip
O2; IV Fluid bolus; may give Terbutaline
SQ to relax uterus; reposition left lateral
side; Report
3. Variable Deceleration- dangerous/emerg
Due to cord prolapse; Abnormal (report)
-abrupt ↓FHR (drops 15 bpm)
-correctable, positioning
-may impair O2
Priority: Decrease pressure to the cord
Cord Prolapse Mgt:
1. Push/tap presenting part upward
2. Position (knee chest/Trendelenburg)
***Don’t follow “LION” for Variable
Deceleration (perform cord prolapse mgt
first)
FETAL HEART DECELERATION LIGHTENING
❖ LIGHTENING
***Sinusoidal FHR - Happens 2 wks before delivery (if
- Due to severe fetal anemia, mother is Primi), the fundus will go
trauma, fetal infection, injury down to 34-35 cm
- No response to contraction - If multipara mother, they
experience Lightening on the onset
of labor
Effect of Lightening
• Urinary frequency (due to increase
***Episodic Acceleration- normal, pressure to pelvis)
document finding • Increase in Vaginal discharge
• Shooting leg pain/cramps/back pain
Advantage (to primi mothers)
• Improve Respiration
❖ ABNORMAL FHR MGT: (HIGH FHR)
“ S & LION ”
1. STOP Oxytocin (1st if w/ oxytocin)
2. Left lateral position
3. IV infusion
4. Oxygen
5. Notify physician
*** Follow “ LION” to all other pregnancy
complications except if w/oxytocin
***HOLD OXYTOCIN
• Contractions >90 secs
• Development of N & V
MY NCLEX NOTES 2021 11 | P a g e
 SIGNS OF LABOR LABOR PROCESS LABOR PROCESS

➢ TRUE LABOR (onset sign of labor) LABOR DYSTOCIA (painful prolong labor) ➢ STAGE 1 (Cervical Dilatation) (ends at full Dilatation)
• Pain: radiate from lower back to Risk factors:
lower abdomen; • ↑Maternal age
• Intensity: Increase uterine • Obesity (BMI >25) Phases Dilatation Intensity Duration Frequency
intensity, duration and frequency • Previous difficulty w/ fertility Latent 0-3cm Mild <40 secs 5-10 mins
• Persistent/consistent even pt Active 4-7cm Moderate strong 40-60 secs 3-5 mins
walk/sit Transition 8-10cm Severe/Intense 60-90 secs 2-3 mins
• Positive Cervical Dilatation (0-10 PREMATURE RUPTURE OF MEMBRANE
cm or 4 inches) & Effacement Danger: Cord Prolapse;
(thinning of cervix; 0-100%) Infection/Chorioamnionitis ***8cm – Rupture of Membrane; place at DR table (if primipara @10cm)
(confirmation of True Labor) ***NO pain meds when Transition phase starts (8cm onwards)
Mgt: Early IV Antibiotic Prophylaxis ***Pain meds best given at Active phase (4-7cm)
***Latent phase- good time for teaching for breathing exercise
➢ FALSE LABOR ***Mother is in Regular diet (not on NPO) (whole stage 1: mother can eat)
• Pain: Localized; pain disappear SPONTANEOUS RUPTURE OF MEMBRANE ***NO IV line (for the comfort of mother) (only attached immediately once baby is out)
• Intensity: Irregular uterine ***IE (sterile gloves, soluble gel) ***Report immediately if duration is >90 secs
intensity, duration and frequency ***Positive Nitrazine test
• Disappear when pt walk/sit ***Palpate abd before applying fetal ***Position: Left Lateral Position (if not yet on labor)
• Negative Cervical Dilatation & monitors ***Position during labor: the position that mother wants (not lithotomy always)
Effacement ***Providing client w/ variety of clear
• Sometimes with blood tinged, liquid drinks (safe: water, ginger tea)
mucoid vaginal discharge ***Tetanic Uterine Contraction
• ***Braxton-Hick’s contractions, - >90 secs
also known as prodromal or false - Emergency
labor pains, usually indicate that
the mother might be due in 2 wks Pudendal Nerve Block – Focus on the perineum (pain mgt technique) during labor

***Pelvic rock/tilt exercise- to relieve back pain during early labor

***BLOODY SHOW w/ mucus plug ***Transition stage- trembling legs due to pressure of presenting part on the pelvis,
- Sign that labor is near, but not a ready to push
true labor sign ***Avoid Narcotic during Latent but depends on situation (give slowly during peak of
next contraction to avoid entering the placenta)
***If cervix open – must deliver baby
regardless of AOG or false labor signs

HENNAJANECE MY NCLEX NOTES 2021 12 | P a g e

 LABOR PROCESS LABOR PROCESS LABOR PROCESS POSTPARTUM ASSESSMENT
➢ STAGE 2 (Delivery of Baby) ➢ STAGE 3 (Delivery of Placenta) ➢ STAGE 4 (Recovery up to 4 hrs) 1. 1st ALWAYS CHECK FUNDUS
(Ends when the baby is delivered) Lasts for 5-30 mins High mortality due to Hemorrhage
2. 2nd LOCHIA
Mechanism of Labor “ EDFIREEE “
• Schultz (Normal placenta; 1. Vital Signs Monitoring
1. Engagement
Separate center; shiny) 1 hr- V/S every 15 mins; Temp every 1 hr Rubra Red 1-3 days
2. Decent (enter the cervix)
• Duncan’s (Dirty Placenta; Edge 2 hr- V/S every 30 mins; Temp every 1 hr Serosa Pink 4-7 days
3. Flexion (Attitude-chin flex to chest)
separation) 3-4 hr- V/S every 1 hr; Temp every 1 hr Brown 8-9 days
4. Internal Rotation
5. Extension (head extend; cause the Alba White 10-21 days
delivery of the head: Crowning) 2. ***FUNDUS (check notes above)
Perform “Ritgen’s Maneuver” (protect Normal: Firm; Contracted
***Clear- Normal
laceration of perineum w/ sterile/clean ***If fundus is at the side-assist to void
cloth)
***Odor - musty/fleshy (normal)
- Foul-smelling (infection
3. PERINEAL PAD (NAPKIN)
Normal: 30mL capacity
***Can resume to sex (4-6 weeks
*** AVA (2 arteries & 1 vein) ***If soaked (100%) in 15 mins means
postpartum); (earliest: if
hemorrhage
clear/transparent discharge/2 wks)
MOTHER Mgt
Soaked
***If still red discharge on 4th day, tell
• Insert IV line Within 5 mins- Fatal; report
mother to avoid strenuous activities
• Infuse Oxytocin once baby is out Within 1 hr- report (hemorrhage)
(promote contraction & prevent Within 2hrs or more- Normal
***If pain on 7th day (blue w/o foul odor),
hemorrhage) because of early coitus
4. TEMPERATURE
***↑Temp w/n 24 hrs- normal due to
blood loss and dehydration
PRIORITY CARE TO THE BABY
6. External Rotation (so shoulder will fit)
Blood loss (NSVD)- 300-500mL
7. Extension of Shoulder (anterior shoulder • Thermoregulation (Promote warmth Blood loss (CS)- 500-1000mL
should be delivered first) to the baby) (wrap baby)
***Crowning- fully dilated; encourage pt to
***Airway & suctioning is not a priority if ***↑Temp after 24 hrs- signs of infection NEONATE (0-28 days)
bear down w/ spontaneous urges to push
Baby is NORMAL because suction is not ***Monitor for Hemorrhage and Hypovolemic Normal
performed anymore Shock (↓BP, ↑HR ↑RR); Persistent
***CESARIAN BIRTH (due to fetal distress) o HR: 120-160bpm
headache/blurred vision preeclampsia)
• Administer O2 8-10 L o RR: 30-60 bpm
• ↑ fluid ***MECONIUM stained (Airway &suction o O2 Sat: 95-100%
ANENCEPHALY
• Place on Left lateral position is the Priority)
***wrap the newborn in warm blanket for
while waiting the parents to hold

HENNAJANECE MY NCLEX NOTES 2021 13 | P a g e

 OB MEDS
➢ TOCOLYTICS
- use to decrease uterine
contraction by relaxing uterus
1. Terbutaline (check maternal
tachycardia); If w/ chest pain, stop &
report
2. Magnesium sulfate
- Seizure prophylaxis; decrease BP;
PIH; relaxes uterus & decrease
uterine contraction
- check BP every dose
- don’t give </ 90/60mmHg)
- Normal level Mg: 1.5-2.5 meq/L
- Therapeutic level of MgSo4: 4-7
meq/L
MgSO4 Toxicity - >7.0 meq/dL
S/sx:
• BP ↓
• Urine ↓30mL/hr
• RR ↓ (<12 bpm report)
• Patellar/Deep Tendon Reflex
(1st sign)- absent/decrease)
Normal: +2 (AbN: if +1 or 0)
Mgt:
• Antidote: Calcium Gluconate
• Assess deep tendon reflexes
hourly
• Have supplemental O2 at bedside
• Limit visitors & avoid bright lights
• Report if UO <30mL/hr
• Monitor renal & cardiac function
HENNAJANECE
OB MEDS OB MEDS FACTORS AFFECTING LABOR
➢ UTEROTONICS/OXYTOXICS
- Increase uterine contractions Contraindicated Meds for PREGNANCY 1. UTERINE CONTRACTION
- Prevent postpartum hemorrhage • Not exceed 90 secs duration
- HOLD if FHR is ↑/↓ normal 1. Isotretinoin (ingredient in beauty (***Report immediately if
products)- teratogenic duration is >90 secs)
1. Oxytocin 2. ACE Inhibitors (“Pril”) • Not exceed 80 mmHg Intensity
- Preferred if BP is ↑
3. ARBS (“Sartan”) • Not exceed 20 mmHg Resting tone
- Given after delivery of baby
- IV side drip infusion pump (a
4. Tetracycline antibiotics-usually • Equal/less than 5 contractions in
for lime disease) 10 mins strip
secondary line)
5. Lithium Carbonate (for manic)-
- Continuous monitoring of FHR and
mother
NO antipsychotic meds Normal duration: <90 secs
- Titrate until contraction of every 2-3 Toxic Level: >1.5 If >90 secs: may lead to Fetal Hypoxia
mins 6. Phenytoin (Dilantin)-
- Risk: postpartum hemorrhage (uterus anticonvulsant (seizures) Mgt (Monitor)
relax due to exhaustion during labor); • Duration (from start of contraction to
uterine tachysystole end of contraction)
***HYPOTONIC UTERINE DYSFUNCTION • Frequency (start of contraction to start
2. Methylergonovine - Contractions weaken during active labor of next contraction)
- Danger: causes ↑BP - Contractions become inefficient or stop
• Interval (end of contraction to start of
- Given if still bleeding after oxytocin during active labor
next contraction)
- Given IM - The pt initially makes normal progress
into active labor, then contractions • Intensity (mild/moderate/strong/
- Contraindicated for HPN (it causes severe/intense)
weaken
vasoconstriction)- may lead to
stroke/seizure
3. Misoprostol (Cytotec)/ Dinoprostone-
Prostaglandin E1
- to ripen cervix & contract uterus
- Alternative to Methergine if HPN
- 2 tabs oral + 2 tabs cervically Interval
- Don’t give w/ other uterotonics
- Don’t give if pt has previous CS
- Don’t give w/ abnormal FHR
- Don’t give if Uterine Tachysystole (>5
contractions/10 mins)
- Can given orally/cervical
- Given rectally if w/ postpartum
hemorrhage
MY NCLEX NOTES 2021 14 | P a g e
 FACTORS AFFECTING LABOR
2. FETAL PRESENTATION
• Head/Cephalic (normal
presentation; Vertex)
• Breech – needs CS to deliver
• Shoulder – needs CS
3. FETAL LIE
- Relationship of spine of mother
w/ spine of the baby
• Normal Fetal Lie
o Longitudinal/ Vertical
(presenting part of baby either
cephalic/breech)
• Abnormal Fetal Lie
o Transverse Lie (shoulder is the
presenting part); needs CS; can
deliver NSVD by external cephalic
version maneuver to move baby
HENNAJANECE
FACTORS AFFECTING LABOR FACTORS AFFECTING LABOR CORD PROLAPSE
Types:
4. ENGAGEMENT 5. FETAL POSITION 1. Occult/Hidden- cord didn’t come
- Relationship of presenting part ***LOA/ROA out
to the level of Ischial Spine Mgt
(station 0; narrowest part of • SECOND letter means fetal landmark • Tap presenting part upward
pelvis; the middle part of pelvic (determine this first) • Position: Knee chest (best
inlet & outlet) o Occiput
position for cord prolapse)
o Mentum
- If still on -3 & -4 (Float) 2. Evident
o Acromion (shoulder)
- If on -1 & -2 (Dipping) Mgt
o Sacrum (buttocks)
- If +3 & +4 (Crowning • Priority: Cover the cord with
- If +1 & +2 (Extension) • FIRST letter means maternal side of sterile & moist NSS
pelvis: Left/Right gauze/cloth/os
• Position: Trendelenburg
• THIRD letter: (elevate pelvic & buttocks
Anterior/Posterior/Lateral area)
Ex. Mentum at the right back (A: RMP)
Mgt
Ex. Sacrum on the left front (A: LSA)
• Push then Position
***Painful if located at posterior
Ex. LOP/ROP
Mgt:
1. Position on knee chest PREGNANCY INDUCED HYPERTENSION
2. Push sacrum
- ↑BP 20 weeks and above
- Causes:
↓18 yo
↑35 yo
DM
- History of HPN
MY NCLEX NOTES 2021 15 | P a g e
 AMNIOTIC FLUID
Act as cushion/ protection
Color: Straw like (clear, transparent)
Amount: 500-1000mL
Oligohydramnios (<300mL)
- May need additional neonatal
personnel
- Cont FHR monitoring
Polyhydramnios (>2000mL)- due to DM
*** “Water broke” (report)
1. 1st Check FHR
2. Verify if AF or urine using Nitrazine
Paper Test
Nitrazine Paper Test
Normal color of paper is yellow
• Blue (Amniotic fluid)-Alkaline
• Yellow (Urine)-Acidic
Fern Test
-To verify false +AF due to sperm/sex
-Sterile swabbing outside cervix
• Positive- Amniotic Fluid
• Negative-not Amniotic Fluid
AMNIOTOMY (artificial rupture of membrane)
• Assess FHR before & after procedure
• Check Temp every 2 hrs (infection)
• It should be painless
• Position upright/semi fowlers
• Note characteristic of the Amniotic
Fluid
HENNAJANECE
PRETERM
Risk factors:
• History of spontaneous abortion
(highest)
• Cervical biopsy/surgery (core
biopsy)
• Tobacco/Illicit drugs
• Under Nutrition
• Non-Hispanic Black Woman
• Periodontal (gum infection) / UTI
• Age: <18 yo ; >35yo
Goal: Prolong Pregnancy
Mgt
• Priority: Tocolytics (to prolong
pregnancy)
(Terbutaline,Indomethazine,
Nefidipine)
• Glucocorticoids (IM
betamethasone)
(Dexamethasone)- hasten lung
maturity
• Antibiotic Prophylaxis (Penicillin)
IV piggyback-prevent group B
infection
• IM MgSO4 (if >32 wks)-
neuroprotector; prevent seizures
• Continuous Fetal monitoring
Prophylactic Cervical Cerclage (stiches)
- Inserted @ 12-14 wks
- Remove at 37 wks
- Avoid strenuous activities
- Report low back aches/pelvic
pressure (preterm labor)
SHOULDER DYSTOCIA UTERINE INVERSION
Too broad shoulder Uterus turned inside out
Mgt Causes:
• Passing Time- document time • Over traction of cord
fetal head delivered (inform HCP • Placenta is attached to fundus
if >5 mins already; baby prone to
cord compression/resp probs) S/sx:
• Maneuvers** 1. Sudden gush of blood *
• Additional Help 2. Non palpable fundus
• No Fundal Push 3. Large tissue mass at cervix
Mgt:
McRoberts Maneuver
--for dystocia, broad shoulder, 1. Priority: Cover the cord with
macrosomia, Turtle’s sign (head in and sterile & moist NSS gauze/cloth/os
out) 2. Don’t remove placenta
-flex pt’s legs/thighs and push towards 3. Perform shock mgt (IV-line G 18,
abdomen blood type, blood transfusion)
4. Don’t push placenta back inside
Suprapubic Pressure 5. Return uterus under general anest
-apply downward pressure above 6. Antibiotics
symphysis pubis
ENDOMETRITIS (happens postpartum)
***Vacuum/Forcep- avoided as much as
possible; may cause Brachial Nerve Plexus S/sx
• Pelvic region pain (lower
ASSISTED BIRTH - indications abdomen)
-shorten 2nd stage • Foul vaginal discharge
-maternal exhaustion • Fever after 24 hrs postpartum
-maternal cardiac problem
-cerebrovascular disease (stroke)
-Fetus: AbN FHR / Arrest Rotation
***only pull or apply vacuum during
contractions
***drains pt bladder using catheter prior
***notes exact time the forceps applied
- ***Palpates contractions and
inform HCP
MY NCLEX NOTES 2021 16 | P a g e
 ABRUPTIO PLACENTA PLACENTA PREVIA Disseminated intravascular coagulation ECTOPIC PREGNANCY
- ↑BP (veins will rupture and bleed; the -Placenta implanted at lower segment of Too many clots scattered in the - Diagnosed thru UTZ
blood will push placenta away from the uterus circulation
uterine wall S/sx
- Early separation of placenta after 20 Causes:
Causes: • Referred shoulder pain
weeks • Multiple gestation
• HELLP Syndrome (due to PIH) • ↓BP ↑HR (due to hemorrhage)
• Uterine anomalies (ex. Tumor)
Causes: • Race (Taiwanese, Filipinos) • Sepsis (ex. Fetal demise) • Dizziness
Pre-eclampsia (#1 cause) ↑BP • Abruption Placenta • Unilateral pain
Uterine anomalies S/Sx • Amniotic Fluid Embolism • Hematoperitoneum
Multiple Gestation (ex. Twins) • Painless • Severe Hemorrhage • Cullen’s Sign (bluish
Short cord (N=20-21 in) • Bright red vaginal bleeding (fresh discoloration of umbilicus)
Trauma blood) *Normal blood loss: 300-500 mL
• Soft, relax, non tender uterus *C/S Delivery blood loss: 500-1000 mL How to know if Ruptured
S/sx • Fundal height may be greater than
Culdocentesis- aspiration of fluid/blood
• Couvelaire’s Sign (boardlike fundus) expected gestational age
Danger: Further Hemorrhage from cul-de-sac/ peritoneal cavity
-continuous contraction
-tender/painful uterus/rigid ***Emergency - Monitor for gum bleeding, - Clear fluid: not rupture
• Concealed dark red vaginal bleeding • Prepare for CS headache, blood in urine - Red fluid: ruptured
• Shock/ Hemorrhage (↓BP, ↑HR • IV-line G18 *Check Fibrinogen/CBC /Platelet
↑RR) • Blood typing & crossmatching Mgt:
• IV Line G18 (PNSS/PLR)
Mgt Mgt (PRIORITY: Notify HCP) ❖ HYPERCOAGULATION • Blood typing for possible blood
1. Pain management • No IE (If IE needed, there should be - Post CS transfusion
2. Shock/hemorrhage mgt (IV NSS blood on standby)
- Risk for thromboembolism • Methotrexate (stops the fetus
gauge 18; blood typing) • No Rectal Examination
- DVT and Pulmonary Edema from growing. The mother's body
3. Emergency CS • Rest Vagina/ Bed rest
• Hydrate; IV Line then usually absorbs the fetal
4. Oxytocin
5. Continuous FHR monitoring • Scheduled CS before onset of labor Pulmonary Edema tissue)
6. V/S every 15-30 mins • Continuous FHR monitoring S/sx:
• Pad counts to assess bleeding • Chest pain
Complications • No sex after 20 wks pregnancy esp • SOB, Dyspnea, Anxious
• Disseminated intravascular w. complete/partial PP • ↑HR, ↓BP, Restless
coagulation (DIC)-will lead to • Repeat UTZ @ 36-37 wks to check
hemorrhage (gum bleeding, low lying or marginal status of
placenta
Mgt
headache, blood in urine; no more
clot factors); also caused by Fetal
• Position Upright
Demise; ***Normal Birth • Administer O2 (obtain oxygen
*Check Fibrinogen/CBC /Platelet Brant Andrew Maneuver- proper maneuver to saturation ready by oximeter)
• Renal Failure pull placenta • Report to HCP Immediately
• HCP will order thrombolytics
(Streptokinase, Alteplase, Tissue
Plasminogen Activator)

HENNAJANECE MY NCLEX NOTES 2021 17 | P a g e

 GESTATIONAL HYPERTENSION PRE-ECLAMPSIA PRE-ECLAMPSIA ECLAMPSIA
S/sx: 4 Classic S/sx of PIH : Level
• ↑BP 140/90 mmHg (2 or more 1. ↑BP (can have headache) 2. Severe Pre-eclampsia S/sx
readings) 2. Edema in hands & face S/sx • BP ↑160/90 mmHg
3. Protein/albumin in urine
• ↑Systolic 30 mmHg • BP 160/90 mmHg • SEIZURE
4. ***Blurring vision
• readings) • Edema Face & hands • Edema Face & hands
• ↑Systolic 30 mmHg Level • Protein +3 +4 • Protein +5 and more
• ↑Diastolic 10 mmHg 1. Mild • HELLP Syndrome • Worsen HELLP
• No Proteinuria/Albuminuria S/sx Hemolysis of blood
• Bp 140/90 mmHg Elevated Liver Enzymes(ALT/AST) Mgt:
Mgt • Edema Face & hands Low Platelet (prone to bleeding) • SEIZURE PREC
• Protein +1 +2
• Hydralazine *** Monitor for aura/ominous - O2 and suction machine at
• w/ occipital headache
• Promote rest signs for seizure bedside
Mgt:
• Diet: ↓NA ↓Fat ; Regular Protein Subj: Epigastric pain - Raise siderails R&L (padded w.
• Hydralazine tablet; MgSO4
Obj: Rolling eyeballs pillow)
• Diet ↑Protein
• Promote rest - Lower head of bed
Pregnancy Induced HPN Mgt - Diazepam IV at bedside
• ↑BP 20 wks or more MAGNESIUM SULFATE • Hydralazine /Labetalol IV • Hydralazine IV Infusion Pump
- Seizure prophylaxis; decrease BP; PIH; Infusion Pump • Diet ↑Protein NGT
Causes: relaxes uterus & decrease uterine • Diet ↑Protein NGT • Promote rest
• ↓18 yo contraction • Promote rest • MgSO4
- check BP every dose • MgSO4
• ↑35 yo and smoker - don’t give </ 90/60mmHg)
• Diabetes Mellitus - Normal level Mg: 1.5-2.5 meq/L ***Don’t put anything in the mouth (ex.
• History of HPN - Therapeutic level of MgSo4: 4-7 meq/L Tongue guard, oropharyngeal airway)

MgSO4 Toxicity - >7.0 meq/dL

S/sx:
• BP ↓
• Urine ↓30mL/hr
• RR ↓ (<12 bpm report)
• Patellar/Deep Tendon Reflex
(1st sign)- absent/decrease)
Normal: +2 (AbN: if +1 or 0)
Mgt:
• Antidote: Calcium Gluconate
• Assess deep tendon reflexes hourly
• Have supplemental O2 at bedside
• Limit visitors & avoid bright lights
• Report if UO <30mL/hr
• Monitor renal & cardiac function

HENNAJANECE MY NCLEX NOTES 2021 18 | P a g e

 FETAL MILESTONES
FIRST TRIMESTER (1-3 mos)
- organogenesis
1 mo (4wks) start organ formation
- CNS (brain)- 14 days
- Heart- 17 days
- Length of body: 1cm
- Germ layers
2 mo (8wks)-organogenesis complete
- The last organ @ 8wks is external
genetal
- Corpus luteum (inside ovary)
degenerate; replaced by placenta
- FHT (8wks)-Doppler UTZ
- Length: 4cm
3 mo(12wks)
- Placenta, Pancreas, Liver, Kidney
function
- Baby starts to swallow/drink AF
- FHT (10wks)-Doppler
- Lenth: 9 cm
- UTZ (Baby sex is not accurate)
SECOND TRIMESTER (4-6 mos)
4 mo (16wks)
- Lanugo hair (for thermoregulation)
- Baby sex is accurate (UTZ)
- Presence of meconium in GI
- FHT(Fetoscope)-not accurate
- Length: 16 cm (cant hide baby
HENNAJANECE
FETAL MILESTONES GERM LAYERS LEOPOLD’S MANEUVER
Position: Supine
5 mo(20wks)- viable Endoderm- Endocrine ***Ask mother to void prior
- Quickening (first movt felt by - Thymus/Thyroid
mother) - Parathyroid 1st Maneuver
• Primi (felt @ 18-20wks) - Liver /Linings of Lungs & GI tract - Palm @Fundus
• Multi (felt @16-18wks) - To determine Fetal Presentation
- Braxton Hicks Contraction Mesoderm- Muscles (part of baby at the pelvis):
- Lowest weight viable = >501gms - Heart (Cephalic/Breech/Shoulder)
- Length: 25 cm - Reproductive
- FHT (steth accurate) @ 18-20 wks - Musculoskeletal 2nd Maneuver
- Kidney - Palm on side of mom abd
6 mo (24 wks) - To locate fetal back (FHT)
- Surfactant in the lungs Ectoderm- Brain & CNS • Below Umbilicus (Cephalic)
- Baby can hear - CNS • Above Umbilicus (Breech)
- Eyes start to blink - Senses (5 senses) • Level of Umbilicus (Shoulder)
- Vernix caseosa (yellow cheeselike - Skin
cover) - Hair 3rd Maneuver
- Length: 30cm - Nails - Grip on the lower Symphysis Pubis
- Mucous membranes - To determine engagement
THIRD TRIMESTER (7-10mos) • Float (unengaged)
• Lock (engaged)- baby deliver
7 mo (28wks)- lungs continue to develop soon
- Lecithin Sphingomyelin ratio 1:2
- Baby looks ugly *wrinkled skin (old 4th Maneuver
man) - Palm at Symphysis Pubis
- Length: 35 cm - Stand at the head part of mother
- To determine the attitude of baby
8 mo(32 wks) degree of flexion
- Lecithin Sphingomyelin ratio 1:1 - Normal
- Some creases; nails • Vertex (Chin touches chest)
- Length: 40cm • Brow (Diamond shape)
; long)
• Face (Poor extension)
9 mo(36 wks) • Mentum (full extension of head
- Lecithin Sphingomyelin ratio 2:1
- Covered by subcutaneous fats
(Brown fat)
- Length: 45 cm
- Viable for extrauterine life
MY NCLEX NOTES 2021 19 | P a g e
 PRENATAL
Prenatal Vitamins
Diet to ↓Risk of Neural Tube Defects
↑Protein (beans, rice, peanut)
↑Folic Acid (beans, fortified cereal, milk)
↑Iron
↑Potassium (sweet potato; PABOWS)
Alpha Feto Protein
- Test during pregnancy if fetus
develop Neural Tube Defect
- Specimen: blood (serum) of the
mother
- Done during 16-20 wks pregnant
• Normal: 10-150 mg/L
• Elevated: + Neural Tube Defect
• Decrease: Down Syndrome
***Cornstarch (not nutritious; Low Iron)
May cause anemia, low O2 (check Hgb &
Hct levels
Preconception Education
• Aim for BMI 18.5-24.9 kg/m2
• Avoid alcohol and tobacco
• Ensure daily intake of 400 mcg
Folic Acid
• Obtain testing for rubella
immunity
• Schedule dental wellness
appointment
HENNAJANECE
VACCINES FOR MOTHERS
SAFE (Inactivated/Killed)
• Influenza IM Injection
• Tetanus, Diphtheria, Pertussis
NOT ALLOWED (Attenuated/Weakened)
• Measles, Mumps, Rubella
• Varicella
• Influenza Nasal Spray
***HEP B (killed)- first vaccine give after
baby birth
Rubella Titer
Normal Rubella Titer- 1:8
Non-immune- <1:8
***If non-immune during pregnancy,
administer MMR immediately postpartum
- Avoid pregnancy w/n 3 mos after
Rubella Vaccine
- Can continue breastfeeding after
vaccine
- Administered SQ route
- Hypersensitivity can occur if pt is
allergic to eggs
- No need to avoid exposure to
immunocompromised indv
HYPEREMESIS GRAVIDARUM
Excess nausea and vomiting
- Metabolic Acidosis
- Presence of ketones in urine
- F&E imbalance
- Nutritional imbalance
Causes:
• ↑HCG
• Thyroid problem
S/sx:
• Dehydration (w/ ↑fever)
• Vomitus (with bile, blood)
• ↑HR, ↑BP
Mgt
• IV line
• F&E Replacement
• Anti emetics (Metoclopramide-
Plasil, Reglan)
MORNING SICKNESS
− Excessive nausea and vomiting
− Due to ↑Human chorionic G,
↑ Progesterone, ↑Estrogen
Mgt
• Small frequent feedings ( 5 meals
or more w/snacks per day)
• ↑ Protein, ↑Carbs, ↓Fats
• Avoid triggers of n/v (oily foods,
peanut, fatty and spicy foods)
• ↑B6 (nuts, seeds, legumes)
• Ginger
• Cold foods
• ↑ Protein snacks before bedtime
and upon awakening
• Dry crackers in the morning
• Drink before and after meals (not
in between)
MY NCLEX NOTES 2021
SYPHILIS IN PREGNANCY
***Could cross placenta
Screening:
• Universal at first prenatal visit
• Third trimester & delivery if high
risk
Serologic Test:
• Non treponemal
- RPR- Rapid Plasma Reagin
- VDRL- Venereal disease
research laboratory Test
• Treponemal
- FTA-ABS - Fluorescent
Treponemal Antibody
Absorption
Treatment
• IM Penicillin G (Benzathine)
Pregnancy Effect
• Intrauterine Fetal Demise
• Preterm Labor
Fetal Effect
• Hepatic (Hepatomegaly; Jaundice)
• Hematologic (Hemolytic Anemia;
↓PLT
• MS (Long bone abnormalities)
• Failure to Thrive
***JARISCH-HERXHEIMER Reaction
Hypersensitivity reaction to a medication
20 | P a g e
 BREASTFEEDING
***NO BF for HIV mothers
***NO oral contraceptive pills
***NO caffeine/ smoke/ alcohol
Let Down Reflex
Signs of good let down reflex:
- Breastfeeding on Right, left breast
will also expel milk
- Psychological (if mom thinks /see
baby, the breast will produce milk)
Breast Engorgement Mgt
• If not BF- cold compress/shower
-chilled, fresh cabbage leaves on
breasts all day
• If BF- warm compress/ shower
***to reposition latch, use finger to break
suction first
Mastitis- infection + inflammation
Due to Staph Aureus (from mouth baby)
S/Sx:
• Infection (↑Fever)
• Pain
• Inflamed breast (red, warm edema)
Mgt
• Continue BF if not too sore
• Proper latch (nipple &areola)
• Warm compress &massage
• Antibiotic (Dicloxacillin, Cephalexin)-
complete cycle
• Rest / Nutrition/ Hydration
• NSAIDS / Acetaminophen
• No tight bra/clothing (use supportive
bra)
• May use breast pump
• Air dry breast (clean w/water only) /
Handwashing
HENNAJANECE
INFECTIOUS
Genital Herpes
• Caused by herpes simplex virus
• Painful lesions/ulcers w/ crust
• Need Acyclovir (Antiviral)
• Need C/S if w/ active lesions
• ***check for genital warts (may
affect baby)
• Prednisone (steroid)
- For Herpes simplex lesions
- Bells Palsy
- *Monitor Glucose (may cause
↑Glucose)
HIV
Mgt
• Zidovudine (so HIV can’t enter
placenta)
• Polymerase Chain Reactive Test
(test done to a month-old baby)
• NO Breastfeeding
• Prescribed antiretroviral therapy
should be continued during
pregnancy
Syphylis
• Cross placenta
• Screen 1st tri/ 3rd tri (if sexually
active)/ after birth
• Test: VDRL/RPR; FTA-AB5
• Drug of Choice: IM Penicillin
***Effect to baby: Preterm; Skeletal
abnormality (long bones); Anemia
Mgt: Penicillin Desensitization (if w/ hx of
allergic rxn to Penicillin)- cant alternate w/
Doxycycline if Pregnant (Contraindicated)
TRAVEL WHILE PREGNANT
Important:
• Bring Prenatal record
• Increase fluid before & during
flight- prevent dehydration
• Lap belt below abdomen
• Unrestrictive clothing/loose
• Wear compression hose
• Walk every 1-2 hrs/
stand/restroom- prevent
thromboembolism
• Don’t go to places with zika/
malaria
MY NCLEX NOTES 2021
GLUCOSE CHALLENGE TEST
➢ Oral Glucose Tolerance Test
➢ To screen Gestational Diabetes, not
to diagnose (use HbA1C for
diagnosis)
➢ Done @ 24 wks
1-hour Oral Glucose Challenge Test
- No fasting
- Takes 50 gms glucose
- Blood test after 1 hr
• ↓140 mg/dL – Normal
• ↑140 mg/dL – abnormal
2-3 hrs Glucose Challenge Test
- NPO post midnoc (6-8 hrs)
- Next day, take 100 gms glucose
- Blood sample every hour
• 1st hour Normal: ↓180 mg/dL
• 2nd hour Normal: ↓155 mg/dL
• 3rd hour Normal: ↓140 mg/dL
***If 1 blood sample is Abnormal- repeat
GCT after 4 wks
***If 2/more are Abn- confirms GDM
21 | P a g e
 AFTER BIRTH CONTRACEPTIVES ADOPTION RH INCOMPATIBILITY PHYSIOLOGIC ANEMIA
- Start even w/o menses • Give mother time to bond and RH Sensitization - Too much blood plasma
grieve If mother is RH(-), may be expose to RH(+) Normal Hgb: 12-16 g/dL (W)
• If Not BF- start on 2nd month • Encourage the birth mother to blood of fetus 14-18 (M)
• If Breastfeeding- will cause hold newborn Mother will develop RH Antigen (cause
Lactation Amenorrhea; start on • Notify other staff who may harm to baby and future pregnancy) Risk factors
3rd month interact w/ birth mother of the Baby will develop Hemolytic Anemia • <18 yo
adoption plan • Chronic bleeding
***First period- usually after 4 wks • Offer the birth mother a chance Indirect Coombs Test • ↓Nutrition
to say goodbye to the newborn To determine if mother develop Rh
SEXUAL ACTIVITY • Use phrase that illustrate Antigen Mgt
- Sex: 4-6 wks after birth adoption is a decision of love, not • Positive antibody result – RH • ↑Iron (organ meats, legumes,
Earliest (2 wks after if no abandonment Antigen heart, liver, nuts)
bleeding) • Negative antibody – give • Iron supplements (drink w/
- Avoid until vaginal bleeding stop RhoGam to mother Vitamin C) (don’t take calcium &
- Expect dryness; use water soluble antacid)(not w/ caffein-will dec
lubricants especially if BF RhoGam absorption)
- Feed baby before engaging in − Given to RH(-) mother (if w/
sexual activity bleeding during pregnancy) – Physiologic Anemia
wait for mom @ 28 wks 1st Tri 11 g/dL Below
− Given w/n 72 hrs after birth (if 2nd Tri 10.5 g/dL Below
mother (-) and baby (+) ) 3rd Tri 11 g/dL Below
− Not needed if newborn’s blood
type is Rh (-)
− Given w/n 72 hrs after
trauma/bleeding
− Additional doses if excessive
fetomaternal hemorrhage (Test:
Kleihauer–Betke)

HENNAJANECE MY NCLEX NOTES 2021 22 | P a g e

 SECOND TRIMESTER TEACHING
• Anticipate light movts (Quickening)
@ 16-20 wks (Multi); 18-20 wks
(Primi)
• Abdominal UTZ for fetal anatomy
evaluation (4th mo- most accurate
time)
• ↑ consumption of Iron-rich foods
(ex. Meat, dried fruits) / ↑ Protein
(↑ amino acids for brain)
• Gestational Diabetes screening test
@24 wks (if done earlier, the glucose
is teratogenic)
• Gain 1 lb (0.5 kg)/wk if pre-
pregnancy BMI is normal
- 1st tri: 1 lb /month
- 2nd & 3rd Tri: 1 lb/wk
HENNAJANECE
GESTATIONAL DIABETES
Effects of Diabetes to Newborn
• Macrosomia (big baby) – 4000-4500
gms
• Intrauterine (death/growth
retardation)
• Neonatal (Hypoglycemia;
Hyperbilirubinemia; Hypocalcaemia
• Delay Lung Maturity – give
Betamethasone to hasten maturity
(newborn risk for respiratory distress
syndrome)
• Defects of organs (Cardiomyopathy;
Congenital; Perinatal Atresia) – due to
hyperglycemia on 1st trimester
INFERTILITY
− Unable to conceive even w/o
protection/contraceptive in 12 mos
Risk
• Maternal age >35 yo
• Polycystic Ovarian Syndrome
• BMI >25
• Endometriosis
• Recurrent Chlamydia/ Gonorrhea
Infection
Over-the-counter Urine Ovulation
Detector Kit
- Use to time sexual intercourse and
may improve chances of conceiving
- If ↑ Luteinizing Hormone- means
ovulation
Use if couple has been trying to conceive
not more than 12 mos yet
MY NCLEX NOTES 2021
PELVIC INFLAMMATORY DS
PELVIC INFLAMMATORY DISEASE
Affects Uterus, fallopian tube, ovaries (1 or
more of these organs)
Cause:
• Multiple sex partner
• Sexually Transmitted Illness
(Gonorrhea; Chlamydia- two most
common infection that causes PID)
• No sex barrier
• Recurrence/history of PUD
• Ager 15-25 yo
• IUD
• Pelvic surgery
• Recent abortion
• Oral contraceptive IS NOT A CAUSE
S/sx
• Pelvic/lower abdomen pain
• Painful sex
• Irregular menstruation/cramps
• Foul vaginal discharge
• Fever
• May cause Infertility (due to scarring
in uterus)
***CHLAMYDIAL INFECTION
Teaching after one-time dose of Azithromycin
(Doxycycline)
- Long term consequence of untreated
Chlamydia is infertility
- Wait for 7 days after (to have sex)
- Still transmittable even w/o symptoms
- Yearly screening
- Partner needs also to be checked &
treated
23 | P a g e
BIRTH CONTROL CONTRACEPTIVES
➢ INTRAUTERINE DEVICE (IUD)
- EFFECTIVE for 10 years
- 99% prevention for pregnancy
- No protection against STD
- Effective Immediately (Copper IUD)
- Need back up for 2 days (if
Levonorgestrel IUD)
- Heavy bleeding w/ menses &
menstrual cramping is expected
- Vaginal spotting & cramping for short
duration is expected after insertion
- Can still be use for sexually active
adolescent
- Best time to insert during menses
- REPORT
o Period Short/missing
o Abdominal Pain
o Infection
o Not feeling well (fever)
o String (check once a month after
menses)
➢ TRANSDERMAL CONTRACEPTIVE
PATCH
❖ Norelgestromin (Progesterone)
+ Ethinyl Estradiol (Estrogen)
Nursing Responsibilities:
• Applied weekly for 3 wks
• 1 week free of hormones/ no patch
• Same s/e w/ combined oral
contraceptives “ACHES”
• ↑ Hypercoagulability (prone to clot
formation)
• Breast Cancer risk
• Less effective to >200 lbs/ obese
• CI for HPN, DM, Cardiovascular
disease
HENNAJANECE
ORAL CONTRACEPTIVES
❖ PROGESTIN ONLY PILLS
− 28 active progesterone pills
− Effective w/n 24 hrs
− Thicken cervical mucous in 24 hrs
− Thins Endometrium
− 3 or more hours late (use backup
contraceptives)
− Vomiting w/n 3 hrs (take additional
pill)
− No periods/irregular period
❖ MIX PILLS (Estrogen + Progestin)
- There are 21 pills + 7 iron/ferrous
sulfate pills/placebo
- Have high risk for developing
DVT
ORAL CONTRACEPTIVES
➢ DANGER OF ORAL CONTRACEPTIVE
PILLS “ACHES”
A (abdominal pain
C (chest pains)
H (headache)
E (eye problem/blurring vision)
S (severe leg pain/cramps)
➢ ADVANTAGES OF OCP
• Will have regular menstrual 28
days cycle
• Increases femininity
• Prevent Anemia (due to Ferrous
sulfate)
• Prevent Uterine Cancer
• May cause Breast Cancer
➢ EXPECTED EFFECTS (NORMAL)
• Breakthrough bleeding -Vaginal
spotting between menses
➢ CONTRAINDICATION
• Not for HPN; Cardiovascular
Problems; DVT (prone to blood
clots); DM pts; not for smoker
• Back up contraception is required
for one month after initiation of oral
contraceptives
• Take emergency OTC contraceptive
w/n 72 hrs of unprotected
intercourse (Levonorgestrel)
MY NCLEX NOTES 2021
MENOPAUSE
− Happens to women 50-52 yo (USA)
Risk (Due to reduction of Estrogen)
• Osteoporosis (↓ Calcium)
• Heart Disease
Mgt
• Calcium supplements & Vitamin D
• Bisphosphonate (↓bone
resorption/brittle)
- Alendronate (Fosamax)
- Residronate (Actonel)
- Ibandronate (Boniva)
✓ Give early morning on empty
stomach
✓ Stay upright 30 mins (to
prevent esophagus irritation)
• See dietician for healthy diet
• Consult HCP for cholesterol
monitoring (accumulatio of fats,
cause estrogen to bind and cause
cancer)
• ↑Fiber (green, leafy vegs) (dairy)
• Seek support to cope w/ emotional
symptoms
***Vaginal spotting after menopause can
be possible sign of Endometrial Cancer
***Estrogen – helps in the absorption of
Calcium & maintain elasticity of blood
vessels
***Hormone Replacement Therapy
Risk for development of clotting disorders
(DVT; Stoke; MI)
Observe for unilateral leg swelling
24 | P a g e
 AMNIOCENTESIS APGAR SCORE APGAR SCORE
- Procedure used to take out a small
sample of the amniotic fluid for Perform at 1 minute & again at 5 minutes after birth
testing
- Normal for pt to leak fluid at needle SIGN 0 points 1 point 2 points
insertion site for 2-4 days A Appearance/color Completely Body pink, Completely pink
- Position: Left lateral/side lying blue/pale extremities blue
P Pulse Absent <100/min >100/min
Performed during: G Grimace/reaction Absent Grimace/whimper Cough/sneeze/cry
12-18 wks (to know genetic problem) A Activity muscle Limp/Flaccid Some flexion Active/spontaneous
30-32 wks ( to know lung maturirty) tone
R Respiratory effort Absent/ not Slow, weak, Regular, good cry
REPORT after Amniocentesis breathing irregular cry
• Fever
• Uterine Contraction (possible
puncture to uterus/baby) APGAR Score Assessment Interventions
• Vaginal bleeding (possible >7 Little or no difficulty adjusting No intervention needed
abortion)
4-6 Moderate difficulty adjusting May need supportive or
resuscitative measures
<3 In distress Needs resuscitative
interventions

HENNAJANECE MY NCLEX NOTES 2021 25 | P a g e

 ENDOCRINE NOTES
DIABETIC KETOACIDOSIS (DKA) DIABETIC KETOACIDOSIS (DKA) HHNS DIABETES MELLITUS
Hyperglycemic Hyperosmolar Non- DM Type 1
- Complication of Diabetes Type 1 Mgt ketotic Syndrome − No Insulin for life
- Pancreas don’t produce insulin 1. Deliver hydration (hydrate fluids − Priority for the pt & caregivers to
- No Insulin – no sugar going into the to treat dehydration) (Isotonic - Complication of Diabetes Type 2 know how to keep blood sugars
cell, so high sugar in extracellular 0.9 NSS) – perform 1st stable
(hyperglycemia) 2. Kill Sugar slowly
- Fat will be metabolized (burn) which a. Regular Insulin (the only Causes:
DM Type 2
will increase energy & Ketones insulin given IV)– if sugar ↑ • Stress
- Have some Insulin
250 • Pain
Causes: b. SQ Insulin + D50 – if sugar • Infection DIET (Nutrition)
• Sepsis (infections)- ↑Glucose ↓ 200
− ↑Complex Carbohydrates
• Sickness (flu, scarlet fever, 3. Add Potassium (even normal K) S/sx ➢ Brown
enteric virus in the GI, influenza) (If in K IV-Monitor Cardiac • Highest Sugar (>500-600mg/dL) • Rice
• Stress exposure (surgery, Monitor; Infusion Pump) • High Fluid Lost (DHN) • Bread (wheat)
accident, trauma) • Head (confused) • Beans (also black)
• Skip Insulin • No abdominal pain/ No Ketones • Peanut butter
***Insulin pushes potassium & sugar to • Slow onset; Normal Potassium
S/sx: go inside cell, so K is low in the blood (so
➢ Whole
• Dehydration & Dry + ↑ sugar kill sugar slowly) Mgt • Grains
(250-500 mg/dL) – due to high ***Sudden drop of potassium will cause 1. Hydration (IV fluids) 1st • Milk
sugar, kidney will increase cardiac arrythmia 2. Stab Insulin (Regular insulin) • Wheat
glomerular filtration rate to ***If DM Type 1- give insulin even w/o
excrete sugar in the urine which food
− ↑Fiber (green vegetables; fruits)
will lead to DHN
− Low Calories
• Ketones (Kussmaul’s Breath—
− Low Simple Sugars/Carbohydrates
rapid breathing; fruity);
(candies)
High level of K (Potassium)
− No deep-fried food, hamburger
• Abdominal Pain; Acidosis
Metabolic (Ph <7.35 & Bicarb
↓22)
❖ GLYCOSYLATED HEMOGLOBIN
- Monitor consumption of
glucose/diet in the last 2-3 mos
• Normal person: goal is <5.5
• Normal if w/ DM: goal/maintain <7
• If >: Give Metformin

HENNAJANECE MY NCLEX NOTES 2021 26 | P a g e

 HYPOGLYCEMIA INSULIN INSULIN DIABETEC FOOT CARE
Fatal; more dangerous than Goals:
Hyperglycemia Types of Peak Duration Mix • Clean
“Hypogly, the brain will die” Insulin • Dry
Glucose <70mg/dL Long Acting None 24 hrs No Lantus (Glargine); Levemir • Injury Free
(Detemir)
S/sx Intermediate 4-6 hrs 14 hrs Yes NPH; Humulin N
(cloudy) F
• Headache/ Light-headedness/ Regular /Short 2-4 hrs 5-8 hrs Yes (clear) Humulin R; Novolin R • No flipflop/no hills (can easily get
Confusion/Lethargy ***Only given IV injured)
• Irritable Rapid/Fast 30-90 3-5 hrs No Lispro (Humalog) • Must wear closed/leather shoes
• Weak (shakiness) mins Aspart (Novolog); • No nylon socks (must be cotton)
• Anxious (trembling, palpitation) Glulicin (Apidra)
• Sweat (cold clammy skin) Onset: O
• Hungry 15 mins ***No Lag very fast • No Over the counter corn removal
***don’t give if pt will not
Mgt eat O
• ***IF AWAKE- Ask to eat • No overly hot bath/pads (DM pt has
15 g Carbohydrates ***PEAK- very important to check (time of hypoglycemia) peripheral neuropathy)
- 4 oz soda ***Before exercise, eat carbs at least 30 mins before • Use thermometer to check water
- 6 oz juice/low fat milk temp not hands/elbow or any body
- 1 tbsp honey Mixing Clear & Cloudy Insulin parts
- 6 hard candies ***Aspirate clear first, then cloudy “Not Ready, Ready Now”
• ***IF SLEEP- Stab D50 IV 1. Inject air to Intermediate T
2. Inject air to regular • Toes Injury Free (look/check daily)
3. Aspirate from regular • Make sure shoes fit properly to
4. Aspirate from Intermediate prevent shoe related injury (allow ½ -
***DM pt only can have low fat if on ¾ inch toe room when closing shoes)
• Can use powder (only less/minimal)
hypoglycemia; diet for everyday is WHOLE
FASTING REQUEST (Islam for Religious Purposes) • Can use oil on feet
foods like whole milk
1. Assess pt first (client’s stability & glycemic control) • Separate toes w/ cotton/lamb wool
2. Intervention (advise risk; refer to HCP & dietician for meal planning) • Cut toenails straight across & file
along curves of toes
• “Break”-in shoes

HENNAJANECE MY NCLEX NOTES 2021 27 | P a g e

 HYPERTHYROIDISM THYROID STORM HYPOTHYROIDISM MYXEDEMA
GRAVE’S DISEASE
↓TSH; ↑T3↑T4 ↑Calcitonin
− Danger complication of ↑TSH − Danger complication of
S/sx: Hyperthyroidism ↓T3 Hypothyroidism
• Heat Intolerance − REPORT immediately ↓T4 − REPORT immediately
• ↑Energy (hyper); Anxiety ↓Calcitonin (high calcium in the blood)
• ↑V/S (Tachy; heart palpitation/atrial
Cause Cause
fibrillation &Temp
• ↑GI (Diarrhea) • Exposure to stress, surgery & S/sx: • Exposure to stress, surgery &
• Moist skin Infection • Cold Intolerance (feeling cold) Infection
• ↑Metabolism (but thin) • ↓Energy (lethargy, difficult to
• ↓Weight (due to hyperactive) S/sx awaken)-fatigue S/sx
• Exophthalmos (eye pads at night) • Dry skin
• High Temp (Fever) • Mental depression
• Goiter
• Confusion/ Agitated (↓ LOC) • ↓V/S &Temp • Low Temp
• Pretibial myxedema (PTM)/ thyroid
dermopathy – localized lesions of the skin • Tetani (Hypocalcaemia) • ↓GI (Constipated) • Hypercalcemia
due to ↑ hyaluronic acid; Hallmark of Grave’s ***High calcitonin will lead to • ↓Hair (loss) • Hypoventilation
Disease low Calcium (Tetani) • ↓Mental Ability, Focus • ↓ Respiratory Rate & O2 Sat
Mgt: Calcium Gluconate • ↓Mood
Meds:
1. PTU (Propylthiouracil) • Slow eater Mgt
- Report sore throat (Agranulocytosis) • ↑Weight (Edema)(Puffiness) • Possible intubation
- Check V/S (Hold if low) Thyrotoxicosis – V/S ↑; Hyper (give • Hoarse cry (weak; in infant)

2. Lugol’s Solution antithyroid therapy & beta-adrenergic

- Check V/S (Hold if low) blocker to block adrenal gland in releasing Meds:
epinephrine & other hormones) 1. Levothyroxine
3. SSKI (Potassium Iodide) Lifelong
- To shrink thyroid
- Cause stain teeth (use straw)
Early morning/ Empty Stomach
- 1 hr apart from other meds V/S ↑ (very high BP
Exophthalmos Oh baby is fine
Diet: • Artificial tears to moisten conjunctiva
↑Calories ↑Protein ↑Meals; No stimulant • Tape eyelids to shut during sleep *Check V/S before administration
• Dark glasses to prevent irritation (hold if V/S ↑)
Mgt
• Teach importance of smoking
Radioactive Iodine Uptake *REPORT if present of
- Destroys thyroid cessation
nervousness, diarrhea & ↑pulse
- Patient is awake during procedure • Exercise the eyes
- NPO 2-4 hrs before & 1-2 hrs after
- Not for pregnant Graefe’s Sign Diet:
- Once started, HOLD all anti-thyroid for 5-7 days − Slow looking downward (lagging of ↓Calories
- Remove jewelry prior the upper eyelid on downward ↓Saturated Fat
- Common s/e : Nausea; taste change;
rotation of the eye, indicating ↓Cholesterol
↓salivation; swollen saliva glands
- AFTER: highly contagious (don’t expose pt to
exophthalmic goiter (Graves'
people/crowd); use same washroom (flush 3x); Disease)
use same food utensils and laundry

HENNAJANECE MY NCLEX NOTES 2021 28 | P a g e

 ADDISON’S DISEASE
Causes:
↓cortisol (steroid)
↓aldosterone (responsible for Na&H2O)
Long use of steroid (suddenly stop)
S/sx:
“Short, weak, tanned”
• Added pigmentation (striae,
stretch mark); Added potassium
(hyperkalemia)
• Decrease wt/energy
• Decrease V/S (hypotension,
temp); Decrease Glucose;
decrease hair (alopecia)
• Sodium low (Hyponatremia)
• Salt craving
Mgt
• Add steroids “sone” (PRIORITY)
Diet: ↑Protein, ↑Carbs
(energy), ↑Na (lack of sufficient
aldosterone means sodium is
lost in the urine, therefore
additional salt is for
replacement)
• Don’t stop steroids abruptly
• Indefinite steroids (lifetime
intake)
ADDISON’S CRISIS
• Hypovolemic S/sx
(↓BP↑HR↑RR)
- Priority Mgt: hydrate
***If pt is under stress, it may trigger
crisis, so the steroids must be increase by
HCP
HENNAJANECE
CUSHING’S DISEASE SIADH DIABETES INSIPIDUS
“Cush”=rush (meaning high) Syndrome of Inappropriate NO ADH (always pee; ↑U.O)
Anti-diuretic Hormone Secretion
Causes: − Too many Anti-diuretic Hormone Causes:
• Small cell lung cancer (retention; Soaked-Inside)
• Damage to brain (brain
• Brain tumor − Dilutional hyponatremia tumor/surgery/trauma)
• ↑level of corticosteroids (Glucocorticoids)
• ↑ACTH- ↑ Cortisol (steroid)
Causes: S/sx
• Small cell lung cancer • Diuresis ↑U.O
S/sx: “big, round, hairy”
• Sepsis brain (meningitis)
• Cushion -like looking (moon face, buffalo • Diluted urine (Specific Gravity ↓
hump, truncal obesity) • Stress / Severe brain trauma
normal)
• Unusual hair (Hirsutism) • Decrease BP
• Skin purple S/sx: 7’S
• Drinks a lot
• High • Stop urine (↓UO)
• Dehydrated (thirsty)
o Glucose • Specific Gravity ↑ (sticky,
• Dry inside (↑osmolality, ↑Na)
o Energy concentrated)
o Wt, (due to ↑water) • Sodium ↓(headache/confusion)
o V/S BP • Seizure (due to↓Na); disoriented if Mgt
o Sodium (Hypernatremia) “cushin”- Na <100 • Desmopressin (nasal spray) /
“asin” • Severe Hypertension Vasopressin
o Calcium (brittle bones) • Stop Fluids (edema inside)- but can - (Antidiuretic, ↓Na)
give Hypertonic - Watch for ↓ Na (headache,
• ↓K (Hypokalemia) • Soaked Inside (↓osmolality; ↓Na) seizure)
• Amenorrhea (females) (low & liquidy labs); but Potassium
- Monitor BP (it will ↑BP)
• Erectile dysfunction (male)
is high
Mgt
Mgt
• Mitotane – to lower steroids
• Salt – if NaCl ↓120
• Decrease stress
• Insulin (to lower Glucose) • Diuretics- if NaCl ↑125
• Surgery • Seizure precaution
• Diet: ↓Protein, ↓Carbs, ↓Na • Give IV line (Hypertonic Only- 3%
Saline IV- it will pull out Na from
***Steroids like S/se cell)
• Immunosuppressed • Low fowlers
•
• Rosy cheeks I&O; weigh daily
• Moon Face • Restrict fluids to 800 mL over 24
• Buffalo Hump hrs
• Truncal Obesity • Administer vasopressin antagonist
• Thin Extremity
• Hirsutism (excessive hair growth) ***Specific Gravity: 1.010-1.030
• Stretch Marks
• GI irritation/ulcer
MY NCLEX NOTES 2021 29 | P a g e
 TONSILLECTOMY THYROIDECTOMY TOTAL HYPOTHYROIDECTOMY HYPERPARATHYROIDISM
Monitor for : CALL SURGEON PRIORITY PREOP: Give Iodine to decrease the Inflammation can occur after surgery S/sx:
• Restlessness vascularity & size of the thyroid gland • ↑CA ↓Phosphorus in the blood
• ↑ PR thereby reducing risk of intraoperative & Report for noisy breathing • Bone resorption (calcium move
• Vomit large amount bright red post-op hemorrhage (obstruction)/stridor out)- brittle bones, painful,
blood fracture
POST THYROIDECTOMY Post op Mgt • Renal Calculi
• Position post-op: Supine slightly • Polyuria (loss of Phosphorus)
• Assess frequently for elevated head • ECG- short QT interval
facial/extremity numbness or • When moving head, support w/
tingling hands Mgt
• Tracheostomy kit suction machine • Check for bleeding at nape area • Parathyroidectomy
at bedside at all times • Suction & tracheostomy set at − Semi fowlers post up
• Maintain head of bed at 30-45 deg bedside − Monitor respiration
• Monitor client’s voice strength & − Trache set and suction at
quality (report for hoarseness if bedside
present after 24 hrs of surgery)
− Watch out for ↓ Ca
• Check bleeding at nape (back of
(Trousseaus/Chvostek);
neck)
Tingling/ numbness
• Check for stridor (airway
• Diet: ↓CA ↑Phosphorus
compromise)
• Give Meds
• Assess Calcium level (risk for ↓
− Calcitonin
Calcium)
❖ Chvostek’s Sign – twitching of
− Lasix
the facial muscles (around − Alendronate
mouth) in response to tapping − Sensipar
over the area of the facial nerve
(CNVII)
❖ Trousseau Sign – carpopedal
spasm & flexion of the wrist
(twitching in arm) when BP cuff
inflated (elicited by placing a
blood pressure cuff on the arm,
inflating the cuff slightly above
the systolic pressure, leaving the
cuff inflated 2 to 3 minutes, and
deflating)
❖ MGT: Assess Calcium FIRST
❖ MGT: Give Calcium Gluconate

HENNAJANECE MY NCLEX NOTES 2021 30 | P a g e

 HYPOPHYSECTOMY
− Removal of Pituitary Gland (due
to tumor)
− Thru the Transsphenoidal
− Incision under/beneath upper lip
Post-op Mgt
Monitor the ff:
• Always check for Nasal Drainage
(Rhinorrhea)
CSF Leakage- clear nasal drainage
with presence of glucose “Halo
Sign”
• REPORT if w/ headache &
glucose level in drainage
• Meningitis – neck pain,
Brudzinski, Kernig
• Bleeding – frequent swallowing
• Diabetes Insipidus – I&O, ↑UO
• Hypoglycemia (no more growth
hormone, so glucose will be low)
Complications:
• Leukocytosis
• Urinary output 800mL/hr
(Diabetes Insipidus) – no more
Pituitary Gland so no more
production of ADH
• Clear drainage or nasal dripper
pad
HENNAJANECE
GROWTH HORMONE METABOLIC SYNDROME ADDITIONAL NOTES
- ↑ production of Growth Hormone due to
possible tumor at Pituitary Gland − Risk for DM/Coronary Artery ❖ PHEOCHROMOCYTOMA
(Pituitary Adenoma)-brain tumor Diseases − Tumor @ Adrenal Gland
− ↑Epinephrine & norepinephrine
ACROMEGALY
- Onset after 18 yo (close EP)
“We Both Think High Glucose” − S/sx : ↑ VS
- Epiphysial plate has already closed, but − Mgt: Phentolamine (↓BP in
there is an increase in growth hormone, ***Need to manifest 3 or more Pheochromocytoma)
so the pt will be bigger sideways
➢ Waist Circumference ❖ PRECOCIOUS PUBERTY
GIGANTISM >35cm (Female) − Early puberty (ex. Girls before 10
- Onset before 18 yo (Open EP)- >45cm (Male) yo there is breast enlargement,
↑Height
small amount of pubic hair)
➢ Blood Pressure − Common in African-American
S/sx
• Earliest: changes in appearance
↑130 SBP − Refer to pediatrician/
Enlargement of forehead/nose (thicken endocrinologist
skin in the nose)/ larynx/hands& feet/ ➢ Triglycerides (Lipids)
Macroglossia (enlargement of tongue)/ • 200 – Cholesterol
• Organomegaly (enlargement of internal (<200 -Normal)
organ-cardio/hepato/splenomegaly
• Weight gain (strain joints) • 150 – Triglycerides
• Knee pain when walking (<150 -Normal)
• Fatigue (activity intolerance)
• Dark leathery skin
• 100 – Fasting Blood Sugar
• Hyperglycemia- FBS High
(<100 -Normal)
Mgt
• Meds: Octreotide (Sandostatin) SQ
abdominal area – inhibits release of ➢ HDL (Good Cholesterol)
Growth Hormone >40 mg/dL (Normal)
Watch out for Abd. Pain (gall <40 mg/dl (abnormal)
bladder/o)
• Transsphenoidal hypophysectomy
➢ Glucose
FBS (Normal:100)
(if >100 is abnormal)
MY NCLEX NOTES 2021 31 | P a g e
 CUSHING’S DISEASE ADDISON’S DISEASE

HENNAJANECE MY NCLEX NOTES 2021 32 | P a g e

 CARDIO NOTES
CARDIAC DRUGS CARDIAC DRUGS CARDIAC DRUGS CARDIAC DRUGS
• ↓BP; does not affect HR; ↓H2O ↓Na
Enalapril, Captopril, Lisinopril • Not for Pregnancy ❖ All HPN drugs except for Digoxin causes
ACE Inhibitors (Take 30 mins prior/ empty stomach) • May cause Angioedema & cough Orthostatic HPN (Mgt: move slowly)
(“Pril) (1st dose Phenomenon: Sudden drop in BP) • Will ↑ Potassium (avoid foods rich in K)
SAFE for pregnant mothers
(Decrease Systemic Vascular Resistance) • Don’t take w/ K sparing diuretic • Hydralazine
• Don’t take w/ kidney problem (↑Creatinine) • Labetalol
• ↓BP; does not affect HR • Methyldopa
• Not for Pregnancy
ARBS
Telmisartan, Losartan, Irbesartan • Will ↑ Potassium (avoid foods rich in K) ***BETA BLOCKER OVERDOSE
(“Sartan”) •
• Don’t take w/ K sparing diuretic ↓BP ↓HR
• Don’t take w/ kidney problem (↑Creatinine) • Restless
• ↓HR ↓BP, ↓IOP • Dyspnea
Selective • Severely drowsy
Non-Selective • Bronchoconstriction (not for pt w/ Asthma &
Affects only B1 (heart) • EKG shows 3rd degree AV block (due to
Affects B1B2 (heart&lungs) COPD) (Can only give Beta 1 Cardio Selective)
↓HR slow HR)
Beta Blockers (↓HR, Bronchoconstriction) • Not for pt w/ AV Block, CHF
• Bisoprolol
(“Lol”) *not for asthma pt • Caution for DM pt (hides s/sx of hypoglycemia - ***NSAIDS
• Atenolol
• Propranolol (Inderal) check blood glucose) - Naproxen; Naproxen; Aspirin; Ketorolac
• Betaxotol
• Pindolol • May ↓ libido - contraindicated for pt w/ HPN (will decrease
• Acebutolol
*Beta 1 & 2 • Penbutolol • Not for <60bpm & <90/60 mmHg effectivity of HPN drugs & Diuretics)
• Esmolol - pt will be prone to bleeding; heart failure; ↑
• Timolol • Must taper down for two weeks/not abruptly stop
• Metoprolol (good BP
• Nadolol • Monitor HR
for COPD) - may cause GI injuries; Peptic Ulcer Disease;
• Take w/ breakfast every morning
CKD
“Very Nice Drugs” • ↓HR ↓BP (Calm the heart) - Take w/ meals
Calcium Channel
Verapamil, Nifedipine (only ↓ BP), Diltiazem • Check HR & BP - Only taken for short time
Blockers
(Amlodipine); Nicardipine • Causes Bad headache
Digoxin (Lanoxin) (Cardiac Glycosides)
Digitalis • ↓HR; no effect BP ***Sildenafil (Viagra)
(Cause Strong contraction & ↓ HR)
- Contraindicated for pt w/ heart illness;
• ↓BP, ↓HR, Vasodilators
- Don’t give w/ vasodilators (nitroglycerine); anti
• Expected s/e (Headache/Hypotension/Hot flashes)
Nitroglycerin, Hydralazine, Nitroprusside, Isosorbide HPN meds
Dilators • For Coronary Spasm; Relaxes heart muscles - Will cause ↓BP (severe hypotension), fatal,
(Isordil), Minoxidil (for severe cases of heart failure)
• ↑O2; ↓Preload afterload; ↓ vascular resistance vasodilator; death
• STOP if SBP <100 mmHg

DIGOXIN TOXICITY
• Digoxin Level: 0.5-2 ng/mL
• Toxic Level: >2 ng/mL
*Earliest sign
- N&V (GI symptoms)
- Dizziness & lightheaded
Antidote: Digibind
S/sx: TOXICITY (REPORT) - Apical Pulse (check 4-5th ICS LMCL) prior; Hold <60bpm ***Angiotensin Converting Enzyme (ACE)
↑BP; Converts Angiotensin 1 to 2 and Inactivate
• Blurred vision - Toxicity: >2 ng/mL
Bradykinin (leads to constricted vessels and ↑BP)
• Dizziness/ lightheaded/headache - Potassium: ↓K in Kidney problem will trigger Toxicity
• Nausea& Vomiting ***ACE Inhibitors
• Confusion *Avoid meds that lowers K (Loop Diuretic & Thiazides) ↓BP ; Prevent conversion of Angiotensin 1 to 2, and
• Arrythmia ↓HR *don’t give if HR <60bpm activated Bradykinin (leads to dilated vessels & ↓BP)
• Diarrhea

HENNAJANECE MY NCLEX NOTES 2021 33 | P a g e

 ECG TRACINGS ECG TRACINGS ECG TRACINGS ECG TRACINGS

Atrioventricular paced rhythm

Supraventricular Tachycardia

ST Elevated Myocardial Infarction

HENNAJANECE MY NCLEX NOTES 2021 34 | P a g e

 ISCHEMIC HEART DISEASE
- Narrowing coronary artery
- ↓O2 in the Heart muscles
1. Coronary Artery Disease
2. Stable Angina
3. Unstable Angina
4. Myocardial Infarction
Causes: “SODDA”
• Stress/Smoking/Stimulants
• Obesity (>25 BMI)
• DM & Hypertension
• Diet
• African-American Male/ Age
↑50yo
***Recommended diet (↓Na,↓Fat,
↓Chole, ↓Fluid) ( Na <2g/day) (Fluid
<2L/day)
***Cholesterol
• Total <200
• Triglycerides <150
• LDL <100
• HDL >40
***Oral Niacin (Nicotinic Acid)
- Use to lower lipids (cholesterol)
- S/e: Facial Flushing
- May cause vessel vasodilation
(↑blood supply)
HENNAJANECE
MYOCARDIAL INFARCTION
Characteristics:
• Sudden, crushing, radiating, heavy
• Pain (Substernal, Jaw, Midback)
• Radiate to Left arm
• Heart burn
• SOB, Dyspnea, labored breathing
• Nausea & Vomiting
• Abdominal pain
• Sweating, cold clammy pale skin
• Anxiety
Mgt OANM
❖ Oxygen
❖ Anticoagulant
❖ Nitroglycerin
❖ Morphine
***First: Oxygen
***Priority: Morphine
***Conserve pt’s O2 & energy
1. Anticoagulants / Fibrinolytics
• Thrombolytics (Streptokinase,
Alteplase, Tissue Plasminogen
Activator, Urokinase)
• Give w/n 4-5 hrs
• Use to dissolve clots
• Only give one dose (window
period 8 hrs)
- ↑Risk for bleeding
- Don’t perform any injections,
IV insertion, SQ, ABG, and
other activities that causes
bleeding
• Perform only on Peripheral line,
not on central line
2. Heparin (to dissolve more clots)
MYOCARDIAL INFARCTION
Diagnostic
1. ECG
• ST Elevation (due to no oxygen
and injury to the heart)
• T wave inversion (Ischemia)
• Pathologic Q wave (last to occur
after MI/ Scar or infarction /
permanent damage)
Q
2. Troponin I
• Normal: ↓ 0.35 ng/dL
• MI: > 0.5 ng/dL
MY NCLEX NOTES 2021
MYOCARDIAL INFARCTION
3. CARDIAC CATHETERIZATION
*Hold Metformin 24 hrs before & 48 hrs
after (may cause lactic acidosis)
❖ A Arterio/Angio
- “Plasty” (repair)- balloon, stent
- “Gram”(view image)
- NPO 6-12 hrs
- Flat position after procedure
❖ B Bypass (Coronary Artery Bypass
Graft)
- Use Saphenous Vein
- 3-5 days healing
- Use vitamin E ointment once
healed
- Can take shower (not bath tub)
❖ C Contrast (Radiopaque Dye)
- Harmful to kidney
• Assess for Allergy (Iodine)
*Safe for Shellfish/Seafood Allergy
• Bleeding at cath site
Direct pressure 5-10 mins
No blood thinners w/n 6 hrs
• Creatinine
(Normal: 0.6-1.3 ng/dL)
Check UO 30 mL/hr
• Can’t palpate Pedal Pulse
Normal w/n 4-12 hrs
Report >12 hrs (↓Pulse, cold
temp distal doppler detect pulse)
***If site (groin) actively bleeding
BEST: don sterile gloves & apply pressure
on the insertion site w/ sterile gauze
Position: Low Fowler (30-40 deg)
35 | P a g e
 NITROGLYCERINE
Side effects (expected)
• Headache (dizziness/light-
headedness)
• Hypotension (orthostatic)
• Hot Flushes (Face redness)
Important:
1. No Viagra (Sildenafil)
2. Stop if- severe ↓BP
(↓100mmHg) or ↓30 mmHg
from initial BP
S/sx of ↓BP
− Irritability
− Sweating
− Pallor
− Pt lacks coordination
NITROGLYCERINE PATCH
− For Unstable Angina
− Given once a day (every 24 hrs)
− Ok to shower
− It’s not PRN
− Rotate daily site
✓ Anywhere upper chest/arm
(subclavian)
✓ Not on broken skin
/callus/burns/scar/hairy)
✓ Clean and shave area
− Application
✓ Use gloves (potent to skin)
− Disposal of used gloves and patch
✓ Fold together sticky part
✓ Dispose in infectious/toxic bins
✓ Trash bin color: ORANGE
HENNAJANECE
NITROGLYCERINE
NITROGLYCERINE PILL/SPRAY
− For Stable Angina
− Goal: No chest pain performing ADL
− Dose: 3 doses (5 mins interval)
✓ 1st: Give 1st dose Nitroglycerine
If not yet in the hospital, call
ambulance/911 after 5 mins if w/
chest pain (after 1st dose)
2nd: If unrelieved pain, give 2nd
dose of Nitro
3rd: If still unrelieved, give 3rd
dose
✓ Given sublingual (make sure
moist mouth)
− Storage:
✓ Dark container
✓ Don’t put in the pocket (place in
the purse/wallet)
✓ Replace stocks every 6 mos
***Emergency HPN / Hypertensive Crisis
- BP >200 mmHg
- Mgt: Vasodilators to lower BP (Ex.
Nitroprusside) (Nicardipine IV)
- If BP is already below 160/90 mmHG-
HOLD
- MILD LOWERING OF BP
- Keep systolic BP above 170 mmHg (sharp
drop in BP is fatal)
HEPARIN
HEPARIN
IV: effective 2-6 hrs
SQ: effective 8-12 hrs
Antidote: Protamine Sulfate
(or Hold and Stop)
− Monitor APTT (length of time for
blood to clot) *Accurate test for
Heparin effectivity
• Normal APTT: 30-40 secs
• If w/ Heparin: 40-70 secs (1.5-2x)
*< (heparin not responding)
*> (heparin over responding)
• Normal Partial Thromboplastin
Time: 60-70 secs
If w/ Heparin: 120-210 secs
*Low Molecular Weigh Heparin
- Less risk for bleeding
- Only monitor CBC & Platelet
• Enoxaparin
- SQ (pinch fold)
- Inject 90 deg angle
- Inject atleast 2 in (5cm) on
the side of umbilicus
- to reduce risk of DVT
• Fraxiparin
*SAFE for pregnant
*NO ASPIRIN, NSAIDS
Heparin Induced Thrombocytopenia
- Due to Heparin
- Sudden drop in Platelet >50%
- Fatal, severe bleeding
MY NCLEX NOTES 2021
WARFARIN
WARFARIN (Coumadin)
Effective 2-3 days (48-72 hrs)
Antidote: Vitamin K
(Avoid green leafy vegetables)
− Monitor PT
(Prothrombin time / Protime)
• Normal PT: 11-16 secs
• If w/ Warfarin: 16-32 secs (1.5-2x)
− Monitor INR
• Normal INR: 1.5-2.0
• If w/Warfarin: 2.0 -3.0
• If w/ valve replacement: 3.0-3.5
• If >5 – toxic (give Vit. K)
*Not for pregnant (teratogen)
***ASSESS FOR BLEEDING
***DON’T GIVE TOGETHER W/ OTHER
ANTICOAGULANTS/NSAIDS
***Give Heparin until Warfarin start it
effects
FACTOR 10a INHIBITORS
• Rivaroxaban/ Apixaban/ Edoxaban
- less risk for bleeding (compared
to Heparin & Warfarin)
- less monitoring of PLT & INR
- Not affected by Vit. K- can eat
green leafy veggies
- avoid NSAIDs/4G’s
36 | P a g e
 ATRIAL FIBRILLATION
− Irregular R-R; short QRS
− May cause clot formation (small
clots but will not cause pulmonary
embolism; but it may block
microcirculation in the brain that
will lead to stroke)
− Atrial 350-600 bpm & Ventricle rates
>100bpm
− PRIORITY GOAL: ventricular control
and ↓HR
S/sx
• Syncope
• Dizziness
• Palpitations
• Hypotension
• Jugular vein distention
• Blood clots formation
Mgt (to ↓ Ventricular Rate)
• Anticoagulants (prevent clot/stroke)
Heparin – short term
Warfarin – long term
• Beta Blockers
• Calcium Channel Blockers/
Cardioversion (50-200 j) – for
conscious w/ pulse pt
• Digoxin (to improve Myocardial
contractility
CARDIOVERSION- Synchronized
DEFIBRILLATION: Manual
HENNAJANECE
VENTRICULAR TACHYCARDIA
FIRST action:
Basic Neurological Assessment
(determine unresponsiveness
❖ Conscious/responsive
1. Amiodarone (to help convert
to sinus rhythm)
2. Cardioversion (50-200 J) –
synchronized
❖ No Pulse/Unconscious/
Unresponsive
1. Defibrillation (200-360 J)
2. Lidocaine
3. Amiodarone
4. Normal Cardiac Arrest Procedure
***If V-tach present:
↓Cardiac Output
↓Blood circulation in the brain
SUPRAVENTRICULAR TACHY
ADENOSINE
− Drug of choice of Supraventricular
Tachycardia
− Administer rapidly over 1-2 secs IV
bolus followed by saline NSS flush
− Short acting (5 secs)
− Inject near heart
− Monitor ECG
− Asystole- ↓impulse in the AV node;
expected temporarily
− Chest pain, palpitation (side effect)
CONGESTIVE HEART FAILURE CIRCULARY OVERLOAD
- Fluid overload Heart Failure
Mgt Lungs (Pulmonary edema, crackles, rales)
• ↓Na (<2g/day)
• ↓Fluid (<2 L/day) Causes: IV line/ blood transufion
• Give Loop Diuretics (↓BP)
- (Furosemide/ Bumetanide)
S/sx
- ↓Preload ↓Pulmonary Edema
- potassium wasting • Dyspnea
- Monitor for Ototoxicity-result of fast • ↑BP
dose >120 mg) Normal is 4mg/min
- Monitor for Nephrotoxicity (effect of Mgt:
high dose)
• Give Potassium Chloride (Kalium Durule) • Maintain IV line
• Monitor vital signs.
RIGHT SIDED HEART FAILURE
- Cause by congestion • Prepare to administer oxygen.
- Exception: Cor Pulmonale (lungs, • Prepare to administer diuretic.
COPD) • Place the client in an upright
- ↑Central Venous Pressure position.
Normal:2-8 mmHG • Notify the primary health care
↑: RSHF (Fluid overload) provider.
S/sx Congestion
• Jugular Vein Distention
• Hepatomegaly
• Edema
• Crackles in lungs
LEFT SIDED HEART FAILURE
- Due to Left Ventricle Problem (ex.
MI)
S/sx Respiratory
• SOB
• Dyspnea
• Crackles
**RR can ↑ 40-50 bpm during mild
exercise to compensate (normal) ***Brain Natriuretic Peptide Level
Normal: <100 pg/mL
If >100- Heart failure
MY NCLEX NOTES 2021 37 | P a g e
 CARDIAC CATHETIRIZATION
- Procedure takes 1-3 hrs
- Pt may experience flushing/ warm
sensation due to radiopaque dye
- The blood vessels & flow of blood will be
examined
- There is minimal discomfort w/ insertion
because local anesthesia used
- Hold Metformin (cause lactic acid
formation w/ radiopaque dye) 24 hrs
before & 48 hrs after
- If hairy, clip hair; don’t shave, may cause
rashes
Nrsg Responsibilities:
• Assess for Allergy (Iodine)
*Safe for Shellfish/Seafood Allergy
• Bleeding at cath site (hemorrhage)
Direct pressure 5-10 mins
No blood thinners w/n 6 hrs
***If site Right Femoral Artery (groin)
actively bleeding
Position: Low Fowler (30-40 deg)
***Antecubital site
Position: High fowler
• Creatinine
(Normal: 0.6-1.3 ng/dL)
Check UO 30 mL/hr
Radiopaque dye is nephrotoxic
• Can’t palpate Pedal Pulse (check
circulation on distal site)
Normal w/n 4-12 hrs
Report >12 hrs (Impaired circulation
↓Pulse, cold temp distal doppler detect
pulse)
• AFTER PROCEDURE
- Assess for Cardiac Arrythmias
- ↑ Fluid to excrete Dye
- No lifting heavy object after
- Can’t take a bath in tub (just shower)
HENNAJANECE
CENTRAL VENOUS CATHETER
Complication:
• Sepsis (infection)
• Air Embolism
Prevention of Complication during
dressing change:
• Place patient in supine position
• Instruct patient to hold breath
when changing injection caps &
tubing (prevent air embolism)
• Patient must not face the
dressing (prone to infection from
mouth during breathing)
• Perform hand hygiene before &
after
• Wear sterile gloves & surgical
mask
If dislodged, prone to Air Embolism
• O2 via non rebreather mask (100%)
• Apply occlusive dressing over
insertion site
• Assist client to left side lying and
Trendelenburg (to trap air at right
atrium)
• Monitor vital signs and respiratory
effort
• Notify HCP
***Monitor & REPORT immediately
- THROMBOPHLEBITIS
Redness, warmth, purulent
discharge at insertion site (ex. In
pt receiving Total Parenteral
nutrition)
CENTRAL LINE
***Perform wound culture every other
day to assess for infection
Drawing blood from central line
• Perform hand hygiene (to
prevent transmission of
infection)
• Use disposable gloves (to prevent
transmission of infection)
• Scrub Catheter hub w/
antiseptic/ 70 % Alcohol prior to
use (to prevent transmission of
infection)
• Discard 6-10 mL of blood drawn
from the line
• Flush the line w/ sterile normal
saline before & after collection
(to remove clots & flush previous
drugs)
• Place Specimen in biohazard bag
(clean bag prio to use w/ 70%
Alcohol) (to prevent transmission
of infection)
• Transport immediately to
laboratory to prevent lysis
SUBCLAVIAN VENOUS CATHETER
• Flush unused lumens of CVC w/
2-3 mL (200-300 units) of
Heparin every 12 hrs
• Use distal port of CVC to monitor
central venous pressure (CVP)
• Change occlusive central line
every 7 days
MY NCLEX NOTES 2021
ABDOMINAL AORTIC ANEURYSM
S/sx:
• Strong pulsation (pulsatile mass)
in the abdomen (periumbilical)
due to Hemorrhage
Mgt:
• Avoid pressure (may rupture)
• No Hot Compress
AAA Repair
• Resection: graft place inside
aneurysm
• Stent
Monitor after repair:
• AAA GRAFT LEAKAGE S/sx
- Shock/Hemorhrage s/sx
- ↓BP ↑HR ↑RR
- ↓HCT
- ↓ blood perfusion in the kidney
- ↑BUN ↑Creatinine
- ↓Urine output
- Weak Peripheral Pulse
- Ecchymosis (penis, groin,
scrotum)
- Pain in the groin
- ↑ Abdominal Girth
• Assess Pedal/Peripheral Pulse
38 | P a g e
EXERCISE ECG STRESS TEST
• Hold Beta Blockers & Calcium
Channel Blockers prior to test
• Don’t go to the gym on the day
of the test
• Wear sneakers
• Wear light, loose, comfortable
clothing
• Eat light meal and drink fluids
HENNAJANECE
CPR PERIPHERAL DISEASES MECHANICAL PROSTHETIC VALVE
1st Basic Neurological Assessment - Durable; long term use
“Hey are you okay?” ❖ Peripheral Arterial Disease - Need Anticoagulant long-term
- also known as peripheral vascular therapy
Compression
disease, atherosclerosis or - *↑Risk for bleeding
− Heal of Hand
hardening of the arteries • Use Electric razor (No straight
− Between nipples, center of chest
− Rate: 100-120/min
- Elevate feet on dependent razor)
− Compression: 30
position but not higher than • Don’t eat leafy green vegetables
− Depth/Pressure: 2-2.4 inches heart (source of Vit K, will ↑risk of
- Ex. Reynaud’s Disease, Buerger’s bleeding)
Airway disease (also known as • Don’t take Gingko Biloba, Garlic,
− Head tilt/ chin lift Thromboangiitis Obliterans) Ginger)
− Except of suspected spinal injury (use • Apply Vitamin E at chest incision
jaw-thrust maneuver) ❖ Peripheral Venous Disease after shower
- circulatory disorder in which the • Prosthetic valve: need antibiotics
Breathing veins that carry blood from the prior to dental procedure
− 2 Rescue Breaths hands and feet to the heart
become damaged or blocked, can
*If mouth is full w/ injury or blood, blow to the
nose occur anywhere in the body.
However, it most often affects
the arms and legs, and is
***Ensure to receive Antibiotic prior to
commonly caused by a blood Dental work for pt with Prosthetic Valve,
CPR on Infant (to assess pulse/circulation)
• <12 mos – use Brachial Pulse clot. Coronary Heart Defect if not treated
• >12 mos – Carotid Pulse - Elevate feet and legs above
heart level
- Ex. Superficial Vein Thrombosis
Deep Vein Thrombosis
***Immediate action if a pt is found:
UNCONSCIOUS
1st Basic Neurological Assessment
“Hey are you okay?”
UNCONSCIOS (NO PULSE)
1st CPR
MY NCLEX NOTES 2021 39 | P a g e
ORTHOSTATIC BLOOD PRESSURE TRANSESOPHAGEAL ECHOCARDIOGRAM

1. Lie supine 5-10 mins - TEE produce sounds, and take

2. Check BP & HR pictures of the heart
3. Instruct pt to stand up - To assess blood clot in the heart
4. Check BP & HR - The tip will be inserted to the
5. Repeat 1-3 mins interval esophagus; then can advance/ place
*Report: to the stomach
difference >20 mmHG - Ordered for pt with possible
SBP >/ 20 mmHg endocarditis
DBP >/ 10 mmHg
Nrsg Responsibilties
• Place pt on NPO (6 hrs before)
Mean Arterial Pressure • Administer O2 via nasal cannula
Average pressure in arterial system felt by • Start peripheral IV line
organs • Give Midazolam (verse) 1 mg IV
Normal: 70-105 mmHg push as sedative
Report: ↓60 mmHG (↓Perfusion) • Consent needed (invasive)
• Left side lying position
MAP = SBP + (DBP x2)
3

Hypertensive Crisis
Needs immediate action:
• Weakness in the left arm (sign of
ischemia, oxygen to the brain)
• Systolic > 200-220
• Diastolic > 100
• Give antihypertensive meds
immediately

HENNAJANECE MY NCLEX NOTES 2021 40 | P a g e


ENTERAL TUBE FEEDING
− Preserve mucosa/gut
− Lessen bacteria movt
− Prevents stress ulcer
Risk
• Hyperglycemia (check blood
glucose)
• Aspiration
ASPIRATION PRECAUTION
- If pt is intubated/mech vent
(endotracheal cuff must be
inflated 25 cm water; suction pt)
- Elevate head of bed 30 deg &
above
- Assess GI intolerance every 4 hrs
o abdominal distention
o residual volume
>400mL- HOLD
<400 – CONTINUE
- Assess tube placement (Gastric
Residual pH)
- Caution w/ sedative
GASTROINTESTINAL NOTES
TOTAL PARENTERAL NUTRITION
TPN (rich in glucose, amino acids & other nutrients)
(INGREDIENTS: Trace minerals; Regular Insulin IV;
Electrolytes; Multivitamins)
***Confirm xray report of correct cath placement
***Sudden stop can lead to Hypoglycemia
Infusion Rate:
− Not more 24 hrs (if exceed, need to
replace TPN & entire tubing)
Preparation
• Remove solution from ref 1 hr prior to warm
• Don’t flush the IV line/ don’t irrigate w/
heparin
• Use clean gloves to change bags
• Compare every ingredient w/ HCP order
Mgt during TPN
• Covering blood glucose levels w/ sliding scale or
regular insulin
• Inspect solution to ensure “layering” of content
is absent
• Don’t adjust rate every shift
• Change injection caps on IV tubing every 72 hrs
• Monitoring liver function test (check pre-
albumin level to check effectivity of TPN
Risk of TPN
• Infection (cause TPN is hook in central vein
access device)
• Hyperglycemia (need to check Blood glucose)
DUMPING SYNDROME PEG
- Common complication of Roux-en-Y Percutaneous Endoscopic Gastronomy
gastric bypass
- Happens 5-30 mins after eating
− A large bore tube to administer
- Meals should be small frequent feeding
feedings & medications
- Lie down few mins after eating
− Flexible feeding tube is placed
- Fluids 30 mins before/after meal
through the abdominal wall and into
S/sx: the stomach, bypassing the mouth
• Sweating & Pallor (1st) and esophagus
• Vertigo − Conscious sedation only
• Syncope (collapse feelings) − Not a major surgery. It does not
• Palpitation
involve opening the abdomen
− The tract matures 1-2 wks
Diet: ↑Protein, Fats, Cholesterol, ↓Carb
− Mature after 4-6 wks & can be use
− If dislodged, REPORT immediately
***Avoid Irritants, milk, sugar, salt
***need to take Iron, calcium supp, cobalamin
injection & other vitamins

NGT insertion landmark Hyperglycemia (PRIORITY: check blood glucose)

• Tip of nose Cause:
• Tip of ear • ↑Infusion of TPN
• Steroids
• Xiphoid Process • Infection
S/sx
• ↑Thirst
• ↑Urination
• Headache; Fatigue
• Blurred Vision
***TEST TAKING: Mgt
If there is machine problem, CHECK PT • ↓Carbohydrate
FIRST • ↓Infusion
• SQ Insulin

HENNAJANECE MY NCLEX NOTES 2021 41 | P a g e

 LIVER
***Albumin – maintain oncotic/intravascular
pressure
“People Drink So Much”
• Produce – Albumin; Bile; Clotting
• Detoxifying – Medication; alcohol;
hormones (estrogen)
• Store –Glucose-Glycogen; half life of
meds
• Metabolism – Drugs; fats;
Effects of High Estrogen
Gynecomastia
Redness in the palm & itching
Spider angioma
Important LAB Values
• Albumin: 3.5-5 g/dL (if ↓-ascites/edema)
• Ammonia: 15-45 mcg/dL (if ↑-enceph;
lethargy, altered LOC)
• INR: 0.75-1.25 (if ↑-bleed/bruise)
• Bilirubin: 0.2-1.2 mg/dL (if ↑-jaundice;
itching)
• Platelet: 150-400K/mm3
LIVER BIOPSY
- Puncture at RUQ
- Check Bleeding time prior to biopsy,
HOLD biopsy if w/ bleeding problem
- Instruct pt to inhale and prolong
expiration, then hold breath to prevent
puncture to lungs
- Position Post Biopsy: Right side w/ small
pillow/folded towel under puncture site
to prevent bleeding after
TRANSJUGULAR INTRAHEPATIC
PORTOSYSTEMIC SHUNT (TIPS) & Beta Blocker
- Use to reduce portal pressure in liver
failure & esophageal varices
HENNAJANECE
LIVER CIRRHOSIS
Scarring/degeneration of liver
Causes:
Alcohol; Infection (Hep B&C); Obesity
Complications:
1. Portal Hypertension
− ↑pressure at portal vein
− ↑Pressure to connecting organs
• Spleen (Splenomegaly) – ↓WBC
↓PLT
• GI/Abd – Ascites
• Esophageal Varices (If HPN is not
controlled, it will rupture)
➢ Priority Mgt
Sengstaken Blakemore Tube
• Inflate balloon to compress bleeding
of esophageal varices
• An NG tube at opposite nares to
collect secretion
• 3 tubes
1. Inflate at esophagus to prevent
bleeding (Esophageal Balloon)
2. Inflate below esophagus above
abdomen near sphincter (Gastric
balloon) Hook to stomach/anchor
3. Tube connected to stomach w/
weight tension)
• ***SCISSORS at bedside for
emergency dyspnea to immediately
deflate
LIVER CIRRHOSIS LIVER CIRRHOSIS
2. Hepatic Encephalopathy 3. Bleeding
− End stage Liver Problem − ↓Vitamin K (Bile can’t absorb ADEK)
− ALTERED LOC − Clotting problems (prolong clotting)
Cause:
• ↑Ammonia level (liver can’t metabolize so
Normal
ammonia is not converted to urea, so it
can’t be excreted in the kidney and can go Protime: 11-16 secs
to the brain) PTT: 60-70 secs
• GI bleeding (the blood in the GI will be APTT: 30-45 secs
converted to Ammonia) INR: 1-2
• Hypokalemia
• Infection 4. Fluid Volume Overload
• Constipation Ascites
Pitting Edema (due to ↓Albumin)
S/sx
Mgt: Strict I&O; Diuretic;
• Altered LOC *** (disoriented/confuse)
• Sleep disturbance/Lethargic/Coma Administer Albumin IV (prevent ↓BP
• Asterixis ↑HR; prevent leakage &ascites)
- Earliest sign of hepatic enceph - Make sure V/S remain normal
- Presence of Liver flap
***Ask the pt to extend the arms forward, 5. Renal Failure
w/ palms facing downward, then bend Due to retention; can’t expel
fingers backward (dorsiflex). When
release, there is presence of involuntary
6. Jaundice – ↑bile
tremors/movt
• Fetor Hepaticus (ammonia smelling
breath)-musty sweet odor 7. Low ADEK vitamins
• Spider Angioma
Mgt
• Diet
- ↓ Protein (if pt has confusion) &
restrict Na
- ↑ Protein (if not confusion)
• Monitor bleeding
• Medication
- Neomycin/Rifaximin (antibiotic)
To kill bacteria in the GI that convert
Protein to Ammonia
- Diuretics (mgt of peripheral edema)
- Lactulose (to ↓ absorption of
Ammonia & excrete to stool) (2-3
stools is Normal)
MY NCLEX NOTES 2021 42 | P a g e
 CYSTIC FRIBROSIS PANCREATITIS PANCREATITIS ACUTE PANCREATITIS
PANCREAS Swelling/inflammation of Pancreas Causes
Located in LUQ; release insulin, enzymes to Mgt • Cholecystitis
metabolize food, amylase Major Causes: • Rest Pancreas; NPO; NGT • Alcohol (most common)
Inflammation of Pancreas due to blockage, • Alcohol • Position: Flex trunk/ Fetal
eventually cause damage & rupture and • Cholelithiasis (Gall Bladder problems) S/sx
position
hemorrhage, then blood can go to the • ↑Fat Intake • Shallow breathing
• Pain medications (Narcotics • Pain (LUQ/ Mid Epigastric radiates to
peritoneum (Peritonitis), and also affects lungs
(ARDS) (Opioids)- Hydromorphone back)
Complications
− Acinar (Amylase, Lipase, Protease) (Dilaudid) (common s/e: • Shock (due to ruptured pancreas)
• Autodigestion (Enzymes will be
stomach acids activate them in the Pruritus); max dose is 2mg • Steatorrhea (oily poop; due to
activated inside & damage the
duodenum • Pancreatic Enzymes absence of lipase)
pancreas) and leads to ARDS (lungs)
− Islets (Produce Insulin & Glucagon) • PPI, H2 Blockers (to ↓acids to
• Malabsorption (Failure to deliver Danger:
prevent activation of enzymes)
enzymes & hormones so no • Bleeding inside Peritoneal Cavity
• Diet after surgery (Clear liquid,
metabolism will happen) due to ruptured Pancreas
CYS “TIC” FRIBROSIS then ↓Fat/Protein/Carb)
• Sugar problem - ↑Glucose (because • Respiratory Problem (Pancreas near
- Affects pancreas & respiration • IV Fluids (Isotonic); TPN lungs)
insulin can’t get out)
- “Thick” mucus overproduction • ***Morphine is contraindicated • Grey Turner’s Sign –ecchymosis or
• ↓Calcium & ↓Vit D (Hypocalcaemia)
- Obstruction in the pancreatic ducts because it causes spasm in the bluish/ bruising of the flanks, the
- Trousseau (carpal spasm)
(Amylase, Lipase, Protease) sphincter of ode part of the body between the last rib
- Chvostek (facial twitching)
and the top of the hip (Pancreas is
- Malabsorption (protein, fats, carbs, - Tetany (continuous muscle spasm)
Diagnostic bleeding)
ADEK) - Arrythmia
• Endoscopic Retrograde • Cullen’s sign – bluish discoloration
Mgt: Calcium Gluconate around umbilicus
S/sx cholangiopancreatography
• Fibrosis, cyst, rupture
• Steatorrhea To dilate/collect/for
• Affect nearby organ
• Diarrhea biopsy/tumor surgery
• Cramping Use of endoscopy and
Classic S/sx
• Flatulence fluoroscopy
Pain: start in Epigastric & radiates
to back
Mgt
• Pancreatic Enzymes ➢ ACUTE PANCREATITIS
Take before meals/snacks - Sudden; autodigestion Mgt
Don’t chew (it needs to activate - Leakage/rupture • Fetal Position / Sitting Upright w/
only in the duodenum) - Bleed (Cullen’s Sign & Grey trunk flexed
Can open capsule & sprinkle on a Turner) • Hydromorphone (check RR)
tablespoon of Applesauce - ARDS (Pruritus-common s/e)
• Hydrate (IV Fluids)
➢ CHRONIC PANCREATITIS
• NPO (rest pancreas)
- Long term; due to alcohol;
• Encourage coughing & deep
clogged ducts; ↑Ca ↑Carbs breathing
intake
• UTZ/CT scan

HENNAJANECE MY NCLEX NOTES 2021 43 | P a g e

 CROHN’S DISEASE
Affects all layers (mucosa, serosa) GI (Small
&Large Intestines); found from mouth to anus
• Unknown cause
Common (Crohn’s & Ulcerative Colitis)
• •
Inflammatory Bowel Disease
• Inflammation
• Ulcers
• Can have remission /exacerbation
• ↑risk for colon cancer
• Cure include total colectomy &bowel
resection w/ ostomy
Pain: Terminal Ileus (RLQ)
Diet:
• ↓Fiber; ↑Protein
• ↑Fluids; No irritating foods
S/sx:
• Diarrhea (pus)
- Dehydration
- Electrolyte Imbalance/Loss
- Malnutrition
- Weight Loss
• Anemia (↓Hgb ↓Hct)
• Abdominal Pain
• Anorexia (↓appetite)
• Malabsorption (Vit. ADEK def)
Meds:
• Rest GI (NPO/IVF/NGT)
• Corticosteroids (Sulfasalazine)
- Immunosuppressant
- Treat the inflammation
- Aminosalicylates
- Expect yellow to orange urine
- Absorb at the colon
- May Crystalize in the kidney
- Monitor for DHN – Urine Specific
Gravity (Normal 1.010-1.030)
• Azathioprine
Complication:
• Fistula
• Strictures (obstruction)
• Anal Fissure
HENNAJANECE
ULCERATIVE COLITIS DIVERTICULITIS IRRITABLE BOWEL SYNDROME
Affects the mucosa of GI (Large Intestines & Diverticulosis Different with the Inflammatory Bowel Disease
rectum); Cause: stress − Small pouches (Diverticula) or pockets Due to stress (functional disorder)
in the wall or lining of any portion of the
Pain: rectum (LLQ) digestive tract; Asymptomatic S/sx:
S/sx: − Due to ↑Intra abdominal pressure • Minor symptoms (alternate LBM,
Diarrhea (blood) 10-20X
− Common cause: chronic constipation constipation)
- Dehydration • Abdominal Pain
- Electrolyte Imbalance/Loss
Diverticulitis • Bloated
- Malnutrition
− Infection or inflammation of pouches • Nausea
- Weight Loss
− Inflammation due to foreign obj, • Flatulence
• Anemia (↓Hgb ↓Hct)
• Abdominal Pain fecalith, (Myths: seeds/nuts/popcorn) • Constipation/Diarrhea
• Anorexia (↓appetite)
• Malabsorption (Vit. ADEK def) S/sx Mgt
• Mucosal irritation (during remission) • Unrelenting cramping type pain • ↑Fiber
• Loss of form to haustra • Blood in stools • Slow chew
• Fever • ↑ Fluids
Complications: • Constipation • Meds depends on the symptoms
• Toxic Megacolon • Abdominal bloating due to Corticosteroids (Sulfasalazine)
(Fever, abdominal distention, obstruction • Avoid gas forming food (legumes;
infection/sepsis) cruciferous; fructose)
• Bleeding/obstruction/abscess/ • Journal diet, stress level, symptoms
Complication:
perforation (Peritonitis) • Perform exercise
• Abscess
• Fistula • Avoid irritants (caffeine)
Mgt (Nutrition & Hydration)
• Bowel Obstruction
• Rest GI (NPO/IVF/NGT)
• Peritonitis
• Diet: ↓Fiber (once diet resume)
• Bleeding
• ↑Protein, ↑ Calories (to prevent wt
loss)
Mgt
• ↑Fluids
• Avoid High fat, red meat
• Vitamins & w/ Calcium
• No ↑ Intraabdominal Pressure (ex.
• Diet Journal
• No irritating & gas forming foods Heavy lifting)
(avoid triggers-milk, fatty, caffeine, • Diet: ↑Fiber (to prevent) (whole
alcohol, nuts) grains; fruits; veggies)
• Diet: ↓Fiber/residue if you have
Meds: Diverticulitis
• Corticosteroids (Sulfasalazine) • ↑Fluids
• Azathioprine (immunosuppressant/ • Exercise regularly
anti-inflammatory) • Fiber supplement
- Use to prevent organ rejection
(kidney & liver transplant)
- Use for Crohn’s Disease &
Ulcerative Colitis
- Don’t give to pt w/ Leukopenia or
↓ immunity
MY NCLEX NOTES 2021 44 | P a g e
 PEPTIC ULCER DISEASE APPENDICITIS APPENDICITIS HERNIA
− Inflammation of Appendix Hiatal Hernia
Cause: Helicobacter Pylori A portion of stomach protrudes through
Pain: RLQ pain (begin at periumbilical area weak part of the diaphragm
Gastric Ulcer Duodenal Ulcer going to McBurney’s Point)
SLIDING OR ROLLING
Left epigastric pain Right epigastric pain - lower abdomen above right hip
GERD like s/sx: Heartburn; Dyspnea
Occur immediately Occur 2-3 hrs after
after meal meal/ empty Common Cause: Fecalith (tiny stool)
stomach Mgt
To relieve pain: pt To relieve pain: pt S/sx • Elevate head of bed after meals
vomit eat food • Pain (rebound tenderness) • Small frequent feedings; Low fat
Wt loss Wt gain • Anorexia diet
Common in pt w/ Common in pt w/ • Increase temp/WBC • ↓fluids during mealtime
blood type A blood type O • Nausea & vomiting • No irritants (caffeine; alcohol;
Prone to develop • Tenderness at McBurney’s Sign
tobacco; spicy; fatty)
cancer • Blumberg's sign – apply slow pressure Mgt
• Avoid ↑ intraabdominal pressure
over McBurney’s point and then quickly • Avoid ↑Intraabdominal Pressure
release. The presence of severe pain when • Avoid ↑circulation to GI (ex.hot compress) (heavy lifting not >10-15 lbs;
Mgt straining; pregnancy; tumor)
• NPO during active phase pressure is released is indicative of a • NPO
positive test • Avoid Pain reliever (if still suspecting) (can • No use of girdle
• Avoid irritant foods; NSAID
• Surgery (in severe cases) • Rovsing sign – positive when pressure over give once diagnosed)
the patient's left lower quadrant causes pain • Avoid coughing/sneezing
❖ Billroth 1/ Gastroduodenostomy
(removal of antrum then remaining in the right lower quadrant.
part of stomach attach to Duodenum) • Dunphy's sign – increased abdominal pain
❖ Billroth 2/ Gastrojejunostomy with coughing; indication of ruptured Rupture/Perforated Appendix
(remaining part of stomach attach to appendix May lead to Peritonitis
• Psoas sign – elicited in an individual lying on S/sx:
Jejunum)
their left side while their right thigh is • Relief pain then recurrent of severe pain
Meds: extended backward Mgt:
• Obturator sign – pain on passive internal • APPENDECTOMY
• Proton Pump Inhibitor (ex. Omeprazole)
– supress source of acid in the GI
rotation of the flexed thigh ➢ Pre-op
• Metronidazole – to kill bacteria • NPO; IVF; NGT Diaphragmatic Hernia
• Avoid Abdominal contents (intestines push
• Tetracycline – to kill bacteria
- Frequent RUQ palpation lungs) herniate through an opening of the
• Bismuth Salicylate – anti inflammation
- Hot compress diaphragm
• Sucralfate/Misoprostol – gastric
- Laxatives & enema
protectant
➢ Post op
• NPO; IVF; NGT
***Burns are risk for Curlings/stress ulcer
• Deep breathing
• Early Ambulation
***Bismuth Salicylate & Aspirin
• Splint incision site when
− Contraindicated for pts w/ viral
coughing/sneezing
infection (influenza/varicella) to
prevent Reye Syndrome (Hepatic
Encephalopathy)

HENNAJANECE MY NCLEX NOTES 2021 45 | P a g e

 PARALYTIC ILEUS
Paralyzed intestine due to general
anesthesia/narcotic/prolong immobility
S/sx
• Nausea
• Abdominal discomfort
• Distention
• Absent bowel sounds
Mgt
• NPO
• NGT & attach to wall suction (to
decongest)
• ↑ IV fluids
• Ondansetron (for nausea)
• Pain meds (Ketorolac, Ibuprofen,
Acetaminophen)
• AVOID Narcotics
• Avoid taking Dicyclomine (anti-
spasm)-will further paralyze
• SALEM SUMP TUBE (Two-lumen
nasogastric/orogastric tube for
gastric suctioning)
• Pt in semi-fowlers position
• Inject 10-20 cc of air if gastric
content refluxes
• Provides mouth care every 4 hrs
• Turns off suction when
auscultating bowel sounds
COLONOSCOPY
• Abdominal cramps is expected after
Danger: Perforation
S/sx
• Signs of Peritonitis
- Abdominal pain
- Rebound tenderness
- Rigid abdomen
• Distention
• Tenesmus (feeling you can’t
empty bowel, even if you’ve
already had one)
• Rectal bleeding
PREPARATION
• NPO 6-8 hrs
• Stop smoking a day prior
• Clear liquid diet a day prior to
evacuate/cleanse colon
• Drink Polyethylene Glycol a day
before (or Cathartics/Laxatives)
ESOPHAGOGASTRODUODENOSCOPY PARACENTESIS
− For Liver Cirrhosis
Risk/Complication − Needle inserted at the abdomen to
• Perforation/Infection (Peritonitis) peritoneum
- ↑Fever, ↑HR, ↑RR − hollow needle or plastic tube
- Rigid abdomen (catheter) to remove fluid from the
- Rebound Tenderness abdominal cavity
− Monitor Hypotension & ↑HR
Expected after procedure (Hypovolemic shock)
• Gag reflex not returned – normal − Supine position and slightly rotated
w/n 4 hrs after EGD (REPORT >6 to the side of the procedure to
hrs) further minimize the risk of
• Sore throat perforation during paracentesis

***HEMICOLECTOMY
Removal of certain part of Colon
Use after (Sequential Compression Device
(SCDs))

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 CHOLECYSTITIS CHOLECYSTECTOMY CHOLECYSTECTOMY GASTRO PARESIS
Inflammation C Tube Nerve damage (Vagus)
- Drain bile Priority teaching pre-op for all major Disrupts stomach function
Bile – digest fats to become ADEK; uses - Use if pt is not scheduled for surgery
Bilirubin as vehicle surgery • Coughing & deep breathing Cause
exercise – to avoid atelectasis • Diabetes
Risk T-Tube (lung collapse) • Surgeries
• Female/obese - Drain bile after ectomy • Sedatives/narcotics
• Old; Has previous history - 500cc/day (REPORT if >500) Open Cholecystectomy (if ruptured)
• Pregnancy - Proper skin care (bile is irritating S/sx
• Native American/ Mexican to skin) • Bloating
American LAPAROSCOPIC CHOLECYSTECTOMY • N&V
Perform if gall bladder is not yet ruptured • Heartburn
S/sx
• Pain (right upper quadrant Diet Post-op:
radiating to right shoulder) 1st Clear Liquid
• Murphy (+ if w/pain) (ask pt to 2nd ↓Fat (after flatus)
exhale, then while inhaling press SMALL BOWEL OBSTRUCTION
gall bladder) Immediate Post-Op Mgt − Affects small intestines
• NPO (if pt starts to vomit ***Assist w/ early ambulation − Fluid & gas formation in proximal
Greenish-yellow stomach (↑Peristalsis, improve breathing, to obstruction
content (bile) prevent paralytic ileus, S/sx
• Jaundice (light stool) thromboembolism) • Abdominal distention
• Steatorrhea • Colicky abd pain
• Fever To prevent Pneumonia post-op • Frequent vomiting
• Bloated • Ambulate w/n 4-8 hrs after • Copious, greenish-brown
• ↑HR surgery if possible drainage from NGT (expected
• Cough w/ splinting every hour due to bile)
Diagnostic • Deep breath & use incentive
• UTZ; CT Scan spirometer every hour Mgt
• HIDA Scan (hepatobiliary • Place in fowler’s position (45 deg) • NPO; NGT
iminodiacetic acid) • IV Fluids
• Pain mgt
Mgt
• ERCP ***Pneumatic Compression Device
• Ectomy - Use to prevent Deep Vein
• T-Tube Thrombosis
- Only for long term immobility

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 REFEEDING SYNDROME
− Happens to pt w/ chronic
malnutrition &anorexia nervosa;
chronic alcoholic who have not
eaten for many days
− Lethal Nutritional Replenishment
S/sx
• Glucose, Na will go out in the
blood (due to ↑ Insulin)
• LOW Potassium, Phosphorus,
Magnesium (it will go inside the
cell)
Normal
- Potassium: 3.5-5.5
- Phosphorus: 2.4-4.4
- Magnesium: 1.5-2.5
Prevention
• Electrolyte
• Gradual increase in Calories
***HYPOMAGNESEMIA
- Same w/ Hypocalcaemia
- Ventricular Arrythmia (Torsade’s de
Pointes)
- Neuromuscular Excitability
(Trousseau, Chvostek, Tetany,
Cardiac Arrythmia)
HENNAJANECE
ACID BASE BALANCE
METABOLIC ACIDOSIS
− Acid retention
− Depletion of Bicarbonate
Cause
• GI (Diarrhea)
• Renal Failure (toxic waste;
clotted AVF, can’t have
hemodialysis)
• Hypertension
• Ketoacidosis
• Lactic Acidosis
• Salicylate toxicity
Mgt
• Sodium Bicarbonate
METABOLIC ALKALOSIS
• Hyperventilation (stress)
• Vomiting
WEIGHT LOSS
− Create multiple small goals w/
rewards for achievement
− Identify list of desired outcomes not
directly related to wt loss
− Perform anxiety-reducing activities
rather than using food to cope w/
stress
− Utilize visual cues such us
motivational quotes
OSLISTAT (XENICAL)
- Lipase inhibitor (fats)
- Prevent breakdown & absorption of
fats
- Take ADEK vitamins (because bile
will be excreted and can’t bind
w/fats to make Fat soluble vitamins)
• Steatorrhea (oily stools)
• Fecal incontinence
Teaching
• Consume low fat diet in w/c no
more than 30% of calories are
from fat
• Take medicine w/ or w/n 1 hr
before meals that contain fats
• When taking vitamins, take it 2
hrs before/after meals because it
can’t be absorbed
• Don’t take at night time
MY NCLEX NOTES 2021
DEHISCENSE & EVISCERATION
DEHISCENSE – surgical incision opens
Mgt:
- Position in such as way to ↓
pressure on abdomen
- Elevate/flex knee and head
- Apply wound binder
EVISCERATION – surgical incision opens
(dehiscence) and the abdominal organs
then protrude or come out of the incision
- First: Cover wound w/ sterile,
saline, soaked dressing
- Second: call HCP immediately
***VALSALVA MANEUVER
Contraindicated for pt:
• Head injury (↑ICP)
• Myocardial Infarction (↑Cardiac
Workload)
• Hypertension (Varices may
rupture)
• Cataract surgery (↑IOP)
48 | P a g e
 COLOSTOMY
❖ OSTOMY
− Left side lower quadrant below the
belt (to not interfere w/ dressing)
− Red (first 3 days)
− Pinkish (after 3 days)

Expected after:
• Pink to brick red
• Minor bleeding
• Swelling (2-3 wks)
• Rosy w/ no stool (the colon is
emptied before the procedure)

REPORT: Pale, dusky, cyanotic, edematous

❖ WAFER – about 1/16” larger than stoma

❖ POUCH
− Replace if 1/3 full
− Irrigate after meals

Mgt
− ***Colostomy doesn’t interfere w/
sex, just make sure to clean prior
− Only irrigate in descending
colostomy
− Avoid gas forming food
− ↑Fluids to 3L/day

STOOLS
Ascending Colon – liquid
Transverse Colon – semi liquid
Descending Colon – Formed stool

**Ileostomy (stool is liquid)

- If new (Low residue diet)
- If healed (High fiber diet)
- Make sure to chew food

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 VIRAL HEPATITIS B HEMORRHOIDECTOMY
− Transmitted thru blood products Thoracic Aortic Aneurysm Hemorrhoids
&sexual intercourse It pushes the Esophagus, w/c − Distended & inflamed vein (due
− Offer small, frequent meals to leads to dysphagia (Difficulty to constipation)
prevent nausea swallowing) − ↑ anorectal pressure (due to
− Promote rest periods in between straining &defecating)
activities
− Low Fat Low Carb diet S/sx
− Teach client not to share • Bleeding
razors/toothbrush w/ others • Pruritus
− Teach client to abstain from alcohol • Prolapse

Mgt
• Pain (spasm of anal sphincter
post surgery)
• NSAIDS
• Hot Sitz Bath (w/n 1-2 days 2-
3x/day)
• Prevent constipation (administer
Docusate to avoid straining)

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MYASTHENIA GRAVIS
Muscle weakness (voluntary muscle- ex.
Closing eyes, raising arms); autoimmune
S/sx
• 1st sign – EYES (Double vision;
Strabismus; Drooping; Ptosis (eyes
close)
• THOAT (Dysphagia-swallow, chew)
(hoarse of voice)
Slurred speech/Impaired voice
• *Respiratory Depression (dyspnea)
• FACE (mask) & EXTREMITIES (weak)
• Muscle weakness
Meds: Pyridostigmine/ Neostigmine
(Anticholinesterase); ↑ Acetylcholine-
make muscle move
❖ Myasthenia Crisis
- late meds/ low dose / low effect of
meds
- Muscle weakness
❖ Cholinergic Crisis
- Too early admin of meds/high dose
*Give Atropine Sulfate after (Antidote
for cholinergic called
anticholinergic)
TENSILON TEST (to test if MC/CC)
Give Edrophonium Hydrochloride
• MC – if there is ↑Muscle strength
• CC – if there is ↑ or further Muscle
weakness
HENNAJANECE
MUSCULOSKELETAL NOTES
MYASTHENIA GRAVIS
Nrsg Responsibilities:
- Schedule of meds is very important
(always give at same time daily)
(use alarm)
- Give meds 30 mins-1 hr before meals
- Increase meals in AM
- Perform ADL after meals
- Small bites of food
- Thick fluids
- Perform activities in the morning
(more energy)
- *Aspiration precaution
- Monitor respiration
- Standby Tracheostomy at bedside
- Possible intubation /mech vent
- Annual flu shot vaccination
Additional meds
• Corticosteroids – treat inflammation
• Plasmapheresis – remove plasma
that has the antibody that cause the
MG & infuse immunoglobulin
PLASTER CAST TRACTIONS
Cast Care: ➢ SKELETAL TRACTION
• Keep cast clean and dry Monitor for drainage/ signs of infection
• Air dry (can use hair dryer on Cool on pin sites
setting only)
• Allow cast to dry completely - Thick yellow drainage (infection)
- Dry: 24-72 hrs - Redness around pin sites (expected)
- Fiber Cast Dry: 30 mins) - Clear/serous/ water drainage from
• Keep cast & extremity elevated (w/ pin sites (normal/expected)
pillow to reduce/prevent edema) - Pain on palpation at the pin sites
• Monitor for Compartment Syndrome (1st (normal/expected)
sign: tingling/numbness in the extremity)
• To relieve itchiness (use hair dryer on
cool setting)
• AFTER REMOVAL
- Wash skin gently w/ soap & water
- Apply skin lotion
- Don’t soak arm in warm water for
long period (may cause skin
breakdown)
- Don’t scrub vigorously
➢ BUCK’S TRACTION
COMPARTMENT SYNDROME - No pins;
↑ external pressure inside cast >30mmHg - Involves use of Pulleys and Wheels
- Skin extension traction
S/sx (7 P’s) - Applied before surgery for hip
• 1st Paresthesia (numbness/tingling) fractures
• Pain - Provides comfort by reducing muscle
• Pulseless spasms
• Pressure - Provides fracture immobilization
• Paresis (hard to move)
• Pallor
• Pain w/ stretch)
Mgt
Bivalve Cast – break cast into two
MY NCLEX NOTES 2021 51 | P a g e
 CRUTCHES USING CRUTCHES
Going Up Stairs ❖ TWO POINT GAIT
1. Good leg goes up One leg is weak (partial wt bearing)
2. 2 crutches Faster
3. Bad leg up & align w/ good leg
1. Right crutch w/ Left foot together
Going Down stairs 2. Left crutch w/ right foot together
1. 2 crutches
2. Bad leg goes down ❖ THREE POINT GAIT
3. Good leg goes down ***For amputated leg (non wt
bearing; one leg can’t touch ground)

Sitting Down &Up 1. 2 crutches + bed leg advance

Good leg nearest chair forward (together)
1. Hold both crutches w/ affected 2. Good leg Three Point Gait
side
2. Good side hold arm rest - Swing to gait – advance 2
3. Use Good leg in sitting & rising crutches then swing legs on the
from the chair (raise bad leg) level of the crutches
4. Sit down/up - Swing through gait – advance 2
crutches then swing legs pass
Important: through
- Tripod position
- Arms/elbow flex 30 deg when ❖ FOUR POINT GAIT
using Two legs are weak (full wt bearing)
- Distance from axilla to pad must Slow
Four Point Gait
be 2 inches (3-4 fingers) Closely resemble normal walking
- Don’t use someone’s else’s crutch
- Remove any scatter/rugs at home 1. Right crutch
- Make sure crutch tip is dry 2. Left foot
- Have spare crutch & tips available 3. Left Crutch
- Wear rubber shoes w/o lace 4. Right Foot
- Carry only small bag/ small
shoulder bag/backpack, not big
purse
- *Rest crutches: Upside Down
- Hand/arm should bear the weight,
not the axilla
- Walk and look forward, don’t look
down on your feet

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 GOUTY ARTHRITIS
↑Uric Acid
Normal Uric Acid: 4-8.5 (M) / 2.7-7.3 (F)
Cause
• Metabolism of Uric Acid
• Unable to excrete Uric Acid
• Secondary to an illness (ex.kidney
problem)
S/sx
• Tophi (urate crystals accumulation in
the joints &skin)-inflammation
• Severe, excruciating Pain
• Low grade fever; malaise; headache
• Pruritus
• Renal Stone/calculi
Mgt
• Immobilize (well align)
• ↑Fluid
• Allopurinol /Colchicine– antigout/
antiinflammation
Colchicine (acute attack)
Don’t take w/Aspirin (will decrease
effectivity)
• Diet: ↓Purine (avoid organ meats,
beans, seafoods, beer)
• Alkaline ash diet (dark veggies-kale,
spinach, avocados)- to have alkaline
urine
• Encourage wt reduction
• Provide heat/cold compress
• Provide bed cradle
• Rest during acute attack
Diagnostic Test:
• Check Synovial Fluid
Positive for Gout: Presence of Uric Acid
HENNAJANECE
OSTEOARTHRITIS
− Progressive deterioration of joints (weight
bearing joints-hip, knees, lower spine,
hands) (degenerative d/o)
− Cause: Unknown
Risk Factors:
• Trauma; Family history (genetics)
• Aging (old); Obese; Smoking
S/sx
• Pain (↑after an activity/later in the
day) (↓after rest
• Joint Swelling (“Crepitus” sound)
• Limited ROM
• Heberden’s (bony swelling on distal
joints) & Bouchard’s nodes (bony
swelling on proximal joints)
• ↓ADL (Self care deficit)
Mgt
• IMMOBILIZE (1st )
• Med (NSAIDS, Muscle relaxant,
Corticosteroids)
• Avoid flexion of knees/hips (no pillows
under head/back/knees)-may lead to
contractures
• Splint/brace affected joint until
inflammation subside (REST)
• Bed cradle (so linen will not touch affected
joint)
• Provide heat/cold compress
• Wt at normal range; well balance diet
• Balance activity w/ rest
• Encourage to participate in exercise regimen
(water aerobics; wt lifting; walking)
• No high impact sports (tennis/jogging)
RHEUMATHOID ARTHRITIS
− Chronic; lifelong; inflammatory disease
(connective &synovial memb) (joints)
− Problem w/ mobility & pain
− Cause: autoimmune
Risk Factors:
• Gender (female); Middle age; Family
history; smoking; obese
S/sx
• Bilateral affectation/ inflammation,
tenderness & stiffness of joins (stiffness
last for >30 mins)
• Low grade fever
• Anorexia, wt loss & anemia, fatigue &
weakness
Diagnostic: ↑ESR
Mgt
• Provide ROM (prevent contractures)
• Balance rest & activity
• Splint/brace affected joint until
inflammation subside (REST)
• Provide heat/cold compress
• Self care (assess need for assistance)
• Occupational therapy/physical therapist
• Encourage independence
• Sit on a high, straight back chair
• Use small pillows & firm mattress when
lying down
• Instruct about prescribed meds
• Instruct importance of follow up visits
w/ HCP
Meds:
• DMARDS (use if NSAIDS is not working)
NSAIDS
• Glucocorticoids
• Gold Salts (↓progression of join
damage) (s/e: rash, pruritus, metallic
taste)
MY NCLEX NOTES 2021
RHEUMATHOID ARTHRITIS
Disease-modifying Antirheumatic Drugs
(DMARDS)
− Slows progression of RA
Ex. Sulfasalazine (GI s/sx) , Methotrexate,
Infliximab (hepatotoxic-monitor liver fxn test;
jaundice)
Azathioprine/Cyclosporine (↓immune),
Hydroxychloroquine (antimalaria; may cause
retinal damage; report visual changes)
Adalimumab (injection- watch out for
numbness, tingling, dizziness, visual prob,
weakness on leg), Anakinra (injection-pain
&pruritus is expected)
Good effects:
• Control of symptoms during period of
emotional stress (prevent inflammation)
• Normal WBC, Platelet, Neutrophil (it
prevent infection)
• Radiological Findings that show no
progression of join degeneration
• An increase range of motion in the affected
joints 3 mos into therapy
Methotrexate
- Anti metabolite/ antineoplastic/anti cancer
- Immunosuppressant (Pancytopenia) – risk
infection; bone marrow suppressant
- Take vaccines (Flu, Influenza) (No live
vaccines)
- Hepatotoxic (No Alcohol)
- Retinal toxicity & Visual problem (have eye
exam every 6 mos)
- Avoid pregnancy while taking this med
*** Juvenile Idiopathic Arthritis (JIA)
Chronic arthritis in children
DMARDS can be use for children
53 | P a g e
 OPEN FRACTURE FRACTURED RIBS HIP FRACTURE ABOVE KNEE AMPUTATION
Mgt Not always Flail chest Cause: Residual leg wrap w/ elastic compression
• Tetanus Toxoid (if >10 yrs since Increase age (frail bones) bandage to prevent edema
last dose) S/sx: Falls *Elevate lower part of the bed, don’t
• Ketorolac • Slow, shallow respiration Accidents elevate the limb only (may cause
• Opioids • Pain especially on inspiration contractures)
• Need to take meds longer Expected
• IV antibiotics Mgt Affected leg – shorter, externally rotated If bandage come off:
• ORIF w/rib plating Pain, fever • Rewrap the residual limb w/ elastic
• Position: High Fowlers Tachycardia compression bandage
Meds
• Cefazolin (Bone antibiotic)
• Cyclobenzaprine (muscle FLAIL CHEST ***Monitor for Hematuria (due to
relaxant/ spasm; pain) Floating section of fractured rib bladder injury)
• Carisoprodol (muscle relaxant/
spasm; pain) S/sx Post- op Mgt
• Paradoxical Chest movt Hip Replacement
• Methocarbamol (muscle
relaxant/ spasm; pain) - Inspiration (fracture move • NO 90 deg flexion
inward) • Don’t sit low (toilet seat)
- Expiration (fracture move • NO bending & tie shoelace
TETANUS TOXOID outward) • NO internal/external rotation
1st Dose – Now - Pain • NO adduction (use abduction
2nd Dose – after 1 month - Dyspnea pillow)
3rd Dose – after 6 months • NO crossing legs
• Sleeping position: Unaffected
***if completed, protected for 10 yrs side
***Booster Dose – given every after 10
yrs

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 FRACTURES FRACTURES HIP DYSPLASIA

Mgt
Hip Spica Cast
− used to keep the ends of a broken
bone (fracture) together so they can
heal correctly. Prevent a bone from
moving after surgery
• Apply waterproof tape to the
cast around genital/diaper area
(for children)
• Use hair dryer on cool setting to
dry cast asap
• Don’t use crossbar (it will cause
damage to the cast)
• Position: High fowlers
• Turn patient supine /prone every
2 hrs

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 FIBROMYALGIA
Pain pressure points in the muscles
Disorder characterized by widespread
musculoskeletal pain accompanied by
fatigue, sleep, memory and mood issues
Mgt
Massage
Duloxetine (muscle relaxant; have anti-
depressant properties)
PARALYSIS DEEP VEIN THROMBOSIS BURSITIS
Flaccid Quadriplegia – four extremities Classic sign: Inflammation of Bursa in the joints
paralysis • Unilateral Leg Pain (Fullness, dull,
achy) Mgt
• One calf larger than other calf • Apply hot and cold compress
***Paralysis due to emotional trauma – • Use ice (not dry ice) for the first
check physiological cause to confirm Others signs: 48 hrs
conversion (somatoform) vs real paralysis • Warmth, Erythema • Immobilize affected site
• Low Fever • Rest affected site on a soft area
Causes:
• Immobility (post surgery)
• Obesity
Hypercoagulability (Postpartum; Post CS;
Cancer)

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 RESPIRATORY NOTES
TUBERCULOSIS TUBERCULOSIS ANTI TB MEDS PNEUMONIA
MOT: Airborne Tuberculin Skin Test (PPD Test) (Mantoux) All Anti-TB meds are hepatotoxic S/sx
Risk Factors - Determine if expose to TB, not to Give on empty stomach • Coarse crackles
• Long term care resident diagnose; Not for active TB pt • O2Sat less than 90%
• Inmate - Positive: >10mm 1st line:
• Productive cough
• IV drug user - *If w/ HIV: Positive >5mm • Rifampicin
• Elevated WBC (Infection)
• HIV • Isoniazid
Gene Xpert (BEST TEST) • Pyrazinamide • ↑ PCO2 (accumulate due to diff
S/sx: - Confirmatory test for TB • Ethambutol breathing)
• Asymptomatic - Sputum (like PCR test) • Tachypnea
• Low grade fever - Result w/n 2 hrs *Rifampicin • Chest pain (due to less
• Dyspnea - Orange urine/sweat oxygenation to heart)
• Night Sweats QuantiFERON-TB Gold Test *Isoniazid • Color of nail beds
• Bloody (Hemoptysis), productive - Confirmatory test for TB - Also given if a person is expose to
cough/chronic purulent cough - Blood specimen active TB pt, take for 9-12 mos
INCENTIVE SPIROMETER
• Cough w/ expectoration of mucoid - Result w/n 24 hrs religiously;
- Pt inhale slowly from the device until
sputum - S/e: Vit B6 Deficiency (tingling &
• Chest pain LATENT TUBERCULOSIS INFECTION numbness of fingers) no longer able, and then hold breath
• Lethargy - Positive Tuberculin skin test (wheal - Hepatotoxic for 3-6 secs and exhale
• Anorexia >10mm w/n 72 hrs) *Pyrazinamide - For deep breathing
• Wt Loss - Asymptomatic - Increases Uric Acid (gout) - Keep record of highest level
- Not communicable *Ethambutol - Wash mouthpiece every after use
Precaution: - Been infected w/ TB for many years - Causes Optic Nerve Inflammation - Perform 10-12x daily while awake
N95 (staff) / Surgical Mask (Patient) but not medicated *Streptomycin
*Pt wears mask if not yet 2 wks of starting ***taking meds that supress immune system - Causes toxicity to Cranial Nerve 8 (Ear
meds (steroids, Prednisone) can reactivate the Toxicity)/ ringing of ear
Tuberculosis *Rifabutin – 2nd line of Anti TB meds
• Activities resume gradually - For active Mycobacterium avium
• Not communicable 2-3 wks after starting SPUTUM TEST complex (MAC) & TB
meds/ 3 negative sputum culture/ s/sx • Rinse mouth w/ water before collecting - S/e:
improvement sputum • Signs of Hepatitis (jaundice)
• Sputum culture needed every 2-4 wks • Be careful not to touch the inside of the • Low Neutrophil count (Normal
once medication therapy is initiated (3 specimen cup or lid Absolute Neutrophil Count:
consecutive negatives for 3 mos should be • Inhale deeply a few times and then cough >1000)
achieve) forcefully (may nebulize w/ NSS to loosen • Ocular pain/blurred vision
• Resp isolation for the family is not thick secretions) (Uveitis- inflame sclera)
necessary after family has been exposed • Position: sitting upright during collection • Flu-like symptom
• Cover mouth and nose when coughing or
sneezing and put used tissues in plastic
bags ***All pt that have BCG vaccine will have
• Take meds religiously, if missed, may lead false positive result in PPD Mantoux test
to multiple drug resistant

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 PULMONARY EMBOLISM PULMONARY EMBOLISM PLEURAL BIOPSY BRONCHOSCOPY
- For Diagnostic/Management
Prevention: Position: Orthopneic (sit upright & lean
Risk Factors INFERIOR VENA CAVA FILTER forward) w/ feet flat on the floor Preparation
• Deep Vein Thrombosis “Green Field Vena Cava Filter” - Invasive; need consent
- Causes: − Placement of net in the Inferior Nrsg Responsibilities - Mild sedation (Lorazepam/Diazepam)
o Endothelial Damage (surgery) Vena Cava; • No unnecessary movement /oral tranquilizer/ Lidocaine spray (so no
o Venous Stasis (due to − Trap/filter thrombus from entering • No coughing/sneezing gag reflex)
immobility) lungs • Local Anesthesia is use
o Hypercoagulability of blood • Make all HCP aware of the filter • Instruct patient to sing/hum/ say Assess after Bronchoscopy: (REPORT)
(ex. Postpartum) prior to any body scans “eeee” (to prevent puncture) • ***Bright red blood mixed w/
o Immobility (Post op pts (c/s, • Stay active; avoid crossing legs for • Bandage after procedure sputum (hemorrhage)
abd surgery; Pneumonia) extended periods • Laryngospasm (check airway)
- Mgt: Sequential • Call HCP if w/ numbness, tingling, Expected
Compression Device; swelling Warm, dry skin Expected
Ambulation • Blood tinge sputum
• Monitor for hemorrhage (chest or Mild pain at biopsy site
• Effects of sedation
back discomfort
S/sx - Absence of gag reflex for up
• Sudden chest pain Complications: to 1-2 hrs (REPORT after)
• Dyspnea Punctured lungs - Headache
• ↑HR S/sx - Respiration and O2 sat
• ↓BP • Dyspnea slightly ↓
❖ AIR EMBOLISM
• Pale • Pallor
• Altered LOC Mgt • Diaphoresis
• Position: Left side/ Trendelenburg • Cough blood
Mgt
- Prevent air entering right side of
• Position: Upright/ High Fowlers
heart and cause air lock
• Oxygen
• Heparin
• Endotracheal Intubation *if
needed

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 CHEST TUBE THORACENTESIS
***Only tape on three sides around the insertion site (to prevent tension hemothorax) - Position: Orthopneic/ Leaning
***When transporting pt w/ Chest tube, lower the chamber than the pt (below insertion forward
site/bed) - No coughing, talking
- Feet (sole) lay flat on the floor
If accidentally remove/dislodge: Apply occlusive dressing (sterile, dry gauze)
Monitor post procedure:
REMOVAL OFF CTT • Level of Alertness- hypoxia,
Do Valsalva Maneuver (hold breath)/ Inhale then Exhale slowly while removing hemorrhage (check lung puncture)
• Lung sounds- check for lung puncture
WATER SEAL • Oxygen Saturation- check lung
If not fluctuating: (2 causes) function
• Blockage (ASSESS: instruct pt to inhale deeply then cough- if no fluctuation, • Respiratory pattern
then there is blockage in the chamber) • Asymmetrical chest expansion &
• Reexpand Lungs (normal)- (if there is fluctuation after coughing, then the ↓breath sounds (Pneumothorax)
lungs have reexpanded, so verify thru xray)
COPD
- Have labored breathing
- Weight loss (loss of calories)
- Due to decrease in O2 in the body
(Hypoxia), it will trigger the bone marrow
to produce more RBC (Polycythemia), and
eventually pt becomes prone to thrombus
formation due to viscous blood
(Thrombocytopenia)
Causes:
• Smoking
• Allergens (Air Pollution)
(Mechanical exposure-carbon
monoxide)
• A1 Antitrypsin Deficiency
(Genetic)- produce in liver (mgt:
liver transplant)
• NOT wt &alcohol& fast food

Mgt
If remove, put • Perform oral hygiene before eating
temporarily in meals (Pt have dry mouth/prone to
plain NSS, mouth ulcers & infection)
don’t clamp. • Pursed lip breathing (to release air
trap) (Inhale for 2 secs thru nose &
keep mouth close, then exhale
thru mouth for 4 secs in pursed lip)
Drainage (always check) • Avoid drinking fluids during meals
(may cause bloating)
• Eat small, frequent feedings
Presence of Label level upon • Diet: ↑calories & protein intake;
gentle, continuous receiving pt. ↓fiber (if pt is bloated)
bubbling in the Report >100mL in 1 hr • Thrombocytopenia & Polycythemia
suction chamber is Check color: Report: mgt (Phlebotomy every other day
normal Bright red 300-500 mL of blood)

Tiotropium (Spiriva)
Check for air leak - For Pneumonia and COPD
- Fluctuate/some bubbles (normal) - Bronchodilator, inhaler
- If continuous bubbles (presence
of air leak in the tube) -Report;
don’t clamp
HENNAJANECE MY NCLEX NOTES 2021 59 | P a g e
 ASTHMA
***During asthma attack
Always assess the severity of the asthma
(use Peak Perspiratory Flow Rate)
Med Mgt
***pt inhales Salmeterol first and then
wait 5 mins before inhaling Fluticasone
• Albuterol (Salmeterol) – short
acting bronchodilator; for
emergency; give first to dilate
bronchi
• Montelukast – to prevent
Asthma attack; not for
emergency
• Steroids – after giving Albuterol;
to manage inflammation
- Hydrocortisone
- Dexamethasone
- Fluticasone propionate
• Omalizumab – anti inflamm; long
term
HENNAJANECE
ACUTE ASTHMA METERED-DOSE INHALER EPIGLOTITIS
- Wheezes (assess the severity of 1. Determine what the client knows Inflammation& Fever
Asthma) about this type of medication.
- No wheezes (dangerous/fatal) – it 2. Wash hands thoroughly w/ soap & Cause:
means close airway warm water • Haemophilus Influenza Type B
3. Insert the medication canister into
Mgt the plastic holder.
4. Remove cap and hold the inhaler S/sx 4 D’s
(If w/o wheezes) upright
• Epinephrine (to dilate airway) 5. Shake the inhaler • Drooling
6. Breathe out slowly through the • Dysphagia (difficulty swallowing)
(If still w/ wheezes) mouth • Dysphonia (muffled speech)
1. Albuterol (give first) 7. Place the mouthpiece into the • Distress Respiration (stridor)
2. Steroids mouth holding the inhaler upright.
8. While breathing in, keep the lips Mgt
***Peak Expiratory Flow Rate should secure around the mouthpiece and 1. Position (upright & Tripod)
increase to determine effectivity of inhale and push top of the canister *PRIORITY
treatment once.
9. Continue to breathe in slowly and as
***MEASURE O2 saturation deeply as you can
Use Spirometer; Pulse Oximeter; Peak 10. Hold your breath for 10 secs, to
Expiratory Flow Rate allow the medication to reach
deeply into the lungs
11. Repeat until desired dose have been
❖ THEOPHYLLINE inhaled (one spray one breath)
Bronchodilator use for Bronchial Asthma 12. Remove the mouthpiece, and inhale
slowly.
Toxic Level: ↑20 mcg/mL 13. Rinse mouth thoroughly w/ water
Toxicity: Arrythmias; Seizure 14. Spit out the water. Don’t swallow
***Extract blood after 30 mins of giving
dose Vaccine
• Haemophilus Influenza Type B
Nrsg responsibilities Vaccine (Hib vaccine)
• Avoid stimulants (caffeine, tea,
chocolates, soft drinks) – ↑CNS
& Cardiovascular s/sx)
MY NCLEX NOTES 2021 60 | P a g e
 CYSTIC FRIBROSIS
CYS “TIC” FRIBROSIS
- Affects pancreas & respiration
- “Thick” mucus overproduction
- Obstruction in the pancreatic ducts
(Amylase, Lipase, Protease)
- Malabsorption (protein, fats, carbs,
ADEK)
S/sx
• Steatorrhea
• Diarrhea
• Cramping
• Flatulence
• Have poor Na absorption during
excessive sweating/hot weather
• Barrel chest
• Pneumonia
• Sinus
• Digital clubbing (poor oxygenation)
Mgt
• Pancreatic Enzymes
Take before meals/snacks
Don’t chew (it needs to activate
only in the duodenum)
Can open capsule & sprinkle on a
tablespoon of Applesauce
Financial needs must be consider
• Diet: ↑ Carb, Protein, Fats,
Calories, ↑Na
• Chest physiotherapy to drain
secretions (lungs) everyday- head
lower than chest
• ↑Fluids (lungs) to thin secretions
• Exercise/sports activities will
tone respiratory muscles
HENNAJANECE
EMERGENCY
While waiting for rapid response team
If w/ airway obstruction (cyanosis,
unresponsive)
1. Position in high fowlers
2. Oropharyngeal suctioning
3. Administer O2 non rebreather
mask
4. Assess lung sounds
5. Notify HCP
Pleural Friction Rub
- Sharp chest pain w/ Inspiration
- Need to REPORT
ARDS NASO PHARYNGEAL AIRWAY
ACUTE RESPIRATORY DISTRESS - Only use in Conscious &
SYNDROME subconscious Pt
- Not for unconscious/semi conscious
- Fluid in capillaries go inside the - To maintain airway patency (if w/
Alveoli severe laceration in the mouth)
- Priority Diagnosis when on Mech Before Insertion:
Vent or pt w/ Pneumonia: • Measure from tip of nose to tip
of earlobe
Impaired Gas Exchange
MECHANICAL VENTILATOR
Reducing Ventilator associated
Pneumonia
• Keep head of bead elevated to at
least 30 deg (prevent aspiration)
• Assess readiness for extubation at
least daily
• Provide oral care w/ Chlorhexidine
solution at lease daily (better than
Bactidol/Betadine)
MY NCLEX NOTES 2021 61 | P a g e
 OXYGEN MASK OXYGEN MASK OXYGEN THERAPY
PORTABLE OXYGEN TANK
CANNULA FACE MASK • Priority: SAFETY (place “NO
- Inexpensive; most comfortable to - Non comfortable smoking” sign at door if at home)
use - Deliver 40-60% O2 • Don’t apply Vaseline to your nose
- Short Term (ex. If pt is given for dryness (Flammable)
Morphine & O2 Sat decrease to • Only use water soluble gel on
89%) nostrils
- Deliver 47% O2 • Must be 5-10 ft away from
flammable object (can’t cook on
gas stove)
• Stay away from electrical wire
• No wool blanket (cause static
electricity)
• Don’t use nail polish
• Not near area w/ soap, detergent
OXYGEN BY NASAL CANNULA
− Only use if pt can breathe in the mouth
VENTURI − Low concentrated/flow oxygen
- Most expensive mask • Humidify the oxygen – prevent
- Gives guaranteed O2 dryness
concentration • Apply water soluble lubricant to
NON-REBREATHER MASK - Best oxygen mask for COPD nares
- Non comfortable • Instruct pt & family about the
- Deliver 90-95% O2 purpose of O2
Fraction of Inspired Oxygen (FiO2)
FiO2= 20% + (4 X oxygen liter flow)
➢ 2 L O2- can deliver 24-28 %
- PaO2: 60-70%
- O2 Sat: 90-93%
➢ 6 L O2- can deliver 44 % oxygen
***If more than 6L of oxygen, use non-
rebreather mask
HENNAJANECE
TRACHEOSTOMY
If suctioning on a conscious client:
- Apply the suction no longer than 5-10
sec
- Normal suction (100-200 mmHg)
- No suction during insertion
- Insert until w/ resistant
- Once w/ resistance, then withdraw
atleast 1cm, then start suctioning
- Wait atleast 1-2 mins between suction
- Neck should touch chin during suction
- Don’t withdraw if pt cough
If pt is alert, oriented, and able to tolerate
oral intake:
- Partially/fully deflate cuff (reduce
risk of aspiration precaution)
- *If suction is needed, suction Trach
first, then suction mouth, then
deflate
If pt is Unconscious & on mech vent:
- Trach tube is inflated
Dislodged Tracheostomy Tube
- Replace w/ sterile tracheostomy tube
using bedside Obturator/hemostat
MY NCLEX NOTES 2021 62 | P a g e
 PLEURAL EFFUSION
− sometimes referred to as “water on
the lungs,” is the build-up of excess
fluid (>15mL) between the layers of
the pleura outside the lungs

S/sx
• ↓ lung expansion in the site of
pleural effusion
• ↓ Fremitus “vibration” (due to
air/fluid)
• Dull Percussion
• Hyper resonant (due to presence of
air)
• ↓ breath sounds (due to air/fluid)
• Atelectasis (lung collapse)

Mgt
• Chest Tube Drainage

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 RENAL NOTES
RENAL ASSESSMENT URINARY INCONTINENCE HYPOSPADIAS URINARY TRACT INFECTION
Assessment Hyperactive bladder; overactive Urethral opening is under − UTI – common bacteria that cause this is
***Stress Incontinence – Uncontrolled leakage − Surgery is done when the child is 6- E.Coli
Urinalysis of urine (when coughing, sneezing) 12 mos − Common in sexually active person;
undergoing frequent catheterization
Color Amber − Delay circumcision (foreskin is use
Cause:
Specific N: 1.010-1.030 • Spinal Cord Injury to cover opening Teaching
Gravity ↑(concentrated; DHN) • Neuro (Parkinson, stroke) • ↑fluids
RBC None • Cystitis (inflammation of bladder) Post op • Void every 2-4 hrs
WBC None Insertion of Catheter stent • Wipe front to back
Protein None REVERSIBLE CAUSE • Placement of catheter stent after • Void immediately after sex
• Delirium surgery (will stay for 1-3 wks) • No douching
Glucose Absent • Restricted Mobility (bed ridden) • To drain & guide urine from • No perineal deodorant products
• Infection bladder • No baths in the tub
• Pharmaceuticals (antidiuretic) / Poly • Maintain patency (priority) • No spermicide (only use for
uric state (frequent urination; possibly diaphragm &cervical cap)
- Urine Output (best indicator of
due to DM)
patency) • Wear underwear w/ cotton crotch
RENAL SYSTEM PHYSICAL ASSESSMENT (no synthetic, nylon, spandex)
“Inspect, Auscultate, Percuss, Palpate” Mgt
1. Advise client to empty the bladder • Decrease weight ***Monogamy sex partner doesn’t guarantee
completely • Anticholinergic - ↓spasm; dry mouth pt cant have UTI
2. Observe skin and contour of abdomen and
(Oxybutynin; Tolterodine)
lower back
3. Auscultate the renal arteries in right and • Avoid irritants (artificial sweetener) ***Priority complication in Elderly w/ UTI
left upper quadrants • Perform pelvic exercise (Kegel) • Confusion – due to ↓blood flow,
4. Percuss and palpate both the right and left • Bladder training/ void every 2 hrs or DHN, Stroke
kidneys more (HIGHEST PRIORITY for Stress
5. Document the assessment of the renal Incontinence) ***NITROFURANTOIN
system function - For infection of bladder / UTI
***Urinary Incontinence r/t Diabetic - Photosensitivity (avoid sun exposure)
Sodium 135-145 Neuropathy (less sensation) - GI irritant (Take medication w/food)
PRIAPISM
Potassium 3.5-5 - Maintain normal fluid intake
Prolong erection; commonly happens w/
- Acute adverse effect
Chloride 96-106 - Encourage pt to bear down while • Pulmonary Reaction (cough, chills,
attempting to void
sickle cell anemia fever, difficulty breathing)
Calcium 8..5-10.5 S/sx
- Inspect perineal area for skin breakdown
Magnesium 1.5-2.5 • Extreme penile pain
- Measure post void residual volume ***URINARY RETENTION
Phosphorus 2.5-4.5 - Tell pt to wait 30 secs after voiding then • ↓ urine output - Creed’s Maneuver
attempt again (Double Voiding) • REPORT: bluish discoloration of Press suprapubic area to assist urine
erect penis (necrosis) drainage (palpate for firmness –
Mgt retention, full bladder)
- Monitor for Hypotension – sudden
• Hydrate & give pain meds drainage of urine after emergency
catheterization
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 RENAL FAILURE ACUTE KIDNEY FAILURE CHRONIC KIDNEY FAILURE CHRONIC KIDNEY FAILURE
ACUTE RENAL FAILURE − Due to untreated Acute Kidney
STAGES OF RENAL FAILURE − Decrease function; ↓ GFR Failure
− Reversible Teaching
STAGES OF CKD • Restrict Sodium & Potassium
1. Initiation – cause stage Causes • Avoid high salty foods (canned)
❖ Pre-Renal 1. Normal GFR (90 & above); • No salt substitutes (have ↑K)
2. Oliguric - ↓GFR - ↓perfusion to kidney (HPN; Proteinuria • Low protein diet
Bleeding; shock; Burns; 2. GFR 60-89 • Avoid eating raw foods (prone to
S/sx ↓ Cardiac output s/t MI) 3. GFR 30-59 infection)
• ↑ BUN ↑Creatinine 4. GFR 15-29 • Monitor I&O (popsicles/ice cream
↑Potassium ↑Fluids ❖ Intra-Renal 5. End Stage Renal Failure- GFR should be counted in intake
↑Phosphorus ↑Magnesium - Damage Nephrons (↓GFR) (↑ <15mL/min because it turns to liquid at room
↓Calcium toxic waste) can’t filter temp)
• Urine output <400mL in 24 hrs - Cause: infection; Injury; drugs S/sx
Mgt (Onco; Aminoglycosides; NSAIDS) • ↑ BP
• ↓Protein; ↓Potassium • ↑Potassium ***REPORT KIDNEY TRANSPLANT PT
• Kayexalate ❖ Post-Renal • ↑ Phosphate THAT HAVE LOW GRADE FEVER AND
• ECG - Blockage, ↑pressure (Hydro • ↑Magnesium GENERALIZED BODY PAINS (systemic
infection due to long steroid use)
• Dialysis Nephrosis) – due to urine • ↓Calcium
backflow • Proteinuria
3. Diuresis – Nephrons recover (↑GFR) - Stone; BPH; stroke • Hematuria
Risk: Hypovolemia; DHN; ↓BP ↓ K • ↑ Creatinine ↑BUN
↓Urine Specific Gravity • Oliguria- expected (indication of
Mgt PD)
• I&O Laboratories (NORMAL) • Pruritis-due to Uremic frost
• Hydrate • No protein in urine (white crystals) ***INTAKE: In recording I&O , count all
• Weigh daily • No blood in urine
• Creatinine: 0.6-1.3 (↑Crea=kidney the foods that are liquid at room
Mgt temperature such as ice cream, Jell-O,
4. Recovery filtration problem)
• Dialysis ice cubes, yogurt, broth, ensure, soup
S/sx • GFR: 90mL/min or above (↓GFR=RF)
• Kidney Transplant (except for pudding)
• Normal GFR • BUN: 10-20 (↑BUN=RF)
• REPORT if pt reports n&v, Note: Ice chips melt to half their
• Normal Urine Output &
headache (hypotension) volume. For example, if the client
Electrolytes
receives 8 oz. of ice chips, record the
intake as 4 oz.

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 BPH
Benign Prostatic Hyperplasia
***BPH is never a risk of Prostate Cancer
Enlarge Prostate; common to >50 yo Male
S/sx
• Acute urinary retention
• Frequent urination
• Difficulty starting urination
• Can’t empty
• Stop & start again
• Weak, intermittent stream
• ↑ urination at night
Mgt
❖ TERAZOSIN (Alpha Adrenergic Blocker)
− Drug of Choice for BPH
− Relax smooth muscle, facilitate
urination; lowers BP
− Effect:
• To increase urine flow
• ↓BP
• Muscle relaxant
− Nrsg responsibilities
• Check BP
• May cause Orthostatic HPN –
rise slowly
• Give at nighttime
TURP w/ Continuous Bladder Irrigation
HENNAJANECE
TURP OPEN RADICAL PROSTATECTOMY ACUTE PROSTATITIS
Transurethral Resection of the Prostate − Open radical removal of Prostate S/sx
− Mgt of Benign Prostatic Hyperplasia − Incision @ lower abdomen • Rectogenital pain
− Trim excess tissue that blocks urine • Urinary
− Non surgical; no incision urgency/hesitancy/burning
− Insert cath to prostate only Post Op
• Lack of Semen (due to removal of
Post op Turp Mgt prostate) Mgt
• ↑Fluid (to flush) • Antibiotic + Anti inflammatory
• ↑Fiber; use stool softener Post Op Responsibilities • Relax bladder & prostate
• Ambulation • ↑Fluids • Alpha Adrenergic (Tamsulosin;
• No Straining; No heavy lifting • No Straining Alfuzosin)
• No long drive • No long drive • Anti Cholinergic (Oxybutynin)
• No sex 4-6 wks • No heavy lifting
• No Aspirin, Ibuprofen, Naproxen Teach
TURP w/ Continuous Bladder Irrigation • Avoid Constipation (use stool
• ↑fluids
Nrsg. Responsibilities softener)
• Ensure drainage patency • Ambulation • No irritants
• Ensure sufficient & continuous infusion • Clean catheter 2x daily w/ warm • Encourage sex & masturbation
rate (NO bladder spasm) water & mild soap (to release urine/fluid from
• No flatus is expected w/n 24 hrs • Tape catheter on upper thigh prostate)
• Blood in the urine is normal • Drainage bag on lower thigh • Use condom
• REPORT: Thick red clots • Stool softener (Docusate)
• REPORT: Irritation s/sx • Hot sitz bath
• Bladder pain (indication of clot;
obstruction) *check Urine output
Mgt: Irrigate w/ NSS until clear
• Drainage should be lower than pt
• Output must be higher than input
(Irrigation + Urine Output)
3-way catheter (taped at lower thigh)
• Irrigation
• Drainage
• Bulb Inflation
***Test Taking: if receiving pt from PACU; if
machine or drip have any problem, always
PRIORITIZE PATIENT (Check patient first)
MY NCLEX NOTES 2021 66 | P a g e
 RENAL CALCULI
Cause: genetic; diet; immobility; DHN
Pain: sudden flank/abdominal w/ nausea
& vomiting
- Renal Colic – flank pain radiates to
costovertebral
- Ureteral Colic – flank pain radiates
to genital
Mgt
• Analgesic at regular schedule
• Hydration (fluids 3L/day)
• Ambulation
• Don’t massage flank
• Strain urine (to know composition of
stones & for dietary modification)
1. Calcium (Oxalate; Phosphate) –
(most common type)
2. Struvite (cause by UTI) – mixture
of Mg & Ammonia
3. Uric Acid
4. Cystine (r/t Ammino acid)
Complication
• Back flow (Hydro Nephrosis)
Meds
• Allopurinol (if Uric Acid stones
• Hydrochlorothiazide (to ↓Calcium)
***Phosphate
Normal: 2.5-4.5
If ↑ (give Calcium acetate to bind w/
Phosphate and excrete Phosphate)
HENNAJANECE
UROLITHIASIS
Stones in the ureter
May lead to Hydronephrosis (overload of
water in the kidney)
Mgt:
• Extra Corporeal Shockwave
Lithotripsy
- Small stones
- Using shockwaves to break stones
- Supine position
- Insert Nephrostomy tube after
• Percutaneous Nephrolithotripsy
- Bigger stones
- Needle insertion
- Supine/Prone Position
- Insert Nephrostomy tube after
• Placement of Ureteral Stent w/
Ureteroscopy
• Analyze the Urinary Stones
• <5mm (give meds)
*Nephrostomy Tube
- After ESL/PNL
- To drain the stones
- To prevent fragment obstruction
and promote kidney healing
- Ensure patent all the time
- Watch out for obstructions
(No drain, flank pain)
Mgt: flush/irrigate small of
amount of NSS)-aseptic
technique
***<5mm stones (size of stones that can
naturally pass through the urine w/o
treatment
ESW LITHOTRIPSY PERCUTANEOUS NEPHROLITHOTHRIPSY
EXTRACORPOREAL SHOCK WAVE − Remove larger stones that can’t be
LITHOTRIPSY removed by ESL
− Insertion of needles w/ sheath to
- Non invasive; break stones >5mm renal pelvis; then Nephoscope is
- Out patient (uses general anesthesia) inserted to break big stones
− Position: Prone
Position: Prone
*Nephrostomy Tube (place after)
Post Op
• ↑ fluids (to flush fragments)
• Expect bruise & flank pain after
(mgt: Analgesic)
• Expect hematuria w/n 24 hrs
• Encourage ambulation
• Report infection (chills&fever)
• Strain urine (to know compositions)
Ureteral Stent
- Protect lining of ureter
- Prevent blockage
- To drain stone fragments
- Insert in urethra, then bladder &
to ureter
- Remove w/n 1-3 wks after
MY NCLEX NOTES 2021 67 | P a g e
 PERITONEAL DIALYSIS
- DWELL TIME: 20-30 mins / depends
to HCP order
- Use Dialysate (warm before infusing
to pt)
- Use peritoneum as semi permeable
membrane
- Aseptic/Sterile Technique
- Position: Fowlers
Factors/Causes of Insufficient Outflow
• Constipation/diarrhea/distention
• Kink/obstruction
• Clot (Mgt: Alteplase)
• Position
Mgt:
• Check level of drainage bag
• Check for kink
• Drainage bag lower than abdomen
• Place pt in good body alignment
• Side Lying Position
• Ambulation
Complications/ Risks:
• PERITONITIS (Infection)
- Painful rigid abdomen
- Cloudy Dialysate output
- Fever & chills
• Wt gain (due to dextrose/glucose in
the dialysate)
• Hernia
• Hypovolemic Shock (↓BP↑HR↑RR)
Mgt:
• Culture & Sensitivity Test **
• Antibiotics
• Check I&O
• Weigh daily
• V/S (BP- may cause hypotension)
PERITONEAL DIALYSIS
EXCHANGE TYPES
1. CONTINUOUS AMBULATORY PD
- 3-5 cycles/day
- 1 long cycle at night
- Can perform ADL
2. CONTINUOUS CYCLIC / AUTOMATED
PD
- Pt hook to machine
- 10-12 hrs at night
- During daytime, not connected to
machine; 1 cycle only
- Can’t perform ADL during cycle
***If pt have sudden dyspnea during PD
1. Stop infusion of Dialysate
2. High fowlers position
3. Drain
***If pt have sudden dyspnea during dwell
time
1. Drain
2. High fowlers position
***PD (promote independence; pt can do at
home)
***HD(done at the hospital)
***If Hemodialysis is missed, pt may possibly
have Hyperkalemia
• ST elevation
• Peak T wave
• Prolong QRS
Mgt: Calcium Gluconate (to immediately
protect pt from dysrhythmia
HEMODIALYSIS
− For ESRD; Drug Toxicity
Assess
• V/S (BP every 15 mins to check
for Hypovolemic shock)
• Weight
• Lung sounds(crackles)
• Heart sounds
• Presence of edema
• AV Fistula patency
- Thrill (palpation)
- Bruit (heard using
stethoscope)
Nrsg responsibilities
• Heparin is added to Dialysate to
prevent clot
• Hold antihypertensive meds (effect
of Dialysis is hypotension)
• Hold Digoxin/ some antibiotics / all
water-soluble vitamins (Vit. B, C)
• Can have Fat soluble vitamins
(ADEK)
• Can have Insulin (fast acting)
• Dialysis can’t excrete Phosphorus,
so give Calcium Acetate so Ph will
bind and will be excreted to the GI
• Monitor for Dialysate Disequilibrium
Syndrome
***BP & Weight – need to check pre &
post dialysis
*Dialysis can lower BP
DISEQUILIBRIUM SYNDROME
Dialysis Disequilibrium Syndrome (DDS)
- Acute neurologic deterioration
attributed to dialysis treatment
- Due to fast dialysis (fast removal of
solutes (toxic waste) in the blood
w/c lead to ↑ Urea in the brain
causing water absorption, then
edema, then ↑ICP
S/sx
• 1st ↑ ICP (Mental Confusion;
Altered LOC
• ↓BP
• ↓PR
• Irregular RR
• Headache
•
Nausea & vomiting
• Seizure
Mgt
• REPORT to HCP (priority)
• Lower the rate of Dialysis

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 ARTERIOVENOUS FISTULA
− AV Fistula – permanent; surgically
attached on brachial forearm;
anastomose (connect artery & vein)
− Wait for AVF to mature (6-12 wks)
before it can be used for dialysis
− Temporary graft shunt (silicon) or IV
w/ 2 needles is use while waiting AVF
maturity
− ***NO puncture/BP/IVF
Expected after creation of AV Fistula
• Bruit – loud swooshing sound
heard upon auscultation
• Thrill – palpate
• 2+ edema of the extremity
• Mild pain on the site (use
squeezing ball for hand grip
exercise)
Arterial Steal Syndrome (danger of AVF)
- Oxygenated from artery is shunted
to vein & mix w/ unoxygenated
blood
• Causes distal ischemia
Pain, pallor, paresthesia (if not
mgt will lead to necrosis)
HENNAJANECE
PERCUTANEOUS KIDNEY BIOPSY
− Obtain kidney tissue to determine
certain kidney disease
− Outpatient procedure
− High risk for bleeding
Before
• Pt need to sign consent
• Hold anticoagulant/anti platelet
• Blood typing for possible blood
transfusion
• BP control (Hold procedure if BP is
not normal)
During
• Position: Prone
After
• Position: Affected side (pressure at
least 30 mins
Monitor V/S every 15 mins for
the first hour
BLADDER PROLAPSE RENAL SYSTEM DIAGNOSTIC TESTING
(Cystoscopy; Blood Culture; Arteriogram)
PESSARY • Report residual urine >100mL after
− To support bladder/uterus/rectum bladder scan
− Non surgical procedure • ↑fluid after arteriogram to flush dye
− Pt can insert/remove (expect ↑urine output)
− Can have sexual intercourse • Urine culture Normal: Less than
− ↑vaginal discharge (normal) 10,000 organisms/mL
− HCP can remove every 2-3 wks if pt
can’t remove it
CYSTOSCOPY
Visualization of bladder
• Pink tinged urine expected w/n
24 hrs
• REPORT: redness; blood clot
• Warm bath & Acetaminophen to
mgt discomfort &bladder spasms
• Frequent & burning urination
expected w/n 24 hrs
• Complication after Cystoscopy
- Hemorrhage
- Infection
- Urinary Retention
MY NCLEX NOTES 2021 69 | P a g e
 GLOMERULAR INJURY ACUTE GLOMERULONEPHRITIS ACUTE PYELONEPHRITIS POLYCYSTIC KIDNEY DISEASE
4 signs Caused by Strep Group A (Skin/Throat) − Bacterial infection causing
1. Proteinuria inflammation of the kidneys and is − Inherited disorder in which
2. Hypoalbuminemia one of the most common diseases clusters of cysts develop
3. Edema (due to ↓albumin) S/sx of the kidney primarily within your kidneys,
4. Hyperlipidemia • Oliguria causing your kidneys to enlarge
• Edema Cause: lower UTI extends to kidney and lose function over time.
S/sx • Hypertension − Cysts are noncancerous round
• ↓ Urine output • Proteinuria S/sx sacs containing fluid.
• Hematuria (Tea colored urine) • Pain (flank radiates to costo − The cysts vary in size, and they
Cause: Idiopathic (Unknown) vertebra) can grow very large
Secondary cause: Mgt • Fever, chills
• Infection to kidney (AGN) • BP Control (ACE or ARBS meds) • Vomiting
• Drug toxicity (antipsych; narcotic) • Diet: ↓Protein ↓Sodium ↓K S/sx
• Acquired immunodeficiency ↓Mg ↑Ca Mgt • Hematuria
1. Obtain blood & urine culture • Flank pain
2. Antibiotic IV • ↑BP
***MOST ACCURATE INDICATOR OF • Proteinuria
FLUID LOSS OR GAIN • Albuminuria
• Daily Weight Measurements
Mgt
• Check Creatinine, BUN

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 HEMOLYTIC UREMIC SYNDROME
− Cause by E.Coli, Salmonella, Shigella
− Hemolysis of blood w/c cause renal
failure
− Can be due to diarrhea that is
caused by E.coli
S/sx
• Triad Symptoms
- Anema
- Acute Renal Failure
- Thrombocytopenia (↓
platelet)
• Hemolysis (bleeding; petechiae)
• ↓Urine output
ILEAL CONDUIT
− Urinary diversion (ureter to ileum)
− Urine comes out in stoma
Nrsg responsibilities:
• Stoma
- Pink or red, moist
- REPORT: Dusky/Bluish
• Pouch
- >0.1 inch (0.25cm) bigger
than stoma
• Use large bag at night to prevent
backflow & infection
VASECTOMY
− Permanent sterilization in men
− Cut Vas Deferens
− Does not affect ejaculation,
consistency, hormone
− Sperm absorb back by body
***Test Semen Sample
Most accurate to determine if already
safe to have unprotected sex
***Use alternative birth control until
cleared by HCP
INGUINAL HERNIA REPAIR
Post-op Mgt
• Elevate scrotum using pillow &
apply ice bag to reduce swelling
• Avoid coughing
• Stand up to use urinal if pt have
difficulty voiding
• Turn in bed & perform deep
breathing every 2 hrs

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CATARACT
− Cloudiness/opaque of eye lens (light can’t
enter)
Causes
• Aging (Senile Cataract)
• Hereditary (Congenital Cataract-inborn)
• Eye Injury
• Diabetes/ Rubella during pregnancy
(Secondary Cataract)
S/sx
• Painless & Blurring of vision
• ↓Color perception
• Diplopia (double vision)
• Absence of red reflex
• Gradual loss of vision
Mgt: No medical mgt; only surgery
• LENS EXTRACTION SURGERY (one eye at a
time) w/ 4wks/1 month interval (OPD)
Pre-op Meds
Mydriatics/Cycloplegics) – dilate
pupils; via eyedrops
Post-op mgt
- Elevate head of bed (ex. 2 pillows),
turn/sleep on unaffected eye on fowlers
position
- Eye patch for 24 hrs
- Avoid activities that require bending over
lower than waist level; No rapid head
movt; avoid sneezing,coughing; lifting
>5lbs;
- Take acetaminophen for minor eye
discomfort
- Eye scratchiness is expected (Don’t rub)
- Report episodes of severe eye pain (sign of
bleeding &↑IOP ) w/ N&V; constipation
- Place eye shield on surgical eye at bedtime
- Eye glasses during daytime
- Contact surgeon of ↓visual acuity occurs
- Take stool softener to prevent straining
- No Valsalva Maneuver (straining)
HENNAJANECE
EENT NOTES
GLAUCOMA
Risk Factors:
Common in Age (↑60yo)/Race (black, Asian,
Hispanic)/Hereditary (Close G)/HPN/DM/pt
w/ Sickle cell anemia)/ nearsighted/
farsighted/long term steroid (via eye drop)
use
Normal IOP: 10-21 mmHg (Tonometry)
TYPES of GLAUCOMA
➢ Acute/Closed Angle – IOP >50 mmHg
- Sudden onset; ↓ drainage of AH
(thick pupil);
- Can be blinded right away; emergency
case;
- Severe eye pain w/ N&V
- Halos around lights
- Tunnel Vision
- SURGERY: Iridotomy (open drainage)
➢ Chronic/Open Angle – IOP >25 mmHg
- Gradual onset; ↑production of AH
- Less pain
- Loss of peripheral vision
- Halos around lights
- Tunnel Vision; have diff adjusting to
dimmed light
- SURGERY: Trabeculoplasty
(↑drainage)
Danger: Irreversible Blindness
GLAUCOMA RETINAL DETACHMENT
Med: − Retina is a blood vessel, w/c
• Betaxolol (beta blocker)/Timolol – supply blood to nerve
↓ production of AH (monitor BP)
• Pilocarpine –Miotics; to constrict pupil
Risk Factors:
to ↑ drainage of AH
• Aging (old)
• Diuretics (Diamox)
• Previous RD history
↓ production of AH
• Near sited (Myopia) pt
• Eye surgery
Contraindicated Meds: • Severe eye injury
• Anti-cholinergic
- ex. Bronchodilators (causes pupillary S/sx
dilation, will cause decrease • Curtain-veil like vision
drainage); Benztropine (Cogentin),
• Floaters of black spots (blood)
Biperiden (Akineton), Artane,
• Flashes of lights
Atropine Sulfate, Benadryl,
• NO Pain (retina no nerve ending)
Mydriatics
- It can further ↑ Intraocular Pressure
Mgt
• Tricyclic Antidepressants • Scleral Buckling (surgery)
- Ex. Amitriptyline, Nortriptyline,
“Pramin” Imipramine
- It can further ↑ Intraocular Pressure
Nrsg Responsibilities:
• Avoid activities that can cause ↑IOP
- Coughing; heavy lifting; bending >90deg
POST OP • Post op Mgt
• Watch our for-eye pain, N&V - Position: elevate head 30-45
deg on non affected side
- Eye patch for 24 hrs
- Eye glass/shield
Patches: - No rapid eye movt
• One Eye: (Cataract/Glaucoma)
- No coughing, sneezing,
• Two Eyes: (Retinal Detachment)
blowing straining, bending
***Normal Pupil Size: 3-5mm below waist
- Watch our for-eye pain, N&V
***Crying doesn’t increase IOP
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 EYE INJURIES
❖ Foreign Obj
- Is it floating/embedded?
- (Floating mgt: Irrigate eyes)
- (Embedded mgt: Eye patch)
❖ Penetrating Obj
Punctured Eye (object inside eye)
Mgt:
- 1st Cover w/ cup (w/ hole at
bottom)- to stabilize the obj
- Cover other eye – to prevent
movement
- Bring to hospital immediately
Eyes hit w/ object
- Mgt
Apply ice to affected eye
❖ Chemical Eye Injury
- Irrigate (position on affected side
so the chemical won’t affect the
unaffected eye)
HENNAJANECE
EYE DROPS EYE ASSESSMENT ORAL SURGERY
- Check any history for heart
1. Wash hands Normal: 20/20 problem (ex. Congenital heart
2. Put gloves on *20/200: acceptable criteria for blindness disease; presence of prosthetic
3. Instruct pt to tilt head backward, valve)
open the eyes, and look down Snellen’s Chart (Visual Accuity) - Assess risk for bleeding (INR <1.1
4. Pull the lower lid down against - 20 ft distance from the chart if not taking Warfarin; 2.0-3.0 if
the cheekbone - Test Right eye, then Left eye, then w/ Warfarin)
5. Hold bottle like holding a pen both
6. Wrist should rest on the cheek - w/ or w/o contact lens during
bone procedure
7. Place the drop in the - OD (right) OS (left)
Conjunctival sac (Lower
conjunctival sac, not on iris (black
part), may cause blindness
8. Instruct pt to close eyes gently
MY NCLEX NOTES 2021 73 | P a g e
 MENIERE’S DISEASE
“Endolymphatic Hydrops”
− Accumulation of fluids @ middle ear
(Cochlea)
− Imbalance in the Endolymphatic
Fluids that affects CN 8
− Affects Balance &Hearing
− Patient can travel via airplane (high
cabin pressure equals to high
pressure in the inner ear)
− Cause: Unknown (& no cure)
Risk Factors
• Family History
• Viral Infection
• Stress
• Allergy
• Age 30-60 yo
3 major s/sx
• Vertigo (out of balance; prone to
injury) SAFETY PRIORITY
Nausea, vomiting, drop attacks
• Hearing loss (sensorineural)
• Tinnitus (ringing ear)
• Nystagmus (rapid eye movt)
• Headache
Meds: (only to control)
• Antivert (Meclizine/Bonamine)
• Antiemetics
• Diuretics
HENNAJANECE
MENIERE’S DISEASE OTOSCLEROSIS EAR IRRIGATION
SAFETY Mgt (Priority) To remove impacted cerumen
• Lower bed; Padded side rails - Abnormal bone growth around one of
• No sudden movt (move slow) the three small bones in the middle Position during: Sitting (place ear basin)
• Promote rest; quiet room, dark ear space called the stapes Position after: Affected side (to drain
• No flickering light/TV; No loud - Mgt: Stapedectomy (removal of irrigation & impacted cerumen)
noise damage stapes & replace it with
• No smoking, caffeine a prosthetic device to restore hearing) • Wash hands before
• Diet: ↓Na/ ↓fluid intake • Warm irrigating solution to a
• Assist pt in ambulating Nrsg responsibilities temperature close to body temp
• Report if acute vertigo occurs • Direct a slow, steady stream
Surgery • Delay air travel for at least 1 month irrigation solution toward the
• Labyrinthectomy (high cabin air pressure cause pain) upper wall (ear wall) of ear canal
- To eliminate vertigo attack • Lie on unaffected side
- S/e: Lifelong deafness on • Sneeze on one nostril at a time
affected ear while mouth is open ***EAR DROPS
- Post-op: Position: Side lying
- Maintain ear pack
- Position: Unaffected side
- Avoid the ff:
Strenuous activities (cough,
sneeze, strain)
Air travel
Drink w/ straw
Wash hair/shower (keep ear
dry)
- Can blow nose but one at a time
HEARING LOSS
- Speak at a normal volume while
facing client directly (in front of pt)
- Before talking, limit environment
noise (close door, window) (open
lights)
- Repeat until pt understand
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CANCER SIGNS
• Change in bladder/ bowel
• A sore that never heal
• Unusual Bleeding
• Thick lump
• Indigestion/Hard to swallow
(Dysphagia)
• Obvious wart/mole change
• Nagging cough/hoarseness of voice
• Unexplained Anemia (Pernicious)
• Severe weight loss
***CANCER CELLS
- Rough/irregular edge; immobile;
hard; fix; no pain
- ***Late signs: pain/
peau d’orange (orange peel)
LYMPH NODES
- Usually not palpable
- Normal: 0.5-1 cm
- Non tender
- Mobile
PERNICIOUS ANEMIA – a condition in
which the body can’t make enough
healthy red blood cells because it doesn’t
have enough vitamin B12
HENNAJANECE
ONCOLOGY NOTES
RADIATION THERAPY BRACHYTHERAPY CHEMOTHERAPY
- Damage DNA of cells (Hemolysis)- Tumor Lysis - Internal Radiation (for
Syndrome cervical/endometrial cancer)
- 1st Affects highly rapidly proliferating cells (oral - Emits radiation near tumor Common S/e of CHEMO
to GI, bone marrow, cancer cells) - Place in the cervix/ uterus endometrium • Alopecia
- S/s of Radiation Exposure - Stay in place for 24-72 hrs inside the • Oral Mucositis
• Low blood cell counts body • ↓Hemoglobin
• Oral mucosal ulceration
• Persistent vomiting
• Vomiting & Diarrhea ❖ TIME • ↓Potassium
❖ DISTANCE
❖ Mgt for head &neck therapy
❖ SHIELDING
• Frequent oral hygiene, before/ after meal &
Filgrastim
at bedtime (Soft bristle brush; gentle/careful
dental floss) • Time: 30 mins/ shitft (nurse/ staff time - It increases WBC Component
• Can rinse mouthwash (non-alcohol) in the room; cluster care to limit (neutrophil count)
• Gargle NSS, baking soda exposure)
• Encourage to sip water • Shielding: Dosimeter Film Badge Cisplatin
• Xerostomia (water soluble lubricant/ use • Use lead apron - Monitor renal function (BUN,
artificial saliva for dry mouth) • Distance: 6ft (nurse to pt, and also Creatinine)
• Mgt Mucositis (inflammation of mouth, teach family to maintain this distance
esophagus, oropharynx) from pt) ***Uric Acid – toxic waste from chemo
• Use Palifermin for anti-inflammation not for • Private room w/ “Radioactive Hazard” - Give Allopurinol to prevent toxic
oral pain signage waster to be converted to ↓ Uric Acid
• Avoid irritants (caffeine, spices, carbonated
• Bedrest (no standing, walk or sit)
drinks, acids, smoke, alcohol)
• Keep the door close (radiation
• Use topical analgesia (lidocaine) to manage
pain to increase oral intake constantly emitting from the client)
• Encourage liquid nutritional supplements • Not for pregnant staff NEUTROPENIC PRECAUTION
(liquid ensure) (throat cancer) • Not for visitor <18 yo − NORMAL: 2,200- 7,700
− ANC <1000 mm3
❖ Mgt for skin − (Normal Absolute Neutrophil Count:
• Supportive, loose, non-tight-fitting cotton Dislodge Radiation Implant >1000 mm3)
cloth; only pat dry when using towel - Use long handled forceps and place in a Mgt
• Avoid sun exposure (only cool & humid lead container • Private room
environment) (wear long sleeves, hats pants, - Contact radiation therapist & radiation • HEPA room/ Positive pressure
SPF 30 & ↑); avoid tanning/sunbath safety officer • Wear mask; apply lotion to prevent
• Avoid chlorine, salt exposure (irritating) skin crack and infection
• Avoid extreme temperatures (hot/ice) • Avoid eating raw fruits/
• Can use deodorant (no fragrance) vegetable/meat(undercook); no
***TELETHERAPY (External Beam Radiation)
• Don’t use cream/lotion/oil/powder (unless
• GOAL: prevent infection/promote healing gardening
approved/ prescribed/recommended w/ Vit.
• Don’t remove ink markers • Avoid standing water
E & D)- NOT over the counter
• Don’t apply bandage/tapes on treatment
• Use mild soap (no fragrance) & tepid
/lukewarm water to clean affected area area
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 CERVICAL CANCER
Risk Factors
• Human Immunodeficiency Virus
• Human Papilloma Virus (warts,
HPV strain 16 &18)
• Multiple sex partners
• Sexual activity before age 18
• Weak immune (HIV)
• Oral contraceptive
• Tobacco use
• Low socio-economic status
***21-28 yo – Pap smears every 3 yrs
***HPV Vaccine – usually done at 12-14
yo; as early as 9 yo
*** Human Papilloma Virus – most
common STD
❖ OVARIAN CANCER
Classic sign
• Pelvic Pressure
• Pelvic Pain
• Asymptomatic during early stage
• Diagnose at late stage
HENNAJANECE
BREAST CANCER
Risk Factors
• Nulliparity
• Genetic (heredity)
• Genetic Mutations in the BRCA1
&BRCA2
• Menarche <12 yo
• Menopause >55yo
• Wt gain post menopausal
• Oral contraceptives(E+P)
Teaching
REPORT: Breast changes unrelated to cycle
(malignant)
Trastuzumab (Herceptin) –
- antineoplastic / treatment for cancer that
is Human Epidermal Growth Factor
Receptor 2 (HER2);
- for breast / stomach cancer
- Cardiotoxic (monitor for irregular apical
pulse/arrythmia)
TAMOXIFEN (taken 5-10 yrs if w/Breast Ca)
- Antagonist: Blocks estrogen that causes
breast cancer,
- Agonist: But ↑ the estrogen in the uterus
(causing thickening- ↑menstrual
bleeding/ Uterine cancer)
- Has thrombolytic effect (monitor for
bleeding, DVT, stroke, embolism)
- S/e
• Menopausal symptoms
o Vaginal Dryness
o ↓ Libido
o Hot flashes
• Flu-like symptoms is expected
FIBROCYSTIC BREAST CHANGES
- Cyst, lump, benign, mobile
- Related to Estrogen
- Resolve after menopause
BREAST CANCER MASTECTOMY
− surgery to remove a breast. Sometimes
JACKSON PRATT BULB DRAIN other tissues near the breast, such as
− 2 closed-suction; to prevent lymph nodes
accumulation of blood on
❖ Radical mastectomy is a surgical
surgical site
procedure involving the removal of
− Normal drainage in 24 hrs
breast, underlying chest muscle
• 80-120 mL (including pectoralis major and pectoralis
• Serosanguineous minor), and lymph nodes of the axilla
− REPORT: bright red drainage & • Need to wear thick mitt hand covers
or use thick pot holders when
>120mL (hemorrhage)
cooking and touching hot pans
− Empty 4-12 hrs or ½ or 2/3 full
(affected area has poor wound
− Pull plug & pour drainage on healing)
measurable cup • Wear gloves when doing gardening
− Squeeze bulb from side to side • Inform all other HCP that the pt have
after draining this surgical procedure
− While compressing, clean spout • No bp or blood drawn on the
w/ alcohol & replace plug affected arm
• Use electric razor not straight
LYMPH EDEMA
- Common complication after
Mastectomy
- Fluid accumulation at soft tissue
(arm, hand, breast)
- Painful & heavy feeling
Mgt
• Massage area to distribute fluids
• Use intermittent pneumatic
compression sleeve (↑compression
on distal from site; ↓compression
on proximal/near site)
• Elevate arm above the heart after
surgery to prevent Lymph Edema
• Perform isometric exercise/ static
exercise (contract muscles)
• NO puncture and BP taking on
HEMOVAC affected side
• Avoid receiving vaccinations in
affected arm
• Prevent injury/infection (area is less
sensitive, prone to burns)
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 COLORECTAL CANCER UTERINE / ENDOMETRIAL CANCER HODGKIN LYMPHOMA TUMOR LYSIS SYNDROME
Risk Factor − Uterine Hyperplasia (thickening) − Cancer of the lymph nodes - Destruction of Cancer cells (including
• 50 yo Male due to estrogen good cells)
• History of Ulcerative Colitis Two Types of Lymphatic Cancer: - May lead to kidney Injury
• Genetics S/sx 1. Hodgkin Lymphoma o Potassium & Phosphate
• Polyps • Hallmark sign is Heavy menstrual/ - Predictable metastasis production (binds w/ Ca so
• Obesity uterine bleeding - Reed Sternberg Cells Calcium will be excreted)
• Smoking • Lower back/ abdominal pain 2. Non-Hodgkin o ↓Ca
• Diet that causes Colon Cancer o Hyperuricemia (toxic waste)
- High Fat, Protein (ex. Meat Risk factor: Classic signs (Hodgkin Lymphoma)
(red-beef) • BRCA (breast cancer gene) • Lymph nodes (painless, enlarged Mgt
- Low Fiber • History of Polycystic Ovary >1cm) in the neck, underarm, • Allopurinol- excrete Uric Acid (toxic
Syndrome groin waster of cancer cell destruction)
S/sx • Obesity • Fever (usually don’t have chills) • IV Fluids NSS- to flush
• Abdominal Pain • Anovulation (History of unsuccessful • Weight loss • Sevelamer 3x daily w/ meals – to
• Blood in stools Infertility treatments; PCOS) • Night sweats bind w/ Phosphate and excrete to
• Change in bowel habits • Early/late menarche • Itching the stool
• Low hemoglobin level • Tamoxifen use • Fatigue • Loop Diuretics- to excrete
• Unexplained weight loss • Estrogen-only pills w/o Potassium (toxic waste of cancer
progesterone (causing uterine cell destruction)
hyperplasia) • Kayexalate- to lower Potassium
Diagnostic Test: level
• Occult Blood Test yearly
• Colonoscopy Every 10 yrs

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 PAPANICOLAOU TEST BLADDER CANCER ORAL CANCER PROSTATE CANCER
“PAP TEST” − Squamous cell carcinoma (non Can metastasize to lymph nodes, liver,
− A procedure in which a small brush or healing lesions) lungs, bones
spatula is used to gently remove cells Classic sign:
from the cervix so they can be checked • Painless Hematuria S/sx Non-modifiable Risk Factors:
under a microscope for cervical cancer • Leukoplakia (white patches in the • African American Male
or cell changes that may lead to cervical Cause mouth) • Genetic/ First degree relative
cancer • Tobacco Use - #1 most common • Mouth bleeding • ↑50 yo
cause • Change salivation
Done at 21-29 yo • Dysphagia Avoid (modifiable risk factors)
Test every 3 yrs • Red meat
>65yo – no more Pap test needed Risk Factors • Animal fats
• Alcohol/tobacco • Dairy products
• Avoid sexual intercourse 24 hrs • Poor oral hygiene • Refined carbohydrates
before test (to avoid inflammation) • Chronic irritation (ex. Unfit • Low fiber
• Result is not accurate if pt have dentures) • Obesity
Diaphragm/Cervical Cap • UV light (ex. Tanning,
• Contraindication for Pap Test sunbathing) Diagnostic Test
- Menstruation • Oral sex • Biopsy
- Douching • Prostate Specific Antigen (PSA)
Vaginal hygiene spray - Normal: < 2.5 ng/mL
- Elevated: Prostate Cancer

***NSAIDS protect against Colorectal &

Prostate Cancer

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ANAPHYLACTIC SHOCK
S/sx
• ↓BP
• Dyspnea
• Lightheadedness
• Skin rash (hives)
• Cardio Edema
• Upper airway edema
• Stridor/ hoarseness
• Bronchospasm
• Wheezing
Mgt
FOR DRUG REACTION HOSPITAL SETTING
1. Stop infusion &call for help
2. Assess airway patent / O2
3. Give IM Epinephrine & Start IV NSS
4. Administer Diphenhydramine IV
5. Monitor V/S for changes
• Stop infusion &call for help
• Assess airway patent / O2
• Give IM Epinephrine & Start IV NSS
• Administer Bronchodilator (adjunct)-
Albuterol
• Anti-histamine- Cetirizine, Benadryl
• Corticosteroid- Solucortef, Prednisone,
Dexamethasone
• Monitor V/S
• Remove inject stinger
• Epinephrine every 5-15 mins IM
• Recumbent, elevate legs (position on the
side); Lower the head of the bed
• Maintain BP
• Cricothyrotomy (Tracheostomy)
• Call for Rapid Response Team
EMERGENCY NOTES
LYME DISEASE
Bitten by tick
Drug of Choice
Doxycycline- antibiotic for 2 wks
- Avoid woody, grassy areas that
may contain ticks
- Start antibiotic immediately
- Blood test 4-6 wks after bite to
detect the presence of disease
- Remove ticks using Twissor
BED BUGS
• Entire house must be treated by
pest control
• Concentrate on alleviating
scratching as it can cause further
complications
• Everyone is at risk
• Can be found anywhere, not just
in the bed
DUST MITES
• Vacuum carpet daily
• Wash bed linens in hot water
once a week (most common
source of dust mites)
WEST NILE VIRUS DISASTER/ CRISIS
− Transmitted to humans by bite of mosquitos that Assure the needs of pt or victims
has fed on infected birds (Flavivirus)
− Originated in Uganda Africa. Common in US,
Israel, Canada & Mexico During disaster, priority is evacuating as
many as you can
− Also called Airborne Encephalitis (inflammation &
encephalitis of BRAIN) Triage only after the disaster
− Incubation: 3-14 days
Focus on RED (urgent/immediate/ high
− Other routes of transmission: transplant,
survival
breastfeeding, blood transfusion
S/sx • RED – high survival rate; need
• Seizure attention now (ex. Bleeding
• Nausea & Vomiting
profusely in the leg ; not a priority if
• Stiff neck
• Altered LOC major arteries like carotid)
• Fever • YELLOW – can’t walk long
• Rash; swollen lymph nodes • GREEN – walking wounded
• + Kernig’s & + Brudzinski sign • BLUE – less survival rate/ dying
• Hepatomegaly; Splenomegaly
• WHITE – bruises/ scratches
Mgt
• SAFETY: Seizure prec
• Supportive therapy (no cure)
• ↑ Fluids
• Rest
• Anti-pyrectic
• Monitor signs of ↑ICP
• Report suspected case to local& state
health dept
Diagnostic
• MRI; CT scan; Lumbar Puncture
Teaching
• No touching dead birds w/o gloves
• Insect repellent
• Ways to stop mosquitoes from breeding
• Avoid wearing bright colors, highly scented
perfumes, deodorant, hair products, which
can attract mosquitoes

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 EPINEPHRINE PEN CPR BURNS FIRE
st
Steps of administration 1 Basic Neurological Assessment Emergent Phase
1. Pull blue safety release “Hey are you okay?” • ↓Na Mgt
2. Firmly press orange tip against outer • ↑K 1. Rescue/ Remove pt from the room
2. Activate alarm
thigh so it clicks (90-deg angle) Compression • ↑ Glucose
3. Contain Fire (close doors/windows
3. Hold for 10 seconds − Heal of Hand • ↑ Hematocrit (due to ↓fluids-
after removing pt out)
4. Seek emergency medical care − Between nipples, center of chest leakage; mgt: monitor U.O at 4. Evacuate/ Extinguish
− Rate: 100-120/min least 30 mL/hr
***even with clothing − Compression: 30 FIRE EXTINGUISHER
***If first dose does not improve pt − Depth/Pressure: 2-2.4 inches 1. Pull the pin
condition, repeat IM Epi Inhalation Injury (Burned face &chest) 2. Aim at the fire
***Go to the hosp after 1st dose • Carbonaceous sputum (brown; 3. Squeeze
Airway
***Don’t store device in extremely hot or involve lung injury) 4. Sweep sideways
− Head tilt/ chin lift
cold temperature − Except of suspected spinal injury • Hair singeing (partially burned)
***FIRST action if there is fire in the lower
***No skin preparation needed (use jaw-thrust maneuver) on head & nose
floor: Turn off O2
• Bright red lips ***Small fire – 1st Extinguish
Expected Breathing • Hoarse voice ***Small fire w/ full smoke –
Rapid heartbeat & palpitations & dizziness • Tachycardia
− 2 Rescue Breaths 1st Rescue/remove
Mgt: 100 % O2 conc (Venturi Mask)
Allergens *If mouth is full w/ injury or blood, blow
Food (nuts, seafood, seashells) to the nose
Medication (antibiotic, B-lactam)
❖ CARBON MONOXIDE POISONING
Insects (Bee)
S/sx
CPR on Infant (to assess • Dull headache
Removing Bee Stingers pulse/circulation) • PaO2 ↓
• Scrape using flat card •
• <12 mos – use Brachial Pulse Carboxyhemoglobin level ↑
• Don’t use twizzors – it will squeeze • Dyspnea
• >12 mos – Carotid Pulse
more the venom • Blurred vision
• Weakness
• Nausea & vomiting
***Immediate action if a pt is found: • Confusion
UNCONSCIOUS • Dizziness
1st Basic Neurological Assessment • Difficulty breathing
SHOCK “Hey are you okay?”
Position: Flat on bed Carboxyhemoglobin Level
PRIORITY: Airway & oxygen (Check for UNCONSCIOS (NO PULSE) - Pollution/carbon monoxide
hypoxia) 1st CPR - Normal: less than 5%
Contraindicated: Raising legs above level - If smoker: less than 10%
of the heart

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 POISON LATEX ALLERGY CHOKING CHOKING
*Ask parents of a child to bring container Risk Heimlich maneuver
to know the substance in the hospital; and • Exposure to balloon
to identify the Antidote • Multiple allergies Infant- tap at the back
Ex. Zonrox (Antidote: Milk) • Spina Bifida

***MAKE SURE TO PLACE ALL MEDICINES w/Latex

&CHEMICAL ON AREA OUT OF REACH OF • Gloves
CHILDREN, AND PLACE A LOCK • Catheter
• Tapes

ASPIRIN INTOXICATION Avoid if pt is allergic to:

Mgt • Banana
➢ Activated Charcoal (Black • Avocado
powder) (charred wheat bread) • Chestnut
mixed w/ Chilled NSS • Kiwi
- To neutralize the substance
& prevent harm

- Gastric Lavage/Aspiration is not

anymore use

- Excreted thru the stool

- Syrup of Ipecac (induce vomiting)

is not use because it may cause
aspiration (Ipecac is toxic esp if
child can’t vomit it out after so it
will stay inside the body)

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 FUNDA NOTES
REPORTING FORMAT DOCUMENTATION ADMISSION STERILE TECHNIQUE
HCP receive important infos immediately ❖ Voluntary
S Situation Key components: • Pt willing to get medical 1. Explain the procedure to the
B Background • Confidential treatment client.
A Assessment • Organized • Pt can sign consent 2. Wash hands.
R Recommend/Request • Accurate • Pt have right to refuse 3. Set up a sterile field.
• Complete treatment 4. Don clean gloves to remove the
• Timely • Pt can go home after signing old dressing
• Subjective & Objective Data Home Against Medical Advise 5. Don sterile gloves, clean the site
as prescribed, and apply a new
dressing.
❖ Involuntary 6. Document the characteristics of
• Pt not willing to get medical the wound.
treatment
• Pt can’t attend to physiologic
DR’S ORDERS NEEDS CLARIFICATION needs LPN – sterile dressing
1. Call the Health Care Provider • Pt have high suicidal risk/ harm UAP – clean dressing (can perform sterile
2. Refer to Nursing Supervisor (If to self & others (ex. Severe dressing if the UAP is a nursing student,
HCP is not around, or if HCP insist schizo) and was taught at school about sterile
a wrong order) • Pt can’t consent (nearest kin technique; and if allowed according to
relative can sign the consent / the hospital policy)
caregiver)
• Pt have no right to refuse
treatment
• Pt needs to be admitted atleast
72 hrs

HENNAJANECE MY NCLEX NOTES 2021 82 | P a g e

 URINE SAMPLE
MIDSTREAM URINE SAMPLE
Clean Technique
• Clean perineum from front to back
• Don’t douche prior to procedure
• Collect the urine in cup midstream
of the urine
• Collect specimen in the morning,
upon awakening
24 HOUR URINE SAMPLE
1. Ask pt to void, discard the 1st
specimen, and note the start time.
2. Keep all the specimen in the ref/ice
box
3. Ask pt to void 15 mins before time
ends
4. Once completed after 24 hrs, bring
all specimen to the laboratory
HENNAJANECE
INDWELLING FOLLEY CATHETER
PROCEDURE
A. Ready equipment
B. Explain procedure
C. Provide privacy/curtain & adequate
lighting
D. Positioning
o FEMALE (dorsal recumbent w/ knees
flexed & feet about two feet apart.
Cover upper body & each leg. Place
catheter set between legs)
o MALE (supine position. Drape pt so
that only area around penis is
exposed. Place cath set next to legs)
INSERTION TO MALE PATIENTS
1. Wash hands
2. Cleanse genital & perineal areas w/
warm soap and water. Rinse and dry.
3. Wash your hands carefully
4. Open sterile cath kit using sterile
technique
5. Put on the sterile gloves
6. Open sterile drape and place on the
patient’s thighs. Place fenestrated drape
w/ opening on the penis
7. Apply sterile lubricant liberally to the
catheter tip. Lubricate at least 6 inches
of the catheter. Leave the lubricated
catheter on the sterile field
8. Pour antiseptic solution over the cotton
balls
9. Place urine specimen collection
container w/n easy reach
10. Grasp the penis between thumb &
forefinger of non dominant hand.
Retract the foreskin of an uncircumcised
male. The gloved hand that has touched
the patient is now contaminated.
11. Use forceps to hold cotton calls. This will
maintain sterility of one hand. Using
forceps, pick up cotton ball and
INDWELLING FOLLEY CATHETER
12. swab the center of meatus outward in
a circular manner.
13. Continue outward, using a new cotton
ball for each progressively larger circle.
Clean the entire glands. Deposit each
cotton ball in the disposable bag. After
the last cotton ball is used, drop
forceps in the disposable bag
14. Hold penis at 90-degree angle.
Advance catheter into the pt’s urinary
meatus. You may encounter resistance
at the prostatic sphincter
15. Pause and allow the sphincter to relax
16. Lower the penis and continue to
advance the catheter
NOTE: never force the catheter to advance.
Discontinue the procedure if the cath will not
advance or patient has unusual discomfort.
Get assistance from the charge
nurse/physician)
SUMMARY
1. Gently insert the tip of the prefilled
syringe into the urethra and instill the
lubricant.
2. Ask the patient to bear down as though
trying to void, as she slowly inserts the
end of the catheter into the meatus.
3. Continue to insert the catheter about 7
to 9 inches (17 to 22.5 cm) or until
urine flows.
4. When urine appears, advance the
catheter 1 to 2 inches (2.5 to 5 cm)
more.
5. Hold the catheter securely with
dominant hand while the urine flows.
6. After urine flows, stabilize the
catheter’s position in the urethra and
use the other hand to pick up the
saline-filled syringe and inflate the
catheter balloon w/ 10cc NSS
7. Slightly pull until balloon is lock in
urethra
MY NCLEX NOTES 2021
INDWELLING FOLLEY CATHETER
• Sterile technique
• Clean the area around urinary
meatus (front to back) before
inserting catheter
• Lubricate catheter before inserting
• Insert: until there is urine flow then
insert additional 2.5 cm (area of
bladder)
• Inflate balloon w/ 10 cc NSS
IFC Indication
• Urinary retention/obstruction
• Strict I&O monitoring
• Medically indicated to pt
• Pre-op procedure
• Prolong immobilization (bedridden)
• End of life comfort
• Promote healing (Perineal/Sacral
wound)
• NOT for convenience
***Catheter must be change w/n 72 hrs]
• ***Limit the use to effectively
reduce incidence of catheter-
associated UTI
***NO URINE AFTER INSERTION
- Leave catheter (serve as
landmark to prevent inserting
again in the wrong hole) and
insert new catheter higher up in
the perineal area
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 ASSESSMENT HYPERTHERMIA PULSE OXIMETER ABG INTERPRETATION
- Measure Hgb on tissue capillaries STEPS TO INTERPRET ABG
❖ Capillary Refill S/sx - Light absorbed by oxygenated Hgb 1. Know PH Value / Base Excess
Normal: 2 secs • ↑ Temp - False result due to interference 2. Look Partner
Abnormal: +1 & 0 • Chills (mgt: cover w/ blanket; - Ex. Dark nail polish; cold extremities;
Normal
don’t do tepid sponge bath if w/ hypotension; peripheral arterial
↓AC
chills) disease PH 7.35-7.45
↑ALK
- Common sites (earlobe, nose, ↓ ALK
❖ AUSCULTATION Mgt forehead, finger tips, toes) PaCO2 35-45
↑ AC
Normal Breath Sounds • Cover w/ blanket if w/ chills Normal: 95-100 % ↓AC
HCO3 22-26
− Vesicular • Increase fluid intake w/ COPD: 88-92 % ↑ALK
− Bronchovesicular • Avoid activities that will cause PaO2 80-100
− Bronchial dehydration • Make sure tissue/skin not Base Excess
compromised *More accurate
• Stay in cool environment ↓AC
• Place on non edematous areas than PH -2 to +2
• Position: Sitting/Upright • Monitor voiding for adequacy of ↑ALK
*If given, don’t
• Use diaphragm of stethoscope urine output • Not on area w/ poor circulation (ex.
use PH
• Placed the stethoscope directly on Peripheral vascular disease-affects
the skin (warm prior) extremities) ❖ Uncompensated
• Ask pt to breath slowly & deeply - Buerger’s disease (also known - Either HCO3/PaCo2 is NORMAL
through the mouth as thromboangiitis obliterans)
affects blood vessels in the ❖ Partially Compensated
body, most commonly in the - Both HCO3/PaCo2 is ABNORMAL
arms and legs. Blood vessels
swell, which can prevent blood ❖ Compensated
flow, causing clots to form. - Normal PH / Base Excess
***BED BATH - Raynaud’s disease limit blood
Partial Bed Bath supply to fingers and toes, METABOLIC ACIDOSIS
Bathe the body parts that would cause which may get pale, cold and • Diarrhea
discomfort or odor if left unbathed numb • Ketoacidosis
• Lactic Acidosis
• Renal Failure (nephritis; hemodialysis)
• Salicylate Toxicity
• Hyperemesis Gravidarum

METABOLIC ALKALOSIS
• Vomiting (acid will be expelled)

RESPIRATORY ALKALOSIS
• Hyperventilate

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 SPINAL ANESTHESIA CENTRAL LINE
Drawing blood from central line
− Regional Anesthesia
− Insert between L2& L3/ L3&L4 (in • Perform hand hygiene (to
the CSF Subarachnoid space) prevent transmission of
infection)
Effect: • Use disposable gloves (to prevent
• Cause temporary weakness & transmission of infection)
paralysis of lower extremities • Scrub Catheter hub w/
antiseptic/ 70 % Alcohol prior to
Nrsg responsibilities: use (to prevent transmission of
• Expose vertebrae (assist pt to infection)
Flex/Fetal Position) • Discard 6-10 mL of blood drawn
• Report if pt have weakness on the from the line
lower extremities prior to • Flush the line w/ sterile normal
procedure saline before & after collection
(to remove clots & flush previous
To know if Anesthesia has worn off: drugs)
• Sensation has resumed • Place Specimen in biohazard bag
• Pt can move lower extremities (clean bag prio to use w/ 70%
Alcohol) (to prevent transmission
of infection)
• Transport immediately to
laboratory to prevent lysis
SUBCLAVIAN VENOUS CATHETER
• Flush unused lumens of CVC w/
2-3 mL (200-300 units) of Heparin
every 12 hrs
• Use distal port of CVC to monitor
central venous pressure (CVP)
• Change occlusive central line
every 7 days
HENNAJANECE
CELLULITIS
Nrsg. Responsibilities
- Apply warm compress to
affected extremity to promote
healing
- Elevated affected leg to
promote lymphatic drainage
- Mark & date the reddened
areas to monitor progress of
healing or if site is getting bigger
- Contact precaution (gown,
gloves, googles)
MY NCLEX NOTES 2021
DIARRHEA/ CONSTIPATION
Assess
• Amount
• Color
• Consistency
• Time (Duration)
CONSTIPATION
↑ Fiber Diet
• Whole grain bread
• Rice, brown rice
DIARRHEA
− Blood-streaked stool is expected
− No highly concentrated sugar
food (will cause more
dehydration)
− Dry Mucous membrane
Home mgt
• Don’t administer antidiarrheal
meds to children (use ORS
instead)
• Normal Diet w/ “BRAT” (banana,
rice, applesauce, toast)
• Record number of wet diapers &
return to clinic if notice decrease
• Use skin barrier cream such as
zinc oxide until diarrhea subside
85 | P a g e
 DIET HIGH POTASSIUM FOODS IRON RICH FOODS MALNUTRITION
• Lacto-vegetarian diets exclude meat, • Potato
fish, poultry and eggs, as well as foods • Avocado Apricot • Green leafy veg (kale; spinach) Malnutrition Assessment
that contain them. • Banana • Cruciferous (cabbage; broccoli) • Diet data (recent 24 hrs) to
• Ovo-vegetarian diets exclude meat, • Orange • Eggs/poultry check if it’s nutritious
poultry, seafood and dairy products, but • Watermelon • Fortified cereals • Albumin (if abnormal level, it
allow eggs. • Strawberry • Dried fruits means ↓ protein intake)
• • BMI
• Lacto-ovo vegetarian diets exclude Red Meat (beef)
• Dairy (milk) • Nuts/beans • Recent wt loss (5% ↓wt in 1
meat, fish and poultry, but allow dairy
products and eggs. • Brownie month/ 10% ↓ wt in 6 mos)
• Meat • Ex. TB, Cancer
• Macrobiotic (whole grains, rice, Liver
seafoods, sea weeds) • Dried Fruits • Seafood/fish
Goals
• Vegan (pure vegetables) • Kiwi • Orange juice
• Stable weight
***Low Potassium ➢ Take Vitamin C – for absorption • Intake equaling output
❖ Clear Liquid Diet Blue & Back berries of Iron • Normal BUN: 10-20 mg/dL
− Clear; no color ➢ Avoid Milk / Caffeine/ Calcium/ • Normal Total Protein: 6.4-8.3
− Coconut water, Pineapple Juice, Antacid – prevents absorption g/dL
Water, Apple juice, Chicken broth, of Iron − Below N: malnutrition
Tea
➢ Need to take Calcium & Vitamin − Above N: obese/ over
D Supplements nutrition
❖ KOSHER DIET
Vitamin D (dairy products/egg
− Jewish Orthodox Diet (Judaism) ***WEIGHT GAIN: best indication that pt
yolks)
− No pork is responding to treatment
➢ Take Ferrous Sulfate
− No shellfish
- Take w/ orange juice
− No fish w/o scales
- Take one hour before
− Separate meat/poultry w/ dairy
breakfast
(must have interval of 3-6 hrs) ***WOUND HEALING
- Drink extra fluids
High sodium – can cause ↓ fluid in
❖ LACTOSE INTOLERANCE intracellular because Sodium pull into the
Adverse effect of Iron (Dextran)
- Lactase Deficiency (↓Lactase to blood; delay wound healing
metabolize Lactose)
• Hypotension
- Effect: Diarrhea
• Light headedness
- NO milk, ice cream, dairy
• Dyspnea
- Can still eat cheese & yogurt if it
• Irregular heart bead
wont make the pt sick
- Take Calcium & Vitamin D
Supplement
- Take Lactase enzyme supplement
during meals w/ dairy

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 GENETIC INHERITANCE
❖ Autosomal Dominant Trait
- Affected offspring has affected
parent
- Dominant – one copy/parent is
enough to cause disease
- Autosomal – any parent
(male/female)
- Ex. Marfan; Huntington (Dementia);
Achondroplasia (short-limbed
dwarfism)
❖ Autosomal Recessive Trait
- Both parent; offspring receives 2
abnormal genes
- Ex. Cystic Fibrosis (persistent lung
infections and limits the ability to
breathe over time); Sickle Cell
Anemia; PKU; Tay-Sachs
(destruction of nerve cells in the
brain and spinal cord)
❖ X-linked Recessive Trait
- Male offspring received abnormal
genes/sex chromosome from female
carrier
- Ex. Hemophilia; Duchenne
(progressive loss of muscle)
Mgt:
• Genetic Counseling
HENNAJANECE
MARFAN SYNDROME
Autosomal Dominant Trait
S/sx
• on pt’s stated needs
Mitral valve prolapse
• Aortic Dissection
• Regurgitant Aortic Valve
• Retinal Detachment
• Fingers long (Arachnodactyly); longs
legs & toes; tall &thin; short torso
• Arm Span longer than height
• Nasal Voice (high arched palate)
• Near sightedness
• Sternal Excavation (depress; deep)
• Scoliosis (curve Spine)
Teaching:
• Avoid pregnancy (may ↑ cardiac
workload)
• Consistently use reliable form of
birth control
HERBAL
• Gingko – mental enhancement
• Ginseng – stimulant (energy)
↑mental performance
• Ginger – pregnancy nausea/vomiting
• Garlic – to lower BP
• Saw Palmetto – BPH (Tip:
Prostate=Palmetto)
• Black Cohosh – Post menopausal
symptoms (Tip: color of blood in
menstruation is dark red/black);
contraindicated for liver injury
• St. John’s Wort – Depression;
Insomnia
• Kava – Anxiety; Insomnia
• Licorice – Stomach ulcers; Bronchi &
Viral infection; anti-inflammatory,
treat upper resp infection, aid
digestion, heartburn
• Echinacea – cold & flu “Eching”
• Ephedra – cold & flu; athlete
enhancement
• Hawthorn – Hypertension; High
cholesterol; heart failure (Tip: heart
problem starts w/ “H”)
• Melatonin – safe barbiturate to help
in sleep
4 G’s (***Avoid if pt has bleeding)
• Gingko Biloba
• Ginseng
• Garlic (control BP; platelet aggregate
inhibitor/prevents clot formation)
• Ginger
MY NCLEX NOTES 2021
TERMINAL ILLNESS
• Offer to contact clergy to support the pt’s
spiritual needs
• Make referrals to other disciplines based
• Plan to balance the pt’s need for
assistance w/ that for independence
(allow to have a normal/ usual day)
• Ask the pt’s about goals for the treatment
plan @ how he/she can best be assisted in
achieving these goals
• PROVIDE MEASURES THAT CAN GIVE
COMFORT TO PATIENT
o Give anti-emetic (N&V)
o Laxative (constipation)
❖ HOSPICE CARE
− Need two primary HCP to certify that
patient has less than 6 mos to live
❖ POST-MORTEM CARE
- Start after the relative grieve or has
left
• RN – notify family if not present);
• UAP – dentures, pillow ( to prevent
pooling of blood to face);
transporting to morgue; washing pt
body
- NAME TAGS (Legal responsibility of
RN is to label corpse)
➢ 3 tags – big toe; body bag (to
lock two zippers); belongings
- Intervention prior to family viewing
o Prepare body to look as clean and
natural
o Don’t cover patient yet
o Remove external tubes & drain
***Adaptive Grief – accepting reality of death
***Death Rattle (loud rattling sound w/
breathing)
− Give Atropine Sublingual Drops to
dry airway secretion
87 | P a g e
 FALL RISK
Fall Risks Pt
• Incontinence; confusion
• Old age
• Lines, tubes, drains
• Splash
Standard
• Hourly rounds & encourage pt to
pee
• Orient to room & call light
• Make sure call light & belongings
are w/n reach to the pt
• Lower bed; side rails but not all
• Uncluttered
• Non slip shoes & socks
High Fall Risks
• Make sure to provide bed alarm
sensor
• Place pt close to nurse’s station
• Place signage “Pt Fall Risk”
HENNAJANECE
MALFUNCTION SEQUENTIAL COMPRESSION DEVICE SUCTIONING
Things to do when machine malfunction Sequential Compression Device (SCDs) ➢ ORAL SUCTIONING
− Inflatable sleeves that fit around 1. Wash hands
1. Assess legs 2. Apply face shield (splashes)
2. Replace − Pumping act as muscle 3. Remove pt’s oxygen mask
3. Label damage machine “Out of − Promote blood flow & prevent 4. Apply clean disposable glove to
Order” blood clots dominant hand & attach the
4. Bring to maintenance − Use after surgery suction catheter to the
− For DVT connecting tubing
5. Insert the catheter into the pt’s
mouth & move the catheter
around the mouth, pharynx and
gum line until secretions are
cleared
***You can allow pt to cough
➢ NASOTRACHEAL SUCTIONING
• Set wall suction pressure below
140 mmHg
• Encourage pt to cough after
suctioning
• Insert suction cath during pt
inhalation
• Insert cath not beyond the point
of gag reflex
• Apply intermitted suction on the
cath during removal for up to
10-15 secs
MOUTH CARE
• Turn pt’s head to one side
• Use small volume fluid to rinse
mouth
• Place emesis basin under pt’s
mouth
• Use gloved hand to open mouth
MY NCLEX NOTES 2021 88 | P a g e
 CLEANSING ENEMA PRESSURE ULCER
LARGE ENEMA NEGATIVE PRESSURE WOUND THERAPY
• Hypotonic (tap water)
• Isotonic (NSS) • Administer prescribed pain
medication 30 mins before
SMALL ENEMA procedure
• Hypertonic • Apply skin protectant to intact skin
• Fleet Enema (commercially surrounding wound (occlusive film
prepared) dressing)
• Apply foam dressing to the wound
bed using sterile technique
Indication of Cleansing Enema • Ensure that foam dressing is
• Pre-op Surgery procedure regularly large; ensure that it will
• Diagnostic procedure shrink after the device is turned on

Volume: 700-1000 mL
Temp: 105-110 deg F (warm)
Position: Left Sim’s w/ Right knee forward
To allow the solution to flow by gravity in
the natural direction of colon

• Use Clean/sterile gloves

• Prime fluid before inserting
• Lubricate tip of catheter
• Lift superior buttocks to expose
• Insert 3-4 inches (7-10cm)
• While inserting catheter, instruct pt
to deep breath slowly

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 INFECTION NOTES
PRECAUTIONS PRECAUTIONS PERSONAL PROTECTIVE EQUIP INFECTIOUS CONTROL
AIRBORNE • Measles (Rubeola) Donning PPE’s ***PROTECT OTHER PEOPLE FROM
• Health care – wears N95 mask • TB GETTING INFECTED”
• Patient – wears surgical mask • Varicella (Chicken pox) “Gow Ma Go Glo”
• Gown; Gloves • Herpes Zoster (Shingles) 1. Gown ❖ PLACE PT IN A PRIVATE ROOM
• Negative Pressure room (HEPA) • MERS-COV
• 3G’s (only if w/ splashes***) • SARS 2. Mask
❖ IDENTIFY THE TYPE OF
3. Google/Face Shield INFECTION
4. Gloves
DROPLET • Sepsis/ Scarlet Fever/ Step
(Body fluids) • Pertussis/Parvovirus/ Pneumonia
• Pt &nurse wears surgical mask • Influenza Removal PPE’s
PRIORITIZING 4 PATIENTS
• Private room • Diphtheria 1. Gloves
1. Remove age & gender
• Can discontinue precaution after 24 hrs • Epiglottitis 2. Googles/Face Shield
of taking antibiotic (*Meningitis) 2. Focus on modifying factors
• Rubella
• 3G’s (w/ splashes, blood, body fluids, 3. Gown 3. Airborne is Priority
• Mumps/ Meningitis/ Mycoplasma
amniotomy) • AdeNovirus 4. Mask 4. “Expose” is least priority
− Gown; Googles; Gloves

CONTACT • Multi Drug Resistant

(By touch)
• Constant hand washing
− Single use /Isolation Gown
− Clean Gloves
− Private room
• 3G’s (w/ splashes***)
• Keep dedicated equipment for client
• Remove gown & hand hygiene before
exiting room (for staff & vsisitor)
• Respiratory Infection ***CENTRAL LINE has higher risk to
• MERS-COV (Airborne & Droplet)
• Skin Infection (Impetigo, Scabies, Ring infection than PERIPHERAL LINE
- Gown
Worm)
• Wound Infection - Glove
• Eye Infection (conjunctivitis) - N95 respirator
• Enteric Infection (GI ex. C.Difficile – - Eye Shield/googles/face shield
won’t die w/ alcohol, need to hand
wash)

STANDARD/UNIVERSAL (Sexually transmitted; blood)

• Constant hand washing • HIV (Human Immunodeficiency Virus)
• Wear gloves • Hepatitis B
• Wear Mask & googles (if w/ splashes)

Nosocomial (Hospital Acquired Infection) • Clostridium Difficile (pts taking multiple

• Alcohol is not effective; use tap water antibiotics for a long time)
w/ soap in washing hands

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 HIV
- HIV – CD4 count >200
- AIDS – CD4 count <200
- Can be acquired; it is a retrovirus
- A virus that attacks immune system
- A parasite that forces cells to make
copies of itself
- If viral load is non detectable, can’t
anymore transmit even w/o condom
- Does not always progress to AIDS
TRANSMISSION
• Pt w/ recent HIV infection & high
viral load are very infectious
• Pt w/ end stage HIV & no drug
therapy are very infectious
• Can be transmitted
sexually/mother to child/blood
transfusion
CD4 Percentage
- ↑15% – good immune
- ↓15% – immunocompromised;
can’t take live/attenuated
vaccines (only HiB, Hep A, PCV)
Anti-Retroviral (use for HIV)
- To ↑ CD4 count
- To ↑ immune system
• Indinavir
• Tenofovir
• Lamivudine
• Zidovudine
• Efavirenz
HENNAJANECE
HIV
❖ Pre-prophylaxis (take so can’t get if
you have sex)
❖ Post-prophylaxis (if person don’t know
that the partner have HIV, take after
sex; also use for needlestick
***AIDS Mgt: Azithromycin; Anti TB meds
***Needlestick
The occupational health nurse should
discuss HIV status w/ client
Pt must consent before performing HIV
test
HUMAN PAPILLOMA VIRUS
- Common strands (dangerous)-
16 ,17,18
- Most common cause of Cervical
Cancer
- Cause of Genital Warts
- Transmission: skin-to-skin contact
(sexual contact and can affect your
genitals, mouth, or throat)
Teaching
• Can transmit virus even when pt
don’t have symptoms
• Can be spread through oral sex
• Avoid sex (can still be
transmitted even w/ condom)
• ***Positive HPV- need annual
Pap smear to check cervical
dysplasia
HPV Vaccines
• Recommended for both males and
females to prevent cancer
- 1st dose – Given as early as 9 yrs
old; Ideally given at 11-12 yrs old
up to 26 yo
- 2nd dose – Given after 4 wks
- 3rd dose – Given 12 wks after 2nd
dose) if immunocompromised
patients
• May cause oral, anal, cervical cancer
MY NCLEX NOTES 2021
GENITAL HERPES
− Small, multivesicular lesions
− Painful
Cause: Herpes Simplex Virus -2
Teaching:
• No contact/sex
• Keep area clean & dry
• Don’t touch lesion to prevent
spreading to other parts of the
body
• Use hair dryer in cool setting to
dry lesions after taking shower
• Use warm running water w/ mild
soap w/o perfume to wash
• Hot sitz bath is recommended
• Oatmeal bath
• No bubble bath
Mgt
• Antiviral medications
(Azithromycin)
91 | P a g e
 EBOLA VIRUS SARS / MERS COV AVIAN INFLUENZA BIRD FLU BIOTERRORISM
− From South Africa
S/sx S/sx ANTHRAX
S/sx • Fever Dyspnea − White powder on pts body
• DHN (Hypovolemia) *** • Shortness of Breath − Most common type of Bioterrorism
• Fever • Dry Cough − PRIORITY: Escort pt to
• Headache • Respiratory Infection Mgt decontamination room
• Vomiting • AIRBORNE PRECAUTION − Assess pt for signs of infection
• Multiple Ecchymoses Precaution: Airborne; Droplet; Contact • IV fluids (Anthrax lab test takes several days
• Ask for recent travel to Asia to wait)
PPE’s • Obtain sputum specimen & nasal
Mgt • Gloves cultures
• ↑Fluids (IV) • Gown
• Acetaminophen (for fever) • Googles
• Ondansetron (antiemetic) • N95 Mask (for nurse) ANTI-VIRAL
Oxygen • Surgical Mask (for pt) RULE: If viral infection, it is most effective to
immediately give Anti-viral medicine to pt
• Oseltamivir (Tamiflu)

VIRAL HEPATITIS IMPETIGO ZIKA VIRUS

S/sx
• Tea colored Urine
• Clay colored stool
Mgt
• Rest
• Diet: ↓Fat, ↓Protein
• NO Alcohol intake
• Don’t take Acetaminophen
- Skin infection (contact precaution)
- Yellow crust
- Non communicable (can go school:
o After 24 hrs of taking oral
antibiotics
o After 2 days of ointment
antibiotics
Teaching
• Keep child’s nails short
• Separate towel & other linens
• Wash hands w/ antibacterial soap
regularly
• Prevent child from scratching lesions
SCABIES
Store stuffed animals and toys in plastic bags
for 5 days
LICE
Vacuum carpets & furniture regularly
Common in Southeast Asia
S/sx
• Rash
• Joint pain
• Conjunctivitis
• Fever
Mgt
• PRIORITY: TEST FOR ZIKA VIRUS
• Multiple Fetal UTZ (if pregnant)
• Constant fetal monitoring (have
impact to fetal development; HCP
may recommend abortion)
• Pt must apply Insect repellent
(prevent mosquito bite because the
mosquito could spread virus to
healthy individual)
• Pregnant pt should avoid travelling
to areas w/ active Zika virus
Use barriers during sex (condoms)

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BLOOD TRANSFUSION
RN to RN checking of blood
RN hook the blood (don’t hook 2 simultaneously)
UAP can get the blood from the blood bank
PRBC run for 2-4 hrs
BLOOD TRANSFUSION STEPS
1. Obtain blood from lab; verify/crossmatch
by 2 license RN
2. Assess V/S; Teach (reactions)
3. Y tubing (always use new y tubing every
bag of blood; Prime NSS then clamp
4. Spike blood (make sure NSS is clamp)
5. Set the infusion pump
6. Stay w/ pt for 1st 15 mins (check reaction,
itchiness, dyspnea)
7. RN Take V/S after 15 mins (then the 2nd-4th
15 mins can be delegated to UAP/LPN for
the 1st hr; then 2nd hr every 30 mins; 3rd
and 4th hr every hour; RN takes the final
V/S
8. Y tubing- open the NSS to flush the blood
9. Dispose according to hosp policy
Blood transfusion reactions:
• Fever; Dyspnea
• Chills
• Itching
• Flushing
• Low back pain (kidney have hard time to
filter blood)
Mgt (Blood Transfusion Reaction)
1. STOP, DISCONNECT
2. Maintain IV access w/ NSS
3. Notify HCP + blood bank
4. Check V/S
5. Check labels, number, blood type
6. Treat symptoms as ordered
7. Blood & urine sample (evaluation)
8. Return blood & tubing set to blood bank
9. Document
HENNAJANECE
HEMA NOTES
THROMBOCYTOPENIC PURPURA
❖ Immune Thrombocytopenic Purpura
- Platelet below 150,000
- Idiopathic/ unknown cause
- Platelet destruction
- High risk for bleeding
Teaching:
• Mouth care (soft bristle brush, mild
mouth rinse)
• No activities causing trauma (can do
walking and wear non skid footwear)
• Use stool softener (ex. Docusate)
• Use electric razor
• NO NSAIDS
❖ Thrombotic Thrombocytopenic Purpura
- Blood clots forming in small blood
vessels throughout the body
- ↓Platelet; RBC Destruction
- Hemolytic Anemia
- Erythrocyte Fragments
Signs of Hemolysis
• ↓Platelet
• Fever
• ↓Renal Function
• Hematuria
• Intracranial Bleeding (Altered LOC)
***BLOOD DYSCRASIA
Rash that has purplish blotches that don’t
blanch (Purpura/ bleeding problem)- REPORT
TUMOR NECROSIS FACTOR INHIBITOR
- Management for inflammation,
Rheumatoid Arthritis, Psoriasis, GI
Chronic Disease
- Immunosuppressants
❖ Adalimumab
❖ Infliximab
❖ *Etanercep
Important
- Tuberculosis Skin Test every year
- Annual Influenza/Flu vaccine
- Avoid live vaccines (BCG, MMR,
Herpes Zoster, Rotavirus, Yellow
Fever)
- Don’t give to pt currently having
infection/high WBC
MY NCLEX NOTES 2021
HEMOPHILIA
− Deficiency Clotting Factor VIII, IX
− Risk for bleeding (80% bleeding in
joints)
− Hemophilia A (Classic; ↓CF 8)
− Hemophilia B (Christmas; ↓CF9)
S/sx
• Bleeding
• Bruising
• Hemarthrosis
PRIORITY MGT: Transfuse clotting factors
• ***Administer coagulation factor
replacement IV Push
Mgt for Hemarthrosis (bleeding joints)
• Rest
• Ice Pack
• Compress
• Elevate in extended position
***NO NSAIDS (Ibuprofen, Aspirin,
Naproxen, Ketorolac, Naproxen) -causes
bleeding; CAN GIVE ACETAMINOPHEN
***Hgb: 12-16 (W)/14-18 (M)
***↓Hgb (Dyspnea, Pallor, Tachycardia)
***4G’s that ↑ Risk of Bleeding
• Gingko
• Ginseng
• Ginger
• Garlic
***Erythrocyte Sedimentation Rate
Male: 1-13 mm/Hr; Female: 1-20 mm/Hr
Result: ↑ - expected if there is
inflammation & infection
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GLYCOPROTEIN PLATELET INHIBITOR
- Prevent occlusion due to a clot after
a surgery (ex. Percutaneous
coronary intervention via the right
groin-angiography)
- Causes bleeding (gum, urine,
dizziness, tarry stool) in site
Ex.
• Abciximab
• Eptifibatide
• Tirofiban
Mgt
• Assess invasive procedure site for
bleeding
• Check CBC (Hgb, Platelet)
• Place pt on continuous cardiac
monitor
• Report black tarry stools (upper
GI bleeding)
• No puncture during and after
procedure
HENNAJANECE
SJOGREN’S SYNDROME
- WBC attacks exocrine gland (affects
moisture)
- Affects salivary, lacrimal glands
Mgt
• Eyes – eye drops; googles
• Mouth – artificial saliva; sugar free
gum; regular dental check up
• Nose – Avoid Decongestants –
may cause dryness of nasal
mucosa
• Skin – use lukewarm water &
avoid harsh soap
• Throat/ Bronchi – stay in area w/
↑ humidity
• Vagina – water soluble lubricant
ANEMIA ALLERGY IMMUNOTHERAPY
➢ MACROCYTIC ANEMIA ALLERGY IMMUNOTHERAPY INJECTION
(MEGALOBLASTIC) “Allergy Shots”
− ↓ Vitamin B12
− RBC big & pale (Hypochromic) - ↑ specific Immunoglobulin
− High risk for people who don’t eat - ↓ allergy signs and symptoms
meat (Vegan) - Small dose allergen is introduce
− *** Vitamin B12 (Folic Acid) rich food every week
(meat, chicken, fish, eggs, milk,
fortified bread/cereal, rice) Danger: Anaphylactic Shock
- Monitor pt
➢ IRON DEFICIENCY ANEMIA - Report for hives, itchiness
− Due to ↓Iron intake; ↓Hgb - Redness is expected at the
− RBC (Microcytic & Hypochromic) injection site after
− Hgb (M: 14-18) (F:12-16) - Pt stays atleast 30 mins after
injection
Foods ↑ Iron (same w/ MA except milk)
• Meat/Chicken/Fish
• Eggs
• Fortified cereals/bread
• Dried fruits
• Red Meat (beef)
• Green leafy veg (kale; spinach)
• Cruciferous (cabbage; broccoli)
• Nuts/beans
• Brownie
• Liver
• Seafood
• Orange juice
➢ Take Vitamin C – for absorption of
Iron
➢ Avoid Milk / Caffeine/ Calcium/
Antacid – prevents absorption of Iron
➢ Take Ferrous Sulfate
- Take w/ orange juice
- Take one hour before breakfast
- Drink extra fluids
MY NCLEX NOTES 2021 94 | P a g e
 VON WILLEBRAND DISEASE
− Deficiency in VW Factor
− Lifelong bleeding disorder in
which your blood doesn’t clot
well

Mgt
• Minor bleeding:
- Desmopressin Intranasal
(prevent dehydration, and
polyuria) (can also be use to
avoid bedwetting in children)
- Topical (Thrombin)

• Major bleeding:
- VWF replacement

Teaching
• Monitor signs of bleeding
- Hemarthrosis (mgt: “R.I.C.E”)
- Headache
- Nose bleed
- Hematuria
- Blood in stool

• Use humidifier to prevent

nosebleed
• NO NSAIDS
• No contact sports
• Mouth wash (soft bristle brush &
floss gently/carefully)
• Report heavy menstruation
• Wear identification bracelet

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 PHARMA NOTES
DRUG / IV CALCULATIONS PHARMA ADDITIONAL NOTES
Desired dose= Prescribed amount(mg/kg) ➢ Drugs are metabolized by liver
x Weight(kg) (Hepatotoxicity)
➢ Drugs are excreted by kidney
Dose to administer= (Nephrotoxicity)
Desired (mg)
Available (mg) x Quantity (mL) ➢ If taking long term use of antibiotic,
take Lactobacilli to prevent GI
Infection
***1 decimal point = 24. 321 (24.3)
***IV Infusion (round off to whole
number) = 24.32 (24)
➢ In pharma, if uncertain w/ the dose,
***1 oz = 30 mL consult: Pharmacist/Drug Literature
IV Infusion Rate
➢ AVOID TRALING ZERO
Total volume to be infused x Drop Factor
Time in Minutes
Ex. 1.0
There is a chance that nurses will read
it 10 (ten)
➢ EXTRAPYRAMIDAL SYMPTOMS
- commonly referred to as drug-
induced movement disorders
are among the most common
adverse drug effects patients
experience from dopamine-
receptor blocking agents
(usually from psych drugs)
1. Tardive Dyskinesia
2. Pseudo Parkinson
3. Dystonia
4. Akathisia
HENNAJANECE
TEST TAKING SULFA DRUGS
SIDE EFFECT EXPECTED Anti-inflammatory; Antibiotic effect;
1. Know DMARD;
2. GI signs &symptoms (drug
absorption) ❖ Sulfasalazine- for Ulcerative Colitis/
GI & Brain are connected thru Crohn’s Disease/ Vaginal Yeast
the vagus nerve Infection/ Anti Inflammatory for
Irritation can signal the brain Rheumatoid Arthritis
S/sx
• Headache ***Check for allergy to Sulfonamides
• Nausea & Vomiting
• Diarrhea S/e
• Constipation • Urine and skin turn orange yellow
3. Pick the mildest symptom (expected)
• Crystalluria (mgt ↑ Fluids)
TOXIC EFFECT/ADVERSE • Photosensitivity (use sunscreen, cap)
Dangerous; need to REPORT • ↓ Folic Acid / prevent FA absorption
1) Pick the choice that you know (need to take Folic Acid supplement)
2) Look for Hepatotoxicity/ • Agranulocytosis / ↓WBC
Nephrotoxicity • Nephrotoxicity
3) Compare & look for more toxic • Bone marrow suppression
(highly severe) • GI effects
• Steven Johnson Syndrome (look for
rashes) (Stop meds and report
immediately)
***In Pharma
STOP if there is toxicity, then find if there Steven Johnson Syndrome
is liver or kidney problems in the - a rare, serious disorder of the
choices, if none, choose the most skin and mucous membranes. It’s
dangerous usually a reaction to medication
that starts with flu-like
symptoms, followed by a painful
rash that spreads and blisters
MY NCLEX NOTES 2021 96 | P a g e
 LITHIUM CARBONATE
− Normal therapeutic level:
0.5-1.5 meq/L
o ↓0.5 0 hyper
o ↑ 1.5 toxic
• Lithium level
s/e (expected)
• Increase fluids; Regular Na
o High (lithium will be
ineffective)
o Low (toxic)
• Toxic signs (Diarrhea, Thirst,
increase urination, vomiting,
altered LOC-DHN)
o Antidote: Diuretics
Mgt
(mannitol/Diamox)
o ***avoid activities that
causes excess perspiration
(causes ↓Na)
• Hold NSAIDS (decrease renal blood
flow)
HENNAJANECE
PHENYTOIN (DILANTIN)
Anti convulsant; long term, wont effect
right away
Normal level: 10-20 mcg/dL
Toxic: >20 (ex. Unsteady walk)
Seizure: < 10
• Gingival Hyperplasia (due to ↓
Folic Acid)
• ↓WBC (prone to infection)
• ↓PLT (prone to bleeding)
• Hirsutism (↑hair growth)
• Osteoporosis
• Rashes
• Oral care (soft bristle brush,
gargle with NSS/plain warm
water)
• ↑Folic Acid (Phenytoin prevent
Vit.B12/Folic Acid absorption
from food, so need supplement)
• ↑Calcium
• Avoid milk & antacid (prevents
absorption of Phenytoin
• Avoid crowded area to avoid
infection
• Avoid fresh fruits, veggies,
uncooked food
• Use electric razor
***IV Administration
Sandwich Effect (10cc) NSS
Inject 5 cc, then slow push Dilantin, then
another 5cc, to prevent crystallization
DIURETICS DIAZEPAM
Effects Anxiolytics/ Benzodiazepine
• Decrease BP “zepam” “zolam”
• Dehydrate
• Drain Fluid Antidote: Flumazenil (Romazicon)
***Take at morning w/food
Effect: “SLOW & LOW”
***May cause sunburn (sun protection)
• Sedate/ drowsiness
***AVOID diet rich in Sodium
• Addictive/Dependence
➢ POTASSIUM WASTING DIURETICS • Hungover effect
• Loop (Furosemide, Torsemide, • Ataxia (balance)
Bumetanide) • Constipation
• Thiazides (Hydrochlorothiazide-
Chlorthalidone, Chlorothiazide) Contraindicated: Valerian Root
OK: Gingko Biloba; Ginseng
Nrsg. Responsibilities
For Alcohol Withdrawal:
• Give only if Potassium is Normal
• Clorazepate Dipotassium
• Give Potassium supplement (Kalium
Durule)
(Tranxene)
• Chlordiazepoxide (Librium)
• Monitor for severe potassium loss,
may lead to hypertension (ex.
Muscle cramps)
• Avoid Licorice Root (it ↓ K) BUSPIRONE (BUSPAR)
• Avoid Digoxin (↓K leads to toxicity) - Anxiolytics
• Thiazide can ↑ Calcium - Can drive (no sedation)
- Not addictive/ no withdrawal
- Safe for long tranquilizer use
➢ POTASSIUM SPARING DIURETICS - Long onset (after 2-4 wks)
• Spironolactone
• Amiloride Hydrochloride
Nrsg. Responsibilities
• NO Potassium rich foods “PABOWS”
• NO salt substitute (have high K)
• NO High salt food (contradict effect)
• Monitor for Cardiac Arrythmia
• Avoid OTC meds
- Cough & Cold Drugs
- Antacid
- Acetaminophen
- NSAIDS
MY NCLEX NOTES 2021 97 | P a g e
PLATELET AGGREGATE INHIBITORS VANCOMYCIN
Risk to pt: Bleeding • PO (for GI problem ex C. Difficile colitis)
• IV (for other infections)-check site every
• Ticagrelor 30 mins for thrombophlebitis ; central
• Dipyridamole line (long); check ↓BP; Infused in 60
• Ticlopidine mins;
• Clopidogrel • Redman’s Syndrome (expected)
• Prasugrel - S/sx: Red face & chest’ flush
• Aspirin - Mgt: Slow rate
- Only discontinue when there is
***HOLD atleast 7 days prior to Coronary Anaphylactic Reaction (wheezes
Artery Bypass Surgery and other surgeries &resp problem, angioedema)
MANNITOL CYCLOPHOSPHAMIDE
Complication: - Also known as cytophosphane among ➢
- Excessive Accumulation other names, is a medication used as
- Due to ↑ Mannitol chemotherapy and to suppress the
immune system. As chemotherapy it is
Fluid Volume Expansion (retention) used to treat lymphoma, multiple
- Not extracted to kidney myeloma, leukemia, ovarian cancer,
- Pulmonary Edema breast cancer, small cell lung cancer,
(crackles) neuroblastoma, and sarcoma. ➢ Lidocaine 5% patch
- Dilutional Hyponatremia - Expected s/e : bloody urine
MICONAZOLE CREAM NYSTATIN ORAL SUSPENSION
− Antibiotic for Oral/skin/intestines/
− Drug of choice for Vaginal Candidiasis vaginal Candidiasis
− Apply at nighttime using vaginal − Assist pt in removing dentures/
applicator soaking them in nystatin
− Insert / apply in the high part of vagina − Inspect oral mucous membranes
− No sex for 3-7 days before administering
− No douching − Swish suspension in the mouth for
several minutes then swallow
❖ VAGINAL CANDIDIASIS
− Shake bottle of suspension
− due to poor hygiene; not
thoroughly before measuring dose
transmitted thru sex
− Complete dose for 48 hrs or more
− thick, white, curd like; red lesions
(never stop Antibiotics until
completion)
HENNAJANECE
METRONIDAZOLE
− It’s used to treat skin infections,
rosacea and mouth infections
(including infected gums and
dental abscesses). It’s used in
the treatment of conditions such
as bacterial vaginosis and pelvic
inflammatory disease
ANALGESIA
Transdermal Fentanyl Patch
- Slow onset
- Wait for 17 hrs to response
- Effective for 24-72 hrs (3 days)
- Not for pt that needs immediate
pain mgt
- Ex. For pt w/ Chronic
Postherpetic Neuralgia
(peripheral pain)
AMINOGLYCOSIDES
− Antibiotics
− Ototoxic/Nephrotoxic
❖ Amikacin
❖ Tobramycin
❖ Gentamycin
S/sx of Toxicity
• Tinnitus (1st sign)
• Vertigo (1st sign)
MY NCLEX NOTES 2021
ONDANSETRON
− Used to prevent nausea and
vomiting caused by cancer
chemotherapy, radiation
therapy, or surgery.
− It is also effective for treating
gastroenteritis.
− It is ineffective for treating
vomiting caused by motion
sickness.
PATIENT CONTROLLED ANALGESIA
Ex of Meds in PCA (Morphine)
➢ 1st PRIORITY: Always assess pain
regularly/PRN (to assess effectivity of
pain mgt)
− Can give bolus 1-2mg (manually
performed by the nurse after doctor
order) (if the dose is not enough in
controlling the pain of pt)
− HCP can order to increase dose
/shorten interval if the medication is
not enough after assessment
TRIPTANS
− For migraines
• Almotriptan
• Sumatriptan
Ergotamine (next in line medication if
Triptans are not working)
- Take as soon as pt notice migraine
symptoms
- Not more than 2 doses in 24 hrs
***CT Scan- is perform first before
starting Triptans to rule out Stoke
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 METOCLOPARAMIDE PROTON PUMP INHIBITORS H2 BLOCKERS ALPHA ADRENERGIC BLOCKER
− Anti emetic/ Treat GERD/ Treat “zole” “Tidine”
Delayed Gastric Emptying − ↓gastric acid in the stomach that ❖ Terazosin
− Oral/IM/IV − Decrease acid in stomach causes heartburn ❖ Doxazosin
(Hydrochloric acid &pepsin) by − Short acting ❖ Alfuzosin
Ex. Reglan; Plasil eliminating the source − Give at night time ❖ Prazosin
− More effective than H2 Blockers − Overnight relief ❖ Tamsulosin
S/e − For heartburn/ulcers/GERD − Don’t’ give with other
− GI symptoms − Long-term Acting medications − CONTRAINDICATED to other smooth
− Long use can cause EPS − ***Don’t’ give with other − Give 30 mins-1 hr before meal muscle relaxants (ex. Sildenafil)
(Tardive Dyskinesia) REPORT medications
S/sx − Taken 1 hr before meals/ 2 hrs after Ex. Cimetidine, Ranitidine, Famotidine
o Lip smacking meals ❖ TERAZOSIN
o Tongue twitching − Drug of Choice for BPH
o Puffing of cheeks − Relax smooth muscle, facilitate
o Excess blinking of eyes Ex. Esomeprazole, Omeprazole, urination; lowers BP
Pantoprazole − Effect:
***PROMETHAZINE (anti-psych) • To increase urine flow
− Also use for Anti-emetic Effects of Long-term use • ↓BP
− Can also cause Tardive Dyskinesia 1) Osteoporosis (↓Ca Absorption) • Muscle relaxant
Check Bone Density − Nrsg responsibilities
***SCOPOLAMINE PATCH Mgt: Calcium & Vit D supplement • Check BP
− The most common Anti-emetic 2) GI Infection • May cause Orthostatic
medicine that is effective for 72 Clostridium Difficile (due to ↓ HPN –rise slowly
hrs (3 days) acid, there is growth of bacteria) • Give at nighttime
− Transdermal patch (back of ear) Mgt: Vancomycin Oral
− Long term mgt for motion 3) Pneumonia
sickness; anti-emetic
− Apply 4 hrs before travel

Nrsg responsibilities
− No hair on site (shave)
− Wear gloves during application
− Remove old patch first before
applying new (avoid overdose)
− Disposal: Fold at the center
(sticky part that touches the pt)
and close; dispose at the
infectious bin

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 SODIUM POLYSTYRENE SULFONATE
− Sodium Polystyrene Sulfonate (Kayexalate)
− To treat ↑ Potassium (Hyperkalemia)
− Infusing Sodium in exchange of Potassium
(Potassium will be excreted in the stool)
− Monitor Fluids & Electrolytes (because
sodium retention absorbs water)
− Monitor passage of stool/frequency of
stools (to check excretion of Potassium)
❖ POTASSIUM
Normal: 3.5-5 mEq/L
If <2.2 (fatal; cause cardiac arrest)
***If pt is taking Potassium, PRIORITY (Attach
to a cardiac monitor)
➢ ↓3.5 (Hypokalemia)
• ST depression
• Flat T wave
• U wave
− Mgt: KCL IV; Kalium Durule
− S/sx: Muscle Cramps
➢ ↑5 (Hyperkalemia)
• ST Elevation
• Peak T wave
• Prolong QRS
− Mgt: Kayexalate
❖ KCL
➢ 5-10 mEq/hr (can be given
peripherally IV)
➢ 20-40 mEq/hr (use central vein
access device to prevent
infiltration/phlebitis)
− Primary Responsibility: Check cardiac
monitor
− If w/ burning & discomfort – SLOW
− Infiltration – STOP & REINSERT
METHOTREXATE SUCRALFATE ANTIBIOTIC
- Anti metabolite/ antineoplastic/anti − Protect layer & lowers PH • If prone to infection
cancer − Barrier/coat • Break into the skin (laceration,
- Chemo drugs (prevent replication of − Does not decrease stomach acid stab wound, animal bite, open
cancer cells due to interfered Folic Acid − Prevent ulcers wound)
metabolism) − May cause Constipation
- Hepatotoxic (No Alcohol) (common s/e)
- Retinal toxicity & Visual problem (have − Take 1 hr before breakfast
eye exam every 6 mos) − Don’t take w/ other meds
- Avoid pregnancy while taking this med (prevent absorption of other
- Nausea/ vomiting is expected for onco meds due to coating effect)
drugs − Take other meds 2 hrs before or
after Sucralfate
ADVERSE EFFECT
• Bone Marrow Suppression
• Anemia (↓Hgb)
• Leukopenia (↓WBC)
• Thrombocytopenia (↓PLT) – purple
spots in the skin (bleeding)
• Immunosuppressant (Pancytopenia)
- Risk infection; Take vaccines (Flu,
Influenza) (No live vaccines)
- Don’t take uncooked foods/ raw
fruits
CONTRAINDICATION
• Caffeine /Folic Acid (decreases the
effect of Methotrexate)

***CALCIUM ACETATE/CARBONATE
Given to treat very ↑Phosphorus
Normal PH: 2.4-4.4 mEq/L

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 MACROLIDE ANTIBIOTICS ALLOPURINOL
❖ Azithromycin − Prevents Uric Acid deposition in the
❖ Clarithromycin joints (gout) / kidney (kidney stones)
❖ Erythromycin − Prevents Gout attacks (can not
manage acute attacks; give
Nursing Responsibility NSAIDS/Colchicine instead)
• Check ECG monitor/Cardiac monitor − ↑ fluids while taking Allopurinol to
(Macrolides causes Prolong QT flush out uric acid into the urine
Interval) − Can cause Nausea (take w/ meals)
• Monitor Liver test (Macrolides are − REPORT: if pt has rashes – fatal sign
Hepatotoxic) of hypersensitivity reaction
HEPATOTOXIC MEDS OTHERS MEDS THAT CAUSE RASHES
• Acetaminophen (REPORT IMMEDIATELY)
• Sulfa Antibiotics • Anticonvulsants (ex. Dilantin,
• Phenothiazine Valproic Acid, Phenobarbital)
• Macrolide • Sulfa Antibiotics
• TB Drugs
ERYTHROPOIETIN DICYCLOMINE HYDROCHLORIDE
− Given to ↑Hgb − Brand name: Bentyl
− Given SQ/IV (not given IM) − Anticholinergic
− Give w/ Iron/Ferrous/ Vitamin B12/ • smooth muscle relaxant
Folic Acid • s/e: dry mouth, constipation,
− Check BP prior to administration urinary retention, vision
(may ↑BP) problems/blurring vision/dilated
pupil
• Contraindicated to Glaucoma
don’t take w/ other smooth
muscle relaxants (Alpha blockers)
HENNAJANECE
ISOTRETINOIN TETRACYCLINE
− Use to mgt severe acne − For Acne Vulgaris
− Capsules (should not crushed/chew) – − Doxycycline; Minocycline
just Swallow
− Not for pregnancy (use 2 birth − Don’t take w/ dairy products
controls: pills & condoms) − Take in the morning w/ full glass of
− Don’t donate blood (to avoid giving to water
a pregnant person) − Take on an empty stomach
− Stop taking Tetracycline prior to − Use additional contraceptive
taking meds techniques (Tetracycline decreases
− Causes Photosensitivity (No excessive effectiveness of OCP)
sun exposure/tanning − Causes Photosensitivity (wear
− It’s a Vitamin A derivative (Don’t take sunblock)
w/ other Vitamin A supplements – will
lead to toxicity;
o liver problem
o ↑ICP symptoms
o GI upsets
BOTULINUM TYPE A (BOTOX)
− To relax muscle
− For facial rejuvenation
− Assess swallowing & breathing
MY NCLEX NOTES 2021 101 | P a g e
 PENICILLIN / CEPHALOSPORIN PHENAZOPYRIDINE HCL HYDROMORPHONE MARIJUANA
− Analgesic for Urinary Tract − Hallucinogen
➢ PENICILLIN Infection • Administer IV hydromorphone
❖ Amoxicillin over 2-3 mins Therapeutic effects:
❖ Ampicillin S/e • Administer PRN stool softener w/ • Stimulate appetite
• Bright red-orange urine/body daily medications • Heightens auditory sensitivity
fluids • Reassess pt after 15-30 mins
➢ CEPHALOSPORIN • Promotes relaxation (pain
• Assist pt in getting out of bed
❖ Cefazolin reliever)
❖ Ceftriaxone Mgt • Does not promote organization
• Wear napkin
❖ Cephalexin & motivation (it will cause
• Wear eye glasses lethargy/drowsiness)
***Penicillin & Cephalosporin have the
same molecules Adverse Effect
• Constipation
• Insomnia
***Inquire allergic reaction before giving
o If Mild/Moderate: give the
medication
o If Anaphylactic reaction: HOLD

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SEIZURE
TYPES:
1. Generalized (involves both side of brain
A. Tonic Clonic/Grand Mal – most
common (general (whole body)
I. Have aura, then lost of
consciousness (prone to injury)
II. Tonic (body stiffness, groan,
foaming saliva, apnea)
III. Clonic (jerking movts, relax, then
spasm) Priority: Time
IV. Post Ictus: Asleep (headache,
confuse)
B. Petit-mal/Absence – common in
pedia
I. Stare blankly then continue
activity
II. Post Ictus: pt not aware
C. Atonic/Drop Attack
I. Sudden lost of muscle tone
PRIORITY: Safety (helmet for
children)
II. Post Ictus: recover immediately
2. Focal/Partial (cause is from localized part
of brain (have aura)
A. Simple (aware)
- Aura; seizure last for <2 mins
- Affects Occipital area
B. Complex (unaware)
- Affects Temporal area
- S/sx Automatism (automatic
motor symptoms; lip smacking,
rubbing hands, fidgety, numbness)
HENNAJANECE
NEURO NOTES
SEIZURE
STAGES:
1. Prodromal – happens hours/days before the
onset of seizure
S/sx Anxiety, Mood, GI, Bladder, Depress,
Angry
2. Aura/Ominous – secs to mins prior to
seizure (not all seizures will have aura)
Pt need to prepare like sit down
S/sx senses (vision prob, familiar stinky
smell, suddenly taste something, hearing)
3. Ictus / Ictal – Seizure episode
Priority: Safety & Airway
Priority to document: Time &Duration
Normal length: 1-3 mins
Dangerous length: Status Epilepticus
>5 mins or back -to-back seizures (REPORT if
in the hosp/call 911 if outside hosp)
4. Post Ictus/ Ictal – After the seizure
Expect pt to be asleep; when awake pt is
dizzy, confuse, temporary memory loss
TRIGGERS “STOP SEIZURE”
• Stress (#1 factor)
• Trauma
• Over exertion
• Period, Pregnancy
• Sleep ↓
• Electrolyte Imbalance (↓Glucose;
Acidosis; DHN)
• Illness (Infection in the brain ex Meningitis
• VisualiZation (senses
probs/overstimulated)
• Undermedication
• Recreational drugs
• ETOH /Alcohol
SEIZURE SEIZURE PRECAUTIONS
Mgt PRIORITY
1. Seizure Precaution 1. Airway
2. Assess History (Aura; Time; Type; 2. Safety
Medications) 3. Medications
3. Surgery (Thymectomy) 4. IV line
5. Observe characteristics
4. Vagus Nerve Stimulator (electrical device;
6. Document
interrupting seizure)
5. Ketogenic Diet (for pedia pt; ↑Fat ↓Carbs
Before Seizure
- *O2 & fxnl suction at bedside
DIAGNOSTICS - *Have IV line/ IV access
1. EEG – non invasive; painless; have light
- *Placed padded 2 siderails/ pillow
breakfast; shampoo head before & after; ask - *No restrictive clothing
hcp if sleep/no sleep; Continue EEG even if - *Nothing in the mouth
pt is having seizure; hold stimulants; perform - Remove objects that may cause injury
to pt w/ seizure & delirium - Identify triggers; Minimize stimuli
2. CT Scan/MRI - Monitor effect of Anti-convulsant
3. Blood works to know therapeutic level of - Lower height of bed
medicines
During Seizure
MEDICATIONS - Promote Head SAFETY; AIRWAY
1. Phenytoin (Dilantin) -front line med (Tonic - Stay w/ pt; ***Observe characteristics,
Clonic & Focal) N:10-20 duration (time); assess behavior
- Sit/laydown for safety
2. Phenobarbital (Seconal) – therapeutic level
- Position pt to left lateral side, if possible, w/
(15-40 mcg/dL); given for Tonic-Clonic &
head flex forward
Focal & Status Epilepticus
- Nothing in the mouth; No restraints
Inhibitory Neuron (GABA)
- Raise padded side rails
S/e: Ataxia (slow movt); ↓RR ↓BP; - Guide pt to the floor &gently cradle head (if
drowsiness non hospital setting)
3. Benzodiazepines (anxiolytics) - Loosen restrictive clothing
Diazepam or Lorazepam – Fastest mgt to - Move objects that cause injury
seizure; DOC for Status Epilepticus - Stay calm & reassure pt
4. Valproic Acid (Depakote) – long-acting anti
convulsant After Seizure
S/e: ↓WBC ↓PLT - Stay w/ pt ; Document start & end time; &
symptoms (to know type)
***Levetiracetam (Keppra) - Continue V/S monitoring, neuro & behavior
assessment; injury
- A medicine used to treat epilepsy &
- Blood works (therapeutic level of anti
seizures (anti convulsant, anti seizure; convulsant: 10-20)
depress brain) - Diazepam/Lorazepam (short term)- give after
- SAFETY – risk of suicidal ideation the seizure
- may cause drowsiness; can’t drive; need
to report increase anxiety & rash
MY NCLEX NOTES 2021 103 | P a g e
 ↑ INTRACRANIAL PRESSURE ↑ INTRACRANIAL PRESSURE BRAIN STEM BRAIN STEM
Normal ICP: 5-15 mmHg Monro Kellie Brain Stem:
Increased: >20mmHg (requires treatment) ↑ volume of one structure, will cause ↓ BRAIN STREM ASSESSMENT Respiratory/Cardio/Vasomotor Center
volume of other structure
Causes:
***↓ Cerebral Perfusion Pressure, then 1. Ice Caloric Water Test Causes of Brain Stem Compression:
Brain injury/trauma; fall; mauling; MVA;
↓ Cerebral Blood Flow (Oculovestibular Test) • ↑ICP (stroke, tumor, brain
tumor; stroke; edema in the brain
- Drop Cold water on ear surgery, contusion, concussion,
1st sign: Altered LOC (Restless/Irritable); - Observe Eye movt meningitis)
CEREBRAL PERFUSION PRESSURE (CPP) (+) Normal
Classic S/Sx Cushing’s Triad Normal: 60-100 mmHg (-) Abnormal (indicate brain damage) PRIORITY (is respi case): Respiratory rate
• ↑BP (Hypertension) (Widened pulse Mean Arterial Pressure – (minus) & rhythm
pressure >40mmHg) Intracranial Pressure 2. Doll’s Eyes (Oculocephalic Reflex)
• ↓HR (Bradycardia • Positive / Normal doll’s eye reflex DECORTICATE/ DECEREBRATE
• ↓RR (Apnea/irregular)
CPP= MAP – ICP - The eyes move in the direction
***Cheyne Stoke (rapid deep
opposite to that of the head DECORTICATE
respiration w/ long period of apnea)
MAP= (DBP x 2) + SBP movement Still an ominous sign of severe brain
S/sx additional 3 - Normal assessment; no damage damage
• Projectile Vomiting (not ordinary • Negative/Absent May still recover
vomiting) Ex. BP 90/40 ICP 19 - Sign of brain stem injury
• Papilledema (inflammation of optic (40x2) +90 / 3= 56.67 (57) (MAP) - Damage/comatose DECEREBRATE
nerve) ;(Oculomotor: Double vision - Eyes move in the direction of the More severe damage involving brain stem
(Diplopia); Crossed eye (Strabismus), 57-19= 38 (CPP) head movement Poor prognosis; may die
uncontrolled movt (Nystagmus)
• Lateralizing sign (like in stroke)
***Dangerous Complication of ↑ ICP: 3. Decorticate/Decerebrate
Mgt IRRIVERSIBLE BRAIN DAMAGE
• (1st) Position: low fowlers (elevated 4. Babinski Reflex
head of bed 30-40 deg, neutral
alignment (to drain) – airway Fan out foot after stimulation
• (2nd) Oxygen/suction/Fxnl Mech vent Normal for 1-2 yo
PaCO2 30-35 mech vent setting Meds of ↑ICP: Abnormal >2 yo & adult
Peak Expiratory Pressure LOW - Osmotic Diuretics (Mannitol)
• Perform neurological assessment
Monitor U.O; assess weight
• Decrease Stimuli/ Promote Rest (dim
- Corticosteroids
light, avoid many visitors, observe
visiting hours, avoid too much noise) - Anticoagulants
• Move belongings closer to pt - Thrombolytics
• Diet: ↓ Fluids (KVO), ↓Na; NPO - Platelet Aggregate Inhibitors
• Do deep breathing exercise using - Antihypertensives
incentive spirometer
• Avoid straining (cough)
• No frequent suction/turning

HENNAJANECE MY NCLEX NOTES 2021 104 | P a g e

 PARKINSON’S DISEASE
Low in Dopamine (no inhibitory neurons,
so excitatory neurons will activate);
autoimmune
S/sx “TRBA” (Major)
1. Tremors (resting/pill rolling);
tremors stop on purposeful
movts
2. Rigidity (ex. Arms not swing
when walking; shuffling gait;
cogwheel-arms bend near body)
3. Bradykinesia (slow movt) (slow
swallowing cause drooling,
salivation-priority safety); may
use rubber pointed cane/walker
4. Akinesia (no movt/freeze)
• *Mood / Depression
• *Highly suicidal
• *Lost of Smell
• *Constipation (mgt: stool softener;
↑fluids & fiber)
• *Slurred Speech
• *Postural Irritability
Benztropine (Cogentin)- Anti-cholinergic;
mgt for rigidity & tremors
Expected side effect:
- ↑HR
- Dizziness when standing up
***Never give Anti-cholinergic to pt w/
Glaucoma (it can further ↑ Intraocular
Pressure)
HENNAJANECE
PARKINSON’S DISEASE
Mgt
• SAFETY
- Watch out for Orthostatic hypotension-
slow movt
- Use cane/walker
- No rubber soles (may trip)
• Nutrition
- Speech Language Pathologist (assist
swallowing ability of pt)
- Soft diet, ↑Protein
- Easily chewed food; chopped smaller
pieces
• Psychosocial (address depression)
- Maximize autonomy/independence
regarding food utensils, clothing
• Meds
➢ ***Sinemet (Carbidopa-Levodopa)
- may cause orthostatic HPN;
- take effect 3 wks or more
- Toxicity: Facial & eye twitching;
- Lessen tremors;
- S/sx expected: Urine & sweat &
saliva may turn reddish brown/black
& this is not harmful
- *** Avoid Vitamin B6 (Pyridoxine)/
avoid Protein
- Don’t take w/ MAOIS – prevent
absorption
➢ Entacapone (Comtan)–
long term; prevent wear & tear of
Sinemet (reinforce to maintain
effectivity of Sinemet)
➢ Ropinirole - ↑Dopamine; may cause
drowsiness
➢ Amantadine (Symmetrel) - ↑ Dopa
➢ MAOI’s – Selegiline (Ensam); Rasagiline
(Azilect); Avoid tyramine rich foods (may
lead to HPN crisis)
• Squeeze rubber ball – control hand tremors
GUILLAIN BARRE SYNDROME MULTIPLE SCLEROSIS
- Affects Myelin sheath Drug of choice:
- Gradual Block of Sensation (GBS) - Baclofen (antispam)
- Involves Peripheral nerves
- Ascending paralysis S/sx
S/sx
• Incoordination when walking
• Numbness & tingling in lower
- Mgt: keep feet apart & use
extremities
cane
• Bladder& bowel
• Respiratory depression
• Swallowing; speech; vision; brain
Intention Tremors
confusion & mood problems &
depression
• Romberg’s sign (close eyes w/ no
Lhermitte’s sign is a sudden sensation
balance)
• Lhermitte’s sign (electric shock resembling an electric shock that passes
when neck move) down the back of your neck and into your
spine and may then radiate out into your
Causes: arms and legs. It is usually triggered by
• Respiratory/GI infection 2 wks ago bending your head forward towards your
or recently chest
• 40% cause by Campylobacter
infection Uhthoff’s Sign (heat worsen s/sx of MS)
• Pt receives recently flu vaccine
• HIV pts; Epstein Barr
Mgt
• Immunoglobulin
• Plasmapheresis (filter the antibody
that causes GBS)
• No cure
• Renal – use indwelling cath
(monitor I&O)
• Low dose anticoagulants (due to
paralyzed; prone to clot formation)
Diagnostic Test
• Lumbar Puncture
- Expected: ↑Protein, (N) WBC
- Position During: Fetal
- Position after: Flat
- ↑fluid during and after
MY NCLEX NOTES 2021 105 | P a g e
 AMYOTROPIC LATERAL SCLEROSI (ALS)
“Lou Gehrig’s Disease
- Motor-neuron disease; autoimmune;
unknown
- Progressive muscle weakness
- Myelin sheath destroyed
- Lifespan of pt: 3-5 yrs
S/sx
• Muscle weakness
- Swallowing (risk for aspiration);
small bites; soft food; assess gag
reflex
- Respiration
- Extremities
- Fatigue
- Slow speech until paralyzed &
can’t speak totally
Mgt
• Rilutek (Riluzole)
- Will not cure, will only slow the
progression of ALS to 3-6 mos
- S/e Dark urine
HENNAJANECE
BACTERIAL MENINGITIS AUTONOMIC DYSREFLEXIA T6 LEVEL INJURY
Inflammation of meninges (brain/SC) Common in people with spinal cord Good torso
(bacterial/viral/fungal (most fatal)) injuries that involve the thoracic nerves of Weak & loss of function below waist/
Highly contagious (droplet) the spine or above (T6 or above) lower extremities
Autonomic Hyperreflexia
S/sx (in infant)
Mgt
• High pitch cry (1st)
• Fever Causes/Triggers: KAFO (Knee Ankle Foot Orthoses)
• Restless (↓LOC) • Bladder (full bladder, catheterization)
• Bowel (constipation)
S/sx (general) • Break in the skin
• Nuchal Rigidity
• ↑ICP; Headache S/sx
• Disoriented • Severe throbbing headache (1st)
• Brudzinski
• Flashy/red face above level of
• CSF (Purulent, Turbid)
injury; nausea
• Photophobia
• ↑BP (↑20-40 mmHg from
Mgt baseline)
• PRIORITY: Antibiotics (Perform C&S before) • ↓HR ↓RR,,,,,,,,,,,,,,,,,,,,,,,,,,,,'
• Lumbar Puncture (if no ↑ICP) to obtain CSF • Diaphoresis – Sweating above
(PERFORM CT SCAN first to check ICP- high level of injury
ICP will cause brain herniation) • Below the level of injury (pale,
(HOLD antibiotics prior to LP) cold, clammy)
• Seizure precaution
• Piloerection
• High glucose
Complications:
• ↑ICP • Stuffy nose
• Brain Damage
• Hydrocephalus – (in infant) Mgt
↑accumulation of CSF in the brain due • Upright position/high fowlers (1st)
to obstruction • Check BP (1st)
Will lead to ↑ ICP • Check & manage the 3 triggers
CSF production rate is normal (ex. Palpate bladder, check fecal
S/sx
impaction, check skin breakdown)
- Bulging fontanelle (early 1st sign)
• Keep linens wrinkle-free under pt
Complication
- Brain damage • No restrictive clothing
- Impaired learning • Prevent unnecessary pressure on
- Permanent hearing loss lower limbs
REPORT if infant have high pitch cry • Avoid bladder catheterization
after Ventriculoperitoneal shunt (there • Turn & reposition pt every 2 hr
is ↑ ICP due to shunt obstruction); • Ensure pt have good bowel movt
REPORT if pt is lethargic; REPORT for
projectile vomiting (↑ICP
MY NCLEX NOTES 2021 106 | P a g e
 STROKE
- Blood not reach brain due to ↓perfusion
due to bleeding or blockage leading to brain
tissue death
TYPES:
1. Ischemic – blockage
A. Embolus (clot that travels ex.
During Afib)
B. Thrombus (Atherosclerosis)
Mgt: Tissue Plasminogen Activator
(Alteplase)
2. Hemorrhagic – bleeding/rupture
Due to uncontrolled HPN (↑BP)
Aneurysm (bulging of blood vessels)
***Dissecting Aneurysm (most common
type of Aneurysm)
3. Transient Ischemic Attack (TIA)
Mini stroke
S/sx lasts for mins to hrs & resolve
Sign of upcoming bigger type of stroke
Diagnostic
• CT Scan/MRI – to rule out bleeding (if
there is a need of TPA)
Mgt
• TPA (only for Ischemic Stoke; never
for Hemorrhagic) – dissolve clots
(Fibrinolysis)
- Given w/n 4.5 hrs
- Given to normal labs (PLT, INR)
- Pt has no recent anticoagulants
- Contraindicated if SBP>180
mmHg
HENNAJANECE
STROKE
S/sx “FAST”
• Face (check asymmetry)
• Arms (check asymmetry) (ex. Arm drift)
• Smile (check if normal smile)
• Time (crucial)
5 A’s
• Aphasia (Express-diff talking/ Receptive-
diff understanding)
• Agnosia (diff recognizing obj/people)
• Apraxia (slow motion)
• Agraphia (diff writing)
• Alexia (diff reading)
2 D’s
• Dysphagia (prone to aspiration)
• Dysarthria (diff articulating/speak clearly
1H
• Hemianopsia (lost of half vison)
Ex. Right HH – can only see L
Nrsg Responsibilities: (SAFETY)
- Place obj w/n reach
- Approach on unaffected side
- Teach pt to scan surrounding while
walking
MEDICATIONS:
1. Mannitol (Osmotic Diuretic)
Excrete Na, Chloride & water
Hold if BP <90/60 mmHg)
2. Steroids (for inflammation)
3. Anticoagulants
4. Platelet Aggregate Inhibitors
(Clopidogrel; Ticlopidine; Aspirin)
5. Antihypertensive Meds
Aphasia Mgt
• Talk slowly, use pictures
• Allow pt to write
STROKE
Assessment/Mgt
• NIH Scale (11 Scales)
- Minimum score: 0 (no signs of stroke)
- Maximum score: 42
- If 21-42 (severe signs of stroke)
• ↑ICP
- Altered LOC (1st sign)
- Cushing’s Triad (Classic Sign)
↑BP ↓HR ↓RR
- Projective Vomiting
• Position: low fowlers (elevated head of
bed 30-35 deg) , neutral alignment
• O2 & Suction at bedside
• Mechanical Ventilator
35-45 (PaCO2) Normal
30-35 (PaCO2) in stroke pt
↓PEEP
• Assess Pupil for Papilledema
• Assess gag reflex (swallowing)
• Assess bladder (bladder scan)/bowel
(attach IFC, enema due to bowel
impaction)
• Assess skin & limb (tell pt to touch every
2 hrs to prevent neglect syndrome)
• Avoid straining (prevent ↑ICP) give
stool softener
• Seizure precaution
• Perform frequent neurological
assessment (decrease in GCS is
crucial even 1 point decrease)
Diet
• Speech Lang Pathologist (gag, swallow)
• Assess pouch on cheek
• Aspiration Pneumonia Precaution
- During eating, instruct to tuck chin
to chest while swallowing
- Add thickening agent to fluids
- Avoid giving sedatives before
meals
- Upright position
MY NCLEX NOTES 2021
RIGHT SIDED HEMIPARESIS
Injury to the left side of the brain
Affects the right side of the body
S/sx
• Aphasic (difficulty talking,
understanding)
• Weakness on the right side of
body, face and tongue
• Lost ability to move right arm/leg
• Unable to walk/ ambulate
independently
• Unable to feed/bathe without
assistance
• Homonymous Hemianopsia (Has
a visual loss in the same half of
the visual field of each eye)
Ex. Right HH – can only see L
Nrsg Responsibilities: (SAFETY)
- Place obj w/n reach
- Approach on unaffected side
- Teach pt to scan surrounding
while walking
STROKE PATIENT POSITION
• If Hemorrhagic – Low fowlers (to
drain)
• If Ischemic – Flat on bed, neutral
alignment (to promote O2 in the
brain)
POST CRANIOTOMY POSITION
• Semi Fowlers to fowlers w/ head
in neutral position
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 ROMBERG TEST ALCOHOL WITHDRAWAL SYNDROME ELECTROENCEPHALOGRAM GENERAL ANESTHESIA
- EEG – non invasive; painless;
Assess balance of pt Antabuse (Disulfiram)- prevents drinking - Duration: ***Ask for family history of bad reaction
- Close eyes Alcohol o 45mins-1 hr (normal) to general anesthesia- if first time to have
- Feet together & hands on the o 8-12 hrs (if sleep EEG) general anesthesia
1. DELERIUM TREMENS
side
- Result: (+) Presence of Ataxia Alcohol Withdrawal (↓BAL <0.1%) S/sx Nursing responsibilities DANGER:
Impaired balance (sensory “CHITS” • Malignant Hyperthermia (Genetics)
problem) • Confuse/ Disoriented • Have light breakfast - Inherited Muscle abnormality
• Hallucination (Visual/Tactile) • Shampoo head before & after - 1st signs: Rigidity, ↑ O2
Mgt • Increase V/S; Irritable • Ask hcp if sleep/no sleep Consumption
Assist patient w/ ambulation • Tremors • Continue eeg even if pt is having - ↑ Temperature (late sign)
• Sweating (1st sign); Seizure (Last sign) seizure (seizure will help determine
brain waves
Mgt
• Hold stimulants, anti convulsant,
• Anxiolytics/Benzodiazepine
- Diazepam/Lorazepam sedatives, anxiolytics 24-48 hrs prior
- Tranxene • Perform to pt w/ seizure & delirium
- Librium

2. KORSAKOFF’S
- Deficiency in Thiamine (B1) & Niacin (B3)
(these vitamins are vital for memory
function)
- S/sx Memory problems
o Amnesia (Antero/Retrograde)
o Confabulation
- Mgt IM IV Thiamine & Niacin (oral can’t be
absorbed because no intrinsic factors)

3. WERNICKE ENCEPHALOPATHY
- Thiamine Deficiency
Proprioception - S/sx
Eye (Nystagmus; Ophthalmoplegia)
− Ability to sense body movt when
Ataxia
eyes are closed - Give Thiamine IM/IV (Vit. B1) to
prevent Wernicke

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 SYSTEMIC LUPUS ERYTHEMATOSUS
Autoimmune
Danger: Kidney failure (LUPUS NEPHRITIS)
(Monitor renal function: Creatinine, BUN,
Urinalysis)
S/sx
• Butterfly rash (1st sign)-
flat/elevated redness on the skin
• Positive Antinuclear Antibody
(ANA) Test
• ↑BUN, ↑ESR
Mgt
• Avoid stress, sunlight (10am-4p)
• Annual Influenza/ Flu vaccine
• Steroids- immunosupressants
• Hydroxychloroquine
• No hot baths (may cause flare
up)
• Manage fatigue
• Sit whenever possible to
conserve energy
• Avoid long periods of rest (may
cause join stiffness)
• Do some exercise (walking) when
not fatigue
• Avoid sun exposure/ sun bathing
(sun exposure only after 3 pm)
HENNAJANECE
SYSTEMIC LUPUS ERYTHEMATOSUS
HYDROXYCHLOROQUINE
Use to treat SLE; anti-malaria
Prevent relapse
Effects
• ↓skin & arthritic symptoms
• ↓exacerbation
• Effect only after several months
Nrsg Responsibilities:
• Monitor for retinal toxicity &
visual problems (perform
ophthalmologic examination
every 6 mos)
Must be taken w/ food
FEBRILE SEIZURE
- Common in 6 mos-6 yo child
- Cause: unknown
- Reassure parents that febrile seizure
is benign, mild
Mgt
• Antipyretics PRIORITY
(Acetaminophen/Ibuprofen) given
every 6 hrs
• Cooling methods
Damp cloth
Convection (exposing to cold
environment)
Avoid methods that cause
shivering (ice bags, bath)
MY NCLEX NOTES 2021
AUTISM SPECTRUM DISORDER
Cause: Highly Genetic
S/sx:
At least 2 symptoms to confirm (DSM5)
1. Repetitive (movts; objects; speech)
2. Adherence to Routine/Rituals (need to
do same routine)
3. Fixated Interest (objects, activities)
4. Hyper/Hypo Active to Sensory
LEVELS
1. Level 1 (support)
- Difficulty initiating social
interaction
- Organization + Planning probs
2. Level 2 (substantial support)
- Limited social interaction (their
interaction is limited if they have
special needs like hungry)
- Repetitive behavior
3. Level 3 (very substantial
support/custodial care always)
- Severe deficit in verbal/non verbal
- Distress/ No focus
Place in private room away from nurses’
station (lessen stimuli); and pt have poor
social interaction
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LUMBAR PUNCTURE (SPINAL TAP)
Contraindication: pt w/ ↑ ICP
Location: Inserted to 3rd-4th Vertebra of
Lumbar area
Position: Fetal/Sit & Lean forward
S/e after
Headache
Continuous drainage mgt
- Blood patch – injecting blood to
insertion site to create a clot & seal
the puncture and stop the
continuous drainage of CSF
- Patient remain flat (supine/prone)
HENNAJANECE
CONCUSSION
Neurological Changes
• Asymmetrical pupillary dilatation
• Headache
• Brief loss of consciousness
• Retrograde amnesia
1st sign of Neurologic Deficit
• ALTERED LOC (Irritable; Restless;
Flat affect; drowsiness)
***Lucid Interval – temporary regain of
consciousness; need to monitor, may be
sign the pt condition will deteriorate
Mgt for discharge
• Pt must abstain from alcohol
• Report to HCP if having diff
walking
• Responsible adult must stay w/
patient
MY NCLEX NOTES 2021
BELLE’S PALSY
− Unilateral; does not affect motor
neuron
− Only affect eye & face (CN 7)
− Out patient
− Self limiting (can recover after few mos)
− Corticosteroids
− Patient can drive
➢ EYE
- Not close (can wear dark glasses
during daytime)
- Inability to smile symmetrically
- Change in lacrimation on affected
side
- Patch or tape eyelid at night
- Artificial Tears (daytime)
- ↑ tear (lacrimation)
➢ Facial muscle weakness
- Can’s chew (chew on unaffected
side)
- Oral hygiene
- Soft diet
➢ Flat Nasolabial fold; drooping lip
➢ Loss of forehead & brow movt
110 | P a g e
 SPINAL IMMOBILIZATION EMERG TRAUMA ASSESSMENT EMERG TRAUMA ASSESSMENT DELIRIUM
Confusion Assessment Method
Findings that indicate the need for Spinal 1st: BASIC NEUROLOGIC ASSESSMENT “SAMPLE Assessment”
Immobilization “NSAIDS” (Perform first; Ask “Hey are you ok?”) (Head to Toe Assessment) Use for Delirium
• Signs & symptoms
• Neurologic deficit (numbness/ Primary Assessment/Survey • Allergies DELERIUM:
↓strength/paralysis/paresthesia) • Medication
• Significant Traumatic Mechanism 1. Airway (apply cervical collar) • Past Health History Cause:
(injury; MVA; hit head after accident) 2. Breathing (respiration) (O2 or • Last Meal • Infection to brain
• ALOC (confusion) intubation) • Events preceding trauma • Hypoxia
• Intoxication (under influence of 3. Circulation (pulse, HR, control • ↓ Sleep
alcohol bleeding) • Hypoglycemia
• Distracting Injury 4. Disability Check (LOC; GCS; check if • DHN
• Spinal Exam (Point tenderness/ neck pt can move extremities) • ↓Na
pain) 5. Exposure (toxins; poison; chemicals; • Meds (Opioids, Anticholinergics)
hot temperature) (remove & • Alcohol
examine parts under pt’s clothes
S/sx “CHITS”
• Confusion
Secondary Assessment/Survey • Hallucination (visual/tactile)
If pt is stable already (done after primary) • Increase V/S
• Tremors
1. Full V/S (including ECG, tube) • Sweating & Seizure
2. Give comfort (position pt) (manage
pain) Mgt
3. Head to Toe Assessment w/ History • Anxiolytics /Benzodiazepines
(“SAMPLE”)
4. Inspect back of pt

Neurologic Assessment
• GCS
• Pupil
• Motor
• V/S (look for Cushing’s Triad)

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 GLASGOW COMA SCALE (GCS) CRANIAL NERVE CRANIAL NERVE CRANIAL NERVE
EYE OPENING
Sensory (S)
Spontaneously 4 Cranial Nerve Mnemonic Motor (M) Assessment
To speech 3 Both (B)
To pain 2 Olfactory (I) On S – Some Smell test
None (no eye opening) 1 Visual acuity & visual fields
Optic (II) Oh S – Say (use Snellen’s Chart)
VERBAL RESPONSE (Peripheral)
Pupil constriction (Pupil
Oriented (ask Equal Round Reactive to
5 Oculomotor (III) Oh M – Marry
time/year/person/place) light) & extraocular movts (6
Confused (able to answer cardinal gaze)
4
but confused) Extraocular movts (inferior
Inappropriate (far out Trochlear (IV) To M – Money adduction) (Let pt look at 1
3
answer) finger, then move it closer)
Incomprehensive (can’t Clench teeth & light touch
understand the 2 Trigeminal (V) Touch B-But
(AbN ex. Tic douloureux)
words/sounds)
Extraocular movts (lateral
None 1 Abducens (VI) And M – My
abduction)
Facial Movt – close eyes,
MOTOR RESPONSE Facial (VII) Feel M – Brother
smiles (AbN ex. Bell’s Palsey)
Acoustic (VIII) A S – Says Hearing & Romberg Test
Obeys command 6
Glossopharyngeal (IX) Girl’s B – Bad Gag reflex &swallowing
Localizes to pain (moving
5 Say “ah” – uvular and palate
towards pain)
Vagus (X) Vagina B – Business movt (Gag reflex
Withdraws from pain
4 &swallowing)
(retracts from stimulus)
Turn head & lift shoulder to
Flexion to pain Spinal Accessory (XI) Ah M – Marry
3 resistant
(decorticate)
Extension to pain Hypoglossal (XII) Heaven M – Money Stick out tongue (movt)
2
(decerebrate)
None 1
Assess gag & swallowing reflexes
RESULT 9-Glossopharyngeal
TOTAL: 15 (Best response) 10-Vagus
Comatose: 3-8
Head Injury Classification:
o Mild (13-15)
o Moderate (8-12)
o Severe (<8)
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 BRAIN BRAIN HUNTINGTON DISEASE BRAIN MALIGNANCY
- a type of Dementia
- Autosomal Dominant Mgt
- Progressive Nerve Degeneration • CT Scan w/ IV Iodinated contrast
Memory; Speech Sensory; Pain Perception (muscle weakness) - Hold Metformin (will cause
- Lifespan: 20 yrs lactic acidosis)
FRONTAL PARIETAL
Hallmark Sign
• Chorea (tics- jerky involuntary
movt)

Cause of death:
OCCIPITAL • Respiratory Complications
(Located at the
TEMPORAL back of the eye)
Vison S/sx
(Near ear)
• Problem in movement
Hearing • Difficulty in swallowing
BRAIN STEM CEREBELLUM
• Affects speech
Balance • Affects cognitive
Respiration/
Cardio/Vasomotor
Center

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TRISOMY 21 (DOWN SYNDROME)
AV Canal Defect
• Atrial Septal Defect
• Ventricular Septal Defect
• Patent Ductus Arteriosus
• Tetralogy of Fallot
Diagnostic Test
Alpha Feto Protein
− Done @ 16-20 wks Pregnancy
− Result:
Normal: 10-150 mg/dL
↓- Down Syndrome
↑- Neural Tube Defect
HENNAJANECE
PEDIA NOTES
PYLORIC STENOSIS
Stenosis: Thickening (causing narrowing)
RUQ mass 3-5 wks after birth (olive shape)
Cause:
• ↑feeding/ overfeed
• ↑Air swallow
S/sx
• Projectile vomiting
• •
“Hungry” vomiters
• Wet burp in infant (Smaller
amounts foods often occur with
burping)
• Vomitus non bilous
• Dehydration, weight loss
• Metabolic Alkalosis
Mgt
• Assess parent’s feeding technique
• Check vomit is projectile
• Compare weight to birth weight
• Pyloromyotomy (cut the pyloric
muscle to enlarge opening)
CELIAC DISEASE PHENYLKETONURIA (PKU)
- “GLUTEN ENTEROPATHY”
- Autoimmune; Sensitive to protein Gluten − Autosomal Recessive Disorder
- Causes irritation/inflammation at the (each baby has 25% chance of
lining of the intestines
- CELIAC CRISIS – malabsorption
having the disease)
(Steatorrhea) − No Phenylalanine Hydroxylase
- Need to take Fat Soluble vitamins (ADEK) from liver
S/sx Complication: Mental Retardation
• Unexplained weight loss (preventable)
Mouth ulcers
• Menstrual irregularities
S/sx
• Inability to tolerate dairy products &
• No melanin (blonde hair, blue
“BROW”
eyes, albino – fair complexion)
• Enamel changes
• No Epinephrine (less energy)
Avoid Gluten for life • No Thyroxine (growth
• Barley (Beer, ale, porter, stout, malt) retardation/ short stature)
• Rye (bread, crackers, beer, and • Musty odor urine
whiskey, flour)
• Oats (cereals) Diagnostic:
• Wheat (bread) • Guthrie Test – Newborn
• ***Dairy products
Screening (perform after 24 hrs
of birth; feed w/ milk only before
Gluten-free ex.
• Fruits (strawberry) procedure)
• Vegetables (potato, broccoli)
• Meat and poultry (grilled chicken,
ground beef) Mgt
• Fish and seafood • Give milk: Lofenalac
• Dairy (yogurt, cheese) • ↓Protein Diet (no milk, yogurt,
• Beans, legumes, and nuts meat, cheese, beans, peanut
• Rice
butter, eggs)
• Cassava
• Low Phenylalanine diet
• Corn (mex corn tacos)
• Soy
• Tapioca
• Millet
• Buckwheat (not related to wheat)
MY NCLEX NOTES 2021 114 | P a g e
 DIARRHEA
Priority: Hydration
Oral Rehydration solution (pedia)
Goal: Bring back pt to regular diet (↑
Protein, ↑Calories) as soon as possible
Avoid:
• Banana
• Rice
• Apple Sauce
• Toast
- Don’t administer anti-diarrhea meds
to the child
- Record number wet diapers (weigh)
and return to clinic if there is
decrease (Diaper weight 1mL=1gm)
- Use petroleum jelly/zinc oxide as
skin barrier cream until diarrhea
subsides.
EPITAXIS
• Direct, continuous pressure/
pinch nostrils (for 5-15 mins)
• Cold pack/cloth on the bridge of
the nose
• Keep child quiet & calm
• Sit upright & tilt head forward
HENNAJANECE
TETRALOGY OF FALLOT NEONATAL HYPERGLYCEMIA BACTERIAL MENINGITIS
Mix of unoxygenated & oxygenated blood “Tet Risk of Neonatal Hyperglycemia − Inflammation of meninges
Spells” • < 2 kgs birth weight − ↑ICP
↓O2 (Hyper cyanotic Spells)
• < 4 kgs birth weight − Bulging of fontanelle
• Preterm <37 wks − Absence of Babinski Reflex
• Ventricular Septal Defect
• Suspected to have
• Right Ventricular Hypertrophy
sepsis/infection (↑glucose) Initial Signs
• Overriding Aorta
• Nuchal Rigidity – 1st sign
• Pulmonary Stenosis
Normal Newborn Blood Sugar • Brudzinski Sign (Passive flexion
Mgt 40-90 mg/dL of head to chest will cause hips
• 1st Positions during “Tet spells”- ↑ and knees to flex)
venous return
- Knee Chest Position (infant)
- Squatting position (kid)
• Swaddle infant during procedures
• Encourage small frequent feedings
• Kernig’s sign (inability to
• Avoid stress
straighten the leg when the hip is
• Promote comfort flexed to 90 degrees)
• Avoid painful procedures
• Offer pacifier when infant begins to cry
• Promote quiet period upon walking up in
the morning
• Avoid frequent wakening during sleep
• Opisthotonos – late sign
REPORT AFTER REPAIR OF TOF (SIGNS OF
HEART FAILURE:
• Venous Congestion/Pulmonary
Regurgitation)
• Cool extremities (poor O2/circulation)
• Decrease appetite
• Puffiness around eyes (backflow of blood
on neck, face, eyes) Other signs
• Reduction in number of wet diapers • Frequent seizures
(↓cardiac output-kidney can’t release • High-pitched cry
urine & blood/ ↓kidney perfusion) •
Poor feeding
• Weight gain
• Vomiting
***Babinski Reflex- normal upto 1-2 yrs
old; If present in adult (neurologic
irritation)
MY NCLEX NOTES 2021 115 | P a g e
 OTITIS MEDIA
Affects middle ear
Best prevention
Vaccines (Influenza & Pneumococcal
Conjugate Vaccine (PCV)
Assessment: <7 yo Child
• Pull pina Back, Down
Eardrops
• Drop on the linings/sides of ears
***Otoscope- last to be performed
(advance device to outer ear only)
***Pt must complete entire course of
antibiotic
***Don’t give decongestant to child
HENNAJANECE
CHEILOPLASTY
Cleft Lip Repair
− Best age to perform the repair
6-12 wks (before development of
speech)
Mgt Post OP:
• Position: Supine/ Sideway
• Observe for bleeding at the
operative site
• Oxygen Tent – if need O2
• Apply elbow restraints (but not
AT ALL times)
• Cleanse suture line gently after
feeding the infant
• Institute measures that will
prevent vigorous & sustained
crying (promote comfort –
prevent crying)
• Assist mother w/ breastfeeding if
this is the feeding method of
choice
SICKLE CELL ANEMIA
- Autosomal Recessive Disorder (needs 2
parents to have disease; if only 1, the child is
only a carrier)
- Sickle shape (crescent) RBC – stiff, short life
span 10-12 days
- Common in African-American
- Clumping &viscous of RBC leading to
occlusion
- Precipitating Factors
• Hypoxia; Acidosis; Dehydration
TYPES OF CRISES
1. Vaso Occlusive Crisis
- Occlusion of small blood vessels; ↓blood
supply leading to ischemia
- ↑ pain in small veins like hands
(Dactylitis); right arm weak/stroke
- Mgt: pain; hydration; bed rest;
relaxation/distraction (tv,music,read,
imagery); gentle massage
2. Megaloblastic Crisis
- Less Folic Acid (due to immature RBC)
- Mgt: give Folic Acid
3. Sequestration Crisis (Emergency)
- Trap blood in spleen; shock symptoms
- Mgt: REPORT (Splenectomy)
4. Aplastic Crisis (Emergency)
- Cause: Bone marrow failure (excessive
production of RBC due to short lifespan)
- Mgt: Bone Marrow Transplant
Sickle Cell Anemia Priority: Oxygen
SICKLE CELL CRISIS
The sickled Hgb blocks the veins/vessels
− Priority
• Pain Mgt (Patient-controlled Analgesia)
• Hydration (maintain IV line; monitor for
DHN)
- Pt will learn to distract self from pain
- NO Meperidine/Demerol (contraindicated
because it will cause Normeperidine
accumulation in blood-toxic to pt)
- Underrated (may be suspected to abuse)
MY NCLEX NOTES 2021
POLYCYTHEMIA VERA
- type of blood cancer. It causes your bone
marrow to make too many red blood cells.
These excess cells thicken your blood,
slowing its flow, which may cause serious
problems, such as blood clots; RBC is
macrocytic
S/sx
• Thrombus (redness, tender, swelling)
DVT
• May have stroke/ pulmonary edema
• ↑RBC, ↑ WBC, ↑ Platelet
• ↑Blood viscosity
• Venous stasis
• Severe skin itchiness (short lifespan
of RBC)
Mgt
• Use compression stockings / Anti-
embolic (before arising to bed)
• Elevate legs (when sitting)
• Hydrate
• *Phlebotomy
- Every other day
- Remove 300-500 mL of blood
- Monitor for hypovolemic shock
(hypo, tachy, tachy)
• No Iron Supplements
• No Blood Transfusion
• Aspirin to prevent thrombus
SECONDARY POLYCYTHEMIA VERA
- Due to Chronic Hypoxia/ COPD/ Lung
disease (bone marrow is stimulated to
produce more RBC when the body sense
hypoxia)
116 | P a g e
 GERD (REFLUX)
− Heart burn (increase by bending,
lying down)
S/sx
• Dysphagia (due to scarring in long
term)
• Hypersalivation
• Epigastric pain
• Nausea/regurgitation
• Vomiting after meal
Confirmation: NGT (1mL of HCL) – if
increasing pain
Diagnostic:
• Barium Swallow
- Pre-op (inform pt for chalky
taste)
- post op (lighten stool after)
• Endoscopy (NPO; then check gag
reflex after; check for perforation
post procedure; check for
hoarseness of voice)
• Esophageal PH (24 hr monitoring)
Mgt
• Small frequent feeding
• Frequent burping in childing
• No stimulants/gas forming food
• Don’t lie down 2 hrs after
feeding
• Antacids/PPI’s
• Nissen Fundoplication –
surgery to correct GERD.
The surgery tightens the junction
between the esophagus and the
stomach to prevent acid reflux.
HENNAJANECE
HIRSCHPRUNG’S DISEASE
- Missing nerve in the Large Intestine (colon);
Aganglionic Mega Colon, lacking nerve
causes distal intestinal obstruction
- Problem passing stools
S/sx:
• Ribbon-like stool
• Swollen belly
• Abdominal Distention
• Bilous Vomiting
• Diarrhea (in adult)
• Failure in internal anal sphincter
relaxation (tight)
• No peristalsis
• No meconium stool in 24-48 hrs
Danger: Dehydration
Mgt
• Surgery (Bypass/Colostomy)
• Pull-through procedure @ 12-18 mos
(resection & anastomosis)
• IV Fluids & electrolytes
• Stabilize hydration status before
surgery
Complication
• Enterocolitis
- Foul smelling Diarrhea w/ fever &
distention
- Infection on that area that has
Hirschsprung
WILM’S TUMOR INTUSSUSCEPTION
“Nephroblastoma” - Ileum (small intestine) telescope in
Tumor inside kidney large Intestine
- Usually happen in <6yo child
S/sx - Ischemia/leakage of blood
• Unusual contour of abdomen - Non congenital (normal at birth, usually
happen during toddler/preschool time)
Mgt - Cause: Idiopathic (possible
• Don’t palpate (it may Hyperperistalsis in the intestines)
disseminate tumor)
• Post warning signs “Don’t S/sx
palpate abdomen) • Currant jelly stool (Stool mixed
• Nephrectomy – Removal of w/ blood & mucus)
kidney • Sausage shape abdominal mass
• Inconsolable crying (calm
between pain) (screaming &
drawing knees up to chest)
• Severe intermittent colicky
abdominal pain
Diagnosis: Barium Enema (check for latex
allergy, not seafood) – for diagnostic/
therapeutic
Mgt
• Reduction Surgery
MY NCLEX NOTES 2021 117 | P a g e
 CLEFT PALATE
− Opening at mouth to nose
− Repair if child is 6-24 mos
Post op
• Pain mgt
• Upright position (supine w/
elevated head)
• Elbow restraint (remove per
policy to check skin & circulatory
assessment)
• No hard object in the mouth
(pacifier, tongue depressor)
• Provide comfort (avoid crying)
HENNAJANECE
NUTRITION
Toddler Nutrition
• SAFETY
• Provide ↑protein food for brain
development (egg, cheese)
• Avoid small, hard, sticky, slippery
• (hotdog, nuts, grapes, carrot
sticks, corn, dry cereal)
• Avoid raw,
uncooked/unpasteurized
• Avoid high sugar (juices)
INFANT FORMULA
• Discard left over milk
• Unused, prepared formula should
be kept in the refrigerator &
discarded after 48 hrs
• Don’t microwave (danger of “hot
spots” may burn mouth)
• Wash (w/hot water/alcohol) top
of formula cans before opening
MENINGITIS HYDROCEPHALUS
− A complication of other disorders 2 TYPES
1. Communicating Hydrocephalus (CH)
Cause: Microorganism - Non-obstructive (more dangerous)
• Bacteria: contagious - No problem in the production of CSF,
o coli (kids not yet potty trained) still can flow
o Neisseria Meningitidis - Impaired absorption of CSF
o Hemophilus Influenza type B (Hib)
• Virus: non-contagious; self limiting
2. Non-communicating Hydrocephalus
o Ex. Paramyxovirus/Coxsackie virus
- Obstructive Hydrocephalus
- Tumor/inflammation
MOT: Droplet
Diagnostic Test: Lumbar Puncture - Easily treated after removal of tumor
S/sx
• Fever
• Hypothermia Normal CSF Flow: 500 mL/day
• ↑ICP (bulging fontanelle)
S/sx Meningeal Irritation S/sx
• Macewan’s Sign (crackpot sound-skull
➢ Brudzinski’s Sign – flex head, then the leg
will flex becomes thin & ↓deposit of Calcium)
➢ Kernig’s Sign – extend knee, involuntary • Sunset Eyes – eyeball rotate downward
resistance/pain will occur • Increase ICP
• Bulging Fontanelle (non pulsatile)
• Dilated Scalp Vein
CSF (Meningitis)
BACTERIAL VIRAL Mgt:
Color Cloudy Clear CH type – surgery; shunt
↑ WBC; 90% Poly
morpho neucular Pre-op
WBC Slightly ↑
cells); immature • Mannitol - ↓ cerebral edema
neutrophil
• Acetazolamide (Diamox) - ↓CSF
Protein ↑ ↑
production
Glucose ↓ Normal
Post-op
• Position on unaffected side (flat for first
Mgt: PUBLIC IS IN PRIORITY
24 hrs to prevent sudden shift of CSF)
• Respiratory Isolation – droplet
• Non stimulating environment – away from • Upright position after 24hrs
nurses’ station; quiet; dim • Monitor
• Monitor complications: o Infection (redness, smelly, bleeding)
➢ ACUTE – happens while the pt is sick; o CSF Leakage – “HALO TEST”
monitor U.O (SIADH/DI) (+) yellow ring when gauze is place
➢ SEQUELAE – after the disease (3 mos); on the site
Visual/Hearing Test (check visual
loss/strabismus/hearing loss); give
steroids
Diet: Balanced Diet
MY NCLEX NOTES 2021 118 | P a g e
 VACCINES / IMMUNIZATION VACCINES / IMMUNIZATION VACCINES / IMMUNIZATION VACCINES / IMMUNIZATION
Hib (Haemophilus Influenza Type B)
Standard vaccines at 12 mos BIRTH 2 mos 4 mos 6 mos - Causative agent of respiratory
- Haemophilus Influenza Type B Hep B Hep B Hep B infection & meningitis
(HiB) Dtap Dtap Dtap
- Hepatitis A Rota #1 Rota #1 Rota #1 IPV (Inactivated Polio Vaccine)
- Measles, Mumps, Rubella Hib Hib Hib - Killed vaccine; OK for patient w/
- Pneumococcal Conjugate Vaccine IPV IPV IPV AIDS
(PCV) PCV PCV PCV - Check: allergy w/ Neomycin/ Gelatin
- Varicella INfluenza
OPV (Oral Polio Vaccine)
Administration (<7 mos) - Live attenuated vaccine
- Ventro Lateral 12 mos
- Vastus Lateralis Influenza
Hib Harry
- *not on the Ventrogluteal (middle)- - Given yearly; protects pt from 3
PCV Potter
this muscle only develop when baby strains
MMR Murdered
starts to crawl - Check: Allergy w/
Varicella Voldemort
egg/chicken/duck/feathers

4 years old MMR (Mumps/Mumps/Rubella) &

MMR My Varicella
Dtap Doctor - Live attenuated
IPV Is - Check: allergy w/ eggs/ Neomycin/
Varicella Very 4getful Gelatin

PCV (Pneumococcal Conjugate Vaccine)

➢ Influenza Vaccine o PCV 13 (Prevnar 13) – for
• Injection (killed)- can be give from 6 mos & above; can be given to pregnant; children
MMR can be given to chronic diseases like AIDS o PCV 23 – adult
1st 12-15 mos − Highest priority
2nd 4-6 yo o 6 mos- 23 mos child Rota Virus
*Exception: o Elderly (>60yo) o Rotarix (2 doses)
If baby <12 mos got expose to measles, o Health care workers o RotaTea (3 doses)
baby need to receive MMR w/n 72 hrs
Then continue w/ normal dose @12-15 • Nasal Spray (live/attenuated)- FLUMIST QUADRIVALENT Hep B (Hepatitis B)
mos & 4-6 yo the only nasal spray flu vaccine available; not for immunocompromised pt - Recombinant vaccine
(cancer, chemo, pregnant); Can only be given to 2-49 yo - Check: Yeast allergy
***Tdap – harmful to baby

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 GROWTH & DEVELOPMENT GROWTH & DEVELOPMENT GROWTH & DEVELOPMENT FREUD: PSYCHOSEXUAL THEORY

Growth Development DEVELOPMENT “OAPhaLaGe”

- ↑ size - ↑ skills & ability ❖ GROWTH CHART Purpose of life is to satisfy libido
- Measurable - Observable - Normal: 10-90% DDST: Denver Developmental Screening Test
- Preschool: 4-5 pounds a year (wt); 2-3.5” Stages Age Zone Name
- Quantitative - Qualitative 4 areas to check
a year (height) Gross motor 0-12
- Criteria for growth Infant Mouth Oral
Fine motor mos
➢ Weight - Growth Gap – minimal changes during
1-3
toddler/preschool Language Toddler Anus Anal
➢ Height Personal Social mos
➢ Head Preschool 3-5 yo Genitalia Phallic
➢ Chest ❖ INFANT (use disposable tape to School age
6-12 No more
Latent
- Dentition: Tooth ❖ PERSONALITY DEVELOPMENT yo zone
measure; level of eyebrow) 13-19
development 1. Freud: Psychosexual Theory Adolescent Genitalia Genital
o HC: 33-35 cm yo
2. Erikson: Psychosocial Theory
o CC: 31-33 cm 3. Piaget: Cognitive Development
o AC: 31-33 cm 4. Kohlberg: Moral Development
GROWTH *Note: At 1 yo: HC = CC 1. ORAL

❖ WEIGHT
➢ 1 yo: CC > HC Characteristic: Thumb sucking

- Normal: 6-9 pounds ➢ At 2 yo, anterior fontanelle

Nrsg Responsibilities:
- First week: Decreased by 10% or ½ or 1 close, stop measuring
o Mother needs to breastfeed frequently
pound o Mother w/ HIV (exclusive bottle
- Losing >1 pound after 1 wk: FTT (Failure feeding); may BF if poor resources
to thrive)- very thin ❖ FONTANELS o Baby Bottle Syndrome – milk stays in
• 6 mos: 2x • Anterior: Diamond: 12-18 mos mouth may cause dental decay
• 1 yo: 3x • Posterior: Triangle: Closes at 2-3 mos o Use of pacifier
• 2 ½ yo: 4x
Oral Fixation Personality Traits (If not satisfied)
❖ DENTITION • Over eating
❖ HEIGHT • Natal teeth: present at birth • Overly talkative
- Normal height: 20’’ • Six mos: First tooth erupt – lower • Smoker/alcoholic
- 4 yo: 2x central incisor; 20 temporary (milk • Sarcastic
- 13 yo: 3x (approximately 60 inches or 5 teeth/Deciduous teeth); may have • Biting
ft) low fever – important to know to
check if baby is biting (PICA) stuff like
crib (paint poisoning)
• 3 yo: complete deciduous teeth –
Brush brush brush three year old
***Wilm’s tumor = nephroblastoma (do not • 6 yo: Deciduous teeth fall off (lower
palpate abdomen incisor first to fall)

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 FREUD: PSYCHOSEXUAL THEORY FREUD: PSYCHOSEXUAL THEORY ERIKSON’S PSYCHOSOCIAL THEORY ERIKSON’S PSYCHOSOCIAL THEORY
Personality based on experiences (Developmental Task)
2. ANAL 3. PHALLIC Continuous development even after adolescent
Characteristic: Holding on/Letting go − Zone: Genitalia
Anal Fixation Personality Traits − Sexual Identity is known STAGES DEVELOPMENTAL TASK
• Extreme orderliness/Messy − Boy (masturbate)/ Girl (penis envy) TRUST vs.
• Obsessiveness − Premature Affection INFANT N/R: satisfy gratification immediately
MISTRUST
• Rigidity
N/R:
❖ Oedipus Complex ❖ Negativism – persistent “NO” answer; struggle for
❖ TOILET TRAINING - Son loves Mother autonomy
- Don’t force (may lead to poor coping - Son hates father
- Don’t ask yes/no
mechanism) - ***Son should identify w/ father - Close ended question (offer choice)
- Play games/challenge child
➢ Readiness to Toilet Train ❖ Electra Complex AUTONOMY vs. ❖ Temper Tantrums – frustrations/manipulation
A. Physiologic - Daughter loves father TODDLER
SHAME/DOUBT N/R:
- Myelination (muscle control; - Daughter hates mother - Ignore except safety compromise
cephalocaudal pattern) - ***Daughter should identify w/ - Consistency
• Sit, Squat, Walk (signs that mother - Time-out – Discipline; Duration: as long as his
myelinization is complete)
age; start at 18 mos
• Stay dry for 2 hrs Anal Fixation Personality Traits
❖ Ritualism – allow security object during
• Vanity hospitalization
B. Psychological Readiness • Exhibitionism
• Verbal cues (saying “wewe”) Initiative – learning how to do things; thinking but not
• Pride INITIATIVE vs.
• Non verbal cues (pulling diaper, PRESCHOOL right; give drawing pad; never ever correct the child;
GUILT
throwing) imaginative play; no need actual toys; abstract drawing
4. LATENCY
Industry – learning how to do things well
− Dormant personality; no zone
➢ Guidelines for Toilet Training Mastery/perfection; repetitive action to gain perfection;
− Focus is socialization INDUSTRY vs.
• Introduce “potty chair” SCHOOL AGE don’t want hospitalization because they will be left
− “Homosexual Stage” (boys play w/ boys, INFERIORITY
aside; allow to continue action; allow continuation of
• Dress in easily remove clothing (no girls w/ girls)
buttons, only garter) school project; competitive
• Set a schedule “Who Am I?” “WHAT AM I GOING TO BE?”
5. GENITAL IDENTITY vs. ROLE
ADOLESCENT Want to decide for themselves; peers; enemy: parents;
− Secondary sex characteristics come out CONFUSION
become a friend to the child; Role confusion
➢ Principles in Toilet Training − Puberty
• Bowel training learned first than bladder YOUNG INTIMACY vs. 20-35 yo
− Body image is important ADULT ISOLATION Long term relationship
training
• Daytime bladder control first than night MIDDLE GENERATIVITY vs. 35-55 yo
MALE FEMALE ADULT STAGNATION Sharing is important; stagnation (self absorb)
time
• ↑Height • Widening pelvis INTEGRITY vs.
• Enuresis (bed wetting) – normal until 6 yo OLD AGE 55 yo; Wisdom
• Change in voice • Thelarche DESPAIR
(If >6 yo REPORT)
• Testicular (breast)
enlargement due • Menarche
Mgt of bed wetting
to Testosterone
o ↓ Fluids at night
• Pubic hair
o Wake child up in the middle of the night
• Axillary hair
o Void before sleeping

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PIAGET’S COGNITIVE DEVELOPMENT PIAGET’S COGNITIVE DEVELOPMENT PRINCIPLES OF DEVELOPMENT DEVELOPMENTAL MILESTONES
4 Stages of Cognitive Development
1. Sensorimotor (0-2 yo) 3. CONCRETE OPERATIONAL 1. Cephalocaudal – head to feet MOTOR
2. Pre-operational (2-7 yo) − PROCEDURES: show prototype 2. Proximodistal – learn/develop from 1 mo Head turn side to side
3. Concrete Operational (7-12 yo) − Characteristics: “Collector” center to side (ex. Arms raise first, 2 mos Lift head
4. Formal Operational (>12 yo) • Decentering – open minded; listening
then learn to pick up) (ex. 1st lower 3 mos Lift head & chest
to others
1. SENSORIMOTOR • Accommodation – adjust to new
central incisor, last-molars) 4 mos Turn front to back
− Cephalocaudal order of development situation (ex. Summer lesson) 3. Differentiation – from simple to Turn back to front; Roll over
− PROCEDURES: w/ mother • Conservation – change in shape complex 5 mos (SAFETY-never leave baby
➢ Reflexive Activity (Involuntary doesn’t mean a change in size (10yo) 4. Secular – universal (applicable to alone)
actions) • Class Inclusion – grouping objects w/ all) 6 mos Sit w/ support
• Tonic Neck reflex “boxing” similar properties 5. Sequential – pattern; predictable 7 mos Sit w/o support
• Grasp reflex (palmar/plantar)
• Step reflex 4. FORMAL OPERATION 8 mos Crawl
- Disappear majority @ 4-6 mos − Mature/ abstract thinking (think of 9 mos Creeping w/ knee support
DENVER DEVELOPMENT SCREENING TEST
- Will be replaced w/ voluntary reflex future) 10 mos Stand w/ support
(DDST)
- Except: Plantar Grasp reflex − There is solution to a problem 11 mos Cruising
1. Gross Motor – general movt
(disappear at 10 mos); Babinski − PROCEDURE: give time to think about 12 mos Walk while holding
(disappear 12-15 mos) the procedure; use pamphlet/ describe (walk/run)
Walking alone (buy push &
➢ Object Permanence 2. Fine Motor – write; draw 15 mos
pull toy if can walk)
- Object continue to exist even can’t 3. Language – use of words to
be seen describe obj
- Learn @ 8-10 mos 4. Personal social – interaction
- Start to have Separation Anxiety HANDS/FINGERS
(start at infant, peak at toddler, end 5 mos Voluntary grasping
at preschool) 7 mos Transfer from one hand to
- Understand that mom is till there *** DEATH other (tip: have hands up on
- Play “peek a boo” Pre-Operation the side like #7)
− Death is “sleep” or form of punishment;
2. PRE-OPERATIONAL 9 mos Thumb & index finger
wishful thinking; reversible
− Procedure: explain right before (Pincer grasp)- risk for
− Magical Thinking – imaginary friend; chocking
Animism (talk to inanimate object)
− Assimilation – inability to adjust to new
situation Know to button
− Egocentrism – close minded (never 3 yo Run
argue w/ the child)) Tricycle
Lace the shoe
***If child have imaginary fear (like monsters 4 yo
at night), go w/ the flow and be the person of Jump
authority Tie shoe
5 yo
- no to co-sleeping Throw ball
- distract the child 6 yo Bicycle (learn to balance)

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 LANGUAGE DEVELOPMENT PERSONAL SOCIAL KOHLBERG MORAL THEORY SEPARATION ANXIETY
PLAY=WORK 3 FEARS
1 mo Crying 3 STAGES 1. Fear of Dark – due to imagination;
Social smile (Tip: making INFANT Solitary (stimulate intervene to distract; use night light
2 mos 2. Fear of Separation
peace sign during picture) senses) 1. PRE-CONVENTIONAL (2-7 yo)
3. Fear of Mutilation – over imagining
3 mos Cooing Safety (no detachable - Moral is right if it benefits self
things (fear of invasive procedures, may
Babbles (report if no coo & parts; no sharp obj; not - Ex. Ate all the pizza leak blood)
4 mos babbles at this age, child too big/small;
possible deaf/mute) Mobile (should be 2. CONVENTIONAL (7-12yo)
5-6 Simple vowel sounds (Tip: 5 lightweight so it move - Concern about what other say Stages of Separation Anxiety
mos vowels) by the wind) - “good boy/nice girl” 1. Protest
9 mos First word “Dada/Papa” Favorite toy of baby: - Following rules - Let the child cry; don’t spank
10 mos 2 words (+ “Mama”) mother - Don’t use time, associate w/ event
4 words (2 words + TODDLER Rough Play (outdoor) 3. POST-CONVENTIONAL (>12 yo) (ex. I will come by dinner)
12 mos Parallel Play (indoor)- - Make decision for self & respect
Dada/Mama)
50 words; 2 words sentence same toys decision of others 2. Despair
2 yo PRESCHOOL Associative/Cooperative
(ex. “Mama go”) - Child is depressed, withdrawn,
900 words; 3-word sentence Sharing/teamwork mumbling, cry
SCHOOL AGE Competitive ***0-2 yo (Amoral)
3 yo Preschool: 300
questions/day Rules/regulation 3. Detachment
4 yo 1500 words There is a winner - Not all reach this stage
5 yo 2000 words ADOLESCENT Entertainment - The child separates their emotions
Something that reflects - Divert self to others
their identity

*** SIBLING RIVALRY

- Neutralize feeling (ex. Bringing home a
doll for her daughter when her baby
SAFETY brother is brought home)
Car Seat - Spend time w/ older child also

INFANT Rear facing ***IMAGINARY FRIEND

TODDLER/ - Mgt: increase social interaction w/ others
>20 lbs (front facing)
PRESCHOOL
SCHOOL AGE Booster Seat ***MASTURBATION
- A sense of security that penis is still there
>13 yo, 5 ft
ADOLESCENT - Don’t stop, may lead to exhibitionism
Front Seat - Tell to do it privately/destruct w/ toys

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 HYDROCEPHALUS
2 TYPES OF SHUNTS
1. VP Shunt (Ventriculoperitoneal
Shunt)
- Inserted at the back of ear, then
the other end is at the chest skin
(put allowance on the length of
the tube for growth of the child);
another surgery (revision of
shunt) will be done at later time;
excess CSF will be absorbed in
the peritoneum
2. VA Shunt (Ventriculoatrial Shunt)
- Excess CSF absorb in the R atrium
of heart; can’t put excess tubing
so this is usually done to a full-
grown child; done if VP is
contraindicated to the child (ex.
Peritonitis)
HENNAJANECE
NEURAL TUBE DEFECT CEREBRAL PALSY RHEUMATIC HEART DISEASE
CNS malformation; CNS didn’t completely form − CNS formed but damage Cause: autoimmune
due to Folic Acid Deficiency (during pregnancy) − Permanent/Irreversible/Non progressive
Precipitating factor: previous GABHS
***Next pregnancy will also have NTD, so the Risk Factors:
parents must plan pregnancy (eat foof rich in Folic (causative agent of sore throat; aerophilic
• Hypoxia (related to prolong labor)
Acid – kale, greens, broccoli, chick peas, kidney wants moist) infection in the tonsils
• Rx Incompatibility
peas, liver, brussel)
TYPES oF CEREBRAL PALSY S/sx JONES CRITERIA
S/sx (+) RHD 2 major sx/ 1 major & 2 minors
➢ Spastic CP
A. Brain (Diagnosis: Anticipatory Grieving)
a. Anencephaly – no cerebrum
- Most common (need custodial care)
b. Exancephaly – brain develop outside skull - S/sx: muscle spasm Major S/sx Minor S/sx
➢ Ataxic CP • Carditis • Fever
B. Spinal Cord - Wide base gait • Erythema • Arthritis
a. SPINA BIFIDA - Cerebellum is commonly affected
Marginatum • Raised ESR/C-
2 TYPES OF SPINA BIFIDA - Astereognosis (inability to identify obj
• Polyarthritis reactive protein
SB Occulta SB Cystica placed in hand)
➢ Dyskinetic CP (Athetoid) • Subcutaneous (markers of
- Hidden Sac at the back
- Disorganized movt if ↑ stress Nodules inflammation)
- Gap in the A. Meningocele
spinal - Contains CSF only; nerve - Move in writhing movt (worm like) • St. Vitus Dance • ECG changes
verterba is intact ➢ Mixed CP (worst type) (Sydenham’s (prolong PR
- Skill dimpling B. Myelomenigocele - Several brain areas affected chorea) interval)
- Tufts of hair - Contains CSF &spinal
- Common site: nerve inside the sac S/sx
Diagnosis
lower lumbar - Prone to permanent • Persistent reflexes
paralysis • ASO-titer (Anti Streptolysin O-titer)
• Delayed development (Universal Sx of CP)
• Abnormal Posture – To check if pt have antibodies
Pre-op (Protect sac) against GABHS)
- Position: Strictly Prone ***Mild Physical sx (severe mentally retarded)
- Don’t put diapers ***Severe Physical sx (mild mr) Mgt
- Moisten w/ NSS; don’t take out dressing, just
• Corticosteroid (Prednisone) -drug of
add another new layer
Diagnosis: UTZ (small brain & head circum) choice; supress inflammation
Post-op (Protect against complication) • Aspirin – antipyretic/anti
Mgt
- Position: Unaffected side (Prone/Lateral) inflammatory
- Myelomenigocele: do Needle Prick test (to • Baclofen (Lioresal) – Muscle Relaxant
• Penicillin Prophylaxis – every
test extent of paralysis) • Botulinum Toxin (Botox) IM injcection
- Use local anesthesia (apply 60 mins month injection at buttocks
Discharge (rehabilitation) before procedure)
- Enema - Wrap/cover after
- Clean intermittedn catheter - Inject every 3 mos
- Assess for Latex Allergy (fruits-
Avocado/Banana/Chestnut/Kiwi); use Nitrile
Vinyl Gloves
MY NCLEX NOTES 2021 124 | P a g e
 KAWASAKI DISEASE
− Mucocutaneous Lymph Node
Syndrome
− Happens before puberty
− Inflamed mucus membrane (ex. Eyes)
− Vasculitis (inflamed nerves)
Cause: Idiopathic
S/sx
• Fever (high fever) – unresponsive to
antipyretic
• Strawberry Tongue
• Inflamed joints
• Red eyes
• Rashes
• Enlarged Lymph Nodes
• Desquamation (peeling)
Diagnosis:
• ESR – severely elevated
• ↑PLT (Thrombocytosis)
Mgt
• Gamma Globulin IV – stop immune
response
• Delay vaccination (will not work due
to low immune response)
• Aspirin (antipyretic/anti
inflammatory/anti platelet)
• Abciximab – platelet inhibitor
Complication
• MI due to ↑ PLT & clotting small
vessels (Monitor for Severe
abdominal Pain)
• Aneurysm – due to bleeding & clot
• Thrombosis
HENNAJANECE
CONGENITAL HEART DEFECTS
2 TYPES
1. Acyanotic Heart Defects
- Shunting of blood from Left to
Right (“other letter”)
2. Cyanotic Heart Defects
- Shunt from Right to Left
A. Tetralogy of Fallot
B. Hypoplastic Left Heart Syndrome
A. TETRALOGY OF FALLOT
- Diagnose immediately during birth
- Most common cyanotic heart defect
Diagnostic
• 2D Echo – Coeur- En- Sabot (boot
shaped heart)
Mgt
• Manage “Tet Spells”
• Position: Knee chest/squatting
• Palliative – “Blalock- Taussig
Procedure” (increase blood flow to
lungs)
• Give Prostaglandin E (to keep Ductus
Arteriosus open & increase blood flow
to lungs)
• Corrective – “Brock Procedure”
B. Hypoplastic Left Heart Syndrome
- Born w/ Left ventricle not working
- No cardiac output
- Worst type of heart defect
- Need heart transplant
CONGENITAL HEART DEFECTS
Acyanotic Heart Defects
A. VENTRICULAR SEPTAL DEFECTS
S/sx: Murmur (heard on the lower Left
ventricular sternal border)
Diagnostic Test: 2D/3D Echocardiography
Mgt
• Open Heart Surgery (if small it will
close eventually)
- Use cardiac catheterization
- Dacron Patch (to cover the hole
in the heart)
- Attach pt to heart-lung machine
(Cardiopulmonary Bypass
Machine)
B. ATRIAL SEPTAL DEFECT
− Hole in between Atrium
S/sx: Murmur (2nd ICS Left upper sternal
border)
Diagnostic Test: 2D/3D Echocardiography
C. ATRIAL VENTRICULAR CANAL
DEFECT
− “Endocardial Cushion Defect”
− Most common among Down
Syndrome
− Hole in the middle of heart (one
area of the heart don’t have
valve)
S/sx: Murmur (Upper left sternal border)
MY NCLEX NOTES 2021
CONGENITAL HEART DEFECTS
Acyanotic Heart Defects
D. PULMONARY STENOSIS
− Narrowing of pulmonic valve
S/sx
• Right Ventricular Hypertrophy
• Split S2 sound
Mgt
• Balloon Valvuloplasty (inflate
balloon in the pulmonic valve and
a stent is placed to keep area
open & allow blood to flow)
E. AORTIC STENOSIS
− Narrowing of aortic valve
S/sx
• ↓Cardiac Output (volume of
blood in the aorta) = Stroke
Volume x HR
• ↓BP
• Weak pulse
Mgt
• Balloon Valvuloplasty
F. COARCTATION OF AORTA
− Narrowing of aortic blood vessels
S/sx:
• Normal Cardiac Output (but there is
imbalance in blood distribution)
(mostly distributed at upper body &
less on lower)
o Upper Body: ↑BP; Strong Pulse
o Lower Body: ↓BP; weak/thready
pulse
Mgt
• Surgical Resection (remove narrow
area & end to end anastomosis)
125 | P a g e
 CONGENITAL HEART DEFECTS
Acyanotic Heart Defects
G. PATENT DUCTUS ARTERIOSUS
− Non closure of Ductus Arteriosus
(connection between Aorta
&Pulmonary Artery; normally
closes after few days of life)
S/sx
• Blood from Aorta will divert to
Pulmonary Artery (the 2nd biggest
artery)
• Machinery Like Murmur
Mgt
• Medication first to decrease
Prostaglandin
• Indomethacin (Prostaglandin
Inhibitor)
Diagnosis: Unknown; just check ↑
Prostaglandin
HENNAJANECE
CONGENITAL HEART DEFECTS
GENERAL S/SX
• Oxygenation problem
• ↑HR ↑RR
• Swelling legs, abdomen, around
eyes, ankle, hands, feet
• Failure to Thrive
• Dyspnea during feeding
• Extreme tiredness & fatigue
• Fainting during exercise
COMPLICATIONS
• Infective Endocarditis
- Mgt: Antibiotic
• Heart Failure
- Mgt:
o Beta Blockers
o Digoxin (make heart stronger;
check apical HR) Hold if
<100bpm in Pedia
• Cerebrovascular Accident
o Ischemic Stroke (due to low O2)
o Polycythemia Vera (many RBC
causing viscous blood w/c can lead
to Thrombosis, then ischemia)
CLEFT LIP / CLEPT PALATE TRACHEOESOPHAGEAL ATRESIA/FISTULA
Risk Factors:
• Genetics ❖ TRACHEOESOPHAGEAL FISTULA (TEF)
• Gender (M-prone to CL; F – prone to CP) − abnormal connection (esophagus
• Medications (teratogenic)
& trachea)
o Thalidomide – cause severe birth
defects
❖ TRACHEOESOPHAGEAL ATRESIA (TEA)
o Valproic Acid – anti convulsant − Closure (part of esophagus;
o Accutane (Vitamin A) – for acne causing backflow)
o Methotrexate – Rheumatoid
Arthritis/SLE
Problem: Prone to aspiration
Mgt
• CL – Cheiloplasty (done younger)
- Perform when child is 10 wks/10 lbs/ 10
g Hgb (non anemic)
• CP – Palatoplasty (when older)
- Perform when child is 6-18 mos (wait
until palatine arch is formed)
Pre-op Mgt
• Feeding Technique (Haberman feeder/
Medicine Dropper)
o Enlarge bottle nipple
o Stimulate suck reflex
o Swallow slowly
o Rest (burp frequently)
Post Op
• GOAL: Protect suture line ***Type C- most common
• Position: Unaffected side (CL); Prone (CP)
• Restraint (to prevent scratching suture) S/sx
o Elbow restraint (remove every 2 hrs • Coughing
for 10-15 mins; remove one at a
• Choking
time)
• Cyanosis (due to laryngospasm)
• No hard objects in the mouth
• Logan’s Bar (keep suture intact in CL) • Drooling of Saliva)
Mgt
• RISK FOR ASPIRATION
(Emergency)
• NPO
• Resection & Anastomosis
MY NCLEX NOTES 2021 126 | P a g e

ADVANCE DIRECTIVES
− Decisions about their treatment
ahead of time in case unable to make
their wishes known
− Ex. Brain hypoxia; Active Alzheimer’s;
Stroke; Altered LOC; Severe Mentally
Ill
• Can change decision (if pt is still
conscious & coherent)
• In the medical record, provide
copies to proxies and client to
put on safe place
• FORM not need notarized;
accomplished in the health care
facility
• 2 witnesses (Cannot be HCPs or
proxies)
• Mild Alzheimer’s –(encouraged
to make AD); but can still follow
decision of pt at present
• DNR may or may not be included
TYPES OF ADVANCE DIRECTIVES
1. LIVING WILL
- Instructions about future medical
treatment if unable to
communicate
2. POWER OF ATTORNEY/
SURROGATE/PROXY
- Designated to make health care
decisions when unable
- Have document to support the
role
Note: POA 2 types
1. Medical
2. Financial
HENNAJANECE
ETHICO LEGAL / CULTURE/ SAFETY NOTES
DNR (DO NOT RESUSCITATE)
TWO TYPES
1. DNR Bracelet (in the hosp)
2. POLST (Portable Orders for Life
Sustaining Treatment)
- Out of Hospital DNR
- No heroic measures to save
- Provide comfort (ex. Give O2;
continue care)
* *+Stop Resuscitation upon knowing DNR
Status
* *If not breathing – next is to CHECK THE
PULSE, EXPLAIN to relative
* *Clinically death (don’t remove lines;
call the agency that handles organ
donation for them to explain to family of
pt)
* *only remove life support if pt is
determined brain dead
ETHICAL NURSING PRACTICE ETHICAL NURSING PRACTICE
➢ JUSTICE: Treating equal (equal ➢ AUTONOMY: Freedom to make
distribution of resources; to the pt Decision for oneself (If pt change
that needs the most) mind, refer to HCP to discuss first,
then if still want to change, then
➢ VERACITY: Tell the truth (ex. The pt respect)
needs to know they are dying)
(needed in making incident report) ➢ CONFIDENTIALITY: Confidential
information is kept, unless w/
permission to share or required
➢ ACCOUNTABILITY: Accepting
responsibility/admitting errors by Law. *e.g. OB history (not
allowed for the nurse to discuss
(ex. Documenting the nurse the ob history if the pregnant
administered wrong medication) mom is w/ a man or other
person- verify later if the patient
➢ FIDELITY: Loyalty and fulfilling is alone)
commitments (meet (expect harm like suicidal
responsibilities) ideation)
➢ NONMALEFICENCE: Doing no harm.
Protect clients who can’t protect
themselves (ex. Pt is lethargic, raise
siderails; nurse don’t endorse pt to
an intoxicated incoming nurse; pt
had sedatives for discharge, ask if pt
have driver/call someone to drive)
(ex. Report abuse to a client)
➢ BENEFICENCE: Promote good and
do what is best for the client
*e.g. PATERNALISM type of
BENEFENCENCE, clients treated
as children.
MY NCLEX NOTES 2021 127 | P a g e
 LEGAL NURSING ISSUES
➢ BATTERY: Intentional touching
without person’s consent
Eg. Insert needed Catheter even if
client refuses it Administer
Morphine to difficult alert client
Surgery with no consent
➢ ASSAULT: Threat without touch
ex threatening to give diazepam if pt
does not comply
➢ FALSE IMPRISONMENT:
Confinement against their will
without legal justification
Ex. Storing pt’s clothes to prevent pt
from leaving prior to treatment
o Except if pt have risk to self &
others (ex. Suicidal) ; pt have
altered LOC (ex. Alcohol
intoxication)
➢ INVASION OF PRIVACY: Disclose
medical information
*”Client Report sheet on pocket
going home (Client report sheet
should be shredded after duty)
*”Can’t censor visitor conversations
ex. Posting on social media about
medical update of a friend
***Malpractice (doing something beyond
your scope of practice)
HENNAJANECE
DOCUMENTATION AMA (AGAINST MEDICAL ADVICE) IMPAIRED STAFF
AMA (AGAINST MEDICAL ADVICE) (Substance Abuse)
➢ DOCUMENTATION - Risk explained and understood - NOTIFY Super or Charge Nurse
- Clear (competent & coherent) - DO NOT ENDORSE CLIENT
- Concise & accurate - Even if POTENTIALLY LIFE - DOCUMENT
o Timely THREATENING (refer to HCP first) - DO NOT CONFRONT unless with
o Truthful o Eg. Coffee-ground emesis from IMMEDIATE HARM
o Appropriate chronic use of aspirin
- Not opinion o ST elevation on ECG Inappropriate Behavior of Staff
o Sickle cell crises on 02 face mask
➢ Report to Nurse Supervisor –
➢ ADVERSE EVENTS if the action is Illegal
- Document (ex. Stealing meds; coming
o actions taken INELIGIBLE TO LEAVE AMA intoxicated w/ alcohol; self abusing
o Time • Mental illness meds)
o Key pertinent negatives • Danger to self or others ➢ Confront/Take Over/Intervene –
o Intervention to reduce harm • ALOC – Altered LOC if the action is Illegal & will cause
• Do not permit life-saving immediate harm
treatment even if religious (ex. Inserting IFC w/o sterile gloves)
➢ ELECTRONIC RECORD reasons (refer to mgt) (ex. HCP didn’t wash hands after
- Factual, descriptive, objective (sees, Except for blood transfusion handling pt; confront and offer
feels, hears, and smells) • Under chemical influence alcohol-based sanitizer) (ex. Drunk
- AVOID seems, appears, and normal • Court decision nurse preparing medications)
➢ Deal w/ it later – action is illegal but
no harm and can be address at later
***If late entry, specify in your time
documentation that it is a late entry ➢ Ignore – Legal and not harmful
***CODE WHITE – calling safety protocol
team (ex. Relative punch a nurse)
***Endorsing to incoming nurse who
smells alcohol on the breath &has slurred
speech
• Don’t continue hand off report
• Document incident
• Notify charge nurse
MY NCLEX NOTES 2021 128 | P a g e
 MINORS PROTECTED HEALTH INFORMATION INFORMED CONSENT INCIDENT REPORTS

MINORS CAN PROVIDE THEIR CONSENT PROTECTED HEALTH INFORMATION ***Pt must be on Legal age, unless INCIDENT REPORTS
(Below 18) deemed emancipated minor − Incidents, accidents, or occurrences
• Not released without client’s that cause actual or potential harm
1. MEDICAL EMANCIPATION permission. FACTORS FOR INFORMED CONSENT to a client, employee, or visitor
• Emergency care • Reasonable effort to limit (Involved − Surgeon EXPLAINS (not the nurse) − Paper form is filed at medical record
• STD with care) (don’t tell the diagnosis to − Client UNDERSTOOD − Not to be mentioned on nurse’s
• Mental health & Substance abuse other health personnel if not needed − VOLUNTARY notes
treatment like other staff need to bring to xray)
• Pregnancy • Not be shared with a partner or • Nurse witnesses signature Purpose:
• Contraception spouse • SEDATED CLIENT REQUIRES • Risk management
o Calling complete names is OK. PROCEDURES NOT LISTED ON THE • Prevent similar incidents
2. LEGAL EMANCIPATION o INADVERTENT COMMUNICATION CONSENT FORM. • Potential litigation claim
• Parent, Married is not a violation (ex. 2 nurses
• Financially independent currently endorsing, then a pt Contact:
• Active Military service accidentally hears an information 1. Medical Power of Attorney * **NURSE NOT DOCUMENT INCIDENT
• HS Graduate about other pt) 2. Legal guardian or next of kin REPORT FILED/REFER TO MEDICAL
o NOT CURRENTLY assigned to the RECORD FOR INCIDENT REPORT
Exception: client is not permitted
o Pregnant minor, living w/ parent &
not financially independent, need **May call pt’s medical power of attorney
parent’s consent or nearest kin to provide consent for
additional surgery if during operation

***Interpreter – must be competent &

approved by the institution

HENNAJANECE MY NCLEX NOTES 2021 129 | P a g e

 REPORT TO STATE BON
REPORT TO STATE BOARD OF NURSING
Behavior that is:
• Unsafe
• Unethical
• Incompetent
• Impaired
• Violation of nursing law
State Board of Nursing
NURSE PRACTICE ACT
1. Distinguish Nursing Practice over
Medical
2. Disciplinary Action of Nurses
3. Rights of Nurses
EVERY CLIENT DEATH
➢ OPS (Organ Procurement Services)
are notified if deemed appropriate
DONOR.
➢ OPS Collaborate with the client’s
staff in approaching the family
***Continue CARDIAC SUPPORT &
RESPIRATORY SUPPORT as ORGAN
DONATION is Discussed
HENNAJANECE
EMERGENT CALL
Contacts the HCP regardless of the time of
day:
• Falls
• Deteriorates
• CRITICAL lab result
• Clarify prescription
• Leaves AMA/run away
• Refuses KEY TREATMENTS
IMPORTANT FOLLOW UP CALLS TO
CLIENTS
• Client must be reached, not the
spouse to decide
• Reach by phone 3x if not be
reached
• Certified letter send by police to
contact the client
COST EFFECTIVE CARE
Not risking quality, safety
• Consider the inside of sterile glove
wrapper as a small sterile field
• Donning clean rather than sterile
gloves to remove client’s dressing
• Never returned opened unused
supplies to central supply room
• Never reuse torniquet to another pt
• Never use remaining sterile saline
bottle
LEGAL CAREGIVER OBLIGATION
LEGAL CAREGIVER OBLIGATION/
RELATIONSHIP
• The nurse has a duty to care visitors
and other personnel
• Implement facility protocol in the
event of emergency
CROSSING PROF BOUNDARIES
PROFESSIONAL BOUNDARIES
• Client needs FIRST
• Never seek personal gain (gifts
more than $20, asking for
investments)
• Never flirt with client
Ex.
Accepting gifts > 20 dollars
Soliciting wealthy client to invest
Staying after work hrs to drink w/ pt
MY NCLEX NOTES 2021
GOOD SAMARITAN LAW
➢ Prevent civil action against nurses
to help individuals.
➢ Nurse can’t receive payment
➢ Perform with REASONABLE &
PRUDENT ACT
* * *CAN BE HELD LIABLE
(Ex. NEGLIGENCE – A person died
because the pt has arterial laceration &
the nurse didn’t press the laceration)
PATIENT CONTOLLED ANALGESIA
PATIENT CONTOLLED ANALGESIA (Gov’t
regulated)
➢ DISPOSE OF LEFTOVER OPIOID:
- Have 2nd licensed registered
nurse/supervisor witness
- Document date, time, amount used,
reason for the waste, & amount
wasted.
130 | P a g e
UNIT QUALITY IMPROVEMENT COMMITTEE
− Assess guidelines procedures;
system, operation
− Concern about recurring errors (ex.
Not available meds on time)
− Errors committed by many staffs
(ex. Increase in catheter associated
infection
− Not based on client/staff perception
− Objective; measurable evidence;
signs of improvement
HENNAJANECE
CULTURAL AWARENESS
− The nurse silently reflects about
how her/his biases regarding a
certain culture can influence how
he/she approaches the client’s
needs
JUDAISM
• Shiva – week-long mourning
period in Judaism for first-degree
relatives (starts after burial)
ISLAM
• Pork in all forms and alcohol are
prohibited; handwashing rituals
are adhered to and there are also
fasting rituals during the holy
season of Ramadan.
JEHOVAH’S WITNESSES
• Prohibit blood transfusions,
foods containing blood
ASSIMILATION is the process in which a
minority group or culture comes to
resemble a society's majority group or
assume the values, behaviors, and beliefs
of another group whether fully or partially
ACCULTURATION is the process of
cultural and psychological change that
takes place as a result of contact between
cultural groups and their individual
members. Acculturation follows migration
and continues in culturally plural societies
among ethnocultural communities.
Japanese people dressing in Western
clothing is an example of acculturation
BICULTURALISM presence of two
different cultures in the same country or
region
ENCULTURATION is the gradual process
by which people learn the culture of their
own group by living in it, observing it, and
being taught things by members of the
group. Enculturation is sometimes also
called socialization
MY NCLEX NOTES 2021 131 | P a g e
 DELEGATION TASKS
REGISTERED NURSE LPN
• ASSESS: Breath sounds, Bowel & Neuro
(Pulse, numbness, capillary refill)
• SQ Injection
NEVER DELEGATE
• Apply Sequential Compression Devices
• Teaching &Nursing Process
• Assess the restraints if lose/tight
• Assessment
• Planning • Compression stockings
• Evaluation • Collect & Report Data
• ***Unstable patient/v/s/symptoms/labs (V/S, CBC, Coagulation Studies)
• Reinforce Teaching
• Accountability • Monitor RN Findings
• Critical/Unstable patients • STERILE Wound Care; Wound culture
• Oral Meds (Analgesic)
• New Admission
(If new onset – RN)
• Colostomy Bag Irrigation
• Fresh Post- operative Care
(Monitor flow rate & drainage)
• Discharge Teaching (If no home medication, can be • MONITOR Catheter Post-op
delegated) (Bleeding at sterile site)
• BLOOD: assist checking, verify client
• Comprehensive Assessment (IPPA)
Monitor Blood Transfusion Rate
• All Medications/ Chemotherapy • Ostomy Care
• Blood Transfusion • Monitor Safety hazards
• Invasive Procedure (assist) • Monitor Behavior changes
• Interpret Data • Titrate oxygen based on unit protocol
• Collaborate – endorse to HCP, other department • Monitor Pain level
HENNAJANECE
UAP
• Stable clients
• SURGICAL DRAINS
(Empty, measure & record output)
• BLOOD: Courier from/to blood bank
Monitor V/S PRIOR & END of transfusion
RN Stays (1st 15 mins transfusion)
• Escort family members
• Report abnormal observations
• DOCUMENT OBSERVATIONS:
(Shortness of breath, then RN will validate)
• Indwelling Folly Catheter
(Perineal Care around IFC)
• Routine Daily Tasks
• V/S, Pulse Oximeter, PAIN SCORE
• Capillary Blood Glucose Monitoring
• Skin Ointment
• Report changes in behavior
• Reapply Sequential Compression Devices
• Hygiene Care
• IV Catheter Removal
• Collect CLEAN CATCH URINE
• Change Colostomy Bag (not initial/new/first bag)
• HEMOVAC: measure, record, compress
• JACKSON PRATT: measure, record, compress
• Remind clients
• Change linens using trapeze on ORTHO (not log roll)
• CLEAN TECHNIQUE Wound Care
• ***NO STERILE PROCEDURE & ENTERAL
MY NCLEX NOTES 2021 132 | P a g e
 ANTIDOTES
DRUGS / SUBSTANCE ANTIDOTE
Lead Calcium Edta
Acetaminophen N-Acetylcysteine
Anticholinesterase (Cholinergic) Atropine Sulfate
Atropine Sulfate Physostigmine (Antilirium)
Antidepressant Phentolamine
Benzo diazepine Flumazenil
Cyanide Sodium Thiosulfate
Digoxin Digi bind
Heparin Protamine Sulfate
Warfarin Vitamin K
Iron Deferoxamine
Methotrexate Leucovorin Calcium
Opioid Narcan
Thrombolytics Aminocaproic Acid
Cyclophosphamide Mesna
Magnesium Sulfate Calcium Gluconate
High Potassium Sodium Polystyrene Sulfonate (Kayexalate)
Zonrox Bleach Milk

HENNAJANECE MY NCLEX NOTES 2021 133 | P a g e


NURSING RESEARCH
WHAT IS NURSING RESEARCH?
Systematic inquiry:
- Develop knowledge about issues
important to nursing
• Practice
• Education
• Administration
EVIDENCE-BASED PRACTICE IN NURSING
– scientific/factual/objective findings
• Collective, quantitative and
qualitative outcome of research
findings
o Encourage appreciation of
patients and families’ aspects of
health and illness
o Carrying-out useful nursing
intervention in the promotion of
health
o Delivery of valuable, profitable
care contained by the health
care system
IMPORTANCE OF RESEARCH IN NURSING
• Continues quality improvement of
nursing care
• Cost-containment practices
established in healthcare
• Introducing and appraising change
and carrying-out steps to achieve
new knowledge significant to
nursing
HENNAJANECE
NURSING RESEARCH
RESEARCH PROCESS
“ CDEAD ”
1. CONCEPTUAL- introduction
o Formulate and delimit the
problem
o Formulate hypotheses
2. DESIGN & PLANNING -review of
related literature
3. EMPIRICAL – data
gathering/methodology
o Identify research variables
o Develop a conceptual Framework
4. ANALYTIC- data analysis,
interpretation, presentation
5. DISSEMINATION – summary,
conclusion, recommendation
GOAL OF RESEARCH
• Develop
• Refine
• Expand Knowledge
SCIENTIFIC METHOD
1. Deciding on and outlining a problem
– Introduction
2. Making inquiries or educated guess
or both – Review of Related
Literatures
3. Data gathering – Methodologies
4. Data analysis – interpretation and
presentation
5. Communicating results – summary,
conclusion and recommendation
TYPES OF RESEARCH
➢ According to Purpose
1. Basic/Pure – develop/refine
knowledge/theory
2. Applied – looking for
solution/interventions that can be
applied to a certain phenomenon
➢ According to Objectives
1. Descriptive/Non-experimental -
accurate portrayal of a particular
situation
2. Exploratory – attempts to know a
phenomenon in a particular study
3. Explanatory – preceded by exploratory
research
4. Prediction & Control
➢ According to Design
1. Experimental (“the effect of…”)
(Manipulation/Intervention/Random
ization, Control Group)
a. TRUE (M/I/R, C G)
b. QUASI (M/I/ C G/ No
Randomization- no equal chance
to be chosen)
2. Non-experimental/Descriptive
(Randomization, Control Group, No
Manipulation)
a. Comparative – describes the
differences in variables
b. Correlational – describes the
relationships between variables
c. Methodological – utilizing new
sets of tools/equipment
d. Survey – obtain infos about the
prevalence, distribution, and
interrelations of variables w/n a
population
MY NCLEX NOTES 2021
TYPES OF RESEARCH
➢ According to Data
1. Quantitative
(measurable/quantifiable/relationship)
2. Qualitative (characteristics/values)
a. Phenomenological – lived
experiences
b. Ethnographic – developing a
theory of cultural behavior
c. Case Study – in depth
investigation on a certain
phenomenon
d. Grounded Theory – discovery of
the existence of problems in a
social scene & how people
handle it
e. Historical – description/ analysis
of events that occurred in the
past
➢ According to Time-Frame
1. Cross- Sectional – one point in
time
2. Longitudinal – different points in
time
3. Retrospective/Ex post facto –
investigating the past to know the
cause
4. Prospective – waiting for future
results
➢ According to Setting
1. Laboratory
2. Field
134 | P a g e
 RESEARCH PROBLEM RESEARCH PROBLEM VARIABLES MEASURING VARIABLES
Formulating a Research Problem
Major Considerations: 4. CREATE A RESEARCH QUESTION that Types of Variables A. PARAMETRIC
• Extent of concepts will be answered by your study. 1. Nominal- assigning numerical
(Researchability/Measurement) o Impacts of teenage pregnancy on • Independent/Change (presume cause) values to classify based on
• Probability (Practicability/Feasibility) marital status • Dependent/Outcome (presumed characteristics/categories (ex.
• Implications o How teenage pregnancy affects effect) Gender/blood type / marital
(Significance/Relevance) certain aspects of children’s lives • Extraneous (affects the link between status
• Ethico-moral Issues o Effects on family’s finances cause & effect) 2. Ordinal- sorting of object bases on
• Intervening/Confounding/Connecting/ relative ranking on attribute (Ex.
Minor Considerations: 5. FORMULATE OBJECTIVES Linking (provides link between cause & Level of anxiety:
• Interest Main: To discover familial effects of effect) Mild/Moderate/Severe/Panic)
• Scale (Magnitude) teenage pregnancy
• Proficiency Specific: B. NON-PARAMETRIC
• Handiness of Data (Availability) o To establish the impact of “ DICE “ 1. Interval – no absolute zero (Ex.
teenage pregnancy on marital • Dependent is the Effect/result Temperature)
relation “The effect ON…” 2. Ratio – w/ absolute zero (Ex.
How to formulate a research problem? o To uncover means in which • Independent is the Cause Board exam/scores/ Height/
teenage pregnancy affects “The effect OF…” weight/income/age)
1. IDENTIFY a broad area of interest certain aspects of children’s lives
(Academic/Clinical Fields) o To discover the effects of
o Teenage pregnancy teenage pregnancy on the
financial condition of the family
2. DIVIDE the broad area into specific
parts 6. ASSESS objectives and technical DV (Dependent Variable)
o Profile expertise IV (Independent Variable)
o Causes o Workload involvement
o Process of becoming o Availability of time
o Familial effects o Financial resources
o Community attitudes o Availability of materials and
o Effectiveness of treatment (if there resources
is any) Precise knowledge and skill

3. CHOOSE a specific part in which you 7. DOUBLE CHECK sufficiency of interest

would like to conduct a research using and adequacy of resources
the process of elimination o Real interest in the study
o Effects of teenage pregnancy o Agreement on the objectives
o Probability of the study

HENNAJANECE MY NCLEX NOTES 2021 135 | P a g e

 HYPOTHESIS
− Educational/ scientific guess
Types of Hypotheses
1. Simple Hypothesis – predicts the
relationship between one IV & one DV
o Ex. Hand hygiene practice among nurses
is related to the level of stress that they
experience
2. Complex Hypothesis – predicts the
relationship between 2 or more IV & 2 or
more DV
o Ex. Leadership and Management,
PURPOSES OF RRL
Incentives, Work environment and
Salaries and Wages are related to clinical
performance and motivation of staff
nurses.
3. Directional/Predictive Hypothesis or
Hypothesis of Association – speculates
the extent of the relationship in terms of
the effect of different treatment groups
on the DV (strong sense of relationship
between variables)
“more/lesser/greater/increases”
o Ex. Staff nurses who are exposed to a
stressful longer workload are more
prone to decrease immunity than those
who are given shorter workload
4. Non-Directional Hypothesis or Hypothesis
of Difference – there is a difference but
does not specify its magnitude
o Ex. There is a difference in the level of
stress among staff nurses who are
exposed in COVID-19 units than those
who are not assigned in COVID-19 units
5. Null Hypothesis – there is no difference
between two situations, groups,
outcomes, or the prevalence of a
condition or phenomenon
ERRORS IN TESTING HYPOTHESIS
TYPE I: TRUE Null Hypothesis is REJECTED
TYPE II: FALSE Null Hypothesis is ACCEPTED
HENNAJANECE
REVIEW OF RELATED LITERATURE
− We attempt to discover what is
known and unknown to a
phenomenon
• Identify, locate and analyze
documents – information related
to research problem
• Description of existing studies
• Related literatures and studies
➢ Identify research problem
➢ Expansion or modification of research
questions or hypothesis
➢ Orientation to what is known and not
known about an area of inquiry best
contribution or research in evidence-
based practice
➢ Determine gaps or inconsistencies
➢ Determine the need for replication in
relation to different settings or
situations Identify or develop of new
or refined clinical interventions to test
through empirical research
➢ Relevance of Theoretical or
Conceptual frameworks in relation to
the research problem
➢ Appropriate designs and data
collection method for the study
➢ Develop research proposals for
subsidy, identification of experts in
the filed who could be of use as
consultants
➢ Assistance in interpreting study
findings and in developing
implications and recommendations
DESIGN AND PLANNING
Identifying the Population
− People who provide information to
the researchers or investigators are:
o Subjects
o Study participants
o Respondents
o Informant (Qualitative study)
❖ Population – All the individuals or
objects with common, defining
characteristics
❖ Target population – Is the aggregate
of cases about which the researcher
would like to generalize.
❖ Sample – Is a subset of population
elements
❖ Sampling – Is the process of selecting
a portion of the population to
represent the entire population so
that inferences about the population
can be made.
❖ Representativeness – The key
consideration in assessing a sample in
a quantitative study
MY NCLEX NOTES 2021
SAMPLING
A. PROBABILITY SAMPLING – involves
random selection of elements
1. Simple Random Sampling – is the
most basic probability sampling design
2. Stratified RS – it subdivides the
population into homogenous subsets
from which an appropriate number of
elements are selected at random
3. Cluster Sampling (Multi-stage
sampling) – involves the successive
selection of random samples from
larger to smaller units by either simple
random or stratified random methods
4. Systematic Sampling – involves the
selection of every nth case from a list,
such as every tenth person on a
patient list
B. NON-PROBABILITY SAMPLING – elements
are selected by non-random methods;
based on the criteria of the researcher
1. Convenience/Accidental Sampling –
entails using the most conveniently
available people as study participants
2. Snowball/Network/Chain Sampling –
is a variant of convenience sampling.
Early sample members are asked to
refer other people who meet the
eligibility criteria
3. Quota Sampling – is one in which the
researcher identifies the population
strata and determine how many
participants are needed from each
stratum (ex. The first 20 of this group)
4. Purposive/Judgment Sampling –
judgmental sampling is a non-
probability sampling technique where
the researcher selects units to be
sampled based on their knowledge &
professional judgment
136 | P a g e
 DATA GATHERING
1. OBSERVATION: Is way of gathering
data by watching behavior, events, or
noting physical characteristics in their
natural setting. – senses
Types of Observation:
1. Overt – Everyone knows they are
being observed
2. Covert – No one knows they are
being observed and the observer
is concealed
2. QUESTIONNAIRES: Is a research
instrument consisting of a series of
questions and other prompts for the
purpose of gathering information
from the respondents.
Types of questions:
1. Closed-ended questions: Is a
question format that provide
respondents with a list of answer
choices from which they must
choice to answer the question.
Example: Do you get well with
your boss
2. Open-ended questions: An open-
ended question is designed to
encourage a full, meaningful
answer using the subject's own
knowledge and/or feelings.
Example: Tell me about your
relationship with your boss
HENNAJANECE
DATA GATHERING
3. INTERVIEW: Is a conversation
between two people (the interviewer
and the interviewee) where questions
obtain information from the
interviewee.
Types of interviews:
1. Structured: Require adherence
to a very particular set of rules.
Each question that is outlined
should be read word for word by
the researcher without any
deviation from the protocol
2. Semi-structured: Semi-
structured interviews are a bit
more relaxed than structured
interviews.
3. Unstructured: Have the most
relaxed rules of the three. In this
type, researchers need only a
checklist of topics to be covered
during the interview. There is no
order and no script.
DESCRIPTIVE STATISTICS
Descriptive Statistics – are brief
descriptive coefficients that summarize a
given data set, which can be either a
representation of the entire or a sample
of a population
A. Measures of Condense
1. Frequency Distribution – is a
systematic arrangement of values
from lowest to highest together
with a count of the number of times
each value was obtained
2. Percentage – is a way of expressing
a number, especially a ratio, as a
fraction of 100
3. Graphic Presentation – the
transformation of data through
visual methods like graphs,
diagrams, maps and charts is called
representation of data
B. Measures of Central Tendency – are
indexes expressed as a single number
that represent the average or typical
value of a set of scores
1. Mode – most frequently occurring
score value in a distribution
2. Median – is the point in a
distribution above which and below
which 50% of cases fall
o Odd (automatic the one in the
midpoint; should be in
chronological order)
o Even (add/get average of two
middle numbers; should be in
chronological order)
3. Mean/Average – is the sum of all
scores, divided by the number of
scores
MY NCLEX NOTES 2021
DESCRIPTIVE STATISTICS
C. Measures of Variability – it shows
how spread out the data
1. Range – simple the highest score
minus the lowest score in a
distribution
2. Standard Deviation – indicates
the average amount of deviation
of values from the mean
3. Variance – is equal to the
standard deviation squared
4. Percentile – is the value of a
variable below which a certain
percent of observations falls
D. Measure of Relationship
1. Pearson’s R – this coefficient is
computed w/ variables measured
on either an interval or ratio
scale
2. Spearman’s Rho (p) – the
correlation index usually used for
ordinal level measures
3. Correlation coefficient –
indicates the magnitude &
direction of a relationship
between two variables. It can
range from -1.00 ( a percent
negative relationship) through
zero to +1.00 ( a perfect positive
relationship)
137 | P a g e
 INFERENTIAL STATISTICS
Inferential Statistics – use a random
sample of data taken from a population to
describe and make inferences about the
population
A. Chi-Square Test – is used to test
hypotheses about the proportion of
cases that fall into different
categories, as when a contingency
table has been created.
B. T-Test (test difference of 2
means/average)
- Assesses whether the means of
two groups are statically different
from each other
- This analysis is appropriate
whenever you want to compare
means of two groups
C. Analysis of Variance (ANOVA) – is the
parametric procedure for testing
differences between means when
there are three or more groups
HENNAJANECE
ASSESSING QUALITY OF RESEARCH
CRITERIA FOR ASSESSING QUALITY OF
RESEARCH
➢ Reliability: Refers to the accuracy
and consistency of information
obtained in a study
➢ Validity: Is a more complex concept
that broadly concerns the
soundness of the study’s evidence-
that is whether the findings are
unbiased, cogent, and well
grounded.
➢ Dependability: Refers to evidence
that is consistent and stable.
➢ Confirmability: Is similar to
objectivity. It is the degree to which
study results are derived from
characteristics of participants and
the study context, not from
researcher biases.
➢ Credibility: An especially important
aspects of trustworthiness, is
achieved to the extent that the
research methods engender
confidence in the truth of the data
and in the researcher’s
interpretation of the data.
ETHICS IN RESEARCH ETHICS IN RESEARCH
4. Beneficence – doing good 9. The Right to Fair Treatment
- Imposes a duty on researchers to
minimize harm and to maximize o Justice – similarly situated (equity
benefits and equality)
- Connotes fairness and equity,
5. The Right to Freedom from Harm and and so one aspect of the justice
Discomfort principle concerns the equitable
distribution of benefits and
6. The Right to Protection from burdens of research.
Exploitation o The Right to Privacy
- Researchers should ensure that
7. The Right to Self determination/ their research is not more
Autonomy intrusive than it needs to be and
- The principle of self- that participant’s privacy is
determination means that maintained throughout the
prospective participants have the study.
right to decide voluntarily o Anonymity –The most secure
whether to participate in a study, means of protecting confidentiality
without risking any penalty or occurs when even the researcher
prejudicial treatment. cannot link participants to their
data.
8. The Right to Full Disclosure/Veracity
and Confidentiality
o Full disclosure – the researcher
has fully described the nature of
the study, the person’s right to
refuse participation, the
researcher’s responsibilities, and
likely risks and benefits.
o Concealment – The collection of
information without the
participants’ knowledge or
consent
o Deception – Either withholding
information from participants or
providing false information
MY NCLEX NOTES 2021 138 | P a g e
 SCALES SLOVIN’S FORMULA
Slovin’s Formula
A. Semantic Differential scale N (8888)
- A survey or questionnaire rating n = --------------
scale that asks people to rate a 1 + N (8888) (e = 0.05)2
product, company, brand, or any e = 0.05 x 0.05 = 0.0025
'entity' within the frames of a
multi-point rating option. These
survey answering options are n = 8888/1 + 8888 (0.0025)
grammatically on opposite n = 382.77
adjectives at each end.
wherein:
B. Delphi technique – panel of experts
n = sample size
N = total population
C. Likert scale - degree of agreement
e = margin of error (the opposite of
and /or disagreement
the level of confidence) 5% - 0.05

N = 12345 (0.0025) = 30.8625 + 1

= 31.8625 = 12345/31.8625
n = 387.44

HENNAJANECE MY NCLEX NOTES 2021 139 | P a g e

 LEADERSHIP & MANAGEMENT ( LMR NOTES )
LEADERSHIP THEORETICAL FOUNDATIONS LEADERSHIP STYLES MANAGEMENT
“Theoretical Foundations of Leadership”
• ➢ The Great Man Theory
Interpersonal behavior (you are dealing − Act or manner of guiding or
with other people – healthcare ✓ Aristotelian philosophy: “Leaders are born and
not made.” Great leaders will arise when the AUTOCRATIC taking charge
professionals and patient/clients)
situation demands it • Bureaucratic − Process of leading and directing
• Requires more complex skill (multi-faceted
• Strong control an organization
skills require to render effective nursing ➢ Charismatic Theory
care and management) • Gives order
✓ Inspirational quality and emotional commitment
• Increases productivity by maximizing • Does the decision MANAGERS
workforce effectiveness (achieve common ➢ Contingency Theory • Leader does the planning • Assigned position within the
goals; goal of the individual) ✓ Flexibility of leaders • Directive formal organization
• Leadership skills essential in ✓ Leading followers depending on situation • Foster dependence • Legitimate source of power
implementation of planned change for • Most effective in crisis • Specific functions, duties and
system improvement ➢ Path-Goal Theory
intervention responsibilities
✓ Minimize obstructions to facilitate
accomplishments of task • Manipulate environment,
LEADERS
✓ Motivation and productivity DEMOCRATIC money, time and resources to
• Does not have delegated authority; obtain
power through other means such as • Consultative achieve organizational goals
➢ Trait Theory • Less control • Greater formal responsibility and
influence
✓ Innate abilities, personal traits to become a leader
• Wider variety of roles • Offer suggestion • accountability
✓ Task-oriented
• Decision maker • Buffer • Makes suggestions • Direct willing and unwilling
✓ Relationship-oriented
• Communicator • Advocate • The group does the planning subordinates
✓ Participative leadership (decision-making)
• Evaluator • Visionary • Participative
• Facilitator • Forecaster ➢ Situational Theory • Foster independence
• Risk taker • Influencer ✓ Leadership varies according to varying situation • Most desirable form of DOUGLAS MCGREGOR
• Mentor • Creative problem ✓ Leader/Follower depending on the situation
• Energizer solver
management ➢ THEORY X
• Coach • Change agent ➢ Transactional Theory • Goal of organization
• Counselor • Diplomat ✓ Management tasks and trade-offs to meet goals LAISSEZ FAIRE • People dislike work and will avoid it
• Teacher • Role model ✓ Followers are motivated by rewards or • Ultraliberal/ Permissive • Workers have no ambition but desire
• Critical thinker • Innovator punishment • No control security
• May or may not be part of formal • Non-directive • Motivation by fear and threats
➢ Transformational Theory
organizations • Abdicates decision making
✓ Employee development
• Focus is on group process, information • No planning ➢ THEORY Y
✓ Attending the needs and motives of followers
gathering, feedback and empowering • Uninvolved
✓ Optimism • Goal of individual
others
✓ Influences change in perception • Foster chaos • Seek responsibility & display
• Emphasize interpersonal relationships
✓ Follower creativity • Effective in highly motivated imagination
• Direct willing followers
• Have goals that may or may not reflect the professionals • Workers have self-direction
➢ Strategy Theory
organization • Motivation by praise and recognition
✓ Human handling skills
✓ Visionary
✓ Communication

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GENERAL MANAGEMENT ROLES STAGES OF NURSING EXPERTISE MANAGEMENT LEVELS THE MANAGEMENT PROCESS
PATRICIA BENNER’S STAGES OF NURSING
EXPERTISE
➢ TOP LEVEL MANAGEMENT 1. PLANNING
1. STAGE I (NOVICE) ➢ Continuous Process
➢ Interpersonal • NO EXPERIENCE (student nurse) • Manages and looks at the
o Assessment and establishment of
• Symbol (signing of documents) • Performance is limited, inflexible, and organization as a whole
goals
• Leader (hires, trains, encourages, governed by context-free rules and • Coordinates internal and external
regulations rather than experience o Implementing and evaluating goals
fires, renumerates, and judges) influences and generally makes o Subject to change
• Liaison (link to community, 2. STAGE II (ADVANCE BEGINNER) - floater decisions with few guidelines or o Deciding in advance (what, who, how,
suppliers and the organization) • Demonstrates MARGINALLY ACCEPTABLE structures. when and where)
PERFORMANCE • e.g., Chief-Executive Officer,
➢ Informational • Recognizes meaningful “aspects” of a real President, Vice-president, Hospital ❖ SCOPE OF PLANNING
situation ➢ Strategic Planning/Long term Planning
• Monitors and disseminates Director, Medical Director, Chief
• Has experienced enough real situations to • 3-5 years in the future
information (external and internal make judgments about them Nurses, Assistant Chief Nurse
• Over all goals and policies
sources)
• Top level management
• Spokesperson or representative of 3. STAGE III (COMPETENT) ➢ MIDDLE LEVEL MANAGEMENT
• 2 TO 3 YEARS OF EXPERIENCE ▪ Vision – Future roles, functions
the organization • Coordinates the efforts of lower
• Demonstrates organizational and planning and aims of the organization
levels of the hierarchy
abilities ▪ Mission – Reason for existence of
➢ Liaison • Differentiates important factors from less • Conduit between lower and top –
an organization
• Entrepreneur or innovator important aspects of care level managers
• Coordinates multiple complex care
▪ Philosophy – Outlines the set of
• Trouble-shooter • e.g., Supervisor, Unit Manager values and beliefs that guides all
demands
• Negotiator actions of the organization
4. STAGE IV (PROFICIENT) ➢ FIRST LEVEL MANAGEMENT ▪ Goals – Actions for achieving the
• 3 TO 5 YEARS OF EXPERIENCE • Concerned with specific unit’s work mission and philosophy
LEADERSHIP VS. MANAGEMENT • Perceives situations as a whole rather than flow ▪ Objectives – Specific end and are
in terms of parts
• Deals with immediate problems in explicit
• Uses maxims as guides for what to
Leadership Management consider in a situation the unit’s daily operations, with
Do the Do things • Has holistic understanding of the client, organizational needs, and with ➢ Intermediate Planning
Motto • 6 months to 2 years
right thing right which improves decision making personal needs of employee.
• Focuses on long-term goals • Top level management in coordination
Challenge Change Continuity • e.g., Head nurse, case manager,
with the lower levels
Structure & 5. STAGE V (EXPERT) nurse practice coordinator, primary • Nursing Supervisors
Focus Purpose care nurse, team leader or charge
Procedure • PERFORMANCE IS FLUID, FLEXIBLE AND
Time HIGHLY PROFICIENT nurse ➢ Operational Planning
Future Present • No longer requires rules, guidelines, or • Departmental plans, maintenance, and
Frame maxims to connect an understanding of
Methods Strategies Schedules improvement goals.
the situation to appropriate action
• Daily and weekly plans for
Who, what, • Demonstrates highly skilled intuitive and
analytic ability in new administration or direct patient care.
Questions Why? when, where, • Head nurses, Charge nurses
how? TAKE NOTE:
Human Potential Performance IF A NURSE FROM A DIFFERENT AREA IS TO BE
TRANSFERRED TO A NEW AREA, HE/SHE WILL BE
CONSIDERED NOVICE TO THE NEW AREA HE/SHE
WILL BE ASSIGNED.

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 THE MANAGEMENT PROCESS
2. ORGANIZING
➢ Process of establishing formal authorities
➢ Organizational structure
• Identification of groupings
• Roles and relationships
➢ Determining staff needed and
distributing them in various areas
➢ Elements of Organizing
➢ Organizational structure
• Organizational Chart
- Characteristics
o Division of work
o Chain of command
o Type of work to be performed
o Grouping of work segments
o Levels of management
- Types:
o Vertical/Tall Chart –
Top level management authority
flowing down the hierarchy
o Horizontal/Flat Chart – Managers
have wide span of control
o Concentric/Circular Chart –
Outward flow of communication
➢ Staffing – It is the process of
determining and providing the
acceptable number and mix of nursing
personnel to produce a desired level of
care to meet the patient’s demand.
HENNAJANECE
THE MANAGEMENT PROCESS
➢ Scheduling
• Centralized
- Done by the Chief Nurse
- Assigns nursing personnel to
various units of the hospital
• Decentralized
- Shifts and offs
- Duties arranged by Nurse
Supervisors or Senior Nurses in a
particular unit
• Cyclical
- Covers designated number of
weeks as one cycle, which is
repeated there on
➢ Development of Job Description
➢ Authority
➢ The right to act or make decisions
without need for approval of higher
administration
➢ Accountability
➢ Taking full responsibility for the
quality of work and behavior – being
answerable/liable
➢ Responsibility
➢ Obligation to perform the assigned
task
➢ Principles of Organization
➢ Unity of Command – one and only
superior
➢ Scalar Principle/Hierarchy/Chain of
Command – flow of authority from
higher to lower
➢ Departmentalization – Grouping of
workers with similar assignments
➢ Span of control – Number of people
or subordinates
➢ Decentralization – reporting of staff
to one person that is higher to them
THE MANAGEMENT PROCESS THE MANAGEMENT PROCESS
Cont. Communication
3. DIRECTING/LEADING
• Issuance of orders, assignments, and LINES OF COMMUNICATION
instructions that enable the nursing personnel
to understand what are expected of them ➢ Downward – from superior to subordinate
• Involves command and coordination - Examples:
• Elements of Directing o Policies
➢ Communication o Rules and regulation
- Transmission of information, opinions and o Memorandum
intentions between and among individuals o Employee Handbooks
o Performance Appraisal
- Types:
o Verbal (oral or written)
➢ Upward – from subordinates upward
o Non-verbal (facials expression, tone of
voice, body language, touch) - Examples:
➢ Delegation o Incident report
- Process by which a manager assigns specific o Grievance report
tasks/duties to workers with commensurate
authority to perform the job ➢ Horizontal – between peers, personnel, or
- Principles: departments on the same level
• Select the right person to whom the job - Examples:
is to be delegated o Endorsements
• Delegate both interesting and o Conferences
uninteresting tasks o Nursing Rounds
• Provide subordinates with enough time
to learn ➢ Outward – From care givers to patient and
• Delegate gradually their relatives
• Delegate in advance - Example:
• Consult before delegating o Discharge
• Avoid gaps and overlaps teaching/planning/rehabilitation –
upon admission
- What CANNOT be Delegated?
• Overall responsibility, authority and
accountability for satisfactory ➢ Diagonal – From individuals or departments
completion of all activities in the unit that are not in the same level or the
• Authority to sign one’s name is never hierarchy
delegated - Example:
• Evaluating the staff and/or taking o Nutrition department to Nursing
necessary corrective or disciplinary Department
action
• Responsibility for maintaining morale or ➢ Grapevine – Informal communication; often
the opportunity to say a few words of rapid and subject to much distortion
encouragement to the staff especially to - Examples:
new ones o Gossip
• Jobs that are too technical and those o Hearsay
that involve trust and confidence
MY NCLEX NOTES 2021 142 | P a g e
 NURSING PERSONNEL RESPONSIBILITIES
RN
• IV Medications and all other
routes of administration
• Health Teaching
• Assessment (initial)
• Evaluation
• Everything that involves the
nursing process
• Over-all accountability
• Unstable/critical Patients
Licensed Practical Nurse/Licensed
Vocational Nurse
• Assessment (secondary)
• Medications (IM, SC, ID, Except IV)
• Wound cleansing
• Osteorized Feeding
• Suctioning
Unlicensed Assistive Personnel
(UAP)/Nursing Assistant
• Routine activities ADLS, Hygiene
• V/S
• Application of pulse oximeter
sensor
• Post Mortem
• Stable patients / ambulatory/
MGH
DISTRIBUTION PER SHIFT
❖ AM – 45%
❖ PM – 37%
❖ NIGHT –18%
HENNAJANECE
NURSING CARE ASSIGNMENTS
− Can also be called modalities of
nursing care, systems of nursing
care, or patterns of nursing care
➢ FUNCTIONAL NURSING
• This kind of nursing modality is
task – oriented in which a
particular nursing function is
assigned to each worker Divides
work to be done & every member
is responsible for his actions
• Best system that can be used if
there are many patients and
professionals
➢ TOTAL CARE NURSING
• One nurse is assigned to one
patient for the delivery of total
care
• Works best when there are plenty
of nurses whereas patients are
few
➢ TEAM NURSING
• One nurse leads a group of
nursing personnel in providing
nursing needs to a group of
patients
• Decentralized system of care
➢ PRIMARY NURSING
• RN is responsible for the total
care of a small group of patients
(4-6) from admission to discharge
• RN remains responsible for the
care of those patients 24 hours
per day
NURSING CARE ASSIGNMENTS
➢ CASE METHOD
• One is to one nurse patient ratio
• e.g., ICU nurse, private duty nurse
➢ MODULAR METHOD
• Also termed as District Nursing
• Modification of team and primary
nursing
• It is sometimes used when there are
not enough RNs to practice nursing
• It differs from team nursing in that
the registered nurse provides direct
nursing care with the assistance of
aides
➢ Supervision
- It is providing guidelines for the
accomplishment of a task or
activity with initial direction and
periodic inspection of the actual
accomplishment of the task or
activity
➢ Staff Development
- Providing structure and assistance
for employees to learn more
- Orientation – familiarization to the
unit/On-boarding – assimilation/
acquiring the culture, environment
and practices
o Done for new employees
o Refers to planned and guided
activities of an employee in
the organization, the work
environment and in his job
MY NCLEX NOTES 2021
NURSING CARE ASSIGNMENTS
- In-Service Education
o Consists of on-the-job
instructions that are given to
enhance employee’s recent
job performance
- Specialty Courses
o Offered by hospitals with
trained specialist, facilities
and source
o e.g., dialysis nursing,
oncology nursing, cardiology
nursing
➢ Coordination
- Unites personnel and services
toward a common objective
- Synchronization of activities
among various services and
department
- Prevents overlapping of functions
- Promotes good working
relationships Work schedules are
accomplished as targeted
143 | P a g e
 CONFLICT MANAGEMENT CONTROLLING
− A clash between two opposing parties. It is -Also called “EVALUATING” (STEP 4)
a type of behavior involving two or more -An on-going function of management
parties in opposition to each other which occurs during planning, organizing
and directing activities.
− Types of Conflict ❖ Basic components of the control
• Intrapersonal (from within one process:
person) • Establish Standards
• Interpersonal (between two persons) • Measure actual performance
• Intragroup (within the group itself) • Compare performance vs. standards
• Intergroup (conflict between two • Reinforce correct behavior
• Implement corrective action
groups of people in the organization)
− Decision-making ❖ Performance Appraisal o A control
• Define the Problem process wherein an employee’s
• Analyze the Problem performance is evaluated against
• Develop alternative solutions standards
• Select possible solutions • Checklists
• Implement follow-up - Compilation of all nursing
performances expected of a
CONFLICT RESOLUTION worker
➢ AVOIDANCE • Rankings
• Avoid confrontation/Ignore the - In simple ranking, the evaluator
situation ranks the employees according
• Lose-Lose to how he or she faired with co-
workers with respect to certain
➢ ACCOMMODATION aspects of performance or
• One gives way to the other qualifications
• Win-Lose • Rating Scales
- Includes a series of items
representing the different tasks
➢ COLLABORATION
• Both work out days to solve the or activities in the nurse’s job
description
problem
• Win-Win • Anecdotal recording
- Describes the nurse’s
➢ COMPROMISE
experience with a group or a
• Both will sacrifice person, or in validating
• Lose-Lose
technical skills and
interpersonal relationships
➢ COMPETITION
• Boss wins
• Win-Lose
HENNAJANECE
CONTROLLING
• Essay
- The appraiser writes a
paragraph or more about the
worker’s strengths,
weaknesses and potentials
• Informal Appraisal
- Consists of incidental
observation of performance
while the worker is engaged in
performing nursing care
• Formal appraisal
- Collecting objective facts that
can demonstrate the
difference between what is
expected and what was done
❖ Characteristics of an Evaluation Tool
Objectivity/Factual/Evidenced-based
• Reliability
• Validity/Accuracy
• Sensitivity
❖ Quality Assurance
• Evaluation of the healthcare
system and the provision of
healthcare services by workers
• Quality Assurance Criteria
▪ Structure
- Physical setting and
condition
- Focus on the structure or
management system used
by the agency to deliver care
▪ Process – Steps in nursing
process
▪ Outcome – Measure results of
care and the desirable changes
in client
MY NCLEX NOTES 2021
CONTROLLING
❖ Benchmarking
A tool to assist in quality-of-care decision
making
A continuous process of measuring what exist
against the best
❖ Total Quality Management (TQM)
A way to ensure customer satisfaction by
involving employees in the improvement of
the quality of every product or service
❖ Continuous Quality Improvement (CQI)
Process of continuously improving a system by
gathering data or performance
❖ Nursing Audit
It measures the actual performance of the
nursing personnel against standards
It is composed of a representative from all
levels of the nursing staff
❖ Patient Care Audit
▪ Concurrent
- One in which patient care is
observed and evaluated through:
o Review of the patients’ charts
while the patients are still
confined
o Observation of the staff as
patient care is given
o Observation of the effects of
patient care
▪ Retrospective
- One in which patient care is
evaluated through:
o Review of discharged patients’
charts
o Questionnaires sent to or
interviews conducted on
discharged patients
144 | P a g e
 CONTROLLING
❖ Peer Review
− Audit one by peers evaluating
another job performance of the
employees of the same rank
against accepted standards
❖ Discipline
− A constructive and effective
means by which employees take
responsibility for their own
performance and behavior
− Stages of Disciplinary Action
▪ Counseling and Oral Warning
o Best given in private and in an
informal atmosphere
o Employee is given a fair chance
to air his side
▪ Written Warning
o Identify the rule violated, list
consequences if behavior is
continued, employee’s
commitment to take corrective
actions
▪ Suspension
o It is given after an evidence of
oral and written warnings.
o Temporary withdrawal from
duties
▪ Dismissal
o Permanent removal of a person
from organization
HENNAJANECE
CHANGE
KURT LEWIN’S THEORY OF CHANGE
❖ Unfreezing
• Development through problem
awareness of a need for change
• Coercion and induction of guilt
and anxiety have been used for
freezing
• Denial stage
❖ Moving
• Working toward change
(identifying problem, exploring
alternatives, defining goals)
❖ Refreezing
• Integration of the change into
one’s personality and the
consequent stabilization of
change
CHANGE
STRATEGIES FOR EFFECTIVE CHANGE
➢ Empirical-Rational
• Based on the assumption that
people are rational and behave
according to rational self-
interest.
• It follows that people should be
willing to adopt a change if it is
justified and if the people are
shown how they can benefit
from the change
➢ Normative-Reeducative
• Based on the assumption that
people act according to their
commitment to sociocultural
norms
• Manager pays attention to
changes in values, attitudes,
skills and relationships in
addition to providing information
➢ Power-Coercive
• Involves compliance of less
powerful people to leadership,
plans and directions of more
powerful people
• e.g., Use of strikes, sit-ins
negotiations, conflict
confrontation and rulings
MY NCLEX NOTES 2021
Components of Budget
• Operating Budget
✓ Daily revenue and expenses including:
➢ Salaries
➢ Supplies
➢ Contractual services
➢ Employee benefits
➢ Laundry services drug and pharma
➢ In-service education
✓ Composed of revenue and expense budget.
o Revenue Budget – summarizes the
income
o Expense Budget – salaries, supplies,
utilities, maintenance
• Cash Budget
✓ Forecasts the amount of money received.
✓ It consists of the beginning cash balance,
estimates of the receipts and disbursements,
and the estimated balance for a given period.
✓ Prepared by estimating the amount of
money to be collected from patients and
allocating it to cash disbursement required to
meet obligations promptly as they come.
• Capital Expenditure Budget – LONG TERM USE
✓ Major expenditures
✓ Consists of accumulated data for fixed
assets that are expected to be acquired during
the budget period.
✓ Replacement, or expansion of the plant,
major equipment, and inventories.
✓ e.g., MRI, IV Stand, CT
• Flexible Budget
✓ Composed of budgets that adjust
automatically over the course of the year
depending on variables such as volume and
labor costs.
• Zero-Based Budgeting
✓ Major advantage of this type of budget is
that it forces managers to set priorities and
justify.
✓ Disadvantage: Time consuming
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