Simple Nursing@Migrant Nurse

Simple Nursing
MIGRANT NURSES
s
Anatomy & physiology
Fundamentals & Health assessment
Labs
ABG & Acid Base Imbalances
EKG
Adult Health :
Cardiac
Liver,Gallbladder and Pancreas
Mental health
Musculoskeletal
Neurological
Oncology
Renal & urinary
Reproductive
Visual & Audio
Respiratory
TPN & Internal Feeding
Maternity
Anatomy & prenatal care
Labor and delivery
Fetal Heart Monitoring
Epidural & Pain control
Preterm Labor
Labor Complications
Newborn
Postpartum
Pediatrics
Physical assessment & Vital signs
Developments Milestones & communication
Cancer- Oncology Cardiac
Dehydration & Diarrhea
Endocrine
Genetic disorders
Gastrointestinal
Hematological
Immunization Dates & Types
Infectious disease
Integumentary skin
Mental Health
Musculoskeletal
Neurological Brain
Poisoning
Respiratory
Renal & urinary
Eye & Ear
Clinical Skills
Critical thinking
BLS & CPR
Burns
Cardiac Care
Hypothermia & Frostbite
Shock
Prioritization & Delegation

Pharmacology
NCLEX Drugs Quick View
Antibiotics
Antibiotics (Bonus cheat sheets)
Antifungal & Antiviral
TB Drugs
Blood thinners-Anti platelets
Anticoagulants
Thrombolytics
Oncology
Diabetes Drugs
Steroids
Thyroid Drugs
HGH & Hormones
GI & Nutrition
Immune
Maternity & pediatrics
Mental health
Musculoskeletal
Nervous System CNS
Nervous System PNS
Cardiac (Anti-hypertensive & Heart failure drugs)
Cardiac
Anatomy & physiology
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Fundamentals
&
Health assessment
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5-9
Wound care: wet to dry dressing change
Purpose
To maintain skin integrity, to prevent infection,provide comfort, maintain a moist environment, remove necrotic tissue if
appropriate, and prevention of complications associated with injury or surgery.
Assessment Risks Education

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

0.1
0.01
0 1 2 3
Acid Base ABG

A B
pH
pH
Acid “acidosis” Base “alkalosis”
7.35 7.45
B A Acidotic NORMAL pH Alkalotic

Carbon Di-ACID PaCO₂ 7.35 pH 7.35 pH 7.45 pH 7.45 pH
35 45
A B
Alkalosis (Base) HCO₃
22 26
Respiratory Acidosis = Low & Slow Kaplan Question

breathing
Respiratory ALKalosis = FAST
Alcohol intoxication Most Tested Cause for respiratory
breathing
Overdose (Low & slow RR)
alkalosis? A - Anxiety Attack
Opioids / Benzos (diazepam)
C - COPD Hyperventilation (Hyperventilation)
C - CO2 retained A - Alkalosis
Sleep apnea
Treatment: Breathing into a
Head trauma PaCO2 35 - 45
paper bag - slow down breathing
Treatment: Hyperventilation, pursed
lip breathing to blow off the CO2
alk alk alk & retain CO2
alk-alooosis
“Panting like a dog will put you into
CO2
Alk alk alkalosis”
Severe Acidosis = Hypercapnic Hypoxia earliest sign

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

Infection PRIORITY
ABCS Priority: Less than 5,000 WBC

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

PTT & INR
ABGs (not pulse oximeter)

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

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

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

for the past 72 hours.
2. A client with swelling and bruising to the left foot
following a running accident.
3. A client with abdominal and chest pain following a
large, spicy meal.
4. A child with a 10 cm laceration to the chin
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Fluid & Electrolytes
Cheat Sheet
Electrolyte Function HYPER “HIGH” Hypo “low”

HYPERkalemia (over 5.0) Hypokalemia (below 3.5)
Heart - TIGHT & CONTRACTED
1ST elevation and Peaked T waves HEART - LOW & SLOW
1 Flat T waves, ST depression, & prominent U wave
2 Severe = Vfib or Cardiac Standstill! MUSCULAR - LOW & SLOW
P - Potassium 3 Hypotension, Bradycardia
Potassium
1 Decreased DTR
P - Priority! Since it.. GI TRACT - TIGHT & CONTRACTED 2 Muscle cramping
1 Diarrhea 3 Flaccid paralysis (paralyzed limbs)
3.5 - 5.0 P - Pumps the heart
& muscles
2 Hyperactive bowel sounds
NEUROMUSCULAR GI - LOW & SLOW
Decreased motility, hypoactive to absent bowel
- TIGHT & CONTRACTED
Paralysis in Extremities sounds, Constipation
Increased DTR Abdominal distention
Profound Muscle Weakness, Paralytic ileus, paralyzed intestines!
(General Feeling of heaviness) *PRIORITY* for SB0 (small bowel obstruction)
HYPERnatremia (over 145) Hyponatermia (below 135)

S - Sodium HYPERNATREMIA = BIG & BLOATED HYPONATREMIA - DEPRESSED & DEFLATED
S - Swells the body 1. SKIN
Sodium to maintain:
FLUSH ‘’Red & Rosy’’
EDEMA ‘’waterbed skin’’
NEURO = Seizures & Coma
HEART = Tachycardia, & weak thready pulses
135 - 145 • Blood Pressure LOW GRADE FEVER RESPIRATORY ARREST

2. POLYDIPSIA EXCESS THIRST
• Blood Volume 3. LATE SERIOUS SIGN
• pH balance SWOLLEN dry tongue NCLEX TIP
GI = nausea & vomiting NCLEX TIP
INCREASED muscle tone NCLEX TIP
Sodium’s sidekick HYPERchloremia (over 107) Hypochloremia (below 97) t
Chloride Maintains:
NEARLY SAME AS HIGH SODIUM NEARLY SAME AS LOW SODIUM
• Blood Pressure
97 - 107 • Blood Volume
NAUSEA & VOMITING
SWOLLEN DRY TONGUE
EXCESSIVE DIARRHEA,
VOMITING, SWEATING
• pH balance CONFUSION FEVER TEST TIP: ONLY DIFFERENCE
HYPERmagnesemia (over 2.1) Hypomagnesemia (below 1.3)
1. CARDIAC - CALM & QUIET 1. CARDIAC - BUCK WILD!

Heart block EKG: ST depression, T wave inversion
Prolonged PR intervals Torsades de pointes
Magnesium M - Magnesium
M - Mellows the
VITALS = bradycardia, hypotension
2. DEEP TENDON REFLEXES -
SEVERE = V fib
VITALS = Tachycardia
1.3 - 2.1 M - Muscles (relaxes) CALM & QUIET

Hyporeflexia - Decreased DTR
2. DEEP TENDON REFLEXES - BUCK WILD
Hyporeflexia - increased DTR
3. EYES - BUCK WILD
3. LUNGS - CALM & QUIET Abnormal eye movements (nystagmus)
Depressed shallow respirations 4. GI - BUCK WILD
3. GI - CALM & QUIET Diarhea
Hypoactive bowel sounds
HYPERcalcemia (over 10.5) Hypocalcemia (below 9.0)
SWOLLEN & SLOW - MOANS, GROANS T - Trousseau’s

Keeps the 3 Bs Strong
Calcium B - Bone
& STONES
1. CONSTIPATION
T - Twerking arm with BP cuff on
C - Chvostek’s
9.0 - 10.5 B - Blood
B - Beats (heart)
2. BONE PAIN
3. STONES Renal Calculi (kidney stones)
C - Cheek smile when touched
Diarrhea
4. DEEP TENDON REFLEXES
Decreased DTR
Circumoral tingling
Severe muscle weakness Weak bones
HYPERphosphatemia (over 4.5) Hypophosphatemia (below 3.0)
‘’LOW CALCIUM’’ BAJA CA+ Swollen & SLOW - MOAN,

1. TROUSSEAU’S SIGNS GROANS & STONES
Helps with bone & teeth 2. CHVOSTEK’S SIGNS
Phosphate formation.
Helps regulate calcium
3. DIARRHEA
4. WEAK Bs
1. CONSTIPATION
2. DECREASED DTR & SEVERE
3.0 - 4.5 Ca HIGH = Phosphate LOW Strong bones? -
WEAK! (fractures)
MUSCLE WEAKNESS
3. DECREASED HR, RR
Ca LOW = Phosphate HIGH 4. INCREASED BP
Strong blood clotting? -
WEAK! (risk for bleeding)
Strong heart beats? -
WEAK! (cardiac dysrhymias)
*Disclaimer: Values above are based on NCLEX standards, many books & hospitals will differ in their values.
34
Fluid Volume
Deficit & Excess
Cardiovascular
• Thready, increased pulse rate, decreased blood pressure and orthostatic hypotension,
flat neck and hand in veins in dependant positions, diminished peripheral pulses,
“HypOvolemia” decreased central venous pressure, dysrhythmias
(LOw fluid volume) Respiratory
• Increased rate and depth of respirations, dyspnea
Neuromuscular
• Decreased central nervous system activity, from lethargy to coma, fever, depending
on the amount of fluid loss, skeletal muscle weakness
Renal
• Decreased urine output
Integumentary
• Dry skin, poor turgor, tenting, dry mouth
Gastrointestinal
• Decreased motility and diminished bowel sounds, constipation, thirst, decreased
body weight
Serum Blood Lab Findings
• Increased serum osmolality, increased hematocrit,
• Increased blood urea nitrogen (BUN), Increased serum sodium level,
• Increased urinary specific gravity
Memory Trick:
• If Osmolality is HIGH = Body is DRY
• If Specific gravity is HIGH = Body is DRY
Cardiovascular
• Bounding, increased pulse rate, elevated blood pressure, distended neck and hand
veins, elevated central venous pressure, dysrhythmias
Respiratory
“Hypervolemia” • Increased respiratory rate (shallow respirations), dyspnea, moist crackles on
(High fluid volume) auscultation
Neuromuscular
• Altered level of consciousness, headache, visual disturbances, skeletal muscle
weakness, paresthesias
Renal & Urinary
• Increased urine output if kidneys cannot compensate; decreased urine output if
kidney damage is the cause
Integumentary
• Pitting edema in independent areas, pale cool skin
Gastrointestinal
• Increased motility in gastrointestinal tract, diarrhea, increased body weight, liver
enlargement, ascites
Serum Blood Lab Findings
• Decreased serum osmolality, decreased hematocrit, decreased BUN level,
• Decreased serum sodium level,
• Decreased urine specific gravity
Memory Trick:
• If Osmolality is Low = Body is Liquidy
• If Specific gravity is Low = Body is Liquidy
35
F&L Quick Notes:
IV Solutions
Isotonic solutions
• Definition: when solutions on both sides of a selectively permeable membrane have
established equilibrium or are equal in concentration, they are isotonic
• Human blood is isotonic thus very little osmosis occurs since isotonic solutions have
the same osmolality as body fluids & thus increase extracellular fluid volume.
Memory Trick:
• Iso-tonic Solutions
• I-so-Perfect (no fluid shift, “I’m so perfect” perfect balance)
• List of fluids:
• 0.9% sodium chloride (normal saline)
• 5 % dextrose in water (DWS)
• 5 % dextrose in 0.225% saline (DSW/ 1⁄4 NS)
• Lactated Ringer’s (LR)
Hypotonic solutions
• Definition: when a solution contains a lower concentration of solute than another more
concentrated solution, then it is a hypotonic solution.
• These solutions have lower osmolality than body fluids.
• They cause the movement of water into cells by osmosis, swelling the cells like a BIG fat
hippo, and therefore, should be administered slowly to prevent cellular edema
Memory Trick:
• HypO - tonic
• HippO - tonic = fluid swells the cell like a big hippo
• 0.45% sodium chloride (1⁄ 2 NS)
• 0.225% sodium chloride (1⁄4 NS)
• 0.33% sodium chloride (1.3NS)
Hypertonic solutions
• Definition: when a solution contains a higher concentration of solutes than another
less concentrated solution, then it is a hypertonic solution.
• These solutions have higher osmolality than body fluids.
• They cause the movement of water outside the cells by osmosis, making the cells skinny
like a hyper person.
Memory Trick:
• Hyper - tonic
• Hyper person = very skinny cells like a hyper person is skinny
• 3% sodium chloride (3% NS)
• 5% sodium chloride (5% NS)
• 10% dextrose in water (D10W)
• 5% dextrose in 0.9% sodium chloride (D5W/NS)
• 5% dextrose in 0.45% sodium chloride (D5W/ 1⁄ 2 NS)
• 5% dextrose in Lactated Ringer’s (D5LR)
36
_ _
ABG
&
Acid Base Imbalances
37
3 Step ABG Interpretation
Mike’s Marching Band Suit Method
Marching band suit method
A B
pH 7.35 7.45 TEST TIP
Write this chart out 5 - 10 times every day the week

B A
PaCO₂
35 45
A B of your ABG exam.

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

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

HCO₃ Step 3 Look at the 3 in HCO2, it comes 3nd.
Kidneys on bottom
Phase 2 - Key numbers to memorize
A B
pH 7.35 7.45
B A
Top line 7.35 - 7.45
PaCO₂ Middle 35 - 45 (7 goes to heaven)
35 45
Bottom 22 - 26 (think 2+2+2 = 6)
A B
HCO₃
22 26
Phase 3 - Label it A & B
A cid
A B
pH 7.35 7.45
B A
PaCO₂
35 45
B ase HCO₃
A
22
B
26
38
ABG Practice Questions
Pathophysiology Course
ABG Practice Question 1 A B

pH 7.35 7.45
pH 7.25 , PaCO₂ 55 , HCO₃ 25 B A
Draw your marching band suit here: PaCO₂
35 45
A B
HCO₃
22 26
ABG Practice Question 2

pH 7.57 , PaCO₂ 25 , HCO₃ 22
Draw your marching band suit here:
ABG Practice Question 3

pH 7.21 , PaCO₂ 39 , HCO₃ 19
39
ABG Compensation Questions
ABG Question 1
Full or Partial compensation?
pH 7.32 , PaCO₂ 55 , HCO₃ 42
ABG Question 2
pH 7.55 , PaCO₂ 49 , HCO₃ 35
ABG Question 3
pH 7.37 , PaCO₂ 52 , HCO₃ 32
ABG Question 4
pH 7.43 , PaCO₂ 43 , HCO₃ 33
40
3 Step ABG Interpretation
Mike’s Marching Band Suit Method
How to Solve ABG Questions in 3 Steps

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

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

A B
pH
Example:
! ! 7.35 7.45
Let’s say pH is under 7.35, PaCO2 is B

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

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

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

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

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

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

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

but the body is trying! B
A
It is like couples counseling, sure the pH is NOT normal, PaCO₂
35 45
but at least the lungs & kidneys are TRYING to work things A
A
B
out. HCO₃
22 26 42
41
ABG Answers Sheet
ABG Practice Question 1 A

pH
B
pH 7.25 , PaCO₂ 55 , HCO₃ 25

7.25 7.35 7.45
B
A
PaCO₂
35 45 55
Step 1: pH A Normal B
7.25 is below 7.35 so it is Acidic HCO₃
22 25 26
Step 2: Match pH with its partner
CO2 is 55 so it is Acid Answer:
We have a match in the lung area = respiratory acidosis Respiratory Acidosis
HCO3 25 - normal range, no match Uncompensated
Step 3: Compensated or Uncompensated?

Is the pH in normal range?
NO, it's not in balance, it did not find common ground in Acidosis
compensation pH is UNcompensated (not normal range)
ABG Practice Question 2 B

pH
A
pH 7.57 , PaCO₂ 25 , HCO₃ 22 B

7.35 7.45 7.57
PaCO₂
Step 1: pH 25 35 45
A B
7.57 is above 7.45 so it is Base (Alkalosis) HCO₃
22 26
CO2 is 25 Base (Alkalosis)
Answer:
We have a match in the lung area = respiratory alkalosis
Respiratory Alkalosis
HCO3 22 - normal range, no match
Uncompensated
Is the pH in normal range? ! !
NO, it's not in balance, it did not find common ground in
compensation pH is UNcompensated (not normal range) Alkalosis !
ABG Practice Question 3 A

pH
B
7.21 7.35 7.45

pH 7.21 , PaCO₂ 39 , HCO₃ 19 A Normal B
PaCO₂
Step 1: pH 35 39 45
A
7.21 is below 7.35 so it is Acid HCO₃
B
19 22 26
CO2 is 39 - normal range, no match Answer:
HCO3 is 19 Acid Metabolic Acidosis
We have a acid match for the kidneys = Metabolic acidosis Uncompensated
NO, it's not in balance, it did not find common ground in
Acidosis !
compensation pH is UNcompensated (not normal range)
42
Acid Base Imbalances + ABGs
Pathophysiology pH
Acid base imbalances are the balance of Acid & Base in the body, Acidotic NORMAL pH
NORMAL pH Alkalotic
kind of like a tug of war the body loves to keep pH in balance. 7.35
7.35 pHpH 7.45
7.45pHpH
- Normal pH: 7.35 - 7.45

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

H⁺
H⁺
H⁺
H⁺
Vomiting Diarrhea
NGT suction Renal Failure
Hypokalemia DKA - Diabetic Ketoacidosis
• Low K+ Potassium (below 3.5) Lactic AcidOSIS Vomiting sounds like
• LOW K+ = AlKaLOWsis • Shock (low perfusion) “ALKKK-alosis”
Compensation • Sepsis (severe infection)
• Slow Compensation
• Shallow respirations • Rapid, deep respirations Metabolic
ACIDosis
K
Memory tricks Memory tricks
Base out the Butt DKA - Diabetic Ketoacidosis
Metabolic ACIDosis
< 3.5
Diarrhea: if it comes
LOW K+ out of your a$$idosis
AlKaLOWsis Renal Failure: when the
kidneys fail, acid prevails!
43
Acid Base Imbalances + ABGs II
Respiratory Acidosis & Alkalosis - Causes

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

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

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

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

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

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

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

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

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

7.35 pH
NORMAL pH Alkalotic
4. Decreased renal excretion of HCO3
7.45 pH
44
ABG Compensation Answers
Remember:
• Full compensation = FULLY Normal pH 7.35 - 7.45
• Partial compensation = pH is not normal
pH
Remember the body will try to balance the pH

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

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

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

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

pH 7.43 , PaCO₂ 43 , HCO₃ 33 B Normal A
PaCO₂
35 43 45
Step 1: pH A B
7.43 = Normal (but pH looks closer to Base) HCO₃
22 26 33
Step 2: Match pH with it’s partner

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

Alkalosis !
Yes, Fully compensated, since the pH is FULLY in normal range.
46
47
48
49
50
_ _
EKG
51
5 Step
EKG INTERPRETATION
Heart rate Rhythm P wave PR interval QRS

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

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

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

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

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

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

S
3 boxes - .12 seconds here. QRS
int.
QT int.
52
9 ECG Strips on the NCLEX
1. Normal sinus rhythm
Treatment:
None - continue to monitor
Causes:
Being healthy
Memory tricks
Normal beat - evenly spaced
2. Bradycardia
Treatment:
BRADY Bunch Atropine ONLY if symptomatic
old TV show (slow times)
showing low perfusion (pale,
cool, clammy)
<60 Causes: ATROPINE
Vagal maneuver (bearing down),

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

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

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

Causes:
Post MI, Hypoxia,
Low potassium, Low magnesium
C
Treatment: C - Count a pulse
C - Cardiovert
1. Early Defibrillation! NCLEX TIP *Synchronize First
Apply defibrillator pads & Sedation
Call out & look for everyone to be
D
CLEAR!
Shock & IMMEDIATELY continue
chest compressions
Memory tricks D - Dead - NO PULSE
2. When to Shock? NCLEX TIP
D - DEFIB!!
V Tach with No pulse = Defibrillation
V Tach Tombstone pattern
*NO Synchronize
V Tach with Pulse = Cardioversion D - Don't wait
53
9 ECG Strips on the NCLEX II
5. Atrial Fibrillation (A Fib) Digoxin

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

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

COPD, after heart surg.
Treatment:
DIGOXIN

*Push Synch
Max 2.0
Check ATP Before giving: 60
A - Apical pulse 60 40 kg

N/V, Anorexia < 3.5
K
Memory tricks
Potasssium
toxicity
K+
A FluTTer = sawTooTh K antidote, moderate green leafy veggies)
7. SVT - Supraventricular Tachycardia KAPLAN

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

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

Treatment:
Magnesium Sulfate NCLEX TIP
M
Mellows out the heart
Memory tricks
Tornado Pointes
54
9 ECG Strips on the NCLEX III
9. Asystole - Flatline
Epinephrine, Atropine & CPR

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

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

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

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

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

Answer: Ventricular Fibrillation
Atrial Fibrillation
If you know these, you will pass the NCLEX! NCLEX TIP
Normal sinus rhythm Bradycardia Ventricular Fibrillation (V Fib)
Ventricular Tachycardia (V Tach) Atrial Fibrillation (A Fib) Atrial Flutter (A Flutter)
3.
SVT - Supraventricular Tachycardia Torsades de Pointes Asystole - flatline
55
EKG Quick view
9 strips to know for the Nclex
Normal sinus rhythm
Bradycardia
Ventricular Fibrillation (V Fib)
Ventricular Tachycardia (V Tach)
Atrial Fibrillation (A Fib)
Atrial Flutter (A Flutter)
SVT - Supraventricular Tachycardia
Torsades de Pointes
Asystole - flatline
56
Heart Sounds &
5 EKG Lead Placement
Memory Trick
APETM
Heart Sounds
“All Pigs Eat Too Much”
AORTIC PULMONIC
A - Aortic (2nd Intercostal Space
(2 Intercostal Space
nd
P - Pulmonic L Sternal Border)
R Sternal Border)
E - Erb’s point
T - Tricuspid
M - Mitral
TRICUSPID
(3nd or 4th Intercostal Space
L Sternal Border)
ERB’S POINT
(3rd Intercostal Space MITRAL
L Sternal Border) (5th Intercostal Space
Midclavicular Line)
5 EKG Lead Placement

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

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

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

(directly under the midpoint of the armpit)
v4R 5th intercostal space, right midclavicular line
57
Adult Health
58
_ _
Cardiac
59
Anatomy & Physiology Cardiac System
Med Surg: Cardiac
Blood flow of the heart

1. Deoxygenated blood gets “vacuumed” back to the
vena cava (superior and inferior vena cava)
2. Right Atria - Tricuspid Valve - Right Ventricle.
3. Through the pulmonary valve & pulmonary arteries RA LA
into the lungs to drop off CO2 & pick up O2 (oxygen) in
the capillaries.
4. This oxygenated blood is then pumped through the Pulmonary valve valve Aortic
pulmonary veins. Valve Valve
5. Left Atrium - Mitral Valve (bicuspid valve) - Left Ventricle
• Side note: Left ventricle is the “BIG momma pumper” RV LV
pumping oxygen rich blood OUT to the body = cardiac
OUTput
6. Left Ventricle pumps O2 rich blood through the aortic
valve & then finally
7. The Aorta & out to the body via the “Arteries =
pump аway”.
Anatomy of the heart 4 valves 4 chambers

Cone shaped organ located in the
mediastinal space. Two atrioventricular valves that close • Right atrium: carries
The pericardial sac encases the at the beginning of ventricular deoxygenated blood from the
heart and protects it, lubricates and contraction. They prevent blood from body via superior and inferior
holds 5-20 ml of pericardial fluid. flowing back into the atria. vena cava.
This has two layers. • Right ventricle: carries blood
• the parietal pericardium which is • Tricuspid valve: on the right side from the right atrium and pumps
the outer membrane. of the heart. it into the lungs through the
• the visceral pericardium is the • Bicuspid valve: on the left side of pulmonary artery.
inner membrane attached to the the heart. • Left atrium: carries oxygenated
heart. blood from the pulmonary veins.
Two semilunar valves that prevent
• Left ventricle: carries oxygenated
Consists of 3 layers blood from flowing back into the
blood from the left atrium and
ventricles during relaxation.
• Pulmonic semilunar valve: pumps it into the systemic circuit
• Epicardium: outermost layer of through the aorta.
the heart. between the right ventricle and
• Myocardium: middle layer of the pulmonary artery.
heart, the contracting muscle. • Aortic semilunar valve:
• Endocardium: innermost layer of between the ventricle and the
the heart, lines the inner aorta. Electrical conduction:
chambers and the valves.
• SA node: pacemaker of the heart
Coronary arteries and initiates contraction at 60-100
Function of circulation BPM.
• Right main coronary artery: • AV: receives impulses from the SA
Delivers 02, nutrients, hormones and
supplies the right atrium and node initiates and sustains impulses
antibodies to organs, tissues and cells.
ventricle, the inferior left at 40-60 BPM.
Removes the end product of cellular
ventricle, posterior septal • Bundle of His: continuation of the
metabolism
wall, 1SA and AV nodes. AV node and branches into the the
• Left main coronary artery: bundle branches which terminate in
Function of the heart consists of two main branches left the purkinje fibers.
anterior descending which • Purkinje fibers: network of
Pumps oxygenated blood into the supplies blood to the left ventricle conducting strands beneath the
arterial system to supply capillaries and the ventricular septum and ventricular endocardium. They can
and tissue. circumflex arteries which supply act as a pacemaker when the SA and
Pumps oxygen poor blood from the blood to the left atrium and the AV fail as pacemakers. They can
venous system through the lungs lateral/posterior aspects of the sustain at 20-40 BPM.
to be reoxygenated. left ventricle.
60
Cardiac Tamponade
Med Surg: Cardiac
Pathophysiology Signs & Symptoms
COMPRESSION OF THE HEART

caused by fluid collecting in the pericardial sac. BECKS TRIAD BEC
(weaker pump = less cardiac output) B • Big Jugular Veins Distension (JVD)
E • Extreme Low BP (Hypotension)
This is a medical emergency as fluid C • Can’t hear heart sounds (muffled)
or blood fills the pericardial sac,
compressing the heart so that it cannot PULSE PARADOXES
fill & pump! The result is a Systolic drop of 10 mmHg
dramatic drop in blood pressure (120/80 to 110/80)
that can kill the client.
ECG
MEMORY TRICK
QRS complexes
• C - Cardiac Tamponade (short & uneven height)
• C - Compression on the heart
• C - Critical client!
Causes
ACUTE
TRAUMA: (Stabbing or MVA)
CHRONIC: Pericarditis
Treatments
PERICARDIOCENTESIS
1. CARDIAC MONITOR
2. CATHETER ATTACHED
to drainage system
3. ASSESS DRAINAGE
(Type & speed of drainage)
61
DVT, RAYNAUD’S & BUERGER’S
DVT - Deep Vein Thrombosis
Pathophysiology Treatments
CLOT in a deep vein
DURING CLOT-DV
D Don’t Walk (bed rest)
V Venous return (eleVate)
Signs & Symptoms

CHANT
COWS AFTER CLOT

C Calf Exercise & Isometrics
C CALF PAIN & CRAMPING H Hydration
O ONE-SIDED SWELLING (Unilateral) A Ambulation NCLEX TIP
W WARM & RED (Blood pooling) N NO long sitting (Car, Airplane, Bedrest)
S SOB & CHEST PAIN = PE! (Call Doctor) T Ted & SCDs (AFTER CLOT resolved)
Raynaud’s & Buerger’s Disease

Signs & Symptoms
R–RAYNAUD’S • R–RING FINGER
B–BUERGER’S • B–BLACK FINGERS & TOES
62
Endocarditis / Pericarditis
Med Surg: Cardiac
ENDOCARDITIS Causes
• Dirty Needles
Pathophysiology • Dental visits
• Heart Surgery: Valve replacements
Inflammation INside the heart
& CABG
• Infective = bacteria (mold on heart valves)
• Untreated Strep Throat
• Noninfective = No bacteria (only inflammation)
Heart valves can’t close fully
Less cardiac output = Less oxygen OUT Treatment
Signs & Symptoms • Antibiotics
• Valve repair or Replacement
• C - Clots in the heart & brain Education
• Risk for stroke CVA - monitor for “agitation” “change
in level of consciousness”
NCLEX TIP MONITOR
• Splinter hemorrhages (clots under fingernails)
• L - Lung fluid (crackles) ORAL CARE

brush 2x day NO FLOSSING
• O - Overheated (fever) LET ALL PROVIDERS KNOW
• T - Too little Oxygen (low cardiac output)
• Clubbing fingers DENTAL VISITS OR SURGERY
*Roth spots, Osler’s nodes, Janeway lesions ADHERENCE
(body’s immune response)
PERICARDITIS
Signs & Symptoms + Labs
• Precordial chest pain
• Elevated WBC (over 10,000)
Pathophysiology • C-reactive protein
• Cardiac Tamponade
Inflammation OUTside the heart 1. JVD
(heart gets compressed & can’t pump) 2. Muffled heart sounds
Less cardiac OUTput = Less oxygen OUT 3. Pulsus paradoxus
(drop in sys. BP by 10 mmHg)
Causes Treatment
• NSAIDS (indomethacin)
HEART ATTACK • Steroids (prednisone)
Acute MI
• Pericardiocentesis (needle in the heart)
AUTOIMMUNE DISORDERS used to drain any fluid or blood in the heart sac.
INFECTION
RENAL FAILURE
Uremia (High BUN)
63
Hypertension
Med Surg: Cardiac
Pathophysiology Numbers to know:

Hypertension is chronic high blood pressure, which if not Systolic/Diastolic
treated can cause damage to organs from all that ‘’San/Diego’’
high pounding pressure Squeeze/Decompress
• Brain - CVA (stroke risk!) NCLEX TIP
• Heart - MI (heart attack) & HF (heart failure)
• Kidney - CKD (Renal failure)
• Blood vessels - Atherosclerosis (scared arteries) STAGE 2: 140/90 (or more)
• Eyes - Blindness (Retinopathy NCLEX TIP
MEMORY TRICK “NORMAL BP” STAGE 1: 130-139/80-89
ELEVATED: 120-129/80
(or less) OVER
NORMAL: 120/80 (or less)
140/90
Signs & Symptoms NO SYMPTOMS = Silent KILLER
LOW: 90/60 (or less)
OH LORDY!
A –Achy head (Headache) NCLEX TIP
B –Blurred vision (retinopathy)
C –Chest pain (angina) Labs
SEVERE: HTN Crisis OVER 180/120
BNP - B-type Natriuretic Peptides Cholesterol Panel
Immediate Action: • 100 & Less = Normal • Total Cholesterol = 200
• B - Beta blockers “Blocks Beats” • 300+ Mild • Triglycerides = 150
• C - CCBs “C Calms the heart” • 600+ Moderate • LDL = Under 100
• D - Dilators (Vasodilators) “Nitro = Pillow” • 900+ SEVERE • HDL = OVER 40
• E - Emergency to ICU!
NOTE: All should be low, except the HDL
“Happy - keep them HIGH”
Imaging
• Echocardiogram measure
Pharmacology
Ejection fraction (blood pumped out of heart)
55 - 70% = normal Blood Pressure Lowering Drugs ABCD
Less than 40% = Heart Failure A –Ace inhibitors -pril Lisinopril
• ECG & EKG - Tall R peaks from the high pumps A–Angioedema
• Side note: 3 BP measurements - 1 week apart, C–Cough
confirms diagnosis E–E+ imbalances (LOW sodium, HIGH potassium)
ARBS “-sartan” Losartan
B –Beta blockers (slows HR) “-lol” Atenalol
Education Blocks Beats
Caution: 4 B’s
Bradycardia (60 or Less)
Bottomed out BP (80/60)
DIET LOW SCC (Sodium, Calories, Cholesterol) Breathing problems (COPD, Asthma)
Blood sugar masking (diabetics)
REDUCE ALCOHOL & CAFFEINE C –Calcium channel blockers
Calms heart, Controls BP
EXERCISE: WALKING (30 min. x 5 days/wk) D
Niphedipine, Cardizem, Verapamil
–Diuretics
STOP SMOKING & ALCOHOL D–Drains Fluid “Diurese”

K+ Wasting–Furosemide & HCT
(caution: Low K+, Eat fruits & green leafy)
STRESS REDUCTION K+ Sparing–Spironolactone
(avoid Salt Substitues)
D –Dilators (vasodilators) (Relieves Pressure)
Nitroglycerin = Pillow (rest & relaxed heart)
Causes Caution: No Viagra = DEATH
SODA AC Anti-Clogging of the arteries

S –Stress, Smoking, Sedentary Lifestyle
O–Obesity, Oral Contraceptives (birth control)
A –Antiplatelet (Anti Clumping)
A–ASA
D–Diet (High sodium & cholesterol) C–Clopidogrel Caution: Bleeding
Diseases C –Cholesterol Lowering
DM, Renal disease, HF, Hyperlipidemia (Over 200) Lovastatin “stay clean”
A–African men & Age (old) Caution: Liver Toxic, NO grapefruit
64
MI, Angina, CAD
Med Surg: Cardiac
Pathophysiology Diagnostics
Myocardial Infarction (MI) the heart muscles DIE “necrosis” 1st–EKG
from lack of oxygen. This occurs when there is a (Any chest pain or MI symptoms)
blockage of the coronary arteries, the “O2 tubes”
feeding the heart oxygen.
Signs & Symptoms

O2
PAIN–Jaw, back, mid back/shoulder pain, heartburn (epigastric),

Substernal NormalNormal ST elevation
ST elevation ST Depression
Key words = priority: “Sudden” “Crushing” “radiating” NCLEX TIP
SOB “dyspnea” “labored breathing”
NAUSEA Vomiting “Abdominal pain”
SWEATING “Diaphoresis”
PALE COOL SKIN “dusky”
ANXIETY
Causes
SODDA 2nd–LABS
T–Troponin (Over 0.5 ng/mL)
S–Stress, Smoking, Stimulants (caffeine, amphetamines) T–Trauma (ONLY indicator of MI)
O–Obesity–(BMI over 25) Other labs: Crp, Ckmb,
D–Diabetes & HTN (over 140/90) Myoglobin, CRP (inflammation)
D–Diet (high cholesterol) animal fats
A–African American males & Age (over 50) Treatment: Pharmacology
*Men more than women
DURING–Any Chest Pain
Progression O–Oxygen
A–Asa
CAM N–Nitro–under tongue x 3 Max
M–Morphine - Any pain after = MI (injury)
C–CAD “coronary artery disease”
A–ACS “acute coronary syndrome” AFTER–MI
Angina - Stable “Safer”- relieved w/rest
Clot Stabilization:
Angina - Unstable “Unsafe” - Unrelieved Heparin: prevents CLOT growth (NOT dissolve only t-PA)
M–MI (heart die) PTT: 46 - 70 “3 x MAX” Antidote: Protamine Sulfate
Memory Trick: “HaPTT” frog
Heart Rest:
B–Beta Blockers (-lol) Atenolol
Blocks both BP & HR (Lol = Low BP & HR)
CAUTION:
B–Bad for Heart Failure patients (CHF)
Patient Education B–Bradycardia (60 or Less) & BP low (HR LESS than 60)
B–Breathing Problems “wheezing” (Asthma, COPD)
DRESS B–Blood sugar masking “hides s/s” (Diabetics)
C–Calcium Channel Blockers
D–Diet low (sodium & fluids (2g/2L per day) Calms BP & HR-(AVOID Low Hr & BP)
Prevent HF Heart Failure=Heavy Fluid (Nifedipine, Diltiazem, Verapamil)
-dipine “declined BP & HR”
Report "New, Rapid" Weight Gain-Water Gain! -zem “zen yoga for heart”
R–Reduce Stress, Alcohol, Caffeine, Cholesterol (animal fats) -amil “chill heart”
E–Exercise (30 min x 5 days/wk) D–Dilators (vasOdilators = O2 to heart)
Nitroprusside (only for HTN crisis) & Isosorbide
S–Smoking Cessation Nitro “Pillow for heart”
S–Sex (2 flights of stairs with NO SOB) NCLEX TIP NO viagra “-afil” Sildenafil = DEATH!
*AVOID NSAIDS (naproxen, ibuprofens) = increases CLOT risk! Nitro drip: STOP if Systolic BP below 90 or 30 mmHg Drop
SE: HA is Common + SLOW Positions changes “syncope” t
Treatment: Pharmacology DISCHARGE–GOING HOME

AC–Anti Clogging of Arteries CHOLESTEROL
Heart Rest:
1st choice A–Ace (-pril) Lisonopril “chill pril”
A–Antiplatelet HOLD if: Platelets 50K or LESS PANEL 2nd choice A–ARBs (-sartan) Losartan “relax man”
“below 50 gets risky” (not INR, not aPTT) Antihypertensive (BP ONLY) *HOLD: Low BP (not HR)
A–ASA C-CLOGGED ARTERIES (risk) Precautions:
A–Avoid Pregnancy
C–Clopidogrel 200 or Less-Total Cholesterol A–Angioedema “thick tongue”
C–Cholesterol Lowering “-Statin” 150 or Less-Triglycerides (Airway Risk) *only Ace NCLEX TIP
100 or Less-LDL C–Cough *only Ace
Lovastatin “stay clean”
Creatinine (Kidney) (normal: 0.9 -1.2) *only Ace
CAUTION: 40 or More = HDL
E–Elevated K+ (normal 3.5-5.0) NCLEX TIP
NO grapefruit AVOID Salt Substitues + Green Leafy veggies
Liver Toxic–report “clay colored stools” • 1st–Cardiac Monitor
• High Potassium = High Pump
Muscle pain (Rhabdomyolysis risk) • Monitor: muscle cramps, spasms,
Late night–take at dinner peaked T waves, ST changes
65
MI, Angina, CAD II
Med Surg: Cardiac
Cath Lab
C–Contrast = Kills Kidneys “Angioplasty, Angiogram, CABG”
A–Allergy to Iodine (warm flushing normal)
B–Bleeding–direct manual pressure (above site)
NO=heparin, warfarin, ASA, clopidogrel
C–Creatinine “Kidney” (normal: 0.9 - 1.2)
REPORT: Creatinine Over 1.3 & Urine below 30 ml/hr
STOP Metformin 48 hrs (before/after)
C–Can’t feel pulses (Pulses = Perfusion O2)
Diminished pulses (4-12 hrs post-procedure) MAX
PRIOITY:
Non palpable pedal pulse AFTER = CALL HCP (Dr.)
Key words: “cool leg, pulse non palpable,
present only with doppler US.
Complications After MI
ACUTE: (weeks after)

Cardiogenic Shock (severe hypotension)
V fib/V tach (no pulse) = DEADLY
Defibrillate=Don’t have a pulse
Cardioversion=Count a pulse *synchronize*
CHRONIC: (lifetime)
Heart failure “Heavy Fluid”
Rapid weight gain (Water Gain),
Worsening crackles (fluid in lungs “pulmonary, edema”)
Sudden edema (JVD, peripheral edema “+1 pitting”)
#1 Priority–IV Diuretics–Furosemide, Bumetanide “dried”
(NOT isosorbide)
NO viagra “-afil” Sildenafil = DEATH!

NitrOglycerin NORMAL ADVERSE EFFECT:
HA=Normal Side Effect
Hypotension=Adverse effect
O2 to Heart
(need slow position changes)
PILL (or spray) Nitro Patch (Transdermal nitro patch)

S–Stable Angina U–Unstable Angina
S–Safe Angina U–Unsafe Angina
S–Stops when activity STOPS (Stress Induced) U–Unrelieved with rest /Unpredictable (anytime)
*Take Before strenuous activity 1 x daily NOT PRN
GOAL: 1 patch at a time NOT 2 patches
NO chest pain=Daily activities YES Shower is ok
“comb hair, fix hair, get dressed, make up, making bed etc.” LOCATION: Rotate locations Daily
TAKING MED: “Clean, Dry, shaven area” teach patient to wash hands
CALL 911: PAIN 5 min. After 1st dose. after application
3 doses max x 5 min apart Upper Body (subclavian, arm, upper chest)
NO SWALLOW–SL under NOT: hairy, scarred, burned, callous
STORAGE: NOT BROKEN SKIN
NO LIGHT–NO HEAT *TEST TIP: Patch fall off? (Over 1 hour ago)
NOT: pill box, car, plastic bag, pocket Take nitro (pill/spray) New patch can take 40–60 min.
YES: purse ok *Nurses wear gloves! Will cause MAJOR HA if it comes
*Replace every 6 months into contact with skin!
0.4 mg
66
MI, Angina, CAD III
Med Surg: Cardiac
Anticoagulants (clot prevention) Bleed Risk (Patient Education)
Antiplatelets (LESS potent)

ASA & Clopidogrel
Platelets LESS than 50k = RISKY (Normal: 150–400k) NO peptic ulcers (or active bleeds)
NOT INR or PTT NO Rugs/dim halls (well-lit halls)
Anticoagulants (MOST potent) NO razors, hard brushing, constipation
Warfarin = INR “warINR” NO NSAIDS like naproxen/ ibuprofen
Range: 2.5–3.5 (3 x MAX range) NO EGGO vitamins
Antidote: Vitamin K (green leafy veggies) *NOT K+ = potassium* E–E Echinacea, Vitamin A
Heparin (Enoxaparin) = aPTT “HaPTT” frog Partial Thromboplastin G–Gingko, Garlic, Ginseng
Range: 46–70 (3 x MAX range) O–Omega 3
Antidote: Protamine Sulfate
MYOCARDIAL INFARCTION
Treatment
(+) Positive Troponin = Heart Attack (MI)
PRIORITY: REMOVE THE CLOT!
“CATH LAB” OR SURGERY CLOT BUSTER “Thrombolytics, Fibrinolytics”
“PCI” -graphy, -plasty
t-PA: Alteplase, Streptokinase (Allergy risk)
Dissolves Clot ONLY (heparin does NOT)
BLEED RISK
8 hour duration
NO injections (IV, SQ, IM, ABG)
NOT via central lines (CVC)
ONLY “compressible site” (IV, PICC)
NOT FOR:
Active Bleeds:
Peptic Ulcers (but menstruation is safe)
History:
Arteriovenous malformations
BEFORE AFTER Intracranial “Cerebral” hemmorhage
NPO 6 - 12 hrs NO heavy lifting–lie flat Hypoglycemia (relative contraindication)
NO Baths–Shower ok (dont soak) Hypertension (over 180/110) TEST TIP
Infected Incision
“red, warm, drainage”
STRESS TEST
Non MI (non priority) • Spot the Narrowing
TREADMILL STRESS TEST CHEMICAL: NUCLEAR PHARMACOLOGICAL STRESS TEST

24–48 hours BEFORE
STOP test: NO Cigarettes, Caffeine (tea, soda, coffee) *NO DECAF
chest pain NO Meds: Nitro, Beta Blocker, Theophylline (stimulant)
ST elevation NPO (nothing oral) 4 hrs before/after
NormalNormal ST elevation
ST elevation
67
Peripheral Vascular
Med Surg: Cardiac
NARROW NARROW
PVD | VEIN PAD | ARTERY

Signs & Symptoms Signs & Symptoms
VEINY ARTS
V VOLUMPTUOUS PULSES - Warm legs A ABSENT PULSES,
E EDEMA (blood pooling) Absent Hair (Shiny) = Cool legs
I IRREGULAR SHAPE SORES (Exotic pools) R ROUND, RED SORES (blood pooling)
N NO SHARP PAIN (Dull pain) T TOES & FEET PALE or BLACK “Eschar”
Y YELLOW & BROWN ANKLES S SHARP CALF PAIN
(intermittent Claudication)
E - Exercise • E-Elevation (recliner chair)
Positioning Patient Education Positioning
PAD
PVD & PAD
C–Constriction AVOID
PVD C–Cross legs

C–Constrictive clothing
C–Cigarettes
VEINS = ELEVATE C–Caffeine
ARTERIES = HANG
C–Cold Temperatures
(Vacuum) T–Toenails trimmed ONLY by Dr. (Away)
NCLEX TIP
68
Valve disorder
Med Surg: Cardiac
Pathophysiology
Mitral valve The heart is like a 4 bedroom suite.
The valves are like doors & the
chambers are like rooms. If valves
have trouble closing it can result in
black flow of blood & insufficient
blood flow to the body.
Aortic valve Stenosis: stiff, narrowed, hard valves
Regurgitation: Return of blood or
backflow of blood as the valve does
not completely close.
Main Types
Mechanical
valves • Aortic Stenosis
• Aortic Regurgitation
• Mitral Stenosis
• Mitral Regurgitation
Causes Pharmacology
Anything that can damage the heart! • Anticoagulants: Heparin & Warfarin
• Congenital heart disease (pre-term babies) • Antiplatelet: Aspirin & Clopidogrel
• Cardiomyopathy - a disease of the heart • Nitroglycerin for chest pain
muscle
• Heart Attack - damaged heart muscles
• Infection: Surgeries
• Rheumatic fever - ruins the heart
• Valve replacement - Warfarin therapy life long
• Endocarditis - infection in the heart
• Balloon valvuloplasty - Stenosis
Signs & Symptoms
Patient Education
Think LOW oxygen from LOW heart pumps.
• AVOID dental procedures for 6 months after
Regurgitation
• Aortic
surgery & take antibiotics before dental exams.
Tachycardia, dyspnea, fatigue • Warfarin (anticoagulant)
• Mitral • Life long drug with “routine blood tests”
Edema, pleural effusion, enlarged organs
& ascites
• 2.5 - 3.5 INR (for valve replacements)
• Even intake of Green leafy veggies (vitamin K)
Stenosis
• Aortic
NOT increased & NOT decreased intake
Angina, sys. murmur, syncope, fatigue, - nice & even
orthopnea • Bleeding precautions
• Mitral
Cyanosis, activity intolerance, diastolic
• NO brushing teeth too hard
murmur, s/s of right ventricular failure, • NO shaving - only electric shaver
clear lung sounds • NO throw rugs & always well lit halls
69
Heart Failure
Med Surg: Cardiac
Patho
The heart fails to maintain adequate cardiac output
(oxygenated blood pumped OUT to the body) due to
impaired pumping ability.
MEMORY TRICKS
• HF - Heart Failure (failure to pump blood forward)

• HF - Heavy Fluid (backs up in lungs / body)
Weight Gain = Water Gain
Signs & Symptoms
R - RIGHT Sided HF L - LEFT sided HF

R - ROCKS BODY with fluid L - LUNG fluid
• Peripheral Edema • Pulmonary Edema

• Weight Gain = Water Gain • Crackles in lungs
• JVD (big neck veins) “Rales that don't clear with
• Abdominal Growth a cough”
- Ascites (fluid in abdomen) • Pink Frothy “blood tinged”
- Hepatomegaly (big liver) sputum
- Splenomegaly (big spleen) • Orthopnea - difficulty
breathing when lying flat
Risk Factors
1. Hypertension (high BP) is the #1 risk factor

Causes 2. Atrial fibrillation & other dysrhythmias
3. Mitral valve regurgitation
R - RIGHT-Sided HF L-LEFT sided HF 4. Cardiomyopathy
• HTN (high BP) Weak heart = weak pump

• Pulmonary HTN • After a heart attack (MI - Diagnostic tests
• Stiff “fibrotic” lungs myocardial infarction)
• Left-sided HF can cause • Ischemic heart disease - • Labs: BNP (brain type natriuretic peptides)
Right HF low oxygen to heart Memory trick: B - Broken ventricles
muscles (CAD, ACS) Over 900+ = SEVERE HEART FAILURE
• Echocardiogram measures
Ejection Fraction (blood pumped out of heart)
55 - 70% = normal
3 Common EXAM Questions: 40% or LESS = BAD (heart failure)
• Hemodynamic Monitoring
Patient with heart failure who is Which food item should the heart “Swanz Ganz” (Pulmonary Artery catheter)
constipated! failure patient avoid? Over 8 = is NOT GREAT! (normal: 2 - 8 mmHg)
What would the nurse recommend? Select all that apply.
1. Walking 1. Chips - NO SODIUM! Priority Interventions

2. Increase fiber 2. Fruits
3. Stool Softeners 3. Veggies For Pulmonary Edema Crisis (lung fluid)
4. Drink extra water - NO! 4. Grilled chicken & fries - NO!
KEY WORDS
5. Canned beans - NO!
6. Bread
“New, sudden, worsening, rapid symptoms”
# 1 Action is Furosemide = “Body Dried”
A client with chronic heart failure took cold medicine for her flu. She
presents with new productive cough with pink frothy sputum and
worsening crackles. • H - HOB 45 degree or higher
What action should the nurse take first? (Semi-fowler’s, High fowler’s, orthopneic position)
1. Assess lung sounds • O - Oxygen
Look for KEY WORDS
2. Give bumetanide IV Push - YES

“New, sudden, worsening, rapid symptoms”
• P - Push Furosemide + Morphine, Positive inotropes
• E - End sodium & fluids
3. Notify the HCP # 1 Action is Furosemide = “Body Dried”
4. Clock out for lunch

(Sodium Swells the body)
NO drinking fluids + STOP IV fluids
70
Heart Failure II
Pharmacology & Care
Pharmacology
Lisinopril • Losartan
A – ACTS on BP only (not HR)
A – ACE (-pril) Lisinopril “chill pril” 1st choice
Atenolol A – ARBS (-sartan) Losartan “relax man” 2nd choice
A–Avoid Pregnancy
A–Angioedema (Airway Risk) *only Ace
Nifedipine, Cardizem, Verapamil C–Cough *only Ace
E–Elevated K+ (normal 3.5-5.0)
Cardiac Glycoside
B – BETA BLOCKERS (-lol) AtenoLOL “LOL = LOW”
Blocks both BP & HR (AVOID Low HR & BP)
Caution: HOLD IF:
Nitroglycerin B–Bradycardia (LESS than 60) & BP low (90/60)
only hold if the patient is in an acute exacerbation of CHF
B–Breathing problems “wheezing” (Asthma, COPD)
Potassium Wasting & Sparing B–Bad for Heart Failure patients
Milrinone *inotropic drug-LAST LINE therapy-palliative care B–Blood sugar masking “hides S/S” (Diabetics)
C – CALCIUM CHANNEL BLOCKERS
Calms BP & HR (AVOID Low HR & BP)
Nursing Care & Interventions (Nifedipine)
-dipine “declined BP & HR
DRBEDSS -amlodipine “chill heart”

D – DIURETICS Drain Fluid
LOW Sodium & Fluid (2L + 2g or LESS/day) D–Drains Fluid “Diurese” “Dried”
K+ Wasting–Furosemide & Hydrochlorothiazide
(Change positions slowly!)
(caution: Low K+, Eat melons, banana & green leafy veg)
(Should NOT be increasing) K+ Sparing–Spironolactone “Spares potassium”
(AVOID Salt Substitues, melons & green leafy veg)
(with pillows) High Fowlers
D – DILATORS (Vasodilators)
(3lbs/day or 5 lbs/7 days = Nitroglycerin, Isosorbide
Worsening!)
Nitroglycerin “Nitro = Pillow for heart”
(2 flights of stairs with NO SOB)
Caution: NO Viagra “-afil” Sildenafil = DEATH!
‘’TED hose’’ (decreases blood pooling, Nitro drip: STOP = Systolic BP below 90 or 30 mmHg Drop
Remove daily) Adverse effect:
HA= side effect
Low BP= adverse effect (SLOW position changes)
D – DIGOXIN (Inotropic)
NO OTC meds (Cough or Flu, Antacids Digs for a DEEP contraction
or NSAIDS) NCLEX TIP Increased contractility
NO Canned or packaged foods (chips, sauces, meats, Apical Pulse x 1 minute
cheeses, wine) Toxicity (over 2.0) Vision changes, N/V TEST TIP
Potassium 3.5 or less (higher r/t toxicity)
NEVER massage calves (CHF patients) NCLEX TIP
71
_ _
Liver,Gallbladder
and Pancreas
72
Hepatitis
Med Surg: GI - Gastrointestinal
Pathophysiology Type Transmission
Refers to an inflammatory condition of the A Fecal-oral

(contaminated food)
liver, commonly caused by a viral infection. B Blood & body fluids

Non-viral causes are:
• Alcohol C Blood & body fluids
• Autoimmune dissease where the body attacks itself D Co-infection with Hep B B
There are 5 types, but the most tested are the B & C E Fecal-oral
Contaminated drinking water D
Causes & Risk
• BCD - blood & body fluids

BCD MEMORY TRICK
A - Anus to mouth
• IV drug use, tatoos, body piercings
BC - Blood Cultures & Sex
• Sharing razors
E - E. Coli water (contaminated water)
• Unprotected sex
Signs & Symptoms Normal Liver Disease Signs
Itching “pruritus”
• Headache Elevated Liver Enzymes PT
• Fever ALT AST
Elevated bilirubin aPTT
● ALT & AST ● Jaundice
• Fatigue (malaise) ● Dark colored urine
• N/V ● Bilirubin ● Clay color stools “Pale stools”
Elevated PT & aPTT

● Bruising
Low Albumin
● Edema
Diagnostics Complications
Liver biopsy ● Acute liver failure Education

After procedure ● Cirrhosis
Lay on RIGHT SIDE to ● Liver cancer
prevent bleeding 1. Small frequent meals to prevent nausea
● Gallbladder issues ● Low Protein (all liver disease)
● Low fat foods (until nausea subsides)
2. Frequent rest periods

3. Protected sex!
Treatments 4. AVOID drinking alcohol
/ Acetaminophen (tylenol)
- typically resolves on - treated with 5. AVOID sharing shaving razors,

B
A toothbrushes
its own with bed rest C antiviral medications
Saunders Saunders Common NCLEX Question Common NCLEX Question Common NCLEX Question
Modes of transmission for
The nurse is teaching the client with The nurse should incorporate which A client is admitted with A client has hepatitis … What
viral hepatitis ... this disease is hepatitis C?
dietary plan to ensure optimal nutrition… hepatitis and complains of advice should the nurse include
characterized by which specific during the acute phase of hepatitis? Select all that apply. constant itching. What
assessment findings? Select all that apply.
regarding personal living?
interventions would the nurse
Select all that apply.
recommend? SATA
● Consume multiple small meals
● Jaundice 1. Blood Do not share
throughout the day
● Clay-colored stools 1. Apply a moisturizer personal care products
● Allow the client to select foods 2. Contaminated water
● Elevated bilirubin levels that are most appealing 2. Avoid the sun
3. Fecal oral
● Dark or tea-colored urine ● Eliminate fatty foods from
4. Semen 3. Apply a cold compress
the meal trays until nausea subsides
5. Vaginal secretions 4. Apply a hot pad
73
Cirrhosis
Pathophysiology Causes
Liver cirrhosis THINK liver Scarrrosis. Anything that causes inflammation & scarring
Since normal healthy tissues get replaced with to the liver:
SCAR tissue, making the liver hard like a rock! • Alcohol abuse
• Chronic Hepatitis (inflammation)
• Cystic fibrosis (serious mucus clogs the
entire body & the liver)
Chronic Hepatitis
Year 3 !
Year 2
Year 1 !
! !
! !
Liver Albumin
Albumin
Transports drugs
Also attracts water Binds with Calcium
4 major roles & responsibilities in the body
Producing Detoxing ammonia Drug metabolism Storing Glycogen
Ca
• A - Albumin
• B - Bile
• C - Coagulation factors
NH3
NH3
NH3 NH3 NH3
NH3 NH3
A - Albumin
A - Attracts water, drugs
& binds with calcium
Bile Clotting Factors
Which we call the Bile Bus helping to scoop up In liver disease, the blood can’t clot fast enough
excess Cholesterol & Bilirubin and take them & leads to a HUGE risk of bleeding.
from the body to the toilet via the bowels. Our #1 concern is the BLEEDING!
When the liver fails we get higher cholesterol
& high bilirubin. Bilirubin causes jaundice in the
body. This is see as yellowing of the skin & the
eyes, specifically the white part of the eye called HESI Question
the sclera.
Memory Trick
Which complication is a patient
with cirrhosis at risk for?
Bilirubin Cholesterol
● Bleeding
!
Bile Bus !
!
74
Cirrhosis II
Signs & Symptoms

Jaundice
Yellow skin & eyes from build up of bilirubin (dead RBCs) as bile can
not take it from the body into the toilet.
Portal Hypertension !
Is high pressure in the portal vein, since the liver is hard like a rock! over 10mmHg !
Naturally, blood flow will back up & fluid now spills over into the !
abdomen called ascites (third spacing)
Ascites
A - Ascites
Huge fluid filled abdomen as fluid backs up from the hard liver & A - Abdominal fluid
now spills into the third space. Clients will look pregnant with fluid.
Esophageal Varices
Key point
The enlargement of veins in the esophagus! As blood backs up
from the liver it forces major pressure on the esophagus causing • NO nasogastric tube (NGT)
the vessels to bulge to the max! Like a ticking time bomb of blood • NO straining (bowel movement)
it can explode & blood can block the airway - VERY DEADLY!
Kaplan Question Common NCLEX Questions HESI Question

PRIORITY
First action when a client with Client with a history of cirrhosis … with Which nursing intervention would be
cirrhosis begins vomiting blood suspected gastroesophageal varices. the highest priority in managing a
after a meal: Which order would the nurse question? patient with ruptured esophageal
● Obtain vital signs New nasogastric varices? Airway
(probable esophageal varices) tube insertion ● Protecting the airway
Client with cirrhosis … portal hypertension, A patient with cirrhosis and

ascites, and esophageal varices. Which of esophageal varices is vomiting, and Breathing
the following is correct patient teaching? the nurse notes hematemesis. Which
action should the nurse take first?
Avoid straining
when having a ● Place the patient in the
bowel movement side-lying position
Circulation
Hepatic Encephalopathy Saunders Top Missed NCLEX Questions

Hepatic encephalopathy Date of birth?
Which assessments would indicate if a

Name?
Date?
Cloudy brain from ammonia A client with cirrhosis … shows

Location?
Twitching extremities in the client with cirrhosis has progressed to

arms & legs = Asterixis. signs of hepatic encephalopathy.
(protein waste). The liver can The nurse should plan a dietary
hepatic encephalopathy?
Select All That Apply
Mental status changes:
not detox the ammonia & now • Confusion & bizarre behavior.
consultation to limit .. which
ingredient? Ask the client for
it builds up in the blood. • Sleepiness.
• Protein
their date of birth,
name, date, and
Key Assessments: location
• Assess hand movements
with arms extended. Tell the client to
extend their arms
Ammonia • Assess mental status with Ammonia Ammonia
those from previous shifts. Compare ammonia

BLOOD TEST
BLOOD TEST
BLOOD TEST
• Assess recent blood draws blood levels with that

for ammonia levels. of previous shifts
2 classic signs of hypocalcemia

Lab Values LIVER FAILURE LABS NCLEX TIP
Common NCLEX Questions
Trousseau's
Which blood lab values are
The ABCs of the liver will Ammonia HIGH → Hepatic Encephalopathy expected to be elevated in a
be low. Including Low client with worsening liver
A Albumin Low (under 3.5) → Calcium Low
cirrhosis? NH3
Calcium from the low Low platelets
Select all that apply
albumin leading to the B Bilirubin HIGH
2 classic signs - C Coagulation Panel (clotting time HIGH) 1. Ammonia
Chvostek's
Trousseau’s & Chvostek’s HIGH PT, PTT, INR 2. Bilirubin
Elevated ALT & AST 3. Prothrombin time (PT) PT
4. Albumin
5. Calcium
ALT AST Cirrhosis Hepatitis
75
Cirrhosis III
Interventions
A client with worsening liver
Ascites = Paracentesis Pruritus - itchy skin failure presents to the med-surg
floor… which assessment
A - Ascites 1. Apply a cool moist cloth findings should the nurse
A - Abdominal fluid to affected areas expect?
1. Empty the bladder 2. Apply moisturizing cream Select all that apply
2. Vital Signs over unbroken skin
1. Enlarged abdomen from ascites
3. Measure abdominal 3. Wear longsleeved clothes
circumference & weight 2. Bruise marks on the skin
60.00
& cotton gloves
4. HOB UP - High fowlers 3. Fatigue and possible confusion
Always tested 4. Trim fingernails short
4. Sclera that appears yellow
5. Reports of itchy skin
HESI
A nurse is assisting with a paracentesis Ascites
for a patient with ascites caused by cirrhosis. ?

?
Which action should the nurse take first?
?
? ?
?
● Have the patient empty their bladder
Diagnostics
Albumin IV
Liver biopsy
NCLEX TIP NCLEX
Increased BP & Bounding pulses

Albumin IV
After procedure
Assess vital signs! NCLEX TIP
Lay on RIGHT SIDE to
Must remain within normal limits
prevent bleeding
NORMAL
= albumin has been effective Students get this wrong all the time
Nursing Care
Ammonia
Diet Bleed Risk

Low Protein = Low Ammonia Soft toothbrush
prevents Hepatic Encephalopathy
Hepatic encephalopathy Electric razor
Low Sodium & Fluid
= Low Swelling Ascites Monitor blood in stools
NO Alcohol
Esophageal Varices
AVOID Valsalva Maneuver:
HESI NO bearing down
(bowel movements)
The nurse is caring for a patient with severe
liver cirrhosis and imbalanced nutrition. NO new NGT nasogastric tube
Which nursing intervention would prevent
malnutrition in this patient?
● Provide oral care before meals
Pharmacology
Neomycin KAPLAN
K
Lactulose NH₃
Lactulose:
NH₃
Lactulose NH₃ NH₃
● Lose the ammonia

NH₃
NH₃ NH₃
NH₃
K
● Loose bowels K
● Monitor for hypokalemia K
K
K
● Lose potassium (hypokalemia)

Hypokalemia
K
76
Pancreatitis
Pathophysiology
Inflammation within the pancreas that happens when enzymes begin to digest the pancreas (autodigestion)
Functions of the Pancreas

Exocrine: Produce Digestive enzymes 3 enzymes
Endocrine: Secrete Insulin & Glucagon Protease - protein
Lipase - fat
Insulin Glucagon
Amylase - carbs
Pancreatitis
Causes Signs & Symptoms

T C
Turner Cullen
Alcohol abuse PAIN NCLEX TIP
Epigastric pain
Gallbladder disease 2020
LUQ pain “radiates to the back”
Cystic fibrosis
ERCP procedure
endoscopic retrograde
cholangiopancreatography Bruising
RUQ LUQ
Turner's sign RLQ LLQ
Common NCLEX Question Cullen’s sign

Which client should the nurse
Saunders
assess first?
A client admitted to the hospital …
Which assessment findings would be
consistent with acute pancreatitis?
Epigastric pain after Jaundice - elevated bilirubin Select all that apply.
endoscopic retrograde
cholangiopancreatography Hypotension “Low BP” ● Gray-blue color at the flank
(ERCP) ● Internal bleeding ● Abdominal guarding and tenderness
● Ascites ● Left upper quadrant pain that
radiates to the back
Diagnostics
Interventions
LABS Common NCLEX Question
Elevated enzymes Lipase
NPO
● Amylase
● Lipase After performing a physical
Sugar Insert a nasogastric tube (NGT)
Elevated Glucose Insulin assessment and obtaining vital
for suction
“Hyperglycemia” signs for a client with acute
Elevated WBC (over 10,000) IV pain meds hydromorphone pancreatitis, which nursing
Hydromorphone
Dilaudid
● Fever
intervention is the priority?
Elevated Coagulation Time ● NO morphine
● PT & aPTT
IV fluids IV fluids and pain control
Elevated bilirubin
Monitor glucose
● Hyperglycemia = Insulin
Complication Pharm:
● Antacids
HESI
ARDS ● Proton Pump Inhibitors Pantoprazole Which food would be most appropriate
● H2 Blockers famotidine
(Acute respiratory distress syndrome) for a patient who recently had a bout of
Peritonitis NCLEX TIP acute pancreatitis?
Report to HCP! Select all that apply.
Pantoprazole
● Fever (over 100.3F) Famotidine
Fried chicken
● Rebound tenderness Proton Pump Inhibitors
H2 Blockers
Potato chips
● “Rigid” or “board-like abdomen” > 100.3 oF
Grilled chicken and a baked potato
Increasing Pain, tenderness
●
Diet Reduced fat cheese and whole
● Restless wheat crackers
LOW fat & LOW sugars
● Fast HR & RR Whole milk with cookies
(tachycardia / tachypnea) Enzymes with meals
Enzyme
77
Cholecystitis
Patho & Causes
Inflammation of the gallbladder. Typically caused by gallstones

also called cholelithiasis that block the ducts leading out of the
gallbladder resulting in a backup of bile which causes inflammation.
Gallstones
(cholelithiasis)
Signs & Symptoms
Highly tested Risk factors Age: > 40
High fat diet

1. RUQ pain “radiates to RUQ LUQ
the RIGHT shoulder ” Obesity
RLQ LLQ
2. Fever with chills Age over 40
3. Tachycardia
Priority Intervention Treatment

Nothing per oral - NO eating or drinking since eating can Lithotripsy - shock waves to break up the stones but if the
cause more pain & complications stones are too large then we can do surgery
NPO status
Lithotripsy
Surgery HESI Question Kaplan Question

Following a laparoscopic Priority action for a
Cholecystectomy - surgical removal of the gallbladder. cholecystectomy … which client scheduled for an
instructions would the open cholecystectomy:
nurse include?
Demonstrate ways to
deep breath and cough
Take a shower
Wait 1 week after surgery
before returning to work
Notify the surgeon of
any redness/swelling at
the incision sites
NCLEX TIP
Post Operative Patient Education HESI Question

Assist with A nurse caring for a patient
early ambulation NCLEX TIP
Lose Weight who recently had the
gallbladder removed knows
Prevent Pneumonia Avoid fatty fried foods the patient will have difficulties
digesting large amounts of
Deep breath & Cough which type of nutrients?
Prevent infection NCLEX TIP Fats
NO baths - shower ONLY

AVO
Report redness/swelling ID
at incision site
Fats
78
_ _
Mental health
79
Anorexia Nervosa
Mental Health "Psychiatric Care"
Pathophysiology
Anorexia nervosa is an eating disorder causing clients to obsess about their weight & what they eat.
Risk Factors:
Distorted body image - Adolescent females are the most affected
- Anorexia also has the highest death rate of all
& fear of being overweight mental disorders due to suicide
KAPLAN
ATI 1st Which statements are true regarding

anorexia nervosa?
Anorexia nervosa: The client has an
Clients see themselves as overweight
unrealistic fear of obesity
Adolescent females are most affected
Anorexia nervosa has the highest
mortality rate of all mental disorders
Signs & Symptoms
HESI
SEVERE 6 NCLEX TIPS
Starvation → Malnutrition Q1: adolescent female with anorexia
1. Extreme weight loss nervosa. Which physical findings
Vigorous Exercise Less than 75% of expected weight support the diagnosis?
“25% below normal weight” NCLEX TIP Select all that apply
2. Fluid & electrolyte imbalance Lanugo
Hypokalemia: potassium below 3.5 (cardiac dysrhythmias) Irregular heart rate
Pulse rate 48 bpm
3. Lanugo (thin hair)
4. Amenorrhea (no menstruation) Q2: ... which assessment finding
5. Cold intolerance meets the criteria for hospitalization?
Serum potassium level 2.6 mEq/L
6. Low Vitals: Low temp., Low BP,
Low HR (below 60)
Treatment
Typically done in an outpatient clinic (outside the hospital), but hospitalization may be needed if the client's
body weight is below 75% ideal.
Priority short-term goal HESI Admitted for Malnutrition 5 NCLEX TIPS HESI
Q1: What is the focus for the acute
2 NCLEX TIPS phase of treatment for anorexia 1. Strict record: protein & calorie intake What is a subjective symptom ... with
anorexia nervosa?
nervosa? Fear of gaining weight
1. Increase caloric intake for Weight restoration
2. Stay with the client during each meal
gradual weight gain & 1 hour after
Saunder’s
2. One-on-one supervision Q2: … anorexia nervosa presents with 3. Morning weights prior to oral intake … cognitive behavioral approach
during feedings severe dehydration and rapid weight
loss in the last week:
4. Help the client identify triggers ● Help the client to examine
Suggest hospital admission dysfunctional thoughts and
5. NO exercise! beliefs
Communication
Let sort out your
Encourage & reinforce: NCLEX TIP emotions together
“Progress toward healthy weight”
35 kg
80
Anxiety Disorders
TYPES HESI Question

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

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

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

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

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

Mild Anxiety ...clinical manifestations ...
expected in a client with Q1: ... a patient tells the nurse, “I feel
Restless, irritability severe anxiety? like I am going to die.” Based on
The client is pacing the the statement the patient made,
Moderate Anxiety hallway and tells the what level of anxiety is the
Increased RR & HR nurse he has a feeling of patient experiencing?
Pacing back & forth impending doom � Severe
Slightly reduced perception
Q2: A male patient is running ... and
keeps repeating, “They are
Severe Anxiety
coming!” ... neither follows staff
Increased RR & HR “hyperventilation” directions nor responds to verbal
Pacing back & forth efforts to calm him. The level of
Feeling of “Impending Doom” anxiety can be assessed as:
Perception is GREATLY reduced: � Severe
Can NOT respond to directions
81
Autism Spectrum Disorder
Pathophysiology Risk Factors

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

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

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

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

B
A
Interact with gestures

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

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

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

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

B
A
are indications of autism spectrum disorder?

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

Repetitive counting I
W
A admitting a child with autism spectrum disorder?
B
Spins a toy repetitively
Placement in a private room down the
Delayed language development
corridor from the nurses’ station
Exhibits ritualistic behavior
82
Bipolar Disorder
Pathophysiology
Bipolar is a mood disorder with cycling periods of lows with Depression followed by highs with Acute Mania.
During depression: clients have low mood, low energy, & motivation & high risk for suicide.
During acute mania: high energy, hyperactivity, elevated mood, & even aggression with violence.
HESI Question
Four or more mood MEMORY TRICK
Depression Acute Mania
episodes in a
12-month period, the Depression Mania
Declined mood More energy + Maniac
patient is said to be
Rapid cycling
ATI Question
Five acute manic
episodes in one year
Rapid cycling
Types of Bipolar Disorders
Bipolar 1 - 1 episode of mania that lasts over 1 week or need for hospitalization
Bipolar 2 - 2 episodes of milder high hypomania, which can last longer
Cyclothymia - milder lows & milder highs cycling over a period of 2 years
Rapid Cycling - 4 episodes of depression & mania within a 12 month period
Causes & Risk Factors
The cause is unknown but what does play a big part is:
• Genetics - having a family member with bipolar, clients are 10x more likely to have it.
• SSRIs (antidepressants) can trigger a manic episode
SSRIs can trigger a manic episode
Genetics SSRI
10x
Signs & Symptoms
M
More energy & Mood Swings
Euphoric energy, impulsive, grandiosity
ATI Question Kaplan Question
Hallucinations & delusions of grandeur
Q1: Acute manic phase: Which symptom
symptoms with manic behavior? does the nurse expect?
A Agitation
Set limits & structured environment
• More talkative than usual
• Easily distracted
• Hyperactivity & irritable
Q2: “I just bought myself a home

• Intense need for activity computer and a large screen TV for
N
the family.” Which interpretation is
Non-stop talking & Flight of ideas most accurate?
Colorful bizarre clothing choices
HESI Question • Mood disturbance and judgement
that is poor at this time
manic phase?
I Insomnia
Cannot sleep for days
• The client is quickly angered
• Flight of ideas
Saunders
Assessment finding that requires
A
• Going rapidly from one activity immediate intervention?
Attention span POOR to another • Nonstop physical activity and poor
Easily distracted = reduce stimuli
• Colorful & outlandish clothing nutritional intake
• Constant delusions
83
Depression
Pathophysiology
Major Depressive Disorder (MDD) also called clinical depression is when a client experiences a severe depressed mood,
loss of enjoyment in life, low energy & few other critical signs and symptoms. Everything is low & slow, it is thought to
be from low levels of neurotransmitters within the brain.
O
Serotonin N O
Neurotransmitters O
Low Serotonin O
Dopamine
Blah... Low Dopamine N O
Low Norepinephrine N
Norepinephrine N N
Risk Factors
ATI Question
a risk factor for depression?
Stressful life event
Stressful life events
Chronic illness
Genetics: Family history KAPLAN Question
recently become unemployed and the
Female client reports feeling depressed. The nurse
Substance abuse disorders understands which statement to be true?
unemployment is a significant
potential stressor
Signs & Symptoms

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

17 year old suddenly lost 15 lbs (6.8 kg)
Low self-esteem (withdrawal)
in 4 weeks
84
Alcohol & Drug Abuse
6 Key Definitions
1. Tolerance: decreased response Enabling & Codependence ATI

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

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

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

Treatment for opioid dependence... which of
the following medications is used for
Signs & Symptoms Treatment treatment of opiate withdrawal?
Naltrexone = Prevents relapse
Runny nose Clonidine
Opioid by reducing cravings
Methadone
Diaphoresis (sweating)
STOP Clonidine = Lowers BP
HESI
Insomnia
Methadone = Low dose opioid ... teaching a patient with a new prescription
Dilated pupils (wean off addiction) NCLEX TIP for naltrexone?
It helps prevent relapse by reducing your
drug cravings
85
Schizophrenia
Pathophysiology Memory trick

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

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

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

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

Vitals
Vitals
in one basket
We will take your vitals
86
ADD/ADHD
Pathophysiology Management
ADD - Attention Deficit Disorder Give a written schedule

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

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

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

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

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

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

CLASSROOM
RULES
● Allow for regular breaks

Risk factors of ADHD… ● Combine verbal instruction
Which of the following with visual cues
should the nurse include ● Establish consistent
in the teaching? classroom rules
● History of head trauma ● Decrease the amount of
homework assigned
87
Alcohol & Drug Abuse II
Alcohol Abuse
Big Key Point
Alcohol is a toxin that causes central nervous
system depression, making the vital signs
<70 Hypoglycemia PRIORITY
low & slow, causing coordination & balance
problems.
Alcohol intoxication & Diabetic

Monitor blood glucose
levels at night NCLEX TIP
Psychosocial Assessments KAPLAN

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

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

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

Anxiety
Which conclusion does the nurse make?
24 hours: anxiety, insomnia, palpitations Tachycardia
The client has early signs of alcohol
Irritability
48 hours: seizures & unstable vitals Tremors
withdrawal
Q2: The nurse admits a client for possible
48 - 72 hours: appendicitis... client states, “Most days I STOP
ATI drink about one pint of vodka.”... alcohol
Delirium Tremens NCLEX TIP ... result of sudden withdrawal from
withdrawal delirium time frame?
48-72 hours after last consumption
barbiturate use?
1. HYPERreflexia “Hand Tremors” Seizures
2. Diaphoresis (sweating)
3. Hallucinations Nursing Care
Increased Vitals:
Tachycardia (HR over 100 BPM) Implement seizure precautions
Hypertension
Fever Kaplan
The nurse admits a client who has a diagnosis
Mood: Agitation & Anxiety of alcoholism and admits to drinking a pint of
Mental: Confused & restless vodka a day.... which intervention is
appropriate?
Seizures!
Ensure seizure precautions are in place
88
Bipolar Disorder II
Interventions
Acute Manic Episode Acute Manic Episode

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

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

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

area with other
patients
Pharmacology
Valporic Acid Lithium
Mania Kaplan Question

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

Q2: Manifestations of lithium toxicity?
• Nausea & vomiting
• Diarrhea
I
Increase FLUID & Sodium (Na+) • Polyuria
VaLproic acid
HIGH RISK Toxicity
= Dehydration & Hyponatremia < 135 mEq/L • Muscle weakness
Liver Toxic Do NOT limit sodium or water intake
Q3: Lithium for treatment of bipolar
T
TOXIC Signs to REPORT: disorder… teaching:
Excessive urination and extreme thirst!
Vomiting & diarrhea • Aspirin is better to use than ibuprofen
• Report excessive thirst & increased
H
urination
HOLD NSAIDS – (Ibuprofen, Naproxen)
NSAIDS decrease renal blood flow = toxicity risk • Avoid exercising outdoors on hot days
• Regular laboratory tests to monitor
lithium level
89
Bulimia
Pathophysiology
Bulimia is an eating disorder that involves 2 cycles:

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

… assessment finding with bulimia
nervosa?
Binge eating Dental erosion

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

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

NCLEX TIP
Q2: A patient with bulimia nervosa

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

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

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

Wellbutrin the patient?
NOT recommended for purge bulimia
Bupropion
Notes
90
Depression II
Treatment Types
3 Phases HESI Question

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

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

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

Q1: … newly admitted client who has
Q1: Client diagnosed with depression … Which
severe depression.
approach by the nurse is best?
Sit with the client and offer
Invite the client to join in group activities
Interventions simple, direct information
Q2: … client seems more withdrawn and
Encourage & Invite client to participate Q2: … crying alone in the room. The client has
depressed than usual. refused to eat breakfast or have morning care.
Assist with ADLs Say to the client, “I would like to Which intervention by the nurse is best?
Help the client get ready NCLEX TIP spend some time with you.” Offer to sit with the client and help the
client get dressed
Spend time with client
“Sit with the client”
Communication with simple & direct language
HESI Question
Reevaluation Which comment … shows Saunder’s Question
improvement in depression?
...diagnosis of depression … plan of care that
“I talked with my family includes which intervention?
about ways we can celebrate A structured program of activities in
holidays together.” which the client can participate
91
Anxiety Disorders II
Signs & Symptoms
HESI Questions
Panic Attack Q1: A symptom associated with panic Panic
attacks is: disorder
Fear of death “Impending doom” � Fear of impending doom
Feeling detachment “Hallucinations”
Q2: A patient who has to undergo
Physical s/s:
surgery ... complains of chest
• Chest Pain & heart palpitations pain, feelings of choking, and hot
• Trembling & Numbness flashes. What appropriate
• Hyperventilation diagnosis does the nurse make
• Sweating & Hot flashes from the patient’s symptoms?
• Nausea & choking sensations � The patient has panic disorder
Interventions
Severe Anxiety HESI Questions ATI Questions Kaplan Questions

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

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

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

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

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

eat with my boss.
Cognitive Behavior Therapy (CBT)
CBT is a type of talk therapy that helps clients reframe their thought processes to
prevent negative thought patterns in order to adapt to stress & anxiety.
92
Schizophrenia II
Negative Symptoms Saunders

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

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

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

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

I see you as my client HESI
watched all the time.” Which response by the nurse is
most appropriate?
“Those are sprinklers in the ceiling that come on if there
is a fire. How does it feel to think you are being watched?”
93
Abuse & Neglect
Elder
Elder neglect is a form of abuse that happens when the caregiver fails to provide for the needs of the elderly client
either emotionally, physically, or socially.
Key signs Caregiver Role Strain (CRS) HESI Question

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

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

Victim … injuries associated with intimate partner violence.
The patient plans to return home. Which of the
Affirm that the patient did not HESI nurse’s actions should be prioritized? Local shelter
deserve or cause the abuse Provide the patient with contact information
for the local shelter.
Developing a plan to assure safety: Local shelter
ATI Question
Psychotherapy (Talk Therapy)
… coping strategies … clients who are
Identity triggers experiencing intimate partner violence...under-
standing of the teaching?
Recognize destructive patterns of behavior &
“I should try to identify issues that increased my
learn alternative responses partner’s stress level.”
94
Depression III
Diet
Remember a big symptom of depression is rapid weight loss or weight gain, typically weight loss is the most tested,
since it is more common. Clients lose appetite & refuse to eat.
HESI Question Saunder’s Question

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

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

BEFORE
generalized seizure. Think of this as jumpstarting the
1. Screen for Medical History & Report to HCP brain like jumpstarting a car or doing a hard reset on
Recent myocardial infarction Saunder’s your iphone. Each seizure lasts around 15 - 20 seconds,
done 2-3 times a week for 6-12 treatments total.
Cerebral neoplasm ATI
2. Assess Concerns: ATI Question HESI Question
What are your concerns about ECT? NCLEX TIP Which of the following is a side effect … electroconvulsive therapy (ECT),
of ECT? which equipment should the nurse make
3. NPO x 6 - 8 hours NCLEX TIP Memory loss sure is available?
4. NO anticonvulsant meds NCLEX TIP Oxygen
Kaplan Question
Valproic Acid, Carbamazepine after ECT… It is most important for the
Suction equipment
Crash cart
5. Remove: dentures & contacts nurse to take which action?
Remind the client that memory loss Saunder’s Question
6. Side Effect: is temporary
ECT ... interventions before procedure?
Memory loss ATI & Kaplan Have the client void
Equipment: Obtain an informed consent
Remove dentures and contact lenses
Cardiac monitor Oxygen Temporary
Withhold food and fluids for 6 hours
Crash cart Suction
Informed Consent signed
REMOVE
AFTER
NO driving (during course of ECT treatment) NCLEX TIP
Temporary confusion & memory loss common after
95
Schizophrenia III
Interventions
• Provide safe & structured environment and promote trust

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

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

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

is necessary?
“I should not be concerned about
fever and muscle stiffness.”
Key terms
NORMAL
HIGH
LOW
96
CBT - Cognitive Behavior Therapy
Pathophysiology
Kaplan Question
CBT is a common type of psychotherapy (talk therapy). It helps clients reframe
A client states ... “I travel only
their thought processes in order to slowly cope with stress & anxiety, helping by train because I am terrified
of flying.” ... the phobic client
to treat many disorders from PTSD & OCD, to eating disorders like anorexia & is most likely to respond to
bulimia, and even depressive disorders. which intervention?
• Systematic desensitization
5 CBT Strategies NCLEX TIP Systematic desensitization

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

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

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

• Silent member: encourage ... one participant ... interrupts others
Kaplan Question interaction, then divide
when they are talking. What is the best
action ... to take in this situation?
Psychiatric inpatient setting: which
description is the best for milieu therapy?
groups into pairs • Allow the group to handle the problem
• Aggressive member:
• Providing a therapeutic physical and
social environment address the anger & separate ATI Question
in another room
HESI Question Q1: Group therapy: Which of
the following is the primary
Primary goal of milieu therapy for patients focus of group therapy?
diagnosed with personality disorders? • Personal feelings that
• Managing the effect of the behavior on
affect behavior
the entire group
ATI Question
Q2: Group therapy: Which
response should the nurse
... how to establish a therapeutic milieu on make to a client’s
the unit? aggressive statement?
• Orient new clients to their environments,
rights, and responsibilities • “You seem very upset.”
97
Crisis Management
ATI Question
4 Phases … which of the following best
1. Trigger event: anxiety in describes what should be in
the first box?
response to threat ● The triggering event
2. Escalation: increasing The
anxiety & agitation Kaplan Question triggering
event
Escalation Crisis Disorganization
3. CRISIS: outburst, The client states, “I feel like I

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

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

to avoid injury
4. Determine the source of anger

I'm Lily and
I'm here to help
I see you
are upset
5. Acknowledge the client's emotions
Pharmacology
Anxiolytics
HESI Question LORAZEPAM
A client who is displaying violent behavior.
Benzos: “-pam” “-lam” Which of the following medications
Lorazepam (brand: Ativan) should the nurse expect the provider to
prescribe? Select all that apply. HALOPERIDOL Ziprasidone
hydrochloride
Antipsychotics: ● Lorazepam Geodon
● Haloperidol
Haloperidol (brand: Haldol) ● Ziprasidone
Ziprasidone (brand: Geodon)
Physical Restraints
1. Get an order for restraints
HESI Question
Physical restraints are placed on the client,
(Renewed every 4 hours for adults) and then the client is put into a seclusion
2. Must be assessed by HCP within room. Which actions must the nurse take in
the next hour?
1 hour of order
● Meet the physical needs of the client
3. Document every 15 minutes ● Obtain a prescription for the restraints
● Objectively document the client’s behavior
4. Monitor & meet physical needs
98
Death & Dying
5 Stages of Grief Bowlby’s 4 Stages of Grief

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

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

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

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

Hold and cuddle the child to reinforce
closeness
99
Dissociative Identity Disorder
Pathophysiology
Dissociative identity disorder occurs when 2 or more identities rotate control over the client’s behavior.
Clients will typically have amnesia or lack of memory, not aware that the alternate identities exist, & often
confused by the big gaps in their memory.
How does this happen? Ususally caused by a traumatic event like abuse or rape, the various identities
& memory gaps serve as protective mechanisms helping to shield the client from the traumatic memories.
Naturally, stress & anxiety that remind the client can trigger the identities into play.
HESI Question
Dissociative episode: .....
Select all that apply. .....
Dissociation is a method for
coping with severe stress
Dissociative symptoms are not under
the person’s conscious control
The existence of two or more
subpersonalities, each with its
own patterns of thinking
Treatment
The goal of care is to help the client merge the various identities into 1 personality by integrating past events.
5 NCLEX TIPS HESI Question HESI Question

grounding techniques...
to alleviate symptoms? Which factor would indicate
1. Grounding techniques: Hold an ice cube in your hand successful treatment?
Deep breathing, counting coins,
The patient has integrated
holding an ice cube past events
2. Journal about feelings & triggers
3. Trust: Develop a trusting Remember?
relationship with each identity
4. Self-harm: Monitor & listen for
expressions of self-harm
5. NEVER ask the client to
recall memories
Notes
100
OCD
Pathophysiology
ATI Question
Client with OCD ... constantly reorganizing
Obsessions = books ... the client uses this behavior to do
Excessive thoughts & impulses which of the following?
You should
Compulsions = take a break. Decrease anxiety to a tolerable level
Repetitive “ritualistic behaviors” 1 2 3 4
Kaplan Question
.. client with OCD must wash, rinse, and dry
Key term door handles before entering or leaving a
Give a reminder that it’s time to take a break, room. Which action by the nurse is best?
since the client has been cleaning for hours. Provide time for the client to complete
the ritual
Treatment You should spend only
HESI Question 5 minutes on this.
Initial Plan of Care 5 NCLEX TIPS ... priority nursing action 3 days
after the admission of a client
1. Decrease ritual time slowly diagnosed with OCD? This time try to spend
only 4 minutes.
NEVER “suddenly” deny ritualistic gradually decrease the

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

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

… client with obsessive-compulsive
personality disorder (OCPD)...
I don’t want change!
information about the diagnosis.
Select all that apply. PAROXETINE
SERTRALINE
Perfectionism and
overemphasis on tasks
This disorder typically involves
inflexibility and a need to be
in control
101
Personality Disorders
HESI
Which behaviors are demonstrated characteristically
Narcissistic Personality Disorder by a patient diagnosed with narcissism?
Grandiose, exploitive, and rage-filled behavior
Believes they are perfect Exploitation of others
Acts entitled, arrogant, & grandiose ATI

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

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

Priority action: 2 NCLEX TIPS Q1: Client with borderline personality disorder … makes numerous minor
1. Assign different staff members to the client each day requests & spends a lot of time near the nurses station. How should the
nurse interpret these behaviors?
2. Assess immediately: any self-harm behavior “superficial cuts” Fear of abandonment and attention-seeking
Q2: Client at greatest risk for suicide?
Personality disorder
KAPLAN
I'm not guilty!
Q1: The client shoves another client out of the way …Which action
Antisocial Personality Disorder should the nurse take?
Calmly confront the behavior and remind the client of consequences for
negative behavior
Impulsive, manipulates others for personal gain & lacks empathy Q2: Which statement best indicates improvement in the client’s condition?
“I get into trouble because I don’t think before I act.”
HESI
ATI
... antisocial personality may present with which characteristic?
1 2 8 4 8 … demonstrating manipulative behavior. Which of the following actions
Lack of remorse
should the nurse take?
Institute consequences for manipulative behavior
HESI
Schizotypal Personality Disorder A patient is withdrawn and suspicious ...
prefers to be alone… patient describes themself
Withdrawn & alone as having “special powers” and states, “I believe
we can all read each other’s thoughts at times.”
“Special powers” & Magical thinking … which personality disorder?
Schizotypal (STPD)
102
Phobias
Pathophysiology
Phobias are excessive fear of an object or situation.
HESI Question
The inability to leave one’s home
because of severe anxiety
Phobias disorder • Panic attacks with agoraphobia
Arachnophobia: fear of spiders

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

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

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

levels little by little when exposed to their phobias. 3 NCLEX TIPS
This is done via systematic desensitization:
meaning the clients gradually get exposed to their phobia 1. Increased comfort while
little by little - to decrease the anxiety over all. exposed to the phobia
Systematic desensitization 2. Verbalizing feelings &
insight about anxiety
KAPLAN Question (self-observation)
“I travel only by train because I
am terrified of flying.” … phobic
client is most likely to respond
to which intervention?
3. Self-distraction: focusing
• Systematic desensitization on something other
than the phobia
103
PTSD & Acute Stress Disorder
Pathophysiology
PTSD - Post Traumatic Stress Disorder
Acute stress disorder ASD is a mental disorder that can

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

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

2. Substance abuse (drugs & alcohol) Q1: … “The war was years ago, but I victim of bank robbery
still remember my friends who
…. reports daily
3. Relationships with family & friends You could not were killed. I don’t know why I
have anticipated
lived and they died.” What is the flashbacks … Which
rape & you did
4. Explain that difficult symptoms not deserve it
nurse’s priority response? action is best?
after the trauma are normal • Are you having any thoughts
of harming yourself? • Offer assurance of
5. Rape Victim: Assess for guilt Q2: PTSD … first stage of the safety, & tell the
& shame NCLEX TIP treatment? client these feelings
• Reinforce the client could not • Stopping self-destructive
behavior of the patient are normal
have anticipated rape
& did NOT deserve it
Interventions Pharmacology
HESI Question
Q1: war veteran … says, “Sometimes I
still hear explosions but I know I am
safe in my home.” What is the
Antidepressants
nurse’s best response?
• You are experiencing flashbacks. I’d
1. Priority Action: NCLEX TIP like to arrange for you to talk more SERTRALINE
about your feelings and reactions
Encourage the client to talk about SSRI: Sertraline & Paroxetine
Q2: Which actions will the nurse include
the traumatic experience at their in the war veteran’s plan of care? TCA: Amitriptyline & Imipramine
own pace • With each session, explore each
traumatic experience more deeply
2. Exposure therapy
Anxiolytics
3. Group therapy PAROXETINE
• Benzodiazepines
4. CBT: thought stopping techniques • Barbiturates
• Buspirone
104
Somatic System Disorders
Pathophysiology
SDD is a psychological disorder where clients have unexplained physical symptoms like abdominal pain, weakness,
chest pain, shortness of breath, & others. The key point is that there is NO medical cause of the physical symptoms!
All diagnostic tests come back negative. These physical symptoms are real & clients are not making them up or faking it.
Unexplained physical symptoms

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

Limit time discussing
NCLEX TIP
physical symptoms
Promote insight
FIRED
Don’t let
Identify stressors that THE EXAMS TRICK YOU
intensify symptoms
- DO NOT reinforce negative exam
Coping mechanisms results when the client wants pain
meds.
(Stress-reducing techniques)
- NEVER debunk or dispute the clients’
Deep-breathing symptoms saying they are not real!
Meditation - DO NOT advocate for more diagnostic
tests or a new diet plan, since it is a
Exercise psychological disorder.
105
Open-ended questions I don’t hear any voices,

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

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

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

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

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

SAUNDERS
helps offer guidance KAPLAN
Q1: … “I can’t believe that my wife died yesterday. I keep
Q1: Client with ... end stage heart failure, says “Why can’t expecting to see her everywhere I go in this house.” …
this just end? I’m no good to anyone anymore.” Which therapeutic nurse response?
response is best?
“It must be hard to accept that she has passed away”
“This must be difficult. Please tell me about your feelings?”
Q2: ... “This condition is just another nail in my coffin.”
Q2: The nurse finds the client crying … & says, “What do Which response by the nurse is therapeutic?
you want? Go away, you can’t help me. I hate you and I
“You seem very distressed over learning you have
hate myself.” Which response by the nurse is best? asthma.”
“You seem to be in pain; I’ll stay with you for a while.” Q3: A client diagnosed with terminal cancer says to the
nurse, “I wish my family would stop hoping for a cure! I get
Q3: Client’s spouse has been unemployed for more than
so angry when they carry on like this.” Which response by
six months, and is afraid of not being able to pay the rent.
the nurse is most therapeutic?
Which response is most appropriate?
“You’re feeling angry that your family continues to hope
“You’re worried that you won’t be able to pay the rent?” for you to be cured?”
106
_ _
Musculoskeletal
107
Fractures
Med Surg: Musculoskeletal
Types of Fractures
Saunders
Closed Fracture: The nurse … is assessing a client
with an open leg fracture. The nurse
Does not break skin should inquire about the last time
Open Fracture “Compound” the client had which done?
Skin surface broken Tetanus vaccine
Complete fracture
Incomplete fracture “GreenStick”
Spiral fracture
Oblique fracture
Compression fracture “Impact” TETANUS
Crush “Compression” fracture
Causes & Risks

HESI
Bed rest A nurse is caring for a patient on bed rest.
Which long-term effect of bed rest on the
Osteoporosis DEXAMETHASONE musculoskeletal system would concern
Steroids “-sone” NCLEX TIP PREDNISONE the nurse the most? Select all the apply
Bone fracture
Fludrocortisone
Prednisone Hydrocortisone
Loss of muscle tone and atrophy

Trauma
Signs & Symptoms

Basilar skull fracture
CSF “cerebrospinal fluid” (rhinorrhea)
Pain & swelling (bruising) Clear liquid drainage: nose area
Crepitus Spine fracture (T-6 or higher)

Neurogenic shock
Muscle spasms Hypotension
Bradycardia
Priority Findings: NCLEX TIP Skin: pink & dry
Internal bleeding Mandibular Fracture <60
Hypotension Bleeding & drooling from the mouth

Tachycardia Suction the mouth
Hematuria
HESI
Hip Fracture NCLEX TIP
Pelvic fracture… which is the most Shortening of leg on the affected area
serious physical assessment finding Muscle spasm around the affected area
for the nurse to report? Ecchymosis on thigh and hip
Groin & hip pain when weight bearing
Hypotension, tachycardia, and
hematuria
108
Buck’s Traction & Postoperative Care
Buck’s Traction
KEY POINTS
KAPLAN
Weights: free hanging at all times The nurse provides care for the client in
Buck’s traction. Which is the most important
Traction ropes TIGHT! nursing action to maintain effective traction?
NOT loose Allow weights to hang freely at all times
NOT resting “on bed or floor”

Saunders
Reposition: hold weights
Q1: Skin traction... The nurse should monitor
which priority finding in this client?
Used short term before surgery to Keep limb in neutral position Signs of skin breakdown
realign hip & femur fractures, and
Assess for skin breakdown Q2: A client has Buck's extension traction
to stop muscle spasms. This device applied to the right leg. Which intervention
should the nurse plan to prevent complications
pulls bones back into place with free Neuro checks on limb: P,M,S,C of the device?
Traction ropes rest against the footboard
hanging weights. Supine position (flat) NCLEX TIP Q3: Client in traction ... The nurse ... should
include which action in the plan?
DO NOT elevate HOB Check the weights to ensure that they are
off the floor
Over 25 degrees
Hip Replacement Postoperative Care KAPLAN

A nurse is caring for a client who is
KEY WORDS postoperative total hip arthroplasty. Which
of the following laboratory values should
Hip & Femur Surgery the nurse report to the provider?
HgB 8 g/dL
● Total hip replacement
● ORIF “open reduction
internal fixation” HESI
● External fixation
Which interventions will the nurse include
in postoperative nursing care for a patient
PRIORITIZE the order

Hemoglobin who has undergone a hip fracture repair?
Wound assessment with special

attention to pain and to color, amount,
1. Bleeding Normal 12 - 18 and odor of exudate.
2. Infection Risky 8 - 11 Saunders

3. Positioning Education
Below 7 Skeletal traction ... When
evaluating the pin sites, the nurse
would be most concerned with
1. Bleeding NCLEX TIP which finding?
WBC 17,000
Thick, yellow drainage from the
Hemoglobin Less than 7 = HEAVEN
pin sites
Report to HCP!!
Monitor pulses distal to injury
Hypotension & tachycardia KAPLAN
2. Infection Total hip arthroplasty … Following surgery,
Elevated WBC NCLEX TIP it is most important to place the patient in
which position?
(norm: 5,000 - 10,000)
Abducted with toes pointing upward
Assess drainage: color, amount & odor
Perform pin care with a sterile solution
3 times per day
HESI
The nurse is providing care for an elderly
patient who has an internal fixation
Positioning Education device after surgery for a hip fracture.
Which interventions should the nurse
Total hip arthroplasty: NCLEX TIP Saunders implement while providing care for this
Abducted legs: Place a pillow between patient? Select all that apply.
... after internal fixation of a
fractured right hip … which Turn the patient every 2 hours
the legs Kaplan
Provide assistive devices for walking,
NO crossing legs method to reposition the client?
such as a walker
NO leaning forward (NO tying shoes) A pillow to keep the right leg Instruct the patient not to cross legs
abducted during turning Elevate the head of the bed to
NO sitting in chairs (90 degree angle) 45-degrees
109
Fat Embolism Syndrome
& Osteomyelitis
Fat Embolism - Pathophysiology

Fat Embolism Syndrome is a major complication with
crushing fractures & long bone injuries (femur, pelvic
& hip fractures). The bones release fat globules into the
bloodstream & just like a blood clot, this fat emboli could
cause a deadly blockage in the brain (CVA), heart (MI),
or lung.
Signs & Symptoms

Intervention KAPLAN
KEY SIGNS Minimize movement of the fracture An older adult client is diagnosed with a
fractured femur. The nurse recognizes which
observation is an early sign of fat embolism?
Mental Status changes NCLEX TIP
Altered mental status
1. Confusion and restlessness #1 MOST TESTED
2. Altered mental status Saunders

O₂ STOP
Dyspnea & chest pain .. the most favorable indication of
resolution of the fat embolism?
Low pulse ox Clear mentation
Petechiae over neck & chest
Osteomyelitis - Pathophysiology Bone infection, caused by a bacteria that enters the blood via:
• Open fracture
• After surgery
• Puncture wound like a dog bite
• Contaminated needles like with a bone marrow aspiration.
Signs & Symptoms:

high fever, pain & even pus or yellow drainage from a puncture site.
Kaplan Question
Several days following a bone marrow
aspiration, the nurse notes a client
has a temperature of 103° F (39.5° C),
and there is yellow drainage from the
aspiration site. Which interpretation
by the nurse is most accurate?
● The client has developed
osteomyelitis
Osteomyelitis - Treatment
IV antibiotics for weeks or months, Surgical debridement to drain any Amputation may be done if not
so clients will go home with a PICC abscesses & to remove necrotic responsive to therapy.
line & a nurse will visit to give the dead bone tissue.
IV antibiotics.
110
Cast Care
& Complications
CAST CARE
C - Clean & Dry NEVER WET
Saunders
� Cover cast with a plastic bag
for bathing NCLEX TIP
Which cast care instructions ... plaster
cast applied to the right forearm?
Kaplan Question
A - Above the heart (First 48 hours) • Keep the cast clean and dry Newly applied plaster cast
� Elevate extremity NCLEX TIP • Allow the cast 24 to 72 hours to dry to the lower extremity. The
• Keep the cast and extremity elevated
nurse takes which action?
S - Scratch an itch?
� Use the hairdryer on a cool Itching under the cast.... client ● Elevates the leg on
statement indicates an understanding
setting NCLEX TIP
of appropriate measures?
pillows and leaves the
T - Take it easy • “I can use a hair dryer on the low cast open to air
� NO bearing weight on plaster casts setting and allow the cool air to
blow into the cast.”
� NO finger indentations or pressure
� NO hard surfaces
CAST CARE Complications
Key terms
• HOT spots: infection
• Compartment syndrome:
decreased perfusion
Key Signs
Compartment Syndrome PAIN P
• Unrelieved with Pain
Extremely painful condition that happens morphine NCLEX TIP
when pressure within the muscles builds • Not resolving with
medication
to dangerous levels - cutting off blood • Extreme pain with
flow & oxygen resulting in a dead limb passive movement
Paresthesia P
• “tingling” “burning” Paresthesia
“numbness” NCLEX TIP
• Problems moving or
extending fingers
or toes.
• “Great difficulty”
Interventions Saunders Saunders

Kaplan Question
Notify HCP immediately
Suspected impairment ... of Plaster cast placed on the lower
Assess fingers & toes “neuro checks”
the client's casted extremity extremity .. which instructions
PMS C should be given to the client?
A nurse is assessing a client for if which findings are noted?
P - Pulses - NOT pulseless Notify the HCP immediately for
compartment syndrome who Select all that apply.
M - Movement - grips has a short leg cast. Which numbness or swelling or if the
S - Sensation would the nurse identify as a • Client reports severe, foot becomes cold and pale.
▪ NO tingling, numbness finding of this condition? deep, unrelenting pain
C - Cap refill & Color • Client reports pain as nurse To assess for signs of compartment
● Pain that increases with assesses finger movement syndrome, the nurse should perform
▪ NOT over 3 seconds
passive movement which action?
▪ NOT pale “pallor” • Client reports numbness
Assess capillary refill, temperature,
Temperature and tingling sensation in
color, and amount of pain
▪ NOT cold or cool the fingers
Key terms
Hot Spots Saunders
Kaplan Question
“Hot areas” “Hot Feeling” The nurse is assessing
Three hours after arriving in the
“Foul odors” orthopedic unit, a client reports a the casted extremity of a
Report HCP NCLEX TIP hot feeling under the cast. Which client. Which sign is
action does the nurse take first?
indicative of infection?
Interventions: ● Assess the circulation in the
• Assess circulation in casted extremity and change Presence of a “hot spot”
extremity the client’s position on the cast
• Change position
111
Crutch & Cane Training
Crutch Saunders
“Why the crutches cannot rest up
Safe Crutch Use underneath the arm” … The nurse
responds knowing which would most
likely result .. ?
1. Weight on Hands & Arms NCLEX TIP
• Injury to the brachial plexus nerves
• NOT armpits! = Injury to the brachial 1 - 2 inches
Use of crutches... which would indicate
plexus nerves that the client understands how to
• DO NOT use someone else's crutches perform this type of gait?
• The client moves both crutches forward,
along with the affected leg, and then
2. Technique Gait moves the unaffected leg forward
Going down the stairs with the

• Step 1: Both crutches forward WITH crutches ... How should the nurse
injured leg demonstrate this technique?
• Step 2: Move unaffected leg forward Crutches and the affected leg
down (BAD), followed by the
unaffected leg (GOOD)
3. Stairs NCLEX TIP
UP with the GOOD = Upstairs
Down with the Bad = Downstairs 3 types of gaits Kaplan Question
Crutches while climbing stairs….
• 2-point gait Correct sequence?
• 3-point gait 1. Place body weight on crutches
2. Advance the unaffected leg
• 4-point gait: most advanced (GOOD) onto the stair
gait NCLEX TIP 3. Shift weight from crutches to
unaffected leg (GOOD)
“most closely resembles 4. Bring the crutches and the
normal walking” affected leg (BAD) up to the stair
Cane
Correct Cane Use Stairs NCLEX TIP
1. Stronger side HOLDs Memory Trick:
UPstairs
the cane UP with the GOOD leg 1. UP with Strong leg
2. Move cane 1st & Down with the BAD Leg 2. Cane moves next
weaker leg 2nd 3. Weak leg last
Downstairs
Memory Trick 1. Descend with Cane
C - Cane 2. Weaker leg down
3. Strong leg
C - Comes 1st

Client with a right total knee replacement … correct teaching?
Memory Trick:
• UP with the GOOD leg
• Down with the BAD Leg
• Cane on strong side
1. Full weight on the right leg when

going up stairs.
2. Descend with cane first, strong leg
second, and weak leg last when
going downstairs.
3. When going upstairs lead with the
left leg first, follow next with the
cane and move the right left after.
4. Hold cane in the right hand while
on stairs.
112
Osteoporosis
Pathophysiology PORous bones OsteoPORosis
Fragile and porous bones. Loss in bone mass resulting in low bone density
& very brittle bones. Typically from increased rate of bone resorption where
bone loss is increased.
KEY Conditions Osteopenia - loss of bone mass & weaker bones

Osteopenia Osteomalacia - softening of the bones caused by severe
Osteomalacia vit D deficiency
Osteopenia Osteomalacia
Female Kaplan Question HESI Question HESI Question

Older age Teaching about osteoporosis Which disease has an increased Which are the risk factors for
Postmenopausal NCLEX TIP prevention. The nurse should chance of occurrence in a osteoporosis?
instruct the client that which of 60-year-old postmenopausal
Caucasian & Asian the following medications can patient?
increase their risk for the Steroid use
Bad Habits: development of osteoporosis? Osteoporosis
High intake of caffeine
Excess caffeine intake Prednisone Being a white or Asian
Smoking or alcohol abuse
Postmenopausal state
Medication: Anticonvulsant therapy for
Anticonvulsants seizure disorders
Steroid “-sone”
NCLEX TIP
Prednisone
Diseases:
PredniSONE
Hyperparathyroidism NCLEX TIP
Cushing Syndrome
Diabetes Mellitus OSTEOPOROSIS
Signs & Symptoms Pharmacology

• Porus bones in the osteoporosis
• Frequent fractures Calcium & Vit. D
• Reduced height Ca
vitamin
Alendronate
• Kyphosis - exaggerated round back Alendronate

(often seen in elderly population)
Treatment & Education

Kaplan Question HESI Question
A nurse is providing education for Which interventions should the
Vit D & Calcium supplements
a client who is at risk for nurse implement while providing
Go outside in the sun osteoporosis. Which of the care for an elderly female patient
Activity following instructions should the with osteoporosis?
nurse include? Select all that apply.
Weight bearing exercises
Walk for 30 minutes Encourage frequent ambulation
Frequent ambulation 4 times per week
Provide rubber mats in showers
Fall precautions
Encourage
Provide rubber mats in showers weight-bearing exercises
Well-lit halls Encourage the patient to
NO throw rugs 30
mins stop smoking
STOP bad habits
Stop smoking
Decrease caffeine
113
Rheumatoid Arthritis (RA)
Pathophysiology RA is an autoimmune disorder where the body attacks the joints

causing major inflammation & deformity. Mainly seen in the hand
joints, but can also involve other organs (skin, eyes, & lungs) with
collateral damage as the body attacks itself.
HESI Question Kaplan Question

A patient with rheumatoid arthritis A client asks the nurse, “What is the
asks the nurse about her condition. difference between rheumatoid
On which knowledge does the arthritis and osteoarthritis?” Which
nurse base patient teaching? response by the nurse is best?
Rheumatoid arthritis is thought Rheumatoid arthritis is a
to be an autoimmune disorder. systemic disease and
osteoarthritis is not
Diagnostics HESI Questions

A patient arrives at the clinic Which tests ... performed to
Synovial fluid aspiration with left knee pain that began confirm rheumatoid arthritis (RA)
1 month ago. The X-ray and rule out other diseases?
Arthroscopy Select all that apply.
examination and magnetic
Blood tests: resonance imaging (MRI) were Synovial fluid aspiration
� RF - Rheumatoid factor inconclusive. The nurse Rheumatoid factor (RF)
� ESR - erythrocyte anticipates which procedure
Erythrocyte sedimentation
sedimentation rate will occur next?
rate (ESR)
� CRP - C-reactive protein Arthroscopy
Signs & Symptoms SAUNDERS Question SAUNDERS Question

Early Signs Suspected rheumatoid arthritis Assessment on a client with ...
Fatigue, anorexia (weight loss)
Boutonniere deformity
(RA). The nurse would expect to rheumatoid arthritis (RA). The
& morning joint stiffness note which early signs and nurse checks for which assess-
Symmetrical pain and swelling symptoms? ment finding that is associated
in the small joints of the hands Swan-neck deformity Select all that apply. with RA?
Fingers: swan-neck and a
Fatigue Systemic symptoms such as
boutonniere deformity
Morning stiffness fatigue, anorexia, and
Contractures of joints HIGH PRIORITY
= HIGH priority weight loss.

Joint pain NCLEX TIP
Pain relief with activity
MORE pain at rest 40.0
0
Education Pharmacology
Kaplan Questions
Pain control - Assess pain levels A nurse is assessing a client
Which nursing intervention is
Do NOT elevate the knees with who has a diagnosis of
most appropriate for a client
pillows at night rheumatoid arthritis. Which of
diagnosed with rheumatoid NSAIDs
the following nonpharmaco-
Exercise (low impact) arthritis and reporting
logical interventions could the
generalized pain?
Steroids “-sone”
nurse suggest to help reduce
Swimming
NCLEX TIP pain? Assist the client with heat Prednisone
Heat & Cold to affected joints Alternate applying heat and application and range of
Warm shower or bath cold to the affected joints. motion exercises. Methotrexate
before bed
Methotrexate
NSAIDS
STEROIDS
-SONE
114
Osteoarthritis (OA) &
Total Knee Replacement
Memory Trick
OsteoArthritis OA - Ouch pain RA - Rude pain
This is progressive degeneration of the protective cartilage cushion

on the end of the bones resulting in BONE on BONE rubbing
- massive pain.
Causes & Risk Factors Pharmacology

MOST tested
Obese NSAIDs
Smoking Steroids “-sone”
Glucosamine NSAIDS
Repetitive stress Prednisone PredniSONE
on the joints Glucosamine
Signs & Symptoms
SAUNDERS Question Joints

Crepitus “crunch sound” Client with osteoarthritis...
Affects one joint
which clinical manifestations are
(usually large joints)
Pain NCLEX TIP associated with the disorder?
Node formation
MORE with activity
Joint pain that
diminishes after rest
Joint pain that
Heberden's nodes
Bouchard's nodes
Relief with rest intensifies with activity
Total knee arthroplasty

Total Knee Replacement
Common surgical interventions for both RA & OA.

Also called a total knee arthroplasty, it is a surgical procedure
to replace the knee joint.
OA RA
Postop care Kaplan Question
NEVER place a support A nurse is providing teaching 1

for a client who had a total HOUR
pillow under a new knee arthroplasty. Which of the
operative knee NCLEX TIP following instructions should
the nurse include?
Early weight bearing & Flex the foot every hour
flexing the foot every hour when awake
Clot Prevention
Heparin & Warfarin - prevent blood clots
Key Term: Start both at the same time in the hospital, since Heparin
works in a hurry & Warfarin has a weak start, taking a few days to catch up.
115
Amputations
Amputations are when we cut off an extremity. KAPLAN

Very common with clients who have diabetes & get bad infections from Client type 1 diabetes ... right below-the-knee
sugary blood. The most tested type of amputation is a below the knee amputation due to gangrenous toes. The client
asks the nurse why the amputation is so
amputation, since it results in better circulation & healing to the limb. extensive… nurse’s response is based on which
understanding?
A below-the-knee amputation results in
better circulation and healing
HEAL TO THE LIMB
Type 1
The Most Tested

HEAL TO THE LIMB
Stump Care (Residual Limb Care) KAPLAN

Immediately following a right below-the-knee
After Surgery amputation... the nurse is most concerned
when which observation is made?
The client reports persistent pain at
Do NOT elevate limb NCLEX TIP the operative site
Keep limb in dependent position

Phantom limb pain
Discharge Teaching
Residual limb Daily Care NCLEX TIPS

Assess: redness & irritation KAPLAN
Q1: The nurse evaluates care given to a client
Wash limb every day w/ soap & water after a left below-the-knee amputation. The
nurse intervenes if which observation is made?
Expose to air The dressing to the surgical site is

dated two days prior
Lay on stomach “Prone” NCLEX TIPS Q2: The nurse teaches a client with a
below-the-knee amputation to care for the
residual limb at home. The nurse advises the
30 min. x 3 times per day 30
mins 3 times/day
client to take which action?
Expose the residual limb to air
Push stump into the bed
Limb socks & wraps:
Clean & Dry
Notes
116
GOUT
Pathophysiology
Uric acid accumulation causes pain & inflammation in

the joints which leads to destruction & eventually arthritis
(bone on bone pain from loss of cartilage).
Most Susceptible
Causes & Risk Factors P Signs & Symptoms

Purines
KAPLAN
High purine foods A client experiences an acute bout of gouty
arthritis. The nurse expects the client’s
affected foot to have which appearance?
Meats: chicken, steak, liver
Red
Alcohol : Wine, beer, liquor P
Pain & Inflammation

Seafood: crabs, lobster, shrimp
Diagnostics Treatments Pharmacology
Prevent Gout NCLEX TIPS Allopurinol & Colchicine

Labs: Serum Uric Acid Levels
Lose weight: “achieve healthy weight”
HESI AVOID high purine foods!

ALLOPURINOL
Pain and swelling of the right great

Meats, Alcohol, Seafood COLCHICINE
toe... Which test will the nurse expect INCREASE fluid intake
the primary care provider to order?
Serum uric acid levels Monitor fluid I & O
BIG KEY DIFFERENCE
HESI
AlloPurinol Colchicine
Which interventions should the nurse
implement .. for a patient with gout? Prevents Gout ACute Gout Attacks
Increase the patient’s fluid intake.
Document the patient’s fluid
MODERATE
A
intake and output.
RICVECI
HI
W
Observe for medication side

GH
LO
LE L
U
effects.
Notes
117
Scoliosis
NCLEX TIP
First noticed during
S - Scoliosis periods of rapid growth
S - “S” shaped Spine
“lateral curvature” NCLEX TIP
especially in adolescent females
ages 10-12
Mild to severe pain & the stiffened spine can make it hard to
move. Severe cases can cause a deformity of the chest cavity.
Diagnosis Treatment
Measuring the Cobb angle can determine the
extent of the deformity & X-rays can be taken
as well. Social interaction
Visit friends NCLEX TIP
Fixing braces: Boston Brace
Wear a cotton shirt under
Cobb angle
the brace at all times NCLEX TIP
Thought to be from a possible defect of

intervertebral discs (the squishy shock Marfan syndrome
absorbers between the spine).
Avoid participating in
Risk factors: often seen in clients with
cerebral palsy, muscular dystrophy, & contact sports NCLEX TIP
Intervertebral discs
even Marfan Syndrome.
Notes
118
_ _
Neurological
119
120
Spinal Cord Injury
Signs & Symptoms

7 Cervical
• Cervical Injury: paralysis below neck (level of injury)
12 Thoracic
• Quadriplegia: 4 limbs paralyzed
5 Quad means 4
Lumbar
diplegia= sounds like paralyzed
5 Sacral & Coccygeal
4
• BREATHING impaired - Life threatening
Happens to a lot of sports figures
• Thoracic Injury - think T for trunk of body
Causes Parapalegic (2 legs)
Legs, pelvic organs
• Trauma - like a fall from a horse, • Lumbar Injury - think of double L’s
or slip & fall, car crash etc. Legs & Leaky bladder
MEMORY TRICK
C C L L T T
CERVICAL INJURY CAN’T MOVE LUMBAR LEGS & THORACIC INJURY LEGS & TRUNK
LEAKY BLADDER
Critical Complications
Neurogenic Shock think S for Severe hypotension (low BP)

• 3 Ds D D D
• Decreased BP DECRESED BP DEPENDENT
EDEMA
DYSREGULATION
OF TEMP
• Dependent edema
• Dysregulation of Temp.
• Autonomic Dysreflexia
NORMAL
HIGH
LOW
• Abnormal stimulation of the autonomic nervous

system below the level of injury
Surgery
PHARMACOLOGY
Halo traction device (a crown or vest)
Neurogenic Shock
- Key priority is Infection risk!!!
Oxytocin
IV Fluids & Vasopressors

- NO showers - ONLY sponge bath
EPINEPHRINE
Increase BP
- Assess pin sites for infection
Steroids “-sone” - Red, warm, smelly drainage
Dexamethasone
NORMAL
HIGH
LOW
Prednisone
Muscle relaxers
121
Autonomic Dysreflexia
Pathophysiology KAPLAN Question

• Occurs with Spinal Cord Injury ABOVE T-6 NCLEX TIP Client with spinal cord injury above level T3
Miscommunication of SNS & PNS in the autonomic reporting headache and nasal congestion,
nervous system. The SNS, speeds up the Vitals via profuse sweating and piloerection.
vasoconstriction causing HIGH BP, and the PNS. Puts the FIRST action?
brakes on the vitals via vasodilation causing LOW BP
resulting in a HUGE risk for STROKE! Answer: Check urinary catheter for kinks
Causes
KAPLAN ATI
● Bradycardia (Below 60 bpm)

NCLEX TIP
● Piloerection (Goosebumps)
● Diaphoresis above injury site

Signs & Symptoms Priority Patient?
300
• Severe hypertension - Up to 300 systolic Answer: Patient with diaphoresis,

• Throbbing headache hypertension, bradycardia &
• Bradycardia - low heart rate from PNS history of T-4 spinal injury.
• Facial flushing
• Nasal congestion
NCLEX Question
Key term: Spinal injury above T6 & HIGH BP - Initial action … cervical spine injury
Think Autodysreflexia with throbbing headache, nausea,
& elevated blood pressure?
Interventions
Answer: Palpate the bladder
1. Notify the HCP

2. Correct the Cause
Priority interventions ...T-1 spinal cord injury
with flushing, diaphoresis & pulse of 58?
NCLEX TIP
NCLEX TIP Correct Options:

● Assess for bladder distention
NCLEX TIP ● Remove tight clothing
NCLEX TIP ● Measure blood pressure

NORMAL
● High Fowler's position

HIGH
LOW
3. BP meds - AFTER Assessment

Correct the cause of symptoms FIRST!
122
Stroke ‘’CVA’’
Pathophysiology Types of Strokes

Cerebral Vascular Accident (CVA) happens when the
brain lacks oxygen resulting in long-term permanent • TIA - Transient Ischemic Attack - tiny lack of oxygen
damage. Typically resulting from a blood clot, narrowed • Transient: short time frame
blood vessels (arteriosclerosis) or a ruptured blood vessel • Ischemic: Low oxygen
(aneurysm). • Attack: Happens suddenly ...TIAs come & go often
resolving
Causes • CVA - Cerebral vascular accident - no oxygen causing
long-term damage!
#1 Hypertension (Over 140 sys) MOST TESTED • Ischemic CVA - Clot = Low O2 (called embolic or
thrombotic stroke)
Most important to PREVENT a stroke:
• Hemorrhagic CVA - Bleed = HIGH ICP (from an
• Take Antihypertensive Meds regularly aneurysm)
HESI Question
Highest risk for stroke
142/94 mmHg.
KAPLAN Question
Hypertension =
highest risk factor for Tricky NCLEX Question
CVA For clients recovering
from Stroke with HIGH BP:
Smoking: Scars the blood vessels making them weak
Hyperlipidemia (HIGH cholesterol) create narrowed blood Over 200 systolic Intervention:
vessels Keep Systolic BP above
Uncontrolled Diabetes: THICK sugar in the blood puts 170 mmHg for the first
loads of pressure on the vessels
24 - 48 hours
Signs & Symptoms
Hemiparesis - Unilateral weakness

F A S T
One-sided weakness Facial & Smile Droop Arm Drift
“1 sided weakness”
Speech Impairment Time to CALL 911!
CT scan Immediately
New, Sudden “Arm Drift” NCLEX TIP
NCLEX TIP
NCLEX Question
Hemorrhagic Stroke Most concerning patient
statement with diplopia
“Ruptured cerebral aneurysm”
and new weakness, & onset
Severe headache vomiting without nausea:
“I have the worst
headache of my life”
123
Stroke ‘’CVA’’ II
L R
Left Brain Right Brain
Language & Logic Reckless & Really Creative
Diagnostics
NCLEX Question
• CT scan immediately!!! Teaching for families of
patients with right-sided
Treatment: Pharmacology brain injuries?
Answer: lack of
impulse control and
behavioral changes.
Strokes cause by Clot
- Give clot busters
Thrombolytics - within ATI Question
4.5 hours of onset of
Manifestations of
symptoms right -sided
hemispheric stroke...
tPA
Visual & spatial
“-as” Alteplase, deficits
Streptokinase Left homonymous
hemianopsia
One-sided neglect
tPA
Alteplase Streptokinase
2 Tricky NCLEX Questions:

Strokes - Hemorrhagic
Question 1: Question 2:
(no clot busters)
Interventions for initial plan Priority nursing action for a Implement seizure precautions
of care for a patient with patient with left-sided
suspected embolic stroke?
- strict bed rest
weakness, lack of verbal
Select All that Apply response, and drooping face? No Blood Thinners
NO Aspirin & Clopidogrel
ASPIRIN
Obtain a STAT CT Maintain patent airway NO Heparin & Enoxaparin

of the head
Stats CT scan NO Warfarin
Perform neuro NO Thrombolytics
Neuro assessment
assessment
Limit any activity that may
Give tPA
Prepare to initiate increase ICP:
alteplase within Administer PRN stool softeners daily
4.5 hours of to prevent straining & bearing down
symptoms onset
during bowel movements
124
Stroke ‘’CVA’’ III
Patient Education
H HEMIANOPSIA Half Vision Loss C COMMUNICATION KEY TERMS
Risk of Self Neglect

Broca Aphasia - “Expressive”
Eat
“Dress the weaker side first” Meat
“Apply clothing on affected side first” Easily frustrated (attempting to speak)

Safety Speech limited to short phrases
“Scan surroundings”
“Turn head to affected side”
Wernicke Aphasia - “Receptive” KEY TERMS
??? ...
Misunderstanding to verbal cues
Unable to comprehend speech
Right Side - Reckless
Lack of impulse control
Behavioral changes
Educate family that behavioral
changes are expected
ATI
Nursing Interventions Priority finding patient recovering from
stroke...
F FEEDING Dysphagia with a regular diet ordered
NPO until swallow screen is performed

Eating KAPLAN
1. “Flex neck” while swallowing Priority intervention for a patient with
2. AVOID sedation meds before meals right-sided hemiplegia, and inability to
eat without assistance...
3. HOB Up - High Fowler's “Upright”
Answer: pureed diet for client with
4. Dysphagia (diff. swallowing) dysphagia
Puree diet - NOT regular diet
Add thickening agent to fluids Prevention of sensory overload in client
AVOID with stroke?
Seizure precautions
Answer: Obtain vitals and assists with
Frequent neuro assessments
morning care in one visit
Cluster Care (prevents sensory overload)
Transferring
A W
B
I
• Use a transfer belt

• Safe transfer from Bed to Chair
(ALWAYS transfer toward the STRONGER SIDE)
AVOID completing tasks for the client Big No Nos!

(to promote independence)
1. Patiently allow time to understand each instruction • DO NOT - complete tasks for the client! Allow them to learn
• DO NOT - speak loud, speak normally - allow time for client to
2. Simple gestures (point) & Show Pictures!
RESPOND
• Example: shower, toilet, toothbrush • DO NOT - give complex instructions or questions - simple yes
3. Ask Yes or No questions or no questions
• Normal voice - Not Loud
...
125
Seizures
Sudden, uncontrolled electrical discharges Anything that can cause brain swelling or hypoxia
in the brain. Epilepsy is lifelong episodes • Infection: meningitis
of seizures. • Trauma: TBI, Concussion
Memory Trick • Brain mass: BRAIN tumors
ePILEpsi - like a PILE of seizures that • Increased ICP
• Fever in infants = “febrile seizure”
come & go over a lifetime •Withdrawal from drugs & alcohol
Types of Seizures
Generalized Partial “Focal”

Tonic - Tight & Tense - Tonic Simple: Fully conscious
Clonic - convulsions, Complex: impared or Loss of
contraction - clonic clicking Consciousness
Tonic Clonic - tight & convulsions Lip smacking
Atonic Biting
Myoclonic Picking
Absent - “spaced out”
Phases of tonic clonic seizure?

Care for a child with a history
Loss of consciousness of absence seizures…
Pt. Falls to ground
Body stiffens for 10-20 seconds Monitor for brief interruptions
Extremities jerk for 30-40 seconds
in consciousness
Pt. feels tired and sleepy
Triggers
S S S S S
Stress Sleep deprived Strobe lights Stimulants Sugar
- fatigue flashing lights & Sodium LOW • Sugar:
NCLEX TIP below 70 (Hypoglycemia)
Sugar Memory Trick: think hypogly
Na+ brain will die
HESI • Sodium:
below 135 (Hyponatremia)
Warm,
Stages or moist of
Phases heat to CN VII
Seizure
• Prodromal phase Warning signs before a seizure leading to Aura Phase
• Aura phase NCLEXKAPLAN TIP Visual, auditory clue that happens prior to a major seizure
• Ictal phase = Seizure Phase THINK ignition phase - the period of the active seizure.
• Postictal Phaseaction:
Priority Hangover
Assessphase
the after the seizure - think POST-ignition phase
• Confused, disoriented,
patient’s pain major headache, & typically feels tired or sleepy
126
Seizures II
Kaplan NCLEX Questions:

Aura: Unusual sensations prior
to the seizure
?
Kaplan Scenario:
Client with seizure disorder tells the This is documented as: History of epilepsy who
nurse “I smell oranges and there aren’t Postictal phase reports having an aura
any on my tray”
What is the best response? Prodromal Aura Ictal Postictal

“Have you experienced this sensation
before?”
Status Epilepticus Diagnostics
MEDICAL emergency!! NCLEX TIP • MRI or CT - to look for abnormalities.

Key points • EEG - electroencephalogram NCLEX TIP
• 5 min. or longer for 1 seizure, or Assesses electrical activity in the brain by
• 30 min. Repeated seizure activity placing sticky electrodes on the scalp
• #1 Priority = STOP the Seizure • Wash Hair (before/ after) to make sure it sticks
(after airway and breathing are secure) • NO Caffeine (tea, coffee, soda) or stimulants:
IV or Rectal benzodiazepine 12 - 24 hours before
Lorazepam (brand: Ativan) • NO Seizure meds
Diazepam (brand: Valium) • NO Sleep - Sleep deprivation is BEST
• YES Eat before test - no need for NPO
1ST
Memory trick
• EEG think of EGG head - electrical activity
of the EGGhead
• ECG - C think C - Cardiac rhythms
Interventions during SZ
#1 - Airway
Turn client to side NCLEX TIP
Prepare for suctioning
NEVER insert anything in the mouth!
NEVER restrain or “Hold down arms”
Call for help & Stay with Client
#1 Drug = STOP the Seizure
Lorazepam (brand: Ativan) #1
Diazepam (brand: Valium)
Rectal or IV
Loosen restrictive clothing
(Neck & chest)
Safety
Pharmacology
Protect - Clear area for any objects
Pad Side Rails
Anticonvulsants
AFTER seizure activity - Phenytoin: Toxic Over 20 hold med
Record Time - Levetiracetam: Driving permissions
Assess LOC, Neuro, Vitals from HCP
127
Alzheimer’s
Pathophysiology
Incurable progressive disease, where plaques build up in neuronal-synapses of the brain disrupting
brain signaling, which severely impairs memory & personality changes.
Signs & Symptoms
Risk Factors &Causes
Stage 1 Stage 2 Stage 3
• #1 Risk Factor: Family history of Alzheimer’s Disease No impairment Forgetfulness & short Long-Term
• “Regular exercise reduces the risks of Alzheimer’s” term memory loss Memory LOSS
• Dementia - a general term for brain damage
• Memory Trick: DeMentia = DaMage to the brain Name
? DeMentia
DaMage
Interventions
Fall Safety
Tricky NCLEX Question
• Remove “Throw rugs & clutter” from floor
• Grab bars - installed in showers & tubs Agitated Client with Alzheimer’s
• Night Light “Well-lit halls”
1. Acknowledge &
Discuss feelings
Location & Locked Down
• “Safe return bracelet” on wrist 2. Redirect with new
activities NCLEX TIP
• Lock doors:
• Stairwell Doors - Fall Risk 3. DO NOT - Present
• Keyed Deadbolt Doors leading to outside reality or Rationalize
• Lock Hazards: toxic chemicals, gas, sharp objects
• Medications Locked or Out of Reach - do not put
in pill dispenser
Living Areas HESI Question

• Allow for free movement
• Place frequently used items within easy reach Q: Stage 3 Alz. client
• Pictures or symbols: with aggression …
• Bathrooms
• Label Hot vs. Cold water A: Complete
crossword puzzles
Simple Communication
• NO open-ended Questions - Yes or No questions
• NOT too many options - Limit choices
Yes
• DO NOT RUSH Client! Yes
or
NCLEX Question
• Allow plenty of time for ADLs & tasks
No
Best nursing action ….

“Decrease Anxiety by Client with Alzheimer's
Decreasing number of choices” is frustrated, stating
ATI scenario: they are waiting for their
husband to pick them
Create outfits and allow the up, but their spouse has
client to choose one each day. been dead for over 10
Treat client as an ADULT! years now.
(not like a child) Answer:
Acknowledge their
Diet feelings & redirect
with new activities
• Correct nursing action: Give half the sandwich
initially and other half later
128
A.L.S.
Amyotrophic Lateral Sclerosis
Pathophysiology
ALS also called Lou Gehrig’s disease presents as deterioration of
motor neurons in the brain & spinal cord, resulting in progressive
TOTAL BODY paralysis, eventually clients die in 3 - 5 years from 3 - 5 YEARS
Respiratory Failure.
ALS = Advanced Life Support
Memory trick:
ALS think ALS like Advanced Life Support, since clients will
eventually have to go on a ventilator to keep them alive.
Signs & Symptoms:

ATI Question
Priority finding… client with ALS?
Progressive muscle weakness A WB I
Increased respiratory secretions
Dyspnea - Difficulty breathing
Dysphagia - Difficulty
swallowing HESI
Dysphasia - Difficulty speaking

Constipation
Respiratory failure #1 Priority
Nursing Care HESI Question

Expected finding with ALS?
Limb weakness
Infection - monitor for pneumonia >100.3⁰F
Fever - Temp over 100.3⁰F
Lung sounds - Rhonchi

� Not Crackles = Pulmonary edema
129
Bell’s Palsy vs.
Trigeminal Neuralgia
Bell’s Palsy Trigeminal Neuralgia

Pathophysiology Pathophysiology
• Damage or inflammation to the 7th cranial • Irritation of Trigeminal nerve, the 5th
nerve in the face Cranial nerve
• Seen as sudden weakness to the muscles
on ONE SIDE Of the FACE, which typically • Severe sharp pain described as ELECTRICAL
resolves on its own. shocks to 1 side of the face!
Memory Trick Memory Trick
• Think Fells Palsy - since Face Falls to
one side • Think Trident gum! Like you’re
Chewing on Gems in TriGEMinal
Causes
Causes
• Unknown
• Some think it’s caused by infections like
Herpes, Varicella, or shingles & even • Multiple Sclerosis (MS) = damage to
some bacteria myelin sheath
Signs & Symptoms
• Tumor or vascular compression
• Drooping of Eyelid & Mouth - inability to Signs & Symptoms
completely close eye on affected side
• Inability to smile symmetrically
• Change in lacrimation on affected side • Electric shock like pain in lips & gums
(dry eye)
• Flattening of the nasolabial fold • Severe pain along cheekbone
• Dental like pain:
Diagnostics - Triggered by hot food or caffeine
• Identify the problem is with the FACIAL NERVE Diagnostics

• Ask patient to close their eyes, lift their
eyebrows, show teeth and frown
• To rule out a Stroke! Trigeminal
Interventions • MRI to rule out MS/ tumor
Interventions
• Corticosteroids to reduce inflammation
• Patient Education:
• Apply eye patch at night or tape down • Carbamazepine (Anticonvulsant) slows
the affected eye nerve firing
• Artificial tears & glasses - prevent dryness • Surgeries to decompress or destroy the cause
• Oral hygiene after meals • MOST tested:
• Chew on unaffected side & give soft diet
• Clients can still drive & balance is NOT affected • Avoid Triggers:
• Caffeine & hot foods
HESI
KAPLAN Question
Warm, moist heat to CN VII
KAPLAN
“I will drink coffee with breakfast
Priority action: Assess the and after dinner”
patient’s pain
130
9-6
Brain abscess
Labs & Diagnostics
Assessment ❖ CT: Is mostly used to
Frontal lobe identify location and size of
❖ Hemiparesis the abscess. Aspiration is
What am i? ❖
❖
Expressive aphasia
Saihetsezur ❖
also guided by CT or MRI.
Culture & Sensitivity: To
A lesion on the brain that is rare in ❖ Frontal headache identify the organism and
healthy people. They are usually a how to treat it.
result of an underlying disease such Temporal lobe ❖ Chest X-Ray: Rules out
as otitis media ❖ Localized headache prior lung infections.
❖ Changes in vision ❖ EEG: To Localize the lesion.
❖ Facial weakness
❖ Receptive aphasia
Patho Cerebellar
Infectious material that has
❖ Occipital headache
collected in the brain mostly
❖ Ataxia
caused by accumulation of
❖ Nystagmus
bacteria. The most common
cause of brain abscess is otitis
media and rhinosinusitis.
Abscesses can also be a result of
Treatments
intracranial surgery, penetrating
head injury, and tongue
piercings. Organisms can spread ❖ Treatment goal is to control ICP, drain the
from the lungs, gums, abscess and treat with antibiotics.
wound, heart, or tongue. ❖ Antibiotics are ordered based on culture and
sensitivity results.
❖ Ceftriaxone: First choice antibiotic.
❖ CT guided aspiration: To Drain the abscess.
Causes ❖ Corticosteroids: To reduce the inflammatory
cerebral edema.
❖ Antiseizure meds may be given to prevent
seizures.
❖ Otitis media
❖ Tongue piercings
❖ Oral infections
❖ Cardiac infections
❖ Lung infections
❖ Mastoiditis
❖ Rhinosinusitis
❖ Systemic infections
Nursing interventions
❖ Continuous neurological monitoring
❖ Monitor vital signs
❖ Administer antibiotics
❖ Monitor for signs of ICP
❖ Monitor blood glucose and Potassium when
administering corticosteroids.
❖ Initiate seizure precautions
❖ Keep patient safe and free of falls
❖ Assess distress and ability to cope with
altered state.
www.SimpleNursing.com
131
Dementia vs. Delirium
?
?
?
?
DeLLLirium DeMMentia DaMMMage
DeLirium Dementia
- Limited, short-term confusion that is easily DaMage to the brain that is irreversible
reversible!
- Correct the causes, correct the Delirium. Causes
Alzheimers, Parkinson's & even Traumatic brain

Causes injuries
Tricky NCLEX Question
• Infection (Sepsis) Key terms:

• Temp over 100.3 F Agitated with Dementia!!
• Urine Culture + Positive 1. Acknowledge & Discuss feelings
• Hypoxia “Low SpO2” 2. DO NOT - Present reality or Rationalize
• Agitation 3. Redirect with new activities
Priority action: “Assess the client”
Other causes: In end stage deMentia, there is too much brain

• Opioid Pain Meds daMage making it IMPOSSIBLE for clients to
• Low sodium (norm: 135 - 145) understand reality.
• Low blood glucose (norm: 70 - 110) This causes more anxiety & aggression,
so interventions revolve around distraction
Priority action: ‘’Assess the client’’
> 100.3 oF ATI

Place personal items such as pictures
Pos
iti ve at client’s bedside
Provide a manual activity to occupy
the client in order to prevent the need
to restrain a client with dementia

Kaplan
Encourage client to
Nurse understands which factors can
cause delirium?
discuss “mixed-up” feelings
82
Positive urine culture with 101 F temp.
Serum sodium level of 123 HESI
Serum blood glucose level of 120
SpO2 82% Q: Patient with Stage 3 Alzhiemers A
H I
Brain damage … Yo dis too much with aggression ... A
A: Redirect by completing a T
crossword puzzles (distraction)

132
9-4 Encephalitis
Labs & Studies
Assessment ❖ EEG: Diffuse slowing or focal
DERM: Cold sores, lesions, ulcers of changes in the temporal lobe.
What am i? the oral cavity, insect bites
NEURO: Nuchal rigidity, changes in
❖ Lumbar Puncture: High opening
pressure, normal glucose range, high
Encephalitis is an acute inflammatory LOComotor dysfunction, neurological protein levels.
process that affects the brain tissue, deficits, seizures, hemiparesis ❖ Viral cultures: Usually negative
the cerebrum, brainstem, and Misc: Nausea, vomiting, travel to ❖ Polymerase Chain reaction:
cerebellum. areas where there is increase rate of Standard test for early diagnoses
disease. Dysphagia. Flu like and identifies the DNA of HSV-1,
Patho
symptoms, hydrocephalus with validity is highest on the 3rd and
fungal infection, HIV. 10th day post symptom onset.
❖
Arthropod infected Lab studies
Encephalitis is an inflammatory process
caused by the herpes simplex virus or H: Herpes Virus infection
bites from a tick or mosquito and ❖ MRI: Inflammation in the basal
E: Enterovirus infection
causes necrotizing hemorrhage of the ganglia ( St. Louis) or periventricular
brain that becomes generalized and is R: Rigidity ( Nuchal)
followed by edema. Encephalitis also P: Populations with lots of disease area ( West Nile)
can cause damage to nerve cell bodies. E: Extreme changes in LOC ❖ EEG: Abnormal brain waves.
Encephalitis commonly affects S: Sores in the mouth ❖ CSF: Immunoglobulin M antibodies
neonates via transmission from an will be present
Fungal Encephalitis
HSV-2 infected mother. Encephalitis V: Varicella infection
caused by insect bites comes from
I: Insect Bites
attempts at replication of viral DNA
R: Really high fever ❖ CSF: Elevated White cells and
which elicit olfactory tract and CNS protein or candida
problems. The virus jumps from neuron U: unilateral paralysis ( hemiparesis)
S: Seizures ❖ Neuroimaging: Identifies CNS
to neuron affect the gray matter of the
brainstem and thalamus. changes
❖ Fungal Encephalitis happens when ❖ MRI: Is the study of choice, identifies
fungal spores enter the body of an hemorrhage, abscess or
immunocompromised person upon inflammation.
inhalation causing fungemia. Fungus
may spread to the CNS and cause
Treatments
meningitis, granuloma, arterial
thrombosis, encephalitis or brain
abscess
❖ Acyclovir: Antiviral agent , decreased
dose if the patient has a history of renal
impairment.
❖
❖
Ganciclovir: Antiviral Agent
Starting antivirals early is well tolerated Transmission
and the patient should continue ❖ Arbovirus: From human to
treatment for up to 3 weeks. mosquito.
❖
Causes
IV administration over 1 hour prevents ❖ West nile virus
crystallization of the medication in the
❖ Western equine
urine.
❖ Viral infection of HSV ❖ Interferon : St. Louis Encephalitis encephalitis
❖ Mosquito bites ❖ Lumbar Puncture and Shunting: Fungal ❖ Eastern equine
❖ Tick bites encephalitis. encephalitis
❖ Bacteria ❖ Amphotericin B: Treats progressive ❖ Powassan virus
❖ Fungi fungal infection. May cause renal ❖ Echovirus
dysfunction ❖ Poliovirus
❖ parasites
❖ Fluconazole: Treats fungal infection
❖ Herpes zoster virus
and may cause bone marrow
depression ❖ Varicella
❖ Herpes simplex-1
❖ Amebic transmission
Nursing interventions
❖ Assess neurological function.
❖ Assess for signs of ICP
❖ Assist client to Turn cough and Deep
breathe
❖ Elevate HOB 30-45 degrees
❖ Comfort measures to reduce headache.
❖
❖
Administer analgesia.
Use opioids cautiously because they can
Education
mask neurological symptoms. ❖ Encourage fluid intake
❖ Seizure precautions. ❖ Small frequent meals
❖ Monitor Blood cultures. ❖ Educate the client on the disease.
❖ Monitor intake and output due to ❖ Educate the client on the treat regimens
possible renal impairment from the
and when to call the HCP.
antivirals.
❖ Initiate rehabilitation for motor
dysfunction.
133
9-2 Focused neurological assessment
Assess level of
consciousness Assess orientation
❖ Oriented x3 : understands spoken and written
❖ Full consciousness: Awake and language and responds appropriately.
Alert ❖ Oriented x2: Mild confusion, guesses date, may be
❖ Lethargic: sleeps frequently but able to recognize time of year. My not be able to follow
awakens easily. instructions. May have memory deficits.
❖ Obtunded: extreme drowsiness, ❖ Oriented x1: confused, unable to give date or time,
requires vigorous stimulation to unable to verbalize where or who they are. Has
waken. memory deficits and can be restless or agitated.
❖ Stupor: minimal movement, ❖ Disoriented: patient does not answer appropriately or
responds inappropriately. Is at all. May be hallucinating or agitated. Unable to
awake briefly with vigorous follow directions.
stimulation or painful stimuli.
❖ Comatose: does not respond to
PEERLA
verbal and tactile stimuli. May
respond appropriately to painful
stimuli.
❖ Test pupil response, size, symmetry, shape. They
should be equal and reactive to light.
❖ Shine the penlight into each pupil. Constriction
should be brisk and equal.
❖ Bilateral dilation can be caused by cerebral anoxia or
Assess muscle strength & function anticholinergic medications. Be sure to assess the
client's medication list and other symptoms.
❖ Have the patient move all extremities. ❖ Bilateral constriction can be caused by: intracranial
❖ Have the patient squeeze your fingers. hemorrhage, opiates, or organophosphates.
❖ Hold your hands up for the patient to push and
pull your hands.
Cranial nerves
❖ Have the patient hold their arms to their eyes.
Note any drifts.
❖ Have the patient dorsiflex and plantar flex. ❖ I: olfactory : Smell, have the client identify familiar smells.
❖ Have the patient raise their legs without ❖ II : Optic: Visual acuity, use snellen eye chart, assess
resistance. peripheral vision.
❖ III: Oculomotor: Pupillary reaction, assess PERRLA
Muscle strength scale ❖ IV: Trochlear: Eye movement, patient follows finger without
0 : No muscle movement. movement.
1: Visible muscle movement, no joint movement. ❖ V: Trigeminal: Facial sensation, touch patient's face, have
2: Movement at the Joint but not against gravity. them open their mouth.
3: Movement against gravity but not resistance. ❖ VI: Abducens: Motor function, patient follows finger without
4: Movement against resistance but less than normal moving head.
5: Normal strength. ❖ VII: Facial: Taste and face movement, have patient smile and
puff cheeks, have patient differentiate between sweet and
salty tastes.
Glasgow coma scale ❖ VIII: Acoustic: Hearing and balance, snap fingers close to
patient's ear, have patient stand with feet together, arms at
side and eyes closed for 5 seconds.
❖ IX: Glossopharyngeal: Swallowing and voice, have the
❖ Eye response
patient swallow and say “ah”
Spontaneously 4
❖ X: Vagus: Gag reflex, use a tongue depressor to swab and
On command 3
elicit a gag reflex.
To pain 2
❖ XI: Spinal accessory: Neck motion, have patient shrug and
No response 1
turn their head against resistance.
Score____
❖ XII: Hypoglossal: Tongue movement, have patient stick their
tongue out and move it around.
❖ Verbal response
Alert and oriented 4
❖ Brain trick to remember the order of cranial nerves.
Confused 3
“ OOO to touch and feel a great velvet super hero”
Inappropriate 2
Posturing
Incomprehensible 1
score____
❖ Decorticate : An abnormal
❖ Motor response
posturing in which a person is stiff
Follows direction 6
with bent arms, clenched fists,
Localizes pain 5
and legs held out straight.
Withdrawal from pain 4
❖ Decerebrate :An abnormal body
Abnormal flexion 3
posture that involves the arms and
Abnormal extension 2
legs being held straight out, the
No response 1
toes being pointed downward,
score____
and the head and neck being
arched backwards
134
G.B.
Guillain-Barré Syndrome
Pathophysiology
RAPID ascending paralysis starting in the legs & eventually reaching the
respiratory system, which kills the client within a few hours to a few days.
Memory Trick:
Ground up barees - paralysis from the legs up
Causes:
Triggered by an infection
Signs & Symptoms:
NCLEX Question
Ascending Symmetrical
muscle weakness
Lower extremity weakness Priority finding:
Client with Guillain-Barré?
Absent deep-tendon reflexes
Inability to lift head or
Neuromuscular respiratory failure cough
Respiratory failure - early signs :
Inability to cough NCLEX TIP
Inability to lift the head or
eyebrows NCLEX TIP KAPLAN
Shallow respirations
Dyspnea and hypoxia Priority for patient with G.B.
Prepare mechanical ventilator
for client with worsening
Guillain Barre
Nursing Intervention:
- Intubation setup bedside &
- Mechanical Ventilator
Treatments:
• IVIG
Plasmapheresis (Plasma exchange) to remove antibodies

Filte
• rs the
bloo
d to
that contribute to the destruction of neurons. rem
ove
antib
odies
that
cont
135 r ibut
e to
Head Injury
Traumatic Brain Injury - TBI
• Motor vehicle accident
Any injury to the head can be open & closed • Fall greater than 20 ft
traumatic brain injuries (TBI). • Child abuse (shaken baby)
>20ft
CLOSED TBI
Concussion - Minor TBI
OPEN TBI - Basilar skull fracture NCLEX TIP
Key Sign KAPLAN Questions NCLEX Questions

▪ CSF leakage from Eyes, Ears, Nose
Client with head injury with What is MOST likely affected by
“Coup - Contrecoup”
“Clear fluid drainage” NCLEX TIP clear nasal drainage noted… coup-contrecoup brain injury?
Answer: Check drainage for glucose Answer: Memory, speech and vision.
Which patient to see first following

Which assessment is expected with
a multi car accident?
occipital lobe injury?
Answer: Patient with clear fluid Answer: Deficits in visual perception.
draining from right ear
Memory Tricks:
• Frontal lobe = Front OFFICE controls speech, memory,
(This is a sign of a BASILAR SKULL
& movement. Frontal lobe Occipital lobe
• Occipital lobe = Ocular Sight controls visual perception FRACTURE! A priority patient!)
• Temporal lobe = Think TEMPO like hearing a beat.
• Parietal lobe = sensory, touch - Think purrrietal like a cat
- soft & fluffy to touch.
• Cerebellum - think cere-BaLance - controls balance
• Brain stem - controls HR & RR
HEMATOMA 3 Types Monitor for Increased ICP

EPIDURAL SUBDURAL
NCLEX TIP
medical emergency! High bleeding & rapid
DEATH from ↑ ICP NCLEX TIP
- Classic sign: Loss of consciousness

- Followed by brief alertness (STAY with &
monitor client who passed out and then
woke up again.
SUBARACHNOID
Interventions
Imaging
ST • CT scan or MRI to show evidence of
1 PRIORITY NCLEX Questions bleeding, bruising, or swelling
Client recovering from head trauma …
GCS of 15 over 2 hours ago, but now Discharge Teaching
GCS score of 14… First action?
Answer: Report to provider immediately
• Return if having difficulty walking
Client in C spine after fall … priority “Ataxia”
assessment? • Adult should stay with the patient
Answer: Obtain Glasgow Coma Scale score. • No alcohol: vasodilates & makes brain
swelling worse
• NOT necessary for patient to stay awake
ALL night
136
Increased ICP
Intracranial Pressure
Increased pressure within the head compresses • Aneurysm stroke: burst blood vessels that fill up the
brain with blood.
blood vessels leading to cerebral hypoxia & can • Head Trauma or Meningitis: Increased swelling &
put pressure on the brain stem - killing the patient. inflammation.
• Tumor: Increased brain tissue
Signs & Symptoms Late DEADLY Signs:

Lungs:
• Irregular Respirations
Early Sign: NCLEX TIP •“Cheyne Stokes Respirations”
Moderate Signs: Neck:
Altered LOC: Irritability, • Nuchal rigidity (stiff neck)
Restless Headache - Constant • “Can not FLEX chin toward chest”
Sudden Vomiting “Emesis” Brain Stem Affected:
Decreased Mental Status Eyes
Without Nausea =
Sleepiness Report to HCP! • Pupils “Fixed & Dilated” 8 mm
• Unequal
Flat affect and
• 8 mm (Normal 2 - 6 mm)
drowsiness
• Doll's eyes: this means Brainstem is intact!
• If the eyes stay fixed & dilated when the
head is turned, it means BRAINSTEM is
Critical LATE signs Memory Trick: affected.
Foot
Cushing triad NCLEX TIP • CUSHing triad think • Babinski reflex (Toes fan out when stimulated = BAD)
CRUSHing triad means brain stem herniation! Normal in an infant
Wide pulse pressure
• HIGH BP “Hypertension” below 1 year old, NOT NORMAL in adult!
• Crushed HR & RR with Seizures & Coma
• Low HR “Bradycardia” Wide blood pressure Abnormal posturing:
Low RR “Decreased
• Decorticate: arms flex toward core
Respirations”
SYS 150
DIA 78
• Decerebrate: arms flexed out to sides = Far WORSE!

PULSC
70
NORMAL
HIGH
LOW
NCLEX Questions Diagnostics

Question:
Which client is priority? • Imaging - CT scan
• 1st test - quick easy picture of the brain
Answer:
- showing the root cause
Closed head injury
waiting for brain imaging • NOT an MRI - they are too long & slow
who reports a headache • NO lumbar puncture (spinal tap)
& emesis of 200 mL
• ICP monitoring (for long-term patients)
without nausea
• Normal ICP: 5 - 15 mmHg
Priority assessment findings for a • HIGH RISK of infection!
client recovering from a head trauma?
1. Eyes that move in the opposite

NCLEX Questions
direction when patient is turned.
2. Extremities that contracted to Client found on the Answer:
the core of the body. floor, appearing Immediate C- Spine
3. Fixed pupils that remain 8mm
when assessed with a pen light.
lethargic, bleeding at immobilization &
4. Level of consciousness that has
the back of head, heart CT scan to rule out
not diminished since admission. rate of 45 BPM & a intracranial bleed
5. Grips 5/5 bilateral blood pressure of BP
6. Toes that fan out when the 220/88. First action?
sole of the foot is stroked.
137
Increased ICP
Intracranial Pressure II
Nursing Interventions
I Immobilize Head
“C-Spine” CI C02 LOW
P Positioning
S Suctioning
HOB - Semi-Fowler’s
• Head in neutral position • Lower CO2 means Lower ICP. 10 Seconds or Less
30 - 35 Degrees or higher
• Log Roll “As one unit” Carbon dioxide vasodilates
the brain resulting in more NO flexion & bending 100% O₂
swelling from more blood extremities
before/after suction
flow. NO coughing, sneezing,
Hyperventilation decreases
CO2 by blowing it out
blowing nose
NO valsalva maneuvers
O₂
or holding breath
KAPLAN Question
HESI Question
Client on ventilator...
Instruct patient to HESI Question
increased PaCO2. The nurse exhale when turning Interventions for increased ICP? Interventions.. increased ICP &
receives an order to increase or moving in bed. Select all that apply ineffective breathing pattern?
the respiratory rate on the Select all that apply
Position - Semi-Fowler’s
ventilator. This change Suction no longer than 10 seconds
Place neck in neutral position
should have what change on
Teach avoid valsalva maneuver 100% O₂ before and after suctioning
the patient’s ICP?
Perform neuro checks using GCS
Answer: NCLEX Question Position avoid flexion of hips,
waist, and neck
Decrease the ICP …. Immediate intervention Suction only as necessary but no
decrease in carbon when client with ICP longer than 10 seconds
dioxide. states…
“I will turn cough,
& deep breathe”
GCS Score: NCLEX Questions

HESI Questions
GCS Score Patient replies…. correct
name & location, but
• 15 = Highest Score
incorrect year & date.
• 8 = intubate How should the nurse
• 3 = lowest score document the patient’s
responses?
REPORT Decreasing Alert and oriented
GCS score! 1
to person and place
‘
SCORE: 11
Treatment: Pharmacology HCP

Phenytoin
• Phenytoin: prevent seizures

• Steroids: Dexamethasone
Phenobarbital
• Phenobarbital: a barbiturate to decrease brain activity

• Mannitol: osmotic diuretic #1 drug to know
Side effect: edema & s/s of heart failure NCLEX TIP MANNITOL
Notes
138
M.G. Myasthenia Gravis
Pathophysiology
HESI
MG is an autoimmune disease where body attacks itself,
attacking & destroying the acetylcholine receptors, What is myasthenia gravis?
resulting in low acetylcholine. Clients present with a weak Autoimmune disease of the
muscles & a dry body from low acetylcholine. neuromuscular junction & is
Memory Trick: characterized by fluctuating weakness
- MG - MYasthenia Gravis of certain muscle groups.
- MG - DRY-asthenia Gravity
Signs & Symptoms
• Ptosis “Droopy eyes” NCLEX TIP Which client should the nurse
Decreased eye & eyelid movements see first?
• Diplopia “Double Vision”
• Dysphagia - difficulty swallowing
• Dyspnea - difficulty breathing Client with myasthenia gravis difficulty
Low & SLOW: swallowing & temperature of 100.7F
- Tiredness with slight exertion KAPLAN
- Improves with rest
100.7F
Myasthenic Crisis!
Airway protection (safety with swallowing)

• Intubation set up - BEDSIDE
• BEFORE meals: HESI
Give pyridostigmine
(anticholinesterase drug) NCLEX TIP Myasthenia gravis safety precautions …
• Encourage semi-solid foods Which instructions should the nurse
include in the patient teaching?
AVOID the 4 Ss = Trigger Flare Ups Select All That Apply
• S - Stress (exercise, surgery, pregnancy)
• S - Sun Use airway protective techniques when
• S - Smoking swallowing
• S - Sickness or Sepsis (infection) Wear medic alert bracelets at all times
• Avoid crowds during flu season &
• Get vaccines (flu, pneumonia, etc) AVOID crowds during cold and flu season
• Fever 100.3
• Wear a medic alert bracelet
AVOID
Diagnostics
Tensilon Test
- Edrophonium (brand: Tensilon) injection helps prevent the breakdown
of the acetylcholine
- If the drug INCREASES muscle strength, then patient has MG.
Pharmacology
• IVIG: the body attacks this substance instead of itself ____STIGMINE

• Steroids - Prednisone to decrease swelling
• Immunosuppressants help the body STOP attacking itself PRENISONE
• Neostigmine: given to treat the dry. Think Stigmine adds Secretions.
139
Neuro
Meningitis
Pathophysiology ! Causes
! !
Meningitis is the inflammation of the Meninges - Infection, head trauma, & auto-immune diseases (Lupus)
(the inner lining of the brain & spinal cord) ! Memory Trick
Inflammation → massive brain swelling → deadly
↑ ICP → leading to death !
!
• Bacterial = Bad news MOST contagious
• Viral = Very common - MOST tested
Signs & Symptoms Diagnostics

H - Headache & Photophobia • + Kernig Sign: Laying on the back & straightening
H - Hard stiff neck “Nuchal rigidity” the leg = very painful.
H - High Temp. “Fever” • + Brudzinski Sign: when neck flexes, hip & knees also
• Pediatrics flex.
• High-pitched cry Memory Trick:
• Bulging fontanelle - Kernig “Krinkle”
• Adults - Brudzinski “Beach Chair”
• Agitation & altered LOC (1st sign)
• Leads to seizures, coma, & DEATH!
Tests:
• CT scan (done first)
• LP (Lumbar Puncture “spinal tap”)
- Viral - Very clear Interventions
- Bacterial - Bad cloudy
- Both types will have elevated WBCs • First action
- AFTER LP: Monitor insertion site dressing - Place client on droplet precautions - PPE 1st!
for clear fluid
Droplet Airborne KAPLAN Scenario NCLEX question

Question: Client with
P - Pertussis M - Measles suspected meningitis… Client admitted for bacterial
I - Influenza ON AIR
T - TB (Tuberculosis) when neck flexes, the meningitis with a BP of

M - Meningitis V - Varicella (shingles/chicken pox)
hip and knee also flex. 78/56… priority action?
P - Pneumonia Priority action?
Admin. bolus of IV
Answer: Immediately normal saline
1. Surgical Mask & Goggles 1. N95 mask - Staff report this finding to
2. Neg. Pressure Room the HCP!!!
2. Single room
3. Door closed
ATI 4. Transport - Patient wears
surgical mask
Teach unlicensed personnel
to wear a mask Interventions
Take OFF “DOFF” • LOW BP will kill!

Put ON “DON”
• Low noise - quiet room
GMGG GGGM • Low light - photophobia
1. Gown 1. Gloves • Low pressure all over:
• NO coughing
2. Mask 2. Goggles
• NO sneezing
• NO bending extremities
• RAISE HOB at least 30 degrees
3. Goggles 3. Gown
Early Sign of ↑ ICP: NCLEX TIP

4. Gloves 4. Mask N95
• Altered LOC: Restlessness, Irritability, Agitation

• Decreased Mental Status
140
M.S. Multiple Sclerosis
Pathophysiology
M.S. M.S.
MS is an autoimmune disease where the body attacks myelin sheaths, MYELIN SHEATH MUSCLE SPASM &
the sheets of fatty tissue around nerve cells which helps the body move. STIFFNESS
Memory Trick:
MS - Myelin Sheath destruction
MS - Muscle Spasm & Stiffness
Diagnostics Causes
• MRI & CT scan show plaque on brain & spinal cord • Female more common
• Lumbar spinal puncture high levels of antibodies • Infection & Vitamin D deficiency
HESI
Signs & Symptoms
3 - 4 mm sclerotic brain
plaques on MRI • Muscle Spasticity: seen with bad flare-ups
that come & go from Myelin Sheath
Elevated gamma globulin in destruction
cerebrospinal fluid (CSF) • Other signs:
KAPLAN
Patient Education
Balance exercise with rest

AVOID 4 Ss = Trigger Flare Ups
S - Stress (exercise, surgery, injury)
S - Sickness or Sepsis
S - Smoking
S - Sun & Extreme heat (hot tub, bath, sauna)
Pharmacology
Promote Independence = All Neuro Patients
1. “SELF Care ADLs”
NEVER do “All ADLs for the client • IVIG - body attacks this substance instead
2. Gait training • Interferon - interferes with body attacking
Teach 1st - Gait training itself
Then offer Cane
Walker
• Steroids - Prednisone - decreases swelling
Last wheelchair • Muscle Relaxants - Baclofen - for muscle
spasms
• Cyclosporine - immunosuppressant
HESI (most important)
• Report signs of infection & bleeding
• NOT for pregnant clients
Correct Answer:
Preparing to place a client with INterferon INnterferes
MS in a bathtub with hot water
CYCLOSPORINE
INTERFERON
Correct Answer:
Interferon
Rest in air conditioned surroundings
141
Neuro Diseases
Intro & Quick Overview
brain & spinal cord

M.S. - Multiple Sclerosis
Parkinsons Promote Independence
All Neuro Disease Patients
Alzhemiers
Huntington disease
peripheral nervous system Never do All ADLs

Gait training
M.G. - Myasthenia Gravis
A.L.S
1st - Teach Gait training

G.B. - Guillain-Barré Syndrome
Highlighted are the Most Tested Then offer Cane, then Walker,
TEST TIP last wheelchair
• NO drugs or interventions will CURE these conditions
• We can only treat to prevent progression
M.S. - Multiple Sclerosis Parkinson’s Disease

(autoimmune disease - body attacks itself) Patho: Low dopamine - HIGH acetylcholine
Memory Trick:
• MS - Myelin Sheath destruction 3 Key Signs for NCLEX
• MS - Muscle Spasm & Stiffness 1. Shuffling gait & Decreased arm swinging NCLEX TIP
• MS - Mellow out & Stay cool (no sun) 2. Pill rolling - looks like rolling a pill between fingers
Teach: 3. Tremors at rest - lots of jittery movements
• Balance exercise & rest
• AVOID 4 Ss = Trigger Flare Ups Memory Trick: You can’t jump ROPE if you got low DOP -
• S - Stress (exercise, surgery, injury) - improved movement with more dopamine.
Don’t over exercise
• S - Sickness or Sepsis - Stay healthy & free from Pharmacology
infections • LevoDOPA & CarbiDOPA
• S - Smoking - use smoking cessation Leaves more DOPAmine in the body & Carbidopa helps
• S - Sun & Extreme heat (hot tub, bath, sauna) conserve MORE dopamine
Pharmacology • AVOID protein - can block absorption
• IVIG - acts as bait - the body attacks this substance Memory Trick: LEAVE the protein with LEVOdopa
instead of the nerves.
• Cyclosporine - immunosuppressive
think “CycloSPARIN”- spares the body from attacking Huntington Disease
itself
Key Point
M.G. - Myasthenia Gravis • Passed on by Genetics
(autoimmune disease - body attacks itself) • Only requires 1 parent!
• Recommend Genetic counseling
Memory Trick:
• MG - MYasthenia Gravis Memory Trick HuntingTON - One parent needed to pass
• MG - DRY-asthenia Gravity on the disease
Dry body & Weak muscles - like Loads of Gravity
weighing down the body.
AVOID the 4 S’s = Trigger Flare Ups (see above) A.L.S. (Amyotrophic Lateral Sclerosis)
Myasthenic crisis: respiratory arrest! • Dysphagia - Difficulty swallowing
Airway protection (safety with swallowing) • Dysphasia - Difficulty speaking
• Intubation set up - BEDSIDE • Priority finding - Increased respiratory secretions
• BEFORE meals:
Give pyridostigmine (anticholinesterase drug) NCLEX TIP
• Encourage semi-solid foods
Pharmacology
Neostigmine: given to treat the dry.
Think Stigmine adds Secretions.
Alzheimer’s
G.B. - Guillain-Barré Syndrome
Patho: Brain damage resulting in Dementia “daMage to
the brain” Patho: clients get RAPID ascending paralysis from the legs up
Signs & symptoms: VERY forgetful & loss of reality eventually reaching the respiratory system which ultimately
kills the patient!
Key Point Memory Trick: Ground up barees - paralysis from the legs up
• Safety: NO rugs, LOCK everything
• Location: Lock doors leading outside! Respiratory failure (early signs)
• Communication: Distract & REDIRECT from reality
REdirect any Dementia clients who get easily frustrated • Inability to cough NCLEX TIP
• Inability to lift the head or eyebrows NCLEX TIP
142
Parkinson’s Disease
Pathophysiology
HESI
A movement disorder with the progressive death of neurons in the brain Q: Dopamine
resulting in Low dopamine & HIGH acetylcholine
A: Neurotransmitter …
primarily affects motor function
Memory Trick & gross subconscious
• Think NO dope in the park - low DOPamine - in PARK-insons movements of the skeletal
• HIGH acetylCCCholine - we get High seCCCretions with lots of drooling muscles.
Signs & Symptoms
• Resting tremors Kaplan HESI

• Bradykinesia: delay in initiation of movement Signs of Parkinson’s ….
3 Key Signs Statement that indicates
an understanding of tremors
1. Shuffling gait & Decreased arm swinging with Parkinson’s? ● “propulsive shuffling gait”
● Drooling of saliva
2. Pill rolling ● “Tremors decrease when ● Decreased arm swing
3. Tremors at rest attention is diverted by activity”
Other common: Dysphagia (diff swallowing) & Drooling
Diagnostics Critical Complications
HESI • Airway = #1
• Suction set up at bedside (excess drooling)
Diagnostic tests for Parkinson’s?
Select All That Apply • Eating
• Pureed Diet + “Small bitesized pieces”
CT brain - cerebral atrophy wasting
away or destruction of brain tissue
• Tissues readily available during eating
Decreased motility in pt. Upper GI tract • “Add thickening agent to fluids”
Positive response to low dose • Dysphagia - Monitor swallowing
carbidopa levodopa
• HOB up - High Fowler's “Sit Upright”
Pharmacology
pa
Levodo
Patient Education NH2

• Increase DOPamine HO
• Decrease Acetylcholine OH
Carbid
opa
Kaplan • Levodopa Dopamine
Realistic goal… • Levodopa & Carbidopa (combo drug)

Parkinson’s disease? • AVOID protein
Maintain optimal function Memory Trick LEAVE the protein with LEVOdopa
within the client’s limitations.
• Benztropine - treat resting tremors
• Pramipexole - dopamine agonist - stimulates more
dopamine
FURTHER teaching
HESI
needed This treatment will
Patient taking
CURE my disease
for a patient statement...

carbidopa-levodopa, selegiline,
Answer: and pramipexole.
This treatment will Based on these meds …
CURE my disease patient has which disorder?
● Parkinson’s disease
Side note:
- Selegiline - actually an MAOI antidepressant - increases availability of dopamine
& other neurotransmitters in the brain
143
_ _
Oncology
144
Breast Cancer
Med Surg: Oncology (Cancer)
Pathophysiology
Breast cancer is the uncontrolled growth of cells in the breast tissue.
It is deadly because the breasts are very vascular with lymph tissue & blood
vessels acting like highways to the body, where cancer can easily spread.
Causes & Risks >50
NCLEX TIPS Saunders

Female
Educational session … discussing the
Age over 50 (common postmenopause)
risk factors with breast cancer.
Family History: sister / mother Select all that apply.
Personal History: ovarian / uterine cancer Early age menstruation
BRCA
Genetic mutations: BRCA Family history of breast cancer
High-dose radiation exposure to
Lifestyle Risks Chromosome Chromosome
chest
Weight gain & Obesity Previous cancer of the breast,
uterus, or ovaries
Oral contraceptives (birth control)
Estrogen & Progesterone
Diet: High fat, Low fiber
70 kg
Alcohol & Smoking
Diagnostics
Mammograms are essential for high risk patients, done every year.
No powder lotion or perfumes.
NO
“Just a reminder that
mammogramming
your breasts is more
important than
instagramming them.”
Signs & Symptoms

Fibroadenoma: Benign breast disorder
Round, Painless, Mobile lump
Self Breast Exam Report to HCP NCLEX TIP Fibrocystic disease: Benign
Red & Warm Nodules: soft, mobile
Orange peel skin Breast changes in size during menstrual cycles
HCP
1
Pitting appearance “small indented areas” Key point D

ELATE
NOT R
Hard painless swelling “immobile” Malignant Cancer!
No pain or discomfort (until it spreads) REPORT breast changes
NOT RELATED to menstrual cycle
Notes
145
Breast Cancer &
Mastectomy
Mastectomy
A mastectomy is surgery to remove the whole breast or partial
breast & sometimes lymph nodes are removed, which
places the client at higher risk for both infection & swelling.
Post-Operative KAPLAN HESI

Q1: 24 hours postoperative after a ...
Mastectomy of the right breast … Which
Blood drainage: Jackson Pratt bulb intervention should the nurse include in
mastectomy ... Which nursing intervention
is most appropriate for this patient?
the plan of care?
Monitor the patient for signs of shock
REPORT to HCP: Instruct the client that the drain will be
removed when there is 25mL or less of
or hemorrhage
drainage within a 24 hour period Q2: Bilateral mastectomy and removal of

Over 100 mL “bright red” the axillary lymph nodes. Interventions to
prevent which complication will be most
important after surgery?
Infection
PRIORITY
24
HCP
1 hours
>100 ml
Teaching
KAPLAN
Key Points NCLEX
Discharge teaching ... postoperative radical
AVOID affected arm mastectomy. Which of the following
NO IV & Blood Draws instructions should the nurse include?
Numbness can occur along the inside

NO Vaccines of the affected arm
NO Blood pressure
Prevent Swelling
Saunders
Compression sleeve
Q1: Following a mastectomy ... Which
Elevate arm above the heart nursing intervention would assist in
preventing lymphedema of the affected
Perform exercises arm?
Elevating the affected arm on a pillow
NORMAL “Expected” above heart level
Numbness Q2: Mastectomy … 2 weeks ago... she has
numbness in the area of the surgery … the
Lymph Node swelling nurse should provide which information to
the client?
These sensations dissipate over several
months and usually resolve after a year
Notes
146
Eye Cancer
Pathophysiology
Retinoblastoma is the most common eye cancer in childhood,

typically diagnosed in children less than 2 years of age.
≤ 2 year-old Retinoblastoma
Signs & Symptoms

MEMORY TRICK
Normal
First recognized when parent report
a white pupil.
NCLEX TIPS RED-inoblastoma
This may be first seen while taking a
1. White pupil (Leukocoria) photograph using a flash.
2. Absent red reflex Late sign
Another sign is a Strabismus, or
wandering misaligned eye, but that
is a late sign.
Interventions Retinoblastoma interventions - Radiation.
Siblings should undergo

ocular screening NCLEX TIP
Enucleation
(removal of the eye & placing a prosthesis)
Siblings should undergo ocular screening as

some forms of retinoblastoma are hereditary.
Notes
147
Leukemia
Pathophysiology
Crowd out the production
of RBCS & platelets
Leukemia is a type of cancer that affects the
blood cells & bone marrow. Bone marrow Leukemia
is responsible for making blood cells: WBCs, • Leuk = Leukocyte (WBC)
RBCs, platelets. In Leukemia there is an
• emia = blood
overproduction of white blood cells (WBCs)
that crowd out the production of normal cells,
leading to low RBCs & low platelets.
Main Types Labs

AML CML
AML - Acute myeloid Leukemia

Pediatrics more common
Labs HEMOGLOBIN HEMATOCRIT
CML - Chronic myeloid Leukemia • High WBCs

ALL CLL ALL - Acute Lymphocytic Leukemia • Low H/H
CLL - Chronic Lymphocytic Leukemia • Low Platelets
Signs & Symptoms ATI Question

A nurse is assessing a child who
has leukemia. Which of the
following findings should the
• Frequent infections nurse expect?
• Fatigue, Unsteady Gait, Pale “Pallor”
● Anorexia
• Bruising, Petechiae, & easy Bleeding ● Petechiae on the extremities
● Unsteady gait
• Weight Loss & Anorexia
• Bone pain ATI Question
Private room 7-year-old with acute
lymphoblastic leukemia who is
being admitted for evaluation
of fever. To which of the
following rooms should the
nurse assign the client?
● Private room in order to
prevent transmission of
infection from others
Diagnostics HESI Question Treatment

A nurse preparing a Radiation & Chemotherapy to kill the cancer.
Bone marrow biopsy patient for a bone marrow
biopsy knows which site
Rarely: Stem cell transplant - like hitting the restart button
Taken from the will most likely be used? to reboot the bone marrow.
posterior iliac crest ● Posterior iliac crest
Stem cell transplant
DOXORUBICIN
148
Lymphoma
Pathophysiology
Hodgkin’s
Hodgkins Non-Hodgkin’s
Non-Hodgkins
Lymphoma is cancer within the lymphatic system, the body’s disease fighting
network including:
• Lymph nodes - the drainage tubes that help to empty the waste
• Spleen - houses the white blood cells (WBCs), which help to defend the body
against infection
• Thymus gland & bone marrow
Diagnostics HESI Question Causes 50% of cases

What is the main diagnostic feature
of Hodgkin’s disease?
Hodgkin’s = Reed-Sternberg Reed-Sternberg cells
Non-hodgkin = NOT reed sternberg cells Epstein Barr virus
Epstein Barr virus
Signs & Symptoms

HESI Question
A nurse caring for a patient with Hodgkin’s
lymphoma knows the patient is at an increased
Painless Bumps & risk for which complication?
“Lumps under arm” Infection
Axillary
Enlarged lymph glands Lymph Node
Fever (no chills or feeling bad) Saunders Question

Hodgkin's disease... Which assessment findings noted
Weight loss in the client's record are associated with this diagnosis?
30 kg

Night sweats (changing sheets)
Fever
Infections Weight loss
Night sweats
Enlarged, painless lymph nodes
Treatment
Clients are treated with chemotherapy and/or radiation.
Notes
149
Ovarian & Cervical
Cancer
Ovarian Cancer Signs & Symptoms

Saunders Question
Bloating & pelvic pressure NCLEX TIP
Educational session on cancer of
Increased abdominal girth the cervix ... early sign of this type
of cancer?
Urinary urgency, frequency Irregular vaginal bleeding
Educational class on ovarian cancer ...

Which signs and symptoms should the
nurse include in the presentation?
Having urinary urgency or frequency
Experiencing pelvic or
abdominal swelling
Cervical Cancer Causes

Saunders Question
NCLEX TIP
Risk factors
HPV Human PapillomaVirus Multiple sex partners
Which are risk factors for
cervical cancer?
Spread by skin-to-skin contact Sexual activity before 18 Select all that apply.
Even with condom use Oral Contraceptives “birth control”
Smoking
Vaccinate before sexual activity HIV
Multiple sex partners
Both boys and girls Human papillomavirus
(HPV) infection
18 First intercourse
before 17 years of age
Cervical Cancer Screening
>21 HESI Question

Pap test “pap smear”
Which diagnostic test is useful
Women over 21 years (sex or not) for diagnosing cervical cancer?
3 years
Every 3 years NCLEX TIP Papanicolaou (Pap) test
Notes
150
Prostate & Testicular
Cancer
Prostate Cancer Pathophysiology Testicular Cancer Risk Factors

Cancer of the prostate, affecting only males. Most common cancer in men between ages 15-35.
Tumor grow under the bladder in front of the rectum Undescended testes when young.
area.
Bladder
Rectum area
Signs & Symptoms

15 35
HESI Question
• Anemia pale skin “pallor” Q1
Screening
A male patient comes to the clinic
complaining of general weakness,
• General weakness & fatigue difficulty urinating, fatigue, and pallor
that began 1 week ago… laboratory
results show anemia. Which question
• Difficult & painful urination NCLEX TIP should the nurse ask next?
● When as your last prostate
TSE - Testicular Self-Exam

examination
Q2 Diagnosed with stage 4 prostate cancer.
Each month on the same day

The nurse knows which characteristic
describes this type of cancer?
During a warm shower or bath

● Widespread metastasis
Palpate:
Each testi: Thumb & first 2 fingers Kaplan Normal
Your last prostate Widespread
metastasis
Both hands feel testis separately should feel

examination?
Smooth, soft & round like an egg HESI

Normal: one testi larger than the other
Risk Factors
Over 50
Report to HCP!
Hardened lump “mass” (painless)
• Older Over 50 Dull ache
• African-American men Swelling & Enlarged scrotum = Hydrocele
• Family history
• Diet: HIGH in red meats Hydrocele
KAPLAN
Diagnostics A nurse is teaching a client how to perform
testicular self-examination. Which instructions
Detected by testing blood sample, transrectal should the nurse include?
Ultrasound ● Roll each testicle between the thumb

and fingers
or digital rectal examination - Prostate exam
Digital Rectal examination

Testing blood Transrectal Ultrasound
Saunders
While performing testicular self-examination
... found a lump the size and shape of a pea.
Which statement is the most appropriate
response to the client?
● That’s important to report even though

it might not be serious
Surgery
Prostatectomy or Turp to take out the prostate

HESI
Prostatectomy TURP
Teaching a patient about testicular self-examination.
Which statement by the patient indicates the need
for further teaching?
● The testes should be smooth and hard

to the touch
151
Skin Cancer
Pathophysiology
Mole = Nevi MEMORY TRICK
KEY TERMS
Uncontrolled growth of cells Purple • BeNign = Be Nice
within the skin. • MALignant = MALicious
TYPES Saunders
Tumor = Neoplasm
• Basal cell carcinoma Red Brown Client diagnosed with
melanoma ... Which
• Squamous cell carcinoma statement by a client
indicates that education
Sarcoma NCLEX TIP was effective?
Causes & Risk

• Melanoma • It is highly metastatic
Signs & Symptoms

NCLEX TIP: Key Terms HESI Question
Screening: Skin Lesions • Irregular or Uneven growth
The nurse notes ... widespread
nevi across the body. Which
NCLEX TIPS • Change: Abrupt, Sudden, Rapid characteristic, if demonstrated
by one of the nevi, would
(color, size, shape)
A - Asymmetry: Irregular is BAD
cause the nurse to be
concerned about malignancy?
• Half raise & half flat
● Irregular border
B - Border irregularity: Uneven edges
C - Color Variation and changes:

• Mixture of brown, tan, black, & red
• Black / dark
D - Diameter Over 6 mm
• Lesion is the size of a coin or nickel
E - Evolving - changes in size, shape,

and color
Causes & Risk Factors Diagnostics
Environmental NCLEX TIPS Tissue biopsy is required to make a definitive

Exposure to UV light diagnosis of skin cancer, but again
Tanning beds HESI Question ONLY the ones with irregular uneven changes.
Sun exposure
• “Frequent sunburns” What would the nurse
• “Outdoor occupation” advise a patient to
avoid to minimize the
Genetics NCLEX TIPS risk of skin cancer?
Education
Family History of skin cancer ● Tanning beds
“father or mother with melanoma”
Caucasian (light skin, blonde NCLEX TIPS
hair, freckles)
Apply broad spectrum sunscreen
High number of moles • 15 minutes before
• SPF over 30
Drug Immunosuppressant
medications Reapply sunscreen
• Every 2 hours
• After swimming
Sunburns can happen on overcast
days & avoid sun 10 am - 4 p.m.
Transplant
AVOID tanning beds

drugs
HIV
medications
152
Cancer Prevention
Education
Saunders
Cancer prevention seminar … effective
Diet if the clients select which food items on
High Fiber the menu?
Broccoli, baked fish, mashed potatoes
Veggies (broccoli, beans, cabbage)
Bran
HESI
Fruit & whole grains
Q1: Increase intake of which foods to aid in
cancer prevention?
AVOID Bad Habits Select all that apply.
Beans
Limit alcohol = less than 2 drinks/day HESI Whole grains
All types of cabbage
Tobacco “Smoking cessation” NCLEX TIP
Q2: Which dietary modifications ... for preventing
Smoking: cigarettes / cigars cancer development?
Chewing tobacco Increase broccoli intake
Consume more dietary bran
Obesity = Lose Weight Restrict alcohol consumption to less than 2
drinks per day
<2 drinks per day
40 kg
Screening 8 warning signs of cancer

“Sudden” “Rapid” “Unexplained” NCLEX TIP
HESI
1. Unusual sudden Bleeding
A nurse is providing education ... prevention &
2. Unusual Weight Loss
detection of cancer. Which information is most
3. Change in Urine And Bowel Habits = Colon Cancer appropriate to include?
Yearly fecal occult blood test HESI Select all that apply.
4. A Non-Healing Sore & Thickened Lump “Know the 8 warning signs of cancer”
5. Cough “Eat a balanced diet that includes
vegetables, fruits, whole grains and fiber”
Nagging, Constant, Persistent “Seek immediate medical attention if you
Hoarseness for months notice a change from what's normal for
6. Skin Changes = Skin or breast cancer you”
Skin lesions “Irregular or Uneven growth”
“Orange peel with “small indented areas”
7. Difficulty swallowing and/or Indigestion
8. Fever & fatigue (night sweats) 8 warning signs
Year 3
Year 2
Year 1
153
Palliative Care &
Neutropenic Precautions
Palliative Care & Hospice - Terminal Cancer
Clients who will pass away from untreatable cancer will typically go home
on hospice care for comfort. Palliative care is delivered by a team of medical
professionals & goals of care must be set up.
Decision making
KAPLAN
Family should participate in
Client who has terminal cancer… tells the
decision making nurse “I wish I could stop these treatments,
I am ready to die.” Which of the following
Patient’s ultimate choice statements should the nurse make?
Intense psychosocial support “Discontinuing the treatments is

your choice if you choose to do so”
Therapeutic communication:
factual, open, and honest
H OICE
LT I M ATE C
U
Neutropenic Precautions
Neutropenia is the very low white blood cell (WBC) count - normally 5,000 - 10,000.
This happens when clients with cancer undergo chemotherapy & radiation which
kill the cancer cells, but also kill the bone marrow where WBCs are produced.
Clients have HUGE risk for infection! Bone Marrow
Interventions SAUNDERS HESI

Client receiving chemotherapy... the white blood A patient about to undergo chemotherapy....
2 BIG TEST TIPS cell count is extremely low and places the client Which expectations will the nurse have when
on neutropenic precautions. Which interventions
providing care to this patient?
are components of these types of precautions?
1. NO Fresh Flowers, Select all that apply. Fresh flowers should be discouraged from
or Fresh Fruits Removing fresh-cut flowers from the the room of a patient with neutropenia
clients’ room
2. AVOID crowds Instructing family members on the proper
& sick people! technique for handwashing
KAPLAN
Instructing family members to wear a mask
3. FEVER is a priority to enter the client’s room
Q1: The nurse is planning care for a client with
OVER 100.3 F (38 C)!!! neutropenia due to chemotherapy. Which
intervention should be included?
NCLEX TIP
Monitor the client’s temperature every
4 hours
Neutropenic precautions
Q2: Client who is receiving chemo... Which of
the following findings should the nurse identify
as priority?
Report of sore throat
154
_ _
Renal & urinary
155
Bladder Cancer &
Cystoscopy
Causes:
ED
- Tobacco use
RY CAUS
- Family history PR IMA
- Chemical exposure
Signs & Symptoms MOST TESTED

Painless hematuria
KAPLAN Question:
Most common finding of bladder cancer?

Painless hematuria
Diagnostic:
Cystoscopy
scope inserted through urethra to view bladder
After Procedure Notify HCP

- Blood clots & bright red blood
- Retention: Over 100ml
- Infection: Fever >100.4 F (38 C)
- Abdominal pain unrelieved by analgesics
HESI:
Cystoscopy teaching…
• “You will feel pressure during insertion of the scope.”
?
KAPLAN:
Client with frequency, urgency, and dysuria after cystoscopy

• Highest nursing priority is to obtain vital signs (monitor for fever)
Common NCLEX Question:

100.4oF
The nurse teaches the client to report (38oC)
which findings after a cystoscopy?
Select all that apply:
Inability to urinate
Elevated temperature over 100.4 (38 C)
Blood clots in urine
156
BPH,
TURP & Prostatectomy
MEMORY TRICK
Benign prostatic hyperplasia: prostate enlargement Big Prostate Holds

that compresses the urethra & surrounding bladder
causing difficulty urinating!
Signs & Symptoms: KEY WORDS

- Urinary Retention
• Sensations of Incomplete emptying
• “Feel the need to urinate again immediately after urinating”
- Urinary Frequency & Nocturia
• Need to awake at night with the ‘’urge to urinate”
- Straining to void
• “strain to begin a stream of urine”
- “Stream of urine - weak or intermittent”
Complications (NOT Normal)
- UTI (infection)
- “burning sensation with urination”
- Cloudy or smelly urine
Treatments:
- Bladder training & avoid caffeine

- Finasteride (brand Proscar)
HESI
What med will shrink the prostate = Finasteride
Memory Trick:
Think of a man with a SWOLLEN prostate riding around on a horse

- OUCH - thats a very painful Ride So think - if you want a Fun ride -
get FINasteRIDE lol
157
BPH,
TURP & Prostatectomy II
Surgery:
• TURP - Transurethral resection of the prostate - less invasive as an instrument
inserted directly through the urethra to remove the prostate.
• Prostatectomy - MORE invasive as a surgical incision is made.
After either procedure - 3 way Foley catheter is used for continuous bladder
irrigation. This gives pressure to bleeding tissue & allows urine drainage.
Key Points:
hours 36
hrs
Normal Immediately After - Bloody urine

- 24 hours After - Urine Light Red & Pink
- 36 hours MAX - Small blood clots
HESI
1. Benign prostatic hypertrophy (BPH) that has been refractory to treatment with other medications?
Answer: Anticipate TURP
2. Instructions for a patient who has undergone prostatectomy?

SATA
• Observe for signs of UTI
• Ensure fluid intake of 2-3 L per day

1
Prostatectomy 5 days ago … small blood clots. First action?
- Advise client to follow up with HCP immediately REPORT
Kaplan
1. Expected assessment immediately post TURP?
• Bloody urinary drainage
2. 24 hours after TURP the nurse notices bright red urine... First action?
• Contact health care provider immediately
3. Third day post-op TURP, catheter is removed … uncontrolled dribbling after urination?
• Temporary incontinence is expected following urinary catheter removal
So when a question says a client is reporting SEVERE PAIN with continuous bladder irrigation
after a TURP.
First nursing Action: Assess amount & urine output - light pink color - BEST
Top test tip:

ml
Output = MORE than input

NOT “equal to” or “less than”
158
Glomerulonephritis
vs. Nephrosis
Glomerulonephritis Nephrosis (Nephrotic syndrome)

- inflammation & scarring of the kidney - Inflammation & scarring
- Key difference HIGH massive amounts
Cause:
of protein dumped into urine
Infection - typically Strep infection
Cause:
and usually gone in 14 days
Autoimmune diseases like Lupus where the
body attacks itself
Triggers - 4 Ss initiates an immune response
- S - stress
- S - sickness or sepsis (infection)
Signs & Symptoms - S - smoking
- S - sun (hot temps)
- LESS protein loss
UA: lower Proteinuria Signs & Symptoms
- Recent Strep infection Low Albumin
(Key assessment) MORE protein loss
- Fever UA: HIGH Proteinuria
Albumin
- Blood Labs: WBC HIGH Blood Labs: Low Albumin
“Hypoalbuminemia”
Treatment:
Memory trick
- Treat cause INFECTION - Nephrotic Syndrome
- Educate - finish all antibiotics - Nasty protein loss
- Limit Protein NCLEX TIP
- Meds -Antihypertensives Deadly Complication
- A - Ace & Arbs Lisinopril
Renal Failure & HTN Crisis!

- “-pril” - Lisinopril
- “-sartan” - Losartan Report key signs:
- B - Betas - Headache & Mental Status Changes
LOSARTAN
- C - CCB - Nausea & Vomiting !
!
- D - Diuretics - “-ide” - Oliguria - NO or low urine output !
- New, Sudden, Rapid Weight Gain

- Loops “FurosemIDE”
- Thiazide “HydrochlorothiazIDE”
Treatment:
Both are potassium wasters - < 3.5
- Increase Protein NCLEX TIP

so watch out for hypokalemia Potasssium
K+ - Treat cause & remove trigger

(potassium less than 3.5) - Steroids “-sone” Prednisone
159
Renal
Hemodialysis
• Machine version of the kidney Deadly Complication

• Helps to clean the blood by filtering
waste & flushes out excess fluid and Dialysis disequilibrium syndrome (DDS)
electrolytes
a condition where solutes are removed too
quickly from blood causing brain cells to swell
Memory Trick with fluid resulting in DEADLY increased ICP
- leading to coma & death!
Any time you see the word “DIAL” Key Signs:
think of the soap, it cleans the blood
• Restless & disoriented
• Vomiting
• Headache
Before Dialysis
Priority Action
Assess Fluid Status • Stop or slow infusion
• Weight (current & previous) • Report to Provider NCLEX TIP
• Vital Signs
Assess Fistula (shunt) NCLEX TIP
• Feel a thrill “vibration”
• Hear a bruit
Hold meds:
Pt Education
• Antihypertensives
A Ace & Arbs
Lisinopril, Losartan Care for Fistula (AV shunt)
B Beta Blockers
Atenolol NCLEX TIP
- Squeeze or Grip: “Rubber ball” “sponge”
- Pitting edema = Normal
C Ca Channel Blockers
Nifedipine, Verapamil, Diltiazem
NOT Normal
D Diuretics
Furosemide, Hydrochlorothiazide Report to HCP NCLEX TIP
P - Pale skin “pallor”
D Dilators
Nitroglycerine P - Paresthesia
“Numbness or tingling”
• Washed Out:
P - Pulses diminished
· Antibiotics P - Poor cap refill
· Digoxin P - Pain (distal to shunt)
· Water-soluble vitamins (B, C, and folic acid)
Monitor:
- Infection - warm, red, or drainage
at shunt site
- Bleeding
Penicillins Cephalosporins
- Feel a thrill - feel a vibration - TEACH
Digoxin
clients to check this several times a day
No Nos
- NO restrictive clothing or jewelry (watch)
- NO BP on affected arm
- NO sleeping on arm
FOLIC ACID - NO creams or lotions
- NO lifting over 5 lbs (NO purse)
VITAMIN VITAMIN
FOLIC ACID
B C
160
Kidney Stones
Pathophysiology ATI
- Renal Calculi - hard stone calcified in renal Expected findings after lithotripsy?
- usually made of calcium
Or names with Lith - meaning stone
Answer: stone fragments in urine
- Urolithiasis - stone in urinary system
- Renal Lithiasis - stone in the renal Percutaneous Nephrolithotripsy
- Ureterolithiasis - stone in the ureter -
tubes connecting the kidney & bladder Also called nephrolithotomy, the HCP
sticks a needle & scope into the kidney
Signs & Symptoms: to suck out stones.
!
!
- Extreme PAIN
!
After the procedure - temporary nephrostomy
- Like knife in the back tube & bag to allow any loose stones fragments
- Equivalent to childbirth to pass & in the bottom you expect to see
sediment. The bad news is that this drainage
tube can get clogged with stones!!
Kaplan
Key Point:
Priority intervention … urinary calculi
with right flank pain. PRIORITY - Maintain tube patency
1. Irrigation of the nephrostomy tube with
Relieving pain sterile normal saline
Urine Analysis: ATI
- Urine analysis: Teach patient to …

report back pain to provider for client with
- Hematuria NCLEX TIP new nephrostomy tube
- Strain all the urine
Procedures: Shockwave Lithotripsy

Treatment:
1. Administer analgesics ANALGESICS
Shock waves to break up LARGE 2. Fluid intake - 3 L/day

stones into smaller stones that 3. Strain all urine for stones
4. Ambulation “Walk & Move”
can be easily passed 5. NOT bed rest
6. NEVER massage
Educate after procedure Diet:
- Restrict Protein: “animal meats”
Teach client to Increase fluid intake - Limit Purines: red meats, organ meats, beer
NORMAL findings:
- Bruising & pain HESI
- Blood in urine up to 24 Hours
NOT Normal Urolithiasis teaching
- Fever or chills - Restriction of animal protein
161
Renal
Peritoneal Dialysis
- The peritoneal cavity is filled up with hypertonic solution to PULL solutes out
Before:
Peritoneal
1.Take Weight
2. Warm solution
Kaplan
Proper preparation for peritoneal dialysis
First action: Warm the dialysate
Infection Risk:
Sterile technique PRIORITY
Peritonitis: Key Signs to REPORT to HCP

- Fever
- Tachycardia
- Cloudy drainage
1
HCP
Memory trick -
- no one likes cloudy dayyyys
- & nobody likes cloudy drainnnnage
Respiratory distress - due to rapid infusion or overfilling the abdomen:
Key Signs
- Crackles in lung bases
- Rapid respirations
- Dyspnea
Priority Intervention:
- First action: Raise HOB
- Remember breathing over circulation
Kaplan Scenario
Patient on peritoneal dialysis … begins to suddenly breathe more rapidly.
• First action: raise HOB
Insufficient outflow
1. Assess Patient = abdomen: distention & Constipation

2. Assess Device = catheter kinks & obstructions
3. Intervention: Repositioning to side-lying position
162
163
Renal
Anatomy & Physiology
Anatomy
Inside the nephron (the functional unit of the kidney) is the 90ml
min
Glomeruli, a network of small blood vessels that help to filter

the blood from waste.
GFR - Glomerular Filtration Rate

Over 90 ml/min is normal
Physiology
Blood Blood
without with
waste waste
Kidney
The kidneys function like 2 washing machines

helping to wash the blood from waste through Filtration,
regulating fluid volume by Reabsorption, and also
stimulate red blood cell production by producing Erythropoietin. Pyramid
Urine
Memory Trick
“FRE the PEE”

F R E
• F - Filtration of medications & waste Filtration Reabsorption Erythropoietin
• H - hydrogen ions (too much = High Acidity) ADH - Anti-Diuretic Hormone

Filtrate
• U - Urea (BUN - Blood Urea Nitrogen)

• C - Creatinine (Over 1.3 = Bad Kidney)
• R - Reabsorption ADH - Anti-Diuretic Hormone
ADH
Water
Urine
ADH - Add Da H20 Memory trick

• E - Erythropoietin (stimulates RBC production in bone)
HESI
Three phases of urine formation?

Answer: Filtration, reabsorption, and secretion
?
HALF-LIFE ?
?
The time it takes for half of the medication to be eliminated
from the body.
164
Renal Failure
Acute vs. Chronic
Acute kidney failure -- sudden short -term loss of 13

6
S
14
M
15
1
8
T
16
W
9 10
17
T
11
18
F
12
19
S
Chronic Kidney Disease

kidney function. If not stopped & reversed - can
20 21 22 23 24 25 26
27 28 29 30
lead to Chronic Renal failure (CRD).

vs Stage 1 Stage 2 Stage 3 Stage 4 Stage 5
Chronic kidney failure --long-term chronic Year 3
damage to kidneys - years & years of destruction

Year 2
Year 1
89- 59- 29-

resulting in permanent damage 90%+
90% 30% 15%
Kidney Kidney Moderate

Severe Kidney failure
Kaplan
damgage damgage to severe
loss of need treatment
normal mild loss loss of
function to live
function of function function
Acute Kidney Injury … correct understanding?

• Sudden loss of kidney function due to loss of
the renal system circulation or glomerular/ tubular 5 stages of CKD
damage
GFR - Glomerular Filtration Rate
Over 90 mL/min - normal HESI
Pathophysiology & Causes Stage 1: 90 + GFR
Polycystic kidney disease
Stage 2: 89 - 60 GFR • At risk for end stage
Acute Renal Failure: Stage 3: 59 - 60 GFR renal disease
1. Prerenal -- think decreased tissue “PRE-fusion” Stage 4: 29 - 15 GFR
• Obstruction - blocks blood flow & oxygen Stage 5: 15 or Less GFR
(emboli, clots, tumors) = End Stage Renal Disease
• Low Blood Pressure - low perfusion
(shock, hypovolemia, dehydration
- from blood or volume loss); low MAP <65 Causes of Chronic Renal failure
• Low Cardiac Output - Older age
- MOST commonly tested
2. INtrarenal - Uncontrolled Diabetes - uncontrolled HIGH sugar
INside the renal >1.3 - Uncontrolled HTN - uncontrolled HIGH blood pressure
• CT Contrast - Unchecked autoimmune disease - body attacks the kidney
CREATININE
Contrast kills the kidney!

• Antibiotics
Vancomycin
Gentamicin 220
• Creatinine over 1.3 = Bad kidney
2. Post Renal -- think Past the Renal

- Kidney stones, tumor, BPH
Key Numbers:
- Creatinine Over 1.3 = bad kidney Diagnostics
- BUN Over 20
- Urine output 30 ml/hr Less = Kidneys in distress • Creatinine - Over 1.3 = Bad Kidney
- Metabolic ACIDosis pH below 7.35 • Creatinine clearance test
• 24 hours - collect all urine in a container
• Discard the FIRST urine specimen
Kaplan
pH < 7.35
Best indicator of good renal functions

• 1500 mL urine in 24 hours
4 Phases Hesi Question

Acute Renal Failure Correct understanding of creatinine clearance test?
Save all urine samples in a container for a designated
1. Onset of injury (initiation) period after discarding the first urine
2. Oliguric phase - less than 400ml in 24 hours
LOW output = thick sticky urine
3. Diuresis phase - “Polyuric phase” - Diuresis = URINE TEST 4 URINE TEST 5 URINE TEST 6
drain urine 3-6 L per day!

URINE TEST 2 URINE TEST 3
4. Recovery phase - SLOW up to 1 year for recovery

165
Renal Failure
Acute vs. Chronic II
Chronic Renal Failure Memory Trick

- 3 Ps
Signs & Symptoms ! P - Potassium is
! P - Priority - since it
! P - Pumps the HEART muscles
Oliguria - LOW urine output
High potassium Over 5.0
Excess waste & electrolytes in the blood - HIGH PUMPS in the heart resulting in
Broken Washing machine! Peaked T waves & ST Elevation
H+ ions (Acid) Kaplan Question:

Metabolic ACIDosis pH
below 7.35 Client with kidney disease is weak/ lethargic
Urea and bradycardic
Uremic frost
Pruritus • K+ 8.5 mEq/L lab value is suspected
HIGH Electrolytes
Sodium Na+ HIGH (norm: 135 - 145)
Sodium
Priority Treatment
Na+
Phosphorus HIGH (norm: 3.0 - 4.5)

Phosphorus
P
1. IV Calcium Gluconate for Dysrhythmias
Potassium K+ HIGH (norm: 3.5 - 5.0)
Potasssium
K+
Memory trick: Gluconate GLUEs
down heart muscles
• Peaked T waves - 6 - 7 mEq/L 2. IV 50% Dextrose + Regular INsulin
• ST elevation - 7 - 8 mEq/L 3. Kayexalate (polystyrene sulfonate)
• Wide QRS complex - OVER 8 mEq/L 4. Dialysis
Kaplan Question: Top 2 Missed NCLEX Questions
Patient with chronic kidney disease? Patient with chronic kidney disease missed 3 dialysis
• Oliguria is expected sessions… potassium level of 8.1 …
wide QRS complexes, heart rate of 58 & lethargy.
Which order should the nurse implement first?
1. IV 50% Dextrose & regular insulin
Hypertensive Crisis 2. Sodium polystyrene sulfonate
Priority Key Signs! NCLEX TIPs!!! 3. Hemodialysis
1. Headache
2. Nausea & Vomiting 4. IV calcium gluconate
3. Change in mental status
End stage renal disease… potassium 7.2, BUN 35,

Signs of Fluid Volume Overload (FVO) creatinine of 3.8, and urine output of 300 ml in 24
hours. Which order is PRIORITY?
• Crackles in the lungs - wet fluid filled lungs
• JVD - jugular vein distention
• Bounding pulses from that fluid excess! 1. IV Regular insulinR & 50% Dextrose
2. IV loop diuretic
Anemia - Low RBCs, since kidneys release 3. Dialysis
Erythropoietin, the hormone that stimulates 4. Put in for vacation time?
bone marrow to produce red blood cells
166
Renal Failure
Acute vs. Chronic III
Milk of
• Daily Weights NSAIDs Magnesia
1 kg = 1 liter of fluid retained

AVO
• Avoid: the top drugs that can cause kidney failure
NSAIDS ID
Milk of Magnesia (Anti Acid)
Antibiotics: Vancomycin + Gentamicin Vancomycin Gentamicin
CT Contrast dye! Thick cement in washers!
Procedures
Hemodialysis: the machine version of the kidney, used to wash the blood.
It is only used for a number of years until a kidney transplant is available.
Diet
• NO Sodium
No canned / packaged foods -
No processed meats -
• NO Potassium CE
CHOI
Apples = BEST choice! NCLEX TIP BEST
NO Salt Substitutes NCLEX TIP
NO Leafy veggies (spinach)
Potasssium
K+
NO Avocados, Carrots, Tomatoes
NO Strawberries, Oranges or Bananas
• Low - Phosphorus
NO Dairy: Yogurt, Pudding, Milk NCLEX TIP
• Low - Protein
HESI Questions KAPLAN Questions

Q: Best food choice for potassium of 6.5?
Rationale for low protein diet?
A: Apple slices or apple juice... low K+ levels
Q: Which statement … need for further

Answer: preserve renal function
education?
Teaching about nutrition has been
A: "I should reduce my sodium intake by
using a salt substitute."
effective when the client states:
Answer: “I will eat red bell peppers
and avoid red meats”
AVOID
167
Renal
Kidney Transplant vs. Biopsy
Kidney Transplant
- Before - immunosuppressants to help prevent organ rejection

- After - Urine output - 30 ml/hr or LESS = kidneys in distress
- s/s infection - low-grade fever is #1 <30 ml/hr
- s/s organ rejection - HTN, pain at sight
ATI Question
Teaching for client with
end-stage kidney disease
awaiting kidney transplant
Hemodialysis sometimes
needed after surgery
Renal Biopsy
- A tissue sample is taken from the kidney to determine specific diseases
Before
WARFARIN
- Discontinue blood thinners at least 7 days before HEPARIN
- anticoagulants - heparin, warfarin

- antiplatelet agents - aspirin & clopidogrel (plavix) NSAIDS
- NSAIDS - ibuprofen, Naproxen IBUPROFEN

NAPROXEN
- Supplements:
- E - Vitamin E
- G - Gingko, Ginseng, Garlic
- O - Omega 3
- S - St john’s Wort
After
- Priority: Assess vital signs every 15 minutes for 1st hour
- Positioned on their back on affected side
168
Lab Values
Memory Trick
The kidneys filter out HUC, since the
kidneys sort of look like a pirate hook.
Hydrogen Ions = High Acid
H+ Are very acidic & too much can push the body into Acidosis.
Renal failure & infection causes a back up of H+ Ions
H+
H+
pH BELOW 7.35 H+
Urea BUN (Blood Urea Nitrogen)
U 10 - 20 Max
Byproduct of protein waste. Think of a protein bar
wrapper, it is trash that the body tosses out.
This trash comes in the form of ammonia, which
the liver converts into UREA, then it’s pushed into
blood & excreted by the kidneys. Hence the name
blood UREA nitrogen.
Creatinine > 1.3
Creatinine = Critical Kidney Lab!
C Key Numbers:
Over 1.3 = Bad Kidney BUN/Creatinine
Urine Output 30 ml/hr or Less = Kidney distress
Higher creatinine levels in the blood = Higher renal impairment.

Creatinine is a waste product produced by the muscles coming
from the normal everyday wear & tear.
List of clients MOST at risk for Client with an infected toe due to
Metabolic Acidosis? Select all that diabetes is scheduled for cardiac
apply. catheterization with contrast, which
1. Renal failure lab value should the nurse report to
2. Pyelonephritis
1. Blood Urea Nitrogen level of 19
3. Patient waiting for hemodialysis
2. Blood glucose of 155
4. Hyperventilation related to anxiety
attack 3. Creatinine level of 1.9
5.Child with diarrhea x 2 days 4. White blood cell count of 14,500
169
UA - Urine Analysis
Color
Light = Hydrated
Darker = Dehydrated
* (Unless on diuretics or in SIADH or DI)
Specific Gravity 1.003 - 1.030

Low Gravity 1.003 = Liquidy body
High Gravity 1.030 = Dry body
RBC “blood” (hematuria)

Cause: Kidney stones, bladder cancer, post-operative TURP.
WBC ‘’Leukocytes’’
Cause: infection (UTI)
Nitrites - Kidney infection “pyelonephritis”

Memory trick: Look for the “N”
kidNey
pyeloNephritis
- N - Nitrites
- N - pyeloNephritis
Urine Culture & Sensitivity

Culture: which bacteria is causing the infection Diabetes
Sensitivity: which antibiotic is the bacteria sensitive to, in order to kill it

Over 10,000 organisms/ml indicates a UTI. MO DERAT E
Protein HIGH = Nephrotic Syndrome - Nasty protein loss

UCOS
W
GL EVE
LO
L
E
L
Glucose HIGH = Diabetes
Exhibit
Spec. Gravity: 1.030

Client with history of diabetes… which does
Protein: None
the nurse suspect?
Glucose: High
Red blood cells: None Dehydration (low fluid intake) & possible UTI.
Leukocytes: Medium
Close
KAPLAN Question
1 2
Procedure for collecting a sterile
urine specimen from a foley bag?
Answer:
1. Clamp drainage tube below port
2. Wait 15-30 minutes
3. Scrub the port using an antiseptic swab
3 4
4. Attach a sterile, needleless access
device to aspirate a specimen via the
port.
170
12-11 Uremic syndrome
Assessment
❖ GI/GU: Oliguria, Hematuria, Labs & Diagnostics
magnesium, potassium, uric acid
❖ Urinalysis: Mild proteinuria may be
What am i?
in the urine. Stomatitis, nausea,
vomiting, diarrhea, constipation. present; red blood cells (RBCs) and
❖ CARDIO: Hypotension or RBC casts may be present.
An accumulation of
nitrogenous waste hypertension, dysrhythmias ❖ (BUN), serum creatinine, and
products in the blood CNS: Altered level of serum electrolyte levels: Elevated.
caused by the kidneys consciousness. ❖ Hematologic determination:
inability to filter out waste ❖ HEME: Anemia with hemoglobin Severe anemia may be present.
products. less than 8 mg/dL. ❖ Hemolytic workup: Results may
show anemia. Bilirubin levels may be
W: Waves of nausea and vomiting.
A: Altered Level of conscious, anemia elevated. Lactate dehydrogenase
S: Some blood in the urine (LDH) levels may be elevated.
T: Terrible BP Haptoglobin levels may be
E: Extra waste in the urine and blood decreased.
D: Dysrhythmias ❖ Stool culture: Evaluate especially
Patho for E coli and Shigella bacteria.
Kidneys become
damaged from disease
process or injury causing
inability to filter out
nitrogenous waste
products. This causes a
buildup of waste in the
blood stream, electrolyte
imbalances, altered
mental status and scanty
output.
Treatments
❖ Hemodialysis, Peritoneal
dialysis, Hemofiltration, and
Renal replacement therapy.
Interventions
Causes ❖ Calcitriol, calcium reducers, ❖ Monitor VS for tachycardia,
erythropoietin. hyper/hypotension and
❖ Kidney transplant. dysrhythmias.
❖ Monitor serum electrolyte
❖ CKD
levels.
❖ AKI
❖ Monitor intake & Output
❖ Diabetes
❖ Provide a high protein diet.
❖ Kidney trauma
❖ Provide a limited sodium,
nitrogen, phosphate and
potassium diet.
Education
❖ Educate the patient on dialysis
procedures.
❖ Educate the patient on
prescribed treatment regimen.
❖ Educate the patient on proper
diet to reduce the risk of
recurrence.
Www. SimpleNursing.com
171
Urinary
Incontinence I
Urinary IN-continence: Client can’t hold urine IN
U URGE
INCONTINENCE
- Sudden URGE to urinate

- Typically known as Neurogenic bladder (loss of bladder control)
S S TRESS
INCONTINENCE
- Pressure STRESS causes urine to spill out
- Coughing, laughing, sneezing, running, jumping
O
MEMORY TRICK
OVERFLOW Big Prostate Holds

INCONTINENCE
- OVERflow leads to dribbling urine
- Incomplete emptying
Causes:
• Urethra prolapse
• Prostate enlargement (BPH)
• Weak bladder muscles - diabetic neuropathy & spinal cord injury
HESI Question:
Q1: Male reporting urine incontinence
• Ensure prostate exam performed
Q2: Stress incontinence cause?

• Expected result of aging
Q3: The leakage of urine occurs in small amounts and is more frequent when the patient coughs.
Which information does the nurse provide to the patient about the disorder?
• “This is called stress incontinence”
• “This is caused by weakness of muscles around the urethra”
• “This occurs when intraabdominal pressure exceeds urethral resistance”
Q4: Elderly female patient experiencing urinary incontinence. Which physiological change does the
nurse expect to see in this patient?
• Decreased muscle tone
172
Urinary
Incontinence II
Management: Common NCLEX Questions:

Incontinence Teaching & Meds:
Priority teaching for a patient newly
• Train Bladder: Void regularly every 2 hours
diagnosed with stress incontinence?
• Weight Loss
• Kegel Exercises 4 x daily
• AVOID: Caffeine, Alcohol, Smoking
1. Voiding every 2 hours
• Anticholinergic Meds:
• Oxybutynin - to decrease sudden bladder spasms 2. Kegal exercises 4 x per day
...B in Butynin & Bladder 3. Avoid alcohol & caffeine
Dry mouth - side effect 4. Take oxybutynin
Kaplan Question The client understands self-care of urge

incontinence with which statements?
1. First nursing action ... for urinary habit training?
Establish the client’s voiding pattern
1. “I am going to void only in the morning & evening to
2. 78 yo client, 200 lbs, with 4 live births
ensure bladder training”
experiencing stress incontinence … most
appropriate statement by nurse? 2. “It is ok to have moderate amounts of wine at night”
3. “I understand that taking oxybutynin may result in dry
“Let’s talk about ways to reduce your weight” mouth”
4. “I understand that having excess weight is ok.”
5. “I will limit my intake of coffee to only 3 cups per day”
6. “I will do Kegel exercises every day”
ATI Question
S M T W T F S
1 2 3 4 5
6 7 8 9 10 11 12
13 14 15 16 17 18 19
20 21 22 23 24 25 26
27 28 29 30
1. Teaching for a client with BMI 32 newly

diagnosed with stress incontinence?
Teach to lose excess weight
Nursing interventions ... overflow urinary
incontinence? Select All That Apply
HESI Question
1. Teach to bear down when voiding
Q1: Patient with stress incontinence after birth 2. Teach to wait 30 seconds after voiding to try & void again
of second child:
3. Monitor for skin breakdown
Teach to perform Kegel exercises 4x daily 4. Record output
5. Ask for overtime pay
Q2: Considering the care plan information below,
which condition is the patient most likely
experiencing?
Care Plan info: 00:30
"Remind patients to perform Kegel exercises
four times per shift"
"Assist to the toilet every 2 hours."
Answer: Urinary incontinence
173
Urinary
Retention
Urinary REtention: Clients REtain urine in the their bladder so that it can’t get out MEMORY TRICK
Causes: Big Prostate Holds
- After surgery - Post op

- After Foley Catheter is D/C
- Men: Benign prostatic hyperplasia (BPH)
HESI Question:
Patient at most risk for urine retention?
Answer: 65 yo man with benign prostatic hyperplasia (BPH)
Medications that cause retention OPIOIDS
- Opioids (makes body low & slow)

- Morphine & Hydromorphone - look for O’s
- Anticholinergics (can’t see, pee, spit, or shh poop) IPRATROPIUM
- IpraTropium (respiratory drug - you can’t Pee with a TroPium)

- Atropine - (increases HR - its hard to Pee with a TroPINE)
- Tricyclic Antidepressants
Ipratropium
Nursing care:
ATROPINE
1. Assessment 1st!
- Palpate the bladder
2. Intervention:
Normal Position - “Help client out of bed”
1. Bladder Scanner
• Over 100 mL = Report to HCP NCLEX TIP
2. In & out catheter
- Hypotension (low BP)
- Bradycardia (slow HR)
Common NCLEX Questions:
Q1: Patient taking hydromorphone with Q3: Urgent catheterization for acute
urinary retention suspected. First action? urinary retention… nurse places priority on
which sign & symptom?
1. Palpate the client’s suprapubic area
1. Bradycardia
2. Check chart input & output for fluid intake
2. Hypotension
3. Offer a bedpan
3. Tachycardia
4. Clock out for lunch NORMAL
4. Risk for infection

HIGH
LOW
5. Painful urination
Q2: Intervention for a patient who has

not urinated …. 10 hours post-operation?
Side note on Foley Catheters

Help the patient out of bed to a normal Always BELOW the bladder
standing position. NEVER hang on back of wheelchair
174
12-9 urosepsis/Urethritis/Urethritis
Assessment Labs & Diagnostics
What am i?
Urosepsis: Fever is the most ❖ Urosepsis: UA/UC prior to abx
common and earliest ❖ Urethritis: UA/UC, STI/STD
Urosepsis: a gram-negative manifestation. testing
bacteremia originating in the Urethritis: ❖ Ureteritis: dependent upon
urinary tract. ❖ Dysuria causative organism
❖ Urinary frequency, urgency (bacterial/viral infections,
Urethritis: inflammation of ❖ Nocturia pyelonephritis).
the urethra, often d/t ❖ Males: clear to mucopurulent
STI/STD, and may be penile discharge
concurrent with cystitis. ❖ Female: lower abd pain
Ureteritis:
Ureteritis: inflammation of ❖ Dysuria
the ureter often associated
with bacterial or viral
❖ Urinary frequency
❖ Clear to mucopurulent penile Education
infections and pyelonephritis discharge
Urosepsis: Finish antibiotics
course of treatment, increase fluid
intake.
Patho
Urethritis: Similar to interventions-
instruct pt to complete abx course,
Urosepsis: most commonly safe sex practices.
caused by E-coli, and in the Ureteritis: Encourage pt to finish
immunocompromised patient, abx treatment, safe sex practices.
from an indwelling urinary
catheter or untreated UTI. The
greatest problem is the
bacteria developing abx
Treatment
resistance.
Urethritis: inflammation of the
Interventions
urethra occurs d/t gonorrhea Urosepsis: IV, then oral abx
or chlamydia in men; in once discharged
women, inflammation occurs
d/t feminine hygiene sprays, Urethritis: Antibiotics, urethral
perfumed feminine products, dilation Urosepsis: Obtain UA/UC before abx tx
UTI, spermicidal jelly, UTI, or is started, administer IV abx as
changes in vaginal mucosal Ureteritis: prescribed and provide teaching
lining. regarding importance of oral abx once pt
❖ Metronidazole (Flagyl) or is home.
Ureteritis: pathophys will be clotrimazole (Mycelex) for
dependent upon causative Trichomonas infection. Urethritis:
disease process ❖ Nystatin and Diflucan for
yeast infections. ❖ Encourage fluid intake
❖ Doxycycline or Zithromax for ❖ Prepare for STI testing.
❖
Causes
chlamydial infections. Instruct pt in how to take a sitz/tub
bath
Urosepsis: Infection from ❖ Instruct females to avoid perfumed
indwelling urinary catheter or feminine products.
untreated UTI ❖ Instruct pt to avoid intercourse until
UTI tx is complete.
❖ If STI is the cause, instruct pt on
Urethritis: Inflammation future prevention (condom use,
results from STI/STD in men or potential for sterility with repeated
in women: UTI, scented infections).
feminine products, changes in Ureteritis: identifying and treating the
vaginal mucosal lining underlying cause, providing symptomatic
relief.
Ureteritis: bacterial or viral
infection, pyelonephritis Www. SimpleNursing.com
175
UTI & Pyelonephritis
Patho
- UTI: urinary tract infection - urethra, bladder Bladder
- Cystitis: Bladder infection
- Pyelonephritis: aka kidney infection - more serious infection Uretha
If that infection gets bad enough it can migrate & sort of climb up the
Ureters to infect the kidneys. UTI
UTI Signs & Symptoms
- Fever
- Dysuria “Burning during urination” NCLEX TIPS
- Urinary Frequency
Diagnostics
- UA:
- Cloudy & smelly
- WBC Assess 1st Interventions 2nd
- Nitrites - Kidney infection
- Urine Culture & Sensitivity
- Over 10,000 organisms/ml
- Cultures FIRST then antibiotics
HESI:
Q1: Cloudy urine specimen is an indication of:
- Bacteria in urine
Q2: Pt reporting dysuria and frequency …

which test does the nurse anticipate to be ordered?
- Urine culture
Kaplan Scenario:
Client with s/s of UTI collected a mid-stream urine specimen 2 hours
prior and left it sitting in the bathroom …. what is the nurse’s priority action?
• Discard the specimen and obtain a new specimen
Pyelonephritis Signs & Symptoms (kidney infection)

Like UTI but worse! Key difference - pain location: Costovertebral tenderness
Dull Flank pain
Extending toward Umbilicus
HESI:
Patient with temperature of 102.5°F (39°C) …. grabbing on to her left side and complaining of dull
pain. The urine specimen appears concentrated with a cloudy appearance.
Findings are associated with?
- Answer: Pyelonephritis
176
UTI & Pyelonephritis II
First action: Memory Trick:

?
?
?
?
Obtain blood and urine cultures and L - DeLirium
then begin ANTI-biotics L - Limited, short term confusion
#1 - fix the cause & fix the patient L - LLLLimited
Pharmacology
Causes:
Treatment
- Urinary retention Antibiotics: Sulfonamides & Levofloxacin
- BPH & Give analgesics for the pain
- Holding urine too long - nurse bladder
- Kidney stones - renal calculi -
can hold back urine
NSAIDs ACETAMINOPHEN
(TYLENOL)
- Foley catheters
- E Coli - MOST COMMON - bacteria in colon
gets into urethra Education
- Wiping back to front - scrapes ecoli into
urethra - Increase Fluid Intake
HESI 2000 mL water daily
- Void after sex ATI HESI
Hesi Question - Take cranberry supplements ATI
- Avoid: Caffeine & Alcohol
Physiologic changes in elderly male admitted
with UTI. SATA The big no no’s:
- NO Douching
• Prostate enlargement may lead to urinary
retention - NO Spermicidal contraceptive
• Urinary retention increases the risk of UTI
• Ineffective bladder contraction leads to - NO Perineal deodorants
urinary retention - NO Synthetic fabrics “Nylon” “Spandex”
- NO Bubble Baths
Complication: - Wipe FRONT to back
Confusion, UTI - quickly turns into urosepsis -

infection in the blood that infects the brain.
HESI:
Q1: Instructions to maximize UTI recovery?
Drink cranberry juice daily to acidify urine
Kaplan
Q2: Urinary frequency caused by cystitis …
most helpful advice? SATA
72 y/o patient suddenly becomes disoriented
• Recommend cranberry juice
to person, place, and time ..
• Assess for signs & symptoms of UTI • Encourage increased fluid intake
• Discourage coffee, tea, cola, and alcohol
177
_ _
Reproductive
178
Menstrual Cycle
Med Surg: Reproductive
Anatomy & Physiology Ovaries
A 28 day cycle of changes that happens every month with female

reproductive organs, specifically the endometrium & the ovaries.
Endometrium
The 1st period is known as menarche & continues every month until
menopause (50 - 55 years old).
Endometrium: Functional layer

The layer of tissues lining the uterus (which houses the fetus during pregnancy). Basal layer
This uterus lining consists of 2 layers:
• Functional layer which is shed during monthly menstrual cycles
• Basal layer which aids in feeding the top functional layer.
Ovarian cycle Uterine cycle

During ovulation hormonal changes Think the “catching phase”.
trigger the ovaries to release an egg. The endometrium beefs up really thick
Kind of like tossing the ball over to the to house a fertilized egg, but if the egg is
uterus. not fertilized within 14 days, then it will
Memory
MEMORY Trick
TRICK shed each month causing menstrual
O - Ovulation bleeding.
O - Ovaries release an
O - Oval shaped egg
O - Over to the uterus
Hormones
Hormones During Ovulation Ovarian Cycle

• Follicular Phase:
2 main phases BeFore an egg is released (before ovulation). A number of hormones pop
1. Follicular phase off like a party popper. The hypothalamus releases
2. Luteal phase GnRH (Gonadotropin releasing hormone), which dominos into the release of
Ovarian Cycle FSH (Follicule Stimulating Hormone) & LH (Hormone) from the anterior
pituitary. Which stimulates the follicles within the ovaries causing ovulation!
Follicular phase (Preovulatory Phase)
• Luteal Phase:
GnRH (Gonadotropin releasing hormone)
Ovulation begins & the egg floats away from the ovaries toward the uterus.
FSH (Follicle Stimulating Hormone)
The empty follicule within the ovary (corpus luteum) releases both estrogen
LH (Hormone) & progesterone (steroid sex hormones) to help to thicken the endometrium
Ovulation = Luteal Phase begins & to turn off excess FSH & LH hormones in order to help a fertilized egg
implant & develop into a baby.
Hypothalamus
But if the egg is NOT fertilized within 14 days, then the egg dies & the thick
GnRH endometrium dissolves, causing menstrual bleeding.
GnRH FSH, LH
Anterior Estrogen
pituitary Estrogen Progesterone
FSH, LH
179
STD/STI
Syphilis & Chlamydia
STD - Sexually Transmitted Diseases

STI - Sexually Transmitted Infections
Syphilis
Bacterial infection commonly spread by sexual contact & during

pregnancy can cross the placenta which can harm or kill the baby.
Symptoms
Screening During Pregnancy
STAGE 1 STAGE 2 STAGE 3
• First prenatal visit

• 3rd trimester
• Delivery (if high risk)
Treatment
Painless sores on After the initial sores DEADLY
the genitals,
heal, a rash presents,
damage to the brain, • Penicillin (only prenatal
then the infection hides
rectum, or mouth. with no signs/symptoms. nerves, eyes, or heart. treatment)
Education
NCLEX TIP EDUCATE
About the potential death or harm to the fetus
if Penicillin is NOT taken
Assess: which type
of allergic reaction
Penicillins
Intervention:
penicillin desensitization
Chlamydia
Chlamydia is the most common STD NCLEX TIPS
affecting people of all ages, but it most
common in young women & those with Antibiotics: Azithromycin & doxycycline
multiple sex partners. LACK OF SYMPTOMS • “NO sex for 7 days after starting”
• Sex partner should get treatment too
• Still spread the infection = Asymptomatic
Signs and Symptoms
Infertility & PID: Untreated chlamydia
Most clients are & gonorrhea infections
asymptomatic or may Screening:
have minor symptoms • Yearly (annually)
• Sex partner checked too
180
STD/STI
Gonorrhea, Herpes, & HPV
Gonorrhea Education
Sex partner should be evaluated

Highly tested & treated! NCLEX TIP
Key point: Avoid sex until treatment
Infertility & PID: Untreated completed (all sex)
chlamydia & gonorrhea infections
Annual screening
HESI Question
Which statement indicates a
need for further education
about gonorrhea?
● “If my partner has gonorrhea
I should avoid vaginal sex
but oral sex is safe”
Herpes Simplex Virus (HSV) HPV (Human Papillomavirus)

HESI Question
Herpes type I: Cold sore The most common STD, associated with
Type I herpes simplex virus...
Which instruction about the cervical cancer (highly tested) & genital warts.
Typically clear up by itself within 10 treatment does the nurse
to 14 days. expect the health care
!
provider to give?
● The infection will clear up

by itself in 10 to 14 days
!
!
Herpes type 2: Genital Herpes HESI Question
Non-curable STI which presents around Which statement regarding type Symptoms
2 herpes simplex, … indicates a
14 days after exposure. need for further education?
● "With medication, I will
Asymptomatic - no symptoms. Clients do not
be able to cure my herpes even know they have it.
virus infection."
!
How many days after exposure
! to genital herpes would an

outbreak generally occur?
Education
! ● 14 days
Signs & Symptoms

Prevention
1. Vaccination: Age 9 - 26
Genital Lesions “Active lesions”
painful, burning, stinging 2. Annual Pap test
ACTIVE LESIONS
Priority to report to HCP during (actively contagious) (papanicolaou test)
pregnancy NCLEX TIP
• Do NOT touch lesions 3. Spread:
& wash hands regularly
• Skin to skin contact
Acyclovir (Antiviral drug) • AVOID SEX when lesions
are present NCLEX TIP (Oral sex & others)
Active Lesions & Birth NCLEX TIP
• NO vaginal delivery - Condoms will NOT WORK! • Condoms do NOT
• C-section “cesarean birth” • AVOID scented soaps protect 100% NCLEX TIP
• Lesions: clean & dry • Transmits even when
asymptomatic (no
symptoms)
181
Menstrual Cycle II
Side Note - Pregnancy
Now if the egg is fertilized with sperm, then the mentrual cycles will
STOP, as the egg attaches to the wall of the uterus.
This embryo releases HCG (human chorionic gonadotropin) hormone,

which is the hormone tested during a pregnancy test. A positive test
means positive for HCG hormone.
This HCG helps to keep estrogen & progesterone levels HIGH by

keeping the corpus luteum open inside the ovaries.
HCG
(human chorionic gonadotropin)
Contraceptives
PROGESTERONE Birth Control:

ESTROGEN Oral contraceptives or the ring, works by
keeping estrogen & progesterone HIGH
in order to control ovulation & prevent
fertilization.
Plan B pill (morning after pill):
This emergency contraception works by
shedding the uterine lining (the endometrium)
Plan B
so that a fertilized egg can not attach & become
a fetus.
After Pill
182
Vasectomy & Prostatitis
Sterilization Vas deferens

Vasectomy
Birth control for men & is a form of sterilization. During the surgical
procedure, the vas deferens is cut, so sperm can no longer be
ejaculated, rather the sperm will now be absorbed by the body.
NCLEX TIP
Key points Cleared by HCP
Sexual intercourse:
Use alternative birth control
until cleared by HCP = Sperm Free
Don’t let the NCLEX trick you! Don’t let

NCLEX TRICK YOU
NOT 3 months, NOT 10 ejaculations.
We must be sperm-free here, only cleared by HCP,
so take alternative birth control until then.
Prostatitis
Bacterial infection causing acute inflammation to the

prostate gland.
Signs & Symptoms

• Fever & Fatigue
• Pain in the lower pelvis
• Burning during urination
• Urgency, hesitancy, & straining during urination
Education Increase fluid intake (water & juice)

Sodium
NO Caffeine Docusate
(iced tea, soda, coffee)

SEX = GOOD! NCLEX TIP
Stool softeners: Docusate
Prevent constipation
AVOID straining NCLEX TIP
Pharmacology
Terazosin & Tamsulosin

Antibiotics: T HESI Question
DO NO
ciprofloxacin & Levofloxacin STO P Acute prostatitis… Which
medication would the nurse Ciprofloxacin
NCLEX TIP anticipate the health provider to
Levofloxacin
Ciprofloxacin prescribe?
Do NOT STOP taking antibiotics
Ciprofloxacin
when feeling better
183
Endometriosis &
Hysterectomy
Endometriosis Risk Factors

Disorder in which there is the growth of endometrial
tissues outside of the uterus. Cells making up the
endometrium migrate to other parts of the body often • Family history of endometriosis
affects fallopian tubes, ovaries, and uterine ligaments.
• Early menses (period)
• Never having been pregnant
Signs & Symptoms Treatment
• Pelvic pain
• Pain management
• Pain during sexual !
intercourse
• Oral contraception
• Infertility NCLEX TIP
• Menstrual irregularities ! (estrogen & progesterone)
!
• Surgery - Hysterectomy
Hysterectomy Indication
The uterus is removed, where the baby lives
during pregnancy. So when the uterus is removed, Uterus cancer Endometriosis PID
clients can no longer get pregnant or have periods.
Postoperative Care
Complications
Prevent atelectasis - alveoli collapse
After surgery, bleeding is a priority complication! TCDB - turn cough & deep breathe & incentive
spirometer every hour.
HESI Question
Vaginal Bleeding NCLEX TIP
… plan of care for a patient who has
PRIORITY
2
had an abdominal hysterectomy?
perineal pads: “Saturated” “changed”
hours
Instruct the patient to take

More than 1 within 1 hour deep breaths after coughing
every hour
184
Menopause
Pathophysiology Memory trick

Menopause
Natural part of the aging process, females over 50 years old have loss
of ovarian function with decrease in estrogen production. Clients have
NO periods for more than 12 months (Amenorrhea).
12 months
Signs & Symptoms
NCLEX TIPS
1. HOT flashes
HESI Question
Which symptoms is the
2. Osteoporosis (Decreased 1 nurse likely to observe in the
bone density) patient with menopause?
3. Loss of skin elasticity Select all that apply
4. Amenorrhea (over 12 months) ● Osteoporosis
● Loss of skin elasticity
5. Postmenopausal bleeding ● Hot flashes and irregular
& spotting REPORT to HCP menses
• Weight gain
• CAD: Coronary Artery Disease
• Depression & Anxiety
Pharmacology
Kaplan Question
Hormone replacement
Hormone Replacement Therapy therapy … which of the
NCLEX TIP following adverse effects
E - Estrogen & progEsterone PROGESTERONE
should the nurse instruct
the patient about?
E - Emboli RISK! (DVT, MI, PE, CVA)
ESTROGEN
• Stop smoking ● Calf pain
• Monitor for unilateral ● Numbness in the arms
leg swelling ● Intense headache
Education
NCLEX TIPS HESI Question

1. CAD: Cholesterol monitoring
Hot flashes caused by
2. Weight loss “weight maintenance”
NORMAL
menopause ... Which

HIGH
LOW
3. Depression: seek support !

instruction should the
4. Osteoporosis: nurse provide?
!
• Daily weight-bearing exercise !
● Decrease caffeine
• Diet: green leafy veggies & intake from food
dairy products
and drinks
5. Hot flashes
• Limit caffeine (tea, soda, coffee)
185
Infertility
Pathophysiology
Primary
Secondary
Inability to achieve a clinical pregnancy after 12 months of regular unprotected 1

ST 2 ND
sex with no birth control.

• Primary (failure of a couple to have any children)
• Secondary or Subfertility (inability to add a child after first successful birth)
Causes & Risks Pharmacology

Female NCLEX TIPS
Age over 35 Drug: Clomiphen
>35 CLOMIPHENE
Cystic fibrosis Encourage sex 5 days AFTER
Endometriosis COMPLETING med NCLEX TIPS
Ovarian issues:
Anovulatory cycles
Polycystic ovarian syndrome HESI
Long-term & untreated STI
The nurse knows a patient taking
chlamydia & Gonorrhea clomiphene (Clomid) has infertility as
PID - Pelvic Inflammatory Disease a result of which condition?
Impaired ovulation
Low sperm and Erectile
Male dysfunction
Procedures HESI
Which information would the nurse include
in explaining the in vitro fertilization (IVF)
procedure?
In vitro fertilization (IVF) Done for patients with tubal obstruction
and diminished sperm count
Embryo develops outside the body and is
later transplanted into the patient’s uterus
Education HIGHLY TESTED Communication
NCLEX TIP Therapeutic communication NCLEX TIPS

Recommend Day 8 Day 19 1. Address the client alone (ask family
urine ovulation detector kit to leave)
to time sexual intercourse 2. Assess with: Active listening &
during “fertile window” open-ended questions
“Tell me more about your emotions”
“Tell me about how your family has
been affected”
Primary Secondary Vesicular Ovulation Corpus Regression Corpus
Follicle Follicle Follicle luteum albicans
HESI
You also stay here
Which action by the nurse would
prevent open communication with a
FSH
couple undergoing fertility treatment?
Asking the patient’s family member
LH
to remain in the room
186
Pelvic Inflammatory Disease (PID)
Pathophysiology & Causes
NCLEX TIP HESI Question

Inflammation in the pelvic area that … teaching a group of young
STD: gonorrhea or chlamydia
typically develops from untreated STD women about pelvic inflammatory
disease (PID)?
like gonorrhea or chlamydia. If untreated Select all that apply.
PID is associated with a higher
due to lack of symptoms it can cause risk of infertility
UNTRE massive inflammation! Causative organisms reach the

ATED pelvic organs through the
cervix in an ascending manner
Complications
!
Infertility
! Risk for ectopic pregnancies
!
Risk Factors
NCLEX TIPS
1. Sexual intercourse with
multiple partners
2. Unprotected sex (without condom)
3. History of STI
(chlamydia & gonorrhea)
4. Recent pelvic surgery / abortion
5. Placement of IUD within 3 weeks
3 weeks
Signs & Symptoms
Fever
Pelvic Pain
Painful intercourse
Treatment
A mix of antibiotics to kill the bacteria Antibiotics
Surgery - remove any scar tissue or adhesions within the

reproductive areas
187
Phenylketonuria (PKU)
Pathophysiology HESI Question

Rare genetic disorder that causes severe brain damage, & neurological Q1 Which pathology pertains to
phenylketonuria (PKU)?
impairment, especially during the developmental years from growing
Defect in amino acid metabolism
fetus during pregnancy, to the age of 12. With PKU, the body lacks the
Q2 Which fetal abnormalities are
enzyme Phenylalanine Hydroxylase required to break down an amino
prevented by monitoring … a client
acid phenylalanine into tyrosine. Amino acids found in high protein with phenylketonuria (PKU) for high
based foods are essential for brain development, especially during pregnancy. levels of phenylalanine?
But in PKU these unconverted amino acids build in the body, resulting in
Cardiac anomalies
permanent brain damage occurring in the fetus & newborns. Intellectual disability
Intrauterine growth restoration
Phenylalanine Hydroxylase
Amino acid
phenylalanine
Tyrosine
Causes
Genetics is number 1, passed on from both parents, so both parents
PRIORITY
need to be carriers in order to pass on the disorder. Therefore,
genetic counseling is always recommended prior to pregnancy.
#1
Education
Kaplan Question
Child client diagnosed at birth with
NCLEX TIPS phenylketonuria (PKU)... the nurse is
most concerned... with which statement?
Special infant formula My child’s favorite lunch is peanut
Low-phenylalanine Diet is required butter and jelly sandwich.
Fruits & veggies are best!

ATI Question
AVOID “HIGH protein & iron foods”
Teaching to a client who has
NO meat, eggs, dairy products
phenylketonuria (PKU).... indicates an
Peanut butter & jelly sandwich understanding of the teaching?
Tyrosine in diet is GOOD Avoid foods high in protein for at 3 months
least 3 months prior to pregnancy
Notes
188
_ _
Visual & Audio
189
Meniere’s Disease
Med Surg: Sensory (Visual & Auditory)
Pathophysiology My Ears - Meniere’s Disease
Fluid collection within the inner ear, typically affecting only 1 side
coming & going with sudden attacks. It can eventually lead to
permanent deafness.
Signs & Symptoms
3 Key Signs:
• Tinnitus (ringing in the ear)
• Unilateral hearing loss
• Vertigo (dizzy & balance loss)
NCLEX TIP - Full Risk
Education
Sodium
Fall precautions NCLEX TIP
• SLOW position changes
Na+
Sodium Restriction
(Sodium Swells)
AVOID: smoking, caffeine,
& alcohol
Notes
190
Eye Injury
Types
Chemical splash: from a household cleaner or another chemical

Penetrating Object: something gets stuck in the eye, for example pencil pentetrates the eye.
!
! ! !
! !
Penetrating object keep both eyes covered since both eyes
work in sync with each other, we cover both to prevent any
KEY POINTS eye movement.
Chemical: Continuous
eye irrigation Chemical - Continuous
Penetrating Object:
• Cover BOTH eyes
= eye shield (2 cups)
Don’t let DO NOT flush the eye that has a penetrating object!
NCLEX TRICK YOU
Never remove any object that has penetrated the body,

since this can cause MAJOR bleeding as arteries can
rupture when you pull the object out. So stabilize the
object & allow only the surgeon or HCP to remove the
impaled object, as they can provide immediate surgery
! ! if needed.
!
Notes
191
Glaucoma
Pathophysiology
Leading cause of blindness, where increased Open angle
Over time
pressure within the eye results from an Over angle
issue in the optic nerve (cranial nerve 2)
2 forms Closed angle 1
HCP
Open angle
EXAM
Closed angle
Signs & Symptoms Memory trick Common NCLEX Question

Closed angle
Close a door Identify which image shows
the effects of glaucoma?
Open angle:
mild pain & gradual loss of 1. Option 1
peripheral vision (tunnel vision) 2. Option 2
PRIORITY 3. Option 3
Closed angle: 4. Option 4
sudden EXTREME pain NCLEX TIPS LIFE & LIMB
3
Key words 1
HCP
EXTREME, “severe”, “sudden”
eye pain
Diagnostics Education
Tonometry test
(normal IOP: 10 - 21 mmHg)
AVOID NCLEX TIPS
HIGH PRESSURE >21 mmHg
Added pressure AFTER surgery
NO Coughing, sneezing
Pharmacology Most TESTED
Closed angle NO Bending at the waist
Beta blockers - Timolol NO Lifting heavy objects
Mannitol (osmotic diuretic) MANNITOL
NO Nausea & vomiting
NO Valsalva maneuver
Surgical (bearing down)
Constipation Priority
* NOT Usually Tested
NO Anticholinergics
• Laser treatments: to kill the aqueous humor producing
cells to decrease fluid.
(Atropine, Ipratropium)
• Trabeculoplasty: helps closed angle by punching a small NO Diphenhydramine
hole in the iris. (brand: Benadryl)
• Implants: bypass the collecting systems & shunt fluid out.
192
Retinal Detachment
Separation of the retina

Pathophysiology
Detachment or separation of the retina from the back of the eye,

resulting in loss of vision.
Causes
Any type of trauma to the head, like being hit in the head with
a baseball bat or even being in a car accident
Signs & Symptoms
The most tested Kaplan Question
Hairnet like vision PRIORITY

Assessing a client with a
detached retina. Which
of the following should
• “curtain-like half vision loss” the nurse expect the

client to report?
• Floaters & cobweb looking vision

● It's like a curtain
closed over my eye
• Flashes of light
Surgical Repair
Key points Education NCLEX TIPS

Avoid pressure here!
AVOID
• Straining on the toilet
(NO constipation)
• Rubbing / scratching
• Eye straining activities
(reading, TV, computer etc.)
REPORT
• “Sudden” “New”
Vision loss, Pain, flashing light
Notes
193
Macular Degeneration
Pathophysiology
Central loss of vision & blindness. One of the top causes of blindness over the age of 60.
Currently no cure & NOT a common part of aging.
One of TOP causes
> 60 years old
Signs & Symptoms
NCLEX TIP KEY POINT
Blurry spot in the middle of vision
When you get an exam question about a client

stating they have a blurry spot in the middle
of vision while reading or while watching Macular degeneration MIDDLE vision loss
something, then report this to the HCP
immediately.
MEMORY TRICK
M - MIDDLE of vision
M - Macular degeneration
Notes
194
_ _
Respiratory
195
Abnormal Lung
Sounds
Wheezes (Whistle) Stridor “Serious Squeak!”
Med. Emergency
High pit1_;7ľlvb1-ѴYte”
) High-pitched harsh inspiratory whistle
Patho: Throat region (during )

Patho: Blockage in the larynx (voice box) or trachea
(windpipe)
Treatment: Disease:
AIM
A Albuterol Treatment: Endotracheal intubation, Surgery
I Ipratropium
M Methylprednisolone
Crackles (rales) “Crazy Fluid” Rhonchi “Rumble”

liquidy bubbling or crackling Low pitched or rumbling (like snoring)
Fine crackles = High Pitched (rubbing
Bronchi (not alveoli)
hair betw;;mCmgers)
Coarse crackles = Low Pitched (velcro Patho: Mucous
pulled apart) Rice
Crispers Disease:
: Lower lobes (Base of lung, basilary) Fibrosis (serious mucous)
Patho: Treatment:
loosen & thin mucus
Disease: Pulmonary edemaľYb7bmѴm]s” (with
CHF) or Pneumonia ( )
Treatment: ide
Cheyne-Stokes
Low pitched - Dry rubbing (like 2 rocks grinding)
breathing - Increase & decrease in RR - Front side of lung (during & )

seen as Start & Stop breathing Patho:
lungs rubbing together
Patho: apnea (stop breathing) leading to
Disease: Worsening pneumonia
blow o@ CO2 Treatment:
Treatment:
196
Respiratory
Airborne vs. Droplet
Droplet Airborne
P - Pertussis M - Measles
I - Influenza T - TB (Tuberculosis)
P - Pneumonia
1. Surgical Mask & Goggles 1. N95 mask - Staff

2. Single room 2. Neg. Pressure Room
3. Door closed
surgical mask
to wear a mask
Top 2 Missed Exam Questions

Patient presents to urgent care 48 hours after a When caring for a patient with bacterial
tuberculin skin test. The site looks red and raised meningococcal meningitis, the nurse implements
with a 19 mm induration. The nurse knows which which of the following?
of the following? Select all that apply
1. Anticipate orders for a chest X-ray or sputum samples 1. Advise unlicensed personnel to wear surgical mask
2. Collect blood for the QuantiFERON-TB test 2. Implement padded side rails
3. The patient has active tuberculosis 3. Keeps light & noise low in room
4. The patient has a tuberculosis infection 4. Places patient to negative pressure room
5. Immediately place the patient on droplet precautions 5. Puts on N-95 mask before entering room
1st
!
!
!
197
Respiratory
Resp. Failure & ARDS
Respiratory Failure Signs & Symptoms

When the capillaries (little blood vessels in the alveoli)
can not adequately exchange CO2 for Oxygen. Hypoxemia LOW O2
0₂ 0₂
#1 Sign = Altered Mental status NCLEX TIP
0₂ 0₂
0₂
0₂
0₂ 1. Agitation
2. Restlessness
Causes
3. Confusion
• Infection causes these alveoli to become swollen,
inflamed, & filled with ARDS
mucus or fluid which blocks gas exchange! Refractory Hypoxemia ?
?
?
• Clients can present with a common FLU which can ? ?
progress into pneumonia Low PaO2 = Despite Oxygen delivery ?
& eventually into DEADLY A.R.D.S.

- Acute Respiratory Distress Syndrome
MEMORY TRICK Lab Values
ABG Arterial Blood Gas
REsistant to Oxygen Low PaO2
High CO2
ARDS Pathophysiology
REfractory Hypoxemia
0₂
0₂
The alveoli become hard due to the capillaries around 0₂

0₂
0₂
0₂
C
the Alveoli becoming inflamed & fluid filled, creating a O O
leaky barrier, which eventually fills up the

PaO2
CO2
little alveoli sac like a sinking ship! THIS makes it

impossible to get oxygen in & to get CO2 OUT! Common EXAM Question
Eventually clients DIE from hypoxia IF they are not on a
ventilator early. Which arterial blood gas (ABG) values
support suspected acute respiratory pH
A B
failure (ARF)?
7.35 7.45
Memory Trick: O2 CO2

in out B
A
• ARDS = HARD Alveoli 1. PaO2 55 mm Hg, PaCO2 47 mm Hg

PaCO₂
35 45 63
Priority Diagnosis 2. PaO2 62 mm Hg, PaCO2 32 mm Hg PaO₂

• Impaired gas exchange 3. PaO2 47 mm Hg, PaCO2 63 mm Hg
47 80 100
4. PaO2 82 mm Hg, PaCO2 22 mm Hg
Causes
• Sepsis - bloodborne infection that inflames the Priority Intevention for ARDS
entire body
• Respiratory inflammation - pneumonia, inhaled Mechanical Ventilation
toxin, or even aspiration.
PEEP (positive end-expiratory
• Acute pancreatitis = HIGH risk for developing
0₂
pressure)
ARDS NCLEX TIP
accidental release of active pancreatic enzymes
& cytokines into
the bloodstream - which get sucked into the lungs H High Fowler's position (HOB up)
causing inflammation.
O Oral suctioning & Oxygen
L Listen to lung sounds
Y
0₂
Yell for help! Notify HCP “provider”
A.R.F. - ACUTE RESPIRATORY FAILURE
2 types:
HypOXemic failure LOW O2
PaO2 <60 1st 2ⁿd 3rd 4th
0₂ HCP
1
(PaO2 60 or LESS) C0₂
HyperCapnic failure HIGH CO2

(PaCO2 Over 50 )
PaCO2 >50
198
Respiratory
Asthma
Pathophysiology Teaching - Peak Expiratory Flow Rate

• A chronic inflammatory disorder in the major • Sort of like a weather forecast - we want to anticipate
pathways of the lungs: Bronchi & Bronchioles. a severe asthma attack - before it happens!
• Asthma comes & goes with flare-ups in the form
of asthma attacks & these ARE REVERSIBLE! Green zone
• Green means go.
Memory Trick: • Asthma is around 80 - 100% under control.
A - Asthma
A - Acute Attacks that come & go Yellow zone
• Yellow means mellow.
Signs and Symptoms • Asthma is NOT under control here! So there is a
HUGE need for additional medication
A Accessory muscle use 1. Rescue drug every 4 hours for 1-2 days
2. Call HCP (provider)
Critical Sign: Paradoxical Breathing
NEED additional meds or change in treatment
S SOB & dyspnea

Critical Sign: Single word dyspnea
Red zone
• Red means Really bad!
T Tight CHEST & Tachypnea

• Emergency treatment is needed immediately if the level
does not return to yellow RIGHT after taking rescue drugs!
H High-pitched wheezing Correct Order - Peak Flow Meter

1. Stand or sit in upright position
M
900
800
700
600
500
400
300
200
100
2. Put the flow meter scale to 0 or
Minimal “diminished breath sounds” lowest value
3. Inhale deeply
A
4. Put the mouthpiece in mouth &
3 As create a seal with the lips
Absent Breath Sounds (Silent Chest) PRIORITY
100
200
300
400
Signs & Symptoms
500
600
700
5. Exhale as quickly & forcibly as
800
900
Acidosis (CO2 retention) possible & record reading
320
Air trapping - Prolonged exhalation 6. Repeat 2 more times, with a
break of 5 -10 seconds between
7. Record 1 score = the HIGHEST
of the 3 attempts
Hypercapnic respiratory failure = HIGH CO2
Teaching Triggers
Hyper Capnic = High Carbon dioxide
A Allergens (dander, dust, pollen)
Elevated Eosinophils
S S - Smoking (second hand cigarette smoke)

S - Stress (emotional, physical)
ABG (Arterial Blood Gas)
pH less than 7.35 = Acidosis 0₂
0₂
0₂
0₂ Kaplan Question
PaCO2 - Over 45 = Acidosis Further teaching is needed
when which statement is made?
PaO2 - Less than 80! = Hypoxic “Stress does not cause
my asthma attacks”
* 1st Sign of Hypoxia = Mental Status Change
1. Agitation
PRIORITY • S - Sickness (Influenza, URI)
2. Restlessness NCLEX TIP
• S - Severe weather (cold)
3. Drowsiness
• S - Strenuous activity - NO need to avoid
Status Asthmaticus NCLEX TIP • Take meds before the exercise!
1. Endotracheal Intubation Drugs to AVOID
• N - NSAIDS Naproxen, Aspirin, ibuprofen, indomethacin,

& ketorolac
• N - Not good for Asthma
Diagnostics • B - Beta blockers
• PFT - pulm function test (not usually tested) • B - Blocked HR & lungs
• Propranolol (Inderal) = Non-selective
• Atenolol = Selective (cardio “Beta 1” selective)
199
Respiratory
Asthma II
Pharmacology
NCLEX TIP
BRONCHOdilators ANTI-INFLAMMATORY Agents
B Beta 2 Agonist
Albuterol
S Steroids
Beclomethasone
A Anticholinergics
Ipratropium
L Leukotriene Inhibitor
Montelukast
M Methylxanthines
Theophylline
M Mast Cell Stabilizers
Cromolyn
Bronchodilator - BAM team

Kaplan Question
• B - Beta 2 agonist - albuterol - think buterols for brutal asthma attacks!
It's considered the 1 & only rescue drug for asthma attacks Aminophylline is a bronchodilator
• A - Anticholinergics - Ipratropium - dries out the body, decreasing secretions
& dilating the airways - you cant pee - with a tro-pium
• M - Methylxanthines - Theophylline - very toxic & very fast HR! HESI Question
10 - 20 therapeutic range
Memory Trick: Phyllines have you feeling toxic & tachycardic Therapeutic Range of
theophylline (10-20 mg/dL)
Anti-inflammatory Agents - SLM Team
• S - Steroids “-sone” like Beclomethasone -

Top side effects - 3 Ss for Sone Steroids MEMORY TRICK
• S - Sores in mouth (oral thrush “candida”) so instruct the client to wash AIM for Acute Asthma Attack
out their mouth after every use & inhalers go into the sink, twicer per week.
• S - Sepsis & sickness (increased risk for infection) & increases WBC count A - Albuterol 1st
in the body I - Ipratropium 2nd
• S - Sugars increased (elevated glucose levels) M- Methyl-predniso-lone
(brand: Solu Medrol)
Last 2 - are NOT highly tested here
• L - Leukotriene inhibitors ending in Lukast like Montelukast (Singular) - think Luke likes to sing
• M - Mast cell stabilizers - Cromolyn
Metered Dose Inhaler Teaching

Most Commonly Missed Question
ATI Question
Client should hold their breath for 10 00:10 Patient with severe asthma: Which medication would you give?
seconds after inhaling so that the Select all that apply
medication gets deep into the airways
• Tachycardia (>120 BPM) 1. Inhaled salmeterol
• Tachypnea (> 30 BPM) 2. Albuterol inhaler
Kaplan Question • O2 sat < 90% on RA 3. Nebulizer Ipratropium
• Peak exp. Flow < 40% 4. IV methamphetamines
Need for further teaching when
client states: predicted or best 5. IV Methylprednisolone
I will be careful not to shake the
< 150L/min)
canister before I use it
200
Respiratory
Bronchoscopy
Pathophysiology
A procedure that allows visualization of the larynx, trachea, bronchi Larynx
Trachea
& deep lung using a flexible scope. The tube is inserted through the Bronchi
Deep lung
nose, mouth or endotracheal area passing the throat, so naturally
a gag reflex & laryngospasm are a big concern!
Performed for 3 common reasons:
• Biopsy of tissue: like when checking for cancer
• Lavage to wash out the lungs
• Suction for deep sputum or a foreign object
Before the procedure

Z
• Mild sedation: makes the vitals low & slow Z
Z
• Topical anesthetic like lidocaine is applied to the LIDOCAINE
throat to prevent the gag reflex
Post-Procedure Care
Kaplan Question
KEY SIGNS Post bronchoscopy …

priority findings to report
to the provider immediately?
● Laryngospasm “stridor” Select all that apply
● Bright red blood tinged sputum
● Blood tinged sputum … bright red
Hemoptysis ● Stridor and increased dyspnea
PRIORITY HCP
Laryngospasm “stridor”
Laryngospasm “stridor” Hemoptysis

Nursing Care
Normal & Expected:
• Low RR & Low O2 saturation: the patient NPO
has had mild sedation - Until alert with a positive gag reflex
making everything low & slow.
• Absence of gag reflex: a numbing agent
has been applied to the throat.
201
Respiratory
Carbon Monoxide Poisoning
Pathophysiology CO
CO
CO
CO
CO
0₂
CO
CO
The body replaces the oxygen in the red blood cells with
CO
CO
carbon monoxide, as it more easily binds to hemoglobin

CO CO CO
CO
CO
CO CO
CO
CO
which results in severe hypoxia leading to death.

Causes:
Inhaled toxins released by cars (auto mechanic shops), stoves,

or fuel burning like wood (typically in poorly ventilated areas).
Key Assessment Questions NCLEX TIPS
Are you a car mechanic or around How have you been keeping your
engine exhaust? house warm?
? ?
Signs & Symptoms:
• Vague & often unnoticed symptoms

• Slight headache, dizziness, dyspnea & even nausea
• Pulse oximeter readings do not accurately reflect hypoxia
with carbon monoxide toxicity. 94%
0₂ CO
CO
• False reading of high sp02 %, but in reality the patient is

CO
CO
CO
CO
CO
CO
very hypoxic.
Priority Action
15 LPM
• 100% oxygen via non-rebreather mask Flow rate of 15 LPM 0₂

OXYGEN
Humidifier
• This will help eliminate carbon monoxide from the body &
allow oxygen to attach to red blood cells once again, solving
the root cause of the hypoxia.
202
Respiratory
Chest Tubes
Chest tubes are used to drain fluid, blood, or air from the MEMORY TRICK
pleural space within the lung in order to re-expand a
collapsed lung & RESTORE the normal negative pressure
in the pleural space Dark Blood = Document
Examples BRIGHT Blood = well that ain't RIGHT!
• Pleural effusion - Fluid in the pleural lung space

• Hemothorax - Blood in pleural lung space
• Pneumothorax - Air in pleural lung space Stopped or decreased drainage?
PRIORITY
1. Auscultate lung sounds
Mechanism of action
diminished breath sounds = PRIORITY
Inserting the tube into the pleural space it simply SUCKS 2. Turn, cough & deep breathe
out all the air, fluid, or blood into a closed 1-way drainage
system. Always keep the chest tube drainage system 3. Reposition the patient
BELOW the CHEST level to help with drainage
HESI
KAPLAN 1st 2ⁿd
Priority for client with three chambered
Keep drainage below patient’s chest drainage system for hemothorax?
chest level
Assess client’s respiratory status
frequently
Chest Tube Chambers:
1 SUCTION CONTROL
CHAMBER
Patient Assessment
• Every 2 hours - listening to breath sounds, dressing around
“gentle, steady or continuous the chest tube to see if blood or pus for infection
• Subcutaneous emphysema (trapped air under the skin)
bubbling” feels like rice krispies under the skin “snap, crackle & pop”
Memory trick
Think of a child sucking down a milkshake, we want gentle Disconection & Damage
bubbling NOT vigorous.
Disconnected from patient
2
MEMORY TRICK
WATER SEAL CHAMBER 1. Cough & Exhale immediately

& AIR LEAK MONITOR
2. Apply occlusive (petroleum gauze)
NO dressing secured on 3 sides
Tidaling (rise & fall) = Good
“continuous bubbling” = BAD
NCLEX
7 6 5 4 3 2 1
HESI KAPLAN
Air leak monitor NCLEX TIP Interventions for a client with a
chest tube for pneumothorax …
Essential equipment to have at the
bedside of a client with closed chest
drainage system?
If the tube becomes dislodged,
ask the patient to cough and Sterile connector, sterile
Memory trick exhale as much as possible petrolatum gauze, padded clamp
Just think of a seal in the ocean for a water seal.
seals float up & down with the TIDE of waves & every time
it takes a breath. THIS is good Tidaling, rising & falling with If chest tube disconnects from the collection chamber itself
the TIDE - we have 2 options:
KAPLAN ATI 2. Damage:
Best response from the nurse when a Possible indication of lung re-expansion? • Water Seal Chest Tube Damage
client asks about tidaling in the water • Place distal end into 250ml sterile saline
Tidaling in the water seal chamber has
seal chamber?
stopped
“It shows your lung has not yet Chest Tube Removal
re-expanded”
Take a deep breath, hold it & bear down (Valsalva maneuver)
3
No Nos
COLLECTION CHAMBER
Notify HCP NCLEX TIP

1. NEVER “milk” “strip”
“bright red blood” Over 100 ml/hr + 2. NEVER “continuous bubbling” in the
(after 1st hour of placement) Water seal / Air leak chamber
D - Dark bloody drainage = Normal
3. NEVER clamp during transport
D - Document & monitor (old blood)
203
COPD -
Chronic Obstructive
Pulmonary Disease
Pathophysiology Memory Trick Causes & Risk Factors
• Smoking
Chronic destruction of the lungs resulting in • Car mechanics
decreased gas exchange, leading to chronic air #1
Memory tricks
trapping & high CO2 in the body.
Chronic Destruction Kaplan Question
Memory trick Risk factor for COPD
= client has smoked
C C for more than 30 years
Chronic air trapping CO2 High

Lab Values
• Don't get tricked: Anemia is NOT common with these
patients, rather increased blood count.
C • ABG (arterial blood gas) Key numbers
O O Low PaO2 32 = Hypoxemia
Below 80 (Normal 80 - 100)
Signs & Symptoms
High PaCO2 = HyperCapnic
Emphysema “Pink puffer” pH less than 7.35 = Acidosis
P I N K PaCO2 - Over 45 = Acidosis
Pink skin & Increased chest No chronic cough
Keep Tripoding
Pursed-Lip breathing “Barrel Chest” (minimal) A B
0₂
pH
7.35 7.45
0₂
0₂
0₂ B A
PaCO₂
35 45
Normal
PaO₂
80 100
Memory trick
COPD - CO2 PrisoneD

Damage to the Alveoli results in loss of lung
elasticity & loss of inflation of lung tissue, Carbon Dioxide
resulting in loss of lung tissue recoil & air trapping. Carbon diACID
Chronic bronchitis “Blue bloater” HESI Question 65 mm Hg
Partial pressure of carbon
B L U E dioxide (PaCO2) is 65 mm Hg
C
This pt. with bronchitis is
Big & Blue skin
“Cyanosis” (hypoxia)
Long term “chronic”
COUGH & Sputum
Unusual lung sounds:
Crackles & Wheezes
Edema peripherally
experiencing hypercapnia
O O
(due to cor pulmonale)
0₂
Rice
Crispers Deadly Complication
0₂
0₂
0
Respiratory Failure:
Hypoxemic respiratory failure = Low O2
Hypercapnic respiratory failure = HIGH CO2
Priority = BiPap
Inflammation of the bronchi & excessive mucus
production resulting in a chronic hacking cough, Memory Trick
& recurrent infections. HyperCAP = Give BiPAP
#1 Monitor: Mental Status Change NCLEX TIP
Key sign: 88-93% • Restless
• Decreased LOC
Low O2 saturation for COPD
NORMAL
• Confusion
clients is expected
204
COPD II -
Chronic Obstructive
Pulmonary Disease
Priority Question Teaching

An elderly client with worsening COPD presents to the emergency department with Diet:
fatigue and altered level of consciousness. Upon assessment the nurse finds O2
saturation of 87%, and ABG: pH 7.21, PaCO2 75, and PaO2 55 mm Hg. Which • Oral hygiene BEFORE meals to wake up the taste buds!
immediate intervention is best? • Eat small, frequent meals (decreases stomach distention)
1. Apply oxygen 4 LPM via HyperCAPnic (High CO2) = BiPAP • HIGH calories & protein
nasal cannula. • AVOID eating high amounts of carbohydrates Kaplan
2. Call respiratory for STAT
• AVOID exercise 1 hour Before/After meals
albuterol treatment. - conserve oxygen for chewing & swallowing
3. Sit the patient upright and
• AVOID Gassy Foods
apply Bilevel Positive Airway • NO carbonated drinks
Pressure BiPAP • NO high-fiber foods (broccoli, beans)
4. Start looking for other jobs Fluids:
in cosmetic surgery.
• Increase fluid intake 8 glasses (2 - 3L/day) to
thin that mucous
• AVOID drinking fluids while eating
Nursing Care
Infection:
• Report increase in sputum 1
• Fever, Worsening dyspnea

Vaccines:
COPD exacerbation
Look for the Os to know
its an opioid: • Pneumococcal every 5 years
• Flu vaccine every year
NO Opioids: Meds: Albuterol if short of breath to vasodilate
the lungs & allow more air flow
• MOrphine
Side Note for our patients with heavy mucus
• HydrOmorphone HYDROCODONE
• HydrOcodone
OXYCODONE
Bronchitis
• OxycOdone • Before Bed - Mobilize Secretions
our crazy pam & lam • Guaifenesin (Brand: Mucinex)
• Cool mist humidifier at night to make breathing easier.
NO Benzos: ending drugs
• Diazepam (brand: Valium) XANAX
(ALPRAZOLAM) Breathing:
• Lorazepam (brand: Ativan) Pursed lip breathing
ATIVAN
(DIAZEPAM) • Inhale: 2 seconds via nose (closed mouth)
• Exhale: 4 seconds with pursed lips
Memory trick:
- 2 nostrils = 2 seconds INhale like smelling a rose
NCLEX Question - Pursed lips for 4 seconds EXhale like blowing a kiss
Kaplan Question ATI Question

Purpose of pursed lip Pursed lip breathing…
breathing?
Prevent airway collapse
Prevent air trapping during expiration
Huff coughing technique

Correct Order:
1. Ipratropium 1. Sit upright in a chair: feet shoulder

width apart & lean forward
2. Hydromorphone 2. Deep slow inhalation through
mouth using diaphragm muscle
3. Rescue inhaler 3. Hold breath: 2-3 seconds & then
forcefully exhale
4. Oxygen via nasal
4. Repeat HUFF once or twice more
cannula 3 L/min
00:02
& avoid from normal coughing

DIAZEPAM
5. Diazepam 5. Rest for 5-10 normal breaths & repeat
as needed until secretions clear
205
Respiratory
Cystic Fibrosis
Pathophysiology
Genetic disorder that causes mucus secretions to be thicker & stickier
than normal. This mucus builds up in the lungs leading to recurrent
respiratory infections & digestive system leading to poor weight gain
& failure to thrive for younger patients.
Serious MuCus
Cystic Fibrosis
Signs & Symptoms: Diagnostics
Not commonly tested on exams or

Resp. Failure Priority boards
= Oxygen Sat. & Airway 0₂ • Sweat chloride test
• DNA, Stool test
0₂
0₂
Low pulse oximetry reading
0₂
75%
(norm: 95 - 100%)
Sudden drop in oxygen saturation
Sweat chloride test DNA, Stool test
Common “Normal” findings

Recurrent lung infections & Blood-tinged
sputum
Weight Loss & Loss of appetite

Pharmacology
Constipation & loose, fatty stool
(steatorrhea) due to mucus build up &
lack of enzymes to help breakdown fat. Acetylcysteine (brand: mucomyst)
Nursing Care MUCOMYST

Acetylcysteine
MOST TESTED
1. Diet:
High calories Acetylcysteine
Enzymes WITH meals (brand: mucomyst)
2. Mucus Antidote: Acetaminophen
Increase fluid intake (Tylenol) poisoning
Exercise
Chest Physiotherapy Key Point
Postural drainage
NOT SAFE
3. Financial counseling Will Worsen bronchospasm!
206
Respiratory
Flail Chest & Rib Fx
Pathophysiology
• Broken ribs typically result after any major Paradoxical

trauma: chest wall
movement
Car accident, falls & the like.
• Flail chest: a segment of the rib cage completely breaks & becomes
detached from the rest of the chest wall, a life-threatening medical emergency.
Signs & Symptoms:
Memory Trick:
• Paradoxical chest wall movement (key sign)
The ribs sort of sucks INward during inspiration & F F
floats out during expiration FLAIL CHEST FUNKY CHEST
WALL MOVEMENT
• Extreme chest pain

• Shallow respirations
Deadly Complications
• High risk for infection Pneumonia is very common
• Hypercapnic respiratory failure from High CO2 retention,

putting the body in an acidotic state.
Interventions
1st PRIORITY
1. Priority = Pain Control
YES - Administer prescribed
Opioids
Morphine
Hydromorphone
Hydrocodone
2. Pulmonary hygiene only AFTER
Pain is controlled
TCDB - Turn, cough, deep
breathing
IS - Incentive Spirometer
to re - expand the lungs
& preventing atelectasis
207
Respiratory
Hemothorax vs. Pneumothorax
Key Sign & Memory Trick
L L
HEMOTHORAX
DULL RESONANCE BLOOD OR FLUID
Hemothorax
H H
PNEUMOTHORAX
HYPERRESONANCE HIGH AIR
Pneumothorax
T T
TENSION PNEUMOTHORAX
Tension TRACHEAL
DEVIATION
TENSION
PNEUMOTHORAX
Pneumothorax
Hemothorax
Blood collects in pleural space (space between lung and chest wall)
resulting in lung collapse. Think hemo meaning blood like HEMOglobin.
Pneumothorax
Lung collapses due to AIR in pleural space. Key sign: hyperresonance -
like taping on a hollow drum or tree.
Tension Pneumothorax
Can result from an open pneumothorax, where air gets sucked into the
pleural space when breathing in & can't get out, known as a sucking chest
wound. All this built-up pressure can push organs & trachea to one side.
HESI Question
During central line placement the
patient develops dyspnea and
Dyspnea Tachycardia Tachypnea
tachypnea and the provider asks
Treatment: for a chest tube tray...
Suspected pneumothorax
Chest tube 1st
Open pneumothorax “sucking sound”
Cover the wound with occlusive
(petroleum gauze) dressing
Tape on 3 sides
208
13-4
Influenza (Rhinovirus)
What am i?
Usually, recent exposure (typically within Throat swabs, nasopharyngeal washes or swabs, or
48 hours) to a person with influenza, No sputum culture isolate the influenza virus.
Known as the “FLU” , a influenza vaccine received during the past
highly contagious acute ❖ Immunodiagnostic techniques show viral
season antigens in tissue culture or in exfoliated
viral respiratory infection.
Types : CNS: Headache nasopharyngeal cells obtained by
❖ A MISC: Malaise, Fatigue, listlessness, washings.
❖ B weakness,Fever,Warm, hot skin, Red, ❖ White blood cell (WBC) count is elevated
❖ C watery eyes; clear nasal discharge, in secondary bacterial infection.
❖ White blood cell count and differential are
Erythema of the nose and throat without
decreased in overwhelming viral or
exudate
bacterial infection.
MS: Myalgia, Pain with eye movement ❖ Rapid influenza antigen tests are positive
Patho Fatigue, listlessness, weakness

RESP: Sore throat, Nonproductive ❖
for the type of influenza (A or B).
Chest radiography rules out pneumonia.
Virus invades the epithelium of
cough,Tachypnea, dyspnea, cyanosis
the respiratory tract, causing
Cardio: Tachycardia
inflammation and
desquamation.
After attaching to the host cell,
viral ribonucleic acid enters
the cell and uses host
components to replicate its
Treatments
genetic material and protein, ❖ Antipyretics: acetaminophen (Tylenol), or
which are then assembled into nonsteroidal anti-inflammatory drugs
new virus particles. (NSAIDs) such as ibuprofen (Advil)
Complications
Newly produced viruses burst ❖ Guaifenesin (Robitussin) or expectorant
out to invade other healthy ❖ Antivirals: oseltamivir phosphate
cells. Viral invasion destroys ❖ Pneumonia
(Tamiflu) or zanamivir (Relenza Diskhaler)
host cells, impairing ❖ Croup
as precautionary medications to family
❖ Ear infections
respiratory defenses members and others not vaccinated and
❖ Myositis
(especially the mucociliary who have been exposed by the infected
❖ Exacerbation of chronic
transport system) and obstructive pulmonary disease even if they are not showing signs or
predisposing the patient to ❖ Reye syndrome symptoms
secondary bacterial infection. ❖ Rhabdomyolysis ❖ Influenza virus vaccine (for prevention)
❖ Myocarditis ❖ Antibiotics for secondary bacterial
❖ Pericarditis
infections such as bacterial pneumonia,
❖
Causes
Transverse myelitis
❖ Encephalitis
otitis media, or sinusitis
❖ Toxic shock syndrome
Infection by the
❖ Acute respiratory distress
orthomyxovirus, which syndrome
is transmitted by ❖
Risk factors
Death
inhaling a respiratory
droplet from an infected
person or by indirect ❖ Weakened immune system
contact (such as ❖ Age (very young or elderly)
❖ Occupation: Health care or
drinking from a
day-care worker
contaminated glass)
❖ Chronic illness
❖
❖
Pregnancy
Living in close quarters with
Interventions
Subtypes
❖ Encourage rest
many people
❖ Encourage fluid intake
❖ Caring for or living with a ❖ Monitor lung sounds
❖ Avian flu: Does not person with influenza ❖ Administer medications as
usually affect humans, prescribed
mainly affects birds. ❖ Institute droplet precautions
❖ Swine flu: A strain of flu
that contains genetics
from swine, avian, and
human influenza www. SimpleNursing.com
viruses.
209
13-11 Lung cancer
What am i ? ❖ Possibly no symptoms. Exposure to
❖ Cytologic sputum analysis shows diagnostic
evidence of pulmonary malignancy.
Malignant tumors arising from the
carcinogens, chronic cough or a ❖ Complete blood cell count may reveal
respiratory epithelium
change in the cough, hemoptysis, anemia, leukocytosis, or hypercoagulable
● Typically divided into two
dyspnea, dysphagia chest or disorders.
major groups:
abdominal pain, hoarseness, fatigue. ❖ Liver function test results are abnormal,
Small-cell (less common)
anorexia especially with metastasis.
Non–small-cell, which is further divided
❖ Dyspnea on exertion, use of ❖ Serum calcium level test may be elevated
histologically into adenocarcinoma,
accessory muscle for breathing; nasal with bone metastasis.
squamous cell carcinoma, and large
flaring, digital clubbing, edema of the ❖ Arterial blood gas analysis may reveal
cell carcinoma.
face, neck, and upper torso, dilated evidence of hypercarbia, hypoxia, and
Most common site is wall or epithelium
chest and abdominal veins (superior acidosis.
of bronchial tree. Poor prognosis for
vena cava syndrome), weight loss, ❖ Chest radiography may show advanced
most patients, depending on the extent
enlarged lymph nodes, enlarged liver lesions and can show a lesion up to 2 years
of the cancer, when it was diagnosed,
(with liver metastasis), decreased or before signs and symptoms appear; findings
and the cell growth rate (5-year survival
absent breath sounds, wheezing, may indicate tumor size and location. It may
after diagnosis in only about 13% of
pleural friction rub. reveal mediastinal widening, atelectasis, hilar
patients)
enlargement, or pleural effusion.
❖ Contrast studies of the bronchial tree (chest
Patho Treatments computed tomography [CT], bronchography)

demonstrate size and location as well as
Patients with lung cancer
❖ Chemotherapy drug combinations: Non-small cell: spread of the lesion.
demonstrate bronchial epithelial
carboplatin (Paraplatin) or cisplatin (Platinol), ❖ Bone scan is used to detect metastasis.
changes progressing from
❖ Targeted drug therapy (in combination with ❖ Computed tomography scanning (thorax) of
squamous cell alteration or
chemotherapy) such as afatinib (Gilotrif), the chest is performed to detect malignant
metaplasia to carcinoma in situ.
bevacizumab (Avastin) pleural effusion and of the brain to detect
Tumors originating in the bronchi
❖ Immunotherapy, such as gefitinib (Iressa), erlotinib metastasis.
are thought to be more mucus
(Tarceva), crizotinib(Xalkori), PD-1/PD-L1 inhibitors; ❖ Positron emission tomography aids in the
producing. Partial or complete
nivolumab (Opdivo) and pembrolizumab (Keytruda) diagnosis of primary and metastatic sites.
obstruction of the airway occurs
❖ Antiemetics, such as ondansetron hydrochloride ❖ Magnetic resonance imaging may reveal
with tumor growth, resulting in
(Zofran), tumor invasion.
lobar collapse distal to the tumor.
❖ Corticosteroids for brain metastasis and spinal cord ❖ Gallium scanning of the liver and spleen help
Early metastasis is present in
compression (small-cell lung cancer) detect metastasis.
other thoracic structures, such as
❖ Analgesics ❖ Peak expiratory flow monitoring may reveal
hilar lymph nodes, the bronchi,
❖ Anti-anxiety medications airflow obstruction.
carinal lymph nodes, and the
❖ Supplemental oxygen therapy ❖ Bronchoscopy can help identify the tumor
mediastinum. Distant metastasis
❖ Partial removal of lung (wedge resection, segmental site. Bronchoscopic washings provide material
to the brain, liver, bone, and
resection, lobectomy, radical lobectomy) for cytologic and histologic study.
adrenal glands occurs.
❖ Total removal of lung (pneumonectomy, radical ❖ Needle biopsy of the lungs (relies on biplanar
pneumonectomy) fluoroscopic visual control to locate peripheral
Causes
tumors before withdrawing a tissue specimen
for analysis) confirms the diagnosis in 80% of
patients.
❖ Tobacco smoking is ❖ Tissue biopsy of metastatic sites (including
major cause (90%) supraclavicular and mediastinal lymph nodes
and pleura) is used to assess disease extent.
Risk Factors
Interventions
Based on histologic findings, staging describes
the disease extent and prognosis and is used
❖ Smoking (16-fold
❖ Monitor vitals & respiratory to direct treatment.
increase in risk)
❖ Status ❖ Mediastinoscopy is used to evaluate enlarged
❖ Exposure to secondhand ❖ Maintain patent airway lymph nodes identified on CT scans.
smoke or radon gas ❖ Daily weights ❖ Thoracentesis allows chemical and cytologic
❖ Exposure to carcinogenic ❖ Meticulous skin care examination of pleural fluid.
❖ Provide support
and industrial air ❖ Exploratory thoracotomy is performed to
❖ Turn patient frequently
pollutants (asbestos, ❖ Offer a high calorie foods with small frequent obtain biopsy specimen.
arsenic, chromium, coal meals.
dust, iron oxides, nickel,
radioactive dust, and
uranium)
❖ Genetic predisposition
❖ Pulmonary fibrosis
❖ Radiation therapy www. SimpleNursing.com
210
Respiratory
Obstructive Sleep Apnea
Memory Trick
Pathophysiology
When the tongue or muscles in the pharynx block the O - Obstructed
airway resulting in moments of no breathing & no airflow,
called Apnea. S - Snoring OSA - Obstructed Snoring Airway
Signs & Symptoms: A- Airway

Morning headaches Daytime Sleepiness Chronic Fatigue
Daytime: HESI Question

• Morning headaches
• Daytime sleepiness
Findings that support obstructive
• Chronic fatigue sleep apnae?
• Irritability, mood swings, depression
Night Time: Select All That Apply
Snoring Episodes of apnea
• Snoring Chronic fatigue

• Episodes of apnea Reports going to bed early, sleeps for 8
hours, and still does not feel rested on
awakening.
Causes: Obese man with hayfever that causes
predominantly nasal symptoms.
O S A
OBESE / OVERWEIGHT SEDATIVES BEFORE BED ALCOHOL
(BENZOS, OPIATES)
HESI Question
40.0
0
Benzos
Patient who is not compliant
with CPAP?
Use BiPap instead of CPAP
Pt Education
Lose weight / Exercise

Limit alcohol intake
NO napping during the day CPAP
NO sedatives at bedtime Continuous positive
airway pressure
NO eating bedtime snacks 40.0
0
Intervention
CPAP: Continuous positive airway Key point Side Note
pressure uses a mask & air
pump to push air pressure 1st Action: Cpaps give continuous pressure
into the nose & mouth which during inhalation & exhalation
Client on CPAP with Low O2 Sat.
keeps the pharynx and tongue making it more uncomfortable
Check tightness of straps
from collapsing backward. and mask. & BIPAP pressures accommodate
for normal breathing
211
Oxygen Delivery Devices
& Hypoxia
Hypoxemia (PaO2 less than 80 mmHg) Late signs <12
Low Vitals
- Bradypnea (below 12)
Early Signs NCLEX TIP

- Bradycardia (below 60)
- Hypotension
Skin Blue
Brain: Mental Status Change - Cyanosis
- Restlessness ECG dysrhythmias
- Agitation “irritability”
- Confusion
Vitals Signs - HIGH

CAUTION: Avoid combustion!
- RR - Tachypnea (over 20 RR)
Oxygen is HIGHLY flammable
- HR - Tachycardia (over 100 bpm)
- BP - Hypertension (over 140 sys.)
NO NO NO
Positioning Smoking (open flame) Static (synthetic / wool fabrics)
= ONLY Cotton
Flammable material
- Accessory muscle use • Alcohol

• Acetone (nail polish)
- Paradoxical breathing
- Tripoding
Device Description Device Description
NC - Nasal Cannula 1 - 6 Liters per minute (LPM) NRB non-rebreather 10 - 15 LPM Medical Emergencies
25 - 45% O2 60 - 100% O2
Key Points:
Short-term use: low oxygenation • Used during carbon monoxide poisoning
after surgery • If the reservoir bag is fully deflated on
Long-term use: can dry out mucous inspiration = Increase oxygen flow.
membranes in the nose, Don't let the EXAMS trick you:
so we use humidification for long • Do not open flutter valves
term use. • Do not tighten face mask straps first if
the reservoir bag is fully deflated.
Simple Face Mask 6 - 10 LPM Venturi Mask 4 - 10 FiO2 Most precise oxygen delivery device
40 - 60% O2
Memory Trick:
V - Venturi Mask
Used in exchange to partial V - Very Accurate O2
rebreather & non-rebreather.
Typically used for patients with unstable
COPD who can not tolerate changes in
oxygen concentration from other devices.
Partial Rebreather 6 - 10 LPM

35 - 60%
Face Tent Used facial trauma & burns
High humidification
F F
Face Tent Face Trauma
Looks very similar to the
non-rebreather
Key difference is the flutter valves
on the sides
212
Oxygen Delivery Devices
& Hypoxia
Common EXAM Question
90%
1. Apply non-rebreather
2. Apply simple face mask
3. Apply nasal cannula
4. Raise the head of bed
BiPAP (Bilevel Positive Airway Pressure)

Mosted tested: used for worsening COPD who have High levels of CO2 retention
(Hypercapnic). Bipap is a positive pressure machine that forcefully PUSHES air Deep
into the lungs giving much needed Oxygen while expelling CO2!! Typically last line
oxygen device before endotracheal intubation.
Respiratory Failure:
Hypoxemic respiratory failure High CO2
PRIORITY
= Low O2
Over 45
Hypercapnic respiratory failure
= HIGH CO2 (Over 45)
Priority = BiPap
Memory Trick
HyperCAP
Give BiPAP
Intubation (Endotracheal intubation)
Ultimate solution to keep the airway open!

A tube is inserted directly into the trachea Complication:
to ventilate the client manually.
VAP - “Ventilator Associated Pneumonia”
• Reposition side to side Q 2 hours
• Oral Care Chlorhexidine Q 2 hours
Monitor Key Signs:

• Positive sputum culture
• Fever
• Chest X-ray: new infiltrates
213
Respiratory
Pulmonary Embolism
Pathophysiology
Deadly PRIORITY medical emergency! PE is a blood clot that obstructs
a pulmonary vessel (blood vessel inside the lung), typically the pulmonary
artery. This blockage prevents blood flow to the Alveoli where gas
exchange is supposed to happen, eventually leading to DEADLY
hypoxemia (deadly low oxygen).
Highest Priority
• Impaired gas exchange r/t imbalance of ventilation & perfusion
Causes:
Typically caused from a DVT blood clot that loosens from another
part of the body (typically the leg) & gets sucked into lungs
- causing a blockage.
Risk Factors
• Smoking, Obesity, Immobility, & even cardiac issues like Atrial
Fibrillation or valve disorders. Memory Trick
• Estrogen birth control “oral contraceptives” MOST TESTED
leads to increased risk for blood clots E - Estrogen
SMOKING OBESITY IMMOBILITY
E - Emboli (blood clots)
Diagnostics:
Signs & Symptoms:
• High D dimer - High risk for blood clots
#1 in the body
#1 Sign = Hypoxemia 0₂
0₂
Memory trick:
0₂
1. Restless 0₂
2. Agitation
• D - Dimer (Positive)
• D - Dime sized clot in body
3. Mental status change
Chest pain HESI Question
Dyspnea & SOB Indications for pulmonary embolism

Tachypnea include...
68- 494
Tachycardia 0₂ 0₂
Positive D-Dimer
Normal range 68- 494 ng/dL)
ng/dL
Anxiety
0₂ 0₂
Pharmacology
Treatments
Pharmacology Surgery
Anticoagulants
• Embolectomy: surgical removal of
Heparin
the clot
Warfarin • Vena Cava filter: acts like a net to catch
Thrombolytics any new clots
tPA Thrombolytics
B - Bolytics
B - Clot Busters
Alteplase
Streptokinase
214
Respiratory
Pleural Effusion & Thoracentesis
Pathophysiology
Pleural Effusion think Plenty of Fluid in the lung space, specifically fluid collection in the
pleural space greater than 15 mls of fluid. This fluid prevents full expansion of the lung > 15ml
& results in decreased gas exchange & atelectasis (collapse of the alveoli).
Causes:
• Pneumonia (lung infection), which fills the lungs with fluid.
• Heart failure causing pulmonary edema, where heavy fluid builds up in the lungs.
Signs & Symptoms: KAPLAN

Suspected pleural effusion findings …
L L
KEY SIGNS “Decreased breath sounds noted in
lower lobe”
DULL RESONANCE FLUID FILLED LUNGS
1. Chest pain during inhalation
2. Dyspnea
3. Diminished breath sounds
4. Dull resonance on percussion
Interventions
Thoracentesis BEFORE procedure:
Provider places a needle through
an intercostal space (the space STOP all blood thinners:
between the ribs) to gently ● Antiplatelets: aspirin & 1st
puncture the lung & drain the fluid! clopidogrel
● Anticoagulants: Warfarin
& heparin (enoxaparin)
Sign a consent form
Chest X-ray before & AFTER procedure to compare fluid & lung expansion
AFTER a thoracentesis:
• Deep breaths to help re-expand the lungs & promote adequate oxygen exchange
• Lie on the unaffected lung to keep BAD LUNG UP!
Complications: REPORT to HCP

ATI
Pneumothorax
Correct instructions after a thoracentesis?
● Asymmetrical chest expansion Have the client take deep breaths after
the procedure
& decreased breath sounds on
affected side
● Hyperresonance
Hyperresonance
● Deviated Trachea
215
Respiratory
Pneumonia
Pathophysiology Memory Trick
Infection that causes severe inflammation in the lungs P P

which makes the alveoli to fill with mucus, fluid, & debris
leading to impaired gas exchange where CO2 can't PNEUMONIA PLAGUE OF
THE INFECTION
get out & oxygen now can’t get IN, resulting in hypoxia
(low oxygen).
O2 CO2
in out
Impaired
gas exchange
Signs & Symptoms KAPLAN

Pleural friction rub?
1. Altered Mental Status
Grating sound or vibration heard
Restlessness, Agitation, Confusion
during inspiration and expiration
2. Fever (Over 100.4 F/ 38oC)
3. Productive cough “Yellow Sputum”
4. Fine or Coarse Crackles Common NCLEX Question KEY TERM
5. Dyspnea “Shortness of Breath” Big Sign

REPORT 0₂
6. Pleuritic Chest pain 1
HCP Priority Patient: who to see first?

0₂
0₂
0₂
₂
(Pleural friction rub) Report to HCP
“Sharp chest pain upon inspiration Post-operative patient with suspected
or coughing” pneumonia temp. of 98.2F, SpO2 94%
... becoming restless & agitated.
1. Pleural Effusion NCLEX TIP 3. Septic Shock

Fluid that fills the pleural space (space between the If the infection gets severe, the body releases chemicals
lung itself & the chest wall) This prevents full expansion into the bloodstream to fight the infection resulting in
of the lung, resulting in decreased gas exchange. severe low blood pressure & total body inflammation
which can damage multiple organs causing them to fail,
known as MODS - multiple organ dysfunction
KEY SIGNS syndrome.
Priority to report
1. D - During inhalation = Chest pain
2. D - Dyspnea
● Asymmetrical Chest Expansion Memory Trick:
3. D - Diminished breath sounds ● Decreased Breath sounds S - Shock
4. D - Dull resonance on percussion
S - Severely Low BP & perfusion
2. ARDS (acute respiratory distress syndrome) Key signs

< 90 Systolic
Hypotension NCLEX TIP
- Deadly STIFF lungs - ARDS - think HARDS hard stuff Systolic < 90 mm Hg
88
lungs
? MAP < 65 mm Hg
KEY SIGNS ? ? ?
Cap refill over 3 - 4 seconds

?
0₂
0₂
0₂
0₂
?
Refractory Hypoxemia = Low PaO2 Tachycardia
MEMORY TRICK
REsistant to Oxygen Early - Fever (Over 100.4)

REfractory Hypoxemia Late - Hypothermia (Under 96.8)
#1 Sign of Low O2 = Altered Mental status Elevated WBC (norm: 10,000 or less)
0₂
1. Confusion
0₂
0₂
0₂
Decreased Urine Output
0₂
2. Agitation
30 ml/hr or Less = Kidney Distress
3. Restlessness
216
Respiratory
Pneumonia II
Risk Factors & Causes Diagnostics

1st
#1 - Advanced AGE • Elevated WBC - white blood cell count CULTURES
• Over 10,000
Over 65 years old >65
• Sputum Culture = Positive
• Test tip - cultures are always taken first -
VAP - “Ventilator Associated BEFORE antibiotics
Pneumonia” • Think A - Antibiotics A - AFTER cultures, in order
to identify the causative bacteria.
1. Reposition side to side Q 2 hours
2. Oral Care & Suctioning Q 2 hours
3. Chlorhexidine
Best indicator of ventilator
Best indicators of VAP NCLEX TIP
2
hrs
associated pneumonia (VAP) ?

positive sputum culture
Positive sputum culture
Fever
Chest X-ray: new infiltrates
Best blood lab value shows effective
treatment of pneumonia after IV
• Prolonged immobility - secretions are not mobilized
antibiotics? TED
& get stuck in body ELEVA
• Post-Operative - Anesthesia - the body is put to sleep
White blood Cell count
which traps infection in the lungs
Patient care
Mobilize secretions & Expand Lungs

HESI
Encourage 3L of fluid intake per day
Chest physiotherapy to promote expectoration
TCDB - turn cough & deep breath!
Huff coughing technique Discharge Teaching
NCLEX TIP
AVOID cough suppressants
Fluid 2 - 3 L per day Mobilize Secretions
Positioning
HOB UP! High Fowler’s
Avoid cough suppressants
Hypoxia in Unilateral Pneumonia? Antitussives: Codeine
= Good Lung Down NCLEX TIP
Cool mist humidifier at night
Common Exam Questions
Increase Fluid
Re-expand Alveoli
IS - Incentive spirometer at home
Prevent Reinfection
Finish oral antibiotics at home
Pneumonia vaccine (Every 5 years)
Early ambulation
Smoking cessation
(within 8 hours after surgery)
Cough with splinti
8
hrs
Handwashing
Handwashing Schedule follow up & Chest X-ray
Mouth Care Q 12 hour Report: increased or Worsening
IS IS
Chlorhexidine swab INCENTIVE INCREASE SIZE
Fever
Confusion
SPIROMETER OF THE ALVEOLI
Incentive Spirometer Q Hour O2 CO2

in out
GIVE Pain Meds SOB, cough, sputum
217
13-17 Chest injuries : pulmonary contusion
Assessment
What am i? ❖ Dyspnea
❖ Hypoxemia
A bruise of the lung,
❖ Increased bronchial
caused by chest trauma.
secretions
As a result of damage to
❖ Hemoptysis
capillaries. blood and
❖ Restlessness
other fluids accumulate in
❖ Decreased breath
the lung tissue. The
sounds
excess fluid interferes with
❖ Crackles and wheezes
gas exchange, potentially
leading to inadequate
oxygen levels (hypoxia).
Patho
Blood and other fluids
accumulate in the lung
tissue. The excess fluid
interferes with gas
exchange, potentially
leading to inadequate
Interventions
❖ Maintain patent airway
oxygen levels (hypoxia).
and adequate
Resulting in decreased
ventilation.
pulmonary compliance,
❖ Place the client in the
this poses an increased
Fowler’s position.
risk for Acute
❖ Administer oxygen as
respiratory syndrome.
prescribed.
.
❖ Monitor for respiratory
distress
❖ Maintain bedrest and
limit activity.
❖ Prepare for mechanical
Causes ventilation.
❖ Car accidents
❖ Contact sports
❖ Intimate partner
violence
❖ Parathyroid
disorders
❖ Endocrine disorders
❖ Bone disorders
www. SimpleNursing.com
218
13-5 Severe acute respiratory distress syndrome
What am i ? Assessment Labs & Diagnostics
Contact with a person known to have SARS.
Mild, moderate, or severe
Travel to an endemic area. Flu like signs and ❖ Antibody testing with enzyme-linked
viral respiratory infection symptoms; initially no respiratory signs or immunosorbent assay and the immunofluorescent
caused by a distinct symptoms during the first 3 to 7 days, then a antibody test confirm diagnosis.
coronavirus. It is Believed to nonproductive cough. ❖ Sputum culture isolates coronavirus.
be less infectious than the RESP: Dry cough, Dyspnea, Tachypnea, ❖ Complete blood count may show leucopenia and
influenza virus. Incubation Rhinorrhea, Crackles, Respiratory distress in thrombocytopenia.
period estimated to range later stages ❖ Liver transaminase level and lactate
GI/GU: Diarrhea,Nausea and vomiting,Sore dehydrogenase test results may be elevated as may
from 2 to 10 days .
throat, creatine kinase levels.
Not highly contagious when MS: Myalgias ❖ SARS-specific polymerase chain reaction test
protective measures are DERM: Rash detects SARS-CoV ribonucleic acid.
taken Currently no known MISC: Fever and chills, Headache, ❖ Blood culture identifies the infection.
transmission worldwide. Fatigue,Malaise, Anorexia ❖ Chest radiography may be normal or may reveal
diffuse interstitial infiltrates or bilateral peripheral
O: Out of country infiltrates.
Patho
U: Undeveloped countries ❖ Computed tomography scanning (thorax) may
T: Travel to endemic areas reveal infiltrates that resemble ground glass or may
reveal obvious consolidation.
Coronaviruses cause O: Out of breath
F: Fever, fatigue
Interventions
diseases in pigs, birds, and
other animals. A theory
B: Bad muscle aches ( myalgias)
suggests that a coronavirus R: Rhinorrhea Respiratory distress
may have mutated, ❖ Symptomatic treatment
E: Excess vomiting
allowing transmission to ❖ Airborne and contact precautions
A: A sore throat/
and infection of T: Tachypnea ❖ Negative-pressure single room for
humans-(SARS-associated H: Headache hospitalized patients
coronavirus [SARS-CoV]). ❖ Strict respiratory and mucosal barrier
Mucous membranes come precautions, including an N95 respirator
in direct or indirect contact ❖ Quarantine of exposed people to prevent
the spread of the virus
Treatments
with infectious respiratory
droplets or fomites. The ❖ Global surveillance and reporting of
virus attaches itself to ● Antivirals: ribavirin (Virazole) or suspected cases to national health
human receptor cells, oseltamivir phosphate (Tamiflu) (not authorities
initiating a nonspecific proven consistently effective) ❖ Intubation and mechanical ventilation, if
acute lung injury. The result ● Combination of steroids and indicated
is diffuse, severe, alveolar antimicrobials (not proven consistently ❖ Venous thromboembolism (VTE)
damage. effective) prophylaxis
● Interferon alfacon-1 (not proven
consistently effective)
● Oxygen therapy
Causes ● IV fluid supplementation
Education
❖ Coronavirus
known as
SARS-associat ❖ Educate on disease process
ed coronavirus ❖ Measures to prevent spread of
(SARS-CoV) infection
❖ Hand hygiene
❖ Not sharing utensils
Two stages ❖
❖
Educate on treatment regimen.
Educate on the importance of
❖ Stage 1 : involving flu like follow up care.
symptoms that begin 2 to 7
days after incubation and
last 3 to 7 days
❖ Stage 2: involving the lower
respiratory tract www. SimpleNursing.com
219
Respiratory
Tuberculosis
Pathophysiology
• Bacterial infection in lungs caused by the bacteria M.Tuberculosis
• Spread via the airborne route, once inhaled it enters the lungs &
spreads to the lymph & bloodstream.
ATI
Signs & Symptoms:
Precautions for a patient with suspected
tuberculosis (TB)?
Airborne precautions
KEY POINTS
HESI Question
Night Sweats
First action for a patient with night sweats,
Anorexia: Weight loss
weight loss, hemoptysis, fever and chills.
Cough + Hemoptysis Airborne precautions
“Blood tinged sputum” NCLEX TIP
Dyspnea & SOB KAPLAN

Fever & chills
Client with anorexia, low-grade fever, night
sweats and a productive cough.
Priority action: Initiate airborne precautions.
Memory Trick
T Terrible cough “blood tinged”
B Bad infection:
Fever, night sweats, weight loss
Diagnostics:
• Intradermal injection (mantoux test) requires
a 2 to 3 day window for reading.
HESI Question
Over 15 mm induration Patient has a Most accurate description of tuberculosis (TB)?
TB infection
= positive TST “Most people who become infected with the
TB organism, do not progress to active disease”
• Chest X-ray & sputum cultures test for

active form.
Key point
KAPLAN
Sputum Culture Diagnosis Route of administration for Mantoux test?
Intradermal
Early morning sterile
sputum specimen
3 consecutive days
ATI
Sputum cultures are taken until 3 negative
Pharmacology (see pharmacology TB study guide) cultures
Family members should be tested for TB
220
TB DRUGS
5 TB Tips Memory Trick
5 NCLEX TIPS ALL are LIVER TOXIC!!!!

So some instructors just use the acronym:
1. Meds Last 6 - 12 months
2. N-95 mask worn all the time
3. Family tested for TB
4. Sputum samples every 2 - 4 Weeks
5. 3 Negative cultures on
3 different days = NO Longer infectious
RIFAMPIN INH #1 TESTED

RED-FAMPIN ISONIAZID TB DRUG
KEY Points: I - Interferes with absorbtion of B6

(pyridoxinde)
- Low Vitamin B6 = Peripheral Neuropathy
1. NORMAL
- Take Vitamin B6 25 - 50mg/day
- Red, Orange: Tears, Urine, Sweat
Teach:
N - Neuropathy
REPORT:
- Wear glasses instead of contacts due - New Numbness
- Tingling extremities
to discoloration of tears NCLEX TIP - Ataxia
2. Oral contraceptives ineffective
H - Hepatotoxicity
“Use non-hormonal REPORT Immediately!!!
- Jaundice (yellow) Skin / Sclera
Back-up birth control” - Dark urine NCLEX TIP
3. Monitor for Jaundice - Fatigue
- Elevated liver enzymes (AST/ALT)
HOLD the Med
- Teach: NO ETOH!!
ETHAMBUTOL - Eye
KEY POINT:
REPORT!
• Blurred vision
PYRAZINAMIDE
Did not come up once in 10,000 questions. • Color changes

it’s a nice to know but NOT A NEED TO KNOW
This information has come up in multiple sections!
TEACH to have baseline eye exams and
routine EYE appointments! For EEEEthambutol
221
Respiratory
Tonsillitis & Abscess
Pathophysiology
Tonsillitis is the inflammation of tonsils, the little soft tissue

masses located near the rear of the throat. When these guys
get inflamed it can lead to a life-threatening airway obstruction!
Key Sign
PRIORITY
KEY SIGN #1
Sore throat with

difficulty opening mouth
and swallowing
Treatments to avoid bleeding after surgery:
Tonsillectomy: simple surgery to remove the tonsils, HUGE RISK

for bleeding.
AVOID
Patient Teaching
● AVOID coughing, blowing nose
● AVOID sharp foods: chips, nuts
● NO milk products
● NO hard brushing or gargling
Key Signs
Priority Findings
Post-Op tonsillectomy
1. Frequent swallowing
2. Restlessness
3. Persistent Coughing
222
Ventilator
(Mechanical Ventilation)
Complications
Mechanical ventilation means that a machine
is mechanically giving breaths or ventilations
to a patient. This machine is like an air pump 1. Dropping O2 Saturation
that pumps air into tires on a bicycle. In the
same way we are pumping air into the lungs, ● Auscultate lung sounds
this is called PPV - positive pressure ventilation ● Secretions = Suction
● Manual ventilation w/ resuscitation bag
PostSuction
- Operative NCLEX TIP
Bedside Essentials
● Extra intubation set up & bag valve mask
5 Key Points (Ambu bag)
1. Suction OUT - never IN ABG •● Kaplan Essential to have

Resuscitation Bag
“Never apply suction when resuscitation bag at bedside
20 minutes
inserting catheter into airway”
2. 10 Seconds or LESS AVOID 2. Pneumothorax - Barotrauma NCLEX TIP
3. 100% Oxygen 30 seconds Before from High PEEP NCLEX TIP

4. AVOID suctioning 3. Hypotension (Low BP)
O₂
O₂
O₂ O₂
NCLEX
O₂
O₂ O₂
before an ABG draw Pneumothorax Positive End-Expiratory Pressure
Over 60% of students miss this!

5. AVOID suctioning “routinely”
- Acute Lung Injury
ONLY when needed Extubation:
ONLY when needed
Kaplan HESI ● Use warm humidified oxygen

Adjust FiO2 when preparing Pt with increased ICP… when via facemask
to suction endotracheal tube should suctioning be performed? ● Oral care (oral sponges)
● When O2 sat. drops bc of ● NPO (nothing per oral)
increased respiratory secretions ● High Fowler’s position
Oral Care
2 DEADLY risks:
VAP 1. Atelectasis & Pneumonia:
“Ventilator Associated Pneumonia”
- Incentive Spirometer Q hour
• Reposition side to side Q 2 hours
• Oral Care Chlorhexidine Q 2 hours
- Turn, Cough, Deep Breathe Atelectasis
(TCDB) to mobilize secretions

2. Stridor “Squeaky”
Pneumonia
Common EXAM Question Common EXAM Question
Best indicator(s) of ventilator Appropriate interventions
associated pneumonia (VAP) ? for a patient intubated on ATI Kaplan
Select all that apply continuous sedation to prevent
ventilator associated pneumonia?
Stridor following extubation Extubated from endotracheal
= Report to provider immediately intubation 10 minutes prior.
1. Positive sputum culture Select All That Apply
Priority assessment finding
2. Fever (Over 100.3 F) 38oC
to report to HCP?
1
HCP
?
3. Chest X-ray: new infiltrates 1. Daily sedation & weaning
protocols “sedation vacations” ● Stridor
2. Elevate HOB 30-45 degrees
10:00
3. Oral care with chlorhexidine

4. Hand hygiene Tracheostomy Care
> 100.3 OF ( 38OC )
5. Clock out for lunch.
Mature tracheostomy
#1 Priority
(7 days or more) NCLEX TIP
“New tracheostomy”
NGT Feeding & GI Ulcers 1. Insert new tracheostomy tube
using curved hemostat
● Checking tightness of ties 2. Cover stoma with
ATI
● 1 finger to fit under ties sterile occlusive dressing &
1. NGT - NO bolus feedings Complication associated with Ventilate lungs with bag valve
long term mechanical ventilation mask over nose/mouth
2. GI “Stress Ulcers” ● Stress ulcers
#1
223
Ventilator Settings
Alarms Mode
Name Description Memory Trick
Low pressure (Low Tidal Volume Alarm) AC Assist Control 100% Machine control A - Actively
L - Loss of connection Full machine control C - Controls breathing
L - Leak
● Cuff leak SIMV “Weaning Mode” Patient controls S - SIMV
breathing mainly, S - Step down
● ET Tube displacement S Synchronized
but machine assists
I Intermittent
● Disconnection
M Mandatory
High pressure (High Peak Pressure Alarm) V Ventilation
H - High Blockage
● Biting tube
● Kinks in the tube
● Excessive airway secretions Settings
● Mucus plug Name Description Memory Trick
● Coughing
VT Tidal Volume (V4) Volume of air set to be Tidal Volume
● Pulmonary edema (V4) delivered with each Tidal Wave of air
● Pneumothorax breath
500 - 800 ml of air
f RR Freq. RR # of breaths / min. f RR

Kaplan 12 - 20 RR freakin RR
A client with emphysema receiving

mechanical ventilation appears FiO₂ Oxygen Concentration 35% - 100% Fi O2
restless and agitated. Higher = More Severe Fi-eed me O₂
Priority action when a high pressure
alarm sounds? PEEP Positive End Keeps alveoli open P - PEEP
● Instruct client to allow machine Expiratory Pressure with positive pressure P - Pushes open alveoli
to breathe for the client at the end of
respiration.
Caution = Barotrauma
Common NCLEX Question PS Pressure Support Push of air to help PS - SPontaneous

with spontaneous breath support
breath
The nurse responding to a
high-pressure alarm on the
ventilator would assess for
which condition?
1. Auscultate the lungs for Monitoring

pulmonary edema Name Description Memory Trick
2. Biting the ET tube
Ve Minute Ventilation Amt. of air delivered V - Ventilations
3. Tube displacement per minute e - every minute
4. Disconnection of tubest
5. Excessive airway secretions PIP Peak Inspiratory Max pressure during PIP is the
Pressure inspiration TIP of max pressure
6. Kinked ventilator tubing
Which complication is associated Pplat Plateau Pressure Pressure applied to Plateau

with excessively high levels of HOLD OPEN Pause lung
small airways & alveoli
PEEP?
before expiration.
Barotrauma (pneumothorax) Indicates Lung
compliance
224
_ _
TPN & Internal

Feeding
225
TPN
Pathophysiology Total Parenteral Nutrtion

Central line
It's basically the client’s entire nutrition Carbohydrate
Fat
Protein
Water
Mineral
CVC (Central Venous Catheter) Internal
jugular line
in a IV bag (right into the blood) bypassing PICC line

Vitamin
Subclavian CVC
the normal process of digestion in the GI tract. Subclavian CVC

PICC
Since it's very thick, only give TPN through a Internal jugular line
central line.
Indication Nursing Care

>180
Daily weights (maintain muscle)
Pancreatitis / Crohn's Disease (NPO)
Glucose levels
40 kg
Severe burns, Trauma (hypercatabolic state)

Day 3
Day 2
Hyperglycemia NCLEX TIP Day 1
Oncology Increased Urination (Polyuria)

Excessive THIRST (Polydipsia)
Chronic malabsorption issues
Carbohydrate
Water
Fat
Protein Mineral
Catabolic
Hormones
Vitamin
Nausea, Headache, Abdominal pain
Administration
KAPLAN
TPN line
NCLEX TIP Priority action when a client’s TPN bag is
NO IV meds (push or piggyback) 60 empty and a new one is not readily
Start & stop slowly Priority action: available:
Never abruptly stop TPN Hang 10% dextrose in water ● Administer dextrose 10% in water
Change bag & tubing Hypoglycemia until the new bag arrives
every 24 hours
Complications NCLEX TIP Refeeding Syndrome
TPN Enteral Feedings Deadly complication with severely malnourished

(NGT, PEG, G-tube) clients! Giving too MUCH nutrition too QUICKLY
- pulls electrolytes from the blood & into the
tissues, resulting in deadly low electrolytes.
NCLEX TIP
Mg
Anorexia nervosa
Mg Chronic Alcoholism
Na Ca
Ca
K
K K Na Ca
Na
24 - 48 hours
starting Enteral or Parenteral Nutrition
Enteral Feedings
(NGT, PEG, G-tube)
A - Aspiration
A - Airway Obstruction
M P P
TPN
Magnesium Potassium Phosphorus
1.3 - 2.1 mEq/L 3.5 - 5.0 mEq/L 2.4 - 4.4 mg/dL
Mg
K P
KEY POINT
REQUEST continuous feedings NCLEX TIP
Displaced PEG tube less than
to prevent aspiration Torsades de Pointes
7 days old
Causes:
Notify the HCP who inserted it Post MI, Hypoxia, Low magnesium
Treatment:
Torsades de Pointes
1
HCP
V Fib & Cardiac Arrest

Vfib Low potassium in this case
Below 3.5
226
_ _
Maternity
227
_ _
Anatomy
&
prenatal care
228
Anemia & Pica I
Maternity
Anemia
The body lacks adequate RBCs (Red Blood Cells) to carry oxygen around the body to perfuse the tissues.
Clients present fatigued, pale skinned, dizzy, and with shortness of breath, as the body lacks oxygen.
Top Tested
B12
B12 1. Iron deficiency Anemia
B12 B12 B12 2. Sickle cell anemia
B12 3. Pernicious Anemia
Fe
Fe Fe Fe
4. Aplastic anemia
• Impairment in bone marrow
Fe
• Pancytopenia
(Low RBC, WBC, Platelets)
5. Hemolytic anemia
• Destruction of RBCs
Aplastic anemia
• Incompatible blood transfusion
(antigen-antibody reactions)
Anemia Causes
NCLEX TIP
• Blood loss: surgery, trauma, excessive menstruation etc. Hemoglobin
• Chemotherapy & Immunosuppressants: suppresses the bone marrow where the Normal: 12 +
RBCs are made. Bad: 8 - 9
• Lack of iron, B12 & other building blocks: like with iron def. anemia & pernicious anemia Less than 7 = Heaven
Iron Deficiency Anemia - Causes Signs & Symptoms
Infants & Children

Fe
Diet low in: meat, fish, & poultry
GI Manifestations:
Fe Fe Fe
Fe
Gastric bypass surgery 1. Premature birth

2. Insufficient oral intake • Stomatitis - inflammation
Pregnancy: fetus stores iron
3. Excessive intake of milk NCLEX TIP of mouth & lips
Pica 4. Preterm infants exclusively • Glossitis - inflammation
• LOW hematocrit and hemoglobin bottle-fed with breast milk of the tongue
levels NCLEX TIP
5. Vegan diet NCLEX TIP
Other Causes: 1. Fortified breads & cereals
• Low vitamin B12 2. HIGH iron foods with
HIGH vitamin C
• Hypochlorhydria (low stomach acid)
3. Calcium & Vitamin D
• Gastric atrophy (Atrophic gastritis)
Pharmacology Treatment
Infants & Children
Limit EXCESSIVE milk intake
KEY POINTS Rich in iron Iron + Vit. C
Ferrous Sulfate (oral) Iron Dextran (IV / IM)
Dark or black stools = 1. Meat, fish, poultry HIGH iron foods
Normal & Expected HIGH vitamin C
NOT GI BLEED
FERROUS IRON
2. Green leafy veggies
like spinach Fe
SULFATE DEXTRAN
Empty stomach
Fe
1 HOUR BEFORE 3. Whole grains
medications
229
Prenatal Care I
Fundamentals of Nursing
Contraindication
We must educate pregnant mothers on a variety of information.
N S
AVOID Medications During Pregnancy

Naproxen Salyslic acid
H
O O
NAPROXEN
O
NSAIDS
H
N - Naproxen
S - Salyslic acid
A I K
A - Aspirin Aspirin
Indomethacin
& Iburofen
Ketorolac
I - Ibuprofen & Indomethacin

K - Ketorolac
INDOMETHACIN
ASPIRIN
ACEs & ARBs = Avoid during pregnancy

- “-pril” Lisinopril (NO Prils during Pregnancy)
- “-sartan” Losartan (Sartans = Satan to pregnancy)
Doxycycline & Tetracycline ! ! !

- Cycling on a bike is dangerous during pregnancy Rx
Carbamazepine
! TETRACYCLINE
Carbamazepine: seizures drug ! !

! ! !
LOSARTAN
Vaccine Safety
Pregnant clients have a suppressed immune system & are at increased risk for illness.
In general, no live virus vaccines are given during & up to 1 to 3 month before pregnancy,
as live vaccines cause serious birth defects to a developing fetus in utero.
ATI Questions
Safe NOT Safe Q1: 30 weeks’ gestation…. vaccines are considered safe?
during pregnancy NO Live Vaccines! Tetanus, diphtheria, and pertussis (Tdap)
(Safe after pregnancy)
Q2: routine education … for a pregnant client?
- Inactivated Influenza (flu shot) - Varicella-zoster (chickenpox) Get a flu vaccine to protect against influenza infection
Tdap vaccine 27 - 36 weeks - Rotavirus
T - Tetanus - Live or Activated Influenza
D - Diphtheria - MMR: measles, mumps, rubella HESI Question
P - Pertussis ... postpartum client before administering the varicella vaccine?
You must return for a second dose in 4 to 8 weeks
Use contraception for 1 month to avoid pregnancy
27 - 36 weeks
Rotavirus
! Newborn
MMR
Vaccine
Rhogam: 72 hrs after birth to
Varicella Influenza
! Rh negative mom with Rh positive baby
Tetanus Diphtheria Pertussis Vaccine
!
VACCINE
Vaccine Vaccine Vaccine
Hepatitis B vaccine: to newborns with
infected moms
Notes
230
Discomforts of Pregnancy I
Morning sickness
Contraindication HESI question
… pregnant client experiencing
Nausea during the first trimester nausea and vomiting?
Eat small, frequent meals
Interventions (every 2 to 3 hours)
• Consume high-protein snacks
upon awakening NCLEX TIP
ATI question
• Small frequent meals
• Drink fluids between meals morning sickness ...
appropriate nursing response?
(30 minutes before or after) Advise the client to
• Ginger consume a high-protein
• Vitamin B6 snack when she awakes
Hyperemesis gravidarum ATI question

… severe hyperemesis
Persistent nausea & vomiting PAST
gravidarum… manifestation
12 weeks → considerable weight loss
of this condition?
(5% pre-preg weight), fluid/electrolyte
5%
0
50.0
imbalance, & malnutrition. Urine ketones present

Signs & Symptoms
Excessive vomiting → dehydration 1.000
Electrolyte imbalance (hypokalemia)

1.010
1.020
1.030
Urine Analysis NCLEX TIP

1.040
• Ketonuria (Ketones in the urine)

• High specific gravity
Weight loss & nutritional deficits
Hyperemesis gravidarum
HESI question
Interventions Ondansetron
Zofran B6
Pyridoxine
… self-management for ..
Monitor: weight and I&Os hyperemesis? Select all that apply.
IV fluids Try to eat more dairy
Antiemetics: Consume protein after
eating a sweet snack
• Ondansetron
Try drinking your water
• Pyridoxine (B6) Vitamin with a slice lemon
Increase → dairy, lemon water,
& protein
Treatments:
Constipation Increase
Increased progesterone levels
decreased GI motility & slowed F F E
further by iron supplementation. Fiber: Fruits & vegetables Fluids: 10-12 cups daily Exercise:
NCLEX TIP Moderate-intensity exercise
AVOID:
Dairy: 2 hrs before & 1 hr after iron
supplement → decreases absorption
Laxatives & stool softeners:
dehydration & electrolyte imbalance
Caffeine: limited to 200-300mg daily
231
Pregnancy Assessment I
Maternity
Contraindication
Signs of Pregnancy
Presumptive signs mean you MIGHT be pregnant 1. Presumptive signs
Probable signs mean you are PROBABLY pregnant
Positive signs mean you are DEFINITELY pregnant 2. Probable signs
3. Positive signs
ATI Question
Presumptive Signs: … presumptive signs of pregnancy. Which of the following
findings should the nurse expect the client to report?
Subjective “self-reported” Select all that apply.
Amenorrhea
Nausea and vomiting
1. Amenorrhea (no period) Quickening
2. Nausea & vomiting

3. Quickening (movement) HESI Question
4. Urinary frequency … symptoms of pregnancy?
5. Breast tenderness & fatigue Urinary frequency
Probable Signs: Objective Signs Goodell’s = Good sign

ATI Question
Goodell’s Sign: cervical softening. “a soft cervix is a GOOD sign” ... bluish discoloration of the cervix ... observed as
Memory trick: Goodell’s = Good sign early as 8-10 weeks… It is known as:
Chadwick’s sign
Chadwick's Sign: blue/purple birth canal.
Memory trick: "Chad is a bully and he'll beat you
black and blue!"
ATI Question
Hegar’s Sign: softening of the lower uterine segment.
Memory trick: ... home pregnancy test.
H - Hegar is like a soft pillow uterus where the
H - HEad GOes
Perform the test the
Ballottement
Positive Pregnancy HCG test: elevated levels of HCG,
first time you urinate
but gestational trophoblastic disease can also cause in the morning
this positive result
Positive signs: Diagnostic 10 - 12 weeks

KAPLAN Question
1. Fetal heartbeat heard by Doppler
device at 10 - 12 weeks NCLEX TIP … client is certain of pregnancy and
120
00 reports feeling the baby move. Which
2. Ultrasound visualization of the response by the nurse is best?
fetus NCLEX TIP “Lie down so that I can listen for the
3. Fetal movement (palpated or fetal heart tones with the Doppler.”
observed by HCP)
Notes
232
Prenatal Care II
Education For Pregnancy NCLEX TIPS Kaplan Question

By the fifth month of pregnancy ...gained 14 pounds:
Avoid alcohol & tobacco products
Inform the client the weight gain is appropriate
Obtain testing for rubella immunity
Schedule dental wellness appointment
Second Trimester:
- Gestational diabetes & preeclampsia screening
- Anticipate quickening “light fetal movements”
- Abdominal ultrasound evaluation
Weight Gain:
- Expected weight gain: 25 - 35 pounds during pregnancy
- Maintain BMI of 18.5 - 24.9 kg
- Gain of 1lb per week if pre-pregnancy BMI was normal
(2nd & 3rd trimester)
25 - 35 pounds
ATI Questions
Education For Pregnancy NCLEX TIPS
Q1: …. folic acid deficiency. Which of the following complications.. ?
Diet & Vitamins Fetal neural tube defects
- Folic Acid 400 mcg / day → prevents neural tube defects Q2: ... ferrous sulfate…. which of the following beverages… increase
- Calcium 500 mg daily the absorption of the medication?
Orange juice
- Iron rich foods meat and dried fruit
- Iron supplements (ferrous sulfate) → prevent anemia HESI Questions
Take on an empty stomach
Q1: … pre-pregnancy instructions?
Risk for constipation 400 mcg of folic acid daily
Increase Vitamin C to aid absorption (Orange juice) Q2: ... risk is associated with iron supplementation for the pregnant
client?
Constipation
Fe
Iron Fe
Fe
Education For Pregnancy NCLEX TIPS HESI Question

Which examples of protein-containing foods …
Protein foods rich with calcium, iron, & B vitamins vegetarian client? Select all that apply.
Dried beans
Example: Grilled chicken, turnip greens,
Seeds
peanut butter, & juice NCLEX TIP Peanut butter
Food to Avoid Peas
Unhealthy: excess salt, butter, fat, margarine ATI Question
Unsafe dairy: unpasteurized or suspicious 8 weeks of gestation…. good source of calcium?
Brie cheese, Raw milk, Dark green, leafy vegetables
Deli-made egg salad / sandwich
HESI Question
Which foods … avoid during pregnancy?
Brie cheese
RAW
! RAW
Unpasteurized milk
Deli made egg salad
MILK MILK
Peanut
! RAW RAW
MILK
Butter MILK
!
233
Discomforts of Pregnancy II
Intrahepatic Cholestasis
883573498 3839
883573498 3839
Liver disorder during pregnancy
after eating
2 hours
Fasting
• Generalized itching on hands &
feet that worsens at night but
no rash NCLEX TIP
• Increases the risk of fetal death
Priority Assessments & Interventions
• Bile acid testing
• Fetal monitoring
• Ursodeoxycholic acid
Treatment
UTI
Antibiotics & give analgesics for the pain
Signs & Symptoms
• Urinary frequency, urgency, burning &
foul-smelling urine
“Running to the bathroom all the time”
“Pain during urination with smelly urine”
• Pyelonephritis (Kidney Infection) NSAIDs ACETAMINOPHEN
Report: Fever or pain in the lower back (TYLENOL)
or flank area NCLEX TIP

→ increased risk for preterm labor.
Heartburn (Pyosis) ATI question

Education 2 NCLEX TIPS … 23 weeks’ gestation with a
1. Eat several small meals each complaint of significant heartburn?
day (6 per day) Eat 6 small meals daily
2. Eliminate fried fatty foods
3. Other Interventions
Keep head of bed elevated
using pillows
Avoid lying down immediately
after eating
Avoid tight-fitting clothes
No caffeine, chocolate,
peppermint & spicy food
Notes
234
Pregnancy Assessment II
Maternity
EDB (Expected Date of Birth)

This is also referred to as EDD (expected due date). Determining this is vitally important because planning &
interventions during pregnancy are based on this information. Labor induction & diagnosing preterm labor are two
examples. The gold standard for determining EDB is the use of ultrasound technology.
EDB 3 7
1st day
of LMP - month
+ days
(Expected Date of Birth) APRIL JANUARY JANUARY JANUARY
Nägele’s Rule
=
S M T W T F S S M T W T F S S M T W T F S S M T W T F S
1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5
EDB
6 7 8 9 10 11 12 6 7 8 9 10 11 12 6 7 8 9 10 11 12 6 7 8 9 10 11 12
First day of LMP - 3 months + 7 days = EDB

13 14 15 16 17 18 19 13 14 15 16 17 18 19 13 14 15 16 17 18 19 13 14 15 16 17 18 19
20 21 22 23 24 25 26 20 21 22 23 24 25 26 20 21 22 23 24 25 26 20 21 22 23 24 25 26
27 28 29 30 27 28 29 30 27 28 29 30 27 28 29 30
Example Question 1
1. First day of LMP: April 1
1st day
of LMP - 3 + 7
month days
2. Subtract - 3 months: January 1
3. Add + 7 Days: January 8 = EDB January 8
=
JULY
3 + 7
OCTOBER JULY JULY
1st day
- month
S M T W T F S
S M T W T F S S M T W T F S S M T W T F S
Example Question 2
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5 1 2 3 4 5
6 7 8 9 10 11 12
6 7 8 9 10 11 12 6 7 8 9 10 11 12 6 7 8 9 10 11 12
of LMP
13 14 15 16 17 18 19
13 14 15 16 17 18 19 13 14 15 16 17 18 19 13 14 15 16 17 18 19
1. First day of LMP: October 1

20 21 22 23 24 25 26
days
20 21 22 23 24 25 26 20 21 22 23 24 25 26 20 21 22 23 24 25 26
27 28 29 30
27 28 29 30 27 28 29 30 27 28 29 30
2. Subtract - 3 months: July 1

3. Add + 7 Days: July 8 = EDB July 8 1st day 3 7
of LMP - month
+ days
Example Question 3
1. First day of LMP: June 25 JUNE MARCH APRIL APRIL
2. Subtract - 3 months: March 25

=
S M T W T F S S M T W T F S S M T W T F S S M T W T F S
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5 1 2 3 4 5
6 7 8 9 10 11 12
3. Add + 7 Days: April 1= EDB April 1

6 7 8 9 10 11 12 6 7 8 9 10 11 12 6 7 8 9 10 11 12
13 14 15 16 17 18 19
13 14 15 16 17 18 19 13 14 15 16 17 18 19 13 14 15 16 17 18 19
20 21 22 23 24 25 26
20 21 22 23 24 25 26 20 21 22 23 24 25 26 20 21 22 23 24 25 26
27 28 29 30
27 28 29 30 27 28 29 30 27 28 29 30
Don’t let 1st day of the last menstrual period

Nägele’s Rule
NCLEX
TRICK YOU 1st day of LMP (last menstrual period) JUNE
- 3 months S M T
1
W
2
T
3
F
4
S
+ 7 days
6 7 8 9 10 11 12
13 14 15 16 17 18 19
= EDB (estimated date of birth)

20 21 22 23 24 25 26
27 28 29 30
ATI Question HESI Question

… reporting that her last … last menstrual period
menstrual period began on began on February 15 and Top Missed NCLEX Question
January 1 and ended on that previously her periods A client presents to the hospital stating that she tested positive on a home pregnancy test.
The client’s last menstrual period was August 7. Today is November 7. Which of the following
January 5. She notes she had were regular (28 day cycles). options are correct for this client?
unprotected intercourse on what is this client’s … Select all that apply.
January 15 and some spotting expected date of birth? Expected date of
on January 22. According to delivery is May 14
November 22
Naegele’s rule, which of the Auscultation of the
fetal heartbeat via
following is the estimated Doppler is possible
date of delivery?
Urinary frequency is
October 8 a common
NOVEMBER
S M T W T F S
OCTOBER 1 2 3 4 5
12 weeks
S M T W T F S 6 7 8 9 10 11 12
1 2 3 4 5
13 14 15 16 17 18 19
6 7 8 9 10 11 12
13 14 15 16 17 18 19 20 21 22 23 24 25 26
20 21 22 23 24 25 26
27 28 29 30
27 28 29 30
Notes
235
Anemia & Pica II
Maternity
Sickle Cell Anemia

Normal Cell Sickle Cell
The RBCs have a distorted shape, transforming from a nice round, plump
O2
shape to a skinny, sucked in shape. These misshapen RBCs die quicker O2

O2
than normal RBCs, carry less oxygen to the body, & get clogged in tiny
O2
O2 O2
O2
O2
O2
O2 O2
blood vessels - blocking or occluding the blood supply & causing ischemia O2
O2
O2
O2 O2
O2
(low oxygen) to the organs. A vaso-occlusive crisis or “sickle cell crisis” can
O2
occur, causing extreme pain from the lack of oxygen!
Signs & Symptoms Complication Splenomegaly
Splenic sequestration crisis

Blood Clot Manifestations
Rapidly enlarging spleen
One-sided arm weakness
Low blood pressure
Swelling of the feet and
hands (Dactylitis)
Treatment Higher doses
EXAM TIP
Hydration: IV fluids
New-onset paralysis of
Bed rest
extremities Pain Control NCLEX TIP
Sudden inability to be • PCA - patient control
analgesia pump
aroused • Call the HCP for
Higher doses
Pernicious Anemia
The body cannot absorb B12, which is a vital building block to B12
B12
create RBCs. Clients lack intrinsic factor in the GI tract, which B12 B12
B12
helps the body take in B12. B12
Glossitis: EXAM TIP

• Inflamed red smooth tongue • B12 - Injection: IM or IV
Extreme weakness
• NOT orally (PO)
Jaundice: “pale yellow skin”
Notes
236
Pregnancy Assessment III
Maternity
Uterine Growth & Fundal Height ATI Question

.. 24 weeks’ gestation… most likely
1. 12 weeks - above the symphysis fundal height?
pubis NCLEX TIP 26 cm
2. 16 weeks - Halfway between the
symphysis pubis and umbilicus 12
3. 20 weeks - At the umbilicus

Pubic symphysis
Memory Trick
Fundal height (in cm) should =
weeks of gestation + or - 2 weeks.
Weeks of
gestation ± 2
Weeks
4. 36 weeks - at Xiphoid process 24
5. 38 - 40 weeks - the fetus engages
& the fundal height drops 20
26cm ± 2
16
12
GPTPAL Assessment Number of pregnancies

0
ATI Question
G Gravidity: (Gravida)
Number of pregnancies
Including: abortion, miscarriages &
… a nurse reads the following data:
G2 T1 P0 A1 L1. Based on this
current pregnancy information, what does the nurse
Nulligravida: number of pregnancies is zero know is true about the client?
Primigravida: the first pregnancy Select all that apply.
Multigravida: the patient has been pregnant The client has delivered one
more than once
newborn at term
P Para: the number of deliveries after

20 weeks gestation
Number of pregnancies
1 The client has had no preterm
deliveries
T Term Births: Number of births over

37 weeks
The client has had two prior
pregnancies
P Preterm births: the number of births

between 20 - 37 weeks
The client has one living child
A Abortion (or miscarriage)

Number of deliveries 1 KAPLAN Question
L Living Children: Live births A client is pregnant for the third time. The client
has one living child and has had one abortion.
Which description does the nurse record?
G3, L1, A1
Number of live births 1 20 weeks

A client is being seen in the pregnancy clinic for a new pregnancy. Last
year she had a spontaneous abortion at 3 months gestation. What will
the nurse document in the client’s chart regarding her GTPAL?
G2 T0 P0 A1 L0
20 weeks 37 weeks
Notes
237
Ectopic Pregnancy
Maternity
Fallopian Tubes
Memory Trick
This occurs when a fertilized egg implants outside the uterus, most often E - Ectopic
in the fallopian tubes.
E - Exit
(egg implants outside the uterus)
PID Saunders Question

Risk factors
… assessment findings predispose the client to an
Recurrent STIs (chlamydia) ectopic pregnancy? Select all that apply.
PID: Pelvic Inflammatory Disease Use of fertility medications

History of Chlamydia
Tubal surgeries, damage/scarring Use of an IUD
IUD History of PID
HCG
Diagnostic
Positive HCG test
Empty uterus upon ultrasound

Red vaginal spotting ... client who has an intrauterine device (IUD)..
reports abrupt, sharp, lower abdominal pain and
Positive urine pregnancy test bright red vaginal bleeding:
1 sided lower abdominal pain Ectopic pregnancy
Ruptured Ectopic Pregnancy

Hypovolemic Shock NCLEX TIP
Hypotension: Low blood pressure
Tachycardia: Fast HR over 100/min.
NCLEX TIP
Dizziness
NCLEX TIP
Shoulder pain
“Severe, Sudden, Sharp” NCLEX TIP SEVERE
Peritonitis SUDDEN
Rigid abdomen
Tenderness SHARP
Low grade fever 100.4
Donor Recipient
A A HESI Question
B B
Interventions
... severe lower left abdominal pain and vaginal
AB AB
spotting. Her last menstrual period was 5 weeks HCG PID
O O ago… next actions?

Monitor vitals closely Select all that apply.
Prep for blood transfusion Check the results of the HCG test
Blood type & cross Ask the client to describe the color of the
?
vaginal bleeding
Large bore IVs Ask the client if she has ever been
Prep for surgery diagnosed with pelvic inflammatory disease
Draw the client’s blood for a type
and crossmatch
Notes
238
Gestational Diabetes
Contraindication
This is impaired blood glucose regulation due to hormonal changes during pregnancyincluding rising MODERATE
blood sugar levels & even insulin resistance. As you know glucose & insulin needs increase throughout
HI
W
pregnancy but now the insulin has trouble getting sugar into the cell with insulin. Unstable glucose
GH
LO
VE
LE
L
levels during pregnancy can result in DANGEROUS effects on both the mother & the baby.
Newborn Complications NCLEX TIPS Over 4,000 grams
Macrosomia (Over 4,000 grams - 8 lbs 13 oz.)

Hypoglycemia in the newborn Saunders Question
“Jitteriness” 8 lbs 13 oz
… at risk for developing gestational diabetes during

Glucose 40 - 60 mg/dL → encourage breastfeeding! this pregnancy?
HEMATOCRIT
Elevated Hematocrit (polycythemia) The client’s last baby weighed 10 pounds at birth 10 lbs
Preterm labor & PROM
RDS: Respiratory distress syndrome (Immature lungs)
Fetal death: miscarriage & stillbirth
Hypomagnesemia
HESI Questions NORMAL
HIGH
LOW
Newborn Complications NCLEX TIPS Q1: … maternal and neonatal risk associated with gestational
diabetes mellitus?
Hypomagnesemia (low magnesium) Mg Maternal preeclampsia and fetal macrosomia

Mg Q2: … associated with maternal diabetes?
Mother: Pre-eclampsia (hypertension) Mg Decreased magnesium
Hypoglycemia
Respiratory distress syndrome
Risk Factors HESI Question

Advanced maternal age (35+) … increased risk for developing gestational diabetes?
The client is 37 years old
Overweight (over 25 BMI) The client is having twins
Multiple gestation: The client’s pre-pregnant weight was
190 lbs/86 kgs Twins
twins, triplets etc. Age 35+
Diagnostics NCLEX TIP

1 hour Glucose Challenge Test (GCT)
<140
No fasting is required initially NCLEX TIP
Less than 140 glucose = Normal
Over 140 glucose → 3 hr GCT: fasting
& hourly BG checks
Hypoglycemia
Signs & Symptoms Saunders Question

… newborn of a mother with diabetes melitus.
Hypoglycemia What is the priority nursing consideration?
Cool, pale, headaches, tremors, clammy low blood glucose levels
Hyperglycemia Hyperglycemia HESI Question
Polyuria - Increased Urine … symptoms of hyperglycemia? Select all that apply.
Polydipsia - Increased thirst Thirst
Zzz
Polyphagia - Increased eating Drowsiness

Drowsiness & constipation Constipation
Saunders Question
… gestational diabetes at 29 weeks’. Which information
Treatment should the nurse discuss with the client? Select all that apply.
Increased fetal monitoring NST: Non Stress Tests Plan for weekly non stress tests at 32 weeks
Obtain nutritional counseling
Diet & Exercise:
Nutritional counseling: fruits, veggies, whole grains! HESI Question
Eat every 3 - 4 hours … gestational diabetes indicates an understanding?
Meds: I will not go more than 4 hours throughout
Oral meds the day without eating
Insulin
Kaplan Question
... gestational diabetes ... teaching is effective if the client
selects which dessert?
Fresh fruit
239
Hydatidiform Mole & Oligohydramnios
Maternity
Hydatidiform Mole
Also called molar pregnancy - is a type of gestational trophoblastic disease that results Molar pregnancy
from abnormal fertilization.
It causes rapid abnormal growth of villi in the placenta that form grape like clusters &
can sometimes turn into choriocarcinoma - a type of fast growing cancer that can KILL the mother.
Very deadly!
The sad part is that there is NO baby but these grape like clusters produce HIGH amounts of HCG
which makes couples think there is a pregnancy but this pregnancy is completely non-viable at any
point & the couple will have to be supported emotionally for their loss.
Signs & Symptoms

Dark, brown vaginal bleeding
“prune juice color” Education
Elevated hCG levels AVOID pregnancy
until cleared by HCP NCLEX TIP
ATI Question
… molar pregnancy. Which of the following Treatment
manifestations should the nurse expect?
Dark brown vaginal discharge
Uterine evacuation of pregnancy
Saunders Question Rhogam: for clients with RhoGAM
... hydatidiform mole ... which findings are associated?
Rh-negative blood types
Vaginal bleeding
Excessive nausea and vomiting
Elevated levels of hCG
Oligohydramnios
Oligohydramnios Aminiotic fluid
Is a condition where there is low amniotic fluid volume within the uterus that
puts the baby at risk for decreased lung development & cord compression! Uterus
Fluid volume gradually declines after 41 weeks gestation.
Fetal kidney
Causes
Undiagnosed rupture of membranes (ROM)
Fetal kidney anomalies
Variable decelerations
Complications
240 240 240
Pulmonary hypoplasia: small,

210 210 210
180 180 180
underdeveloped fetal lungs 150
120
150
120
150
120
Umbilical cord compression → continuous

90 90 90
60 60 60
fetal monitoring for variable decels 30 30 30
100 100 100
Interventions
80 80 80
60 60 60
40 40 40
20 20 20
0 0 0
Additional neonatal personal present to

help support with birth NCLEX TIP
Notes
240
Placenta Previa
Maternity
Pathophysiology
This is the abnormal implantation of the placenta over the cervix either
completely or partially at the bottom of the uterus. As you know, the
cervix is the door to the baby condo which is now blocked by the placenta,
making a normal vaginal delivery impossible.
As pregnancy progresses, the placenta grows in size & can migrate away from
the cervical opening. This means it may resolve on its own by the 3rd trimester.
Therefore, additional ultrasounds are typically performed closer to the time Complete previa Partial previa
of delivery - around 36 weeks to reassess placental location.
Causes & Risk factors

Scar tissue
Previous cesarean section, abortion,
uterine surgery, multiparity (twins, triplets)
Maternal age 35 or older
Smoking
Age 35 or older
ATI Question
… at 24 weeks … painless, bright red vaginal bleeding.
Signs & Symptoms

Which of the following conditions does the nurse suspect?
Placenta previa
HESI Question
Painless vaginal bleeding ... after 20 weeks... painless bright red vaginal bleeding:
“bright red” NCLEX TIP Placenta previa
Decreased H&H Kaplan Question

… at 29 weeks … reporting vaginal bleeding… indicative
of a placenta previa?
“The bleeding scares me, other than that, I feel fine”
Interventions NCLEX TIPS Education NCLEX TIPS

Anticipate Blood Transfusion
Initiate 2 large-bore IV catheters Saunder’s Question Pelvic rest (no sex, no douching,
no vaginal examination)
Draw blood for type and screen ... placenta previa… question which Additional ultrasound around 36 weeks
Pad counts to assess for bleeding prescription? gestation & prior to onset of labor
Electronic fetal monitoring Obtain equipment for a manual
Discharge home
Cesarean birth before the onset of labor pelvic examination
Betamethasone: preterm newborns for Only if bleeding stops and
lung development ATI fetal status is reassuring
NO vaginal exams, “digital exams” Instruct to return to the hospital
if bleeding occurs
Bedrest: decrease physical activity
Scheduled cesarean birth before
onset of labor
Obtain equipment
for a manual pelvic
examination
241
Placental Abruption
Maternity
Pathophysiology
It is a deadly condition where the placenta prematurely detaches
Blood
from the uterine wall while the baby is still inside, like ripping off
a scab. Placenta prematurely detaches
Placental
from the uterine wall while
It’s either partial detachment, complete, or concealed. the baby is still inside
Either way, it results in the mother having severe pain & major
bleeding in the uterus.
The fetus suffers from hypoxia (lack of oxygen), which can be
deadly, as it has no means of getting oxygen or nutrients.
Causes
Trauma: motor vehicle accident, fall,
blunt force trauma, etc.
Hypertension
Stimulants: cocaine & smoking
History of previous abruption
First child Second child
Signs & Symptoms Report to HCP HESI Question

Which signs and symptoms ... with abruptio placentae?
Dark red vaginal bleeding NCLEX TIP Select all that apply.
Severe continuous abdominal pain Abdominal pain
Vaginal bleeding
Rigid & tender uterus
Uterine tenderness
Decreased H&H and Hypovolemic shock
For the baby ATI Question

Abnormal fetal heart patterns … abruptio placentae … complications associated
with this problem.. ?
Uterine tachysystole Hypovolemic shock
Interventions Saunders Question

Interventions 4 NCLEX TIPS … placental abruption is present. Which intervention
should the nurse prepare for?
1 2 3 4 Delivery of the fetus
Anticipate emergent Apply continuous IV access & Monitor for signs of

cesarean birth external fetal draw blood for hypovolemic shock
monitoring type and screen → Pallor, tachycardia,
blood transfusion hypotension
NORMAL
HIGH
LOW
Notes
242
Preeclampsia & HELLP
Maternity
Pathophysiology
NORMAL
Preeclampsia is a potentially dangerous complication of pregnancy characterized by high
HIGH
LOW
blood pressure, proteinuria, & signs of damage to other organs like the liver & kidneys.
It can be deadly to both the baby & mother if left untreated.

Typically, it begins after 20 weeks of pregnancy in women with NORMAL blood pressure,
often presenting with NO symptoms.
Signs & Symptoms > 140 > 155

systolic systolic
High blood pressure (over 140/ systolic)

Saunders Question REPORT
Increase in blood pressure of 15 mmHg … mild preeclampsia … call the HCP if which
since last visit NCLEX TIP occurs?
Proteinuria: Protein in the urine Weight increases by more than 1 pound lbs
151
Peripheral edema: swelling in face & fingers in a week
Weight gain = Water gain !
!
Seizures (eclampsia)
Complications Pharmacology Antihypertensives

HELLP Syndrome Magnesium Sulfate (Mellows the body) B Beta blockers
Prevents seizures
Labetalol
Hemolysis Elevated Liver enzymes Low Platelets 8 NCLEX TIPS
1. Therapeutic range: 4 - 7 mEq/L C Calcium channel blockers
Critical Signs: 2. Successful → Seizure activity stops Nifedipine
3rd trimester with right upper quadrant pain, Toxicity Signs Cardizem
nausea & vomiting NCLEX TIP 3. Over 7 mEq/L = TOXIC!
Epigastric pain 4. Low DTRs (Assess hourly) V Vasodilators
Absent or decreased DTRs (hyporeflexia)
Hydralazine
Example: 0/4 patellar reflex
Other Complications from HTN 5. Low Vitals: Avoid the A’s NCLEX TIP
Respirations less than 12 /min
Placental abruption: placenta prematurely Low blood pressure & HR A ACE inhibitors: Lisinopril, Enalapril
detaches from the uterine wall Decreased mental status
Report to HCP 6. Low urine output: 30 ml/hr or less = kidney distress! A ARBs: Losartan, Valsartan
Dark red vaginal bleeding NCLEX TIP Treatment

7. Stop IV magnesium
Urine output 30ml/hr or less ATI Questions
8. Antidote: Calcium gluconate NCLEX TIP
= Kidney Distress! Report to HCP Supplemental oxygen 8-10 L/min by facemask Q1: … severe preeclampsia … sign of magnesium
Persistent headache with blurred vision & suction supplies ready sulfate toxicity? Select all that apply.
Respiratory rate less than 12/min
Decreased level of consciousness
HESI Question
ATI Questions
… preeclampsia. Which statement would the
nurse include in discharge teaching?
HESI Question Q2: … preeclampsia … infusion of magnesium
sulfate. Which of the following actions will be
Return to the hospital if you have … severe preeclampsia .. on an intravenous infusion
implemented? Select all that apply.
epigastric pain of magnesium sulfate. ... treatment is a success?
Monitor urine output
Seizures do not occur
HESI Question Assess deep tendon reflexes
magnesium sulfate… discontinuing the therapy?

Respiratory rate is 10 breaths/min
HESI Question
… magnesium sulfate therapy…. drowsiness, Seizure Precautions:
slurred speech, and depressed respiration.
Hyperreflexia or clonus Saunders Question
Which medication would the nurse anticipate ?
→ seizure activity is impending … severe preeclampsia. Which nursing action
Intravenous calcium gluconate should be included? Select all that apply.
Seizure precautions (padded bed,
ATI Question suction supplies, & oxygen) Keep the room semi-dark
Decrease environmental stimuli Initiate seizure precautions
… 37 weeks’ gestation. The healthcare provider (dim lights & limit visitors) to minimize Pad the side rails of the bed
should be called immediately: stimulation NCLEX TIP
Avoid environmental stimulation
Severe headache and blurred vision Ensure adequate protein intake Reduce external stimuli
243
Toxoplasmosis & TORCH Infections
Maternity
T Toxoplasmosis
TORCH is an acronym for a list of infections.
O
Other infections (Syphilis,
Contraction of these infections pose a GREAT RISK chicken pox, mumps, HIV)
to the fetus as they cross the placental barrier.
R Rubella
We will be covering only the top tested need to know C CMV

key points here:
H Herpes
ATI Question
... prevention of a TORCH infection.
T TOXOPLASMOSIS
Parasitic infection
Avoid consuming undercooked meat
while pregnant
Cat feces (litter box exposure) HESI Question

Soil-contaminated fruits & veggies Which infection could be contracted through
contact with a cat?
(Educate clients who garden & eat
Toxoplasmosis
homegrown vegetables) NCLEX TIP
Raw or undercooked meat Kaplan Question
… prenatal clinic. The nurse is most concerned
if a client makes which statement?
“I clean the cat’s litter box daily.”
S SYPHILIS
Treatment This is a sexually transmitted infection that crosses the placenta & may
IM penicillin injection
cause birth defects. All pregnant clients are screened at their initial prenatal
visit and HIGH risk clients are screened again during their 3rd trimester &
Allergy to penicillin: NCLEX TIP before labor!
penicillin desensitization is required
to receive appropriate treatment
ATI Question
… a pregnant client is not immune to rubella.
R RUBELLA Do not provide the vaccine to a pregnant

client. The client cannot receive the vaccine
until after childbirth
KEY POINTS
No rubella vaccine until AFTER childbirth Rubella
Saunders Question
Vaccine
If exposed: check rubella titer results Rubella A pregnant woman … reports exposure to a
titer result Rubella child with rubella.
immediately
I will check your rubella titer results, and
we can immediately identify whether
interventions are needed
H HERPES Is another STI that presents with periods

of remission & outbreak. Saunders Question
Active outbreak → painful genital lesions
... positive history of genital herpes but has not
Report to the HCP HCP
1
had lesions during this pregnancy. What should

Outbreak the nurse plan to tell the client?
Interventions You will be evaluated at the time of
Acyclovir delivery for genital lesions and if any are
Immediate antiviral therapy: Acyclovir
present, a cesarean delivery will be needed
Active lesions before delivery
→ cesarean section
244
Reproductive System
Female
MALE External genitalia
External genitalia ❖ mons pubis
❖ Penis: reproductive and urinary elimination. ❖ labia majora and minora
❖ Scrotum: External sac that houses testes. ❖ Clitoris
Protects the testes from trauma & testicular ❖ Vestibule
temperature regulation. ❖ perineum
Internal reproductive organs
Internal reproductive organs ❖ Vagina: muscular tube that leads from the vulva to the
❖ Testes: produce male sex hormone and from uterus
spermatozoa ❖ Cervix: dips into the vagina and forms fornices, which are
❖ Ductal system: “ vas deferens” the tube in which arch-like structures or pockets.
sperm begin the journey out of the body. ❖ Ovaries :two sex glands homologous to the male testes,
❖ Accessory glands: The seminal vesicles are are located on either side of the uterus. (Hatfield 55)
paired glands that empty an alkaline, fructose-rich Fallopian tubes: The paired fallopian tubes (also known as oviducts)
fluid into the ejaculatory ducts during ejaculation. are tiny, muscular corridors that arise from the superior surface of the
Prostate: muscular gland that surrounds the first part of the uterus near the fundus and extend laterally on either side toward the
urethra as it exits the urinary bladder. The alkaline fluids ovaries. The fallopian tubes have three sections
secreted by these glands are nutrient plasmas with several ❖ Isthmus
key functions, including the following: ❖ Ampulla
❖ Enhancement of sperm motility (i.e., ability to ❖ infundibulum
move) Uterus: uterus, or womb, is a hollow, pear-shaped, muscular
❖ Nourishment of sperm (i.e., provides a ready structure located within the pelvic cavity between the bladder and
source of energy with the simple sugar fructose) the rectum.
❖ Protection of sperm (i.e., sperm are maintained in The uterus is divided into four sections.
an alkaline environment to protect them from the ❖ cervix
acidic environment of the vagina) (Hatfield 51) ❖ uterine isthmus
❖ corpus
❖ fundus (Hatfield 53)
Cellular development
Menstrual cycle Soma cells:
❖ Makeup organs and bodily tissue of the human body.
Two main components : Ovarian cycle and Uterine cycle ❖ Gametes: germ cells/ sex cells found only in the reproductive
Ovarian cycle : Cyclical changes in the ovaries occur in glands
response to two anterior pituitary hormones: ❖ Nucleus: contains 23 pairs of chromosomes
follicle-stimulating hormone (FSH) and luteinizing hormone ❖ Each parent donates 1 par of chromosomes ( 46 Chromosomes
(LH). There are two phases of the ovarian cycle, each equals little Mikey)
named for the hormone that has the most control over that ❖ Each parent donates 22 pairs of autosomes: genetic traits such
particular phase. The follicular phase, controlled by FSH, as eye color, hair color, ear wax consistency.
encompasses days 1 to 14 of a 28-day cycle. LH controls ❖ One pair of sex chromosomes
the luteal phase, which includes days 15 to 28
❖ Follicular phase
❖
Fetal development
Luteal phase
Uterine cycle: changes that occur in the inner lining of the

uterus. These changes happen in response to the ovarian Pre-embryonic stage : 3-4 weeks
hormones estrogen and progesterone. gestation
There are four phases to this cycle: Embryonic: 5-10 weeks gestation
❖ Menstrual Fetal: 11-40 weeks gestation
❖ Proliferative
❖ Secretory
❖ ischemic.
Signs of pregnancy
❖ Presumptive: subjective data the
woman reports to the HCP for
example, “ My breasts hurt”
❖ Probable : objective data such as
cervical changes
❖ Positive : diagnostic confirmation
such as, fetal heartbeat & ultrasound
245
Hematologic Changes
❖ Blood volume increases by
45-50%
PREGNANCY ❖
Weight gain
A woman should increase her
❖ Red blood cell count caloric intake by 300 kcal/day
during 2nd & 3rd trimesters.
Signs of pregnancy
increases up to 30%
❖ Recommended weight gain
❖ Plasma increases up tp 50%
depends on pre pregnancy BMI.
❖ Hemoglobin decreases ❖ Presumptive: subjective data ❖ FIRST TRIMESTER : 3-4 lb total
❖ Hematocrit decreases the woman reports to the HCP ❖ REMAINDER OF PREGNANCY: 1
❖ for example, “ My breasts hurt” lb per week.
❖ Total weight gain: 25-35 lb for a
Cardiac changes
❖ Probable : objective data such
as cervical changes woman with a normal BMI
❖ Positive : diagnostic
❖ Blood pressure slightly
confirmation such as, fetal
decreases
heartbeat & ultrasound
Nutrition
❖ Heart rate increases by
10-15 BPM
❖ Cardiac output increases ❖ When a woman isn't getting the proper nutrients this can cause
Amenorrhea which can inhibit the ability to become pregnant.
❖ Lack of folic acid can cause neural tube defects( spina bifida) and cause
damage to the growing fetus.
❖ Deficits in Vit C have been shown to also cause birth defects and
Integumentary changes
cancer.
❖ Pica:
❖ Chloasma : “ pregnancy mask” ❖ persistent ingestion of nonfood substances such as clay, laundry
brown blotchy areas on the skin of starch, freezer frost, or dirt.It results from a craving for these
substances that some women develop during pregnancy.
the face, cheeks, nose and
❖ These cravings disappear when the woman is no longer pregnant.
forehead.
❖ Pica is associated with iron-deficiency anemia, but it is unknown
❖ Linea nigra: a dark line down the whether iron deficiency is the cause or the result
middle of the skin on the abdomen
Nutritional requirements
❖ Striae: develop in response to
increased glucocorticoid levels.
Also known as stretch marks ❖ Proteins: Growth and repair of fetal tissue, placenta, uterus,
breasts, and maternal blood volume
❖ Minerals: Prevent deficiencies in the growing fetus and maternal
stores
Musculoskeletal changes
❖ Iron : Formation of hemoglobin; essential to the oxygen-carrying
capacity of the blood
❖ Calcium: Nerve cell transmission, muscle contraction, bone
❖ Lordosis: Excessive inward building, and blood clotting
curvature of the spine ❖ Phosphorus: Promotes strong bone growth
❖ Diastasis rectus abdominis: ❖ Zinc: Fetal growth and maternal milk production
tearing of the rectus abdominis ❖ Iodine : Promotes normal thyroid activity, preventing specific birth
muscles defects
Vitamin requirements
Respiratory changes Folic acid (Vitamin B9)
❖ Nasal mucosa edematous due to ❖ Necessary for formation of the nervous system
vasocongestion ❖ Prevents up to 70% neural tube defects
❖ Nasal congestion and voice ❖ Diet should include at least 400 mcg of folic acid per day
changes possible
❖ Accommodations to maintain lung Vitamin A
capacity ❖ Recommended intake via beta-carotene
❖ May feel short of breath when ❖ Too much can be toxic to the fetus
❖ Too little can stunt fetal growth and cause impaired dark adaptation
eupneic
and night blindness
❖ Third trimester diaphragm pressure
Vitamin C
❖ Essential in the formation of collagen, a necessary ingredient to
GI changes
wound healing
Vitamin B6
❖ Necessary for the healthy development of the
❖ Intestines are displaced fetus’s nervous system
upwards & to the side. Vitamin B12
❖ Pressure changes in the ❖ Needed to maintain healthy nerve cells, RBCs, form DNA
esophagus & stomach
which leads to heartburn.
❖ constipation
246
_ _
Labor and delivery
247
Stages Of Labor I
Maternity
Contraindication
Full Term: 37 - 42 weeks
Labor is the delivery of the baby - from the mother & into the world.
Preterm Labor: before 37 weeks
1 2 3 4
4 Stages of Labor
Stage 1: Get to 10 cm The whole process typically takes around
Stage 2: Delivery of the baby
12 - 18 hours, but time can vary greatly.
Stage 3: Placenta delivery
Stage 4: Don't let your client bleed to death!
12 - 18 hours
4 Signs of TRUE Labor

4. Cervix
4 Signs of TRUE Labor 1. Dilatation: how wide is the cervix (goal = 10cm)
Memory Trick 10 cm
D - Dilatation
1. “Bloody show”: mucus & blood D - Door OPENING
2. Water breaking: Amniotic sac rupture Measured in cm 0 - 10 cm
10 cm is the GOAL!
3. True Labor Contractions 1 1 1
Increased Frequency (regular & rhythmic) 2. Effacement: cervix gets thinner & shorter Not effaced 50% effaced
Increased Intensity & Duration

or dilated and not dilated
2 3 2
3
2 3 Memory Trick
E - Effacement
1
2
E - Elastic cervix gets thinner & shorter
3
Measured in percentages from 0 to 100%
100% effaced and Fully dilated
dilated to 3cm to 10cm
When you do a vaginal exam, you literally stick a sterile-gloved finger through the cervix.
How thick is it?
• As thick as your finger is 0% 0%
50%
• To your middle knuckle is 50% 100% 80%
• Half way between the tip and your first knuckle is 80%
• Paper thin: 100%
Kaplan Question
Braxton Hicks Contractions
… 4 cm dilated and 60%
effaced... explain the meaning False labor contractions
of this information? Disappear with walking or
The opening of the cervix is position change
4 cm wide and the cervical No dilatation of cervix
canal is 60% shorter than normal
HESI question
false labor contractions?
Decrease in intensity with
60% ambulation
4cm
Notes
248
5 P’s of Labor
Maternity
The 5 P’s of labor occur in the first AND second stages of labor (when the baby is being delivered).
P PASSENGER (baby)
P PASSENGER (baby)
P PASSENGER (baby)
Baby delivery: fetal head & body size Baby delivery: fetal head & body size Baby delivery: fetal head & body size
▪ Presentation “Presenting Part”
Fetal Attitude (Flexed = good & Extended = bad) ▪ Position of the baby
- Cephalic Presentation: Head first NCLEX TIP
Best Bad ▫ Diamond-shaped & soft in the middle
● ROA: Right Occiput Anterior
Fully flexed Flaccid is indicative of
BEST ● LOA: Left Occiput Anterior
1. Chin to chest a CNS problem
Position
2. Rounded back Memory Trick
3. Flexed arms & legs
- OA think AOkay :)
P
Fetal Lie: position of baby’s back in relation to “sunny side up”
mom’s back PASSENGER (baby) ● OP: Occiput Posterior (left or right)
BEST High Risk ● OT: Occiput Transverse (left or right)

for Vaginal Delivery for Breech - C-section Delivery
Baby delivery: fetal head & body size Bad Memory Trick
Longitudinal lie: both
Position - OP - OhPoop not good!
- Transverse: “sideways” baby
baby & mother’s body - Oblique: baby is at an angle ▪ Fetal Station degree of fetal descent - OT - Oh Trouble!
are parallel
into the pelvis Complication:
BACK labor → possible C-section
P PASSENGER (baby)
-5
-4
-3
Station
-1 to -5
Pelvic Inlet
Baby’s head is ABOVE mom’s ischial spine
-2
Baby delivery: fetal head & body size

-1
0
(baby is deeper inside the pelvis)

+1
+2
+3
▪ Position of the baby

+4
+5
Station 0 Ischial Spine & Engagement

- Complete Breech Fetal Station
Breech Baby’s head is level with mom’s ischial spine
- Frank Breech
Presentation *Head is engaged & ready for labor!
- Footling Breech
Interventions
- External cephalic
version (ECV)
- C-section
P PASSENGER (baby) Station
+1 to +5
Crowning & emerging from vagina
Baby’s head is coming out! “Crowning”
Placenta: placenta previa (blocks the cervix) Start pushing!
HESI Question
P PASSAGEWAY Which are factors that accelerate dilation of the

cervix? Select all that apply.
Strong uterine contractions
▪ Birth canal: maternal pelvis & soft tissues Pressure by amniotic fluid
Birth canal Force by fetal presenting part
P
3 Contraction Indications of
Assessments: Progressing Labor
POWER
1. Frequency AVOID
2 - 3 minutes apart
(how often - minutes)
▪ C - Contractions to OPEN the cervix
2. Duration Lasting 60 seconds
▪ D - Dilation: 10 cm (fully open) (how long - seconds) 60 seconds between
AVOID pushing until 10cm dilated contractions 10 cm
▪ E - Effacement: 100% thin 3. Intensity Contractions increase

(how strong) closer to delivery
P POSITION
Mother: squat position makes labor easy

- Promotes fetal descent
P PSYCHOLOGICAL
RESPONSE OF MOTHER
▪ Cultural considerations
▪ Coping mechanisms
249
Stages Of Labor II
Maternity
TRUE Labor FALSE Labor

Q1: Which signs are most indicative of true labor?
Regular (increasing frequency, Irregular Select all that apply.
CONTRACTIONS duration, & intensity) Pain in lower back that moves to lower abdomen
Progressive cervical effacement & dilation
10 cm
Regular & rhythmic contractions that increase in frequency
Contractions become more intense with walking
0% 100%
PAIN Does NOT decrease with rest Alleviated with rest or changing
position Top Missed NCLEX Questions
Q2: Which questions would help determine if the client is in true labor?
Contraction
frequency?
“Do you feel like the contractions are getting stronger?”
“Does anything you do make the pain better?”
CERVIX *progressive change NO change “Do the contractions feel the same when lying down?”
Dilation & effacement “How frequent are the contractions?”
“Where do you feel the contraction pain most?”
SIDE NOTE
Back pain “back labor” NCLEX TIP SLOW progression, LONG labor
Occiput Posterior position (OP)
Memory Trick: BACK PAIN
OP - OhPoop not good!
2 Interventions NO position changes & remaining in bed during EARLY labor increases
risk for persistent fetal malposition & will SLOW labor progression!
1. Apply counterpressure to the sacrum Left lateral position will NOT alleviate the client’s back pain - this
during contractions NCLEX TIP position is good for fetal oxygenation & blood flow.
2. Reposition the mother on her hands &
knees with birth ball & encourage to The MOST tested
change position every 30 - 60 minutes
30 - 60minutes
HESI Question
Q1: Client reports intense back pain … fetal position is right occiput
posterior. Which intervention would help alleviate the back pain
during early labor?
“Applying counterpressure to the sacrum during contractions
Which supportive care measure ...
back labor pain?
Lean over a birth ball with her
Q2: Appropriate task to delegate to the unlicensed assistive
knees on the floor personnel (UAP)?
Reposition an unmedicated client who is in active
labor onto a birthing ball
1st Stage of Labor Phase 1: Early/Latent Phase

Early Education & Encouragement
Early/ Latent Phase - the client is relaxed & contractions are mild.
0 - 3 cm cervix dilation
Active Phase - things are getting serious, breathing techniques are in full swing 0 - 30% Effaced (thinner cervix)
& irritable! Oxytocin stimulates uterine
Transition Phase - is when the cervix dilates to that perfect 10! contractions! Key Point
Irregular Contractions
Stage 1 begins with the onset of labor & ends with FULL cervical dilation (Short & far apart)
at 10 cm - the perfect 10 � Frequency 5 - 30 min
� Duration 30 seconds
3 phases Monitor fetal heart rate!
1 2 3 Priority
Assess for late decelerations (not
Early/ Latent Phase Active Phase Transition Phase
enough oxygen getting to the baby)
1
2 3
10 cm
0cm 3cm
250
Stages Of Labor III
Maternity
1st Stage of Labor
ATI Question HESI Question Kaplan Question

latent phases of labor? … what do you closely monitor during the … purpose of the fetal monitor?
Contractions every 5 to 10 latent phase of the first stage of labor? “To determine if the fetus is receiving
Fetal heart rate an adequate amount of oxygen.”
Phase 2: Active Phase Top Missed NCLEX Question

GO to the HOSPITAL! Remember narcotics make the vitals A client in latent labor receiving an oxytocin infusion for
Breathing techniques & pain management

low & slow leading to newborn sedation labor augmentation is requesting IV pain medication.
Which nursing action is appropriate?
4 - 7 cm cervix dilation (Goal = Perfect 10 cm) & respiratory depression at birth! Give the medication slowly during the peak of the
100% effaced (fully thinned cervix) IV narcotics given at the peak of next contraction
Contractions (stronger & longer) contractions reduce the amount of

Pain Medications: narcotic that crosses the placental barrier
• Epidural
NARCOTICS
• IV narcotics - give slowly during the

& will help to decrease the sedation of
peak of the contractions NCLEX TIP the fetus.
Phase 3: Transitional Phase HESI Question

Focus & staying in control
8 - 10 cm cervix dilation (Goal = Perfect 10 cm)
… expected during the transition
100% effaced (fully thinned cervix)
Contractions (strongest & closer) phase of the first stage of labor?
5 Key Points: 8cm 10cm Vomits
1. Anxiety & Vomiting Bloody mucus
2. Urge to have a bowel movement
3. Strong urge to push with each contraction
Urge to have a bowel movement
4. DO NOT push until 10cm (fully dilated)
Risk for cervical swelling & lacerations
5. Amniotic sac ruptures “bloody show”
Priority Assess color of amniotic fluid
(water break)
• Meconium-stained fluid (dark fluid)
Sign of fetal distress or hypoxia
Aspiration risk!
Interventions Every 15 minutes
4 NCLEX TIPS
1. Emotional support & encouragement
2. Breathing techniques
3. 10 cm dilated - document fetal HR
every 15 minutes Saunders
4. AVOID pushing until 10cm (fully dilated)
10 cm Risk for cervical swelling & lacerations

A laboring client reports anxiety, vomiting, & the need to ATI Questions
have a bowel movement. What is the expected cervical
examination finding? 100% Q1: … 30 weeks of gestation. Which medication... to
accelerate fetal lung maturity?
A. 7 cm dilated, 100% effaced Betamethasone
B. 8 cm dilated, 100% effaced Q2: … terbutaline. Which of the following client statements
indicates an understanding of the teaching?
C. 6 cm dilated, 70% effaced
This medication is used to stop my contractions
D. Go to the break room
8cm 10cm
Notes
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Stages Of Labor IV
Maternity
2nd Stage of Labor

2nd Stage of Labor (Delivery of baby) is also called the HESI Question
descent phase or the pushing stage, because the baby is … second stage of labor?
pushed out of the birth canal. significant increase in contractions
4 Key Points Ferguson reflex activated
The client experiences a strong urge
1. Cervix MUST be 100% effaced & 10 cm dilated
to bear down
Memory Trick Think perfect 10!
2. Signs:
Increase in contractions & urge to push/ poop 10 cm
Ferguson reflex: Spontaneous urge to push during labor. 10 = Perfect

It occurs when the presenting part of the fetus reaches
the pelvic floor. Top Missed NCLEX Question
3. Interventions A client presents to the emergency department after her water broke. She appears anxious
Positioning of the mother is Priority: HESI
and in pain, bearing down with each contraction. What assessment questions should the
High Fowlers, Lithotomy, Side lying nurse ask immediately to prepare for birth & potential newborn resuscitation?
Push properly
1. AVOID holding breath or tightening the abdomen When your water broke, what
Push down
2. Push when feeling the urge was the color of the fluid?
Opioid
3. Breath IN deep What is your expected due date (EDD)?
4. Breathe OUT slowly through the mouth How many babies are you expecting?
& keep mouth open while pushing down HESI
Frequency
Do you have any active sexually
4. Assessments transmitted disease?
Fetal heart rate before, during, & after the contraction
Recently have you taken any
Frequency of contractions medications, opioids, or illicit drugs?
Duration of contractions
Contraction
Uterine tone between contractions
3rd Stage of Labor High Risk for

Infection - if placenta parts are not
In the 3rd Stage of Labor (Placenta Delivery) - the Uterus contracts & fully removed
Uterine inversion (pulling on the cord)
the placenta spontaneously detaches from uterine wall. Severe hemorrhaging (bleeding)
Placenta MUST BE delivered carefully. Decreasing blood pressure
Increasing heart rate
NEVER pull on the cord to deliver the placenta! Pharmacology AFTER placental delivery
There is a HIGH risk for tearing the placenta & leaving behind placenta parts P - Placenta delivery
& possible uterine inversion - this is when the uterus flips inside out, both of P - Pitocin (oxytocin): to prevent hemorrhage
which put the client at risk for hemorrhage and infection. Key point Oxytocin stimulates
uterine contractions
ATI Question
... third stage of labor?
The baby has been delivered &
the mother is now delivering
the placenta
4th Stage of Labor Maternal Assessment Interventions

Infection: temperature over 100.4 Fundus check First
Hemorrhage Soft & boggy → massage until firm
4th Stage of Labor (Recovery) - (contract & stop bleeding)
The Recovery Stage lasts around 2 - 4 Priority Assessments: Void or use catheter (in & out)
hours after birth. At this point we Peri pads Pitocin (oxytocin): IV or IM
encourage skin to skin & breastfeeding Fully saturated in less than 1 hour! control bleeding after childbirth
for multiple reasons. Decreasing blood pressure Breastfeeding: stimulate release of
Increasing heart rate natural oxytocin
Fundus Assessment
Breastfeeding stimulates maternal Assess 3 times, every 5 minutes
oxytocin release (to help the uterus
contract). It provides nourishment and Notes Then, every 15 minutes for an hour
supports blood sugar of the newborn. Fundus of uterus
252
Stages Of Labor V
Maternity
4th Stage of Labor
NORMAL Fundus NOT Normal

Firm Displaced fundus above umbilicus or to
Midline one side = bladder distension
Level with the umbilicus (belly button) Intervention
VOID every 2-3 hours
(bed pan prefered)
Fundus of uterus
In & out catheter NCLEX TIP
Soft or boggy (uterine atony)
= increase risk for hemorrhaging
Intervention
Oxytocin infusion
Fundal massage NCLEX TIP
Top Missed NCLEX Questions Top Missed NCLEX Questions

Q1: A client who gave birth vaginally with epidural Q2: A client who had a vaginal birth 1 hour ago has a
anesthesia reports no urge to urinate 3 hours after boggy fundus that is deviated to the left and above
birth. The client’s fundus is above the umbilicus, but 3 the umbilicus. Which intervention should the nurse
cm to the right. What should the nurse do next? perform first?
Perform in and out catheterization Assist client to use the bedpan to void
ATI Question Kaplan Questions

Fundus of uterus
... the client delivered a baby 8 hours Q1: ... six hours after a vaginal delivery … the
Methergin nurse notes the perineal pad is soaked
ago… the fundus is boggy and soft. Which
interventions are most appropriate? and there is blood underneath the client’s
Select all that apply. buttocks. Which action does the nurse
take first?
Firmly massage the fundus
Assess the fundus
Encourage the client to void
Administer Methergine per orders
HESI Questions
Q1: … profuse bleeding in a postpartum client…
Kaplan Questions priority intervention?
Q2: ... after delivery the nurse administers Palpate the uterus and massage it if OXYTOCIN
oxytocin…. this medication is used for it is boggy
which purpose?
Simulate firm contractions of the uterus HESI Questions
Q2: Which drug is used for treating a client with
severe postpartum bleeding?
Oxytocin
Saunder’s Questions
Fundus of uterus
Q1: Fourth stage of labor ... Early sign of excessive
blood loss? 102 Q2: Fourth stage of labor... client’s perineal pad
An increased pulse rate of 88 to 102 bpm saturated with blood & blood soaked into the
bed linen. Which is the nurse’s initial action?
Gently massage the uterine fundus
Notes
253
Stages Of Labor VI
Maternity
Lochia Assessment
Lochia is the discharge after birth from the sloughing off of the inner lining of the uterus.
Lochia should become LIGHTER in COLOR and AMOUNT with each passing postpartum day,
It's going to start out heavy and red (rubra), then go pink/brown (serosa), & finally return to white/clear (alba).
Color It lasts...
Normal NOT Normal
RUBRA Dark red 3 - 4 days 3 Stages of Lochia Notify the provider
SEROSA Pinkish brown 4 - 10 days Lochia Rubra: Large clots!

Bright red flow (3 - 4 days) Malodorous “Foul odor”
ALBA Whitish yellow 10 - 28 days * Small clots are expected
Excessive bleeding:
Lochia Serosa: 1 pad in 15 minutes
Pink-brown (4-10 days) Check under the client for
pooled lochia
Lochia Alba:
White-yellow (10-28 days)
ATI Questions Lochia serosa

Kaplan Question
Q1: The nurse is assessing a … client who
… client gave birth three hours ago… a delivered a baby 3 days ago. When
sudden gush of blood from the vagina while assessing for lochia, the nurse notes
ambulating. Which is the most likely cause pink discharge with a serosanguinous 3 days
of the bleeding? consistency. This is best described as:
Lochia has pooled in the client’s vagina Lochia serosa
Q2: a client … 6 weeks postpartum. Which
of the following findings is normal for
this client?
Creamy colored discharge with
Peri-care a fleshy odor 6 weeks
Cleaning ATI
1. Squeeze bottle with warm water
2. Wipe front to back ATI Question
3. Blot perineum dry … a client who has an episiotomy Warm water
Pain … proper perineal care?
1. Sitz baths Use a squeeze bottle with
2. Ice packs warm water to keep the site
clean
3. Pharm: Opioids & NSAIDS
4. Topical witch hazel
5. Laxatives & stool softeners HESI Question
(prevent constipation)
Which medication is appropriate
Warm water
for a postpartum client with
perineal lacerations ...
now experiencing constipation?
Opioids NSAIDs
Laxatives
Notes
254
_ _
Fetal Heart Monitoring
255
Fetal Heart Monitoring I
Maternity
0₂
0₂ 0₂
0₂
Fetal heart rate monitoring is a way to identify fetal well being & oxygenation during labor. 0₂ 0₂
During labor it is vital to monitor both uterine contractions & the baby’s heart rate.
Abnormal reading may indicate the baby is not getting enough oxygen or other problems.
There are 2 types of devices used for External Fetal Monitor -

The sono or ultrasound (used for the baby’s HR) & the toco
or tocometer (for mom’s uterine activity).
External Fetal Monitor THE POINT OF That is the best place to put the fetal heart rate
sensor. The PMI is found between the shoulders.
Find Point of Maximal Impulse (PMI) MAXIMAL IMPULSE!!!!
this is point where the baby’s heart If the baby is cephalic or head down, it will be placed
rate can be heard the loudest
Point of Maximal on the mother’s lower abdomen & if the baby is
Impulse (PMI) breech, the monitor will find the PMI in the upper
abdomen.
Finally a 2nd sensor is the contraction monitor.

The sensor is placed high on the mothers abdomen
to monitor contractions.
A more accurate but more invasive method of monitoring the baby is an

Internal fetal monitor (Fetal Scalp Electrode - FSE). These monitors are Internal fetal monitor
typically only used for high risk pregnancies. Fetal Scalp Electrode - FSE
This method uses a thin wire electrode that is placed directly on the baby’s scalp
through the cervix.
This method gives better readings as it's not affected by movement.

It can ONLY be used after the amniotic sac has ruptured & the cervix is
open to at least 2 cm in dilation.
The FSE comes with a HIGH risk of infection since we are placing a foreign
object into the mother’s vagina & onto the baby’s head.
ATI question
Which of the following must be present before
the nurse initiates internal fetal monitoring?
Cervical dilation of at least 2 cm
2cm
Notes
256
Fetal Heart Monitoring II
Maternity
Top 8 Strips to Know Always assess FIRST!

240
210
As you can see, there are 2 strips here showing squiggly lines - similar to 180
an EKG. Fetal heart rate is on top - which we always assess FIRST!

150
120
90
Mothers contractions are on bottom. The double red lines represent

60
30
1 minute in time.
100
75
50
25
210
0
Variability: how jiggly or wiggly is the line?

As labor progresses, we180 expect the fetal
Key Terms for FHR Variability heart rate to have wiggly lines -
this is called variability.
Baseline: Normal FHR 110-160 bpm
Variability: how jiggly or wiggly is the line? It means that the baby’s neuro system is
150
More wiggly = More happy baby
intact & the baby is happy!
In general we say
the more wiggly=more120 happy baby.
We have different types of variability, kind of like a traffic light.

The RED light where we STOP what we’re doing & run to get the baby out is
Absent variability: NOT jiggly = NOT good!
Types of Variability
Absent variability: NOT jiggly = NOT good!
Minimal variability: Flatter line that looks “sleepy & sad”
Moderate variability: Normal & desired finding!
Marked variability: Jagged jiggles = stressed baby!
Absent variability: NOT jiggly = NOT good! Minimal variability: Flatter line that looks “sleepy & sad”
FHR 240bpm
210
210
180
180 150
120
150
90
120 60
90
100 100 100
60 75 75 75
50 50 50
30 25 25 25
0 0 0
Moderate variability: Normal & desired finding! Marked variability: Jagged jiggles = stressed baby!
210 210 210
180 180 180
210 210
150 150 150
120 120 120 180 180
90 90 90
150 150
60 60 60
120 120
30 30 30
90 90
100 100 100
75 75 75 60 60
50 50 50
30 30
25 25 25
257
Fetal Heart Monitoring III
Maternity
Accelerations
These are temporary increases in FHR. It indicates great oxygenation for the baby!
We call these “happy little mountains”. They are little bonus points that show the baby is doing well!
210 210 210
Accelerations 180 180 180
Temporary increases in FHR.

150 150 150
Indicates great oxygenation for the baby! 120 120 120
“Happy little mountains” 90 90 90
60 60 60
30 30 30
Decelerations
These are dips from baseline & there are 3 different types. Always look at the shape & timing with each contraction.
Decelerations: Dips from baseline

210 210 210
180 180 180
150 150 150
Early Decels: are GOOD! 120 120 120
Shallow, bowl shaped dips that mirror

90 90 90
GOOD!
60 60 60
mother’s contractions
30 30 30
• Indicates head compression 100 100 100
Memory Trick
75 75 75
50 50 50
Good to be Early with Early Decels 25
0
25
0
25
240 240 240 240 240
210 210 210 210 210
Variable Decels: is Very concerning with

180 180 180 180 180
150 150 150 150 150
VERY
120 120 120 120 120
Very deep “sharp V dips”

90 90 90 90 90
CONCERNING!
60 60 60 60 60
30 30 30 30 30
• Indicates cord compression 100
80
60
100
80
60
100
80
60
100
80
60
100
80
60
40 40 40 40 40
20 20 20 20 20
0 0 0 0 0
These are the WORST!

210 210 210
180 180 180
150 150 150
Late Decels: BAD!!!

120 120 120
90 90 90
• Indicates decreased oxygen (hypoxia) BAD! 60
30
60
30
60
30
Memory Trick: Bad to be late to the 100 100 100
party (don’t be late with the dip!) 75
50
75
50
75
50
25 25 25
0 0 0
V Variable Decelerations
W or V shaped dips V C C Cord Compression
CHANGE mom’s position
FETAL
ACCELERATIONS
E Early Decelerations
Mirror the contractions E H H Head Compression
HAPPY baby baby is ready for delivery
& DECLERATIONS A Accelerations

Temporary increase in HR A O O Okay
Oxygen for baby
L Late decelerations
Lower HR after contractions L P P Placental Insufficiency
PROBLEM
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Cesarean Birth
Maternity
Contraindication
Performed after 28 weeks of gestation. C-sections can either be planned or an unplanned emergency.
Top reasons Common NCLEX Question

1. Planned C section Which client statement should prompt the nurse to
Previous C-sections request a primary cesarean birth from the provider?
Large baby or a lot of babies (triplets “I lost my acyclovir prescription and I’ve noticed
lesions on my labia that are stinging and burning.”
or twins)
Genital herpes or other infections (mom)
Placenta previa (placenta blocks the cervix) HESI Question
2. Emergency C-section Which condition places the pregnant client at a
Fetal distress: if the baby’s life is in danger higher risk for a cesarean delivery?
Placental Abruption
Placental abruption: placenta separates A client with the fetus in a transverse lie
from the wall of the uterus
Prolapsed cord: umbilical cord is
compressed, limiting oxygen to the baby
Long labor or contractions not
strong enough
Breech birth: baby is in an odd position.
Transverse lie or oblique lie
Transverse Lie
Surgical Procedure
- The client is put to sleep with anesthesia or awake with local anesthesia.
- Then Incisions are made on the abdomen through the uterus and the
health care provider will rupture the amniotic sac to deliver the baby.
- The entire process typically takes only a few minutes to get the baby out.
But can take longer in certain cases.
Complications
After a c-section, the highest priority is to monitor the client for hemorrhage & shock. This severe bleeding will
lead to low blood pressure that will kill the client!
Complications Hemorrhage & Shock

Hemorrhage & shock KAPLAN
Placenta Previa: placenta attaches in Kaplan Question
the wrong location, over the cervical
Cesarean delivery... The nurse places the
opening
highest priority on monitoring the client for
Placenta Accreta: where the placenta which potential complication?
attaches to the uterus too firmly NORMAL
Hemorrhage and shock
Uterine rupture: if this uterus is
HIGH
LOW
scarred from a previous C-section it

has weak spots that can rupture.
Post-Operative Care
Obviously the client will be in pain with a big incision that is healing.
Surgical Wound Dressing
The key point is focused on removal of the surgical wound dressing.
ONLY the surgeon removes the initial (first) dressing!
The initial (first) dressing is ONLY removed by the surgeon …
Not the nurse, not the aid, not the student, NOBODY but the surgeon!
If the surgical site is bleeding, do you remove the surgical dressing then?
No, only the surgeon removes the initial dressing.
If it’s bleeding, just keep adding pads to the site & call the surgeon. DO NOT REMOVE!
Once the surgeon removes the initial dressing, then you can assess the wound like normal.
Always assess for infection with any surgical site:
-Warm
-Red
-Draining
259
Fetal Heart Monitoring IV
Maternity
HESI questions
240
Q1: What happens when oxytocin levels are elevated…? 210
180
Uterine contractions will increase 150
120
Q2: The nurse assesses fetal well-being during labor by monitoring

90
60
which factor?
30
100
Response of the fetal heart rate to uterine contractions 75
50
25
Key Terms for Uterine Contractions

During contractions, babies will hold their breath & fetal oxygenation Key Terms for Uterine Contractions
is impaired - so knowing this is VITAL to keep the baby well
1. Frequency: measures how FAR APART
oxygenated in between. There are 4 components to know.
the contractions are
Frequency (minutes) 2. Duration: measures how LONG the
Intensity (mmHG) contractions last
0₂
3. Intensity: rates how STRONG the
contractions are
0₂ 0₂
0₂
0₂ 0₂
4. Rest (Tone & Time): the uterus should
be SOFT to palpation between
0s 60s contractions for at least 60 seconds.
Duration (seconds)
Normal Contractions 2-3 mins

(Rule of 60) Intensity: 60 mmHg
Frequency: contractions
that are 2 - 3 mins apart in
active labor.
Duration: 60 seconds
Intensity: 60 mmHg
Rest: 60 seconds or rest in
between contractions 60 seconds Duration: 60 seconds
Normal UC pattern
Tachysystole Complication!
Over 5 contractions in 10 minutes
Too many contractions → Fetal Distress!
Including Hypoxia & reduced placental
blood flow
Tachysystole pattern
10 mins
260
Fetal Heart Monitoring V
Maternity
Normal NOT Normal

Expected Findings Fetal Distress
1. Normal FHR 110 - 160 bpm 4. Tachy/bradycardia
2. Accelerations 5. Late decelerations
3. Early decelerations 6. Variable decelerations
7. Sinusoidal Tracing
Memory Trick:
Good to be Early With early decels Memory Trick:
BAD to be LATE Late or variable
180 210
180
150
100 120
90
60
30
8 Strips on the Nclex
Normal FHR Strips Normal 110 - 160bpm

1. Normal FHR: 110 - 160 bpm
Baseline is between contractions
2. Accelerations:
Temporary increase in FHR (this is ok!)
GOOD!
3. Early decelerations Acceleration Acceleration
Mirror contractions with decreased
FHR during contractions = ok! HESI question
• Cause: Head compression Which fetal heart rate tracing
during the contractions
characteristics are considered
• Intervention: Prepare for
reassuring or normal?
delivery of the baby
Memory Trick:
Early decelerations, either
Good to be Early present or absent
With early decels
Not Reassuring (Risky!) ATI Question HESI Questions

… client with a fractured wrist who is 36 weeks Q1: While monitoring the FHR ... the nurse notes
4 . Fetal Tachycardia
pregnant. Which of the following assessment tachycardia. Which is a probable cause for
increase in FHR over 160/min for over 10 minutes this condition?
items should the nurse prioritize?
Early sign of fetal distress! HESI
The fetal heart rate is 210/min Early signs of fetal distress
Causes
Trauma to mother (broken bone)
Maternal Infection or fever
Fetal anemia
Dehydration HESI Questions
Stimulants (Cocaine) Q2: ... a FHR baseline of 175 bpm. The nurse
Interventions knows that this can be caused by which
Oxygen factor?
IV fluids 210 Fetal tachycardia
Antipyretic
Not Reassuring (Risky!)

Saunder’s Question
5 . Fetal bradycardia HESI Questions
decrease in FHR over 110/min for over 10 minutes … slowing of the fetal heart rate and a loss of
Causes variability… nursing action? Q1: ... maternal cardiac output can be increased
Uteroplacental insufficiency by which factor?
Turn the client onto her side & give
Umbilical cord prolapse oxygen by facemask at 8-10 L/min Change in position
Maternal hypotension
Analgesic medication
Kaplan Question HESI Questions
Interventions
… Abrupt and rapid fluctuations in the fetal heart rate Q2: ... sudden drop in fetal heart rate (FHR) from its
Memory Trick
(FHR) from baseline to 90 beats per minute and back to baseline of 125 down to 80. The nurse repositions the
R Reposition mom: side lying position baseline … The fluctuations in fetal heart rate occur with client, provides oxygen, increases intravenous (IV) ...
no relationship to the contraction pattern. Which response Five minutes have passed and the FHR remains in the
O Oxygen via Facemask
by the nurse is best? 80s. Which additional measure would the nurse take?
A Alert the HCP (provider)
“This is a potential problem that requires a Immediately notify the primary health care provider
D Discontinue oxytocin position change.”
I Increase IV fluids
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Fetal Heart Monitoring VI
Maternity
8 Strips on the Nclex

Amnioinfusion
CRITICAL Findings! The installation of sterile saline into the amniotic
cavity to refill the lost fluid.
6 . Variable decelerations Report Immediately
Abrupt decreases in FHR Indications of Overfilling NCLEX TIPS
Less than 30 seconds from onset to baseline Uterine resting tone that increases to 45 mm Hg
& 15 bpm below baseline for 15 sec - 2 min Dry perineal pads
Causes
Umbilical Cord Compression! NCLEX TIP
Critical: Oxygen tube is compressed!
120 120 120
100 100 100
Decreased amniotic 80 80 80
60 60 60
Interventions 40 40 40
Prolapsed cord 20 20 20
Memory Trick 0 0 0
R Reposition mom: side lying position

O Oxygen via facemask Resting tone:
A Alert the HCP (provider) 45mmHg
D Discontinue oxytocin
I Increase IV fluids
CRITICAL Findings! TOP TESTED Top Missed NCLEX Question Kaplan Question
A new nurse is evaluating the fetal monitoring strip of a client in labor who is receiving
7 . Late decelerations an oxytocin infusion. Which of the following actions should the nurse take next?
… fetus is experiencing distress if which heart
Click the exhibit Select all that apply.
Decreased FHR after contractions with prolonged rate pattern is observed?
time before returning to baseline Slow the oxytocin infusion
Indicates that oxygenation is compromised! NCLEX TIP

Reposition the client to left/right side Late decelerations
Amnioinfusion
Causes Oxygen by face mask
Placental insufficiency
ATI Question
Initiate an IV bolus of 0.9% saline
(Uteroplacental insufficiency) HESI Notify the provider & prepare terbutaline
Uterine tachysystole NCLEX TIP

Which of the following interventions ... after
Side effects of oxytocin causing severe contractions
HESI Question examining this fetal monitoring strip?
→ Reduced placental blood flow & impaired fetal
oxygenation Oxytocin induction … the last five contractions, the fetal Discontinue oxytocin
heart rate has fallen below the baseline … and returns to
Over 5 contractions in 10 minutes baseline in 20 to 30 seconds after the end of the contraction. Run the IV fluids wide open
STOP Oxytocin
Late decels What actions must the nurse take?
Hypotension Select all that apply.
Memory Trick Contact the health care provider
BAD to be LATE With late, absent or variable decels
Stop the infusion of oxytocin
Interventions Increase the infusion of the mainline IV fluid
Memory Trick Apply oxygen by facemask Oxytocin
R Reposition mom: side lying position
O Oxygen via facemask
A Alert the HCP (provider)
D Discontinue oxytocin
I IV fluids (0.9% NS bolus or LR)
Prep for C-Section if late decels persist
CRITICAL Findings! Top Missed NCLEX Question

The nurse is observing the fetal heart rate (FHR) tracings
8 . Sinusoidal FHR
of 4 clients. Which pattern would be most concerning?
Repetitive, wave-like fluctuations (hills) with 1. 240 240 240
Early decelerations Variable Decelerations
NO variability & NO response to contractions
210 210 210
180 180 180
1. 2.
150 150 150
120 120 120 240 240 240 240 240 240
90 90 90 210 210 210 210 210 210
Causes
60 60 60 180 180 180 180 180 180
30 30 30
150 150 150 150 150 150
120 120 120 120 120 120

100 100 100
80 80 80 90 90 90 90 90 90
Mother abdominal trauma

60 60 60
40 40 40 60 60 60 60 60 60
20 20 20
30 30 30 30 30 30
0 0 0
(fall, motor accident) 2.

100 100 100 100 100 100
80 80 80 80 80 80
240 240 240
60 60 60 60 60 60
210 210 210 40 40 40 40 40 40
→ leading to fetal blood loss or anemia

20 20 20 20 20 20
180 180 180
0 0 0 0 0 0
150 150 150
120 120 120
90 90 90
60 60 60
Interventions
30 30 30
100 100 100

80 80 80
Sinusoidal FHR Fetal tachycardia

60 60 60
40 40 40
Emergency Cesarean Section

20 20 20
0 0 0
3. 4.
3.
“Crash C-section”
240 240 240 240 240 240
240 240 240
210 210 210 210 210 210
210 210 210
180 180 180 180 180 180
180 180 180
150 150 150 150 150 150 150 150 150
120 120 120 120 120 120 120 120 120
90 90 90 90 90 90 90 90 90
60 60 60 60 60 60
60 60 60
30 30 30
30 30 30 30 30 30
Critical finding!
100 100 100
80 80 80 100 100 100 100 100 100
60 60 60 80 80 80 80 80 80
40 40 40 60 60 60 60 60 60
20 20 20 40 40 40 40 40 40
0 0 0 20 20 20 20 20 20
0 0 0 0 0 0
4.
Intervention required
240 240 240
210 210 210
180 180 180
150 150 150
120 120 120
90 90 90
60 60 60
Sinusoidal FHR
30 30 30
100 100 100

80 80 80
60 60 60
40 40 40
20 20 20
0 0 0
262
_ _
Epidural & Pain control
263
Epidural & Pain Control I
Maternity
Non Pharmacological
This means no medications are used for pain control during labor.
Breathing techniques HESI Question

Imagery
Which is an effective nursing intervention for a
Massage: effleurage client experiencing pain related to back labor?
Back labor pain: Sacral counter pressure Counter pressure against the sacrum
NCLEX
Monitor for nonverbal signs
of ineffective coping with labor
Panic
Anxiety
Squirming movements
Pain medication
Medication SEDATIVES
Pain control during labor with pain medications, like sedatives & opioids, are best given
during the early stages of labor, as they can cause serious side effects like respiratory Opiates
depression when given closer to birth!
These medications can be VERY DEADLY - we like babies with strong cries,
NOT FLOPPY BABIES. It’s best to give these 2-4 hours BEFORE birth so that the drug
has time to wear off BEFORE birth. 2 - 4 hours
Sedatives Opioids Opioids

Barbiturates 1. Meperidine hydrochloride (brand: Demerol)
Phenobarbital (brand: Tedral) 2. Butorphanol tartrate (brand: Stadol)
3. Nalbuphine hydrochloride (brand: Nubain)
Caution : Respiratory depression
Caution! 3 Key points for NCLEX Memory trick

1. ONLY give opioids: Opioids make labor slOw
During contractions
After the cervix is 4 cm dilated Opioid
or it will slow labor
HESI Questions 2. Assess fetal heart rate (FHR)
10 minutes prior
Q1: ... IV pain medication for a client in labor? 3. Have Naloxone (opioid antidote) ready
Administer the medication only when
the client is having a contraction
Assess the fetal heart rate (FHR) for 10 Naloxone HESI Questions
minutes prior to administering the pain
medication Q2: Which action would the nurse take before
administering meperidine hydrochloride to a
Naloxone will reverse the pain relief
client to relieve labor pain?
provided by the opioid
Monitor maternal vital signs and fetal
heart rate Fetal Heart Rate
Notes
264
Epidural & Pain Control II
Maternity
Epidural Anesthesia
Epidural anesthesia also called an epidural block, is an injection into the lower back that temporarily blocks
pain from the waist down. For the procedure, clients will lie on their side with knees tucked in or sit up right & lean
forward. To help visualize the position, nurses tell clients to curl over like a cooked shrimp.
When in the correct position, the provider will insert a needle into the client’s epidural space between the
dura mater & the vertebral wall just outside of the spinal cord.
A catheter is threaded through and secured as the epidural needle is removed. The catheter is used by the provider
to administer pain relief when needed.
NCLEX Questions
Q1: Which laboratory value is the priority to
Epidural Anesthesia report to the provider prior to epidural
anesthesia?
Epidural Block
Platelet count of 95,000
Blocks sensation from waist down:
umbilicus (belly button) to legs NCLEX Questions
After the cervix is 4 cm dilated Q2: An epidural was administered 20 minutes
ago and now the client reports feeling dizzy and
Less than nauseated. Which action should be performed
Caution ≤ 150,000
Normal first?
Maternal hypotension (low BP) 150,000 - 400,000 Bleed Risk! Obtain blood pressure
Fetal bradycardia (low HR)
Low platelet count in the mother Kaplan Question
Normal 150k - 400k
A client is 6 cm dilated and ready for epidural
Less than 150k = risky! BLEED RISK anesthesia. Which position will the nurse assist
the client?
On the left side, shoulders parallel, legs
flexed, and back arched
Spinal Anesthesia
Spinal Block
C-section
100% loss of motor movement &
sensation
Spinal Anesthesia
Interventions: Epidural & Spinal block HESI Question ATI Questions

… spinal block in place for pain… the client’s blood Q1: Which of the following can result in fetal
IV fluids to help counteract side effects pressure is 20% lower than the baseline level. bradycardia?
Which nursing action is appropriate?
of maternal hypotension The mother has received spinal anesthesia
Turn the client to the left lateral position or
Q2: After the epidural, the nurse notes decreased
place a pillow under her hip beat to beat variability and late decelerations on
Exam Question:
the fetal heart monitor. Which of the interventions
Nursing action for hypotension should the nurse implement?
Turn the mother to the left lateral Turn client on the left side
position & increase IV fluid rate Increase IV fluid rate
Pudendal Nerve Block ATI Question Top Missed NCLEX Question

Which of the following is correct regarding a A laboring client in the later part of 2nd stage of labor is urgently
Perineum pudendal block? requesting pain relief for the perineal area… cervix is 10 cm
dilated and 100% effaced, with the fetal head at -1 station.
Vulva A pudendal block anesthetizes the What is the most appropriate pain management technique
perineum, vulva, and rectum for this client?
Rectum Breathing techniques
Epidural anesthesia
Spinal anesthesia
Good: Vulva
Pudendal nerve block
Given quickly when birth is imminent
Bad: Perineum
DOES NOT relieve contraction pain Rectum
265
_ _
Preterm Labor
266
Preterm Labor I
Maternity
Preterm Labor refers to labor that begins too early between 20 - 37 weeks of pregnancy
characterized by CERVICAL change (that can be dilation or effacement), where as labor after Preterm Labor
37 weeks is considered full term and labor before 20 weeks is categorized as spontaneous 20 - 37 weeks of pregnancy
abortion - as the newborn will not survive.
Preterm labor is the number 1 cause of neonatal mortality, as babies born prematurely
do not have fully developed organs.
For example, the lungs do not have maturity to breathe on their own & the chambers in the
heart have not fully closed yet, just to name a few. Sort of like a cake coming out of the oven
too soon - it is not fully cooked.
In the same way, the baby is like a bun in the oven that comes out too soon & does not
have enough time to fully cook or develop. Naturally, we will see less complications the longer
the baby stays in the womb.
Causes & Risk Factors ATI Questions

D - Distended Uterus Q1: A 42- year-old pregnant client … at risk
Fetal macrosomia of preterm labor. Which information
Polyhydramnios (too much amniotic fluid) from the nurse is correct regarding
Multiple gestation (twins, triplets etc.) prevention of preterm labor?
Diseases Do not lift heavy bags of groceries or
Diabetes Mellitus young children which requires use of
Eclampsia (High BP) abdominal muscles
Heart disease
Anemia (HgB less than 10) NCLEX TIP
I - Infection ATI Questions

UTI - Urinary tract infections
Q2: Which of the following factors increases
STI - Sexually transmitted infections
the client’s risk of preterm labor?
Periodontal disease (gum infection) NCLEX TIP Select all that apply.
P - Placental Abruption Periodontal disease
Urinary tract infection
Placenta separates from the wall of the uterus Multifetal pregnancy
during pregnancy Diabetes mellitus
No 1 risk
S - Stress: Emotional or Physical
Short cervical length or too thin
(cervical insufficiency) HESI Question
Smoking & Stimulants (cocaine)
Other risk factors: Which intervention would ...help prevent
preterm delivery?
History of preterm births
Lifting heavy object (if at risk) ATI Suggest that the client avoid smoking
Signs & Symptoms Notify NCLEX TIP

Key Signs of Preterm Labor the HCP HESI Question
… signs of preterm labor with a client at 28 weeks gestation.
1. Rupture of membranes 20 - 37 weeks Which client statement indicates a need for further teaching?
Report watery discharge from vagina ATI Select all that apply.
I expect the discharge from my vagina will change
2. Low back pain NCLEX TIP from thick to brown over the next two weeks
The baby’s movement will decrease and be almost still
3. Contractions every 10 minutes or less from here on out
4. Pelvic pressure I should expect low back pain and diarrhea as the baby grows
20 - 37 weeks
5. Diarrhea
Diagnostics Fetal membranes
Speculum exam: to visualize the cervix

HESI Question
Effacement - thinned out cervix A client at 26 weeks of gestation...
Dilation - opening of the cervix Which finding indicates that preterm
Fetal membranes intact or ruptured labor is occuring?
Fetal Fibronectin Test (FFN)
The cervix is effacing and
Transvaginal Ultrasound (less than 34 weeks)
dilated to 2 cm
Shortened cervix length
267
Preterm Labor II
Maternity
Preventative Measures
12 - 28 weeks
Prophylactic Cervical Cerclage
To prevent preterm delivery
Cervical insufficiency
Signs of Preterm Labor Notify the HCP
12 to 28 weeks gestation
Stitches are removed at 36 - 37 weeks 1. Rupture of membranes
Report watery discharge from vagina ATI
Interventions
2. Low back pain NCLEX TIP NCLEX TIP
Education (after cerclage)
Activity restriction & bed rest 3. Contractions & pelvic pressure
No sexual intercourse
Mild abdominal cramping is expected
Assess fetal movement daily HESI
Interventions SIDE NOTE
Continuous fetal monitoring Clients who have had a history of preterm labor are
Amniotomy (AROM) is the manual commonly prescribed progesterone throughout the PROGESTERONE
induction of labor by rupturing the pregnancy, as it will reduce the risk for future preterm
amniotic membranes & is contraindicated! labor.
Pharmacology 4 NCLEX TIPS Top Missed NCLEX Question

A pregnant client is admitted for preterm labor at 30
1. Antibiotics PENICILLIN weeks gestation. Which treatment options should the
nurse anticipate?
Penicillin IV piggyback Select all that apply.
Prevent group B strep infections Intramuscular betamethasone
Penicillin via IV piggyback
2. Steroids: antenatal glucocorticoids IV magnesium sulfate
Stimulate surfactant for fetal lung maturity Calcium gluconate ready
Betamethasone Steroid HESI Question

-sone
3. Tocolytic agent Betame- ...magnesium sulfate to prevent preterm
To relax the uterus thasone
labor. Which would the nurse assess in
Terbutaline the client to determine drug toxicity?
Nifedipine Respiratory status

Level of consciousness (LOC)
Indomethacin Deep tendon reflexes
4. Magnesium Sulfate
Protects the baby’s brain (neuroprotection) MAGNESIUM
Kaplan Question
Reducing the risk for cerebral palsy SULFATE
Magnesium sulfate IV ... the client’s deep
tendon reflexes are decreased. Which
Continuous fetal monitoring is required for
action does the nurse take first?
Mag Sulf infusion
Discontinues the IV infusion
Mag Toxicity
ATI Questions
Monitor mother’s respiratory rate,
blood pressure, & DTRs
STOP Q1: … 30 weeks of gestation. Which medication... to
accelerate fetal lung maturity?
MAGNESIUM Betamethasone
Discontinue: low RR, BP, & depressed DTRs SULFATE
Q2: … terbutaline. Which of the following client statements
indicates an understanding of the teaching?
Antidote: Calcium gluconate This medication is used to stop my contractions
Notes
268
PROM & AROM
Maternity
PROM Pathophysiology
PPROM PROM
As you know, the baby is floating in amniotic fluid within the P Preterm
chorioamniotic membrane, making up the amniotic sac.
P Premature P Premature
This is held inside the uterus, which we call the baby apartment Aminiotic fluid
since it is where the baby lives during fetal development. Chorioamniotic R Rupture R Rupture
membrane
Aminiotic sac
O Of O Of
The cervix is the door to the apartment that holds it all in. M Membranes M Membranes
In PROM, the mother’s water breaks too early & this amniotic
fluid leaks out! *Before 37 weeks *After 37 weeks
Risk factors
Treatment Over 37 Weeks
Anything that weakens the strength of
the chorioamniotic membrane Prevent infection HOURS
Infections UTI STD/STI Over 37 weeks gestation

UTI 90% of clients will go into
STI (STD) spontaneous labor within 24 hours NCLEX TIP
Bacterial vaginosis
Bacterial vaginosis
Nurse care
Short cervical length
Smoking Give prophylactic antibiotics to Prophylactic
Antibiotics
Abdominal trauma prevent GBS infection - Group B

GBS Infection
Prior distention Beta Streptococcus NCLEX TIP

Polyhydramnios - increased 1. Membranes ruptured at/over NCLEX TIP
amniotic fluid 18 hours
Multiple gestations 2. Temperature over 100.4
(twins, triplets +)
x2 3. Gestation less than 37 weeks
Diagnostics
Nitrazine Test
Speculum exam (”Pooling”) Saunders Question
A speculum is placed inside the vagina A pregnant 39 week-gestation ... has had a positive group HCP
& the client is asked to cough or bear B streptococcus (GBS) ... the cervix is dilated 6 cm and
down. If amniotic fluid is seen coming 90% effaced. Which should be the nurse’s first action? Prophylactic
Antibiotics
out of the cervix when this pressure is Call the health care provider (HCP) to obtain a
prescription for intravenous antibiotic prophylaxis
applied, the client has ROM.
Ultrasound
Screening for STIs
AROM
Amniotomy - this is a procedure performed by the health care provider to manually HESI Question
induce labor by rupturing the amniotic membrane or in other words breaking the Amniotomy ... Immediately after the procedure what is
client’s water. most important information for the nurse to obtain?
Fetal heart rate
Amniotomy 1st Priority
Manual induction of labor by rupturing

ATI Question
AROM the amniotic membrane
Amniotomy ... Which of the following is the priority for
Risk for Umbilical Cord Prolapse assessment by the nurse?
A Artificial causing fetal bradycardia due to Fetal heart rate
cord compression
R Rupture 4 NCLEX TIPS: Interventions
Normal NOT Normal
1. Assess fetal heart rate
O Of BEFORE & AFTER
Clear
Colorless
Yellow-green fluid
Meconium
No foul odor Strong foul odor
2. Assist to upright position after
M Membranes
Infection
3. Temperature every 2 hours

4. Characteristics of amniotic fluid
Color, amount & odor
269
Procedures to Assist Labor & Delivery
Maternity
Administering Oxytocin ATI Question

Secondary line
Use an IV infusion pump on a secondary IV line Primary line Q1: … receiving oxytocin after prolonged
Monitor 2 NCLEX TIPS labor. Intervention is necessary when
which assessment item is noted?
1. Mother’s uterine contraction pattern,
blood pressure & heart rate 6 contractions in 10 minutes
2. The fetal heart rate (continuously) Q2: Which of the following findings …
requires intervention by the nurse?
STOP Oxytocin 3 NCLEX Key Points
Duration of contraction of
1. Contractions: 100 seconds
Duration OVER 90 seconds
STOP
Kaplan Question
Frequency less than 2 minutes apart
Intensity over 90 mmHg … oxytocin infusion to induce labor. The
Resting tone greater than 20 mmHg nurse stops the infusion if it occurs?
2. Late decelerations in FHR Contractions last 90 to 120 seconds
3. Over 5 contractions in 10 minutes & are 2 minute intervals
Complications Uterine Rupture Top Missed NCLEX Questions

1. Uterine Rupture ATI A client is receiving oxytocin infusion for labor
augmentation. The provider asks the nurse to increase the
2. Late declarations oxytocin infusion rate. Which of the following actions
Abdomen should the nurse take?
3. Water intoxication (dilutional hyponatremia)
Click
Clickthe
theexhibit.
exhibit
4. Increased risk for
Recommend that the infusion rate be decreased
Placental abruption
Uterine atony Soft or boggy fundus Rupture
increased risk for postpartum hemorrhaging Oxytocin
5. Uterine tachysystole NCLEX TIP Uterine tachysystole
Side effects of oxytocin causing severe contractions
10 minutes
→ reduced placental blood flow & impaired
fetal oxygenation.
1 2 3 4 5 6
STOP Oxytocin
Over 5 contractions in 10 minutes
Late decels
Amniotomy
Manual induction of labor by
rupturing the amniotic membrane
Risk for Umbilical Cord Prolapse
Causing fetal bradycardia due to
cord compression
NCLEX TIP
Forceps spoon like devices used to assist delivery
Bishop Score
HESI Question
Caution! Never apply fundal pressure during forcep use System for assessing cervical
Uses: fetal distress or abnormal fetal presentation
Complication... forceps-assisted delivery? readiness for induction of labor.
Complication Presence of vaginal lacerations
Uterine rupture
OVER 6 - 8 score indicates
Bladder injury induction will be successful
Vaginal Lacerations
Vacuum traction applied to the fetal head NCLEX TIP

Cervix
Bishop score
Caution! Never apply fundal pressure NCLEX TIP
0 1 2 3
Uses:
Consistency Firm Medium Soft
Mother not pushing effectively or unable to push
Fetal distress, rotation, or abnormal FHR Position Mid-
Posterior Anterior
positon
Complication
Dilation 0 cm 1-2 cm 3-4 cm ≥ 5 cm
Uterine rupture
Lacerations Effacement 0% - 30% 40 - 50% 60 - 70% ≥ 80%
Infant subdural hematoma
Station -3 -2 -1, 0 +1, +2
270
_ _
Labor Complications
271
Labor Complications I
Maternity
Amniotic Fluid Embolism

Pathophysiology
This is a deadly condition that occurs when amniotic fluid inside the uterus leaks
out & enters the mother’s blood stream, leading to very high risk for mortality in Amniotic fluid inside the uterus leaks
out & enters the mother’s blood stream
both the mother & baby! Most do not survive. It occurs most often during delivery
or in the immediate recovery period.
Symptoms Interventions
Sudden chest pain Notify the provider!
Hypotension (low BP) IV fluids & blood transfusion
Tachycardia (fast HR) Assist with intubation
Dyspnea (difficulty breathing) Oxygen
Cyanosis (blue, pale skin)
0.9% PRBC 0₂
Sodium Chloride 0₂
0₂
NORMAL
0₂
HIGH
LOW
0₂
0₂
Dystocia
Pathophysiology Interventions
Slow or difficult labor or delivery Reposition or ambulate the mother
Oxytocin: induce labor
Memory trick
Amniotomy: the provider manually
D - Dystocia
breaks the water
D - Difficult Labor
Oxytocin
Saunders Question
Causes & Risk Factors ... labor dystocia... which risk factors in the client’s
history placed her at risk for this complication?
Macrosomia (big baby over 8lbs 13 oz) Select all that apply.
Age 54
Overweight (BMI over 25) Body mass index of 29
Over 8lbs 13oz
Older age Previous difficulty with fertility
Previous difficulty with fertility

Age 54 BMI = 29
Failure of the uterus and cervix to
contract
Insufficient cervix dilation, effacement,
4cm
& descent of the baby
272
Labor Complications II
Maternity
Shoulder Dystocia
Pathophysiology Nursing Interventions

Fetal head delivers, but the top of the NCLEX TIPS
shoulder becomes wedged behind or 1. Document the time of events & position for example
Fetal head position, should maneuvers
under the mother’s symphysis pubis.
2. Verbalize passing time to guide provider for example
Longer than 5 minutes → HIGH RISK “1 minute has passed”
for fetal asphyxia (hypoxia) 3. Maneuvers to relieve shoulder impaction

McRoberts maneuver: Flex the client’s legs back
against the abdomen
Suprapubic pressure: Press downward on the
symphysis pubis
4. Request additional assistance from other nurses &
5
mins
staff
0₂
Shoulder Dystocia
AVOID NCLEX Traps

?
MAGNESIUM McRoberts
Terbutaline SULFATE Maneuver
Administering tocolytic agents
(Terbutaline, Mag Sulfate)
Fundal pressure
Use of forceps or vacuum
Precipitous Labor
This is quick labor - some professors call these “cannonball” babies, because they shoot out with impressive force
and everything can get damaged - baby & mom included!
Pathophysiology Risks
Labor within 3 hours or less! Hypertonic uterine contractions
After the onset of contractions
Use of Oxytocin
Memory trick:
Multiparous mother
P - Precipitous Labor
P - Pretty Quick labor (multiple previous births)
Within 3 hours or less
Complications Interventions
Prepare to assist with birth
1. Mom:
Keep the infant warm! NCLEX TIP
Postpartum hemorrhage
Uterine rupture O2 Dried & placed skin-to-skin on the
mothers abdomen
Amniotic fluid embolism
AVOID NCLEX Traps
2. Baby
APGAR SCORE
2 points
Do NOT pull on the cord!
Intracranial hemorrhage → Uterine inversion or cord avulsion
Fundal massage ONLY after placenta is
Hypoxia delivered
273
Labor Complications III
Maternity
Uterine Rupture
Causes
Pathophysiology Previous C-section attempting a vaginal
delivery (weak spots in the uterus that
Spontaneous tearing of the uterus that
can rupture)
may result in the fetus being expelled
Forceps delivery
into the peritoneal cavity Uterine Rupture
Traumatic events (car accident or fall)
Overdistension of uterus: Twins,
triplets, or more
Symptoms Too much oxytocin
Severe sudden abdominal pain! Saunders Question

“Tearing or ripping” ... risk of uterine rupture if which occurred?
Fetal heart rate that is non assuring Forceps delivery
for example
Bradycardia
Variable or late decels
Decreased variability
Interventions
Fetal distress Immediate Cesarean delivery
Mother s/s of bleeding (C-section)
Hypovolemic shock Hysterectomy
Hypotension (low BP) IV fluids & blood products
Tachycardia (fast HR)
ATI Question
… 38 weeks gestation who reports severe sudden
! abdominal “ripping” pain when receiving an
oxytocin infusion during labor. The client's heart
! NORMAL
rate is 130/min and she is tachypneic. The fetal

HIGH
LOW
heart rate monitor reveals minimal variability and

! bradycardia. Which of the following tasks does the
nurse anticipate?
Prepare for immediate cesarean delivery
Uterine Inversion
Pathophysiology Symptoms Interventions

Placenta fails to detach from the uterine Severe abdominal pain 1. Relax the uterus: (Tocolytic)
wall and pulls the uterus inside-out Mother s/s of bleeding Terbutaline
Hypovolemic shock Magnesium sulfate
Causes Hypotension (low BP) 2. Provider repositions the uterus
Tachycardia (fast HR)
Excess cord traction 3. AFTER the uterus is repositioned
Oxytocin
(pulling the umbilical cord)
Saunders AVOID
Excess fundal massage
Placenta accreta: the placenta is too ... immediately after delivery of the placenta. IV oxytocin before the inverted
Which … could indicate uterine inversion? uterus is corrected NCLEX TIP
firmly attached to the uterus
Complaints of severe abdominal pain
4. IV fluids & blood products
0.9% PRBC
AVOID
Sodium Chloride
AVOID
274
Labor Complications IV
Maternity
Umbilical Cord Prolapse & Compression

Signs
This is a potentially deadly emergency for the fetus! Common after spontaneous rupture of
membrane (water breaks) or amniotomy
Pathophysiology FHR - Fetal Heart Rate
Fetal bradycardia
Umbilical cord protrudes out of the
mother’s cervix or vagina BEFORE the baby Abrupt fetal heart rate decelerations
→ cuts off oxygen rich blood to the baby NCLEX TIP
So if the oxygen tube is compressed, it leads to DEADLY Abrupt fetal

low oxygenation! This results in lifelong brain damage or heart rate
death for the baby! Very serious!
decelerations
HESI Question
… cause of variable fetal heart rate (FHR)
deceleration is which factor?
Umbilical cord compression
Saunders Question
… umbilical cord compression if which is noted on
the external monitor tracing during a contraction?
Variable decelerations
Nursing Interventions Saunders Question

1. Call for assistance ... umbilical cord protruding from the vagina…
nursing action?
2. Insert sterile gloved hand:
Wrap the cord loosely in a sterile towel
Sterile
1 or 2 fingers into mother’s vagina

Normal
Saline
soaked with warm sterile normal saline

to relieve compression
3. Reposition mother: ATI Question
Knee-chest position
... extrusion of the umbilical cord ... priority
Trendelenburg position nursing intervention after calling for assistance?
4. Wrap cord loosely with a Use a sterile gloved hand and apply finger
sterile towel or gauze soaked with pressure to elevate the presenting part of
the fetus
sterile normal saline
5. Prepare for emergency C-section HESI Questions
(cesarean delivery)
Q1: … umbilical cord protruding from the client’s
vagina. The nurse immediately positions the client in
O2
the Trendelenburg position and inserts a finger into
O2
O2
O2
O2 O2
O2 O2 O2
O2
O2
O2 O2
O2
the client’s vagina. Which additional care?
O2 O2
O2
O2
Prepare for an emergency cesarean delivery
O2
Q2: … amniotic membrane rupture, and a prolapsed

cord is suspected… priority intervention?
Knee-chest position
Notes
275
Labor Complications V
Maternity
DIC
Pathophysiology This is severe bleeding inside & outside the mother’s body.
As the body uses up all clotting factors & platelets, it makes little clots all
DIC = disseminated intravascular over the body & uses up all means to stop bleeding elsewhere in the body,
coagulation leaving the mother with no means to stop bleeding anywhere!
Causes & Risks Placenta

HESI Question
Placental abruption: placenta separates … high risk for disseminated intravascular
from uterine wall coagulation (DIC)?
Intrauterine fetal demise (stillbirth) Placental abruption

Placental Abruption Fetal demise
Interventions
Signs & Symptoms Priority! NCLEX TIP Coagulation Fibrinogen
test
External bleeding: venipuncture site Draw coagulation tests, fibrinogen,
Internal bleeding: petechiae & ecchymosis & platelet count
Organ damage: Administer blood products, volume Platelet
Respiratory distress expanders & oxygen

Renal failure Monitor for bleeding which is
sudden & deadly
Meconium Stained Amniotic Fluid HESI Question

... amniotic fluid was meconium stained
during labor. Which further assistance
Pathophysiology Signs would the nurse provide to the newborn?
Amniotic fluid color: green, yellow, or brown Provide endotracheal tube suction
Fetus has defecated in the amniotic assistance with ventilation
Foul smelling odor
fluid.
Key Points ATI Question
Common in: … warning signs of potential complications?
Breech position Select all that apply.
When the mother’s water breaks, we After events of fetal distress
expect it to be clear, but with meconium Term/ post term infants Meconium stained amniotic fluid
Foul-smelling vaginal discharge
stained, the fluid changes color to Indicates fetal hypoxia
various shades of green, yellow or Prep for neonatal resuscitation
brownish & it often even smells foul. Endotracheal tube & ventilation
Meconium Aspiration Syndrome HESI Question

Risk Factors
… 41 weeks of gestation. Which complication?
Pathophysiology Over 40 weeks gestation
Meconium aspiration syndrome
Diabetes
Newborn breathes a mixture of meconium
& amniotic fluid into the lungs High blood pressure ATI Question
Long or difficult labor
… meconium aspiration syndrome. Which of
Newborn breathes a mixture of meconium the following is true?
& amniotic fluid into the lungs around the Pneumothorax may occur
time of delivery. It’s like coating the inside
Complications
of the lungs with tar! KAPLAN Question
Fetal distress
Gas exchange is nearly impossible, making Pneumothorax Meconium-stained amniotic fluid alerts the
nurse to the possibility of which problem?
it the leading cause of severe illness & Perinatal asphyxia Fetal distress and perinatal asphyxia
death in newborns.
276
_ _
Newborn
277
Apgar Score I
Maternity
Contraindication
APGAR SCORE
0 points 1 points 2 points
The APGAR is a simple quick assessment tool used to rapidly describe a newborn's well-being
immediately after birth & how they’re adjusting to life outside the womb.
Infants are rated on a scoring system from 0 to 10. The higher the score the healthier the baby
1
It's important to note it is done twice - at 1 minute & at 5 minutes after delivery. min
& It may be reassessed for a 3rd time at 10 minutes if the score is less than 7. 1st
5
mins
NCLEX 2nd < 7 points

10
7 or Less = Reassess
mins
3rd
Sign 0 points 1 points 2 points

Interventions Based on Score
Appearance (skin color) Blue/ Pale Blue arms Completely
A Core & legs Pink
Pulse (heart rate) Absent

Pink Body
Less than OVER

0-3 Severe Distress
= Resuscitate Fully!
P 100/ min. 100/ min.
4-6: Moderate distress

G
Grimace (reaction & reflex) Absent Grimace Cry & Pull
away
= Some resuscitation
7-10: Adequate
A Activity (muscle tone) Limp Minor flexion Active flexion
& extension = Provide post delivery
R Respiratory effort Absent Weak cry Strong cry (Oxygen, Suction, Stimulate baby
by rubbing back & feet)
Always remember to start with 10 points & then focus on what’s BAD! Start subtracting bad signs so:
REALLY BAD - subtract 2 points
KINDA BAD - subtract 1 point.
TEST TIP Be sure to write out this chart at least 10 - 15 times, every day the week of your exam.
Sign 0 points 1 points 2 points

Appearance (skin color) Blue/ Pale Blue arms Completely
A Core & legs Pink
Pink Body
It's vital to know these numbers & how to rate it. P Pulse (heart rate) Absent Less than OVER
100/ min. 100/ min.
You need to spot lower ratings - as this means the newborn
Grimace (reaction & reflex) Absent Grimace Cry & Pull
is in severe distress! G away
Activity (muscle tone) Limp Minor flexion Active flexion

A & extension
R Respiratory effort Absent Weak cry Strong cry
Notes
278
Newborn Assessment I
Maternity
After the baby is stabilized & the APGAR score is assessed, a newborn head to toe assessment
is completed. We mainly look for signs & symptoms of maturity and prematurity - in order to Full Term Birth
guide the care that will be delivered.
Think of the baby as a bun in the oven or in this case a chicken that just came out of the oven.
A Full Term infant - born 37 weeks to 40 weeks is like a perfectly baked chicken breast. 37 weeks 40 weeks
The skin is opaque, & presence of vernix - that white cheesy substance, predominantly located
in the skins folds but the baby looks well balanced - not over or under - perfectly "done"!
Preterm Infant
A Preterm infant - born between 20 to 37 weeks - is like an undercooked raw chicken breast.
The baby’s skin is smooth, shiny, gooey (lots of vernix), translucent, and extremely flexible -
like undercooked dough! 20 weeks 37 weeks
This bun came out of the oven too soon! & is not done baking!
Post-Term
Post Term infant over 40 weeks gestation is like an over cooked, burned chicken breast.
The baby will be larger, more chunky and not so flexible. The skin literally appears burned
(dried, cracked & peeling). There are also deep creases on the hands/feet. 40 weeks
Phase 1 - Stabilization
According to ATI - newborn assessment & care is broken down into 3 phases: Phase 2 - Infant physical exam
Phase 3 - Routine care
Assessment Normal NOT normal Assessment Normal NOT normal

Vernix caseosa: white cheesy Preterm: 20 - 37 weeks Anterior: Diamond shaped Caput succedaneum: localized edema
Skin substance, predominantly NCLEX TIPS Fontanelles of the scalp (like a cap)
Posterior: Triangular
located in the skins folds 1. Shiny, wrinkly skin & Head Shape Cephalhematoma: localized hematoma
2. “Translucent”, very fragile, Molding: mis-shapen head resulting beneath the periosteum caused by
Lanugo: fine hair all over
Smooth, red/pink skin with visible veins from pressure in the birth canal; trauma
the body to hold the vernix
3. Flat areolas without palpable breast buds disappears in 3 - 7 days.
in place
4. Abundant lanugo on shoulders & back
Mongolian spots: purple, & gooey (lots of vernix) HESI
brown, gray flat discolorations
Postterm: Over 40 weeks ATI
typically found on the back,
Cracked, dried, peeling skin (desquamation)
buttocks & lower extremities
Cyanosis: blue, pale core REPORT TO HCP
Acrocyanosis:
Bluish discoloration on the Jaundice “yellowing of the skin” REPORT
hands & feet with a pink trunk
Nevus vasculosus (strawberry hemangioma):
→ Place the newborn skin-to raised, red nodule.
skin with mother NCLEX TIP
Nevus flammeus (port wine stain): 3 - 7 days
Peeling around the 3rd day pink, red, purple patch of skin, often on the face.

Eyes open Low-set ears & flat nose bridge REPORT TO HCP Epstein’s pearls: white pearl-like cysts Assess for cleft lip or palate
Eyes, Ears Mouth on gum margins & palate NCLEX TIP
Ear stiff but pliable Eyes:
& Nose (more stiff is more mature) Ptosis of an eyelid REPORT
Milia: white papules “white heads” Cataract seen as red reflex REPORT
on the nose Jaundice Sclera within the first 24 hours
Coloboma - defect in the pupil
HCP
1
ATI Question
neonate after delivery…. Which of the following
assessment is most concerning? Cleft lip Cleft palate
Ptosis of the left eyelid
279
Newborn Complications I
Maternity
Hyperbilirubinemia
Hyperbilirubinemia, or jaundice, is the yellowing of skin from too much bilirubin - those dead RBCS in the blood.
Patho & Causes
Pathologic
Structural defects in the liver HESI Question
→ build up of bilirubin
… highest priority to which finding?
Physiologic
RBCs breakdown (from birth trauma) Skin color that is slightly jaundiced YES!
1 Always report yellow skin!
produces bilirubin
Immature & can’t keep up
hyperbilirubinemia → Jaundice Saunders Question
Can cause multisystem organ damage
& irreparable brain damage Which assessment finding should alert the
nurse to suspect the potential for jaundice
Signs & Symptoms in this infant?
Yellowish hues Report to HCP Presence of cephalhematoma
Face or eyes (sclera)
Trunk & extremities
Treatment
Phototherapy - In the hospital setting most commonly include fiberoptic phototherapy blankets & pads.
Bili lights (lamps) - where the baby is placed under heat lamps like a food item at a buffet
Treatment: Phototherapy
Nursing Interventions PRIORITY ATI Question
1. Skin Care
Monitor skin temperature closely
37.5
… plan of care for an infant
Reposition every 2 hours receiving phototherapy?
Giving additional fluids
Saunder
2. Dehydration risk → Give fluids NCLEX
every 2 hours every two hours

3. Eye care → Cover infants eyes
with protective pads
Hypothermia (cold stress)

Cold babies with low body temperature, although easy to treat, it is VERY dangerous and can lead to hyperbilirubinemia,
hypoxia (low oxygen), & hypoglycemia (low blood sugar)! This is because oxygen consumption and metabolism are
increased leading to an unstable baby.
HESI Question
Signs & Symptoms 5 NCLEX TIPS
Which signs indicate the need for placing the
1. Altered mental status neonate in a prewarmed radiant warmer?
“Irritability or lethargy”
Hypotonia
2. Bradycardia, tachypnea & hypoxia Bradycardia
Feeding intolerance
3. Hypoglycemia & feed intolerance
4. Hypotonia, weak suck & cry ATI Question
5. NO shivering ability Q1: Which of the following findings is
unexpected when assessing a
preterm newborn for cold stress?
Causes & Risk Factors Shivering
Thin layer of subcutaneous fat Q2: … cause of neonatal hypoglycemia in

relation to cold stress?
Wet infant - Evaporation
Increased metabolic rate
Notes
280
Apgar Score II
Maternity
Sign 0 points 1 points 2 points Sign 0 points 1 points 2 points
A Appearance (skin color) Blue/ Pale

Core
Blue arms
& legs
Completely
Pink
A Appearance (skin color) Absent Less than
100/ min.
OVER
100/ min.
Pink Body
P P Pulse (heart rate)
G G <100 >100
A A
R Acrocyanosis R
A Appearance (skin color) Absent Grimace Cry & Pull

away
A Appearance (skin color) Limp Minor flexion Active flexion
& extension
P Pulse (heart rate) P Pulse (heart rate)
G Grimace (reaction & reflex) G Grimace (reaction & reflex)
A A Activity (muscle tone)
R R

Sign 0 points 1 points 2 points While conducting an Apgar assessment, the nurse discovers the newborn is completely blue, has a
heart rate of 115/min, weak cry, active movements, flexes extremities, and shows facial grimaces
A Appearance (skin color) Absent Weak cry Strong cry when nose is suctioned. The nurse should assign which Apgar score to the newborn?
Apgar score of 6
P Pulse (heart rate)
1 2 Sign 0 points 1 points 2 points
G
Appearance Blue/ Pale Blue arms Completely
Grimace (reaction & reflex)
115 A
6
(skin color) Core & legs Pink
Pink Body
Pulse Absent Less than OVER

P
A
(heart rate) 100/ min. 100/ min.
Activity (muscle tone) Grimace Absent Grimace Cry & Pull
G
0
(reaction & reflex) away
R
Activity Limp Minor flexion Active flexion
A
Respiratory effort (muscle tone) & extension
Respiratory Absent Weak cry Strong cry

R effort
2 1

Saunders Question Appearance Blue/ Pale Blue arms Completely
ATI Question Appearance Blue/ Pale Blue arms Completely
… Apgar score. The nurse notes a heart

A (skin color) Core & legs Pink A (skin color) Core & legs Pink
Pink Body ... Apgar score. The infant is crying lustily Pink Body
rate of 92, a weak cry, some flexion of
Less than OVER and has a heart rate of 130 bpm; he has Pulse Absent Less than OVER
extremities, grimacing with stimulation, P Pulse
(heart rate)
Absent
100/ min. 100/ min. some muscle tone and his body is pink P (heart rate) 100/ min. 100/ min.
and a pink body with blue extremities.
but his hands and feet are blue. Which
On the basis of this score, what should Grimace Cry & Pull Grimace Absent Grimace Cry & Pull
the nurse determine? G
Grimace
(reaction & reflex)
Absent
away
of the following is the most appropriate G (reaction & reflex) away
Apgar score?
The newborn requires some Activity Limp Minor flexion Active flexion
resuscitative interventions A Activity
(muscle tone)
Limp Minor flexion Active flexion
& extension
8 A (muscle tone) & extension
Respiratory Absent Weak cry Strong cry Respiratory Absent Weak cry Strong cry
R effort R effort
4 2 1 1
130 8
Saunders Question HESI Question
When should the nurse plan to 1st 2nd ... Apgar score of 10 at 1 minute after birth?
An infant having no difficulty adjusting
determine the Apgar score?
to extrauterine life but who should be
At 1 minute after birth and assessed again 5 minutes after birth
5 minutes afterbirth 1 min 5 mins
281
Newborn Assessment II
Maternity

Heart: Listen for murmurs Lungs Sounds: REPORT 1 vein, 2 arteries NCLEX TIP REPORT TO HCP
Chest Wheezes, stridor, or persistent crackles Umbilical cord
Lung Sounds: MEMORY TRICK: Only 1 artery or any other abnormal findings
after the first few hours of birth
Crackles (rales) indicate fluid in the AVA: 2 Arteries 1 Vein
lungs & are expected immediately Respiratory Distress: REPORT Normal Finding:
HCP
1
AFTER birth Chest wall retractions opaque or whitish-blue & covered
Nasal flaring with Wharton’s jelly
HESI Question Grunting
… expect to find while assessing a neonate Tachypnea (over 60/min.)
during the first 30 minutes after birth?
Fine crackles
Vein
Arteries

Bowel sounds may be absent or No voiding in 24 hours NCLEX TIP REPORT Plantar creases up the entire sole of Preterm: 20 - 37 weeks
Abdomen hypoactive until the first feed Abdominal distention
Hand & Feet the foot NCLEX TIP Very smooth soles of the feet
Voiding & passing meconium is Acrocyanosis: Club foot: Talipes equinovarus
Olive shaped mass - Pyloric stenosis
expected within 24 hours Bluish discoloration on the hands & Syndactyly: Fused fingers or toes
feet with a pink trunk
24
hours

Reflexes Report to HCP
Back & Spine
Sacral dimples → Spina bifida
occulta NCLEX TIP
Good muscle tone Decreased muscle tone Birthmarks & Mongolian spots
& muscle tone hypotonia “head lag” NCLEX TIP Myelomeningocele
Birthmark
Assessment NOT normal Assessment Normal NOT normal

Female: discharge of blood Anus: Imperforate anus
Hips DDH - Developmental Dysplasia of the Hips Genitalia or mucus Males:
& Anus Male: descended testes into � Hydrocele: fluid-filled sac around a testicle
the scrotum that swells within the scrotum.
� Hypospadias: misplaced meatus -
urinary opening.
� Cryptorchidism: an undescended testicle
that is typically NOT concerning since most
will descend on their own by 6 months.
Notes
282
Newborn Complications II
Maternity
Hypothermia (cold stress) ATI Question

Warm that baby up! The newborn infant is pale and doesn't cry...
Remember a warm baby will most appropriate action?
decrease the risk for hypoglycemia, Place the infant in a radiant warmer
Interventions 5 NCLEX TIPS hypoxia, & hyperbilirubinemia! and dry him with a towel
Saunders Question
Skin-to-skin contact newborn & mother
Dry the newborn immediately after delivery … most effective in preventing heat loss
& place hat by evaporation?
Provide care under radiant warmers Drying the infant with a warm blanket
Cover scale with warmed blankets
before weighing the newborn HESI Question
Use prewarmed incubator when transporting Which nursing action ... immediately
following the vaginal birth?
Drying the infant on the mother’s chest
and then placing a hat on the infant
Hypoxia
As you know the newborn must transition quickly from a fluid-filled environment to an air-filled environment
so the lungs must expand with the help of surfactant which prevents collapse of the alveoli within the lungs
Causes Interventions
Signs of Respiratory Distress Fluid or mucus Dry, stimulate, suction
obstruction
Pathologic apnea 00:15
Intercostal retractions Prematurity Support ventilation
Central cyanosis (lack of surfactant)
Give surfactant
Nasal flaring (Betamethasone)
Grunting, wheezing
Cardiac Defect Monitor & Surgery
Intercostal retractions
(PDA or PFO)
Hypoglycemia
Newborn blood glucose should be kept above 40mg/dL at all times. Risk Factors
Mom with diabetes (all types)
Newborns are at risk for hypoglycemia because the placenta (the source HYPOTHERMIA
of maternal glucose) is removed & the infant’s pancreas is still producing Sepsis
insulin at a rate that matches the levels of maternal glucose during pregnancy.
Signs & Symptoms
Less than 40 mg/dL
Shaking, sweating, & irritability
Lethargy
>40 High-pitched or weak cry
Seizures
Breast feeding is #1 !
Identify high risk newborns
Keep infant warm
283
Newborn Assessment III
Maternity

The nurse is performing assessments on several newborns. Which of
Newborn Vital Signs Kaplan Question
the following should be reported to the health care provider (HCP)? Assessed every 30 min after birth for 2 hours ... apical pulse on a 8 lb 4 oz newborn infant. The
Select all that apply nurse takes which action?
Then every 4 - 8 hrs. reassess
Chest wall retractions Places the bell of the stethoscope at the fourth
No bowel sounds immediately after birth Heart rate (resting - not crying) intercostal space at the left midclavicular line
No voiding in 24 hours • 110 - 160 /min. We assess at the apical pulse
Decreased muscle tone
Sacral dimple with a small skin tag listen for 1 full minute
Single artery in the umbilical cord • Put the bell of the stethoscope at the
Peeling skin in a 42 week newborn • 4th intercostal space - left midclavicular line
Side note 4th intercostal space
• 80/min during rest
Resolve on its own • 180/min when crying or agitated
Respirations:
• 30 - 60 breaths/min - assess for 1 full minute
Axillary temperature: (No rectal temp!)
• 97.7-99.5 F (36.5-37.5 C)
Blood pressure:
• 73/55 mm Hg
Newborn Glucose Levels

Blood glucose 40 or more mg/dL
1 hour after birth is expected
During pregnancy the fetus stores large quantities of glycogen that are used → encourage breastfeeding!
during the transition to life outside the womb & into the world!
As a result glucose levels are decreased 1 hour after birth, then stabilize within
2 to 3 hours. HESI Question
Glycogen In most healthy newborns,
Glucose Glucose Glucose
blood glucose levels stabilize at
____mg/dL during the first hours
after birth.
50 - 60
1 hour 2-3 hours
Medications HESI Question Interventions for LGA

Eyes: Erythromycin ointment administer vitamin K ..
(given within 1 hour of birth) 1. Assess for birth injuries
Vastus lateralis muscle cephalhematoma, or clavicular fracture
Prevents Ophthalmia neonatorum
(conjunctivitis) → blindness HESI
Thighs (Vastus Lateralis Muscle) ATI 2. Monitor for hypoglycemia
ATI Question Blood glucose < 40 - 45 mg/dL
Vitamin K: helps produce clotting
factors to prevent internal bleeding vitamin K ... Report to HCP
(given within 6 hours after birth) “The injection prevents Glucose checks prior to feedings
Hepatitis B vaccine: bleeding as newborns Encourage breast feeding every
provides antibodies against Hep B have a higher risk.” 2-3 hours
(given within 24 hours after birth) Discuss the need for feeding
supplementation if s/s of
Body Measurements hypoglycemia occur
Head circumference: 33 - 35 cm Saunders Question

Chest circumference: 30 - 33 cm 2,500 - 4,300 grams ... the infant's weight is 4400 g... may
be at risk for which complications?
Length: 45 - 55 cm Hypoglycemia
Fractured clavicle
Weight: 2,500 - 4,300 grams (5.5 to 9.5 lb) Congenital heart defect
� SGA: less than 10th percentile
� AGA: between 10th & 90th percentile 4.3kg HESI Question
� LGA: over the 90th percentile ... low birth weight (LBW) based on
which assessment finding?
� Macrosomia: more than 4000 grams Weight is less than 2.5 lbs
284
NRP & NEC
Maternity
NRP - Neonatal Resuscitation Program

Critical Interventions
As you know, newborns are evaluated using APGAR
immediately after birth. Any baby presenting unresponsive, 1. Place the newborn on NCLEX TIP
or limp without spontaneous respirations should be the warmer
immediately handled in the following way: 2. Sniffing position “appropriate
for ventilating” NCLEX TIP
Indicator 0 Points 1 Point 2 Points 3. Suction airway
4. Dry & stimulate the newborn
A Appearance
(Skin color)
Blue; Pale
Pink Body;
Blue Extremities
Pink for 30 seconds
P Pulse Absent Below 100 bpm Over 100 bpm
G Grimace
(reflex irritability)
Floppy
Minimal Response
to Stimulation
Prompt Response
to Stimulation
Critical Interventions
A Activity
(muscle tone)
Absent Flexed Arms
and Legs
Active
Infant's heart rate

R Respiration Absent Slow and Irregular Vigorous Cry 160 - 100/ minute → Positive 60-100
Pressure Ventilation (PPV) PPV - Positive Pressure Ventilation
NCLEX TIP
Below 60/ minute
� Epinephrine
� Chest compression
30 seconds after quality PPV
(heart rate remains less than 60)
Necrotizing Enterocolitis
This is an inflammatory disease of the gastrointestinal mucosa due to ischemia (low oxygenation), resulting in necrosis
(dead tissue within the GI tract), & perforation of the bowel (basically an explosion of the bowel).
Pathophysiology
Signs & symptoms HESI Question

Which are risk factors for
Feeding intolerance
Abdominal distention necrotizing enterocolitis (NEC) Daily abdominal girth
Bloody stools in preterm infants? measurements NCLEX TIP
Risk Factors Polycythemia
Prematurity Myelomenigocele
Polycythemia
Myelomenigocele ATI Question
... necrotizing enterocolitis
(NEC). Which of the following
findings should the nurse
recognize as a risk factor?
Gestational age of 35 weeks
20 - 37 weeks
285
FTT & FAS
Maternity
FTT - Failure To Thrive The first 3 years of life
This growth failure is defined as a state of malnutrition, inadequate growth, or weight

less than 80% ideal for age within the first 3 years of life.
<80% 2.8kg
ATI Question
Causes & Risk Factors Signs & Symptoms: ... failure to thrive. Which of the
Socioeconomic following findings should the nurse
Poverty: “unemployed” Signs of malnutrition anticipate in this infant?
Primary caregiver cognitive disabilities Developmental delays The infant will avoid making
Abuse: child or spousal
Lack of nutritional knowledge
Abnormal feeding behaviors eye contact
Parents social or emotional isolation Increased metabolism
No eye contact HESI Question
Physiological
Anorexia nervosa prior to having children What clinical manifestations would
Preterm birth the nurse expect in an infant
Breast feeding difficulties diagnosed with failure to thrive?
Gastroesophageal reflux Malnutrition, developmental
Cleft Palate delays, feeding disorders
Kaplan Question
Observe the child feeding NCLEX TIP ... failure to thrive... The nurse instructs the
toddler’s parents about mealtimes. Which
Develop a structured routine for suggestion by the nurse is most appropriate?
bathing, sleeping, and playing Develop a structured routine for bathing,
Assess overall parenting skill sleeping, and playing
FAS - Fetal Alcohol Syndrome

Fetal exposure to alcohol (from maternal drinking) is the leading cause
of intellectual disability and developmental delay in the US.
Diagnostics
History of prenatal alcohol exposure
Risk factors HESI Question Growth deficiency
NCLEX TIP Neurological symptoms like microcephaly
Prenatal exposure to which substance can result in
ANY alcohol consumption in pregnancy craniofacial anomalies in the newborn?
Signs & Symptoms Alcohol Nursing Interventions

Intellectual disability Educate the mother on NO alcohol
Developmental delay
Saunders Question consumption during pregnancy
Hypotonia (weak muscle tone)
Poor sucking reflex & feeding Q1: ... hypotonia, irritability, and a poor sucking reflex in a Monitor the newborn’s response to
Abnormal palmar creases full-term newborn … The nurse suspects fetal alcohol
feeding & weight gain pattern
Infant irritability syndrome and is aware that which additional sign
would be consistent with this syndrome?
Minimal response to stimuli
Distinct facial characteristics NCLEX TIPS Abnormal palmar creases
Indistinct philtrum Q2: ... monitoring a newborn born to a client who abuses
Thin upper lip alcohol. Which findings should the nurse expect ...?
Short palpebral fissures Irritability

Epicanthal folds Minimal response to stimuli
Flat midface
NCLEX TIP
286
NAS & RDS
Maternity
NAS - Neonatal Abstinence Syndrome

This results from habitual use of opioids or illicit drugs during pregnancy. Pathophysiology
Opioid abuse including those with the O’s like HydrOcOdOne, MethadOne,
mOrphine & even HerOin, but sedatives like benzOs can also contribute to Signs & Symptoms
this condition. CNS findings: Irritability,
restlessness, high-pitched cry
Symptoms typically present within 24-72 hours of birth, but can take abnormal sleep pattern
days to weeks to appear. (sleeping very short intervals)
Kaplan Question ANS findings: nasal congestion
... newborn delivered by a client addicted to & frequent sneezing, tachypnea
ocodone
narcotics. At which time is the nurse most likely
GI: poor feeding & diarrhea
Hydr
to observe symptoms of narcotic withdrawal?

Within 24-72 hours after birth “loose stools”
Nursing Interventions: ATI Question HESI Question

… mother who used oxycodone daily during The nurse is caring for a newborn with a
Swaddle and gently rock pregnancy. Which of the following is indicated high-pitched cry, tremors, diarrhea, poor feeding,
Side-lying position for feeding ATI in infants with neonatal abstinence syndrome? tachypnea, nasal stuffiness… What is the most
common reason for these symptoms in a neonate?
Small, frequent feedings Swaddling the newborn and placing in a
Drug withdrawal
side-lying position for feedings
Skin protectants
RDS - Respiratory Distress Syndrome

This is a very SERIOUS respiratory disorder in newborns that is typically due to lung immaturity related to surfactant
deficiency! As you know, surfactant helps the baby’s lungs to be lubricated & expand in order to help get oxygen in!
Most full term babies can naturally produce surfactant, but is not always the case with premature infants.
Mature lungs in a baby have a 2 to 1 L:S ratio - the Lecithin Sphingomyelin ratio unless mom has diabetes -
which delays surfactant production
Pathophysiology
Diagnostics:
Risk Factors Saunders Question
Silverman-Anderson Index HESI
Preterm birth KAPLAN ... monitoring a preterm newborn for respiratory
distress syndrome. Which assessment finding should
IUGR - Intrauterine growth restriction alert the nurse to the possibility of this syndrome? Nursing Interventions
PPROM Select all that apply.
Steroids
Maternal DM, HTN, or drug use Cyanosis
Neonatal sepsis Tachypnea Betamethasone
Retractions
Audible grunts
Surfactant (via ET tube) HESI
Signs & Symptoms Admit to NICU for stabilization
Absent breathing or crying at birth HESI
Nasal flaring
Intercostal retractions HESI Question Feature Score 1 Score 2
Respiratory
Score 3
Seesaw
Audible grunting Chest Equal Lag Respiratory
Movement
Cyanosis & Tachypnea Which infant behavior would the Intercostal
nurse recognize as indicating Retraction
None Minimal Marked
respiratory distress? Xiphoid

None Minimal Marked
Retraction
Absent cry after birth Nasal Flaring None Minimal Marked
Expiratory Audible w/
None Audible
Grunt stethoscope
Notes
287
SIDS & Neonatal Sepsis
Maternity
SIDS - Sudden Infant Death Syndrome Educate Parents 6 NCLEX TIPS
Sudden Infant Death Syndrome is the unexpected death of an infant less 1. Place infants in supine position during sleep
than 1 year old. It occurs most frequently during sleeping in infants less “Put to sleep on their back” in a safe crib
Dress newborn in “wearable blanket”
than 6 months.
“sleep sack”
Memory Trick 2. Breastfeed the infant
A B C 3. Have up to date vaccinations
Alone Back Crib 4. Ensure a smoke-free environment

(no pillows, blankets, (supine) (no bed sharing or 5. Provide a firm sleep surface for the infant
stuffed animals) co-sleeping)
6. NO NO list
Avoid sleeping with the infant
(NO bed sharing, NO cosleeping)
NO pillows
NO loose or soft items: blankets, toys,
stuffed animals
NO bumper pads on the sides of the crib
HESI Question
... high risk of developing sudden infant death
Risk factors syndrome (SIDS)?
An infant whose mother smokes
Boys are at higher risk than girls Infant with an Apgar score of 4
Low apgar score at birth

Infants with a caregiver that smoke ATI Question
… reduce the risk of SIDS in infants?
Placing the infant in the supine position
Neonatal Sepsis
Risk Factors
Infection contracted by the neonate before, during, or after delivery, due
to the newborn’s limited immunity and inability to localize infection, Premature birth, PROM,
infections can spread quickly into the bloodstream. prolonged labor
Maternal TORCH infection
Meconium aspiration
HESI Question
Signs & Symptoms ... signs of neonatal sepsis?
Lethargy
Lethargy, irritability, poor Tachypnea
muscle tone Apnea
Respiratory distress:
Apnea or Tachypnea ATI Question
Heart rate instability ... immediately prioritized for assessment and care? Nursing Interventions
Temperature instability
A 3-week-old infant who has been feeding
poorly with a temperature of 100.5 F and Assess infection risks
sunken fontanelle
Vomiting/diarrhea → Draw labs/cultures
sunken fontanelles IV access
Poor feeding 100.5ᴼF
Blood glucose instability
288
_ _
Postpartum
289
Complications Postpartum I
Maternity
Infection
Infection is common postpartum. We already expect the mother to have elevated WBCs & a higher temperature
after birth - this is normal.
Normally, WBCs are between 5,000-10,000, but postpartum, we may see a WBC count up to 30,000.
This is expected after birth, but leukocyte counts that do not decrease require further evaluation.
Endometritis HESI Question

Which risk factors are associated with an
Pathophysiology increased risk for postpartum infection?
Inflammation or irritation of the lining Select all that apply.
of the uterus caused by infection. Hematoma
Prolonged labor
Cesarean delivery
Prolonged labor NCLEX TIP Postpartum hemorrhage
Prolonged rupture of membranes Prolonged rupture of membranes
(water broke) over 24 hours
Cesarean section delivery
Internal fetal monitoring
Postpartum hemorrhaging
Retained placenta fragments
Endometritis HESI Question

… cesarean delivery reports fever, loss of
appetite, pelvic pain, and foul-smelling
Signs & Symptoms lochia… increased pulse rate and uterine
Foul-smelling lochia “offensive” tenderness. Which clinical condition
would the nurse suspect?
or “musty”
Endometritis
Report this! NCLEX TIP
Fever (Over 100.4 F) within the The MOST tested

first 24 hours indicators of infection
Elevated WBC over 10,000

(leukocytosis)
Tachycardia
Uterine pain & tenderness
Endometritis ATI Questions

CLINDAMYCIN
Q1: Which of the following measures … to reduce
Interventions the risk of infections?
Wash your hands before and after voiding
Draw blood for culture & sensitivity Change the perineal pad from front to back
(before antibiotics) after voiding
Q2: … episiotomy after vaginal delivery … proper
Antibiotics: Clindamycin NCLEX TIP perineal care?
Use a squeeze bottle with warm water to
Good hand hygiene keep the site clean
Q3: … heart rate of 100/min, a temperature of
Peri Care (especially after an episiotomy) 38.3 C (101 F), and dark malodorous lochia.
1. Squeeze bottle with warm water Notes The prescriber has entered orders to initiate
antibiotics, obtain a blood specimen for
2. Wipe front to back culture and sensitivity, and administer a fluid
bolus… most appropriate initial intervention?
3. Blot perineum dry Draw blood for culture and sensitivity
290
Breastfeeding I
Maternity
Breastfeeding is very important for both the mother & newborn. NOT ONLY does it
contain powerful nutrients like fats, protein, & antibodies to which help strengthen
the newborn’s immune system to fight infection, as well as lowering rates of
allergies, sudden infant death syndrome (SIDS), & other disorders! BUT, it also helps
the mother & baby to bond with skin to skin - which should be done soon after birth.
Oxytocin
Prolactin helps to produce milk and oxytocin helps with the let down of the milk. Memory trick
Breastfeeding helps the mother, too, primarily in reducing uterine bleeding &
preventing severe postpartum hemorrhage. The act produces natural oxytocin Oxytocin helps to
Opens the nipple
release in the mother, which stimulates uterine contractions to prevent postpartum
hemorrhage.
Colostrum
Along with other added benefits like reduced risk of certain cancers, osteoporosis,
arthritis, heart disease, & other disorders. Initially, the breast makes colostrum -
a yellowish fluid that is rich in antibodies. Immune cells coat the newborn’s GI tract,
helping the baby to pass meconium - the baby’s first stool.
Colostrum is secreted during pregnancy & for 2-3 days after delivery. Milk is
produced 3-5 days after delivery & has higher fat content than colostrum.
Correct Breastfeeding Technique Correct Breastfeeding Technique Correct Breastfeeding Technique

Before During Bad Latch: Shallow latch
1. Wash hands prior to feeding 2. Good Latch: Only the tip of the nipple inside the
Baby’s mouth wide open covering both baby’s mouth!
the areola & the nipple Causes less milk flow & nipple soreness,
Ensure the bottom of the areola is in cracking & bleeding
baby’s mouth
Nipple up against the roof of the mouth
Baby’s tongue against the bottom of
the areola
Reposition the baby’s latch → always
use 1 finger to break the suction first Apply breast milk to sore
NCLEX TIP
nipples & allow to air dry
SIDE NOTE
If the mother is unsuccessful, the first intervention is EDUCATION & demonstration.

Do not go to bottle feeding first! Teach the mother good latch technique FIRST & don’t let
the NCLEX trick you with offering formula feeding first. This is wrong!
ATI Question
Correct Breastfeeding Technique
... initiating breastfeeding. Which of
After the following should the nurse relay
3. Fully empty the breasts with each feeding to this client?
Use a breast pump if needed
4. Initially: feed every 1-3 hours 1 DAY The mother should awaken the
x 8 - 12 feeds per day baby at least every 3 hours during
the day to feed
291
Breastfeeding II
Maternity
Education
Encourage fluid intake for adequate Education
milk production Breast engorgement
Wear a supportive bra • Feed or pump more regularly
Mastitis signs Report to HCP (at least every 1-3 hours)
• Flu like symptoms • Recognize feeding cues from the
Fever & muscle aches baby: rooting reflex, suckling motion,
• Unilateral breast swelling, pain hand-to-mouth movements.
& inflammation • Use chilled, fresh cabbage leaves on
(redness, warmth, edema) breasts throughout the day NCLEX TIP
• Before breastfeeding or pumping:
Blocked milk duct Warm compresses or a warm shower
• Before breastfeeding: Apply warm • Apply breast milk to sore nipples
compress to breasts to open milk & allow to air dry after feeding
ducts & prevent blockage
• After: Apply cool compresses
ATI Questions
Q1: … client is experiencing engorgement…
HESI Question
most appropriate response from the nurse? Which early feeding-readiness cues are
“Before you try to feed your baby again, exhibited for a breastfed newborn?
take a warm shower” Select all that apply.
Q2: … breast discomfort and engorgement? Rooting reflex
The client should apply a small amount Suckling motions
of breast milk to sore nipples and let Hand-to-mouth movements
them air dry after feeding
AVOID during breastfeeding

HESI Question
Alcohol (wait 2 hours or 1 drink per day
... taking analgesics ... and is anxious
more after consumption that the medication may pass into ANALGESICS
to breastfeed) her breast milk

Smoking 2 hours
Take the medication
immediately after breastfeeding
Drugs
Newborn weight loss during Infant Formula

the first 3 to 4 days of life 7 Rules & NCLEX TIPS
Weight loss OVER 7%
Normal newborn weight 1. Wash the top of formula cans before opening
loss is 5 - 6%
3.8kg
3-4 days
3.5kg
2. Refrigerate unused formula & discard after
48 hours
REPORT weight loss 3. Throw away leftover formula after feeding
OVER 7% within 3 to 4 4. Boil or wash in a dishwasher: bottles, nipples,
days of life NCLEX TIP caps & other parts
5. Before feeding, warm the formula & tes tthe
temperature on the inner wrist before serving.
It should be lukewarm, not hot!
6. NEVER over dilute or over concentrate
the formula
Breastfeeding support
TOP TESTED
Formula supplementation
292
Complications Postpartum II
Maternity
Mastitis
HESI Question
Mastitis Mastitis ... mastitis. Which instruction
Pathophysiology Interventions NCLEX TIPS should the nurse provide to
Inflammation of breast tissue that can result this client?
from poor breastfeeding technique, inadequate Breastfeeding
Continue breastfeeding frequently Breastfeed the infant,
milk duct drainage & may include infection. ensuring that both breasts
(every 1-3 hrs)
Causes & Risk Factors “ensure complete emptying of the breasts” are completely emptied
Blocked milk ducts Teach proper technique:
Poor breastfeeding technique Alternate feeding positions & proper latch
(only sucking nipple & not entire areola) Education:
Poor hand hygiene � Apply warm compresses to breast & massage
� Increase oral fluid intake
Signs & Symptoms
� Wash hands before & after feeding
Flu like symptoms
� AVOID tight bras or underwire bras
� Fever
� Muscle aches Pharmacology:
Unilateral breast swelling, pain & � Antibiotics: dicloxacillin, cephalexin
inflammation (redness, warmth, edema) � Ibuprofen or acetaminophen for pain
UTI - Urinary Tract Infection

UTI - Urinary Tract Infection
Pathophysiology UTI - Urinary Tract Infection
Infection & inflammation of the urinary tract
Causes & Risk Factors Treatment
Urinary catheters Antibiotics: Levofloxacin
Cesarean section delivery
Frequent pelvic exams
Increase fluid intake
Symptoms Cranberry juice
Burning pain upon urination AVOID:
Urinary urgency & frequency
Cloudy, foul odor in the urine � Wiping back to front
Fever � Bubble baths
Diagnostics � Spandex
UA: Urinalysis
� Elevated WBC
� Nitrites
DVT - Deep Vein Thrombosis Signs & Symptoms

C O W S
One sided
Pathophysiology Calf pain & cramping
“unilateral” leg swelling
Warm, red leg
(blood pooling)
SOB & chest pain
A DVT is a blood clot in the deep vein,

typically 1 leg.
Thrombophlebitis is an inflammatory
process that causes a blood clot to
form & block one or more veins.

Cesarean section (C-section) Treatments Prevention of DVT
Obesity C A L F
Smoking Calf exercises
(flex toes in bed)
Ambulate early & frequently
Avoid crossing legs
Leg compression stockings
(Ted hose & SCD)
Fluids increase
(2 - 3 L per day)
Avoid smoking & sitting for
Complication
long (car, airplane, bedrest)
PE: Pulmonary Embolism
ATI Question Treatments During a DVT
… tenderness, warmth, and D V T

Venous return (eleVate the entire leg)
redness of the lower extremity.
Do not walk or massage legs! Touch or leg massage AVOID!!!
NO pillows “under the knee”
Entire leg must be elevated above heart
Which of the following does this
finding most likely represent?
Thrombophlebitis
293
Postpartum Hemorrhage
Maternity
Over 500 mL Over 1,000 mL

after vaginal birth after C-section
Massive bleeding after giving birth, defined as over 500mL blood loss after
vaginal birth and over 1,000mL after C-section.
Uterine Disorders Medications

Uterine atony: Magnesium sulfate MAGNESIUM
SULFATE
Boggy soft uterus that fails to contract after birth Terbutaline
#1 intervention = massage that fundus! Inhaled anesthesia (general anesthesia)
Every 15 minutes x 1 - 2 hours Uterine Atony
Prolonged use of oxytocin
Overdistention of the uterus:
Macrosomia (big baby over 8lbs 13 oz) NCLEX TIP
Multiple gestation (Twins, triplets, or more)
Placental disorders:
Multiparity (many pregnancies) Placental abruption
Polyhydramnios (excess amniotic fluid) Placenta Accreta: placenta attaches to the
uterus too firmly
Uterine fatigue (labor lasting over 24 hours)
Retained placental fragments or fetal demise
Uterine rupture or inversion: Retained placental
uterus tears or turns inside out Over 8lbs 13oz fragments
Precipitous Labor: quick labor in 3 hour or less
Trauma & HTN

Vaginal lacerations & hematoma: ATI Questions
use of forceps or vacuum Q2:… postpartum hemorrhage. Which of the following
Preeclampsia (hypertension) Vaginal lacerations Vaginal hematoma may have increased the risk of the client’s condition?
MAGNESIUM
SULFATE
Thrombin Disorders Magnesium sulfate during labor

Large for gestational age neonate
DIC: Disseminated Intravascular Coagulation
ITP: Idiopathic Thrombocytopenic Purpura
Interventions
HCP
1
Boggy, soft fundus

1
HESI Question
Saturated perineal pads hour
within 15 min. - 1 hour Notify the HCP

Which is an early sign of 00:04
Heavy bleeding with blood clots (days after birth)
Blood clots - BIGGER than a quarter hemorrhagic shock?
Steady flow or “constant oozing of blood” from vagina
H & H is decreased Capillary refill time of
HgB less than 7 = Heaven NCLEX TIP HEMOGLOBIN
4 seconds
Hemorrhagic shock from excess bleeding:
Tachycardia & hypotension
< 7g/dL
Cold clammy skin
Long capillary refill time
Firmly massage the fundus (every 15 min x 1-2 hours)

Empty bladder
ATI Question
Start with fundal massage, then use meds to stop the IV fluids for hypotension &
Start a secondary IV line for blood transfusion postpartum client ... blood pressure
bleeding. If that doesn’t work, try a tamponade balloon of 146/94 mm Hg. Which of the following
next. A total or complete hysterectomy (removal of the Notes
Pharmacology:
1. Oxytocin bolus prescriptions should the nurse clarify
entire uterus) can be performed as a last resort to stop 2. Methylergonovine (Methergine) with the provider?
NOT for clients with high blood pressure NCLEX TIP
postpartum hemorrhage. (preeclampsia & pre-existing HTN)
Methylergonovine 0.2 mg IM now
Misoprostol: safe for clients with hypertension NCLEX TIP
294
Complications Postpartum III
Maternity
PE - Pulmonary Embolism
A major complication of a DVT is a Pulmonary Embolism (PE).

The DVT clot breaks loose from the leg & travels to the lungs!
It can be very deadly, as it blocks blood flow to the lungs!
Signs & Symptoms

#1 Sign = Hypoxemia
1
0₂
0₂
0₂
Assess respiratory status 0₂
1. Restlessness Oxygen
2. Agitation, anxiety Notify the HCP!
3. Mental status changes
Pharmacology
Assessment NCLEX TIP
Anticoagulants
Obtain oxygen saturation
reading by pulse oximeter Heparin Anticoagulants
Warfarin (contraindicated
Chest pain during pregnancy)
“pleuritic chest pain”
Thrombolytics “clot busters”
SOB & Dyspnea tPA
Tachypnea Alteplase
Tachycardia Streptokinase
Top Missed NCLEX Questions ATI Question

While assessing a postpartum client after a cesarean … a client at 12 weeks gestation for
section, the client reports anxiety, pain, appears restless, treatment of a deep vein thrombosis.
and breathing quickly with a heart rate of 122. What action
should the nurse take first? Which of the following medications is
contraindicated during pregnancy?
Obtain oxygen saturation reading by pulse oximeter
Warfarin
95%
Vaginal Hematoma Pathophysiology

A vaginal hematoma is formed when there
is trauma to the tissues of the perineum
Forceps or vacuum assisted vaginal birth
Episiotomy
Signs & Symptoms
Persistent severe vaginal pain Forceps Vacuum
Feeling of fullness
Firm, midline uterus
Large hematomas:
Decreased hemoglobin levels (Hgb)
Vital sign changes: low BP, fast HR ACETAMINOPHEN
IBUPROFEN 325 mg
Interventions
Cool compress
Ibuprofen & acetaminophen
295
Postpartum Depression & Baby Blues
Maternity
Postpartum mood disorders are classified into 3 buckets or classifications: Postpartum Baby Blues
Postpartum This is our small problem. It’s the shortest in duration &
Baby Blues typically resolved on its own.
Postpartum Depression
Postpartum
Depression (PPD)
Is the medium problem lasting longer & interventions are needed.
Is the BIG problem, VERY SEVERE! Lasting the longest & early Postpartum Psychosis
Postpartum
Psychosis
interventions are required for the safety, as mothers lose touch
with reality.
Postpartum Depression (PPD) Postpartum Psychosis

Postpartum Baby Blues
Within 2-3 weeks of delivery
10 days or less & resolves on its own 2 weeks or more Risk factor: History of bipolar disorder
Signs: (not debilitating) Onset within 4 weeks after delivery Signs: (extremely debilitating)
Crying & sadness but don’t know why Signs: (debilitating) Confusion
Anxiety, panic Delusions & hallucinations
Fatigue, exhaustion
Overwhelmed & stressed Paranoia
HIGH RISK for harm “thought of
Persistent sadness & mood swings harming self / baby”
Apathy (loss of interest) Immediate Interventions
Decreased appetite & anorexia Inpatient Hospitalization treatment:
Insomnia: Inability to sleep therapy & meds
Psychiatric care
Requires interventions
Rule out other causes: Hypothyroidism
Longer maternity leave
Counseling/ Talk therapy: “psychotherapy”
Depression therapy
Meds:
Medication Antidepressants
More frequent follow ups Antipsychotics
Mood stabilizers
ECT: Electroconvulsive therapy
10-20%
10 days
4 weeks
Interventions: Fetal Demise 4 NCLEX TIPS Adoption Interventions

Stillborn infant who has died before 1. Allow parents to stay with the baby 4 NCLEX TIPS
as long as they want 1. Alert other staff of the adoption plan
or during delivery.
2. Acknowledge adoption plan EARLY
2. Ask the parents if they would like to
(before birth)
help bathe the infant
This encourages the client to express
3. Encourage the parents and family emotions & be involved in decision-making
members to hold the infant 3. Encourage the birth mother to hold the
4. Offer to obtain handprints, footprints, newborn, take pictures, & offer the birth
& photographs of the infant mother a chance to say goodbye
4. Use phrases & words that portray adoption
as a decision of love, not abandonment
AVOID: “giving up” “giving away”
your baby
Use: “choosing adoption”
You chose
adoption. He will
be fine.
HESI Question
This is very traumatic for both the Which priority action would be most
beneficial in helping a couple cope with
parents & family members. fetal loss after the delivery of a stillborn?
It requires specific therapeutic Allow the parents to hold and view the
interventions. baby after delivery if they so request
296
Drug Moa Indication Contraindication / dose / route Nursing action
adverse effects
Phytonadione Helps prevent bleeding by Prevention and treatment IM Monitor for frank and occult
Vit K activating clotting factors of hypoprothrombinemia Pain, swelling, flushing, , Subcut, IV (Children 1 bleeding
dizziness, rapid heartbeat, mo): 1– 2 mg single dose. pulse and BP frequently;. Apply
sweating pressure to all venipuncture
sites for at least 5 min; avoid
unnecessary IM injections.
Erythromycin Suppresses protein Infections caused by infantile hypertrophic pyloric IV/ P.O Monitor for allergic reaction.
Erythrocin synthesis at the level of the susceptible organisms stenosis, PO (Neonates ):
50S bacterial ribosome including pancreatitis,interstitial Ethylsuccinate—20– 50
nephritis.rash. mg/kg/day divided q 6– 12
benzyl alcohol should be hr.
avoided in neonates. IV (Children 1 mo): 15–
50 mg/kg/day divided q 6
hr, maximum 4 g/day.
HEp B vaccine Causes a primary immune Provides immunity against Do not give if baby is already 5 mcg/0.5 mL ; 5 mcg/mL Assess patient anaphylaxis
response. HEP B + ; 10 mcg/0.5 mL (hypotension, flushing, chest
tightness, wheezing, fever, d
HEP B IG Confers passive immunity hepatitis b infection in erythema at IM site, pain, IM : 0.5 mL within 12 hr of Assess patient anaphylaxis
BayHep B, Nabi-HB to hepatitis B infection post neonates born to HBsAg- swelling, tenderness birth. (hypotension, flushing, chest
exposure + women, provides Hypersensitivity to immune tightness, wheezing, fever,
passive immunity. globulins, glycine, or dizziness.
thimerosal.
297
Drug Mode of Action indications Contraindications/ side dose/route Nursing actions
effects
Hydrocodone Bind to opiate receptors in Management of moderate to Avoid chronic use ROUTE PO Monitor respirations
bitartrate/ the CNS. severe pain. ● Dizziness, sedation, —2.5– 10 mg q 3– 6 hr as needed; Do not give laxatives
acetaminophen respiratory depression,
(Norco)/ Lortab hypotension
Rho(d) immune Prevent production of Administered to Prior hypersensitivity reaction to ROUTE IM/IV Assess vital signs
globulin (human) anti-Rho(D) antibodies in Rho(D)-negative patients who human immune globulin; Rho(D)- or 600 IU (120 mcg) w periodically during therapy
Rho(D)-negative patients have been exposed to Rho(D)- Du-positive patients. 40– 125 mg qid, after meals and at
who were exposed to positive blood by: Pregnancy or ● HTN, hypotension, bedtime (up to 500 mg/day)
Rho(D)-positive blood. delivery of a Rho(D)-positive anemia
infant,
Simethicone Passage of gas through Relief of painful symptoms of Not recommended for infant colic ROUTE 40– 125 mg qid, after Assess patient for
Gas-X the GI tract by belching or excess gas in the GI tract that ● None significant meals and at bedtime (up to 500 abdominal pain, distention,
passing flatus may occur postoperatively mg/day) and bowel sounds prior to
and periodically throughout
Docusate Promotes incorporation of Prevention of constipation (in Hypersensitivity; Abdominal pain, ROUTE PO Assess for abdominal
Peri-Colace, water into stool, resulting in patients who should avoid nausea, or vomiting, : 2 tablets once daily at bedtime; distention, presence of
softer fecal mass straining, such as after MI or maximum 4 tablets twice daily. bowel sounds, and usual
rectal surgery) pattern of bowel function.
298
Drug MOA Indication Contraindication/ route/dose Nursing actions
Side effects
Surfactant Replaces surfactant Treatment of respiratory None Intratracheal: Monitor ECG, heart rate, color, chest expansion,
(beractant) in premature infants distress syndrome in ● O2 desaturation (4 mL/kg birth weight); 4 doses may o2 sat, and ET tube patency continuously
premature infants. be given in first 48 hr of life, q 6 hr Continuous bedside monitoring for 30min
apart
Caffeine citrate Decrease periods of Short-term treatment of Hypersensitivity ROUTE IV/PO necrotizing enterocolitis (abdominal distension,
apnea idiopathic apnea of ● Tachycardia, Maintenance dose—starting 24 hr vomiting, bloody stools, lethargy).
preemie infants between feeding after loading dose 5 mg/kg
28 and 33 wk gestational intolerance,
age. gastritis
Prostaglandin E1 relaxes smooth Temporary maintenance Respiratory distress ROUTE IV respiratory rate, heart sounds, and neurological
(alprostadil) muscle of the of patent ductus arteriosus syndrome 0.05– 0.1 mcg/kg/min initially; may status frequently
ductus arteriosus in neonates ● Seizures, be increased up to 0.4 mcg/kg/min
cerebral bleeding, until satisfactory response
ampicillin Binds to bact cell Treat bacterial infections Hypersen to PCN ROUTE IM/IV Observe for anaphylaxis (rash, pruritus,
wall ● Seizures, pseud Children 40 kg): 100– 200 mg/kg/day laryngeal edema, wheezing).
colitis in divided doses q 6– 8 hr (not to
exceed 12 g/day).
HMF (human milk Increased digestion Pancreatic insufficiency Hypersen to hog proteins ROUTE PO Monitor stools for high fat content Stools will be
fortifiers) of fats, carbs, and ● Shortness of (Children 1 yr): 2000– 4000 lipase foul-smelling/frothy.
enzymes proteins in the GI breath, dyspnea units per 120 mL of formula/breast Assess patient for allergy to pork
tract. milk.
299
Postpartum Assessment I
Maternity
Contraindication
Postpartum Assessment
POST-PARTUM ASSESSMENT
“BUBBLE HE”
B Breast
U Uterus (fundus)
B Bladder
B Bowel
L Lochia
E Episiotomy
H Hemorrhoids
E Extremity (DVT signs)
B Breast
This assessment includes examining the areolas for cracking, tenderness, or masses and
also assessing breastfeeding technique.
U Uterus (fundus)
Postpartum hemorrhage can happen rapidly and the client can bleed out. Remember,
we DO NOT want a soft or boggy fundus. This indicates an increased risk for postpartum
hemorrhage. Postpartum hermorrhage
B Bladder
First, assess for bladder distension. Because a distended bladder can displace the fundus,
making it more difficult for the uterus to get firm/contract, tell the client to empty their
bladder shortly after delivery. A soft or boggy fundus increases the risk for hemorrhage.
Assess for Urinary Tract Infections (UTI) by asking about common symptoms including:
dysuria, urinary urgency, and urinary frequency.
B Bowel
Auscultate bowel sounds and ask when the last bowel movement occurred.
The main goal is to prevent postpartum constipation, as we want to prevent straining.
Remember, the client may have stitches for lacerations or an episiotomy.
Any pressure from bearing down can cause immense pain and even rip stitches.
Teach clients to preventatively administer their stool softeners or laxatives and increase
the 3 F’s-Fluid, Fiber, and Freaking walk around man.
Lacerations Episiotomy
L Lochia
Lochia is the vaginal discharge after birth containing a mixture of blood, Lochia Assessment
mucus, and uterine tissue. Assess amount, color, odor, and size of clots Large clots!
Normal signs include: a small-moderate amount of discharge that is Rubra
Malodorous “Foul odor”
(red). Abnormal findings that should be reported to the provider include:
- Large clots! Excessive bleeding: 1 pad in 15 minutes
- Malodorous “Foul odor” Check under the client for pooled lochia
- Excessive bleeding: (soaking through 1 pad per hour)
- Check under the client for pooled lochia
300
Postpartum Assessment II
Maternity
E Episiotomy
Episiotomy as you know is a surgical incision of the

Episiotomy
perineum between the vagina to anus. It’s typically
performed during delivery to prevent tearing & help to
quickly enlarge the opening for the baby to pass through. R E E D A
Redness Edema Ecchymosis Drainage Approximation
Use the memory trick REEDA for quick assessment of this

wound:
H Hemorrhoids SIDE NOTE

H Homan’s sign
Hemorrhoids are swollen veins in the lower rectum area that result from the
pressure in this area during pregnancy. It causes much discomfort & minor bleeding.
Topical
As mentioned before, topical witch hazel is good for inflammation. witch hazel
Side note - a few resources use this H for Homan’s sign to assess for DVT risk.
E Extremity (DVT signs)

This is where a blood clot forms in a deep vein, typically 1 of the legs, Complication for DVT
due to the hypercoagulable state of pregnancy. PE: Pulmonary Embolism
Three factors that contribute to DVTs in pregnant clients are:

Blood stasis - think of that HUGE uterus compressing vessels C O W S
Altered coagulation - thanks, hormones Calf pain One sided Warm, red leg SOB & chest pain
Localized vascular damage from the recent birth! & cramping “unilateral” leg swelling (blood pooling) = indicates PE
In terms of assessment we use the acronym cows - since the affected leg Pulmonary
Embolism
beefs up like a little baby cow. All signs must be reported to the provider. Notify provider!
Emotional wellbeing
Assessments to include:
- Emotional & psychological status (mainly sadness)
- Attachment
- Fatigue
- Affect disorders
Sadness can turn into postpartum depression even though depression typically manifests
when the client gets back home. Make sure the mother is bonding with the infant &
participating in the care of the newborn and look at social issues concerning the child.
Education
E Education
AVOID sex until:
The BIG focus is on sex after labor, but we want to educate the mother about Vaginal discharge is white: Lochia alba
Episiotomy is healed
nutrition/ fluids and balancing rest & activity.
OTC lubcriants during sex
Teach the client to use condoms BEFORE menses returns NOT after, unless their Ovulation may occur 4 weeks after delivery
goal is to get pregnant again very soon! BEFORE menses returns!
Use contraception (condoms) immediately!
301
_ _
Pediatrics
302
_ _
Physical assessment
&
Vital signs
303
Pediatric Vital Signs I
Pediatrics: Assessment
PEDIATRIC VITAL SIGNS CHEAT SHEET

HEART RATE
AGE HEART RATE
Neonate (1-28 days) 110 - 180 bpm
Infant (1-12 months) 110 - 160 bpm
Toddler (1-3) 80 - 110 bpm
Preschool Child (3-6) 70 - 110 bpm
School-age Child (6-12) 65 - 105 bpm
Adolescent (12-18) 60 - 100 bpm
RESPIRATORY RATE
AGE RESPIRATORY RATE
Neonate (1-28 days) 30 - 60 breaths/min
Infant (1-12 months) 30 - 60 breaths/min
Toddler (1-3) 24 - 40 breaths/min
Preschool Child (3-6) 22 - 34 breaths/min
School-age Child (6-12) 18 - 30 breaths/min
Adolescent (12-18) 12 - 18 breaths/min
BLOOD PRESSURE
SYSTOLIC
AGE SYSTOLIC DIASTOLIC
HYPOTENSION
Neonate (1-28 days) 60 - 90 20 - 60 <60 (0-28 days old)
Infant (1-12 months) 70 - 105 35 - 55 <70 (1mo - 12mo)
Toddler (1-3) 85 - 105 40 - 65 <70 + (age in year x 2)
Preschool Child (3-6) 90 - 110 45 - 70 <70 + (age in year x 2)
School-age Child (6-12) 97 - 120 55 -70 <70 + (age in year x 2)
Adolescent (12-18) 110 - 130 65 - 80 <90
TEMPERATURE
AGE TEMPERATURE
Infants - children < 5 years old Rectum: 97.9oF (36.6oC) - 100.4oF (38oC)
(the younger the child, the higher the baseline
Oral: 95.9oF (35.5oC) - 99.5oF (37.5oC)
temperature)
Axillary: 97.8oF (36.5oC) - 99.5oF (37.5oC)
Ear: 96.4oF (36.7oC) - 100.4oF (38oC)
Children > 5 years old 98.6oF (37oC)
OXYGEN SATURATION
GOAL ALWAYS: > 95% SpO2
TEST TIP Focus on the highlighted information! Most exams focus on heart rate, respiratory rate & blood pressure,
specifically in the neonate, infant & toddler age ranges, as these are the MOST vulnerable clients.
*Ranges will vary by textbook & nursing school. These vital signs were verified by 5 textbooks and NCLEX standards.
304
Assessment of Growth and Development
of the Infant
Head should measure 13.75 cm at birth

-Posterior fontanelle should close by 2nd month Well checkup schedule
-Anterior fontanelle should close in 12-18 months • Second week of life
Height and weight • 2, 4, 6, 9 months of age.
- In the first 6 months, birth weight doubles and baby should grow 6 inches
- By 12 months birth weight should triple and baby should grow 10-12 in.
Skeleton
- Is made up of cartilage at 3 month gestation and continues to ossify and grow Vitals
throughout life.
• HR: 70 resting - 180 awake and crying
- Bone age, injury, abuse or nutritional deficits can be determined by X-Ray.
(accurate HR is taken apically)
Circulation • RR: 30 but can range from
- Hemoglobin and RBCs decrease when respiratory system takes over until
20-50 with increase or decrease of activity.
3 months of age
• BP: 85/60 mmHg
Neuro • Temp: 98.6
- Nerve cells grow and coordination begins in an orderly pattern.
Physical Milestones Psychological Milestones

• Focuses 8-12 in away
• Jerky quivering arm movements,
• Eyes wonder and cross
• Brings hands to mouth, makes fists
• Likes black and white/ high contrast patterns.
• Head flops back if unprepared
• Prefers human face to other patterns
• Strong reflexes
• Hearing is fully mature, may turn toward sound
• 5-8 feedings per day - 3 meals 2 snacks
• Likes sweet smells, dislikes sour
• Progresses from sleeping 20 hours a day to 10-12 hours at night
• Likes soft sensations
and two naps by 12 months, place awake child in crib to sleep
• Likes to be handled gently
Social Milestones Emotional Growth

• 0-1 mo: general tension
• 0-1 month: extensive sleep, dependent, eye contact
• 1 mo: happy and sad emotions
• 0-3 months: smiles and fixes on faces, solitary play
• 6 mo: separation anxiety
• 3-6 mo: enjoys peekaboo, smiles at familiar faces
• 6-12 mo: stranger anxiety, shows curiosity by 12 months.
• 6-12 mo: knows name, gives and takes objects, understands
easy commands.
Nutrition
Rapid growth causes a need for the greatest amount of nutrients
Language • 4-6 mo - 12 mo: breast milk or commercial formula, introduction of
solid foods. One food at a time starting with veggies.
• You may need to supplement Vit C/D iron, fluoride.
• 0-3 mo: Cries, grunts and Coo • 6 mo: iron-rich foods are needed to supplement
• 0-6 mo: Babbling, vowels, half consonants • 7-8 mos: self-feeding begins by grasping and bringing food to mouth.
• 12 mo: 1-2 words, imitation, responding to simple commands Ends with use of utensils
• WIC program helps children and women get proper nutrition when
they qualify
Age Theorist Stage Description Nursing Care

Encourage
Birth - Pleasure center self-feeding.
Sigmund Freud Oral
18 months in mouth Avoid putting objects
in mouth
Depends on parents Encourage bonding

Trust vs
1st year Erik Erikson to meet needs to and family
mistrust
create trust relationships
Coordinates sensory Plan tactile activities

Sensorimotor
experiences with with use of colorful
Birth - 2 yrs Jean Piaget stage
physical action materials
305
Pediatric Physical Exam I
4 KEY POINTS
1. Interact with parents 1st & child 2nd
FIRST LAST
2. Encourage the parent
to be involved with the child NCLEX TIP
3. Communicate with age appropriate

“simple language”
38.5
4. Keep medical equipment out of sight

5. Invasive procedures always LAST!
(Ex: ear exam, BP cuff)
ATI Question TOP Missed NCLEX Question

physical examination of a toddler ... appropriate While preparing to perform a physical #1 #2
FIRST
assessment on a 22-month-old child, the
nursing intervention?
nurse should complete the following
Keep the medical equipment out of the actions in which order?
toddler’s sight until its needed #3 #4
Unordered Options Ordered Response
?
#1 Take the child’s weight & height #4 Interact with the parent first
#2 Use a toy to play with the child #2 Use a toy to play with the child
14kg
#3 Obtain vital signs #1 Take the child’s weight & height
#4 Interact with the parent first #5 Listen to heart & lung sounds
#5
#5 Listen to heart & lung sounds #3 Obtain vital signs
Infants 0-12 Months

Growth
1. Height
1 inch per month
50% increase at 12 months
2. Weight
Doubles at 6 months NCLEX TIP
Triples at 12 months 2.7kg 5.4kg
g
8.2k
Example: Newborn baby weighs

6 lb (2.7kg) 6 months 12 months
6 month = 12 lb (5.4 kg)

12 months = 18 lb (8.2 kg)
Kaplan Question TOP Missed NCLEX Question

8-month-client ... possible delay in Which assessment finding should
growth and development? the nurse report to the health
HCP
care provider? 1
“My child has almost doubled the
birth weight.” 6-month-old child with
birth weight of 8 lb 5 oz (3.8 kg)
who now weighs 14 lb 4 oz (5.4 kg)
x2
OWTH
DELAYED GR
14.4lbs
3.2kg 6.1kg 6.1kg
6 month old 8 month old
306
Pain Scale Assessment
Cries Scale 0-6 months

C R I E S
Crying Requires oxygen Increased Expression Sleepless
vital signs
0₂
0₂
0₂
0₂
NORMAL
HIGH
LOW
0 - 6 months
Flacc Scale 2 months - 7 years

F L A C C
Face Legs Activity Cry Consolability
2 month - 7 years
Faces Scale 3 years & up

Children 3 - 6 years old view pain as “magical thinking”, thinking pain is a punishment,
or that pain will magically disappear & even blaming someone else for the pain.
Saunders Question
4-year-old child. When experiencing
pain, the nurse anticipates:
• Views pain as punishment
0 1 2 3 4 5 • Blames someone else for the pain
NO HURT HURTS HURTS HURTS HURTS HURTS
LITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORST
• Believes pain will disappear magically
Numeric Scale 5 years & up
0 1 2 3 4 5 6 7 8 9 10
O Onset
P Provocation
Q Quality
R Radiation
S Severity
T Time
No Mild Moderate Severe Very Severe Worst Pain

Pain Pain Pain Pain Pain Possible
307
Pediatric Physical Exam II
Infants 0-12 Months

4-6 months of age
Nutrition
Breast milk or iron fortified formula S M T W T F S S M T W T F S S M T W T F S
(No cow’s milk)

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5
6 7 8 9 10 11 12 6 7 8 9 10 11 12 6 7 8 9 10 11 12
13 14 15 16 17 18 19 13 14 15 16 17 18 19 13 14 15 16 17 18 19
20 21 22 23 24 25 26 20 21 22 23 24 25 26 20 21 22 23 24 25 26
27 28 29 30 27 28 29 30 27 28 29 30
Solids begin at 4 - 6 months

ONLY 1 NEW food per week
Only 1 NEW food per week
NCLEX TIP
Head
#1
Fontanelles: Posterior Prior
Saunders Question
Bulging (at rest): Meningitis, Increased ICP 2 months old
3 month old ... monitoring for signs of increased
Sunken: Dehydration, FVD intracranial pressure… anterior fontanel is soft
Closure of Fontanelles NCLEX TIP #2 and flat… most appropriate action?
Anterior After Document the finding
Posterior fontanelle by 2 months 12-18 months old
Anterior fontanelle by 12 - 18 months
HESI ATI
PRIORITY
At birth, the head circumference is slightly bigger than the
chest but equals in size around 12 to 18 months. Fontanels
on the top of the head should be flat & only slightly pulsate
when the baby cries, coughs, or lies flat. These fontanels
should never be bulging at rest or sunken! This is a priority!
Respiratory Distress
1st - Assess
Nasal flaring 2nd - Interventions
Accessory muscle use Pattern
Abdominal breathing
Nonproductive cough
Frequency
SAVED
Excessive Crying NCLEX TIP Interventions
Assess infants pattern, frequency, Quality
& quality of crying
Assessments
High pitched = increased ICP
or brain damage
Teeth 6 - 10 months
First tooth: 6-10 months
(lower central incisor)
Signs of teething:
Drooling & irritability
Intervention: Teeth care
with washcloth
308
Pediatric Vital Signs II
Key Points ATI Question

Which of the following should
the nurse assess first on a
well-child exam in a 6 week old
1. Talk to parents 1st & then the infant who is sleeping?
child 2nd Auscultation of lung and
heart sounds
2. Always start with least invasive
vitals FIRST TOP Missed NCLEX Question
3. Infants - should be in caregiver’s 10-month old ... crying & vomiting with abdominal
lap during the assessment distension for the past 6 hours. The infant is now
quietly resting with a pulse of 220/min and blood AGE
HEART RATE
HEART RATE
pressure of 85/45. What should the nurse report

Neonate (1-28 days) 110 - 180 bpm
Infant (1-12 months) 110 - 160 bpm
Toddler (1-3) 80 - 110 bpm
FIRST LAST to the HCP?

Client is now lethargic with tachycardia BLOOD PRESSURE
SYSTOLIC
AGE SYSTOLIC DIASTOLIC
HYPOTENSION
The question says:
220 85/45
Tachycardia
Heart & Respiratory Rate

HESI Question
• Count & listen for 1 full minute … assessing the heart rate of a 1 year old?
RESPIRATORY RATE
(60 seconds) for infants and toddlers, Listen to apical pulse for a full minute AGE RESPIRATORY RATE
to screen for irregularities. Neonate (1-28 days)

Infant (1-12 months)
30 - 60 breaths/min
30 - 60 breaths/min
Saunders Question Toddler (1-3)

Preschool Child (3-6)
24 - 40 breaths/min
22 - 34 breaths/min
60
seconds School-age Child (6-12) 18 - 30 breaths/min
12 month old with respiratory infections Adolescent (12-18) 12 - 18 breaths/min
... respiratory rate of 36:

Document the findings
Blood Pressure ATI Question

Blood pressure: 2 year old … 92/60 mm Hg.
… this blood pressure would be:
Normal
• Children have a lower BP than adults due BLOOD PRESSURE
to the smaller size of their organs. AGE SYSTOLIC DIASTOLIC
SYSTOLIC
HYPOTENSION
Preschool Child (3-6) 90 - 110 45 - 70 <70 + (age in year x 2)
School-age Child (6-12) 97 - 120 55 -70 <70 + (age in year x 2)
Adolescent (12-18) 110 - 130 65 - 80 <90
Temperature
Oral temp: 5 - 6 yrs old
Axillary: all ages
Rectal: Infants (most common)
Risk for perforation of the bowel! ATI Question 88%
NOT for immunosuppressed clients & DOXORUBICIN
... child has an oxygen saturation of

those on chemotherapy & radiation
88%.. most appropriate initial action?
NOT for clients with cardiac conditions
88%
Verify the position of the pulse

NOT for clients with diarrhea /
fecal impaction oximetry probe
O2 saturation 38.5
Accurate wave form “steady wave”

matching the child’s pulse
309
of the Toddler 1 -3
Physical growth Discipline

• Slows Training and instructing to produce positive
• Communication and mobility skills increase Safety behavior patterns
• Stubbornness , explore, dependent • Self-control is gradual
• Proper restraint in car seat
• Begin to explore Autonomy • 2 yrs: begin accepting responsibility
• Never leave the toddler
“ I DO MYSELF” • Consistency and timing are key
alone in water even buckets
Height and weight pose a drowning risk • Calmly remove the child from the situation
- Gain 5 to 10 LBs per year • Put away poisons and • Tell child the behavior is bad, not them
- Grow 3 inches per year medications with locks
- Normal to go on food jags • Burns from hot appliances
Well visits
and water are common • 15 mo for shots
Learns to stand alone and walk, • Annually after that
1 year Need 12-14 hours a day of sleep • Assess growth/ development, caregiver skill,
3 years Need 10-12 hours and relationship between toddler and parent
• Lordosis and pot belly, organs adapt moderately to stress • Well established walking
• Well established walking • Hand eye coordination
• Growth is slowed and stable • Progressive development of fine motor skills
• Bones and muscles still immature requires nutrition and exercise • They begin to draw and write
for adequate development • Bladder control is gained , with occasional relapses
• Brain is 90% developed by age 5
Social Milestones
Emotional Growth
• Moves to parallel play, mostly imitates role models • Many emotions in one day
• Does Not share readily until later toddler years • Increased use of emotion language and understanding of emotion
• Separation anxiety is overcome easily • Causes/ consequence understanding
Nutrition
Language • Require about 1000-1400 calories a day
• Toddlers should be active 60 min a day
• Vocabulary begins to increase names objects, body parts, animals, • Fruites: 1-1.5 cups
and familiar locations • Veggies: 1-1.5 cups
• Primary method of communication • Grains : 3-5 oz
• Continuous questioning “why” • Protein : 2-4 oz
• Toys that talk are preferred • Dairy : 2-2.5 cups
• Brief sentences • Allow children to eat when hungry instead of forcing meals.

18 months Pleasure center in Encourage the family to
Sigmund Freud Anal
- 3 years the anus teach good hygiene
Autonomy vs Mastering
Support bonding and
1-3 years Erik Erikson shame and environment and
family relationships
doubt building self-esteem
Sensory / action Plan drawing and

coordination, writing, tactile
2-7 years Jean Piaget Preoperational symbolic thinking. experiences. Use
Represent world and colorful materials to
words together stimulate senses
310
Pediatric Physical Exam III
Infants 0-12 Months

Kaplan Question ATI Question
Infant reflexes
9-month-old ... the nurse expects which reflex? 2 month old infant … placed on their back &
Babinski head turned to one side. The infant responds
by flexing the arm on the opposite side and
Top 3 Tested HESI Questions extending the arm that is pointing in the same
direction she is facing. Which of the following
1. Babinski reflex: 0 - 12 months Q1: What is the reflex assessed by stroking the best describes this reflex?
outer sole of the foot?
Tonic neck reflex
2. Rooting (sucking) reflex: 0 - 4 months Babinski
Q2: How will the nurse assess the rooting reflex?
3. Tonic neck reflex: 0 - 4 months Tonic neck reflex
By stroking the cheeks of the newborn
Moro reflex: 0 - 4 months

Stepping reflex: 1 month +
Palmar grasp: 0 - 3 months
2 months old
Plantar grasp: 0 - 8 months
GI assessment HESI Question

Bloody mucus in a What color stool would the nurse
newborn's diaper? NCLEX TIP explain to expect on the third day 3rd day of life
of life?
Continue to monitor the color, Yellowish brown-colored stools
amount, & consistency
Toddlers 1-3 years
TOP Missed NCLEX Question

Growth 39-month-old child. Which finding
requires immediate follow up with
1. Height the primary care provider? Diet
x4
3 inches per year Weight is 6 times greater than
birth weight
2. Weight
Average yearly gain of 4 - 6 lb (1.8 - 2.7 kg) 3.2kg
12.8k
g
NCLEX TIP
30 months
At 30 months (2.5 yrs) weight should be
4 times greater than birth weight
Head circumference increases by 1 inch (2.5 cm) during

the 2nd year, but then slows by half until age 5. Nutrition
Chest circumference exceeds abdominal circumference Milk: 16 - 24 oz per day (2 - 3 cups)
by age 2. The body begins to sprout up like a green plant Juice: 4 - 6 oz per day
= taller & more slender appearance.
16-24 oz/day 4-6 oz/day
LIMIT
2.5cm 1.25cm
2 years old 5 years old
311
of the Preschool Child
Growth rate has slowed

• Language and play change remarkable
• Soak up info “little sponges, let them choose their own clothes” Well Checkup Schedule
• 3 yrs still chubby-faced • Boosters and vaccines 4-6yrs
• 5 yrs leaner and taller and better coordinated but can't distinguish fantasy from real life. • Annual exams for growth and health
Height and weight
• Gains 3-5 lb a year and grows 2.5 in. a year
• By 12 months birth weight should triple and baby should grow 10-12 in.
Skeleton
• Gross motor skills improve by age 5 they can climb, jump, catch and throw Vision
a ball and ride a bicycle. • Still immature
• 5 yrs, leaner taller and better coordinated, teach them to wash hands thoroughly • Distance judgement faulty
• Bathing and brushing teeth still need supervised, can't wash own hair. • Screen for amblyopia
Dentition • 20/20 vision by age 6
• The skull is 90% of adult size by age 6 • Depth perception occurs at 8-10 yrs old.
• Early preschool insidious teeth have completely emerged ,you floss their teeth.
• End of preschool teeth have erupted w/ incisors being first.

• Aware of their sexuality • Develop imagination
• May be attracted to parent of the opposite sex • May have an imaginary friend
• Parents should teach accurate sexual info • Magical thinking
• Teach the difference between good and bad touch • May be afraid of the dark or have nightmares
• Calm matter of fact response to masturbation • 4: Temper tantrums, pushing, hitting, and manipulating environment
• Teach safety and privacy regarding genitals • Discipline: teach the child responsibility and self
control and consistency.
• Taking favorited away is more effective than hitting
Social Milestones
• Preschoolers use imitative play, all types of play are needed for Emotional Growth
development
• Dramatic play: act out situations and control it • 0-1 mo: general tension
• Cooperative play: organized groups • 1 mo: happy and sad emotions
• Associative play: play together but unorganized and no leader • 6 mo: separation anxiety
• Solitary: playing alone away from groups • 6-12 mo: stranger anxiety, shows curiosity by 12 months .
Language Nutrition
• Do not need large quantities of food, keep portions small.
• 3-4: non communicative w/ language
• Requires high amount of protein
• 4: communicate with language
• Erratic appetite, frequent small meals are better
• 4-5: use naughty words
• Guide them when choosing food
• Converse in a way they can understand
• Provide healthy snacks
• Delays can be caused by: hearing impairment, lack of stimulation
• Rituals are important.eals.

3-6 Pleasure center in Explain to the family and
Sigmund Freud Phallic
years the genitals teach hygiene
Monitor and protect from

Child develops a
injury and poisoning.
3-5 years Erik Erikson Initiative vs guilt conscious and sense
Encourage them to ask
of right and wrong
questions
Preoperational The child sees the Plan drawing and writing

2-7 years Jean Piaget
phase world egocentrically activities
312
Growth and Development of the
School Aged Child
Head Should measure 13.75 cm at birth

• School starts Well Checkup Schedule
• Thinking skills develop • Annual physicals
• Booster tetanus and diphtheria
Height and weight • Visit the dentist 2x a year
• Growth is slow and steady gains 5-6 lb a year • Screening for scoliosis at 10-11
• Grows 2.5 in. a year until pre-teen
• Vision and hearing screen The birds and the bees
• Spine straightens and abdomen flattens
• Long bone growth is noted • Help develop a positive attitude of
sexuality
Dentition Substance abuse • Sexual roles
• Starts to lose baby teeth at about 6 • Teach family values • Satisfaction with being a boy or girl
• Eruption of permanent teeth begins • Teach right and wrong
• Set rules and enforce
Neuro
• Refines motor and cognitive skills • Teach facts about drugs and alcohol
• Engages in meaningful tasks • Actively listen

• Displays a sense of duty and accomplishment
• Slowed growth, graceful on their feet
• Applies energy from play to complete tasks
• Strength and abilities double
• Develops positive sense of self
• Loss of baby teeth
• Magical thinking, sit still for short periods
• Structural bone changes
• Understands taking turns, enjoys groups
• Girls begin to experience secondary sex characteristics
• Enjoys real life activities
• Give consistent rules, positive attention, and clear expectations,
questions parents standards
Social Milestones
• Develop confidence in family and explore relationships outside Emotional Growth

of family
• Peers become important • Greater understanding of complex emotions
• Motivated by accomplishment • Understands they can have more than one emotion
• Success/ failure have a strong impact • Greater ability to control emotion
• Uses strategies to redirect feelings
Language Nutrition
• Language is refined vis grammar education
• Requires more food for increased energy demands
• Ability to use words to express knowledge
• Choose foods from all food groups
• Narrative skills improve
• Food jags and increased appetite are normal
• Able to make inferences
• Limit fat intake, supervise snack habits
• Able to evaluate speech and messages
• Offer choices.

Encourage sibling and
Preparing for adult
6-10 peer contact. Assess for
Sigmund Freud Latency life but awaiting
years sexual activity in later
maturity
stage
Industry vs Developing sense of Provide activities based

6-10 years Erik Erikson
Inferiority self worth and talent on talents and abilities
Preoperational The child sees the Plan drawing and writing

2-7 years Jean Piaget
phase world egocentrically activities
313
Pediatric Physical Exam IV
Toddlers 1-3 years

Crib safety
Safety Teaching Infant on back to prevent SIDS

Never on stomach/
Choking Hazard prone position unattended = SIDS!
Children under the age of 4, avoid...
Cut food into bitesize pieces DON’T put the infant to bed with
Hot dogs Marshmallows a bottle = dental caries
Sit child up when eating &
Cut food into bite size shape Remove crib musical mobiles at
4-5 months
Avoid Round Foods! Carrots Nuts and Seeds
Car seat
Burns
Apples Popcorn Rear facing in the back seat
Cover electrical outlets at 45 degree angle
Face handles inward = stove top NEVER place the car seat in front seat
Grapes Celery
pots & pans
NEVER place padding under or behind
Apply sunscreen SPF 15 or greater an infant or child in a car seat
BEFORE going outside (it can eject the child during a car crash)
Peanut
Peanut Butter Chewing Gum

butter
& reapply every 2-3 hours while in Used until 30 lbs (13.6 kg)
the sun
Raisin Hard Candy
Booster seat
Drowning
8 - 12 years
Never leave child alone near 4’9 tall
a body of water
35 - 80 lbs (15.9 - 36.3 kg)
Preschool & Kindergarten 3 -6 years Common NCLEX Question

4-year-old beliefs?
Growth
Magical thinking
Select all that apply. (Do NOT understand cause & effect)
3-6 years old

1. Height: 2 - 3 inches per year Believe that an injury is the result
of misbehaving
2. Weight: gain of 4.5 - 6.5 lb per year 4.5-6.5lb Feels responsible for being placed
for adoption NCLEX TIP It’s my fault that
my parents left me.
Nutrition 26lbs 31.5l

bs
50% Less calories than adults
Activity & Sleep

1 hour of activity Saunders Question
12
hours
12 hours of sleep (at around 7:00pm) 4 year-old-child. When experiencing pain,

the nurse anticipates… Select all that apply.
Beliefs Views pain as punishment
Blames someone else for the pain
Magical thinking Believes pain will disappear magically
Ear Assessment Growing UP HESI Questions

Less than 3
Less than 3 years: Pull Down & Back pull less pull it UP Q1: … position the pinna to visualize the
eardrum of a 4 year old child?
Over 3 years: Pull Up & Back
Up and back
Memory Trick Q2: … direction to pull the pinna of an infant
during an ear exam?
Growing UP - pull it UP & back
Down and back
Less than 3 - pull less (down & back)
314
of the Adolescent 11-18 years
Head Should measure 13.75 cm at birth

• Puberty : reproductive maturity
• Starts at age 10 in girls and ends with menstruation
• Starts age 12 in boys and ends sperm production
Growth Well checkup schedule

• Girls achieve 98% of height by 16 yrs
• 2x during teens
• Skeletal growth outpaces muscle growth
• Nonvoluntary with early menses, 13-15 ovulation begins • Immunizations, hearing, vision, scoliosis,
• Boys : grow rapidly from 13-20 thyroid and pelvic for sexually active girls
• Muscle strength and coordination develop rapidly • BP, height and weight
• Larynx becomes enlarged
• Both sexes : body takes on contours
• Primary sex organs develop, hormonal activity increases
• Bone growth continues until 20s
• Anorexia and bulimia can happen due to body image issues

• Girls : 9-11: growth spurts last 18 months • They wonder who they are
• Grows 3 in annually until menarche • What will they become
• Begin to develop figure • More mobile
• Boys: 11-13: slower and steadier than girls • Seek out intimate relationships
• Changes in penis, testes and scrotum • Most are heterosexual, homosexuality can be difficult emotionally
• Nocturnal emissions “ wet dreams” • Body image is closely related to self esteem
• Underdevelopment causes anxiety
Social Milestones Emotional Growth

• Rebellious
• Greater focus on peers develops a separate self from parents
• Emotional highs and lows
• Moral development
• Focus on appearance
• Less egocentric
• Sexually active teens may have impaired self image
• Focused on mixed gender friendships
• Privacy becomes important
Nutrition
Language
Rapid growth causes a need for the greatest amount of nutrients
• Appetite increases and teens eat frequently
• Able to communicate complex thoughts • Food choices not always wise
• May skip meals
• Can have nutritional deficits of vit A, D and B, folic acid, iron and zinc.
Due to menses, girls need additional iron.

Encourage safe sex,
Pleasure center in
Puberty Sigmund Freud Genital educate on teen
the genitals
pregnancy and STI
Support self-esteem, be
Integrating multiple honest maximize
Identity vs role
10-20 years Erik Erikson roles, self-image and positive aspects of
confusion
peer pressure image and minimize
defects
Formal Reasons in more Discuss conditions

11- adulthood Jean Piaget operational abstract idealistic openly with client. Allow
stage ways privacy to discuss
315
Pediatric Physical Exam V
School Age 6-12 years
Growth
1. Height: 2 inches per year
2. Weight: yearly gain of 4.5 - 6.5 lb
Activity & Sleep 4.5-6.5lb

4’9 inches
Competitive & team play
9 hrs of sleep per night
s s
31lb
Safety
37lb
Use car seat until 4 feet 9 inches

Never in/near pool alone

Physical Examination 11-year-old client with abdominal
discomfort ... What are the best actions
MINI ADULT
Treat them like mini adults during a physical exam?
Same head-to-toe assessment Complete a full head-to-toe assessment in the
same way as an adult
Same pain scale assessment Explain the results of the examination to both
parent & child
Same subjective assessment Ask the child to describe their primary symptoms
Explain results of the exam to the child Respect the request to be examined without
guardian present
Respect privacy NCLEX TIP 6-12 years old
Adolescents 12-18 years
Growth
1. Boys stop growing 18 - 20 years old
2. Girls stop growing 2.5 years old HESI Questions
after 1st period (menarche) Q1: Growth difference between girls & boys?
Activity Growth in height ceases 2 to 2.5 years after

menarche in girls
Priority Intervention Q2: General puberty age... for girls and boys?
Encourage meeting with friends & peers 10 years for girls
NCLEX TIP 12 years for boys
NO Socialization Q3: 16 year old girl who has not started menstruation?
1. Immediate Post-Op Refer the adolescent for an evaluation
2. Immunocompromised (Chemo, radiation)
3. Contagious infectious disease
Notes
316
_ _
Developments Milestones
&
communication
317
Erikson’s 8 Stages -
Psychosocial Development
Pediatrics: Development
Age & Stage Attributes Need & Focus Good Outcome Bad Outcome
Trust & faith in Fear & suspicion
0-18 months Trust vs. Mistrust Safety w/ Mother
environment and with people &
Infant Virtue: Hope & Optimism (caregiver)
with caregivers environment
Autonomy vs. Independence &

18 mo. - 3 yrs. Shame & Doubt Independent from control over
Failure to achieve
Toddlers & autonomy leads to
Virtue: Will use freedom & parents behavior & skills = shame & doubt
Early childhood self-restraint Autonomy
3 - 6 yrs. Initiative vs. Guilt Initiative Asserting too

Powerful within family
Virtue: Purpose, ability to + Assertive = much power =
Preschool start activities & goals
& exploring Sense of purpose disapproval & guilt
Industry vs. Inferiority Feeling competent Failure in

6 - 12 yrs. Virtue: Competence in Good w/ Neighbors, with social & social & academia
School Age intellectual, social Classmates, & friends academic demands = feeling inferior
& physical skills
Identity vs. Sense of self & Confused with

12 - 18 yrs. Role Confusion Socializing personal identity self identity =
Adolescence Virtue: Fidelity, fitting into & Fit into Peer Groups Staying true to yourself Lonely, isolated
the world as own person
Intimacy vs. Isolation Love Strong Weak

19 - 40 yrs. Virtue: Love, finding & losing Partners relationships relationships =
Early Adulthood self in others & career. & Friends (intimate & loving) lonely & isolated
Generativity vs. Provide value to Feeling of Shallow sense

40 - 65 yrs. Stagnation household / accomplishment & of self with limited
Adulthood Virtue: Care
society usefulness in involvement in
Guidance & teaching family & society the world.
new generation “Give a gift”
Integrity vs. Despair Wisdom & Regret,

65+ yrs. Virtue: Wisdom
Reflection on life
fulfillment while bitterness &
Maturity Fulfillment & satisfaction “Receive a gift” reflecting on life despair with life
Who am I? ATI Questions

Q1: Which age group experiences the stage of
Kaplan Question autonomy vs shame and doubt?
… adolescence … associated with Toddlers
establishment of which developmental goal? Q2: successful achievement of Erikson’s … for
Sense of identity the 3-year-old toddler?
Encouraging the child to assist in removing
the dressing on his leg
HESI Questions Saunders Questions

C C
Q1: Which task… belongs to infancy?
Q1: 8-year-old ... seems to be more attentive to friends
Trust C
C B C
than anything else. Using Erikson’s ... which response? T A C U
Q2: A 4-year-old ... Which stage of Erikson’s theory … is
At this age, the child is developing his own personality
the nurse addressing when teaching inhalation therapy?
Initiative Q2: 2 ½ year old child…. Using Erikson’s which should
Q3: ... most significant impact on the socialization of the nurse plan care around?
school age children? Autonomy versus Shame and Doubt
Classmates
318
Piaget Theory of Cognitive Development I
Pediatrics: Stages of Development
Age Stage Teaching Example
Sensorimotor
Teach in the present moment!
Thinks in the present moment
0-2 through the senses.
(not past or future)hesioi
HESI
Teach them:
“What you ARE doing
Foley catheter insertion for
an 18 month child?
Infant & Object permanence while you ARE doing it” Teach the child what you
Toddler (objects are still there (pre-procedure teaching for ARE DOING as you do it
even if you can’t see it) the parents not child)
Example: Peekaboo
Preoperational Thinking
Imaginative, Symbolic thought Teach shortly before. Foley catheter insertion for
Magical thinking
3-6 (Do NOT understand
cause & effect)
Teach them:
“The day of...”
a 4 year old child?
Teach the child what you
Preschool “The morning of…” or
are GOING to do
scraped knee was caused by “A few hours before..”
earlier misbehavior
Understands the Future & Past
Teach days before.

Concrete Operational Include skills like: Which child can the
7 - 11 Logical thought, - Insulin injections nurse teach bandage

Follows rules, rigid thinking Demonstration & reading placement skills?
Skill learning ATI
Only 1 way to do somethingaaaaaa Teach them: 7 year old & up
Limited abstract thoughtsaaaaaa
HESI “Tomorrow we will…”
“You will do this every day”
Teach like an adult! Which child can manage
12 - 15
Med Surg style their own care?
Formal Operational 12 yrs + can 14 year old with DM type 1
(adolescents) Developing abstract thought, Manage their own care
Adults Cause & effect thinking Teach them: NCLEX TIP
(example: Love, hate, morality) “Report these findings …”
Learning Risk-taking behavior
“If you see this follow up with = non-compliance
your provider”
Notes
319
Developmental Milestones I
Age Gross Motor Fine Motor Language Social/Cognitive
• Head lag • Grasp reflex 0 - 3 mo. • Responds to touch & • Finds safety with
1 (poor head control) • Babinski reflex 0-12 mo. voices caregiver & Looks at
month • Rooting reflex 0 - 4 mo. • Sensory motor face
• Tonic-neck reflex 0 - 4 mo. communication
• Kicks legs NCLEX TIP • Grasp reflex diminishes • Response to sounds • Smiles & coos when
Memory Trick: • Able to make sounds seeing a familiar face
2-3
2 legs kick at 2 months with mouth NCLEX TIP
months Raises head when prone Memory Trick:
Less head lag Smiles - Second month
• NO more head lag • Grabs object voluntarily • Mimics sounds heard • Soothed by caregiver’s
(Report if head lag is (Grabs rattle) HESI • Able to change cry voice
found after 4 months) • Diminished Moro reflex tone for different • Copies expressions
(startle reflex) & other needs • Cries when doesn't get
4-5 NCLEX TIP
their way
months Memory Trick: reflexes
After month 4
= head lag NO MORE
5 months rolls from front
to the back Kaplan ATI
Birth weight DOUBLES at • 6 months • Babbling words ATI • Identifies faces &
6 months NCLEX TIP holds a big bottle “Mama Dada” strangers
• Responds to name • Separation anxiety
6-9 6 - 9 Months • 7 months
• Rolls from back to front Transfers objects from NOT babbling begins at 6 months
months 9 months?
• Can sit up unsupported 1 hand to the other NCLEX TIP
• Can pull self up MUST REPORT IT Memory Trick:
Separation at Six mo.
• 10 months - 10 months: 3 NCLEX TIP • Able to make a variety • Vocalization & speech
prone to sitting position 1. Pincer grasp of sounds (Talking toys & books)
“Pick up small finger foods” • Mimics gestures Purposeful play
2. Grasps a rattle or doll by • Understands simple
10 - 12 the arm words Yes & No
months 3. Transfers objects from
hand to hand
Memory Trick:
10 months uses
10 fingers to grab things
2 NCLEX TIPS 3 NCLEX TIPS • 3 - 5 words • Shy: stranger danger

• Birth WEIGHT TRIPLES • Nonverbal gestures • Can follow short simple
1. Fully developed 2
• Sits down from standing (waving, head nodding) directions
finger pincer grasp
• Crawls up stairs • Searches for hidden
2. Tries to build 2 block
• Walks 1st steps while objects
12 tower unsuccessfully
holding hand Saunders (Object permanence)
months 3. Attempts to turn book
pages
Memory Trick:
12 mo. use fingers
1 & 2 - fully developed
pincer grasp
320
Language & Communication
Language & Communication

HESI Question My cute
baby
Which age would the nurse expect the infant to
Newborns 0 - 1 month be able to say, “mama” and “dada” with meaning?
● 10 months
• Respond to touch & voices
Sensory motor communication
Saunders Question 10 months

Expected growth & development at 9 months
Mama
Infants 1 - 12 months ● Should be able to say “mama” and “dada”
● Will pull up and stand for several seconds
holding on to furniture
• At around 10 months ● Will be able to pick up small pieces of food Dada
Say “Momma” & “Dada”
• Over 12 months: Up to 3 - 5 words Kaplan Question
An infant client is able to stand holding on to
objects, plays “peek-a-boo”, and is starting to say
“mama” and “dada.” … which age?
● 9 months
ATI Question
Assessing speech development ….
300+ words
Toddlers & Preschool 1 - 5 years refer for further examination? Why you laugh?
● An 18-month-old who only says “no”
• Priority Finding Why the
Why mama
bird can fly?
to report to HCP NCLEX TIP eat that?
2-year-old “does not talk or respond” Kaplan Question Where is
my candy?
while being assessed
Speech impairment?
● A 5-year-old who only answers with
1 year 5 years
single words
School age 6 - 12 years

• Uses logic
HESI Question Priority
16-year-old refusing classmates visits…

Which concern will the nurse plan to
Adolescence 12 - 18 (teenagers) address first?
● Social isolation
• Abstract thinking
• Privacy - ask certain questions
without the parents present Saunders Question
• Encourage peer contact NCLEX TIP Q1: A 16-year-old admitted to the
HUGE Risk for social isolation! hospital … Which nursing
1. “have friends to come visit at intervention is most appropriate?
the hospital” ● Allow the client to interact with
2. “meeting other teens who are others in his or her same age group
receiving similar treatment” Q2: 14-year-old girl … hospitalized & has
been placed in traction. Which nursing
action would be appropriate to meet
the child’s needs?
● Let the child wear her own clothing
when friends visit
Notes
321
Play Types II
Age Best Toy Play Type Description Play is an integral part of how a little baby brain learns &
0 - 6 month
Musical Mobile or
Soft & large toy
Sensorimotor
& Solitary Play
Stimulates both
motor & sensory
develops cognitively. During hospitalization, play can also
serve as a therapy to relieve stress & anxiety.
Top 3 Considerations
0 - 6 months
C A
C B
T U
1. Safety
� Choking Hazard
Under 4 yrs. = No small toys
� No metal toys near oxygen use
(sparks = fire)
Cover & Uncover toys Sensorimotor Learning � Infection:
6 - 9 month
(Peek a boo/ & Solitary Play Object permanence Hard toys for the
Jack in the box)
immunosuppressed (easier to clean)
2. Age appropriate
3. Realistic
6 - 9 months
C A
C B
T U
Saunders Questions
9 - 12 month
Talking toys, books Sensorimotor
Learning
Vocalization & Speaking
Q1: 10-month-old infant ... the most
appropriate intervention?
● Consistent routine with touching,
HESI Question
Hard plastic blocks ATI & Solitary Play Purposeful play: rocking, & cuddling
Which type of play … toddler?
“Build, sort, stack, 9+
(Tickle me Elmo) Q2: 5-year-old … most appropriate
make, construct”
months ● Crayons and coloring book ● Parallel
ABC... ABC... Q3: 7-year-old child ... most appropriate
AAA... ABC...
play activity?
● A board game
9 - 12 months
C A
C B
T U
T
C B
A
U
C
C A
Q1: What age group does the nurse suspect ... children are
C B
T U
1 - 3 yrs. Push / Pull Toy Parallel Play Learning

Gross motor skills
observed borrowing blocks from each other without direct
Toddlers (Wagon, stroller, HESI
Stacking hard plastic blocks) “Children play
(running & jumping)
interaction with others?
Kaplan & ATI NEXT to each other NO finger dexterity
NO direct interaction with others” • No Scissors Age Best Toy Play Type Description
Memory Trick:
• No color pencils Memory Trick Push / Pull Toy Parallel Play
HESI
Learning
Gross motor skills
1 - 3 yrs.
1 - 3 yrs they play
(Wagon, stroller,
C 1 - 3 yrs they play Stacking hard plastic blocks) “Children play
(running & jumping)
C 1 by 1 separate Toddlers Kaplan & ATI NEXT to each other NO finger dexterity
C • No Scissors
1 by 1 separate
B NO direct interaction with others”
T U
A • No color pencils
Memory Trick:
1 - 3 yrs they play
1 - 3 yrs
1 by 1 separate
1 - 3 years old
(Toddlers)
C C
C C C
C B U
C B C B
T A A U
3 - 6 yrs. Pretend Play Associative Play, Learning

(dolls, puppets, tea party, Fine motor & Balance
Preschool Imaginary Play,
dressup, imitating adults) • Yes - scissors 1 - 3 yrs
Kaplan Symbolic Play ATI • Yes - Tricycles
Arts & Crafts
(crayons & coloring)
Saunders

Memory Trick:
F - Four years
F - Fake Play (dolls, dressup)
3 - 6 yrs
Q2: Long-term hospitalization of a 4-year-old … Which toy is most appropriate

to aid in the development of this child? Select All That Apply
Memory Trick
Preschoolers 3 - 6 yrs.
6 - 12 yrs. Legos, board games Cooperative Play Learning Pretend (dolls, puppets,
Creativity & Creation dress up, tea parties)
School Age Collecting cards, C - Creative
Blank paper & crayons C - Collecting
(encourage creativity ) C - Competitive 1. Dolls
Saunders
2. Puppets
??
3. Stacking hard
?
plastic blocks
6 - 12 yrs
?$
4. Jack in the box

$
5. Dress up clothing
??
?
?$
6. Meeting with peers

$
12 - 18 yrs. Meeting, texting, Socialization Learning

Peer group
Adolescent talking with friends
socialization
Priority
Kaplan Questions
NO Meeting
Encourage meeting
with friends & peers
1 - Immediate Post-Op
2 - Immunocompromised ATI Questions
3 - Contagious Q1: 13-month-old toddler … best toy to Q1: A push-pull toy:
promote development at this age? ● 18 to 20 months
● A pull toy
12 - 18 yrs
Q2: Symbolic play? Q2: preschool-age …

● A 3-year-old pretends a rug is a play activity?
magic carpet
● Imitating the actions
Q3: 11-month-old infant who is hospitalized
…Best toy?
of the nurse or health
● A bucket of plastic blocks care provider
322
Erikson’s 8 Stages -
Psychosocial Development II
Age & Stage Attributes Need & Focus Good Outcome Bad Outcome Age & Stage Attributes Need & Focus Good Outcome Bad Outcome
0-18 months Trust vs. Mistrust Safety w/ Mother Trust & faith in Fear & suspicion 12 - 18 yrs. Identity vs. Socializing Sense of self & Confused with
Infant Virtue: Hope & (caregiver) environment and with people & Adolescence Role Confusion & Fit into Peer personal identity self identity =
Optimism with caregivers environment Virtue: Fidelity, Groups Staying true Lonely, isolated
fitting into the world to yourself
as own person
Po...
Po... EEE...E...
Who am I?
?
?
AAA...
18 mo. - 3 yrs Autonomy vs. Independence & 19 - 40 yrs. Intimacy vs. Isolation Love Strong Weak
Independent Failure to achieve
Toddlers & Shame & Doubt control over autonomy leads to Early Adulthood Virtue: Love, finding Partners relationships relationships =
Early childhood from parents behavior & skills =
& losing self in & Friends (intimate & loving) lonely & isolated
Virtue: Will use shame & doubt others & career.
freedom & Autonomy
self-restraint
C C
C
C
C C
C
B C C
A
T A C U T
C
C
T A
3 - 6 yrs Initiative vs. Guilt Powerful within family Initiative Asserting too 40 - 65 Generativity vs. Provide value to Feeling of Shallow sense
Preschool + Assertive = much power = Adulthood Stagnation household / accomplishment & of self with limited
Virtue: Purpose, & exploring
ability to start Sense of purpose disapproval & guilt Virtue: Care society usefulness in involvement in
activities & goals Guidance & teaching “Give a gift” family & society the world.
new generation
How can I
contribute
NO Let’s me to the world?
help you
How can I
contribute
to the world
6 - 12 Industry vs. Inferiority Good w/ Neighbors, Feeling competent Failure in

65 + Integrity vs. Despair Reflection on life Wisdom & Regret,
School Age Virtue: Competence Classmates, & with social & social & academia Virtue: Wisdom “Receive a gift” fulfillment while bitterness &
Maturity
in intellectual, social friends academic demands = feeling inferior Fulfillment reflecting on life despair with life
& physical skills
...
Did I live a
meaningful
life?
?
?
?
Notes
323
Piaget Theory of Cognitive Development II
Age Stage Teaching Example Age Stage Teaching Example
0-2 Sensorimotor
Teach in the present moment!
Teach them:
an 18 month child? 3-6 Preoperational Thinking
Imaginative, Symbolic thought
Teach shortly before.
Teach them:
a 4 year old child?
Infant & Preschool
through the senses. “What you ARE doing Teach the child what you Magical thinking “The day of...” Teach the child what you
Toddler while you ARE doing it” ARE DOING as you do it
HESI (Do NOT understand “The morning of…” or are GOING to do
Object permanence (pre procedure teaching for cause & effect) “A few hours before..”
(objects are still there the parents not child) scraped knee was caused by
even if you can’t see it) I am inserting earlier misbehavior
Example: Peekaboo Foley catheter? Today we will
Understands the Future & Past I’m going to insert
I am eating.
your procedure. Foley catheter
for you.
3 - 6 years
0 - 2 years
Past Present Future
Age Stage Teaching Example Age Stage Teaching Example
7 - 11 Concrete Operational
Logical thought,
Teach days before.
Include skills like:
Which child can the
nurse teach bandage 12 - 15 Formal Operational
Developing abstract thought,
Teach like an adult!
Med Surg style
Which child can manage
their own care?
Skill Learning (adolescents)
Follows rules, rigid thinking - Insulin injections placement skills? Cause & effect thinking 12 yrs + can 14 year old with DM type 1
Adult
ATI
Only 1 way to do somethingaaaaaa Demonstration & reading 7 year old & up (example: Love, hate, morality) Manage their own care
Learning NCLEX TIP
HESI Teach them: Teach them:
“Tomorrow we will…” 7 years old “Report these findings …” Risk-taking behavior
“You will do this every day” “If you see this follow up with = non compliance
& up
MEMORY TRICK your provider”
Tomorrow
you will ...
7 - 11 years
take insulin
injection.
TOP Missed NCLEX Question

A 14-year-old with type 1 diabetes
8 years old
You should avoid
… admitted to the ICU with a blood these high fat foods.
It’s not good
glucose over 500 mg/dL…. What is for your health. ATI Question
contributing to the noncompliant
behavior? Which of the following children would
be classified as being in the concrete
Client’s psychosocial
operational stage, as defined by Piaget?
developmental stage
An 8-year-old third grade student
Concrete Operational
Saunders Questions
7 - 11
Logical thought,
HESI Questions Skill learning

Follows rules, rigid thinking
ATI
Only 1 way to do somethingaaaaaa
Q1: ... behavior is characteristic of the
HESI
Q1: Which phase of cognitive development formal operations stage? Sensorimotor
are infants?
Sensorimotor
The child has the ability to
think abstractly
0-2 through the senses.
HESI
11 -14 Infant & Object permanence
Q2: What description characterizes years old Q2: 6 year old does not recognize the Toddler (objects are still there
normal cognition during the period of objects exist when the objects are
even if you can’t see it)
Example: Peekaboo
early adolescence (11 to 14 years) ?
outside the visual field… which
Limited abstract thoughts action should the nurse take?
Report it to the pediatrician
Notes
324
Developmental Milestones II
Age Gross Motor Fine Motor Language Social/Cognitive
2 NCLEX TIPS 2 NCLEX TIPS • 10 + words • Angry baby:

• Walk up/down stairs • Turns 2 pages in a book • Follows commands temper & ownership
while holding a hand at a time (uncoordinated) “don’t touch that” “mine”
• Throws ball • Holds cup & spoon • Uses gestures to show
what they want Parallel Play
• Jump in place with both 1 - 3 yrs.
feet • Build tower of 4 blocks
Top missed “Children play
HESI • Scribbles with crayon
NCLEX Question: NEXT to each other &
NO finger dexterity
MEMORY TRICK
18-month old ... “NO direct interaction
• No Scissors
18 months What findings should with others”
• No color pencils
1 hand helps the baby the nurse report to the
that looks like an 8 provider for follow-up
18 (looks like a baby developmental screen-
months snowman) ing?
1. Uses 4 words
2. Cannot hold a
spoon or cup
3. Unable to sit
down from standing
position
4. Finds it difficult to
pick up small food
items with thumb &
index finger.
1. Walks without help 2. Builds a tower of 7 3. Says own name NCLEX Imitates adult behavior
• Run & kick ball blocks HESI • 300 + words T - Toilet Training
• Walks up & down stairs • Draws vertical lines • 2-3 word sentences T - Toddlers by age
independently 1 step at • Books: able to turn 1 • Identifies pictures T - Two yrs old
2 a time HESI page at a time with names (up to 24 months)
years Memory Trick: • Open doors by turning Gains independence
2 years, 2 legs for walking door knobs Saunders
2 names (first & last)
2 - 3 word sentences
Toilet Trained by Two
• Tricycle & jumps • Draws circles • 3-4 word sentences Associative Play
forward ATI • Spoon feeds self ATI • Asks “why” a lot 3 - 6 yrs.
• Learning balance • Undresses self • Knows age “Unorganized play
3
• Walks up stairs with • Holds crayon with fingers • Follows more complex without a goals or rules”
years alternating feet instead of fist instructions
• Imaginary friends &
- Yes - Scissors
Symbolic Play
• Zips up a zipper ATI
• Skips, hops on 1 foot • Draw 4 sided shapes like • Able to tell stories • Imaginary play:
• Catches a ball 50% of a square/ rectangle • Can memorize alphabet Dress up & Tea Party
4 the time • Can pour drinks & make & numbers • Plays with other children
years • Climbs & jumps food rather than alone
Memory Trick:
4 years 4 sided shapes
325
Developmental Milestones I
Developmental milestones are a list of skills that most children can do by

a certain age. It is vitally important! If a child does NOT meet these key
milestones it can likely indicate developmental delay & severe disablement
(if not caught & addressed early).
Age Gross Motor Fine Motor Language Social/Cognitive Age Gross Motor Fine Motor Language Social/Cognitive
1
Grasp reflex 0 - 3 mo. - Responds to touch 2 NCLEX TIPS - 10 + words
Head lag Babinski reflex 0-12 mo. & voices Finds safety with - Angry baby:
- Walk up/down stairs 2 NCLEX TIPS - Follows commands
(poor head control) Rooting reflex 0 - 4 mo. - Sensory motor caregiver & Looks at face temper & ownership
month while holding a hand - Turns 2 pages in a book at a “don’t touch that”
Tonic-neck reflex 0 - 4 mo. communication “mine”
- Uses gestures to show
18
- Throws ball time (uncoordinated)
Kicks legs NCLEX TIP - Smiles & coos when - Jump in place with both feet
- Holds cup & spoon what they want Parallel Play
2-3 Memory Trick: - Response to sounds seeing a familiar face months HESI - Build tower of 4 blocks 1 - 3 yrs.
- Able to make sounds Top missed
2 legs kick at 2 months Grasp reflex diminishes
NCLEX TIP Memory Trick:
- Scribbles with crayon “Children play
with mouth NO finger dexterity NCLEX Question:
months Raises head when prone Memory Trick: 18 months NEXT to each other &
Less head lag Smiles - Second month 1 hand helps the baby that
• No Scissors 18-month old ... “NO direct interaction
• No color pencils
looks like an 8 What findings should with others”
NO more head lag
(looks like a baby snowman) the nurse report to the
(Report if head lag is provider for follow-up
found after 4 months) Grabs object voluntarily - Soothed by caregiver’s developmental
4-5
(Grabs rattle) HESI - Mimics sounds heard voice screening?
NCLEX TIP Select all that apply
Memory Trick: Diminished Moro reflex - Able to change cry tone - Copies expressions
months After month 4 (startle reflex) & other for different needs - Cries when doesn't get 1. Uses 4 words
= head lag NO MORE
reflexes their way 2. Cannot hold a
5 months rolls from front spoon or cup
to the back Kaplan ATI 3. Unable to sit down
from standing
- Identifies faces & position
Birth weight DOUBLES at - Babbling words ATI 4. Finds it difficult to
6 months strangers
6 months NCLEX TIP “Mama Dada” pick up small food
6-9
holds a big bottle - Separation anxiety
6 - 9 Months - Responds to name items with thumb &
7 months begins at 6 months
- Rolls from back to front NOT babbling index finger.
months Transfers objects from 9 months? NCLEX TIP
- Can sit up unsupported
1 hand to the other MUST REPORT IT Memory Trick: 1. Walks without help
- Can pull self up Separation at Six mo. - Run & kick ball 2. Builds a tower of 7 blocks Imitates adult behavior
- Walks up & down stairs - Draws vertical lines HESI 3. Says own name NCLEX
T - Toilet Training
2
10 months: 3 NCLEX TIP independently 1 step at a - 300 + words
time HESI - Books: able to turn 1 page T - Toddlers by age
1. Pincer grasp - 2-3 word sentences
Memory Trick: at a time T - Two yrs old
“Pick up small finger foods” years - Identifies pictures
10-12
- Able to make a variety 2 years, 2 legs for walking - Open doors by turning (up to 24 months)
2. Grasps a rattle or doll by of sounds Vocalization & speech 2 names (first & last) with names
10 months the arm door knobs Saunders Gains independence
- Mimics gestures (Talking toys & books) 2 - 3 word sentences
months - prone to sitting position 3. Transfers objects from - Understands simple Purposeful play Toilet Trained by Two
hand to hand words Yes & No
Memory Trick: - Draws circles Associative Play
10 months uses - Tricycle & jumps - Spoon feeds self ATI - 3-4 word sentences 3 - 6 yrs.
3
10 fingers to grab things forward ATI - Undresses self - Asks “why” a lot
“Unorganized play
- Learning balance - Holds crayon with fingers - Knows age
3 NCLEX TIPS without a goals or rules”
years - Walks up stairs with instead of fist - Follows more complex
1. Fully developed 2 finger alternating feet - Yes - Scissors instructions - Imaginary friends &
2 NCLEX TIPS pincer grasp - Shy: stranger danger
- Zips up a zipper ATI Symbolic Play
12 - Birth WEIGHT TRIPLES 2. Tries to build 2 block tower - Can follow short simple
- 3 - 5 words
- Sits down from standing unsuccessfully directions - Draw 4 sided shapes like
- Nonverbal gestures - Imaginary play:
months - Crawls up stairs 3. Attempts to turn book pages
(waving, head nodding)
- Searches for hidden - Skips, hops on 1 foot a square/ rectangle - Able to tell stories
4
- Walks 1st steps while objects Dress up & Tea Party
Memory Trick: - Catches a ball 50% of - Can pour drinks & make - Can memorize alphabet
holding hand Saunders 12 mo. use fingers (Object permanence) - Plays with other children
the time food & numbers
1 & 2 - fully developed years rather than alone
pincer grasp
- Climbs & jumps Memory Trick:
4 years 4 sided shapes
HESI Questions ATI Questions Kaplan Questions Saunders Questions

Q1: Fine motor skills of a 2-year-old? Q1: 9 month old… need for further investigation? Q1: 4-month-old (full-term)... The nurse is most Q1: Expected growth & development by 12 months:
● Draws a vertical line ● The child is not babbling concerned with which finding? ● Walks while holding on to someone’s hand
Q2: Gross motor skill at 18 months of age? Q2: 6 month old… expected finding? ● The infant’s head lags when pulled from Q2: 24-month-old child… highest-level
● Jumps in place with both feet ● Rolls over in both directions a lying to a sitting position developmental milestone?
Q3: 3-year-old … developmental delay? Q2: 5-month-old … The nurse expects to make ● The child opens a door by turning the
● Unable to use a spoon to feed himself which observation? doorknob
Q4: 3-year-old child.. age-appropriate development. ● The infant rolls to back (supine) from
● Copies a circle prone position
● Rides tricycle Q3: Child walks up and down steps.. has
● Undresses without help steady gait & can use short sentences …
how many months?
● 24 months (2 years old)
Notes
326
Developmental Milestones II
Age Gross Motor Fine Motor Language Social/Cognitive Age Gross Motor Fine Motor Language Social/Cognitive
1
Head lag Grasp reflex 0 - 3 mo. - Responds to touch Finds safety with Birth weight DOUBLES 6 months - Babbling words ATI - Identifies faces &
month
(poor head control) Babinski reflex 0-12 mo.
Rooting reflex 0 - 4 mo.
& voices
- Sensory motor
caregiver & Looks at face
6-9 at 6 months NCLEX TIP
6 - 9 Months
holds a big bottle
7 months
“Mama Dada”
- Responds to name
strangers
- Separation anxiety
Tonic-neck reflex 0 - 4 mo. communication months - Rolls from back to front Transfers objects from NOT babbling begins at 6 months
- Can sit up unsupported 1 hand to the other 9 months? NCLEX TIP
0-3mo. MUST REPORT IT
- Can pull self up Memory Trick
0-12mo. Mama Separation at Six mo.
Dada ?
?
3.1 kg 6.4 kg
0-4mo. 0-4mo.
HCP
1
...
10-12
Kicks legs NCLEX TIP - Response to sounds - Smiles & coos when 10 months 10 months: 3 NCLEX TIP - Able to make a variety Vocalization & speech
2-3 Memory Trick Grasp reflex diminishes
- Able to make sounds
with mouth
seeing a familiar face - prone to sitting position 1. Pincer grasp
“Pick up small finger foods”
of sounds (Talking toys & books)
Purposeful play
months
2 legs kick at 2 months
Raises head when prone
NCLEX TIP
Memory Trick:
months 2. Grasps a rattle or doll by
- Mimics gestures
- Understands simple
Less head lag Smiles - Second month the arm words Yes & No Goo...
3. Transfers objects from Neh
GO!
Mama GO!
2 months hand to hand Goo Goo!
Dad
Memory Trick: Gah!
A... A... 10 months uses

10 fingers to grab things
2 months
AAA...
2 months
Yes
NO more head lag Grabs object voluntarily - Mimics sounds heard - Soothed by caregivers 2 NCLEX TIPS 3 NCLEX TIPS - 3 - 5 words - Shy: stranger danger
4-5 (Report if head lag is
found after 4 months)
(Grabs rattle) HESI
Diminished Moro reflex
- Able to change cry voice
tone for different needs - Copies expressions
12 - Birth WEIGHT TRIPLES 1. Fully developed 2 finger - Nonverbal gestures
- Sits down from standing pincer grasp (waving, head nodding)
- Can follow short simple
directions
months NCLEX TIP (startle reflex) & other - Cries when doesn't get months - Crawls up stairs 2. Tries to build 2 block - Searches for hidden
Memory Trick: reflexes Poop their way - Walks 1st steps while tower unsuccessfully objects
Poop Goo Goo!
After month 4 holding hand Saunders 3. Attempts to turn book
Mama (Object permanence)
It'OK, Car
= head lag NO MORE Po... it's OK pages Dad
5 months rolls from front Owh
Memory Trick:
to the back Kaplan ATI 12 mo. use fingers
1
HCP
3.1 kg 9.6 kg
1 & 2 - fully developed
pincer grasp
Hand up!
EEE...E...
5 months
NCLEX TIPS 2 NCLEX TIPS - 10 + words - Angry baby: - Tricycle & jumps - Draws circles - 3-4 word sentences Associative Play
18 1. Walk up/down stairs
while holding a hand
- Turns 2 pages in a
book at a time
- Follows commands “don’t
touch that”
temper & ownership
“mine” 3 forward ATI
- Learning balance
- Spoon feeds self ATI NCLEX
- Undresses self
- Asks “why” a lot
- Knows age
3 - 6 yrs.
months 2. Throws ball (uncoordinated) - Uses gestures to show what Parallel Play years - Walks up stairs with - Holds crayon with fingers - Follows more complex “Unorganized play
3. Jump in place with - Holds cup & spoon they want Car
Goo Goo! Mama
1 - 3 yrs. alternating feet instead of fist instructions without a goals or rules”
- Yes - Scissors
Cat
both feet HESI - Build tower of 4 blocks
Pee
Eat
Dog
“Children play
Don’t Dad
Why you laugh?
Memory Trick - Zips up a zipper ATI
Owh
- Scribbles with crayon NEXT to each other &
touch that Poop
I’m 3
18 months NO finger dexterity “NO direct interaction year old
Why mama
eat that?
1 hand helps the baby • No Scissors with others” Where is
that looks like an 8 • No color pencils my candy?
(looks like a baby

snowman) Top missed NCLEX Question: Mine
18-month old ... What findings should the
nurse report to the provider for
follow-up developmental screening? Could you put
away candy box
Select all that apply for me, please?
1. Uses 4 words
2. Cannot hold a spoon or cup
3. Unable to sit down from standing position C C
4. Finds it difficult to pick up small food C C
C B C B
items with thumb & index finger.
T A A U
2
1. Walks without help 2. Builds a tower of 7 blocks 3. Says own name NCLEX Imitates adult behavior - Skips, hops on 1 foot - Draw 4 sided shapes like - Able to tell stories - Imaginary play:
years
- Run & kick ball - Draws vertical lines HESI - 300 + words
- Walks up & down stairs - Books: able to turn 1 page - 2-3 word sentences
T
Toilet Training 4 - Catches a ball 50% of
the time
a square/ rectangle
- Can pour drinks & make
- Can memorize
alphabet & numbers
Dress up & Tea Party
- Plays with other
independently 1 step at a time - Identifies pictures years - Climbs & jumps food children rather than
at a time Kaplan - Open doors by turning with names Memory Trick: alone
Memory Trick: door knobs Saunders 300+ words 4 years 4 sided shapes
2 years, 2 legs for walking ... ...
... ...
2 names (first & last) T T
I’m Thomas Denn
2 - 3 word sentences Toddlers by age Two yrs old
I love
Toilet Trained by Two
Is it
candy?
candy
ABCDEF...
1...2...3..
Horse Gains independence 4...5...6...
I’m Thomas Gomez
Is it
Can I have
candy? some candy,
please?
Notes
327
Toilet Training
Don't get tricked

Toilet training begins during toddler age during 18 - 24 months, as anal &
urethral spincter control occurs during this timeframe.
The body is NOT ready before 18 months old! Memorize this! 18 - 24 months
NOT 15 months
Some exam & nclex questions try to trick you with 15 month olds & toilet
training, but don't get tricked.
Memory Trick for NCLEX

HESI Question
control of the anal and urethral
T - Toddlers (18 - 24 months) Poop
Poop
sphincters… typically achieved?
T - Toilet Training • 18 to 24 months
T - Tell you they need to poop

T - Two years old
1. Bowel control
2. Bladder control
(around 24 months)
18 months 24 months
The NCLEX stresses that the below factors also determine readiness, rather than simply the child's age alone
PRIORITY
Determine Readiness
1. Follow simple commands
2. Walk to & sit on the toilet
3. Remain on the toilet for
5 - 8 min.
4. Pull clothes up & down
Key Point Do NOT punish the child if they make a mistake!
(Does not have to fully
Simply clean it up & go on with life, it is a learning process.
dress themself)
ATI Question
… which of the following indicates the NCLEX TIPS
child is ready to begin toilet training?
● The child can communicate and
follow directions
T T T T
Toddlers Tell you they Two years old
Saunders Question (18 - 24 months) Toilet Training 1. Bowel control
need to poop
2. Bladder control around 24 months)
Poop
.... need for further information Poop
regarding toilet training? 1st 2nd
● Bladder control is usually achieved
before bowel control
HESI Question
What major task characterizes 18 months 24 months
toddlerhood?
● Toilet training
328
_ _
Cancer- Oncology
329
Osteosarcoma vs. Ewing’s Sarcoma
Pediatrics: Cancer
Osteosarcoma - Pathophysiology MEMORY TRICK

Osteosarcomas are types of bone cancer that begin in the osteoblasts (the cells that Malignant = Malicious (Cancer)
form bones). They simply “blast out” too much osteoid tissue & form a big tumor,
Benign = Be nice (non-cancerous)
commonly around the ends of long bones.
Osteosarcoma Osteoblasts Benign = Be nice Malignant = Malicious
Ewing’s Sarcoma - Pathophysiology MOST common

Ewing’s sarcoma is bone cancer that commonly starts in the femur and sacrum bones, 10 - 20 years old
or in nearby soft cartilage & nerves. These tumors can develop at any age, but are
commonly developed from ages 10 - 20 years old.
Sacrum bone
Femur bone

For both conditions: • Imaging - X-ray, CT scan, MRI
• Biopsy of the tumor or bone marrow
1. Bone pain • Blood tests - CBC - complete blood count measures
the levels of white blood cells, red blood cells, and
2. Swelling platelets in the blood.
3. Fractures An abnormal CBC result might suggest the cancer has

spread to the bone marrow, where these blood cells are
Common s/s of Cancer made.
Fever, Fatigue, Weight loss

CBC Test
Treatment
• Chemotherapy & Radiation therapy - to kill cancer
cells & decrease the size of the tumor.
• Surgery - to take out the tumor & even amputation Therapeutic Communication
may be done.
ATI
DOXORUBICIN New diagnosis of Ewing’s sarcoma.
Which of the following actions should
the nurse take?
Spend time with the adolescent
to answer any questions
330
Neuroblastoma
Pediatrics: Cancer
Pathophysiology
Neuroblastoma is cancer that develops from immature nerve cells, specifically
neural crest cells found in the spinal cord & adrenal glands. During infant
development these neural crest cells do not differentiate properly & begin to
form tumors, which can easily spread to bone marrow, liver & lymph nodes.
EXAM TIP Spinal cord Adrenal glands
Neuroblastoma is NOT to be confused with Nephroblastoma (Wilms tumor)

which is a tumor in the Nephron of the kidney.
Signs & Symptoms HESI Question

Which is the main difference between
Fever neuroblastoma and Wilms tumor?
Weight Loss Wilms tumor is confined to one side
Fatigue of the abdomen
Location of Tumor:
Lungs: difficulty breathing, chest pain, ATI Question
Neck & face: … Neuroblastoma of the adrenal gland with
Periorbital ecchymosis primary metastasis. Which of the following
findings should the nurse expect? Select all
Exophthalmos that apply.
Bones: Bone pain
Bone pain & fractures Periorbital ecchymosis
Decreased RBC Exophthalmos
Abdominal mass with pain & swelling Fatigue
Diagnostics
- CT scans can check for the presence of tumors.

- Urine & blood tests can check for catecholamines like norepinephrine & epinephrine,
as neuroblastoma cells can produce excess amounts of these chemicals.
Epinephrine Norepinephrine
Treatment EARLY
Early: Radiation & surgery can be used to both shrink and surgically remove
the tumor.
Late: If the cancer has metastasized (spread around the body):

LATE
- Chemotherapy can be used to kill the cancer cells
- Immunotherapy is used to stimulate the immune system to fight the Bone marrow transplant
cancer cells
- Bone marrow transplant is used to rebuild the immune system & blood
after chemotherapy.
331
Wilms Tumor (Nephroblastoma)
Pediatrics: Cancer
Pathophysiology & Causes MEMORY TRICK
Nephro blastoma
Nephroblastoma is the most common type of kidney cancer in children.

When kidney cells do not fully develop to maturity, the cells overgrow
resulting in a Wilms tumor.
Nephro - meaning kidney

Q1: Which is the main difference between
One-sided abdominal
neuroblastoma and Wilms tumor?
Wilms tumor is confined to one side
mass “bulging” NCLEX TIP of the abdomen
Q2: Which are the clinical manifestations of

Fever Wilms tumor? Select all that apply.
Fatigue
Fever
Fatigue
Hematuria Hematuria
Abdominal swelling or mass
Intervention
DO NOT PALPATE HESI

DO NOT PALPATE ABDOMEN
Wilms tumor: What is the most important safety
the abdomen NCLEX TIP precaution for a child?

Place a “do not palpate abdomen” sign on
head of bed
Place a BIG SIGN over the patient’s bed stating ATI

DO NOT PALPATE Abdomen. Wilms tumor: Which of the following signs should
Palpating the abdomen increases the risk of the nurse place over the child’s bed?
rupturing the encapsulated tumor, which could Do not palpate abdomen
cause cancer cells to spread all over the body.
Treatment
Nephrectomy surgery is done to remove either the whole kidney or only

part of the kidney & surrounding tissues.
After surgery, chemotherapy & radiation therapy is used to ensure the
elimination of cancer cells.
HESI
A 3 year old child is scheduled for surgery to
remove a Wilms tumor … What treatments …
will be necessary after surgery?
Chemotherapy with or without
radiotherapy is indicated
332
_ _
Cardiac
333
Congenital Heart Disease I
Pediatrics: Cardiac
Pathophysiology Causes & Risk Factors

These are abnormalities in the heart that develop before birth.
There are 1 or more problems with the heart's structure that change the
way blood flows through the heart & out to the body. Genetics
• Family history
Normal Heart Function Heart Defects
• Down Syndrome
1. Deoxygenated blood is Heart structures are changed!
vacuumed back to the heart via During pregnancy
the veins (through the vena cava Decreased cardiac OUTput =
into the right side of the heart) Decreased blood is pumped OUT • Infection (Rubella)
2. Next, the RIGHT side of the heart
to the body.
• Alcohol/Drug abuse
pumps this blood into the
lungs to get oxygenated. • Diabetes
Decreased cardiac
3. This oxygenated blood is pushed OUTput meaning
into the LEFT side of the heart to
be pumped OUT to the body &
Less oxygen rich blood
this is cardiac OUTput - oxygen OUT to the body
rich blood OUT to the body.
Blood pumped OUT to body

Cardiac OUTput
0₂ 0₂ 0₂
0₂ 0₂ 0₂ >150
0₂ 0₂
0₂
Types of Heart Defects
Congenital Heart Defects type

Aortic Normal Normal Ebstein’s anomaly
Aortic valve stenosis Coarctation of the aorta Ebstein’s anomaly Patent ductus arteriosus
Pulmonary valve stenosis Septal defects Single ventricle defects Tetralogy of Fallot
Total anomalous pulmonary Transposition of the great Truncus arteriosus

venous connection arteries
334
Heart Failure I
Pediatrics: Cardiac
Pathophysiology
Heart failure in pediatric clients has key clinical manifestations
& interventions that are different from adults. Clinical manifestations
MEMORY TRICK & Interventions
• HF - Heart Failure (failure to pump blood forward)
• HF - Heavy Fluid (backs up in lungs / body)
Weight Gain = Water Gain
Signs & Symptoms HESI Questions EARLY SIGN
Q1: Which is an early sign of congestive heart failure?

As the heart fails to pump blood forward, heavy fluid can back up into Tachypnea
the lungs making it difficult to breathe during breast or bottle feedings! Q2: 2 year old with … congestive heart failure.
Which information is most important for the parents
to report to the health care provider?
Fluid also backs up into the body resulting in WEIGHT GAIN from Exhibits a sudden and unexplained weight gain
Water Gain.
Orthopnea
HF - Heart Failure
ATI Question
A nurse is assessing a preschooler who has heart
failure. Which of the following manifestations should
HF - Heavy Fluid
the nurse expect?
Orthopnea
HEAVY
FLUID
SAUNDERS Questions
Q1: ... infant with congenital heart disease. ?
1. Weight Gain = Water Gain NCLEX TIP Which, if noted in the infant, should alert the
nurse to the early development of heart failure?
? ?
2. Difficulty breathing (fluid filled lungs) 4 Signs EXAM
Diaphoresis during feeding
Q2: infant with congenital heart disease … early

12kg
Orthopnea (SOB while lying flat) sign of heart failure?

Tachycardia
3. Sweating during feeding Saunders Q3: ...infant with heart failure… call the health
care provider:
4. Tachycardia & Tachypnea HESI Saunders Weight gain of 1 lb (0.5 kg) in 1 day
Other Classic Manifestations

R - RIGHT Sided HF L - LEFT sided HF
R - ROCKS BODY with fluid L - LUNG fluid
• Peripheral Edema • Pulmonary Edema

• Weight Gain = Water Gain • Crackles in lungs
• JVD (big neck veins) “Rales that don't clear with
• Abdominal Growth a cough”
- Ascites (fluid in abdomen) • Pink Frothy “blood tinged”
- Hepatomegaly (big liver) sputum
- Splenomegaly (big spleen) • Orthopnea - difficulty
breathing when lying flat
Causes
Congenital heart defects
Congenital heart disease or defects, are the BIGGEST CAUSE of heart

failure in children.
The child is born with 1 or more problems with the heart's structure
that changes the way blood flows through the heart resulting in a
backup of blood.
335
Heart Failure II
Pediatrics: Cardiac
Pharmacology ATI Question

infant who has heart failure and is taking
digoxin…. therapeutic response?
Digoxin 3 NCLEX TIPS My baby is breathing easier than before
HESI Questions
A - Apical Pulse (Listen 60 sec.) Q1: An infant is receiving digoxin for congestive
heart failure. The apical heart rate is 80 bpm.
Infants (0-12 months) What action should the nurse take first?
100 - 160 beats per min. D is for DEEP Contraction Obtain a therapeutic drug level
Q2: ..infant started on digoxin.... poor feeding

Child 70 beats per min. DIGOXIN DEEP contraction and vomiting, and a heart rate of 96 bpm. The
am digoxin level is 2.3 ng/mL. What is the nurse’s
next action?
T - Toxicity Notify the health care provider
Over 2.0 ng/mL

Q3: … important laboratory test result ... before
Digoxin administering digoxin for a child with congestive
heart failure?
Vomiting / Poor feeding Serum potassium level
P - Potassium LOW SAUNDERS Questions

Q1: A 1 year old infant with heart failure is
Less than 3.5 means prescribed digoxin... the apical pulse 102
beats/minute. What is the nurse’s best action?
Increased r/t toxicity Administer the medication
Q2: Newborn has a digoxin blood level of 1.6

ng/mL and an apical heart rate of 90 beats/min...
#1 Tested Drug is Digoxin just vomited her formula. Which intervention
Children with heart failure, the heart is weak & having trouble pumping blood Withhold the medication and notify the
primary health care provider
forward.
Digoxin helps the heart Dig for a Deep contraction! OVER 100 bpm
100% GOOD to GIVE
Under 100 bpm
It is a cardiac glycoside that increases contractility within the heart. HOLD
Fancy words for a more forceful heart pump, which PUSHES blood FORWARD, so that
it does not back up into the lungs & or body!
Key Point
Digoxin
No more fluid filled lungs means breathing is easier!
D DIURETICS Loop or Thiazide

Furosemide & HCTZ o
#2 MOST tested ATI Question
Bumetanide … side effects?
Monitor for postural hypotension
D – DIURETICS Drain Fluid Observe for ototoxicity
Potassium HESI Question

D–Drains Fluid “Diurese” “Dried”
K+ Wasting–Furosemide & Hydrochlorothiazide K+ … child is on furosemide. What high potassium
selections will the nurse encourage the mother to
include in the child’s diet?
(caution: Low K+, Eat melons, banana & green leafy) Bananas
Mandarin oranges
K+ Sparing–Spironolactone “Spares potassium” Blueberries
(AVOID Salt Substitutes, melons & green leafy)
Interventions HESI Questions

Q1: infant with heart failure… best intervention
Give the child a lot of rest in order to take work load off the heart & decrease that for decreasing the cardiac demand of the infant?
Allow the infant to have uninterrupted periods
cardiac demand! of sleep
Limit play time Q2: The nurse asks the parent of the infant with
pulmonary congestion to help the infant sit up.
Cluster the care for uninterrupted sleep What is the nurse trying to achieve?
Relief from dyspnea at rest
Rest:
Cluster Care
Z
Uninterrupted sleep Z
Z
Sit up to relieve dyspnea at rest

336
Congenital Heart Disease II
Complications: Hypoxia & CHF
Complications CHF (Congestive Heart Failure)

LEFT to right: ASD, VSD, PDA, AVSD
Hypoxia (low O2) PRIORITY
Memory Trick
RIGHT to left blood flow: TOF, TGA HF - Heart Failure
HF- Heavy Fluid
Memory Trick 0₂
0₂
0₂ Signs & symptoms
T - Trouble! 0₂
Weight Gain = Water Gain NCLEX TIP
T - Tetralogy of Fallot (TOF) 1. Pale, cool extremities
T - Transposition of the Great 2. Puffiness around the eyes (periorbital edema)
Vessels (TGA) If it starts with a 3. Reduction in number of wet diapers
& Grunting (during
Diaphoresis
T - Truncus Arteriosus T think Trouble! feedings) NCLEX TIP
T - Tricuspid Atresia
Always priority! Dyspnea
Tachypnea & Tachycardia
These defects take blood away from the lungs & push Poor weight gain
blood from the RIGHT to the left side of the heart, resulting
in hypoxia (low oxygen making blue babies).
Priority: Report Hemoglobin

Signs & symptoms level OVER 22 =
Cyanosis (blue skin) high risk for blood clots!
Poor feeding & weight gain
Clubbing fingers Polycythemia: 3.2kg
Dyspnea & Tachypnea Increased production of red

Polycythemia
blood cells due to hypoxia!
Blood clot risk! The body makes loads of new
Report Hemoglobin level red blood cells (RBCs) to These defects are less deadly, as hypoxia is NOT a
OVER 22 g/dL NCLEX TIP compensate for this low oxygen. primary problem.
Priority intervention = Hydration Blood is pushed from the LEFT side of the heart to
Instead of perfusing the body
the extra RBCs cause a traffic the right side & into the lungs. This OVERLOADS the
jam within the blood vessels lungs with too much blood flow, making it difficult
leading to deadly blood clots. to breathe during feedings!
CVA - Cerebral Vascular Accident
Saunders Question
.. infant with congenital
heart disease…. chronic
KAPLAN Question hypoxia: HESI Questions
The nurse knows a • Clubbing of the fingers
Kaplan Question Q1: Polycythemia.. highest priority?
cyanotic congenital heart Cyanotic congenital heart defect. ● Maintaining adequate hydration
defect is associated with … child with a diagnosis The nurse understands that chronic
Q2: … primary reason for a newborn
hypoxia from this disorder can result
which symptom? of a right-to-left cardiac in which finding?
with congenital heart disease to
be kept well-hydrated?
• Poor feeding with no or shunt… which is the ● Polycythemia
● To reduce the risk of
very poor weight gain most common cerebrovascular accidents (CVA)
assessment finding?
• Bluish discoloration
of the skin
337
Congenital Heart Disease III
Right to Left Blood Flow Disorders = Hypoxia
T TOF: Tetralogy of Fallot Hypercyanotic Spell “TET spells” Treatment

4 defects (Tetra = 4) 5 NCLEX TIPS Surgical repair
1. P - Pulmonary Stenosis During an Episode
2. R - Right Ventricular Hypertrophy 1. Infants: Knees to chest
3. O - Overriding Aorta
4. V - VSD (ventricular septal defect)
Older children: Squatting position HESI Question
Prevention
... Tetralogy of Fallot repair. Which
Symptoms 2. DO NOT interrupt sleep &
postoperative finding indicates
“TET Spells” MOST TESTED Provide a calm quiet environment that the repair is successful?
• Cyanosis (blue skin) upon waking up Select all that apply.
• Hypoxemia: O2 sat 65 - 85% 3. Offer a pacifier during crying
• Absence of cyanosis
Clubbing fingertips 4. Small & frequent feedings when feeding
Polycythemia = Blood clot risk! 5. Swaddle or hold the infant • Lips are pink when crying
during procedures • Respiratory rate of
Report Hemoglobin level 32 breaths/min
OVER 22 g/d NCLEX TIP
4 defects in 1 ATI Question

A child with a cardiac defect assumes a
5 Heart Failure signs
squatting position... To REPORT NCLEX TIPS
● Less dyspnea
Memory Trick
Pulmonary
Overriding Aorta
HESI Question HF - Heart Failure
Stenosis Infant … which action when a
Right Ventricular Ventricular hypercyanotic spell occurs? HF- Heavy Fluid
Hypertrophy septal defect ● Knee-chest position
1. Weight Gain = Water Gain
Hemoglobin
Saunders Question 2. Puffiness around the eyes
(periorbital edema)
MEMORY TRICK A child with Tetralogy of Fallot who is
3. Pale, cool extremities
OVER 22 g/dL
experiencing a hypercyanotic spell…
Tetra like Tetris = 4 order of priority. (Order response) 4. Reduction in number of
1. Knee to chest position wet diapers
2. 100% oxygen 5. Decreased feeding
RT
REPO 3. Morphine sulfate as prescribed
4. IV fluids
5. Document
T TGA: Transposition of the Normal Heart

Great Vessels
Reversal of the 2 main arteries
leaving the heart (pulmonary
artery & aorta)
Pulmonary valve Aorta
Treatment
Surgical repair
T Tricuspid Atresia
1. Closure of the tricuspid valve 2

2. ASD (atrial septal defect)
3. VSD (ventricular septal defect)
1
T Truncus arteriosus
3
Connection between the aorta
& pulmonary artery & VSD
(ventricular septal defect)
338
Rheumatic Fever & Kawasaki Disease
Pediatrics: Cardiac
Rheumatic Fever - Pathophysiology ATI Question

Acute rheumatic
fever... Which of the
This disease can result after NOT treating strep throat or scarlet fever correctly! following assessments
For example, not finishing the antibiotics or just not treating the infection. is the nurse’s priority?
• Auscultating the rate
The untreated infection causes total body inflammation, damaging the & characteristics of the
heart valves so clients will typically present with a heart murmur. child’s heart sounds.
• Sore throat Labs The goal of treatment is to kill the streptococcal

• Fever • Elevated CRP & ESR bacteria infection (antibiotics) & control the
• Hemolytic strep inflammation (NSAIDs).
• Joint Pain • Antistreptolysin O titer
NEVER give Aspirin = High Risk for Reye's syndrome!
Saunders
Saunders Rheumatic fever…
The nurse notes that
HESI Question
Laboratory results for a child aspirin is prescribed …
with rheumatic fever … expect
to note which findings? ASPIRIN
Which nursing action
What assessment will Select all that apply. is most appropriate?
the nurse include in a • Elevated ESR
child’s care plan with • Elevated C-reactive • Consult with the
rheumatic fever? protein (CRP) primary health care
• Elevated antistreptolysin provider to verify
• Sore throat in the O titer
• Presence of group A beta
the prescription
past 2 to 6 weeks.
hemolytic strep
Kawasaki disease - Pathophysiology
Memory trick
Kawasaki disease think K - Krazy inflammation within the blood vessels,
particularly the coronary arteries, the blood vessels that feed the heart K - Kawasaki
oxygen! It also affects lymph nodes, skin, and mucous membranes. K - Krazy inflammation
Signs & Symptoms Interventions Discharge Instructions

1
Fever
Priority 2 NCLEX TIPS NCLEX TIP
If the child develops a FEVER!
Monitor for a gallop heart rhythm &
Gallop heart rhythm NCLEX TIP *Reported to HCP immediately
decreased urine output
Decreased urine output Check temperature regularly Monitor temp. Q 6 hours for
first 48 hours
Red strawberry tongue ATI
Red eyes, lips, hands & feet
Skin peeling Saunders Question
Kawasaki disease... the nurse Treatment
Joint pain should monitor the child for signs of
which condition?
● Heart failure IV immunoglobulin (IVIG)
Aspirin (be cautious with
ATI Question Reyes syndrome)
Kawasaki disease…. which of HESI Question NCLEX TIP

NO live vaccines for 11 months
the following criteria needs to Which nursing interventions are
after IVIG
be present? most important ... child with
Kawasaki disease? 1. Measles, mumps, rubella (MMR)
● Strawberry tongue 2. Varicella (chicken pox)
● Monitor the temperature carefully
● Check the patency of the IV line 3. Influenza
339
Congenital Heart Disease IV
Left to Right Blood Flow Disorders = CHF
ASD Atrial Septal Defect

Left-to-right Cardiac Shunts
4 NCLEX TIPS
1. Diaphoresis (during feedings)
VSD Ventricular Septal Defect 2. Heart murmur
3. Poor weight gain
PDA Patent Ductus Arteriosus

4. Increased Risk: heart failure
& Pulmonary HTN
ASD VSD
AVSD Atrioventricular Septal Defect
Increased blood flow into the

3.2kg
lungs makes it very difficult to

breathe with decreased lung
PDA AVSD compliance & increased risk
for heart failure.
Surgical Repair is Main Treatment

ASD Atrial Septal Defect Don’t let
Hole between the Atria NCLEX TRICK YOU
Symptom
Murmurs are Expected!
• Murmur (normal & to be expected) NCLEX TIP
Treatment
• Closes naturally
• Surgical repair
VSD Ventricular Septal Defect Grunting = Priority

(breathing problem)
Hole between the Ventricles (septal opening)
Symptoms
• Grunting during feeding NCLEX TIP
• Systolic heart murmur (left sternal border)
Treatment
• Closes naturally
• Surgical repair
Patent DUCKtus arteriosus
PDA Patent Ductus Arteriosus

Opening that connects aorta to pulmonary artery Saunders Question
Symptom … machinery-like murmur on auscultation of the
• Loud machine-like murmur NCLEX TIP heart and signs of heart failure… which disorder?
Memory Trick: Loud machine like DUCK • Patent ductus arteriosus
Treatment
HESI Question
• Indomethacin (NSAID)
• Surgical ligation
Surgical repair for patent ductus arteriosus (PDA)
AVSD Atrioventricular Septal Defect is performed to prevent which complication?
Both ASD & VSD • A worsening of pulmonary vascular congestion
2 holes: Atria & Ventricles
Notes
340
Congenital Heart Disease V
Stenosis = Stiff Valves
Stenosis (stiff valve)

Stenosis is the stiffening & narrowing of the heart valves resulting in
a blockage of blood flow out of the heart chamber, backing up of
blood & decreased cardiac output.
2 Types of Stenosis:
- Pulmonary Stenosis (pulmonic)
- Aortic Stenosis
S Stenosis S Stiff & narrow
Memory Trick: Decreased cardiac OUTput 0₂
S - Stenosis Less oxygen rich blood OUT to the body 0₂

0₂
0₂
S - Stiff & narrow
Pulmonic Stenosis
Pulmonary valve: stiff, small, narrow valve.
Symptoms
• Right ventricular hypertrophy
• Loud “systolic ejection”
heart murmur
Treatments
• Balloon angioplasty
• Surgical repair (Valvotomy)
Aortic Stenosis HESI Questions

Q1: pathophysiology of a newborn with
Aortic valve: narrowing aortic stenosis?
Symptoms Select all that apply.
• Decreased cardiac output
• Decreased cardiac OUTput • Left ventricular hypertrophy
Decreased O2 blood OUT to the body • Pulmonary vascular congestion
• Activity intolerance Q2: Which cardiac defect causes
• Vitals: Low BP, Tachycardia narrowing of the aortic valve?
• Aortic stenosis
• Left ventricular hypertrophy
• Pulmonary congestion
Symptoms
Saunders Question
… suspected aortic stenosis. The nurse
• Balloon angioplasty expects … which clinical manifestation?
• Surgical repair (Valvotomy) • Activity intolerance
COA: Coarctation of the Aorta

HESI Question
Narrowed aorta: coarctation of the aorta... child’s initial
decreased cardiac OUTput assessment supports this medical diagnosis?
(Decreased O2 blood OUT to the body) • Bounding pulses in the arms
• Cool lower extremities
Symptoms
• Upper extremities: High BP,
Bounding pulses
• Lower extremities: Cool, low
BP & diminished pulses
Symptoms
• Balloon angioplasty
• Stents Balloon Stents
angioplasty
341
Congenital Heart Disease VI
Treatments
Treatments
Cardiac catheterization (often called cardiac cath) is a procedure used to treat & diagnose certain cardiac conditions.
A long thin tube called a catheter is inserted in an artery or vein in the groin, neck or arm and threaded through the
blood vessels to the heart.
Cardiac Catheterization
1
HESI Questions
Q1: After cardiac catheterization, the nurse
BEFORE assesses that the pulse distal to the
catheter insertion site is weaker. Which
• Allergy to Iodine is the nurse’s best action?
• NPO 4 - 6 hours (children) • Record the data on the nurse’s notes
Shorter NPO status (infants) Q2: After cardiac catheterization of a child,
which assessment finding is most
• Report to HCP concerning to the nurse?
Severe diaper rash NCLEX TIP • The affected extremity feels cool
when touched
AFTER
Q3: ... child who has just undergone cardiac
Priority Assessments: catheterization. Which intervention does
1. Pulses distal to cath site! the nurse implement?
Normal: Weak pulse NCLEX TIP • Keep the site clean and dry
NOT normal!: Cool, cold, pale extremity • Administer acetaminophen or ibuprofen
to relieve the child’s pain
2. Straight leg for 4 - 8 hours • Assess pulses, temperature, and color
of extremities
3. Incision site:
• Remove the pressure dressing the day
• Assess for bleeding after catheterization and cover the site
• Infection - no baths with an adhesive bandage
Chest Tube Monitoring

Chest tubes are placed during cardiac surgery to help drain excess fluid & air for lung expansion.
After surgery, it remains in place to drain excess blood.
HESI Questions
Priority Report to HCP
Q1: The nurse is assessing the chest tube
NCLEX TIP drainage of a 2 kg infant after cardiac surgery.
Which drainage would prompt the nurse to
contact the provider immediately?
• 1 hour: Over 5 - 10 mL/kg 2 kg
• 3 hours: Over 3 mL/kg/hr 1 � 1 hour: Over 5 - 10 mL/kg → 10 - 20 mL
� 3 hours: Over 3 mL/kg/hr → 6 mL/hr
Indicates: severe bleeding (18 mL in 3 hrs)
Answer:
& cardiac tamponade > 5 - 10 mL/kg
Drainage greater than 12 mL/hr for more
than 3 hours
For example
Q2: … drainage from the chest tube of
• Child weighs 6 kg 4 ml/kg/hr for the past 3 hours. What does
• 1 hour: 30 - 60 mL/kg this finding suggest?
� 1 hour: Over 5 - 10 mL/kg
• 3 hours: 6 kg x 3 mL = 18mL/hr
> 3 mL/kg/hr
� 3 hours: Over 3 mL/kg/hr

(54 mL in 3 hours) Answer:
The child may be at risk for cardiac tamponade
Post-Op Care & Teaching

Kaplan Question
Surgical repair of a congenital heart defect .…
Elevate the head of bed (HOB) to reduce respiratory effort. most important for the nurse to include in the
Surgical sites - infection! Report fever, warm surgical site, smelly purulent postoperative care plan?
● Elevate the client’s head to reduce
drainage & no heavy lifting or strenuous activity for the first 3 to 4 weeks. respiratory effort
Saunders Questions
Q1: … after cardiac surgery. Which statement
1
made by the parents indicates a need for

further instruction?
1
● I can apply lotion or powder to the

incision if it is itchy
Q2: discharged after heart surgery asks the
1
nurse when the child will be able to return

to school?
● The child may return to school in 3
weeks but need to go half-days for
the first few days
342
_ _
Dehydration
&
Diarrhea
343
Diarrhea & Dehydration
Pediatrics: Gastrointestinal
Pathophysiology
Diarrhea is loose watery stool with more frequent bowel movements, Memory trick
leading to SEVERE fluid & electrolyte depletion especially in pediatric
patients. Where fluids FLOW
Electrolytes GO!
� Hyponatremia (low sodium below 135)
� Hypokalemia (low potassium below 3.5)
Signs & Symptoms

Q1: A 5-month-old infant with The 3-year-old child ... vomiting and
Sunken eyes & fontanels (infants) vomiting and diarrhea … started diarrhea for the past three days. Which
3 days ago… focused assessment finding is the nurse most likely to see?
for which of the following?
Dry mucous membranes Select all that apply.
● Sunken eyes
● Sunken fontanels
Weight loss = Water loss ● Dry mucous membranes
● Weight loss
HESI Question
Fatigue, lethargy ● Decreased or absent tearing Q1: Which skin assessment... adequate
hydration and nutrition in a child?
Q2: 13-year-old client with diarrhea. ● Skin turgor
Decreased tearing The client has dry lips and loss of
Q2: A child presents with vomiting and
15kg
skin turgor. What is the best
diarrhea for 36 hours. Which finding
Decreased skin turgor course of action for the nurse?
● Notify the healthcare is most concerning to the nurse?
provider (HCP) ● Urine specific gravity of 1.035
Causes HESI Question

! Q1: Most common cause of
diarrhea in children under 5?
! ● Rotavirus
• Typically caused by viruses that can cause infection. Q2: Which factors predispose a
! child to diarrhea?
• Bacteria and parasites - typically from undercooked Select all that apply.
food causing salmonella & poor sanitation or lack of ● Poor sanitation
● Age of the child
clean drinking water ● Lack of clean water
● Nutritional deficiency
• Medications - Antibiotic & even laxatives ANTIBIOTIC
Q3: Causes of acute diarrhea?
• Lactose intolerance Select all that apply
● Laxative use
● Antibiotic therapy
● Upper respiratory infections
Interventions Education
ATI Question
8-month-old infant with a 2 day history of diarrhea…
Hydration
temperature of 101F, heart rate 160/min, respiratory
rate 35, and blood pressure 70/40 mm Hg. The anterior
fontanelle is sunken… with capillary refill of 4 seconds.
Which of the following is the most appropriate?
Normal diet (solid foods)

2 NCLEX TIPS
● Give 20 mL/kg bolus of 0.9% NS over 20 minutes
Kaplan Question = Acute Diarrhea

B R
A toddler … vomiting, and diarrhea. Which
1. ORS: Oral Rehydration Solutions implementation is best for the nurse to use to maintain
an adequate fluid intake? NOT “BRAT” diet Bananas Rice
B - Bananas
● Offer oral rehydration solutions (ORS) to rehydrate
2. IV fluids: 20 mL/kg - IV normal

HESI Question R - Rice
saline bolus Which fluid is inappropriate when attempting to
A T
rehydrate a young child?
● Sports drinks A - Applesauce Applesauce Toast (bread)
T - Toast (bread)
20 mL/kg AVOID antidiarrheal meds
1st 0.9%
Sodium Chloride
Loperamide (brand: Imodium)
250 mL
344
_ _
Endocrine
345
Diabetes - Type 1 & Type 2
Pediatrics: Endocrine
Pathophysiology Basics
Type ONE
None: body does NOT produce insulin
INsulin = puts INto the cell (sugar & K+) Autoimmune (body attacks the pancreas)
SON: heredity “you can pass it on”
GLycogen = Stored GLucose in Liver
Type TWO
IN
FEW-insulin receptors work
“Insulin resistance” (Diet)
sulin YOU: your diet (high simple sugars)

& sedentary lifestyle
Lab Values
Glycosylated hemoglobin
ATI
… School-aged child who has type 1 diabetes mellitus.
Which of the following laboratory tests measures the
RANDOM FASTING GTT HgBA1C
HbA1c
average blood glucose level over the past 120 days? ‘’TOLERANCE’’
Glycosylated hemoglobin (HbA1C)

NORMAL 70-115 UNDER 100 UNDER 140 UNDER 5.7
HESI
Q1: Which is the best method for assessing control Diabetes PRE-DM 100-125 140-199 5.7-6.4
of diabetes?
HbA1C
200+ 126+ 200+
6.5+
DM
Q2: The child’s blood reports show the hemoglobin
A1c is 6%. What does the nurse tell the parents?
The patient’s diabetes is under control; please
continue the same regime of treatment
Hyperglycemia - Signs & Symptoms
HESI
Q1: A nurse is caring for a 15-year-old girl who is experiencing
HIGH sugar polyuria, polydipsia, and polyphagia. The girl is underweight
and reports being extremely fatigued over the past 3 days. The
hot and dry = sugar high nurse anticipates testing will confirm which diagnosis?
Type 1 diabetes
“Hyperglycemia” Q2: Which action will the nurse take first for the child known
to have diabetes … admitted to the emergency room?
(blood turns to mud) Take a blood glucose reading
3 Ps:Polyuria ATI
Polydipsia … Teaching an adolescent who has diabetes mellitus about
manifestations of hyperglycemia. Select all that apply.
Polyphagia Increased urination

Hunger
Dark yellow-colored urine
Hypoglycemia - Signs & Symptoms

ATI
HESI … Adolescent who has type 1 diabetes
LOW sugar (70 or LESS) Q1: Which symptoms are associated with newborn hypoglycemia? mellitus. Which of the following statements
Select all that apply. by the adolescent indicates an understanding
cold and clammy need some candy Tremors
of the teaching?
“I should drink a glass of low fat milk
Hypoglycemia Jitteriness
Eye rolling when I am feeling irritable.”
MORE SEVERE! “Hypogly Brain will Die!” High-pitched cry
Q2: A child with diabetes who is treated with insulin is trembling

• Cool, pale “pallor”, sweaty, & sweating profusely. The nurse learns that the child has skipped
lunch. Which is the nurse’s best action?
clammy = candy NOT hot or flushing Give the child 3 to 6 oz of orange juice
Q3: Which food items to treat hypoglycemia will the nurse include
• Trembling, Nervous, Anxious in the teaching plan for the child with insulin-dependent diabetes?
Half cup of fruit juice
• HIWASH = Headache, Irritable, Weakness, Four sugar cubes
One teaspoon of honey RAISINS
Anxious, Sweaty, Shaky, Hungry One small box of raisins
346
Hypo & Hyperpituitarism
Normal Anatomy & Physiology

HGH
The pituitary is responsible for secreting importatant hormones like HGH,
human growth hormone responsible for growth & development.
Hypopituitarism Hyperpituitarism
Clients present small & frail.

Clients present as big & tall with acromegaly: enlarged
face, jaw, hands & feet.
HYPO = LOW amounts of growth hormones
HYPER = HIGH amounts of growth hormones
Signs & Symptoms
HESI
Short stature … Common clinical manifestation of
hypopituitarism that occurs due to
deficiency of growth hormone (GH) ?
Short stature
Signs & Symptoms
Kaplan
Hypopituitarism: clinical manifestation? HYPER = HIGH amounts of growth hormones
Short stature
HESI
Which assessment findings ... hyperpituitarism?
Causes Select all that apply.
Overgrowth of the long bones
Thickened, deeply creased skin
A tumor in the pituitary gland.
Malocclusion of teeth & enlarged jaw
Diagnostics
Causes
CT - checks for a tumor or other pituitary gland problems. Noncancerous tumors.
Treatment Treatment
Hypophysectomy: Surgical removal of the tumor is

Growth hormone considered the first line therapy.
Corticosteroids Complications post-operative:

Increased ICP, meningitis (infection in the brain),
Levothyroxine hypopituitarism & CSF leakage.
Testosterone & estrogen
Levothyroxine
Tablets
GROWTH Estrogen
HORMONE
347
Diabetes - Type 1 & Type 2 II
Insulin Types
LONG ACTING NPH REGULAR RAPID Aspart, lispro, glulisine
NO Peak iNtermediate Ready to go IV

Aspart/Lispro/
Memory Trick
NO Mlx
• Detemir
NEVER IV drip
or IV bag
Regular goes
right into the vein
Glulisine Regular
PEAKS =
Insulin levels
• Glargine
Mix clear to
cloudy
ONLY IV insulin NPH A - Aspart = MOVE your ASS-parts
• Levemir =
Given 2x per
Long acting
day Detemir L - Lispro = LESSpro LESS time
PEAK
Glargine
30-90 hour
G - Glulisine = Go LImousine
15 minute
PEAK ONSET
2-4 hour
MOST DEADLY 0 2 4 6 8 10 12 14 16 18 20 22 24
PEAK
4-12 hour
Hours
NO PEAK PEAK TIMES = Hypoglycemia risk 70 or Less

Hypogly brain will DIE NCLEX TIP
7 Insulin Tips HESI

Q1: When does rapid-acting insulin peak?
1. Peaks + Plates = Food during PEAK times (prevent HYPOgly=brain die) 30-90 minutes after injection
Q2: The nurse is teaching an adolescent with newly diagnosed
2. NO Peak NO Mix = Long acting “old guys”–Detemir & Glargine type 1 diabetes ways to minimize discomfort with insulin
injections. Which recommendations? Select all that apply.
3. IVP or IVPB ONLY = Regular insulin “ready to go IV” Do not reuse needles
Remove all bubbles from the syringe before the injection
4. Draw Up: Clear to Cloudy “you want CLEAR days before cloudy ones” Do not move the direction of the needle-syringe during
insertion or withdrawal
5. Rotate locations-Macarena-BEST on abdomen ATI

(2 inches from: Umbilicus, Naval, “belly button”) Q1: … Child with diabetes mellitus, nutrition and
medication... teaching?
6. DKA - Type 1–“sick days”–YES INSULIN without food!!! You should give four or five injections around
one area before switching sites
7. Hypoglycemia (70 or LESS) Q2: A teen with type 1 diabetes mellitus is receiving
NPH (Humulin N) insulin. A nurse is helping a teen
Awake = Ask them to Eat (soda, juice, low fat milk) and her parents plan her diet. The nurse explains that
the primary purpose of bedtime snack is to provide
Sleeping = Stab with IV D50 (dextrose 50) which of the following?

Nourishment with latent effect to counteract late
"Unresponsive" "Responsive ONLY to pain" insulin activity
Insulin Teaching
4 NCLEX TIPS
Key Point: 1. Recite a few signs & symptoms of low blood
1. Encourage school-aged children 5 years and older to 2. Help clean the site for a finger-stick glucose testing
participate in care & educate parents to transfer
3. Identify insulin injection sites
management of care to the child in small steps.
4. Press the plunger of insulin syringe after a parent
2. Children less than 14 years of age should inserts and stabilizes the needle
NOT adjust insulin dose!
Insulin Infusion Pump Diet Education
• Steady dose of insulin = #1 benefit! D-Diet ‘’low sugar’’

LOW Calories & LOW Simple Carbs
Fewer swings in blood sugar
• Great for non-compliant children with type AVOID: Simple Sugars
(soda, candy, white bread/rice, juices)
1 diabetes who forget to take their insulin GOOD Carbs
• Push insulin bolus button at meal times High Fiber (complex carbs)
BROWN (bean, rice, bread, peanut butter)
‘’whole wheat/grain/milk’’

HESI
After soccer practice an 11-year-old
Q1: How is the insulin infusion pump different from female with type 1 diabetes … appears
delivery of insulin through subcutaneous injection? confused, with pale diaphoretic skin and
shaky. What is the first priority action?
5%
DEXTROSE
Insulin infusion pump delivers fixed amounts of
D
FIXE
insulin continuously 1. Prepare to give the child insulin
Q2: The mother of a child with type 1 diabetes 2. Provide 6 oz of a regular soft drink
mellitus asks why her child cannot avoid all “those 3. Emergency IM injection of glucagon
shots” and instead take pills as the uncle does… most 4. Dextrose IV push
appropriate response?
Your child needs to have insulin replaced
348
Hyperthyroidism & Hypothyroidism II
HYPERthyroidism HYPOthyroidism
Graves = GAINS ‘’HIGH’’ HashimOtos | LOW & SLOW
Signs & Symptoms Signs & Symptoms
HIGH & HOT! LOW & SLOW = HYPO

CLASSIC SIGNS - NCLEX KEY WORDS
CLASSIC SIGNS
G GRAPE EYE ‘’Exophthalmos’’
(Use Eye patch/Tape Eyelids down) NCLEX TIP LOW energy “fatigue, weakness, muscle pains, aches”
LOW metabolism–Weight GAIN/Water Gain (Edema eyes)
G GOLF BALLS in throat ‘’Goiter’’ NCLEX TIP
LOW digestion “Constipation” NOT diarrhea
HIGH BP-HTN Crisis 180/100+ LOW HAIR LOSS “alopecia” NOT hirsutism NCLEX TIP
(MI,CA, Aneurysms) LOW mental–forgetful, ALOC (altered)
HIGH HR-Tachycardia 100+ (normal 60-100) LOW mood–depression, “apathy, confusion”
HEART PALPITATIONS + Atrial Fibrillation LOW Libido–Low sex drive, infertile
HIGH TEMP. = NOT DRY! SLOW DRY skin turgor NCLEX TIP
HOT & Sweaty Skin ‘’diaphoresis’’
Heat Intolerance NCLEX TIP
HIGH GI ‘’Diarrhea’’ 3 NCLEX TIPS
ATI 1. Difficult to awaken

… Adolescent who has Grave’s disease… 2. Dry skin
expected findings? Select all that apply. 3. Hoarse cry
Moist skin
Tachycardia Enlarged fontanelles
Weight loss Poor feeding
Protruding tongue
Constipation
Critical Complication
PRIORITY: EXTREME HIGH = Thyroid Storm Critical Complication

”Agitation & confusion” early sign
PRIORITY: EXTREME LOW = Myxedema Coma

Low RR—Respiratory FAILURE
Diet
PRIORITY: Place “Tracheostomy Kit” by bedside NCLEX TIP
HIGH METABOLISM KEY WORD: “Endotracheal Intubation set up”
HIGH calories (4,000–5,000 per day) NCLEX TIP Low BP & HR “hypotension” “bradycardia” (below 60)
HIGH protein & carbs (meals & snacks) Low Temp. “cold intolerance” NO electric blankets
NOT high fiber = LOW FIBER! (unless constipated)
NO caffeine (coffee, soda, Tea)
NO spicy food
Diet
HESI
An infant born with a goiter. Which are the priority LOW Metabolism
nursing considerations for this infant?
LOW Calories
Preparation for emergency ventilation LOW Energy “Frequent rest periods” NCLEX TIP
Having a tracheostomy set at the bedside
Place the neck into a hyperextended position
349
DKA & HHNS
DKA HHNS
Patho & Causes: Patho & Causes:
TYPE 1–FASTER & YOUNGER TYPE 2–SLOWER & OLDER “H COMES 2ND
FRUITY BREATH “D COMES 1ST IN ALPHABET” IN ALPHABET”
HEADACHE &
CONFUSION
S–SEPSIS (INFECTION) NCLEX TIP ILLNESS

S–SICKNESS "STOMACH VIRUS & FLU" INFECTIONS
(MOST COMMOM) OLDER AGE HARDER TO FIX
S–STRESS (SURGERY) NO FRUITY BREATH
S–SKIP INSULIN EASIER FIX

Signs & Symptoms
ABDOMINAL PAIN
Signs & Symptoms
H–HIGHEST SUGAR OVER-600+
D–DRY & HIGH SUGAR 250-500+ NCLEX TIP
NO ABDOMINAL PAIN
H–HIGHER fluid loss & Extreme

K–KETONES & KUSSMAUL RESP. dehydration NCLEX TIP
(DEEP/RAPID/REGULAR RESPIRATIONS H–Head change–LOC, Confusion, Neurological
AND FRUITY BREATH) NCLEX TIP Manifestations
A–ABDOMINAL PAIN N–No ketones No Acid, (NO fruity breath/
A–ACIDOSIS METABOLIC LESS THAN 7.35 ketones)
(NORMAL 7.35—7.45) S–Slower Onset & Stable Potassium (3.5-5.0)
HYPERKALEMIA (ABNORMALLY HIGH K+)
Interventions
D–Dehydration FIRST! (0.9% normal saline) NCLEX TIP
Memory Trick K–Kill the sugar (SLOWLY) prevent low sugar
*Hourly BS checks* “land the plane slow & smooth” Common NCLEX Question
D Dehydration 1st
(0.9% Normal Saline) Over 250: IV Regular insulin ONLY (bolus 1st)
Below 200 (or ketones resolve): SQ insulin + 1/2
Q:Child is nauseous NOT eating—maybe vomiting—do you
still give INSULIN?
K Kill the sugar with INsulin

NS with D5W IV
A–Add Potassium K+ (Yes even if norm: 3.5 - 5.0)
A: Yes, we give sick day insulin to prevent DKA...
because glucose is HIGH during times of illness.
During IV Insulin NCLEX TIP

A Add potassium K+
(even when normal)
IN-sulin = sugar & K+ IN the cell
HESI Question
ATI D K A Urinalysis of a patient with type 1 DM 0.9%
Dehydration
Sodium Chloride
shows ketones, glucose, and high
... Child who has type 1 diabetes mellitus.
concentrations of H+ ions.
Which of the following are manifestations
of diabetic ketoacidosis? On examination, the nurse finds that the
Dehydration
1st patient’s skin is dry, the radial artery pulse
is weak, and the level of consciousness is
decreased.
The nurse alerts the provider and prepares
to perform which interventions? Select all
HESI O that apply.
Q1: … Signs and symptoms of diabetic ketoacidosis

R R’ Administer intravenous fluids Insulin
DKA? Administer insulin

Administer potassium supplements
Ketonuria
Ketonemia
Dehydration ATI
Acetone breath 1st 2ⁿd
>180 0.9%
Sodium Chloride A 13-year-old ... type 1 diabetes mellitus...
Q2: The diabetic child ... with a fever & respirations hot skin, dry mucous membranes, and a
are deep and rapid… priority nursing intervention blood glucose level of 375 mg/dL. Arterial
for this child? blood gases reveal a pH of 7.28. Which Potassium
Supplements
action should the nurse prioritize first?
Determine the blood glucose level of the child
Begin infusion of normal saline
350
Hyperthyroidism & Hypothyroidism III
Graves = GAINS ‘’HIGH’’ HashimOtos | LOW & SLOW
Pharmacology Pharmacology
SSKI (Potassium Iodide)
L–Levothyroxine (LevO = HYPO)

S–Shrinks the Thyroid
S–Stains Teeth (use straw + juice)
K–Keep 1 hour apart of other meds “Leaves” T3 & T4 in the body MEMORY TRICK
PTU-Propylthiouracil MEMORY TRICK
“Puts Thyroid Underground”
Baby safe L–Lifelong + Long slow onset (3-4 weeks till relief)
REPORT: Fever/Sore Throat
BETA BLOCKERS “-lol” Propranolol E–Early morning /Empty stomach x 1 daily (NOT at night)
L–Low BP
L–Low HR V–Very active (HIGH HR & BP) Report “agitation/confusion”
Treatments O–Oh the baby is fine! (pregnancy safe)
NO FOOD–take 1 hour BEFORE breakfast
RAIU–Radioactive Iodine Uptake (Destroys the Thyroid)
NO Cure–med will NOT cure, only treat
BEFORE:
Pregnancy test before
NO Doubling doses (missed dose? Take it!)
REMOVE neck jewelry & dentures NEVER “abruptly” STOP = Myxedema Coma
5–7 days before Hold antithyroid Meds
AWAKE–NO anesthesia or Conscious Sedation
Diet: Before–NPO 2–4 hrs
After–NPO 1–2 hrs
AFTER: AVOID EVERYONE!

NO pregnant people NO crowds
NOT same restroom (Flush 3 x) NOT same food utensils
NOT same laundry as your family
LIFELONG EARLY MORNING
+ Long slow onset EMPTY STOMACH
Patient Education (3-4 weeks till relief)
x 1 daily (NOT at night)
E–Exophthalmos” (grape eyes)

Eye Exercise “full range of motion” (YES MOVE EYES)
Eye Drops “artificial tears in conjunctiva” (NO dry eye)
Dark Sunglasses (avoid irritation) NO Massaging
T–Tape the eyelids closed or use Eye Patch NCLEX TIP
AVOID 5 S’s
Can Trigger THYROID STORM! NCLEX TIP
NO Sodium (eye swelling) + HOB Up (drain the eyes)
NO Stimulants (Cluster care/ Dim Lights)
NO Smoking, Stress, Sepsis “sickness” (infection)
*Don’t Touch Neck... release MORE T3 & T4*
Thyroidectomy Surgery
Risk for THYROID STORM! NCLEX TIP
Priority: Stridor/Noisy breathing NCLEX TIP VERY HYPER OH BABY IS FINE
A–Airway–Endotracheal Tube bedside #1 Priority (HIGH HR, BP, Temp.) (Pregnancy safe)
Tracheostomy Set REPORT ‘’agitation/confusion’’
B–Breathing–Laryngeal Stridor “Noisy breathing”
Keywords: “Monitor Voice strength & Quality”
C–Circulation–bleeding around pillow & Incision site
Neutral head & neck alignment NCLEX TIP
- NOT SUPINE! HOB 30–45 degree
- NO FLEXING or Extending Neck NCLEX TIP
C–Calcium LOW below 8.6 (normal: 8.6–10.2)
Chvostek (Cheek Twitch when touched)
Trousseau (“Twerk arm” with BP cuff x 3 min.)
Tingling around mouth/Muscle Twitching NCLEX TIP
MEMORY TRICK: “Remove the T (thyroid) Check the C (calcium)”
351
_ _
Genetic disorders
352
Down & Marfan’s Syndrome
Pediatrics: Genetic Disorders
Down Syndrome - Pathophysiology Trisomy 21
Down syndrome, also called trisomy 21, is a genetic disorder caused when 1 2 3 4 5 6 7 8
abnormal cell division results in extra genetic material from chromosome 9 10 11 12 13 14 15 16
21 leading to developmental delays both physically & mentally. 21
Signs & Symptoms Parental Teaching

Nurses should educate parents that children with Down
Common: Cardiac murmur NCLEX TIP syndrome usually have delays in physical and mental
Facial appearance: Small nose,
growth development. ?
mouth, & ears
? ?
Flat nasal bridge Flat nasal bridge
Small nose, mouth, & ears

Short, stocky stature
HESI Question Kaplan Question My child’s development will

become more rapid in time.
Q1: A 2-year-old child with trisomy 21 … child with Down syndrome. Which
(Down syndrome) … Which assessment parental statement indicates to the
finding suggests the presence of a nurse that further teaching is necessary?
common complication often experi-
“My child’s development will become
enced by those with Down syndrome? more rapid in time.”
Presence of a systolic murmur
Q2: Which clinical manifestations are
appropriate for Down syndrome?
ATI Question
Select all that apply. Which statement by the parents indicates
Flat nasal bridge that they have some understanding of
Down syndrome?
Separated sagittal suture
High, arched, narrow palate “There is a broad spectrum of mental
Short stature, protruding tongue, capabilities and physical characteristics
and decreased muscle tone in children with Down syndrome.”
Marfan’s Syndrome - Pathophysiology
This is an inherited disorder that affects connective tissues,

mainly in the heart, muscles, bones, eyes, & blood vessels.
Marfan syndrome
Signs & Symptoms Teaching
Clients with Marfan syndrome develop very tall and thin

with long arms, legs, fingers, and toes. AVOID contact sports NCLEX TIP
S - Scoliosis
S - “S” shaped Spine
S
curvature of the spine Lateral curvature
A - Aorta Problems ATI Question
A - Aneurysm / Aortic Tear

Marfan syndrome... What should the
nurse prioritize in the discharge teaching
for the parents?
Participation in contact sports should
be avoided.
Aortic aneurysms or dissections
353
PKU: Phenylketonuria
Pediatrics: Genetic Disorders
Pathophysiology HESI Question

Q1 Which pathology pertains to
Rare genetic disorder that causes severe brain damage & neurological phenylketonuria (PKU)?
impairment, especially during the developmental years from growing Defect in amino acid metabolism
fetus during pregnancy, to the age of 12. With PKU, the body lacks the Q2 Which fetal abnormalities are
enzyme Phenylalanine Hydroxylase required to break down an amino prevented by monitoring … a client
acid phenylalanine into tyrosine. Amino acids found in high protein with phenylketonuria (PKU) for high
foods are essential for brain development, especially during pregnancy. levels of phenylalanine?
But in PKU these unconverted amino acids build in the body, resulting in Select all that apply.
permanent brain damage occurring in the fetus & newborns. Cardiac anomalies
Intellectual disability
Intrauterine growth restoration
Phenylalanine Hydroxylase
Amino acid
phenylalanine
Tyrosine
Causes
Genetics is number 1, passed on from both parents, so both parents

PRIORITY
need to be carriers in order to pass on the disorder. Therefore,
genetic counseling is always recommended prior to pregnancy.
#1
Education
Kaplan Question
Child client diagnosed at birth with
NCLEX TIPS phenylketonuria (PKU)... the nurse is
most concerned .. with which statement?
Special infant formula My child’s favorite lunch is peanut
Low-phenylalanine Diet is required butter and jelly sandwich.
Fruits & veggies are best!

ATI Question
AVOID “HIGH protein & iron foods”
Teaching to a client who has
NO meat, eggs, dairy products
phenylketonuria (PKU).... indicates an
Peanut butter & jelly sandwich understanding of the teaching?
Tyrosine in diet is GOOD Avoid foods high in protein for at 3 months
least 3 months prior to pregnancy
Notes
354
_ _
Gastrointestinal
355
Achalasia & Pyloric Stenosis
Pediatrics: Gastrointestinal (GI)
Achalasia - Pathophysiology
Esophageal peristalsis
Achalasia is a condition where infants regurgitate formula or milk after

feeding. It’s a motility disorder characterized by limiting esophageal Lower Esophageal
peristalsis and nonrelaxation of the lower esophageal sphincter (LES). Sphincter (LES)
Signs & Symptoms

Colicky behavior (frequent
crying and fussiness), during or
immediately after feeding
Frequent or recurrent vomiting
Refusing to eat or difficulty

eating with choking or gagging
Education
After feeding: ATI

30
min
Achalasia: The visiting nurse instructs the

1. Keep upright for 30 minutes
infant’s mother to...
2. Elevate the head Keep the infant in a semi-sitting
3. Small frequent feedings position, especially after feedings
Pyloric Stenosis - Pathophysiology

Hypertrophic Pyloric Stenosis
Hypertrophic Pyloric Stenosis (HPS), is a condition in newborns,
where the lower sphincter of the stomach becomes enlarged, P P Memory Trick
preventing food from entering the small intestine.
This blockage results in projectile vomiting immediately after Projectile Vomiting
feeding, which leads to severe dehydration & constant hunger. Pyloric Stenosis

... plan of care for an infant with pyloric stenosis?
NCLEX TIPS
Labs NCLEX TIPS Observe for projectile vomiting
1. Projectile vomiting after feeding

High Labs = High Hematocrit KAPLAN
2. Abdominal distention & hunger
The newborn is vomiting, has abdominal distention, &
Metabolic alkalosis (pH over 7.45 ) is diagnosed with pyloric stenosis. Which characteristic
3. Poor weight gain & dehydration
of the newborn’s emesis does the nurse expect?
compare birth weight to current weight Low potassium (3.5 or less)
Projectile and forceful
Causes Diagnostics Surgery Post Op Teaching

Unknown, but genetic and Olive-shaped lump
Resume feeding =
environmental factors might play in the epigastric area to the right side
No vomiting after feeding NCLEX TIP
a role. of the belly button
? Once surgery for pyloric stenosis has

been completed, the condition is
cured!
356
Cleft Lip & Cleft Palate
Pathophysiology
• Cleft lip: split of the lip
• Cleft palate: opening or cleft in the roof of
the mouth (the palate) into the nasal cavity
Both occur when the tissues don’t fuse together during fetal development
before birth. Naturally a HUGE complication is inadequate feeding, as infants
Cleft lip Cleft palate
can not achieve proper suction. It becomes very difficult to pull milk or formula
from the nipple & also are at HUGE risk for aspiration, breathing that milk or
formula into the lungs!
Risk Factors Diagnostics

Cleft lip and cleft palate are seen on ultrasound before
HESI the baby is born.
Which substance use is associated with
increased incidence of cleft lip?
Alcohol
Anticonvulsant
Cigarette smoking
Surgery #1 #2
Postoperative Care
1. Cleft lip repair: 3 - 6 months of age

3 - 6 months of age 12 months Interventions
#3
2. Cleft palate repair: 12 months (or earlier)
4 NCLEX TIPS
3. Follow-up surgeries: between age 2 &
teen years 1. NO objects into mouth
(pacifiers, straws, tongue depressors)
2+ years of age
2. Position after feeding = upright, supine with an
elevated head of bed
Education 3. Advise caregivers to hold and comfort the child
4. Elbow restraints:
Oral Intake (before surgery) Remove elbow restraints per policy to assess
skin & circulatory status
5 NCLEX TIPS HESI

1. Use special bottles or nipples Q1: … cleft lip repair. What is the most important reason to
minimize this child’s crying during the recovery period?
2. Burp often Crying stresses the suture line
Q2: A 3-month old infant returns from cleft lip surgery with
3. Upright position during feeding elbow restraints ... Which action should the nurse take to
maintain suture line integrity?
4. Point bottle down & away from the cleft Place the infant upright in a seated position
5. Slow feeding to 20 - 30 minutes ATI

12 month old infant … 6 hours postoperative following
cleft repair. Which interventions should the nurse include in
the infant’s plan of care? Select all that apply.
Apply and release elbow restraints every hour
Encourage the parents to rock the infant
357
Constipation, TEF & EA
Constipation - Pathophysiology Signs & Symptoms

Infrequent bowel movements or • Passing fewer than three stools a week
difficult passage of stools that • Having lumpy or hard stools
persists for several weeks or longer. • Straining to have bowel movements < 3/week
Causes Treatment
HESI
• Stress
• Low Fluid & Fiber High Fluid & Fiber Q1: Which suggestion of the nurse helps the child
in relieving constipation?
You should eat a high fiber diet
Ambulation (walking)
Q2: A mother of a 4 year old... reports that her
Diet low in fiber, typically from not enough fruits, veggies, child has hard and dry stools. She reports a diet
high in whole milk, processed meats, bananas, and
or whole grains. Fiber can also cause constipation if fluid macaroni and cheese. What is the nurse’s best
reply?
intake is low, since fiber inflates with fluids to scrub the Try replacing the macaroni with a
GI tract. whole wheat macaroni
Complications HESI
Fecal incontinence (Encopresis)
Which is most associated with a child with a fecal
impaction?
3 Steps to Treatment Encopresis
Diary
1. Laxatives & stool softeners

2. Fluid & fiber
3. Change Habits
Schedule regular toilet visits after meals
Keep a diary for toilet sessions
Reward system for effort NCLEX TIPS
& NOT rewarding for each bowel movement
Encopresis
Tracheoesophageal Fistula & Esophageal Atresia - Pathophysiology HESI

Atresia of the esophagus and tracheoesophageal
fistulas:
The upper and lower segments of the
Tracheoesophageal Fistula (TEF) is an abnormal connection between esophagus end in a blind sac
the esophagus and the trachea, resulting in high risk for aspiration Atresia The upper segment of the esophagus ends
in a blind pouch;
during feedings! the lower segment connects with

the trachea by small fistulous tract
Fistula Kaplan
Esophageal Atresia (EA) is when the esophagus is divided into 2
segments without connecting to one another. Both of these Infant with... excessive amount of oral secretions
after birth. During the first feeding the infant has a
conditions (TEF & EA) often occur together. choking episode accompanied by cyanosis.
Tracheoesophageal fistula
Signs & Symptoms Interventions
1. Stop the feeding STOP

Choking & cyanosis 2. Suction the mouth
during feeding NCLEX TIP
HESI
The nurse assesses a newborn during an initial
feeding of formula and notes choking, coughing,
and bluish lips. What is the nurse’s next action?
Stop the feeding
358
Hirschsprung’s & Pinworms
Hirschsprung's disease - Pathophysiology

Missing nerve cells
A condition in infants that affects the large intestine (colon) & causes problems with in the colon
passing stool. It results due to the missing nerve cells in the colon, which leads to
bowel obstruction as the anal sphincter is unable to relax and coupled with no
peristalisis (meaning no movement of the intestines).
Surgery is often required to bypass the affected part of the colon or remove it entirely.
Signs & Symptoms Surgery
3 NCLEX Keywords
ATI
Stoma Assessment
2-day-old infant
… 1 day old infant who has suspected
1. No passage of stool (meconium)
Hirschsprung disease. Which of the following
Or thin ribbon like stool
2. Distended abdomen
should the nurse anticipate on assessment of this?
Priority to Report to HCP
3. Refusing to feed & vomiting green bile No passage of meconium
Key words
Abdominal distention
Complications “Gray-tinged edges”
Fever & episodes of “Blue, purple, pale, dusky”
foul-smelling diarrhea
Report to HCP immediately!
Report to HCP
Pinworms (Enterobiasis) - Pathophysiology Signs & Symptoms
Intestinal worm infection Anal itching that is

worse at night NCLEX TIP
ATI Question
Pinworm infection… Which of
the following symptoms does
the nurse expect?
Anal itching that increases
at night
Diagnostics Pharmacology
Tape Test: teach the caretaker to place tape on the
Mebendazole HESI Question
anus of the child in the morning. If there are worms
present on the tape then the child most likely has a Albendazole (brand: Albenza) Which drugs are administered to
the child experiencing bedwetting,
pinworm infection. perianal itching, restlessness, poor
MEBENDAZOLE
sleep, who has also developed
HESI Question perianal dermatitis and excoriation?
Albendazole
Tape test?
Pyrantel pamoate
Collect the sample in the morning ALBENZA
(albendazoLe)
when the child awakens
359
Intussusception
Pathophysiology
Intussusception occurs when 1 part of the intestines slides inside another

part of the intestines, sort of like a telescope. This creates an obstruction
that blocks normal flow of bowels, leading to increased pressure, swelling,
and decreased blood flow within the bowels causing ischemia (lack of oxygen
to the bowel tissues leading to tissue death)!
Normal Intussusception
Complication
Medical Emergency!
The most severe complications include perforation & peritonitis

where the bowels explode & infection settles into the peritoneal
cavity! This is a medical emergency as clients can go into sepsis
& die quickly
Signs & Symptoms
NCLEX TIPS
Intu ss usception
1. Stool: blood-streaked & mucus mix
“Currant jelly appearance”
MEMORY TRICK S ausage-shaped abdomnal mass
2. “Sausage-shaped” abdominal mass

S treaks of blood Intu SS usception
3. Vomiting (non-projectile)
with mucu S
4. Intermittent Pain!
Guarding
Crying & Drawing knees to chest
Peritonitis
5. Fever
6. Abdominal rigidity
7. Rebound tenderness
Treatment
Enema NCLEX TIPS BEFORE

1. Pneumatic (air) enema Primary intervention
HESI Question
Clear liquid diet Barium
2. Saline enema
… child with intussusception who is
3. Barium enema
scheduled for a barium enema prior to
“Clear liquid diet prior to procedure” a surgical procedure. What action
should the nurse take first?
GOAL
Place the child on a clear liquid diet
4. Passage of “normal brown stool”
= Report to HCP
360
Dental Care
Important Dental Care Milestones

2 NCLEX TIPS
The first dental visit is recommended within 6 months of the child’s first
tooth eruption or at least by their first birthday. 1. Initial dental visit: within 6 months
after the child’s first tooth
Teething is the process by which a baby's primary teeth erupt, or break 2. Risk of misaligned teeth happens
through the gums, generally occurring between 6 to 24 months of age.
when thumb sucking / pacifier use
Symptoms include irritability, tender and swollen gums, with drooling,
sucking more frequently & placing objects or fingers into the mouth in an AFTER eruption of permanent teeth
attempt to reduce discomfort.
HESI Question Teething
Saunders Question Q1: 6 month old infant … with drooling, Kaplan Question
sucking more often on the fingers, and
Which statement, if made by the mother, The 17-month-old client sucks the thumb,
biting on objects?
indicates a need for further instruction? especially at night … Which is an
Teething
“Proper dental care is not necessary appropriate suggestion by the nurse?
Q2: Relief for teething pain?
for the toddler until the permanent “Don’t intervene; it will subside. The
Give the child a cold teething
teeth erupt” behavior usually peaks at 24 months.”
ring to relieve inflammation
Dental Caries (Cavities) - Pathophysiology & Causes

Tooth enamel
Cavities are permanent damage to areas of the teeth, caused from poor dental hygiene,
sugary foods or drinks like candy, desserts & sodas. These sugary foods lead to a buildup of
slimy sticky plaque on the teeth where bacteria settle in to cause tooth decay.
Over time, plaque wears away protective tooth enamel resulting in cavities, these tiny
holes in the teeth can reach deep into the tooth to trigger the nerve pain!
Signs & Symptoms Education
Toothache: spontaneous mild or 8 NCLEX TIPS

sharp pain when eating or drinking Diet
something sweet, hot, or cold. 1. Sugar-free gum
2. Limit consumption of sweet, sticky foods
(soda, candy, & dried fruit)
Fillings & Root Canal 3. Whole grains & vegetables
4. Dairy: milk, yogurt, & cheese
Untreated cavities that result in tooth decay must be Routine
filled with a filling or a crown. Severe cases may need
5. DO NOT put infants to sleep with a
a root canal or total tooth removal.
bottle of milk or juice
6. Rinse mouth with water after meals
(when brushing is not available)
7. Brush & Floss at least twice a day
8. Drink tap water (fluoride)
HESI Question
Q1: Childhood dental caries:
Bottle of milk or juice at naptime
or bedtime predisposes the child
to this syndrome
Q2: Preventing dental caries in school
age children?
Brushing teeth after meals, after
snacks, and at bedtime
361
Dental Injury
Tooth Avulsion
Tooth Avulsion is a dental emergency where the tooth falls out or gets separated from
the gums! It's an emergency since the tooth can die if not reinserted to re-establish
blood supply.
Priority Action
Rinse & reinsert the tooth into the gum immediately to re-establish blood supply!
If the tooth cannot be re-inserted, it should be kept moist by submerging into cold milk,
sterile saline, or even saliva as a last line measure.
NEVER scrub the tooth as this can damage the root &
Priority Action NCLEX TIPS NEVER wrap the tooth in sterile gauze as this would dry
Don’t let the tooth out
1. Rinse the tooth
THE NCLEX TRICK YOU
2. Reinsert into the gingival HESI Question

R R R Actions: avulsed permanent tooth?
socket within 15 minutes & REMOVED RINSE REINSERT Select all that apply.
hold it in place tooth
Recover tooth
If tooth is dirty rinse under water
or saline
Insert tooth into gingival socket
and have child hold it in place
Oral Mucositis
Refers to open sores & ulcers inside the mouth, and is a very common complication of cancer treatment.
ATI Question
Warm saline
Oral mucositis: Which of the following
interventions should the nurse implement?
Offer the child a straw for drinking fluids
Provide a soft, disposable toothbrush
for oral care
Encourage gargling with a warm saline
mouthwash
Notes
362
_ _
Hematological Blood
363
Anemia Types & Iron Deficiency Anemia
Pediatrics: Hematological
Anemia Pathophysiology
Top Tested
Anemia is when the body lacks enough RBCs (Red Blood Cells) to carry oxygen 1. Iron deficiency Anemia
2. Sickle cell anemia
around the body to perfuse the tissues. Clients present with tired, fatigued & pale
3. Pernicious Anemia
skin, with shortness of breath and dizziness, as the body lacks oxygen.
Anemia Causes
NCLEX TIP
• Blood loss: surgery, trauma, excessive menstruation etc. Hemoglobin
• Chemotherapy & Immunosuppressants: which suppresses the bone marrow where the Normal: 12 +
RBCs are made. Bad: 8 - 9
• Lack of iron, B12 & other building blocks: like with iron def. anemia & pernicious anemia Less than 7 = Heaven
Iron Deficiency Anemia Fe

Fe Fe Fe
The body lacks iron (Fe) a critical building block to help make
RBCs - red blood cells. This is the most common form of anemia globally Fe
Causes Treatment
Kaplan Question
Infants & Children Rich in iron The nurse counsels a client
diagnosed with iron deficiency
1. Premature birth 1. Meat, Fish, Poultry anemia. The nurse determines
> 24 oz/day teaching is effective if the
2. Insufficient oral intake 2. Spinach “green leafy” client selects which menu?
& whole grains Select all that apply
3. Excessive intake of milk NCLEX TIP ● Flank steak & green leafy
vegetables
4. Preterm infants exclusively ● Liver & onions, spinach
bottle-fed with breast milk Infants & Children
Limit EXCESSIVE milk intake
5. Vegan diet NCLEX TIP
Iron + Vit. C
1. Fortified breads & cereals HIGH iron foods
2. HIGH iron foods with HIGH vitamin C
HIGH vitamin C
3. Calcium & Vitamin D Fe
Fe C
Fe Vitamin
Signs & Symptoms Pharmacology

HESI Question
Ferrous Sulfate (oral) Iron Dextran (IV / IM) A nurse is educating a patient
Dyspnea with iron deficiency on foods high
in iron. Which meal, if chosen by
the patient, demonstrates an
Pallor “pale skin” FERROUS
SULFATE
IRON
DEXTRAN understanding of iron-rich foods?
Grilled chicken thigh, sauteed
Tachycardia spinach, and whole grain bread
KEY POINTS ATI Question

ATI Question Q1: … toddler who has iron
Teaching to the parent of a
school-age child who has Dark or black stools = deficiency anemia. Which of the
following food choices... best
iron-deficiency anemia and a Normal & Expected source of iron?
new prescription for a liquid
iron supplement. Which of the
NOT GI BLEED ● 1 cup of diced chicken breast
Fe
Fe
Fe
Fe
Fe
following parent statements Q2: Which best describes why

indicates an understanding of Empty stomach infants are started on solid foods
the teaching?
1 HOUR BEFORE at about 5 to 6 months of age?
● I will administer this
medications ● The fetal reserve of iron is
medication using a straw depleted by this age
364
Epistaxis
Pediatrics: Nosebleed
Patho & Causes
Epistaxis is the medical term for a nose bleed, described as an acute hemorrhage from the
nostril, nasal cavity, or nasopharynx.
Typically caused from dry mucous membranes, like when exposed to dry air or elevation, and also
from trauma like nose picking or shoving a foreign body in the nose.
NOSEBLEED
or bloody nose
Interventions
4 NCLEX TIPS HESI Question

1. Sit up & lean forward Q1: Appropriate way to stop
an epistaxis?
2. Direct pressure below the ● Having the child sit up and
lean forward
nasal bone by pinching
Q2: Bloody nose... What actions
the nostrils will the nurse take?
3. Cold pack to the bridge ● Have the child pinch the
of the nose nose closed tightly
● Set the timer for 10 minutes
4. Keep calm & quiet
Notes
365
Sickle Cell Anemia & Pernicious Anemia
Sickle Cell Anemia

Normal Cell Sickle Cell
The RBCs have a distorted shape, transforming from a nice round plumb O2
shape to a skinny sucked in sickle shape. These misshaped RBCs die O2

O2
O2 O2
quicker than normal RBCs, carry less oxygen to the body & get clogged O2 O2
O2
O2
O2
O2
in tiny blood vessels - blocking or occluding the blood supply causing O2
O2
O2
O2 O2
O2
ischemia (low oxygen) to the organs. A vaso-occlusive crisis or
O2
“sickle cell crisis” can occur, causing extreme pain from the lack of oxygen!
Signs & Symptoms Complication Splenomegaly
Splenic sequestration crisis

One sided arm weakness Kaplan Question
Rapidly enlarging spleen
Swelling of the feet and Client experiencing a
vaso-occlusive crisis. The nurse Low blood pressure
hands (Dactylitis) determines care is appropriate
if which observation is made?
NCLEX TIP
● The client receives regular
neurological assessments Treatment ATI Question
New-onset paralysis of Hydration: IV fluids
A pediatric nurse is giving
instructions to a 12-year-old
extremities
client with sickle cell disease
Bed rest and his parents. To prevent a
crisis, the nurse explains that the
Pain Control NCLEX TIP
Sudden inability to be
child should do which of the
• PCA - patient control following? Select all that apply.
aroused analgesia pump

• Call the HCP for
● Stay away from sick children
● Increase fluids
● Be aware that high altitudes
Higher doses
may lead to a crisis
Pernicious Anemia
The body can not absorb B12, which is a vital building block to create RBC’s. HESI Question
Clients lack intrinsic factor in the GI tract, which helps the body take in B12. Which factor results from
pernicious anemia?
B12 The absence of intrinsic
B12
B12 B12
B12
factor secreted by the
gastric mucosa
B12

Kaplan Question Kaplan Question
Clinical manifestations • B12 - Injection: IM or IV Client diagnosed with pernicious
anemia asks why vitamin B12 cannot
of pernicious anemia? be given in pill form. Which response
• NOT orally (PO) by the nurse is best?
● Glossitis: A smooth,
Glossitis: EXAM TIP red tongue ● “Stomach doesn’t secrete the
necessary substance for B12
• Inflamed red smooth tongue to be absorbed orally.”
Extreme weakness HESI Question

HESI Question A client asks the nurse how long
A nurse is caring for a patient injections of vitamin B12 will be
Jaundice: “pale yellow skin” The nurse is caring for a patient with pernicious anemia needed. Which response by the
who reports extreme weakness
secondary to total gastrectomy. nurse is best?
and glossitis, and the nurse
identifies pale yellow skin. Which
The nurse would question which ● You may need lifelong injections
type of anemia does the nurse provider's order?
anticipate in the patient?
● Vitamin B12 supplement, PO
● Pernicious anemia
B12
B12
B12
B12 B12
B12
B12 B12 B12
B12
B12
B12 B12
B12
B12 B12
366
Hemophilia
Pathophysiology Hemophilia A
Hemophilia is an inherited bleeding disorder in which the blood cannot clot Lack of clotting factor VIII (8)
normally. Clients have an increased risk of excessive bleeding from small Hemophilia B
injuries like a paper cut or a fall on the ground.
Lack of clotting factor IX (9)
Clotting factor VIII Clotting factor IX
HESI Question
A nurse is caring for a patient diagnosed
with hemophilia A. The nurse knows this
type of hemophilia is caused by an absence
of which clotting factor?
Hemophilia A Hemophilia B • VIII
Signs & Symptoms

HESI Question
A nurse is caring for a patient with
hemophilia. Which concerns
Pain, Bruising, & Petechiae would be expected on the nursing
care plan?
Ineffective tissue perfusion Select all that apply.
Joint stiffness & Pain

Anxiety
Lack of mobility Deficit of fluid volume
Ineffective tissue perfusion
Treatment Kaplan Question

Q1 Client with hemophilia develops painful
swelling of the knee after bumping the
leg... which initial action is most
AVOID Injections: IV, IM, SQ appropriate for the nurse to take?
Apply ice to the knee and
Administers coagulation elevate the leg
replacement factors Q2 The nurse reviews the medical record for

4 hr
a client diagnosed with hemophilia. It is
Ice packs & most important for the nurse to question
Meperidine
Elevate the affected area which entry?

Meperidine 75mg IM q 4 hr
for severe pain
Education
4 NCLEX TIPS Vaccinations

1. Wear a medical alert
bracelet at all times
2 NCLEX TIPS
2. Avoid giving the child 1. Admin vaccines via
over-the-counter aspirin subcutaneous route
The big bleed risk with the smallest needle
3. Noncontact sports: 5
min
swimming, jogging 2. Hold pressure on the

injection site for
4. Joint destruction =
5 minutes or more.
long-term complication
367
Thrombocytopenia
Pathophysiology Platelets ≤ 150,000
Normal: 150,000 - 400,000

Thrombocytopenia: Thrombocytopenia
Thrombocytopenia occurs when clients have low platelets. 150,000 or less 100,000 ≤ 50,000
100,000 = MAJOR RISK

50,000 or Less = DEADLY
Thrombocytopenia Thrombocytopenia
Signs & Symptoms

HESI Question
Huge risk for hemorrhaging, like a ticking time bomb.
Any small bump or fall will cause major bleeding Which sign is observed in the
• Bleeding gums patient with thrombocytopenia?
• Tachycardia Petechiae Petechiae
• Petechiae (Tiny red brown-purple spots on the skin)
Causes Complication
Bleeding - Huge risk for injury, like a ticking

Immunosuppressants time bomb
Liver disease (Hep. / Cirrhosis)

PRIORITY
ITP - Immune Kaplan Question
thrombocytopenia purpura
NCLEX The nurse cares for a client diagnosed
with immune thrombocytopenia purpura.
Which nursing diagnosis is a priority
when caring for this client?
Interventions
Risk for injury
P P
Platelets Less than 100k HeParin AsPirin
ASPIRIN
The NCLEX will give lab values & ask for priority action!
Hold the P’s THINK: what KILLS the patient first!
HeParin
P P Immunosuppressants
Labor & Epidural Cirrhosis
AsPirin CloPidogrel EnoxaParin & Surgery
CloPidogrel Exhibit Exhibit Exhibit
Laboratory result Laboratory result Laboratory result

EnoxaParin
CLOPIDOGREL
WBCs 3,000 Blood group A+ Albumin 2.7 g/dL
Notify the HCP 1

Hemoglobin
Platelets
9.5 g/dL
68,000
Rh factor
WBCs
Negative
18,000
Bilirubin
Platelets
Platelets
Negative
45,000
45,000
Obtain vital signs ?

Platelets 75,000 Ammonia 125
78 BPM
120/80
98% 24 RPM
98.6 F
Teaching
1. Look for the most critical lab!
All are less than 100,000, but cirrhosis is the lowest -
less than 50,000.
NO Razors 2. It’s your JOB as a nurse to SAVE LIVES!
NO NSAIDS over the counter NSAIDs The NCLEX will make sure you do.
3. This is why you MUST know your numbers.
368
_ _
Immunization Dates
&
Types
369
Immunization - Dates & Types
Pediatrics: Infectious Disease
Basic Concepts
Immunizations, also called vaccines, are little doses of big dangerous viruses. It helps ATI Question
the body develop early immunity, so that it can form a defense system early in age. Communicable diseases...
Immunizations are given to children, as the primary means of protecting the body best primary prevention
against deadly communicable diseases like: strategy?
● Obtaining scheduled
immunizations
• Polio,
• Hepatitis,
HepB
• Pneumonia, DTaP
Hib
• Varicella, IPV
• Measles, RV
PCV13
• Mumps, Flu
MMR
• Rubella (MMR) Varicella
HepA
Top Tested Key Points
NO LIVE Vaccines! Low Immune System

• Varicella-zoster (chickenpox) NCLEX TIP • Cancer: Leukemia, Lymphoma etc. NCLEX TIP
• Influenza (flu shot) • Chemotherapy & Radiation
• MMR: measles, mumps, rubella • Immunosuppressants (Methotrexate)
• Rotavirus • IVIG (immunoglobulin therapy)
Side Note: Pregnant clients too
Varicella Influenza
*Pregnant mothers don't have a low immune system

Methotrexate
but we don't give any live vaccines
MMR Rotavirus IVIG
vaccine
Top Missed NCLEX Questions Saunders Question

The nurse should clarify with the provider before administering which vaccination? child receiving long-term
Varicella-zoster immunosuppressive therapy…
vaccine for client which vaccine is contraindicated? MMR
vaccine
recently diagnosed ● MMR
with leukemia
HESI Question
Contraindicated for children
who are immunocompromised?
Varicella Select all that apply.
● Varicella Varicella
● Measles, mumps, and

rubella (MMR)
Reaction After Vaccination ATI Question

Six month old infant scheduled for routine
immunizations ... fever of 103 degrees… nurse’s
Common Severe! BEST response is to:
(expected) (NOT expected) ● Advise the parent to have the child seen by
the pediatrician but the immunizations will
• Mild fever NCLEX • Fever above 102 F (38.9 C) NCLEX need to be postponed until the baby is well
• Redness & swelling at injection site • Febrile seizures!
Saunders Question
(Apply cold pack to site) Ask parents calling in: >102ᴼF
Side NOTE: “What is your child’s temp right now?”
Vaccine
If the client has a common cold/minor illness? Administer acetaminophen The student should question whether to administer
Yes still give vaccine TEST TIP Over 102 immunizations to a child with which condition?
● A severe febrile illness
Vaccine
HESI Question
Varicella and measles, mumps, and rubella
(MMR) vaccines?
Vaccine ● Children can be vaccinated when they have
the common cold
370
Immunization - Dates & Types II
Immunization Schedule
Organized by Organized by
Vaccine Age
Immunization Age of child Age Memory Trick Immunization
HepB 0, 2, 6 months Birth Hep B at Birth Hepatitis B (HepB) 0,2,6 months ATI
Hepatitis B (0, 1-2 months, 6-18 months) ATI 0, 1-2 months, 6-18 months
HESI Questions
12 year old child who has not received the hepatitis B vaccine?
2 months B DR. HIP
B Hepatitis B (HepB) 0,2,6 months
● The three-dose series would be started at this time
D DTaP Diphtheria-Tetanus-Pertussis
RV
Rotavirus
2, 4, 6 months R RV RotaVirus
IPV 2, 4, 6 months H Hib Haemophilus influenzae type B
Inactivated Polio Vaccine 4 - 6 years I IPV Inactivated polio vaccine
PCV
Pneumococcal Vaccine
2, 4, 6, 12 months P PCV Pneumococcal vaccine
Hib 2, 4, 6, 12 months 4 months DR. HIP Same 2 months

Haemophilus influenzae type B (no Hep B) Memory Trick “I FOUR-got the Hep B”
DTap 2, 4, 6, 12 months 6 months B DR. HIP Same as 2 months B DR. HIP

Diphtheria-Tetanus-Pertussis 4 - 6 years TOP TESTED Flu · Influenza (flu shot) 1st dose
Kaplan Questions 12 months MAD HPV

M MMR (1 & 4 years)
6-month old infant … at 2 months of age received the first DTaP. (1 year)
Which action by the nurse is most appropriate?
● Give second DTaP A Hepatitis A 2 doses by 2 years (6 mo. btwn doses)
Influenza Begins at 6 months

D DTaP
Flu shot & Annual flu shot there after H Hib
MMR
Measles, Mups, Rubella
1 & 4 years (12-18 mo. & 4-6 yrs.) P PCV
VAR V Varicella (1 & 4 years)

1 & 4 years (12-18 mo. & 4-6 yrs.)
Varicella
4 - 6 yrs. Very DIM
HepA 1 - 2 years (6 mo. after 1st dose) VERY Varicella (1 & 4 years)
D
Hepatitis A 2 Doses by 2 yrs old
DTaP (2,4,6,12 mo. & 4-6 yrs)
HPV 9 - 12 years (Boys & Girls)
Human Papillomavirus I Influenza & IPV “polio” (2,4,6 mo. & 4-6 yrs)
HESI Questions
HPV vaccine is to prevent what?
M MMR (1 & 4 years)
● Cervical cancer
11 - 12 yrs. MITH Meningitis, Influenza, TdaP, HPV
MCV 11 - 12 years
Meningitis “Meningococcal” 16 - 18 years booster 16 - 18 yrs. Men Flu Meningitis booster & Annual flu shot
Immunization Allergy / Adverse Effect

Any client who has had an allergic reaction
Influenza to neomycin will probably have a reaction
Allergic reaction to eggs HESI
Flu shot to MMR & polio vaccine.
MMR Prior allergic reaction to neomycin HESI
Measles, mumps, rubella Adverse effect: Arthritis Kaplan
ANTIBIOTIC
HepB
Hepatitis B
Prior anaphylactic reaction to yeast ATI
IN
MMR IPV
NEOMYC vaccine
IPV NEOMYCIN
Inactivated Polio Vaccine

Prior anaphylactic reaction to neomycin Saunders
Notes
371
Immunization - Dates & Types III
Immunization Age of child Immunization Age of child

HepB 0, 2, 6 months Influenza Begins at 6 months
Hepatitis B (0, 1-2 months, 6-18 months) ATI Flu shot & Annual flu shot there after
HESI Question
12 year old child who has not received the hepatitis B vaccine?
● The three-dose series would be started at this time
Influenza DTaP
Hepatitis B
Hepatitis B Hepatitis B Hepatitis B
6 months
RV 2, 4, 6 months MMR 1 & 4 years (12-18 mo. & 4-6 yrs.)

Rotavirus Measles, Mups, Rubella
2 months 4 months
Rotavirus MMR
vaccine
6 months 12 months 18 months 4 yrs. 6 yrs.
IPV 2, 4, 6 months VAR 1 & 4 years (12-18 mo. & 4-6 yrs.)
Inactivated Polio Vaccine 4 - 6 years Varicella
2 months 4 months
Varicella
IPV
6 months 4 yrs. 6 yrs. 12 months 18 months 4 yrs. 6 yrs.
PCV 2, 4, 6, 12 months HepA 1 - 2 years (6 mo. after 1st dose)

Pneumococcal Vaccine Hepatitis A 2 Doses by 2 yrs old
Rotavirus Hepatitis A Hepatitis A Hepatitis A Hepatitis A
2 months 4 months 6 months 12 months

6 mo. 2yrs
Hib 2, 4, 6, 12 months HPV 9 - 12 years (Boys & Girls)

Haemophilus influenzae Human Papillomavirus HESI Question
type B
HPV vaccine is to prevent what?
● Cervical cancer
2 months 4 months
HPV
Vaccine
HiB
HPV
Vaccine
6 months 12 months
DTap 2, 4, 6, 12 months MCV 11 - 12 years

Diphtheria-Tetanu 4 - 6 years TOP TESTED Meningitis “Meningococcal”
16 - 18 years booster
-Pertussis
Kaplan Question
6-month old infant … at 2 months of age received the first DTaP.
Which action by the nurse is most appropriate?
● Give second DTaP
MCV
DTaP Vaccine
DTaP DTaP
9yrs 12yrs 16yrs 18yrs
372
Injections & Safe Med Admin
4 Key Points Injections can be downright SCARY

for anyone, especially children!
Be sure to follow the 4 key points outlined.
1. Communication
Use simple, age-appropriate language
& tell the truth!
“This medication will
NCLEX TIP
go under the skin”
“The skin may sting for a few minutes”
2. School age (6 - 12 yrs) fear loss of control
Ask these children to count The skin may sting
NCLEX TIP for a few minutes.
out loud during injection
1, 2, 3,...
3. Encourage caregiver to hold child during
injection (on lap or in arms)
4. Hiding procedural objects:
Appropriate: Toddlers (1 - 3 yrs)
NOT appropriate:
NCLEX TIP
School Age (6 - 12 yrs)
SQ - Subcutaneous
Saunders Questions
Q1: MMR vaccine to a 5 year old child.
• Subcutaneous fat tissues: Abdomen, behind arms, interior thigh.
The nurse should administer this
• 25-30 gauge needle, less than 0.5 ml vaccine by which method?
Subcutaneously in the outer
aspect of the upper arm
25-30 Q2: Correct sequence of priority.

All options must be used.
1. Verify prescription
2. Assess for allergies
0.5ml
3. Obtain parental consent
4. Check expiration & lot number
5. Select appropriate site &
administer vaccine
6. Provide vaccination records to
the parents
IM - Intramuscular
• 22-25 gauge, 1-1½ inch length

• Vastus lateralis, gluteal, or deltoid Infants (0-12 months)
vastus lateralis is the recommended site
22-25
1-1½ inch
ATI Question
90o
intramuscular injection to a 6 month
old child. Which site should be used?
Vastus lateralis
373
_ _
Infectious disease
374
Airborne vs. Droplet Precautions
Droplet Airborne
P - Pertussis M - Measles
I - Influenza T - TB (Tuberculosis)
P - Pneumonia

3. Door closed
surgical mask
to wear a mask
Top Missed Exam Question

When caring for a patient with bacterial
meningococcal meningitis, the nurse implements
which of the following?
MEMORY TRICK Select all that apply
• On AIR with MTV
• ‘’PIMP my ride’’ the old show like 1. Advise unlicensed personnel to wear surgical mask
DROPping lowrider 2. Implement padded side rails
3. Keeps light & noise low in room
4. Places patient to negative pressure room
5. Puts on N-95 mask before entering room
ON AIR
375
MMR (Measles, Mumps, Rubella)
Measles - Pathophysiology 2 hours
Measles is a very contagious viral illness that is spread via the air.
When an infected person sneezes or coughs, it projects the virus into the
air or on surfaces, where it can remain for up to 2 hours!

Manifestations typically don’t appear until 7 to 14 days
after exposure. They include: NCLEX TIPS
- Cough 1. Airborne precautions:
- Runny nose Negative-pressure isolation room
- Inflamed eyes N-95 mask (staff)
- Sore throat Door closed
- Fever 2. Recommend measles vaccine for
- Red, blotchy skin rash exposed family members After 12 months
3. Vitamin A = decreases risk of death 4-6 years
DON'T let the NCLEX trick you! 4. Vaccination

6 months
NOT itchy pruritic rash, this is typical of varicella 1st dose: 6 months old
(chickenpox) 2nd dose: After 12 months old
3rd dose: 4 - 6 years 1st 2nd 3rd
7 - 14 days
Saunders Question TOP Missed NCLEX Question

N95
An infant less than 12
… measles. Which supplies.. to prevent months old, who is not yet
transmission of the virus? vaccinated with MMR is
N-95 Mask and gloves exposed to measles, what is
the most appropriate action
by the nurse?
MMR
After 12 months
Recommend parents to
HESI Question
vaccine
6 months
bring the child in to get
measles vaccination? the measles, mumps,
rubella (MMR) vaccine 72 hours
First dose of measles vaccine is given
at 6 months, with a second one after
12 months of age
1st 2nd
MMR Immunization Consideration

Kaplan Question
HESI Question Adverse effect most often identified
Which vaccine ... to avoid because of with measles, mumps, and rubella
risk of allergic reaction from neomycin? MMR (MMR) immunizations?
vaccine
MMR Arthritis
Notes
376
Pneumonia
Pathophysiology
Memory Trick
Infection that causes severe inflammation in the lungs which makes the
alveoli to fill with mucus, fluid, & debris leading to impaired gas exchange P P
where CO2 can't get out & oxygen now can’t get IN, resulting in hypoxia
PNEUMONIA PLAGUE OF
(low oxygen). THE INFECTION
O2 CO2
in out
Impaired
gas exchange
Signs & Symptoms KAPLAN

Pleural friction rub?
1. Altered Mental Status
Grating sound or vibration heard
Restlessness, Agitation, Confusion during inspiration and expiration
2. Fever (Over 100.4 F/ 38oC)
3. Productive cough “Yellow Sputum”
4. Fine or Coarse Crackles
Common NCLEX Question KEY TERM
Big Sign
5. Dyspnea “Shortness of Breath” 0₂
Priority Patient: who to see first? 0₂

0₂
REPORT 0₂
₂
6. Pleuritic Chest pain HCP
1
(Pleural friction rub) Report to HCP Post-operative patient with suspected

pneumonia temp. of 98.2F, SpO2 94%
“Sharp chest pain upon inspiration ... becoming restless & agitated.
or coughing”
3. Septic Shock
1. Pleural Effusion NCLEX TIP
If the infection gets severe, the body releases chemicals
Fluid that fills the pleural space (space between the into the bloodstream to fight the infection resulting in
lung itself & the chest wall). This prevents full expansion severe low blood pressure & total body inflammation
of the lung, resulting in decreased gas exchange. which can damage multiple organs causing them to fail,
known as MODS - multiple organ dysfunction
KEY SIGNS syndrome.
1. D - During inhalation = Chest pain
Priority to report
● Asymmetrical Chest Expansion MEMORY TRICK
2. D - Dyspnea
3. D - Diminished breath sounds ● Decreased Breath sounds S - Shock
4. D - Dull resonance on percussion S - Severely Low BP & perfusion
2. ARDS (acute respiratory distress syndrome) Key signs

< 90 Systolic
Hypotension NCLEX TIP
Deadly STIFF lungs - ARDS - think HARDS hard stuff lungs. 88
Systolic < 90 mm Hg
? ?
? MAP < 65 mm Hg
0₂
0₂
0₂
0₂ KEY SIGNS ? ?
? Cap refill over 3 - 4 seconds
Refractory Hypoxemia = Low PaO2
MEMORY TRICK Tachycardia
REsistant to Oxygen Early - Fever (Over 100.4)
REfractory Hypoxemia
Late - Hypothermia (Under 96.8)
#1 Sign of Low O2 = Altered Mental status
0₂
1. Confusion
Elevated WBC (norm: 10,000 or less)
0₂
0₂ Decreased Urine Output

0₂
0₂
2. Agitation
3. Restlessness 30 ml/hr or Less = Kidney Distress
377
TB: Tuberculosis
Pathophysiology
• Bacterial infection in lungs caused by the bacteria M. Tuberculosis

• Spread via the air, once inhaled it enters the lungs & spreads to
the lymph & blood stream.
Signs & Symptoms

ATI
Precautions for a patient with suspected
tuberculosis (TB)?
KEY POINTS Airborne precautions
Night Sweats
HESI Question
Anorexia: Weight loss
First action for a patient with night sweats,
Cough + Hemoptysis weight loss, hemoptysis, fever and chills.
“Blood tinged sputum” NCLEX TIP Airborne precautions
Dyspnea & SOB
Fever & chills KAPLAN
Client with anorexia, low-grade fever, night
sweats and a productive cough.
Memory Trick Priority action: Initiate airborne precautions.
T Terrible cough “blood tinged”
B Bad infection:
Fever, night sweats, weight loss
Diagnostics
• Intradermal injection (mantoux test) requires

a 2 to 3 day window for reading. HESI Question
Most accurate description of tuberculosis (TB)?
Over 15 mm induration Patient has a “Most people who become infected with the
TB infection TB organism, do not progress to active disease”
= positive TST
• Chest X-ray & sputum cultures test for

active form.
Key point KAPLAN

Route of administration for Mantoux test?
Intradermal
Sputum Culture Diagnosis
Early morning sterile
sputum specimen
3 consecutive days
ATI
Sputum cultures are taken until 3 negative
cultures
Pharmacology (see pharmacology TB study guide) Family members should be tested for TB
378
Conjunctivitis
Conjunctivitis, also called pink eye, is the inflammation or infection of the conjunctiva
(the transparent membrane that covers the white part of the eyeball).
Signs & Symptoms

Red, itchy, swollen - affected eye
A gritty feeling & even purulent discharge

in one or both eyes that forms a crust.
Causes HESI Question

Which agent would
• Viruses produce purulent
• Bacteria discharge from the eyes,
• Allergies crusting and swollen
eyes in a child?
Pink eye common In newborns, a blocked tear duct leads to a buildup
● Bacteria
of bacteria.
Treatment
Prevent Transmission
� Wash hands before and after HESI Question
eye drop instillation NCLEX TIP
instruct the parent ... child who
has bacterial conjunctivitis?
tic
io
tib
An
Wipe from the inner

Medication canthus downward and
Bacterial conjunctivitis: Antibiotics outward away from the
� Sulfacetamide HESI opposite eye
� Fluoroquinolones (Levofloxacin)
Allergic Conjunctivitis
� Steroids
� Antihistamines
Notes
379
MMR (Measles, Mumps, Rubella) II
MUMPS - Pathophysiology Simplified & organized according to the MOST tested topics.
Salivary
glands
MUMPS are viral infection that affects the
MMR
salivary glands, so the disease spreads through vaccine
infected saliva.
Signs & Symptoms

Asymptomatic
Flu like symptoms -
• Fever
• Muscle pain
• Poor appetite
• Painful swelling of salivary glands
Some clients can present asymptomatic

(without symptoms).
Treatment
Treatment focuses on symptom relief, as there are no specific antiviral
medications used.
Teach clients to eat soft foods & encourage fluids, AVOID fruit juices,
as they stimulate production of saliva.
AVOID
Recovery takes about two weeks. The disease can be prevented by the MMR vaccine.
Rubeola & Rubella - Pathophysiology
Rubeola & Rubella, called German measles, both viral infections that spread via
the airborne route, when a person comes in direct contact with saliva or mucus
of an infected person.
2 - 3 weeks
Symptoms often appear two to three weeks after exposure.
Kaplan Question
Runny, stuffy nose, sneezing, Which signs or symptoms of rubeola are
& cough exhibited before the appearance of the rash?

Runny nose, sneezing, and coughing
High Fever
ATI Question
Koplik Spots: Symptoms of rubeola generally include:
Rash on mucus membranes A high fever and Koplik spots in
the mouth
Interventions
MMR Vaccination
IBUPROFEN
No treatment
Vitamin A
NAPROXEN
(established infection)
380
Pneumonia II
Risk Factors & Causes Diagnostics

1st
• Elevated WBC - white blood cell count CULTURES
#1 - Advanced AGE • Over 10,000

Over 65 years old • Sputum Culture = Positive
>65
VAP - “Ventilator Associated TEST TIP Cultures are always taken first -
Pneumonia” BEFORE antibiotics
1. Reposition side to side Q 2 hours • Think A - Antibiotics A - AFTER cultures, in
order to identify the causative bacteria.
2. Oral Care & Suctioning Q 2 hours
3. Chlorhexidine Common NCLEX Question
Best indicators of VAP NCLEX TIP
2 Best indicator of ventilator
positive sputum culture
hrs
associated pneumonia (VAP) ?

Fever Positive sputum culture
Chest X-ray: new infiltrates
Best blood lab value shows effective
treatment of pneumonia after IV
• Prolonged immobility - secretions are not mobilized antibiotics?
& get stuck in body TED
White blood cell count ELEVA
• Post-Operative - Anesthesia - the body is put to sleep
which traps infection in the lungs
Patient Care HESI

Encourage 3L of fluid intake per day
Mobilize secretions & Expand Lungs
to promote expectoration
Chest physiotherapy
TCDB - turn cough & deep breath!
Huff coughing technique
NCLEX TIP Discharge Teaching
AVOID cough suppressants
Fluid 2 - 3 L per day Mobilize Secretions
Positioning
HOB UP! High Fowler’s Avoid cough suppressants
Hypoxia in Unilateral Pneumonia? Antitussives: Codeine
= Good Lung Down NCLEX TIP
Cool mist humidifier at night
Increase Fluid
Common Exam Questions
Re-expand Alveoli
IS - Incentive spirometer at home
Prevent Reinfection
Finish oral antibiotics at home
Pneumonia vaccine (Every 5 years)
Early ambulation
Smoking cessation
(within 8 hours after surgery)
Cough with splinting
8
hrs
Handwashing
Handwashing Schedule follow up & Chest X-ray
Mouth Care Q 12 hour Report: increased or worsening
IS IS
Chlorhexidine swab INCENTIVE INCREASE SIZE
Fever
Confusion
SPIROMETER OF THE ALVEOLI
Incentive Spirometer Q Hour O2 CO2
SOB, cough, sputum

in out
GIVE Pain Meds
381
TB: Tuberculosis II
5 TB Tips
MEMORY TRICK
5 NCLEX TIPS
1. Meds Last 6 - 12 months ALL are LIVER TOXIC!!!!

2. N-95 mask worn all the time So some instructors just use the acronym:


(pyridoxine)
1. NORMAL - Low Vitamin B6 = Peripheral Neuropathy
Teach: N - Neuropathy
REPORT:
to discoloration of tears NCLEX TIP - Tingling extremities
- Ataxia
“Use non-hormonal
H - Hepatotoxicity
REPORT Immediately!!!
Back-up birth control” - Jaundice (yellow) Skin / Sclera
- Dark urine NCLEX TIP
HOLD the Med
- Teach: NO ETOH!!
ETHAMBUTOL - Eye
KEY POINT:
REPORT!
PYRAZINAMIDE • Blurred vision
Did not come up 1 x in 10,000 questions. • Color changes

382
Mononucleosis & Fifth Disease
Mononucleosis - Pathophysiology
Mono is spread via saliva, by sharing drinks or even kissing so it's often called the kissing disease.
Caused by the Epstein-Barr virus. When introduced into the oropharynx, the virus spreads through the
lymphatic system & becomes a lifelong infection, with periodic reactivation.
HESI Question
Mononucleosis?
Kissing disease
Epstein Barr virus is the principal cause
Epstein-Barr virus
Signs & Symptoms
Fatigue
Fever
Sore throat
Spleen
Deadly complications
Swollen lymph nodes
Airway obstruction “Stridor”
Splenomegaly (big spleen)
Abdominal pain = Splenic rupture
Hepatomegaly (big liver) Splenomegaly
Treatment
ATI Question
NO antibiotics NCLEX TIP
mononucleosis. Which of the
Rest
ANTIBIOTIC
following statements .. indicates an

understanding? Select all that apply.
Increase fluid intake I should drink plenty of liquids
Avoid strenuous activity I should avoid playing football
while I am sick
& contact sports I should rest often
Fifth Disease - Pathophysiology Signs & Symptoms Treatment
This is a viral infection that is a common, Since it is a virus, antibiotics can

highly contagious childhood illness. Red rash on the cheeks NOT be used, and the infection
Joint pain usually goes away on its own.
Encourage rest & increased fluid
Caused by human parvovirus Key Point & NCLEX TIP intake.
(HPV-B19) NCLEX TIP Once the rash & symptoms appear
- the child is NO LONGER infectious!
HESI Question
Which causative agent is responsible for ANTIBIOTIC
... fifth disease?

Human parvovirus B19
383
Pertussis (whooping cough)

HESI Question
Pertussis is a very dangerous respiratory tract infection spread via droplets. Which mode of
Droplet
It is caused by the pertussis bacteria, which attach to small hairs in transmission of Route
pertussis (whooping
the airway causing swelling, making it particularly dangerous for infants, cough) is common?
as airway structures are smaller and easily obstructed. • Droplet
Signs & Symptoms

This coughing is often violent & uncontrollable, ATI Question
making it hard to breathe & becoming very deadly
Pertussis…
for infants if untreated.
Spasmodic cough manifestations should
the nurse expect?
“Whoop” (seal bark) Other symptoms include: Select all that apply.
• Mild fever, • Coughing spasms
Coughing spasms • Runny nose also called Rhinorrhea, • Rhinorrhea
• Nasal congestion, • Fever
• Red, watery eyes
Don’t let
NCLEX TRICK YOU DO NOT give cough suppressants!
The goal is for the client to cough up
the mucus. Suppressing the cough
may cause airway obstruction.
Diagnostics Treatment
• Nose or Throat culture
• Blood Tests NCLEX TIPS
1. Put client on droplet precautions
� Staff: surgical mask & goggles
� Single private room
(NOT neg. pressure room = airborne)
2. Assess & monitor for airway obstruction
Blood Test
3. Antibiotics: azithromycin
4. Humidified oxygen, suction airway
& give small amount of fluids frequently
Notes
384
RSV (Respiratory Syncytial Virus)
Pathophysiology
RSV is a very contagious viral infection that affects the respiratory tract, specifically the
bronchioles, and usually infects most children before their 2nd birthday.
RSV is spread via droplets. Children typically get the virus from being coughed or sneezed
on from other infected children.
Risk Factors & Causes
Respiratory or Respiratory or
Premature babies Very young infants Congenital heart defects
Neuromuscular disorders Neuromuscular disorders
<6 months of age
Signs & Symptoms
It looks just like a cold or respiratory infection

• Runny nose
• Dry Cough
• Sore Throat
• Low-grade Fever <100.4 F
• Wheezing
• Nasal flaring
• Short, shallow, and rapid breathing
Complications Airway is always #1 PRIORITY!

PRIORITY
Removing secretions from the nose is critical before
Key terms bed & before feedings.
Bronchiolitis due to RSV
Don't let the NCLEX Trick you!
Use drops of saline & a bulb syringe Airway is always a priority. SALINE
to suction nose NCLEX TIP NOT giving medications & do not stop breastfeeding
the baby, since fluids are needed to prevent dehydration
during the illness.
Pharm & Education

ATI Question
Medication: palivizumab HESI Question

Preventing the transmission of respiratory
syncytial virus (RSV). Which of the following
should be included in the teaching?
Palivizumab. What is the purpose of
this medication?
Prevent respiratory syncytial virus Spread by direct contact
(RSV) infection Spread by indirect contact
Palivizumab Frequent hand washing helps reduce the
spread of RSV
385
Rotavirus & Roseola
Rotavirus - Pathophysiology MOST COMMON
Rotaviruses are the most common cause of diarrheal disease among children.
Nearly every child in the world is infected with a rotavirus by the age of five.
The primary mode of transmission is the fecal-oral route, by scratching the

anus & putting fingers in the mouth.
Signs & Symptoms

PRIORITY
HESI Question
Diarrhea & Vomiting
Rotavirus ...causing severe diarrhea is admitted
Dehydration: NCLEX TIPS
for treatment. Which action should the nurse
Decreased urinary output take first?
Dry Mucous membranes Insert an IV line and begin IV fluids
Orthostatic hypotension
Education
Teaching has been effective?
NCLEX TIPS
1. “Handwashing is extremely important”
2. “I will monitor my child for a decrease in
urinary output & dry mucous membranes.”
3. “The infection can spread with contaminated
hands, toys, and food.”
Roseola - Pathophysiology
This is a viral illness most commonly affecting kids between 6 months and Saunders Question
2 years old. It is spread via respiratory secretions & saliva.
Child with roseola… prevention of the
transmission to siblings:
Avoid allowing the children to share
MOST COMMON drinking glasses or eating utensils
6 -24 months of ages because the disease is transmitted
through saliva

• Bed rest,
High fever followed by drop in temp. • Fluids,
Rash
• Medications to reduce fever.
ATI Question
Most common characteristic finding of roseola?
High fever followed by a drop in temp., and
then a rash
386
Scarlet Fever & Scabies
Scarlet Fever - Pathophysiology
This is a complication that develops from streptococcal pharyngitis Streptococcal pharyngitis

(strep throat infection) in the back of the throat. This nasty strep
infection can travel down to the kidneys & cause renal issues like
(strep throat)
glomerulonephritis & cardiac issues like rheumatic fever.
Bright Red pruritic rash:chest & neck Streptococcal Pharyngitis

“Looks like sunburn” 3 NCLEX TIPS
“Sandpaper rash”
Strawberry tongue (red & bumpy) 1. Complete all the antibiotics even if
feeling better
2. Cool liquids & soft diet
Diagnostics 3. Replace toothbrush 24 hours after starting

Key term antibiotics
NEW
Rapid streptococcal
antigen test NCLEX TIP Rapid streptococcal
antigen test
50% 24
hrs
Scabies - Pathophysiology
!
Scabies is a highly contagious infestation of little bugs or mites that tunnel
down into skin, causing massive irritation & itching. These little mites lays eggs
under the skin where the infestation spreads and become highly contagious.
Signs & Symptoms

HESI Question
Severe Itching
The mother of a 1 year old states “Look at
Thin, irregular burrow tracks
those red raised areas all over my baby!
Infants & children - Common sites What could they be?” … next nursing action?
Scalp Ask, “Has the baby been around anyone

with scabies?”
Palms & soles of the feet 1 year old
Behind the knees
Treatment
TOP tested ATI Question
4 NCLEX TIPS NCLEX 2 year-old diagnosed with scabies, which of the
following points should the nurse include?
Education The entire family should be treated
1. All people in close contact with the patient
needs treatment Permethrin
2. Wash the clothing and bedding in hot water
3. Non washable belongings = sealed in bag
NIX
for over 3 days
Pharmacology
4. Put Permethrin Cream on all skin surfaces TREAT
387
Varicella (Chickenpox)
Pathophysiology
Varicella is a highly contagious viral infection that is spread via the air. HESI Question
It causes an itchy, blister-like rash on the skin, typically seen in school aged
children. contact and airborne isolation precautions
for a child with which illness?
Chickenpox
It is caused by the varicella zoster virus, the same virus that causes shingles
in adult clients. It is spread from contact with skin lesions or the respiratory
tract. Therefore, airborne precautions are used, including:
ON
VERY COMM
- N95 mask, gloves, & gown
- Placing the client in a negative pressure room.
Signs & Symptoms

HESI Question
Skin lesions Which disease presents with fever, malaise,
and a highly pruritic rash that started as a
Pruritic rash (itchy) papule and became a vesicle?
Papules and vesicles Varicella
Weeping
Crusts over within 7 days
(no longer infectious) NCLEX TIP
Fever
Malaise
Treatment ATI Question

KEY TERM Interventions for healthy children … who develop
chickenpox? Select all that apply.
NCLEX TIPS Diphenhydramine
NOT Contagious Application of mittens
1. Stop the Itch: Lesions Crust over
Apply topical diphenhydramine cream Kaplan Question
to lesions after shower & bath chickenpox: The nurse determines that teaching
is effective if the parent makes which statement?
2. Acetaminophen (brand: Tylenol)
“My child can return to school when the lesions
NO Aspirin = Reye syndrome risk are crusted.”
3. Immunocompromised clients SAUNDERS Question

Acyclovir (antiviral) Mother… asks the nurse if the child is infectious
NO “Live vaccines” (Varicella Vaccine) to the other children? Which response is most
appropriate?
4. No longer infectious The infectious period begins 1 to 2 days before
AFTER the lesions have CRUSTED over! the onset of the rash and ends about 5 days
after the onset & crusting of the lesions
Immunization Key term: After a varicella immunization (chickenpox shot), be sure to

cover the vesicle with a bandage until completely dry or crusted over!
Key term This is done to reduce the risk of transmission from any pus or fluid
that may leak out.
Cover the vesicles with a small band-aid
until they are completely dry Normal side effects after immunization include discomfort, redness, &
even presence of a few vesicles at the injection site. This is very common
& completely normal. NO need to alert the HCP.
388
_ _
Integumentary skin
389
Acne
Pediatrics: Integumentary
Pathophysiology
Acne is a common skin disorder where obstructed

sebaceous glands within the skin results in
blackheads & white heads. When bacteria settles in,
it can cause inflammation resulting in pustules & papules.
Causes & Risks
• Puberty & pregnancy (explosion of hormones)

• Bacteria overgrowth
• Genetics
• Stress
Education
AVOID: NCLEX TIPS

Vigorous scrubbing / washing
Squeezing or picking lesions HESI
The nurse is teaching .. interventions to
Antibacterial soap maintain healthy skin. Which teaching does
Smoking the nurse include?
Wash hair & skin frequently “gently” Refrain from smoking any tobacco
Apply Wash your hair and skin frequently
Apply moisturizer after showering
Moisturizer
Drink eight glasses of water per day
Skincare products “non-comedogenic”
Diet:
“well balanced”
Fluid intake: 8 glasses of water / day
Treatment
TETRACYLINE
Tetracycline
Isotretinoin Vitamin A
Notes
390
Eczema
Pathophysiology
Eczema is a chronic disorder of the skin in which the skin becomes red, itchy, & dry.
It’s common in children but can occur at any age.
It tends to flare up periodically when exposed to allergens.
HESI
Eczema… The nurse knows the
treatment plan is centered on which
concept?
Decreasing exposure to the allergen
Interventions
NCLEX TIPS
Trim nails
Lukewarm “tepid” sponge baths with soap
Pat dry with towels
Apply moisturizer immediately after bathing
Cotton clothing (soft)
NOT wool clothing
Notes
391
Lice & Impetigo
Lice - Pathophysiology & Causes

Head lice are wingless insects that live on the human scalp and Pediculosis Capitis
feed on human blood. Infestations are common in children and are
typically caused by coming in contact with another child with lice. Memory Trick
Cap-itis
Cap = hat

ATI
Itching & sores on the scalp, neck, and shoulders. … teaching the guardian of a child who has pediculosis
capitis…? Select All That Apply
Use medication containing 1% permethrin

Pharmacology Seal non-washable items in airtight plastic bags
Permethrin (brand: Nix) HESI
Education
Which drug is used ... pediculosis capitis?
Diagnostics Permethrin 1% cream rinse
Wash with HOT water: clothing,

School screenings are done to look for lice eggs sheets, & towels 1% permethrin
called nits or full grown lice. Seal non-washable items in airtight
plastic bags Nix
DO NOT share hats, scarfs, brushes Permethrin
Impetigo - Pathophysiology & Causes Strep infection Staph infection

Memory Trick
Impetigo is a highly contagious skin infection Impetigo
affecting infants & children. It is caused by a strep
or staph infection, which is really dangerous Infant -igo
in children, as strep infections can travel down
to the kidneys causing glomerulonephritis. Glomerulonephritis secondary
to streptococcus infection

HESI
• Itchy red sores
NCLEX TIPS
• Mainly on the nose & mouth … Child has impetigo. What action should the
nurse take?
1. NO school / daycare Send the child home with the parents
If sores burst & dry into honey-colored crusts, this is 2. Wash hands before & after
to see the HCP
when the infection is MOST contagious & most easily touching infected areas KAPLAN
spread! 3. Separate child’s clothes &
… Care for a child with impetigo. Which information
towels from other laundry &
Ecthyma is a more serious form of impetigo that penetrates does the nurse include in the teaching plan?
wash with HOT WATER Soften and remove crust and debris
deeper into the skin causing painful sores to turn into deep
4. Short & filed fingernails
ulcers.
5. Softly remove crust & debris
Impetigo Ecthyma
Family Child
392
Ringworm (Tinea)
Pathophysiology
Both are very contagious fungal infections that live on the surface of the skin.
HESI
Tinea - ringworm infection
Tinea capitis, tinea corporis, and
Tinea pedis - athlete's foot

tinea pedis are examples of which
type of infection?
infection Fungal infections
Signs & Symptoms

HESI
Q1: A patch of skin that itches on the right
Circular rash
forearm... a well-defined circular rash with a
red border and clear center. The nurse
anticipates a diagnosis of which skin disorder?
Tinea corporis
Scaly
Q2: A patient with tinea pedis has increased
moisture and pruritus around the toes. Which
instructions does the nurse give?
Pruritus (itchy)
Wear cotton stockings
Use warm soaks for the toes
Keep your toes clean and dry
Soak the toes in Burow’s solution
Education Treatment
Griseofulvin = Tinea corporis (Ringworm)

Key Points
PRIORITY: Tinea Corporis NCLEX TIPS
Takes weeks to months
Most important to teach ways to DO NOT discontinue once itching stops
prevent the spread BEST absorbed after eating a high fat
meal
Ringworm is spread very easily (HIGHLY tested) so HESI

we must educate the clients NOT to share The nurse is caring for a patient with
personal items like brushes, towels, hats, clothes, tinea capitis. The nurse anticipates
& anything else. administering which drug?
Griseofulvin
393
_ _
Mental Health
394
Child abuse & Neglect
Pediatrics: Mental Health
Interventions
When child abuse is suspected, the first thing that must be done in nursing process is assessment.
Assessment
ATI
Conduct a detailed interview & physical A 2-year-old boy … severe dental caries, dry
examination NCLEX TIP mucous membranes, and a diaper that is soaked
with urine and stool. Which of the following is
Assess parent-child interaction the next step in managing this patient?
Abuse: blaming, refusal to comfort, Assess caregiver interactions with the child
& belittling
Changes in story
HESI
Q1: The parent and a 6-year-old child presents to the clinic ... The child
Report to Authorities
weighs 35 pounds (15.9 kg), is wearing torn and dirty clothing, and sits
quietly with an apparent subtle rocking motion... nurse’s next actions?
It’s totally your fault!

1. Take the child’s height and vital signs
After a detailed assessment & full history 2. Assess the child for any bruising or lacerations
3. Ask the accompanying parent to leave the room

RT
REPO 4. Ask the child about attendance at school
5. Stay with the child during the healthcare provider’s assessment
Communication Q2: Suspected child abuse: What type of questions would help the
nurse to elicit information from the person?
Open-ended questions that require descriptive responses
1. Not your fault & you are not to blame
2. You are not in trouble & did the right thing
ATI PROMISES
… Child reports being physically abused by his
guardian. Which of the following statements HESI Question
should the nurse make?
… Suspected child abuse?
“It is not your fault that this happened.”
3. NO promises or secrets! NCLEX TIP SECRETS Report any case of suspected child abuse
Characteristics of perpetrators
ATI Question
The Abuser Risk Factors Q1: A nurse is teaching a group of newly licensed nurses about
risk factors for child maltreatment. Which of the following risk
factors should the nurse include in the teaching?
6 NCLEX TIPS Select all that apply
A parent who has a history of alcohol use disorder
1. Grew up in an environment of domestic violence A parent who often acts on impulse
A parent who believes in an authoritarian approach to raising
2. History of alcohol / substance abuse their child
3. Low self- esteem / Acts impulsive Expresses unrealistic expectations of an infant

Q2: … In-service for a group of elementary school teachers about
4. Authoritarian & overly critical identifying risk factors for maltreatment of children:
The child lives in a single-parent home
5. Teenage parents or single-parent home The child was born premature and has developmental delays
6. Child with developmental delays A toddler who has autism
Notes
395
ADD & ADHD
Pathophysiology Management
ADD - Attention Deficit Disorder

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

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

A nursing diagnosis that should be
considered for a child with attention
deficit hyperactivity disorder is
1. Hyperactivity “restless” ● Risk for injury
2. Inattention “reduced ability to focus”

ATI Question
3. Impulsiveness “excessive talking” … new diagnosis of ADHD… which
of the following statements should
4. Low self-esteem & impaired social the nurse include in the teaching?
skills NCLEX TIP ● Your child is at an
increased risk for injury
Communication ATI Question

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

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

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

Risk factors of ADHD…
● Combine verbal instruction
with visual cues
should the nurse include
in the teaching? ● Establish consistent
classroom rules
● History of head trauma
● Decrease the amount of
homework assigned
396
Autism Spectrum Disorder
Pathophysiology Risk Factors

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

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

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

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

C
Does NOT
T
U
C
B
Maintain eye contact NCLEX TIP

A
Interact with gestures

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

hungry?
Routines & Consistency
Delay in language development Give a schedule of daily activities NCLEX TIP C C
B B
A A
Maintain daily routines when possible HESI

A
Repetitive
Avoid making acute changes in their environment
Actions “Ritualistic behavior”
Words (echolalia)
HESI HESI
HESI Limit
Q1: Child with autism spectrum disorder (ASD). Q2: Child with autism spectrum disorder. Which
The parents say, “We are going to move our child
Child who plays alone, does not maintain eye statements by the parents indicate … that they
to a different bedroom in our home.” understand the teaching?
contact, repeatedly twists fingers, has inadequate
ASD - Autism Spectrum Disorder Select the nurse’s therapeutic response. Select all that apply. C
B
C
B
speech, and does not interact with gestures?

A A
“Children with autism spectrum disorder Repetitive movements are common

usually prefer for things to stay the same.” Non-verbal communication is limited
Autism spectrum disorder (ASD) Maintain a daily routine whenever possible
T
C Kaplan
U
C Child with autism is admitted to the pediatric
A
B unit ... Which response by the nurse is best?
Prevent Overstimulation
“The inability to maintain eye contact
is a characteristic of autism.” Limit number of visitors & choices
Private room away from the
ATI nurse’ station NCLEX TIP
1... 2... 3...
4... 5... 6...
C
Which of the following manifestations … A

B
are indications of autism spectrum disorder?

Select all that apply. ATI
A
A
A
Nonverbal behavior
What is the most important intervention when
Repetitive counting I
W
A admitting a child with autism spectrum disorder?
B
Spins a toy repetitively
Delayed language development Placement in a private room down the
corridor from the nurses’ station
Exhibits ritualistic behavior
397
Child abuse & Neglect II
Signs
Failure of a parent or primary caregiver to provide basic necessities: food, clothing, shelter, supervision.
Neglect
ATI Question
Q1: … Education seminar about child maltreatment.
Which of the following factors would indicate neglect?
D
ATE
The child is undernourished
R E
The child is dirty and poorly clothed
U NT
The child has untreated dental conditions
Q2: … Parents do not use a child safety seat when
transporting the child:
Child neglect
HESI Question
Which form of child maltreatment is considered the
most common?
Neglect
Physical Abuse Any non-accidental physical injury to the child: striking, kicking, burning, biting etc.
ATI Question
Expected finding of physical abuse?
Burns on bilateral hands
Spiral fracture of the right forearm
Reddened welt across the back
HESI Question
A child arrives in the emergency department
with cigarette burns on the arm. Which type
of abuse does the nurse document?
Physical abuse
Injury to emotional stability of the child as evidenced by an observable or

Emotional Abuse substantial change in behavior, emotional response, or cognition, for example:
anxiety, depression, withdrawal, or aggressive behavior.
HESI Question
You’re not worth a second look
Q1: A 4-year-old child tells the nurse, “I’m a

bad boy. Daddy always says I’m not worth a
second look”... is an example of?
I’m a
Emotional abuse bad boy
Q2: Which statement made by the child ...

emotional neglect?
My father does not praise me even
when my teacher praises my drawings
398
Separation Anxiety
Pathophysiology
Kaplan
Separation anxiety occurs when the primary caregiver leaves the child, which
When the parents leave, the 18-month-old child
produces more stress & anxiety than any other factor. This is common during starts to cry loudly… After a while the child stops
hospital stays when the parents/ caregiver may leave & a new nurse or other crying & becomes quiet and withdrawn.
The nurse thinks that the child has accepted the
caregiver must assume care. situation and has adjusted well to the separation.
Which statement is TRUE?
The nurse fails to see that the child has
entered the second stage of separation anxiety
Key Point 3 Stages HESI

Begins at 6 months NCLEX TIP 1. Protest: cries & screams Q1: During which phase of separation anxiety is a
toddler most likely to cling to the parent?
Protest
Peaks at age 10 - 18 months 2. Despair: quiet & withdrawn Q2: Signs of separation anxiety in the protest
Usually resolves after the child phase?
turns 3 3. Detachment: suddenly happy Attacking strangers verbally & crying
6 months & older

HESI
6 NCLEX TIPS Ease the feelings of separation from home?
1. Encourage the parent to remain with the child Surround the child with familiar items
whenever possible
2. Keep the same home routine / “daily schedule” ATI
during hospital stay (meal & sleep times)
Most appropriate intervention … separation
3. Provide a quiet sleep environment anxiety?
4. Give many opportunities for play & activity Encourage the parents to leave the child’s
favorite toys and books
5. Upset child → STAY with the child
(calm presence)
Kaplan
6. Familiar objects:
Which action should the nurse take to minimize
Blanket separation anxiety?
Parent’s shirt Keep toys from home in the bed with
Child’s favorite toy or stuffed animal the child
Picture of the child’s family
A top missed NCLEX Question:

Parents of a 2-month-old have to leave the infant
in the care of hospital staff while they work. Key Point
The nurse educates the parents about separation Begins at 6 months NCLEX TIP
anxiety. Which statement by the parent is correct? Peaks at age 10 - 18 months

Usually resolves after 3-years-old
“I know my baby will not cry because we are
leaving, since my baby is too young.”
<6 months old
Over 50% of students got this wrong
399
_ _
Musculoskeletal
400
Clubfoot & Scoliosis
Pediatrics: Musculoskeletal
Clubfoot - Pathophysiology Talipes equinovarus

Signs & Symptoms
Clubfoot, also called Talipes equinovarus, The foot or feet point down and
is a bone deformity in which either one or inwards, and the soles of the
both feet are twisted out of shape or position. feet face each other.
Treatment
Casting usually begins soon after birth. The HCP places a long-leg cast on the affected foot or feet & weekly
recasting over 5 to 8 weeks. This is needed for gradual foot reposition & to maintain foot correction after casting.
The client is often put in a Denis Browne brace that sort of looks like a snowboard for babies.
• Never place these children on their stomach to sleep!

• High Risk for SIDS - Sudden Infant Death Syndrome
HESI Question ATI Question Kaplan Question

Education 4 NCLEX TIPS Q1: ... baby with clubfoot who has had
What is the goal of ... major difference between
a cast applied. The nurse should
clubfoot and positional
1. New cast placed every week treatment for a provide additional teaching to the
deformity… Which statement
newborn with clubfoot? parents if they state:
for 5 to 8 weeks ● “I should use a pillow to elevate is appropriate?
• Correction of my child’s foot as she sleeps”
• “A clubfoot is corrected
2. Check toes several times a the deformity
Q2: … care instructions to the parents with surgery and casting,
day = pink & warm of an infant with talipes
equinovarus (clubfoot) who is
but a positional deformity
having the cast removed. Which can be passively corrected.”
3. Keep the cast dry = bathing instructions should the nurse
provide concerning exercise of the
& changing diapers affected foot?
● Exercise with each diaper change
4. DO NOT elevate feet with a
pillow during sleep & NOT on
stomach during sleep
Scoliosis - Pathophysiology Signs & Symptoms
NCLEX TIP
S - Scoliosis First noticed during
Mild to severe pain & the stiffened
spine can make it hard to move.
S - “S” shaped Spine periods of rapid growth
Severe cases can cause a
especially in adolescent females
“lateral curvature” NCLEX TIP deformity of the chest cavity.
ages 10-12
Measuring the Cobb angle can determine the
extent of the deformity & X-rays can confirm this. Social interaction
Visit friends NCLEX TIP
Fixing braces: Boston Brace
Cobb angle Wear a cotton shirt under
the brace at all times NCLEX TIP
ATI Question HESI Question KAPLAN Question

A brace is ordered for the adolescent to correct a
... nursing instructions: 13 year old female with scoliosis … a girl with scoliosis is prescribed a Milwaukee brace …
scoliosis deformity. Which parental statement indicates
who is discharged with a ... brace? Which instruction should the nurse provide to this client?
teaching is successful?
Wear a cotton t-shirt underneath the brace Remove the brace 1 hour each day for bathing only
“The brace should be worn 23 hours a day”
401
Legg-Calve-Perthes Disease &
Fractures + Cast Care
Legg-Calve-Perthes Disease - Pathophysiology

Legg-Calve-Perthes disease
This childhood hip disorder occurs when there is decreased blood flow to the
femoral head (the round ball part of the bone at the top of the femur). The limited
blood flow causes the bone to die from the lack of oxygen & nutrients. Gradually,
the head of the femur breaks apart and can lose its round shape, which is very serious,
as this ball and socket joint of the hip is needed for walking & range of motion!
Signs & Symptoms

ATI Question
child who has Legg-Calve-Perthes
Limited range of motion disease…. manifestations should the
nurse expect? Select all that apply.
Hip pain & stiffness Hip stiffness
Limited range of motion
Limp when walking Limp when walking
• X-rays - of the hip can show deformity This condition typically resolves on its own over
• MRI - can show shape of the bone & new blood vessels time, so treatment revolves around rest,
formations pain control, & physical therapy.
ATI Question
A brace may be used to keep the legs
Legg-Calve Perthes disorder... abducted & the femoral head inline to
diagnostic procedures?
promote healing. Also, surgery may be
Radiographs
needed to provide more permanent
placement if the femoral head is displaced.
Fractures & Cast Care - Pathophysiology Causes & Risk ATI Question
Q1: … which of the following injuries in a 2
Closed Fracture: year old is most concerning for child abuse?
Bed rest
Humerus fracture
Does not break skin Osteoporosis
Open Fracture “Compound” Q2: ... 8 year old child who has a greenstick
Steroids “-sone” NCLEX TIP fracture after falling from his bicycle. Which
Skin surface broken Prednisone of the following items represents this type
of fracture?
Complete fracture
Trauma Greenstick fracture
Incomplete fracture “GreenStick”
Spiral fracture
Oblique fracture DEXAMETHASONE
Compression fracture “Impact” PREDNISONE

Greenstick fracture
Crush “Compression” fracture
Fludrocortisone
Hydrocortisone
CAST CARE New Cast Assessments Complications

PAIN
C - Clean & Dry NEVER WET Notify HCP immediately • Unrelieved with
� Cover cast with a plastic bag Assess fingers & toes “neuro checks” morphine NCLEX TIP
for bathing NCLEX TIP • Not resolving with
PMS C medication
A - Above the heart (First 48 hours) P - Pulses - NOT pulseless
� Elevate extremity NCLEX TIP Key terms • Extreme pain with
M - Movement - grips passive movement
S - Scratch an itch?
� Use the hairdryer on a cool
S - Sensation
▪ NO tingling, numbness
• HOT spots: infection
• Compartment syndrome: Paresthesia
setting NCLEX TIP C - Cap refill & Color decreased perfusion • “tingling” “burning”
“numbness” NCLEX TIP
T - Take it easy ▪ NOT over 3 seconds
• Problems moving or
� NO bearing weight on plaster casts ▪ NOT pale “pallor” extending fingers
� NO finger indentations or pressure Temperature or toes.
� NO hard surfaces ▪ NOT cold or cool • “Great difficulty”
402
Juvenile RA vs. IA
Juvenila RA - Pathophysiology
RA is an autoimmune disorder where the body attacks the joints causing
major inflammation & deformity. Mainly seen in the hand joints, but can
RA - Rheumatoid Arthritis also involve other organs (skin, eyes, & lungs) with collateral damage as the
body attacks itself.

A patient with rheumatoid arthritis A client asks the nurse, “What is the
asks the nurse about her condition. difference between rheumatoid
On which knowledge does the arthritis and osteoarthritis?” Which
nurse base patient teaching? response by the nurse is best?
Rheumatoid arthritis is thought Rheumatoid arthritis is a
to be an autoimmune disorder. systemic disease and
osteoarthritis is not
Signs & Symptoms Education

Kaplan Questions
HESI Question Pain control - Assess pain levels
Early Signs Q1: A nurse is assessing a Q2: Which nursing intervention is
Fatigue, anorexia (weight loss) child experiencing an exacerbation of Do NOT elevate the knees with client who has a diagnosis of most appropriate for a client
juvenile rheumatoid arthritis (JRA)… rheumatoid arthritis. Which of diagnosed with rheumatoid
& morning joint stiffness pillows at night the following nonpharmaco- arthritis and reporting generalized
cause of the child’s impaired mobility?
logical interventions could the
Symmetrical pain and swelling Joint inflammation
Exercise (low impact) pain?
nurse suggest to help reduce
in the small joints of the hands Swimming pain? Assist the client with heat
NCLEX TIP Alternate applying heat and
Fingers: swan-neck and a Heat & Cold to affected joints
application and range of
cold to the affected joints. motion exercises.
boutonniere deformity
Contractures of joints Warm shower or bath
= HIGH priority before bed
Joint pain NCLEX TIP
Pain relief with activity
MORE pain at rest
JIA - Pathophysiology
JIA
JIA - Juvenile Idiopathic Arthritis is also an autoimmune disorder where the
body attacks itself causing joint inflammation! It is the most common type
of arthritis in kids and teens.
Signs & Symptoms Education Pharmacology

-sones -swelling
NCLEX TIPS
Joint pain that is worse Steroids “-sone”
Physical activity: LOW IMPACT
in the morning Prednisone
Swimming PredniSONE
Joint swelling & stiffness Yoga ATI Question

Fever & skin rash Exercise bicycle “stationary” Q1: … child who has juvenile idiopathic
arthritis (JIA). Which instructions
should the nurse include?
HESI Question Administer prednisone on an
Q1: ... care plan of a 12 year old with juvenile alternate-day schedule
idiopathic arthritis? Select all that apply. Q2: child with juvenile idiopathic arthritis PredniSONE
and is returning to school…. Which

Apply cold packs to the affected joints instructions should the nurse include?
Position the affected joints in a Select all that apply.
neutral position Involve the school nurse in
Warm shower or bath in the morning medication management
upon rising Make arrangements to have a set of
books at school and a set at home
Q2: … best diagnostic evaluation tool to diagnose
Request an individualized education
juvenile idiopathic arthritis?
plan for patients that requires
Physical manifestations extensive modification for school
403
Hip Dysplasia
Pathophysiology
Hip dysplasia, or more commonly DDH Developmental Dysplasia of the Hip, is a condition where the ball & socket
joint of the hip does not form properly. This leads to hip instability that can result in FULL dislocation of the hip joint,
where the head of the femur pops out of the hip socket making the affected leg shorter as the femur head gets
displaced. DDH typically presents at the time of birth or present in the first few years of age.
Normal
MEMORY TRICK
Developmental Dysplasia of the Hip
Hip Dislocation
Hip Dysplasia
Causes
HESI Question
Risk factor is most closely related
Breech birth & large infant size
to developmental hip dysplasia?
Family history of hip dysplasia
Breech presentation

HESI Questions Developmental dysplasia of the hip in
0 - 12 weeks old Q1: Newborn assessment … A clicking preschoolers… which assessments
Extra gluteal folds NCLEX TIP sensation is noted when abducting the should the nurse include?
child’s thigh and placing gentle pressure Trendelenburg sign
(inguinal / thigh folds)
over the greater trochanter. How will
Instability & “clicking sensation” the nurse document this finding?
Ortolani test
when abducting thighs Positive Ortolani maneuver
After 12 weeks Q2:… an infant who does not pull
Limited hip abduction to a standing position by 11 to 12
Shortened leg on the affected side months of age?
Developmental dysplasia of the hip
Walking years
Pelvic tilt “Trendelenburg sign” Barlow test
Treatment
ATI Questions
MEMORY TRICK Q1: plaster spica
Check the temperature of the
Abducted infant's toes every hour for at

least the first 24 hours
Q2: spica cast… proper skin
Parent Education Abduction care? Select all that apply.
Check exposed areas for signs
3 NCLEX TIPS
1. NEVER put legs straight & together! of redness or irritation
2. Swaddle the infant with the hips abducted & flexed Inspect the inside edges of the
(bent upward)
Kaplan Question cast to look for extra pieces of
3. Car seats / strollers with wide bases newborn …with hip dysplasia. The nurse anticipates cast material
Pavlik harness which treatment? Provide regular sponge baths
Pavlik harness for the client
BEFORE 6 months of age
7 NCLEX TIPS Q3: placement of a spica
1. NO adjusting harness straps! = ONLY HCP HESI Questions A cast applied from the chest
2. NO taking off. Leave the harness on 100% of the day to the thighs or knees
Q1: What complication .. infant with a Pavlik harness?
3. Check skin 2 - 3 times daily
Skin breakdown
4. Massage under the straps every day &
check for redness
Q2: A newborn infant, diagnosed with developmental
5. Dress the child with clothes under the straps dysplasia of the hip (DDH). Which nursing action
6. Put diapers on under the straps (only 1 at a time) should be included ...?
Observe the parents reapply a pavlik harness
7. AVOID: powders & lotions
404
Osteogenesis Imperfecta &
Muscular Dystrophy
Osteogenesis Imperfecta - Pathophysiology

Osteogenesis imperfecta (OI), also called brittle bone disease,
Brittle bone is the most common type of osteoporosis in childhood resulting
Memory Trick in frequent fractures.
OI is a group of inherited genetic disorders that impairs the

OsteoPORosis creation of collagen by osteoblasts in the bone, caused by
PORous bones MOST
COMM
ON
defective genes in the parents. The bones present like Swiss cheese,
with small holes, resulting in fractures often from mild pressure
or no apparent cause. For example, putting on a blood pressure
cuff too tightly in the hospital!
HESI Questions Interventions

Q1: Which statement concerning
osteogenesis imperfecta (OI) is true? Osteogenesis imperfecta
OI is an inherited disorder Take blood pressure manually to avoid
Q2: … most common osteoporosis syndrome over-tightening the cuff NCLEX TIP
in childhood?
Osteogenesis imperfecta Reposition frequently using supportive devices
Q3: A 6-year-old patient has … fractures on 5
different occasions. The nurse prepares to Lift the infant / child under the broadest areas
assist in the screening for which condition?
of the body AVOID
Osteogenesis imperfecta
Muscular Dystrophy - Pathophysiology HESI Questions

Q1: How is Becker muscular dystrophy
MD is a genetic disorder that causes muscle different from Duchenne muscular dystrophy?
weakness, due to the replacement of muscle It progresses much slower

Memory Trick
fibers with connective tissue. Mostly affecting Its age of onset is over 7 years
MD MD boys between the ages of 2 & 5 years old. Q2: Duchenne muscular dystrophy (DMD)?
Muscle weakness, usually beginning around
the age of 3 years
Muscular Dystrophy Muscular Damage There is a change in the DNA sequencing
& Weakness
resulting in a low production of the protein
From 3 years old
dystrophin, which is needed for muscle
stabilization.
MD is a progressive disease, meaning it worsens

over time. As more & more muscle cells die
turning into fat & scar tissue, the muscles can
look big and strong, but in reality they are weak
& frail.
Signs & Symptoms Interventions Pharmacology
4 NCLEX TIPS Education

1. Walks on tiptoes Remove throw rugs NCLEX TIP
2. Disproportionately large calves
Diet: fluids & fiber
Prednisone
3. Frequently trips & falls
Gentle exercise: swimming, yoga, walking
4. Places hands on thighs to stand up
(Gower sign)
NOT weightlifting PredniSONE SSSSwelling
Gower
Sign PREDNISONE
405
_ _
Neurological Brain
406
Cerebral Palsy
Pediatrics: Neurological Disorders

Cerebral palsy is a permanent disorder of movement presenting with stiff muscle
tone, tremors, and involuntary motions. The client also has an abnormal posture, MEMORY TRICK
and lack of physical coordination as muscle spasms come & go.
Cerebral - Brain
CP stems from abnormal brain development, often before birth, which results in
Palsy - Pausing
delayed development specially with walking, speaking and swallowing, as these
require various muscles.
HESI Question
... Most common cause ... for the
diagnosis of cerebral palsy (CP)?
Prenatal brain abnormalities
Permanent
Signs & Symptoms

Kaplan Question HESI Questions
Q1: What assessment findings will the nurse
Poor head control The nurse identifies which finding as an
NCLEX TIP early warning sign of cerebral palsy (CP)? expect to see in a 9-month-old with
(Over 6 months) The infant has poor head control
cerebral palsy? Select all that apply.
Positive Babinski sign
“Infant’s head that falls back behind Presence of the tonic neck reflex
the shoulders”
Treatment Irritability and excessive crying
Rigidity of the arms and legs
Rigid muscles Q2: Which drug prevents the risk of cerebral
palsy in the fetus?
Positive Babinski sign / reflex Magnesium sulfate
Treatment ATI Questions HESI Question

Q1: … Child who has cerebral palsy experiencing A 7-month-old male infant diagnosed with spastic
Long-term treatment includes physical therapy, painful muscle spasms. Which of the following cerebral palsy … immediate intervention by the
speech therapy, pharmacology, & sometimes medications should the nurse administer? nurse?
Baclofen My son often chokes while I am feeding him
surgery. Q2: 4-year-old child with cerebral palsy.
Referral to a speech-language therapist
PRIORITY
Pharmacology
#1
Baclofen
EN
BACLOF BACLOFEN
Baclofen muscle relaxant to help ease those

painful muscle spasms.
Notes
407
Meningitis & Increased ICP II
Tests
• CT scan (done first) Droplet Airborne
• LP (Lumbar Puncture “spinal tap”)
- Viral - Very clear P - Pertussis M - Measles
I - Influenza ON AIR
- Bacterial - Bad cloudy T - TB (Tuberculosis)

- Both types will have elevated WBCs P - Pneumonia
- AFTER LP: Monitor insertion site dressing
for clear fluid
3. Door closed
Interventions 4. Transport - Patient wears
ATI
surgical mask
Infants 0 - 12 months to wear a mask
Bacterial Meningitis NCLEX TIP

Put ON “DON” Take OFF “DOFF”
Giving antibiotics is the priority GMGG GGGM
1. Gown 1. Gloves
OVER 35% got it WRONG!

2. Mask 2. Goggles
PRIORITY
3. Goggles 3. Gown
4. Gloves 4. Mask N95
3 NCLEX TIPS
1. Low light & noise - dark quiet room Top Missed NCLEX Question
Minimize environmental stimuli A 4-month-old infant with bacterial meningitis
received new orders … which of the following
should the nurse prioritize first?
2. Low pressure
Elevate the HOB at 30-degrees 1. Assess fontanels & high-pitched cry
2. Give ciprofloxacin IV immediately
3. Implement seizure precautions 3. Monitor level of consciousness
4. Implement seizure precautions
ATI Question CIPROFLOXACIN
6-year-old child who has bacterial meningitis…

PRECAUTION
interventions?
Implement seizure precautions
Notes
408
Meningitis & Increased ICP
Pathophysiology & Causes !

Meningitis is the inflammation of the meninges (the inner
lining of the brain & spinal cord). Typically caused infection ! !
!
! !
(bacterial or viral), head trauma, & even auto-immune
diseases like Lupus.
!
Disease progression: !
Inflammation → massive brain swelling → deadly ↑ ICP → !
crushed brain stem → DEATH!
Signs & Symptoms Complications
6 NCLEX TIPS Hydrocephalus is a deadly complication that increases pressure within the
baby’s brain. It happens when fluid collects within the brain from the
2 years or less obstructed flow of cerebrospinal fluid (CSF). If NOT corrected quickly the
1. High pitched cry baby can die!
2. Bulging fontanelles at REST
(Report to HCP)
Bulging fontanelles at rest is the first sign of increased ICP! NCLEX TIP
3. Irritability
4. Vomiting & poor feeding

ATI Questions
5. Frequent seizures MEMORY TRICK Q1: Infant born 3 days ago. Which finding should
the nurse … report to the primary care provider?
6. Sunset eyes: “sclera visible above the iris”
The infant’s anterior fontanel is bulging
Infant Complication = Hydrocephalus B B
Q2: 6-month-old infant … scheduled for a lumbar
puncture. Which actions should the nurse take?
Priority: Fontanel assessment Bulging Fontanelles Brain Damage!!!
at rest Hold the infant’s chin to his chest and knees to
his abdomen during the procedure
#1 PRIORITY
Q3: Lumbar puncture (LP) … Which actions
HCP Instruct the parents to keep the toddler in a flat

1
position for 30 minutes to one hour after the

procedure

Q1: A 2-month-old infant with viral meningitis … the nurse knows to Q2: 3-month-old infant with meningitis …
assess for which clinical manifestation? What is the most important assessment in
Select all that apply the plan of care?
1. Temperature
1. Fever
2. Fontanel assessment
2. High-pitched cry
3. Vomiting
3. Vomiting INTAKE- OUTPUT CHART
4. Input & output

Name
Date
Time INTAKE (ml) OUTPUT (ml)
MORNING
SHIFT
4. Seizures
5. Poor feeding
6. Flattened fontanelles
Notes
409
Hydrocephalus
Pathophysiology CSF - Cerebrospinal Fluid
Hydrocephalus is a deadly complication where brain collects excess cerebrospinal

fluid builds (CSF) resulting in deadly increased intracranial pressure (ICP) progressing
to brain damage & death.
Signs & Symptoms MEMORY TRICK
B B
Bulging Brain
2 years or less 6 NCLEX TIPS

Fontanelles Damage
HESI Questions
Q1: Which clinical finding would the nurse interpret as a possible
1. High pitched cry sign of hydrocephalus?
1
HCP Head circumference greater than chest

2. Bulging fontanelles (Report to HCP) circumference
3. Irritability & change in LOC HESI

ATI Question
Q2: 8-month-old child … assessment for increased intracranial
pressure?
4. Vomiting & poor feeding Select all that apply.
High-pitched cry
5. Frequent seizures Infant born 3 days ago. Which finding should the
Increased head circumference
nurse … report to the primary care provider?
6. Sunset eyes “sclera visible above the iris” Poor suck-swallow when feeding
The infant’s anterior fontanel is bulging Prominent sclera over the iris
Q3: Which is a sign of increased intracranial pressure in infants?
KAPLAN Question
Irritability
Priority: Q4: An infant … hydrocephalus suddenly awakens with a

high-pitched, shrill cry and cannot be comforted. What is the next
Fontanel assessment … The baby’s “soft spot” bulges out when the baby cries.
nursing action?
Increased head circumference bigger than chest The anterior fontanel will normally bulge out Contact the health care provider
when the baby coughs or cries
Causes Diagnostics
Infections: Meningitis • Ultrasound

Tumors • Magnetic resonance imaging (MRI)
• Computed tomography (CT) scan
Bleeding inside the brain
Treatments
ATI
Q1: 2 ½-year-old boy … with a ventriculoperitoneal
shunt. The nurse advises the parents to call the clinic
VP shunt - Ventriculoperitoneal shunt if the child:
Appears irritable & vomits after a nap
Post-op care: Q2: … Following ventriculoperitoneal (VP) shunt
Measure head circumference 30-45o placement. Which of the following positions should
the nurse place the child?
Semi-Fowler’s
Notes
410
Reye Syndrome
Pathophysiology & Causes Rare life-threatening
Reye syndrome is a rare life-threatening condition that causes massive brain

swelling, which leads to seizures & liver damage.
Risk Factors
1. Recent influenza infection NCLEX TIP
MOST tested trigger
MOST tested 2. Aspirin (salicylate acid)
DO NOT GIVE TO BABIES
ATI Question ASPIRIN
Child with influenza … increased risk for

development of Reye syndrome?
“I gave my child aspirin to reduce his fever”
Signs & Symptoms Brain Swelling

Seizures
Bulging fontanelles ?
Liver damage ? ?
Elevated ammonia
Encephalopathy cloudy brain from ammonia
Confusion
“ALOC”
Mental status change
Elevated Liver labs: AST, ALT
Elevated Coag. Time: increased r/t bleeding!
Interventions Diagnostics
Monitor & decrease ICP MANNITOL
1. HOB elevated (over 30 o )

PRECAUTION
Liver enzymes
2. Mannitol (diuretic)
3. Seizure precautions Liver biopsy
4. Vit. K (to stop bleeding)
Complications
Hepatic encephalopathy can result from the increased ammonia levels within the blood! Since the liver is damaged,
it can’t convert ammonia into urea, so all the ammonia sits in the blood causing hepatic encephalopathy.
Notes
411
Seizures
Sudden, uncontrolled electrical discharges in the brain. Anything that can cause brain swelling or hypoxia
Epilepsy is lifelong episodes of seizures.
MEMORY TRICK
• Infection: meningitis
ePILEpsi - like a PILE of seizures that • Trauma: TBI, Concussion
come & go over a lifetime • Brain mass: BRAIN tumors
• Increased ICP
• Fever in infants = “febrile seizure”
• Withdrawal from drugs & alcohol
Types Stages or Phases of Seizure

6 months - 6 years of age
• Prodromal phase Warning signs before a seizure

Febrile seizures leading to Aura Phase
• Aura phase Visual, auditory clue that happens prior to a
Key Points major seizure
Give ibuprofen or acetaminophen every 6 hours • Ictal phase = Seizure Phase THINK ignition phase -
the period of the active seizure.
Cool, damp compress on forehead 911
• Postictal Phase Hangover phase after the seizure -
Call 911 = seizures lasting longer than 5 minutes think POST-ignition phase
• Confused, disoriented, major headache, & typically
feels tired or sleepy
Status Epilepticus Diagnostics

• MRI or CT - to look for abnormalities.
Status Epilepticus- MEDICAL • EEG - electroencephalogram NCLEX TIP
emergency!! NCLEX TIP Assesses electrical activity in the brain by
5 min. or longer - 1 seizure 1ST placing sticky electrodes on the scalp
30 min. - Repeated seizure activity • Wash hair (before/ after) to make sure it sticks
#1 Priority = STOP the Seizure • NO Caffeine (tea, coffee, soda) or stimulants:
IV or Rectal benzodiazepine 12 - 24 hours before
Lorazepam (brand: Ativan) • NO Seizure meds
Diazepam (brand: Valium)
• NO Sleep - Sleep deprivation is BEST
• YES Eat before test - no need for NPO
MEMORY TRICK
• EEG think of EGG head - electrical activity
Interventions during SZ
of the EGGhead
• ECG - C think C - Cardiac rhythms
#1 - Airway
Turn client to side NCLEX TIP ATI Questions
Q1: First priority for a client having
NEVER insert anything in the mouth! a seizure?
NEVER restrain or “Hold down arms” Turn client to the side
Call for help & Stay with Client
#1
#1 Drug = STOP the Seizure Q2: Tonic clonic seizure nursing
Lorazepam (brand: Ativan) interventions?
Loosen restrictive clothing
Diazepam (brand: Valium) Prepare to suction the client’s airway
Rectal or IV
Loosen restrictive clothing Q3: Client who is at risk for seizures:
(Neck & chest) Ensure a patent IV
Safety
Protect - Clear area for any objects
Pad Side Rails
Pharmacology
AFTER seizure activity
Record Time Anticonvulsants
Assess LOC, Neuro, Vitals
- Phenytoin: Toxic Over 20 hold med
- Levetiracetam: Driving permissions from HCP
412
Spina Bifida
Pathophysiology
Spina bifida is a birth defect in which an infant spinal cord fails to develop properly.
Specifically, the neural tube fails to fuse, or there is failure in formation of the vertebral neural arches.
Normal Spina bifida M yelo-meningocele
2 main Neural Tube Defects

M EGA sac protrusion
Spina bifida occulta

Myelomeningocele
Signs & Symptoms
Spina bifida occulta HESI Questions

2 Key Signs Q1: Which neural tube defect is not
visible externally?
1. Small tuft of hair at the Kaplan Question Spina bifida occulta
base of spine NCLEX TIP Myelomeningocele. Which action does Q2: … Findings to report to the HCP?
2. Small dimple or birthmark the nurse perform? A pigmented nevus with tuft of
hair at the base of the lumbar spine
(nevus birthmark) Applies moist, sterile dressing
Sacral dimple
Myelomeningocele: Q3: Why does a myelomeningocele require

ATI Question protection after birth?
Mega sac protrusion from
… assessment should the nurse Reduce the chance of infection
the back area Myelomeningocele
prioritize for follow-up? Improve the prognosis
Priority Interventions tuft of hair at the base of for ambulation
the lumbar spine Prevent damage to the spinal cord
1. Cover the area with a moist and nerves
sterile dressing Prevent the leakage of
2. Asepsis = most important cerebrospinal fluid
Kaplan HESI
3. Prone position
Diagnostics Causes Education

An MRI or spinal ultrasound can be Vitamin B-9: Folate (Folic Acid) deficiency During Pregnancy
used, but the MOST tested was:
AVOID Anti-seizure medications: 400 mcg of Folic Acid per day NCLEX TIP
Valproic Acid Green Leafy vegetables

Amniocentesis: Carbamazepine Spinach
Broccoli
Alpha-Fetoprotein test Green peas
Starch NCLEX TIPS
ATI Question HESI Questions

Q1: Pregnant client … taking carbamazepine.
Black beans & rice
Fortified cereals & milk
High risk for? Peanut butter
Alpha-fetoprotein test? Spina bifida Enriched bread
Q2: Vitamin … to prevent neural tube defects
To identify fetal in infants?
neural tube defects 0.4 mg of folic acid
Q1: … Pregnant client identifying the food
items highest in folic acid.
Amniocentesis Leafy green vegetables
ATI Question Q2: A good source of folic acid?
Spinach
Folic acid is important before and
AFP Test
during pregnancy:
To prevent neural tube defects
in the newborn
413
Tay-Sachs Disease

Tay-Sachs disease is a group of disorders that destroy nerve cells in the brain & spinal cord. Typically appearing
around six months of age, it is caused by the absence of an enzyme that helps break down fatty substances.
As the disease progresses, the child loses muscle control, vision loss, paralysis, and death.
Brain
Spinal cord
Signs & Symptoms
Loss of motor skills, including

Turning over
Crawling
Sitting up
Seizures
Vision & hearing loss
"Cherry-red" spots in the eyes
Diagnostics Hexosaminidase
Blood test checks the levels of an enzyme called hexosaminidase

in the child's blood.
Treatment
Respiratory care (high risk of Feeding tubes

lung infections)
Feeding tubes (trouble
swallowing & aspiration)
Physical therapy
Notes
414
MD: Muscular Dystrophy
Pathophysiology
Muscular dystrophy (MD) is a genetic disorder that causes muscle weakness, due to the replacement of muscle
fibers with connective tissue. There is a change in DNA sequencing resulting in a low production of the protein
dystrophin, which is needed for muscle stabilization.
Memory Trick
MD MD
Muscular Dystrophy Muscular Damage

& Weakness
MD mostly affects boys between the ages of 2 & 5 years old, and is
considered a progressive disease, meaning it gets worse over time.
Signs & Symptoms
4 EXAM TIPS
Patho Test Tips
1. Walks on tiptoes Motor weakness
Waddling gait & difficulty climbing stairs
Gower 2. Disproportionately large calves
Gower maneuver (Gower sign)
Sign
3. Frequently trips & falls Kyphoscoliosis
Respiratory infections
4. Places hands on thighs to stand up
Cardiomyopathy
(Gower sign)
Treatment & Nursing Interventions

There is no cure for MD, so children in adolescence typically use a wheelchair
& most die due to respiratory failure in their 20s or 30s.
Adolescence 20-30 years old

Remove throw rugs NCLEX TIP
Diet: fluids & fiber

NO CURE
Gentle exercise: swimming, yoga, walking
NOT weightlifting
Pharmacology
PredniSONE SSSSwelling
NOT muscle relaxants like baclofen - that’s more Prednisone
for muscle spasm, which is not present in MD.
PREDNISONE
415
_ _
Poisoning
416
Lead Poisoning
Pediatrics: Poisoning
Pathophysiology
!
Lead poisoning occurs when toxic levels of lead build up inside the !
bloodstream. Children younger than 6 years of age are most at risk
since small amounts of lead can cause serious health problems. Pb Year 3
Year 2
Year 1 !

HESI Question
• Lead-based paints found in houses built in & before the 1970s Q1: Which source is a
• Drinking from lead piping in older homes common cause of lead
poisoning in children?
● Lead-based paint
Q2: Which metal is

Pb
appropriate to test for
in the child that lives in
a house built in 1960?
● Lead
1900’s 1970’s 1900’s 1970’s
Signs & Symptoms

ATI Question ATI Question
Which of the following is the most A child who has severe lead toxicity.
Neurocognitive impairment serious concern associated with an
elevated blood lead level?
Which of the following actions
should the nurse plan to take?
NCLEX TIP ● Neurocognitive impairment ● Administer chelation therapy
Mild
� Hyperactivity
Kaplan Question HESI Question
Chronic lead poisoning. Which
� Impulsive symptoms does the nurse expect to see? Which nursing intervention is
appropriate when the blood lead
Moderate ● Anemia, seizures, learning disabilities
level (BLL) is within 5 and 14 mcg/dL
� Learning disabilities in an adolescent client?
� Vision & hearing HESI Question Select all that apply.

● Refer to social services
Which effect does increased lead ● Conduct follow-up blood testing
Severe absorption have on a patient? within 1 month and then every
� Seizures ● Anemia 3 to 4 months
� Death
Anemia Kaplan HESI
Weight loss
Sluggishness and fatigue
1 3 4
month months months
Education Most tested on Treatment
SATA questions
Chelated therapy like activated
3 NCLEX TIPS charcoal & EDTA injection can be
given depending on time & severity
1. Return for follow-up blood of exposure.
tests for lead level Pb
2. Get the home inspected !

!
for the source of lead !
3. Wash the child’s hands often ACTIVATED

CHARCOAL
EDTA
(especially before meals)
417
Drug Toxicity
Pediatrics: Poisoning
Causes
MEDICINE
Drug toxicity is always a big concern with toddlers learning how to walk &
get around, they are curious about everything, get into medicines, and
love to put foreign objects into their mouths!
Treatment ATI Questions HESI Questions

Q1: 3-year-old child … father just found him Q1: “I think my baby swallowed a bottle of
holding an empty bottle of ibuprofen... Tylenol.” What is the nurse’s next action?
initial action? Take the child’s vital signs
Activated charcoal Q2: Acetaminophen overdose?
Ibuprofen (NSAID) Q2: An 8-year-old child has swallowed

twelve 325 mg acetaminophen tablets.
Acetylcysteine
Acetaminophen (tylenol) The mother brings the alert child to the Kaplan Questions
emergency department.
Q1: Treatment of acetaminophen overdose?
Aspirin (salicylate) Prioritize the nurse actions that
should occur.
Acetylcysteine
1. Ensure patent airway Q2: Preschool-age client diagnosed with an

Priority Interventions 2. Prepare to give activated charcoal acetaminophen overdose. Which
laboratory test result is most important
3. Complete a history & physical
for the nurse to evaluate?
1. Emergency department 4. Check blood acetaminophen levels
Liver function test
2. Activated charcoal
3. Full assessment w/ labs Acetaminophen
levels
Acetylcysteine EG
ACTIVATED
CHARCOAL Acetylcysteine EG
Education
Which nursing information is appropriate when “I just found my 2-year-old in the kitchen
teaching parents about poison prevention? surrounded by several bottles of cleaning
SATA solutions and the bottles are all open!”
• Keep medications locked & out Keep medications locked & out of the Which action by the nurse is best?
sight of children
of the sight of children Put the contact number for the poison
Call the poison control center
control center near the phone

• Have the contact number for the
poison control center near the
phone ACETAMINOPHEN
(TYLENOL)
IBUPROFEN
2 years old POISON
CONTROL
Poison control:
09-xxxxxx
CENTER
ASPIRIN
Calling...
Notes
418
_ _
Respiratory
419
Asthma
Pediatrics: Respiratory
Pathophysiology
Asthma is a chronic inflammatory disorder in the major pathways of the lungs:
Bronchi & Bronchioles. It comes & goes with flare-ups in the form of asthma attacks
that are reversible!
MEMORY TRICK During an asthma attack, 2 key things happen:

A - Asthma 1. Bronchoconstriction:
A - Acute Attacks that come & go Bronchi puff up with inflammation & get VERY tight.
2. Wet, mucus filled lungs:
Excessive mucus production from goblet cells that line the
#1 #2 respiratory tract.
Bronchoconstriction wet & mucus filled
PRIORITY! Since the respiratory tract is so constricted that oxygen cannot get
in & CO2 cannot get out, resulting in air trapping and making it hard to exhale.
Signs & Symptoms
Top Missed NCLEX Question:

A Accessory muscle use
Critical Sign: Paradoxical Breathing
S
Which child in the pediatric unit
SOB & dyspnea
should the nurse see first?
Critical Sign: Single word dyspnea
T
1. 8 year old with cystic fibrosis
Tight CHEST & Tachypnea presenting with fever &
green sputum
H
2. 10 year old with croup
presenting with a barking
High-pitched wheezing cough & tachypnea
3. 6 year old with acute asthma
M
exacerbation suddenly has
no wheezing
Minimal “diminished breath sounds”
4. 11 year old with new
A
tachycardia & anxiety after
albuterol nebulizer treatment
3 As 6 year old
Absent Breath Sounds (Silent Chest) PRIORITY
Acidosis (CO2 retention)
Air trapping - Prolonged exhalation
Critical Complications Key Sign of Status Asthmaticus Test Tip
Hypercapnic respiratory failure = HIGH CO2 Pulsus paradoxus 150
100
Pulsus paradoxus
Drop in systolic blood pressure

Hyper Capnic = High Carbon dioxide
50
More than 10 mmHg

1. Decrease in stroke volume
2. Decrease in systolic blood pressure
(systolic squeeze)
ABG (Arterial Blood Gas) 0₂
0₂
0₂
0₂ 3. Pulse wave amplitude during inspiration
pH less than 7.35 = Acidosis
PaCO2 - Over 45 = Acidosis
PaO2 - Less than 80! = Hypoxic
* 1st Sign of Hypoxia = Mental Status Change Patho: increased negative pressure > 10 mmHg
1. Agitation PRIORITY
within the lungs puts a lot of added 90
2. Restlessness NCLEX TIP
3. Drowsiness pressure on the left ventricle,
Status Asthmaticus NCLEX TIP making it difficult for the heart to
1. Endotracheal Intubation pump oxygen rich blood to the body.
420
Croup
Croup - Pathophysiology
Viral Infection of the upper airway.
Signs & Symptoms
6 months - 3 years old
Barking cough
Fever
Treatment / Education
1. Assess respiratory status

2. Discharge education:
stand in front of the open freezer
ATI Question
3 year old with croup. The most important
initial intervention to perform is:
Assess respiratory status KAPLAN Question
The 3-year-old child is seen... for croup.
The parent asks what to do for the child
HESI Question at home to alleviate symptoms?
After a 3-day hospitalization for croup ... “Stand with your child in front of
the nurse is working with the parents to an open freezer.”
discharge the child … best action?
Ask, “Do you have a freezer with
your refrigerator?”
Notes
421
Asthma II
Diagnostics
PFT - Pulmonary Function Test
This diagnostic test shows how well the lungs are working.
It measures total lung capacity, volume, gas exchange & rates
of flow. This data helps the healthcare provider (HCP) diagnose
& treat lung disorders
Peak Expiratory Flow Rate Red zone

• Red means Really bad!
• Sort of like a weather forecast - we want to anticipate • Emergency treatment is needed immediately if the level
a Severe asthma attack - before it happens! does not return to yellow RIGHT after taking rescue drugs!
Green zone Correct Order - Peak Flow Meter

• Green means go.
900
800
700
600
500
400
300
200
100
1. Stand or sit in upright position
• Asthma is around 80 - 100% under control. 2. Put the flow meter scale to 0 or
lowest value
3. Inhale deeply
Yellow zone 4. Put the mouthpiece in mouth & HESI
create a seal with the lips
• Yellow means mellow. 5. Exhale as quickly & forcibly as
Q1: … understanding the peak expiratory flow
rate test?
• Asthma is NOT under control here! So there is a possible & record reading Assesses the severity of asthma
HUGE need for additional medication 6. Repeat 2 more times, with a Q2: A child … with a new diagnosis of asthma…
1. Rescue drug every 4 hours for 1-2 days break of 5 -10 seconds between
discharge plan?
2. Call HCP (provider) 7. Record 1 score = the HIGHEST
Teach the parents about peak expiratory
flow rates
NEED additional meds or change in treatment of the 3 attempts Home assessment for allergens
Triggers HESI
Q1: Which triggers tend to aggravate asthma in
children?
Exercise
Tobacco smoke
MEMORY TRICKS
A
Q2: Which reason is appropriate when preventing
respiratory tract infections in children with Allergens (dander, dust, pollen)
asthma? Elevated Eosinophils
Can trigger an episode or aggravate an
S
asthmatic state
S - Smoking (second hand cigarette smoke)
S - Stress (emotional, physical)
Kaplan
… determining the cause of the acute asthma
attack?
“My child slept on a new pillow last night.”
Extrinsic (External)
Drugs to AVOID
Type I hypersensitivity
Immediate allergic reaction NAPROXEN
• N - NSAIDS Naproxen, Aspirin, ibuprofen, KETOROLAC
indomethacin, & ketorolac

Intrinsic (Internal)
• N - Not good for Asthma
Airway hyperresponsiveness (adult-onset)
Asthma attacks brought on by:
• S - Sickness (Respiratory infection)
• B - Beta blockers
• S - Stress
• B - Blocked HR & lungs
• S - Severe weather (cold)
• Propranolol (Inderal) = Nonselective
• S - Strenuous activity (exercise)
• Atenolol = Selective (cardio “Beta 1” selective)
• Drugs
422
Cystic Fibrosis
Pathophysiology
Cystic fibrosis is serious mucus all over the body, which clogs
& damages the lungs, digestive tract, & reproductive organs
Cystic Fibrosis
Signs & Symptoms

4 NCLEX TIPS
0₂
1. Chronic hypoxemia (low oxygen) >150
0₂
0₂
0₂ & respiratory infections
2. Bowel obstruction “Meconium ileus”
& Vitamin deficiencies 15kg
Diabetes Mellitus
B1
3. Weight LOSS & Failure to thrive
C
B12
D 4. Diabetes mellitus (HIGH blood sugar)
Causes Diagnostics ATI

.. child who is suspected of having cystic
Children inherit 1 copy of the gene from Blood sample or sweat test, fibrosis (CF). Which of the following
each parent in order to have the disease. once the infant is at least 2 weeks old. diagnostic tests will confirm the diagnosis?
Sweat chloride test
Blood sample Sweat chloride test

HESI
… child admitted to rule out cystic fibrosis. Which
2 weeks old
result should be reported to the HCP?
Sweat chloride concentration of 80 mEq/L
Complications
HESI
Bowel obstruction “Meconium ileus” Q1: … endocrine disorder commonly found in
children with cystic fibrosis?
>150 Diabetes mellitus
Diabetes Mellitus (HIGH blood sugar) Meconium ileus Q2: Which is the earliest postnatal manifestation
of cystic fibrosis?
Meconium ileus
Since the pancreas is clogged with mucus INsulin cannot get out of
the pancreas to put that sugar INto the cell, resulting in diabetes. Diabetes Mellitus
Nursing Care ATI KAPLAN

A 9 month old infant diagnosed with cystic Q1: … child diagnosed with cystic fibrosis.
fibrosis. Which of the following strategies The nurse should intervene when:
2 NCLEX TIPS should the nurse explain when instructing

the parents? The child takes the pancreatic enzymes
one hour after eating
Performing chest physiotherapy
High calories Q2: The nurse instructs the parents of a
High fat, protein, carbohydrates

7-year-old child diagnosed with cystic fibrosis
about required dietary modifications.
Increase protein & carbohydrates
Pancreatic Enzymes
423
Asthma III
Pharmacology
NCLEX TIP
BRONCHOdilators ANTI-INFLAMMATORY Agents
B Beta 2 Agonist
Albuterol
S Steroids
Beclomethasone
A Anticholinergics
Ipratropium
L Leukotriene Inhibitor
Montelukast
M Methylxanthines
Theophylline
M Mast Cell Stabilizers
Cromolyn
Bronchodilator - BAM team ATI

… new prescription for levalbuterol solution via
nebulizer. Which of the following statements ...
• B - Beta 2 agonist - albuterol - think buterols for brutal asthma attacks! indicates an understanding of the teaching?
It's considered the one & only rescue drug

My child could have heart palpitations
while taking this medication
for asthma attacks

• A - Anticholinergics - Ipratropium - dries out the body, decreasing secretions MEMORY TRICK
& dilating the airways - you cant pee - with AIM for Acute Asthma Attack
a tro-pium
A - Albuterol 1st
• M - Methylxanthines - Theophylline - very toxic & very fast HR! I - Ipratropium 2nd
10 - 20 therapeutic range M- Methyl-predniso-lone
MEMORY TRICK Phyllines have you feeling toxic & tachycardic (brand: Solumedrol)
Anti-inflammatory Agents - SLM Team

• S - Steroids “-sone” like Beclomethasone -
Top side effects - 3 Ss for Sone Steroids
S S S
• S - Sores in mouth (oral thrush “candida”) so instruct the client to wash
out their mouth after every use & inhalers go into the sink, twice per week.
• S - Sepsis & sickness (increased risk for infection) & increases WBC count BECLOMETHASONE
in the body
• S - Sugars increased (elevated glucose levels)
Last 2 - are NOT highly tested here

• L - Leukotriene inhibitors ending in Lukast like Montelukast (Singular) - think Luke
likes to sing
• M - Mast cell stabilizers - Cromolyn
Metered Dose Inhaler

Top Missed NCLEX Question: Top Missed NCLEX Question:
Teaching a child proper use of a
metered dose inhaler (MDI) with a spacer.
Place the instructions in order. The best indicator that treatment
900
800
700
has been effective for a child with
acute asthma.
92%
600
Ordered Response 500
400 1. Less wheezing heard without

300 stethoscope
3. Shake the MDI & then attach it to spacer
200
2. No wheezing heard during
auscultation of the chest
100
2. Exhale fully
4. Firmly place lips around the mouth piece 3. Oxygen saturation has
increased from 85% to 92%
1. Deliver one push of the medication
4. Peak expiratory flow rate that
1st
increases showing increased
2ⁿd
6. Take a deep breath slowly & hold for 10 seconds
airflow
Highly missed question 5. Wash mouth out with water
424
Epiglottitis
Pathophysiology
Epiglottis is a DEADLY medical emergency, where severe & sudden

inflammation near the epiglottis blocks the child's airway!
Inflamed
epiglottis
The epiglottis is the flap in the throat that prevents food entering
the trachea. When it gets inflamed it blocks the airway quickly! Tongue
Children can present with no symptoms, to having a completely
Airway
occluded airway within hours!
Signs & Symptoms

HESI Question
Kaplan Question
Q1: Which clinical manifestations are The 4 year old with... acute
appropriate for acute epiglottitis?
Anxious & restless behavior Select all that apply.
epiglottitis. Which assessment finding
is most significant?
● Pain
● Drooling of saliva
Stridor (squeak) NCLEX TIP ● Fever
● Drooling
Fever, drooling, & tripod

● Tripod position ATI Question
Q1: ... Which client should the nurse
Q2: Which student action will the
positioning NCLEX TIP nurse need to correct when
assess first?
● A school-age child who has
caring for a child with epiglottitis?
acute epiglottitis, is drooling,
● Take an oral temperature and has an absence of
spontaneous cough
Q2: … 4 year old child who has
epiglottitis…. action should the
nurse take?
● Monitor oxygen saturation

Epiglottitis affects more males than
females.
A lot of students get this wrong!
Haemophilus influenza
type B (HiB)
Missing standard
vaccinations NCLEX TIP
Interventions & Education

HESI Question
FIRST
Which treatment is
4 NCLEX TIPS appropriate for the child
with epiglottitis and severe
Airway Breathing Circulation
respiratory distress?
1. Priority = AIRWAY!
● Nasotracheal intubation
or tracheostomy
2. NO throat inspection & NO
oral temp
Until endotracheal intubation
& tracheostomy kit is ready
3. Tripod position
4. GET standard immunizations
425
Tonsillitis & Tracheostomy Care
Tonsillitis - Pathophysiology
Tonsillitis is the inflammation of tonsils, the little soft tissue masses located near the rear
of the throat. When these guys get inflamed it can lead to a life-threatening airway obstruction!
Signs & Symptoms
Trismus: inability to open mouth Trismus requires immediate attention, as it indicates a tonsillar abscess
Report to HCP! NCLEX TIP (collection of pus) that prevents the mouth from opening, resulting in a
Muffled voice & pooling saliva blocked airway. Very deadly!
T T
ATI Question
... findings of hemorrhage following
a tonsillectomy:
My child swallows frequently.
Frequent swallowing
Trismus Treated ?
HESI Question
A 9 year old child is recovering from a
tonsillectomy. The nurse notes that
the child is swallowing frequently.
What is the nurse’s next action?
Place in a side-lying position
Tracheostomy Care - Teaching MOST tested
The big key point is teaching the parents about accidental decannulation
(cannula popping out & getting dislodged). This is very deadly, as it means
the child has lost their airway & has no means to ventilate!
Teaching for New Trach HESI Question

… 7 year old child going to school for
Always travel with: NCLEX TIP the first time… has a permanent
tracheostomy. What information must
2 spare tracheostomy tubes the nurse include to the parents?
1 same size & 1 smaller size Place suctioning supplies on

the back of the wheelchair
when transporting
Same size Smaller
426
_ _
Renal & urinary
427
UTI & Pyelonephritis
Pediatrics: Urinary & Renal
UTI
UTI- Pathophysiology
- UTI: urinary tract infection - urethra, bladder
- Cystitis: Bladder infection Bladder
Uretha
If that infection gets bad enough it can migrate & sort of climb up the
Ureters to infect the kidneys. UTI
Signs & Symptoms Urinalysis

NCLEX TIPS
▪ Fever ▪ Cloudy & smelly

▪ Dysuria ▪ WBC
“Burning during urination” ▪ Nitrites - Kidney infection
▪ Urinary Frequency ▪ Urine Culture & Sensitivity Assess 1st Interventions 2nd
constant feeling of having to void Over 10,000 organisms/ml
Pyelonephritis - Pathophysiology Signs & Symptoms
Pyelonephritis: aka kidney infection

- more serious infection. Dull Flank pain
Kidney pain
Ureteral pain
Extending toward Umbilicus

Causes
- Urinary retention
- BPH
- Holding urine too long - nurse bladder Diagnostics
- Kidney stones - renal calculi - #1
can hold back urine
First Action:
- Foley catheters Obtain blood and urine cultures
- E Coli - MOST COMMON - bacteria in and then begin ANTI-biotics
colon gets into urethra
- Wiping back to front - scrapes ecoli
into urethra Nursing Interventions
Complication NO Douching
?
?
?
? Increase Fluid Intake
2000 mL water daily
NO Spermicidal contraceptive
Confusion, UTI - quickly turns into NO Perineal deodorants
Void after sex
urosepsis - infection in the blood that NO Synthetic fabrics
Take cranberry supplements “Nylon” “Spandex”
infects the brain. NO Bubble Baths
Avoid: Caffeine & Alcohol
Wipe FRONT to back
Pharmacology
Treatment
VCF
Antibiotics: Sulfonamides & Levofloxacin

& Give analgesics for the pain NSAIDs ACETAMINOPHEN
(TYLENOL)
428
Cryptorchidism & Hypospadia / Epispadia
Cryptorchidism
This condition describes undescended testicles, when a testicle that has not NOT priority
descended into the scrotum before birth, which is very common in premature descend spontaneously
male babies. It’s not a priority, since most cases resolve on their own 6 months by 6 months after birth
after birth.
Don’t let
> 1 YEAR OLD
NCLEX
If NOT corrected by the time the child is 1 year old the TRICK YOU
male baby can become sterile later on in life meaning they
will not be able to have children. Surgery can be used to fix
this condition.
Epispadia
This is a rare birth defect where the opening of the urethra presents on
the top of the penis (the dorsal surface) rather than the tip.
HESI Question
In what defect ... is the meatus
opening located on the dorsal
surface of the penis?
Epispadias
Epispadia Normal
Hypospadia NCLEX Favorite

Hypospadia is a congenital birth defect in which the Key Points
NCLEX urethral opening is on the underside of the penis
rather than the tip. Surgical correction typically takes
Circumcision is delayed
place before 18 months of age. NO Urinary output = priority
NCLEX TIP
After surgery, urinary output is very closely
monitored due to a temporary stent or catheter
placement.
NO Urinary Output = Priority! HESI Question
Hypospadia Normal This indicates that the urethra is blocked & must be Hypospadias... Which parent statement indicates
reported to the HCP immediately. the nurse’s teaching has been successful?
A circumcision will not be performed
before discharge
YED KEY TERM
DELA
ATI Question
… A urinary stent after a procedure to repair
hypospadias. Which of the following should the
PRIORITY nurse advise the parents?
Avoid tub baths until the stent is removed
Notes
429
Enuresis (Bed-wetting) & Vesicoureteral Reflux
Enuresis - Pathophysiology
Involuntary urination or bedwetting at night especially in younger children.

It is thought to be caused by certain medical conditions like urinary tract infections,
>120
diabetes, & constipation, and some studies show mental health conditions like
increased stress or even night terrors.
Treatment Pharmacology
HESI Question
We can use Imipramine, which is a tricyclic
Patient Education Which nursing actions are
appropriate to include in the plan antidepressant, but it also helps to inhibit
4 NCLEX TIPS of care for a child with enuresis?
urination.
1. AVOID punishment
HESI Question
• Implement a calendar to record
wet and dry nights
2. AVOID disposable diapers/ • Teach positive reinforcement
training pants instead of punishment
• Limit the amount of fluid intake Which medication is
3. Teach positive reinforcement after 1800 appropriate for a child
• Calendar to record wet & • Teach parents to observe for side
effects of any medications used diagnosed with enuresis?
dry nights
• Encourage child to help • Imipramine
clean soiled sheets
4. Void:
• Wake the child at an expected
I T
LIM
time each night to use the toilet
IMIPRAMINE
• Before bed
• Restrict fluids after dinner time
Vesicoureteral Reflux Complications
Recurrent kidney
Vesicoureteral reflux
infections HESI Question
Vesicoureteral reflux
Vesico = bladder ! is associated with

which condition?
!
Ureteral = Ureter • Recurrent kidney
infections
Reflux = backed flow !
This describes the backflow of urine into the kidney, Another complication is Hydronephrosis - where we see
typically caused by a faulty valve within the bladder. an overfilled distended kidney from this backup of urine,
This backup of urine remains in the body causing which could cause kidney damage!
infection leading to recurrent UTIs & kidney infections.
Surgery
Clients recover from surgery with a ureter tube draining
from the kidney. It is a priority to monitor urinary output!
NO Urinary Output = Priority!
Ureteral Reported to the HCP immediately.
Ureter
Priority
BACKED
FLOW
NO Urinary output
Vesico = priority NCLEX TIP
Bladder Reflux
430
Glomerulonephritis vs. Nephrotic Syndrome
Glomerulonephritis - Pathophysiology GlomeruloNEPH-ritis
Glomerulonephritis is inflammation & scarring of the kidney, specifically in the

glomeruli, the little washing machine bubble in the kidney. This inflammation
destroys the little glomeruli causing increased permeability, like poking holes
in a coffee filter, the kidneys now leak small amounts of protein instead of filtering it.
Causes HESI
Which condition is appropriate when considering
Streptococcal infection like strep throat can travel down to the kidneys, causing common post-infection renal diseases in childhood?
glomerulonephritis. It typically resolves by itself within 14 days once the infection is gone. Acute glomerulonephritis
Signs & Symptoms

Top Missed NCLEX Question:
Glomerulonephritis While caring for a 9-year-old ATI
with acute glomerulonephritis,
UA: lower Proteinuria the nurse knows which clinical 10-year-old child who has glomerulonephritis ...
assessment finding is priority to priority for the nurse to report to the provider?
• Recent Strep infection monitor? Serum creatinine 1.3 mg/dL
• Fever NORMAL
1. Proteinuria
• Blood Labs: WBC HIGH
HIGH
LOW
HESI
2. Urine output
3. Blood pressure
4. Daily weight measurements Which clinical manifestations are appropriate
with the diagnosis of ... glomerulonephritis?
Edema, decreased urine volume,
“Daily weight hypertension
NCLEX TIP
measurements”
WG = Weight Gain 20 kg
Water Gain
Nephrotic Syndrome - Pathophysiology High

Protein Loss
Nephrotic Syndrome, also called nephrosis, is an autoimmune disorder where the body
attacks its own kidneys, triggered by the 4 Ss: stress, sickness, smoking & sun exposure.
Key Point Nephrosis results in HIGHER PROTEIN LOSS when compared to glomerulonephritis.
Signs & Symptoms Low Albumin

HIGHER protein loss
Top missed NCLEX Question when compared to
glomerulonephritis.
Albumin
A 6-year-old male client is diagnosed with nephrotic

syndrome. According to the lab results, what can be
Exhibit
concluded about the pathophysiology of this disease?
Click on exhibit. UA: HIGH Proteinuria
Lab Results
Glomerular injury Blood Labs: Low Albumin
Serum Albumin: 2.5 g/dL “Hypoalbuminemia”
Total Cholesterol: 350 mg/dL
Urinalysis, protein: 2+
Urinalysis, glucose: Negative MEMORY TRICK
Urinalysis, blood: Moderate
Close
- Nephrotic Syndrome
- Nasty protein loss
Deadly Complication Education

Oliguria
LOW urine output
Renal Failure & HTN Crisis!
2 NCLEX TIPS Limit
Report key signs:
• Headache & Mental Status Changes
! Limit visitors
!
• Nausea & Vomiting
• Oliguria - NO or low urine output Do NOT organize playdates
• New, Sudden, Rapid Weight Gain with other children
!
431
Wilms Tumor (Nephroblastoma)
Pediatrics: Cancer
Pathophysiology & Causes MEMORY TRICK
Nephro blastoma
Nephroblastoma is the most common type of kidney cancer in children.

When kidney cells do not fully develop to maturity, the cells overgrow
resulting in a Wilms tumor.
Nephro - meaning kidney

Q1: Which is the main difference between
One sided abdominal

neuroblastoma and Wilms tumor?
Wilms tumor is confined to one side
mass “bulging” NCLEX TIP of the abdomen
Q2: Which are the clinical manifestations of

Fever Wilms tumor? Select all that apply.
Fatigue
Fever
Fatigue
Hematuria Hematuria
Abdominal swelling or mass
Intervention
DO NOT PALPATE HESI

DO NOT PALPATE ABDOMEN
Wilms tumor: What is the most important safety
the abdomen NCLEX TIP precaution for a child?

Place a “do not palpate abdomen” sign on
head of bed
Place a BIG SIGN over the client’s bed stating ATI

DO NOT PALPATE Abdomen. Wilms tumor: Which of the following signs should
Palpating the abdomen increases the risk of the nurse place over the child’s bed?
rupturing the encapsulated tumor, which could Do not palpate abdomen
cause cancer cells to spread all over the body.
Treatment
Nephrectomy surgery is done to remove either the whole kidney or only

part of the kidney & surrounding tissues.
After surgery, chemotherapy & radiation therapy is used to ensure the
elimination of cancer cells.
HESI
A 3 year old child is scheduled for surgery to
remove a Wilms tumor … What treatments …
will be necessary after surgery?
Chemotherapy with or without
radiotherapy is indicated
432
_ _
Eye & Ear
433
5 Eye Disorders
Pediatrics: Visual & Audio
MYOPIA STRABIMUS AMBLYOPIA
1. Myopia TOP TESTED

2. Strabismus
3. Amblyopia
ASTIGMATISM HYPEROPIA
4. Astigmatism
5. Hyperopia
Myopia - Pathophysiology MEMORY TRICK
MYopia MY or mine
Myopia, also called nearsighted, clients have trouble seeing at a distance, (bring objects closer)
meaning clients can see better when objects are near!
In a normal eye, images are focused & dialed in on the retina, but in myopia
the eye structures focus images in FRONT of the retina causing far images
to be blurred.
Signs & Symptoms

HESI Questions
Q1: … difficulty reading the board at school
4 NCLEX TIPS and complains of frequent headaches?
1. Squinting to read word far away Myopia
2. Holding books close to the face to read Q2: … clinical manifestations appropriate
3. Sitting too close to the TV for myopia in children?
4. Headaches, dizziness, & clumsiness HESI
Dizziness Clumsiness
Headaches Eye rubbing
Strabismus - Patho & Signs Complication Treatment

This is a disorder where the eyes
appear crossed (crossed eyes) &
don't look in the same direction
at the same time.
Untreated by age 5 or 6 Patch over the stronger eye NCLEX TIP
MEMORY TRICK Amblyopia: Permanent loss of visual acuity
CROSSED EYES
HESI Questions
Over 30%
Strabismus of student got this WRONG
Stray-bismus ... importance of detecting strabismus
in young children?
Amblyopia (a type of blindness)
434
Otitis Media
M
id
Otitis Media (OM) is an infection within the eustachian tubes, the air-filled
dl
ee
ar
space behind the eardrum. The infection leads to major inflammation &
purulent fluid inside the middle of the ear. Eustachian tubes
Since eustachian tubes are shorter in younger clients, children less than
2-years-old tend to get these infections frequently.
Less than 2 years old Normal ear Otitis Media
KAPLAN Question
Memory trick Frequent acute otitis media infections ...
which explanation?
Otitis Media = Middle ear Children have shorter eustachian tubes
Risk Factors Key Points:

Pacifiers & attending daycare
NO routine vaccinations
U
C History of chronic ear infections
B
A C
Parents that smoke
(cigarettes / cigars) NCLEX TIP
Signs & Symptoms

ATI Question
5 NCLEX TIPS
Q1: … which finding indicates a tympanic membrane rupture?
1. High fever
Sudden relief of pain in a child with otitis media with effusion
2. Refusing to eat
Q2: ... infant who has acute otitis media. Which of the
3. Restless and irritable “crying more” following statements should the nurse expect the parents to
4. Not sleeping make? Select all that apply.
My baby has been pulling at her ears
5. Ear pain - Frequently tugging on
the affected ear My baby has not been drinking her bottles lately
Z
Z
Z My baby is not sleeping at night
Complication My baby has been very irritable and crying more lately
Sudden relief of pain
Nursing Care AVO

ID
1. Encourage routine vaccinations
(influenza & pneumonia)
Otoscopic examination
2. Examine the ear at the very end of assessment
3. AVOID inserting too far into the ear!
Only to the bony interior part of the ear canal
4. Inspect the tympanic membrane for redness,
bulging, and perforation
END OF ASSESSMENT
435
5 Eye Disorders II
Amblyopia - Patho & Causes

Also called a lazy eye, is a type of blindness or reduced visual acuity that
can occur if strabismus is untreated by age 5 or 6. It is caused by a
dysfunctional nerve pathway between the brain & eye resulting in the HESI Questions
brain favoring one eye.
... reduced visual acuity in one eye
5-6 years old despite appropriate optical correction?
Amblyopia
One or both wandering eye(s) that wander inward or • Eye patches,

outward. Vision is impaired with poor depth perception • Drops,
resulting in the client squinting or shutting an eye in
• Glasses, or contact lenses,
order to see.
• Surgery (sometimes).
Astigmatism - Patho & Causes Symptoms Treatment
Refractive error in which the eye does Symptoms naturally include • Glasses,
not evenly focus light on the retina. eyestraining, squinting, headaches, • Contact lenses
This results in distorted or blurred vision and trouble driving at night. • Surgery
at any distance.
Hyperopia - Patho & Causes Signs & Symptoms Treatment
Also called farsightedness, patients can Nearby objects = blurry • Corrective lenses - contacts or
only see FAR objects, distant objects look Squinting, headaches, & burning glasses
somewhat clear, but close objects eyes with eye aches too. • Refractive surgery
appear blurry.
It is caused by a refractory error where
images focus in the BACK of the retina
making close images blurry. Lazer
Normal Hyperopia
E E
436
Otitis Media II
Pharmacology
Antibiotics: Amoxicillin
48-72
hours 2 NCLEX TIPS Amoxicillin Amoxicillin
1. Return to the clinic if s/s

do not improve within 48 - 72 hours
2. Finish all antibiotics - DO NOT stop

halfway through!
50%
Education
3 NCLEX TIPS Over 50% got it WRONG!
1. Smoking cessation by caretakers

2. Routine vaccinations STOP
(influenza & pneumonia)
3. Stop pacifier use after 6 months old
Surgical
ATI Question
Tympanostomy tubes … tympanostomy tubes inserted: understanding of the teaching?
I should insert earplugs before my child swims in a lake or ocean
Myringotomy HESI Question
Education Post-Op:
.. 2-year-old who just underwent a myringotomy. What instructions
will the nurse include? Select all that apply.
Do not immerse the child’s head in water when bathing
Earplugs before going swimming Administer the Tylenol as prescribed
Do not substitute aspirin for the prescribed Tylenol

DO NOT immerse child’s head in water Purchase earplugs and place them during bath time
Notes
437
Hearing Deficit & Visual Screening
Hearing Deficit Pathophysiology & Causes

With hearing deficit there is a blockage in the middle ear that prevents
sound waves from reaching the middle ear, resulting in the client only Conductive hearing loss
hearing muffled sounds.
Key Point:
(middle ear problem)
Infants with hearing impairment can have delayed speech development
if not corrected early! As the child grows, the speech will become more &
more distorted. HESI Questions
Q1: Which type of hearing loss is
Caused from repeated ear infections, the use of certain medications, characterized by interference
or certain congenital disorders. with the loudness of sound?
Conductive
??? Inner ear
Q2: Which complication is appropriate

for prolonged middle ear disorders?
S o u n d w a ve s
Loss of hearing
Middle ear
Infants MOST tested Use sign language and hearing aids.
No babbling sound “mama, dada”

Toddlers 3 NCLEX TIPS
Speech that is monotone

Uses LOUD voice
Shy withdrawn behavior
& Lack of attention
Visual Screening
HESI
Visual assessment begins with the use of a Snellen chart or Tumbling E chart,
Which tests are used to assess visual acuity
clients are asked to read the letters from top to bottom. Children stand 10 feet in children ages 3 to 5 years?
away & adults stand 20 feet away from the chart. Select all that apply.
Tumbling E
Snellen letters
An ophthalmologist referral is made if a child is unable to identify at least 4
letters on the 10/15 line (equivalent to 20/30 vision).
Snellen chart or Tumbling E chart

Children: 10 ft away (3m) NCLEX TIP
from the chart

4 - 6 letters
10ft (3m) Adults: 20 ft away (6m)
20ft (6m)
Infant Assessment
HESI
Infants: use light reflex tests Which is a sign of visual impairment
To assess vision in in an infant?
to observe blink response,
newborns & infants: No reaction to light
alertness, & following the light.
438
Retinoblastoma
Pathophysiology
Retinoblastoma is the most common eye cancer in childhood,

typically diagnosed in children less than 2 years of age.
≤ 2 year-old Retinoblastoma
Signs & Symptoms

MEMORY TRICK Normal
First recognized when parent report a
RED-inoblastoma white pupil.
NCLEX TIPS This may be first seen while taking a
1. White pupil (Leukocoria) photograph using a flash.
Late sign Another sign is a Strabismus, or wandering
2. Absent red reflex misaligned eye, but that is a late sign.
Interventions Retinoblastoma interventions - Radiation
Siblings should undergo

ocular screening NCLEX TIP
Enucleation
(removal of the eye & placing a prosthesis)
Siblings should undergo ocular screening as some forms

of retinoblastoma are hereditary.
Notes
439
_ _
Clinical Skills
440
441
442
443
444
445
446
447
448
449
8-14 Personal protective equipment
Purpose
To protect yourself and the client from infection and disease transmission.
Donning Removing
★ Hand hygiene ★ Gloves
★ Gown ★ Goggles
★ Mask ★ Gown
★ Goggles ★ Mask
★ Gloves ★ Hand hygiene
Precautions
Contact Airborne
M: Multidrug resistant
M: Measles
Droplet
organisms S: Sepsis, scarlet fever,
R: Respiratory infections T: TB
V: Varicella strep
S: Skin infections P: Parvovirus, pneumonia,
pertussis
W: Wound infections I: Influenza
E: Enteric infections D: Diphtheria
E: Eye infections E: Epiglottitis
R: Rubella
V: Varicella M: Mumps, meningitis,
C: Cutaneous diphtheria mycoplasma, meningeal
H: Herpes simplex pneumonia.
I: Impetigo A: Adenovirus, AIDS
P: Pediculosis N: Now repeat it twice!
S: Scabies
Standard precautions
★ Apply to all body fluids secretions, excretions and mucous membranes.
★ Handwashing: Before and after procedure, and when soiled, wash hands in
warm water vigorously while singing happy birthday 2x.
★ Gloves.
★ Gown.
★ Mask. www.SimpleNursing.com
★ Eye protection. 450
451
452
453
_ _
Critical thinking
454
_ _
BLS & CPR
455
BLS & CPR
Pathophysiology Instruction
Done for clients who go into cardiac arrest If NO caregivers are around to help, you must
meaning the heart has stopped pumping! initiate immediate CPR with high quality
compressions. Start chest compressions BEFORE
calling for help if you are the only caregiver!
CARDIAC ARREST (Most students get this wrong on exams)
Causes
Immediate CPR with
Caused by a variety of factors from Hypoxia, high quality compressions
respiratory failure, toxins, blood clots, electrolyte
imbalances & others. They are commonly
described as Hs & Ts.
#1
Hypoxia Respiratory failure Toxins
Immediate CPR with chest compressions helps to

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

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

min min
Chest compressions Immediately paused every 2 mins to assess

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

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

0 00:00:00
AED
₂
O
00:06
LOWER HALF
OF STERNUM
NO IV sedation needed.
Left lateral chest
NO synchronized button.
That is for cardioversion
456
BLS & CPR II
Pediatric AED Infant CPR
1. Brachial pulse for 10 seconds

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

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

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

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

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

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

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

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

Key terms
Comatose/
NCLEX TIP not following commands
Chest compressions slightly higher Priority intervention:
on the sternum - Cold fluids for
Uterus: manually displaced to therapeutic hypothermia
6 hours
left side or place a rolled blanket
under right side
NOT SUPINE
NCLEX TIP
C C
Priority, if circulation does not return after 4 minutes then
#1 PRIORITY
an immediate C-section must take place typically within
5 minutes of starting CPR
COMATOSE COLD FLUIDS
not following Commands therapeutic hypothermia
PRIORITY
4
mins
5 mins
457
_ _
Burns
458
Burns
Types & Causes Care for Minor Burns

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

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

REMOVING ALL
• Dry with blanchable redness instructs the employees that
what is the first consideration in
Second-degree (partial thickness) immediate care?
• Painful Blisters NCLEX TIP • Removing all clothing,
! including gloves, shoes,
• “Red, moist, shiny fluid filled vesicles” and any undergarments
Third-degree (full-thickness)
Kaplan Question
!
• Dry waxy white, leathery, or charred
black color, non-blanchable
The nurse is caring for a client
Fourth-degree (full-thickness) with full thickness burns
covering 20% of their body.
What is the priority of care
after ensuring a patent airway:
! ! ! ! !
! !
! ! !
!
● IV fluids
! ! ! !
Notes
459
Major Burns
Pathophysiology
Saunders
Massive tissue damage & cellular destruction leads to
widespread systemic inflammation that increases vascular Extensive burn injury ... 45% of
total body surface area… 45%
permeability (leaky blood vessels that fill up the body like a
planning for fluid resuscitation, !
water balloon). This results in low fluid volume within the the nurse should consider that
blood vessels leading to Hypovolemic Shock & then death! fluid shifting to the interstitial !
!
spaces is greatest during which
Low fluid volume
time period?
18 - 24 hours
! • Between 18 and 24 hours
after the injury
!
!
Signs & Symptoms
First 24-hours Over 5.0

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

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

pulse rate of 110, and a urine
IV Lactated Ringer’s IV Normal Saline output of 20 mL over the past
(LR) solution (0.9% sodium Chloride) hour. The nurse ... anticipates
which prescription?
Increasing IV Lactated
LACTATED RINGER’S Ringer’s solution
NaCl 0.9%
#1
Administer enteral feedings ≥ 30 mL/hr
Once bowel sounds return
Kaplan Question
Assessment of ≥ 90 Systolic
Fluid Resuscitation
≥ 30 mL/hr
90 Patient with burns who is
immunocompromised….
1. Urine output
30 mL/hr or MORE NCLEX TIP What precautions should be
taken to prevent ... infection?
2. Blood pressure
(90/systolic Or MORE) Avoid placing fresh
3. Heart rate less than 120/min. < 120/min flowers or plants in or
near the client’s room
460
Burns - Rule of 9s
& Rehabilitation Phase
Rule of 9s Rehabilitation Phase

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

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

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

1%
For the perineum

9% 9% 9% 9%
E - Exercise daily
(Range-of-motion)
Once the total body surface area is calculated
then the volume needed for emergency fluid
resuscitation within the FIRST 24 hours can be
calculated using the Parkland Formula
Parkland Formula
40.0
0
4 mL x kg of body weight x TBSA %
4 mL body weight %TBSA
461
Burns
Top Missed Questions
Top MISSED Questions

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

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

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

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

TBSA… calculate the lactated 4 mL 100 kg 19% TBSA
Ringer’s fluid resuscitation
needed? 3,800 mL 3,800 mL
4 mL x 100 kg x 19 TBSA
LACTATED RINGER’S LACTATED RINGER’S
Answer = 7,600 ml
(within the first 24 hours)
8 hours 16 hours
462
_ _
Cardiac Care
463
5 Step
EKG INTERPRETATION
Heart rate Rhythm P wave PR interval QRS

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

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

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

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

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

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

S
3 boxes - .12 seconds here. QRS
int.
QT int.
464
9 ECG Strips on the NCLEX
1. Normal sinus rhythm
Treatment:
None - continue to monitor
Causes:
Being healthy
Memory tricks
Normal beat - evenly spaced
2. Bradycardia
Treatment:
BRADY Bunch Atropine ONLY if symptomatic
old TV show (slow times)
showing low perfusion (pale,
cool, clammy)
<60 Causes: ATROPINE
Vagal maneuver (bearing down),

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

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

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

Causes:
Post MI, Hypoxia,
Low potassium, Low magnesium
C
Treatment: C - Count a pulse
C - Cardiovert
1. Early Defibrillation! NCLEX TIP *Synchronize First
Apply defibrillator pads & Sedation
Call out & look for everyone to be
D
CLEAR!
Shock & IMMEDIATELY continue
chest compressions
Memory tricks D - Dead - NO PULSE
2. When to Shock? NCLEX TIP
D - DEFIB!!
V Tach with No pulse = Defibrillation
V Tach Tombstone pattern
*NO Synchronize
V Tach with Pulse = Cardioversion D - Don't wait
465
Antidysrhythmics I
Cardiac Pharmacology
Class Drug Name Mainly for Image of ECG Strip

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

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

Potassium-channel blockers V Fib
Class 4 Verapamil Atrial Fibrillation

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

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

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

A
Atropine Symptomatic Bradycardia
L
Adenosine SVT (supraventricular tachycardia)
Lidocaine V Tach & V Fib
SE: Low BP, Low Platelets
Hypertension, SVT, Tachycardia,
B
Beta Blockers
“Propranolol” A fib & A flutter SA node
A
SE: LoL = Low BP, Low HR, bronchospasm AV node Amiodarone V Tach & V Fib
SE: Low BP, Low HR,
C
Ca Channel Blockers Hypertension, SVT, Tachycardia, Pulmonary TOXICITY!!!
“Verapamil” “Diltiazem” A fib & A flutter
SE: Low BP, Low HR, dizziness
P
Procainamide V Tach
D
Digoxin A fib & Heart Failure
SE: Toxicity (NV, Vision changes)
466
Atropine
Symptomatic Bradycardia
Drug name: Memory tricks Side Note
AtroPINE ATROPINE
Symptomatic bradycardia
ATROPINE
If drugs do not work to fix the problem, then we

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

Correct sequence:
1. Atropine
Symptomatic ATROPINE
2. External pacing
bradycardia
MOA:
Atropine acts to increase the heart rate by blocking the
action of the vagus nerve to block the PNS (parasympathetic
Signs: Symptomatic bradycardia nervous system) REST & DIGEST, and turns ON the SNS
?
? (fight & flight) in the heart like flicking a light switch.
Mental status changes
?
? ?
?
1. Confusion
2. Irritability
3. Agitation
SNS
ATROPINE
PNS
Parasympathetic nervous system
Key points
Atropine is effective when we see normal sinus
rhythm and reversal of the symptoms. They will Common NCLEX Question
show you normal sinus rhythm like this & no Atropine for a client with a heart rate of 38,
more hypoxic symptoms, like confusion, agitation, bp of 88/65, reports confusion and dizziness.
Which ECG strip would show medication
hypotension or syncope. effectiveness?
1. 60-100
Normal Sinus rhythm R peak x 10
and reversal of the symptoms 2.
8 x 10 = 80
3.
ATROPINE
4. CORRECT
467
Antidysrhythmics II
ABCDs - Atrial Rhythm drugs
MEMORY TRICK Notes
A
B SA node
Think ABCD, start on the
TOP of the heart affecting
atrial rhythms affecting
C AV node
the SA or AV node
D L
A
P
Drug Name Indication & Key Terms: TOP MISSED Test Question
A Atropine Symptomatic Bradycardia Atropine for a client with a heart rate of 38,
bp of 88/65, reports confusion and dizziness.
effectiveness?
Puts the heart rate really HIGH like on TOP of “a PINE” tree for
60-100
atroPINE. 1.
Given for: ‘’Symptomatic Bradycardia’’ below 60 BPM with signs 8 x 10 = 80

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

1. Give it FAST = IV push in
1-2 seconds NCLEX TIP
2. Saline Flush immediately AFTER
DEcreases the heart rate, like putting it into a DEN (for foxes) or
Downstairs.
Given for:
* Key points:
Know how this rhythm looks! SVT = Super Fast!
Give it FAST = IV push in 2 seconds followed by flush
Super Fast = SVT
B Beta Blockers
“Propranolol”
A fib & A flutter
SE: LoL = Low BP, Low HR
Common Question
What drug is causing this rhythm?
Propranolol
Beta blockers end in “-LOL”
Memory trick: Lower the 2 L’s - Low HR & Low BP
Given for: <60
Hypertension & to put the brakes on fast rhythms like SVT, tachycardia, A fib, & A flutter. 5 x 10 = 50
Side Effects: 1 2 3 4 5
• B - Bradycardia (HR below 60 BPM) & low BP
• B - Bronchospasm (avoid asthma & COPD)
• B - Blood glucose masking s/s of low sugar
• B - Bad for clients in end stage heart failure
* Orthostatic hypotension (dizziness upon standing) - teach slow position changes!
468
Antidysrhythmics III
ABCDs - Atrial Rhythm Drugs
C
C C
Ca Channel Blockers Hypertension, SVT, Tachycardia, Calcium Contracts the muscles
Calcium
Ca
Since calcium contracts the muscles, when calcium is blocked with CCBs,
it calms the heart
Memory Trick: CCBs lower the Couple heart vitals: HR & BP
Given for:
Hypertension, tachycardia, SVT, A Fib, & A Flutter
Side Effects:
Orthostatic hypotension (dizziness upon standing) - teach slow position changes
3 Common Questions
Q1: Intended EFFECT for Q2: Priority adverse effect Q3: Most important patient
Diltiazem? to watch for when giving teaching when giving
Amlodipine? Verapamil?
Ventricular rate decreased Dizziness Slow position changes
from 160 to 70s
Q1: Intended EFFECT for Q2: Priority adverse effect
Diltiazem? KEY WORD
to watch for when giving
Q2: Priority adverse effect Q3: Most important patient Amlodipine?
to watch for when giving teaching when giving Slow position changes
Amlodipine? Verapamil? Ventricular rate decreased Dizziness
Dizziness
160 70 beats/min Slow position changes
from 160 to 70s
Diltiazem
Drug Name Indication & Key Terms: D is for DEEP Contraction

D Digoxin A fib & Heart Failure
DIGOXIN DEEP contraction
Digoxin Digoxin
Is a TOXIN so monitor levels - under 2.0 is SAFE.
It DIGs for a deeper heart contraction to help the heart contract more
forcefully & decreases the heart rate (NOT Blood pressure), so no need
for slow position changes
Main Side Effect = Toxicity Key Sign Common NCLEX Question

Max Range 2.0 Report "dizziness & lightheaded" Q1: A client on digoxin is having difficulty
1st signs of toxicity: reading a book or some type of vision
Anorexia Bradycardia problem
Nausea / Vomiting
Vision changes (difficulty reading)
Max 2.0 what is the key lab value to monitor?
Digoxin
Creatinine! Over 1.3 = bad kidney
469
Antidysrhythmics IV
LAP - Ventricular Rhythm Drugs
L Lidocaine
SA node
Think LAP like in your lap,
A Amiodarone AV node since these drugs affect
ventricular rhythms
L
P Procainamide A
P
Mainly give for those deadly ventricular rhythms:

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

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

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

therefore not commonly tested.
470
9 ECG Strips on the NCLEX II
5. Atrial Fibrillation (A Fib) Digoxin

Causes:
COPD, after heart surg. A T
Treatment:
Max 2.0
*Push Synch 60
Check ATP Before giving:
A - Apical pulse 60
40 kg

N/V, Anorexia P
Memory tricks toxicity
< 3.5
No P wave = Fibrillation FloPPing K antidote, moderate green leafy veggies)
Potassium
K+
6. Atrial Flutter (A Flutter) Causes:

COPD, after heart surg.
Treatment:
DIGOXIN

*Push Synch
Max 2.0
Check ATP Before giving: 60
A - Apical pulse 60 40 kg

N/V, Anorexia < 3.5
K
Memory tricks
Potasssium
toxicity
K+
A FluTTer = sawTooTh K antidote, moderate green leafy veggies)
7. SVT - Supraventricular Tachycardia KAPLAN

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

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

Treatment:
M
Mellows out the heart
Memory tricks
Tornado Pointes
471
Adenosine
Drug name: MEMORY TRICK Indication:

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

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

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

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

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

SYNC
Don’t let
THE NCLEX TRICK YOU
CARDIOVERSION DEFIBRILLATION
Cardioversion Defibrillation
C - Cardioversion D - Defibrillation - if you
C - Count a pulse D - Don't have a pulse
C - Controlled Rhythms D - Deadly rhythms (VFib & Vtach no pulse)
Synchronized button & sedation D - Don't Synch (shock away!)
PULSE NO PULSE
SYNC
SYNC
SYNC
472
Vasopressors
Top Tested Drugs
Epinephrine & Norepinephrine Kaplan Question

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

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

Dopamine Dopamine
Activates alpha 1 and beta 1 receptors Given for a patient with
hypotension, what indicates
Therapeutic Effects: effectiveness?
• Low doses act on dopamine
receptors 1 1 Answer: Increased cardiac output
• Moderate doses acts on beta 1
receptors
• High doses acts on alpha 1 and
ATI Question
beta 1 receptors
Dobutamine, Dopamine
Assess IV site hourly for s/s infiltration • Assess BP hourly
• Monitor vital signs
Notes
473
9 ECG Strips on the NCLEX III
9. Asystole - Flatline
Epinephrine, Atropine & CPR

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

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

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

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

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

Answer: Ventricular Fibrillation
Atrial Fibrillation
If you know these, you will pass the NCLEX! NCLEX TIP
Normal sinus rhythm Bradycardia Ventricular Fibrillation (V Fib)
Ventricular Tachycardia (V Tach) Atrial Fibrillation (A Fib) Atrial Flutter (A Flutter)
3.
SVT - Supraventricular Tachycardia Torsades de Pointes Asystole - flatline
474
Inotropic, Chronotropic,
Dromotropic
D D D INOtropic
Digoxin Dopamine Dobutamine “INcreased cardiac contractility”
“INcreased forceful contraction”
3 Ds for DEEP contraction
Digoxin
DOPAMINE Dobutamine D - Digoxin
2.0 +
D - Dopamine
D - Dobutamine
Chronos
Clock
HR<60 Neg. Chronos - Neg time
Positive Chronos - Positive time
Faster HR - Positive Chronotropic
Lower HR - Negative Chronotropic
Dromo
Drums
Neg. Dromotropic -
stable heart rhythm
Inotropic Chronotropic Dromotropic

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

B beta blockers
Atenolol - Neg. - Neg. - Neg.
C calcium CB - Neg. - Neg. - Neg.
C cardiac glycosides
+ Pos. - Neg. - Neg.
Digoxin
D dobutamine + Pos. X X
D dopamine + Pos. + Pos. X
E epinephrine + Pos. + Pos. X
475
Hypothermia &
Frostbite
476
Hypothermia
Pathophysiology
Occurs when core body temp is less than 95oF (35oC).

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

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

Heart:
- Pulses are weak and thready from the cold heart muscles
Lungs:
- Wheezing may be heard indicating bronchospasms
- Crackles at bases of lungs indicating pulmonary edema
from fluid buildup!
Interventions
NCLEX TIP
1st 2 nd Airway: Anticipate Mechanical Ventilation
Circulation: Attach the cardiac monitor
(anticipate defibrillation)
Rewarming Process:
Airway Breathing Circulation Passive methods
Active internal warming
Warmed IV fluids via 2 large bore IVs
Cover with warm blankets (head & trunk)
1st
2 nd
477
Frostbite
Pathophysiology
Tissue in the body basically freezes like a popsicle

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

Warm water soaks (whirlpool)
Elevate affected extremity after
rewarming
Provide analgesic pain meds
NO pressure to the site
NO heavy clothing, blankets
NO massaging, rubbing
NO occlusive dressings on wounds
NCLEX TIP
478
Shock
479
Shock
Memory trick
Pathophysiology S S
Shock is a critical condition 0₂ 0₂ Shock Severely low 0₂ 0₂

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

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

0₂
anaerobic metabolism, meaning

0₂
0₂
metabolism without oxygen - Neurogenic shock caused by spinal

Blood glucose
T-6
BUT s/s are absent in this stage cord injury T-6 or higher.
II. Compensatory
3. Hypovolemic shock (hemorrhagic)
The body is trying to compensate for the LOW oxygen,
So the heart will pump faster (tachycardia) & RR Hypovolemic shock (hemorrhagic) caused by blood
increases to get more oxygen (tachypnea) body loss like from a trauma or a gunshot wound or even
compensates with the sympathetic nervous system from surgery or burns
to speed up the vital signs & renin-angiotensin
activation to maintain BP and oxygenation to keep the
organs perfused
III. Progressive
Key sign 4. Cardiogenic shock
Cold and clammy skin Cardiogenic shock where the heart fails to pump like
PRIORITY NCLEX TIP in heart failure exacerbation or an MI heart attack
heart muscles are weak & fail to pump
IV. Irreversible
5. Anaphylactic shock
Death is imminent
Anaphylactic shock from a severe allergic reaction like
from a bee sting, eating seafood or something you
have an allergy to
480
Septic Shock
Pathophysiology
Septic shock Pathophysiology results from a septic widespread
bloodborne infection that overwhelms the body typically caused
by a bacterial infection like Pneumonia - infection in the lungs or
even UTI or kidney infection that gets worse. A systemic cytokine
release inside the bloodstream causes extreme vasodilation & fluid
Lorem
leakage from capillaries
Signs & Symptoms Memory trick
S S
Severely low blood pressure Severely low
Shock 0₂ 0₂
blood pressure
0₂ 0₂
0₂
0₂
0₂
NORMAL
NORMAL
HIGH
LOW
HIGH
LOW
Low blood pressure

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

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

oxygen, intravenous fluids, antibiotics, and
other medications.
481
Neurogenic Shock
Pathophysiology
The Autonomic nervous system is damaged resulting in the blockage Spinal Cord Injury
of the sympathetic nervous system which is supposed to speed up
(T-6 or higher) NCLEX TIP
the vitals & vasoconstriction. Only the parasympathetic system is
intact - which puts the breaks on the vitals causing widespread
vasodilation & hypotension naturally, we see low & slow vital signs
like low heart rate & low BP as Vasodilation occurs making it difficult
for blood to return BACK to the heart. This decreased blood flow
BACK to the heart leads to decreased blood flow OUT of the heart
basically decreased cardiac OUTput - meaning less oxygenated blood
OUT of the heart to the body & this leads to poor tissue perfusion
T-6
from the lack of oxygen & impaired cell metabolism resulting in organ
failure & death.
Bradycardia NCLEX TIP PRIORITY

NORMAL
● IV Normal Saline
HIGH
LOW
P P (0.9% sodium chloride)
PNS Parasympathetic Puts the breaks Increases the blood pressure
on the vitals
<60
PNS
PNS
SIDE NOTE
● Spinal cord injury ABOVE T-6
Autonomic dysreflexia T-6
Saunders
A client is admitted to the hospital with Triggered by a full bladder, constipation, or tight
a diagnosis of neurogenic shock after a
traumatic motor vehicle collision.
fitting clothes - anything with constriction thus
Which manifestation best characterizes place Foley in spinal trauma patients to keep the
this diagnosis?
bladder empty and offer laxatives & loose clothes
Bradycardia can save a client with a spinal cord injury
ABOVE T-6
<60
NCLEX TIPS
Low HR (bradycardia) Less than 60
Low BP (hypotension) Less than 80/systolic
Skin: Warm, Pink, & Dry
482
Hypovolemic Shock
Pathophysiology
Caused by anything that can lower blood volume - Think HYPO

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

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

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

2
nd
HYPOvolemic (hypotension)
NORMAL
HIGH
LOW
483
Cardiogenic &
Anaphylactic Shock

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

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

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

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

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

Severe allergic reaction - like from a
bee sting or peanut allergy.
NCLEX TIP
Anaphylactic shock - severe ALLERGIC reaction
Epinephrine
EPINEPHRINE
EPINEPHRINE
Adrenaline
EpiPen Auto Injector
484
Perioritization
&
Delegation
485
Prioritization Beyond ABCs
ABC’s Highest Breathing = RR & Oxygenation Circulation

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

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

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

Immunosuppressants CT contrast
Antibiotics: Vancomycin & Gentamicin
Low grade fever will KILL!
Toxic lab levels #1 PRIORITY
Lithium 1.5 + LIMB
Neutropenia Low Grade FEVER <100.4 F Digoxin 2.0 +
Theophylline 20 +
Phenytoin 20 + (brand: Dilantin)
Creatinine > 1.3 Urine Output < 30ml/hr
Compartment Syndrome
<1,500 BUN/Creatinine
Notes
486
Delegation
RN’s do NOT Delegate below
• New admission
• Returning to floor after procedure
NO Delegating: RN ONLY
U Unstable
clients
• “Post-Operative” after surgery
• Unstable blood sugar, vitals, Lab values
1st
2nd
LVN LPN
• Sudden change RR, neuro status. • IV PUSH (IV piggy back varies state to state)
• Blood transfusion & blood products
E Evaluation
Trending / Interpreting data
• Lab Values, Pain, Vital Signs • Central line drugs: Chemo, TPN
A Assessments Initial, First, Primary assessments

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

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

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

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

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

recovering from surgery 4. Reporting to the nurse that
5. Urinary catheterization the patient complained of
chest pain
6. Secondary assessment of clients
chest pain
487
Pharmacology
NCLEX Drugs
Quick View
Need to know
medications for NCLEX I
ANALGESICS ANTICONVULSANTS
• Opioids ↑ interval between seizures

• ↑ pain threshold by altering pain
perception Common Brand Name Generic Name
Dilantin Phenytoin
Common Brand Names Generic Names
Neurontin Gabapentin
Demerol Meperidine HCL
Tegretol Carbamazepine
Dilaudid Hydromorphone
Depakote Valproic Acid
Duragesic, Sublimaze Fentanyl
Morphine Sulfate Morphine Sulfate *Neurontin is sometimes prescribed for

chronic pain neuropathy
Vicodin, Norco Hydrocodone *Monitor blood levels: Dilantin, Tegretol,
and Depakote
BENZODIAZEPINES (Pam & Lam) ANTIDEPRESSANTS
• SSRIs
• Enhance/facilitate GABA, an inhibitory
neurotransmitter • Act by inhibiting serotonin reuptake in CNS
Common Brand Name Generic Name Celexa Citalopram
Xanax Alprazolam Effexor Venlafaxine
Valium Diazepam Lexapro Escitalopram Oxalate
Ativan Lorazepam Paxil Paroxetine
Versed Midazolam Prozac Fluoxetine
Zoloft Sertraline
ANXIOLYTICS TRICYCLICS
• Azaspirodecanedione derivatives • Act by blocking reuptake of norepinephrine

• ↓ anxiety. Action unknown, thought to act by and serotonin at nerve endings
↓ the amount/action of serotonin in certain parts
of the brain.
Common Brand Names Generic Names Common Brand Names Generic Names
Buspar Buspirone Hydrochloride Elavil Amitriptyline

Pharm Quick Glance
Medication Classifications Pregnancy Categories
• Antacids - reduces hydrochloric acid in • Category A—No risk in controlled human studies
the stomach. • Category B—No risk in other studies.
• Antianemics - increases blood cell Examples: Amoxicillin, Cefotaxime.
production. • Category C—Risk not ruled out.
• Anticholinergics - decreases oral Examples: Rifampicin (Rifampin), Theophylline
secretions. (Theolair).
• Anticoagulants - prevents clot formation, • Category D—Positive evidence of risk.
• Anticonvulsants - used for management Examples: Phenytoin, Tetracycline.
of seizures and/or bipolar disorders. • Category X—Contraindicated in Pregnancy.
• Antidiarrheals - decreases gastric motility Examples: Isotretinoin (Accutane), Thalidomide
and reduce water in bowel. (Immunoprin), etc.
• Antihistamines - block the release of • Pregnancy Category N—Not yet classified
histamine.
• Antihypertensives - lower blood pressure
and increases blood flow.
• Anti-infectives - used for the treatment of
infections Nursing Considerations
• Bronchodilators - dilates large air passages
in asthma or lung diseases (e.g.,COPD). • Digoxin (Lanoxin) - Assess pulses for a full
• Diuretics - decreases water/sodium from minute, if less than 60 bpm hold dose. Check
the Loop of Henle. digitalis and potassium levels.
• Laxatives - promotes the passage of • Aluminum Hydroxide (Amphojel) - Treatment
stool. of GERD and kidney stones. Monitor constipation.
• Miotics - constricts the pupils. • Hydroxyzine (Vistaril) - Treatment of anxiety
• Mydriatics - dilates the pupils. and itching. WOF dry mouth.
• Narcotics/analgesics - relieves moderate • Midazolam (Versed) - given for conscious
to severe pain. sedation. Watch out for respiratory depression
and hypotension.
• Amiodarone (Cordarone) - diaphoresis,
dyspnea, lethargy. Take missed dose any time
Drug Schedules in the day or to skip it entirely. Do not take
double dose.
• Warfarin (Coumadin) - Watch for signs of
Drug Schedules bleeding, diarrhea, fever, or rash. Stress
• Schedule I - no currently accepted medical use importance of complying with prescribed
and for research use only (e.g., heroin, LSD, dosage and follow-up appointments.
MDMA). • Methylphenidate (Ritalin) - Treatment of
• Schedule II - drugs with high potential for abuse ADHD. Assess for heart related side-effects
and requires written prescription (e.g., Ritalin, and reported immediately. Child may need a
hydromorphone (Dilaudid), meperidine (Demerol), drug holiday because the drug stunts growth.
and fentanyl). • Dopamine - Treatment of hypotension, shock,
• Schedule III - requires new prescription after six and low cardiac output. Monitor ECG for
months or five refills (e.g., codeine, testosterone, arrhythmias and blood pressure.
ketamine). • Rifampicin - causes red-orange tears and
• Schedule IV - requires new prescription after six urine.
months (e.g., Darvon, Xanax, Soma, and Valium). • Ethambutol - causes problems with vision,
• Schedule V - dispensed as any other prescription liver problem.
• • Isoniazid - can cause peripheral neuritis, take
or without prescription (e.g., cough preparations,
Lomotil, Motofen) vitamin B6 to counter.
Need to know
medications for NCLEX II
SEDATIVES/HYPNOTICS DIURETICS
• ↓ fluid volume in the body
Common Brand Names Generic Name **NI= monitor daily weight under standard
conditions, assess BP, I&O, presence of edema
Ambien Zolpidem Tartrate
Lunesta Eszopiclone LOOP DIURETICS

• Inhibit reabsorption of Na+, CL-, K+ and H2O
(in loop of Henle), but also in proximal and
distal renal tubules
Common Brand Names Generic Name
Bumex Bumetanide
Demadex Torsemide
ANTICOAGULANTS Lasix Furosemide
• Interferes with blood clotting processes.

Used to prevent thrombus and embolus

Thiazide Diuretics
Coumadin Warfarin
• ↑ excretion of Na+, Cl-, K+,H2OGeneric
in distalName
tube
Lovenox Enoxaparin and ascending loop of Henle
Heparin Sodium-from
Heparin Common Brand Names Generic Name
beef/pork
Diuril Chlorothiazide Sodium
Hydrodiuril, HCTZ Hydrochlorothiazide
Zaroxolyn Metolazone
ANTIPLATELETS
• Interferes with the 1ST step in the clotting

process: platelet aggregation
Common Brand Names Generic Name POTASSIUM-SPARING DIURETICS

Generic Name
ASA - aspirin Acetylsalicylic Acid
• Contains aldosterone at receptor sites in
Plavix Clopidogrel distal tubule; excrete Na+, Cl-, H2O, not K+
• *Pepto-Bismol contains aspirin Common Brand Names Generic Name
Aldactone Triamterene
Dyrenium Spironolactone
Need to know
medications for NCLEX III
ANTIHYPERTENSIVES –(PRIL) ALPHA 1 ADRENERGIC BLOCKERS-(ZOSYN)
• ACE Inhibitors • Dilate blood vessels and ↓ (PVR)

• Block the conversion of angiotensin I to angiotensin II
(potent vasoconstrictor)-Causing vasodilation and
PVR (peripheral vascular resistance) without ↓ cardiac Common Brand Names Generic Name
output/rate/contractility-Aldosterone is also blocked,
causing a ↓ in Na+ and H2O retention. Side effect: Hytrin Terazosin
Nagging, nonproductive cough, angioedema
Minipress Prazosin
Common Brand Name Generic Name
Altace Ramipril
ALPHA & BETA ADRENERGIC BLOCKERS-(LOL)
Capoten Captopril
• Alpha blockers-block alpha 1 receptors
Prinivil, Zestril Lisinopril
→ vasodilation. Beta blockers-block beta 1
Vasotec Enalapril & beta 2 receptors:
• → reduce HR, myocardial irritability, force of
*check potassium level contraction
• → depress automaticity of SA node,
ALPHA 2 ANTAGONISTS ↓ speed of AV & intraventricular conduction
→ suppress release of renin from the kidneys
• centrally-acting anti-hypes causing
↓ amounts of norepinephrine to be
released, ↓ sympathetic activity Common Brand Names Generic Name
Coreg Carvedilol
Trandate, Normodyne Labetalol
Catapres Clonidine
CALCIUM CHANNEL BLOCKERS

BETA BLOCKERS-(OLOL)
• Block Na+ influx into the beta-receptors
• Prevent sympathetic stimulation of the heart, • ↓ force of myocardial contraction/conductivity
thus ↓ HR and contractility. • ↓ HR, ↓ PVR.
• ↓ myocardial irritability, depress • Produce relaxation of coronary & vascular
automaticity of SA node,↓ speed of AV & smooth muscle; dilates coronary arteries;
intraventricular conduction ↑ myocardial O2 delivery, ↓ O2 demand.
• suppress release of renin from the kidneys. • Side effect: edema, dysrhythmias

Inderal Propranolol
Cardizem Diltiazem
Lopressor Metoprolol Tartrate
Norvasc Amlodipine
Toprol-XL Metoprolol Succinate
Procardia Nifedipine
Tenormin Atenolol
Verelan, Isoptin, Calan Verapamil
• *May cause bronchoconstriction.
Common Drug Antidotes
& Therapeutic Ranges
Drug Antidote
Opioid Analgesics Nalaxone
Heparin Protamine sulfate
Coumadin Vitamin K
Benzodiazepines Fluzmazenil
Acetominophen Acetylcysteine
Magnesium sulfate Calcium gluconate
Cholinergics Atropine
Digoxin Digiband
Beta blockers Glucagon
Aspirin Sodium bicarbonate
Cyanide Sodium thiosulfate
Drug Therapeutic range

Digoxin 0.5-2.0 mg/ml
Lithium 0.8-1.5 mEq/ L
Dilantin 10-20 mcg/ dL
Theophylline 10-20 mcg/dL
5—10 mcg/ml (peak), <2.0 mcg/ml

Gentamycin (valley)
20—40 mcg/ml (peak), 5 to 15 mcg/ml

Vancomycin (trough)
Carbamazepine 4—10 mcg/ml
Phenobarbital 15—40 mcg/mL
Phenytoin 10—20 mcg/dL
Tobramycin 5—10 mcg/mL (peak),

0.5—2.0 mcg/mL (valley)
Valproic Acid 50—100 mcg/ml

Need to know
medications for NCLEX IV
ARBS-(SARTAN) NITRATES
• Block binding of angiotensin II at the receptor • Peripheral and coronary vasodilators.
site, preventing vasoconstriction & aldosterone • Treat/prevent angina, ↓ BP ↓, preload/afterload,
secreting effect usually caused by angiotensin II ↓ myocardial O2 demand.
• **NI=rotate transdermal patches/remove after 12-14
Brand Names Generic Name
hours =(“patch free” interval of 10-12 hours daily)
Atacand Candesartan
Cozaar Losartan
Nitro BID
Tridil
Diovan Valsartan Nitroglycerin
Transderm Nitro
Nitrostat
CARDIAC GLYCOSIDES Imdur Isosorbide Mononitrate
• Positive inotropes (improve contractility Isorbid

and cardiac output) Isordil Isosorbide Dinitrate
• Negative dromotropic slow AV Sorbitrate
conduction rate.
• *Check Potassium Level
• Negative chronotropes ↓ HR & improve
cardiac output.
• Act as antiarrhythmic via tropic effect.
• **NI=Monitor K+ level, S/S toxicity ANTI-DIABETICS
Brand Names Generic Names
• Sulfonylureas
Lanoxin Digoxin • Promotes insulin secretion by the
pancreas; ↑ tissue response to insulin
• *Monitor Dig & K+ level, S/S toxicity

BIGUANIDES
Amaryl Glimepiride
• ↓ hepatic glucose production &
Diabeta
intestinal absorption of glucose
Glynase Glyburide
• improves insulin sensitivity
Micronase
(tissue response to insulin)
Glucotrol (XL) Glipizide
Glucophage Metformin
• *Initial drug therapy for newly DX T2DM. GLITAZONES-(GLITAZONE)

• *Most common side effect: GI.
• *Rare side effect: Lactic acidosis • Decrease insulin resistance

Actos Pioglitazone
Januvia Sitagliptin
Avandia Rosiglitazone
GLIPTINS (DPP-4 Enzyme Inhibitors)
*Edema; HF secondary to renal retention of fluid
• ↑ levels of incretins-naturally occurring substances
control blood sugar by ↑ insulin release,
especially after a meal.
Common Drug Suffixes
CNS Neuromuscular Infectious Disease

Family Drug Example Family Drug Example
-chol Muscarinic agonist carbachol Cell wall inhibitor “Broad Imipenem
-penam
spectrum” Meropenem
-trop Atropine
Muscarinic blocker
scop- Scopolamine Ciprofloxacin
-floxacin Fluoroquinolone
-stigmine Achase inhibitor Neostigmine Levofloxacin
-curium Nondepolarizing Atracurium -conazole Ketoconazole

Antifungal
-curonium neuromuscular blocker
Mivacurium ‘’Azole’’ Fluconazole
Pancuronium
-ane Inhailed anasthetic Halothane Chloroquine

-quine Antimalarial
Primaquine
-caine Local anaesthetic Lidocaine
Acyclovir
Antiviral “ DNA polymerase
-pam Diapam -ovir Ganciclovir
Benzodiazepine inhibitors” treats herpes
-lam Lorazopam Valacyclovir
-tal Barbiturate Phenobarbital Neuraminidase inhibitor “

-ivir Zanamivir
treats influenza”
Typical antipsychotic Chlorpromazine
-zine Antiviral protease Indinavir
or antihistamine Thoridazine -avir
inhibitor “treats HIV/AIDS” Ritonavir
-apine Clozapine
Atypical antipsychotic
-idone Risperidone
COMT inhibitor for Tolcapone

-capone
parkinson's disease Entacapone
Cardiovascular GI
Family Drug Example Family Drug Example
-olol Beta blocker metoprolol -tidine H2 blocker Cimetidine
-alol Sotalol -prazole PPI Pantoprazole

Alpha-Beta blockers
-ilol cardviolol
Vascular Calcium -setron 5HT3 blocker ‘’Anti Emetic’’ Ondansetron

-dipine Nifidipine
channel blocker
Terazosin
-zosin Alpha -1 blocker
Doxazosin
-pril Ace inhibitor Lisinopril Oncology

-sartan ARB Losartan Family Drug Example
-darone Antiarrhythmic Amiodarone Vincristine
vin- Microtubule inhibitor
Vinblastine
Anti hyperlipidemic Hmg
-statin Rosuvastatin -rubicin Cancer drug Doxorubicin
coa reductase inhibitor
-mab Monoclonal antibody drug Rituximab
Carbonic anhydrase
-zolamide Acetazolamide
inhibitor -tinib Tyrosine kinase inhibitor Imatinib
-semide Loop diuretic Furosemide
Low molecular weight

-parin Enoxaparin
heparin
-rudin Direct thrombin inhibitor Lepirudin

Need to know
medications for NCLEX V
PROTON PUMP INHIBITORS (PPI) H2-HISTAMINE RECEPTOR ANTAGONISTS

• Inhibit histamine at histamine H2-receptor
• Block final step of gastric acid production sites, gastric acid secretion
• Ulcer-reducing
Pepcid Famotidine
Nexium Esomeprazole
Zantac Ranitidine
Prilosec Omeprazole
Protonix Pantoprazole
ANTILIPIDEMICS
• STATINS (HMG-COA REDUCTASE INHIBITORS)
ANTIEMETICS • Inhibits HMG-CoA reductase, an early step in
cholesterol production
• Act by ↓/preventing nausea & vomiting Brand Names Generic Name
Brand Names Generic Name Crestor Rosuvastatin
Phenergan Promethazine Lipitor Atorvastatin
Zofran Ondansetron Zocor Simvastatin
• *Rhabdomyolysis, Hepatotoxicity
GI MEDS
MISCELLANEOUS ANTILIPIDEMICS
• Non-absorbable medications used
prophylactically to treat/prevent
ulcers and GERD
Brand Name Generic Name • GI Protectant
• Mixes with gastric acid to form a
Zetia Ezetimibe protective coating of gastric mucosa
Inhibits absorption of
Selective cholesterol cholesterol by small
absorption inhibitor Brand Names Generic Names
intestine
Carafate Sucralfate
TriCor Fenofibrate
↓ triglyceride
Fibric Acid Derivative synthesis in liver
GI STIMULANT
Lopid Gemfibrozil
↓ triglyceride • Act by ↑ resting tone of esophageal sphincter
Fibric Acid Derivative synthesis in liver • Promotes gastric emptying/intestinal transit
Questran Cholestyramine
Bile acid sequestrant Binds bile acids, Reglan Metoclopramide
(food additive improving impeding absorption
quality) (elimination in feces)
• *Sometimes used with diabetic gastroparesis
Need to know
medications for NCLEX VI
STOOL SOFTENERS CORTICOSTEROIDS

• surface tension of interfacing liquid • inflammation, produce intentional
contents of the bowel-promoting additional immunosuppression, and treat adrenocortical
liquid into stools=softer mass. insufficiency
Brand Names Generic Name Brand Names Generic Names
Colace Docusate Sodium Celestone Betamethasone
Surfak Docusate Calcium Decadron Dexamethasone
Deltasone Prednisone
Solu-Cortef Hydrocortisone
ANTI-INFECTIVES Solu-Medrol Methylprednisolone
• Aminoglycosides • *Monitor WBC and Blood Glucose levels

ANTIPROTOZOAL
Gentamicin Gentamicin Sulfate Brand Names Generic Names
Streptomycin Streptomycin Sulfate Flagyl Metronidazole

Tobramycin Tobramycin Sulfate
• *No alcohol products, including mouthwash,
aftershave, deodorant, bath splashes.
• Disulfiram- type reaction may occur (flushing,
RESPIRATORY MEDICATIONS nausea, vomiting, palpitations).
• ß-LACTAMs
• ß-Lactam antibiotics include:
PCNs, cephalosporins, monobactams,
• Bronchodilators carbapenems
• Relax bronchial smooth muscle • *Assess for allergies to any ß-Lactam antibiotic
Proventil, Ventolin Albuterol Sulfate

CEPHALOSPORINS
Brovana Arformoterol Tartrate
Foradil Formoterol Fumarate Brand Name Generic Name

Xopenex Levalbuterol Rocephin Ceftriaxone
Spiriva Tiotropium Maxipime Cefepime
Fluticasone/Salmeterol Mefoxin Cefoxitin

• *combo drug
Advair (flut-potent Ancef Cefazolin
Advair Diskus anti-inflam
effects/Salm-bronch
odilator)
Need to know
medications for NCLEX VII
PENICILLINS CARBAPENEMS
Brand Names Generic Names Brand Names Generic Name
Amoxil Amoxicillin Invanz ErtapenemSulfate
Omnipen Ampicillin Merrem MeropenemSulfate
Unipen Nafcillin Primaxin ImipenemSulfate
Pipracil Piperacillin
Zosyn Piperacillin/Tazobactam
FLUOROQUINOLONES (oxacin)
SULFONAMIDES
Bactrim SMZ-TMP Cipro Ciprofloxacin

Bactrim DS Trimethoprim-Sulfa
Septra methoxazole Levaquin Levofloxacin
*Avoid or use with extreme caution if allergic to • *Tendon rupture.

sulfa: Erythromycin-Sulfisoxazole, Sulfasalazine, • *Adjust dosage for renal patients.
Dapsone, Sulfonamides, Celebrex, Imitrex, Lasix,
Hydrochlorothiazide HCTZ
VANCOMYCIN TETRACYCLINES
Vancomycin Tetracycline Tetracycline

Vancocin
Hydrochloride
Vibramycin Doxycycline
• *Nephrotoxicity, Ototoxicity, Red-Man Syndrome

• *Peak: 30 minutes to 1 hour after administration.
• *Trough: 30 minutes before the next dose.
Drug Activity in the body
Pharmaceutic Phase Phases Of Activity Key Terms

During this phase the drug is • Pharmaceutic phase • First pass effect: The concentration
dissolved in the body. Liquid • Pharmacokinetic phase of a drug is greatly reduced before it
medications and IV medications are • Pharmacodynamic phase. reaches the systemic circulation
already dissolved therefore they • Half life: Time is takes for the body
absorb much faster in the body. A to eliminate 50% of the drug.
tablet or capsule must pass through • Onset of action: Time it takes for the
Influences On Absorption
the GI tract to become dissolved. drug reach therapeutic effect after
Enteric coated medications are time • Route: IV/IM are the fastest to be administration.
released capsules or tablets that must absorbed. • Peak concentration: When the
meet the alkaline environment of the • Solubility absorption rate equals the elimination
small intestine before it dissolves. • Condition of body tissues rate.
• Duration: How long the drug
Pharmacokinetic Phase produces a therapeutic effect.
• Pharmacogenomics: People's
This phase refers to how the drug is Influence On Metabolism
response to medication are variable.
transported and distributed. The drug Genetic makeup can alter how a drug
canbe distributed or transported via • Age
• Weight works.
absorption, distribution, metabolism,
• Sex • Teratogen: Any substance that
and excretion.
• Disease causes abnormal development of a
• Absorption: moves the drug • Route fetus.
from the point of administration • Idiosyncrasy: unusual or abnormal
to the body fluids via active reaction to a drug.
transport, passive transport, Interactions • Drug tolerance: Decreased response
pinocytosis. to a drug that requires an increase in
• Distribution: The systemic • Additive drug interaction: The dosage.
circulation distributes drugs to combined effect of two drugs has • Cumulative drug effect: Seen in
various body tissues. Distribution an equal effect if the drug was people with liver or kidney disease,
depends on protein binding, given alone. the body is unable to excrete one
blood flow, and solubility. The dose of the drug before the next dose
• Synergistic interaction: When
drug comes into contact with is given causing an accumulation of
albumin or remain free, only free drugs interact and create an
increased effect example: the drug in the system.
circulating particles can produce
a therapeutic effect. Hypnotics and alcohol when taken
• Metabolism: Or biotransformation, together will cause increased CNS
the body changes the drug to be depression. Reactions
more or less active and excretable. • Antagonistic interaction: One
Most are metabolized by the liver drug interferes with the action of • Adverse drug reactions:
or kidneys, lungs, plasma, and another for example : Naloxone Undesirable drug effects. They may
intestinal mucosa. reverses the effects of opioids. be mild, severe or life threatening.
• Excretion: Elimination of the • Food interaction: Some food and May occur at the first dose or after
drug from the body after the decrease or increase the metabolism subsequent doses.
liver renders it in active it is then
of a drug. • Allergic drug reactions:
excreted by the kidneys via Immediate hypersensitivity reaction.
urine. Occurs because the individual's
immune system responds to the
Effects On The Nervous System drug as a foreign substance. Some
Pharmacodynamic Phase reactions occur immediately or they
• Sympathomimetic: physiological
can take time. They can be mild,
effects characteristic of the
Deals with the drugs action and effect severe or life threatening.
sympathetic nervous system by
on the body. • Anaphylactic shock: Extremely
promoting the stimulation of
serious reaction that usually occurs
• Primary effect: The desired sympathetic nerves.
immediately after drug
therapeutic effect. • Sympatholytic: antagonistic to or
administration. This requires
• Secondary effect: Any other inhibiting the transmission of nerve
immediate medical intervention to
effect the drug has on the impulses in the sympathetic nervous
raise the BP and improve breathing.
body. For example, sildenafil system.
was made for treatment of Can be fatal if not treated immediately.
• Parasympathomimetic: stimulates the
hypertension. It was also • Angioedema: Allergic reaction
parasympathetic nervous system (PSNS).
found to help with Erectile manifested by collection of fluid in
These chemicals are also called
dysfunction which is its the subcutaneous tissue. Most
cholinergic drugs because acetylcholine.
secondary effect. commonly affects the eyes, lips,
(ACh) is the neurotransmitter used by
A drug exerts its action by two mouth and throat.
the PSNS.
main mechanisms. • Toxic reaction: Toxic levels build
• Alteration in cellular function • Parasympatholytic: reduces the activity
up in the body when the body
• Alteration in cellular environment of the parasympathetic nervous system.
cannot excrete the drug.
Antibiotics
Antibiotics:
6 TEST TIPS OF ABX
1. Finish med 2. Accidental pregnancy 3. NO alcohol

To prevent SUPER infection!
C - Child Care
ABX are hard on liver
C - “-Cillins” -Penicillin, Amoxicillin
Key Words C - “-Cycline” -Doxycycline, Tetracycline
Take until all med is finished Key Words

DO NOT stop when feeling
better Oral contraceptives ineffective
Use additional contraception
like IUD.
4. NO FOOD 5. NO sun 5. NO sun

MTF “Move The Food ” AVOID “Fun The Sun” Others
M - Macrolides - Azithromycin F - Fluoroquinolones - Levofloxacin
T - Tetraclycine – Doxycycline Sulfonylureas (Glyburide)
T - Tetracycline – Doxycycline
F - Fluoroquinolones - Levofloxacin S - Sulfa drugs = SUN burns Diuretics (thiazide/loops)
Trimethoprim – sulfa methox azole
(Brand: Bactrim)
Key Words
Key Words
Photosensitivity
Take on EMPTY stomach Avoid “direct sun exposure”
Full glass of water Sun Burns (Wear Sun Block
& Avoid Sun)
Don’t let
6. SUPER Toxic 6. SUPER Toxic NCLEX TRICK YOU
(Kidney + Ears) (Kidney + Ears)
Key Words
Vancomycin
Gentamicin REPORT: Signs of Toxicity
Ear Damage “Ototoxicity”
Neomycin - Vertigo (loss of balance)
- Tinnitus (ringing of the ears) Mycins
Key Words Kidney Damage “Nephrotoxic”
REPORT IMMEDIATELY!!
PEAK & Trough Creatinine OVER 1.3 = Bad Kidney “- Thromycin” like AziTHROmycin
Too HIGH = Kidneys DIE BUN Over 20 “-floxacin” like Cipro-flox-acin
Too Low = Infections Grows Urine output
30ml/hr or LESS = Kidney Distress
Penicillin &
Cephalosporins
Drug name: COMMON SIDE EFFECTS
Penicillin -Ceph = Diarrhea -Cillins = Bleeding

Amoxicillin (monitor platelet count)
Ampicillin
Piperacillin Tazobactam
Cephalosporins
Cephalexin (brand: Keflex) NCLEX TIP
Cefazolin
Ceftriaxone (brand: Rocephin)
Penicillin end in CILLIN KEY POINT & MEMORY TRICK
Cephalosporins start with CEPH

C C C
MOA: CROSS SENSITIVITY CEPH / CEF CILLIN
(ALLERGY) (CEPHALEXIN, CEFAZOLIN) (AMOXACILLIN)
Weakens bacteria cell wall
Patient teaching:
AMOXACILLIN
CEFAZOLIN
Key Words DURING A REACTION
Oral contraceptives are

STOP ASSESS EPINEPHRINE
ineffective (“HOLD”) MEDICATION
the type of reaction
(prepare to admin)
Use additional contraception • Auscultate Lungs
Penicillin cause accidental pregnancy

EPINEPHRINE
CEPHALEX
since it BUMPs the PILL
Anaphylaxis allergy:
“-Cillins” & “Cephs”
Nurse should What is the best action for the
CLARIFY PRESCRIPTION nurse to take before
administering amoxicillin to a
Both are PREGNANCY SAFE and patient with allergies to
levofloxacin & ceftriaxone.
BREASTFEEDING SAFE
CEFAZOLIN
1. Clarify the order with pharmacy
Administration 2. Ask the patient about the type of
reaction they have to ceftriaxone.
“-Cillin”
3. Notify the HCP of the allergy to
KEY Terms:
· Take with food if GI upset ceftriaxone.
(nausea/ vomiting/diarrhea) 4. Administer meds separately with
· Shake well before use normal saline in between.
Notes
Vancomycin
GLYCOPEPTIDES CLASS &
AMINOGLYCOSIDE CLASS
Glycopeptides Class Key NCLEX Tips: Aminoglycosides Class
Vancomycin Tobramycin
KEY Words: Gentamicin Cystic Fibrosis
Indication: REPORT Signs of Toxicity

Neomycin
MRSA C DIFF
Given for serious infections like: Ear Damage “Ototoxicity”

MRSA & C Diff in the gut NCLEX TIP - Vertigo (loss of balance) Indication:
NCLEX TIP - Tinnitus (ringing of the ears)
Treat infections in cystic fibrosis

MOA: Kidney Damage “Nephrotoxic”
MOA:
Inhibits cell wall synthesis REPORT / NOTIFY HCP
Creatinine Blocks protein synthesis of the

OVER 1.3 = Bad Kidney
bacteria to STOP bacterial
KEY Words: growth but the NCLEX
BUN Over 20
PEAK & Trough does not focus on this, but
Urine output 30ml/hr rather on the way this drug
Check 15 – 30 minutes BEFORE
“next dose” or “administration”
or LESS = Kidney Distress can HARM THE PATIENT
Draw & review levels
REPORT and HOLD NCLEX

Over 20 = Vancomycin
KEY POINT:
Draw & Review levels
Assess site every 30 minutes for: KEY POINT:
pain, redness & swelling BUN/Creatinine
Very Toxic in combo with

Red mans Syndrome Vancomycin
KEY Words:
Rapid infusion
***Notify HCP of Increas-
Sudden onset of severe: Monitor BP
ing
Infuse SLOWLY at least BUN/Creatinine!
Hypotension
over 60 minutes
Flushing & pruritis “itching” (<10mg/min)
Red rash on face, neck,

chest & extremities Common NCLEX Question
120/80 A patient in sepsis is prescribed
90/60
several antibiotics during their
80/50
hospital stay. What patient teaching
should be included?
(see exhibit for list of meds)
Levofloxacin
Doxycycline
ANAPHYLAXIS Vancomycin
Azithromycin
Hive 1. Avoid direct sun exposure

Wheezing 2. Oral birth control ineffective
IMMEDIATELY 3. Take until symptoms subside

STOP infusion & administer 4. Monitor QT interval
Epinephrine!
5. Suppliment with vitamin B6
E – Edema “Angioedema”
P – Pruritis & Hives 6. Monitor creatinine and BUN
I – Insp. / Exp. “Wheezes”
Notes
Macrolides
Azithromycin
Drug name: Key NCLEX Tips:

Macrolides end in ‘’-thromycin’’
They are also: Hepatotoxic or LIVER TOXIC.
So monitor Liver Labs (ALT/AST):
YES it’s TRUE, they sound
Report increase to HCP
a lot like our other mysins,
Azythromycin but these are THROmycin.
Erythromycin THROmycin
AST/ALT
“mysin”
Be careful with acetaminophen for Fever
They are not too hard on RENALS or EARS but during infection. Tylenol is liver TOXIC
they are DANGEROUS in their own way.
Side Effects:
Key Words:
Common SIDE EFFECTS - Now don’t be tricked!
Common test questions ask If you stop giving during
for Nausea, vomiting, fever & decreasing WBC’s
KEY POINT:
Prolonged QT
MONITOR ECG and report

changes to Dr. or HCP!!!!!
Nausea and vomiting is common since

it’s taken on empty stomach
MEMORY TRICKS
T
Q Fever is expected during an infection,
Thromycin so keep on giving
T
Throws ECG waves

“Prolonged QT intervals”
Decreasing WBC means infection is
improving so DON’T BE TRICKED!
Notes
Tetracyclines
Drug name: Indication:
Mainly used for SKIN ACNE

Tetracyclines
Doxycycline MOA:
It blocks protein synthesis to STOP

KEY Points: bacterial growth.
Patient Teaching:
Key Terms:
Memory Trick:
Use additional contraception

• Cycling is DANGEROUS - Not safe for a
pregnant mothers! Take on empty stomach
Sit Up 30 minutes after taking…
DO NOT LAY DOWN!!!
• You can get BUGS in your teeth while AVOID - Calcium products:
cycling on a bike leading to tooth
discoloration 1. NO Dairy (milk, cheese)
2. NO Antacids (tums, Milk of Mg)
3. NO Iron
• Use SUN BLOCK - when out for cycling
around
Notes
Metronidazole
Indication:
Normal Side effect
Metronidazole NO need to report!
(brand: Flagyl)
Dark urine “Discoloration”
#1 Drug to treat C-diff (brown & rusty)
infection Metallic taste
STI (Trichomoniasis) HESI TIP
(Metro-Metallic Taste)
KEY POINT: DEADLY Side effect

Avoid ETOH (alcohol)
Report any new rash or
During & 3 days after skin peeling!
treatment
Patients will have violent Stevens-Johnson Syndrome,
vomiting & cramping if which is NECROSIS of skin
and mucous membranes!
alcohol is consumed Always TEACH patients
during and after treatment to REPORT immediately
Stevens-Johnson Syndrome
Memory Trick:
METALLIC ETOH TREATS RASH OH NOT

Taste & Dark Avoid C Diff & STI or Skin Peeling “Dazole”ing
Urine (Trichomoniasis)
NORMAL REPORT
Notes
Sulfonamides
& Fluoroquinolones
Sulfonamides MOA: KEY POINT
Stops bacteria folic Rash while on Glyburide?

Potential allergy to sulfa drugs!!!!
NOT Pregnancy Safe
Trimethoprim acid synthesis

sulfamethoxazole SULFA
-METHO-XAZOLE !
(Brand: Bactrim)
FOLIC ACID GLYBURIDE
Memory Trick: Key NCLEX Tips:

Contraindications:
S U L F Hypersensitivity to sulfa drugs

Assess for allergies to sulfonylureas like
Glyburide - An oral diabetic drug
SUNBURN URINE LOVE FOLIC ACID

(sunblock & avoid sun) Crystals & Specific Gravity water!! 2-3L per day (take daily)
HIGH = DRY!
1
SULFA GLYBURIDE
FOLIC ACID -METHO-XAZOLE
Gravity HIGH
Fluoroquinolones Indication:
KEY POINTS:
Given for Pneumonia & UTIs
Levofloxacin Avoid Sun “direct sun exposure”
(Brand: Levaquin) TEST TIP
Achilles tendon RUPTURE!!
Ciprofloxacin REPORT NEW MUSCLE PAIN!
Contraindication: Tendonitis FLUOROQUINOLONES
Key NCLEX Tips:

Many students want to avoid FLOXACIN
when creatinine & BUN is elevated. Memory Trick:
Floxacin sounds very simillar to MYCIN
(antibiotics that kill the kidneys) FLOXACIN = FALL XACIN
Look at the entire suffix so you don’t end tricked.
FLEX-ACIN
!
DON’T
GET TRICKED FLOXACIN MYCIN !
VancoMYCIN
GentaMICIN
Notes
Phenazopyridine
Drug name: Indication: Memory Trick:
UTI Analgesic given for Pain Since its used to ease the firey
relief during the burning & burn from UTI’s & It turns body
Phenazopyridine irritation of UTIs fluids RED & ORANGE Like a FIRE
(Brand: Pyridium))
NOT an Antibiotic
UTI
ANALGESIC
PYROdine
UTI
ANALGESIC
KEY POINT HESI Question
Normal – No need to Report REPORT:

Red + Orange urine & body fluids Yellow SKIN / Sclera = Jaundice
Since it pyro-dine, STAINS underwear,

clothing & bedding
Patient Teaching:
• Wear sanitary pads

• Wear glasses instead of contacts while taking medicine VE
NE P
R
STO
• NEVER STOP antibiotic therapy! UTI
ANALGESIC
ANTIBIOTIC
NOT EVEN when starting to feel better
Commonly patients FEEL better with this med Always teach clients to
& think the infection is GONE So they STOP their FINISH THE ENTIRE COURSE OF ABX!
Antibiotic, that’s a BIG NO NO!
STOP
ANTIBIOTIC
NO
NO
NO
Notes
Antibiotics
(Bonus cheat sheets)
Anti Infectives
- Aminoglycosides
How do they work? “Action” Nursing management

The aminoglycosides exert their bactericidal effect • Before administering any antibiotic be sure to evaluate
by blocking the ribosome from reading the mRNA, the results of the culture and sensitivity test.
a step in protein synthesis necessary for bacterial • Take the drug at the prescribed time intervals. These
multiplication. time intervals are important because a certain amount
of the drug must be in the body at all times for the
infection to be controlled..
• Always report serious adverse reactions, such as a
severe hypersensitivity reaction, respiratory difficulty,
Indications severe diarrhea, or a decided drop in blood pressure,
to the primary health care provider immediately,
• Infections caused by gram negative organisms because a serious adverse reaction may require
• Before abdominal surgery to reduce normal flora emergency intervention.
in the bowel • Monitor temperature and evaluate the effectiveness of
the treatment via labs and vitals.
• Neuromuscular blockade or respiratory paralysis may
occur with the administration of aminoglycosides. It is
imperative to monitor respiratory status and report any
Adverse Reactions respiratory difficulty immediately.
• To detect ototoxicity, carefully evaluate the patient’s
• Nausea complaints or comments related to hearing, such as a
• Vomiting ringing or buzzing in the ears.
• Anorexia
• Rash
Interactions:
• Urticaria
• Nephrotoxicity • Cephalosporins: Increased risk of nephrotoxicity
• Ototoxicity • Loop diuretics (water pills): Increased risk of
• Neurotoxicity ototoxicity
• Pavulon or Anectine (general anesthetics):
Increased risk of neuromuscular blockade
Contraindications & Caution Favorable Outcomes
• Hypersensitivity • Patient reports comfort without fever.

• Pre existing Hearing loss • Orientation and mentation remain intact.
• Myasthenia gravis • Patient has adequate renal tissue perfusion.
• No evidence of injury is seen due to visual or
• Parkinsonism
auditory disturbances.
• Pregnancy & lactation • Patient does not experience diarrhea. (Ford 91)
Generic Trade Use Dose

3 mg/kg/day in 3 divided doses IM or IV
Treatment of serious infections caused
Gentamicin N/A by susceptible strains of microorganisms
For life-threatening infection: 5
mg/kg/day in divided doses
Treatment of serious infections caused 15 mg/kg/day IM or 25–30 mg/kg IM 2–3

Streptomycin N/A by susceptible strains of microorganisms times per week
Treatment of serious infections caused

Tobramycin N/A by susceptible strains of microorganisms 3–5 mg/kg/day IM, IV in 3 equal doses
PLUS TREATMENT OF TB
Anti Infectives
Drugs that interfere with protein synthesis

• Daptomycin is a member of a new category of • Before administering any antibiotic be sure to
antibacterial agents called cyclic lipopeptides. evaluate the results of the culture and sensitivity
• Linezolid (Zyvox) is the first drug in a new drug class, test.
the oxazolidinones • Complete the entire course of treatment. Do not
• Spectinomycin (Trobicin) is chemically related to but stop the drug, except on the advice of a primary
different from the aminoglycosides. health care provider, before the course of
• Quinupristin/dalfopristin has bactericidal action against treatment is completed, even if symptoms
both methicillin-susceptible and methicillin-resistant improve or disappear. Failure to complete the
staphylococci. prescribed course of treatment may result in a
return of the infection.
Indications
• Daptomycin is used to treat complicated skin and skin Interactions:
structure bacterial infections as well as Staphylococcus
aureus infections of the blood. • Antiplatelet drugs (aspirin or the nonsteroidal
• Linezolid is used in the treatment of vancomycin anti-inflammatory drugs [NSAIDs])-increased
resistant Enterococcus faecium (VREF) , health risk of bleeding and thrombocytopenia
care–and community-acquired pneumonias, and skin • Monoamine oxidase inhibitor (MAOI)
and skin structure infections. antidepressants-decreased effectiveness
• Spectinomycin is used for treating gonorrhea in patients • Large amounts of food containing tyramine
who are allergic to penicillins, cephalosporins, or (e.g., aged cheese, caffeinated beverages, yogurt,
probenecid chocolate, red wine, beer, pepperoni)
• Quinupristin/dalfopristin is a bacteriostatic agent also -risk of severe hypertension
used in the treatment of VREF.
Contraindications Adverse Reactions
• Linezolid: Known hypersensitivity, PKU, pregnancy. • Nausea

• Daptomycin, spectinomycin, and • Vomiting
quinupristin/dalfopristin: known hypersensitivity to the • Diarrhea or constipation
• Headache and dizziness
drug, and it should not be used during pregnancy • Insomnia
(pregnancy category B) or lactation. • Rash
• Chills
Nursing Alert • Fatigue
• Depression
• Nervousness
Quinupristin/dalfopristin is irritating to the vein. After • Photosensitivity
peripheral infusion, the vein should be flushed with 5% • Pseudomembranous colitis and thrombocytopenia
dextrose in water (D5W), because the drug is incompatible are the most serious adverse reactions caused by
with saline or heparin flush solutions. (Ford 88) linezolid.

Complicated skin and skin structure infections, 4 mg/kg IV daily for 7–14 days
Daptomycin Cubicin C Staphylococcus aureus blood infections
Infections with VREF; pneumonia from

Staphylococcus aureus and penicillin-susceptible 600 mg orally or IV q 12 hr
Linezolid Zyvox Streptococcus pneumoniae; skin and skin structure
infections
Quinupristin-
Synercid VREF 7.5 mg/kg IV q 8 hr
dalfopristin S
Anti Infectives
- Cephalosporins

Cephalosporins have a β-lactam ring and target the bacterial cell • Before administering any antibiotic be sure to evaluate the
wall, making it defective and unstable. This action is similar to results of the culture and sensitivity test.
the action of penicillin. The cephalosporins are usually • Be sure to question the patient about allergy to penicillin or
bactericidal. (Ford 73) cephalosporins before administering the first dose, even when
an accurate drug history has been taken
• After administering penicillin IM in the outpatient setting, ask
Indications the patient to wait in the area for at least 30 minutes.
Anaphylactic reactions are most likely to occur within 30
• Respiratory infections
minutes after injection.
• Otitis media (ear infection)
• Take the drug at the prescribed time intervals.
• Bone/joint infections
• Complete the entire course of treatment. Do not stop the drug,
• Genitourinary tract and other infections caused
except on the advice of a primary health care provider, before
by bacteria
the course of treatment is completed, even if symptoms
improve or disappear. Failure to complete the prescribed
course of treatment may result in a return of the infection.
Adverse Reactions
• Take drugs that must be taken on an empty stomach 1 hour
before or 2 hours after a meal.
• Nephrotoxicity
• Malaise • Distinguish between immediate- and extended-release
medications. Do not break, chew, or crush
• Steven johnson syndrome
extended-release medications.
• Nausea
• Vomiting
• Diarrhea
• Headache Nursing Alert
• Dizziness
• Heartburn • A patient who is allergic to penicillin also may be allergic to the
• Fever cephalosporins.
• Aplastic anemia (deficient red blood cell • A disulfiram-like (Antabuse) reaction may occur if alcohol is
production) consumed within 72 hours after administration of certain
• Toxic epidermal necrolysis (death of the epidermal cephalosporins
layer of the skin) • Symptoms of a disulfiram-like reaction: include flushing,
throbbing in the head and neck, respiratory difficulty,
vomiting, sweating, chest pain, and hypotension. Severe
Contraindications & Caution reactions may cause dysrhythmias and unconsciousness.
• People with phenylketonuria (PKU) need to be aware that the
• Do not administer cephalosporins if the patient has a history oral suspension cefprozil (Cefzil) contains phenylalanine,
of allergies to cephalosporins. a substance that people with PKU cannot process.
• Cephalosporins should be used cautiously in patients with
renal disease, hepatic impairment, bleeding disorder,
pregnancy (pregnancy category B), and known penicillin
allergy. (Ford 73) Generations Of Cephalosporins
• First generation—cephalexin (Keflex), cefazolin (Ancef)
Interactions: • Second generation—cefaclor (Raniclor), cefoxitin (Mefoxin),
cefuroxime (Zinacef)
• Aminoglycosides: Increased risk for nephrotoxicity • Third generation—cefoperazone (Cefobid),
• Oral anticoagulants: Increased risk for bleeding cefotaxime (Claforan), ceftriaxone (Rocephin)
• Loop diuretics: Increased cephalosporin blood level • Fourth generation—cefepime (Maxipime)

Infections due to susceptible
Cefadroxil n/a 1–2 g/day orally in divided doses
microorganisms,
Cefoxitin Mefoxin microorganisms, 250 mg orally q 8 hr
perioperative prophylaxis
Drugs that disrupt the cell wall:
Penicillins

Penicillin is a widely used antibiotic prescribed to treat staphylococci and • View the culture and sensitivity results
streptococci bacterial infections. Penicillin belongs to the beta-lactam • Monitor symptoms of hypersensitivity or anaphylaxis
family of antibiotics, the members of which use a similar mechanism of • Prophylaxis—Take the drug as prescribed until the primary health care
action to inhibit bacterial cell growth that eventually kills the bacteria provider discontinues therapy.
• Infection—Complete the full course of therapy. Do not stop taking the
drug, even if the symptoms have disappeared.
Indications • Take the drug at the prescribed times of day because it is important to
keep an adequate amount of drug in the body throughout the entire
24 hours of each day.
• Urinary tract infections (UTIs) • Penicillin (oral)—Take the drug on an empty stomach either 1 hour
• Septicemia before or 2 hours after meals (exceptions: penicillin V and amoxicillin).
• Meningitis • Take each dose with a full 8-ounce glass of water.
• Intra-abdominal infections • Avoid drinking alcoholic beverages when taking the cephalosporins and
• Sexually transmitted infections (syphilis) for 3 days after completing the course of therapy, because severe
• Pneumonia and other respiratory infections reactions may occur.
• Prophylaxis for anticipated bacterial infections • To reduce the risk of superinfection during antibiotic therapy, take
yogurt, buttermilk, or Acidophilus capsules.
• If you are a woman who has been prescribed ampicillin and penicillin V
Adverse Reactions and who takes birth control pills containing estrogen, use additional
contraception measures.
• Notify the primary health care provider immediately should one or
• Glossitis (inflammation of the tongue) when given orally
more of the following occur: skin rash; hives (urticaria); severe diarrhea;
• Stomatitis (inflammation of the mouth), dry mouth vaginal or anal itching; black, furry tongue; sores in the mouth; swelling
• Gastritis around the mouth or eyes; breathing difficulty; or GI disturbances such
• Nausea, vomiting as nausea, vomiting, and diarrhea. Do not take the next dose of the
• Diarrhea, abdominal pain drug until the problem has been discussed with the primary health
• An anaphylactic reaction care provider.
• Anemia (low red blood cell count) • Never give this drug to another individual even though his or her
• Thrombocytopenia (low platelet count) symptoms appear to be the same as yours.
• Leukopenia (low white blood cell count) • Never skip doses or stop therapy unless told to do so by the primary
• Bone marrow depression health care provider (see Patient Teaching for Improved Patient
Outcomes: Preventing Anti-Infective Resistance). When a penicillin is
to be taken for a long time for prophylaxis, you may feel well despite
Contraindications & Caution the need for long-term antibiotic therapy. There may be a tendency
to omit one or more doses or even neglect to take the drug for an
• Hypersensitivity to penicillin or cephalosporins extended time. (Ford 77)
Herbal Considerations
Interactions:
Goldenseal (Hydrastis canadensis) is an herb found growing in certain
• Oral contraceptives (with estrogen): Decreased effectiveness of areas of the northeastern United States, particularly the Ohio River
contraceptive agent (with ampicillin, penicillin V). valley. Goldenseal has been used to wash inflamed or infected eyes and
• Tetracyclines: Decreased effectiveness of penicillins in making yellow dye. There are many more traditional uses of the herb,
• Anticoagulants: Increased bleeding risks (with large doses of including as an antiseptic for the skin, as a mouthwash for canker sores,
penicillins) and in the treatment of sinus infections and digestive problems such as
• β-adrenergic blocking drugs: May increase the risk for an peptic ulcers and gastritis. In the 19th century, goldenseal was touted as
anaphylactic reaction an “herbal antibiotic” for treating gonorrhea and UTIs. Though used over
time by American Indian tribes as an insect repellent, stimulant, and
diuretic, there is no scientific evidence to support its benefit for these
Contraindications & Caution purposes. Another myth surrounding goldenseal use is that taking the
herb masks the presence of illicit drugs in the urine. Evidence does
support the use of goldenseal to treat diarrhea caused by bacteria or
• Augmentin - combination of amoxicillin and clavulanic acid intestinal parasites, such as Giardia. The herb is contraindicated during
• Timentin - combination of ticarcillin and clavulanic acid pregnancy and in patients with hypertension. Adverse reactions are rare
• Unasyn - combination of ampicillin andsulbactam when the herb is used as directed. However, this herb Anaphylaxis
• Zosyn - combination of piperacillin and tazobactam (Ford 71) should not be taken for more than 1 week. (Ford 72)

Infections due to susceptible Up to 20–30 million Units/day IV
penicillin G
Pfizerpen microorganisms; meningococcal or IM; dosage may also be based
(aqueous) meningitis, septicemia on weight
penicillin V Veetids 125–500 mg orally q 6 hr or q 8 hr
organisms
Anti Infectives
- Fluoroquinolones

The fluoroquinolones exert their bactericidal effect by • Before administering any antibiotic be sure to evaluate
interfering with the synthesis of bacterial DNA. This the results of the culture and sensitivity test.
interference prevents cell reproduction, causing death • Monitor labs and evaluate the effectiveness of the
of the bacterial cell (Ford 96) treatment
• Monitor vitals and temperature
Indications • Complete the entire course of treatment. Do not stop
the drug, except on the advice of a primary health care
• Lower respiratory infections provider, before the course of treatment is completed,
• Bone and joint infections even if symptoms improve or disappear. Failure to
• Urinary tract infections complete the prescribed course of treatment may
• Infections of the skin result in a return of the infection.
• Sexually transmitted infections • There is a risk with all fluoroquinolone drugs of causing
pain, inflammation, or rupture of a tendon. The Achilles
tendon is particularly vulnerable. Those 60 years of age
Adverse Reactions and older who take corticosteroids are at greatest risk
for tendon rupture.
• Nausea
• Diarrhea
• Headache
• Abdominal pain or discomfort
• Dizziness
• Photosensitivity
Favorable Outcomes
Contraindications & Caution
• A superinfection can develop rapidly and is potentially
• Hypersensitivity serious and even life-threatening. Antibiotics can
• Children younger than 12 or adults older than 60 disrupt the normal flora (nonpathogenic bacteria in the
who are on corticosteroids because of the risk of
bowel), causing a secondary infection or superinfection.
achilles tendonitis
This new infection is “superimposed” on the original
infection. The destruction of large numbers of
Interactions: nonpathogenic bacteria (normal flora) by the antibiotic
alters the chemical environment. This allows
uncontrolled growth of bacteria or fungal
• Theophylline: Increased serum theophylline level
microorganisms that are not affected by the antibiotic
• Cimetidine: Interferes with elimination of the
being administered. A superinfection may occur with
antibiotic
the use of any antibiotic, especially when these drugs
• Oral anticoagulants: Increased risk of bleeding
are given for a long time or when repeated courses of
• Antacids, iron salts, or zinc: Decreased absorption
therapy are necessary. (Ford 96)
of the antibiotic
• Nonsteroidal anti-inflammatory drugs (NSAIDs):
Risk of seizure.
Treatment of infections due to 250–750 mg orally q 12 hr;

Ciprofloxacin Cipro susceptible microorganisms 200–400 mg IV q 12 hr
Bronchitis and
Gemifloxacin Factive 320 mg/day orally
community-acquired pneumonia
Treatment of infections due to

Levofloxacin Levaquin 250-750 mg/day orally
susceptible microorganisms
Anti Infectives
- Lincosamides

They act by inhibiting protein synthesis in susceptible • Before administering any antibiotic be sure to evaluate
bacteria, causing cell death. They disrupt the functional the results of the culture and sensitivity test.
ability of the ribosomes (which assemble amino acids in • Complete the entire course of treatment. Do not stop
the cell), causing cell death. the drug, except on the advice of a primary health care
provider, before the course of treatment is completed,
even if symptoms improve or disappear. Failure to
complete the prescribed course of treatment may result
Indications in a return of the infection.
• Evaluate the effectiveness of the treatment by
Treatment of infections caused by a range of monitoring temperature and vital signs.
gram-negative and gram-positive microorganisms. • Evaluate lab results for decreasing WBC counts to ensure
Lincosamides are used for the more serious infections the drug regamein is working.
and may be used in conjunction with other antibiotics.
(Ford 87)
Adverse Reactions
Interactions:
• Abdominal pain
• Esophagitis • Kaolin- or aluminum-based antacids: Decreased
• Nausea absorption of the lincosamides
• Vomiting • Neuromuscular blocking drugs: Increased action of
• Diarrhea neuro muscular blocking drug, possibly leading to
• Skin rash severe and profound respiratory depression
• Blood dyscrasias
• Pseudomembranous colitis
Contraindications & Caution Nursing Alert
• Hypersensitive to the lincosamides • Food impairs the absorption of lincomycin. The patient
• Taking cisapride (Propulsid) or the antipsychotic drug should take nothing by mouth (except water) for 1 to
pimozide (Orap) 2 hours before and after taking lincomycin. Clindamycin
• With minor bacterial or viral infections may be taken with food or a full glass of water.

Serious infection: 150–
Treatment of infections due to 450 mg orally q 6 hr; severe infection: 600–2700
Clindamycin Cleocin
susceptible microorganism mg/day in 2–4 equal doses; life-threatening
infection: up to 4.8 g/day IV, IM
Treatment of infections due 500 mg orally q 6–8 hr; 600 mg IM q 12–24 hr;
Lincomycin Lincocin
to susceptible microorganism up to 8 g/day IV in life-threatening situations
Anti Infectives
- Macrolides

The macrolides are bacteriostatic or bactericidal in • Before administering any antibiotic be sure to evaluate
susceptible bacteria. The drugs act by causing changes in the results of the culture and sensitivity test.
protein function and synthesis. • Take the drug at the prescribed time intervals. These
time intervals are important because a certain amount
Indications of the drug must be in the body at all times for the
infection to be controlled..
• A wide range of gram-negative and gram-positive • Do not increase or omit the dose unless advised to do so
infections by the primary health care provider.
• Acne vulgaris and skin infections • Complete the entire course of treatment. Do not stop
• Upper respiratory infections caused by Haemophilus the drug, except on the advice of a primary health care
influenzae (with sulfonamides) provider, before the course of treatment is completed,
(Ford 86) even if symptoms improve or disappear. Failure to
complete the prescribed course of treatment may result in
Adverse Reactions a return of the infection.
• Nausea
• Vomiting
• Diarrhea Interactions:
• Abdominal pain or cramping • Antacids (kaolin, aluminum salts, or magaldrate):
• Visual disturbances (associated with telithromycin) Decreased absorption and effectiveness of the
may also occur. macrolides
• Digoxin: Increased serum levels
Education • Anticoagulants: Increased risk of bleeding
• Clindamycin, lincomycin, or chloramphenicol:
• Take the drug at the prescribed time intervals. These intervals
Decreased therapeutic activity of the macrolides
are important because a certain amount of the drug must be in
the body at all times for the infection to be controlled. • Theophylline: Increased serum theophylline
• Do not increase or omit the dose unless advised to do so by the
primary health care provider.
• Complete the entire course of treatment. Never stop the drug,
except on the advice of a primary health care provider, before Contraindications & Caution
the course of treatment is completed even if symptoms
improve or disappear. Failure to complete the prescribed These drugs are contraindicated in patients with
course of treatment may result in a return of the infection. hypersensitivity to the macrolides and in patients with
• Take each dose with a full (8-ounce) glass of water. Follow the pre-existing liver disease. Telithromycin (Ketek) should
directions given by the clinical pharmacist regarding taking the
drug on an empty stomach or with food (see Patient Teaching
not be ordered if a patient is taking cisapride (Propulsid)
for Improved Patient Outcomes: Avoiding Drug–Food or pimozide (Orap).
Interactions). (Ford 86)

Treatment of infections due to 500 mg orally first day then 250
Azithromycin Zithromax, Zmax
susceptible microorganism mg/day orally
Helicobacter pylori therapy,

Clarithromycin Biaxin Treatment of infections due to 250–500 mg orally q 12 hr
susceptible microorganism
E-Glades, Eryc, Treatment of infections due to 250 mg orally q 6 hr or 333 mg

Erythromycin
Ery-Ped, E.E.S. susceptible microorganism q 8 hr up to 4 g/day
Anti Infectives
- Sulfonamides

Bacteriostatic agents that are used to halt the growth of bacteria. Their • Before administering any antibiotic be sure to evaluate the results of
ability to inhibit the activity of folic acid in bacterial cell metabolism. They the culture and sensitivity test.
are often used to control infections caused by both gram-positive and • Take the drug at the prescribed time intervals. These time intervals are
gram-negative bacteria, such as Escherichia coli, Staphylococcus aureus, important because a certain amount of the drug must be in the body
and Klebsiella and Enterobacter species. (Ford 62) at all times for the infection to be controlled..
• Do not increase or omit the dose unless advised to do so by the primary
health care provider.
Indications • Complete the entire course of treatment. Do not stop the drug, except
on the advice of a primary health care provider, before the course of
• Urinary tract infections (UTIs) and acute otitis media treatment is completed, even if symptoms improve or disappear.
• Ulcerative colitis Failure to complete the prescribed course of treatment may result in a
• Mafenide (Sulfamylon) and silver sulfadiazine (Silvadene) are topical return of the infection.
sulfonamides used in the treatment and prevention of infections in • Take drugs that must be taken on an empty stomach 1 hour before or
second- and third-degree burns. 2 hours after a meal.
• Distinguish between immediate- and extended-release medications.
Do not break, chew, or crush extended-release medications.
Adverse Reactions • Notify the primary health care provider if symptoms of the infection
become worse or if original symptoms do not improve after 5 to 7 days
• Nausea, vomiting, anorexia of drug therapy.
• Diarrhea, abdominal pain • Avoid any exposure to sunlight or ultraviolet light (tanning beds,
• Stomatitis (inflammation of the mouth) sunlamps) while taking these drugs and for several weeks after
• Chills, fever completing the course of therapy. Wear sunblock, sunglasses, and
• Crystalluria (crystals in the urine) protective clothing when exposed to sunlight.
• Photosensitivity • Specific Instructions Regarding Sulfonamides
• Steven johnson syndrome • Take sulfasalazine (Azulfidine) with food or immediately after a meal.
• TEN • When taking sulfasalazine, the skin or urine may turn orange-yellow;
• Leukopenia - decrease in the number of white blood cells this is normal. Soft contact lenses may acquire a permanent yellow
• Thrombocytopenia - decrease in the number of platelets stain. It is a good idea to seek the advice of an ophthalmologist
• Aplastic anemia - deficient red blood cell production in the bone
marrow
Interactions:
• Oral anticoagulants: Increased action of the anticoagulant
• Hypersensitivity to sulfonamides • Methotrexate: Increased bone marrow suppression
• During lactation • Hydantoins: Increased serum hydantoin level
• In children younger than 2
Herbal Considerations
Nursing Alert
Cranberries and cranberry juice are commonly used folk remedies for
• If sulfonamides are given near the end of pregnancy, significantly high preventing and relieving symptoms of UTIs. The use of cranberries in
blood levels of the drug may occur, causing jaundice or hemolytic combination with antibiotics has been recommended by physicians for
anemia in the neonate. In addition, the sulfonamides are not used for the long-term suppression of UTIs. Cranberries are thought to prevent
infections caused by group A beta (β)-hemolytic streptococci because bacteria from attaching to the walls of the urinary tract. The suggested
the sulfonamides have not been shown to be effective in preventing dose is 6 ounces of juice twice daily. Cranberry capsules are not
the complications of rheumatic fever or glomerulonephritis. recommended because the fluid for hydration may be as helpful as the
(Ford 63) berries (Brown, 2012). Extremely large doses can produce GI
• When diabetic patients are prescribed sulfonamides, assess for a disturbances, such as diarrhea or abdominal cramping. Although
possible hypoglycemic reaction. Sulfonamides may inhibit the cranberries may relieve symptoms or prevent the occurrence of a UTI,
(hepatic) metabolism of the oral hypoglycemic drugs tolbutamide and their use will not cure a UTI. If an individual suspects a UTI, medical
chlorpropamide (Diabinese). (Ford 63) attention is necessary. (Ford 63)

UTIs, chancroid, acute otitis media,
Loading dose: 2–4 g orally; maintenance
Haemophilus influenzae and
Sulfadiazine Pfizerpen meningococcal meningitis, rheumatic
dose: 2–4 g/day orally in 4–6 divided
doses
fever
Initial therapy: 1–4 g/day orally in divided
Azulfidine, UTI, acute otitis media, Haemophilus
Sulfasalazine Azulfidine EN-tabs influenzae, meningococcal meningitis
doses; maintenance dose: 2 g/day orally
in evenly spaced doses (500 mg QID)
Anti Infectives
- Tetracycline

Tetracyclines interfere with protein synthesis and are composed • Before administering any antibiotic be sure to evaluate the
of natural and semisynthetic compounds. They are used in lieu results of the culture and sensitivity test.
of penicillin when there is an allergy resent to penicillin or • Take the drug at the prescribed time intervals. These time
cephalosporins intervals are important because a certain amount of the drug
must be in the body at all times for the infection to be
controlled..
Indications • Always report serious adverse reactions, such as a severe
hypersensitivity reaction, respiratory difficulty, severe diarrhea,
• Rickettsial diseases (Rocky Mountain spotted fever, typhus or a decided drop in blood pressure, to the primary health care
fever, and tick fevers) provider immediately, because a serious adverse reaction may
• Intestinal amebiasis require emergency intervention.
• Some skin and soft tissue infections • When a tetracycline has been prescribed, avoid exposure to the
• Uncomplicated urethral, endocervical, or rectal infections sun or any type of tanning lamp or bed. When exposure to
caused by Chlamydia trachomatis direct sunlight is unavoidable, completely cover the arms and
• Severe acne as an adjunctive treatment legs and wear a wide-brimmed hat to protect the face and neck.
• Infection with Helicobacter pylori in combination with Application of a sunscreen may or may not be effective.
metronidazole and bismuth subsalicylate Therefore, consult the primary health care provider before
using a sunscreen to prevent a photosensitivity reaction.
Adverse Reactions
• Nausea or vomiting Interactions:
• Diarrhea
• Antacids containing aluminum, zinc, magnesium, or
• Epigastric distress
bismuth salts: Decreased effectiveness of tetracycline
• Stomatitis
• Oral anticoagulants: Increased risk for bleeding
• Sore throat
• Oral contraceptives: Decreased effectiveness of contraceptive
• Skin rashes
agent (breakthrough bleeding or pregnancy)
• Photosensitivity reaction (demeclocycline seems to cause the
• Digoxin: Increased risk for digitalis toxicity
most serious photosensitivity reaction, whereas minocycline
is least likely to cause this type of reaction)
Education
Diarrhea may be an indication of a superinfection or
• Hypersensitivity to sulfonamides pseudomembranous colitis, both of which can be serious.
• During lactation & pregnancy Inspect all stools for blood or mucus. If diarrhea is dark or there
• In children younger than 9 because it can discolor the teeth is mucus in the stool, save a sample and test for occult blood
using a test such as Hemoccult. If the stool tests positive for
blood, save a sample of the stool for possible further laboratory
Nursing Alert analysis.
Teach the patient to avoid the following dairy products
• Women of childbearing age should be assessed for oral before or after taking tetracycline:
contraception use whenever tetracyclines are prescribed. • Milk (whole, low fat, skim, condensed, or evaporated) and
• Do not give tetracyclines along with dairy products (milk or milkshakes
cheese), antacids, laxatives, or products containing iron. • Cream (half-and-half, heavy, light), sour cream, coffee
• When the aforementioned drugs are prescribed, make sure creamers, and creamy salad dressings
they are given 2 hours before or after the administration of a • Eggnog
tetracycline. Food or drugs containing calcium, magnesium, • Cheese (natural and processed) and cottage cheese
aluminum, or iron prevent the absorption of the tetracyclines • Yogurt and frozen yogurt
if ingested concurrently. (Ford 89) • Ice cream, ice milk, and frozen custard (Ford 91)

Atridox, Doryx, Monodox, 150 mg orally QID or 300 mg orally BID;
Treatment of infections due to
Doxycycline Periostat, Oracea, gonorrhea: 600 mg orally initially then
susceptible microorganisms
Vibra-Tabs, Vibramycin 300 mg orally q 12 hr for 4 days
Treatment of infections due to 1–2 g/day orally in 2–4 divided

Tetracycline n/a
susceptible microorganisms doses
Antifungal
&
Antiviral
Anthelmintic

• Albendazole (Albenza) interferes with the synthesis of • Follow the dosage schedule exactly as printed on the prescription
the parasite’s microtubules, resulting in death of container. It is absolutely necessary to follow the directions for taking
the drug to eradicate the parasite.
susceptible larvae. This drug is used to treat larval forms
• Follow-up stool specimens will be necessary because this is the only
of pork tapeworm and to treat liver, lung, and peritoneum way to determine the success of drug therapy.
disease caused by the dog tapeworm. • When an infection is diagnosed, multiple members of the family may
• Mebendazole blocks the uptake of glucose by the be infected, and all household members may need to be treated.
helminth, resulting in depletion of the helminths own Playmates of the infected child may also need to be treated.
glycogen. This drug is used to treat whipworm, pinworm, • It is important to wash all bedding and bed clothes once treatment
has started.
roundworm, American hookworm, and the common • Daily bathing (showering is best) is recommended. Disinfect toilet
hookworm. facilities daily, and disinfect the bathtub or shower stall immediately
• The activity of pyrantel (Antiminth) is probably due to after bathing. Use the disinfectant recommended by the primary
its ability to paralyze the helminth (Ford 129) health care provider or use chlorine bleach. Scrub the surfaces
thoroughly and allow the disinfectant to remain in contact with the
surfaces for several minutes.
• During treatment for a ringworm infection, keep towels and facecloths
Indications for bathing separate from those of other family members to avoid the
spread of the infection. It is important to keep the affected area clean
Roundworms, pinworms, whipworms, hookworms, and and dry.
• Wash the hands thoroughly after urinating or defecating and before
tapeworms are examples of helminths . These drugs are
preparing and eating food. Clean under the fingernails daily and avoid
used to eradicate helminths out of the body. putting fingers in the mouth or biting the nails.
• Food handlers should not resume work until a full course of treatment
is completed and stools do not contain the parasite.
• Child care workers should be especially careful of diaper disposal and
proper hand washing to prevent the spread of infections.
Adverse reactions • Report any symptoms of infection (low-grade fever or sore throat) or
thrombocytopenia (easy bruising or bleeding).
• Drowsiness, dizziness • Albendazole can cause serious harm to a developing fetus. Inform
• Nausea, vomiting women of childbearing age of this. Explain that a barrier contraceptive
is recommended during the course of therapy and for 1 month after
• Abdominal pain and cramps, diarrhea discontinuing the therapy.
(Ford 129) (Ford 132-133)
Interactions
Contraindications & Caution Albendazole (Albenza)

• Dexamethasone: Increased effectiveness of
• The anthelmintic drugs are contraindicated in patients albendazole
with known hypersensitivity to the drugs and during • Cimetidine: Increased effectiveness of albendazole
pregnancy (pregnancy category C). (Ford 129)
• They should be used cautiously in lactating patients, Mebendazole
patients with hepatic or renal impairment, and patients • Hydantoins and carbamazepine: Lower levels of
with malnutrition or anemia. mebendazole

Parenchymal neurocysticercosis due
Weight greater than or equal to 60 kg:
to pork tapeworms, hydatid disease
albendazole Albenza 400 mg
(caused by the larval form of the dog
Weight less than 60 kg: 15 mg/kg/day
tapeworm)
Treatment of whipworm, pinworm, 100 mg orally morning and evening for

mebendazole N/A roundworm, common and American 3 consecutive days
hookworm Pinworm: 100 mg orally as a single dose
pyrantel Antiminth, Reese’s Treatment of pinworm 11 mg/kg orally as a single dose;

Pinworm and roundworm maximum dose, 1000 mg
Antiretrovirals

Protease inhibitors, which block the protease enzyme so the • Antiviral drugs are not a cure for viral infections, but they will
new viral particles cannot mature Reverse transcriptase shorten the course of disease outbreaks and promote healing
inhibitors, which block the reverse transcriptase enzyme so the of the lesions. The drugs will not prevent the spread of the
HIV material cannot change into DNA in the new cell, preventing disease to others. Topical drugs should not be applied more
frequently than prescribed but should be applied with a finger
new HIV copies from being created Non Nucleoside reverse
cot or gloves. All lesions should be covered. There should be
transcriptase inhibitors, which latch on to the reverse
no sexual contact while lesions are present. Notify the primary
transcriptase molecule to block the ability to make viral DNA health care provider if burning, stinging, itching, or rash
Entry inhibitors, which prevent the attachment or fusion of HIV worsens or becomes pronounced.
to a host cell for initial entry Integrase inhibitors, which prevent • Some drugs cause photosensitivity, so precautions should be
enzymes from inserting HIV genetic material into the cell’s DNA taken when going outdoors, such as wearing sunscreen, head
(Ford 115) coverings, and protective clothing. Patients should also refrain
from using tanning beds.
• Some patients have experienced an acute exacerbation of the
disease when medications used to treat hepatitis B are
Indications
stopped. Hepatic function should be closely monitored in
these patients.
Antiretroviral drugs are used in the treatment of HIV infection
and AIDS.
Nursing alert
Patients receiving antiretroviral drugs for HIV infection may
continue to contract opportunistic infections and other
Adverse reactions complications of HIV disease. Monitor all patients closely for
signs of infection such as fever (even low-grade fever), malaise,
• Nausea, vomiting sore throat, or lethargy. All caregivers are reminded to use good
• Diarrhea hand hygiene technique. (Ford 118)
• Altered taste
• Rash Interactions
• Numbness and tingling in the circumoral area (around the
mouth) or peripherally, or both • Antifungals: increased serum level of the antiretroviral
• Clarithromycin: Increased serum level of both drugs
• Sildenafil: Increased adverse reactions of sildenafil
• Opioid analgesics: Risk of toxicity with ritonavir
HERBAL CONSIDERATIONS • Anticoagulant, anticonvulsant, antiparasitic agents: Decreased
effectiveness when taking ritonavir
• Individuals have tried St. John’s wort for both the • Oral contraceptives: decreased birth control effectiveness
antidepressive and antiviral effects of the supplement.
Researchers have found that in patients with HIV infection who
receive prescribed protease inhibitors, the effectiveness of
drug therapy is reduced if the patient also takes St. John’s wort. Do not administer antiretrovirals if the patient has a history of
Patients need to be instructed to disclose the use of all allergies to the drug or other antiretrovirals. Women who are
over-the-counter medications and supplements to their lactating should not use antiretroviral drugs. Antiretrovirals
primary health care provider to prevent potentially harmful should not be prescribed to the patient who is using cisapride,
pimozide, triazolam, midazolam, or an ergot derivative. Ritonavir
interactions. (Ford 116)
is contraindicated if the patient is taking bupropion (Wellbutrin),
zolpidem (Ambien), or an antiarrhythmic drug. (Ford 116)
HIV infection, prevention of 600 mg/day orally in divided

zidovudine Retrovir
maternal–fetal HIV transmission doses; 1 mg/kg IV q 4 hr
HIV: 150 mg orally BID

lamivudine (3TC) Epivir, Epivir-HB HIV infection, chronic hepatitis B
HBV: 100 mg/day orally daily
infection
Antifungals

Antifungal drugs may be fungicidal (able to destroy fungi) or Renal damage is the most serious adverse reaction to the use of
fungistatic (able to slow or retard the multiplication of fungi). amphotericin B. Renal impairment usually improves with a modification
of the dosage regimen (reduced dosage or increased time between
• Amphotericin B (Fungizone IV), miconazole (Monistat), nystatin, doses). Serum creatinine levels and blood urea nitrogen (BUN) levels are
voriconazole (Vfend), micafungin (Mycamine), and ketoconazole checked frequently during the course of therapy to monitor kidney
(Nizoral) are thought to have an effect on the cell membrane function. If the BUN exceeds 40 mg/dL or the serum creatinine level
of the fungus. exceeds 3 mg/dL, the primary health care provider may discontinue
• Fluconazole (Diflucan) has fungistatic activity that appears to the drug or reduce the dosage until renal function improves. (Ford 128)
Before administering fluconazole to an older adult or a patient with renal
result from the depletion of sterols (a group of substances impairment, the primary health care provider may order a creatinine
related to fats) in the fungus cells. (Ford 125) clearance test. Watch for and report the laboratory results to the
• Griseofulvin (Grisactin) exerts its effect by being deposited in primary health care provider because the dosage may be adjusted
keratin precursor cells, which are then gradually lost (because based on the test results. (Ford 128)
of the constant shedding of top skin cells) and replaced by new,
non infected cells.
• Clean the involved area and apply the ointment or cream to the skin
• Flucytosine (Ancobon) inhibits DNA and RNA synthesis in the as directed by the primary health care provider.
fungus. • Do not increase or decrease the amount used or the number of times
• Clotrimazole (Lotrimin, Mycelex) binds with phospholipids in the ointment or cream should be applied unless directed to do so by
the fungal cell membrane, increasing permeability of the cell the primary health care provider.
• Griseofulvin—Beneficial effects may not be noticed for some time;
and resulting in loss of intracellular components. (Ford 125) therefore, take the drug for the full course of therapy. Avoid exposure
to sunlight and sun lamps because an exaggerated skin reaction
(which is similar to severe sunburn) may occur even after a brief
exposure to ultraviolet light. Notify the primary health care provider if
Indications fever, sore throat, or skin rash occurs. (Ford 128)
• Ketoconazole—Complete the full course of therapy as prescribed by
• Superficial and deep fungal infections the primary health care provider. Do not take this drug with an antacid.
• Systemic infections such as aspergillosis, candidiasis, and In addition, avoid the use of nonprescription drugs unless use of a
specific drug is approved by the primary health care provider.
cryptococcal meningitis (Ford 128)
• Superficial infections of nail beds and oral, anal, and vaginal • Itraconazole—The drug is taken with food. Therapy continues for at
areas (Ford 125) least 3 months until infection is controlled. Report unusual fatigue,
yellow skin, darkened urine, anorexia, nausea, and vomiting. (Ford 128)
Contraindications & Caution Interactions

• Known hypersensitivity Amphotericin B
• Pregnancy • Corticosteroids: Risk for severe hypokalemia
• Both voriconazole and itraconazole are contraindicated in • Digoxin: increased risk of digitalis toxicity
patients taking cisapride, pimozide, or quinidine. The systemic • Aminoglycosides & Cephalosporins: increased risk of
agent itraconazole should not be used to treat fungal nail nephrotoxicity
infections in patients with a history of heart failure. (Ford 127) Fluconazole
• Oral hypoglycemics: increased hypoglycemic effects
• Phenytoin: decreased effects of phenytoin
Griseofulvin
Herbal Considerations • Barbiturates: decrease sedative effect
Researchers have identified several antifungal herbs that are
• Oral contraceptives: decreased effects of birth control
effective against skin infections, such as tea tree oil (Melaleuca
alternifolia) and garlic (Allium sativum). Tea tree oil comes from Adverse reactions
an evergreen tree native to Australia. The herb has been used as
a non irritating antimicrobial for cuts, stings, wounds, burns, and • Headache
acne. It can be found in shampoos, soaps, and lotions. Tea tree • Rash
oil should not be ingested orally but is effective when used • Anorexia and malaise
topically for minor cuts and stings. • Abdominal, joint, or muscle pain
• Nausea, vomiting, diarrhea (Ford 127)
Abelcet, AmBisome, Systemic fungal infections, cryptococcal Desoxycholate: 1–1.5 mg/kg/day IV

amphotericin B
Amphotec, Fungizone meningitis in patients with HIV infection Lipid-based: 3–6 mg/kg/day IV
70-mg loading dose IV, followed by 50

caspofungin Cancidas Invasive aspergillosis, hepatic insufficiency
mg/day IV for at least 14 days
Antivirals

Antiviral drugs work by interfering with the virus’s ability to • Antiviral drugs are not a cure for viral infections, but they will
reproduce in a cell. Antiviral drugs can be toxic to human cells, shorten the course of disease outbreaks and promote healing
and viruses can develope resistance to antiviral drugs of the lesions. The drugs will not prevent the spread of the
disease to others. Topical drugs should not be applied more
frequently than prescribed but should be applied with a
finger cot or gloves. All lesions should be covered. There should
Indications be no sexual contact while lesions are present. Notify the
primary health care provider if burning, stinging, itching, or
• Cytomegalovirus (CMV) in transplant recipients rash worsens or becomes pronounced.
• Herpes simplex virus (HSV) 1 and 2 (genital) and herpes zoster • Some drugs cause photosensitivity, so precautions should be
• Human immunodeficiency virus (HIV) taken when going outdoors, such as wearing sunscreen, head
• Influenza A and B (respiratory tract illness) coverings, and protective clothing. Patients should also refrain
• Respiratory syncytial virus (RSV; severe lower respiratory tract from using tanning beds.
infection primarily affecting children)
• Some patients have experienced an acute exacerbation of the
disease when medications used to treat hepatitis B are
• Hepatitis B and C stopped. Hepatic function should be closely monitored in
these patients.
• Those taking antiretrovirals should be cautioned that there is
Adverse reactions an increased risk of adverse reactions (hypotension, visual
disturbances, prolonged penile erection) when the drug
• Nausea, vomiting sildenafil (Viagra) is used. Symptoms should be reported
• Diarrhea promptly to the primary health care provider.
• Headache • Some drugs affect mental status. Activities requiring mental
• Rash alertness, such as driving a car, should be delayed until the
• Fever effect of the drug is apparent because vision and coordination
can be affected. Patients should rise slowly from a prone to a
• Insomnia sitting position to decrease the possibility of lightheadedness
caused by orthostatic hypotension. Changes such as
nervousness, tremors, slurred speech, or depression should
Contraindications & Caution be reported.
• Some patients are on an alternate-dosage schedule. In this
Do not administer antivirals if the patient has a history of case, it is important to designate the days the drug is to be
allergies to the drug or other antivirals. Cidofovir (Vistide) should taken; calendars are helpful aids to track schedules.
not be given to patients who have renal impairment or in • Zanamivir (Relenza) is taken every 12 hours for 5 days using a
“Diskhaler” delivery system. If a bronchodilator is also
combination with medications that are nephrotoxic, such as
prescribed for use at the same time, the bronchodilator is used
aminoglycosides. Ribavirin should not be used in patients with before the zanamivir. The drug may cause dizziness. The
unstable cardiac disease. These drugs should be used during patient should use caution when driving an automobile or
pregnancy (pregnancy categories B and C) and lactation only operating dangerous machinery. Treatment with this drug
when the benefit outweighs the risk to the fetus or child does not decrease the risk of transmission of influenza to
(ribavirin is a pregnancy category X). others.
Nursing alert Interactions

• Probenecid: Increased serum levels of the antivirals
• Zanamivir (Relenza) is taken every 12 hours for 5 days using a • Cimetidine:Increased serum level of the antiviral valacyclovir
“Diskhaler” delivery system. If a bronchodilator is also • Ibuprofen: Increased serum level of the antiviral adefovir
prescribed for use at the same time, the bronchodilator is • Imipenem-cilastatin: With ganciclovir only, increased risk of
used before the zanamivir. The drug may cause dizziness. seizures
The patient should use caution when driving an automobile or • Anticholinergic agents: With amantadine only, increased
operating dangerous machinery. Treatment with this drug adverse reactions of anticholinergic agent
does not decrease the risk of transmission of influenza to • Theophylline: With acyclovir only, increased serum level of
others. theophylline

Oral: 200–800 mg q 4 hr for 5 doses per day,
HSV, herpes zoster, varicella
acyclovir Zovirax treat for 5–10 days; IV: 5–10 mg/kg q 8 hr;
zoster
Topical: apply to lesions q 3 hr
Prevention and treatment of 75 mg orally BID for 5 days

oseltamivir Tamiflu
influenza A and B
Antiprotozoal

Antiprotozoal drugs interfere with, or are active against, • Follow the dosage schedule exactly as printed on the
the life cycle of the protozoan. prescription container. It is absolutely necessary to follow the
directions for taking the drug to eradicate the parasite.
• Follow-up stool specimens will be necessary because this is the
only way to determine the success of drug therapy.
• When an infection is diagnosed, multiple members of the family
Indications may be infected, and all household members may need to be
treated. Playmates of the infected child may also need to be
• Malaria treated.
• Giardiasis • It is important to wash all bedding and bed clothes once
• Toxoplasmosis treatment has started.
• Daily bathing (showering is best) is recommended. Disinfect
• Intestinal amebiasis toilet facilities daily, and disinfect the bathtub or shower stall
• Sexually transmitted infections (trichomoniasis) immediately after bathing. Use the disinfectant recommended
• Pneumocystis pneumonia by the primary health care provider or use chlorine bleach.
• Antimalarial drugs are used for suppressing Scrub the surfaces thoroughly and allow the disinfectant to
(i.e.,preventing) malaria remain in contact with the surfaces for several minutes.
• During treatment for a ringworm infection, keep towels and
facecloths for bathing separate from those of other family
members to avoid the spread of the infection. It is important
to keep the affected area clean and dry.
Adverse reactions • Wash the hands thoroughly after urinating or defecating and
before preparing and eating food. Clean under the fingernails
Anorexia daily and avoid putting fingers in the mouth or biting the nails.
• Nausea, vomiting • Food handlers should not resume work until a full course of
• Abdominal cramping and diarrhea treatment is completed and stools do not contain the parasite.
• Child care workers should be especially careful of diaper
• Headache and dizziness disposal and proper hand washing to prevent the spread of
• Visual disturbances or tinnitus infections.
• Hypotension or changes detected on an • Report any symptoms of infection (low-grade fever or sore
electrocardiogram (ECG;associated with chloroquine) throat) or thrombocytopenia (easy bruising or bleeding).
• Cinchonism —a group of symptoms associated with • Albendazole can cause serious harm to a developing fetus.
Inform women of childbearing age of this. Explain that a barrier
quinine administration, including tinnitus, dizziness, contraceptive is recommended during the course of therapy
headache, GI disturbances, and visual disturbances. and for 1 month after discontinuing the therapy.
These symptoms usually disappear when the dosage (Ford 132-133)
is reduced.
• Peripheral neuropathy (numbness and tingling of the
extremities), with metronidazole Interactions
• Nephrotoxicity and ototoxicity, with paromomycin
• Antacids: Decrease absorption of the antimalarial
• Iron: Decreased absorption of the antimalarial
Contraindications & Caution • Digoxin: Increased risk of digoxin toxicity
• Cimetidine: Decreased metabolism of metronidazole
Quinine should not be prescribed for patients with • Phenobarbital: Increased metabolism of metronidazole
myasthenia gravis, because it may cause respiratory
distress and dysphagia. Quinine
• Warfarin: Increased risk of bleeding

Treatment and prevention Treatment: 160–200 mg IM and repeat in 6 hr if necessary
chloroquine Aralen of malaria, extraintestinal Prevention: 300 mg orally weekly; begin 1–2 wk before
amebiasis travel and continue for 4 wk after return from endemic area
Monodox, Vibramycin, Short-term prevention of 100 mg orally daily, 1–2 days before travel and for 4 wk
doxycycline
Vibra-Tabs malaria after return from endemic area (Ford 135)
quinine Qualaquin Treatment of malaria 260–650 mg TID for 6–12 days

Antifungal
& Anti-viral
Drug names: Indication: Drug name: Indication:
Mainly used to Treat Candida For serious fungus

First up end in Amphotericin B
FUNGAL infections. So think & causes SERIOUS TERROR
“-Nazole”
NAZOLE treats NAIL fungus!!! on the body!
Fluconazole Taken for 2-6 weeks & very Lots of side effects!
Ketoconazole Liver toxic like most Anti-fungal
NAZOLE
ADVERSE EFFECT
KEY POINT RENAL INJURY
Creatinine
“-Dazole”
Does NOT “-Nazole” OVER 1.3 = Bad Kidney
TREAT C-Diff Nail Fungus Da Gut
(C Diff bacteria)
Urine 30 ml/hr or Less =
Kidney Distress
Oliguria: Low Urine
Drug name: Indication: Anti-Viral

Given to treat candida infections
Nystatin Of the mouth, GI, skin, even
Acyclovir
vagina.
“-Cyclovir”
Valacyclovir
NYSTATIN
herpes (genital & cold sores)
NYSTATIN
herpes zoster (shingles)
KEY Points:
KEY POINTS
Taken daily
Treats oral candidiasis NO Cure! (Only slows the Virus)

Shake well - Liquid suspension AVOID sex while lesions are present
Inspect mucus membranes for
Drink extra fluids
irritation
Remove and soak client’s dentures Effective: Less frequent eruption of
lesions
Teach to swish in mouth for several T
minutes then swallow NO
DO TOP
S NYSTATIN
Continue AFTER S/S subside NYSTATIN
Notes
TB Drugs
TB Drugs:
Ethambutol

Many antitubercular drugs are bacteriostatic against the M. • Ask the patient what he or she thinks causes the symptoms;
tuberculosis bacillus. These drugs usually act to inhibit bacterial promote health literacy by integrating the patient’s beliefs and
cell wall synthesis, which slows the multiplication rate of the fears into how the bacteria invades the body and how the
bacteria. Isoniazid is bactericidal, with rifampin and
drugs work to kill it.
streptomycin having some bactericidal activity.
• Discuss tuberculosis, its causes and communicability, and the
need for long-term therapy for disease control using simple,
non medical terms.
Indications • Review the drug therapy regimen, including the prescribed
drugs, doses, and frequency of administration.
• Treatment of TB in a protocol • Reassure the patient that various combinations of drugs are
effective in treating tuberculosis.
• Urge the patient to take the drugs exactly as prescribed and
Adverse reactions not to omit, increase, or decrease the dosage unless directed
to do so by the health care provider.
• Anaphylactoid reactions • Instruct the patient about possible adverse reactions and the
(unusual or exaggerated need to notify the prescriber should any occur.
allergic reactions)
• Arrange for direct observation therapy with the patient and
• Optic neuritis
• Dermatitis and pruritus family.
(itching) • Instruct the patient in measures to minimize gastrointestinal
• Joint pain upset.
• Anorexia • Advise the patient to avoid alcohol and the use of
• Nausea and vomiting nonprescription drugs, especially those containing aspirin,
unless use is approved by the health care provider.
• Reassure the patient and family that the results of therapy will
Contraindications & Caution be monitored by periodic laboratory and diagnostic tests and
follow-up visits with the health care provider.
Ethambutol is not recommended for patients with a history of
hypersensitivity to the drug or children younger than 13 years. The drug
is used with caution during pregnancy (category B), in patients with
hepatic or renal impairment, and in patients with diabetic retinopathy or Phases of treatment
cataracts. (Ford 105)
• The recommended treatment regimen is for the
administration of the primary drugs—rifampin (Rifadin),
Interactions isoniazid (INH), pyrazinamide, and ethambutol
(Myambutol)—for a minimum of 2 months
• Antacids containing aluminum
salts: Reduced absorption of isoniazid
• The second or continuation phase includes only the
• Anticoagulants: Increased risk for drugs rifampin and isoniazid. The CDC recommends this
bleeding phase for 4 months or up to 7 months in special
• Phenytoin: Increased serum levels of populations.
phenytoin
• Alcohol: Higher incidence of
drug-related hepatitis
Special populations
Nursing alert • Positive sputum culture after completion of initial
treatment
Older adults are particularly susceptible to a potentially fatal • Cavitary (hole or pocket of) disease and positive sputum
hepatitis when taking isoniazid, especially if they consume
alcohol on a regular basis. Two other antitubercular drugs, culture after initial treatment
rifampin and pyrazinamide, can cause liver dysfunction in the • When pyrazinamide was not included in the initial
older adult as well. Careful observation and monitoring for signs treatment
of liver impairment are necessary (e.g., increased serum • Positive sputum culture after initial treatment in a
aspartate aminotransferase [AST], alanine aminotransferase patient with previously diagnosed HIV infection
[ALT], and bilirubin levels, and jaundice). (Ford 107)
Ethambutol
Myambutol Pulmonary TB 15–25 mg/kg/day orally
Primary drug
TB Drugs:
Isoniazid

bacteria. Isoniazid is bactericidal, with rifampin and streptomycin drugs work to kill it.
having some bactericidal activity. • Discuss tuberculosis, its causes and communicability, and the
non medical terms.
drugs, doses, and frequency of administration.
• Treatment of TB in a protocol • Reassure the patient that various combinations of drugs are
not to omit, increase, or decrease the dosage unless directed
Adverse reactions
to do so by the health care provider.
• Peripheral neuropathy With • Instruct the patient about possible adverse reactions and the
toxicity need to notify the prescriber should any occur.
• Severe hepatitis • Arrange for direct observation therapy with the patient and
• Nausea and vomiting family.
• Epigastric distress • Instruct the patient in measures to minimize gastrointestinal
• Fever
upset.
• Skin eruptions
• Advise the patient to avoid alcohol and the use of
• Hematologic changes
• Jaundice nonprescription drugs, especially those containing aspirin,
• Hypersensitivity unless use is approved by the health care provider.
be monitored by periodic laboratory and diagnostic tests and
follow-up visits with the health care provider.
Isoniazid is contraindicated in patients with a history of
hypersensitivity to the drug. The drug is used with caution
during pregnancy (category C) or lactation and in patients with
hepatic and renal impairment. Interactions
(Ford 105)
• Antacids containing aluminum salts:
Reduced absorption of isoniazid
Nursing alert • Anticoagulants: Increased risk for bleeding
• Phenytoin: Increased serum levels of phenytoin
• Isoniazid is taken with foods containing tyramine, such as aged • Alcohol (in beverages): Higher incidence of drug-related
cheese and meats, bananas, yeast products, and alcohol, an hepatitis
exaggerated sympathetic-type response can occur (i.e.,
hypertension, increased heart rate, and palpitations).
(Ford 105)
• Older adults are particularly susceptible to a potentially fatal
hepatitis when taking isoniazid, especially if they consume
alcohol on a regular basis.

Isoniazid Active TB: 5 mg/kg (up to 300
Primary NA Active TB; prophylaxis for TB mg/day) orally or 15 mg/kg 2–3
treatment times weekly
TB Drugs:
Pyrazinamide

Many antitubercular drugs are bacteriostatic against the • Ask the patient what he or she thinks causes the
M. tuberculosis bacillus. These drugs usually act to inhibit symptoms; promote health literacy by integrating the
bacterial cell wall synthesis, which slows the multiplication patient’s beliefs and fears into how the bacteria invades
rate of the bacteria. Isoniazid is bactericidal, with rifampin the body and how the drugs work to kill it.
and streptomycin having some bactericidal activity. • Discuss tuberculosis, its causes and communicability,
and the need for long-term therapy for disease control
using simple, non medical terms.
• Review the drug therapy regimen, including the
prescribed drugs, doses, and frequency of
Indications administration.
• Reassure the patient that various combinations of drugs
• Treatment of TB in a protocol are effective in treating tuberculosis.
• Urge the patient to take the drugs exactly as prescribed
and not to omit, increase, or decrease the dosage unless
directed to do so by the health care provider.
• Instruct the patient about possible adverse reactions
Adverse reactions and the need to notify the prescriber should any occur.
• Arrange for direct observation therapy with the patient
• Hepatotoxicity and family.
• Nausea • Instruct the patient in measures to minimize
• Vomiting gastrointestinal upset.
• Diarrhea • Advise the patient to avoid alcohol and the use of
• Myalgia nonprescription drugs, especially those containing
• Rash aspirin, unless use is approved by the health care
provider.
• Reassure the patient and family that the results of
therapy will be monitored by periodic laboratory and
diagnostic tests and follow-up visits with the health
Contraindications & Caution care provider
• Hypersensitivity
• Gout
• Severe hepatic damage
Interactions
• When pyrazinamide is administered with the anti gout

Nursing alert medications allopurinol (Zyloprim), colchicine, or
probenecid, its effectiveness decreases.
• Pyrazinamide should be used cautiously in patients
during pregnancy (category C) and lactation and in
patients with hepatic and renal impairment, HIV
infection, and diabetes mellitus.
(Ford 106)

15–30 mg/kg/day orally,
Pyrazinamide
n/a Active TB maximum 3 g/day orally; 50–70
Primary treatment
mg/kg twice weekly orally
TB Drugs:
Rifampin

bacteria. Isoniazid is bactericidal, with rifampin and drugs work to kill it.
streptomycin having some bactericidal activity. • Discuss tuberculosis, its causes and communicability, and the
non medical terms.
• Treatment of TB in a protocol drugs, doses, and frequency of administration.
• Reassure the patient that various combinations of drugs are
Adverse reactions
not to omit, increase, or decrease the dosage unless directed
• Nausea and vomiting to do so by the health care provider.
• Epigastric distress, heartburn, fatigue • Instruct the patient about possible adverse reactions and the
• Vertigo (dizziness) need to notify the prescriber should any occur.
• Rash • Arrange for direct observation therapy with the patient and
• Reddish-orange discoloration of body fluids (urine, tears, family.
saliva, sweat, and sputum) • Instruct the patient in measures to minimize gastrointestinal
• Hematologic changes, renal insufficiency upset.
(Ford 106) • Advise the patient to avoid alcohol and the use of
nonprescription drugs, especially those containing aspirin,
unless use is approved by the health care provider.
Rifampin is contraindicated in patients with a history of be monitored by periodic laboratory and diagnostic tests and
hypersensitivity to the drug. The drug is used with caution follow-up visits with the health care provider.
during pregnancy (category C) and lactation and in patients
with hepatic or renal impairment.
(Ford 106)
Interactions
Nursing alert • Antiretrovirals (efavirenz, nevirapine): Decreased serum

levels of antiretrovirals
• Leprosy , also referred to as Hansen’s disease, is caused by • Digoxin: Decreased serum levels digoxin
the bacterium Mycobacterium leprae. Leprosy is a chronic, • Oral contraceptives: Decreased contraceptive effectiveness
communicable disease that is not easily spread and has a • Isoniazid: Higher risk of hepatotoxicity
long incubation period. Since 1985, the prevalence of leprosy • Oral anticoagulants: Increased risk for bleeding
has dropped by 90%. About 100 new cases are diagnosed • Oral hypoglycemics: Decreased effectiveness of oral
yearly in the United States (primarily the southern states,
hypoglycemic agent
Hawaii, and U.S. possessions).
• Chloramphenicol: Increased risk for seizures
• Peripheral nerves are affected, causing sensory loss and
• Phenytoin: Decreased effectiveness of phenytoin
muscle weakness. The traditional fear of leprosy relates to
skin involvement, which may present with lesions confined • Verapamil: Decreased effects of verapamil
to a few isolated areas or may be fairly widespread over the
entire body. Dapsone, clofazimine (Lamprene), rifampin
(Rifadin), and ethionamide (Trecator) are drugs currently used
to treat leprosy (Ford 106)
Active TB, Hansen’s disease 10 mg/kg (up to 600 mg/day)

Rifampin Rifadin, Rimactane
(Ford 109) orally, IV (Ford 109)
TB DRUGS
5 TB Tips Memory Trick
5 NCLEX TIPS ALL are LIVER TOXIC!!!!

So some instructors just use the acronym:
1. Meds Last 6 - 12 months
2. N-95 mask worn all the time


(pyridoxinde)
- Low Vitamin B6 = Peripheral Neuropathy
1. NORMAL
Teach:
N - Neuropathy
REPORT:
- Tingling extremities
to discoloration of tears NCLEX TIP - Ataxia
H - Hepatotoxicity
“Use non-hormonal REPORT Immediately!!!
- Jaundice (yellow) Skin / Sclera
Back-up birth control” - Dark urine NCLEX TIP
HOLD the Med
- Teach: NO ETOH!!
ETHAMBUTOL - Eye
KEY POINT:
REPORT!
• Blurred vision
PYRAZINAMIDE
Did not come up 1 x in 10,000 questions. • Color changes

Blood thinners
Anti platelets
Antiplatelets
Abciximab
Drug name: Nursing care:

KEY TERM:
1. Assess
Glycoprotein (GP)
receptor inhibitors HEMOGLOBIN PLATELETS PLATELETS
<7 <150,000 <50,000
Abciximab
Eptifibatide
Tirofiban
!
Indication:
2. Assess for bleeding
Mainly used after cardiac procedures
like heart cath - Coronary Stent Placement REPORT TO HCP!
to prevent reocclusion
Red tinged urine “hematuria”
“Dark” tarry stools /
Black or bloody stools
Monitor groin (insertion site)
for s/s bleeding
Adverse Effects:
3. Place client on
Adverse Effects cardiac monitor
Thrombocytopenia
Bleeding ECG changes!
4. NO needles!
(no new IV or IM)
Notes
Antiplatelets
Acetylsalicylic & Clopidogrel
Drug name: A C
A C ASPIRIN CLOPIDOGREL HESI KEY TERM:
ANTI CLOT
ASPIRIN CLOPIDOGREL
(Salicylic Acid) Use for post - PCI
- percutaneous coronary intervention
ASPIRIN IX
AV
PL
KEY Numbers
HGB < 7
MOA: Hgb < 7 = HEAVEN
Platelets: (normal 150 – 400K) 150,000 - 400,000
They prevent the platelets from - Less than 150,000 NOTIFY HCP !!!
aggregating together. Sort of - Less than 50K VERY RISKY!! !

Spreading platelets out from each other. * These meds SHOULD NOT
decrease plt levels
< 150,000 < 50,000

Memory Trick:
COMMON QUESTION
Don’t let
ANTI PLATELETS Platelet count of 75,000 … or 40,000

CLOPIDOGREL
NCLEX TRICK YOU
PRIORITY? PLT
1. HOLD the DRUG IRN & PT

T
IRN &
They LOWER platelet aggregation, so we have 2. Question the prescription ASPIRIN
PTT
3. NOTIFY the Health Care provider
less chances of them sticking together.
A nti C logging
Aspirin Toxicity:
HESI & ATI Exit Exams

KEY SIGNS
of Aspirin toxicity
Indication: Treatment:
Tinnitus
Activated Charcoal
Hyperventilation
Mainly for Clot prophylaxis KEY TERM:
Notify the HCP
Initial treatment of salicylate
(Aspirin) toxicity
• Heart: MI / CVA prevention
• Narrowed arteries
- ACS (heart)
- TIA (brain)
- PAD (extremities) Activated
Charcoal
• Prevention of stent/bypass re-occlusion
ATI Question
Long term aspirin
“Assess for tinnitus”
ASPIRIN
ACS TIA PAD
Notes
Anticoagulants
Anti-Coagulants
Heparin vs. Warfarin
Indication: Memory Trick:
KEY WORD NCLEX

Heparin Warfarin
PREVENTING
PREVENTION H Therapeutic Range WAR Therapeutic Range
GROWTH
of NEW clots
of existing clots 46 – 70 PTT 2 – 3 INR
HEPARIN
Memory Trick: WARFARIN
Memory Trick:
“HePTT” the FROG “War-K-IN”
H – Heparin W – Warfarin
P – Protamine Sulfate (Antidote) K – Vitamin K (Antidote)
PTT – 46 – 70 Max range IN – INR 2 -3 range
Specifically with patients recovering from
An MI heart attack or those at RISK for DVT *FAST onset = Frogs are FAST *Slow onset = “Is it even WARkin?”
Key Point:
Don’t let
Deep Vein Thrombosis NCLEX
TRICK YOU
tPA
Heparin:
• Heparin works QUICKLY, or Heparin works Anti-coags DO NOT DISSOLVE CLOTS!

Hella FAST, within 20 minutes Only thrombolytics do that, like TPA or Alteplase
Key Words:
• Heparin starts in a hurry, but is gone in a hurry Both medications given TOGETHER
for several days. This gives Warfarin
• It can only be injected into the patient. IV or SQ some time to catch up.
like Enoxaparin, the lower lighter weight heparin
LABS:
LABS – BY FAR the biggest TOPIC on
Enoxaparin
Test Questions: SINCE IT’S THE MOST DEADLY!!
Warfarin: So just think if Labs:
• Warfarin has a weaker START, typically taking TOO HIGH = pt will bleed out & DIE
5 days to reach FULL effect. So warfarin takes TOO LOW = then CLOTS will GROW
a LONGER TIME to kick in, but it last LONGER
& can be taken longer
LABS
15
• So think of the WAR in Warfarin, like a
WAR that lasts a LONG TIME!
Notes
Anti-Coagulants
Heparin
Key Numbers for NCLEX ATI Question

Patient on Heparin with
PTT: 46 - 70
PTT
46 - 70
Bleeding at IV SITE!!
PROTAMINE
SULFATE
Antidote: Priority action:

Protamine Sulfate
“Blood Oozing
at surgical incision”
Be careful, NCLEX, will yty & trick you!
NOT INR & NOT PTT OVER 70!
INR
<70
Priority Action:
H -HaPTT
1 STOP the Heparin – Notify HCP HEPARIN
Memory Trick:
“HePTT” the FROG

H – Heparin
2 Prepare Antidote: Protamine Sulfate PROTAMINE
SULFATE
3
P - Protamine Sulfate Antidote HEPARIN
Reassess labs (1 hour)
PTT - 46 – 70 Max range
HESI Question Heparin drip

aPTT 85 or 100!
NCLEX MEMORY TRICK!
HePTT
HEPARIN
Priority Action
1 STOP the Heparin

– Notify HCP 2 Prepare Antidote:
Protamine Sulfate 3 Reassess labs (1 hour)
Heparin goes FAST!!
PROTAMINE
SULFATE
HEPARIN
Notes
Anti-Coagulants
LMW Heparin
Heparin SQ Indication: Administration:

· -parin Key term 1 2
· Enoxaparin (Lovenox)
Inject at
· Dalteparin Prevention of DVT 25 G Needle ⅝ inch
90 degree angle
Less heavy and less after surgery

chances of major bleeding
90º
Common ATI question: HESI question:
3
Enoxaparin “Client on ENOXAPARIN” LOCATION
“Which statements needs Report to HCP:
FURTHER TEACHING” NCLEX KEY WORD
1. H & H decreased
I will inject the med into my thigh 2. BP drops by 20 points 2 inches from Umbilicus NOT thigh NOT IV route
I will need Frequent Blood tests
2 inches
NCLEX Key Term:

Notify HCP and clarify order for enoxaparin if H/H Slightly low! 4 NO NO’S
Open fractures & H&H LOW - Enoxaparin is a NO GO!

Never aspirate SQ NEVER RUB site!
H
KEY Numbers
Another risk is HIT - Heparin
Induced Thrombocytopenia!
Platelets should be
If Platelets decrease by HALF
150k – 400k
in 24 hours after starting Normal to have mild ‘’pain, bruising,
HOLD MED Plt heparin of any type,
less than 50,000 irritation, redness at site’’
this typically indicates HIT and
it’s VERY DEADLY!
Enoxaparin Labs:
H H H
30%
Enoxaparin Labs
HIT is when HALF platelets Heparin

GONE in 24 hours! Low Platelets
STUDENTS WRONG
NOT aPTT or INR
?
Most commonly
HEPARIN
chosen distractor!
PRIORITY ACTION P – Parin P – Platelet

(Enoxaparin) FOCUSED
1. Alert the HCP!
HCP
Notes
Anti-Coagulants
Warfarin
5.0
Key Numbers for NCLEX 4.5 Vitamin K Foods

Liver
4.0
INR 3.5
2 - 3 Therapeutic Range 3.0 Green leafy vegetables
2.5 – 3.5 (heart valve replacements)
2.5 (Broccoli, Spinach)
Antidote: Vitamin K 2.0
“K = Kills Warfarin” 1.5
Key Patient Teaching:
NCLEX KEY TERMS:
1.0 - Consistent & Moderation
Vitamin K Keep K – Consistent
- NOT! given if warfarin within - Key words:
therapeutic range
· NOT increased
- NOT! until AT LEAST 5 days of *2.5-3.5 for heart valve · NOT decreased
warfarin when switching from IV Hep!!!
replacements · NOT avoid TOTALLY
NCLEX MEMORY TRICK!

NICE to KNOW!!
W – Warfarin
WARFARIN
W – WarKIN Antibiotics INCREASE risk for Bleeding
By INCREASING INR
W K IN
Since the ABX KILL the intestinal bacteria
Warfarin Vitamin K Antidote INR (2-3 range) that produce vitamin K...We have vitamin
5.0
4.5
K deficiency & INCREASED risk for bleeding
4.0
3.5
3.0
WARFARIN 2.5
2.0 VITAMIN K
VITAMIN K
1.5
1.0
ATI Question Common Question on EXIT EXAMS

PATIENT TEACHING
INR of 4 or 5 !!! Key Term:
· Assess for Bleeding.
· Get Vitamin K antidote
READY!!
1. Life Long Therapy
“I will increase my 2. Mechanical Valve
intake of dark green INR of 2.0 in an Replacements
leafy vegetables” ischemic CVA client 3. Frequent Blood Tests
· GIVE the Warfarin to get to 2.5!
Notes
Dabigatran
& Argatroban
Indication:
Used to prevent clot in high risk A Fib patients
KEY POINTS
DO NOT STOP THE MED FOR GI ISSUES
STOP med if black tarry STOOLS

NOT Stores IN PILL BOX ... in original
container!!!
NOT crushed, taken whole
Memory Trick = Take DA BIG pill whole!
• HOLD clopidogrel
• HOLD before surgery
ATI QUESTION HESI QUESTION
Meds to Hold before Pt on Dabigatran Do

Surgery Dabigatran not take with clopidogrel
CLOPIDOGREL
Notes
Blood Thinners
Generally comes in 3 sizes:

Small, Medium, LARGE
Small Medium Large
By comparison think of:
Antiplatelets like Aspirin & Clopidogrel

like a water gun - those are small ones
Anticoagulants - Heparin & Warfarin,

like bazooka - those are the medium
Thrombolytic Clot busters - TPA & Alteplase

like an ATOMIC BOMB.
Those are large ones and MOST deadly,
since THEY HAVE the HIGHEST BLEED RISK!
!
Notes
Factor XA
Inhibitors
Drug name:
MEMORY TRICK Rivaroxaban
Rivaroxaban
(brand name Xarelto)
RIVAROXABAN
Edoxaban RIVAROXABAN
Apixaban
Key Points: RIVER ROCK band! Blood flows like RIVER

ASPIRIN
NSAIDs
• AVOID ASPIRIN while taking this med

Bad News:
• AVOID any & all over the counter meds that • Risk for neurological impairment
increase bleeding! Especially NSAIDS!
Rock Band can cause brain bleeding,
think too much head banging
• The supplements - EGGO
- E - Vitamine E E
- G - Garlic
- G - Ginger Ginkgo
- O - Omega 3’s
OMEGA 3’S
Good News:
• There is a lower risk of bleeding compared HESI -Common Question

to warfarin
• NO need for routine clotting studies Rivaroxaban
• NO need to avoid Vit K food such as leafy · Teach client methods to
greens or liver. Eat up that liver & spinach reduce bleeding.
RIVAROXABAN
RIVAROXABAN
RISK OF BLEEDING
Notes
Anti-Coagulants
Fondaparinux
Drug name: Caution:
Fondaparinux DON’T GIVE IT:

(related to low weight heparins) To patient who report severe back
pain, decreased LOC or paralysis.
Major Advantage: Always call the HCP and HOLD the meD!
No risk for HIT
HIT HCP
Fondaparinux
HEPARIN
Major Disadvantage:
NCLEX KEY TERMS

Key Term:
NO Fondaprinux for NO Anticoagulants
Fondaparinux can cause at least 6 hours after surgery with spinal epidural catheter
an epidural bleed!
Fondaparinux
Notes
Patient Teaching
Bleeding
Key Numbers:
P P P
Heparin Warfarin AsPirin CloPidogrel EnoxaParin
H Therapeutic Range WAR Therapeutic Range

46 – 70 PTT 2 – 3 INR ASPIRIN
CLOPIDOGREL
HEPARIN
Memory Trick: WARFARIN
Memory Trick:
“HePTT” the FROG “War-K-IN”
H – Heparin W – Warfarin
P – Protamine Sulfate (Antidote) K – Vitamin K (Antidote)
PTT – 46 – 70 Max range IN – INR 2 -3 range Platelets
“Less than 50k = Risky”
*FAST onset = Frogs are FAST *Slow onset = “Is it even WARkin?”
Thrombocytopenia < 50,000
HOLD All heParin HEPARIN
50,000
Nursing Care:
BLEEDING PRECAUTIONS
- NO Active Bleed
- “peptic ulcer” NCLEX TIP AVOID Trauma: HESI KEY TERMS
NO small rugs or dim halls
= Well Light Halls
CHANT NO EGGGOS NO hard brushing
= soft bristle tooth brush
C - Cirrhosis E - Vitamin E NO flossing
H - Hepatitis G - Ginseng NO alcohol based mouth wash
A - Alcohol HESI EXAM G - Ginkgo Biloba NO razors = electric shaver
N - NSAIDS ATI EXAM G - Garlic NO constipation = Fiber + Fluids NCLEX TIP
T - Tylenol overdose - O - Omega 3 NO contact sport
Liver damage S - St Johns Wort Medic Alert Braclet
SIGNS OF BLEEDING
NOTIFY the HCP ASAP!! KEY WORDS
Black Tarry Stools - GI bleed
Hematuria (blood tinged urine)
Epistaxis – nose bleed
Petechiae on chest
Easy Bruising
Notes
Thrombolytics
Thrombolytics
tPA & Alteplase
Drug name:
NCLEX Key Contraindications:
tPA
AVOID giving to:
“-Ase” 1. Active bleeding
Alteplase KEY TERM: Peptic ULCER
Reteplase 2. Uncontrolled HTN 180/110 +
3. Recent surgery within 2 weeks
Streptokinase
Clarify Prescription with Provider !
· A – Accidents “Recent Trauma” NCLEX TIP
· A – Aneurysm - Hx of hemorrhagic CVA
· A - AV malformation NCLEX TIP NCLEX TIP
Key Point:
• Clot Busters - our ATOMIC BOMB! KEY TERMS

The MOST powerful 1 time push drugs!
3 – 4.5 hour from
ONSET of symptoms
• These are the ONLY ones that dissolve clots!
• Aspirin & Clopidogrel - NOT clot busters,

they are Anti-Platelets
KEY TERMS
• Heparin & Warfarin - NOT clot busters, THE BIG caution here is
HEPARIN WARFARIN they prevent new clots & existing clots the MASSIVE - BLEEDING
from getting bigger. RISK !!!!!
• The big caution here is the MASSIVE -

BLEEDING RISK! And it’s the MOST DEADLY!
KEY TERMS
These drugs can only be given

in a compressible site like an
• NO injections at all! peripheral IV.
Yes “Existing” peripheral IV
• NO NEW: NOT Central Line
NO IV’S NO SUB Q NO IMS NO ABG
Notes
Thrombolytics
These drugs break down fibrin clots by • Must administer within 4-6 hours post
converting plasminogen to plasmin. thrombus formation
Plasmin is an enzyme that breaks down the • Assess the patient for bleeding every 15
fibrin of a blood clot. This reopens blood minutes during the first 60 minutes of
vessels after their occlusion and prevents therapy, every 15 to 30 minutes for the next 8
tissue necrosis. hours, and at least every 4 hours until therapy
is completed. Vital signs are monitored
continuously. If pain is present, the primary
health care provider may order an opioid
analgesic. Once the clot dissolves and blood
Why do we give it? ‘’Reason’’ flows freely through the obstructed blood
vessel, severe pain usually decreases.
• Acute stroke or MI by lysis (breaking up) of (Ford 396)
blood clots in the coronary arteries • Lab Test Considerations: Monitor activated
• Blood clots causing pulmonary emboli and partial thromboplastin time (aPTT) and
DVT hematocrit before and after and periodically.
• Suspected occlusions in central venous When intermittent IV therapy is used, draw
catheters (Ford 394) aPTT levels 30 min before each dose during
initial therapy and then periodically.
• During continuous administration, monitor
aPTT levels every 4 hr during early therapy.
Adverse effects
• Bleeding
Interactions:
Contraindications • When a thrombolytic is administered with
medications that prevent blood clots, such
• Active bleeding as aspirin, dipyridamole, or an anticoagulant,
• History of stroke the patient is at increased risk for bleeding.
• History of aneurysm
• Recent intracranial surgery
Activase, Cathflo Activase (for IV Acute MI, acute ischemic stroke, Total dose of 90–100 mg IV,
Alteplase
catheter occlusions only) PE, IV catheter clearance given as a 2- to 3-hr infusion
Oncology
Chemotherapy
Drug names: Adverse Effects: Key Points:
• Doxorubicin All fast growing Low RBC & LOW CBC -“Anemia”
• Cisplatin cells die Normal: 4.5 - 6 million RBC
• Cyclophosphamide
DOXORUBICIN CISPLATIN
4.5 - 6 million
Low Platelets
• Bone cells DIE Normal plt 150 - 400,000
Indication: • Blood cells DIE Less than 100,000 =

• Low immunity Thrombocytopenia 150,000 - 400,000
Slow & stop the growth Low WBC - leukopenia < 4,000
of tumors Normal: 5,000 - 10,000
< 4000
KEY WORDS
MOA: “Immunodeficiency”
“Immune compromised” KAPLAN
Directly inhibiting growing FEVER is a priority
Doxorubicin- Temperature is highest
> 100.3 F/ 38oC
cells in the body OVER 100.3 F (38 C)!!!

priority Over 100.5 F (38 C)
NCLEX TIP
Cisplatin: Creatinine > 1.3

MEMORY TRICK
KEY POINT BUN/Creatinine
Renal toxicity CISplatin PISSplatin

Monitor Urine- Input & Output BUN > 20
Creatinine
OVER 1.3 = Bad kidney BUN/Creatinine
BUN OVER 20 CISPLATIN

Urine Output < 30ml/hr
Urine ouput 30ml/hr

or LESS = Kidney Distress
Drug name:
VINCRISTINE
Vincristine Vincristine
The nurse is caring for a client with ovarian
cancer taking doxorubicin, which assessment <50,000
Normal 150,000- 400,000
finding should the nurse report to the health
Only chemo drug that does NOT care provider? Select All That Apply
cause bone marrow suppression!
1. Partial thromboplastin time 55.
Memory Trick:
2. Platelet count of 48,000. > 100.3 F/ 38oC
Very Cool CHRISTIAN 3. Red blood cell count 5 x 10^6.

4. Temperature of 100.7 (38.2 C).
Just a gentle Saintly soul, 5. White blood cells 3,600.
does not harm the bone
< 4,000
marrow Normal 5,000- 10,000
Notes
Breast Cancer
& Immunotherapy
Drug name: KEY WORDS NCLEX Question

When preparing to administer tamoxifen to a
Tamoxifen ▪ Clots Risk!
patient with breast cancer, the nurse is most
▪ E - Estrogen concerned by which patient report?
▪ E - Emboli (clot risk)
A. “I have been experiencing really heavy menstrual
Contraindication:
MOA: cycles recently.”
History of DVT or PE CLARIFY
B. “My hot flashes seem to be decreasing in frequency.”
Blocks estrogen receptors in order with provider! C. “I feel like I may be developing a sinus infection.”
the breast to stop estrogen D. “I just don’t have the energy for sex the way that I
dependent cancer used to.”
SIDE EFFECT
NORMAL KAPLAN
HESI Question
DON’T Endometrial cancer
GET TRICKED Tamoxifen - Treats breast cancer Report “heavy periods” “excessive
Bleeding”
Drug names: Indication: Key Point:

Stimulates WBC
(neutrophil) production
Filgrastim NEUPOGEN
Expected = INCREASE neutrophil count

Pegfilgrastim Neupogen
PEGFILGRASTIM
WBC- neutrophil
Drug name: Indication: ATI HESI

Adverse Effects
Increases platelet production, Patient Scenario:
Stimulates growth of hematopoietic Fluid retention
Oprelvekin for patients in chemo who have stem cells
Oprelvekin effectiveness =
A fib
Anaphylaxis
high risk for thrombocytopenia Increased platelets
(low platelet)
OPREL-
OPREL- VENKIN
VENKIN
Drug name: Indication: Side Effects:

HESI
Stimulates the body’s Flu like symptoms:
Interferon immune system to Fever, muscles aches, Interferon beta
detect & kill cancer chills are NORMAL ● Apply warm compress before
cells & viruses giving injection to reduce risk of
Memory Trick: pain at site
INTERFERON ● Administer med late in the
day so flu like symptoms occur
during sleep
Interferon
NORMAL
Notes
Cancer Treatment
Radiation & Brachytherapy
Name: Name:
Radiation (outside of the body) Brachytherapy (radiation inside the body)
Indication: Indication:
Typical radiation outside of the body is used • Endometrial cancer Endometrial cancer
in combo with chemotherapy to help shrink

Cervical cancer
• Cervical cancer
cancerous tumors before surgery
24-72H
NCLEX #1 goal is safety

A radioactive implant is placed
directly inside the tumor for
24 -72 hours - making this patient
Side Effects: like a radioactive hazard!
Very hard on the skin: red, dry & itchy

KEY POINTS
• NO hard scrubbing of skin
1. Time:
• NO tape or deodorants ● Cluster care 30 minutes per shift!
• NO shaving ● Staff is to wear radiation film badge (dosimeter)
• NO lotions, creams, perfumes, powders,
makeup cosmetics 2. Distance:
● TEACH all visitors distance of at least 6 feet
NO
● NO Pregant Company
● NO one less than 18 years old
● Private room + toilet
● Close door to room at all times
● Sign on door “caution radioactive”
ATI 3. Shielding:
Use Lead Apron when in DIRECT CONTACT with
patient
Client with cancer undergoing
radiation therapy
I will use my hands rather than
a washcloth to clean the
radiation area
CAUTION RADIOACTIVE
Notes
Diabetes Drugs
Diabetes Drugs
- Insulin
How it works? “Action” Contraindications & Caution

Activates a process that allows glucose molecules to enter the cell Specific insulin products are contraindicated when the patient is hypoglycemic.
“ Thick of it like a Key opening a door, the cell is the door. The insulin is Insulin is used cautiously in patients with renal or hepatic impairment and during
the key” pregnancy and lactation. The insulins are grouped in pregnancy category B,
Onset, peak, and duration are three important properties of except for insulin glargine and insulin aspart, which are in pregnancy category C.
insulin: Insulin appears to inhibit milk production in lactating women and could interfere
• Onset: when insulin first begins to act in the body with breastfeeding. Lactating women may require adjustment in insulin dose and
• Peak: when the insulin is exerting maximum action diet. (Ford 451)
• Duration: the length of time the insulin remains in effect
Interactions:
Indications
Eucalyptus products: May cause decreased blood sugar.
Insulin is used to: Drugs That Increase the Effect (Less Insulin May Be
• Control type 1 diabetes Required)
• Control type 2 diabetes when uncontrolled by diet, exercise, or • angiotensin-converting enzyme (ACE) inhibitors, alcohol
weight reduction • anabolic steroids, antidiabetic drugs, oral, β-blocking drugs
• Treat severe diabetic ketoacidosis (DKA) or diabetic coma • Calcium, clonidine, disopyramide,fluoxetine, fibrates, lithium
• Treat hyperkalemia in combination with glucose • MAOIs,mebendazole,pentamidine, pentoxifylline Pyridoxine, salicylates,
somatostatin analog, sulfonamides, tetracycline
Selected Drugs That Decrease the Effect (More Insulin May Be Required)
Adverse Reactions • Acetazolamide,albuterol, antipsychotics (atypical or second generation)
• Asparaginase, calcitonin,contraceptives, oral corticosteroids
Hypoglycemia • Cyclophosphamide, danazol, diltiazem, diuretics, dobutamine
• The patient eats too little food. • Epinephrine, estrogens, glucagon, human immunodeficiency virus
• The insulin dose is incorrectly measured and is greater than that (HIV) antivirals
prescribed. • Isoniazid, lithium, morphine sulfate, niacin, nicotine,
• The patient has drastically increased demands (activity or illness). phenothiazines, phenytoin, progestogens, protease inhibitors,
somatropin, terbutaline, thiazide diuretics,thyroid hormones
Hyperglycemia
• The patient eats too much food.
• Too little or no insulin is given.
• The patient experiences emotional stress, infection, surgery, Types of Insulins Names
pregnancy, or an acute illness. insulin Lispro-Humalog
Rapid-Acting
Insulin Aspart-Novolog
Regular Insulin-Humulin R
Nursing management Short-Acting • Regular insulin is the only one given IV
• Concentrated insulin-Insulin U-500
• Obtain FSBS before administration of any insulin.
• Obtain FSBS 30 minutes post insulin administration. Intermediate-Acting NPH-Humulin N, Novolin R
• Educate the patient how to self administer insulin and signs of
symptoms of hyper/hypoglycemia. Insulin Glargine-Lantus
• Monitor for hypoglycemia Long-Acting • Cannot mix with others Insulin
• Monitor for hyperglycemia Detemir-Levemir
• Monitor potassium levels
• Regular insulin is clear, whereas intermediate- and long-acting NPH/REG
insulins are cloudy. The clear insulin should be drawn up first. When • Humulin 50/50 • Humulin 70/30 • Novolin 70/30
insulin lispro is mixed with a longer-acting insulin, the insulin lispro Premixed Aspart protamine/aspart • Novolog Mix 70/30
is drawn up first. (Ford 456) Lispro protamine/lispro • Humalog Mix 75/25
Generic Trade Safe Dose Route
Lispro (Humalog) 5m 60-90min 4-6h
Aspart (Novolog) 10-20m 1-3h 3-5h

Regular SQ: 30-60m SQ: 2-4h SQ: 5-7h
(Humulin R) IV: 10-30m IV: 15-30m IV: 30-60m
NPH (Humulin N, 8-12h 18-24h None
Novolin R)
Glargine (Lantus) None None 24h
Detemir (Levemir) 3-14h None 24h

Diabetes Drugs
- Non Sulfonylureas
How do they work? “Action” Interactions:

Metformin sensitizes the liver to circulating insulin levels • Increased risk of lactic acidosis when metformin is
and reduces hepatic glucose production. given with corticosteroids.
alpha (α)-glucosidase inhibitors acarbose (Precose) and • Digestive enzymes may reduce the effect of miglitol.
miglitol (Glyset) lower blood glucose levels by delaying the
digestion of carbohydrates and absorption of
carbohydrates in the intestine.
The thiazolidinediones, also called glitazones, decrease Nursing management
insulin resistance and increase insulin sensitivity by
modifying several processes, resulting in decreased • Stop metformin 48 prior to and post radiologic studies.
hepatic gluconeogenesis (formation of glucose from • Temporarily discontinue metformin before surgical
glycogen) and increased insulin-dependent muscle procedures.
glucose uptake. • Take the drug exactly as directed on the container (e.g.,
Examples of the thiazolidinediones are with food, 30 minutes before a meal).
rosiglitazone (Avandia) and pioglitazone • An antidiabetic drug is not oral insulin and cannot be
(Actos). (Ford 453) substituted for insulin.
• Never stop taking this drug or increase or decrease the
dose unless told to do so by the primary health care
Indications provider.
Oral antidiabetic drugs are used in the treatment of
• Take the drug at the same time or times each day.
patients with type 2 diabetes mellitus whose condition
• Metformin—there is a risk of lactic acidosis when using
this drug. Discontinue the drug therapy and notify the
cannot be controlled by diet alone. (Ford 452)
primary health care provider immediately if any of the
following occur: respiratory distress, muscular aches,
Adverse Reactions unusual somnolence, unexplained malaise, or
nonspecific abdominal distress.
• GI upset (e.g., metallic taste, abdominal bloating, nausea, • When a hypoglycemic patient is taking an
cramping, flatulence, and diarrhea). α-glucosidase inhibitor (e.g., acarbose or miglitol),
• Adverse effects of thiazolidinediones include upper give the patient an oral form of glucose, such as
respiratory infections, sinusitis, headache, pharyngitis, glucose tablets or dextrose, rather than juice, honey,
myalgia, diarrhea, and back pain. Lactic acidosis (buildup or candy (sucrose). Absorption of sugar is blocked by
of lactic acid in the blood) may also occur with the acarbose or miglitol. (Ford 458)
administration of metformin.
• Metformin can also cause weight loss
Lactic Acidosis
• Very rare but can be fatal
• Heart failure Occurs mainly in patients with kidney disfunction
• Renal disease Symptoms: malaise (vague feeling of bodily discomfort),
• Acute or chronic metabolic acidosis abdominal pain, rapid respirations, shortness of breath,
• Ketoacidosis and muscular pain. In some patients, vitamin B12 levels
• Those over 80 are decreased. (Ford 453)
• Pregnancy Reversible with administration of B12 or discontinuation
of drug therapy.

Acarbose Type 2 Diabetes as an adjunct to
• a-Glucosidase Precose sulfonylurea to improve glycemic 25-100 mg orally TID
inhibitor control
Type 2 Diabetes as an adjunct to
Metformin Glucophage, Riomet,
sulfonylurea to improve glycemic 500-3000 mg/ day orally
• Biguanide Fortamet control
Pioglitazone Type 2 diabetes in combination with

Actos 5-15 mg orally TID
• thiazolidinediones metformin for glycemic control
Diabetes Drugs
- Sulfonylureas

Sulfonylureas act to lower blood glucose by stimulating Increased hypoglycemic effects:
the β cells of the pancreas to release insulin. • Anticoagulants
Sulfonylureas are not effective if the β cells of the • Chloramphenicol
pancreas cannot release a sufficient amount of insulin to • Clofibrate
meet the individual’s needs. (Ford 452) • Fluconazole
• histamine H2 antagonists
Indications • Methyldopa
• monoamine oxidase inhibitors (MAOIs)
Oral antidiabetic drugs are used in the treatment of • nonsteroidal anti-inflammatory drugs (NSAIDs),
patients with type 2 diabetes mellitus whose condition • salicylates, sulfonamides, and tricyclic antidepressants.
cannot be controlled by diet alone. (Ford 452)
Decreased Hypoglycemic effect
• β blockers, calcium channel blockers
Adverse Reactions • cholestyramine, corticosteroids
• estrogens, hydantoins, isoniazid
• Hypoglycemia • oral contraceptives, phenothiazines, rifampin
• Anorexia • thiazide diuretics, and thyroid agents.
• nausea, vomiting
• epigastric discomfort, weight gain
• heartburn, and various vague neurological symptoms,
such as weakness and numbness of the extremities.
Nursing management
• Monitor blood glucose closely when starting or stopping
• Known hypersensitivity therapy.
• DKA • Monitor HbA1c number is to be lower than 6%
• Severe infection • Chlorpropamide, tolazamide, and tolbutamide are given
• The first-generation sulfonylureas (chlorpropa with food to prevent GI upset. However, because food
mide, tolazamide, and tolbutamide) are delays absorption, glipizide should be given 30
contraindicated in patients with coronary minutes before a meal. Glyburide and glimepiride are
artery disease or liver or renal dysfunction. (Ford 453) administered with breakfast or with the first main meal
of the day. Repaglinide can be taken immediately or up
to 30 minutes before meals. Nateglinide is taken up to
Hypoglycemia 30 minutes before meals.
• Take the drug exactly as directed on the container (e.g.,
Methods of terminating a hypoglycemic reaction
with food, 30 minutes before a meal).
include the administration of one or more of the
• An antidiabetic drug is not oral insulin and cannot be
following:
substituted for insulin.
• 4 ounces of orange juice or other fruit juice
• Never stop taking this drug or increase or decrease the
• Hard candy or 1 tablespoon of honey
dose unless told to do so by the primary health care
• Commercial glucose products such as glucose gel or
provider.
glucose tablets
• Take the drug at the same time or times each day.
• Glucagon by the subcut, IM, or IV routes
(Ford 460)
• Glucose 10% or 50% IV (Ford 458)

Chlorpropamide Type 2 Diabetes as an adjunct to diet
Diabense 100-250 mg orally/ day
First Generation and exercise. Diabetes insipidus
Glimepiride Type 2 Diabetes as an adjunct to diet

Amaryl 1-4 mg orally/day
2nd Generation and exercise. May be used with insulin
Nateglinide Type 2 diabetes in combination with 60-120 mg orally TID

Starlix
Meglitinide metformin for glycemic control before meals
Diabetes Drugs
- Incretin Mimetics
How do they work? “Action” Contraindications & Caution

Hormone mimetic agents help control blood • Type 1 diabetes mellitus
glucose levels by maintaining β cell function of • Diabetic ketoacidosis
the pancreas, enhancing insulin secretion, and • Kidney disease
suppressing glucagon, which signals the liver to • Pregnancy
decrease release of glucose. Gastric emptying is
also delayed, which slows carbohydrate
absorption. Interactions:
Sitagliptin (Januvia) lowers the blood glucose
level of those with type 2 diabetes by enhancing • May slightly increase serum digoxin levels.
the secretion of the endogenous incretin Monitoring recommended.
hormone. • Increased risk of hypoglycemia when used with
Exenatide (Byetta) mimics the action insulin, glyburide, glipizide, or glimepiride (may
of the incretin hormone. Pramlintide (Symlin) need to increase dose of insulin or
mimics the action of another secretion, amylin. sulfonylurea).
Nursing management
Indications
• Observe patient for signs and symptoms of
Oral antidiabetic drugs are used in the hypoglycemic reactions (abdominal pain,
treatment of patients with type 2 diabetes sweating, hunger, weakness, dizziness,
mellitus whose condition cannot be controlled headache, tremor, tachycardia, anxiety).
by diet alone. (Ford 452) • Monitor for signs of pancreatitis (nausea,
vomiting, anorexia, persistent severe
abdominal pain, sometimes radiating to the
Adverse Reactions back) during therapy. If pancreatitis occurs,
discontinue sitagliptin and monitor serum and
• nausea urine amylase, amylase/creatinine clearance
• vomiting ratio, electrolytes, serum calcium, glucose, and
• upset stomach lipase.
• diarrhea • Assess for rash periodically during therapy.
• constipation • Advise patient to stop taking sitagliptin and
• weight loss notify health care professional promptly if
• loss of appetite symptoms of hypersensitivity reactions (rash;
• heartburn hives; swelling of face, lips, tongue, and throat;
• dizziness difficulty in breathing or swallowing) or pancre
• headache atitis occur.
Sitagliptin Januvia Type 2 Diabetes 100 mg orally daily
5-10 mcg sub q within

Exenatide Byetta Type 2 Diabetes
one hour of a meal
Liraglutide Victoza Type 2 diabetes 0.6-1.2 mg subq daily

PATHOPHYSIOLOGY BASICS
INsulin = puts INto the cell (sugar & K+) DIABETES MELLITUS TREATMENT—PATIENT EDUCATION
D–DIET –Low carbs
GLycogen = Stored GLucose in Liver TYPE 1 vs. TYPE 2 AVOID: Simple Sugars (soda, candy, white bread/rice, juices)
• Good High Fiber = BROWN (bean, rice, bead, peanut butter)
“whole wheat/grain/milk”
PATHO & CAUSES DIAGNOSTIC LABS • Bad Low fiber = White (bread, rice, bread potatoes (fries), low fat milk)
Type ONE Type TWO D–DIABETIC FEET “Delicious Feast for bacteria”
HgBA1C
GOAL: Clean, Dry, Injury Free
DON't-produce insulin (Born) FEW-insulin receptors work AVOID
Autoimmune “body attacks itself” “Insulin resistance” (Diet) F–Flip Flops, high heels, Nylon,
SON-hereditary YOU-diet “high simple sugars” O–OTC corn removal
& sedentary lifestyle O–Overly HOT (baths, pads etc.)
T–Toe Injuries — cut nails STRAIGHT
NCLEX KEY WORDS:
Daily inspection — NOT weekly
Shoes fit properly — NO sandals
SIGNS & SYMPTOMS SOFT Cotton Socks — NOT nylon
Nails trimmed–cut straight — NOT curved angles
HIGH sugar LOW sugar (70 or LESS) Non healing skin wounds — Report to HCP (Dr.)
hot and dry = sugar high cold and clammy need some candy NO callous removal
“Hyperglycemia” Hypoglycemia NO heavy Powder — light powder
(blood turns to mud) MORE SEVERE! “Hypogly Brain will Die!” NO rubbing feet hard “vigorously”
3 P’s: Polyuria • Cool, pale “pallor”, sweaty, NO HOT baths or HOT pads — warm is ok
Polydipsia clammy = candy NOT hot or flushing
Polyphagia • Trembling, Nervous, Anxious
• HIWASH = Headache, Irritable, Weakness, COMPLICATONS
Anxious, Sweaty, Shaky, Hungry KIDNEY–Nephropathy (High Creatinine OVER 1.3)
RISK FACTORS CAUSES EYE–Retinopathy (blind)
HEART–HTN & Atherosclerosis
Type ONE -None (born) HIGH sugar (115 or MORE) LOW sugar (70 or LESS) BRAIN–CVA (strokes)
Type TWO Sepsis (infection #1 cause), Exercise NERVES–Neuropathy (loss of feeling)
Stress (surgery, hospital stay), Alcohol
“MetaBOLic Syndrome”-Increased risk for diabetes, heart disease, stroke
Skip insulin Insulin PEAK times
B–BP meds or HTN (over 130 sysolic) NOTES
Steroids (predniSONE) MOST DEADLY! “Hypogly brain will DIE”
B–Blood Sugar Meds (insulin, oral diabetics) or High Blood Sugar (over 100+)
TREATMENT: Insulin 1st TREATMENT:
O–Obese (waist size: 35+ Female 45+ Male)
L–Lipids HIGH Total Cholestrol/Triglyceride/LDL 200-150-100—HDL 40 Awake? Ask to eat:
(higher LDL and lower HDL are risk factors) Juice, Soda, Crackers, Low Fat Milk
NOT high fat milk or peanut butter
*3 or MORE criteria*
Sleep? Stab them (D50 given IV/IO)
INSULIN TYPES ORAL HYPOGLYCEMICS (Type 2 Only) 7 INSULIN TIPS
1. DIET & EXERCISE BEFORE oral meds and insulin 1. Peaks + Plates = Food during PEAK times (prevent HYPOgly=brain die)
2. METFORMIN–Minimal chance of Low Sugar “hypoglycemia” 2. NO Peak NO Mix = Long acting “old guys”–Detemir & Glargine
1. Weight GAIN 3. IVP or IVPB ONLY = Regular insulin “ready to go IV”
2. Lactic Acidosis: NO Alcohol + STOP 48 hours before and 4. Draw Up: Clear to Cloudy “you want CLEAR days before cloudy ones”
after cath 5. Rotate locations-Macarena-BEST on abdomen
IV Contrast = Kills Kidney
(2 inches from: Umbilicus, Naval, “belly button”)
3. GLIPIZIDE GLYBURIDE–Heart can DIE (bad for CHF)
6. DKA - Type 1–“sick days”–YES INSULIN without food!!!
LOW blood sugar (Avoid alcohol “ETOH” = hypoglycemia)
TOXIC: Renal, Liver & elderly population 7. Hypoglycemia (70 or LESS)
Sun Burns = sunscreen & protective clothing Awake = Ask them to Eat (soda, juice, low fat milk)
4. THIAZOLIDINEDONE (TZD) Pioglitazone (ONE heart) Sleeping = Stab with IV D50 (dextrose 50)
NO Heart Failure patients–new pitting edema, crackles (lungs) "Unresponsive" "Responsive ONLY to pain"
NO Liver failure patients “Cirrhosis” “Liver Failure”
NOTES
NPH
PEAK TIMES=Hypoglycemia risk 70 or Less

Hypogly brain will DIE NCLEX TIP
DKA HHNS
PATHO & CAUSES: PATHO & CAUSES:
TYPE 1–Faster & Younger “D comes 1st in alphabet” TYPE 2–slower & older “H comes 2nd in alphabet”
S–Sepsis (infection) NCLEX TIP Illness
FRUITY BREATH
S–Sickness "Stomach Virus & Flu" (most commom) Infections
S–Stress (surgery) Older age Harder to fix
S–Skip insulin Easier fix
SIGNS & SYMPTOMS:
SIGNS & SYMPTOMS:
D–Dry & High sugar 250—500+ H–HIGHEST SUGAR OVER—600+
K–Ketones & Kussmaul resp. (Deep/rapid/REGULAR H–HIGHER fluid loss & Extreme dehydration NCLEX TIP
respirations and fruity breath) H–Head change–LOC, Confusion, Neurological Manifestations NO FRUITY BREATH
A–Abdominal Pain N–No keytones No Acid, (NO fruity breath/ketones)

A–Acidosis Metabolic LESS than 7.35 (normal 7.35—7.45) S–Slower Onset & Stable Potassium (3.5-5.0)
Hyperkalemia (Abnormally high K+) TREATMENT:
TREATMENT: H–Hydration–0.9% NS 1st, then HYPOtonic NCLEX TIP
D–Dehydration FIRST! (0.9% normal saline) S–Stabilize Sugars (Insulin)
K–Kill the sugar (SLOWLY) prevent low sugar CAUTION: Insulin IV = ONLY Regular Insulin
*Hourly BS checks* “land the plane slow & smooth” • IV bolus
Over 250: IV Regular insulin ONLY (bolus 1st) • IV titration
Below 200 (or ketones resolve): SQ insulin + 1/2 NS • SQ injection & IV
with D5W IV • SQ only
A–Add Potassium K+ (Yes even if norm: 3.5 - 5.0)
During IV Insulin
IN-sulin = sugar & K+ IN the cell DKA patients DIE from hypokalemia where
HHNS patients die from hypovolemia
RE-ASSESSMENT Potassium IV (Normal 3.5 - 5.0) POTASSIUM PUMPS MUSCLES NOTES

Blood Glucose Hourly • First Action = Heart monitor High Potassium (5.0+) Low Potassium (Below 3.5)
COMMON NCLEX QUESTION Re-Hydration Signs: Never push = DEATH High Pump Low Pump
Q: Child is nauseous NOT • BP stable & Cap Refill (3 sec or less) • 10–20 mg MAX per hour IV!! (IV Pump) Peaked T waves, ST elevation Flat T wave, ST depression, U wave
eating—maybe vomiting—do • Skin color & warm temp (NOT cool/pale) • Site (central) and Slow infusion
you still give INSULIN? • 30ml/hr + Urine Output
• Low spec gravity (1.005–1.030)
A: Yes, we give sick day insulin to NOT Apical pulse NOT Lung sounds NOT Pupils
prevent DKA...because glucose
is HIGH during times of illness.
Steroids
Anabolic Steroids
How do they work? “Action” Adverse Reactions

Anabolic steroids are synthetic drugs chemically • Virilization in women
related to the androgens. Like the androgens, they • Acne
promote tissue-building processes. Given in normal • Nausea, vomiting, diarrhea, fluid and electrolyte
doses, they have a minimal effect on the accessory imbalances
sex organs and secondary sex characteristics. • testicular atrophy, jaundice, anorexia, and muscle
(Ford 491) cramps may also be seen.
• Blood-filled cysts of the liver and sometimes the
spleen, malignant and benign liver tumors, an
increased risk of atherosclerosis, and mental
Indications changes
Anabolic steroid use includes the Nursing management

following:
• Management of anemia of renal insufficiency • Assess and document the patient’s physical and
• Control of metastatic breast cancer in women nutritional status before starting therapy
• Promotion of weight gain in those with weight • Baseline laboratory studies may include a
loss after surgery, trauma, or infections complete blood count, hepatic function tests,
(Ford 491-492) and serum electrolytes and serum lipid levels.
Review these studies and note any abnormalities.
• Sodium and water retention may also occur with
androgen or anabolic steroid administration,
It’s not always about them gains! causing the patient to become edematous. In
The use of anabolic steroids to promote an increase addition, other electrolyte imbalances, such as
in muscle mass and strength has become a serious hypercalcemia, may occur. Monitor the patient for
problem. Anabolic steroids are not intended for this fluid and electrolyte disturbances.
use. Unfortunately, deaths in young, healthy • Anabolic steroids may cause nausea and GI upset.
individuals have been directly attributed to the use Take this drug with food or meals.
of these drugs. Young men and women should be • Keep all primary health care provider or clinic
discouraged from the illegal use of anabolic steroids visits, because close monitoring of therapy is
to increase muscle mass. (Ford 492) essential.
• Female patients: Notify the primary health care
provider if signs of virilization occur.
Contraindications Interactions:
• Known hypersensitivity • Oral anticoagulants: Increased antidiuretic
• Liver disorders effect
• Serious cardiac disease • Imipramine and androgen: Increased risk of
• Prostate gland disorders paranoid behavior
• Pregnancy category x do not give • Sulfonylureas and anabolic steroids: Risk of
to pregnant or lactating women hypoglycemia
Generic Trade Use Route

Anemia of renal insufficiency, human
Nandrolone n/a immunodeficiency virus (HIV) wasting 50–200 mg/wk IM
syndrome
Oxymetholone Anadrol -50 Anemia 1–5 mg/kg/day orally
Bone pain, weight gain, protein 2.5–20 mg/day orally

Oxandrolone Oxandrin
catabolism in divided doses
Androgens

Testosterone and its derivatives are male hormones that cause the Electrolyte imbalances
reproductive maturation in the adolescent male. From puberty onward, • Hypernatremia
androgens continue to aid in the development and maintenance of • Hypercalcemia
secondary sex characteristics: facial hair, deep voice, body hair, body fat In males:
distribution, and muscle development. Testosterone also stimulates the
• Breast enlargement “ gynecomastia”
growth in size of the sex organs (penis, testes, vas deferens, prostate) at
• Testicular atrophy
the time of puberty. The androgens also promote tissue-building
processes (anabolism ) and reverse tissue-depleting processes
• May inhibit testicular function
(catabolism ). (Ford 491) • Impotence
• Penile enlargement
• vomiting, jaundice, headache, anxiety,
Indications • male-pattern baldness, acne, and depression.
• Fluid and electrolyte imbalances, which include
Androgen therapy may be given as replacement to treat: sodium, water, chloride, potassium, calcium, and
• Testosterone deficiency phosphate retention.
• Hypogonadism (failure of the testes to develop) In females:
• Delayed puberty • Amenorrhea
• Development of testosterone deficiency after puberty Androgens • Virilization “ male characteristics”
may given to females to treat
• Menstrual irregularities
• Postmenopausal, metastatic breast carcinoma
• Male pattern baldness
• Premenopausal, hormone-dependent metastatic breast carcinoma
Transdermal testosterone system
• Acne
• replacement therapy when endogenous (produced by the body)
testosterone is deficient or absent.
Anabolic steroid use is indicated for Nursing management
• Management of anemia of renal insufficiency
• Control of metastatic breast cancer in women •Monitor vitals every 4 or 8 hrs
• Promotion of weight gain in those with weight loss after surgery, • Monitor weight for patients with advanced breast
trauma, or infections (Ford 491-492) carcinoma. Contact the HCP if the patient gains or loses
5 pounds
• Monitor for edema
Contraindications • Monitor for fluid and electrolyte imbalance
• Older adults with cardiac problems or kidney disease
• Known hypersensitivity are at increased risk for sodium and water retention
• Liver disorders when taking androgens or anabolic steroids. (Ford 493)
• Serious cardiac disease • Anabolic steroids may cause nausea and GI upset.
• Prostate gland disorders Take this drug with food or meals.
• Pregnancy category x do not give to pregnant or • Keep all primary health care provider or clinic visits,
lactating women
because close monitoring of therapy is essential.
• Female patients: Notify the primary health care provider
if signs of virilization occur. (Ford 494)
Interactions: • When the androgens are administered to a patient with
diabetes, blood glucose levels should be measured
• Oral anticoagulants: Increased antidiuretic effect frequently because glucose tolerance may be altered.
• Imipramine and androgen: Increased risk of paranoid behavior Adjustments may need to be made in insulin dosage,
• Sulfonylureas and anabolic steroids: Risk of hypo glycemia oral antidiabetic drugs, or diet. (Ford 493)

Males: Hypogonadism, delayed puberty
Males: 5–20 mg/day orally
Fluoxymesterone n/a Females: Inoperable advanced breast
Females: 10–40 mg/day orally
cancer
Males: Hypogonadism, delayed puberty Males: 10–50 mg/day orally

Methyltestosterone Testered
Females: Inoperable advanced breast cancer Females: 50–200 mg/day orally
Buccal: 30 mg BID
Gel: apply daily
Androgel, androderm, Primary or hypogonadotropic
testosterone Injectable: 50–400 mg every 2–4 wk
depo-testosterone hypogonadism, delayed puberty Transdermal: 6 mg/day, apply patch daily
Spray: 30–120 mg daily
Glucocorticoids

Glucocorticoids influence or regulate functions such as the immune • Fluid and electrolyte disturbances: Sodium and fluid retention,
response;glucose, fat, and protein metabolism; and the potassium loss, hypokalemic alkalosis, hypertension, hypokalemia,
anti-inflammatory response. Glucocorticoids enter target cells and hypotension or shock-like reactions
bind to receptors, initiating many complex reactions in the body • Musculoskeletal disturbances: Muscle weakness, loss of muscle
mass, tendon rupture, osteoporosis, aseptic necrosis of femoral and
humeral heads, spontaneous fractures
• Cardiovascular disturbances: Thromboembolism or fat embolism;
Indications thrombophlebitis; necrotizing angiitis; syncopal episodes; cardiac
arrhythmias; aggravation of hypertension; fatal cardiac arrhythmias
• Adrenocortical insufficiency (replacement therapy)
with rapid, high-dose IV methylprednisolone administration; HF in
• Allergic reactions
susceptible patients
• Collagen diseases (e.g., systemic lupus erythematosus) • GI disturbances: Pancreatitis, abdominal distention, ulcerative
• Dermatologic conditions esophagitis, nausea, vomiting, increased appetite and weight gain,
• Rheumatic disorders possible peptic ulcer or bowel perforation, hemorrhage
• Shock • Dermatologic disturbances: Impaired wound healing; thin, fragile
• Multiple other conditions skin; petechiae; ecchymoses; erythema; increased sweating;
suppression of skin test reactions; subcutaneous fat atrophy; purpura;
striae; hirsutism; acneiform eruptions; urticaria; angioneurotic edema;
Contraindications perianal itch
• Neurologic disturbances: Convulsions, increased intracranial
• Tuberculosis pressure with papilledema (usually after treatment is discontinued),
• fungal and antibiotic-resistant infections. vertigo, headache, neuritis or paresthesia, steroid psychosis, insomnia
Glucocorticoids are administered with caution to patients with • Endocrine disturbances: Amenorrhea, other menstrual irregularities,
renal or hepatic disease, hypothyroidism, ulcerative colitis, diverticulitis, development of cushingoid state, suppression of growth in children,
peptic ulcer disease, inflammatory bowel disease, hypertension, secondary adrenocortical and pituitary unresponsive (particularly in
times of stress), decreased carbohydrate tolerance, manifestation of
osteoporosis, convulsive disorders, or diabetes.
latent diabetes mellitus, increased requirements for insulin or oral
Patients taking ACTH should avoid any vaccinations with live virus. The
hypoglycemic agents (in diabetic patients)
live virus vaccines can potentiate virus replication with ACTH, increase • Ophthalmic disturbances: Posterior subcapsular cataracts, increased
any adverse reaction to the vaccine, and decreasethe patient’s antibody intraocular pressure, glaucoma, exophthalmos
response to the vaccine. • Metabolic disturbances: Negative nitrogen balance (due to protein
catabolism)
• Other disturbances: Anaphylactoid or hypersensitivity reactions,
Interactions: aggravation of existing infections, malaise, increase or decrease in
sperm motility and number
• Cholestyramine: Effects of hydrocortisone may be decreased.
• Oral contraceptives: Effects of corticosteroid may be increased.
• Estrogens: Effects of corticosteroid may be increased. Nursing management
• Hydantoins: Effects of corticosteroid may be decreased. • Never omit a dose of a glucocorticoid
• Ketoconazole: Effects of corticosteroid may be increased. • Patients with diabetes who are receiving a glucocorticoid may require
• Rifampin: Effects of corticosteroid may be decreased. frequent adjustment of their insulin or oral antidiabetic drug dosage.
• Anticholinesterases: Anticholinesterase effects may be antagonized (Ford 476)
in myasthenia gravis. • Administration of the glucocorticoids poses the threat of adrenal gland
• Oral anticoagulants: Anticoagulant dose requirements may be insufficiency (Ford 476)
reduced. Corticosteroids may decrease the anticoagulant action. • Glucocorticoid therapy should never be discontinued suddenly
(Ford 476)
• Digitalis glycosides: Coadministration may enhance the possibility of
• Take the drug exactly as directed in the prescription container. Do not
digitalis toxicity associated with hypokalemia. increase, decrease, or omit a dose unless advised to do so by the
• Isoniazid: Isoniazid serum concentrations may be decreased. primary health care provider.
• Potassium-depleting diuretics: Hypokalemia may occur. • Take single daily doses before 9:00 a.m.
• Salicylates: Corticosteroids will reduce serum salicylate levels and • Follow the instructions for tapering the dose, because they are
may decrease their effectiveness. extremely important.
• Theophyllines: Alterations in the pharmacologic activity of either • If the problem does not improve, contact the primary health care
agent may occur. provider. (Ford 477)

Endocrine disorders, rheumatoid disorders,
collagen disease, dermatologic disorders,
Medrol, Depo-Medrol, allergic state, ophthalmic disorders, respiratory Individualize dosage based on severity
Dexamethasone
Solu-Medrol disorders, hematologic disorders, neoplastic of condition and response
disease, edema, GI disease, Nervous system
disorders
Individualize dosage: initial dose

Prednisone None Same as dexamethasone
usually between 5 and 60 mg/day orally
Mineralocorticoids
How do they work? “Action” Contraindications

Natural mineralocorticoids consist of Fludrocortisone is contraindicated in patients
aldosterone and desoxycorticosterone and with hypersensitivity to fludrocortisone and
play an important role in conserving sodium those with systemic fungal infections.
and increasing potassium excretion. Because of
these activities. Mineralocorticoids are
important in controlling salt and water balance.
Aldosterone is the more potent of these two
hormones. Deficiencies of mineralocorticoids
result in a loss of sodium and water and a
retention of potassium. (Ford 474)
Nursing management
• Take the drug as directed. Do not increase or
decrease the dosage except as instructed to
do so by the primary health care provider.
Indications
• Do not discontinue use of the drug abruptly.
Mineralocorticoids are important in controlling • Inform the primary health care provider if the
salt and water balance. Aldosterone is the more following adverse reactions occur: edema,
potent of these two hormones. Deficiencies of muscle weakness, weight gain, anorexia,
mineralocorticoids result in a loss of sodium swelling of the extremities, dizziness, severe
and water and a retention of potassium. headache, or shortness of breath. (Ford 477)
(Ford 474)
Adverse Reactions
Adverse reactions may occur if the dosage is
too high or prolonged or if withdrawal is too
rapid. Administration of fludrocortisone may Interactions:
cause: • Fludrocortisone decreases the effects of
• Edema hydantoins and rifampin. There is a
• Hypertension decrease in serum levels of salicylates
• HF, enlargement of the heart when those agents are administered with
• Increased sweating, allergic skin rash fludrocortisone. (Ford 474)
• Hypokalemia, muscle weakness, headache,
hypersensitivity reactions (Ford 474)
Partial replacement therapy for Addison’s 0.1 mg 3 times a week to 0.2 mg/day
Fludrocortisone None
disease, salt-losing adrenogenital syndrome orally
Steroids
Drug name: ADDISON vs. CUSHING TREATMENTS:

S S
STEROIDS Stress & Swelling 7 S’s STEROID PRECAUTIONS
hormone
‘’-sone’’ prednisone, hydrocortisone, dexamethasone
STEROIDS
s SWOLLEN (Water gain = Weight gain)

KEY TERMS: ‘’Sudden’’ ‘’excessive’’, ‘’rapid’’
REPORT: 1 Lb. in 1 day, or 2-3lbs in a few
S – STEROIDS
S – Stress & Swelling hormone Prednisone Dexamethasone s SEPSIS (Infections or Illness)
‘’Low WBC’’ Fever is PRIORITY NCLEX TIP
s
“-Sone”
- Prednisone SUGAR INCREASED
- Dexamethasone Fludrocortisone
‘’Hyperglycemia’’ NCLEX TIP
s
- Hydrocortisone Hydrocortisone
- Fludrocortisone
SKINNY
Muscle & Bones ‘’Osteoporosis’’ (R/F Fx)
Indication:
Given to help the body respond to

inflammation & STRESS!
Commonly for:
s SIGHT
(Cataracts risk) refer to Optometrist
COPD
PREVENT CRISIS:
s
• Inflamed Lung like COPD
• Inflamed joints like Rheumatoid Arthritis SLOWLY taper off
• Inflamed SKIN like Psoriasis (NEVER abruptly stop) NCLEX TIP
s
• Inflamed body - like Lupus where the body
attacks itself STRESS or Surgery
• Allergic reaction where EVERYTHING swells UP (increase dose)
TOP 3 MISSED Questions:

The nurse should be concerned Which priority teaching is Which of the follow is an
when the client states: required for a patient prescribed indication that the client needs
“I have a sore on my leg that prednisone for Lupus? additional teaching,
won’t go away”. while taking fludrocortisone?
Which medication should be 1. Report slight increases in blood
reviewed with HCP.
sugar to HCP immediately. 1. I will not discontinue this
2. Increase dose before surgery medication abruptly
or during times of stress. 2. New bilateral pedal edema
1. Naproxen
3. Monitor weight weekly. is normal
2. Dihydromorphinone
4. Take with full meal at breakfast. 3. The most important value
3. Dexamethasone
to monitor is my weight.
4. Hydrocodone
4. I will report signs &
5. Hydrocortisone
symptoms of infection
Notes
Thyroid Drugs
Thyroid Drugs

These hormones increase the metabolic rate of • Hypersensitivity to the drug
tissues, which results in increases in the heart and respi- • An uncorrected adrenal cortical insufficiency
• Thyrotoxicosis.
ratory rate, body temperature, cardiac output, oxygen • These drugs should not be used as a treatment for
consumption, and the metabolism of fats, proteins, and obesity or infertility.
carbohydrates. (Ford 483) • Thyroid hormone should not be used after a recent
myocardial infarction. (Ford 483)
Indications Nursing management

Thyroid hormones are used in the treatment or • Monitor cardiac status
prevention of hypothyroidism caused by the • Monitor thyroid labs
following:
• Replacement therapy is for life, with the exception of
• Subacute or chronic thyroiditis (Hashimoto’s
disease or viral thyroiditis) transient hypothyroidism seen in those with thyroiditis.
• Hormone supplement after hyperthyroid treatment • Do not increase, decrease, or skip a dose unless advised
• Euthyroid goiter (enlargement of a normal thyroid to do so by the primary health care provider.
gland)
• Thyroid nodules and multinodular goiter • Take this drug in the morning, preferably before
• Some types of depression breakfast, unless advised by the primary health care
• Thyroid cancer (Ford 483) provider to take it at a different time of day.
• Notify the primary health care provider if any of the
following occur: headache, nervousness, palpitations,
diarrhea, excessive sweating, heat intolerance, chest
pain, increased pulse rate, or any unusual physical
Adverse effects of Levothyroxine change or event.
• Do not change from one brand of this drug to another
• Palpitations without consulting the primary health care provider.
• Tachycardia (Ford 486-487)
• Headache
• Nervousness
• Insomnia
• Diarrhea
• Vomiting
• weight loss Interactions:
• Fatigue
• Sweating • Digoxin, beta (β) blockers: Decreased effectiveness of
• flushing (Ford 488) cardiac drug
• Oral antidiabetics and insulin: Increased risk of
hypoglycemia
• Oral anticoagulants: Prolonged bleeding
• Selective serotonin reuptake inhibitor (SSRI)
Adverse Reactions antidepressants: Decreased effectiveness of thyroid
drug
The most common adverse reactions are signs of • All other antidepressant drug categories:
overdose and hyperthyroidism as titration of the drug is Increased effectiveness of thyroid drug
being attempted. Adverse reactions other than symptoms (Ford 483)
of hyperthyroidism are rare. (Ford 483)
Generic Trade Dose Route

Hypothyroidism, thyroid-stimulating
Levothroid, Levoxyl, 100–125 mcg/day
Levothyroxine hormone suppression, thyrotoxicosis,
Synthroid, Unithroid orally
thyroid diagnostic testing
Antithyroid Drugs
How do they work? “Action” Adverse effects of PTU

• Numbness
Antithyroid drugs or thyroid antagonists are used to treat • Headache
hyperthyroidism. In addition to the antithyroid drugs, • loss of hair
• skin rash
hyperthyroidism may be treated by the use of radioactive • nausea, vomiting
iodine or by surgical removal of some or almost all of the • agranulocytosis
thyroid gland (subtotal thyroidectomy). (Ford 484)
Antithyroid drugs inhibit the manufacture of thyroid
hormones. Nursing management
• Take these drugs at regular intervals around the clock
(e.g., every 8 hours) unless directed otherwise by the
Indications primary health care provider.
• Do not take these drugs in larger doses or more
• Methimazole (Tapazole) and propylthiouracil (PTU) frequently than as directed on the prescription
are used for the medical management of
hyperthyroidism. container.
• Potassium iodide may be given orally with methima • Notify the primary health care provider promptly if any
zole or propylthiouracil to prepare for thyroid surgery. of the following occur: sore throat, fever, cough, easy
(Ford 484)
bleeding or bruising, headache, or a general feeling of
malaise.
• Record weight twice a week and notify the primary
health care provider if there is any sudden weight gain
Adverse Reactions or loss. (Note: the primary health care provider may also
• Hay fever, sore throat, skin rash, fever, headache want the patient to monitor pulse rate. If this is recom
• Nausea, vomiting, paresthesias mended, the patient needs instruction in the proper
• Agranulocytosis (decrease in the number of white blood
cells) technique and a recommendation to record the pulse
• Exfoliative dermatitis, granulocytopenia, rate and bring the record to the primary health care
hypoprothrombinemia provider’s office or clinic.)
• Drug-induced hepatitis (Ford 485)
• Avoid the use of nonprescription drugs unless the
primary health care provider has approved the use of a
specific drug. (Ford 486)
Contraindications
Mothers taking methimazole or propylthiouracil should Interactions:
not breastfeed their children. Radioactive iodine (preg-
nancy category X) is contraindicated during pregnancy • Digoxin, beta (β) blockers: Decreased effectiveness of
and lactation. Methimazole and propylthiouracil are used cardiac drug
with extreme caution during pregnancy (pregnancy • Oral antidiabetics and insulin: Increased risk of
category D) because they can cause hypothyroidism in hypoglycemia
the fetus. However, if an antithyroid drug is necessary
during pregnancy, propylthiouracil is the preferred • Oral anticoagulants: Prolonged bleeding
drug, because it does not cross the placenta. The • Selective serotonin reuptake inhibitor (SSRI)
potential for bleeding increases when these products are antidepressants: Decreased effectiveness of thyroid
taken with oral anticoagulants. (Ford 485) drug
• All other antidepressant drug categories: Increased
effectiveness of thyroid drug (Ford 483)
Generic Trade Dose Route
5–40 mg/day orally, divided doses at

Propylthiouracil None Hyperthyroidism
8-hr intervals
Graves = GAINS "HIGH" HashimOtos | LOW & SLOW
EMERGENCY CONDITION: EMERGENCY CONDITION:

Thyroid Storm “thyrotoxicosis” Myxedema Coma (Mini hypothyroid)
VERY HIGH = “Agitation/Confusion” + HTN crisis! VERY Low/Slow:
Airway, Breathing, Low BP = D EATH!
PATHO & CAUSES PATHO & CAUSES

HIGH T3 & T4 Thyroid Hormones LOw T3 & T4 Thyroid hormones
Too much Iodine Low Iodine, Antithyroid Treatments
Too much Thyroid Meds. (Levothyroxine) Pituitary Tumor
Autoimmune: Graves = GAINS “HIGH”
AUTOIMMUNE: HashimOtos | LOW & SLOW
AUTOIMMUNE: Graves = G
AINS “HIGH”
SIGNS & SYMPTOMS SIGNS & SYMPTOMS

PRIORITY: EXTREME HIGH = Thyroid Storm PRIORITY: EXTREME LOW = Myxedema Coma
”Agitation & confusion” early sign Low RR—Respiratory FAILURE
PRIORITY: Place “Tracheostom Kit” by bedside

HIGH & HOT! KEY WORD: “Endotracheal Intubation set up”
Low BP & HR “hypotension” “bradycardia” (below 60)
CLASSIC SIGNS–NCLEX KEY WORDS Low Temp. “cold intolerance” NO electric blankets
G GRAPE EYE “Exopthalamos”
(Use Eye patch/Tape Eyelids down) LOW & SLOW = HYPO
G GOLF BALLS in throat “Goiter”
HIGH BP–HTN Crisis 180/100+ CLASSIC SIGNS
(MI, CVA, Aneurysms) LOW energy “fatigue, weakness, muscle pains, aches”
HIGH HR–Tachycardia 100+ (normal 60–100) LOW metabolism–Weight GAIN/Water Gain (Edema eyes)
HEART PALPITATIONS + Atrial Fibrillation LOW digestion “Constipation” NOT diarrhea
HIGH TEMP. = NOT DRY! LOW HAIR LOSS “alopecia” NOT hirsutism
HOT & Sweaty Skin “diaphoresis” LOW mental–forgetful, ALOC (altered)
Heat Intolerance LOW mood–depression, “apathy, confusion”
HIGH GI “Diarrhea” LOW Libido–Low sex drive, infertile
SLOW DRY skin turgor
LOW & SLOW–menstruation “irregular”
LABS NO period “missed”–Amenorrhea “AMEN no period!”
SLOW heavy period–Hypermenorrhea (Hyper Menstruation)
HIGHT3 & T4 HYPER
Low—TSH
(look at T3 & T4 levels FIRST)
LABS
DIET LOw T3 & T4 hypO
HIGH METABOLISM - HIGH TSH
HIGH calories (4,000–5,000 per day) “TSH always opposite of T3 & T4”
HIGH protein & Carbs (meals & snacks)
NOThigh fiber = LOW FIBER! (unless constipated) DIET
NOcaffeine (coffee, soda, Tea) LOW Metabolism
NOspicy food LOW Calories
LOW energy “Frequent rest periods”
NOTES
Graves = GAINS "HIGH" HashimOtos | LOW & SLOW
PHARMACOLOGY PHARMACOLOGY
SSKI (Potassium Iodide) L–Levothyroxine (LevO= HYPO)
S–Shrinks the Thyroid “Leaves” T3 & T4 in the body MEMORY TRICK
S–Stains Teeth (use straw + juice)
K–Keep 1 hour apart of other meds L–Life Long + Long slow onset (3-4 weeks till relief)
METHIMAZOLE E–Early morning /Empty stomach x 1 daily (NOTat night)
NOT baby safe V–Very active (HIGH HR & BP) R eport “agitation/confusion”
PTU-Propylthiouracil O–Oh the baby is fine! (pregnancy safe)
“Puts Thyroid Underground” M
EMORY TRICK NO FOOD–take 1 hour BEFORE breakfast
Baby safe NO Cure–med will NOT cure, only treat
REPORT: Fever/Sore Throat NO Doubling doses (missed dose? Take it!)
NEVER “abruptly” STOP = Myxedema Coma
BETA BLOCKERS “-lol” Propranolol
L–Low BP
L–Low HR
NOTES
TREATMENTS
RAIU–RadioactiveIodine Uptake (Destroys the Thyroid)
BEFORE:
Pregnancy test before
REMOVE neck jewelry & dentures
5–7 days before Hold antithyroid Meds
AWAKE–NOanesthesia or Conscious Sedation
Diet: Before–NPO 2–4 hrs
After–NPO 1–2 hrs
AFTER: AVOID EVERYONE!
NOpregnant people NO crowds
NOTsame restroom (Flush 3 x) NOTsame food utensils
NOTsame laundry as your family

PATIENT EDUCATION
E–Exophthalamos” (grape eyes)
Eye Exercise “full range of motion” (YESMOVE EYES)
Eye Drops “artificial tears in conjunctiva” (NOdry eye)
DarkSunglasses (avoid irritation) NO Massaging
T–Tape the eyelids closed or use Eye Patch
AVOID 5 S’s
Can Trigger THYROID STORM!
NOSodium (eye swelling) + HOB Up (drain the eyes)
NOStimulants (Cluster care/ Dim Lights)
NOSmoking, Stress, Sepsis “sickness” (infection)
*Don’t Touch Neck... release MORE T3 & T4*
THYROIDECTOMY SURGERY
Risk for THYROID STORM!
Priority: Stridor/Noisy breathing
A–Airway–Endotracheal Tube bedside #1 Priority
Tracheostomy Set
B–Breathing–Laryngeal Stridor “Noisy breathing”
Keywords: “Monitor Voice strength & Quality”
C–Circulation–bleeding around pillow & Incision site
Neutralhead & neck alignment
- NOT SUPINE! HOB 30–45 degree
- NO FLEXING or Extending Neck
C–Calcium LOW below 8.6 (normal: 8.6–10.2)
Chvostek (Cheek Twitch when touched)
Trousseau (“Twerk arm” with BP cuff x 3 min.)
Tingling around mouth/Muscle Twitching
MEMORY TRICK: “Remove the T (thyroid) Check the C
(calcium)”
HGH & Hormones
Posterior Pituitary Hormones

Vasopressin and its derivative, desmopressin (DDAVP), • Norepinephrine: Decreased antidiuretic effect
regulate the reabsorption of water by the kidneys. • Lithium: Decreased antidiuretic effect
Vasopressin is secreted by the pituitary when body fluids • Oral anticoagulants: Decreased antidiuretic effect
must be conserved. • Carbamazepine: Increased antidiuretic effect
• Chlorpropamide: Increased antidiuretic effect
Patho
This mechanism may be activated when, for example, an Adverse Reactions
individual has severe vomiting and diarrhea with little
or no fluid intake. When this and similar conditions are • Tremor, sweating, vertigo
present, the posterior pituitary releases the hormone • Nasal congestion
vasopressin, water in the kidneys is reabsorbed into the • Nausea, vomiting, abdominal cramps
blood (i.e., conserved), and the urine becomes • Water intoxication
concentrated. Vasopressin exhibits its greatest activity on
the renal tubular epithelium, where it promotes water
reabsorption and smooth muscle contraction throughout
the vascular bed. Vasopressin also has some vasopressor
activity. (Ford 466)
Nursing management
• Before administering vasopressin to relieve abdominal
distention, document the patient’s blood pressure,
Indications pulse, and respiratory rate. Auscultate the abdomen
and record the findings. Additionally, measure and
• Diabetes insipidus document the patient’s abdominal girth. (Ford 467)
• Unlabeled Use: Management of pulseless VT/VF unre
• Excessive dosage is manifested as water intoxication
sponsive to initial shocks, asystole, or pulseless electrical
(fluid overload). Symptoms of water intoxication include
activity (PEA) (ACLS guidelines). Vasodilatory shock.
Gastrointestinal hemorrhage ( Davis 1) drowsiness, listlessness, confusion, and headache
(which may precede convulsions and coma). If signs of
excessive dosage occur, notify the primary health care
provider before the next dose of the drug is due; a
change in the dosage, the restriction of oral or IV fluids,
and the administration of a diuretic may be necessary.
Contraindications
• Monitor fluid volume status
Vasopressin is used cautiously in patients with a history of • Monitor vitals
seizures, migraine headaches, asthma, congestive heart • Monitor intake and output closely
failure (HF), or vascular disease (because the substance • Monitor weight
may precipitate angina or myocardial infarction) and in
those with preoperative polyuria.
(Ford 467)

Diabetes insipidus, hemophilia A, Von Diabetes insipidus: 5–10 units IM,
Vasopressin None Willebrand's disease, nocturnal subcut q 3–4 hr, parenteral solution
enuresis may be used intranasally
Diabetes insipidus, hemophilia A, Von Doses are individualized, administered
Desmopressin DDAVP Willebrand's disease, nocturnal orally, intranasally, or subcut
enuresis
Somatotropins

Somatropin is identical to human GH and produces • Closure of epiphyses
skeletal growth in children. This drug is administered • Active neoplasia
to children who have not grown because of a • Hypersensitivity to growth hormone or m-cresol
deficiency of pituitary GH; it must be used before preservative
closure of the child’s bone epiphyses. (Ford 470) • Acute critical illness (therapy should not be
initiated)
• Respiratory failure
Indications • Diabetic retinopathy
• Prader-Willi syndrome with obesity and respiratory
• Growth failure in children due to Prader-Willi impairment (risk of fatal complications; can be
syndrome. Growth failure in children due to used only if growth hormone deficiency is
deficiency of growth hormone. Growth failure in documented).
children born small for gestational age (SGA) who
fail to manifest catch-up growth by age 2
Nursing management
Adverse Reactions • Monitor bone age annually and growth rate

determinations, height, and weight every 3– 6 mo
• Edema of the hands and feet during therapy.
• Hyperglycemia • Monitor bone age annually and growth rate
• hypothyroidism, insulin resistance determinations, height, and weight every 3– 6 mo
• PANCREATITIS. during therapy.
• pain at injection site, local lipoatrophy or • Assure parents and child that these dose forms are
lipodystrophy with subcutaneous use synthetic and therefore not capable of transmitting
• arthralgia.
Creutzfeldt-Jakob disease, as was the original
somatropin, which was extracted from human
cadavers.
Interactions:
• Advise parents to monitor blood glucose closely in
• Excessive corticosteroid use (equivalent to 10– 15 children with diabetes mellitus. Parents should also
mg/m2 /day) may decrease response to growth be advised to report persistent severe abdominal
hormone. pain; may be a symptom of pancreatitis.
• Emphasize need for regular follow-up with
endocrinologist to ensure appropriate growth rate,
to evaluate lab work, and to determine bone age by
Genotropin, Humatrope, Growth failure due to deficiency of Doses are individualized,

Somatropin
Norditropin, Nutropin, pituitary GH in children, replacement administered by subcut
• Growth hormone
Serostim of endogenous GH in adults injection weekly
Octreotide
Reduction of GH in acromegaly 50 mcg subcut
• Growth hormone Sandostatin
and treatment of certain tumors or IV BID or TID
inhibitor
GI -Nutrition
Acid Neutralizers
How do they work? “Action” Caution

They neutralize or reduce the acidity of stomach and duodenal • Aluminum-containing antacids: gastric outlet obstruction or
contents by combining with HCl and increasing the pH of the those with upper GI bleeding.
stomach acid. They may increase the sphincter tone of the lower • Magnesium- and aluminum-containing antacids: decreased
esophagus. Examples of antacids include aluminum (Amphojel), kidney function.
magaldrate (Riopan), and magnesium (Milk of Magnesia). • Calcium-containing antacids: respiratory insufficiency, renal
impairment, or cardiac disease.
• Antacids are classified as pregnancy category C drugs and
Why are they used for? ‘’Indications’’ should be used with caution during pregnancy
• Heartburn, acid indigestion, or sour stomach
• Gastroesophageal reflux disease (GERD)
• Peptic ulcer
• Aluminum carbonate: Treats hyperphosphatemia associated
Interactions:
with chronic renal failure
• Digoxin, isoniazid, phenytoin, and chlorpromazine:
Decreased absorption of the interacting drugs results in a
Adverse effects decreased effect of those drugs
• Tetracycline: Decreased effectiveness of anti-infective
• Aluminum-containing antacids: constipation, intestinal • Corticosteroids: Decreased anti-inflammatory properties
impaction, anorexia, weakness, tremors, and bone pain • Salicylates: Pain reliever is excreted more rapidly in the urine
• Magnesium: containing antacids—severe diarrhea,
dehydration, and hypermagnesemia (nausea, vomiting,
hypotension, decreased respirations)
• Calcium-containing antacids: rebound hyperacidity, Nursing management
metabolic alkalosis, hypercalcemia, vomiting, confusion,
headache, renal calculi, and neurologic impairment • Because of the possibility of an antacid interfering with the
• Sodium bicarbonate: systemic alkalosis and rebound activity of other oral drugs, no oral drug should be
hyperacidity administered within 1 to 2 hours of an antacid.
• When one of these drugs is given IV, monitor the rate of
Contraindications infusion at frequent intervals. Too rapid an infusion may
induce cardiac arrhythmias.
• Severe abdominal pain of unknown • Keep a record of the patient’s bowel movements, because
• During lactation these drugs may cause constipation or diarrhea.
• Sodium-containing antacids are contraindicated in patients • Observe the patient for signs of dehydration, which include
with cardiovascular problems, such as hypertension or heart poor skin turgor, dry mucous membranes, decrease in or
failure, and those on sodium-restricted diets. absence of urinary output, concentrated urine, restlessness,
• Calcium-containing antacids are contraindicated in patients irritability, increased respiratory rate, and confusion.
with renal calculi or hypercalcemia. • Instruct the patient to chew the tablets thoroughly before
swallowing and then drink a full glass of water or milk.
• Magnesium-containing products may produce a laxative effect
Think out of the box
and may cause diarrhea; aluminum- or calcium-containing
Sodium bicarbonate antacids may cause constipation.
• Use: Symptomatic relief of peptic ulcer and stomach • Taking too much antacid may cause the stomach to secrete
hyperacidity excess stomach acid. Consult the primary health care provider
• Adverse effects: Electrolyte imbalance and metabolic alkalosis or pharmacist about appropriate dose. Do not use the
maximum dose for more than 2 weeks, except under the
Sodium bicarb is also given to someone who is in acidosis to supervision of a primary health care provider.
bind to the hydrogen ions and balance PH.

2 tablets or capsules (10 mL of
Aluminum Symptomatic relief of peptic ulcer and
Basaljel regular oral suspension) as often
carbonate stomach hyperacidity, hyperphosphatemia as q 2 hr, up to 12 times daily
Calcium carbonate Symptomatic relief of peptic ulcer and stomach

(May cause acid rebound) Caltrate 0.5–1.5 g orally
hyperacidity, calcium deficiencies (osteoporosis)
Antacid: 622–1244 mg (5–15 mL

Magnesia Milk of Symptomatic relief of peptic ulcer and
in suspension) orally QID
(magnesium hydroxide) Magnesia stomach hyperacidity, constipation Laxative: 15–60 mL orally
Aminosalicylates
How do they work? “Action” Nclex Tip

Exert a topical anti-inflammatory effect in the bowel. The Hypoactive bowel sounds in severe cases of
exact mechanism of action of these drugs is unknown. obstipation (liquid stool leaked around the fecal mass,
presenting as loose stool) are evidence that the patient
is constipated, which would indicate very different drug
Why are they used for? ‘’Indications’’ therapy. (Ford 439)
The aminosalicylates are used to treat Crohn’s disease
and ulcerative colitis as well as other inflammatory Nursing management
diseases.
• Review the patient’s chart for the course of treatment
and find the reason for administration of the prescribed
Adverse Reactions
drug
• Abdominal pain • Question the patient regarding the type and intensity of
• Nausea symptoms (e.g., pain, discomfort, diarrhea, or
• Diarrhea. constipation) to provide a baseline for evaluation of the
• Headache effectiveness of drug therapy. (Ford 439)
• Dizziness • Assess for relief of symptoms
• Fever • Monitor vitals
• Weakness. • Report abdominal distention , fever, or abdominal pain
• If diarrhea is chronic encourage increased fluid intake
such as , weak tea, water, bullion, or drinks that have
Contraindications added electrolytes (pedialyte, gatorade)
• Monitor fluid intake & output
• Known hypersensitivity
• hypersensitivity to sulfonamides and sulfites
• Intestinal obstruction Herbal Considerations
• Children younger than 2 years.
Chamomile has several uses in traditional herbal therapy,
including as a mild sedative and for treatment of
Caution digestive upsets, menstrual cramps, and stomach ulcers.
It has been used topically for skin irritation and inflamma-
Aminosalicylates are pregnancy category B drugs (except
tion. Chamomile is on the U.S. Food and Drug
olsalazine, which is in pregnancy category C); all are used
Administration (FDA) list of herbs generally recognized as
with caution during pregnancy and lactation
safe. It is one of the most popular teas in Europe. When
(safety has not been established).
used as an infusion, it appears to produce an
(Ford 436)
antispasmodic effect on the smooth muscle of the GI
tract and to protect against the development of stomach
Interactions ulcers. Although the herb is generally safe and nontoxic,
the infusion is prepared from the pollen-filled flower
• Digoxin: Reduced absorption of digoxin heads and has resulted in mild symptoms of contact
• Methotrexate: Increased risk of immunosuppression dermatitis to severe anaphylactic reactions in individuals
• Oral hypoglycemic drugs: Increased blood glucose hypersensitive to ragweed, asters, and chrysanthemums
level (DerMarderosian, 2003). (Ford 436)
• Warfarin: Increased risk of bleeding
Balsalazide Colazal Treats active ulcerative colitis 2250 mg orally TID for 8 wk
Treats active ulcerative colitis, 800–1000 mg orally TID or QID

Mesalamine Asacol, Pentasa,
proctosigmoiditis, proctitis Suspension enema: 4 g daily
Maintenance and remission of

Olsalazine Dipentum 1 g/day orally in two divided doses
ulcerative colitis
Ulcerative colitis, rheumatoid Initial: 3–4 g/day orally in divided

Sulfasalazine Azulfidine
arthritis doses Maintenance: 2 g orally QID
Antiemetics
Anti-Nausea & Vomiting
Drug name: Drug name:
Ondansetron Metoclopramide
(brand: Zofran) (brand: Reglan)
Ondansetron
Zofran
HESI EXIT HESI

Priority side effect: Torsades de Pointes
Contraindicated
- bleeding duodenal ulcer
Key Point:
QUESTION
KEY POINT
prescription “order”
& REPORT TO HCP
IMMEDIATELY!!
NORMAL
HIGH
LOW
Agitation Hypertension KEY WORDS

Lip smacking
Puffing of cheeks
Blinking of eyes
Tachicardia Muscle Rigidity
Serotonin Syndrome
ATI Question
Ondansetron used to decrease
Nausea & Vomiting caused by
chemo Memory Trick:
HESI Question
Question: KEY POINT
During infusion, child reports
nausea and vomits, priority M - Metoclopramide
nursing action? M – Major lip smacking
& puffing cheeks
Answer:
STOP the chemo, flush the line REPORT
and administer ondansetron
Notes
Emetics

They neutralize or reduce the acidity of stomach • Do not use on patients who are fully
and duodenal contents by combining with HCl conscious
and increasing the pH of the stomach acid. They • Only use under the supervision of a licensed
may increase the sphincter tone of the lower healthcare provider
esophagus. Examples of antacids include alumi- • Do not use if turpentine, corrosives, alkalies
num (Amphojel), magaldrate (Riopan), and mag-
(lye for soap), strong acids, petroleum
nesium (Milk of Magnesia).
distillates, kerosene, cleaning fluid, paint
thinner, or furniture polish.
• Do not use if patient is comatose , has altered
mental status, or is at risk for aspiration of
stomach contents
Why are they used for? ‘’Indications’’ • Do not give if a patient is having seizures
Used to empty the stomach rapidly when • Do not give if the substance ingested can
someone has ingested poison or for drug cause altered mental status or seizures
overdose • Do not give if the agent is caustic or corrosive
such as kerosene which brings a high risk of
pulmonary aspiration.
• Do not give if the patient has a medical
condition that can be exacerbated by vomiting;
Adverse effects Bradycardia severe hypertension, hemorrhagic
diathesis.
• Dehydration • Do not give during pregnancy or lactation
• Nausea vomiting • Do not give if the patients has crohn's disease
• Tachycardia
• Electrolyte imbalance
Nursing management
• Before giving the emetic you must know:

Interactions: The chemical ingested, time ingested, and
what symptoms occur before being brought in.
• Activated charcoal: Decreases the effects of • The primary healthcare provider should also
Ipecac call the poison control center to obtain
information on proper treatment.

To cause vomiting after suspected poisoning: 15mL
ipecac syrup followed by 1-2 glasses of water. This dose
may be repeated once in 20 minutes if vomiting does not
Induction of vomiting post poison
Ipecac n/a occur. Before using ipecac syrup to treat poisoning, call a
ingestion or drug overdose poison control hotline for advice. Ipecac syrup is available
both as a nonprescription product and as an FDA-approved
prescription product.
Antiflatulents
How do they work? “Action” Caution

Work by reducing flatus in the GI tract via • Pregnancy category C
expulsion such as:
• Belching or passing gas.
• Simethicone also has a defoaming
• Agent that disperses and prevents
• The formation of gas pockets.
Interactions
• Decreases the effectiveness of other drugs
Why are they used for? ‘’Indications’’

• Post op gas distention & air swallowing
• Dyspepsia
• Peptic ulcer
Nursing management
• Irritable bowel syndrome
• Diverticulosis • Assess patient for abdominal pain, distention,
• Charcoal may be used to prevent pruritus and bowel sounds prior to and periodically
associated with kidney dialysis treatment & as throughout course of therapy. Frequency of
an antidote in poisoning belching and passage of flatus should also be
assessed.
• PO: Administered after meals and at bedtime
for best results. Shake liquid preparations well
prior to administration. Chewable tablets
Adverse Reactions should be chewed thoroughly before
No adverse reactions have been reported. swallowing, for faster and more complete
results.
• Drops can be mixed with 30 mL of cool water,
infant formula, or other liquid as directed.
Shake well before using.
Contraindications • Explain to patient the importance of diet and
exercise in the prevention of gas. Also explain
• Known hypersensitivity
that this medication does not prevent the
formation of gas.
• Advise patient to notify health care
professional if symptoms are persistent.

Intestinal gas, Diarrhea,
Charcoal Charcocaps, Flatulex 520 mg orally after meals
poisoning antidote
Gas-x , mylicon, Post op gas distention, dyspepsia, 40-125 mg QID after

Simethicone
maalox, mylanta IBS, peptic ulcer meals and at bedtime
GI Stimulants

Increases the motility of the upper GI tract without • Cholinergic blocking drugs or opioid analgesics:
increasing the production of secretions. By sensitizing Decreased effectiveness of metoclopramide
tissue to the effects of acetylcholine, the tone and • Cimetidine: Decreased absorption of cimetidine
amplitude of gastric contractions are increased, resulting • Digoxin: Decreased absorption of digoxin
in faster emptying of gastric contents into the small • Monoamine oxidase inhibitor antidepressants:
intestine. It also inhibits stimulation of the vomiting center Increased risk of hypertensive episode
in the brain. • Levodopa: Decreased metoclopramide and levodopa
Why are they used for? ‘’Indications’’

Nursing management
• GERD
• Gastric stasis (failure to move food normally out of the • When one of these drugs is given IV, monitor the rate of
stomach) in diabetic patients, in patients with nausea infusion at frequent intervals. Too rapid an infusion may
and vomiting associated with cancer chemotherapy, and induce cardiac arrhythmias.
in patients in the immediate postoperative period • Give on an empty stomach
• Monitor for symptoms of EPS and tardive dyskinesia
• Keep a record of the patient’s bowel movements,
because these drugs may cause constipation or
Adverse effects diarrhea.
• Observe the patient for signs of dehydration, which
Higher doses or prolonged administration may produce include poor skin turgor, dry mucous membranes,
central nervous system (CNS) symptoms, such as decrease in or absence of urinary output, concentrated
restlessness, drowsiness, dizziness, extrapyramidal effects urine, restlessness, irritability, increased respiratory rate,
(tremor, involuntary movements of the limbs, muscle and confusion.
rigidity), facial grimacing, and depression. • Instruct the patient to chew the tablets thoroughly
before swallowing and then drink a full glass of water or
milk.
• Magnesium-containing products may produce a laxative
Contraindications effect and may cause diarrhea; aluminum- or
calcium-containing antacids may cause constipation.
• Hypersensitivity to the drug
• Taking too much antacid may cause the stomach to
• GI obstruction, gastric perforation or hemorrhage
secrete excess stomach acid. Consult the primary
• Pheochromocytoma.
health care provider or pharmacist about appropriate
• Patients with Parkinson’s disease or a seizure disorder
dose. Do not use the maximum dose for more than 2
who are taking drugs likely to cause extrapyramidal
weeks, except under the supervision of a primary health
symptoms should not take these drugs.
care provider
Caution
• Diabetes and cardiovascular disease Critical Thinking
• Caution during pregnancy and lactation because it is
excreted in breastmilk • Tardive dyskinesia (nonreversible, involuntary muscle
spasms), which is typically associated with conventional
antipsychotics, is known to occur with long-term use (12
weeks or more) of metoclopramide. Immediately report
extrapyramidal symptoms to prevent tardive dyskinesia
from occurring.

Diabetic gastroparesis, GERD,
Metoclopramide Reglan 10–15 mg orally; 10–20 mg IM, IV
prevention of nausea and vomiting
Histamine H2 Agonist
- Acid Reducers

Reduces the secretion of gastric acid by inhibiting the • Antacids and metoclopramide: Decreased
action of histamine at H2 receptor cells of the stomach. absorption of the H2 antagonists
• Carmustine: Decreased white blood cell count
• Opioid analgesics: Increased risk of respiratory
depression
• Oral anticoagulants: Increased risk of bleeding
Why are they used for? ‘’Indications’’ • Digoxin: May decrease serum digoxin levels
• Heartburn, acid indigestion, and sour stomach

(frequently sold as over-the-counter remedies)
• GERD Nursing management
• Gastric or duodenal ulcer
• Gastric hypersecretory conditions (excessive gastric • Because of the possibility of an antacid interfering with
secretion of HCl) the activity of other oral drugs, no oral drug should be
administered within 1 to 2 hours of an antacid.
• When one of these drugs is given IV, monitor the rate of
infusion at frequent intervals. Too rapid an infusion may
induce cardiac arrhythmias.
Adverse effects • Keep a record of the patient’s bowel movements,
because these drugs may cause constipation or
• Dizziness, somnolence, headache diarrhea.
• Confusion, hallucinations, diarrhea, and reversible • Observe the patient for signs of dehydration, which
impotence include poor skin turgor, dry mucous membranes,
decrease in or absence of urinary output, concentrated
urine, restlessness, irritability, increased respiratory rate,
and confusion.
• Instruct the patient to chew the tablets thoroughly
Contraindications before swallowing and then drink a full glass of water or
milk.
• Hypersensitivity • Magnesium-containing products may produce a laxative
effect and may cause diarrhea; aluminum- or
calcium-containing antacids may cause constipation.
• Taking too much antacid may cause the stomach to
secrete excess stomach acid. Consult the primary health
Caution
care provider or pharmacist about appropriate dose. Do
• Renal or hepatic impairment not use the maximum dose for more than 2 weeks,
• In severely ill, older, or debilitated patients. except under the supervision of a primary health care
• Cimetidine is used cautiously in patients with diabetes. provider.
Histamine H2 antagonists are pregnancy category B
(cimetidine, famotidine, and ranitidine) and C (nizatidine)
drugs and should be used with caution during Hint!
pregnancy and lactation.
• Look for similarities such as uses and suffixes
• Meds that end in * Dine are H2 antagonists

800–1600 mg/day orally; 300 mg q
Gastric/duodenal ulcers, GERD, gastric
Cimetidine Tagamet 6 hr IM or IV
hypersecretory conditions, GI bleeding, heartburn
Gastric/duodenal ulcers, GERD, gastric 20–40 mg orally; IV if unable to

Famotidine Pepcid
hypersecretory conditions, GI bleeding, heartburn take orally
150–600 mg orally in one dose or divided
Gastric/duodenal ulcers, GERD, gastric
Ranitidine Zantac doses orally; 50 mg q 6–8 hr IM, IV
hypersecretory conditions, GI bleeding, heartburn (do not exceed 400 mg/day)
Lactulose &
Sodium Polystyrene Sulfonate
Lactulose Sodium Polystyene Sulfonate

Given to decrease HIGH pottasium (over 5.0)
LAC
L - Laxative for Memory Trick:
A - Ammonia levels-decrease
C - Cognition returns
“improved mental status” Kayexalate - helps K+ to Exit the body
Given to decrease ammonia levels in Cirrhosis EXIT

patients, to treat hepatic encephalopathy
(cloudy brain) K
Memory Trick:
Ammonia
Lacto - LOSE K KEY WORDS

Helps the large intestine to
remove excess K+ within
K the body
K
K
‘’Lose ammonia via Loose bowels’’ K
Key Points: Key Points:
KEY POINTS: Ammonia

KEY POINTS
2 - 3 soft stools per day
Assess the Abdomen
Ammonia levels decrease
Cognition improved
Recent bowel patterns
“Improved mental status” NCLEX TIP & frequency of stools
Bowel Function
Potassium (K+) within normal
limits (3.5-5.0 mEq/L)
NOT a Diuretic
NO NO NO
renal excretion of
ammonia
it does not decrease
portal HTN
Abdominal distention
will not improve with HESI Question
lactulose
Sodium Polystyrene
Encourage patient to
drink fluids after administration
Notes
Acid Reducers
- Proton Pump Inhibitors
How do they work? “Action” Critical Thinking

These drugs suppress gastric acid secretion by inhibition of the • Menopausal Women
hydrogen-potassium adenosine triphosphatase (ATPase) enzyme
An increase in fractures of the hip, wrist, and spine have been
system of the gastric parietal cells. The ATPase enzyme system is
seen in those taking high doses of proton pump inhibitors and
also called the acid (proton) pump system. The proton pump
undergoing treatment of osteoporosis with bisphosphonates.
inhibitors suppress gastric acid secretion by blocking the final
step in the production of gastric acid by the gastric mucosa.
Think of it as putting a cap on a volcano so it doesn't erupt!
Interactions:
• Sucralfate: Decreased absorption of the proton pump inhibitor
Why are they used for? ‘’Indications’’ • Ketoconazole and ampicillin: Decreased absorption of the
anti-infective
• Gastric and duodenal ulcers (specifically associated with H. • Oral anticoagulants: Increased risk of bleeding
pylori infections) • Digoxin: Increased absorption of digoxin
• GERD and erosive esophagitis • Benzodiazepines, phenytoin: Risk for toxic level of antiseizure
• Pathologic hypersecretory conditions drugs
• Prevention of bleeding in high-risk patients using antiplatelet • Clarithromycin (with omeprazole, specifically): Risk for an
drugs increase in plasma levels of both drugs
An important use of these drugs is combination therapy for the • Bisphosphonates: Increased risk of fracture
treatment of H. pylori infection in patients with duodenal ulcers.
One treatment regimen used to treat infection with H. pylori is
a triple-drug therapy, such as one of the proton pump inhibitors Nursing management
(e.g., omeprazole or lansoprazole) and two anti-infectives (e.g.,
amoxicillin and clarithromycin). (Ford 2006) • Because of the possibility of an antacid interfering with the
activity of other oral drugs, no oral drug should be adminis
tered within 1 to 2 hours of an antacid.
Adverse effects • When one of these drugs is given IV, monitor the rate of
infusion at frequent intervals. Too rapid an infusion may
• Headache, nausea, diarrhea, and abdominal pain. induce cardiac arrhythmias.
• Keep a record of the patient’s bowel movements, because
these drugs may cause constipation or diarrhea.
Contraindications • Observe the patient for signs of dehydration, which include
poor skin turgor, dry mucous membranes, decrease in or
• Hypersensitivity absence of urinary output, concentrated urine, restlessness,
• lansoprazole, rabeprazole, and pantoprazole (pregnancy irritability, increased respiratory rate, and confusion.
category B) are contraindicated during pregnancy and • Instruct the patient to chew the tablets thoroughly before
lactation. swallowing and then drink a full glass of water or milk.
• Magnesium-containing products may produce a laxative effect
and may cause diarrhea; aluminum- or calcium-containing
Caution antacids may cause constipation.
• Taking too much antacid may cause the stomach to secrete
• Older adults
• patients with hepatic impairment. excess stomach acid. Consult the primary health care provider
• Prolonged treatment may decrease the body’s ability to absorb or pharmacist about appropriate dose. Do not use the
vitamin B12, resulting in anemia. maximum dose for more than 2 weeks, except under the
• Omeprazole (pregnancy category C) supervision of a primary health care provider.

Erosive esophagitis, GERD, H. pylori eradication,
esomeprazole Nexium 20–40 mg/day orally
NSAID-associated gastric ulcers
Same as esomeprazole, hypersecretory
omeprazole Prilosec 20–60 mg/day orally
conditions, heartburn, reduce risk of upper GI bleeding
40 mg/day orally or IV
pantoprazole Protonix GERD, erosive esophagitis and hypersecretory conditions
Hypersecretion: 80 mg IV q 12 hr
Same as esomeprazole, hypersecretory conditions,

lansoprazole Prevacid 15–30 mg/day orally
cystic efibrosis (intestinal malabsorption)
Antidiarrheal

Difenoxin (Motofen) and diphenoxylate (Lomotil) are • Anorexia, nausea, vomiting, and constipation
chemically related to opioid drugs; therefore, they • Abdominal discomfort, pain, and distention
decrease intestinal peristalsis (Ford 436) • Dizziness, drowsiness, and headache
Loperamide (Imodium) acts directly on the muscle wall of • Sedation and euphoria
the bowel to slow motility and is not related to the
opioids. (Ford 437) Interactions
• Antihistamines, opioids, sedatives, or hypnotics:
Increased risk of central nervous system (CNS)
Why are they used for? ‘’Indications’’ depression
• Antihistamines and general antidepressants:
• Loperamide: Chronic diarrhea associated with Increased cholinergic blocking adverse reactions
irritable bowel syndrome • Monoamine oxidase inhibitor (MAOI):
• Difenoxin & diphenoxylate: Diarrhea Increased risk of hypertensive crisis
Nursing management
Contraindications
• Review the patient’s chart for the course of treatment
• Known hypersensitivity and find the reason for administration of the prescribed
• In patients whose diarrhea is associated with organisms drug
that can harm the intestinal mucosa (Escherichia coli, • Question the patient regarding the type and intensity of
Salmonella and Shigella spp.) (Ford 437) symptoms (e.g., pain, discomfort, diarrhea, or
• Pseudomembranous colitis constipation) to provide a baseline for evaluation of the
• Abdominal pain of unknown origin effectiveness of drug therapy. (Ford 439)
• Obstructive jaundice • Assess for relief of symptoms
• Antidiarrheal drugs are contraindicated in children • Monitor vitals
younger than 2 years of age. • Report abdominal distention , fever, or abdominal pain
• If diarrhea is chronic encourage increased fluid intake
such as , weak tea, water, bullion, or drinks that have
added electrolytes ( pedialyte, gatorade)
Caution • Monitor fluid intake & output
• Severe hepatic impairment

• Pregnancy category C drugs and should be used Nclex Tip
cautiously during pregnancy and lactation.
• Loperamide is a pregnancy category B drug but is If diarrhea persists for more than 2 days when
not recommended for use during pregnancy and over-the-counter (OTC) antidiarrheal drugs are being
lactation. used, the patient should discontinue use and seek
treatment from the primary health care provider.
(Ford 437)

Pepto bismol, H. pylori infection with duodenal 2 tablets or 30 mL orally every 30 min
Bismuth ulcer, nausea, vomiting diarrhea,
bismatrol to 1 hr, up to 8 doses in 24 hr
abdominal cramps
Initial dose: 2 tablets orally, then 1
Difenoxin with Relieves symptoms of acute
Motofen tablet after each loose stool (not to
atropine diarrhea exceed 8 tablets/day)
Diphenoxylate with Relieves symptoms of acute

Lomotil, lonox 5 mg orally QID
atropine diarrhea
Initial dose 4 mg orally; then 2 mg after
Imodium, kaopectate, Relieves symptoms of acute
Loperamide each loose stool (not to exceed 16
maalox diarrhea mg/day)
Tincture of opium Paregoric Severe diarrhea 0.6 mL orally QID

Antispasmodic
- Dicyclomine
Drug name: Side Effect:
Dry body: Constipation, dry mouth, urine retention

Dicyclomine
(brand: Bentyl)
Dicyclomine
Bentyl
MOA:
Relaxation of smooth muscle & dries secretions

KEY POINT
Contraindications AVOID
NOT - Paralytic Ileus
or bowel obstruction
NOT - Narrow-angle glaucoma
(cataracts are ok!)
Antispasmodic Anticholinergic NOT - Full bladder ( > 400 mL)
“urinary retention”
Indication:
IBS (Irritable bowel syndrome) > 400 ML
with many loose stools per day

20
MEMORY TRICK
NO pee NO see NO spit & NO sh*t

Not for full bladder Not glaucoma Bowel obstruction & Paralytic ileus
> 400 ML
Notes
Anti-inflammatory
SULFasalazine
MOA:
INDICATION Kaplan
Decreases colon inflammation by
stopping prostaglandins Continue medication
Inflammatory bowel (which cause inflammation) even after symptoms
disease (IBD)
subside
Crohn disease
Ulcerative Colitis NO
DO OP
T
ST
Side Effects:
HESI
NORMAL Contraindicated in
patient with SULFA
• Yellow-orange discoloration allergy.
of the client’s skin and urine
• No need for follow-up! TAKING

DO NOT stop taking med MED SULFASALAZINE
Major Adverse Effects:
S U L F
Sun Dried! Urine Crystals Low Urine Output Fluid & Folic Acid
(sunblock & dry body!) (Kidney Stones) (SG HIGH = Dry)
FOLIC ACID
Photosensitivity Dehydration
• DRINK 8 glasses of water daily
• Wear sunblock • Elevated urine Specific Gravity
• TAKE Folic acid - 1mg/day
• Avoid “direct” sun exposure • High & DRY!!! (norm: 1.003-1.030)
Notes
Laxatives

There are many forms of laxatives,but the main goal is to relieve • Known hypersensitivity
constipation. • Persistent abdominal pain
• Nausea or vomiting of unknown cause
• Signs of acute appendicitis
Why are they used for? ‘’Indications’’ Caution

• Stimulant, emollient, and saline laxatives—evacuate the colon Magnesium: Used cautiously in any degree of renal impairment
for rectal and bowel examinations
• Stool softeners or mineral oil—prevention of strain during
defecation (after anorectal surgery or a myocardial infarction)
• Psyllium and polycarbophil—irritable bowel syndrome and
diverticular disease Nursing management
• Hyperosmotic (lactulose) agents—reduction of blood ammonia
levels in hepatic encephalopathy • Avoid long-term use of these products unless use of the
product has been recommended by the primary health care
provider. Long-term use may result in the “laxative habit,”
which is dependence on a laxative to have a normal bowel
movement. Constipation may also occur with overuse of these
drugs. Laxatives are not to be used for weight loss. Read and
Adverse Reactions follow the directions on the label.
• Do not use these products in the presence of abdominal
• Constipation
pain, nausea, or vomiting.
• Diarrhea and a loss of water and electrolytes
• Notify the primary health care provider if constipation is not
• Abdominal pain or discomfort, nausea, vomiting, perianal
relieved or if rectal bleeding or other symptoms occur.
irritation, fainting, bloating, flatulence, cramps, and weakness.
• To avoid constipation, drink plenty of fluids, get exercise, and
• Prolonged use of a laxative can result in serious electrolyte
eat foods high in bulk or roughage. Cascara sagrada or
imbalances, as well as the “laxative habit”, that is, dependence
senna—Pink-red, red-violet, red-brown, yellow-brown, or black
on a laxative to have a bowel movement.
discoloration of urine may occur. (Ford 440)
• Some of these products contain tartrazine (a yellow food dye),
which may cause allergic-type reactions (including bronchial
asthma) in susceptible individuals. Obstruction of the
esophagus, stomach, small intestine, and colon has occurred
when bulk-forming laxatives are administered without Types
adequate fluid intake or in patients with intestinal stenosis.
• Bulk-producing laxatives are not digested by the body and
therefore add bulk and water to the contents of the intestines.
The added bulk in the intestines stimulates peristalsis, moves
the products of digestion through the intestine, and
encourages evacuation of the stool. Sometimes these laxatives
Interactions are used with severe diarrhea to add bulk to the watery bowel
contents and slow transit through the bowel.
• Mineral oil may impair the GI absorption of fat-soluble Psyllium “Metamucil”
vitamins (A, D, E, and K). • Emollient laxatives lubricate the intestinal walls and soften the
• Laxatives may reduce absorption of other drugs present in the stool, thereby enhancing passage of fecal material. Mineral oil
GI tract by combining with them chemically or hastening their • Stool softeners promote water retention in the fecal mass and
passage through the intestinal tract. soften the stool. One difference between emollient laxatives
• When surfactants are administered with mineral oil, they may and stool softeners is that the emollient laxatives do not
increase mineral oil absorption. promote the retention of water in the stool. Docusate
• Milk, antacids, histamine H2 antagonists, and proton pump • Hyperosmolar drugs dehydrate local tissues, which causes
inhibitors should not be administered 1 to 2 hours before irritation and increased peristalsis, with consequent
bisacodyl tablets because the enteric coating may dissolve evacuation of the fecal mass. Glycerine or lactulose
early (before reaching the intestinal tract), resulting in gastric • Irritant or stimulant laxatives increase peristalsis by direct
lining irritation or dyspepsia and decreasing the laxative effect action on the intestine. Cascara sagrada
of the drug. • Saline laxatives attract or pull water into the intestine, thereby
increasing pressure in the intestine, followed by an increase in
peristalsis. Magnesium preparations
Pancrelipase
Enzymes
Indication: MOA:
Given to replace digestive enzymes • Enzymes help break down food

in patients with cystic fibrosis • end in ‘’-ase’’
ENZYMES
Helps break
down food
Lipase —> Fat
Protease —> Protein
Amylase —> Carb
KEY POINTS Kaplan Question

MUST be eaten Pancrelipase Admin:
WITH every Meal & Snack Open capule &
or med is not effective sprinkle contents on
NOT before food without chewing
NOT After
HESI Question
KEY TERM
Pancrelipase Admin:
Reduction in fatty
stools is an expected
outcome
Notes
Vitamins &
Electrolytes
Drug name:
Iron Indication: Kaplan &
KEY POINTS
HESI Question
Treat anemia r/t Dark or black stools =
Indication:
Ferrous Sulfate (oral)Iron Dextran (IV / IM)
iron deficiency Normal & Expected Calcium given with ferrous sulfate
BLOCKED Absorption
NOT GI BLEED
Orange juice/ fruit juice = enhance
FERROUS
Empty stomach absorption
IRON
SULFATE DEXTRAN 1 HOUR BEFORE Ferrous Sulfate
medications Teaching is Effective when the Client
states: “I will eat more fresh fruits and
whole grain bread”
B12 (Cyanocobalamin) Key Point: Folic Acid While taking Pregnant patients HESI
Sulfa drugs
(Sulfasalazine) Prevents of neural
Indication: Pernicious anemia Patients who lack tube defects
Body lacks intrinsic factors Folic acid
Folic acid: Anemia
so can’t absorb building supplement Take before
(low blood cell count), - 1 mg/day pregnancy
blocks to make RBCs
Sulfa drugs decrease
(iron, folic acid, B12)
folic acid absorption
SULFA
DRUGS
Pottasium K+ Indication: Memory Trick:

K+ Wasting K+ Sparing
Diuretics Drugs
Hypokalemia
(low K+ below 3.5) S - Spironolactone
“-ide”
POTASSIUM S - “-Sartans” LoSartan
K
Furosemide
PUMPS muscles
P - “-Prils” LisinoPril
Hydrochlorothiazide
3.5
Supplement
Key Point: Potassium Pumps the Heart

Potassium IV (Normal 3...5-5.0)
K
KEY POINTS
1. First Action = Heart monitor
SLOW infusion rate 3 2. Never push = DEATH
if infusion irritates client
reports of burning/ discomfort
3. ONLY 10-20 mEq/hr! (IV Pump)
most commonly
chosen distractor 48% 4. Slow infusion (if arm burns)
Magnesium Indication: Key Terms: HESI Question ATI Question
Sulfate Magnesium sulfate …

Possible findings in a newborn? Mg
When to STOP the infusion?
Preterm labor = wild contractions CAUTION ○ Flaccid muscle tone
○ Respiratory rate below 12 ○ Respiratory depression
Anticonvulsant Respiratory Depression
MAGNESIUM SULFATE ○ Decreased DTRs
Cardiac = Torsades de Pointes Paralysis & weak muscles
MELLOWS the muscles NCLEX TIP
= Low DTRs
Kaplan Question
STOP What is the indication for

Mag Sulfate? MAGNESIUM
SULFATE
○ Replace for low magnesium Mg
(below 1.5)
DTR ○ Treatment for Torsades de 1.5
Pointes NCLEX TIP

Herbal Supplements
Bleed Risk:
E G G PRIORITY
Vitamin E Ginger Garlic
All Supplements LOSARTAN

Vitamin E
KEY POINTS
Assess for interactions with clients
G G O other meds
PRIORITY! Drug to drug
Ginkgo Ginseng Omega 3
Biloba interactions 2 - 3 weeks
STOP 2 - 3 weeks before surgery
<80 JOINT Prostate

Glucosamine Saw
Palmetto
Saw Palmetto: TREATs BPH
WATCH for hypoglycemia
when taking anti-diabetic meds
SP – Saw Palmetto
Benign Prostate SP – Swollen Prostate
Hypertrophy
Menopause – “HOT FLASHES”

ATI Question
Black
Cohosh Black Cohosh
Glucosamine
Bad CoHOT flash
Glucosamine
= Treats arthritic pain
Mental -
S S S Depression & Insomnia
V - Valerian
V - Valium effects
H H
! S - St. John Wort affects
Heart S - Serotonin - CAUTION
- Serotonin syndrome!
Hawthorn
H - Heart Serotonin S - Stay away from
H - Hawthorn extract
Extract
Antidepressants !!
KEY PRIORITY
DO NOT MIX!!!
1. Antidepressants SSRI’s,
E E Skin MAOIs, TCAs
2. Serotonin Syndrome
E - Eczema/ Mild signs
Shivering/ Diarheas
Evening
Primrose Oil skin irritations
Severe signs
E - Evening Muscle rigidity/ Fever
Primerose Seizures
Death
Notes
Acid Prevention
Antacid, H2 Blockers & PPI
Antacid: MOA:
IT DOESN’T
S Sodium Bicarbonate (brand: Alka-selzer) Immediately neutralizes stomach acid, LAST LONG
but ONLY temporary (NOT long lasting)
C Calcium Carbonate (brand: Tums, Rolaids)
A Aluminum Hydroxide
HESI Question KEY POINTS & MEMORY TRICK
M Magnesium Hydroxide (brand: Milk of Mag)
Magnesium hydroxide
Anti –Acids
Side Effects: Can upset stomach +
Anti –MIXING with other MEDs
Liquid bowel movements
Aluminum & Calcium Magnesium ‘’mellow’’
Constipation = Diarrhea 1 hour BEFORE or AFTER
OTHER MEDs !
Al Gi
MILK OF
NOT for heart failure!
Mg
MAGNESIA
· Nothing OTC “over the counter”
Ca · Sodium = Swells
H2 Blockers: Indication: MOA:
GERD & Ulcers Reduces gastric secretions by

“-tidine”
(duodenal & gastric) prevention BLOCKING H20 receptors in H2
Ranitidine
(brand: Zantac)
the stomach
Famotidine Patient Education:
(brand: Pepcid)
KEY POINTS & MEMORY TRICK
• No over eating
• No stress/smoking 30 MIN BEFORE MEALS
• No NSAIDS + Asa - GI bleeds
RANITIDINE
NSAIDS
ASA
PPI: MOA:
P
P
Inhibits proton pump in the parietal cells of the P
Proton Pump Inhibitor

P
stomach to reduce gastric acid

P
“-prazole”
Omeprazole
Key Terms: KEY POINTS & MEMORY TRICK
(brand: Prilosec)
Esomeprazole
(brand: Nexium)
Pantoprazole
P P P P
Stress ulcer
prophylaxis
(brand: Protonix)
Prevents holes Porous Bones Possible GI infections
Prazole
“Stress ulcer prophylaxis” “regular bone density tests” “C-Diff”
in hospitalized
/surgical
Indication: patients
Stress ulcer prevention,

GERD, heart-burn
Mucosal Protectant

SUCRALFATE
Sucralfate SUCRALFATE
Misoprostol
(brand: Carafate)
Indication:
Indication: Protect against gastric ulcers
Given to treat and prevent both MOA:

stomach and duodenal ulcers
(small intestines) Synthetic prostaglandin that
increases protective mucous
inside the stomach
MOA:
Major Adverse Effect:
Forms thick protective layer over
ulcers to provide aphysical barrier
against stomach acids & enzymes Misoprostol
Miscarriage RISK!!!
KEY Point Due to cervical ripening
AVOID
FOOD & MEDS at least
1-2 hours before or after
taking med
DO NOT TAKE WITH

ANY OTHER MEDS!
Patient Education:
HESI Key Term

MEMORY TRICK Cervical ripening
MUST
SucralfATE Reliable birth control
2 hours Before YOU
Do not take with
ATE!!! antacids
Taken LATE (Anti-Acids = Anti ANTIACIDS
Mixing meds)
Notes
Immune
Antineoplastics ‘’Cell Cycle Nonspecific’’
- Alkylating Agents
What do they do? Herbal Consideration

Alkylating agents make the cell a more alkaline environment, which in The shiitake mushroom, an edible variety of mushroom, is associated
turn damages the cell. Malignant cells appear to be more susceptible to with general health maintenance but not with any severe adverse
the effects of alkylating drugs than normal cells. reactions. Mild side effects, such as skin rashes and GI upset, have been
reported. Lentinan, a derivative of the shiitake mushroom, is proving to
be valuable in boosting the body’s immune system and may prolong the
survival time of patients with cancer by supporting immunity. In Japan,
lentinan is commonly used to treat cancer. Additional possible benefits
of this herb include lowering cholesterol levels by increasing the rate at
Indications which cholesterol is excreted from the body. Under no circumstances
should shiitake or lentinan be used for cancer or any serious illness
without consulting a primary health care provider (DerMarderosian,
• Treatment of cancer 2003).
Nursing management
Adverse Reactions • Wear personal protective equipment when preparing any of these
drugs for parenteral administration.
• Bone marrow suppression (anemia, leukopenia, thrombocytopenia )
• Administer any prophylactic medications or fluids in a timely manner to
• Stomatitis
prevent reactions.
• Diarrhea
• and hair loss. • Observe the patient closely before, during, and after the administration
• The most common reactions are leukopenia and thrombocytopenia of an antineoplastic drug.
• Observe the IV site closely to detect any signs of extravasation
(leakage into the surrounding tissues). Tissue necrosis can be a
serious complication. Discontinue the infusion and notify the oncology
health care provider if discomfort, redness along the pathway of the
Nursing Alert vein, or infiltration occurs.
• Continually update nursing assessments, nursing diagnoses, and
Radiation recall is a skin reaction in which an area that was previously nursing care plans to meet the changing needs of the patient.
irradiated becomes reddened when a patient is administered certain • Notify the oncology health care provider of all changes in the patient’s
specific chemotherapy drugs. This is well differentiated from a reaction general condition, the appearance of adverse reactions, and changes in
exclusive to the drugs, because of the defined outline of the previous laboratory test results.
radiation treatment field on the body. • Provide the patient and family with both physical and emotional
support during treatment.
• Institute neutropenic precautions to prevent infections.
• Immediately report a temp higher than 100.4 or higher, cough, sore
throat, chills, frequent urination, or a white blood cell count of less than
Contraindications 2500/mm3.
• Immediately before administering the first dose of an antineoplastic
Antineoplastic drugs are contraindicated in patients with
drug, take the patient’s vital signs and obtain a current weight
leukopenia, thrombocytopenia, anemia, serious infections, serious renal
disease, or known hypersensitivity to the drug, and during pregnancy • Get a baseline CBC before first dose
• Monitor ongoing blood results
• You may need to hydrate the patient before administration of cisplatin.
• You may need to administer antiemetics prior to administration.
• Educate the patient on side effects including weight loss and alopecia.
Interactions: • Provide support and comfort.
• Teach the patient to report to you or to the health care provider
• Phenytoin: Increased risk of seizures immediately any of the following: bleeding gums, easy bruising,
• Aminoglycosides: Increased risk of nephrotoxicity and ototoxicity petechiae (pinpoint hemorrhages), increased menstrual bleeding, tarry
• Loop diuretics: Increased risk of ototoxicity stools, bloody urine, or coffee-ground emesis.
Generic Side Effects Route

Leukemia/lymphomas: ALL, AML, CLL, advanced
Immediate: nausea, vomiting lymphomas, Hodgkin’s disease
During therapy cycles: leukopenia, Solid tumors: breast, ovary, neuroblastoma,
Cyclophosphamide retinoblastoma
hemorrhagic cystitis, thrombocytopenia Nonmalignant: mycosis fungoides, nephrotic
Long term: fertility problems, secondary cancers syndrome (children), rheumatoid arthritis,
systemic lupus erythematosus, multiple sclerosis
During therapy cycles: anemia, leukopenia,

Leukemia/lymphomas: chronic lymphocytic
Chlorambucil thrombocytopenia
leukemia (CLL), lymphomas, Hodgkin’s disease
Long term: fertility problems
Immunologic Agents
- IG & Antivenin
What do they do? Contraindications
Immune globulins are solutions obtained The immune globulins are contraindicated in
from human or animal blood containing patients with a history of allergic reactions after
antibodies that have been formed by the administration of human immunoglobulin
body to specific antigens. Because they preparations and in individuals with isolated
contain ready-made antibodies, they are immunoglobulin A (IgA) deficiency (individuals
given for passive immunity against disease. could have an anaphylactic reaction to
Antivenins are used for passive, transient subsequent administration of blood products
protection from the toxic effects of bites by that contain IgA).
spiders (black widow and similar spiders) Human immune globulin intravenous (IGIV)
and snakes (rattlesnakes, copperhead and products have been associated with renal
cottonmouth, and coral). The most effective impairment, acute renal failure, osmotic nephro-
response is obtained when the drug is sis, and death. Individuals with a predisposition
administered within 4 hours after exposure. to acute renal failure (e.g., those with
pre-existing renal disease), those with diabetes
mellitus, individuals older than 65 years of age,
Interactions or patients receiving nephrotoxic drugs should
Antibodies in the immune globulin not be given human IGIV products.
preparations may interfere with the immune
response to live virus vaccines, particularly
measles, but including others such as
mumps and rubella. It is recommended that
the live virus vaccines be administered 14 to
30 days before or 6 to 12 weeks after
administration of immune globulins.
No known interactions have been reported
with antivenins.
Notes
Immunosuppressants
NCLEX Questions
Indication: Bad News: NCLEX TIPS
Given to help the body STOP attacking Bone marrow suppression =

itself - like in clients with autoimmune dieases 1. Low WBC = Infection Risk
2. Low Plt = Bleed Risk Infections Bleeding
A patient is prescribed What should the nurse include in

methotrexate for treatment of an teaching for a patient newly
autoimmune disorder. Which prescribed hydroxychloroquine for
patient report requires immediate the treatment of systemic lupus
assessment and intervention by the erythematosus? Select all that apply.
nurse? 1. Ensure to see your optometrist
A. “I will consult with my at least every 2 years.
provider before discontinuing 2. Report any new visual changes
birth control.” to your provider.
B. “I noticed that I have 3. This medication is likely to
developed tiny reddish-purple increase feelings of fatigue
lesions all over my arms.” associated with lupus.
C. “I have not had a normal 4. Notify your provider if no
bowel movement in two days.” improvement in symptoms is
D. “I seem to be losing an noticed within one week of
excessive amount of hair since beginning this medication.
starting this medication.”
The nurse is instructing a patient with a Which lab results should the nurse review
severe allergy to wasp stings on the prior to administration of etanercept to a
proper use of the epinephrine patient with psoriatic arthritis? Select all
auto-injector. Which patient statement that apply
best demonstrates that teaching has been Negative Tuberculosis skin test
1.Tuberculin skin test (TB skin

effective?
test)
1. “I will keep my epi-pen stored
90o
2. aPTT (partial thromboplastin

EPIPEN
in my refrigerator at all times.”

time)
2. “I will inject the medication
3. White blood cell count
1st into my outer thigh at the first
4. Total cholesterol panel
sign of an allergic reaction.”
5. Red blood cell count
EPIPEN
EPINEPHRINE
3. “I will seek follow-up treatment

Epipherine
within 24 hours of injecting the
medication.”
4.“I will hold the epi-pen firmly in
place for at least 5 seconds to
ensure full delivery of the
medication.”
Notes
Immunosuppressants

OQUINE
YCHLOR
HYDROX
Hydroxychloroquine Cyclosporine / Azathioprine CYCLOSPORINE
Treat autoimmune diseases where Prevent organ transplant
the body is attacking itself rejection
Lupus
MEMORY TRICK
MOA:
Cyclo-Sporine CycloSPARIN
Sparing the organ
INcreased energy levels CYCLOSPORINE from rejection
NOT decreased
KEY POINT ADVERSE EFFECT

KEY POINT KEY POINT
BEFORE giving
Major Adverse Effects: - Check WBC + Plts Common Side Effect
REPORT leukopenia Cyclosporine
Retinal damage & vision problems
Low WBC < 4000 Gingival hyperplasia
Teach: Regular eye appt. Monitor for bleeding
Every 6 -12 months No pregnant patients -
Use Contraception
6 - 12 months
MEMORY TRICK
ATI HESI
Hyyy-dddroxy Chloroquine Teaching - Cyclosporine &
Notify provider for
“Eyyye Damage Clorine” Azathioprine
any sign of infection
Avoid crowds
No live vaccines
1
(Herpes Zoster + Shingles)
CHLORINE
Soft bristled toothbrush
Use contraception
KAPLAN
HESI Question Patient statement that requires CYCLOSPORINE
further teaching
Teaching is effective when the “I will mix cyclosporine with
grapefruit juice”
client states
Cyclosporine teaching: Organ
transplant
“I need to see my optometrist Take med for life
at least once a year” HCP will eval blood work
regularly
Take med at same time everyday
Notes
Immunologic Agents
- Vaccines & Toxoids
What do they do? Contraindications

The weakened or killed antigens contained in the vaccine • Immunologic agents are contraindicated inpatients with
do not have sufficient strength to cause disease. Although known hypersensitivity to the agent or any component
it is a rare occurrence, vaccination with any vaccine may of it. Allergy to eggs is a concern with some vaccines.
not result in a protective antibody response in all • The measles, mumps, rubella, and varicella vaccines are
individuals given the vaccine. contraindicated in patients who have had an allergic
A toxin that is attenuated (or weakened) but still capable reaction to gelatin, neomycin, or a previous dose of one
of stimulating the formation of of the vaccines
antitoxins is called a toxoid. • Vaccines and toxoids are contraindicated during acute
febrile illnesses, leukemia, lymphoma,
immunosuppressive illness or drug therapy, and non
localized cancer. Always ask about allergy history before
preparing a vaccine for administration.
Indications
Interactions
• Routine immunization of infants and children
Vaccinations containing live organisms are not •dminis-
• Immunization of adults against tetanus
tered within 3 months of immune globulin administration,
• Immunization of adults at high risk for certain diseases
because antibodies in the globulin preparation may
(e.g.,pneumococcal and influenza vaccines)
interfere with the immune response to the vaccination.
• Immunization of children or adults at risk for exposure
Corticosteroids, antineoplastic drugs, and radiation
to a particular disease (e.g., hepatitis A for those going
therapy depress the immune system to such a degree
to endemic areas)
that insufficient numbers of antibodies are produced to
• Immunization of prepubertal girls or nonpregnant
prevent the disease. When the salicylates are
women of childbearing age against rubella Routine
administered with the varicella vaccination, there is an
immunization of infants and children
increased risk of Reye’s syndrome developing.
• Immunization of adults against tetanus
• Immunization of adults at high risk for certain diseases
(e.g.,pneumococcal and influenza vaccines)
• Immunization of children or adults at risk for exposure
to a particular disease (e.g., hepatitis A for those going
to endemic areas)
• Immunization of prepubertal girls or nonpregnant Nursing management
women of childbearing age against rubella
• Most vaccine preparations require refrigeration. Always
have a backup plan for storage of the vaccine should the
health care facility lose power. Temperature fluctuations
can harm the vaccines.
• Monitor the patient before allowing them to leave after
administering any vaccine.
• State agencies, drug companies, and immunization
organizations all provide standardized forms for parents
or caregivers that document immunization history. In
Adverse Reactions addition to your facility documentation, provide or
record on the document presented by the parent or
• Chills, fever caregiver the following information:
• muscular aches and pains • Date of vaccination
• Rash • Route and site, vaccine type, manufacturer
• lethargy • Lot number and expiration date
• Name, address, and title of individual administering
vaccine
Tumor Necrosis Factor Inhibitors
Etanercept, Infliximab, Adalimumab
Drug name:
ETANERCEPT Flu
Vaccine
Etanercept Negative Tuberculosis skin test
Infliximab Infliximab
PATIENT EDUCATION
Adalimumab ▪ Tuberculosis (TB) Reactivation
Adalimumab ▪ Neg. TB skin test needed to start therapy
▪ Vaccines:
▪ Yearly flu vaccine
MEMORY TRICK ▪ NO Live vaccines
(herpes zoster or shingles)
INTERCEPT
▪ Contraindication:
ETANERCEPT
ADALIMUMAD Cannot take med: Chronic,
INFLIXIMAD reoccurring, or recent infections!
- Etanercept - Intercepts immune response

- causing immune suppression AVOID Chronic
- MAB ending think MAD immune suppression Reoccurring
adalimumab & infliximab Recent
KEY POINT
LABs
▪ REPORT ! Elevated WBCs
Priority to Report to HCP! ▪ Elevated CRP
▪ Elevated WBC = NOT “the most important” lab
▪ Fever (over 100.3 F, 38 C)
NCLEX TIP
(CRP is the most commonly chosen wrong answer

nearly 50% of the time) Elevated CRP is expected
with these patients, since there is inflammation
all over the body
Important!
CRP
> 100.3o F/ 38oC most commonly CRP

chosen wrong answer
Notes
Epinephrine
Epi auto-injectors ‘’Epi-Pen’’
Indication: KAPLAN
Anaphylaxis (severe allergic reaction) Patient scenario:
Administration of ampicillin & client
reports itchiness and difficulty
breathing.
EPIPEN
Priority actions:
EPINEPHRINE
1. Stop infusion
2. Auscultate lungs
WHO
SYS
mmHg
DIA
3. Prepare to administer epinephrine

mmHg
MOA:
1st
- Vasopressor that presses the vital signs up! Effective management of shock
BP 130/67
- Increased BP, RR, HR Apical HR 99
Cap refill less than 2 seconds 99
KEY POINT
Epi is the 1st drug
HESI Normal EXPECTED
to use for anaphylaxis. Side Effects HR > 100
First signs of
ATI Tachycardia (HR over 100)
Palpitations
anaphylaxis (hives, dyspnea,
Dizziness
hypotension) give Epi Pen
Repeat every 5 -15 minutes if
s/s continue NCLEX TIP
Repeat Epi until signs & How to use Epi-Pen
symptoms resolve! NCLEX TIP KEY POINTS
1. Inject into outer THIGH at 90

degree angle at onset of s/s
HESI “Stab pen into outer thigh”
1st 2ⁿd 3rd Hold in place for 10 seconds

2. Seek immediate medical
attention after use!
Go to the hospital!
Albuterol
3. Store epi pens in dark place at
EPIPEN
room temperature
Steroids (not too cold/ not too hot)
EPINEPHRINE
Diphenhydramine
Albuterol
Epinephrine Diphenhydramine
Steroids 90o
EPIPEN
EPIPEN
EPINEPHRINE
Notes
Immunosuppressants
Methotrexate
Drug name: MEMORY TRICK
Meth NOOO trexate

Methotrexate
Methotrexate
NO NO NO
Indication:
Kaplan
Mainly for Rheumatoid Arthritis

(Autoimmune disease) body is
attacking it’s own joints
• NO pregnant clients
MOA:
• NO crowds or LIVE vaccines
Stops folic acid metabolism, which Folic Acid
• NO razors or brushing teeth hard
stops cell reproduction
KEY POINT AVOID
Adverse Effects:
Infection & Bleeding
Infection Risk
• Low immunity = Infections ▪ Report Fever (over 100.3º F, 38ºC)
AVOID
▪ Avoid crowds & sick people
• Low Platelets = serious bleeding ▪ Avoid fresh fruit & flowers
Thrombocytopenia (platelets under 100,000)
• Fetal death in pregnancy ▪ Report bleeding:
▪ Petechiae (bleeding under skin)
< 100,000
▪ Purpura (purple spots on skin)
▪ Melena (black tarry stool)
▪ Hematemesis (vomiting blood)
▪ Bleeding Gums Thrombocytopenia
HESI Question KEY POINT

NO Pregnancy - NOT BABY SAFE
Methotrexate: MUST use Birth Control
Suppresses B and T lymphocytes
▪ “No pregnancy until one menstrual
cycle after treatment is resolved”
▪ “No pregnancy until 3 months after

treatment is finished” January
▪ “Men … no trying for a baby until 3

months after treatment with
Methotrexate
B lymphocyte T lymphocyte methotrexate is complete”
Notes
Maternity
&
pediatrics
Contraception
Drug names: Drug names:
2 types
Estrogen & Progesterone ESTROGEN
PROGESTERONE
Copper
Intrauterine Device
MIRENA
Levonorgestrel
Major Adverse Effects

That’s why it’s not given to
▪ Increased risk for
patients with:
blood clots!
MI DVT PE CVA stroke
KEY POINTS
Copper Intrauterine Device
Mild discomfort upon insertion
(spotting/ cramping)
Heavier bleeding and increased
KEY POINTS Memory Trick cramping during menses
Patient teaching:
DO NOT smoke! HESI Both IUDs TEACH:
E - Estrogen & Progesterone
REPORT: 1. Check strings MONTHLY after
Severe leg pain, E - Emboli
swelling, vision loss menses to ensure IUD still in place
(Could be DVT/ CVA)
2. Longer, shorter, missing string =
REPORT to the HCP
HESI Question KAPLAN Question 1
HCP
Estrogen & Smoking = Priority finding:
increases risk for blood clots Client taking estrogen with report ?
Estrogen = contraindication of left leg pain behind the knee
for a patient with Thrombophlebitis = possible DVT
Don’t let
NCLEX TRICK YOU

ATI Question QUESTION BANK IUDs are NOT
Do not take with
affected by
MedroxyprogEsterone acetate
carbamazepine... lubricants
makes oral Instruct client that ovulation may Missed periods randomly - NOT normal
contraceptives
not occur for a few months after
using this med.
- COULD MEAN PREGNANCY!
NOT affected
ineffective by weight gain
or loss
Notes
Uterine Drugs
- Oxytocics
How do they work? “Action” Indications

Uterine stimulants increase the strength, duration, and frequen- • Prevent postpartum and postabortal hemorrhage caused by
cy of uterine contractions and decrease the incidence of uterine uterine atony
bleeding. They are given after the delivery of the placenta and • Induce an early vaginal delivery when there are fetal or
are used to prevent postpartum and postabortal hemorrhage maternal problems, such as a woman with diabetes and a large
caused by uterine atony (marked relaxation of the uterine fetus, Rh problems, premature rupture of the membranes,
muscle). These drugs include carboprost, methylergonovine, and uterine inertia, and preeclampsia
misoprostol. (Ford 506) • Managing inevitable or incomplete abortion
Oxytocin is an endogenous hormone produced by the posterior
pituitary gland. This hormone has uterus-stimulating properties,
acting on the smooth muscle of the uterus, especially on the
pregnant uterus.
Nursing management
Adverse Reactions When oxytocin is administered with vasopressors,
however, severe maternal hypertension may occur.
Administration of oxytocin may result in the following: • Obtain an obstetric history (e.g., parity, gravidity, previous
• Fetal bradycardia, uterine rupture, uterine hypertonicity obstetric problems, type of labor, stillbirths, abortions,
• Nausea, vomiting, cardiac arrhythmias, anaphylactic reactions live-birth infant abnormalities) and a general health history.
• Oxytocin is similar to the hormone vasopressin and because of • Keep a record of the activity of the uterus (strength, duration,
its antidiuretic effect, serious water intoxication (fluid and frequency of contractions, if any).
overload, fluid volume excess) may occur. • All patients receiving IV oxytocin must be under constant
Adverse reactions associated with other uterine stimulants observation to identify complications. In addition, the health
include the following: care provider attending the delivery should be immediately
• Nausea, vomiting, diarrhea available at all times.
• Elevated blood pressure, temporary chest pain When monitoring uterine contractions, immediately stop the
• Dizziness, water intoxication, headache oxytocin infusion and notify the health care provider attend-
• Allergic reactions may also occur. In some instances ing the delivery immediately if any of the following occurs:
hypertension associated with seizure or headache may occur. • A significant change in the FHR or rhythm
(Ford 506) • A marked change in the frequency, rate, or rhythm of uterine
contractions; uterine contractions lasting more than 60
seconds; or contractions occurring more frequently than every
Contraindications 2 to 3 minutes, or no palpable relaxation of the uterus
• A marked increase or decrease in the patient’s blood pressure
Oxytocin or pulse or any significant change in the patient’s general
• Cephalopelvic disproportion condition (vital signs are typically obtained every 15 to 30
• Unfavorable fetal position or presentation. minutes in active labor)
• Also contraindicated in obstetric emergencies, situations of Other uterine stimulants
fetal distress when delivery is not imminent • When the patient is to receive any of these drugs after
• Severe preeclampsia, eclampsia, and hypertonic uterus, delivery, it is important to take the blood pressure, pulse, and
• During pregnancy when there is total placenta previa. respiratory rate before administration. (Ford 507)
• It is contraindicated as an agent to induce labor when vaginal • Methylergonovine is administered for uterine atony and
delivery is contraindicated hemorrhage, abdominal cramping can occur and is usually an
Other uterine stimulants indication of drug effectiveness. The uterus is palpated in the
• Methylergonovine is not used before delivery of the placenta. lower abdomen as small, firm, and round. However, report
• It is contraindicated in those with known hypersensitivity to persistent or severe cramping to the primary health care
the drug or hypertension. (Ford 506) provider. (Ford 508)
Generic Trade Dose Use

Control of postpartum bleeding 0.2 mg IM, IV after delivery of the placenta;
Methylergonovine Methergine
and hemorrhage, uterine atony 0.2 mg orally TID, QID
Postpartum hemorrhage,
Misoprostol Cytotec 100-mcg tablet vaginally administered
cervical ripening
Antepartum: to initiate or Induction of labor: individualize dose not to

improve uterine contractions exceed 10 units/min
Oxytocin Pitocin Postpartum: control of Postpartum bleeding: IV infusion of 10–40 units
postpartum bleeding and in 1000-mL IV solution or 10 units IM after
hemorrhage placenta delivery
Labor Drugs
Terbutaline Terbutaline
Oxytocin
Induces labor & stimulates

Delays labor momentarily by
contractions
suppressing contractions
Nursing Care:
Memory Trick
TurbutaLINE HESI Question

Wait in LINE for the baby &
Terbutaline slows down Oxytocin
Turbulent contractions Used to stimulate
uterine contractions
Administered 6 - 12
hours after last dose
MOA: of dinoprostone
Activated beta 2 receptors to activate

the sympathetic nervous system,
which suppresses labor
HESI Question 00:60
Beta 2 Discontinue if contractions last longer than

60 seconds Oxytocin
Maintain one on one care

Piggyback the oxytocin into the main IV fluids
HESI Question KAPLAN Question 02:00
Stop oxytocin infusion for contractions

Terbutaline 48h sustained over 2minutes
Priority action for 3 consecutive late Oxytocin
decelerations = Turn off Oxytocin

May be used for
48 hours to suppress
preterm labor
ATI Question
Turn the client to the side if late decelerations
are noted.
Notes
Uterine Drugs
Tocolytics
How do they work? “Action” Critical Thinking

These drugs are used to manage premature Incase of emergency, when administering magnesium
labor.Indomethacin is an NSAIDS that inhibits the sulfate have calcium gluconate and reflex hammer ready
production of prostaglandins which contribute to uterine in case of overdose.
contractions.. Beta (β)-2-adrenergic and calcium channel
blockers are used to delay the delivery process for 24 to 48
hours. These drugs block the contractions of the smooth
muscle of the uterus. Magnesium is used drugs to
decrease uterine muscle contractions, and is used for
seizure control with eclampsia. Magnesium is a calcium
antagonist that works to decrease the force of uterine Nursing management
contractions.
During the ongoing assessment of a patient receiving a
tocolytic drug, nursing activities include the following at
15- to 30-minute intervals:
Indications • Obtaining blood pressure, pulse, and respiratory rate
• Monitoring FHR
• Used to stop or decrease uterine contractions in preterm • Checking the IV infusion rate
labor • Examining the area around the IV needle insertion site
for signs of infiltration
• Monitoring uterine contractions (frequency, intensity,
length)
Adverse Reactions • Measuring maternal intake and output
• Maternal reflexes (if using magnesium) (Ford 509)
• Fatigue, flushing, headache, dizziness, diplopia
• Nausea, vomiting, stomach upset, heartburn
• Prolonged vaginal bleeding
• Sweating, hypotension, depressed reflexes, and flaccid
paralysis are other adverse reactions associated with IV
administration. They are related to hypocalcemia
induced by the therapy. Interactions
• Increase CNS depressant effects of opioid analgesics
when given with magnesium
Contraindications
Magnesium and calcium channel blockers are
contraindicated in patients with known hypersensitivity to
these drugs, in patients with heart block or myocardial
damage, and when the woman is within 2 hours of deliv-
ery. (Ford 509)
Generic Trade Dose Use

Preterm labor before 100 mg rectally, then 50 mg orally q 6
Indomethacin Indocin
31 weeks’ gestation hr for a total of 8 doses
Preterm labor, 4–6 g IV over 2 min, then

Magnesium n/a
seizure control infuse 1–4 g/hr
Subcut: 250 mcg hourly until contractions stop

Terbutaline Brethine Preterm labor
Orally: 2.5 mg q 4–6 hr until delivery (Ford 511)
Prenatal
Folic Acid & Betamethasone
Vitamin name: Drug name:
Celestone
Soluspan
Folic Acid FOLIC Betamethasone

ACID Celestone
Soluspan
Helps lung development

with preterm babies
MOA:
Increases surfactant production

which helps lungs to expand
Given to prevent spina bifida:

Prevention of neural
tube defects
Begin taking before
pregnancy
ATI Question
Evaluation of effectiveness
Normal respiratory
pattern in newborn
FOLIC FOLIC
ACID ACID
Notes
Mental health
Antidepressants
- 4 Rules
1. Increased risk of suicide 2. Slow Onset & SLOW taper off

Antidepressants can increase NEVER STOP abruptly
suicidal thoughts in first few
weeks of Treatment SSRI
NOTIFY provider of any suicidal 3. NEVER Mix

thoughts! SSRI + St John’s Wart or
St John’s Wart
CLARIFY any new prescription MAOI + Antidepressant MAOI
MONITOR for: (TCA, SSRI, SNRI) Antidepressant
- New thoughts of suicide

- Unusual behavior Decrease BP
- Worsening depression 4. ALL psych drugs

NORMAL
HIGH
LOW
Decrease BP (slow position
changes)
Cause weight changes 40.0
0
SSRI SNRI TCA MAOI

TOP 3 MISSED Questions:
Which medication have the Which combination of drugs Most potential for injury?
most potential risk should the nurse question? Select all that apply
for injury ? Select all that apply
Select all that apply SSRI
Looking for sedating meds Sertraline 1. Amitriptyline to treat fibromyalgia pain
Escitalopram
Citalopram 2. Headache while on Phenelzine
1. Amitriptyline MAOI 3. Taking St Johns wart with Sertraline
2. Diphenhydramine Phenelzine 4. Discontinuing escitalopram the day
3. Colace Selegiline before taking Isocarboxazid.
4. Alprazolam 5. Peanut butter and jelly sandwhich
1. Sertraline with Selegiline
5. Buspirone while on Selegiline
2. Alprazolam with citalopram
3. Buspirone with Phenelzine 6. Reporting sore throat, fatigue and low
4. Lithium with Ketorolac grade fever while on clozapine
5. St John’s Wort with

Buspirone
Notes
Atypical
Antidepressant
Z
Trazodone Z
Z
Bupropion SR, XL
Brand: Wellbutrin
KEY WORD
Avoid ETOH
& other sedatives
Indication:
Depression & aid to stop smoking

Indication:
Depression & Sleep aid
Side Effects & Memory Trick:
Side Effects:
Sleepy and sedated
Insomnia, HA, weight loss
TraZZZadone TRANCEadone
Z
Z Z
Patient Teaching:
• Avoid ETOH & other sedatives
(benzos, antihistamines)
Antihistamines
KEY POINT
XL, SR pill
• Take at night NEVER crush, chew, cut
• Orthostatic hypotension =
Teach: Slow position changes
NORMAL
• Never ‘’double up’’ on missed

HIGH
LOW
dose
• Rare: Priapism (erection)
Teach: Erection that lasts for hours - • Do not crush XR - extended
go to hospital! release or SR - Sustained release
Notes
Antidepressants
- MAOI
Drug names:
NARDIL
PHENELZINE KEY Words
PHENELZINE Brand: Nardil
SELEGILINE Pt States: “This med is not
ISOCARBOXAZID
SELEGILINE
working after 2 weeks”
TRANYLCYPROMINE ASSESS 1st
ISOCARBOXAZID
Further expressions of:

1. Hopelessness
Indication:
2. Despair
3. Suicidal thoughts
Very powerful antidepressants:
4. Thoughts of self-harm
Depression, Panic disorder & Social
phobia. Used for depression that is
ANTIDEPRESSANTS
resistant to other meds

MOA:
Increase availability of norepinephrine,

serotonin, and dopamine in brain
NOREPINEPHRINE SEROTONIN DOPAMINE
M A O O I
Massive A VOID O
TC drugs O
ther I
ncreased
HTN crisis Risk TYRAMINE = HTN CRISIS!!! Antidepressants Suicide risk
SSRIs MAOIs TCAs
NORMAL NH₂
HIGH
LOW
HO
Tyramine
NCLEX Key terms: 1. Wine & Cheese C – Calcium Serotonin Syndrome NCLEX Key terms:
Headache (NO wine tasting) A – Anti acids 2 week wash-out When starting med.
Increased Agitation 2. Beer & Sausage, Salami A – Acetaminophen KEY DRUGS: Increasing Dose
(NO beer fest) N – NSAIDS NO! Escitalopram (SSRI)
3. Chocolate (Naproxen, Ibuprofen) NO! Imipramine (TCA)
Notes
Antidepressants
SNRI vs. TCA
DULOXETINE IMIPRAMINE
AMITRIPTYLINE
SLOW position changes
Indication:
IMIPRAMINE AMITRIPTYLINE
1. Depression Indication:
1. Depression, Anxiety
2. Pain: Neuro pathic pain
= Diabetics & Fibromyalgia
2. Neuro pathic pain =
Diabetics & Fibromyaliga
Memory Trick:
Side Effects:
DUAL-OXETINE
Dry body (can’t see, pee, spit or shh - poop)
- DOUBLE PURPOSE
- DEPRESSION & PAIN
Patient Education:
NCLEX TIP
‘’If a fibromyalgia patient is prescribed this &
they’re not depressed they need education
on the purpose that it is to help with their
pain ‘’ KEY POINT
Orthostatic Hypotension
- Slow position changes esp
Duloxetine
MEMORY TRICK
Amitriptyline – Amy trips on

things !! – SLOW position
changes
KEY POINT Urinary Retention MAOI Anti
depressant
MEMORY TRICK
Imipramine - Inhibit my PEEING

NEVER take with MAOI
Helps with chronic pain & 2 week wash-out period
improves sleep in patients NO MAOI + Antidepressants
with fibromyalgia (TCA, SSRI, SNRI)
Notes
Antidepressants
- SSRI
Drug names: Indication: ANXIETY
DEPRESSION PTSD
Depression, Anxiety, PTSD

SERTRALINE
CITALOPRAM MOA:
ESCITALOPRAM Inhibits the REuptake of Serotonin
PAROXETINE keeping MORE around. So Serotonin
FLUOXETINE levels are INCREASED
E
SELECTIVE
LIN
SEROTONIN
TRA
SER
CIT
ALO
PRA
M
REUPTAKE
FLUOXETINE
PAROXETINE
ESCITALOPRAM
INHIBITORS SEROTONIN
Side Effects:
1. Sexual dysfunction 2. Weight Gain 3. Insomnia, NOT sleepiness

or sedation, don’t get tricked
Serotonin Syndrome
SUICIDE Risk SLOW Onset & SWEATY & HOT RIGID muscles INCREASED
INCREASED Slow Taper off! + FEVER + Restlessness Heart Rate
& Agitation “Tachycardia”
2-4
weeks
Notes
ADHD Meds
Drug names: Indication:
Methylphenidate
Given to treat:
Methylphenidate
Ritalin
(brand: Ritalin)
ADHD in children & adolescents
Amphetamine mixture AMPHETAMINE
MIXTURE
ADRENAL
& even narcolepsy
(brand: Adrenal)
Dextroamphetamine
Stimulants DEXTROAMPHETAMINE
KEY POINT
F- A
Loss of Appetite & Weight

Loss of Sleep
Restlessness
Give last dose NO LATER than
6 PM
Improvements in school work
PRIORITY nursing assessments
6 p.m
Monitor BP
MONITOR and report height,
weight trends with HCP
PRIORITY nursing asssessment
Reversal Agent: Alprazolam
MOA:
Norepinephrine
Enhance effects of dopamine

and norepinephrine in brain
Dopamine
Notes
Antipsychotics
Drug name: Normal Side Effects:

No need to report to HCP Key Signs Priority Action
1 generation Typical
- EPS ‘’extrapyramidal symptoms’’
st
High
High Fever
Fever &&Diaphoresis
Diaphoresis 1. HOLD Haloperidol
Dystonia (spasm of neck, face &
HALOPERIDOL
HALOPERIDOL Change inMental

Change in Mental Status
Status 2. Assess patient
tongue) Muscle Rigidity
Muscle Rigidity 3. NOTIFY HCP
Tremors
Tremors immediately!!!
Indication:
HALOPERIDOL
1. Schizophrenia
2. Tourettes - to control Key point
motor movement
NEUROLEPTIC MALIGNANT
SYNDROME
LIFE threatening!
Drug name: Normal Side Effects: Memory Trick

Priority Action
No need to report:
CloZAPine
1
2nd generation A-typical Weight gain, drooling & sedation Immediately report
CLOZAPINE CLOZAPINE
RISPERIDONE
Zaps WBCS!! to HCP!!
RISPERIDONE
Z
Z
Z
Key Points
Indication: HESI question:
Killer Side Effects: Sore Throat
Schizophrenia & Schizoaffective Fever
who are NOT responding to Report To Provider Flu like symptoms Which med order for
dementia patient
other antipsychotics Leukopenia - Low WBC Requires intervention by
High Risk for Infection the NURSE?
Major Adverse Effects
Risperidone
Drug name: Indication:

KEY POINT
Bipolar mania, acute psychosis MEMORY TRICK
Hypotension
& agitation Monitor for Widened QT intervals
Ziprasidone hydrochloride
(brand: Geodon) ZiprasiDONE
T NORMAL
HIGH
LOW
NORMAL
Q
HIGH
LOW
Ziprasidone Bipolar Mania Acute Psychosis

hydrochloride
Geodon
T Done prolonged your QT
Q interval & dropped the BP
T
Q
Agitation
Notes
Anxiolytics
Class: Indication:
MEMORY TRICK
KEY POINT:
Benzodiazepines Anxiety, seizures
Take at bedtime NCLEX TIP
Drug names: MOA:
Don’t skip doses NCLEX TIP
Increases GABA Stop drinking alcohol (wine)
Do not operate dangerous
“-lam” Neuron activity
machines
AlprazoLAM MEMORY TRICK
MEMORY TRICK
MidazoLAM Antidote Benzos: Flumazenil

Antidote Opioids: Naloxone
FAST LANE FAST LANE
“-pam” BENZ
Side Effects: (brand: Narcan)
TemazePAM
FAST FAST FAST FAST FAST
HIGHLY
Addictive DANGEROUS
ClonazePAM Low & slow vitals

& brain
Class: GOOD NEWS HESI Question

Lasts LONGER
Barbiturates
in the body Is a scenario of a patient,
Drug name: on phenobarbital with
low blood pressure &
PHENOBARBITAL PHENOBARBITAL
increased sedation!
Phenobarbital
BAD NEWS
Memory Trick:
Take LONGER
to get out of the body BARBITAL
PHENOBARBITAL
Sedation like at a bar &
Higher risk for Toxicity lasts a long time,
leading to hypotension, like stuck behind bars
Respiratory depression
Drug name: Memory Trick:
BAD NEWS
Buspirone Takes a LONG TIME 2 Common Test questions for Anxiolytics:
PIRONE to kick in
Patient teaching for Diazepam? Client on phenobarbital, which of the
Select All That Apply follow should the nurse do? SATA
KEY POINT 1. Avoid valerian root

Patient Teaching: 2. Avoid Ginkgo and Ginseng
3. Avoid muscle relaxants
- OK to drive 4. Report history of reaction to

midazolam
- ‘’drive the BUSpirone’’ 5. Naloxone is the antidote for
- NOT used for acute attacks this med.

6. Decrease alcohol consumption
Notes
Bipolar Meds
Carbamazepine vs. Valproic Acid
Carbamazepine Valproic Acid

Carbamazepine
Indication: Side Effects & Memory Trick:
• Bipolar & Seizures

VALLLLLLLL
• Trigeminal neuralgia
(neuropathic pain) Think of L’s for vaLLproic Acid
Side Effects:
• L - Liver toxic
Jaundice & Liver labs (ALT & AST)
• Leukopenia - LOW WBC
• Increased risk for BIG infection

ALT AST
KEY WORD
Report fever / sore throat!! • L - Low Platelets
AKA - Thrombocytopenia
Accidental Pregnancy!! BIG bleed risk
Oral contraceptives ineffective
Will need alternative birth
control methods
Thrombocytopenia
Not Pregnancy Safe!

Teach client not to discontinue abruptly
Carbamazepine
Notes
Bipolar Meds
- Lithium
Drug name:
L LEVELS OVER 1.5 MEQ/L
= TOXIC!
1.5mEq/L
Common Test Question:
Lithium Is it lithium at Therapeutic level?

Yes - continue at CURRENT dose
Indication:
I INCREASE FLUID &
SODIUM (NA+)
KEY POINT Contraindicated

Na+
Dehydration!
Treatment: Low sodium “Hyponatremia”
below 135 mEq/L
Bipolar Do NOT limit sodium
Schizoaffective disorder or water intake
HIGH RISK Toxicity
Stomach Flu (diarrhea & vomiting)
Given for long term treatment
T TOXIC SIGNS
Lithium Battery ‘’B’’ Bipolar
Since Lithium lasts a Long time REPORT to HCP!
MEMORY TRICK Report excessive urination
and extreme thirst!!
Vomiting & diarrhea
Neuro Muscular excitability
- Lithium + (tremors / myoclonic jerks)
KEY POINT
H HOLD NSAIDS
Urine Output < 30ml/hr
Toxicity Over 1.5

1.5mEq/L
(Ibuprofen, Naproxen)
Key Kidney signs:

KEY POINT
Creatinine Creatinine > 1.3
OVER 1.3 = BAD kidney! NSAIDS (ibuprofen)

decrease renal blood flow NAPROXEN
Urine: 30 ml / hr or LESS increasing r/t toxicity

= kidneys DISTRESS! AVOID!! NEED
S/S = Tinnitus (ringing of FURTHER TEACHING!
the ears)
Notes
Withdrawal Meds
Methadone Disulfiram
(opioid withdrawal) (brand: Antabuse)
Caution:
Indication: alcohol based products
with ARTS & CRAFTS
Opioid withdrawal
Methadone
Indication:
Key Points:
Alcohol withdrawal
LONG half life Expected Effects:

Early signs of Toxicity:
Including patient teaching to be caution
N & V and lethargy
with working with rubbing alcohol, or
Frequent emesis
alcohol based products with ARTS &
Monitor: CRAFTS could cause a reaction
Prolonged QT interval (ECG)
O2 Sat less than 90%
(95-100% in healthy adults)
Client falls asleep easily
Rubbing
Alcohol
<90 %
O 2
Z
Z
Z
95-100%
in healthy adults
Notes
Musculoskeletal
Uric Acid
Allopurinol & Colchicine
Indication: Patient Teaching:
Given for Gout - uric acid build • Increase fluids & take with full
glass of water
up causes inflammation in the
joints • AVOID clients with Kidney & Liver Disease
• Evaluation of effectiveness?
= Normal uric acid levels
BIG KEY DIFFERENCE
AlloPurinol - Prevents gout
Colchicine - for aCute gout attacks
NOT given to reduce pain, but to

reduce uric acid HESI Question ALLOPURINOL
Allopurinol - Do not take for acute

gout attacks
Colchicine - for acute attack, DOES
KEY POINT COLCHICINE
ACute Gout Attacks
NOT provide pain relief

Naproxen (NSAID) - used for PAIN
Uric Acid Pain Uric Acid Inflammation relief with gout. NSAIDS
KEY POINTS: KAPLAN Question

Allopurinol
“I can use ibuprofen for pain … Gout”
IBUPROFEN
NCLEX TIP
MEMORY TRICK
Rash ALL Over HESI Question
ALLopurinol = Deadly
Needs FURTHER teaching it

Lim
when taking Allopurinol NE
VER
“I will limit my fluid intake

ALLOPURINOL
with this medication”
Notes
Bones
Calcium Carbonate CALCIUM

End in ‘’-dronate’’
alendronate
CARBONATE
ALENDRONATE
SODIUM
risedronate
Indication:
Osteoporosis & bone health to Indication:

help make bones stronger
Osteoporosis
KEY POINTS MOA:
▪ TAKE IN DIVIDED DOSES- Inhibits bone reabsorption by

> 500 mg
Less than 500 mg reducing osteoclast activity, OSTEOCLAST
which breaks down the bone

CALCIU ATE
M
CARBON
▪ Doses OVER 500 mg

at one time are NOT absorbed
KEY POINT
NO need for frequent blood
tests or routine labs
Monitor bone density
Take on Empty Stomach

COMMON SIDE EFFECT
Esophagitis = Sit up
30 minutes NCLEX TIP
NORMAL
HESI Question
Treats Osteoporosis 8OZ

• Constipation which is normal & to be expected.
• Just add fluids & ambulation
Drink full 8 oz with
MEMORY TRICK medication
Since calcium makes bones

hard, just think Calcium
Ca makes bowels hard too!
KAPLAN Question
• High CAL = Hard Bowel
Teach patient to sit upright
Ca • Low CAL = Loose Bowel for at least 30 minutes
Notes
Skeletal Muscle Drugs
- Dmards
How do they work? “Action” Interactions

When the immobility and pain of RA can no longer be • Sulfa antibiotics: Increased risk of methotrexate
controlled by pain relief agents and anti-inflammato- toxicity
ry drugs, DMARDs are used. These drugs have prop-
erties to produce immunosuppression, which in turn
decreases the body’s immune response. Therefore, Nursing management
in RA treatment, DMARDs are useful for their
immunosuppressive ability. • Because DMARDs are designed to produce
immunosuppression, patients need to be
monitored routinely for infections. Instruct patients
to report any problem, no matter how minor, such
as a cold or open sore—even these can become
Indications
life-threatening.
• Rheumatoid arthritis • Explain carefully that treatment for the disorder
• Crohn's disease includes drug therapy, as well as other medical
• Fibromyalgia management, such as diet, exercise, limitations or
specifications of activity, and periodic physical
therapy treatments.
• Teach the importance of asking the primary health
care provider before taking any nonprescription
Adverse Reactions drugs or supplements.
• Some drugs used for RA require self-administered
• Nausea
subcutaneous injections. Teach the patient and
• Stomatitis
family proper injection and disposal techniques.
• Alopecia (hair loss)
• Teach about site rotation, and have the patient
• The adverse reactions to sulfa-based drugs, such as
demonstrate proper injection technique before this
sulfasalazine, include ocular changes,
becomes a self-administered procedure.
gastrointestinal (GI) upset, and mild pancytopenia.
• Patients need to be taught how to manage the
discomfort to the site of injection and to report
redness, pain, and swelling to the primary health
care provider.
Contraindications • When using drugs to treat RA:
• When taking methotrexate, use a calendar or some
Patients with renal insufficiency, liver disease, alcohol other memory device to remember to take the drug
abuse, pancytopenia, or folate deficiency should not on the same day each week.
take methotrexate. Etanercept (Enbrel), adalimumab • Notify the primary health care provider immediately
(Humira), and infliximab (Remicade) should not be if any of the following occur: sore mouth or sores in
used in patients with congestive heart failure or the mouth, diarrhea, fever, sore throat, easy
neurological demyelinating diseases. Anakinra bruising, rash, itching, or nausea and vomiting.
(Kineret) should not be used in combination with • Women of childbearing age should use an effective
etanercept, adalimumab, or infliximab. contraceptive during therapy with methotrexate
and for 8 weeks after therapy.

RA; other autoimmune
Adalimumab Humira 40 mg subq every other week
disorders (e.g., Crohn’s disease)
25 mg subcut twice weekly, or 50 mg

Etanercept Enbrel RA
subcut weekly
Hydroxychloroquine Plaquenil RA, antimalarial 400–600 mg/day orally

- Skeletal Muscle Relaxants

Many of these drugs do not directly relax • Central nervous system (CNS) depressants,
skeletal muscles, but their ability to relieve such as alcohol, antihistamines, opiates,
acute painful musculoskeletal conditions may and sedatives: Increased CNS depressant
be due to their sedative action. effect
Cyclobenzaprine appears to have an effect on Cyclobenzaprine
muscle tone, thereby reducing muscle spasm • MAOIs: Risk for high fever and convulsions
Orphenadrine
• Haloperidol: Increased psychosis
Tizanidine:
Indications Antihypertensives:
• 11.3445 pt Increased risk of
hypotension
• Skeletal muscle relaxants are used in various
acute painful musculoskeletal conditions, such
as muscle strains and back pain.
Adverse Reactions
• Drowsiness
• Sedation
• sleepiness, lethargy, constipation
• Diarrhea
• bradycardia or tachycardia, and rash. Nursing management
• This drug may cause drowsiness. Do not drive
or perform other hazardous tasks if
drowsiness occurs.
Contraindications • This drug is for short-term use. Do not use the
drug for longer than 2 to 3 weeks.
• Baclofen is contraindicated in skeletal muscle
• Avoid alcohol or other CNS depressants while
spasms caused by rheumatic disorders.
taking this drug.
• Carisoprodol is contraindicated in patients
with a known hypersensitivity to
meprobamate.
• Cyclobenzaprine is contraindicated in patients
with a recent myocardial infarction, cardiac
conduction disorders, and hyperthyroidism.
• Cyclobenzaprine is contraindicated within 14
days of the administration of a monoamine
oxidase inhibitor (MAOI).
• Oral dantrolene is contraindicated during
lactation and in patients with active hepatic
disease and muscle spasm caused by
rheumatic disorders.
Muscle Relaxers
Top 3 Missed Questions

3 BIG TEST TIPS
Which teaching should the nurse What teaching should the nurse When providing education to a
provide for a patient who is include for a patient newly prescribed patient who is newly prescribed
1. Dizziness upon prescribed calcium carbonate for a
new diagnosis of osteoporosis?
allopurinol for the treatment of gout?
cyclobenzaprine, which
instructions should be included?
changing positions Select all that apply.

1. Report the development of any
is expected
1. Always take calcium new rash to your provider 1. Notify the provider of a
carbonate in divided doses less immediately. temperature greater than 99.5 F
than 500 mg per dose. 2. Take your allopurinol at the first 2. Report any drowsiness to the
2. NO alcohol 2. Take calcium carbonate 2

hours before or after meals.
sign of an acute attack.
3. You may continue to treat pain
health care provider.
3. Do not stop taking this
3. Stop taking calcium carbonate associated with acute attacks medicationa abruptly.
3. DO NOT Abruptly Stop if constipation develops

4. Schedule weekly blood draws
with ibuprofen.
4. Report any symptoms of nausea
4. Limit wine consumption to
3-4 glasses per day while taking
to monitor serum calcium levels. to your provider immediately. this medication.
5. Continue taking Vitamin D 5. Allopurinol helps prevent the 5. Avoid taking ibuprofen while
supplements while taking build up of uric acid which leads taking this medication.
calcium carbonate. to acute attacks.
Drug name: Indication: SIDE EFFECT KAPLAN

Dantrolene
Dantrolene • Spinal Cord injury
Muscle relaxant
• Cerebral Palsy
DANTROLENE
• Multiple Sclerosis HESI
LIVER TOXIC SEDATION
“DROWSINESS”
Dantrolene
MOA: Contraindicated in client with MS
MEMORY TRICK and Cirrhosis
Acts directly on the muscle to
prevent the release of calcium Calcium Contracts muscles
Less calcium = Less Contraction
Drug name: Indication: Side Effects

HESI Question
CycloBENzaprine Reduces muscle spasms after
Carisoprodol
& Carisoprodol CYCLOBENZAPRINE
CARISOPRODOL
surgery on open fractures Risk of dependence

Drowsiness & sedation
MEMORY TRICK Pt teaching

CycloBENZaprine CycloBACKzzaprine
ATI Question
Taper off medication -
CYCLOBENZAPRINE
DO NOT stop abruptly!
Drug name: MOA: HESI Question

KEY POINTS
Enhances GABA to make Gaba Side effects of Baclofen:
• Baclofen BACLOF
EN BACLOFEN
everything low & slow

Dizziness upon changing
positions Ortho-hypotension,
Dizziness, Nausea
NOT a contraindication
Side Effects: to giving this med Potential Deadly Effects:
Indication: Rhabdomyolysis
NEVER Abruptly Stop
(any muscle relaxant) Multiple organ failure
Decrease in flexor and extensor - Constipation
spasticity with spinal cord - Low BP & orthostatic
injury, MS & cerebral palsy hypotension Memory Trick
Baclofen
Back off slowly (do
not abruptly stop)
- Uric Acid Inhibitors
Allopurinol (Zyloprim) reduces the production Allopurinol and febuxostat

of uric acid, thereby decreasing serum uric acid • Ampicillin: Increased risk of rash
levels and the deposit of urate crystals in joints. • Theophylline: Increased risk of theophylline
This probably accounts for its ability to relieve toxicity
the severe pain of acute gout. Febuxostat • Aluminum-based antacids:
(Uloric), a newer drug, is used to reduce serum • Decreased effectiveness of allopurinol
uric acid levels, preventing gout attacks. Probenecid
• Penicillins, cephalosporins, acyclovir,
rifampin, and the sulfonamides: Increased
Indications
serum level of anti-infective
Drugs indicated for treatment of gout may be • Barbiturates and benzodiazepines:
used to manage acute attacks of gout or in Increased serum level of sedative
preventing acute attacks of gout (prophylaxis). • NSAIDs: Increased serum level of NSAID
• Salicylates: Decreased effectiveness of
probenecid
Adverse Reactions
• Headache
• Urinary frequency
• One adverse reaction associated with Nursing management
allopurinol is skin rash, which in some cases • Drink at least 10 glasses of water a day until the
has been followed by serious hypersensitivity acute attack has subsided.
reactions, such as exfoliative dermatitis and • Take this drug with food to minimize GI upset.
Stevens-Johnson syndrome. Colchicine admin • If drowsiness occurs, avoid driving or
istration may result in severe nausea, vomiting, performing other hazardous tasks.
and bone marrow depression; therefore, it is • Acute gout—notify the primary health care
used as a second line of treatment when other provider if pain is not relieved in a few days.
drugs fail. • Notify the primary health care provider if a skin
rash occurs.
Contraindications • When using drugs for muscle spasm and
cramping:
• Colchicine is contraindicated in patients with • This drug may cause drowsiness. Do not drive
serious GI, renal, hepatic, or cardiac disorders or perform other hazardous tasks if
and those with blood dyscrasias drowsiness occurs.
• Probenecid is contraindicated in patients with • This drug is for short-term use. Do not use the
blood dyscrasias or uric acid kidney stones, drug for longer than 2 to 3 weeks.
and in children younger than 2 years. If • Avoid alcohol or other CNS depressants while
patients are taking azathioprine (Imuran), taking this drug.
mercaptopurine, or theophylline they should
not be prescribed febuxostat.
Allopurinol Zyloprim Management of symptoms of gout 100–800 mg/day orally
Prophylaxis:
0.5–0.6 mg/day orally
Relief of acute attacks of gout, Acute attack: initial dose 0.5–1.2 mg orally or 2
Colchicine NA
prevention of gout attack mg IV, then 0.5–1.2 mg orally q 1–2 hr or 0.5
mg IV q 6 hr until attack is aborted or adverse
effects occur
- Bisphosphonates

Bisphosphonates act primarily on the bone by inhibiting • When bisphosphonates are administered, serum calcium
normal and abnormal bone resorption. This results in levels are monitored before, during, and after therapy.
increased bone mineral density, reversing the progression • When to treat. Diagnosis for osteoporosis treatment is
of osteoporosis. made by your T-score (from the bone mineral density
scan). You may not be a candidate for treatment if you
have gastroesophageal problems, kidney disease, or
severe vitamin D deficiency. Some preparations are
Indications taken daily and others as infrequently as monthly.
Research shows good results when taken for 5 to 10
• Osteoporosis in postmenopausal women and men
years—so correct administration is important.
(caused by glucocorticoid use)
• Supplements. These drugs work by using the building
• Hypercalcemia (increased serum calcium) of malignant blocks of bone formation. You need an intake of 1500
diseases and bony metastasis of some solid tumors mg of calcium and 400 to 800 units of vitamin D daily.
• Paget’s disease of the bone The drug you take may or may not have this supplement
in the preparation. Check with your primary health care
provider and follow the vitamin supplement
Adverse Reactions recommended.
• Specific drug administration routine. These drugs are
• Increased or recurrent bone pain absorbed slowly from the stomach and can cause severe
• Headache irritation of the esophagus. You must take the pill with 6
• Dyspepsia (GI discomfort), acid regurgitation, dysphagia to 8 ounces of plain water and cannot eat or drink for 30
• Abdominal pain minutes after taking the drug, and you must be in
an upright position during that time. Here are
suggestions to make taking this drug easier and build it
into your weekly routine:
Contraindications • Use a calendar or cell phone alert to remember your
monthly dose.
• Alendronate (Fosamax) and risedronate (Actonel) are
• Put the medication out the night before in a place you
contraindicated in patients with hypocalcemia. will see it when you first get up out of bed.
Alendronate is a pregnancy category C drug and is • Take your medication and then do a distracting activity,
contraindicated during pregnancy. such as taking your morning shower or sitting in a chair
• Delayed esophageal emptying or renal impairment. and watching the morning news on television, listening
Concurrent use of these drugs with hormone replace to music on the radio, or looking at or answering email.
ment therapy is not recommended. • Make this morning’s breakfast special with foods you
especially like to eat; use breakfast as a reward for
having taken your medication correctly!
Interactions • Make a habit of calling your primary health care provider
at least every 6 months (if taking monthly) to talk about
• Calcium supplements or antacids with magnesium and whether you are or are not having any GI changes
aluminum: Decreased effectiveness of bisphosphonates (belching, pressure, heartburn)—it could be from the
• Aspirin: Increased risk of GI bleeding medication.
• Theophylline: Increased risk of theophylline toxicity

Treatment and prevention of
postmenopausal osteoporosis, 5–10 mg orally, in daily or (70-mg) weekly
Alendronate Fosamax
glucocorticoid-induced osteoporosis, doses
osteoporosis in men, Paget’s disease
Hypercalcemia of malignancy, Paget’s 60–90 mg in a single IV dose infused over

Pamidronate Aredia
disease 2–24 hr
Nervous System
CNS
CNS Stimulants
- Amphetamines

Amphetamines are sympathomimetic “adrenergic”. • Anesthetics: Increased risk of cardiac arrhythmias
Which means that they mimicking a response from • Theophylline: Increased risk of hyperactive
the sympathetic nervous system, causing the CNS to behaviors
speed up, resulting in : • Oral contraceptives: Decreased effectiveness of
• Elevated blood pressure oral contraceptive when taken with modafinil
• Wakefulness
• Increased or decreased pulse rate
Nursing management
• An increased risk of suicidal ideation in children and
Indications adolescents has been found when using the drug
atomoxetine (Strattera). Patients with ADHD started on
• ADHD atomoxetine should be monitored carefully for suicidal
• Drug-induced respiratory depression thoughts or behaviors.
• Post Anesthesia respiratory depression, without • Stimulants enhance dopamine transmission to areas of
reduction of analgesia the brain that interpret well-being. To maintain pleasur
• Narcolepsy able feelings, people continue the use of stimulants,
• Obstructive sleep apnea which leads to their abuse and the potential for
• Exogenous obesity addiction.
• Fatigue (caffeine) • Older adults are especially sensitive to the effects of the
CNS stimulants and may exhibit excessive anxiety,
nervousness, insomnia, and mental confusion.
Adverse Reactions Cardiovascular disorders, common in the older adult,
may be worsened by the CNS stimulants. Careful
• Excessive CNS stimulation, headache, dizziness monitoring is important because these reactions may
• Apprehension, disorientation, hyperactivity result in the need to discontinue use of the drug.
• Nausea, vomiting, cough, dyspnea • ADHD: Give the drug in the morning 30 to 45 minutes
• Urinary retention, tachycardia, palpitations before breakfast and before lunch. Do not give the drug
in the late afternoon.
• Narcolepsy: Keep a record of the number of times per
day that periods of sleepiness occur, and bring this
Contraindications record to each visit to the primary health care provider
or clinic.
• Known hypersensitivity • Amphetamines and anorexiants: These drugs are
• Convulsive disorders taken early in the day to avoid insomnia. Do not increase
• Ventilation disorders ( COPD) the dose or take the drug more frequently, except on the
• Cardiac problems advice of the primary health care provider.
• Hypertension • Caffeine (oral, nonprescription): Over-the-counter
• Hyperthyroidism caffeine preparations should be avoided if the individual
• Glaucoma has a history of heart disease, high blood pressure, or
• Pregnancy stomach ulcers.

Narcolepsy: 5–60 mg/day orally in divided
Narcolepsy, ADHD,
Amphetamine N/A doses ADHD: 5 mg BID, increase by 10
exogenous obesity N
mg/wk until desired effect.
2.5 mg orally BID; maximum dosage, 20
Dexmethylphenidate Focalin ADHD
mg/day
ADHD: up to 25 mg/day orally

Methamphetamine Desoxyn ADHD, exogenous obesity
Obesity: 5 mg orally 30 min before meals
CNS Stimulants
- Analeptics
How do they work? “Action” Facts

Drugs that stimulate the respiratory center of the Stimulants enhance dopamine transmission to areas
brain and cardiovascular system, used with of the brain that interpret well-being. To maintain
narcolepsy and as an adjuvant treatment for pleasurable feelings, people continue the use of
obstructive sleep apnea stimulants, which leads to their abuse and the poten-
tial for addiction. (Ford 190)
Indications
Nursing management
• Narcolepsy • An increased risk of suicidal ideation in children and
• Obstructive sleep apnea adolescents has been found when using the drug
atomoxetine (Strattera). Patients with ADHD started on
atomoxetine should be monitored carefully for suicidal
Adverse Reactions thoughts or behaviors.
• Stimulants enhance dopamine transmission to areas of
• Excessive CNS stimulation, headache, dizziness the brain that interpret well-being. To maintain
• Apprehension, disorientation, hyperactivity pleasurable feelings, people continue the use of
• Nausea, vomiting, cough, dyspnea stimulants, which leads to their abuse and the potential
• Urinary retention, tachycardia, palpitations for addiction.
• Older adults are especially sensitive to the effects of the
CNS stimulants and may exhibit excessive anxiety,
nervousness, insomnia, and mental confusion.
Contraindications Cardiovascular disorders, common in the older adult,
• Known hypersensitivity may be worsened by the CNS stimulants. Careful
• Convulsive disorders monitoring is important because these reactions may
result in the need to discontinue use of the drug.
• Ventilation disorders ( COPD)
• ADHD: Give the drug in the morning 30 to 45 minutes
• Cardiac problems before breakfast and before lunch. Do not give the drug
• Hypertension in the late afternoon.
• Hyperthyroidism • Narcolepsy: Keep a record of the number of times per
• Glaucoma day that periods of sleepiness occur, and bring this
• Pregnancy record to each visit to the primary health care provider
or clinic.
• Amphetamines and anorexiants: These drugs are
Interactions taken early in the day to avoid insomnia. Do not increase
the dose or take the drug more frequently, except on the
• Anesthetics: Increased risk of cardiac arrhythmias advice of the primary health care provider.
• Theophylline: Increased risk of hyperactive • Caffeine (oral, nonprescription): Over-the-counter
behaviors caffeine preparations should be avoided if the individual
• Oral contraceptives: Decreased effectiveness of has a history of heart disease, high blood pressure,
oral contraceptive when taken with modafinil or stomach ulcers.

Narcolepsy, obstructive sleep apnea, 150–250 mg/day orally in a
Armodafinil Nuvigil
sleepiness due to shift work single morning dose
Respiratory depression: postanesthesia,
Doxapram Dopram drug-induced, acute respiratory 0.5–1 mg/kg IV
insufficiency superimposed on COPD
Modafinil Provigil Narcolepsy, obstructive sleep apnea 200–400 mg/day orally

CNS Stimulants
- Anorexiants

Anorexiants are drugs pharmacologically similar to the amphet- • Known hypersensitivity
amines. Their ability to suppress the appetite is thought to be • Convulsive disorders
due to their action on the appetite center in the hypothalamus. • Ventilation disorders ( COPD)
(Ford 190) • Cardiac problems
• Hypertension
• Hyperthyroidism
• Glaucoma
Indications • Pregnancy
Treatment of obesity via appetite suppression
Interactions
Adverse Reactions
• Anesthetics: Increased risk of cardiac arrhythmias
• Excessive CNS stimulation, headache, dizziness • Theophylline: Increased risk of hyperactive behaviors
• Apprehension, disorientation, hyperactivity • Oral contraceptives: Decreased effectiveness of oral
• Nausea, vomiting, cough, dyspnea contraceptive when taken with modafinil
• Urinary retention, tachycardia, palpitations
Education Nursing management

• These drugs are intended for patients with chronic weight • An increased risk of suicidal ideation in children and
management issues when used with an approved diet and adolescents has been found when using the drug atomoxetine
physical activity program. (Strattera). Patients with ADHD started on atomoxetine should
• These drugs should only be used for obesity (body mass index be monitored carefully for suicidal thoughts or behaviors.
[BMI] of 30 or greater) or overweight (BMI of 27) when comor • Stimulants enhance dopamine transmission to areas of the
bid conditions exist, such as hypertension, type 2 diabetes, or brain that interpret well-being. To maintain pleasur able
dyslipidemia. feelings, people continue the use of stimulants, which leads to
• Never take over-the-counter weight loss preparations with their abuse and the potential for addiction.
these drugs. • Older adults are especially sensitive to the effects of the CNS
• If you have not achieved 5% weight loss in 12 weeks, contact stimulants and may exhibit excessive anxiety, nervousness,
your primary health care provider; never increase the dose to insomnia, and mental confusion. Cardiovascular disorders,
speed up or increase weight loss. common in the older adult, may be worsened by the CNS
• Call your primary health care provider immediately if you stimulants. Careful monitoring is important because these
experience mental changes (agitation or hallucinations), rapid reactions may result in the need to discontinue use of the drug.
heartbeat, dizziness, lack of coordination, or feelings of • ADHD: Give the drug in the morning 30 to 45 minutes before
warmth. This may be a condition called neuroleptic malignant breakfast and before lunch. Do not give the drug in the late
syndrome, which needs emergent treatment. afternoon.
• Be aware of possible impairment in the ability to drive or • Narcolepsy: Keep a record of the number of times per day that
perform hazardous tasks. periods of sleepiness occur, and bring this record to each visit
• Avoid other stimulants, including those containing caffeine such to the primary health care provider or clinic.
as coffee, tea, and cola drinks • Amphetamines and anorexiants: These drugs are taken early
• Read labels of foods and nonprescription drugs for possible in the day to avoid insomnia. Do not increase the dose or take
stimulant content. the drug more frequently, except on the advice of the primary
• Women: Use pregnancy protection and do not breastfeed when health care provider.
using these drugs. • Caffeine (oral, nonprescription): Over-the-counter caffeine
• Men: Seek immediate medical treatment if you have an preparations should be avoided if the individual has a history
erection lasting more than 4 hours. (Ford 192) of heart disease, high blood pressure, or stomach ulcers.
Benzphetamine Didrex Obesity 25–50 mg orally 1–3 times/day
Phendimetrazine Bontril Obesity 35 mg orally 2–3 times/day

CNS Drugs
- Cholinesterase Inhibitors

The cholinesterase inhibitors act to increase the level of • Should cholinesterase inhibitor therapy be discontinued,
acetylcholine in the central nervous system (CNS) by inhibiting its individuals lose any benefit they have received from the drugs
breakdown and slowing neural destruction. (Ford 197) within 6 weeks.
• Keep all appointments with the primary care provider or clinic,
because close monitoring of therapy is essential. Dose changes
Indications may be needed to achieve the best results.
• Report any unusual changes or physical effects to the primary
Cholinesterase inhibitors are used to treat early and moderate health care provider.
stages of dementia associated with AD. Their use for severe • Take the drug exactly as directed. Do not increase, decrease, or
cognitive decline as well as other dementias, such as vascular or omit a dose or discontinue use of this drug unless directed to
Parkinson’s dementia, is being studied. (Ford 198) do so by the primary health care provider.
• Do not drive or perform other hazardous tasks if drowsiness
occurs. Discuss with your primary health care provider when
patients should be evaluated for their continued ability to
Adverse Reactions drive.
• Do not take any nonprescription drug before talking to your
• Anorexia, nausea, vomiting, diarrhea
• Dizziness and headache
• Keep track of when the drug is taken. Marking the calendar, cell
phone alarms, or a pill counter that holds the medicine for
each day of the week may be helpful tools to remind the
Interactions patient to take the medication or determine whether the
medication has been taken for the day.
• Anticholinergics: Decreased effectiveness of anticholinergics • Notify the primary care provider if the following adverse
• Nonsteroidal anti-inflammatory drugs: Increased risk of GI reactions are experienced for more than a few days:
bleeding nausea, diarrhea, difficulty sleeping, vomiting, or loss of
• Theophylline: Increased risk of theophylline toxicity appetite.
• Immediately report the occurrence of the following adverse
reactions: severe vomiting, dehydration, or changes in neuro
logic functioning.
Dementia Vs. • Notify the primary health care provider if the patient has a
Delirium Dementia
Delirium history of ulcers, feels faint, experiences severe stomach
pains, vomits blood or material that resembles coffee
grounds, or has bloody or black stools.
Progressive
Onset Sudden change
change
• Remember that these drugs do not cure AD but slow the
mental and physical degeneration associated with the
disease. The drug must be taken routinely to slow the
progression.
Affects memory
Presentation Affects senses
and judgment
Herbal Consideration
Ginkgo, one of the oldest herbs in the world, has many beneficial
Yes, when cause No, can slow
effects. It is thought to improve memory and brain function and
such as oxygen progression with enhance circulation to the brain, heart, limbs, and eyes.
or chemical drugs, need to However, research is inconclusive as to whether or not his is
Reversibility imbalances or change true. Ginkgo is contraindicated in patients taking selective
infections environment for serotonin reuptake inhibitor (SSRI) or monoamine oxidase
found and patient to inhibitor (MAOI) antidepressants because of the risk of a toxic
treated remain safe reaction.

Mild to severe dementia due to AD,
memory improvement in dementia due
Donepezil Aricept 5–10 mg/day orally
to stroke, vascular disease, multiple
sclerosis
Galantamine Razadyne Mild to moderate (AD) dementia 16–24 mg BID orally

Nervous System
PNS
PNS Drugs
- A/B Blocking Drugs
How do they work? “Action” Nursing Alert

α/β-Adrenergic blocking drugs block the stimulation When administering a sympatholytic drug, such as
of both the α- and β-adrenergic receptors, resulting propranolol (Inderal), take an apical pulse rate and
in peripheral vasodilation. The two drugs in this blood pressure before giving the drug. If the pulse is
category are carvedilol (Coreg) and labetalol below 60 beats/min, or if there is any irregularity in
(Trandate). (Ford 256) the patient’s heart rate or rhythm, or if systolic blood
pressure is less than 90mm Hg, withhold the drug
and contact the primary health care provider.
(Ford 258)
Indications
• Carvedilol is used to treat essential hypertension
and in HF to reduce progression of the disease.
• Labetalol is used in the treatment of hypertension,
either alone or in combination with another drug,
Nursing management
such as a diuretic. (Ford 256)
• Do not stop taking the drug abruptly, except on the
advice of the primary health care provider. Most of
these drugs require that the dosage be gradually
Adverse Reactions
decreased to prevent precipitation or worsening of
General body system adverse reactions include adverse effects.
fatigue, dizziness, hypotension, drowsiness, • Notify the primary health care provider promptly if
insomnia, weakness, diarrhea, dyspnea, chest, pain, adverse drug reactions occur.
bradycardia, and skin rash. (Ford 256) • Observe caution while driving or performing other
hazardous tasks because these drugs (β-adrenergic
blockers) may cause drowsiness, dizziness, or
lightheadedness.
Contraindications • Immediately report any signs of HF (weight gain,
difficulty breathing, or edema of the extremities).
• Hypersensitivity to the drugs bronchial asthma • Do not use any nonprescription drug (e.g., cold or
• Decompensated HF flu preparations or nasal decongestants) unless you
• Severe bradycardia have discussed use of a specific drug with the
• Inform dentists and other primary health care
providers of therapy with this drug.
Interactions
• Keep all primary health care provider appointments
• Antidepressants (tricyclics and SSRIs): because close monitoring of therapy is essential.
Increased risk of tremors • Check with a primary health care provider or
• Cimetidine: Increased effect of the adrenergic clinical pharmacist to determine if the drug is to be
blocker taken with food or on an empty stomach.
• Clonidine: Increased effect of the clonidine (Ford 259-260)
• Digoxin: Increased serum level of the digoxin and
higher risk of digoxin toxicity (Ford 256)

Hypertension, HF, left ventricular
Carvedilol Coreg 6.25–25 mg orally BID
dysfunction
200–400 mg/day orally in divided
doses IV: 20 mg over 2 min with
Labetalol Trandate Hypertension
blood pressure monitoring, may
repeat
Neuromuscular Drugs
- Cholinergic Blocking Drug
How do they work? “Action” Drugs with Parkinson-like Adverse Reactions

Drugs with cholinergic blocking activity block ACh in the The following drugs can produce symptoms similar
CNS, enhancing dopamine transmission. to Parkinson’s disease, also known as extrapyramidal
symptoms (EPS), which may be treated with
similar drugs to reduce the adverse reactions:
• Antidepressants
Indications • Antiemetics
• Antipsychotics—first generation
Adjunctive therapy in all forms of Parkinson-like • Lithium
symptoms and in the control of drug-induced extrapyra- • Stimulants
midal disorders • Individuals older than 60 years frequently develop
increased sensitivity to anticholinergic drugs and
require careful monitoring. Confusion and
disorientation may occur. Lower doses may be
required.
Adverse Reactions
• Dry mouth
• Blurred vision
• Dizziness, mild nausea, and nervousness
• Skin rash, urticaria (hives)
Nursing management
• Urinary retention, dysuria
• Tachycardia, muscle weakness • If dizziness, drowsiness, or blurred vision occurs,
• Disorientation and confusion avoid driving or performing other tasks that require
alertness.
• Avoid the use of alcohol unless use has been
approved by the primary health care provider.
• Relieve dry mouth by sucking on hard candy (unless
Contraindications the patient has diabetes) or taking frequent sips of
• Glaucoma (angle-closure glaucoma) water. Consult a dentist if dryness of the mouth
• Pyloric or duodenal obstruction interferes with wearing, inserting, or removing
• Peptic ulcers, prostatic hypertrophy, achalasia (failure of dentures or causes other dental problems.
the muscles of the lower esophagus to relax, causing • Keep all appointments with the primary health care
difficulty swallowing), myasthenia gravis, and megacolon. provider or clinic personnel because close
monitoring of therapy is necessary.
• Ask your primary health care provider before
buying vitamin supplements when taking levodopa.
Vitamin B6 (pyridoxine) may interfere with the
Interactions
action of levodopa.
• Amantadine: Increased anticholinergic effects
• Digoxin: Increased digoxin serum levels
• Haloperidol: Increased psychotic behavior
• Phenothiazines: Increased anticholinergic effects
Parkinson’s disease, 0.5–6 mg/day orally

Benztropine Cogentin
drug-induced EPS Acute dystonia: 1–2 mL IM or IV
Diphenhydramine Benadryl Drug-induced EPS, allergies 25–50 mg orally TID or QID

PNS Drugs
- Alpha Adrenergic Blockers

Stimulation of α-adrenergic nerves results in • Do not stop taking the drug abruptly, except on
vasoconstriction. If stimulation of α-adrenergic the advice of the primary health care provider.
nerves is interrupted or blocked, the result is Most of these drugs require that the dosage be
vasodilation. gradually decreased to prevent precipitation or
worsening of adverse effects.
• Notify the primary health care provider
promptly if adverse drug reactions occur.
Indications • Observe caution while driving or performing
• Hypertension caused by pheochromocytoma (a other hazardous tasks because these drugs
tumor of the adrenal gland that produces (β-adrenergic blockers) may cause drowsiness,
excessive amounts of epinephrine and dizziness, or lightheadedness.
norepinephrine) • Immediately report any signs of HF (weight
• Hypertension during preoperative preparation gain, difficulty breathing, or edema of the
• They are also used to prevent or treat extremities).
tissue damage caused by extravasation of • Do not use any nonprescription drug (e.g., cold
dopamine. or flu preparations or nasal decongestants)
unless you have discussed use of a specific
drug with the primary health care provider.
Adverse Reactions providers of therapy with this drug.
• Keep all primary health care provider
• weakness, orthostatic hypotension
appointments because close monitoring of
• cardiac arrhythmias, hypotension, and
therapy is essential.
tachycardia.
• Check with a primary health care provider or
clinical pharmacist to determine if the drug is
to be taken with food or on an empty stomach.
(Ford 259-260)
Contraindications
• Hypersensitivity Interactions
• Coronary artery disease None listed.

Diagnosis of pheochromocytoma,
hypertensive episodes before and 5 mg IV, IM
during surgery, Tissue necrosis: 5–10 mg in 10 mL
Phentolamine Regitine
prevention/treatment of dermal saline solution infiltrated into
necrosis after IV administration of affected area
norepinephrine or dopamine
PNS Drugs
- Cholinergics

• Cholinergic drugs that act like the neurotrans • Aminoglycoside: Anti-infective agent
mitter ACh are called direct-acting cholinergics. Increased neuromuscular blocking effect
Cholinergic drugs causes contraction of the • Corticosteroids: Decreased effect of the
bladder smooth muscles and passage of urine. cholinergic drug
(Ford 266)
• Cholinergic drugs that prolong the activity of
ACh by inhibiting the release of AChE are called
indirect-acting cholinergics or
anticholinesterase muscle stimulants. Nursing Alert
Cholinergic crisis (cholinergic drug toxicity)
symptoms include severe abdominal cramping,
Indications diarrhea, excessive salivation, muscle weakness,
rigidity and spasm, and clenching of the jaw.
• Urinary retention Patients exhibiting these symptoms require
• Myasthenia gravis immediate medical treatment. In the case of
drug overdose, an antidote such as atropine (0.4
to 0.6 mg intravenously [IV]) is administered.
Adverse Reactions (Ford 267)
• Nausea, diarrhea, abdominal cramping

• Salivation
• Flushing of the skin
• Cardiac arrhythmias and muscle weakness Nursing management
Because of the need to make frequent dosage
adjustments, observe the patient closely for
Contraindications symptoms of drug overdose or underdose. Signs
of drug overdose include muscle rigidity and
Hypersensitivity to the drugs, asthma, peptic spasm, salivation, and clenching of the jaw. Signs
ulcer disease, coronary artery disease, and of drug underdosage are signs of the disease
hyperthyroidism. Bethanechol is contraindicated itself, namely, rapid fatigability of the muscles,
in those with mechanical obstruction of the GI or drooping of the eyelids, and difficulty breathing.
genitourinary tracts. Patients with secondary If symptoms of drug overdose or underdose
glaucoma, iritis, corneal abrasion, or any acute develop, contact the primary health care
inflammatory disease of the eye should not use provider immediately.
the ophthalmic cholinergic preparations.
(Ford 267)

Acute non obstructive urinary
Duvoid, 10–50 mg orally BID to QID; 2.5–5
Bethanechol retention, neurogenic atony of urinary
Urecholine mg subcutaneously TID to QID
bladder with urinary retention
Ambenonium Mytelase Myasthenia gravis 5–75 mg orally TID, QID

PNS Drugs
- B-Adrenergic Blockers

These drugs decrease the heart’s excitability, decrease cardiac • Antidepressants (monoamine oxidase inhibitors
workload and oxygen consumption, and provide [MAOIs], selective serotonin reuptake inhibitors
membrane-stabilizing effects that contribute to the antiarrhyth- [SSRIs]): Increased effect of the β blocker, bradycardia
mic activity of the β-adrenergic blocking drugs. Examples of • Nonsteroidal anti-inflammatory drugs (NSAIDs),
β-adrenergic blocking drugs used for cardiac purposes are salicylates: Decreased effect of the β blocker
esmolol (Brevibloc) and propranolol (Inderal). (Ford 256) • Loop diuretics: Increased risk of hypotension
• Clonidine: Increased risk of paradoxical hypertensive effect
• Cimetidine: Increased serum level of the β blocker and higher
risk of β blocker toxicity
• Lidocaine: Increased serum level of the β blocker and higher
Indications risk of β blocker toxicity
• Hypertension (first-choice drug for patients with stable angina)

• Cardiac arrhythmia (abnormal rhythm of the heart), such as Nursing Alert
ventricular or supraventricular tachycardia
• Migraine headaches Hypertension research studies demonstrate better patient
• Heart failure (HF) outcomes for African Americans when β blockers are used in
• Angina pectoris combination with diuretics than other drugs alone to treat
• Glaucoma (topical ophthalmic eye drops) hypertension, such as angiotensin-converting enzyme (ACE)
(Ford 256) inhibitors (Ferdinand, 2007). (Ford 256)
Nursing management
Adverse Reactions • Do not stop taking the drug abruptly, except on the advice of
the primary health care provider. Most of these drugs
Cardiac reactions that affect the body in a generalized manner require that the dosage be gradually decreased to prevent
include orthostatic hypotension, bradycardia, dizziness, vertigo, precipitation or worsening of adverse effects.
and headache. Gastrointestinal (GI) reactions include hyperglyce- • Notify the primary health care provider promptly if adverse
mia, nausea, vomiting, and diarrhea. Another bodily system drug reactions occur.
reaction is bronchospasm (especially in those with a history of • Observe caution while driving or performing other hazardous
asthma). (Ford 256) tasks because these drugs (β-adrenergic blockers) may cause
drowsiness, dizziness, or lightheadedness.
• Immediately report any signs of HF (weight gain, difficulty
breathing, or edema of the extremities).
• Do not use any nonprescription drug (e.g., cold or flu
Contraindications preparations or nasal decongestants) unless you have
discussed use of a specific drug with the primary health care
These drugs are contraindicated in patients with an allergy to β provider.
blockers; in patients with sinus bradycardia, secondor third-de- • Inform dentists and other primary health care providers of
gree heart block, or HF; and in those with asthma, emphysema, therapy with this drug.
and hypotension. The drugs are used cautiously in patients with • Keep all primary health care provider appointments because
diabetes, thyrotoxicosis, or peptic ulcer. (Ford 256) close monitoring of therapy is essential.
• Check with a primary health care provider or clinical pharmacist
to determine if the drug is to be taken with food or on an
empty stomach. (Ford 259-260)

Hypertension: 400 mg orally in 1–2 doses
Hypertension, ventricular
Acebutolol Sectral Arrhythmias: 400–1200 mg/day orally in
arrhythmias H
divided doses
Cardiac arrhythmias, MI, angina, Arrhythmias: 10–30 mg orally TID, QID

hypertension, migraine prophylaxis, Hypertension: 120–240 mg/day orally in
Propranolol Inderal hypertrophic subaortic stenosis, divided doses, Angina: 80–320 mg/day
pheochromocytoma, essential tremor orally in divided doses, Migraine: 160–240
mg/day orally in divided doses
27-1
NEUROMUSCULAR DRUGS: CHOLINERGIC BLOCKING DRUGS
HOW DO THEY WORK? Contraindications Nursing management
“Action”
❖ Glaucoma (angle-closure glaucoma) ❖ If dizziness, drowsiness, or blurred
❖ pyloric or duodenal obstruction vision occurs, avoid driving or
Drugs with cholinergic ❖ peptic ulcers, prostatic hypertrophy, performing other tasks that require
blocking activity block ACh achalasia (failure of the muscles of the alertness.
in the CNS, enhancing lower esophagus to relax, causing ❖ Avoid the use of alcohol unless use
dopamine transmission. difficulty swallowing), myasthenia has been approved by the primary
gravis, and megacolon. health care provider.
❖ Relieve dry mouth by sucking on hard
candy (unless the patient has diabetes)
or taking frequent sips of water.
Consult a dentist if dryness of the
Indications
mouth interferes with wearing,
inserting, or removing dentures or
Adjunctive therapy in all forms causes other dental problems.
of Parkinson-like symptoms ❖ Keep all appointments with the
and in the control of
Interactions
primary health care provider or clinic
drug-induced extrapyramidal personnel because close monitoring of
disorders ❖ Amantadine: Increased anticholinergic
therapy is necessary.
❖ Ask your primary health care provider
effects before buying vitamin supplements
❖ Digoxin: Increased digoxin serum levels when taking levodopa. Vitamin
Adverse reactions ❖ Haloperidol: Increased psychotic behavior B6(pyridoxine) may interfere with the
action of levodopa.
❖ Dry mouth ❖ Phenothiazines: Increased anticholinergic
❖ Blurred vision effects
❖ Dizziness, mild
nausea, and
nervousness
❖ Skin rash, Drugs With Parkinson-Like Adverse Reactions
urticaria (hives) The following drugs can produce symptoms similar to Parkinson’s disease,
❖ Urinary retention, also known as extrapyramidal symptoms (EPS), which may be treated with
similar drugs to reduce the adverse reactions:
dysuria ❖ Antidepressants
❖ Tachycardia, ❖ Antiemetics
❖ Antipsychotics—first generation
muscle weakness ❖ Lithium
❖ Disorientation ❖ Stimulants
❖ Individuals older than 60 years frequently develop increased sensitivity to
and confusion anticholinergic drugs and require careful monitoring. Confusion and
disorientation may occur. Lower doses may be required.
benztropine Cogentin Parkinson’s disease, 0.5–6 mg/day orally

drug-induced EPS Acute dystonia: 1–2 mL IM
or IV
diphenhydramine Benadryl Drug-induced EPS, allergies 25–50 mg orally TID or

QID
PNS DRUGS: CHOLINERGICS
26-11
HOW DO THEY WORK? Contraindications

“Action” Hypersensitivity to the drugs, asthma, peptic ulcer
Nursing management
disease, coronary artery disease, and
❖ Cholinergic drugs that act like the hyperthyroidism. Bethanechol is contraindicated in
neurotransmitter ACh are called those with mechanical obstruction of the GI or
Because of the need to make frequent dosage
direct-acting cholinergics. genitourinary tracts. Patients with secondary
adjustments, observe the patient closely for
cholinergic drugs causes glaucoma, iritis, corneal abrasion, or any acute
symptoms of drug overdose or underdose. Signs of
contraction of the bladder smooth inflammatory disease of the eye should not use the
drug overdose include muscle rigidity and spasm,
muscles and passage of urine. ophthalmic cholinergic preparations. (Ford 267)
salivation, and clenching of the jaw. Signs of drug
(Ford 266)
underdosage are signs of the disease itself, namely,
❖ Cholinergic drugs that prolong the
Interactions
rapid fatigability of the muscles, drooping of the
activity of ACh by inhibiting the
eyelids, and difficulty breathing. If symptoms of
release of AChE are called
drug overdose or underdose develop, contact the
indirect-acting cholinergics or ❖ Aminoglycoside: Anti-infective
primary health care provider immediately.
anticholinesterase muscle agent Increased neuromuscular
stimulants. blocking effect
❖ Corticosteroids: Decreased
Indications
effect of the cholinergic drug
❖ Urinary retention
❖ Myasthenia gravis
Adverse reactions
❖ Nausea, diarrhea,
abdominal cramping
❖
❖
Salivation
Flushing of the skin Nursing alert
❖ Cardiac arrhythmias and Cholinergic crisis (cholinergic drug toxicity) symptoms include
muscle weakness severe abdominal cramping, diarrhea, excessive salivation, muscle
weakness, rigidity and spasm, and clenching of the jaw. Patients
exhibiting these symptoms require immediate medical treatment.
In the case of drug overdose, an antidote such as atropine (0.4 to
0.6 mg intravenously [IV]) is administered. (Ford 267)

bethanechol Duvoid, Urecholine Acute non obstructive urinary 10–50 mg orally BID to QID; 2.5–5
retention, neurogenic atony of urinary mg subcutaneously TID to QID
bladder with urinary retention
ambenonium Mytelase Myasthenia gravis 5–75 mg orally TID, QID

Cardiac
(Anti hypertensive
&
Heart failure drugs)
Antihypertensives: Adrenergic blocking drugs
/ Alpha & Beta Central and Peripherally Acting
How it works? “Action” Nursing management
Peripherally acting: Inhibits norepinephrine in the • Monitor intake and output ratios and daily weight
PNS ( treats BPH, HTN) • Assess for edema daily, especially at beginning of
therapy.
Centrally acting: Decreases CNS activity (HTN) • Monitor BP and pulse prior to starting, frequently
during initial dose adjustment and dose increases
and periodically throughout therapy.
• Titrate slowly in patients with cardiac conditions or
those taking other sympatholytic drugs.
Why do we give it? ‘’Reason’’ Report significant changes.
• Transdermal: Instruct patient on proper application
• Certain cardiac arrhythmias of transdermal system. Do not cut or trim unit.
• BAH Transdermal system can remain in place during
• HTN bathing or swimming.
Adverse effects Interactions:

EENT: dry eyes. • Adrenergic: risk of HTN
CV: AV block, bradycardia, hypotension (with • Levodopa: hypotension, decrease levodopa
epidural), palpitations. • Anesthetic agents: increase anesthetic
GI: dry mouth, constipation, nausea, vomiting. • Beta blockers: hypertension
GU: erectile dysfunction. • Lithium: lithium toxicity
Derm: rash, sweating. • Haloperidol: psychotic behavior
F&E: sodium retention, hyperkalemia
Metab: weight gain.
Neuro: paresthesia.
Misc: withdrawal phenomenon
Contraindications
• Central: Hepatic disease ( active ) , MAOI

antidepressant therapy
• Peripheral: ulcerative colitis , peptic ulcer
Generic Trade Central / peripheral Safe dose Route

100 mcg (0.1 mg)
Clonidine Catapres Central PO, TD
BID
250– 500 mg 2– 3
Methyldopa N/A Central PO
times daily
Cardura, Cardura
Doxazosin Periphera 1 mg once daily PO
XL
1 mg 2– 3 times
Prazosin Minipress Periphera PO
daily
Diuretics
- Carbonic Anhydrase Inhibitors
• Diuretics work by altering the reabsorption or • Monitor BP and pulse frequently

excretion of electrolytes and alter fluid volume. • Assess for allergy to sulfonamides
Carbonic anhydrase inhibitors: sulfonamides • Monitor intake and output ratios and daily weight.
without bacteriostatic action, inhibit CAH • Do not stop the drugs abruptly unless you speak
enzyme thus results in excretion of Na+ K+ HC03 with the DR.
and H20 • If GI upset occurs then take the med with food
or milk
• Take early in the morning
Why do we give it? ‘’Reason’’ • Do not reduce fluid intake
• Hypertension • Avoid alcohol and non prescription drugs
• Used with antihypertensives • Notify the healthcare provider if: muscle cramps,
• To reduce edema weakness, dizziness, diarrhea, restlessness,
• Glaucoma excessive thirst, general weakness, rapid pulse,
• Seizures
• Renal disease. increased heart rate or pulse, gi distress.
• Weight yourself daily.
• These drugs may cause hypokalemia, monitor
Adverse effects serum potassium levels and electrolytes.
Neuro: Dizziness, headache, encephalopathy,

lightheadedness,weakness, fatigue
EENT: Hearing loss, tinnitus
CV: Orthostatic hypotension
GU: Electrolyte imbalances, glycosuria Interactions:
GI: Anorexia, nausea, vomiting
Derm: Rash, photosensitivity • Primidone: decreased effectiveness of primidone
• Barbiturates & aspirin: decrease diuretic
Endo: Hyperglycemia, hyperuricemia. effectiveness
F & E: Dehydration, hypocalcemia, • tricyclic antidepressants: can lead to toxicity
hypochloremia, hypokalemia, hypomagnesemia,
hyponatremia, hypokalemia, metabolic alkalosis
MS: Arthralgia, muscle cramps, myalgia.
Contraindications Simple Nursing Brain bits
• Hypersensitivity If a client has an allergy to sulfonamides this

• Electrolyte imbalances drug should not be given.
• Severe kidney or liver dysfunction
• Anuria.
• Mannitol: active intracranial bleeding except
during craniotomy

250– 1000 mg/day in
Acetazolamide Diamox PO
1– 4 divided doses
50– 100 mg 2– 3 times

Methazolamide Neptazane PO
daily.
Heart Failure
Patho Nursing Care

HF–HEART FAILURE (failure to PUMP forward) DR. BEDS
HF–HEAVY FLUID (lungs & body) D–Diet: Low SCC (Sodium, Calories, Cholesterol)
Low Sodium & Fluid (2L + 2g or LESS/day)
Memory Trick: NO OTC meds (Cough or Flu, Antacids
or NSAIDS NCLEX TIP
S–Sodium Swells NO Canned or packaged foods (chips, sauces, meats, cheeses,
W–Weight Gain = Water Gain Crisis! wine)
R–Risk for Falls! (Change positions slowly!)
B–Blood Pressure & BNP (shoud NOT be increasing)
Signs & Symptoms E–Elevate HOB & Legs (with pillows) high fowlers
R–RIGHT sided HF L–LEFT sided HF D–Daily Weights and Is and Os (0ver 3 lbs/day or
R–ROCKS the BODY with fluid L–LUNG fluid 5 lbs in 7 days) = Worsening! NCLEX TIP
Peripheral Edema “Pulmonary Edema” S–Stairs (No sex until able to climb 2 flights of stairs
Weight Gain = Water Gain Crackles “rales” that don't clear without dyspnea)
Edema (pitting) with cough (NOT rhonchii or wheeze) S–Stocking (TED hose) (decreases blood pooling, remove daily)
JVD (big neck veins) Frothy Pink “blood tinged” sputum
Abdominal Growth orthopnea–dyspnea while lying flat NEVER massage calves (CHF patients) NCLEX TIP
Ascites
Hepatomegaly (big liver) Pharmacology
Splenomegaly (big spleen)
A–ACTS on BP only (not HR)
Causes A–ACE (-pril) Lisinopril “chill pril” 1st choice
R–RIGHT sided HF L–LEFT sided HF A–ARBS (-sartan) Losartan “relax man” 2nd choice
Left sided HF can cause Right HF (weak heart = weak pump) A–Avoid Pregnancy
MI (heart attack) A–Angioedema (Airway Risk) *only Ace
Pulmonary HTN
Ischemic Heart Disease C–Cough *only Ace
Fibrotic Lungs “stiff lungs”
E–Elevated K+ (normal 3.5-5.0)
(CAD, ACS)
B–BETA BLOCKERS (-lol) AtenoLOL “LOL = LOW”
Treatment Priority Blocks both BP & HR (AVOID Low HR & BP)
Caution: HOLD IF:
B–Bradycardia (LESS than 60) & BP low (90/60)
KEY WORDS: new, sudden, worsening, rapid = only hold if the patient is in an acute exacerbation of CHF
Pulmonary Edema CRISIS (Lung Fluid!) B–Breathing problems “wheezing” (Asthma, COPD)
B–Bad for Heart Failure patients
#1 Furosemide “Body Dried” (drain fluid) B–Blood sugar masking “hides S/S” (Diabetics)
H–HOB 45 degrees + (semi fowlers, high fowlers, orthopneic C–CALCIUM CHANNEL BLOCKERS
position) Calms BP & HR (AVOID Low HR & BP)
O–Oxygen (Nifedipine)
P–Push Furosemide + Morphine, Positive inotropes -dipine “declined BP & HR
E–End sodium & fluids (Sodium Swells) -amilipine “chill heart”
NO drinking fluids + STOP IV fluids D–DIURETICS Drain Fluid
D–Drains Fluid “Diurese” “Dried”
Diagnostic tests K+ Wasting–Furosemide & Hydrochlorothiazide
(caution: Low K+, Eat melons, banana & green leafy)
Labs: BNP–”Broken Venticles” K+ Sparing–Spironolactone “Spares potassium”
(AVOID Salt Substitues, melons & green leafy)
300+ Mild • 600+ Moderate • 900+ SEVERE HF D–DILATORS (Vasodilators)
Echo Nitroglycerin, Isosorbide
Ejection Fraction 40% or LESS is HF! (normal-55-70%) Nitroglycerin “Nitro = Pillow for heart”
LVH–Left Ventricular Hypertrophy Caution: NO Viagra “-afil” Slidenafil = DEATH!
Nitro drip: STOP = Systolic BP below 90 or 30 mmHg Drop
Hemodynamic Monitor “Swan Ganz" (Pulmonary artery catheter)
Adverse effect:
CVP (norm: 2-8) Over 8 = NOT GREAT HA= side effect
Low BP= adverse effect (SLOW position changes)
Risk Factors D–DIGOXIN (Inotropic)
Digs for a DEEP contraction
#1 risk factor is HTN Increased contractility
ECG Dysrhythmias (Atrial Fibrillation) Apical Pulse x 1 minute
Valvular Malfunction (mitral valve regurgitation) Toxicity (over 2.0) Vision changes, N/V TEST TIP
Cardiomyopathy Potassium 3.5 or less (higher r/f toxicity)
Notes
Antihypertensives
Ace Inhibitors

Suppress the renin-angiotensin-aldosterone system • Monitor BP and pulse frequently
and prevent the activity of ACE which converts • Assess patient for signs of angioedema
angiotensin 1 to angiotensin 2 (vasoconstrictor). (dyspnea, facial swelling).
Inhibiting the conversion causes Na+ and H2O to • Heart Failure: Monitor weight and assess patient
not be retained thus sodium and BP will decrease. routinely for resolution of fluid overload
(peripheral edema, rales/crackles, dyspnea,
weight gain, jugular venous distention).
• May cause hyperkalemia.
Why do we give it? ‘’Reason’’
• Instruct your clients to get up slowly and avoid salt
• Treatment of hypertension substitutes.
Adverse effects Interactions:

CV: Orthostatic hypotension, syncope • NSAIDS: Reduced hypotensive effects
tachycardia, hypotension, chest pain • Rifampin: Decreased ace1 effects
CNS: Dizziness, fatigue, headache, weakness. • Allopurinol: Increased risk of hypersensitivity
GI: Abdominal pain, diarrhea, nausea, vomiting • Digoxin: Decreased dig levels
GU: Erectile dysfunction, impaired renal • Loop diuretics: Decrease diuretic effects
• Lithium: Possible lithium toxicity
function.proteinuria • Hypoglycemics(insulin): Increase risk of
Derm: Rashes. F and E: hyperkalemia. hypoglycemia
Misc: ANGIOEDEMA • Potassium sparing diuretics: Elevated potassium
RESP: Upper respiratory infections and cough, levels ( hyperkalemia )
HEMAT: Neutropenia
Simple Nursing Brain bits
• Be mindful of suffixes! All ACE inhibitors end in

Contraindications ‘’april’’ Use caution with African American population
• ACE1/Angiotensin receptor blockers: HF, salt or as drugs may not be effective and/or may cause
volume depletion, bilateral stenosis, angioedema, extremely uncomfortable side effects
pregnancy 2nd/3rd trimester due to neonatal
death.
Generic Trade with/without food Safe dose Route
Captopril Capoten Without food 12.5– 25 mg 2– 3 PO

times daily
Lisinopril Prinivil With food 10 mg once daily PO
Enalapril Vasotec with/ without 2.5– 5 mg once PO , IV

daily
Ramipril Altace with/without 2.5 mg once daily PO

- Alpha & Beta
Block Alpha receptors causing vasodilation by • Monitor BP, pulse, and ECG every 2 min until stable
relaxing the smooth muscle of the blood vessels in during IV administration. If hypotensive crisis
ophthalmic preps they constrict the pupil occurs, epinephrine is contraindicated and may
cause paradoxical further decrease in BP.
Norepinephrine may be used
• Instruct client to change positions slowly to
minimize orthostatic hypotension.
• Instruct patient to notify health care professional if
chest pain occurs during IV infusion
• Carvedilol: essential HTN, HF to reduce progression

• Labetalol: HTN usually as an adjunct to a Diuretic
Interactions:
• Antidepressants: tremors
• Cimetidine: increased adrenergic blocker effect
Adverse effects • Clonidine: increase clonidine effects
• Digoxin: digoxin toxicity
CNS: Dizziness, fatigue, weakness, anxiety,
depression, drowsiness, insomnia, memory loss,
mental status changes, nervousness, nightmares.
EENT: Blurred vision, dry eyes, intraoperative floppy
iris syndrome, nasal stuffiness.
Resp: bronchospasm, wheezing.
CV: BRADYCARDIA, HF, PULMONARY EDEMA Contraindications
GI: diarrhea, constipation, nausea. GU: erectile
dysfunction,plibido. • History of serious hypersensitivity reaction.
Derm: STEVENS-JOHNSON SYNDROME, TOXIC • Stevens-Johnson syndrome, angioedema,
EPIDERMAL NECROLYSIS, itching, rashes, urticaria. anaphylaxis
Endo: hyperglycemia, hypoglycemia. • Pulmonary edema
MS: arthralgia, back pain, muscle cramps. • Cardiogenic shock
Neuro: paresthesia. • Bradycardia, heart block or sick sinus syndrome
Misc: ANAPHYLAXIS, ANGIOEDEMA, drug-induced • Uncompensated HF requiring IV inotropic agents
lupus syndrome. (wean before starting carvedilol); Severe hepatic
impairment; Asthma or other bronchospastic
disorders.
Carvedilol Coreg, Coreg CR 6.25 mg twice daily PO
Labetalol Trandate 100 mg twice daily PO, IV

Diuretics
- Loop Diuretics

excretion of electrolytes and alter fluid volume. • Monitor intake and output ratios and daily weight.
Loop diuretics: inhibit the reabsorption of sodium • Do not stop the drugs abruptly unless you speak
chloride in the proximal and distal convoluted with the HCP.
tubules and the loop of henle. This site increase • If GI upset occurs then take the med with food
their effectiveness .
or milk.
• Take early in the morning.
Why do we give it? ‘’Reason’’ • Do not reduce fluid intake.
• Avoid alcohol and non prescription drugs.
• Hypertension • Notify the healthcare provider if: muscle cramps,
• Used with antihypertensives
• To reduce edema weakness, dizziness, diarrhea, restlessness,
• Glaucoma excessive thirst, general weakness, rapid pulse,
• Seizures increased heart rate or pulse, gi distress.
• Renal disease. • Weight yourself daily.
Adverse effects serum potassium levels

CV: Orthostatic hypotension Interactions:
GU: Electrolyte imbalances, glycosuria
• Cisplatin/aminoglycosides: increased risk
GI: Anorexia, nausea, vomiting of ototoxicity
Derm: Rash, photosensitivity • Anticoagulant/thrombotic: increased risk of
Endo: Hyperglycemia, hyperuricemia. bleeding
F & E: Dehydration, hypocalcemia, • Digitalis: increase risk of arrhythmia
• Lithium: increased risk of lithium toxicity
hypochloremia, hypokalemia, hypomagnesemia, • Hydantoins: decreased diuretic effect
hyponatremia, hypokalemia, metabolic alkalosis • Nsaid: decreased Diuretics effect
Contraindications
• Electrolyte imbalances
• Severe kidney or liver dysfunction • Taking this medication early in the day can
• Anuria. prevent injury r/t getting out of bed at night
• Mannitol: active intracranial bleeding except for the client.
during craniotomy

0.5– 2 mg/day given in
Bumetanide Bumex PO
1– 2 doses
20– 80 mg/day as a
Furosemide: Lasix PO, IM, IV
single dose
Torsemide Demadex 2.5– 5 mg once daily PO

Antihypertensives
Angiotension Receptor Blockers

Block the binding of angiotensin 2 at various sites • Monitor BP and pulse frequently
on smooth muscle, blocking the vasoconstriction • Assess patient for signs of angioedema
effects of the renin-angiotensin-aldosterone system
(dyspnea, facial swelling).
thus causing a decrease in blood pressure.
• Heart Failure: Monitor weight and assess patient
routinely for resolution of fluid overload
(peripheral edema, rales/crackles, dyspnea,
weight gain, jugular venous distention).
Why do we give it? ‘’Reason’’ • May cause hyperkalemia.
• Instruct your clients to get up slowly and avoid salt
• Treatment of hypertension substitutes.
Adverse effects
Interactions:
CNS: dizziness, fatigue, headache, insomnia,
weakness. • NSAIDS: Reduced hypotensive effects
• Rifampin: Decreased ace1 effects
CV: chest pain, edema, hypotension. • Allopurinol: Increased risk of hypersensitivity
EENT: nasal congestion. • Digoxin: Decreased dig levels
Endo: hypoglycemia, weight gain. • Loop diuretics: Decrease diuretic effects
• Lithium: Possible lithium toxicity
GI: diarrhea, abdominal pain, dyspepsia, nausea. • Hypoglycemics(insulin): Increase risk of
GU: impaired renal function. hypoglycemia
F and E: hyperkalemia. • Potassium sparing diuretics: Elevated potassium
levels ( hyperkalemia )
MS: back pain, myalgia.
Misc: ANGIOEDEMA, fever.
• Be mindful of suffixes! All ARBS end in ‘’TAN’’

Contraindications These replace ACE in african american population
and when the side effects of ace become too much
• ACE1/Angiotensin receptor blockers: HF, salt or
volume depletion, bilateral stenosis, angioedema, the client.
pregnancy 2nd/3rd trimester due to neonatal
death.
Irbesartan Apravo 150 mg once daily PO
Losartan Cozaar 50 mg once daily PO
80 mg or 160 mg once
Valsartan Diovan PO
daily
- Alpha
Block Alpha receptors causing vasodilation by • Monitor BP, pulse, and ECG every 2 min until stable
relaxing the smooth muscle of the blood vessels. during IV administration. If hypotensive crisis
In ophthalmic preps they constrict the pupil. occurs, epinephrine is contraindicated and may
cause paradoxical further decrease in BP.
• Norepinephrine may be used
• Instruct client to change positions slowly to
minimize orthostatic hypotension.
• Instruct patient to notify health care professional if
chest pain occurs during IV infusion.
• Hypertension caused by pheochromocytoma

• Hypertension caused by pre op prep.
• Treat tissue damage caused by dopamine injection.
Interactions:
• Epinephrine or methoxamine:
Adverse effects Severe hypotension
• Ephedrine or phenylephrine:
CNS: CEREBROVASCULAR SPASM, dizziness, Decreased pressor response
weakness.
EENT: nasal stuffiness.
CV: HYPOTENSION, MI, angina, arrhythmias,
tachycardia.
GI: abdominal pain, diarrhea, nausea, vomiting,
aggravation of peptic ulcer.
Derm: flushing. Local: injection site pain (local).
Interactions
If you are giving multiple meds remember, If it makes

you hyper or shaky check the drug book before
administering it with Alpha Adrenergic blockers
Contraindications
• Coronary artery disease
5 mg given 1– 2 hr pre
op, repeated PRN. can
Phentolamine Oraverse, Regitine IM, IV, Local
infuse at 0.5– 1 mg/min
during surgery.
Diuretics
- Osmotic

excretion of electrolytes and alter fluid volume. • Monitor intake and output ratios and daily weight
Osmotic Diuretics: increase the density of the • Assess patient for anorexia, muscle weakness,
filtrate in the glomerulus preventing selective numbness, tingling, paresthesia, confusion, and
reabsorption of h20 and it passes as urine. excessive thirst. Report signs of electrolyte
imbalance.
• Avoid alcohol
• Hypokalemia, monitor serum potassium levels and
Why do we give it? ‘’Reason’’ electrolyte levels
Adjunct in the treatment of:

• Acute oliguric renal failure
• Edema
• Increased intracranial or intraocular pressure
• Toxic overdose.
• GU irrigant During transurethral procedures
(2.5– 5% solution only).
Interactions:
• Digoxin: Hypokalemia increases the risk of

dig toxicity
Adverse effects
CNS: Confusion, headache.

EENT: Blurred vision, rhinitis.
CV: Transient volume expansion, chest pain, HF,
pulmonary edema, tachycardia.
GI: Nausea, thirst, vomiting.
GU: Renal failure, urinary retention. Simple Nursing Brain bits
F and E: Dehydration, hyperkalemia, hypernatremia,
hypokalemia, hyponatremia. Symptoms of fluid and electrolyte imbalance include
dry mouth, thirst, weakness, lethargy, drowsiness,
Local: Phlebitis at IV site.
restlessness confusion, muscle pain or cramps,
confusion, gastrointestinal disturbances,
hypotension, oliguria, tachycardia, and seizures.
Contraindications
• Mannitol: active intracranial bleeding

except during craniotomy
• Anuria
• Dehydration
• Severe pulmonary edema or congestion.

50– 100 g as a 5– 25%
Mannitol Osmitrol IV
solution
Antihypertensives
Beta Blockers

Block beta receptors in the heart to decrease cardiac • Monitor BP, heart rate, ECG, cardiac output, CVP,
workload to decrease HR and dilate blood vessels, and urinary output continuously
provides membrane stabilizing effects. Timolol • Abrupt withdrawal of propranolol may precipitate
treats glaucoma. life-threatening arrhythmias, hypertension, or
myocardial ischemia
• Take HR and BP immediately prior to administering
Why do we give it? ‘’Reason’’ medication and 30 minutes after. Observe
provider’s parameters to hold drug if BP and/or
• Hypertension HR are low.
• Cardiac arrhythmia • Advise patient to notify health care professional if
• Heart failure slow pulse, difficulty breathing, wheezing, cold
• Angina hands and feet, dizziness, lightheadedness,
• Glaucoma confusion, depression, rash, fever, sore throat,
• Prevention of MI unusual bleeding, or bruising occur. If diabetic
monitor for hypoglycemia. Teach not to stop taking
abruptly.
Adverse effects
CV: Orthostatic hypotension, bradycardia, Interactions:

PULMONARY EDEMA, • Antidepressants: bradycardia and increase beta
ENDO: May cause ^ BUN, serum lipoprotein, blocker effects
potassium, triglyceride, and uric acid levels. • NSAID: decrease beta blocker effects
May cause ^ blood glucose levels. In labile • Diuretics: increase beta blocker
effects/hypotension
diabetic patients, hypoglycemia may be • Clonidine: paradoxical hypertensive effects
accompanied by precipitous ^ of BP. • Cimetidine: beta blocker toxicity
RESP: bronchospasm (hx of asthma) • Lidocaine: beta blocker toxicity

Contraindications
• Never give a beta blocker to a client with a history of
• Sinus bradycardia asthma because it can cause bronchospasm.
• Heart block • Beta Blockers end in -OLOL
• Heart Failure 4 B'S
• Asthma • Bradycardia
• Emphysema • Blood pressure decrease
• Hypotension • Bronchial constriction (relief)
• Blood sugar masking

Inderal, Inderal LA, 80– 320 mg/day in 2– 4 divided
Propranolol PO, IV , PO-ER
InnoPran XL doses
Metoprolol:
lopressor 25– 100 mg/day as a single dose PO, IV , PO-ER
lopressor
Sotalol
Betapace, Betapace
Give on an 80 mg twice daily PO
AF
empty stomach
One drop of 0.25% eye drops into
Timolol
Novo-Timol each affected eye(s) twice daily, Ophthalmic
Ophthalmic
approximately 12 hours apart.
Diuretics
- Potassium Sparing

• Do not stop the drugs abruptly unless you speak
Potassium Sparing Diuretics: reduce the excretion
with the HCP.
of potassium, block the reabsorption of sodium
into the kidney. And thereby increasing sodium • If GI upset occurs then take the med with food or
and h20 in the urine and reduces excretion of K+ milk.
• Take early in the morning
• Do not reduce fluid intake
• Notify the healthcare provider if: muscle cramps,
• Hypertension weakness, dizziness, diarrhea, restlessness,
• Used with antihypertensives excessive thirst, general weakness, rapid pulse,
• To reduce edema increased heart rate or pulse, GI distress.
• Glaucoma • Weight yourself daily.
• Seizures • These drugs may cause hyperkalemia, monitor
serum potassium levels.
Adverse effects

CV: Orthostatic hypotension Interactions:
GU: Electrolyte imbalances, glycosuria • Angiotensin converting enzyme/potassium
GI: Anorexia, nausea, vomiting supplement:
Derm: Rash, photosensitivity Increased risk of hyperkalemia
• Nsaids/anticoagulants: decreased diuretic effect
Endo: Hyperglycemia, hyperuricemia.
F & E: Dehydration, hypocalcemia,
hypochloremia, hyperkalemia,
hypomagnesemia, hyponatremia, hypokalemia,
metabolic alkalosis
MS: Arthralgia, muscle cramps, myalgia. Simple Nursing Brain bits
Avoid foods high in potassium:

Contraindications Avocado, Acorn squash, Spinach, Sweet potato,
• Hypersensitivity Wild-caught salmon, Dried apricots, Pomegranate,
• Electrolyte imbalances, hyperkalemia Coconut water, White beans, Banana
• Severe kidney or liver dysfunction
• Anuria.
• Mannitol: active intracranial bleeding
except during craniotomy

25– 400 mg/day
Spironolactone Aldactone PO
as a single dose
Calcium Channel Blockers
How it works? “Action” Contraindications

Systemic and coronary arteries are influenced by • Calcium channel blockers: sick sinus syndrome,
Ca++ moving across cell membranes. CCB act by 2nd/3rd degree atrioventricular block, ventricular
inhibiting the movement of calcium across the cell dysfunction, cardiogenic shock.
membrane of cardiac and arterial muscles. Resulting
in less calcium available for nerve impulse
transmission and relax blood vessels to increase 02
supply to decrease cardiac workload
Nursing management
• Monitor BP and pulse frequently

• Monitor intake and output ratios and daily weight.
Why do we give it? ‘’Reason’’ Assess for signs of HF (peripheral edema,
• Hypertension rales/crackles, dyspnea, weight gain, jugular
• Angina pectoris venous distention).
• Vasospastic (Prinzmetal’s) angina • Angina: Assess location, duration, intensity, and
precipitating factors of patient’s anginal pain
• Avoid large amounts (6– 8 glasses of grapefruit
juice/day)
• Have the client check pulse and report any sudden
changes
Adverse effects
CNS: dizziness, fatigue.

CV: peripheral edema, angina, bradycardia,
hypotension, palpitations.
GI: gingival hyperplasia, nausea. Interactions:
Derm: flushing • Cimetidine: increase effects of CCB
• Theophylline: toxic effects of theophylline
• Digoxin: Dig toxicity
• Rifampin: decreased CCB effects
Amlodipine Norvasc 5– 10 mg once daily PO
30– 120 mg 3– 4
Diltiazem Cardizem PO
times daily o
80– 120 mg 3
Verapamil Calan PO, IV
times daily
Diuretics
- Thiazides
• Diuretics work by altering the reabsorption or • Monitor BP and pulse frequently .

Thiazide Diuretics: Inhibit reabsorption in the • Do not stop the drugs abruptly unless you speak
ascending portion of the loop of henle and early with the DR.
distal tubule. Excrete sodium, chloride, and H2O • If GI upset occurs then take the med with food
or milk.
• Take early in the morning.
Why do we give it? ‘’Reason’’ • Do not reduce fluid intake.
• Hypertension • Notify the healthcare provider if: muscle cramps,
• Used with antihypertensives weakness, dizziness, diarrhea, restlessness,
• To reduce edema excessive thirst, general weakness, rapid pulse,
• Glaucoma
• Seizures increased heart rate or pulse, gi distress.
• Renal disease. • Weight yourself daily.
serum potassium levels.
• May cause in serum and urine glucose in diabetic
Adverse effects patients. May cause anqin serum bilirubin, calcium,
Neuro: Dizziness, headache, encephalopathy, creatinine, and uric acid.
CV: Orthostatic hypotension
GU: Electrolyte imbalances, glycosuria
GI: Anorexia, nausea, vomiting Interactions:
Derm: Rash, photosensitivity
Endo: Hyperglycemia, hyperuricemia. • Allopurinol: increased risk of hypersensitivity to
allopurinol
F & E: Dehydration, hypocalcemia, • Anesthetics: increased anesthetic effects
hypochloremia, hypokalemia, hypomagnesemia, • Antineoplastic drugs: extended leukopenia
hyponatremia, hypokalemia, metabolic alkalosis • Antidiabetic drugs: hyperglycemia
Contraindications Simple Nursing Brain bits
• Hypersensitivity • Thiazide and Loop: liver disease, lupus, diabetes,

• Electrolyte imbalances a cross sensitivity may occurs with thiazides and
• Severe kidney or liver dysfunction sulfonamides
• Anuria. • Yellow dye may cause allergic reactions or
• Mannitol: active intracranial bleeding except bronchial asthma with thiazides.
during craniotomy

12.5– 100 mg/day in 1–
Hydrochlorothiazide Microzide PO
2 doses
Metolazone Zaroxolyn 2.5– 5 mg/day PO

Cardiotonic Drugs

Cardiotonics such as digoxin increase cardiac output The physical assessment should include the following:
through positive inotropic activity (an increase in the • Taking blood pressure, apical-radial pulse rate,
force of the contraction). They slow the conduction respiratory rate
velocity through the atrioventricular (AV) node in the • Auscultating the lungs, noting any unusual sounds
heart and decrease the heart rate through a during inspiration and expiration
negative chronotropic effect. • Examining the extremities for edema
Milrinone has inotropic action and is used in the • Checking the jugular veins for distention
short-term management of severe heart failure • Measuring weight
that is not controlled by the digitalis preparation. • Inspecting sputum raised (if any) and noting the
appearance (e.g., frothy, pink tinged, clear, yellow)
(Ford 403)
• Looking for evidence of other problems such as cyanosis,
shortness of breath on exertion (if the patient is allowed
Why do we give it? ‘’Reason’’ out of bed) or when lying flat, and mental changes
(Ford 405)
• Heart failure • Pediatric
• Atrial fibrillation • The drug is withheld and the primary health care
provider notified before administration of the drug if
the apical pulse rate in a child is below 70 bpm, or
Contraindications below 90 bpm in an infant.
• Daily weights
• Digitalis toxicity
• known hypersensitivity
• ventricular failure, ventricular tachycardia, cardiac Interactions:
tamponade, restrictive cardiomyopathy, or AV block.
(Ford 404) • Thyroid hormone: Decreased effects of digoxin
• Thiazide and loop diuretics: Increased diuretic
Digoxin toxicity & electrolyte imbalances electrolyte disturbances, especially hypokalemia
• Plasma digoxin levels are monitored closely. Blood for

plasma level measurements should be drawn Adverse effects
immediately before the next dose or 6 to 8 hours after
the last dose regardless of route. Therapeutic drug • Headache
levels are between 0.8 and 2 nanograms/mL. Plasma • Weakness, drowsiness
digoxin levels greater than 2 nanograms/mL are • Visual disturbances (blurring or yellow halo)
considered toxic and are reported to the primary health
care provider Hypokalemia makes the heart muscle • Arrhythmias
more sensitive to digitalis, thereby increasing the • Nausea and anorexia
possibility of developing digitalis toxicity. At frequent
intervals, observe patients with hypokalemia closely for
signs of digitalis toxicity. (Ford 405)

Loading dose:* 0.75–1.25 mg
orally or 0.6–1 mg IV
Heart failure,
Digoxin Lanoxin Maintenance: 0.125–0.25 mg/day
atrial fibrillation orally
Lanoxicaps: 0.1–0.3 mg/day orally
Short-term management Short-term management Loading dose: 50 mcg/kg IV

Milrinone.
of heart failure of heart failure IV: Up to 1.13 mg/kg/day
Nitrates

The nitrates act by relaxing the smooth muscle layerof • The dose of sublingual nitroglycerin may be repeated every 5
blood vessels, increasing the lumen of the artery or minutes until pain is relieved or until the patient has received
arteriole, and increasing the amount of blood flowing three doses in a 15-minute period. One to two sprays of
through the vessels. (Ford 382) translingual nitroglycerin may be used to relieve angina, but
no more than three metered doses are recommended within
a 15-minute period.
• Do not rub the nitroglycerin ointment into the patient’s skin,
because this will immediately deliver a large amount of the
drug through the skin. Exercise care in applying topical
nitroglycerin and do not allow the ointment to come in
contact with your fingers or hands while measuring or
applying the ointment, because the drug will be absorbed
• Relieve pain of acute anginal attacks through your skin, causing a severe headache.
• The primary health care provider is notified if any of the
• Prevent angina attacks (prophylaxis )
following occur:
• Treat chronic stable angina pectoris (Ford 382)
• Heart rate of 20 bpm or more above the normal rate
• Rapid weight gain of 5 lb or more
• Unusual swelling of the extremities, face, or abdomen
• Dyspnea, angina, severe indigestion, or fainting
• Avoid the use of alcohol unless use has been permitted by the
• Notify your emergency response providers if the drug does not
Adverse effects
relieve pain or if pain becomes more intense despite use of
this drug.
• Central nervous system (CNS) reactions, such as • Follow the recommendations of the primary health care
headache (may be severe and persistent), dizziness, provider regarding frequency of use.
weakness, and restlessness • Keep an adequate supply of the drug on hand for events, such
• Other body system reactions, such as hypotension, as vacations, bad weather conditions, and holidays.
flushing (caused by dilation of small capillaries near the • Keep a record of the frequency of acute anginal attacks (date,
surface of the skin), and rash (Ford 382) time of the attack, drug, and dose used to relieve the acute
pain), and bring this record to each primary health care
provider or clinic visit.
Interactions:
Contraindications
• Aspirin: Increased nitrate plasma concentrations and
action may occur
• Hypersensitivity to the drugs, severe anemia,
• Calcium channel blockers: Increased symptomatic
closed-angle glaucoma, postural hypertension, early
orthostatic hypotension
myocardial infarction (sublingual form), head trauma, • Dihydroergotamine: Increased risk of hypertension and
cerebral hemorrhage (may increase intracranial decreased antianginal effect
hemorrhage), allergy to adhesive (transdermal system), • Heparin: Decreased effect of heparin
or constrictive pericarditis. Patients taking • Phosphodiesterase inhibitors: Severe hypotension and
phosphodiesterase inhibitors (drugs for erectile cardiovascular collapse may occur
dysfunction) should not use nitrates. (Ford 382) • Alcohol: Severe hypotension and cardiovascular collapse
may occur

Initial dose 5–20 mg orally;
maintenance dose 10–40 mg BID,
Isordil, Dilatate SR, Treatment and TID orally
Isosorbide
Monoket prevention of angina Sublingually: 2.5–5 mg
Prevention: 5–10 mg sublingually,
5 mg chewable
CNS Drugs
Central Acting Antiadrenergics
How do they work? “Action” Nursing Alert

Acts on the central nervous system (CNS) rather than If a significant decrease in blood pressure (a drop of
on the peripheral nervous system. This group affects 20 mm Hg systolic or a systolic pressure below 90
specific CNS centers, thereby decreasing some of the mm Hg) occurs after a dose of an adrenergic
activity of the sympathetic nervous system. blocking drug, withhold the next drug dose and
(Ford 256) notify the primary health care provider immediately.
A dosage reduction or discontinuation of the drug
may be necessary. Some adrenergic blocking drugs
Indications (e.g., prazosin or terazosin) may cause a first-dose
effect. A first-dose effect occurs when the patient
• Hypertension
experiences marked hypotension (or postural
• BPH
hypotension) and syncope with sudden loss of
consciousness with the first few doses of the drug.
(Ford 259)
Adverse Reactions
• Dry mouth, drowsiness, sedation, anorexia, rash,
malaise, and weakness are generalized reactions to Nursing management
antiadrenergic drugs that work on the CNS. • Do not stop taking the drug abruptly, except on the
• Hypotension, weakness, lightheadedness, and advice of the primary health care provider. Most of
bradycardia are adverse reactions associated with these drugs require that the dosage be gradually
the administration of peripherally acting decreased to prevent precipitation or worsening of
antiadrenergic drugs. (Ford257) adverse effects.
• Notify the primary health care provider promptly if
adverse drug reactions occur.
Contraindications • Observe caution while driving or performing other
hazardous tasks because these drugs (β-adrenergic
Centrally acting antiadrenergic drugs are blockers) may cause drowsiness, dizziness, or
contraindicated in active hepatic disease, in lightheadedness.
antidepressant therapy using MAOIs, and in patients • Immediately report any signs of HF (weight gain,
with a history of hypersensitivity to these drugs. difficulty breathing, or edema of the extremities).
(Ford 257) • Do not use any nonprescription drug (e.g., cold or
flu preparations or nasal decongestants) unless you
have discussed use of a specific drug with the
Interactions primary health care provider.
• Adrenergic drugs: Increased risk of hypertension
providers of therapy with this drug.
• Levodopa: Decreased effect of the levodopa,
• Keep all primary health care provider appointments
hypotension
because close monitoring of therapy is essential.
• Anesthetic agents: Increased effect of the
• Check with a primary health care provider or
anesthetic
clinical pharmacist to determine if the drug is
• β blockers: Increased risk of hypertension
to be taken with food or on an empty stomach.
• Lithium: Increased risk of lithium toxicity
(Ford 259-260)
• Haloperidol: Increased risk of psychotic behavior

Hypertension, severe pain 100–600 mcg/day orally
Catapres, Catapres-TTS
Clonidine in patients with cancer Transdermal: release rate 0.1–0.3
(transdermal
mg/24 hr
250 mg orally BID or TID;
Hypertension,
Methyldopa N/A maintenance dose: 2 g/day; 250–500
hypertensive crisis
mg q 6 hr IV
PNS Drugs
- Peripherally Acting Antiadrenergics
How do they work? “Action” Education

Inhibits the release of norepinephrine from certain Instruct patients to rise slowly from a sitting or lying
adrenergic nerve endings in the peripheral nervous position. Provide assistance for the patient getting out of
system. (Ford 256) bed or a chair if symptoms of postural hypotension are
severe. Place the call light nearby and instruct patients to
ask for assistance each time they get in and out of bed or
a chair. Assist the patient in bed to a sitting position and
Indications have the patient sit on the edge of the bed for about 1
minute before ambulating. Help seated patients to a
• Hypertension standing position and instruct them to stand in one place
• BPH for about 1 minute before ambulating. Remain with the
patient while he or she is standing in one place, as well as
during ambulation. Instruct the patient to avoid standing
in one place for prolonged periods. This is rarely a prob-
lem in the hospital but should be included in the patient
Adverse Reactions and family discharge teaching plan. Teach the patient to
avoid taking hot showers or baths, which tend to increase
• Dry mouth, drowsiness, sedation, anorexia, rash,
malaise, and weakness are generalized reactions to vasodilation. (Ford 259)
antiadrenergic drugs that work on the CNS.
• Hypotension, weakness, lightheadedness, and
bradycardia are adverse reactions associated with the Nursing management
administration of peripherally acting antiadrenergic
drugs. (Ford 257) • Do not stop taking the drug abruptly, except on the
advice of the primary health care provider. Most of these
drugs require that the dosage be gradually decreased to
prevent precipitation or worsening of adverse effects.
• Notify the primary health care provider promptly if
Contraindications
adverse drug reactions occur.
The peripherally acting antiadrenergic drugs are • Observe caution while driving or performing other
contraindicated in patients with a hypersensitivity to any hazardous tasks because these drugs (β-adrenergic
of the drugs. Reserpine (Serpasil) is contraindicated in blockers) may cause drowsiness, dizziness, or
patients who have an active peptic ulcer or ulcerative lightheadedness.
colitis and in patients who are mentally depressed. • Immediately report any signs of HF (weight gain, difficulty
breathing, or edema of the extremities).
• Do not use any nonprescription drug (e.g., cold or flu
preparations or nasal decongestants) unless you have
Interactions discussed use of a specific drug with the primary health
care provider.
• Adrenergic drugs: Increased risk of hypertension • Inform dentists and other primary health care providers
• Levodopa: Decreased effect of the levodopa, of therapy with this drug.
hypotension • Keep all primary health care provider appointments
• Anesthetic agents: Increased effect of the anesthetic because close monitoring of therapy is essential.
• β blockers: Increased risk of hypertension • Check with a primary health care provider or clinical
• Lithium: Increased risk of lithium toxicity
pharmacist to determine if the drug is to be taken with
• Haloperidol: Increased risk of psychotic behavior
food or on an empty stomach. (Ford 259-260)

Hypertension: 1–8 mg orally daily
Doxazosin Cardura Hypertension, BPH
BPH: 1–16 mg orally daily
1–20 mg orally daily in divided

Prazosin Minipress Hypertension
doses
Cardiac
Antidysrhythmics I
Class Drug Name Mainly for Image of ECG Strip

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

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

Potassium-channel blockers V Fib
Class 4 Verapamil Atrial Fibrillation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1. Give it FAST = IV push in
1-2 seconds NCLEX TIP
2. Saline Flush immediately AFTER
DEcreases the heart rate, like putting it into a DEN (for foxes) or
Downstairs.
Given for:
* Key points:
Know how this rhythm looks! SVT = Super Fast!
Give it FAST = IV push in 2 seconds followed by flush
Super Fast = SVT
B Beta Blockers
“Propranolol”
A fib & A flutter
SE: LoL = Low BP, Low HR
Common Question
What drug is causing this rhythm?
Propranolol
Beta blockers end in “-LOL”
Memory trick: Lower the 2 L’s - Low HR & Low BP
Given for: <60
Hypertension & to put the brakes on fast rhythms like SVT, tachycardia, A fib, & A flutter. 5 x 10 = 50
Side Effects: 1 2 3 4 5
• B - Bradycardia (HR below 60 BPM) & low BP
• B - Bronchospasm (avoid asthma & COPD)
• B - Blood glucose masking s/s of low sugar
• B - Bad for clients in end stage heart failure
* Orthostatic hypotension (dizziness upon standing) - teach slow position changes!
Antidysrhythmics III
ABCDs - Atrial Rhythm Drugs
C
C C
Ca Channel Blockers Hypertension, SVT, Tachycardia, Calcium Contracts the muscles
Calcium
Ca
Since calcium contracts the muscles, when calcium is blocked with CCBs,
it calms the heart
Memory Trick: CCBs lower the Couple heart vitals: HR & BP
Given for:
Hypertension, tachycardia, SVT, A Fib, & A Flutter
Side Effects:
Orthostatic hypotension (dizziness upon standing) - teach slow position changes
3 Common Questions
Q1: Intended EFFECT for Q2: Priority adverse effect Q3: Most important patient
Diltiazem? to watch for when giving teaching when giving
Amlodipine? Verapamil?
Ventricular rate decreased Dizziness Slow position changes
from 160 to 70s
Q1: Intended EFFECT for Q2: Priority adverse effect
Diltiazem? KEY WORD
to watch for when giving
Q2: Priority adverse effect Q3: Most important patient Amlodipine?
to watch for when giving teaching when giving Slow position changes
Amlodipine? Verapamil? Ventricular rate decreased Dizziness
Dizziness
160 70 beats/min Slow position changes
from 160 to 70s
Diltiazem
Drug Name Indication & Key Terms: D is for DEEP Contraction

D Digoxin A fib & Heart Failure
DIGOXIN DEEP contraction
Digoxin Digoxin
Is a TOXIN so monitor levels - under 2.0 is SAFE.
It DIGs for a deeper heart contraction to help the heart contract more
forcefully & decreases the heart rate (NOT Blood pressure), so no need
for slow position changes
Main Side Effect = Toxicity Key Sign Common NCLEX Question

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

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

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

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

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

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

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

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

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

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

SYNC
Don’t let
THE NCLEX TRICK YOU
CARDIOVERSION DEFIBRILLATION
Cardioversion Defibrillation
C - Cardioversion D - Defibrillation - if you
C - Count a pulse D - Don't have a pulse
C - Controlled Rhythms D - Deadly rhythms (VFib & Vtach no pulse)
Synchronized button & sedation D - Don't Synch (shock away!)
PULSE NO PULSE
SYNC
SYNC
SYNC
Antihypertensive
Clonidine
Indication MEMORY TRICK
Clonidine Cardiac DOWN

Very strong blood pressure lowering drug! Used last if
CLONIDINE
high blood pressure is not responsive to other meds. NORMAL
CLONIDINE
HIGH
LOW
NCLEX TIP Caution
Don’t get tricked!
Don’t get tricked with sound alike drug names!
Clonidine is not Famotidine or Clozapine.
FAMOTIDINE
• Famotidine (H2 blocker for acid reflux) CLOZAPINE
• Clo-zapine (antipsychotic med)
Mech Action
It decreases the heart rate, cardiac output, & blood pressure.
In fancier terms, it is an Alpha 2 agonist & decreases the
sympathetic response from the central nervous system (CNS)
resulting in decreased peripheral vascular resistance and
vasodilation.
Patient Teaching #1 PRIORITY

MEMORY TRICK
NEVER
STOP
Abruptly
If BP is Low = Got to go SLOW
Key point CLONIDINE Clonidine
PRIORITY Teaching:
NCLEX TIP NORMAL
HIGH
LOW
1. Do NOT stop taking “Abruptly”

180 Systolic
180
2. Slowly taper off over 2 - 4 days

3. Teach Slow position changes

Clonidine Clonidine Patch...
Do NOT stop taking abruptly!
Change the patch Antihistamines
Selectively activates every 7 days
alpha 2 receptors in CNS
NEVER
STOP
7 days
Abruptly
Clonidine
CLONIDINE
NSAIDs ACETAMINOPHEN
(TYLENOL)
Clonidine CNS
DEPRESSANT
2 2
2
2 2
2 2
Vasopressors
Top Tested Drugs
Epinephrine & Norepinephrine Kaplan Question

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

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

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

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

B beta blockers
Atenolol - Neg. - Neg. - Neg.
C calcium CB - Neg. - Neg. - Neg.
C cardiac glycosides
+ Pos. - Neg. - Neg.
Digoxin
D dobutamine + Pos. X X
D dopamine + Pos. + Pos. X
E epinephrine + Pos. + Pos. X
SIGNS & SYMPTOMS TREATMENT: PHARMACOLOGY
PAIN–Jaw, back, mid back/shoulder pain, heartburn (epigastric), Substernal MYOCARDIAL INFARCTION DURING–Any Chest Pain
Key words = priority: “Sudden” “Crushing” “radiating” NCLEX TIP O–Oxygen
SOB “dyspnea” “labored breathing” A–Asa
NAUSEA Vomiting “Abdominal pain” PATHO DIAGNOSTICS N–Nitro–under tongue x 3 Max
SWEATING “Diaphoresis” M–Morphine - Any pain after = MI (injury)
MI=Heart muscles DIE “necrosis” (minutes = muscle death) 1st–EKG AFTER–MI
PALE COOL SKIN “dusky”
Blockage of Coronary Artery “O2 Tube” (Any chest pain or MI symptoms) Clot Stabilization:
ANXIETY
Heparin: prevents CLOT growth (NOT dissolve only t-PA)
PTT: 46 - 70 “3 x MAX” Antidote: Protamine Sulfate
CAUSES Memory Trick: “HaPTT” frog
Heart Rest:
SODDA B–Beta Blockers (-lol) Atenolol
S–Stress, Smoking, Stimulants (caffeine, amphetamines) Blocks both BP & HR (Lol = Low BP & HR)
O–Obesity–(BMI over 25) CAUTION:
D–Diabetes & HTN (over 140/90) B–Bad for Heart Failure patients (CHF)
D–Diet (high cholesterol) animal fats B–Bradycardia (60 or Less) & BP low (HR LESS than 60)
A–African American males & Age (over 50) B–Breathing Problems “wheezing” (Asthma, COPD)
B–Blood sugar masking “hides s/s” (Diabetics)
*Men more than women C–Calcium Channel Blockers
Calms BP & HR-(AVOID Low Hr & BP)
PROGRESSION (Nifedipine, Diltiazem, Verapamil)
“Ischemic heart disease” -dipine “declined BP & HR”
CAM -zem “zen yoga for heart”
C–CAD “coronary artery disease” -amil “chill heart”
A–ACS “acute coronary syndrome” D–Dilators (vasOdilators = O2 to heart)
Angina - Stable “Safer”- relieved w/rest 2nd–LABS Nitroprusside (only for HTN crisis) & Isosorbide
Angina - Unstable “Unsafe” - Unrelieved T–Troponin (Over 0.5 ng/mL) Nitro “Pillow for heart”
M–MI (heart die) NO viagra “-afil” Sildenafil = DEATH!
T–Trauma (ONLY indicator of MI) Nitro drip: STOP if Systolic BP below 90 or 30 mmHg Drop
Other labs: Crp, Ckmb, SE: HA is Common + SLOW Positions changes “syncope”
Myoglobin, CRP (inflammation) DISCHARGE–GOING HOME
Heart Rest:
1st choice A–Ace (-pril) Lisonopril “chill pril”
TREATMENT: PHARMACOLOGY 2nd choice A–ARBs (-sartan) Losartan “relax man”
Antihypertensive (BP ONLY) *HOLD: Low BP (not HR)
PATIENT EDUCATION AC–Anti Clogging of Arteries Precautions:
A–Antiplatlet HOLD if: Platlets 50K or LESS A–Avoid Pregnancy
DRESS “below 50 gets risky” (not INR, not aPTT) A–Angioedema “thick tongue”
D–Diet low (sodium & fluids (2g/2L per day) A–ASA (Airway Risk) *only Ace *NCLEX TIP*
Prevent HF Heart Failure=Heavy Fluid C–Clopidogrel C–Cough *only Ace
Report "New, Rapid" Weight Gain-Water Gain! C–Cholesterol Lowering “-Statin” Creatinine (Kidney) (normal: 0.9 -1.2) *only Ace
R–Reduce Stress, Alcohol, Caffeine, Cholesterol (animal fats) Lovastatin “stay clean” E–Elevated K+ (normal 3.5-5.0) *NCLEX TIP*
E–Exercise (30 min x 5 days/wk) CAUTION: AVOID Salt Substitues + Green Leafy veggies
S–Smoking Cessation NO grapefruit • 1st–Cardiac Monitor
S–Sex (2 flights of stairs with NO SOB) NCLEX TIP Liver Toxic–report “clay colored stools” • High Potassium = High Pump
Muscle pain (Rhabdomyolysis risk) • Monitor: muscle cramps, spasms,
*AVOID NSAIDS (naproxen, ibuprofens) = increases CLOT risk! peaked T waves, ST changes
Late night–take at dinner
CATH LAB
C–Contrast = Kills Kidneys “Angioplasty, Angiogram, CABG”
A–Allergy to Iodine (warm flushing normal)
B–Bleeding–direct manual pressure (above site)
NO=heparin, warfarin, ASA, clopidogrel
C–Creatinine “Kidney” (normal: 0.9 - 1.2)
REPORT: Creatinine Over 1.3 & Urine below 30 ml/hr
STOP Metformin 48 hrs (before/after)
C–Can’t feel pulses (Pulses = Perfusion O2)
Diminished pulses (4-12 hrs post-procedure) MAX
PRIOITY:
Non palpable pedal pulse AFTER = CALL HCP (Dr.)
Key words: “cool leg, pulse non palpable,
present only with doppler US.”
COMPLICATIONS AFTER MI
ACUTE: (weeks after)
Cardiogenic Shock (severe hypotension)
V fib/V tach (no pulse) = DEADLY
Defibrillate=Don’t have a pulse
Cardioversion=Count a pulse *synchronize*
CHRONIC: (lifetime)
Heart failure “Heavy Fluid”
Rapid weight gain (Water Gain),
Worsening crackles (fluid in Lungs “pulmonary, edema”)
Sudden edema (JVD, peripheral edema “+1 pitting”)
#1 Priority–IV Diuretics–Furosemide, Bumetanide “dried”
(NOT isosorbide)
NitrOglycerin NO viagra “-afil” Sildenafil = DEATH!

NORMAL ADVERSE EFFECT:
HA=Normal Side Effect
Hypotension=Adverse effect
O2 to Heart (need slow position changes)
PILL (or spray) Nitro Patch (Transdermal nitro patch)

S–Stable Angina U–Unstable Angina
S–Safe Angina U–Unsafe Angina
S–Stops when activity STOPS (Stress Induced) U–Unrelieved with rest /Unpredictable (anytime)
*Take Before strenuous activity 1 x daily NOT PRN
GOAL: 1 patch at a time NOT 2 patches
NO chest pain=Daily activities YES Shower is ok
“comb hair, fix hair, get dressed, make up, making bed etc.” LOCATION: Rotate locations Daily
TAKING MED: “Clean, Dry, shaven area” teach patient to wash hands
CALL 911: PAIN 5 min. After 1st dose. after application
3 doses max x 5 min apart Upper Body (subclavian, arm, upper chest)
NO SWALLOW–SL under NOT: hairy, scarred, burned, callous
STORAGE: NOT BROKEN SKIN
NO LIGHT–NO HEAT *TEST TIP: Patch fall off? (Over 1 hour ago)
NOT: pill box, car, plastic bag, pocket Take nitro (pill/spray) New patch can take 40–60 min.
YES: purse ok *Nurses wear gloves! Will cause MAJOR HA if it comes
*Replace every 6 months into contact with skin!
ANTICOAGULANTS (clot prevention) BLEED RISK(Patient Education)

Antiplatelets (LESS potent) NO peptic ulcers (or active bleeds)
ASA & Clopidogrel NO Rugs/dim halls (Well lit halls)
Platelets LESS than 50k = RISKY (Normal: 150–400k) NO razors, hard brushing, constipation
NOT INR or PTT NO NSAIDS like naproxen/ ibuprofen
Anticoagulants (MOST potent) NO EGGO vitamins
Warfarin = INR “warINR” E–E Echinacea, A vitamin
Range: 2.5–3.5 (3 x MAX range) G–Gingko, Garlic, Ginseng
Antidote: Vitamin K (green leafy veggies) *NOT K+ = potassium* O–Omega 3
Heparin (Enoxaparin) = aPTT “HaPTT” frog Partial Thromboplastin Time
Range: 46–70 (3 x MAX range)
Antidote: Protamine Sulfate
MYOCARDIAL INFARCTION
TREATMENT
(+) Positive Troponin = Heart Attack (MI)
PRIORITY: REMOVE THE CLOT!
“CATH LAB” OR SURGERY CLOT BUSTER “Thrombolytics, Fibrinolytics”
“PCI” -graphy, -plasty t-PA: Alteplase, Streptokinase (Allergy risk)
Dissolves Clot ONLY (heparin does NOT)
BLEED RISK
8 hour duration
NO injections (IV, SQ, IM, ABG)
NOT via central lines (CVC)
ONLY “compressible site” (IV, PICC)
NOT FOR:
Active Bleeds:
Peptic Ulcers (but menstruation is safe)
History:
Arteriovenous malformations
Intracranial “Cerebral” hemmorhage
Hypoglycemia (relative contraindication)
BEFORE AFTER
Hypertension (over 180/110) TEST TIP
NPO 6 - 12 hrs NO heavy lifting–lie flat
NO Baths–Shower ok (dont soak)
Infected Incision
“red, warm, drainage”
STRESS TEST
Non MI (Non priority) • Spot the Narrowing
TREADMILL STRESS TEST CHEMICAL: NUCLEAR PHARMACOLOGICAL STRESS TEST
STOP test: 24–48 hours BEFORE
chest pain NO Cigarettes, Caffeine (tea, soda, coffee) *NO DECAF
ST elevation NO Meds: Nitro, Beta Blocker, Theophylline (stimulant)
NPO (nothing oral) 4 hrs before/after
NOTES
Cholesterol
Lowering Agents
Drug name: Memory Trick:

Caution
“-statin” statin Nystatin

NYSTATIN
S - Statin S - Statin
NYSTATIN
Atorvastatin S - Stay Clean S - Smooth Tin Can

“StaaaTIN”
Simvastatin
Lovastatin NOT Nystatin – that’s an antifungal
Rosuvastatin medicine for treating YEAST infections
Indication: MOA:
It does this by preventing cholesterol production in the liver. Technically
High cholesterol levels by preventing an enzyme the LIVER needs to make the cholesterol!
• Hypercholesterolemia
• Hyperlipidemia Bad Good
Total Cholesterol 200 HDL “HIGH Lipids” 40
(Different names for the same thing)
Triglycerides 150
LDL “Loser Lipids” 100
NORMAL
HIGH
LOW
KEY POINTS S TAT ATI Question

“Patient on Lovastatin, when would the
“MUSCLE CRAMPS”
nurse notify the HCP?”
“MUSCLE spasms”
Answer: Muscle aches & cramps
Sore MUSCLES “MUSCLE ACHES”
Kaplan Question
Toxic Liver (ALT & AST) “Report new muscle tenderness to the HCP”
AVOID Grapefruit & St Johns Wart

HESI Question
Take at NIGHT NCLEX Term “Report muscle pain & Tenderness without Injury”
“Take at dinner time or bed-time” Answer: Rosuvastatin
Notes

Simple Nursing@Migrant Nurse

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Simple Nursing@Migrant Nurse

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Simple Nursing

Prioritization & Delegation

Assessment Risks Education

❖ Put on a new pair of clean gloves.

BMP Basic Metabolic Panel

Potassium (K+) Potassium pumps the heart muscles

Electrolytes Labs Treatment

K+ 3.5 - 5.0 mEq/L Hyperkalemia Hypokalemia

Common NCLEX Question

1. IV Regular insulin R & 50% Dextrose

Normal ST elevation ST Depression

Sodium Calcium Magnesium

Ca 9.0 - 10.5 mEq/L Mg+ 1.3 - 2.1 mEq/L

Immunity - the defense system of the body to ﬁght infection.

The whole blood in the blood vessels.

Blood clotting proteins that help to stop bleeding by

Below 7 = Heaven or blood transfusion

Hematocrit - hemato creek

RBC - Red blood cell count

Low = Anemia, Renal Failure

Phenytoin 2.0 + Kidney Killers

WBC - White Blood Cells

1. WBC Total Count

B - Big stretched out ventricles

Acid Base ABG

B A Acidotic NORMAL pH Alkalotic

Respiratory Acidosis = Low & Slow Kaplan Question

Severe Acidosis = Hypercapnic Hypoxia earliest sign

Who to see ﬁrst

ABCS Priority: Less than 5,000 WBC

HTN crisis (over 180 sys) = Unrelieved with pain meds

ABGs (not pulse oximeter)

INR > 1.3 aPTT > 100 PRIORITY

aPTT - Over 100 Priority: Less than 5,000 WBC

Common NCLEX Question

1. A client with a low-grade fever, headache, and fatigue

Electrolyte Function HYPER “HIGH” Hypo “low”

HYPERnatremia (over 145) Hyponatermia (below 135)

135 - 145 • Blood Pressure LOW GRADE FEVER RESPIRATORY ARREST

Sodium’s sidekick HYPERchloremia (over 107) Hypochloremia (below 97) t

HYPERmagnesemia (over 2.1) Hypomagnesemia (below 1.3)

1. CARDIAC - CALM & QUIET 1. CARDIAC - BUCK WILD!

1.3 - 2.1 M - Muscles (relaxes) CALM & QUIET

HYPERcalcemia (over 10.5) Hypocalcemia (below 9.0)

SWOLLEN & SLOW - MOANS, GROANS T - Trousseau’s

HYPERphosphatemia (over 4.5) Hypophosphatemia (below 3.0)

‘’LOW CALCIUM’’ BAJA CA+ Swollen & SLOW - MOAN,

• These solutions have lower osmolality than body ﬂuids.

• These solutions have higher osmolality than body ﬂuids.

Marching band suit method

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

A B of your ABG exam.

Set Up the Chart

Phase 1 - Set up the chart

HCO3 comes 3rd.

Phase 2 - Key numbers to memorize

Phase 3 - Label it A & B

ABG Practice Question 1 A B

ABG Practice Question 2

ABG Practice Question 3

How to Solve ABG Questions in 3 Steps

pH below 7.35 = Acidosis A B

Step 2 - Match pH with partner

Let’s say pH is under 7.35, PaCO2 is B