mark-klimek-nclex-rn-audio-review123.pdf
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Sep 05, 2024
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About This Presentation
Nclex preparation
Slide Content
Mark Klimek Nclex RN Audio Review
Adult (EDP University)
Scan to open on Studocu
Studocu is not sponsored or endorsed by any college or university
Mark Klimek Nclex RN Audio Review
Adult (EDP University)
Scan to open on Studocu
Studocu is not sponsored or endorsed by any college or university
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Adult (EDP University)
Scan to open on Studocu
Studocu is not sponsored or endorsed by any college or university
Mark Klimek Nclex RN Audio Review
Adult (EDP University)
Scan to open on Studocu
Studocu is not sponsored or endorsed by any college or university
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Mark Klimek NCLEX RN Audio Review
Acid Base Balance
If the pH and the bicarbs (HCO3) are in the same direction then it is
metabolic.
Different direction it is respiratory
Normal pH is 7.35-7.45
Normal Bicarbonate (HCO3) is 22-26
pH↓ Bicarbs↓ both are in the same direction so they are metabolic acidosis (P+↑)
pH↑ Bicarbs↑ both are in the same direction sot they are metabolic alkalosis (P+↓)
pH ↓ Bicarbs↑ both of them are not in the same direction so they are respiratory
acidosis
pH ↑ Bicarbs ↓ both of them are not in the same direction so they are respiratory
alkalosis
Ex. pH of 7.50 and Bicarbs (HCO3) of 25 will be respiratory alkalosis
Signs and Symptoms of Acid Base
As the pH goes so goes my patient which means if the pH goes up
everything in my patient system will go up. And if the pH goes down my
patient system shut down. EXCEPT FOR POTASSIUM.
Alkalosis s/s- irritability, hyperreflexia of 3 and 4, tachypnea, tachycardia,
borborygmi (increase bowel sound). Seize. Needs suction machine at the
bedside
Acidosis s/s- hyporeflexia, bradycardia, leathery, obtunded, paralytic ileus,
coma. Respiratory Arrest. Needs an ambu bag at the bedside
Causes of Acid Base Balances
If it is a lung scenario then it respiratory
Over ventilating pick respiratory alkalosis
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Acid Base Balance
If the pH and the bicarbs (HCO3) are in the same direction then it is
metabolic.
Different direction it is respiratory
Normal pH is 7.35-7.45
Normal Bicarbonate (HCO3) is 22-26
pH↓ Bicarbs↓ both are in the same direction so they are metabolic acidosis (P+↑)
pH↑ Bicarbs↑ both are in the same direction sot they are metabolic alkalosis (P+↓)
pH ↓ Bicarbs↑ both of them are not in the same direction so they are respiratory
acidosis
pH ↑ Bicarbs ↓ both of them are not in the same direction so they are respiratory
alkalosis
Ex. pH of 7.50 and Bicarbs (HCO3) of 25 will be respiratory alkalosis
Signs and Symptoms of Acid Base
As the pH goes so goes my patient which means if the pH goes up
everything in my patient system will go up. And if the pH goes down my
patient system shut down. EXCEPT FOR POTASSIUM.
Alkalosis s/s- irritability, hyperreflexia of 3 and 4, tachypnea, tachycardia,
borborygmi (increase bowel sound). Seize. Needs suction machine at the
bedside
Acidosis s/s- hyporeflexia, bradycardia, leathery, obtunded, paralytic ileus,
coma. Respiratory Arrest. Needs an ambu bag at the bedside
Causes of Acid Base Balances
If it is a lung scenario then it respiratory
Over ventilating pick respiratory alkalosis
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A woman over zestily using her breathing technique during labor. It is a lung
scenario and the client is over ventilating. (Respiratory Alkalosis)
Under ventilating pick respiratory acidosis
You a have child who was a victim of near drowning. It’s a lung scenario and
under ventilating. (Respiratory Acidosis)
Patient has emphysema and air trapping. Lungs/ under ventilating/Respiratory
acidosis
Pay attention to the SaO2 (95-100) when it is low/under ventilating
Somebody on a PCA/ depress respiration rate/ what acid base disorder would tell
that the patient needs get out of that pump. ANS would be respiratory acidosis
If it not lungs then it metabolic
If the patient has prolong gastric vomiting or suctioning pick metabolic alkalosis
(losing acid)
Patient has had GI surgery and has a NG tube to low to intermitted suctioning for
three days/metabolic alkalosis
Your patient has hyperemesis-gravidarum /metabolic alkalosis
For everything else that’s not lung pick metabolic acidosis
Acute renal failure is metabolic acidosis
Your patient with hyperemesis-gravidarum is now dehydrated/metabolic acidosis
Infant has diarrhea/metabolic acidosis
Third degree burn over 60% of the body first phase/ metabolic acidosis
Diarrhea will cause metabolic acidosis
Kussmal respirations is metabolic acidosis
Before measuring the ABGs you should perform the Allen’s test. The results
should be positive then it’s ok to take the ABGs from the patient.
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scenario and the client is over ventilating. (Respiratory Alkalosis)
Under ventilating pick respiratory acidosis
You a have child who was a victim of near drowning. It’s a lung scenario and
under ventilating. (Respiratory Acidosis)
Patient has emphysema and air trapping. Lungs/ under ventilating/Respiratory
acidosis
Pay attention to the SaO2 (95-100) when it is low/under ventilating
Somebody on a PCA/ depress respiration rate/ what acid base disorder would tell
that the patient needs get out of that pump. ANS would be respiratory acidosis
If it not lungs then it metabolic
If the patient has prolong gastric vomiting or suctioning pick metabolic alkalosis
(losing acid)
Patient has had GI surgery and has a NG tube to low to intermitted suctioning for
three days/metabolic alkalosis
Your patient has hyperemesis-gravidarum /metabolic alkalosis
For everything else that’s not lung pick metabolic acidosis
Acute renal failure is metabolic acidosis
Your patient with hyperemesis-gravidarum is now dehydrated/metabolic acidosis
Infant has diarrhea/metabolic acidosis
Third degree burn over 60% of the body first phase/ metabolic acidosis
Diarrhea will cause metabolic acidosis
Kussmal respirations is metabolic acidosis
Before measuring the ABGs you should perform the Allen’s test. The results
should be positive then it’s ok to take the ABGs from the patient.
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Ventilator Machine
High pressure alarms- kinks in the tubing/unkink, water condensing in the
tube/empty water of tubing, mucous secretions/change position cough deep breath
first then suction if not working. (Obstructions Problem)
Low pressure alarm- decrease resistance, disconnection of main tubing/ reconnect
the tube back, oxygen sensor tubing disconnection/ just plug it back in.
(Disconnections Problem)
-Respiratory Alkalosis (over) means the ventilator is too high
-Respiratory Acidosis (under) means the ventilator is too low
Alcoholism/Drugs
-The number problem with alcoholism is denial.
-Denial allows the abuser to keep doing what they are doing.
-Denial is refusing to accept reality of their problem.
-Treat denial by confronting by pointing to person of what they are doing.
-Don’t attack the abuser but confront them about their problem (Don’t Support)
-Don’t confront another health care worker with “You” but with “I”
-You support a person that a lose and grief in a family or friend
Dependency is when the abuser gets the significant other to do things for them or
make decision for them
Co-dependency is when the significant other is having a positive self-esteem for
the abuser
Treatments are set limits and enforce them by teaching the significant other to say
“NO” and work on their self-esteem.
Manipulation is the abuser gets the significant other to do things for them that’s
not in the best interest of the significant other. The nature of the act is interest and
harmful. Very easy to treat
Wernicke’s is an encephalopathy and Korsakoff’s is psychosis
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High pressure alarms- kinks in the tubing/unkink, water condensing in the
tube/empty water of tubing, mucous secretions/change position cough deep breath
first then suction if not working. (Obstructions Problem)
Low pressure alarm- decrease resistance, disconnection of main tubing/ reconnect
the tube back, oxygen sensor tubing disconnection/ just plug it back in.
(Disconnections Problem)
-Respiratory Alkalosis (over) means the ventilator is too high
-Respiratory Acidosis (under) means the ventilator is too low
Alcoholism/Drugs
-The number problem with alcoholism is denial.
-Denial allows the abuser to keep doing what they are doing.
-Denial is refusing to accept reality of their problem.
-Treat denial by confronting by pointing to person of what they are doing.
-Don’t attack the abuser but confront them about their problem (Don’t Support)
-Don’t confront another health care worker with “You” but with “I”
-You support a person that a lose and grief in a family or friend
Dependency is when the abuser gets the significant other to do things for them or
make decision for them
Co-dependency is when the significant other is having a positive self-esteem for
the abuser
Treatments are set limits and enforce them by teaching the significant other to say
“NO” and work on their self-esteem.
Manipulation is the abuser gets the significant other to do things for them that’s
not in the best interest of the significant other. The nature of the act is interest and
harmful. Very easy to treat
Wernicke’s is an encephalopathy and Korsakoff’s is psychosis
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They are induce by thiamine deficiency (vitamin B1)
This client loss touch with reality
S/S is amnesia is memory loss with confabulation is making stories
To treat Wernicke’s Korsakoff’s by redirect them if they are thinking and doing
something wrong. Don’t present reality to them.
Treatment is vitamin B1 so they won’t get worst.
Alcoholism drug treatment
Disulfiram is a version therapy which mean for the alcoholic to hate drinking
alcohol.
The therapy last for two weeks and be on it for two weeks
Patient teaching for this drug is to teach the patient stay away from forms of
alcohol to prevent from nausea and vomiting.
They need to avoid mouth wash, aftershaves, perfumes and colognes, insect
repellents, and over the counter drugs the end with elixirs, hand sanitizers,
uncooked icings. DO NOT PICK THE RED WINE VINAIGRETTE.
Over Dose and Withdraws Drugs
The Upper Drugs are caffeine, cocaine, PCP/LSD, methamphetamine, adderall
S\S- Everything in the system goes up
Overdose on cocaine everything will go up
Withdraw from cocaine everything will go down (Narcan)
Drug abuser in the Newborns
Intoxication is always at birth
24hr afterbirth the baby will go into withdraw which makes everything goes up
Alcohol Withdrawal Syndrome vs. Delirium Tremens
In 24hrs every alcoholic goes to alcohol withdraw. In 72hrs delirium tremens starts
Not all alcoholics have delirium tremens.
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This client loss touch with reality
S/S is amnesia is memory loss with confabulation is making stories
To treat Wernicke’s Korsakoff’s by redirect them if they are thinking and doing
something wrong. Don’t present reality to them.
Treatment is vitamin B1 so they won’t get worst.
Alcoholism drug treatment
Disulfiram is a version therapy which mean for the alcoholic to hate drinking
alcohol.
The therapy last for two weeks and be on it for two weeks
Patient teaching for this drug is to teach the patient stay away from forms of
alcohol to prevent from nausea and vomiting.
They need to avoid mouth wash, aftershaves, perfumes and colognes, insect
repellents, and over the counter drugs the end with elixirs, hand sanitizers,
uncooked icings. DO NOT PICK THE RED WINE VINAIGRETTE.
Over Dose and Withdraws Drugs
The Upper Drugs are caffeine, cocaine, PCP/LSD, methamphetamine, adderall
S\S- Everything in the system goes up
Overdose on cocaine everything will go up
Withdraw from cocaine everything will go down (Narcan)
Drug abuser in the Newborns
Intoxication is always at birth
24hr afterbirth the baby will go into withdraw which makes everything goes up
Alcohol Withdrawal Syndrome vs. Delirium Tremens
In 24hrs every alcoholic goes to alcohol withdraw. In 72hrs delirium tremens starts
Not all alcoholics have delirium tremens.
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Alcohol withdrawal syndrome is not life threatening to self and others everything
will go up while they are withdrawing from alcohol (stable)
Regular diet
Semi-private anywhere
They can go anywhere they want to go
No restraints
Tranquilizers (Diazepam, Lorazepam, and Chlordiazepoxide)
Give a blood pressure pill
Vitamin B1
Delirium tremens are very dangerous to self and others and everything will go up
while they have delirium tremens (unstable)
NPO
Clear liquids
Private room near nurse’s station
Restricted bed rest
Must be restraints (Vest restraint or Two Point lock leathers restraint of the
opposite of right arm and left leg change every 2hrs.)
Give a blood pressure pill
Tranquilizers (Diazepam, Lorazepam, and Chlordiazepoxide)
Vitamin B1
Drugs
Aminoglycosides very powerful antibiotics (A mean Old Micin)
Treats very serious, life threatening, resistant, and gram negative
infections
Treats TB, sepsis peritonitis, pyelonephritis, septic shock, and
infection wound burns over 80% of the body.
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will go up while they are withdrawing from alcohol (stable)
Regular diet
Semi-private anywhere
They can go anywhere they want to go
No restraints
Tranquilizers (Diazepam, Lorazepam, and Chlordiazepoxide)
Give a blood pressure pill
Vitamin B1
Delirium tremens are very dangerous to self and others and everything will go up
while they have delirium tremens (unstable)
NPO
Clear liquids
Private room near nurse’s station
Restricted bed rest
Must be restraints (Vest restraint or Two Point lock leathers restraint of the
opposite of right arm and left leg change every 2hrs.)
Give a blood pressure pill
Tranquilizers (Diazepam, Lorazepam, and Chlordiazepoxide)
Vitamin B1
Drugs
Aminoglycosides very powerful antibiotics (A mean Old Micin)
Treats very serious, life threatening, resistant, and gram negative
infections
Treats TB, sepsis peritonitis, pyelonephritis, septic shock, and
infection wound burns over 80% of the body.
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Three drugs that are not mean old micin erythromycin, azithromycin,
and clarithromycin. (Throw them off the mean old list)
The two toxic effects are ototoxicity and nephrontoxicity
Monitor for hearing, ringing in the ears (tinnitus), vertigo and
dizziness, 24hrs clearance creatinine is the indication of the kidney
function, DO NOT PICK URINE, BUN, DAILY WEIGHT,
URINE OUTPUT
Given IM or IV every 8hrs and can damage cranial #8 which is the
ears
Do not give PO because they cannot absorb.
Only liver encephalopathy can take aminoglycosides PO to get rid of
the ammonia in the stomach and it won’t hurt the liver.
Also is given at preoperative bowel surgery to sterilize the bowel and
kill gram positive ecoli
Two drugs to sterilize the bowel and they are Neomycin and
Kanmycin. Who can sterilize my bowel? ANS: NEO KAN
Trough and Peaks Levels
Trough means when the drug is at its lowest
Peaks means when the drugs is at its highest
T-Draw the trough 30mins before the next dose in Sublingual, IM, IV,
and PO meds
A-Administer the drug
P- Draw the peak on sublingual 5-10mins after the drug is dissolves,
IV peak level 15-30mins after the drug is finish, IM peak levels 30-
60mins after given
Aminoglycosides drugs need to draw trough level
Calcium Channel Blockers (Heart Drugs)
-Calms the heart down
- Negative Ino, Chrono, Dromo means its relaxes the heart rate
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and clarithromycin. (Throw them off the mean old list)
The two toxic effects are ototoxicity and nephrontoxicity
Monitor for hearing, ringing in the ears (tinnitus), vertigo and
dizziness, 24hrs clearance creatinine is the indication of the kidney
function, DO NOT PICK URINE, BUN, DAILY WEIGHT,
URINE OUTPUT
Given IM or IV every 8hrs and can damage cranial #8 which is the
ears
Do not give PO because they cannot absorb.
Only liver encephalopathy can take aminoglycosides PO to get rid of
the ammonia in the stomach and it won’t hurt the liver.
Also is given at preoperative bowel surgery to sterilize the bowel and
kill gram positive ecoli
Two drugs to sterilize the bowel and they are Neomycin and
Kanmycin. Who can sterilize my bowel? ANS: NEO KAN
Trough and Peaks Levels
Trough means when the drug is at its lowest
Peaks means when the drugs is at its highest
T-Draw the trough 30mins before the next dose in Sublingual, IM, IV,
and PO meds
A-Administer the drug
P- Draw the peak on sublingual 5-10mins after the drug is dissolves,
IV peak level 15-30mins after the drug is finish, IM peak levels 30-
60mins after given
Aminoglycosides drugs need to draw trough level
Calcium Channel Blockers (Heart Drugs)
-Calms the heart down
- Negative Ino, Chrono, Dromo means its relaxes the heart rate
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-Treats Antihypertensive, Anti-Angina, Atrial Arrhythmia and SVT
-Side effects are Headache, Hypotension, and Bradycardia
-Names of calcium channel blockers are anything ending with “dipine”
Cardizem and Verapamil
-Cardizem can be given continuous IV drip
-Before given calcium channel blocker the nurse needs to measure the blood
pressure
-Hold if the Systolic is 100 or lower
-If Cardizem drip is given by IV and the blood pressure is low then the nurse
will have to titrate (change or slow the IV rate).
Cardiac Arrhythmia
Normal Sinus rhythm there’s a P wave to every
QRS follows by a T wave. The peaks of the P wave are equal with each
other. The P wave can be up or down.
V-Fib is a chaotic squeaky line. 911 Treatment
is CPR and D-Fib (Shock)
V- Tach shape pecks with pattern. Wide bizarre QRS.
Treatment is Lidocaine and Aminodorone. No pulse 911, CPR and cardio
version
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-Side effects are Headache, Hypotension, and Bradycardia
-Names of calcium channel blockers are anything ending with “dipine”
Cardizem and Verapamil
-Cardizem can be given continuous IV drip
-Before given calcium channel blocker the nurse needs to measure the blood
pressure
-Hold if the Systolic is 100 or lower
-If Cardizem drip is given by IV and the blood pressure is low then the nurse
will have to titrate (change or slow the IV rate).
Cardiac Arrhythmia
Normal Sinus rhythm there’s a P wave to every
QRS follows by a T wave. The peaks of the P wave are equal with each
other. The P wave can be up or down.
V-Fib is a chaotic squeaky line. 911 Treatment
is CPR and D-Fib (Shock)
V- Tach shape pecks with pattern. Wide bizarre QRS.
Treatment is Lidocaine and Aminodorone. No pulse 911, CPR and cardio
version
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Asystole a flat line. No QRS. Treatment is epinephrine
1mg first every 3-5mins IV fluids and CPR. 911
A-flutter saw tooth. Treatment calcium channel
blocker
PVC Treatment is Lidocanine and Aminodorone.
More than 6 per min in a row or the PVC fall on the T wave of previous beat
need to be concerned about it. Ventricular
SVT Narrow QRS
Treatment is
1. A-denosine push less than 8sec. Watch out for when the
patient heart rhythm goes to asystole
2. B-eta Blocker (LOL)
3. C-alcium Channel Blockers
4. D-igitalis (Lanoxin)
QRS Depolarization it is ventricular
P wave is atrial
Chest Tube
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1mg first every 3-5mins IV fluids and CPR. 911
A-flutter saw tooth. Treatment calcium channel
blocker
PVC Treatment is Lidocanine and Aminodorone.
More than 6 per min in a row or the PVC fall on the T wave of previous beat
need to be concerned about it. Ventricular
SVT Narrow QRS
Treatment is
1. A-denosine push less than 8sec. Watch out for when the
patient heart rhythm goes to asystole
2. B-eta Blocker (LOL)
3. C-alcium Channel Blockers
4. D-igitalis (Lanoxin)
QRS Depolarization it is ventricular
P wave is atrial
Chest Tube
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Suction Chamber-Water Seal Chamber-Collection Chamber
The purpose of the chest tube is to re-establish negative pressure pleural
space.
Pneumothorax removes air
Hemothorax removes blood
Things to report to the DR. are the (1) chest tube is not bubbling, (2) the
chest drain 800mL in first 10hrs, (3) the chest tube is not draining, and (4)
the chest tube is intermitting bubbling.
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The purpose of the chest tube is to re-establish negative pressure pleural
space.
Pneumothorax removes air
Hemothorax removes blood
Things to report to the DR. are the (1) chest tube is not bubbling, (2) the
chest drain 800mL in first 10hrs, (3) the chest tube is not draining, and (4)
the chest tube is intermitting bubbling.
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Hemothorax suppose to drain blood. Nurse must report #3
Pneumothorax supposes to remove air report #1 and #2 to the DR.
The two locations of the chest tubes:
Apical- if the chest tube in this location which is up high then Air is
removing. (NO DRAINING SHOULD BE FROM THE CHEST TUBE)
Basilar- if the chest tube is place in the bottom of the lungs then it is
removing Blood. (NO BUBBLING SHOULD BE IN THE CHEST TUBE)
Chest tube after surgery or trauma is Unilateral Pneumohemothorax (ONE
SIDE ONLY)
Troubleshooting of the chest tube:
If the chest tube is knock down the nurse will have to:
(1)Set back up
(2)Tell the patient to take some deep breaths
4 things to do when the water seal breaks on a chest tube:
(1) Clamp it. FIRST THING TO DO
(2) Cut broken device of the tube
(3) Submerged or put the tube in water ( normal saline) BEST THING
TO DO
(4) Unclamp
4 things to do if the chest tube comes out:
(1) Cover the hole with a gloved hand
(2) Put on a Vaseline gauze dressing
(3) Put on sterile occlusive dressing
(4) Tape on 3 sides
Collection Chamber (NO Bubbling in this one)
-The drainage should be serosangious color/ Call Dr. If is bright red
(hemorrhage) or greater than 100mL/hr.
-Asses Q4hrs/ If new assess more frequently
Water Seal Chamber (Intermittently Bubbling)
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Pneumothorax supposes to remove air report #1 and #2 to the DR.
The two locations of the chest tubes:
Apical- if the chest tube in this location which is up high then Air is
removing. (NO DRAINING SHOULD BE FROM THE CHEST TUBE)
Basilar- if the chest tube is place in the bottom of the lungs then it is
removing Blood. (NO BUBBLING SHOULD BE IN THE CHEST TUBE)
Chest tube after surgery or trauma is Unilateral Pneumohemothorax (ONE
SIDE ONLY)
Troubleshooting of the chest tube:
If the chest tube is knock down the nurse will have to:
(1)Set back up
(2)Tell the patient to take some deep breaths
4 things to do when the water seal breaks on a chest tube:
(1) Clamp it. FIRST THING TO DO
(2) Cut broken device of the tube
(3) Submerged or put the tube in water ( normal saline) BEST THING
TO DO
(4) Unclamp
4 things to do if the chest tube comes out:
(1) Cover the hole with a gloved hand
(2) Put on a Vaseline gauze dressing
(3) Put on sterile occlusive dressing
(4) Tape on 3 sides
Collection Chamber (NO Bubbling in this one)
-The drainage should be serosangious color/ Call Dr. If is bright red
(hemorrhage) or greater than 100mL/hr.
-Asses Q4hrs/ If new assess more frequently
Water Seal Chamber (Intermittently Bubbling)
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-Intermittently bubbling in the water seal is Good and just document it.
-Continuous bubbling in the water seal is bad and there is a leak the nurse
has to find the leak and put tape over it to stop the leak.
-It allows air to go out from the patient but nothing going in
Suction Chamber (Continuous Bubbling)
-Intermittently bubbling in the suction control chamber is bad and it’s too
low. Needs to turn it up to have continuous bubbling in the suction control
chamber.
-Continuous bubbling is good in the suction chamber
Never clamp a chest tube no longer than 15sec without a doctor’s order. Use a
rubber tipped double clamp
NG Tube
1. During procedure sit the patient upright (High Flower Position)
2. Measure the distal end of tube at the tip of the nose and measure to
earlobe, then xiphoid. Apply tape to the tube to determine when to stop
3. Ask client to tilt head downward
4. Ask client to sip some water
5. Stop tube and pull back if client coughs or choking during procedure
Nurse Management
1. Chest x-ray for proper placement
2. Aspirate gastric placement pH of 6 or greater is in the intestinal.
pH of 4 or less is in the gastric
3. Check placement every 4hrs after insertion
Tracheotomy Tube
1. Maintain head of bed 30 degrees
2. Ambu bag at bedside
3. Keep a spare trach
4. Suction client if coughing, noisy respiration or adventitious breath
sounds.
5. Hyperoxygenate before and after suction for no more than 10sec
6. Assess for redness or infection signs.
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-Continuous bubbling in the water seal is bad and there is a leak the nurse
has to find the leak and put tape over it to stop the leak.
-It allows air to go out from the patient but nothing going in
Suction Chamber (Continuous Bubbling)
-Intermittently bubbling in the suction control chamber is bad and it’s too
low. Needs to turn it up to have continuous bubbling in the suction control
chamber.
-Continuous bubbling is good in the suction chamber
Never clamp a chest tube no longer than 15sec without a doctor’s order. Use a
rubber tipped double clamp
NG Tube
1. During procedure sit the patient upright (High Flower Position)
2. Measure the distal end of tube at the tip of the nose and measure to
earlobe, then xiphoid. Apply tape to the tube to determine when to stop
3. Ask client to tilt head downward
4. Ask client to sip some water
5. Stop tube and pull back if client coughs or choking during procedure
Nurse Management
1. Chest x-ray for proper placement
2. Aspirate gastric placement pH of 6 or greater is in the intestinal.
pH of 4 or less is in the gastric
3. Check placement every 4hrs after insertion
Tracheotomy Tube
1. Maintain head of bed 30 degrees
2. Ambu bag at bedside
3. Keep a spare trach
4. Suction client if coughing, noisy respiration or adventitious breath
sounds.
5. Hyperoxygenate before and after suction for no more than 10sec
6. Assess for redness or infection signs.
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Congenital Heart Defects
TRouBLe
The bad congenital heart defects have right to left shunts and cyanotic (BLUE)
The good congenital heart defects have left to right shunt and acyanotic (Not
BLUE)
All children with congenital heart defects has a murmur and an echocardiogram
done
The four defects of Tetrology of Fellot are
(1) Ventricular Defect- VD
(2) Pulmonic Stenosis-PS
(3) Overriding Aorta-OA
(4) Right Hypertrophy-RH
Best way to remember the defects is Valentine time Day Pick Someone Out A
Red Heart
Infection Disease and Transmission Base Precautions
Four transmission Base Precautions are:
(1) Standard Universal
(2) Contact Precaution- RSV transmitted by droplet, Herpatic infection (Hep
A), Staph infections Enteric (bowel) infections, and Herpes infection.
Private room
Gloves
No mask
Gown- if giving direct care
Hand washing
Disposable supplies
Clean stethoscope in their room only
(3) Droplet Precaution- All meningitis and all influenza, Pertusis, Diptheria,
Mumps
Private room
Mask
Gloves
No gown
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TRouBLe
The bad congenital heart defects have right to left shunts and cyanotic (BLUE)
The good congenital heart defects have left to right shunt and acyanotic (Not
BLUE)
All children with congenital heart defects has a murmur and an echocardiogram
done
The four defects of Tetrology of Fellot are
(1) Ventricular Defect- VD
(2) Pulmonic Stenosis-PS
(3) Overriding Aorta-OA
(4) Right Hypertrophy-RH
Best way to remember the defects is Valentine time Day Pick Someone Out A
Red Heart
Infection Disease and Transmission Base Precautions
Four transmission Base Precautions are:
(1) Standard Universal
(2) Contact Precaution- RSV transmitted by droplet, Herpatic infection (Hep
A), Staph infections Enteric (bowel) infections, and Herpes infection.
Private room
Gloves
No mask
Gown- if giving direct care
Hand washing
Disposable supplies
Clean stethoscope in their room only
(3) Droplet Precaution- All meningitis and all influenza, Pertusis, Diptheria,
Mumps
Private room
Mask
Gloves
No gown
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Hand washing
Disposable/dedicated equipment
Pt wears mask when leaving room
(4) Airborne- Measles and TB, and Varicella
Private room
Mask
Gloves
Hand washing
Special respiratory mask for TB
Pt. wears mask when leaving room
Disposable/dedicated supplies
Negative airflow room
Donning PPE
1. Gown (cover the all body first)
2. Mask (cover the nose & mouth)
3. Goggles (cover the eyes)
4. Gloves (hands last thing to cover)
Removing PPE
1. Gloves
2. Goggles
3. Gown
4. Mask (outside the pt. room)
Crutches, Canes and Walkers
Crutches are measured to 2-3cm/finger widths below anterior axillary fold to a
point lateral and slightly in front of the foot. Elbow flexion should be 30 degrees
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Disposable/dedicated equipment
Pt wears mask when leaving room
(4) Airborne- Measles and TB, and Varicella
Private room
Mask
Gloves
Hand washing
Special respiratory mask for TB
Pt. wears mask when leaving room
Disposable/dedicated supplies
Negative airflow room
Donning PPE
1. Gown (cover the all body first)
2. Mask (cover the nose & mouth)
3. Goggles (cover the eyes)
4. Gloves (hands last thing to cover)
Removing PPE
1. Gloves
2. Goggles
3. Gown
4. Mask (outside the pt. room)
Crutches, Canes and Walkers
Crutches are measured to 2-3cm/finger widths below anterior axillary fold to a
point lateral and slightly in front of the foot. Elbow flexion should be 30 degrees
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2 point gait-partial and weight bearing
1. One crutch and right foot forward
2. Move the left leg and the right crutch forward together
Right foot and left crutch advanced together, and then the left foot and right crutch
3point gait- Non-weight bearing on the affected leg (Two crutches and one
good leg.
1. Move two crutches and bad leg together
2. Move good foot
3. Move all three together and then the good leg
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1. One crutch and right foot forward
2. Move the left leg and the right crutch forward together
Right foot and left crutch advanced together, and then the left foot and right crutch
3point gait- Non-weight bearing on the affected leg (Two crutches and one
good leg.
1. Move two crutches and bad leg together
2. Move good foot
3. Move all three together and then the good leg
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4point gait- move nothing
1. Move the right crutch forward
2. Move the left forward foot
3. Move the left crutch forward
4. Move the right foot forward
Swing Through- Used for two braced extremities. Amputees/ None weight bearing
1. Move both crutches forward together 6inches
2. Move both Legs 6inches
3. Then Hop
Use the even gaits which 2 and 4 when weakness is evenly distributed
2point is for mild bilateral weakness
4point for a severe bilateral weakness, Fresh post Op
If one leg is weak then 3point gait is needed
Always move the crutches with the bad leg
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1. Move the right crutch forward
2. Move the left forward foot
3. Move the left crutch forward
4. Move the right foot forward
Swing Through- Used for two braced extremities. Amputees/ None weight bearing
1. Move both crutches forward together 6inches
2. Move both Legs 6inches
3. Then Hop
Use the even gaits which 2 and 4 when weakness is evenly distributed
2point is for mild bilateral weakness
4point for a severe bilateral weakness, Fresh post Op
If one leg is weak then 3point gait is needed
Always move the crutches with the bad leg
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Hold the cane on the strong side and advance with the weak side.
Walkers pick it up, set it down and walk to it. Always push, never pull it.
Psych
Non psychotic no insight and is reality based (Good therapeutic communication)
Psychotic has insight and not reality based. They believe they are not sick and
blame people for their illness. (No good therapeutic communication for these
people)
Signs and Symptoms of Psychotic person are
1. Delusion-false fixed belief. No sensory component
Three types of delusions
Paranoid- false fixed belief that people are out to harm you
Grandiose- False fixed belief that they are superior
Somatic-False fixed belief about a body part
2. Hallucination- False fixed sensory experience. The 5 types are
Auditory (most common)
Visual (most common)
Tactile (most common) feeling something in the body part that is not
there
Olfactory
Gustatory
3. Illusion- Is misinterpretation of reality. This person will refer something from
reality that is really there.
Diabetes Type 1 and 2
Diabetes is when the person don’t metabolizes their glucose well
Type 1 treatment Diet, Insulin, Exercise
Type 2 treatment Diet and Exercise. Six small feeding a day
Insulin lowers the blood glucose
Regular Insulin Short Acting
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Walkers pick it up, set it down and walk to it. Always push, never pull it.
Psych
Non psychotic no insight and is reality based (Good therapeutic communication)
Psychotic has insight and not reality based. They believe they are not sick and
blame people for their illness. (No good therapeutic communication for these
people)
Signs and Symptoms of Psychotic person are
1. Delusion-false fixed belief. No sensory component
Three types of delusions
Paranoid- false fixed belief that people are out to harm you
Grandiose- False fixed belief that they are superior
Somatic-False fixed belief about a body part
2. Hallucination- False fixed sensory experience. The 5 types are
Auditory (most common)
Visual (most common)
Tactile (most common) feeling something in the body part that is not
there
Olfactory
Gustatory
3. Illusion- Is misinterpretation of reality. This person will refer something from
reality that is really there.
Diabetes Type 1 and 2
Diabetes is when the person don’t metabolizes their glucose well
Type 1 treatment Diet, Insulin, Exercise
Type 2 treatment Diet and Exercise. Six small feeding a day
Insulin lowers the blood glucose
Regular Insulin Short Acting
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Have the big R on the bottom and clear
Onset is 1hr
Peak is 2hrs
Duration is 4hrs
Can use as an IV drip
NHP Intermitted Acting
Has N in all of them and cloudy
Onset is 6hrs
Peak is 8-10hrs
Duration 12hrs
Don’t give it fast/ No IV
Humalog Very Fast Acting 15-30-3
Give with meal
Onset is 15minutes
Peak is 30minute
Duration is 3hrs
Lantus/Glargine Long Acting
Safe to give it at bedtime
Slowing absorb
Low risk for hypoglycemia
Duration 12-24hrs
The causes of Hypoglycemia
Not enough food
Too much insulin (#1) cause
Too much exercise
The big danger is BRAIN DAMAGE
S/S of shock and being drunk, clammy, weak, slurred speech, liable,
thread pluses
Treatment is fast metabolizable carb such as fruit juices, candy, and honey
with protein or starch. ½ Skim milk is the best for them.
Unconscious give them glucagon IM or Dextrose 50 IV
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Onset is 1hr
Peak is 2hrs
Duration is 4hrs
Can use as an IV drip
NHP Intermitted Acting
Has N in all of them and cloudy
Onset is 6hrs
Peak is 8-10hrs
Duration 12hrs
Don’t give it fast/ No IV
Humalog Very Fast Acting 15-30-3
Give with meal
Onset is 15minutes
Peak is 30minute
Duration is 3hrs
Lantus/Glargine Long Acting
Safe to give it at bedtime
Slowing absorb
Low risk for hypoglycemia
Duration 12-24hrs
The causes of Hypoglycemia
Not enough food
Too much insulin (#1) cause
Too much exercise
The big danger is BRAIN DAMAGE
S/S of shock and being drunk, clammy, weak, slurred speech, liable,
thread pluses
Treatment is fast metabolizable carb such as fruit juices, candy, and honey
with protein or starch. ½ Skim milk is the best for them.
Unconscious give them glucagon IM or Dextrose 50 IV
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High Blood Glucose (DKA) Type 1
o Too much food
o Not enough insulin
o Not enough exercise
Acute viral upper respiratory infection within last 2wks (#1) cause
S/S
D-ehydration
K-etones in the urine and blood, Kussmaul Resp. and K+ High potassium,
A-cidosis, Acetone breath, Anorexia due to nausea
Treatment
IV at high rate (150-200) mL/hr with insulin R
High blood glucose in type 2 is (HHNK) Hyperosmolar, Hyperglycemic, and
Non-Ketotic coma
S/S- Dehydration
Treatment
Rehydrate but no insulin in the bag.
Priority Diabetes Complications
1. Hypoglycemia
2. DKA
3. HHNK
Long term problems from diabetes are:
1. Peripheral neuropathy which they can’t feel it when they injured
themselves
2. Poor tissue perfusion is when the wound don’t heal well when they
injured themselves.
HGBA1C-H1Ac
6 and lower is good in controlled
7 need an evaluation
8 and higher is not good out of controlled
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o Too much food
o Not enough insulin
o Not enough exercise
Acute viral upper respiratory infection within last 2wks (#1) cause
S/S
D-ehydration
K-etones in the urine and blood, Kussmaul Resp. and K+ High potassium,
A-cidosis, Acetone breath, Anorexia due to nausea
Treatment
IV at high rate (150-200) mL/hr with insulin R
High blood glucose in type 2 is (HHNK) Hyperosmolar, Hyperglycemic, and
Non-Ketotic coma
S/S- Dehydration
Treatment
Rehydrate but no insulin in the bag.
Priority Diabetes Complications
1. Hypoglycemia
2. DKA
3. HHNK
Long term problems from diabetes are:
1. Peripheral neuropathy which they can’t feel it when they injured
themselves
2. Poor tissue perfusion is when the wound don’t heal well when they
injured themselves.
HGBA1C-H1Ac
6 and lower is good in controlled
7 need an evaluation
8 and higher is not good out of controlled
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Drugs Toxicity
Lithium
Use for bipolar for the mania
Therapeutic level 0.6-1.2
The toxic level is greater than or equal to 2.0
Lanoxin (digoxin)
Use to treats CHF and A-Fib
Therapeutic level 1-2
The toxic level is greater than or equal to 2.0
Aminophylline
Airway anti-spasm
It’s a muscle relaxer for the spasms in the airway.
Therapeutic level 10-20
Toxic level is 20 or over
Dilantin
Use for seizures
Therapeutic level 10-20
Toxic level is 20 or over
Bilirubin
Normal level for neonate is 10-20
Elevated level is 20 or over
Kernicterus is a condition when bilirubin is in the brain, over 20 and in the
CSF
Opisthotonos is position of hyperextension seen with kernicterus.
Place the baby on their side if present
Call the DR.
Draw bilirubin level
Increase the IV rate and start bilrubin
Slightly extension of the neck will be an alert
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Lithium
Use for bipolar for the mania
Therapeutic level 0.6-1.2
The toxic level is greater than or equal to 2.0
Lanoxin (digoxin)
Use to treats CHF and A-Fib
Therapeutic level 1-2
The toxic level is greater than or equal to 2.0
Aminophylline
Airway anti-spasm
It’s a muscle relaxer for the spasms in the airway.
Therapeutic level 10-20
Toxic level is 20 or over
Dilantin
Use for seizures
Therapeutic level 10-20
Toxic level is 20 or over
Bilirubin
Normal level for neonate is 10-20
Elevated level is 20 or over
Kernicterus is a condition when bilirubin is in the brain, over 20 and in the
CSF
Opisthotonos is position of hyperextension seen with kernicterus.
Place the baby on their side if present
Call the DR.
Draw bilirubin level
Increase the IV rate and start bilrubin
Slightly extension of the neck will be an alert
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GI
Hiatal Hernia
Gastric content moving in the WRONG DIRECTION and
CORRECT RATE
Acid come back up into the esophagus
Has TWO STOMACH
S/S- GERD when lying after meals
Position in high flowers during and 1hr after meals
Increase fluids with meal
Increase Carbs and decrease protein
Dumping Syndrome
Post-op gastric surgery complication
Gastric content moves too fast into the duodenum
Moves in the right direction and incorrect rate
S/S- Acute abdominal distress=gas, cramping, bloating and drunk and
shock
Lay flat on side during and 1hr after meals
Decrease fluids during meals (drink between meals)
Decrease carbs and increase protein
Electrolyte Imbalance
Normal Potassium is 3.5-5.3
Kalemias (Potassium) do the opposite of the prefix except for the HR and urine
output
Never push Potassium IV 40mEq (If higher than 40mEq go clarify
order)
HyperKalemia is everything is high and HR and urine output is low
To decrease High K+ give D5W with insulin R. K+ exits early
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Hiatal Hernia
Gastric content moving in the WRONG DIRECTION and
CORRECT RATE
Acid come back up into the esophagus
Has TWO STOMACH
S/S- GERD when lying after meals
Position in high flowers during and 1hr after meals
Increase fluids with meal
Increase Carbs and decrease protein
Dumping Syndrome
Post-op gastric surgery complication
Gastric content moves too fast into the duodenum
Moves in the right direction and incorrect rate
S/S- Acute abdominal distress=gas, cramping, bloating and drunk and
shock
Lay flat on side during and 1hr after meals
Decrease fluids during meals (drink between meals)
Decrease carbs and increase protein
Electrolyte Imbalance
Normal Potassium is 3.5-5.3
Kalemias (Potassium) do the opposite of the prefix except for the HR and urine
output
Never push Potassium IV 40mEq (If higher than 40mEq go clarify
order)
HyperKalemia is everything is high and HR and urine output is low
To decrease High K+ give D5W with insulin R. K+ exits early
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Kayexelate get rid of K+ slow and late (K-Exits-Late) Also the pt. will
have high sodium.
HypoKalemia everything is low and the HR and urine output is high
Calcemias do the opposite of the prefix plus BP changes
Normal Calcium 8.5-10.2
HypoCalcemia is everything is high plus BP changes (Chvosteks sign
Push the cheek and it spasms) (Trousseaus signs BP cuff inflated and cause a
carpal spasm)
HyperCalcemia is everything is low plus BP changes
Magnesemias do the opposite of the prefix plus the BP changes
Normal Magnesium is 1.5-2.5
HyperMagnesemia is everything is low (low BP)
HypoMagnesemia everything will be high (High BP)
Natremias (Sodium)
HypErnatremia is dehydration (E)
HypOnatremia is overload (O)
Early sign of electrolyte overload is numbness and tingling (Parasthesia)
Muscle weakness (Paresis) is the universal s/s of an electrolyte imbalance
Endocrine
Hyperthyroidism is hyper metabolism which increase of energy
S/S- agitated, nervous, diarrhea, hot ^HR ^BP, thin, hyperactive
Treatment
Radioactive iodine 1
st
24hr they should be alone
PTU (worry about immunosuppresion) WBC will be low
Surgical removal
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have high sodium.
HypoKalemia everything is low and the HR and urine output is high
Calcemias do the opposite of the prefix plus BP changes
Normal Calcium 8.5-10.2
HypoCalcemia is everything is high plus BP changes (Chvosteks sign
Push the cheek and it spasms) (Trousseaus signs BP cuff inflated and cause a
carpal spasm)
HyperCalcemia is everything is low plus BP changes
Magnesemias do the opposite of the prefix plus the BP changes
Normal Magnesium is 1.5-2.5
HyperMagnesemia is everything is low (low BP)
HypoMagnesemia everything will be high (High BP)
Natremias (Sodium)
HypErnatremia is dehydration (E)
HypOnatremia is overload (O)
Early sign of electrolyte overload is numbness and tingling (Parasthesia)
Muscle weakness (Paresis) is the universal s/s of an electrolyte imbalance
Endocrine
Hyperthyroidism is hyper metabolism which increase of energy
S/S- agitated, nervous, diarrhea, hot ^HR ^BP, thin, hyperactive
Treatment
Radioactive iodine 1
st
24hr they should be alone
PTU (worry about immunosuppresion) WBC will be low
Surgical removal
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Total Thyroidectomy needs hormone replacement (Synthroid)
They at risk for Hypocalcaemia
Sub-total are at risk for thyroid storm in12-48hrs 911
S/S- Same as Graves’ disease but higher and psychotic delirium
First treatment is ICE PACK, then cooling blanket (BEST WAY)
Treatment is High flow 02 10Liters and 5 ice packs
-2 under each arm
-2 for the groin area,
-1back of the neck
Post-op thyroidectomy risk in the 1
st
24hrs is HEMORRHAGE and AIRWAY
After 1
st
12hrs they are stable.
12-48hrs they at risk for tentany
Hypothyroidism is Hypometabolism
S/S- tired and sluggish
Treatment- Hormone supplement. NO SEDATATION
Never hold the thyroid pills from these patients
Adrenal Cortex
Addison’s Disease- Under secretion of adrenal cortex
S/S- Hyperpigmentation and do not adapt well to stress and dehydrated
easily.
Treatment-Chronic steroid (glucocorticoids) High blood glucose and
immunsuppression
Cushing Syndrome is over secretion of the adrenal cortex
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They at risk for Hypocalcaemia
Sub-total are at risk for thyroid storm in12-48hrs 911
S/S- Same as Graves’ disease but higher and psychotic delirium
First treatment is ICE PACK, then cooling blanket (BEST WAY)
Treatment is High flow 02 10Liters and 5 ice packs
-2 under each arm
-2 for the groin area,
-1back of the neck
Post-op thyroidectomy risk in the 1
st
24hrs is HEMORRHAGE and AIRWAY
After 1
st
12hrs they are stable.
12-48hrs they at risk for tentany
Hypothyroidism is Hypometabolism
S/S- tired and sluggish
Treatment- Hormone supplement. NO SEDATATION
Never hold the thyroid pills from these patients
Adrenal Cortex
Addison’s Disease- Under secretion of adrenal cortex
S/S- Hyperpigmentation and do not adapt well to stress and dehydrated
easily.
Treatment-Chronic steroid (glucocorticoids) High blood glucose and
immunsuppression
Cushing Syndrome is over secretion of the adrenal cortex
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Treatment-Adrenalectomy
Toys for Children
Children under 4yrs old cannot have small toys
Children has O2 they cannot used mental toys because of sparks of fire
Beware of Foramites which is a nonliving object that harbors
microorganisms
Best toys for 0-6months old are musical mobile and soft and large (get rid at
6months or when the baby is sitting up)
6-9months- Cover/uncover toys and anything large that they can’t swallow
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Toys for Children
Children under 4yrs old cannot have small toys
Children has O2 they cannot used mental toys because of sparks of fire
Beware of Foramites which is a nonliving object that harbors
microorganisms
Best toys for 0-6months old are musical mobile and soft and large (get rid at
6months or when the baby is sitting up)
6-9months- Cover/uncover toys and anything large that they can’t swallow
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9-12months- Talking toys and anything that is purposeful like a rolling ball
1-3yrs- Push/Pull toys (Gross motor) Parallel play with other child but alone
3-6yrs- Fine motor (fingers) Preschoolers, Pretend play, Co-operative play
(together)
7-11yrs- Creative, Collecting, and Competitive (No coloring book for them)
12-18yrs- Peer associated
Laminectomy
Cervical-neck Thoracic-upper body Lumber-lower body
Surgical removal of the back of one or more vertebrae to relieve
pressure on the nerves
The 3P’s of nerve root S/S
Pain
Paresis-muscle weakness
Parasthesia
Pay attention of the location of the laminectomy
Pre-op cervical laminectomy assessment would be
1. Check the breathing rate and rhythm
2. Check arm and motor sensory function
Pre-op thoracic laminectomy assessment would be
1. Check cough (use abdominal muscles)
2. Check bowel sounds
Pre-op lumber laminectomy assessment
1. When the last time void or can they void
2. Check the leg motor and sensory function
Post-op for all laminectomys
1. Log roll these Patients
2. Do not dangle (sit on the edge of the bed)
3. May stand, walk, and lie down without restrictions
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1-3yrs- Push/Pull toys (Gross motor) Parallel play with other child but alone
3-6yrs- Fine motor (fingers) Preschoolers, Pretend play, Co-operative play
(together)
7-11yrs- Creative, Collecting, and Competitive (No coloring book for them)
12-18yrs- Peer associated
Laminectomy
Cervical-neck Thoracic-upper body Lumber-lower body
Surgical removal of the back of one or more vertebrae to relieve
pressure on the nerves
The 3P’s of nerve root S/S
Pain
Paresis-muscle weakness
Parasthesia
Pay attention of the location of the laminectomy
Pre-op cervical laminectomy assessment would be
1. Check the breathing rate and rhythm
2. Check arm and motor sensory function
Pre-op thoracic laminectomy assessment would be
1. Check cough (use abdominal muscles)
2. Check bowel sounds
Pre-op lumber laminectomy assessment
1. When the last time void or can they void
2. Check the leg motor and sensory function
Post-op for all laminectomys
1. Log roll these Patients
2. Do not dangle (sit on the edge of the bed)
3. May stand, walk, and lie down without restrictions
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4. Do not sit longer than 30minutes
Post-op complications
Post-op complication for cervical laminectomy
Pneumonia/Atelectesis
Post-op complication for thoracic laminectomy
1. Pneumonia
2. Cough and Aspiration
3. Paralytic ileus
Post-op complication for lumber laminectomy
1. Urinary retention
2. Legs problems
Laminectomy incision site that is very painful and the most drainage/bleeding is
the Hip site. Infection would be 50/50
Laminectomy Nursing Discharge Teaching
1. Don’t sit for longer than 30mins for 6wks
2. Lie flat and log roll for 6wks
3. No driving for 6wks
4. Do not lift more than 5lbs for 6wks
Permanent restrictions for Laminectomy
1. Do not lift by bending at the waist
2. No crazy activities
3. Cervical laminectomy cannot lift objects above the head
LAB VALUES
The levels of Prioritize from A-D
A- The lab value is abnormal but not priority
B- The lab value is abnormal but need to be concern/watch them closer
C- The lab value is abnormal and it’s critical and high priority need to
do something about it now.
D- The lab value is abnormal and it’s the highest priority
Creatnine (Cr)
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Post-op complications
Post-op complication for cervical laminectomy
Pneumonia/Atelectesis
Post-op complication for thoracic laminectomy
1. Pneumonia
2. Cough and Aspiration
3. Paralytic ileus
Post-op complication for lumber laminectomy
1. Urinary retention
2. Legs problems
Laminectomy incision site that is very painful and the most drainage/bleeding is
the Hip site. Infection would be 50/50
Laminectomy Nursing Discharge Teaching
1. Don’t sit for longer than 30mins for 6wks
2. Lie flat and log roll for 6wks
3. No driving for 6wks
4. Do not lift more than 5lbs for 6wks
Permanent restrictions for Laminectomy
1. Do not lift by bending at the waist
2. No crazy activities
3. Cervical laminectomy cannot lift objects above the head
LAB VALUES
The levels of Prioritize from A-D
A- The lab value is abnormal but not priority
B- The lab value is abnormal but need to be concern/watch them closer
C- The lab value is abnormal and it’s critical and high priority need to
do something about it now.
D- The lab value is abnormal and it’s the highest priority
Creatnine (Cr)
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-Best indicator of kidney function
-0.6-1.2 (same as lithium)
-Abnormal creatnine is a level A (not a priority)
-Kidney disease will have high creatnine
-If they would have a surgery with a dye in it then it
would be a priority
INR
Monitors Pts on Coumadin/Warafin therapy
Normal range is 2-3
Above 4 level C (High Priority) Do something
1. Hold all Coumadin/Warafin
2. Assess bleeding
3. Prepare to give vitamin K
4. Call the doctor
Potassium (K+)
Normal range is 3.5-5.3
If below 3.5 level C (High Priority) Do something
1. Assess the heart
2. Prepare to give potassium
3. Call the doctor
If high (5.4-5.9) still is high level C (High Priority)
1. Hold the potassium if in the IV
2. Assess the heart
3. Prepare to give D5W with insulin
4. Call the doctor
If it is greater or equal to 6 then a D level (911)
1. Stop what whatever you are doing and assess
2. If negative effects call Rapid Response
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-0.6-1.2 (same as lithium)
-Abnormal creatnine is a level A (not a priority)
-Kidney disease will have high creatnine
-If they would have a surgery with a dye in it then it
would be a priority
INR
Monitors Pts on Coumadin/Warafin therapy
Normal range is 2-3
Above 4 level C (High Priority) Do something
1. Hold all Coumadin/Warafin
2. Assess bleeding
3. Prepare to give vitamin K
4. Call the doctor
Potassium (K+)
Normal range is 3.5-5.3
If below 3.5 level C (High Priority) Do something
1. Assess the heart
2. Prepare to give potassium
3. Call the doctor
If high (5.4-5.9) still is high level C (High Priority)
1. Hold the potassium if in the IV
2. Assess the heart
3. Prepare to give D5W with insulin
4. Call the doctor
If it is greater or equal to 6 then a D level (911)
1. Stop what whatever you are doing and assess
2. If negative effects call Rapid Response
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3. If no negative effects do the same as high in the
5’s
pH
Normal is 7.35-7.45
pH in the 6 ’s D level
1. Assess vital signs
2. Call the doctor ASAP
BUN
Normal is 8- 25
BUN elevated assess for dehydration
*Dehydration is a good answer when the lab values are high
Hemoglobin (Hgb)
Normal is 12- 18
8-11 B level
If under 8C level
1. Assess for bleeding
2. Prepare to give blood
3. Call the doctor
Elevated Hgb is dehydration
Bicarb (HCO3)
Normal HCO3 is 22- 26
Abnormal HCO3 is A level
Carbon Dioxide (CO2)
Normal 35- 45
CO2 in the 50’s C level (People without COPD)
1. Assess respiratory status
2. Do pursed lip breathing
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5’s
pH
Normal is 7.35-7.45
pH in the 6 ’s D level
1. Assess vital signs
2. Call the doctor ASAP
BUN
Normal is 8- 25
BUN elevated assess for dehydration
*Dehydration is a good answer when the lab values are high
Hemoglobin (Hgb)
Normal is 12- 18
8-11 B level
If under 8C level
1. Assess for bleeding
2. Prepare to give blood
3. Call the doctor
Elevated Hgb is dehydration
Bicarb (HCO3)
Normal HCO3 is 22- 26
Abnormal HCO3 is A level
Carbon Dioxide (CO2)
Normal 35- 45
CO2 in the 50’s C level (People without COPD)
1. Assess respiratory status
2. Do pursed lip breathing
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3. Increased exhale to get rid of CO2
4. Do not give O2 if above
5. Call the doctor
CO2 in the 60’s D level Respiratory failure 911
1. Assess respiratory status
2. Do pursed lip breathing (Maybe)
3. Prepare for intubation
4. Call respiratory therapist
5. Call the doctor
Hematocrit (Hct)
Normal is 36-54 (Multiply the Hemoglobin level with 3)
Elevated Hct is a B level
Assess for Dehydration
PO2 from the ABG
Normal is 78-100
PO2 70- 77
1. Assess respiratory status
2. Give O2
PO2 below 60’s D level
1. Assess respiratory status
2. Give O2
3. Prepare for intubation
4. Call respiratory therapist
5. Call the doctor
O2
Normal is 93-100
Peds below 95 is bad
O2 below 93 C level
1. Assess respiratory status
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4. Do not give O2 if above
5. Call the doctor
CO2 in the 60’s D level Respiratory failure 911
1. Assess respiratory status
2. Do pursed lip breathing (Maybe)
3. Prepare for intubation
4. Call respiratory therapist
5. Call the doctor
Hematocrit (Hct)
Normal is 36-54 (Multiply the Hemoglobin level with 3)
Elevated Hct is a B level
Assess for Dehydration
PO2 from the ABG
Normal is 78-100
PO2 70- 77
1. Assess respiratory status
2. Give O2
PO2 below 60’s D level
1. Assess respiratory status
2. Give O2
3. Prepare for intubation
4. Call respiratory therapist
5. Call the doctor
O2
Normal is 93-100
Peds below 95 is bad
O2 below 93 C level
1. Assess respiratory status
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2. Give O2
BNP
Normal is less than 100
Good indicator of CHF
Best indicator of CHF is ANF
ANF and CHF is CHF
Sodium (Na)
Normal is 135- 145
Abnormal Na is ok unless the change in LOC B level
WBC
Normal is 5,000-11,000
Absolute neutrophil count (ANC)
Normal is above 500
CD4 Level C
Needs to above 200 Less than 200 is AIDS
Low WBC call
-Leukopenia
-Neutropenia
-Agranulocytosis
-Immunosupression
-Bone marrow suppression
Platelets
Normal 150,000-400,000
Below 90,000 C level
1. Check for bleeding
2. Place on bleeding precautions
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BNP
Normal is less than 100
Good indicator of CHF
Best indicator of CHF is ANF
ANF and CHF is CHF
Sodium (Na)
Normal is 135- 145
Abnormal Na is ok unless the change in LOC B level
WBC
Normal is 5,000-11,000
Absolute neutrophil count (ANC)
Normal is above 500
CD4 Level C
Needs to above 200 Less than 200 is AIDS
Low WBC call
-Leukopenia
-Neutropenia
-Agranulocytosis
-Immunosupression
-Bone marrow suppression
Platelets
Normal 150,000-400,000
Below 90,000 C level
1. Check for bleeding
2. Place on bleeding precautions
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Below 40,000 D level
1. Prepare platelet transfusion
2. Call the doctor
RBC
Normal 4-6million
The 5 D’s The HIGHEST PRIORITY PEOPLE
1. pH in the 6s
2. Potassium 6s
3. CO2 60s
4. PO2 60s
5. Platelet court of less than 40,000
The 8 Cs level HIGH PRIORITY PEOPLE
1. INR above 4 level C (High Priority) Do something
2. If potassium below 3.5 level C (High Priority) Do something
3. If potassium high (5.4-5.9) still is high level C (High Priority)
4. If the hemoglobin is under 8C level
5. CO2 in the 50’s C level
6. PO2 of 70-77
7. Low WBC under 5000, ANC under 500, CD4 above 200 or lower
than 200
8. Platelets of 90,000
PSYCH DRUGS
All Psych drugs cause weight gain and low BP
Phenothiazines
Ends in “zine”
Do not cure psych disease
They reduces the symptoms
Large doses is Anti-psychotic
Small doses is Antiemetics
Major doses is Tranquilizers BIG GUNS
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1. Prepare platelet transfusion
2. Call the doctor
RBC
Normal 4-6million
The 5 D’s The HIGHEST PRIORITY PEOPLE
1. pH in the 6s
2. Potassium 6s
3. CO2 60s
4. PO2 60s
5. Platelet court of less than 40,000
The 8 Cs level HIGH PRIORITY PEOPLE
1. INR above 4 level C (High Priority) Do something
2. If potassium below 3.5 level C (High Priority) Do something
3. If potassium high (5.4-5.9) still is high level C (High Priority)
4. If the hemoglobin is under 8C level
5. CO2 in the 50’s C level
6. PO2 of 70-77
7. Low WBC under 5000, ANC under 500, CD4 above 200 or lower
than 200
8. Platelets of 90,000
PSYCH DRUGS
All Psych drugs cause weight gain and low BP
Phenothiazines
Ends in “zine”
Do not cure psych disease
They reduces the symptoms
Large doses is Anti-psychotic
Small doses is Antiemetics
Major doses is Tranquilizers BIG GUNS
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Side Effects:
1. A-nticholinegic SE dry mouth
2. B-lurred vision
3. C-onstipation
4. D-rowsiness
5. E-xtra paramital syndrome (uncontrolled movement
of body parts)
6. F-otosensitivity to sunlight
7. aG-granulocytosis (Low WBC)
Nursing teaching to report:
1. Sore throat
2. Any signs of infection
Nursing Diagnosis is Safety
Drugs with a “D” behind it is a Deconoate
Deconoate is a long acting IM form given to noncompliant patients.
Tranquilizers
Tranquilizers works ASAP
Tranquilizers should not be taken for a long time
Antidepressants work in 2-4wks
Antidepressants can be taken for a long time
The four Tricyclic antidepressants are:
1. Elavil
2. Tofranil
3. Aventyl
4. Desyrel
Side Effects
1. A-nticholinergic effect dry mouth
2. B-lured vision
3. C-onstipation
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1. A-nticholinegic SE dry mouth
2. B-lurred vision
3. C-onstipation
4. D-rowsiness
5. E-xtra paramital syndrome (uncontrolled movement
of body parts)
6. F-otosensitivity to sunlight
7. aG-granulocytosis (Low WBC)
Nursing teaching to report:
1. Sore throat
2. Any signs of infection
Nursing Diagnosis is Safety
Drugs with a “D” behind it is a Deconoate
Deconoate is a long acting IM form given to noncompliant patients.
Tranquilizers
Tranquilizers works ASAP
Tranquilizers should not be taken for a long time
Antidepressants work in 2-4wks
Antidepressants can be taken for a long time
The four Tricyclic antidepressants are:
1. Elavil
2. Tofranil
3. Aventyl
4. Desyrel
Side Effects
1. A-nticholinergic effect dry mouth
2. B-lured vision
3. C-onstipation
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4. D-rowsiness
5. E-uphoria
Tricyclic elevates the mood
Benzodiazepines
Anti-anxiety
Minor tranquilizers
Has “zep” in the name
Must not take no more than 6wks
Used for:
1. Anesthesia induction
2. Muscle relaxant
3. Alcohol withdrawal
4. Seizures
5. Facilitates mechanical ventilation
Side Effects:
1. A-nticholinegic effects
2. B-lured vision
3. C-onstipation
4. D-rowsiness
Nursing Diagnosis is Safety
MAOI’s
Treats depression
1. Mar-plan
2. Nar-dil
3. Par-nate
Side Effects
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5. E-uphoria
Tricyclic elevates the mood
Benzodiazepines
Anti-anxiety
Minor tranquilizers
Has “zep” in the name
Must not take no more than 6wks
Used for:
1. Anesthesia induction
2. Muscle relaxant
3. Alcohol withdrawal
4. Seizures
5. Facilitates mechanical ventilation
Side Effects:
1. A-nticholinegic effects
2. B-lured vision
3. C-onstipation
4. D-rowsiness
Nursing Diagnosis is Safety
MAOI’s
Treats depression
1. Mar-plan
2. Nar-dil
3. Par-nate
Side Effects
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1. A-nticholinergic effects Dry mouth
2. B-lured vision
3. C-onstipation
4. D-rowsiness
Avoid Tyramine Food
1. Bananas
2. Avocados
3. Dry fruits (Raisins)
4. Organ meats
5. Smoke, dry, pickle meats
6. Process lunch meats (Hot dogs)
7. Age cheese (except for cottage and mozzarella)
8. Yogurt
9. No alcohol (elixlars)
10. No chocolate (caffeine)
11. Soy sauce
12. Do not take over-the-counter drugs
Lithium
Treats bipolar disorder
Decrease the mania
Side Effects (Give and Do not call the dr.)
1. Peeing
2. Pooping
3. Parasthesia (numbness and tingling)
Toxic Side Effects (Hold and call the dr.)
1. Metallic taste
2. Severe diarrhea
3. Tremors
#1Nursing Intervention is keep them hydrated
If sweating give them Gatorade
Monitor sodium level
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2. B-lured vision
3. C-onstipation
4. D-rowsiness
Avoid Tyramine Food
1. Bananas
2. Avocados
3. Dry fruits (Raisins)
4. Organ meats
5. Smoke, dry, pickle meats
6. Process lunch meats (Hot dogs)
7. Age cheese (except for cottage and mozzarella)
8. Yogurt
9. No alcohol (elixlars)
10. No chocolate (caffeine)
11. Soy sauce
12. Do not take over-the-counter drugs
Lithium
Treats bipolar disorder
Decrease the mania
Side Effects (Give and Do not call the dr.)
1. Peeing
2. Pooping
3. Parasthesia (numbness and tingling)
Toxic Side Effects (Hold and call the dr.)
1. Metallic taste
2. Severe diarrhea
3. Tremors
#1Nursing Intervention is keep them hydrated
If sweating give them Gatorade
Monitor sodium level
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Prozac
SSRI
Side effects
1. A-nticholinergic effect dry mouth
2. B-lured vision
3. C-onstipation
4. D-rowsiness
5. E-uphoria
Causes Insomnia and give before noon
Give BID 6AM and 12N
When the dose is change for a young adult watch for SUICIDE
Haldol
Average dose is 5mg
Side Effects
1. A-nticholinegic SE dry mouth
2. B-lurred vision
3. C-onstipation
4. D-rowsiness
5. E-xtra paramital syndrome (uncontrolled movement
of body parts)
6. F-otosensitivity to sunlight
7. aG-granulocytosis (Low WBC)
If an elderly patient over dose on Haldol they at risk for (NMS) Neuropeptic
Malignant Syndrome (911) and has Hyperpyrexia (BAD FEVER) temps-106-108
Clozaril (Clozapine)
(“zap”)
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SSRI
Side effects
1. A-nticholinergic effect dry mouth
2. B-lured vision
3. C-onstipation
4. D-rowsiness
5. E-uphoria
Causes Insomnia and give before noon
Give BID 6AM and 12N
When the dose is change for a young adult watch for SUICIDE
Haldol
Average dose is 5mg
Side Effects
1. A-nticholinegic SE dry mouth
2. B-lurred vision
3. C-onstipation
4. D-rowsiness
5. E-xtra paramital syndrome (uncontrolled movement
of body parts)
6. F-otosensitivity to sunlight
7. aG-granulocytosis (Low WBC)
If an elderly patient over dose on Haldol they at risk for (NMS) Neuropeptic
Malignant Syndrome (911) and has Hyperpyrexia (BAD FEVER) temps-106-108
Clozaril (Clozapine)
(“zap”)
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Olanzapine
Paliperidone
Lurasidone
Lloperidone
Aripiprozole
Treats severe schizophrenia
Side Effect is Agranulocytosis (Increase infection)
Sertraline (Zoloft)
SSRI
Taken in evening
Cause insomnia
Decrease metabolism
Cause toxic drug level
Stay away from St. John’s wort it cause Serotonin Syndrome
Watch out for bleeding when the pt is on Coumadin
S/S of Serotonin Syndrome
1. S-weating
2. A-pprehension
3. D-izziness
4. H-eadache
Maternity
Nageles rule
1. 1
st
day of the last menstrual period
2. Add 7days
3. Subtract 3months
Normal weight gain for pregnancy
28+ or -3lbs
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Paliperidone
Lurasidone
Lloperidone
Aripiprozole
Treats severe schizophrenia
Side Effect is Agranulocytosis (Increase infection)
Sertraline (Zoloft)
SSRI
Taken in evening
Cause insomnia
Decrease metabolism
Cause toxic drug level
Stay away from St. John’s wort it cause Serotonin Syndrome
Watch out for bleeding when the pt is on Coumadin
S/S of Serotonin Syndrome
1. S-weating
2. A-pprehension
3. D-izziness
4. H-eadache
Maternity
Nageles rule
1. 1
st
day of the last menstrual period
2. Add 7days
3. Subtract 3months
Normal weight gain for pregnancy
28+ or -3lbs
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1
st
trimester 1lb each month (1
st
3months) =3lbs
2
nd
/3
rd
trimester 1lb each week
At end of 12wk she should gain 3lbs
At 13wk gain 4lbs etc…….
To get the ideal weight gain is weeks – 9
Fundus
Palpable at 12 weeks end of the trimester
It is at naval at 20-22 weeks end of second trimester
Positive signs of pregnancy
1. Fetal skeleton on X-ray
2. Fetal presence of ultrasound
3. Auscultation of FHR (At 8-12wks)
4. Examiner palpates fetal movement
Probable/presumptive signs of pregnancy (Maybe)
All urine and blood test
Chadwick’s signs
Cervical change to cyanosis (blue hue)
Goodell’s signs
Cervical softening
Hegar’s signs
Softening moved from the cervix to the uterus.
The pattern of Office visits
Go to the doctor once a month and until 28wks (1
st
, 2
nd
, 3
rd
)
At 28wks go see the doctor once every 2wks until 36wks
After 36wks go see the doctor every wk until 42wks
After 42wks C-section or induction
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st
trimester 1lb each month (1
st
3months) =3lbs
2
nd
/3
rd
trimester 1lb each week
At end of 12wk she should gain 3lbs
At 13wk gain 4lbs etc…….
To get the ideal weight gain is weeks – 9
Fundus
Palpable at 12 weeks end of the trimester
It is at naval at 20-22 weeks end of second trimester
Positive signs of pregnancy
1. Fetal skeleton on X-ray
2. Fetal presence of ultrasound
3. Auscultation of FHR (At 8-12wks)
4. Examiner palpates fetal movement
Probable/presumptive signs of pregnancy (Maybe)
All urine and blood test
Chadwick’s signs
Cervical change to cyanosis (blue hue)
Goodell’s signs
Cervical softening
Hegar’s signs
Softening moved from the cervix to the uterus.
The pattern of Office visits
Go to the doctor once a month and until 28wks (1
st
, 2
nd
, 3
rd
)
At 28wks go see the doctor once every 2wks until 36wks
After 36wks go see the doctor every wk until 42wks
After 42wks C-section or induction
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Hemoglobin will fall (NORMAL)
1
st
trimester Hgb will be 11
2
nd
trimester Hgb will be 10.5
3
rd
trimester Hgb will be 10
Complications during Pregnancy
1. Morning Sickness (1
st
trimester)- Treatment is Dry carbs before
getting out bed
2. Unrinary incontinence (1
st
and 3
rd
trimester) - Void Q2hrs
3. Difficulty breathing (Dyspnea) (1
st
& 2
nd
trimester)- Tri-pod
position (sit, lean forward, elbows on knees)
4. Back pain (2
nd
& 3
rd
trimester)- Pelvic tilt exercises
5. Urinate Q2hrs
Labor & Birth
A true sign of labor is onset of regular contractions
Dilation is the opening of the cervix (0-10cm)
Effacement is the thinning of the cervix (0-100%)
Station is the baby’s presenting part (head of the baby) to the mother’s ischial
spine
Baby if above the ischial spine –number (bad news)
Baby if below the ischial spine +number (goods news)
Station 0 is engagement
Lie is relationship between the spine of the baby and mother
Vertical (parallel) is good
Transverse (perpendicular) is bad (c-section)
ROA and LOA are the best presentation part
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1
st
trimester Hgb will be 11
2
nd
trimester Hgb will be 10.5
3
rd
trimester Hgb will be 10
Complications during Pregnancy
1. Morning Sickness (1
st
trimester)- Treatment is Dry carbs before
getting out bed
2. Unrinary incontinence (1
st
and 3
rd
trimester) - Void Q2hrs
3. Difficulty breathing (Dyspnea) (1
st
& 2
nd
trimester)- Tri-pod
position (sit, lean forward, elbows on knees)
4. Back pain (2
nd
& 3
rd
trimester)- Pelvic tilt exercises
5. Urinate Q2hrs
Labor & Birth
A true sign of labor is onset of regular contractions
Dilation is the opening of the cervix (0-10cm)
Effacement is the thinning of the cervix (0-100%)
Station is the baby’s presenting part (head of the baby) to the mother’s ischial
spine
Baby if above the ischial spine –number (bad news)
Baby if below the ischial spine +number (goods news)
Station 0 is engagement
Lie is relationship between the spine of the baby and mother
Vertical (parallel) is good
Transverse (perpendicular) is bad (c-section)
ROA and LOA are the best presentation part
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The first stage of labor has 3 phases
Latent Phase
1. 0-4cm dilated
2. Contractions are 5-30mins apart
3. Lasting 15-30sec
4. They are mild
Active Phase
1. 5-7cm dilated
2. Contractions are 3-5mins apart
3. Lasting 30-60sec
4. They are moderate
Transition phase
1. 8-10cm dilated
2. Contractions are 2-3mins apart
3. Lasting 60-90sec
4. They are strong
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Latent Phase
1. 0-4cm dilated
2. Contractions are 5-30mins apart
3. Lasting 15-30sec
4. They are mild
Active Phase
1. 5-7cm dilated
2. Contractions are 3-5mins apart
3. Lasting 30-60sec
4. They are moderate
Transition phase
1. 8-10cm dilated
2. Contractions are 2-3mins apart
3. Lasting 60-90sec
4. They are strong
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Contractions should be no longer than 90sec and closer than 2mins
Assessments
Assess frequency at the beginning of one contraction to the
beginning of another
Assess the duration at the beginning to end of contraction
Assess the intensity by palpating with one hand over the fundus
with the fingertips
Complication during Labor
1. Painful back labor (OP)-Knee to chest position and use your fist and
press on the sacrum (LOW PRIOITY)
2. Prolapsed cord (911) (HIGH PRIOITY)
I. Push the baby head back in
II. Position in knee chest position or trendelenburg
III. Or elevate hips on pillows
IV. Cover the cord in moist saline
3. Interventions for all other OB complications use LION
a) L-eft side position
b) I-ncrease IV rate
c) O-2
d) N-otify doctor
If PITOSIN is running in OB crisis stop first then LION
Fetal Heart Rate
Low fetal heart rate
Under 110
Use LION
High fetal heart rate
Over 160 No big deal
Just take MOM temperature
Low baseline variability (heart rate not changing)
Bad
LION
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Assessments
Assess frequency at the beginning of one contraction to the
beginning of another
Assess the duration at the beginning to end of contraction
Assess the intensity by palpating with one hand over the fundus
with the fingertips
Complication during Labor
1. Painful back labor (OP)-Knee to chest position and use your fist and
press on the sacrum (LOW PRIOITY)
2. Prolapsed cord (911) (HIGH PRIOITY)
I. Push the baby head back in
II. Position in knee chest position or trendelenburg
III. Or elevate hips on pillows
IV. Cover the cord in moist saline
3. Interventions for all other OB complications use LION
a) L-eft side position
b) I-ncrease IV rate
c) O-2
d) N-otify doctor
If PITOSIN is running in OB crisis stop first then LION
Fetal Heart Rate
Low fetal heart rate
Under 110
Use LION
High fetal heart rate
Over 160 No big deal
Just take MOM temperature
Low baseline variability (heart rate not changing)
Bad
LION
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High baseline variability
HR changing a lot (OK)
Late deceleration- Bad and LION
Early deceleration-Head pressed on (OK)
Variable deceleration-
HR up or down
Cord compression
Very bad
VEAL CHOP
V-Variable C-Cord Compression
E-Early Decels H-Head Compression
A-Accelerations O-Ok
L-Late Decels P-Placenta
Second Stage of Labor
1. Deliver the head
2. Suction 1
st
mouth then the nose
3. Check for cord around the baby neck (Nuchle)
4. Deliver shoulders and body
5. Put an ID band on the baby
Third Stage of Labor
1. Make sure the placenta is there
2. Check for the three vessel (2 arteries & 1vein)
Fourth Stage of Labor (4*hr)
1. Check VS for S/S of shock
2. Check the fundus-if boggy massage. If displaced make them void
3. Perineal pad- excessive lochia saturated Q15mins (911)
4. Roll on side and check the pad for bleeding
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HR changing a lot (OK)
Late deceleration- Bad and LION
Early deceleration-Head pressed on (OK)
Variable deceleration-
HR up or down
Cord compression
Very bad
VEAL CHOP
V-Variable C-Cord Compression
E-Early Decels H-Head Compression
A-Accelerations O-Ok
L-Late Decels P-Placenta
Second Stage of Labor
1. Deliver the head
2. Suction 1
st
mouth then the nose
3. Check for cord around the baby neck (Nuchle)
4. Deliver shoulders and body
5. Put an ID band on the baby
Third Stage of Labor
1. Make sure the placenta is there
2. Check for the three vessel (2 arteries & 1vein)
Fourth Stage of Labor (4*hr)
1. Check VS for S/S of shock
2. Check the fundus-if boggy massage. If displaced make them void
3. Perineal pad- excessive lochia saturated Q15mins (911)
4. Roll on side and check the pad for bleeding
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Post-Partum Assessment
The Uterus
1. Must be firm not boggy
2. Fundal height=days postpartum (3days=3cm below naval)
3. Midline
Lochia Color
1. Red is ruba
2. Pink is serosa
3. White is alba
Moderate lochia is 4-6inches on the pad in one hour
Excessive lochia is saturated pad in 15mins
Extremity assessment post-partum check
Pulses
Edema
S/S of thrombophlebitis-bilateral calf circumference is the best
way to check
New Born Findings
Cephalohematoma is swelling caused by bleeding between the
osteum and periosteum of the skull. Do Not Cross Suture Lines
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The Uterus
1. Must be firm not boggy
2. Fundal height=days postpartum (3days=3cm below naval)
3. Midline
Lochia Color
1. Red is ruba
2. Pink is serosa
3. White is alba
Moderate lochia is 4-6inches on the pad in one hour
Excessive lochia is saturated pad in 15mins
Extremity assessment post-partum check
Pulses
Edema
S/S of thrombophlebitis-bilateral calf circumference is the best
way to check
New Born Findings
Cephalohematoma is swelling caused by bleeding between the
osteum and periosteum of the skull. Do Not Cross Suture Lines
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Caput Succedaneum is edematous swelling on the scalp caused
by pressure during birth. It crosses suture line. Disappears in a
few days
OB Meds
1. Tocolytics use for stopping labor
Terbutaline=Brethine
Side Effects of Terbutaline- Tachycardia. Not good for pts with
heart issues
Nifediopine=Procardia
2. Magnesium Sulfate (HyperMagnesium)
Side Effects of Magnesium Sulfate
Hypotension
Uterine contraction will go down
Reflexes will go down( lower than 2 slow the mag) NO 1
Low respiratory rate (slow the mag is resp. is lower than 12)
NO 11
Low LOC
3. Oxyrocics use to start labor
Pitocin=Oxytocin use for PP hemorrhage
Side Effects of Pitocin
Can cause hyperstimulation (contractions longer that 90sec
and closer than 2mins.)
If the FHR is less than 110 stop it, if the FHR is normal slow it
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by pressure during birth. It crosses suture line. Disappears in a
few days
OB Meds
1. Tocolytics use for stopping labor
Terbutaline=Brethine
Side Effects of Terbutaline- Tachycardia. Not good for pts with
heart issues
Nifediopine=Procardia
2. Magnesium Sulfate (HyperMagnesium)
Side Effects of Magnesium Sulfate
Hypotension
Uterine contraction will go down
Reflexes will go down( lower than 2 slow the mag) NO 1
Low respiratory rate (slow the mag is resp. is lower than 12)
NO 11
Low LOC
3. Oxyrocics use to start labor
Pitocin=Oxytocin use for PP hemorrhage
Side Effects of Pitocin
Can cause hyperstimulation (contractions longer that 90sec
and closer than 2mins.)
If the FHR is less than 110 stop it, if the FHR is normal slow it
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Methergine- cause High Blood Pressure
Cervidil=Prostaglandin
After an Epidural give fluid bolus for hypotension (At risk for fall)
Neonatal Lung Meds
Betamethasone is given to the mother before delivery IM
Side Effects ^the glucose so monitor blood sugar
Survanta given to the baby after delivery by inhalation
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Cervidil=Prostaglandin
After an Epidural give fluid bolus for hypotension (At risk for fall)
Neonatal Lung Meds
Betamethasone is given to the mother before delivery IM
Side Effects ^the glucose so monitor blood sugar
Survanta given to the baby after delivery by inhalation
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Medication Hints
Humulin 70/30 is 70% N-insulin and 30% R-Insulin (Mix of Insulin).7
for 70 .3 for 30
When drawing up insulin draw RN mean R-first then N-second
Pressurizing drawing up is NR mean N-first then R-second
To find the right needle gauge look at the first letter of injection site. If not pick the
closest one.
A-21 5/8in
B-22 1in
C-21 1in
D-25 5/8in
For injection needle an IM needle must be (C) 21 1in. (I) 1
SUBQ injection needle (D) 25 5/8 (S) 5
Heparin
1. Given IM or SUBQ
2. Cannot be given more than 3wks (except for Lovenox)
3. Works very fast
4. Do not thin blood. It prevent clots form happening
5. Monitor for PTT
6. Antidote is Protamine Sulfate
7. Pregnancy class (C) Yes
Coumadin
1. Given oral
2. Can be given for the rest of your life
3. Works 3-5days
4. Monitor Pt-INR
5. Antidote is vitamin K
6. Pregnancy class (X) NO
Switching from Heparin to Coumadin must be 14days after heparin (5days before
Coumadin) or there is a risk for DIC
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Humulin 70/30 is 70% N-insulin and 30% R-Insulin (Mix of Insulin).7
for 70 .3 for 30
When drawing up insulin draw RN mean R-first then N-second
Pressurizing drawing up is NR mean N-first then R-second
To find the right needle gauge look at the first letter of injection site. If not pick the
closest one.
A-21 5/8in
B-22 1in
C-21 1in
D-25 5/8in
For injection needle an IM needle must be (C) 21 1in. (I) 1
SUBQ injection needle (D) 25 5/8 (S) 5
Heparin
1. Given IM or SUBQ
2. Cannot be given more than 3wks (except for Lovenox)
3. Works very fast
4. Do not thin blood. It prevent clots form happening
5. Monitor for PTT
6. Antidote is Protamine Sulfate
7. Pregnancy class (C) Yes
Coumadin
1. Given oral
2. Can be given for the rest of your life
3. Works 3-5days
4. Monitor Pt-INR
5. Antidote is vitamin K
6. Pregnancy class (X) NO
Switching from Heparin to Coumadin must be 14days after heparin (5days before
Coumadin) or there is a risk for DIC
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All K+ wasting diuretics ends in X and everything else is K+ sparing diuretics
Baclofen (Lioresil or Flexeril)
Muscle relaxer
Side Effects are muscle weakness and drowsiness
Patient Teaching
1. Don’t drive
2. Don’t operate machinery
3. Don’t drink alcohol
Piaget Stages
1. 0-2yrs old is Sensor motor (They only think about what sensoring
right now) Don’t understand the future. Teach them verbally
2. 3-6yrs old is Pre-operational (Fantasy players) The morning of
teaching. Learn through play (DOLLS)
3. 7-11yrs old is Concrete operation. (Go by the rule) Visual materials
4. 12-15yrs old is Formal operations. ( Teach them like an adult)
Prioritization
The four rules of prioritization
1. Acute beat Chronic
2. Fresh post-op (12hrs.) beats medical or surgical
3. Unstable beats stable
4. The more vital the organ the higher the priority (The best rule
for prioritize)
What makes a patient stable
1. Chronic illness
2. Over 12hrs post op
3. Local or regional anesthesia
4. Unchanged assessment
5. Phrase “to be discharged”
6. Lab values A or B
7. Typical S/S for the disease they have or what they are receiving
treatment for
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Baclofen (Lioresil or Flexeril)
Muscle relaxer
Side Effects are muscle weakness and drowsiness
Patient Teaching
1. Don’t drive
2. Don’t operate machinery
3. Don’t drink alcohol
Piaget Stages
1. 0-2yrs old is Sensor motor (They only think about what sensoring
right now) Don’t understand the future. Teach them verbally
2. 3-6yrs old is Pre-operational (Fantasy players) The morning of
teaching. Learn through play (DOLLS)
3. 7-11yrs old is Concrete operation. (Go by the rule) Visual materials
4. 12-15yrs old is Formal operations. ( Teach them like an adult)
Prioritization
The four rules of prioritization
1. Acute beat Chronic
2. Fresh post-op (12hrs.) beats medical or surgical
3. Unstable beats stable
4. The more vital the organ the higher the priority (The best rule
for prioritize)
What makes a patient stable
1. Chronic illness
2. Over 12hrs post op
3. Local or regional anesthesia
4. Unchanged assessment
5. Phrase “to be discharged”
6. Lab values A or B
7. Typical S/S for the disease they have or what they are receiving
treatment for
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What makes a patient unstable
1. Acute illness
2. Post-op less than 12hrs
3. General anesthesia
4. Changed assessment
5. Phrase “newly admitted or newly diagnosed”
6. Labs C & D
7. Unexpected S/S
What 4 things that always considered unstable
1. Hemorrhage
2. Hypoglycemia
3. Fever over 104
4. Pulselessness and breathlessness
The main 6 organs in prioritized order
1. Brain
2. Lung
3. Heart
4. Liver
5. Kidney
6. Pancreas
Perfect Glasgow Coma Score is 15
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1. Acute illness
2. Post-op less than 12hrs
3. General anesthesia
4. Changed assessment
5. Phrase “newly admitted or newly diagnosed”
6. Labs C & D
7. Unexpected S/S
What 4 things that always considered unstable
1. Hemorrhage
2. Hypoglycemia
3. Fever over 104
4. Pulselessness and breathlessness
The main 6 organs in prioritized order
1. Brain
2. Lung
3. Heart
4. Liver
5. Kidney
6. Pancreas
Perfect Glasgow Coma Score is 15
Downloaded by Javad Malekan ([email protected])
lOMoARcPSD|15524743
Downloaded by Javad Malekan ([email protected])
lOMoARcPSD|15524743
lOMoARcPSD|15524743
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