Best Bet for Kids

Age​: 0 – 6 months ​(Safety)

Activity: ​Babbling, reflective smiling, rolling over front to back, holding their neck up.
NCLEX TIPS: ​Posterior fontanelle closes at 2 months, Toy​ ​Teething ring or rattle.

Age: ​6 – 9 months ​(Object permanence)

Activity: ​sitting up without support, imitation of sound, waves goodbye.
NCLEX TIPS: ​ok to give solid food starting at 6 months **First solid food RICE
CEREAL**, Initiate 1 food at a time for a week being caution about food allergies, in 6
months the infant doubles their weight, Toy​ ​building blocks/play peekaboo.

Age: ​9 – 12 months ​(Verbal Development)

Activity: ​Standing alone without support, crawling, saying small words.
NCLEX TIPS: ​Should be in a car seat, NOT ok to give cow’s milk or dairy before 12 months,
give WHOLE MILK after 12 months because babies need the fats.

Age: ​1 – 3 years ​(Parallel Play: ​play side by side not good at sharing​)
Activity: **​Gross Motor skills** Walking, kicking, running
NCLEX TIPS: ​Anterior fontanelle closes at 18 months, fear of separation from parents (never
separate them) make sure baby is sitting on mom’s lap, least invasive procedure 1​st​ =listen to
heart and lung before taking BP and starting IV.

Age: ​3 – 6 years ​(Associative Play: ​pretending​)

Activity: **​Fine Motor Skills** Hopping on one leg, skipping, tie shoes.
NCLEX TIPS: ​Ritualistic = Likes to do the same thing over and over again. It’s ok because it
reinforces safety. Picky eaters. Do procedure on doll or teddy bear 1​st​.

Age: ​7 – 12 years ​(Fair play or justice play: ​Highly competitive​)

Activity: ​ Loves group work
NCLEX TIPS:​ Brushes and flosses teeth independently, with adult supervision they can give
themselves insulin and check blood sugar levels.

Age: ​12 – 18 years ​(Internalization)

Activity: ​Peer association, self-development
NCLEX TIPS:​ Boys develop 2 years behind girls and 2 inches shorter than girls during
puberty. Teens learn from their friends.

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 Normal and High Risk Newborn
Apgar​ score is done at ​1 ​and ​5 ​minutes.
Sign Score = 0 Score = 1 Score = 2

Heart Rate ♥ Absent Below 100 Above 100

Respirations Absent Weak gasp Strong cry
Muscle Flaccid = weak or Some flexion Well flexed
limp
Appearance (color) Cyanotic = blue Troch pink but Overall pink/normal
extremities blue color
Reflex (irritability) No response Facial grimace Good response

Score at ​5 minute ​is more valuable.

Eyes: ​All newborns get the ​ERYTHROMYCIN OPTHALMIC OINTMENT​ in their eyes to
protect them from infections.

Temperature: ​98. 6 is Normal

Pulse: ​120 – 160 is Normal

Respirations: ​30 – 60 is Normal

Abdomen: ​3 vessels ​ ​ 2 Arteries and 1 vein

Skin:​ Blotchy or spotty especially the extremities.

Jitteriness ​and Lethargy can indicate ​Hypoglycemia. ​If the newborn is hypoglycemic, the
treatment is ​IV DEXTROSE.

Which vital sign is the top nursing priority for a normal newborn infant?
1. Temp
2. HR
3. RESP
4. BP

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 Normal & High risk Newborn

℘ Drug Addicted Newborn: ​Illegal substance taken during pregnancy.

● Signs/Symptoms: ​Low birth weight, poor sucking ability, High pitch cry, irritable,
irregular vital signs.

● Nursing care: ​Feed the baby, swaddle the baby, provide low environment stimuli, no
heavy light, no music, no rocking the baby.

℘ HIV Mother
● What isolation? ​Standard ​with cesarean birth No vaginal delivery.
● No breast feeding
● Can the baby stay in the room with mother? Yes
● What are the live vaccinations that are administered by nurses? ​MMR, VARICELLA,
AND ORAL POLIO VIRUS. ​Don’t give live vaccination to HIV patient.
● Give Baby ​Vitamin K shot, why? ​For blood clot

High Risk Newborn

℘ Fetal Alcohol Syndrome signs

1. Low birth weight
2. Cranio facial malformations (flat nose, small eyes, thin lips)
3. Cardiac problems
4. Respiratory Distress
*** Big Risk for mental retardation** Hold these babies

℘ Spina Bifida
1. It Is an incomplete development of the spinal cord &/or it’s covering.
2. Major nursing priority ​ ​NOT let sac Burst.
3. Proper position = keep in prone position, turn head either left or right to preserve
airway even when feeding.

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 4. No cause, could be genetic or environmental no certain cause.

**Nutrition is a major concern for both of these birth defects.

Infant Heart Defects

Blue Babies Pink Babies

1. Tetralogy of Fallot 1. Ventricular septal defect
2. Transposition if great arteries​ – 2. Arterial septal defect
Pulmonary artery and aorta are 3. Patent ductus arteriosus
switched into the wrong position, the
baby is receiving deoxygenated blood.
3. Tricuspid atresia​ (not there)
4. Truncus arteriosus ​ - instead of 2
arteries one is doing the job of 2.

All ​Blue Babies ​problems begin with the letter ​T. (Trouble)

Emergency Position: ​If the baby is experiencing active Respiratory distress, place them in the
Knee to Chest Position.

Diseases To know

TETROLOGY OF FALLOT

Real Right ventricular hypertrophy

Oxygenation Overriding aorta
Problem Pulmonary stenosis
Very Scary Ventricular septal defect

How should a nurse Identify a child?

- Name and Birthday
If the child can’t provide their name and Birthday what should the nurse do?
- Ask the parents

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 Age Specific Nursing Care
No matter the age all patients have the same rights for
1. Safety
2. Confidentiality
3. Pain management
4. Control – ability to refuse
5. Comfort
6. Family member or significant other involvement
7. Privacy

Age group 1 – 12
℘ Top 2 nursing concerns are
1. Medication errors
a. Pediatric clients are ​3​ times more likely to have a medication error.
2. Complications from IV, they pull on things.
℘ Before administering medications ask client for: ​Name and Birthday
℘ If the patient is too young? ​Ask Parent

#1 Fear of children ​Separation Anxiety

#1 Fear of adults ​Public Speaking

** When kids this age get sick, they tend to Regress!

Age Group 13 – 18
℘ Goals
1. Develop ​relationship with the ​Opposite Sex.
2. Cope ​with body ​Changes experiencing.

℘ The need to establish independence from primary care giver

℘ Patient Priority Concerns

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Female: ​Menarche
Male: ​Acne

NCLEX acne Medications

Medication NCLEX Points
Isostritonen 1. Elevate triglycerides in pt. (Fats found
in the blood)
2. Need to be on 2 forms of birth control
while on this meds because causes
severe birth defects.
3. Contains ​Vitamin A​ don’t take
Vitamin A and this med Together.
4. Irritant to skin ​ ​ Causes Inflammation
before it becomes therapeutic lips,
mouth, everything red and swollen.
These are all Normal and must
continue their meds

℘ Psych Priority
Depression - Suicide ​is a prevalent cause of death in this age group.

Age Group: 19 – 40
1. Resolve issues that are still present from their adolescent years.
2. When they are sick they think about who is going to fulfill their responsibilities, who is
going to manage kids, work? These are barriers to learning.

Psych Priority: ​Overcome Barriers To Learning

Age Group: 40 – 60
#1 concern is to identify ​Diseases ​early on.
The best way to anticipate disease is to look at ​Risk Factors.

Community Health nursing - There are 3 levels of Prevention

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Primary - Patient who is healthy and you are trying to prevent any
diseases.
- Example: immunizations, clean environment, no pollutions,
sanitary clean water.
Secondary - Screenings!!
- Recognizing disease early and treating it.
- Example: Meds, screenings, HIV Tests
Tertiary - Examples: physical therapy after a stroke, dietary measures.
Psych concerns:
Caring for ​children and parents ​at the same time.
Age group 60 – up

Goals
1. Maintain ​physical abilities
2. Prevent ​cognitive ​decline
3. Positively ​grieve the loss of ​spouse ​or ​job.

Nclex Nursing Concerns

1. Medication Safety - Elder have low metabolism, not eating much, not hungry,
high % of body fat than muscle mass.
2. Fall prevention - Communication: be vigilant about call lights
- Address pain
- Prevention: non-skid docks, bed at lowest position,
bowel and bladder training.
3. Skin breakdown - Poor nutrition status
- Mobility
- Restrains
- Braden scale-standardized tool to assess risk

Nursing Care for Wounds

1. Frequent ​change position ​q 2 hours.
2. Never give a ​hot bath ​or use ​hot ​period on Dermal pressure ulcer.
3. Pillows ​for support and raise ​the bed ​at least ​30 degrees.
4. Lift ​don’t ​pull.
5. Never ​massage ​over ​bone prominences.
6. Give ​at least 2,000 ml fluid ​a day.

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 Pregnancy
Human Chorionic Gonadotropin (HCG)​ is the hormone responsible for pregnancy.

℘ Probable Signs​ – All blood and urine tests.

℘ Positive Signs​ – X-ray, ultrasound, Doppler.
℘ Naegele’s Rule
o Add ​7 ​days
o Subtract​ 3​ months
o Add ​1​ year
Example: LMP was April 14, 2000 estimated due date: January 21, 200.
℘ Doctor’s Visits:
o up to 28 weeks ​ ​Monthly
o 28 – 36 weeks ​ ​Every 2 weeks
o 36 – 42 weeks ​ ​Weekly
**After 42 weeks, induce labor or do a C-section**
● Gravidity: ​The number of pregnancies a woman had (even abortion and
miscarriages)
● Parity: ​The number of pregnancies that have been carried to term or resulted in live
birth.
A woman has 4 children (2 singles and a set of twins) her parity is = 3

℘ Pregnancy and …
1. Morning Sickness:​ Dry carbohydrates, result of blood sugar dropping. Eat salt crackers,
ginger ale, clear liquids.
2. Backache:​ use good posture, low heel shoes, pelvic rocking technique.
3. Leg cramps:​ point big toe toward the ground. Stretches out gastric demies muscle and
then point it up to the ceiling. Plantar and dorsi flexion of leg.

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 4. Diet: ​prenatal vitamins ​ ​ folic acid (to help prevent neural defects), High protein.
5. Anemia: ​Normal to be slightly anemic, because it takes the extra RBC to help the baby
develop hemoglobin and hematocrit will drop but plasma increases.
6. Kegel’s exercises:​ Helps prevent urinary incontinence some pregnant women experience
it because as the uterus expands it puts pressure on the bladder.

℘ Danger Signs​ – sudden abdominal pain. Abrupt flow of vaginal fluid. Vaginal bleed.
Puffiness in face and hands.
o If the baby is not full term these signs indicate a woman needs to go to the
hospital immediately​.
o If a pregnant woman is bleeding never asses Vaginally​!

℘ Complications of Pregnancy
o Preterm Labor – Any labor before the baby is ready to come out. Any labor before 37
weeks is considered preterm.
▪ Medication to STOP premature Labor
● If you give TERBUTALINE ​ ​Watch for: Tachycardia in mom
and baby
● If you give Magnesium Sulfate ​ ​Watch for: Decrease reflexes,
respirations, and Urine output. Initiate Foley or indwelling catheter
to monitor the urine output. It should be 30 ml/hr.
o Pre-eclampsia – Hypertensive seen in pregnancy
▪ The three defining characteristics are
1. Hypertension
2. Edema (puffiness on face)
3. Protein urea
❖ Treatment: ​Bed rest and Magnesium Sulfate
Only cure is to deliver the baby!

Nursing care for Pre-eclampsia

1. Put patient on bed rest ​ ​ in left lateral position
2. Monitor diet ​ ​ Low sodium, fluid restriction
3. Monitor for eclampsia
4. Difference between pre-eclampsia and eclampsia?
Eclampsia = ​patient starts to have seizures very bad. When
pre-eclampsia woman arrives, they put her on seizure
precautions. ​Seizure precautions =​low lightening, low

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 stimuli, bed lowest position, pad side rails, oxygen and
suction at bedside. NEVER put anything in mouth. Time
the seizure.

℘ Labor​ – onset of regular contractions that increase in frequency, strength, and duration.
1. If you want to help labor along give? ​Pitocin or Oxytocin ​to start regular
contractions.
2. Stop when? When contractions are 2 mins apart and last for 60 sec.

Stages of Labor
1. First Stage
a. Pre-labor: Days before the contractions begin.
b. Early labor: cervix open from 0 – 4 cm can be spent at home.
c. Active labor: Cervix open 5 – 7 cm
d. Transition: Cervix open 8 – 10 cm
**Don’t push until Stage 2**

2. Second Stage
a. Push/birth: Push until the baby comes out.
b. When baby comes out and the cord is around the neck, do you suction mouth first
or unwrap the cord? ​Unwrap the cord!
3. Third Stage
a. Deliver Placenta: Placenta coming out in one whole piece. You don’t want parts
coming out because it puts patient in risk for infection and hemorrhage.
4. Fourth Stage
a. Recovery: Most critical, after baby and placenta has been delivered. Do frequent
Vital signs, check temperature, assessing extremities.

Fetal Heart Response to Labor

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 ℘ Reassuring
fetal Heart Rate
baseline Variability
Decelerations

℘ Non-reassuring
etal heart rate – Not good
aseline Variability – Not good
ecelerations – Not good, baby not getting enough O2.
ble decelerations - Not good cord is compressed

If you see any of the bad signs treat with LION

ateral Side
e or address IV fluids
en with mask
the doctor

Post-Partum Assessment

Biggest risk for post-partum complication is ​Within first 24 hr.

t: ​Advantages of breast feeding Vs. Bottle feeding
- Engorgement is the painful overfilling of the breast with milk.
- To stop milk production, when taking a shower, turn away from water, use cool
cabbage leaves, wear supportive bras.

s: ​and the fundus should be midline and firm. If it feels boggy then need to massage the
uterus.

er: ​Void before fundus assessment or uterus assessment.

: ​Expect 1 – 3 days post-partum. Stool softener to make it possible.

a: ​Post-partum discharge, should never be trickling bc it indicated hemorrhage. No foul

smell. No saturation of pad with less than 1 hr.

COLORS
1. Rubra = 1 – 3 days
2. Serosa = 4 – 6 days
3. Alba = 7 – 14 days

otomy: ​Treat for pain. Anything >4 do non-pharm pain or just give medication. Look for
signs of infection and inflammation.

an’s: ​DVT’s

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 mities: ​Measure circumference of calf muscles. Looking is there any redness or
inflammation, pain when ambulating to prevent DVT tell them to get up and walk.

Client Teaching:​ Mastitis is the inflammation of the breast tissue. Typically caused by staph
infection in the mom’s breast or babies mouth. Mother must take antibiotics. Must continue
to empty out the breast duct breast feed.

Diets
Diet Indication Food
Liquid - Prevent dehydration Clear: ​Water, jello,
and have less output. popsicles, broth.
- Clear and full liquids
- Clear ​ ​ You can see Full: ​Milk, ice cream,
trough at room temp pudding.
Soft - Patient with difficulty - Pureed
chewing. - Not soft nuts and
seeds
Bland - Patient - No fried or spicy
Gastrointestinal food.
problems. Ulcerative - Low fat
colitis or chron’s
Low protein - Renal or kidney - Avoid red meat organ
patients meat.
- Fresh food and
veggies.
Low Sodium - Heart problems - No can foods
- HTN - No preserved foods
- CHF - Fresh fruits and
veggies.
- Carbs

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High Fiber - Prevent constipation - Whole grain
- Those on bed rest - Fruits and veggies

Low Purine - Gout - Avoid organ meats

- Kidney and liver
- Avoid sea food
High protein - Elderly and burn - Foods are red meat,
patients fish and beans. This is
- Pregnant women the Focus.
Diabetic - Whole grain
- Sugar
- Carb
Celica’s - Gluten free diet - Barley
- Rye
- Oats
- wheat

Expected Changes During Aging

As we age our bodies undergo certain physiologic changes that are a natural part of growing old.

System Changes Tested on NCLEX

Cardiac - Fatigue with activity
- Blood pressure watch for orthostatic hypotension <120/80
- Risk for blood clots

Respiratory - Fatigue with activity

- Decrease oxygenation to tissue
- Decrease lung expansion

Integumentary - Wrinkled, thin, dry skin

- Poor wound healing ability
- Decreased circulation to tissue can cause ischemia.

Reproductive - Female: Painful intercourse menopause

- Male: Delay erection, risk for BPH
- Encourage sexual activity

Musculoskeletal - Weight loss decreased strength and flexibility

- Joint pain is a common complication
- Atrophy of muscles

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 - Decrease ROM

Genitourinary - Urinary retention

- Urinary frequency
- Urinary incontinence
- Risk for UTI ​ ​ confusion

Gastrointestinal - Dry mouth

- Decreased appetite
- Chewing becomes less effective
- Cycle of constipation, then fecal impaction, then diarrhea.

Nervous - Slow reaction/Reflex times

- Short term memory decline
- Long term memory should remain intact
- Behavior changes

Sensory - Vision: Diminishes

- Hearing: Decrease with high pitch sounds
- Taste: Decrease between sweet and sour
- Smell: Decrease ability to discern

Basic Care and Comfort

Non-Pharmacological Efforts

Non-pharmacological means no medicine.

1. Distraction
2. Heat/cold therapy
3. Massage but never bony prominences and legs do to clots
4. Prayer
5. Music
6. Positioning

Which method works best in children?

- Distraction
Which method works best in teens?
- Cooping statement “I can do this”
Which method works best in adults?
- Whatever they want give choice

Nutrition

Vitamins –
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Diets

Calories per gram

Protein 4 cal/g
Carbohydrate 4 cal/g
Fats 9 cal/g

Hydration​ – To know hydration, you have to be able to properly assess ​dehydration​.

Signs: ​Dry mucus membranes, poor skin turgor, thirst increase, and low urine output.

Cardiac Changes: ​Weak thread pulse, systolic Blood pressure drops, Orthostatic
Hypotension, Sinus tachycardia, Heart rate increases but weak pulse.

In dehydration, urine levels may drop below 30 ml/hr

Lab to watch
Urine specific gravity increases (Normal 1.000 to 1.030)
Urine color:​ Dark yellow color
BUN/creatine ratio​: Normal ratio is 10:1 to 15:1. Ratios greater than 20:1 blood is not getting
to the kidneys so it is either ​Dehydration or CHF​.

Common causes: ​UTI, diarrhea, fever, and Nausea and vomiting

Medications also cause dehydration ​ ​Diuretics

Oral Hydration can be just as effective as IV hydration if started early enough.

NCLEX Tips:
1. If patient is vomiting it’s still okay to proceed with clear liquid or oral hydration start
with small about 5 ml per sip and no more
2. If oral not tolerated next step is NG tube not IV.
3. Always least restrictive

Bladder and Bowel elimination

℘ Urine

How much a day? 1,000 – 2,000 a day

Odor? Ammonia must be liver disease; Sweet must
be diabetes
Specific Gravity 1.016 – 1.022
pH 4.6 – 8.0

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 Why are UTI more common in women than men?
- Women have short urethra

Alteration in normal urine pattern

1. Anuria: ​No kidney function
2. Glycosuria: ​Glucose in the urine
3. Hematuria: ​Blood in the urine
4. Pyuria: ​Pus in the urine
5. Enuresis: ​Involuntary urination at night

Need to know NCLEX Skill:​ Collection of 24-hour urine

1. Start with an ​Empty Bladder​. Ask patient to void then throw away
2. All urine must be kept in ​Together in one Container.
3. If one urine sample missed then ​start all over again.
4. Keep urine ​all in Ice to help prevent bacteria.

℘ Bowel

ling normal Stool: ​Universal/Standard

Age How often they go?

Infant 3 to 6 times
Children 1 to 2 times and adults
Elderly Every 3 days

Listen for bowel sounds in all four quadrants for ​5 minutes.

Definition of constipation: <5 sounds in 5 mins can indicate patient is constipated.
Definition of diarrhea: >30 sounds in 5 mins issues with diarrhea.

When doing any enemas or digital removal of impaction watch out for: ​Vagus Nerve
Stimulation ​because it has the ability to​ drop Heart rate.

Bowel test to know

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Guaiac test/hemo occult stool test - Blood that can’t be seen in stool
Culture and sensitivity - Done on stool, urine and blood. Looking for
which microorganism are growing in the
stool and which antibiotic is best to treat.

Orthopedics
1. Canes – ​The cane moves with the ​Bad ​leg. Then the ​Good ​leg follows.
2. Casts – ​Use ​Palm ​to handle during 1​st​ 24 hrs.
a. Do not get cast wet***
b. What about scratching underneath cast? No scratching, use blow drier on Cool
setting.
c. Always remember to do ​Neurovascular checks. ​ Checking for circulation,
numbness, pulse, tingling, and pressure.
3. Crutches - ​ Top of crutches should be ​2 fingers ​below armpits.
a. Do not let the ​Crutch ​press into ​Armpits.
b. Gaits (Weight bearing on uninjured leg)
▪ 2 – point:​ move left crutch with right foot then right crutch with left foot.
▪ 3 – point:​ Move crutches and weaker leg, then strong leg.
▪ 4 – point:​ Move left crutch, then right foot, then move right crutch and
follow with left foot.
c. (Non-weigh bearing) amputations, fractures
▪ Swing through​ – Move both crutches forward then bear all weight on
crutches and swing legs forward at the same time.

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 d. Stair walking with crutches
▪ Stairs – Up: ​1st​​ with good leg, then Bad with crutches.
▪ Down: ​1st​​ bad leg with crutches, then good leg.

**​Up with the good and down with the bad**

4. Walkers – ​Never try to use ​Stairs ​or ​Escalators.
a. ​Elbows flexed at 20 to 30 degrees. Same measurement as cane.
b. Step first with BAD leg then follow with GOOD leg.
c. DO NOT pick up walker when walking.

Promoting circulation 1. Need an order

Thromboembolic compression 2. Put on before they get out
(TED) of bed.
Sequential compression device 3. Promote circulation

Clients are NOT allowed to:

1. Cross their legs
2. Sit for long periods of time
3. Put pillow behind the knees

Medication Administration
Before you give medications check the ​6 rights!
1. Right patient
2. Right medication
3. Right dose
4. Right route
5. Right time
6. Right documentation
**Never give PO med with antacids and NEVER tell kids that medication is candy!

PO Crushed: ​Never crush meds that end in EC, ER, EX, & SR.
Liquid: ​Always measure on flat surface

Ear Adult: ​Up and Back. ​Child: ​Down and back <3 yrs.
Always room temperature, but should never be stored bed side.
Between each drop wait 5 minutes then give another.

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Enema 2 types: ​Rectal and Orally.
3 types of Oral enemas: ​BARIUM, LACTULOSE, & KAYEXALATE.
When giving rectal enemas always use a lubricant, water soluble is best!
Water temp should be 100 – 105 degrees.
Bag should be 12 – 18 inches above rectum.

Eye Wear gloves

Never directly on eye
If patient has prosthetic eye should the nurse take the eye out before giving eye drop? ​NO!

Gastric Tube X-ray or aspiration checking pH.

Check residual - What is left over from last feeding. It should be 100 ml, anything greater is bad sign
means patient has delayed gastric emptying.
Hold med and feeding and notify doctor.

IM Given frequently
Adult:​ 5 ml
Child:​ 2 ml
*Don’t administer IM med to patient with paraplegic, use arm not legs!!

Topical Lotion, ointment, powders wear gloves.

Thin medication and rotate sites.

Medications That….
Change color of urine Phenazopyridine, Rifampin, TB meds

Change color of stool Barium (White stool), Bismuth subsalicylate, & Iron (Black
stool)

Should always refrigerated Blood/blood products, TPN, & Amoxicillin

Should never be refrigerated Clindamycin, epinephrine, & heparin

Antibiotics
Class Examples How they help How they Harm
Aminoglycosides - Vancomycin - Infection of - Ototoxicity
- Streptomycin blood or - Nephrotoxicity (monitor
- Gentamycin infection of kidney function urinary
heart. output)
- With vancomycin Dr. will ask
for peak & trough.
- Peak:​ how much the med is
in the body at its highest
point. If given ​orally,​ draw
peak 1 hr after administration.
When given ​IV​ check 30
mins after giving it.

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 - Trough:​ draw 30 mins before
the next dose.

Penicillin - Amoxicillin - For gram - Do not give it to someone

- Ampicillin negative, who is allergic!
bacterial - If pt has never has penicillin,
infections. stay with them for half an
- EX: hour to make sure they don’t
Gonorrhea, experience any symptoms ​
pneumonia, Itching, hives, swelling.
& UTI - Never mix Aminoglycosides
with Penicillin’s.
- Either wait or give through 2
separate lines.
Tetracycline’s - Demicycline - If the pt is - Toxic to the liver and Kidney.
- Doxycytline allergic to - Hepatotoxicity
penicillin - Nephrotoxicity
you can give - Monitor liver enzymes as well
them as liver function
tetracycline’s - Light sensitivity
they are the (Photophobia)
same things. - Avoid direct sunlight
- Never give it to child under
12 yr old bc teeth will turn
black.
- Don’t take with cow’s milk
because it deactivates effect
of med.
- Whichever antibiotic you give
tell pt it will cause GI upset.

Central Lines
Very important to know what kind of line your patient has end in vena cava.

Why do clients need it?

- Because they are getting large amounts of medication like chemo or long-term
antibiotics.
Subclavian and femoral

#1 priority is to prevent infection

Top 4 ways to prevent infection:
1. Wash hands
2. Skin asepsis – use chlorhexidine gluconate solution to 30 sec.
3. Assess hub clean with alcohol
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 4. Dressing change

2 types of central lines

**Both are verified with chest x-ray!

Peripherally inserted central catheter - Ends in the vena cava. Flush with 10
(PICC Lines) ml of fluid before and after.
- To prevent clots, give heparin.

Port – a – cath - Wear a mask

Total Parenteral Nutrition

What are the Nutrients going through?
- Veins

Who needs TPN?

- GI tract not functioning properly

What labs to monitor?

- Blood Glucose levels

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How often does the nurse change the Tubing?
- Every 24 hours every day

What electrolyte imbalances can TPN cause?

- Hyperkalemia (High potassium)
- Hypemagnesemia (High magnesium)
- Hyperphosphatemia (High phosphorus)

What is your emergency substitute for TPN?

- Dextrose D10%

How do you stop TPN?

- Gradually stop
- Given with pump never gravity

Pain Management
Pain is ​Subjective.

Rating Technique
Adults 0 – 10 Scale

Babies/Children Face scale

Routes for Pain medication:

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 - What is the best way of titrating med?
o IV is the best way
- These patients need less pain medications: Elderly, children/babies, COPD, asthma, other
respiratory diseases, cystic fibrosis, and cancer in lungs.

Major NCLEX concern: ​NEVER want respiratory <10, if less call doctor!

NCLEX Pain Traps

Idiopathic Pain: ​Unexplained pain & patient complaining of this need to be assessed and
treated per doctor’s order.

Patients ask for pain meds before time? ​Assess pain, check last time given, offer
complementary therapy. EX: Heating pad or massage.

Give med before: ​Ambulation, and wound care.

Substance Abuse
A. Alcoholism-excessive consumption and dependence
Most alcoholics are in: ​Denial

Nursing communication should be ​Objective ​and ​Non-Judgmental.

Withdrawal Symptoms: ​Anxiety, sweating, agitation, tachycardia, & tremors.

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Treatment: ​regular diet and multivitamin

Names to know
Wernicke’s Syndrome: ​Neuro changes due to low THIAMINE (Vitamin B1 deficiency) ​
Confusion and black out.

Korsafoff’s Psychosis: ​Delirium, Confusion, short-term memory loss, & delusions

Medications for Alcoholism – NO CURE ONLY ABSTINANCE

Disulfiram: ​If patient taking it they can’t have anything with alcohol in it.

Librium: ​CNS depressant. Temporary Medication. **No Driving!!

Room Assignment: ​Regular ETOH withdrawal can be in shared room.

Severe withdrawal signs: ​Such as Delirium need private room. Seizures, tremors can occur.

Treatment:​ Pt need to be in restraints. Get Doctor order within 1 hr. Bedrest, restraints,
benzodiazepine, BP medication and seizure precautions.

B. Narcotics ​– Addictive substance that alters Mood and

Room Assignment: ​Shared room except if post-op we don’t want them to share the same
bathroom because they have flu like symptoms.

Sever withdrawal Signs:

Treatment: ​Supportive care, monitor Vital signs, can give METHADONE.

Tonicity of IV Fluids
Tonicity means: ​Concentration of the solution or number of dissolved particles in the IV
solution.

This is in relationship to ​Intracellular Fluid.

24
 Tonicity IV FLUIDS
ISOTONIC - Tonicity or concentration of dissolved
- 0.9% NS particles is equal to intracellular fluid.
- D5W
- LR
- Used for dehydration, shock, Fluid
volume deficit, to accompany blood
administration, and to increase Blood
pressure

HYPOTONIC - The tonicity or concentration of

- 0.45 saline (1/2 NS) dissolved particles is less than
- Water goes inside the cell Intracellular fluid.
- Never give to patient with ​liver
disease, burns or trauma. - So, water is drawn into the cell which
- Also, NEVER give to patient with causes the cells to swell up.
Increased Intracranial pressure​!!!

HYPERTONIC - The tonicity or concentration of

- Water OUT of the cell dissolved particles is greater than ICF.
- 5% Dextrose in LR
- 5% dextrose in Saline - This will cause the water to move out
- 5% Dextrose in 0.9% saline of the cell causing the cell to shrink.
- 10% Dextrose in water
- Never give to patient that are
dehydrated.
▪ Ex: ​DIABETIC KETO ACIDOSIS
(DKA)

Easy Electrolytes
Electrolyte Hyper signs Hypo signs

Potassium Hyperkalemia Hypokalemia

25
3.5 – 5 - Everything up except HR & urine - Everything goes down
output. except Heart rate and
- Tall T waves, diarrhea, Urine output.
palpitations, thirsty, bradycardia, - U waves, depressed
& low urine output. ST, hypotension,
- In acidosis K is High constipation
- In alkalosis K is Low

Calcium 1. Bone pain 3 T’s

2. Stones in kidney - Tetany
8 – 10.2 3. Groans abdominal pain - Twitches
- What glands help absorb - Trousseau’s sign (late
calcium? sign)
​ arathyroid gland
P

Magnesium Everything goes down Everything going up

1. Respiratory arrest 1. Tachycardia
2. Weakness 2. Diarrhea
3. Organ failure 3. Palpitations
Sodium Dehydration or Diabetes insipidus Overload fluid
SIADH
135 - 145
Lithium
0.5 – 1.3

Diabetes Insipidus VS. Symptom of inappropriate ADH (SIADH)

Diabetes Insipidus SIADH

26
 ❖ SIADH is too much​ ADH.
❖ Both are a problem with ​ADH.
❖ Signs of SIADH are
❖ Diabetes insipidus​ is too LITTLE ADH. 1. Fluid Overload
2. Really swollen
❖ Signs of Diabetes Insipidus are 3. Water on their brain
1. Urine 4. Sodium level drops
2. Orthostatic HTN 5. Decrease level of consciousness
3. Sinus tachycardia 6. Confusion
4. Dehydration 7. Lethargic
5. Excessive thirst.
❖ Treatment for SIADH is
❖ ***All caused by tumor in the brain. 1. Diuretics are given
2. Find cause and treat the cause
❖ Treatment for Diabetes Insipidus are 3. Then give diuretics
Vasopressin. 4. Daily weights to monitor fluid
overload closely.

Positions

27
Dorsal Recumbent - Vaginal and rectal exams
- When feet are in this position for a
long time they are at risk for blood
clots.
Fowlers - Relax abdominal content
- Eases breathing
- Prevents aspiration
- If pt has autonomic dysreflexia or
mastectomy put in fowlers position.

Lateral - Seizures
- Maternal fetal distress
- Sims ​ ​ for enemas or rectal
suppository
- After liver biopsy put them in right
lateral position.

Lithotomy - Vaginal delivery

- Pelvic examination
- Risk for blood clot

Prone - Head should be turned to one side

- Spina bifida
- Never put these patient in prone​ ​ Pt
with Difficult breathing, abdominal
incision, unconscious.

Supine - Suspected neck injuries

- Log roll them for any movement
- Risk for skin break down

Trendelenburg - Hypovolemic shock

- Cord compression

Who needs to be on a turning schedule?

- Supine

Disaster Management
28
 Inside disaster Outside Disaster
1. Loss of electricity 1. Bomb threat
2. Huge fire 2. Earth quake
3. Chemical spill 3. Tsunami

Think the worst first ​ ​Dead last

1. Those with worst condition treat first Worst pt leave last
2. ABC ventilation pt, Oxygen pt, 1. Walkie talkies
respiratory pt, COPD, Asthma, the 2. Assisted living
circulation wounded. 3. Unresponsive fatal
3. Assisted living need help getting
around
4. Walki-talkie those with nauseas and
vomiting.

Emergency Priority treatment

1. Tension pneumothorax Needle decompression

2. Chest wound Occlusive dressing

3. Spinal cord injury Immobilize your pt and protect airway

4. Fire RACE

5. Bomb, Shooting, terrorism Follow hospital protocols. Don’t try to

manage situation on your own.

Discharge Rules Who goes home or get relocated?

1. Walkie talkie
2. Assisted living
3. Unresponsive

29
 Herbal Medications
Herbal Action Patient teaching
St. John’s Worth - Used to treat - It interacts with SSRI
depression and and causes sun
anxiety sensitivity
Garlic - Used to lower blood - It interacts with blood
pressure and thinners.
cholesterol. - Any herbal med that
starts with G will
interact with blood
thinners ​ ​ Coumadin,
heparin, aspirin.
- Garlic also thins out
the blood.
Ginko biloba - Used to improve - Interacts with blood
memory. thinners
- Don’t take it if you
have history of
seizures.
Echinacea - Is used to improve the - Echinacea can cause
immune system. liver toxicity in renal
patients and it is not
effective with HIV.
Ginger - Used to improve - It will interact with
Nausea and Vomiting. blood thinners.
- Don’t take it if you
have a history of DVT
Black Cohosh - Used to treat - Contraindicated in
menopausal pregnancy can cause
symptoms such as hot premature labor.
flashes.
Ginseng Root - Used to improve - Should NOT be given
immune function and to patients who are
acts on the CNS diabetics it can cause
which will stimulate the blood sugar to
an energetic response. drop.
- Ginseng should NOT
be given to patients
with hypertension it
can cause
Hypertensive crisis.
Kava Kava - Used to treat Decreases the effects of
insomnia/muscle pain Anti-Parkinson’s meds

30
 Blood Gas Interpretation Numbers
pH-level of acuity HCO3
▪ - 7.35 – 7.45 ▪ - 22-26

Think R.O.M.E
Respiratory Opposite Metabolic Equal

1. How would you interpret this blood gas? pH 7.48, PaCO2 33, HCO3 30, PaO2 72?
- pH 7.48 ​Up ​HCO3 30 ​Up = Metabolic Alkalosis

2. How would you interpret this blood gas? Ph 7.50, PaCO2 24, HCO3 16, BE-3?
- Ph 7.50 ​up ​HCO3 16 ​DOWN = Respiratory alkalosis

3. How would you interpret this blood gas? Ph 7.32, Paco2 35, HCO318, PaO2 89?
- ph 7.32 ​down ​HCO3 18 ​down = metabolic acidosis

Respiratory Metabolic
- First thing to ask is it a respiratory - If the answer is not respiratory then it
problem yes or no if the answer is yes is Metabolic problem!
then the first part of the answer will be
respiratory!
Alkalosis = ​Breathing TOO FAST ​ omiting or suction
Alkalosis= V

Acidosis= ​Breathing TOO SLOW Acidosis= ​Everything else is acidosis

1. Which blood gas value would you expect to see in a client with acute renal failure?
- Metabolic Acidosis

2. Which blood gas value would you expect to see in a client who was Hyperventilating?
- Respiratory Alkalosis

3. Which blood gas value would you expect to see in a client who has continues gastric
suctioning?
- Metabolic Alkalosis

4. Which blood gas value would you expect to see with depressed respirations from a drug
overdose?
- Respiratory Acidosis

5. Which blood gas value would you expect to see in a client who entered into a marathon and
ran for 40 hours straight?
- Metabolic Acidosis

31
6. Which blood gas value would you expect to see in a client who currently has a blood glucose
level of 6?
- Metabolic Acidosis
Chest Tubes
℘ Function: To remove​ air​ and or ​fluid ​from the plural space.
℘ Air in plural space is called a ​Pneumothorax.
℘ Blood in the plural space is called a ​Hemothorax.
℘ Chest Tubes re-expand the lungs.
℘ You can have both air and blood in the plural space which is called pneumohemothorax.
℘ Remember normal breathing works on ​Negative pressure.
℘ Medical Emergency: Tension Pneumothorax air gets trapped between Lung and chest wall;
which can be caused by trauma, surgery, falls, etc. Outside air creates a one way valve inside
the lung.

℘ Classic Signs of a tension Pneumothorax:

Trachea - Shifted to the right
Blood pressure - Goes down
Heart Rate - Goes up
Lung Expansion - Decreased
Oxygenation - Decreased
Jugular Veins - Distended

Deviated trachea and distended neck veins are late signs due to restricted blood flow.

This is a medical emergency, client needs treatment right away!

Treatment of tension Pneumothorax:
- Needle decompression​ ​ ​ it is like bursting a bubble.

Chest Tube Setup: All chest tube systems have these three chambers
Collection Chamber Water Seal Suction Control
Record Drainage​ – every 8 Make sure Nothing comes in Amount of suction applied
hours or every shift. Make but Air comes out.
sure you know how much
your patient has put out
during your shift. Look at it at Bubbling Bubbling
the beginning of your shift to Continuous – is BAD sign, Continuous - Good sign!
know the starting point. not good at all!
Intermittent – Bad sign!
Notify M.D.​ if the drainage is Intermittent – Is good sign!
greater than 100 ml/hr or
bright red. What does It
indicate? It means that they
might be hemorrhaging
internally.

32
Care of client with chest tube
1. Assess ​client for ​respiratory distress, breath sounds, and stable vital signs​.
2. Chest tubes should be placed ​Below ​Chest level.
3. DO NOT ​Milk/strip chest tube without M.D. order.
4. Daily x-ray​ are needed to check fluid removal.
5. Clients will have ​OCCLUSIVE ​Dressing at insertion site.
6. Never ​CLAMP ​a chest tube without a M.D. order unless it’s an emergency situation.

Common NCLEX TROUBLE SHOOTING…

1. Noticed the water seal is broken:
o what are you going to see?
▪ continuous bubbling this is a scenario where you need to clamp the chest
tube. If there is an air leak it can cause a tension pneumothorax.
▪ Pull the water seal tubing out and stick it into sterile water.
▪ 3 things that are needed at the bed side ​ ​ Occlusive dressing, a clamp, and
sterile water if your patient has a chest tube.
2. Pulled the chest tube out..
o What are you going to do?
▪ Cover up the hole with the occlusive dressing that is at the bed side.
3. Received an order to have client cough and deep breath to prevent
o Atelectasis (Lung collapse) and pneumonia
o Breath in through nose hold breath 3 – 5 sec contracting the abdominal muscles
and out through the mouth slowly.

Critical thinking Chest tubes

1. What kind of lung sounds would you expect to hear with a patient who needs a chest tube?
- Diminished lung sounds and crackles

2. When caring for a client with a chest tube what should the nurse do to evaluate the
effectiveness of the chest tube?
- Mark the chest tube drainage every shift

3. What should be done once the fluid in the water seal chamber no longer fluctuates with
inspiration/expiration?
- Assess the pt because maybe there must be nothing left in there.

4. After a patient has his chest tube removed by a physician which dressing should the nurse
have ready to place over the incision site?
- Xeroform Petroleum dressing

33
 Vent Alarms
These are the only two you need to know

Tip about ventilator alarms! High alarm sound​ = obstruction, such as

mucus or biting.
If you don’t know what to do then: Low alarm sound​ = Air blowing too freely.
Take them off the ventilator and bag the Leaking or disconnection problem
patient.

H High Alarm
O Obstruction
L Low Alarm
D Disconnection

Minor Nclex Definitions

FiO2 Amount of oxygen vent delivers
Assist control Vent doing all the work whether patient is
breathing on their own or with the vent only.

PEEP – positive end-expiratory pressure This allows the lungs to stay open instead of
collapsing after every breath Normal to start
with 5 cm should never be greater than 20 cm.

SIMV – Synchronized intermittent This allows the patient to draw some breaths
mandatory ventilation on his or her own, not every breath is assisted.
He or she is able to breath on their own
between assistance.

34
 Congestive Heart Failure
℘ CHF happens when the heart can’t pump enough blood to meet the body’s needs.

Think about the kidneys, because the kidneys are related to CHF
Kidneys job is to get rid of liquid waste, if the kidney can’t do its job what is your pt going to have
problem with? Fluid overload

Left Side Right side

L think – lungs R think- Rest of the body

- All the fluid buildup will be in the - Peripheral edema

lungs. - Acities (distended abdomen)
- What are we going to hear? - Enlarged organs
▪ Crackles - Distended neck veins
▪ Cough
▪ frothy pink sputum
▪ SOB
▪ Orthopnea (pt can’t lie down flat)
▪ Restlessness
▪ Sinus tachycardia.

Most clients have Failure

℘ Tests
1. ABG
2. Chest X-ray
3. ProBNP

℘ Medications
1. If pt has ProBNP 400 give ​Diuretic.
2. Morphine ​ ​ for pain
3. Oxygen
4. Digoxin​ – builds up in the system they can become toxic

℘ Nursing Interventions

35
1. Bed rest
2. Monitor oxygen toxicity
3. Monitor digoxin toxicity
4. Diet low sodium

Diagnostic Procedures
1. Lumbar Puncture: ​The purpose is to obtain spinal fluid.
o Position: ​Lateral side lying OR fetal position.

o Pt. Teaching: ​Headache is the most common complaint. Nurses should tell the
patient to lie flat quietly.

2. M.R.I: ​Are used to visualize internal structures.

o Position: ​Supine

o Pt. teaching: ​Pt can talk during exam. No jewelry, dentures, and no pacemakers
into the scanner.

3. C.T: ​are used to visualize internal structures through the use of X-ray.
o Position: ​Supine

o Pt. teaching: ​No talking during the test. The patient teaching is no jewelry and
ask about Iodine/shellfish allergy.

4. EDG: ​Stands for Esophagogastroduodenoscopy. It is used to determine upper GI issues

such as ulcers, acid reflux, H. pylori.
o Position: ​Semi-fowlers to prevent aspiration.

o Pt. teaching: ​NPO status before procedure. Pt may receive a sedative to help
them relax. No eating until GAG reflex returns.

5. Liver biopsy: ​Purpose is to obtain a specimen of tissue from the liver.

o Position: ​Supine with the left side up. The liver is on the right side of the body.

o Pt. teaching: ​After the procedure, place the pt on the right side with a pillow
underneath to put pressure on the liver. Once it is cut it can bleed for a long time.
Also, hold all blood thinners heparin, aspirin etc.

36
 Lowering Cholesterol
℘ The goal of therapy is to lower total cholesterol and triglycerides.
℘ Why does cholesterol matter?
o Because the body naturally makes it’s own cholesterol, so we don’t really need to
be adding extra cholesterol into our system. The body has nowhere to store it so it
puts it in out VESSELS. Which leads to having clogging and putting us at risk for
having stroke.
℘ Values to know:
o LDL (Bad cholesterol it’s in the liver)= <100
o HDL (Good this is the protective cholesterol it protects the heart) = >60
o Total cholesterol = <200
o Triglycerides (fat in the food and blood) = <150
℘ Examples of dyslipidemias:
o Simvastatin
o Rosuvastatin
o Atrovastatin
℘ Drug name ending in = Statin
℘ Side effects of statins:
o Liver toxicity, monitor liver
o Muscle pain
℘ What about B3 vitamin Niacin?
o Niacin will naturally lower cholesterol
℘ Side effects of niacin:
o Flushing face
***Advicor (Niacin + Statin) side effects of both classes
℘ When your client is on a dyslipidemia assess them for?
o Rhabdomyolysis – it’s muscle distruction from medications.
o The meds start breaking down muscle tissue.
o The patient will complain of difficulty walking, difficulty climbing the stairs, muscle
aches.
o Medical emergency**
℘ How will the muscle tissue be excreted?
o In the urine
o We will see protein in the urine which we should never see
℘ How to treat it?

37
 o IV fluids and call the doctor

NCLEX teaching about Statins

℘ Goal of Low cholesterol diet:
o We take the medication in the evening at bed time
o Never take with grapefruit juice
o Tell pt to quit smoking

Ear Spotlight
Meniere’s Disease: ​A chronic disease that occurs in the inner ear resulting in too much
endolymphatic fluid.

℘ The cause of Meniere’s is unknown. Many factors: Viruses, Bacteria, Allergies etc.

℘ 3 main symptoms:
o Vertigo
o Tinnitus
o Hearing loss ​it will be one side

℘ Pt may also complain of: Nausea and vomiting

℘ Best position during a Meniere’s attack: Lie down flat with eyes closed.

℘ If complaining of tinnitus: play soft music.

℘ Diagnosis: hearing test, and MRI to see fluid

℘ Diet: low sodium fluid restrictive diet

℘ Treatment:

o Medical – Aminoglycosides, antihistamines, diuretics, sedatives, anti-emetics

o Surgical - Labyrinthectomy
▪ For two weeks after surgery
● Do not bend over at waist
● Don’t sleep on affected side
● Do not drink through straw
● No coughing
● No straining

℘ NCLEX prep:
o Not to smoke

38
 o follow their diet
o assist with ambulation

Diabetes Overview
Diabetes mellitus is a metabolism disorder in which the blood glucose levels are too high.

Diabetes put out a lot of sweet urine.

Two types of Diabetes Mellitus

Diabetes 1 Diabetes 2
1. Age Child Adult

2. Is body producing No Yes, not enough

insulin

3. Insulin dependent Yes, no insulin production No, not always

4. Ketone(forms when Yes, you will see No, you won’t see
body starts to break
down fat for energy,
when there is not
enough glucose the
body has to use
something. They are
the waste product of
the body and are
very toxic.)
production

5. Treatment Modified diet Modified diet

Insulin Oral glycemic
Activity Activity

Signs and symptoms: polyuria, polydipsia, polyphagia

39
Normal Glucose level is 70 – 110

Complications of diabetes

Hyperglycemia – High blood sugar

Diabetes 1 Diabetes 2
Cause Diabetic Ketoacidosis (DKA) Hyperosmolar,
- Not enough insulin, hyperglycemic Non-ketotic
they will start using (HHNK)
fat for energy. - When blood sugar is
high
- Dehydration
Signs D – Dehydration Are signs of dehydration: dry
mucus membranes, poor urine
K – Ketones and Kussmal output, complaining of thirst,
breathing orthostatic hypotension, sinus
tachycardia.
A – Acidosis and anorexia

Treatment IV fluids and regular insulin Iv fluids and regular insulin

Hypoglycemia – low blood sugar

usually treated when below 60
Diabetes 1 Diabetes 2
Cause Too much insulin or not Too much insulin or too
enough much exercise
Signs Looks like drunk: slurred Looks like SHOCK: Blood
speech unsteady gait, pressure drops but heart rate
emotional, combative goes up sinus tachycardia,
cold and clammy need some
candy.
40
treatment If they are awake – want them If they are awake – want them
to eat, orange juice, candy, to eat, orange juice, candy,
sandwich, sandwich,

If unconscious- give iv If unconscious- give IV

dextrose. dextrose.

Hemoglobin A1C is a blood test used to determine blood sugar control over 3 months. You want
it to be less than 7%

Insulin types and actions

Types Generic Names Onset Peak Duration
Rapid Novolog <15 min (make 1 HR 3 hrs
sure you have
food in front of
your patient
when
administering
this)
Short Novolin R 1 hr 2 hr 4 hr
(Regular)
- (clear
insulin)
only
insulin
that can
be given
IV

Intermediate NPH 4 hr 8 hr 12 hr

Long Acting Lantus glargine Very slow No peak 24 hr

- Given at
night

Oral Antidiabetics Agents: Metformin, byetta (It’s an injection but it’s for type 2 diabetics only),
(Glucophage and Avandia are same thing.)

Contraindicated meds
1. Never give these oral pills with Coumadin
41
 2. with birth control pills
3. steroids of any kind.
Insulin and
1. Diet ​ ​ Make sure majority of their calories comes from carbohydrates. They last longer
in the system making the blood glucose levels more stable.
2. Exercise ​ ​ it drops it, the more you exercise you do the less insulin you need.

Endocrine Review

Thyroid gland what is it responsible for?

- Oxygen consumption
- Metabolism
- Producing the thyroid hormone
What is the parathyroid gland responsible for?
- Calcium and phosphorus absorption
- But think calcium for NCLEX

Hyperthyroidism – ​Everything goes up! Hypothyroidism – ​everything goes down

Signs: Signs:
- High Heart Rate - Decreased Heart Rate
- High Blood pressure - Decreased Blood Pressure
- Hyperactive - Lethargic
- High energy - Weak
- High metabolism - Depressed
- Diarrhea - Weight Gain
- Intolerance to heat - Edema
- Weight loss - Intolerance to Cold
- Exophthalmos - Goiters
- Irritable
- “Graves’ disease”
Treatment: Treatment
- Medical: #1 radioactive Iodine: - Medical treatment:
Propylthiouracil or P.T.U (Puts the Levothyroid/Synthroid: replaces the
thyroid under, shrinks the thyroid). It thyroid hormone. Make sure you give
can be given PO of IV. it on an empty stomach typically first
- Surgical: Thyroidectomy – taking the thing in the morning or before meals.
thyroid out.

42
Precautions:
- Gown and gloves
- Remember that the body fluids (urine,
stool, blood) are also going to be
radioactive. Never directly tough
them. Use hazardous clean ups for all
body fluids.
- Flush the toilet 3 times after using it
- No pregnant nurses allowed to take
care of the patient
- No children to visit the patient

Or

Watch for: Watch for:

- Thyroid storm: ​is an extreme version Hyperthyroidism
of Hyperthyroidism
▪ Life threatening
▪ High vitals
▪ Sweating
▪ Fever
▪ Nausea/vomiting
▪ Seizures
▪ Delirious

Treatment:
- Beta blockers
- Oxygen
- Acetaminophen (If pt is nausea and
vomiting and have to give Tylenol
how do you give it? ​ ​given
Suppository)
- IV fluids
- Calcium gluconate to help with the
thyroid hormone and improve calcium
levels.

43
Nursing care: Nursing care:
- Keep neck in Neutral position ​ ​semi - Make sure the pt is taking their med
fowlers every day.
- At bed side have tracheostomy kit, - Once they are on this medication they
oxygen, and suction bc just had have to take It for the rest of their
surgery in the neck and the patient can lives.
start hemorrhaging
- You want to check the dressing at the
back of the neck
- If the parathyroid glands were
removes what kind of deficiency
might the patient experience?
​calcium deficiency
After a thyroidectomy is a hoarse voice
normal?
- NO, it may indicate laryngeal edema
or damage.

If the pt is frequently swallowing that may

indicate ​ ​ Hemorrhage.

Adrenal Disorders
- The adrenal glands help us make adrenaline and cortisol
℘ Addison’s Disease – ​“too little” by the adrenal cortex.
- Patients with Addison’s disease cannot handle stress well. EX. If they are told they need
surgery they faint. Remember steroids end in “Sone” example cortisone, prednisone.
o Signs of Addison’s
▪ Depressed
▪ Lethargic
▪ Unable to tolerate changes
▪ They go into shock very easily
▪ Mood swings
▪ Bronze color skin
o Treatment:
▪ Replace cortisol with cortisone or prednisone.
℘ Cushing’s Syndrome – “​too much” by the adrenal cortex.
o Signs:
▪ Moon face
▪ Trunk obesity
▪ Buffalo hump
▪ Striae (purple stretch marks)
▪ Skinny arms and legs
o Treatment:
▪ Hyperglycemic

44
 ▪ Low potassium (Hypokalemia)
▪ Immunocompromised – constantly at risk for getting infections

**Never abruptly stop taking steroids teach client to taper the drug off**

Therapeutic communication
The purpose of using these strategies is to help your client express their feelings more
effectively.
Do this:
1. Sit in silence
2. Observe with openness
3. Lean forward and listen
4. Be at eye level
5. Relax

Don’t do
1. Giving personal opinions
2. Changing the subject
3. False reassurance
4. Arguing with patient

On NCLEX choose
1. Never ask WHY questions
2. Open ended questions
3. Answers that focuses on feelings
4. Answer that reflect or rephrase what client is saying

45
 Digoxin Parameters
Age Hold
Newborn If HR Is <100
1 – 3 yrs If HR Is <90
3 – 8 yrs If HR Is <70
8 – adult If HR Is <60

Drug Antidotes
Magnesium sulfate Calcium gluconate
Acetaminophen Mucomyst
Insulin Glucagon
Morphine Narcan
Coumadin Vitamin K
Heparin Protamine sulfate

Needle Information
Route Skin layers Gauge Length
SQ Epidermis, dermis & 25 5/8th inch
into the fat.
Intradermal Epidermis & dermis 25 5/8​th​ inch
IM Epidermis, dermis & 21 1 inch
subcutaneous tissue
& into the muscle.

Psych
℘ Depression/Mania
These clients are oriented to
Depression Mania
Signs Negative signs Positive signs
- Crying - Energetic
- Weight loss - Impulsive
- Not want to eat - Pleasure seeking
- Lethargic - Have lots of partners
- Sad - Spend money they
- Empty don’t have
- No pleasure in things - Easily distracted
- Fatigue - Delusional at times
Similarity - Mood swings - Mood swings
- Memory loss - Memory loss
- fatigue - fatigue
Treatment - Mood stabilizer such - Mood stabilizer such
as lithium as lithium
- Group counseling - Group counseling

46
 - Antipsychotic if - Antipsychotic if
delusional delusional
If patient has depression and mania together it’s called Bipolar Disorder.

℘ Schizophrenia - ​Can’t tell the difference between what is real and what is not real. Disease
is chronic and requires life-long treatment.
℘ Positive psychotic symptoms
o Delusions – ​False thoughts in the mind. False beliefes that the patient thinks it’s
real.
o Hallucinations – ​false beliefs with sensory component.​ Ex. ​Hearing, touching,
tasting, smelling, feeling.
o Neologism – ​making up new words.
o Echolalia – ​repeating the same thing over and over
o Flight of ideas – ​jumping from topic to topic.
℘ Negative psychotic signs: Mute, catatonic, homicidal, suicidal, withdrawn

℘ Nursing Care
1. Always keep in mind experience to the client is real.
2. Acknowledge their feelings.
3. Present reality
4. Set boundaries
5. Avoid changing the subject

℘ Psych drugs
1. Anxiolytics
▪ Benzodiazepines: ​Diazepam, flurazepam, alprazolam, lorazepam
▪ Drugs that end in -PAM
▪ They help to reduce anxiety.
▪ Short-term use only
▪ Addictive
▪ Safer in elderly than HALDOL (Typical antipsychotic)
▪ Monitor respirations – bc it depresses repirations
▪ Monitor liver function
▪ Benzodiazepines can also be used as Anticonvulsants (stops seizures), sedatives,
and muscle relaxants.
▪ Side effects: ​Think “ABCDS”
▪ Altered vital signs – low BP & HR
▪ Blurry vision, bradycardia
▪ Constipation
▪ Dry mouth
▪ Sedation

47
 ▪ Stasis of urine
▪ If client overdoses on benzodiazepines give? Flumazenil
2. Phenothiazines
▪ EX.​ Chlorpromazine, prochlorperazine, Trifluoperazine, promethazine
▪ Prochlorperazine & promethazine in smaller doses can be used as antiemetics.
▪ Route: ​PO, IV, IM
▪ Which route last the longest? ​ ​ IM
▪ Phenothiazines are Typical antipsychotics.
▪ Typical psych drugs work best on the “positive psychotic symptoms”
▪ EX. ​Haloperidol​, thiothixene, perphenazine, Chlorpromazine.
▪ Typical antipsychotics are also called “FIRST GENERATION
ANTIPSYCHOTICS or NEUROLEPTICS”
▪ What does Neurolepsis mean?
● Altered motor skills
● Decreased LOC
● Rocking back and forth
● Tongue in and out

- Side effects: ABCDSS + Tardive dyskinesia

● Altered vital signs – low BP & HR
● Blurry vision, bradycardia
● Constipation
● Dry mouth
● Sedation
● Stasis of urine

▪ Nursing Assessments:
▪ Monitor for tardive dyskinesia (expected)
▪ Monitor vital signs particularly bc if they are having changes it means that
they are having an adverse reaction.
● If they have bp or temp changes they need to come off of the med.

▪ What drug can we give to lessen the side effects? ​ ​ ​Benztropine

▪ ​We have to tell pt that: must take meds or their psychotic symptoms will
return.
▪ Neuroleptic malignant Syndrome (NMS)
▪ Signs:​ ABCDS +Tardive dyskinesia + extreme vital signs
● If pt has all three of these it’s a medical emergency!​!
● The bp is very high, the temp is high, they are having seizures,
throwing up, catatonic,
▪ Nursing care

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 ● After the oxygen and airway are secure, you want to make sure
you control the temperature bc the brain can only stay hot for
so long.
● You flush the medication IV fluids
● Acetaminophen suppository
● Cooling blankets
● Bata blockers for blood pressure
● Oxygen

3. Atypical Antipsychotics ​also known as SECOND GENERATION antipsychotics.

▪ Examples: ​Clozapine, olanzapine, risperidone, quetiapine, aripiprazole
▪ Most end in pine
▪ They still have the ABCDS
● Altered vital signs – low BP & HR
● Blurry vision, bradycardia
● Constipation
● Dry mouth
● Sedation
● Stasis of urine

▪ Atypical antipsychotics have less tardive dyskinesia (extrapyramidal symptoms).

▪ Monitor patient for
▪ Metabolic changes
▪ Atypical Antipsychotics can cause
▪ Diabetes mellitus
▪ Weight gain
▪ Dyslipidemia – cholesterol too high which makes pt risk for stroke or
heart attacks.

**When your patient is on an ​atypical antipsychotic​ medication monitor them for

AGRANULOCYTOSIS (low WBCs).​ If they have agranulocytosis they will
complain of fever, body aches, chills, sore throat etc. Basically, signs of the flu!!
▪ Hospitalized immediately and they have to be taken off this
medication.
▪ Close monitoring
▪ Broad spectrum antibiotic ​ ​Vancomycin

4. Antidepressants
▪ M.A.O.I ​(Monoamine Oxidase inhibitors)
▪ These drugs block M.A.O enzyme that breaks down epinephrine, dopamine,
serotonin which leads to depression. They also block tyramine which outs client
at risk for hypertensive crisis.
**Not used as often due to various drug and food interactions*

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 ▪ Isocarboxazid
▪ Phenelzine
▪ Tranylcypromine
▪ Side effects:​ ABCDS
▪ Altered vital signs – low BP & HR
▪ Blurry vision, bradycardia
▪ Constipation
▪ Dry mouth
▪ Sedation
▪ Stasis of urine
▪ Diet restrictions​: see tyramine diet chart
▪ Client teaching​: M.A.O. I’s take long time to start working. May take 4 – 6
weeks to work. NEVER take them with ​SSRI’s!!!

- MAOIs makes glaucoma worse chronic or acute!!!

Tyramine Restricted diet
Meats - No organ meats or preserved
Grains - No grains with active yeast
- Nothing that rises up!
- Flatbread is a good alternative
- No muffins
Vegetables - No BAR: Bananas, Avocados, Raisins
Fruits - No BAR: Bananas, Avocados, Raisins
Dairy - No cheese except cottage cheese
- No yogurt
Sweets/oils - No coffee
- No tea
- No chocolate
Condiments - No soy sauces

5. Antidepressants
▪ S.S.R.I (​Selected Serotonin Reuptake Inhibitors)
▪ These drugs inhibit the reuptake of serotonin.
▪ Side Effects:
▪ Altered vital signs – low BP & HR
▪ Blurry vision, bradycardia
▪ Constipation
▪ Dry mouth
▪ Sedation
▪ Stasis of urine
▪ Headache
▪ Sexual dysfunction

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 etine – ​Causes suicidal ideation in children. Give it before 2 pm because it
causes insomnia. Which means your pt will be up all night if you give it later
on in the day.
pram – ​Very sedative. Don’t drive over operate heavy machinery or drink
alcohol after taken this med.
aline – ​Can be given in the evening, but you can’t give it with ANTIBUSE (med
used to abstain from alcohol.)
faxine – ​Interacts with tegament, and NSAIDS AND Lithium.

▪ Contraindications:​ Never give SSRI with MAOI

▪ Client Teaching: ​Do not take SSRI with the herbal medication St. John’s Wort.
▪ If you take both of them together your patient is at risk for serotonin
overload or serotonin syndrome.
▪ All SSRI may cause SADHEAD
● Sweating
● Apprehensive
● Dizziness
● Headache

EKG Overview

- The Nclex may give you a question with rhythm strips that look just like this. You must
be able to identify what they are and/or treatment.

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Normal sinus rhythm = ​Normal Heart Rate for an adult is 60 – 100 beats per minute.

1. What is the rate? - 60 – 100

2. What is the rhythm? - Regular
3. Is there a P wave before each QRS? - Yes
4. Are the P waves upright and similar? - Yes
5. What is the length of the PR interval? - 0.12 – 0.20 secs
6. What is the length of the QRS - 0.06 – 0.12
complexes?

Rules: No treatment needed for this patient, do not give any meds.

- The saw tooth pattern looks like shark teeth. So think I see a shark and my heart flutters!

Atrial Flutter = ​Saw tooth pattern

7. What is the rate? - Atrial rate is represented by the

P-wave
- Atrial ​ ​ 250 – 400 bpm
- Ventricular rate is represented by the
QRS complex’s.
- Ventricular ​ ​Variable
8. What is the rhythm? - Atrial regular
- Ventricular irregular
9. Is there a P wave before each QRS? - Normal P waves are absent
10. Are the P waves upright and similar? - Saw tooth pattern
11. What is the length of the PR interval? - Can’t measure
12. What is the length of the QRS - 0.6 – 0.12
complexes?

These Nclex patients have atrial Flutter:

▪ Valve disorder (Mitral)
▪ Ischemia
▪ Cardiomyopathy
▪ Thickening of the heart muscle
▪ COPD
▪ Emphysema

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Nursing interventions for atrial flutter
- CARDIOVERSION ​is the Treatment choice for Atrial Flutter and NCLEX.

**Slow the Ventricular Rate by using: Diltiazem, Verapamil, digitalis, or beta blocker.

- Patient’s with A-flutter tend to develop clots why?

▪ Blood is just sitting there and when it’s sitting there it clots.
▪ That is why they have to be put on heparin or aspirin.

Ventricular Tachycardia = ​Has wide QRS complex

- This strip is actually Monomorphic V-Tach

13. What is the rate?

- Atrial ​ ​Q
- Ventricular ​ ​ 100 - 200
14. What is the rhythm?
- Regular
15. Is there a P wave before each QRS?
- Absent
16. Are the P waves upright and similar?
- Absent
17. What is the length of the PR interval?
- Not measureable
18. What is the length of the QRS complexes?
- Wide greater than 0.10 sec.
- Ask first if the patient is sable or unstable.
- These patients have Ventricular Tachycardia
▪ Cocaine Users
▪ Chest trauma
▪ Digoxin takers
▪ Enlarged heart history
▪ Hypokalemia or low serum potassium
- Treatment
▪ Defibrillation

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 ▪ Do CPR until defibrillation machine arrives
▪ There is no tissue profusion or Blood pressure with Unstable V-tach.
▪ NEVER pick epinephrine as a treatment because it stimulates ventricles.
▪ It will make you appear really unsafe on NCLEX
▪ When the patient is stable just document bc you are new nurse with no
experience.

Asystole = ​means no electrical activity no pulse or blood pressure!

- Treatment
▪ 1​st​ Epinephrine
▪ 2​nd​ Atropine
** If the monitor says Asystole but the patient is alive and well check for Lead Placement!!!

Premature Ventricular Contractions (PVC) = ​are essentially normal sinus rhythm with a
single or recurrent wide QRS complex.
- PVC’s can happen in healthy individuals without cause. Be concerned if more than 6 in
one minute or 6 in a row.
- Patients with PVC’s have
▪ Infection
▪ Caffine
▪ Nicotine
▪ Etoh abuse
- Treatment ​ ​ if has one then goes away then no treatment is really needed.
Isolation Precautions
1. Universal precautions – ​Do these things no matter what.
- Wash our hands for 25 – 20 sec
- Wear gloves (when in contact with bodily fluids)
- Disposable items in the room (nobody should be sharing personal items)
-

2. Contact precautions

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 - Wear a gown
- Contact diseases ​ ​ MRSA, VRE, Herpes, C. Difficle, roseola, shigella or
shigellosis (causes really bad diarrhea)
- If your pt is under contact precautions should the door be open or closed? ​ ​ it
can be Opened no reason for it to be closed.

3. Droplet Precautions
- Everything you do for universal and contact but now adding mask
- Add goggles or face shield (especially when changing wound or suctioning a
patient)
- Communicable within 3 feet
- Droplet diseases ​ ​ Pneumonia, influenza, meningitis, rubella
- When transporting the client they need to have mask on them
- The door can be opened

4. Airborne Precautions
- N95 mask get fitted once a year.
- Eye and face shield at all times
- Private room with negative air flow
- Airborne diseases -- > Measles, Tuberculosis, varicella, Shingles/herpes
zoster
- Door needs to be CLOSED all the time.

When cohorting patients put similar precautions together.

Never put a clean patient with a dirty patient.

Isolation Precautions

Disease Precaution
- How is it transmitted? ​ ​ through blood.
- Standard precautions

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 al Yeast infection - Standard

ea - Standard

nucleosis or Epistein Barr virus - Kissing disease

- Transmitted through saliva/ body fluids
- Standard

ile virus transmitted by mosquitos - Standard

- Through blood
- Standard

– staph infection - Can get it from pt

- Contact

- Very contagious
- Contact

irus - Contact

osis - Contact

ice - They can give it to someone else

- Contact

ttis - Strain of the flu virus

- Droplets

nza (Seasonal) - Droplet

a (German Measeles) - Droplet

ping cough (Pertussis) - Droplet

gitis - Droplet

lla (Chicken Pox) - airborne

- incubation time 3 weeks

y Pox - airborne

la (Measles) - airborne

Accident & Error Prevention

1. Top Nclex Accidents
a. Falls

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 b. Medication errors
c. Fires (Always use R.A.C.E ​ ​ Rescue, Alarm, close doors and windows,
extinguish)

Let’s talk Seizures

Seizure precautions
1. Do Not restrain
2. Time & duration the seizure
3. Do not put anything in mouth
4. Place pt in lateral position
5. Oxygen/suction at the bed side
6. Pad sides
7. Put the bed in lowest position

2. Error Prevention
a. Restraints – ​physical or chemicals, only RN can put on a restraint without the
doctor’s order, but have to get an order within 1 hr of putting on the restraints.
Order has to be renewed every 24 hrs by the physician orders are a prescription so
it has to have specific things.

▪ Prescription Have
1. Type
2. Reason
3. Location
4. Duration
b. Charting – ​immediately after a procedure. Verbal orders are very important we
always want to write down and read back the verbal order and only RN can take
verbal order. LPN SHOULD NOT take verbal orders. Chart any medication you
waste like a narcotic, heparin or insulin it takes 2 RNs to waste.

c. Incident reports – ​Never go into the Patients chart. Anyone who comes into the
hospital who has an incident and you see it you need to do an incident report.
Your priority as a nurse if you witness an incident, is to asses that person, see if
they are hurt, provide care, then file an incident report by putting in their NAME
AND ADDRESS.

Case Management
*​This makes sense because nurses are on the front lines doing the most assessment, they are able
to tell what the patient needs.
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Case management is NOT managing care!

Manages care is techniques used to reduce the cost of health benefits.

Collaboration means working with MD, OT, RT, PT, & Social workers.

Nurses are always the team managers.

Legal Eagle
℘ Advanced Directives​ – Legal documents that allow you to make decisions in advance.

They are not required by law.

There are two advanced directives are
Durable Power of Attorney Living will
1. Client names the DPA The living will is the client starting what they
2. 18 years or older want done in regards to life sustaining
3. Accept/refuse treatment treatments.
** Know client’s Status DNR Status.
CPR on DNR = Assault!!! If you try to bring someone back that is DNR you will be charged
with battery**

℘ Informed Consent​ – make sure client is able to understand what is going to happen during a
procedure, exam, test. (Advantages/Disadvantages do not give if patient is sedated.)

Need written consent to do Can do without written consent

1. All diagnostic tests 1. BASIC Nursing CARE
2. To give blood 2. IV
3. Any kind of anesthesia 3. NG tubes
4. Foley caths

**In an emergency situation DO NOT interfere with care in order to get a consent.
Who gets the consent? ​ ​ The doctor doing the procedure is the only one who can toughly
explain the advantages and disadvantages of that procedure.

How to handle the impaired (drug/alcohol using) Nurse

1. Get the Facts, only report subjective behaviors. Not your opinion

2. Report To the supervisor or nurse manager

3. Never confront the co-worker. Stay in your lane!

Delegation
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 ℘ Delegation – Know who can do what.
RN
Patients
1. Teaching
2. Assess
3. Plan
4. Interpret
5. Evaluate
6. Restrain
7. Triage

LPN Aide/UAP

1. Routine procedures 1. NO treatments or procedures at all.

2. Predictable and expected outcomes 2. ADLs ​ ​ feeding, dressing, toileting,
3. Tube feeding Combing hair, painting finger nails.
4. Indwelling catheters 3. Cart vitals
5. Sterile dressing changes 4. Transport STABLE clients
6. Follow-up teaching 5. Post mortem care
7. Applying hot/cold therapy
8. Measuring (canes, walkers, crutches)
9. Collecting specimens

LPN can NOT DO

1. IV meds
2. Blood administration
3. Care plans

Can LPNs delegate task to Aides/UAP? ​ ​ Yes

Can Aides delegate task to other Aides? ​ ​ NO

If there is a code who gets the code cart? ​ ​ The Aide/UAP you want the ones with the license to stay
with the patient.

Prioritization

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 All the answers will seem right but only one is the ​Priority!!
℘ Do not let NCLEX distract you with Age or Gender
℘ Only think about what is happening right Now!
℘ Looking for the patient who is going to Die first, who is the most critical patient, who has a
change in their condition?!

Reverse Priority
Which pt you should see last?
1. Least amount of assessment

2. Condition plainly stated

3. Least critical

Tips to master NCLEX

1. Speak only positive things to yourself

2. Practice on computer
3. Never thinking about seeing on job or hospital
4. Pick the text book answer
5. Know broad concepts
6. Give yourself permission to get some wrong

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