HESI Hints & NCLEX Gems

Maslow's Hierarchy of Needs Delegation

* Physiologic o RN Only

* Safety * Blood Products (2 RNs must check)

* Love and Belonging * Clotting Factors

* Esteem * Sterile dressing changes and procedures

* Self-actualization * Assessments that require clinical judgment

* Ultimately responsible for all delegated duties

Nursing Process
o Unlicensed Assistive Personnel
* Assessment
* Non-sterile procedures
* Diagnosis (Analysis)

* Planning

* Implementation (treatment)
Arterial Blood Gases ... Used for Acidosis vs. Alkalosis
* Evaluation
* PH 7.35-7.45

ABCs * CO2 35-45 (Respiratory driver) ... High = Acidosis

* Airway * HCO3 21-28 (Metabolic driver) ... High = Alkalosis

* Breathing * O2 80-100

* Circulation * O2 Sat 95-100%

Normal Values o Cholesterol < 200

o Hgb o Bilirubin Newborn 1-12

* Males 14-18 o Phenylalanine Newborn < 2, Adult < 6

* Females 12-16 o Na+ 136-145

o Hct o K+ 3.5-5

* Males 42-52
* HypoK+ . . . Prominent U waves, Depressed ST segment, Flat T
* Females 37-47 waves

o RBCs * HyperK+ . . . Tall T-Waves, Prolonged PR interval, wide QRS

* Males 4.7-6.1 million o Ca++ 9-10.5

* Females 4.2-5.4 million * Hypocalcemia ... muscle spasms, convulsions, cramps/tetany, +

Trousseau's, + Chvostek's, prolonged ST interval, prolonged QT
o WBCs
segment
* 4.5-11k
o Mg+ 1.5-2.5
o Platelets
o Cl- 96-106
* 150-400k
o Phos 3-4.5
o PT (Coumadin/Warfarin)
o Albumin 3.5-5
* 11-12.5 sec (INR and PT TR = 1.5-2 times normal)
o Spec Gravity 1.005-1.030
o APTT (Heparin)
o Glycosylated Hemoglobin (Hgb A1c):
* 60-70 sec (APTT and PTT TR = 1.5-2.5 times normal)
4-6% ideal, < 7.5% = OK (120 days)
o BUN 10-20
o Dilantin TR = 10-20
o Creatinine 0.5-1.2
o Lithium TR = 0.5-1.5
o Glucose 70-110
Antidotes Precautions & Room Assignments
o Digoxin ... Digiband o Universal (Standard) Precautions ... HIV initiated

o Coumadin ... Vitamin K (Keep PT and INR @ 1-1.5 X normal) * Wash hands

o Benzodiazapines ... Flumzaemil (Tomazicon) * Wear Gloves

o Magnesium Sulfate ... Calcium Gluconate? * Gowns for splashes

o Heparin ... Protamine Sulfate (Keep APTT and PTT @ 1.5-2.5 X normal) * Masks and Eye Protection for splashes and droplets

o Tylenol ... Mucomist (17 doses + loading dose) * Don't recap needles

o Opiates (narcotic analgesics, heroin, morphine) ... Narcan (Naloxone) * Mouthpiece or Ambu-bag for resuscitation

o Cholinergic Meds (Myesthenic Bradycardia) ... Atropine * Refrain from giving care if you have skin lesion

o Methotrexate ... Leucovorin o Droplet (Respiratory) Precautions (Wear Mask)

* Sepsis, Scarlet Fever, Strep, Fifth Disease (Parvo B19), Pertussis,

Pneumonia, Influenza, Diptheria, Epiglottitis, Rubella, Rubeola,
Meningitis, Mycoplasma, Adenovirus, Rhinovirus

* RSV (needs contact precautions too)

* TB ... Respiratory Isolation

o Contact Precautions = Universal + Goggles, Mask and Gown

o No infection patients with immunosuppressed patients

Fall Precautions Bleeding Precautions (Anticoagulants, etc.)
o Room close to nurses station o Soft bristled tooth brush

o Assessment and orientation to room o Electric razor only (no safety razors)

o Get help to stand (dangle feet if light headed) o Handle gently, Limit contact sports

o Bed low with side rails up o Rotate injection sites with small bore needles for blood thinners

o Good lighting and reduce clutter in room o Limit needle sticks, Use small bore needles, Maintain pressure for 5
minutes on venipuncture sites
o Keep consistent toileting schedule
o No straining at stool - Check stools for occult blood (Stool softeners
o Wear proper non-slip footwear prn)
o At home ... o No salicylates, NSAIDs, or suppositories
* Paint edges of stairs bright color o Avoid blowing or picking nose
* Bell on cats and dogs o Do not change Vitamin K intake if on Coumadin

Neutropenic Precautions (Immunosuppressed)

o No plants or flowers in room

o No fresh veggies ... Cooked foods only

o Avoid crowds and infectious persons

o Meticulous hand washing and hygiene to prevent infection

o Report fever > 100.5 (immunosuppressed pts may not manifest fever
with infection)
 o Peptic Ulcers ... Feed a Duodenal Ulcer (pain relieved by food) ...
Weird Miscellaneous Stuff Starve a gastric ulcer
o Rifampin (for TB) ... Rust/orange/red urine and body fluids o Acute Pancreatitis ... Fetal position, Bluish discoloration of flanks
o Pyridium (for bladder infection) ... Orange/red/pink urine (Turner's Sign), Bluish discoloration of pericumbelical region (Cullen's
Sign), Board like abdomen with guarding ... Self digestion of pancreas
o Glasgow Coma Scale ... < 8 = coma by trypsin.

o Myesthenia Gravis o Hold tube feeding if residual > 100mL

* Myesthenic Crisis = Weakness with change in vitals (give more meds) o In case of Fire ... RACE and PASS

* Cholinergic Crisis = Weakness with no change in vitals (reduce meds) o Check Restraints every 30 minutes ... 2 fingers room underneath

o Diabetic Coma vs. Insulin Shock ... Give glucose first - If no help, give o Gullain-Barre Syndrome ... Weakness progresses from legs upward -
insulin Resp arrest

o Fruity Breath = Diabetic Ketoacidosis o Trough draw = ~30 min before scheduled administration

o Acid-Base Balance Peak Draw = 30-60 min after drug administration.

* If it comes out of your ass, it's Acidosis.

* Vomiting = Alkalosis

o Skin Tastes Salty = Cystic Fibrosis

o Lipitor (statins) in PMs only - No grapefruit juice

o Stroke ... Tongue points toward side of lesion (paralysis), Uvula

deviates away from the side of lesion (paralysis)

o Hold Digoxin if HR < 60

o Stay in bed for 3 hours after first ACE Inhibitor dose

o Avoid Grapefruit juice with Ca++ Channel Blockers

o Anthrax = Multi-vector biohazard

o Pulmonary air embolism prevention = Trendelenburg (HOB down) +

on left side (to trap air in right side of heart)

o Head Trauma and Seizures ... Maintain airway = primary concern

Nutrition Mental Health & Psychiatry
o K+ ... Bananas, dried fruits, citrus, potatoes, legumes, tea, peanut o Most suicides occur after beginning of improvement with increase in
butter energy levels

o Vitamin C ... Citrus, potatoes, cantaloupe o MAOIs ... Hypertensive Crisis with Tyramine foods

o Ca++ ... Milk, cheese, green leafy veggies, legumes * Nardil, Marplan, Parnate

o Na+ ... Salt, processed foods, seafood * Need 2 wk gap from SSRIs and TCAs to admin MAOIs

o Folic Acid ... Green leafy veggies, liver, citrus o Lithium Therapeutic Range = 0.5-1.5

o Fe++ ... Green leafy veggies, red meat, organ meat, eggs, whole o Phenothiazines (typical antipsychotics) - EPS, Photosensitivity
wheat, carrots
o Atypical Antipsychotics - work on positive and negative symptoms,
* Use Z-track for injections to avoid skin staining less EPS

o Mg+ ... Whole grains, green leafy veggies, nuts o Benzos (Ativan, Lorazepam, etc) good for Alcohol withdrawal and
Status Epilepticus
o Thiamine (B1) ... Pork, beef, liver, whole grains
o Antabuse for Alcohol deterrence - Makes you sick with OH intake
o B12 ... Organ meats, green leafy veggies, yeast, milk, cheese, shellfish
o Alcohol Withdrawal = Delerium Tremens - Tachycardia, tachypnea,
Deficiency = Big red beefy tongue, Anemia anxiety, nausea, shakes, hallucinations, paranoia ... (DTs start 12-36
o Vitamin K ... Green leafy veggies, milk, meat, soy hrs after last drink)

o Vitamin A ... Liver, orange and dark green fruits and veggies o Opiate (Heroin, Morphine, etc.) Withdrawal = Watery eyes, runny
nose, dilated pupils, NVD, cramps
o Vitamin D ... Dairy, fish oil, sunlight
o Stimulants Withdrawal = Depression, fatigue, anxiety, disturbed sleep
o Vitamin E ... Veggie oils, avocados, nuts, seeds

o BMI ... 18.5-24.9 = Normal (Higher = Obese)

Medical-Surgical
o Steroid Effects = Moon face, hyperglycemia, acne, hirsutism, buffalo
o Hypoventilation = Acidosis (too much CO2) hump, mood swings, weight gain - Spindle shape, osteoporosis,
o Hyperventilation = Alkalosis (low CO2) adrenal suppression (delayed growth in kids) . . . (Cushing's Syndrome
symptoms)
o No BP or IV on side of Mastectomy
o Addison's' Crisis = medical emergency (vascular collapse,
o Opiate OD = Pinpoint Pupils hypoglycemia, tachycardia ... Admin IV glucose + corticosteroids) ...
No PO corticosteroids on empty stomach
o Lesions of Midbrain = Decerebrate Posturing (Extended elbows, head
arched back) o Potassium sparing diuretic = Aldactone (Spironolactone) ... Watch for
hyperK+ with this and ACE Inhibitors.
o Lesions of Cortex = Decorticate Posturing (Flexion of elbows, wrists,
fingers, straight legs, mummy position) o Cardiac Enzymes ... Troponin (1 hr), CKMB (2-4 hr), Myoglobin (1-4
hr), LDH1 (12-24 hr)
o Urine Output of 30 mL/hr = minimal competency of heart and kidney
function o MI Tx ... Nitro - Yes ... NO Digoxin, Betablockers, Atropine

o Kidney Stone = Cholelithiasis o Fibrinolytics = Streptokinase, Tenecteplase (TNKase)

* Flank pain = stone in kidney or upper ureter o CABG = Coronary Artery Bypass Graft

* Abdominal/scrotal pain = stone in mid/lower ureter or bladder o PTCA = Percutaneous Transluminal Coronary Angioplasty

o Renal Failure ... Restrict protein intake o Sex after MI okay when able to climb 2 slights of stairs without
exertion (Take nitro prophylactically before sex)
* Fluid and electrolyte problems ... Watch for HyperK+ (dizzy, wk,
nausea, cramps, arhythmias) o BPH Tx = TURP (Transurethral Resection of Prostate) ... some blood
for 4 days, and burning for 7 days post-TURP.
* Pre-renal Problem = Interference with renal perfusion
o Only isotonic sterile saline for Bladder Irrigation
* Intra-renal Problem= Damage to renal parenchyma
o Post Thyroidectomy - Keep tracheostomy set by the bed with O2,
* Post-renal Problem = Obstruction in UT anywhere from tubules to
suction and Calcium gluconate
urethral meatus.
o Pericarditis ... Pericardial Friction Rub, Pain relieved by leaning
* Usually 3 phases (Oligouric, Diuretic, Recovery)
forward
* Monitor Body Wt and I&Os
Post Strep URI Diseases and Conditions O2 Administration
* Acute Glomerulonephritis * Never more than 6L/min by cannula

* Rheumatic Fever ... Valve Disease * Must humidify with more than 4L/hr

* Scarlet Fever * No more than 2L/min with COPD ... (CO2 Narcosis)

o If a chest-tube becomes disconnected, do not clamp ... Put end in * In ascending order of delivery potency: Nasal Cannula, Simple Face ,
sterile water Nonrebreather Mask, Partial Rebreather Mask, Venturi Mask

o Chest Tube drainage system should show bubbling and water level * Restlessness and Irritability = Early signs of cerebral hypoxia
fluctuations (tidaling with breathing)

o TB ... Treatment with multidrug regimen for 9 months ... Rifampin

effectiveness of OCs and turns pee orange ... Isoniazide (INH) IVs and Blood Product Administration
increases Dilantin blood levels
o 18-19 gauge needle for blood with filter in tubing
o Use bronchodilators before steroids for asthma ... Exhale completely,
Inhale deeply, Hold breath for 10 seconds o Run blood with NS only and within 30 minutes of hanging

o Ventilators ... Make sure alarms are on ... Check every 4 hours o Vitals and Breath Sounds ... before, during and after infusion (15 min
minimum after start, then 30 min later, then hourly up to 1 hr after)

o Suctioning ... Pre and Post oxygenate with 100% O2 ... No more than o Check Blood: Exp Date, clots, color, air bubbles, leaks
3 passes ... No longer than 15 seconds ... Suction on withdrawal with
o 2 RNs must check order, pt, blood product ... Ask Pt about previous
rotation
transfusion Hx

o Stay with Pt for first 15 minutes ... If transfusion rxn ... Stop and KVO
with NS
COPD o Pre-medicate with Benadryl prn for previous urticaria rxns
* Emphysema = Pink Puffer

* Chronic Bronchitis = Blue Bloater (Cyanosis, Rt sided heart failure =

bloating/edema)
Isotonic Solutions Diabetes and Insulin
* D5W o When in doubt - Treat for Hypoglycemia first

* NS (0.9% NaCl) o First IV for DKA = NS, then infuse regular insulin IV as Rx'd

* Ringers Lactate o Hypoglycemia ... confusion, HA, irritable, nausea, sweating, tremors,
hunger, slurring
* NS only with blood products and Dilantin
o Hyperglycemia ... weakness, syncope, polydipsia, polyuria, blurred
vision, fruity breath

o Insulin may be kept at room T for 28 days

Sexually Transmitted Diseases
o Draw Regular (Clear) insulin into syringe first when mixing insulins
o Syphilis (Treponema pallidum) ... Chancre + red painless lesion
(Primary Stage, 90 days) ... Secondary Stage (up to 6 mo) = Rash on o Rotate Injection Sites (Rotate in 1 region, then move to new region)
palms and soles + Flu-like symptoms ... Tertiary Stage = Neurologic
o Rapid Acting Insulins ... Lispro (Humalog) and Aspart (Novolog) ... O:
and Cardiac destruction (10-30 yrs) ... Treated with Penicillin G IM.
5-15 min, P: .75-1.5 hrs
o Gonorrhea (Neisseria Gonorrhea) ... Yellow green urethral discharge
o Short Acting Insulin ... Regular (human) ... O: 30-60 min, P: 2-3 hrs (IV
(The Clap)
Okay)
o Chlamydia (Chlamydia Trachomatis) ... Mild vaginal discharge or
o Intermediate Acting Insulin ... Isophane Insulin (NPH) ... O: 1-2 hrs, P:
urethritis ... Doxycyclin, Tetracycline
6-12 hrs
o Trichomoniasis (Trichomonas Vaginalis) ... Frothy foul-smelling
o Long Acting Insulin ... Insulin Glargine (Lantus) ... O: 1.1 hr, P: 14-20
vaginal discharge ... Flagyl
hrs (Don't Mix)
o Candidiasis (Candida Albicans) ... Yellow, cheesy discharge with
o Oral Hypoglycemics decrease glucose levels by stimulating insulin
itching ... Miconazole, Nystatin, Clomitrazole (Gyne-Lotrimin)
production by beta cells of pancreas, increasing insulin sensitivity and
o Herpes Simplex 2 ... Acyclovir decreasing hepatic glucose production

o HPV (Human Pappilovirus) ... Acid, Laser, Cryotherapy * Glyburide, Metformin (Glucophage), Avandia, Actos

o HIV ... Cocktails * Acarbose blunts sugar levels after meals

 * Mastectomy ... Radical Mastectomy = Lymph nodes too (but no mm
Oncology resected)
o Leukemia ... Anemia (reduced RBC production), Immunosuppression
* Avoid BP measurements, injections and venipuncture on surgical side
(neutropenia and immature WBCs), Hemorrhage and bleeding
tendencies (thrombocytopenia) o Anti-emetics given with Chemotherapy Agents (Cytoxan,
Methotrexate, Interferon, etc.)
* Acute Lymphocytic = most common type, kids, best prognosis
* Phenergan (Promethazine HCl)
o Testicular Cancer ... Painless lump or swelling testicle ... STE in shower
> 14 yrs ... 15-35 = Age * Compazine (Prochlorperazine)

o Prostate Cancer ... > 40 = Age * Reglan (Metocolpramide)

* PSA elevation * Benadryl (Diphenhydramine)

* DRE * Zofran (Ondansetron HCl)

* Mets to spine, hips, legs * Kytril (Granisetron)

* Elevated PAP (prostate acid phosphatase)

* TRUS = Transurethral US

* Post Op ... Monitor of hemorrhage and cardiovascular complication

o Cervical and Uterine Cancer

* Laser, cryotherapy, radiation, conization, hysterectomy, exenteration

... Chemotherapy = No help

* PAP smears should start within 3 years of intercourse or by age 21

o Ovarian Cancer = leading cause of death from gynecological cancer

o Breast Cancer = Leading cause of cancer in women

* Upper outer quadrant, left > right

* Monthly SBE

* Mammography ... Baseline @ 35, Annually after age 50

* Mets to lymph nodes, then lungs, liver, brain, spine

 * Thoracocentesis ... Unaffected side, HOB 30-45 degrees
Perioperative Care
* Enema ... Left Sims (flow into sigmoid)
o Breathing Es taught in advance (before or early in pre-op)
* Liver Biopsy ... Right side with pillow/towel against puncture site
o Remove nail polish (need to see cap refill)
* Cataract Sx ... Opp side - Semi-Fowler
o Pre Op ... Meds as ordered, NPO X 8 hrs, Incentive Spirometry &
Breathing Es taught in advance, Void, No NSAIDS X 48 hrs * Cardiac Catheterization ... Flat (HOB no more than 30 degrees), Leg
straight 4-6 hrs, bed rest 6-12 hrs
o Increased corticosteroids for surgery (stress) ... May need to increase
insulin too * Burn Autograph ... Elevated and Immob 3-7 days

o Post Op restlessness may = hemorrhage, hypoxia * Amputation ... Supine, elevate stump for 48 hrs

o Wound dehiscence or extravisation - Wet sterile NS dressing + Call Dr. * Large Brain Tumor Resection ... On non-operative side

o Call Dr. post op if ... < 30 mL/hr urine, Sys BP < 90, T > 100 or < 96 o Incentive Spirometry ... Inhale slowly and completely to keep flow at
600-900, Hold breath 5 seconds, 10 times per hr
o Post Op Monitoring VS and BS ... Every 15 minutes the first hour,
Every 30 min next 2 hours, Every hour the next 4 hours, then Every 4 o Post Op Breathing Exercises ... Every 2 hours
hours prn
* Sit up straight
o 1-4 hrs Post Op = Immediate Stage
* Breath in deeply thru nose and out slowly thru pursed lips
2-24 hrs Post Op = Intermediate Stage
* Hold last breath 3 seconds
1-4 days Post Op = Extended Stage
* Then cough 3 times (unless abd wound - reinforce/splint if cough)
o Post Op Positioning
o Watch for Stridor after any neck/throat Sx ... Keep Trach kit at bed
* THR ... No Adduction past midline, No hip flexion past 90 degrees side

* Supratentorial Sx ... HOB 30-45 degrees (Semi-Fowler) o Staples and sutures removed in 7-14 days - Keep dry until then

* Infrantentorial Sx ... Flat o No lifting over 10 lbs for 6 weeks (in general)

* Phlebitis ... Supine, elevate involved leg o If chest tube comes disconnected, put free end in container of sterile
water
* Harris Tube ... Rt/back/Lt - to advance tube in GI
o Removing Chest Tube ... Valsalvas, or Deep breath and hold
* Miller Abbott Tube ... Right side for GI advancement into small
intestine o If chest tube drain stops fluctuating, the lung has re-inflated (or there
is a problem)
o Keep scissors by bed if pt has S. Blakemore Tube (for esoph varices)...
Sudden respiratory distress - Cut inflation tubes and remove
Decubitus (pressure) Ulcer Staging
o Tracheostomy patients ... Keep Kelly clamp and Obturator (used to * Stage 1 = Erythema only
insert into trachea then removed leaving cannula) at bed side * Stage 2 = Partial thickness
o Turn off NG suction for 30 min after PO meds * Stage 3 = Full thickness to SQ
o NG Tube Removal ... Take a deep breath and hold it * Stage 4 = Full thickness + involving mm /bone
o Stomach contents pH = < 4 (gastric juices aspirated)
Head Injuries
o NG Tube Insertion ... If cough and gag, back off a little, let calm,
advance again with pt sipping water from straw * Even subtle changes in mood, behavior, restlessness, irritability,
confusion may indicate increased ICP
o NG Tube Length ... End of nose, to ear lobe, to xyphoid (~22-26
inches) * Change in level of responsiveness = Most important indicator of
increased ICP
Acute Care * Watch for CSF leaks from nose or ears - Leakage can lead to
meningitis and mask intracranial injury since usual increased ICP
o CVA ... Hemorrhagic or Embolic
symps may be absent.
* A-fib and A-flutter = thrombus formation

* Dysarthria (verbal enunciation/articulation), Apraxia (perform

Spinal Cord Injuries
purposeful movements), Dysphasia (speech and verbal * Respiratory status paramount ... C3-C5 innervates diaphragm
comprehension), Aphasia (speaking), Agraphia (writing), Alexia
(reading), Dysphagia (swallowing) * 1 wk to know ultimate prognosis

* Left Hemisphere Lesion ... aphasia, agraphia, slow, cautious, anxious, * Spinal Shock = Complete loss of all reflex, motor, sensory and
memory okay autonomic activity below the lesion = Medical emergency

* Right Hemisphere Lesion ... can't recognize faces, loss of depth * Permanent paralysis if spinal cord is compressed for 12-24 hrs
perception, impulsive behavior, confabulates, poor judgment,
* Hypotension and Bradycardia with any injury above T6
constantly smiles, denies illness, loss of tonal hearing
* Bladder Infection = Common cause of death (try to keep urine acidic)
Burns
* Infection = Primary concern

* HyperK+ due to cell damage and release of intracellular K+

* Give meds before dressing changes - Painful

* Massive volumes of IV fluid given, due to fluid shift to interstitial

spaces and resultant shock

* First Degree = Epidermis (superficial partial thickness)

* Second Degree = Epidermis and Dermis (deep partial thickness)

* Third Degree = Epidermis, Dermis, and SQ (full thickness)

* Rule of 9s ... Head and neck = 9%, UE = 9% each, LE = 18% each, Front
trunk = 18%, Back Trunk = 18%

* Singed nasal hair and circumoral soot/burns = Smoke inhalation burns

Fractures
* Report abnormal assessment findings promptly ... Compartment
Syndrome may occur = Permanent damage to nerves and vessels

* 5 P's of neurovascular status (important with fractures)

* Pain, Pallor, Pulse, Paresthesia, Paralysis

* Provide age-appropriate toys for kids in traction

 o Elevated ICP = Increased BP, widened pulse pressure, increased Temp
Special Tests and Pathognomonic Signs
o Pill-Rolling Tremor = Parkinson's (Tx with Levodopa, Cardidopa) - Fall
o Tensilon Test ... Myesthenia Gravis (+ in Myesthenic crisis, - in
precautions, rigid, stooped, shuffling
Cholinergic crisis)
o IG Bands on Electrophoresis = MS ... Weakness starts in upper
o ELISA and Western Blot ... HIV extremities - bowel/bladder affected in 90% ... Demyelination - Tx
o Sweat Test ... Cystic Fibrosis with ACTH, corticosteroids, Cytoxan and other immunosuppressants

o Cheilosis = Sores on sides of mouth ... Riboflavin deficiency (B2) o Reed-Sternberg Cells = Hodgkin's

o Trousseau's Sign (Carpal spasm induced by BP cuff) ... Hypocalcemia o Koplik Spots = Rubeola (Measles)
(hypoparathyroidism)
o Erythema Marginatum = Rash of Rheumatic Fever
o Chvostek's Sign (Facial spasm after facial nerve tap) ... Hypocalcemia
o Gower's Sign = Muscular Dystrophy ... Like Minor's sign (walks up legs
(hypoparathyroidism)
with hands)
o Bloody Diarrhea = Ulcerative Colitis

o Olive-Shaped Mass (epigastric) and Projectile Vomiting = Pyloric

Stenosis

o Current Jelly Stool (blood and mucus) and Sausage-Shaped Mass in

RUQ = Intussiception

o Mantoux Test for TB is + if 10 mm induration 48 hrs post admin

(previous BCG vaccine recipients will test +)

o Butterfly Rash = SLE ... Avoid direct sunlight

o 5 Ps of NV functioning ... Pain, paresthesia, pulse, pallor, paralysis

o Cullen's Sign (periumbelical discoloration) and Turner's Sign (blue

flank) = Acute Pancreatitis

o Murphy's Sign (Rt. costal margin pain on palp with inspiration) = GB

or Liver disease

o HA more severe on wakening = Brain Tumor (remove benign and

malignant)

o Vomiting not associated with nausea = Brain Tumor

 * Ties shoes at 5 years
Pediatrics
* Girls' growth spurt as early at 10 years ... Boys catch up ~ Age 14
o Bench Marks
* Girls finish growing at ~15 ... Boys ~ 17
* Birth wt doubles at 6 months and triples at 12 months
o Autosomal Recessive Diseases
* Birth length increases by 50% at 12 months
* CF, PKU, Sickle Cell Anemia, Tay-Sachs, Albinism,
* Post fontanel closes by 8 wks
* 25% chance if: AS (trait only) X AS (trait only)
* Ant fontanel closes by 12-18 months
* 50% chance if: AS (trait only) X SS (disease)
* Moro reflex disappears at 4 months
o Autosomal Dominant Diseases
* Steady head control achieved at 4 months
* Huntington's, Marfans, Polydactyl, Achondroplasia, Polycystic Kidney
* Turns over at 5-6 months
Disease
* Hand to hand transfers at 7 months
* 50% if one parent has the disease/trait (trait = disease in autosomal
* Sits unsupported at 8 months dominant)

* Crawls at 10 months o X-Linked Recessive Diseases

* Walks at 10-12 months * Muscular Dystrophy, Hemophilia A

* Cooing at 2 months * Females are carriers (never have the disease)

* Monosyllabic Babbling at 3-6 months, Links syllables 6-9 mo * Males have the disease (but can't pass it on)

* Mama, Dada + a few words at 9-12 months * 50% chance daughters will be carriers (can't have disease)

* Throws a ball overhand at 18 months * 50% chance sons will have the disease (not a carrier = can't pass it on)

* Daytime toilet training at 18 mo - 2 years * This translates to an overall 25% chance that each pregnancy will
result in a child that has the disease
* 2-3 word sentences at 2 years
o Scoliosis ... Milwaukee Brace - 23 hrs/day, Log rolling after Sx
* 50% of adult Ht at 2 years
o Down Syndrome = Trisomy 21 ... Simian creases on palms, hypotonia,
* Birth Length doubles at 4 years protruding tongue, upward outward slant of eyes
* Uses scissors at 4 years o Cerebral Palsy ... Scissoring = legs extended, crossed, feet plantar-
flexed
o PKU ... leads to MR ... Guthrie Test ...Aspartame (NutraSweet) has o Children with Rubella = threat to unborn siblings (may require
phenylalanine in it and should not be given to PKU patient temporary isolation from Mom during PG)

o Hypothyroidism ... Leads to MR o Pain in young children measured with Faces pain scale

o Prevent Neural tube disorders with Folic Acid during PG o No MMR Immunization for kids with Hx of allergic rxn to eggs or
neomycin
o Myelomeningocele ... Cover with moist sterile water dressing and
keep pressure off o Immunization Side Effects ... T < 102, redness and soreness at
injection site for 3 days ... give Tylenol and bike pedal legs (passively)
o Hydrocephalus ... Signs of increased ICP are opposite of shock ...
for child.
* Shock = Increased pulse and decreased BP o Call Physician if seizures, high fever, or high-pitched cry after
* IICP = Decreased pulse and increased BP ... (+ Altered LOC = Most immunization
sensitive sign) o All cases of poisoning ... Call Poison Control Center ... No Ipecac!
* Infants ... IICP = Bulging fontanels, high pitched cry, increased hd o Epiglottitis = H. influenza B ... Child sits upright with chin out and
circum, sunset eyes, wide suture lines, lethargy ... Treat with tongue protruding (maybe Tripod position) ... Prepare for intubation
peritoneal shunt - don't pump shunt. Older kids IIPC = Widened pulse or trach ... DO NOT put anything into kid's mouth
pressure
o Isolate RSV patient with Contact Precautions ... Private room is best ...
* IICP caused by suctioning, coughing, straining, and turning - Try to
Use Mist Tent to provide O2 and Ribavirin - Flood tent with O2 first
avoid and wipe down inside of tent periodically so you can see patient
o Muscular Dystrophy ... X-linked Recessive, waddling gait, hyper o Acute Glomerulonephritis ... After B strep - Antigen-Antibody
lordosis, Gower's Sign = difficulty rising walks up legs (like Minor's complexes clog up glomeruli and reduce GFR = Dark urine, proteinuria
sign), fat pseudohypertrophy of calves.
o Wilm's Tumor = Large kidney tumor ... Don't palpate
o Seizures ... Nothing in mouth, turn hd to side, maintain airway, don't
restrain, keep safe ... Treat with Phenobarbitol (Luminol), Phenytoin o TEF = Tracheoesophageal Atresia ... 3 C's of TEF = Coughing, Choking,
(Dilantin: TR = 10-20 ... Gingival Hyperplasia), Fosphenytoin (Cerebyx), Cyanosis
Valproic Acid (Depakene), Carbamazepine (Tegritol)
o Cleft Lip and Palate ... Post-Op - Place on side, maintain Logan Bow,
o Meningitis (Bacterial) ... Lumbar puncture shows Increased WBC, elbow restraints
protein, IICP and decreased glucose
o Congenital Megacolon = Hirschsprung's Disease ... Lack of peristalsis
* May lead to SIADH (Too much ADH) ... Water retention, fluid due to absence of ganglionic cells in colon ... Suspect if no meconium
overload, dilutional hyponatremia w/in 24 hrs or ribbon-like foul smelling stools

o CF Kids taste salty and need enzymes sprinkled on their food

o Iron Deficiency Anemia ... Give Iron on empty stomach with citrus Cardiovascular Disorders
juice (vitamin C enhances absorption), Use straw or dropper to avoid
staining teeth, Tarry stools, limit milk intake < 32 oz/day o Acyanotic = VSD, ASD, PDA, Coarc of Aorta, Aortic Stenosis

o Sickle Cell Disease ...Hydration most important ...SC Crisis = fever, abd * Antiprostaglandins cause closure of PDA (aorta - pulmonary artery)
pain, painful edematous hands and feet (hand-foot syndrome),
o Cyanotic = Tetralogy of Fallot, Truncus Arteriosis (one main vessel
arthralgia ...Tx + rest, hydration ... Avoid high altitude and strenuous
gets mixed blood), TVG (Transposition of Great Vessels) ...
activities
Polycythemia common in Cyanotic disorders
o Tonsillitis ... usually Strep ... Get PT and PTT Pre-Op (ask about Hx of
* 3 T's of Cyanotic Heart Disease (Tetralogy, Truncus, Transposition)
bleeding) ... Suspect Bleeding Post-Op if frequent swallowing,
vomiting blood, or clearing throat ... No red liquids, no straws, ice o Tetralogy of Fallot ... Unoxygenated blood pumped into aorta
collar, soft foods ... Highest risk of hemorrhage = first 24 hrs and 5-10
days post-op (with sloughing of scabs) * Pulmonary Stenosis

o Primary meds for ER for respiratory distress = Sus-phrine (Epinephrine * VSD

HCl) and Theophylline (Theo-dur) ... Bronchodilators * Overiding Aorta
o Must know normal respiratory rates for kids ... Respiratory disorders * Right Ventricular Hypertrophy
= Primary reason for most medical/ER visits for kids ...
* TET Spells ...Hypoxic episodes that are relieved by squatting or knee
* Newborn ... 30-60 chest position
* 1-11 mo ... 25-35 o CHF can result ... Use Digoxin ... TR = 0.8-2.0 for kids
* 1-3 years ... 20-30 o Ductus Venosus = Umbelical Vein to Inferior Vena Cava
* 3-5 years ... 20-25 o Ductus Arteriosus = Aorta to Pulmonary Artery
* 6-10 years ... 18-22 o Rheumatic Fever ... Acquired Heart Disease ... Affects aortic and
* 11-16 years ...16-20 mitral valves

* Preceded by beta hemolytic strep infection

* Erythema Marginatum = Rash

* Elevated ASO titer and ESR

* Chest pain, shortness of breath (Carditis), migratory large joint pain,

tachycardia (even during sleep)

* Treat with Penicillin G = Prophylaxis for recurrence of RF

 o Para = # of Deliveries (not kids) after 20 wks gestation
Maternity
o Nagale's Rule ... Add 7 days to first day of last period, subtract 3
o Day 1 of cycle = First day of menses (bleeding) ... Ovulation on Day 14
months, add 12 months = EDC
... 28 days total ... Sperm 3-5 days, Eggs 24 hrs ... Fertilization in
Fallopian Tube o Hgb and Hct a bit lower during PG due to hyperhydration

o Chadwick's Sign = Bluing of Vagina (early as 4 weeks) o Side-lying is best position for uteroplacental perfusion (either side tho
left is traditional )
o Hegar's Sign = Softening of isthmus of cervix (8 weeks)
o 2:1 Lecithin:Sphingomyelin Ratio = Fetal lungs mature
o Goodell's Sign = Softening of Cervix (8 weeks)
o AFP in amniotic fluid = possible neural tube defect
o Pregnancy Total wt gain = 25-30 lbs (11-14 kg)
o Need a full bladder for Amniocentesis early in PG (but not in later PG)
o Increase calorie intake by 300 calories/day during PG ... Increase
protein 30 g/day ... Increase iron, Ca++, Folic Acid, A & C o Lightening = Fetus drops into true pelvis

o Dangerous Infections with PG ... TORCH = Toxoplasmosis, other, o Nesting Instinct = Burst of Energy just before labor
Rubella, Cytomegalovirus, HPV
o True Labor = Regular contractions that intensify with ambulation, LBP
o Braxton Hicks common throughout PG that radiates to abdomen, progressive dilation and effacement

o Amniotic fluid = 800-1200 mL (< 300 mL = Oligohydramnios = fetal o Station = Negative above ischial spines, Positive below
kidney problems)
o Leopold Maneuver tries to reposition fetus for delivery
o Polyhydramnios and Macrosomia (large fetus) with Diabetes
o Laboring Maternal Vitals ... Pulse < 100 (usually a little higher than
o Umbelical cord: 2 arteries, 1 vein ... Vein carries oxygenated blood to normal with PG - BP is unchanged in PG). T < 100.4
fetus (opposite of normal)
o NON-Stress Test ... Reactive = Healthy (FHR goes up with movements)
o FHR = 120-160
o Contraction Stress Test (Ocytocin Challenge Test)... Unhealthy = Late
o Folic Acid Deficiency = Neural tube defects decels noted (positive result) indicative of UPI ... "Negative" result =
No late decels noted (good result)
o Pre-term = 20-37 weeks
o Watch for hyporeflexia with Mag Sulfate admin . . . Diaphragmatic
o Term = 38-42 weeks
Inhibition
o Post-term = 42 weeks+
* Keep Calcium gluconate by the bed (antidote)
o TPAL = Term births, Pre-term births, Abortions, Living children
o Firsts
o Gravida = # of Pregnancies regardless of outcome
* Fetal HB ... 8-12 weeks by Doppler, 15-20 weeks by fetoscope
* Fetal movement = Quickening, 14-20 weeks * Every 15 min X 1 hr

* Showing = 14 weeks * Every 30 min X next 2 hours

* Braxton Hicks - 4 months and onward * Every Hour X next 2-6 hours

o Early Decels = Head compression = OK * Then every 4 hours

o Variable Decels = Cord compression = Not Good o Normal BM for mom within 3 days = Normal

o Late Decels = Utero-placental insufficiency = BAD! o Lochia ... no more than 4-8 pads/day and no clots > 1 cm ... Fleshy
smell is normal, Foul smell = infection
o If Variable or Late Decels ... Change maternal position, Stop Pitocin,
Administer O2, Notify Physician o Massage boggy uterus to encourage involution ... empty bladder
ASAP - may need to catheterize ... Full bladder can lead to uterine
o DIC ... Tx is with Heparin (safe in PG) ... Fetal Demise, Abruptio atony and hemorrhage
Placenta, Infection
o Tears ...1st Degree = Dermis, 2nd Degree = mm/fascia, 3rd Degree =
o Fundal Heights
anal sphincter, 4th Degree = rectum
* 12-14 wks ... At level of symphysis o APGAR = HR, R, mm tone, Reflex irritability, Color ... 1 and 5 minutes
* 20 weeks ... 20 cm = Level of umbilicus ...7-10 = Good, 4-6 = moderate resuscitative efforts, 1-3 = mostly
dead
* Rises ~ 1 cm per week
o Eye care = E-mycin + Silver Nitrate ... for gonorrhea
o Stages of Labor
o Pudendal Block = decreases pain in perineum and vagina - No help
* Stage 1 = Beginning of Regular contraction to full dilation and with contraction pain
effacement
o Epidural Block = T10-S5 ... Blocks all pain ... First sign = warmth or
* Stage 2 = 10 cm dilation to delivery tingling in ball of foot or big toe

* Stage 3 = Delivery of Placenta o Regional Blocks often result in forceps or vacuum assisted births
because they affect the mother's ability to push effectively
* Stage 4 = 1-4 Hrs following delivery
o WBC counts are elevated up to 25,000 for ~10 days post partum
o Placenta Separation ... Lengthening of cord outside vagina, gush of
blood, full feeling in vagina ... Give oxytocin after placenta is out - Not o Rho(D) immune globulin (RhoGAM) is given to Rh- mothers who
before. deliver Rh+ kids... Not given if mom has a +Coombs Test ... She
already has developed antibodies (too late)
o Schultz Presentation = Shiny side out (fetal side of placenta)
o Caput Succedaneum = edema under scalp, crosses suture lines
o Postpartum VS Schedule
o Cephalhematoma = blood under periosteum, does not cross suture * Respirations < 12
lines
* Urinary Output < 30/hr
o Suction Mouth first - then nostrils
* Fetal Bradycardia
o Moro Reflex = Startle reflex (abduction of all extremities) - up to 4
o Pitocin (Oxytocin) use for Dystocia... If uterine tetany develops, turn
months
off Pitocin, admin O2 by face mask, turn pt on side. Pitocin can cause
o Rooting Reflex ... up to 4 months water intoxication owing to ADH effects.

o Babinski Reflex ... up to18 months o Suspect uterine rupture if woman complains of a sharp pain followed
by cessation of contractions
o Palmar Grasp Reflex ...Lessens by 4 months
o Pre-Eclampsia = Htn + Edema + Proteinuria
o Ballard Scale used to estimate gestational age
o Eclampsia = Htn + Edema + Proteinuria + Seizures and Coma ...
o Heel Stick = lateral surface of heel Suspect if Severe HA + visual disturbances
o Physiologic Jaundice is normal at 2-3 days ... Abnormal if before 24
o No Coumadin during PG (Heparin is OK)
hours or lasting longer than 7 days ... Unconjugated bilirubin is the
culprit. o Hyperemesis Gravidarum = uncontrollable nausea and vomiting ...
May be related to H. pyolori ... Reglan (metaclopromide)
o Vitamin K given to help with formation of clotting factors due to fact
that the newborn gut lacks the bacteria necessary for vitamin K o Insulin demands drop precipitously after delivery
synthesis initially ... Vastus lateralis mm IM
o No oral hypoglycemics during PG - Teratogenic ... Insulin only for
o Abrutio Placenta = Dark red bleeding with rigid board like abdomen control of DM

o Placenta Previa = Painless bright red bleeding o Babies born without vaginal squeeze more likely to have respiratory
difficulty initially
o DIC = Disseminated Intravascular Coagulation ... clotting factors used
up by intravascular clotting - Hemorrhage and increased bleeding o C-Section can lead to Paralytic Ileus ... Early ambulation helps
times result ... Associated with fetal demise, infection and abruptio
placenta. o Postpartum Infection common in problem pregnancies (anemia,
diabetes, traumatic birth)
o Magnesium Sulfate used to reduce preterm labor contractions and
prevent seizures in Pre-Eclampsia ... Mg replaces Ca++ in the smooth o Postpartum Hemorrhage = Leading cause of maternal death ... Risk
mm cells resulting relaxation ... Can lead to hyporeflexia and factors include:
respiratory depression - Must keep Calcium Gluconate by bed when * Dystocia, prolonged labor, overdistended uterus, abrutio placenta,
administering during labor = Antidote ... Monitor for: infection
* Absent DTR's
 Tx includes ... Fundal massage, count pads, VS, IV fluids, Oxytocin,
notify physician

o Jitteriness is a symptom of hypoglycemia and hypocalcemia in the

newborn

o Hypoglycemia ... tremors, high pitched cry, seizures

o High pitched cry + bulging fontanels = IICP

o Hypothermia can lead to Hypoxia and acidoisis ... Keep warm and use
bicarbonate prn to treat acidosis in newborn.

o Lay on right side after feeding ... Move stomach contents into small
intestine

o Jaundice and High bilirubin can cause encephalopathy ... < 12 =

normal ... Phototherapy decomposes bilirubin via oxidation ... Protect
eyes, turn every 2 hours and watch for dehydration ... The dangerous
bilirubin is the unconjugated indirect type.
Gerontology Common Ailments:
o Essentially everyone goes to Hell in a progressively degenerative * Delerium and Dementia
hand-basket
* Cardiac Dysrhythmias
 Thin skin
* Cataracts and Glaucoma
 bad sleep
 mm wasting * CVA (usually thrombotic, TIAs common)
 memory loss
 bladder shrinks * Decubitus Ulcers
 incontinence
* Hypothyroidism
 delayed gastric emptying
 COPD * Thyrotoxicosis (Grave's Disease)
 Hypothyroidism
* COPD (usually combination of emphysema and CB)
 Diabetes
* UTIs and Pneumonia ... Can cause confusion and delerium

o Memory loss starts with recent - progresses to full

o Dementia = Irreversible (Alzheimer's) ... Depression, Sundowning,

Loss of family recognition

o Delerium = Secondary to another problem = Reversible (infections

common cause)

o Medication Alert! ... Due to decreased renal function, drugs

metabolized by the kidneys may persist to toxic levels

o When in doubt on NCLEX ... Answer should contain something about

exercise and nutrition.
Advanced Clinical Concepts Piaget ... Cognitive Development
* Sensorimotor Stage (0-2) ... Learns about reality and object
Erickson ... Psycho-Social Development permanence
* 0-1 yr (Newborn) ... Trust vs. Mistrust
* Preoperational Stage (2-7) ... Concrete thinking
* 1-3 yrs (Toddler)... Autonomy vs. Doubt and Shame ... Fear intrusive
* Concrete Operational Stage (7-11) ... Abstract thinking
procedures - Security objects good (Blankies, stuffed animals)
* Formal Operational Stage (11-adult) ... Abstract and logical thinking
* 3-6 yrs (Pre-school) ... Initiative vs. Guilt ... Fear mutilation - Band-Aids
good o Freud ... Psycho-Sexual Development

* 6-12 yrs (School Age) ... Industry vs. Inferiority... Games good, Peers * Oral Stage (Birth -1 year) ... Self gratification, Id is in control and
important ... Fear loss of control of their bodies running wild

* 12-19 yrs (Adolescent) ... Identity vs. Role Confusion ... Fear Body * Anal Stage (1-3) ... Control and pleasure wrt retention and pooping -
Image Distortion Toilet training in this stage

* 20-35 yrs (Early Adulthood) ... Intimacy vs. Isolation * Phallic Stage (3-6) ... Pleasure with genitals, Oedipus complex,
SuperEgo develops
* 35-65 yrs (Middle Adulthood) ... Generativity vs. Stagnation
* Latency Stage (6-12) ... Sex urges channeled to culturally acceptable
* Over 65 (Older Adulthood) ... Integrity vs. Despair
level, Growth of Ego

* Genital Stage (12 up) ... Gratification and satisfying sexual relations,
Ego rules

Kohlberg ... Moral Development

* Moral development is sequential but people do not aromatically go
from one stage to the next as they mature

* Level 1 = Pre-conventional ... Reward vs. Punishment Orientation

* Level 2 = Conventional Morality ... Conforms to rules to please others

* Level 3 = Post- Conventional ... Rights, Principles and Conscience (Best

for All is a concern)
Calculations Rules & Formulas Conversions
o Round final answer to tenths place o 1 t = 5mL

o Round drops to nearest drop o 1 T = 3 t = 15 mL

o When calculating mL/hr, round to nearest full mL o 1 oz = 30 cc = 30 mL = 2 T

o Must include 0 in front of values < 1 o 1 gr = 60 mg

o Pediatric doses rounded to nearest 100th. Round down for peds o 1 mg = 1000 ug (or mcg)

o Calculating IV Flow Rates o 1 kg = 2.2 lbs

* Total mL X Drop Factor / 60 X #Hrs = Flow Rate in gtts/min o 1 cup = 8 oz = 240 mL

o Calculating Infusion Times o 1 pint = 16 oz

* Total mL X Drop Factor / Flow Rate in gtts/min X 60 = Hrs to Infuse o 1 quart = 32 oz

o Degrees F = (1.8 X C) + 32

* o Degrees C = (F - 32) / 1.8

* 37 C = 98.6 F

* 38 C = 100.4 F

* 39 C = 102.2 F

* 40 C = 104 F