lOMoARcPSD|11022437
ATI - reviewing for ATI
Nursing Care of Children (Arizona College of Nursing)
StuDocu is not sponsored or endorsed by any college or university
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
Normal Lab Values
• Hgb (hemoglobin): males=14-18 females=12-16; w/ <6.8= NC of 2L
o <12= iron deficiency anemia…… >15= dehydration, HF, or COPD
• Hct (hematocrit):
seizures
males=42-52 females=37-47; ↑ of >4 points in 2 weeks= ↑ risk for
• RBC’s:
males=4.7-6.1 million
• WBC’s:
4,500-11,000 (4.5-11 K)
• Platelets:
1,500-400,000 (150-400 K)
females=4.2-5.4 million
• PT (Coumadin/Warfarin): 11-15 sec. (INR:2-3 & PT TR)… must be 1.5-2x’s normal
• PTT ( Heparin): 60-70 sec. (APTT: 30-40 & PTT TR)… must be 1.5-3x’s normal
• BUN: 10-20
• Creatinine: 0.5-1.2
• Specific Gravity: 1.005-1.030
• Sodium: 136-145……. <135= flat neck veins, generalized weakness, ↓ DTR’s, hyperactive
bowel sounds….>145= Cushing’s syndrome, pts w/ corticosteroids
• Potassium: 3.5-5……………..<3.5=prominent U waves, ↓ ST segment, & flat T waves…………….
>5= tall peaked T waves, prolonged PR interval & wide QRS.
• Calcium: 9-10.5………<9= muscle spasm, convulsions, cramps, tetany, + trousseau’s, +
chvostek’s, prolonged ST interval, prolonged QT interval, & wide QRS.
• Magnesium: 1.5-2.5
• Chloride: 96-106
• Phosphorus: 3-4.5 …<2.9 malnutrition/ starvation, alcoholism ……>4.5 renal insufficiency or
tumor lysis syndrome.
• Pre Albumin: 20-36
Albumin: 3.5-5
Serum Protein level: 6-8
• Dilantin TR: 10-20
• Lithium TR:1.5-1.5. >1.5= toxicity: fine tremors, nausea, drowsiness, slurred speech,
muscle weakness, diarrhea, & vomiting. ↓Na levels puts the pt @ risk for toxicity; Maintain
normal Na & fluid intake. Takes 1-4 weeks to reach therapeutic level: avoid driving until
then. NO CAFFEINE! Regular blood tests & maintain weight.
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
• Digoxin TR: 0.8-2.0…..hold>2.0…..>2.5=toxic (visual disturbances: yellow halos/lights);
greater ↑ risk w/ ↓ K+. Monitor K+
• LDL:
<130
HDL: >40
• Lactate level: <2.2= normal
…………….>4=septic
• Bilirubin (newborn): 1-12 >15 requires phototherapy
• ASA (therapeutic anti-arthritic levels): 20-30…>30=toxic
• PSA: <4
• Amylase: 25-151… w/ acute pancreatitis is doesn’t exceed 3 x’s the normal value
• Blood urea nitrogen 8-25 is checked to see if Tx of UTI or dehydration was successful.
o <8 fluid overload
>25 dehydration
Arterial Blood Gases
o pH: 7.35-7.45
o CO2 (respiratory driver): 35-45- Acidodic
o HCO3 (metabolic driver): 21-28- Alkalosis
**Compensated-pH becomes Normal **
**Partially compensated- CO2+HCO3 are BOTH ↑↓ & pH is abnormal.
** Uncompensated- ALL are abnormal**
҉ Diarrhea/DKA (fruity breathe) = Metabolic Acidosis
҉ Vomiting= Metabolic Alkalosis
҉ Hypoventilation= Respiratory Acidosis → too much CO2
҉ Hyperventilation= Respiratory Alkalosis → low CO2
Fluid & Electrolytes
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ Fluid Volume Deficit
↑hematocrit
↓ BP
↑ Urine specificity >1.030
↑ CVP (normal 4-11)
↑ BUN
Fluid Volume Excess
↓ hematocrit
↑BP
↓ urine specificity
o Types of solutions:
▪ Hypotonic= hydrates the cell; tap water, .45% NaCL, .33% NaCL
▪ Isotonic= stays put; D5%W, RL, NS 0.9%. *Only sterile saline for bladder
irrigation*
▪ D5W w/ KCL: should be no faster than 20 mEq/h
▪ Hypertonic= expands volume; D10%W, D5%NS, Albumin
Antidotes
⬥ Digoxin→ Digiband
⬥ Coumadin→ Vitamin K
⬥ Benzodiazepines→ Flumazenil (Tomazicon)
⬥ Mg Sulfate→ Calcium Gluconate
⬥ Heparin→ Protamine Sulfate
⬥ Tylenol→ Mucomist (17 doses + a loading dose)
⬥ Opiates (heroin/morphine)→ Narcan (Naloxone)
⬥ Cholinergic Drugs (myesthenic bradycardia)→ Atropine
⬥ Methotrexate→ Leucovorin
Pediatrics
◇ The preferred injection site for vitamin K in the newborn is the lateral aspect of
the middle third of the vastus lateralis muscle in the newborn's thigh.
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
◇ Newborn S&S of hiatal hernia: vomiting, coughing, wheezing, short periods of
apnea, and failure to thrive.
◇ Newborn w/ ↑ immunoglobin IM indicates they were exposed to an intrauterine
infection
◇ Koplik spots= Rubeola (Measles)
◇ Autistic kids= bizarre behavior
o Most effective approach-sitting w/ them
o Not aware of others or others feelings
o Stereotyped body movements
▪ Nursing interventions: communication, minimize holding, structures
activities.
◇ Rheumatic fever
o Strep throat hx
o Carditis
o Major joints hurt @ various locations
o Chorea-involuntary movement
o Erythema Marginatum-rash
o ↑ ASO, ESR, C-Reactive protein
▪ TX= penicillin- acute phase: steroids, antipyretics, bed rest
▪ ↑ ASO titer= damage to glomerulus which can lead to
glomerulonephritis
◇ Myelomeningocele= cover w/ moist sterile water dressing, prone positioningprevents meningitis
◇ NO MMR on kids w/ an egg/ neomycin
◇ Celiac disease= AVIOD: barley, wheat, & rye. Gluten free diet
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
◇ Epiglottitis= H influenza B… child sits upright with chin out & tongue protruding
(tripod) positioning. Nurse must prepare for intubation/ trach, no direct exams
(tongue depressor) & NPO!!!
◇ Cystic fibrosis= Affects GI & Respiratory tract
o Problem with chloride metabolism: it blocks the pancreatic duct with
thick sticky mucus. Its recommended they get their basic vaccines + yearly
influenza vaccine
▪ Steatorrhea which leads to FTT (failure to thrive)
▪ COPD
▪ CHF
▪ Salty skin (sweat test check the sodium amounts)
• Pancreatic enzymes are given with food
• In a sweat test, the amount of sweat chloride is measured. A
chloride level >60 mEq/L is considered to be a positive test result.
A sweat chloride level < 40 mEq/L is considered normal.
◇ SVT- child should put thumb in mouth & blow the thumb as if it were a trumpet.
◇ Croup LTB- hx of URI; stridor, hoarseness, brassy cough
o Tx=mist tent wooden toys are ok; they don’t conduct electricity & clear
liquids
◇ Post-op cleft & palate repair: place on side, maintain Logan Bow & elbow
restraints
◇ Tonsillitis/ Tonsillectomy:
o PT & PTT (pre-op) = they are at ↑ risk for hemorrhage (1st 24 hours & then
5-10 days later w/ the sloughing of the scabs) & lose teeth.
▪ If hemorrhaging occurs turn pt to LT side & notify physician
o Post op- Ice collar, soft foods, & clear cold drinks (apple juice). **No red
liquids or straws**
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
◇ Physiologic jaundice is normal @ 2-3 days caused by a rupture of large amounts
of blood cells within a short period.
o Treatment consists of UV lighting w/ a bilirubin >15 which coverts indirect
bilirubin to a less toxic compound.
o Rh- mother w/ a + father is a risk factor for jaundice.
◇ Pathologic jaundice-Abnormal before 24 hours or lasting > 7 days.
o If the area around the eyes suddenly disappears the eye patches need to
repositioned to prevent UV light from entering the eyes.
◇ Caput succedaneum= edema under scalp; crosses suture lines
◇ Cephal hematoma= blood under periosteum; does not cross suture lines
◇ Jitteriness= hypoglycemia & hypocalcemia in newborns.
◇ 2 arteries (away) & 1 vein in fetus; they are obligatory nose breathers; Vit K to
↓ risk for bleeding. Circumcision care consists of Vaseline & gauze. Scarf sigh,
undeveloped pubic area, no body fat = prematurity
◇ Hypothermia in newborn leads to hypoxia & acidosis. Keep warm & use
bicarbonate PRN.
o Hypothermia can lead- ventricular fibrillation
◇ Fetal alcohol syndrome= craniofacial abnormalities- small head circumference,
↓weight, intrauterine growth restriction, cardiac problems, abnormal palm
creases & respiratory distress,
◇ **Betamethason** given w/ Mg sulfate to increase surfactant in fetal lungs.
◇ Cerebral palsy= walking-scissoring
◇ Guthrie test- for PKU is done 24 hrs after protein ingestions & @ 6 weeks
through urine test
o No diet drinks or proteins
◇ S&S in respiratory distress: cyanosis, tachypnea, tachycardia, retractions,
apnea, & nasal flaring, expiratory grunt.
o Management- positioning, suctioning
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o Acrocyanosis= bluish discoloration in hands & feet in association w/
immature peripheral circulation
◇ If a newborn has a glucose level of 25, nurse should give 10% dextrose via IV
infusion to ↑ glucose to at least 45
◇ Newborns should be placed on their RT side after feeding to aid in digestion &
prevent aspirations
◇ Autosomal Recessive diseases: cystic fibrosis, sickle cell anemia, albinism
◇ Conjunctivitis= contagious, child should be sent home, need antibiotics eye
drops.
◇ X linked recessive diseases: muscular dystrophy hemophilia.
▪ Females are the carriers they never have the disease. Males get it
but can’t pass it. 25% chance w/ each pregnancy the child will have
the disease.
▪ Will get Percocet for pain; crippling knee & joint deformities.
◇ If a child is disruptive in class & does not participate they should be checked for
visual impairments.
◇ Reye’s syndrome (acute encephalopathy) = viral infection + aspirin= swelling of
brain & liver. Provide a quiet environment w/ dimmed lighting to ↓ stress,
cerebral tissue & neuron responses.
◇ Lead poisoning: Pb> 15= health hazard; S&S: Pb> 70, neuro
o TX= chelating agents, BAL in oils, calcium EDTA
o Encourage milk consumption
◇ Assessment in infants:
o Auscultate heart & lungs
o Record HR & RR
o Palpate & percuss the abdomen
o Examine eyes, ears & mouth; elicit the moro reflex
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ Normal finding:
• Head circumference: 33-35 cm
• Chest circumference 1 in less than head
• Acrocyanosis & edema of scalp
◇ Assessment findings:
o Posterior fontanel closes @ 2 months
o Cooing @ 2 months
o Monosyllabic babbling 3-6 months
o Rooting disappears by 4 months
o Moro reflex disappears by 4 months
o Palmar grasp disappears by 4 months.
o Head control by 4 months
o Back to side by 4 months
o Turns over @ 5-6 months
o Sits with support @ 6 months
o Responds to own name @ 6-8 months
o Hand to hand transfer @ 7 months
o Sits unsupported by 8 months
o Crawls by 7-8 months
o Sits up from a lying position 7-9 months
o Stranger anxiety 7-9 months
o Understand NO & love peek a boo 7-9 months
o Mama-dada @ 7-9 months
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o Pincer grasps (cereal) @ 9 months
o Stands 11-12 months; cruise & walk while holding on
o Mama-dada + few words @ 10-12 months
o Drinks from a cup, plays with push-pull toys, 10-12 months
o Walks @ 1 year
o Birth weight triples @ 12 months
o Birth length ↑ by 50% @ 12 months
o Anterior fontanel closes @ 12-18 months
o Babinski reflex disappears by 1 yr
o Throws ball over head @ 18 months
o 18 months walks alone & climbs stairs
o Build tower of 3-4 blocks @ 18 months
o 2-3 word sentence @ 2 years
o 50% of adult height @ 2 years
o Runs (after a ball) @ 2 years
o Toilet training 2.5-3 years
o Uses tricycles @ 3 years
o 3 year old toys: pull toys, large balls, crayons, truck/dolls
o Uses scissors @ 4 years
o Birth length doubles @ 4 years
o Hops & skips @ 4 years
o Ties shoes @ 5 years
o Throws & catches@ 5 years
o Jump ropes @ 5 years
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o Copies an X or O; we learn if they are now LT or RT handed @ 5 years
o Hops on 1 foot @ 5 years
o Alternates feet on stairs @ 5 years
o Concept of time “next week” @ 5 years
◇ Hydrocephalus- nursing priority includes repositioning frequently
o S&S:
▪ ↓pulse
▪ ↑BP
▪ Bulging fontanels
▪ High pitched cry
• V-P shunt may be placed, do not sit them up immediately- hemorrhage
◇ Toddler stages of anxiety
▪ Protest-crying
▪ Despair- sucking thumb not crying
▪ Denial- when mom & dad come & they prefer the nurse
◇ Respiratory rates:
• Newborn= 30-60
• 1-11 months= 25-35
• 1-3 years= 20-30
• 6-10 years= 18-22
• 11-16 years 16-20
◇ Heart rates
o Fetal: 120-160
◇ Gestational ages
▪ Preterm: 20-37 weeks
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ Term: 38-42 weeks
▪ Post term >42 weeks
◇ APGAR (HR 0-2,respirations 0-2, muscle tone 0-2, reflex irritability 0-2, color 0-2) @ 1 & 5
min
• 7-10= good
• 4-6 moderate resuscitative needs
• 1-3 mostly dead
• Erikson’s
o 0-12 months= trust vs mistrust (solitary play)
o
1- 3 years= autonomy vs shame & doubt… fear of intrusive procedures, security
objects good- blankets, stuffed animals (parallel play)
o 3-6 years= initiative vs guilt… fear of mutilation, Band-Aids-are good, likes to help
parents (associative play)- pretend kitchen or workshop
o 6-12 years= industry vs inferiority… games good, peers are important, fear of loss of
control over their bodies, projects are important (cooperative play-teams)
o 12-19 years= identity vs role confusion… teens
• Paget’s
o 0-2 years= sensorimotor- learns about reality & object permanence.
o 2-4 years= preoperational- concrete thinking (magical thinking/ no cause &
effect)
o 4-7 years= preoperational- intuitive
o 7-11 years= concrete operational- abstract thinking,
o 11- adult= formal operational- abstract & logical thinking.
• Freud: Id, Super ego, Ego
o Oral (birth- 1 year)
o Anal (1-3 years) pleasure of retention & pooping (toilet training); “No to everything”
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o Phallic (3-6 years) pleasure w/ genital & superego development; marrying parents
o Latency (6-12 years) sex urges & growth of ego
o Genital (>12 years) satisfying sexual relations
• Kohlberg
o Pre-conventional: reward & punishment
o Conventional: conforms to rules to please others
o Post-conventional: rights, principles, & conscience
• Immunization schedule
o Hep B:
0,2,6 months
o DTP:
2,4,6 months
o HIB:
2,4,6 months
o POLIO:
2, 4 months
o PCV:
2,4,6 months
o MMR:
4-6 years
12-15 months
15-18 months
4- 6 years
12-15 months
15 months
o Varicella:
o TB testing:
15-18 months
4-6 years
12-15 months
12 months
4-6 yrs
14- 16 yrs
(DTP= diphtheria, tetanus, pertussis) (HIB- haemophilus influenza B) (PCV- pnemoccocal conjugate vaccine) (MMRmeasles, mumps, rubella; “German measles”)
•
Flu vaccine in children < than 2 yrs
Maternity
◇ Priority nursing action for a pt w/ ectopic pregnancy? Monitoring pulse- An elevated
pulse rate is an indicator of shock
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
◇ Cesarean delivery is the primary risk factor for uterine infection, especially after
emergency procedures. Other risk factors include prolonged rupture of membranes,
multiple vaginal examinations, and an excessive length of labor.
◇ After epidural the mother is given 500 cc bolus to counteract vasodilation.
◇ Retained placental fragments and infections are the primary causes of subinvolution.
◇ RhoGam is given 300 MG @ 28 weeks & post-partum w/ a – Coombs test… no
antibodies. Also with a spontaneous abortion before the age of variability even if we
don’t know if the fetus was Rh+.
◇ Calorie intake ↑ by 300 calories/ day; ↑ protein 30 g/ day
◇ Amniotic fluid= 800-1200ml (<300= oligohydramnious- fetal kidney problems) allows
fetal movement, protects & maintains temperature.
◇ Placenta= fetal food & 02.
◇ Umbilical cord= 2 arteries & 1 vein; veins carry oxygenated blood to the fetus.
◇ TPAL: term births, preterm births, abortions, living children
◇ Gravida: # of pregnancies including this pregnancy regardless of outcomes
◇ Para: # of pregnancies carried to the point of variability 26-28 weeks. (twins count as
one para since they were one pregnancy)
◇ Hgb & Hct: ↓ during pregnancy due to overhydration.
◇ Side lying (LT side) is the best position for uteroplacental perfusion.
◇ 2:1 lecithin: sphingomyelin ration= mature fetal lungs
◇ AFP in amniotic fluid= possible neuro tube defects; full bladder is needed for
amniocentesis ( early pregnancy/ empty in late pregnancy)
◇ Pt w/ Mg sulfate causes diaphragmatic inhibition & hyporeflexia; given to ↓ preterm
contractions & prevent seizures in preeclampsia … keep calcium gluconate handy.
⬥ Hold if respirations <14; reflexes are lost before respirations
⬥ Monitor urine output
⬥ May slow contractions; need pitocin
⬥ If BP is too high have antihypertensive available
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
⬥ Watch for precipitous delivery
✓ S&S of toxicity= difficulty swallowing, drooling, & flushing
◇ Dystocia= difficult prolonged labor- monitor fetal HR.
◇ True labor= ↑ contraction intensity/ duration
◇ After an amniotomy nurse should 1st assess fetal HR pattern
◇ Pts who have been pushing for >1 hr should rest between contractions.
◇ Pitocin used for dystocia (long labor). If uterine atony develops turn off Pitocin,
administer 02 by face mask, turn on side.
✓ Proper positioning for C-section= supine w/ wedge under right hip
✓ Episodic accelerations- caused by fetal movement they signify fetal well-being &
adequate O2 reserve.
✓ Nurse should first assess fetal HR (baseline)
⬥ Internal fetal monitor assesses contractions
◇ Reglan (metaclopromide) for hyperemesis gravidarum= uncontrollable nausea/
vomiting… caused by H pylori.
◇ Insulin ↑ during PG (2-3 trimester) & ↓ after delivery… NEVER oral
◇ Post-partum hemorrhage: leading cause of maternal death, abruptio placenta,
infection.
◇ W/ a prolapsed cord nurse should 1st place the pt in Trendelenburg’s to relieve
compression.
◇ Abruptio placenta= dark red bleeding w/ rigid board like abdomen (sudden- colic
like). Bradycardia/absent FHR, late decels may require immediate C-section. Treat
blood loss & shock.
◇ Placenta Previa= painless bright red bleeding. No vaginal exams!!! Pt will have a soft,
relaxed, nontender uterus; fundal height > than expected.
◇ DIC ↑ risk= fetal demise, infection, abruption placenta, preeclampsia, or
hemorrhage.
◇ WBC count are elevated up to 25,000 for 10 days post-partum
◇ It’s safe for PG women to be on TB medications ( Isoniazid & rifampin)
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
◇ PG women w/ cardiac disease should drink adequate amounts of fluid & ↑fiber (↓
Valsalva maneuver which causes the blood to rush into the heard & overload the
cardiac system). No Pitocin can be used on them.
◇ Hep. B prevention of PG mother should include hand washing & drying hands before/
after perineal care & usage of gloves when feeding.
◇ Assessment findings:
✓ Amenorrhea=presumptive sign/ subjective
✓ Fatigue= presumptive sign/ subjective
✓ Nausea/vomiting= presumptive sign/ subjective
✓ Urinary frequency= presumptive sign/ subjective
✓ Breast changes= presumptive sign/ subjective
✓ + pregnancy test=Probable sign/objective
✓ Ballottement (finger is placed in vagina & taps gently upward, fetus rises &
then sinks causing examiner to feel a gentle tap)= Probable sign/objective
✓ Uterine enlargement= Probable sign/objective
✓ Braxton hicks: >4 months= Probable sign/objective
✓ Chadwick’s sign= bluing of the vagina as early as 4 weeks= Probable sign/
objective
✓ Hegar’s sign= softening of the isthmus of the cervix… 8 weeks= Probable sign/
objective
✓ Goodell’s sign= softening of the cervix= Probable sign/objective
✓ Heart beat @ 8 weeks
✓ Sex can be determined @ 12 weeks
✓ Quickening 14-20 weeks.
✓ Starts showing @ 14 weeks
✓ Able to hear the lungs @ 38 weeks
✓ Schultz presentation= shiny side-fetal side
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
✓ Lochia no > 4-8 pads/day & no clots >1cm. Fleshy smell=normal; foul=infection
⬥ Rubra (bright red) 2-4 days, if prolonged this indicates slowed involution
or retained placenta fragments.
⬥ Serosa (brown/dark red) 4-10 days
⬥ Alba (white/yellow discharge) 10 days→ 3-6 weeks
✓ With mastitis the mother will get antibiotics & breast feeding is okay. Clean
nipples with water & air dry.
✓ Pica cravings- iron deficiency anemia
✓ Good exercise during pregnancy- swimming
✓ Encourage pregnant women to wear panty hose/support hose & non slip shoes.
✓ When cramping occurs teach pt to bend foot towards body (dorsiflexion) while
extending the knee.
✓ Kick counts= # of movements/ kicks in a sitting/ lying position <10 in a 12 hr
period→ contact physician
✓ Rubella teaching- can’t be communicable through breast milk but must not get
PG within 1-3 months since it can be administered postpartum. They should
avoid immunocompromised people since they can shed through (urine/ body
fluids). It is given sub Q route; they can’t be allergic to eggs
✓ A pH of 7.15 → intrauterine asphyxia & resuscitation should be started before
the APGAR @ 1 min.
✓ DM & PG pt can be managed through sliding scale 24 hrs after delivery.
✓ PIH= common S&S- HA, oliguria, or edema. Must have 2 out of 3=Protein in
urine, HTN (>140/90), & edema (hands/face)
⬥ Pts with epigastric pain & ↑ BP= keep pt safe w/ impeding seizure.
⬥ Preeclamptic pt demonstrates clonus; nurse should count # of taps &
record it in medical record.
✓ Full bladder= uterine atony & hemorrhage.
✓ Iron deficiency anemia= fatigue, cold, ↑ BP, koilonychias- upward curvature,
glossitis
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
✓ PG pt w/ thrombophlebitis should apply= warm soaks to affected leg
✓ The cardiovascular system is the most developed by 3 weeks gestation.
✓ Post-partum assessment finding:
⬥ Temp >100.4=dehydration
⬥ Orthostatic hypotension, help is needed when getting out of bed,
⬥ Bowel sounds return within 2-3 days
⬥ Locia flow: heavy= 1 perineal pad/ hr; Excessive= 1 perineal pad in 15
minutes. **Earliest sign of hemorrhage= ↑ pulse**
✓ Teaching: perineal care involves changing perineal care everytime
they go to RR & when they are soiled.
✓ Station
⬥ (-) = above the ichial spine… (+)= outside the vagina.
✓ Station 0= Engagement; common problem to fetus remaining in this
station is the mother has a full bladder.
✓ Positioning
⬥ LOA= occiput is facing the left anterior pelvis… **Most Common**
⬥ LOP= occiput is facing the left posterior pelvis
⬥ ROA= occiput is facing the right anterior pelvis
⬥ ROP= occiput is facing the right posterior pelvis
✓ Dilation- opening of the cervix 10 cm
✓ Effacement= thinning of the cervix; loss of cervical canal
✓ Stages of labor
⬥ 1= beginning of regular contractions to full dilation & effacement
⬥ 2= 10 cm dilation to delivery
⬥ 3= delivery of placenta
⬥ 4= 1-4 hrs following delivery- fundus palpable @ umbilicus
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
✓ Fundal heights: if they fall below= intrauterine growth restriction.
⬥ 12-14 weeks= level of symphysis
⬥ 20 weeks (20 cm)= level of umbilicus (rises 1cm per week)
⬥ 36 weeks= xyphoid process
✓ Post-partum= @ 1 hr level of umbilicus, @ 12 hrs 1 cm above the
umbilicus, descends at least 1 cm/day
◇ Non-stress test: reactive= healthy (↑ w/ fetal movement) → HR (120-160) w/
>2 accelerations of <15 b/m in a 20 minute interval.
◇ Contraction stress test= (oxytocin challenge) positive=unhealthy-late decels. 3
contractions, 40-60 seconds long in 10 minutes
◇ Early decels= head compression… normal findings
◇ Variable decels= cord compression… Not good
✓ Chance position, stop oxytocin, administer O2, notify physician.
◇ Hypertonic contractions
✓ Stop oxytocin
✓ Reposition
✓ Administer O2 via face mask (8-10 L)
✓ Perform vaginal exam, check BP
✓ Give pain medication & medication to ↓ uterine activity
◇ Late decels= utero-placental insufficiency…BAD!!!
✓ First turn off oxytocin first.
✓ Requires O2 via face mask while maintaining pt on LT side; if
tachycardia occurs it requires immediate C-section.
Leopold’s Maneuvers
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
A- Fundal grip
B- Umbilical grip
C- Pawlick’s grip
D-Pelvic grip
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
Gerontology
o Most reliable sign of infection >65= tachypnea
o Renal threshold ↑
o Alzheimer’s
▪ Stage 1: memory loss- names, location of objects; emotionally unstable
▪ Stage 2: lasts 2-12 yrs., loss of recent memory, inappropriate social actions,
can’t concentrate.
• agnosia= can’t figure out what object is for (comb/toothbrush)
• aphasia= speech problems
• apraxia= tying shoes, cooking
▪ Stage 3: months- 5 yrs. inability to communicated, delusions, hallucinations,
paranoia, agitation, loss of physical functioning.
o Dementia= irreversible (Alzheimer’s)… depression, sun downing (place them near the
windows-natural lighting) - very disoriented @ night, memory deficit- loss of family
recognition irritable, poor judgment, & confabulation.
o Delirium= “acute” secondary to another problem= reversible (UTI’s, infection, or
pneumonia common cause)
▪ When they become combative first thing to check for is their O2 levels
▪ Alcoholics
▪ Erikson’s
o 20-35 years= Intimacy vs isolation: “us” career or marriage
o 35-65 years= Generativity vs stagnation: teaching Sunday school, girl scouts, clubs,
tends to contribute to society.
o >65 years= Integrity vs despair: voluntarism vs rocking chair
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
Medical-Surgical
▪ Respiratory
o Assess cough reflex & ability to swallow before giving fluids= ↑ ICP & risk for
aspiration.
o Rifampin for TB= turns urine rusty/red/orange * NO eye contacts.
o Isoniazid (INH) for TB= ↑ Dilantin levels
o Use bronchodilators before steroids!!! ( exhale completely → inhale deeply → hold
breath for 10 seconds )
o COPD never >2 L/min → CO2 narcosis
▪ Emphysema= pink puffer: AVOID carbohydrates, the convert to CO2
▪ Chronic bronchitis= blue bloater→ Right sided HF= cyanosis & peripheral edema
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o Flail chest: chest on affected side is pulled inward during inspiration & outward
(bulges) during expiration.
▪ Monitor VS for shock
▪ Pain med s@ regular intervals
▪ Encourage turn, cough, & deep breath
▪ Monitor ABG’s
o PE prevention: Trendelenburg HOB ↓ on the left side (traps air on the right side of the
heart).
o If chest tube becomes disconnected do NOT clamp but put the ends in sterile water.
o Chest tube drainage system should show bubbling & water level fluctuations (tidaling
w/ breathing)
o Ascending order of potency: nasal cannula → simple face mask (40-60%) → nonrebreather mask (80-90%) → partial rebreather mask → venturi mask (100%)
▪ CPAP: uses room air not O2 its not combustible: its used to keep the alveoli
open & ↓ hypoxia
o Histoplasmosis is a fungal infection from bird or bat droppings. Typical S&S similar to
TB: include fever, dyspnea, cough, and weight loss. Tx: Amphotericin B- SE= bone
marrow suppression, local phlebitis, kidney damage (monitor I & O)
o Hypotension, shock, or the use of peripheral vasoconstricting medications may result
in inaccurate pulse oximetry readings as a result of impaired peripheral perfusion.
o Respiratory alkalosis: ↑RR & depth, headache, lightheadedness, vertigo, mental status
changes, paresthesias such as tingling of the fingers and toes, hypokalemia,
hypocalcemia, tetany, and convulsions.
o TB test is read with fingers (induration). Most conclusive test to detect TB= sputum. Pt
will remain under isolation until the sputum comes back negative.
▪ >5 mm in immunocompromised
▪ >10mm in children < 4 yrs. old
▪ > 15 mm in people > 4 yrs.
• Vit. B6 will be needed
o Air leaving cavity in water seal= gentle intermittent bubbling. No bubbling this
means the lung has reinflated or there’s an obstruction. Think about how long it’s
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
been placed. *Listen to breathe sounds *(2-3 cm/water)… petroleum gauze (air
occlusive) dressing must be available for tube removal or for accidental removal.
o If there is no bubbling in suction control- *check if it’s turned on 1st*, then check for
leaks; should have gentle continuous bubbling. (15-20 cm/water)
o Chest PT- best is between meals, bedtime, or early in the morning. Never after a
meal.
o Pt on mechanical ventilation …NO WOOL carpeting.
▪ 1st thing to assess following ventilation is BP may cause hypotension from ↓
CO2.
o Humidifier is needed w/ o2 >4 L
o When doing tracheal suctioning & pts begin to cough we must remove the catheter &
let them cough= better when getting rid of secretions.
▪ Pressure Never >20; should be checked every 8 hrs.
o Always hyperoxygenate before & after suctioning <10-15 sec. Suctiong pressure should
be at least 120.
o Tracheal deviation= pneumothorax → chest tube
o TEF= Tracheoesophageal atresia: coughing, chocking, & cyanosis
o Primary meds when in respiratory distress= Sus-phrine & theophylline=
bronchdialators.
o Ventilator settings
▪ CMV (controlled mode ventilation): pt can’t breathe on their own, requires
sedation
▪ A/C (assist control):
▪ IMV: not synchronized to pts breathing
▪ SIMV: (synchronized intermittent mandatory ventilation): pts triggers
ventilation.
• Weaning parameter:
o Vital capacity:2-4
o Tidal volume: > 300
o Neg. inspiratory force: -20
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
• Peek pressures:
o High= requires suctioning/ sedation (biting tube, pulmonary
edema, ↓ lung resistance)
o Low= tube is disconnected, dislodged, partially intubated, or
there is a lot of water in tubing; ambu bag the pt. & call RT stat)
o **Good lung UP- Bad lung DOWN**
▪ Pts w/ RT lower lobe pneumonia complaining of unrelieved pain should be
encouraged to lie down on RT side.
o **Adventitous sounds**
▪ Tachypnea= rapid respirations (pneumothorax)
▪ Stridor- upper airway obstruction *life threatening*
▪ Crackles- air passing through secretions
▪ Cheyne strokes- rhythmic respirations w/ periods of apnea
▪ Kussmauls- deep grasping pattern (diabetic coma)
• Hyperpnea= deep rapid respirations (metabolic acidosis, DKA)
▪ Cardiac
♥ Hold digoxin <60
♥ Stay in bed after 1st ACE inhibitor dose.
♥ Pts w/ hypertension should avoid weight lifting & hot baths/sauna- can lead to
hypotension.
♥ Pericarditis (pericardial friction rub): pain is relieved by leaning forward.
♥ The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL
indicates hypomagnesemia. In hypomagnesemia, tall T waves and a depressed ST
segment would be observed.
♥ Heat stroke= leg cramps, red face, dry skin, pt should be moved to shady area &
sprayed w/ cool water.
▪ Hypotension
▪ Tachypnea
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ Tachycardia
▪ Hot & dry skin
♥ MI= give O2, morphine, & nitro. *NO digoxin, BB, OR Atropine*
▪ Morphine= ↓ blood return to the RT side of the heart & ↓ in peripheral
resistance.
♥ Atrial flutter/ fibrillation= thrombus formation.
♥ Care for pt w/ a CVA should revolve around preventing corneal abrasion.
♥ Temporary pacemaker= ↑ cardiac output ( needed w/ 2nd degree heart block)
▪ Permanent pacemaker requires the nurse to assess if pt has hearing aid- might
interfere.
♥ Defibrillate= pt w/ pulseless tachy
▪ 1st place gel pads on chest
▪ Set @ 200 joules
• Then 300
• & last 360
♥ Cardiovert= pt w/ pulse & tachy requires Midazolam to be given: prevents ventricular
fib after cardioversion.
♥ Pt w/ a hx of HF who has a productivr pink-tinged sputum requires immediate
intervention= fluids in the lungs. Requires cardiac glycoside & diuretics.
♥ LT HF
RT HF
▪ ↑ CWP pressure
Peripheral edema
▪ Pulmonary congestion
distended jugular veins
▪ Dyspnea/Restlessness
weight gain
▪ 3rd heart sounds
♥ Cardiac meds:
▪ Nitro: treats angina
▪ Morphine: for chest pain caused by MI. It ↓ preload & afterload pressure
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ Lidocaine: treats ventricular tachycardia
▪ Dopamine: augments cardiac output by ↑ myocardial contractibility & stroke
volume.
▪ Neuro
✓ Meniere’s disease pt require a ↓ Na diet to ↓ fluid retention.
✓ Romberg’s sign= closing of the eyes while standing with arms out forward- check for
balance.
✓ Pts w/ glaucoma should be seen the the morning for more accurate results since BP &
IOP is ↑
▪ Tonometry- measures pressure in eyes
✓ Bacterial meningitis: ↑ WBC & protein (ICP), ↓ glucose
▪ May lead to SIADH (too much ADH) = water retention, fluid overload, dilutional
hyponatremia.
▪ Plan of care= respiratory isolation for 24 hrs until cultures obtained &
antibiotics are initiated.
✓ Myasthenia Gravis:
▪ S&S muscle weakness, ptosis (drooping eyelids), diplopia (double vision)
▪ **Neostigmine (Prostigmin) **- prevents the destruction of ACH. Contact
physician if pt experiences ↑ weakness= cholinergic crisis
▪ They are given anticholinergics & plasmapheresis.
• Most important= warm blankets to prevents chills
▪ Meds are given on time & before meals w/ milk or crackers.
▪ Never give them any morphine. (quinidine)
▪ Nursing care: check gag reflex & swallowing before starting their mechanical
soft diet.
▪ Tensilon test: + in myesthenic crisis; - in cholinergic crisis
• Myesthenic crisis= weakness w/ change in VS (give ↑ meds); weakness
will improve w/ meds.
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
• Cholinergic crisis= weakness w/ no change in VS (↓ meds); weakness will
↑ w/ more meds.
✓ Brain location functions:
▪ Temporal: hearing
• Sensorineural: caused by loud noises. CAN’T be treated!
• Conductive: caused by an obstruction.
▪ Frontal: personality
▪ Occipital: visual
▪ Brain stem: bowel & bladder
✓ Brain disorders
▪ Dysarthia- verbal enunciation/articulation
▪ Apraxia- purposeful movements
▪ Dysphasia- speech & verbal communication/ comprehension
▪ Aphasia- speaking
▪ Agraphia- writing
▪ Alexia- reading
▪ Dysphagia- swallowing
✓ Stroke pts will have their tongue pointing to the side of lesion (paralysis) & uvula
deviates away from the lesion (paralysis)
▪ Stroke (acute phase) maintain the pt in midline supine position w/ HOB
elevated @ 15-20°= facilitates venous drainage & ↓ ICP
• Risks:
o African American race, male, substance & alcohol abuse, &
smoking.
• LT hemisphere lesion (CVA)
o Aphasia, agraphia, slow, cautious, anxious, memory is okay.
• RT hemisphere lesion (CVA)
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o Can’t recognize faces, loss of depth of perception, impulsive
behavior, confabulation, poor judgment, constantly smiles, denies
illness, loss of tonal hearing, disoriented to: time, place, &
person.
✓ Head injuries: =↑ ICP subtle changes in mood, behavior, restlessness, irritability, or
confusion
o Early signs= nausea, infants→ bulding fontanels or dilated scalp veins.
o Late signs= ↑ BP, ↓ pulse, ↑ temp., ↓ LOC, widening pulse pressure,
changes in pupil: size & reactivity, cheyne stokes, coma, reactivity
posturing.
• Midbrain lesions: decerebrate posturing→ extended elbows; head
arched back.
• Cortex lesions: decorticate posturing (mummy positons) → flexion
of elbows, wrists, & fingers; straight legs.
✓ Spinal cord injuries
• C3-C5 innervates the diaphragm
• C6- injury w/ HA should be assessed for autonomic dysreflexia.
▪ May need an antihypertensive.
▪ Place them in a sitting position 1st then assess the bladder or
foley for kinks.
▪ Assess bowel & bladder function
• Spinal shock= complete loss of all reflex, motor, sensory, & autonomic
activity below the lesion= medical emergency
• Injury above T6= hypotension & bradycardia. Bladder infection is the most
common cause of death. Keep urine acidic.
✓ Burns:
▪ Infection is primary concern
▪ Hyperkalemia due to damage & release into the intracellular potassium.
▪ Pre medicate
▪ RULE OF 9’s= 11x 9
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
• Head & neck= 9% (front/back= 4.5%)
• Upper extremities=9% each (front/back= 4.5%)
• Lower extremities= 18% each (front/back= 9%)
• Front trunk= 18% (top/bottom= 9%)
• Back trunk= 18% (top/bottom= 9%)
• Pubic= 1%
✓ Single nasal hair or circumoral soot burns= smoke inhalation burn
✓ Parkinson’s disease
o S&S : pill rolling, tremors, bradykinesia, slurred speech, & propulsive, rigid
stooped, shuffling gait= fall precautions
▪ w/ their medications monitor ↑ BP & Pulse.
✓ Down syndrome: triosomy 21
▪ Simian creases on palms, hypotonia, protruding tongie, upward outward
slant of eyes.
✓ Cerebral palsy: Scissoring= legs extended, crossed feet, plantar-flexed
✓ PKU: leads to mental retardation (hypothyroidism too). Guthrie test is used.
Aspartame should be avoided.
o When infants test + the nursing priority involves around offering the
infant- Lofenalac
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
✓ Glasgow coma scale <8= coma
✓
▪ Endocrine
✶ Hypophysectomy- removal of pituitary gland
▪ Check output- they might not be producing ADH which will lead to copious
amounts of urine.
▪ Hormone replacement
▪ Antibiotics to prevents meningitis
▪ Check CSF leaks-glucose
▪ Low fowlers
▪ No bending/ tooth brushing
✶ SIADH
▪ Increased ADH, common in lung cancer
▪ Diuretics/ fluid restriction
▪ I & O’s/ weights
▪ Diuretic hyponatremia
▪ **seizure precautions**
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
✶ Diabetes Insipidus
▪ Decrease in ADH
▪ Polyuria, polydipsia
▪ *Vasopressin (pitressin)/ Lypressin (Diapid) nasal.
✶ Hyperthyroidism S&S
▪ ↑ metabolic rate, HR-tachycardia, RR, tremors, diarrhea, energy
▪ ↓ scanty menses, weight loss
• Grave’s disease- bulging eyes. Provide frequent rest periods
o Propranolol- is given to slow the HR.
o May be given radioactive iodine to shrink the thyroid gland. Then
they will receive thyroid replacement.
▪ Double flush the toilet
▪ Can’t sleep with anyone- avoid prolong time w/ people;
safe to eat dinner w/ family
▪ Going to class- sit in back.
▪ Working is ok if you work in cubicle. NOT if working in a
pediatrics clinic.
✶ Hypothyroidism S&S
▪ ↓Slow metabolic rate, HR (50-60), RR (6-8/min), no energy, prone to
constipation, Always COLD!!! AVOID: narcotics, barbiturates, & anesthetics.
▪ heavy menses, weight gain
• Myxedema- droopy eyes, tired, arthrosclerosis, lethargy, weight gain,
intolerance to cold.
o Thyroxin- check for tachycardia, angina; cardiovascular
compromise due to ↑ pulse & cardiac output.
o Improvement occurs when the pt discusses family finances.
Hypothyroidism slows mental functioning.
• Goiter- thyroid enlarges because of TSH; give PTU followed by Sx.
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
✶ Pts taking corticosteroids undergoing surgery should continue (or ↑) intake otherwise
it could lead to adrenal atrophy which ↓ the ability to withstand stress.
▪ Take w/ food to ↓ gastric irritation.
✶ Thyroid scan teaching- D/C thyroid meds gradually 7-10 days before the test
▪ No shrimp/lobster
▪ Before any test that uses iodine dye
✶ Pre-op thyroidectomy
▪ PTU
▪ Lugol’s- potassium iodine solution
• Or radioactive iodine alone
✶ Post- thyroidectomy
▪ Keep a tracheostomy set by the bed w/ O2, suction & calcium gluconate.
▪ Frequently ask pt their name to check that their laryngeal nerve is intacthoarseness.
▪ Check for tetany=hypocalcemia=hyperreflexia
• Muscle spasms= could lead to laryngospasm→ airway!!!
✶ Hypoparathyroism/ hypocalcemia: ↑ calcium foods
▪ Trousseau’s: carpal spasm induced by BP cuff
▪ Chvostek’s: facial spasm after facial nerve tap
✶ DM Diagnostic tests:
▪ FBG: 70-100
▪ 2 HR PPG: 70-140
▪ *Oral GTT*:
• Fasting 70-100
• 1 hr: <200
• 2 hr <140
• 3 hr 70-100; urine neg. for glucose.
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
• A1C: 6=135, 7=170, 8=205, 9=240, 10=275, 11= 310, 12= 345
✶ When pts are on flurosemide & digoxin they should be encourage to drink OJ to
restore k+
✶ Oral hypoglycemic ↓ glucose levels by stimulating insulin production by beta cells in
pancreas, ↑ insulin sensitivity & ↓ hepatic glucose production.
✶ Diabetic diet: CHO: 40-60%, Protein: 20%, Fat: <30%. (corn, peas, beets belong to the
starch group *breads). Glycemic index foods should be ↓= veggies & ↑fibers.
▪ DM pts w/ an underlying infection need an ↑ in the dose of insulin
▪ Metformin is taken w/ meals to ↓ nausea & vomiting.
✶ When drawing insulin the regular insulin (clear) is 1st then NPH (cloudy). NEVER mix
long-acting insulin with any insulin. It should be given using a 90° angle (27-29
gauge); 60 ° angle for an emaciated patient. Alcohol should be avoided because it
causes hypoglycemia.
▪ Rotate injection sites or it can cause glucose levels to rise temporarily: poor
absorption
✶ Peritoneal dialysis= cap the catheter during dwell time.
▪ If pt has a bloody outflow we must determine if the pt is menstruating.
✶ Types of Insulin
▪ Rapid acting: onset= 5-15 min.
Peak=30 min -1 hr.
• *Lispro (Humalog)
• *Aspart (Novalog)
▪ Short acting: onset= 30-60 min.
Peak= 2-5 hrs.
• *Regular*
▪ Intermediate: Onset= 1-2.5 hrs
Peak= 8-14 hrs
• *NPH*
▪ Long acting: onset= 4-6 hrs
Peak= 6-12 hrs.
• Glargine (Lantus)
✶ S&S Hypoglycemia: put sugar under tongue if unconscious, its ok to give coke, or
cranberry/ orange juice.
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ Confusion
▪ HA
▪ Irritability
▪ Nausea
▪ Sweating
▪ Tremors
▪ Polyphagia (↑ Hunger )
▪ Slurring
✶ S&S Hyperglycemia
▪ Weakness
▪ Syncope
▪ Polydipsia (↑ thirst)
▪ Blurred vision
▪ Fruity breath (DKA)
✶ Pheochromocytoma
▪ ↑ BP- doesn’t respond to anything; adrenalectomy
▪ Tachycardia
✶ Adrenocortical insufficiency= hyponatremia, hypoglycemia, & hyperkalemia
✶ Addison’s disease
▪ Not enough glucocorticoid (Cortisone) or mineralocorticoids (Aldosterone)
hormones.* Hormone replacement* S&S: muscle cramps, fatigue, &
hypotension.
• Unable to respond to stress
• Hypovolemic shock
• Hyperkalemia-cardiac dysrhythmias
• Skin darker-tan
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ Addison’s crisis (vascular collapse): medical emergency. Administer IV glucose +
corticosteroids *NO PO’s on empty stomach*
• Restlessness & weak pulse occur @ first.
• Hypoglycemia
• Tachycardia
✶ Cushing’s syndrome is a metabolic disorder characterized by abnormally increased
secretion (endogenous) of cortisol, caused by increased amounts of
adrenocorticotropic hormone (ACTH)
▪ Moon face
▪ Hyperglycemia
▪ Acne
▪ Hirsutism/ scalp baldness
▪ Weight gain
▪ Adrenal suppression/immune suppression
▪ Osteoporosis
▪ Buffalo hump
▪ Red striae
▪ Ecchymosis
▪ HTN
▪ Fluid retention
▪ Hypokalemia
▪ Deep voice
✶ Acute pancreatitis: fetal position= bed rest, NPO, opioids-fentanyl
▪ Turner’s sign= Bluish discoloration of flanks
▪ Cullen’s sign= Bluish discoloration of preumbilical region “C”
▪ Board like abdomen w/ guarding… self-digestion of pancreas by trypsin
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ Gastrointestinal
• Lipitor (statin) given in PM only! No grapefruit juice.
• Peptic ulcer disease should avoid: ASA, Alcohol, & caffeine.
• Duodenal ulcer (feed) pain is relieved by food.
• Gastric ulcer (starve)
• Dumping syndrome: avoid bread (carbs) & fluids. They can lie down after eating, small
frequent meals.
• Always give the lower GI series 1st (barium enema)
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ Barium enema- slow deep breaths when administering.
• Aluminum-containing antacids are constipating, so the client should be instructed to
take a stool softener or additional bulk-type laxatives to relieve this uncomfortable
side effect.
▪ Should be taken after meals
• Assessment finding indicates that the colostomy is beginning to function= passage of
flatus
▪ 72 hours after surgery, although it may take up to 5 days. The nurse should
assess for a return of peristalsis, listen for bowel sounds, and check for the
passage of flatus)
▪ Should be irrigated @ the same time every day to establish normal pattern &
elimination
• Drink cranberry juice, buttermilk, parseley, or yogurt (helps w/ odor).
Prepared deodorizer okay
• Eat crackers or toast (↓ gas)
• DO NOT skip meals, chew gum, smoke, or drink beer= ↑ gas
• Anorexia Nervosa: person experiences hunger but refuses to eat. Due to distorted
body image. Can lead to death by starvation. “Good children”
▪ W/ anorexia nervosa pts manage their anxiety by= observing rigid rules;
“moralistic” rules & rituals
▪ Hospitalization criteria: HR<40, weight loss >30% of total weight in 6 months,
temp <96.1° F
▪ Observe her 2 hours after eating; weekly weight (check pockets), reward for
weight gain.
• Bulimia: uncontrollable binge eating, “purge” self-vomiting, laxative abuse, excessive
exercise. Person generally maintains a normal weight & is aware of abnormal behavior.
▪
Pts. most important goal is to identify the S&S of electrolyte imbalance=
hypokalemia.
▪ If they develop a hoarse voice- laryngitis means they are at ↑ risk for
tracheoesophageal fistula.
• PRN prescription for loperamide hydrochloride (Imodium) is indicated to manage acute
and chronic diarrhea in conditions such as inflammatory bowel disease
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
• Ulcerative colitis= bloody diarrhea. Best indicated for UV light therapy
• Olive shaped mass (epigastric)= projectile vomiting- pyloric stenosis
• Jelly stools ( blood & mucus) + sausage shaped mass in RUQ= intussusception
• GB or Liver disease= Murphy’s sign (RT costal pain on palpation w/ inspiration.
• If when assessing the abdomen the nurse hears a bruit over the aorta= medical
emergency (aneurysm)
• Pt w/ cirrhosis admitted w/ ascites should 1st administer albumin
• Bowel sounds assessment:
▪ Hypoactive: 1-2 sounds in 2 minutes
▪ Normal: 6-30 sounds/ minute
▪ Hyperactive >30
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ Renal
✰ Post- strep URI disease= acute glomerulonephritis, scarlet fever, or
rheumatic fever.
▪ Acute glomerulonephritis is commonly seen in pts w/ impetigo
▪ Chronic Glomerulonephritis
• Complications of glomerulonephritis= venous thrombosis
✰ Pt undergoing creatinine clearance test cant workout the night before it
will ↑ creatinine levels.
✰ Nephrotic syndrome= intake adequate protein & ↓ Na for healing
✰ Minimal compensaty= 30 ml/hr
✰ Pts w/ a ↑ BUN are @ risk for falls. Since Na ↑ & water ↓: this causes
confusion, orthostatic hypotension.
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
✰ Kidney stones= chlethiasis
▪ Drink <2000-3000 ml of water/day. Avoid foods w/ spinach,
asparagus, & cabbage & exercise.
✰ Wilm’s tumor: large kidney tumor. * DON’T PALPATE*
✰ Renal Failure
▪ Pre-renal= interference w/ renal perfusion
▪ Intra-renal= damage to renal parenchyma
▪ Post- renal= obstruction in UT
▪ 3 Phases:
1. Oliguric
2. Diuretic
3. Recovery
▪ Genitourinary
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
• PET scan= teaching: empty bladder before test
• Clomidene- increases ovulation… S/E= multiple births
• Pyridium is a medication for bladder infection. It will change urine
orange/red/pink.
• BPH TX= TURP (transurethral resection of prostate): there will be some
blood loss for 4 days & burning for 7 days post-op.
• Endometriosis is greater in pts who never have had children… can cause
infertility.
• **Bethanecol** (cholinergic drug) is given to pt w/ neurogenic bladder
(urinary retention) following spinal cord injury.
• Contraceptives
▪ Diaphragm- must be left in place for 6 hrs after intercourse. “
▪ “Pill” raises the progesterone levels and tricks the body into thinking
you are pregnant so no ovulation occurs. Avoid smoking ↑ your risks
for DVT.
• If one pill is missed- take 2 the next day
• If two pills are missed-take 2 the next 2 days
• If 3 are missed find another form of contraceptive (D/C & continue the
next month)
• STI’s
▪ Syphilis: TX= Penicillin
• Primary stage (90 days) = chancre + red painless lesion
• Secondary stage (6 months) = rash on palms & soles w/ flu-like
symptoms.
• Tertiary stage (10-30 yrs.) = neurologic & cardiac destruction.
▪ Gonorrhea: “CLAP”.
• Yellow-green urethral discharge
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ **Chlamydia: TX= Tetracycline** Most common can cause blindness in
newborn.
• Mild vaginal discharge or urethritis
▪ Trichomoniasis: TX= Flagyl
• Frothy foul smelling vaginal discharge
▪ HPV= cervical cancer, bleeding after intercourse- suggest cancer of
the cervix
▪ Candiasis: TX= Miconazole, Nystatin… can cause thrush in newborn
• Yellow cheesy discharge w/ itching
▪ Musculoskeletal
• Following a myelogram encourage fluids to get rid the oil based dye.
• Never pull yourself up using a walker= safety
• Measure 2 inches below the axilla to a point 6 inches in front of the tip of the tow & 2
inches outside the foot.
• Squeezing a rubber ball helps strengthening hand muscles in preparation for using
crutches.
• Pts who develop paralysis to either RT or LT side should have a sign placed in their
door stating “DO NOT USE the affected side for lifting”- they cant offer resistance so
shoulder could be dislocated.
• Degenerative joint disease: occurs mainly in those with obesity, DM, Paget’s or
hemophilia.
• Pt w/ halovest when placed on wheel chair needs to have legs rests lowered or will
cause the wheel chair to tip backward
• Following total knee replacement: nurse should place sequential compression devices.
• Cane is held on the non-affective side, moving the weak leg & the cane.
▪ Move cane forward followed by the weak leg then the strong leg.
▪ When going UP the stairs step up w/ the strong extremity
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ When going DOWN the stairs lead w/ the weak leg & the cane.
• When using crutches (3 point gait= not baring weight on affected foot). The bad foot
always goes with the crutches. Ex. Advance crutches & the weak foot, then advance
the strong foot while balancing weight on the crutches.
▪ Stair climbing w/ crutches= *up w/ the good down w/ the bad*. Have your
weight on the crutches & move the good foot up then bring up both crutches &
repeat. When coming down balance weight on the good foot put the crutches
down to the next step & bring the good foot down & repeat.
• 4 point gate= baring weight on both feet (crutch… opposite foot… crutch) Ex. Pt w/ a
left ankle injury= move the right crutch first then the left foot followed by the crutch
& the right foot. Usually used on pts w/ generalized weakness
• Cast care:
▪ Air dry-plaster cast
▪ Palm the wet cast- plaster cast: water can dissolve it not fiberglass cast
▪ Elevate limb: ↓ swelling & edema
▪ Neuro- sensation/motion; vascular- blanching/ temperature/swelling
▪ Skin care: pedaling the cast-plaster. Itching because of shedding which can lead
to developing an ulcer if they cut their skin. They can use a blow drier in the
cool setting.
▪ Smell the cast
• Traction:
• Skin
o Buck’s- foot & leg goes to a boot. Used for ppl w/ a fracture hip until
Sx. Continuous traction. (Allow weights to hang freely)
▪ Remove foam boot 3x’s/day & inspect
▪ Turn pt on nonaffected side
▪ Back care every 2 hrs to prevent sores
▪ Ask pt to dorsiflex the affected foot (assesses the peroneal
nerve)
▪ Elevate the foot off the pts bed
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o Russell’s- fractures of the femur; vertical & horizontal pull. Do arterial
& venous circulation. Restraint depends on the situation.
o Bryant’s- used for children < 2 & <30 lbs. w/ hip fracture. 90° angle &
you must be able to put hand under buttocks.
o Head halter traction (Halo)-Cervical; intermittently applied- if pain is
felt 24-48 hrs. when chewing the pins might of slipped into the temporal
plate= notify physician
o Pelvic used for back issues. Weights are hanging freely w/ knees bent.
• Skeletal
o Pins are inserted into bones. Pin site care= soap & water (saline).
Cleaning the area & apply antibiotic ointment. Make the bed from top to
bottom & pts use the trapeze bar.
• Fractures:
▪ Simple fracture= closed fracture
▪ Compound fracture= open fracture, tetanus shot for pts w/ bone fracture that
breaks the skin.
▪ Greenstick fracture only in children
▪ Commuted fracture the bone is splintered into fragments
• Carpal tunnel syndrome assessment requires the nurse to perform the Phalen’s
maneuver= put back of hands together & bend both wrist @ the same time, it will
cause pain or tingling.
• Compartment syndrome: permanent damage in 6-8 hrs. Bivalve the cast it might help.
▪ Volkmann contracture: happens w/ compartmental syndrome= fingers & wrists
become contracted. EMERGENCY!!!
• Fat embolism: usually on leg fractures= chest pain, dyspnea, & petechia
• Hip replacement care= extension & abduction. Put a pillow between the legs when
turning. High chair & toilets to prevent hip flexion.
• Arthritis- systemic autoimmune disease.
▪ Rheumatoid= if left untreated can lead to bone alkalosis which is the loss of
complete movement. Tx w/ ASA, NSAIDS, steroids, Antimalarials, gold (Au)
weeks to months to be effective, immunosuppressant’s * Methotrexate*
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ Osteoarthritis: place joints in their functional position
▪ Gout: usually big toe pain. It’s treated w/ allopurinol… push FLUIDS!!! Low
purine diet: reduce consumption in meats, fowl (birds), fish & shell fish, lentils,
dry peas & beans, nuts & oats. NO ALCOHOL!!! Eat fresh fruits & whole grains.
▪ Lupus: young African American women are at greater increase. Manifestations=
butterfly rash on face, Reynaud’s, photosensitivity, hair loss, joint pain, can
damage the kidneys & heart years later. Tx is the same as for rheumatoid
arthritis. No Cure or prevention
▪ Lyme disease: tick bite manifests are a bull’s eyes rash. If treated quickly the
disease will not progress. Tx w/ tetracycline… prevention is w/ long sleeves &
pants tucked into your sock w/ light colored clothing. To remove the tick use
tweezers… never burn the tick.
• Rocky mountain spotted fever (dog tick) mayor symptoms: fever, rash on
palms & soles of feet, HA. Tx w/ tetracycline family.
• Guillain-Barre syndrome: weakness progresses from the legs upward → respiratory
arrest.
• Mobility of the client with hyperparathyroidism should be ↑ to avoid renal calculi.
• Lumbar puncture: if HA occurs assess the site for leakage & position side lying.
• Herniated nucleus pulposus= herniated disk. Puts pressure on the spinal nerve. Tx:
muscle relaxants, traction, heat, PT, Sx
▪ Cervical= shoulder & arm pain
• Laminectomy/discectomy- semi recumbent position) 20-30°= low
fowlers)… keep the neck straight; use log rolling. Assess airway & upper
extremities neuro checks- squeeze my hand etc.
▪ Lumbar= low back & leg pain
• Laminectomy/discectomy- flat/ supine for the first few hours. Assess
lower extremities neuro checks & bowel & bladder functioning.
• Multiple sclerosis (MS): Ig bands on electrophoresis. Weakness starts in upper
extremities; bowel & bladder are affected 90% (demyelination). Tx: ACTH,
corticosteroids, Cytoxan & other immunosuppressant’s.
▪ Urinary retention, ↓ LOC, hypoactive DTR’s, numbness/tingling, ↓ short term
memory
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ A fluid intake of 2000 mL/day is recommended. The client should initiate the
bowel program on an every-other-day basis, approx. 45 minutes after the
largest meal of the day
▪ Should try to sleep on their stomach as much as possible to ↓ the spasm of the
muscle of the hips/knees as well as contractures/ ulcers
• Gower’s sign= muscular dystrophy … like minor’s sign ( walks up legs w/ hands)
• Milwaukee brace- worn 23 hrs /day; log rolling after sx.
• PAD= pain is relieved when legs are @ rest or in a dependent position (below the
heart). Extremities are cold to touch & have no hair. **pain, pallor, paresthesia, &
paralysis**
▪ They cannot distinguish between sharp & dull
▪ They can have a heating pad placed on abdomen once a day to promote cause
reflex vasodilation. NO hot tub soaking.
▪ No smoking, exercise even if in pain, stay inside during extreme weather
changes, never use warm packs-burns
• PVD= (above the heart) avoid massaging. Warm to touch, hair present, purplish.
Peripheral pulses
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
Psychiatry
▪ Pts admitted against their will still retain their right to refuse tx.
▪ Phobias involve projection & displacement
▪ MAOI’s: HTN crisis occurs w/ tyramine foods (meats, tenderizer, smoked/pickled fish,
sausage, chocolate, caffeine, avocado, beer, & yogurt.
o S&S= restlessness
▪ Phenothiazines: typical antipsychotics- induce (EPS) Parkinsonism & photosensitivity.
▪ CCU psychosis occurs in some clients in the critical care milieu. The ability to focus
fluctuates over the course of a day
▪ Atypical antipsychotics: work on the + & - symptoms, ↓ EPS.
▪ Suicidal pts care consists of providing authority, action & participation.
▪ Benzodiazepines (Ativan, lorazepam): good for alcohol withdrawal & status
epilepticus.
▪ The nurse monitors the CBC because hematological effects of this therapy include
aplastic anemia, agranulocytosis, leukopenia, and thrombocytopenia= Dilantin
▪ Grapefruit juice ↑ levels of Carbamazepine (Tegretol)
▪ Neuroleptic malignant syndrome (NMS): lethal S/E of antipsychotic meds
(Haloperidol). S&S ↑ temp. (102), pulse, incontinence, & muscle rigidity.
▪ Serotonin syndrome= diaphoresis, HA, agitation, & confusion → give Prozac
▪ Pts w/ severe depression should have activities w/ little concentration (drawing)
▪ Antabuse: given for alcohol deterrence; makes you sick w/ alcohol intake.
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o Given after alcohol detoxification to maintain abstinence.
o Teaching: No alcohol in any form (mouth wash), abstain 12 hrs. before taking,
no alcohol for 2 weeks after last dose
▪ S/E: HA, dry mouth, flushing
▪ A client with severe anxiety may feel abandoned and become overwhelmed if left
alone. Placing the client in a quiet room is also indicated, but it is more important to
stay with the client.
o Anxiety attack= support & protect pt. Always assess 1st
▪ Schizophrenia: provide short frequent contacts; clarify: be specific (short phrase);
provide individually packaged or canned foods
o Associative looseness
o Affective inappropriateness
o Ambivalence: conflicting feelings (love-hate same person)
o Autism: delusions- don’t attack them, express doubt, hallucinations- present
reality, ideas of reference, & depersonalization.
▪ Neologism: made up words- tell them you don’t understand don’t
reinstate.
▪ negative symptoms: flat affect
▪ Phobias: TX: antianxiety, desensitization, behavior modification, relaxation
technique. DON’T confront or try to reason!!!
o Simple phobia: object or situation
o Agoraphobia: open or public places (elevators)
▪ Pts w/ OCD= rituals are performed to control unpleasant thoughts/feelings.
o W/ a newly admitted pt the nurse should create a trusting nurse-client
relationship
o Don’t interrupt rituals but set limits; distract; assess: skin breakdown
o Desensitization
o Behavior modification
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o Help pt. express feelings in appropriate ways
o Individual & group therapy.
▪ Conversion disorder: sudden loss of motor & sensory function (Voluntary nervous
system)-short term= they don’t care
o Primary gain: person no longer to be in the anxiety provoking situation
o Secondary gain: attention
▪ Dissociative disorder: sudden or gradual loss of identity or memory usually by a
traumatic event.
▪ Somatization= emotional turmoil expressed in physical signs (loss of functioning)
o Rule out actual disease/
o Don’t focus on physical symptoms
o AVOID being over attentive
o Discourage secondary gains: benefits from being sick-special attention
o Teach alternative coping mechanisms
o Diversion
▪ Antisocial personality disorder: no conscience
o little motivation to change
o manipulative
o Set limits!
o Improvement= expresses sincere concern about another pt.
▪ Bipolar personality disorder:
o Nursing care involves refraining from self-mutilation.
▪ Finger foods
o Manic phase: flight of ideas, don’t argue, fast speech
▪ Bipolar Affective disorder mania
o ↑ mood
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o Irritable
o Non-stop physical activity
o Poor nutritional intake
▪ Borderline personality disorder:
o Manipulates
o Impulsive
o Suicidal/poor self-image
o Bored, trouble being alone
o Mood swings
o Anger expressed w/o control
▪ TX: set limits, positive feedback/acceptable behavior, confront
inappropriate behavior, expression of feeling not acting on them, DON’T
make decision for pt.
▪ Defense mechanisms
o Repression- “unconscious forgetting” causes most of anxiety disorders
o Suppression- “conscious forgetting” person knows but chooses to ignore
o Denial- not admitting there’s a problem “alcoholic”
o Displacement- feelings towards a person/situation is taken on something/
someone else. Banging kitchen door when mad at your boss or yelling @ your
spouse when having problem @ work.
o Regression- back to an earlier stage you were comfortable in (hospitalized
infants)
o Projection- paranoia towards others or things done; Alzheimer’s
o Rationalization- make an excuse
o Reaction formation- “opposite underlying reactions”. Person goes in to
convenient store looking to see if there are any signs of pornography & tells the
owner to get rid of it, when in reality he likes porn”
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o Transference- transferring feeling you had towards someone to someone else.
(pt affection feeling towards nurse)
o Ideas or reference- the person believes everyone is doing things against them;
common in paranoid pts.
▪ Grief stages
o 1st -denial
o 2nd -anger
o 3rd- bargaining
o 4th- depression
o 5th-acceptance
▪ ECT prep: after 3 sessions results can be seen as soon as 1 week
o Withhold food 6 hrs prior
o Pt should void before
o Instruct pt to wash hair & keep clean
o Sign informed consent
▪ Withdrawal Delirium
o HTN
o Changes in LOC
o hallucinations
▪ S&S of Stimulants withdrawal:
o Dilated pupils
o Depression
o Fatigue
o Anxiety
o Disturbed sleep
▪ S&S of Opiate withdrawal:
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o Watery eyes
o Pinpoint pupils beginning- dilated late
o Nausea/Diarrhea/vomiting
o Cramps
o Runny nose
▪ S&S of Alcohol withdrawal:
o Delirium tremens: **Safety** prevent injury
o Tachycardia/ tachypnea-early
o Anxiety/paranoia-early
o Nausea/anorexia-early
o Hallucinations-early
▪ Delegation
✓ Activities such as turning, ambulation, strict intake & output, and feeding can be
delegated to the UAP
▪ Immune
o B lymphocytes have the job of making antibodies and mediating humoral
immunity.
o Elevated hematocrit levels are seen in persons with dehydration,
pernicious anemia, or polycythemia.
▪ Integumentary
• Cellulitis is a skin infection into deeper dermis and subcutaneous fat
▪ Pt requires a private room until 24 hrs. after therapy started.
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
Oncology
▪ Terminal Stages of grief
▪ Testicular CA= painless lump/swelling in testicle. STE >14 yrs.…(15-35 yrs.)
▪ Prostate CA= >40 yrs., PSA ↑, PAP ↑
▪ Pap smears should start w/in 3 yrs. of intercourse or by age 21 (baseline)
▪ Following a mastectomy the pt should keep the affected arm elevated above
heart level to prevent lymph swelling.
• No carry or having BP taken on that arm. Reach to recovery helpful with
how to deal with changes now.
▪ Day of surgery hand/wrist/elbow exercises.
▪ Following day (2-3 days) combing hair & wall climbing.
▪ Following lumphectomy of breast nurse should instruct pt to wear loose fitting
bra made of 100% cotton.
▪ Breast CA= leading cause of CA in women. LUOQ
• Mammography @ 35- baseline.
• Mammography 40-50 every alternate year
• Mammography from age 50- every year.
▪ Ovarian CA= leading cause of gynecological death
▪ Leukemia= Anemia (↓ RBC’s), immunosuppression ( neutropenia & immature
WBC’s, hemorrhage & bleeding tendencies (thrombocytopenia= ↓ platelets)
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ Hodgkin’s= red Sternberg cells
Positioning
◇ NG tube placement: high fowler’s
◇ G-tube= liquid med (sorbitol) is of great concern since it can cause diarrhea
◇ THR- (only abducted) NO! adduction past midline or hip flexion past 90°
◇ Supratentorial sx… HOB 30-45 ° (semi fowlers), Midline, neutral, & on non-operative
side. Avoid extreme hep/neck flexion
◇ Infratentorial Sx …flat
◇ Phlebitis/DVT must be supine w/ elevated affected leg
◇ Harris tube… RT/ BACK / LT to advance tube in GI= gastric & abdominal distention.
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
◇ Miller Abbott tube= RT side for GI advancement into small intestine= intestinal
obstruction.
◇ Thoracentesis- unaffected side w/ HOB 30-45° or over head table
◇ Enema- LT sim’s; HOB not elevated.
◇ Liver biopsy- RT side w/ pillow or towel against puncture site.
◇ Cataract Sx- opposite side in semi fowlers; may wear glasses.
◇ Cardiac cath- flat (HOB <30°), leg straight for 4-6 hours, bed rest for 6-12 hours.
◇ Burn autograph- elevated & immobilized 3-7 days
◇ Amputation- supine w/ elevated stump for the first 24 hours then prone or flat to ↓
hip contractures.
◇ Large brain tumor resection: non-operative site
◇ Trendelenburg= insertion of a central venous catheter (CVC) for TPN.
◇ Following a pneumonectomy- never on affected side= mediastinal shift; instead now
we put them on a semi sitting- upright position.
◇ W/ a lobectomy place the pt on the unaffected on a semi fowler’s position to promote
lung expansion.
◇ Cholecystectomy- <20 ml/hr, positioned semi fowlers
◇ Shock- lower extremities should be elevated (improves circulation to brain & vital
organs w/o increasing workload or impairing respiratory effort)
◇ Cholecystitis- most pertinent dx
◇ Cystic fibrosis percussion & postural drainage:
o Position child in side-lying position to the right side of the chest elevated on
pillows.
o Place on prone w/ thorax & abdomen elevated
o Place in a knee chest position w/ pillows under chest.
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
Pre/post-operative care:
✶ Breathing is taught before sx
✶ Incentive spirometry= inhale slowly & completely hold for 5 seconds. Done 10
x’s a day.
✶ ↑ corticosteroids & insulin’s too if needed
✶ Restlessness= hemorrhage
✶ Wound dehiscence/extravasation- wet steril NS dressing & call Dr.
✶ Call Dr. post of if <30 ml of urine, systolic BP <90, temp >100, or <96.
✶ W/ Blakemore tubes (esophageal varices) keep scissors @ bedside. If resp.
distress occurs nurse must cut tube & remove it.
✶ Turn off NG suction after PO meds are given for 30 min
✶ Tracheostomy pts. Keep Kelly clamp & obturator @ bedside.
✶ Bronchoscopy- scope down the trachea. Pt NPO before & after procedure until
gag reflex returns. They also undergo conscience sedation so monitor VS.
✶ Total laryngectomy= before procedure it’s most important to ask pt if they can
read or write. Pt safety will include asking if there are smoke detectors in their
homes; will no longer be able to smell smoke, shower or tub bathe, No
swimming, boating or water skiing.
✶ “Time out”
o Surgeon will indicate the operative site
o Pt will indicate the procedure being done
o Circulating nurse will identify pt by name & face
o Nurse & surgeon need to agree on the area that will be part of surgery.
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
✶ Watch for stridor after any neck/throat sx… keep trach kit @ bedside.
o Staples & sutures will get removed in 7-14 days so they must be dry until
then.
o No lifting anything >10 lbs for 6 wks.
Diseases/Illnesses
• Reynaud’s disease:
o Warm up car before starting to drive/ avoid cold weather: wear wool gloves & stay
home.
o Go to yoga class after clinic (↓ stress)
o Avoid caffeine & smoking
• Legionnaires’ disease ↑ risk: found in warm stagnant water
o Advance age
o Immunosuppression
o ESRF
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o DM
o Pulmonary disease
• Scabies= nurse should question Lindane because it can penetrate intact skin and cause
seizures if absorbed in sufficient quantities. A client with a preexisting seizure disorder is at
high risk.
• COPD: small frequent meals- high protein & calorie meals & fluids (water). Must get flu &
pneumonia vaccine.
o Emphysema
o Bronchitis
Herbs
• Chamomile interferes w/ anticoagulants
• St. John’s wort: Contraindicated in pregnancy & lactation. Do not take if experiencing major
depression, or while on: MAOI’s, SSRI’s, or levodopa. AVOID: tyramine foods & excessive
sunlight
• Eucalyptus: used to treat coughs, bronchitis, nasal congestion, sore muscles. S/E: nausea,
vomiting, muscle weakness, seizures. Contraindicated in pts w/ liver disease or inflammation
of the intestinal tract.
• Hawthorn: used for mild to moderate HF, HTN, cholesterol reduction. S/E: nausea, fatigue,
& sweating. **Interferes w/ cardiovascular meds & potentiates= digoxin & CNS
depressants**
• Echinacea: used to prevent & treat colds, flu, wound healing, & UTI. S/E= immune
suppression, tingling sensation or unpleasant taste on tongue, nausea, vomiting.
Contraindicated in immunosuppressed pt or those w/ allergies to sag weed (daisies)
o Echinacea, garlic, ginseng may ↓ glucose
• Garlic: used to reduce cholesterol, prevent atherosclerosis, cancer, stroke, & MI, ↓ BP, &
prevent or treat colds/flu. S/E= flatulence, heartburn, irritation of mouth, esophagus, or
stomach. Contraindicated: in ppl w/ peptic ulcers or reflux. **↑ effects of anticoagulants &
antiplatelets, ↑ hypoglycemic effects of insulin & may stimulate labor**
• Ginseng: ↑ stamina, adjunct w/ chemotherapy & radiation. S/E= HA, insomnia, nervousness,
palpitations, manic episodes if combines w/ MAOI’s. Caution w/ cardiovascular disease,
hypotension, hypertension, & steroid therapy
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
• Gingko: used for dementia, short-term memory loss, vertigo, PVD, depression, sexual
dysfunction (SSRI’s). S/E: HA, GI upset, contact dermatitis, dizziness. **May ↑ glucose,
potentiates MAOI’s, & ↓ the effectiveness of anticonvulsants**
o Garlic, ginger, ginkgo increase bleeding when taking w/ anticoagulants
Nutrition
• K+= bananas, dried fruits, citrus, potatoes, legumes, tea, peanut butter, raisins,
cantaloupe, & strawberries.
• Vit. C= citrus potatoes, cantaloupe (OJ ↑ iron absorption)
• Calcium= milk, cheese, green leafy vegetables, legumes
• Folic acid= green leafy vegetables liver, citrus
• Thiamine (B1)= pork, beef, liver, whole grains, nuts (↑ in pts w/ cirrhosis)
• B12- organ meats, green leafy vegetables, yeast, milk, cheese, shell fish. (Beefy red
tongue in ppl w/ vegan diet)
• Vit. K= green leafy veggies, milk meat, soy
• Vit. A= liver, orange, & dark green fruits/ vegetables
• Vit. E Vegetable oils: avocadoes, nuts, seeds
⬥ BMI of 18.5-24.9= normal
Diets
⬥ Full liquid: plain ice, cream, sherbet, custards, milk, pudding, soups, breakfast
drinks.
⬥ Clear liquids: water, bouillon, broth, coffee, gelatin, lemonade, tea, hard
candy, carbonated beverages
⬥ **Liver disease**: ↓ carbs, ↓ protein, ↓ Na
⬥ **Renal disease**: limit protein, sodium & phosphorus; ↑ carbs (good: wheat
toast, cereal, eggs, fish, poultry, pasta; AVOID: OJ ↑ protein)
⬥ **Ulcerative colitis**: ↑ calorie, protein, & ↓ residue diet (raisin bran, raw
fruit, & beans)
⬥ **Systemic sclerosis**: eat small, frequent meals. Avoid spicy foods & alcohol.
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ Feedings
⬥ When preparing to D/C PN the nurse should first slow down the infusion rate.
▪ Nurse must get infusion pump before hanging infusion.
▪ Ask patient to take a deep breath, hold it & bear down when removing.
▪ Have 10% dextrose available before hanging solution.
▪ On home visits the nurse should first check temperature & weight. Also
noting any S&S of hyperglycemia.
Pharmacology
▪ Anticonvulsants **CNS depressants**
o Phenytoin (Dilantin)→10-20 therapeutic level
▪ Gum hyperplasia
▪ ↓ blood counts
▪ Monitor kidney & liver function
▪ Avoid alcohol!!! (meds)
o Benzodiazepines (Valium)
o Carbamazepine (Tegretol)
o Barbiturates- Phenobarbital (luminal)- folic acid needed for long term use,
Nyastagmus early sign of toxicity.
o Valproic acid (Depakote): monitor platelets
▪ Cardiac arrest:↑ BP & Cardiac output
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o Norepenipherine (Levophed)
o Dopaine (Intropin)
o Epinepherine (Adrenalin)
o Phenylephrine (Neo-synephrine)
o Dobutamin hydrochloride (Dobutrex)
▪ Anti-Anxiety: CNS depressant (↓ BP) & anticholinergic (Benzos)
o Chlodiazepoxide (Librium)- helps pts prevent/during withdrawals
o Diazepam (Valium)
o Aprazolam (Zanax)- check renal & hepatic function
o Lorazepam (Ativan)
o Midasolam (Versed)
▪ Antidysrhythmics
o Licocaine (Xylocaine)- (local anesthetic)- for ventricular dysrhythimas
o Propanolol (Inderal)- contraindicated in HF & pulmonary edema
o Esmolol (Brevibloc)
o Sotalol (Betapace)
o Amiodarone (Cardarone)
o Diltiazem (Cardizem)
o Verapamil (Calan)
▪ Anticholinergics (red, hot, dry, blind, mad)
o Triotropium (Spiriva)- bronchospasm & long term tx of asthma
o Iprotropium (Atrovent)- given only through aerosol
o Cogentin: (Parkinson’s) contraindicated in pts w/ glaucoma/ BPH
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ Anticoagulants
o Heparin-monitor PTT; Protamine sulfate
▪ Do not massage site
▪ Use 25-27 gauge
▪ Site= abdomen (never aspirate!)
o Enoxaparin (Lovenox)- No testing necessary
o Warfarin- Monitor PT; Vitamin K
▪ Antiplatelet: Aviod vit K foods, d/c 2 weeks before surgery, Monitor HR &BP
o Copidrogel (Plavix)
o Dipryridamole (Aggrenox)
o ASA
o Triclopidine (Ticlid): sometimes used in sickle cell crisis
▪ Antidepressants: ↑ the uptake of serotonin- CNS depressant (↓ BP) & anticholinergic
o Fluoxetine (Prozac)-SSRI= chew sugarless gum & sit on side of bed before rising; use
2-4 weeks to work, sunscreen.
o Citalopam (Celexa)
o Proxetine (Paxil)
o Sertraline (Zoloft)
o Venlafine (Effexor)
▪ Antidiarrheals
o Bisthmuth (Pepto-bismol)
o Atropine Sulfate (Lomotil)
o Ioperamide (Imodium)
▪ Antiemetics
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o Ondansetron (Zofran)- 30 minutes before chemo
o Metrochlopramide (Reglan)- before meals; ↓ tube feeding residuals
o Dimenhydrinate (Dramamine)
▪ Anti-microbials/Antibiotics
o Erythromycin: take on an empty stomach w/ a glass of water
o Penicillin: will probably be allergic to cephalosporin’s= ask what reaction they had &
notify physician
o (Choromycetin)- Used for H influenza Meningitis; typhoid fever, rocky mountain
spotted fever
▪ Aplastic anemia
▪ highly toxic
o Tetracycline’s:
▪ NO milk, zinc or iron
▪ Photosensitivity- can lead to rash
▪ Gray teeth in children
▪ Antifungals:amphoterrible; histoplasmosis
o Nystatin (Mycostatin)- should be swished around then swallowed
o Fulconazol (Difulcan)
o Metronidazole (Flagyl)
▪ Antigout
o Allupurinol
▪ Antihistamine
o Diphenhydramine (Benadryl)- given w/ food
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o Promethacon HCL (Phenergan)
o Loratadine (Claritin)
o Cetirizide (Zyrtec)
o Fexofenadine (Allegra)
▪ Antilipemic: ↓ LDL levels & causes peripheral vasodilation; take w/ food
o Chlolesytryramine (Questran)
o Atrovastin (Lipitor)
o Rosavastine (Crestor)
▪ Antipsychotics:
o *Phenothiazine*= S/E extrapyramidal-balance, anticholinergic, hypotension (CNS
Depressant), photosensitivity-long sleeves, & agranulocytosis (↓ WBC).
▪ Chloropromazine (Thorazine)- Signs of toxicity= tremors
• Use sunscreen
• AVOID alcohol
• Stay away from sick people
o Haloperidol (Haldol)- S/E: shuffling gait
o Resperidone (Resperdal)
o Aripiriprazole (Abilify)
o Chlorazapine (Clorazil)
o Olanzapine (Zyprexa)- stiffness & tremors are expected for the 1st two weeks.
▪ Bronchodilators
o Iprtropium (Atrovent)
o Albuterol (Proventin)
o Salmetrol (Servent)
o Acetycyateine (Mucomyst)
▪ Narcotics (↑ ICP/vomiting, ↓ LOC/ GI)
o Morphine sulfate
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o Codeine
o Mereperidine (Demerol)
o Hydromorphine ( Dilaudid
o Hydrocodone (Vicodin)
▪ NSAIDS
o Ibuprofen (Motrin)
o Ketorabe (Toradol)
o Naproxen- check for urinary retention & dizziness
▪ Antihypertensives: orthostatic hypotension
o Calcium channel: Hold if pulse <60
▪ Nifedipine (Procardia)
▪ Diltiazem (Cardizem)
▪ Vasotec
▪ Verapamil (Calan)
▪ Amlodipine (Norvasc)
o Angiotensin II receptors
▪ Irbesartan (Avapro)
▪ Losartan(Cozaar)
▪ Valsartan (Diovan)
▪ Other
o Megase- for loss of appetite
o Xanaderm- wound healing
o Zolpidem (Ambien)- for insomnia
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
o Flexiril- muscle relaxant
o Ketaconazole (Nizoral)- candiasis
▪ Miscellaneous
o
Ginko, gensin, garlic= antiplatelet properties
o
Trough draw: 30 min. before administration.
o
Peak draw: 30 min. after administration.
o
Watch for hyperK+ w/ aldactone (spironolactone) & ACE inhibitors.
o
Fibronolytics= streptokinase
o
Persantine combined with warfarin sodium (Coumadin) is prescribed to protect the client's
artificial heart valves.
o
w/ Rimfampin check levels of SGPT (liver)
o
Neupogen ↑ levels of uric acid. (When using the IV line should be flushed before & after w/
5% dextrose)
o
Pentazopine hydrochloride (Talwin) - for stenosis of the spine. Assess of respirations &
lethargy.
o
Amoxifen citrate (Nolvadex) causes soft tissue disease & subsides rapidly.
o
Carbidopa (Sinemet) - makes levodopa more readily available for transport.
o
Risperdal-S/E includes hyperglycemia, weight loss, & blurred vision.
▪
Monitor glucose
o
Cyclophosphamide (Cytoxan)- S/E are leukopenia; check WBC
o
Phentolamin mesylate- should be infiltrated when extravasation of dopamine occurs.
o
Sodium thiomate- S/E are a ↓ in platelets- check for bruising & bleeding.
o
Clozapine (clorazil)-schizophrenia=adverse effect- agranulocytosis-leukemia; monitor WBC’s.
o
Gentamicin sulfate- avoid sunlight exposure (photosensitivity).
o
Zoloft- watch out for nausea, vomiting, abdominal cramps, & diarrhea= hyponatremia.
o
Plasma cholesterol screening: only sips of water for 12 hours before the test.
Safety
▪ In case of fire:
RESCUE
PULL THE PIN
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
ALARM
AIM THE NOZZLE @ BASE OF FIRE
CONTAIN
SQUEEZE THE HANDLE
EXTINGUISH
SWEEP
▪ If after administering the medications preop the nurse finds out the consent wasn’t
signed the nurse should notify nursing supervisor.
▪ Restraints: need to be checked every 30 min; 2 finger btw
▪ FFP is given to promote rapid volume expansion as a result of fluid/ blood loss
▪ Neutropenic pts are given granulocytes or WBC’s
▪ Pts w/ meningitis get put in a private room or cohort pts
▪ NEVER given by IV push: vancomycin or potassium chloride
▪ Pts w/ radiating implants should wear gloves when emptying bed pan, keeping all
linens until the implant is removed
✓ w/ internal radiating implants the pt. is on a strict bed rest on her back w/ HOB
<20 °, movement is restricted. A foley is inserted to prevent the implant from
being dislodged by a full bladder. Sever radiation occurs w/ a distended
bladder.
▪ PICC line insertion
✓ Cap, gown, mask, & gloves
▪ CPR guidelines
✓ Pulse should be palpated @ medial edge of the sternocleidomastoid muscle in
neck.
✓ Each rescue breath should be given over 1 second & produce a visible chest
rise.
▪ 20 breaths/ min
▪ 100 compressions/ min
▪ Depress sternum by 1 ½- 2 inches
✓ for 5 year olds to relieve airway obstruction the thrusts should be between the
umbilicus & xyphoid process
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
✓ abdominal thrusts
▪ On pregnant conscious women who’s 8 months pregnant should have a
blanket rolled under her right hip abdominal flank & hip area.
• Steps for abdominal thrusts:
1. Assess consciousness
2. Open airway= jaw thrust maneuver
3. Look into mouth & remove object blocking
4. Attempt ventilation
5. Perform abdominal thrusts
▪ Standard precautions:
✓ HIV
✓ H. influenza pneumonia
✓ Herpes zoster (shingles)
✓ Lyme disease
✓ Cutaneous anthrax
▪ Contact precautions:
• RSV (Bronchiolitis)- w/ another RSV pt-okay but private room is best. Use mist tent to
provide O2 & riboflavin
• When providing colostomy care on pt w/ MRSA wear: gloves, gown, goggles, & face
shield. Mask is not necessary- Not airborne!!!
• Croup
▪ Droplet precautions:
▪ Haemophilus Influenzae Type B
▪ Meningococcal pneumonia
▪ Influenza: for 7 days or until 24 hrs. of resolution of fever & respiratory symptoms.
(can leave door open but stand <3 ft. from pt.)
▪ Wound dehiscence steps
▪ Low fowlers
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
▪ Cover organs w/ sterile dressing
▪ Instruct Pt to remain silent
▪ Contact surgeon
▪ Prepare Pt for wound closure
▪ Document actions taken
▪ Blood transfusion steps
✓ Verify prescription by physician
✓ Verify consent
✓ Insert 18-19 gauge needle
✓ Double verify compatibility of ordered blood to pts blood type
✓ Obtain blood from blood bank
✓ Ask another nurse to confirm compatibility (identify pt)
✓ Hang bag
✓ Evaluate reactions
Blood reactions
▪
▪
If pt begins to vomit, has a ↓ BP, ↑ temperature, chills, diarrhea, shock= septicemia
Hyperkalemia= weakness paresthesia’s, abdominal cramps, & dysrhythmias
▪
Circulatory overload= cough, dyspnea, chest pain, wheezing, tachycardia, & HTN.
▪
Delayed transfusion= days-years later which include fever, mild jaundice.
•
Use a blood warmer when administering several units to prevent dysrhythmias
Autologous transfusion
o
Can be given up to 5 weeks before the procedure
o
Can give 2-4 units
o
No donation can be given 3 days prior to surgery
Procedures
✓ Inserting urinary cath
1. Cleanse genital area w/ soap & water
2. Position pt to expose the perineum
3. Expose the urethral meatus
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
4. Wipe perineal area front-back w/ cotton ball saturated in antimicrobial solution
5. Advance catheter 2-3 inches or until urine flows
6. Inflate the balloon.
✓ Proper removal of PPE (first to last
7. Gloves
8. Eyes wear
9. Unti gown strinfs
10.Fold gown inside out
11.Remove mask
✓ Newborn 1st bath
12.Place infant in warm surface
13.Cleanse the eyes from the inner canthus to outer
14.Cleanse face using warm water
15.Cleanse the body w/ warm water & mild soap
16.Wrap the infant in a towel/ pre-warmed blanked
17.Shampoo hair/head
✓ Pt care for ECT
18.Explain procedure
19.Ask to void
20.Administer atropine
21.Orient the pt
✓ Preoperative activities
22.Verify operative permit is signed
23.Obtain & record VS
24.Ask pt to empty bladder
25.Instruct pt to remain in bed
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
26.Administer preop meds
▪ If needing to pee after meds are given- offer bed pan
✓ Blood transfusion reaction
27.Stop infusion
28.Give NS
29.Notify health provider
30.Collect urine sample
31.Return blood to blood bank
✓ Emptying a drainage evacuator
32.Wash hands
33.Don gloves
34.↑ bed to workable height
35.Pour drainage into measuring cup
36.Compress the evacuator & replace the plug
✓ Preparing a sterile field
37.Assemble the necessary equipment
38.Place the sterile drape on the works surface
39.Open the wrapper of the sterile item
40.Dispose of the outer wrapper
✓ Care for pt following mastectomy w/ drainage evacuator
41.Secure in pts gown w/o applying tension
42.Should be fully compressed in the drainage evacuator w/ one hand while replacing
the spout plug w/ the other hand.
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
43.Use sterile gauze to clean the drainage evacuators spout & plug prior to
reestablishing the vacuum
44.Rapid re=inflation= air leak; compress unit & again plug in for a secure fit
✓ Proper application of condom catheter
45.Clip the hair @ the base of penis
46.Leave 2 inches btw the tip of pwnis & end of catheter
47.Secure the urinary drainage to the colletion bag & bed frame
48.Elastic adhesive strip should be wrapped in a spiral pattern w/o overlapping onto
itself to ensure circulation
49.Assess penis 30 minutes after applying looking for any swelling or darkness=
impaired circulation.
✓ Stoma care:
50.Use fingers to apply ointment around stoma
51.Uncover when taking bubble bath
52.Cover when taking a shower
53.Wear a cotton scarf when going outside
54.Never insert drops into stoma; humidification is provided through humidifier.
✓ Breast self-examination
55.Looking in a mirror, look for changes in breasts & nipples (dimpling, retractions,
discharge, odor)
56.w/ hands on side inspect breasts
57.w/ hands on hips examine breasts
58.use the pads in the middle of the 3 fingers to palpate breasts to detect unusual
growth while lying down.
✓ Wet-dry dressing change
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
59.Assess comfort level
60.Remove gauze dressing
61.Observe appearance of the wound
62.Clean the wound w/ saline
63.Apply moist gauze in a single layer to wound
64.Tape & record date & time applied
✓ Positioning for a pt w/ a T1 spinal cord injury
65.Place the pt in a sitting position
66.Check the foley catheter for kinks/ obstruction
67.Monitor BP every 10-15 minutes
68.Label the chart w/ visible notes about autonomic dysreflexia
69.Instruct the pt about preventing autonomic dysreflexia
✓ Incorrect medication administration
70.Record dose given
71.Assess
72.Contact physician
73.Chart adverse effects
74. Submit report to risk manager < 24 hrs.
✓ Catheterization- sterile
75.Male= 90° angle; best to put it lateral to the thigh or up to the abdomen… NEVER
down= will irritate/damage urethra.
76.Female= between the clitoris & vagina
77.Indwelling urinary catheter- specimen for culture… clamp tubing… cleanse with
wipe & aspirate. If there is no sampling port a needle must be inserted into the
bifurcation (section distal to where we inflate the balloon).
✓ Allen’s test: (ABG’s)
78.Explain the procedure to the client.
79.Apply pressure over the ulnar and radial arteries.
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
80.Release pressure from the ulnar artery.
81.Ask the client to open and close the hand repeatedly.
82.Assess the color of the extremity distal to the pressure point.
83.Document the findings.
✓ Insertion of central venous catheter (it’s on right side)
84.Turn head to left side until procedure in complete
85.Shave or clip hair (night before)
86.Head down until insertion (Trendelenburg)
87.Valsalva maneuver to ↓ air embolism risk
✓ Chest drainage system
88.Drainage system should be below the pts chest & an occlusive dressing over
insertion site.
89. If the chest tube becomes disconnected place the end of the tube in a bottle of
sterile water & hold it below the level of the chest.
90.Removal= Valsalva maneuver (deep breath & bear down)
91.Dislodged= grasp the retention sutures & spread the opening if the agency permits
the nurse can attempt to replace the tube immediately.
92.Suction chamber (seal chamber)= Continuous gentle bubbling should be noted with
inhaling/exhaling
✓ Peg tubes
93.Hold feeding is residual is >100
✓ ET tube
94.Removal: nurse must monitor for resp. distress or stridor & report it immediately
(↑pitched, coarse sound heard over the trachea). Cuff pressure= <20, drain away
from pt.
Downloaded by Arianna Tomaino (att2097@gmail.com)
lOMoARcPSD|11022437
✓ NG tube
95.Placement= gastric contents <4.
96.insertion= cough & gag, back off a little then let the pt calm down & advance again
w/ a pt sipping on water from a straw.
97.Removal= deep breath & hold it
98.If when administering NG tube the pt becomes dyspnic & starts to cough/ resp.
distress: withdraw tube slightly, stop advancement until distress subsides
99.Plan of care: frequent oral care, measure drainage every 8 hrs, secure the tube to
client’s gown.
Downloaded by Arianna Tomaino (att2097@gmail.com)