NCLEX® Strategies
An important point to remember is that the NCLEX® exam is a nursing
examination, not a medical one. Therefore, focus on nursing and select the option
that relates to a nursing intervention rather than a medical one. The only situation
in which you may need to select a medical intervention is if the question indicates
to do so. For example, if the question query states, “Which intervention does the
nurse anticipate to be prescribed?”
In most situations, if an option contains a closed-ended word, it is incorrect. As
you read each option, if you note a word that is closed-ended, eliminate that
option. Conversely, as you read an option and note an open-ended word, then that
may be the correct option. A list of closed-ended and open-ended words follows.
Closed-Ended Words
All
Always
Cannot
Every
Must
Never
None
Not
Only
Will not
Open-Ended Words
Generally
May
Possibly
Usually
Open-ended words may indicate a correct option!
Positioning Patients
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Asthma—orthopneic position where patient is sitting up and bent forward
with arms supported on a table or chair arms.
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Post Bronchoscopy—flat on bed with head hyperextended.
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Cerebral Aneurysm—high Fowler’s.
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Hemorrhagic Stroke: HOV elevated 30 degrees to reduce ICP and facilitate
venous drainage.
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Ischemic Stroke: HOB flat.
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Cardiac Catheterization—keep site extended.
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Epistaxis—lean forward.
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Above Knee Amputation—elevate for first 24 hours on pillow, position on
prone daily for hip extension.
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Below Knee Amputation—foot of bed elevated for first 24 hours, position
prone daily for hip extension.
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Tube feeding for patients with decreased LOC—position patient on right
side to promote emptying of the stomach with HOB elevated to prevent
aspiration.
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Air/Pulmonary embolism—Turn patient on left side and lower the HOB
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Postural Drainage—Lung segment to be drained should be in the
uppermost position to allow gravity to work.
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Post Lumbar puncture—patient should lie flat in supine to prevent
headache and leaking of CSF.
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Continuous Bladder Irrigation (CBI)—catheter should be taped to thigh so
legs should be kept straight.
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After myringotomy—position on the side of affected ear after surgery
(allows drainage of secretion).
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Post cataract surgery—patient will sleep on unaffected side with a night
shield for 1-4 weeks.
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Detached retina—area of detachment should be in the dependent position.
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Post thyroidectomy—low or semi-Fowlers, support head, neck and
shoulders.
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Thoracentesis—sitting on the side of the bed and leaning over the table
(during procedure); affected side up (after procedure).
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Spina Bifida— position infant on prone so that sac does not rupture
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Buck’s Traction—elevate foot of bed for counter-traction.
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Post Total Hip Replacement—don’t sleep on operated side, don’t flex hip
more than 45-60 degrees, don’t elevate HOB more than 45 degrees. Maintain
hip abduction by separating thighs with pillows.
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Prolapsed cord—knee-chest position or Trendelenburg.
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Cleft-lip—position on back or in infant seat to prevent trauma to the suture
line. While feeding, hold in upright position.
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Chest tube insertion—patient’s arm should be raised above their head
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Cleft-palate—prone.
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Hemorrhoidectomy—assist to lateral position.
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Hiatal Hernia—upright position.
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Preventing Dumping Syndrome—eat in reclining position, lie down after
meals for 20-30 minutes (also restrict fluids during meals, low fiber diet, and
small frequent meals).
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Enema Administration—left-side lying (Sim’s position) with knees flexed
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Post supratentorial surgery (incision behind hairline)—elevate HOB 3045 degrees.
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Post infratentorial surgery (incision at nape of neck)—position patient
flat and lateral on either side.
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Increased ICP—high Fowler’s.
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Laminectomy—back as straight as possible; log roll to move and sand bag
on sides.
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Spinal Cord Injury—immobilize on spine board, with head in neutral
position. Immobilize head with padded C-collar, maintain traction and
alignment of head manually. Log roll client and do not allow client to twist or
bend.
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Liver Biopsy—right side lying with pillow or small towel under puncture site
for at least 3 hours.
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Paracentesis—flat on bed or sitting.
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Intestinal Tubes—place patient on right side to facilitate passage into
duodenum.
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Nasogastric Tubes—High Fowlers; elevate HOB 30 degrees to prevent
aspiration. Maintain elevation for continuous feeding or 1hour after
intermittent feedings.
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Pelvic Exam—lithotomy position.
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Rectal Exam—knee-chest position, Sim’s, or dorsal recumbent.
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During internal radiation—patient should be on bed rest while implant is in
place.
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Autonomic Dysreflexia—place client in sitting position (elevate HOB) first
before any other implementation.
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Shock—bed rest with extremities elevated 20 degrees, knees straight, head
slightly elevated (modified Trendelenburg).
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Head Injury—elevate HOB 30 degrees to decrease intracranial pressure.
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Peritoneal Dialysis when outflow is inadequate—turn patient side to side
before checking for kinks in the tubing.
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Myelogram
o Water-based dye—semi Fowler’s for at least 8 hours.
o
Oil-based dye—flat on bed for at least 6-8 hours to prevent leakage
of CSF.
o
Air dye—Trendelenburg.
THERAPEUTIC FUNCTIONS OF CLIENT POSITIONS
Supine
(flat, face up) Minimizes hip flexion
Side
Allows drainage of oral secretions
Side with leg bent (Sims’)
Allows drainage of oral secretions (abdominal
tension)
Head elevated (Fowler’s)
Increased venous return; allows maximal lung
expansion
Head and knees elevated slightly Increased venous return; relieves pressure on
lumbosacral area
Feet elevated 20° and head
Increased venous return; increased blood
slightly elevated (modified
supply to brain
Trendelenburg)
Elevation of extremity
Increases venous return
Flat on back, thighs flexed, legs
Exposes perineum
abducted (lithotomy)
Prone (flat, face down)
Promotes extension of hip joint
Nutrition
Honey:
Don’t give to patient less than one year old due to risk of infant botulism (produces
muscle paralysis)
S/S: constipation, decreased reflexes, weakness, respiratory failure
Infant Nutrition:
Birth-6 months: exclusive breastfeeding
Start introducing solid food between 4-6 months (start off with iron fortified cereal)
Give 5-7 days between food introductions to observe for allergies
1 year: introduce milk
Carbohydrates Milk, grains, fruits, veggies
Fats Beef, pork, lamb, dark chicken, diary, lard
Protein Lean meat, seafood, bean, soy, eggs, nuts, seeds
Clear liquid Water, bouillon, clear broth, carbonated beverage, gelatin, hard
candy, lemonade, ice pop
Full fluid Plain ice cream, sherbet, milk, pudding/custard, fruit juice Mechanical
soft Pureed, mashed, ground, chopped. Avoid nuts, fruit+ veg, and tough meat
Foods that increase electrolytes
Potassium
P- pork and potatoes
0- oranges
T- tomatoes
A- apricots and avocados
S- strawberries
S- spinach
I- think "ish" FISH
U- think "U" MUSHROOMS
M- melon (cantaloupe)
Magnesium
"Always Get Plenty of Foods Containing Large Numbers of Magnesium"
A-avocado
G- green leafy veggies
P- pork, potatoes, peanut butter
0- oatmeal
F- fish (white canned tuna)
C- cauliflower, dark chocolate
L- legumes
N- nuts
0- oranges
M-milk
Calcium
"MR. STACY'S CHEESE"
M-milk
R- rhubarb
S- spinach
T-tofu
A- almonds
C- cauliflower
Y-yogurt
S- sardines
C-cheese
Sodium & Potassium have an inverse relationship; high Na= low K
Calcium & Vitamin D have a similar relationship; high Ca= high Vit D
Magnesium & Calcium have a similar relationship; low Mg= low Ca
Magnesium & Potassium have a similar relationship; low Mg= low K
Magnesium & Phosphorus have an inverse relationship; low Mg= high
Phosphorus Calcium & Phosphorus have an inverse relationship; high Ca = low
Phosphorus
Sociocultural influences on Nutritional Intake
*Note: not every member of a culture chooses to follow all of its traditions.
Orthodox Jewish
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Dietary laws based on biblical and rabbinical regulations
Laws pertain to selection, preparation, and service of food
Laws
Milk/milk products never eaten at same meal as meat (milk may not be taken
until 6 h after
eating meat)
Two meals contain dairy products and one meal contains meat
Separate utensils are used for meat and milk dishes
Meat must be kosher (drained of blood)
Prohibited foods
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Pork
Diseased animals or animals who die a natural death
Birds of prey
Fish without fins or scales (shellfish—oysters, crab, lobster)
Muslim
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Dietary laws based on Islamic teachings in Koran
Laws
Fermented fruits and vegetables prohibited
Pork prohibited
Alcohol prohibited
Foods with special value: figs, olives, dates, honey, milk, buttermilk
Humane slaughter of animals for meat
30-day period of daylight fasting required during Ramadan
Hispanic
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Basic foods: dried beans, chili peppers, corn
Small amounts of meat and eggs
Puerto Rican
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Starchy vegetables and fruits (plantain and green bananas)
Large amounts of rice and beans
Coffee main beverage
Native American
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Food has religious and social significance
Diet includes meat, bread (tortillas, blue corn bread), eggs, vegetables (corn,
potatoes, green beans,
tomatoes), fruit
Frying common method of food preparation
African American
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Minimal milk in diet
Leafy greens (turnips, collards, and mustard)
Pork common
French American
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Foods are strong-flavored and spicy
Frequently contains seafood (crawfish)
Food preparation starts with a roux made from heated oil and flour;
vegetables and seafood added
Chinese
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Freshest food available cooked at a high temperature in a wok with a small
amount of fat and
liquid
Meat in small amounts
Eggs and soybean products used for protein
Japanese
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Rice is basic food
Soy sauce is used for seasoning
Tea is main beverage
Seafood frequently used (sometimes raw fish—sushi)
Southeast Asian
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Rice is basic food, eaten in separate rice bowl
Soups
Fresh fruits and vegetables frequently part of diet
Stir-frying in wok is common method of food preparation
Italian
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Bread and pasta are basic foods
Cheese frequently used in cooking
Food seasoned with spices, wine, garlic, herbs, olive oil
Greek
Bread is served with every meal
Cheese (feta) used for cooking
Lamb and fish frequent
Eggs in main dish, but not breakfast food
Fruit for dessert
COMMON THERAPEUTIC DIETS
Clear Liquid Diet
Full Liquid Diet
Low-Fat, Cholesterol-Restricted Diet
Sample meal items:
Sample meal items:
Sample meal items:
Gelatin dessert, popside, tea with
lemon, ginger ale, bouillon, fruit juice
without pulp
Common medical problems:
Postoperative; acute vomiting or
diarrhea
Purpose:
To maintain fluid balance
Not allowed:
Fruit juices with pulp, milk
Milkshakes, soups, custard; all dear
liquids
Common medical problems:
GI upset (diet progression after surgery)
Purpose:
Nutrition without chewing
Not allowed:
Jam, fruit, solid foods, nuts
Fruit, vegetables, cereals, lean meat
Common medical problems:
Atherosclerosis, cystic fibrosis (CF)
Purpose:
To reduce calories from fat and
minimize cholesterol intake
Not allowed:
Marbled meats, avocados, milk, bacon,
egg yolks, butter
Sodium-Restricted Diet
High-Roughage,
High-Fiber Diet
Low-Residue Diet
Sample meal items:
Sample meal items:
Sample meal items:
Cold baked chicken, lettuce with sliced
tomatoes, applesauce
Common medical problems:
Heart failure, hypertension, cirrhosis
Purpose:
To lower body water and promote
excretion
Not allowed:
Preserved meats, cheese, fried foods,
cottage cheese, canned foods, added
salt
Cracked wheat bread, minestrone soup,
apple, Brussels sprouts
Common medical problems:
Constipation, large bowel disorders
Purpose:
To maximize bulk in stools
Not allowed:
White bread, pies and cakes from white
flour, "white" processed foods
Roast lamb, buttered rice, sponge cake,
"white" processed foods
Common medical problems:
Temporary GI/elimination problems
(e.g., lower bowel surgery)
Purpose:
To minimize intestinal activity
Not allowed:
Whole wheat, corn, bran
High-Protein Diet
Kidney Diet
Low-Phenylalanine Diet
Sample meal items:
Sample meal items:
Sample meal items:
30 grams powdered skim milk and 1 egg
in 100 ml water or Roast beef
sandwich and skim milk
Common medical problems:
Burns, infection, hyperthyroidism
Purpose:
To reestablish anabolism to raise
albumin levels
Not allowed:
Soft drinks, "junk" food
Unsalted vegetables, white rice, canned
fruits, sweets
Common medical problems:
Chronic renal failure
Purpose:
To keep protein, potassium, and
sodium low
Not allowed:
Beans, cereals, citrus fruits
Fats, fruits, jams, low-phenylalanine
milk
Common medical problems:
Phenylketonuria (PKU)
Purpose:
Low-protein diet to prevent brain
damage from imbalance of amino
acids
Not allowed:
Meat, eggs, beans, bread
TRANSMISSION-BASED PRECAUTIONS:
AIRBORNE
“My chicken has TB”
My- Measles
Chicken - Chicken Pox/Varicella
Has - Herpes Zoster/Shingles
TB- tuberculosis
DROPLET
“Spiderman”
S - sepsis
S - scarlet fever
S - streptococcal pharyngitis
P - parvovirus B19
P - pneumonia
P - pertussis
I - influenza
D - diphtheria (pharyngeal)
E - epiglottitis
R – rubella
M - mumps
M - meningitis
M - mycoplasma or meningeal pneumonia
An - Adenovirus
CONTACT PRECAUTIONS
“MRS.WEE”
M - multidrug resistant organism
R - respiratory infection
S - skin infections*
W - wound infection
E - enteric infection - clostridium difficile
E - eye infection - conjunctivitis
SKIN INFECTIONS
“VCHIPS”
V - varicella zoster
C - cutaneous diphtheria H - herpes simplex
I - impetigo
P - pediculosis S - scabies
Endocrine System
Hyperthyroidism: Hyperthyroid state resulting from the hypersecretion of thyroid
hormones T3 and T4, TSH is low (common cause is Grave’s disease)
S/S: Irritability, fine tremors, heat intolerance, weight loss, smooth skin, palpitations +
cardiac dysrhythmias, diarrhea, exophthalmos, HTN, goiter
Hypothyroidism: Hypothyroid state resulting from hyposecretion of thyroid hormones and
characterized by a decreased rate of body metabolism T4 is low and TSH is elevated
S/S: Change in personality, such as irritability, agitation, and mood swings, Nervousness and
fine tremors of the hands, heat intolerance, weight loss, smooth, soft skin and hair
Diabetes mellitus A chronic disorder of glucose intolerance and impaired
carbohydrate, protein, and lipid metabolism caused by a deficiency of
insulin or resistance to the action of insulin. A deficiency of insulin results in
hyperglycemia
Diabetes insipidus The hyposecretion of antidiuretic hormone from the posterior pituitary
gland, resulting in failure of tubular reabsorption of water in the kidneys and diuresis.
Diabetic ketoacidosis A life-threatening complication of diabetes mellitus that develops
when a severe insulin deficiency occurs, resulting in hyperglycemia. Hyperglycemia
progresses to ketoacidosis over a period of several hours to several days. Acidosis occurs in
clients with type 1 diabetes mellitus, persons with undiagnosed diabetes, and persons who
stop prescribed treatment for diabetes
Hypoglycemia
“Cold and Clammy I Need Some Candy”
Cold, clammy, irritable, pale, weak, diaphoretic
Hyperglycemia
“Hot and Dry my Sugar is High”
Polyphagia, polyuria, polydipsia, blurred vision,
fruity breath,
hot + dry
Type
Rapid acting
(Lispro, Aspart, Glulisine
Short acting
(Regular)
Intermediate acting
(NPH)
Long acting
(Glargine, Detemir)
Insulin
Onset
<15 minutes
Peak
1-2 hours
Duration
3-6 hours
30-60
minutes
2-4 hours
2-4 hours
6-10 hours
4-8 hours
10-18 hours
1-2 hours
NO PEAK
Up to 24 hours
Addison’s Disease – Hypo Cortisol
Addison's disease is adrenocortical insufficiency
or hypofunction of the adrenal
cortex
Lethargy, fatigue, and muscle weakness
Gastrointestinal disturbances
Weight Loss
Menstrual Changes in women; impotence in
men
Hypoglycemia, hyponatremia Hyperkalemia,
hypercalcemia
Postural Hypotension
Hyperpigmentation of the skin (bronzed) with
primary
Disease
Addisonian Crisis Caused by stress, infection,
trauma, surgery. Can lead to hyponatremia,
hyperkalemia, hypoglycemia, and shock
Lifelong glucocorticoid therapy Priority: salt
and sugar/dextrose replacement, steroid
replacement, support physiologic function,
search for and treat cause
Cushing’s – Hyper Cortisol
Generalized muscle wasting and
weakness
Moon face, buffalo hump
Truncal obesity with think extremities,
supraclavicular fat pads, weight gain
Hirsutism (masculine characteristics in
females)
Hyperglycemia, hypernatremia
Hypokalemia, hypocalcemia
Hypertension
Fragile skin that easily bruises, reddishpurple striae on the abdomen and
upper thighs
Priority: Strict intake & output
monitoring; take daily weights
Thyroid storm An acute, potentially fatal exacerbation of hyperthyroidism that may
result from manipulation of the thyroid gland during surgery, severe infection, or stress.
S/S: fever, tachycardia, HTN, agitation + tremors, confusion, seizures, delirium, coma
Thyroidectomy Surgical removal of the thyroid gland; may be done to treat persistent
hyperthyroidism or thyroid tumors.
Myxedema Coma Rare but serious disorder results from persistently low thyroid
production. Coma can be precipitated by acute illness, rapid withdrawal of thyroid
medication, anesthesia and surgery, hypothermia, or the use of sedatives and opioid
analgesics
S/S: hypotension, bradycardia, hypothermia, hyponatremia, hypoglycemia, edema,
respiratory failure, coma
*Levothyroxine is most commonly prescribed*
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Leads to water intoxication and hyponatremia Fluid overload, change in LOC, weight gain,
HTN, tachycardia
Priority: 1. Monitor neuro status 2. Monitor intake + output, weight, serum osmolality,
and urine specific gravity 3. Restrict fluid intake 4. Administer diuretics 5. Seizure
precautions
Metabolic Syndrome: 3 or more of the following factors are present which increases
patient’s risk of stroke, cardiovascular disease, and diabetes abdomen obesity (male > 40
inches, female > 35 inches), high triglyceride level (> 150 mg/dL) , low HDL (male <40,
female <50), HTN, or fasting blood sugar > 5.6
Hematology/Oncology System
Cancer A neoplastic disorder that can involve all body organs. Cells lose their
normal growth-controlling mechanism, resulting in uncontrolled cell division.
Metastasis Cancer cells move from their original location to other sites
Cancer Grading
Grade I: Cells differ slightly from normal cells and are well differentiated
(mild dysplasia.)
Grade II: Cells are more abnormal and are moderately differentiated
(moderate dysplasia).
Grade Ill: Cells are very abnormal and are poorly differentiated (severe
dysplasia).
Grade IV: Cells are immature (anaplasia) and undifferentiated; cell of
origin is difficult to determine
Stage O: Carcinoma
in situ
Cancer Staging
Stage I: Tumor limited to the tissue of origin; localized tumor growth
Stage II: Limited local spread
Stage Ill: Extensive local and regional spread
Stage IV: Distant metastasis
Warning Signs of Cancer: Sore that doesn't heal, indigestion, hoarseness, obvious
change in wart/mole, lump in breast, unusual bleeding
Sickle Cell Crisis:
Sickled blood cell shape= RBC cannot carry oxygen
Inadequate 02 or hydration worsens the sickling by making the RBCs
clumptogether vaso-occlusion
Priority: 1. IV fluids (decreased blood viscosity) 2. Supplemental 02
Breast cancer:
Non-modifiable risk factors: female> 50 years, 1st degree relative of person with
breast ca, BRCA1 + BRCA2 mutations, hx of endometrial or ovarian cancer,
menarche before 12 years or menopause after 55 years
Modifiable risk factors: smoker, alcohol consumption, high fat intake,
sedentarylife, hormone therapy postmenopausal
Breast Self-Exam:
Perform in shower when skin is slippery, use R hand to examine L breast (and
viceversa), use small circular motions in a spiral motion to examine entire
breast, checkfor lumps/hard knots/thickening of tissue. In the mirror with
hands at side: raise arms overhead and assess for any changes in shape of
breasts/dimpling/change in nipple. Next, place hands on hip+ press firmly
(tightens pectoral muscles) and observe for changes in symmetry. When lying
down, feel breasts in spiral motion
Testicular Self-Exam:
Best to assess right after a shower (scrotal skin is relaxed/moist). Gently lift each
testicle (should feel like an egg with no lumps), roll each testicle between
thumb and middle finger to feel for lumps/swelling/mass. Notify physician if any
changesare noted from one month to the next
Post-Mastectomy:
Avoid overusing the affected arm during the first few months, keep affected arm
elevated to avoid lymphedema, avoid strong sunlight on affected arm, do not let
affected arm hang dependently, avoid constricting clothing + blood work + blood
pressure assessment on affected arm
Iron Deficiency Anemia:
Iron-deficiency anemia is a common type of anemia that occurs if you do not have
enough iron in your body.
S/S: pale skin, general fatigue, low hemoglobin + hematocrit, SOB, strange cravings,
brittle nails, weakness, dizziness
Priority: 1. Oral iron intake 2. Iron supplements (give between meals and with fruit
juice for max absorption; avoid giving with milk or antacids decreases absorption)
3. Teach parents about expected dark stool color + constipation
Hemophilia:
Hemophilia is a rare disorder in which the blood doesn't clot normally because it
lacks sufficient blood-clotting proteins (clotting factors)
Hemophilia A due to deficiency in Factor 8
Hemophilia B due to deficiency in factor 9
S/S: abnormal bleeding, joint pain and swelling, unexplained or easy bleeding, large
and deep bruises, frequent nosebleeds, bleeding gums, blood in urine or stool
Priority: 1. Monitor for bleeding 2. Replace missing clothing factor 3. Assess LOC
(increased risk of intracranial hemorrhage) 4. Avoid contact sports
Von Willebrand’s Disease
VWD is caused by inheritance of abnormal gene that controls Von Willebrand
factor, a protein involved in blood clotting.
S/S include abnormal bleeding after an injury or surgery, nose bleeding which lasts
for a longer time, heavy menstrual bleeding, blood in urine or stool. VWD has no cure.
Treatment: medications to prevent and control bleeding.
Renal System
Creatinine Level:
Will only increase once at least 50% of kidney function is lost
Acute Kidney Injury:
S/S (occur due to retention of nitrogenous wastes, fluids, and inability to regulate
electrolytes): decreased UO, increased fluid volume (HTN, edema, CHF), changes in
LOC, uremia (anorexia, nausea, vomiting, pruritus)
Priority: 1. Monitor electrolytes 2. Monitor BP 3. Monitor intake + output along with
daily weight 4. Renal diet (low protein, high carb) 5. Dialysis if needed
Chronic Kidney Disease:
Normal GFR > 90
Mild CKD GFR 60-89
Moderate CKD GFR 30-59
Severe CKD GFR 15-29
End stage KD GFR < 15
Requires dialysis (process of filtering client’s blood; removes waste and maintains
buffer system of the body)
Priority during dialysis: 1. Monitor for hypovolemia/shock (due to blood loss) 2.
Monitor for bleeding 3. Hold antihypertensives and meds that could be removed
during dialysis (e.g. water-soluble vitamins, ABX, digoxin) 4. Monitor for arterial
steal syndrome in pts with internal AV fistula (too much blood is sent to vein that
arterial perfusion to hand is compromised) 5. Palpating a thrill or auscultating a
bruit ensures that a fistula is patent
UTI:
Lower UTI urethritis, cystitis (due to ascending pathogens such as E. coli); S/S:
frequency, urgency, burning
Upper UTI pyelonephritis (due to urine reflux from bladder into ureters or
obstruction causing inflammation);
S/S: calculi, stricture, enlarged prostate
Nephrotic Syndrome:
Proteinuria, hypoalbuminemia, edema
S/S: weight gain, edema (most prominent in morning), low urine output, ascites,
HTN, lethargy
Enuresis:
Patient unable to control bladder function
Cystitis
inflammation of the bladder; may be infectious (bacteria, virus, fungal) or
noninfectious (irritation)
S/S: Urgency, Frequency, Burning during urination (dysuria), Cloudy, foul smelling
urine
Predisposing factors
Female more prone
Catheterization, instrumentation
Hospital-acquired infections (e.g., E. coli)
Priority: 1. Encourage/Increase fluids to 3,000 ml/d 2. Urine for culture and
sensitivity (C and S) 3. Antibiotic therapy (e.g., trimethoprim/sulfamethoxazole) or
antifungals (e.g., ketoconazole) 4. Urinary antiseptics (e.g., nitrofurantoin) 5.
Bladder analgesics (e.g., phenazopyridine) 6. Encourage drinking cranberry juice to
maintain acid urine 7. Discourage caffeine, carbonated beverages, tomatoes 8Teach
females to void following intercourse 9.Clean properly after defecation (front to
back)
Pyelonephritis
inflammation of the kidney
S/S: Chills, Fever, General malaise, Urinary frequency, dysuria
Priority: 1. Serial urine culture—usually caused by E. coli 2. Periodic blood tests 3.
Bedrest during acute phase 4. Antibiotic therapy, antiseptics, analgesics 5.
Encourage fluid intake 3000 ml/day
Urinary Tract Calculi
mineral crystallization formed around organic matter
Urolithiasis—urinary stones
Nephrolithiasis—kidney stones
S/S: Pain (renal colic), Location depends on location of stone, Radiates from flank to
abdomen, labia, or scrotum
Priority: 1. Monitor I and 0 2. Force fluids 3. Strain urine and check pH of urine 4.
Monitor temperature 5. Pain management—NSAIDs, oxybutynin, propantheline,
opioids
Benign prostatic hyperplasia (BPH)
prostate gland enlargement
S/S: Retention, Hesitancy, frequency, urgency, dysuria, Nocturia
Hematuria before or after voiding, Urinary stream alterations; dilated ureter
Dribbling
Diagnostic tests—BUN, prostatic-specific antigen (PSA), ultrasound, biopsy
Priority: 1. Urinary antiseptics 2. 5-alpha reductase inhibitor (e.g., finasteride) 3. 4.
Alpha-blocking medications (e.g., tamsulosin) 5. Saw palmetto or lycopene 6.
Suprapubic cystostomy—to empty bladder 7. Surgery—three common approaches
to prostate gland removal
Transurethral resection of prostate (TURP)
Suprapubic resection (incision through bladder)
Retropubic resection (incision through abdomen)
Postop care of TURP
Assess for shock and hemorrhage—check dressing and drainage: urine may be
bright red for 12 h; monitor vital signs I and O—after catheter removed, expect
dribbling and urinary leakage around wound Avoid long periods of sitting and
strenuous activity until danger of bleeding is over
Neurological System
Neuro Exam:
GCS, PERRLA, CSMT (color, sensory, motor, temperature), VS
Cerebellum:
2 major functions: voluntary movement (test: finger tapping, finger to nose, heel to
shin) + balance/posture (test: gait, heal to toe)
Basilar Skull Fracture:
S/S: battle sign (bruise behind ear), periorbital hematoma (racoon eyes), CSF
leakage from nose/ear
Priority: 1. Support ABC 2. C-spine immobilization 3. Neuro monitoring
Posture:
Decorticate indicates non-functioning cortex
Decerebrate indicates brainstem lesion
LOC:
*Most sensitive indicator of neuro status
Pupils:
Normal size: 3-5 mm
Increased ICP:
Impedes on circulation to brain + functioning of nerve cells ( can lead to brainstem
compression + death)
Cushing’s Triad (sign of increased ICP) = HTN, bradycardia, wide pulse pressure
S/S: change in LOC*, headache, increased BP with widening pulse pressure,
bradycardia, fever, pupil changes
Priority: 1. Keep HOB @ 30 degrees (promotes venous drainage) but not more than
30 degrees (causes decreased cerebral perfusion) 2. Keep body midline/straight
(flexion decreases drainage) 3. Stool softeners (prevents straining)
4. Calm environment (dim lights, low noise, etc. to prevent stress on body) 5.
Suction if needed 6. Treat fever and body temp (shivering can increase ICP) 7. Teach
patient about avoiding Valsalva maneuver
CSF Assessment:
Color: normal clear + colorless
Content: normal little protein + glucose, no WBC, no RBC, no microorganism
Pressure: normal 60-150 mmH2O
Volume: normal 125-150 mL
CSF appears as concentric rings (bloody fluid surrounded by yellow stain Halo sign)
when placed on a white
background. It will test positive for glucose if a strip test is done
Ischemic Stroke
Due to blockage of blood flow  causes
issue with brain tissue perfusion
HTN is common (in order to maintain
brain perfusion distal to the area of
blockage) Avoid suctioning for > 10s to
avoid increased ICP
Priority: TPA to be given 3-4 hours
from onset of S/S (contraindicated in
thrombocytopenia, uncontrolled HTN,
head trauma within past 3 months,
major surgery within past
14 days)
Hemorrhagic
Due to bleed in brain (blood vessel
ruptures)
Seizure can occur due to high ICP,
dysphagia
Priority: 1. NPO 2. Neuro assessment 3.
Prevent activities that
increase ICP or BP 4. Stool softeners 5.
Bed rest with body
midline
*Anticoagulants are contraindicated
Autonomic Dysreflexia/Hyperreflexia:
Due to SNS stimulation after injury @ T6 or higher. Most commonly caused by a
noxious stimulus (usually distended bladder or constipation) It is a neurological
emergency (can lead to hypertensive stroke)
S/S: severe HTN, headache, diaphoresis above level of injury, bradycardia,
piloerection, flushing, nausea
Priority: 1. Monitor BP and provide antihypertensives if needed 2. Monitor bladder
distention 3. Assess for bowel impaction 4. Remove restrictive clothing 5. HOB @ 45
degrees
Cerebral Cortex
Frontal
Broca’s area for speech
Emotions, reasoning & judgement, concentration
Parietal
Interpreting senses (taste, pain, touch, temp, pressure)
Spatial perception
Temporal
Auditory Wernicke’s area for sensory & speech
Occipital
Visual
Unconscious patient:
S/S: unarousable, no response to pain, altered respirations, decreased response to
cranial nerve test and reflex tests
Priority: 1. Emergency airway equipment @ bedside 2. Assess circulation 3. Suction
as needed 4. Semi Fowlers and
avoid Trendelenburg 5. Reposition q2h 6. Keep NPO and assess for gag reflex
before resuming diet
Wernicke’s encephalopathy:
Can be due to low thiamine intake (Vit B1). Severe alcoholism can cause low
absorption of B1 S/S: altered mental status, oculomotor dysfunction, ataxia
Meningitis:
Inflammation of arachnoid + pia mater of brain + spinal cord; bacterial or viral
cause
S/S: irritability, nuchal rigidity, headache, muscle pain, fever, tachycardia,
photophobia, abnormal pupil assessment, Brudzinski’s (involuntary flexion of hip
and knee when neck is flexed) Kernig’s (patient is unable to straighten leg when it is
flexed at knee and hip)
Priority: 1. Droplet/contact precautions 2. Assess for signs of increased ICP 3. Keep
HOB @ 30 degrees and avoid flexion of body 4. Seizure precautions 5. Prepare for
lumbar puncture
*Droplet precautions are not needed for viral meningitis (only for bacterial
and meningococcal)
Concussion
Epidural Hematoma
Subdural Hematoma
Intracerebral
Hemorrhage
Head Injury
Jarring of brain, no loss of consciousness
Retrograde amnesia can occur (amnesia regarding the event)
Rest + light diet are encouraged
*Most serious hematoma; hematoma forms quickly
Due to arterial bleed (middle meningeal artery)
Forms between skull and dura mater
Loss of consciousness and then patient feels better quickly “lucid interval”
followed by quick decline in
mental function
Slow bleed from venous injury
Blood vessel in brain ruptures, causing blood to leak inside of the brain
Spinal Cord Injury:
Total transection of cord = total loss of sensation, movement, and reflex below the level of
injury (If injury is between
C1-C8; quadriplegia. If injury is between T1-L4; paraplegia)
C2-C3 injury is usually fatal
Any injury @ C4 or above = respiratory difficulty
Priority: 1. Always assume spinal cord injury traumas until it’s ruled out. 2. Immobilize
patient on backboard 3. Body midline with head in neutral position 4. Maintain patent
airway 5. Logroll patient if needed 6. Monitor ABGs to assess respiratory status
Spinal Immobilization:
C spine is needed if: concerning neuro exam, significant trauma, decreased LOC,
intoxication, patient has another injury along with spinal injury, concerning spinal exam
Cerebral Aneurysm:
Can lead to rupture*
S/S: headache, irritable, vision changes, tinnitus, nuchal rigidity, seizures
Priority: 1. Bed rest 2. Calm + dark environment 3. Avoid any straining activities 4. Prevent
HTN and pain
Multiple Sclerosis:
Demyelination of neurons which causes CNS degeneration
S/S: weakness, ataxia, tremors/spasms, paresthesia, vision changes, dysphasia,
bladder/bowel disturbances, hyperreflexia + positive Babinski, confusion, decreased
perception to pain/touch/temperature
Priority: 1. Protect from injury 2. Assist with frequent bladder/bowel elimination 3.
Regular exercise and rest 4. PT and SLP involvement 5. Fluid intake + low fat high fiber diet
Myasthenia Gravis:
Weakness + fatigue of voluntary muscles due to defective nerve impulses (due to
insufficient ACh, increased
cholinesterase (breaks down Ach), or muscles don’t respond to ACh)
S/S: weakness, dysphagia, vision changes, difficulty breathing, potential respiratory
paralysis/failure
Priority: 1. Deep breathing + coughing 2. Suction + emergency equipment @ bedside 3.
Prevent aspiration (high fowlers when eating) 4. Time exercise/activities for when patient
has maximal muscle strength (muscles are stronger in the am and weaker in the pm) 5.
Administer anticholinesterase 6. Avoid stress
Cholinergic Crisis
The crisis is caused by overmedication with anticholinesterase
S/S: abdominal cramps, nausea/vomiting, vision changes (blurred), pallor, facial muscle
twitching, hypotension
Priority: 1. Prepare to hold cholinergic medication 2. Administer antidote atropine sulfate
Myasthenic crisis
Acute exacerbation of MG
S/S: Increased pulse, respirations, and blood pressure, dyspnea, anoxia, and cyanosis,
bowel and bladder incontinence, decreased urine output, absent cough and swallow
reflex
Priority: Increase anticholinesterase medication, as prescribed
Edrophonium test: used to diagnose MG + differentiate between myasthenia crisis and
cholinergic crisis
To diagnose MG: edrophonium will cause muscle strength improvement. Negative for
MG = no improvement in muscle strength/deterioration in muscle strength
To differentiate between MC and CC: If after edrophonium, muscle strength improves =
MC; patient will need more medication. If after administration, weakness worsens = CC;
patient is overmedicated with anticholinesterase and needs atropine sulfate given
*Pt is at risk for ventricular fibrillation/cardiac arrest during this test
Parkinson’s Disease
is a degenerative disease caused by the depletion of dopamine, which
interferes with the inhibition of excitatory impulses, resulting in a dysfunction of the
extrapyramidal system. It is a slow, progressive disease that results in a
crippling disability. The debilitation can result in falls, self-care deficits, failure of body
systems, and depression. Mental deterioration occurs late in the disease.
S/S: bradykinesia (abnormal slowness of movement, and sluggishness of physical and
mental responses), monotone speech, tremors + pill rolling, jerky movements,
restlessness, blank facial expression, drooling, difficulty swallowing/speaking, lack of
balance + shuffling gait, handwriting becomes progressively smaller
Priority: 1. Monitor neuro status 2. Check ability to swallow and chew (soft diet high in
calories, protein, and fiber) 3. Increase fluid intake 4. Safety measures 5. Promote physical
therapy and rehabilitation.6. Avoid food high in B6 (blocks effect of antiparkinsonian
meds) 7. Avoid MAOIs (can cause hypertensive crisis) 8. Ambulation assistance
Bell’s Palsy
Lower motor neuron lesion of CN 7 resulting in paralysis of one side of face; recovery
usually in a couple weeks. Does not affect vision, balance, or extremity motor function
S/S: flaccid facial muscles, loss of taste, inability to raise eyebrows, frown, smile, close
eyelids or puff out cheeks
Priority: 1. Facial muscle exercises 2. Protect eyes from becoming dry (artificial tears,
wear patch @ night) 3. Provide oral care 4. Have patient chew on unaffected side
*Recovery normally occurs in a few weeks without residual effects
Guillain Barré:
Acute infection (usually preceded by respiratory infection or gastroenteritis) causing
neuronitis of cranial and peripheral nerves (immune system overreacts and this leads to
myelin sheath destruction)
S/S: potential respiratory failure, pain/hypersensitivity, weakness of lower extremities,
progressive weakness of upper extremities, high protein in CSF
Priority: 1. Monitor respiratory status (prepare for resp support)
Amyotrophic Lateral Sclerosis, also known as Lou Gehrig’s disease
Degeneration of motor system (no changes in sensory, autonomic, or mental status); no
cure
S/S: respiratory difficulty (at the end of the disease, resp muscles are affected leading to
death), muscle weakness, dysphagia
Musculoskeletal System
Strains
are an excessive stretching of a muscle or tendon.
Priority: involves cold and heat applications, exercise with activity limitations,
anti-inflammatory medications, and muscle relaxants. Surgical repair may be required for
a severe strain (ruptured muscle or tendon).
Sprains
are an excessive stretching of a ligament, usually caused by a twisting motion, such as in a
fall or step on an uneven surface.
S/S: Sprains are characterized by pain and swelling.
Priority: Management involves RICE (rest, ice, a compression bandage, and elevation) to
reduce swelling and provide joint support. RICE is considered a first-aid treatment rather
than a cure for soft tissue injuries. Casting may be required for moderate sprains
to allow the tear to heal. Surgery may be necessary for severe ligament
damage.
Types of Fractures
Closed or simple: Skin over the fractured area remains intact.
Complete: The bone is separated completely by a break into two parts.
Compression: A fractured bone is compressed by other bone.
Depressed: Bone fragments are driven inward.
Greenstick: One side of the bone is broken and the other is bent; these
fractures occur most commonly in children.
Impacted: A part of the fractured bone is driven into another bone.
Incomplete: Fracture line does not extend through the full transverse width
of the bone.
Oblique: The fracture line runs at an angle across the axis of the bone.
Open or compound: The bone is exposed to air through a break in the skin,
and soft tissue injury and infection are common.
Buck’s Tractions ensure proper body alignment, that weights hang freely and don’t touch
floor or, do not remove/lift weights without MD order, ensure that pulleys are not
obstructed, elevate foot of bed, and check ropes for fraying
Complications of fractures: fat emboli, pulmonary emboli, compartment syndrome,
infection, avascular necrosis
Priority: 1. Immobilize extremity 2. Monitor neurovascular status
Cast Care:
Keep cast elevated, allow 24-72 hours for cast to dry, handle a wet cast with palms of
hands, turn the extremity q1- 2hrs to allow air circulation, use hair dryer on cool setting to
help with drying process (do NOT use heat), do not insert any objects into cast to relieve
itching, monitor for S/S of infection, keep cast clean + dry
Fat Embolism:
Can occur after a fracture (long bone fractures are greatest risk)
S/S: hypoxemia, change in LOC, tachycardia, hypotension, SOB
Priority: 1. O2 as needed 2. IV fluids 3. Monitor respiratory status 4. Bed rest
Compartment Syndrome:
Pressure increases in a muscle group (usually after cast being put on) decreased blood
flow, tissue ischemia, neurovascular impairment
After 4-6 hours of this syndrome, neurovascular damage is irreversible
S/S: paresthesia, limb pain, pressure, pallor, pulselessness distal to area, paralysis
Priority: 1. Notify doctor 2. Fasciotomy to relieve pressure buildup 3. Loosen restrictive
cast
Crutches:
Priority: 1. Proper measurement (2-3 finger widths between axillae and arm piece,
elbows flexed 20-30 degrees) 2. Stand on pts affected side when ambulating 3. Do not rest
axillae on axillary bars 4. Stop ambulation if numbness/tingling occurs in hands/arms
Avascular necrosis:
When a # disrupts blood supply to bone - bone death
Hip post-op:
Hip fractures commonly hemorrhage, whereas femur fractures are at risk for fat emboli
Priority: Avoid internal and external rotation and hip flexion that’s greater than 90
degrees. Keep HOB 30-45 degrees for meals only 4. Avoid weight bearing on affected leg
5. Keep post-op leg extended, supported, and elevated when standing up 6. Monitor
neurovascular status of extremity 7. Avoid crossing legs and any activity that requires
bending
Amputation post-op:
Priority: 1. Monitor for bleeding/drainage 2. Explain phantom limb pain 3. Do not elevate
residual limb on pillow 4. First 24 hours = elevate food of bed (reduces edema), after 24
hours = keep bed flat (prevents flexion contracture) 5. After 24-48 hours = prone position
(stretches muscles)
Osteoporosis:
Risk factors smoking, early menopause, alcohol use, family hx, female, increasing age, low
calcium intake, sedentary life, thin/small frame, European or Asian race
Patients with osteoporosis are at an increased risk for pathological fractures
Gout:
Buildup of urate crystals in joints (due to high uric acid in body)
S/S: painful joints, tophi (hard nodules), pruritis, renal stones
Priority: 1. Low purine diet (avoid organ meats, wine, and aged cheese) 2. High fluid
intake 3. Avoid alcohol 4. Bed rest during painful attacks 5. Heat or cold application during
pain
Rheumatoid Arthritis
Osteoarthritis
Chronic systemic inflammation leading to
destruction of connective tissue + synovial
membrane in joints. Ultimately leads to
dislocation and permanent deformity of joint
S/S: inflammation of joints, pain + stiffness in the
morning, muscle atrophy, spongy joints, weight
loss
Deterioration of articular cartilage in peripheral
and axial joints; mostly on weight-bearing joints
(hips, knees, hands)
Priority: 1. Rheumatoid factor blood test
confirms diagnosis 2. ROM exercises 3. Balance
between rest + activity 4. Prevent flexion
contractures 5. Avoid weight bearing on inflamed
joints 6. PT and OT 7. Use chairs with high backs
8. Use a small pillow when laying down
S/S: pain that increases with activity and decreases
with rest, pain increases with temperature change,
Heberden’s or Bouchard’s nodes, joint swelling
may be minimal, crepitus
Priority: 1. Pain + corticosteroid meds 2. Avoid
flexion of knees + hips 3. Avoid large pillows when
laying 4. Apply cold pack when joint is inflamed 5.
Rest 6. Balance activity + rest 7. Limit activity
when in pain
Developmental Dysplasia of the Hip:
Head of femur not in proper placement
Signs of dysplasia: asymmetry of gluteal+ thigh folds, limited hip abduction,
shortening of limb on
affected side, Ortolani click (in patient< 4 weeks)
Priority: 1. Pavlik harness continuously (maintains flexion, abduction, and external
rotation)
Five P's of Fractures: Pain, Paresthesia, Pallor, Pulselessness, and Polar (cold)
Fall Prevention
1.
2.
3.
4.
5.
6.
7.
8.
Teach patient how to use the call bell
Make sure patient is oriented to their room (especially blind patients!!)
Raise 3 of the 4 siderails (all siderails being raised is a restraint!!!)
Keep bed in lowest position Secure rugs to the floor
Use good lighting
Clear any obstructions from floor Slip resistant shoes and socks
Clean up spills immediately
Know what medications can increase risks for a fall (drowsiness etc.) Limit
patient distractions
9. Ask for help from a colleague when you need it or unsure
Ambulating with a Cane
(Remember the cane always goes first!!!!)
"Good=UP" and "Bad=Down"
Going UP the stairs: the patient will move the "good" leg (hence noninjured leg) UP
onto the step FIRST and then will move the "bad" leg (hence injured leg) and
crutches up onto the step.
Going DOWN the stairs: the patient will move both crutches DOWN onto the step
and then move the "bad" leg (hence injured leg) DOWN and then move the "good"
leg down.
Deep Tendon Reflexes
0
No response or absent reflex
1+
Trace or decreased response
2+
Normal response
3+
Exaggerated or brisk response
4+
Hyperactive response
Grading of Pulses
1+
Weak/barely palpable
2+
Normal/easily palpable
3+
Full pulse/increased
4+
Strong/bounding
Respiratory System
Oxygen therapy is prescribed at the lowest flow rate needed to manage
hypoxemia.
Tuberculosis:
Caused by Mycobacterium tuberculosis
Tuberculin Skin Test is assessed 48-72 hours post administration
Negative: redness without induration
Positive: induration > 15 mm in healthy individuals, OR induration > 10 mm in
immunocompromised pts (e.g. children under 4, IV drug users, recent immigrant from
high prevalence TB country, homeless), OR induration > 5 mm in high risk patients (e.g.
HIV, organ transplant patient s, recent contact with TB person)
Positive and NO SYMPTOMS OF TB  Chest x-ray to be done
Positive and SYMPTOMATIC OF TB  sputum culture to be collected
Latent TB
Asymptomatic, no TB transmission, normal CXR, no sputum needed to be collected
Active TB
Cough, fever, chills, weight loss, anorexia, fatigue, TB can be transmitted, abnormal CXR,
positive sputum culture
S/S: fatigue, lethargy, anorexia, weight loss, chills, fever, chest pain
Priority: 1. Droplet precautions (N95 mask) 2. 6 air exchanges per hour 3. Patient to wear
mask if leaving room
Ventilator Alarms:
High pressure: increased secretions, tube kink, patient biting on tube or coughing
Low pressure: tube disconnected, patient stopped breathing
Flail Chest:
S/S: paradoxical respirations (chest moves in with inspiration and out with expiration;
opposite of normal), severe
pain, SOB, cyanosis, tachycardia, hypotension, increased RR, decreased lung sounds
Priority: 1. Fowler’s position 2. Provide supplemental O2 3. Coughing + deep breathing 4.
Analgesics 5. Bed rest 6. Prep for intubation
Influenza:
Viral respiratory infection
S/S: acute fever, headache, fatigue, sore throat, cough
Priority: 1. Monitor lung sounds 2. Rest 3. Fluid intake 4. Administer antivirals,
antipyretics
Pneumothorax (Collapsed Lung):
Air in pleural space = lung collapses and can push heart and its associated blood vessels
towards the other lung
Open pneumothorax: opening in chest wall allows entrance of air into the pleural space
Tension pneumothorax: blunt chest injury
S/S: no breath sounds on affected side, cyanosis, SOB, hypotension, chest pain,
subcutaneous emphysema (crepitus
on palpation), sucking sound (with open chest wound), tachycardia, increased
respirations, tracheal deviation to unaffected side (with tension pneumothorax)
Priority: 1. Nonporous dressing over an open chest wound 2. Apply O2 as prescribe 3.
Place patient in Fowler’s position 4. Prepare for chest tube insertion 5. Monitor chest tube
drainage system
Asthma:
Airway inflammation + hyperresponsiveness to stimuli (e.g. allergens, animals,
environmental change exercise, irritants) leading to smooth muscle constriction, mucus
secretion, obstruction of airways, air trapping, respiratory acidosis, and hypoxemia
S/S: wheezing, SOB, coughing, chest tightness
*Status asthmaticus life threatening emergency
Priority: 1. Keep airway patent 2. Administer systemic corticosteroids (e.g. prednisone,
methylprednisolone)
COPD:
disease state characterized by airflow obstruction caused by emphysema (damaged
alveoli) or chronic bronchitis (airway swollen & filled with mucous).
S/S: cough, SOB, wheezing & crackles, weight loss, barrel chest, orthopnea, hyperinflation
of chest, ABG shows respiratory acidosis & hypoxemia
Remember that a normal SPO2 is 88-92%; do not try to raise the SPO2 level higher than
this (a lower SPO2 level is what stimulates a COPD patient to breathe!)
Administer bronchodilators as prescribed
Clients with chronic obstructive lung disease are at risk for oxygen induced hypercapnia.
The Venturi mask is preferred over the nasal cannula, because it delivers more precise
oxygen levels; however some clients do not tolerate having a facemask.
Pneumonia:
Acute inflammation of the air sacs in one or both lungs due to bacterial, viral, fungal
infection
Sputum Culture and Sensitivity test will identify the organism
Pneumococcal or streptococcal pneumonia, caused by Streptococcus pneumoniae, is
the most common cause of community-acquired pneumonia.
Aspiration pneumonia: can occur in a community or health care facility setting and
results from inhalation of foreign matter, such as vomitus or food particles, into the
bronchi (most common in older patients, patients with a decreased
level of consciousness, and those receiving nasogastric tube feedings)
S/S: chills, elevated temperature fever, pleuritic pain (pain that is sharp and increases
during inspiration), tachypnea, wheeze, accessory muscle use with breathing, mental
status change, sputum production. Elderly clients with pneumonia may first appear
with only an altered mental status and dehydration due to a blunted immune
response.
Priority: 1. Droplet precautions 2. Supplemental O2 3. Monitor LOC 4. Deep breathing +
coughing 5. Semi-fowlers to assist with breathing 6. Chest physiotherapy to mobilize
secretions 7. Fluid intake to thin the secretions 8. Antibiotic administration
Individuals 65 years of age and older and those with chronic health conditions should take
the pneumonia vaccine. The PPV23 vaccine contains antigens from 23 different types of
pneumonia organisms.
Some medications used in the treatment of pneumonia require special
attention:
1. Tetracycline—Should not be given to women who are pregnant or to small children
because of the damage it can cause to developing teeth and bones.
2. Gentamicin —An aminoglycoside, it is both ototoxic and nephrotoxic. It is important to
monitor the client for signs of toxicity. Serum peak and trough levels are obtained
according to hospital protocol. Peak levels for Gentamicin are drawn 30 minutes after the
third or fourth IV or IM dose. Trough levels for Gentamicin is drawn 30 minutes before the
third or fourth IV or IM dose. The therapeutic range for Gentamicin is 4–10 mcg/mL.
There is limited drug therapy for multidrug-resistant TB (MDR TB) and extremely
drug-resistant TB (XDR TB). Sirturo (Bedaquiline), Pyrazinamide, and Moxifloxacin
has been approved for treating MDR TB. Clients with drug-resistant TB usually
require higher doses for longer periods of time than those without drug resistant
TB.
Streptokinase, an older thrombolytic, is made from beta strep; therefore, clients
with a history of beta strep infections might respond poorly to therapy with
streptokinase, because they might have formed antibodies. Streptokinase is not
clot specific; therefore, the client might develop a tendency to bleed from incision
or injection sites. Streptokinase is no longer marketed in the United States.
A similar disease to SARS, Middle Eastern Respiratory Syndrome (MERS) is caused
by MERS CoV. Although SARS is more contagious, MERS has a higher mortality rate.
Pleural Effusion:
Collection of fluid in pleural space
S/S: pleuritic pain that is sharp and increases with inspiration, SOB, nonproductive cough,
tachycardia, fever, decreased breath sounds over area
Priority: 1. Prep patient for thoracentesis 2. Keep patient in Fowlers 3. Monitor breath
sounds 4. Encourage coughing and deep breathing
Empyema:
Collection of pus in the pleural cavity, the pus is thick, foul smelling, and opaque
Priority: 1. Treat infection 2. High Fowler’s Position 3. Prepare for thoracentesis 4.
Encourage patient to splint the chest when needed
Pulmonary Embolism:
When a thrombus lodges in the branch of the pulmonary artery (can also be due to fat
emboli from fracture of a long bone)
S/S: blood-tinged sputum, chest pain, cough, cyanosis, JVD, SOB, feeling of impending
doom, hypotension, tachypnea, tachycardia
Priority: 1. HOB elevated 2. Administer O2 3. ABG 4. Anticoagulants (Heparin)
Fat emboli are associated with fracture of long bones (such as a fractured femur);
most fractured femurs occur in young men 18–25, the age of most football players
Remember the three Fs associated with fat emboli:
1. Fat
2. Femur
3. Football player
Respiratory Need to Know
Atelectasis
1. develops when there’s interference with the normal negative pressure that
promotes lung expansion.
2. the most common respiratory disorder to occur in the first 24 to 48 hours
after surgery.
Emphysema
1. In emphysema, the wall integrity of the individual air sacs is damaged,
reducing the surface area available or gas exchange.
2. Because of the large amount of energy it takes to breathe, clients with
emphysema are usually cachectic.
3. A client with emphysema should receive only 1 to 3 L/minute of oxygen, if
needed, or he may lose his hypoxic drive.
Positive end-expiratory pressure (PEEP) delivers positive pressure to the lung at
the end of expiration, helps open collapsed alveoli, and helps them stay open so
gas exchange can occur in these newly opened alveoli, improving oxygenation.
The continuous positive airway pressure (CPAP) mask provides pressurized
oxygen continuously through both inspiration and expiration; the client has less
resistance to overcome in taking in his next breath, making it easier to breathe.
Continuous positive airway pressure (CPAP) can be provided through an oxygen
mask to improve oxygenation in hypoxic clients.
Bilevel positive airway pressure (BiPAP) delivers both continuous positive airway
pressure (CPAP) and positive end-expiratory pressure (PEEP).
Bilevel positive airway pressure (BiPAP) provides the differing pressures
throughout the respiratory cycle, attempting to optimize a client’s oxygenation and
ventilation.
Inspiratory and expiratory pressures are set separately to optimize the client’s
ventilatory status in bilevel positive airway pressure (BiPAP).
The fraction of inspired oxygen is adjusted to optimize oxygenation in bilevel
positive airway pressure (BiPAP).
Gastrointestinal
Vomiting:
Puts patient at risk of dehydration, electrolyte imbalance, metabolic alkalosis, aspiration,
and pneumonia
Projectile vomiting = pyloric stenosis or increased ICP
Priority: 1. NPO 2. IV fluids
Diarrhea:
Puts patient at risk of dehydration, electrolyte imbalance, and metabolic acidosis
Constipation:
Priority: 1. Ambulate as tolerated (increases peristalsis) 2. High fiber diet (softens stool) 3.
Drink 2-3 L/day 4. Bowel regimen 5. Avoid caffeine (promotes diuresis which causes
dehydration)
Retroperitoneal Hemorrhage:
S/S: hypoT, back pain, Grey-Turner sign, hematoma, decreased distal pulses
Colostomy:
Priority: 1. Keep liquid stool from leaking out (causes skin irritation due to the digestive
enzymes) 2. Change bag q5-10 days 3. Increase fluid intake to prevent dehydration 4.
Empty bag when 1/3 full
Colonoscopy:
A colonoscopy evaluates colonic mucosa. Therefore, clients should follow instructions to
keep the colon clean with no stool left for better visualization during the procedure.
The instructions included:
1. Clear liquid diet the day before
2. Nothing by mouth 8 to 12 hours prior to the examination
3. The HCP prescribes a bowel cleansing agent such as cathartic, enema or polyethylene
glycol the day before the test.
A risk of colonoscopy is perforation. Signs of perforation include abdominal pain (w/
shoulder tip pain), positive rebound tenderness, guarding, abdominal distention,
tenesmus, and/or board like (rigid) abdomen. Another potential complication is recital
bleeding
Ileostomy:
An ileostomy is a surgical procedure that creates and opening (stoma) in the abdominal
wall that originated from the intestinal mucosa of the ileum. The normal functions of the
large intestine (fluid and electrolyte absorption, vitamin K production) are circumvented,
resulting in liquid draining from the stoma into a pouching device attached to the
abdominal skin.
Ulcerative Colitis
Chron’s Disease
Chronic inflammation leading to poor
absorption of nutrients.
Begins in rectum and spreads upward
Colon is edematous + bleeding lesions
form
S/S: frequent bloody diarrhea, abdominal
pain, fever, fatigue, weight loss
Priority: 1. NPO 2. IV fluids 3. Monitor
stools 4. A low-residue, high-protein,
high-calorie diet
Inflammation that can occur anywhere in
GI tract
S/S: fever, cramps, diarrhea, weight loss,
dehydration During acute episode,
priorities are same as UC.
Because Crohn disease has a higher
incidence in siblings, it may have a
genetic cause.
Bowel Perforation:
S/S: abdominal guarding + pain + distention, fever, pale, tachycardia + tachypnea
Paracentesis:
Removal of fluid from peritoneal cavity, performed @ bedside (patient is in upright
position at edge of bed)
Priority: 1. VS + weight pre-procedure 2. Have patient void 3. Upright position 4. Dry
sterile dressing @ puncture site 5. Measure fluid removed
GERD:
Heartburn, epigastric pain, dyspepsia, nausea + vomiting, pain with swallowing Have
patient avoid peppermint, chocolate, coffee, fried foods, carbonated drinks, and
alcohol (irritants)
*Antacids, H2 receptor antagonists, or PPIs are given as medication
Diverticulosis:
Diverticular disease of the colon is a condition in which there are sac-like
protrusions in the large intestine (diverticula).
Usually discovered during colonoscopy; asymptomatic and no treatment needed Can
develop into diverticulitis  treated with antibiotics and clear liquid diet
ERCP:
Examination of hepatobiliary system with endoscope down the esophagus
Prep: NPO before procedure
Post procedure: monitor for return of gag reflex and for signs of perforation
A PEG tube is inserted via minor surgical procedure in which the tube passes through the
stomach to the abdominal wall. There are internal and external bumpers to told the tube
in place. The tract created starts to mature in 1 to 2 weeks but is not completely formed
for 4 to 6 weeks. Dislodging before the tract matures can result in gastric contents
spilling into the intraperitoneal cavity. If dislodgement occurs a repeat procedure must be
done.
Cholecystitis is inflammation of the gall bladder. Symptoms include pain in the Right
Upper Quadrant with referred pain to the right should and scapula. Clients often report
eating fatty food prior to the onset of the pain.
Peptic Ulcer Disease:
IF PUD is gastric- hematemesis, if PUD is duodenal - melena stool
Esophageal Varices:
Monitor for rupture and hemorrhage life threatening*
Enteral Feeding:
Abdominal cramping can occur if feed is too fast or too cold
Priority: 1. HOB @ 30-45 degrees pre+post feed 2. Tube flushes pre+post feed 3. Assess
bowel function
Dysphagia:
Patient is at an increased risk of aspiration pneumonia
Priority: 1. Thickened liquids 2. HOB in high fowlers 30 mins post-meal 3. Swallow twice
before another bite 4. Avoid OTC cold medications (they have anticholinergic effects
decrease saliva)
Gastritis:
Acute gastritis = Stomach inflammation due to contaminated food
S/S: abdominal discomfort, nausea, vomiting, headache, reflux
Chronic gastritis = due to H. pylori
S/S: nausea, vomiting, heartburn, sour taste in mouth, Vit B12 deficiency
Priority: 1. NPO 2. Avoid irritating foods (spicy food, caffeine, alcohol) 3. Take antibiotics
and antacids
Dumping Syndrome:
Rapid emptying of gastric content into S.I after a gastric resection
S/S will occur 30 mins after eating: nausea, vomiting, abdominal cramps, diarrhea,
tachycardia, weakness/dizzy, borborygmic (loud gurgling abdominal sound)
Priority: 1. Eat small meals and avoid fluids while eating 2. Lie down after meals 3. Avoid
sugar, salt, and milk 4. Eat high protein, high fat, and low carbs
Cholecystitis:
Acute (associated with gallstones) or chronic (due to inefficient bile emptying)
inflammation of gallbladder
S/S: nausea, vomiting, flatulence, *epigastric pain radiating to R scapula 2-4 hrs after fatty
food, RUQ pain, guarding, rebound tenderness, mass in RUQ, * Murphy’s sign (cannot
take a deep breath because of pain when fingers are pressed on hepatic margin),
tachycardia
Obstruction in gallbladder = jaundice, orange urine, steatorrhea + clay colored stool,
pruritis
Priority: 1. NPO 2. NG decompression 3. Eat small, low fat meals
Cirrhosis:
Destruction of hepatocytes = scar tissue formation
Complications: portal HTN (due to flow obstruction), ascites (due to congested hepatic
capillaries that leads to plasma leakage), bleeding esophageal varices, jaundice (liver
cannot metabolize bilirubin), portal systemic encephalopathy (change in LOC due to
failure of liver to detoxify ammonia - a neurotoxic agent)
Priority: 1. Provide vitamin supplements 2. Restrict sodium and fluid intake 3. Enteral or
parenteral feeds 4. Diuretic medications for ascites 5. Weigh patient daily 6. Monitor LOC
7. Administer lactulose (facilitates excretion of ammonia) 8. Administer antibiotics (inhibits
synthesis in bacteria and decreases ammonia production) 9. Avoid opioids and sedatives
10. Teach importance of alcohol abstinence 11. Monitor ammonia levels 12. To help with
pruritis: cut nails short, calamine lotion, cool/wet cloths, cholestyramine, avoid hot
showers
Appendicitis:
*Rupture can occur quickly = leads to peritonitis and sepsis
S/S: pain in periumbilical area radiating to RLQ, abdominal pain at McBurney’s point,
abdominal rigidity, fever, nausea/vomiting, abdominal guarding
Priority: 1. NPO 2. IV fluids to prevent dehydration 3. Do not palpate or apply heat to
abdominal (increases risk of rupture = peritonitis) 4. Apply ice packs 5. Avoid
laxatives/enemas The focus of care for the client with appendicitis is to assess for
peritonitis. Peritonitis is an inflammation of the peritoneal cavity. Peritonitis is most
commonly caused by appendix rupture and invasion of bacteria, which could be
lethal. In the acute phase of appendicitis, management should focus on minimizing
preoperative complications and recognizing when they may be occurring.
Irritable Bowel Syndrome:
Chronic uncontrolled inflammation causing edema, ulcers, bleeding, and extreme fluid
loss
S/S: abdominal cramps, pain, diarrhea, dehydration, weight loss/cachexia, anemia (due to
active bleeding), 5-10 diarrhea BM/day
Priority: 1. Monitor hgb 2. Monitor intake + output
Acute Pancreatitis:
Sudden inflammation causing mild-severe discomfort
S/S: Cullen’s sign (discolored abdominal and periumbilical area), Turner’s sign (blue
discoloring of flanks)
Priority: 1. NPO 2. NG tube to suction 3. Parenteral nutrition 4. Avoid alcohol
Total Parenteral Nutrition:
Avoid stopping it abruptly as it can lead to hypoglycemia
Priority: 1. Monitor CBG (glucose is main component of TPN) 2.
Monitor S/S of hyperglycemia (polyphagia, polydipsia, polyuria)
ALT and AST:
Enzymes released when hepatic cells are inured
Small Bowel Obstructions
Large Bowel Obstruction
Rapid onset nausea + vomiting,
Gradual onset of S/S, cramping abdominal
intermittent abdominal pain,
pain, abdominal
abdominal distention
distention, complete constipation, no flatus
Priority: 1. NPO 2. NG tube insertion 3. IV fluids 4. Manage pain
Paralytic Ileus:
Temporary halting of peristalsis for 24-48 hours after a bowel procedure (no bowel
sounds will be auscultated)
Characteristics of Stool
Possible Etiology
Small, dry, rocky hard masses
Constipation
Mucus or pus
Biliary obstruction
Greasy, foamy, foul smelling, fatty Chronic pancreatitis
Light grey colored
Biliary obstruction
Black tarry
Upper GI bleed
Blood on surface of stool
Hemorrhoids
Bright red bloody
Lolwer GI beed
Cardiovascular
Angina:
Stable chest pain with exertion/activity, relieved with rest or nitro.
Unstable chest pain that is unpredictable, may or may not be relieved with nitro
Variant/Prinzmetal’s--chest pain due to coronary artery spasm, may occur @ rest
Myocardial Infarction:
S/S: chest pain/pressure, diaphoresis, dyspnea, anxiety
Female-specific S/S: fatigue, indigestion, shoulder or jaw pain
Acute MI = ST elevation in localized leads
Priority: 1. ABC, VS assessment 2. ECG + cardiac marker bloodwork 3. O2 if needed 4.
Nitroglycerin, morphine
Percutaneous Coronary Intervention:
Catheter inserted into femoral or radial vein and advanced into the pulmonary artery to
obtain information about the structure and performance of the chambers, valves, and
coronary circulation Procedure will improve coronary artery patency + increase cardiac
perfusion
Complications: thrombosis, stent occlusion, hematoma, limb ischemia
Peripheral Artery Disease
Decreased blood flow to lower extremities
due to atherosclerosis
Intermittent claudication (muscle pain), hair
loss, decreased peripheral pulses, cool + dry
skin, gangrene, thick nails, ulcers
Coronary Artery Disease
Obstruction/narrowing of a coronary artery due
to atherosclerosis
Chest pain, palpitations, SOB, syncope, fatigue,
cough
Mechanical Valves:
Pt needs to be on lifetime anticoagulant therapy to avoid thromboembolism
Cardiac Electrical Activity:
SA node
Main pacemaker initiating every heartbeat
Generates impulses 60-100 beats per minute
AV node
Receives impulse from SA node
If SA node does not work, then AV node will take over and
sustain a HR of 40-60 beats per minute
Bundle of His
Separates into left and right bundle branches, located in the
ventricles
Can act as the pacemaker of the heart if SA and AV node fail; HR
between 20-40 beats per minute
Pacemaker:
Device that provides electrical stimulation to maintain HR when pts intrinsic pacemaker
(SA node) fails to provide a rhythm
Vertical spike will appear on ECG indicating a pacing stimulus (spike before p wave = atrial
pacing, spike before QRS complex= ventricular pacing)
Priority: 1. Report swelling/redness/drainage 2. Teach patient how to take pulse; tell them
to notify MD if pulse is too
low 3. No cellphone over the site 4. No MRIs 5. Microwaves are safe 6. Avoid heavy lifting
after surgery
Congestive Heart Failure:
Heart unable to meet metabolic needs of the body due to pumping issue - blood backs
up into lungs (left sided HF) and/or body (R sided HF)
Left Sided Heart Failure
Right Sided Heart Failure
Shortness of breath, cough, crackles,
Fatigue, ascites, enlarged liver and
wheezes, blood-tinged sputum,
spleen, distended jugular veins,
tachypnea, restlessness, confusion,
anorexia & complaints of GI distress,
orthopnea, tachycardia, fatigue,
weight gain, dependent edema
cyanosis
Priority: 1. High Fowlers 2. Supplemental O2 3. Administer diuretics 4. Monitor output 5.
Fluid and sodium restriction 6. Monitor weight daily 7. Monitor number of pillows used to
facilitate breathing while sleeping
Mean Arterial Pressure (MAP):
Average pressure in systemic circulation; calculated by: SBP + (DBP x 2) /3
Normal MAP = between 60-70 for proper organ perfusion
Low MAP = organs are under perfused and can become ischemic
Central Venous Pressure (CVP):
Measurement of R ventricular preload
Normal CVP = 2-8 mmHg
High CVP = volume over load (S/S: edema, weight gain, tachypnea, crackles, bounding
pulse)
Cardiac Tamponade:
Fluid accumulation in the pericardium
S/S: pulsus paradoxus, high CVP, JVD with clear lungs, muffled heart sounds, low cardiac
output, narrow pulse pressure
Priority: 1. IV fluids 2. Pericardiocentesis
Cardiac Inflammation:
Pericarditis
Inflammation of
pericardium, causing
compression of the heart
S/S: sharp pleuritic chest
pain that’s worse
during inspiration +
coughing (and relieved
when leaning forward),
pericardial friction
rub, fever, fatigue
Acute pericarditis = ST
elevation in all leads
Priority: 1. High Fowlers 2.
Pain meds, NSAIDS,
ABX administration 3.
Monitor for tamponade
(pulsus paradoxus, JVD,
narrow pulse pressure,
tachycardia, muffled heart
sounds)
Myocarditis
Inflammation of myocardium
Endocarditis
Inflammation of lining of heart
+ valves
S/S: Fever, pericardial friction
rub, murmur, S/S of CHF,
fatigue, tachycardia, chest pain
S/S: Fever, weight loss, fatigue,
murmur, CHF, petechiae +
splinter hemorrhages in nail
beds, clubbing of fingers
Priority: 1. O2 if needed 2.
Periods of rest 3. Avoid
overexertion 4. Pain meds, antidysrhythmics, ABX
Priority: 1. Rest 2. TEDs 3.
Monitor for S/S of
emboli/thrombus 4.ABX
Thrombus Formation:
Venous stasis, hypercoagulability, injury to venous wall, pregnancy, ulcerative colitis, oral
contraceptive use, fractures
BNP:
BNP > 100 = patient is in heart failure
BNP is produced when ventricles stretch from high blood volume, and when there are
high levels of extracellular fluid
Shock:
Hypotension, tachycardia, weak/thread pulse
Hypertensive Crisis can cause organ damage and is to be treated immediately
S/S: headache, confusion, change in vision, change in LOC, tachycardia, tachypnea,
cyanosis
DVT:
Presents as warm skin + calf or groin pain with or without swelling
Risk factors - Virchow’s Triad (decreased flow/stasis, endothelial damage,
hypercoagulable state)
Priority: 1. Elevate extremity 2. Avoid pillow under knees 3. Do not massage the area 4.
Apply anti embolism stockings 5. Measure circumference of thigh or calf 5. Apply warm,
moist compress as needed 6. Antithrombolytics 7. Avoid prolonged sitting
T.E.D. (ThromboEmbolic-Deterrent) anti-embolism stockings – provide
continuous pressure to the lower extremities to keep blood from pooling and
blood clots from developing in the deep veins of the lower extremities.
Available in knee length or thigh length. Priority: 1. Proper fit 2. No folds or
wrinkles 3. Wounds are covered with dressings
Defibrillation:
Synchronizer switch must be turned on
Cardioversion shock must be delivered on R wave (if delivered on T wave = can lead to a
lethal arrhythmia)
Atrial Fibrillation is a cardiac arrythmia characterized by disorganized electrical activity in
the atria and an irregular pulse rate. Clients may experience this condition chronically or
in response to other medical conditions (e.g. electrolyte
imbalance)
Results in: decreased CO, d/t loss of atrial kick and/or a rapid ventricular response. Clots
may form in the atria, putting
the client at an increased risk of stroke.
Treatment: rate control, and anticoagulation.
Atrial Flutter
Recurring, regular, saw-toothed shaped flutter waves.
Ventricular Fibrillation is a lethal arrythmia characterized by disorganized electrical
activity in the heart ventricles. Because of this erratic electrical activity the heart’s muscle
lose the ability to contract, result in loss of blood flow and pulse (eg cardiac arrest). Nurse
who identity VF should immediately check the pulse, start CPR, and prepare the client for
defibrillation
Ventricular tachycardia is a potentially lethal dysrhythmias characterized by organized
rapid firing activity within the ventricles may impair perfusion and often leads to cardiac
arrest or ventricular fibrillation.
Asystole Total absence of ventricular electrical activity (pulseless, apneic, unresponsive)
Treatment: CPR, ACLS, epinephrine and/or vasopressin, advanced airway use, and any
reversible treatment.
Torsades des pointes (i.e. twisting of the points) is a polymorphic ventricular tachycardia
characterized by QRS complexes that change in size and shape in a characteristic twisting
pattern. Torsades de pointes is usually due to a prolonged QT interval (more than half the
RR interval) which is the result of electrolyte imbalances, especially hypomagnesemia or
some medications. The first line treatment is IV magnesium. Treatment may also include
defibrillation and discontinuation of any QT prolonging medications.
Integumentary
Impetigo:
Bacterial infection of skin caused by group A Streptococcus and Staphylococcus aureus. It
can occur anywhere on the body.
S/S: vesicle/pustule that progresses to an exudative lesion with honey-colored crusts,
burning, pruritis
Priority: 1. Contact precautions (*highly contagious) 2. Keep lesion open to air; let it dry
out 3. Daily bathing 4. Warm saline compress to lesion 2-3/day 5. Topic and oral ABX 6.
Proper hand hygiene 7. Use separate towels/linens for patient
Lice:
S/S: frequent scratching of scalp, visible nits in hair (can range in color from white to
brown)
Priority: 1. Pediculicide 2. Fine tooth comb to remove nits 3. Change + clean clothing and
linen daily 4. No sharing of clothing, hats, or brushes
Psoriasis: Autoimmune Disorder; chronic, noninfectious skin inflammation
involving keratin synthesis that results in psoriatic patches
S/S: Shedding, silvery, white scales on a raised, reddened, round plaque that usually
affects the scalp, knees, elbows, extensor surfaces of arms and legs, and sacral
regions
Priority: 1. Provide emotional support to patient 2. Tell patient to avoid
alcohol. 3. Reinforce instructions to the client to wear light cotton clothing over
affected areas. 4. Assist the client with identifying ways to reduce stress if stress is a
predisposing factor. Treatment: Topical corticosteroids, Photo Therapy, Medication
(Methotrexate)
Herpes Zoster (Shingles)
With a history of chickenpox, shingles is caused by the reactivation of the varicella
zoster virus; shingles can occur during any immunocompromised state in a client
with a history of chickenpox.
S/S: 1. Unilaterally clustered skin vesicles along peripheral sensory nerves on the
trunk, thorax, or face 2. Fever, malaise 3. Burning and pain 4. Pruritus 5. Paresthesia
Priority: 1. Standard precautions and other precautions as appropriate such as
contact/airborne as long as vesicles are present 2. Keep patient from scratching 3.
Assess neurovascular status and seventh cranial nerve function; Bell’s palsy is a
complication. 4. Use an air mattress and bed cradle on the client’s bed if
hospitalized, and keep the environment cool; warmth and touch aggravate the
pain.
Bell’s Palsy: caused by inflammation of cranial nerve VII
Stage One
Stage Two
Pressure Ulcer Stages
Skin intact non-blanchable with local
redness
Open, shallow, red/pink color,
noslough, intact
Stage Three
or open blister
Full thickness skin loss, possible visible
Stage Four
fat, NO bone/muscle showing
Full thickness skin loss with bone,
Unstageable
tendon, or muscle showing
Full thickness with slough
(scabbing) or eschar (necrotic tissue)
Type of Wound
Serous
Fibrinous
Serosanguineous
Sanguineous
Seropurulent
Purulent
Hemorrhagic
Appearance
Clear, Amber, Thin and Watery; part of
normal healing process
Cloudy and thin with strands of fibrin
Clear, pink, thin and watery
Reddish (blood vessel trauma), thin and
watery- uncommon in wounds
Yellow or tan, cloudy and thick
Opaque, milky; sometimes green - due to
infection
Red, thick blood leaking from vessel;
uncommon
Superficial-thickness burn
Burns
damage to epidermis the blood supply to the
dermis is still intact; pink/red with no blisters;
discomfort lasts about 48 hours heals in 3-6
Superficial partial-thickness
burn
days; no scarring
damage into the dermis blood supply to the
dermis is reduced; Mottled pink to red base and a
broken epidermis, with a wet, shiny, and weeping
surface is characteristic.; heals in 10-
Deep partial-thickness burn
21 days
Extends deeper into the dermis. Wound surface is
red and dry with white areas in deeper
Full-thickness burn
parts. Heals in 3-6 weeks.
Destruction of the epidermis and the dermis;
grafting may be required. Appears dry, waxy
white, deep red, yellow, brown, or black.
Sensation is reduced or absent because of nerve
ending destruction. Healing weeks to months.
Deep full-thickness burn
injury extends to muscle/bone/tendons; skin is black
and hard; healing takes months (involves
Priority for Burn Patients
skin grafting)
AIRWAY---IV fluid replacement to prevent shock-Assess for S/S of infection (fever, high WBC,
purulent drainage , redness)-keep
patient warm
Immune
HIV:
Standard precautions are used; HIV is spread only when nonintact skin is in contact
with pts blood, breast milk, semen, vaginal secretions
Priority: 1. Protect patient from infection 2. Aseptic technique for all procedures
AIDS:
Viral disease due to HIV (T cells are destroyed  patient is at high risk for infection
and malignancy) Incubation period can be up to 10 years
S/S: low WBC, low plt, low CD4, high CD8, high IgG + IgA, weakness, fever, weight
loss, leukopenia, night sweats, infections, neoplasms (Kapos infections, vital
infections, bacterial infections
High risk: hetero or homosexuals involved with high-risk person, IV drug user,
patient receiving blood products, healthcare workers, babies born to infected mom
Priority: 1. O2 as needed 2. Monitor for infection 3. Standard precautions
4. Meticulous skin care
Sjogren's syndrome is an autoimmune condition. It causes inflammation of the
exocrine glands (e.g., lacrimal, salivary), resulting in decreased production of
tears and saliva and leading to dry eyes (xerophthalmia) and dry mouth
(xerostomia).
Treatment with over-the-counter, preservative-free artificial tears can relieve eye
dryness, burning, itching, irritation, pain, and a gritty sensation in the eyes.
Wearing goggles can protect the eyes from outdoor wind and dust. Dry mouth is
treated with artificial saliva. Using a room humidifier and not sitting in front of fans
and air vents can also help
Anaphylaxis:
Immediate hypersensitivity reaction with release of histamine
S/S: dizzy, paresthesia, pruritis, angioedema, urticaria, narrowing airway, wheezing,
stridor, SOB, respiratory arrest, hypotension, tachycardia, cardiac arrest, abdominal
pain, nausea + vomiting
Priority: 1. Patent airway 2. O2 administration 3. IV normal saline infusion 4.
Prepare diphenhydramine and epinephrine
Scleroderma:
Inflammation, fibrosis, and sclerosis of connective tissue; no cure
S/S: pain, stiff muscles, pitting edema, tight, shiny, thick, and hard skin, dysphagia,
contractures
Renal crisis is a life-threatening complication causes HTN due to narrowing of
blood vessels going to kidney
SLE:
S/S: butterfly rash, dry rash on upper body, fever, weakness, weight loss,
photosensitivity, joint pain, red palms, anemia
Priority: 1. Mild soap on skin 2. Frequent oral care 3. High vitamin and iron diet 4.
Conserve energy and avoid direct sunlight exposure 5. Topical corticosteroids
Lyme Disease:
Due to Borrelia burgdorferi from tick bites
S/S: ring shaped rash (can occur anywhere on body, not only @ site of bite)
Priority: 1. Remove tick 2. Antibiotic administration 3. Have patient avoid woody
areas 4. Have patient wear long sleeved tops and long pants when outside 5. Use
tick repellent
Immunoglobulins
IgA viral protection
IgD unknown function
IgE allergy + parasitic infestation
IgG secondary antibody protection
IgM primary antibody protection
EYE
Snellen test— test of visual acuity
 Client stands 20 ft from chart of letters
 One eye is covered at a time
 Client reads chart to smallest letter visible
 Test results indicate comparison of distance at which this client reads to what normal eye sees
at 20 ft
Visually Impaired Patient
1. Knock on the door and ask to enter the room
2. Describe room layout to patient including dimensions
3. Place the phone and call bell beside the table within the patient's reach
4. When ambulating patient walk slightly in front of them while they hold your
arm. Ask the patient which side they would like you to stand on.
5. Instruct other staff members to not move items around in the patient's room.
6. Use clock coordinates to describe the location of food on the plate and all items on the tray.
7. Stay in the patient's field of vision
8. Indicate to patient when you are leaving the room.
9. Describe any unusual noises or sounds to the patient
Eye Trauma
Nursing Considerations
Eye patch for 24 hours
Types
Nonpenetrating—abrasions
Nonpenetrating—contusions
Cold compresses, analgesics
Penetrating—pointed or sharp
Cover with patch; refer to surgeon
objects
Types
Chemical Acids, cleansers,
insecticides
Burns of the Eye
Nursing Considerations
Eye irrigation with copious amounts of
water for 15–20 min
Radiation Sun, lightning, eclipses
Prevention—use of eye shields
Thermal Hot metals, liquids,
other occupational hazards
Use of goggles to protect the cornea;
patching;
analgesics
Detached retina Separation of the retina from the choroid, caused by trauma, the aging process,
diabetes or a tumor
S/S: Flashes of light; Blurred or "sooty" vision, "floaters"; Sensation of particles moving in line of
vision; Delineated areas of vision blank; A feeling of a coating coming up or down; Loss of vision;
Confusion, apprehension
Treatment 1. Sedatives and tranquilizers 2. Surgery-retina to adhere to choroid
Priority: 1. Bedrest, do not bend forward, avoid excessive movements 2. Affected eye or both eyes
may be patched to decrease movement of eye(s) 3. Specific positioning-area of detachment should
be in the dependent position 4. Take precautions to avoid bumping head, moving eyes rapidly, or
rapidly jerking the head 5. Hair washing delayed for 1 week 6. Avoid strenuous activity for 3 months
Cataracts Partial or total opacity of the normally transparent crystalline lens, caused by
trauma, aging process, associated with diabetes mellitus, intraocular surgery and/or congenital
S/S: Objects appear distorted and blurred; Annoying glare; Pupil changes from black to gray to
milky white
Assessment Partial or total opacity of the normally transparent crystalline lens
Surgical management-laser surgery

Extracapsular extraction-cut through the anterior capsule to express the
opaque lens material

Intracapsular extraction (method of choice)-removal of entire lens and capsule

Lens implantation
Nursing management
Observe for postoperative complications!

Hemorrhage

Increased intraocular pressure

Slipped suture(s)

If lens implant, pupil should remain constricted; if aphakic, pupil remains dilated
Educate patient to:
Avoid straining and no heavy lifting
Bend from the knees only to pick things up
Instruct about instillation of eye drops, use of night shields
Protect eye from bright lights
Adjustments needed in perception if aphakic
Diversional activities
Glaucoma Abnormal increase in intraocular pressure leading to visual disability and blindness­
obstruction of outflow of aqueous humor
S/S: Cloudy, blurry, or loss of vision; Artificial lights appear to have rainbows or halos around
them; Loss of vision; Decreased peripheral vision; Pain, headache; Nausea, vomiting; Tonometer
readings exceed normal intraocular pressure (10-21 mmHg)
Types of Glaucoma
1. Angle-closure (closed angle); sudden onset, emergency- associated with ocular
diseases, trauma
Treatment of closed-angle glaucoma
a. Medications-miotics, carbonic anhydrase inhibitors, oral glycerin (Osmoglyn) and
mannitol
b. Surgery
2. Open-angle (primary); most common; blockage of aqueous humor flow- associated
with aging, heredity, retinal vein occlusion
Treatment of open-angle glaucoma
a. Medications-miotics, carbonic anhydrase inhibitors, anticholinesterase betablocking agents, adrenergic agonists, prostaglandin agonists
b. Surgery-laser trabeculoplasty, standard glaucoma surgery
Nursing management of Glaucoma Clients

Compliance with medical therapy

Avoid tight clothing (e.g., collars)

Reduce external stimuli

Avoid heavy lifting, straining at stool

Avoid use of mydriatics
Educate public to five danger signs of glaucoma:
1) Brow arching
2) Halos around lights
3) Blurry vision
4) Diminished peripheral vision
5) Headache or eye pain
CARE FOR THE CLIENT UNDERGOING EYE SURGERY
Preoperative care
1) Assessment of visual acuity
2) Preparation of periorbital area
3) Orientation to surroundings
4) Preoperative teaching—prepare for postoperative course
5) Teach postop necessity to avoid straining with stool, stooping
Postoperative care
1) Observe for complications—hemorrhage, sharp pain, infection
2) Avoid sneezing, coughing, straining with stool, bending down
3) Protect from injury; restrict activity
4) Keep signal bell within reach
5) Administer medications as ordered; medication for nausea, vomiting, restlessness
6) Shield worn for protective purposes
7) Discharge teaching—avoid stooping or straining at stool; use proper body mechanics
Mental Health
Bipolar:
Bipolar I (sustained mania with depressive episodes)
Bipolar II (at least one major depression episode with at least one hypomanic
episode)
Patients with bipolar disorder experience unusually intense emotional states that
occur in distinct periods called "mood episodes"
Schizophrenia:
A mental disorder where patients do not think clearly or act normally in social
situations and cannot differentiate between reality and fantasy and do not have
normal emotional responses. Schizophrenia is characterized by having two or more
symptoms a significant portion of the time over a period of one month.
Symptoms may include: delusions, hallucinations, disorganized speech,
disorganized behavior, and negative symptoms (loss of pleasure, flat affect, poor
grooming, poor social skills, and social withdrawal)
Delirium - an acute state of confusion that usually affects older adults following
surgery or a serious illness. A longer length of stay can oftentimes be associated
with an increase in mortality. Providing as much normalcy for these patients is
essential. Examples of this may include maintaining a sleep/wake cycle pattern,
reality orientation and maintaining a safe environment.
Dementia - a chronic state of confusion typically seen in elderly patients over time.
Interventions may include providing meaningful stimuli, maintaining a safe
environment, and avoiding stressful situations.
PTSD:
Stressors: natural disaster, terrorist attack, accident, rape/abuse, crime/violence
Depression:
Treatment: counseling, antidepressants, and ECT
If risk for harm exists: provide safety from suicidal actions, do not leave patient
alone for extended periods, if patient has suicidal plan have one-on-one
supervision and create a "no suicide" contract
ECT: causes a brief seizure within the brain. It is an effective treatment when no
other pharmacological methods of treating depression have worked
Personality Disorder:
Maladaptive behavior that can impair functioning+ relationships; patient lacks
insight into their behavior; can lead to a psychotic state
Cluster A: odd + eccentric (schizoid, schizotypal, and paranoid)
Cluster B: overemotional+ erratic (histrionic, narcissistic, antisocial, and borderline)
Cluster C: anxious+ fearful (OCD, avoidant, and dependent)
Agoraphobic fears: Its intense anxiety about being in a situation from which there
may be difficulty escaping in the event of a panic attack
Being outside home alone
Being in a crowd or standing in line
Traveling in a bus, train, car, ship, airplane
Being on a bridge or in a tunnel
Being in open spaces (parking lots, market places)
Being in enclosed spaces (theaters, concert halls, stores)
Critical Care
CPR:
CAB = compressions, airway, breathing
1. Determine unconsciousness
2. Check carotid pulse
3. Chest compressions
4. Open airway using head tilt chin lift
5. Check breathing + deliver breaths
Foreign Body Airway Obstruction:
Avoid blind finger sweeps risk of pushing object further into airway
1. Stand behind patient
2. Place your arms around patient’s waist
3. Make a fist
4. Place thumb side of fist above umbilicus (and below xiphoid)
5. 5 quick in + up thrusts (use chest thrusts for obese or pregnant patients)
For infant place patient over arm or on lap with head lower than trunk; 5 back slaps
with heel of hand in between shoulder blades, turn infant and perform 5 chest
thrusts, check for foreign object (only remove if visible)
Tracheostomy:
Inflated cuff = used for patients at risk of aspiration (e.g. unconscious or
mechanically ventilated patients); it is uncomfortable for patients who are awake
because it’s difficult to swallow/talk
Deflated cuff = used when patients improve and are not at risk for aspiration
When suctioning: pre-oxygenate with 100% O2, insert suction tube without suction
turned on, intermittent suctioning in circular motion during withdrawal, suction no
more than 10 seconds, wait 1-2 mins before suctioning again (patients will cough
when suction tube is inserted this is ok insert until resistance is felt)
Tracheostomy Care:
Priority: 1. Keep patient in semi-fowlers 2. Wear mask, goggles, and clean gloves 3.
Remove soiled dressing 4. Don sterile gloves 5. Remove old cannula + replace with
new one 6. Clean around stoma with sterile water, dry, and replace sterile gauze
Impaled Object:
To not manipulate/remove! Stabilize the object
Triage:
Red life-threatening injury that a patient may survive if treated within next hour
E.g.: hemothorax, tension pneumothorax, unstable chest and abdominal wounds,
incomplete amputations, open fracture of long bones, and 2nd/3rd degree burn
with 15%-40% of total body surface
Yellow patient can wait 1-2 hours without loss of life or limb
E.g.: Stable abdominal wounds without evidence of hemorrhage, fracture requiring
open reduction, debridement, external fixation, most eye and CNS injuries
Green “Walking Wounded”
E.g.: upper extremity fracture, minor burns, sprains, small lacerations, behavior
disorders
Black unlikely to survive
E.g.: Unresponsive, spinal cord injuries, 2nd/3rd degree burn with 60% of body
surface area, seizures, profound shock with multiple injuries, no pulse/BP, pupils
fixed or dilated
Sepsis:
SIRS inflammatory responses (fever, tachycardia, tachypnea)
Sepsis SIRS + infectious source (e.g. pneumonia, UTI)
Septic shock sepsis + hypotensive despite adequate IV fluids
MODS septic shock + multiple organ damage (e.g. ARDS, AKI, low plt)
Angioedema:
Rapid swelling of lips, tongue, throat, face, and larynx - can result in airway
obstruction and death
Post Mortem Care:
Wash body, change linens + gown, close eyes, place pillow under head, fold towel
under chin to help close mouth, replace dentures, remove lines/tubes/dressings,
place pad under perineum, straighten body/limbs, remove soiled linen
Leadership
Delegation, think PEAT do not delegate what you can PEAT!
P- plan
E- evaluate
A- asses
T-teach
LPN’s Scope of Practice vs RN
Registered Nurse






Clinical Assessment
Initial Client Education
Discharge Education
Clinical Judgement
Blood Transfusions
Psychosocial Support
Licensed Practical Nurse
 Education reinforcement to patient
 Catherization
 Medication Administration (there
are some exceptions such as
Heparin, LPNs DO NOT
administer Heparin or Blood
Products)
 Ostomy Care
 Tube patency and enteral
feedings
 Focused Assessments
Scope or Practice for UAP
 ADLs
 Hygiene
 Position Changes
 Linen Changes
 Vitals (patient must be stable!)
 Documentation of input and output
The LPN should be assigned to clients who are medically stable and have expected
outcomes. LPNs should not be assigned to clients who require complex care and clinical
judgment and have potential negative outcomes.
When taking the NCLEX PN teaching, assessment, clinical judgment, and evaluation of
a client are the responsibility of the RN and should never be delegated to the LPN.
Even thought you may do it as an LPN in the "NCLEX WORLD" you cannot do it.
Advanced Directives:
A written document by a competent person, regarding their health
care preference.An Advance Directive may include a living will and/or
a durable power of attorney for health care.
A living will is a written directive regarding the course,
continuation, or discontinuation of medical treatment in the event
that a person becomesincompetent.
A durable power of attorney for health care is a written designation
to authorizeone or more person(s) to make health care decisions in the
event of a person becoming incompetent to make their own decisions.
Informed consent is the legal obligation to provide full disclosure to
a patient regarding potential risks and outcomes of tests and
treatments. The obligation is operative in the development of the
Advance Directive because the corollary is theright not to consent to
treatment.
Fire Safety think "RACE"
R-rescue: protect/evacuate clients in danger
A-alarm: activate alarm/report the fire
C-contain: close doors/windows
E-Extinguish: use the correct extinguisher to eliminate the fire
Pediatrics
Growth and development
A strong hand grasp is demonstrated within the first month of life.
The Babinski reflex is present at birth and disappears at 1 year. The toes
hyperextend and fan out when the lateral surface of the sole is stroked in an
upward motion. Absent Babinski or a weak reflex may indicate a neurological
defect.
The triangular posterior fontanel normally closes between ages 2 and 3 months.
The palmar grasp reflex disappears around age 3 to 4 months.
The plantar grasp reflex disappears at age 6 to 8 months.
The Moro reflex disappears around age 4 months.
An infant holds on to furniture while walking (cruising) at 10 months, walks with
support at 11 months, and takes his first steps at 12 months.
The diamond-shaped anterior fontanel normally closes between ages 9 and 18
months.
Holding one object while looking for another is accomplished by the 20th week.
By 12 months, a child can say a few words, with more words and short phrases
being added each month.
At 16 months, a child engages in solitary play and has little interaction with other
children.
At age 3 months, the most primitive reflexes begin to disappear, except for the
protective and postural reflexes (blink, parachute, cough, swallow, and gag
reflexes), which remain for life.
At age 3 months, the infant reaches out voluntarily but is uncoordinated.
At 2 to 3 months of age, the infant begins to hold up his head, begins to put hand
to mouth, develops binocular vision, and cries to express needs.
The instinctual smile appears at 2 months and the social smile at 3 months.
At age 5 to 6 months, the infant rolls over from stomach to back, cries when the
parent leaves, attempts to crawl when prone, and voluntarily grasps and releases
objects.
Gross motor skills of the 6-month-old infant include rolling from front to back
and back to front.
Teething usually begins around age 6 months; therefore, offering a teething ring is
appropriate at this age.
Visual coordination is usually resolved by age 6 months.
At age 6 months, fine motor skills include purposeful grasps.
The 6-month-old infant should have good head control and should no longer
display head lag when pulled up to a sitting position.
At age 7 to 9 months, the infant can self-feed crackers and a bottle.
Fear of strangers appears to peak during the 8th month of age.
At age 10 to 12 months, birth weight triples and birth length increases about 50%.
The infant says “mama” and “dada” and responds to his own name at age 10
months. He can say about five words but understands many more.
The toddler period includes ages 1 to 3 and is a slow growth period with a weight
gain of 4 to 9 lb (2 to 4 kg) over 2 years.
The toddler uses at least 400 words as well as two- to three-word phrases and
comprehends many more by age 2; the toddler uses about 11,000 words by age 3.
the preschool child, is between ages 3 to 5 years.
the school-age child, is between ages 5 to 12 years
Accidents are a major cause of death and disability in children ages 5 to 12.
A child may regress in his or her behaviors when hospitalized.
Preschoolers see death as temporary, a type of sleep or separation.
Thinking about the future is typical of an adolescent facing death.
Ages 12 to 18 years encompass the adolescent period, which is a period of rapid
growth characterized by puberty-related changes in body structure and
psychosocial adjustment.
If you gave a toddler a choice about taking medicine and he says no, you should
leave the room and come back in five minutes, because to a toddler it is another
episode. Next time, don’t ask.
According to Piaget’s theory of cognitive development, an 8-month-old child will
look for an object after it disappears from sight to develop the cognitive skill of
object permanence.
During the school-age years, the most important social interactions typically are
those with peers, and children socialize more frequently with friends than with
parents.
Peer-to-peer interactions lead to the formation of intimate friendships between
same-sex children.
Friendships with opposite-sex children are uncommon during the school-age
years.
Interest in peers of the opposite sex generally doesn’t begin until ages 10 to 12.
Magical thinking and fantasy play are more characteristic during the preschool
years.
At age 3, gross motor development and refinement in hand-eye coordination
enable a child to ride a tricycle.
A preschooler typically asks for a bandage after having blood drawn because he
has poorly defined body boundaries and believes he will lose all of his blood from
the hole the needle has made.
An adolescent might be upset about a surgical scar because he’s concerned about
body image.
A school-age child might ask why his friends don’t visit because peers become
important by that age.
School-age kids (5 and up) are old enough, and should have an explanation of
what will happen a week before surgery such as tonsillectomy.
Object permanence is exhibited by the infant looking for objects that have been
hidden from sight.
Returning blocks to the same spot on the table is imitative behavior.
Recognizing that a ball of clay is the same object even when flattened out is an
example of the theory of conservation, which occurs during Piaget’s concrete
operational stage in early school-age children (ages 7 to 11).
Chest circumference is most accurately measured by placing the measuring tape
around the infant’s chest with the tape covering the nipples. If chest
circumference is measured above or below the nipples, a false measurement is
obtained.
Sexual maturity in males and females is classified according to Tanner’s stages,
named after the original researcher on sexual maturity.
Cleft Lip/Palate
Congenital anomalies due to failure of soft tissue or bone to fuse occurs during
pregnancy
Cleft lip will close earlier than a cleft palate; cleft lip repair = 3-6 months, cleft palate
repair = 6-24 months
Cleft palate can lead to speech impairment and otitis media
Priority: 1. Assess ability to suck/swallow/breathe 2. Monitor fluid intake and daily
weight 3. Hold infant upright and direct milk to side/back of mouth 4. Provide feeds
in small amounts 5. Suction and bulb syringe @ bedside 6. ESSR feeding enlarge
nipple, simulate sucking reflex, swallow, rest
Esophageal Atresia:
Congenital defect; food/fluids enter lungs or air enters stomach (issue is with the
esophagus)
S/S: 3 Cs (coughing, choking, cyanosis), frothy saliva, vomiting, abdominal
distention, resp distress
Priority: 1. NPO 2. IV fluids 3. Suction as needed 4. Supine 5. Antibiotics for
potential pneumonia
Umbilical Hernia:
Bowel protrudes through opening in abdominal wall (usually through umbilicus or
inguinal canal) incarcerated hernia= medical emergency due to compromising
blood supply
Conjunctivitis:
Bacterial+ viral conjunctivitis is very contagious
S/S: redness, edema, discharge, burning
Priority: 1. Hand hygiene 2. Antibiotics or antiviral eye drops 3. No sharing of towels
4. No school or daycare until 24 hours post antibiotic administration 5. Avoid
rubbing eyes and wearing eye makeup
Nosebleed:
Do not put patient in laying down position= risk of aspiration
Otitis Media:
Common after a respiratory infection. Common in children due to shorter, wider,
and straighter eustachian tubes
To prevent: feed infant upright, breast feed for first 6 months, avoid smoking,
maintain immunizations
S/S: fever, ear pain, crying, no appetite, head rolling side to side, pulling on ear, ear
drainage, red+ opaque tympanic membrane *remember to pull child under 3yearsold pinna down+ back when giving meds (older than 3 years =pinna up and
back)
Intussusception (pictured left):
Results in obstruction of GI
content
S/S: abd. pain (patient has
knees up to abdominal)
vomiting up bile-stained
emesis, currant jelly like stool,
distended abdominal with
sausage shaped mass in RUQ
Passing of normal stool =
intussusception has resolved
Priority: 1. Monitor for
perforation (fever, tachycardia,
resp distress)2. ABX and IV
fluids 3. NGT for decompression
Epiglottis refers to inflammation of the epiglottis that may result in life threatening
airway obstruction.
Haemophilus influenzae type b (Hib) was the most common cause, but the
incidence has decreased dramatically with widespread Hib vaccination.
Symptoms begin with abrupt onset of high-grade fever and a severe sore throat,
followed by the 4 Ds: drooling, dysphonia, dysphagia, and distressed airway
(inspiratory stridor).
Children are typically toxic-appearing and may be "tripoding" (sitting up and leaning
forward) with inspiratory stridor.
Hirschsprung’s Disease (pictured left)
No ganglion cells in rectum = mechanical
obstruction due to low motility
S/S: no meconium, refusing to suck,
abdominal distention, delayed growth,
vomiting, constipation, ribbon like stools
Priority: 1. Monitor for enterocolitis
(fever, GI bleed, diarrhea) 2. Low fiber,
high calorie, high protein diet 3. Stool
softeners 4. Rectal irrigations 5. NPO 6.
Monitor
weight
Bacterial form of croup
Emergency due to possibility of severe respiratory distress
S/S: fever, red/inflamed throat, painful swallowing, no cough, muffled voice +
drooling, agitation, stridor, tachycardia, tachypnea, tripod position (see picture
above)
Priority: 1. Patent airway 2. Do not measure oral temp 3. Do not leave child
unattended 4. NPO 5. Avoid supine positions 6. IV antibiotics, analgesics, and
antipyretics 7. Cool mist 8. Do not attempt to visualize pharynx or take throat
culture (can lead to spasm  airway occlusion)
Sudden Infant Death Syndrome (SIDS)
Most frequent in winter, during sleep, and in male infants age 2-3 months of age.
Incidence is lower in breastfed infants—High Risk for SIDS: prone sleep position, cosleeping, mother who abused substances or smoked while pregnant, excessive
sheets in bed, exposure to smoke, soft bed
Epispadias + Hypospadias:
Epi = dorsal urethral opening, hypo = ventral urethral opening; can lead to bacteria
entering urine. Circumcision is not performed (foreskin needs to be used for
reconstruction)
Cystic Fibrosis:
Autosomal recessive trait; no cure; protein responsible for transporting Na and Cl is
defective= secretions are thicker and stickier
Mucus production is thick and copious, causing obstruction in small passageways
of respiratory, GI, and reproductive systems pancreatic fibrosis, chronic lung
disease, sweat gland dysfunction
S/S: emphysema, hypoxemia, wheezing, cough, dyspnea, cyanosis, barrel chest,
meconium ileus, frothy stools, rectal prolapse, very high concentration of Na+ Cl in
sweat, delay in female puberty, sterility in males
Priority: 1. Antibiotics 2. Chest physiotherapy daily (do not perform after a meal) 3.
Mucous removal 4. Huff cough 5. Bronchodilators 6. High calorie, high protein, high
fat diet 7. Monitor stools 8. Pancreatic enzyme replacement within 30 mins of
eating+ with all snacks 9. Salt replacement
Autism:
S/S: impaired social interaction, verbal impairment, intellectual deficit, altered
behavior (attachment to objects, self­ injuries, repetitive routine or body
movements)
Priority: 1. Safe environment 2. Maintain a consistent routine 3. Avoid placing
demands on patient
Neural Tube Defects:
Neural tubes fail to close= sensorimotor deficits, dislocated hips, clubfoot, and
hydrocephalus Types of neural tube defects= spina bifida, meningocele,
myelomeningocele
Priority: 1. Protect the exposed sac (cover with sterile moist dressing) 2. Change
sac dressing regularly 3. Monitor neuro status and ICP 4. Aseptic technique 5.
Monitor for infect ion, give patient ABX 6. Place patient in prone position 7. Prep for
surgery
RSV:
Acute viral infection that is highly communicable by direct contact with resp
secretions Common cause of respiratory infection and bronchiolitis
Affects ciliated cells= bronchiolar swelling= increased mucous production Mostly
occurs in winter+ spring
S/S: rhinorrhea, cough, wheezing, fever, tachypnea, retractions, cyanosis, apneic
episodes
Priority: 1 Contact precautions 2. Maintain patent airway with HOB @ 30-40
degrees 3. Cool humidified 02 4. Suction if needed 5. Antiviral and antipyretic
medication 6. IV fluids for dehydration 7. Palivizumab given to high-risk infants
Mongolian Spots (pictured left) - a
congenital dermal melanocytosis
(Mongolian spot) is a benign
discoloration of the skin most
commonly seen in newborns of
African American and Asian descent.
The color is usually bluish grey and
easily misidentified as a bruise.
Rheumatic Fever
Inflammatory autoimmune disease affecting connective tissue of heart, joints, skin,
blood vessels, and CNS Most serious complication = rheumatic heart disease
RF occurs after untreated streptococcal infection of upper respiratory tract (ask
about recent sore throat)
S/S: chorea (involuntary movement of extremities+ face, can affect speech), fever,
carditis (inflammation of mitral valve), abdominal pain, erythema marginatum (red
lesions on trunk), subcutaneous nodules, polyarthritis
Priority: 1. Bed rest 2. Limit activity 3. ABX, analgesics, anti-inflammatories 4.
Seizure precautions if patient has chorea
Kawasaki Syndrome
Acute systemic inflammatory illness; no known cause
Most serious complication = aneurysms
S/S: fever, red throat, swollen hands with rash, cracked lips, peeling of skin on
fingers + toes, joint pain, thrombocytosis
Priority: 1. Monitor for fever 2. Asses for edema, redness, and peeling 3. Soft food
diet 4. ROM exercises 5. Aspirin
Hydrocephalus: Increased CSF due to
tumor, hemorrhage, infection, trauma =
head enlargement S/S: high shrill cry,
increased head circumference,
Macewen’s sign, bulging anterior
fontanel, dilated veins, setting sun eyes.
Priority: 1. Ventriculoperitoneal
(pictured left) or ventriculoarterial
shunt to drain CSF accumulation
A child with a ventriculoperitoneal
shunt will have a small upperabdominal incision
Cerebral Palsy:
Abnormality in extrapyramidal + pyramidal motor system = impaired movement+
posture
S/S: irritability, difficulty feeding, stiff+ rigid muscle tone, delayed milestones,
abnormal posture, seizures
Priority: 1. PT, OT, speech therapy 2. Mobilizing devices 3. Interact with child based
on developmental level rather than chronological age 4. Safe environment with
seizure precautions 5. Upright position after meals
Increased ICP:
S/S: high pitch cry, bulging fontanel increased head circumference, setting sun sign
(sclera shows above iris), dilated scalp veins, late S/S (change in LOC, decorticate or
decerebrate posture, Cheyne stokes, coma)
Priority: 1. Patent airway, 02 PRN 2. Head and body midline 3. Calm and quiet
environment 4. Seizure precautions 5. NPO 6. Administer Tylenol, anticonvulsants,
osmotic diuretic and ABX 7. Monitor for nose+ ear drainage (test for CSF)
Brainstem Injury:
S/S: deep+ rapid respirations, bradycardia, wide pulse pressure, dilated+
unequal pupils
What is an intraosseous infusion? In pediatric life-threatening emergencies,
when iv access cannot be obtained, an osseous (bone) needle is hand-drilled into
a bone (usually the tibia), where crystalloids, colloids, blood products and drugs
can be administered into the marrow. It is a temporary, life-saving measure, and I
have seen it once! (Gruesome.) When venous access s achieved it can be d/c’d.
One medication that cannot be administered by intraosseous infusion
is isoproterenol, a beta agonist. (I don’t know more about that drug; it was just
pointed out on a practice exam.)
Pediatric Cardiovascular System
Hypotension is considered a late sign of shock in children.
Infants and children with heart defects tend to have poor nutritional intake and
weight loss, indicating poor cardiac output, heart failure, or hypoxemia.
The child can appear lethargic or tired because of the heart failure or hypoxia.
Premature atrial contractions are common in fetuses, neonates, and children.
Atrial fibrillation is an uncommon arrhythmia in children that arises from a
disorganized state of electrical activity in the atria.
Bradyarrhythmias are congenital, surgically acquired, or caused by infection.
Premature ventricular contractions are more common in adolescents.
In the immediate post catheterization phase, the child should avoid raising the
head, sitting, straining the abdomen, or coughing.
When the heart stretches beyond efficiency, an extra heart sound, or S3 gallop, may
be audible.
Respiratory symptoms, such as tachypnea and dyspnea, are seen as a result of
pulmonary congestion in heart failure.
Energy expenditures need to be limited to reduce metabolic and oxygen needs in
the child with heart failure.
In older children with heart failure, fluids may be restricted but fluid restriction is
contraindicated in infants because their nutritional requirements depend on fluid
needs.
In a child with heart failure, an upright position facilitates lung expansion, provides
less restrictive movement of the diaphragm, relieves pressure from abdominal
organs, and decreases pulmonary congestion.
For an infant in heart failure, formulas with increased caloric content are given to
meet the greater caloric requirements from the overworked heart and labored
breathing.
A neonate’s vascular system changes with birth; certain factors help to reverse the
flow of blood through the ductus arteriosus and ultimately favor its closure.
Ductus arteriosus closure typically begins within the first 24 hours after birth and
ends within a few days after birth.
At birth, oxygenated blood normally causes the ductus arteriosus to constrict, and
the vessel closes completely by age 6 weeks.
Patent ductus arteriosus is considered an acyanotic defect with increased
pulmonary blood flow. It can cause excessive blood flow to the lungs because of the
high pressure in the aorta.
Heart failure is common in premature infants with a patent ductus arteriosus.
Preterm neonates having patent ductus arteriosus with good renal function may
receive oral indomethacin, a prostaglandin inhibitor, to encourage ductal closure.
If indomethacin isn’t effective in closing a patent ductus arteriosus, surgery is
suggested.
The continuous, turbulent flow of blood from the aorta through the patent ductus
arteriosus to the pulmonary artery produces a machinelike murmur.
With an acyanotic heart defect, the increase in blood flow to the lungs may cause
tachycardia and increased respiratory rates to compensate.
Poor growth and development may be seen in a child with an acyanotic heart
defect because of the increased energy required for breathing.
Failure of a septum to develop between the ventricles results in a left-to-right
shunt, which is noted as a ventricular septal defect.
When the septum fails to develop between the atria, it’s considered an atrial septal
defect.
For small ventricular septal defects, a stitch closure is performed; larger ventricular
septal defects may be repaired by sewing a patch over the defect.
Surgery with pulmonary artery banding may be a palliative procedure for a child
with a ventricular septal defect in heart failure who is too small or too ill for surgical
repair of the defect.
The pulse below the catheterization site should be strong and equal to the pulse in
the unaffected extremity.
A weakened pulse below the cardiac catheterization site may indicate vessel
obstruction or perfusion problems.
Atrial septal defects shunt from left to right because pressures are greater on the
left side of the heart.
Pulmonic stenosis, tetralogy of Fallot, and total anomalous pulmonary venous
return will show a right-toleft shunting of blood.
With coarctation of the aorta, as blood is pumped from the left ventricle to the
aorta, some blood flows to the head and upper extremities while the rest meets
obstruction and jets through the constricted area.
A child with tetralogy of Fallot will be mildly cyanotic at rest and have increasing
cyanosis with crying, activity, or straining, as with a bowel movement.
Higher pressures in the upper extremities are characteristic of coarctation of the
aorta.
Chronic hypoxia of longer than 6 months’ duration causes clubbing of the fingers
and toes when untreated, such as with a child with tetralogy of Fallot.
Hypoxia varies with the degree of pulmonic stenosis in a child with tetralogy of
Fallot.
Growth and development may appear normal in a child with tetralogy of Fallot.
A child with tetralogy of Fallot may squat or assume a knee-chest position in order
to breathe more easily.
The arterial oxygen saturation of infants with tetralogy of Fallot can suddenly drop
markedly; called a “tetralogy spell,” this usually results from a sudden increased
constriction of the outflow tract to the lungs, which further restricts the pulmonary
blood flow.
The lips and skin of infants who have a sudden decrease in arterial oxygen level
from a “tetralogy spell” will appear acutely more blue.
Decreased or absent pulses in the lower extremities is a sign of coarctation of the
aorta.
In tetralogy of Fallot, chest X-rays will show right ventricular hypertrophy pushing
the heart apex upward, resulting in a boot-shaped cardiac silhouette.
Echocardiogram scans define such defects as large ventricular septal defects,
pulmonic stenosis, and malposition of the aorta.
Tricuspid atresia is failure of the tricuspid valve to develop, leaving no
communication between the right atrium and right ventricle.
Narrowing at the aortic outflow tract is called aortic stenosis.
Total anomalous pulmonary venous return is a defect in which the pulmonary veins
don’t return to the left atrium, but instead return to the right side of the heart.
Narrowing at the entrance of the pulmonary artery represents pulmonic stenosis.
Cyanosis is the most consistent clinical sign of tricuspid atresia.
Tachypnea and dyspnea are commonly present in tricuspid atresia because of the
decreased pulmonary blood flow and right-to-left shunting.
A child who has pulmonary venous obstruction will exhibit signs of increasing
respiratory distress, such as increased respiratory rate, dyspnea, and shortness of
breath.
The child with tricuspid atresia will be dusky, particularly around mucous
membranes and nail beds, for the
rest of his life as a result of chronic hypoxemia.
An atrial septal defect is common in association with total anomalous pulmonary
venous return.
In pulmonic stenosis, right-to-left shunting develops through a patent foramen
ovale, an atrial septal defect, or a ventricular septal defect due to right ventricular
failure and an increase in pressure in the right side of the heart.
Children with aortic stenosis may develop chest pain similar to angina when they’re
active.
The most common causes of heart failure in children are congenital heart defects.
Some congenital heart defects result from the blood being pumped from the left
side of the heart to the right side of the heart.
Infective endocarditis is usually caused by the bacteria Streptococcus viridans and
commonly affects children with acquired or congenital anomalies of the heart or
great vessels.
Bacteria in endocarditis may grow into adjacent tissues and may break off and
embolize elsewhere, such as the spleen, kidney, lung, skin, and central nervous
system.
Endocardial cushion defects represent inappropriate fusion of the endocardial
cushions in fetal life.
Symptoms of bacterial endocarditis may include a low-grade intermittent fever,
decrease in hemoglobin level, tachycardia, anorexia, weight loss, and decreased
activity level.
In bacterial endocarditis, bacterial organisms can enter the bloodstream from any
site of infection, such as a urinary tract infection.
Gram-negative bacilli are common causative agents of bacterial endocarditis.
Dental work is a common portal of entry in bacterial endocarditis if the client is not
pretreated with antibiotics.
Reproductive System
Continuous Bladder Irrigation:
Removes clotted blood from bladder post-TURP (3-way catheter is used)
S/S to report: pain/spasm (indicates obstruction), output < input (indicates clot or
kink)
*Titrate irrigation rate so that urine is light pink
HPV:
Females should have Pap smear @ 21 years old
Pubic Lice:
Priority: 1. Lice shampoo 2. Remove nits with fine tooth comb 3. Wash belongings
separately from others 4. Sexual partners to be treated as well
Urinary Tract Infection:
Common kidney infection due to lack of proper hygiene and indwelling catheters
Priority: 1. ABX administration 2. Monitor for confusion in the elderly
Inserting a Foley Catheter:
1. Gather equipment.
2. Explain procedure to the patient
3. Assist patient into supine position with legs spread and feet together
4. Open catheterization kit and catheter
5. Prepare sterile field, apply sterile gloves
6. Check balloon for patency.
7. Generously coat the distal portion (2-5 cm) of the catheter with lubricant
8. Apply sterile drape
9. If female, separate labia using non-dominant hand. If male, hold the penis
with the non-dominant hand. Maintain hand position until preparing to
inflate balloon.
10. Using dominant hand to handle forceps, cleanse peri-urethral mucosa with
cleansing solution. Cleanse anterior to posterior, inner to outer, one swipe
per swab, discard swab away from sterile field.
11. Pick up catheter with gloved (and still sterile) dominant hand. Hold end of
catheter loosely coiled in palm of dominant hand.
12. In the male, lift the penis to a position perpendicular to patient's body and
apply light upward traction (with nondominant hand)
13. Identify the urinary meatus and gently insert until 1 to 2 inches beyond
where urine is noted
14. Inflate balloon, using correct amount of sterile liquid (usually 10 cc but check
actual balloon size)
15. Gently pull catheter until inflation balloon is snug against bladder neck
16. Connect catheter to drainage system
17. Secure catheter to abdomen or thigh, without tension on tubing
18. Place drainage bag below level of bladder
19. Evaluate catheter function and amount, color, odor, and quality of urine
20. Remove gloves, dispose of equipment appropriately, wash hands
21. Document size of Foley and amount of cc inserted into balloon
Infectious Disease
Rubeola/Measles:
Spread by respiratory secretion, blood, and infected urine (droplet+ direct contact)
S/S: Three C’s (coryza, cough, and conjunctivitis) weakness, fever, rash on face that turns red brown
over time, Kolpik’s spots (are red spots with blue center characteristic of the prodromal stages of
Measles)
Priority: 1. Airborne, droplet+ contact precautions 2. Bed rest+ quiet environment 3. Cool mist for
cough+ coryza 4. Antipyretics
Rubella/German Measles:
Spread by nasopharyngeal secretion, blood, stool, and urine (droplet+ direct contact)
S/S: fever, weakness, pink/red maculopapular rash over entire body, petechiae on soft palate
Priority: 1. Airborne, droplet+ contact precautions 2. Keep away from pregnant women
Varicella {Chickenpox):
Spread by respiratory secretions and direct contact with skin lesions (droplet+ direct contact)
S/S: fever, weakness, macular rash (lesions will pus, dry, and crust)
Priority: 1. Airborne, droplet+ contact precautions 2. Acyclovir
Pertussis {Whooping cough):
Spread by respiratory secretions (droplet+ contact precautions)
S/S: cough (with whooping inspiration), cyanosis, respiratory distress, listlessness
Priority: 1. Airborne, droplet+ contact precautions 2. Antimicrobials 3. Reduce irritants (dust, smoke, etc.)
4. Suction and humidified O2 if needed 5. Infants don’t receive maternal immunity to Pertussis
Normal reactions to a vaccine: tenderness, redness, swelling, low grade fever, drowsiness, decreased
appetite MMR vaccine is given subcutaneously
I
Remember!
Iron injections should be given z-track so they don’t leak into SQ
Anaphylactic reaction to baker’s yeast is a contraindication for Hep B Vaccine
Ask for allergy to eggs before Flu Shot
Ask for anaphylactic reaction to eggs or Neomycin before MMR
Children who have a cold can still receive their vaccinations
Sexually Transmitted Infections
Definition—contagious disease spread by contact during sexual intercourse
Overall picture
1. Prevention involves education and contact investigation
2. Measures to control spread include prophylactic vaccine development
Syphilis
S/S: Stage 1: painless chancre disappears within 4 weeks Stage 2: copper colored rash on palms and
soles; low-grade fever Stage 3: cardiac and CNS dysfunction
Treatment: Penicillin G IM
If client has a Penicillin allergy treat with Erythromycin for 10-15 days
Gonorrhea
S/S for FEMALES: Thick discharge from vagina or urethra. Frequently asymptomatic in females
If female has symptoms, usually has purulent discharge, dysuria, and dyspareunia (painful intercourse)
S/S for MALES: painful urination and a yellow-green discharge
Treatment: IM ceftriaxone 1 time and PO doxycycline BID for 1 week; azithromycin IM aqueous penicillin
with PO probenecid (to delay penicillin urinary excretion)
Chlamydia
S/S for FEMALES: may be asymptomatic, thick discharge with acrid odor, pelvic pain, yellow-colored
discharge; painful menses
S/S for MALES: dysuria, frequent urination, watery discharge
Treatment: azithromycin, doxycycline, erythromycin
Gential Herpes (HSV-2)
S/S: Painful vesicular genital lesions, Difficulty voiding, Recurrence in times of stress, infection, menses
Treatment: Acyclovir (not a cure!)
Maternity
Gestation:
Time from fertilization until date of delivery; approximately 280 days (9 mos)
menstrual period - 3 months + 7 days + 1 year = estimated date of delivery
Gravidity + Parity:
Gravida = pregnant woman
Gravidity =
for the first time, multigravida is in at least her 2 nd pregnancy)
Parity = number of births past 20 weeks gestation (whether born alive or not) (e.g. nullipara has not had a birth more
than 20 weeks gestation, primipara has had 1 birth that occurred after 20 weeks gestation)
GTPAL: gravidity, term births (longer than 37 weeks), preterm births, abortions/miscarriages, current living children
Pregnancy Signs
Presumptive Signs
Probable Signs
Positive Signs
Amenorrhea
Breast enlargement/tenderness
Fatigue
Nausea and vomiting
Quickening (first movement of fetus)
Urinary frequency
Ballottement (fetal movement in response to tapping lower uterus/cervix)
Braxton Hicks contractions
-deep violet vaginal wall color)
Positive pregnancy test
Abdominal + uterine enlargement
Fetal heartbeat
Fetal movement
Ultrasound findings
Fundal Height:
Measured to evaluate gestational age of fetus
*In 2nd and 3rd trimester: fundal height in cm = fetal age in weeks +/- 2 cm
Priority: 1. Monitor for supine hypotension when placing pt in supine position
Physiological changes when pregnant:
Cardiovascular: heart displaced upward, increased blood volume, increased resting HR, increased venous pressure,
increased RBC
GI: displacement of intestines, nausea and vomiting, hemorrhoids, constipation
Endocrine: increased basal metabolic rate, increased prolactin, estrogen, and cortisol levels, decreased insulin
production
Respiratory: compression of lungs, displacement of diaphragm, abdominal breathing, increased RR
Integumentary: hyperactive sweat glands, increased pigmentation, stretch marks
Genitourinary: dilated uterus, increased renal function (increased urea and creatinine clearance), decreased bladder
tone, sodium retention
Nutrition: calories, protein, vitamins, minerals, and fiber intake should increase during pregnancy. *Folic acid is
important to prevent fetal anomalies (e.g. neural tube defect)
Nausea/Vomiting
Syncope
Urinary Urgency
Discomforts during pregnancy
Prevention/Interventions:
st
rd
occurs in 1 month, subsides by 3
Eat dry crackers before arising, avoid brushing teeth right
after arising, eat small frequent meals, drink in between
month
meals, avoid fried/spicy food
st
occurs in 1 trimester, supine
Elevate feet when sitting, change positions slowly
hypotension in 2nd and 3rd trimester
occurs in 1st + 3rd trimester due to
2L fluid restriction, void regularly, side lying sleep position,
uterus pushing on bladder
Kegel exercises
Breast tenderness
Vaginal discharge
Fatigue
Heartburn
1st-3rd trimester
1st-3rd trimester
1st and 3rd trimesters
2nd and 3rd trimesters
Ankle edema
2nd and 3rd trimesters
Varicose veins
2nd and 3rd trimesters
Hemorrhoids
2nd and 3rd trimesters
Wear supportive bra, avoid soap on nipples
Proper cleansing, cotton underwear, avoid douching
Frequent rest periods, regular exercise
Small frequent meals, sit up right 30 mins post-meal, drink
milk between meals, avoid fatty/spicy food
Elevate legs BID, side lying sleep position, supportive
stockings, avoid sitting/standing in one position for long
Wear supportive stocking, elevate legs when sitting, lay
with feet elevated, avoid crossing legs
Soak in warm sitz bath, sit on soft pillow, high fiber foods +
fluid intake, increase exercise
Pregnancy Health Care Visits:
Visit MD every 4 weeks for first 28-32 weeks, every 2 weeks from 32-36 weeks, and every week from 36-40 weeks
Nonstress Test
Noninvasive test measuring fetal heart accelerations in
response to fetal movement
Done between 32-34 weeks gestation
Nonreactive result = further testing is needed to determine
if the result indicates fetal hypoxia or if result is due to
sleep pattern, or maternal prescription drugs
Reactive result = normal. Indicates that blood flow and
oxygen to fetus is adequate
First Stage
Second Stage
Third Stage
Fourth Stage
Stress Test
Test triggers contractions and predicts how baby will react
during labor
If fetal HR slows during contraction = positive result. Fetus
may be experiencing stress during contractions (cannot
tolerate contractions) Further testing may be needed
result. Indicates that the fetus is reacting properly to stress
of contractions
Stages of Labor
Onset of true labor complete dilation of cervix
Lasts anywhere from 2-18 hours
3 phases:
1. Latent phase cervix dilated 0-3 cm, irregular contraction, cervical effacement almost complete
2. Active phase cervix dilated 4-7 cm, contractions 5-8 minutes apart, cervical effacement
complete
3. Transitional phase cervix dilated 8-10 cm, contractions 1-2 minutes apart + lasting 60-90
seconds
Complete dilation of cervix delivery
Usually lasts ~40 minutes
Delivery expulsion of placenta
Usually lasts 5-30 minutes
Maternal-neonatal bonding period
Usually lasts 1-4 hours
Presentation:
Cephalic head first (most common), can be vertex, military, brow, or face
Breech buttocks first (C section may be required), can be frank, full, or footling
Shoulder tran
Station:
Progress of descent in cm above or below midplane
0 at ischial spine
Minus above ischial spine
Plus below ischial spine
True Labor
Regular contractions that become stronger, last longer, and
occur closer together
Cervical dilation + effacement progress
Fetus becomes engaged in pelvis and begins to descend
False Labor
Contractions are irregular, without progression
No dilation, effacement, or descent
Activity (e.g. walking) relieves false labor
Preterm Labor:
After 20th week but before 37th week gestation
Palpating to determine presentation + position
Head = hard, round, movable
Buttocks = irregular shape, more difficult to move
Back = smooth, hard surface (should be felt on 1 side of abdomen)
Fetal Heart Rate:
FHR < 110 for 10 mins+ = bradycardia
FHR >160 for 10 mins+ = tachycardia
Accelerations: brief increase in FHR lasting about 15 seconds; reassuring sign showing a responsive fetus; usually
occurs with fetal movement (or with contractions)
associated with any fetal compromise; no intervention needed
Late decelerations: decrease in FHR well after the contraction; indicates uteroplacental insufficiency; fetal
oxygenation is a priority
Variable decelerations: due to restricted flow through umbilical cord; significant when FHR is <70 bpm for more than
60 seconds
V C
V = variable decelerations; C = cord compression
E H
E = early decelerations; H = head compression
A O
A = accelerations; O = okay, not a problem!
L P
L = late decelerations = placental insufficiency
Priority with an un-reassuring FHR: turn woman on L side, give O2, stop Pitocin, increase IV fluids
Premature Rupture of Membranes:
S/S: fluid pooling, positive nitrazine test
Priority: 1. Monitor for infection 2. Avoid vaginal exams 3. ABX if needed
Prolapsed Umbilical Cord:
Causes compression of cord and compromised fetal circulation
S/S: feeling of something coming through vagina, visible/palpable cord, slow FHR with variable decelerations,
potential fetal hypoxia
Priority: 1. Elevate fetal part lying on cord 2. Place pt into Trendelenburg 3. Admin O2 (8-10 L) 4. Monitor FHR 5. IV
fluids 6. Prepare for birth
APGAR:
2 points
Appearance
Pulse
Grimace
Activity
Respiration
All pink
>100
Cough
Flexed
Strong cry
1 point
Pink and blue
<100
Grimace
Flaccid
Weak cry
0 points
Blue/pale
Absent
No response
Limp
Absent
Score of 7-10 is excellent, 4-6 indicates moderate depression, and 0-3 is severely depressed (resuscitation needed)
Placenta Previa
Placenta implanted low in uterus or over cervical os
S/S: sudden painless, bright red bleeding
Priority: 1. Ultrasound to confirm 2. Avoid vaginal exam 3. Side
lying position 4. Monitor amount of blood 5. IV fluids and
blood products 6. C-section may be needed
Abruptio Placentae
Premature separation of placenta from wall
S/S: painful dark red bleeding, uterine pain, uterine rigidity,
abdo pain
Priority: 1. Trendelenburg 2. Monitor bleeding 3. O2, IV fluids,
blood products 4. Prepare for delivery ASAP
Supine Hypotension:
S/S: pallor, dizziness, tachycardia, hypotension, cool skin, fetal distress
Priority: 1. Side lying position
Lochia:
(Postpartum)
Scant less than 2.5 cm in 1 hr
Light less than 10 cm in 1 hr
Moderate less than 15 cm in 1 hr
Heavy saturated pad in 1 hr
Excessive saturated pad in 15 mins
Day 1-3: rubra, Day 4-10: serosa, Day 11-14: alba
Postpartum Blue
Anger, anxiety, cries easily, letdown feeling, fatigue, headache,
insomnia, restless, sad
Emotional Changes
Postpartum Depression
Anxiety, change in appetite, cries, difficulty making
decisions, fatigue, guilty, irritable, lacks energy,
less responsive to baby, loss of pleasure in normal
activities, suicidal thoughts
Postpartum Psychosis
Break with reality, confusion,
delirium, delusions,
hallucinations, panic
50
Types of Abortions
An abortion is the loss of the fetus prior to the time when it can live outside the uterus. Several types of
abortions can be experienced by the client:
Elective abortion —Evacuation of the fetus. There are several types of elective abortions, but all of them
require early diagnosis of the pregnancy.
Threatened —Produces spotting. The treatment is bed rest. If bleeding or cramping continues, the client
should contact the physician immediately because the doctor might order tocolytic medications such as
magnesium sulfate, bethrine, or yutopar.
Inevitable —If there are no fetal heart tones and parts of the fetus are passed, the client is said to be
experiencing an inevitable abortion. This type of abortion produces bleeding and passage of fetal parts.
The treatment is a dilation and curettage (D&C).
Incomplete —In an incomplete abortion, fetal demise exists but part of the conception is not passed.
The treatment is a dilation and evacuation (D&E).
Complete —In a complete abortion, all parts of the conception are passed. There is no treatment.
Septic—A septic abortion includes the presence of infection. The treatment is administering antibiotics.
Missed —In a missed abortion, there is fetal demise but there is no expulsion of the fetus. The
treatment is an induction of labor or a surgical removal of the fetus. Complications of all types of
abortion include bleeding and infection. The client should be taught to report to the doctor any
bleeding, lethargy, or elevated temperature .
Preterm Labor
Premature labor can be managed with hypnotics or sedatives. Several medications stop contractions,
including
Brethine (terbutaline sulfate )—A commonly used bronchodilator that is contraindicated in clients with
cardiovascular disease because it causes tachycardia and in clients with diabetes because it elevates the
blood glucose levels.
Magnesium sulfate—A drug used to treat preeclampsia. It can also help to decrease uterine
contractions. If this drug is given to treat premature contractions, the client should be monitored for
magnesium toxicity.
Maternity Need to Know
TORCHS is a syndrome that includes toxoplasmosis, rubella, cytomegalovirus, herpes, and syphilis
HELLP syndrome means hemolysis, elevated liver enzymes, and low platelets. This syndrome results in
an enlarged liver and associated bleeding. If it’s not treated, the client can die as a result of bleeding.
The treatment for this problem is early delivery of the fetus.
Clients receiving magnesium sulfate should have a Foley catheter inserted to monitor the output hourly.
The client should be assessed for hypotension and respiratory distress.
If the physician decides to induce labor, the pitocin can be continued and prostaglandin gel can be used
to ripen or soften the cervix.
NOTE
Pitocin should always be infused using a pump or controller.
Leakage of spinal fluid can result in a headache. The client should be maintained supine following
delivery for eight hours, and fluids should be encouraged. If a spinal headache occurs following spinal
anesthesia, the doctor might perform a blood patch. A blood patch is done by injecting maternal blood
into the space where spinal fluid is being lost. This allows for quicker replenishing of spinal fluid and
restoration of equilibrium.
Premature rupture of membranes—Can indicate premature labor and lead to infections.
Chills and fever—Can be an indication of a urinary tract infection or sepsis.
Excessively rapid uterine enlargement—Can indicate a hydatidiform mole.
A hydatidiform mole is a rapid proliferation of cells within the uterus due to trophoblastic disease. A
complete molar pregnancy results from fertilization of an egg whose nucleus has been lost. The rapid
cell growth can be associated with chorionic carcinoma. The client with a hydatidiform mole is treated
by performing a dilation and curettage. The client should be instructed not to become pregnant for
approximately 6 to 12 months following a hydatidiform mole because a rising human chorionic
gonadotropin (HCG) level will stimulate cancer cell growth.
The client having an amniocentesis prior to 20 weeks gestation should be instructed not to void until
after the amniocentesis. A full bladder helps to push the uterus up in the abdominal cavity, thereby
providing access to pockets of amniotic fluid. After 20 weeks, the client should be asked to void prior to
the amniocentesis because there is an increased risk of damaging the bladder with the amniocentesis
needle.
Note that clients having a vaginal ultrasound should be instructed to void prior to the exam. Please note
that this is different than the preparation for a client having an abdominal ultrasound
Management of severe preeclampsia include
. Complete bed rest
. Moderation in sodium
. Magnesium sulfate
Magnesium sulfate, or magnesium gluconate, is the treatment of choice. A therapeutic level of 4.8–9.6
mg/dL is achieved by controlled infusion of intravenous magnesium sulfate.
Magnesium sulfate is a vasodilator that rapidly lowers the blood pressure. Complications associated
with the use of MgSO4 include maternal hypotension, oliguria, and apnea. Hourly intake and output
should be done to access for oliguria.
Common side effects of MgSO4 infusion are drowsiness and hot flashes. Every effort should be
made to prevent seizures. A quiet, dark environment must be maintained and visitors should
be restricted. The client should be assessed for signs of toxicity, which include hyporeflexia,
oliguria, and decreased respirations. Magnesium levels should be checked approximately every
six hours and the results reported to the doctor.
The treatment for magnesium sulfate toxicity is the administration of calcium gluconate.
Calcium gluconate should be kept at the bedside along with an airway and tracheotomy set.
Medication Administration
Seven Medication Rights
1.
2.
3.
4.
5.
6.
7.
Right client
Right medication
Right dose
Right time and frequency
Right route
Right indication
Right documentation
NCLEX® Exam Tip
On the NCLEX exam, medication and IV calculation questions will most likely be in a fill-in-the
blank format. You are provided with an on-screen calculator for these medication and IV
problems. Even if you use the calculator to calculate dosages and flow rates, it is important to
recheck the calculation before typing the answer. Follow the formula, place the decimal points
in the correct places, and check the accuracy of the calculation. Read the question carefully,
because many of these questions will ask you to record your answer using one decimal place
or to record your answer to the nearest whole number. Always follow the directions
accompanying the question. In addition, if you are asked to round numbers, always round at
the end of performing the calculation.
Pharmacology
Drug
Heparin
Pancuronium Bromide
Iron Overdose
Digoxin (Lanoxin)
Magnesium Sulfate
Coumadin
TPA
Aspirin
Antidote
Protamine Sulfate
Neostigmine/ Atropine
Deferoxamine
Digibind (immune Fab)
Calcium Gluconate
Vitamin K
Amicar
Activated Charcoal
PCP
Ammonia
Tylenol (Acetaminophen)
Activated Charcoal
Lactulose
Mucomyst (acetylcysteine)- administered
orally
Medications, everything you need to know
Oxybutynin (Ditropan)is an anticholinergic medication that is frequently used to treat overactive bladder
Digoxin- cardiac glycoside that increases cardiac contractility and slows the heart rate and conduction. It is used in heart failure to increase cardiac
output; check pulse if less than 60 hold, check dig levels and potassium levels, since it is excreted by the kidney check BUN and Creatinine levels as well
to check kidney function
Amphojel: treatment of GERD and kidney stones .... watch out for constipation, Long term can cause WEAK BONES
Vistaril: treatment of anxiety and also itching ... watch for dry mouth. given preop commonly
Versed: given for conscious sedation ... watch for resp depression and hypotension
Lasix (furosemide) Potassium depleting loop diuretic. Hypokalemia can lead to heart palpitations and/or dysrhythmias.
Sinemet: treatment of Parkinson ... sweat, saliva, urine may turn reddish brown occasionally ... causes drowsiness
Artane: treatment of Parkinson .. sedative effect also
Coqentin: treatment of Parkinson and extrapyramidal effects of other drugs
Tigan: treatment of postop n/v and for nausea associated with gastroenteritis
Timolol (Timoptic)-treatment of glaucoma
PTU and Tapazole- prevention of thyroid storm
Terazosin alpha adrenergic blocker that relieves urinary retention associated with benign prostatic hyperplasia. Instruct patient to change positions
slowly because it can cause hypotension
Bactrim: antibiotic .. don’t take if allergic to sulfa drugs ... diarrhea common side effect.. .drink plenty of fluids
Gout Meds: Probenecid (Benemid), Colchicine, Allopurinol (Zyloprim)
Ipratropium A client who has a peanut allergy could have an anaphylactic reaction to ipratropium given by a metered dose inhaler because it
contains soy lecithin.
Apresoline (Hydralazine):treatment of HTN or CHF, Report flu-like symptoms, rise slowly from sitting/lying position; take with meals.
Bentyl: treatment of irritable bowel .... assess for anticholinergic side effects.
Calan (Verapamil): calcium channel blocker: treatment of HTN, angina ... assess for constipation
Carafate: treatment of duodenal ulcers .. coats the ulcer ... so take before meals
Theophylljne: treatment of asthma or. OED .. therapeutic drug level: 10-20
Mucomyst is the antidote to Tylenol and is administered orally
Diamox: treatment of glaucoma, high altitude sickness ... don’t take if allergic to sulfa drugs
Indocin: (NSAID) treatment of arthritis (osteo, rheumatoid, gouty), bursitis, and tendonitis.
Synthroid: treatment of hypothyroidism .. may take several weeks to take effect ... notify doctor of chest pain .. take in the AM on empty stomach ..
could cause hyperthyroidism.
Librium: treatment of alcohol withdrawal ... don’t take alcohol with this ... very bad nausea and vomiting can occur.
KWELL: treatment of scabies and lice ... (scabies) apply lotion once and leave on for 8-12 hours ... (lice) use the shampoo and leave on for 4 minutes with
hair uncovered then rinse with warm water and comb with a fine-tooth comb
Premarin: treatment after menopause estrogen replacement
Enoxaparin is an anticoagulant, a complete blood count should be assessed periodically with this medication
Dilantin (Phenytoin): treatment of seizures. therapeutic drug level: 10-20; -Toxicity: gait disturbances (ataxia); a known side effect of Dilantin is gingival
hyperplasia
Vancomycin is a very potent antibiotic that can cause ototoxicity and nephrotoxicity. Trough serum vancomycin concentrations are the most accurate
and practical method to monitor efficacy. A trough should be obtained just prior (about 15-30 minutes) to administration of the next does. Vancomycin
should be administered over 60 minutes (100 mins if infusing > or = 1 gram). Patients may receive diphenhydramine (antihistamine) prior to
administration if the clients has developed red man syndrome with a prior Vancomycin infusion.
Navane: treatment of schizophrenia .. assess for EPS
Ritalin: treatment of ADHD .. assess for heart related side effects report immediately ... child may need a drug holiday b/c it stunts growth.
Dopamine (Intropine): treatment of hypotension, shock, low cardiac output, poor perfusion to vital organs ... monitor EKG for arrhythmias, monitor BP
Lidocaine: used for ventricular tachycardia
Atropine: med of choice for asystole (no heart beat) ALSO reduces secretions and is given before surgery
Adenosine/Adenocard: med of choice for supraventricular tachycardia
Methadone: opioid analgesic used to detoxify/treat pain in narcotic addicts
Heparin: prevents platelet aggregation
Epinephrine: anaphylactic shock
ACE Inhibitors: used to treat hypertension and congestive heart failure; common side effect is intractable dry cough; contraindicated in pregnancy, can
cause orthostatic hypotension in early treatment patients should be taught ways to prevent it; Medications that are ACE Inhibitors
Captopril (Capoten), Enalapril (Vasotec), Lisinopril (Prinivil, Zestril) Quinapril (Accupril,) Fosinopril (Monopril), and Ramipril (Altace)
Valium and Ativan: meds of choice for Status Epilepticus
Lithium: med of choice for bipolar disorder
Protonix is given prophylactically to prevent stress ulcers
Amiodarone is effective in both ventricular and atrial complications.
Levodopa: treatment of Parkinson disease, contraindicated in pts with glaucoma, avoid B6
Phenergan an antiemetic used to reduce nausea
Diazepam is a commonly used tranquilizer given to reduce anxiety before OR
Demerol is for pain control DO NOT GIVE THIS TO PATIENTS THAT HAVE A SICKLE CELL CRISIS
Diamox, used for glaucoma, can cause hypokalemia
Dexedrine, used for ADHD, may alter insulin needs, avoid taking with MAOI's, take in morning (insomnia possible side effect)
Cytovene, used for retinitis caused by cytomegalovirus, patient will need regular eye exams, report dizziness, confusion, or seizures immediately
Rifampin, treatment of tuberculosis (makes body fluids orange)
Haldol preferred anti-psychotic in elderly, but high-risk extrapyramidal side effects (dystonia, tardive dyskinesia, tightening of jaw, stiff neck, swollen
tongue, later on swollen airway), monitor for early signs of reaction and give IM Benadryl
Risperdal, antipsychotic, doses over 6mg can cause tardive dyskinesia, first line antipsychotic in children
Sinemet, for Parkinson’s, contraindicated with MAOI's
Hydroxyurea, for Sickle Cell, report GI symptoms immediately, could be sign of toxicity
Zocor, for Hyperlipidemia, take on empty stomach to enhance absorption, report any unexplained muscle pain, especially if accompanied with a fever
BOTOX used to treat strabismus to relax vocal cords in spasmodic dysphonia
Proton Pump Inhibitors (eg, omeprazole, esomeprazole, pantoprazole) Are associated with decreased bone density (calcium malabsorption) which
increases the possibility of fractures; increase the risk of clostridium difficle “c diff”; doesn’t affect blood pressure; take medication prior to meals; tell
patient to increase calcium and Vitamin D intake to prevent osteoporosis
Aspirin (NSAID) can cause GI bleeding! Signs and Symptoms of GI bleeding (coffee ground emesis and black tarry stools) It also decreases platelet
aggregation and thereby inhibits blood clotting.
Tylenol (Acetaminophen) should not exceed 4 grams in 24 hours
Nitroglycerine causes vasodilation and can lower blood pressure; patients can take up to 3 pills in a 15-minute period; patients should take 1 pill every 5
minutes; educate patient that the tablets are heat and light sensitive and should be kept in a dark bottle and capped tightly
Statins (rosuvastatin, atorvastatin, simvastatin) are the most preferred agents to reduce LDL cholesterol, total cholesterol and triglyceride levels.
Contraindicated in severe liver or muscle injury.
Lactulose helps excrete ammonia in cirrhosis with hepatic encephalopathy. Achieve 23 soft stools/day
Tagamet used to prevent ulcers take with FOOD
Rifampin – treats tuberculosis can cause red/orange tears and urine, contraceptives don’t work when taking this
Ethambutol treats tuberculosis messes with your eyes
Carafate (GI med) before meals to coat stomach
Give NSAIDS, Corticosteroids, drugs for Bipolar Disorder, Cephalosporins, and Sulfonamides WITH food
Best time to take Growth Hormones is in the Evening Contraindicated in severe liver or muscle injury.
Best time to take Steroids is in the Morning
Best time to take Diuretics is in the Morning
Best time to take Aricept is in the Morning
Best time to take Antacids is AFTER Meals
INTAL, an inhaler used to treat allergy induced asthma may cause bronchospasm
Apply eye drops to conjunctival sac and afterwards apply pressure to nasolacrimal duct/inner canthus
NO VITAMIN C with Allopurinol; Push fluids with Allopurinol (flushes the uric acid out of the system)
Symptoms Associated with Need-to-Know Diseases
Disease/Condition
Symptom
Pulmonary Tuberculosis (PTB) low-grade afternoon fever
Pneumonia
Rusty sputum
Asthma
Wheezing on expiration
Emphysema
Barrel chest
Kawasaki Syndrome
Strawberry tongue
Pernicious Anemia
Red beefy tongue
Down Syndrome
Protruding tongue
Cholera
Rice watery stool
Malaria
Stepladder like fever with chills
Typhoid
Rose spots in abdomen
Diphtheria
Pseudo membrane formation
Measles
Kolpik’s spots
Systemic Lupus Erythematosus
(SLE)
butterfly rashes
Liver Cirrhosis
spider like varices
Leprosy
Lioning face
Bulimia
Chipmunk face
Appendicitis
Rebound tenderness
Dengue
petechiae or (+) Herman’s sign
Tetanus
risus sardonicus (spasm of facial muscles)
PYLORIC STENOSIS
Olive like mass
Patent ductus arteriosus
Machine like murmur
Addison’s Disease
Bronze like skin pigmentation
Cushing’s Syndrome
Moon face appearance and buffalo hump
Hyperthyroidism/Grave’s
Disease
Pancreatitis
Exophthalmos (Eye balls protrude from socket)
Intussusception
Sausage shaped mass
Benign Prostatic Hyperplasia
Reduced size and force of urine
Epiglottis
3Ds’ Drooling, Dysphonia, Dysphagia
Cystic Fibrosis
Salty Skin
Acromegaly
Coarse facial feature
Deep Vein Thrombosis (DVT)
Homan’s Sign
Chicken Pox
Diabetes
Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners
spots.
Vesicular Rash (central to distal) dew drop on rose petal
polyuria, polydipsia, polyphagia
Parkinson’s
Pill rolling tremors
Angina
Crushing stabbing chest pain relieved by Nitroglycerin
Guillain Barre Syndrome
ascending muscle weakness
Multiple Sclerosis
Charcot’s Triad (IAN)
Myasthenia Gravis
Descending muscle weakness
Laryngotracheobronchitis (LTB) Inspiratory stridor
Infectious Mononucleosis
sore throat, cervical lymph adenopathy, fever
Tetany
hypocalcemia (+) Trousseau’s sign/carpopedal spasm;
Chvostek sign (facial
spasm).
Myocardial Infarction (MI)
Crushing stubbing pain which radiates to left shoulder,
neck, arms, unrelieved by Nitroglycerin
Fibrin Hyalin
Expiratory Grunt
Diabetes Mellitus
polyuria, polydipsia, polyphagia
Hepatic Encephalopathy
Flapping tremors
Hypocalcemia
Cystitis
Chvostek & Trousseau’s sign
Burning on urination
Increased Intracranial Pressure
HYPERtension BRADYpnea BRADYcardia (Cushing’s Triad)
Meniere’s Disease
Shock
Lyme Disease
Ulcerative Colitis
Diabetic Ketoacidosis
Hodgkin’s Disease/Lymphoma
Vertigo and Tinnitus
HYPOtension TACHYpnea TACHYcardia
Bull’s eye rash
Recurrent bloody diarrhea
Kussmauls breathing (Deep Rapid RR)
painless, progressive enlargement of spleen & lymph
tissues, Reedstenberg Cells
Meningitis
Kernig’s sign (leg flex then leg pain on extension),
Brudzinski sign (neck flex = lower leg flex).
Muscular Dystrophy
Gower’s sign
GERD
Barrett’s esophagus
Hydrocephalus
Bossing sign (prominent forehead)
Nursing Implications for Diagnostics Tests
 Thoracentesis – Fasting and sedation is not required, test is performed under local anesthesia. Administer cough suppressant if indicated (movement
can coughing during the procedure may cause inadvertent damage to lung or pleura). Take vitals shave area around needle insertion, position
patient with arms on pillow on over bed table or lying on side, notify patient that pressure may be felt when needle is inserted. Post Thoracentesis
- listen for bilateral breath sounds, check vitals frequently, apply a dressing over the puncture side an tell patient to lie on the unaffected side, obtain
a chest x-ray if ordered, notify patient that normal activities can be resumed in one hour if no evidence of pneumothorax or other complication is
present

Electroencephalogram (EEG)- test detects abnormal brain function, provides a graphic record of brain’s electrical activity (brain waves) and is useful
in evaluating seizure activity. Client Preparation: Withhold fluids, foods, and medications (as prescribed) that may stimulate or depress brain waves.
These include anticonvulsants, tranquilizers, depressants, and caffeine-containing foods (e.g., coffee, tea, colas, and chocolate). Medications are
usually withheld for 24 to 48 hours before the test. Help the client wash the hair before the test. Client Teaching: The test takes about 1 hour. The
test is painless and will be performed while sitting in a comfortable chair or lying on a stretcher. The electrodes are applied to the scalp with a thick
paste. During the test, you will first be asked to breathe in and out deeply for a few minutes. Then, you will close your eyes while a light is flashed on
them and, finally, you will lie quietly with your eyes closed.

Liver Biopsy- NPO 4-6 hours prior to exams, asses vitals, review prothrombin time and platelet count, administer Vitamin K as ordered, immediately
before biopsy instruct patient to empty bladder, place patient in supine position on far-right side of bed; turn head to left and extend right arm
above head to improve access to biopsy site. Teach client that obtaining tissue sample only requires 10 to 15 seconds and there may be some pain or
discomfort during this time. Apply pressure to site immediately after needed is removed, Post-Op position patient on right side, teach patient that
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some pain in right shoulder may be noted as anesthetic wears off, monitoring for bleeding post-op, withhold food and fluids for 2 hours post op,
educate patient to avoid coughing, lifting or straining for 1 to 2 weeks

Before going for Pulmonary Function Tests a patient’s bronchodilators will be with-held and they are not allowed to smoke for 4 hours prior

For a lung biopsy, position patient lying on side of bed or with arms raised up on pillows over bedside table, have patient hold breath in
midexpiration, chest x-ray done immediately afterwards to check for complication of pneumothorax, sterile dressing applied

For a lumbar puncture, Empty the bladder before procedure. Performed in the lateral recumbent or sitting upright position. Help widen space
between the vertebrae and allow easier insertion of the needle. A sterile needle will be inserted between the L3/4 or L4/5 interspace. Pain may be
felt radiating down the leg, but it should be temporary.
AFTER the procedure: Lie flat with no pillow for at least 6 hours to reduce the chance of spinal fluid leak and resultant headache. Increase fluid intake for
at least 24 hours to prevent dehydration.

Kidney Biopsy Bleeding is a major complication following the procedure. Pre procedure: client must give consent and d/c all anticoagulants (heparin,
warfarin, rivaroxaban) and antiplatelet agents (aspirin, clopidogrel, NSAIDS) for at least 1 week
Post procedure: monitor v/s at least Q15 mins for the first hour as tachycardia, tachypnea, and hypotension can indicate blood loss. Assess puncture site
dressing for bleeding. BUN and creatinine levels would not change much within 3060 mins. These are usually measured once every 24 hours and
rarely every 12 hours. Inserting an indwelling urinary catheter is not necessary to perform a kidney biopsy. Place prone during procedure to facilitate
access to kidney. Place on affected side after procedure to provide pressure and help prevent bleeding. Bed rest for 24 hours.
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Remember to perform the Allen's Test prior to doing an ABG to check for sufficient blood flow
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Vastus Lateralis
 Large muscle in adults.
 Use in kids at any time, even < 3 years.
Ventrogluteal
 Preferred in adults due to sciatic
nerve injury with dorsogluteal
 Use in kids > 3 years
Deltoid
 OK for nonirritating meds in adults.
 Never in kids
Gluteus Medius or Dorsogluteal
 Need to roll.
 Use in kids >6 years.
 May cause sciatic nerve injury