THE COMPLETE
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BUNDLE
BROUGHT TO YOU BY
Nurse
in the making
Nurse
in the making
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@KRISTINE_NURSEINTHEMAKING
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KRISTINE@ANURSEINTHEMAKING.COM
@NURSEINTHEMAKINGKRISTINE
TABLE OF CONTENTS
Head To Toe Assessment...................................................................4
Dosage Calculation.........................................................................6
Lab Value Cheat Sheet...................................................................18
Lab Value Memory Tricks................................................................19
Blood Types................................................................................20
Fundamentals..............................................................................21
Pharmacology: Suffixes, Prefixes, & Antidotes...................................... 41
Mental Health Disorders............................................................... 49
Mental Health Pharmacology.......................................................... 59
Mother Baby.............................................................................. 65
Pediatric Milestones.....................................................................80
Med-Surg
Renal / Urinary System.......................................................... 85
Cardiac System.................................................................... 95
Endocrine System................................................................107
Respiratory Disorders............................................................117
Hematology Disorders........................................................... 122
Gastrointestinal Disorders..................................................... 125
Neurological Disorders.......................................................... 129
Burns............................................................................... 134
ABG’s ..................................................................................... 138
Templates & Planners.................................................................. 142
Note from Kristine..................................................................... 161
3
HEAD-TO-TOE ASSESSMENT
Introduction
INSPECT
• Knock
PALPATE
• Introduce yourself
PERCUSS
• Wash hands
• Provide privacy
AUSCULTATE
Orientation
"Normal" Vital Signs
• What is your name?
PULSE: 60-100 bpm
• Do you know where you are?
• Do you know what month it is?
• Verify patient ID and DOB
• Explain what you are doing
(using non-medical language)
• Who is the current U.S. president?
BLOOD PRESSURE:120/80 mmHg
O2 SATURATION: 95-100%
• What are you doing here?
TEMPERATURE: 97.8-99.1° F
• A&O X4 = Oriented to Person,
Place, Time, and Situation
RESPIRATIONS: 12-20 breaths per min
Head & Face
HEAD
Neck, Chest (Lungs) & Heart
NECK
• Inspect head/scalp/hair
• Inspect and palpate
• Palpate head/scalp/hair
• Palpate carotid pulse
FACE
• Inspect
• Check for symmetry
• To assess Cranial Nerve 7, check the following:
– Raise eyebrows
– Smile
– Frown
– Show teeth
– Puff out cheeks
– Tightly close eyes
EYES
• Check skin turgor (under clavicle)
POSTERIOR CHEST
• Inspect
• Auscultate lung sounds in posterior and lateral chest
– Note any crackles or diminished breath sounds
ANTERIOR CHEST
• Inspect:
– Use of accessory muscles
– AP to transverse diameter
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• Inspects external eye structures
• Palpate: symmetric expansion
• Inspect color of conjunctiva and sclera
• Auscultate lung sounds – anteriorand lateral
• PERRLA
– Pupils Equal, Round, Reactive to Light,
& Accommodation
– Note any crackles or diminished breath sounds
HEART
• Auscultate heart sounds (A, P, E, T, M)
with diaphragm and bell
– Note any murmurs, whooshing, bruits,
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4
Peripherals
Spine
PERIPHERALS
ELBOWS
• Have the patient stand up (if able)
Upper extremities
• Inspect, palpate, and assess
• Inspect the skin on the back
• Inspect and palpate.
HANDS AND FINGERS
• Inspect: spinal curvature
(cervical/thoracic/lumbar)
• Note any texture, lesions, temperature,
moisture, tenderness, & swelling
• Palpate radial pulses bilaterally
(+1, +2, +3, +4)
SHOULDER
• Inspect, palpate, and assess
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• Palpate spine
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• Check muscle strength of hands bilaterally
– Does each hand grip evenly?
+1 = Diminished
+2 =”Normal”
+3 =Full
+4 =Bounding, strong
Lower Extremities (hips, knees, ankles)
LOWER EXTREMITIES
• Inspect:
– Overall skin coloration
– Lesions
– Hair distribution
– Varicosities
– Edema
• Palpate: Check for edema (pitting or non-pitting)
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• Note any lesions, lumps,
or abnormalities
Abdomen
• Inspect:
– Skin color
– Contour
– Scars
– Aortic pulsations
• Auscultate bowel sounds:
all 4 quadrants (start in RLQ and go clockwise)
• Light palpation: all 4 quadrants
ABSENT: Must listen for at least 5 minutes to chart
absent bowel sounds
HIPS
• Inspect and palpate
HYPOACTIVE: One bowel sound every 3-5 minutes
NORMOACTIVE: Gurgles 5-30 time per minute
KNEES
• Inspect and palpate
HYPERACTIVE: Can sometimes be heard without a
stethoscope constant bowFl sounds,
> 30 sounds per minute
ANKLES
• Inspect and palpate
• Post tibial pulse (+1, +2, +3, +4)
• Dorsal pedis pulse bilaterally (+1, +2, +3, +4)
– Check strength bilaterally
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OVERALL
• Positions and drapes patient appropriately
during exam (gave patient privacy)
• Gave patient feedback/instructions
• Exhibits professional manner during exam,
treated patient with respect and dignity
• Organized: exam followed a logical sequence
(order of exam “made sense”)
5
v
DOSAGE
CALCULATION
BROUGHT TO YOU BY
Nurse
in the making
6
ABBREVIATIONS
LE
EXAMP
TIMES OF MEDICATIONS
ac
before meals
pc
after meals
daily
every day
bid
two times a day
tid
three times a day
qid
four times a day
qh
every hour
ad lib
A patient is receiving 1 mg tid.
How many mg will they receive in one day?
Remember: tid = 3X a day
Answer: if they are receiving 1 mg for 3X a day,
that’s 1 mg x 3 = 3 mg per day
ROUTES OF ADMINISTRATION
PO
by mouth
IM
intramuscularly
PR
per rectum
as desired
SubQ
subcutaneously
stat
immediately
SL
sublingual
q2h
every 2 hours
ID
intradermal
q4h
every 4 hours
GT
gastrostomy tube
q6h
every 6 hours
IV
intravenous
IVP
intravenous push
prn
as needed
IVPB
intravenous piggyback
hs
at bedtime
NG
nasogastric tube
DRUG PREPARATION
tab, tabs
tablet
cap, caps
capsule
gtt
drop
EC
APOTHECARY
AND HOUSEHOLD
METRIC
gtt
drop
min, m, mx
minim
tsp
teaspoon
pt
pint
kilogram
gal
gallon
L
liter
dr
dram
mL
milliliter
oz
ounce
mEq
milliequivalent
T, tbs, tbsp
tablespoon
qt
quart
g (gm, Gm)
gram
mg
milligram
enteric coated
mcg
microgram
CR
controlled release
kg (Kg)
susp
suspension
el, elix
elixir
sup, supp
suppository
SR
sustained release
7
CONVERSIONS
BASED ON VOLUME
THE METRIC SYSTEM
1 mg = 1,000 mcg
Large unit to small unit
Small unit to large unit
1 g = 1,000 mg
1 oz = 30 mL
8 oz = 1 cup
1 tsp = 5 mL
1 dram = 5 mL
1 tbsp = 15 mL
1 tbsp = 3 tsp
1 L = 1,000 mL
1 mL = 15 gtts (drops)
TIP
move decimal to the right
move decimal to the left
Moving to a larger unit? Move the decimal place to the Left
(Ex: mcg → mg) (Larger unit think Left)
EXAMPLE
1500 mcg =
mg
A “mg” is larger (Larger unit think Left) than a “mcg”
Therefore you move decimal 3 places to the Left
1500. mcg = 1.500 mg (1.5 mg)
BASED ON WEIGHT
1 kg = 2.2 lbs
1 lb = 16 oz
lb
kg
DIVIDE
by 2.2
kg
lb
MULTIPLY
by 2.2
Example:
120 lbs = _____kg
Example:
45.6 kg = ______lb
120 lbs / 2.2 = 54.545 kg
45.6 kg x 2.2 = 100.32 lb
8
DOSAGE CALC RULES
KEY
Medication errors kill,
PREVENTION is crucial!
1
Show ALL your work.
2
Leading zeros must be placed before any decimal point.
The decimal point may be missed without the zero
EXAMPLE
.2 mg should be 0.2 mg
WHY? .2 could appear to be 2
(0.2 mg of morphine is VERY different than 2 mg of morphine!)
3
No trailing zeros.
4
DO NOT round until you have the final anwser!
0.7 mL NOT 0.70 mL
1 mg NOT 1.0 mg
WHY? 1.0 could appear to be 10!
HOW TO ROUND YOUR FINAL ANSWER
If the number
in the thousands place
is 5 or greater
→
The # in the hundredth place is rounded up
EXAMPLES: 1.995 mg is rounded to 2 mg
1.985 mg is rounded to 1.99 mg
If the number
in the thousands place
is 4 or less
5
→
DECIMAL REFERENCE GUIDE
34.732
tens
ones
The # is dropped
thousandths
hundredths
tenths
EXAMPLE: 0.992 mg is rounded to 0.99 mg
Most nursing schools, if not all, do not give partial credit.
(THIS MEANS EVERY STEP MUST BE DONE CORRECTLY!)
9
FORMULA METHOD
(FOR VOLUME-RELATED DOSAGE ORDERS)
D
x V = A
H
D = DESIRED
NOTE:
Some medications
like Heparin and Insulin
are prescribed in
units/hour
Example: “The physician orders 120 mg...”
H = DOSAGE OF MEDICATION AVAILABLE
Example: “The medication is supplied as 100 mg/5 mL”
V = VOLUME THE MEDICATION IS AVAILABLE IN
Example: “The medication is supplied as 100 mg/5 mL”
A = AMOUNT OF MEDICATION REQUIRED FOR ADMINISTRATION
KEY
Your answer
EXAMPLE 1
Ordered: Drug C 150 mg
Available: Drug C 300 mg/tab
How many tablets should be given?
D
x V = A
H
What’s our desired? Drug C 150mg PO
What do we have? Drug C 300mg/tab
What’s our quantity/volume? tablets
150 mg
150
300 mg x 1 tab = 0.5 tabs
300 = 0.5 x 1 = 0.5 tabs
FINAL ANSWER:
0.5 tabs
You should assume that all
questions are asked “per dose”
unless the question gives a
timeframe (example: “how
many tablets will you give in 24
hours?”)
EXAMPLE 2
Ordered: Drug C 10,000 units SubQ
Available: Drug C 5,000 units/mL
How many mL should be given?
D
x V = A
H
What’s our desired? Drug C 10,000 SubQ
What do we have? Drug C 5,000 units
What’s our quantity/volume? 1 mL
10,000 units
10,000
5,000 units x 1 mL = 2 mL
5,000 = 2 x 1 = 2 mL
FINAL ANSWER:
2 mL
10
IV FLOW RATES
mL / hour
mL of solution
total hours
= mL/hr
What if
the question
is given in
minutes?
If the question is asking
for flow rate and you’re
given units of mL, you
need to write the answers
in mL/hr!
mL/hr is always
rounded to the
nearest
whole number!
mL of solution
min
333.333 mL/hr
50 mL
mL of solution
total minutes
gtt / min
Remember our abbreviations:
gtt means “drop”!
60 min
30 min
ANSWER: 333 mL/hr
What if
the question
is given in
hours?
NOTE:
If a drop factor is included,
the question is asking for
flow rate in gtt/min.
You need to write the
answers in gtt/minute!
Convert hours to minutes!
For example: 1 hours = 60 minutes
2.5 hours = 150 minutes
EXAMPLE #2
Ordered: 1000 mL of Lactated Ringer’s to
infuse at 50 mL/hour. Drop factor for tubing is
a 5 gtt/mL. (Convert: 1 hour = 60 min)
5 gtt/mL
4 gtt/min
50 ÷ 60 = 0.833 x 5 = 4.166
Round to the nearest whole number → 4
Ordered: 100 mL of Metronidazole to infuse
over 45 minutes. The tubing you are using
has a drop factor of 10 gtt/mL.
100 mL
45 min
10 gtt/mL
4 gtt/min
Remember Rule #4
Don’t round till the end!
22 gtt/min
100 ÷ 45 = 2.222 x 10 = 22.222
Round to the nearest whole number → 22
NOTE:
NOTE:
FINAL ANSWER:
100 mL/hr
ANSWER: 100 mL/hr
drop
factor = gtt/min
EXAMPLE #1
60 min
= mL/hr
Ordered: Infuse 3 grams of Penicillin in 50 mL
normal saline over 30 minutes.
(rounded to the nearest whole number)
50 mL
60
(minutes)
EXAMPLE #2
Ordered: 1000 mL D5W to infuse over 3
hours. What will the flow rate be?
3 hr
NOTE:
Since there are 60 minutes in one hour, use this formula:
EXAMPLE #1
1000 mL
NOTE:
FINAL ANSWER:
22 gtt/min
Remember Rule #4
Don’t round till the end!
11
PRACTICE QUESIONS
Do all 10 questions without looking at the correct answers on the following pages. Don’t forget to show
all your work. After you are done, walk through each question…even the questions you got correct!
1
ORDERED: Rosuvastatin 3000 mcg PO ac
AVAILABLE: Rosuvastatin 2 mg tablet (scored)
How many tabs will you administer in 24 hours?
2
ORDERED: Tylenol supp 2 g PR q6h
AVAILABLE: Tylenol supp 700 mg
How many supp will you administer?
Round to nearest tenth.
3
4
ORDERED: Potassium cholride 0.525 mEq/lb PO
dissolved in 6 oz of juice at 0930
AVAILABLE: Potassium cholride 12 mEq/mL
How many mL of potassium chloride
will you add to the juice for a 66.75 kg
patient? Round to nearest tenth.
6
250 mL normal saline over 5 hours.
Tubing drop factor of 10 gtt/mL.
7
Humulin R 200 units in 100 mL of normal
saline to infuse at 4 units/hr.
8
Dopamine 600 mg in 200 mL of normal saline to
infuse at 10mcg/kg/min. Pt weight = 190 lbs.
9
2.5 L normal saline to infuse over 48 hours.
1000 mL D5W to infuse over 4 hours.
10
5
ORDERED: Morphine 100 mg IM q12h prn pain
AVAILABLE: Morphine 150 mg/2.6 mL
How many mL will you administer?
Round to nearest hundredth.
150 mL Cipro 250 mcg
to infuse over 45 minutes.
12
COMPREHENSIVE REVIEW
1
ORDERED: Rosuvastatin 3000 mcg PO ac
AVAILABLE: Rosuvastatin 2 mg tablet (scored)
2
ORDERED: Tylenol supp 2 g PR q6h
AVAILABLE: Tylenol supp 700 mg
How many tabs will you
administer in 24 hours?
How many supp will you administer?
Round to nearest tenth.
STEP 1: CONVERT DATA
STEP 1: CONVERT DATA
mcg → mg
g → mg
3000 mcg = 3 mg
2g
= 2000 mg
Remember: small to big, move the decimal point
3 to the left (unit is getting Larger think Left)
Remember: big to small, move the decimal point
3 to the right
STEP 2: READY TO USE DATA
STEP 2: READY TO USE DATA
Ordered: 3 mg
Available: 2 mg
Volume: 1 tab
Administered ac: before each meal
Question is asking: dosage in 24 hours
Ordered: 2000 mg
Available: 700 mg
Volume: 1 supp
STEP 3: IRRELEVANT DATA
STEP 3: IRRELEVANT DATA
N/A
N/A
STEP 4: FORMULA USED
STEP 4: FORMULA USED
SHOW YOUR WORK
SHOW YOUR WORK
D
x V = A
H
3 mg
2 mg
NOTE:
= 1.5
1.5 x 1 tab = 1.5
1.5 x 3 = 4.5 tabs per day
ROUND: No rounding necessary
FINAL ANSWER:
D
x V = A
H
4.5 tabs
Don’t forget to check times of
medication! The medication is
ordered to be given AC,
which means before each meal.
Since there are 3 meals in a
day (24 hours), the answer
must be multiplied by 3.
2000 mg
700 mg
NOTE:
= 2.857
Remember Rule #4
Don’t round till the end!
2.857 x 1 supp = 2.857 supp
ROUND: Nearest tenth
2.857 supp
→ 2.9 supp
FINAL ANSWER:
2.9 supp
13
COMPREHENSIVE REVIEW
3
ORDERED: Potassium chloride 0.525 mEq/lb PO
dissolved in 6 oz of juice at 0930
AVAILABLE: Potassium chloride 12 mEq/mL
4
1000 mL D5W to infuse over 4 hours.
How many mL of potassium chloride will
you add to the juice for a 66.75 kg patient?
Round to nearest tenth.
STEP 1: CONVERT DATA
STEP 1: CONVERT DATA
kg → lb
N/A
66.75 kg x 2.2 (lb/kg) = 146.85 lb
NOTE:
In this case, ordered
amount depends on
patient weight
mEq/lb → mEq
( 0.525 mEq/lb x 146.85 lb = 77.096 mEq )
STEP 2: READY TO USE DATA
STEP 2: READY TO USE DATA
Ordered: 77.096 mEq
Available: 12 mEq
Volume: 1 mL
1000 mL
4 hr
STEP 3: IRRELEVANT DATA
Dissolved in 12 oz of juice at 0930
STEP 3: IRRELEVANT DATA
KEY
Question asked for
“per dose” because no
timeframe was given
STEP 4: FORMULA USED
STEP 4: FORMULA USED
D
x V = A
H
mL of solution
= mL/hr
total hours
SHOW YOUR WORK
77.096 mEq
12 mEq
= 6.424
6.424 X 1 mL = 6.424 mL
ROUND: Nearest tenth
6.424 mL
→ 6.4 mL
FINAL ANSWER:
N/A
SHOW YOUR WORK
NOTE:
1000 mL
Remember rule #4
Don’t round till the end!
4 hr
= 250 mL/hr
NOTE:
mL/hr is always rounded
to nearest
whole number!
ROUND: No rounding necessary
6.4 mL
FINAL ANSWER:
250 mL/hr
14
COMPREHENSIVE REVIEW
5
6
150 mL Cipro 250 mcg to infuse
over 45 minutes.
Remember:
If the question is asking
for flow rate (“to infuse”) and
you’re given mL of solution, you
need to write the answer in
mL/hours!
STEP 1: CONVERT DATA
250 mL normal saline over 5 hours.
Tubing drop factor of 10 gtt/mL.
STEP 1: CONVERT DATA
hr → min
N/A
1 hour = 60 minutes
5 hr x
STEP 2: READY TO USE DATA
mL of solution: 150 mL
total hours: 45 min
60 min
= 300 min
1 hr
STEP 2: READY TO USE DATA
mL of solution: 250 mL
total minutes: 300 min
Drop factor: 10 gtt/mL
STEP 3: IRRELEVANT DATA
Cipro 250 mcg
Important: don’t let this information lead you to
use the wrong formula. In this example, we’re
asked for a flow rate which requires mL of solution
and total time.
STEP 4: FORMULA USED
mL of solution
total minutes
45 min
mL of IV solution
x drop factor = gtt/min
time in minutes
x 60 = mL/hr
NOTE:
Remember rule #4
Don’t round till the end!
= 3.333 x 60 = 200 mL/hr
NOTE:
mL/hr is always rounded
to nearest
whole number!
ROUND: No rounding necessary
FINAL ANSWER:
200mL/hr
N/A
STEP 4: FORMULA USED
SHOW YOUR WORK
150 mL
STEP 3: IRRELEVANT DATA
SHOW YOUR WORK
250 mL
300 min
NOTE:
= 0.8333 mL/min
Don’t round till the end!
0.8333 mL/min x 10 gtt/mL = 8.3333 gtt/min
ROUND: gtt/mL is always rounded to the nearest whole number!
8.3333 gtt/min
→ 8 gtt/min
FINAL ANSWER:
8 gtt/min
NOTE:
The question may not specify
to round the final answer to
a whole number; you are
expected to know this with
gtt/min units.
15
COMPREHENSIVE REVIEW
7
Humulin R 200 units in 100 mL of normal saline
to infuse at 4 units/hr.
8
Dopamine 600 mg in 200 mL of normal
saline to infuse at 10 mcg/kg/min.
Pt weight = 190 lbs.
Remember:
If the question is asking
for flow rate (“to infuse”) and
you’re given mL of solution, you
need to write the answer in
mL/hr!
STEP 1: CONVERT DATA
STEP 1: CONVERT DATA
mcg → mg
N/A
Remember:
Small to big: move the decimal
point 3 to the left (unit is getting
Larger think Left)
10 mcg = 0.010 mg
lb → kg
190 lb / 2.2 = 86.363 kg
STEP 2: READY TO USE DATA
KEY
mg/kg
mg
→
min
min
Desired: 4 units/hr
Available: 200 units
Volume: 100 mL
In this case, ordered
amount depends on patient
weight
0.010 mg/kg/min x 86.363 kg = 0.863 mg/min
STEP 2: READY TO USE DATA
STEP 3: IRRELEVANT DATA
Desired: 0.863 mg/min
Available: 600 mg
Volume: 200 mL
N/A
STEP 3: IRRELEVANT DATA
N/A
STEP 4: FORMULA USED
STEP 4: FORMULA USED
SHOW YOUR WORK
SHOW YOUR WORK
D
x V = A
H
4 units/hr
200 units
D
x V = A
H
0.863 mg/min
= 0.02 /hr
0.02 /hr x 100 mL = 2 mL/hr
ROUND: No rounding necessary
FINAL ANSWER:
2 mL/hr
= 0.00143 /min
600 mg
0.00143 /min x 200 mL = 0.2878 mL/min
NOTE:
mL/hr is always rounded
to nearest
whole number!
0.2878 mL/min x 60 min = 17.2727 mL/hr
WAIT!
This is mL/min...
we need units of
mL/hr!
ROUND: mL/hr is always rounded to nearest whole number!
17.2727 mL/hr
→ 17 mL/hr
FINAL ANSWER:
17 mL/hr
16
COMPREHENSIVE REVIEW
9
2.5 L normal saline to infuse over 48 hours.
Remember:
If the question is asking
for flow rate (“to infuse”) and
you’re given mL of solution, you
need to write the answer in
mL/hours!
STEP 1: CONVERT DATA
L → mL
10
ORDERED: Morphine 100 mg IM q12h prn pain
AVAILABLE: Morphine 150 mg/2.6 mL
How many mL will you administer?
Round to nearest hundredth.
STEP 1: CONVERT DATA
N/A
Remember: big to small, move the decimal point
3 to the right
2.5 L = 2500 mL
STEP 2: READY TO USE DATA
STEP 2: READY TO USE DATA
mL of solution: 2500 mL
total hours: 48 hr
Ordered: 100 mg
Available: 150 mg
Volume: 2.6 mL
STEP 3: IRRELEVANT DATA
N/A
STEP 3: IRRELEVANT DATA
IM q12h prn pain
STEP 4: FORMULA USED
mL of solution
= mL/hr
total hours
SHOW YOUR WORK
2500 mL
48 hours
ROUND: mL/hr is always rounded to nearest whole number!
52.0833 mL/hr
FINAL ANSWER:
→
52 mL/hr
52 mL/hr
Question asked for
“per dose” because no
timeframe was given
STEP 4: FORMULA USED
D
x V = A
H
SHOW YOUR WORK
100 mg
= 52.0833 mL/hr
KEY
= 0.6666
150 mg
0.6666 x 2.6 mL = 1.7333 mL
ROUND: nearest hundredth
1.7333 mL
→ 1.73 mL
FINAL ANSWER:
1.73 mL
17
LAB VALUE CHEAT SHEET
VITAL SIGNS
BASAL METABOLIC PANEL (BMP)
• Blood pressure
RENAL
• Sodium: 135 – 145 mEq/L
• Systolic: 120 mmHg
• Potassium: 3.5 – 5.0 mEq/L
• Diastolic: 80 mmHG
• Chloride: 95 - 105 mEq/L
• Heart Rate: 60 - 100 BPM
• Calcium: 9 - 11 mg/dL
• Respirations: 12 - 20 Breaths per min
• BUN: 7 - 20 mg/dL
• Oxygen: 95% - 100%
• Creatinine: 0.6 – 1.2 mg/dL
• Temperature: 97.8 °F - 99 °F
• Albumin: 3.4 - 5.4 g/dL
• Calcium: 9 - 11 mg/dL
• Magnesium: 1.5 - 2.5 mg/dL
• Phosphorus: 2.5 - 4.5 mg/dL
• Specific gravity: 1.010 - 1.030
• GFR: 90 - 120 mL/min/1.73 m2
• BUN: 7 - 20 mg/dL
• Creatinine: 0.6 – 1.2 mg/dL
• Total protein: 6.2 - 8.2 g/dL
LIVER FUNCTION TEST (LFT)
LIPID PANEL
ABG’S
• ALT: 7 - 56 U/L
• Total cholesterol: <200 mg/dL
• AST: 5 - 40 U/L
• Triglyceride: <150 mg/dL
• ALP: 40 - 120 U/L
• LDL: <100 mg/dL → Bad cholesterol
• Bilirubin: 0.1 - 1.2 mg/dL
• HDL: >60/dL → Happy cholesterol
• PH: 7.35 - 7.45
• PaCO2: 35 - 45 mmHg
• PaO2: 80 - 100 mmHg
• HCO3: 22 - 26 mEq/L
HbA1c
REMEMBER
• Non-diabetic: 4 - 5.6%
PANCREAS
ROME
• Pre-diabetic: 5.7 - 6.4%
Opposite
Metabolic
Equal
• Diabetic: > 6.5% (GOAL for diabetic: < 6.5%)
• Amylase: 30 - 110 U/L
Respiratory
• Lipase: 0 - 150 U/L
COMPLETE BLOOD COUNT ( CBC )
COAGs
• WBC: 4,500 - 11,000
• RBC’s: 4.5 - 5.5
• PT: 10 - 13 sec
• PLT: 150,000 - 450,000
• PTT: 25 - 35 sec
• Hemoglobin (Hgb)
Female: 12 - 16 g/dL Male: 13 - 18 g/dL
• Hematocrit (HCT)
Female: 36% - 48%
Male: 39% - 54%
• aPTT: 30 - 40 sec (heparin)
• INR
- NOT ON Warfarin < 1 sec
- ON Warfarin 2 - 3 sec
OTHER
Measured
with
Therapeutic Range
Antidote
HEPARIN
aPTT
1.5 - 2.0 x normal “control” value
Protamine Sulfate
WARFARIN
PT/INR
1.5 - 2.0 x normal “control” value
Vitamin K
*The higher these numbers = higher chance of bleeding
• MAP: 70 - 100 mmHg
• ICP (intracranial pressure): 5 - 15 mmHg
• BMI: 18.5 - 24.9
• Glascow coma scale: Best = 15
Mild: 13-15 Moderate: 9-12 Severe: 3-8
18
ELECTROLYTES
LAB VALUE MEMORY TRICKS
SODIUM: 135 - 145
POTASSIUM: 3.5 - 5
*Commit to memory!
BANANAS:
There are about 3-5 in every
bunch & you want them half
ripe (½)
PHOR: 4
US: 2 (me + you = 2)
*don’t
forget
the .5
So, think 3.5 - 5.0
CALCIUM: 9 - 11
CALL 911
COMPLETE
BLOOD COUNT (CBC)
PHOSPHORUS: 2.5 - 4.5
MAGNESIUM: 1.5 - 2.5
MAGnifying glass
you see 1.5 - 2.5
bigger than normal
CHLORIDE: 95 -105
Think of a chlorinated pool that
you want to go in when it’s
SUPER HOT: 95 - 105 °F
• Hemoglobin (Hgb)
Female: 12 - 16 g/dL
Male: 13 - 18 g/dL
• Hematocrit (HCT)
Female: 36% - 48%
Male: 39% - 54%
To remember HCT,
multiply Hgb by 3
12 X 3 = 36
16 X 3 = 48
13 X 3 = 39
BASAL METABOLIC
PANEL (BMP)
18 X 3 = 54
BUN: 7 - 20 mg/dL
Think hamburger BUNs...
Hamburgers can cost anywhere
from $7 - $20 dollars
(Female)
(Male)
CREATININE: 0.6 – 1.2 mg/dL
This is the same value as
LITHIUM’s therapeutic range (0.6 - 1.2 mmol/L)
Lithium is excreted almost solely by the kidneys...
And creatinine is a value that tests how well your kidneys filter
19
BLOOD TYPES
ANTIGENS:
Proteins that elicit immune response
→
→
→
Plasma
WBC’s
RBC’s
A
Identifies the cell
PLASMA ANTIBODIES
Protects body from “invaders” (think ANTI)
Opposite of the type of antigen that is found
on the RBC
B
rsal
Unive
ENT
RECIPI
AB
rsal
Unive
R
DONO
Antigen:
A
Antigen:
B
Antigen:
Antibodies:
B
Antibodies:
A
Antibodies: NONE
Recipient:
Donor:
A, O
A, AB
Recipient:
Donor:
B, O
B, AB
A&B
Recipient:
Donor:
ALL
AB
O
Antigen:
NONE
Antibodies:
A&B
Recipient:
Donor:
O
ALL
Rh FACTOR
Has Rh on surface
Can receive
Does not have Rh on surface
Can receive
20
FUNDAMENTALS
Nurse
in the making
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39
SCOPE OF PRACTICE
RN
LPN/LVN
UAP
• Post-op assessment
• Stable client
• Routine, stable vital signs
• Initial client teaching
• Monitor RN’s findings &
gather data
• Documenting input and
output
• Specific assessments
• Can get blood from the
blood bank
• Starting blood products
• Sterile procedures
• IV’s & IV medications
• Discharge education
• Clinical assessment
ADPIE
• Reinforce teaching
• Routine procedures (catheterization, ostomy care,
wound care)
• Monitors IVF’s & blood
products
• Administer injections &
narcotics (not IV’s meds &
1st IV bag)
• Tube potency & enteral
feedings
NOTE:
When a registered nurse delegates
tasks to others, responsibility is
transferred but accountability for
patient care is not transferred. The
RN is still responsible!
• Sterile procedures
SPECIFIC ASSESSMENTS
• Activities of daily living
(ADL’s)
ADL’S
• Feeding (not with
aspiration risk)
• Positioning
• Ambulation
• Cleaning
• Linen change
• Hygiene care
Lung sounds, bowel
sounds, & neurovascular
checks
RN = Registered Nurse, LPN = Licensed Practical Nurse, LVN = Licensed Vocational Nurse, UAP = Unlicensed Assistive Personnel
40
PHARMACOLOGY
Suffixes, Prefixes, & Antidotes
in the making
41
ANTIBIOTICS / ANTIBACTERIALS
Broad spectrum antibiotics
-oxacin
Tetracyclines
-cycline
Sulfonamides
sulf-
Cephalosporins
-cef ceph-
Penicillins
-cillin
Aminoglycosides & macrolides
-mycin
Fluoroquinolones
-floxacin
ANTIVIRALS
Antiviral (disrupts viral maturation)
-virimat
Antiviral (undefined group)
vir- -vir- -vir
Antiviral (neuraminidase inhibitors)
-amivir
Antiviral (acyclovir)
-cyclovir
HIV protease inhibitors
-navir
HIV / AIDS
-vudine
ANTIFUNGAL
Antifungal
-azole
42
CARDIAC
ANT I H Y P ERT EN S IV ES
ACE inhibitors
-pril
Beta-blockers
-olol
Angiotensin II receptor antagonists
-sartan
Calcium channel blockers
-pine -amil
Vasopressin receptor antagonists
-vaptan
Alpha-1 blockers
-osin
Loop diuretics
-ide -semide
Thiazide diuretics
-thiazide
Potassium sparing diuretics
-actone
ANT I H Y P ERLIP ID EM IC S
HMG-CoA reductase inhibitor
-statin
O T H ER
Anticoagulants (Factor Xa inhibitors)
-xaban
Anticoagulants (Dicumarol type)
-arol
Anticoagulants (Hirudin type)
-irudin
Low-molecular-weight heparin (LMWH)
-parin
Thrombolytics (clot-buster)
-teplase -ase
Antiarrhythmics
-arone
43
RESPIRATORY
UP P ER RES P IRAT O RY
Second-gen antihistamines (H1 antagonist)
-adine
Second-gen antihistamines (H1 antagonist)
-tirizine
Second-gen antihistamines (H1 antagonist)
-ticine
Nasal decongestants
-ephrine -zoline
L O W E R RES P IRAT O RY
Beta2-agonists (Bronchodilator)
-terol
Xanthine derivatives
-phylline
Cholinergic blockers
-tropium
Cholinergic blockers
-clindidiun
Immunomodulators & leukotriene modifiers
-zumab -lukast
44
ANESTHETICS / ANTIANXIETY
Local anesthetics
-caine
Barbiturates (CNS depressant)
-barbital
Benzodiazepines (for anxiety/sedation)
-zolam
Benzodiazepines (for anxiety/sedation)
-zepam
ANTIDEPRESSANTS
Selective serotonin
reuptake inhibitors (SSRIs)
-oxetine -talopram -zodone
Serotonin-norepinephrine
-faxine -zodone -nacipram
reuptake inhibitors
(SNRI/DNRI)
Tricyclic antidepressants (TCAs) -triptyline -pramine
45
ANALGESICS / OPIOIDS
Opioids
-done
Opioids
-one
NSAID’s (anti-inflammatory)
-olac -profen
Salicylates
Asprin (ASA)
Nonsalicylates
Acetaminophen
GASTROINTESTINAL
Histamine H2 antagonists (H2-blockers)
-tidine -dine
Proton pump inhibitors (PPIs)
-prazole
Laxatives
-lax
46
ANTIDIABETIC
Oral hypoglycemics
-ide -tide -linide
Inhibitor of the DPP-4 enzyme
-gliptin
Thiazolidinedione
-glitazone
MISCELLANEOUS
Corticosteroids
-asone -olone -inide
Triptans (anti-migraine)
-triptan
Ergotamines (anti-migraine)
-ergot-
Antiseptics
-chloro
Antituberculars (TB)
rifa-
Bisphosphonates
-dronate
Neuromuscular blockers
-nuim
Retinoids (anti-acne)
tretin-
Phosphodiesterase 5 inhibitors
-afil
Carbonic anhydrase inhibitors
-lamide
Progestin (female hormone)
-trel
Atypical antipsychotics
-ridone
47
ANTIDOTES
Opioids / narcotics
Naloxone (Narcan)
Warfarin
Vitamin K
Heparin
Protamine sulfate
Digoxin
Digibind
Anticholinergics
Physostigmine
Benzodiazepines
Flumazenil (Romazicon)
Cholinergic crisis
Atropine (Atropen)
Acetaminophen (Tylenol)
Acetylcysteine
Magnesium sulfate
Calcium gluconate
Iron
Deferoxamine
Lead
Chelation agents
Lead
Dimercaprol & disodium
Alcohol withdrawal
chlordiazepoxide (Librium)
Beta blockers
Glucagon
Calcium channel blockers
Glucagon, insulin, or calcium
Aspirin
Sodium bicarbonate
Insulin
Glucose
Pyridoxine
Deferoxamine
Tricyclic antidepressants
Sodium bicarbonate
Cyanide
Hydroxocobalamin
48
MENTAL HEALTH
DISORDERS
Nurse
in the making
49
THERAPEUTIC COMMUNICATION TECHNIQUES
Client-centered type of communication to build and help
relationships with clients, families, and all relationships.
DON’T
DO
• Ask “why”
• Allow client to control the discussion
• Give recognition/validation
• Active listening!
• Use open-ended questions
• Ask too many questions
• Give advice
• Give false reassurance
Don’t be a LOSER, be an active listener!
L
O
S
E
R
• Change the conversation topic
Lean forward toward the client
Open posture
Sit squarely facing the client
Establish eye contact
Relax & listen
• Give approval or disapproval
• Use close-ended questions/statements
EXAMPLES
EXAMPLES
“Is there something you
would like to talk about?”
“Don’t worry!”
“Tell me more about that”
“I think you should _____”
“So you are saying you
haven’t been sleeping well?”
“Don’t be silly”
“That’s great!”
“Tell me more about ______”
THERAPEUTIC COMMUNICATION CAN BE BOTH...
VERBAL COMMUNICATIONS
Words a person speaks
&
35%
65%
NON-VERBAL COMMUNICATIONS
You may say all the “right” things
but deliver it poorly.
Facial expressions
Movement
Eye contact
Appearance
Posture
Body language
Vocal cues
(yawning, tone of voice, pitch of voice)
50
CLUSTER C
CLUSTER B
CLUSTER A
PERSONALITY DISORDERS
PARANOID
Odd
or
Eccentric
SCHIZOID
Indifferent
Suspicious of others
Seclusive
Thinks everyone
wants to harm them
Detached
Strange appearance
BORDERLINE
HISTRIONIC
NARCISSTIC
Unstable
Seeks attention
Manipulative
Manipulative
to self & others
Doesn’t follow
the rules
Fear of neglect
Center of attention
by being seductive
& flirtatious
Egocentric
AKA narcissus
No care for others
Aggressive
AVOIDANT
Anxious
or
Insecure
Odd thinking
(magical thinking)
Doesn’t care for
close relationships
ANTISOCIAL
Dramatic
or
Emotional
SCHIZOTYPAL
Anxious in
social settings
Avoids social
interactions but desires
close relationships
Fear of abandonment
NURSING CARE
• Safety is a priority
DEPENDENT
OBSESSIVE-COMPULSIVE
Extreme dependency
one someone
Perfectionist
Searches urgently to
find a new relationship
when the other fails
Clients with a personality
disorder are at a ↑ risk
for violence & self-harm
• Develop a therapeutic relationship
• Respect the patient’s needs while still setting
limits and consistency
• Give the client choices to improve their
feeling of control
Needs consistent
applause
Control issue
Rigid
TREATMENT
Medications such as
• Antidepressants
• Anxiolytics
• Antipsychotics
• Mood stabilizers
Therapies such as
• Psycho
• Group
• Cognitive
• Behavioral
51
EATING DISORDERS
ANOREXIA NERVOSA
BULIMIA NERVOSA
↓ Weight (BMI <18.5)
Binge eating followed by purging
↓ Blood pressure
Normal weight to overweight
(BMI 18.5 - 30)
↓ Heart rate
from dehydration
& electrolyte imbalance
↓ Sexual development
Teeth erosion
↓ Subcutaneous tissue = Hypothermia
Bad breath
↓ Period regularity
May use laxatives and/or diuretics
BINGE EATING
Binge eating not followed by purging
Tend to be overweight
Binging causes:
• Depression
• Hatred
• Shame
TREATMENT
Amenorrhea (period may stop)
Refuses to eat
Monitor client during and
after meals
for acts of purging
Lanugo (thin hair to keep the body warm)
Typically does not purge
Restricts self from eating
Fear of gaining weight
Constipation (from dehydration)
TREATMENT
↑ Weight slowly
(2 -3 lbs a week)
Monitor excerise
REFEEDING SYNDROME
Potential complications when fluids, electrolytes,
and carbohydrates are introduced too quickly to a
malnourished client. Treatment should be done
slowly to avoid this syndrome.
TREATMENT FOR ALL EATING DISORDERS
Teach
coping skills
Maintain
trust
Have the client be a part
of the decision making
& the plan of care!
Therapy
group, individual or family
52
BIPOLAR DISORDER
MOOD SWINGS:
Depression to mania with periods of normalcy
SWI
N GS FRO M
MANIC PHASE
DEPRESSIVE PHASE
Periods of HIGH mood
Irritable & hyper
May require hospitalization
Periods of LOW mood
SIGNS & SYMPTOMS
Sad
SIGNS & SYMPTOMS
Restless
↓ Sleep
Low energy levels
Flight of ideas
Delusions
Sleep disturbances:
Conversation is all over
the place with rapid speech
Grandiosity
Hyper mood
Leads to exhaustion
Poor judgement
Manipulative behavior
too much or too little sleep
Hallucinations
Impulsivity
Examples: maxing out credit cards,
engaging in risky behavior
Elevated activity
Leads to malnutrition & dehydration
For clients with mania, the nurse should
offer energy & protein-dense foods that
are easily consumed on the go (finger foods!)
HAMBURGERS • SANDWICHES
FRUIT JUICES • GRANOLA BARS • SHAKES
TREATMENT
• Provide a safe environment
Remove harmful objects from the room
NURSING CONSIDERATIONS
FOR THE ACUTE PHASE
• Set limits on manipulative behavior
• Provide finger foods & fluids
• Re-channel energy for physical activity
• ↓ Stimuli
– Turn off or turn down the TV & music
– Keep away from other clients if they are bothersome
• Lithium carbonate
PHARMACOLOGY
• Anticonvulsants
• Antidepressants
• Antipsychotics
• Antianxiety
See pharmacology section for more details
53
SCHIZOPHRENIA SPECTRUM DISORDER OVERVIEW
POSSIBLE CAUSES (not fully known)
PHASES
1
PRE-MORBID
Normal functioning.
Symptoms have not become apparent yet.
2
PRODROMAL
More tempered form of the disorder.
Can be months to years for the disorder to become
obvious.
3
SIGNS & SYMPTOMS
4
SCHIZOPHRENIA
RESIDUAL
↑ in the neurotransmitter
DOPAMINE
Positive symptoms are noticeable and apparent.
Periods of remission. Negative symptoms may remain,
but S&S of the acute stage (positive symptoms) are gone.
POSITIVE
NEGATIVE
Delusions
Flattened/bland effect
Lack of energy
Anxiety/agitation
Reduced speech
Hallucinations
Avolition
Auditory *most common
Lack of motivation
Jumbled speech
Disorganized behavior
Anhedonia
Illicit substance
(LDS & Marijuana)
Environmental
(malnutrition, toxins, viruses during pregnancy)
Genetics
(family history)
TREATMENT
• Medication
- Antipsychotic medications
- Antidepressants
- Mood stabilizers (lithium)
- Benzodiazepines
Not capable of feeling joy or pleasure
• Therapy
Lack of social interaction
• Exercise
NURSING CONSIDERATIONS
• Try to establish trust with the patient
HOW TO ADDRESS HALLUCINATIONS?
• Encourage compliance with the medications
• Don’t address the hallucinations
Example: “I don’t see spiders on the wall but I see you are scared”
• Promote self-care
• Be compassionate
• Encourage group activities
• Offer therapeutic communication
• Bring the conversation back to reality
• Do not argue with the client
• Provide safety for the client & the staff!
54
TYPES OF DEPRESSION
MAJOR DEPRESSIVE DISORDER (MDD)
Has at least 5 of these symptoms
every day for at least 2 weeks:
•
•
•
•
•
Depressed mood
• Not able to feel pleasure
• ↑ or ↓ motor activity
Too much or too little sleep
• Weight fluctuations
Indecisiveness
(5% change within a month)
Thoughts of death (suicide)
↓ ability to think/concentrate
FACTS
• MDD impairs the client’s normal functioning
• MDD is not the same depression seen in bipolar disorder
• MDD is not a mood swing, it’s constant
TREATMENT PHASES FOR MDD
ACUTE: 6 - 12 weeks
Hospitalization & medications may be perscribed
GOALS:
• ↓ Depressive symptoms
• ↑ Functionality
CONTINUATION: 4 - 9 monthsMedication is continued
GOALS:
• Prevent relapse
MAINTENANCE: 1+ year
Medication may be continued or be phased out
GOALS:
• Prevent relapse & further depressive episodes
PREMENSTRUAL DYSPHORIC DISORDER (PMDD)
Depression that occurs during the luteal phase of the menstrual cycle.
SUBSTANCE INDUCED DEPRESSIVE DISORDER
Depression associated with withdrawal or the use of alcohol and drugs.
PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA)
A more mild form of depression compared to MDD,
although it can turn into MDD later in life.
SEASONAL AFFECTIVE DISORDER (SAD)
Depression that occurs seasonally.
Often occurs during the winter months when there is less sunshine.
TREATMENT: Light therapy
TREATMENT
ELECTROCONVULSIVE THERAPY (ECT)
Used for clients who are unresponsive to other treatments.
MEDICATIONS
Transmits a brief electrical stimulation to the patient’s brain.
• SSRI’s
• TCA’s
• The patient is asleep under anesthesia
• SNRI’s
• MAOI’s
• The client will not remember
and is unaware of the procedure
NON-PHARMACOLOGICAL
• Muscle relaxants may be given to
THERAPIES
↓ seizure activity & ↓ risk for injury
• Light therapy
• Client may have memory loss, confusion,
• St. John’s wort
& headache post-procedure
THE PROCEDURE
Treatme
nt
for the
c
will refle lient
ct w
phase th hat
ey
are in!
SYMPTOMS
• Emotional
• ↑ Eating
• ↓ Energy
• ↓ Concentration
POSTPARTUM
Depression that happens after
a woman goes through childbirth.
The woman may feel disconnected
from the world. She may have a fear of
harming her newborn.
NURSING CONSIDERATIONS
• Safety is a priority. Those struggling with
depression have a higher suicide risk.
Initiate suicide precautions:
- Remove sharp things
- Keep medications out of reach
- Remove objects that may be used for strangulation (wires)
• Help the client identify coping methods
& teach alternatives if needed
• Provide local resources such as churches,
local programs, community resources, etc.
• Encourage:
- Physical activity
- Self-care
- Supportive relationships
Individual therapy, support groups, & peer support
55
DIFFERENT TYPES OF ANIXETY DISORDERS
LEVELS OF ANXIETY
WORST
MILD
MODERATE
SEVERE
PANIC
Normal/healthy
amount of anxiety.
Allows one to have sharp
focus & problem solve.
Thinking ability is
impaired. Sharp focus
& problem-solving can
still happen just at a
lower level.
Focus & problem solving
are not possible.
Feelings of doom
may be felt.
Most extreme anxiety.
Unstable & not in touch
with reality.
SYMPTOMS
NORMAL
Nail-biting
Tapping
Foot jitters
GI upset
Headache
Voice is shakey
Dizziness
Headache
Nausea
Sleeplessness
Hyperventilation
Pacing
Yelling
Running
Hallucinations
Separation
Anxiety Disorder
Experiences extreme fear of anxiety when separated from
someone they are emotionally connected to. This is a
normal part of infancy, but not a normal part of adulthood.
SOME EXAMPLES:
ANXIETY DISORDERS
Specific Phobia
Social Anxiety Disorder
(Social Phobia)
Panic Disorder
Agoraphobia
OBSESSIVE COMPULSIVE DISORDERS
Generalized Anxiety
Disorder (GAD)
Obsessive Compulsive
Disorder (OCD)
Irrational fear of a particular object or situation.
• Monophobia - Fear of being alone
• Zoophobia - Fear of animals
• Acrophobia - Fear of heights
Fear of social situations or presenting in front of groups. They fear embarrassment.
They may have symptoms (real or fake) to escape the situation.
Reoccurring panic attacks that last 15 - 30 minutes with physical manifestations.
Extreme fear of certain places where the client feels unsafe or defenseless.
May even be too fearful of places to maintain employment.
Agora
means
“open space”
Uncontrolled extreme worry for at least 6 months
that causes impairment of functionality.
OBSESSION:
Recurrent thoughts
COMPULSION:
Recurrent acts or behaviors
This obsessiveness is usually because it decreases stress & helps deal with anxiety.
Hoarding Disorder
Compulsive desire to save items even if they have no value to the person.
It may even lead to unsafe living environments.
Body Dysmorphic
Disorder
Preoccupied with perceived flaws or imperfections in physical appearance
that the client thinks they have.
56
SOMATIC SYMPTOM & RELATED DISORDERS (SOMATOFORM DISORDERS)
SOMATIC SYMPTOM DISORDER
Somatization is psychological stress that presents
through physical symptoms that can not be explained by any pathology or diagnosis.
NURSING CONSIDERATIONS
• SAFETY is a priority
Asses for symptoms or thoughts
of self-harm or suicide
MANIFESTATIONS
• Consumed by physical manifestations
to the point it disrupts daily life
• Seeks medical help from multiple places
• Remission & exacerbations
• Overmedicates with analgesic and
antianxiety medications
• Understand the somatic symptoms are real
to the client even though they are not real
• ↑ Stress = ↑ somatic symptoms
• Help the client verbalize their feelings while
limiting the amount of time talking about
their somatic symptoms
PHQ-15:
PATIENT HEALTH QUESTIONNAIRE 15
• Asses coping mechanism & educate
on alternative ways of coping
CONVERSION DISORDER
Sudden onset of neurological manifestations &
physical symptoms without a known neurological
diagnosis. It can be related to a psychological conflict/need beyond their conscious control.
NURSING CONSIDERATIONS
• Ensure SAFETY
• Gain trust & rapport with the client
• Asses coping mechanism
& educate on alternative ways of coping
• Asses stress management methods
An assessment tool used to identify 15
of the most common somatic symptoms
MANIFESTATIONS
MOTOR
Paralysis pseudoseizures
Pseudocyesis:
Signs & symptoms of pregnancy without the
presence of a fetus AKA false pregnancy.
This may be present in a client who desires
to become pregnant
SENSORY
Blindness
Deafness
Sensations (burning/tingling)
Inability to smell/speak
• Encourage therapy such as:
- Individual therapies
- Group therapies
- Support groups
MEDICATIONS
POSTTRAUMATIC STRESS DISORDER (PTSD)
MANIFESTATIONS
Mental health condition where exposure to a traumatic event has occured.
NURSING CONSIDERATIONS
• Teach relaxation techniques
• Teach ways to ↓ anxiety
• Support groups
The client may be prescribed
antidepressants or anxiolytics
Lasting longer than 1 month:
• Anxiety
• Detachment
• Nightmares of the event
MEDICATIONS
Antidepressants may be prescribed
57
NEUROCOGNITIVE DISORDERS
Dementia & Alzheimer’s are NOT the same.
Dementia is a general term that refers to a group of symptoms, not a specific disease.
Dementia may advance to a major neurocognitive disorder such as Alzheimer’s disease.
SHORT TERM / SUDDEN CHANGE
Impairment (hours - days)
ALZHEIMER’S
ONSET
DELIRIUM
CONTINUOUS
Decline of function (months - years)
There is always an underlying cause...
something is causing the delirium!
Delirium is a medical emergency and
requires prompt diagnosis & treatment
• Disorganization
- Most common to time & place
- Happens mostly at night
• ↓ Memory
• Anxiety & agitation
• Delusional thinking
Head Injury
Traumatic brain injuries (TBI) & head trauma
Advanced Age
>65 have the highest risk
Cardiovascular Disease & Lifestyle Factors
Inactivity, unhealthy diet, high cholesterol, obesity, & diabetes
STAGES OF ALZHEIMERS DISEASE
• Ranges from lethargic to hypervigilance!
SEVERE MODERATE MILD
• Secondary to a medical condition
(infection, electrolyte imbalance,
substance abuse...etc)
RISK FACTORS
• Stroke
• Surgery
• Restraints
MANIFESTATIONS
• Hospitalization
• ICU delirium
• Polypharmacy
• Old age
Genetics
Family history (immediate family)
Early stage
not noticeable
to others
Middle Stage
noticeable to others
Late Stage
Requires
full assistance
• Memory lapse
• Misplacing things
• Short term memory
• Difficulty focusing
• Can still accomplish
own ADL's
• Forgets own history
• Gets lost & wanders often
• Difficulty completing tasks • Gets angry & frustrated
• Personality changes
• Unable to do some ADL’s & self-care
(may be incontinent)
• Needs assistant with all ADL’s
• Losing the capability to have discussions
• Losing physical skills (walking, sitting, swallowing)
• May result in death or coma
• Safety: prevent physical harm
• Avoid restrains when possible
• Remember physical needs
(Hygiene, food, water, sleep, etc)
• May be prescribed
anti-anxiety/antipsychotic medications
INTERVENTIONS
Caring for a pt. with Alzheimer’s is very complex!
• Help families in planning for
extended care
• Monitor nutrition, weight,
& fluids status
• Maintain a quiet environment
to ↓ stimuli
• Cholinesterase inhibitor may be
prescribed to improve quality of life
but does NOT cure the disease.
Communication
• Speak slowly
• Give one direction at a time
• Don’t ask complex or open-ended
questions
• Ask simple, direct questions
• Face the client directly when speaking
RX
Reversible if prompt treatment is initiated
CURE?
Used in early & moderate stages of
dementia & Alzheimer’s disease. May
also be used for Parkinson’s dementia.
GENERIC
TRADE NAME
donepezil
Aricept
galantamine
Razadyne
Rivastigmine
Exelon
Irreversible
58
MENTAL HEALTH
PHARMACOLOGY
Nurse
in the making
59
LITHIUM CARBONATE
MOOD STABILIZER:
Known for its side effects and narrow therapeutic range
THERAPEUTIC RANGE:
0.6 - 1.2 mEq/L
USES
ADVERSE REACTIONS
• Nausea
Bipolar disorder
Helps regulate the “mood swings”
(depression & mania)
TOXICITY
LEVELS
• Confusion
• Diarrhea
• Thirst
• Polyuria
TOXICITY!
• Blurred vision
• Vomiting
Mild: 1.5 - 2 mEq/L
Moderate: 2 - 3 mEq/L
• Tinnitus
Ringing in ears
Severe: > 3 mEq/L
• Slurred speech
• Coma
• Convulsions
• Tremors
• Weight gain
HOW DOES TOXICITY HAPPEN?
• Dehydration
causes ↑ lithium levels in blood
• Hyponatremia
• Old age
↓ kidney function...this means lithium
builds up in the blood
EDUCATION
• Carry ID that shows you are taking lithium
CONTRADICTIONS
• Pregnancy category D:
Contradicted in pregnancy & breastfeeding
• Renal / cardiovascular disease
• Dehydrated patients
Excessive diarrhea or vomiting
• Receiving diuretics
• Sodium depletion
• Hypersensitivity to tartrazine
• Educate on signs & symptoms of toxicity
• Educate and stress importance of taking
medication regularly
• Serum lithium levels should be checked
every 1-2 months
• Do not operate heavy machinery or drive
• Educate on drinking plenty of water to
avoid dehydration (therefore avoiding toxicity)
• Avoid starting a low salt diet
Sudden ↓ in salt = ↑ in lithium
60
ANTIDEPRESSANT DRUGS
SNRI’s/DNRI’s
SSRI’s
Serotonin / Norepinephrine
&
Dopamine / Norepinephrine reuptake inhibitor
DRUG TABLE
NURSING CONSIDERATIONS
SIDE EFFECTS
USES
ACTION
Selective serotonin
reuptake inhibitor
Inhibits uptake
of serotonin = ↑ serotonin
• Depression
• Anxiety
NEURO
• Headache
• Tremors
• Difficulty sleeping
3 S’s of SSRI’s
Think
Smiley
Serotonin
• OCD
• Eating disorders
GI
• Nausea
• Urinary retention
• Dry mouth / thirst • Sexual dysfunc• Constipation
tion
SEROTONIN SYNDROME
• Serotonin syndrome
• Sexual dysfunction
• Stomach issues
• Too much serotonin
in the brain
• Mental changes
• Tachycardia
• Tightness in muscles
• Difficulty walking
• ↑BP & temp
Affects serotonin,
norepinephrine & dopamine
• Depressive episodes
• Anxiety disorders
• Fibromyalgia
• Diabetic neuropathy pain
NEURO
• Headache
• Dizziness
• Vertigo
• Photosensitivity
• Agitation/tremors
• Insomnia
GI
• Dry mouth/thirst
• Dehydration
• Constipation
• Nausea/diarrhea
• May take 4 -6 weeks to take effect
Educate on the importance of compliance
• Take medication in the morning
• First line drug for depression/anxiety
SUICIDE WARNING
A client who had suicidal plans may now have the
energy due to the medication to carry out the plans!
• May take 4-6 weeks to take effect
Educate on the importance of compliance
• Do not mix with TCA’s or MAOI’s
• Zyban is used for smoking cessation.
Do not use it while taking bupropion
for depression – it could cause overdose.
GENERIC
sertraline
TRADE NAME
Zoloft
GENERIC
bupropion
TRADE NAME
Zyban & Wellbutrin
citalopram
Celexa
duloxetine
Cymbalta
escitalopram
Lexapro
venlafaxine
Effexor XR
fluoxetine
Prozac
milnacipran
Savella
vilazodone
Viibryd
nefazodon
—
SUFFIXES
SUFFIXES
-talopram, -oxetine, -zodone
-faxine, -zodone, -nacipram
61
ANTIDEPRESSANT DRUGS
Tricyclic antidepressants
Monoamine oxidase inhibitor
Blocks reuptake of serotonin
& norepinephrine in the brain
Blocks monoamine oxidase which causes ↑ in
epinephrine, norepinephrine, dopamine, &
serotonin, which causes stimulation of the CNS!
Depression
USES
MAOI’s
ACTION
TCA’s
• Depressive episodes
• Bipolar disorder
• OCD
• Neuropathy
• Enuresis
Ca
heart p uses
patien roblems in
isting c ts with pre-e
xa
or elde rdiac conditio
rly clie
ns
with ca nts...give
ution!
Educate on the importance of compliance
• WAIT 14 days after being off MAOI’s
to start taking TCA’s
• Amoxapine is not an antipsychotic drug
but similar to these drugs, it may cause
TD & NMS (D/C the drug immediately
if these symptoms occur)
GI
• Constipation
• Dry mouth
• Nausea/ vomiting
HYPERTENSIVE CRISIS
• Headache
• Stiff neck
• Nausea / vomitting
• Fever
Seek
• Dialated pupils medical h
elp
to
blood ↓
pressu
re
• Can take up to 4 weeks to reach
therapeutic levels
Educate on the importance of compliance
• Educate on the signs
& symptoms of HTN crisis
• Avoid foods with Tyramine
• Aged cheese
• Fermented meats
• Chocolate
• Caffeinated beverages
• Sour cream & yogurt
TRADE NAME
—
GENERIC
phenelzine
TRADE NAME
Nardil
amoxapine
—
tranylcypromine
Parnate
clomipramine
Anafranil
isocarboxazid
Marplan
protriptyline
Vivactil
nortriptyline
Pamelor
SUFFIXES
DRUG TABLE
GENERIC
amitriptyline
NURSING CONSIDERATIONS
• May take 2- 3 weeks to take effect
NEURO
• Orthostatic hypotension
• Dizziness
• Blurred vision
SIDE EFFECTS
• Constipation
• Dry mouth
• Drowsiness
• Blurred vision
• Orthostatic hypotension
• Urine retention
• Cardiotoxic
-triptyline, -pramine
62
ANTIANXIETY DRUGS (ANXIOLYTICS)
BENZODIAZEPINES
Not a fi
rst-line
drug fo
r treatin
g
long-te
rm
psychia
tric anx
ie
ty
conditio
ns
RX
Bipolar disorder
Benzo’s are mainly prescribed for acute anxiety,
sedation/muscle relaxant, seizures, & alcohol withdrawal
ACTION
GENERIC
alprazolam
TRADE NAME
Xanax
lorazepam
Ativan
diazepam
Valium
clonazepam
Klonopin
chlordiazepoxide
Librium
SUFFIXES
Binds to cell receptors enhancing the effects of GABA
-zolam & -zepam
GABA (inhibitory neurotransmitter)
slows/calms the activity of the nerves in the brain
Antidote: FLUMAZENIL
ADVERSE DRUG REACTIONS (ADR’S)
• Mild drowsiness, sedation
• Lightheadedness, dizziness, ataxia
• Visual disturbances
NURSING CONSIDERATIONS
TO HELP WITH ADR’S
Take at night if it makes you dizzy/drowsy
Rise slowly from sitting or lying
Do not drive or operate heavy machinery
• Anger, restlessness
• Nausea, constipation, diarrhea
• Lethargy, apathy, fatigue
Fluids, fiber, & exercise!
Give with food to ↓ GI upset
Sips of water, suck on hard candy,
chewing sugar-free gum
• Dry mouth
SYMPTOMS OF WITHDRAWAL
Withdrawals typically happen when the
medication is stopped abruptly or taken
for >3 months
• ↑ Anxiety
• Agitation
• ↑ HR
• Seizures/tremors
• ↑ BP
• Insomnia
• ↑ Temp/sweating
• Vomiting
• ↓ Memory
• Muscle aches
NURSING CONSIDERATIONS
• Not meant for long term therapy
because ↑ risk for physical & psychological
DEPENDENCE
• Use of long term therapy leads to
TOLERANCE
Larger doses of the drug are required to
achieve the desired outcome
• Must be TAPERED
↓ the dosage gradually.
NEVER stop the medication abruptly!
CONTRAINDICATIONS & PRECAUTIONS
• Pregnant, laboring & lactating
women
(Preg Category D)
• Elderly (↑ chance of dementia)
• Impaired liver or kidney function
• Debilitation
ACTION
NONBENZODIAZEPINES
Depends on the drug
buspirone (Buspar)
acts on serotonin receptors
hydroxyzine (Vistaril)
acts on the hypothalamus &
brainstem reticular formation
GENERIC
TRADE NAME
buspirone
Buspar
doxepin
Silenor
hydroxyzine
Vistaril
meprobamate
—
63
ANTIPSYCHOTICS
Most commonly used for psychosis (schizophrenia)
REVIEW: Why are SGA’s better than FGA’s?
SGA's work on both postive & negative symptoms, and have a lower risk of developing tardive dyskinesia (TD).
FIRST GENERATION
ANTIPSYCHOTICS (FGA’s)
SECOND GENERATION
ANTIPSYCHOTICS (SGA’s)
Also called typical/conventional
Also called atypical
GENERIC
TRADE NAME
GENERIC
TRADE NAME
risperidone
Risperdal
chlorpromazine
—
clozapine
Clozaril
haloperidol
Haldol
quetiapine
Seroquel
loxapine
Adasuve
ziprasidone
Geodon
aripiprazole
Abilify
ACTIONS OF FGA’s
ACTIONS OF SGA’s
• Blocks/inhibits dopamine from being
released in the brain
• Acts on both serotonin & dopamine in the brain
• Helps diminish positive symptoms of schizophrenia
SIDE EFFECTS OF FGA’s
• Helps diminish positive symptoms of schizophrenia
& helps negative symptoms as well!
SIDE EFFECTS OF SGA’s
SIDE EFFECTS OF BOTH
• Lower risk of TD, EPS & NMS
• Anticholernergic effects
• Higher risk of TD, EPS, & NMS
• ↑ Weight
• Photophobia
• Orthostatic hypotension
• ↑ Cholesterol
• ↑ Triglyceride
• Photosensitivity
• ↑ Blood sugar
• Sedation/lethargy
TARDIVE DYSKINESIA (TD)
EXTRAPYRAMIDAL SYNDROME (EPS)
NEUROLEPTIC MALIGNANT SYNDROME (NMS)
• Involuntary movements of the face, tongue, or limbs that may be irreversible.
• Parkinson’s like symptoms • Akathesia (restlessness) • Dystonia (muscle twitching)
• Combination of symptoms: EPS, high fever, & autonomic disturbance
• One can recover 7-10 days after DC of medication, but it can be fatal
if not treated in time
• Parkinson’s disease
• Comatose pt.
• Liver problems
• Depressed
• Coronary artery
disease
• Bone marrow
depression
• Blood dyscrasias
• Hyper or
hypotension
• Educate that it may take
6 - 10 weeks to take
effect
• Tell patient about adverse
reactions and emphasize
that adherence is very
important
FGA’s
• Hypersensitivity
NURSING CONSIDERATIONS
SGA’s
CONTRAINDICATIONS
• Teach S&S of TD, EPDS, & NMS!
• Advise the client to get up slowly
• Check labs
(blood sugar, LDL, triglycerides)
• To decrease the risk of gaining weight,
advise the patient about exercise,
low-calorie diet, & monitor their
weight.
64
MOTHER BABY
Nurse
in the making
65
ABBREVIATIONS
IUP/IUFD....... Intrauterine pregnancy / intrauterine fetal demise
SAB................ Spontaneous abortion
TAB................. Therapeutic abortion
LMP................ Last menstrual period
ROM............... Rupture of membranes
SROM............. Spontaneous rupture of membranes
AROM............ Artificial rupture of membranes
PROM............. Prolonged rupture of membranes (>24 hours)
PPROM.......... Preterm premature rupture of membranes
SVD................ Spontaneous vaginal delivery
FHR................ Fetal heart rate
EFM................ Electronic fetal monitoring
US................... Ultrasound transducer (detects FHR)
FSE................. Fetal scalp electrode (precise reading of FHR)
IUPC............... Intrauterine pressure catheter (strength of contractions)
LTV................. Long term variability
SVE................. Sterile vaginal exam
MLE................ Midline episiotomy
NST................ Non-stress test
CST................. Contraction stress test
BPP................. Biophysical profile
VBAC.............. Vaginal birth after cesarean
AFI.................. Amniotic fluid index
BUFA.............. Baby up for adoption
NPNC............. No prenatal care
PTL................. Preterm labor
BOA................ Born on arrival
BTL................. Bilateral tubal ligation
D&C / D&E.... Dilation & curettage / dilation & evacuation
LPNC.............. Late prenatal care
TIUP............... Term intrauterine pregnancy
VMI / VFI....... Viable male infant / viable female infant
EDB................ Estimated date of birth
EDC................ Estimated date of confinement
EDD................ Estimated date of delivery
PREGNANCY DURATION
40 weeks
gestational age
The number of completed
weeks counting from the
1st day of the last normal
menstrual cycle (LMP).
38 weeks
fetal age
This refers to the age of the
developing baby, counting
from the estimated date of
conception. The fetal age
is usually 2 weeks less than
the gestational age.
TRIMESTERS
First Trimester
0 – 13 WEEKS
Second Trimester
14 – 26 WEEKS
Third Trimester
27 – 40 WEEKS
PRENATAL TERMS
Gravida / Gravidity
Preterm
A woman who is pregnant / the number of pregnancies
Nulligravida
Primigravida
Multigravida
Never been pregnant
Pregnant for
the first time
A woman who has
had 2+ pregnancies
Parity
The number of pregnancies that have reach viability (20
weeks of gestation) whether the fetus was born alive or not
Nullipara
Primipara
Multipara
0
Zero pregnancies
beyond viability
(20 weeks)
1
One pregnancy
that has reached
viability
(20 weeks)
2+
Two or more
pregnancies that
have reached
viability (20 weeks)
Pregnancies that have reached 20 weeks
but ended before 37 weeks
Term
Pregnancies that
have lasted between
week 37 and week 42
Early Term: 37 – 38 6/7
Full Term:
39 – 40 6/7
Late Term:
41 – 41 6/7
Postdate/Postterm
A pregnancy that goes beyond 42 weeks
66
GTPAL
An acronym used to assess pregnancy outcomes
G
T
P
GRAVITY
The number of pregnancies
TERM BIRTHS
The number born at term
PRE-TERM
BIRTHS
The number of pregnancies delivered
beginning with the 20th - 36 6/7th weeks
of gestation
• Includes the present pregnancy
• Includes miscarriages / abortions
• Twins / triplets count as one
• > 37th week of gestation
• Includes alive or stillborn
• Twins / triplets count as one
• Includes alive or stillborn
• Twins / triplets count as one
A
ABORTIONS /
MISCARRIAGES
The number of pregnancies delivered
before 20 weeks gestation
L
LIVING
CHILDREN
The number of current living children
• Counts with gravidity
• Twins / triplets count as one
• Twin / triplets count individually
ANSWER KEY
Q#1 is (D) 3-2-0-1-2
Q#2 is (C) 4-2-1-0-4
PRACTICE QUESTION 1
You are admitting a patient to the mother-baby
unit. Two hours ago she delivered a boy on
her due date. She gives her obstetric history
as follows: she has a three-year-old daughter
who was delivered a week past her due date
and last year she had a miscarriage at 8 weeks
gestation. How would you note this history
using the GTPAL system?
A. 2-2-1-0-2
B. 3-2-1-0-1
C. 3-2-1-0-2
D. 3-2-0-1-2
PRACTICE QUESTION 2
A prenatal client’s obstetric history indicates that
she has been pregnant 3 times previously and
that all her children from previous pregnancies are
living. One was born at 39 weeks gestation, twins
were born at 34 weeks gestation, & another child
was born at 38 weeks gestation. She is currently 38
weeks pregnant. What is her gravidity & parity using
the GTPAL system?
A. 4-1-3-0-4
B. 4-1-2-0-3
C. 4-2-1-0-4
D. 4-2-2-0-4
67
PREGNANCY SIGNS & SYMPTOMS
PRESUMPTIVE SUBJECTIVE
P Period Absent (Amenorrhea)
R Really tired
E Enlarged breasts
S Sore breasts
U Urination increased (urinary frequency)
M Movement perceived (quickening)
E Emesis & nausea
PROBABLE
OBJECTIVE
Think
“Mom”
These are changes felt by the women that are subjective.
Can be associated with other things.
NOT a definite diagnosis for pregnancy!
Why is quickening not a positive sign?
Quickening can be difficult to distinguish from
peristalsis or gas so it can not be a positive sign.
Pregnancy signs that the
Think
“Doctor” nurse or doctor can observe
P Positive (+) pregnancy test (high levels of the hormone: hCG)
R Returning of the fetus when uterus is pushed w/ fingers (ballottement)
O Objective
Why is a positive pregnancy test not a positive sign?
B Braxton hicks contractions
A A softened cervix (Goodell's sign)
B Bluish color of the vulva, vagina, or cervix (Chadwick's sign)
L Lower uterine segment soft (Hegar's sign)
E Enlarged uterus
High levels of hCG can be associate with other
conditions such as certain medications or
hydatidiform mole (molar pregnancy).
POSITIVE
OBJECTIVE
F Fetal movement palpated by a doctor or nurse
E Electronic device detects heart tones q
T The delivery of the baby
U Ultrasound detects baby
S Seeing visible movements
Think
“Baby”
Can only be attributed to a fetus
Definite diagnosis for pregnancy!
68
PREGNANCY PHYSIOLOGY
HORMONES
Prolactin: Allows for breast milk production
Estrogen: Growth of fetal organs & maternal tissues
Progesterone & Relaxin: Relaxes smooth muscles
hCG: Produced by placenta, prevents menstruation
Oxytocin: Stimulates contractions at the start of labor
MUSCULOSKELETAL
• Lordosis: center of gravity shifts forward
leading to inward curve of spine
• Low back pain
• Carpal tunnel syndrome
• Calf cramps
RESPIRATORY
• ↑ Basal metabolic rate (BMR)
• ↑ O2 needs
• Respiratory alkalosis (MILD)
PITUITARY
• ↓ FSH/LH due to ↑ Progesterone
• ↑ Prolactin
• ↑ Oxytocin
CARDIOVASCULAR
• ↑ Cardiac output
(↑ Heart rate + ↑ stroke volume)
• Blood pressure stays the same
or a slight decrease
• ↑ in plasma volume
• Enlarges
(May develop systolic murmurs)
THYROID
• ↑ Thyroxine
• May have moderate enlargement
of the thyroid gland (goiter)
• ↑ Metabolism & ↑ appetite
q
RENAL
• ↑ GFR from ↑ plasma volume
• Smooth muscle relaxation
of the uterus = ↑ risk of UTI’s!
• ↑ Urgency, frequency & nocturia
• EDEMA!!
GASTROINTESTINAL
• Pyrosis
↑ Progesterone = LOS to relax = ↑ heartburn
• Constipation & hemorrhoids
↑ Progesterone = ↓ gut motility
• Pica
Non-food cravings such as ice, clay,
and laundry starch
SKIN
• Striae
Stretch marks (abdomen, breasts, hips, etc)
• Chloasma
Mask of pregnancy
Brownish hyperpigmentation of the skin
• Linea Nigra
“Pregnancy line” dark line that develops
across your belly during pregnancy
• Montgomery glands / Tubercles
Small rough / nodular / pimple-like appearance
of the areola (nipple)
HEMATOLOGICAL
FIBRINOGEN
Non-pregnant levels: 200-400 mg/dL
Pregnant levels: up to 600 mg/dL
Pregnant women are
HYPERCOAGULABLE
(increased risk for DVT's)
• ↑ White blood cells
• ↓ Platelets
RBC VOLUME
PLASMA VOLUME
ANEMIA
ANEMIA
Plasma volume is greater than the amount of
red blood cell (RBC) = hemodilution = physiological anemia
69
NAEGELE'S RULE
→
Used for estimating the expected date of delivery (EDD) based on LMP (last menstrual period)
REMEMBER:
→
How many days
are in each month?
30 days hath
September, April,
June & November.
All the rest have 31,
except February alone
(28 days)
EXAMPLE
Date of Last Menstrual Period
– 3 Calendar Months + 7 Days + 1 Year
1st day of last period:
Minus 3 calendar months:
Plus 7 days:
Plus 1 year:
September 2, 2015
June 2, 2015
June 9, 2015
June 9, 2016
(EDD)
FACTS ABOUT NAEGELE'S RULE
q Bases calculation on a woman who has a
28-day cycle (most women vary)
q The typical gestation period is 280 days (40 weeks)
q First-time mothers usually have a slightly longer
gestation period
WHAT TO AVOID DURING PREGNANCY
TERATOGENIC DRUGS
REMEMBER
THE
!
MNEMONIC
TERA-TOWAS
T Thalidomide
E Epileptic medications (valproic acid, phenytoin)
R Retinoid (vit A)
A Ace inhibitors, ARBS
T Third element (lithium)
O Oral contraceptives
TORCH INFECTIONS
TORCH infections are a group of
infections that cause fetal abnormalities.
Pregnant women should avoid these
infections!
REMEMBER
THE
!
MNEMONIC
TORCH
T Toxoplasmosis
Parv O Virus-B19 (fifth disease)
W Warfarin (coumadin)
R Rubella
A Alcohol
C Cytomegalovirus
S Sulfonamides & sulfones
H Herpes simplex virus
70
STAGES OF LABOR
STAGE 1
LATENT (EARLY)
INTERVENTIONS
Longest
Stage
CERVIX DILATES FROM 0-10 CM
q Cervix dilates: 1- 3 cm
q Intensity: Mild
q Contractions: 15 - 30 mins
ACTIVE
q Promote comfort
- Warm shower, massage, or epidural
q Offer fluids & ice chips
q Provide a quiet environment
q Encourage voiding every 1 - 2 hours
q Encourage participation in care & keep informed
q Instruct partner in effleurage (light stroking of the abdomen)
q Encourage effective breathing patterns & rest between contractions
q Cervix dilates: 4 - 7 cm
q Intensity: Moderate
q Contractions: 3 -5 min (30-60 sec in duration)
REMEMBER
THE
!
MNEMONIC
TRANSITION
q Cervix dilates: 8 - 10 cm
q Intensity: Strong
q Contractions: Every 2-3 min (60-90 sec in duration)
STAGE 2
STAGE 3
THE BABY IS DELIVERED
>30 MIN =
RETAINED
PLACENTA
THE PLACENTA IS DELIVERED
→ Starts when cervix is fully dilated & effaced
The PLACENTA is expelled (5 - 30 min after birth)
→ Ends after the baby is delivered
SIGNS OF A PLACENTA DELIVERY
!!!
PUSHING
q Provide praise & encouragement to the mother
q Maintain privacy & encourage rest between
contractions
q Encourage effective breathing patterns & rest
between contractions
q Monitor for signs of birth
(perineal bulging or visualization of fetal head)
STAGE 4
INTERVENTIONS
q Monitor uterine contractions & mothers vital signs
RECOVERY!
DELIVERY MECHANICS
q Gush of blood
"Shiny Schultz"
Side of baby delivered 1st
q Uterus changes from oval
to globular shape
"Dirty Duncan"
Side of mother delivered 1st
q Lengthening umbilical cord
q Provide ice chips & ointment for dry lips
INTERVENTIONS
Labor
Actively
Transitioning
q Assessing mothers vital signs
q Uterine status (fundal rubs every 15 minutes)
q Provide warmth to the mother
q Promote parental-neonatal attachment
q Examine placenta & verify it's intact
- Should have 2 arteries & 1 vein
q FIRM
A A
V
q Midline
RECOVERY: first 1-4 hours after delivery of the placenta
q Soft
q Assessing the fundus
q Boggy
q Continue to monitor vital signs & temperature for infection
q Displaced
q Administer IV fluids
q Monitor lochia discharge (lochia may be moderate in amount & red).
q Monitor for respiratory depression, vomiting, & aspiration if general anesthesia was used
q Great time to watch for complications such as bleeding (postpartum hemorrhage)
TIP
Looks like
smiley face!
2 "A" for Arteries
1 "V" for Vein
71
TRUE VS. FALSE LABOR
CONTRACTIONS
FALSE LABOR
• Irregular
• Stops with walking / position change
• Felt in the back or the abdomen
above the umbilicus
• Often stops with comfort measures
TRUE LABOR
• Occur regularly
- Stronger
- Longer
- Closer together
• More intense with walking
• Felt in lower back -> radiating to the lower
portion of the abdomen
• Continue despite the use of comfort measures
CERVIX
• May be soft
• NO significant change in....
- Effacement
- Dilation
• No bloody show
• In posterior position
(baby's head facing mom's front of belly)
• Progressive change
- Softening
- Effacement
- Dilation signaled by the
appearance of bloody show
- Moves to an increasingly anterior position
(baby's head facing mom's back)
FETUS
• Presenting parts become engaged in the pelvis
• Presenting part is usually
not engaged in the pelvis
• Increased ease of breathing
(more room to breathe)
• Presenting part presses downward &
compresses the bladder = urinary frequency
SIGNS OF LABOR
LABOR
Moving the fetus, placenta,
& the membranes out of the
uterus through the birth canal
Signs of Preceding Labor
• Lightening
• Increased vaginal discharge (bloody show)
• Return of urinary frequency
• Cervical ripening
• Rupture of membranes "water breaking"
• Persistent backache
• Stronger Braxton Hicks contractions
• Days preceding labor
- Surge of energy
- Weight loss (1- 3.5 pounds) from a fluid shift
72
FETAL HEART TONES
fetal heart rate
Cause:
q From head compression
Intervention:
q Continue to monitor
q No intervention needed
mom's
contractions
NORMAL!
EARLY DECELERATIONS
fetal heart rate
mom's
contractions
NON-REASSURING
LATE DECELERATIONS
mom's
contractions
fetal heart rate
VARIABLE DECELERATIONS
NON-REASSURING
Normal
fetal heart rate
120 - 160 BPM
"Mirror" image of mom's contractions
(They don't technically come early )
Literally comes late after mom's contraction
Cause:
q Uteroplacental insufficiency
Intervention:
q D/C oxytocin
q Position change
q Oxygen (nonrebreather)
q Hydration (IV fluids)
q Elevate legs to correct
the hypotension
*Variable: Looks "V" shaped
Cause:
q Cord compression
Intervention:
q D/C Oxytocin
q Amnioinfusion
q Position change
q Breathing techniques
q Oxygen (nonrebreather)
Side-lying or knee
chest will relieve
pressure on cord
73
PREECLAMPSIA OVERVIEW
20 WEEKS
CHRONIC HTN:
2nd Trimester
GESTATIONAL HTN: HTN after 20 weeks without systemic features
SIGNS & SYMPTOMS
PATHOLOGY
"PRE" eclampsia
E Edema
Triad Signs
Rising BP
SYSTOLIC >140
OR
PREECLAMPSIA: HTN after 20 weeks gestation with systemic features
Before pregnancy
or before 20 weeks!
P Proteinuria
3rd Trimester
HYPERTENS
IO
T IS
A
H
q Visual disturbances
Hypertension may be
abbreviated "HTN"
Pathology isn't
completely known
q HX of preeclampsia in previous
PLACENTA
is the root cause
q Family history of preeclampsia
pregnancies
q 1st pregnancy
q Obesity
AMA (advanced
maternal age)
q Very young (<18) or very old (>35)
q Medical conditions
q Systemic vasoconstriction
& endothelial dysfunction
q RUQ or epigastric pain
DIASTOLIC > 90
RISK FACTORS
q Defective spiral
artery remodeling
q Severe headache
N?
1st Trimester
W
Overview of Hypertensive disorders during pregnancy
(Chronic HTN, renal disease,
diabetes, autoimmune disease)
q ↓ Urine output
q Hyperreflexia
ECLAMPSIA
q Rapid weight gain
ROME
HELLP SYND
(seizures activity or a coma)
Variant of preeclampsia
Life-threatening complication
Immediate care:
• Side-lying
• Padded side rails with pillows/blankets
H Hemolysis
• O2
EL Elevated liver enzymes
• Suction if needed
• Do not restrain
LP Low platelet count
• Do not leave
MAGNESIUM SULFATE
TOXICITY!
RX given to prevent seizures during & after labor.
*Remember: magnesium acts like a depressant
THERAPEUTIC RANGE:
4 – 7 mg/dL
*Mag is excreted in urine
• RR <12
↓UOP → ↑Mag levels
• ↓ DTR's
• UOP <30 mL/hr
• EKG Changes
ANTIDOTE: calcium gluconate
*because magnesium sulfate can cause respiratory depression
74
VEAL CHOP
A tool to help interpret fetal strips
V
E
A
L
Variability
→
Early Decelerations
→
Accelerations
→
Late Decelerations
→
C
H
O
P
Cord Compression
Head Compression
OK (normal fetal oxygenation)
Placental Insufficiency
ASSESSMENT OF UTERINE CONTRACTIONS
Duration
Frequency
Intensity
Resting
Tone
BEGINNING of the
contraction to the END
of that same contraction
• Lasts 45 - 80 seconds
• Should not exceed 90 seconds
Number of contractions
from the BEGINNING of
one contraction to the
BEGINNING of the next
• 2 - 5 contractions every 20 minutes
• Should not be more FREQUENT
then every 2 minutes
Only measured through external monitoring
Strength of a
contraction
at its PEAK
• 25 - 50 mm Hg
• Should not exceed 80 mm HG
Only measured through external monitoring
Can be palpated
• Average: 10 mm HG
TENSION in the uterine
muscle between contractions • Should not exceed 20 mm HG
(relaxation of the uterus =
Can be palpated
fetal oxygenation between
contractions)
Mild - nose
Moderate - chin
Strong - forehead
Soft = good
Firm = not resting
enough
75
LABOR & BIRTH PROCESSES
5 P's 5 factors that affect the process of labor & birth
PASSENGER
PASSAGEWAY
POSITION
POWERS
PSYCHOLOGY
Fetus & Placenta
The Birth Canal
Position of the Mother
Contractions
Emotional Response
PASSENGER
Fetus & Placenta
SIZE OF THE FETAL HEAD
FETAL PRESENTATION
FONTANELS
• Space between the bones of
the skull allows for molding
• Anterior (larger)
- Diamond-shaped
- Ossifies in 12-18 months
• Posterior
- Triangle shaped
- Closes 8 - 12 weeks
Refers to the part of the fetus that enters
the pelvic inlet first through the birth canal
during labor
ANTERIOR
Moston
CEPHALIC
Comm
• Head first
• Presenting part: Occipital
(back of head/skull)
BREECH
• Buttocks, feet, or both first
• Presenting part: Sacrum
MOLDING
• Change in the shape of the
fetal skull to "mold" & fit
through the birth canal
POSTERIOR
SHOULDER
• Shoulders first
• Presenting part: Scapula
FETAL LIE
Relation of the long axis (spine) of the fetus to the long axis (spine) of the mother
LONGITUDINAL OR VERTICAL
• The long axis of the fetus is parallel with the long axis of the mother
• Longitudinal: cephalic or breech
TRANSVERSE, HORIZONTAL, OR OBLIQUE
• Long axis of the fetus is at a right angle to the long axis of the mother
• Transverse: vaginal birth CANNOT occur in this position
• Oblique: usually converts to a longitudinal or transverse lie during labor
CONTINUED →
76
LABOR & BIRTH PROCESSES
PASSENGER
CONTINUED
FETAL ATTITUDE
FETAL POSITION
GENERAL FLEXION
• Back of the fetus is rounded so that
the chin is flexed on the chest, thighs
are flexed on the abdomen, legs are
flexed at the knees
BIPARIETAL DIAMETER
• 9.25 cm at term, the largest transverse
diameter and an important indicator of
fetal head size
FETAL STATION
• Where the baby's presenting part is located in the pelvis
• Presenting part?
- Head, foot, butt (closest to exit of uterus)
• Measured in centimeters (cm)
- Find the ischial spine = zero
- Above the ischial spine is (-)
- Below the ischial spine is (+)
+4 / +5 = Birth is about to happen
- Documented
-5, -4, -3, -2, -1, 0, +1, +2, +3, +4, +5
ENGAGEMENT
• Fetal station zero = baby is "engaged"
• Presenting parts have entered down into the pelvis
SUBOCCIPITOBREGMATIC DIAMETER
inlet & is at the ischial spine line (0)
• Most critical & smallest of the
• When does this happen?
anteroposterior diameters
- First-time moms:
38 weeks
G
N
I
N
E
Already had babies:
LIGHT is this?
t
a
can
happen when
h
W
drops"
baby "
e
th
n
labor
starts
Whe
other's
em
pelvis
into th
PASSAGEWAY
The Birth Canal: Rigid bony pelvis, soft tissue of cervix, pelvic floor, vagina & introitus
TYPES OF PELVIS
GYNECOID
• Classic female type
• Most common
ANDROID
• Resembling the male pelvis
ANTHROPOID
• Oval-shaped
• Wider anteroposterior diameter
PLATYPELLOID
• The flat pelvis
• Least common
SOFT TISSUE
LOWER UTERINE SEGMENT
• Stretchy
CERVIX
• Effaces (thins) & dilates (opens)
• After fetus descends into the vagina, the cervix is drawn
upward and over the first portion
PELVIC FLOOR MUSCLES
• Helps the fetus rotate anteriorly
VAGINA
INTROITUS
• External opening of the vagina
77
LABOR & BIRTH PROCESSES
POSITION
Position of the mother during
Moston
Comm
UPRIGHT POSITION
Sitting on a birthing stool or cushion
LITHOTOMY POSITION
Supine position with buttocks on the table
"ALL FOURS" POSITION
On all fours: putting your weight
on your hands & feet
LATERAL POSITION
Laying on a side
POWERS
Frequent changes in
position helps with:
• Relieving fatigue
• Increasing comfort
• Improving circulation
Contractions: Primary & Secondary
PRIMARY POWERS
SECONDARY POWERS
Involuntary uterine contractions
Signals the beginning of labor
Does not affect cervical dilation but helps with
expulsion of infant once the cervix is fully dilated
• Voluntary bearing-down efforts by the women
once the cervix has dilated
DILATION
• Dilation of the cervix is the enlargement or
widening of the cervical opening & canal
once labor has begun
• Cervix: closed
→ full dilation (10 cm)
• Pressure from amniotic fluid can also
apply force to dilate
• Shortening & thinning of the cervix during
the first stage of labor
2 -3 cm long
1 cm thick
• Laboring women start to feel an involuntary
urge to push & she uses secondary powers to
aid in the expulsion of the fetus
PSYCHOLOGY
EFFACEMENT
• Cervix normally:
• When the presenting part reaches the pelvic
floor, the contractions change in character
& become expulsive.
Degre
e of
EFFAC
E
M
ENT
is EXP
RESSE
D in %
(0-100
%)
• The cervix is "pulled back / thinned out"
by a shortening of the uterine muscles
FERGUSON REFLEX
• When the stretch receptors release oxytocin,
it triggers the maternal urge to bear down
Emotional
Response
Anxiety can increase pain perception
& the need for more medications
(analgesia & anesthesia)
THINGS TO CONSIDER:
SOCIAL SUPPORT
PAST EXPERIENCE
KNOWLEDGE
78
NEWBORN ASSESSMENT
APGAR
SCORE
Activity
(Muscle tone)
Pulse
Grimace
(Reflex irritability)
Appearance
O POINTS
1 POINT
2 POINTS
Absent
Flexed arms
& legs
Active
0
< 100
> 100
Floppy
(Skin color)
Respiration
No
breathing
VITAL SIGNS
Slow &
irregular
Assess for
a full minute!
Si
Head & chest
circumference
s
tres
Dis
Respiratory Rate:
30 - 60 BREATHS /MIN
*Irregular pattern, abdominal breathers
Heart Rate: 110 - 160 BPM
Can be 180 if crying
Can be 100 if sleeping
Take apical pulse for 1 full min
Temperature (Axillary):
Respirator
s of
y
97.7 - 99.5 F
gn
36.5 - 37.5 C
Retra
Blood Pressure:
ctions
Nasa
Not done routinely
l Flari
ng
Systolic 60 – 80 mm Hg
Grunt
Diastolic 40 – 50 mm Hg
ing
MAP
# of weeks gestation or higher
GENERAL CHARACTERISTICS
1ST PRIORIT
Y
Pink
all over
Vigorous
cry
2ND PRIORI
TY
Dry with
a blanket
= WARMTH
or place
in warme
r.
CIRCULATORY SYSTEM
• Blood flow from umbilical vessels & placenta
stop at birth
• Acrocyanosis:
Blueness of hands & feet
(normal during the first 24 hours of life)
• Closure of
q Ductus arteriosus
q Foramen ovale
q Ductus venosus
• Transient murmurs are normal
HEAD
Caput Succedaneum:
• Edema (collection of fluid)
• Crosses the suture lines
(like a baseball cap)
Cephalohematoma:
• Birth trauma (collection of blood)
• Does not cross the suture lines
• Molding: abnormal head shape that results from pressure (normal)
• Fontanelles:
Bulging = Increased ICP or hydrocephalus Fontane
lles may
be bulgin
when the
Sunken = Dehydration
g
newb
or is lying
UMBILICAL CORD
A A
V
Should have
2 arteries
& 1 vein
Length & weight
Expected Length
Head circumference
44 - 55 cm
32 - 39 cm
17 - 22 in
14 - 15 inches
*measure above eyebrows Expected Weight
2,500 - 400 g
Chest circumference
5 lb, 8 oz - 8 lb, 14 oz
30 - 36 cm
12 - 14 inches
*measure above nipple line
= AIRWAY
Suction w
ith bulb s
yringe / d
*Newbor
e
ns are ob
ligatory n ep suction
ose brea
thers
Prompt
Minimal
response to response to
stimulation stimulation
Pink body,
Blue / pale Blue
extremities
all over
(acrocyanosis)
(Effort)
INITIAL GOALS:
↓ TEMP
orns cr
down. Th y, vomits,
is is norm
al.
Should be dry,
no odor, & no drainage
HEAT LOSS DUE TO:
↓
A
P
G
A
R
7 - 10 supportive care
4 - 6 moderate depression
< 4 aggressive resuscitation
Evaporation: Moisture from skin & lungs
Convection: Body heat to cooler air
Conduction: Body heat to a cooler surface in direct contact
Radiation: Body heat to a cooler object nearby
79
PEDIATRIC
MILESTONES
Nurse
in the making
80
PEDIATRIC MILESTONES
INFANT
BIRTH - 12 MONTHS
GROSS MOTOR
FINE MOTOR
1
MONTH
• Head lag
• Rounded back while sitting
• Lifts and turns head to the side in prone position
2
MONTHS
• Raises head & chest
• Head control improving
3
MONTHS
• Raises head 45 degrees in prone
• Tiny head lag in pull-to-sit
4
MONTHS
• Lifts head & looks around
• Rolls from prone to supine
• Head leads body when pulled to sit
5
MONTHS
• Rolls from supine to prone & back again
• Sits with back upright when supported
6
MONTHS
• Tripod sit
• Releases objects in hand
to take another
7
MONTHS
• Sits alone with some use of hands for support
• Transfers objects from
one hand to the other
8
MONTHS
• Sits unsupported
• Gross pincer grasp (rakes)
9
MONTHS
• Crawls with abdomen off the floor
• Bangs objects together
10
MONTHS
• Pull to stand
• Able to cruise on objects (furniture)
• Fine pincer grasp
• Puts objects into
containers & takes them out
• Fists mostly clenched
• Involuntary hand
movements
• Makes verbal noise (coos)
• Holds hand in front of
face with hands open
FUN TIP!
Rolls on the floor
rhymes with four!
• Bats at objects
• Babbling (copies noises)
• Grasps rattle
FUN TIP!
You grasp something with five fingers
11
MONTHS
12
MONTHS
LANGUAGE
• Babbles (nonspecific)
• Offers objects to others
& releases them
• Walks independently
• Sits down from standing position without assistance
RECEPTIVE LANGUAGE
• Understands common words independent of
context
• Follows a one-step gestured command
• Feeds self finger-foods
• Draws simple marks on paper
• Turns pages in a book
EXPRESSIVE LANGUAGE
• First word (example: “mama”)
• Uses a finger to point to things
• Imitates: gestures & vocal
• Receptive Language
• Expressive Language
• Signs of Delay
SIGNS OF DELAY
• After independent walking for several months
- Persistent tiptoe walking
- Failure to develop a mature walking
81
PEDIATRIC MILESTONES
TODDLER
GROSS MOTOR
15
MONTHS
• Walks independently
18
MONTHS
• Climbs stairs
• Kicks a ball
• Pulls toys
• Able to stand on tiptoes
RECEPTIVE LANGUAGE
EXPRESSIVE LANGUAGE
30
MONTHS
FUN TIP!
Think: terrible twos!
• Uses index finger to
point
• Uses their hands a lot for:
reaching, grabbing,
releasing, stacking blocks
• Full pincer grasp
developed
• Removes shoes and socks
• Turns book pages
• Stacks four cubes
SIGNS OF DELAY
24
MONTHS
• Climbs on & off furniture
• Feeds self finger foods
FINE MOTOR
1-3 YEARS
• Builds tower of 6-7 cubes
• Right/left-handed
• Scribbles, paints,
& imitates strokes
• Turns doorknobs
• Puts round pegs into holes
• Understands
100-150 words
• Understands “no”
• Follows commands
without gestures
• Says: “what’s this?”
• Listens to simple stories
• Repeats words
• Vocab: 15-20 words
• Vocab: 40-50 words
• Babbles sentences
• Uses names of familiar
objects
• Sentences of 2-3 words
(ex. “want cookie")
• Understands 200 words
• Looks at adults when
communicating
• Points to named body
parts/pictures in books
• Follows a series of 2
independent commands
• Says: “my” & “mine”
• Vocab:150-300 words
• Use descriptive words:
hungry, hot, cold
• Persistent tiptoe walking
• Not walking
• Does not develop a
mature walking pattern
• Not speaking 15 words
• Does not understand the
function of common
household items
• Does not: use two-word
sentences, imitate
actions, or follow basic
instructions
• Cannot push a toy with
wheels
82
PEDIATRIC MILESTONES
PRESCHOOL
3-6 YEARS
G ROS S MOTOR
FI NE MOTOR
• Climbs well and runs easily
• Pedals tricycle
• Walks up & down stairs with
alternating feet
• Bends over without falling
• Throws ball overhead
• Kicks ball forward
• Can bounce a ball back
• Hops on one foot
• Alternating feet going up & down steps
• May be able to:
• Skip
• Swim
• Skate
• Climb
• Swing
• Undresses self
• Copies circles
• Tower of 9-10
• Holds a pencil
• Screws and unscrews lids
• Turns book pages one at a time
• Uses scissors
• Copies capital letter
• Draws circles, squares, & traces
a cross or diamond
• Draws a person with 2-4 body parts
• Laces shoes
• Can draw a person and some letters
• May dress/undress themselves
• Can use a fork, spoon, & knife
• Mostly cares for own toileting needs
• Understands most sentences
• Speaks in complete sentences
• Understands physical relation
(in, on, under)
• Tells a story
• Most of the child’s speech can be
understood
• Follows a 3-part command
• Half of the conversation understood
by outside family
COMMUNICATION
• Says: “why?”
• 75% of speech understood by
outside observers
• Stays on topic in conversation
• Knows the name of familiar animals
• 3 or 4-word sentences
• Knows at least one color
• Talks about past
• Vocab: 1,000 words
• Says their name, age, & gender
• Uses pronouns and plurals
• Participates in long & detailed
conversations
• Talks about past, future, and
imaginary events
• Answers questions that use “why”
and “when”
• Can count to 10
• Can count a few numbers
• Recalls part of a story
• Vocab: 1,500 words
• Difficulty with stairs
• Falls a lot while walking
• Can’t build a 4+ block tower
• Extreme difficulty separating
from parents
• No make-believe play
• Can't copy a circle
• No short paragraphs
• Doesn’t understand simple instructions
• Unclear speech & drooling
• Little interest in other kids
• Explains how an item is used
• Uses language to engage in
make-believe
Why?
SIGNS OF D ELAY
5
YEARS
4
YEARS
3
YEARS
• Says name & address
• Speech should be completely
intelligible, even if the child has
articulation difficulties
• Speech is generally grammatical correct
• Vocab: 2,000 words
• Can't jump in place or ride a tricycle
• Can’t stack 4 blocks
• Can’t throw a ball overhead
• Does not grasp crayon with thumb
and fingers
• Difficulty with scribbling
• Can’t copy a circle
• Doesn’t say 3+ word sentences
• Can’t use the words “me” & “you”
• Ignores other children or doesn’t
show interest in interactive games
• Still clings or cries if parents leave
• Sad often
• Little interest in playing with other kids
• Unable to separate from their parents
• Is extremely aggressive, fearful,
passive, or timid.
• Easy distorted (can't concentrate for
5 minutes)
• Can not do ADL’s by themselves
(brush teeth, undress, wash & dry
hands, etc)
• Rarely engages in fantasy play
83
PEDIATRIC MILESTONES
PHYSIOLOGICAL CHANGES
Early Adolescence
Middle Adolescence
Late Adolescence
10-13
YEARS
14-16
YEARS
17-20
YEARS
MAL E
• Pubic hair spread
laterally, begins to curl,
pigmentation increases
• Growth &
enlargement of testes
& lengthening of the
penis
• Lengthy look due to
extremities growing
faster than the trunk
• Pubic hair becomes
more coarse in texture
& takes on adult distribution
• Testes, scrotum, &
penis continue to grow
• Mature pubic hair
distribution &
coarseness
• Breast enlargement
disappears
• The skin around the
scrotum darkens
• Adult size & shape
of testes, scrotum, and
penis
• Glands penis develops
• Scrotum skin
darkening
• May experience
breast enlargement
FEMA LE
• First menstrual period (average age is
12 years)
• Breasts bud and
areola continue to
enlarge (no separation
of the breasts)
• Pubic hair begins to
curl & spread over the
mons pubis
• Pubic hair becomes
coarse in texture
• Amount of hair
increases
• Mature pubic hair
distribution and
coarseness
• Areola & papilla
separate from the
contour of the breasts
to form a secondary
mound
84
MED-SURG
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in the making
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MED-SURG
BURNS
Nurse
in the making
134
BURNS
BURNS INJURY DEPTH
WHAT IS A BURN?
Damage to skin integrity
1st
Degree
TYPES OF BURNS
THERMAL
SUPERFICIAL
• Epidermis
• Pink & painful (still has nerves)
• No scarring
• Blanching: present
• Heals: few days
most
common
Superficial heat
Examples: liquid, steam, fire
CHEMICAL
2nd
Degree
Burn caused by a toxic substance
Can be Alkali or Acidic
Examples: bleach, gasoline, paint thinner
• Epidermis & dermis
• Blisters, shiny, & moist
• Painful
• Blanching: present
• Heals: 2 - 6 weeks
RADIATION
Sunburns (UV radiation)
& cancer treatment (radiation therapy)
INHALATION
3rd
Degree
Caused by inhaling smoke which can cause
flame injury or carbon monoxide poisoning
FULL THICKNESS
• Epidermis, dermis, & hypodermis
• May look black, yellow, red & wet
• No pain/ limited pain (nerve fibers are destroyed)
• Skin will not heal (need skin grafting)
• Eschar: dead tissue, leathery; must be removed!
FRICTION
Burn caused when an object rubs off the skin
Examples: road rash, scrapes, carpet burn
COLD
SUPERFICIAL PARTIAL THICKNESS
LAYERS OF THE SKIN
Skin has been overexposed to cold
Example: frostbite
ELECTRIC
Electrical current that passes
through the body causing damage within
POTENTIAL COMPLICATIONS
Dysrhythmias, Fracture of bones.
Release of myoglobin & hemoglobin
into the blood which can clog the kidneys.
↓
EPIDERMIS
DERMIS
HYPODERMIS
subcut/fatty tissue
BURN LOCATION
RESPIRATORY
• Face
• Neck
• Chest
• Torso
INFECTION
DISABILITY
• Hands
• Feet
• Joints
• Eyes
Any open area where
bacteria can easily enter
• Perineum
• Ears
• Eyes
TROUBLE HEALING
• Poor blood supply
• Diabetes
• Infection
COMPARTMENT SYNDROME
• In the extremities
Tight skin such as eschar acting
like a band around the skin
cutting off blood circulation
INHALATION INJURY
Damage to the respiratory system!
Happens mostly in a closed area
SIGNS OF
INHALATION INJURY
Hair singed
around the face, neck or
torso
Trouble talking
Soot in the nose or mouth
Confusion or anxiety
CARBON MONOXIDE (CO)
POISONING
Carbon monoxide travels
faster than oxygen, making
it bind to hgb first.
Now oxygen cannot bind
to hgb = HYPOXIC
Classic symptom: cherry red skin
Treatment: 100% O2
NOTE:
Oxygen saturation
may appear normal
135
PHASES OF BURN MANAGEMENT
E
MERGENT PHASE
24 - 48 HOURS
after burn
Onset of Injury to the restoration of capillary permeability
PATHO
VITAL SIGNS
↑ Capillary permeability (leaky vessels)
causing:
Leads to
Edema
Leads to fluids volume deficit (FVD)
in the intravascular space
NURSING CONSIDERATIONS
THINK:
Hypovolemic
SHOCK!
↓ Urine output
(from ↓ perfusion to the
kidneys)
LABS
• Plasma leaves the intravascular space
• Albumin & sodium follows
• Fluids shift to the interstitial tissue
↑ Pulse
↓ Blood pressure
↓ Cardiac output
↑ Potassium (K+)
↑ Hematocrit (HCT)
↓ White Blood Cells (WBC’s)
↑ BUN/Creatine
ACUTE PHASE
Capillary permeability stabilized - to wound closure
PATHO
Capillary permeability is restored which leads to
the body diuresing (increased urine production).
All the excess fluid that shifted from the interstitial tissue shifts back into the intravascular space.
GOALS
• Prevent infection
- Systemic antibiotic therapy
• Ensure proper nutrition
- Needs ↑ calories
- Protein & Vit C to promote healing
• Alleviate pain
• Wound care
- Always premedicate before wound care!
- Debridement or grafting
• Establish IV access (preferrably 2)
• Fluids (Lactated Ringer's, crystalloids)
• Parkland formula
• Foley catheter to monitor urinary
output (UOP)
- Goal: > 30 mL/hr of UOP
THINK:
• Decrease edema
ABC's
- Elevate extremities
above heart level
48 - 72 HOURS
after burn & until wounds have healed
NURSING CONSIDERATIONS
• Renal
- Diuresis is happening
- Foley catheter to monitor UOP
• Respiratory
- Possible intubation if respiratory complications occurred
• Gastrointestinal
- Since the client is in FVD, there is
↓ perfusion to the stomach
• Paralytic ileus
• Curlings ulcer
- Medication to decrease chance of ulcers
• H2 histamine blocking agent (↓HCl)
- Monitor bowel sounds
- May need NG tube for suctioning
REHABILITATIVE PHASE
Burn healed and the patient is functioning mentally & physically
GOALS
• Psychosocial
• Activities of daily living (ADL’s)
• Physical therapy (PT)
• Occupational theory (OT)
• Cosmetic corrections
136
FLUID RESUSCITATION FOR BURNS
THE PARKLAND FORMULA
RULE OF NINES
Used to calculate the total volume of
fluids (mL) that a patient needs 24 hours
after experiencing a burn
Apply only in 2nd & 3rd degree burns.
4 mL X TBSA (%) X Body Weight (kg) = total mL of fluid needed
Give half of the solution for the
FIRST 8 HOURS
Give half of the solution for the
NEXT 16 HOURS
RULE OF NINES
Quick estimate of the % of the total body
surface area (TBSA) has been effected by a
partial & full-thickness burn in an adult client.
PART 1
PRACTICE QUESTION
A 25 year old male patient who weighs 79 kg has
sustained burns to the back of the right arm, posterior trunk, front of the left leg, and their anterior head
and neck. Using the Rule of Nines, calculate the total
body surface area percentage that is burned.
Back of right arm - 4.5%
Posterior trunk - 18%
Front of left leg - 9%
Anterior head & neck- 4.5%
Answer:
36%
NOTE:
The formula uses TBSA (%). However, you must calculate
PART 2
using 36. Not 0.36 (also written as 36%).
Use the Parkland formula to calculate
the total amount of Lactated Ringer's solution
that will be given over the next 24 hours.
Answer:
11,376 mL
4 mL X 36% X 79 kg = 11,376 mL
10,360 / 2 = 5,688 mL
FIRST 8 HOURS
10,360 / 2 = 5,688 mL
NEXT 16 HOURS
Keep in mind: the question could ask you for mL given in the first 24 hours, the
first 8 hours, etc., so read the question carefully.
137
ARTERIAL
BLOOD GASES (ABG's)
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Dear future nurse,
:)
You may be stressed, you may feel tired,
and you may want to give up. Nursing school is
hard, there's no doubt about it. Everyone cries,
everyone has meltdowns, and there will be
moments you don't feel qualified for the task at
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– Kristine Tuttle, BSN, RN
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