NUR 475 HESI-Exit-and-NCLEX-Exam-Gems 2021/2022
HESI Hints & NCLEX Gems
Answering NCLEX Questions
• Maslow’s Hierarchy of
... [Show More] Needs
o Physiologic
o Safety
o Love and Belonging
o Esteem
o Self-actualization
• Nursing Process
o Assessment
o Diagnosis (Analysis)
o Planning
o Implementation (treatment)
o Evaluation
• ABCs
o Airway
o Breathing
o Circulation
Normal Values
• Hgb
• Hct
o Males 14-18
o Females 12-16
o Males 42-52
o Females 37-47
• RBCs
o Males 4.7-6.1 million
o Females 4.2-5.4 million
• WBCs
o 4.5-11k
• Platelets
o 150-400k
• PT (Coumadin/Warfarin)
o 11-12.5 sec (INR and PT TR = 1.5-2 times normal)
• APTT (Heparin)
o 60-70 sec (APTT and PTT TR = 1.5-2.5 times normal)
• BUN 10-20
• Creatinine 0.5-1.2
• Glucose 70-110
• Cholesterol < 200
• Bilirubin Newborn 1-12
• Phenylalanine
o Newborn < 2
o Adult < 6
• Na+ 136-145
• K+ 3.5-5
o HypoK+
▪ Prominent U waves
▪ Depressed ST segment
▪ Flat T waves
o HyperK+
▪ Tall T-Waves
▪ Prolonged PR interval
▪ wide QRS
• Ca++ 9-10.5
o Hypocalcemia
▪ muscle spasms
▪ convulsions
▪ cramps/tetany
▪ + Trousseau’s OR + Chvostek’s
▪ prolonged ST interval
▪ prolonged QT segment
• Mg+ 1.5-2.5
• Cl- 96-106
• Phos 3-4.5
• Albumin 3.5-5
• Spec Gravity 1.005-1.030
• Glycosylated Hemoglobin (Hgb A1c):
o 4-6% ideal
o < 7.5% = OK (120 days)
• Dilantin TR = 10-20
• Lithium TR = 0.5-1.5
Antidotes
• Digoxin Digiband
• Coumadin Vitamin K (Keep PT and INR @ 1-1.5 X normal)
• Benzodiazapines Flumzaemil (Tomazicon)
• Magnesium Sulfate Calcium Gluconate?
• Heparin Protamine Sulfate (Keep APTT and PTT @ 1.5-2.5 X normal)
• Tylenol Mucomist (17 doses + loading dose)
• Opiates (narcotic analgesics, heroin, morphine) Narcan (Naloxone)
• Cholinergic Meds (Myesthenic Bradycardia) Atropine
• Methotrexate Leucovorin
Delegation
• RN Only
o Blood Products (2 RNs must check)
o Clotting Factors
o Sterile dressing changes and procedures
o Assessments that require clinical judgment
o Ultimately responsible for all delegated duties
• Unlicensed Assistive Personnel
o Non-sterile procedures
o Precautions & Room Assignments
Universal (Standard) Precautions (HIV initiated)
• Wash hands
• Wear Gloves
• Gowns for splashes
• Masks and Eye Protection for splashes and droplets
• Don’t recap needles
• Mouthpiece or Ambu-bag for resuscitation
• Refrain from giving care if you have skin lesion Droplet (Respiratory) Precautions Mask
• Sepsis
• Scarlet Fever
• Strep
• Fifth Disease (Parvo B19)
• Pertussis, Pneumonia, Influenza
• Diphtheria, Epiglottitis, Rubella, Rubeola, Meningitis, Mycoplasma, Adenovirus, Rhinovirus
• RSV (needs contact precautions too)
• TB Respiratory Isolation
Contact Precautions Universal + Goggles, Mask and Gown No infection patients with immunosuppressed patients
Weird Miscellaneous Stuf
• Rifampin (for TB) … Rust/orange/red urine and body fluids
• Pyridium (for bladder infection) … Orange/red/pink urine
• Myesthenia Gravis
• Myesthenic Crisis
o Weakness with change in vitals (give more meds)
• Cholinergic Crisis
o Weakness with no change in vitals (reduce meds)
• Diabetic Coma vs. Insulin Shock
o Give glucose first – If no help, give insulin
• Lipitor (statins) in PMs only – No grapefruit juice
• Stroke
o Tongue points toward side of lesion (paralysis)
o Uvula deviates away from the side of lesion (paralysis)
• Stay in bed for 3 hours after first ACE Inhibitor dose
• Avoid Grapefruit juice with Ca++ Channel Blockers
• Anthrax = Multi-vector biohazard
• Pulmonary air embolism prevention
o Trendelenburg
o On left side (to trap air in right side of heart)
• Head Trauma and Seizures Maintain airway
• Peptic Ulcers
o Feed a Duodenal Ulcer (pain relieved by food)
o Starve a gastric ulcer
• Acute Pancreatitis
o Fetal position
o Turner’s OR Cullen’s Sign
o Board like abdomen with guarding
o Self-digestion of pancreas by trypsin.
• In case of Fire RACE/PASS
• Check Restraints every 30 minutes
o 2 fingers room underneath
• Gullain-Barre Syndrome
o Ascending weakness
o Resp arrest
• Trough draw: 30 min before scheduled administration
• Peak Draw: 30-60 min after drug administration.
Mental Health & Psychiatry
• Most suicides occur after beginning of improvement with increase in energy levels
• MAOIs + Tyramine Hypertensive Crisis
o Nardil, Marplan, Parnate
• Need 2 week gap from SSRIs and TCAs to admin MAOIs
• Lithium Therapeutic Range = 0.5-1.5
• Phenothiazines (typical antipsychotics)
o EPS
o Photosensitivity
• Atypical Antipsychotics
o work on positive and negative symptoms
o less EPS
• Benzos: Ativan, Lorazepam)
o good for Alcohol withdrawal and Status Epilepticus
• Antabuse for Alcohol deterrence
• Alcohol Withdrawal Delerium Tremens (DTs start 12-36 hrs after last drink)
o Tachycardia
o Tachypnea
o Anxiety
o Nausea
o Shakes
o Hallucinations
o Paranoia
• Opiate Withdrawal (Heroin, Morphine)
o Watery eyes
o runny nose
o dilated pupils (pinpoint opiate OD)
o NVD
o Cramps
• Stimulants Withdrawal
o Depression
o Fatigue
o Anxiety
o Disturbed sleep Medical-Surgical
• Hypoventilation = Acidosis (too much CO2)
• Hyperventilation = Alkalosis (low CO2)
• No BP or IV on side of Mastectomy
• Opiate OD = Pinpoint Pupils
• Lesions of Midbrain
o Decerebrate Posturing
• Lesions of Cortex
o Decorticate Posturing
• Urine Output of 30 mL/hr = minimal competency of heart and kidney function
• Cholelithiasis- Kidney Stone
o Flank pain- stone in kidney or upper ureter
o Abdominal/scrotal pain- stone in mid/lower ureter or bladder
• Renal Failure … Restrict protein intake
o Fluid and electrolyte problems
▪ HyperK+ dizzy, weak, nausea, cramps, arrhythmias
o 3 phases
▪ Oliguric
▪ Diuretic
▪ Recovery
o Monitor Body Wt and I&Os
• Steroid Efects
o Moon face
o Hyperglycemia
o Acne
o Hirsutism
o bufalo hump
o mood swings
o weight gain – Spindle shape, osteoporosis, adrenal suppression (delayed growth in kids) . . . (Cushing’s Syndrome symptoms)
• Addison’s’ Crisis- medical emergency
o vascular collapse
o hypoglycemia
o tachycardia
o Tx: Admin IV glucose + corticosteroids
• No PO corticosteroids on empty stomach
• Spironolactone + ACE Inhibitors hyperK+
• Cardiac Enzymes
o Troponin (1 hr)
o CKMB (2-4 hr)
o Myoglobin (1-4 hr)
o LDH1 (12-24 hr)
• MI Tx:
o Nitro – Yes
o NO Digoxin, Betablockers, Atropine
o Fibrinolytics = Streptokinase, Tenecteplase (TNKase)
o CABG = Coronary Artery Bypass Graft
o PTCA = Percutaneous Transluminal Coronary Angioplasty
o Sex after MI okay when able to climb 2 Flights of stairs without exertion (Take nitro prophylactically before sex)
• BPH Tx
o TURP (Transurethral Resection of Prostate) some blood for 4 days, and burning for 7 days post- TURP.
o Only isotonic sterile saline for Bladder Irrigation
• Post Thyroidectomy
o Keep tracheostomy set by the bed with O2, suction, and Calcium gluconate
• Pericarditis
o Pericardial Friction Rub
o Pain relieved by leaning forward
• Post Strep URI Diseases and Conditions:
o Acute Glomerulonephritis
o Rheumatic Fever (Valve Disease)
o Scarlet Fever
• If a chest-tube becomes disconnected do not clamp Put end in sterile water
• Chest Tube drainage system should show bubbling and water level fluctuations (tidaling with breathing)
• TB
o Treatment with multidrug regimen for 9 months
o Rifampin reduces efectiveness of OCs and turns pee orange
o Isoniazide (INH) increases Dilantin blood levels
• Use bronchodilators before steroids for asthma
o Exhale completely, Inhale deeply, Hold breath for 10 seconds
• Ventilators
o Make sure alarms are on
o Check every 4 hours minimum
• Suctioning
o Pre and Post oxygenate with 100% O2
o No more than 3 passes
o No longer than 15 seconds
o Suction on withdrawal with rotation
• COPD:
o Emphysema = Pink Pufer
o Chronic Bronchitis = Blue Bloater (Cyanosis, Rt sided heart failure = bloating/edema)
• O2 Administration
o Never more than 6L/min by cannula
o Must humidify with more than 4L/hr
o No more than 2L/min with COPD … (CO2 Narcosis)
• Restlessness and Irritability Early signs of cerebral hypoxia
• IVs and Blood Product Administration
o 18 g needle for blood with filter in tubing
o Run blood with NS only and within 30 minutes of hanging
o Vitals and Breath Sounds before, during and after infusion
▪ 15 min after start, then 30 min later, then hourly up to 1 hr after
o Check Blood: Exp Date, clots, color, air bubbles, leaks
▪ 2 RNs must check order, pt, blood product
o Ask Pt about previous transfusion Hx
o Stay with Pt for first 15 minutes, If transfusion rxn Stop and KVO with NS
o Pre-medicate with Benadryl prn for previous urticaria rxns
• Isotonic Solutions
o D5W
o NS (0.9% NaCl)
o Ringers Lactate
o NS only with blood products and Dilantin
• Diabetes and Insulin
o When in doubt – Treat for Hypoglycemia first
o First IV for DKA = NS infuse regular insulin IV as Rx’d
o Hypoglycemia
▪ confusion, HA, irritable, nausea, sweating, tremors, hunger, slurring
o Hyperglycemia
▪ weakness, syncope, polydipsia, polyuria, blurred vision, fruity breath
o Insulin may be kept at room T for 28 days
o Draw Regular (Clear) insulin into syringe first when mixing insulins
o Rotate Injection Sites (Rotate in 1 region, then move to new region)
o Types:
▪ Rapid Acting Insulins … Lispro (Humalog) and Aspart (Novolog) … O: 5-15 min, P: .75-1.5 hrs
▪ Short Acting Insulin … Regular (human) … O: 30-60 min, P: 2-3 hrs (IV Okay)
▪ Intermediate Acting Insulin … Isophane Insulin (NPH) … O: 1-2 hrs, P: 6-12 hrs
▪ Long Acting Insulin … Insulin Glargine (Lantus) … O: 1.1 hr, P: 14-20 hrs (Don’t Mix)
o Oral Hypoglycemics decrease glucose levels by stimulating insulin production by beta cells of pancreas, increasing insulin sensitivity and decreasing hepatic glucose production
▪ Glyburide, Metformin (Glucophage), Avandia, Actos
▪ Acarbose blunts sugar levels after meals
Oncology
• Leukemia
o Anemia, Immunosuppression, Hemorrhage, and bleeding tendencies
• Acute Lymphocytic
o most common type
o kids
o best prognosis
• Testicular Cancer
o Painless lump or swelling testicle
o STE in shower > 14 yrs
• Prostate Cancer > 40 y/o
o PSA elevation
o Mets to spine, hips, legs
o Elevated PAP (prostate acid phosphatase)
o TRUS = Transurethral US
o Post Op … Monitor of hemorrhage and cardiovascular complication
• Cervical and Uterine Cancer
o Laser, cryotherapy, radiation, conization, hysterectomy, exenteration
o Chemotherapy = No help
o PAP smears should start within 3 years of intercourse or by age 21
• Ovarian Cancer = leading cause of death from gynecological cancer
• Breast Cancer = Leading cause of cancer in women
o Upper outer quadrant, left > right
o Monthly SBE
o Mammography
▪ Baseline @ 35
▪ Annually after age 50
o Mets to lymph nodes, then lungs, liver, brain, spine
o Mastectomy: Radical Mastectomy = Lymph nodes too
▪ Avoid BP measurements, injections and venipuncture on surgical side
▪ Anti-emetics given with Chemotherapy Agents (Cytoxan, Methotrexate, Interferon, etc.)
• Phenergan (Promethazine HCl)
• Compazine (Prochlorperazine)
• Reglan (Metocolpramide)
• Benadryl (Diphenhydramine)
• Zofran (Ondansetron HCl)
• Kytril (Granisetron)
Sexually Transmitted Diseases
• Syphilis (Treponema pallidum)
o Chancre + red painless lesion
o Primary Stage: 90 days
o Secondary Stage: up to 6 months Rash on palms and soles + Flu-like symptoms
o Tertiary Stage: 10-30 yrs. Neurologic and Cardiac destruction
o Tx: Penicillin G IM
• Gonorrhea (Neisseria Gonorrhea)
o Yellow green urethral discharge (The Clap)
• Chlamydia (Chlamydia Trachomatis)
o Mild vaginal discharge or urethritis
o Tx: Doxycyclin, Tetracycline
• Trichomoniasis (Trichomonas Vaginalis)
o Frothy foul-smelling vaginal discharge
o Tx: Flagyl
• Candidiasis (Candida Albicans)
o Yellow, cheesy discharge with itching
o Tx: Miconazole, Nystatin, Clomitrazole (Gyne-Lotrimin)
• Herpes Simplex 2
o Tx: Acyclovir
• HPV (Human Pappilovirus)
o Tx: Acid, Laser, Cryotherapy
• HIV Cocktails
Perioperative Care
• Breathing Es taught in advance (before or early in pre-op)
• Remove nail polish (need to see cap refill)
• Pre Op
o Meds as ordered, NPO for 8 hrs, Incentive Spirometry & Breathing Es taught in advance, Void, No NSAIDS for 48 hrs
o Increased corticosteroids for surgery (stress)
o May need to increase insulin
• Post Op
o Restlessness may = hemorrhage, hypoxia
o Wound dehiscence or extravasation Wet sterile NS dressing + Call Dr.
o Call Dr. post op if:
▪ < 30 mL/hr urine
▪ Sys BP < 90
▪ T > 100 or < 96
o Post Op Monitoring VS and BS:
▪ Every 15 minutes the first hour, Every 30 min next 2 hours, Every hour the next 4 hours, then Every 4 hours prn
o Immediate Stage: 1-4 hrs Post Op
o Intermediate Stage: 2-24 hrs Post Op
o Extended Stage: 1-4 days Post Op
o Post Op Positioning
▪ THR: No Adduction past midline, No hip flexion past 90 degrees
▪ Supratentorial Sx: HOB 30-45 degrees (Semi-Fowler)
▪ Infrantentorial Sx: Flat
▪ Phlebitis: Supine, elevate involved leg
▪ Harris Tube: Rt/back/Lt – to advance tube in GI
▪ Miller Abbott Tube: Right side for GI advancement into small intestine
▪ Thoracentesis: Unafected side, HOB 30-45 degrees
▪ Enema: Left Sims (flow into sigmoid)
▪ Liver Biopsy: Right side with pillow/towel against puncture site
▪ Cataract Sx: Opp. side and Semi-Fowler
▪ Cardiac Catheterization: Flat (HOB no more than 30 degrees), Leg straight 4-6 hrs, bed rest 6-12 hrs
▪ Burn Autograph: Elevated and Immob 3-7 days
▪ Amputation: Supine, elevate stump for 48 hrs
▪ Large Brain Tumor Resection … On non-operative side
o Incentive Spirometry
▪ Inhale slowly and completely to keep flow at 600-900, Hold breath 5 seconds, 10 times per hr
o Post Op Breathing Exercises: Every 2 hours
▪ Sit up straight
▪ Breath in deeply thru nose and out slowly thru pursed lips
▪ Hold last breath 3 seconds
▪ Then cough 3 times (unless abd wound – reinforce/splint if cough)
o Watch for Stridor after any neck/throat Sx … Keep Trach kit at bed side
o Staples and sutures removed in 7-14 days – Keep dry until then
o No lifting over 10 lbs for 6 weeks (in general)
o If chest tube comes disconnected, put free end in container of sterile water
o Removing Chest Tube Valsalva’s
o If chest tube drain stops fluctuating, the lung has re-inflated (or there is a problem)
o Keep scissors by bed if pt has S. Blakemore Tube (for esophageal varices)
▪ Sudden respiratory distress – Cut inflation tubes and remove
• Tracheostomy patients
o Keep Kelly clamp and Obturator (used to insert into trachea then removed leaving cannula) at bed side
o Turn of NG suction for 30 min after PO meds
• NG Tube Removal: Take a deep breath and hold it
o Stomach contents pH = < 4 (gastric juices aspirated)
• NG Tube Insertion
o If cough and gag, back of a little, let calm, advance again with pt sipping water from straw
o NG Tube Length: End of nose, to ear lobe, to xyphoid (22-26 inches)
• Decubitus (pressure) Ulcer Staging
o Stage 1 = Erythema only
o Stage 2 = Partial thickness
o Stage 3 = Full thickness to SQ
o Stage 4 = Full thickness + involving mm /bone
Acute Care
• CVA: Hemorrhagic or Embolic
• A-fib and A-flutter thrombus formation
• Dysarthria (verbal enunciation/articulation), Apraxia (perform purposeful movements), Dysphasia (speech and verbal comprehension), Aphasia (speaking), Agraphia (writing), Alexia (reading), Dysphagia (swallowing)
• Left Hemisphere Lesion
o aphasia, agraphia, slow, cautious, anxious, memory okay
• Right Hemisphere Lesion
o can’t recognize faces, loss of depth perception, impulsive behavior, confabulates, poor judgment, constantly smiles, denies illness, loss of tonal hearing
• Head Injuries
o Even subtle changes in mood, behavior, restlessness, irritability, confusion may indicate increased ICP
o Change in level of responsiveness = Most important indicator of increased ICP
o Watch for CSF leaks from nose or ears
▪ meningitis and mask intracranial injury since usual increased ICP symps may be absent.
• Spinal Cord Injuries
o Respiratory status paramount (C3-C5 innervates diaphragm)
o 1 wk to know ultimate prognosis
o Spinal Shock- Complete loss of all reflex, motor, sensory and autonomic activity below the lesion (Medical emergency)
o Permanent paralysis if spinal cord in compressed for 12-24 hrs
o Hypotension and Bradycardia with any injury above T6
o Bladder Infection = Common cause of death (try to keep urine acidic)
• Burns
o Infection is Primary concern
o HyperK+ due to cell damage
o Give pain meds before dressing changes
o Massive volumes of IV fluid given, due to fluid shift to interstitial spaces and resultant shock
o Types:
▪ First Degree = Epidermis (superficial partial thickness)
▪ Second Degree = Epidermis and Dermis (deep partial thickness)
▪ Third Degree = Epidermis, Dermis, and SQ (full thickness)
o Rule of 9s:
▪ Head and neck = 9%
▪ UE = 9% each
▪ LE = 18% each
▪ Front trunk = 18%
▪ Back Trunk = 18%
o Singed nasal hair and circumoral soot/burns = Smoke inhalation burns
• Fractures
o Report abnormal assessment findings promptly
▪ Compartment Syndrome may occur Permanent damage to nerves and vessels
o 5 P’s of neurovascular status (important with fractures)
▪ Pain, Pallor, Pulse, Paresthesia, Paralysis
o Provide age-appropriate toys for kids in traction
• Special Tests and Pathognomonic Signs
o Tensilon Test: Myasthenia Gravis (+ in Myasthenic crisis, - in Cholinergic crisis)
o ELISA and Western Blot: HIV
o Sweat Test: Cystic Fibrosis
o Cheilosis- Sores on sides of mouth: Riboflavin deficiency (B2)
o Trousseau’s Sign (Carpal spasm induced by BP cuf): Hypocalcemia (hypoparathyroidism)
o Chvostek’s Sign (Facial spasm after facial nerve tap): Hypocalcemia (hypoparathyroidism)
o Bloody Diarrhea = Ulcerative Colitis
o Olive-Shaped Mass (epigastric) and Projectile Vomiting: Pyloric Stenosis
o Current Jelly Stool (blood and mucus) and Sausage-Shaped Mass in RUQ: Intussusception
o Mantoux Test: TB Pos. if 10 mm induration 48 hrs post admin (previous BCG vaccine recipients will test +)
o Butterfly Rash: Lupus (avoid direct sunlight)
o Murphy’s Sign (Rt. costal margin pain on palp with inspiration): GB or Liver disease
Pediatrics
o HA more severe on wakening: Brain Tumor (remove benign and malignant)
o Vomiting not associated with nausea: Brain Tumor
o Elevated ICP: Increased BP, widened pulse pressure, increased Temp
o Pill-Rolling Tremor: Parkinson’s (Tx with Levodopa, Cardidopa) Fall precautions, rigid, stooped, shuffling
o IG Bands on Electrophoresis: MS
▪ Weakness starts in upper extremities
▪ bowel/bladder afected in 90% (Demyelination)
▪ Tx: ACTH, corticosteroids, Cytoxan and other immunosuppressants
o Reed-Sternberg Cells: Hodgkin’s Lymphoma
o Koplik Spots: Rubeola (Measles)
o Erythema Marginatum: Rash of Rheumatic Fever
o Gower’s Sign: Muscular Dystrophy (walks up legs with hands)
• Bench Marks
o Birth wt. doubles at 6 months and triples at 12 months
o Birth length increases by 50% at 12 months
o Post fontanel closes by 8 wks
o Ant fontanel closes by 12-18 months
o Moro reflex disappears at 4 months
o Steady head control achieved at 4 months
o Turns over at 5-6 months
o Hand to hand transfers at 7 months
o Sits unsupported at 8 months
o Crawls at 10 months
o Walks at 10-12 months
o Cooing at 2 months
o Monosyllabic Babbling at 3-6 months, Links syllables 6-9 mo
o Mama, Dada + a few words at 9-12 months
o Throws a ball overhand at 18 months
o Daytime toilet training at 18 mo - 2 years
o 2-3 word sentences at 2 years
o 50% of adult Ht at 2 years
o Birth Length doubles at 4 years
o Uses scissors at 4 years
o Ties shoes at 5 years
o Girls’ growth spurt as early at 10 years (Boys catch up ~ Age 14)
o Girls finish growing at ~15 (Boys ~ 17)
• Autosomal Recessive Diseases
o CF, PKU, Sickle Cell Anemia, Tay-Sachs, Albinism,
o 25% chance if: AS (trait only) X AS (trait only)
o 50% chance if: AS (trait only) X SS (disease)
• Autosomal Dominant Diseases
o Huntington’s, Marfan’s, Polydactyl, Achondroplasia, Polycystic Kidney Disease
o 50% if one parent has the disease/trait (trait = disease in autosomal dominant)
• X-Linked Recessive Diseases
o Females are carriers (never have the disease)
o Males have the disease (but can’t pass it on)
o 50% chance daughters will be carriers (can’t have disease)
o 50% chance sons will have the disease (not a carrier = can’t pass it on)
o This translates to an overall 25% chance that each pregnancy will result in a child that has the disease
o Hemophilia A
o Scoliosis Milwaukee Brace: 23 hrs/day, Log rolling after Surgery
o Down Syndrome = Trisomy 21 … Simian creases on palms, hypotonia, protruding tongue, upward outward slant of eyes
o Cerebral Palsy: Scissoring = legs extended, crossed, feet plantar-flexed
o PKU MR: Guthrie Test
▪ Aspartame has phenylalanine in it and should not be given to PKU patient
o Hypothyroidism: MR
o Myelomeningocele: Cover with moist sterile water dressing and keep pressure of
o Hydrocephalus: Signs of increased ICP are opposite of shock
▪ Shock = Increased pulse and decreased BP
▪ IICP = Decreased pulse and increased BP (Altered LOC = Most sensitive sign)
▪ Infants: IICP = Bulging fontanels, high pitched cry, increased head circumference, sunset eyes, wide suture lines, lethargy
• TX: peritoneal shunt (don’t pump shunt).
▪ Older kids: IIPC = Widened pulse pressure
▪ IICP caused by suctioning, coughing, straining, and turning
o Muscular Dystrophy
▪ waddling gait, hyper lordosis, Gower’s Sign = difficulty rising walks up legs (like Minor’s sign), fat pseudohypertrophy of calves.
• Seizures:
o Nothing in mouth, turn head to side, maintain airway, don’t restrain, keep safe
o Tx: Phenobarbitol (Luminol), Phenytoin (Dilantin: TR = 10-20 Gingival Hyperplasia, Fosphenytoin (Cerebyx), Valproic Acid (Depakene), Carbamazepine (Tegritol)
• Meningitis (Bacterial):
o Lumbar puncture shows Increased WBC, protein, IICP and decreased glucose
o May lead to SIADH (Too much ADH) … Water retention, fluid overload, dilutional hyponatremia
• Children with Rubella: May be threat to unborn siblings (may require temporary isolation from Mom during PG)
• No MMR Immunization for kids with Hx of allergic rxn to eggs or neomycin
• Immunization Side Efects
o T < 102, redness, and soreness at injection site for 3 days
o Give Tylenol and bike pedal legs (passively) for child.
o Call Physician if seizures, high fever, or high-pitched cry after immunization
• All cases of poisoning Call Poison Control Center (No Ipecac!)
• Epiglottitis = H. influenza B
o Child sits upright with chin out and tongue protruding (maybe Tripod position)
o Prepare for intubation or trach
o DO NOT put anything into kid’s mouth
• Isolate RSV patient with Contact Precautions
o Use Mist Tent to provide O2 and Ribavirin
o Flood tent with O2 first and wipe down inside of tent periodically so you can see patient
• Acute Glomerulonephritis: After B strep
o Antigen-Antibody complexes clog up glomeruli and reduce GFR = Dark urine, proteinuria
• Wilm’s Tumor = Large kidney tumor (Don’t palpate)
• TEF = Tracheoesophageal Atresia
o 3 C’s of TEF = Coughing, Choking, Cyanosis
• Cleft Lip and Palate
o Post-Op: Place on side, maintain Logan Bow, elbow restraints
• Congenital Megacolon = Hirschsprung’s Disease
o Lack of peristalsis due to absence of ganglionic cells in colon
o Suspect if no meconium w/in 24 hrs or ribbon-like foul smelling stools
• Iron Deficiency Anemia
o Give Iron on empty stomach with citrus juice (vitamin C enhances absorption)
o Use straw or dropper to avoid staining teeth, Tarry stools
o Limit milk intake < 32 oz/day
• Sickle Cell Disease
o Hydration most important
o SC Crisis: fever, abd. pain, painful edematous hands and feet (hand-foot syndrome), arthralgia
o Tx: rest, hydration
o Avoid high altitude and strenuous activities
• Tonsillitis: usually Strep
o Get PT and PTT
o Pre-Op (ask about Hx of bleeding)
o Suspect Bleeding Post-Op if frequent swallowing, vomiting blood, or clearing throat
o No red liquids, no straws, ice collar, soft foods
o Highest risk of hemorrhage = first 24 hrs and 5-10 days post-op (with sloughing of scabs)
• Primary meds for ER for respiratory distress: Sus-phrine (Epinephrine HCl) and Theophylline (Theo-dur) and Bronchodilators
• Normal respiratory rates for kids: Respiratory disorders are primary reason for hospital visits for kids
o Newborn: 30-60
o 1-11 m: 25-35
o 1-3 years: 20-30
o 3-5 years: 20-25
o 6-10 years: 18-22
o 11-16 years: 16-20
• Cardiovascular Disorders
o Acyanotic
▪ VSD, ASD, PDA, Coarctation of Aorta, Aortic Stenosis
• Antiprostaglandins cause closure of PDA (aorta - pulmonary artery)
o Cyanotic
▪ Tetralogy of Fallot- Unoxygenated blood pumped into aorta
• Pulmonary Stenosis
• VSD
• Overriding Aorta
• Right Ventricular Hypertrophy
• TET Spells- Hypoxic episodes that are relieved by squatting or knee chest position
• CHF Use Digoxin … TR = 0.8-2.0 for kids
▪ Truncus Arteriosis (one main vessel gets mixed blood)
▪ Transposition of Great Vessels
▪ Polycythemia common in Cyanotic disorders
o Ductus Venosus = Umbilical Vein to Inferior Vena Cava
o Ductus Arteriosus = Aorta to Pulmonary Artery
o Rheumatic Fever: Acquired Heart Disease and afects aortic and mitral valves
▪ Preceded by beta hemolytic strep infection
▪ Erythema Marginatum = Rash
▪ Elevated ASO titer and ESR
▪ Chest pain, shortness of breath (Carditis), migratory large joint pain, tachycardia (even during sleep)
▪ TX: Penicillin G Prophylaxis for recurrence of RF
Maternity
• Day 1 of cycle: First day of menses (bleeding)
• Day 14: Ovulation
• Lifespan of: Sperm 3-5 days; Eggs 24 hrs
• Chadwick’s Sign- Bluing of Vagina (early as 4 weeks)
• Hegar’s Sign = Softening of isthmus of cervix (8 weeks)
• Goodell’s Sign = Softening of Cervix (8 weeks)
• Pregnancy Total wt gain = 25-30 lbs (11-14 kg)
• During Pregnancy:
o Increase calorie intake by 300 calories/day
o Increase protein 30 g/day
o Increase iron, Ca++, Folic Acid, A & C
• Dangerous Infections with PG
o TORCH = Toxoplasmosis, other, Rubella, Cytomegalovirus, HPV
• Braxton Hicks common throughout PG
• Amniotic fluid = 800-1200 mL
o Oligohydramnios- < 300 mL (fetal kidney problems)
• Polyhydramnios and Macrosomia (large fetus) with Diabetes
• Umbilical cord: 2 arteries, 1 vein
o Vein carries oxygenated blood to fetus (opposite of normal)
• FHR: 120-160
• Folic Acid Deficiency Neural tube defects
• Gestation Time:
o Pre-term 20-37 weeks
o Term = 38-42 weeks
o Post-term = 42 weeks+
• TPAL
o Term births
o Pre-term births
o Abortions
o Living children
• Gravida- # of Pregnancies regardless of outcome
• Para- # of Deliveries (not kids) after 20 wks gestation
• Nagale’s Rule: day of last period - 3 months + 7 days = EDC
• Hgb and Hct a bit lower during PG due to hyperhydration
• Side-lying is best position for uteroplacental perfusion
• 2:1 Lecithin:Sphingomyelin Ratio = Fetal lungs mature
• AFP (Alpha-fetoprotein) in amniotic fluid = possible neural tube defect
• Need a full bladder for Amniocentesis early in PG (but not in later PG)
• Lightening- Fetus drops into true pelvis
• Nesting Instinct- Burst of Energy just before labor
• True Labor
o Regular contractions that intensify with ambulation
o Lower back pain that radiates to abdomen
o progressive dilation and efacement
• Station- Negative above ischial spines, Positive below
• Leopold Maneuver tries to reposition fetus for delivery
• Laboring Maternal Vitals
o Pulse < 100 (usually a little higher than normal with PG)
o BP is unchanged in PG
o T < 100.4
• NON-Stress Test
o Reactive = Healthy (FHR goes up with movements)
• Contraction Stress Test (Ocytocin Challenge Test)
o Unhealthy = Late decels noted (positive result) indicative of UPI; Negative result = No late decels
• Mag Sulfate Watch for hyporeflexia Diaphragmatic Inhibition
o Keep Calcium gluconate by the bed (antidote)
• Firsts
o Fetal HB … 8-12 weeks by Doppler, 15-20 weeks by fetoscope
o Fetal movement = Quickening, 14-20 weeks
o Showing = 14 weeks
o Braxton Hicks – 4 months and onward
• Fetal Heart Rate
o Early Decels = Head compression = OK
o Variable Decels = Cord compression = Not Good
o Late Decels = Utero-placental insufficiency = BAD!
o If Variable or Late Decels: Change maternal position, Stop Pitocin, Administer O2, Notify Physician
• DIC
o Caused by: Fetal Demise, Abruptio Placenta, Infection
o Tx: Heparin (safe in PG)
• Fundal Heights
o 12-14 wks … At level of symphysis
o 20 weeks … 20 cm = Level of umbilicus
o Rises ~ 1 cm per week
• Stages of Labor
o Stage 1 = Beginning of Regular contraction to full dilation and efacement
o Stage 2 = 10 cm dilation to delivery
o Stage 3 = Delivery of Placenta
▪ Placenta Separation … Lengthening of cord outside vagina, gush of blood, full feeling in vagina … Give oxytocin after placenta is out – Not before.
o Stage 4 = 1-4 Hrs following delivery
• Schultz Presentation = Shiny side out (fetal side of placenta)
• Postpartum VS Schedule
o Every 15 min for 1 hr
o Every 30 min for next 2 hours
o Every Hour for next 2-6 hours
o Then every 4 hours
• Normal BM for mom within 3 days = Normal
• Lochia
o no more than 4-8 pads/day and no clots > 1 cm
o Fleshy smell is normal
o Foul smell = infection
• Massage boggy uterus to encourage involution
o Empty bladder ASAP – may need to catheterize
o Full bladder uterine atony and hemorrhage
• Tears
o 1st Degree = Dermis
o 2nd Degree = mm/fascia
o 3rd Degree = anal sphincter
o 4th Degree = rectum
• APGAR
o HR, R, mm tone, Reflex irritability, Color
o 1 and 5 minutes
o 7-10 = Good, 4-6 = moderate resuscitative eforts, 1-3 = mostly dead
• Eye care: E-mycin + Silver Nitrate (for gonorrhea)
• Anesthesia
o Pudendal Block- decreases pain in perineum and vagina. No help with contraction pain.
o Epidural Block (T10-S5)
▪ Blocks all pain.
▪ First sign = warmth or tingling in ball of foot or big toe
o Regional Blocks often result in forceps or vacuum assisted births because they afect the mother’s ability to push efectively
• WBC counts are elevated up to 25,000 for 10 days post-partum
• Rho(D) immune globulin (RhoGAM)
o Given to Rh- mothers who deliver Rh+ kids
o Not given if mom has a +Coombs Test
o She already has developed antibodies (too late)
• Caput Succedaneum- edema under scalp, crosses suture lines
• Cephalohematoma- blood under periosteum, does not cross suture lines
• Suction Mouth first then nostrils
• Reflexes:
o Moro Reflex– up to 4 months
o Rooting Reflex- up to 4 months
o Babinski Reflex- up to18 months
o Palmar Grasp Reflex- Lessens by 4 months
• Ballard Scale used to estimate gestational age
• Physiologic Jaundice
o Normal at 2-3 days
o Abnormal if before 24 hours or lasting longer than 7 days
o Caused by Unconjugated bilirubin
o Can encephalopathy
o < 12 = normal
o Phototherapy decomposes bilirubin
o Protect eyes, turn every 2 hours and watch for dehydration
• Vitamin K given to help with formation of clotting factors due to fact that the newborn gut lacks the bacteria necessary for vitamin K synthesis initially. Vastus lateralis mm IM
• Abrutio Placenta = Dark red bleeding with rigid board like abdomen
• Placenta Previa = Painless bright red bleeding
• Magnesium Sulfate
o Used to reduce preterm labor contractions and prevent seizures in Pre-Eclampsia
o Mg replaces Ca++ in the smooth muscle cells relaxation hyporeflexia and respiratory depression
o Calcium Gluconate = Antidote
o Monitor for:
▪ Absent DTR’s
▪ Respirations < 12
▪ Urinary Output < 30/hr
▪ Fetal Bradycardia
• Pitocin (Oxytocin) use for Dystocia
o If uterine tetany develops turn of Pitocin, admin O2 by face mask, turn pt on side.
o Can cause water intoxication, due to ADH efects
• Suspect uterine rupture if woman complains of a sharp pain followed by cessation of contractions
• Pre-Eclampsia = Htn + Edema + Proteinuria
• Eclampsia = Htn + Edema + Proteinuria + Seizures and Coma
o Suspect if Severe HA + visual disturbances
• No Coumadin during PG (Heparin is OK)
• Hyperemesis Gravidarum- uncontrollable nausea and vomiting
o May be related to H. pylori
o Tx: Reglan (metaclopromide)
• Diabetes
o Insulin demands drop precipitously after delivery
o No oral hypoglycemics during PG (Teratogenic)
o Insulin only for control of DM
• Babies born without vaginal squeeze more likely to have respiratory difficulty initially
• C-Section can lead to Paralytic Ileus
o Early ambulation helps
• Postpartum Infection common in problem pregnancies (anemia, diabetes, traumatic birth)
• Postpartum Hemorrhage = Leading cause of maternal death
o Risk factors include:
▪ Dystocia, prolonged labor, overdistended uterus, Abruptio placenta, infection
o Tx: Fundal massage, count pads, VS, IV fluids, Oxytocin, notify physician
• Jitteriness is a symptom of hypoglycemia and hypocalcemia in the newborn
o Hypoglycemia: tremors, high pitched cry, seizures
• Hypothermia can lead to Hypoxia and acidosis
o Keep warm and use bicarbonate prn to treat acidosis in newborn.
• Lay on right side after feeding (Move stomach contents into small intestine
Nutrition
• K+: Bananas, dried fruits, citrus, potatoes, legumes, tea, peanut butter
• Vitamin C: Citrus, potatoes, cantaloupe
• Ca++: Milk, cheese, green leafy veggies, legumes
• Na+: Salt, processed foods, seafood
• Folic Acid: Green leafy veggies, liver, citrus
• Fe++: Green leafy veggies, red meat, organ meat, eggs, whole wheat, carrots
o Use Z-track for injections to avoid skin staining
• Mg+: Whole grains, green leafy veggies, nuts
• Thiamine (B1): Pork, beef, liver, whole grains
• B12: Organ meats, green leafy veggies, yeast, milk, cheese, shellfish
• Deficiency = Big red beefy tongue, Anemia
o Vitamin K: Green leafy veggies, milk, meat, soy
o Vitamin A: Liver, orange and dark green fruits and veggies
o Vitamin D: Dairy, fish oil, sunlight
o Vitamin E: Veggie oils, avocados, nuts, seeds
• BMI: 18.5-24.9 = Normal (Higher = Obese)
Gerontology
• Thin skin, bad sleep, mm wasting, memory loss, bladder shrinks, incontinence, delayed gastric emptying, COPD, Hypothyroidism, Diabetes
• Common Ailments:
o Delirium and Dementia
o Cardiac Dysrhythmias
o Cataracts and Glaucoma
o CVA (usually thrombotic, TIAs common)
o Decubitus Ulcers
o Hypothyroidism
o Thyrotoxicosis (Grave’s Disease)
o COPD (usually combination of emphysema and CB)
o UTIs and Pneumonia confusion and delirium
o Memory loss starts with recent – progresses to full
o Dementia = Irreversible (Alzheimer’s) … Depression, Sundowning, Loss of family recognition
o Delirium = Secondary to another problem = Reversible (infections common cause)
• Medication Alert!
o Due to decreased renal function, drugs metabolized by the kidneys may persist to toxic levels
• When in doubt on NCLEX, Answer should contain something about exercise and nutrition.
Advanced Clinical Concepts
• Erickson … Psycho-Social Development
o 0-1 yr (Newborn) … Trust vs. Mistrust
o 1-3 yrs (Toddler)… Autonomy vs. Doubt and Shame … Fear intrusive procedures - Security objects good (Blankies, stufed animals)
o 3-6 yrs (Pre-school) … Initiative vs. Guilt … Fear mutilation – Band-Aids good
o 6-12 yrs (School Age) … Industry vs. Inferiority… Games good, Peers important … Fear loss of control of their bodies
o 12-19 yrs (Adolescent) … Identity vs. Role Confusion … Fear Body Image Distortion
o 20-35 yrs (Early Adulthood) … Intimacy vs. Isolation
o 35-65 yrs (Middle Adulthood) … Generativity vs. Stagnation
o Over 65 (Older Adulthood) … Integrity vs. Despair
• Piaget … Cognitive Development
o Sensorimotor Stage (0-2) … Learns about reality and object permanence
o Preoperational Stage (2-7) … Concrete thinking
o Concrete Operational Stage (7-11) … Abstract thinking
o Formal Operational Stage (11-adult) … Abstract and logical thinking
• Freud … Psycho-Sexual Development
o Oral Stage (Birth -1 year) … Self gratification, Id is in control and running wild
o Anal Stage (1-3) … Control and pleasure wrt retention and pooping – Toilet training in this stage
o Phallic Stage (3-6) … Pleasure with genitals, Oedipus complex, SuperEgo develops
o Latency Stage (6-12) … Sex urges channeled to culturally acceptable level, Growth of Ego
o Genital Stage (12 up) … Gratification and satisfying sexual relations, Ego rules
• Kohlberg … Moral Development
o Moral development is sequential but people do not aromatically go from one stage to the next as they mature
▪ Level 1 = Pre-conventional … Reward vs. Punishment Orientation
▪ Level 2 = Conventional Morality … Conforms to rules to please others
▪ Level 3 = Post- Conventional … Rights, Principles and Conscience (Best for All is a concern)
Calculations
• Degrees F = (1.8 X C) + 32
• Degrees C = (F – 32) / 1.8
Fall Precautions
• Room close to nurse’s station
• Assessment and orientation to room
• Get help to stand (dangle feet if light headed)
• Bed low with side rails up
• Good lighting and reduce clutter in room
• Keep consistent toileting schedule
• Wear proper non-slip footwear
• At home:
o Paint edges of stairs bright color
o Bell on cats and dogs
Neutropenic Precautions
• No plants or flowers in room
• No fresh veggies (Cooked foods only)
• Avoid crowds and infectious persons
• Meticulous hand washing and hygiene to prevent infection
• Report fever > 100.5 (immunosuppressed pts may not manifest fever with infection)
Bleeding Precautions (Anticoagulants, etc.)
• Soft bristled tooth brush
• Electric razor only (no safety razors)
• Handle gently, Limit contact sports
• Rotate injection sites with small bore needles for blood thinners
• Limit needle sticks, Use small bore needles, Maintain pressure for 5 minutes on venipuncture sites
• No straining at stool - Check stools for occult blood (Stool softeners prn)
• No salicylates, NSAIDs, or suppositories
• Avoid blowing or picking nose
• Do not change Vitamin K intake if on Coumadin [Show Less]