NCLEX Study Guide

1. ABCs (Airway, Breathing, Circulation)

2. When in distress DO NOT ASSESS! Unless 2nd hand information is received.
3. Scenario
 Expected outcome with Disease Process
o Continue to monitor
o Document finding
 Unexpected finding with Disease Process
o Nursing intervention that must make a difference
o Call HCP
4. Mini Maslow’s
1) ABCs (& Pain unrelieved by meds)
2) Safety
3) Comfort (Pain)
4) Psychological
5) Social
6) Spiritual
5. STAT words → Pick the answer that failing to do so will kill or cause great harm
● Highest Priority
● Most Important
● Immediate Action
6. *Least Invasive First*
7. Secondhand Info → Any time you have 2nd hand info, the right answer is assess
∙ UAP ∙ Family
∙ Labs ∙ EMR
∙ EKG ∙ BP machine
8. Never ever take away the coping mechanism a patient uses during a crisis, except if the mechanism puts the patient or
others @ risk
9. Eliminate answer choices & DNR
10. Never withhold Tx! If you’re left with two answer choices and the options are to Tx, or watch the patient, Pick Tx!
11. Anytime there’s a reversal from the norm, you must worry!
Ex: rebound tenderness (pain after you relieve pressure)
12. Stable Patients
∙ UAP ∙ LPN ∙ New nurse
∙ Graduate Nurse ∙ Float Nurse ∙ Travel nurse
13. Anytime you see excessive findings, That’s not normal!
14. Always empower your patient
15. If a question has “ ”, pick an answer that has what they’re feeling & not what they’re saying
16. 3 R’s of Psych
1) Reality – Functional psych patient
2) Reassure – Delirium
3) Redirect – Dementia

Default Answers
1. Give meds either 1 hour before meal or 2 hours after meal
2. Give antacids 1 hour before med or 4 hours after med
3. When in doubt pick K (potassium)
4. 2 – 3 L of fluids
5. When in doubt pick answer that has you stay with patient
6. Anytime you see restless & ↓ level of consciousness = early sign always pick
7. Head of Bead → 30-45 degrees for any neuro patient
8. Elderly with acute onset confusion → UTI
9. Secretions will turn Orange/Red for meds
10. Anytime you have GI problem/exacerbation = NPO
11. All surgeries
1st 24 hrs – bleeding
48 hrs – infection
12. Check daily weights if it’s a fluid problem
13. Lateral position for maternity
14. Remove answer choices that are ‘absolutes’

Kaplan NCLEX Strategies

Kaplan RN Decision Tree
Step 1 – Can you identify the topic of the question
Step 2 – Are the answers assessment (get data) or implementation (to effect change)?
Step 3 – Apply Maslow: Are the answers physical or psychosocial? (Physical trumps psychosocial)
Step 4 – Are the answer choices related to ABCs?
Step 5 – What is the outcome of each of the remaining answers?

Rules for Delegation

RN ASSIGNMENT
● Cannot delegate assessment, teaching, or nursing judgement
LPN/LVN ASSIGNMENT
● Assign stable with expected outcomes
UAP ASSIGNMENT
● Delegate standard, unchanging procedures

Five Rights of Delegation

RIGHT TASK – scope of practice, stable client
RIGHT CIRCUMSTANCES – workload
RIGHT PERSON – scope of practice
RIGHT COMMUNICATION – specific task to be performed, expected results, follow-up communication
RIGHT SUPERVISION – clear directions, intervene if necessary

Therapeutic Communication Tips

DO: DO NOT:
● Do respond to feeling tone ● Do not ask ‘why’ questions
● Do provide information ● Do not ask ‘yes/no’ questions, except in the case of possible self-harm
● Do focus on the client ● Do not focus on the nurse
● Do use silence ● Do not explore
● Do use presence ● Do not say, “Don’t worry!”
Who Do You See First?

Consider:
∙ Unstable vs. Stable ∙ Acute vs. Chronic
∙ Unexpected vs. Expected ∙ Actual vs. Potential
∙ ABCs
Common NCLEX Traps
∙ Do not ask “Why?” ∙ Do not ‘do nothing.’
∙ Do not leave the client. ∙ Do not read into the question
 ∙ Do not persuade the client. ∙ Do not pass the buck.
∙ Do not say, “Don’t worry!”

Strategies
● Only use textbook nursing – textbook knowledge
● Pain is psychosocial, unless, it’s severe, acute, & unrelenting
● If it’s a position question, is it going to prevent or promote something – position, prevent, promote
● Teaching/learning – use T/F on each answer
● Risk Questions – use Risk Factors
● If the answers have an absolute in them, do not pick them
● Question that have the phrase ‘And Then’ – did they miss something

Important Lab Values

WBC 4K – 11K
RBC 4–6
Hgb 12 – 16, 0r 12-18
Hct 36 – 48, or 37-52
Plt 150K – 400K
BUN 8 – 20, or 7-22
Cr/Lithium 0.6 – 1.2
Urine 85 – 135,
Clearance (GFR)=maintain above
60

Uric Acid 250 – 750 mg

Na 135 – 145
Cl 98 – 106
Ca 8.5 – 10.5
K 3.5 – 5.0
PO 2.5 – 4.5g
Mag 1.5 – 2.5, 4-7 if pregnant
and receiving Toco

Warfarin INR 2.0 – 3.5

Heparin PT 10 – 13 Seconds
PTT 25 – 35 Seconds

Therapeutic PTT: 1.5 – 2x the normal value (46 – 76 Seconds)

Cholesterol
HDL x> 50
LDL x< 100
Triglycerides x< 150
Total Cholesterol x< 200

Therapeutic Ranges
Dilantin Theophylline 10 – 20
Acetaminophen
Digoxin 0.5 – 2.0

Albumin level 3.5 to 5.5

 Acid-Base Balance
From the ass (diarrhea) –Metabolic Acidosis
From the mouth (vomitus) –Metabolic Alkalosis

Potassium & Alkalosis – ALKALOSIS: K is LOW

– Acidosis is just the opposite: K is High

Arterial Blood Gases

1. Prior to drawing an ABG, perform the Allen’s Test to check for sufficient blood flow
2. When drawing an ABG, the blood needs to be put in a heparinized tube.
● Ensuring there are no bubbles.
3. Put on ice immediately after drawing, with a label.
● The label should indicate if the pt was on room air, or how many liters of O2.

General Notes
● The person who hyperventilates is most likely to experience respiratory alkalosis.

Antidotes
● Aspirin → Activated Charcoal
● Coumadin (Warfarin) → Vitamin K
● Heparin → Protamine Sulfate
● Tylenol (Acetaminophen) → Mucomyst (acetylcysteine) – administered orally
● Digoxin (Lanoxin) → Digibind (immune Fab)
● Opioids → Narcan
● Iron overdose → Deferoxamine
● PCP → Activated charcoal
● Magnesium Sulfate → Calcium Gluconate
● TPA → Aminocaproic acid
● Pancuronium Br (NM blocking agent) → Neostigmine/Atropine

Blood
For blood types:
● "O" is the universal donor (remember "o" in donor)
● "AB" is the universal recipient

4)Fever
5)Chills

Thrombocytopenia – Bleeding precautions!

Blood transfusion – sign of allergies in order: 1)Soft bristled toothbrush
1)Flank pain 2)No insertion of anything! (c/i suppositories, douche)
2)Frequent swallowing 3)No IM meds as much as possible!
3)Rashes

Sickle Cell Anemia

During sickle cell crisis there are two interventions to prioritize: fluids and pain relief.

Iron deficiency anemia – easily fatigued

1)Fe PO (Iron) - give with Vitamin C or on an empty stomach
2)Fe via IM- Interferon via Z Track
-- Peds: Kids are at risk for iron deficiency anemia if they ingest too much milk; >24oz/ day.

Pernicious Anemia - s/s include pallor, tachycardia, and Sore Red, Beefy tongue; will take Vit.B12 for life!
Shilling Test – test for pernicious anemia/ how well one absorbs Vit b12
General Notes
● A patient with a low hemoglobin and/or hematocrit should be evaluated for signs of bleeding, such as dark stools.

Burns
Rule of nines, 9 = head, 18 = arms, 36 = torso, 36 =legs, and 1= perineum
= 100%

The Parkland formula is a formula used for calculation the

total fluid requirement in 24 hours for a burn patient
4ml x TBSA % (Total Burn Surface Area) x body weight (kg) = Total
amount of fluid the patient will receive in 24 hrs
50% given in first eight hours
50% given in next 16 hours.

The Number #1 Priority for Burn Patients is maintaining a patent

airway

1st Degree – Red and Painful

2nd Degree – Blisters
3rd Degree – No Pain because of blocked and burned nerves
Cancer
A cancer patient is getting radiation. What should the nurse be most
concerned about?
● Skin irritation? No.
● Infection kills cancer patients most because of the leukopenia caused by radiation.

General Notes
● A breast cancer patient treated with Tamoxifen should report changes in visual acuity, because the adverse effect
could be irreversible.
● Common sites for metastasis include the liver, brain, lung, bone, and lymph.
● Bence Jones protein in the urine confirms multiple myeloma (cancer of plasma cells)
● Patients with leukemia may have epistaxis (nosebleeds) b/c of low platelets

Cardiac
All – Aortic Valve
Physicians – Pulmonary Valve
Earn – Erb’s Point
Their – Tricuspid Valve
Money – Mitral Valve (PMI)
Or APE To Man

Cardiac Catheter
● Pre-Op – NPO 8-12hr prior, empty bladder, check pulses, tell pt they may feel heat, palpitations, or desire to cough
with dye injection.
● Post Op – V/S, & keep leg straight, bed rest 6-8 hrs, Sleep supine.

General Notes
● Blood tests for MI: Myoglobin, CK and Troponin
● Coarctation of the aorta causes increased blood flow and bounding pulses in the arms
● Cor Pulmonale is right sided heart failure caused by left ventricular failure; (so pick edema, JVD, if it is a choice.)
● Normal PCWP (pulmonary capillary wedge pressure) is 8-13. Readings of 18-20 are considered high.
● Pulmonary sarcoidosis (an inflammatory disease) leads to right sided heart failure.
● Anytime you see fluid retention. Think heart problems first.
 Circulation
EleVate Veins; dAngle Arteries for better perfusion
For PVD remember DAVE (Legs are Dependent for Arterial & for Venous Elevated)

Virchow’s Triad → Risk Factors for DVT

V – Vascular Trauma
I – Increased Coagulability
R – Reduced Blood Flow

–Definitive diagnosis for abdominal aortic aneurysm (AAA) → CT scan

Fat Embolism S/S

● Blood tinged sputum (related to inflammation) <Pink frothy sputum>
● increased erthyro sedimentation rate (ESR)
● Respiratory alkalosis (related to tachypnea)
● Hypocalcemia, increased serum lipids
● "Snow Storm" effect on Chest x-ray

General Notes
● Hypotension and vasoconstriction meds may alter the accuracy of O2 sats.
● A newly diagnosed hypertension patient should have BP assessed in both arms

Cranial Nerves
Sensory=S Motor=M Both=B

1. Oh (Olfactory I) Some
2. Oh (Optic II) Say
3. Oh (Oculomotor III) Marry
4. To (Trochlear IV) Money
5. Touch (Trigeminal V) But
6. And (Abducens VI) My
7. Feel (Facial VII) Brother
8. Very (Vestibulocochlear/Auditory VIII) Says
9. Good (Glossopharyngeal IX) Big
10. Velvet (Vagus X) Brains
11. Such (Spinal Accessory XI) Matter
12. Heaven (Hypoglossal XII) More

On Old Olympus Towering Top A Finn And German Viewed Some Hopes

Cultural
Greek heritage - they put an amulet or any other use of protective charms around their baby's neck to avoid "evil eye" or
envy of others

Lyme Disease is found mostly in Connecticut

Jewish Folks: no meat and milk together

Diabetes
Blood Sugar ~ Hyperglycemia – Hot & Dry ~ Sugar High
 Hypoglycemia – Cold & Clammy ~ Need some candy

To remember how to draw up INSULIN think:Nicole Richie RN <Regular is clear & don't wanna put dirty needle in
clear so Regular<CLOUDY> is pulled in first>
Air into NPH, then air into Regular, draw up Regular insulin then draw up NPH

Oral Hypoglycemics
● Do not attempt to give an oral hypoglycemic to an unconscious pt, as this poses the risk of aspirations
● A typical adverse reaction is rash, photosensitivity.

HbA1c – test to assess how well blood sugars have been controlled over the past 90-120 days.
4- 6 corresponds to a blood sugar of 70-110;
7 is ideal for a diabetic and corresponds to a blood sugar of 130

Fluids are the most important intervention with HHNS as well as DKA, so get fluids going first.

DKA
● While treating DKA, bringing the glucose down too far and too fast can result in increased intracranial pressure
due to water being pulled into the CSF.
● Serum acetone and serum ketones rise in DKA.
● As you treat the acidosis and dehydration expect the potassium to drop rapidly, so be ready, with potassium
replacement.

HHNS
● With HHNS there is no ketosis, and no acidosis.
● Potassium is low in HHNS (d/t diuresis

General Notes
● Extra insulin may be needed for a patient taking Prednisone (remember, steroids cause increased glucose).
● Second voided urine most accurate when testing for ketones and glucose.

Drugs
General Notes
● Give NSAIDS, Corticosteroids, drugs for Bipolar, Cephalosporins, and Sulfonamides WITH food.
● Best time to take Growth Hormone PM (Octreotide), Steroids AM, Diuretics AM, Aricept (Donepezil) AM - for
Alzheimer’s disease.
● Antacids are given after meals
● Remember the action of vasopressin because it sounds like “press in”, or vasoconstrict.
● If mixing antipsychotics (i.e. Haldol, Thorazine, Prolixin) with fluids, meds are incompatible with caffeine and
apple juice
● The main hypersensitivity reaction seen with antiplatelet drugs is bronchospasm (anaphylaxis) - “think NSAIDS
causing bronchoconstriction in asthma patients”
● Glucagon increases the effects of oral anticoagulants.
● All psych meds' (except Lithium) side effects are the same as SNS but the BP is decreased
o SNS- Increase in BP, HR and RR (dilated bronchioles), dilated pupils (blurred vision), Decreased GUT
(urinary retention), GIT (constipation), Constricted blood vessels and Dry mouth.

Anti-Anemics
● Iron injections should be given Z-track, so they don't leak into SQ tissues.
● Take iron elixir with juice or water.... never with milk

Antiarrhythmics
● Verapamil: a calcium channel blocker, used to treat hypertension, angina; assess for constipation
 ● Digoxin: Check pulse, if it’s less than 60, hold medication, prior to administration check both potassium and dig
levels
o Pick ‘do vitals’ before administering that dig. (apical pulse for one full minute).
o Making sure that patients on Digoxin and Lasix are getting enough potassium, because low potassium
potentiates Digoxin toxicity and can cause dysrhythmias.
o Digitalis increases ventricular irritability and could convert a rhythm to v-fib following cardioversion.
● Adenosine: is the treatment of choice for paroxysmal atrial tachycardia.
● Flecainide (Tambocor): Antiarrhythmics med, limit fluids and sodium intake, because sodium increases water
retention which could lead to heart failure.

Antianxiety
● Diazepam is a commonly used tranquilizer given to reduce anxiety before OR
● Midazolam: an anesthetic given for conscious sedation, watch out for respiratory depression and hypotension
● Chlordiazepoxide: treatment of alcohol withdrawal; don’t take alcohol with this medication, causes nausea &
vomiting
● Hydroxyzine: treatment of anxiety as well as itching, commonly administered pre-op, watch out for dry mouth
● Lorazepam: treatment of choice for status epilepticus

Anti-asthmatics
● INtal<cromolyn sodium aerosol>: an inhaler used to treat allergy induced asthma may cause bronchospasm,
think... INto the asthmatic lung

Antibiotic
● Aminoglycocides: Adverse Effects are bean shaped - Nephrotoxic to Kidneys and Ototoxic to Ears
o __Mycin (drugs that end in or have in their name); except erythromycin (have -thro- in drug name)
● Sulfamethoxazole/trimethoprim: an antibiotic; common side effect is diarrhea (drink plenty of fluids); do not
take if allergic to sulfa drugs

Anticholinergic---- INE ending**

● Anticholinergic effects –– assessment
o dry mouth – can't spit
o urinary retention – can't piss
o constipated – can't shit
o blurred vision – can't see
● Atropine used to decrease secretions & asystole
o Atropine blocks acetylcholine (remember acetylcholine reduces secretions)
o Atropine OD
Hot as a Hare (Temp)
Mad as a Hatter (LOC)
Red as a Beet (flushed face)
Dry as a Bone (Thirsty)
● Benztropine: Treats Parkinson as well as extrapyramidal side effects of other drugs

Anticonvulsants
● Phenytoin <Dilantin>: treatment of seizures; therapeutic drug level: 10-20; contraindicated during pregnancy;
Side effects include rash (stop med if seen), gingival hyperplasia (can be prevented w/ good hygiene).
o Dilantin Toxicity → poor gait + coordination, slurred speech, nausea, lethargy, & diplopia
● Phenobarbital: treatment of epilepsy; can be taken during pregnancy

Antidepressants
● Zoloft/Sertraline: side effects include agitation, sleep disturb, and dry mouth (SSRI)
● MAOI’s: antidepressant
o An easy way to remember MAOI'S! think of PANAMA!
 PA – parnate- Tranylcypromine
NA – nardil- Phenelzine
MA – marplan- Isocarboxazid
o MAOI's used for depression all have an arrr sound in the middle (Parnate, Marplan, Nardil) – Remember
that Pirates say arrr, so think “pirates take MAOI's when they're depressed”
o They have metallic bitter taste

Antifungal
● Amphotericin B: This medication causes hypokalemia (amongst many other side effects as well); patient will
most likely get a fever; pre-medicate with acetaminophen and/or diphenhydramine (preferably both) before
administering to a patient

Antiemetic should
● Trimethobenzamide <Tigan>: Treatment of postop nausea and vomiting, and for nausea associated with
gastroenteritis
● Promethazine <Phenergan>: an antiemetic used to reduce nausea

Anti-gout Agents
● Probenecid, Colchicine, Allopurinol
● Allopurinol: Push with fluids, in order to flush the uric acid out of system; DO NOT TAKE W/ VITAMIN C

Antihypertensives
● hydralazine: treatment of HTN or CHF, Report flu-like symptoms, rise slowly from sitting/lying position; take
with meals.

Antimanic
● Lithium:
L-level of therapeutic effect is 0.5-1.5
I-indicate mania
T-toxic level is 2-3 - nausea & vomiting, diarrhea, tremors
H-hydrate 2-3L of water/day
I-increased Urinary output and dry mouth
U-uh oh; give Mannitol and Diamox if toxic signs and symptoms are present
M-maintain Na intake of 2-3g/day*

Antimetabolites
● Hydroxyurea: treatment of sickle cell & certain types of leukemia; when used to Tx sickle cell, report GI
symptoms immediately, could be sign of toxicity

Antineoplastic
● vincristine: treatment of leukemia; given IV ONLY
● Asparaginase: treatment for acute lymphoblastic leukemia; Test for hypersensitivity prior to administration

Antiparkinsonian Agents
● Carbidopa-Levodopa: treatment of Parkinson; side effects include drowsiness and the patient’s sweat, saliva,
urine may occasionally turn reddish brown; contraindicated with MAOI's
● Trihexyphenidyl treatment of Parkinson, causes sedation
● Levodopa: Contraindicated in patients’ w/ glaucoma, avoid B6

Antipsychotics
● Risperidone: Doses over 6mg can cause tardive dyskinesia, this is a first line antipsychotic in children
● Clozapine: Side effects include agranulocytosis, tachycardia, and seizures, WATCH FOR INFECTION*
● Thiothixene: treatment of schizophrenia; assess for EPS
● Haloperidol: preferred antipsychotic in elderly, but it has a high risk of extrapyramidal side effects (dystonia,
 tardive dyskinesia, tightening of jaw, stiff neck, swollen tongue, later on swollen airway)
o The nurse must monitor for early signs of reaction and give IM Benadryl
● 1st generation antipsychotics are the leading cause of Akathisia
o Akathisia is characterized by motor restlessness, i.e. a need to keep going
o Can be mistaken for agitation
o Treated with Anti Parkinson's meds

Anti-rheumatics
● Indomethacin: an NSAID; treatment of arthritis (osteo, rheumatoid, gouty), bursitis, and tendonitis.

Antispasmodics
● dicyclomine: treatment of irritable bowel; assess for anticholinergic side effects.

Antitubercular
● Rifampin: Red orange tears and urine (b/c it dyes bodily fluid orange); contraceptives don't work as well
● Ethambutol: messes with your Eyes
● Isoniazid (INH): treatment & prevent TB; it can cause peripheral neuritis/neuropathy (nerve damage); do not
give with Phenytoin → can cause phenytoin toxicity; monitor LFT's; give B6 along with; hypotension will occur
initially, then resolve
● TB drugs are liver toxic (hepatotoxic).
o An adverse reaction is peripheral neuropathy
o Ask patients if they have Hep B

Antithyroid
● PTU and Tapazole: Tx of hyperthyroidism & prevention of thyroid storm
● Lugol’s Solution: adjunct Tx for hyperthyroidism as well as radiation protectant. An adverse reaction: Burning
sensation in the mouth, and brassy taste. Report it to the doctor.

Antiulcer
● Aluminum hydroxide: treatment of GERD and kidney stones, watch out for constipation.
o Long term use of amphogel (binds to phosphates, increases Ca, robs the bones...leads to increased
Ca reabsorption from bones → WEAK BONES)
o Amphogel and Renegal should be taken with meals
● Sucralfate: treatment of duodenal ulcers, this medication coats the ulcer by creating a mucosal barrier, so the
patient should take this medication before meals; be aware of constipation as a potential side effect
● Cimetidine: an H2 antagonist taken with food; use cautiously in the elderly population; interacts with a lot of
other drugs
● Peptic ulcers caused by H. pylori are treated with Flagyl, Prilosec and Biaxin. This treatment kills bacteria and
stops production of stomach acid but does not heal ulcer.

Antiviral
● Ganciclovir: used for retinitis caused by cytomegalovirus, patient will need regular eye exams, report dizziness,
confusion, or seizures immediately

Anthelmintic/Anti-worm
● Mebendazole: Administer this medication with a high fat diet as this increase’s absorption

Beta Blockers
● Timolol: treatment of glaucoma

Bronchodilators
● Theophylline: Tx of asthma or COPD; therapeutic drug level is 10-20; increases the risk of digoxin toxicity and
decreases the effects of lithium and Phenytoin; causes GI upset, give with food
CNS Stimulants
● Dexedrine: treatment of ADHD; may alter insulin needs; avoid taking with MAOI's; take in morning (insomnia
possible side effect)
● Methylphenidate: Tx of ADHD; assess for heart related side effects, report them immediately; child may need a
drug holiday b/c it stunts growth.

Digestive Agent
● Pancrealipase: These are pancreatic enzymes, which are to be taken with each meal! Not before, not after, but
W/ each meal.

Diuretics
● Mannitol (osmotic diuretic): used for Head injuries; it crystallizes at room temp so ALWAYS use filter needle
● Acetazolamide: Tx of glaucoma, & high-altitude sickness; do not take if allergic to sulfa drugs; may cause
hypokalemia
● Lasix: Tx of edema due to heart failure; can cause a patient to lose his appetite (anorexia) due to reduced
potassium
o Patients receiving Lasix and Dig, need to be getting enough potassium, b/c low potassium potentiates
Dig Toxicity and can cause dysrhythmias.

Hormones
● Levothyroxine: Tx of hypothyroidism, this medication may take several weeks to take effect; notify doctor of
chest pain; take in the AM on empty stomach; may cause hyperthyroidism
o Insomnia is a side effect of thyroid hormones (Ex: Synthroid) → Increases met. rate, your body is "too
busy to sleep" as opposed to the folks with hypothyroidism who may report somnolence (dec. met rate,
body is slow and sleepy).
● Conjugated estrogens: treatment occurs after menopause for estrogen replacement

Hypokalemic
● Sodium Polystyrene Sulfonate: When giving administering this drug, we need to worry about dehydration
(K has inverse relationship with Na)
o Don’t use this medication if patient has hypoactive bowel sounds.

Opioid Analgesics
● Meperidine <Demerol>: Tx for moderate to severe pain; used for patients with pancreatitis (these patients could
NOT receive morphine sulfate); Do not give Demerol to pts. with sickle cell crisis

Pediculocides
● Lindane <Antiparasite>: Tx of scabies and lice;
o Scabies ~ apply lotion once and leave on for 8-12 hours
o Lice ~ use the shampoo and leave on for 4 minutes with hair uncovered then rinse with warm water and
comb with a fine-tooth comb

Skeletal Muscle Relaxant

● Dantrolene: treatment for spasticity, associated w/ spinal cord injury, stroke, cerebral palsy, or MS; it may take a
week or more to be effective.
● succinylcholine: is used for short-term neuromuscular blocking agent for procedures like intubation and ECT.
● Vecuronium Bromide: an adjunct medication for general anesthesia-induced muscle relaxation for endotracheal
intubation/mechanical ventilation, it’s used for intermediate or long-term.

Statins
● Simvastatin’s: Treatment for hyperlipidemia; take on empty stomach to enhance absorption; report any
unexplained muscle pain, especially if fever is present

Sympathomimetic
 ● Dopamine (Intropine): Tx of hypotension, shock, low cardiac output, poor perfusion to vital organs; monitor EKG
for arrhythmias, and BP

Vasodilators
● Nitroprusside: When the patient is on this medication, monitor thiocyanate (cyanide). The normal value should
be 1, >1 is heading toward toxicity

Endocrine Diseases

Addison’s: hypoNa, hyperK, hypoglycemia, dark pigmentation, decreased resistance to stress, fractures,

alopecia, weight loss, GI distress – Addison's disease (need to "add" hormone)
Blood pressure is the most important assessment parameter in Addison’s, as it causes severe hypotension.
Addisonian Crisis: Nausea & vomiting, confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration,
decreased BP
Managing stress in a patient with adrenal insufficiency (Addison’s) is paramount, because if the adrenal glands
are stressed further it could result in Addisonian crisis.

Cushing’s: hyperNatremia, hypoKalemia, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN,
hirsutism, moon-face/buffalo hump – Cushing's syndrome (have extra "cushion" of hormones)

Sex Salt Sugar

Addison’s ↓ ↓ ↓
Cushing’s ↑ ↑ ↑
OR

Addison’s= down, down, down, up, down

Cushing’s= up, up, up, down, up

Addison’s= hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia

Cushing’s= hypernatremia, hypertension, increased blood vol, hypokalemia, hyperglycemia
Addison's disease (need to "add" hormone)
Cushing's syndrome (have extra "cushion" of hormones)

Diabetes Insipidus (decreased ADH): excessive urine output and thirst, dehydration, weakness; administer Vasopressin
SIADH (increased ADH): change in LOC, decreased deep tendon reflexes, tachycardia, n/v/a, HA; administer
Declomycin, diuretics

Hyper-parathyroid: fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium); diet should consist
of low Ca, & high phosphorus diet (Calcium and phosphorus has inverse relationship)
● Polyuria is common with the hypercalcemia caused by hyperparathyroidism.
Hypo-parathyroid: CATS – convulsions, arrhythmias, tetany, spasms, stridor, & decreased calcium; diet should consist
of high Ca, & low phosphorus diet

Hyperthyroidism/Graves’ disease: accelerated physical and mental function; sensitivity to heat, fine/soft hair
For HYPERthyroidism think of MICHAEL JACKSON in THRILLER! SKINNY, NERVOUS, BULDGING
EYES, up all night, heart beating fast

Thyroid Storm: is HOT (hyperthermia), ↑ HR, & HTN

Hypothyroidism/Myxedema: slowed physical and mental function, sensitivity to cold, hypothermia, dry skin and hair
Post-thyroidectomy: Must watch for hypercortisolism and temporary diabetes insipidus. Position the patient in semi-
Fowler’s, prevent neck flexion/hyperextension, and have trach at bedside

Pheochromocytoma: hypersecretion of too much of epi/norepi, persistent HTN, increased HR, hyperglycemia,

diaphoresis, tremor, pounding heart; avoid stress, frequent bating and rest breaks, avoid cold and stimulating foods,
surgery to remove tumor

Pancreatitis: Pt is placed in fetal position, maintain NPO, gut rest, prepare antecubital site for PICC b/c will probably be
receiving TPN/Lipids. After pain relief, cough and deep breathe is important because of fluid pushing up in the
diaphragm.

Hepatitis

Hepatitis A = –ends in a VOWEL, comes from the BOWEL (Hep A)

Hepatitis B = Blood and Bodily fluids
● Anaphylactic reaction to baker's yeast is contraindication for Hep B vaccine.
Hepatitis C = is just like B
● During the acute stage of Hep-A gown and gloves are required.
● In the convalescent stage it is no longer contagious.

Eyes & Ears

Ears
● Pull pinna down and back for kids < 3 yrs. when instilling eardrops

Meniere's Disease
● Tx: Admin diuretics to decrease endolymph in the cochlea
● Nursing Care: restrict Na, lay on affected ear when in bed
Triad:
1)Vertigo
2)Tinnitus
3)Nausea & vomiting

Strabismus Treatment is BOTOX

● Patch the GOOD eye, so that the weaker eye can get stronger.
● Botox can be used with strabismus to relax vocal cords in spasmodic dysphonia.

Eyes
OU – Both eyes
OS – Left eye
OD – Right eye (dominant Right eye – just a tip to remember)

General Notes for Eyes

● Assessing extraocular eye movements check cranial nerves 3 (oculomotor), 4 (trochlear), and 6 (Abducens).
● Glaucoma intraocular pressure is greater than the normal (22 mm Hg), give miotic to constrict (pilocarpine), NO
ATROPINE
● Apply eye drop to conjunctival sac and afterwards apply pressure to nasolacrimal duct / inner canthus

Fluid & Electrolyte Imbalances

Hypovolemia (FVD) – increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety, urine specific gravity
>1.030. (More U Specificity means urine more concentrated. More particles in urine and less dilution)
Hypervolemia (FVE) – bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, hypertension, urine specific
gravity <1.010; Semi-Fowler’s
Fluid volume overload caused by IVC fluids infusing too quickly and CHF can cause an S3 heart sound.
Hyponatremia: nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic diuretics, fluids
Hypernatremia (greater than 145: increased temp, weakness, disorientation/delusions, hypotension, tachycardia;
hypotonic solution
Remember…. Hypernatremia presents similarly to Fluid Volume Deficit
Hyponatremia presents similarly to Fluid Volume Excess
Remember SALT… Skin flushed
Agitation
Low grade fever
Thirst

Hypokalemia: muscle weakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges, beans, potatoes, carrots,
celery)
No Pee, no K (do not give potassium without adequate urine output)
Hyperkalemia: MURDER – Muscle weakness, Urine (oliguria/anuria), Respiratory depression, Decreased cardiac
contractility, ECG changes, Reflexes

Hypocalcemia <Non sedation>: CATS – convulsions, arrhythmias, tetany, spasms and stridor

Hypercalcemia <Sedative effect>: muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon
reflexes, sedative effect on CNS

HypoMg <Non sedative effect>: tremors, tetany, seizures, dysrhythmias, depression, confusion, dysphagia; dig toxicity
(not enough magnesium, everything goes up)
HyperMg <Sedative effect>: depresses the CNS, hypotension, facial flushing, muscle weakness, absent deep tendon
reflexes, shallow respirations, emergency (More magnesium, everything goes down)

Fundamental Skills

Order of Assessment Order of Assessment for Abdomen/Children

Inspection Inspection ∙ Bowels Sounds may be obstructed and not
Auscultation Auscultation heard, if performed out of order
Palpation Percussion
Percussion Palpation ∙ In Kids, go from least to most invasive

If your normally lucid patient starts seeing bugs you better check his respiratory status first. The first sign of hypoxia is
restlessness, followed by agitation, and things go downhill from there all the way to delirium, hallucinations, and coma.
So, check the o2 stat, and get ABG’s if possible.

The immediate intervention after a sucking stab wound is to dress the wound and tape it on three sides which allows air
to escape. Do not use an occlusive dressing, which could convert the wound from open pneumo to closed one, and a
tension pneumothorax is worse situation. After that get your chest tube tray, labs, iv.

An example of when you would implement before going through a bunch of assessments is when someone is
experiencing anaphylaxis. Get the ordered epinephrine in them stat, especially if the stem clearly states the s/s
(difficulty breathing, increasing anxiety, etc.)

Radioactive iodine – The key word here is flush. Flush substance out of body w/3-4 liters/day for 2 days and flush the
toilet twice after using for 2 days. Limit contact w/patient to 30 minutes/day. No pregnant visitors/nurses, and no kids.

Role-Relationship Pattern, a nursing diagnosis focused on the person’s roles in the world and relationships with others. To
access the role relationship pattern, focus on image, and relationships with others.

Bleeding is part of the ‘circulation’ assessment of the ABCD’s in an emergent situation.

● Therefore, if airway and breathing are accounted for, a compound fracture requires assessment before Glasgow
Coma Scale and a neuro check (D=disability, or neuro check)
Potassium
● The vital sign you should check first with high potassium is pulse (due to dysrhythmias).
● Never give potassium if the patient is oliguric or anuric (because can’t pee out the potassium = hyperkalemia)

NG Tube
● An NG tube can be irrigated with cola and should be taught to family when a client is going home with an NG tube.
● An antacid should be given to a mechanically ventilated patient with an NG tube if the pH of the aspirate is <5.0
(because pH is low, acidic)
o Aspirate should be checked at least every 12 hrs.

Hemovac
● Can be used after mastectomy
● How to Clean/Empty:
o Empty when full or q8hr, remove plug, empty contents, place on flat surface, cleanse opening and plug with
alcohol sponge, compress evacuator completely to remove air, release plug, check system for operation.

Liver
● Liver Biopsy:
o Prior to a liver biopsy it's important to be aware of the lab result for prothrombin time
o NPO for 6 hrs morning of biopsy, & administer vitamin k (for clotting factors), as well as a sedative
o Teach patient that he will be asked to hold breath for 5-10sec, supine position, lateral with upper arms
elevated.
o Post Op – position on right side, frequent vital signs, report severe abdominal pain stat, no heavy lifting
1 week.
● A patient with liver cirrhosis and edema may ambulate, then sit with legs elevated to try to mobilize the edema.
● For esophageal varices, a Sengstaken Blakemore tube is used, keep scissors at bedside (to cut the tube in an
emergency situation) - U world question!!!
● Tylenol poisoning – liver failure possible for about 4 days. Close observation required during this timeframe, as well
as treatment with Mucomist (Tylenol/acetaminophen antidote).

Paracentesis: (removing a ton of fluid from abdomen from liver failure)

● Pre-Op – The patient should empty their bladder
● Post Op – Vital signs, report elevated temperature (for infection), observe for signs of hypovolemia.

MRI
● Claustrophobia
● No metal
● Assess pacemaker

Laparoscopy - (fiber-optic instrument is inserted through the abdominal wall to view the organs in the abdomen or to
permit a surgical procedure)
● CO2 used to enhance visual
● General anesthesia is administered, and a foley is inserted
● Post Op – Walk w/ patient to decrease CO2 build up used for procedure.

Compartment Syndrome ~ an EMERGENCY situation

● Paresthesia and increased pain are classic symptoms!!!! <No relief from Opioids>
● Neuromuscular damage is irreversible, 4-6 hours after onset

General Notes
● For patients with Halo device; Remember safety first & have a screwdriver nearby. (Keep the pins infection free)
● Iatrogenic means it was caused by treatment, procedure, or medication.
● A 3-way occlusive dressing is used if a chest tube is accidentally pulled out of the patient.
● Cultures are obtained before starting IV antibiotics!!!! (what would you do first!?!)
● Orthostatic hypertension is verified by a drop-in pressure with increasing heart rate
● You will ask every new admission if he has an advance directive, and if not, you will explain it, and he will have the
option to sign or not.
● A guy loses his house in a fire. Priority is using community resources to find shelter, before assisting with
feelings about the tremendous loss. – (Maslow)
● No nasotracheal suctioning with head injury or skull fracture (increases intracranial pressure!!!)
● Feed upright to avoid otitis media.
● Water intoxication will be evidenced by drowsiness, and altered mental status, in patients with TURP syndrome, or
as an adverse reaction to desmopressin (for diabetes insipidus).
● Other than initially to test tolerance, G-tube and J-tube feedings are usually given as continuous feedings.
● Four side-rails up can be considered a form of restraint. Even in LTC (long term care) facility when a client is a fall
risk, keep lower rails down, and one side of bed against the wall, lowest position, wheels locked.

Gastrointestinal
Dumping syndrome: increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis, wait
1 hr after meals to drink!!!!! (know!!!)

Weighted NI (Naso intestinal tubes) must float from stomach to intestine. Don't tape the tube right away after
placement, may leave coiled next to patient on head of bed. Position patient on RIGHT to facilitate movement through
pylorus.

After g-tube placement the stomach contents are drained by gravity for 24 hours before it can be used for feedings.

Stomach
● Mucus in ileal conduit is expected.
● Dusky Stoma = Poor blood supply
● Protruding = Prolapsed
● Sharp pain + Rigidity = Peritonitis

General Notes
● Don’t fall for ‘reestablishing a normal bowel pattern’ as a priority with small bowel obstruction. Because the patient
can’t take in oral fluids, ‘maintaining fluid balance’ comes first. “think ABC’s!!”
● Gastric Ulcer pain occurs 30 minutes to 90 minutes after eating, not at night, and doesn't go away with food.
Duodenal ulcer pain goes away with food.
● Cushing’s ulcers related BRAIN injury & increased intracranial pressure.
● When you see Coffee-brown emesis, think peptic ulcer.
● Patients should not have cantaloupe before an occult stool test; because cantaloupe is high in both vitamin C,
which causes a false positive for occult blood!

Glasgow Coma Scale – Eyes, Verbal, Motor

Remember… < than 8 intubate
It is similar to measuring dating skills...max 15 points -one can do it if
below 8 you are in Coma.
EYES: So, to start dating you got to open your EYES first, if you able to
do that spontaneously and use them correctly to SEE whom you dating
you earn 4. But if she has to scream on you to make youopen them it is
only 3....and 1 you don’t care to open even if she tries to hurt you.
VERBAL: If you get good EYE contact (4 points) then move to
VERBAL. Talk to her/ him! If you can do that You are really
ORIENTED insituation she/he unconsciously gives you 4 points! if you
like her try not to be CONFUSED (3), and of course do not use
INAPPROPRIATE WORDS (3), she will not like it, try not to RESPOND
WITH INCOMPREHENSIBLE SOUNDS (2), if you do not like her –just
show no VERBAL RESPONSE(1)
MOTOR: Since you've got EYE and VERBAL contact you can MOVE now using your Motor Response Points. This is
VERY important since Good moves give you 6!

Decorticate is toward the 'core'.

Decerebrate the other way (out).
Decorticate positioning in response to pain = Cortex involvement
Decerebrate in response to pain = Cerebellar, brain stem involvement (this is the worst one)

Hallmark Signs of Symptoms

01. Pulmonary TB (pulm-TB) – low-grade afternoon speech.
fever. 30. Multi-Gravitis – descending muscle weakness
02. PNEUMONIA – rusty sputum or pink frothy 31. Guillain Barre Syndrome – ascending muscle
sputum. weakness
03. ASTHMA – wheezing on expiration. 32. DVT – Homan’s Sign
04. EMPHYSEMA – barrel chest. 33. CHICKEN POX – Vesicular Rash (central to
05. KAWASAKI SYNDROME – strawberry tongue. distal) dew drop on rose petal
06. PERNICIOUS ANEMIA – red beefy tongue (need 34. ANGINA – Crushing stabbing pain relieved by NTG
vitamin B12). 35. MI – Crushing stabbing pain which radiates to left
07. DOWN SYNDROME – protruding tongue. shoulder, neck, arms, unrelieved by NTG
08. CHOLERA – rice watery stool. 36. Latent TB (latent-TB) – inspiratory stridor
09. MALARIA – step ladder like fever with chills. 37. TEF (trach-esoph-fist) – 4Cs’ Coughing, Choking,
10. TYPHOID – rose spots in abdomen. Cyanosis, Continuous Drooling
11. DIPTHERIA (infection of nose and throat)– pseudo 38. EPIGLOTTITIS – 3Ds’ Drooling, Dysphonia,
membrane formation Dysphagia
12. MEASLES – Koplick’s spots are red spots with 39. HODGKIN'S DSE/LYMPHOMA – painless,
blue center, usually in the mouth progressive enlargement of spleen & lymph tissues,
13. Systemic Lupus E – butterfly rashes. Reed Sternberg Cells
14. LIVER CIRRHOSIS – spider like varices. 40. INFECTIOUS MONONUCLEOSIS – Hallmark:
15. LEPROSY – leonine face (skin lesions and nerve sore throat, cervical lymphadenopathy, fever
damage) 41. PARKINSON’S – Pill-rolling tremors
16. BULIMIA – chipmunk face. 42. FIBRIN HYALIN – Expiratory Grunt
17. APPENDICITIS – rebound tenderness. 43. CYSTIC FIBROSIS – Salty skin
18. DENGUE (fever from mosquitos) - petechiae or 44. DM – polyuria, polydipsia, polyphagia
(+) Herman’s sign. 45. DKA – Kussmaul's breathing (Deep Rapid RR)
19. MENINGITIS – Kernig’s sign (leg flex then leg 46. BLADDER CA – painless hematuria
pain on extension), Brudzinski sign (neck flex = lower 47. BPH – reduced size & force of urine
leg flex). 48. PEMPHIGUS VULGARIS – Nikolsky’s sign
20. TETANY – hypocalcemia (+) Trousseau’s (separation of epidermis caused by rubbing of the skin)
sign/carpopedal spasm; Chvostek sign (facial spasm). 49. RETINAL DETACHMENT – Visual Floaters,
21. TETANUS – risus sardonicus (grinning facial flashes of light, curtain vision
spasm). 50. GLAUCOMA – Painful vision loss, tunnel/gun
22. PANCREATITIS – Cullen’s sign (ecchymosis of barrel/halo vision (Peripheral Vision Loss)
umbilicus); (+) Grey turner's spots. 51. CATARACT – Painless vision loss, Opacity of the
23. PYLORIC STENOSIS – olive like mass. lens, blurring of vision
24. PDA – machine like murmur. 52. RETINOBLASTOMA – Cat’s eye reflex (grayish
25. ADDISON’S DISEASE – bronze like skin discoloration of pupils)
pigmentation. 53. ACROMEGALY – Coarse facial feature (too
26. CUSHING’S SYNDROME – moon face appearance much growth hormone)
and buffalo hump. 54. DUCHENNE’S MUSCULAR DYSTROPHY –
27. HYPERTHYROIDISM/GRAVE’S DISEASE – Gowers’ sign (use of hands to push one’s self from
exophthalmos. the floor)
28. INTUSSUSCEPTION – sausage shaped mass, 55. GERD – Barrett's esophagus (erosion of the lower
Dance Sign (empty portion of RLQ) portion of the esophageal mucosa)
29. Multiple Sclerosis – Charcot’s Triad (IAN)- 56. HEPATIC ENCEPHALOPATHY – Flapping
nystagmus, intention tremor, and scanning or staccato tremors
57. HYDROCEPHALUS – Bossing sign (prominent 62. HYPOCALCEMIA – Chvostek & Trousseaus
forehead) sign
58. INCREASE ICP – HYPERtension BRADYpnea 63. ULCERATIVE COLITIS – recurrent bloody
BRADYcardia (Cushing’s Triad) diarrhea
59. SHOCK – HYPOtension TACHYpnea 64. LYME’S Disease – Bull’s eye rash
TACHYcardia 65. Basilar Fracture – Otorrhea
60. MENIERE’S Disease – Vertigo, Tinnitus 66. Orbital Fracture – Battle signs & Raccoon’s Eye
61. CYSTITIS – burning on urination

Immunology
Sepsis and anaphylaxis (along with the obvious hemorrhaging) reduce circulating volume by way of increased capillary
permeability, which leads to reduced preload (volume in the left ventricle at the end of diastole).

Allergies
● Basophils release histamine during an allergic response.
● Latex allergies → Assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados,
chestnuts, tomatoes, peaches
● Prior to a CT scan, assess for allergies

Immunizations
● Ask for allergy to eggs before Flu shot
● Age 4 to 5 yrs child needs DPT/MMR/OPV (OPV = Polio vaccine)
● If kid has cold, can still give immunizations
● MMR and Varicella immunizations come later, around 15 months.
● MMR
o The MMR vaccine is given SQ not IM.
o Ask for anaphylactic reaction to eggs or neomycin before MMR vaccine
● For HIV kids avoid OPV and Varicella vaccinations (live) but give Pneumococcal and influenza.
o MMR is avoided only if the kid is severely immunocompromised.
● Pneumovax 23 gets administered post splenectomy to prevent pneumococcal sepsis.
● kids can get vaccines if they have mild illness (fever <101, cold, ear infection, mild diarrhea) but should be related
signs and symptoms, if it is moderate-severe. ok if they are taking antibiotics but not antivirals!

Leadership
If one nurse discovers another nurse has made a mistake it is always appropriate to speak to
her before going to management. If the situation persists, then take it higher.

Delegation
DO NOT delegate what you can EAT!
E – evaluate
A – assess
T - teach
Rules for Delegation
RN ASSIGNMENT
● Cannot delegate assessment, teaching, or nursing judgement
LPN/LVN ASSIGNMENT
● Assign stable with expected outcomes
UAP ASSIGNMENT
● Delegate standard, unchanging procedures
Five Rights of Delegation
RIGHT TASK – scope of practice, stable client
RIGHT CIRCUMSTANCES – workload
RIGHT PERSON – scope of practice
RIGHT COMMUNICATION – specific task to be performed, expected results, follow-up communication
RIGHT SUPERVISION – clear directions, intervene if necessary
 Maternity/Women’s Health

Fetal Heart Rate Pattern Etiology

V Variable Decels C Cord compression
E Early Decels H Head compression
A Accels O Okay, not a problem
L Late Decels P Placental Insufficiency
A= appearance (color all pink, pink and blue, blue [pale])
P= pulse (>100, < 100, absent)
G= grimace (cough, grimace, no response)
A= activity (flexed, flaccid, limp)
R= respirations (strong cry, weak cry, absent)
APGAR measures
Skin color, HR, Reflexes, Muscle tone, RR;
each section is scored between 0-2 points.
0–3 = Severely Depressed (RESUSCITATE)
4–6 = Moderately Depressed
7 –10 = Excellent (OK)
Fetal alcohol syndrome
-Upturned nose -Thin upper lip

1. ABCs (Airway, Breathing, Circulation)

2. When in distress DO NOT ASSESS! Unless 2nd hand information is received.

-Flat nasal bridge -Small for Gestational Age

Rhogam Factor
● Given at 28 weeks, 72 hours postpartum, IM.
● Only given to Rh NEGATIVE mother.
● If indirect Combs’ test is positive, don’t need to give Rhogam, because the mother already has the antibody
● Only administer if coombs’ test result is negative

General Notes
● When a patient comes in and she is in active labor, the nurse’s first action is to listen to fetal heart tone/rate
● One way to remember which type of measles [regular measles (rubeola) or German measles (rubella)] is
dangerous to pregnant mothers ~ Never get pregnant with a German (rubella)
● Placental abruptio: bleeding with pain, don't forget to monitor volume status (I&O)
● If a laboring mom’s water breaks and she is any minus station, must better know there is a risk of prolapsed cord.
(because baby is inside above ischial spine and can compress the cord)
● For cord compression, place the mother in the TRENDELENBURG position because this removes pressure of the
presenting part off the cord. (If her head is down, the baby is no longer being pulled out of the body by gravity) or
hands and knees position.
● If the cord is prolapsed, cover it with sterile saline gauze to prevent drying of the cord and to minimize
infection.
● For late decelerations, turn the mother to her left side, to allow more blood flow to the placenta (because late
decelerations = placenta deficiency)
● For any kind of bad fetal heart rate pattern, you give O2, often by mask
● When doing an epidural anesthesia, hydration before-hand is a priority (because causes hypotension).
● Hypotension and bradypnea / bradycardia are major risks and emergencies.
● NEVER check the monitor or a machine as a first action. Always assess the patient first!!
o For example: listen to the fetal heart tones with a stethoscope in NCLEX land.
● Sometimes it's hard to tell who to check on first, the mother or the baby; it's usually easy to tell the right answer if the
 mother or baby involves a machine. If you're not sure who to check first, and one of the choices involves the machine,
that's the wrong answer.
● If the baby is in a posterior presentation, the sounds are heard at the sides.
● If the baby is anterior, the sounds are heard closer to midline, between the umbilicus and where you would
listen to a posterior presentation (because anterior is in front/close to midline)
● If the baby is breech, the sounds are high up in the fundus near the umbilicus (because head is up, feet down
first)
● If the baby is vertex, they are a little bit above the symphysis pubis. (vertex= head first, so breath sounds right
above pubis bone)
● Best way to warm a newborn: skin to skin contact covered with a blanket on mom.
● Amniotic fluid is alkaline and turns nitrazine paper blue. Urine and normal vaginal discharge are acidic and turn
it pink. Pink for acid and Blue for Alkaline.
● Amniotic fluid yellow with particles = meconium stained
● Cephalohematoma (caput succedaneum) resolves on its own in a few days. This is the type of edema that crosses the
suture lines.
● The biggest concern with cold stress and the newborn is respiratory distress!
● Glucose Tolerance Test for preggies, a result of 140 or higher needs further evaluation.

Medical (Diagnostic) Signs

Murphy’s sign – pain with palpation of gallbladder area seen with cholecystitis

Cullen’s sign – ecchymosis in umbilical area, seen with pancreatitis

Turner’s sign – flank grayish blue (turn around to see your flanks) pancreatitis

McBurney’s Point – RLQ pain indicative of appendicitis

LLQ Pain – diverticulitis , low residue, no seeds, nuts, peas

RLQ Pain – appendicitis, watch for peritonitis

Guthrie Test – Tests for PKU, baby should have eaten source of protein first

Allen’s test – Occlude both ulnar and radial artery until hand blanches then release ulnar. If the hand pinks up, ulnar
artery is good, and you can carry on with ABG/radial stick as planned. ABGS must be put on ice and whisked to the
lab.

Trendelenburg Test – A tests for varicose veins. Pt is supine, and the leg is flexed at the hip and raised above the level of
the heart. The veins will empty due gravity or with assistance from the examiner’s hand squeezing blood towards the heart
→ If they fill proximally = varicosity.

Babinski Sign – Assessment for nervous system problems.

Toes curl = - sign |Normal in adults & kids above 2 yrs| Abnormal in kids 2 yrs & under
Toes fan = + sign |Abnormal in adults & kids above 2 yrs| Normal in kids 2 yrs & under

Mental Health

Remember with Psych patients, SAFETY is the #1 Priority

Munchausen Syndrome is a psychiatric disorder that causes an individual to self-inflict injury or illness or to fabricate
symptoms of physical or mental illness, in order to receive medical care or hospitalization.
In a variation of the disorder, Munchausen by proxy (MSBP), an individual, typically a mother, intentionally causes or
fabricates illness in a child or other person under her care.

Neuroleptic malignant syndrome (NMS): ~ rxn to antipsychotic medications

-NMS is like S&M;
-you get hot (hyperpyrexia)
-stiff (increased muscle tone)
-sweaty (diaphoresis)
-BP, pulse, and respirations go up &
-you start to drool

General Notes
● Tardive Dyskinesia – irreversible – involuntary movements of the tongue, face and extremities, may happen after
prolonged use of antipsychotics
● Depression often manifests itself in somatic ways, such as psychomotor retardation, GI complaints, and pain.
● For phobic disorders, use systematic desensitization.
● Safety over Nutrition with a severely depressed client.
● Absence of menstruation leads to osteoporosis in the anorexic.

Musculoskeletal/Neurological

ICP AND SHOCK HAVE OPPOSITE V/S

Shock Cushing’s Triad (r/t to ICP in Brain)
Blood Pressure ↓ ↑ (Widening Pulse Pressure - ↑ Systolic/ ↓ Diastolic)
Pulse ↑ ↓
Respirations ↑ ↓ (Cheyne-Stokes or Irregular Respirations)
Amyotrophic Lateral Sclerosis (ALS) is a condition in which there is a degeneration of motor neurons in both the upper &
lower motor neuron systems.

Autonomic Dysreflexia: potentially life-threatening emergency

– Symptoms: HTN, Bradycardia, Pounding H/A, Severe Nasal Congestion
– Elevate head of bed to 90 degree
– Loosen constrictive clothing
– Assess for bladder distention and bowel impaction (trigger) <TREAT THEM>
– Administer antihypertensive meds (may cause stroke, MI, seizure)

Multiple Sclerosis is a chronic, progressive disease with demyelinating lesions in the CNS which affect the white matter
of the brain and spinal cord.
Hyperactive deep tendon reflexes, vision changes, fatigue and spasticity are all symptoms of MS
Motor S/S: limb weakness, paralysis, slow speech
Sensory S/S: numbness, tingling, tinnitus
Cerebral S/S: nystagmus, ataxia, dysphagia, dysarthria

Myasthenia gravis is caused by a disorder in the transmission of impulses from nerve to muscle cell; worsens with
exercise and improves with rest.
● Give neostigmine to pts w/ MG about 45 min before eating, so it can help w/ chewing & swallowing.
Myasthenia Crisis: it’s used to confirm the diagnosis; a positive reaction to Tensilon – will improve symptoms
Cholinergic Crisis: caused by excessive medication-stop med-giving Tensilon will make it worse

Huntington's Chorea: 50% genetic, autosomal dominant disorder

S/S: chorea → writhing, twisting, movements of face, limbs and body
–gait deteriorates to no ambulation
–no cure, just palliative care

Myelogram
● Pre-Op – NPO 4-6hr, assess hx of allergies, the table will be moved to various positions during test, the following
meds are withheld 48hr prior; phenothiazines, CNS depressants, and stimulants
● Post Op – Neuro checks q2-4 hrs, water soluble HOB up, oil soluble HOB down, oral analgesics for h/a, encourage
PO fluids, assess for distended bladder, inspect site.
Electroencephalography (EEG)
● Pre-Op – 24-48 hrs prior holds meds (especially tranquilizers and stimulants), no caffeine or cigarettes (i.e.
stimulants) for 24 hrs prior, meals not withheld, no sleep the night before, pt may be asked to hyperventilate for 3-4
min and watch a bright flashing light
● Post Op – Assess pt for possible seizures, since they’re not at greater risk

Cerebral Angiogram
● Pre-Op – well hydrated, lie flat, site shaved, check pulses marked
● Post Op – keep flat for 12-14hr, check site, check pulses, force fluids.

Meningeal Irritation S/S

● Nuchal rigidity
● Positive Brudzinski + Kernig signs
● PHOTOPHOBIA

General Notes
● Lumbar Puncture Post Op – Neuro assessments q15-30 until stable, pt lays flat for 2-3hr, encourage fluids, oral
analgesics for headache, observe dressing
● CSF in meningitis will have high protein, and low glucose.
● Decreased acetylcholine is related to senile dementia.
● Level of consciousness is the most important assessment parameter with status epilepticus.
● Hyper reflexes (upper motor neuron issue “your reflexes are over the top”)
● Absent reflexes (lower motor neuron issue)

Nutrition
Fat Soluble Vitamins are A, D, E, K

General Notes
● Be wary of questions regarding children drinking too much milk i.e. more than 3-4 cups of milk each day. Too much
milk intake reduces intake of other essential nutrients, especially iron. Watch for anemia with milk-aholics.
● Vitamin D’s presence is required by the parathyroid gland, in order for it to function.
● If the patient is taking digoxin or K-supplements, avoid salt substitutes because many are potassium based
● Potassium Sources: bananas, potatoes, citrus fruits
● No milk (as well as fresh fruit or veggies) on neutropenic precautions.
● Nondairy sources of calcium include RHUBARB, SARDINES, COLLARD GREENS
● Nonfat milk reduces reflux by increasing lower esophageal sphincter pressure
● Yogurt has live cultures, so do not give to immunosuppressed patients
● No phenylalanine with a kid positive for PKU (no meat, no dairy, no aspartame).
● Acid Ash diet: cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread
● Alk Ash diet: milk, veggies, rhubarb, salmon

Ortho
Casts:
● You can petal the rough edges of a plaster cast with tape to avoid skin irritation.
● Itching under cast area- cool air via blow dryer, ice pack for 10- 15 minutes. NEVER use Qtip or anything to
scratch area

Walking Devices
 COAL (cane walking): When ascending stairs w/ a cane: ● Remember the phrase “step
C – Cane 1 – Step up with the stronger leg first up” when picturing a person
O – Opposite 2 – Move the cane next while bearing going up stairs with crutches.
A – Affected weight on the stronger leg The good leg goes up first,
L – Leg 3 – Finally, move the weaker leg followed by the crutches and
then the bad leg. The opposite
The cane always moves When descending stairs w/ a cane: happens going down. The
before the weaker leg. 1. Lead with the cane crutches go first, followed by
2. Bring the weaker leg down next the good leg.
3. Finally, step down with the stronger ● Place a wheelchair parallel to
leg the bed on the side of
weakness
Mnemonic – “Up with the good and
down with bad.”

SIGNS of a Fractured hip Paget's Disease S/S

● EXTERNAL ROTATION ● Tinnitus
● SHORTENING ● bone pain
● ADDUCTION ● enlarged/thick bones

General Notes
● Never release traction UNLESS you have an order from the MD to do so
● Osteomyelitis is an infectious bone disease → get blood cultures & antibiotics, then if necessary → surgery to drain
abscess.
● Pain is usually the highest priority with RA
● Swimming is a great exercise for Arthritis
● William's position - Semi Fowlers with knees flexed (Inc. knee gatch) to relieve lower back pain.
o With low back aches, bend knees to relieve
● Greenstick fractures, usually seen in kids bone breaks on one side and bends on the other

Patient Positioning

1. Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending
doom) → turn pt to left side and lower the head of the bed.

2. Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal bradycardia, etc) → turn
on left side (and give O2, stop Pitocin, increase IV fluids)

3. Tube Feeding w/ Decreased LOC → position pt on right side (promotes emptying of the stomach) with the HOB
elevated (to prevent aspiration)

4. During Epidural Puncture → side-lying

5. After Lumbar Puncture (and also oil-based Myelogram) → pt lies in flat supine (to prevent headache and leaking of
CSF) for 4 to 12 hrs or 2 to 3 hrs as prescribed. Dressings must be kept sterile & frequent neuro assessments should
be performed

6. Pt w/ Heat Stroke → lie flat w/ legs elevated (to get fluid to go to head to correct hypotension)
7. During Continuous Bladder Irrigation (CBI) → catheter is taped to thigh so leg should be kept straight. No other
positioning restrictions.

8. After Myringotomy (surgical incision into the eardrum, to relieve pressure or drain fluid).
 → position on side of affected ear after surgery (allows drainage of secretions)

9. After Cataract Surgery → pt will sleep on unaffected side with a night shield for 1-4 weeks.

10. After Thyroidectomy → low or semi-Fowler’s, support head, neck and shoulders.

11. Infant w/ Spina Bifida → position prone (on abdomen) so that sac does not rupture

12. Buck’s Traction (skin traction) → elevate foot of bed for counter-traction

13. After Total Hip Replacement → don’t sleep on operated side, don’t flex hip more than 45- 60 degrees, don’t elevate
HOB more than 45 degrees. Maintain hip abduction by separating thighs with pillows (use a wedge pillow)

14. Prolapsed Cord → knee-chest position or Trendelenburg

15. Infant w/ Cleft Lip → position on back or in infant seat to prevent trauma to suture line. While feeding, hold in
upright position.

16. To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) → eat in reclining position or Low-
fowlers (so food doesn’t empty and dump so fast), lie down after meals for 20-30 minutes (also restrict fluids during
meals, low cholesterol and fiber diet, small frequent meals)

17. Above Knee Amputation → elevate for first 24 hours on pillow, position prone daily to provide for hip extension.

18. Below Knee Amputation → foot of bed elevated for first 24 hours; position prone daily to provide for hip extension.

19. Detached Retina → area of detachment should be in the dependent position

20. Administration of Enema → position pt in left side-lying (Sim’s) with knee flexed

21. After Supratentorial Surgery (incision behind hairline) → elevate HOB 30-45 degrees

22. After Infratentorial Surgery (incision at nape of neck) → position pt flat and lateral on either side.

23. During Internal Radiation → on bedrest while implant in place

24. Autonomic Dysreflexia/Hyperreflexia (S&S: pounding headache, profuse sweating, nasal congestion, goose flesh,
bradycardia, hypertension) → place client in sitting position (elevate HOB) first before any other implementation

25. Shock → bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified
Trendelenburg)

26. Head Injury → elevate HOB 30 degrees to decrease intracranial pressure

27. Peritoneal Dialysis when Outflow is Inadequate → turn pt from side to side BEFORE checking for kinks in tubing
(reposition patient, to see if it affects the flow and output of the catheter!)

28. During a lumbar puncture → The patient is positioned in lateral recumbent fetal position
29. Lung Biopsy → Position the patient lying on the side of the bed or with arms raised up on pillows over bedside
table, have the patient hold their breath in mid expiration, chest x-ray done immediately afterwards to check for
complication of pneumothorax, sterile dressing applied

30. Pt w/ GERD → Patient should be lying prone on their left side, with HOB elevated 30 degrees

31. Pt w/ Pancreatitis → Patient should be place in Fetal position!!

32. After Appendectomy → Position the patient on the right side with legs flexed. (Puts pressure where appendix was)

33. Pt w/ Pneumonia → Lay the pt on the affected side to splint and reduce pain. If attempting to reduce congestion, the
congested lung goes up.

34. Infant Position while Asleep → To prevent SIDS, the infant lays on their back while asleep, in a bare crib.

35. During Paracentesis → Patient should be semi-fowlers, or upright on the edge of the bed.

36. During Thoracentesis → Patient position patient with arms on pillow on over bed table or lying on side

Hemoglobin
Neonates 18 – 27
3 Months 10.6 – 16.5
3 yrs 9.4 – 15.5
10 yrs 10.7 – 15.5
Pediatrics

Injection Sites

IM ∙ Vastus Lateralis for 6 months infants

∙ Ventrogluteal for Toddlers above 18 months
∙ Deltoid & Gluteus Maximus for Children

Developmental Stages

∙ 2-3 months: turns head side to side ∙ 8-9 months: stands straight at eight
∙ 4-5 months: grasps, switch & roll ∙ 10-11 months: belly to butt (phrase has 10 letters)
∙ 6-7 months: sit at 6 and waves bye-bye ∙ 12-13 months: twelve and up, drink from a cup

● Stranger anxiety is greatest 7 - 9 months

● Separation anxiety peaks in toddlerhood
● If you gave a toddler a choice about taking medicine and he says no, you should leave the room and come back in
five minutes, because to a toddler it is another episode. Next time don’t ask.
● School-age kids (5 and up) are old enough and should have an explanation of what will happen a week before
surgery such as tonsillectomy.

Interpersonal model (Sullivan) – Behavior motivated by need to avoid anxiety and satisfy needs

1. Infancy 0–18 months – others will satisfy needs

2. Childhood >6yrs – learn to delay need gratification
3. Juvenile 6–9 years – learn to relate to peers
4. Preadolescence 9–12 yrs – learns to relate to friends of opposite sex
5. Early adolescence 12–14 yrs – learn independence and how to relate to opposite sex
6. Late adolescence 14–21 yrs – develop intimate relationship with person of opposite sex
A child with a ventriculoperitoneal shunt will have a small upper-abdominal incision. This is where the shunt is guided
into the abdominal cavity and tunneled under the skin up to the ventricles. Assess for possible abdominal distention,
since fluid from the ventricles will be redirected to the peritoneum, as well as signs of increasing intracranial pressure.

ICP in Infants ICP in Toddlers

∙ Irritability ∙ Lack of appetite
∙ Bulging fontanels ∙ Headache
∙ High-pitched cry

Bed-position after shunt placement is flat, so fluid doesn’t reduce too rapidly. If S/S of increasing icp are present, then
raise the hob to 15-30 degrees.

Congenital Cardiac Defects

● These defects result in hypoxia which the body attempts to compensate for (influx of immature RBC’s)
o Labs supporting this would display: ↑ Hematocrit, Hemoglobin (compensating for hypoxia and
deoxygenated blood) & RBC count
● Tetralogy of Fallot;
o When children w/ Tetralogy of Fallot experience Tet spells, they’re treated with morphine.
o Think DROP (child drops to floor or squats) or Remember HOPS or POSH

D – defect, septal H – hypertrophy of right ventricle P – pulmonary stenosis

R – right ventricular hypertrophy O – overriding aorta O – overriding aorta
O – overriding aorta P – pulmonary stenosis S – septal defect (ventricle)
P – pulmonary stenosis S – septal defect (ventricle) H – hypertrophy of right ventricle

Transesophageal Fistula (TEF) – esophagus doesn't fully develop (this is a surgical emergency)
The 3 C's of TEF in the newborn:
1) Choking
2) Coughing
3) Cyanosis

Hirschsprung’s Ds. → bile is lower obstruction; no bile is upper obstruction; ribbon like stools.
● Diagnosed with rectal biopsy looking for absence of ganglionic cells.
● Cardinal sign in infants is failure to pass meconium, and later the classic ribbon-like and foul-smelling stools.

Cystic Fibrosis
● Respiratory problems are the chief concern with CF
● Give diet low fat, high sodium, fat soluble vitamins ADEK
● Intussusception common in kids with CF. Obstruction may cause fecal emesis, currant jelly- like stools (blood
and mucus). A barium enema may be used to hydrostatically reduce the telescoping. Resolution is obvious, with
onset of bowel movements.
● Treatment: Aerosol bronchodilators, mucolytics, and pancreatic enzymes.

Group-a strep precedes rheumatic fever.

● Chorea is part of this sickness (grimacing, sudden body movements, etc.) and it embarrasses kids.
● The child will have joint pain.
● Watch for elevated ant streptolysin O to be elevated.
● Treatment is Penicillin!!!! Assess for allergy

Children w/ HIV
● Parents of HIV+ should wear gloves for care, not kiss kids on the mouth, and not share eating utensils.
● Western blot
o A positive Western blot in a child <18 months (presence of HIV antibodies) indicates only that the mother
 is infected.
● p24 antigen Test
o Two or more positive p24 antigen tests will confirm HIV in kids <18 months.
o The p24 can be used at any age.

Prepubescent Penis
● Hypospadias: abnormality in which urethral meatus is located on the ventral (back) surface of the penis anywhere
from the corona to the perineum (remember hypo, low (for lower side or under side)
● Epispadias: opening of the urethra on the dorsal (front) surface of the penis
● Undescended testis or cryptorchidism is a known risk factor for testicular cancer later in life.
o Start teaching boy’s testicular self-exam around 12, because most cases occur during adolescence.
● After a hydrocele repair provide ice bags and scrotal support.

There’s an association between low-set ears and renal anomalies.

● The kidneys and ears develop around the same time in utero. Hence, the kidneys & ears similarly shaped.
● When doing an assessment of a neonate, if the nurse notices low set or asymmetrical ears, there is good reason to
investigate renal functioning.

Pyloric Stenosis
● The first sign of pyloric stenosis in a baby is mild vomiting that progresses to projectile vomiting.
● Later a mass may be palpable, the baby will seem hungry often, and may spit up after feedings.
● Would expect hematocrit and BUN related to dehydration

What is an intraosseous infusion (think into to the bone = intra – osseous (bone)
● In pediatrics, it’s a temporary, life-saving measure, for life-threatening emergencies, when iv access cannot be
obtained, an osseous (bone) needle is hand-drilled into a bone (usually the tibia), where crystalloids, colloids,
blood products and drugs can be administered into the marrow.
● When venous access is achieved it can be discontinued.
● Isoproterenol (blood pressure support medication), a beta agonist, is contraindicated via intraosseous
infusion.

Children in Traction
● What traction is used in a school-age kid with a femur or tibial fracture with extensive skin damage?
o Ninety, ninety. The name refers to the angles of the joints.
▪ A pin is placed in the distal part of the broken bone, and the lower extremity is in a boot cast. The rest
are the normal pulleys and ropes commonly seen with balanced suspension.
● A child hinder should clear the bed when in Bryant’s traction (also used for femurs and congenial hip for young
kids).

General Notes
● Bottle Rot: Do NOT let the mother/father/grandma put anything but water in a child’s bottle during
naps/over-night → Juice or milk will rot the child’s teeth right out of his head
● It is essential to maintain nasal patency with children < 1 yr, b/c they are obligatory nasal breathers.
● Kawasaki disease causes a heart problem, specifically, coronary artery aneurysms due to the inflammation of
blood vessels.
● Kids with RSV; no contact lenses or pregnant nurses in rooms where ribavirin is being administered by hood, tent,
etc.
● Neonates with heroin withdrawal are irritable and are poor at suckling
● If you can remove the white patches from the mouth of a baby it is just formula. If you can’t, its candidiasis.
● Don’t pick cough over tachycardia for signs of CHF in an infant.
● When performing CPR on an infant check the brachial pulse
● Test children for lead poisoning around 12 months of age
● body surface area (BSA) is considered the most accurate method for medication dosing with kids.
● In a five-year old breath once for every 5 compressions doing CPR
● An ill child regresses in behaviors
● No aspirin with kids b/c it is associated with Reye’s Syndrome, and also no NSAID’s such as ibuprofen. Give
Tylenol.
● 4-year-old kids cannot interpret TIME. Need to explain time in relationship to a known COMMON EVENT (eg:
"Mom will be back after supper").
● Toddlers need to express autonomy (independence)
● Prolonged hypoxemia is a likely cause of cardiac arrest in a child.
● With omphalocele and gastroschisis (herniation of abdominal contents) dress with loose saline dressing covered
with plastic wrap and keep eye on temperature. Kid can lose heat quickly.
● It is always the correct answer to report suspected cases of child abuse.

Reproductive Health
General Notes
● Diaphragm must stay in place 6 hours after intercourse. They are also fitted so must be re- fitted if you lose or
gain a significant amount of weight.
● Gonorrhea is a reportable disease
● Priapism: painful erection lasting longer than 6 hrs.

Respiratory
Can’t cough=ineffective airway clearance

Incentive Spirometry steps

1) Sit upright
2) Exhale
3) Insert mouthpiece
4) Inhale for 3 seconds, and then HOLD for 10 seconds

Pulmonary Embolism
● First sign of PE is sudden chest pain, followed by dyspnea and tachypnea.
● When o2 deprived, as with PE, the body compensates by causing hyperventilation (resp alkalosis).
o Should the patient breathe into a paper bag?
▪ No. If the PaO2 is well below 80 they need oxygen.
o Look at all your ABG values. As soon as you see the words PE you should think oxygen first.

Carbon Dioxide Narcosis: a reversible state of CNS depression induced by a drug(s).

● High potassium is expected with this condition, (hydrogen floods the cell forcing potassium out).
● Causes ↑ intracranial pressure.

Asthma
● Coughing without other s/s is suggestive of asthma.
● If child who is wheezing, stops wheezing. It could mean he is worsening.
● If a pt has intercostal retractions – be concerned
● The best exercise for asthmatics is swimming (slow, long, controlled breathing)

Tuberculosis
● If a TB patient is unable/unwilling to comply with Tx they may need supervision (direct observation).
● TB is a public health risk.
PPD is positive if area of induration is:
>5 mm in an immunocompromised patient - lower parameters because immunocompromised
>10 mm in a normal patient
>15 mm in a patient who lives in an area where TB is very rare.
A positive PPD confirms infection, not just exposure. A sputum test will confirm active disease.

Ventilators
● Complications of Mechanical Ventilation: Pneumothorax, Ulcers
HO LD
High alarm – Obstruction due to increased secretions, kink, patient coughs, gag, or bites the tubing
Low press alarm – Disconnection or leak in ventilator or in pt. airway cuff, pt. stops spontaneous breathing

Thoracentesis:
● Pre-Op – Take vital signs, shave area around needle insertion, move the patient into tripod position over a bed table,
while holding a pillow
● During – Withdraw no more than 1000cc at one time
● Post Op – Listen for bilateral breath sounds, vital signs, check leakage, sterile dressing.

What could cause bronchopulmonary dysplasia? (dysplasia means abnormality or alteration)

● Mechanical ventilation is the primary cause. Other causes could be infection, pneumonia, or other conditions
that cause inflammation or scarring.
● Premature newborns with immature lungs are ventilated and over time it damages the lungs.

General Notes
● TIDAL VOLUME is 7 – 10ml / kg
● For COPD pts REMEMBER: 2L Nasal Cannula (2LNC) or less (hypoxic NOT hypercapnic drive)
o Pa02 of 60ish and Sa02 90% = normal (b/c these pts is chronic CO2 retainers)
● The first sign of ARDS is increased respirations. Later comes dyspnea, retractions, air hunger, cyanosis.
● Signs of hypoxia: restless, anxious, cyanotic tachycardia, increased resps. (also monitor ABG's)
● Crackles suggest pneumonia, which is likely to be accompanied by hypoxia, which would manifest itself as mental
confusion, etc.
● When using a bronchodilator inhaler conjunction with a glucocorticoid inhaler, administer the bronchodilator first
● In emphysema the stimulus to breathe is low PO2, not increased PCO2 like normal pts, so don’t slam them with
oxygen.
o Encourage pursed-lip breathing which promotes CO2 elimination, encourage up to 3000mL/day fluids,
high-fowlers and leaning forward.
● Ambient air (room air) contains 21% oxygen.
● Before going for Pulmonary Function Tests (PFT's), a pt's bronchodilators will be with-held and they are not
allowed to smoke for 4 hrs prior (so it doesn’t alter test results)
● Tension pneumothorax trachea shifts to opposite side.

Transmission-Based Precautions
● SARS (severe acute resp syndrome) → airborne + contact (just like varicella)
● Tetanus, Hepatitis B, HIV are STANDARD precautions

Airborne

My – Measles Measles
Chicken – Chicken Pox/Varicella OR remember MTV TB
Hez – Herpes Zoster/Shingles Varicella
TB-- TB
● Disseminated Herpes Zoster is AIRBORNE PRECAUTIONS
Private Room – negative pressure with 6-12 air exchanges/hr, Mask, N95 for TB

Droplet

think of SPIDERMAN!
S – sepsis
S – scarlet fever
S – streptococcal pharyngitis P - parvovirus B19
 P – pneumonia
P – pertussis
I – influenza
D – diphtheria (pharyngeal)
E - epiglottitis
R – rubella
M – mumps
M – meningitis
M – mycoplasma or meningeal pneumonia
An – Adenovirus
Private Room or cohort Mask, door open, 3 ft distance

Contact
MRS. WEE
M – multidrug resistant organism (MRSA) V – Varicella zoster
R – respiratory infection C – Cutaneous diphtheria
S – skin infections ~ VCHIPS H – Herpes simplex
W – wound infxn I – Impetigo
E – enteric infxn – clostridium difficile P – Pediculosis
E – eye infxn – conjunctivitis S – Scabies

● Localized Herpes Zoster is CONTACT PRECAUTIONS

● A nurse with a localized herpes zoster CAN care for patients as long as the patients are NOT
immunosuppressed, and the lesions must be covered!
● Hepatitis A is contact precautions

Triage
Red- Immediate: Injuries are life threatening but survivable with minimal intervention. Ex: hemothorax, tension
pneumothorax, unstable chest and abdominal wounds, INCOMPLETE amputations, OPEN fix’s of long bones, and
2nd/3rd degree burn with 15%-40% of total body surface, etc.
∙ Red – unstable, i.e., occluded airway, actively bleeding, see first
Yellow- Delayed: Injuries are significant and require medical care but can wait hrs without threat to life or limb. Ex:
Stable abd wounds without evidence of hemorrhage, fix requiring open reduction, debridement, external fixation, most
eye and CNS injuries, etc.
∙ Yellow – stable, can wait up to an hour for treatment, i.e. burns, see second
Green- Minimal: Injuries are minor, and Tx can be delayed to hrs or days. Individuals in this group should be moved
away from the main triage area. Ex: upper extremity fix, minor burns, sprains, sm. lacerations, behavior disorders.
∙ Green – stable, can wait even longer to be seen, "walking wounded"
Black- Expectant: Injuries are extensive, and chances of survival are unlikely. Separate but don’t abandoned, comfort
measures if possible. Ex: Unresponsive, spinal cord injuries, wounds with anatomical organs, 2nd/3rd degree burn with
60% of body surface area , seizures, profound shock with multiple injuries, no pulse, b.p, pupils fixed or dilated.
∙ Black – unstable clients that will probably not make it, need comfort measures

General Notes
● DOA – Dead On Arrival
● Orange tag in triage is non-emergent Psych
● In a disaster you should triage the person who is most likely to not survive last (black code)

Urinary/Renal System
Peritoneal Dialysis
● It’s ok to have abdominal cramps, blood tinged outflow and leaking around site if the Peritoneal Dialysis cath
(tenkhoff) was placed in the last 1-2 wks.
● Cloudy outflow NEVER NORMAL - peritonitis or infection!!

Kidneys
● Low magnesium and high creatinine signal renal failure.
● Renal impairment: serum creatinine elevated, and urine clearance decreased
● Glomerulonephritis
o Take vital signs q4hrs & daily weights
o Consider blood pressure to be the most important assessment parameter.
o Dietary restrictions you can expect include fluids, protein, sodium, and potassium.
● WBC shift to the left in a patient with pyelonephritis (neutrophils kick in to fight infection)
● Nephrotic syndrome is characterized by massive proteinuria (looks dark and frothy) caused by glomerular damage.
Corticosteroids are the mainstay. Generalized edema common.
o Signs: Edema & Hypotension
o Turn and reposition (pt is @ risk for impaired skin integrity)
● A laxative/bowel prep is given the night before an IVP in order to better visualize the organs.
o IVP = Intravenous Pyelogram, an x-ray of the kidneys, ureters, and urinary bladder
o Pre-Op – Assess allergies (contrast dye)
● Kidney Glucose threshold is 180

General Notes
● Uremic fetor → smell urine on the breath
 NCLEX TIPS
1. When getting down to two answers, choose the assessment answer (assess, collect, auscultate, monitor, palpate) over
the intervention except in an emergency or distress situation. If one answer has an absolute, discard it. Give priority to
answers that deal directly to the patient’s body, not the machines/equipment.
2. Key words are very important. Avoid answers with absolutes for example: always, never, must, etc.
3. With lower amputations patient is placed in prone position.
4. Small frequent feedings are better than larger ones.
5. Assessment, teaching, meds, evaluation, unstable patient cannot be delegated to an Unlicensed Assistive Personnel.
6. LVN/LPN cannot handle blood.
7. Aminoglycosides (like vancomycin) cause nephrotoxicity and ototoxicity.
8. IV push should go over at least 2 minutes except for adenosine which goes superfast, 2-4 seconds..
9. If the patient is not a child an answer with family option can be ruled out easily.
10. In an emergency, patients with greater chance to live are treated first
11. ARDS (fluids in alveoli), DIC (disseminated intravascular coagulation) are always secondary to something else
(another disease process).
12. Cardinal sign of ARDS is hypoxemia (low oxygen level in tissues).
13. in pH regulation the 2 organs of concern are lungs/kidneys.
14. edema is in the interstitial space not in the cardiovascular space.
15. weight is the best indicator of dehydration
16. wherever there is sugar (glucose) water follows.
17. aspirin can cause Reye’s syndrome (encephalopathy) when given to children
18. when aspirin is given once a day it acts as an antiplatelet.
19. Use Cold for acute pain (e.g. Sprain ankle) and Heat for chronic (rheumatoid arthritis)
20. guided imagery is great for chronic pain.
21. when patient is in distress, medication administration is rarely a good choice.
22. with pneumonia, fever and chills are usually present. For the elderly confusion is often present.
23. Always check for allergies before administering antibiotics (especially PCN). Make sure culture and sensitivity has
been done before administering first dose of antibiotic.
24. Cor pulmonale (s/s fluid overload) is Right sided heart failure causedby pulmonary disease, occurs with bronchitis or
emphysema.
25. COPD is chronic, Pneumonia is acute. Emphysema and Bronchitis are both COPD.
26. In COPD patients the baroreceptors that detect the CO2 level are destroyed. Therefore, O2 level must be low because
high O2 concentration blows the patient’s stimulus for breathing.
27. Exacerbation: acute, distress.
28. Epi always given in TB syringe.
29. Prednisone toxicity: Cushing’s syndrome= buffalo hump, moon face, high glucose, hypertension.
30. 4 options for cancer management: chemo, radiation, surgery, allow to die with dignity.
31. No live vaccines, no fresh fruits, no flowers should be used for neutropenic patients.
32. Chest tubes are placed in the pleural space.
33. Angina (low oxygen to heart tissues) = no dead heart tissues. MI = dead heart tissue present.
34. Mevacor (anti-cholesterol med) must be given with evening meal if it is QD (per day).
35. Nitroglycerine is administered up to 3 times (every 5 minutes). Ifchest pain does not stop go to hospital. Do not give
when BP is < 90/60.
36. Preload affects amount of blood that goes to the right ventricle.Afterload is the resistance the blood has to overcome
when leaving the heart.
37. Calcium channel blocker affects the afterload.
38. For a CABG operation when the great saphenous vein is taken it isturned inside out due to the valves that are inside.
39. Unstable angina is not relieved by nitroglycerin.
40. Dead tissues cannot have PVC’s (premature ventricular contraction). If left untreated PVC’s can lead to VF
(ventricular fibrillation).
41. 1 t (teaspoon)= 5 ml
1 T(tablespoon)= 3 t = 15 ml
1 oz= 30 ml
1 cup= 8 oz
1 quart= 2 pints
 1 pint= 2 cups
1 gr (grain)= 60 mg
1 g (gram)= 1000 mg
1 kg= 2.2 lbs.
1 lb.= 16 oz
* To convert Centigrade to F. F= C+40, multiply 9/5 and subtract 40
* To convert Fahrenheit to C. C= F+40, multiply 5/9 and subtract 40.
42. Angiotensin II in the lungs = potent vasodilator. Aldosterone attracts sodium.
43. REVERSE AGENTS FOR TOXICITY
Heparin= protamine sulfate
Coumadin= vitamin k
Ammonia= lactulose
Acetaminophen=-Acetylcysteine
Iron= deferoxamine
Digitoxin, digoxin= Digi bind
Alcohol withdrawal= Librium
- Methadone is an opioid analgesic used to detoxify/treat pain in narcotic addicts.
- Potassium potentiates dig toxicity.
44. Heparin prevents platelet aggregation.
45. PT/PTT are elevated when patient is on Coumadin
46. Cardiac output decreases with dysrhythmias. Dopamine increases BP.
47. Med of choice for Ventricular tachycardia is lidocaine
48. Med of choice for SVT is adenosine or adenocard
49. Med of choice for Asystole (no heartbeat) is Atropine
50. Med of choice for CHF is Ace inhibitor.
51. Med of choice for anaphylactic shock is Epinephrine
52. Med of choice for Status Epilepticus is Valium.
53. Med of choice for bipolar is lithium.
54. Amiodarone is effective in both ventricular and atrial complications.
55. S3 sound is normal in CHF, not normal in MI.
56. Give Carafate (GI med) before meals to coat stomach
57. Protonix is given prophylactically to prevent stress ulcers.
58. After endoscopy check gag reflex.
59. TPN (total parenteral nutrition) given in subclavian line.
60. Low residue diet means low fiber
61. Diverticulitis (inflammation of the diverticulum in the colon) pain is around LL quadrant.
62. Appendicitis (inflammation of the appendix) pain is in RL quadrant with rebound tenderness.
63. Portal hypotension + albuminemia= Ascites.
64. Beta cells of pancreas produce insulin
65. Morphine is contraindicated in Pancreatitis. It causes spasm of the Sphincter of Oddi. Therefore, Demerol
should be given.
66. Trousseau and Chvostek signs observed in hypocalcemia
67. With chronic pancreatitis, pancreatic enzymes are given with meals, not before or after, given with meal.
68. Never give K+ in IV push.
69. Mineralocorticoids are given in Addison’s disease.

70. Diabetic ketoacidosis (DKA)= when body is breaking down fat instead of sugar for energy. Fats leave ketones (acids)
that cause pH to decrease.
71. DKA is rare in diabetes mellitus type II because there is enough insulin to prevent breakdown of fats.
72. Sign of fat embolism is petechiae. Treated with heparin.
73. For knee replacement use continuous passive motion machine.
74. Give prophylactic antibiotic therapy before any invasive procedure.
75. Glaucoma patients lose peripheral vision. Treated with meds
76. Cataract= cloudy, blurry vision. Treated by lens removal-surgery
77. Co2 causes vasoconstriction.
78. Most spinal cord injuries are at the cervical or lumbar regions
79. Autonomic dysreflexia (life threatening inhibited sympathetic responseof nervous system to a noxious stimulus-
patients with spinal cord injuriesat T-7 or above) is usually caused by a full bladder.
80. Spinal shock occurs immediately after spinal injury
81. Multiple sclerosis= myelin sheath destruction, disruption in nerveimpulse conduction.
82. Myasthenia gravis= decrease in receptor sites for acetylcholine. Since smallest concentration of ACTH
receptors are in cranial nerves, expect fatigue and weakness in eye, mastication, pharyngeal muscles.
83. Tensilon test given if muscle is tense in myasthenia gravis.
84. Guillain-Barre syndrome= ascending paralysis. Keep eye on respiratory system.
85. Parkinsons = RAT: rigidity, akinesia (loss of muscle movt), tremors.Treat with levodopa.
86. TIA (transient ischemic attack) mini stroke with no dead brain tissue
87. CVA (cerebrovascular accident) is with dead brain tissue.
88. Hodgkin’s disease= cancer of lymph is very curable in early stage.
89. Rule of NINES for burns
Head and Neck= 9%
Each upper ext= 9%
Each lower ext= 18%
Front trunk= 18%
Back trunk= 18%
Genitalia= 1%
90. Birth weight doubles by 6 month and triple by 1 year of age.
91. If HR is <100 do not give dig to children.
92. First sign of cystic fibrosis may be meconium ileus at birth. Baby is inconsolable, do not eat, not passing
meconium.
93. Heart defects. Remember for cyanotic -3T’s( ToF, Truncus arteriosus, Transposition of the great vessels). Prevent
blood from going to heart. If problem does not fix or cannot be corrected surgically, CHF will occur following by death.
94. With right side cardiac cath=look for valve problems (tricuspid valve problems)
95. With left side in adults look for coronary complications.
96. Rheumatic fever can lead to cardiac valves malfunctions.
97. Cerebral palsy = poor muscle control due to birth injuries and/or decrease oxygen to brain tissues.
98. ICP (intracranial pressure) should be <2. measure head circumference.
99. Dilantin level (10-20). Can cause gingival hyperplasia
100. for Meningitis check for Kernig’s/ Brudzinski’s signs.
101. Wilm’s tumor is usually encapsulated above the kidneys causing flank pain (don’t palpate abdomen)
102. Hemophilia is x-linked. Mother passes disease to son.
103. When phenylalanine increases, brain problems occur.
104. Buck’s traction= knee immobility
105. Russell traction= femur or lower leg
106. Dunlap traction= skeletal or skin
107. Bryant’s traction= children <3y, <35 lbs. with femur fx.
108. Place apparatus first then place the weight when putting traction
109. Placenta should be in upper part of uterus
110. Eclampsia is seizure. (hypocalcemia) - give calcium
111. A patient with a vertical c-section surgery will more likely have another c-section.
112. Perform amniocentesis before 20 weeks’ gestation to check for cardiac and pulmonary abnormalities.
113. Rh - mothers receive RhoGAM to protect next baby.
114. anterior fontanelle closes by 18 months. Posterior 6 to 8 weeks.
115. Caput succedaneum= diffuse edema of the fetal scalp that crosses the suture lines. Swelling reabsorbs within 1
to 3 days.
116. Pathological jaundice= occurs before 24hrs and lasts 7 days. Physiological jaundice occurs after 24 hours.
117. Placenta previa = there is no pain, there is bleeding. Placenta abruption = pain, bleeding.
118. Betamethasone (celestone)=surfactant. Med for lung expansion.
119. Dystocia= baby cannot make it down to canal
120. Pitocin med used for uterine stimulation
121. Magnesium sulfate (used to halt preterm labor) is contraindicated if deep tendon reflexes are ineffective. If patient
experiences seizure during magnesium adm. Get the baby out stat (emergency).
122. Do not use why or I understand statement when dealing with patients
123. Milieu therapy= taking care of patient/environment
124. cognitive therapy= counseling
125. Crisis intervention=short term.
126. FIVE INTERVENTIONS FOR PSYCH PATIENTS
-Safety
-Setting limits
-Establish trusting relationship
-Meds
-Least restrictive methods/environment.
127. SSRI’s (antidepressants) take about 3 weeks to work.
128. Obsession is to think. Compulsion is to action
129. If patients have hallucinations redirect them. In delusions distract them.
130. Thorazine, Haldol (antipsychotic) can lead to EPS (extrapyramidal side effects)
131. Alzheimer’s disease is a chronic, progressive, degenerative cognitive disorder that accounts for more than 60% of all
dementia
132. Change in color is always a LATE sign!
133. Let’s say every answer in front of you is an abnormal value. If potassium is there, you can bet it is a problem they
want you to identify, because values outside of normal can be life threatening. Normal potassium is 3.5-5.0. Even a bun
of 50 doesn’t override a potassium of 3.0 in a renal patient’s priority.
134. Look carefully when you have no idea. In a word like rhabdomyosarcoma you can easily ascertain it has something
to do with muscle (myo) cancer (sarcoma). The same thing goes for drug names. For example, if it ends in –ide it’s
probably a diuretic, as in Furosemide, and Amiloride.
135. When choosing an answer, think in this manner...if you can only do ONLY one thing to help this patient what would
it be? Pick the most important intervention.
136. An answer that delays care or treatment is ALWAYS wrong.
137. If two of the answers are the exact opposite, like bradycardia or tachycardia → one is probably the answer.
138. If two or three answers are similar or are alike, none is correct.
139. When asking patients questions NEVER use “why” questions. Eliminate all “why?” answer options.
140. If you have never heard of it → please don’t pick it!
141. Always deal with actual problems or harm, before potential problems.
142. Always select a “patient focused” answer.
143. An answer option that states "reassess in 15 minutes"is probably wrong.
144. Think positive and you can achieve great things.
145. Think of present and future, the past is gone. Forget your past mistakes and focus on your successes encouraging
yourself to greater achievements in the future.
146. Always do your best so you can be proud that you gave it your best shot.
147. Focus on your achievements rather than your failures. If you do find yourself thinking about how you failed, then
look at what you managed to do right, and how you could correct what you did for next time.

Maternity Notes NCLEX:

Menstrual Cycle- 28-day cycle; ovulation occurs around day 14 of the cycle; it either leads to a pregnancy or a
menses (hormones include: FSH, LH, Estrogen, Progesterone)
S/s: cramps from contraction of uterus muscle, acne, rise in hormones that then fluctuate, breast tenderness,
mood changes
Treat: exercise for positive endorphins, NSAIDS, no sugary foods; want complex carbs

Gestation: time period of carrying the pregnancy (40wks)

Determined by:
 **NAGELES RULE** = used to estimate date of delivery; ask when their last menstrual cycle was, subtract 3
months, add 7 days, add 1 year)
Ultrasound: we measure the embryo/fetus from their crown (head) to their rump (bottom); make sure we lay pt
flat with a slight incline when doing this; explain this before doing so as well
 Know that this can either be internal US which is transvaginal bc it could be their first checkup when
pregnancy in 6-11wks; external US when mother is pregnant longer
Education: when mom should come back for prenatal care; and allow them to know their estimated due
date!!!!!!

Gravidity and Parity:

 Gravida- pregnant woman
 Gravidity- number of pregnancies
 Parity- the number of pregnancies at at least 20wks
 Nullipara- never given birth; this includes miscarriage or abortion prior to 20wks
GTPAL ACRONYM:
Remember even if a woman gives birth to twins that is still considered one pregnancy in total so a G1
Gravidity= number of pregnancies, including current pregnancies
Term Births= number of pregnancies carried to 37 weeks or more
Preterm Births= number of births between 20 and 37 weeks
Abortion/miscarriage= number of pregnancies that ended in these ways including a parity if past 20 wks
Living children= number of living children
Signs of pregnancy:
1.) Presumptive- felt by mom
 N/V
 Amnoherra
 Quickening- mom feels this; it is the initial movements of the baby (earlies around 16wks)
 Positive urine test HCG; may get false positive so that’s why this is a presumptive sign
2.) Probable- things the doctor or midwife notices; “probably are pregnant”
 Positive blood test is a probable sign not presumptive
 Ballottement- provider pushes against cervix and feels the head move up and then back down
 Chadwick’s- blue/purple color the cervix looks due to increased vascularity
 Hager’s Sign- lower uterine segment gets soft (around 4-6wks)
 Goodells- softening of the cervical tip
3.) Positive- “for sure pregnant”; determined by fetal heart rate, ultrasound, kick count felt by physician or
midwife

Therapeutic Management: should be started when probable signs are determined

 We want to start folic acid in mom
 Want to determine mom’s meds to make sure they are okay for baby
 Want to determine if mom needs to be prescribed meds to help manage pregnancy symptoms

Fundal Height Assessment: always tell mom about importance for emptying bladder (every two
hours)
Fundus definition:  the top of the uterus, palpable; either firm, soft, or boggy
 used to measure the gestation based on height of uterus; if gestational age doesn’t match measurement
it could mean the baby is too big or too small
Fundal Height Measurement: helps evaluate age of fetus during pregnancy and determine the fundal
height in the postpartum period to help ensure the uterus is contracting properly

1.) Measured externally in pregnancy in centimeters and should equal the gestational age
 28 cm should be 28 weeks pregnant
 Lie then back but not flat; measure at beginning of symphysis pubis and go to top of uterus;
measure in centimeters
2.) Measured post pregnancy during the postpartum recovery in “fingerbreadths” or centimeters
 Immediately after birth the fundus should be found at the level of the umbilicus
 Fundal height should move down 1 cm every 12-24 hours
 At two weeks the uterus should be non palpable**
 Measurement: pt should void, lie them flat, palpate the top of the uterus while the other hand is at
base of the uterus, feel the fundus and measure how far below or above the umbilicus it is; use
centimeters or fingers
 U = its at the umbilicus
 U-1, U-2, U-3=it is 1,2,or 3 cm below the umbilicus
 U+1,U+2= it is 1, or 2 cm above the umbilicus

Maternity Risk Factors:

Need to assess mother when gaining info about these topics; and then treat any issues they have as well
as maybe get them a referral to specialist’s

 Genetic Diseases- Risk of passing disease to offspring

 Abuse and Violence- Risk of injury to mother or fetus
 Nicotine, Drugs and Alcohol- Risk of fetal dependence to substance; Risk of injury or illness to fetus;
EX: fetal alcohol syndrome
 Sexually Transmitted Infections- May be transmitted to fetus; EX: HIV, herpes, syphilis, chlamydia,
gonorrhea
 Mental Illness- Can worsen during or after pregnancy; this could lead to Postpartum depression or even
psychosis
 Cardiac Risks- Increased workload to heart due to blood volume; Can be problematic for pregnant
patients with pre-existing heart conditions
 Diabetes- Risk for hormone imbalances or difficult diabetes management; when pregnant blood sugars
rise; Risk for macrosomia (large baby)
 Underweight, Overweight or Obesity- Puts fetus at risk for developmental concerns due to poor
nutrition
 Thyroid Disorders- Increased risk for miscarriage and stillbirth
 Young or Advanced Age- Patients under 20 or over 35 are at greater risk for potential complications to
both pregnant patient and fetus (younger aged are at risk for preeclampsia; the older maternal ages 35
and older are at risk of having genetic concerns bc of having older eggs)
 Poverty- Risk for inadequate care due to lack of resources; EX: no transportation to prenatal
appointments, not eating as healthy if not having money for healthy foods, not getting prenatal vitamins
as they should, no insurance.

Prenatal Period

Physiological changes in pregnancy= changes that occur to the bodies function; not physically
 Scheduled of prenatal visits:

1. Q4 weeks from 8-32 weeks

2. Q2 weeks from 32-36 weeks
3. Q1 weeks from 36-40 weeks

1. Caused by hormones (Hcg, estrogen (increase in vascularity causing nasal congestion), progesterone
(slowing everything down), aldosterone which increased bld plasma volume leading to more work for the
heart)
2. Increased blood volume and uterus changes
3. Multiple systems changed
4. Respiratory increased oxygen consumption, congestion occurs, stuffiness or nose bleeds, diaphragm
pushed on by baby growing; increased ventilaiton
5. Cardiacmore bld volume, murmurs normal, edema/fluid retention, increased pulse 10-15bpm, bp
decreased in second trimester that can cause hypotension issues, increased preload and CO; never lie
them on their back flat which could cause supine hypotenstion!!! Always have them lie on their side
6. Gastro everything slows down due to progesterone; constipation, N/V, bloating
Renal frequent urination, weight of uterus grows and presses on the bladder bc it can’t fill up as
much, frequent UTI’s are common so emptying bladder is important
7. Musculoskeletal relaxin hormone released, lumbar lordosis, changes in pelvic girdle
8. Hematologic increase in coagulation; needed for more clotting bc of bleeding excessively after baby is
born; increased risk for DVT’s tho!!!!!

Patient Education:

 Normal changes to expect

 Ways to improve symptoms: eat crackers before rising from bed, don’t let stomach get empty due to
nausea, take Zofran, diet changes to eat small frequent meals
 Correct posture to prevent back discomfort
 Let them know when to be seen or when to be concerned with changes!!!!  frequent vomiting and
weight loss, signs of blood clots or DVT’s, UTI symptoms
 To help discomfort in entire body you can = elevate legs/feet for edema, over the counter antacids for
heartburn, rest and elevation to stop swelling in legs, over the counter meds or home remedies for
nausea, constipation, headaches, back aches, cramps, ect.

Fetal Well-being Assessment: Antepartum

**General: least invasive first!!!!!!  No comlications detected continue with routine prenatal care!!!**

Routine Diagnostics:

 Blood type and Rh Factor

 Rubella titer  Determine immunity; Cannot give rubella vaccine during pregnancy due to it potentially
crossing placenta because it is a live vaccine
 Complete blood count H/H; Platelets
 STI testing  Mandated in some states; Pap smear with cultures; May test for: HIV, HPV, herpes,
gonorrhea, syphilis, chlamydia, trichomoniasis; Hep B screening
 Glucose challenge  Done around 28 weeks; OGTT
o Patient drinks 50 g oral glucose
o Check 1-hour BG
 o If they fail, they do a 3 hour glucose test; 3 hour glucola
o Fasting sugar Drink 100g glucose Check at 1 hr, 2 hr, 3hr If fail then gestational diabetic
and need referral

Routine Testing:

 Urinalysis with culture urine dip to check for glucose (diabetes), protein (preeclampsia indicator),
bacteria (infection)
 Nonstress test want to see a reaction; determines FHR, it should increase with movement, mom hits
button anytime she feels fetal movement!!! Want to see
FHR rise with each movement; it should move up 15bpm; EX: if FHR resting is 120 then with this
movement we want to see FHR change to something like 135bpm!!!; not painful, assess fetal wellbeing,
changes in HR with movement, and how the placenta is functioning and its oxygenation
o If this occurs the nonstress test is reactive which is normal
o If it does not occur it is considered nonreactive which is abnormal
 Group Beta Strep- vagina swab done on mom b/w 34-37 wks prego! If positive will be treated in labor
with ABX; if not testing this it could cause the infant to be sick/septic
 Kick counts mother counts number of kicks during 2 hour period while lying on side; notify if less
than 10 in 2 hours

Non-Routine Testing:

 Contraction Stress Testwant to induce contractions with Pitocin, breast pump = want to see negative
result; want to have 3 contractions induced and we watch FHR; want to see FHR not react to
contraction in a bad way; if it is positive that means the baby is positive for stress reactions with
contraction
 Chorionic villus sampling invasive, looking at genetics; get sample from placenta that gives genetic
info; done early on 11-14wks (side effects: cramping, fever, chills, leaking fluid
 Amniocentesis needle pulls up amniotic fluid; tells genetics; can determine a decrease in fetal
movement
 Must EMPTY BLADDER
 Percutaneous umbilical blood sampling transducer used to detect position of fetus; sample obtained
from fetal blood from the umbilical cord; bloods tested to detect any fetal anemia
 Alpha-fetoprotein screening blood sample from mom b/w 16-18wks; protein released from liver and
detected in maternal blood supply
 Nitrazine Test checking for amniotic fluid in vaginal secretions; determines if water breaks vs urine;
swab turns blue if it is amniotic fluid, will also measure the pH alkaline

Pregnancy Nutrition:

**expected weight gain is different in every pregnancy; normal gain is 25-35lbs; if pt is underweight they
should gain 20-40lbs, if obese they should only gain 12-25lbs**

Foods to encourage high in iron (legumes and spinach), foods high in calcium, prenatal vitamins, folic acid,
fruits and vegetables (wash well), increase cal intake to 300 cals/day during pregnancy, increase total cal to 500
cal/day during lactation after delivery

Foods to avoid alcohol, more than 200mg a day of caffeine, undercooked deli meats due to bacteria listeria,
undercooked raw meats or raw items like sushi, fish high in mercury (no shark, swordfish, king maceral),
unpasteurized and soft cheeses, limit tuna to less than 6oz/week
Educate pts who are vegan or vegetarian= lack of nutrients; important to consume complete proteins and
vitamins (Vit D, calcium, zinc, B12, omega 3’s)

Educate pts with anemia= milk and tea with meals as well as vitamin c!! folic acid!!!

Risk Conditions of Pregnancy:

Cardiac (heart) disease: increased workload due to increased volume and increased weight!!
 baseline assessment of hemodynamics of mom and baby
 auscultate and not abnormal heart/lung sounds (murmur normal due to extra bld flow)
 not any pain with normal activity
 cardiac monitoring may be indicated during labor
Education: educate on appropriate wt, baseline obesity places mom at more risks for issues, healthy low sodium
diet

Chorioamnionitis: bacterial intrauterine infection of the amniotic cavity can lead to endometritis and
sepsis!!!!!
CAUSES: intrauterine or invasive procedures, amniocentesis, prolonged rupture of membranes= all can
introduce infection
S/S:= fever of 100.4 and greater, leukocytosis (increasedWBC), maternal and fetal tachycardia. Foul smelling
discharge
TREATMENT= v/s (bp, hr, temp, fetal distress), assess for FHR of fetal decels (don’t want, this tells that baby
is in distress), blood cultures before ABX, then give Gentamycin or Ampicillin, draw fluid to determine WBC
count with amnio or chorionic sample, monitor the baby (CBC, bld cultures, possibly ABX for that baby)
EDUCATION report s/s of infection to nurse of provider (temp, changes in hr and bp, discharge, ect)

Gestational Diabetes: diagnosed in pregnancy at 28 wks, body cant respond to increased insulin requirements
due to increased hormones, as well as change in carb metabolism
**sugar crosses the placenta, insulin does not** ; baby makes own insulin but needs glucose, so it pulls glucose
from mom and can make mom more likely to be hypoglycemic
Assessments= screen for DM during prenatal visits, screen for glucose and protein in urine at regular prenatal
visits, lastly check BS 24-28 wks with glucola testing; will be diagnosed this way
Newborn Changes: baby grows faster and larger, but their function is still reflective of age, not size;
macrosomic= 4000g!!!! When baby is born they will be larger, but hypoglycemic not hyperglycemic bc
they have too much insulin not sugar**
range for baby blood sugar is 40-50 after birth!!
EDUCATION= hypo/hyperglycemia, manage BG, insulin admin, self monitoring of BG teaching, log for
glucose levels, diet and exercise, monitor blood pressure!!

Ectopic Pregnancy: fertilized egg implants and begins to grow in area other than the uterus; could occur in
fallopian tubes, cervix, interstitial tissue, ovary, ect= could lead to rupture bc it grow and gets bigger with
nowhere to go
S/S: vaginal bleeding and spotting, tachycardia, increased RR, low BP, severe low abd pain, N/v, weakness
(signs of shock if ruptured). Shoulder pain
NURSING CARE= prevent rupture and preserve fallopian tube, minimize bleeding and reduce chances of
shock, surgical removal may be needed (laparoscopy or laparotomy), methotrexate given IM to inhibit rapid cell
division that is occurs (causes medical abortion), Rh- moms get Rhogam for future pregnancies to stop the body
from attacking the fetus
EDUCATION= report any severe abdominal pain or right shoulder pain (referred pain= rupture), bleeding or
slight spotting, need to education and explain the termination of this pregnancy, provide comfort and coping

Hematoma: collection of swelling of clotted blood within tissues its NOT supposed to be; can be from
episiotomy, c-section, vacuum assisted birth, regular birth, ect.
ASSESSMENT AND EDUCATION: peri pressure feeling like they have to poop, sensitive and edema at peri
area, see shock signs, severe pain unresolved, cannot void
TREAT: pain, restore fluids, surgical repair to drain the blood, give blood products due to blood loss, ABX’s,
monitor labs like CBC and WBC’s, I & O’s

Molar Pregnancy: clump of growing tissues; doesn’t contain original maternal nucleus
S/SFundal height larger than expected, never any FHR, pt can have high BP, vaginal bleeding (bright red to
dark brown), HCG rises quick causing N/V
TREATMENT: Dilation and Curate vacuum aspiration to remove the contents (mole sent to pathology to make
sure it has not become malignant), oxytocin to help contract uterus to stop the fast uterine growth and fundal
height, methotrexate given to inhibit cell division, HCG watched until baseline reached
**this pt cannot get pregnant following one year of this happening, so we need to educate pt on resources to
help with coping of loss of pregnancy, and needing contraception to not get pregnant for a year after this**

Hyperemesis Gravidarum: horrible nausea; vomiting 3 or more times a day; hormones are a cause of this
S/S: vomiting and how often, weight loss, dehydrated, labs with electrolytes
TREATMENT AND EDUCATION: s/s to report, diet of bland foods, pt sit upright after meals, eat before
rising (such as crackers), B6 to help with nausea, medications given to help with nauses (Zofran, Phenergan),
IV fluids or TPN to help with protein and lyte levels, monitor vitals, calorie counts for adequate nutrition for
mom and baby

Gestational HTN: bp of 140/90 or greater with no other symptoms; this can worsen and progress to
preeclampsia!!!!!
ASSESSMENT: evaluate BP, assess for progression, labs (CMP, BMP), urine for protein, 24hr urine for CC,
assess baby often with Ultrasound (high bp can reduce healthy blood flow to fetus and restrict growth)
TREATMENT: antihypertensives, may need early induction to outweigh risks of staying pregnant
ACE & ARBS are CONTRAINDICATED IN PREGNANCY
EDUCATION: report s/s such as headache, blurred vision, increase in swelling, teach how to take and monitor
BP and track it, teach about medications if taking!!

Infections in Pregnancy: TORCH cross placenta and reach baby (during delivery or during prego across the
placenta)
1. Toxoplasmosis—comes from cat litter, parasitic disease; causes neurological issues
2. Other- group beta strep (bacteria found in vaginal of all woman (taken 34-37wks) if detected and above
a threshold level they will be positive so penicillin given if not sepsis can occur in newborn), HIV
(deliver by C-section, infants given antiretrovirals after delivery, no breastfeeding), syphilis, hepatitis
3. Rubella- titers drawn, if not immune then we worry that the baby could have congenital anomalies or
death if mom gets rubella during pregnancy (cannot give vaccine during pregnancy bc it is a live
vaccine)
4. Cytomegalovirus- transmitted by bodily fluids, pt feels like they have a cold, crosses placenta and can
cause baby to have blindness, jaundice, seizures, enlarged liver, enlarged spleen, hearing loss,
microencephaly, death 
5. Herpes- acyclovir if active or nonactive lesions from past and c-section if active lesions
ASSESSMENTS: rubella titer, HIV status, hepatitis liver labs, baby assessments to look for skin lesions, make
sure head is measuring normal, is baby growing properly
TREATMENT: depends on infection= antiretrovirals, antibiotics, antivirals, monitoring to see that fetus is
doing okay as well as checking bld flow to baby; educate hand hygiene and STD protection

Preeclampsia (pree)- before: hypertensive disorder, proteinuria (happens after 20wks gestation)
Eclampsia is diagnosed when a seizure occurs!!!!
ASSESSMENTS: bp has to be 140/90 x2 and it has to be 4 hours apart; or 160 of SBP or DBP of 90;
edema in hands and feet due to fluid retention, sudden weight gain, headache from high BP, epigastric or RUQ
pain (organs inflamed), vision changes due to bp increases (inflammation occuring in CNS!!!!), protein in urine
bc our kidney is inflamed so the filter of protein normally is damaged spilling it into the urine rather than
keeping it in the blood
TREAT AND EDUCATION: delivery is the only cure for the pt, pt on bedrest in the hospital, given IV mag
sulfate prophylactically to lower BP and prevent seizures in becoming eclampsic, antihypertensives (labetalol),
fetal assessments and measurements (head circumference, body measurements) **teach when to call HCP of s/s
to look for, kick count check of 2 hours to have 10 kicks and if not call dr, assess bp on own

HELLP Syndrome:
Risk factors: older age of 34 or more, twins/multiparity, exacerbation of preeclampsia
LABS: hemolysis, elevated liver enzymes (ALT, AST), low platelets  DON’T NEED TO HAVE ALL
THREE OF THESE TO HAVE HELLP SYNDROME
S/S: petechia, abd pain & N/V from liver inflamed, tachycardia & dizzy due to hemolysis (anemia)
TREAT: have to deliver baby; could cause death in mom, monitor lab values for changes or progression,
attempt to stabilize mom with labetalol, fluids if safe, and mag sulfate if you can

Fetal Development: prenatal vitamins; medications known if mom can keep taking or not, no alcohol

 P-Preembryonic-fertilization and implantation (conception occurs)

 E-Embryonic- FHR present, US shows baby, brain structures in place, bone begins to replace cartilage,
embryo is 1.2 inches long
 F-Fetal-circulatory system and all organs present, heartbeat heard external US, fetus can hear, open eyes
and close them at 28wks, lungs develop and complete at 35wks, placenta does gas exchange

**As the fetus "expands" or grows, it passes through three stages - the Preembryonic stage up to week 2, the
Embryonic stages from weeks 2 - 8, and the Fetal stage from week 8 to birth**

Fetal Environment: safe medications taken by mom, no alcohol, prenatal vitamins

1. Amnion
a. Inner membrane that forms the amniotic sac that later surrounds the embryo/fetus
2. Chorion
a. Outer membrane that forms the fetal side of the placenta
b. Eventually develops vascular structures
c. Forms placenta
3. Amniotic fluid
a. Cushions, protects, temperature control
b. Fetus will swallow amniotic fluid, urinate it out, and move it through their respiratory system
4. Placenta gives to baby via umbilical cord; two arteries and one vein (AVA)
a. Fully formed at 10 weeks and at 12 weeks produces hormones
b. Provides gas exchange, exchange of nutrients and waste products between mom and baby
 Process of Labor:

Mom: 4ps

Powers= voluntary (can control how she pushes), involuntary (contractions)

Passageway= how much space is there in the pelvis

Passenger= baby and placenta, what is coming out

Psyche= emotional state (is she supported or fearful)

Fetal: Alppps

Attitude= how the head is, flextion (chin to chest) or extension (harder to deliver)

Lie= relationship to maternal and fetal spine; longi (parallel to each other) or transverse

Presentation= what is the position, cephalic or vertex (head down), breech (butt or foot first)

Presenting part= which part is leading the way? (head, shoulder, hip, foot)

Position= what is the presenting part? Is it the head, occiput (head first), scapula first (SC), chin (M-mentum),
sacrum (S) then determine which way it is facing to moms pelvis (anterior or posterior)

Station= where fetus is in the pelvis (ischial spine = 0, plus one is 1cm below ischial spine, minus one is 1cm
above the ischial spine)

Mechanisms of Labor:

True labor= contractions occuring that are strong and regular that can be timed, cervical changes such as
dilation and effacement, nothing will stop the contractions or dilation/effacement from occuring

False labor= contractions that don’t get stronger and are irregular, they just stop; no cervical change
(BRAXTON HICKS CONTRACTIONS) resting, hydration, walking around will stop them
 Effacement and Expulsion of fetus Separation of Physical recover
dilation of cervix placenta

Three stages Pushing stage; baby Removal of placenta 1-4 hr after removal
out of placenta
Latent= 0-3cm Begins when baby is
Begins with 10 cm out ends when Look for retained
Active= 4-7cm dilation ends with placenta is out pieces
expulsion of baby
Transition= 8-10cm

Mother is talkative Mother has intense Mother is relieved Mother is tired but
and eager in latent concentration on after birth of newborn eager to become
phase, tired and pushing with mom is usually tired acquainted with
restless as labor contractions newborn
intensifies and
contractions get
stronger

Fetal Positions:

Vertex positions Face positions Breech positions Other

Right occipitoanterior right mentoanterior Left sacroanterior brow
Left occipitoanterior Left mentoanterior Left sacroposterior shoulder
Right Right mentoposterior
occipitoposterior
Left occipitoposterior
Right
occipitotransverse
Left
occipitotransverse

Fetal Monitoring pt 1: veal vs. chop

Variable deceleration Cord compression!!!!!
Early deceleration Head compression!!!
Acceleration Okay!!! This is okay to have
Late deceleration Placental insufficiency!!!

Fetal Monitoring pt 2: 110-160 HR for Fetus

1. External= noninvasive, monitor placed on back of fetus on moms abdomen
2. Internal= invasive, fetal scalp electrode that goes under fetal scalp; requires rupture of
membranes and for mom to be dilated 2-3cm
Treat abnormal FHR’s: prolapsed cored and mom is hypotensive on monitoring; stop the Pitocin, put mom on
left side, and give oxygen

Leopold’s Maneuver: palpating mom’s uterus/fundus to determine the presenting part of the fetus and to know
where to place the fetal heart rate monitor; want monitor on fetal back
Mom= empty bladder before palpating

Labor & Delivery Complications:

Premature Rupture of Membranes: occurs before onset of labor; biggest concern is infection (water broke
early)
ASSESSMENT: amount can be anywhere from 50-300ml at once or a slow leak, color should be clear, check
for odor
MANAGEMENT: amnisure test (swab to detect placental protein found in amniotic fluid= positive result of
PROM); nitrazine test to determine if it is amniotic fluid=should turn blue if so); monitor for s/s of infection and
give ABX if needed; fetal monitoring indicated (watch for fetal tachycardia=infection s/s); teach when mom
should see HCP!!

Prolapsed Umbilical Cord: medical emergency; umbilical cord provides baby with oxygen but pressure is
applied from the fetus on the displaced cord (o2 is compromised)
ASSESSMENT: can see cord protruding from vag; feel pulsation of something squishy on cervical exam; FHR
decelerations; mom feels something soft and squishy b/w legs
MANAGE: knee to chest position to open up pelvis; Trendelenburg (help shift fetus to relieve pressure), elevate
presenting part to relieve pressure; supplemental o2 no matter what; FHR monitored; prepare for emergent c-
section; nurse must put sterile glove and sleeve on to hold umbilical cord in while c-section being done

Placenta Previa: placenta implanted improperly in the uterus and covers the cervix or opening
ASSESS: painless bright red vaginal bleeding; placental location determined on ultrasound
MANAGE: vaginal exams contraindicated; interventions depend on the age of fetus, degree of placenta previa
and if the fetus or mom is in distress!!!! C-section may be indicated; pt put on bedrest

Abruptio Placenta: placenta detaches from uterine wall prior to delivery; EMERGENCY
 Internal= if incomplete separation; massive bleeding builds up behind placenta
 External= if complete separation from uterine wall
ASSESS: dark red bleeding; severe abdominal pain; uterine rigidity/board like; fetal distress (bradycardia);
may see shock symptoms if lots of bld loss, fundal height increased
MANAGE: FHR monitor for heart tones and patterns; VS, change in fundal height, fluids and blood products
**prepare for delivery (vaginal with partial abruption; emergent c-section with fetal distress)= baby has
decreased perfusion of oxygen and nutrients bc placenta not attached to mom’s circulation**
Preterm/Premature Labor: 20-36 wks when labor occurs; baby at risk for respiratory difficulties due to
underdeveloped lungs and other organs
ASSESS: regular contractions, cramping, change in vaginal discharge (thick to thin or brown to bloody), pelvic
pressure or pain, low back pain, early rupture of membranes
MANAGE: attempt to stop it with terbutaline=tocolytics (relax uterus); IV fluids to reduce dehydration risk;
monitor mom and baby, bedrest, infection prevention =reduce vaginal exam checks
Precipitous labor= baby delivered quick; within 3 hours; risks for tears and hemmorhage
Dystocia= prolonged labor due to large baby, moms pelvic structure being narrow, hypo/hyper labor
 Hypotonic labor= weak and ineffective contractions, no progression of labor, risk for infection if
membrane rupture occurs
 Hypertonic labor= strong contractions, fast contractions, prevents time for dilation and effacement,
causes fetal distress
TREAT: pain meds, IVF, oxytocin in hypotonic labor, tocolytics for hypertonic labor, walking to get into good
patter, rest in b/t contractions; turn and repo a lot

BUBBLE HE: postpartum assessment, intervention, education!!!!

1. Breasts
a. Estrogen and progesterone levels plummet → ↑ prolactin levels and therefore milk production
b. Colostrum is secreted for first 3-4 days
c. Milk typically comes in on day 5-6
d. Mothers not breastfeeding will still have milk come in
i. No nipple stimulation
ii. Wear tight bra
iii. Milk production typically stops after 5-7 days
iv. Mild pain meds may be needed to ease engorgement
v. Cabbage on breasts
2. Uterine changes
a. Rapid shrinking / involution
i. Patients who are breastfeeding will experience more rapid shrinking due to oxytocin
release
ii. “Afterpains” are the pains after birth from uterine contractions
1. Due to the release of oxytocin
2. Breastfeeders will have more afterpains
b. Fundal height decreases approximately 1 cm each day and should be midline
3. Bowel (GI changes)
a. Hemorrhoids and constipation are common
b. Administer stool softeners as ordered
4. Bladder
a. Excessive output / diuresis the first 12 hrs post delivery due to fluid shifts
b. Encourage regular emptying of the bladder to prevent urinary retention and displacement of
uterus
 c. Note whether urinary retention occurs as it can be common due to any trauma, meds, anesthesia,
etc.
5. Lochia
a. Because fetus has occupied the uterus for 9 months, the lining has not shed as it normally does
with each menstrual cycle.  The lining is no longer needed and must be shed.
b. Postpartum mothers will experience vaginal bleeding for up to 6 weeks as the uterine lining is
shed.  
c. Lochia is shed in 3 stages:
i. Rubra – bloody
ii. Serosa – brownish pink
iii. Alba – milky white
d. Most accurate way to determine amount of lochia =  weigh pad before and after use
i. Heavy amount of lochia = saturating a pad in 1 hour
ii. Excessive amount of lochia = saturating a pad in 15 minutes
iii. 1 g = 1 mL
e. Menstruation
i. Return to normal cycle depends if mother is breastfeeding or not
ii. Breastfeeding moms might have amenorrhea until they stop breastfeeding or could return
sooner
iii. Breastfeeding moms may have amenorrhea but may still ovulation.  
1. Education is important! Some may rationalize that if they do not have their
normal monthly bleeding that they cannot get pregnant again – not true!
iv. Non-breastfeeding moms will return in 1-2 months
6. Episiotomy and/or Vagina
a. Decreased tone: Will likely never return to pre-pregnancy state
b. Assess perineum for tears; blood clots
c. Monitor infection signs

Therapeutic Management

1. Pain medication→ afterpains

a. Ibuprofen
b. Oxycodone
c. Tylenol
2. Ice packs→ vaginal swelling
3. Tucks pads→ Hemorrhoids; witch hazel
4. Stool softeners→ hemorrhoids
5. Nipple care→ breastfeeding; lanolin medicated ointment for nipple damage, want good latch from baby

Patient Education

1. Fundal height
a. Involuting, fundus moving lower
b. Assessed for bleeding
2. Lochia
a. It is a progression
b. Should not go from red to brown and back to red
c. How much is too much?
i. Soaking a pad an hour
3. Breast care
 a. Nipple care
b. Non-breastfeeding→ tight bra, no stimulation, no pumping, cabbage leaves, keep warm
water on back; don’t hand express or pump milk

Psych: postpartum

1.) Postpartum Blues crying, occasionally unprovoked and random; increased irritability,
anxiety, feelings of sadness and confusion, issues with sleeping, labile emotions
NORMAL
2.) Postpartum Depression feelings of guilt, low energy levels, suicidal thoughts, not
responsive to newborn/unconnected, anxiety, loss of enjoyment in normal activities,
crying (unrelenting sadness), irritable
3.) Postpartum Psychosis delirium, disconnected from reality, hallucinations, delusions
(very dangerous to self and children)
TREAT: open ended questions asked, confirm feelings, hot line and support groups, encourage
dialogue b/w yourself, mom, and support system, comfort and listen to pt

Important facts to know about breastfeeding!!!!!

 First feeding should occur within the first hour after birth
 Exclusive breastfeeding for the first 6 months of life
 Meconium passes, breastfed baby’s stools transition and are seedy, yellow, watery, and
frequent
 Mom should increase caloric intake up to 500 additional cals and continue prenatal
vitamins during breastfeeding
 Baby should get as much of the breast in the mouth (all of areola); sucking should be
silent if good latch occurred; listen for swallowing

Postpartum Complications:

Postpartum Hemorrhage: early (first 24hrs) or late (after 24hrs) blood loss

Biggest risk factor= subinvolution( after childbirth the uterus doesn’t return to its normal size)

ASSESS: Vaginal= anything greater than 500ml; C-section= anything greater than 1000ml; boggy uterus
(atony) on assessment or puddle of blood or constant trickle; signs of shock

MANAGE: fundal massage/assess (q 15 for the first hour, q 30 mins x2, and q hour x4); estimate blood loss,
make sure to turn pt to see any pooling of blood; H & H labs, hysterectomy or D&; MEDS= oxytocin,
methylergonovine, carpropost= all used to contract the uterus/fundus and firm it up

Mastitis: bacterial infection associated with breastfeeding (common 2-3wks after delivery)

ASSESS: flu like symptoms; fever, pain, localized edema and redness of breast
MANAGE/EDUCATE: CONTINUE TO BREASTFEED IT IS SAFE; pain meds or ABX if needed, support
breasts with bra without underwire, do not want to clog ducts so use warm compress on breast!!!!

Initial Care of Newborn:

ASSESSMENT

1. APGAR score is immediate assessment at 1 and 5 minutes (scoring is 0,1,2)

1. Appearance- acrocyanosis, pink torso and extremities
2. Pulse- palpable pulses, 120-160bpm
3. Grimace- vigorous cry
4. Activity- flexed posture, coordinated movements, Ortolani maneuver of hips (no click), actively
moving
5. Respiration- 30-60bpm, should be no distress, effective cry
2. Observe respirations and assist (clear secretions) if needed
1. Regular irregular respirations
3. Note and characterize any respiratory issues like nasal flaring, grunting, or retractions
4. Vitals
1. Acrocyanosis = cyanosis of hands or feet→ normal
2. First infant temperature 97.8-99F
3. If mom had a temp before delivery, then the baby will post delivery
5. Head to toe assessment= pink, loud cry, well flexed, full ROM, fontanelles (anterior diamond shaped
and posterior triangular shaped)
6. Weight (6-10lbs) length (18-22in), head (33-35cm), chest (30-33cm)

Therapeutic Management

1. Use a bulb syringe to suction mouth, then nares

1. Baby’s first breath is a large inhale and he/she will suck in the fluid in the mouth
2. Dry the baby quickly while rubbing/stroking their back to stimulate their first cry if they are not already
doing so
1. This helps clear the lungs of fluid
2. The amniotic fluid on the baby can make them very cold
3. Do not remove vernix until bath time, this helps to moisturize and protect baby’s skin
1. Known as “cheesy babies”
2. Therefore, an earlier gestation baby will have more vernix=more protection
3. Delay bath to 24 hours to best protect the baby
4. Grab a fresh blanket, diaper, and cap, put baby against mom’s chest (skin to skin) and place blanket
around baby and mom and cap on head to maintain temp stability
5. Properly identify baby with matching arm bands to mother and a support person the mother chooses
6. Golden Hour
1. Keep mom and baby skin to skin for at least an hour, if medically appropriate
2. If breastfeeding, encourage the first feeding during this hour
7. After the golden hour, give meds (vitamin K for bleeding risks, eye ointment to prevent blindness from
chlamydia, hep b can be given, PKU done after 24hrs when feedings have occurred)
1. Maternal fingerprint and baby footprints
2. Alarm tag (safety of baby)

Newborn Tests:
Hearing Exam: electrodes watch brain waves with noise, some fail and need rescreening

Metabolic Screening: state regulated test, PKU blood sample; MUST BE EATING SUCCESSFULLY FOR
24HRS BEFORE SCREENING; looks for metabolic disorders

Bilirubin Test: jaundice and yellowing skin, excreted by stool; if built up it can cause KERNICTERUS
(BRAIN DAMAGE)= phototherapy done (goggles to protect eyes), frequent feeding for more stools

 Pathological jaundice= appears w/in first 24 hours of life; requires further assessment (due to blood
incompatibility, problem with liver)= need to notify MD
 Physiological jaundice= starts 2nd or 3rd day of life; (due to breastfeeding, prematurity, broken down
RBC’s)

Weight: every day and diapers; 1g diaper = 1ml of urine; must know weight of dry diaper

Should have 6-8 wet diapers a day

Addiction Screening: drugs or alcohol!!! S/S= fever, sweating, high pitched cry, tachypnia or distress, diarrhea
and vomiting, sneezing/stuffy nose, excessive suck, poor feeding, tremors, hypertonic reflexes

Fetal Alcohol Screening: grow with issues in judgement, behavior issues, hearing or seeing issues, low
intelligence; S/S= thin upper lip, up turned nose, wide set eyes, small eye openings, smooth b/w nose and
mouth; CNS issues (encephalopathy, increase sensitivity to stimuli, siezures, learning disabilities, memory
trouble, ADHD, impulsive, growth deficiencies)

HIV Screening: can be given by birth and breastfeeding; ongoing assessments up to 18 months after birth;
S/S= immunodeficiencies; CD4 increased; treat with antiretrovirals (Zidovudine)

Newborn Reflex Table:

Suck Reflex Finger, nipple touches roof of mouth and

infant sucks
Rooting Reflex Touch finger, cheek, lip, corner of mouth with
nipple= baby turns head that directions and
sucks nipple
Swallowing Reflex Sucking or something touches back of throat;
coordinated sucking and swallowing=
permanent
Palmar Grasp Reflex Place finger in their hand= curls hand fingers
around examiners finger
Plantar Grasp Reflex Rub bottom of foot= toes curl downward
Moro/startle Reflex Gently lift newborn up from lying position
and allow to fall back= symmetrical spreading
of arms out then pulling of arms in
Pull to Sit Reflex Pull from supine to sitting= head will lag
behind
Babinski Reflex Stroke gently upward on lateral side of foot=
toes fan; disappears by age 2 (neuro issues
indicated if reflex not present)
Stepping Reflex Hold newborn up in standing position= baby
 walks; disappears at 2months
Crawling Reflex Place newborn on stomach= makes crawling
movement with extremities; disappears at
6wks
Tonic Neck Reflex Head turns to one side; arm on same side
extends while other side is flexed; disappears
at 7months

OB Drug Cheat Sheet

Tocolytics used to prevent preterm labor by suppressing uterine contractions

Terbutaline (Brethine) beta 2 adrenergic agonist; used to cause smooth muscle relaxation in uterus (side
effect to know= cardiac issues such as maternal tachycardia)

Betamethasone used to accelerate fetal lung maturity and decrease severity of respiratory distress; be careful
bc this is steroid, so monitor BG levels

Mag Sulfate used to decrease risk of preeclampsia from turning into eclampsia; may suppress uterine
contractions, used to also decrease BP; ANTIDOTE= CALCIUM GLUCONATE

 CLOSLY MONITOR MAG LEVELS: 1.5-2.5!!!; MONITOR FOR HYPOTENSION, ASSESS

PATELLAR REFLEX & SEE IF SUPPRESSED OR NOT, THIS COULD BE A SIGN OF
RESPIRATORY ARREST; CHECK RR

Opioids used for breakthrough/acute pain; EX: dilaudid, morphine, stadol, nalbuphine, oxycodone,
hydrocodone= be careful can get baby addicted; ANTIDOTE= NALOXONE

Prostaglandins used to stimulate uterine contractions and used for getting the cervix ripened and ready to
dilate and efface; Side effects= overstimulation to uterine muscles and more than 6 contractions in 10mins=
high!!!

Oxytocin/Pitocin used to stimulate contractions and increases intensity, strength, and duration of
contractions; used to control postpartum hemorrhage too

 IF BABY HAS NON REASSURING HEART TONES STOP INFUSION, TURN MOM ON
LEFT SIDE, GIVE 02, ASSESS BABY AND MOM, AND NOTIFY MD

Rhogam given during and after pregnancy to prevent the RH neg mom from developing antibodies that could
attack the fetus now or in future pregnancies; GIVEN AT 28WKS PREGO & WITHIN 72 HRS OF
DELIVERY!!!

Erythromycin used to protect neonatal from conjunctivitis or blindness caused by chlamydia or gonorrhea;
GIVEN 1 HOUR OF LIFE; DON’T WIPE OFF IT WILL ABSORB

Vitamin K IM injection given for coagulation factors and to prevent hemorrhagic disorders; GIVEN 1
HOUR AFTER BIRTH
Hep B given within first 12hrs of life, IM injection

IV Solution Cheat Sheet

Type Description Osmolality Use Miscellaneous

0.9% NaCl in Water Isotonic Increases  Replaces losses without altering fluid
Crystalloid Solution (308 mOsm) circulating plasma concentrations.
volume when red  Helpful for Na+ replacement
Normal Saline (NS) cells are adequate

0.45% NaCl in Hypotonic Raises total fluid  Useful for daily maintenance of body
Water (154 mOsm) volume fluid, but is of less value for replacement
Crystalloid Solution of NaCl deficit.
1/2 Normal Saline  Helpful for establishing renal function.
(1/2 NS)  Fluid replacement for clients who don’t
need extra glucose (diabetics)

Normal saline with Isotonic Replaces fluid and  Normal saline with K+, Ca++, and
Lactated Ringer’s electrolytes and (275 mOsm) buffers pH lactate (buffer)
(LR) buffer  Often seen with surgery

Dextrose 5% in Isotonic (in the Raises total fluid  Provides 170-200 calories/1,000cc for
water Crystalloid bag) volume. energy.
solution *Physiologically Helpful in  Physiologically hypotonic -the dextrose
hypotonic rehydrating and is metabolized quickly so that only
D5W (260 mOsm) excretory water remains - a hypotonic fluid
purposes.

Dextrose 5% in Hypertonic Replaces fluid  Watch for fluid volume overload

0.9% saline (560 mOsm) sodium, chloride,
D5NS and calories.
 Dextrose 5% in Hypertonic Useful for daily  Most common postoperative fluid
0.45% saline (406 mOsm) maintenance of
body fluids and
D5 1/2 NS
nutrition, and for
rehydration.

Dextrose 5% in Hypertonic Same as LR plus  Watch for fluid volume overload

Lactated Ringer’s (575 mOsm) provides about 180
D5LR calories per
1000cc’s.

Normosol Isotonic Replaces fluid and  pH 7.4

(295 mOsm) buffers pH  Contains sodium, chloride, calcium,
Normosol-R potassium and magnesium
 Common fluid for OR and PACU

TOP DRUGS

A
1. ACETAMINOPHEN (Tylenol)
 EFFECTS:
 Analgesic (mild to moderate pain)
 Antipyretic
 NO anti-inflammatory action
NO platelet action
 THERAPEUTIC LEVEL: 10 – 30 mg/dL
 ANTIDOTE: Acetlycysteine (Mucomyst)
 ADVERSE EFFECTS: hepatotoxic

2. AMINOGLYCOSIDES
 STREPTOMYCIN/ GENTAMYCIN
 Obtain Peak and trough level
o Peak level – 30 minutes after taking the drug
o Trough level – 30 minutes before the next dose
 Adverse effects:
 Neurotoxic
 Ototoxic  therapeutic to Meniere’s disease to relieve from vertigo (but this is the last resort because it will lead to permanent
deafness)
 Nephrotoxic  Monitor BUN

3. ANESTHESIA
 Epidural anesthesia  Spinal headache
 Spinal anesthesia  Hypotension

4. ANTICOAGULANTS AND THROMBOLYTICS

WARFARIN SODIUM HEPARIN
(Coumadin) (Hepalean)
Action Blocks prothrombin synthesis Blocks conversionof prothrombin to thrombin
Onset 2 to 5 days 30 seconds to 1 minute
 Use  Thrombosis and embolism  Thrombosis and embolism
 Atrial fibrillation with embolization  Prevention of clotting in heparin lock sets, blood samples and during
 Adjunct in treatment of coronary occlusion dialysis
 Treatment of disseminated intravascular coagulation
Route Oral SQ, IV
(DO NOT give IM, may lead to hematoma and pain)
Expressed in Milligrams Units
Antidote Vitamin K/ Phytonadione (AquaMEPHYTON) Protamine sulfate
Laboratory Prothrombin time (PT) Partial Thromboplastin Time (PTT)
Test Normal value:11 to 13 seconds Normal value: 60 to 70 seconds; 2 to 2.5 times the control
Activated Partial thromboplastin time (APTT)
Normal value: 30 to 45 seconds; 1.5 to 2 times the control
Usage Long term therapy Short term therapy
Effect Slow Quick

 Coumadin and Heparin CAN BE GIVEN together

 WHAT ARE THE DRUGS THAT ENHANCE THE EFFECTS OF ANTICOAGULANTS?

4A – Aspirin, Antihistamines, Alcohol, Antibiotics
5G – Ginseng, Garlic, Ginger, Ginko biloba, Guiafenesin

 ANTICOGULANT – prevents clot formation

 THROMBOLYTICS – dissolves clot
 USE: pulmonary embolism, coronary artery thrombosis, deep vein thrombosis, MI
 SIDE EFFECT: bleeding
 Start therapy as soon as possible after thrombus appears as thrombi older than 7 days react poorly to streptokinase
 Heparin is discontinued before streptokinase is started
 IM injections are contraindicated
 ANTIDIOTE: aminocaproic acid (Amicar)
 Examples: streptokinase (Streptase) – PROTOTYPE; alteplase (Activase), urokinase (Abbokinase), reteplase (Retavase),
tenecteplase (TNKase), anistreplase (Eminase)

5. ANTIDEPRESSANTS
 2 weeks interval in shifting from one type of anti-depressant to another
 Antidepressant effect: 2 – 4 weeks
 Tricyclic Antidepressants (TCA) – increases norepinephrine and/or serotonin in CNS by blocking the reuptake of norepinephrine by
presynaptic neurons
1. Imipramine (Tofranil)
2. Amitriptyline (Elavil)
 SIDE EFFECTS: hypotension, arrhythmias, blurred vision, constipation, urinary retention, dry mouth
 NURSING CONSIDERATIONS:
 Check BP and PR
 Give drug at BEDTIME
 Changing from TCA to MAOI, patient must discontinue TCA for 14 days
 2 to 4 weeks needed before the full therapeutic effect happens
 TCA OVERDOSE (anticholinergic toxicity):
o Coma, convulsion
o Ataxia, agitation
o Stupor, sedation

 Selective Serotonin Reuptake Inhibitor (SSRI)  inhibits CNS neuron uptake of serotonin, but not of norepinephrine
1. Fluoxetine (Prozac)
2. Sertraline (Zoloft)
 SIDE EFFECTS: hypotension, headaches, arrhythmias, insomnia, dry mouth, weight loss, sexual dysfunction
 NURSING CONSIDERATIONS:
o Give drug in the MORNING
o Takes 4 weeks for full effect
o Changing from MAOI to SSRI, patient must discontinue MAOI for 2 weeks
Changing from SSRI to MAOI, patient must discontinue SSRI for 5 weeks
o Monitor for weight
o Provide oral hygiene

 Monoamine Oxidase Inhibitor (MAOI) – acts as a psychomotor stimulator or psychic energizers; blocks oxidative deamination of
naturally occurring monoamines (epinephrine, norepinephrine, serotonin) causing CNS stimulation
1. tranylcypromine (Parnate)
2. isocarboxazid (Marplan)
 3. phenelzine (Nardil)

 SIDE EFFECTS: Hypertensive crisis – happens if the drug is taken with tyramine-containing foods
o Sweating Constipation
o Headache, HPN Orthostatic hypotension
o Urinary retention Photophobia, dilated pupils
o Nausea, Neck stiffness Agranulocytosis
o Tachycardia

 AVOID tyramine or tryptophan containing foods:

o Aged meat, avocado
o Banana, beans
o Chocolates, coffee, cheese (cheddar, aged, swiss), chicken and beef liver
o Drinks that are fermented (wine, beer)
o Smoked fish, soy sauce, sour cream, sausage
o Pickled foods (herring)
o Overripe foods
o Raisins
o Tea
o Yogurt, yeast

 ALLOW: cottage and cream cheese

 Monitor BP
 Therapeutic effect are achieved within 10 days to 4 weeks

6. ANTI-GOUT
 COLCHICINE (Novocolchine)  anti-inflammatory
o SIDE EFFECTS; diarrhea, abdominal cramps
o NURSING CONSIDERATIONS:
 DO NOT give IM or SQ, this may lead to irritation
 Administer drug after meals
 No more than 12 tablets should be given in a 24 hour period

 ALLOPURINOL (Zyloprim)  prevent production of uric acid by inhibiting the enzyme xanthine oxidose
o USE: prophylactic for attacks of gout; clients with calcium oxalate calculi
o SIDE EFFECTS: hepatotoxic

 PROBENECID (Benemid)/ SULFINPYRAZONE (Anturane) – uricosuric agents: reduces uric acid in the blood by increasing its
renal excretion

7. ANTI-PARKINSONS
 Dopaminergic Drugs (increase dopamine)
1. Amantadine (Symmetrel)
2. Levodopa (L-dopa)
3. Levodopa-Carbidopa (Sinemet)

 Anticholinergic Drugs (decrease Acetylcholine)

1. Akineton
2. Cogentin
3. Artane
4. Benadryl

8. ANTI-PSYCHOTIC (MAJOR TRANQUILIZERS)

 USE: Schizophrenia
1. Haloperidol (Haldol)
2. Chlorpromazine (Thorazine)
 SIDE EFFECTS:
 HYPOtension
 leukopenia (sore throat)
 NEUROLEPTIC MALIGNANT SYNDROME (HYPERthermia/ diaphoresis, HYPERtension)
 pink-red urine (normal: thorazine)
9. ASPIRIN/ SALICYLATES/ ACETYLSALICYLIC ACID
 EFFECTS:
 Antiplatelets  reduce risk of myocardial infarction and transient ischemic attack
 Anti-inflammatory  rheumatic fever, Kawasaki disease, rheumatoid arthritis
 Antipyretic  fever
 Analgesic  mild to moderate pain

 Aspirin toxicity
 Tinnitus – early sign of salicylism
 Metabolic acidosis – late sign of salicylism
 Epistaxis, nephrotoxic
 ANTIDOTE: activated charcoal (can also give Ipecac syrup to induce vomiting of aspirin)
 Give the drug with full stomach after meals
 Aspirin is ulcerogenic
 Monitor CBC, Prothrombin time, renal and liver functions
 DO NOT give with any anticoagulant (Coumadin, Heparin). It may cause additive effect, high risk for bleeding
 AVOID Aspirin in patients with viral infection to prevent Reye’s Syndrome
 AVOID Aspirin with OHA  causes hypoglycemia

10. ATROPINE SULFATE (Atropair, AtroPen)

 block neurotransmitter acetylcholine and inhibits parasympathetic actions
 USE: pre-op medication to reduce secretions and bradycardia; produces mydriasis
 CONTRAINDICATED in acute glaucoma, prostatic hypertrophy

B
11. BETABLOCKERS
 Example: propanolol (Inderal), timolol (Blocadren), pinolol (Visken), nadolol (Corgard), metoprolol (Lopressor), timolol maleate
(Timoptic)
 MODE OF ACTION: inhibit sympathetic stimulation of beta receptors in the –
 HEART – decreasing myocardial oxygen consumption and demand by:
 decreases heart rate and ***
 decreases force of myocardial contraction
 EYES – decreases intraocular pressure (IOP) by
 decreasing aqueous humor formation and increases aqueous humor outflow
 Change of position gradually
 Take pulse before taking drug***

12. BRONCHODILATOR
 USE: bronchospasms, asthma
 EXAMPLES:
 BETA-ADRENERGIC: abuterol (Proventil, Ventolin), metaproterenol (Alupent)
 XANTHINES: theophylline (Theo-Dur) – PROTOTYPE, aminophylline (Truphylline)
 THERAPEUTIC LEVEL OF THEOPHYLLINE: 10 – 20 mcg/ml (mg/dl)
 SIGN OF THEOPHYLLINE TOXICITY:
 Tachycardia
 nausea and vomiting
 FOODS TO BE AVOID
 ICE TEA – caffeine and caffeine containing foods because Theophylline is a xanthine derivative which has same effect with
caffeine

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13. DIAZEPAM (Valium)
 USE: Drug of choice for status epilepticus
 EFFECTS:
 Anxiolytic
 Anti-convulsant
 Muscle relaxant
 DO NOT MIX with other drugs
 DO NOT withdraw abruptly
 AVOID alcohol, smoking, activities that requires alertness
 May cause physical dependence
 Oral form should be given BEFORE MEALS
 Examples: alprazolam (Xanax), clorazepate (Tranxene), flurazepam (Dalmane), midazolam (Versed), triazolam (Halcion),
chlordiazepoxide (Librium), clonazepam (Klonopin), lorazepam (Ativan)

14. DIGOXIN (Lanoxin)

 Effects:
o (+) inotropic – increases FORCE OF CONTRATION  increase cardiac output
o (-) chronotropic – decreases HEART RATE  decrease oxygen demand of the heart muscles

 Digoxin toxicity – nausea, yellow color vision, arrhythmia, sign of hypokalemia (weakness, muscle cramps)
 Antidote: Digibind

15. DIURETICS
CLASSIFICATIONS SITE OF EXAMPLES INDICATIONS SPECIAL NURSING
ACTION INTERVENTIONS
Carbonic Anhydrase Proximal Acetazolamide (Diamox) Meniere’s disease,
Inhibitors tubule OPEN glaucoma
Loop Diuretics Loop of Furosemide (Lasix) Potent diuretic
Henle Bumetanide (Bumex)
Osmotic Diuretics Glomerulus Mannitol Increased ICP Warm solution to avoid
Osmitrol crystallization
Glycerin
Urea
Potassium Sparing Distal Spironolactone (Aldactone) Mild diuretic, CHF, Avoid potassium-rich foods
tubule Amiloride (Modiuretic, Midamor) HPN (banana, potatoes, spinach,
Triamterene (Dyrenium) broccoli, nuts, prunes,
tomatoes. Oranges, peaches)
Thiazide and Thiazide- Proximal Hydrochlorothiazide HPN (Not effective for
like tubule Chlorothiazide (Diuril) immediate dieresis)
Metolazone

 K-sparing: Spironolactone, Amiloride, Triamterene

 K-wasting: CAI, Loop, Osmotic Thiazides

NURSING INTERVENTION
1. Monitor blood pressure (first/ before) and weight (second/ after)
2. Administer in the MORNING
3. Administer with FOOD

EVALUATION: for effectiveness of therapy

 Weight loss
 Increased urine output
 Resolution of edema
 Decreased congestion
 Normal BP

H
16. HERBAL DRUGS that causs BLEEDING
 GINKO BILOBA
  GINGER
 GARLIC
 GINSENG

I
17. IMCI DRUGS: IRON
 1 dose daily x 14 days
AGE or TABLET SYRUP DROPS
WEIGHT Ferrous sulphate 200mg + 250 mcg Folate Ferrous sulphate 150 mg per 5 ml Ferrous sulphate 25
(60 mg elemental iron) (6 mg elemental iron per ml) (25 mg elemental iron per ml)
2 to 4 months THY 2.5 ml (1/2 tsp) 0.6 ml
(4 to <6 kg)
4 to 12 months 4 ml (3/4 tsp) 1 ml
(6 to <10 kg)
1 to 3 years ½ tablet 5 ml (1 tsp) 1.5 ml
(10 to <14 kg)
3 to 5 years 1 tab 7.5 ml (1.5tsp) 2 ml
(14 to <19 kg)

18. IMCI DRUG: VITAMIN A

VITAMIN A CAPSULES
AGE
100,000 IU 200,000 IU
6 months to 12 months 1 ½ capsule
12 months to 5 years 2 capsules 1 capsules

19. IMCI DRUG: MEBENDAZOLE/ ALBENDAZOLE

AGE or WEIGHT Albendazole 400 mg tablet Mebendazole 500 mg tablet
12 months to 24 months ½ or 200 mg tablet 1
24 months to 59 months 1 1

20. INSULIN
 MODE OF ACTION: decreases blood sugar by –
 Increasing glucose transport across cell membranes
 Enhancing conversion of glucose to glycogen

TYPE DESCRIPTION ONSET PEAK DURATION

RAPID-ACTING: Color: Clear 30 min – 1 hr 2 – 4 hrs 6 – 8 hrs
Regular, Humulin R Route: IV, SQ
INTERMEDIATE-ACTING: Color: Cloudy 1 – 2 hrs 6 – 8 hrs 18 – 24 hrs
NPH/ Neutral Protamine Hagedorn Route: SQ
(Insulin Isophane Suspension),
Humulin N
LONG-ACTING: Color: Cloudy 3 – 4 hrs 16 – 20 hrs 30 to 36 hrs
Ultralente (extended insulin zinc suspension) Route: SQ
Humulin U

 PEAK TIME – time of hypoglycemic episodes

 1ml of tuberculin = 100 units of insulin
 U100 insulin syringe is – 100 units
 Administer insulin in room temperature
 ROUTE: SQ
 Administer insulin at either 45 degree (for skinny patient) or 90 degrees (for fat patients)
 Area:
 Abdomen – fastest absorption
 Deltoid
 thigh
 buttocks
  AVOID:
 massage and apply compression (increase absorption)
 aspirate after injection
 shake. Gently roll vial in between palms
 Cold insulin  lipodystrophy
 STORAGE:
 In room temperature – last for 1 month
 Refrigerated once opened – last for 3 months
 ADJUSMENT OF DOSE:
 increase insulin requirement  Infection, Stress, Illness
 decrease insulin requirement  Breast feeding (Antidiabetic effect)
 Mixing of insulin: (Aspirate 1st – clear, Inject air 1st – cloudy)
(1) Inject air to NPH
(2) Inject air to Regular
(3) Aspirate Regular
(4) Aspirate NPH

 Most common used: U100 (1)

U40 (2)

21. IRON SUPPLEMENTS

 SIDE EFFECTS: dark stools (tarry stool), constipation, abdominal cramps
 Tablet: give with citrus juice (orange, tomato)
Liquid: give with citrus juice (orange, tomato) and straw
IM: Z-track method; DO NOT massage
 BEST given with empty stomach
 Citrus juice is AVOIDED with iron elixir preparation

L
22. LACTULOSE (DUPHALAC, CEPHULAC)
 Laxative
 SIDE EFFECT: ammonia binder (therapeutic to patient with hepatic encephalopathy)

23. LITHIUM
 Anti-mania
 Therapeutic Level: 0.5 – 1.5 mEq/L
 Lithium toxicity (n/c, anorexia, abdominal cramps, diarrhea)
 PREPARATIONS:
o Tablets: 300, and 450mg.
o Capsules: 150, 300, and 600 mg.
o Syrup: 300 mg/5 ml
 Maintain:
o increase fluid (3L/day)
o Increase Na (3 gm/day)

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24. MAGNESIUM SULFATE
 tocolytic agent
 USE: premature labor, anticonvulsants in pregnancy induced hypertension (PIH)
 Check:
o deep tendon reflex (DTR) – FIRST reflex lost with CNS toxicity
 o Check RR (at least >12 breaths/ min
o Check urine output (at least 30 mL/ hr)
 ANTIDOTE: calcium gluconate

25. METRONIDAZOLE (FLAGYL)

 Anti-amoeba
 AVOID alcohol (Metronidazole + Alcohol = Disulfiram-like effect)

26. MORPHINE SULFATE (Duramorph)

 EFFECT: induce sedation, analgesia and euphoria
 INDICATION: moderate to severe pain, pain relief in myocardial infarction
 DECREASES preload and afterload
 DECREASES workload
 SIDE EFFECTS of Morphine SO4
 Miosis
 Orthostatic hypotension
 Respiratory depression
 Produces tolerance and dependence
 Hyperglycemia
 Increase urinary retention/ constipation,
 Nausea and vomiting
 Euphoria
 Sedation/ dizziness
 Assess client’s pain before giving medication
 Check before and after the respiration
 May lead to tolerance
 FIRST SIGN of tolerance is decrease duration of effect of the analgesic
 AVOID activities that require alertness, alcoholic beverages, smoking, CNS depressants, sedatives, muscle relaxants
 Change position gradually

N
27. NITRATES AND NITROGLYCERINE (Nitro-bid, Nitrodur, Nitrostat IV)
 MODE OF ACTION: vasodilator
 USE: angina pectoris and hypertension
 SIDE EFFECTS OF NITRATES: headache, flushing, orthostatic hypotension, dizziness
 Other Related drugs: isosorbide dinitrate (Isordil), isosorbide mononitrate (Imdur)
 SUBLINGUAL form: 0.15 – 0.6 mg
 No more than 3 tablets should be taken in a 15 minute period (one tablet every 5 minutes); if pain not relieved after 15 minutes
and 3 tablets, notify physician immediately
 SIGN OF POTENCY: burning sensation under tongue
 Drink water first BEFORE taking drug
 OINTMENT
 applied to a hairless or clipped/ shaved area
 new site should be used with each new dose
 use ruled applicator paper that comes with ointment to measure dose
 wear gloves during application
 leave applicator on site and cover it with plastic wrap and secure it with tape
 TRANSDERMAL PATCH
 Apply a patch once a day only
 Rotate site
 Place patch in non-hairy area
 Determine a base region and remove the old patch
 Wear gloves during application
 IV form: 5 mcg/ min
 dilute IV nitroglycerine in 5% dextrose or 0.9% sodium chloride and titrate every 3 to 5 minutes
 STORAGE:
 store in original dark glass container in a cool, dry place.
 date bottle when opening
 discard after 6 months
  NURSING CONSIDERATIONS:
 Change position gradually to prevent dizziness
 HEADACHE is a sign that the drug is taking effect. It will discontinue with long term use.
 AVOID alcohol, hot baths
 Carry drug at all times
 DO NOT administer nitrates with sildenafil (Viagra), both drugs are vosadilator which may lead to HYPOTENSON

28. NONI JUICE

 Morinda citrifolia
 High in fibers

O
29. OCTREOTIDE (SANDOSTATIN)
 Inhibits GROWTH HORMONE, GLUCAGON, INSULIN
 2 formulations
 Sandostatin®is a short acting version
 Sandostatin LAR®is a long acting version.
 Sandostatin® is given by subcutaneous injection  It may be necessary to take the shot several times a day. The injection sites
should be rotated regularly. This medication may also be given intravenously.
 Sandostatin LAR® is given by intramuscular injection. This medication is generally given once every 4 weeks. The preferred site
for injection is the hip, because it is painful given into the arm.
 Sandostatin LAR® should NOT be given by S.C. or IV routes.
 COMMON SIDE EFFECT: constipation

30. OXYTOCIN (Pitocin)

 stimulate uterine contraction
 USE: postpartum bleeding, labor induction
 ADVERSE EFFECTS: uterine hyperstimulation, arrhythmias, tachycardia, hypertension
 Given IM or IV; IV via piggyback and delivered with an infusion pump
 Observe fetal hypoxia or distress

P
31. PANCREATIC ENZYMES
 USE: aid in digestion; cystic fibrosis
 Give WITH MEALS***
 Expected outcome of the drug is absence of steatorrhea
 EXAMPLES: pancreatin (Dizymes), pancrelipase (Cotazym)

32. PHENYTOIN (Dilantin)

 USE: seizure
 SIDE EFFECT: gingival hyperplasia, may turn urine pink, red, or red-brown
 ADVERSE EFFECTS: hepatotoxic, Steven-Johnson’s syndrome
 DO NOT administer IM
 Give drug with NSS BEFORE AND AFTER (flushing) drug administration
 Provide oral hygiene, Use soft, bristled toothbrush
 Takes 7 to 10 days to achieve therapeutic serum level
 Therapeutic level: 10 – 20 mg/ dl
 S
33. STEROIDS
 EFFECTS:
 Anti-inflammatory
 Hormonal replacement
 USE: USE: bronchial asthma, Addison’s disease, allergies
 Examples: hydrocortisone (Cortisol), prednisone (Strap red), dexamethasone (Decadron), methylprednisone (Solu- medrol),
betamethasone (Celestone)
 SIDE EFFECTS:
 Cushing’s syndrome
 Immunosuppression  therapeutic to AUTOIMMUNE DISEASES 9 like nephrotic syndrome, SLE, multiple sclerosis,
Rheumatoid arthritis, for organ transplant, hyperthyroidism, allergies)
 causes GI irritation and ulceration
 Long term: Adrenal insufficiency***, osteoporosis
 Short term: Immunosuppresant, hypokalemia, hypocalcemia, edema
 Give with food
 Watch out for infection
 Taper the dose (abrupt withdrawal may lead to acute adrenal crisis)
 Parenteral form: Give IM avoid SQ
Oral form: Give it WITH food or milk, may cause gastric irritation
Topical creams: DO NOT apply in broken skin and near eyes
 Administer in the morning (before 9 am); Take medication with breakfast (corresponds to biorhythms and reduces gastric irritation)
 Wear medic alert bracelet
 Isolation precaution
 AVOID sunlight, people with infections or crowded place
AVOID immobility to prevent osteoporosis
AVOID crowd
 DIET: Restrict sodium, alcohol and caffeine; high potassium foods
 Carry extra medication during travel.
 Adjust medications during periods of acute or chronic stress such as pregnancy or infections; contact health care provider.

34. SYMPATHETIC AND PARSYMPATHETIC

SYMPATHETIC PARASYMPATHETIC
SNS (Adrenergic) PNS (Cholinergic)
Dumping Syndrome, MG Glaucoma, GERD
Atropine Prostigmine
Cholinesterase Anticholinesterase
“fight or flight” response “Sleep and digest” response
(BIOAMINE THEORY) Acetylcholine – slowly release but long
Epinephrine (Adrenaline) – faster release but short acting acting
Norepinephrine
Dopamine
Serotonin
(Increase) HR, RR, BP (Decrease) HR, RR, BP
(Decrease) peristalsis, UO, secretions (Increase) peristalsis, UO, secretions
Pupil dilation (mydriasis) Pupil constriction (miosis)
Bronchodilation Bronchoconstriction
Hyperglycemia
Diarrhea
Urinary frequency
Miosis (constriction)
Bradycardia
Bronchoconstriction
Erection/ emesis
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Salivation
 T
35. THYROID AND ANTI-THYROID DRUGS
 THYROID AGONISTS – used to increase blood thyroid hormones
 LEVOTHYROXINE (Synthroid)
 USE: hypothyroidism (myxedema), cretinism (congenital hypothyroidism)
 SIDE EFFECTS: insomnia, tachycardia, diarrhea
 Taper the dose
 Monitor vital signs (temperature, BP, PR)
 Give the drug in the morning (due to insomnia side effect)
 CONTRAINDICATIONS:
 Cabbage, Cauliflower
 Peaches, Peas, Pears
 Raddish, turnips
 Spinach

 THYROID ANTAGONISTS – used to decrease blood thyroid hormones

A. ANTITHYROID DRUGS – inhibit synthesis of thyroid hormones
Examples: propylthiouracil (PTU, Propacil, Propyl-Thyracil), methimazole (Tapazole)
B. IODIDES – inhibit secretion/ release of thyroid hormone; decrease vascularity of the thyroid gland (for thyroidectomy
preparation)
Examples: Potassium Iodide Saturated Solution (Lugol’s solution)
 Give at least 10 day before surgery

 SIDE EFFECTS:
o agranulocytosis (sore throat)
o paresthesias
o bleeding (inhibits vitamin K)
 Taper the dose
 Monitor vital signs (temperature, BP, PR)
 AVOID iodine, iodine containing foods and sea foods
 ORAL form: dilute with water or juice (to improve taste) and use straw (to prevent discoloration)