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594 Cards in this Set

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must discontinue iodine containing med how long before thyroid scan?
1 week
Propylthiouracil (PTU) and Methimazole (Tapazole)
- stops thyroid from making hormone
- used preop
- goal is euthyroid (normal)
- ok in pregnancy
- 3x/day PTU
- 1x/day Tapazole
- agranulocytosis and hypothyroid side effects
Potassium Iodine (SSKI), Strong Iodine Solution (Lugol's Solution)
- decrease size and vascularity of gland to decrease risk of bleeding
- give in milk, juice, and use straw to prevent staining teeth
- dif from dietary iodine
- causes soreness in mouth also
Propanolol (Inderal)
- Beta Blocker- don't let you release epi and nor epi
- decreases myocardial contractility
- could decrease cardiac output
- decreases HR and BP
**do not give beta blockers to asthmatics or diabetics
**Decreases anxiety
Radioactive Iodine
- Given PO, usually 1 dose
- rule out pregnancy first
- Destroys thyroid cells
- expected to become hypothyroid after about 3 months, then have serial TSH
- radioactive precautions
* Watch for thyroid storm (thyrotoxicosis or thyrotoxic crisis), could be rebound effect of radioactive iodine
Radioactive precautions for radioactive iodine
- stay away from babies for 24 hours
- don't kiss anyone for 24 hours
Thyroid surgery can cause vocal cord ________, which leads to______
vocal cord paralysis

airway obstruction--> immediate trach
hypothyroid at birth
cretinism--> very dangerous, can lead to slowed mental and physical development if undetected (thyroid profile checked in hospital)
Hypothyroid pts have a tendency to also have?
post op thyroid removal
- HOB up to decrease edema
- nutrition--> increase calories
- assess for hoarsness/weak voice
- put personal items close as to not put tension on sutures
- teach to report any complaints of pressure
- trach at bedside
hypoparathyroid electrolyte levels
low serum calcium
high phosphate
hyperparathyroid electrolytes levels
high serum calcium
low phosphate
phosphoSoda and Fleet Enema
give to increase phosphate and lower calcium
Meds for hypercalcium
- phosphoSoda, Fleet Enema
- steroids
- Calcitonin (lowers serum calcium and puts it back in bone)
Meds for hypocalcemia
- phosphate binders- Renegel, PhosLo
- IV Calcium--> GIVE SLOW, watch for arrythmias!
- Calcium carbonate (Os-Cal)
Pheocromotytoma secretes
Epi and nor epi in boluses from adrenal medulla
VMA (vanillylmandelic acid) test
- 24 hour urine test for metnephrines
- no vanilla for about a week
- remain calm, no caffeine, no stress, no exercise, etc.
Adrenal medulla hormones
Epi and Nor Epi
Adrenal Cortex Steroids
Sex hormones
Glucocorticoids do what
- change mood (insomnia, depressed, psychotic, euphoric)

- alter defense mechanisms (immunosuppressed, infection risk)

- breakdown of fats and proteins

- inhibit insulin (hyperglycemia, do accuchecks-might need insulin)
Aldosterone--> make you retain Na and water and secrete potassium
Adrenocorticotropin hormones (ACTH)
made in pituitary ad stimulate cortisol

cortisol is made in adrenal cortex

too many steroid or too much ACTH = hypercortisolism
Addison's Disease
- not enough steroids- all three, but main is aldosterone
- shock risk
- high potassium
S/S of Addison's
- hyperkalemia signs
- Anorexia/Nausea
- hyperpigentation (bronzing) and vitiligo (white patchy areas)
- decreased Na
- hypoglycemia (lack of steroids)
Fludrocortisone (Florinef)
- weights daily
- frequent changes
- for Addison's (low aldosterone)
- keep weight within 2-3 lbs (+ or-) of their normal weight
Addisonian Crisis =
severe hypotension and vascular collapse
too much steroids (all 3). Think symptoms of increased gluco, increased sex, and fluid volume excess (mineral, aldosterone)
- hypokalemia
- increased cortisol levels
Pre treatment diet for Cushings
increased K
decreased Na
Increased Protein
Increased Calcium
What may be in urine of Cushings pt
ketones and glucose (NOT protein unless kidney damage)
why quiet environment for cushings
can't handle added stress, need removal of adrenal glands (1 or 2)
when u see polyuria think...
think shock first
Normal glucose level (fasting)
70-110 mg/dL
Metabolic syndrome
Syndrome X

- insulin resistence
- obesity
- increased triglycerides
- decreased HDL
- increased BP
Extreme blood sugar =
vascular damage
Glipizide, Metformin, Actos
oral anti-diabetic agents, only give to Type II
Illness in Diabetics=
IV push, like syrup, large bore IV

can also give injectable Glucagon if no IV access (IM)
Insulin decreases _____ and _____
glucose and potassium
IV fluids for DKA
NS then when glucose around 300 switch to D5W to prevent hypoglycemia

Potassium may be added eventually also
3 products that have a lot of Na
Alka Seltzer
Fleet enema
IVF with Na
Where is aldosterone found
adrenal glands (cortex)

- retain WATER and Na
ADH is found
- retain only WATER
ANP found where
opposite of aldosterone
causes secretion of Na and H2O
Normal specific gravity
1.016- 1.022 (Concentrated goes up)
Water deprivation test
neuro vs kidney test

hold water, give vasopressin
If it works, then neuro
Vasopressin or Desmopressin Acetate (DDAVP)
for ADH replacement or DI
not enough ADH--> diuresis

Diluted urine, Concentrated blood

Fluid volume deficient --> Shock
too many letters, too much water
decreased in UOP (urine concentrated)
Diluted blood

Fluid volume excess
Weighing patient rules
- same time
- same scale
- same clothes
- void before

**NOT SAME nurse
Fluid retention think...
think heart problems FIRST
Measure what when have ascites
abdominal girth (could have breathing problems from fluids pushing on diaphragm)
2 reasons for decreased urine output in fluid volume deficit
either not being perfussed or trying to conserve fluids
Pulse in fluid deficit and excess
both are up with is bounding in excess and thready and weak in deficit
Isotonic solutions
NS, LR, D5W, D51/4NS

called "crystalloid"
DO not use isotonic solutions in clients with-
HTN, cardiac disease, or renal disease

because the solutions can cause HTN and hypernatremia (with NS)
Hypotonic solutions
1/2NS, .33% NS, D2.5W

- does not cause HTN but rehydratres- goes into vascular space then goes into cells

- HTN, renal, and cardiac pts
or replacement for nausea, vomiting, burns, hemorrhage

- also used for hypernatremia and cellular dehydration

** watch for cellular edema, fluid deficit, and decreased BP
Hypertonic solutions
D10W, 3%NS, 5%NS, D5LR, D51/2 NS, D5NS, TPN, Albumin

- hyponatremia, 3rd spacng, severe edema, burns ascites--> will return it to vascular space

Called "Colloid"

- watch for volume excess, usually in ICU for monitoring
-think muscles first
- flushing, warmth (vasodilate)
- DTRs down, muscle tone down, arrythmias, LOC down, Pulse down, respirations down

- caused by renal failure and antacids
-think muscles first
- brittle bones, kidney stones
- DTRs down, muscle tone down, arrythmias, LOC down, Pulse down, respirations down

- caused by hyperparathyroidism, thiazides (retain calcium), immobilization
Normal magnesium levels
Normal calcium levels
8.6 to 10,6
- think muscles first

- increased muscle tone, seizure risk, strodor or laryngeospasm, swallowing problems, Chovstek's (cheek), Trousseau's (hand shakes with BP), arrythmias, increased DTRs, Mind changes (psychotic or depressed)

- causes: diarrhea (lots of MG in intestines)
Alcoholism** (suppresses ADH, and its hypertonic)
not eating or drinking
Monitor what when giving Mg

stop infusion if output drops

Seizure precautions (low Mg)
When giving calcium...
IV- give SLOWLY and put on cardiac monitor!!
- think muscles first

- increased muscle tone, seizure risk, strodor or laryngeospasm, swallowing problems, Chovstek's (cheek), Trousseau's (hand shakes with BP), arrythmias, increased DTRs, Mind changes (psychotic or depressed)

- causes: hypoparathyroidism, radical neck, thyroidectomy
Foods high in magnesium
veggies, seeds, and halibut
if pt starts flushing and sweating when giving IV mg, do what??
STOP infusion, could be normal but could be S/S of something worse
With sodium, think....
think neuro changes
Hypernatremia causes
- too much Na, not enough water

- hyperventilation
- heat stroke
- DI
Hypernatremia s/s
dry mouth
swollen tongue

neuro changes
Na is the only electrolyte that cares about...
Hyponatremia causes

- drinking only water for replacement from vomiting and sweating
- psychogenic polydipsia
- D5W (sugar and water)
hyponatremis S/S
- HA
- Seizure
- Coma

- neuro changes!
If having hyponatermia with neuro changes then pt needs...
hypertonic solution!

- 3% or 5% NS
- watch for fluid overload as it will draw water into vascular system as it gives Na
Feeding tube pts tend to become...
Hyperkalemia causes
- renal problems (K excreted by kidneys)
- Aldactone diuretic (retain K)
- Metabolic acidosis
Hyoerkalemia S/S
- begins with muscle twitching
- proceeds to weakness
- then flaccid paralysis

- life threatening arryhtmias!
Hypokalemia causes
- vomiting
- NG suction (lots of K in stomach)
- diuretics
- not eating
- muscle cramps
- weakness

- life threatening arryhtmias
ECG changes for hyperkalemia
bradycardia, tall and peaked T waves
prolonged PR interval, flat or absent P waves, and widened QRS, conduction blocks, V-fib
ECG changes for hypokalemia
U waves, PVCs, and ventricular tachycardia
Tx for hyperkalemia
- dialysis (kidneys aren't working)
- calcium gluconate (decreases arrythmias)
- glucose and insulin
- Kayexalate

- removing K puts pts at higher risk for increased Na since they are inverse relationship. so push fluids to prevent dehydration
Kayexalate worry
make sure pt has bowel sounds!!
Any time you give IV insulin worry about...
hypoglycemia and hypokalemia
Tc for hypokalemia
Give K
Aldactone (retain K)
Eat more Potassium
Major problem with PO Potassium
Gi upset, give with food
Assess what before giving K
Always give IV K on ...
a pump, never hang free. Prefer to put in central line instead of peripheral also

Foods high in potassium
veggies, fruit, tuna, halibut
Increase in CO2 S/S
decreased LOC (confused, sleepy, coma)

increase in CO2= decrease in O2
If pt restless think...
hypoxia first! Give O2 before the Ativan
Respiratory acidosis
O2 does not help!, have to blow of Co2 first! (deep breathing exercises, HOB up, incentive spirometer) or get rid of pneumonia, etc.
Acute aspiring OD can cause
respiratory alkalosis (aspirin stimulates resp center to breath more, like hyperventilation)
Metabolic acidosis causes and tx
DKA, starvation (ketones are acid), renal failure, severe diarrhea (lower Gi loss- bicarb)

tx: treat problem and can give sodium bicarb (1x IV push) for temporary fix

Metabolic alkalosis causes and tx
- upper Gi loss (stomach)
- too many antacids (too much base)
- too much IV bicarn (like in a CODE situation)


tx:fix problem and replace K
In burns, when is most edema (increased capillary perm)
first 24 hours
Epinephrine with burns
Epinephrine is excreted by body in order to vasoconstrict (because of fluid deficit from edema) in order to shunt blood to vital organs and bring BP back up
burn edema body compensatory thins
epinephrine, ADH, and aldosterone secretion in order to increase blood volume
SBP for adequate perfusion
how would carbon monoxide pt appear
cherry red but normal O2 sat because all it sees is that SOMETHING is on RBCs
Rule of Nines
Trunk front-18
Trunk back- 18
Leg- 18
Genital area- 1
Formula used if pt has more than 20-25% burns
Parkland formula
When start 24 hours after burn
first 24 hours is based on when the burn actually occurred NOT when treatment was started
Parkland Formula
4mL LR x kg body weight x % number for first 24 hours

albumin given later too
With burns,you would determine the clients fluid volume is adequate by?
Urine output (not daily weight because giving so much fluid, of course weight is gonna go up)

for things other than burns, weight is a good indicator
what type of water and other things can be used on burn pt to stop burning proicess
COOL water (not ice water!)

can use blankets to hold in body heat and decrease germs

remove jewelry to decrease swelling and metal gets hot

remoe non-adherent clothing and cover with clean dry cloth
In a client that is receiving fluids rapidly, what is best measurment to ensure not overloading?
Immunization after burns
Tetanus toxoid (active immunity, takes 2 weeks)

Immune globulin ((immediate protection, passive immunity)
If urine is brown or red after burn?
call MD so dr can flush out myoglobin--> Mannitol would do this (monitor closely for fluid deficit, when pee clear call Dr immediately to stop Mannitol)
about 48 hours after burn pt will...
start to diurese as fluid goes back into vascular space, NOW worry about excess
Curling's ulcer
burn related ulcer
what give to prevent Curlings ulcer
Mylanta, Protonix, Pepcid

Amphogel, Milk of Magnesia, Zantac, Pepcid, Axid, Nexium
Gi risk in burns
ulcer and paralytic ileus (pt NPO and NG)

NG will be removed when hear bowel sounds
Travase, Santyl
enzymatic drugs for burns that eat dead tissue

don't use on:
- face, pregnant, over large nerves, open body cavity
soothing, apply more if comes off, can lower WBC, can cause rash
stings, apply more if rubs off, can cause acid base problems
Silver nitrate
keep dressings wet, can cause electrolyte problems
atings, stains, allergies, acid-base problems
electrical burn
- first 24 hours on cardiac monitoring (Vfib risk)
- renal damage from myoglobin and hemoglobin
Chemical burn
- flush for 15-20 min or dust off powder then flush
Female prevention screenings
- monthly breast exams over 20 yo (day 7-12)
- Yearly MD breast exam over 40, 20-39 every 3 years
- annual pelvic exam
- pap smear every 4 yrs if no problem
- mammogram yearly starting at 40
(no deo, pwdr, lotion)
- colonoscopy at age 50 then every 10 yrs

- no sex or douche prior to pap smear
Male prevention screenings
- Monthly breast exam
- monthly testicular exam (15-36 esp)
- yearly digital rectal and yearly PSA for over 50
- colonoscopy at 50 and every 10 yr
extreme wasting and malnutrition
How to prevent dislodgement of radioactive implants
bed rest, decrease fiber, prevent bladder distention (foley)
is radioactive pt immunocomprimised?
YES! private room if possible and non-infectious for sure
If chemo drug is a vesicant...
then have to stay with pt the whole time

extravasation--> STOP infusion, ice packs so it does't spread (THINK vasoconstriction!)
Radioactive and chemotherapy length of "worry"
Radioactive- 24-48 h

chemo- 48 hours )waste is hazardous, eash linens x2 and special bag, flush toilet x2)

*****Bleeding precautions in cancer pts because of pancytopemia!!
some infection prevnetion for immunocompormised (cancer pt)
- change IV tubring q 24h
- no fresh flowers or plants
- bath warm, moist areas 2x/day
- avoid raw fruits and veg
- wash hands after pets
- frewsh water only (less than 15 min sitting out)

**absolute neutrophil count is most important!! and slight temp increase = sepsis!!
Classic S/S for cervical cx
painless vaginal bleeding

- may also have watery, blood tinged discharge, pelvic pain (may occur with intercourse), leg pain alon sciatic nerve, and flank/back pain

100% curable if caught early
if have abnormal pap smear...
repeat it!
removal of part of cervix
Uterine cancer risks
greater than 50
estrogen without progesterone
no pregnancy
late menopause
uterine cx s/s
after menopausal bleeding (50% chance of cancer if this happens)
rules out ovarian cancer involement
Most difiniative dx of uterine cx
TAH- total abdominal hysterectomy
uterus and cervix only
Radical hysterectomy
ALL pelvic organs

- greatest time for hemorrhage for first 24 hours (pelvic congestion of blood)
- Avoid high fowlers (suture tension and makes blood go to pelvis even more)
- may have abdominal and perineal dressings
major complication after abdominal hysterectomy
hemorrhage (pt can hemorrahge 10-14 days after surgery still!!)
major complication of vaginal hysterectomy
chemo, cardio toxic
Plantinol AQ
Chemo for uterine cx
Depro-Provera, Tamoxifen
estrogen inhibitors (uterine cx)
Tail of Spence
almost half of breast cancers located here in the upper outer quadrant
Post op masectomy
elevate arm on affected side
stay away from affected arm side FOREVER! (no constriction of ANY kind)

have pt brush har, squeeze ball, wall climbing, fles and extend elbow of affected side
- have pt look at incision, see if they can
Taxol, Adriamycin
chemo for breast cancer (adriamycin is cardio toxic)
Tamoxifen, Lupron, Zoladex
for breast cancer, estrogen inhibitors or blockers (breast tumors are estrogen dominant)
lung cancer and TB
Tb has night sweats
after bronchoscopy has respiratory depression...
perforated airway? EMERGENCY!! RR may be lower but not under 12 (abnormal)!
sputum specimen
first thing in moring, sterile, rinse pt mouth first to decrease bacteria in mouth
remove part of lung

Chest tube and surgical side up!
remove entire lung

- position ON affected side (good lung up so it doesn't fill with fluids!)
- no chest tubes
- avoid severe lateral positioning (mediastinal shift)
Total laryngectomy
removal of vocal cords, epiglotis, thyroid--> perm trach

- position in highest position but NOT high fowlers (rarely choose high fowlers). semi fowlers is good (30-40)
complication of total laryngectomy
carotid artery rupture (nicked)- watch drains

Bloom-Singer device
connection is made between trachea and esophagus, keep it clean and mucus free
handheld device held up to clients cheek or neck
if vagus nerve is activated with suctioning, is the pt hypoxic?
no, because HR goes bradycardic in vagus and hypoxia causes tachycardia
Most frequent site of metastasis of colorectal cx
liver (same blood supply)
flexible sigmoidoscopy frequency
every 5 yrs after age 50 (or colonoscopy every 10 yrs after age 50)
Gi onstruction s.s
visible peristalsis, high pitched tinkling bowel sounds
Dont take rectal temp if?
thrombocytopenicm abdominoperineal resection, immunocommpromised
major symptoms of bladder cancer
painless intermittent gross/microscopic hematuria
ileal conduit
made from intestines, increase fluids, change appliance in morning before pt starts drinking alot
#1 place for prostate metastasis
bone--> alkaline phosphatase increases if gone to bone (likes to go to spine, sacrum, pelvis)
acid phosphatase also increased with bone metasisis
most common sign of prostate cancer
painless hematuria
PSA normal levels
less then 4ng/mL
frequency of PSA
if you have two or more 1st degree relatives with prostate cx, start by age 45
pudendal nerve damage
can cause erectile dysfunction with radical prostectomy (nerve will try to be conserved if there is no lymph involvement, no increase in acid phosphatase, and no metastasis)
TURP (prostectomy)
usually reserved for just benign prostatic hypertrophy, most common complication is bleeding, but some bleeding is normal

-continuous bladder irrigation to maintain patency and flush out clots (can affect kidneys)
***never manually irrigate an catheter with fresh surgery without a specific order

- when cath removed watch for urine retention
Belladonna and Opium Suppository (B&O Suppository) and Oxybutynin
given for bladder spasms
If pt has pain would u assess for kinks or bladder distention first?
bladder distention-assess actual pt first!
decreases testosterone for prostate cx (can also have bilateral orchiectomy-testicle removal)
high risk for stomach cx
hy pylori, pernicious anemia, achlorhydrai (no stomach acid)

- pickled foods, salted meats/fish, nitrates, increased salt

-billroth II (partial gastrectomy with an anastomosis)

-tobacco and alcohol
Treatment for obstruction
NPO, NG tube to suction for abd decompression
Schillings test
measures urinary excretion of Vit B12 for diagnosis of pernicious anemia
5-FU, Adriamycin, Mitomycin-C, Platinol-AQ
The 5 P's
Pulselessness, Pallor, Pain, Parasthesias, Paralysis
Are palpitations normal after cardiac cath?
bed rest after cardiac cath
bed rest for 4-6 hours

Report pain ASAP! (hematoma, and bleeding)
CPK-MB time frame
elevates in 3-12 hours and peaks in 24hrs

cardiac specific
T and I
Elevates within 3-4hrs and remains elevated for 3 weeks
Normal troponin levels
T <.2
I < .03
increases within an hour and peaks at 12 hours

not cardiac specific, any muscle
If negative, then no muscle damage, including heart
Lidocaine toxicity
think neuro changes
used for V fib and fast arrythmias

Lidocaine can also be used to prevent second episode, or amiodarone

can cause hypotension which can lead to further arrythmias
why put head up on MI pt?
decreased cardiac workload and increased CO
Streptokinase, t-PA, TNKase, Retavase

- want within 6-8 hours of MI pain onset
- brain is within 3 hours
Absolute contraindications of fibrinolytics
intracranial neoplasm, intracranial bleed, suspected aortic disection, internal bleeding of any kind
Aspirin, Plavix, RReoPro IV
anti platelet drugs
If chest pain after PCI (percutaneous coronary intervention)
call Dr immediately! need to go back to OR!
Pcemakers are used when?
symptomatic bradycardia
Always worry if the rate goes_____ if pt on a pacemaker
down, should never decrease!
loss of capture
no mechanical event or contraction

- may not be programmed properly, electrodes and be dislodged, or battery depleted

watch for a decrease in Co or decreased rate (most conclusive)
Killer combination of Pulmonary artery placement (swanz ganz)
air embolus --> pulmonary infarction
A line rules
never put medicine in it, placed in radial, Allen's test done (want positive), make sure stop cocks are in right position
must be turned off for 2 hours prior to drawing BNP (will cause false high)
used with HF and A-fib

strengethens contraction
decreases HR to given ventricles more time to fill
leads to increased cardiac output
Digoxin normal values
.5-2 ng/mL
Digoxin toxicity s/s
anorexia, N/V

arrythmias and vision changes late

****hypokalemia increases toxicity risk!!
K sparing and decreases aldosterone levels too
Report a weight gain of...
2-3 lbs
Ace inhibitors

used for HTN and HF
watch for hyperkalemia, angioedema (laryngeal swelling), non productive cough (reversible after stop med), renal dysfunction

used for HTN and HF
-watch for hyperkalemia, hypotension, and renal dysfunction
Beta blockers

used for angina, chest pain, HTN, ventricular dysrhythmias, and thyroid storm

- don't given to asthmatics or diabetics
causes diuresis and vasodilation to decrease preload and afterload

- 40 mg IV push over 1-2 minutes (SLOW) to prevent HTN and ototoxicity
1-2 mg IV push over 1-2 minutes, diuretic
vasodilation to decrease afterload
short temr therapy, not longer than 48 hours

stop for 3 hours before pulling blood for BNP

has a diuretic effect
continuouse infusion

vasodilates veins and arteries
increass CO
Cardiac tomponade CVP and BP
increased CVP and decreased BP (opposite of what normally happens)

Neck veins distended cause they can't empty into heart
Pulsus Paradoxus
BP is greater than 10mm higher on expiration than incpiration

a S/S of cardiac tomponade (increased pressure on heart in inspiration)
Narrowed pulse pressure
worry if 30 or below (or 40 or under?)

results from decreased contraction
Acute arterial occlusion (numb, pain, cold, no pulse)
A medical emergency!!!
Intermittent claudication
hallmark pain, only have this with ARTERY problems
Rest pain in arterial obstructions
indicates a SEVERE obstruction, medical emergency!!
Dangle____problems, elevate_____problems
artery, venous
After AAA and decreased in lower pulses
call MD!!!
Buerger's disease
inflammation of veins adn arteries, men, heavy smoking, cold, emotions

causes vasoconstriction

usually lower extremities and sometimes fingers
Reynaud's disease
female, bilaterally in finger tips

white, blue, red

can cause gangrene
DVT, give oxygen?
no, oxygen does not help!
aPTT, PT, and INR normal values
aPTT- 30-40s
OT- 11-12.5s
INR- 1.3-2
anticoag med (like warfarin, plavix, etc.)
limit foods with ? with DVT and o blood thinners
Vitamin K, no more than 3x/week
with known clot, put what on area?
warm, moist heat to decrease inflammation

** never cold on a vein and never hot on a vein!!

If there is something the nurse can do before calling Dr, do it!
A good nursing dx for schizophrenia
alteration in communication
how to rechannel anger (suicidal)?
the most exerting answer there is
last resort
check every 15 min
hydration, nutrition, elimination

observation at 15-30 min intervals or one on one if client cant contract for safety
Meds that can be given for OCD
Stages of alcohol withdrawal
Stage I- mild trmors, Nausea, nervousness

Stage II- increased tremors, hyperactive, nightmares, disorientation, hallucinations, increased pulse, increased BO

Stage III- most dangerous, severe hallucinations (visual and kinesthetic), grand mal seizures

II and III are DT's (withdrawal delirium)---keep the light on! they are scared, don't want them to injur themselves

stage I and II walk and talk to them

**Don't be araid to given an anxiolytic!, they can handle meds every 2 hours
Korsakoff's syndrome
chronic problem after detox

disoriented to time, confabulates
Wernicke's syndrome
chronic problem after detox

emotions labile, moody, tire easily
S/S of alcoholics also
peripheral neuritis (b vitamin deficiencies)

liver and pancreas, impotence, gastritis

Mg and K loss

many deny and rationalize
Deterrent to drinking (bad reaction with alcohol so have to agree to not have ANY of ANY kind)
panic disorder symptoms will peak when?
10 minutes
ECT (electro-convulsive therapy)
- void
- atropine to dry secretions
- signed permit
- series of txs
Succinylcholine Chloride to relax muscles

* postiion pt on side afterwars, stay with client as they are scared and confused, temp memory loss (reorient), make sure family knows they will be confused, involve pt in days activity as soon as possible

** always check for injury after procedure!
Elavil, Pamelor, Tofranil

risk of OD, not first choice anymore, anticholinergic side effects

for OCD and depression
Luvox, Celexa, Prozac, Effexor, Paxil, Lexapro

less S/E
HA, increased sweating, blurred vision, weight gain, sexual side efects
Parnate, Nardil, Marplan

causes HTN crisis with foods with tyramine

Avoid: aged cheese, avocados, raisins, beer, red wines, no OTC cough meds contaiin ephedrine or ephedrin-like
Serotonin syndrome
muscle spasms
muscle rigidity

St johns wart increases risk as well as more than one med
valium, ativan, xanax, flurazapam, librium

-sedation, dizziness, constipation, raise seizure threshold, relaxes client

non benzo- Buspar
Tegretol, Depakote, Neurontin, Lamictal, Trilecliental

good for manic states

S/E: drowsiness, vertigo, blurred vision, unsteady gait

Lithium (anticonvulsant, for mood stabalization)
Normal level- .6-1.2
up to 1.5 for acute states

>2 = TOXIC

S/S: hand tremors, N/V, slurred speech, unsteady gait, life threatening

Keep food, fluid, exercise constant. If changes, lithium levels change (salt?)
Glomerulonephritis cause
strep or other infections
Glomerulonephritis S/S
fluif volume excess (facial edema, BP up)
urine specific gravity up (concentrated) and decreased UOP

flank pain, sediment, protein, blood in urine (rusty, coca cola), BUN and creatinine up, malaise and HA (toxins), sore throat

diuresis will begin in 1-3 weeks after onset, could lead to renal failure (s/s are toxins plus fluid)
Fluid replacement for glomerulonephritis
24 hour fluid loss plus 500 mL (to account for insensible losses)
Diet changes for glomerulonephritis
decrease protein, decrease Na, increase carbs for energy
Nephrotic syndrome description
glomerulous but with a lot of protien loss leading to major edema and alodosteroine cycle kicking in and making it worse
TOTAL body edema
Problems associated with high protein loss
blood clots (dehydrated and losing proteins/clotting factors)

Cholesterol and triglycerides up as liver tries to produce proteins
tx for nephrotic syndrome
diuretics, ace inhibitors to block aldosterone, prednisone to decrease inflammation (shrink protein holes)--> immunosuppression!, lipid lowering meds, lower Na, INCREASE protein, anticoagulants for 6 months, dialysis if needed
Meds that causes intrarenal failure
Aminoglycosides, mycins (nephrotoxic)
Specific gravity in renal failure
intitially concetrated with decreased UOP

but as kidneys lose ability to concentrate and dilute urine it will be fixed no matter hwo much fluids are given (fluid challenge of 250mL)
why anemia in kidney problems?
no erythropoetin
what electrolytes/acid base problems with renal failure
hyperkalemia (retain)
metabolic acidosis
hyperphosphatemia (retain)
Oliguric phase
1-3 weeks
UOP of 100-400ml/24 hours (would be a good time to do a fluid challenge)

fluid volume excess and hyperkalemia
Diuretic phase
increase in UOP
fluid volume deficit--> shock
nurseing care if pt has vascular access (dialysis)
no BP, no needles sticks, no contriction to arm of ANY kind!
Tenckhoff catheter
for paritoneal dialysis
Continuous abulatory peritoneal dliaysis (CAPD)
manual exchange, 4x/day, 7 days a week, fluid causes pressure on back, can't do if have a colostomy (high risk for infection!)
Continuous Cycle Peritoneal Dialysis (CCPD)
connected at night onle, may have trouble sleeping or may not have insurance to pay for this machine
complications of peritoneal dialysis
#1- cloudy effluent- peritonitis!
constant sweet taste (fluid has glucose in it)
altere body image/sex
anorexia (constant sweet taste can affect this)
low back pain
diet of peritoneal dialysis pt
increase fiber (decreased peristalsis because of abd fluid)

increased protein (lose protein through peritoneum with each exchage)
CContinuous renal replacement therapy (CRRT)
24h/day, 7days a week
never more than 80mL out of body at one time
on pt with fragile cardiovascular system and acute renal failure (very sick pts)
if you suspect a kidney stone...
get a urine specimen and have it checked for RBCs

If stone present, immediate pain meds (not imagery, etc.)
Toradol, Zofran, Dilauded
meds used for kidney stones
Pancreatitis pain
increased with eating
Rigid boardline abdomen =
think bleeding first, but can also be peritonitis
Cullen sign
bruising around umbilicus (pancreatitis)
Gray Turner's sign
brusiing in flank area (pancreatitis)
pt with pancreatitis gets hypotension from...
asites or bleeding
Peritoneal lavage results
if pink tinged = bleeding
Normal Amylase levels
45-200 U/L
Normal lipase levels
0-110 U/L (more specific)
Pancreatitis labs
- increased lipase and amylase
- increased WBCs
- Increased blood sugar (beta cell destruction)
- ALT, AST increased (liver involved and bleeding)
- Prolonged PT, PTT
- Increased bilirubin
- Increased or decreaed H and H (dehydration OR bleeding)
With pancreas client keep stomach...
dry and empty! (NPO, NG to suction, bed rest to decrease secretions, antocholinergics (cogentin, lonox/atropine), protonix, santac, pepcid, antacids

Also given steroids to decrease inflammation
Why would a pancreatitis pt need insulin?
beta cell destruction
If lier is sick, number one concern is
Never give _____ to liver pts
When spleen is enlarged...
the immune system is involved
ammonia =
Position during liver biopsy
supine with R arm behind head, exhale an hold to get diaphragm out of way during biopsy (only like 2 sec, not 30s)
Post liver biopsy position
lie on R side, can have pillow under there too, worry about bleeding, check vitals
have client void to move bladder
position sitting up
vitals sign (removing fluids, shock risk)

avoid narcotics (liver can't metabolize)
flapping of hands from ammonia (hepatic coma)
ammonia breath
What 2 things will also increase ammonia?
Protein and blodd (old GI blood)
any time pt is anemic...
give oxygen
Sengstaken Blakmore tube
hold pressure on varices

make sure to tape an dmark
may need restraints if confused
lowers BP in liver
After gastroscopy watch for...
pain, bleeding, or trouble swallowing
Upper Gi series avoid
NPO past midnight
smoking also increases moticile and secretions which will alter test--> stop them if you see them smoking, it is an aspiration risk!!
Need to follow peptic ulcer pts for?
a year
S/S of gastric ulcers
laboring pt, malnourished, pain half hour to hour after eating, food doesn't help, vomiting does, vomit coffee ground blood
S/S of duodenal ulcers
executives, well nourished, night time pain commona and 2-3 hours after meals, food helps, blood in stools (black, tarry)
S/S of dumping syndrome
fullness, palpitations, faintness, weakness, cramping, diarrhea
lay on what sude to keep food in stomach?
left side
dumping syndrome tx
semi recumbent with meals, lie down after meals (left), no water with meals, decrease carbs
Rebound tenderness =
peritoneal inflammation (ulcerative colitis, Crohns, appendicitis)
Colonscopy pre care
clear liquid for 12-24 h
NPO 6-8h
Avoid NSAIDs
laxatives and enemas until clear (watch pts, hard to handle)
Gl-Lytely 8oz every 10 min, may need to give antiemetic and serve cold, NO straw (air)
post colonoscopy care
WATCH for perforation!!
never ignore pt complaint, send for US to chack for free air or perf
Diet for ulcerative/Crohns
low fiber to limit motility and conserve fluids
Kocks ileostomy
nipple valve that opens and closes to empty intestines (for ulcerative colitis) (no external pouch)
J pouch
removes colon and attaches the ileum into rectum (no external pouch)
If giving enema...
put ot on left side
stop and check fluid temp if pt complains (same for irrigations)
Best time to irrigate colostomy
same time every day, and after a meal

(bowel training)

**ONLY irrigate descending and sigmoid colostomies

want pt lying flat if possible and stop if complains and check temp of irrigant
Position of pt waiting for appendectomy
right side and sitting up just in case it ruptures
first sigsn of appendicitis
first abdominal pain, then N/V
Enema for appendicitis?
do not do, worried about rupture, tell surgeon you are nervous about doing that
TPN care
- keep refrigerated but room temp before use
- central line needed
- filter needed
- nothing else in that line
- dicontinue gradually (to prevent hypoglycemia)
- may need to be on insulin
- daily weights
- accu checks q 6h
- check urine for glucose and ketones
- can be hung for 24 hours
- change tubing with each new bag
- on a pump
- handwashing if at home (high infection risk!)
#1 TPN complication
If ketones in TPN urine pt
needs more lipids in TPN
Would there be proteins in TPN pt urine?
only if there is kidney damage
Central line plaement pt position
If air gets in line what position for central line?
left side, trendelenburg
do what before adminstering meds, etc in central line???
xray- check for pneumothorac and placement
Cushing triad
(increased ICP)

- HTN, bradycardia, irregular resp, widening PP
Occulocephalic reflex (Doll's eyes)
want a positive doll eye reflex (means eyes should move in opposite direction as moing head, only works for unconscious pt)
Ice cold water calorics (oculovestibular reflex)
assesses brain stem

50mL cool water in ear
eyes will move to irrigated ear and back (positive)
put pt on side and elevate head (unless contraindicated) before leaving, may cause nausea
Babinski or plantar reflex
Want positive babinski <1yr (flare toes)

Want negative >1 year old (toes curl)
can talk in MRI
no pacemakers or jewelry in MRI (magnetic and MRI will make pacemaker stop working right)
old tattoes may matter (lead) for MRI

no radiation in MRI
bed rest after cerebral angiogram
4-6 hours (same femoral area used as in heart cath)
major complication of cerebral angiogram

can go anywhere! but brain emboli would show change in LOC, weaknes, paralysis, motor/sensory deficits
Can't have what beofre EEG?
hold sedatives, no caffein, NOT NPO (this would drop blood sugar)
Where is lumbar puncture performed?
3rd-4th lumbar subarachnoid space
client position for lumbar puncture
head down, propped on table
lie on side in fetal position
Complication of lumbar puncture
meningitis (fever, chills, positive kernig and brudinski, vomiting, nuchal rigidity, photophobia)

- most common is HA (increases with sitting up and decreases with lying down)--> treat with fluid, pain meds,and possible blood patch

-brain herniation
positive kernig sign
can't fully extend raised knee/leg when pt supine
positive Brudzenski sign
when neck flexed, knees and kips flex
post lumbar puncture
lie flat for 2-3 hours and increase fluids
Basal skull fractures s/s
battles sign (mastoid bruising)

raccoon eyes (periorbital)

cerebrospinal rhinorrhea (no blowing nose, no sticking anything up there, let flow freely)
Signs of increased ICP
difficult awakening/speaking, confusion, severe HA, vomiting, pulse changes, unequal pupils, one side weakness
Epidural hemoatoma
injury, loss of consciousness, recovery period, can't compensate, neuro changes
Subdural hematoma
VEIN, acute, subacute, chronic

slow bleed may be mistake for drunk or DM
spinal cord injury above T6 worry about
hyperreflexia, autonomix disreflexia
autonomic disreflexia
HTN and HA, bradycardia, nasal stuffiness, flushing, sweating, blurred vision, anxiety, sudden onset, emergency due to HTN and stroke risk
causes adn tx of autonomic disreflexia
distended bladder, constipation, painful stimuli, cold draft, pressure ulcers, etc.

Tx: sit pt up to lower BP, treat the cause!
Steroid do what to ICP
decrease ICP
why no restraints in pt recovereing from coma
restraints increase ICP!

need quiet environment, seizure precautions
Normal ICP
< or equal to 15
Additional signs of increased ICP
- earliest sign is change in LOC
- change in speech
- resp pattern chances (cheyne stokes, ataxic respirations)
- increased drowsy
- mood changes subtle
- quiet to restless
- absent reflexes
- pupil changes
- projectile vomiting
pupils in profound coma
fixed and dilated
arched spine, plantar flexion (WORST)
toward "core"
arms flexed inward, legs extended with plantar flexion
Glasgow scale normal
want like 13-15, intubate if less then 8
for increased ICP

increases circulating blood volume and icnreases work load of heart

* watch for crystalizing in tubing and fluid volume excess
Steroid to decrease cerebral edema
to decrease ICP, may set respirations to...
hyperventilation, to keep CO2 on low side, don't want it tooo low with will cause vasoconstriction in brain
goal temp for ICP pt
less than 100.4 (may need cooling blanket if hupothlamus not working right)
barbituate induced coma to decreased cerebral metabolism
head position for ICP
elevated and midlin (JV drainage)
fluids for ICP
restrict to 1200-1500 ml per day
Vitals to watch for in ICP
bradycardia and increased BP (blood not pumping enough volume or increased pressure which will decreased cerebral perfussion)
If a pt can't sit up for thoracentesis, what position should they be in
lie on unaffected side with HOB 45 degrees
chest tube placement for removal of air
2nd intercostal space
chest tube placement for fluid removal
8th or 9th intercostal space
What type of bubbles in the water seal chamber
intermittent and fluctuation/tidaling ok
continuous not ok (possible air leak)
If nothing, then expanded or kinked or dependent loop

has 2 cm of water

If tidaling stops= expanded
Suction control chamber bubbling
should have slow, gentle, continuous bubbling

20 cm of water or knob turned to 20 cm if dry system. turn wall suction up till have slow, gentle, continuous bubbling but otherwise wall does not control suction, 20 cm do.
Notify physician if draininage is what?
>100 ml of drainage in 1st hour and if there is a change to bright red
Tension pneumo s/s
subcu emphysema, absence of breath sounds on affected side, asymetry of thorax/trachea, respiratory disease

emergency!! cause of decrease in CO
if pt has open pneumo (sucking chest wound) positioned?
if can, sit up to expand lungs, but if trauma pt they eed to say flat till other injuries evaluated
If pt has broekn ribs/sternum, what meds?
NON narcotic pain meds as to not suppress RR. its hard for them to breath already, don't use chest binders or immobilizers (can lead to pneumo or flail chest)
bi level positive airway pressure

used a lot with COPD, HF, sleep apnea

exerts dif levels on insp and exp

may be used in vent weening
Continuous Positive Airway pressure

constant pressure for insp and exp

used for obstructive sleep apnea
Anytime you see PEEP, CPAP, BiPAP, your priority nursing assessment is?
Checking bilateral breath sounds
Right sided HF can be caused by...
pulmonary embolism
Will O2 help PE?
NO, with pulm embolism, O2 can't get to needed area
D Dimer
increased if clot anywhere in body, not just if pt post op, this will already be up!
If PE, CXR will show...
Splints help what?
fat emboli and muscle spasm
Most important thing with ortho injuries
neurovascular checks (pulse, color, movement, sensation, capillary refill, temp)
Fat embolism s/s
petechia or rash over chest
Conjunctival hemorrhages
snow storm on CXR
young mails (risk takers)

*FIRST 36 HOURS* After this, can get other embolism though!!
Common bones for fat embolism
long bones, pelvic frractures, crushing injury

same bones increase risk of hypovolemia
Compartment syndrome
fluid accumulation in tissues, muscle swells and hard, pain NOT relieved with pain meds

pain is disproportional to injury

if undetected can cause nerve injury
Common compartment syndrome areas
forearm and quad

can be from fracture or burns
tx for compartment syndrome

soft cast then rigid

loosen cast to restore circulation (better have a horrible neurovasc check to actually remove whole cast)

If pt has pain and in cast what to assess?
neurovascular check, 5 P's

If neurovascular check ok, then give pain meds
skin traction
short term for immobilization and prevent muscle spasms until surgery

do good skin assessments (its tape like)
pin cleaing for skeletal traction
steril, remove crusts, serious drainage is OK
Any time you have someone with an orthopedic or joint injury they need what?
a firm mattress
post op hip replacement
no weight bearing until MD says

avoid crossing legs or bending over (no flexion)

dont sleep on operated side till dr says

don't given injectable pain meds in operation side

prevent external rotation with trochanter roll

tense and squeeze muscles

want abduction (keep hips apart)

neutral toes, to the ceiling

no lifting HOB (flexion)

*teach pt that stresses to hip need to be minimal in first 3-6 months
dislocation s/s
shortening of leg, abnormal rotation, cant move extremity, PAIN
best exercise for hip replacement pt
1- walking
2. swimming

rocking chair
where to NOT store CPM (continuous passive motion)
on the floor --> infection!
total knee replacement post op
CPM to prevent scar tissue

neer hyperextend or hyperflex knee

neuro checks

pain relief

tell fam not to touch CPM machine
amputation post op
want extension to prevent contractions

only elevate for SHORT time if going to as this will cause contractions

do not elevte on pillow, elevate whole foot of bed

make sure limb lies copleely flat on bed

if BKA, prone positiong to extend hip and knee

limp sock for edema and hemorrhage reduction first then for shaping
phantom pain tx
diversion al activities first, seen more with AKAs

usually subsides in 3 months but not always
is it ok to massage stump?
yes, improves circulation and reduce tenderness

soft pillow, firm pillow, bed, chair (sand)
crutches up and down stairs
up with the good leg and down with the bad leg
Goodell's sign
softening of cervix, 2nd month (probable sign)
Chadwick's sign
bluish color of vaginal mucosa and cervix, week 4

probable sign
Hegar's sign
softening of the lower uterine segment, 2nd-3rd month
fetal heartbeat/doppler dates
10-12 weeks
Fetoscope dates
17-20 weeks
how many times been pregnant
how many times fetus has reached 20 weeks or more
How many have reached 24 weeks (ability to live outside of uterus)
A 20 week baby is NOT considered
L- living children
Negel's rule
LMP + 7 days - 3 months and add 1 year
pregnancy exercise rule
don't let HR go above 140 bpm (decreases CO)
don't rec any meds until...
talking to MD
danger signs in pregnancy
sudden gush of vaginal fluid
persistent vomiting
severe HA
abdominal pain
increased temps
no fetal movement
date for fetal quickening
16-20 weeks
normal fetal HR
(worried and watching when 110-120)
(pain if less than 110!)
If pregnant pt gains more than 1 lb a week in 3rd trimester, what should u worry about?
fetal stations
measuring in cm

measures the relationship of the presenting part of fetus ad the ischial spines of the mother
when presenting part of fetus, usually head, descends into the pelvis

usually 2 weeks before term
signs of labor
lightening (less congestion and easier to breath, urinating more)

engaement (head we hope)

fetal stations

more frequent and stronger braxton hicks contractions

softening of cervix

bloody show (not heavy bleeding, that would be hemorrhage)

sudden burst of energy (nesting)


rupture of membranes
when should client go to hospital
when contractions are 5 min apart or when membranes rupture
#1 worry with rupture of membranes
prolapsed cord (fastest problem)

infection is next
Reactive Non stress test
want to see two or more accelerations of 15beats/min (more more) WITH fetal movement

over 20 minute period
Acceleration =
acceleration= greater than or equal to 15 beats per min above baseline and lasts at least 15 seconds. HR should come back to baseline within 2 minutes
Biophysical profile test (BPP)
done in last trimester,
32-34 weeks in high risk pregnancy (may have it twice a week or every week in 3rd tri)

measurements done by US- want 8-10/10, 6 worry, <4 omninous.
MD may deliver with 6 or less

Measures HR (NST), muscle tone (1 flexion/extension in 30 min), movement (3 times in 30 min), breathing (breathing movement 1/30 min), amniotic fluid (is there enough around baby?)
Contraction stress test (CST)- Oxytocin challenge test
if NST non reactive

hifh risk

to see if baby can hande uterine contractions

looks for late decellerations (placenta wearing out)

WANT a NEGATIVE- negative for late decels

rarely done before 28 weeks

results are good for one week only
what decels are bad?
late and variable

late- uteroplacental insufficiency
variable- umbilical cord compression
true labor vs false
regular, increased, back and radiates to abd, activity increases pain

irregular, abdomen, pain dereases with activity
epidrual position
lie on left side, legs flexed, not as arched as lumbar (don't go as deep)
when is epidural given
stage 1- 3-4cm
HA after epidural?
no, that would be lumbar
If hypotension after epidural
put in semi fowlers on side to preent vena cava compression

(1000ml NS or LR given preventively)

alternate position hourly side to side
Oxytocin nursing care
one-on-one, don't leave pt

watch for hypertonic laor, fetal distress, uterine rupture
s/s complete uterine rupture
sudden, sharp, shooting pain (soething gave way), if in labor pain and contractions will stop

pt may also have signs of hypovolemic shock due to hemorrhage

If placenta seperates, the fetal heart tones will be absent
s/s of incomplete uterine rupture
stop in peritoneal cavity

internal bleeding

may not have pain

fetus may or may not have late decels

client may vomit

hypotonic uterine contractions and lack of progress

fetal heart tones may be lost
VBAC risk
increased risk for uterine rupture, especially with oxytocin and high risk or forceps
D/C oxytocin if
contractions are too often, contractions last too long
fetal distress (late decels)

make sure you don't turn off main IV fluid when turning off oxytocin
Best position with oxytocin
any position BUT flat (alwyas contra in pregnancy)

left side is best, especially if fetal bradycardia
Post partum normal vitals
temp may increase to 100.4
stable BP
HR 50-70 common for 6-10 days (diuresis after birth causes this, diuresis begins 24 hrs after birth)
when does engorgement start
2-3 days after
Diastasis recti
separation of abd muscles
goes away by its self or with VIGOROUS exercise
fundus immediately after birth
2-3 fingerbreadths below umbilicus

a few hours after birth it will rise to umbilicus or one FB above

will decrease 1FB/day
If pt has boggy fundus...
massage and check for bladder distention (suspected if uterus is above normal area)
when fundus descends and uterus returns to its pre pregnancy size

If it doesn't --> hemorrahge risk
common for first 2-3 days and will continue to be common if mother breastfeeds (increases oxytocin)
blood color after pregnancy
rubra for 3-4 days (red)
serosa for 4-10 days (pink brown)
alba for 10-28 days (whitish, yellow)

clots ok unless bigger thana nickle (hemorrhage risk)
Peripad rule
no more than 1 pad saturation/hr
In infancy, trust is not only a emotion need but also.....
physiological (#1 in Maslow)
Kangaroo care
1 hr at least 4 times a week
non breast feeding care of breasts
ice packs, binders, chilled cabbage leaves (dialtes capillaries, lowers inflammation and engorgment)
When infection risk post partum
10 days (ecoli, beta hemolytic strep)
post partum hemorrhage definitions
early- more than 500 mL blood lost in first 24 hours AND a 10% drop in Hematocrit

late- after 24 hours but up to 6 weeks post partum at risk
Meds to halt excessive post partum hemorrhage
within 204 weeks, staph, baby not feeding properly, needs to empty all the way
treatment of mastitis
binding and cabbage leaves if stopping breastfeeding completely

bed rest, supportive bra, frequent feeding and pumping, pcn or erythromycin

pain med


feed baby frfrequently and offer affected breast FIRST, even if it hurts!
Apgar scores
done at 1 and 5 min

HR, R, muscle tone, reflex irritability, color

want at least an 8 or 10 (most get a 9 cause of feet and hand cyanosis)
eye ointment for newborn
erythromycin for neisseria gonococcus, chlamydia, etc.
Vit K, IM in vastus lateralis to promote formation of clotting factors
cord care
dries and falls off in 10-14 days
cleanse with each diaper changing with alcohol or NS (up to MD)

fold diaper below cord

no water immersion till cord falls off, watch for infection
risk for baby hypoglycemia
large for gestational age, small for gestational age, perterm, babies of diabetic moms
pathologic jaundice
first 24 hours, usually means Rh/ABo incompatibility
physiological jaundice
after 24h
due to normal hemolysis of excess RBCs releasing bilirubin, or liver immaturity
Erythroblastosis fetalis
increase in immature RBCs in fetal circulation, from Rh incompatibility

- hyperbilirubinemia
- anemia
- hypoxia
- HF
- neurologic damage
- hydrops fetalis (a severe form of erythroblastosis fetalis)

at some point baby will stop growing
Indirect Coomb's test
on Mother, measure her antibodies in her blood
Direct Coomb's test
on baby, looks to see if any antibodies stuck to RBCs
given (2nd or more child), withi 72 hours at birth (mother, to protect next baby) and at 28 weeks, any bleeding episode in pregnancy

**once mother has antibpdies she has them for life, has to be given before antibodies are formed

**GIVE with ANY bleeding
If client has had one ectopic pregnancy then..
she is at risk for another
given to mother to stop growth of embryo to save tube, in ectopic pregnancy
Most common cause of bleeding in later months (7th)
placenta previa
problem with placenta previa
baby doesn't get enough oxygen during contractions and the placents comes out first instead of baby
s/s of placenta previa
painless bleedig in 2nd half of pregnancy (could be spotting pr perfuse)
Complete previa requires...
hospitalization, from as early as 32 weeks until birth, to prevent blood loss and fetal hypoxia if client goes into labor

if there is not much bleeding- bed rest and watch closely (like with partial, low, etc)
If pt has placenta previa and starts contractions...
call MD, not going to be a normal delivery

C- section is delivery of choice
DO NOT_____ with placental previa
vaginal exams!, can puncture placenta and cause emergency surgery and hemorrhage
Abruptio placenta
normal placental placement
may be partial or complete

concealed means bleeding into uterus

caused by MVC, domestic violence, previous C section, rapid decompreesion of utereus with membrane rupture, cocain, PIH, smoking
If there is EVER unexplained bleeding...
NEVER EVER do a vaginal exam
incimpetent cervix
4th month, repeated 2nd trimester miscarriages

tx is cerclage at 14-18 weeks
tx for hyperemesis gravidarum
NPO 48h
IVF 3000mL for 1st 24h
antiemetic IV
replace vitamins
quiet environment
oral hygiene
don't talk about food and keep emesis basin out of sight
6-8 small, dry feedings followed by clear liquids
make foods and liquids icy cold or steamy hot
well ventilated room
increase BP (if moms prepreg baseline is not known go with 130/90 being mild preecamplsia
proteinuria (losing protein so edema, must increase protein intake)

after 20th week

may also have HA, blurred visions, seeing spots from vasospasms, increased DTR
If pt has increased DTRs or hyperreflexia think...
clonus--> seizure!!!!!
Severe preeclampsia
BP elevated above 160/110 documented 6 hours apart

sedate to delay seizures

Mag sulfate is drug of choice
Magnesium sulfate
anticonvulsant, sedative, vasodilation

vasodilation increases renal perfussion

place on side, preferrably left

mag sulfate is hypertonic (salt). If kidnye function is impared then fluid shift may be too fast, watch for pulmonary edema
Mag sulfate nursing care
watch for pulm edema
check mag toxicity q 1-2 hours (BO, respirations, DTRs, LOC)
UOP (excreted through kidneys)

mag sulfate will decrease labor, it can be used for preterm labor for this effect
If diastolic is >100 give...
Hydralazine with mag sulfate

watch for tachycardia
cure for preeclampsia
delivery is only cure, but pt at risk for seizures for 48 hours after delivery

-dingle room, very quiet environment, dim lights, no tv, decrease stimulation
Steroid therapy for preterm
Bethamethasone- stimulates surfactant, given between 24 and 34 weeks

monitor FHT
watch for labor, HF, stroke, MI, renal failure, DIC, HELLP, neuro damage, multisystem organ failure
pregnancy induced HTN

after 20 weeks with proteinuria
Gestational HTN
after 20 weeks, NO proteinuria
Preterm labor definition
labor between 20 and 37th week
to stop pre term labor

s/e are increased HR and hyperactivity

its actually a bronchodilator
Preterm labor can sometimes be stopped by...
hydration and treated vaginal and urinary infections
If cord ceases to pulsate =
fetal death
if prolapsed cord...
lift head off cord untill MD arrives, never release!!

trendelenburg or knee-chest position
admin o2
monitor FHT
don't push cord back in, hold head off of it!!
Shoulder dystocia
delivery prevented by shoulder stuck in maternal pelvis

can lead to cerebral palsy and asphyxia

brachail plexus injury (Erbs point) causing drooping or paralysis of arm

broken clavicle

bell's pasy

can be caused by forceps

many resolve but can lead to perm damage
At risk for shoulder distocia
LGA or macrosomia (>4000 grams)
gestational diabetes
previous hx of shoulder dystocia
post fate delivery (large fetus)
McRoberts Maneuvers
nurse pulls legs to hyperextend
Mazzanti techniques
applies suprapubic pressure to assist shoulder to pass

**never apply fundal pressure- the physician must do this or call another physician to do it!!**
Leading cause of neonatal morbidity
Group B streptococcus (GBS), not an STD

risk to fetus is only after ruptre of membranes

preterm baby risk, positive cultures in pregnancy, PROM (longer than 18h), past hx, intrapartum maternal fever higher than 100.4

PCN or clindamycin given
Order of vitals in peds
*count HR and R for one whol emin because of irregularities
Rectal temp on peds
DO NOT use in children over 3 months old, but it is the most reliable core temp
Axillary temp on peds
all ages when oral can't be done
Oral temp on peds
start at age 5-6
Tympanic temp on peds
all agesw, evidence that less accurate in under 3yo
pulse ox should correlate with
childs radial pulse
growth charts
within 5-95% for H, W, HC is desired

15% is median

growth slows between 6-12yo but will have growth spurt after

girsl have adolescence 1-2y earlier
pale skin sign of
CRIES acronym
for infants

requires increased oxygen
increased vitals

0-2 on each
higher the worse pain
FLACC scale
2 months to 7 yrs

face, legs, activity, crying, consolability

each 2 pts, 10 is worst
Wong Baker
face pics, if pt not cognitive development use FLACC

usually by 3yo can use

Numerical scale if over 5
Croup, usually under 5

diarrhea, barking or brassy cough, increased temp

distress depends on size of airway
mild croup tx
home with steam, cool mist humidifier, car rides with windowns down, breath in freezer

if symptoms worsen or don't improve then hospitalization for corticosteroids
H influenza, most kids are vaccinated now

absence of cough
look worse than they sound

Emergency!, may require intubation or trach, iv antibiotics, corticosteroids

LTB sounds worse than they look
difficulty swallowing, mouth breather, bad breath, swollen can block ear drainange and cause otitis media
position on side with HOB elevated or prone with no HOB elevation to prevent aspiration

no red or brown fluids

watch for frequent swallowing, sign of hemorrhage
how many days post op tonsillectomy is pt at risk for hemorrhage
10 days, teach parents
Otitis media tx
heating pads on ear
avoid chewing, provide soft foods
lie ON affected side for drainage
may not hear you
avoid smoke
may require pressure equalizing tubes, stay in for 6 months then fall out
prevention of otitis media
ear plugs if have tubes
baby sit up during feedings
no bottle propping
gentle nose blowing (shoot ifection to ear)
avoid smoke
RSV- Respiratory syncytial virus
leading cause of lower resp tract infections in less than 2 yo

becomes worse 2-3 days after onset

URI, nasal discharge, mild fever, dyspnea, nonproductive cough, tachypnea and nasal flaring, retraction or wheezing

can range from mild to severe with resp distress
dx RSV
nasal or naso pharyngeal swab- to make sure its not asthma
precautions for RSV

treat symptoms
mya be given for severe RSV with aerosol or ten

**if tent, shut off for a bit before opening to nurse doesn't inhale it
Down syndrome pts are likely to develop what?
respiratory infections because of poor immune system

heart defects
Cystic fibrosis
inherited from both parents

thick, sticky, secretions in lungs and GI, exocrine gland dysfunction

pancreas enxymes can't get through mucus so get Gi problems and pancreatitis

Positive sweat chloride test, taste salty
Electrolyte imbalance of cystic fibrosis pt
earliest sign in newborn of cystic fibrosis
meconium ileus

will also have steatorrhea, fatty, frothy stools
tx for CF
pancreatic enzymes, 30 min prior to eating, do not crush or chew

well balanced, low fat diet (increased enzymes with more fat), high protein

require 150% of daily allowances

need water soluble ADEK since they can't have a lot of fat
Digoxin in peds
infants rarely given more than 1mL

give 1 houre before and 2 hours after feeding

DO NOT mix with food or fluid

ALWAYS check dose with another nurse

check apical pulse for 1 min
Ace inhibitors for peds
enalapril, captopril

decrease BO, kidney problems, dry cough (can stop med and try a dif one)

block aldosterone
nursing care of peds HF pt
well rested and may give O2 before eating, decrease crying

small frequent feedings with large opening in nipple

may require gavage feedings

usually dont require Na and water restrictions because they aren't taking in as much food etc anyways
Rheumatic fever
loves hearts and kidneys

Kawasake disease
inflammation of small and medium sized vesseld, coronary arteries most susceptible

high does of IV immune-globulin, aspirin therapy, quiet environment
post op position for cleft lip repair
back or side lying to protect suture line
do not place prone
clean sutures with saline
Post op cleft palate repaire
place prone to promote drainage (no sutures to worry about)

avoid putting things in mouth (temp, straws, etc.), soft diet

elbow restrains if have to pick one to keep arms straight

need speech therapy so best time for surgery is before speech is developed
position for GERD in peds
upright for feedings and at night

30 degree prone to decrease reflux and improve stomach emptying

small, thickened, frequent feedings (rice cereal mix)
Esophageal Atresia
no connection to stomach

no meconium cause never digested amniotic fluid

fed with gastrostomy tube
T-E fistula s/s
coughing, choking, cyanosis

this is why first feeding needs to be sterile (breast milk or sterile O2)

top nursing dx is aspiration!
positiong for TE/atresia surgery
infant placed on their back with head and shoulders elevated so secretions pool in lower esophagus
Pyloric stenosis
projectile vomiting after eating

very hungry

olive shaped mass in epigastric region, near umbilicus (enlarged pyloris)

obvious peristalsis/waves
Intussusception and s/s
piece of bowel backward on self

sudden onset, cramping, abd pain-ACUTE!!


drawing knees up

currant jelly stools (maroon colored of blood and mucus)
barium enema, this will sometimes fix problem

teach reoccurance signs

in hospt for 10-14 days
Hirschsprung's disease
congenital anomaly
also known as aganglionic megacolon
obstruction of bowel (usually sigmoid) because of no nerves in area/no peristalsis

constipation, distention, ribbon like stools,

remove portion of bowel, temp colostomy possible
Imperforate anus
no rectal opening, no meconium passed

temporary colostomy
Celiac disease
no gluten

can't have BROW

CAN have RCS
UTI in <2
<2 non specific s/s, might seem like GI, girls more than boys

failure to thrive, feeding problems, vomiting and diarrhea

untreated leds to renal failure

fishy urine smell

risks are: renal anomalies, consitpation (bladder distention), bubble baths, poor hygiene, pin worms, sexual abuse
UTI >2
frequency, dysuria, fever, flank pain, hematuria

may need cath, but try other methods first
Testicular torsion

peak is 13 yrs of age

most common cause of testicular loss in adolescent males

unilateral pain to affected testicle
possible n/v
discoloration of testicle
when caring for pts with hemotological disorders always include...
protective isolation in plan of care
Sickle cell disease
sickled hgb/rbcs

bed rest, HYDRATION!!!! (may stop sickling on its own!), pain meds, antibx, blood transfusions, oxygen
leukemia in child
immature WBCs
ALL (acute lymphoid) or AML (acute muelogenous)
s/s of leukemia
fever, pallor, anorexia, petechiaw, vague abdominal pain, early acquired infections
always think what three things with leukemia...
immunosupression, thrombocytopenia, anemia
Wilm's tumor

swelling, non tender mass on one side of abd


gentle care when caring for pt
distubance of ventricular circulation of the CSF in brain --> increased ICP

bulgind of anterior fontanel
dilated scalp veins
depressed eye (forehead protruding)
irritability and changes in LOC
high pitched cry (associated with anything that casues increased ICP)
Insertion of a VP shunt
measure the frontal occipital circumference

fontanel and cranial suture line assessment

monitor temp

SUPINE position (if have meningeocele MD may want steril gauze over it and hurry to surgery so it doesn't hurt it)
Seizure disorders
a symptom of underlying conditions

first indicator of problem may be school work deterioration
partial seizure
particular location in brain

simple- loss of consciousness with numbness, tingling, pricking, or pain

complex- imparied consciousness and may be confused and unable to response
Generalized seizures
loss of consciousness

tonic-clonic- formally known as grand mal

myoclonic- sudden, brief contractures or muscles, may look like startle reflex

absence- petit mal, brief loss of consciousness
tape test
to dx pin worms

do early i morning
pinworm S/S
intense rectal itching
poor sleep
bed wetting
short attention span
Pinworm medication
lots of times only need one dose or maybe one more a week or 2 later

if ped has chicken pox and high risk for severe varicella then will given
mono and spleen
enlarged spleen, no contact sports
When delegating you must communicate...
- time frame and priority of the task
- provide clear directions and expectations and what you want reported
If floating nurse is from different floor..
give them no specialized care, but basic nursing knowledge stuff, pretend they are a brand new nurse
Never delegate...
assessment, evaluation
LPNs can
help with data collection but not assessment, no evaluations
who must do new admission history?
RN only (new unstable pt!)
Can the LPN do tasks on the plan of care?
yes, but RN must do the planning for the care
LPN and teaching?
LPN can not teach a newly diagnosed pt, etc. they can only implement STANDARDIZED techniques (like cough and deep breathing)
what type of pts can RN delegate to LPN?
STABLE!, it can be complex as long as it is stable!!, don't let chronic, complex dx make you not delegate if they are stable (like COPD or something)
Always consider a new admission...
what can an LPn do in an unstable situation? (like a code)
specific things, like "go take the blood pressure and tell me"
what type of tasks can Rn delegate to assistive personnel?
routine, non-complex tasks, they can do CPR

NO ONE receiving blood, IV dopamine, or IV nitroglycerine (vitals, etc.)

look at each situation. CNA can feed a client with 2 broken arms but not a dysphagia pt or can bathe a stroke pt but not a burned pt, etc.

if there is EVER a degree of potential hard, the RN must retain the task no matter how routine it is!!
make sure to also be...
cost effective

remember that you are a manager of patient care
5 rights of delegation
right task
right circumstances
right person
right directions (tell staff all rules for daily weights, etc.)
right supervision ad evaluation
Sigs of transfusion reaction
chest pain, hives or skin rash, HTn or hypoTN, fever, chills, anxiety, wheezing, HA or muscle pain with fever, flushing, back pain, dizziness, itching, urticaria, tachycardia, tachypnea, dyspnea, N/V
If an adverse reaction occurs during transfusion...
stop it immediately
remove blood and blood tubing- may have to be returned to blood bank

start NS with new set at KVO

check and document vitals, STAY with client

notify MD and monitor pt close for anaphylaxis

notify blood bank of reaction
type and screen is good for...
72 hours
infusion of blood should be started within..
30 min of receiving blood from blood bank

all blood administered within a 4 hour time frame (must be discarded otherwise)

afterwards, flush with NS
normal AST/ALT
AST- 8-40 U/L
ALT 10-30 U/L
Hemoglobin normal
men- 14-18
women- 12-16
hematocrit normal
men- 40-45%
women- 38-47%
10-20 mg/dL
Creatinine normal

men- .6-1.3
women- .5-1
RBC normal
4.7-6.1 (men)
4.2-5.4 million.mm3 (women)
Digoxin normal
CVp normal
PAOP normal
Absolute neutrophils cautions
<1500- neutropenic
<1000- mind-mod infections risk
<500- severe infection risk
Total cholesterol normal
HDl normal
45-50 men, 55-60 women
LDL normal
Urine pH normal
urine alb normal
urine WBC normal

negative for glucose
Albumin normal
Lithium level normal
Bilirubin normal
Total: .3-1
Ammonia normal
10-80 mg/dL
Total protein
men 0-10, women 0-20
PSA normal
less then 4ng/mL