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Nclex study guide pdf

General Biology (Evergreen Valley College)

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NCLEX
STUDY
GUIDE
Everything you need to know to pass the
NCLEX

ETSY - NURSINGSTUDENTGUIDES

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CONTENTS

1 ADVICE FOR NCLEX

2 STUDY CALENDAR

3 MUST KNOW

4 HALLMARK SIGNS

5 PATIENT POSITIONING

6 DIAGNOSTIC SIGNS/TESTS

7 GENERAL NURSING

8 MEDICAL SURGICAL

9 CRITICAL CARE

10 PEDIATRICS

11 MATERNITY

12 MENTAL HEALTH

13 LEADERSHIP

14 PHARMACOLOGY

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Advice for NCLEX

Plan to study for the NCLEX for at LEAST one month

The KEY for passing NCLEX is taking as many test questions as you
can

Knowledge of disease processes and pharmacology is important,

but it is more important to understand what the question is really
asking.

Become very comfortable with Select All That Apply (SATA) 7

75% of my exam was SATA

Test banks and resources I recommend:

U-World
#1 choice if you had to pick anything
Read the entire rationale for each question, even if you got it
right
Nurse Achieve
CAT (Computerized Adaptive Testing) format which is the
exact testing format used on the NCLEX
Highly recommend taking a few CAT exams one to two
weeks before your scheduled NCLEX date
Saunders Comprehensive Review for the NCLEX-RN
Testing bank
Book provides a comprehensive review of all testing
Materials on NCLEX
I only recommend purchasing the book if you
graduated from your nursing program a while ago
and do not remember a lot of material

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NCLEX STUDY
SCHEDULE
Month:

Mon Tues Wed Thru Fri Sat Sun

Med Surg

Review
previous
Critical Care concepts
Test
Questions

Review
Pediatrics
Test
Questions

Maternity Review

Test
Questions

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NCLEX STUDY
SCHEDULE
Month:

Mon Tues Wed Thru Fri Sat Sun

Review
Mental Health Leadership
Test
Questions

Test
Questions
Pharmacology
Review topics
that you don't
feel confident
in

NCLEX

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Must Know
Labs

Vital Signs

INR

Key
NI- nursing interventions
S/sx - signs and symptoms
Pt - patient
UO - urine output

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Must Know
PT - Prothrombin Time
Blood test that assesses how FAST blood clots
Dependent on vitamin K (made by the liver) to make clots
High levels caused by: vitamin K deficiency, cancer, liver disease

INR
Lab used for patients who are taking warfarin
INR level determines amount of warfarin given

*Warfarin*
Measures the speed of clotting using extrinsic pathway

PTT - Partial Thromboplastin Time

Lab used to assess if blood-thinning therapy (heparin) is working

Intracellular - fluid inside of a cell

Extracellular - fluid outside of cells

Includes: interstitial fluid, connective tissue, bone, blood

Intravascular - fluid inside a blood vessel

Isotonic
No osmotic pressure; cells stay same size
0.9% NS, Lactated Ringers, D5W

Hypotonic
Water enters the cells. *Assess for edema*
0.45% NS, 0.33% NS

Hypertonic
Water is removed from cells
3% and 5% NS, D5W with ½ NS, D10W, D5LR

Colloid
Fluid moves from interstitial to intravascular compartment. *Given to patients in severe hypovolemia*
Albumin, Dextran

Beta 1 and Beta 2

Beta 1 - found in heart
Beta 2 - found in lungs
Remember: 1 heart, 2 lungs

Electrolyte Level Relationships

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Must Know
Acid Base Balance

From the butt (diarrhea) - Metabolic Acidosis

From the mouth (vomitus) - Metabolic Alkalosis

ALKALOSIS: K is LOW
Acidosis: K is HIGH

Hyperventilation increases chance of respiratory alkalosis due to increase of carbon dioxide in the
blood
Alkalosis: too much bicarb or loss of acid from the blood

Antidotes
Heparin → Protamine Sulfate
Warfarin (Coumadin) → Vitamin K
Potassium → Insulin, Kayexalate
Magnesium sulfate → Calcium Gluconate
Tylenol (Acetaminophen) → Mucomyst (acetylcysteine)
Opiates → Narcan
Narcotics → Narcan
Digoxin → Digiband
Insulin → Glucose
Cholinergic crisis → Atropine and oximes
Iron → Deferoxamine
Beta Blockers → Glucagon
TPA → Aminocaproic acid
Benzodiazepines → Romazicon

Important Info
NPO anytime there is a GI issue
Pt needs 2-3L of fluid/day
Give meds 1 hour before meal or 2 hours after meal
Give antacids 1 hour before meds or 4 hours after meds
Neuro pt → keep head of bed 30-45 degrees
After surgery monitor: first 24 hours → bleeding. 48 hours → infection
If pt is admitted for a fluid problem → check daily weights
In patients with severe vomiting and diarrhea, monitor for electrolyte imbalances
Anaphylaxis → give ordered epinephrine
ALWAYS obtain cultures before starting antibiotics
If pt has dysphagia → risk for aspiration pneumonia

When in doubt
Electrolytes: choose potassium (K+)
Choose an answer that has you stay with your patient
Remove any answer choices that are absolutes (all/none)
Pick the least invasive option first (if it is not an emergency)
Emergency → choose STAT words. Choose the first thing you would do in order to save or avoid
causing harm to the pt
Never withhold treatment from a patient
Empower your patient

Tell Tale Signs

Older patient with acute onset confusion → UTI
Restlessness, agitation, decreased level of consciousness → EARLY SIGN of deterioration

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Hallmark Signs
Addison’s - bronze skin IBS - GI pain, diarrhea, constipation

Anaphylaxis- tachycardia & wheezing ICP (elevated) - Cushing’s Triad (HTN,

bradycardia, bradypnea)
Angina - sharp chest pain
Intussusception - sausage-shaped mass on R
Appendicitis - rebound tenderness side

Asthma - expiratory wheezing Kawasaki Syndrome - strawberry tongue

Bulimia - chipmunk cheeks Leprosy - lioning face

BPH - polyuria at night Liver cirrhosis - spider veins

Cataract - blurred vision Lupus - butterfly rash

Cushing’s - moonface/buffalo hump Lyme Disease - Bull’s eye rash

Cystic fibrosis - salty skin Measles - Koplick’s spots

Cystitis - burning urinaiton Meningitis - Brudzinski and Kernig’s sign

Diabetes Mellitus - polyuria, polyphagia, Myasthenia Gravis - descending weakness

polydipsia
Myocardial infarction - chest pain, radiated to
DKA - Kussmaul’s breathing left arm and neck

DVT - Homan’s sign Pancreatitis - Cullen’s sign

Emphysema - barrel chest Parkinson’s - tremor

Epiglottitis-Dysphagia,dysphonia, drooling Pernicious anemia - beefy red tongue

Glaucoma - halo vision; painful Pneumonia - rust colored sputum

Guillain Barre - ascending weakness Sepsis- tachycardia, hypotension, SOB

Hyperglycemia - acetone breath Shock - tachycardia, tachypnea, hypotension

Hyperthyroidism - bulging eyes TEF - cyanosis, choking, coughing, continuous

drooling
Hypocalcemia - Chvostek and Trosseaus sign
Ulcerative collitis - frequent bloody diarrhea

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Patient Positioning
Epidural puncture → side lying

During lumbar puncture → lateral recumbent fetal position

After lumbar puncture → supine (to prevent headache and leaking of CSF)

Pulmonary embolism → turn to left side and lower HOB

Shortness of breath → high fowlers

Lung biopsy → lay on side of the bed or with arms raised up on pillows over
bedside table

Chest tube insertion → arm raised above head

NG tube placement → high fowlers

Tube feeding with decreased LOC → put on right side (promotes emptying of
stomach) with HOB elevated (prevent aspiration)

Prevent dumping syndrome → eat in low-fowlers, lie down after meals for 30
min

Hiatal hernia → Fowler or semi-Fowler (reduce regurgitation)

After thyroidectomy → low semi-fowlers

After myringotomy → lay on affected ear (allows drainage)

After cataract surgery → lay on unaffected side

During continuous bladder irrigation → keep leg straight

During internal radiation → on bedrest while implant in place

Pt with heat stroke → lie flat with legs elevated

After total hip replacement → sleep on unaffected side, don’t elevate HOB more
than 45 degrees, maintain hip abduction by separating thighs with pillow

Buck’s Traction → elevate foot of bed for counter traction

Above and below knee amputation → elevate for first 24 hours, position prone
daily for hip extension

Back pain → William’s position

Myocardial infarction → semi-fowlers

Autonomic dysreflexia/hyperreflexia → elevate HOB

Head injury → elevate HOB 30 degrees (decrease intracranial pressure)

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Patient Positioning
After supratentorial surgery (incision behind hairline) → elevate HOB 30-45 degrees

After infratentorial surgery (incision at nape of neck) → lay flat and lateral on either
side

Peritoneal dialysis when outflow is inadequate → turn pt side to side then check for
kinks in tubing

Administering an enema → lay on left side with knees flexed (Sim’s)

After appendectomy → right side with legs flexed

During paracentesis → High fowler’s (HOB 45-90 degrees)

During thoracentesis → sit at edge of bed, lean forward, and rest arms on table

Spina bifida → prone (so sac doesn’t rupture)

Infant with cleft lip → side, supine, or upright in infant seat to prevent ripping of
suture line.

Infant with ONLY cleft palate → side or abdomen

Woman in labor with unreassuring FHR → turn on left side

Prolapsed cord → knee to chest or Trendelenburg

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Diagnostic Signs/Tests
Allen’s Test
Assesses arterial blood supply in hand. Positive test means the pt does NOT have adequate
blood supply to the hand
How to do: block both radial and ulnar arteries until skin becomes pale, then release ulnar.
If hand becomes pink, ulnar arter works, and a ABG/radial stick can be done

Cullen’s Sign
Internal hemorrhage causing ecchymosis around umbilical region; seen in pancreatitis

Turner’s sign
Internal hemorrhage seen as grayish blue on your flanks; pancreatitis

Murphy’s Sign
Pain with palpation of gallbladder area; cholecystitis

McBurney’s Point- RLQ pain indicative of appendicitis

LLQ Pain- diverticulitis; make sure pt has no seeds, nuts, peas
RLQ Pain- appendicitis; assess for peritonitis

Guthrie Test
Neonatal heel prick that tests for PKU (phenylketonuria)

Babinski Sign- assessessment for nervous system issues done by stimulating bottom of foot
Negative: toes curl
Normal in adults and children older than 2 years, abnormal in children 2 years and
under
Positive: toes fan
Abnormal in adults and children older than 2 years, normal in children 2 years and
under

Beck’s Triad
Indicative of cardiac tamponade - hypotension, JVD, muffled heart sounds

Halo Sign
Positive - appears as concentric rings (bloody circle surrounded by yellow border)
Fluid from head injury contains cerebrospinal fluid (CSF); fluid also contains glucose

Endoscopic Retrograde Cholangio Pancreatography (ERCP)

Procedure to examine diseases of the pancreas, liver, gallballder, and bile ducts
Preop - NPO. Postop- assess gag reflex and s/sx of perforation

Additional Notes
If at home: Call 911 if chest pain is not relieved by nitroglycerine; keep med in original
container and away from light
Definitive diagnosis for abdominal aortic aneurysm → CT scan

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General Nursing
#1 Priority- ABC’s
Airway
Breathing
Circulation

Maslow’s Hierarchy
ABC’s
Safety
Comfort (Pain)
Psychological
Social
Spiritual

When in distress, DO NOT ASSESS!

Fire Safety
RACE - rescue patients at risk, activate alarm, contain fire by closing doors and windows, extinguish
fire if able

Prevention Types
Primary
Preventing disease or injury
Ex: educating on first aid

Secondary
Treating patients who are injured
Ex: emergency department, triage

Tertiary
Follow-up care

Nursing Process:
1. Assessing - gather information
2. Diagnosing - name the problem
3. Outcome/Planning - develop plan of care
4. Implementing - perform nursing interventions
5. Evaluating - did interventions work?

Order of Assessment

*In kids, go from least to most invasive

Pulse Strength
0 absent, 1+ weak, 2+ normal, 3+ bounding

Arterial Blood Gases

Before drawing an ABG, perform the Allen’s Test to check for sufficient blood flow
ABG needs to be in a heparinized tube (blocks clotting cascade)
Put on ice immediately after drawing

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General Nursing
Burns
#1 priority: Maintain a patent airway
Rule of 9s
9= head
18= arms
36= torso
36= legs
1= perineum
Parkland Formula
Calculation for the total fluid requirement 24 hours after a burn
4ml x Total Burn Surface Area x body weight (kg) = Total fluid pt will receive in 24 hrs
50% given in the first 8 hours
50% given in the next 16 hours
1st Degree- red and painful
2nd Degree- blisters and edema
3rd Degree- no pain due to nerve damage

Burn Types

NI: airway patency (intubation may be necessary), give O2, assess vital signs, give IV fluids, assess for
paraltic ileus, pain management, assess for s/sx of infection

Glasgow Coma Scale

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General Nursing
Cranial Nerves

Cultural
Jewish: no meat and milk together
Greek: puts protective charms on baby’s neck to avoid eny from others

Blood
O- universal donor
AB + is the universal recipient
Patients who are Rh negative should NOT receive Rh positive blood

Blood Transfusions
Stay with pt for first 15 minutes
Multiple blood transfusions = risk for hyperkalemia
Transfusion reactions s/sx: fever, SOB, hypotension, fever, dizziness
If reaction occurs: STOP transfusion, start IV line with NS, call MD and blood bank, monitor pt for s/sx

Compartment Syndrome
Emergency situation caused by increased pressure and restricted blood flow to an extremity, which
results in pain and paresthesia
Requires immediate action, as damage is irreversible after 4-6 hours
5 P’s: pain, paresthesia, paralysis, pallor, pulselessness
NI: notify MD, fasciotomy to relieve pressure, loosen cast

Sucking stab wound

Dress wound and tape it on 3 sides so air can escape
Do NOT use occulsive dressing
Next steps: get chest tube tray, labs, and start an IV

Chest Tube
If it is accidently removed, use occulsive dressing taped on 3 sides (allows air to escape and prevents
tension pneumothorax)
If it becomes disconnected, do NOT clamp
Place the end of the tube in a container of sterile saline (or water if saline not available)
Fluctuations = good (fluid moves up with each inspiration and down with expiration) mean the chest
tube is working
No fluctuations → check for kinked tubing, occlusions, or ask patient to change position
Continuous bubbling when the chest tube is connected to suction → air leak

Safety in the patient’s room

Ensure all the wheels are locked and bed is in lowest position
Having all 4 side rails up is a form of restraint (even in patients who are considered a fall risk)

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General Nursing
Pressure Ulcer Stages

Don and Doff Order

Precautions
Contact
Gloves, gown
*water and soap for c. diff

Mrs. Wee
M - multidrug resistant organism
R - respiratory infection
S - skin infections (herpes simplex, impetigo, scabies)
W - wound infections
E - enteric infection (c. diff)
E - eye infection

Droplet
Gloves, gown, face mask, eye shield

Spiderman
S - Sepsis, streptococcal pharyngitis, scarlet fever
P - Pneumonia, pertussis, parovirus B19
I - Influenza
D - Diphtheria
E - Epiglottitis
R - Rubella
M - Meningitis, meningeal pneumonia, mumps
An - Adenovirus

Airborne
Standard Precautions +
gloves, N95 mask
MTV
M - Measles
T - Tuberculosis
V - Varicella Zoster

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Medical Surgical
Respiratory
Early sign of cerebral hypoxia → restlessness and irritability

Respiratory status
Key is visualization and assessment of breath sounds
If lungs sound clear and patient is blue, they are not receiving enough oxygen

Asthma
Difficulty of breathing due to the narrowing, swelling, and production of mucus in the airway
S/sx: SOB, wheezing, coughing, hypoxemia, respiratory acidosis
NI: Administer bronchodilators and steroids, maintain hydration, deliver oxygen or nebulizer as
prescribed
Avoid morphine → histamine releasing opioid can lead to exacerbation
Avoid NSAID’s and aspirin - can worsen asthma symptoms

COPD - characterized by bronchospasm and dyspnea

Bronchitis
Inflamed bronchioles, increased mucus
Blue bloaters, barrel chest
Emphysema
Destruction of alveoli
Pink puffers
Encourage pursed-lip breathing (promotes CO2 Bronchitis Emphysema
elimination), high-fowlers and leaning forward
Normal SpO2 for COPD: 88-92%. Do NOT raise SpO2 level
higher than 92% bc a low SpO2 is what stimulates pt to breathe
NI: offer mechanically soft foods (to save pt energy), teach pt to inject at least 3L of fluid/day (thins
mucus)

Empyema
Pus in the pleural cavity; associated w/ pneumonia or after thoracic surgery
NI: elevate HOB, abx, chest tube or thoracentesis (drainage)

Acute Respiratory Distress Syndrome (ARDS)

Fluid fills the alveoli in the lungs and inhibits oxygen exchange; causes severe hypoxemia
First sign- increased respirations. Followed by dyspnea, retractions, cyanosis
Hypoxemia is NOT responsive to O2 therapy bc the fluid in the alveoli blocks the diffusion of oxygen
NI: mechnicanial ventilation with PEEP

Pulmonary Embolism (PE)

Thrombus gets lodged into pulmonary artery,
blocking blood flow. Other cause is fat embolism
from long bone fracture
First sign - chest pain. Then dyspnea, tachypnea,
blood tinged sputum
Body compensates by hyperventilating → respiratory
alkalosis
NI: elevate HOB, give O2, thrombolyic therapy,
pain control, encourgage ambulation (prevent
venous stasis)

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Respiratory
Pneumonia
Infection resulting in decreased gas exchange in the affected
lung lobes
V/Q Mismatch
Alveoli become blocked with purulent fluid → impairs ventilation
Alveoli continue to receive perfusion from the pulmonary
Ventilation (airflow) or
artery resulting in deoxygenated blood
perfusion (blood flow) in
Ventilation to perfusion (V/Q) mismatch or pulmonary shunt
the lungs is impaired
May result in hypoxia and respiratory distress
Blood flow in the lungs is partially influenced by gravity,
S/sx: SOB, fatigue,
meaning blood flows in higher volumes to dependent parts
headache, confusion,
of the lung
dizziness, cyanosis
Unilateral pneumonia should be positioned with the
unaffected (good) lung down to improve perfusion and
oxygenation
*Ex: pt with a left lobar pneumonia: position in the right
lateral position
Unaffected (good) lung down (right lung) to increase
blood flow to the lung most capable of oxygenating
blood
Crackles heard on auscultation suggest pneumonia
At risk: people 65 or older and infants under 2 years old
(immune system still developing)
Pneumococcal vaccine recommended for pts 65 years and older
S/sx: pleuritic pain, wheezing, fever, sputum, change in LOC
NI: Droplet precautions, O2 as needed, encourage deep
breathing and coughing, increase fluid intake (thin mucus), abx,
monitor LOC

Pleural Effusion
Fluid buildup between the lungs and chest; prevents lung expansion
S/sx: pleuritic pain, dyspnea, dry cough, orthopnea
NI: high Fowler’s, monitor breath sounds, encourage deep breathing and coughing, prep for
thoracentesis

Pleurisy
Stabbing chest pain that usually increases on inspiration or with cough
Caused by inflammation of the visceral pleura (over the lung) and the parietal pleura (over the chest
cavity)
The pleura space (between the 2 layers) normally contains about 10 mL of fluid to help the layers glide
easily with respiration
When inflamed, they rub together and cause pleuritic pain

Fremitus
Palpable vibration felt on the chest wall
Expected finding in pneumonia
Sound travels faster in solids (consolidation) than in aerated lung → increased fremitus in pneumonia

Tuberculosis
PPD test: skin assessed 48-72 hours post administration
Positive if induration is: >15 mm in healthy pt or >10 mm in immunocompromised pts or >5 mm in
high risk pts (HIV, recent contact with TB pt)
Positive and no symptoms → chest x-ray
Positive and symptomatic → sputum culture
Anyone who has received a bacillus Calmette-Guerin (BCG) vaccine will have a positive test and
needs chest x-ray
Airborne precautions, pt must wear mask if leaving room
Public health risk; if pt does not comply with treatment, they need supervision
Teaching is very important! Drug therapy is typically 6 months or longer
Med: Rifapentine (Prifin) - may cause orange colored body secretions, take w/ meals

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Respiratory
Pneumothorax
Lung collapse due to air in pleural space (space b/w lungs and chest wall)
Open pneumothorax -air circulates freely into pleural space
Closed - air in pleural space does not increase
Tension pneumothorax - air cannot leave pleural space; compresses lungs
and shifts the mediastium
S/sx: sharp chest pain, SOB, cyanosis, tachycardia, tachypnea, hypotension
NI: 3 way dressing, oxygen, chest tube, surgery (if needed)

Nasopharyngeal airway
Tube-like device used to maintain upper airway patency
Used in alert or semiconscious patients; less likely to cause gaging
NEVER insert them in a pt who may have had a head trauma (which might occur during a seizure) bc
if they have a skull fracture, it may be malpositioned into structures and tissues in the brain
CT must be done first to rule out fracture
Size- measure tip of nose to the earlobe; select diameter smaller than naris

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Cardiovascular
Blood Flow
Tricuspid → Pulmonic → Mitral → Aortic
Toilet Paper My Ass

Listening to Heart Sounds

APE To Man
Aortic valve, pulmonary valve, Erb’s point,
tricuspid valve, mitral valve

Acute Coronary Syndromes

Unstable Angina
Minor occlusion → pain
Typically relieved by meds
PCI (percutaneous coronary intervention) may be diagnostic
NSTEMI
Partial occlusion leads to ischemia and damages heart muscle
Labs: elevated biomarkers
Requires PCI or thrombolytic
STEMI
Full occlusion → infarction or death of heart muscle
Labs: elevated biomarkers
ST elevation on EKG
PCI needed

Angina
Chest pain caused by reduced blood flow to heart
NI for active angina: have pt rest, take vitals, ECG, give no more than 3 nitroglycerin (vasodilator)
tablets 5 minutes apart, get help if no pain relief after med administration

Prinzmental’s Angina (aka variant, angina inversa)

Chest pain that occurs at rest, usually at night or early morning
Triggered by emotional stress, cold weather, smoking, medications that narrow blood vessels
NI: Nitrates, calcium channel blockers

Myocardial Infarction
Blockage of blood flow to heart; ECG shows ST Meds for MI
elevation
M Morphine
S/sx: severe chest pain/pressure, dyspnea, diaphoresis
O Oxygen
Women s/sx: neck, shoulder or jaw pain, fatigue, SOB,
N Nitroglycerine
n/v, heartburn
A Aspirin
Meds to give: MONA
Morphine, oxygen, nitrates, aspirin
Tests: Myoglobin, CK, and Troponin

Heart Failure
Heart is unable to pump enough blood to meet the
body’s oxygen demands
Blood backs up into body (right sided HF) or into lungs
(left sided HF)
NI: O2 if needed, diuretics, monitor vital signs and I&O’s,
listen to heart and lung sounds, assess for hypoxia and
edema, daily weights, fluid and sodium restriction

Right-sided HF/ Cor Pulmonale

Caused by left ventricular failure Normal Heart Failure
S/sx: peripheral edema, JVD, weight gain, hepatomegaly

Left Sided HF
S/sx: pulmonary edema, dyspnea, orthopnea crackles,
cough

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Cardiovascular
Cardiac Tamponade
Fluid buildup in the pericardium → creates pressure → heart unable to pump effectively
Medical emergency → cardiac arrest and circulatory shock
Beck’s Triad - hypotension, JVD, muffled heart sounds
Pericardiocentesis needed to remove pericardial fluid

Pericarditis
Inflammation of outer layer of the heart
Indicator: presence of a friction rub. S/sx: pleuritic chest pain
ECG finding: ST elevation and T-wave inversion
NI: pain control, NSAID’s, corticosteroids, monitor for s/sx of tamponade

Myocarditis
Inflammation of the myocardium; typically caused by viral infection
S/sx: fever, fatigue, chest pain, SOB
NI: O2 as needed, bed rest, diuretics, ACEi, sodium restriction (if heart failure develops)

Endocarditis
Inflammation of inner lining of heart
Causes: Infection (TB or Staph), autoimmune conditions (lupus)
S/sx: SOB, fever, palpitations, night sweats, chest pain
NI: IV abx, promote oral hygiene, assess for signs of emboli, surgery if needed

Peripheral Arterial Disease (PAD)

Chronic atherosclerotic disease caused by buildup of plaque within the arteries
Commonly affects lower extremities → tissue necrosis (gangrene)
Management: lower extremities below heart, moderate exercise to promote circulation, daily skin
care, maintain mild warmth (socks, blankets), stop smoking, avoid stress and tight clothing, take
prescription meds (vasodilators, antiplatelets) to increase blood flow

Coronary Artery Disease (CAD)

Plaque buildup causes coronary arteries to narrow → limits blood flow to heart
S/sx: angina, fatigue, SOB, heart attack
NI: control BP, low fat and low salt diet, quit smoking, exercise, encourage healthy lifestyle

Scleroderma
Causes abnormal blood flow in response to cold → Raynaud phenomenon

Fat Embolism
Usually occurs after fractures of long bones
At risk: femur fracture
S/sx: SOB, confusion, tachycardia, lethargy
Diagnostic/labs: “snow storm” on chest x-ray, increased ESR (detects inflammation in the body),
hypocalcemia, respiratory alkalosis
NI: Oxygen, IV fluids, bed rest, assess respiratory status

Deep Vein Thrombosis (DVT)

Thrombus forms in vein; typically legs
Risk → Virchow’s Triad Virchow's Triad
S/sx: warm skin, calf pain, edema
S Stasis of venous circulation
NI: bed rest (prevent clot dislodgment), elevate
H Hypercoagulability
extremity, compression stockings, administer
E Endothelial damage
anticoagulants and/or thrombolytics, measure
circumference of affected area

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Cardiovascular
Additional Notes:
Improve perfusion → EleVate Veins, dAngle Arteries
Assess BP in both arms of patients who have new diagnosed hypertension
If pt has mechanical valves → need anticoagulation therapy for life to prevent thromboembolism
If your patient has fluid retention, think heart issue first
BNP (lab) is made by the heart and is released when the heart is under stress, trying to meet the
demands of the body
BNP >100 pg/mL = heart failure

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Neurology
Decorticate positioning
Arms bent, legs straight, stiff Key Words
Damage to cortex Aphasia- inability to speak
Dysphasia- difficulty speaking
Decerebrate positioning
Arms and legs straight Dysarthira- slurred speech
Severe damage to cerebellum or brain stem Apraxia- inability to perform movements
or tasks
Seizures
Tonic- stiff then loss of consciousness
Clonic- body spasms
Myoclonic - quick muscle jerk
Atonic - sudden lack of muscle strength
Postictal phase - occurs after a seizure and ends when pt is back to baseline

Status epilepticus
Seizure lasting more than 5 min or having multiple seizures without regaining full consciousness
Convulsive vs nonconvulsive
Convulsive - most dangerous; tonic-clonic seizures

Seizure Nursing Interventions (NI):

help pt lay down, place on side (to maintain airway), loosen tight clothes, give O2, record seizure
duration

Strokes
Risk factors: hypertension, atherosclerosis, history of strokes, diabetes, smoking
S/sx: motor loss (hemiparesis or hemiplegia), communication loss (dysphasia, dysarthria, apraxia,
aphasia), vision changes, decreased mental acuity
Start rehabilitation as soon as patient is stable
NI: control BP, neuro assessment, position pt to decrease edema, bed rest, stool softeners

Ischemic Stroke; TIA Hemorrhagic Stroke

Blockage of blood flow to brain due to clot Brain bleed due to ruptured blood vessels
NI: give TPA within 3-4 hours of symptoms Anticoagulation therapy is contraindicated

Aneurysm
Buldge in a blood vessel that can lead to rupture → hemorrhagic stroke
S/sx: vision changes, headache, nuchal rigidity, dizziness
NI: promote calm environment, bed rest

Parkinson’s Disease
Central nervous system disorder that affects motor ability due to low dopamine levels
S/sx: tremors, pill rolling movement, rigidity, stooped posture, bradykinesia, difficulties with gait
NI: promote pt safety, schedule activities later in the day (conserves pt energy to perform self-care
activities), calm environment, soft diet, physical therapy

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Neurology
Increased ICP
Cushing's Triad
Pressure builds in the skull; blocking brain circulation
Sign = Cushing's Triad, change in LOC or pupil size, headache, Bradycardia
blurry vision, vomiting
Hypertension
NI: elevate HOB 30 degrees, keep body widline, promote calm
environment, give stool softeners, tell pt to avoid Valsalva Wide pulse
maneuver pressure
Meningitis
Inflammation of the membranes surrounding the brain and spinal cord
Caused by viral, bacterial, or fungal infections
Early warning signs: photophobia, drowsiness, confusion
S/sx: nuchal rigidity (stiff neck), Brudzinski’s (when pt neck is flexed → flexion of knees & hips) and
Kernig’s sign (pt unable to straighten leg when hip is flexed), fever, headache, muscle pain
Diagnostic test: Cerebrospinal fluid test
If positive, CSF will have high protein and low glucose
NI: give abx, Droplet/contact precautions, neuro assessment, vital signs, keep environment dark
and calm, seizure precautions

Guillain Barre
Immune system attacks it’s own nerves, causing ascending paralysis
S/sx: paresthesia (numbness and tingling), difficulty breathing, pain, vision changes
NI: Assess respiratory status, mechanical ventilation may be needed

Multiple Sclerosis
Chronic disease that affects the brain and spinal cord; more common in women
Immune system attacks myelin sheath → breakdown of communication between neurons
Bladder and bowel dysfunction occurs in most cases
S/sx: numbness, vision problems, slurred speech, fatigue
NI: promote tolerable exercises, implement rest breaks, create voiding schedule, high fiber diet and
fluid intake

Myasthenia Gravis
Muscle weakness and fatigue of voluntary muscles; d/t issues concerning ACh
Improves with rest and worsens with physical activity
S/sx: diplopia (double vision), ptosis (eyelid drooping), weakness, breathing issues
NI: assess respiratory status, have trach kit at bedside, administer cholinergic meds, cluster care (to
conserve pt energy), encourage deep breathing and coughing

Myasthenia Crisis
Medical emergency due to worsening muscle weakness, causing respiratory failure
Caused by undermedication, stress, or infection
S/sx: worsening MG symptoms
Diagnostic: positive Tensilon test

Cholinergic Crisis
Occurs when there is excessive acetylcholine (ACh) in the neuromuscular junction
Typically caused by too much anticholinesterase medication (given in myasthenia gravis)
S/sx: cramps, diaphoresis, diarrhea
NI: give antidote = atropine sulfate

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Neurology
Amyotrophic Lateral Sclerosis (ALS)
Progressive muscular disease caused by the degeneration of nerve cells
Affects voluntary muscle movements, such as walking, breathing, and talking
NI: assess respiratory status, encourage PT/OT/SP

Autonomic Dysreflexia
Medical emergency seen in spinal cord injuries - T6 or higher
S/sx: severe hypertension, bradycardia, sweating, anxiety, headache
Nursing: elevate HOB to 90 degrees, remove tight clothing, administer antihypertensive medications

Basilar Skull Fracture

Fracture of one of the bones at the base of the skull
S/sx: Bruise behind ear (battle sign), periorbital hematoma (raccoon eyes), halo sign, hearing loss
NI: assess ABC, neuro exam, GCS, CT scan

Wenicke’s Encephalopathy
Neuro disorder characterized by low thiamine (Vitamin B1)
D/t alcohol abuse, eating disorders, or chemo C
S/sx: confusion, ataxia, abnormal eye movements

Spinal Cord Injuries

If injury is between:
T1 - L4 - Paraplegia T
C1 - C8 = Quadriplegia
C2 - C3 = Typically fatal
C4 and above = require ventilator
NI: assess respiratory status, neuro checks, immobilize pt on
backboard, keep body midline

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Immunology
Immunoglobulins
IgA- viral protection
IgE- allergy and parasite infestation
IgG- second antibody protection
IgM- primary antibody protection

Allergies
Basophiils release histamine during an allergic response
In pts with latex allergies → assess for allergies to bananas, kiwis, apricots, avocados, grape

Sepsis
Medical emergency in which the body’s response to an infection gets out of control, which can cause
tissue damage and organ failure
S/sx: Hypotension, tachycardia, SOB, fever, confusion

Anaphylaxis
Severe allergic reaction that requires immediate intervention
S/sx: nausea/vomiting, SOB, rash, anxiety

HIV
Spread by contact through blood, semen, vaginal secretions, breast milk
No cure but can be controlled. Pt is on standard precautions
Priority: prevent infection
Lab testing: positive ELISA, Western blot test, PCR
If not treated, it can lead to AIDS

AIDS
Virus caused by aids
S/sx: low WBC, low CD4, low platets, weight loss, fever, night sweats, weakness, infections
Pt must maintain strict adherence to antiretroviral therapy
Official diagnosis: CD4+ falls below 200 cells/mcl
Incubation is variable, but typically occurs within 10 years after infection

Systemic Lupus Erythematosus (SLE)

Autoimmune disease that causes extensive inflammation and tissue damage
S/sx: butterfly rash, joint pain, fever, fatigue, weight loss, nephritis
Triggers: sunlight, stress, drugs, pregnancy
NI: teach patient to avoid sunlight exposure, provide steroids, advise patient to wash skin with mild
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Oncology & Hematology

Radiation
Monitor pt for infection due to leukopenia

Metastasis
Common sites: liver, brain, bone, lung, lymph

Breast Cancer
Modifiable risk factors: alcohol consumption, smoking, sedentary lifestyle, poor diet high in fat
Non-modifiable risk factors: BRCA1 & BRCA2 mutations, having a 1st degree relative with breast
cancer, history of uterine cancer, menarche before 12 years old, menopause after 55 years old
Exam: check for lumps or hard knots in the shower, under arms and around entire breast area.
Examine any changes in the shape of the breast and nipple by looking in the mirror.
Perform exam monthly, preferably post menstrual bleeding. If postmenopausal, exam should be
done the same date every month.
Mammography is helpful in early detection
Treatment depends on stage of disease: mastectomy, chemotherapy, radiation, hormonal therapy

Post Mastectomy
Elevate arm to avoid lymphedema, avoid heavy activity and lifting, do not wear constrictive clothing or
get BP reading from affected arm

Testicular Cancer
Small, hard lump on the front or side of testicle
At risk: men whose testes have not dropped into the scrotum or whose testes dropped after age 6
All men 14 years and older should do self exams monthly in the shower

Multiple Myeloma
Cancer of plasma cells (WBC’s that produce antibodies)
Myeloma cells prevent the normal production of antibodies → infection

Radioactive Iodine
***FLUSH with at least 3-4 liters/day for 2 days and flush the toilet twice
Limit contact with others to 30 minutes/day
No pregnant nurses, visitors, and no kids

Immunosuppression
Most oncologic meds cause immunosuppression → prevention of infection is vital
Place pt in private room. Pt should NOT eat raw fruits or vegetables

Tumor Lysis Syndrome

Tumor cells release their contents into the bloodstream
Causes hyperkalemia requires insulin to IV solution to decrease potassium level. *Check blood
glucose

Thrombocytopenia
Place on bleeding precautions
Give soft bristled toothbrush
Decrease IM meds and do not insert anything (enema or suppositories)

Iron Deficiency Anemia

Give iron PO with vitamin C or on an empty stomach
Iron given IM- Inferon via Ztrack

Pernicious Anemia
Needs to take Vitamin B12 for LIFE- due to lack of intrinsic factor in the gastric mucosa
S/sx: tachycardia, pallor, beefy red tongue
Shilling Test- determines how well one absorbs Vit. B12

*If a patient has low hematocrit and/or hemoglobin, assess for signs of bleeding (i.e. dark stools)

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Nephrology
Acute Kidney Injury
Kidney’s unable to filter waste from the blood; potentially reversible
S/sx: High level of creatinine and/or reduction in urine output, fluid retention (edema, HTN), changes
in LOC, uremia
NI: Monitor I&O, daily weight, BP, hyperkalemia, limit sodium and fluid intake, dialysis may be needed

Chronic Renal Failure

Irreversible damage which causes uremia
Dialysis needed to remove waste from blood
Pt at risk for hyperkalemia and fluid overload
NI: Restrict protein in CRF patients, monitor for fluid overload (JVD), daily weights, monitor I&O

Glomerular Filtration Rate (GFR) Ranges

>90 = normal
60-89 = mild CKD; Stage 2
30-59 = moderate CKD; Stage 3
15-29 = severe CKD; Stage 4
<15 = end stage renal disease ; Stage 5

Urinary Tract Infection (UTI)

Upper - pyelonephritis; potentially life threatening → urosepsis
S/sx: Flank and back pain, fever, n/v
Lower - urethritis & cystitis; commonly caused by E. coli
Risk: pregnant women, pts w/ diabetes, men with prostatic hypertrophy, older adults
NI: abx, teach pt to take entire course of abx, increase fluid intake, I&O’s, encourage pt to void q2-3h,
monitor for confusion in elderly pts, avoid catheterization

Urinary Tract Obstruction

Blockage in one or both ureters, inhibiting urine to drain from kidneys to bladder
Causes: caliculi, strictures, tumors
Location of stone can be determine by location of pain
NI: pain control, increase fluid intake (to dislodge stone), IV abx (as needed), assess urine for stone,
I&O’s

Neurogenic Bladder
Lack of bladder control due to CNS issues
Also seen in pts w/ Parkinson’s, MS, and spina bifida
S/sx: UTI, urinary incontinence, kidney stones
NI: create voiding schedule, double voiding, pelvic floor exercises, intermittent cath, pt may need
indwelling cath

Benign Prostatic Hyperplasia (BPH)

Enlargement of the prostate that occurs in older men
S/sx: increased frequency or urgency to urine, nocturia, difficulty initiating urininating
NI: encourage frequent voiding, increase fluid intake, monitor vital signs, I&O’s, medications
(antispasmodics, alpha-adrenergic antagonists)
Transurethral Resection of Prostate (TURP) may be needed
Continuous bladder irrigation is needed post op to remove blood clots. Irrigate until urine is light
pink.

Nephrotic Syndrome
Leads to proteinuria → hypoalbuminemia → fluid shifts → edema

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Nephrology
Additional Notes:
Kidneys normally excrete 1mL/kg/hr.
Typical adult urine output: 1500 - 2000 mL (varies based on condition)
Indicator for renal status and fluid retention → body weight (weigh pt at same time & same scale daily)
If pt is receiving dialysis → monitor for s/sx of shock (d/t blood loss)
Restrict protein in CRF pts
GFR is used as an indicator for protein consumption

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Endocrine
Diabetes
Hyperglycemia
Type I DM
Insulin deficiency due to destruction of beta cells hot and dry
Without insulin, fats are metabolized for energy, Hypoglycemia
which results in ketones acidosis
cold and clammy

Diabetic Ketoacidosis
Sudden onset, increased ketones and acetone due to inadequate insulin dose
Glucose >300, ketones in urine, fruity breath, confusion, Kussmaul’s respirations, increased thirst and
urination
1st thing to do → start IV infusion of normal saline
Severe dehydration occurs and must be rehydrated before insulin is administered
*Expect potassium to drop rapidly, so be ready with potassium replacement
Dropping glucose down too fast can cause increased intracranial pressure d/t water being pulled
into the CSF

Type II DM
Resistance or lack of insulin

Hyperglycemic Hyperosmolar Nonketonic Syndrome (HHNS)

Glucose >600
Severe dehydration, low potassium due to diuresis, no ketones or acidosis
S/sx: altered LOC, increased thirst and urination, lethargy, coma

HbA1C
Test that averages blood glucose levels over the past 90-120 days
4-6 = blood sugar level around 70-110
7 is ideal for a diabetic

Drawing up insulin: Nicole Richie RN

Air into NPH, then air into Regular, draw up Regular insulin then NPH

Insulin

Dawn Phenomenon
Early morning hyperglycemia in pts with diabetes

Somogyi Effect
Occurs when pt takes insulin before bed, has hypoglycemia around 2-3am, and wakes up with
hyperglycemia.
The insulin lowers the blood sugar too much, causing a rebound effect

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Endocrine
Additional Notes
Fluids are the most important intervention in DKA and HHNS
Do NOT give oral hypoglycemic meds to unconscious patients d/t risk of aspiration
Additional insulin may be needed for patients on steroids (i.e. prednisone). Steroids increase glucose
levels.

Diabetic neuropathy
Earliest sign is microalbuminuria

Diabetes Insipidus: disorder of salt and water metabolism

Excessive thirst and urination, dehydration, weakness
Decreased ADH
NI: monitor electrolytes, I&O’s, give fluids, monitor urine specific gravity and serum osmolality

SIADH: water retention and dilutional hyponatremia

Body retains water which can lead to water intoxication and hyponatremia
Increased ADH
Nursing interventions: daily weights (monitor for fluid overload), give diuretics, assess deep tendon
reflexes, assess for neurological changes if sodium <115, maintain quiet environment and prevent
overstimulation (prevent seizures)

Risks for metabolic syndrome

Abdominal obesity, sedentary lifestyle, high levels of triglycerides
These increase the risk for coronary artery disease, DM Type II, stroke

Addison’s Disease - hypocortisolism

Dark pigmentation, weight loss, alopecia, decreased resistance to dress, GI distress
Labs: hyperkalemia, hyponatremia, hypoglycemia
*Most important assessment in Addisons → blood pressure, as it causes severe hypotension
Help patient work on managing stress to avoid Addisonian crisis
Addisonian crisis s/sx: confusion, weakness, nausea/vomiting, abdominal pain, hypotension,
hypoglycemia, dehydration

Cushing’s Syndrome - hypercortisolism

Moonface/buffalo hump, hirsutism, hypertension, muscle wasting, weakness
Hyperglycemia, hypernatremia, hypokalemia
NI: monitor weight, I&O’s

Grave’s Disease - Hyperthyroidism

Accelerates metabolism, causing weight loss and arrhythmias
Fine/soft hair, sensitive to heat, irritability, exophthalmos
Thyroid Storm: think HOT (hyperthermia), hypertension, tachycardia

Myxedema - Hypothyroidism
Slows metabolism, dry skin and hair, sensitive to cold, faitgue
Myxedema coma - due to severe hypothyroidism; medical emergency
S/sx: decreased mental status, hypothermia, slows function of organs

Post-thyroidectomy
Assess for hypocortisolism and temporary diabetes insipidus
Patient position: semi-fowlers, prevent neck flexion, and have trach at bedside

Hyper-parathyroid
fatigue, memory loss, body aches, difficulty sleeping, joint pain (d/t increased calcium), renal calculi
Give calcitonin (regulates calcium levels in blood by decreasing it)
Diet focused on low calcium and high phosphorus foods

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Endocrine
Hypo-parathyroid
CATS: convulsions, arrhythmias, tetany, spasms, stridor. Decreased calcium levels.
Diet focused on high calcium and low phosphorus foods. Give Vitamin D to help calcium absorption

Chvostek sign
Sign of hypocalcemia
Twitching of facial muscles after tapping on a pts cheek

Trousseau sign
Sign of hypocalcemia
Carpopedal spasm (involuntary flexion of muscles in hand and wrist) resulting from ischemia
How to test: place BP cuff on patients arm and begin to inflate (spasm is induced by compression)

Pheochromocytoma
Hormone secreting tumor that can occur in the adrenal glands
Causes hypertension, headache, tachycardia, hyperglycemia, diaphoresis
Avoid stress and stimulating foods. Surgery to remove the tumor is usually required.

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Gastrointestinal
Bowel Obstruction
2 types: mechanical (caused by an object) or non-mechanical (paralytic ileus)

Small Bowel Obstruction

Causes: hernia, abd surgery, adhesions
S/sx: cramping, n/v, pain is mid-abdominal, severe constipation
NI: NPO, IV fluids, I&O’s, NG-tube w/ low suction, pain management

Large Bowel Obstruction

Medical emergency - risk for intestinal rupture
S/sx: lower abdominal pain, n/v, diarrhea, constipation, no appetite
NI: NPO, IV fluids, I&O’s, NG-tube w/ low suction, pain management

Colostomy
Operation where a pt’s colon is diverted to an opening in the abdominal wall; temporary or
permanent
NI: assess skin integrity around stoma, clean stoma with warm water and pat dry, prevent liquid stool
in bag from overflowing, teach colostomy care

Dumping Syndrome
Can develop after stomach surgery and causes abdominal pain
Increase consumption of fats and proteins, eat small meals, lie down after meals, wait 1 hr after meals
to drink liquids

Hiatal Henria
Part of stomach bulges through the diaphragm, causing heartburn and abd
pain
NI: eat small frequent meals, eliminate foods that worsen symptoms, have pt
sit upright for one hour after eating, place pt in Fowler or semi-Fowler
position (to reduce regurgitation)
Hiatal Hernia
Peptic Ulcer Disease (PUD)
Sore in the mucosal wall of the GI tract; can be caused by H. pylori
Coffee brown emesis
Duodenal → melana stool
Gastric → hematemesis
NI: Monitor stools and test for occult blood, give meds and mucosal healing agents, give small
frequent meals

Gastroesophageal Reflux Disease (GERD)

Regurgitation of stomach acid into the esophagus, causing
heartburn, dysphagia, chest pain
Pain typically occurs after eating and worsens when lying down
Pt should avoid triggers: spicy food, caffeine, chocolate, citrus fruits
NI: encourage small frequent meals, teach pt to stop eating 3 hours
before bed, give H2 antagonists, PPI, antacids
Closed sphincter Open sphincter

Esophageal Varices
Enlarged veins in esophagus; occurs when blood flow to liver is blocked by the portal vein
NI: maintain open airway, monitor for rupture and hemorrhage, suction if needed
Management: insertion of esophagogastric balloon tamponade, coagulation factors, vitamin K,
vasopressors

Stoma
Opening on the abdomen; should be pinkish
Dark/Dusky stoma = poor blood supply
Black = necrosis
Protruding = prolapsed

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Gastrointestinal
Crohn’s Disease
Inflammation of digestive tract causing abdominal pain, diarrhea,
malnutrition, weight loss
Diet should be low fat, high protein, no dairy or spicy foods
NI: monitor I&O and electrolytes, track weights, assess bowel
patterns, educate pt to avoid alcohol, smoking, and caffeine

Ulcerative Colitis
Inflammation of large intestine and rectum that causes liquid stools
(blood & mucus), abdominal pain, rectal bleeding, anemia, fatigue
NI: refer to Crohn’s

Cirrhosis
Liver damage which causes scarring and liver failure; causes
jaundice and palpable liver
Labs: elevated ammonia
Slows metabolism of drugs, so they linger in the body
Causes: hepatitis and chronic alcohol use
NI: give ADEK vitamins, assess mental status, avoid anything that
could cause bleeding, give lactulose (excretes ammonia), daily
weights, monitor I&O, monitor protein intake

Hepatitis

Pancreatitis
Caused by digestive juices or enzymes attacking the pancreas
Signs - Cullen and Turner’s sign
Cullen sign - discoloration of umbilical area, Turner’s sign - bruising of the flanks
NI: Place patient in knee-chest position (decrease pain), NPO, typically will be placed on gut rest and
need a PICC for TPN/lipids

Cholecystitis
Gallbladder inflammation d/t the buildup of bile in the gallbladder
Causes cholelithiasis (gallstones), which blocks bile from being excreted
S/sx: n/v, epigastric pain that radiates to right scapula after eating high fat foods, RUQ pain, rebound
tenderness, jaundice, Murphy’s sign, guarding
NI: NPO, IV fluid, abx, anticholinergics, pain control

Enema
Monitor for water intoxication (signs/symptoms: weakness, pallor, dizziness, diaphoresis)

Additional Notes:
Stopping TPN abruptly → hypoglycemia
Injured hepatic cells release AST and ALT. High levels of AST & ALT = liver injury or disease

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Musculoskeletal / Ortho
Ascending Stairs
Cane
Step with stronger leg, move the cane to the next step,
Walking
then move the weaker leg
C Cane
Descending Stairs O Opposite
Lead with the cane, bring weaker leg down, then step A Affected
down with stronger leg L Leg

*Remember: Up with the good, down with the bad *Cane always moves before
weaker leg*
5 P’s of fractures
Pain, pallor, pulselessness, polar (cold), paresthesia

Types of Fractures
Displaced - bone breaks in pieces and moves out of alignment
Non-Displaced - bone breaks and stays in alignment
Open - bone breaks through skin
Closed - skin is not broken
Comminuted - bone breaks into multiple pieces
Complete - bone breaks across entire section
Incomplete - bone does not break across entire section
Oblique - bone broken at angle
Compression - bones are crushed
Transverse - bone breaks in a straight line
Segmental - bone broken in at least 2 places; a segment of bone is separated by breaks
Stress - hairline fracture
Spiral - fracture spirals around bone; caused by twisting injuries
Greenstick fracture - bone breaks on one side and bends on the other; common in peds

Buck’s Traction
Ensures proper alignment, weights hand freely and do NOT touch the floor
Do not remove or lift weights without a doctor’s order

Casts
NEVER insert anything under cast; allow 24-72 hrs for cast to dry
To relieve itch, use cool air from blow dryer

Hip Fracture
Monitor for s/sx of hemorrhage
Thromboembolism is the most common complication; prevention includes passive ROM exercises,
elevate foot of bed to 25 degrees, wear elastic stockings
NI: avoid internal and external rotation of more than 60 degrees, avoid weight bearing on affected leg,
leg position should be ABDUCTION (prevents dislocation), avoid crossing legs, monitor neurovascular
status of the injury site (skin color, sensation, cap refill, temp, mobility)

Oblique Comminuted Spiral Complete Greenstick Segmental Transverse

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Musculoskeletal / Ortho
Joint replacement
Major complication post op is infection

Immobility d/t orthopedic limitations

Pt’s are prone to venous thrombosis, skin integrity issues, and buildup of urinary calculi

Osteoporosis
Bones become weak and brittle; pts are prone to fractures
S/sx: hump or kyphosis, back pain, loss of height
At risk: postmenopausal, thin, white women
NI: encourage a high calcium diet, weight-bearing exercise, supplemental calcium (& Vit D for
absorption)

Osteomyelitis
Infectious bone disease
NI: Get blood cultures and antibiotics. If necessary, surgery may be required to drain abscess

Gout
High uric acid in the body causes buildup of uric acid crystalls in the joints
Causes severe pain, inflammation, and redness
NI: low purine diet (avoid sugar, organ meats, alcohol, yeast), promote high fluid intake, NSAID’s,
corticosteroids, rest as needed

Rheumatoid Arthritis
Autoimmune and inflammatory disease that affects joints
Pain relief is high priority
During an acute episode, do NOT assess range of motion,
as this is painful. Teach patient not to exercise swollen
joints
S/sx: generalized weakness, fatigue, stiffness, joint
deformity
NI: Assess the pt using strength testing, palpation, and
inspection. avoid weight bearing on inflamed joints, rest,
PT & OT
Rheumatoid Arthritis
Treatment: corticosteroids, immobiliztion, splinting,
immobilization, NSAID’s (pain), rest
Diagnostic: Rheumatoid factor blood test

Normal Osteoarthritis Rheumatoid arthritis

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Integumentary / ENT / Eyes

Wound Drainage

Psoriasis
Chronic skin disease that causes a rash with scaly patches; itchy
Meds: topical corticosteroids, methotrexate
NI: Educate pt on triggers - stress, dry skin, trauma, infection. Advise patient to limit or eliminate
alcohol and smoking.

Shingles (Herpes Zoster)

Painful rash caused by reactivation of chickenpox virus
S/sx: fluid-filled blisters, fever, shooting pain, pruritis
Treatment: pain relief and antiviral medications
Place on contact precautions

MRSA
Resistant bacteria that is difficult to treat with antibiotics
Causes painful red bumps on skin that may turn into abscesses
Place on contact precautions

Meniere’s Disease
Disorder of the inner ear that causes vertigo and hearing loss
Nursing: administer diuretics, restrict sodium, lay on affected ear when in bed

Eyes
OS - Left eye
OD - Right eye
OU - Both eyes

Strabismus (crossed eyes)

Can be treated with botox
Patch the GOOD eye so the weaker one gets stronger

Glaucoma
In angle closure glaucoma do not take meds that dilate the pupil → can precipitate acute and severely
increase intraocular pressure
NO atropine medications

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Critical Care
Pulmonary Capillary Wedge Pressure (PCWP)
Normal: 8-13 mm Hg
Measures left atrial pressure

Cardiac Arrhythmias Treatments

Uncontrolled atrial fibrillation → synchronized cardioversion
Ventricular dysrhythmias → Lidocaine
Ventricular fibrillation or unstable ventricular tachy Defibrillate
Sinus bradycardia → Atropine

Implantable Cardioverter Defibrillator (ICD)

Given with life-threatening dysrhythmias
Pacemaker capabilities
Pt teaching: refrain from lifting affected arm above shoulder until physician says OK. Firing can be
painful.
Ventilator Alarms
High Alarm - obstruction due to increased secretions, Ventilator Alarms - HOLD
tubing kink, or if they pt coughs or gags on tubing
H High alarm
Low Alarm - disconnection or leak; pt stops breathing
O Obstruction
NI: assess what alarm went off and provide intervention
L Low Alarm
as needed; assess oxygen level; call RT and/or MD if
D Disconnection
assistance is needed

Positive End-Expiratory Pressure (PEEP)

Used during mechanical ventilation to maintain airway pressure above atmospheric pressure
Improves oxygenation while decreasing FiO2 to a less toxic level

Tracheostomy
Trach care: clean inner cannula, suction, and place new dressing
Always have suction equipment at bedside

Blood Transfusion
1. Find pt’s blood type and crossmatch with another RN
a. Need at least 2 pt identifiers
b. Blood must be administered within 20 minutes
2. Obtain baseline vital signs, educate pt on s/sx of transfusion reaction
3. Prepare Y tubing with NS; clamp NS
4. Spike blood bag and leave blood clamp open
5. Infuse slowly for first 15 minutes and stay with pt to assess for reactions (nausea, vomiting, chills,
hypotension, fever, back pain, dyspnea)
6. Take vital signs after 15 minutes AND when infusion is done
7. Deliver blood over 2-4 hours
8. After infusion is complete, open NS clamp to flush blood from tubing

Reaction Suspected
Immediately STOP transfusion
Disconnect tubing and assess s/sx of reaction
STAY with the pt. NEVER leave pt alone until MD comes or symptoms resolve.
Notify MD and blood bank
Document event

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Critical Care
Shock
Shock
Widespread reduction of tissue perfusion that can lead to organ damage (d/t lack of oxygen and
nutrients)
Early s/sx: restlessness and agitation (d/t cerebral hypoxia)
S/sx: hypotension, tachycardia, weak peripheral pulses
Shock can lead to multiple organ dysfunction syndrome (MODS), systemic inflammatory response
syndrome (SIRS), respiratory distress, pleural effusion, death
NI: Oxygen/ventilation, IV fluid rescusitation (restore tissue perfusion), assess vital signs, cardiac meds
(varies based on type of shock)

Disseminated Intravascular Coagulation

Coagulation disorder that causes thrombosis and hemorrhage
Labs: prolonged PT & PTT, decreased fibrinogen and platelet count
S/sx: petechia, hemoptysis, oozing from IV sites & gums, GI bleeding, hypotension, tachycardia
NI: assess for s/sx of bleeding, monitor PT/INR levels, IV heparin during first phase to inhibit
coagulation, provide emotional support

Multi-Organ Dysfunction Syndrome (MODS)

Inadequate tissue perfusion and increased oxygen demands

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Critical Care
ABG

pH

Low High

Acidosis Alkalosis

High Low Low High

PaCO2 HCO3 PaCO2 HCO3

Respiratory Metabolic Respiratory Metabolic

Acidosis Acidosis Alkalosis Alkalosis

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Pediatrics
3 H’s of peds on why they code
Hypoxia
Hypothermia
Hypoglycemia

Symptoms of hypoxia
Difficulty eating, sternal retractions, nares flaring

Urinary output
Infants and childrem should be 1-2 mL/kg/hr

Vaccines
No LIVE vaccines for immunocompromised children
Varicella-zoster
Measles/mumps/rubella
Rotavirus
Yellow fever

Immunizations
Ask if pt has an allergy to eggs before flu shot and MMR vaccine
Child can still receive immmunzations if they have a cold
Children with HIV: avoid Polio and Varicella vaccinations (live). Can still get pneumococcal and
influenza
Avoid MMR only if the child is severely immunocompromised

Varicella (Chickenpox)
Viral disease that cause itchy skin lesions
Airborne precautions; Spread by direct contact & droplet
Meds: acyclovir, analgesic, antihistamine

Rubeola (Measles)
High contagious viral disease characterized by rash, Koplik’s spots (lesions in the mouth), photophobia
Airborne precautions
“10 day measles”
NI: bed rest, encourage fluids, ensure pt has short nails (protect skin), antipyretics, keep skin moist
with prescribed lotion

Rubella (German Measles)

Viral disease characterized by rash that starts on face and spreads, low grade fever, sore throat,
enlarged lymph nodes
Droplet precautions
“3 day measles”
NI: keep infected pt away from pregnant women as they are a risk to the fetus

Pertussis (Whooping Cough)

Infectious respiratory disease characterized by uncontrollable coughing, respiratory distress, cyanosis,
exhaustion
Droplet precautions
NI: Abx, oxygen and suction as needed

Neutropenic Precautions
Wash hands often
Avoid contact with sick people, those recently vaccinated, and large crowds
No milk, yogurt (live cultures), fresh fruit, or vegetables

Lead poisoning
Assess if child lives in a home built before the 1950’s
Elevated blood lead levels >5 mcg/dL requires follow-up blood work
Chelatin therapy given if blood lead levels are high

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Pediatrics
Ears
Pull pinna down and back for kids < 3 years old when putting in eardrops

Otitis Media
Infection of the middle ear
To prevent: Feed upright, breatfeed for first 6 months, immunizations
S/sx: fever, child may pull ear, enlarged lymph nodes, discharge from ear
NI: abx, reduce body temp through tepid bath, position child on affected side, may need
tympanostomy tubes placed

Lice
S/sx: itchy scalp, irritability, red bumps on affected areas
NI: Use PPE to assess scalp, behind ears, base of neck, and crown of head for lice, use Wood’s lamp
(black light) to find lice, apply pediculicide shampoo, comb hair with nit comb, change linen and
clothes daily

Impetigo
Red sores around nose and mouth caused by bacteria (typically staphylococcus). Sores rupture, ooze,
then turn yellow-brown
Risk: children aged 2-5, close contact with others, warm/humid weather
NI: Contact precautions, keep sores open to air, abx (topic and oral), promote proper hygiene

Cleft Lip/Palate
Pt born with opening in roof of mouth and/or lip due to
failure of bone/soft tissue to fuse
ESSR
Cleft lip repair done at 3-6 months; cleft palate repair E Enlarge Nipple
done 6-24 months S Stimulate infant to suck
Pt at risk for otitis media and speech impairment S Swallow
NI: promote family bonding and grieving, teach family R Rest
surgery is available, assist with feeding using ESSR, bulb
syringe at bedside to remove oral secretions

Esophageal Atresia with Traceoesophageal Fistula

Congenital abnormality in which the esophagus does not fully develop
3 C’s of TEF - coughing, choking, cyanosis; also causes excess salivation
Surgical emergency
NI: NPO, IV fluids, gastrostomy tube care, suction, give pacifier to promote developmental needs
Post op- monitor for dysphagia, drooling, regurgitated food

Pyloric Stenosis
Swelling of the pyloris (muscle b/w stomach and intestines) that occurs between birth - 6 months.
Causes forceful vomiting → dehydration
Treated with surgery - pyloromyotomy

Intussusception
Part of intestine telescopes inside another, resulting in partial or complete obstruction
S/sx: abd pain (raises legs up to abd), currant jelly stools, sausage shaped mass in RUQ, vomiting
NI: assess for shock and perforation, IV fluids, barium enema, I&O’s

Hirschsprung’s Disease
Absence of ganglion cells in colon and rectum → S/sx Perforation
peristalsis → obstruction
S/sx: no meconium within 24 hrs after birth, vomiting
distended abd, constipation, ribbonlike stools increased abd pain
(older children) abd distention
Pre-op: bowel cleansing, measure abd girth, cyanosis
assess for perforation dyspnea
Post-op: Teach family temporary colostomy care

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Pediatrics
Reye Syndrome
Disorder that causes severe encephalopathy and hepatic dysfunction
Causes: pt recovering from viral infection (flu or chickenpox), aspirin use
S/sx: lethargy, n/v, diarrhea, confusion
NI: neuro assessment, give mannitol (if prescribed), I&O’s

HIV
Children born from HIV positive mothers should be given antiretroviral treatment
Souce of infection: perinatal transmission, breast milk, HIV infected blood procedurs, sexual abuse

Sickle Cell Anemia

Main interventions: fluids and pain relief

Leukemia
Cancer of the blood or bone marrow
May cause epistaxis (d/t low platelets), hyperplastic gums (overgrowth of gum tissue around teeth),
increase in WBC count, weakness

Hemophilia
X linked recessive disorder characterized by the inability to form clots
S/sx: increased bleeding, bruising, epistaxis, blood in stool or urine
NI: assess for bleeding, administer clotting factors

Von Willebrand disease

Genetic bleeding disorder that inhibits coagulation d/t low levels of von Willebrand factor
S/sx: bleeding of mucus membranes, epistaxis, heavy menstrual bleeding

Epiglotitis
Medical emergency that causes airway obstruction Tripod
Do NOT examine throat (can lead to spasm → obstruction) Position
S/sx: fever, barking cough, dysphagia, drooling, restlessness,
Sitting upright
child assumes tripod position
with chin out,
NI: maintain airway, do not leave child alone, keep pt in
tongue protruding
upright position, cool mist O2, prepare for intubation/trach, IV
abx, do NOT measure oral temp

Bronchiolitis
Respiratory virus typically casued by RSV that is characterized by thick secretions
S/sx: cough, rhinorrhea, congestion, tachpnea, wheezing
Teach parents to use saline nose drops and suction nares with bulb syringe
NI: Contact isolation, monitor respiratory status, suction airway with bulb syringe, O2 as needed, oral
and IV fluids

Cystic Fibrosis
Autosomal recessive disorder that causes secretions to be thicker and stickier
CF severely damages the lungs, digestive system, and reproductive system d/t thick mucus causing
obstruction
Typically occurs in white infant or children
S/sx: recurrent respiratory infx, pulmonary congestion meconium ileus at birth, steatorrhea (excessive
fat, greasy stools), bad smelling bulky stools, skin that tastes salty
NI: monitor respiratory status, IV abx, pancreatic enzymes (take with food), fat-soluble vitamins
(ADEK), respiratory treatments: oxygen, nebulizer, vest, teach pt they will need a diet high in calories,
protein, mod-high fat, low carbs, exercise

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Pediatrics
Congestive Heart Failure (CHF)
Heart is unable to meet the demand’s of the body
S/sx: SOB, tachypnea, cyanosis, weight gain & edema, difficulty feeding, hepatomegaly
NI: daily weights, vital signs, elevate HOB, O2 as needed, diuretics and digoxin as prescribed, I&O’s, low
sodium and/or fluid restriction
Weigh pt daily at the same time and on the same scale

Cyanotic Heart Disease Acyanotic Heart Disease

Cyanotic Acyanotic
Unoxygenated blood enters Oxygenated blood enters systemic
systemic circulation circulation

Both acyanotic and cyanotic have abnormal circulation.

Kawasaki Disease
Systemic vasculitis that casues damage to vessels, mucus membranes, lymph nodes, and skin
S/sx: Strawberry tongue, rash on trunk and genitals, redness or peeling of hands/feet, high fever, n/v,
joint pain
NI: administer IVIG and aspirin, antipyretics, I&O’s, mouth care, place cool compresses and lotion on
skin

Rheumatic Fever
Inflammatory disease that affects the tissues of the heart, blood vessels, joints, and skin
Occurs weeks after untreated strep throat or scarlet fever
Ask parents if the child was recently sick
S/sx: SOB, chest pain, fever, migratory joint pain, chorea (irregular involuntary movements), rash,
subcutaneous nodules over bony prominences
NI: abx, aspirin (for antiinflammatory and anticoagulation), bed rest, vital signs

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Pediatrics
Cerebral Palsy
Irreverisble disorder that causes neuromuscular issues of dyskinesia (involuntary movements) or
spasticity
S/sx: involuntary movements, poor sucking, abnormal posture, scissoring of legs, seizures, delayed
developmental milestones
NI: PT/OT/ST, place pt in upright position when eating (prevent aspiration), provide support to family,
anticonvulsant meds, diazepam (muscle spasms)

Hydrocephalus
Abnromal buildup of CSF within the ventricles in the
brain → pressure on brain tissue
Toddlers and children show signs of ICP: increased BP, Increased Shock
decreased HR ICP vs
Increased ICP is the opposite of shock Decreased HR Increased HR
Infants with increased ICP: enlarged head Increased BP Decreased BP
circumference, lethargy, irritability, bulging fontanels,
sunset eyes, widening suture lines
S/sx: irritability, change in LOC, waking up w/headache,
vomiting, unequal pupil size, seizures
NI: assess pt’s baseline data to compare new s/sx of ICP,
seizure precautions, elevate HOB, prep for ventricular
shunt placement (drains excess fluid)

Spina Bifida
Neural tube defect that occurs when the spinal cord fails to form properly
Prevention: teach women in childearing years to take minimum 400 mcg folic acid daily
S/sx: dimple at base of spine, presence of sac on lumbar, flaccid paralysis
NI: screen pt for latex allergy
Post-op: teach family and pt (if applicable) to self catheterization, give continence meds, high fiber
diet, increased fluids, assess skin integrity, ROM exercises

Hypospadias
Opening of urethra is located on the ventral side of the penis, not the tip
S/sx: altered voiding stream, undescended testes, inguinal hernia
NI: surgery needed, monitor urinary drainage post op, IV fluids, teach family home care for
catheterization

Infant Feeding Regimen

Breastfeed from birth - 6 months
Introduce solid foods b/w 4-6 months
Wait 5-7 days after introducing new foods to assess for allergic reactions
Cow’s milk ok to give at 1 year old

Nutrition Notes
Do NOT give honey to pts under 1 years old. They are at risk for botulism
Look out for questions regarding how much milk they are drinking (more than 3-4 cups/day). Too
much milk reduces the amount of iron they intake so watch for anemia.
Patients with PKU cannot break down phenylalanine. Avoid high protein foods - meat, dairy, nuts,
legumes. Do NOT give them aspartame.

Additional Notes:
Normal urine output for infants and children is 1-2 mL/kg/hr
The usage of ipecac for posion removal is no longer recommended by the American Academy of
Pediatrics. The nurse should teach parents to not induce vomiting, as it may be more harmful
Do NOT use tongue blade during a seizure, as it can damage oral cavity

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Maternity
Terminology

Gestation Nulligravida
Time from fertilization until date of delivery Woman who has never been pregnant
Gravida Primigravida
Pregnant woman Woman who is pregnant for the first
Gravidity time
# of pregnancies Multigravida
Parity Woman who is pregnant for at least the
# of births past 20 weeks gestation 2nd time
(born alive or not)
GTPAL
Nullipara
Gravidity
Woman who has not had a birth
Term births (at least 37 weeks)
greater than 20 weeks gestation
Preterm births
Primipara Abortion/miscarriages
Woman who has had 1 birth that
Current living children
happened after 20 weeks gestation

Pregnancy Length
Length: 280 days, 40 weeks, 9 calendar months, 10 lunar months (28 day months)
1st Trimester: starting from the first day of last menstrual period - 13 weeks
2nd Trimester: 14 -26 weeks
3rd Trimester: 27 - 40 weeks

Pregnancy
Causes a hypercoagulable state that protects the mother from hemorrhage after birth → may lead to
thrombus formation

Nagele Rule for Estimating Date of Birth

Find the first day of the last menstrual period (LMP)
Add seven days
Then subtract 3 months
Ex: LMP is November 1, 2022
Add 7 days = November 8, 2022
Subtract 3 months = August 8, 2023

Fundal Height
Measurement of the uterus to determine gestational age of fetus

Fetal Heart Rate

Can be heard via Doppler at 10-12 weeks gestation

Prenatal Visits for Low-Risk Pregnant Women

Visit MD every 4 weeks until 28 weeks, every 2 weeks from 28-36, then once a week from 36-40
weeks

Defect Screenings
Some states require screening for neural tube defects
They will use maternal alpha-fetoprotein (AFP) levels or amniotic fluid AFP levels. Note this specific
test is prone to false positives/negatives

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Maternity
Amniocentesis
Done early in pregnancy → bladder must be full
If done late in pregnancy → empty bladder (to avoid being punctured)

Epidural
Hydrate before

C-section
Increases risk for DVT (deep vein thrombosis)

Placenta abruption
Rigid boardlike abdomen, dark red vaginal bleeding
Severe pain
Monitor I&O

Placenta Previa
Soft abdomen
Painless, bright red vaginal bleeding

Amniotic fluid
Fluid is alkaline, which turns nitrazine paper blue. Urine and vaginal discharge are acidic and will turn
it pink
If the fluid is yellow with particles → meconium stained

Folic Acid
Give before pregnant and throughout pregnancy
Vitamin; used for anemia
Leafy vegetables, eggs, citrus foods

NSAID’s
May take in 1st and 2nd trimester only if benefits outweigh the risks
Avoid in 3rd trimester due to risk of premature closure of the ductus arteriosis in the fetus

Acetaminophen
Pain reliever/fever reducer commonly taken during pregnancy
Do not exceed 4g per day

Magnesium Sulfate
Used in preeclampsia
Therapeutic range: 4-8 mg/dL

Nonstress Test
Noninvase test in which fetal heart rate is monitored in response to fetal movement
Mom pushes event marker every time she feels movement or when the FHR strip records movement
Performed after 28 weeks gestation
Reactive result = Normal
Fetal HR increased with movement (15 BPM for 15 seconds)
Indicates adequate blood flow and oxygen to fetus
Nonreactive result = Further testing needed (Stress Test or BPP)
Fetal HR does not increase with movement
Other tests will determine if the result is due to sleep patterns, maternal medications, or fetal
hypoxia
If no fetal movement is shown, suspect fetus is sleeping
Stimulate fetus acoustically or have mom move fetus around

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Maternity
Stress Test
Induction of uterine contractions to show how the baby will respond during labor
Contractions are induced by nipple stimulation or oxytocin infusion
Performed after 34 weeks gestation and only if mother had an atypical result from a nonstress test or
biophysical profile
Negative result = Normal
Fetus HR does not slow during contraction → fetus properly responding to stress (3 contractions in
10 min)
Positive result = Abnormal
Fetus HR slows during contraction → fetus is under stress

Biophysical Profile
Nonstress test + ultrasound to assess the health of the fetus
5 areas are assessed:
Body movement, breathing movement, muscle tone, heartbeat, and amniotic fluid
Each area is scored as either 0 (abnormal) or 2 (normal)
Scores: 8-10 = normal, 6 = borderline, <6 = sign of possible complication

APGAR

Scoring: 0-3 = Severely Depressed (Resuscitate), 4-6 = Moderately Depressed, 7-10 = Excellent

VEAL CHOP

NI: change pt position, administer O2, discontinue oxytocin (Pitocin), notify MD

Positioning
Cord prolapse → knee-chest position or push the presenting part off the cord until a c-section is done
Cord compression → Trendelenberg
Removes pressure from the cord
Late decels → turn to left side (allows more blood flow to placenta)

L/S Ratio
Test that examines lung maturity, lung surfactant, and development
Most important determinant of fetal maturity for survival post birth

Station
Location of presenting part in cm above or below the spine; the specific part of the baby that is
leading the way through the birth canal (e.g. head, shoulder, feet, etc.)
0 - Engaged; at ischial spine
Minus: above ischial spine (e.g. -2)
Plus: below ischial spine (e.g. +2)

Cervical Effacement
Ripening; cervix shortens, thins, and softens to prepare for birth

Leopold Maneuvers
Palpation of the abdomen to detmerine fetal presentation, position, lie, and engagement

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Maternity
Stages of Labor

Hyperventilation during Labor

Can cause respiratory alkalosis
NI: give mom paper bag to breathe

Nitrazine Paper
Used to determine if membrane has ruptured
The paper turns dark blue/back

Oxytocin (Pitocin)
Causes uterine contractions
Give after placenta is delivered
Giving it before may can placenta retention → hemorrhage and infection

Lochia Types
Rubra- bloody discharge that lasts 2-3 postpartum
Serosa- pinkish brown discharge that lasts 1 week postpartum
Alba - thick, white/yellow discharge that lasts up to 4 weeks postpartum

Lochia Amount (per hr)

Scant: < 1inch or 2.5 cm
Small: < 4 inch or 10 cm
Moderate: < 6 inch 15 cm
Heavy: fully saturated pad

Breast Engorgement
Breats feels tender, warm, and taut
Treatment: have baby suck frequently, breast massage, do interventions that increase milk flow, warm
water, supportive bra
Cabbage leaves can also treat breast engorgement

Meconium
Stained fluid that is yellow/green or gold may indicate fetal stress

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Maternity
Fetal Alcohol Syndrome
Thin upper lip, flat nasal bridge, small for gestational age

Rhogam Factor
Given IM at 28 weeks and 72 hours postpartum
Only given mothers who are Rh-NEGATIVE (negative Coomb’s test) who have a Rh-positive baby
If indirect Coomb’s test is positive, that means the mother already has the antibody

Cephalhematoma (Caput Succinidanium)

Edema that crosses the sutures lines
Resolves on its own a few days after birth

Severe Pre-Eclampsia s/sx

HELLP
Hemolysis
Elevated Liver Function tests
Low Platelet count

If → Then
If a pregnant woman is choking and loses consciousness → then place in supine position with a wedge
under right hip
Displaces uterus to the right and prevents supine hypotension
If a woman comes to the hospital in active labor, the nurses first action is to listen to fetal heart rate
If cord is prolapsed, cover it with sterile saline gauze to minimize risk for infection and drying of the
cord
If there is any dangerous fetal heart rate pattern, give mom oxygen
If the baby is vertex (normal), the sounds are above the symphysis pubis
If the baby is in a posterior presentation, heart sounds are heard at the sides
If the baby is anterior, heart sounds are heard around midline (under umbilicus)
If the baby is breech, heart sounds are high in the fundus (above umbilicus)

Labor Notes
If pt has hypotension, bradypnea, or bradycardia: EMERGENCY
Never check the monitor or machine as first action/priority. Always assess the pt first
Determine cervical dilation before telling them to push. Pushing should begin at 10 cm (if started too
early, cervix can become swollen → inhibiting full dilation)
FHR is best heard through the fetal back in vertex

Newborn Notes
Best way to warm a newborn → skin to skin contact

Additional Notes:
Assess women in private if they are experiencing emotional or physical abuse from their partner

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Mental Health
Pt SAFETY is #1 PRIORITY

Delirium
Acute onfusion or disorientation
NI: Reassure pt, stay calm, provide safe environment

Dementia
Chronic
Redirect and orient pt to reality, show familiar objects, set daily schedule

Alzheminer’s Disease
5 A’s
Amnesia (loss of memories)
Aphasia (impacts ability to communicate)
Apraxia (difficulty with skilled movement)
Anomia (unable to recall known words)
Agnosia (unable to identify objects, sounds, people)

Magical Thinking
Pt believes their thoughts can control other people and events

Schizophrenia
Impaired ability to perceive reality
S/sx: hallucinatiosn, delusions, disorganized speech and behavior, catatonia, negative symptoms
NI: establish trust, provide safe environment, assist with ADL’s and hygiene, sit with mute pt’s, be
nonjudgmental, use clear and simple sentences, avoid arguing with pt, praise socially acceptable
behaviors
Treatment: antipsychotics, individual and family therapy, social skills training

Positive Symptoms:
Hallucinations
Delusions

Negative Symptoms:
Flat affect
Anhedonia (lack of pleasure)
Poverty of speech
Movement disorders

Obsessive-Compulsive Disorders
NI: actively listen to pt, acknowledge how the pt feels, provide empathy, avoid judgement
Treatment: Antianxiety, SSRI’s, tricyclic antidepressants

Post Traumatic Stress Disorder (PTSD)

Triggered by traumatic event that can cause anxiety, flashbacks, and nightmares
NI: actively listen to pt, assess suicide risk, help pt see the event objectively and identify areas of no
control
Treatment: antianxiety and anytipsychotic meds

Personality Disorders
Pt displays inappropriate emotional responses to stress, which is shown through anxious and
fearful behaviors
Includes: antisocial, narcissistic, borderline, schizotypal, avoidant, obsessive-compulsive
NI: establish trust, protect pt from injury to self and others, help pt realize manipulative behaviors
and set limits, focus on pt’s strengths, encourage socialization

Munchausen Syndrome
A person who pretends to be ill or inflicts self harm or illness in order to receive medical care or
hospitalization

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Mental Health
Munchausen by Proxy
A person (usually a mother) intentionally causes or makes up an illness in another person (usually a
child)

Tardive Dyskinesia
Irreversible, involuntary movements of the tongue, face and extremities
Due to prolonged use of antipsychotic meds

Depression
Always assess pt, especially if they have a sudden increase in energy or mood (might be planning
suicide)
Symptoms can be manifested in somatic ways (pain, sleep issues, changes in appetite, low energy)
NI: Directly ask pt how they feel and if they are suicidal, implement suicide precautions, monitor
sleep and nutrition, encourage participation in activities, promote independence, sit quietly with pt
if they do not want to talk, spend time with pt and keep your word (if you tell pt you will be back at
5pm, see them at 5pm)
Suspect immediate suicide attempt if a depressed pt suddently feels better → happy affect may
imply pt is relieved to have a suicide plan and plans to follow through
Signs pt is improving: pt takes interest in appearance, performs self-care activities,

Bipolar Disorder
Bipolar I - mania with depressive episodes
Bipolar II - milder episodes of hypomania that alternate with episodes of severe depression
Manic s/sx: increased energy, impulsiveness, talkative, reduced need for sleep, excessive spending,
delusions of grandeur or persecution
NI: Ensure pt has adequate nutrition and rest, provide safe environment, decrease environmental
stimulation, do not give attention to bizarre behavior, provide small frequent snacks/food (finger
eating food)
Treatment: Lithium, antipsychotics, sedatives, family therapy

Phobic Disorders
Intense periods of fear and discomfort that can be incapacitating
NI: Acknowledge fear, use systematic desensitization (exposure therapy) only AFTER trust is
established

Anorexia Nervosa
2 Types: restrictive and binge/purging
S/sx: weight loss (at least 15% of original body weight), distorted body image, excessive exercise, low
self esteem, decreased BP and irregular HR, hair loss, dry skin, dehydration, no menstruation
Absence of menstruation can lead to osteoporosis
NI: monitor weight, vital signs, and electrolyte levels, provide supportive environment and
structured mealtimes, set eating time limits, close assessment to food and fluid intake, watch for
discarding of food, use positive reinforcement to build self esteem
Treatment: Antidepressants, family therapy

Bulimia Nervosa
S/sx: dental damage (d/t vomiting), sore throat, concerned with body shape (bulimics are not
typically underweight), diarrhea, constipation, bloating
NI: monitor weight, vital signs, and electrolyte levels, provide supportive environment and
structured mealtimes, monitor for induced vomiting after meals, discuss strategies to stop laxative
use and vomiting, provide positive reinforcement for increase self esteem
Treatment: Antidepressants, family therapy

Alcoholism
5 D’s
Denial, destructive, demanding, domineering, dependency

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Mental Health
Extrapyramidal Side Effects
Rigidity, shuffling gait, tremors
Administer an anticholinergic (ex: benztropine mesylate) to reverse side effects

Neuroleptic Malignant Syndrome (NMS)

EMERGENCY caused by a reaction to antipsychotic meds
NMS is like S&M: fever, diaphoresis, muscle rigidity, hypertension, tachycardia, tachypnea, drooling

Additional Notes:
Do not argue with a pt about delusions. State things as a matter of fact and divert delusion to
reality
Do not tell pt you also hear voices
Be supportive and nonjudgmental to all patients
Adolescents are at an increased risk for suicide

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Leadership
RN LVN/PN CNA/UAP

RN
Responsible for assessment, pt teaching, and nursing judgment Do not delegate
CANNOT delegate anything stated above what you can EAT

LVN/PN E Evaluate
Similar to role of RN but CANNOT push or give any IV medications A Assess
Can be given nursing interventions, but CANNOT assess pt T Teach

Advanced Directive
Legal document that states a person’s wishes regarding medical care
Used in the event they are no longer able to make medical decisions for themselves due to serious
injury/illness
2 types: living will & power of attorney
Living will: describes medical treatments a pt would/would not want to use used to keep them
alive, as well as, organ donation and pain management
Power of attorney: Delegated person to make decisions for the pt when they are unable to do so.
Also called health care agent/proxy. The person can be a spouse, family member, friend, or
member of a faith community that is 18 years of age or older

Ethics
Fidelity
Fulfilling commitments made to others
Loyalty

Negligence
Failure to adequately uphold the standard of care

Nonmaleficence
Do no harm

Beneficence
To do good

Justice
Treating all patients fairly

Veracity
Telling the truth

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Pharmacology

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Pharmacology
Antihypertensives - decrease BP

Cardiac (ABCDD)

A Ace Inhibitor *decreases BP

Ends in –pril
Ex: Lisinopril

B Beta Blocker *decreases HR

Ends in –lol
Ex: Atenolol

C Calcium Channel Blocker *decreases BP & HR

Ends in –dipine, -zem, amil
Ex: Nifedipine, Diltiazem, Verapamil

D Digoxin *increase contractility

Cardiac glycoside → deep contraction and increases contractility
Hold if apical pulse is <60, Potassium under 3.5, Digoxin toxicity >2 (signs and symptoms: vision
changes, nausea/vomiting, fatigue, dizziness)

D Diuretics *decreases BP
Loop or thiazide
Furosemide causes dehydration (furosemide=body is dried)
Potassium WASTING → teach pt. to increase intake of potassium foods

Cardiac Notes:
Vasopressin - think press in/vasoconstrict
If on oral anticoagulants, glucagon (controls glucose levels) may increase effect → risk for bleeding

Morphine
Preload reducer = less blood in right atrium

Nitroglycerine
Vasodilator → increases oxygen, reduces preload

Analgesics
Acetaminophen (Tylenol) - used for fever and pain relief

NSAIDS
Used for inflammation, fever, and pain relief
Types
Indomethacin
Ibuprofen
Naproxen (treats joint pain and inflammation)
Side effects
GI toxicity: black tarry stools, dyspepsia and pain if taken on empty stomach
Kidney injury
HTN and HF: cause fluid retention
Bleeding risk
Monitor liver enzymes

Antivirals
Help body fight off virus; not a cure
Acyclovir (Zovirax)

Antibiotics
Destroys or slows down growth of bacteria
NI: always obtain cultures before starting antibiotics

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Pharmacology
Anticoagulant
Slows down the body’s process of making clots Emergency
Heparin, Warfarin, Lovenox, Plavix Medications

L Lidocaine
Antiplatelet
E Epinephrine
Prevent platelets from clumping together to form a clot
A Atropine Sulfate
Aspirin
N Narcan
Given to pts who have had a MI or stroke

Bronchodilators
Relaxes bronchi → allows air to come in and out of the lungs & assists with excreting mucus
Used in inhalers or nebulizers
Ipratropium (Atrovent), budesonide (Pulmicort)

Antacids
Reduce gastric acidity by raising pH of the stomach contents and protecting stomach mucosa
Treats heartburn, ulcers, gastritis, esophagitis, hyperphosphatemia

Antiemetics
Reduces nausea, vomiting, and motion sickness
Ondansetron (Zofran)

Antihistamines
Reduces s/sx of allergies; some cause drowsiness
Cetirizine (Zyrtec), fexofenadine (Allegra)

Steroid Side Effects

6 S’s
Sugar - hyperglycemia
Salt - salt and water retention → HTN
Sex - decreased libido
Sad - depression
Soggy bones - osteoporosis
Sick - decreased immunity

Antidepressants
SSRI’s
Antidepressant that is effective for sadness, compulsions, and panic

MAOI’s - antidepressant
Think PANAMA and arrrr (Pirates say arrr → Pirates take MAOI’s when they are depressed)
PA- parnate, NA - nardil, MA - marplan

Antipsychotics
Treats psychosis and decreases agitation and confusion
Typical - positive symptoms
Atypical - negative symptoms
Can take several weeks to reach desired effect

When to Take
Diuretics → AM
Steroids → AM
Growth Hormone → PM

Additional Notes
Pt’s taking digoxin or potassium supplements: avoid salt substitutes (contain potassium)
Atropine is also used for pupil dilation and paralysis in preparation for examination or surgery
Do NOT give morphine sulfate to patients with pancreatitis. Give pt demerol
Pt’s taking digoxin and/or lasix are at risk for hypokalemia. Ensure pt is receiving enough potassium.
Hypokalemia → Digoxin toxicity → hyperkalemia

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Good luck on the NCLEX!

Notes

References
All figures (exception to pg 16) were generated using Servier Medical Art, provided by Servier, licensed
under a Creative Commons Attribution 3.0 unported license
([Link]

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