Do not delegate - What you can *EAT*
*E*-evaluate
*A*-assess
* T-*teach
Addison's & Cushings - Addison's = down down down up down
Cushings= up up up down up
hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia,
hypo/hyperglycemia
Better peripheral perfusion? - Elevate veins, D-Angle Arteries
APGAR - Appearance (all pink, pink and blue, blue (pale)
Pulse (>100, <100, absent)
Grimace (cough, grimace, no response)
Activity (flexed, flaccid, limp)
Respirations (strong cry, weak cry, absent)
Airborne precautions - MTV or My chicken hez tb measles, chickenpox (varicella)
Herpes zoster/shingles TB
Airborne precautions protective equip - private room, neg pressure with 6-12 air
exchanges/hr mask & respirator N95 for TB
Droplet precautions - spiderman! sepsis, scarlet fever, streptococcal pharyngitis,
parvovirus, pneumonia, pertussis,
influenza,
diptheria,
epiglottitis,
rubella,
mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus
(Private room and mask)
Contact precaution - MRS WHISE
protect visitors & caregivers when 3 ft of the pt.
Multidrug-resistant organisms
RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases
caused by micro-organisms (C diff),
Gloves and gowns worn by the caregivers and visitors
Disposal of infectious dressing material into a single, nonporous bag without touching
the outside of the bag
,PMGG= Private room/ share same illness, mask, gown and gloves
Skin infection- *VCHIPS* - Varicella zoster
Cutaneous diptheria
Herpes simplez
Impetigo
Peduculosis
Scabies
Air or Pulmonary Embolism - S/S chest pain, dyspnea, tachycardia, pale/cyanotic,
sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.)
Woman in labor (un-reassuring FHR) - (late decels, decreased variability, fetal
bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids!
Tube feeding with decreased LOC - Pt on Right side (promotes emptying of the
stomach) Head of bed elevated (prevent aspiration)
LOC - Level of Consciousness
After lumbar puncture and oil based myelogram - pt is flat SUPINE (prevent headache
and leaking of CSF)
Pt with heat stroke - flat with legs elevated
during Continuous Bladder Irrigation (CBI) - catheter is taped to the thigh. leg must be
kept straight.
After Myringotomy - position on the side of AFFECTED ear, allows drainage.
Myringotomy - surgical incision into the eardrum, to relieve pressure or drain fluid.
After Cateract surgery - pt sleep on UNAFFECTED side with a night shield for *1-4
weeks*
after Thyroidectomy - low or semi-fowler's position, support head, neck and shoulders.
Infant with Spina Bifida - Prone so that sac does not rupture
Buck's Traction (skin) - elevate foot of bed for counter traction
After total hip replacement - don't sleep on side of surgery, don't flex hip more than 45-
60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction
by separating thighs with pillows.
Prolapsed cord - Knee to chest or Trendelenburg
, oxygen 8 to 10 L
Cleft Lip - position on back or in infant seat to prevent trauma to the suture line. while
feeding hold in upright position.
To prevent dumping syndrome - (post operative ulcer/stomach surgeries) eat in
reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals,
low CHO and fiber diet. small, frequent meals.
AKA (above knee amputation) - elevate for first 24 hours on pillow. position prone daily
to maintain hip extension.
BKA (below knee amputation) - foot of bed elevated for first 24 hours. position prone to
provide hip extension.
detached retina - area of detachment should be in the dependent position
dependent position - supported
administration of enema - pt should be left side lying (Sim's) with knee flexed.
supratentorial - (incision behind hairline on forhead) e
After supratentorial surgery - elevate HOB 30-40 degrees
HOB - head of bed
infratentorial - (incision at the nape of neck)
After infratentorial surgery - position pt flat and lateral on either side.
During internal radiation - on bed rest while implant in place
Autonomic Dysreflexia/Hyperreflexia - S/S pounding headache, profuse sweating, nasal
congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate
HOB) FIRST!
Shock - bedrest with extremities elevated 20 degrees. knees straight, head slightly
elevated (modified Trendelenberg)
Head Injury - elevate HOB 30 degrees to decrease ICP
Peritoneal Dialysis (when outflow is inadequate) - turn pt from side to side BEFORE
checking for kinks in tubing