NUR 475 HESI-Exit-and-NCLEX-Exam-Gems 2021/2022,100% CORRECT

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