BIO 2020 103 NCLEX/MedSurg Master
Study Guide
, NCLEX/MedSurg Master Study Guide
Nursing Process:
A-
assessment
D - diagnosis
O - outcome planning (specific, measurable, timely)
• Ex. The patient will walk 300 ft in the hallway by the end of the
shift (3pm) P - planning
• Planning is done WITH patient, not FOR them. Let them assist in making goals
that they see as doable
I-
intervention
E-
evaluation
• Reflecting on whether the goal was met/ what could be changed to help the
pt. Reach it
• not evaluating **ourselves** we are evaluating whether or not the
goal was MET Nursing Virtues:
Beneficence - “do good”
Non maleficence - “do no harm”
Veracity - telling the truth, never lying or trying to deceive a patient
• If you make a med error, if a patient asks you about their disease
Fidelity - keeping your promises
Autonomy - pt. Is allowed (and supported) to make their own decisions
• Choosing treatment plans, right to advance directives, DNR orders, etc.
Justice - providing fair care to all
• Providing equal care to patients no matter what (age, sex, race, LGBT,
religion, disease)
Confidentiality - keeping things between you and the patient
• If a patient tells you something, it should remain between the two of you
• The ONLY times you can break confidentiality are when the patient’s safety
is involved (ex. Pt. is going to commit suicide, mandatory reporting of elder
abuse, etc)
Privacy - pt. Is entitled to their own personal privacy
• Closing the door /curtain when they are physically exposed/leaving the
room if the patient is on the toilet
Normal Lab Values:
Digoxin 0.5-2, anything above 2 will give nausea, vomiting, diarrhea,
and VISUAL disturbances (yellow halo around anything they are looking
at)
• If the patient is hypokalemic (low potassium), makes it easier for them to
go into Dig. toxicity
• Hold digoxin if their heart rate is below 60 bpm
Lithium - 0.5-1.5, hold for anything higher! Tremors, confusion, seizures etc.
• Typically used for bipolar disorder
• Never double up 22 on lithium doses if you miss one -- safety!
• Lithium messes with their sodium! They need to stay stable with their
sodium intake and consult their doctor before vigorous work outs / saunas /
etc. because sweat can cause
them to lose too much sodium. When they lose sodium, it makes it easier for
lithium toxicity to occur
Phenytoin/Dilantin 10-20
• Used most often for seizure disorders
• Blood levels have to monitored over time to adjust dosage -- pt. Gets frequent
lab draws
• Phenytoin reaction can cause anemia - dyspnea, fatigue, paleness, rashes,
, swelling and bleeding of the gums.
BUN: 10-20, indicative of kidney function, monitor for nephrotoxic drugs
Creatinine: 0.6-1.3, indicative of kidney function, monitor for nephrotoxic drugs
, INR (Warfarin) normal 1-2, on warfarin want it to be 2-3 to prevent clots
PT (Warfarin) normal 11-13 seconds,want it to be 1.5-2x longer than that
aPTT (Heparin) (remember 2 T’s in H) normal 30-45 seconds, want it to be 1.5-2.5x
longer than that. <45sec =clots!
Hgb 12-18%
HCt female: 37-47%, male: 42-52%
• In pregnancy, H&H can **appear** lower because the woman’s plasma
volume is expanding -- does not mean they are necessarily bleeding if
H&H dips a little bit
CVP (central venous pressure, in the heart) 2-6, low CVP is dehydration, high CVP is
fluid overload
• High CVP = rales in lungs, JVD, dyspnea, tachycardia
• Low CVP = shock, signs of dehydration
Platelets 150,000-400,000, below 150 we are worried about bleeding - bleeding
precautions!
ANC (Absolute neutrophil count) - ~2200-7000
Minimum urine in an hour: 30ml/hr
GFR (glomerular filtration rate): should be above 60 with healthy kidneys
WBC’s: 4,000-11,000
Sodium: 135-145 - low/high sodium causes neuro problems = confusion, altered LOC,
coma
ALL things potassium:
Potassium: 3.5-5 -- altered potassium = HEART Dysrhythmias, mainly V-tach
• Foods with a lot of potassium: bananas, sweet potatoes
• We NEVER give potassium via IV push, it can kill the person!!
• K+ always given on IV pump, needs to be SLOW over 2-4 HOURS so that
we don’t change their K+ too quickly; never more than 10 mEq/hr
• If patient has hyperkalemia - Give IV insulin and then immediately give IV
dextrose - forces potassium back into cells so it is not floating around in
the blood causing problems
• Hyperkalemia: HIGH potassium = peaked T waves, wide QRS, wide PR
(everything is UP)
• Hypokalemia: LOW potassium = U wave at the end, depressed “low
waves”, muscle cramps = especially CALF -- if pt has low potassium they
can go into torsades = BAD
•
• Also tell patient to avoid “salt substitutes” in their diet because those
oftentimes contain potassium in them instead
Calcium:
normal 8.6-10.2
• Low calcium = crazy muscles!
• Laryngospasms*** priority because this is your throat! Airway
compromise!
• Positive chvostek / trousseau’s sign
• Seizures
• Muscle tightness and cramping
• Hyperactive bowel sounds, diarrhea
• When to worry about low calcium?? After a thyroidectomy!! The
parathyroid glands (which break down bone and put calcium into the
blood) are on the thyroid….. So
sometimes during surgery the parathyroid glands can be removed with the
thyroid!! This will cause low low calcium = look for the low calcium signs
when they get back from thyroid surgery!
Study Guide
, NCLEX/MedSurg Master Study Guide
Nursing Process:
A-
assessment
D - diagnosis
O - outcome planning (specific, measurable, timely)
• Ex. The patient will walk 300 ft in the hallway by the end of the
shift (3pm) P - planning
• Planning is done WITH patient, not FOR them. Let them assist in making goals
that they see as doable
I-
intervention
E-
evaluation
• Reflecting on whether the goal was met/ what could be changed to help the
pt. Reach it
• not evaluating **ourselves** we are evaluating whether or not the
goal was MET Nursing Virtues:
Beneficence - “do good”
Non maleficence - “do no harm”
Veracity - telling the truth, never lying or trying to deceive a patient
• If you make a med error, if a patient asks you about their disease
Fidelity - keeping your promises
Autonomy - pt. Is allowed (and supported) to make their own decisions
• Choosing treatment plans, right to advance directives, DNR orders, etc.
Justice - providing fair care to all
• Providing equal care to patients no matter what (age, sex, race, LGBT,
religion, disease)
Confidentiality - keeping things between you and the patient
• If a patient tells you something, it should remain between the two of you
• The ONLY times you can break confidentiality are when the patient’s safety
is involved (ex. Pt. is going to commit suicide, mandatory reporting of elder
abuse, etc)
Privacy - pt. Is entitled to their own personal privacy
• Closing the door /curtain when they are physically exposed/leaving the
room if the patient is on the toilet
Normal Lab Values:
Digoxin 0.5-2, anything above 2 will give nausea, vomiting, diarrhea,
and VISUAL disturbances (yellow halo around anything they are looking
at)
• If the patient is hypokalemic (low potassium), makes it easier for them to
go into Dig. toxicity
• Hold digoxin if their heart rate is below 60 bpm
Lithium - 0.5-1.5, hold for anything higher! Tremors, confusion, seizures etc.
• Typically used for bipolar disorder
• Never double up 22 on lithium doses if you miss one -- safety!
• Lithium messes with their sodium! They need to stay stable with their
sodium intake and consult their doctor before vigorous work outs / saunas /
etc. because sweat can cause
them to lose too much sodium. When they lose sodium, it makes it easier for
lithium toxicity to occur
Phenytoin/Dilantin 10-20
• Used most often for seizure disorders
• Blood levels have to monitored over time to adjust dosage -- pt. Gets frequent
lab draws
• Phenytoin reaction can cause anemia - dyspnea, fatigue, paleness, rashes,
, swelling and bleeding of the gums.
BUN: 10-20, indicative of kidney function, monitor for nephrotoxic drugs
Creatinine: 0.6-1.3, indicative of kidney function, monitor for nephrotoxic drugs
, INR (Warfarin) normal 1-2, on warfarin want it to be 2-3 to prevent clots
PT (Warfarin) normal 11-13 seconds,want it to be 1.5-2x longer than that
aPTT (Heparin) (remember 2 T’s in H) normal 30-45 seconds, want it to be 1.5-2.5x
longer than that. <45sec =clots!
Hgb 12-18%
HCt female: 37-47%, male: 42-52%
• In pregnancy, H&H can **appear** lower because the woman’s plasma
volume is expanding -- does not mean they are necessarily bleeding if
H&H dips a little bit
CVP (central venous pressure, in the heart) 2-6, low CVP is dehydration, high CVP is
fluid overload
• High CVP = rales in lungs, JVD, dyspnea, tachycardia
• Low CVP = shock, signs of dehydration
Platelets 150,000-400,000, below 150 we are worried about bleeding - bleeding
precautions!
ANC (Absolute neutrophil count) - ~2200-7000
Minimum urine in an hour: 30ml/hr
GFR (glomerular filtration rate): should be above 60 with healthy kidneys
WBC’s: 4,000-11,000
Sodium: 135-145 - low/high sodium causes neuro problems = confusion, altered LOC,
coma
ALL things potassium:
Potassium: 3.5-5 -- altered potassium = HEART Dysrhythmias, mainly V-tach
• Foods with a lot of potassium: bananas, sweet potatoes
• We NEVER give potassium via IV push, it can kill the person!!
• K+ always given on IV pump, needs to be SLOW over 2-4 HOURS so that
we don’t change their K+ too quickly; never more than 10 mEq/hr
• If patient has hyperkalemia - Give IV insulin and then immediately give IV
dextrose - forces potassium back into cells so it is not floating around in
the blood causing problems
• Hyperkalemia: HIGH potassium = peaked T waves, wide QRS, wide PR
(everything is UP)
• Hypokalemia: LOW potassium = U wave at the end, depressed “low
waves”, muscle cramps = especially CALF -- if pt has low potassium they
can go into torsades = BAD
•
• Also tell patient to avoid “salt substitutes” in their diet because those
oftentimes contain potassium in them instead
Calcium:
normal 8.6-10.2
• Low calcium = crazy muscles!
• Laryngospasms*** priority because this is your throat! Airway
compromise!
• Positive chvostek / trousseau’s sign
• Seizures
• Muscle tightness and cramping
• Hyperactive bowel sounds, diarrhea
• When to worry about low calcium?? After a thyroidectomy!! The
parathyroid glands (which break down bone and put calcium into the
blood) are on the thyroid….. So
sometimes during surgery the parathyroid glands can be removed with the
thyroid!! This will cause low low calcium = look for the low calcium signs
when they get back from thyroid surgery!
