Feb 22, 2011

Final comprehansive notes 1

Dilantin detoxified by liver.

The nurse cares for a client receiving IV antibiotics every 8 hours for the past 4 days. The antibiotic is mixed in D5W. The nurse determines that a post-infusion phlebitis has occurred if which of the following is observed?

1. Tenderness at the IV site.

2. Increased swelling at the insertion site.

3. Area around the IV site is reddened with red streaks.

4. Fluid is leaking around the IV catheter.

a. Tenderness occurs with phlebitis but is not specific to it.

b. May indicate either infiltration or phlebitis

c. CORRECT—reddened, warm area noted around insertion site or on path of vein; discontinue IV, apply warm, moist compresses, restart IV at new site

d. Not indicative of phlebitis

Ethacrynic Acid (Edecrin)—are considered loop diuretics and are potassium wasting; encourage client to increase intake of potassium-rich foods. Orange juice/Bananas, etc.

Aminophylline (Truphylline)—is a xanthine bronchodilator; major side effects: palpitations, nervousness, rapid pulse, dysrhythmias, nausea, and vomiting. Toxic effects: confusion, headache, flushing, tachycardia, and seizure.

Morphine Sulfate—decreases blood return to the right side of the heart, and decrease peripheral resistance. In other words, decreases preload and afterload pressures and cardiac workload; causes vasodilation and pooling of fluid in extremities; provides relief from anxiety.

Intropin (Dopamine)—vasoactive medication are given IV to restore BP in hypotensive states; Increases blood return to the right side of the heart, and increase peripheral resistance; side effects: headache, severe hypertension, dysrhythmias; check BP q2 minutes until stabilized, then q5 minutes

TPN—hang no longer than 24 hours; IV tubing and filters every 24 hours; site of catheter changed every 4 weeks.

Fluoxetine (Prozac)—a selective serotonin reuptake inhibitor (SSRI) used to treat depression and obsessive compulsive disorder. Side effects: postural hypotension, dry mouth, rapid heartbeat, anorexia, weight loss, severe headache. If dose is missed, omit dose and instruct client to return to regular dosing schedule.

Propanolol (inderal)—a beta-adrenergic blocker used as antihypertensive; Side effects: bronchospasm, bradycardia, depression, increase airway resistance. Take pulse and count respirations before administration and gradually decrease when discontinuing. Do not give to asthmatic patients.

Glipizide (Glucotrol)—an oral hypoglycemic that decreases blood sugar by stimulating insulin release from the beta cells of the pancreas; may cause aplastic anemia and photosensitivity.

Prednisone (Deltasone)—a corticosteroid. Side effects: hyperglycemia

Bethanechol (Urecholine)—a cholinergic or parasympathomimetic used to treat functional urinary retention; mimics action of acetylcholine.

Ventricular Tachycardia—causes chest pain, dizziness, and fainting.

1 grain = 60mg

Levothyroxine (Synthroid)—thyroid preparation should be administered at breakfast to prevent insomnia.

Carbamazepine (Tegretol)—interferes with action of hormonal contraceptives. Side effects: photosensitivity.

Aluminum Hydroxide (Amphojel)—an antacid; neutralizes hydrochloric acid and reduces pepsin activity; take one hour before and hour of sleep. Antacids most effective after digestion has started, but prior to the emptying of the stomach.

Isoniazid (INH)—Side effects: peripheral neuropathy (administer pyridoxine), rash, urticaria, and swelling of the face, lips, and eyelids.

Pyridoxine (Vitamin B6, Beesix, Doxine)—required for amino acid, carbohydrate, and lipid metabolism. Used in the transport of amino acids, formation of neurotransmitters, and sythesis of heme. Prevention of neuropathy.

Carbamazepine (Tegretol)—prevention of seizures and relief of pain in trigeminal neuralgia. Trigeminal neuralgia (Tic douloureux) is an agonizing pain that may result in severe depression and suicide.

Clonidine (Catapres-TTS)—is a centrally acting alpha-adrenergic used to treat hypertension; Side effects: drowsiness, sedation, orthostatic hypotension, heart failure. If patch used be cautious around microwaves results in burns, dispose of carefully, and heat will increase medication absorption leading to toxicity.

Phlebitis—tenderness, redness; remove iv, apply warm soaks to decrease inflammation, swelling, and discomfort.

Autologous blood—may give blood 5 weeks before surgery; can give 2 to 4 units of blood; may have to take iron pills

Partial-thickness burn; only part of skin is damaged or destroyed; large, thick-walled blisters develop; underlying tissue is deep red, appears wet and shiny; painful with increased sensitivity to heat; healing occurs by evolution of undamaged basal cells, takes about 21-22 days. I.E., Redness and swelling with fluid-filled vesicles noted on right arm or Blistering and blanching of the skin noted on the back.

Full-thickness burn; all skin is destroyed and muscle and bone may be involved; substance that remains is called eschar, dry to touch, doesn’t heal spontaneously, requires grafting. I.E., Charred, waxy, white appearance of skin on left leg.

Superficial burn; skin appears pink, increased sensitivity to heat, some swelling, healing occurs without treatment. I.E., Reddened blotchy painful areas noted on the face.

Carbidopa/Levodopa (Sinemet)—used to treat symptoms of Parkinson’s disease. Take immediately before meals and high-protein meals may impair effectiveness of medication. Reduces rigidity and bradykinesis and facilitates client’s mobility.

Doxycycline (Vibramycin)—a tetracycline that is taken at regular intervals but not within 1 hour of bedtime because it may cause esophageal irritation. Use another method of birth control, do not take antacids within 1-3 hours of taking medication, and may cause photosensitivity.

Albuterol (Proventil)—a bronchodilator. Side effects: tremors, headache, hyperactivity, tachycardia. Use first before steroid medication so opens up bronchioles for steroid to get in. Wait one minute between puffs of the inhalers for best effect.

Beclomethasone (Vanceril)—a steroid medication. Side effect: fungal infections, dry mouth, throat infections.

Insulin—NPH Onset: 1.5 hours Peak: 4-12 hours Regular Onset: 0.5 hours Peak: 2.5-5 hours

Topiramate (Topamax)—is an anticonvulsant. Should drink 2000-3000ml of fluid daily to prevent kidney stones. Side effects: orthostatic hypotension, ocular symptoms, blindness, and decrease effects of hormonal contraceptives.

Propranolol (Inderal)—a beta-blocker that takes up beta-adrenergic receptor sites, which prevents adrenaline from causing symptoms and glycogenolysis. Inderal may mask symptoms of hypoglycemia, removing the body’s early warning system.

Phenazopyridine (Pyridium)—acts on urinary tract mucosa to produce analgesic or local anesthetic effects. Side effects: bright orange urine, yellowish discoloration of skin or sclera indicates drug accumulation due to renal impairment.

Trimethoprim-sulfamethoxazole (Bactrim)—most common side effect mild to moderate rash (urticaria)

Aminoglycosides are ototoxic.

Butorphanol Tartrate (Stadol)—analgesic used for moderate to severe pain; Side effects include change in BP, bradycardia, respiratory depression.

Infant normal resting heart rate: 120-140

Salt substitutes contain potassium

When directing a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be reported. Because the RN is responsible for all care-related decisions, only implementation tasks should be assigned because they do not require independent judgment.

When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis)




Rash and blood dyscrasias are side effects of anti-psychotic drugs. A history of severe depression is a contraindication to the use of neuroleptics.

Children with celiac disease should eat a gluten free diet. Gluten is found mainly in grains of wheat and rye and in smaller quantities in barley and oats. Corn, rice, soybeans and potatoes are digestible in persons with celiac disease.

The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk because Decadron increases the production of hydrochloric acid, which may cause gastrointestinal ulcers.

The protest phase of separation anxiety is a normal response for a child this age (2 year-old hospitalized child). In toddlers, ages 1 to 3, separation anxiety is at its peak

Signs of tardive dyskinesia include smacking lips, grinding of teeth and "fly catching" tongue movements.

Verapamil, Bretylium, and Amiodarone increases serum dig levels, possibly causing Digitalis Toxicity

Signs/Symptoms of Digital Toxicity: first signs include abdominal pain, anorexia, nausea, vomiting, visual disturbances, bradycardia, and other arrhythmias. In infants and small children, the first symptoms of overdose are usually cardiac arrhythmias.

Restlessness, confusion, irritability and disorientation may be the first signs of fat embolism syndrome followed by a very high temperature.

A Neologism is a new word self invented by a person and not readily understood by another that is often associated with a thought disorder.

Pancreatic enzymes give before meals.

Clinical features of delusional disorder include extreme suspiciousness, jealousy, distrust, and belief that others intend to harm.

The UAP can be assigned to care for a client with a chronic condition after an initial assessment by the nurse. This client has no risk of instability of condition.

Never leave your patient. For example, Ask the LPN/LVN to stay with the child and his parents while the nurse obtains phone orders from the physician.

Tips for charting: don’t use inflammatory words, no nurse judgments, be as specific as possible. I.E.,

“Vital signs stable” is incorrect for of charting.

Restraint: frame of bed, quick release ties, document need for restraint Q4 hours

Never ask “WHY” questions in the NCLEX!

Gag Reflex: don’t assess gag reflex to a client that has an absent swallow reflex

Nifedipine (Procardia XL): do not crush

An RN that is not assigned to a patient does not have the authority to tell a nurse what to do. Refer it to nursing supervisor.

If doctor has orders it should carried out unless contraindicated in nurse’s decision.

Physical assessment: Inspection, Percussion, Palpation, Auscultation (Except for abdomen: Inspection, Auscultation, Percussion, Palpation)

Coronary artery bypass graft (CABG)—halt medications before surgery, can do 5 at a time; will be on mechanical ventilations after surgery; chest tubes

Acromegaly—monitor blood sugar, atrium—90 implant care (radioactive, nasally implanted, monitor vision)

Bone marrow Aspiration---done at iliac crest; painful

Postoperative care after Supratentorial surgery: maintain airway, elevate head 30-45

Position care after Infratentorial surgery: flat and lateral

Orange juice does not help acidify urine it makes it more alkaline.


· Water-soluble dye—elevate head of bed 30 degrees (not removed)

· Oil based dye—flat in bed (removed)

· Involves lumbar puncture w/ injection of contrast medium, allowing x-ray visualization of the vertebral canal.


ü Immobilize joint above and below fracture

ü Cover open fracture with cleanest material available

ü Check temperature, color, sensation, capillary refill distal to fracture

ü Close reduction—manually manipulate bone or use traction

Buck’s Traction

ü Use to relieve muscle spasm of leg and back

ü If used for muscles spasms only, they can turn to either side.

ü If used for fracture treatment, only can turn to unaffected side.

ü Use 8-20 lbs of weight, if used for scoliosis will use 40 lbs of weight.

ü Elevate head of bed for countertraction or foot bed

ü Place pillow below leg not under heel or behind knee.

Russell’s Traction

ü Sling is used

ü Check for popliteal pulse

ü Place pillow below lower leg and heel off the bed

ü Don’t turn from waist down

ü Lift patient, not the leg

Cervical Tongs

ü Never lift the weights

ü No pillow under head during feedings

Balanced Suspension Traction

ü For femur realignment

ü Maintain weights hanging free and not on floor

ü Maintain continuous pull

Halo Jacket

ü Maintain pin cleansing


ü Don’t rest on hard surface

ü Don’t cover until dry 48+ hours

ü Handle with palms of hands not with fingers

ü Keep above level of heart

ü Check for CSM

Fractured Hip

· Assessments

§ Leg shortened

§ Adducted

§ Externally rotated

· Implementation

§ Care after a total hip replacement

· Abduction pillows

· Crutch walking with 3-point gait

· Don’t sleep on operated side

· Don’t flex hip more than 45-60 degrees

· Don’t elevate head of the bed more than 45 degrees


· Guillotine (open)

· Flap (closed)

· Delayed prosthesis fitting

§ Residual limb covered with dressing and elastic bandage (figure eight)

· Figure-8 doesn’t restrict blood flow, shaped to reduce edema

§ Check for bleeding

§ Elevated 24 hours (AKA-pillow, BKA-foot of bed elevated)

§ Position prone daily

§ Exercises, crutch walking

§ Phantom Pain: acknowledge feelings, that pain is real for them.

Thiamin (Vit. B1)—carbohydarte metabolism; deficiency will cause Beri-Beri

Pyridoxine (Vit. B6)—amino acid metabolism; deficiency will cause anemia, seizures

Folic acid—RBC formation; deficiency will cause anemia

Cyanocobalamin (B12)—nerve function; deficiency cause pernicious anemia

Calcium deficiency causes Rickett’s

Cultural Food Pattern’s

ü Orthodox Jewish (Kosher)—milk and meat cannot be eaten at same meal

ü Muslin—30 day fast during Ramadan

ü Japanese—rice is basic food, tea is main beverage

ü Greek—bread is served with every meal

Enteral feeding held if: 150 or > cc’s aspirated or 50% given in the hour is aspirated

ü If cramping, vomiting occurs decrease rate of enteral feeding or keep it warm.

TPN—supply nutritions via intravenous route

ü Peripherally or centrally

ü Initial rate 50/hour and can be increased to 100-125ml/hour.

ü A pump must be used to keep rate constant

ü Prevent sepsis: maintain closed system,, don’t draw blood/infuse anything in line, dry sterile dressing

ü Verify placement of line

ü Monitor Glucose, acetone

ü Change IV tubing/Filter Q24 hours

ü Solution refrigerated then warmed

ü If solution not available, start 10% in water.

ü 3/week check BUN, electrolytes (ca, mg)

ü When TPN Dc’d taper patient off or else will get rebound hypoglycemia (use hypotonic to do this)

Specific gravity 1.010-1.030

Ph 4.5-8


Crede’s Manuever—push urine out

Pernicious Anemia

- monthly Vitamin B12 IM injections

Metered dose inhaler

- Beclomethasone (Vanceril)

- Albuterol (Proventil)

Guillain-Barre Syndrome

- GBS often preceded by a viral infection as well as immunizations/vaccinations

- Intervention is symptomatic

- Acute phase: Steroids, plasmapheresis, aggressive respiratory care; prevent hazards of immobility, maintain adequate nutrition; physical therapy; pain-reducing measures; eye care, prevention of complications (UTI, aspiration); psychosocial support

Organ Donation Criteria

- No history of significant, disease, process in organ/tissue to be donated

- No untreated sepsis

- Brain death of donor

- No history of extracranial malignancy

- Relative hemodynamic stability

- Blood group compatibility

- Newborn donors must be full term (more than 200g)

- Only absolute restriction to organ donation is documented case of HIV infection

- Family members can give consent

- Nurse can discuss organ donation with other death-related topics (funeral home to be used, autopsy request)

Accurate way to verify NG tube position is to aspirate for gastric contents and check pH.

Parkinson’s disease

- Activities should be scheduled for late morning when energy level is highest and patient won’t be rushed

- Symptoms: tremors, akinesia, rigidity, weakness, “motorized propulsive gait, slurred monotonous speech, dysphagia, drooling, mask-like expression.

- Nursing care: encourage finger exercises. Administer Artane, Congentin, L-Dopa, Parlodel, Sinemet, Symmetrel.

- Teach: ambulation modification

- Promote family understanding of disease intellect/sight/hearing not impaired, disease progressive but slow, doesn’t lead to paralysis

Normal urine output (1200-1500 cc’s/day or 50-63 cc/hr, normal voiding pattern 5-6 times/day.

Green leafy vegetables contain vitamin K.


HbA1c (4.5-7.6%)

- indicates overall glucose control for the previous 120 days

Serum Amylase / Somogyl (60-160 u/dL)

- elevated in acute pancreatitis

Erythrocyte Sedimentation Rate (ESR)

- Men (1-15)

- Women (1-20)

- Rate at which RBC’s settle out of unclottted blood in one hour

- Indicates inflammation/neurosis

Hematocrit (Hct)

- Men (40-45) u/mL

- Women (37-45) u/mL

- Relative volume of plasma to RBC

- Increased with dehydration

- Decreased with volume excess

Creatine Kinase (CK)

- Men (12-70)

- Women (10-55)

- Enzyme specific to brain, myocardium, and skeletal muscles

- Indicates tissue necrosis or injury

Serum Glucose

- 60-110 mg/dL

Sodium (Na+)

- 135-145 mEq/L

- Hypernatremia

o Dehydration and insufficient water intake

Chloride (Cl-)

- 95-105 mEq/L

Potassium (K+)

- 3.5-5.0 mEq/L

Bicarbonate (HCO3)

- 22-26 mEq/L

- Decreased levels seen with starvation, renal failure, diarrhea.

Blood, Urea, Nitrogen (BUN)

- 6-20 mg

- Elevated levels indicate rapid protein catabolism, kidney dysfunction, dehydration

Creatinine Clearance Test

- normal 125 ml/min.

- Lower levels reflect renal insufficiency and may influence the excretion of many drugs and toxins from the body.


- targeted blood level: (1-1.5 mEq/L)

Tofranil and Anafranil—OCD medications

Pick physical needs over psychosocial needs!!!!!!!!!!!!!!!

Focus on here and now!!!!!!!!!!!!!!!!!

Oculogyric crisis: uncontrollable rolling back of eyes: side effect of Phenothiazines

Moribund means dying patient.

Don’t leave your patients. Stay with your patients.

Assess before implementation.

Manic patient: decrease stimuli and increase rest period and no competition.

Lithium helps control impulsive behaviors.

Fluphenazine (Prolixin): antipsychotic medication

Thiamine sources: organ meats, liver, whole grain, nuts, legume, egg, and milk.

Don’t document abuse. Report suspected abuse to nursing supervisor.

Never promise a patient “Not to tell.”

Tonometry—measures intraocular pressure; to rule out glaucoma

Myopia—nearsightedness (near clear, distance clear)

Hyperopia—farsightedness (distance is clear, near vision blurry)

Presbyopia—changes with aging

Blind client: address by name, introduce self, keep furniture arrangement consistent, open or close doors walk ½ step ahead, identify food location on tray.

Instilling ear drops lie patient on unaffected ear to absorb drops.

Position patient on affected ear to promote drainage.

Regular Insulin only given IV.

Sick day rules: take insulin as ordered, check blood glucose q3-4 hours, soft foods, liquids

Phenylketonuria—high blood phenylalanine (no enzyme), results in mental retardation; milk substitutes, low-protein diet

Celiac Disease (SPrue)—intestinal malabsorption, malnutrition (unable to digest wheat/rye/oats/barley); gluten-free diet

Hepatobiliary disease—decrease in ability of bile to absorb fat, fat malabsorption; low-fat high-protein diet, vitamins

Cystic fibrosis—absence of pancreatic enzymes, malabsorption of fat, lung disease, pancreatic enzyme replacement, high-protein, high-calorie diet, respiratory care/suction

Position right side to promote gastric emptying.

Dumping syndrome prevention: restrict fluid with meals, lie down after eating, small, frequent meals, low-carbohydrate, low-fiber diet

Sengstaken-Blakemore Tube—to treat pt. with esophageal varices.

Normal Vital Signs

1-4 year old

Normal Vital Signs


· Pulse 120-140 bpm, increases with crying

· Respirations 30-50/min, diaphgramatic (abdomen moves), can be irregular

· BP 60/40 – 80/50 mmHg

· Pulse: 80-140

· Resp: 20-40

· BP: 90-60 – 99/65

5-12 year old

· Pulse: 70-115

· Resp: 15-25

· BP: 100/56 – 110/60


· Pulse: 60-100

· Resp: 12-20

· BP: 90/60-140/90

Hepatitis B Vaccine

Given IM to vastus lateralis or deltoid

Side effects: mild tenderness at site

· 1st shot – Birth to 3 months

· 2nd shot – 1 to 4 months

· 3rd shot – 6 to 18 months

DTaP (Diptheria, Tetanus, and Pertussis)

Given IM anterior or lateral thigh

Side effects: fever within 24-48 hours, swelling, redness, soreness

Don’t treat with aspirin, use other antipyretic.

· 1st shot – 2 months

· 2nd shot – 4 months

· 3rd shot – 6 months

· 4th shot – 15 to 18 months

· 5th shot – 4 to 6 years

· Only TD shot – 11 to 16 years

Hib (Influenza)

· 1st shot – 2months

· 2nd shot – 4months

· 3rd shot – 6 months

· 4th shot – 12 to 18 months

IPV (Inactive Polio Vaccine)

Given PO, Few side effects

· 1st shot – 2 months

· 2nd shot – 4 months

· 3rd shot – 6 to 18 months

· 4th shot – 4 to 6 years

MMR (Mumps, Measles, and Rubella)

Given SC anterior or lateral thigh

Side effects: rash, fever, arthritis in 10 days to 2 weeks.

· 1st shot – 12 to 18 months

· 2nd shot – 4 to 6 years

Varicella (Chickenpox)

· 12 to 18 months

PCV (Pneumococcal)

· 1st shot – 2 months

· 2nd shot – 4 months

· 3rd shot – 6 months

· 4th shot – 12 to 18 months


Given intradermal

Evaluated in 48 to 72 hours


Given IM into anterior or lateral thigh

Repeated every 10 years

Live attenuated Rubella

Given once SC into anterior or lateral thigh

Given to antibody-negative women

Prevent pregnancy for 3 months after receiving immunization

Live attenuated mumps

Given once SC

Prevents orchitis

Aortic Valve: Right of Sternum at the 2nd intercostal space

Pulmonic Valve: Left of Sternum at the 2nd intercostal space

Tricuspid Valve: Immediately left of sternal border at the 5th Intercostal Space

Mitral Valve (Point of Maximal Impulse): Left of Sternum Mid-Clavicular Line at the 5th Intercostal Space

Erbb’s Point: Left of Sternum at the 3rd intercostal space

Infant (Point of Maximal Impulse): Lateral to sternum 4th intercostals space

Obese person choking use Chest Thrusts.

Tracheostomy tube placement of cuff maintained to prevent aspiration

Care for patient first, equipment second

Signs for hypoxia: restlessness, tachycardia

CPR: Shake, shout, summon help, open airway, look, listen, feel for signs of breathing, pinch nose, give 2 full breaths (if no rise, reposition)

Adults 12/min check carotid, chest compressions 80-100/min 1.5 inches

Infants 20/min check brachial pulse, chest compression 100/min ½ - 1 inch

15:2 Adult 4 cycles

Infant 20 cycles

Reassess pulse and breathing

Continue CPR until:

· Victim responds

· Someone else takes over

· Victim is transferred

· Rescuer is unable to continue


· Chest pain radiating to arms, jaw, neck (which is unrelieved by rest or nitroglycerin)

· Dyspnea

· Indigestion

· Apprehension

· Low grade fever

· Elevated WBC (5-10, ESR, CK-MB, LDH)

Implementation for MI

· Thrombolytic therapy-streptokinase, t-PA

· Bedrest

· Beta-blockers, morphine sulfate, dysrhythmics, anticoagulants

· Do not force fluids (will give heart more to work with)


· Start CPR first

· 1st attempt – 200 joules

· 2nd attempt – 200 to 300 joules

· 3rd attempt – 360 joules

· Check monitor between shocks for rhythm


· Elective procedure, Informed Consent

· Valium IV

· Synchronizer on

· 25-360 joules

· Check monitor between rhythm

Epidural hematoma – short period of unconsciousness, ipsilateral papillary dilation, contralateral weakness of extremities

Subdural hematoma – decreased LOC, ipsilateral papillary dilation, contralateral weakness of extremities, personality changes

CSF leakage – good place to look is behind the ears.

Head Injury – elevate bed 30 degrees, barbiturate therapy, hypothermia, glucocorticoids (Decadron)

Flail Chest

Affected side goes down during inspiration and up during expiration

Sucking Chest Wound

(Sucking Open Pneumothorax)

· Sucking sound with respiration

· Pain

· Decreased breath sounds

· Anxiety


Collapse of lung due to alteration of air in intrapleural space

· Dyspnea

· Pleuritic pain

· Restricted movement on affected side

· Decreased/absent breath sounds

· Cough

· Hypotension


Monitor for shock

Humidified oxygen

Thoracentesis (aspiration of fluid from pleural space)

Chest Tubes

Cullen’s Sign – ecchymosis around umbilicus

Turner’s Sign – ecchymosis around either flank

Balance’s sign – resonance over spleen (+) means rupture of spleen

Shock Signs and Symptoms

· Cool, clammy skin

· Cyanosis

· Decreased alertness

· Tachycardia

· Hypotension

· Shallow, rapid respirations

· Oliguria


Decreased in intravascular volume


Decreased cardiac output


Problem with blood flow to cells

Implementation for shock

· Monitor CVP: <3>11 too much fluid

Increased ICP


· Altered LOC (Earliest Sign)

· Glasgow coma scale <7>

· Confusion

· Restlessness

· Pupillary changes

· Vital sign changes – WIDENING PULSE PRESSURE


· Monitor vital signs

· Monitor Glasgow Coma Scale

· Elevate head 30-45 degrees

· Avoid neck flexion and head rotation

· Reduce environmental stimuli

· Prevent Valsalva maneuver

· Restrict fluids to 1200-1500 cc/day

· Medications – Osmotic diuretics, corticosteroids


ü do not restrain

ü do not insert anything in mouth


Potassium: 3.5-5.0 mEq/L

Sodium: 135-145 mEq/L

Calcium: 4.5-5.2 mEq/L

Magnesium: 1.5-2.5 mEq/L

Hypokalemia Assessments

· K+ < 3.5 mEq/L

· Muscle weakness

· Paresthesias

· Dysrhythmias

· Increased sensitivity to digitalis

Hypokalemia Implementations

· Potassium Supplements

· Don’t give > 40 mEq/L into peripheral IV or without cardiac monitor

· Increase dietary intake – oranges, apricots, beans, potatoes, carrots, celery, raisins

Hyperkalemia Assessments

· K+ >5.0 mEq/L

· EKG changes

· Paralysis

· Diarrhea

· Nausea

Hyperkalemia Implementations

· Restrict oral intake

· Kayexalate

· Calcium Gluconate and Sodium Bircarbonate IV

· Peritoneal or hemodialysis

· Diuretics

Hyponatremia Assessments

· Na+ < 135 mEq/L

· Nausea

· Muscle cramps

· Confusion

· Increased ICP

Hyponatremia Implementations

· I & O

· Daily weight

· Increase oral intake of sodium rich foods

· Water restriction

· IV Lactated Ringer’s or 0.9% NaCL

Hypernatremia Assessments

· Na+ >145 mEq/L

· Disorientation, delusion, hallucinations

· Thirsty, dry, swollen tongue

· Sticky mucous membranes

· Hypotension

· Tachycardia

Hypernatremia Assessments

· I & O

· Daily Weight

· Give hypotonic solutions: 0.45% NaCl or 5% Dextrose in water IV

Hypocalcemia Assessments

· Ca+ <>

· Tetany

· Positive Trousseau’s sign

· Positive Chvostek’s sign

· Seizures

· Confusion

· Irritability, paresthesias

Hypocalcemia Implementations

· Oral calcium supplements with orange (maximizes absorption)

· Calcium gluconate IV

· Seizure precautions

· Meet safety needs

Hypercalcemia Assessments

· Ca+> 5.2 mEq/L

· Sedative effects on CNS

· Muscle weakness, lack of coordination

· Constipation, abdominal pain

· Depressed deep tendon reflexes

· Dysrhythmias

Hypercalcemia Implementations

· 0.4% NaCl or 0.9% NaCl IV

· Encourage fluids (acidic drinks: cranberry juice)

· Diuretics

· Calcitonin

· Mobilize patient

· Surgery for hyperparathyroidism

Hypomagnesemia Assessments

Ø Mg+<>

Ø Neuromuscular irritability

Ø Tremors

Ø Seizures

Ø Tetany

Ø Confusion

Ø Dysphagia

Hypomagnesemia Implementations

Ø Monitor cardiac rhythm and reflexes

Ø Test ability to swallow

Ø Seizure precautions

Ø Increase oral intake—green vegetables, nuts, bananas, oranges, peanut butter, chocolate

Hypermagnesemia Assessments

Ø Mg + > 2.5 mEq/L

Ø Hypotension

Ø Depressed cardiac impulse transmission

Ø Absent deep tendon reflexes

Ø Shallow respirations

Hypermagnesemia Implementations

Ø Discontinue oral and IV magnesium

Ø Monitor respirations, cardiac rhythm, reflexes

Ø IV Calcium to antagonize cardiac depressant activity (helps to stimulate heart)

Burns Assessments

· Superficial partial thickness—pink to red, painful

· Deep partial thickness—red to white, blisters, painful

· Full thickness—charred, waxy, white, painless

Wound Care for Burns

ü Never break blisters

ü Isotonic fluids (Lactated Ringer’s)

ü Closed method (Silvadene) covered with dressings

ü Open method (Sulfamylon) that are not covered with dressings

ü IV pain medication initially: not PO takes too long, not IM circulation impaired

ü Medicate patient before wound care

ü Silver nitrate (warn patient skin will turn black)

ü High calorie, High carbohydrate, High protein diet

ü Vitamin B,C, and Iron

ü TPN maybe

ü Prevent contractures

Addisson’s Disease Assessments

ü Fatigue

ü Weakness

ü Dehydration

ü Eternal tan

ü Decreased resistance to stress

ü Low Sodium

ü Low Blood Sugar

ü High Potassium

Addisson’s Disease Implementations

ü High protein, High carbohydrate, high Sodium, Low potassium diet

ü Teach life-long hormone replacement

Addisonian Crisis Assessments

· Hypotension

· Extreme weakness

· Nausea vomiting

· Abdominal pain

· Severe hypoglycemia

· Dehydration

Addisonian Crisis Implementations

· Administer NaCl IV, vasopressors, hydrocortisone

· Monitor vital signs

· Absolute bedrest

Cushing’s Syndrome Assessments

· Osteoporosis

· Muscle wasting

· Hypertension

· Purple skin striations

· Moon face

· Truncal obesity

· Decreased resistance to infection

Cushing’s Syndrome Implementations

· Low Carbohydrate, Low Calorie, High Protein, High Potassium, Low sodium diet

· Monitor glucose level

· Postop care after adrenalectomy or hypophysectomy

Pheochromocytoma Assessments—hypersecretions of the catecholamines (epinephrine/norepinephrine)

· Persistent hypertension

· Hyperglycemia

· Pounding headache

· Palpitations

· Visual disturbances

Pheochromocytoma Implementations

· Histamine Test, Regitine Test, 24- hour urine VMA test

· Avoid emotional and physical stress

· Encourage rest

· Avoid coffee and stimulating foods

· Postop care after adrenalectomy and medullectomy

COPD Assessments

· “Blue Bloaters”

· “Pink Puffers”

· Weakness

· Change in postured day and hs (don’t sleep laying down, have to stay erect)

· Use of accessory muscles of breathing

· Dyspnea

· Cough

· Adventitious breath sounds

COPD Implementations

· Assess airway clearance

· Listen to breath sounds

· Administer low-flow oxygen (1-2 L, not too much because your trying to prevent CO2 narcosis)

· Encourage fluids

· Small frequent feedings

· Use metered dose inhalers (MDI)

Pneumonia Assessments

· Fever

· Leukocytosis

· Productive Cough (rust, green, yellow)

· Dyspnea

· Pleuritic pain

· Tachycardia

Pneumonia Implementations

· Check breath sounds

· Cough and deep breath q 2 hours

· Chest physiotherapy

· Antibiotics

· Incentive spirometer

· Encourage fluids

· Suction PRN

· Provide oxygen

· Semi-Fowler’s position

· Bedrest

· Medications—mucolytics (Mucomyst), expectorants (Robitussin), Bronchodilators (Aminophylline), Antibiotics (Bacterim)

Acyanotic Congenital Heart Anomalies Assessments

· Normal Color

· Possible exercise intolerance

· Small stature

· Failure to thrive

· Heart murmur

· Frequent respiratory Infections

Cyanotic Congenital Heart Anomalies Assessments

· Cyanosis

· Clubbing of fingers

· Seizures

· Marked exercise intolerance

· Difficulty eating

· Squat to decrease respiratory distress

· Small stature

· Failure to thrive

· Characteristic murmur

· Frequent respiratory infections

Acyanotic Congenital Heart Anomalies Types:

· Ventricular Septal Defect (VSD)—abnormal opening between right/left ventricles; hole size of pinhole or absence of septum; hear a loud harsh murmur, at age of 3 hole may close otherwise surgery such as purse-string suture

· Atrial Septal Defect (ASD)—abnormal opening between the two atria; audible murmur (if defect is severe closure is done later in childhood)

· Patent Ductus Arteriosis (PDA)—failure of fetal structure to close after birth; ductus areteriosis in the fetus connects the pulmonary artery to aorta to shunt oxygenenated blood from the placenta to systemic circulation (which bypasses the lungs). Once the child is born that structure should close because it is no longer needed because blood passes through to lungs; vascular congestion, right ventricular hypertrophy; murmur, bounding pulse, tachycardia; surgical to divide or ligate the vessel.

· Coarctation of the Aorta—narrow of aorta; high blood pressure and bounding pulse in areas that receive blood proximal to the defect. Weak and absent blood distal to aorta. Surgical end-to-end anastomosis.

· Pulomonic Stenosis—narrowing at entrance to pulmonary artery; causes resistance to blood flow and right ventricular hypertrophy; surgery

· Aortic Stenosis—narrowing of aortic valve; causes decrease cardiac output; surgery

Cyanotic Congenital Heart Anomalies Types:

· Tetralogy of Fallot—VSD, pulmonic stenosis, overriding aorta, right ventricular hypertrophy; squats/knee chest position to help breath; surgery needed

· Transposition of great vessels—pulmonary artery leaves left ventricle and aorta leaves right ventricle; oxygenated blood not going into systemic circulation

· Truncus arteriosus—failure of normal septation and embryonic division of the pulmonary artery and aorta; rather than two distinctly different vessels there is a single vessel that overrides both ventricles and gives rise to both pulmonary and systemic circulation; blood enters from both common artery and either goes to the lungs or to the body; cyanosis, murmur, difficult intolerance

· Total anomalous venous return—absence of direct communication between pulmonary veins and left atria; pulmonary veins attach directly to right atria or drains to right atria

Congenital Heart Anomalies Compensatory Mechanisms

· Tachycardia

· Polycythemia (increase formation of RBC’s)

· Posturing—squatting, knee-chest position

Congenital Heart Anomalies Implementations

· Prevention

· Recognize early symptoms

· Monitor vital signs and heart rhythms

· Medications—digoxin, iron, diuretics, potassium

· Change feeding pattern

Left-Side CHF

· Dyspnea, orthopnea

· Cough

· Pulmonary edema

· Weakness/Changes in mental status

Right-Side CHF

· Dependent edema

· Liver enlargement

· Abdominal pain/Nausea/Bloating

· Coolness of extremities

CHF Implementations

· Administer digoxin, diuretics

· Low-sodium, low-calorie, low-residue diet

· Oxygen therapy

· Daily weight

· Teach about medications and diet

Arterial Peripheral Vascular Disease


· Rubor

· Cool shiny skin

· Ulcers

· Gangrene

· Intermittent Claudication (pain with exercise/walking relieved with rest)

· Impaired sensation

· Decreased peripheral pulses

Arterial Peripheral Vascular Disease


· Monitor Peripheral pulses

· Good foot care

· Stop smoking

· Regular exercise

· Medications—vasodilators, anticoagulants

Venous Peripheral Vascular Disease


· Cool, brown skin

· Edema

· Normal or decreased pulses

· Positive Homan’s sign

Venous Peripheral Vascular Disease


· Monitor peripheral pulses

· Elastic stockings

· Medications—anticoagulants

· Elevate legs

· Warm, moist packs

· Bedrest 4-7 days (acute phase)

Anemia Assessments (reduction in hemoglobin amount/erythrocytes)

· Palpitations

· Dyspnea

· Diaphoresis

· Chronic fatigue

· Sensitivity to cold

Anemia Implementations

· Identify cause

· Frequent rest periods

· High protein, high iron, high vitamin diet

· Protect from infection

Iron Deficiency Anemia Assessments

· Fatigue

· Glossitis

· Spoon fingernails

· Impaired cognition

Iron Deficiency Anemia Implementations

· Increase iron-rich foods (liver, green leafy vegetables)

· Iron supplements (stains teeth)

Pernicious Anemia Assessments (gastric mucosa fail to secrete enough intrinsic factor for stomach to absorb)

· Schilling’s Test

· Fatigue

· Sore, red tongue

· Paresthesia in hands and feet

Pernicious Anemia Assessments

· Vitamin B12—IM

· Rest of life can’t be absorbed PO

Sickle Cell Anemia Assessments

· Pain /Swelling/Fever

· Schlerae jaundiced

· Cardiac murmurs

· Tachycardia

Sickle Cell Anemia Implementations

· Check for signs of infection (prevent crisis)

· Check joint areas for pain and swelling

· Encourage fluids

· Provide analgesics with PCA pump c crisis

Hemophilia Assessments (female to male gene transmission)

· Easy bruising

· Joint pain

· Prolonged bleeding

Hemophilia Implementations

· Administer plasma or factor VIII

· Analgesics

· Cryoprecipitated antihemophilic factor (AHF)

· Teach about lifestyle changes

· Non contact sports

Cancer Implementation: External Radiotherapy

· Leave markings on skin

· Avoid use of creams, lotions (only vitamin A&D ointment)

· Check for redness, cracking

· Wear cotton clothing

· Administer antiemetics

Cancer Implementation: Internal radiation sealed source

· Lead container and long-handled forceps in room

· Save all dressings, bed linen until source removed

· Urine and feces not radioactive

· Don’t stand close or in line with source

· Patient on bed rest

Cancer Implementation: Internal Radiation

· Time and distance important

· Private room sign on door

· Nurse wears dosimeter at all times

· Limit visitors and time spent in room

· Rotate staff

· Self-care when can do

Cancer Implementation: Internal radiation unsealed source

· All body fluids contaminated

· Greatest danger first 24-96 hours

Leukemia Assessments

· Ulcerations of mouth

· Anemia

· Fatigue

· Weakness

· Pallor

Leukemia Implementations

· Monitor for signs of bleeding: petechiae, ecchymosis, thrombocytopenia

· Infections

· Neutropenia (private room/limit # people, wbc done daily, no fruit, no flowers/plotted plants, clean toothbrush with weak bleach solution

· Good mouth care

· High calorie, high Vitamin diet (avoid salads/raw fruit/pepper/don’t reuse cup/don’t change litter box/digging in garden

Intracranial Tumors Assessments

· Motor deficits

· Hearing or visual disturbances

· Dizziness

· Paresthesia

· Seizures

· Personality disturbances

· Changes in LOC

Intracranial Tumors Implementations

· Preoperative: do neurological assessment, patient head shaved

· Postoperative: maintain airway, elevate head 30-45 after supratentorial surgery

· Flat and lateral after infratentorial surgery

· Monitor vital and neurological signs

· Glascow coma scale

Therapeutic Positions

Ø Supine—avoids hip flexion

Ø Dorsal recumbent—supine with knees flexed

Ø Prone—extension of hip joint(after amputation)

Ø Side lateral—drainage of oral secretions

Ø Knee-chest—visualization of rectal area

Ø Sim’s—decreases abdominal tension (side lying with legs bent)

Ø Fowler’s—increases venous return, lung expansion

Ø High Fowler’s—60-90

Ø Fowler’s—45-60

Ø Semi-Fowler’s—30-45

Ø Low Fowler’s—15-30

Ø Modified Trendelenburg—used for shock;Feet elevated 20 degrees, knees straight, trunk flat, head slightly elevated

Ø Elevation of extremity—increases blood to extremity and venous return

Ø Lithotomy—used for vaginal exam

4 point Gait

Weight bearing both legs


2 point Gait

Bearing both legs


3 point Gait

Bearing one leg

Weaker leg both crutches, then stronger leg

Swing-to-swing through

Partial weight bearing both legs

Both crutches, one or two legs


Ø Going up—“good” leg first, crutches, “bad” leg

Ø Going down—crutches with “bad” leg, then “good” leg

Ø “Up with the good, down with the bad”


· Flex elbows 20-30 degrees when hands are on grips

· Lift and move walker forward 8-10 inches

· Step forward with “bad” leg, support self on arms, follow with “good” leg

· Stand behind client holding onto gait belt

Myelogram—x-ray visualization of the spinal canal by injection of radiopaque dye.

· Hydration done 12 hours before procedure

· Cleansing enemas

· Avoid seizure-promoting medications


· Water-soluble dye—elevate head of bed 30 degrees (not removed)

· Oil based dye—flat in bed (removed)

· Bedrest 24 hours encourage fluids

Laminectomy—excision portion of lamina to expose area of affected disc

· Preopcare: moist heat

· Fowler’s position

· Isometric exercises for abdominal muscles

· Muscle relaxants, NSAIDs, Analgesics

· Traction, TENS

Postoperative care:

· Assess circulation and sensation

· Log roll Q2 hours with pillow between leg

· Calf exercises, assist with ambulation keeping back straight

· Muscle relaxants, NSAIDS, analgesics, Teaching—daily exercises, firm mattress, avoid prone position and heavy lifting

· Avoid sitting long time

Dysplasia of the Hip Assessment

· Uneven gluteal folds and thigh creases

· Limited abduction of hip

· Ortolani’s sign—place infant on back with legs flexed, clicking sound with abduction of legs

· Shortened limb on affected side

Dysplasia of the Hip Implementations

Newborn to 6 months

· Reduced by manipulation

· Pavlik harness for 3 to 6 months

6 to 18 months

· Bilateral Bryant’s traction

· Hip spica cast

Older child

· Open reduction

· Hip Spica cast

Scoliosis Assessments—lateral deviation of one or more of vertebrae accompanied by rotary motion of spine

· Uneven hips or scapulae

· Kyphosis lump on back

· Bend at waist to visualize deformity

· Structural (flexible deviation corrected with bending) or functional (permanent heredirary that is seen)

Scoliosis Implementations

· Exercises to strengthen abdominal muscles (if functional)

· Surgery: spinal fusion insertion of Herrington Rod

· Milwaukee brace: used with curves 30-40 degrees

· Wear 4-6 years, worn 23 hours of the day, wear undershirt to prevent irritation, teach isometric exercises

Cerebral Palsy Assessments

· Voluntary muscles poorly controlled due to brain damage

· Spasticity, rigidity, ataxia, repetitive involuntary gross motor movements

Cerebral Palsy Implementations

· Ambulation devices, PT and OT

· Muscle relaxants and anticonvulsants

· Feeding: place food at back of mouth with slight downward pressure. Never tilt head backward.

· High calorie diet

Muscular Dystrophy Assessments

Atrophy of voluntary muscles

Muscle weakness, lordosis, falls

* Braces to help ambulation

* Balance activity and rest

Parkinson’s Disease Assessments

· Deficiency of dopamine

· Tremors, rigidity, propulsive gait

· Monotonous speech

· Mask like expression

Parkinson’s Disease Implementations

· Teach ambulation modification: goose stepping walk (marching), ROM exercises

· Medications—Artane, Cogentin, L-Dopa, Parlodel, Sinemet, Symmetrel

Myasthenia Gravis Assessments

· Deficiency of acetylcholine

· Muscular weakness produced by repeated movement

· Dysphagia

· Respiratory distress

Myasthenia Gravis Implementations

· Good eye care, restful environment

· Medications—anticholinesterases, corticosteroids, immunosuppressants

· Avoid crisis: infection

· Symptoms: sudden ability to swallow

Clear liquid

§ No milk

§ No juice with pulp

Full liquid

§ No jam

§ No fruit

§ No nuts

Low-fat cholesterol restricted

§ Can eat lean meat

§ No avocado, milk, bacon, egg yolks butter

Sodium restricted

§ No cheese

High roughage, high fiber

§ No white bread without fiber


§ Minimize intestinal activity

§ Buttered rice white processed food, no whole wheat corn bran

High protein diet

§ Restablish anabolism to raise albumin levels

§ Egg, roast beef sandwich,

§ No junk food


§ Keeps protein, potassium and sodium low

§ No beans, no cereals, no citrus fruits

Low-phenylalanine diet

§Prevents brain damage from imbalance of amino acids

§Fats, fruits, jams allowed

§No meats eggs bread