THE METHOD

• READ THE LAST PART OF THE QUESTION

• PUT IT IN YOUR OWN WORDS
• FIGURE OUT THE SITUATION
• START WITH THE LAST ANSWER, COMPARE IT TO ELIMINATE ONE ANSWER
• SATA: EACH ONE OF THE SATA IS A CONCEPT, AND AN ANSWER CHOICE OF ITS OWN

PRIORITIZATION
• ASK GRAPH:
o AIRWAY, SEPSIS, K+, HYPOGLYCEMIA, LETHARGY OR GRUNTING, ALTERED LOC, PERITONITIS, HEMORRHAGE

• STABLE VERSUS STABLE

• EXPECTED VERSUS UNEXPECTED

• BRAIN >> LUNGS >> HEART >> LIVER >> KIDNEY >> PANCREAS

• MASLOW’S HIERARCHY: (MENTAL HEALTH)

o PHYSIOLOGICAL: OBJECTIVE (K+ 2.8)
o SAFETY: FALL RISK, SUICIDAL
o COMFORT: SUBJECTIVE & “I” STATEMENTS (PAIN)
o PSYCH/EMOTION
o SOCIAL: MARITAL STATUS, ETC.
o SPIRITUAL: HOPE
CHEST TUBE
• WATER SEAL CHAMBER:
o INTERMITTENT: GOOD
o CONTINUOUS: BAD
• SUCTION CONTROL CHAMBER:
o INTERMITTENT: BAD
o CONTINOUS: GOOD
VENTILATOR PRESSURE ALARMS
• HIGH PRESSURE ALARM
o OBSTRUCTION, KINK, INCREASED SECRETIONS
• LOW PRESSURE ALARM
o DISCONNECTION, CUFF LEAK, LOSS OF AIRWAY
GAIT
• “UP WITH THE GOOD, DOWN WITH THE BAD.”
• CANE IS HELD ON THE STRONG SIDE, AND ALWAYS MOVES BEFORE THE WEAKER LEG
• CRUTCHES ARE HELD ON THE BAD SIDE
o FLEXION AT 30 DEGREES
• TYPE OF GAIT CRUTCHES WALKING PATTERN: REVIEW VIDEOS ON REGISTEREDNURSERN
§ 2 POINT – MOST CLOSELY RESEMBLES NORMAL WALKING
§ 3 POINT
§ 4 POINT
5 D’S LAB VALUES
• K+ = > 6
• PH = 6 & > 6
• CO2 IN THE 60S
• PO2 IN THE 60S
• PLATELET BELOW 40K
FOOD CONTRAINDICATIONS
• MAOI—AVOID TYRAMINE; BAR (BANANAS, AVOCADO, RAISINS) + DRY FOOD
• CELIAC DISEASE—AVOID BROW (BARLEY, RYE, OATS, WHEAT)
• PKU—AVOID HIGH PROTEIN AND HIGH-PHENYALANINE FOOD (MEAT, DAIRY, EGGS)
• GRAPEFRUIT—CONTRAINDICATED IN STATINS AND CA-CALCIUM BLOCKERS (NIFEDIPINE)
HERBAL SUPPLEMENTS
• GINGKO BILOBA, GARLIC, GINSENG, & FEVERFEW--INCREASES THE RISK FOR BLEEDING
• ST. JOHN’S WORT—COMMONLY USED FOR DEPRESSION/MOOD DISORDERS; IT MAY CAUSE HTN & SEROTONIN SYNDROME WHEN USED WITH
OTHER ANTIDEPRESSANTS
• SAW PALMETTO—USED TO TREAT BENIGN PROSTATIC HYPERPLASIA
• BLACK COHOSH—USED BY PERIMENOPAUSAL CLIENTS EXPERIENCING HOT FLASHES
• ECHINACEA—HELP BOOST IMMUNE SYSTEM AND FIGHT OFF INFECTIONS
PPE/ISOLATION PRECAUTIONS – HANDWASHING!
• STANDARD/UNIVERAL PRECAUTION -- ANTHRAX
 o GLOVES
•
CONTACT – ENTERIC, VRE, MRSA, C.DIFF, HEPATITIS A, GI NOROVIRUS, GI ROTAVIRUS
o PRIVATE ROOM, GLOVES, GOWN
• RSV = CONTACT + MASK
• DROPLET – “PIMP” = PERTUSSIS, INFLUENZA, MENINGITIS, PNEUMONIA, VIRUSES, RUBELLA
o PRIVATE ROOM, GLOVES, SURGICAL MASK, PT WEARS SURGICAL MASK WHEN LEAVING THE ROOM
§ IF THERE IS A RISK OF CONTACT WITH BODY FLUIDS DURING PROCEDURE GOWN & FACE SHIELDS ARE USED.
• AIRBONE—“MTV” = MEASLES (RUBEOLA), MUMPS, TB, VARICELLA, SARS, MERS
o N95, NEGATIVE AIRFLOW ROOM, PT WEARS SURGICAL MASK WHEN LEAVING THE ROOM
PROPER ORDER FOR PPE
• DONNING: GOWN >> MASK >> GOGGLES >> GLOVES
• DOFFING: GLOVES >> GOGGLES >> GOWN >> MASK

PHLEBITIS INFILTRATION EXTRAVASATION

• INFLAMMATION OF THE VEIN
• PAIN, INCREASED TEMPERATURE, REDNESS
• D/C IV LINE + WARM COMPRESS
• COMPLICATION THAT OCCURS WHEN
SOLUTION INFUSES INTO THE SURROUNDING
TISSUES OF THE INFUSION SITE.
• LEAKAGE OF IV SOLUTION/MEDICATION
(NON-VESICANT/IV SOLUTIONS) INTO THE
EXTRAVASCULAR TISSUE
• PAIN, DECREASED TEMPERATURE, EDEMA,
PALLOR
• D/C IV LINE + WARM COMPRESS, ELEVATE
EXTREMITY
• IV CATHETER BECOMES DISLODGED AND
(VESICANT/MEDICATION) INFUSES INTO THE
TISSUES
• PAIN, STINGING, BURNING, SWELLING,
REDNESS
• D/C IV LINE + COOL COMPRESS, ADMINISTER
ANTIDOTE IF EXIST
• AVOID WARM COMPRESS

EXTRAPYRAMIDAL SYMPTOMS
• SIDE EFFECTS OF ANTIPSYCHOTIC MEDICATIONS
o -ZINES + HALOPERIDOL
• INCLUDE MOVEMENT OF DYSFUNCTION SUCH AS:
o DYSTONIA (CONTINOUS SPASMS/MUSCLE CONTRACTIONS)
o AKATHISIA (MOTOR RESTLESSNESS)
o PARKINSONISM (RIGIDITY)
o BRADYKINESIA (SLOWNESS OF MOVEMENT)
o TREMOR

DUCHENNE MUSCULAR AMYOTROPHIC LATERAL GUILLAIN BARRE SYNDROME MULTIPLE SCLEROSIS MYASTHENIA GRAVIS
DYSTROPHY (DMD) SCLEROSIS (GBS) (MS)
(ALS)
“LOU GEHRIG DISEASE”
• MOST COMMON • DEBILITATING, • ASCENDING MUSCLE • PROGRESSIVE, • AUTOIMMUNE DISEASE
FORM OF CHILDHOOD PROGRESSIVE WEAKNESS AND DEMYELINATING INVOLVING A DECREASED
MD NEURODEGENERATIVE ABSENT DEEP TENDON DISEASE OF THE CNS NUMBER OF
• X-LINKED RECESSIVE DISEASE WITH NO CURE REFLEXES • MUSCLE WEAKNESS, ACETYLCHOLINE
• DUE TO LACK OF A • CLIENTS DEVELOP • HX OF RESPIRATORY SPASTICITY, RECEPTORS AT THE
PROTEIN CALLED FATIGUE AND MUSCLE TRACT INFECTION / GI INCOORDINATION, NEUROMUSCULAR
“DYSTROPHIN” WEAKNESS THAT INFECTION LOSS OF BALANCE, JUNCTION.
NEEDED FOR MUSCLE PROGRESSES TO • POTENTIAL AND FATIGUE ARE • AS A RESULT, THERE IS A
STABILIZATION PARALYSIS, DYSPHAGIA, COMPLICATION: PRESENT—CAUSING FLUCTUATING WEAKNESS
• DISEASE ONSET IS 2-5 DIFFICULTY SPEAKING, PROGRESSING IMPAIRED OF SKELETAL MUSCLES,
YEARS OF AGE AND RESPIRTATORY PARALYSIS & MOBILITY/RISK FOF MOST OFTEN PRESENTED
• PROXIMAL LOWER FAILURE. RESPIRATORY DISTRESS FALL & INJURY. AS PTOSIS/DIPLOPIA,
EXTREMITIES AND • RILUZOLE IS THE ONLY • MEASUREMENT OF • GAIT TRAINING AND BULBAR SIGNS
PELVIS ARE AFFECTED MEDICATION APPROVED SERIAL SPIROMETRY ASSISTIVE DEVICES (DIFFICULTY
FIRST FOR ALS TREATMENT—IT (FVC) IS GOLD CAN HELP PREVENT SPEAKING/SWALLOWING)
• GOWER SIGN – USE OF IS THOUGHT TO SLOW STANDARD FOR FALLS, INJURY AND AND DIFFICULTY
ONE’S HANDS TO RISE NEURON ASSESSING PRESERVE BREATHING.
FROM A SQUAT THERE DEGENERATION. VENTILATION IN INDEPENDENCE AS • MUSCLES ARE STRONGER
IS NO EFFECTIVE CURE; CLIENTS WITH GBS LONG AS POSSIBLE. IN THE MORNING, AND
GOAL IS TO AVOID BECOME WEAKER WITH
MUSCLE ATROPHY THE DAY’S ACTIVITY AS
THE SUPPLY OF
AVAILABLE
ACETYLCHOLINE IS
DEPLETED.
DONNING/DOFFING OF STERILE GLOVES
• PERFORM HAND HYGIENE
• REMOVE OUTER PACKAGE
• OPEN INNER GLOVE PACKAGE BY FOLDING BACK THE EDGES
• USE NON-DOMINANT HAND TO GRASP CUFF ON INSIDE OF THE DOMINANT HAND GLOVE
• PULL ON DOMINANT HAND GLOVE
• PLACE DOMINANT HAND FINGERS UNDER CUFF ON OUTSIDE OF NON-DOMINANT GLOVE
• PULL ON NON-DOMINANT HAND GLOVE

CUSHING DISEASE ADDISON’S DISEASE

• OVER SECRETION OF ADRENAL CORTEX • UNDER SECRETION OF STEROIDS IN THE ADRENAL CORTEX
• S/SX: “CUSHMAN” • S/SX:
o MOON FACE o POOR STRESS RESPONSE
o ACNE o HYPERPIGMENTATION/BRONZE
o HIRSUTISM • TX: GIVE STEROIDS “—SONE”
o GYNECOMASTIA
o BUFFALO HUMP
o FLUID RETENTION
o STRIAE
o BRUISING
o TRUNCAL OBESITY
o OSTEOPOROSIS
o HYPOKALEMIA
o HYPERGLYCEMIA
o HYPERTENSION
o EMOTIONAL LABILITY
o AMENORRHEA
o PRONE TO INFECTION

• TX: ADRENOECTOMY (UNILATERAL OR BILATERAL)

TYPES OF INSULIN (PEAK)

LISPRO/ASPART = REGULAR/CLEAR = NPH/CLOUDY = GLARGINE/DETEMIR/DEGLUDEC
RAPID ACTING SHORT ACTING INTERMEDIATE ACTING = LONG ACTING
• PEAK: 30 MIN-3 HOURS • PEAK: 2-5 HOURS • PEAK: 4-12 HOURS • NO PEAK
• PREFFERED TO BE GIVEN • CAN BE GIVEN 30 MIN • DOES NOT NEED TO BE • CAN LAST 12-24 HOURS
WITH MEAL BEFORE MEAL TIMED WITH MEAL • CAN BE GIVEN AT
• CAN BE GIVEN TWICE DAILY NIGHT/ONCE DAILY

CRANIAL NERVES **MEMORIZE

CRANIAL NERVES FUNCTION SENSORY/MOTOR/BOTH
• OLFACTORY • SMELL • SENSORY
• OPTIC • VISION • SENSORY
• OCULOMOTOR • EYE MUSCLES • MOTOR
• TROCHLEAR • EYE MUSCLES • MOTOR
• TRIGEMINAL • CHEWING • BOTH
• ABDUCENS • EYE MUSCLES • MOTOR
• FACIAL • FACIAL EXPRESSION • BOTH
• VESTIBULOCOCHLEAR • EQUILIBRIUM & HEARING • SENSORY
• GLOSSOPHARNYX • SWALLOWING • BOTH
• VAGUS • VISCERAL ORGANS • BOTH
• ACCESSORY • HEAD/NECK/SHOULDER MUSCLES • MOTOR
• HYPOGLOSSAL • TONGUE • MOTOR

TOCOLYTIC VS OXYTOCICS:
TOCOLYTIC OXYTOCICS
• STOPS LABOR • STARTS LABOR—STIMULATES CONTRACTION OF THE
• TERBUTALINE & NIFEDIPINE UTERINE SMOOTH MUSCLE
• COMMONLY ADMINISTERED TO INDUCE/AUGMENT LABOR
AND PREVENT PPH
 • OXYTOCIN
o HIGH ALERT MEDICATION
o INCREASES THE RISK OF ABNORMAL FHR,
EMERGENCY C-SECTION, UTERINE TACHYSYSTOLE,
PLACENTAL ABRUPTION, AND UTERINE RUPTURE.
o PROLONGED ADMINISTRATION INCREASES THE RISK
OF WATER INTOXICATION AND PPH.

VITAL SIGN PARAMETERS

PEDIATRICS ADULT
HEART RATE 100-160 BPM 60-100 BPM
BLOOD PRESSURE 120/80 MM HG
MEAN ARTERIAL PRESSURE 70-100 MM HG
TEMPERATURE 97-99 F/36.1-37.2 C
RESPIRATIONS 30-60 BPM 12-16 BPM
BLOOD GLUCOSE >40-45 MG/DL 70-99 MG/DL
BODY MASS INDEX 18.5 – 24.9

KAWASAKI DISEASE
• CAUSES INFLAMMATION OF THE ARTERIAL WALLS AND CAN LEAD TO SCARRING OF THE CORONARY ARTERIES OR DEVELOPMENT OF
CORONARY ANEURYSMS.
o UNKNOWN ETIOLOGY
o NOT CONTAGIOUS
• 3 PHASES:
o ACUTE—SUDDEN ONSET OF HIGH FEVER, SWOLLEN
RED FEET/HANDS, SWOLLEN LIPS/STRAWBERRY
TONGUE,
o AND IRRITABILITY
o SUBACUTE—SKIN BEGINS TO PEEL, CHILD REMAINS
VERY IRRITABLE
o CONVALESCENT—SYMPTOMS DISAPPEAR SLOWLY
• TREATMENT:
o IVIG
§ MONITOR SIGNS OF HEART FAILURE (DECREASED URINARY OUTPUT, ADDITIONAL HEART SOUNDS (S3), TACHYCARDIA
AND DIFFICULTY BREATHING).
o ASPIRIN
DRUG TOXICITIES
DRUG USE THERAPEUTIC LEVEL TOXIC LEVEL SYMPTOMS AT TOXIC LEVEL
LITHIUM FOR BIPOLAR DISORDER 0.6 – 1.2 >2 N/V, ATAXIA, TREMORS
DIGITALIS FOR HEART FAILURE 0.5 – 2 >2 GI SYMPTOMS, LOW HR, VISUAL DISTURBANCES
AMNIOPHYLLINE FOR RESPIRATORY SPASM 10 – 20 > 20
PHENYTOIN FOR SEIZURES 10 - 20 > 20 NYSTAGMUS, ENCEPALOPHATHY, DYSARTHRIA

DIABETEST INSIPIDUS VS. SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE

DIABETES INSIPIDUS – PEEING TOO MUCH SIADH – WATER RETENTION
DI = “DRY INSIDE” SI = “SOAK INSIDE”
• OCCURS DUE TO • OCCURS DUE TO CNS DISRUPTION (STROKE, INFECTION,
INSUFFICIENT PRODUCTION TRAUMA, NEUROSURGERY), SMALL CELL LUNG CARCINOMA,
OF ADH DESMOPRESSIN/CARBAMEZAPINE, PNEUMONIA
• 2 TYPES: • ADH OVERPRODUCTION LEADS TO:
• NEUROGENIC • WATER RETENTION
• MANIPULATION OF THE • DECREASED SERUM
PITUITARY OSMOLALITY (DILUTED)
• S/SX: • HIGH URINE SPECIFIC
• POLYDIPSIA GRAVITY
• POLYURIA—"PEEING TOO MUCH” (CONCENTRATED URINE)
• LOW SPECIFIC URINE GRAVITY (DILUTED URINE) • INCREASED TOTAL BODY
• FLUID VOLUME DEFICIT CAN LEAD TO: WATER
§ DEHYDRATION • DILUTIONAL
§ WEIGHT LOSS HYPONATREMIA
§ HYPERNATREMIA § CAN CAUSE
§ HIGH SERUM OSMOLALITY CONFUSION,
• TX:
 • ADH REPLACEMENT DRUGS SEIZURES, AND OTHER NEUROLOGIC COMPLICATIONS
§ DESMOPRESSIN • RN MANAGEMENT:
• RN MANAGEMENT: • SEIZURE PRECAUTIONS
MONITOR UO, URINE SPECIFIC GRAVITY, & SERUM SODIUM TO AVOID • TX:
HYPONATREMIA • FLUID RESTRICTION
• ORAL SALT TABLETS
• HYPERTONIC SALINE (3%)
• VASOPRESSIN RECEPTOR ANTAGONIST

BECKS TRIAD (CARDIAC TAMPONADE)

• CARDIAC TAMPONADE
o POSSIBLE COMPLICATION OF ACUTE PERICARDITIS THAT IMPAIRS CARDIAC OUTPUT.
o LIFE THREATENING
• CLINICAL FEATURES (BECK’S TRIAD)
o HYPOTENSION
o MUFFLED HEART SOUNDS
o JVD
CUSHING’S TRIAD
• INCREASED INTRACRANIAL PRESSURE
o EARLY SIGNS: CHANGE IN LOC
o LATER SIGNS: CUSHING’S TRIAD
• CLINICAL FEATURES (CUSHING’S TRIAD)
o HYPERTENSION WITH WIDENED PULSE PRESSURE
o BRADYCARDIA
o RESPIRATORY DEPRESSION
VIRCHOW’ TRIAD
• VENOUS THROMBOEMBOLISM
o PREVENTABLE COMPLICATION OF HOSPITALIZATION, SURGERY, AND IMMOBILIZATION.
• CLINICAL FEATURES (VIRCHOW’S TRIAD)
o VENOUS STASIS
o ENDOTHELIAL DAMAGE
o HYPERCOAGULABILITY OF BLOOD

PERIPHERAL ARTERY DISEASE PERIPHERAL VASCULAR DISEASE

• DECREASED SENSATIONS FROM NERVE ISCHEMIA/CO-EXISTING • 6 P’S – PALLOR, PAIN, PARESTHESIA, PARALYSIS,
DIABETES MELLITUS PULSELESSNESS, POIKOLOTHERMIA (INABILITY TO REGULATE
• DECREASED BLOOD SUPPLY TO THE EXTREMITIES CORE BODY TEMPERATURE)
• RN MANAGEMENT—FOCUSES ON IMPROVING BLOOD • RN MANAGEMENT:
FLOW/CIRCULATION o ELEVATE LEGS
o NEVER APPLY DIRECT HEAT
o DO NOT ELEVATE LEGS – ELEVATING LEGS IMPEDES
BLOOD FLOW TO THE FEET
o DANGLE/DEPENDENT POSITION
• CLINICAL FEATURES:
o LACK OF HAIR
o BRITTLE NAILS
o DRY SKIN
o SKIN ATROPHY

IV FLUIDS **
HYPOTONIC ISOTONIC HYPERTONIC
DEFINITION • HIGHER SOLUTE • SAME CONCENTRATION • LOWER SOLUTE
• WATER WILL MOVE OUT OF • WATER WILL MOVE INTO THE
THE CELL CELL
• CRENATION • LYSIS/BURST
SOLUTIONS • 0.45% NACL • 0.9% NACL • 3% NACL
• D5W • 5% SODIUM BICARB
• LR
USE • DKA • BLOOD LOSS • HYPONATREMIA
 • HYPERGLYCEMIA • DEHYDRATION • CEREBRAL EDEMA
RISK • EDEMA • FLUID OVERLOAD

THYROID HTN CRISIS ADDISONIAN CRISIS/ACUTE SEROTONIN SYNDROME (EXCESS

STORM/THYROTOXICOSIS ADRENOCORTICAL INSUFFICIENCY DOSES)
• LIFE-THREATENING CONDITION • LIFE THREATENING • LIFE THREATENING • LIFE-THREATENING
THAT CAN OCCUR IN EMERGENCY DUE TO THE COMPLICATION OF ADDISON’S CONDITION, DEVELOPS WHEN
UNCONTROLLED POSSIBILITY OF SEVERE ORGAN DISEASE—CAN LEAD TO DRUGS AFFECTING THE
HYPERTHYROIDISM/GRAVE’S DAMAGE. SHOCK; TRIGGERED BY STRESS BODY’S SEROTONIN LEVELS
DISEASE WHEN A STRESSFUL • IF NOT TREATED PROMPTLY— • S/SX: ARE ADMINISTERED
INCIDENT TRIGGERS A SUDDEN COMPLICATIONS SUCH AS ICH, o HOTN SIMULTANEOUSLY OR IN
SURGE OF THYROID HORMONE. HF, MI, RENAL FAILURE, AORTIC o TACHYCARDIA OVERDOSE.
• S/SX: DISSECTION, RETINOPATHY o DEHYDRATION • DRUGS WHICH MAY TRIGGER
o TACHYCARDIA MAY OCCUR. o HYPERKALEMIA THIS REACTION INCLUDE—
o HTN • S/SX: o HYPONATREMIA SSRI, MAOI,
o DIAPHORETIC o BLURRED VISION o HYPOGLYCEMIA DEXTROMORPHAN,
o IRRITABILITY o DIZZINESS o FEVER ONDANSETRON, ST. JOHN’S
o TREMORS o SEVERE HEADACHE o WEAKNESS WORT, AND TRAMADOL.
o NERVOUSNESS o SOB o CONFUSION • S/SX:
• TX: • TX: • TX: o LOC CHANGES (ANXIETY,
o BETA BLOCKERS o CONTINUOUS IV o SHOCK MANAGEMENT AGITATION,
• RN MANAGEMENT: VASODILATORS o FLUID RESUSCITATION DISORIENTATION)
o ECG MONITORING (NITROPRUSSIDE (0.9% NS AND D5W) o AUTONOMIC
o SUPPORTIVE CARE FOR SODIUM)E o ADMINISTRATION OF DYSREGULATION
S/SX (FEVER, • TX GOAL: HIGH-DOSE (HYPERTHERMIA,
TACHYCARDIA, HTN, GI o BP LOWERED TO HYDROCORTISONE IVP DIAPHORESIS,
DISTRESS) PREVENT ORGAN TACHYCARDIA, HTN)
DAMAGE o NEUROMUSCULAR
o MAINTAIN MAP OF 110- HYPERACTIVITY
115 MM HG (TREMOR, MUSCLE
RIGIDITY, CLONUS,
HYPERREFLEXIA)

HASHIMOTO DISEASE = HYPOTHYROIDISM GRAVES DISEASE = HYPERTHYROIDISM

• IDENTIFIED BY LOW CIRCULATING T3 & T4 (THYROID GLAND) + • IDENTIFIED BY HIGH T3 & T4 (THYROID GLAND) + LOW TSH
HIGH TSH (PITUITARY) + HIGH TRH LEVELS (HYPOTHALAMUS) (PITUITARY) + LOW TRH LEVELS (HYPOTHALAMUS)
• OCCURS WHEN TSH IS UNABLE TO STIMULATE THE THYROID TO • MOST COMMON CAUSE OF HYPERTHYROIDISM
PRODUCE THYROID HORMONES • TX:
• ALSO KNOWN AS “CHRONIC LYMPHOCYTIC THYROIDITIS” o RAI (RADIOACTIVE IODINE)—MAKES CLIENTS
• MOST COMMON CAUSE OF HYPOTHYROIDISM PERMANENTLY HYPOTHYROID, AND REQUIRE LIFE-LONG
• TX: LEVOTHYROXINE THYROID SUPPLEMENTS.

PLACENTA ABRUPTIO PLACENTA PREVIA UTERINE RUPTURE

• CLASSIFIED AS PARTIAL, COMPLETE, • ABNORMAL IMPLANTATION OF THE PLACENTA • CLIENTS ATTEMPTING VAGINAL BIRTH
MARGINAL, OVERT, CONCEALED RESULTING IN PARTIAL/COMPLETE COVERING OF AFTER C-SECTION HAVE A SLIGHT
• RF: THE CERVICAL OS. INCREASED RISK FOR UTERINE RUPTURE
o ABD TRAUMA
 o HTN • MAY RESULT IN MASSIVE BLOOD LOSS AND DUE TO PREVIOUS SCARRING OF THE
o COCAINE USE MATERNAL/FETAL COMPROMISE; AT RISK FOR UTERUS.
o HX OF PREVIOUS ABRUPTION HEMORRHAGE • S/SX:
o PREMATURE RUPTURE OF • DIAGNOSED BY ULTRASOUND o FIRST SIGN—ABNORMAL FHR
MEMBRANES • S/SX: (DECELERATION, DECREASED
• S/SX: o PAINLESS VAGINAL BLEEDING VARIABILITY, BRADYCARDIA)
o SUDDEN ONSET VAGINAL o ULTRASOUND FINDING OF PLACENTA o SUDDEN ONSET VAGINAL
BLEEDING COVERING CERVICAL OS BLEEDING
o ABD/BACK PAIN • RN MANAGEMENT: o CONSTANT ABD PAIN
o RIGID/TENDER UTERUS o VAGINAL EXAMINATIONS & VAGINAL o CESSATION OF UTERINE
o TACHYSYSTOLE (FREQUENT INTERCOURSE ARE CONTRAINDICATED CONTRACTIONS
UTERINE CONTRACTIONS) o CONTINOUS FHR o LOSS OF FETAL STATION
o DARK RED VAGINAL BLEEDING o PAD COUNTS o FETAL DETERIORATION
• RN MANAGEMENT:
o MONITOR MATERNAL VS • TX:
o ASSESSED FOR S/SX OF SHOCK o TYPE & SCREEN
(TACHYCARDIA & HOTN) o LARGE BORE IV ACCESS FOR FLUID
• TX: VOLUME REPLACEMENT AND BLOOD
o RAPID VOLUME REPLACEMENT PRODUCTS
WITH IV FLUID AND BLOOD o PELVIC REST & MODIFIED BED REST IS
PRODUCTS RECOMMENDED
o LARGE BORE IV ACCESS (16/18 G) o C-SECTION

NMS (NEUROLEPTIC MALIGNANT SYNDROME) EPS (EXTRAPYRAMIDAL SYMPTOMS) / TARDIVE DYSKINESIA

• A RARE BUT POTENTIALLY LIFE THREATENING REACTION. • DRUG INDUCED MOVEMENT DISORDERS
• SEEN WITH TYPICAL ANTIPSYCHOTICS (HALOPERIDOL, • S/SX: SYMPTOMS RESEMBLING PARKINSON’S DISEASE
FLUPHENAZINE) o DYSTONIA—ABNORMAL MUSCLE MOVEMENTS OF
• S/SX: THE FACE, NECK, TRUNK
o FEVER o LIP SMACKING
o MUSCULAR RIGIDITY o CHEWING MOVEMENTS
o ALTERED LOC o TWISTING FINGERS
o AUTONOMIC DYSFUNCTION (SWEATING, HTN, o FROWNING OR BLINKING OF EYES
TACHYCARDIA) o PUFFING OF CHEEKS
• TX: • TX:
o REDUCE FEVER o BENZTROPINE (COGENTIN) – ANTICHOLINERGIC
o REDUCE MUSCLE RIGIDITY DRUG
o INTENSIVE CARE UNIT
o DISCONTINUE THE ANTIPSYCHOTIC MEDICATION
AND NOTIFY HCP

ROOM ASSIGNMENT RULES:

• CLIENTS INFECTED WITH DIFFERENT ORGANISM CANNOT BE PLACED TOGETHER IN THE SAME ROOM.
o CLIENTS INFECTED WITH THE SAME CAUSATIVE PATHOGENS CAN BE PLACED TOGETHER.
• AN INFECTIOUS CLIENT CANNOT BE HOUSED WITH AN IMMUNOCOMPROMISED ONE; IMMUNOCOMPROMISED PATIENTS ARE CLIENTS WHO
ARE:
o (ON STEROIDS, CHEMOTHERAPHY, HIV POSITIVE, NEW POST-OPERATIVE, MULTIPLE CHRONIC MORBIDITIES, SPLENECTOMY,
DIABETES, VERY YOUNG AND ELDERLY).
• RN SHOULD CONSIDER INFECTION CONTROL, PHYSICAL LOCATION, ACUITY LEVEL, AND INDIVIDUAL CLIENT NEEDS.
• A CLIENT WITH INFECTION SHOULD NOT BE ASSIGNED WITH A CLIENT WHO HAD SURGERY OR IS IMMUNOCOMPROMISED.
o POST-SPLENECTOMY PATIENTS ARE AT LIFELONG RISK FOR RAPID SEPSIS.
• PEDIATRIC ROOM PLACEMENT SHOULD BE BASED ON DISEASE PROCESS, SEX, AND DEVELOPMENTAL STAGE.
o THE CHARGE RN MUST CONSIDER CLIENT SAFETY FIRST.

PRESSURE ULCER:
• RISK FACTORS:
o ADVANCED AGE, IMPAIRED SENSATION, NUTRITIONAL DEFICITS,
PERFUSION/OXYGENATION DEFICITS, SKIN MOISTURE
• RN MANAGEMENT:
o SKIN CARE, REPOSITIONING, NUTRITION, SUPPORT SURFACES
• STAGES OF PRESSURE ULCER:
o STAGE I: ERYTHEMA
o STAGE II: BLISTER, EXPOSED DERMIS (PARTIAL THICKNESS)
o STAGE III: EXPOSED SUBQ FAT (FULL THICKNESS)
o STAGE IV: EXPOSED MUSCLE & BONE (FULL THICKNESS + DEEPER TISSUE
LOSS)
o UNSTAGEABLE: SLOUGH/ESCHAR

OA RA
• DEGENERATIVE • CHRONIC
• PROGRESSIVE EROSION • SYSTEMIC
• NON-INFLAMMATORY • INFLAMMATORY
• AUTOIMMUNE CONDITION
• S/SX: • NO CURE FOR THE DISEASE
o ASYMMETRICAL PAIN
o PAIN EXACERBATED BY WEIGHT BEARING ACTIVITIES • S/SX:
o CREPITUS o SYMMETRICAL PAIN AND SWELLING
o MORNING STIFFNESS WITHIN 30 MINUTES o MORNING JOINT STIFFNESS >60 MINS TO SEVERAL
o DECREASED JOINT MOBILITY/ROM HOURS
o ATROPHY OF SUPPORTING MUSCLES o ELEVATED ESR & RHEUMATOID FACTOR LEVELS

• TX:
o REMAIN ACTIVE TO PREVENT CONTRACTURE
o TAKE IMMUNOSUPPRESANT MEDICATIONS
§ METHOTREXATE
o EAT A BALANCED DIET

IRRITABLE BOWEL ULCERATIVE COLITIS DIVERTICULITIS HIRSCHPRUNG DISEASE INTUSSECEPTION

SYNDROME
• COMMON, CHRONIC • CHRONIC • SAC-LIKE PROTRUSIONS • OCCURS WHEN A • AN INTESTINAL
BOWEL CONDITION INFLAMMATORY IN THE LARGE INTESTINES CHILD IS BORN OBSTRUCTION THAT
CAUSED BY ALTERED BOWEL DISEASE • OCCURS WHEN MISSING OCCURS WHEN A
INTESTINAL MOTILITY CHARACTERIZED BY DIVERTICULA BECOMES SPECIALIZED NERVE SEGMENT OF THE
INFLAMMATION AND INFECTED AND INFLAMED CELLS IN THE DISTAL BOWEL
• S/SX: ULCERATION OF THE • ETIOLOGY HAS BEEN LARGE INTESTINE— FOLDS/TELESCOPES.
o DIARRHEA LARGE INTESTINE THAT LINKED TO CHRONIC RENDERING THE
o CONSTIPATION RESULTS IN: CONSTIPATION CAUSING INTERNAL ANAL • S/SX:
o ABD PAIN INTRACOLONIC PRESSURE SPHINCTER UNABLE o ABD PAIN—
• RN MANAGEMENT: o BLOODY DIARRHA TO RELAX DRAWING
o AVOID GAS o ANOREXIA • RN MANAGEMENT: KNEES UP TO
PRODUCING o ANEMIA o PREVENT • S/SX: THE CHEST
FOOD CONSTIPATION o NO o INCONSOLABLE
o INCREASE FIBER • RN MANAGEMENT: o CONSUME HIGH MECONIUM CRYING
o AVOID GI o PAIN FIBER DIET o VOMIT GREEN o CURRANT JELLY
IRRITANTS MANAGEMENT o INCREASE FLUID BILE STOOLS
o ADDRESS INTAKE o ABD o SAUSAGED
PSYCHOSOCIAL o EXERCISE DISTENTION SHAPED ABD
NEEDS REGULARLY o MEGACOLON MASS
o ASSESS FLUID o FAILURE OF
BALANCE INTERAL ANAL
o EVALUATE SPHINCTER TO
TREATMENT RELAX
ADHERENCE
o PROMOTE
NUTRITION

HIATAL HERNIA DUMPING SYNDROME

 • ABNORMAL MOVEMENT OF THE • COMPLICATION OF POST-OP GASTRIC SURGERY IN WHICH
STOMACH AND/OR GASTRIC CONTENTS DUMP TOO QUICKLY INTO THE DUODENUM
ESOPHAGOGASTRIC JUNCTION
INTO THE CHEST DUE TO A • S/SX:
WEAKNESS IN THE DIAPHRAGM o ABD PAIN, CRAMPING, DIARRHEA, HOTN, N/V,
• REGURGITATION OF ACID INTO GENERALIZED SWEATING
ESOPHAGUS BECAUSE UPPER
STOMACH HERNIATES UPWARD • RN MANAGEMENT:
THROUGH THE DIAPHRAGM o LIE DOWN AFTER MEALS
o DECREASED FLUID INTAKE
• S/SX: o CONSUME LOW CARB, HIGH FIBER, HIGH PROTEIN, AND
o INCREASED ABDOMINAL HIGH FAT
PRESSURE
• GASTRIC CONTENTS MOVE IN THE RIGHT DIRECTION, AT THE
• RN MANAGEMENT--EDUCATE CLIENTS TO: WRONG RATE
o AVOID ACTIVITIES THAT INCREASE ABDOMINAL PRESSURE • LOWER GI
(WEIGHT LIFTING)
o KEEP HOB ELEVATED
o REMAIN UPRIGHT FOR SEVERAL HOURS AFTER MEALS

• GASTRIC CONTENTS MOVE IN THE WRONG DIRECTION, AT THE

RIGHT RATE
• UPPER GI

GESTATIONAL HTN PRE-ECLAMPSIA ECLAMPSIA/SEIZURES HELLP SYNDROME

• NEW ONSET ELEVATED • NEW ONSET ELEVATED BP AT • PRE-ECLAMPSIA • SEVERE FORM OF PRE-
BP AT >20 WEEKS >20 WEEKS GESTATION • + NEW ONSET OF TONIC- ECLAMPSIA
GESTATION • + PROTEINURIA CLONIC SEIZURES • HEMOLYSIS
• NO PROTEINURIA OR • OR SIGNS OF END-ORGAN • ELEVATED LIVER ENZYMES
SIGNS OF END ORGAN DAMAGE • LOW PLATELETS
DAMAGE
• S/SX: • S/SX:
o HEADACHE o RUQ PAIN
o VISUAL DISTURBANCES o N/V
o FACIAL SWELLING o MALAISE

• TX: • COMPLICATIONS:
o MAGNESIUM o PLACENTAL
SULFATE—PREVENT ABRUPTION
SEIZURE o STROKE
o DEATH

CRITICAL CARE NURSING

CARDIAC OUTPUT • CARDIAC FUNCTION 4-8

CARDIAC INDEX • CARDIAC FUNCTION 2.2 – 4.0
CVP • RIGHT VENTRICLE PRELOAD 2 – 8 MM HG
• FLUID VOLUME STATUS
MEAN ARTERIAL PRESSURE • PERFUSION 70 – 100 MM HG
PULMONARY ARTERY WEDGE • LEFT VENTRICLE PRELOAD 6 - 12
• LEFT HEART FUNCTION
SYSTEMIC VASCULAR RESISTANCE • VESSEL DILATION/CONSTRICTION 800 - 1200

AMNIOCENTESIS / CHRONIC VILLI SAMPLING / RH ALLOIMMUNIZATION / NITRAZINE PH

• AMNIOCENTESIS (PERFORMED AT 15-17 WEEKS)

o PRENATAL PROCEDURE IN WHICH AMNIOTIC FLUID IS REMOVED
o TEST CHECKS FOR FETAL ABNORMALITIES
§ DOWN SYNDROME/TRISOMY 21
§ CYSTIC FIBROSIS
 § NEURAL TUBE DEFECTS
§ EDWARDS SYNDROME/TRISOMY 18

• CHRONIC VILLUS SAMPLING (PERFORMED AT 10-12 WEEKS)

o PRENATAL PROCEDURE WHICH INVOLVES TAKING A SAMPLE OF TISSUE FROM THE PLACENTA
o TEST CHECKS FOR CHROMOSOMAL ABNORMALITIES
§ DOWN SYNDROME/TRISOMY 21
§ CYSTIC FIBROSIS
§ NEURAL TUBE DEFECTS
§ EDWARDS SYNDROME/TRISOMY 18

• RH ALLOIMMUNIZATION
o OCCURS WHEN A PREGNANT CLIENT WITH AN RH-NEGATIVE BLOOD TYPE IS EXPOSED TO RH-POSITIVE FETAL RBCS DURING PREGNANCY
AND BIRTH
o AFTER EXPOSURE MATERNAL IMMUNE SYSTEM PRODUCES ANTIBODIES TO THE RH ANTIGEN THAT CAN CAUSE SERIOUS
COMPLICATIONS FOR AN RH-POSITIVE FETUS DURING FUTURE PREGNANCIES.
§ HEMOLYTIC ANEMIA
o RHOGAM PREVENTS ANTIBODY FORMATION BY SUPPRESSING THE MATERNAL IMMUNE SYSTEM RESPONSE
§ SHOULD BE ADMINISTERED WITHIN 72 HOURS OF BIRTH
§ IF THE NEWBORN IS RH NEGATIVE, RHOGAM IS NOT NECESSARY POSTPARTUM
o RN SHOULD VERIFY THAT THE CLIENT IS NOT RH SENSITIZED BY CHECKING FOR A NEGATIVE ANTIBODY SCREEN/INDIRECT COOMBS TEST
§ A POSITIVE MATERNAL ANTIBODY SCREEN WOULD WARRANT FURTHER CLARIFICATION FROM THE HCP

• NITRAZINE PH TEST STRIP

o HELP DIFFERENTIATE BETWEEN AMNIOTIC FLUID, WHICH IS ALKALINE, AND NORMAL VAGINAL FLUIDS WHICH IS ACIDIC.
§ POSITIVE RESULT:
• BLUE-GREEN: PH 6.5
• BLUE-GRAY: PH 7.0
• DEEP BLUE: PH 7.5
o RECENT SEXUAL INTERCOURSE SHOULD ALERT THE RN TO NOTIFY HCP
§ RESULTS MAY BE FALSELY POSITIVE DUE TO PRESENCE OF SEMEN IN THE VAGINA

ETHICAL PRINCIPLES IN NURSING

AUTONOMY • DECIDING FOR ONE’S SELF

BENEFICENCE • DOING GOOD
o INVOLVES HELPING TO MEET THE CLIENT’S EMOTIONAL NEEDS THROUGH UNDERSTANDING.
• IT CAN INVOLVE NOT SAYING ALL KNOWN INFORMATION IMMEDIATELY
o BUT DELAYING NOTIFICATION UNTIL APPROPRIATE SUPPORT IS IN PLACE.
NON-MALEFICENCE • TO DO NO HARM
• RELATES TO PROTECTING CLIENTS FROM DANGER WHEN HE/SHE IS UNABLE TO DO SO THEMSELVES
o DUE TO A MENTAL/PHYSICAL CONDITION
VERACITY • BEING TRUTHFUL
• TELLING THE TRUTH AS A FUNDAMENTAL PART OF BUILDING A TRUSTING RELATIONSHIP.
JUSTICE • TREATING ALL CLIENTS FAIRLY
FIDELITY • EXHIBITING LOYALTY
• FULFILLING COMMITMENTS MADE TO ONESELF AND OTHERS
• MEETING THE EXPECTED RESPONSIBILITIES OF PROFESSIONAL NURSING PRACTICE
• PROVIDES THE BASIS OF ACCOUNTABILITY
MATERNAL WEIGHT GAIN

• 1ST TRIMESTER: 1-13 WEEKS

o WEIGHT GAIN OF 1.1-4.4 LBS
o FHR IS DETECTABLE BY DOPPLER AT 10-12 WEEKS GESTATION
o FOLIC ACID FIRST 8 WEEKS, PREVENT NEURAL TUBE DEFECTS
• 2ND TRIMESTER: 14 WEEKS, 0 DAYS TO 27 WEEKS, 6 DAYS
o INCREASED FUNDAL HEIGHT
§ AFTER 20 WEEKS OF GESTATION, THE FUNDAL HEIGHT MEASUREMENT IN CM
SHOULD CORRELATE CLOSELY WITH THE NUMBER OF WEEKS PREGNANT
• 24 CM = 24 WEEKS
o WEIGHT GAIN OF 1LB/WEEK
o QUICKENING
§ 14-16 WEEKS IN MULTIGRAVIDAS
§ 18-20 WEEKS IN PRIMIGRAVIDAS
o PTL WARNINGS AND SIGNS OF PRE-ECLAMPSIA SHOULD BE REVIEWED AT 20 WEEKS
GESTATION
o ULTRASOUND AROUND 18-20 WEEKS
o GESTATIONAL DIABETES SCREENING BETWEEN 24-28 WEEKS
o IRON RICH FOOD AFTER 20 WEEKS, TO PREVENT ANEMIA
• 3RD TRIMESTER: 28 WEEKS TO END OF PREGNANCY
o WEIGHT GAIN OF 1LB/WEEK
o ADMINISTRATION OF TDAP VACCINE
TYPES OF INCONTINENCE

STRESS INCONTINENCE • INVOLUNTARY LEAKAGE ON EFFORT OR EXERTION

URGE INCONTINENCE
OVERFLOW INCONTINENCE
FUNCTIONAL INCONTINENCE
o SNEEZING
o COUGHING
• INVOLUNTARY LEAKAGE ACCOMPANIED BY/IMMEDIATELY PROCEEDED BY URGENCY
• UNEXPECTED LEAKAGE OF SMALL AMOUNTS OF URINE BECAUSE OF AN OVERFILLED BLADDER
o DRIBBLING
• INVOLUNTARY LEAKAGE
• ASSOCIATED WITH COGNITIVE, FUNCTIONAL, MOBILITY DIFFICULTIES
o IMPAIRS THE ABILITY TO USE THE TOILET
§ A CLIENT WITH SEVERE ARTHRITIS UNABLE TO UNBUTTON PANTS QUICKLY ENOUGH

ADVANCE DIRECTIVE LIVING WILL DURABLE POWER OF ATTORNEY

• PREPARED BY A CLIENT PRIOR TO THE
NEED TO INDICATE CLIENT’S WISHES.
• THE TWO MOST COMMON FORMS OF
ADVANCE DIRECTIVES ARE LIVING WILLS
AND DURABLE POWER OF ATTORNEY.
• THESE TAKE EFFECT WHEN THE CLIENT
CANNOT SELF-ADVOCATE.
• GIVES INSTRUCTIONS ABOUT FUTURE
MEDICAL CARE AND TREATMENT IF THE
CLIENT IS UNABLE TO COMMUNICATE.
• REPRESENTS THE CLIENT’S WISHES
REGARDING ACTIONS TO BE TAKEN IN
SPECIFIC SITUATIONS.
o DEALING WITH SPECIFIC EVENTS
AND ISSUES.
• INDIVIDUAL DESIGNATED TO MAKE
HEALTH CARE DECISIONS SHOULD A
CLIENT BECOME UNABLE TO MAKE
AN INFORMED DECISION; IT ALLOWS
MORE FLEXIBILITY TO DEAL WITH
UNIQUE SITUATIONS.
• IN OTHER WORDS, A COMPETENT
ADULT ESTABLISHES WHEN THE
CLIENT CAN NO LONGER SELF-
ADVOCATE.

PALLIATIVE CARE HOSPICE

• APPROPRIATE FOR CLIENTS WHO WISH TO FOCUS ON QUALITY OF
LIFE AND SYMPTOM MANAGEMENT RATHER THAN LIFE-
PROLONGING TREATMENTS.
• THE CLIENT WITH AN ADVANCED, TERMINAL DISEASE IS OFTEN
AN APPROPRIATE CANDIDATE FOR PALLIATIVE CARE.
• EMPHASIZES THE QUALITY OF LIFE AND SYMPTOMS CONTROL
• PROVIDED BY A MULTIDISCIPLINARY CARE TEAM WITH A FOCUS
ON THE CLIENT AND HIS/HER FAMILY.
• COMFORT CARE WITHOUT CURATIVE INTENT/AT THE END OF
LIFE
• PATIENT NO LONGER HAS CURATIVE OPTIONS
• BEGINS AFTER TREATMENT OF THE DISEASE IS STOPPED, AND
WHEN IT IS CLEAR THAT THE PERSON IS NOT GOING TO SURVIVE
THE ILLNESS
• PROGNOSIS IS 6 MONTHS OF LESS

NEGLIGENCE BATTERY ASSAULT DOMESTIC ABUSE

• OCCURS WHEN CAREGIVERS • INVOLVES MAKING PHYSICAL • AN ACT THAT THREATENS • PRIORITY IS TO REMOVE
INTENTIONALLY OR CONTACT WITH THE CLIENT THE CLIENT AND CAUSES THE VICTIM FROM ANY
UNINTENTIONALLY FAIL TO MEET WITHOUT PERMISSION. THE CLIENT TO FEAR HARM,
 PHYSICAL, EMOTIONAL, OR • IN OTHER WORDS, BATTERY BUT WITHOUT THE CLIENT SOURCES OF
SOCIAL NEEDS. IS THE INTENTIONAL BEING TOUCHED. IMMEDIATE DANGER.
• COMMONLY NEGLECTED TOUCHING OF A PERSON
NECESSITIES INCLUDE: WATER, THAT IS LEGALLY DEFINED AS
FOOD, MEDICATION, HYGIENE, UNACCEPTABLE OR OCCURS
AND CLOTHING. WITHOUT THE PERSON’S
CONSENT.

OTHER ETHICS/LEGAL:
• A COMPETENT ADULT HAS THE RIGHT TO MAKE ANY DECISION REGARDING THE CLIENT’S HEALTH CARE.
• PARENTS DO NOT HAVE THE RIGHT TO PLACE THEIR MINOR CHILD IN A LIFE-THREATENING POSITION.
• PARENTS HAVE A LEGAL AUTHORITY TO MAKE CHOICES ABOUT THEIR CHILD’S HEALTH CARE.
o NOT WHEN THE PARENTS DO NOT PERMIT LIFE-SAVING TREATMENT OR WHEN THERE IS POTENTIAL CONFLICT OF INTEREST
§ (CHILD ABUSE/NEGLECT).
• PARENTS ARE AUTOMATICALLY THE LEGAL GUARDIANS AND DECISION MAKERS FOR THEIR MINOR CHILDREN.
o AS LONG AS DECISIONS DO NOT PUT ANY OF THEIR CHILDREN IN DANGER.
INFORMED CONSENT:
• RN IS RESPONSIBLE FOR:
o WITNESSING THE CLIENT’S SIGNATURE
o ENSURING THE CLIENT IS COMPETENT AND UNDERSTANDS INFORMATION PROVIDED BY THE SURGEON.

CALCULATIONS
MEAN ARTERIAL PRESSURE • (2 X DBP + SBP)/3
• NORMAL: 75-100 MM HG
PARKLAND FORMULA/RULE OF NINES • 4 ML X TBSA% X BODY WEIGHT IN KG
o EX: 4 ML X 90 KG X 45% TBSA = 16,200 ML
• 50% GIVEN IN FIRST 8 HOURS; 50% GIVEN IN NEXT 16 HOURS
INTAKE & OUTPUT • TOTAL INTAKE – TOTAL OUTPUT = NET FLUID BALANCE
NAEGELE’S RULE • (LAST MENSTRUAL PERIOD + 7 DAYS) – 3 MONTHS
o EX: SEPT 7 + 7 = SEPT 14 – 3 MONTHS = JUNE 14

DELIRIUM
• REVERSIBLE BUT DIFFICULT TO DIAGNOSE
o CONFUSION ASSESSMENT METHOD
o INTENSIVE CARE DELIRIUM SCREENING
• ACUTE ONSET
• IMPAIRED CONSCIOUSNESS
• S/SX:
o NEW ONSET CONFUSION
o DIFFICULTY FOCUSING
o SHORT TEM MEMORY LOSS
o INCREASING LETHARGY