VITAL SIGNS

ABG VALUES
Heart rate: 80—100 bpm PH: 7.36—7.45
Respiratory rate: 12-20 rpm HCO3: 24—26 MEQ/L
Blood pressure: 110-120/60 CO2: 35—45 MEQ/L
mmHg PAO2: 80%—100%
Temperature: 37 °C (98.6 °F) SAO2: >95%
NCLEX

HEMATOLOGY
VALUES

RBCs: 4.5—5.0 million

WBCs: 5,000—10,000
Platelets: 200,000—400,000
Hemoglobin (Hgb): 12—16 gm
(female); 14—18 gm (male).
Hematocrit (Hct): 37—47
(female); 40—54 (male)

ACID-BASE
BALANCE

ROME=Respiratory
opposite/metabolic equal
respiratory acid/base disorders the pH
is opposite to the other components.
Use the Tic-Tac-Toe Method for
interpreting ABGs.

SERUM
ELECTROLYTES
Sodium: 135—145 mEq/L
Potassium: 3.5—5.5 mEq/L
Calcium: 8.5—10.9 mEq/L
Chloride: 95—105 mEq/L
Magnesium: 1.5—2.5 mEq/L
Phosphorus: 2.5—4.5 mEq/L
THERAPEUTIC
DRUG LEVELS
CHEMISTRY
VALUES
Glucose: 70—110 mg/dL
Specific Gravity: 1.010—1.030
BUN: 7-22 mg/dL
Serum creatinine: 0.6—1.35 mg/dL
LDH: 100-190 U/L
Protein: 6.2—8.1 g/dL
Albumin: 3.4—5.0 g/dL
Bilirubin: <1.0 mg/dL
Total Cholesterol: 130—200 mg/dL
Triglyceride: 40—50 mg/dL
Uric acid: 3.5—7.5 mg/dL
CPK: 21-232 U/L

Carbamazepine (Tegretol): 4—10 ANTICOAGULANT

mcg/ml THERAPY
Digoxin (Lanoxin): 0.8—2.0 ng/ml
The antidote is Vitamin K.
Gentamycin (Garamycin): 5—10
mcg/ml (peak), <2.0 mcg/ml (valley)
Sodium warfarin (Coumadin) PT:
Lithium (Eskalith): 8—1.5 mEq/L
10—12 seconds (control).
Phenobarbital (Solfoton): 15—40
INR (Coumadin): 0.9—1.2
mcg/mL
Heparin PTT: 30—45 seconds
Phenytoin (Dilantin): 10—20 mcg/dL
(control). The antidote is protamine
Theophylline (Aminophylline): 10—
sulfate.
20 mcg/dL
APTT: 3—31.9 seconds
Tobramycin (Tobrex): 5—10 mcg/mL
Fibrinogen level: 203—377 mg/dL
(peak), 0.5—2.0 mcg/mL (valley)
Valproic Acid (Depakene): 50—100
mcg/ml
Vancomycin (Vancocin): 20—40
mcg/ml (peak), 5 to 15 mcg/ml (trough)
 DEVELOPMENTAL MATERNITY
MILESTONES NORMAL VALUES

Fetal Heart Rate: 120—160 bpm

2—3 months: able to turn head up, and
Variability: 6—10 bpm
can turn side to side. Makes cooing or
Amniotic fluid: 500—1200 ml
gurgling noises and can turn head to
Contractions: 2—5 minutes apart
sound.
with duration of < 90 seconds and
4—5 months: grasps, switch and roll
intensity of <100 mmHg.
over tummy to back. Can babble and
APGAR Scoring: Appearance,
can mimic sounds.
Pulses, Grimace, Activity, Reflex
6—7 months: sits at 6 and waves bye-
Irritability. Done at 1 and 5 minutes
bye. Can recognize familiar faces and
with a score of 0 for absent, 1 for
knows if someone is a stranger. Passes
decreased, and 2 for strongly
things back and forth between hands.
positive. Scores 7 and above are
8—9 months: stands straight at eight,
generally normal, 4 to 6 fairly low,
has favorite toy, plays peek-a-boo.
and 3 and below are generally
10—11 months: belly to butt.
regarded as critically low.
12—13 months: twelve and up, drinks
AVA: The umbilical cord has two
from a cup. Cries when parents leave,
arteries and one vein.
uses furniture to cruise

PREGNANCY
CATEGORY OF
DRUGS
Category A—No risk in controlled human studies
Category B—No risk in other studies. Examples:
Amoxicillin, Cefotaxime.
Category C—Risk not ruled out. Examples: Rifampicin
Theophylline (Theolair).
Category D—Positive evidence of risk. Examples: Phenytoin,
Tetracycline.
Category X—Contraindicated in Pregnancy. Examples:
Isotretinoin (Accutane), Thalidomide (Immunoprin), etc.
Pregnancy Category N—Not yet classified
 DRUG CONVERSIONS
SCHEDULES

1 teaspoon (t) = 5 ml
Schedule I— use only (e.g. heroin,
1 tablespoon (T) = 3 t = 15 ml
LSD, MDMA).
1 oz = 30 ml
Schedule II—drugs with high potential
1 cup = 8 oz
for abuse and requires written
1 quart = 2 pints
prescription (e.g., Ritalin,
1 pint = 2 cups
hydromorphone (Dilaudid), meperidine
1 grain (gr) = 60 mg
(Demerol), and fentanyl).
1 gram (g) = 1,000 mg
Schedule III—requires new
1 kilogram (kg) = 2.2 lbs
prescription after six months or five
1 lb = 16 oz
refills (e.g., codeine, testosterone,
Convert C to F: C+40 multiply by 9/5
ketamine).
and subtract 40
Schedule IV—requires new
Convert F to C: F+40 multiply by 5/9
prescription after six months (e.g.,
and subtract 40
Darvon, Xanax, Soma, and Valium).
Schedule V—dispensed as any other
prescription or without prescription
(e.g. cough preparations, Lomotil, RULES OF NINES
Motofen).

Rules of nines for calculating Total

STOP
Treatment for maternal hypotension
after an epidural anesthesia:
Stop infusion of Pitocin.
Turn the client on her left side.
Administer oxygen.
If hypovolemia is present, push IV
fluids.
Body Surface Area (TBSA) for burns
Head and neck: 9%
Upper limbs: 18% (9% each)
Trunk: 36%
Legs: 36% (18% each)
Genitalia: 1%
 MEDICATION
MEDICATIONS
CLASSIFICATIONS

Digoxin (Lanoxin)—Assess pulses for

Antacids—reduces hydrochloric acid in
a full minute, if less than 60 bpm hold
the stomach.
dose.
Antianemics—increases blood cell
Aluminum Hydroxide (Amphojel)—
production.
Treatment of GERD and kidney
Anticholinergics—decreases oral
stones. WOF constipation.
secretions.
Hydroxyzine (Vistaril)—Treatment of
Anticoagulants—prevents clot
anxiety and itching. WOF dry mouth.
formation,
Midazolam (Versed)—given for
Anticonvulsants—management of
conscious sedation.
seizures and bipolar disorders.
Amiodarone (Cordarone)—WOF
Antidiarrheals—decreases gastric
diaphoresis, dyspnea, lethargy. Take
motility and reduce water in bowel.
missed dose any time in the day. Do
Antihistamines—block the release of
not take double dose.
histamine.
Warfarin (Coumadin)—WOF for
Antihypertensives—lower blood
signs of bleeding, diarrhea, fever, or
pressure and increases blood flow.
rash. Stress importance of complying
Anti-infectives—used for the treatment
with prescribed dosage and follow-up
of infections,
appointments.
Bronchodilators—dilates large air
Methylphenidate (Ritalin)—
passages in asthma or lung diseases
Treatment of ADHD. Assess for heart
(e.g., COPD).
related side-effects and reported
Diuretics—decreases water/sodium
immediately.
from the Loop of Henle.
Dopamine—Treatment of
Laxatives—promotes the passage of
hypotension, shock, and low cardiac
stool.
output. Monitor ECG for arrhythmias
Miotics—constricts the pupils.
and blood pressure.
Mydriatics—dilates the pupils.
Rifampicin—causes red-orange tears
Narcotics/analgesics—relieves
and urine.
moderate to severe pain.
Ethambutol—causes problems with
vision, liver problem.
Isoniazid—can cause peripheral
neuritis, take vitamin B6 to counter.
 COMMON DIETS

Acute Renal Disease—protein-restricted, high-calorie, fluid-controlled,

sodium and potassium controlled.
Addison’s disease—increased sodium, low potassium diet.
ADHD and Bipolar—high-calorie and provide finger foods.
Burns—high protein, high caloric, increase in Vitamin C.
Cancer—high-calorie, high-protein.
Celiac Disease—gluten-free diet (no BROW: barley, rye, oat, and wheat).
Chronic Renal Disease—protein-restricted, low-sodium, fluid-restricted,
potassium-restricted, phosphorus-restricted.
Cirrhosis (stable)—normal protein
Cirrhosis with hepatic insufficiency—restrict protein, fluids, and sodium.
Constipation—high-fiber, increased fluids
COPD—soft, high-calorie, low-carbohydrate, high-fat, small frequent
feedings
Cystic Fibrosis—increase in fluids.
Diarrhea—liquid, low-fiber, regular, fluid and electrolyte replacement
Gallbladder diseases—low-fat, calorie-restricted, regular
Gastritis—low-fiber, bland diet
Hepatitis—regular, high-calorie, high-protein
Hyperlipidemias—fat-controlled, calorie-restricted Hypertension, heart
failure, CAD—low-sodium, calorie-restricted, fatcontrolled
Kidney Stones—increased fluid intake, calcium-controlled, low-oxalate
Nephrotic Syndrome—sodium-restricted, high-calorie, high-protein,
Potassium-restricted.
Obesity, overweight—calorie-restricted, high-fiver
Pancreatitis—low-fat, regular, small frequent feedings
Peptic ulcer—bland diet
Pernicious Anemia—increase Vitamin B12 (Cobalamin), found in high
amounts on shellfish, beef liver, and fish.
Sickle Cell Anemia—increase fluids to maintain hydration since sickling
increases when patients become dehydrated.
Stroke—mechanical soft, regular, or tube-feeding.
Underweight—high-calorie, high protein
Vomiting—fluid and electrolyte replacement
 POSITIONING
CLIENTS

Asthma—orthopneic position sitting up and bent forward with arms

supported on a table or chair arms.
Post Bronchoscopy—flat on bed with head hyperextended.
Cerebral Aneurysm—high Fowler’s.
Hemorrhagic Stroke: HOV elevated 30 degrees to reduce ICP and facilitate
venous drainage.
Ischemic Stroke: HOB flat.
Cardiac Catheterization—keep site extended.
Epistaxis—lean forward.
Above Knee Amputation—elevate for first 24 hours on pillow
Below Knee Amputation—foot of bed elevated for first 24 hours, position prone
daily for hip extension.
Tube feeding for patients with decreased LOC—position patient on right side
to promote emptying of the stomach with HOB elevated to prevent aspiration.
Air/Pulmonary embolism—turn patient to left side and lower HOB.
Postural Drainage—Lung segment to be drained should be in the uppermost
position to allow gravity to work.
Post Lumbar puncture—patient should lie flat in supine to prevent headache
and leaking of CSF.
Continuous Bladder Irrigation (CBI)—catheter should be taped to thigh so legs
should be kept straight.
After myringotomy—position on the side of affected ear after surgery (allows
drainage of secretion).
Post cataract surgery—patient will sleep on unaffected side with a night shield
for 1-4 weeks.
Detached retina—area of detachment should be in the dependent position.
Post thyroidectomy—low or semi-Fowlers, support head, neck and shoulders.
Thoracentesis—sitting on the side of the bed and leaning over the table (during
procedure); affected side up (after procedure).
Spina Bifida— position infant on prone so that sac does not rupture.
Buck’s Traction—elevate foot of bed for counter-traction.
Post Total Hip Replacement—don’t sleep on operated side, don’t flex hip more
than 45-60 degrees, don’t elevate HOB more than 45 degrees. Maintain hip
abduction by separating thighs with pillows.
 POSITIONING
CLIENTS

Prolapsed cord—knee-chest position or Trendelenburg.

Cleft-lip—position on back or in infant seat to prevent trauma to the suture line.
While feeding, hold in upright position.
Cleft-palate—prone.
Hemorrhoidectomy—assist to lateral position.
Hiatal Hernia—upright position.
Preventing Dumping Syndrome—eat in reclining position, lie down after meals
for 20-30 minutes.
Enema Administration—position patient in left-side lying (Sim’s position) with
knees flexed.
Increased ICP—high Fowler’s.
Laminectomy—back as straight as possible; log roll to move and sand bag on
sides.
Spinal Cord Injury—immobilize on spine board, with head in neutral position.
maintain traction and alignment of head manually. don't allow client to twist
bend.
Liver Biopsy—right side lying with pillow or small towel under puncture site
for at least 3 hours.
Paracentesis—flat on bed or sitting.
Intestinal Tubes—place patient on right side to facilitate passage into
duodenum.
Nasogastric Tubes—elevate HOB 30 degrees to prevent aspiration. Maintain
elevation for continuous feeding or 1hour after intermittent feedings.
Pelvic Exam—lithotomy position.
Rectal Exam—knee-chest position, Sim’s, or dorsal recumbent.
Shock—bed rest with extremities elevated 20 degrees, knees straight, head
slightly elevated (modified Trendelenburg).
Head Injury—elevate HOB 30 degrees to decrease intracranial pressure.
Peritoneal Dialysis when outflow is inadequate—turn patient side to side
before checking for kinks in the tubing.
Water-based dye—semi Fowler’s for at least 8 hours.
Oil-based dye—flat on bed for at least 6-8 hours to prevent leakage of CSF.
Air dye—Trendelenburg.
 COMMON SIGNS
AND SYMPTOMS

Pulmonary Tuberculosis (PTB)—low-grade afternoon fever.

Pneumonia—rust-colored sputum.
Asthma—wheezing on expiration.
Emphysema—barrel chest.
Kawasaki Syndrome—strawberry tongue.
Pernicious Anemia—red beefy tongue.
Down syndrome—protruding tongue.
Cholera—rice-watery stool and washer woman’s hands
Malaria—stepladder like fever with chills.
Typhoid—rose spots in the abdomen.
Dengue—fever, rash, and headache. Positive Herman’s sign.
Diphtheria—pseudomembrane formation.
Measles—Koplik’s spots (clustered white lesions on buccal mucosa).
Leprosy—leonine facies (thickened folded facial skin).
Bulimia—chipmunk facies (parotid gland swelling).
Appendicitis—rebound tenderness at McBurney’s point. Rovsing’s sign
(palpation of LLQ elicits pain in RLQ). Psoas sign (pain from flexing the
thigh to the hip).
Meningitis—Kernig’s sign (stiffness of hamstrings causing inability to
straighten the leg when the hip is flexed to 90 degrees), Brudzinski’s sign
(forced flexion of the neck elicits a reflex flexion of the hips).
Tetany—hypocalcemia, [+] Trousseau’s sign; Chvostek sign.
Tetanus— Risus sardonicus or rictus grin.
Pancreatitis—Cullen’s sign (ecchymosis of the umbilicus), Grey Turner’s
sign (bruising of the flank).
Pyloric Stenosis—olive like mass.
Addison’s disease—bronzelike skin pigmentation.
Cushing’s syndrome—moon face appearance and buffalo hump.
Grave’s Disease (Hyperthyroidism)—Exophthalmos (bulging of the eye out
of the orbit).
Intussusception—Sausage-shaped mass.
Multiple Sclerosis—Charcot’s Triad: nystagmus, intention tremor, and
dysarthria.
Myasthenia Gravis—descending muscle weakness, ptosis
 COMMON SIGNS
AND SYMPTOMS

Guillain-Barre Syndrome—ascending muscles weakness.

Deep vein thrombosis (DVT)—Homan’s Sign.
Angina—crushing, stabbing pain relieved by NTG.
Myocardial Infarction (MI)—crushing, stabbing pain radiating to left
shoulder, neck, and arms. Unrelieved by NTG.
Parkinson’s disease—pill-rolling tremors.
Cytomegalovirus (CMV) infection—Owl’s eye appearance of cells (huge
nucleus in cells).
Glaucoma—tunnel vision.
Retinal Detachment—flashes of light, shadow with curtain across vision.
Basilar Skull Fracture—Raccoon eyes (periorbital ecchymosis) and
Battle’s sign (mastoid ecchymosis).
Buerger’s Disease—intermittent claudication (pain at buttocks or legs from
poor circulation resulting in impaired walking).
Diabetic Ketoacidosis—acetone breathe.
Pregnancy Induced Hypertension (PIH)—proteinuria, hypertension,
edema.
Diabetes Mellitus—polydipsia, polyphagia, polyuria.
Gastroesophageal Reflux Disease (GERD)—heartburn.
Hirschsprung’s Disease (Toxic Megacolon)—ribbon-like stool.

SEXUAL TRANSMITTED INFECTIONS:

Herpes Simplex Type II—painful vesicles on genitalia
Genital Warts—warts 1-2 mm in diameter.
Syphilis—painless chancres.
Chancroid—painful chancres.
Gonorrhea—green, creamy discharges and painful urination.
Chlamydia—milky discharge and painful urination.
Candidiasis—white cheesy odorless vaginal discharges.
Trichomoniasis—yellow, itchy, frothy, and foul-smelling vaginal
discharges.
 IMPORTANT
TIPS

Assign the most critical client to the RN.

Clients who are being discharged should have final assessments done by the
RN.
The Licensed Practical Nurse (LPN) can monitor clients with IV therapy,
insert urinary catheters, feeding tubes, and apply restraints.
Assessment, teaching, medication administration, evaluation, unstable
patients cannot be delegated to an unlicensed assistive personnel.
Weight is the best indicator of dehydration.
When patient is in distress, administration of medication is rarely the best
choice.
Always check for allergies before administering antibiotics.
Neutropenic patients should not receive vaccines, fresh fruits, or flowers.
Nitroglycerine patch is administered up to three times with intervals of five
minutes.
Morphine is contraindicated in pancreatitis because it causes spasms of the
Sphincter of Oddi. Demerol should be given.
Never give potassium (K+) in IV push.
Infants born to an HIV-positive mother should receive all immunizations of
schedule.
Gravida is the number of pregnancies a woman has had, regardless of
outcome.
Para is the number of pregnancies that reached viability, regardless of
whether the fetus was delivered alive or stillborn. A fetus is considered viable
at 20 weeks’ gestation.
Lochia rubra is the vaginal discharge of almost pure blood that occurs
during the first few days after childbirth.
Lochia serosa is the serous vaginal discharge that occurs 4 to 7 days after
childbirth.
Lochia alba is the vaginal discharge of decreased blood and increased
leukocytes that’s the final stage of lochia. It occurs 7 to 10 days after
childbirth.
In the event of fire, the acronym most often used is RACE.
(R) Remove the patient. (A) Activate the alarm. (C) Attempt to contain the fire
by closing the door. (E) Extinguish the fire if it can be done safely.
 IMPORTANT
TIPS

Before signing an informed consent form, the patient should know whether
other treatment options are available and should understand what will occur
during the preoperative, intraoperative, and postoperative phases; the risks
involved; and the possible complications. The patient should also have a general
idea of the time required from surgery to recovery. In addition, he should have
an opportunity to ask questions.
The first nursing intervention in a quadriplegic client who is experiencing
autonomic dysreflexia is to elevate his head as high as possible.
Veracity is truth and is an essential component of a therapeutic relationship
between a health care provider and his patient.
Beneficence is the duty to do no harm and the duty to do good.
Tyramine-rich food, such as aged cheese, chicken liver, avocados, bananas, meat
tenderizer, salami, bologna, Chianti wine, and beer may cause severe
hypertension in a patient who takes a monoamine oxidase inhibitor.
Projection is the unconscious assigning of a thought, feeling, or action to
someone or something else.
Sublimation is the channeling of unacceptable impulses into socially acceptable
behavior.
Repression is an unconscious defense mechanism whereby unacceptable or
painful thoughts, impulses, memories, or feelings are pushed from the
consciousness or forgotten.
People with obsessive-compulsive disorder realize that their behavior
isunreasonable, but are powerless to control it.
A significant toxic risk associated with clozapine (Clozaril) administration is
blood dyscrasia.
Adverse effects of haloperidol (Haldol) administration include drowsiness;
insomnia; weakness; headache; and extrapyramidal symptoms, such as
akathisia, tardive dyskinesia, and dystonia.
 INSULIN
HHNK (non ketonic coma): dehydration

Regular: Rapid – peaks 2h Treatment goal:

Can be IV drip
Rapid & Run (rapid and can run IV)
Insulin NPH – onset 6h, peak 8-10h
Not so fast & not in the bag
rehydration,
insulin not required
Peripheral neuropathy: nerve damage and
poor tissue perfusion
Best indicator of long term glucose: HbgA1C
< 7 (best is well controlled diabetics)

Humalog (Lantis):
DIABETES
The fastest insulin & long acting
Onset 15 min, peak 30 min Type 1 Diabetes (IJK)
So fast that it needs to be given with Insulin dependent
meals, not before meals Juvenile onset
No peak, no risk for hypoglycemia – can Makes Ketones
be given at night
Type 1: DIE
Refrigerate before opening, but after opening Diet (3) → Inulin (1) → Exercise (2)
you don’t have to
Type 2 Diabetes (Non IJK)
Non insulin dependent
DANGERS Adult onset (not really true anymore)
Hypoglycemia – not enough food, too much Doesn’t make Ketones
insulin, too much exercise
Type 2: DOA
High priority – brain damage Diet (1) → Oral hypoglycemic (3) → activity (2)
Drunk looking & shock s/s (pale, cold, rapid) Restrict calories, 6 meals per day
Administer sugar & protein

DKA – too much food, not enough insulin, not Diabetes Mellitus: error in glucose metabolism
enough exercise Polyuria, polydipsia, polyphagia (hunger)
Diabetes Insipidus: Not enough ADH or
Illness or respiratory infections in a type 1 pituitary gland
Dehydration
Ketones, MacKaussmaul, K
Acidosis, acetone breath, anorexia
Give dextrose & Insulin R at high rate (150-
200ml/h)

Dehydration makes you hot – water is like a

coolant for your car
 DRUG TOXICITY ELECTROLYTES

Lithium – antimania
Therapeutic: 0.6-1.2 HYPERKALEMIA:
Toxic: >2.0 everything goes ↑ , HR and UO go ↓

Lanoxin (digoxin) – CHF and Atrial Get rid of excess K before the heart
arrhythmias stops
Therapeutic: 1-2 D5W with insulin R (saves you time)
Toxic: >2.0 Then give K-excelate

Aminophylline – Spasms of airway HYPOKALEMIA:

Therapeutic: 10-20 everything goes ↓ , HR and UO go ↑
Toxic: >20
Give more K
Dilantin – anti seizure NEVER push IV
Therapeutic: 10-20 NEVER more than 40 meg/L
Toxic: >20
Calcemias do OPPOSITE of prefix
Bilirubin Hypercalcemia: everything goes ↓
Elevated level: 10-20 Hypocalcemia: everything goes ↑
Toxic: >20
Chvosteks: push and cheek spasms
Kernicterus – Bili >20 & in CSF Trousseau: BP cuff inflates, and causes
Opisthertonus – position of hypertension spasm
seen in Kernicterus
Place baby on its side Magnesium do OPPOSITE of prefix
Arching of the neck – so neck rises off Hypermagnesium: Everything goes ↓
the bed Hypomagnesium: Everything goes ↑

Natremias: The one with the E is

Dehydration, the one with the O is Overload

Hypernatremia: Dehydration
Hyponatermia: Fluid Overload
(numbness/paresthesia)

Universal S/S of electrolyte imbalance –

muscle weakness / paresi
 ENDOCRINE SYSTEM

Thyroid & Adrenal HYPOTHYROID

Thyroid = Always metabolism Tired, sluggish, slow
Myexema
HYPERTHYROID: Do NOT sedate!
UP, UP, UP – Agitated, nervous diarrhea, etc
Adrenal Cortex:
Most common: Graves All begin with A or C (Addison and Cushing)
You’re going to RUN yourself into the
GROUND Addison’s Disease
Radioactive iodine: urine is dangerous Not enough adrenal hormones
PTU: Puts Thyroid Under (slows it down) Super tanned / brown skin
Don’t react well to stress
Total Thyroidectomy
Lifelong thyroid hormones ADD A SONE: corticosteroids ending with
Tetany “SONE”

Subthyroidectomy Cushing’s Syndrome

Thyroid storms Too much adrenal hormones (cushy)
Like Graves – but much worse. Moon face
UP, UP, UP – super high vitals Hairy
Psychotic delirium Full of water
No meds ordered – just cooling blankets Buffalo hump
and O2 (just keep them alive!) Muscle wasting
Total: can’t have thyroid storm when you Central obesity
don’t have a thyroid Bruising
High glucose (but not diabetic)

Adrenalectomy
Unilateral
Bilateral

PRECAUTIONS:
Hep A: Anus Hep B: Blood
Contact
RSV, hepatic, staph, enteric
Private room, door open
Gloves, gown if in contact
Disposable supplies
Droplet
Meningitis, influenza, diphtheria, pertussis,
mumps
Private room – door open
Mask
Out of room – pt wears a mask
Disposable equipment
Airborne
SARS, TB, Measles, varicella
Private room – door closed
Mask, gown, special filter mask
Mask when leaving room
Neg airflow
 ACID BASE ABG’S

As pH goes, so does my Pt! Except for K Amino Glycosides

A Mean Old Mycin
pH ↓ Pt goes ↓ (HR, RR, all vitals) K goes ↑ Amino Glycosides only treat Mean old
pH ↑ Pt goes ↑ K goes ↓ Infections!

Except for K – it does the opposite
pH ↑ : Alkalosis
Seizures, hyperactivity, borborgemy (↑BS)
Kussmaul breathing = MacKausamal
(Metabolic Acidosis breathing)
Lung: Respiratory
Everything else: Metabolic
When you don’t know: it’s probably
metabolic acidosis (It’s super common)
True mean old Mycins don’t have “Thro”
If it has “Thro” – Thro it away!
Ex: Zithromycin
Mean Old Mycins destroy ears (ototoxicity)
and kidneys (nephrotoxicity)
Must check Creatinine for Nephrotoxicity –
NOT urine output
Drawing TAP Levels (Peak and Trough)

For drugs that have a narrow therapeutic

VENTILATORS:
level and are toxic

High Pressure Alarm

Route determines TAP – Not the drug
Obstructed airflow
Having to use too much pressure
TROUGH PEAK
Kinks, water collection in tube, mucous
IV 30 MIN BEFORE NEXT DOSE IV 15-30
Turn, cough, deep breathe
min after its done
IM 30 MIN BEFORE NEXT DOSE IM 30-
Low Pressure Alarm
60 min after its given
↓ Resistance – machine finding job too
SUB Q 30 MIN BEFORE NEXT DOSE
easy
Subling 5-10 min after its in the system
Disconnected tube
PO 30 MIN BEFORE NEXT DOSE
02 sensor disconnected
If tube goes lower than pt level –
contaminated
HEART RHYTHMS: CHEST TUBES:

Ca Channel Blockers are chill pills for the The only chest surgery that doesn’t require a
heart chest tube is a pneumonectomy – because
They end in DEPIM or ZEM you remove the entire lung.

RHYTHMS Water seal breaks

Asystole: No QRS – Lethal 1. Clamp
Flutter: Sawtooth 2. Cut
Afib: Chaotic with QRS pattern 3. Put in Water
Vfib: Chaotic without QRS pattern – Lethal 4. Unclamp
Vent tachy: Wide bizarre QRS
SVT: Narrow QRS Chest tube comes out
PVC: random rhythm change – only 1. Cover with gloved hand
concerned if > 6 or 6 in a row 2. Vaseline gauze
Change in rhythm: check pulse or BP for 3. Sterile dressing taped on 3 sides
cardiac output
Bubbling: Where? When?
Treat ventriculars with lidocaine
V→L Water Seal
ABCD Intermittent: good
Treat SVT (it’s actually an atrial) Continuous: bad (air leak)
A denosine – puts you in asystole for 20
seconds Suction Control
B eta bockers – all end it “lol” Intermittent: bad (dial up suction)
C a channel blockers Continuous: Good
D igitalis Do NOT clamp chest tube longer than 15
seconds
Crutches
Congenital Heart Defects
Elbow at 30 degrees
2 pt: 2 touch Two classes: Trouble and No Trouble
3 pt: 1 foot up Trouble defects all start with “T”
4 pt: everything moves separately R → L defects are Trouble
Swing: amputee All CHD have a murmur
Tetralogy of Fallot: VarrieD PictureS Of A
Stairs RancH
Up with good VD: ventricular defect
Down with bad PS: pulmonary stenosis
OA: Over Riding aorta
Cane RH: right hypertrophy
Hold on good side
Advance with bad side
Walkers: pick it up, put it down, walk towards
it
 LAB VALUES

Kidney Function: Creatinine (common Hgb

before dye) Normal: 12-18
Normal: 0.6-1.2 Below 8
INR – Warfarin therapy Assess bleeding
Therapeutic: 2-3 Prepare blood transfusion
If INR > 4 Call Dr
Hold warfarin Above 18
Assess bleeding Dehydration
Prepare to give K
Call Dr BiCarb (HC03)
Normal: 22-26 (the bicarb years)
POTASSIUM
Normal: 3.5-5.3 C02
Below 3.5 Normal: 35-45
Assess heart In the 50s (and non COPD)
Prepare to give K Assess RR – pursed lips
Call Dr Do NOT give 02
Above 5.3 If above not working, call Dr
Hold K IV In the 60s
Assess heart Resp failure & death
Prepare to give D5W IV with insulin Intubate
Call Dr
Above 6 SEVERE ACIDOSIS
Can be deadly! hyperkalemia – biggest priority
Assess immediately, possibly call RR
team HCT
normal: 36-54
pH
Normal: 7.35-7.45 P02
Under 6 Normal: 78-100
Deadly 70s
Assess vitals – still alive?? Assess RR status
Call Dr Give 02
AS PH GOES, SO DOES MY PT – EXCEPT Below 60
FOR K Assess RR status
Give 02
BUN Prepare for intubation
Normally 8 buns in a pack Call RR therapy
Normal: 8-30 Call Dr
Elevated = Dehydrated BNP indicator of CHF (normal <100) – Best
If a lab is high, you don’t know why – indicator of CHF – ANF
Dehydration
Sodium
Normal: 135-145
Change in LOC?

WBC
Normal: 5-11,000
High – leukocytosis
Low – leukopenia, neutropenia, immunosuppressed
Strict handwashing, shower BID with antimicrobial, avoid crowds, private
room, no flowers, low
bacteria diet

Platelet
Normal: 150-400,000
Below 90,000 – bleeding precautions
Below 40,000 – platelet transfusion – call Dr

RBC
Normal: 4-6 million
5 D’s (deadly)
pH < 6
Platelet < 40,000
K>6
O2 < 60s
C02 in 60s

DUMPING SYNDROME
Hiatal Hernia
Gastric content going in the wrong direction at the correct rate
Regurgitation of acid into the esophagus
s/s: GERD upon lying after meals
Treatment – want stomach to empty faster
Elevate head of bed, increase fluids PO, increase carbs

Dumping Syndrome
Gastic content empty into duodenum in correct direction but too fast
s/s:
Acute abdominal distress
Dumping (s/s drunkenness)
Syndrome (s/s shock)
Treatment: want stomach to slow down
No fluids with meals, low carb, high protein, lay flat on side after meals
 MENTAL HEALTH

Non psychotic: insight and reality based
Not all psych patients are psychotic
Therapeutic communication
Delusion: false fixed belief
No sensory component – it’s simply a
thought
Paranoid
Grandiose
Somatic – about the body (my arm is
bionic, I am pregnant)
Psychosis of Dementia: Non Functional
Alzheimer’s, dementia, Wernicke’s, senial
Brain damaged people
Delirium can eventually become
dementia if untreated
Dementia: will not talk reality
1. Acknowledge feelings
2. Redirect – take what pt is expressing
inappropriately, and get them to express it
appropriately

Hallucination: Pure sensation – no reality Delirium: chemical imbalance in brain – non

Auditory, permanent
visual, Example: being on drugs, being in
tactile (can feel cockroaches in arm), withdrawal, or UTI
olfactory,
gustatory Word salad: bob, car, food, sleep

Illusion: Misinterpretation of reality Functional – reinforce

Sensory experience Dementia – Redirect
I see a clock on the wall, but think it’s a Delerium – reassure
bomb (the clock is REAL)
Ideas of reference: everyone is talking about
Functional Psychosis: Potential to learn me and laughing at me
reality
Schizophrenia
Schizoaffective
Bipolar
Don’t treat all psych pt’s the same – half of
them are not psychotic

Functional psychotic having a delusion

Acknowledge feelings and present reality
Set a limit
Enforce the limit – try to have reality
based conversations
MEDICATION TIPS Piagets
0-2: sensory motor (only the right now)
Only teach as you are doing right now
Insulin 70/30 rule
70% N & 30% R 3-6: preschooler (fantasy, no reason or
Always pressurize before you draw up logic)
Draw up – Clear before Cloudy Teach the day of so they don’t have
R before N time to imagine scary things
Pressurize N, pressurize R, draw up R,
draw up N (NRRN) Over 6 or 7: concrete operational – by the
rules
IM – Looks like 1M Can teach day ahead
Pick the needle that has 1 in gauge and 1 in Learn through play
length Can only know things one way – don’t
try to change the rules all of a sudden
SQ – look for 5 in gauge and 5 in length Age appropriate games and reading
Ex: 25g 5/8 inch Over 12: can manage own care

Heparin – IV or SubQ
Works fast PSYCH DRUGS
Only use for 21 days
Pregnancy – yes
Lab – PTT (clotting)
Antidote: protamine sulfate All cause: weight changes and low BP
Penothiazines
Coumadin – PO All end with “zine”
Takes days to work Do not cure disease – only control
Works for life symptoms
Labs – PT INR Large doses – psych med
Antidote: Vit K (think Koumadin) Small doses – antiemetic (n/v)
Pregnancy – NO Major tranquillizer
Prevent clots from forming and getting bigger,
not a blood thinner Huge s/e – dry mouth
A: anticholinergic
Baclofin / Flexoril B: Blurred vision
Muscle relaxant C: Constipation
Makes you drowsy D: Drowsiness
Muscle weakness E: extrapyramidal syndrome (parkinsonian)
Teaching – no alcohol, no downers, no F: Fotosensitivity (skin sensitive to sun)
driving, don’t take care of kids < 12 years G: aGranulocytosis (low WBC,
When you are on baclofen you’re on your immunosuppression)
BACK LOAFIN’
Deconoate Lithium
Long acting IM for non-compliant client Bipolar disorder – decreases mania
2-3 weeks Peeing, Pooping, Paresthesia -
Court ordered Dehydration
Toxicity – 2 or greater
Tricyclic Antidepressants o Tremors, metallic taste, severe diarrhea
Elavil, tofranil, aventyl, desryl o Intervention: fluids. If sweating:
Mood elevator electrolytes
Takes 2-3 weeks to work Monitor: Sodium

A: Anticholinergic Prozac
B: Blurred vision SSRI – similar to Elavil. Long term
C: Constipation antidepressant
D: Drowsiness A: Anticholinergic
E: Euphoria (happiness) B: Blurred vision
C: Constipation
Benzodiazepines D: Drowsiness
Antianxiety – minor tranquillizer E: Euphoria
Have “zep” in name o Diazepam plus Also: Insomnia. Give in the morning!
Xanax Suicide warning
Often pre-op , muscle relaxant, alcohol
withdrawal, seizures, mechanical Haldol
ventilation Major Tranquillizer – just like Thorizine
Don’t take for > 6 weeks A, B, C, D, E, F, G
ZINES are majors, ZEPS are minors
Heparin is to Coumadin, as Tranquillizers are Clozaril (Clozapine)
to Antidepressants Schizophrenia
Agranulocytosis really bad in susceptible
MAOI’s Monitor WBC weekly for 1 month
Antidepressants – happy pill ZINE: Major tranquillizer
Names: MAR, NAR, PAR (marplan, nardil, ZEP: Minor tranquilizer
parnate) ZAP: atypical major tranquilizer
A: Anticholinergic
B: Blurred vision Zoloft
C: Constipation SSRI like Prozac
D: Drowsiness Antidepressant
But doesn’t cause insomnia
MAOI’s interact with LOTS Interactions: St johns wart (serotonin
Avoid all foods containing tyramine syndrome) and coumadin
Salad BAR: bananas, avocados, raisins S: Sweating
No organ meats: heart, lung, tongue… A: Apprehension
No preserved meats: smoked, dried, D: Dizziness
cured…
No dairy, alcohol, tinctures, caffeine, HEAD: headache (↑BP)
chocolate, licorice, soy sauce
No OTC medications

MATERNITY &
NEWBORN
Weight gain
Total: 28 lbs (+ or -) 4
1st trimester: 1 lbs per month (total 3 lbs)
2nd & 3rd trimester: 1lbs per week
Week (-) 9 = weight gained
30 weeks – 9 = 21 lbs should be gained
Fundal height
Not applicable until week 12
20-22 weeks at naval
Signs of pregnancy
Xray, ultrasound
Fetal HR
Examiner palpated fetal movement
Hgb: will drop during pregnancy
Morning sickness: dry carbs
Urinary incontinence: void q2h (1st and 3rd
trimester only)
Dyspnea: tripod position
Back pain: pelvic tilt (foot up on stool)
LABOUR AND DELIVERY
Sign of labour: regular contractions
Dilation: opening of cervix
Effacement: thinning cervix
Station: presenting part vs mothers ischial
spine
How high or low baby is
+ is good and – is not good
Lie: vertical (good) transverse (not good
Stages of giving birth
1. Labour (latent, active, transition)
2. Delivery
3. Placenta
4. Recovery
Stages of Labour
1. Latent: 0-4 cm, mild contractions
2. Active: 5-7cm, moderate contractions
3. Transition: 8-10cm, strong contractions
Trouble: Contractions longer than 90
seconds and closer than 2 minutes
Cord prolapse
1. Push head in
2. Knee-chest position
3. Not on left side
4. Cover cord with moist saline
All other complications: LION
Stop pitosin then start LION
L: left side
I: increase IV
O: Oxygen
N: Notify Dr
Pain: no systemic medication if baby will
come with medication peaks
Example: morphine peaks in 15 minutes
FHR monitor
LION < 110bpm FHR > 160 is fine
LION no variability
LION late decels Early decels are fine
Variable decels are VERY BAD
Causes: Veal Chop
V: Variable C: Cord Compression
E: Early Decel H: Head Compression
A: Accels O: Okay
L: Late Decels P: Placenta
When guessing in OB: Check FHR
Delivery AVERSION THERAPY
1. Deliver head Antabuse drug makes alcoholics
2. Suction mouth → Suction nose extremely sick if they have a drink
3. Check for cord around neck Onset 2 weeks
4. Deliver shoulders → then body Takes 2 weeks to leave system
Missing placenta
Respiratory arrest: ambu bag
0-72h → Hemorrhage Seizure: suction
Over 72h → Infection
DRUGS
Mom addicted to drugs, at birth baby is:
PRIORITIZATION intoxicated
Acute > Chronic If more than 24h since last drug was
Post Op > Med Surg taken, baby is in: Withdrawal
Unstable > Stable
Acute DELIRIUM TREMENS
Post of > 12 h Life threatening
General anaesthesia Restraint, private room, NPO
Changed assessment findings Happens 72+ hours after last drug
New admin, new diagnosis, or (happens after withdrawal)
unexpected findings Withdrawal
+ 24h – non lethal and expected finding
6 ORGANS
1. Brain 2 point restraint
2. Lungs one arm and opposite leg
3. Heart check on limbs q15 min
4. Liver rotate limbs q2
5. Kidney

DRUGS
Maslow’s hierarchy
1. Physiological
2. Safety
3. Comfort (pain)
4. Psychological
5. Social NCLEX
6. Spiritual

ALCOHOL
Wernicke’s
Psychosis induced by Vit B1 deficiency
(thiamine)
Amnesia – non reversible
Preventable by taking B1 vitamin