Cystic Fibrosis

-Resp Problem w/ copious amounts of mucous.

For all resp problems involving mucous:
6 small meals
Fluids
No milk or milk products
-Postural drainage, chest percussions with cupped
hands
When draining lower lobes, head is dependent
Drain lower lobes before upper (only do at least 1 hr
after food).
Monitor/assess- clubbing
-Cystic Fibrosis affects the Pancreas
Pancreatic Enzymes with all food (Pancrease with all
food)
-Cystic Fibrosis clients excretes 4X the normal
amount of salt
Extra salt daily, with each meal
Advise against activities to produce stress
-Cystic Fibrosis is autosomal recessive (both parents
must carry for child to have it)
If only one parent has or carries, the child has no
chance of contracting CF
-Cystic Fibrosis has a growth problem/failure to thrive

Developmental Stages
A 15 month old can
Climb up and fall down stairs
Vocabulary:
1 year old (2-6 words)
18 months -2 years ( short sentences/4 word
sentences, up to 300 words)
3 year old (900 words)

Toddlers
Picky about food, this is normal
Newborn
Positive Babinski for 6-12 months after birth
If temp becomes low, put on a cap
Activities should be age AND condition appropriate
Preschooler
Can tie shoes
Can name 5 colors
School age
Rules and rituals dominate play
Likes to accomplish or produce
Adolescents

Have all permanent teeth except molars

Cardiac
Do not lie a cardiac problematic person flat/ supine!!
Do not use energy to walk to the car
-Nitroglycerin:
1 q 5 min X3
sublingual, dark bottle
will fizz under the tongue
may cause headache b/c it is a vasodilator
give nitro before calling 911
Coumadin
can cause bleeding
Melena is dark tarry stool from an upper GI bleed
Echymosis, petechiae, etc. could concern you
PT, prothrombin time
Therapeutic PT on Coumadin will be 1.5 times the
normal value
INR monitored (1/1.5-2/2.5)
-Melana
Either an upper GI Bleed or they are on Iron
-Do not INCREASE intake of green leafy vegetables,
continue to eat them as normal
-Cranberry juice increases INR and cause more
bleeding
-Must tell pt on Coumadin to not buy OTC vitamins,
failure to do so can be NEGLIGENT
OTC vitamins may have vitamin K
-OTC medications may be contraindicated with
Coumadin, may cause more bleeding
Aspirin
Gingko Biloba (for Memory)
Garlic
Ginger
-Can cross the placental barrier
Heparin is safe during pregnancy, it
CANNOT cross placental barrier
Pregnancy puts women at high risk for DVT, she may
need prophylactic heparin if she has DVT
DVT
What indicates a DVT
leg is edematous
painful
warm to touch
may be pink/red
Interventions for DVT
Measure both extremities daily for
comparison
Pain medication
Warm compresses to increase circulation
Venous (elevate leg) (V=legs up) (A=legs
down for arterial clots)
Heparin
What shows improvement of DVT
Decreased leg circumference

What concerns you for client with DVT

Pulmonary Embolism:
Petechiae on chest
Chest pain
Cough/SOB/Respiratory Problems
Hemopsis
Disorientation, combative, Mental status
Change

Mental Status Change

-Caused by:
any time BLOOD is not getting O2 and getting O2 to
the BRAIN
Any respiratory problem
Any cardiac problem
Fluid volume deficit
Fluid volume overload (pressure on the
brain, ICP)
Electrolyte imbalance
- Sodium
If increases greatly, the client should be:
more alert
If decreases from normal to very below normal,
expect:
Lethargic
Malaise

-Heparin
Moniter PTT (normal 15-30) Therapeutic (1.5-2.5 X
30)
-Platelet count
If 100,000 or less, monitor for bleeding

Digoxin
Toxicity symptoms
Nausea/Vomiting
Anorexia
Bradycardia
Halo, double, blurred Vision
If ct on digoxin refuses breakfast and lunch today...
Check digoxin level, possible toxicity

Therapeutic Effects of Digoxin

Slows and strengthens the heart
Increases CO and BP
Increases urine output

Theophylline (aminophylline)
Bronchodilator
Accelerates everything
Side effects
Nausea/Vomiting
Tachycardia
Tachypnea
Nervousness
Insomnia
Hypotension
Always give bronchodilator before steroids
Do not crush/ mix digoxin and theophylline together
CHF and HF patients can have both
Digoxin to slow and strengthen the heart
Theophylline to help with expiratory
wheezing
Give these two meds to same patient, but separately

Paracentesis, Thoracentesis, Liver Biopsy

Have patient void (to move bladder out of the way)
Have pt take deep breath, EXHALE, hold and bear
down til needle is in
Do not cough during procedure
After procedure monitor for signs of pneumothorax:
Deviated trachea to one side
Asymmetrical/ uneven chest movements
Decreased breath sounds on one side
Monitor for signs of hypovolemic shock:
BP low (80/40)
Rapid thready pulse
Rapid shallow respirations
Pale, cool, clammy
Thoracentesis
Position:
Side of bed, arms on bedside table
If patient is too sick, sit up in bed with arms on table
over bed
Paracentesis
Position:
Side of bed, stabilize feet
If sick, semi-fowlers or fowlers
Liver biopsy
Position:
Lay supine, tilted on left side a little, right arm over the
head
post biopsy- lay on right side
Lab before biopsy:
Prothrombin time PT, we want it to be normal (11-15)
Big risk of bleeding with liver biopsy
Big risk for Bile Peritonitis (leaking Bile into
peritoneum)

Peritonitis

Can be caused by appendicitis or any other infection

in the abdominal cavity
Symptoms:
Rigid/ board-like abdomen
Shallow respirations (pushing on diaphragm)
Severe abdominal pain

TPN w/ Central Line

-can cause pneumothorax, watch for deviated septum
-can cause air embolus:
Petechaie on chest
Chest pain
Cough/resp problems
Mental status change

Life Support/Ethics
Only the parents of children can decide about
continuation of life support

Delegation
Floating Nurse
Give simplest patient
Give OB nurse mastectomy, hysterectomy, DVT, noninfectious, etc
What patient can we send to OB? -Non infectious
Pediatric nurse can care for any age client with a
compatible/similar diagnosis of a pediatric client.
IF pediatric nurse comes to med surg, which client do
u give?
12 hrs post hysterectomy?
or
Status asthmaticus 24 hours ago?- correct
answer
Psych nurse- Give alzheimers, dementia, anorexia,
bulimia, etc.
Do Not give traction pt whos husband was
killed (even though they have psych issues, she
should not handle the medicle)
ER nurse- give trauma, trachs, chest tubes, wounds
CNA Can..
ADLs
Ambulate a patient with ataxia (gait problems)
Ambulate a client 24 hours post laminectomy (back
surgery)
Ambulate client with a halo, foley catheter
Strain urine for stones/renal calculi
Can shave or prep surgery patient
CNA Cannot..
Feed a dysphagia patient, Myasthenia Gravis
Feed a drooling patient
Feed a trach patient
Ambulate a chest tube client
Cannot get total hip, pneumonectomy, post op, post
heart cath etc out of bed for first time
Give instructions
Monitor vitals first 15 after blood infusion

Determine if patient can have water

LPN
Assign simplest task but that can be performed with
license
Can perform teaching to patients but RN must
supervise and make sure the patient has learned
Lithium
If patient is on Lithium, keep sodium at a normal level
Carbonated drinks are high in sodium
Do not do anything to make you perspire more than
usual
Do not eat foods high in sodium
Lithium is not effective for 2-4 weeks
Lithium is a mood stabilizer, for pts with bipolar
disorder
Cerebrovascular Accident
Left stroke = Right sided weakness/issues
Cane always goes in unaffected hand
The cane and the bad foot forward same time, same
distance then bring up good foot
If right side is weak dress right side first, always dress
bad side first!
Undress the GOOD side first
Intrapartum
Epidural anesthesia, internal monitoring is needed
Before applying electrodes, the membranes must
have ruptured, and presenting part must be low
enough for identification
Abruptio Placenta
pain with bleeding
Placenta previa
painless bleeding
First Stage of Labor
Teach client to pant- not take deep breaths
because we do not want her to push, panting keeps
her distracted and will not allow her to push

Second Stage of Labor

10 cm dilated
perineal and rectal bulging
crowning
100% or completely effaced
Chorionic Villus Sampling
Risk for spontaneous abortion

Postpartum
Immediately after:
If fundus is lateral, empty bladder
Fundus should be at level of umbilicus, firm and
midline

If fundus is at umbilicus, firm and midline, but patient

is still bleeding excessively
Check perineum for lacerations

If nurse floating to OB from Surgery

Do not give OB
Do not give High risk (15 year old, PIH)
Give a c-section (surgery patient)
If you have no bed on OB but have an emergency CSection she can be sent to Med/Surg floor after she is
stable
signs of post partum psychosis-irritable and cant
sleep
Stillborn birth
Stay with family as long as needed then give privacy
Someone will take a picture of baby after family
leaves
Magnesium Sulfate
CNS Depressant
Can be used for pregnancy induced hypertension
Interventions with giving this:
Knee jerk/DTRs every hour
Monitor respirations (keep 12-14) (the
diaphragm is a muscle)
Foley to monitor output (keep at least
30mL/hr)
Concerning findings with Magnesium Sulphate:
An increase in BP
Preeclampsia
Risk for seizures
When seizure occurs, the patient has Eclampsia
Symptoms:
Facial Edema
Edema in hands
Increased bp
proeteinurea(albumin)
For pregnant patient with bp 160/100, facial edema
and 3+ albumin in urine, what is priority?
Risk for seizure, have O2 / suction at
bedside

Radiation
External radiation:
Not radioactive
Can be in a semi-private room
Can have visitors
Do not wash off painted markings around radiated
area
Do not apply lotion or powder on area prior to
radiation, it will burn
Nausea and vomiting CAN be a side effect
Side effects are usually site specific

head-alopecia
mouth-stomatitis
chest- burn
abdomen- can cause diarrhea
Internal Radiation:
Radioactive
private room
far from nurses station
Strict BED REST, no sitting in chairs, etc.
Time, Distance, Shielding
Nurse can only be in room 30 minutes for
direct pt care, after that nurse must stand at door or at
foot of bed
Family CAN visit BRIEFLY, must stand 6
feet back
Children should not be in room at all
If radioactive implant is found outside pts body, use
lead tongs to pick it up, place in lead lined container,
call the radiation oncologist
Stomatitis
Rinse mouth with baking soda and water- soothe
irritation
Rinse mouth with miracle/magic mouthwash -no
alcohol
Do not use lemon/glycerine swabs! -will burn
Do not use OTC mouthwash -alcohol
Do not tell them to drink plenty of Orange Juice -will
burn
Do not use hard bristle toothbrush
Bucks Traction
On correctly if patient is in good alignment
Pt is supine
Only elevate head 20-22 degrees -they may slide
down in bed if higher
Leg should not be rotated internally or externally
Pts leg should not be elevated but straight out

Esophageal Varices
Causes:
Alcohol- can burn esophagus and cause a bleed
Portal Hypertension
Excessive gastro-esophageal Reflux
Sengstaken Blakemore tube
Used to press/ a balloon, to press against
the bleed in the esophagus
Keep scissors at bedside to cut in case of
emergency to make room for intubation
Concerns:
Fresh fruits and fresh vegetables are rough and can
tear the varices that have been controlled
Frequent swallowing- indicates bleeding
Pale, cool, clammy- bleeding, could be in shock
What is most concerning in diet of esophageal varices
client?
Fresh fruit/veggies or Pretzels
Pretzels are ok, after chewing it becomes doughy

CT Scan
Contraindicated for pregnant women

Tonsillectomy
Post surgery
Give popsicles/ jello, etc but NOT RED - this could be
mistaken for blood if vomiting occurs
Do not give milk products -Mucous

Lactulose (Cephalac)

with Contrast
Ask about allergies to shellfish or contrast dye
Provide fluids post procedure

Peptic Ulcer Disease

H2 receptor blockers
Tagumet, Carafate, Zantac, Pepcid, Losec
Given 30 min-1hr before meal

Potent laxative
Hepatic Encephalopathy
If Lactulose is given to this pt, ammonia level is sky
high (possibly 140, normal 10-40),
ammonia will bind with the increased loose stools and
reduce symptoms of sky high ammonia.
Ammonia level lowers= less lethargic

Newborn Assessment
Look for fractured clavicle
crepitus in right clavicle
Chrons and Ulcerative Colitis
Irritated Bowels
Diarrhea
Give low fiber, low residue diet to slow down bowels
Low Residue= NO MILK PRODUCTS, it is hard for
bowel to break down
To replace nutrients lost in diarrhea
high calorie
high vitamin
high protein
Therapeutic Communication
Allow angry patient to express anger, tell them it is
acceptable to express anger
Colostomy, ileostomy, mastectomy, terminal illness,
spinal cord injury, etc. may all have difficult times
dealing with feelings/ anger. Let family and pt know it
is acceptable.

Pericarditis, Endocarditis, Rheumatic, Scarlet Fever

Can be caused by strep throat
Ask pts with these illnesses if they have had a sore
throat or cold
Tell pts with these illnesses not to be around crowded
places
Do not be in close contact with patient with infection

Scoliosis
Pants leg, skirt hem uneven
Shoulder blades, iliac crest uneven

Antacids
Malox, Mylanta
given 1-2 hours after the meal

Borderline Personality Disorder

Who is most at risk:
Person who was abused as a child
Symptoms:
Rage, intense relationships, manipulation
Antisocial Personality Disorder
Have no responsibility or remorse, aggression, poor
work history
Do not assign to do chore by themselves
Assign to do task with 2-3 other people to make sure
it is done
OCD
Never eliminate or forbid a compulsion of an OCD
patient
Do not interrupt an OCD
Do not limit
Goal for an OCD
psychotherapy has very little effect
want behavioral change, want them to
change behavior
want them to do creative activities instead of
automatic/impulsive behavior
do creative activity to cope with anxiety,
therefore decreasing compulsive behavior
Antipsychotics
Used for schizophrenia

Schizophrenia
Keep the person in reality
Tell the patient that no one else has seen the things
they are seeing
Do not tell them their hallucinations arent there or
real because these things are real to them
Back surgery/injury
laminectomy, discectomy, spinal fusion

Pt can stand and lie but has trouble sitting

Always log roll

can cause numbness and tingling/

parasthesia around mouth/perioral, of fingers and
toes

Amputation
If prosthesis causes severe pain REMOVE it! -this
could break down the stump, and cause need for
further amputation
Tell Ct. Pre-op about phantom limb sensation
Tingling, itching, etc.
If post-op, they have phantom limb pain, medicate
and tell them this is ok
You can have 3 major complications from
amputations
Infection
Hemorrhage- keep tourniquet at bedside
contracture-most serious

Interventions
Keep calcium gluconate at bedside incase calcium
drops
Keep trach set at bedside

to prevent contracture
only elevate stump for first 24 hours-to
prevent edema and hemorrhage
after first 24 hours lay stump flat
at intervals, turn patient prone

Bacterial Meningitis
Meningitis is neuro
Respiratory Droplet precautions -mask within 3 feet

Concerns
Dressing is getting tighter, pressure on neck- means
the neck is swelling
Crowing respirations (inspiratory stridor)- partial
airway obstruction, swelling
Frequent swallowing- bleeding
Pertussis
Whooping cough
Respiratory Droplets
Immunization can cause seizures- DPT immnization

Respiratory Droplet
Bacterial Meningitis
Pertussis
Scarlet fever
Airborne/contact
Chickenpox
Contact

Meningocele
Good prognosis is expected with surgery

Cholecystectomy
They will probe in common bile duct to look for
stones, this may cause edema of duct
The t-tube prevents the bile duct from closing
With T-Tube
Do not want bloody drainage
Do not want over 500 mL in 24 hours
Concerns:
Clay colored stool
Dark urine
Chickenpox
Incubation period 7-10 days
Contact isolation, gown and gloves
Respiratory airborne
Activities should be age appropriate
keep on contact
keep quiet and busy
Thyroidectomy
Patient at risk for damage/ partial removal to
parathyroid
this could decrease the clients calcium

Cellulits
MRSA
VRE

Traction weights
i.e. Russells traction
Keep bone in good alignment
Prevent muscle spasms
If not pulling, or weights are on floor, this could cause
pain

Total Hip Replacement

Do not sit at a total 90 degree angle
Do not bend at hip, do not flex hip for 8 weeks
Do not cross knees, ankles, do not adduct!
Do not internally rotate
Knee never higher than hip
1 day post op
ambulate short distance 2-3 steps and place in a
recliner with feet elevated

Rheumatoid Arthritis
Want exercise for joint mobility
Increased periods of rest will cause stiffness

Rest frequently but not for extended amount of time

We want to EXTEND joints to prevent contracture,
make door knobs larger, eating utensils larger, etc.
intervention for arthritic client
give a warm bath in the morning
warm compresses on joints prior to exercise
tell them to do chores in early afternoon they have morning stiffness
COPD
Only gets 2L of O2, prevent oxygen toxicity
They are always short of breath, respiratory distress
is when we need to be concerned
Oxygen therapy
Anything that could cause static electricity
Nylon pajamas or blanket
matchbox cars
Anything that could get moist and harbor bacteria
Stuffed animals/teddy bears

HIV/AIDS
Does not have to be in a private room
Do not place with an infection- they are neutropenic
You CAN place patient with
Appendicitis, Cholecystitis, pancreatitis,
diverticulitis
Are NOT infections, they are inflammations!

Anorexia Nervosa
low self esteem
anti- social
wears big clothes
is a perfectionist
usually 15% under ideal body weight
To assess progress do a daily weight in the morning
after voiding

Vasectomy
Must have three sperm free specimens before
considered sterile
Each ejaculation will have decreased sperm until
sperm free
Use ice on incision
Manipulation from surgery can cause discoloration of
scrotum, this is normal
Alzheimers
These people like to wander
Make sure their room is near a family room
to ensure safety
Goal for this patient
Be able to do ADLs as long as possible
Goals involving recovery are unrealistic
Vegetarians
Deficient in B12, B12 is found in animal products
Breast Cancer
Biggest at risk
Nullapara-no babies
First baby after 30
mensus before 13
menapause after 55
If woman has more than one of these she is at a
greater risk

Dysphagia
Parkinsons, CVA, Myasthenia Gravis
First symptoms of all these are difficulty swallowing,
and salivation
CNA cannot feed a patient with dysphagia, or a trach
patient, or drooling patient
CNA cannot feed a Myasthenia Gravis
Diet

Crutches
4 point gait- baby steps, crutch THEN opposite foot,
crutch THEN opposite foot
2 point gait- crutch and opposite foot same time same
distance
3 point gait- partial weight bearing- both crutches and
affected foot same time same distance, then bring
good foot up
the swing-to - no weight bearing or amputee, both
crutches then swing good leg up
stairs
up stairs good foot first
down stairs bad foot first
DIC
Paradoxical issue where pt bleeds and clots
Monitor Hematocrit

No liquids
No steak and potatoes, hot dogs, etc
Soft foods
Soft foods w/ sauces
Developmental Stages
4 week old- grasp finger and pull to mouth
*Never give toddlers hot dogs or carrots!
How to get child to cooperate?
speak in age appropriate language about
procedure
tell them just before the procedure
never tell them in detail
tell them what you expect of them during and
after the procedure

never show them the equipment, but if

possible let them play with non-intimidating equipment
3 year old- can ride a tricycle
5 year old- can ride a bicycle

Delirium- disoriented to time and place ACUTELY,

maybe for a couple hours
Dementia- disoriented progressively, CHRONIC,
possibly for years
Cervical Cancer

2-3 year old thinks dead person is asleep

4-5 year old blames themselves for the death of
others and feel guilty
Coping
How do you know the parents of a terminally ill child
are not coping?
My husband and I are strong and know our
child will get better
Incident Reports
Contact the physician and then complete incident
report Hospital property, Do not Chart about it!
Do not chart that Risk Management Team was
contacted- they are only involved with data collection,
do not call risk management just send the data
afterwards
Always chart that the Doctor was contacted, if he was
contacted
Incidents:
Give medication to wrong patient what do you chart?
Demoral 50, given IM Right deltoid, for pain
10 am, physician notified
DO NOT Chart wrong patient
If wrong IV is hanging, how do we chart?
Physician ordered D5 half normal saline, but hanging
is D5NS, how do we chart?
D5 NS discontinued, D5 Half normal started,
physician notified
Do Not chart wrong fluid

Risks
Smoking
Multiple sex partners

SLE/Lupus
Can be exacerbated by:
Stress, physiological or psychological
Butterfly rash over nose and cheeks
Discoid lesions/coin like lesions over the body
photo-sensitive
Can damage Kidneys, nephritis (BUN, Creatinine,
albumin in urine(should be 0), Output)
Intermittent claudication
pain with walking but subsides with rest
arterial
intervention (A = legs down, dependent)
elevating legs of arterial patient can cause pallor and
blanching

Pancreatitis
Fatty foul smelling stools
Nausea, vomiting
Left upper quadrant pain
Abdominal pain
Numbness and tingling of fingers, toes, around mouth
from low calcium

Peritoneal Dialysis
You want clear outflow, not cloudy
ICP
Normal is 0-15
If pt has neuro surgery, head injury or CVA
Place head at 30 or 45 degrees to prevent
increased ICP
Do not flex neck or hips!
Do not sit at 90 degrees/high fowlers
Do not lay flat/supine or prone
MRSA and VRE
Contact isolation, gown and gloves
Wipe off equipment used on patient
*when gloves are removed use alcohol solution
EXCEPT with c-diff, wash with soap and water and
THEN alcohol solution
Delirium
If spouse brings husband to ER with delirium, what
question do we ask her?
What medication is he currently on

Lung resection/lobectomy
Place on unaffected side as to expand the affected
lung
Best air exchange is obtained semi-fowlers
Pneuonectomy
Do not lie on unaffected side, lie on side without the
lung so they can expand the only lung they have
Best air exchange is obtained in semi-fowlers
Bulemia Nervosa
Tooth decay
Callouses on fingers -from gagging herself

Ampicillin/ antibiotics
observe for white spots in the mouth (candida)
give nystatin or mycostatin swish and
swallow- adults
for babies- put in syringe, squirt into cheeks,
not straight towards throat to prevent aspiration

ampicillin can also cause diarrhea

Ileostomy
Do not irrigate- it is liquid stool
Must wear bag at all times- bowel schedule not
regulated
If ct has not had stool in 3 hours, this is a concern!
Must monitor electrolytes more closely for this than
colostomy

Colonoscopy
Post colonoscopy may have rectal bleeding with clots
(normal)
Patient should not be on aspirin or steroids prior to
procedure

Addisons
Needs to ADD some cortisol (an anti-inflammatory)
These people have no anti-inflammatory they can get
critical fast!
See them first for fever, pain, diaphoresis, signs of
infection
Older adults
Do not drink enough water
Eat less than they did earlier in life (still have appetite)
Get up early and take naps
Tympanic membrane thins (worse at hearing)
Do not drive at night because of glare
Presbyopia - difficulty seeing things up close
Black older people
Get bluish spots on the sacrum

Glomerulonephritis
Can damage the kidneys
BUN
CreatinineC
Albumin
Output
Tetracycline
Do not give with milk, food or antacids-will not absorb
well
Do not give to pregnant lady- can stain babies teeth
Do not give to small children- can stain teeth
Makes patient photo-sensitive
Thorazine, elavil, halidol, Bactrim- all make
pt photosensitive
people with SLE/Lupus are also
photosensitive
Elavil
Causes photosensitivity
Shows results in 2-4 weeks
Bryants Traction
Little bryant is 2 years or less
20 lbs or less
has fractured femur or dislocated hip
buttocks off mattress, legs straight up 90 degrees to
mattress
Renal Disease
Restrict:
Protein
Potassium
Sodium
Fluids
Lactated Ringers has sodium and potassium!!
If they are on dialysis they CAN have protein
*ALWAYS SEE FIRST patient unrelieved by pain
meds 1 hour after administration!
Or pain unrelieved by narcotic analgesia

Nutrition
Toddlers that drink too much milk may become
anemic from lack of room for iron rich foods
Babies milk consumption should be reduced once
solid foods can be introduced in the diet
How to get people who arent eating well to eat well
Let person eat with other people
Make the food attractive and appetizing

Tuberculosis
If sputum culture is Acid Fast Bacillus Positive
ISOLATE, TB positive
Respiratory airborne
Negative pressure vented to outside
N95 Respirator, Fitted/ Particulate Mask
Family must wear surgical mask while at
hospital (but not at home)
Report TB to health department
Teach to cover mouth/nose with tissue when cough or
sneeze (cloth handkerchiefs are concerning, they
cannot be burned for disposal)
If they need to be taken out of the room
Call ahead to place they are going to make
sure they have a room ready (x-ray, ct, mri etc.) and
put a SURGICAL MASK on patient for transport and
give them a disposable recepticle (plastic bag) for
tissue disposal
early symptoms:
cough
chest pain
low grade fever (esp in afternoon)
night sweats
anorexia
weight loss
Late symptoms:
hemopsis
Isoniazid (INH) and Rifampin
can damage liver and kidneys

what would concern nurse if pt is on INH?

Yellow skin and sclera (any answer involving
the liver)
Check BUN albumin Creatinine output (kidney fxn)
Must be taken for 9-12 months!
INH:
vitamin b6 is given to prevent neuropathies
Rifampin:
can turn secretions (tears, saliva, urine) orange
* Peridium can turn urine red/orange
Nurse is negligent if she does not tell TB patient?
Do not be in contact with pregnant women or
small children ( they are at high risk)

TB Skin Test
Anterior aspect of forearm
26-27 gauge needle
Hold at 15 degree angle (intradermal)
0.1 mL of solution
Check site at 48 and 72 hours
10 mm induration is positive
AIDS patients-5 mm positive
If checking site at 48 hours and it is 8 mm
induration, check again in 72
If site checked at 48 hours and is a 6 mm
induration and 8 mm redness, you would
know...results are inconclusive at present, check
again in 72

Dehydration
monitor for seizures (mental status change)

Tracheoesophageal Fistula
Opening between trachea/esophagus
Monitor for Aspiration

Prostigman- drug of choice for MG

Peak in 30 min to 1 hour
What doctors order do we question?
He ordered valium for MG pt. - this is a
muscle relaxer, theyre already weak
How do we know MG pt is getting worse?
Drooping of 1 or both eyelids
If you give Myasthenia Gravis pt Prostigman, what
would we expect?
I can breathe and swallow better
See the pt who needs prostigman first! They need
help breathing!

Eye Surgery
Concern- Intraocular Pressure
Do not life or bend
Do not do valsalva

Glaucoma
Do not give Atropine or Antihistamine - drying agents,
will dry the eyeball
They do not have peripheral vision- stand directly in
front to talk to them

*If in ER and give benedryl, you are negligent if you

do not tell
Do not drive or operate heavy equipment
Pilocarpine
Is a myotic, it constricts the pupil
affects aqueous humor more than the vitrus humor
Timolol/ timoptic drops -Beta blocker
Optic Drops
Place finger in the inner canthus (tear duct) for 1
minute after administration to keep medicine from
going systemic
Cataracts
Speak to them on unaffected side

Aortic Anerysm
Repair (arteriogram)
Check all pulses
Check lower extremities for cool temp and
discoloration
Check for bleeding (hypotension)

Myasthenia Gravis
Extremely weak muscles
Difficulty swallowing
Difficulty breathing
Soft foods/ sauces, no liquids etc.

Glascow Coma Scale

7 or below is coma
3 is lowest score
Raynauds
Vasospasm of small vessels in the fingers and toes
Causes numbness and tingling on exposure to cold
Interventions:
Do not smoke -vasoconstrictor
Reduce stress
Spica Cast
Give toy too large to stick down into cast- Teddy bear,
etc.

Fractures
Fractures of long bones can cause Fat Emboli
Fat emboli:
Petechiae on chest
Chest Pain
Cough
Shortness of Breath
Hemopsis
Mental status change
Laryngeal Cancer
Difficulty swallowing- causes increased salivary
secretions/drooling
Pt can do three things:
Radiation
Chemotherapy
Surgery
If they have surgery (laryngectomy) they will have a
trach
For trach pt:
Use communication board
After trach can be removed they have a permanent
trach stoma
3 methods of speech after trach removal:
Prosthesis-allows them to be able to cover stoma with
finger and speak
Electrolarynx- Sounds like a robot
Esophogeal Speech- burp the words
A thin scarf can be worn over stoma
Cover stoma when putting on make-up
Cover stoma when shaving the face
Cover stoma when showering but not with a plastic
bag
Teach to install a smoke detector (they cannot smell
smoke anymore)
Teach someone to check food periodically (they cant
smell if its spoiled)

Heart Failure
Left
Left=lung:
Dyspnea
Orthopnea
Wheezing, rales, rhonci
Pleural effusion
Pulmonary edema
Pulmonary hypertension
Pink, frothy sputum
Right heart failure (COR PULMONALE) caused from
left heart failure
Right ventricular hypertrophy (trying to push the blood
into already full lungs)
System symptoms:

JVD
Ascites
anascarca (generalized edema)
Hepato/Spleno meglia

*vesicular breath sounds normal

*adventitious breath sounds abnormal (a for adven..
and abnormal)
NG/TPN
If infusing too fast or is too concentrated- Diarrhea
If NG or TPN pt has diarrhea, call doctor and ask to
slow rate or decrease concentration
TPN
Monitor:
glucose
electrolytes
if through central line
monitor for:
air embolus
pneumothorax (deviated trachea or absent breath
sounds, unequal chest movements)

When central line is inserted, tell patient:

take deep breath and HOLD IN - to prevent
air embolus

Aminoglycocides
All mycin medications
Can damage:
hearing
kidneys
If client is on Vancomycin for MRSA, what concerns
the nurse?
BUN is 50
Gastrectomy or Gastric Bypass
Dumping syndrome:
For 30 minutes after eating with gastrectomy or gastic
bypass patients
they have symptoms of GI virus (diarrhea,
distention)
Intervention:
Rest/ lie down for 30 min after eating
Do not give liquids with the meal- give 30-45 min
before or 30-45 min after meal
Give 6 small dry feedings
Do not give concentrated sweets
We want to promote protein for tissue repair
Milwaukee Brace
Used for scoliosis
Worn 23 hours a day

Sickle Cell Anemia

Interventions:
Plenty fluids (most important)
Oxygen
Pain medication (poor circulation causes aching and
pain)
Apply heat to pains
Do not travel by plane or go to high altitudes (Denver,
Colorado)
If doctor orders for a patient with sickle cell anemia, 1
and 1/2 times the normal amount of fluids?
Give as ordered

PTSD
Dont want to talk about it
Show no emotion
Flashbacks
insomnia
nightmares
What would make the nurse feel the PTSD is
improving?
Talks a little about the incident in group
therapy and cried

Use finger tips not palms

Start circular around nipple
Extend and include the axilla
If a mass is found, it will most likely be in the upper
outer sector of breast
While examining one side she can put her arm
upward, hand behind head or hand on hip
mastectomy
Dont carry heavy bag on that side
No sticks, IVs, BP cuffs on that arm
No watches, jewelry, anything tight on that arm
At risk for lymphedema for life
No injuries, sunburns, even pin pricks on that arm
Never leave the arm dependent, even at night it is
elevated
If standing in a long line, etc, put arm across chest do
not let it hang down

Tegretol
Can damage bone marrow
What lab would we monitor if client is on tegretol?
CBC
If pt is on Tegretol monitor for:
Anemia
Red Cells
Bleeding
Platelets
Infection
White cells

Leukemia
Immunosuppressed
Neutropenic
Thallium Stress Test, PET Scan, MUGA Scan
NPO 6-8 hours prior
Nuclear Medicine
*Bone Scan is only nuclear medicine test that is NOT
NPO
*Cardiac Cath is NPO 6-8 hours but uses dye, not
nuclear medicine
Enema
Turn patient on left side (direction of bowel)

Manic Patient, Inappropriate Behavior

Restrain only last resort
Medicate only if last resort
Always tell them that behavior is unacceptable first!
Then remove them from the situation
If violence is threatened, ask for assistance to take
patient to room
Self Breast Exam
Pre-menopausal: do bse 7-10 days after period
Post-menopausal: tell to do on the same day of the
month every month
Do this in front of the mirror or in the shower

Multiple Myeloma
Bone cancer
Affects bone marrow
Interventions
Monitor CBC, anemia, infection, bleeding
Give Back brace-pathologic fractures of
vertebrae can cause death
Ambulate-drives calcium back into the bones
Give fluids-excess calcium in blood can
cause kidney stones

Aphasia
Expressive Aphasia
Ask yes or no, simple questions
Always speak at a normal tone/volume and do not
use gestures (this goes for hearing impaired patients
too)
Receptive Aphasia
When patient doesnt understand statement, Say the
same statement in the exact same words to let the
mind program what is being said
What concerns you with receptive aphasia patient
being discharged this afternoon?
Multiple family/ friends coming to visit,
patient will not understand all the info

Renal
What can damage kidneys?
Lupus/SLE
TB Medication (INH, Rifampin
All Mycin drugs/ aminoglycosides can damage
hearing and kidneys
Amphotericin B- an antifungal
Chemo medication can damage liver and kidneys
Who do we not give milk?
Milk is hard for bowels to break down..
Chrons
Gastroenteritis
Diverticulitis
Ulcerative Colitis
Immunization
Live vaccines (varicella, rubella)
Do not give to pregnant women
May have slight fever after shot
Do not give to a sick child

Antibiotics/Cultures
Always get a culture before starting antibiotic or it
could ruin the culture
Hepatitis A and E
Oral-fecal transmission
If they come in with vomiting and/or diarrhea-contact
isolation gown and gloves
with enteric precautions (disposable plates
and utensils)
Who is most at risk?
child care worker (diaper changes)
CNA (bed pans)
people who eat fish from contaminated water
The cook/chef who does not wash hands

Hepatitis B,C,D
Dialysis
Hemophilia
IV Drug users
Healthcare workers
Unprotected Sex
Epiglottitis
Cherry red epiglottis
Throat is rapidly swelling/edematous
Have trach set equipment ready at bedside-risk of
respiratory distress
May be drooling (cannot swallow)
Do not check or swab the throat - could cause spasm
Let sit on parents lab-do not want them to cry and
cause spasm
If Inspiratory stridor, crowing respirations- partial
airway obstruction!
what do we do first?
Head tilt chin lift!

If your client this morning for breakfast had 3 ounces

of juice, 4 ounces of coffee, 6 ounces of milk.. how
many milliliters?
30 mL = 1 ounce

Menieres
menieres has fluid in the ears
Vertigo
Dizziness
Tinnitus (ringing in the ears)
Stand immediately in front to speak to patient
They are a fall risk
Low sodium diet (fluid build up)
Do not give foods high in sodium-Peanut
butter is high in salt!
Best for menieres client??
Elevate head of bed, pillows etc
or
Place in dark quiet room with distant/soft musiccorrect answer (helps with ringing in ears, vertigo)
Lyme Disease
Bite from deer tick
Doxicycline is drug of choice
Bulls Eye Lesion (remember you shoot deer, deer
tick, bulls eye)
Best time to check for ticks-bath time
Gout
Build up of uric acid
Caused by eating too much purine food
red meats
organ meats
fish (sardines)
Monitor uric acid levels
No alcohol
Reduce weight if overweight
Meds
Cholchicine
Allopurinol
ProBenicid
First symptoms-pain or inflammation of great toe
Osteoporosis
Post menopausal women- advise to remove risks for
falls, wear non skid shoes, well fitted etc.
What is best to advise a 62 year old woman?
enroll in dance class -correct answer (any activity to
keep calcium in bones)
or
take multivitamins (very little calcium in multis)
Most at risk person-person who smokes or drinks
alcohol

Padgets Disease
Loss of bone mass, replaced with deformities
Give (also for osteoporosis)
Fosemex
Actinel
Boniva
Give these with Vitamin D to aid in
calcium absorption
Give with lots of water on empty
stomach
Must sit or stand for 30 min-1 hour
Placing clint into a room
Condition and age appropriate
AIDS
Does not need private room
Do not place with infectious clientneutropenic
Diverticulitis, pancreatitis, appendicitis, cholecystitis
are not infectious
Lupus, Hep B,C,D are not infectious they are
standard precautions
Surgery clients do not place with infectios clients
Dont mix infectious clients!

*Blood transfusion Reaction

Febrile reaction: fever and chills
Allergic: pruritis, uticaria (hives),
anaphylaxis
Hemolytic: back and/or chest pain
*Addisons Patient with sore throat, diaphoresis and
chilling
*Open fracture of femur- they can bleed and go into
shock
*Client with burned face, singed nasal hair, etc
*Right pneumonectomy that is placed on left side
*Mom not bonding with newborn who has a cleft lip
*Platelet count of 80,000 with bleeding gums
*client with a head injury who returned home from ER
2 hours prior with a headache
Need to check vitals, neuro status, if they are
vomiting, drowsy, etc.
* a baby with bulging fontanels

GENERAL REVIEW

WHO TO SEE FIRST?

*Dysphagia (difficulty swallowing)- aspiration risk
Increased salivary secretions, drooling, etc.
(unless its a 6 month old/teething)
*Pain 1 hour after pain medication or
Pain unrelieved by pain medication
*Post thyroidectomy with a dressing that is tighteningedema of airway!
or Crowing respiration/inspiratory stridor
Numbness or tingling in fingers, toes around
mouth,- low calcium give Calcium Gluconate!
*Frequent swallowing
Tonsillectomy
thyroidectomy
rhinoplasty
esophageal varices
*Blood
Once blood arrives at unit start ASAP- within 30
minutes
note: CNA cannot monitor vitals the first 15 minutes! student nurses can

*client with prolapsed cord

Interventions:
knee chest position
elevate hips
Trendelenburg
Sterile gloved hand to hold presenting part
off cord (if dilated enough!)
*client who has had ruptured membranes
Check fetal heart rate
*14 year old with edema and scrotal pain- twisted
testicle, have an hour to get surgery
*Post thyroidectomy, laryngectomy, tonsillectomy
*Over 400 Blood Glucose
*status asthmaticus who suddenly stopped wheezingtheyve arrested, BAD
*restless and trouble breathing
start oxygen and call doctor
*restless and in pain
align them if in traction/ cast etc
*restless, pale, cool, clammy
elevate feet about a foot

*panic and manic patient -safety risk to self/others

note: never see first any patient with fixed pupils and
glascow coma scale of 3 before other patients (others
could be saved, this person is unlikely to survive)

PLACE IN ORDER
(DRAG AND DROP)
Removal of a central line

SAMPLE QUESTIONS
While talking with client and they fall over in a chair
what to do first?
apical pulse?
Call for help?
Tap shoulder and assess if unresponsive?correct answer!
While making rounds, client is on ventilator and trach
is out of place, what do you do?
Call code?
Assess for breathing?- Correct answer
Replace the trach?
Making rounds, cts IV site is red and edematous and
is receiving O2 at 2L nasal cannula. O2 is out of nose
but patient is fine, what do you do?
Replace oxygen (they may need it
discontinued if they are doing better but if it is ordered
put it back asap!)

IV pump is beeping, pt having pain and pain meds are

due, priority?
Give pain meds!
if a unit of blood has been in nursing unit for 10
minutes and thyroidectomy starts complaining of
numbness around mouth, what is priority?
The blood can be taken back to blood bank
to be re-refrigerated (never put in any
other
refrigerator because it is not controlled)
Check thyroidectomy!

Heimlich Maneuver
How to Remove a Trach
How to Move Patient in Traction up In Bed
Stabalize traction (put weights on bed)
Head of bed down
Get assistance to pull up
Put HOB back up
Replace traction weights
How to draw up regular or NPH insulin
Roll NPH
Clean top of vial and inject air into NPH
Inject air and clean top of regular
DRAW UP REGULAR
Draw up NPH
How to use Metered Dose Inhaler (MDI)
How to use a C-PAP
Pursed Lip Breathing
Take deep breath
Hold 2-3 seconds
Exhale slowly through pursed lips
Purpose of Incentive Spirometer? Expand the lungs.
How to use it
Exhale and take a slow very deep breath to
make ball go up
Deeper they inhale the higher the ball goes
How to insert an NG tube
How to insert a vaginal suppository

Who do we see first?

A COPD with resp 26 and O2 92%
or
24 hours post head injury with GCS decreased from
14-12
or
12 hours post total knee, client is restless with
petechiae on chest -correct answer!
Client has restlessness (first symptom of
hypoxia)
Which would you see first?
Post thoracotamy with closed drainage
or
Post thyroidectomy -correct answer
or
Bilateral knee replacement with wound vac

How to put on sterile gloves

How to get dressed and undressed for contact
isolation
Venturi Mask
21% is 1-2 L
35% is about 4 L

QUESTION A DOCTORS ORDER IF

A Steroid every other day for an Addisons client
Should Give every day for the rest of life

Irrigate the colostomy at bedtime the day of surgery

It doesnt even function for 2-3 days
You dont irrigate for 5-7 days

Lactated Ringers for Renal Patient

Has sodium and potassium
K, NA and protein are restricted

Plavix for a client with Ulcerative Colitis

Nothing is given that could increase
bleeding, bloody stool
If heparin is ordered in mL
Heparin is ordered in 5,000 or 10,000 UNITS
Protime/ Prothrombin time ordered for Heparin
Heparin is PTT
Protime/ Prothrombin time and INR are for
coumadin
Valium or muscle relaxant for myasthenia gravis
They already have weak muscles