NCLEX Exam Study Guide Part 1

DO NOT delegate what you can EAT! E - evaluate A - assess T - teach addisons= down, down down up down cushings= up up up down up addisons= hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia cushings= hypernatremia, hypertension, incrased blood vol, hypokalemia, hyperglycemia No Pee, no K (do not give potassium without adequate urine output) EleVate Veins; dAngle Arteries for better perfusion A= appearance (color all pink, pink and blue, blue [pale]) P= pulse (>100, < 100, absent) G= grimace (cough, grimace, no response) A= activity (flexed, flaccid, limp) R= respirations (strong cry, weak cry, absent) TRANSMISSION-BASED PRECAUTIONS: AIRBORNE My - Measles Chicken - Chicken Pox/Varicella Hez - Herpez Zoster/Shingles TB or remember... MTV=Airborne Measles TB Varicella-Chicken Pox/Herpes Zoster-Shingles Private Room - negative pressure with 6-12 air exchanges/hr Mask, N95 for TB DROPLET think of SPIDERMAN! S - sepsis S - scarlet fever S - streptococcal pharyngitis P - parvovirus B19 P - pneumonia P - pertussis I - influenza D - diptheria (pharyngeal) E - epiglottitis R - rubella M - mumps M - meningitis M - mycoplasma or meningeal pneumonia An - Adenovirus Private Room or cohort Mask 1 CONTACT PRECAUTION MRS.WEE M - multidrug resistant organism R - respiratory infection S - skin infections * W - wound infxn E - enteric infxn - clostridium difficile E - eye infxn - conjunctivitis SKIN INFECTIONS VCHIPS V - varicella zoster C - cutaneous diphtheria H - herpez simplex I - impetigo P - pediculosis S - scabies 1. Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending doom) --> turn pt to left side and lower the head of the bed. 2. Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal bradycardia, etc) --> turn on left side (and give O2, stop Pitocin, increase IV fluids) 3. Tube Feeding w/ Decreased LOC --> position pt on right side (promotes emptying of the stomach) with the HOB elevated (to prevent aspiration) 4. During Epidural Puncture --> side-lying 5. After Lumbar Puncture (and also oil-based Myelogram)--> pt lies in flat supine (to prevent headache and leaking of CSF) 6. Pt w/ Heat Stroke --> lie flat w/ legs elevated 7. During Continuous Bladder Irrigation (CBI) --> catheter is taped to thigh so leg should be kept straight. No other positioning restrictions. 8. After Myringotomy --> position on side of affected ear after surgery (allows drainage of secretions) 9. After Cataract Surgery --> pt will sleep on unaffected side with a night shield for 1-4 weeks. 10. After Thyroidectomy --> low or semi-Fowler's, support head, neck and shoulders. 11. Infant w/ Spina Bifida --> position prone (on abdomen) so that sac does not rupture 12. Buck's Traction (skin traction) --> elevate foot of bed for counter-traction 13. After Total Hip Replacement --> don't sleep on operated side, don't flex hip more than 4560 degrees, don't elevate HOB more than 45 degrees. Maintain hip abduction by separating thighs with pillows. 14. Prolapsed Cord --> knee-chest position or Trendelenburg 2 15. Infant w/ Cleft Lip --> position on back or in infant seat to prevent trauma to suture line. While feeding, hold in upright position. 16. To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) --> eat in reclining position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low CHO and fiber diet, small frequent meals) 17. Above Knee Amputation --> elevate for first 24 hours on pillow, position prone daily to provide for hip extension. 18. Below Knee Amputation --> foot of bed elevated for first 24 hours, position prone daily to provide for hip extension. 19. Detached Retina --> area of detachment should be in the dependent position 20. Administration of Enema --> position pt in left side-lying (Sim's) with knee flexed 21. After Supratentorial Surgery (incision behind hairline) --> elevate HOB 30-45 degrees 22. After Infratentorial Surgery (incision at nape of neck)--> position pt flat and lateral on either side. 23. During Internal Radiation --> on bedrest while implant in place 24. Autonomic Dysreflexia/Hyperreflexia (S&S: pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia, hypertension) --> place client in sitting position (elevate HOB) first before any other implementation. 25. Shock --> bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified Trendelenburg) 26. Head Injury --> elevate HOB 30 degrees to decrease intracranial pressure 27. Peritoneal Dialysis when Outflow is Inadequate --> turn pt from side to side BEFORE checking for kinks in tubing (according to Kaplan) 28. Lumbar puncture => AFTER the procedure, the client should be placed in the supine position for 4 to 12 hrs as prescribed. (Saunders 3rd ed p. 229) Demorol for pancreatitis, NOT morphine sulfate Myasthenia Gravis: worsens with exercise and improves with rest. Myasthenia Crisis: a positive reaction to Tensilon--will improve symptoms Cholinergic Crisis: caused by excessive medication-stop med-giving Tensilon will make it worse Head injury medication: Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use filter needle Prior to a liver biospy its important to be aware of the lab result for prothrombin time From the a** (diarrhea)= metabolic acidosis From the mouth (vomitus)=metabolic alkalosis Myxedema/hypothyroidism: slowed physical and mental function, sensitivity to cold, dry skin and hair 3 Graves’ disease/hyperthyroidism: accelerated physical and mental function; sensitivity to heat, fine/soft hair Thyroid storm: increased temp, pulse and HTN Post-thyroidectomy: semi-Fowler’s, prevent ncek flexion/hyperextension, trach at bedside Hypo-parathyroid: CATS – convulsions, arrhythmias, tetany, spasms, stridor (decreased calcium), high Ca, low phosphorus diet Hyper-parathyroid: fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium), low Ca, high phosphorus diet Hypovolemia – incrased temp, rapid/weak pulse, increase respiration, hypotension, anxiety, urine specific gravity >1.030 Hypervolemia – bounding pulse, SOB, dyspnea, rares/crackles, peripheral edema, HTN, urine specific gravity <1.010; Semi-Fowler’s Diabetes Insipidus (decreased ADH): excessive urine output and thirst, dehydration, weakness, administer Pitressin SIADH (increased ADH): change in LOC, decreased deep tendon reflexes, tachycardia, n/v/a, HA; administer Declomycin, diuretics Hypokalemia: muscle ewakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges, beans, potatoes, carrots, celery) Hyperkalemia: MURDER – muscle weakness, urine (oliguria/anuria), respiratory depression, decreased cardiac contractility, ECG changes, reflexes Hyponatremia: nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic diuretics, fluids Hypernatremia: increased temp, weakness, disorientation/delusions, hypotension, tachycardia; hypotonic solution Hypocalcemia: CATS – convulsions, arrhythmias, tetany, spasms and stridor Hypercalcemia: muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, sedative effect on CNS HypoMg: tremors, tetany, seizures, dyrshythmias, depression, confusion, dysphagia; dig toxicity HyperMg: depresses the CNS, hypotension, facial flushing, muscle ewakness, absent deep tendon reflexes, shallow respirations, emergency Addison’s: hypoNa, hyperK, hypoglycemia, dark pigmentation, decreased resistance to stress, fractures, alopecia, weight loss, GI distress Cushings: hyperNa, hypoK, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump Addisonian crisis: n/v, confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP Pheochromocytoma: hypersecretion of epi/norepi, persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bating and rest breaks, avoid cold and stimulating foods, surgery to remove tumor 1. Neuroleptic malignant syndrome (NMS): -NMS is like S&M; -you get hot (hyperpyrexia) -stiff (increased muscle tone) -sweaty (diaphoresis) -BP, pulse, and respirations go up & -you start to drool 4 2. I kept forgetting which was dangerous when you're pregnant; regular measles (rubeola), or German measles (rubella), so remember: -never get pregnant with a German (rubella) 3. When drawing up regular insulin & NPH together, remember: -RN (regular comes before NPH) 4. Tetralogy of fallot; remember HOPS Think DROP(child drops to floor or squats) or POSH Defect, septal Right Ventricular hypertrophy Overriding aorts Pulmonary stenosis 5. MAOI's that are used as antidepressants: weird way to remember, I know. pirates say arrrr, so think; pirates take MAOI's when they're depressed. - explanation; MAOI's used for depression all have an arrr sound in the middle (Parnate, Marplan, Nardil) Autonomic dysreflexia: potentially life threatening emergency - elevate head of bed to 90 degree - loosen constrictive clothing - assess for bladder distention and bowel impaction (triger) - Administer antihypertensive meds (may cause stroke, MI, seisure ) easy way to remember MAOI'S! think of PANAMA! PA - parnate NA - nardil MA - marplan metallic bitter taste. Digoxin-check pulse, less than 60 hold, check dig levels and potassium levels. Amphojel: tx of GERD and kidney stones....watch out for contipation. Vistaril: tx of anxiety and also itching...watch for dry mouth. given preop commonly Versed: given for conscious sedation...watch for resp depression and hypotension PTU and Tapazole- prevention of thyroid storm Sinemet: tx of parkinson...sweat, saliva, urine may turn reddish brown occassionally...causes drowsiness Artane: tx of parkinson..sedative effect also Cogentin: tx of parkinson and extrapyramidal effects of other drugs Tigan: tx of postop n/v and for nausea associated with gastroenteritis Timolol (Timoptic)-tx of gluacoma 5 Bactrim: antibiotic..dont take if allergic to sulfa drugs...diarrhea common side effect...drink plenty of fluids Gout Meds: Probenecid (Benemid), Colchicine, Allopurinol (Zyloprim) Apresoline(hydralazine)-tx of HTN or CHF, Report flu-like symptoms, rise slowly from sitting/lying position; take with meals. Bentyl: tx of irritable bowel....assess for anticholinergic side effects. Calan (verapamil): calcium channel blocker: tx of HTN, angina...assess for constipation Carafate: tx of duodenal ulcers..coats the ulcer...so take before meals. Theophylline: tx of asthma or COPD..therap drug level: 10-20 Mucomyst is the antedote to tylenol and is administered orally Diamox: tx of glaucoma, high altitude sickness...dont take if allergic to sulfa drugs Indocin: (nsaid) tx of arthritis (osteo, rhematoid, gouty), bursitis, and tendonitis. Synthroid: tx of hypothyroidism..may take several weeks to take effect...notify doctor of chest pain..take in the AM on empty stomach..could cause hyperthyroidism. Librium: tx of alcohol w/d...dont take alchol with this...very bad nausea and vomiting can occur. Oncovin (vincristine): tx of leukemia..given IV ONLY kwell: tx of scabies and lice...(scabies)apply lotion once and leave on for 8-12 hours...(lice) use the shampoo and leave on for 4 minutes with hair uncovered then rinse with warm water and comb with a fine tooth comb Premarin:tx after menopause estrogen replacement Dilantin: tx of seizures. thera drug level: 10-20 Navane: tx of schizophrenia..assess for EPS Ritalin: tx of ADHD..assess for heart related side effects report immediately...child may need a drug holiday b/c it stunts growth. dopamine (Intropine): tx of hypotension, shock, low cardiac output, poor perfusion to vital organs...monitor EKG for arrhythmias, monitor BP Have trouble remembering fhr patterns in OB? Think VEAL CHOP VC EH AO LP V = variable decels; C = cord compression caused E = early decels; H = head compression caused A = accels; O = okay, not a problem! L = late decels = placental insufficiency, can't fill 6 For cord compression, place the mother in the TRENDELENBERG position because this removes pressure of the presenting part off the cord. (If her head is down, the baby is no longer being pulled out of hte body by gravity) If the cord is prolapsed, cover it with sterile saline gauze to prevent drying of the cord and to minimize infection. For late decels, turn the mother to her left side, to allow more blood flow to the placenta. For any kind of bad fetal heart rate pattern, you give O2, often by mask... When doing an epidural anesthesia hydration before hand is a priority. Hypotension and bradypnea / bradycardia are major risks and emergencies. NEVER check the monitor or a machine as a first action. Always assess the patient first; for exmaple listen to the fetal heart tones with a stethoscope in NCLEX land. Sometimes it's hard to tell who to check on first, the mother or the baby; it's usually easy to tell the right answer if the mother or baby involves a machine. If you're not sure who to check first, and one of the choices involves the machine, that's the wrong answer. If the baby is a posterior presentation, the sounds are heard at the sides. If the baby is anterior, the sounds are heard closer to midline, between teh umbilicus and where you would listen to a posterior presentation. If the baby is breech, the sounds are high up in the fundus near the umbilicus. If the baby is vertex, they are a little bit above the symphysis pubis. Also for ventilator alarms HOLD High alarm- Obstruction due to incr. secretions, kink, pt. coughs, gag or bites Low press alarm- Disconnection or leak in ventilatior or in pt. airway cuff, pt. stops spontaneous breathing 1. to remember blood sugar: hot and dry-sugar high (hyperglycemia) cold and clammy-need some candy (hypoglycemia) 2. ICP AND SHOCK HAVE OPPOSITE V/S ICP-increased BP, decreased pulse, decreased resp. shock- decreased BP, increased pulse, increased resp. 3. cor pulmonae: right sided heart failure caused by left ventricular failure (so pick edema, jvd, if it is a choice.) 4. herion withdrawal neonate: irratable poor sucking 5. Jews: no meat and milk together 6. Brachial pulse: pulse area cpr on an infant. 7. Test child for lead poisioning around 12 months of age 8. bananas, potatoes, citrus fruits source of potassium 11. Cultures are obtained before starting IV antibiotics 7 12. a pt with leukemia may have epitaxis b/c of low platelets 13. best way to warm a newborn: skin to skin contact covered with a blanket on mom. 14. when a pt comes in and she is in active labor...nurse first action is to listen to fetal heart tone/rate 15. phobic disorders...use systematic desensitiztion. NCLEX TIPS 1. When getting down to two answers, choose the assessment answer (assess, collect, auscultate, monitor, palpate) over the intervention except in an emergency or distress situation. If one answer has an absolute, discard it. Give priority to answers that deal directly to the patient’s body, not the machines/equipments. 2. Key words are very important. Avoid answers with absolutes for example: always, never, must, etc. 3. with lower amputations patient is placed in prone position. 4. small frequent feedings are better than larger ones. 5. Assessment, teaching, meds, evaluation, unstable patient cannot be delegated to an Unlicensed Assistive Personnel. 6. LVN/LPN cannot handle blood. 7. Amynoglycosides (like vancomycin) cause nephrotoxicity and ototoxicity. 8. IV push should go over at least 2 minutes. 9. If the patient is not a child an answer with family option can be ruled out easily. 10. In an emergency, patients with greater chance to live are treated first 11. ARDS (fluids in alveoli), DIC (disseminated intravascular coagulaton) are always secondary to something else (another disease process). 12. Cardinal sign of ARDS is hypoxemia (low oxygen level in tissues). 13. in pH regulation the 2 organs of concern are lungs/kidneys. 14. edema is in the interstitial space not in the cardiovascular space. 15. weight is the best indicator of dehydration 16. wherever there is sugar (glucose) water follows. 17. aspirin can cause Reye’s syndrome (encephalopathy) when given to children 18. when aspirin is given once a day it acts as an antiplatelet. 19. use Cold for acute pain (eg. Sprain ankle) and Heat for chronic ( rheumatoid arthritis) 20. guided imagery is great for chronic pain. 21. when patient is in distress, medication administration is rarely a good choice. 22. with pneumonia, fever and chills are usually present. For the elderly confusion is often present. 23. Always check for allergies before administering antibiotics (especially PCN). Make sure culture and sensitivity has been done before adm. First dose of antibiotic. 24. Cor pulmonale (s/s fluid overload) is Right sided heart failure caused by pulmonary disease, occurs with bronchitis or emphysema. 25. COPD is chronic, pneumonia is acute. Emphysema and bronchitis are both COPD. 26. in COPD patients the baroreceptors that detect the CO2 level are destroyed. Therefore, O2 level must be low because high O2 concentration 8 blows the patient’s stimulus for breathing. 27. exacerbation: acute, distress. 28. epi always given in TB syringe. 29. prednisone toxicity: cushing’s syndrome= buffalo hump, moon face, high glucose, hypertension. 30. 4 options for cancer management: chemo, radiation, surgery, allow to die with dignity. 31. no live vaccines, no fresh fruits, no flowers should be used for neutropenic patients. 32. chest tubes are placed in the pleural space. 33. angina (low oxygen to heart tissues) = no dead heart tissues. MI= dead heart tissue present. 34. mevacor (anticholesterol med) must be given with evening meal if it is QD (per day). 35. Nitroglycerine is administered up to 3 times (every 5 minutes). If chest pain does not stop go to hospital. Do not give when BP is < 90/60. 36. Preload affects amount of blood that goes to the R ventricle. Afterload is the resistance the blood has to overcome when leaving the heart. 37. Calcium channel blocker affects the afterload. 38. for a CABG operation when the great saphenous vein is taken it is turned inside out due to the valves that are inside. 39. unstable angina is not relieved by nitro. 40. dead tissues cannot have PVC’s(premature ventricular contraction. If left untreated pvc’s can lead to VF (ventricular fibrillation). 41. 1 t (teaspoon)= 5 ml 1 T(tablespoon)= 3 t = 15 ml 1 oz= 30 ml 1 cup= 8 oz 1 quart= 2 pints 1 pint= 2 cups 1 gr (grain)= 60 mg 1 g (gram)= 1000 mg 1 kg= 2.2 lbs 1 lb= 16 oz * To convert Centigrade to F. F= C+40, multiply 9/5 and substract 40 * To convert Fahrenheit to C. C= F+40, multiply 5/9 and substract 40. 42. angiotensin II in the lungs= potent vasodialator. Aldosterone attracts sodium. 43. REVERSE AGENTS FOR TOXICITY heparin= protamine sulfate coumadin= vitamin k ammonia= lactulose acetaminophen= n-Acetylcysteine. Iron= deferoxamine Digitoxin, digoxin= digibind. Alcohol withdraw= Librium. - methadone is an opioid analgesic used to detoxify/treat pain in narcotic addicts. - Potassium potentiates dig toxicity. 44. heparin prevents platelet aggregation. 45. PT/PTT are elevated when patient is on coumadin 46. cardiac output decreases with dysrythmias. Dopamine increases BP. 47. Med of choice for Vtach is lidocaine 48. Med of choice for SVT is adenosine or adenocard 49. Med of choice for Asystole (no heart beat) is atropine 9 50. Med of choice for CHF is Ace inhibitor. 51. Med of choice for anaphylactic shock is Epinephrine 52. Med of choice for Status Epilepticus is Valium. 53. Med of choice for bipolar is lithium. 54. Amiodorone is effective in both ventricular and atrial complications. 55. S3 sound is normal in CHF, not normal in MI. 56. give carafate (GI med) before meals to coat stomach 57. Protonix is given prophylactically to prevent stress ulcers. 58. after endoscopy check gag reflex. 59. TPN(total parenteral nutrition) given in subclavian line. 60. low residue diet means low fiver 61. diverticulitis (inflammation of the diverticulum in the colon) pain is around LL quadrant. 62. Appendicitis (inflammation of the appendix) pain is in RL quadrant with rebound tenderness. 63. portal hypotension + albuminemia= Ascites. 64. beta cells of pancreas produce insulin 65. Morphine is contraindicated in Pancreatitis. It causes spasm of the Sphincter of Oddi. Therefore Demerol should be given. 66. Trousseau and Tchovoski signs observed in hypocalcemia 67. with chronic pancreatitis, pancreatic enzymes are given with meals. 68. Never give K+ in IV push. 69. mineral corticoids are give in Addison’s disease. 70. Diabetic ketoacidosis (DKA)= when body is breaking down fat instead of sugar for energy. Fats leave ketones (acids) that cause pH to decrease. 71. DKA is rare in diabetes mellitus type II because there is enough insulin to prevent breakdown of fats. 72. Sign of fat embolism is petechiae. Treated with heparin. 73. for knee replacement use continuous passive motion machine. 74. give prophylactic antibiotic therapy before any invasive procedure. 75. glaucoma patients lose peripheral vision. Treated with meds 76. cataract= cloudy, blurry vision. Treated by lens removal-surgery 77. Co2 causes vasoconstriction. 78. most spinal cord injuries are at the cervical or lumbar regions 79. autonomic dysreflexia ( life threatening inhibited sympathetic response of nervous system to a noxious stimulus- patients with spinal cord injuries at T-7 or above) is usually caused by a full bladder. 80. spinal shock occurs immediately after spinal injury 81. Multiple sclerosis= myelin sheat destruction, disruption in nerve impulse conduction. 82. myasthenia gravis= decrease in receptor sites for acetylcholine. Since smallest concentration of ACTH receptors are in cranial nerves, expect fatigue and weakness in eye, mastication, pharyngeal muscles. 83. Tensilon test given if muscle is tense in myasthenia gravis. 84. Guillain-Barre syndrome= ascending paralysis. Keep eye on respiratory system. 85. parkinson’s = RAT: rigidity, akinesia (loss of muscle mvt), tremors. Treat with levodopa. 86. TIA (transient ischemic attack) mini stroke with no dead brain tissue 87. CVA (cerebrovascular accident) is with dead brain tissue. 88. Hodgkin’s disease= cancer of lymph is very curable in early stage. 89. Rule of NINES for burns Head and Neck= 9% Each upper ext= 9% Each lower ext= 18% 10 Front trunk= 18% Back trunk= 18% Genitalia= 1% ? 90. Birth weight doubles by 6 month and triple by 1 year of age. 91. if HR is <100 do not give dig to children. 92. first sign of cystic fibrosis may be meconium ileus at birth. Baby is inconsolable, do not eat, not passing meconium. 93. heart defects. Remember for cyanotic -3T’s( Tof, Truncys arteriosus, Transposition of the great vessels). Prevent blood from going to heart. If problem does not fix or cannot be corrected surgically, CHF will occur following by death. 94. with R side cardiac cath=look for valve problems 95. with L side in adults look for coronary complications. 96. rheumatic fever can lead to cardiac valves malfunctions. 97. cerebral palsy = poor muscle control due to birth injuries and/or decrease oxygen to brain tissues. 98. ICP (intracranial pressure) should be <2. measure head circonference. 99. dilantin level (10-20). Can cause gingival hyperplasia 100. for Meningitis check for Kernig’s/ Brudzinski’s signs. 101. Wilm’s tumor is usually encapsulated above the kidneys causing flank pain. 102. hemophilia is x-linked. Mother passes disease to son. 103. when phenylalanine increases, brain problems occur. 104. Buck’s traction= knee immobility 105. Russell traction= femur or lower leg 106. Dunlap traction= skeletal or skin 107. Bryant’s traction= children <3y, <35 lbs with femur fx. 108. place apparatus first then place the weight when putting traction 109. placenta should be in upper part of uterus 110. eclampsia is seizure. 111. a patient with a vertical c-section surgery will more likely have another c-section. 112. perform amniocentesis before 20 weeks gestation to check for cardiac and pulmonary abnormalities. 113. Rh- mothers receive rhogam to protect next baby. 114. anterior fontanelle closes by 18 months. Posterior 6 to 8 weeks. 115. caput succedaneum= diffuse edema of the fetal scalp that crosses the suture lines. Swelling reabsorbs within 1 to 3 days. 116. pathological jaundice= occurs before 24hrs and last7 days. Physiological jaundice occurs after 24 hours. 117. placenta previa = there is no pain, there is bleeding. Placenta abruption = pain, but no bleeding. 118. bethamethasone (celestone)=surfactant. Med for lung expansion. 119. dystocia= baby cannot make it down to canal 120. pitocin med used for uterine stimulation 121. Magnesium sulfate(used to halt preterm labor) is contraindicated if deep tendon reflexes are ineffective. If patient experiences seizure during magnesium adm. Get the baby out stat (emergency). 122. Do not use why or I understand statement when dealing with patients 123. milieu therapy= taking care of patient/environment 124. cognitive therapy= counseling 125. crisis intervention=short term. 126. FIVE INTERVENTIONS FOR PSYCH PATIENTS -safety -setting limits 11 -establish trusting relationship -meds -leas restrictive methods/environment. 126. SSRI’s (antidepressants) take about 3 weeks to work. 127. Obsession is to thought. Compulsion is to action 128. if patients have hallucinations redirect them. In delusions distract them. 129. Thorazine, haldol (antipsychotic) can lead to EPS (extrapyramidal side effects) 130. Alzheimer’s disease is a chronic, progressive, degenerative cognitive disorder that accounts for more than 60% of all dementias 1. To remember how to draw up INSULIN think: Nicole Richie RN (a teacher taught us this is school, thought it was funny and never forgot it!!!) Air into NPH, then air into regular, draw up regular then draw up NPH 2. HYPERthyroidism think of MICHAEL JACKSON in THRILLER! SKINNY, NERVOUS, BULDGING EYES, Up all night, heart beating fast Atropine used to decrease secretions Phenergan an antiemetic used to reduce nausea Diazepam is a commonly used tranquilizer given to reduce anxiety before OR Demerol is for pain control Do not give demerol to pts. with sickle cell crisis. Iron injections should be given Z-track so they don't leak into SQ tissues. All Physicians Earn Too Much Money Or APE To Man Cranial Nerves: *I am sorry if this vulgar for some, but hey, it sticks Sensory=S Motor=M Both=B Oh (Olfactory I) Some Oh (Optic II) Say Oh (Oculomotor III) Marry To (Trochlear IV) Money Touch (Trigeminal V) But And (Abducens VI) My Feel (Facial VII) Brother A (Auditory VIII) Says Girls (Glossopharyngeal IX) Big Vagina (Vagus X) Bras And (Accessory XI) Matter Hymen (Hypoglassal XII) More 12 Hyper natremia (greater than 145) Skin flushed Agitation Low grade fever Thirst Developmental 2-3 months: turns head side to side 4-5 months: grasps, switch & roll 6-7 months: sit at 6 and waves bye-bye 8-9 months: stands straight at eight 10-11 months: belly to butt (phrase has 10 letters) 12-13 months: twelve and up, drink from a cup Hepatitis Hepatitis: -ends in a VOWEL, comes from the BOWEL (Hep A) Hepatitis B=Blood and Bodily fluids Hepatitis C is just like B Apgar measures HR,RR,Muscle tone, Reflexes,Skin color each 0-2 point. 8-10 OK. 0-3 RESUSCITATE. GLASGOW COMA SCALE. EYES, VERBAL,MOTOR! It is similar to measuring dating skills...max 15 points -one can do it if below 8 you are in Coma. So, to start dating you gotta open your EYES first, if you albe to do that spontaneously and use them correctly to SEE whom you dating you earn 4. But if she has to scream on you to make you open them it is only 3....and 1 you dont care to open even if she tries to hurt you. if you get good EYE contact (4 points) then move to VERBAL. talk to her/ him! if you can do that You are really ORIENTED in situation she/he uncontiously gives you 4 points! if you like her try not to be CONFUSED (3), and of cause do not use INAPPROPRIATE WORDS (3), she will not like it)), try not to RESPOND WITH INCOMPREHENSIBLE SOUNDS (2), if you do not like herjust show no VERBAL RESPONSE(1) Since you've got EYE and VERBAL contact you can MOVE now using your Motor Response Points. THis is VERY important since Good moves give you 6! The person who hyperventilates is most likely to experience respiratory alkalosis. avoid salt substitutes when taken dig and k-supplements because many are potassium based Signs of hypoxia: restless, anxious, cyanotic tachycardia, increased resps. (also monitor ABG's) Addison's disease (need to "add" hormone) Cushing's syndrome (have extra "cushion" of hormones) Dumping syndrome: increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis, wait 1 hr after meals to drink. 13 For blood types: "O" is the universal donor (remember "o" in donor) "AB" is the universal receipient Disseminated Herpes Zoster is AIRBORNE PRECAUTIONS, as to Localized Herpes Zoster is CONTACT PRECAUTIONS. A nurse with a localized herpes zoster CAN care for patients as long as the patients are NOT immunosuppressed and the lesions must be covered! Fat soluble vitamins are Vitamins A, D, E, K Give NSAIDS, Corticosteroids, drugs for Bipolar, Cephalosporins, and Sulfanomides WITH food. Ativan is the treatment of choice for status epilepticus When using a bronchodilator inhaler inconjuction with a glucocorticoid inhaler, administer the bronchodilator first Theophylline increases the risk of digoxin toxicity and decreases the effects of lithium and Dilantin INtal, an inhaler used to treat allergy induced asthma may cause bronchospasm, think… INto the asthmatic lung Isoniazid causes peripheral neuritis Peptic ulcers caused by H. pylori are treated with Flagyl, Prilosec and Biaxin. This treatment kills bacteria and stops production of stomach acid, but does not heal ulcer. Weighted NI (Naso intestinal tubes) must float from stomach to intestine. Don't tape the tube right away after placement, may leave coiled next to pt on HOB. Position patient on RIGHT to facilitate movement through pylorus. * Diaphragm must stay in place 6 hours after intercourse. They are also fitted so must be refitted if you lose or gain a significant amount of weight. * Best time to take Growth Hormone PM, Steroids AM, Diuretics AM, Aricept AM. * Carafate (Sulcrafate) before meals (mucosal barrier; constipation) * Tagamet with food (H2; messes with elderly ppl be careful ! Interacts with alot of things) *Antacids after meals * Long term use of amphogel (binds to phosphates, increases Ca, robs the bones...leads to increased Ca resortion from bones and WEAK BONES) *Cushings ulcers r/t BRAIN injury *Cushings triad r/t ICP in BRAIN (htn, bradycard, irr. resp) *Thyroid storm is HOT (hyperthermia) *Myxedema coma is COLD (hypothermia) *Glaucoma intraocular pressure is greater than the normal (22 mm Hg), give miotics to constrict (pilocarpine) NO ATROPINE. * Non dairy sources of calcium include RHUBARB, SARDINES, COLLARD GREENS * You can petal the rough edges of a plaster cast with tape to avoid skin irritation. *With low back aches, bend knees to relieve * Push fluids with Allopurinol - flush the uric acid out of system * Koplick's spots are red spots with blue center characteristic of PRODROMAL stage of Measles. Usually in mouth. * INH can cause peripheral neuritis, take Vit B6 to prevent also hepatotoxic 14 * Rifampin - Red orange tears and urine, also contraceptives don't work as well * Ethambutol - messes with your Eyes * Apply eye drop to conjunctival sac and after wards apply pressure to nasolacrimal duct / inner canthus * Pancreatitis patients but them in fetal position, NPO, gut rest, prepare antecubital site for PICC cuz they'll probably be getting TPN/Lipids * Trendelenburg test - for varicose veins. If they fill proximally = varicosity. Rule of nines, 9 = head, 18 = arms, 36 = torso, 36 =legs, and 1= perineum = 100% When giving Kayexalate we need to worry about dehydration ( K ha ineverse relationship with Na) Yogurt has live cultures- dont give to immunosuppressed pt Itching under cast area- cool air via blow dryer, ice pack for 10- 15 minutes. NEVER use qtip or anything to scratch area Murphy’s sign – pain with palpation of gall bladder area seen with cholecystitis Cullen’s sign – ecchymosis in umbilical area, seen with pancreatitis Turner’s sign – flank grayish blue (turn around to see your flanks) pancreatitis McBurney’s Point – pain in RLQ indicative of appendicitis LLQ – diverticulitis , low residue, no seeds, nuts, peas RLQ – appendicitis, watch for peritonitis Guthrie Test – Tests for PKU, baby should have eaten source of protein first Shilling Test – test for pernicious anemia/ how well one absorbs Vit b12 Allen’s test – occlude both ulnar and radial artery until hand blanches then release ulnar. If the hand pinks up, ulnar artery is good and you can carry on with ABG/radial stick as planned. ABGS must be put on ice and whisked to the lab. oIt’s ok to have abdominal craps, blood tinged outflow and leaking around site if the Peritoneal Dialysis cath (tenkhoff) was placed in the last 1-2 wks. Cloudy outflow NEVER NORMAL. oAmniotic fluid yellow with particles = meconium stained oHyper reflexes (upper motor neuron issue “your reflexes are over the top”) oAbsent reflexes (lower motor neuron issue) oRhogam : given at 28 weeks, 72 hours post partum, IM. Only given to Rh NEGATIVE mother. Also if indirect Coomb’s test is positive, don’t need to give Rhogam cuz she has antibody only give if negative coombs oVit K is to coumadin as Protamine Sulfate is to Heparin as Ca Glu is to MgSo4 as Mucomyst is to Acetominophen as Amicar is to TPA…get it? Antidotes/treatments for overdose Order of assessment: Inspection, Palpation, Percussion and Ausculation. EXCEPT with abdomen cuz you don’t wanna mess with the bowels and their sounds so you Inspect, Auscultate, Percuss then Palpate (same with kids, I suppose since you wanna go from least invasive to most invasive sine they will cry BLOOD MURDER ! Gotta love them kids !) Latex allergies => Assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes, peaches 15 Tensilon is used in myesthenia gravis to confirm the diagnosis. Myesthenia gravis is caused by a disorder in the transmission of impulses from nerve to muscle cell. Amyotrophic lateral sclerosis ( ALS ) is a condition in which there is a degeneration of motor neurons in both the upper & lower motor neuron systems. Transesophageal Fistula (TEF) - esophagus doesn't fully develop (this is a surgical emergency) The 3 C's of TEF in the newborn: 1) Choking 2) Coughing 3) Cyanosis The MMR vaccine is given SQ not IM. Red--unstable, ie, occluded airway, actively bleeding, see first Yellow---stable, can wait up to an hour for treatment, ie burns, see second Green---stable, can wait even longer to be seen, "walking wounded" Black--unstable clients that will probably not make it, need comfort measures DOA---dead on arrival Greek heritage - they put an amulet or any other use of protective charms around their baby's neck to avoid "evil eye" or envy of others 4 year old kids cannot interpret TIME. Need to explain time in relationship to a known COMMON EVENT (eg: "Mom will be back after supper"). ** Anaphylactic reaction to baker's yeast is contraindication for Hep B vaccine. ** Ask for allergy to eggs before Flu shot ** Ask for anaphylactic rxn to eggs or neomycin before MMR ** When on nitroprusside, monitor thiocynate (cyanide). Normal value should be 1, >1 is heading toward toxicity **If kid has cold, can still give immunizations **SARS (severe acute resp syndrome) airborne + contact (just like varicella) ** Hepatitis A is contact precautions ** Tetanus, Hepatitis B, HIV are STANDARD precautions ** William's position - Semi Fowlers with knees flexed (inc. knee gatch) to relieve lower back pain. ** SIGNS of a Fractured hip: EXTERNAL ROTATION, SHORTENING, ADDUCTION ** Fat Embolism: Blood tinged sputum (r/t inflammation), inc ESR, respiratory alkalosis (not acidosis r/t tachypnea), hypocalcemia,increased serum lipids, "snow storm" effect on CXR. **Complications of Mechanical Ventilation: Pneumothorax, Ulcers ** Paget's Disease - tinnitus, bone pain, enlargement of bone, thick bones. ** NO VITAMIN C with Allopurinol ** IVP requires bowel prep so they can visualize the bladder better **Acid Ash diet - cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread ** Alk Ash diet- milk, veggies, rhubarb, salmon ** Orange tag in triage is non emergent Psych ** Greenstick fractures, usually seen in kids bone breaks on one side and bends on the other 16 Insomnia is a side effect of thyroid hormones. Saunders confirms it. Makes sense though! Increased met. rate, your body is "too busy to sleep" as opposed to the folks with hypothyroidism who may report somnolence (dec. met rate, body is slow and sleepy). Ok some more facts. ** BOTOX for strabismus. Patch the GOOD eye so that the weaker eye can get stronger. Found a cool link about its use in peds pt with strabismus. I had to look it up cuz I heard it was important *ah hem ah hem* ** TIDAL VOLUME is 7 – 10ml / kg ** COPD patients REMEMBER: 2LNC or less (hypoxic NOT hypercapnic drive), Pa02 of 60ish and Sa02 90% is normal for them b/c they are chronic CO2 retainers. ... ** Neostigmine/Atropine (anticholinergic) to reverse effect of pancuronium. **Ampho B causes hypokalemia (amongst many other things..gotta premedicate before giving. Pts will most likely get a fever) ** Test 4 hypersensitivity before the administration of asparginase. ** Take Vermox with high fat diet (increases absorption) ** Kidney Glucose threshold is 180 ** Amphogel and Renegal take with meals ** Stranger anxiety is greatest 7 - 9 months, Separation anxiety peaks in toddlerhood ** MMR is a SQ shot Lymes is found mostly in Conneticut Asthma and Arthritis--swimming best Asthma has intercostal retractions--be concerned Tardive Dyskinesia - irreversible - involuntary movements of the tongue, face and extremities, may happen after prolonged use of antipsychotics Akathisia - motor restlessness, need to keep going, tx with antiparkinsons meds, can be mistaken for agitation. When drawing an ABG, you need to put the blood in a heparinized tube, make sure there are no bubbles, put on ice immediately after drawing, with a lable indicating if the pt was on room air or how many liters of O2. Remember to preform the Allen's Test prior to doing an ABG to check for sufficient blood flow Before going for Pulmonary Fuction Tests (PFT's), a pt's bronchodilators will be with-held and they are not allowed to smoke for 4 hrs prior For a lung biopsy, position pt lying on side of bed or with arms raised up on pillows over bedside table, have pt hold breath in midexpiration, chest x-ray done immediately afterwards to check for complication of pneumothorax, sterile dressing applied For a lumbar puncture, pt is positioned in lateral recumbent fetal position, keep pt flat for 2-3 hrs afterwards, sterile dressing, frequent neuro assessments EEG, hold meds for 24-48 hrs prior, no caffine or cigarettes for 24 hrs prior, pt can eat, pt must stay awake night before exam, pt may be asked to hyperventilate and watch a bright flashing light, after EEG, assess pt for seizures, pt's will be at increased risk Diamox, used for glaucoma, can cause hypokalemia 17 Dexedrine, used for ADHD, may alter insulin needs, avoid taking with MAOI's, take in morning (insomnia possible side effect) Cytovene, used for retinitis caused by cytomegalovirus, pt will need regular eye exams, report dizziness, confusion, or seizures immediately INH, used to treat and prevent TB, do not give with dilantin, can cause phenytonin toxicity, monitor LFT's, give B6 along with, hypotension will occur initially, then resolve Rifampin, for TB, dyes bodily fluids orange If mixing antipsychotics (ie Haldol, Throazine, Prolixin) with fluids, med is incompatible with caffine and apple juice Haldol preferred anti-psychotic in elderly, but high risk extrapyramidal side effects (dystonia, tarditive dyskinesia, tightening of jaw, stiff neck, swollen tongue, later on swollen airway), monitor for early signs of reaction and give IM Benadryl Risperdal, antipsychotic, doses over 6mg can cause tarditive dyskinesia, first line antipsychotic in children Levodopa, for parkinsons, contraindicated in pts with glaucoma, avoid B6 Sinemet, for parkinsons, contraindicated with MAOI's Hydroxyurea, for sickle cell, report GI symptoms immediately, could be sign of toxicity Zocor, for hyperlipidemia, take on empty stomach to enhance absorption, report any unexplained musle pain, especially if fever Decorticate is toward the 'cord'. Decerebrit is the other way (out) ** BOTOX ** (Botulin Toxin) can be used with strabismus also to relax vocal cords in spasmodic dysphonia. 18 -Munchausen Syndrome is a psychiatric disorder that causes an individual to self-inflict injury or illness or to fabricate symptoms of physical or mental illness, in order to receive medical care or hospitalization. In a variation of the disorder, Munchausen by proxy (MSBP), an individual, typically a mother, intentionally causes or fabricates illness in a child or other person under her care. -Multiple Sclerosis is a chronic, progressive disease with demyelinating lesions in the CNS which affect the white matter of the brain and spinal cord. Motor S/S: limb weakness, paralysis, slow speech Sensory S/S: numbness, tingling, tinnitus Cerebral S/S: nystagmus, ataxia, dysphagia, dysarthria Huntington's Chorea: 50% genetic, autosomal dominant disorder S/S: chorea --> writhing, twisting, movements of face, limbs and body -gait deteriorates to no ambulation -no cure, just palliative care -WBC shift to the left in a patient with pyelonephritis (neutrophils kick in to fight infection) -Definitive diagnosis for abd. aortic aneurysm (AAA) --> CT scan -Don't use Kayexalate if patient has hypoactive bowel sounds. -Uremic fetor --> smell urine on the breath -Hirschsprung’s --> bile is lower obstruction, no bile is upper obstruction; ribbon like stools. -Pancreatic enzymes are taken with each meal! Not before, not after, but WITH each meal. 19 Thank you, I finally realize why a person shouldn't have cantaloupe before a occult stool test, because cantaloupe is high in vit c and vit c causes a false + for occult blood. Now I just need to figure out why they can't have fish. Hypospadias: abnormality in which urethral meatus is located on the ventral (back) surface of the penis anywhere from the corona to the perineum (remember hypo, low (for lower side or under side) Epispadias: opening of the urethra on the dorsal (front) surface of the penis Priapism: painful erection lasting longer than 6 hrs. Anticholinergic effects--assessment dry mouth==can't spit urinary retention=can't **** constipated =can't **** blurred vision=can't see When you see Coffee-brown emesis, think peptic ulcer 2.Anytime you see fluid retention. Think heart problemsfirst. 3.An answer that delays care or treatment is ALWAYSwrong 4.For PVD remember DAVE (Legs are Dependent forArterial & for Venous Elevated) more to come.......... When choosing an answer, think in this manner… if you can only do ONLY one thing to help this patient what would it be? Pick the most important intervention.                    If two of the answers are the exact opposite, like bradycardia or tachycardia... one is probably the answer. If two or three answers are similar or are alike, none is correct. When asking patients’ questions NEVER use “why” questions. Eliminate all “why?” answer options. If you have never heard of it… please don’t pick it! Never release traction UNLESS you have an order from the MD to do so Questions about a halo? Remember safety first, have a screwdriver nearby. Remember compartment syndrome is an emergency situation. Paresthesias and increased pain are classic symptoms. Neuromuscular damage is irreversible 4-6 hours after onset. Always deal with actual problems or harm before potential problems Always select a “patient focused” answer. An answer option that states "reassess in 15 minutes" is probably wrong. Interpersonal model (Sullivan) Behavior motivated by need to avoid anxiety and satisfy needs 1. Infancy 0-18 months others will satisy needs 2. childhood >6yrs learn to delay need gratification 3. juvenile 6-9 years learn to relate to peers 4. preadolescence 9-12 yrs learns to relate to friends of of opposite sex 5. early adolescence12-14yrs:learn independence and how to relate to opposite sex 6. late adolecence 14-21yrs: develop intimate relationship with person of opposite sex is this not about communication?.... 20   Fetal alcohol syndrome -upturned nose -flat nasal bridge -thin upper lip -SGA vastus lateralis is IM administration site for 6month infants  For toddlers above 18 months ventrogluteal The deltoid and gluteus maximus are appropriate sites for children OU- both eyes OS- left eye OD- right eye ( dominent Right eye- just a tip to remember) 1. COAL (cane walking): C - cane O - opposite A - affected L - leg Red- Immediate: Injuries are life threatening but survivable with minimal intervention. Ex: hemothrax, tension pneumothorax, unstable chest and abdominal wounds, INCOMPLETE amputations, OPEN fx's of long bones, and 2nd/3rd degree burn with 15%-40% of total body surface, etc. Yellow- Delayed: Injuries are significant and require medical care, but can wait hrs without threat to life or limb. Ex: Stable abd wounds without evidence of hemorrhage, fx requiring open reduction, debridement, external fixation, most eye and CNS injuries, etc. Green- Minimal: Injuries are minor and tx can be delayed to hrs or days . Individuals in this group should be moved away from the main triage area. Ex: upper extremity fx, minor burns, sprains, sm. lacerations, behavior disorders. Black- Expectant: Injuries are extensive and chances of survival are unlikely. Seperate but dont abandoned, comfort measures if possible. Ex: Unresponsive, spinal cord injuries, woulds with anatomical organs, 2nd/3rd degree burn with 60% of body surface area , seizures, profound shock with multipe injuries, no pulse, b.p, pupils fixed or dilated. Thoracentesis prep- Take v.s., shave area around needle insertion, position patient with arms on pillow on over bed table or lying on side, no more than 1000cc at a one time. Post- listen for bilateral breath sounds, v.s., check leakage, sterile dressing. CT- assess allergies MRI- claustrophobia, no metal, assess pacemaker Cardiac cath- npo 8-12hr, empty bladder, pulses, tell pt may feel heat palpitations or desire to cough with dye injection. Post- Vital signs keep leg straight bedrest 6-8hr. cerebral angio prep- well hydrated, lie flat, sire shaved, pulses marked post- keep flat 12-14hr, check site, pulses,force fluids. Lumbar puncture- fetal postion. post- nuero assess q15-30 until stable, flat2-3hr, encourage fluids, oral anlgesics for headache, observe dressing 21 EEG- no sleep the night before, meals not withheld, no stimulants for 24hr before, tranquilizer/stimulant meds held 24-48hr before, may be asked to hyperventilate 3-4min and watch a bright flashing light. Myelogram- Npo 4-6hr, allergy hx, phenothiazines, cns depressants, and stimulants withheld 48hr prior, table will be moved to various postions during test. Post- neuro q2-4, water soluble HOB up, oil soluble HOB down, oral analgesics for h/a, encourage po fluids, assess for distended bladder, inspect site. Liver biopsy- Adm vit k , npo morning of exam 6hr, give sedative, Teach pt that he will be asked to hold breath for 5-10sec, supine postion, lateral with upper arms elevated. Post- postion on right side, frequent v.s., report severe ab pain stat, no heavy lifting 1wk. Paracentesis- semi fowlers or upright on edge of bed, empty bladder. Post- v.s., report elevated temp, observe for signs of hypovolemia. Laparoscopy- CO2 used to enhances visual, general anesthesia, foley. Post- walk patient to decrease CO2 build up used for procedure. Pyelogram- assess allergies Sengstaken blakemore tube used for tx of esophageal varices, keep scissors at bedside. Hemovac- used after mastectomy, empty when full or q8hr, remove plug, empty contents, place on flat surface, cleanse opening and plug with alcohol sponge, compress evacuator completely to remove air, release plug, check system for operation. Common Signs and Symptoms 01. PTB – low-grade afternoon fever. 02. PNEUMONIA – rusty sputum. 03. ASTHMA – wheezing on expiration. 04. EMPHYSEMA – barrel chest. 05. KAWASAKI SYNDROME – strawberry tongue. 06. PERNICIOUS ANEMIA – red beefy tongue. 07. DOWN SYNDROME – protruding tongue. 08. CHOLERA – rice watery stool. 09. MALARIA – stepladder like fever with chills. 10. TYPHOID – rose spots in abdomen. 11. DIPTHERIA – pseudo membrane formation 12. MEASLES – koplik’s spots. 13. SLE – butterfly rashes. 22 14. LIVER CIRRHOSIS – spider like varices. 15. LEPROSY – lioning face. 16. BULIMIA – chipmunk face. 17. APPENDICITIS – rebound tenderness. 18. DENGUE – petechiae or (+) Herman’s sign. 19. MENINGITIS – Kernig’s sign (leg flex then leg pain on extension), Brudzinski sign (neck flex = lower leg flex). 20. TETANY – hypocalcemia (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm). 21. TETANUS – risus sardonicus. 22. PANCREATITIS – Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots. 23. PYLORIC STENOSIS – olive like mass. 24. PDA – machine like murmur. 25. ADDISON’S DISEASE – bronze like skin pigmentation. 26. CUSHING’S SYNDROME – moon face appearance and buffalo hump. 27. HYPERTHYROIDISM/GRAVE’S DISEASE – exopthalmus. 28. INTUSSUSCEPTION – sausage shaped mass, Dance Sign (empty portion of RLQ) 29. MS – Charcot’s Triad (IAN) 30. MG – descending muscle weakness 31. Guillain Barre Syndrome – ascending muscle weakness 32. DVT – Homan’s Sign 33. CHICKEN POX – Vesicular Rash (central to distal) dew drop on rose petal 34. ANGINA – Crushing stubbing pain relieved by NTG 35. MI – Crushing stubbing pain which radiates to left shoulder, neck, arms, unrelieved by NTG 36. LTB – inspiratory stridor 37. TEF – 4Cs’ Coughing, Choking, Cyanosis, Continous Drooling 38. EPIGLOTITIS – 3Ds’ Drooling, Dysphonia, Dysphagia 39. HODGEKIN’S DSE/LYMPHOMA – painless, progressive enlargement of spleen & lymph tissues, Reedstenberg Cells 23 40. INFECTIOUS MONONUCLEOSIS – Hallmark: sore throat, cervical lymph adenopathy, fever 41. PARKINSON’S – Pill-rolling tremors 42. FIBRIN HYALIN – Expiratory Grunt 43. CYSTIC FIBROSIS – Salty skin 44. DM – polyuria, polydypsia, polyphagia 45. DKA – Kussmauls breathing (Deep Rapid RR) 46. BLADDER CA – painless hematuria 47. BPH – reduced size & force of urine 48. PEMPHIGUS VULGARIS – Nikolsky’s sign (separation of epidermis caused by rubbing of the skin) 49. RETINAL DETACHMENT – Visual Floaters, flashes of light, curtain vision 50. GLAUCOMA – Painfull vision loss, tunnel/gun barrel/halo vision (Peripheral Vision Loss) 51. CATARACT – Painless vision loss, Opacity of the lens, blurring of vision 52. RETINO BLASTOMA – Cat’s eye reflex (grayish discoloration of pupils) 53. ACROMEGALY – Coarse facial feature 54. DUCHENNE’S MUSCULAR DYSTROPHY – Gowers’ sign (use of hands to push one’s self from the floor) 55. GERD – Barretts esophagus (erosion of the lower portion of the esophageal mucosa) 56. HEPATIC ENCEPHALOPATHY – Flapping tremors 57. HYDROCEPHALUS – Bossing sign (prominent forehead) 58. INCREASE ICP – HYPERtension BRADYpnea BRADYcardia (Cushing’s Triad) 59. SHOCK – HYPOtension TACHYpnea TACHYcardia 60. MENIERE’S DSE – Vertigo, Tinnitus 61. CYSTITIS – burning on urination 62. HYPOCALCEMIA – Chvostek & Trosseaus sign 63. ULCERATIVE COLITIS – recurrent bloody diarrhea 64. LYME’S DSE – Bull’s eye rash Ottorhea s/s of basilar fracture Battles sign and racoons eyes s/s of orbital fracture 24 Take iron elixir with juice or water.... never with milk Kawasaki's leads to cardiac problems Dilantin 10-20 Theophyline 10-20 Acetaminophen 10-20 Lithium 0.5-1.5 Digoxin 0.5-2.0 Osteomyletitis is an infectious bone dz. Give blood cultures and antibiotics, then if necessary surgery to drain abscess. Nephrotic syndrome s/s edema + hypotension. Turn and reposition (risk for impaired skin integrity) To access role relationship pattern focus on image and relationships with others. Renal impairment: serum creatinine elevated and urine clearance decreased Norm. Serum creatinine 0.8-1.8 (men), 0.5-1.5 (women) Norm. Urine clearance 85-135 Atropine Overdose Hot as a Hare (Temp), Mad as a Hatter Bone (Thirsty) (LOC), Red as a Beet (flushed face) and Dry as a Hemoglobin Neonates 18-27 3 mos 10.6-16.5 3 yrs 9.4-15.5 10 yrs 10.7-15.5 Glomerulonephritis: take vs q 4 hrs + daily weights Age 4 to 5 yrs child needs DPT/MMR/OPV Cystic Fibrosis give diet low fat, high sodium, fat soluble vitamins ADEK. Aerosal bronchodilators, mucolytics and pancreatic enzymes. Airborne Precautions: measels, chicken pox and TB. private room, negatvie pressure w/ 6-12 air exchanges, Mask N95. Droplet Precautions:sepsis, scarlet fever, streptococcal pharyngitis, parovirus B19, pnuemonia, pertusis, influenza, diptheria, epiglottis, rubella, mumps, meningitis, mycoplasma and adenovirus. Door open, 3 ft distance, private room or cohort, mask Contact Precautions: multidrug resistant organism; respiratory, skin, wound enteric and eye INFECTIONS Zoloft s/e agitation, sleep disturb, and dry mouth Clozapine s/e agranulocytosis, tachycardia and siezures Blood tests for MI: Myoglobin, CK and Troponin 25 Salt substitutes may contain pottasium Placental abruptio: bleeding with pain, don't forget to monitor volume status (I&O) An ill child regresses in behaviors Meningeal irritation S/s nuchal rigidity, positive Brudzinski + Kernig signs and PHOTOPHOBIA too! Babinski sign - toes curl great! toes fan bad Glucose Tolerance Test for preggies result of 140 or highter needs further evaluation. Assessing extraocular eye movements check cranial nerves 3, 4, and 6. Stomas dusky stoma means poor blood supply, protruding means prolapsed, sharp pain + rigidity means peritonitis, mucus in ileal conduit is expected. Dilantin s/e rash (stop med), gingival hyperplasia (good hygiene) toxicity-->poor gait + coordination, slurred speech, nausea, lethargy, and diplopia. Phenobarbital can be taken during pregnancy but Dilatin is contraindicated. Tension pneumothorax trachea shifts to opposite side. This is GREAT! Here's some I got from a review class I went to several months ago... *Change in color is always a LATE sign! *Incentive Spirometry steps:1) Sit upright 2) Exhale 3) Insert mouthpiece 4) Inhale for 3 seconds, and then HOLD for 10 seconds *Aminoglycocide (__Mycin ; except erythromycine) Adverse Effects are bean shaped Nephrotoxic to Kidneys and Ototoxic to Ears *MRSA - Contact precaution ONLY *VRSA - Contact AND airborne precaution (Private room, door closed, negative pressure) *LITHIUM L-level of therapeutic affect is 0.5-1.5 I-indicate mania T-toxic level is 2-3 - N/V, diarrhea, tremors H-hyrdrate 2-3L of water/day I-increased UO and dry mouth U-uh oh; give Mannitol and Diamox if toxic s/s are present M-maintain Na intake of 2-3g/day *All psych meds' (except Lithium) side effects are the same as SNS but the BP is decreased. *SNS- Increase in BP, HR and RR (dilated bronchioled), dilated pupils (blurred vision), Decreased GUT (urniary retention), GIT (constipation), Constricted blood vessels and Dry mouth. *Blood transfusion- sign of allergies in order: 1)Flank pain 2)Frequent swallowing 3)Rashes 4)Fever 5)Chills *Thrombocytopenia -Bleeding precautions! 1)Soft bristled toothbrush 2)No insertion of anything! (c/i suppositories, douche) 26 3)No IM meds as much as possible! *Iron deficiency anemia - easily fatigued 1)Fe PO - give with Vitamin C or on an empty stomach 2)Fe via IM- Inferon via Ztrack *Pernicious Anemia - Red, Beffy tongue; will take Vit.B12 for life! *BURNS 1st Degree - Red and Painful 2nd Degree - Blisters 3rd Degree - No Pain because of blocked and burned nerves *Meniere's Disease - Admin diuretics to decrease endolymph in the cochlea, restrict Na, lay on affected ear when in bed. Triad: 1)Vertigo 2)Tinnitus 3)N/V *Gastric Ulcer pain occurs 30 minutes to 90 minutes after eating, not at night, and doesn't go away with food *Think positive and you can achieve great things. Think of present and future, the past is gone. *Forget your past mistakes and focus on your successes encouraging yourself to greater achievements in the future. *Always do your best so you can be proud that you gave it your best shot. *Focus on your achievements rather than your failures. If you do find yourself thinking about how you failed then look at what you managed to do right and how you could correct what you did next time. *A mind that is troubled with doubt won't be able to focus on the victory to be had. *Take it one day at a time. *Take time for yourself. A fried mind can't focus or learn. Pediatric Tips: What is an intraosseous infusion? In pediatric life-threatening emergencies, when iv access cannot be obtained, an osseous (bone) needle is hand-drilled into a bone (usually the tibia), where crystalloids, colloids, blood products and drugs can be administered into the marrow. It is a temporary, life-saving measure, and I have seen it once! (Gruesome.) When venous access is achieved it can be d/c’d. One medication that cannot be administered by intraosseous infusion is isoproterenol, a beta agonist. (I don’t know more about that drug; it was just pointed out on a practice exam.) During sickle cell crisis there are two interventions to prioritize: fluids and pain relief. With glomerulonephritis you should consider blood pressure to be your most important assessment parameter. Dietary restrictions you can expect include fluids, protein, sodium, and potassium. Remember yesterday when I mentioned how congenital cardiac defects result in hypoxia which the body attempts to compensate for (influx of immature rbc’s)? Labs supporting this would show increased hematocrit, hemoglobin, and rbc count. Did you know there is an association between low-set ears and renal anomalies? Now you know what to look for if down’s isn’t there to choose. (just to expand on it a little, the kidneys and ears develop around the same time in utero. Hence, they're shaped similarly. Which is why when doing an assessment of a neonate, if the nurse notices low set or asymmetrical ears, there is good reason to investigate renal functioning. Knowing that the kidneys and ears are similar shapes helped me remember this). 27 School-age kids (5 and up) are old enough, and should have an explanation of what will happen a week before surgery such as tonsillectomy. If you gave a toddler a choice about taking medicine and he says no, you should leave the room and come back in five minutes, because to a toddler it is another episode. Next time, don’t ask. The first sign of pyloric stenosis in a baby is mild vomiting that progresses to projectile vomiting. Later you may be able to palpate a mass, the baby will seem hungry often, and may spit up after feedings. We know Kawasaki disease causes a heart problem, but what specifically? Coronary artery aneurysms d/t the inflammation of blood vessels. A child with a ventriculoperitoneal shunt will have a small upper-abdominal incision. This is where the shunt is guided into the abdominal cavity, and tunneled under the skin up to the ventricles. You should watch for abdominal distention, since fluid from the ventricles will be redirected to the peritoneum. You should also watch for signs of increasing intracranial pressure, such as irritability, bulging fontanels, and high-pitched cry in an infant. In a toddler watch lack of appetite and headache. Careful on a bed position question! Bed-position after shunt placement is flat, so fluid doesn’t reduce too rapidly. If you see s/s of increasing icp, then raise the hob to 15-30 degrees. What could cause bronchopulmonary dysplasia? Dysplasia means abnormality or alteration. Mechanical ventilation can cause it. Premature newborns with immature lungs are ventilated and over time it damages the lungs. Other causes could be infection, pneumonia, or other conditions that cause inflammation or scarring. It is essential to maintain nasal patency with children < 1 yr. because they are obligatory nasal breathers. Watch out for questions suggesting a child drinks more than 3-4 cups of milk each day. (Milks good, right?) Too much milk reduces intake of other essential nutrients, especially iron. Watch for anemia with milk-aholics. And don’t let that mother put anything but water in that kid’s bottle during naps/over-night. Juice or milk will rott that kids teeth right out of his head. What traction is used in a school-age kid with a femur or tibial fracture with extensive skin damage? Ninety, ninety. Huh? I never heard of it either. The name refers to the angles of the joints. A pin is placed in the distal part of the broken bone, and the lower extremity is in a boot cast. The rest is the normal pulleys and ropes you’re used to visualizing with balanced suspension. While we’re talking about traction, a kid’s hinder should clear the bed when in Bryant’s traction (also used for femurs and congenial hip for young kids). If you can remove the white patches from the mouth of a baby it is just formula. If you can’t, its candidiasis. Just know the MMR and Varicella immunizations come later (15 months). Undescended testis or cryptorchidism is a known risk factor for testicular cancer later in life. Start teaching boys testicular self exam around 12, because most cases occur during adolescence. Not pediatrics but have to throw it in – A guy loses his house in a fire. Priority is using community resources to find shelter, before assisting with feelings about the tremendous loss. (Maslow). No aspirin with kids b/c it is associated with Reye’s Syndrome, and also no nsaids such as ibuprofen. Give Tylenol. 28 CSF in meningitis will have high protein, and low glucose. It is always the correct answer to report suspected cases of child abuse. No nasotracheal suctioning with head injury or skull fracture. Feed upright to avoid otitis media. Position prone w hob elevated with gerd. In almost every other case, though, you better lay that kid on his back (Back To Sleep - SIDS). Pull pinna down and back for kids < 3 yrs. when instilling eardrops. Kids with RSV; no contact lenses or pregnant nurses in rooms where ribavirin is being administered by hoot, tent, etc. Positioning with pneumonia – lay on the affected side to splint and reduce pain. But if you are trying to reduce congestion the sick lung goes up. (Ever had a stuffy nose, and you lay with the stuff side up and it clears?) A positive ppd confirms infection, not just exposure. A sputum test will confirm active disease. Coughing w/o other s/s is suggestive of asthma. Speaking of asthma, watch out if your wheezer stops wheezing. It could mean he is worsening. You better pick ‘do vitals’ before administering that dig. (apical pulse for one full minute). Tet spells treated with morphine. Group-a strep precedes rheumatic fever. Chorea is part of this sickness (grimacing, sudden body movements, etc.) and it embarrasses kids. They have joint pain. Watch for elevated antistreptolysin O to be elevated. Penicillin! Don’t pick cough over tachycardia for signs of chf in an infant. Random Tips: No milk (as well as fresh fruit or veggies) on neutropenic precautions. Tylenol poisoning – liver failure possible for about 4 days. Close observation required during this time-frame, as well as tx with Mucomyst. Radioactive iodine – The key word here is flush. Flush substance out of body w/3-4 liters/day for 2 days, and flush the toilet twice after using for 2 days. Limit contact w/patient to 30 minutes/day. No pregnant visitors/nurses, and no kids. The main hypersensitivity reaction seen with antiplatelet drugs is bronchospasm (anaphylaxis). Common sites for metastasis include the liver, brain, lung, bone, and lymph. Orthostasis is verified by a drop in pressure with increasing heart rate. Bence Jones protein in the urine confirms multiple myeloma. 29 Don’t fall for ‘reestablishing a normal bowel pattern’ as a priority with small bowel obstruction. Because the patient can’t take in oral fluids ‘maintaining fluid balance’ comes first. Pernicious anemia s/s include pallor, tachycardia, and sore red tongue. With flecainide (Tambocor), an antiarrythmic, limit fluids and sodium intake, because sodium increases water retention which could lead to heart failure. Basophils release histamine during an allergic response. Adenosine is the treatment of choice for paroxysmal atrial tachycardia. Iatragenic means it was caused by treatment, procedure, or medication. Other than initially to test tolerance, G-tube and J-tube feedings are usually given as continuous feedings. Four side-rails up can be considered a form of restraint. Even in LTC facility when a client is a fall risk, keep lower rails down, and one side of bed against the wall, lowest position, wheels locked. Your cancer patient is getting radiation. What should you be most concerned about? Skin irritation? No. Infection kills cancer patients most because of the leukopenia caused by radiation. A breast cancer patient treated with Tamoxifen should report changes in visual acuity, because the adverse effect could be irreversible. Pneumovax 23 gets administered post splenectomy to prevent pneumococcal sepsis. Let’s say every answer in front of you is an abnormal value. If potassium is there you can bet it is a problem they want you to identify, because values outside of normal can be life threatening. Normal potassium is 3.5-5.0. Even a bun of 50 doesn’t override a potassium of 3.0 in a renal patient in priority. You better be making sure that patient on Dig and Lasix is getting enough potassium, because low potassium potentiates Dig and can cause dysrrhythmias. You will ask every new admission if he has an advance directive, and if not you will explain it, and he will have the option to sign or not. An example of when you would implement before going through a bunch of assessments is when someone is experiencing anaphylaxis. Get the ordered epinephrine in them stat, especially if they stem clearly states the s/s (difficulty breathing, increasing anxiety, etc.) In a disaster you should triage the person who is most likely to not survive last. A little trick regarding potassium: ALKALOSIS: K is LOW Acidosis is just the opposite: K is High The vital sign you should check first with high potassium is pulse (due to dysrhythmias). Give neostigmine to clients with Myesthenia Gravis about 45 min. before eating, so it will help with chewing and swallowing. 30 Anectine is used for short-term neuromuscular blocking agent for procedures like intubation and ECT. Norcuron is for intermediate or long-term. The parathyroid gland relies on the presence of vitamin D to work. Glucagon increases the effects of oral anticoagulants. Bleeding is part of the ‘circulation’ assessment of the ABCD’s in an emergent situation. Therefore, if airway and breathing are accounted for, a compound fracture requires assessment before Glasgow coma scale and a neuro check (D=disability, or neuro check) The immediate intervention after a sucking stab wound is to dress the wound and tape it on three sides which allows air to escape. Do not use an occlusive dressing, which could convert the wound from open pneumo to closed one, and a tension pneumothorax is worse situation. After that get your chest tube tray, labs, iv. An occlusive dressing is used if a chest tube is accidentally pulled out of the patient. When o2 deprived, as with a PE, the body compensates by causing hyperventilation (resp alkalosis). Should the patient breathe into a paper bag? No. If the pao2 is well below 80 they need oxygen. Look at all your abg values. As soon as you see the words PE you should think oxygen first. A typical adverse reaction to oral hypoglycemics is rash, photosensitivity. Serum acetone and serum ketones rise in DKA. As you treat the acidosis and dehydration expect the potassium to drop rapidly, so be ready, with potassium replacement. Fluids are the most important intervention with HHNS as well as DKA, so get fluids going first. With HHNS there is no ketosis, and no acidosis. Potassium is low in HHNS (d/t diuresis). Atropine blocks acetylcholine (remember it reduces secretions). Decorticate positioning in response to pain = Cortex involvement. Decerebrate in response to pain = Cerebellar, brain stem involvement Dantrium, for spasticity, may take a week or more to be effective. Decreased acetylcholine is related to senile dementia. Hyperactive deep tendon reflexes, vision changes, fatigue and spasticity are all symptoms of MS After removal of the pituitary gland you must watch for hypocortisolism and temporary diabetes insipidus. Position on right side with legs flexed after appendectomy. Hirschsprung’s diagnosed with rectal biopsy looking for absence of ganglionic cells. Cardinal sign in infants is failure to pass meconium, and later the classic ribbon-like and foul smelling stools. Intussusception common in kids with CF. Obstruction may cause fecal emesis, currant jellylike stools (blood and mucus). A barium enema may be used to hydrostatically reduce the telescoping. Resolution is obvious, with onset of bowel movements. 31 With omphalocele and gastroschisis (herniation of abdominal contents) dress with loose saline dressing covered with plastic wrap, and keep eye on temp. Kid can lose heat quickly. After a hydrocele repair provide ice bags and scrotal support. No phenylalanine with a kid positive for PKU (no meat, no dairy, no aspartame). Second voided urine most accurate when testing for ketones and glucose. Never give potassium if the patient is oliguric or anuric. Nephrotic syndrome is characterized by massive proteinuria (looks dark and frothy) caused by glomerular damage. Corticosteroids are the mainstay. Generalized edema common. A positive Western blot in a child <18 months (presence of HIV antibodies) indicates only that the mother is infected. Two or more positive p24 antigen tests will confirm HIV in kids <18 months. The p24 can be used at any age. For HIV kids avoid OPV and Varicella vaccinations (live), but give Pneumococcal and influenza. MMR is avoided only if the kid is severely immunocompromised. Parents should wear gloves for care, not kiss kids on the mouth, and not share eating utensils. Hypotension and vasoconstricting meds may alter the accuracy of o2 sats. An antacid should be given to a mechanically ventilated patient w/ an ng tube if the ph of the aspirate is <5.0. Aspirate should be checked at least every 12 hrs. Ambient air (room air) contains 21% oxygen. The first sign of ARDS is increased respirations. Later comes dyspnea, retractions, air hunger, cyanosis. Normal PCWP (pulm capillary wedge pressure) is 8-13. Readings of 18-20 are considered high. First sign of PE is sudden chest pain, followed by dyspnea and tachypnea. High potassium is expected with carbon dioxide narcosis (hydrogen floods the cell forcing potassium out). Carbon dioxide narcosis causes increased intracranial pressure. Pulmonary sarcoidosis leads to right sided heart failure. An NG tube can be irrigated with cola, and should be taught to family when a client is going home with an NG tube. Digitalis increases ventricular irritability, and could convert a rhythm to v-fib following cardioversion. If your normally lucid patient starts seeing bugs you better check his respiratory status first. The first sign of hypoxia is restlessness, followed by agitation, and things go downhill from there all the way to delirium, hallucinations, and coma. So check the o2 stat, and get abg’s if possible. The biggest concern with cold stress and the newborn is respiratory distress. Look carefully when you have no idea. In a word like rhabdomyosarcoma you can easily ascertain 32 it has something to do with muscle (myo) cancer (sarcoma). The same thing goes for drug names. For example, if it ends in –ide it’s probably a diuretic, as in Furosemide, and Amyloride. Lasix can cause a patient to lose his appetite (anorexia) due to reduced potassium. If your laboring mom’s water breaks and she is any minus station you better know there is a risk of prolapsed cord. In a five-year old breathe once for every 5 compressions doing cpr. After g-tube placement the stomach contents are drained by gravity for 24 hours before it can be used for feedings. Cephalhematoma (caput succinidanium) resolves on its own in a few days. This is the type of edema that crosses the suture lines. During the acute stage of Hep-A gown and gloves are required. In the convalescent stage it is no longer contagious. Low magnesium and high creatinine signal renal failure. Pain is usually the highest priority with RA If a TB patient is unable/unwilling to comply with tx they may need supervision (direct observation). TB is a public health risk. Level of consciousness is the most important assessment parameter with status epilepticus. Crackles suggest pneumonia, which is likely to be accompanied by hypoxia, which would manifest itself as mental confusion, etc. Can’t cough=ineffective airway clearance Absence of menstruation leads to osteoporosis in the anorexic. Toddlers need to express autonomy (independence) A patient with a low hemoglobin and/or hematocrit should be evaluated for signs of bleeding, such as dark stools. A laxative is given the night before an IVP in order to better visualize the organs. A patient with liver cirrhosis and edema may ambulate, then sit with legs elevated to try to mobilize the edema. Managing stress in a patient with adrenal insufficiency (Addison’s) is paramount, because if the adrenal glands are stressed further it could result in Addisonian crisis. While we’re on Addison’s, remember blood pressure is the most important assessment parameter, as it causes severe hypotension. After pain relief, cough and deep breathe is important in pancreatitis, because of fluid pushing up in the diaphragm. Safety over Nutrition with a severely depressed client. 33 Prolonged hypoxemia is a likely cause of cardiac arrest in a child. Fluid volume overload caused by IVC fluids infusing too quickly (or whatever reason) and CHF can cause an S3 Coarctation of the aorta causes increased blood flow and bounding pulses in the arms A newly diagnosed hypertension patient should have BP assessed in both arms Depression often manifests itself in somatic ways, such as psychomotor retardation, gi complaints, and pain. Respiratory problems are the chief concern with CF speaking of TB... PPD is positive if area of induration is: >5 mm in an immunocompromised patient >10 mm in a normal patient >15 mm in a patient who lives in an area where TB is very rare. another tiP: HbA1c - test to assess how well blood sugars have been controlled over the past 90-120 days. 46 corresponds to a blood sugar of 70-110; 7 is ideal for a diabetic and corresponds to a blood sugar of 130. BSA is considered the most accurate method for medication dosing with kids. (I though it was weight, but apparently not) Place a wheelchair parallel to the bed on the side of weakness If one nurse discovers another nurse has made a mistake it is always appropriate to speak to her before going to management. If the situation persists, then take it higher. Sepsis and anaphylaxis (along with the obvious hemorrhaging) reduce circulating volume by way of increased capillary permeability, which leads to reduced preload (volume in the left ventricle at the end of diastole). This is a toughie…think about it. Amniotic fluid is alkaline, and turns nitrazine paper blue. Urine and normal vaginal discharge are acidic, and turn it pink. Gonorrhea is a reportable disease Remember the phrase “step up” when picturing a person going up stairs with crutches. The good leg goes up first, followed by the crutches and the bad leg. The opposite happens going down. The crutches go first, followed by the good leg. While treating DKA, bringing the glucose down too far and too fast can result in increased intracranial pressure d/t water being pulled into the CSF. Polyuria is common with the hypercalcemia caused by hyperparathyroidism. Remember the action of vasopressin because it sounds like “press in”, or vasoconstrict. Water intoxication will be evidenced by drowsiness and altered mental status in a patient with TUR syndrome, or as an adverse reaction to desmopressin (for diabetes insipidus). Burning sensation in the mouth, and brassy taste are adverse reactions to Lugol solution (for 34 hyperthyroid). Report it to the doc. Give synthroid on an empty stomach Extra insulin may be needed for a patient taking Prednisone (remember, steroids cause increased glucose). Nonfat milk reduces reflux by increasing lower esophageal sphincter pressure Patients with GERD should lay on their left side with the HOB elevated 30 degrees. Unusual positional tip - Low-fowlers recommended during meals to prevent dumping syndrome. Limit fluids while eating. In emphysema the stimulus to breathe is low PO2, not increased PCO2 like the rest of us, so don’t slam them with oxygen. Encourage pursed-lip breathing which promotes CO2 elimination, encourage up to 3000mL/day fluids, high-fowlers and leaning forward. Theophylline causes GI upset, give with food TB drugs are liver toxic. (Does your patient have hepB?) An adverse reaction is peripheral neuropathy. 35