NCLEX PN Notes 1 Flashcards
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.
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)
Tube Feeding w/ Decreased LOC –>
position pt on right side (promotes emptying of the stomach) with the HOB elevated (to prevent aspiration)
During Epidural Puncture –>
side-lying
After Lumbar Puncture (and also oil-based Myelogram)–>
pt lies in flat supine (to prevent headache and leaking of CSF)
Pt w/ Heat Stroke –>
lie flat w/ legs elevated
During Continuous Bladder Irrigation (CBI) –>
catheter is taped to thigh so leg should be kept straight. No other positioning restrictions.
After Myringotomy –>
position on side of affected ear after surgery (allows drainage of secretions)
After Cataract Surgery –>
pt will sleep on unaffected side with a night shield for 1-4 weeks.
After Thyroidectomy –>
low or semi-Fowler’s, support head, neck and shoulders.
Infant w/ Spina Bifida –>
position prone (on abdomen) so that sac does not rupture
Buck’s Traction (skin traction) –>
elevate foot of bed for counter-traction
After Total Hip Replacement –>
don’t sleep on operated side, don’t flex hip more than 45- 60 degrees, don’t elevate HOB more than 45 degrees. Maintain hip abduction by separating thighs with pillows.
Prolapsed Cord –>
knee-chest position or Trendelenburg
Infant w/ Cleft Lip –>
position on back or in infant seat to prevent trauma to suture line. While feeding, hold in upright position.
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)
Above Knee Amputation –>
elevate for first 24 hours on pillow, position prone daily to provide for hip extension.
Below Knee Amputation –>
foot of bed elevated for first 24 hours, position prone daily to provide for hip extension.
Detached Retina –>
area of detachment should be in the dependent position
Administration of Enema –>
position pt in left side-lying (Sim’s) with knee flexed
After Supratentorial Surgery (incision behind hairline) –>
elevate HOB 30-45 degrees
After Infratentorial Surgery (incision at nape of neck)–>
position pt flat and lateral on either side.
During Internal Radiation –>
on bedrest while implant in place
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.
Shock –>
bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified Trendelenburg)
Head Injury –>
elevate HOB 30 degrees to decrease intracranial pressure
Peritoneal Dialysis when Outflow is Inadequate –>
turn pt from side to side BEFORE
checking for kinks in tubing (according to Kaplan)
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)
worsens with exercise and improves with rest.
Myasthenia Gravis:
a positive reaction to Tensilon–will improve symptoms
Myasthenia Crisis:
caused by excessive medication-stop med-giving Tensilon will make it worse
Cholinergic Crisis:
Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use filter needle
Head injury medication:
Prior to a liver biospy
its important to be aware of the lab result for prothrombin time
Demorol for pancreatitis,
NOT morphine sulfate
From the a** (diarrhea) =
metabolic acidosis
From the mouth (vomitus) =
metabolic alkalosis
slowed physical and mental function, sensitivity to cold, dry skin and hair
Myxedema/hypothyroidism:
accelerated physical and mental function; sensitivity to heat, fine/soft hair
Graves’ disease/hyperthyroidism:
increased temp, pulse and HTN
Thyroid storm:
semi-Fowler’s, prevent ncek flexion/hyperextension, trach at bedside
Post-thyroidectomy:
CATS – convulsions, arrhythmias, tetany, spasms, stridor (decreased calcium), high Ca, low phosphorus diet
Hypo-parathyroid:
fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium), low Ca, high phosphorus diet
Hyper-parathyroid:
– incrased temp, rapid/weak pulse, increase respiration, hypotension, anxiety, urine specific gravity >1.030
Hypovolemia
– bounding pulse, SOB, dyspnea, rares/crackles, peripheral edema, HTN, urine specific gravity <1.010; Semi-Fowler’s
Hypervolemia
excessive urine output and thirst, dehydration, weakness, administer Pitressin
Diabetes Insipidus (decreased ADH):
change in LOC, decreased deep tendon reflexes, tachycardia, n/v/a, HA; administer Declomycin, diuretics
SIADH (increased ADH):
muscle ewakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges, beans, potatoes, carrots, celery)
Hypokalemia:
MURDER – muscle weakness, urine (oliguria/anuria), respiratory depression, decreased cardiac contractility, ECG changes, reflexes
Hyperkalemia:
nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic diuretics, fluids
Hyponatremia:
increased temp, weakness, disorientation/delusions, hypotension, tachycardia; hypotonic solution
Hypernatremia:
CATS – convulsions, arrhythmias, tetany, spasms and stridor
Hypocalcemia:
muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, sedative effect on CNS
Hypercalcemia:
tremors, tetany, seizures, dyrshythmias, depression, confusion, dysphagia; dig toxicity
HypoMg:
depresses the CNS, hypotension, facial flushing, muscle ewakness, absent deep tendon reflexes, shallow respirations, emergency
HyperMg:
hypoNa, hyperK, hypoglycemia, dark pigmentation, decreased resistance to stress, fractures, alopecia, weight loss, GI distress
Addison’s:
hyperNa, hypoK, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump
Cushings:
n/v, confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP
Addisonian crisis:
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
Pheochromocytoma:
