o Calcium has an inverse relation to phosphorus

 When Calcium goes up, Phosphorus goes down

(Hypophosphatemia) and vice versa
o Sodium has an inverse relation to Potassium
 When sodium goes up, Potassium goes down
and vice versa

 HyperParathyroidsm = HYPERCALCEMIA = HYPOPHOSPATEMIA

Every time you see Hyperparathyroidism that’s the same exact thing as
Hypercalcemia

o Epinephrine is secreted – vasoconstrictor

When Hypovolemic (blood volume deficit), ADH and aldosterone will be secreted so keep
blood volume up

**Weight is the best indicator for fluid status EXCEPT for Burns, Its Urine Output**

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 ventilator or in pt. airway cuff, pt. stops
spontaneous breathing

To remember blood sugar:

hot and dry-sugar high (hyperglycemia)
cold and clammy-need some candy (hypoglycemia)

Eu = Normal for example: Euthyroid is normal thyroid

Increase of LDL, THINK Coronary Artery Disease

Increase secretion of PTH makes serum calcium go up

Decrease secretion of PTH makes serum calcium go down

You dangle artery problems and you elevate vein issue

problems
IMPORTANT

WHEN IT ASKS FOR PRIOIRTY, ASK YOURSELF YOURE

GOING TO DO THAT OVER AND OVER AGAIN AND
NOTHING ELSE  EXAMPLE: client is hemorrhaging, do you check for
vital signs or call the HCP
 Hypervolemia: Too much fluid in the vascular space (too much water in the hose)

Will Cause: HF  Weak Heart  low Cardiac output  Low Urine Perfusion  Low
Urine Output
Heart Failure
Renal Failure

S/S: Bounding Pulse

SOB; Dyspnea
Crackles/ wet lung sounds (listen to the low area in the back)
Distended Neck (JVD) and Peripheral Veins
Peripheral Edema (sacrum area) and Third spacing
Rapid Weight gain
Low urine output (specific gravity of 1.010 or less)

Central Venous Pressure (CVP): More volume (Hypervolemia) = More Pressure

CVP normal is 2-8 Low volume (Hypovolemia) = Low Pressure

Position: Semi Fowler; BED REST FOR THESE PATIENTS (hyper & Hypo)

Diet: Hypertension, heart failure, CAD—low sodium, calorie-restricted, Low fat

Treatment: Hydrochlorothiazide: Will make you lose Potassium

Furosemide: Will make you lose Potassium
Bumetanide: Will make you lose Potassium
 Give SPIRONOLACTONE to retain Potassium but watch for
Hyperkalemia
o KEEP CLIENT ON BED REST (helps reduce sodium and water)

Teaching: Check Daily weights and Input and Output

***clients with History of HF and Kidney, give fluids slow and

watch for Hypervolemia***
 HYPOVOLEMIA: Fluid not in the vascular space  SHOCK
(COLD AND CLAMMY)
Look for Hypovolemia in (anything that causes losing fluid):
Trauma
SURGERY patients
NG tube
Paracentesis  you losing fluid
Vomiting and diarrhea
Ascites: fluid in the abdomen;
Edema: Fluid in the wrong spot so check for Hypovolemia
Polyuria: Fluid in the wrong spot so check for Hypovolemia

Will Cause: Third spacing: When fluid goes somewhere else other than
Other than the vascular space
Ascites: fluid in the abdomen  People with liver Disease will have this
Edema
Polyuria: When you see this, THINK Shock First

** When you go into HYPOVOLEMIC STATE (Hemorrhage, vomiting, or

anything that causes you to lose water), the ALDOSTERONE hormone
secretion will increase to preserve/retain sodium and water***

S/S: Increased temp

Decreased skin Turgor
Low mucous
COLD AND CLAMMY
Rapid/weak/thready pulse,
High pulse (tachycardic) and Tachypnea
Increased Respirations
Hypotension (Orthostatic/postural mainly)
Anxiety,
weight loss
Decreased Urine output
Urine specific gravity >1.030
Low CVP pressure
Vessels are vasoconstricted
 *Concentrated makes labs go up like hematocrit and dilute makes it go down*

Position/Nursing Intervention for SHOCK: THINK DIZZINISS

Bedrest with extremities elevated 20 degrees
Knees straight
Head slightly elevated (modified Trendelenburg)

Treatment: Give Fluids

Safety precautions (high risk for falls)
Monitor IV fluids (weight check and I and O)

TYPES OF IV FLUIDS

ISOTONIC (0.9%)

- *D5W
- Normal Saline
- Lactated Ringers
- D5 ¼ NS (used for Peds)

**Contraindicated: Hypertensive, Renal, and heart disease**

HYPOTONIC SOLUTION (0.33%)

- D2.5W
- ½ NS OR 0.33 NS

***Use for: Hypertension, Heart problem, Renal Disease***

**Watch for Cellular Edema**

Hypertonic Solution (TPN):

- D10W, 3% NS, 5% NS
- D5 LR, D1/2 NS, D5NS
- **TPN (most common)
- Albumin

**Watch for pulmonary edema, Fluid volume excess, Hypertension**

Aldosterone = Steroids aka Mineralocorticoids retains sodium and water

Cushing’s Syndrome: Too much Aldosterone (steroids)

Hyperaldosteronism (Conn’s Syndrome): Too much Aldosterone (steroids)

S/S: HyperNa: If you are obese, you have to much sodium

HypoK
Hyperglycemia,
Prone to infection,
Muscle wasting; weakness,
Edema; Obesity
HTN,
Hirsutism,
Moon face
Buffalo hump

Diet: Low sodium, High potassium diet.

Increase protein, Increase Calcium

***Cushing: Everything is High Except Potassium***

CLIENT NEEDS QUITE ROOM

Risk for osteoporosis

Protein means kidney damage

Glucose and ketones are for long term use which will show in urine sample

Uric acid is kidney stones

 ADDison disease is ABSENT of steroids.  think of a
bodybuilder who’s on steroids, he’s very big vs the other guy who is
not taking steroids. He will be SMALL, AND WEAK AND TAN

With Addison disease, they have Absent of steroids meaning

LOW so everything will be LOW except 2 things
LOW BP (CRITICAL)  Shock
LOW weight (water loss)
LOW sodium (hyponatremia)
LOW glucose (Hypoglycemia)
LOW or slow periods (amenorrhea)
LOW resistance to stress
Fractures
Alopecia
Weight loss
GI distress

HIGH Potassium (hyperKalemia)

HIGH pigmentation “Bronze Pigment”  don’t get this
confused with the Acanthosis nigricans

Loss of libido and decreased axillary and pubic hair are common in
Addison's disease due to lower levels of androgens.

Diet: Increased sodium, low potassium diet.

Addisonian Crisis: N/V
Confusion
Abdominal pain
Extreme weakness
Hypoglycemia
Dehydration
Decreased BP

- Treatment: Meds:  NEVER STOP TAKING MEDS ABRUPTLY

 Prednisolone: 2x a day in split days
 Fluicosteriods: this is Aldosterone
SIADH: too much ADH  potential complication of head injury

Syndrome of inappropriate antidiuretic hormone (SIADH) is potential

complication of head injury or Pituitary (located right through the
bridge of the nose so any nose/sinus injury can also be it too) or a
TRANSSPHENOIDAL HYPOPHYSCEMETY and INTERCRANIAL
PRESSURE. In SIADH, the extra ADH leads to excessive water
absorption by the kidneys.

IF YOU HAVE ICP, ABSERVE FOR ADH PROBLEMS

DO NO GIVE YOUR PATIENT FLUIDS IF THEY HAVE SIADH.  KEEP THEM ON FLUID
RESTRICTIONS

S/S OF SIADH:
Low urine output (cuz their brain is absorbing it all so no point in
giving them more unless you tryna kill your patient!! HAH ROT IN JAIL)
Increased urine gravity
Decrease in urine osmolality (if one is increased the other one is
obviously decreased Ex: high urine output so low urine osmolality)
BASICALLY REMEMBER OPPOSITES ATTRACT
- ALSO WILL BE HYPONATERMIA!!
- Changes in LOC
- Decreased deep Tendon Reflexes
- Tachycardia
- N/V
-
 Side note: all these are bullshit, just know SIADH has to do with LOW URINE OUTPUT
which obviously means Increase in urine gravity
o The higher the urine output, the lower urine gravity
o The lower the urine output, the higher urine gravity

Treatment: Administer Desmopressin

Diuretics
Declomycin

Lab work: Urine specific Gravity

Sodium
Hematocrit
SIADH: causes include central nervous system disorders (eg, stroke,
trauma, neurosurgery) and some commonly used medications (eg,
desmopressin, carbamazepine
Diabetes insipidus (DI): think D for dehydrated so they are Dry Inside  Diabetes Insipidus
R N
Y S
I
***WHEN YOU SEE DI, REMEMBER D FOR DIURESES*** D
E
 High Urine Output (because they are peeing everything
out, so they are dry inside)
 Low urine gravity which automatically means they’ll have
high osmolality
 HyperNatremia  this goes with the High Osmolality, if
you have high osmolality, you’ll have high sodium and vice
versa
 Polydipsia aka DIURESIS (since they are dry inside, they’ll
be thirsty
 Dry mucous membranes CUZ they DRY INSIDE DUHH!
 HYPOTENSION REMEMBER CARDIAC, when you have a
low fluid inside, you turn HYPOTENSIVE  SHOCK
 DESMOPRESSION AKA VASOPRESSIN gets your BP up AND
decreases Urine output  can cause deadly headaches
because it also decreases sodium

***BIGGEST COMPLICATION IS SHOCK FOR DI***

TREATMENT: Any Med with -RESSIN (desmopressin, Pitressin)

 Hyper Magnesium and Hyper Calcium: Think Act like Sedatives
Everything goes Down!!!
Magnesium: normal: 1.5-2.5 mEq/L

HYPER magnesium: Excreted through Kidneys and GI

- Causes of Hyper magnesium:

 Kidney Failure  if you can’t excrete it, then it will cause this
 Antacids  has too much magnesium

 S/S: (vasodilation) ----- Hyper Magnesia: will make everything go down

o Depresses the CNS/ LOC
o Hypotension
o Facial flushing/warmth  vasodilation
o Muscle weakness
o Absent deep tendon reflexes
o Shallow/Decreased respirations
o Arrhythmias
o Emergency

** Sometimes Magnesium is given to Preeclampsia patients to

prevent seizures because magnesium relaxes everything**

 Treatment:
o Ventilator if O2 is >10 breathe
o Dialysis: kidneys not working
o Calcium Gluconate  antidote
o Safety precautions:

HYPERCalcemia:

 Causes of Hypercalcemia:
 Too much PTH (parathyroid Hormone)
 Thiazides: makes you retain calcium
 Immobilization: If you’re immobile, calcium goes into the blood
which makes PTH go up
  ^Intervention: client must be weight bearing and mobile
 S/S: (same s/s as hyper magnesium but these 2 added)
o Brittle Bones
o Kidney Stones

 Treatment:
o Move
o Fluids – To prevent Kidney stones
o Increase Phosphorus (diet)  Calcium has an inverse
relation to phosphorus
o Steroids: decreases calcium levels so increase in steroids
o Safety precautions

 Meds:
o Biphosphate – Adrenalin and Calcitonin
 Calcitonin treats osteoporosis

Hypo Magnesium and Hypo Calcium: Not enough Sedatives

Everything goes Down!!!

HYPO magnesium: Excreted through Kidneys and GI

- Causes of Hypo magnesium:

 Diarrhea
 Alcoholic – Suppresses the release of ADH so Decrease of ADH
mean client will Diuresis (Urinate more) more

- S/S: (not sedated so everything down)

o Rigid and tight muscles
o Possible seizures
o Stridor/ Laryngospasm and Tetany (spasms of the hands and feet,
cramps, spasm of the voice box (larynx))
o POSTIVIE CHVOSETK’S (hyper irritability) AND TROUSSEAU
o Arrythmias
o Increase deep tendon reflex
 o Mind changes (wild, see things, depression, etc)
o Swallowing problems (dysphagia)
- Treatment:
o Give Magnesium
 Check kidney function before giving IV Mg

 Diet: High in Mg (Remember Vegetables , seeds, and peppermint)

o Spinach
o Greens
o Squash
o Broccoli
o Halibut
o Turnip
o Pumpkin seeds
o Peppermint
o Cucumber
o Green beans
o Celery
o Kale
o Sunflower seeds
o Sesame seeds
o Flax seeds

HYPOCalcemia:

 Causes of Hypocalcemia:
 Not enough Parathyroid Hormone (PTH) 
Hypoparathyroidism
 Radical Neck
 Thyroidectomy

 S/S: SAME AS HYPOMAGNESIUM

o Rigid and tight muscles
o Possible seizures
 o Stridor/ Laryngospasm and Tetany (spasms of the hands and feet,
cramps, spasm of the voice box (larynx))
o POSTIVIE CHVOSETK’S (hyper irritability) AND TROUSSEAU
o Arrythmias
o Increase deep tendon reflex
o Mind changes (wild, see things, depression, etc)
o Swallowing problems (dysphagia)

 Treatment:
o Give Calcium: Make sure client has heart monitor on when giving calcium
 Give IV calcium slowly b/c too fast will cause widened QRS
aka Arrythmias
o Vitamin D: This Utilizes the calcium for better absorption
o Phosphate binders to excrete phosphate: Calcium acetate
(hydrochloride)

 Diet:
o Decrease in Phosphate foods

Sodium: Think Neuro changes!!!

Hypernatremia: Dehydration

 Causes of HyperNatremia: Think what causes Dehydration

 Hyperventilation: When you exhale too much, you lose water
 Heat stroke
 DI
 Vomiting
 Diarrhea

 S/S:
o Thirsty
o Dehydration
o Swollen Tongue
o Neuro Changes (disorientation/delusions)
o Increased temp
 o Weakness
o Hypotension
o Tachycardia

 Treatment:
 Restrict Sodium
 IV fluids (Hypotonic Solutions)
 DAILY WEIGHTS AND I&O
 Lab work

***Clients on Tube feedings, Check Sodium levels***

HYPO Natremia: Too much water and not enough sodium

 Causes of HypoNatermia:
 Psychogenic polydipsia (drinking too much water)
 Too much water
 SIADH

 S/S:
o Headache
o Seizures
o Coma
o Nausea
o Muscle cramps
o Increased ICP; Hypertension
o Muscular twitching

 Treatment:
 Not water, but give Sodium (Hypertonic Solution)
 3% NS or 5% NS

Potassium: Excreted by kidney

HyperKalemia: Excreted by Kidney

  Causes of HyperKalemia:
 Kidney Trouble
 Drugs such as Spironolactone

 S/S: Early to Late (severe) sign -Mnemonic is (FMURDER)

o Muscle Weakness and twitching
o Flaccid Paralysis
o Urine (oliguria/anuria)
o Respiratory depression
o Decreased cardiac contractility
o ECG changes
o Reflexes

 Treatment:
o Dialysis: Kidneys not working
o Calcium Gluconate
o Glucose and insulin  Watch for Hypokalemia and Hypoglycemia
o Sodium Polystyrene (kayexalate)  used only for clients who are
hyperkalemic ONLY
  given as enema
o Push Fluids

HypoKalemia:

 Causes of HypoKalemia  They are all losing potassium

 NG Suction
 Vomiting
 Diuretics
 Not eating

 S/S: Early to Severe

o Muscle Cramps
o Muscle Weakness
o Arrhythmias
  Treatment:
o Give potassium Spironolactone
o Increase K Foods
 Raisins
 Bananas
 Apricots
 Oranges
 Beans
 Potatoes
 Carrots
 Celery

 Safety Issues with Potassium:

o Oral Potassium causes GI upsets – Give with foods
o **Assess Urinary Output before/during IV Potassium**
o Always put IV Potassium on a Pump
o Mix well
o Never give potassium PUSH
o Burns during infusion? Yes, very common

Acid/ Base Solution (Listen to MARK!!)

From the a** (diarrhea)= metabolic acidosis

From the mouth (vomitus)=metabolic alkalosis

s
 Burns:

 Safety Considerations:

o Electrical sockets covered

o Smoke alarm
o Heating elements: Only one heating element per socket
o Dryers
o Practice escape plan
o Pot handles
o Stove attached to walls
o No tablecloths if toddlers present
o Watch for small appliances (iron)
o Water heater <120 F*  Elderly with neuropathy: use Antiscald devices with
devices with showerheads and faucet fixtures

 S/S: They can go in SHOCK  HYPOTENSION: vessels are leaking

o Hypotension  SHOCK
o Tachycardia
o Hypothermia
o Low hemoglobin
o Low urine Output: volume deficit so low urine output
o Low kidney perfusion: kidneys aren’t working properly OR needs to hold water
o Epinephrine is secreted – vasoconstrictor
o ADH and aldosterone are secreted: Will make blood volume go up

 Rule of nine
o Head = 9%
o Each arm = 9%
o Each Leg = 18%
o Stomach = 18%
o Back = 18%
o Genitals = 1%

 BURNS
o 1st Degree - Red and Painful
o 2nd Degree – Blisters
o 3rd Degree - No Pain because of blocked and burned nerves

 Diet:
o high protein
 o high caloric,
o Increase in Vitamin C

 Treatment:
o Fluid replacement: 2 large bore IVs  Lactated ringers or Albumin
(colloids)…. Give half of fluid for the first 8 hrs, The remaining half is given
over the next 16 hrs.
o Oxygen
o Make sure to time what time the burn occurred

 Management:
o Wrap client in blanket  Helps with hypothermia
o Cool Water: No more than 10 min – NO ICE
o Remove Jewelry
o Remove non-adherent clothing
o Do not remove stuck Clothes
o Inhalation injury  Give 100% oxygen b/c low hemoglobin
o Intubate if airway is compromised

**Weight is the best indicator for fluid status EXCEPT for Burns, Its Urine Output**

 Immunizations:
o Tetanus  If client doesn’t know he had it, give Immunoglobulin
  Oncology: KNOW ALL THESE!!

 Risk Factors:
 Tobacco and alcohol
 Obesity
 Low fiber diet: you retain more carcinogens
 Increased red meat consumption
 Increased animal fat
 Nitrates: processed sandwich meats. Salt cured or smoke meats
 Preservatives and additives
 Aging
 African Americans
 Radiation
 Stress
 Chronic Irritations  GERD
 History

 Diet:
o High fiber: Increase in fruits
o High Calorie
o High Protein

 Cancer  Primary Prevention: Teaching

o No smoking
o Exercise
o Lose weight
o Vaccines – Heb B, and HPV
o Wear sunscreen, and avoid sun, and secondhand smoking

 Secondary Prevention  Screening

 Tertiary Prevention  Treatment (support group and Rehab)

o
 The warning signs of cancer can be remembered with
the acronym CAUTION:

 Change in bowel or bladder habits

 A sore that does not heal
 Unusual bleeding or discharge from a body
orifice
 Thickening or a lump in the breast or elsewhere
 Indigestion or difficulty in swallowing
 Obvious change in a wart or mole
 Nagging cough or hoarseness

 Bone Marrow cancer leads to

 Anemia: Low RBC (hypotension) and Hypoxic; increase in
pulse (Tachycardic)
 Leukopenia
 Thrombocytopenia

 Blood Tests:
o CBC & differentials  Monitor Neutrophils
o Liver Enzymes  AST & ALT monitor closely
o Tumor markers  Substance that increase in the urine, blood, or
bloody tissue bio markers

 Treatment:
o Trach 
 When changing the string, you have to hold onto the
trach
 If Trach falls out, You CAN reinsert the dirty trach
back in
o Total Laryngectomy: Removal of Epiglottis, vocal cords and Thyroid cartilage)
 Will have permanent Tracheostomy so
suction frequently
 Post op care for Total Laryngectomy:
o NG feedings
o Monitor drains
o Watch for carotid artery rupture (Hemorrhage)
o Provide frequent mouth care
o NO SWIMMING
o Cannot whistle or drink from a straw
 o When client gets discharged, they will have a
protective Bib to cover the trach
 NO PLASTIC BIB
 No cloth fibers
 No powder: it will irritate it
 Humidifier is good

 Can not whistle or drink from a straw

*** CALL HCP IF PATIENT HAS HEMOORHAGE, DON’T PICK VITAL

SIGNS FOR PRIORITY***

 Mastectomy post op care:

o Check back of draining: blood Pooling can occur into the tissues
o Abdominal surgical site: if own skin has been used
o Check Hemovac or Jackson pitt drains:
 Hemovac- Used after mastectomy,
o Empty when full or q8hr,
o Remove plug, empty contents,
o Place on flat surface,
o Cleanse opening and plug with alcohol sponge
o compress evacuator completely to remove air
o Release plug,
o Check system for operation

 Nursing care for Mastectomy:

o Stay away from the arm that is affected side forever
o No constriction
 No BP cuffs
 No elastic
 No watch
 No pulse
 No nail biting
 No injections
 Wear gloves when gardening
 Watch for cuts
 No IV
o
 CAN DO: USE WITH AFFECTED SIDES
o Brush hair
o Squeeze tennis balls
o Wall climbing
o Flexing and extending the elbow

 Treatment: Radiation therapy

 Nursing assignment should be
rotated daily so same nurse isn’t
getting radiation everyday
 One client per shift  no pregnant
nurse can be assigned

o Hazards to others for 24-48 hrs

 Short visits
 Distance should be as far as possible
 Wear lead shield (shielding)
o Precautions:
 Private room
 Film badge at all times
 Restrict visitors – limit 30 min/day per visitor and 6ft away
 No pregnant visitors or less than 16 yrs of age or nurses
 Mark the room for isotope (radiation room)
 Wear gloves

 Radiation dislodgment device: (DURING)

o Keep bed rest
o Low fiber diet
o Prevent bladder distension – will have indwelling
catheter to prevent bladder distention

 IF DISLODGES:
 Wear gloves
 Pick it up with forceps
 Place in lead lined container (YELLOW containers)
 Call the radiation people to grab it
  Post-op:
o Do not share bed for 1-11 days
o No public transport
o Stay away from children for 3 days
o No work immediately
o No sharing or cooking
o When flushing, close the lid and flush 2-3 times

 Chemotherapy precautions: This is also for body fluids excretion!!

 Wear coated chemotherapy gown (change if gown is
contaminated)
 2 pairs of chemotherapy gloves (NO LATEX)
 Goggles
 Mask if splash or inhalation can occur
o TEACH FAMILY ABOUT WEARING THESE IF FLUID
EXCRETIONS ARE INVOLVED!!! EXCRETIONS CAN LAST 3-7
DAYS

*If chemo spills, what to do?

1. Wash Hands
2. Get the spill kit
3. Wear respirator so you don’t inhale
4. Wear chemo gown
5. 2 set of gloves
6. Wear goggles
7. Use absorbent pads to wipe up spills

**Vesicant drugs should be given through PICC line so it doesn’t infiltrate

(extravasation)**
IF extravasation happens: S/S is PAIN
 Stop the infusion
 Get the extravasation kit
 Stay with the client

 Side effects of chemo drugs:

o GI:
 Nausea and vomiting: antiemetics meds (Ondansetron) given for
the first week to help with this or herbal stuff: ginger, acupuncture
 Stomatitis: diarrhea included: watch out for fluid and
electrolyte imbalance and nutrient deficiency
 o Integumentary System:
 Alopecia (hair loss)
 Mastectomy
 Scar tissue

o Hematopoietic system:
 Low RBC, WBC, and platelet: watch for infection, anemia,
and bleeding

Other general side effects include:

 Fatigue
 Pain: give opioids
o Side effect of opioid is
constipation so give stool
softeners

 Complications:
o Low neutrophils (best indicator for infection)
 Neutropenic clients:
 No live vaccines
 No Fresh fruits/vegetable,
 No milk
 No flowers
 DVT b/c prolonged bed rest
 DVT can delvelop into PE
 Thrombocytopenia: Decrease of platelets
 Avoid: (NSAID)
o Aspirin
o Clopidogrel
o Heparin
o warfarin
o
 Endocrine:

Thryoid gives you energy

Thyroid: produces 3 hormones: T3, T4, Calcitonin

Calcitonin decreases calcium levels.

Calcitonin if given with med can decrease Osteoporosis

You need Iodine to make all these 3 hormones

 Graves’ Disease: Hyperthyroidism

o Attention Span Decreases
o Appetite up
o Weight decrease
o Arrythmias
o Sweating and hot
o Heat tolerance and soft hair
o Exophthalmos (bulging eyes)
o Diarrhea and increased bowel sounds
o BP and Pulse increase (Arrythmias and palpatations)

o Diagnosis:
o Increase in T3 and T4
o TSH will decrease
o Thyroid scan:
 CLIENT MUST STOP ANY IODINE MED ONE
WEEK BEFORE THIS TEST.
 Must wait 6 weeks to start any iodine med after test
o Ultrasound
o CT and MRI

 Treatment: Med
o Methimazole (stops making thyroids)  also used in preop to stop
the thyroids from making more
 o Iodine Compounds (Potassium Iodine solutions, and SSKI):
decreases the size and vascularity of the gland BASICALLY it will
decrease them from bleeding… Give these meds in milk, juice and
USE A STRAW
o Beta Blockers: helps with the symptoms only like BP ALSO
DECREASES ANXIETY
 DIABETIC AND ASTHMA PATIENTS SHOULD NOT BE
TAKING THIS

** BETA BLOCKERS DECREASE HEART RATE AND BP SO YOU WILL

NOT GIVE PEOPLE THIS IF THE HEART RATE IS LOW**

**Euthyroid= Normal**

 Curative Procedure:
o Radioactive iodine therapy: Destroys the thyroid cells so you will
become Hypothyroid (THIS IS EXPECTED)
 STAY AWY FROM BABIES
 DON’T KISS PEOPLE FOR ONE WEEK

ANYBODY WHO HAS THYROID ISSUE CAN GO TO A THYROID

STORM AT ANYTIME

Thyrotoxicosis (THYROID STORM) (eg, fever, chills, tachycardia),

including small rises in body temperature

 Surgery: thyroidectomy
o Post op care:
 HEMORRHAGE  S/S:
o Report any feelings of pressure
on the neck
o Check for bleeding or swelling
behind the neck and at the
incision sites for pooling

 Assess for Laryngeal damage by listening for an increase

HOARNESS OR WEAK VOICE: can lead to vocal paralysis
  Keep Trach at bedside: for possibility of hypocalcemia 
Assess for parathyroid removal (serum calcium will go down)
so look for s/s of hypocalcemia (not sedated)

 Support the neck by using pillows and put personal items

close to them

 Elevate HOB to decrease Edema

 Thyroidectomy: Biggest thing is risk for Hypocalcemia…. facial or

extremity numbness or tingling, stridor, Trousseau and
Chvostek signs

Thyrotoxicosis (THYROID STORM) (eg, fever, chills, tachycardia),

including small rises in body temperature

 Position:
 Elevate HOB to decrease Edema

 Diet:
 Avoid spicy food for people with Hyperthyroidism
 MORE CALORIES b/c they are losing weight

 HYPO thyroidism/ Myxedema: everything is slow

People with hypothyroidism usually also have CORONARY ARTERY DISEASE

o S/S:
 No energy
 Dry skin and hair
 Slow and slurred speech
 Tired/sleepy
 Weight gain
 GI slow
 Cold intolerance
 Amenorrhea
  Diagnosis:
o Decreased T3 and T4
o Increased TSH

 Treatment: LIFELONG MED

o Levothyroxine: start from low dose b/c risk for MI
 HR and BP increase with this med so WATCH for Rhythm
changes and chest pain
 TAKE IT ON AN EMPTY STOMACH!!

 Parathyroid: Secretes PTH so Serum calcium will go up

 HyperParathyroidsm = HYPERCALCEMIA = HYPOPHOSPATEMIA

Every time you see Hyperparathyroidism that’s the same exact thing as
Hypercalcemia

o S/S:
 Serum Calcium is high
 Serum phosphorus is low
 Fatigue
 Muscle weakness
 Renal calculi,
 Back and joint pain

o Treatment:
 Partial Parathyroidectomy
o Look for S/S of HypoCalcemia

 Diet:
o High Protein
o Low Calcium
  HYPO Parathyroid: Every time you see HYPOparathyroidism that’s the
same exact thing as HYPOcalcemia

 S/S:
o Serum Calcium is low so think of s/s of Hypocalcium
o Serum Phosphorus High

 Treatment:
o IV calcium (Selvidmere, Calcium acetate)

 Pheochromocytoma: Benign tumors that secrete epi and nor epi 

Adrenal gland problem

Avoid palpating the abdomen with Pheochromocytoma because it will cause a

sudden outburst of epi and nor epi

o S/S:
 Persistent HTN
 Increased HR and have palpations
 Flushed and headaches (comes and goes)
 Hyperglycemia
 Diaphoresis
 Tremor
 Pounding Headaches

 Diagnosis:
o Catecholamine test
o VMA test: Vanilla will alter this test
o 24 hr urine test: throw away the first one and the keep the last

 Client teaching before the test

 Avoid stress
 Treatment:
 Frequent bathing and rest breaks
 Avoid cold and stimulating foods
 Surgery to remove tumor
Adrenal Cortex are steroids

Steroids puts a patient on high risk for infection

 4 major actions of steroids

o Changes mood – can cause depression, and insomnia
o Lowers/ Suppress the immune system and inflammatory response
o Makes glucose higher
o Breaks down fat

**NEVER STOP STERIODS ABRUPTLY**

With steroid medications, you increase if you have stress!!

 Mineral corticosteroids makes you retain Aldosterone (sodium and water)

 Also helps you lose Potassium
 Given to Addison Patients

 Diabetes Mellites: body starts breaking down fat and protein, When you
break down fat, you get ketones

Diabetes Lab values that are effected are fat and protein in the urine

 Type 1: Think MAC Kussmauls (Metabolic acidosis  kusmaals

respirations

 DKA = Hydrate them first no matter what

IF YOU SEE DKA, PICK DEHYDRATION  first thing you do is give normal saline

 Patients who go DKA, will be Hyperkalemic (potassium goes up) so make sure
to give them potassium even if their potassium levels are stable because you don’t want
it going down after giving them Insulin

Monitor: Hourly outputs

 ECG: because of the hypokalemia

Watch for HypoKalemia and hypoglycemia when giving them

insulin

 Type 2 Diabetes Mellitis: is usually Found by accident

 Diagnose:
o wound that won’t heal
o Repeated vaginal infections
o Acanthosis nigricans is a skin condition that occurs with
diabetes

 Treatment: Meds  oral or subQ

o Metformin: Discontinue if undergoing surgery or any radiologic
procedure (contrast (with dye) xray
o Can resume after 48 hrs. if kidney function is good and creatinine
is good

**Clients should eat when insulin is at its peak**

 Hypoglycemia:
o S/S:
 Cold & Clammy
 Confusion
 Shaky
 Headache
 Nervous
 Nausea
 Increased pulse and low BP
 Hunger

** When treating Hypoglycemia, DO NOT pick a food that’s high on fat, Pick
simple carbs like coke or juice** Then Eat complex carbs after recovering
NPH Peak (cloudy): 4-12 hrs
Duration: 16-24 hrs

Long Acting: Peak: no peak

Duration: 24 hrs

Detemir is a long-acting (basal) insulin

 Client Teaching
o Clients should have an A1C drawn every 3-6 months
o Increase insulin dose when sick  Illness= DKA
o Rotate sites
o Wear well fitting shoes
o Inspect feet everyday
o No harsh chemicals
o Infusion pumps are only used for Rapid acting insulin
 Gestational Diabetes
o Scan on 1st prenatal visit, then retest 24-28 weeks
o All moms ate 24-28 weeks

 Complications to baby if mom has GD:

 Increased birth weight

 Hypoglycemia
 Cardiac

Left ventricle = Cardiac Output

 Meds that affect (increase) HR and BP

 Beta blockers
 Calcium channel blockers
 Digoxin

 Meds that affect (increase) BP only:

 Furosemide
 Nitrates (nitroglycerin)
 Inotropes (dopamine,
 Ace inhibitors (enalprines)
 ARBS (losartan)

Atropine is AN agent used to increase heart rate in clients with

symptomatic bradycardic - ATROPINE (ANTI CHEOLNERGIC MEDS
CAN TREAT COPD AND OVERACIVE BLADDERS) Anything 50 and
below give atropine!!!
  Coronary Artery Disease: Decrease blood flow to the heart ..Angina or
CAD or any heart disease is also linked with ISCHEMIA 
meaning no oxygen so when YOU THINK HEART, also think
ISCHEMIA CAN HAPPEN  which can bring on temp pain and
pressure to the chest

o Treatment: Nitroglycerin
 Causes Venous and Arterial dilation (which is good)
 Have to take it every 5 min x (up to) 3 doses
 DO NOT SWALLOW NITRO
 KEEP IN DARK GLASS BOTTLE
 DO NOT MIX AND DO NOT OPEN FREQUENTLY
 KEEP IT DRY
 May burn or fizz in client’s mouth (normal and expected)
 Headache is normal and expected so don’t report
 Replace every 6 months and 2 years if it’s a spray

Nitroglycerin is used for chest pain

BUT can worsen hypotension and should be held. Other pain
medications (eg, morphine) may be given for chest pain if blood
pressure is low. (CONTRAINDICATED FOR PEOPLE WITH
HYPOTENSTION)

 Beta blockers – prevents angina NOT for angina attacks

 Drops BP, AND Pulse

 Calcium channel blockers- Prevention of angina

Digoxin: used in long-term treatment of heart failure.

When you are getting a cardiac test done, DO NOT take your cardiac
meds such as:
Nitrates (nitroglycerine or isosorbide)
Dipyridamole
Beta blockers
And DO NOT TAKE THEOPHYLINE: used for asthma or COPD

Over the counter meds increase BP not Decrease so if a client is having hypertensive and is
feeling dizziness, PLEASE DON’T ASKM if hes taking any OTC meds CUZ AGAIN those things
INCREEASE BP

o Patient education:
 Rest frequently and reduce stress
 Avoid overeating; LOSE weight
 Low fat and high fiber diet
 Avoid excess caffeine
 Wait 2 hours after eating to exercise
 Avoid extreme temperatures
 Stop smoking
 Lose weight
 AVOID ISOMETRIC EXERCISE (weight lifting)

o Diet:
 Low fat and high fiber diet
 low- sodium,
 calorie-restricted
  Avoid excess caffeine
o Procedure to Diagnose: Cardiac Catherization  dye excretes from kidney
 Pre- procedure:
 Ask if allergic to iodine or shellfish
 Check kidney function if poor renal function DON’T
give
 Give Acetylcysteine (mucomyst): protects the kidneys
 Will receive “hot shot” (dye) but called hot shot b/c
they will feel warm and flushed  this is for any dye-
based things
 PALPATATIONS are NORMAL
 Do baseline assessment

 Post procedure:
 Hold Glucophage meds for 48 hours
 Monitor vital signs
 Watch for hematoma or bleeding
 Assess extremity DISTAL to the puncture site
 Assess for 5 P’s:
 Pulselessness
 Pallor
 Pain
 Paralysis
 Paresthesia: Abnormal sensation of the
skin (tingling)
 Check circulation
 Bed rest, flat, 4-6 hrs
 Worry about HEMMORRHAGE/ BLEEDING

o Position: flat

o Complication: bleeding and Hemorrhage

  Acute Coronary Syndrome: Ischemia and Necrosis can occur  this isn’t cause by
client’s action, they can be asleep and still have an MI
 REST OR NITRO WILL NOT relieve this pain

o S/S:
 Crushing pain OR “elephant sitting on me”
 Discomfort in left jaw
 Women present with GI pains
 Indigestion
 Feeling of fullness in the abdomen
 Chronic fatigue
 Inability to catch ones breathe  #1 sign in the elderly patients
 Cold and clammy
 BP is dropping
 ECG changes and PVC
 Vomiting

o Complications for Acute coronary syndrome

 Sudden death
 Arrythmias
 Pulseless v- tach
 V-fib……  REMEMBER for V-fib, you Defib
 Asystole

V-fib, you Defib also do CPR till you get a heartbeat (CPR between Defib)

If client remains in V-fib after doing Defib, give Epinephrine, and if that doesn’t work, give
Amiodarone (Cardarone)

 Amiodarone or Lidocaine is used to prevent a second V-fib

 Lidocaine: toxicity Watch for neuro change

o Amiodarone: Watch for Hypotension b/c it can lead to Asystole

o Treatment for Acute Coronary Syndrome: Follow the order

o Oxygen if O2 is <90
o Aspirin (chewable works faster than tablets)
o Nitro
o Morphine (if pain is not relieved by morphine)

o Position for Acute Coronary sydrome:

  Head up (Semi fowler)
 Thrombolytic therapy eg, alteplase, tissue plasminogen
activator [tPA]) is used to dissolve blood clots and restore
perfusion to brain tissue in clients with an ischemic stroke
unless contraindicated (eg, active bleeding, uncontrolled
hypertension, aneurysm).

***Anything with the suffix -Place (mostly -place) or - Kinase will be

a thrombolytic***

o Complication for Thrombolytic is BLEEDING so ask for

any recent surgeries, or bleeding histories

 Bleeding precautions when using:

o Acetameiphine
o Liver problems

o Contraindication for thrombolytic: If given, will cause

Hemorrhage
 Intercranial neoplasm or bleed
 Suspected aortic dissection
 Internal bleeding

***Do NOT draw ABGs on thrombolytic patients***

 Heart patients: Teaching

 No Isometric
 No straining
 Client will be on docusate
 You can have sex, if you walk a flight of stairs or 1 week to 10 days
o Safest time for sex is morning
 Walking best exercise for MI client
 Teach them about S/S:
 Weight gain
 Ankle edema
 SOB
 Confusion

***ANYTIME an elderly client has mood/behavioral changes, its not normal, she can be
having a UTI ***  Assume the worst
  Heart failure:

o Causes:
 Cardiomyopathy
 Valvular heart disease
 Endocarditis
 Acute MI
 Hypertension (leading cause)

Left sided heart failure: blood is not moving forward from the Aorta
to the body, rather it’s moving back to the lungs
o Left = Lungs  That’s why your S/S are all
pulmonary

o S/S:  LEFT
 D- DSYPNEA
 O- ORTHOPNEA
 C- COUGH and CRACKLES
 H- HEMOPTYSIS (coughing up blood aka lung bleeding)
 A-ADVENTIOUS SOUNDS
 P- PULMONARY EDEMA/CONGESTION

Right Sided Heart Failure: Blood is not moving forward so it will go

back into the venous system
o Right = Venous system

o S/S:  RIGHT
 A - Anorexia
 W- weight gain
 H- hepatomegaly
 E- edema pitting
 A-Acities
 D- distended veins

Pulmonary Embolism is right Sided heart failure!!

Hypoxic will always be right sided heart failure!!
NSAIDS ARE CONTRAINDICATED WITH HEART FAILURE!!!

 Diagnosis:
Clients with heart failure are expected to have elevated brain
natriuretic peptide (BNP) levels  best indicator
Turn off Nesiritide 2 hrs before you draw a BNP b/c it will give a false
positive
o BNP
o Enlarged heart (xray)
o ECG
 When you are getting a cardiac test done, DO NOT
take your cardiac meds such as:
 Nitrates (nitroglycerine or
isosorbide)
 Dipyridamole
 Beta blockers
 And DO NOT TAKE THEOPHYLINE:
used for asthma or COPD

o Treatment for HF:

 ACE inhibitors
o Drug of choice for HF
o Blocks Aldosterone (you will lose water and
sodium BUT retain Potassium) so monitor for
HyperKalemia
o Increases stroke volume (which is good)
o Side effect: Nagging Dry cough (normal)
 ARBS:
 Beta blockers: also drug of choice
 Digoxin: Used in long-term treatment of heart failure, sinus
rhythm or A-fib
o Slows heart rate down; hold if below 50
o Monitor for Toxicity anything over 2, you are
toxic
o Monitor electrolytes Especially Potasassium
(hyperkalemia)
 Early signs for Digoxin toxicity
 Nausea/vomiting
 Anorexia
 Late signs for Digoxin toxicity
 Arrythmias
 Vision changes (halos)
 Diuresis: Lasix
o Give in the morning

o Nursing consideration for HF patients:

 o Do NOT give whole blood unless if going into surgery
o Always diuresis HF clients
o Digitalizing dose (loading dose)  first few doses will be
a larger dose
o Check APICAL pulse before giving Digioxin
 5th intercostal space and left mid clavicular line

Fluid retention think HF first

o Diet:
 Low fat and high fiber diet
 low- sodium,
 calorie-restricted
 Avoid excess caffeine

 Pacemakers: sends out impulses to make the heart

o Post procedure:
 Monitor the incision
 Electrode displacement aka the wires are pulled out (common
complication)
 Immobilize the arm
 You can do some range of motion to Prevent frozen shoulder
 NEVER EVER raise higher than shoulder wires can get
pulled out
 Monitor ECG for pacemaker malfunction
o S/S:
 Loss of capture Contraction does
not follow the stimulus
 Any sign of decrease Cardiac output
or pulse

o Client Education:
 Check pulse daily
 Carry ID card or bracelet
 Avoid magnet fields like cellphones sould be used in the
opposite ears
 Stay away from MRI
 They CAN use a microwave
  Pulmonary Edema: can’t move the volume forward

o Causes: Usually occurs at night

 Anybody getting fluids fast
 Young or very old
 Anyone with heart or kidney disease

o S/S:
 Sudden onset
 Breathless: hard to breathe when lungs are filling up with fluid
 Restless, and anxious  Severe hypoxia
 Pink frothy sputum

***Anytime you see restless and anxious, think of severe HYPOXIA***

frothy, pink-tinged sputum or blood tinged is always going to be

pulmonary edema crackles (left sided HF)

o Treatment:
 Administer high flow oxygen and keep above 90%
 Lasix  give slowly over 1-2 min to prevent
hypotension and ototoxicity
 Bumetanide: to provide rapid fluid removal
 Nitroglycerine: it decreases afterload
 Morphine IV push: vasodilator
 Nesiritide: vasodilator and has a diuretic effect

o Position:
 Upright; legs down

o Prevention:
 Check lung sounds
 Avoid fluid volume excess

--------
  Cardiac Tamponade: When you have blood, fluid or exucdates that has
leaked into the pericardial sac RESULTING into compression of the heart
muscle

When assessing clients with pericarditis, it is critical for the nurse to

observe for signs of cardiac tamponade (eg, muffled or distant heart
tones, hypotension, jugular venous distension)

o Risks:
 MI
 Car accident
 Right ventricle biopsy
 Hemorrhage post CABG (open heart transplant)

Remember High BP = High CVP and  EXCEPT FOR CARDIC TAMP

Low BP = Low CVP  EXCEPT FOR CARDIC TAMP

Hallmark sign for cardiac Tamponade: Low BP and High CVP

o S/S: BIGGEST sign is Low BP and High

 Muffled/distant heart sounds: because you’re listening through
blood, fluid or excaudate
 Neck vein distended BUT client will have clear lung sounds
 Shock: due to decreased BP
 Narrowed pulse pressure  Tachycardic
 Tachypnea; dyspnea


o Treatment:
 Pericardiocentesis: To remove the blood around the heart
 Surgery so monitor fluid output

-------------
  Atherosclerosis: if you have it in one place, you have it everywhere  Emergency
only if you have an ACUTE arterial occlusion

Remember Arterial blood is oxygenated blood**** and veins= deoxygenated

blood

IF you see Artery think OXYGEN

 Artery can include:
o Carotid: feeds brain
o Femoral: feeds legs
o Radial Artery: hands

C is correct

o S/S:
 Numbness and pain
 Extremeity will be cold
 No palpable pulses
 Decreased peripheral pulse: Priority nursing assessment
 Decreased muscle tone: lack of oxygen to muscles
 Bruit: Anytime you see bruit, think turbulent blood flow
 Symptomatic Lower extremities
 Intermittent claudication AKA Pain is the biggest sign

You ONLY have intermittent claudication with Artery problems NOT vein problems

You dangle artery problems and you elevate vein issue

problems

o Position:
 Dangle legs

o Treatment:
 Angioplasty

Angina or CAD or any heart disease is also linked with ISCHEMIA 
meaning no oxygen so when YOU THINK HEART, also think ISCHEMIA
CAN HAPPEN

Distended jugular veins and lung crackles indicate volume overload.

The main risk with ectopic pregnancy is hypovolemic (hemorrhagic)
shock. Jugular veins would be flat in hypovolemic shock.

Atropine is AN agent used to increase heart rate in clients with

symptomatic bradycardic - ATROPINE (ANTI CHEOLNERGIC MEDS
CAN TREAT COPD AND OVERACIVE BLADDERS) Anything 50 and
below give atropine!!!

Spironolactone makes potassium high so avoid high potassium foods

Hypokalemia results in muscle weakness/paralysis and soft, flabby

muscles. Paralytic ileus (abdominal distension, decreased bowel
sounds) is also common with hypokalemia. However, the most
serious complication is cardiac arrhythmias.

frothy, pink-tinged sputum or blood tinged is always going to be

pulmonary edema crackles (left sided HF)

cardiac is mostly with water and fluid overload for the lungs

If you see cardioversion or cardioverter, PICK SOMETHING WITH

SYNC

Right sided VS Left Sided HF:

Atorvastatinis a lipid-lowering medication

Dipine: calcium channel

Verapamil: same as metoprolol

Lisinopril may cause hyperkalemia and hypotension, and should be

administered only to clients with normokalemia and normotension

Metoprolol lowers blood pressure and heart rate

Docusate sodium is a stool softener that reduces straining during
bowel movements

When giving Furosimide, Assess for BP, BUN, creatinine, and

Potasissum

Partial thrmobinplastin time (PTT) checks of overose of heparin

Normal Value of PTT is 100 seconds or less

Cardiac Tamponade s/s:

 Hypotension with narrowed pulse pressure (Option 1)
 Muffled or distant heart tones (Option 4)
 Jugular venous distension (Option 5)
 Pulsus paradoxus
 Dyspnea, tachypnea
 Tachycardia

A coronary arteriogram(angiogram) is an invasive diagnostic study

of the coronary arteries,

PACEMAKER IS WITH HEART RATE SO IF YOU SEE PACEMAKER, GO

WITH HEART RATE
***Pace maker CANNN use microwave

Nitroglycerin is used for chest pain

BUT can worsen hypotension and should be held. Other pain
medications (eg, morphine) may be given for chest pain if blood
pressure is low. (CONTRAINDICATED FOR PEOPLE WITH
HYPOTENSTION)

When MAP is asked use formula: Systolic + (diastolic x2) / 3

A normal MAP is 70-105 mm Hg

Dry, shiny, hairless skin are common clinical manifestations of

chronic peripheral arterial disease

Positioning the client on the left side is appropriate if a central line is

inadvertently pulled out
Hypotension has to do with dehydration which means fluid volume deficiency

VITAMIN K is a reversal agent for WARFARIN

therapeutic aPTT level between 46-70 seconds

Antidote for Heparin is Protamine sulfate

About 1 question so know these

KNOW BOTH LEFT AND RIGHT HEAT FAILUTE!!! Know what’s below

Left:
D- DSYPNEA
O- ORTHOPNEA
C- COUGH
H- HEMOPTYSIS (coughing up blood aka lung bleeding)
A-ADVENTIOUS SOUNDS
P- PULMONARY EDEMA/CONGESTION

Right:
A - Anorexia
W- weight gain
H- hepatomegaly
E- edema
A-Acities
D- distended veins
CVP is a measurement of right ventricular preload (volume within
the ventricle at the end of diastole) and reflects fluid volume
problems. The normal CVP is 2-8 mm Hg. An elevated CVP can
indicate right ventricular failure or fluid volume overload.

Clinical signs of fluid volume overload include the following:

 Peripheral edema
 Increased urine output that is dilute
 Acute, rapid weight gain
 Jugular venous distension
 S3heart sound in adults
 Tachypnea, dyspnea, crackles in lungs
 Bounding peripheral pulses

Dry mucous membranes and hypotension are signs of deficient fluid

volume or dehydration.
Ventricular tachcardia^

Anticoagulation with heparin is indicated if the client's pain is

determined to be due to acute coronary syndrome  you give
heparin if patient has acute CORONARY SYNDROME

The client should avoid lifting the arm above the shoulder on the
side of the pacemaker until approved by the HCP as this can cause
dislodgement of the pacemaker lead wires.

Elevating the legs promotes venous return but does not promote arterial
circulation SO DO NOT PUT LEGS UP WHEN A PATIENT HAS PAD (PERIPHERAL
ATERIAL DISEASE)

(PERIPHERAL ATERIAL DISEASE): Heating pads should not be used in clients

with altered perfusion or sensation due to the increased risk for burns.
When assessing clients with pericarditis, it is critical for the nurse to
observe for signs of cardiac tamponade (eg, muffled or distant heart
tones, hypotension, jugular venous distension)

Rescue breaths every 5-6 seconds (10-12 breaths/min) are given to

clients who have a pulse but are not breathing normally. For clients
with no pulse, the nurse should deliver cycles of 30 compressions
followed by 2 rescue breaths.

CHEST TUBE OUTPUT IS THE SAME THING AS CHEST DRAINAGE They just wanna trick you to
see if you know what they both are SO 100< or less is good 100> or more REPORT TO THE
DAMN DOCTOR

When you think of vomiting, what do you think of??? DEHYDRATION (forget this and you can sit
your ass back to nursing school and kiss business goodbye)

Over the counter meds increase BP not Decrease so if a client is having hypertensive and is
feeling dizziness, PLEASE DON’T ASKM if hes taking any OTC meds CUZ AGAIN those things
INCREEASE BP

A normal platelet count is 150,000-400,000/mm 3 BUT 80,000 is expected for

liver cirhossis

A normal prothrombin time is 11-16 seconds for WARFARIN

Digoxin: used in long-term treatment of heart failure.

When you are getting a cardiac test done, DO NOT take your cardiac
meds such as:
Nitrates (nitroglycerine or isosorbide)
Dipyridamole
Beta blockers
And DO NOT TAKE THEOPHYLINE: used for asthma or COPD

Clients with heart failure are expected to have elevated brain

natriuretic peptide (BNP) levels.
Stridor is consistent with a laryngospasm or edema, of the upper
airway, and epiglottitis.

Bronchial breath sounds are normally heard over the trachea

When you see the word TRANSPLANT, always remember client is at risk for INFECTION

IF central venous catheter (CVC) gets dislodged, you are at risk of

developing AIR EMBOLISM  you want to put them on their left side
TRENDELONBURG POSITION, so all the blood comes rushing to the
heart. --- DO NOT PICK FOWLERS, CUZ THAT’S NOT GOING TO DO
ANYTHING BUT CAUSE THEM HARM. BY MAKING THEIR RESPRITORY
DISTRESS EVEN WORSE

Diuretic medications cause clients to urinate more. Morning is the

appropriate time to take this type of medication. Evening
administration would cause nocturia and interrupted sleep.

NSAIDS ARE CONTRAINDICATED WITH HEART FAILURE

ANY ENDOVASCULAR repairs are not invasive so NO INCISIONS  think of Endo as Easy; E for
Easy……… Make sure to palpate or monitor peripheral body and monitor urine output

Patients with HF, their BNP will go up

VENOUS INSUFFUCIENCY are varicose vein

Know your damn TRENDELUNBURG AND REVERSE TRENEDELONBRUG

Bounding pulse has to do with fluid overload aka hypertension

You check INR only for clients who are taking WARFRIN

CARDIAC TAMPONADE: life threatening BP is becoming slow so they dying  remember BLM
(Black lives matter) for signs and symptoms
B: Big jugular vein distention (JVD)
L: Low BP
M: Muffled heart sounds or distant heart sounds aka YOU CAN’T HEAR THE DAMN
HEART SOUNDS AKA when you see distant heart sounds/tone PICK IT!!!
Cardioverters have the same restrictions as a pace maker so meaning you cant put your hands
above your heart

Septic shock can lead to HYPOTENSION so give fluids

Psychiatric….REVIEW SECTION 3!!!!

Anhedonia: loss of pleasure

For suicide, use closed ended statements

You never give naloxone PO and YES, they do need hosputalizaion after emergency treatment
of Naloxone… AND must be administered every few hours till opiod levels are non toxic

 Treamtment for Opoid is Methoadone:

 Long acting opoid
 Can later on be titrated to ease withdrawal
symptoms

Alcohol: seizure precautions

You can give them Anxiolytic drugs

-----------------
 Renal:
Kidneys and heart coincide so if you have heart problem you’ll have
kidney problem

-Glomerulo = Filtering
-Nephr = Kidney

 Glomerulonephritis: Inflammation of the filtering portion of the kidneys

so DECREASED filtering will occur
o It can start with sore throat or skin disease

o Causes:
o Strep – Group A Beta heart and kidney can be infected if
not treated
o Skin infection – impetigo, hepatitis

o S/S:
 Flank pain aka Costovertebral angle tenderness or CVA
tenderness
 Decreased urinary output
 Urine gravity is increased
 Hematuria – Blood in the urine
 Proteinuria – protein in the urine
 Periorbital Edema
 Raised BP – fluid volume excess
 Raised BUN and Creatinine
 Malaise (discomfort) and headache

o Treatment:
o Cure the Strep
o Monitor I &O and daily weights
o Diuretics
o Monitor BP
o Restrict fluids – To determine how much fluid to give= 24hr fluid loss
+ 500 mL
o Balanced activity with rest
 o Diet: everything low except carbs
 Increased carbs
 Protein restricted
 Restrict/low sodium
 Fluid restricted
 Potassium restricted
 Phosphorus restricted

o Client education:
 Client will dieurese within 1-3 weeks after onset
 Blood and protein may stay in the urine for months
 Teach S/S of Renal failure:
o Malaise (discomfort)
o Headache
o Anorexia
o N/V
o Decreased Output
o Weight gain

Notify doctor if you see these symptoms

----------------------------

 Nephrotic Syndrome: inflamed kidneys (glomeurlous) where big holes starts forming
and protein leaks out

Protein = Albumin  So they will be hypoalbuminemia (low albumin)

KNOW ABOUT ALBUMINS (HYPERALBUMINIEMIA AND HYPOALBUMENIA

When Albumins are low (HYPO), pitting edema and Ascites can occur

proteins (albumin) in the blood that pulls water into the circulatory
system. Albumin (normal: 3.5-5.0 g/dL [35-50 g/L])
When Albumin is low, Aldosterone kicks which makes you retain sodium and water

 Anasarca is extreme edema

 When you Lose protein, you can develop:
 Blood clots (thrombosis)
 High Cholesterol and triglycerides

o Causes:
 Infection
 NSAIDS
 Cancer
 Lupus and diabetes

o S/S:
 Massive Proteinuria
 Hypoalbuminemia
 Edema (anasarca)
 Hyperlipidemia

o Treatment:
 Diuretics (Thiazides or diuretics prescribed)
 Ace inhibitors to block aldosterone secretions
 Prednisone for inflammation
 Cyclophosphamide: chemotherapy agent that decreases body’s immune
response
 So, it will shrink holes and inflammation
 But they will be immunosuppressed
 So, INFECTION is major complication

o Diet:
 Small frequent meals
 sodium-restricted
 high calorie
 high protein: only kidney problem where you increase protein
 potassium- restricted
 give lipid lowering drugs – anything with statins
 dialysis
 Anticoagulants therapy for up to 6 months

o Nursing considerations:
 Monitor Daily weights and I&Os
 Measure abdominal girth and extremity size
 Good skin care with edema
 Acute Kidney Injury (AKI):

o Causes:  Pre-Renal Failure:

 Hypotensive
 Decreased Heart rate: means Decreased
cardiac output which will decrease the amount of
blood coming to the kidneys
 Any type of shock

  Intra-Renal Failure
o Damage inside the kidney – Glomuronephritis, nephrotic
syndrome
o Malignant hypertension: aka uncontrolled hypertension
o Diabetes
o Hypotension
o Sepsis
o Drugs that causes kidney injury – mycin and NSaids
drugs
o Dyes can damage kidneys too

 Post-kindey: urine cant leave the kidney

o Enlarged prosate
o Kidney stones
o Ureter obstructions
o Tumors
o Edematous stoma

 4 phases of Acute kidney injury:

o Initiation Phase  Injury occurs
o Oliguric phase  Output is less <100ml/24hr
o Diuretic phase Kidneys are recovering
o Recovery phase  3-12 months
 o S/S:
 BUN and Creatinine levels increase
 Serum Calcium levels Decrease: Clients with kidney injuries
retain phosphorus clients will be hypocalceamic
o To compensate, the body will pull calcium from the
bones so now they have Osteoporosis too now
 Anemia can occur: Anytime kidney is damaged, they can’t produce a good
amount of erythropoietin (blood)
 Hyperkalemia: we get rid of Potassium from our kidneys so If kidneys are
damaged, the body cant excrete potassium
 Metabolic Acidosis: Client cant filter acids produced by the body
 Specific gravity will increase BUT Severe Kidney injury, you’ll get a fixed
specific gravity
 Hypertension and HF: b/c they are retaining fluids
 Anorexia: they are retaining toxins
 Can’t fliter Hydrogen and Bicarb
 Itching frost (Uremic Frost)
 Maintain good skin care: too much urea and it will come out from your skin

 Phosphorus is linked with calcemia

o Nursing Consideratons:
 Monitor hourly outputs
 Checking CVP
 Looking for S/S of urinary infection so if they have an indwelling
catheter, GET RID OF IT
 Assess BP and treat Hypotension QUICKLY
o Give them fluids
o Bed rest
o Elevate the leg
 Prevent infections
 Use aseptic technique
 Prevent pressure ulcers
 Mouth care
 No catheter
 Protect from infection disease
 Renal replacement therapy may be needed: they replace kidney
functions aka dialysis
  Client and family support

o Treatment:
 Bedrest to decrease Metabolism
 Turn, cough, and deep breathe
 Monitor intake and output
 Daily weights
 Monitor vital signs closely

 Meds:
o Loop and osmotic Diuretics
o IV glucose and insulin: for hyperkalemia  IV and
insulin moves the potassium out of the blood and
back to the cells
o Make sure to check drugs
o IV calcium Gluconate: for dysrhythmias
o K-acelate: to decrease Potassium
o Phosphate bindings drugs: to prevent
Hypocalcemia
 Give IV meds in small volumes so you don’t overload with fluids

o Diet:
 Increase calories, carbs and fat
 Low protein
 Avoid phosphate food
 Low sodium
 Low potassium: coffee

 Renal Replacement Therapy  Hemodialysis:

o Before Dialysis begins, assess fluid status  weight, BP, peripheral edema,
lungs and heart sounds, and temp
o Electrolyte and BP are monitored constantly
o Vital signs 30-60 min during dialysis
o Some can’t tolerate hemodialysis: some go to shock every single time
o Client is given Heparin during dialysis so watch for bleeding precautions, and
avoid invasive procedure
o Depression  suicide by eating too many bananas
 Vascular access: During Dialysis, 2 needles are inserted into the vascular
access
 One will allow the blood to go to the dialysis machine and the other
from the dialysis machine

To the dialysis machine = Arterial

From the dialysis machine = Low pressure venous

o Care of Access:
 Do not use as IV access
 No BP
 No needle Stick
 No constriction – no watches, no carrying purses

o Assessment of access: to ensure patency

 Palpate for thrill
 Auscultate for bruit

 Continuous renal replacement therapy is used for Acute kidney injury

 Peritoneal Dialysis:
o Warm the dialysis
o Drainage should look clear or straw colored …. Cloudy = infection
o If all fluid doesn’t come out, turn client side to side
o Increase protein and fiber when doing dialysis
  Kidney stones: Fancy words Nephrolithiasis, Urolithiasis, or Ureterolithiasis
 Sharp flank pain
 N/V due to extreme flank pain
 Increased WBC in the urine
 Hematuria*** blood in the urine

 Anytime you suspect kidney stone, get a urine specimen and checked for
RBC (hematuria)

 If kidney stone is present, the client will get pain medication immediately

o Treatment:
 Ondansetron
 NSAIDS or opioid narcotics
 Alpha adrenergic blockers (relax smooth muscles of ureter)
 Increase fluids FOREVER
 Maybe surgery to remove stone
 Lithotripsy to crush stone
 Strain urine – to keep and send stones for analysis

o Diet:
 Increased fluid intake
 Calcium-controlled
 Low oxalate

Total means Always and it will never be always

 GI:

 Pancreatitis:
o Cause:
 Gallbladder Disease: #1 cause for acute or chronic
 Alcohol: #2 leading cause

o S/S:
 Pain increases
 Abdominal distention: can lead to ascites
 Abdominal mass: that’s your swollen pancreas
 Rigid board-like abdomen: this means they’re
bleeding inside, and it can lead to peritonitis
 Peritonitis
 Bruising: They can have bruising around the
umbilical area AKA Cullen’s sign
 Bruising in the Flank pain: called Gray Turner’s
sign
 Fever and inflammation
 N/V
 Jaundice: means liver is involved
 Hypotensive: b/c they might be bleeding or cuz of
ascites

o Diagnosis: everything will go up

 Lipase and Amylase serum going to increase
o Lipase is the most specific enzyme for pancreatitis
 WBC increase
 Blood sugar will increase you can be diabetic forever
 ALT and AST will increase:
 These are your liver enzymes…….*Hint liver enzymes
will always go up or be normal but NEVER down**
 PT and aPTT will be longer: which means it takes longer for
your blood to clot
 If it was shorter, you would be at risk for too many clots
 Serum bilirubin will increase: Liver
 HgB and HcT can go up or down:
  If you are bleeding it will go down
 If you are dehydrated, it will go up

o Treatment:
 KEEP THEM NPO and daily weights
 Fix pain

o Meds:

Morphine is contraindicated in Pancreatitis. It causes spasm of

the Sphincter of Oddi. Therefore, Demerol should be given

 Demerol
 Anticholinergic drugs: they keep the stomach dry
 PPI
 Antacids
 TPN (total parenteral nutrition)
 Insulin: because pancreas is sick so no adequate insulin

o Diet:
 low-fat,
 regular, small frequent feedings;
 tube feeding or total parenteral nutrition.

----------
 Liver:
o 4 main functions:
 Detoxifying your body
 Helps your blood to clot: so with
liver problems, bleeding is the
biggest complication
 Breaks down drugs: NEVER GIVE
ACTEMINOPHEN OR TYLONOL
to patients with liver problems
 Synthetizes albumin
Antidote for Tylenol: Acetylcysteine or Mucomyst
 Should be mixed with carbonated drink cuz it smells like rotten eggs

 Cirrhosis: Liver cells are destroyed so it alters the circulation

within the liver
o BP goes up in the liver known as Portal Hypertension
which can lead to hepatic coma

o S/S:
 Firm nodular liver: it becomes HUGE
 Jaundice
 Abdominal pain
 Chronic dyspepsia (GI upset)
 Change in bowel habits
 Ascites
 Splenomegaly
 Peripheral Edema
 Fatigue
 Anemia
 Hepatic encephalopathy: anytime you have liver problems,
look for the ammonia levels
 Rye syndrome

o Diagnosis:
 Decreased serum Albumin: Main reason why people have ascites is
because their albumin is messed up. Albumin is in charge to keep water in the
vascular
o Liver makes ALBUMIN
 Increased ALT and AST
 Confirmed with Liver biopsy: concerned about bleeding so do
o Clotting studies: PT, aPTT, INR
o Vital signs: b/c of hemorrhage
o Position:
 Pre-Procedure:
 Supine with right arm behind head
 Then exhale and hold breathe: to move the diaphragm
 Post procedure: Lie on right side
 o Treatment:
 Antacids, vitamins, diuretics
 No more alcohol
 Monitor I&O and daily weights
 Rest
 Prevent bleeding: no aspirin, or no IM injection
 Measure abdominal girth: cuz of ascites
 Paracentesis
o Have client void before
o High fowler position; NO SUPPINE or semi fowl
o Get baseline vitals and check it later
 Monitor Jaundice
 Skin care
 Avoid Narcotics

o Diet:
 Low protein: if they eat high protein, it will make their ammonia levels go up
which will make their LOC decrease
 Low sodium
 Low Fluids

COOL Side info: When you eat protein, it transforms into ammonia, then your
liver turns it into Urea. Urea gets excreted through the kidneys

 Hepatic Coma: when your body can’t transform ammonia into urea
o S/S:
 LOC down
 Asterixis: hand tremors
 Handwriting changes: First sign of ammonia changes
 Reflexes decreases
 EEG will be slow
 Breathe smells like ammonia
 GI bleeders

o Treatment:
  Lactulose: decreases Ammonia
 Enemas: need to take too much blood out from body cuz
blood increases ammonia levels
 When giving this, place client on left side
 Decreased protein
 Monitor Ammonia levels everyday

---------

 Bleeding Esophageal Varices: You have High BP in your liver, and that
pressure, excretes back to the esophageal
o No one realizes they have this, till it pops
o Once it ruptures, most commonly you start vomiting large bright
red blood

o Treatment:
 Replace blood
 Check vital signs
 Check CVP
 Anemic = oxygen
 Enema: to get rid of blood
 Lactulose
 Saline lavage: to get blood out of the stomach
 Sengstaken- Blakemore tube AKA balloon tamponade:
o It holds pressure on the bleeding varices so
hemorrhage doesn’t occur
o Mark the tube
o These clients are usually hypoxic b/c they were
bleeding so much and alcoholic, so they are
confused
o Doctor might order restraints b/c clients will want
to remove it
o IF THE PATIENT CAN’T BREATHE, CUT IT!!

** In the NCLEX, stay away from restraints, they don’t lke nurses to use
restraints***

---------
 Peptic Ulcer: H. pylori
o Common cause of GI bleeding

o S/S:
 Erosion is present  Can lead to burning pain or knowing
sensation all the way to the back
 Heart burn or dyspepsia

o Diagnosis:
 Gastroscopy (EGD)  These things can be applied to any tube going to the
mouth
o NPO pre procedure
o Sedated
o NPO till gag reflex returns
o Watch for perforation: S/S: pain, bleeding or trouble
swallowing  monitor for these when they come back

 Upper GI serious: Looks at stomach and esophagus with dye

o NPO past midnight
o No gum, no mints
o REMOVE nicotine patch  this applies to anyone whos
NPO too
o No smoking either: it will increase stomach secretions

o Treatment:
 Antacids: liquid only to coat stomach
o Empty and at bedtime (only med where you take at
bedtime)  Usually after meals you would take
Antacids
 Proton pump inhibitors  Any drug with suffix -prazole
 H2 Antagonist: like Pepcid
 Antibiotics for H. Pylori
 Sucralfate

o Client Teaching:
 Decrease stress
 No smoking
 Eat what you can handle (Avoid spicy food)
 Avoid caffeine
 Follow up b/c it takes long for it to heal
 Hiatal Hernia: The hole in the diaphragm is too large, so the stomach
moves up into the thoracic cavity

o S/S:
 Large abdomen: b/c something is pushing it up
 Heartburn
 Fullness after eating
 Regurgitation: This is when they tie their shoes, and all the
food and water comes up
 Reflux
 Dysphagia: difficulty swallowing

o Treatment:
 Small frequent meals
 Sit up for 1 hr after eating
 Elevate HOB  upright postion

 Dumping Syndrome: When stomach empties too quickly after eating

o Gastric bypass or Gastrectomy and gallbladder disease can cause
this

o S/S:
 Fullness, weakness, palpitations
 Cramping, faintness, diarrhea

o Treatment:
 No fluids with meals
 Small and frequent
 Avoid foods high in carbs and electrolyte

o Position:
 Semi recumbent: that’s to lie back a little while eating
 Lie left flat after meals

 Lie flat on left to keep food in

 Lie flat on right side helps empty the food
 Ulcerative Colitis and Crohn’s Disease are classified as IBD:
o Ulcerative Colitis: just in the Large Intestine

o Crohn’s disease: also called Regional Enteritis, but inflammation in

the ileum (small intestine) but it can be found either in small or large

o S/S:
 Bloody Diarrhea
 Rectal bleeding
 Vomiting
 Anemia
 Weight loss  Anorexia
 Cramping
 Dehydration
 Blood in stool
 Rebound tenderness means peritoneal inflammation
 Fever
 Pain

o Diagnose:
 Colonoscopy
o Need to be Clear liquid diet for 12-24 hrs
o NPO for 6-8 hrs
o Avoid NSAIDS prior to the procedure: because of
bleeding
o Laxatives and enemas till clear
 Watch client so they don’t get too weak
o Drink polyethylene glycol:
 Get it icy cold: the colder it is, the more they can
tolerate it
 Don’t drink it with a straw
o Will be sedated for this procedure
o Watch for Perforation: S/S  pain and unusual
discomfort, and abdominal distention
 Barium enema: AKA lower GI series

o Diet:
 Low residue diet aka Low fiber diet
 Avoid cold foods and smoking
 o Treatment:
 Illiosotomy:  care is for any ostomy
o Post op care:
 Going to drain liquid, they don’t get clogged up
so we don’t have irrigate it
 Client will a lot of fluid and electrolyts, so they
will be dehydrated so they will need Gatorade or
water  at risk for kidney stones
 Decrease motility so low fiber foods

 Colostomy care: Post op 

o Irrigate in the descending colon  irrigate same time
and Irrigate after a meal too
o If client starts cramping, stop the fluid and lower the
bag or/and check the temp of the bag  this is also for
enema

 For colostomy bags Eliminate foods that cause gas and odor
(broccoli, cauliflower, dried beans, brussels sprouts) AND
EMPTY THE BAG OUT WHEN ITS ONE THIRD FULL….. Also give
low fiber foods in the beginning


 Appendicitis: inflammation of the appendix

o Position client in semi fowler right side

o Causes:
 McBurney’s point: meaning pain in RLQ
 Rebound tenderness
 N/V

 With suspected Appendicitis, NEVER give Enemas or Laxative, b/c it will

cause it to burst

o Treatment:
 Surgery
o After Abdominal surgery, place in fowler position

---------
  Total Parenteral Nutrient or parenteral nutrition:
o Keep it refrigerated
o Warm it up before giving (meaning keep it on the counter)
o Central line only not peripheral unless it’s a picc line
o Filter needed
o Nothing can be mixed with this, this is specifically for the TPN
o We discontinue gradually to Avoid hypoglycemia  never go into the
room and discontinue it abruptly
o Do daily weights  client should not be losing weight!!
o Clients may have to take insulin  accu checks every 6 hrs
o Check Urine: for glucose and ketones….  if you got glucose in your,
they need insulin and if you have ketones in your urine, it means TPN
isn’t doing its job b/c your body breaking down its fat…it means they
need fat
o Mixture adjusted according to their electrolytes so monitor
electrolytes
o TPN can be hung only for 24 hours and tubing needs to change with
each new bag
o TPN is covered with dark bag: to prevent chemical breakdowns
o Needs to be on a pump
o Handwash Is important  infection is most common complication
o Placement will be confirmed via chest Xray and to see if
pneumothorax has occurred
o Position will be Trendelenburg when putting in a TPN in the central
line
o If air gets into the line, left side Trendelenburg
o To avoid Air into the tubes:
 Clamp it off
 Valsalva: take a deep breathe, hold or Hummmm

Side note: protein will not leak from the kidneys (glomerulus to be more specific)
unless there is kidney damage so if you want to click proteinuria, ask yourself, is
there kidney damage?

----------
 Respiratory

 Hemothorax: blood in the pleural space

 Pneumothorax: air in the pleural space

o S/S:
 Short of breath
 Tachycardic
 Diminished breathe sounds on the effected side
 Chest pain and cough
 Air or blood will show up on Xray

Off track side note: never pull out a penetrating object!!

o Treatment:
 Thoracentesis/chest tubes: GO DOWN to find out more info
about these
 Daily chest Xray

 Tension Pneumothorax: pressure has built up and has collapsed the lungs so
pressure pushes everything to the opposite side  called mediastinal shift
 Basically, if your trachea is on one side of your neck, it aint good
sis!! You’d rather have a normal pneumothorax
 Medical Emergency!!!

o Causes:
 Trauma
 Too much PEEP (positive end expiratory pressure) set on the
ventilator
 Clamping a chest tube
 Insertion of central venous lines
 Taping a pneumothorax on all 4 sides without an air valve
 So, TAPE only 3 sides!!!
 o S/S:
 Subcutaneous emphysema
 Decreases cardiac output
 Absence of breath sounds
 Asymmetry of thorax: trachea will be off centered
 Respiratory distress
 JVD
 Cyanosis

o Treatment:
 Large bore needle placed in the second intercostal space for air
to escape
 Find the cause
 Chest tubes will be inserted

 Open Pneumothorax: when an opening is in the chest, which is large enough

that it allows air into the pleural space  “sucking chest wound”

o Treatment:
 Valsalva: inhale and hold
 Then place Petroleum gauze over the area and tape ONLY 3
SIDES!! LEAVE THE 4TH SIDE OPEN
 Sit up to assist with lung expansion

Valsalva maneuver is contraindicated in clients with glaucoma and

recent eye surgery, stroke and abdominal surgery, and liver
cirrhosis.

o Thoracentesis: Chest procedure to remove excess fluid or air

o Pre-Procedure:
 Check for signed consent
 Stop any anticoagulant meds
 Obtain baseline vitals: O2 and pain level so we can compare
 Make sure chest Xray has been performed
  Either client will be upright, if they can’t then head of the bed
elevated (45 degrees) and lie on unaffected side (good lung is
down)

o During procedure: As the fluid is being removed in this stage, the lungs should re-expand
 Client must be still (no coughing or deep breathing)
 Check vital signs  O2 and pain levels
 When you are removing large volumes, BP goes down and Pulse
goes up

o Post procedure:
 Another chest Xray will be done
 Monitor vital signs and listen to lungs
 Check puncture sites for bleeding
 Monitor for tension pneumothorax, emphysema, infection
 We want them to turn, cough and deep breathe

o Chest tube: The lung has collapsed so that’s why we need a chest tube
 Ex: Chest drainage tube
o If the chest tube is placed in the upper lungs (second intercostal
space), that’s for removal of air
o If the chest tube is placed laterally in the lower chest (8 th or 9th
intercostal space), that’s for drainage
o Client can have both

**Air rises and drain goes down***

o The steps are the same thing as the thoracentesis with the petroleum
gauze and shit

o Chest Drainage tube/Unit

is to normalize the pressure
 o Nursing Management:
 Palpate chest tube insertion: can indicate poor tube placement
 Record chest drainage every hour for 24 hours then every 8 hrs
 Report if bright red
 Use incentive spirometer
 Watch for elevated WBC or fever
 Promote gravity drainage

o Maintaining chest tube:

 Straight and free from all kinks
 Tape all connections
 It must be a closed system
 Seeing tidaling and fluctuation is good
 Bubbling becomes a problem if its continuous in the water seal
chamber  can indicate an air leak
 NEVER CLAMP A CHEST TUBE WITHOUT A PRESCRIPTION

o PROBLEMS:
 If it dislodges  reconnect it EVEN if its dirty because the lung
will collapse
 If Chamber falls over  Reestablish the water seal, deep
breathe and cough in case any air went inside the pleural space
 If the tube dislodges directly from the chest  DO NOT PUT IT
BACK INTO THE BODY, surgeon can only do that. Use sterile
occlusion and TAPE IT ON 3 SIDES
 When Doctor takes the chest tube out, you tell the patient to take a deep
breath and hold aka VALSALVA

 CPAP: delivered continuously Used for obstructive sleep apnea and infants
who can’t breathe

 BiPAP: Used for nonobstructive sleep apnea, and its more tolerated

 You NEVER GIVE TOO MUCH OXYGEN FOR A COPD PATIENT UNLESS THEY ARE
COATING (THEY ARE NOT BREATHING AT ALL)
  Pulmonary/air embolism: this is usually a blot clot in your lungs, but can also
be fat, if there’s a clot, then gas exchange isn’t taking place

o Causes: This can be for DVT, PE, VTE (meaning both)

 Dehydrated
 Prolonged immobility
 Birth control pills
 Heart Arrythmias like Afib
 Clotting disorders
o S/S:
 Hypoxemia: #1 sign
 PO2 will go down
 Cough
 Cor pulmonae: Means Right sided heart failure
 Chest pain
 Increased resp rate/ tachpnea
 Tachycardic
 Petechia over the chest
 Short of breath
 Restless
 Cyanosis
 Atelectasis
 Hemoptysis (Coughing up blood)

Cor Pulmonae is right sided heart failure caused by left ventricular failure (so
pick edema, jvd, if it is a choice.

o Diagnosed:
 D-dimer: this will tell you if theres a clot anywhere in the body
 CT scan: if dye is used, be sure to check renal function because
that’s contraindicated
 Angiography: invasive
 o Prevention:
 Early mobilization: change position every 2 hours
 Flex and extend knees and hips
 Compression hose: be sure it’s on correctly
 Pneumatic compression is not used if they suspect a DVT
 Hydrate

o Treatment:
 Elevate legs
 Administer anticoagulants: Warfarin, heparin, factor X

 YES, they can take Heparin and warfarin together

 Limit Green leafy vegtables when on warfarin
o Use soft brush
o Electric razor
o Avoid rough activities
 tPA can DISSOLVE blood clots and is used for strokes

Thrombolytic therapy eg, alteplase, tissue plasminogen activator

[tPA]) is used to dissolve blood clots and restore perfusion to brain
tissue in clients with an ischemic stroke unless contraindicated (eg,
active bleeding, uncontrolled hypertension, aneurysm).

o Position: Turn patient to the left side and Lower HOB

Orthopedic:

 Fat embolus is a big complication for fractures  Fat emobolism likes to go

to the lungs
o You can find fat embolus in: long bones pelvic fractures, and crushing
injuries
 S/S:
 Petechia on chest
 Conjunctival hemorrhages
 SNOW STORM on chest xray: white fluffy stuff
Fat embolism syndrome: is a rare, but life-threatening complication that
occurs in clients with long bone and pelvis fractures
S/S: Dyspnea
Confusion
Petechia (rash): PE (PULMOARY EMBOLISM doesn’t have
this type
Of rash
Fever

--------

 Compartment syndrome: Fluid accumulates in the tissue and

impairs tissue perfusion  common areas are forearms and
quadriceps

 Carpal tunnel is a type of compartment syndrome

Carpel Tunnel Syndrome: paresthesia and pain of the wrist; to RELIEVE it wear wrist
immobilization splints……. EXCERCISES MAKE IT WORSE

 That’s why we elevate when you have fractures

Compartment Syndrome: 6 Ps (pain, Paranesthesia, pallor, paralysis, poikilothermic,

pulseless)

Volkmann contracture: inability to extend the fingers; is a sign of

compartment syndrome

IF PAIN DOES NOT HEAL AFTER GIVING MEDS, THAT IS A SIGN OF

COMPARTMENT SYDROME!!!!!

o Treatment:
 If you have a cast, loosen it to restore circulation  if you see an
answer that says “remove the cast” that shouldn’t be your first choice unless if
that’s the only right answer
 Fasciotomy: Doctor cuts into the tissure to remove pressure
and restore circulation
o Cast care:
 Use palm to handle plaster cast  no fingertips cuz of
indentation
 Keep uncovered for plaster cast
 Always ask if they are diabetic
 Don’t rest cast on hard surface or sharp edge but you can rest
it on SOFT PILLOWs BUT NOT PLASTIC
 If they bleed, circle the area and mark date and time
 Neurovascular checks especially if the client is in pain
 NEVER INSERT ANYTHING INSIDE A CAST, I DON’T
CARE HOW SOFT IT IS  just use a hair dryer

o Traction:
 This has to be continuous SO NEVER RELEASE
CONTRACTION
 Buck’s Traction—elevate foot of bed for counter-traction.
 Exercise mobile joints
 Ropes should move freely
 Weight should hang freely
 Monitor pin sites for any inflammation every 8 hrs
 Pin sites, use sterile technique
 Purpose of pins are to immobilize the leg so if pins fall
out, immobilize the leg

o Total hip replacement:

 Pre-op: Buck’s traction is used
 Post op:
 Neurovascular checks
 Monitor drains if they have drain
 Firm mattress
 Over bed trapeze
 We want to limit flexion and neutral position
 We want abduction: feet apart, like an abduction pillow
 They can do isometric exercises in bed
 Trochanter roll: to prevent external rotation...
Document this too
 No weight bearing
  No bending over, or no crossing legs
 Don’t sleep on the operative side
 Hydration is important: pneumonia can occur if they
 are immobile
 No pain meds in the operative hip

o Complication:
 Dislocation: you may see shortening of the leg and pain
 Infection: remove foley catheter ASAP
 Avascular necrosis
 DVT/VTE
o Client education/rehab:
 Walking
 Swimming
 Rocking in the wheelchair
 Avoid flexion:
 So avoid low chairs
 Traveling long distances
 Sitting more than 30 min
 Lifting heavy objects
 Excessive bending
 Stair climbing

residual limb refers to the part of the body that remains after an amputation
has been performed

o Amputation:
 Post op:
o Limb should lie completely flat
o Put client on prone position
o Phantom pain: pain that isn’t there, but don’t be
judgy so do some diversional activity and then
some pain med  avoid meds in the nclex as
much as you can
o Massages are okay
o Proper way of walking with a crutch:
 Should fit properly: 1-2 in below the axilla (armpit) 
you’ll get brachial nerve damage if not fitted properly
 Rest body weight on hands
 Walking up and down the Stairs: up with the good and
down with the bad

o Proper way of walking with a cane:

 Use strong side with the cane
 Neuro:

Glasgow Coma Scale

4 - Spontaneous (open with blinking at baseline)
3 - To speech
(E)ye opening 2 - To pain only
(Maximum = 4) 1 - None
(C - Not assessable [eg, trauma, edema])

5 - Oriented
4 - Confused (converses but confused, disoriented)
(V)erbal 3 - Inappropriate (inappropriate words)
response 2 - Incomprehensible (sounds, no words)
(Maximum = 5) 1 - None
(T - Not assessable [intubated])

6 - Obeys commands for movement

5 - Localizes to pain
(M)otor 4 - Withdraws from pain
response 3 - Flexion in response to pain (decorticate posturing)
(Maximum = 6) 2 - Extension in response to pain (decerebrate
posturing)
1 - None

 Use best response for each category (range = 3-15).

 Coma: Does not open eyes, does not follow commands, and does
not utter understandable words; Glasgow Coma Score (GCS) 3-8.
 Head injury classification: Mild, GCS 13-15; moderate, GCS 9-12;
severe, GCS ≤8.

----------

Normal pupils are 2-6 mm in diameter from hurst and Uworld is 3-5
mm

 Positive Babinski: when toes fan out when you stroke it 

normal for infants up to 1 yr  if they do, it means theres a
nervous system problem
Know this thing above^^^^^^^^^^^^^^^

 Lumbar puncture: The site will be at the lumbar subarachnoid space

o Purpose is to
 attain spinal fluid to analyze for infecetion, tumor
 Reduce CSF
 Measure Pressure readings

o Position:
 Fetal postion
 o Nursing Consideration:
 Be sure to inspect the puncture site so its clean
 Spinal fluid should look clear like water
 Post procedure: they should lie flat or prone 4-8hrs
 Increase fluids

o Complication:
 Common one is headache: bed rest, fluids, pain meds and
BLOOD PATCH
 Increases when they are sitting up
 Decreases when they are lying down
 Brain herniation: if you even think, they are having ICP, tell
the doctor because when the needle is inserted, the brain will
pull down and it will cut supply to the brain  Ischemia
 Infected lesions on the puncture site can cause meningitis

 Lumbar puncture is contraindicated if you have ICP

  Increased intercranial pressure:
o S/S:
 Early signs:
o Change in LOC
o Change in attention span or even coma
o Slurred speech
o Delay in response in verbal commands
o Increase in drowsiness
o Restlessness
o Confusion
 Late signs:
o Change in LOC
o Progressing tto stupor
o Coma
o Vital sign changes
o Cushing triad  immediate intervention
 Systolic hypertension with a
WIDENING PULSE
 SLOW, AND BOUNDING PULSE
 IRREGULAR RESPIRATIONS 
Cheyne-stokes
o Decerebrate and decorticate they are burning
calories a lot
 Remembering DeCORticate: is
towards the core of your body
 Remembering Decerebrate: away
from you body  this one is more
dangerous

 Cushing's triad is related to increased intracranial pressure

(ICP). Early signs include change in level of consciousness.

 Late signs include bradycardia, increased systolic blood

pressure with a widening pulse pressure(difference between
systolic and diastolic), and slowed irregular (Cheyne-Stokes)
respirations.
o

ANYTIME A PERSON HAS A HEADACHE, THINK ICP IS GOING UP

Same thing with PROJECTILEE VOMITITNG
Anytime you have a fast or acute bleeding in your head, ICP will go up, whether
be stroke, head injury, cerebral anyreusm

o MISCELENOUS SIGNS:
 Changes in pupils
 Projectile vomiting

o Complications for ICP:

 Brain herniation
 Obstructs blood flow
 DI and SIADH

o Treatment: reduce cerebral edema by

maintaining maintain cerebral perfusion
 Short term drugs
o Avoid hypotension/bradycardia
o Give oxygen
o Isotonic saline
o Norepinephrine
o Dobutamine: (short term drug)

 Long term
 Keep temp below <100.4
 Elevate head of bed (high fowlers)
 Watch ICP while turning but its supposed
to come down within 15 min
 Avoid
o restraints
o Avoid bowel and bladder
distention
o Hip
o Valsalva
o No nose
o Limit suctioning and coughing
o No isometric
 Use osmotic diuretics  mannitol
decreases ICP
 FLUID RESTRICTION
 ICP
  medication: Mannitol (osmotic diuretic)-crystallizes at room temp so
ALWAYS use filter needle
 Meningitis: inflammation of the brain
 Caused by viral or bacterial
 It can also be caused by a lumbar puncture

 Make sure client is on Droplet precautions!!

o S/S:
 Chills and high fever
 Severe headache
 Disorientation that can become into a coma
 Nuchal rigidity (stiff neck)
 N/V
 Photophobia
 Seizures
 Positive Kernig (Severe stiffness of hamstring) and Brudzinski
(sever neck stiffness causes hips and knees to flex neck is
flexed)

o Treatment:
 Corticosteroids
 Antibiotic: if its bacterial
 Analgesics
 Anticonvulsants: if seizures are present

--------
 Contusions:
o Seen with acceleration and deceleration
o Brain is bruised and damaged

 Hematomas: A small hematoma that develops rapidly is more fatal than a

large hematoma that develops slowly
 ICP will go up

 Epidural Hematoma: Rupture or laceration of the middle  EMERGENCY

o Treatment:
 Burr holes: to remove, clot stop the bleeding and control the
ICP
  Subdural Hematoma: Collection of blood between the dura and brain
o Classifications:
o Acute: means fast
o Sub-acute: means medium
o Chronic: means slow  tricky one b/c it imitates
other conditions. Sometimes we think he’s
drunk!! Things can happen after a month
 Here, they bleed inside but it compensates
till the body can’t handle

o Treatment:
 Immediate Craniotomy: to remove clot and control ICP

---

 Concussion: Temp loss of neuro function with complete recovery  key

here is no obvious damage

o Client Education: Teach client to come back to the hospital if these occur:
 Difficulty
 Awakening***
 Speaking
 Confusion
 Severe headache
 Vomiting
 Pulse changes
 Unequal pupils
 One sided weakness
^^^^^^All of these are signs of ICP going UP meaning its not just a
concussion anymore!!!!!!!!!

--------
  Autonomic dysreflexia/Hyper-reflexia: life threatening emergency that
occurs above the level of T6  EMERGENCY

- If not treated, hypertensive Stroke can occur

o S/S: sudden onset

 Severe hypertension
 Headache
 Bradycardia
 Nasal stuffiness
 Flushing and sweating Especially on the forehead
 Blurred vison
 Nausea
 Anxiety

o Causes:
 Distended bladder******
 Constipation or impaction
 Stimuli to the skin
place client in sitting position (elevate HOB) first before any other
implementation.

o Treatment: place client in sitting position (elevate HOB) first before any other
implementation.
 Sit up to lower BP
 Semi fowlers
 Insert catheter
 Remove impaction
 Alleviate skin pressure even a cold breeze
 Antihypertensive: if the BP remains high after stimuli has
been removed
 Teach preventive measures
 Management of Care: LISTEN TO MARK FOR THIS!!

- 5 rights of delegation/Assignment:
 Right task:
 Right Circumstances
 Right person
 Right direction or communication
 Right supervision and evaluation & feedback

o UAP: Right task

 can perform tasks on Stable clients
 Routine, simple and Repetitive: feeding, hygiene, I &O,
routine vital signs and ambulation’s
 CANNOT let UAP take vital signs for a client who’s receiving
blood, IV dopamine, or IV nitro
 UAP cannot get a urine specimen from a catheter:  that is a
sterile procedure
 UAP can do some enemas BUT NOT medicated enemas

o LPN: Think what a nursing student can do!! Can ONLY do stable
clients
 LPN’s cannot do tasks that involve assessments or evaluation
 LPN cannot do any sort of evaluation
 CANNOT develop a plan of care
 Can do data collection
 Updates client data
 Can NOT do IV PAIN MEDS
 They can monitor blood transfusion BUT CANNOT
ADMINISTER
 Can implement task: treatments, administer meds, and
fingerstick, and suction
 They can monitor and reinforce, AND calculate

o Unstable clients include:

 Low Blood sugar
 Sudden changes of nuero checks
 No admission
 Client who is returning from a procedure
 ANYTIME you see acid-base imbalance, they are always
unstable
  COPD client is stable
 Acute is unstable

 Critical Thinking:
Clients with AIDS/HIV have to be in different rooms

Try thinking like the next nurse isn’t as bright

aka dumb so would you really give a partial thickness burn patient (open wound) to a
dumb nurse who is taking care of an HIV (contagious) person. What if the dumb nurse
doesn’t wash his/her’s hand?
 Management Care:

LPNs don’t do Triage (Assessment)

Nonmaleficence is best illustrated with the nurse’s action, as the goal is to do no harm to the
client. With timely reporting of an error, further complications may be prevented.

Beneficence : refers to doing good. This may include compassion and kindness.

Justice : refers to equitable distribution of resources. Triage in the ED is one action that
illustrates justice.

Fidelity : refers to truth-telling. If the client were to ask if a medication error was made, the
nurse would answer yes to the question as a way of demonstrating fidelity

NO BROCHURE = when family expresses fear for something don’t

encourage/promote it. Even if it’s good, it’s not the right time.

FLUIDS near bedside = juices, LPN do NOT mess with IV

Do NOT delegate infections that are contagious and Newly admitted

patients with crazy syndromes to a Floating nurse. POST
CARDIAC CATH is fine to delegate when no S:S ( OB to MED )

Pancreatitis: Back pain , Fever, TACHY, Bruising on the umbilical.

Morphine no good- give Demerol.

AAA- S/S Do NOT include SOB & Hoarseness. Watch out for
pulsation, Abdominal Bruit

Thoracic aneurysm : Hoarseness, back pain and SOB are present.

CARE for ICP and hemorrhage: clients with increased intracranial

pressure need the head placed midline to facilitate cerebral drainage.
Placing the client on the right side would not be performed while the
drain remains in place.
POST-OP- IF patients health is declining, high chances of CALL HCP

Guillain-Barre’ Syndrome- is an acute, rapidly progressing, and

potentially fatal form of polyneuritis. It is characterized by ascending,
symmetric paralysis affecting the cranial and peripheral nerves. Signs
and symptoms include paresthesia, hypotonia, areflexia, muscle aches,
cramps, orthostatic hypotension, hypertension, bradycardia, facial
flushing, facial weakness, dysphagia, and respiratory distress.

Myasthenia Gravis: worsens with exercise and improves with rest

These are three of the primary symptoms of myasthenia gravis. The
muscles of the head and neck are weak and have difficulty holding the
head up. Facial paralysis occurs and drooping of the eyelids develops as
the client’s muscles get tired. The main symptom is weakness in the
voluntary skeletal muscles, which are muscles under your control

Huntington’s disease: Writhing, twisting movements of the face, limbs,

and body is known as chorea

Buerger’s diseas: Tingling, numbness and cool feet are expected findings. These
signs/symptoms are typical of this disorder. The disease is characterized by inflammation in the
arteries that results in a vaso-occlusion type phenomenon. The claudication, with symptoms
described here, can quickly progress to a critical degree of limb ischemia. As it progresses,
revascularization may not be possible, and amputation may be the only viable option. This is
seen almost exclusively in heavy smokers or those who use other forms of tobacco. Medications
are not generally helpful, so stopping tobacco use is basically the only way to stop the
progression of this disease.

Changes associated with menopause, with its dramatic decline in

estrogen, include loss of muscle mass, increased fat tissue leading to
thicker waist, dryness of the skin and vagina, hot flashes, sleep
abnormalities, and mood changes.