nclex charts

8/9/2019 Nclex Charts

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MY NCLEX NOTES & CHARTS

YouTube: @Heyrona

"Our greatest weakness lies in giving up. The most certain way to

succeed is always to try just one more time."

-Thomas A. Edison


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Cerebral Angiography

BEFORE

1. Informed consent2. Explain procedure

3. Lie the patient flat

4. Dye injected into femoral artery. Fluoroscopy & radiologic films taken after injection

5. Procedure Sedation6. Skin prep; Chosen site shaved

7. Mark peripheral pulses

8. May experience feeling of warmth and metallic taste when dye injected

AFTER1. Neurological assessment every 15-30 minutes until vitals stable

2. Keep flat in bed 12 to 14 hours3. Check puncture site every hour

4. Immobilize site for 6 to 8 hours5. Assess distal pulses, color & temperature

6. Observe symptoms of complications (allergic response to dye, puncture site,

hematoma)

7. Force fluids8. Accurate I&O


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Lumbar Puncture

BEFORE

1. Informed Consent2. Explain procedure

3. Position patient in lateral recumbent\fetal position at edge of bed

AFTER1. Neuro checks every 15-30 minutes

2. Position flat for several hours

3. Encourage P.O. fluid to 3,000 mL

4. P.O. analgesics for headache

5. Observe insertion site for bleeding


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Urinary Frequency Teaching

1. Empty the bladder frequently (every 2 hours)2. Drinking at least 2000 mL of fluid per day

3. Limiting fluid intake before bedtime (NOT avoiding fluid

intake)

4. Perform kegel exercises to strengthen the perineal muscles

5. Wearing a perineal pad

OB Maternity

*May occur in the first trimester and then again late in the third

trimester because of pressure placed on the bladder by the enlargeduterus


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Sanguineous

BRIGHT REDIndicates active bleeding

Serous

Watery or Clearusually normal

Serosanguineous

Pink tingedIndicative of some bleeding

Purulent

Yellow/GreenInfection


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CVA (Stroke)LEFT CVA

Aphasia (language difficulty) Alexia (reading difficulty)

Agraphia (writing difficulty)

Right hemiplegia or hemiparesis

Slow, cautious behavior

Depression & quick frustration visual changes, such as hemianopsia

*Responsible for language, mathematic skills, & Analytic thinking

RIGHT CVA

Unawareness of deficits

Loss of depth perception

Disorientation

Impulse control difficulty Poor Judgment

Left hemiplegia OR hemiparesis

Visual changes, such as hemianopsia

*Responsible for visual and spatial awareness &proprioception


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Phosphate Rich Foods

Fish

Eggs

Milk

Cheese

Large amounts of meat & fish

Whole grains

Carbonated beverages


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Cardiac Catheterization

BEFORE1.

Informed consent

2.

Explain procedure

3.

NPO 8-12 hours

4.

Empty bladder

5.

Check pulse

6.

Explain client may experience heat palpitations; desire to cough

when dye injected

AFTER

1.Monitor vitals every 15 min for 2 hours. Then every 30 min for 1

hour2.

Check pulses, sensations, and bleeding at insertion site

3.Bed rest 6-8 hours with insertion site extremity straight!


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SIADH

Early symptoms

1.

Headache2.

Muscle cramps

3.

Weight gain (no edema: Due to water being retained, NOT sodium)

Nursing Interventions

1.

Restrict oral fluids 500-1000mL/day

2.

Weigh dailysame clothes + same time

3.Report altered LOC [headaches, confusion, lethargy]

4.

Take seizure precautions

5.

Monitor intake/output accurately

6.

Medications: Demeclocycline or Lithium carbonate

7.

Monitor Vitals: tachycardia, increased BP, hypothermia8.

Monitor decreased serum sodium + elevated urine sodium

osmolality


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Iron Rich Foods

Red meat

Kidney & Lima beans

Egg yolk

Chickpeas

Cooked Swiss chard

Liver

Molasses

Lentils

Carrots

Raisins

Apricots

Kale

Spinach

Organ Meats

Clams


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Blood Transfusion Reactions

Circulatory overload*Chest or lumbar pain, cyanosis, dyspnea, moist productive

cough, crackles in the lung bases, distended neck veins,

increased BP

Sepsis*Tachycardia, Fever, abdominal cramps, N/V, diarrhea

Allergic + Transfusion Reaction

*Flushing, itching, urticarial, tachycardia, low back pain

Febrile Reaction

*Fever, chills, nausea


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Sodium (135-145)Below 135 = Hyponatremia

Nausea Seizures

Confusion

Muscle weakness

Headache

Apprehension

*Fresh water drowning

Above 145 = Hypernatremia Lethargy

Neuromuscular excitability

Irritability

Muscle twitching

Weakness Fever

Increased Blood Pressure

Edema

*Heart Failure, Cushing's Syndrome, Diabetes Insipidus


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Tyramine Rich Foods

Red wine

Beer

Chocolate

Aged Cheese

Yogurt

Soy Sauce

Sauerkraut (sour cabbage)

Liver

Pizza or Homemade bread

Meats that have been fermented

Figs

Bananas


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Peripheral IV Complications

Infiltration Pain on IV site

Cool and pale

Flow of IV Stopped

IV now into subcutaneous

tissue

Phlebitis Redness

Pain

Swelling

Inflammation of vein

Infection

Fever Pain at the site

Thrombosis Presence of a blood clot

Absent pulses below the site of

the clot formation

Thrombophlebitis

Pain & swelling

Redness Warmth

Fever

Leukocytosis (Increased

WBC)

Hematoma

Leak of blood Bruise

Swelling


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Peripheral IV Treatment (Contin.)Treatment

1.

Stop the IV2.

Apply warm compress

3.

Elevate arm

4.

Start IV in new site OR opposite arm

*Infiltration, Phlebitis, Infection, Thrombosis, Thrombophlebitis

Treatment

1.

Discontinue IV

2.

Apply pressure

3.Apply cool compress

4.Start IV in new site OR opposite arm

*Hematoma


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Therapeutic Drug Levels

Digoxin: 0.5-2.0 ng/mL

Lithium: 0.8-1.5 mEq/mL

Dilantin: 10-20 mcg/mL

Theophylline: 10-20 mcg/mL


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Need to know *** Lab values***

Electrolytes

Sodium: 135-145Potassium: 3.5-5.0

Calcium: 8.5-11

Chloride: 95-105

Magnesium: 1.5-2.5

Phosphorus : 2.5-4.5

Hematology

RBC: 4.5-5.0 million

WBC: 5,000-10,000

Platelets: 200,000-400,000Hemoglobin: 12-18

Chemistry

Glucose: 70-110BUN: 7-22

Creatinine: 0.5-1.2

CPK: 21-232

Urine specific gravity: 1.010-

1.030Bilirubin:


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Breast Self-Examination

1. Stand in front of the mirror. Observe both breasts for anything unusual, such as lumps,dimpling, nipple retraction or scaling of the skin.

2. Watching closely in the mirror, clasp hands behind your head and press hands forward.

3. Next, press hands firmly on HIPS and bow slightly as you pull your shoulders and

elbows forward.

4. Raise your left arm behind your head. Use three or four fingers of your right hand to

feel for nodes, irregularity, and tenderness. Beginning at the outer edge, press the flat part

of your fingers in small circles, moving the circles slowly around the breast. Graduallywork toward the nipple. Then switch to the right arm behind your head and use the leftarm to exam the breast.

5. Gently squeeze each nipple and observe for discharge.

6. Steps 4 and 5 should be repeated while lying flat on your back.


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Testicular Self-Examination

1. Stand in front of a mirror and check for any swelling on the scrotal skin.2. Cup one testicle at a time using both hands. This is best performed during or after a

warm shower.

3. Roll the testicle gently between the thumbs and fingers. You should not feel any pain

when doing the examination.

4. Feel for lumps, changes in size or irregularities.


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Calcium (8.5-11)Below 8.5 = Hypocalcemia

Tetany

Positive Trousseau's sign

Positive Chvostek's sign

Seizures

Confusion

Irritability

Above 11 = Hypercalcemia

Muscle weakness

Lethargy

Constipation

Kidney stones

Nausea

Dysrhythmias


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Potassium (3.5-5.0)

Below 3.5 = Hypokalemia

Dysrhythmias Muscle weakness

Nausea/Vomiting

Respiratory Depression

Constipation

Above 5.0 = Hyperkalemia

EKG changes

Dysrhythmias-Irregular

Muscle weakness

Irritability &Anxiety

Decreased BP

Diarrhea

Nausea

*Addison's Disease


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The FIVEP'sand F's

Fractures - 5 P'sPallor

Pain

Pulselessness

Paralysis

Parasthesia

Cholelithiasis - 5 F's

Fat

Forty

Fair Skin

FertileFemale


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Calcium Rich Foods

Collard greens Dairy

Spinach

Tofu

Sesame Seeds

Almonds

Cereal Broccoli

Bok Choy

Black beans

Turnip greens


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Parkinson's Disease

Clinical manifestations

Resting tremor Pill rolling of fingers

Drooling

Shuffling gait

Mask-like face

Forward flexion of trunk

Muscle rigidity + weakness

Alzheimer's Disease

Clinical manifestations

Forgetfulness

Short attention span

Night wandering

Dysphasia

Inability to perform ADLS

Depression

Combativeness


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Blood Transfusion Reaction

If transfusion reaction suspected

1. STOPblood transfusion2. Run normal saline to maintain IV access

3. Notify physician and blood bank of reaction STAT

4. Administer ordered medications

5. Draw blood sample for culture, plasma and hemoglobin

6. Collect urine sample and send to lab

7. Monitor voiding for hematuria

Anaphylactic Reaction

Support airway, breathing, circulation

Administer epinephrine, antihistamines, and corticosteroids

Hemolytic Reaction

Consider low-dose dopamine to improve renal blood flow

Maintain renal perfusion with aggressive fluid resuscitation Furosemide to increase renal blood flow

Febrile

Acetaminophen to treat fever

If patient develops chills, cover with blanket unless temp is >102 F.


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Pediatrics - Normal Vitals

Newborn

RR 30-60 per minHR 120-160 bpm

BP 65/40 mm Hg

1-4 years

RR 20-40 per min

HR 80-140 bpm

BP 90-99/60-65 mm Hg

5-12 years

RR 15-25 per min

HR 70-115 bpm

BP 100-110/56-60 mm Hg

Adult

RR 12-20 per min

HR 60-100 bpm

BP


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Diets and Diseases

Gout:Low purine diet (no fish or organ meats)

Celiac disease:Gluten free diet (No wheat, oats, rye, barley)

Renal failure:High calorie, low protein diet, as allowed by kidney function

Cystic Fibrosis:Replacement of pancreatic enzymes before or with meals. High

protein and High Calorie

Atherosclerosis:Low saturated fat die, Cholesterol lowering agents given before

meals


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Iron Supplements

Take with Vitamin C [Increase absorption] DO NOT take with antacids

Will have greenish black stools from meds

Should always be taken with food to decrease gastric upset

Decrease Iron Absorption1.

Milk

2.

Antacids

3.

Caffeine (coffee, tea, soda)

4.

Calcium supplements


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Diabetes

Patient Teaching Inspect feet daily

Wash feet daily with mild soap and warm water

Pat feed dry; especially between toes

Use mild foot powder on sweaty feet

Consult podiatrist

No commercial remedies to remove calluses or corn

The best time to cut nails is after a bath or shower

Separate overlapping toes with cotton

Avoid open toe or open heel shoes

Leather shoes preferred over plastic ones

DO NOT go barefoot

Wear clean cotton socks

Avoid prolonged sitting; standing; crossing legs


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Strokes

Always be sure to assess a client's ability to swallow before feeding and apost-stroke client

Medications do NOT always need to be crushed

ALL medications should be administered one at a time

Assess gag reflex; ability to swallow and cough

If unilateral weakness, place medication on stronger side of the mouth

Strawsare NOT to be indicated to patients with swallowing impairment(Increases risk for aspiration)


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Expected Normal Postpartum Vitals

Temperature Could increase to 100.4 F. Any higher elevation may be caused by infection

and must be reported.

Pulse

May decrease to 50 beats/min. Pulse


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Pneumonia

Interventions Administer heated and humidified oxygen therapy as prescribed

Position the client in high-fowler's position to facilitate air exchange

Encourage coughing, or suction to remove secretions

Encourage deep breathing with an incentive spirometer to prevent alveolar collapse

Administer medications as prescribed:

-Antibiotics

-Bronchodilators-Corticosteroids-Immunizations

Promote adequate nutrition

Provide support to the client and family

Encourage verbalization of feelings


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TuberculosisAssessment

Persistent cough

Purulent sputum; possibly blood-streaked

Fatigue + lethargy

Weight loss + anorexia

Night sweats + Fever

Interventions

Administer heated and humidified oxygen therapyas prescribed

Obtain sputum samples

Prevent infection transmission.

-Wear N95or HEPA respirator when caring for hospitalized TB client

-Negative airflow room and Airborne precautions

-Client must wear a mask if transportation to another department is necessary

Administer medications and encourage fluid intake

Diet: Foods rich in protein, iron and vitamin C

Teaching

Teach client and family importance of medication regimen (6 months to a year)

Encourage proper hand washing

Cover the mouth and nose when coughing or sneezing

Clients with active Tb should wear masks when in public places

Clients are not longerconsidered infectiousafter three negative sputum culture


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BarbituratesIntoxication Withdrawal

-Talkative -Decrease respiration

-Slurred Speech -Seizures-Hallucinations/Delirium -Insomnia

-Euphoric -Tremors

-Fever -Anxiety/Tachycardia

Opioid/NarcoticsIntoxication Withdrawal

-Pin point pupils -Dilated eyes

(dolls eyes) -Fever-Slurred Speech -Yawning

-Respiratory & -Abdominal cramps

circulatory depression -Watery eyes

-Unconsciousness/death -Diaphoresis

Alcoholism

Minor Withdrawal Major withdrawal-Anxiety -Life threatening

-Agitation -Hypertension

-Irritability -Tachycardia

-N/V -Tremors

-Hangover -Seizures


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