Nclex Charts
Transcript of 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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