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
Cerebral Angiography BEFORE 1. Informed consent 2. Explain procedure 3. Lie the patient flat 4. Dye injected into femoral artery. Fluoroscopy & radiologic films taken after injection 5. Procedure Sedation 6. Skin prep; Chosen site shaved 7. Mark peripheral pulses 8. May experience feeling of warmth and metallic taste when dye injected AFTER 1. Neurological assessment every 15-30 minutes until vitals stable 2. Keep flat in bed 12 to 14 hours 3. Check puncture site every hour 4. Immobilize site for 6 to 8 hours 5. Assess distal pulses, color & temperature 6. Observe symptoms of complications (allergic response to dye, puncture site, hematoma) 7. Force fluids 8. Accurate I&O
Lumbar Puncture BEFORE 1. Informed Consent 2. Explain procedure 3. Position patient in lateral recumbent\fetal position at edge of bed
AFTER 1. 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
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 enlarged uterus
Potassium Rich Foods • • • • • • •
Kiwi Oranges Dried Fruit Bananas Cantaloupe Avocados Broccoli
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Dried Beans/Peas Lima Beans Mushrooms Potatoes Seaweed Soybeans Spinach
Sanguineous BRIGHT RED Indicates active bleeding •
Serous Watery or Clear usually normal •
Serosanguineous Pink tinged Indicative of some bleeding •
Purulent Yellow/Green Infection •
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 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 • • • • • • •
Phosphate Rich Foods • • • • • • •
Fish Eggs Milk Cheese Large amounts of meat & fish Whole grains Carbonated beverages
Cardiac Catheterization BEFORE 1. 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 hour 2. Check pulses, sensations, and bleeding at insertion site 3. Bed rest 6-8 hours with insertion site extremity straight!
SIADH Early symptoms 1. Headache 2. 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 daily same 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, hypothermia 8. Monitor decreased serum sodium + elevated urine sodium osmolality
Heart Failure Teaching Teaching 1. Follow fluid and sodium restrictions 2. Conserve energy schedule REST PERIODS 3. Adhere to medication regimen 4. Weight self daily notify health care provider of weight gain of 2lbs/24 hours OR 5lbs in 1 week* 5. Get influenza vaccine yearly 6. If prescribed DIGOXIN, DIGOXIN, take take pulse for 1 minute. Notify health care provider if pulse is below 60bpm. 7. Take diuretics in early morning and early afternoon 8. Notify 8. Notify health care provider provider of increased dyspnea, orthopnea, and inability to wear rings or shoes*
Iron Rich Foods • • • • • • • •
Red meat Kidney & Lima beans Egg yolk Chickpeas Cooked Swiss chard Liver Molasses Lentils
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Carrots Raisins Apricots Kale Spinach Organ Meats Clams
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
Magnesium (1.5-2.5) Below 1.5 = Hypomagnesaemia • • • • • • • •
Arrhythmias Seizures Tetany Muscle weakness Irritability Lethargy Dizziness Confusion
Above 2.5 = Hypermagnesaemia • • • • • • • •
Arrhythmias Muscle weakness and fatigue Nausea/Vomiting Flushing & Sweating Loss of deep tendon reflexes Respiratory depression Hypotension Loss of consciousness
Sodium (135-145) Below 135 = Hyponatremia Nausea Seizures Confusion Muscle weakness Headache Apprehension *Fresh water drowning • • • • • •
Above 145 = Hypernatremia Lethargy Neuromuscular Neuromuscu lar excitability excitability Irritability Muscle twitching Weakness Fever Increased Blood Pressure Edema *Heart Failure, Cushing's Syndrome, Diabetes Insipidus • • • • • • • •
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 • • • • • • • • • • • •
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 • • • •
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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 1. Stop the IV 2.Apply 2. Apply warm compress 3.Elevate 3. Elevate arm 4.Start 4. Start IV in new site OR opposite arm *Infiltration, Phlebitis, Infection, Thrombosis, Thrombophlebitis Treatment 1.Discontinue 1. Discontinue IV 2.Apply 2. Apply pressure 3.Apply 3. Apply cool compress 4.Start 4. Start IV in new site OR opposite arm *Hematoma
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
Need to know *** Lab values*** Electrolytes Chemistry Sodium: 135-145 Glucose: 70-110 Potassium: 3.5-5.0 BUN: 7-22 Calcium: 8.5-11 Creatinine: 0.5-1.2 Chloride: 95-105 CPK: 21-232 Magnesium: 1.5-2.5 Urine specific gravity: 1.010Phosphorus : 2.5-4.5 1.030 Bilirubin: <1.0 Hematology Total Cholesterol: 130-200 RBC: 4.5-5.0 million LDH: 100-190 WBC: 5,000-10,000 Triglyceride: <150 Platelets: 200,000-400,000 Protein: 6-8 Hemoglobin: 12-18 Albumin: 3.5-5.0 Uric acid: 3.5-7.5
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. Gradually work toward the nipple. Then switch to the right arm behind your head and use the left arm 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.
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, lumps, changes in size or irregularities. irregularities.
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 • • • • • •
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 • • • • • • •
The FIVE P's P's and and F's Fractures - 5 P's Pallor Pain Pulselessness Paralysis Parasthesia Cholelithiasis - 5 F's Fat Forty Fair Skin Fertile Female
Calcium Rich Foods • • • • • • • • • • •
Collard greens Dairy Spinach Tofu Sesame Seeds Almonds Cereal Broccoli Bok Choy Black beans Turnip greens
Parkinson's Disease Clinical manifestation manifestationss 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 wandering Dysphasia Inability to perform ADLS Depression Combativeness • • • • • • •
Blood Transfusion Reaction If transfusion reaction suspected 1. STOP blood transfusion 2. 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.
Pediatrics - Normal Vitals Newborn RR 30-60 per min HR 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 <120/80 mm Hg
Diets and Diseases Gout: Low Gout: Low purine diet (no fish or organ meats) Celiac disease: Gluten disease: Gluten free diet (No wheat, oats, rye, barley) Renal failure: High failure: High calorie, low protein diet, as allowed by kidney function Cystic Fibrosis: Replacement Fibrosis: Replacement of pancreatic enzymes before or with meals. High protein and High High Calorie Calorie Atherosclerosis: Low saturated fat die, Cholesterol lowering agents given before Atherosclerosis: Low meals
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 Absorption 1. Milk 2. Antacids 3. Caffeine (coffee, tea, soda) 4. Calcium supplements
Diabetes Patient Teaching Inspect feet daily Wash feet daily with mild soap and warm water Pat feed dry; especially between between toes Use mild foot powder on sweaty feet Consult podiatrist No commercial commercial remedies to remove calluses 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 • • • • • • • • • • • • •
Strokes Always be sure to assess a client's ability to swallow before feeding and a post-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 Straws are NOT to be indicated to patients with swallowing impairment (Increases risk for aspiration) • • • • •
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<100 beats/min could indicate excessive blood loss or infection. Respirations Should be within normal limits. If RR increase significantly, suspect pulmonary embolism, uterine uterine atony or hemorrhage. Blood Pressure Should be within normal limits. Suspect hypovolemia if it decreases •
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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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Tuberculosis Assessment • Persistent cough • Purulent sputum; possibly blood-streaked • Fatigue + lethargy • Weight loss + anorexia Night sweats + Fever Interventions • Administer heated and humidified oxygen therapy as prescribed • Obtain sputum samples •
Prevent infection transmission. -Wear N95 or 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 longer considered infectious after three negative sputum culture • Clients are not longer considered •
Barbiturates Intoxication -Talkative -Slurred Speech -Hallucinations/Delirium -Euphoric -Fever
Withdrawal -Decrease respiration -Seizures -Insomnia -Tremors -Anxiety/Tachycardia
Opioid/Narcotics Intoxication -Pin point pupils (dolls eyes) -Slurred Speech -Respiratory & circulatory depression -Unconsciousness/death
Withdrawal -Dilated eyes -Fever -Yawning -Abdominal cramps -Watery eyes -Diaphoresis
Alcoholism Minor Withdrawal -Anxiety -Agitation -Irritability -N/V -Hangover
Major withdrawal -Life threatening -Hypertension -Tachycardia -Tremors -Seizures
Strategies I used for the NCLEX Expected vs. Unexpected Chronic vs. Acute Stable vs. Unstable Potential vs. Actual Problem Safe vs. Unsafe Fast vs. Slow Physical vs. Psychosocial
A, B, C's Getting clues from the answers If you can do one thing and go home for your patient
NCLEX TIPS 1. NEVER ask "why?" or say "do not worry" 2. NEVER leave the patient alone 3. ALWAYS choose the safest answer possible 4. DO NOT read into the question 5. DO NOT pass the buck 6. DO NOT "do nothing" or "continue to document" UNLESS everything is normal or expected! 7. NEVER persuade the patient 8. ELIMINATE answers with absolute words: "ALWAYS, NEVER, ONLY" 9. DO NOT delegate assessment, teaching, or evaluation 10. ELIMINATE answers with YES/NO questions 11. COMA, COMA AND RULE: All parts of the answe r must be correct! 12. Pay attention to words such as: PRIORITY, FIRST, BEST, INITIAL etc . 13. You ALWAYS have an order 14. READ the question and the answer you choose before clicking NEXT. 15. DO NOT be too quick to answer familiar questions. ALWAYS carefully read and understand questions before answering. 16. NEVER panic when you don't know the topic or answer to a question. Don't give up. Try getting clues from the answers and begin to eliminate choices that are: not safe, are not priority, etc. 17. RELAX:) Take a few deep breaths before each question. It only takes a few seconds! IT HELPS! 18. TAKE A BREAK! Even if you want to keep going, your brain needs a break. 19. REST AND DIGEST the night before! 20. STAY POSITIVE! Would it hurt to stay positive? :) You CAN do this!!!!
