��Scope of Practice - determined by a state's Nurse Practice Act �Standards of Practice - established by the nursing profession, i.e., the American Nurses Association �Standard of Care - institutional policy and procedure documents

SBAR technique - provides a standardized framework for communication between members of the health care team S = situation (a concise statement of the problem) B = background (pertinent and brief information related to the situation) A = assessment (analysis and considerations of options - what you found/think) R = recommendation (action requested/recommended - what you want)

2. "I PASS the BATON" - used to improve "handoffs" and transitions in health care, with opportunities to ask questions, clarify, and confirm I = introduction (introduce yourself and your role/job) P = patient (name, identifiers, age, gender, location) A = assessment (presenting chief complaint, vital signs and symptoms and diagnosis) S = situation (current status/circumstances, including code status, recent changes, response to treatment) S = safety concerns (critical lab values/reports, socio-economic factors, allergies, alerts such as falls, isolation, B = background (co-morbidities, previous episodes, current medications, family history) A = actions (what actions were taken or are required and provide brief rationale) T = timing (level of urgency and explicit timing, prioritization of actions) O = ownership (who is responsible - nurse/doctor/team and patient/family responsibilities) N = next (what will happen next? anticipated change? what is the PLAN? What is the contingency plan?)

CUS - a process used to more effectively advocate for clients when there is a concern C = concern ("I am concerned...") U = uncomfortable ("I am uncomfortable...") S = safety ("this is unsafe...")

Five Rights of Delegation �Right Task �Right Circumstances �Right Person �Right Direction/Communication �Right Supervision/Evaluation

The 4 C's of Communication 1. Clear - Does the team member understand what I am saying? 2. Concise - Have I confused the direction by giving too much unnecessary information? 3. Correct - Is the direction given according to policy, procedures, job description, and the law? 4. Complete - Does the delegatee have all the information necessary to complete the task?

Remember the steps in the Nursing Process - A Delicious PIE A= Assessment D= Diagnosis P= Planning I= Implementation

E= EvaluationDocumentation has six key components (CO-ACTS) C onfidential O rganized (chronologically) A ccurate C omplete T imely S ubjective and objective data

REMEMBER IT! A former client sues a nurse for negligence. The client must prove that the nurse not only committed a breach of duty but that this breach of duty was the proximate cause of any damages incurred by the client.

If there is a fire, remember R-A-C-E: R=Rescue or remove clients A=Activate fire alarm system C=Contain fire by closing windows and doors E=Extinguish flames (with fire extinguishers)

Fall & injury prevention 1. Assesses client for risk factors Use the mnemonic FRAIL MOM & DAD for assessing the geriatric client in the primary care setting: Falls Relative or caregiver strain Activities of daily living Incontinence Living situation Memory Impairment Oculo-otic impairment (visual and auditory problems) Malnutrition Drugs Advance directives Depression

Test-taking Tips: Remember that safety always takes “priority” when it is an option and the question is about the priority.

calculate due date: Naegele's Rule (when first day of last normal period = N, then due date is N plus 7 days, minus 3 months, plus 1 year)

The delivery process is described in these terms: •Fetal Station: the relationship between the presenting part of the baby with the mother's pelvis •Fetal Lie: the relationship between the head to tailbone axis for both the fetus and the mother •Fetal Attitude: the relationship of the fetal body parts to one another •Fetal Presentation: portion of the fetus that enters the pelvic inlet first (cephalic, breech, shoulder)

Maternal Postpartum Assessment: BUBBLE-HE

B: BreastsU: Uterine fundusB: Bladder functionB: Bowel functionL: LochiaE: Episiotomy (Perineum)

H: Homan's sign (legs)E: Emotions

Postpartum assessments that would require notifying the health care provider:

MaternalTemperature greater than 100.4 F (38 C) Increased lochia, clots or foul odor Perineal pain or swelling Calf tenderness Appetite loss Sleep disturbances Continued mood swings or depression Elimination problems (burning, frequency or urgency of urination, or persistent constipation)

NewbornTemperature greater than 100.4 F (38 C) Poor feeding effort Vomiting or diarrhea Inconsolable crying Inability to arouse; exceedingly sleepy Yellowing of the skin No wet diaper in eight hours

Postpartum assessment: BUBBLE B=Breasts U=Uterus B=Bowels B=Bladder L=Lochia E=Episiotomy/C-section incision E---can also stand for maternal emotions about the outcomes of the birth and the new baby

Erikson's Eight Stages of Psychosocial Development

Name of Stage Age* Major Characteristic(s)Trust vs. Mistrust Birth to 18 months The development of trust is based on the dependability and quality of the child's caregivers, i.e., feedingAutonomy vs. Shame and Doubt Toddlers (18mts to 3 years-old)Children develop a greater sense of personal control, i.e., toilet trainingInitiative vs. Guilt Preschool (3 to 5 years-old)Children begin to assert their power and control over the world through directly play and other social interaction, i.e., independenceIndustry vs. InferioritySchool age (6 to 11 years-old)Through social interactions, children begin to develop a sense of pride in the accomplishmentsIdentity vs. Role ConfusionAdolescence

(12 to 18 years-old)Exploring independence and developing a sense of selfIntimacy vs. Isolation Early adulthood (18 to 40 years-old) Exploring personal relationships is important, especially love relationshipsGenerativity vs. StagnationAdulthood (40 to 64 years-old) Building careers and familyIntegrity vs. Despair Older adult (65 years to death)Focused on reflecting back on life

Can prevent or minimize illness and disability REMEMBER IT Primary - Prevent Secondary - Screen Tertiary - Treat

CN I: OlfactoryRecall Tip: Odor = one (nose) Identify smells Inability to identify aromCN II: OpticVisual acuity and full visual fieldsFundoscopic exam reveals no pathologyInability to identify full visual fieldsTotal or partial blindness in one or both eyesCN III: OculomotorFollows up to six cardinal positions of gazePupils are unremarkableExhibits no nystagmus and no ptosis One or both eyes will deviate from normal positionCN IV: Trochlear Same as CN III: Oculomotor Same as CN III: OculomotorCN V:TrigeminalClenches teeth with firm bilateral pressureNo lateral jaw deviation with mouth openDifferentiates sharp and dull sensations on faceCorneal reflex: blinks when cotton is touched to each cornea

Absent or one-sided blinking of eyelidsCN VI: Abducens Same as CN III: OculomotorSame as CN III: OculomotorCN VII: Facial Facial symmetry with and without smileCan raise eyebrows symmetrically and grimaceCan shut eyes tightlyCan identify sweet, sour, salt or bitter on the anterior tongue Irregular and unequal facial movementsInability to taste or to identify salt, sweet, sour, or bitter substances on the anterior two-thirds of tongue

Inability to smile symmetricallyCN VIII: Auditory (Acoustic)

Recall Tip: Ear = eighthCan hear a whisper at 1 to 2 feetCan hear a watch tick at 1 to 2 feetDoes not lateralize the Weber testCan hear air conduction better than bone conduction in the Rinne test Inability to hear spoken wordCN IX: GlossopharyngealSwallows and speaks without hoarsenessPalate and uvula rise symmetrically when client states: "ah"Bilateral gag reflexCan identify taste on the posterior tongue Unequal or absent rise of uvula and soft palate as client states: "ah"

Absent gag reflexInability to taste or identify taste on the posterior tongueCN X: Vagussame as CN IX: Glossopharyngealsame as CN IX: GlossopharyngealCN XI: Spinal Accessory Resists head turningCan shrug against resistanceWeak or absent should and neck movementCN XII: HypoglossalCan stick tongue out and move it from side to sideCan push tongue against resistance

REMEMBER IT There are a lot of mnemonics to remember the names of the 12 cranial nerves; here's one of the "cleaner" versions: On Old Olympus Towering Tops A Fin And German Viewed Some Hops

Here's a version to help remember which of the cranial nerves carry sensory, motor, or both types of impulses (S=sensory, M=motor, B=both): Some Say Marry Money But My Brother Says Big Business Makes Money

assist in discussions of future plans as appropriate REMEMBER IT Tasks of mourning (common to the models of grief): R E A L Real - accept that the loss is real Experience the emotions associated with the loss Adjust or re-adjust to life and activities Let go and move on with one's own life

Stress response involves both localized and general adaptation REMEMBER IT PANIC episode: Palpitations Abdominal distress Nausea Increased perspiration Chest pain, chills, chokingWarning Signs of Suicidal Thoughts or Plans

Previous suicide attempt Threatening to commit suicide Giving away prized possessions Collecting and discussing information on suicide methods

Expressing hopelessness, helplessness, and anger at self or world Death or depression in talk, writing, or artwork Client states or suggests s/he would not be missed Client expresses no hope for the future Self-mutilation Recent loss of friend or family member through natural death, accident or suicide; other major loss such as job or divorce Acute personality changes such as unusual withdrawal or aggressiveness, moodiness, or taking risks Sudden change in academic performance, truancy, or running away Physical symptoms such as insomnia or excessive sleeping, headaches, stomach aches Use or increased use of potentially addictive substances Low self esteem; feeling worthless, ashamed, guilty, self-hatingPutting affairs in order, tying up loose ends, changing a will

Communication with individuals with aphasia or dementia is enhanced if you remember the K.I.S.S. technique: Keep It Short and Simple!

The only FDA-approved type of medications used to treat this disorder are SSRIs. Post-traumatic stress disorder (PTSD)

Electroconvulsive therapy (ECT) is used to treat a severe form of this disorder. Depressive disorder

Russell’s sign is observed with this disorder. Bulimia nervosa

A person with this disorder may experience drastic changes in mood accompanied by extreme changes in energy, activity, sleep and behavior. Bipolar disorder

A “drug holidays” are sometimes used in the management of this disorder. Attention deficit hyperactivity disorder (ADHD)

A person with this disorder recognizes their behavior is excessive and unreasonable but cannot stop the behavior. Obsessive-compulsive disorder

A person with this disorder experiences hallucinations and delusional thoughts. Schizophrenia

Malabsorption syndrome and Wernicke-Korsakoff syndrome are associated with this disorder. (Chronic) Alcoholism

This disorder includes Alzheimer’s disease, traumatic brain injury, and Huntington’s disease. Neurocognitive disorders

The child with this disorder has difficulties with social interaction and verbal and nonverbal communication and also exhibits repetitive behaviors. Autism spectrum disorder (ASD)

water soluble : vitamin C and B-complex vitamins (thiamin, riboflavin, niacin, pantothenic acid, biotin, B6, folate, B12) • cannot be stored in body daily intake required

• excess is eliminated daily • little risk of toxicity

ii. fat soluble : A, D, E, K • stored in body (primarily in liver and adipose tissues) • absorbed by the body from the intestinal tract • risk of toxicity

Major electrolytes a. anions

i. chloride • most abundant anion in extracellular fluid • helps balance sodium • normal lab value for serum chloride is 95-105 mEq/L

ii. bicarbonate • part of bicarbonate buffer system • limits the drop in pH by combining with an acid to form carbonic acid and a salt • important in acid-base analyses (arterial blood gases [ABG]) • normal arterial bicarbonate 22-26 mEq/L, normal venous bicarbonate 24-30 mEq/L iii. phosphate • participates in cellular energy metabolism • combines with calcium in bone • assists in structure of genetic material • balanced by parathyroid gland, along with calcium • normal serum phosphate level 2.8-4.5 mg/dL b. cations i. sodium • most abundant cation in extracellular fluid • regulates cell size via osmosis • needed to maintain water balance, transmit nerve impulses, and contract muscles; •used to control blood pressure and blood volume regulates acid-base balance by exchanging hydrogen ions for sodium ions in kidney •sodium is regulated by salt intake, aldosterone, and urinary output •normal lab value for serum sodium is 135-145 mEq/L • large changes may occur with minimal clinical findings • low levels of 125 mEq/L or less result in mental confusion, hostility, hallucinations • excess levels may result in hypertension or generalized edema, called anasarca ii. potassium • most abundant cation of intracellular fluid • potassium pump draws potassium into cell • essential for polarization and repolarization of nerve and muscle fibers • regulates neuromuscular excitability and muscle contraction • regulated by kidneys •normal lab value for serum potassium is 3.5-5 mEq/L • small changes may result in significant clinical findings • high and/or low findings may result in a fast or slow heart rhythm and muscle function with results of cramping in abdomen or legs iii. calcium • needed for cardiac contraction, healthy bones and teeth, functioning of nerves and muscles, clotting of blood • vitamin D is needed for calcium absorption • normal values - total calcium 8.5-10.5 mg/dL hypercalcemia • causes: hyperparathyroidism, metastasis of cancer,

Paget�s disease of bone, prolonged immobilization • findings: weakness, paralysis, decreased deep tendon reflexes

hypocalcemia • causes: rickets, vitamin D deficiency, renal failure, pancreatitis, chelation therapy, hypoparathyroidism • findings: muscle tingling, twitching, tetany iv. magnesium • about half of total body magnesium is found in bone • needed for more than 300 biochemical reactions - involved in normal muscle and nerve function, heart rhythm, immune system, blood sugar regulation, blood pressure, energy metabolism, protein synthesis, and bone strength • normal values - 1.5-2.5 mEq/L

hypermagnesemia • causes: chronic renal disease, overuse of magnesium-containing antacids as Maalox and Mylanta, Addison�s disease, uncontrolled diabetes mellitus • findings: lethargy, nausea, vomiting, slurred speech, muscle weakness, paralysis, decreased deep tendon eflexes, slowing of cardiac conduction

hypomagnesemia • causes: malnutrition, toxemia in pregnancy, malabsorption, alcoholism, diabetic acidosis • findings: mood irritability, cardiac irritability, muscle tingling, twitching, tetany, delirium, convulsions

Types of Vegetarian Diets Vegan: refrains from eating animal products Lacto-ovo vegetarian: consumes eggs and dairy products but excludes meat, poultr

y, seafood Lacto-vegetarian: consumes dairy products, but excludes eggs, meat, poultry, seafood

Remember the reversible causes of urinary incontinence using the mnemonic D.R.I.P. Delirium Restricted mobility (or Retention [urinary]) Infection (or Inflammation or Impaction [fecal]) Pharmaceuticals (or Polyuric states)

Pain Management ABCs A- Assess the client by asking about the pain B- Believe the client�s pain is real C- Let the client make pain management choicesPQRST Format for Assessing Pain P- What provokes the pain? Q- What is the quality of the pain? R- Does the pain radiate? What causes relief? S- What is the severity? T- What is the timing?Normal lab values to know: Sodium: 135 - 145 mEq/L Potassium: 3.5 - 5.1 mE1/L Chloride: 98 - 107 mEq/L Bicarbonate: 22 - 29 mEq/L

As a general rule, classes of drugs have the same generic "last" name: "PRILS" = ACE inhibitors (enalapril, lisinopril) "SARTANS" = angiotensin receptor blockers (losartan, valsartan) "TRIPTANS" = treatment of acute migraine headache "STATINS" = lower LDL cholesterol (simvastatin, rosuvastatin) "DIPINES" = calcium channel blockers (amlodipine, nifedipine) "PRAZOLES" = proton pump inhibitors (omeprazole) "AZOLES" = antifungals (miconazole)

most states require LPN/VNs to observe IV sites and to report the findings to the RN or health care provider; observe for • leakage • clean, dry dressing • site: less than 3 days old infection • warmth • redness • swelling • drainage • tenderness or pain infiltration • swollen • cool to touch • infusion rate slowing or stopping phlebitis • regional pain and swelling • red streak along vein line • leakage, infiltration, or impaired infusion rate

Instilling Eye Drops 1. Wash hands and apply gloves; rinse powdery residue from gloves 2. Instruct client to recline or tilt head back 3. Instruct client to look up 4. Pull lower lid down and to the side

5. Apply drop at lower, outer aspect of eye (lower conjunctival sac) 6. Apply mild pressure to inner canthus for 1 minute to decrease systemic absorption 7. Instruct client to gently close eyes 8. Wait 2 to 5 minutes before instilling additional eye drop (in same eye)

open ear canal • In a child younger than age 3, pull the lobe down and back • In a child older than 3 years, pull the pinna up and back

Coenzyme Q10, coral calcium, ginkgo biloba, huperzine A, omega-3 fatty acids are being used to help with symptoms of dementia (Alzheimer�s Association).

271 271 271271271271271271s

High potassium protein sources: all meats, poultry and fish fruits: apricots, banana , cantaloupe, honeydew, kiwi, oranges, prunes, tomatoes, raisins vegetables: lima beans, potatoes, spinach, (baked) sweet potato with skin, avocado dairy: milk , prune juice other: sunflower seeds , molasses

Vitamin-rich foods iron lean red meat, liver; also clams, oysters, sardines folic acid green leafy vegetables, milk, eggs, liver vitamin B12 meat, seafood, eggs, cheese vitamin K dark green leafy vegetables

Lipid soluble beta blocker eyedrops for glaucoma can be absorbed systemically. If your client states s/he is feeling "blah" or has no energy, don�t assume s/he is depressed. A CNS side effect of these drugs (timolol [Timoptic] and betaxolol [Betoptic]) is fatigue.

O-L-D-C-A-R-T: a comprehensive assessment of clinical indicators of pain O = Onset When did it begin? L = Locations Where is it? D = Duration How long does it last? C = Characteristics What are the qualities? What is the description? A = Attributes How did it start? What caused it? R = Related findings What is the relationship with other things such as eating, position changes, activity, rest? T = Therapy & timing What effective and remedies have been tried? When does it occur (time of day; before or after something else)? Any patterns?

Common AntidotesMedicationMedication Type-PoisonAntidoteacetaminophenN-acetylcysteine (Mucomyst, Acetadote)most effective given within 8 hours of ingesting acetaminophenanticholinergicsphysostigmine

arsenicchelation therapy1) dimercaprol2) penicillamine3) calcium disodium edetate4) succimer (DMSA)benzodiazepines flumazenil (Romazicon, Anexate)

beta blockers(high dose) glucagon

calcium channel blockers glucagon, calcium chloride, calcium gluconate (10%)

cholinergics tropine, pralidoxime (2-PAM)

cyanideamyl nitratesodium thiosulfatehyperbaric oxygen chamber

digitalis/digoxin digoxin antibodies: digoxin immune fab, DigiFab, Digibind

dnoxaparin (Lovenox) protamine sulfate

ethylene glycol Ethanolfomepizole (Antizol)pyridoxine hydrochloride (vitamin B6)

HeparinProtamine sulfate

Hypoglycemic agentsGlucagonoctreotide (Sandostatin)

iron deferoxamine mesylate

leadchelation therapy:1) dimercaprol (BAL)2) penicillamine3) calcium disodium edetate (CaNa2EDTA)4) succimer (DMSA)

magnesium sulfate calcium gluconate

mercury helation therapy:1) dimercaprol (BAL)2) penicillamine3) calcium disodium edetate (CaNa2EDTA)

4) succimer (DMSA)

methanol folinic acid (Leucovorin) and then folic acidfomepizole (Antizol)

mushrooms, muscarinic atropine sulfate

nerve gas (Sarin, soman and VX) atropine sulfate

pralidoxime chloride2-PAM Cl, Protopam)

opioids (codeine, morphine) Naloxone (narcan), nalmefene

snakes (rattlesnakes, copperheads, cottonmouths)Antivenin (Crotalidae) Polyvalent (equine origin)Crotalidae Polyvalent Immune Fab (Ovine)

spiders (black widow) Antivenin (Latrodectus mactans), equine

tricyclic antidepressants sodium bicarbonate

vasopressor infiltration and extravasation phentolamine mesylate (Regitine)

warfarin phytonadione (vitamin K)

(Hypernatremia) Serum Na+ level > 145 mEq/L Thirst, elevated temperature, dry mucous membranes, oliguria, hyperreflexia; infants exhibit depressed fontanelles and irritability

(Hyponatremia) Serum Na+ level < 135 mEq/L Nausea and vomiting; headache; confusion; lethargy; fatigue; appetite loss, restlessness and irritability; muscle weakness, spasms or cramps; seizures; decreased consciousness or coma

(Hyperkalemia) Serum K+ level > 5 mEq/LClient may experience irregular heartbeat; nausea; bradycardia; EKG changes include peaked T wave and depressed P wave, wide QRS complex

(Hypokalemia) Serum K+ level < 3.5 mEq/LMuscle weakness, aches and cramps; tetany; hypotension; constipation; arrhythmias

(Hypercalcemia) Serum calcium level > 10.2 mg/dLConstipation, anorexia, nausea, abdominal pain, muscle twitches and weakness, dementia, irritability

(Hypocalcemia) Serum calcium level < 8.2 mg/dL

Seizures; extrapyramidal symptoms; papilledema; muscle stiffness, myalgias, spasms; positive Chvostek�s and Trousseau�s sign; prolongation of QT interval; diaphoresis

(Hypermagnesemia) Serum magnesium level > 2.1 mEq/LUncommon -Usually associated with increased intake; prolonged PR interval and widened QRS; hyporeflexia, hypotension, respiratory depression and cardiac arrest

(Hypomagnesemia) Serum magnesium level < 1.4 mEq/L Anorexia, nausea, lethargy, weakness, tetany, positive Trousseau’s or Chvostek’s sign, fasciculations, tremor; usually accompanies hypokalemia and hypocalcemia

(Hyperphosphatemia) Serum phosphorus level > 4.1 mg/dLUsually asymptomatic; similar to hypocalcemia

(Hypophosphatemia) Serum phosphorus level < 2.4 mg/dLUsually asymptomatic; anorexia, muscle weakness, osteomalacia

Normal Adult Electrolyte ValuesElectrolyte Value (milliequivalents per liter or mEq/L)Sodium 135 - 145 mEq/LPotassium 3.5 - 5.1 mE1/LChloride 98 - 107 mEq/LBicarbonate (venous) 22 - 29 mEq/LCare of the client in T-R-A-C-T-I-O-N: Temperature (extremities, infection) Ropes hang freely Alignment Circulation check (the 5 P�s) Type & location of fracture Increase fluid intake Overbed trapeze No weight(s) on bed or floorFor client to navigate stairs with crutches, remember: "Up with the Good, Down with the Bad." �To go up stairs, lead with the unaffected or "good" leg, and follow with the affected "bad" leg. �To go down stairs, lead with the affected or "bad" leg, and follow with the unaffected "good" leg.

Postoperative period - postanesthesia care unit (PACU) nursing intervaentionsCare CategoryInterventions Maintain PATIENT AIRWAYMaintainRespiratory effort, rate, rhythm, and depth Stabilize vital signs Position Position client on side (unless contraindicated) or on back with head to side Keep side rails up at all times with bed in lowest position (if possible) Provide For client physical and psychological safety Oxygen as ordered Administer pain medication as ordered StimulateAsk client to spit out airway (shows gag reflex is back) and to lift head off pillow Facilitate elimination of residual anesthesia, indicates ability to clear airway

Stimulate client to take a few deep breaths every 5 to 10 minutes StayCheck vital signs every 15 minutes until stable, then every 30 minutes or as ordered Stay with restless client Determine if restlessness is due to hypoxia

recovery complications and how to reactComplication Reaction 1 Reaction 2Reaction 3 Reaction 4Hypothermia*Apply warmed blankets; always keep client coveredIncrease temperature of recovery roomChange method of assessing Temp and compare results

Hemorrhage√ dressing for intactness√ any dependent area of the dressing, e.g., behind client, and on bed for drainage, blood pooling√ all drainage tubes and note color and amount of drainage√ for internal bleeding, looking for tautness or distention at abdomen or incision siteHypotensionGive IV fluids as orderedMonitor HR and blood pressureAuscultate lungsElevate legs as ordered*Note: shivering may result from certain anesthetics and is not always indicative of hypothermia

REMEMBER IT This might help you to remember the names and location of the heart valves: Tiny right side of the heart = Tricuspid valve Mighty (or Big) left side of the heart = Mitral (or Bicuspid) valve

Leukocytes (white blood cells) increase with infections or inflammation: Leukocyte TypeIncreases in Response to NeutrophilGranulocyteInfection by bacteria or fungus LymphocyteAgranulocyteViral infection or tumor EosinophilGranulocyteInflammation from allergiesBasophil

Granulocyte Inflammation from allergies MonocyteAgranulocyteInfections - nonspecific

THE "CARDIO FIVE" TEACHING PLANTDDDSTopicNursing ActionTTests and Treatments Explain tests and treatments in simple, culturally sensitive waysDDrugsWrite out names and explain reason for drugs, their side effects, and how long client will take themDDietGood nutrition and restrictions, i.e., low sodium diet, reduce cholesterol levelsDDiseaseExplanation of the disorder and treatment planSSmoker? Encourage to stop smoking

abnormal heart sounds : murmur, S3 or gallop or friction rub

Management for symptomatic mitral stenosis - use the DO-ABLE mnemonic D = diuretics - to relieve pulmonary congestion, fluid overload & return to baseline weight O = oxygen - to correct hypoxia A = ACE inhibitors- to reduce preload and afterload, counteracting compensatory hormones B = beta-blockers - to prevent arrhythmias and reduce heart workload L = low sodium diet - to prevent fluid retention E = exercise as tolerated - to monitor response to therapy and return to baseline functional status g. surgery - mitral valve repair or replacement for severe or recurrent episodes of heart failure

Self-care instructions for heart failure: R-E-A-L keys R=eport findings of heart failure to provider - weight gain, worsening dyspnea, orthopnea, fatigue E=xercise is important - start low & go slow to increase functional capacity, attending to symptoms A=dherence to cardiac medications is essential to staying healthy L=ow sodium diet - 2000 grams per day

CARDIAc LeVeLS assessment for heart failure symptoms and complications C = chest discomfort A = activity tolerance R = response to drug therapy D = depression and anxiety I = increased weight A = arrhythmias L = lightheadedness V = vital sign - changes

L = level of consciousness - decreased S = shortness of breath Treatment for pulmonary edema: M DOG M= Morphine D= Diuretics (furosemide) O= Oxygen G= Gases (blood gasses)

Therapeutic treatment for Myocardial infarction: "O BATMAN!" O=Oxygen B=Beta blocker A=ASA (aspirin) T=Thrombolytics (heparin) M=Morphine A=ACE (especially for those with heart failure or a lower ejection fraction) N=Nitroglycerin

Heart Failure symptoms listed in order of earliest to later findings Right Left

Significant weight gain Fatigue and activity intolerance Jugular vein distention Bilateral dependent peripheral edema Liver engorgement (hepatomegaly with abdominal pain, anorexia, and nausea) Ascites Fatigue and activity intolerance Cough (often dry initially) Mild weight gain that leads to early pulmonary symptoms Shortness of breath/orthopnea Paroxysmal nocturnal dyspnea Tachypnea Crackles S3 heart sound Cardiac cachexia and muscle weakness in advanced stage

Acute pulmonary edema: Frothy sputum (may be blood-tinged) Restlessness, irritability, hostility, agitation, anxiety Prominent crackles throughout lung fields Diaphoresis Cyanosis

classic triad of signs a. hypotension with b. muffled heart sounds with c. marked jugular vein distention if no hypovolemia

Clinical practice guidelines indicate that individuals with a systolic blood pressure of 120–139 mm Hg or a diastolic blood pressure of 80–89 mm Hg should be considered as "prehypertensive" and will require health-promoting lifestyle modifications to prevent cardiovascular disease (National Heart Lung and Blood Institute, 2003).

Complementary and Alternative Medicine Garlic, ginseng dried root, hawthorn, and snakeroot have been used to treat hypertension; however, there’s not enough research to support the efficacy and safety of these herbal therapies. Supplements: Coenzyme Q10 (CoQ10) supplements may cause small decreases in blood pressure; lo

w blood levels of CoQ10 have been found in people with hypertension Omega-3 fatty acids supplements may lower blood pressure Amino acid L-arginine diet supplements may temporarily lower blood pressure

Alternative systems of care Traditional Chinese medicine Avurveda

Note: Licorice and ephedra should not be used by people with hypertension because they can increase blood pressure.

Management of atrial fibrillation: ABCD A=Anticoagulant B=Beta blocker to control rate C=Cardioversion (if beta blocker ineffective or calcium channel blocker to control rate) D=Digoxin

6 P�s of acute arterial occlusion: Pallor (or mottling) Pain Paresthesia (numbness or tingling) Pallor (cool or cold skin) Pulselessness (distal to the blockage) Paralysis (or weakness or muscle spasm)

Remember Acid-Base lab interpretation using - R.O.M.E. R=Respiratory O=Opposite M=Metabolic E=Equal

respiratory acidosis*↓ (< 7.35)↑ (> 26)↑ (> 45)increased renal acid excretion respiratory alkalosis↑ (> 7.45)↑ (> 26)↑ (> 45)decreased renal acid excretion metabolic acidosis ↓ (< 7.35) ↓ (< 22) ↓ (< 35)hyperventilate metabolic alkalosis↑ (> 7.45)↑ (> 26)↑ (> 45)hypoventilate

To remember the classic findings of Parkinson�s disease think: T-R-A-P T= tremors R= rigidity A= akinesia/bradykinesia P= postural instability

To help remember PUD treatment, use this phrase: "Please Make Tummy Better" P= Proton pump inhibitor M= Metronidazole T= Tetracycline B= Bismuth subsalicylate

Don�t confuse these three! Ileum = most distal part of the small intestine Ileus = an obstruction (often in an intestine) Ilium = part of the hipbone

The 6 �F�s for gallbladder disease: Fair (skin and hair) Fat Forty (and older) Fertile (lots of children) Female Flatulent

Antihypertensives may cause orthostatic (postural) hypotension. Remember to teach clients to change "postures" slowly to prevent "postural" hypotension. Men taking medications for erectile dysfunction are at greater risk.

Don�t be confused by these terms! Cystocele is a hernia (the bladder drops into the vagina), but endometriosis can lead to cyst formation outside the uterus.

ENDOCRINEAdrenal gland (cortex) hormones - SSS S=Sugar (glucocorticoids) S=Salt (mineralocorticoids) S=Sex (androgens)

To help remember the glands of the endocrine system, remember: "Herman Probably Pasted The Paper To A Pot Of Tea" H=Hypothalamus P=Pituitary P=Pineal T=Thyroid P=Parathyroid T=Thymus A=Adrenal P=Pancreas O=Ovaries T=Testes

S/of hyperparathyroidism can be remembered as: "moans, groans, stones, and bones... with psychic overtones."

When reading the stem of the question, give special attention to words such as: BEST, MOST, LEAST, FIRST, PRIORITY, INITIAL

Although it�s extremely oversimplified, think of the relationship between insulin and glucose as a see-saw. When one is higher, the other tends to be lower.

Nursing Care for sprains and strains: RICE R= Rest I= Ice C= Compression E= Elevationapply cold to minimize edema The 5 P�s of circulation checks:

P=Pain P=Paresthesia P=Paralysis P=Pulse P=Pallor (Paleness)

Carefully read each multiple-choice question to looking for key concepts that are familiar to you. Try rephrasing the question, but do NOT read anything into it.

For client to navigate stairs with crutches, remember: "Up with the Good, Down with the Bad." �To go up stairs, lead with the unaffected or "good" leg, and follow with the affected "bad" leg. �To go down stairs, lead with the affected or "bad" leg, and follow with the unaffected "good" leg.

ONCOLGY

CANCER Interventions:

C=Comfort A=Altered body image N=Nutrition C=Chemotherapy E=Evaluate response to medications R=Respite for caretakers

Age appropriate diversional activities:

Toddler washable soft toys, appropriate cartoons, action toys (wagon, push toys) Kindergartenappropriate cartoons, washable stuffed doll, coloring books and crayons, action toys School -age appropriate cartoons or video games, coloring book and crayons, school work when appropriate, computer, beads for creating jewelry Middle - School computer or cell phone, appropriate video games, school work when appropriateHigh -School computer or cell phone, appropriate video games, school work when appropriate

Children, particularly toddlers and pre-schoolers, tend to have bruises as a result of play. Any unusual bruising -on the back or neck, large or dark bruises- needs to be checked out. It could be the first sign of leukemia or it could possibly due to child abuse. If you are unsure, be sure that another nurse checks the child with you.

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Types of shock are classified according to etiology: CHANS Cardiogenic - caused by inability of the heart to pump blood effectively (due to heart attack or heart failure) Hypovolemic - caused by inadequate blood volume (due to bleeding or dehydration) Anaphylactic - caused by allergic reaction Neurogenic - caused by damage to nervous system (due to extreme emotional upset due to personal tragedy or disaster) Septic - caused by systemic infection

AplicationNursing ActionRationaleAActivities of daily living(ADLs) Help the client with ADLs it stresses the heart lessBBed rest Maintain bed rest it reduces the oxygen demands on the heartCCommode

Commode at bedsideit stresses the heart less than using abedpanDDiversionsOffer diversionary activities while on bedrestoffer diversions that don�t stress the heartEElevate Elevate head of bed (semiFowler�s) or sit client upto increase chest expansion and improve ventilationFFeelings Listen to client�s concerns; provide emotional support to reduce anxietyanxiety increases oxygen demand

THE TRAUMA CLIENTAssessment and early management of the trauma client includes the following:Emergency trauma assessment: ABCDEFGHI Primary Assessment = A, B, C, D & E Secondary Assessment = F, G, H & I

Remember A-I mnemonic for trauma client�s: A=Airway with simultaneous cervical spine protection B=Breathing C=Circulation D=Disability (neurologic status) E=Exposure/environmental controls F=Full set of vital signs/focused adjuncts/family presence G=Give comfort measures H=History and Head to toe assessment I=Inspect posterior surfaces

Primary survey: ABCs A = airway maintenance with spinal cored control, i.e., cervical stabilization B = breathing C = circulation

For the initial assessment - use the AVPU mnemonic: A=Alert - Speak to the client; a client who is alert and responsive is considered "A" (for "alert") V=Verbal - The client who responds to verbal stimuli is considered "V" (for "verbal") P=Pain - Apply a painful stimulus; a client who does not respond to a verbal stimuli but does respond to a painful stimulus is considered "P" (for "pain") U=Unresponsive - The client who does not respond to a painful stimulus is considered "U" (unresponsive)

CPR Compressions - Airway - Breathing ("C-A-B")

Complications of a trauma client: TRAUMATIC T=Tissue perfusion problems R=Respiratory problems A=Anxiety U=Unstable clotting factors M=Malnutrition A=Altered body image

T=Thromboembolism I=Infection C=Coping problems

PEDSCyanotic defects - the 4 T�s: T=Tetralogy of fallot T=Truncus arteriosus T=Transportation of the great vessels T=Tricuspid atresia

When assessing diarrhea or constipation, remember the acronym ACCT: A= amount C= color C= consistency T= time (duration)

Associate Hirschsprung�s with a girl ("her") who wears "ribbons" in her hair - to recall that "ribbon-like" stools are a classic finding of this disease.

Newborn’s skin is thinner, more easily hurt by endotoxins and tearing forces Child’s body absorbs more of topical products Harder to regulate body temperature