Contact Precautions

Before entering: Wash hands THEN don gloves 1st and gown 2nd .
Pt. gets private room.
Upon leaving: Remove gloves 1st and then gown. Gown worn
during transport.
Examples: MRSA, RSV (also droplet), C. DIFF, Scabbies
Airborne Precautions
Same order for don. Wear N95 mask, and remove
mask AFTER leaving the pts room.
Keep pts door closed at all time, private room with neg. air
pressure. Mask worn during transport.
Examples: Varicella (chicken pox), Measles (Rubeola), TB, Herpes
disseminated.
Droplet Precautions
Private room, and door may be open. Only need surgical mask
within 3 feet of patient.
Example: Pneumonia, Menicoccal Menigitis, Influenza, RSV,
Strept, Scarlet Fever, Pertussis, Rubella, Mumps, H. Influenzae
type B.

ELECTROLYES/THYROID/GLUCOSE
Hypocalcemia: (CATS) Convulsions, Arrhythmias, Tetany,
Spasms.
Hypercalcemia: (Moans and Groans) Fatigue/lethargy,
Constipation, stones, muscle weakness

Hypokalemia: Anorexia, N/V, Weak Pulses, increased chance

of DIG TOXICITY.
Hyperkalemia: Vfib, cardiac arrest, muscle twitching, extremity
numbness
Hyponatremia: N/V, HA, twitching, confusion
Hypernatremia: Increased temperature, weakness, thirst,
hypotension, tachycardia
Hyperglycemia: Hot and Dry: Sugar High increased thirst,
fatigue, confusion, wt. loss, hot & dry skin.
Hypoglycemia: Cold and Clammy: Need some candy. Cold &
Clammy skin, trembling, fatigue, blurred vision, Nausea,
Fainting.
Hyperthyroidism: Hot, thinning of skin, brittle hair,
restlessness, hyperactive reflexes
Hypothyroidism: Fatigue, wt. gain, cold, hair loss.
COMMON PROBLEMS
Addisons Dz: Hyponatremia, Hypotension, decreased blood
volume, HYPERkalemia, hypoglycemia
Cushings: Hypernatremia, hypertension, increased blood
volume, HYPOkalemia, hyperglycemia.
Diabetic Ketoacidosis: Body is unable to produce enough
insulin, breaks down fats instead which increases ketone bodies.
S/S: Kussmaul respirations, fruity breath, excessive thirst,
increased voiding, N/V, Ketones in urine.
Myasthenia Gravis: Signs/Symptoms start at the top. Facial
droop, ptosis, diplopia, and difficulty swallowing risk for
aspiration and choking (BIG DEAL). Avoid excessive heat and
alcohol. More prone for infection as well. Improves with rest.

MS: Will have numbess and Diplopia. Use steroids, sleep on

stomach to avoid contractures, and avoid excessive head. At risk
for injuries.
Guillain Barre: Bodys immune system attacks nervous system
(peripheral). Give high doses of immunoglobins. S/S: Resp.
Failure, flaccid paralysis, urinary retention.
Legionnaires DZ: Severe pneumonia caused by Legionella. NOT
contagious (standard precautions). Inhaled directly from source,
not by person.
Menieres Syndrome: Vertigo, avoid excessive movement while
communicating with patient. Decrease patients head movement
in bed.
Gastric Ulcers: Not relieved by food intake, pain most
noticeable 30-60 minutes post meal.
Heroin Withdrawal: Runny nose, yawning, muscle/joint pain,
diarrhea.
Plebitis: Inflammation of vein. Remove catheter, apply warm
moist packs and change IV site.
Preeclampsia: Edema, proteinuria, HTN. Give Magnesium
Sulfate for uterine relaxation and slow down the preterm labor.
Hip Replacement: Can keep pillow between legs, want to avoid
ADDuction (displaces). Try to keep abducted, but no more than
60 degrees.
Hypoxia: Restlessness and anxiousness most commonly seen.
Auscultate lungs. Seen very often with vented patients, and
pneumonia/asthma patients.
IBS: Muscle contractions of colon. Cramping, bloating, diarrhea,
constipation seen. Eliminate gluten, FODMAP (Fructoses,
Lactose, etc.). Give FIBER, antidiarheals, anticholinergics, and
antidepressants if needed.

IBD:
Ulcerative Colitis (Attacks Large intestine). Lining of colon
becomes inflamed, autoimmune. This causes
discomfort/emptying of stomach.
Chrons: Attacks any part of the intestine. Same S/S, and is
autoimmune. Both are considered as a part of IBD.
Diet: Increase Caloric intake as well as protein. Eat only low
residue foods: no RAW fruits or foods high in fiber.
Pancreatitis: Inflammation of pancreas. Upper and Mid GI pain,
N/V, Fever, Increased HR. Keep pt. NPO to decrease work on
pancreas. ABSOLUTELY NO ETOH, and LIMITED fats. May be
caused by chronic use, or from stones obstructing the pathway of
elimination.
Diverticulosis: Small pouches in digestive system lining. When
INFLAMED it is known as diverticulitis. Antibiotics for infection.
Increase fiber and fluids, no seeds, nuts, or corn.
Hemolytic Reaction: Hypotension, lower back pain, fever. MOST
DANGEROUS.
Allergic Reaction: Urticaria (Hives), itching, respiratory distress
(Wheezing), epiglottal edema. Give Benadryl.
Incentive Spirometer: Have pt. breathe IN and hold for 3
seconds before exhaling. Have patient sit up (fowlers-high
fowlers) before proceding.
Autonomic Dysreflexia: Most commonly seen from a T6 injury
and above. Excessively high BP, pounding head ache, profuse
sweating, nasal congestion, Bradycardia. Decrease BP by raising
HOB, take off loose clothes. THIS IS A HUGE EMERGENCY
(usually top priority on NCLEX).
Diabetes Insipidus: ADH is not adequately produced. Increased
voiding, and increased thirst. Electrolyte imbalance seen,
Hypernatremia.

SIADH: ADH is inappropriately used. This causes fluid to be

retained. Hyponatremia is most commonly seen.
NG Tube: Make sure to aspirate to make sure tube is in place.
pH should be equal to gastric contents. Irrigate only after
positioning is verified.

Wet-to-Dry Dressing: Avoid wetting dressing when taking it off

so that optimum debris is removed. After removed, place new
guaze in saline, squeeze until not dripping, pack into wound and
cover dressing with dry pad, then tape.

Fetal Heart Rate Patterns:

VC
EH
AO
LP
V = variable decels; C = cord compression caused
E = early decels; H = head compression caused
A = accels; O = okay, not a problem!
L = late decels = placental insufficiency, can't fill
Place mother in trendelenbergs for cord compression to remove
pressure off of cord, stop pitocin, and give oxygen. For LATE
decels, turn mother to side, give O2. Always manually monitor
fetal heart tones right after water breaks.
RH: Mother is negative, baby is positive. RhoGAM is given for
second child.
SCANS
PET: Empty bladder before test, warm tracer dye is injected

through IV. This test allows organs to be seen clearly. Ie. Brain
cancer, poor blood flow.
MRI: Uses magnetic and radio waves to create pictures. No
radiation used. Inform physician if patient has artificial heart
valves, clips, pacemakers, ear devices or anything with metal.
EMG: Electrodes attached to legs generally allows for muscles
to be monitored.
CT: Uses X-rays. Some may require contrast dyes. If dyes are
used, no eating for 4-6 hours before test. Increase fluid intake to
remove dye and decrease work on the kidneys.
IVP: X-ray of kidneys, bladder, ureters, and urinary tract. Used
to identify stones, infections, obstructions, and tumors. Contrast
material used: IODINE. Check for iodine allergy. Caution with
diabetes or kidney problems. Increase fluid intake to remove dye
and decrease work on the kidneys.
POSITIONING
Post AKA and BKA: Avoid adduction, place in prone position
often during the first 24 hours.
Blood pressures: Hypertension put HOB up (fowlers, high
fowlers). Hypotension HOB goes down, lay patient supine.
Increased ICP keep in low fowlers.
Post Lumbar Puncture & Myelogram: Patient positioned
supine to prevent leakage of CSF. Nurse should assess for clear
drainage requires IMMEDIATE attention.
Dumping Syndrome: Patient lies flat after meal for 30 minutes.
Eat in reclining position.
Enema: Side lying position or sims.
Shock: Extremities elevated 20 degrees, modified
Trendelenbergs.

Air/Pulmonary Embolism: Turn pt to left side and lower head

of bed. S/S include sudden onset of chest pain, difficulty
breathing, sense of impending doom.

DELEGATION
Nurses are the ones that can assess and teach. For priority
questions, any patient that is a new admission, being discharged,
just returned from surgery, or needs something taught is given to
the RN.
TIPS:
- Know all lab values, and the effects on the body when they are
not in range.
- Airway is always the priority. If the patient cant adequately
take in oxygen, the rest of the body is USELESS.
- Cast care is key! Check for blanching and color changes.
Sudden pain may be compartment syndrome. VERY SERIOUS.
- Patients with a deteriorating mental status (Decrease in
Glasgow) are always given to RN. Decrease in LOC is first sign
generally.
- Bleeding is usually assessed for during the first 24 hours.
Infection doesnt usually occur until around 48-72 hours.
- Cane use: the good goes up and the bad comes down. Good
foot goes up when walking up stairs, bad foot goes first when
walking down.
- Give lidocaine for VTACH, and Atropine for anything Brady.
- Draw up Regular insulin before N-Insulin. Regular is clear, N is
cloudy.
- 24 hr. urine collection: discard first void of the morning, then
collect in a container for the rest of the day.
- Weight doubles by 6 months and triples by 1 year for infants.
Babinskis leaves by 1 year.
- Do plenty of questions (SATA and Priority)
- TB drugs are liver toxic and may turn urine orange. Assess for
jaundice.